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Radiological Features
To begin with there is reduction in the joint space with
juxta-artcular osteopenia. In advanced stage of arthritis
the radiological appearance of hip has been classified
by Prof TK Shanmuga sundaram into:
1. Normal type
2. Wandering acetabulum: There occurs destruction of
the acetabulum in its superior due to the disease. The
temporal head shifts proximally on the ilium. This is
called wandering acetabulum.
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46. In case of Poliomyelitis, 'residual stage' of
paralysis is called after
A. 3 months of onset of acute Poliomyelitis
B. 6 months of onset of acute Poliomyelitis
C. 12 months of onset of acute Poliomyelitis
D. 24 months of onset of acute Poliomyelitis
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46. In case of Poliomyelitis, 'residual stage' of
paralysis is called after
A. 3 months of onset of acute Poliomyelitis
B. 6 months of onset of acute Poliomyelitis
C. 12 months of onset of acute Poliomyelitis
D. 24 months of onset of acute Poliomyelitis
D
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Residual Paralysis: As the acute phase of illness (0-4
weeks) subsides, the recovery begins in paralyzed
muscles. The extent of recovery is variable ranging from
mild to severe residual paresis at 60 days, depending
upon the extent of damage caused to the neurons by
the virus. Maximum neurological recovery of the
paralyzed muscle takes place in the first six months of
the illness but slow recovery continues up to two years.
After two years, no more recovery is expected and the
child is said to have “Post Polio residual paralysis”,
which remains as such through out life. However, the
child can learn to use muscles which were not
paralyzed to compensate for lost muscle power.
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Syme's Amputation
includes ankle disarticulation, removal of malleoli,
& anchoring heel pad to the wt bearing surface)
allows execellent gait with a cosmetic
prosthesis;
- symes amputations will not heal w/o palpable
posterior artery pulse;
- surgery may be performed in 2 stages;
- most common indication for this is infection;
- ankle is disarticulated in the first stage and the
amputation is revised approximately 6 weeks later
during the second stage;
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- components of the 2nd stage include resection of
the malleoli flush w/ joint surface, fixation of the fat
pad to residual bone, and revision of redundant
skin;
- this amputation allows for intermittent wt
bearing; however, skin break down may occur if a
prosthesis is used on a regular basis;
- majority of patients w/ Syme's amputation will
require prothesis designed to relieve end weight
bearing;
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Most surgeons agree that early and adequate surgery is
the most effective and primary means of treating
clostridial myositis. If the diagnosis is made early, while
the gangrene is relatively localized and incipient, radical
decompression of the involved fascial compartments by
free longitudinal incisions and excision of the infected
muscle usually arrest the process and eliminate the need
for amputation. Local excision preferred to amputaion,
whenever posibie, to conserve a functional extremity. If
diagnosis is reached when the process is extensive and
has caused irreversible gangrenous changes implying
permanent loss of function of the limp, open
amputation of the guillotine type or some modification
becomes necessary.
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A "Boxer's fracture" is the second and/or third
metacarpal transverse neck fracture that is more
likely to occur from a straight punch.
The "Boxer's" designation is suggestive of the
generally well tolerated way of striking a hard object
with the closed fist, with the second and third
metacarpal bones, of the index and middle fingers
respectively, absorbing most of the force.
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LACHMAN-TEST - is the most sensitive test for ACL
tear
It is done with the knee flexed at 20 degree,
stablizing the distal femur with one hand and
pulling forward on the proximal tibia with the other
hand with an intact ligament minimal translation of
the tibia occurs and a firm end point is felt with a
torn ACL more translation is noted and the end
point is soft or mushy
• The blood supply of ACL is primarily derived from
Middle genicular artery***
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ANTERIOR -DRAWER TEST - is done with the knee at
90° degree of flexion and is not as sensitive as
Lachman test but serves as an adjunct in the
evaluation of ACL instability
LOSEE TEST - THE PIVOT- SHIFT- PHENOMENON
Demonstrate the instability associated with an ACL
tear,
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'As described by losee, a valgus and internal rotation
force is applied to the tibia. Starting at 45 degree of
flexion. The lateral tibial plateau is reduced. Extending
the knee causes the lateral plateau to subluxate
anteriorly with a thud at approximately 20 degrees of
flexion. It reduces quietly at full extension.
