Short Cases in Orthopaedics For PG Practical Examination

 

Prelims.pdf Chapter-01_Short Cases.pdf Chapter-02_Things to be Taken.pdf Chapter-03_Cases Seen in Ward Rounds.pdf

 

Short Cases in

ORTHOPAEDICS

 

Short Cases in

ORTHOPAEDICS for PG Practical Examination 

S Kumaravel MS (Ortho) D (Ortho) DNB (Ortho) (PhD) MNAMS

Associate Professor Department of Orthopaedics Government Thanjavur Medical College and Hospital Thanjavur, Tamil Nadu, India

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This book has been published in good faith that the contents provided by the author contained herein are original, and is intended for educational educati onal purposes only. While every effort is made to ensure accuracy of information, the publisher and the author specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work. If not specifically stated, all figures and tables are courtesy of the author. Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device. Short Cases in Orthopaedics for PG Practical Examination  First Edition :

2013

ISBN: 978-93-5090-083-3 Printed at 

 

Preface

The thought that why to write such a book when lots of  clinical orthopaedics books are available is normal. In fact, this is not a regular clinical orthopaedics book. It is conceived and written with the only intention to make passing the practical examination so easy, so that there is no need to panic.

After the theory examination, the candidate faces the practical examinatio examination. It istips a different ball game. Here, the confrontation occurs.n.The for examination given in this  book will make you to clear the paper with much ease. This approach when put to use for others, for example, my postgraduate postgradu ate students at two Medical Colleges, Colleges, worked wonders. Even a few students who had some difficulties in presenting cases found later that they can confidently answer the questions. This unique approach is a variety of methods to tackle the examinations, including a range of hypothetical questionnaire, ways to elicit present complaints and past history, correct methods to palpate, how to examine and how to diagnose cases, etc. Not a single candidate who followed this approach has been unsuccessful. The external examiners were also happy to have examined a good set of postgraduates. One of the students became the  best outgo outgoing ing MS Orthop Orthopaedics aedics student of the Tamil Nadu Dr MGR Medical University, Chennai, Tamil Nadu, India.

 

vi

SHORT CASES IN ORTHOPAEDICS

However, this book is not an alternative for your teacher’s direct guidance—as orthopaedics is a surgical speciality—it is learned mainly by apprenticeship. WHY THIS BOOK Any amount of work you do in the wards, any number of 

hours you work, toil with textbooks, the ultimate fruit of  all this is achieved only, if you pass the examination. When it comes to postgraduate examinations, examinations, either it is diploma, degree or DNB examination, the day’s performance holds the key. When you are writing a theory examination then the “confrontation factor” is not there, because you have a question paper and questions set to be answered. You can select, which questions to be answered first. This is not so in practical examinations. You cannot choose which question you will answer first. This will obviously irritate the examiner. So only, I decided to write something useful for the students which will help to confront the examiner and sail smoothly to pass the examination. Very useful words for the young minds are: 1. “Do “Don’t n’t beg for a pass pass—yo —you u shoul should d deman demand d it”. it”. 2. Any stu student dent ente enters rs the the hall hall wit with h 100% 100% mar marks ks and, and, by his misdeeds and unforced errors, he loses marks slowly. So, if, at all, a postgraduate fails, it is he who fails and not the examiner. Having gone through 3 such postgraduate examinations: Diploma in Orthopaedics, MS Orthopaedics, and DNB Orthopaedics, I decided to expose the weak areas in our mind, which need to be strengthened to clear the examination with ease. S Kumaravel

 

Acknowledgements

I thank—all my professors, assistant professors, tutors, senior postgraduates, junior postgraduates and orthotist who have gave ideas and new insight. I acknowledge all my teachers while doing my undergraduation undergraduatio n at Coimbatore Medical College, especially Dr Muthu Meenakshi Ramanathan, Dr Perumal Rajan, Dr Kesavalu, Dr Sadasivam, Dr Chandra and also my Postgraduate teachers at Madras Medical College my alma mater, Professor K Sriram, Professor Mayilvahanan Natarajan, Professor K Annamalai, Professor CT Alagappan, Professor RH Govardan, Professor K Chandran, Professor M Subramanian, Professor R Dhanapal, Professor Nalli R Uvaraj, Professor R Selvaraj, Professor Sudheer, Professor Gopinath Menon, Professor S Najimudeen. I acknowledge Professor SP Mohanty, Professor Benjamin Joseph and Professor Bhaskar Anand Kumar of  Mahe Manipal for enriching my knowledge while, I was a visiting fellow there. I sincerely acknowledge Professor DK Taneja our past IOA president and my DNB examiner, who has enlightened me during his COE lectures. I acknowledge professors, Professor V Shanmugam, Professor KJ Mathiazhagan, Professor A Navaneethan, Professor R Rathinasabapathy and Professor M Gulammohideen for their encouragement.

