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 />
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 of forearm, causing lack of reperfusion of tissues resulting in tissue death causing compartment syndrome.
Therefore the complications of elbow dislocations include the following:<br />
Posttraumatic periarticular calcification, which occurs in 3-5% of elbow injuries
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).
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. (http://en.wikipedia.org/wiki/Cubitus_valgus)
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 (Apley’s concise 3rd edition page 311)
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 />
Transverse fracture of the radius
1 inch (2.54 cm) proximal to the radio-carpal joint
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 />
Taken from http://emedicine.medscape.com/article/86659-overview
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.
Interruption of Shenton's line can indicate (in the correct clinical scenario)
Type 3 is displaced (often rotated and angulated) with varus displacement but still has some contact between the two fragments.
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 minimal hip pain
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 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.
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 bone cyst (a local benign condition) (http://www.gpnotebook.co.uk/simplepage.cfm?ID=859111436)
T previous traumatic fracture (pathological fracture is due to pathologic bone-weakening condition) (http://www.wrongdiagnosis.com/p/pathological_fracture/causes.htm)
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)
The common sites of fractures in patients with osteoporosis are :
Femoral neck (True) (typical fragility occurs in vertebral column, hip, ribs , and wrist) http://en.wikipedia.org/wiki/Osteoporosis
Traumatic anterior dislocation of the shoulder :
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)
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)
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)
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)
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)
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 />
Low back pain
Pain in leg (unilateral or bilateral) that starts in the buttocks and travels down the back of the thighs and legs (sciatica)
Numbness in the groin or area of contact if sitting on the saddle (perineal or saddle paresthesia)
Bowel and bladder disturbances (urinary and fecal retention)
Lower extremity muscle weakness and loss of sensations
(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 />
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 />
A short course of rest, limited to one to two days
Pain medication, such as NSAIDs (e.g. ibuprofen) and/or acetaminophen
Application of ice and/or heat on the lower back to decrease inflammation.
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 />
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 />
(Ref: Apley’s Concise System of Orthopedics and Fracture, 3rd edition, page 198)
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 />
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 />
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 />
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 />
Diabetic gangrene of the foot require amputation at the distal tibia F
Below knee amputation ,weight is taken on the stump F
Above knee amputation,weight is taken on the ischial tuberosity T
Elderly patient refuse to use above knee prostheses because of the high energy requirement T
Pain due to neuroma formation is a complication T
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 />
Reference: Apley’s Concise System of Orthopaedics & Fractures 3rd edition, page 131-134
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 />
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).
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
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.
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 />
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.
(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 />
Occur when bleeding or edema increases the pressure in one of the osteofascial compartment beyond systemic blood pressure. F
Is adequately treated by analgesics and elevating the limb. F
Cause little long term disability in untreated condition. F
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 />
Regarding traumatic paraplegia.
Complete paralysis and anaesthesia is a consequence of spinal shock. T
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 />
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.
Source – Apley’s Concise System of Orthopaedics & Fractures,
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 />
Surgery is not indicated if displaced fracture F
Garden type II is complete with minimal displacement. F
Garden’s Classification of femoral neck fractures
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 />
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 />
Laboratory Studies - The following studies are indicated in patients with osteomyelitis:
CBC count: The WBC count may be elevated, but it is frequently normal.
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 />
Treatment for osteomyelitis involves the following:
Initiation of intravenous antibiotics that penetrate bone and joint cavities
Referral of the patient to an orthopedist or general surgeon
Possible medical infectious disease consultation
Select the appropriate antibiotics using direct culture results in samples from the infected site, whenever possible.
Empiric therapy is often initiated on the basis of the patient's age and the clinical presentation.
Empiric therapy should always include coverage for S aureus and consideration of CA-MRSA.
(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).<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 />
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:
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.
Loss of sensation in the skin over a small part of the lateral upper arm.
(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 />
Prognostic features for Perthes disease in a child is based on:
= 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)
(ref: Apley’s Concise System of Orthopaedics and Fractures)
= 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.
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 />
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.
(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.)
= 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.
(ref: Apley’s Concise System of Orthopaedics and Fractures, http://emedicine.medscape.com/article/826935-overview)
= Trendelenberg sign is an exaggerated up-and-down motion of the pelvis during ambulation which the patient’s pelvis will sag. This sign usually present late on the physical examination. The prognostic features depend on age of onset, involvement of femoral head, presence of metaphyseal rarefaction and any lateral displacement of the femoral head. Therefore, this answer is false.
(Ref: Apley’s Concise System of Orthopaedics and Fractures)
mangled limb/extremities are defined as high energy transfer or crush resulting in some combination of injuries to artery, bone, tendon, nerve and/or soft tissue. It usually caused by motor vehicle crash, auto-pedestrian crash, crush injury, farm/industrial injury, fall from height and close range shotgun wound. It is not the absolute indication for amputation as it is better delayed decision as we should consider attempting limb salvage initially. The criteria to do immediate amputation are:
Shredded muscle and transected nerves beyond elbow or knee especially posterior tibial nerve in lower extremities.
Crushed or mangled extremity with >6hours arterial occlusion upon arrival.
Associated mangling or severe injury to the ipsilateral hand or foot.
Severe associated polytrauma with persistent hypothermia, acidosis or coagulopathy (“life over limb”).
(Ref:http://www.facs.org/trauma/publications/mangledextremity.pdf/AmericanCollegeOfSurgeon2002 /Management of the Mangled Extremities)<br />
False In below knee amputations, the weight bearing is taken on the stump end.
In below knee amputations, they bear weight on patellar tendon, the lateral part of the lower limb. Transmetatorsal, Symes and knee disarticulation all bears weight on stump end. While, there should be no pressure on either the fibula head, tibial plate, hamstrings or end of stump as this might severe pressure sore.
False The energy requirement to move the prosthesis is higher as the level of the amputation is more distal.
The higher the level of a lower-limb amputation, the greater the energy expenditure that is required for walking. As the level of the amputation moves proximally, the walking speed of the individual decreases, and the oxygen consumption increases.<br />
Impact of energy costs:
AMPUTATION LEVELMETABOLIC COSTTRAUMATIC VASCULARTrans tibial 25%40%Trans femoral68%100%Bilateral trans tibial41%Trans tibial and trans femoral118%Bilateral trans femoral186%<br />
False Formation of neuroma will occur if the nerve is severed near the stump end
Any cut nerve will always form a tiny neuroma regardless of the site and occasionally this is painful and tender. It can be manage by excising 3cm of the nerve above the bulb or alternatively, the epineural sleeve of the nerve stump is freed from nerve fascicles for 5mm and then sealed with a synthetic tissue adhesive or buried within muscle or bone away from pressure points.
(Ref: Apley’s Concise System of Orthopaedics and Fractures)
True Phantom limb is a known complication following amputation
Phantom limb also one of the complications of amputation. It can be described as the feeling that the amputated limb is still present. In most cases, the feeling recedes and eventually disappears. A painful phantom limb is very difficult to treat. Other complications of amputation are:
EARLYLATESecondary hemorrhageInfection Breakdown of the skin flapsGas gangreneSkin – eczema, tender purulent lump, ulcerationMuscle- risk of contracture,Artery- lead to poor circulationDeep vein thrombosisNeuroma<br />
(ref: Apley’s Concise System of Orthopaedics and Fractures)
The ganglion often disappears after some months, so there should no haste about the treatment. It can be recurred again.
(ref: Apley’s Concise System of Orthopaedics and Fractures)
False Must be incised to prevent pressure necrosis of the underlying bone
Usually ganglion is characteristic by painless lump which well defined margin, cystic in nature and non tender. Thus, it often disappeared after some months. The main complication of ganglion is restricted movement of the wrist. It never causes pressure necrosis to the underlying bone.
(Ref: Apley’s Concise System of Orthopaedics and Fractures, HYPERLINK "http://archives.chennaionline.com/health/Homoeopathy/2005/04homoeopathy37.asp" http://archives.chennaionline.com/health/Homoeopathy/2005/04homoeopathy37.asp, http://emedicine.medscape.com/article/1243454-treatment)
False On the dorsum of the hand is often tender
Patient with ganglion will present with a painless lump, usually on the back of the wrist. The lump is well defined, cystic and non tender.
(ref: Apley’s Concise System of Orthopaedics and Fractures)
False Commonly occur along the germinal zone of the growth plate
The injuries usually run transversely through the hyperthrophic (calcified) layer of the growth plate, often veering off towards the shaft to include a triangular piece of the metaphysis. This has little effect on the longitudinal growth, which takes place in the germinal and proliferating layers of the physis. However, the fractures also can transverses the cellular ‘reproductive’ layers of the plate.
(ref: Apley’s Concise System of Orthopaedics and Fractures)
True Are classifieds as Salter Harris Type 2 when fracture occurs through the physis and metaphysis.
Salter Harris classification is widely used in physeal injuries. It can be divided into 5 types which are
Type 1: Separation of the epiphysis. A transverse fracture through the hyperthrophic of calcified zone of the plate. The growing zone of the physis is usually not injured and growth disturbance uncommon.