Posterior drawer test - evaluates the integrity of the
PCL
MC- Murray test - with the Me Murray test forced
flexion and rotation of the knee elicits a clunk along
the joint line if there is meniscus injury**
Investigation of choice in Knee joint injury is MRI
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Anatomic correlation of clinical ligament instability
examination of the knee joint
Direction of force Position Ligament instability
Varus or valgus Full extension Posterior cruciate/ posterior capsule
Varus Flexion at 30 degree Lateral collateral ligament /capsule
Valgus Flexion at 30 degree Medial collateral ligament
Anterior Flexion at 30° neutral
position (AP)
Anterior cruciate ligament
Anterior Flexion at 90° neutral
internal or external
rotation
Anterior cruciate ligament
Posterior 90° (Sag test) Posterior cruciate ligament
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Important Points
• Medial meniscus has less mobility than the lateral
meniscus and is more susceptible tearing when
trapped between the femoral condyle and tibial
plateau
• Anterior cruciate ligament prevents anterior
translation and rotation of the tibia on the femur,
• Posterior cruciate ligament prevents posterior
subluxation of the tibia on the femur
• Posterior glenohumeral instability can be tested by
Jerk Test
• Coronary ligament of the knee axe —ligaments
connecting the menisci to tibia***
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Tear of Quadriceps Tendon - occurs most often in patients
over the age of 40, apparent tears that represent avulsions
from the patella occur in patients with renal osleodystrophy
or hyperparathyroidism. The tear commonly results from
sudden deceleration, such as stumbling or stipping on a wet
surface. A small flake of bone may be avulsed from the
superior pole of the patella or the tear may occur entirely
through tendinous and muscular tissues
Quadriceps rupture at the upper margin of the patella - This is
commonly known as an avulsion of the rectus femoris. It
occurs in elderly patients. It is diagnosed by the palpation of a
gap in the extensor apparatus just above the patella two
fingers can be placed in the gap usually the lateral expansions
are intact (Watson & Jones).
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Muscles Actions
• Rectus femoris • Extension of leg at knee joint flexes thigh at hip
joint***
• Vastus medialis • Extension of leg at knee joint: Stabilies patella
• Vastus intermedius • Extension of leg at knee joint: articularis genus
retracts synovial membrane
• Vastus lateralis • Extension of leg at knee joint
• Biceps femoris • Chief flexors of knee. They are weak extensors of
the hip particularly in walking
• The rectus femoris muscle can rupture in sudden violent extension
movement of the knee joints**
• Vastus medialis is the first part of the quadriceps muscle to atrophy in
knee joint and the last to recover***
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VON-ROSEN'S SPLINT - is an H-shaped melleable
splint
• Object of splintage is to hold the hips some what
flexed and abducted
• Used in congenital dislocation / dysplasia of hip
joint
Also - Remember
• Frog leg or Lorenz cast or Batchelor cast used in
CDH
• Broomstick plaster used in perthe's disease
• Patella Tendon Bearing (PTB) cast used in- Both
bones leg fracture
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• Gutter splint- phalyngeal and metaphalyngeal
fractures
• Denis Browne splint used in CTEV, Stirrup splint
Ankle fractures
• Knuckle-bender splint- ulner nerve palsy, Cock up
splint - Radial nerve palsy
• Milwaukee brace (Cervical thoracolombosacral
orthosis) used in Scoliosis
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• Risser's localizer cast, Turn buckle cast- Scoliosis
• Minerva cast - cerical spine disease
• U slab or Hanging cast - fracture of humerus
• Tube cast (Cylindrical cast) - used for fracture around
knee (# patella)
• Halo cast (vest) - for spinal injury
