<ul><li>Supracondylar #:</li></ul>A supracondylar fracture is a fracture of the distal humerus just above the epicondyles....
spasm of the artery and
compression of the artery relieved by manipulation of the fracture
compression of median nerve. Causing Pink and Pulseless hand in supra condylar fracture. Thus there is loss of circulation...
Myositis ossificans or calcific tendinitis
Neurovascular injuries (8-21% of cases) — ulnar nerve injuries are most common, followed by brachial artery injuries (5-13%)
Osteochondral defects, intra-articular loose bodies, and avascular necrosis of the capitellum
Instability
Secondary injury
Most commonly brachial artery injury, and if left untreated could lead to Volkmann's contracture (permanent flexion contra...
Taken from http://en.wikipedia.org/wiki/Supracondylar_fracture
T – among the commonest fractures in children (Apley’s concise 3rd edition page 311)
F – can cause compartment syndrome (http://emedicine.medscape.com/article/1269576-treatment)
F – Occur as a complication of fracture of the lateral condyle of the humerus, which may lead to tardy ulnar nerve palsy. ...
F – Existence of collateral arteries (Netter 4th edition page 434)
T – distal fragment may be displaced and / or tilted either posteriorly / anteriorly / medially / laterally / rotated (Apl...
Colle’s #:</li></ul>A Colles' fracture, also Colles fracture, is a distal fracture of the radius in the forearm with dorsa...
1 inch (2.54 cm) proximal to the radio-carpal joint
dorsal displacement and angulation
Taken from http://en.wikipedia.org/wiki/Colle's_fracture</li></ul>Complications:<br /><ul><li>Circulatory impairment
Nerve injury (median nerve in carpal tunnel)
Malunion
Tendon rupture (tear of EPL)
Joint stiffness
Complex regional pain syndrome
Treatment:
Undisplaced fracture – splintage
Displaced fracture – CMR under anesthesia
Comminuted and unstable fracture – external fixation with K wire
Taken from Apley’s concise 3rd edition page 325
T – so-called ‘dinner for deformity’ (Apley’s concise 3rd edition page 324)
F – dorsal displacement of the distal fragment of the radius (Apley’s concise 3rd edition page 324)
F – control manual reduction is sufficient if its displaced (Apley’s concise 3rd edition page 324)
T – can cause stiffness if it the joint is not being used for movement (Apley’s concise 3rd edition page 324)
F – Tear of extensor pollicis longus (EPL) a few weeks after fracture (Apley’s concise 3rd edition page 325)
# of the femoral neck:</li></ul>In general, these injuries occur in 2 distinct populations, (1) young, active individuals ...
The Shenton line is an imaginary line drawn along the inferior border of the superior pubic ramus(superior border of the o...
Interruption of Shenton's line can indicate (in the correct clinical scenario)
developmental dysplasia of the hip (DDH)
fractured neck of femur
taken from http://radiopaedia.org/articles/shenton-s-line-1
Garden classified this fracture into four types:
Type 1 is a stable fracture with impaction in valgus.
Type 2 is complete but non-displaced.
Type 3 is displaced (often rotated and angulated) with varus displacement but still has some contact between the two fragm...
Type 4 is completely displaced and there is no contact between the fracture fragments.
Taken from http://en.wikipedia.org/wiki/Hip_fracture
Nonoperative management is reserved only for those with extremely high surgical risk or demented nonambulators with minima...
Taken from http://www.orthopaedia.com/display/Main/Femoral+neck+fractures
Operative treatment is almost mandatory. Displaced fracture will not unite without internal fixation. Impacted fracture ca...
Complications include AVN, non-union, OA, general (thromboembolism, bed sores)
Taken from (Apley’s concise 3rd edition page 363)
F – most commonly seen in elderly osteoporotic people (Apley’s concise 3rd edition page 362)
T – interruption of the Shenton’s line may indicate # of femoral neck (http://radiopaedia.org/articles/shenton-s-line-1
F – Garden stage II shows complete but undisplaced fracture (Apley’s concise 3rd edition page 362)
T – operative treatment is almost mandatory (Apley’s concise 3rd edition page 363)
T  - (Apley’s concise 3rd edition page 362)
Compartment syndrome:</li></ul>Causes include:<br /><ul><li>Bleeding
Edema
Inflammation
Tight plaster cast</li></ul>Clinical features of compartment syndrome:<br /><ul><li>Pain
Paresthesia
Pallor
Paralysis
Pulselessness</li></ul>Treatment:<br /><ul><li>Cast, bandage and dressings must be removed
Limb should be nursed flat (elevating the limb causes further decrease in end capillary pressure and aggravates muscle isc...
Fasciotomy
Debridement if there is necrosis
T – bleeding, edema, inflammation (Apley’s concise 3rd edition page 294)
T – presence of pulse does not exclude the diagnosis (Apley’s concise 3rd edition page 295)
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Ganyang MCQ Ortho Answers

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  1. 1. <ul><li>Supracondylar #:</li></ul>A supracondylar fracture is a fracture of the distal humerus just above the epicondyles. While relatively rare in adults it is one of the most common fractures to occur in children and is often associated with the development of serious complications. Presenting complaints: The child presents with history of a falling on an outstretched hand followed by pain, swelling and inability to move the affected elbow.<br />On examination: Unusual prominence of olecranon process but because it is a supracondylar fracture, the three bony point relationship is maintained, as in a normal elbow.<br />Neurovascular complications<br /><ul><li>tear or entrapment of the brachial artery
  2. 2. spasm of the artery and
  3. 3. compression of the artery relieved by manipulation of the fracture
  4. 4. compression of median nerve. Causing Pink and Pulseless hand in supra condylar fracture. Thus there is loss of circulation of forearm, causing lack of reperfusion of tissues resulting in tissue death causing compartment syndrome. </li></ul>Therefore the complications of elbow dislocations include the following:<br /><ul><li>Posttraumatic periarticular calcification, which occurs in 3-5% of elbow injuries
  5. 5. Myositis ossificans or calcific tendinitis
  6. 6. Neurovascular injuries (8-21% of cases) — ulnar nerve injuries are most common, followed by brachial artery injuries (5-13%)
  7. 7. Osteochondral defects, intra-articular loose bodies, and avascular necrosis of the capitellum
  8. 8. Instability
  9. 9. Secondary injury
  10. 10. Most commonly brachial artery injury, and if left untreated could lead to Volkmann's contracture (permanent flexion contracture of the hand at the wrist, resulting in a claw-like deformity of the hand and fingers).
  11. 11. Taken from http://en.wikipedia.org/wiki/Supracondylar_fracture
  12. 12. T – among the commonest fractures in children (Apley’s concise 3rd edition page 311)
  13. 13. F – can cause compartment syndrome (http://emedicine.medscape.com/article/1269576-treatment)
  14. 14. F – Occur as a complication of fracture of the lateral condyle of the humerus, which may lead to tardy ulnar nerve palsy. (http://en.wikipedia.org/wiki/Cubitus_valgus)
  15. 15. F – Existence of collateral arteries (Netter 4th edition page 434)
  16. 16. T – distal fragment may be displaced and / or tilted either posteriorly / anteriorly / medially / laterally / rotated (Apley’s concise 3rd edition page 311)
  17. 17. Colle’s #:</li></ul>A Colles' fracture, also Colles fracture, is a distal fracture of the radius in the forearm with dorsal (posterior) displacement of the wrist and hand. The fracture is sometimes referred to as a "dinner fork" or "bayonet" deformity due to the shape of the resultant forearm. For a more detailed discussion see distal radius fracture.<br />The term Colles fracture is classically used to describe a fracture at the distal end of the radius, at its cortico-cancellous junction. However, now the term tends to be used loosely to describe any fracture of the distal radius, with or without involvement of the ulna, that has dorsal displacement of the fracture fragments. Colles himself described it as a fracture that “takes place at about an inch and a half (38mm) above the carpal extremity of the radius” and “the carpus and the base of metacarpus appears to be thrown backward”. <br />The classic Colles fracture has the following characteristics: <br /><ul><li>Transverse fracture of the radius
  18. 18. 1 inch (2.54 cm) proximal to the radio-carpal joint
  19. 19. dorsal displacement and angulation
  20. 20. Taken from http://en.wikipedia.org/wiki/Colle's_fracture</li></ul>Complications:<br /><ul><li>Circulatory impairment
  21. 21. Nerve injury (median nerve in carpal tunnel)
  22. 22. Malunion
  23. 23. Tendon rupture (tear of EPL)
  24. 24. Joint stiffness
  25. 25. Complex regional pain syndrome
  26. 26. Treatment:
  27. 27. Undisplaced fracture – splintage
  28. 28. Displaced fracture – CMR under anesthesia
  29. 29. Comminuted and unstable fracture – external fixation with K wire
  30. 30. Taken from Apley’s concise 3rd edition page 325
  31. 31. T – so-called ‘dinner for deformity’ (Apley’s concise 3rd edition page 324)
  32. 32. F – dorsal displacement of the distal fragment of the radius (Apley’s concise 3rd edition page 324)
  33. 33. F – control manual reduction is sufficient if its displaced (Apley’s concise 3rd edition page 324)
  34. 34. T – can cause stiffness if it the joint is not being used for movement (Apley’s concise 3rd edition page 324)
  35. 35. F – Tear of extensor pollicis longus (EPL) a few weeks after fracture (Apley’s concise 3rd edition page 325)
  36. 36. # of the femoral neck:</li></ul>In general, these injuries occur in 2 distinct populations, (1) young, active individuals with unaccustomed strenuous activity or changes in activity, such as runners or endurance athletes, and (2) elderly individuals with osteoporosis. <br /><ul><li>Taken from http://emedicine.medscape.com/article/86659-overview
  37. 37. The Shenton line is an imaginary line drawn along the inferior border of the superior pubic ramus(superior border of the obturator foramen) and along the inferomedial border of the neck of femur. This line should be continuous and smooth.  
  38. 38. Interruption of Shenton's line can indicate (in the correct clinical scenario)
  39. 39. developmental dysplasia of the hip (DDH)
  40. 40. fractured neck of femur
  41. 41. taken from http://radiopaedia.org/articles/shenton-s-line-1
  42. 42. Garden classified this fracture into four types:
  43. 43. Type 1 is a stable fracture with impaction in valgus.
  44. 44. Type 2 is complete but non-displaced.
  45. 45. Type 3 is displaced (often rotated and angulated) with varus displacement but still has some contact between the two fragments.
  46. 46. Type 4 is completely displaced and there is no contact between the fracture fragments.
  47. 47. Taken from http://en.wikipedia.org/wiki/Hip_fracture
  48. 48. Nonoperative management is reserved only for those with extremely high surgical risk or demented nonambulators with minimal hip pain
  49. 49. Taken from http://www.orthopaedia.com/display/Main/Femoral+neck+fractures
  50. 50. Operative treatment is almost mandatory. Displaced fracture will not unite without internal fixation. Impacted fracture can be left to unite, but there is always a risk that they may become displaced, even while lying in bed, so fixation is safer.
  51. 51. Complications include AVN, non-union, OA, general (thromboembolism, bed sores)
  52. 52. Taken from (Apley’s concise 3rd edition page 363)
  53. 53. F – most commonly seen in elderly osteoporotic people (Apley’s concise 3rd edition page 362)
  54. 54. T – interruption of the Shenton’s line may indicate # of femoral neck (http://radiopaedia.org/articles/shenton-s-line-1
  55. 55. F – Garden stage II shows complete but undisplaced fracture (Apley’s concise 3rd edition page 362)
  56. 56. T – operative treatment is almost mandatory (Apley’s concise 3rd edition page 363)
  57. 57. T - (Apley’s concise 3rd edition page 362)
  58. 58. Compartment syndrome:</li></ul>Causes include:<br /><ul><li>Bleeding
  59. 59. Edema
  60. 60. Inflammation
  61. 61. Tight plaster cast</li></ul>Clinical features of compartment syndrome:<br /><ul><li>Pain
  62. 62. Paresthesia
  63. 63. Pallor
  64. 64. Paralysis
  65. 65. Pulselessness</li></ul>Treatment:<br /><ul><li>Cast, bandage and dressings must be removed
  66. 66. Limb should be nursed flat (elevating the limb causes further decrease in end capillary pressure and aggravates muscle ischemia)
  67. 67. Fasciotomy
  68. 68. Debridement if there is necrosis
  69. 69. T – bleeding, edema, inflammation (Apley’s concise 3rd edition page 294)
  70. 70. T – presence of pulse does not exclude the diagnosis (Apley’s concise 3rd edition page 295)
  71. 71. T – may be caused by swelling of a limb inside a tight plaster cast (Apley’s concise 3rd edition page 294)
  72. 72. F – remove cast, bandages or dressings – and the limb should be nursed flat – fasciotomy (Apley’s concise 3rd edition page 295)
  73. 73. ??