Type 2: Fracture through the physis and metaphysis. Similar to type 1 but towards the edge the fractures deviates away from the physis and splits off the triangular piece of metaphyseal bone. Growth usually not affected.
Type 3: The fracture runs along the physis and then veers off the joint, splitting the epiphysis. Inevitably it damages the reproductive zone of the physis and may result in the growth disturbance.
Type 4: Vertical fracture through the epiphysis and the adjacent metaphysic. This fracture liable to displacement and a consequent misfit between the separated parts of the physis, resulting in asymmetrical growth.
Type 5: Crushing of the physis without visible fracture. A longitudinal compression injury of the physis. May result in growth arrest.
(ref: Apley’s Concise System of Orthopaedics and Fractures).
Patients typically complain of what seems to be localized joint pain, often following a traumatic event (eg, fall, collision). Swelling near a joint with focal tenderness over the physis is usually present, as seen in the image below. Lower extremity injuries present as an inability to bear weight on the injured side; upper extremity injuries present with complaints of impaired function and reduced range of motion, quite similar to ligamentous injury. Ligamentous laxity tests of the joints of the injured side may elicit pain and positive findings similar to those indicative of joint injury. (An SH III or SH IV fracture of the distal femur is the classic example.) Do not dismiss positive joint laxity test findings as only involving the related joint tissues.
(ref: Apley’s Concise System of Orthopaedics and Fractures/ http://emedicine.medscape.com/article/1260663-overview).
False Do not warrant treatment via open reduction and internal fixation.
In displaced fractures Salter Harris Type 3 and 4, it demands perfect anatomical reduction. It can be achieved by gentle manipulation under general anesthesia. If this successful, the limb is held in a cast for 4-8 weeks (the longer periods for Type 4 injuries). Then, check x-rays at about 4 and 10 days are essential to ensure the position has been retained. If the injury cannot be reduced accurately by closed manipulation, immediate open reduction and internal fixation is called for. The limb is then splinted for 4-6 weeks, but it takes that long again before the child is ready to resume unrestricted activities.
(ref: Apley’s Concise System of Orthopaedics and Fractures)
True May result in premature fusion of the growth plate
The complications of injury to the physis are:
Type 1 and 2 injuries usually have excellent prognosis and the bone growth is not adversely affected if properly reduced. Exceptions to this rule are injuries involving the distal femoral and proximal tibial physes; both are undulating in shape (transverse fracture may pass through several zones in the physis and result in a focal point of fusion). Type 3 and 4 injuries more likely to cause premature fusion of part of the growth plate, resulting in cessation of growth or asymmetrical growth and deformity of the bone end.
(Ref: Apley’s Concise System of Orthopaedics & Fractures)<br />Other than that, the clinical features also can be of joint pain, muscle spasm and restriction of movements and deformity to the affected joint. (Ref: Indian Journal of Orthopaedics)<br />75% of active tuberculosis cases come from the lung. In the other 25% of active cases, the infection moves from the lungs, causing other kinds of TB, collectively denoted extrapulmonary tuberculosis. This occurs more commonly in immunosuppressed persons and young children. Extrapulmonary infection sites include the pleura in tuberculosis pleurisy, the central nervous system in meningitis, the lymphatic system in scrofula of the neck, the genitourinar system in urogenital tuberculosis, and bones and joints in Pott's disease of the spine. An especially serious form is disseminated TB, more commonly known as miliary tuberculosis. Extrapulmonary TB may co-exist with pulmonary TB as well. (Ref: www.wikipedia.com). <br />Bone and Joint tuberculosis results from haematogenous spread from a pulmonary or other visceral or lymph node focus. (Ref: Indian Journal of Orthopaedics)<br />
De Quervain’s Disease is painful inflammation of tendons in the thumb that extend to the wrist (tenosynovitis). Basically, what happens is the inflamed tendon and its coverings rub against the narrow tunnel which they pass. It will cause acute tenderness at very tip of the radial styloid. The tendons that affected are abductor pollicis longus and extensor pollicis brevis because both tendons are tightly secured against the radial styloid by overlying extensor retinaculum. (Ref: www.emedicine.com)
The most common test to diagnose De Quervain’s disease is Finklestein’s test. The thumb is tucked in close to the palm, and then turn the wrist sharply towards the ulnar side gives stab pain over the radial styloid. When repeating movement with the thumb left free is relatively painless. Thus, abduction of the thumb cause painless. Adduction the thumb which includes cross the palm cause painful. In resistant cases need operation, which consist of slitting the thickened tendon sheath. (Ref: Apley’s Concise System of Orthopaedics & Fractures)
51. Complications of plaster immobilization (POP) are:<br />Local complication<br />- Tight cast will lead to limb swelling, pain and vascular compression. (Ref: Apley’s Concise System of Orthopaedics & Fractures)<br />-Loose cast - Because swelling occurs with most fractures especially after reduction, padding will be put under the cast to protect the skin. Once this padding gets compressed. After 48 hours when the edema is subsiding, the cast may be too loose to hold the bone ends in position. This complication may seriously delay wound healing and may produce permanent deformity. (Ref: Apley’s Concise System of Orthopaedics & Fractures)<br />- Nerve damage - Loss of power, tingling and numbness distal to the cast are signs of impaired nerve function. The cause may be direct compression by bone ends or plaster pressure, indirect compression of edematous tissue or tourniquet effect, or reduced blood flow.<br />-Pressure sores over the bony prominence (patella, heel, elbow, and head of the ulna). (Ref: Apley’s Concise System of Orthopaedics & Fractures)<br />-Skin abrasion or laceration especially during removal of plasters using electric saw. (Ref: Apley’s Concise System of Orthopaedics & Fractures)<br />Systemic complication<br />The most serious is deep venous thrombosis leading to pulmonary embolism. Pain in the calf is an important sign needing medical advice. (Ref: www.broadspine.com)<br />Immobilisation in trunk plasters or plaster beds may also produce nausea, abdominal muscle cramps, retention of urine and abdominal distention. (Ref: www.broadspine.com)<br />Good nursing and diet with regular exercises will help ensure that the initial period of extensive immobilization is achieved without complications. (Ref: www.broadspine.com)<br />*Non union is the complication for internal fixation. (Ref: Apley’s Concise System of Orthopaedics & Fractures)<br />*Plaster of Paris in a type of cast that is used for immobilization of limbs. In case of patient with allergy to the Plaster of Paris, therefore, they came out with another type of cast which is fiber glass. But of course there are pros and cons of using it. Usually, patient with allergy of POP, they will complaint of rashes and itchiness at the affected site. (Ref: I have asked doctor during bedside teaching)<br />
52. Injuries to the spine<br />Fracture of the pedicle C2 is known as Hangman’s fracture<br />
FALSE. (Ref: Apley’s Concise System of Orthopaedics & Fractures)
Anterior wedge compression fractures will affect the anterior part of the vertebrae only. <br />
FALSE. (Ref: Apley’s Concise System of Orthopaedics & Fractures)
In fracture dislocation, the posterior ligaments are ruptured and the spine is potentially unstable. If it is associated with greater degrees of displacement >25%, spine definitely unstable and cord damage is likely. <br />
TRUE. (Ref: Apley’s Concise System of Orthopaedics & Fractures)
Thoracolumbar junction injuries are sustained in a fall from height and combination of forces due to axial compression and flexion. <br />
TRUE. (Ref: Apley’s Concise System of Orthopaedics & Fractures)
Injury to spine can be either stable or unstable and complete or incomplete. Usually, as far as the injury is stable and won’t affect the nerve roots and vertebral column, there will be no neurological deficit. However, most of the spinal injury will affect the cord and cause neurological deficits (Sorry. I can’t find reference for this question)<br /> 53. Acute lumbar disc prolapse<br />TRUE<br />A prolapsed (slipped) disc is a problem where the inter-vertebral disc is forced out of the annulus fibrosus (the outer covering of the disc) due to mechanical forces increasing intradiscal pressure. majority occur at the lowest 2 levels of spine ( L4/5 & L5/S1)<br />TRUE<br />TRUE <br />-The pain of may fluctuate from mild to severe. It can radiate to the legs due to pressure on the sciatic nerve which supplies the leg muscles (Sciatica is severe pain referred to lower limb happen due to compression to dural envelope of the nerve root).<br />-Distension of the annulus produces pain. The outer parts of the annulus are rich in nerves. If the inner pulp tracks from within to the peripheral parts of the disc, stretching of the annulus produces pain. The disc usually prolapses backward and to the side, left or right. <br />-The pain is described variously as aching or needle-like pricks, or burning, or like an electric shock. Numbness and tingling may also occur in the same region.<br />(http://www.krishnaraman.com/Lumbardiscprolapse.pdf)<br />FALSE <br />-Plain x-rays – these are usually taken to rule out any fracture or malalignment. Dynamic x-rays taken in flexion and extension may be performed to look for any instability. Plain x-rays do not give any information on nerve root or spinal cord compression.<br />-CT L-spine – It gives some information on bony alignment but often fails to demonstrate a disc prolapse. Occasionally it is combined with a myelogram to demonstrate any functional compression/obstruction.<br />-MRI lumbar-spine – this is the gold standard in looking for lumbar disc prolapses and to grading the degree of nerve root or cauda equine compression.<br />(http://www.vbsc.org.au/downloads/C_LumbarDiscPro_MM.pdf) <br />