• Velpeau bandage and sling and Swathe splint are
used in - Shoulder dislocation**
• Thromboembolic disease (Pulmonary embolism) is
the most common cause of death after Total hip
replacement*** (Watson jones operation)
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• Pectorafis major and minor muscles are the most
common congenitically absent muscles in
humans**
• Pollicization refer to reconstruction of the thumb
with a substitute finger (i.e. index finger)
• Bohler's Tuber Joint angle and crucial angle of
Gissane are measured for intraarticular #
ofcalcanium
Development Dysplasia of the hep (DDH)
• More common in female, short stature**
• Oligohydramnios is associated with a higher risk of
DDH
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• The hourglass appearance of the capsule may
prevent a successful closed reduction
• In a child with bilateral dislocation - Waddling gait-
unilateral dislocation Trendelenburg's gait*
• X-ray shows break in shenton's line*
• Striking feature is widening of perineum & marked
lumber lorodosis*
• Wandering acetabulum is sen in T.B of hip joints
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Angles of Importance
(i) Cobb's angle - Scoliosis
(ii) Kite's angle - CTEV
(iii) Meary's angle - Pes cavus
(iv) Hilagenreiner's epiphyseal angle - congenital
coxa-vera
(v) Baumann's angle - Supracondylar #
Rocker bottom foot or vertical talus is associated
with Arthrogrypasis multiplex congenital spina
bifida & trisomy 13-18
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CONGENITAL - DISLOCATION OF THE HIP (CDH) - In
western races. It is one of the commonest congenital
disorder but it is uncommon in India and some other Asian
countries probably because of the culture of mother
carrying the child on the side of their waist with the hips
of the child abducted. This position helps in the reduction
of an unstable hip which otherwise would have dislocated
(200-M)
• Dislocation is very common in Lapps and North
American Indians who swaddle their babies and carry
them with legs together, hips and knees fully extended
and is rare in southern Chinese and African Negroes who
carry their babies astride their backs with legs widely
abducted (Apley)
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• Investigation of choice in newborn is real time
ultrasound
Aetiology and pathogencsis
• Genetic factor - dominant trait, and acetabular
dysplasia
• Hormonal factors - High levels of maternal
oestrogen progesterone and relaxin
• Breach position with extended legs
• Postnatal factors - contribute to persistence of
neonatal instability and acetabular maldevelopment
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Diagnosis of CDH
• Limitation of the abduction
of the hip
• Ortoloni'test is positive (Jerk of
entry')
• Asymmetrical thigh fold • Barlow's test
• High buttock fold on the
affected side
• Telescopy positive
• Galeazzi 's sign • Trendelenburg, waddling gait*
• Limb is short and slightly
externally rotated
• Trendelenburg's test
positive
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Important X-ray findings in CDH
- Delayed appearance of ossific centre for the head of
the femur .
- Retarded development of ossific centre of the head of
the femur
- Slopping acetabulum
- Lateral and upward displacement of the ossific centre
of the femoral head
- A break in shenton 's line***
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Most common organisms in Osteomyelitis
• Acute osteomyelitis- children under 4 years of age. H.
influenme
• Acute osteomyelitis in older children, adults - Staph.aureus
• Sickle cell disease - salmonella
• Heroin addicts and immunocopromised—Pseudomonas,
aeniginosa, proteus mirabilis, Bacteroids
• Sub acute haematogenous osteomyelitis - Staph. aureus
• Post traumatic osteomyelitis, Infected metal implants
Staph. aureus
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• Post operative osteomyelitis - Mixed infection (Staph.