  74. 74. Indication of internal fixation</li></ul>Indications for ORIF of fractures http://wiki.answers.com/Q/Indication_for_open_reduction_with_internal_fixation#ixzz1HzHp6VFz<br />Absolute<br /><ul><li>Unable to obtain an adequate reduction
  75. 75. Displaced intra-articular fractures
  76. 76. Certain types of displaced epiphyseal fractures
  77. 77. Major avulsion fractures where there is loss of function of a joint or muscle group
  78. 78. Non-unions
  79. 79. Re- implantations of limbs or extremities</li></ul>Relative<br /><ul><li>Delayed unions
  80. 80. Multiple fractures to assist in care and general management
  81. 81. Unable to maintain a reduction
  82. 82. Pathological fractures
  83. 83. To assist in nursing care
  84. 84. To reduce morbidity due to prolonged immobilisation
  85. 85. For fractures in which closed methods are known to be ineffective</li></ul>Questionable<br />Fractures accompanying nerve of vessel injury<br />Open fractures<br />Cosmetic considerations<br />Economic considerations<br /><ul><li>T when fracture is unstable and prone to displace
  86. 86. (http://wiki.answers.com/Q/Indication_for_open_reduction_with_internal_fixation)
  87. 87. F open fracture with gross contamination F
  88. 88. (http://wiki.answers.com/Q/Indication_for_open_reduction_with_internal_fixation)
  89. 89. F polytrauma, when to minimize risk of acute respiratory distress syndrome
  90. 90. T pathological fracture, whereby bone disease may prevent healing (http://wiki.answers.com/Q/Indication_for_open_reduction_with_internal_fixation)
  91. 91. F shortage hospital bed
  92. 92. (http://wiki.answers.com/Q/Indication_for_open_reduction_with_internal_fixation
  93. 93. Causes of pathological fracture
  94. 94. A pathological fracture is one that occurs in abnormal bone, as a result of a normally insignificant stress.
  95. 95. Possible causes include:
  96. 96. metastatic tumours:</li></ul>breast, lung, thyroid, kidney, prostate<br /><ul><li>generalised bone disease:</li></ul>osteogenesis imperfecta, postmenopausal osteoporosis, metabolic bone disease, myelomatosis, polyostic fibrous dysplasia, Paget's disease<br /><ul><li>local benign conditions:</li></ul>chronic infection, solitary bone cyst, fibrous cortical defect, chondromyxoid fibroma, aneurysmal bone cyst, chondroma, monostotic fibrous dysplasia<br /><ul><li>primary malignant tumours:</li></ul>chondrosarcoma, osteosarcoma, Ewing's tumour<br /><ul><li>http://www.gpnotebook.co.uk/simplepage.cfm?ID=859111436
  97. 97. F repetitive stress (repetitive stress is a cause for stress fracture) (http://medical-dictionary.thefreedictionary.com/pathological+fracture)
  98. 98. T osteomyelitis (Chronic infection which is a local benign condition) (http://www.wrongdiagnosis.com/p/pathological_fracture/causes.htm)
  99. 99. (http://www.gpnotebook.co.uk/simplepage.cfm?ID=859111436)
  100. 100. T bone cyst (a local benign condition) (http://www.gpnotebook.co.uk/simplepage.cfm?ID=859111436)
  101. 101. T previous traumatic fracture (pathological fracture is due to pathologic bone-weakening condition) (http://www.wrongdiagnosis.com/p/pathological_fracture/causes.htm)
  102. 102. T secondary to bone tumour ( osteosarcoma, osteoblastoma, metastatic tumors) (http://www.wrongdiagnosis.com/p/pathological_fracture/causes.htm) (http://www.gpnotebook.co.uk/simplepage.cfm?ID=859111436)
  103. 103. The common sites of fractures in patients with osteoporosis are :
  104. 104. Femoral neck (True) (typical fragility occurs in vertebral column, hip, ribs , and wrist) http://en.wikipedia.org/wiki/Osteoporosis
  105. 105. http://library.med.utah.edu/WebPath/TUTORIAL/OSTEO/OSTEOPOR.html
  106. 106. Distal tibia (False)
  107. 107. Sacrum (False)
  108. 108. Distal radius (True)
  109. 109. Vertebrae (True)
  110. 110. Traumatic anterior dislocation of the shoulder :
  111. 111. Is caused by forced adduction and internal rotation (False) (by forced abduction and external rotation of the soulder) (APLEY’S CONCISE SYSTEM OF ORTHOPAEDICS AND FRACTURES, THIRD EDITION, page 306)
  112. 112. Causes the head of the humerus to end up just below the coracoids process (True) ( X-ray shows head of humerus lying below and medial to the socket) (APLEY’S CONCISE SYSTEM OF ORTHOPAEDICS AND FRACTURES , THIRD EDITION, page 306)
  113. 113. Is less common occurred as compare to posterior dislocation (False) (humeral head displacement is usually anterior, less often posterior) (APLEY’S CONCISE SYSTEM OF ORTHOPAEDICS AND FRACTURES , THIRD EDITION, page 306)
  114. 114. Would result in axillary nerve injury as a complication (True) (The axillary nerve may be injured) (APLEY’S CONCISE SYSTEM OF ORTHOPAEDICS AND FRACTURES , THIRD EDITION, page 306)
  115. 115. Would likely to become recurrent if occurred in younger patient (True) (When shoulder dislocation occurs in adolescents and children, it has the worst natural history of any injury; the rate of recurrence in later years is at least 70%) ( http://emedicine.medscape.com/article/1262004-overview)</li></ul>Regarding fractured bone healing:<br />The process starts subsequently from inflammation stage, reparative stage and remodelling stage T (complete phases are, tissue destruction, inflammation, callus formation, consolidation and remodelling) Apley’s pg 268.<br />Stabilization of the fracture ends is necessary for healing process to occur T (in order for bone healing to occur, immobilization is of important factor)<br />Osteoprogenitor cells within the periosteum are mobilized T<br />Healing is always associated with callus formation F (there is also healing without callus) Apley’s 268<br />Remodeling stage would take two weeks to complete the process F (months or years) Apley’s pg 269<br />Fractured healing<br />-can be divided into healing with callus and without callus.<br />Healing with callus (secondary bone healing)<br />-the process varies according to types of bone involved and amount of movement at fractured site. Consists 5 stages:<br />Tissue destruction and haematoma formation<br />-vessels are torn and heamatoma forms around and within the fractured leads to deprivation of blood supply and dies for few mm thick.<br />Inflammation and cellular proliferation.<br />-within 8 hours of the fracture there is an acute inflammatory reaction with proliferation of cells under periosteum and within the breached medullary canal. Fragments end are surrounded by cellular tissue and later bridges fractured site. New vessels form.<br />Callus formation<br />-potentially chondrgenic and osteogenic. The thick cellular mass (proliferating cell) with its surrounding immature bone and cartilage forming callus or splint on the periosteal and endosteal surface. Process aided by inductive proteins (fibroblast, growth factor, transform GF and bone morphogenic protein)<br />Consolidation <br />-woven bone (immature bone) transformed into lamella bone. Fractured line filled by osteoblastic activity. Slow process, may need several months for bone to be able to carry normal load. <br />Remodelling<br />-process of alternating bone resorption and formation (reshaped) especially in children. <br />Healing without callus (primary bone healing)<br />-usually occur if the fracture site is absolutely immobilized (rigid fixation) eg: fracture rigidly immobilize by internal fixationthere is no need for callus formation, instead new bone formation occur directly between the fragments gap. (Gaps invaded by new capillaries and bone-forming cell growing in from the edgesosteogenesisdirectly forming lamellar bone! Wider gaps filled by woven bone first (gap healing)<br />-compared to healing with callus proliferating cells are needed to form cellular mass together with woven bone and immature cartilage forming callus. It also ensues mechanical strength while bone end heals!<br />-however, this type of healing is dependent to the internal fixation for its integrity due to absence of callus. The implant also diverts stress away from the bone (reduces weight bare of bone), therefore it is no fully recover until metal prosthesis is removed.<br />The time factor<br />-The rate of repair varies. Often depends upon:<br />Types of bone involvedcancellous bone heals faster than cortical bone. (Highly vascularised)<br />Types of fracturetransverse fracture heals longer than a spiral fracture<br />State of blood supplypoor circulation means poor healing<br />Pt’s general constituentshealthy bone heals faster<br />Pt’s agehealing is almost 2x faster in children than in adults.<br />Average time for fracture healingCallus visible UL (2-3 weeks)LL (2-3 weeks)Union UL (4-6 weeks)LL (8-12 weeks)Consolidation UL (6-8 weeks)LL (12-16 weeks)<br />Factor associate in non-union fracture (answers directly from Apley’s pg 270)<br />Infection T<br />Smoking F<br />Splintage with POP F (this is to promote union)<br />Interposition of periosteum between fragments T<br />Excessive traction T<br />Delayed union, non union, and malunion.<br />Delayed union<br />-the time of treatment is prolonged (callus seen after expected time of treatment). Causes can be due to either biological or biomechanical.<br />Poor blood supply<br />-often in badly displaced fracturecausing tearing of periosteum and interruption of intramedullary BSfracture surface may become necroticdelayed callus formation and delayed healing.<br />Severe soft-tissue damage<br />periosteal stripping<br />Imperfect spilntage<br />-excessive traction (creating a fracture gap) and excessive movement at fracture site will delay ossification in callus<br />Over rigid fixation<br />-rigid fixation delays rather than promote union. <br />Infection <br />-tissue healing is severely hampered by bone lysis, necrotic and pus formation later causing implant to loosen and fracture stability is lost.<br />-clinical features persistant fracture tenderness. More acute pain when subjected to stress.<br />-treatment 2 important principles (1)to eliminate any possible cause of delayed union (2)to promote healing by providing most appropriate biological env.<br />also, immobilization (cast or int fixation) to prevent movement at fracture site. Still fracture loading is an important stimulus for union, so encourage muscular exercise ang weight bare in cast or brace (partial weight bare). <br />if union is delayed >6 months and there is no signs of callus formation, int fixation and bone grafting is indicated. (Operative)<br />4257675241300Non-union<br />-can occur in either hyperthropic non-union or atrophic non-union.<br />-hyperthrophic non-unionbone end are enlarged, suggesting osteogenesis still active but not capable of bridging the gap.<br />-atrophic non-unionthe bone end is tapered or rounded with no suggestion of new bone formation.<br />-treatmentif symptomless, no need! Even if symptoms persist, use props to stimulate union (eg: pulsed electromagnetic fields and low frequency pulsed U/S) <br />(operative) hyperthrophic non-union, rigid fixation may lead to union. Atrophic non-union, sclerosed bone end should be excised and bone graft together with rigid fixation should be done.<br />Malunion <br />-bone fragment join in an unsatisfactory position (false angulation, rotation and shortening)<br />-causes include (1)failure to reduce fracture adequately, (2)failure to hold reduction while healing process, (3)gradual collapse of comminuted or osteoporotic bone.<br />-clinical featureobvious deformity esp limbs if compared to normal one. Sometimes, only apparent on Xray.<br />-treatmentfew guidelines are offered:<br />In adult, angulation >10-15 degrees in a long bone or noticeable rotational deformity may need correction by remanipulation or by osteotomy and int fixation.<br />In lower limb, shortening of >2cm is acceptable, in case of severe limb shortening, limb lengthening should be considered. <br />Patient expectationcosmesis purpose.<br />Angular deformity >15 degree in weight bearing joint to prevent OA.<br />In young children, angular deformity near the bone end will often remodel with time. However, rotational not. <br />Sports injuries of knee<br />Meniscus tear is most common F (ligamental tear is most common when it comes to sport. Meniscus tear usually occur in young footballer due to weight bear on flex knee with twisting force also in middle age due to fibrosis) Apley’s pg 226<br />Haemarthrosis usually occur due to torn meniscus T (meniscus tear may present with joint effusion) Apley’s pg 227<br />Swelling of the knee for the next day commonly due to cruciate ligament tear F (meniscus tear, usually swelling appear some hours later or the next day as compared to ligamental tear, it appear immediately) Apleys pg 227 and374<br />Positive posterior drawer test indicate anterior cruciate ligament tear F ( when positive ant drawer test, PCL is torn. When positive anterior drawer test, ACL is torn) PE orthopaedic surgery, pg 132<br />Lateral meniscus tear is more common rather than medial meniscus tear F (medial is more common as its attachement to the capsule make it less mobile) Apley’s 227 <br />Meniscal tear<br />-menisci have an important role in (1)increasing the stability of the knee (2)controlling the complex rolling and gliding actions of the joint (3)distributing load during movement.