-treatment for PID: rest, reduction and removal .<br />The goals of therapy are to reduce pain and inflammation by giving NSAIDs (ibuprofen ,naproxen). <br />-Surgical emergency – presence of cauda equina compression syndrome > 6 H because cauda equina damage may be irreversible . symptoms may: Numbness around the bottom and anus, Impotence or sexual dysfunction, loss of bowel or bladder control.<br /> (Apley’s Concise Orthopedic, 3rd Edi, page 195-198)<br />(http://www.vbsc.org.au/downloads/C_LumbarDiscPro_MM.pdf) <br />54. Congenital Talipes Equino Varus (CTEV) <br />FALSE <br />The true etiology of congenital clubfoot is unknown. Most infants who have clubfoot have no identifiable genetic, syndromal, or extrinsic cause.<br />FALSE <br />The male-to-female ratio is 2:1.<br />TRUE <br />-bilateral in one-third of cases (30-50% of cases.)<br />-Treatment usually surgery. No specific contraindications to surgery exist, although the child's size that surgery is best performed at approximately age 6 months.<br />FALSE <br />-deformities are (1) equinus heel ( pointing downward) (2), varus hindfoot (tilted towards the midline), (3) adducted & supinated forefoot<br />-The heel is small and empty. The heel feels soft to the touch .<br />-Similar deformities are seen with myelomeningocele and arthrogryposis ( always examine TRO other causes!)<br /> (Apley’s Concise Orthopedic, 3rd Edi, page 241)<br />(http://www.tsrhc.org/downloads/PDF/Clubfoot.pdf) <br />(e-medicine/club foot)<br />55. Tredelenburg sign is positive in this condition <br />TRUE <br />-The Trendelenburg test is a simple maneuver to evaluate the strength of the gluteus medius and gluteus minimus muscle <br />-pain & shortening happen commonly at osteoporosis patient. Garden’s Classification of # (1-incomplete #, 2-complete but still in line, 3- complete but displaced not in line, 4- complete # with full displacement)<br />TRUE<br />-Poliomyelitis is a viral disease that can affect nerves and can lead to partial or full paralysis. Clinical poliomyelitis affects the central nervous system (brain and spinal cord), and is divided into nonparalytic and paralytic forms. It is characterized by asymmetric paralysis that most often involves the legs. Bulbar polio leads to weakness of muscles innervated by cranial nerves. <br />-hip abductor muscles consists of gluteus medius, gluteus minimus, tensor fascia lata with superior gluteal nerve supply<br />TRUE <br />Positive sign in dislocation & subluxation of the hip<br />FALSE<br />TRUE <br /> any painful disorder of the hip( synovitis, Tb, osteomyelitis, arthritis, RA)<br /> (Apley’s Concise Orthopedic, 3rd Edi, page 202)<br />56. Foot disorder in Diabetes mellitus <br />
MTP joints hyperextended & IPJ flexed due to weak intrinsic muscles.
-(A claw toe is a lesser toe with dorsiflexion of the proximal phalanx on the lesser metatarsophalangeal (MTP) joint and concurrent flexion of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints)<br />FALSE <br />-Dry gangrene can be left to demarcate before amputation, but wet gangrene & infection are immediate amputation<br />
Neuropathic ulcer develop at areas of high plantar pressures (metatarsal heads, plantar aspect of the great toe, heel or over bony prominences ), painless, unless they are complicated by infection.
The gangrenous area is black, swollen and smelly. There is callus formation at the borders of the ulcer. Its base is red, with a healthy granular appearance.<br />TRUE <br />-Ankle brachial systolic pressure index (ABSI) essential to measure perfusion to the muscle tissue (usually need >0.8 before amputation for healing prosess)<br />
-Charcot foot (neuropathic osteoarthropathy) is a progressive condition characterized by joint dislocation, pathologic fractures, and severe destruction of the pedal architecture. <br />-patient experience on lack of position sense & pain sensation make patient complaint of instability, sweeling and deformity without warmth and tenderness) <br />(PDF Atlas of Diabetic Foot & Apley’s page 248)<br />57. Median nerve palsy<br /> <br />AT Thumb opposition and abduction are weak.Median nerve supply opponens policis that fx to oppose(flex/ abduct)the thumb. ( Netter’s concise orthopedic anatomy, 2nd edition, page207)BFMedian supply sensation at RADIAL three and a half fingers (palmar aspect) Ulnar nerve supply ULNAR one and half fingers (palmar n dorsal)Radial supply at RADIAL three and a half fingers (dorsal aspect)- typical area of sensory loss- a small patch of sensory loss on the back of the hand at the base of the thumb.(Netter’s concise orthopedic anatomy, 2nd edition, page204)CTLow lesion is due to cuts in front the wrist or carpal dislocation. High lesion due to forearm fracture or elbow dislocation. Stabs and gun shot may damage the nerve at any level.(Apley, 3rd edition, page 110)D/EF/TIn high lesion long flexors to the thumb, index (and middle )fingers are paralysed. Showing pointing index sign.P/S: Basicly in median nerve palsy, thenar eminence is wasted, the thumb abduction and position is weak, sensation loss over radial 3rd n half digit, trophic changes may be seen...+++ pointing index sign in high lesion.(Apley, 3rd edition, page 118)<br />58. Degenerative spine disease.<br />ATSpinal stenosis, refers to the narrowing of the spinal canal anywhere along its axis. Although the disorder often results from acquired degenerative changes (spondylosis) it may also be congenital in nature.. The canal components that contribute to acquired degenerative stenosis include the facets (hypertrophy, arthropathy), ligamentum flavum (hypertrophy), posterior longitudinal ligament (OPLL), vertebral body (Bone spur), the intervertebral disk, and the epidural fat. Spinal stenosis is most common in the cervical and lumbar areasLATERAL canal stenosis at any region of the spine may lead to nerve root compression. The patients may experience radicular pain, weakness, and numbness along the distribution of the affected spinal nerve. Lateral recess syndrome in the lumbar spine is a result of such focal stenosis.Stenosis of the CENTAL cervical and thoracic spine may result in myelopathy from cord compressionMyelopathy is the gradual loss of nerve function caused by disorders of the spine. Myelopathy can be directly caused by spinal injury resulting in either reduced sensation or paralysis. Degenerative disease may also cause this condition, with varied degrees of loss in sensation and movement.Spinal cord injury that results in myelopathy is classed as complete or incomplete. The cord does not have to be severed to produce myelopathy. Significant damage to the spine can cause complete paralysis or incomplete paralysis.Complete myelopathy describes a spinal injury which results in no sensation below the origin of the spinal injury. For example, a person with a spinal injury slightly above the waist would not feel his or her legs, could not walk, would have loss of bladder control and bowel function, and would not have sexual function. This is termed complete because nothing below the injury works. In incomplete myelopathy as a result of spinal injury, considering the same type of injury as above helps explain the distinction. A person in this case might have bladder, bowel, and sexual function, but still not be able to walk. In this type of myelopathy, some functions below the spinal injury may be unaffected or only partially affected. (http://www.wisegeek.com/what-is-myelopathy.htm)CATEGORIES Transverse lesion syndrome: - corticospinal, spinothalamic, and posterior cord tracts are involved equally; - associated with the longest duration of symptoms - may represent end stage of the disease Motor system syndrome: - corticospinal tracts and anterior horn cells are injured causing spasticity; - Central cord syndrome: - motor and sensory deficits affected the upper extremities more severely than the lower extremities; - Brown-Séquard syndrome: - ipsilateral motor deficits with contralateral sensory deficits may be the least advanced form of the disease; Brachialgia and cord syndrome: radicular pain in the upper extremity along with motor and/or sensory long-tract signs.(http://www.wheelessonline.com/ortho/myelopathy)BFBabinski's sign may not be present until myelopathy becomes severe(http://www.wheelessonline.com/ortho/myelopathy)CT The symptoms come on after standing upright or walking for 5 to 10 minutes and are consistently relieve by sitting or squatting with the spine somewhat flexed ~ spinal claudication (emedicine orthopaedics - spinal stenosis.)DFTreatment can be conservative or surgical. The modes of conservative therapy include rest, physical therapy with strengthening exercises for paraspinal musculature, bracing, use of optimal postural biomechanics, nonsteroidal anti-inflammatory medications, analgesics, and antispasmodics.Surgical decompression is indicated in persons who experience incapacitating pain, claudication, neurologic deficit, or myelopathy(emedicine orthopaedics - spinal stenosis.)ETThe pathophysiology of spinal stenosis is related to cord dysfunction elicited by a combination of mechanical compression and degenerative instability. With aging, the intervertebral disk degenerates and collapses, leading to spur formation(emedicine orthopaedics - spinal stenosis.)<br />59. Indication of internal fixation<br />AFWe can do internal fixation in Gustilo type one – Dr Omar, other do External Fixation.Gustilo Anderson Classification of open fracture:I Low energy, wound less than 1 cm, cleanII Wound greater than 1 cm with moderate soft tissue damage n contaminationIII High energy wound greater than 1 cm with extensive soft tissue damage n contamination. IIIA Adequate soft tissue coverIIIB Inadequate soft tissue cover + periosteal strippingIIIC Associated with arterial injuryBF(NO FRACTURE x yah lah wat internal fixation), internal fixation is one of the principal treatment for fracture NOT wound..C/DTIndication of internal fixation:Fractures that cannot be reduce except by operation.Fractures that are inherent unstable and prone to redisplacement after reduction# that unite poorly and slowly- principally # of the femoral neck.Phatological # in which bone disease may prevent healing.Multiple fractures where early fixation reduce the risk of general complication.