aureus Proteus, Pseudomonas)
• Osteomyelitis of the spine - Staph, aureus, Pseudomonas
aeruginosa
• Squamous cell carcinoma arising from a chronic
osteomyelitis - occurs in areas of burn scars, chronic pressure
ulcers, and ostomies as well as as sites of chronic draining
osteomyelitis Stable chronic osteomyelitis for an average of
approximately 20 years
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Earliest site of bone involvement in hematogenous
osteomyelitis is - Metaphysis**
Markers of Bone formation Markers of Bone resorption
• Serum bone specific alkaline
phosphatase**
• Serum osteocalcin
• Serum propeptide or type I
procollagen
• Urine and serum N- telopeptide
• Urine and serum C- telopeptide*
• Urine total free deoxypyridinoline
• Urine Hydroxyproline*
• Serum tartarate resistant- Acid
phosphatase*
• Serum bone sialoprtein
• Urine hydroxylysine glycosides
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• Infective endocarditis due to pseudomonas is most
commonly seen with IV drug abuse of pentazocin**
Classification systems for Osteomyelitis
1. Traditional system - Acute (<2 weeks) subacute (weeks to
months) chronic (>3months)
2. Waldvogel system
- Hematogenous
- Arising from contiguous infection No vascular disease
- Vascular disease present chronic
3. Cierny- Mader system
Anatomic extent of infection
1. Medullary only (acute hematogenous)
2. Superficial cortex (continguous spread or soft tissue
trauma)
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3. Localized (cortical and medullary, mechanically stable)
4. Diffuse (cortical and medullary mechanically unstable)
5. Subtype by host's physiologic status
A Healty
Bs Compromised because of systemic factors
B1 Compromised because of local factors
B1s Compromised because of both local and systemic
factors
C Treatment worse than the disease
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56. A-man is stucked with lathi,below the knee in
lateral aspect of the leg. He drags the toes and
cannot feel the sensation in dorsum of feet which of
the following is intact
A. Inversion
B. Eversion
C. Dorsiflexion
D. Loss of sensation in 1st & 2nd toes
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56. A-man is stucked with lathi,below the knee in
lateral aspect of the leg. He drags the toes and
cannot feel the sensation in dorsum of feet which of
the following is intact
A. Inversion
B. Eversion
C. Dorsiflexion
D. Loss of sensation in 1st & 2nd toes
A
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Clinical picture suggest diagnosis is a lateral
popliteal nerve injury
• Causes of Lateral popliteal nerve palsy (Waston &
Jones')
• Rupture of the external lateral ligament
• Avulsion of the styloid process of the fibula
• Dislocation of the knee joint
• Compressed by. Splint, POP or strapping
• Ganglion arising from superior tibio-fibular joint
• Cyst of the lateral meniscus
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Clinical features
• Paralysis of the anterior tibial and peroneal
muscle
• Loss of sensibility in the outer aspect of the leg
and dorsum of the foot
PERONEAL NERVE (Apley)
• Injuries may affect either the common peroneal
{lateralpopliteal) nerve or one of its branches the
deep or superficial peroneal nerve
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[A]. Common peroneal nerve (Lateral popliteal
nerve)
• The patient has drop foot and can neither
dorsifiex nor evert the foot**
• He walks with a high stepping gait to avoid
catching the toes
• Sensation is lost over the front and outer half of
the leg and the dorsum of the foot**
• Planter flexion & Inversion are normal**
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[B]. Deep peroneal nerve
• Pain and weakness of dorsiflexion
• Sensory loss in a small area of skin between the first and second
toes**
• Paraesthesia and numbness on the dorsum around the first web
space
[C]. Superficial peroneal nerve
• Pain in the lateral part of the leg and numbness or paraesthesia
of the foot
• There may be weakness of eversion and sensory loss on the
dorsum of the foot
• Most commonly injured in misplaced gluteal injection - Sciatic
nerve injury
• Most common cause of insertional tendonitis of tendoachilis is -
over use**
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• Anterior dislocation is much more common than
posterior
Posterior dislocation of Schoulder is rare
Mechanism of injury — Indirect force producing
marked internal rotation* and adduction* must
needs be very sever to cause a dislocation. This
happens most commonly during a fit or convulsions
or with electric shock.
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ANTERIOR SHOULDER DlSLOCATION POSTERIOR SHOULDER
DISLOCATION
• Due to shallowness of the glenoid socket, the
extra ordinary range of the movement,
ligamentous laxity or glenoid dysplasia
• The lateral out line of the shoulder may be
flattened, bulge may be felt just below the
clavicle
• The front of the shoulder looks flat
with a prominent coracoid
• Posterior displacement is usually
apparent
• The characteristic physical sign is loss
of lateral rotation of the shoulder which
is locked in medial rotation (Watson &
Jones)
• Posterior dislocations are often
difficult to diagnose because the patient
may have a normal contour to the
shoulder or the deltoid of a well
developed athlete may mask signs of a
displaced humeral head (207-current
diagnosis & treatment 4th)
• A "reverse Hill- Sachs lesion" may
appear on the anterior articular surface
of the humerus
Patho physiological changes
• Bankart's lesion — Dislocation causes stripping
of the glenoidal labrum along with the
periosteum from the anterior surface of the
glenoid and scapular neck***
• Hill- Sach 's lesion — is a depression on the
humeral head in its postero-lateral quadrant.