<br />-tear common in young adult (footballer) mechanism: weight on the flex knee together with twisting strain. In middle life, tear occur with relatively little force due to fibrosis.<br />-medial meniscus is commonly affected due to its attachment to the capsule, male it less mobile. <br />3676650-6350-patterns of tear: <br />Bucket-handle teartrauma (young patient)<br />horizontal tear (transverse/radial)degenerative or repetitive minor trauma.<br />-clinical features: pain is severe and further activity is avoided, often the knee is locked in partial flexion. Swelling appear hours later or following day. Sx subside when rest. May occur periodically after strains or twist. <br />-in pt >40 age, may present with recurrent ‘’locking’’ and ‘’giving way’’ sx. Locking (inability to extend the knee fully) suggest a Bucket-handle tearsometimes, they even learns to unlock their knee. <br />-o/e, joint maybe slightly flex, tenderness over the joint line (commonly medial side), full flexion but limited extension. Apley’s grinding test maybe positive!<br />-investigation MRI and athroscopy <br />-treatment arthroscopic surgery, cleanly excised displaced portion and post-op physiotherapy.<br />Safety and road traffic accident : (aku x jumpe explaination utk soklan ne, seems mcm kne pikir logic je laa kot.)<br />Accident is misnomer term, because mostly accident caused by the negligence T<br />Usage of technologies can cause the accident T<br />Strict law totally abolish road traffic accident (RTA) F<br />Accident can give impact to economic growth and insurance T<br />Road design itself can induce accident T<br />TB spondylitis<br />Biopsy is a helpful diagnosis <br />Multiple drug regime is the treatment of choice for uncomplicated case <br />Destructive process caused by delayed hypersensitivity reaction <br />It is often difficult to distinguish TB from other types of infection or metastatic (klu based on clinical features and spine x-rays only). If there is doubt, a needle biopsy may provide the answer.<br />Other investigations may help in diagnosis of TB spondylitis. For example:<br />Mantoux test (positive)<br />ESR (raised)<br />Pus bacteriology examination and culture<br />TRUE<br />(Ref: Apley’s Concise System of Orthopedics and Fracture, 3rd edition, page 194)<br />For less advanced cases (no progressive bone destruction present), conservative treament is usually sufficient and curative. Anti-tuberculous chemotherapy should be continue for 6-12 months. Anti-tuberculous chemotherapy are:<br />Rifampicin<br />Isoniazid <br />Pyrazinamide<br />Ethambutol<br />However, there are some criterias/indications for operation:<br />Abscess formation (must be drained)<br />Marked bone destruction and progressive deformity (requires spinal fusion)<br />Threatened paraplegia that does not respond to conservative treatment<br />TRUE<br />(Ref: Apley’s Concise System of Orthopedics and Fracture, 3rd edition, page 194 and 195)<br />Delayed hypersensitivity reactions occurs 48 to 72 hours after antigen exposure. It is a major mechanism of defense against various intracellular pathogens, including mycobacteria, fungi and certain parasites, and it occurs in transplant rejection and tumour immunity. The host respone againts intracellular pathogens such as Mycobacterium tuberculosis is markedly impaired due to loss of CD4+. This lead to granulomatous formation, which contain enzyme that caused bone destruction.<br />TRUE<br />(Ref: http//emedicine.medscape.com/article/136118-overiew)<br />Spinal injury:<br />Vertebral fracture commonly cause spinal cord injury <br />Neurovascular examination is performed to reveal the level of spinal cord injury <br />Resuscitation is the initial management of spinal cord injury <br />Vertebral fracture and spinal cord injuries are due to:<br />direct force eg: penetrating wounds from firearms @ knives)<br />indirect force (more common) eg: following a fall from a height when the spinal column collapses in its vertical axis, during violent free movements of the neck or trunk <br />There are mechanisms come into play, often simultaneously that lead to spinal cord injury: <br />axial copmression<br />flexion<br />extension<br />rotation<br />shear<br />distraction<br />Ade beberape types of vertebral fractures yg patut kita ambik perhatian bcoz ade fracture of spine yg common menyebabkan spinal injury dan ade jgk yg extremelly rare menyebabkan spinal injury:<br />Wedge fracture (flexion – compression mechanism) . Neurological involvement - extremelly rare <br />Burst fracture (axial – compression mechanism) . Neurological involvement – common due to retropulsion<br />Flexion – dislocation mechanism. Neurological involvement – common<br />So, as a general vertebral fracture commonly cause spinal cord injury.<br />TRUE<br />(Ref: Apley’s Concise System of Orthopedics and Fracture, 3rd edition, page 342 and 349) <br />Hangman’s fracture<br />Known as traumatic spondylolisthesis of c2 <br />First noted on crimal in death sentenced by hanging as post-mortem examination <br />Symptom – pain radiating along the course of greater occipital nerve <br />Initial management – immobilize with Philadelphia collar <br />Spondylolisthesis means vertebral displacement. Listhesis is nearly always between L4 and L5 or between L5 and the sacrum. It can be classifified into: <br />Dysplastic spondylolisthesis<br />Lytic spondylolisthesis<br />Degenarative spondylolisthesis<br />However, in some scholars they classified spondylolisthesis into 6 group:<br />Dysplastic spondylolisthesis<br />Isthmic spondylolisthesis<br />Degenerative spondylolisthesis<br />Traumatic spondylolisthesis<br />Pathologic spondylolisthesis<br />Iatrogenic spondylolisthesis<br />In Hangman’s fracture, the pedicles of the axis (C2) are fractured and the C1/2 disc is torn; the mechanism is extension with distraction. It can presented with undisplaced or displaced fracture. <br />Traumatic spondylolisthesis is extremely rare, results from a traumatically-induced fracture to the neural arch other than the pars region. The most common example of traumatic spondylolisthesis is Hangman’s Fracture.<br />So the answer for (B) is TRUE <br />(Ref: Apley’s Concise System of Orthopedics and Fracture, 3rd edition, page 199 and 345, http: //www.chirogeek.com/005_Spondylolisthesis_main_final.htm# Traumatic)<br />TRUE<br />I am sorry.I could not find the answer. Tp kt cni kite nk share clinical features of Hangman’s fracture as general. The presentation may be late. Initial symptoms are often slight and the patient usually experiences occipital neuralgia with some local discomfort and stiffness of the upper cervical spine. Inded, the symptoms and signs may resemble miningism.<br />(Ref: http://web.jbjs.org.uk/cgi/reprint/57-B/1/82.pdf)<br />The management of Hangman’s fracture is based on types of fracture. For undisplaced fractures, they are threated in semi rigid collar (Philadelphia cervical collar) or halo-vest until united. Displaced fractures may need reduction before immobilization in a halo-vest for 12 weeks. <br />TRUE<br />(Ref: Apley’s Concise System of Orthopedics and Fracture, 3rd edition, page 345, http://journals/lww.com/euro-emergencymed/Fulltext/2001/03000/Indications_of_Philadelphia_collar_in_the 7.aspx)<br />In low back pain <br />Symptoms of cauda equina syndrome are:<br /><ul><li>Low back pain
  116. 116. Pain in leg (unilateral or bilateral) that starts in the buttocks and travels down the back of the thighs and legs (sciatica)
  117. 117. Numbness in the groin or area of contact if sitting on the saddle (perineal or saddle paresthesia)
  118. 118. Bowel and bladder disturbances (urinary and fecal retention)
  119. 119. Lower extremity muscle weakness and loss of sensations
  120. 120. Reduced or absent lower extremity reflexes
  121. 121. Impairment of penile erection
  122. 122. TRUE</li></ul>(Ref: Apley’s Concise System of Orthopedics and Fracture, 3rd edition, page 98, http://www.emedicinehealth.com/cauda_equina_syndrome/page2_em.htm)<br />The commenest age to develop a prolapsed disc is between 30 and 50 years old. Twice as many men as women are affected<br /><ul><li>TRUE
  123. 123. (Ref: http://www.patient.co.uk/health/Prolapsed -Disc-(Slipped-Disc).htm)</li></ul>Since most episodes of lower back pain are self-limited, it is often advisable for patients to employ back care on their own early in the course of low back pain.<br />In most cases, do-it-yourself back care for low back pain should center on a combination of:<br /><ul><li>A short course of rest, limited to one to two days
  124. 124. Pain medication, such as NSAIDs (e.g. ibuprofen) and/or acetaminophen
  125. 125. Application of ice and/or heat on the lower back to decrease inflammation.</li></ul>Slow mobilization and gentle stretching is then an advisable form of lower back pain care, and the sooner a patient can return to his or her normal functional activities, the sooner the episode of lower back pain will usually get better.<br />Other form of lower back pain are:<br />Walking is often an excellent exercise for low back pain since it is gentle on the back and helps oxygenate the soft tissues in the back to stimulate a healing response.<br />If walking is too painful, exercising in the water (water therapy or pool therapy) is usually tolerable. Such back care is typically beneficial for lower back pain because the water counteracts gravity and helps to support the patient’s weight in a controlled fashion.<br />Sitting upright (e.g. in an office chair, driving) will often aggravate low back pain, since this position loads the back three times more than standing. Sitting in a reclining position, however, relieves pressure on the lower back and is often the most comfortable position for patients experiencing an episode of back pain in the lower back (lumbar spine).<br /><ul><li>TRUE
  126. 126. (Ref: http://www.spine-health.com/conditions/lower-back-pain/back-care-lower-back-pain</li></ul>The answer will be TRUE if the question is more specific. As I mentioned early, according to Apley’s there have 3 types of spondylolisthesis. Spinal claudication only occur in degenerative type of spondylolisthesis due to narrowing of the spinal canal; not the typical presentation for all types of spondyllolisthesis.<br /><ul><li>FALSE
  127. 127. (Ref: Apley’s Concise System of Orthopedics and Fracture, 3rd edition, page 198)</li></ul>Clinical symptoms pun dah cukup utk diagnose acute disc prolapsed (ADP) which are sudden back pain with nerve root symptoms. In most cases, no test are needed as the symptoms often settle within a few weeks. Some people do not have symptoms sebab prolapse tu kecil or occur away from the nerves. Spine X-rays or scan may be advised if symptoms persist. MRI scan dpt bg more information regarding the site and size of a prolapsed disc. MRI dpt highlightkan soft tissue. So, from x-ray tak byk info yang kita boleh dpt tentang abnormality in ADP. <br /><ul><li>TRUE
  128. 128. (Ref: http://www.patient.co.uk/health/Prolapsed -Disc-(Slipped-Disc).htm)</li></ul>Loose bodies in the knee joint can be produced by<br /><ul><li>Synovial chondromatosis T
  129. 129. Osteochondritis dissecans T
  130. 130. Osteoarthritis T
  131. 131. Pigmented villous nodular synovitis  T