# in patients who present severe nur sing difficulties(Apley, 3rd edition, page 256)EFthis actually included in the risk of infection of internal fixation not indication.(Apley, 3rd edition, page 256)<br />60. Compartment syndrome…<br /> <br />AT Bleeding and edema (inflammation/infection) can cause increase in pressure within one osteofascial compartment.(Apley, 3rd edition, page 294-295)BTREMEMBER!!! That the presence of pulse does not exclude the diagnosis!!!(Apley, 3rd edition, page 294-295)CT Classic features of ischemia: pain, paraesthesia, pallor, paralysis and pulselessness.(Apley, 3rd edition, page 294-295)DF The limb should be nursed flat!!! Elevating the limb cause futher decrease in end capillary pressure and aggravates the muscle ischemia.Treatment: Cast, bandage and dressing must be completely removed.If the differential pressure (diastolic pressure- compartment pressure) less than 30 mmHg (4 kPa), immediate open fasciotomy is performed!!!!~ measure by catheter that been introduced into the compartment!!If no facilities to measure, desicion to operate is to be made on clinical ground. – limb should be examine 15 min interval, if no improvement within 2 hours- perform fasciotomy!!! (muscle dead after 4-6 hours of total ischemia.)After fasciotomy, wound left OPEN, inspect 2 days later ~ if muscle necrosis- debride!!! , if healthy- suture (without tension), or skin grafted or simply allowed to heal by secondary intention!!!! EASY kan???? ; ).(Apley, 3rd edition, page 294-295)ET Nerve is capable of regeneration but muscle once infracted can never recover and is replaced by inelastic fibrous tissue (Volkmann’s ischemic contracture).(Apley, 3rd edition, page 294-295)<br />61. <br />QANSREASON(S)SOURCEAFGaleazzi #=# of distal 1/3 of radius + dislocation of DRUJApley’s 3rd ed, page 323BT1)PIN maps around the radial neck, hence # of radial head or displaced # thru the radial neck tend to injure the PIN.2)Pure motor lesion leads to no sensory disturbances. It may be damaged in fracture of the proximal end of the radius or during dislocation of the radial head.Extra notes: # of radial neck is commoner in paeds age group. Proximal epiphysis is cartilaginous, therefore prone to # rather than radial head which has a hard articular surface).1)http://emedicine.medscape.com/article/1240337-overview2)pan arab-journals, volume 2: radial nerve compression syndromesCTWe retrospectively reviewed the results of operative treatment of chronic Monteggia lesions (Bado type I or the equivalent) with anterior radiocapitellar dislocation in seven patients. There were fourteen complications, including malunion of the ulnar shaft in one patient; residual radiocapitellar subluxation in two patients (one anterior and one posterolateral); radiocapitellar dislocation (dynamic anterior subluxation of the radial head in supination) in one patient; transient ulnar-nerve palsy in three patients (with residual weakness in two); partial laceration of the radial nerve in one patient; loss of the fixation in two patients; and non-union of the ulnar osteotomy site, compartment syndrome, conversion reaction, and possible fibrous synostosis of the forearm in one patient each. The patients lost a mean of 36 degrees of pronation and a mean of 27 degrees of supination of the forearm compared with the contralateral, uninjured extremity.Chronic Monteggia lesions in children. Complications and results of reconstruction. J Bone Joint Surg Am. 1996 Sep;78(9):1322-9DT1)greater threat n difficult dx if the forearm is wrapped up in plaster2)Dr Fairudz also said that # of the femur rarely give rise to compartment syndrome coz there is large space there. But # of the tibia n forearm tend to result in compartment syndrome due to lack of space for oedema to expand.1)Apley’s 3rd ed page 3222)Dr. FairudzETradial # tend to displaced coz of strong muscle contraction. Therefore, need internal fixation. Positioning of the hand depends on level of #: upper 1/3=supinated, middle 1/=neutral position, lower 1/3=pronated.Apley’s 3rd ed page 322<br />62. Colles fracture<br />QANSREASON(S)SOURCEAT1)Distal radius fractures are classified as intra-articular if the fracture line extends to or through the articular surface of either the radiocarpal or the distal radioulnar joints2)Examples of intra-articular distal radial # are distal Barton # and volar Barton #1)Christopher H. Allan, MD. Orthopaedics Knowledge Online, AAOS).2)Wheeless online textbook of orthopaedicsBF1)Fracture that Colles described (Abraham Colles was a professor of surgery in Dublin): - was within 1 inch of the wrist joint- had dorsal angulation of the distal fragment-had dorsal displacement of the fragment- was a/w a fracture of the ulnar styloidANS: false as dorsal displacement is one of the criteria1)Essential orthopaedics and trauma, Dandy and Edwards, 4th ed page 205.CTusual case: postmenopausal woman with hx of FOOSH (fall on outstretched hand).Apley’s 3rd ed page 324.DFtreatment option: 1) undisplaced: dorsal splint until swelling subside, the cast for 4 weeks. 2) displaced: reduction under anaesthesia. Then, dorsal backslab (below elbow to metacarpal neck). C) comminuted & unstable: PC K-wire, or external fixation. Even the unstable # pun x perlukan ORIF.Apley’s 3rd ed page 324-325.EF1)Gunstock deformity aka cubitus varus is a cx of supracondylar # in children. So called gunstock coz its varus shape resemble gunstock (butt end of the shotgun).2)Malunion in Colles # is common d/t incomplete reduction or overlooked displacement within within the plaster. Treatment isn’t necessary, if got marked disability then radial osteotomy can be done.1)Apley’s 3rd ed page 313.2)Apley’s 3rd ed page 325<br />63. Regarding Tuberculosis, which statement is true:-<br />QANSREASON(S)SOURCEATPathophysiology: 1) hematogenous spread. 2) thru OM metaphysis (in neonates) Pathophysiology 1): bac lodge in synovial tissue leading to synovitis > synovial membrane secretes excessive fluid > later, proliferation, thickening and studding of its inner surface with tubercles. On its outer surface, fibrosis develops. > tuberculous granulation tissue covers the hyaline articular cartilage as a pannus > eventually, destruction of underlying articular cartilage and subchondral bone occur. > as the dss progress, increasing amount of caseous necrotic material and tuberculous exudates are released > “pus” forms > spreads by dissecting along tissue planes b/w muscles or muscle sheaths, being limited by the deep fascia. > With increasing tension the deep fascia perforates and the abscess becomes subcutaneous (eg: psoas abscess). > If the original focus remains active and these abscesses remain untreated, they will rupture externally through the skin to form sinuses, the results being the inevitable secondary infection by pyogenic bacteria, and complete destruction of the affected joint.2)OM of metaphysis can lead to infective arthritis in neonates coz their metaphysis is intracapsular (especially metaphysis of shoulder, hip, radial head, and ankle). Then, the pathophysiology follow the one that has been explained above.http://boneandspine.com/arthritis/tuberculous-arthritispathology-clinical-features/2) WHEELESS ONLINE TEXTBOOK OF ORTHOPAEDICSBTThe affected joint will be stiff, and soon the “night-cries” develop; because irritation from the process is low-grade, muscle spasm protects the part quite satisfactorily during the day, but when the child is asleep the protective action of the muscles is lost, and on motion, pain is produced; hence, the cry.http://boneandspine.com/arthritis/tuberculous-arthritispathology-clinical-features/CTas explained above.Can also look at Apley’s 3rd ed page 24DFanti-Tb chemotherapy (9 months course first 2/12 of HRZE and the next 7/12 of HR. if worse, then arthrodesis.WHO guidelines on treatment of tuberculosis, 4th ed, page 88 and page 32: table 3.2a<br />64. Regarding ulnar Nerve:-<br />
QANSREASON(S)SOURCEAFLess clawed in higher lesion. Ulnar claw=hyperextension of the 4th and 5th finger at MCP joint, but flexed at IP joint. (need good knowledge of anatomy of ulnar nerve and the muscles that it supplied to understand this question :p)Clawing occur in lower lesion (usually at the level of the wrist) coz the long flexor that is innervated by ulnar nerve (Flexor Digitorum Profundus) is not affected hence, flexion of IP joint at 4th and 5th finger. Ulnar nerve lesion at this site paralyzed the lumbricals muscle which flexed the MCP joint therefore the 4th and 5th fingers are extended at their MCP joint. Paralysis of dorsal interossei and palmar interossei makes abduction and adduction of the fingers impossible.In higher lesion (usually at the cubital tunnel), both the FDP and INTRINSIC MUSCLES (lumbricals, dorsal interossei, palmar interossei) are affected. The affected hand will show extension of MCP joint but no clawing noted coz FDP no longer working. ALL ARE TAKEN FROM DR OMAR’S NOTES AND BASED ON HIS EXPLANATION DURING LECTURE. ANY DOUBT CAN JUZ READ ON ANATOMY AND THEN ONLY WE CAN U/STAND THE TOPIC WELLBFSensory part of ulnar nerve supplies ulnar 1 and a half finger (i.e the little finger + half of ring finger).CTAdduction of thumb is due to the action of Adductor Pollicis. Paralysis of Adductor Pollicis is tested by Froment’s sign=give the pt a piece of paper to grasp and examiner will try to pull the paper. In normal ppl, they will be able to maintain the paper firmly. If the pt got paralysis of Adductor Pollicis, we will see the IP joint of the thumb flexed in order to maintain the grasp. This is merely compensation by the FPL (flexor pollicis longus which is innervated by AIN of median nerve).DTLumbricals muscle’s action is to flex the MCP joint. In ulnar nerve lesion, MCP joint is extended due to paralysis of lumbricals (intrinsic muscles of the hand).