• Eburnated rim of the glenoid
• Associated # of the GT of the humerus or rim of
the glenoid
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• Dugas' test, Hamilton ruler test, callway's test are
positive in Anterior dislocation of the shoulder joint
• Axillary nerve and Axillary artery injury is common in
Anterior dislocation of the shoulder joint
Empty glenoid sign - in AP- film the humeral head
because it is medially rotated, looked abnormal in
shape (like an electric light bulb) and it stands away
somewhat from glenoid fossa is seen in posterior
dislocation of the shoulder joint
• Patella almost always dislocates laterally
• Recurrent dislocations are extremely rare in the
Ankle joints*
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Recurrent dislocations of shoulder joints
Three important lesions
1. Hill sach's lesions**
2. Bankart's lesion**
3. Erosion of anterior rim
of glenoid cavity
Oilier pathologic lesions
1. Capsular laxity*
2. Sub capsular's deficiency
3. Glenoid fossa deficiency
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Anterior cruciate ligament Posterior cruciate ligament
• Prevent anterior translation of the
tibia on the femur**.limits hyper
extension
• Attached on tibia just behind
anterior horn of medial meniscus
Runs upwards bat Km aids and
laterally
• Attached on femur over medial
surface of lateral femoral condyle
• It is intracapsular and
intrasynoviai*
• It is tout during extension of knee
• Prevent posterior translation on
tibia on the femur**
• Attached on tibia behind posterior
horn of medialmeniscus Runs
upwards forwards and medially
• Attached on femur over lateral
surface of medial femoral condyle
• It is intracapsular but
extrasynovial*
• It is tout during flexion of knee*
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Cohart placement in an area with an independent air
supply, exhaust system & bathroom facilities
• Surgeons may use double gloves, space suits adherent
plastic drapes, pulstile lavage, and laminar flow operating
rooms or rooms with ultraviolet lights as additional
techniques that may lower the risk of intraoperative
contamination
The main preventive measures of Infection control are
1. Isolation - Infectious patients must be isolated
2. Hospital staff- Those who are suffering from skin
diseases, sore throat, common cold, ear infection diarrhea
or dysentery and other infectious ailments should be kept
away from work until completely cured
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3. Hand washing - The most common route of
infection is via the hands. Hand washing with soap
and water may not be sufficient, a suitable
disinfectant must be employed for handwashing
4. Dust control - Hospital dust contains numerous
bacteria and viruses, suppression of dust by wet
dusting and vaccume cleaning are important control
measures
5. Disinfection - The article used by the patient as
well as patients urine, faeces, sputum should be
properly disinfected proper sterilization of
instrument should be enforced
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6. Control of droplet infections-use of face masks,
proper bed spacing, prevention of over crowding
and ensuring adequate lighting and ventilation are
important control measures
7. Nurshing technique - Barrier nurshing and task
nurshing have been recommended to minimum
cross infections
8. Administrative measures - There should be a
hospital "control of infection committee" to
formulate policies regarding control of hospital
acquired infections
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COHORT NURSHING - refer to the grouping of patients with a
given infection within an isolated area short of strict (single room
isolation) cohort grouping of infectious patients & nurshing them
within an area of a hospital ward is widely recommended as a
strategy for controlling transmission of health care acquired
infections
According to WHO highly aerosolized infected cases should be
isolated & accommodated as follows in depending order or
preference
- Negative pressure room with the door closed**
- Single room with their own bathroom facilities
Cohart placement in an area with an independent air supply
exhaust system & bathroom facilities
The body exhaust system in total hip arthroplasty.