  132. 132. Osteochondral fracture T</li></ul>Regarding loose bodies in the knee<br />Patients complain of sudden locking of the joint which is usually reversible<br />A pedunculated loose body may be felt on palpation; one that is truly loose tends to slip away ‘joint mouse’<br />X-ray: most loose bodies are radioopaque, and the film may show an underlying joint abnormality<br />Rx: a loose body in the joint causing symptoms should be removed with the aid of arthroscopy unless the joint is severely osteoarthritic<br />other causes of loose bodies in the knee <br />Charcot’s disease – large osteocartilaginous bodies are separated by repeated trauma in a joint that has lost protective sensation<br />References: Apley’s Concise System of Orthopaedics & Fractures 3rd edition, page 230<br />Synovial chondromatosis <br />Synovial chondromatosis is a rare and benign metaplasia of the synovial membrane resulting in the formation of multiple intra-articular cartilaginous bodies, sometimes HUNDREDS of loose bodies <br />Causes pain and limitation in mobility<br />Most often in middle aged men<br />Location:<br />over one-half of cases occur in the knee, followed by the elbow<br />other common sites include the hip, shoulder, wrist and ankle<br />when located in the foot or ankle the term "soft tissue chondroma" may be used<br />Classification:<br />early: no loose bodies but active synovial disease<br />transitional: active synovial disease, and loose bodies<br />late: loose bodies but no synovial disease<br />On x-ray may show intraaricular loose bodies, if not seen then do MRI (T2 weighted)<br />Rx: total open synovectomy treatment of choice<br />True<br />References:http://www.wheelessonline.com/ortho/synovial_chondromatosis, http://www.bonetumor.org/tumors-unknown-type/synovial-chondromatosis, Apley’s Concise System of Orthopaedics & Fractures 3rd edition, page 230 <br />TRUE Osteochondritis dissecans <br /> <br />Osteochondritis is a group of conditions where there is compression (in crushing), fragmentation (in traction) or separation (in dissecansdissect) of a small segment of bone, usually at the bone end and involving the attached articular surface <br />It is a condition where bone damage and necrosis follows trauma to articular surfaces<br />The affected portion of bone shows many features of ischaemic necrosis, including increased vascularity and reactive sclerosis in the surrounding bone on x-ray<br />Mostly occurs in children & adolescents<br />It can be divided into 3 types: <br />Shearing osteochondritis (osteochondritis dissecans):<br /> In which a small, well-demarcated piece of bone and overlying cartilage becomes separated and forms a loose body because of avascularity<br /> May form 1 or 2 loose bodies<br />Most commonly is due to repeated minor trauma producing an osteochondral fracture of a convex joint surface<br />Most commonly affects the knee; especially the lateral part of the medial femoral condyle<br />On x-ray the dissecting fragment is defined by a radiolucent line of demarcation and when it separates a crater is obvious<br />Rx: <br />Fragment in position – conservative: weight relief & restrict activity<br />Fragment detached + symptoms – operative: fix back in position or remove completely<br />Crushing osteochondritis:<br /> The ossific nucleus which undergoes avascular necrosis, is crushed under pressure<br />Spontaneous; no cause<br />Areas usually affected:<br />Metatarsal head – Freiberg’s disease<br />Navicular bone – Kohler’s disease<br />Lunate bone – Kienbock’s disease<br />Capitulum – Panner’s disease<br /> On x-ray shows increased density, in later stages bone collapse can be seen<br />Rx: <br />Conservative: analgesics + splintage<br />Lunate affected - operative<br />Pulling osteochondritis (traction apophysitis) <br />Excessive pull by a large tendon may damage the unfused epiphysis to which it is attached<br />Typically occurs at 2 sites: <br />Tibial tuberosity - Osgood-Schlatter’s disease<br />Calcaneal apophysis – Sever’s disease<br />On x-ray shows increased density due to slight trauma rather than necrosis<br />Rx: <br />Conservative: rest<br />References: Apley’s Concise System of Orthopaedics & Fractures 3rd edition, page 228-230<br />TRUE Osteoarthritis <br />Osteoarthritis is a chronic joint disorder in which there is progressive softening and disintegration of articular cartilage accompanied by new growth of cartilage and bone at the joint margins (osteophytes) and capsular fibrosis <br />2 mechanisms:<br /> weakening of articular cartilage (due to genetic type II collagen defect or enzymatic activity in inflammatory disorders such as RA) <br />or increased mechanical stress in some parts of articular surface (due to excessive impact loading or joint incongruity) <br />or both<br />Features<br />Early: insidious pain, stiffness which is worse after periods of rest <br />Advanced: sweliing, deformity (usually genu varus if knees affected), loss of mobility and muscle wasting <br />No systemic manifestations (as opposed to RA)<br />Pieces of cartilage or osteophyte can come loose and form loose bodies <br />Can be primary (no obvious cause) or secondary (follows a joint disease or injury)<br />3 characteristic features on x-ray:<br />Reduced joint space (due to cartilage depletion)<br />Subarticular cyst formation and sclerosis<br />Osteophyte formation<br />Rx:<br />Early: conservative - pain relief, joint mobility, load reduction<br />Intermediate: joint debridement (for knee) or realignment osteotomy (for hip or knee)<br />Late: surgery<br />Indications: unrelieved pain<br />Progressive disability<br />Types:<br />Arthroplasty (op of choice for >60 y/o)<br />Arthrodesis (if stiffness can be tolerated because it will eliminate movement)<br />References: Apley’s Concise System of Orthopaedics & Fractures 3rd edition, page 41, 230 <br />TRUE Pigmented villous nodular synovitis <br />It is a slow-growing, benign and locally invasive tumor which affects synovial lined joints, bursae and tendon sheaths characterized by fibrous stroma, hemosiderin deposition, histiocytic infiltrate and giant cells<br />Villi formed in patients with PVNS can twist, infarct, and form a loose body<br />Location: most often involves the knee (also in hip, ankle, elbow, etc.)<br />always consider PVNS in a younger patient with unexplained hip pain<br />Acute episodic attacks of pain and swelling may occur<br />Patients may have mechanical symptoms (locking and catching)<br />Most have hemorrhagic, dark brown synovial fluid<br />Biopsy is diagnostic<br />Sub-types: it usually presents as a monoarticular hemarthrosis, and may exist in a nodular or a diffuse form<br /> diffuse form: <br />disease may be active or inactive<br />look for peri-articular erosions on radiographs<br />diffuse mass may be present on exam<br />nodular form:<br />less common than the diffuse form of the disease<br />does not show the same destructive changes as the diffuse form of PVNS<br />may cause recurrent hemarthrosis and aspirate may be of normal color (may not show classic brown color)<br />Rx: <br />arthroscopic synovectomy<br />may be indicated for nodular form or for inactive form of diffuse disease<br />open synovectomy<br />treatment of choice for patients w/ active form of diffuse disease <br />References:http://books.google.com.my/books?id=TbxYM_Ts-3YC&pg=PA83&lpg=PA83&dq=pigmented+villous+nodular+synovitis&source=bl&ots=K_wx0nyZee&sig=Nigi-lNiUyefw39vAaUjDPHHEM0&hl=en&ei=DVqLTeCfOovMrQeBlMTNDg&sa=X&oi=book_result&ct=result&resnum=10&ved=0CGAQ6AEwCQ#v=onepage&q=pigmented%20villous%20nodular%20synovitis&f=false, http://www.wheelessonline.com/ortho/pigmented_villonodular_synovitis<br />TRUE Osteochondral fracture (injury)<br />An osteochondral fracture is a type of fracture in which the articular cartilage at the end of a joint becomes torn<br />These fractures are most commonly seen in the knee and ankle joints, as these joints take a lot of strain and bear a lot of weight, which make them vulnerable to damage<br />When an osteochondral fracture occurs, it is common for there to be fragments of bone and cartilage inside the joint. Sometimes they remain attached to the joint, in which case they are known as stable, while in other instances, they are unstable, floating around inside the joint. <br />These fragments are a cause of concern because they can grind at the joint, causing additional damage in addition to making the joint rather painful<br />References: http://www.wisegeek.com/what-is-an-osteochondral-fracture.htm, Apley’s Concise System of Orthopaedics & Fractures 3rd edition, page 23<br />The features that should trigger more active investigation of TB of the joint<br /><ul><li>A long history of joint swelling T
  133. 133. Involvement of multiple joint T
  134. 134. Marked synovial thickening T
  135. 135. Periarticular osteoporosis T
  136. 136. Marked muscle swelling F</li></ul>TB can affect the vertebra and large synovial joints<br />Features of TB of the joint include pain, muscle wasting, synovial thickening, limited movement, stiffness, deformity. In late cases there may be a sinus<br />Diagnosis of TB of the joint may not be suspected in areas where TB is not endemic because in many respects it resembles rheumatoid arthritis<br />Features that are suggestive of TB of the joint and which calls for more active investigations include:<br />Long history<br />Involvement of only 1 joint<br />Marked synovial thickening<br />Marked muscle wasting<br />Periarticular osteoporosis on x-ray<br />ESR is usually raised and Mantoux test is +ve<br />Synovial biopsy for histological examination and culture often necessary <br />Reference: Apley’s Concise System of Orthopaedics & Fractures 3rd edition, page 25<br />True<br />Involvement of multiple joints<br />TB of the joint is a chronic monoarthritis affecting a large joint, usually the hip or knee<br />False<br />Marked synovial thickening<br />True<br />Periarticular osteoporosis on x-ray<br />True<br />Marked muscle swelling <br />Marked muscle wasting is characteristic in joint TB<br />False<br />Factors/aetiology of DDD<br /><ul><li>Obesity T
  137. 137. Genetic and hereditary T
  138. 138. Frequent cracking the knuckles of finger F
  139. 139. DM T
  140. 140. Gout F</li></ul>Regarding DDD:<br />Degenerative disc disease is not really a disease but a term used to describe the normal aging changes in spinal discs <br />The discs act as shock absorbers for the spine, allowing it to flex, bend, and twist<br />Degenerative disc disease can take place throughout the spine, but it most often occurs in the discs in the lower back (lumbar region) and the neck (cervical region)<br />The changes in the discs can result in back or neck pain as well as:<br />Osteoarthritis<br />Herniated disc <br />Spinal stenosis <br />These conditions may put pressure on the spinal cord and nerves, leading to pain and possibly affecting nerve function<br />As we age, our spinal discs break down, or degenerate, which may result in degenerative disc disease in some people. These age-related changes include:<br />Dehydration of discs due to reduced water attracting molecules. This reduces the ability of the discs to act as shock absorbers and makes them less flexible. Loss of fluid also makes the disc thinner and narrows the distance between the vertebrae<br />Tiny tears or cracks in the outer layer (annulus fibrosus) of the disc due to changes in collagen structure. The jellylike material inside the disc (nucleus pulposus) may be forced out through the tears or cracks in the capsule, which causes the disc to bulge, rupture, or break into fragments<br />These changes are more likely to occur in people who:<br />smoke cigarettes because it will reduce the amount of water in discs <br />do heavy physical work (such as repeated heavy lifting)<br />people who are obese<br />genetics – some people may inherit a prematurely aging spine<br />An acute injury leading to a herniated disc (such as a fall) may also begin the degeneration process<br />As the space between the vertebrae gets smaller, there is less padding between them, and the spine becomes less stable and more mobile<br />The body reacts to this by constructing bone spurs (osteophytes) to reduce the hypermobility<br />Osteophytes can put pressure on the spinal nerve roots or spinal cord, resulting in pain and affecting nerve function<br />The pain often gets worse with movements such as bending over, reaching up, or twisting (mechanical)<br />Diagnosis is mainly clinical, but radiography (AP and lateral taken) may show signs of degeneration such as loss of disk height, sclerosis of the endplates, or osteophytic ridging In addition, spondylolisthesis can be diagnosed and the degree of slippage visualized easily on lateral images. Oblique views may be helpful is spondylolysis is suggested. CT and MRI may be more specific<br />Rx: (for prolapse/herniation)<br />Conservative: pain relief, exercise<br />Definitive: 4 R’s<br />rest<br />reduction<br />removal <br />lumbar: operative discectomy. Indications:<br />cauda equina compression syndrome<br />persistent pain and severely limited straight leg raising after 2 weeks conservative Rx<br />neurological deterioration<br />frequently recurring attacks<br />cervical: operative anterior disc removal and fusion, rarely indicated<br />rehabilitate<br />References:http://www.webmd.com/back-pain/tc/degenerative-disc-disease-topic-overview, http://www.spineuniverse.com/conditions/degenerative-disc/what-degenerative-disc-disease, Apley’s Concise System of Orthopaedics & Fractures 3rd edt, page 182-183, 195-197<br />True<br />Obesity <br />True<br />FALSE <br />Frequent cracking the knuckles of finger <br />Unrelated to the intervertebral discs<br />True<br />Diabetes mellitus<br />There may be an association between diabetes mellitus and development of DDD according to a study done by Anekstein et al, although the percentage is not high<br />Reference: http://www.ncbi.nlm.nih.gov/pubmed/20450123<br />False<br />Gout <br />Gout usually affects the large joint of the big toe, but can also affect other joints, such as the knee, ankle, foot, hand, wrist and elbow<br />In rare cases, it may later affect the shoulders, hips or spine. Gout does not spread from joint to joint<br />Although gout can affect the spine, there is no evidence to say that it can lead to DDD<br />References: http://www.healthcentral.com/osteoarthritis/h/can-gout-affect-in-your-arms-hand-over-shoulders-and-back.html<br />Regarding amputation<br /><ul><li>Diabetic gangrene of the foot require amputation at the distal tibia F
  141. 141. Below knee amputation ,weight is taken on the stump F