65. Ankylosing Sponylitits<br />Associated with HLABRA 7 (F)<br />HLA-B27 (Apley’s concise pg.30)<br />Always associated with false positive rheumatoid factor (F)?<br />Common in Africans (T)<br />Prevalence is about 0.2 per cent in Western Europe, but much lower in Japanese and Negroid peoples (Apley’s concise pg.30)<br /> <br />66. In stenosing tenovaginitis (trigger finger)<br />The extensor tendon is commonly involved (T)<br />The 1st dorsal compartment (abductor pollicis longus and extensor pollicis brevis) and the second dorsal compartment (extensor carpi radialis longus and brevis) are the one most commonly affected (Apley’s pg.165)<br />The usual cause is thickening of the fibrous tendon sheath (T)<br />Over-use or repetitive minor trauma will result in synovial inflammation which causes the secondary thickening of the sheath and stenosis of compartment that further compromises the tendon. (Apley’s pg.165)<br />The triggering occurs during flexion of the involved finger (T)<br />Signs of TF are as follows:<br />Triggering on active or passive extension by the patient<br />Palpable snapping sensation or crepitus over the A1 pulley<br />Tenderness over the A1 pulley<br />Palpable nodule in the line of the (flexor digitorum superficialis)FDS, just distal to the MCP joint in the palm<br />Fixed-flexion deformity in late presentations, especially in the proximal interphalangeal (PIP) joint<br />Evidence of associated conditions (eg, RA, gout)<br />Early signs of triggering in other digits (may be bilateral)<br />(http://emedicine.medscape.com/article/1244693-overview)<br />A tender nodule can be felt in front of the affected area (T)<br />The ring and middle fingers are most commonly affected (F)<br />Volar flexor tenosynovitis (ie, trigger finger)<br />This type of tenosynovitis most commonly affects the thumb or ring finger.<br />Most common in middle-aged women<br />More common in patients with diabetes<br />Locking of involved finger in flexion is followed by sudden release (hence the name trigger finger); hand pain radiates to fingers. In more severe cases, the finger may require passive manipulation to regain extension.<br />(http://emedicine.medscape.com/article/809777-overview)<br />67. Gas gangrene:<br />Is caused by Streptococcus pyogenes infection (F)<br />Organisms in the spore-forming clostridial species, including Clostridium perfringens, Clostridium septicum,and Clostridium novyi, cause most of the cases<br />Is characterized by myonecrosis (T)<br />The hallmarks of this disease are rapid onset of myonecrosis with muscle swelling, severe pain, gas production, and sepsis.<br />Often manifests itself within 24 hours of injury (T)<br />The incubation period is usually less than 24 hours but has been described to be anywhere from 7 hours to 6 weeks, though when symptoms start, clinical deterioration can occur within hours.<br />Causes little pyrexia but increases pulse rate (F)<br />Vital signs: Unusually, fever is not a prominent feature of infection and may only be low grade throughout the clinical course. The degree of systemic involvement may produce a spectrum of changes from tachycardia through outright septic shock including hypotension and diaphoresis.<br />Is treated mainly by strong antibiotics (F)<br />The treatment is a combination of antibiotics, surgery, and hyperbaric oxygen<br />(All answers from http://emedicine.medscape.com/article/809777-overview)<br />68. Rotator cuff tears:<br />May occur as a complication of chronic tendinitis (T)<br />One of the signs of chronic tendinitis is crepitus/clicking during movement that suggests a partial tear of the rotator cuff (Apley’s pg.145)<br />Is mostly presentable as limitation of glenohumeral joint movement in all directions (F)<br />Basically partial/complete tear will result in weakness in abduction. To distinguish between partial and complete tears, pain is abolished by injecting a local anaesthetic and if active abduction is now possible, the tear must be only partial.(Apley’s pg.146)<br />Is associated with ‘hook’ shaped acromion (T)<br />Hook shaped acromion is a Type III acromion which has more significant association with rotator cuff tears compared to Type I acromion which has flat surface(3% only assoc wt rotator cuff tears)(MRI of the Shoulder pg.120)<br />Is commonly occur to supraspinatus tendon (T)<br />Partial tears of the rotator cuff frequently occur with supraspinatus tendinitis; indeed, it is possible that tendinitis is precipitated by a minor tear.(Apley’s pg 146)<br />Is ideally repair surgically in all elderly patients (F)<br />Operation is contraindicated in old or sedentary individuals, and long standing cases that are painless and accompanied by satisfactory function. (Apley’s pg. 147)<br />69. Developmental dislocation of the hip<br />
Can be demonstrated by Ortoloni test.(T)
How to do? Put your thumb at the medial thigh; fingers at greater trochanter à flex hip join 90˚à abduct<br />If normal à smooth abduction 90˚<br />If dislocate à the movement is impeded à sometimes if you press the greater trochanter; the dislocation can be reduce<br />Other test: Barlow’s test<br />
Trendelenburg test is positive in a child who is able to stand.(T)
Positive in 4 conditions:<br />Dislocation & subluxation of the hip<br />Weakness f the abductors<br />Shortening of the femoral head<br />Painful hip<br /> <br />
It is common in a child who presented with breech position during intrauterine. (T)
Because in breech position + extended leg would favour hip dislocation<br />Other causes:<br />
Genetic à generalized joint laxity & shallow acetabula
Hormonal changes in late pregnancy à aggravate joint laxity
Postnatal factors à the baby is carried with hips & knee fully extended
This is one of the features in plain x-ray. Normal angle: <30˚<br />Other 2 features:<br />Epiphysis should medial to a vertical line (Perkin’s line) below horizontal line (Hilgenreiner’s line)<br />With the hips abducted 45˚ the femoral shafts should point into the acetabula<br />(source: apley concise pg 206)<br /> <br />70. Regarding malignant bone tumours<br />
No definite answer<br />Try read this article maybe helpful: uitm library – online database – ebook – American College of Surgeon – Ch 6 vascular surgery – diabetic foot<br /> <br />72. Radiological features of OA<br />
Not sure because no definite answer from the book<br />Btw periosteum is not the bone. Histologically it contain condense fibrous tissue (Weather’s functional histology)<br />So, how come it can be osteoporotic???<br />73. Ganglion cyst around wrist:<br />Common in male<br />Present as solitary nodule only<br />Mucoid degeneration of collagen and connective tissue<br />Contain mucin, albumin and globulin<br />Common in volar aspect of wrist<br />A little bit to know about ganglion cyst: <br />What is it? – tumor or swelling arise from cystic degeneration in the joint capsule/tendon sheath. <br />It is more common in women<br />(ref:http://www.emedicinehealth.com/ganglion_cyst/article_em.htm)<br />So, the answer is FALSE<br />Multiple small cysts can give the appearance of more than one cyst, but a common stalk within the deeper tissue usually connects them<br /> (Ref: http://www.emedicinehealth.com/ganglion_cyst/article_em.htm)<br />Patients with ganglion cysts typically have only one lesion, but some people seem to be predisposed to having them in multiple locations.<br />Even the word ‘only’ pun slalu indicate FALSE in MCQ. <br />So, the answer is FALSE<br />The etiology is unknown, but the theory is there is cystic degeneration of the mucoid connective tissue, specifically collagen, in the joint capsule/ tendon sheath that forming the cyst ,when Ledderhose described it as such. <br />(Ref: http://emedicine.medscape.com/article/1243454-overview)<br />Thus, the answer is TRUE<br />It has also been suggested that degeneration of the connective tissue is caused by an irritation or chronic damage causing the mesenchymal cells or fibroblasts to produce mucin (fluid in the cyst). (http://emedicine.medscape.com/article/1243454-overview)<br />The mucin itself contain high concentration of hyaloronic acid, as well as glucosamine, albumin and globulin. <br />(Ref:Google book: Essential of physical medicine and rehabilitation)<br />Thus, the answer is TRUE<br />Ganglion cysts can occur at any joint or tendon sheath, but they most often present in the dorsum of the wrist at the scapholunate joint, (60-70% of all hand and wrist ganglia ) followed by the volar wrist (20%). (http://emedicine.medscape.com/article/1243454-overview)<br />So, the answer is FALSE<br />74. In crystal deposition disorder<br />FALSE<br />Crystal deposition disorder bkn saje gout.. there are few other clinical condition assoc with crystal deposits. Clinical conditions associated with crystal deposition d/o: <br />Gout (monosodium urate monohydrate crystal) –disorder of purine metabolism, hyperuricaemia<br />Tx principle in acute attack- resting the joint<br />-give large dose of NSAIDS<br />Pseudogout (calcium pyrophosphate dihydrate),<br />Calcium hydroxyapatite (HA) deposition disorder <br />(Ref: Apley’s concise system pg. 37-39)<br />
Yes, diagnosis rest on identifying the crystal in syn. fluid. Characteristics of crystal in gout (monosodium urate) seen under a polarizing microscope, is bright yellow needlelike negatively birefringent crystal. <br />
(Ref: Cleveland Journal of Medicine- the gout diagnosis http://www.ccjm.org/content/75/Suppl_5/S17.full.pdf )