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SUPRACONDYLAR FRACTURE HUMERUS
• Radial nerve is the most commonly injured nerve,
the median nerves also sometimes affected
• Median nerve may be injured but loss of function
is usually temporary.
• The nerve most commonly affected is median :
radial palsies are rare, and the ulnar nerve is only
involved when the fracture displacement is anterior
(Watson & Jones)
• In single choice best answer is - Median nerve
(anterior interroseous branch)
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Compression of median nerve within the carpal
tunnel is the most common upper extremity
compressive neuropathy
Causes of carpal tunnel syndrome - Pregnancy
amyloidosis, flexor tenosynovitis, over use
phenomenon acute or chronic inflammatory
conditions, traumatic disorders of the wrist, DM and
hypothyroidism
• Dunlop traction is used for supracondylar fracture
of the humerus
• Best prognosis after nerve repair is - Radial**
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• Most common nerve used for monitoring during
anaesthesia is ulnar nerve
• Earliest reversal is orbicularis occuli supplied by facial
nerve
• Three bony point relationship is maintained in- supra
condylar # humerus
• Three bony point relationship is reversed m
dislocation of elbow joint
• Allen's test - is performed to identify patency of the
radial and ulnar arteries at the wrist and is indicator of
the integrity of the palmar arch, .
• Neuronal degeneration is seen in crush nerve injury
fetal development and senescence
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Condition Features & Test
Medial nerve palsy • Pointing index
• Pen test (test Abductor pollicis brevis)
• Benediction test
• Oschner clasp test & opposition loss
• Ape thumb deformity
• Carpal tunnel syndrome
Ulnar nerve • Book test (format sign)
• Card test
• Egawastest
• Musician nerve
Radial nerve • Wrist drop*
• Thumb drop*
• Finger drop*
Sciatic nerve is the thickest* nerve of the body. It is the terminal branch of the
lumbo-sacral plexus
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Clinical Applications of Radio-isotopes
1. Diagnosis of stress fracture (or other undisplaced fracture)
2. Detection of a small bone abscess or an osteoid osteoma
3. Investigation of loosening or infection around prosthesis
4. Diagnosis of femoral head ischaemia in perthe’s disease or
avascular necrosis in adults
5. Early detection of bone metastases
**the best indication for a bone scan is suspected multiple bony
lesions such as in metastatic carcinomas, and lymphoma of bone
• Bone- infarcts are seen in – Sickle cell anemia**
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61. A lateral blow at the level of the knee
joint may cause all except :
A. Rupture of anterior cruciate ligament
B. Rupture of medial collateral ligament
C. Avulsion of lateral meniscus
D. Bumper fracture of tibia
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61. A lateral blow at the level of the knee
joint may cause all except :
A. Rupture of anterior cruciate ligament
B. Rupture of medial collateral ligament
C. Avulsion of lateral meniscus
D. Bumper fracture of tibia
C
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65. The treatment of osteoclastoma
includes the following measures except:
A. Curettage of tumor tissue & packing
cavity with bone chips
B. Excision with safety margin of bone
C. Radiotherapy
D. Chemotherapy
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65. The treatment of osteoclastoma
includes the following measures except:
A. Curettage of tumor tissue & packing
cavity with bone chips
B. Excision with safety margin of bone
C. Radiotherapy
D. Chemotherapy
D
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68. Common complications of plastering of
fractures is :
A. Ischemia of the limb distal to the plaster.
B. Venous congestion and venous
thrombosis.
C. Delayed or malunion of fracture.
D. Orthostatic oedema of the limb:
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68. Common complications of plastering of
fractures is :
A. Ischemia of the limb distal to the plaster.
B. Venous congestion and venous
thrombosis.
C. Delayed or malunion of fracture.
D. Orthostatic oedema of the limb:
D
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71. Supracondylar fractures of the humerus in
children
A. Are common in children below the age of 10
B. More often result in a flexion injury than an
extension injury
C. May be complicated by a compartment
syndrome in the upper arm, if the brachial
artery is affected
D. Feeble radial pulse is an absolute indication
for immediate open exploration
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71. Supracondylar fractures of the humerus in
children
A. Are common in children below the age of 10
B. More often result in a flexion injury than an
extension injury
C. May be complicated by a compartment
syndrome in the upper arm, if the brachial
artery is affected
D. Feeble radial pulse is an absolute indication
for immediate open exploration
Answer A
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These fractures are common in young children.