  142. 142. Above knee amputation,weight is taken on the ischial tuberosity T
  143. 143. Elderly patient refuse to use above knee prostheses because of the high energy requirement T
  144. 144. Pain due to neuroma formation is a complication T</li></ul>Indications for amputation 3D’s<br />Dead eg in PVD (most common – 90%)<br />Dangerous eg in malignant tumors, lethal sepsis, crush injuries<br />Damned nuisance eg pain, gross malformations, recurrent sepsis or severe loss of function<br />Reference: Apley’s Concise System of Orthopaedics & Fractures 3rd edition, page 131-134<br />False<br />Diabetic gangrene of the foot require amputation at the distal tibia <br />For diabetic gangrene there are 2 types of amputations: minor and major<br />Minor (partial foot) amputations: eg Ray amputation where a toe and part of the corresponding metatarsal bone is removed and the wound is usually left open to heal, or transmetatarsal amputation <br />Rarely major (wholefoot) amputations: eg Syme’s which is through-ankle amputation<br />FALSE In below knee amputation, weight is taken on the stump<br />The patient who underwent below the knee amputation usually uses the knee for weight bearing rather than step on the stump when moving from place to place without wearing the prosthesis<br />Stepping on the stump may induce pain and pressure wound can develop on the skin that covers the bone<br />Protrusion of the bone through the skin is a very serious complication<br />It is thus obvious that an amputee could not transfer the body weight on the bottom of the stump <br />Reference: http://www.freepatentsonline.com/4778470.html<br />Weightbearing areas of amputations:<br />Transmetatarsal, Syme’s and knee disarticulation all bear weight on the stump<br />Below knee amputations bear weight on the patella tendon, the lateral part of the lower limb. There should be no pressure on the fibula head, tibial plate, hamstrings or end of stump as this can lead to severe pressure sores<br />Reference: http://www.rehabsa.co.za/content/articles/Amputation.pdf<br />True<br />In above knee amputation, weight is taken on the ischial tuberosity <br />The above knee amputee will support their body weight on the ischial tuberosity (seat bone), with the soft tissue of the residual limb bearing only a minimal amount of weight<br />Reference: http://www.brownfieldstech.com/above_knee.asp<br />True <br />Elderly patients refuse to use above knee prostheses because of the high energy requirement <br />As the amputation level rises so does the energy expenditure necessary to walk<br />Individuals with amputations of the distal third of the foot (transmetatarsal level) often achieve near normal mobility with the aid of a custom insole<br />A below knee amputation (BKA) requires a 25 percent increase in energy expenditure to ambulate (walk)<br />Walking with an above knee amputation (AKA) requires 65 percent more energy than the normal state<br />Reference: http://www.reversegangrene.com/A.htm<br />True<br />Pain due to neuroma formation is a complication <br />Complications of amputation<br />Early:<br />breakdown of skin flaps - due to ischemia or suturing under excessive tension or an unduly long tibia pressing against the flap <br />gas gangrene – due to clostridia and spores from perineum in high above knee amputation<br />Late:<br />skin <br />eczema or tender purulent lumps in the groin<br />ulceration – due to poor circulation<br />muscle - instability if too much muscle at end stump<br />artery - cold, blue stump due to poor circulation which is liable to ulcerate<br />nerve - a cut nerve always forms a tiny ‘neuroma’ which is occasionally painful<br />phantom limb<br /><ul><li>Reference: Apley’s Concise System of Orthopaedics & Fractures 3rd edition, page 131-134</li></ul>Reference for question 21-24:Apley’s concise system pg116-117<br />Median nerve injury<br />Low lesions may be caused by cuts in front of the wrist or by carpal dislocations - t<br />The is thenar eminence wasted - t<br />Thumb abduction and opposition are weak - t<br />Sensory is lost over the one and a half fingers - f<br />Trophic changes may be seen - t<br />Anatomy <br />Forearm <br />Superficial flexor <br />Pronator teres<br />Flexor caopi radialis <br />Palmaris longus <br />Flexor carpi ulnaris<br />Intermediate flexor <br />Flexor digitorus superficialis <br />Deep flexor <br />Supply by AIN (ant. interossious.n)Flexor degitorum profundus <br />Flexor pollicis longus<br />Pronator quadrate<br />Sensory: NONE <br />Hands <br />Thenar.m (consist of: abductor pollicis, flexor digiti minimi, opponens digiti minimi digiti minimi stand for little finger and it fn base on it name) and part of intrinsic.m- lat 2 of lumbrical.<br />Sensory: thumb, index, middle and half of ring finger. – specific point at the tip of index finger<br />Low lesion <br />Cause: cut at the wrist, carpal bone dislocation<br />Effect: wasting of the thenar area <br />Weak thumb abduction and opposition <br />Loss of sensation over the lateral 3 and half of the finger at palmar surface <br />Trophic change <br />High lesion <br />Cause: elbow dislocation and frac at the forearm <br />Effect: pts unable to flex the thumb, index and middle finger when we ask the pts to genggam <br />jari pointing index sign- bcoz lateral aspect of flexor digitorum profundus is supply by <br />the median.n. it fn is to flex thumb, index and middle finger. <br />In high lesion (lesion at the elbow) flexor digitorum profundus is also be affected <br />there is absent of flexion of the thumb, index and middle finger causing appearance of <br />pointing index sign<br />+ Loss of motor and sensory, same like low lesion<br />Axillary nerve injury<br />Can be caused by fracture of neck of femur - f<br />pts able to abduct his arm at 30 degrees – f - <br />Associated with small patch of numbness over deltoid area - t<br />Unable to abduct the shoulder - t<br />Can only be treated through surgical intervention - f<br />Anatomy: it supply deltoid abduction of the arm (deep branch)<br />Teres minor external rotation (superficial branch)<br />Sensory: lat upper arm at the regimental badge area<br />Cause: shoulder dislocation, frac of neck of humerus <br />Effect: unable to abduct the arm from 15-90 degree.<br />Flat shoulder<br />loss of sensation at regimental batch (5 finger breath from the tip of acromion)<br />Tx: recover spontaneously<br />But if after 8wks still not recover >> explore and nerve grafting <br />If fail >> tendon transfer<br />Radial nerve injury<br />Low lesions are usually due to fracture or dislocations at the elbow - t<br />Patient can extend the MCP joint in low lesion - f<br />very high lesions occur due to fracture of humerus - f<br />In high lesion, wrist drop is common manifestation - t<br />Small patch of sensory loss on the back of the hand at the base of the thumb can be seen in low lesion - f<br />Anatomy : radial.n supplies the whole extensor muscle of the upper limb. From top it runs through the triangular interval with deep artery of the arm and passing through the spiral groove (radial grove) of humerus. Then it divide at the elbow into 1. PIN (post interossious.n)-purely motor. This nerve runs through the supinator.m. 2. Sup. Radial.n- sensory, to the dorsal lat. 3 and half finger.<br />Arm <br />Motor: triceps extend the elbow <br />Anconeous<br />Sensory: lat arm (via inferior lat cutaneous.n)<br />Post arm (via post cutaneous.n)<br />Forearm <br />Motor – mobile WAD<br />Supply by radial.n- mainly for wrist extension Brachioradialis<br />Extensor carpi radialis longus <br />Extensor carpi radialis brevis <br />Superficial extensor <br />Extensor carpi ulnaris <br />Extensor digiti minimi<br />Extensor digitorum<br />Supply by PIN- mainly for finger extension <br />Deep extensor<br />Supinator <br />Abductor pollicis longus <br />Extensor pollicis longus<br />Extensor pollicis brevis <br />Extensor indicis<br />Sensory: post forearm<br />Hands<br />Motor: NONE<br />Sensory: dorsal lat 3 and half finger (via superficial radial.n) – specific point at the 1st finger web<br />Low lesion:<br />Cause: frac or dislocation at elbow, open wound frac of the arm <br />Effect: unable to extend MCPJ finger drop bcoz only the PIN is affected <br />Sensory is still intact <br />High lesion:<br />Cause: frac of humerus or pressure (Saturday night palsy)<br />Effect: unable to extend the wrist wrist drop bcoz the radial.n is effected. So it involve the <br />mobile WAD wrist extension, superficial and deep extensor finger extension <br />Sensory loss (dorsal aspect of tumb, index, middle finger and half of ring finger)<br />Very high lesion:<br />Cause: pressure (crutch palsy)<br />Effect: unable to extend the elbow bcoz also involve the tricep<br />tricep muscle wasting <br />loss of motor and sensory just like high lesion<br />Ulnar nerve injury<br />Low lesion may be caused by pressure or a laceration at the wrist - t<br />Claw hand present in the low lesion - t<br />High lesions occur with elbow fractures - t<br />Sensation is loss over the ulnar medial one and a half fingers in low lesion - t<br />Patient is difficult to make full grip and pinch - t<br />Anatomy - ulnar nerve supply the hypothenar muscle (consist of: abductor digiti minimi, flexor digiti minimi, opponens digiti minimi digiti minimi stand for little finger and it fn base on it name), intrinsic muscle (consist of: dorsal interossie finger abduction, palmar interossei finger abduction, lumbricals fn flex MCP and extend PIP), adductor pollicis adduction of the tumb, flexor pollicis brevis (together with median.n)<br />Ulnar.n sensory supply: little and half of ring finger on palmar and dorsal (specific point-at tip of little finger)<br />Low lesion <br />Cause: pressure or laceration at the wrist<br />Effect: ulnar true clawed hand (hyperextend of MCPJ and flexion of IPJ of little and ring finger)- this is how to differentiate btw low lesion or high lesion <br />Hypothenar muscle wasting <br />Weak finger abduction<br />Loss of thumb adduction difficulty to pinch<br />Loss of sensation of little and half of ring finger, on palmar and dorsal side. <br />High lesion <br />Cause: elbow frac, pressure after lying with the flex elbow and pressing on the bed, cubitus valgus due to malunion <br />Effect: less claw hand (ulnar paradox)- bcoz medial aspect of flexor digitorum profundus is <br />supply by ulnar.n, it fn is to flex little and ring finger.<br />In low lesion (lesion at the wrist) flexor digitorum profundus is not affected as it’s supply by ulnar.n at higher up there is flexion of the little and ring finger causing appearance of claw hand. But there will be minimal claw hand in higher lesion because the flexor digitorum profundus also affected (from drfairudz)<br />+ Loss of motor and sensory, same like in low lesion <br />25Regarding the clubfoot. ACan occur in the association with arthrogryposisTApley’s pg 241. Similar deformities are seen with myelomeningocele and arthrogryposis.( http://emedicine.medscape.com/article/1237077-overview)BFemale is more predominantFBoy : girl = 2:1 (apley’s pg 241)C50% bilateral involvementTThe male-to-female ratio is 2:1. Bilateral involvement is found in 30-50% of cases. There is a 10% chance of a subsequent child being affected if the parents already have a child with a clubfoot. (http://emedicine.medscape.com/article/1237077-overview).The condition is bilateral in one third of cases. (apley’s pg 241).DDeformity described as fixed equines,heel varus,fore foot and mid foot adductionTApley’s pg 241 (first line).ESurgical correction is gold standardFSurgical correction in resistant cases. (Apley’s pg 241). Earliest treatment is by conservatively. Repeat manipulation and adhesive strapping or POP. Surgical releases of Achilles tendon needed to complete correction.<br /><ul><li>26Imaging of osteomyelitisAEarliest changes include minimal periosteal destruction and thickeningFFirst 10 days, no abnormalities , 2nd week rarefaction of metaphysic and periosteal new bone formation. (Apley’s pg 19).BUsefulness of radionuclide scanning limited by an overall lack of specificity and marginal sensitivityFhttp://emedicine.medscape.com/article/785020-diagnosis nie xsure xdapat cari explaination.CMRI can also evaluate extents of infectious problemsFMRI help to distinguish between bone and soft tissue infection. (apley’s pg 19).DCT  scan distinguish between soft tissue and bone infections and aids in biopsy and aspiration siteFMRI is use to distinguish (Apley’s pg 19). Aspiration guided by ultrasound (http://emedicine.medscape.com/article/785020-diagnosis).CT to look for abnormal calcification, ossification and intracorticol abnormalities. Often choose when MRI unavailable (http://emedicine.medscape.com/article/785020-diagnosis).ESclerotic changes and periosteal new bone formation suggest acuteFNie xsure. Sclerotic and cortical thickening seen in chronic (Apley’s pg 20), periosteal new bone formation seen end of second week (acute stage la kan???) (Apley’s pg 19).