(Reasoning for C,D.E are all written dlm jwpan A)<br />75. Amputation<br />TRUE<br />In the presence of extensive wet gangrene of foot, a guillotine amputation through distal tibia or fibula may be indicated. <br />(Ref: Essential of surgery: scientific principle and practice)<br />FALSE <br />Major weight bearing areas of below knee amputation patella tendon and tibial flares<br />Symes amputation (through ankle), major weight bearing area end of stump<br />TRUE<br />Above knee amputation major weight bearing are= ischium<br />(Ref: Lower limb amputation for ischaemia with special reference to the diabetic patient-CME article/paper)<br />TRUE<br />Advantage of above knee amputation is greater than 90% primary healing rate. <br />Disadvantages, however, are that only 40 to 50% of above knee amputation patients can learn to ambulate independently. There is a large increased energy requirement amounting to 80 to 120° greater than normal <br />(ref: http://www.vascdocs.com/health/amputation.shtml) <br />The increased energy requirements of prosthetic ambulation can limit the use of a prosthesis. An individual who has a lower extremity amputation and requires a walker or crutches to ambulate (with or without a prosthesis) uses 65% more energy than does someone with a normal gait.<br />TRUE<br />Late complication of amputation: neuroma(swelling of nerve)-a cut nerve always forms a tiny ‘neuroma’ and occasionally painful and tender<br />(Ref: Apley’s concise system: Amputation, page 33)<br />76. Regarding tenosynovitis:<br />In the proliferative type, it starts within the synovial lining of tendon sheath or invades the tendon from involvement of a contagious joint.<br />In crystalline type, precipitation of crystalline outside the confines of an enclosed space triggers fulminant inflammatory reaction.<br />Calcium pyrophosphate deposition disease can cause acute inflammatory tenosynovitis within carpal tunnel.<br />81. DVT(pg 134,135)<br />FALSE<br /> “Homan’s sign-increased calf pain on passive dorsiflexion of the foot and toes-is often thought to secure or exclude the dx of DVT. This is regrettable as more accurate techniques have shown that the sign is unreliable” Concise Apley’s pg 135<br />TRUE<br />The symptoms for DVT includes:<br />Asymptomtic;common<br />Symptomatic; pain in calf or thigh, swelling, soft-tissue tenderness, increased temp, increased pulse rate.<br />The surgical management for DVT includes:<br />TRUE<br />The investigations of DVT are:<br />Apart from basic-line ix, venography and ultrasound should be done to confirm the dx.<br />TRUE<br />The medical management for DVT are:<br />Heparin IV, warfarin, low-molecular-weight heparin<br />Answers taken from Appley Concise<br />82. In slipped capital femoral epiphysis (pg 214, 215)<br />FALSE. Prevalence; Boys affected more than gurls<br />TRUE<br />“The onset may be sudden and in30 percent there is a history of trauma(acute slip)” pg 214<br />FALSE bcoz it occurs in the hypertrophic zone of the cartilaginous growth plate<br />FALSE bcoz of the word confine, restricted. It usually occurs in male patients age 15 to 16 but bcoz of the word restricted=only, it is FALSE<br />83. in fracture of phalanges and metaphalanges(not well-elaborated in Concise. I’ll still be looking up for it and ill email later?)<br />A. Undisplaced # of phalanges can be splinted to its neighbor<br />B. It is important to correct malrotation<br />C. Bernett # occur at the base of 5th metacarpal<br />D. Immobilization should be at least 6/52<br />E. Stiffness is the most important complication<br /> <br />84. Regarding CTEV(club-foot) (pg 241, 242)<br />Clinical features of congenital talipes equinovarus;CTEV(idiopathic club-foot);(Concise Apley’s pg 241)<br />Foot; both turned and twisted inwards<br />Hindfoot; varus(tilted towards the midline)<br />Mid-foot and forefoot; adducted n supinated(twisted medially and the sole turned upwards)<br />Soles; faces posteromedially<br />Heel; small n high, equivinus(pointing downwards)<br />Deep creases; posteromedially<br /> Treatment (Concise Apley’s pg 241)<br />Conservative; manipulation, strapping or serial of casting<br />Operative; lizarov fixator<br /> Kirschner wires<br /> Dennis Browne boots(prevention of complications of surgery)<br />Hindfoot dorsiflex (FALSE) bcoz the c/fx for CTEV hindfoot is in varus<br />Forefoot is internally rotated(TRUE) its in varus position<br />Forefoot is everted(FALSE) bcoz its suppose to be inverted<br />Calf muscle is under-developed()<br />Txm begins 2-3 days after birth(FALSE) treatment starts conservatively 1-2 days after birth but if it fails then proceed with surgical treatment(Concise Apley’s pg 241)<br />85. Regarding Amputation<br />F – because wt is taken on the stump when the amputation done through or near a joint, eg; through knee or through ankle amputation. In below knee amputation or transtibial amputation, the wt was transmitted to the patellar,knee.<br />T – wt can be transmitted through ischial tuberosity, patellar tendon, upper tibia or the soft tissue. (Apley, pg 133)<br />T – energy requirement in above knee prostheses (transfemoral amputation)<br />Unilateral : 60-70%<br />Bilateral : >200%<br />(http://books.google.com.my/books?id=2sLvNV58V8oC&pg=PA24&lpg=PA24&dq=weight+transmission+in+below+knee+amputation&source=bl&ots=1LwvydVVo3&sig=tLcnCkr8J70EcVf5D3zBRFBwlbI&hl=en&ei=Eg6MTfbuA8j5rAfmkv3sDQ&sa=X&oi=book_result&ct=result&resnum=3&ved=0CCkQ6AEwAg#v=onepage&q=weight%20transmission%20in%20below%20knee%20amputation&f=true )<br />T – a cut nerve always forms a tiny neuroma n it is painful n tender (Apley, pg 133)<br />86. Fat embolism<br />A. T <br />B. T – no specific tx for fat embolism but the most important measure is to reduce hpoxemia by giving O2.<br />C. T<br />D. F – mostly occur in young adult after closed fractures of long bones<br />E. T<br />(source: Apley 3rd edition, pg 264)<br />87. Archilles tendon rupture<br />T (Apley 3rd edition, pg 250)<br />T – Simmonds’ test: ask px to prone, squeeze the calf, if tendon intact-the foot will plantarflex. If not, means the tendon is ruptured and the test is +ve. (Apley 3rd edition, pg 250)<br />F – plaster can be applied if the x is seen early. (Apley 3rd edition, pg 250)<br />T - When the calf muscle contracts, it shortens and pulls on the Achilles tendon resulting in pushing the foot downward. We use our Achilles tendon in this manner when pushing off during walking, running, and jumping.This action of the Achilles is also what we use to walk on our tip toes. (http://physicaltherapy.about.com/od/humananatomy/p/AchillesTendon.htm) <br />T - In the past, the complications of surgical repair of the Achilles tendon made surgeons think twice before suggesting surgery. The complications arose because the skin where the incision must be made is thin and has a poor blood supply. This can lead to an increase in the chance of the wound not healing and infection setting in. Now that this is better recognized, the complication rate is lower and surgery is recommended more often.<br />88. Carpal tunnel syndrome<br />F – more common in women (http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001469/) <br />F – in late case, causing thenar m/s wasting (Apley 3rd edition, pg 166)<br />T - In autoimmune diseases, the body's immune system abnormally attacks its own tissue, causing widespread inflammation, which, in many cases, affects the carpal tunnel of the hand. Such autoimmune diseases include rheumatoid arthritis, systemic lupus erythematosus, and thyroiditis, which can lead to hypothyroidism..<br />(http://www.umm.edu/patiented/articles/what_causes_carpal_tunnel_syndrome_000034_3.htm) <br />T – Phalen’s test (http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001469/ and Apley, pg 166) <br />F – transverse carpal ligament (Apley,pg 166)<br />89. Regarding examination of the knee<br />
The answer is false because anterior drawer test indicate ACL injury not PCL. PCL was tested by posterior drawer test—physical examination in orthopedic surgery by Lee Joon Kiong,page 130
Lachman test done when the patient’s knee is flexed 20 degree-Apley’s Concise System of Orthopedic & Fracture,page 223
-the cruciate ligaments are tested with both knees flexed 90 degree<br />
actually not really sure but you can look at this explanation:
- Q angle is the angle formed by a line drawn from the ASIS to central patella and a second line drawn from central patella to tibial tubercle; - an increased Q angle is a risk factor for patellar subluxation - normally Q angle is 14 deg for males and 17 deg for females; - Agliettis et. al. Clin. Ortho 1983: - 75 normal males: Q angle = 14 deg (+/- 3) - 75 normal females: Q angle = 17 deg (+/- 3) - biomechanics of patellofemoral joint are effected by patellar tendon length & the Q angle; - q angle is increased by: - genu valgum - increased femoral anteversion - external tibial torsion - laterally positioned tibial tuberosity - tight lateral retinaculum- Clincal Determination: (see examination of the patellofemoral joint) - deficiency of vastus medialis oblique is best assessed while leg is suspended in 15-20 deg of flexion; - large convexity at superomedial corner of patella indicates vastus medialis deficiency; - this is best measured both w/ the knee in extension as well as flexion; - Q angle may not be accurrate in extension, since a laterally dislocated patella may give false impression that the Q angle is normal; - in flexion, this is not a problem since the patella is well seated in the trochlear groove; - a sitting Q angle of more than 8 deg is abnormal;<br />- Wheeless' Textbook of Orthopaedics-http://www.wheelessonline.com/ortho/q_angle_of_the_knee<br />
There must be a moderate amount for this test to be positive. Too much fluid can prevent the patella being pushed on to the condyles; too little will not life the patella free from them- http://www.olympus.co.in/SingleColumn-Medical-V-11-01.pdf
The answer is false because the word ‘classically’ for bucket handle tear of knee menisci.