Most are hypertension injuries. A brachial
artery compromise may cause a forearm (not
upper arm) compartment syndrome, and call
for a trial of immediate closed reduction
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72. Ulnar nerve compression: all of the following
are true, EXCEPT:
A. It may present with weakness rather than
pain
B. It usually requires nerve conduction studies
for diagnosis of site compression
C. Surgery is indicated for pain, but not for
weakness
D. it is less common than the carpal tunnel
syndrome
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72. Ulnar nerve compression: all of the following
are true, EXCEPT:
A. It may present with weakness rather than
pain
B. It usually requires nerve conduction studies
for diagnosis of site compression
C. Surgery is indicated for pain, but not for
weakness
D. it is less common than the carpal tunnel
syndrome
Answer C
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74. Shoulder dislocation: the following are all
true EXCEPT:
A. It is the commonest of joint dislocations in
adults
B. It is predisposed to by a Hill-Sach's lesion
C. It is usually posterior
D. It can be reduced by the Kocher method
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74. Shoulder dislocation: the following are all
true EXCEPT:
A. It is the commonest of joint dislocations in
adults
B. It is predisposed to by a Hill-Sach's lesion
C. It is usually posterior
D. It can be reduced by the Kocher method
Answer C
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75.Fractures of the proximal humerus
A. Are increased in incidence in older persons
B. Are more likely to need surgery in elderly
patients
C. Are classified according to mason's
classification
D. All of the above are true
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75.Fractures of the proximal humerus
A. Are increased in incidence in older persons
B. Are more likely to need surgery in elderly
patients
C. Are classified according to mason's
classification
D. All of the above are true
Answer A
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76.A 25 year old male presents to the emergency
department after a road traffic accident. Clinical
examination shows a blood pressure of 100/70 and
mild abdominal tenderness. Iliac crest "springing" for
a pelvic fracture is positive. Which of the following is
the LEAST important next step in management?
A. Start immediate intravenous fluids
B. Conduct a careful examination for other injuries
C. Carry out immediate diagnostic peritoneal lavage
(DPL) for intra-abdominal trauma
D. Send blood for hemoglobin levels and cross-matching
132. Dreamz Learning Innovations_____________________________________________ Page 132
76.A 25 year old male presents to the emergency
department after a road traffic accident. Clinical
examination shows a blood pressure of 100/70 and
mild abdominal tenderness. Iliac crest "springing" for
a pelvic fracture is positive. Which of the following is
the LEAST important next step in management?
A. Start immediate intravenous fluids
B. Conduct a careful examination for other injuries
C. Carry out immediate diagnostic peritoneal lavage
(DPL) for intra-abdominal trauma
D. Send blood for hemoglobin levels and cross-matching
Answer C
133. Dreamz Learning Innovations_____________________________________________ Page 133
All patients with potentially significant trauma
require at least one, and preferably two, i.v.
lines for fluid infusion and blood. Every
patient requires a quick clinical examination
of the entire body. Except in the direst
circumstances, every patient requires
detailed clinical examination. Blood
transfusion in this patient may be required,
even if the hemoglobin is normal, but a DPL
is not indicated at this stage, when the
hemodynamic stability of the patient has not
been confirmed.
134. Dreamz Learning Innovations_____________________________________________ Page 134
77.A 55-year-old laborer presents to the casualty of
a primary health center after a fall from a height.