 

viii SHORT CASES IN ORTHOPAEDICS

I acknowledge Mr Pandian, Orthotist, Institute of  Physically Handicapped, New Delhi. I sincerely acknowledge all my patients who kept their patience till all my demonstrations of test were being photographed. I thank my Postgraduate Dr Gopi Shankar Balaji now a full-fledged orthosurgeon, who helped in proofreading and preparation of the text. I thank my postgraduates Dr R Vijayakumar, Dr Manogaran, Dr Sivaraj for their help. I thank Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director) and Mr Tarun Duneja (DirectorPublishing) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India and Mr Jayanandan of Chennai Branch for the encouragement and support for this book. I thank my parents Sri G Shanmugasundaram and Smt Jayalaxmi for their sincere blessings. My work is not possible but for silent cooperation from my better half Dr Mangaleswari MDS and my son Vishva.

 

Contents

Short Cases .... ......... .......... .......... .......... .......... .......... .......... .......... .......... ......... .... 1 1. Con Congen genita itall Talip Talipes es Equin Equinova ovarus rus (CT (CTEV) EV) 2

3. 4. 5. 6.

• Lis Listt of Fin Findin dings gs above above Dow Downwa nwards rds 4 Oste Os teos osaarco coma ma 6 • Qu Quest estion ionss on Loc Local al Sta Stagin gingg 6 • Biopsy 8 Erb’s Palsy 19 Exostosis 20 Ost steo eomy myel elit itis is 24 Wing Wi ngin ing g of of Sca Scapu pula la 31

7. 8. 9. 10.. 10 11. 12. 13. 14.. 14

Cubit Cub itu us Va Varus 33 Cub Cu bit itu us Val algu guss 36 Tard Ta rdy y Ulna Ulnarr Nerv Nervee Pals Palsy y 37 Latera Lat erall Con Condyl dylee Non Nonuni union on 40 Maluni Mal united ted Int Interco ercondy ndylar lar Fra Fractur cturee 41 Unredu Unr educed ced Dis Disloc locati ation on of Elb Elbow ow 42 Post-tr Pos t-traum aumati aticc Stif Stiffne fness ss of Elb Elbow ow 43 Arth Ar thri riti tiss of of Elb Elbow ow 46

2.

15. 16.. 16 17.. 17 18. 19. 20.. 20 21.. 21 22.

Congenita Congen itall Radi Radiouln oulnar ar Syn Synost ostosi osiss 47 Frac Fr actu ture re Medi Medial al Epic Epicon ondy dyle le 48 Maluni Mal union on of Bot Both h Bones Bones For Forear earm m 50 Galea Ga leazzi zzi Fra Fractu cture re Disl Disloca ocatio tion n 52 Sudeck’s Sude ck’s Ost Osteod eodyst ystrop rophy hy (RSD (RSD)) 53 Volkma Vol kmann nn’s ’s Ischaem Ischaemic ic Contra Contractu cture re 55 Oste Os teoc ocla last stom omaa 58 Neglec Neg lected ted Sho Should ulder er Dis Disloc locati ation on 62

 

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SHORT CASES IN ORTHOPAEDICS

23.. Fr Fres esh h Di Disl sloc ocat ated ed El Elbo bow w 64 23 24.. Non 24 Nonuni union on of of Both Both Bone Bone For Forear earm m 66 25.. Br 25 Brac achi hial al Pl Plex exus us In Inju jury ry 67 26.. Torticollis 74 26 27.. Ce 27 Cere rebr bral al Pa Pals lsy y 75 28. Wrist Drop 84 29. Claw Hand 87 30.. Ra 30 Radi dial al Cl Club ub Ha Hand nd 91 31.. Com 31 Compo pound und Pa Palma lmarr Ga Gang nglio lion n 92 32.. Ne 32 Neur urop opat athi hicc Joi Joint nt 93 33. Carp 33. Carpal al Tun Tunne nell Synd Syndro rome me 94 34.. Du 34 Dupuy puytre tren’s n’s Co Contr ntrac actur turee 95 35.. Sp 35 Spin inaa Ve Vent ntos osaa 96 36. Mall 36. Mallet et Fing Finger er (Bas (Basee Ball Ball Finger Finger)) 97 37. Foot Drop 98 38. Ba Bak ker er’s ’s Cy Cyst st 101 39. Ma Madu duro rom myc ycos osiis 103

40. Gen enu u Valgum 104 41. Genu Varum 105 42.. Resi 42 Residu dual al Pol Polio iomy myel elit itis is 109 • Hi Hist story ory of the Pat Patie ient nt 109 • Ge Gene nera rall Exam Examin inat atio ion n 109 • Me Meas asur urem emen ents ts 109 • Sp Spec ecia iall Tes Tests ts 110

43.. Non 43 Nonuni union on Fra Fractu cture re Bot Both h Bone Bone Leg 113 44. Nonu 44. Nonuni nion on Pa Pate tell llaa 118 45. Con Congen genita itall Pseud Pseudart arthro hrosis sis of Tib Tibia ia 120 46. Osg Osgood ood-Sc -Schla hlatte tter’s r’s Dis Diseas easee 122

 

CONTENTS   xi

Things to be Taken .... ......... .......... .......... ......... ......... .......... ....... 123 Things to be Taken to the Clinical Examination Hall 124