Mc Murray is actually test to check meniscus injury whether lateral or medial meniscus. Bucket Handle Test can be discovered during straightening the femur, if patient has suffered repeated locking of the joint. This indicates a lesion of cartilage in its anterior section. At the same time, click can be produced from the same cartilage posteriorly<br />.-McMurray Test: (Br.J.Surg. 1942. 407)- http://www.wheelessonline.com/ortho/mcmurray_test_brj_surg_1942_407<br />90. Posterior hip dislocation<br />
posterior dislocation is the commonest- Apley’s Concise System of Orthopedic & Fracture,page 361
leg is short and lies adducted, internally rotated & slightly flexed- Apley’s Concise System of Orthopedic & Fracture,page 361
usually occur in road accident when people seated in a truck or car is thrown forward, striking the knee against dashboard. Femur is thrust upward and femoral head is forced out of its socket.- Apley’s Concise System of Orthopedic & Fracture,page 361
fracture of the femoral head prevent the reduction.
- Management of posterior hip fracture dislocation - attempt closed reduction unless: - bone fragment is noted in the acetabulum: - it is essential to determine whether the hip is stable following reduction by stress testing; - stress testing is especially important if posterior wall frx is present; - type II frx of significant size may be treated non operatively if there is no posterior hip instability; - unstable reduction: - hip redislocates w/ 90 deg flexion; - frx of the femoral head prevents the reduction - comminuted frx of acetabulum, esp. posterior wall frx.<br />- Wheeless' Textbook of Orthopaedics http://www.wheelessonline.com/ortho/type_ii_v_posterior_fracture_dislocations<br />
complication-sciatic nerve injury (10-20%), avascular necrosis(10%) and OA- Apley’s Concise System of Orthopedic & Fracture,page 361
91. Acute lumbar disc prolapsed<br />
two common level is L4/L5 and L5/S1- Apley’s Concise System of Orthopedic & Fracture,page 195
If it occurs at L4 and L5 intervetebral disc space, both L4 and L5 can be compressed. L4 compression occur in lateral herniation and for L5 compression occur in medial herniation- Lecture Dr Omar,Degenerative Spine Disease, page 32
X-ray is essential to exclude bone disease. CT and MRI are the best way identifying the disc and localizing the lesion- Apley’s Concise System of Orthopedic & Fracture,page 196
the symptom actually depend on structure involved & degree of compression:
-presure on ligament-backache<br />-Pressure of the dural envelope of the nerve root - severe pain referred to the lower limb (sciatica)<br />-compression of nerve-numbness, paraesthesia & muscle weakness- Apley’s Concise System of Orthopedic & Fracture,page 195<br />
indication for operative removal of disc:
1) Cauda equine compression syndrome which does not clear up within 6 week of starting bed rest & traction. <br />2) Persistent pain & severely limited straight-leg raising after 2 week of conservative treatment.<br />3) Neurological deterioration while under conservative treatment<br />4) Frequently recurrent attack <br />-Apley’s Concise System of Orthopedic & Fracture,page 197<br />92. Spondylolisthesis <br />
Spondylolisthesis means vertebral displacement. Actually, Normal laminae & facets act as locking mechanism to prevent each vertebra from moving forward on the one below. Forward shift occur when this mechanism fail. X-ray finding: forward shift of upper part of spinal column on the vertebral below & elongation of the arch or defective facets may be seen- Apley’s Concise System of Orthopedic & Fracture,page 198-199
listhesis nearly always between L4 and L5 or L5 and sacrum- Apley’s Concise System of Orthopedic & Fracture,page 198
degenerative is one of the conditions. Look at the causes of it:
-at any age if the symptom disabling<br />-in the young adult even with moderate symptom<br />-neurological compression is marked<br />-Apley’s Concise System of Orthopedic & Fracture,page 198<br />93.Multiple myeloma<br />
T –Multiple myeloma is a malignant B-cell lyphoproliferative disorder of the marrow predominantly plasma cells ( Apley’s pg 93 )
F –Marrow-cell proliferation & increased osteoclastic activity result in osteoporosis and appearance of discrete lytic lesions throughout the skeleton (myelomatosis)
T - Healing occurs in three distinct but overlapping stages: 1) the early inflammatory stage; 2) the repair stage; and 3) the late remodeling stage (http://www.medscape.com/viewarticle/405699_6)
T – Primary cortical healing (direct bone healing) represents an attempt by the cortex to directly re-establish cortical continuity. This type of healing requires absolute rigid stabilization (i.e. with a metal plate) after anatomic reduction of the fracture ends. Regions where the cortical ends are in contact stabilize the other regions where small gaps are found. Within the gaps, blood vessels will infiltrate and mesenchymal cells will follow. Osteoclasts at the tip of cutting cones then begin to bridge the gaps and replace the tiny callus between the bones with new osteons (“gap healing” process). (http://www.teambone.com/chapters/basic/fracture.html)
T - Secondary fracture healing (indirect bone healing) is a process that relies on the periosteum for healing where it becomes the primary blood supply to the surrounding bone. Osteoprogenitor cells within the periosteum are mobilized and begin to form bone by processes analogous to intramembranous ossification and endochondral bone formation
F – Healing can occur without callus formation if the fracture site is absolutely immobile or fracture rigidly immobilized by internal fixation. New bone formation occurs directly between the fragments. Gaps between fracture surfaces are invaded by new capillaries & bone forming cells growing in from the edges – “Gap Healing” ( Apley’s pg 269 )
F –Remodeling stage can take 3 months to several years to complete (http://www.teambone.com/chapters/basic/fracture.html)
95.Fracture in children<br />
F –Rotational mal-alignment of fracture bone does not remodel.
* these fractures have a low chance of remodeling (may require closed/open reduction):
(Pediatric secrets By Richard Alan Polin, Mark F. Ditmar question no 58 & 59)
F– Premature partial or complete closure of growth plate occurs secondary to epiphyseal #, separated epiphyses and other metaphyseal # closed to growth plates. Metapyseal alignment avulsion # does not cause growth arrest.