  145. 145. 27Achilles tendon ruptureACommon in people > 40 years oldTApley’s pg 250BSimmond’s test positiveThttp://web.jbjs.org.uk/cgi/reprint/74-B/2/314.pdfhttp://www.youtube.com/watch?v=AmDi08rlR3IUsed to test for rupture of tendo achillis. Positive when no movement of plantarflexion when the culf is squeeze or pushed while the patient is prone and the foot is hanging by the side of the bed.CResult in difficult to walk tip-toeTPatient unable to tiptoe. (Apley’s pg 250).DCannot be treat non-operativelyFImmobilization by plaster is still needed with or without surgery and is worn for 8 weeks with the foot in equines. Shoe with raised heel worn for a further 6 weeks. (apley’s pg 250).Lockable brace is a more sophisticated alternative. (apley’s pg 250).ETreatment via surgical reconstruction will result in wound dehiscence asThttp://www.emedicinehealth.com/achilles_tendon_rupture/page7_em.htm#Surgeryhttp://emedicine.medscape.com/article/85024-treatment
  146. 146. 28Adhesive capsulitis (frozen shoulder)ACommonly occurs in patient aged 40-60 years  oldTApley’s pg 147.BIs presented with loss of shoulder movement in all directionsTApley’s pd 147.http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001490/http://www.medicinenet.com/frozen_shoulder/article.htmCIs caused by a trauma to the shoulderTApley’s pg 147. As part of history of the patient.DIs a self limiting diseaseTResolves spontaneously after 18 months. (apley’s pg 147) EIn association with diabetes mellitus would result in poor recoveryT Xjumpa sumber2 yg reliable…..http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001490/ ……diabetes is one of the risk factor, so should treated/controlled first to get proper/faster recovery.</li></ul>Pseudogout<br />Is presented as an acute attack of arthritis which is self limiting T<br />Is due to deposition of monosodium urate crystal F<br />Is demonstrated by positive birefringent in polarized light microscopy T<br />Can result in the formation of tophi F<br />Is shown as chondrocalcinosis on plain x-ray T<br />Patient typicically middle aged women, complaint acute pain and swelling in 1 large joint,usually knee. Untreated condition last for few weeks and then subsides spontaneously. <br />From the reasoning above, the answer for (a) is TRUE<br />(Ref: Apley, 3rd edition 2008, page 39)<br />Calcium pyrophosphate dehydrate deposition occurred at : <br />Chondrocalcinosis<br />Pseudogout<br />Chronic pyrophosphate arthropathy<br />Monosodium urate crystal = gout <br />From the reasoning above, the answer for (b) is FALSE<br />(Ref: Apley, 3rd edition 2008, page 39 and 37)<br />Diagnosis of pseudogout can be confirmed by finding positive birefringent crystals in synovial fluid.<br />(Ref: Apley, 3rd edition 2008, page 40)<br />Polarized light microscopy of synovial fluid shows negative birefringent crystal in gout<br />(Ref: Oxford handbook medicine, 7th edition, page 534)<br />From the reasoning above, the answer for (c) is TRUE<br />During chronic gout, tophi appear around joint, olecranon and pinna ear. It can ulcerate and discharge is chalky material<br />Pseudogout only has pain and swelling of joint.<br />(Ref: Apley, 3rd edition 2008, page 39)<br />From the reasoning above, the answer for (d) is FALSE<br />Xray may show signs of chondrocalcinosis <br />(Ref: Apley, 3rd edition 2008, page 40)<br />From the reasoning above, the answer for (e) is TRUE<br />Trendelenburg’s sign in hip examination results is positive when conducted on patient with:<br />Non-union femoral neck fracture F<br />Poliomyelitis affecting hip abductor muscles T<br />Chronic hip joint dislocation T<br />Fracture of lesser trochanter of the femur F<br />Ankylosed hip F<br />Trendelenburg test used to assess stability. Ask patient to stand by 1 leg, unassisted, lift the other leg by bending the knee.<br />Normal: pelvis rise at the lift leg (hip is stable by abductors muscle)<br />Abnormal: Pelvis drop at the lift leg.<br />Positive: <br />dislocation of hip<br />Weakness abductors muscle<br />Shortening femoral neck<br />painful disorder of hip <br />(Ref: Apley, 3rd edition 2008, page 202)<br />Answer for question A and D was not stated anywhere. I have asked this question to Dr Ramli Baba, he said that, Trendelenburg test cannot be done on fracture patient as they already pain, how they could stand on the affected limb. <br />Fractures:<br />When due to repetitive stress are called pathological fractures F<br />When due to forcible traction by a tendon are referred to as avulsion fractures. T<br />Are classified to as comminuted when there is more than 1 fragment. F<br />Will usually unite even the bone ends lie side by side with fractures surfaces making no contact at all. F<br />In adults when incomplete is referred to as greenstick fractures. F<br />Repetitive stress is called stress fractures<br />Pathological fracture is normal stress acting on abnormal weakened bone <br />(Ref: Apley, 3rd edition 2008, page 266)<br /><ul><li>An avulsion fracture is an injury to the bone in a place where a tendon or ligament attaches to the bone. When an avulsion fracture occurs, the tendon or ligament pulls off a piece of the bone. </li></ul>(Ref: http://orthopedics.about.com/od/brokenbones/a/avulsion.htm)<br />Comminuted fracture is more than 2 fragment, poor interlocking of fragment caused it to be unstable.<br />(Ref: Apley, 3rd edition 2008, page 267)<br />Fracture can never unite if the end surface does not have any contact at all. <br />Cause of non union includes distraction and separation fragment (end surface no contact)<br />(Ref: Apley, 3rd edition 2008, page 270)<br />Greenstick fractures, the bone are bent. Seen in children, whose bone are more springy/pliable compared to adult.<br />Adult usually complete fracture<br />(Ref: Apley, 3rd edition 2008, page 267)<br />Factors associated with non union of fractures include:<br />Fracture angulation T<br />Smoking T<br />Splintage with Plaster of Paris F <br />Interposition of periosteum between the fragments.F<br />Osteoporosis T<br />Fracture caused non union<br />Distraction and separation fragment<br />Interposition soft tissue between fragment<br />Excessive movement<br />Poor blood supply<br />Severe damage soft tissue that makes them non viable<br />Infection-DM<br />Abnormal bone (osteoporosis)<br />Smoking, alcohol (Ref: http://en.wikipedia.org/wiki/Nonunion)<br />Obese <br />(Ref: Apley, 3rd edition 2008, page 270)<br /> http://apps.djoglobal.com/bonestim/patients/fracture.asp)<br />Monteggia fracture - originally it is a fracture of the shaft of the ulnar (A/T, B/F) associated with disruption of the proximal radioulnar joint (D/F) and dislocation of radiocapitellar joint but nowadays it may includes olecranon fracture combined with radial head dislocation (C/T).Aims of treatment is to restore the length of fractured ulnar, only then dislocated joint be fully reduced and remain stable by means of operation with plates and screws in adults (E/T). (The unstable # in Monteggia is actually means by the joint dislocation only can be reduced after the ulnar # has been fixed, so ORIF is a definitive treatment!!!)Source – Apley’s Concise System of Orthopaedics & Fractures, 3rd Edition, Solomon: Warwick: Nayagam (pg 322-323)<br /><ul><li>Compartment Syndrome:
  147. 147. Occur when bleeding or edema increases the pressure in one of the osteofascial compartment beyond systemic blood pressure. F
  148. 148. Is characterized by excruciating pain F
  149. 149. Is a complication of a tight plaster cast T
  150. 150. Is adequately treated by analgesics and elevating the limb. F
  151. 151. Cause little long term disability in untreated condition. F</li></ul>Compartment syndrome is actually due to increase osteofacial compartment pressure that disrupts the capillary blood flow to the compartment and lead to ischemia (A/F ) and not really associate with systemic blood pressure. This process will undergo vicious cycle until 12h where the nerve and the muscle become necrosis. The nerve is capable of regeneration but muscle, once infracted, can never recover and will be replaced by inelastic fibrous tissue leads to Volkmann’s ischemic contracture. Compartment syndrome also can occur in a swelling limb which has been put inside thought plaster cast (C/T).Source – Apley’s Concise System of Orthopaedics & Fractures, 3rd Edition, Solomon: Warwick: Nayagam (pg 322-323)<br />The classical features of ischemia are pain, parasthesia, pallor, paralysis and pulselessness and usually they describe the pain as a ‘bursting’ sensation (B/F).Source – Apley’s Concise System of Orthopaedics & Fractures, 3rd Edition, Solomon: Warwick: Nayagam (pg 322-323)<br />Aim of treatment in compartment syndrome is to relieve the high pressure by means of prompt decompression. Casts, bandages and dressings must be completely removed and the limb should be in flat position because by elevating the limbs will cause a further decrease in end-capillary pressure and aggravates the ischemia(D/T). Open fasciotomy is performed to open the compartment so that the pressure will be reduce. The wound should be left open and inspected 2 days later, if there is muscle necrosis, debridement should be done but if the tissue is healthy, the wound can be sutured, skin-grafted or allowed to heal by secondary intention.Source – Apley’s Concise System of Orthopaedics & Fractures, 3rd Edition, Solomon: Warwick: Nayagam (pg 322-323)<br /><ul><li>Regarding traumatic paraplegia.