Plain X-rays confirm a fracture of both pubic
rami. The patient is hemodynamically stable,
but during observation of 5 hours it is noted that
he does not pass urine. At that time abdominal
examination shows that the bladder is full. If a
urologist is unavailable, the most appropriate
next step is:
A. Administer intravenous carbachol to stimulate
bladder contraction
B. Administer sympathomimetics to decrease
prostatic congestion
C. Pass a urethral catheter
D. Carry out a suprapubic catheterization ' "
135. Dreamz Learning Innovations_____________________________________________ Page 135
77.A 55-year-old laborer presents to the casualty of a primary
health center after a fall from a height. Plain X-rays
confirm a fracture of both pubic rami. The patient is
hemodynamically stable, but during observation of 5
hours it is noted that he does not pass urine. At that time
abdominal examination shows that the bladder is full. If a
urologist is unavailable, the most appropriate next step
is:
A. Administer intravenous carbachol to stimulate bladder
contraction
B. Administer sympathomimetics to decrease prostatic
congestion
C. Pass a urethral catheter
D. Carry out a suprapubic catheterization ' "
Answer D
136. Dreamz Learning Innovations_____________________________________________ Page 136
The other three steps mentioned are all
disastrous. Even in tertiary care centers,
where retrograde urethrography facilities
exist, suprapubic catheterization is never a
wrong step in a patient with pelvic fracture
and retention
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78.A 62 year old woman presents with a history of
fall while bathing. On examination she is
hemodynamically stable, but is unable to move
the left leg, which is lying in an attitude of
external rotation. The following are all true
EXCEPT:
A. The patient is likely to have an intracapsular
fractureof the femoral neck
B. Plain X-rays are enough for diagnosis, and CT is
rarely required
C. Surgical reduction and fixation or replacement is
always needed, and conservative treatment is
contraindicated
D. The commonest complication of this fracture is
malunion
138. Dreamz Learning Innovations_____________________________________________ Page 138
78.A 62 year old woman presents with a history of fall while
bathing. On examination she is hemodynamically stable,
but is unable to move the left leg, which is lying in an
attitude of external rotation. The following are all true
EXCEPT:
A. The patient is likely to have an intracapsular fractureof
the femoral neck
B. Plain X-rays are enough for diagnosis, and CT is rarely
required
C. Surgical reduction and fixation or replacement is always
needed, and conservative treatment is contraindicated
D. The commonest complication of this fracture is malunion
Answer D
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The commonest complications of intracapsular
fracture are nonunion and avascular
necrosis. Unlike pelvic fractures, plain X-rays
are usually enough to diagnose femoral
fractures. If the X-rays are inconclusive
despite compelling clinical signs, the patient
should undergo repeat X-rays after 2-3 days,
or MRI.
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79.A 13 year old boy sustains a closed, stable
fracture of the upper tibia. After reduction
and application of a cast, he complains of
excessive calf pain. The following step
should be taken:
A. X-rays to check for cast fragments V
B. Elevate the limb 5-10°
C. Elevate the limb by about 90°
D. Remove the cast
141. Dreamz Learning Innovations_____________________________________________ Page 141
79.A 13 year old boy sustains a closed, stable
fracture of the upper tibia. After reduction
and application of a cast, he complains of
excessive calf pain. The following step
should be taken:
A. X-rays to check for cast fragments V
B. Elevate the limb 5-10°
C. Elevate the limb by about 90°
D. Remove the cast
Answer D
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The boy has probably developed an impending
compartment syndrome in the leg. This is
caused by insufficient vascularity in the
affected limb. The first step is to remove the
cast and elevate the limb, and observe. If the
pain continues the patient will require a
fasciotomy.
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80. The following is true of ankle fractures:
A. The most frequent mechanism is pronation
of the forefoot and internal rotation at the
ankle
B. Swelling and tenderness are typically absent
or negligible
C. Undisplaced fractures should be treated with
a cast
D. Post-traumatic arthritis is rare at the ankle
144. Dreamz Learning Innovations_____________________________________________ Page 144
80. The following is true of ankle fractures:
A. The most frequent mechanism is pronation
of the forefoot and internal rotation at the
ankle
B. Swelling and tenderness are typically absent
or negligible
C. Undisplaced fractures should be treated with
a cast
D. Post-traumatic arthritis is rare at the ankle
Answer C
145. Dreamz Learning Innovations_____________________________________________ Page 145
Fractures at the ankle result from a twist. The
injury develops during supination of the
forefoot with external rotation at the ankle.
Tenderness is marked, and swelling occurs.
The commonest late complication is arthritis.