(Pediatric Fractures and Dislocations By Lutz von Laer pg 32)
F– Apophysis is connected to bone through a histologically recognizable physis. The shape and size of apophysis are influenced by the forces placed on it by its muscle or tendon attachments. Regardless of its location, apophyseal avulsion represents an epiphysis #. As this avulsion most often occurs in adolescents when the posterior portion of the growth plate is already closed, growth disturbances are not normally to be expected
(Pediatric Fractures and Dislocations By Lutz von Laer pg 336)
F –Salter Harris Type 3 & 4 demand perfect anatomical reduction ( Apley’s pg 274)
T – Preferred treatment for displaced supracondylar humerus fracture is closed reduction and percutaneous pin fixation using prone-patient positioning where it can facilitates fracture reduction and safe pin placement while avoiding elbow hyperflexion (http://www.wheelessonline.com/ortho/pediatric_supracondylar_fractures_of_the_humerus)
96.Definite indication for internal fixation<br />According to Apley’s pg 286 , indications for internal fixation are :<br /># that cannot be reduced except by operation<br /># that are inherently unstable and prone to re-displacement after reduction<br /># that unite poorly and slowly, principally # of the femoral neck<br />Pathological # in which bone disease may prevent healing<br />Multiple # where early fixation reduces the risk of general complications<br /># in pt who present severe nursing difficulties<br />
T – (Apley’s pg 286)
T – Method of fixation depends on Gustilo’s classification ( if no obvious contamination, time lapse <8 hours, open fractures of all grades up to IIIa can be treated as for closed injuries ; cast splintage, intramedullary nailing, plating or external fixation.
F – Management of humeral fractures with radial nerve injury remains controversial. Humeral shaft # with primary radial nerve injury do not usually require nerve exploration. If the # reduction can be maintained, closed treatment will result in # healing & good outcome. (Fractures By Donald A. Wiss- pg 69)
frozen shoulder<br />FALSE<br />Commonly found in younger age <br />Frozen shoulder should be reserved for a well defined disorder characterized by progressive pain and stiffness. The patient aged 40-60 may give a history of trauma often trivial followed by pain. The condition very rarely appears in people under 40.<br /> (apley’s conscise M/S 147, Wikipedia frozen shoulder)<br />FALSE<br />Restrict movement in forward flexion only <br />Apart from slight wasting, the shoulder looks quite normal, tenderness is seldom marked. The cardinal feature is a stubborn lack of active and passive movement in all directions. There is progressive loss of passive ROM (PROM) and active ROM (AROM) of the glenohumeral joint in a capsular pattern. That is, the movements are usually restricted to a characteristic pattern, with proportionally greater passive loss of external rotation than of abduction and internal rotation.<br /> (apleys system of ortho n fractures M/S 287, emedicine frozne shoulder)<br /> <br />TRUE<br />Cause by trauma to shoulder <br />It can be traumatic or idiopathic. Idiopathic disease is more common in older patients, diabetics and women, other predisposing factor include cervical, neoplastic, pulmonary, and personality disorders.<br /> (Current essentials orthopedics M/S 53)<br />TRUE<br />Self limiting disease <br />It is an idiopathic disease with 2 principal characteristics: pain and contracture.<br />It is usually resolves spontaneously after about 18months but untreated, stiffness persists for another 6-12months. Gradually movement is regained but may not be return to nomal. Natural history has 3phases:<br />painful freezing phase (2-9months)<br />progressive stiffness phase in which motion becomes stiff in all planes while pain decreases<br />resolution phase during which range of movement gradually improves (1month to several years)<br /> (apley’s conscise M/S 147, Current essentials orthopedics M/S 53, emedicine frozen shoulder)<br />Recover process is difficult in DM <br />Frozen shoulder in diabetic patients is generally thought to be a more troublesome condition than in the non-diabetic population, and the recovery is longer. <br />(source : Wikipedia frozen shouder)<br />
Causes of pathological fracture
FALSE<br />repetitive stress <br />A stress or fatigue fracture is one occurring in the normal bone of a healthy patient. It is caused not by a specific traumatic incident but by repetitive stress, which are of two main kinds, bending and compression. Most likely occur in new army recruits, athletes in training and ballet dancers.<br /> (apleys system of ortho n fractures M/S 574)<br />FALSE<br />Osteoporosis <br />Osteoporosis is classify under insufficiency fractures which occur following minimal trauma to bones that are significantly weaker than normal, typically osteoporotic and osteomalacic bones.<br /> (apley’s conscise M/S 276)<br />TRUE<br />Bone cyst <br />When abnormal bone gives way, this is referred to as a pathological fracture. The causes are numerous and varied. Often diagnosis is not made until biopsy is examined. <br />Causes of pathlogical fracture can be classified into 4 categories which are:<br />generalized bone disease (osteogenis imperfect, postmenopausal osteoporosis, metabolic bone disease, myelomatosis, polyostotic fibrous dysplasia, and paget’s disease)<br />local benign conditions (chronic infection, solitary bone cyst, fibrous cortical defect, chondromyxoid fibroma, aneurismal bone cyst, chondroma, monostotic fibrous dysplasia)<br />primary malignant tumours (chondrosarcoma, osteosarcoma, ewing’s tumour)<br />metastatic tumours (carcinoma from breast, lung, kidney, thyroid, colon, and prostate)<br /> (apleys system of ortho n fractures M/S 575)<br />FALSE<br />Previous traumatic fracture <br />Causes of fractures can be divided into:<br />fractures due to sudden trauma<br />stress or fatigue fractures<br />pathological fractures<br />Previous traumatic fracture is under fractures due to sudden trauma.<br /> (apley’s conscise M/S 265)<br />TRUE<br />Secondary to bone <br />This is under 4th categories of the causes of pathological fractures which is metastatic tumours.<br />(apleys system of ortho n fractures M/S 575)<br />
Anterior shoulder instability
FALSE<br />Commonly occur in elderly men followed by an acute traumatic event <br />Shoulder instability can be divided into anterior instability(95%), posterior instability and multidirectional instability. For the anterior instability, the patient is usually a young man who gives a history of his shoulder ‘coming out’ perhaps during a sporting event. Traumatic anterior instability usually follows an acute injury in which the arm is forced into abduction, external rotation and extension.<br /> (apleys system of ortho n fractures M/S 289)<br />TRUE<br />Can cause humeral head articular damage <br />Pathology of anterior instability can be either recurrent dislocation or recurrent subluxation.<br />In recurrent dislocation, the labrum and capsule are detached from the anterior rim of the glenoid ( the classic bankart lesion). In addition, there may be an indentation on the posterolateral aspect of the humeral head ( the hill-sachs lesion), a compression fracture due to the humeral head being forced against the anterior glenoid rim each time it dislocates.<br />In recurrent subluxation, the patient may describe a ‘catching’ sensation, followed by ‘numbness’ or ‘weakness’- dead arm syndrome. Between episodes, the diagnosis rests on demonstrating the apprehension sign. With the patient seated, the examiner cautiously lifts the arm into abduction, external rotation, and then extension, at crucial moment, patient senses humeral head is about to slip out anteriorly and his body tautens in apprehension.<br /> (apleys system of ortho n fractures M/S 289)<br />TRUE<br /> Is associated with Bankart lesion <br />From the reasoning in answer (B)<br />TRUE <br />Positive Apprehension test <br />From the reasoning in answer (B) <br />TRUE<br />Mainly treated by conservative treatment <br />If dislocation recurs only at long intervals, the patient may choose to put up with the inconvenience.<br /> Indications for operative treatment :<br />frequent dislocations esp if painful<br />a fear of recurrent subluxation or dislocation<br /> Three types of operation are used:<br />repair or re-attachment of the glenoid labrum (Bankart)<br />shortening and tightening of the anterior capsule and muscles (Putti-Platt)<br />reinforcement of the anterior-inferior capsule using adjacent muscles( Bristow)<br /> (apley’s conscise M/S 150)<br />
Late complications of fracture include
TRUE<br />Non-union<br />Complications of fractures can be divided into early and late.<br />Non union is one of the late complications. Minority of cases, delayed union gradually turns into non-union, and becomes apparent that the fracture will never unite without intervention. <br />Other late complications include:<br />delayed union<br />malunion<br />AVN<br />growth disturbance<br />bed sores<br />myositis ossificans<br />tendon lesions<br />nerve compression<br />muscle contracture<br />jt instability and stiffness<br />algodystrophy<br />OA<br /> (apleys system of ortho n fractures M/S 566)<br />FALSE <br />Joint contracture <br />From the reasoning in answer (A) <br />FALSE<br />Osteomyelitis<br />OM is bone infection.<br />Infection is one of the early complication of fractures. Open fractures may become infected, closed fractures hardly ever do unless they are opened by operation. Other early complication include :<br />visceral injury<br />vascular injury<br />nerve injury<br />compartment syndrome<br />haemarthrosis<br />gangrene<br />plaster sores and pressure sores)<br /> (apleys system of ortho n fractures M/S 564)<br />TRUE<br />Muscle atrophy<br />Muscle atrophy is defined as a decrease in the mass of the muscle; it can be a partial or complete wasting away of muscle.<br />Following arterial injury or a compartmental syndrome, the patient may develop ischaemic contractures of the affected muscles ( volkmann’s ischaemic contracture). In a severe case affecting the forearm, there will be wasting of the forearm and hand and clawing of the fingers.<br /> (apleys system of ortho n fractures M/S 572)<br />TRUE<br />Bleeding<br />The fractures most often associated with damage to a major artery. The artery may be cut, torn, compressed or contused, either by intial injury or subsequently by jagged bone fragments. <br /> ( apleys system of ortho n fractures M/S 562)<br />