  152. 152. Complete paralysis and anaesthesia is a consequence of spinal shock. T
  153. 153. Bladder training is required T
  154. 154. Flexion contracture cannot be avoided. F
  155. 155. Bedsore developed after 2 day. F
  156. 156. Emotional rehabilitation is not vital F</li></ul>Complete transaction of the cord results in either paraplegia/quadrapelgia. Initially there will be complete paralysis and anaesthesia with loss of the anal reflex result from spinal shock (A/T). After 24h, the anal reflex returns and the neurological deficit still persist, we can assume it is complete cord lesion/injury. Gradually, UMN lesion features will appear: spastic paralysis & hypereflexia.Incomplete transaction – partial motor and sensory loss below the level of lesion with signs varies according to the part of cord has been damaged.Cauda equina injury – features of LMN lesion: flaccid paralysis.Source – Apley’s Concise System of Orthopaedics & Fractures, 3rd Edition, Solomon: Warwick: Nayagam (pg 351)<br />Due to loss of nerve innervations to the bladder, it can cause bladder distension, overflow urinary incontinence and infections. To prevent those complications, bladder trained should be initiated as soon as possible for example: intermittent catheterization under sterile/clean condition and continuous closed drainage with disposable bag changed twice a week. In cauda equina injury, local reflex will be lost and there will be no bladder emptying, so the patient needs to empty their own bladder by manual suprapubic pressure method (B/T).Source – Apley’s Concise System of Orthopaedics & Fractures, 3rd Edition, Solomon: Warwick: Nayagam (pg 351-352)<br /><ul><li>In prolonged immobilization, untreated muscle paralysis will cause severe flexion contracture and it is actually preventable by moving the joints (C/F) passively through their full range twice daily.If the lesion is below the cervical cord, standing and walking within 3 months is important to prevent contracture. Calipers usually needed to keep the knees straight and the feet plantigrade. The upper limbs must be trained until they develop sufficient power to enable the patient to use crutches and a wheelchair.If flexion contracture still or are allow to develop; tenotomies, neurectomies, rhizotomies or intrathecal injection of alcohol are the possible solution.
  157. 157. Source – Apley’s Concise System of Orthopaedics & Fractures,
  158. 158. 3rd Edition, Solomon: Warwick: Nayagam (pg 351)</li></ul>Bedsores or pressure sores may develop just within a few hours of immobilize patient (D/F) especially who had spinal injury due to anaesthetic skin. Initially, meticulous nursing of the skin is important to prevent pressure sores usually by gentle rolling onto the patient side and the back is carefully washed, dried and powdered for every 2 hours. After a few weeks, the patient may turn in bed by their ownself to relieve skin pressure intermittently guided by proper education from the healthcare staffs.Source – Apley’s Concise System of Orthopaedics & Fractures, 3rd Edition, Solomon: Warwick: Nayagam (pg 351)<br />The morale of paraplegic patient is a liable to reach low ebb or depression and to restore the patient self-confidence is an important part of treatment. The earlier the patients get up the better the prognosis, and they must be trained for a new job as quickly as possible to improve their quality of life. (E/F)Source – Apley’s Concise System of Orthopaedics & Fractures, 3rd Edition, Solomon: Warwick: Nayagam (pg 352)<br /><ul><li>Neck of femur fracture
  159. 159. Avascular necrosis is late complication F
  160. 160. Occur commonly in older men T
  161. 161. Occur commonly in osteoporotic T
  162. 162. Surgery is not indicated if displaced fracture F
  163. 163. Garden type II is complete with minimal displacement. F
  164. 164. Garden’s Classification of femoral neck fractures</li></ul>Grade I is an incomplete or valgus impacted fracture.Grade II is a complete fracture without bone displacement. (E/F)Grade III is a complete fracture with partial/minimal/moderate displacement of the fracture fragments.Grade IV is a complete fracture with total displacement of the fracture fragments. <br />Source – Apley’s Concise System of Orthopaedics & Fractures, <br /><ul><li>3rd Edition, Solomon: Warwick: Nayagam (pg 362-363)http://emedicine.medscape.com/article/86659-overview</li></ul>Operative treatment is almost mandatory because in displaced fracture, union will not be occur without internal fixation (D/F) and it is important for elderly to mobilize and be active without delay to prevent pulmonary complications and pressure sores. Eventhough incomplete impacted fracture can be left to unite, internal fixation is always useful as there is always a risk to become displaced even while lying on bed.Source – Apley’s Concise System of Orthopaedics & Fractures, 3rd Edition, Solomon: Warwick: Nayagam (pg 363)<br />Avascular necrosis is really an early complication of bone injury because ischemia occurs during the first few hours following fracture or dislocation. Especially at the head of femur following femoral neck fracture (A/F) and hip dislocation, proximal part of scaphoid, the lunate following dislocation and body of talus after its neck fracture. (in chapter 6 apleys it is actually classified under late complication! Hmmm…..)In femoral head necrosis, 30% of patients will develop following displaced fractures and 10% following undisplaced fractures. It is because when there is fracture at the neck of the femur, the branches from the nutrient artery are severed, the retinacular vessels from the capsule are torn and the remaining blood supply from ligamentum teres may be insufficient to prevent ischemia of the femoral head. All of those disruptions will lead to bone dies and eventually collapse.Source – Apley’s Concise System of Orthopaedics & Fractures, 3rd Edition, Solomon: Warwick: Nayagam (pg 299 & 365)<br />37<br />AFMedial meniscus injury is more common than lateral meniscus injury with the ratio of 3:1 (Netter’s concise orthopedic anatomy, 2nd edition, page 328)BTThere usually bleeding & swelling into the tissue surrounding the knee in collateral ligament tear. The tear may also caused bleeding into the joint itself. http://www.orthogate.org/patient-education/knee/collateral-ligament-injuries.htmlCFThe plan for surgical or non-surgical of ACL tear depends on age, skeletal maturity, xtvt/skill level, a/w meniscal & ligamentous injury, frequency of instability, pts compliance & motivation. If there is an isolated tear of ACL, treat it by early op reconstruction if the individual is a professional sportsman. But in all other cases, it is more prudent to follow the conservative management. But if there is combined ACL & collateral ligament injury, start the treatment with joint bracing & physiotherapy to restore good ROM then followed by ACL reonstruction.Usually the surgical management is delayed 4-6 weeks after the injury because early surgery will cause arthrofibrosis(Apley, 3rd edition, page 375&376; seminar sport injury dr faisal)DFSwelling in cruciate ligament tear appears almost immediately compare to swelling in meniscus injury. The swelling in meniscus injury appears some hours later or perhaps the following day. (Apley, 3rd edition, page 227&374)ETPosterior tibial sagging sign can be detect laterally by putting the patient in supine with the knee and hip in 90˚ flexion. The gravity will pulls the tibia posteriorly. In the case of PCL tear, the tibial falls even or behind the femoral condyle. Compare with the opposite knee.http://emedicine.medscape.com/article/90514-overview<br /> 38<br />AFOsteosarcoma has bimodal age distribution. 1st peak is during adolescent, coinciding with the pubertal growth spurt. 2nd peak is in adults >65 years of age and it is more likely represent a secondary malignancy (Paget’s disease) (Pediatric and adolescent osteosarcoma by Norman Jaffe, Oyvind S.Bruland, page 3)Osteosarcoma most commonly found in children and adolescent (Apley 3rd edition, page 91) (10-20 years)BFMost commonly it affects the long bones metaphysic especially around the knee, proximal end of humerus (Apley 3rd edition, page 91)CFThe incidence of osteosarcoma higher in boys than in girls (Pediatric and adolescent osteosarcoma by Norman Jaffe, Oyvind S.Bruland, page 3).DTOsteosarcoma is a primary bone cancer, means the cancer originates in the bone itself (http://www.boneandcancerfoundation.org/pdfs/Osteosarcoma-2.pdf)EFSpreading to regional lymph nodes is almost never occur. This probably due to the poor lymphatic supply to the bone and most important the tumor is so vascular therefore hematogenous spread is more common.Hematogenous spread Pulmonary metastasis (Most common & occur early (10%))Direct spread to the surrounding soft tissues & along the medullary cavity of a long bonehttp://www.medic.usm.my/~pathology/bonepath/bonepath/Osteosarcoma.html<br /> 39<br />AFNeurapraxia is a REVERSIBLE block to the nerve conduction which there is loss of sensory/motor power. After few days or weeks, there will be spontaneous recovery of neurapraxia. The nerve is intact but mechanical pressure caused demyelination of axons in a limited segments (Apley, 3rd edition, page 110)BTNeurotmesis is complete disruption of the nerve, such as may occur in an open wound. There are disruption of epineurium, perineurium, endoneurium, myelin sheath and axon. (Involved all nerve layers) (Netter’s concise orthopaedic anatomy, 2nd edition, page 22)It will never recover without surgical intervention, poor prognosis (Apley, 3rd edition, page111)CFIn axonetmesis, there is loss of conduction but the nerve is still in continuity and the neural tubes intact (epineurium layer still intact). Axonal regeneration will occur within hours of nerve damage. (Apley, 3rd edition, page 111 & Netter’s concise orthopedic anatomy, 2nd edition, page22)DTAxonal regeneration starts within hours of nerve damage. The new axonal processes grow at a speed of 1-2mm per day (Apley, 3rd edition, page 111)ETAxonotmesis usually seen after closed fracture and dislocations (Apley, 3rd edition, page 110)<br />40<br />ATGout is more widespread in men than in women (ratio 20:1),usually men at the age of >30 years, rarely seen in female before the menopause (Apley 3rd edition, chapter 4, page 37&38)BFMyeloproliferative disease is classified into secondary gout which comprises only 5% causes of gout (others 2ndary gout due to administration of diuretics or renal failure). The 95% is due to primary gout where there is absence of any obvious cause and may be due to constitutional under-excretion or over-production of urate (Apley 3rd edition, chapter 4, page 38)CFGOUT- Examination of aspirated joint fluid under polarizing microscope shows needle-shape, negative birefringent monosodium urate crystalsPSEUDOGOUT – examination of aspirated joint fluid under polarizing microscope shows rhomboid shape (rectangular), positive birefringent calcium pyrophosphate crystals(Family medicine By David R. Rudy, page 162)Birefringent definition= the quality of transmitting light unequally in different directions (Dorland’s medical dictionary).Birefringent (double refraction, pembiasan berganda) = there is decomposition of a ray of light into two ray after pass through the anistropic materials (e.g: calcium pyrophosphate crystal)( http://en.wikipedia.org/wiki/Birefringence)DTGout can be confused with septic arthritis in an acute attack because they have similar presentation, acute onset of hot severe joint pain, extremely tender, fever, chills, and malaise. (Apley 3rd edition, page 22&38)Take careful history taking to identify the risk factors of septic arthritis (exposure to gonorrhea, recent puncture wound over the joint, systemic signs of disseminated infection) and gout (hyperlipidemia, hypertension, hyperTG, kidney failure, obese, insulin resistance, alcohol intake). (http://emedicine.medscape.com/article/808628-overview)Gout also occasionally can co-exist with septic arthritis. The details differences of joint fluid characteristics between gout and septic arthritis, refer CPG, management of gout, October 2008, MOH; page 17EFAcute gout: NSAIDs- rapidly effective in relieving pain & reducing inflammation. E.g: diclofenac, indomethacin & ketoprofen. Avoid aspirin (causes urate retention unless given in very high doses). Caution in pts that having hx of peptic ulcer disease, HPT, renal impairment & cardiac failureOther 1st line agents: steroid and low-dose colchicines.Colchicine is an alternative drug for those whom NSAID & COX-2 inhibitors are contraindicated. Colchicines acts as an anti-inflammatory drugs. Use with low doses because of its side effects such as nausea, vomiting, abdominal pain & profuse diarrhea Allopurinol used as a prophylaxis of gout when hyperuricemia. Because the allopurinol is xanthine oxidase inhibitor prevent production of uric acid.Allopurinol cannot be used in acute attack because it may precipitate or worsen an acute attack of gout. It should be initiated only with concurrent use of colchicines or NSAIDs. (Apley, 3rd edition, page 39; Family practice examination and board review by Mark Graber, Jason K.Wilbur, page382)Other uricosuric agents: probenecid or sulphinpyrazone can be used if renal function is normalCPG, Management of gout October 2008 <br />Rheumatoid arthritis<br />ESR increase T<br />Investigation for RA : <br />in active phase the erythrocyte sedimentation rate (ESR) is raised and C- reactive protein is present. <br />serological test for rheumatoid factor are positive in 80% of ptnt; sometimes antinuclear factors also are present.<br />( appley’s , p-28, para- investigations ) <br />Positive rheumatoid factors makes diagnosis certain F<br />Minimal criteria for diagnosing RA : <br />Bilateral , symmetrical poluarthritis<br />Involving the proximal joint of the hands or feet<br />Present for at least 6 weeks. <br />In addition, there are subcutaneous nodules or periarticular erosion on x ray, the diagnosis is certain. <br />A positive test for rheumatoid factor in the absence of the above features is not sufficient to diagnose rheumatoid arthritis, nor does a negative test exclude the diagnosis if all the other features are present. <br />(appley’s , p-28 , para- diagnosis )<br />Periarticular erosions on xrays are characteristic<br />Explanation as above<br />Diseases show relentless progression in majority of cases T<br />In 80% follows periodic course, with intermittent “flares “ during which sx and signs are more severe. With time these attacks occur less frequently and the disease may become almost quiescent; by then, joint are often permanently damaged. <br />In 5% of cases there is relentless progression of the disease, with increasing inflammatory activity, joint destruction, muscle wasting and visceral involvement.<br />In 10%( usually men over 55yr sx starts explosively but, rather paradoxically, the condition tends to subside and follows a relatively mild course) <br />(appley’s , p-29, para – course)<br />Splintage of inflamed joint is contraindicated as it causes stiffness. F<br />physiotherapy is still important- one of the oldest methods of treating inflammation. <br />during acute flare up, the pntn may benefit from a few weeks’s rest; gentle active and passive exercise are kept up and care should be taken to prevent postural deformities.<br />Sometimes a week or two of continuous splintage ( for the wrist or knees) is all that needed; night splints can be used intermittently at any stage of the disease. <br />( appley’s , p- 30 , para – 5)<br />Traumatic posterior dislocation of the hip joint<br />Occur following a dashboard injury T<br />post dislocation usually occurs in road traffic accident when someone seated in a truck or car is thrown forwarrrds, striking the knee against the dashboard. <br />The femur is thrust upwards and the femoral head is forced out of its socket; often a piece of bone at the back of the acetabulum is sheared off ( frrracture dislocation)<br />(appley’s , p- 361, para – posterior dislocation ) <br />Cause the hip to be positioned into externally rotated and flexed F<br />in a straightforward case the diagnosis is easy: the leg is short and lies adducted, internally rotated and slightly flexed<br />(appley’s , p-361, para – special features )<br />Will result in avascular necrosis of the femoral head as its late complication   T<br />Complication of post dislocation of the hip : <br />Sciatic nerve injury <br />damaged in 10-20% of injury<br />usually recovers, recovery often takes months and in meantime limb must be protected form injury and ankle splinted to overcome foot -drop<br />avascular necrosis <br />blood supply of femoral head is seriuously impaired<br />if there is a small necrotic segment, realignment osteotomy is method of choice.<br />Younger ptnt, choice is between femoral head replacement or hip arthrodesis <br />Ptnt >50 yrs – thp is better. <br />Osteoarthritis <br />Secondary OA is not uncommon and is due to:<br />cartilage damage at the time of the dislocation <br />the presence of retained fragments in the joint (3)ischemic necrosis of the femoral head. <br />(appley’s , p- 361, para – complication ) <br />Will be associated with femoral nerve injury F<br />explanation as above<br />Require an urgent open reduction F<br />the dislocation must be reduced under general anesthesia. <br />an assistant steadies the pelvis; the surgeon flexes the ptnt’s hip and knee to 90◦ and pulls the thigh vertically upwards. <br />x rays essential to confirm reduction and to exclude fractures. <br />if it is suspected that bone fragment have been trapped in the joint, CT is needed. <br />(appley’s , p- 361 , para – treatment )<br />In acute hematogenous osteomyelitis:<br />Adults are more commonly affected than children F<br />acute OM almost invariably occurs in children; when adults are affected it may be because of compromised host resistance due to debilitation, disease or drugs ( e.g. immunosuppressive therapy) <br />(appley’s , p- 17 )<br />Can result in septic arthritis if occur in young children T<br />Complication of OM : <br />spread – infx may spread to joint ( septic arthritis) or to other bones ( mets OM)<br />growth disturbance – if the physis is damaged, there may later be shortening or deformity.<br />Persistent infx – may result in chronic OM<br />(appley’s p-19, para – complications)<br />Plain x-rays changes are evident within 1 week T<br />for the first 10 days, x rays shows no abnormality. However, radioisotope scans may show increased activity( non specific sign of acute inflammation)<br />by the end of the second week there may be early radiographic signd of rarefaction of the metaphysic and periosteal new bone formation. <br />later still, if treatment is delayed bone may appear increasingly ragged.<br />with healing there is sclerosis and thickening of the cortex. <br />(appley’s, p- 19, para – imaging ) <br />C-reactive protein will be positive T<br /><ul><li>Laboratory Studies - The following studies are indicated in patients with osteomyelitis:
  165. 165. CBC count: The WBC count may be elevated, but it is frequently normal.</li></ul>A leftward shift is common with increased polymorphonuclear leukocyte counts.<br />The C-reactive protein level is usually elevated and nonspecific; this study may be more useful than the erythrocyte sedimentation rate (ESR) because it reveals elevation earlier.<br />The ESR is usually elevated (90%); however, this finding is clinically nonspecific.<br />CRP and ESR have limited roles in the setting of chronic osteomyelitis and are often normal<br />Culture: Superficial wound or sinus tract cultures often do not correlate with the bacteria that is causing osteomyelitis and have limited use. Blood culture results are positive in approximately 50% of patients with hematogenous osteomyelitis. However, a positive blood culture may preclude the need for further invasive procedures to isolate the organism. Bone cultures from biopsy or aspiration have a diagnostic yield of approximately 77% across all studies.<br />(http://emedicine.medscape.com/article/785020-treatment)<br />Emphirical antibiotic is given without knowing the causative organism T<br /><ul><li>Treatment for osteomyelitis involves the following:
  166. 166. Initiation of intravenous antibiotics that penetrate bone and joint cavities
  167. 167. Referral of the patient to an orthopedist or general surgeon
  168. 168. Possible medical infectious disease consultation
  169. 169. Select the appropriate antibiotics using direct culture results in samples from the infected site, whenever possible.
  170. 170. Empiric therapy is often initiated on the basis of the patient's age and the clinical presentation.
  171. 171. Empiric therapy should always include coverage for S aureus and consideration of CA-MRSA.
  172. 172. Further surgical management may involve removal of the nidus of infection, implantation of antibiotic beads or pumps, hyperbaric oxygen therapy, HYPERLINK "javascript:showcontent('active','references');" 11,12 or other modalities.</li></ul>(http://emedicine.medscape.com/article/785020-treatment)<br />The axillary nerve injury<br />The axillary nerve supplies three muscles; deltoid (a muscle of the shoulder), teres minor (one of the rotator cuff muscles) and the long head of the triceps brachii (an elbow extensor).[1]<br />The axillary nerve also carries sensory information from the shoulder joint, as well as the skin covering the inferior region of the deltoid muscle - the "regimental badge" area (which is innervated by the Superior Lateral Cutaneous Nerve branch of the Axillary nerve).<br />When the axillary nerve splits off from the posterior cord, the continuation of the cord is the radial nerve.<br />(http://en.wikipedia.org/wiki/Axillary_nerve)<br />associated with fracture of the humeral head T??<br />The axillary nerve may be injured in anterior-inferior dislocations of the shoulder joint, compression of the axilla with a crutch or fracture of the surgical neck of the humerus<br />(http://en.wikipedia.org/wiki/Axillary_nerve)<br />Is a complication following traumatic shoulder dislocation T<br />traumatic shoulder dislocation is common; humeral head displacement is usually anterior, less often posterior <br />compliacation of dislocation of the shoulder is nerve injury whereby the axillary nerve maybe injured. <br />( appley’s, p- 306, para – dislocation of shoulder and nerve injury ) <br />Results in weakness in shoulder abduction T<br /><ul><li>The axillary nerve may be injured in anterior-inferior dislocations of the shoulder joint, compression of the axilla with a crutch or fracture of the surgical neck of the humerus. Injury to the nerve results in:
  173. 173. Paralysis of the teres minor muscle and deltoid muscle , resulting in loss of abduction of arm (from 15-90 degrees), weak flexion, extension, and rotation of shoulder. Paralysis of deltoid & teres minor results in Flat shoulder deformity.
  174. 174. Loss of sensation in the skin over a small part of the lateral upper arm.</li></ul>(http://en.wikipedia.org/wiki/Axillary_nerve)<br />Results in numbness over the proximal forearm F<br />the patient is unable to contract the deltoid muscle and there maybe a small patch of anesthesia over the muscle( regimental batch) <br />(appley’s , p- 306 , para – nerve injury )<br />Occur following a closed injury is often neupraxia T<br />the lesion is usually a neurapraxia , which recovers spontaneously after a few weeks <br />( appley’s, p- 306, para- nerve injury )<br /><ul><li>Prognostic features for Perthes disease in a child is based on:
  175. 175. Age T
  176. 176. = following the age, if the onset of the Perthes’ disease under the age of 6, it is favorable prognostic sign where they need no active treatment and have to be put under follow up. While, if the onset >6 years old, it is unfavorable sign (poor prognosis) and they need treatment by containment of the femoral head. (‘containment’= keeping the femoral head well seated within the acetabulum)
  177. 177. (ref: Apley’s Concise System of Orthopaedics and Fractures)
  178. 178. Sex T
  179. 179. = Perthes’ disease affects boys four times more frequently than girls. (M: F=4:1).
  180. 180. (ref: Apley’s Concise System of Orthopaedics and Fractures)
  181. 181. Degree of the head involvement T
  182. 182. = involvement of femoral head also one of the prognostic feature in Perthes disease which we can follow Herring classification. Herring classification is recommended as one of the prognostic grading system, based on the severity of structural disintegration of the lateral pillar of the femoral epiphysis apart from Salter-Thomson and Catterall staging. It compares the height of lateral epiphyseal pillar to the height of the contra-lateral epiphysis. (Group A: there is no collapse of the lateral pillar and there is little density changes; Group B: lateral pillar margins has >50% of original height; Group C: collapse of lateral pillar >50 %.). If only partial involvement of the femoral head, it give good prognosis.</li></ul>Catterall classification is based on radiographic appearances and specifies 4 groups during the period of greatest bone loss. Catterall staging is as follows:<br />Stage I — Histologic and clinical diagnosis without radiographic findings<br />Stage II — Sclerosis with or without cystic changes with preservation of the contour and surface of femoral head<br />Stage III — Loss of structural integrity of the femoral head<br />Stage IV — Loss of structural integrity of the acetabulum in addition<br /><ul><li>The Salter-Thomson classification simplifies the Catterall classifications by reducing the groups to 2. The first, called group A, includes Catterall groups I and II; for patients in this group, less than 50% of the head is involved. The second, called group B, includes Catterall groups III and IV; for patients in this group, more than 50% of the head is involved. For both classifications, if less than 50% of the ball is involved, the prognosis is better, whereas if more than 50% is involved, the prognosis is potentially poor.
  183. 183. (ref: Apley’s Concise System of Orthopaedics and Fractures, http://www.wheelessonline.com/ortho/radiographic_evaluation_of_perthes_disease, http://emedicine.medscape.com/article/410482-overview.)
  184. 184. Duration of the hip pain F
  185. 185. = Duration of the hip pain did not become one of the prognostic features of Perthes’ disease as usually the children will feel intermittent pain for several weeks to months as they often did not complaint about it. The prognostic features for Perthes disease mostly based on age and x-ray appearance.
  186. 186. (ref: Apley’s Concise System of Orthopaedics and Fractures, http://emedicine.medscape.com

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