Casess Seen Case Seen in in Ward Ward Round Roundss ... ...... ...... ...... ...... ..... .. 125 1. Cases and Appli Appliances ances You may be Asked Asked in Ward Ward Rounds in DNB and Notes for Them 126 Ward Procedures 126 Region with Condition 128 • Sh Shoul oulder der (Rot (Rotato atorr Cuff Cuff Tear) Tear) 128 • Arm 130 • Elbow 132 • Wri rist st an andd Han Handd 135

• Hip 142 • Thigh 143 • Knee 145 Foot and Ankle 151 • Re Retr troc ocal alcan caneal eal Burs Bursit itis is 154 • Lo Loca cali lise sedd Gig Gigan anti tism sm 157 2. Pa Paed edia iatr tric ic Ca Case sess 165 • Birt Birthh Fractu Fractures res in a 3-day 3-day-old -old Child 169

3. Complica Complication tionss of of Injur Injuries ies and Trea Treatmen tmentt 170 4. Met Metab abol olic ic Bo Bone ne Di Diso sord rder erss 174 • Ost steo eom mal alac acia ia 179 5. Spine 180

 

How to Use this Book

We would start with the common cases in postgraduate examinations—their presentations, history/examination

and viva. Firstly let us see Pearls, which provides essential items needed and expected of you in the examinations. Later in the cases section we would be presenting a case, then start questioning, 1. dur urin ing g the hi hist sto ory 2. du duri ring ng th thee exa exami mina nati tion on 3. af afte terr the the di diag agno nosi siss and and 4. di disc scus usss the the ma mana nage geme ment nt.. This volume is about the common short cases. cases. Some will  be heavily heavily “theory” “theory” filled, filled, some some not. I have even included included few cases which may be of some use in ward rounds, in DNB examination, in objectively structured clinical examinations and also in day-to-day practice. I like to suggest you to sit with one of your batchmates and ask these questions to each other, where one playing the role of the examiner. Thus, you can familiarise with the usual questions and startlers. I have tried to be exhaustive but firmly believe that there is always scope for improvement and so, I look forward towards your suggestions for further enriching the quality of this book.

 

Pearls

READ ONE BY ONE CAREFULLY

• Do no nott ign ignor oree any any pr prob oble lem m of of pat patie ient nt.. For example, patient has no cause of right hip but has some findings for right hip, you may be caught napping. • Do no nott avo avoid id pr pres esen enti ting ng an any y fin findi ding ng.. • The presen presentt histo history ry sta starts rts fro from m the the time time of of onset onset of the the complaint. You may think a mild restriction of movement in the contralateral hip is of no use but this will definitely change the diagnosis. • Do no nott irr irrit itat atee the the ex exam amin iner er.. • Ta Talk lk co conf nfid iden entl tly, y, no nott ar arro roga gant ntly ly.. • See See the the exte extern rnal al exa exami mine ner’ r’ss eyes eyes and and tal talk. k. Do not see the internal examiner (if any). Its a sign of  weakness. • Dress neatly. • Imp Impres resss the the exami examiner ner at the the firs firstt insta instance nce,, eithe eitherr it a short or a long case. • Tr Trai aini ning ng is at wa ward rd,, it itse self lf.. For example, any question from patients or the attendant of the patient may be an examination question. For example, in a tumor case a patient’s attendant will ask:  Doctor can you cure it?  Can you remove it fully?  Can you burn the tumor (irradiation)?

 

xvi SHORT CASES IN ORTHOPAEDICS



Can you give chemotherapy?

 

How long will he/she live? Can she marry and have children? • In the the exa exami mina nati tion ons, s, ans answe werr in a bro broad ad bas based ed manner. • Wh Whil ilee pres presen enti ting ng,, do not not go go for for a diag diagno nosi sis. s. • Re Real al cas casee does does not not mat matte ter— r—di diag agno nosi siss does does not not matter. Its how you fight for your case. Do not avo avoid id pres present enting ing or alt alter er any any find finding ing.. Just Just tell tell what the patient has. If you you are are giv given en a ch chan ance ce to to go ba back ck and and see see,, go an and d see the case, and after afte r all, which doctor will you prefer? Thee one Th one who who will will mak makee sure sure one one mor moree time time his his fin findi ding ngss or the one who bluntly tell his findings are correct, if you are the patient? Whil Wh ilee thin thinki king ng abo about ut a tre treat atme ment nt tel telll what what is is the the

• • •

•

treatment if you have the problem, i.e. what would you like to have as treatment if you were at the patient’s end? • Do not see X-r X-rays ays at any any of of your your clin clinica icall prese presenta ntatio tion. n. If your eyes see the X-rays, it freezes your brain and it runs in the same orbit and never thinks further; X-rays come last. • Try to sta stand nd and pr prese esent nt rath rather er sit sit—si —sitti tting ng is psychologically cramps you to the chair. • Onc Oncee you fin finish ish off tak taking ing his histor tory y and cli clinic nical al examination, sit and think. 1. Wha Whatt will will be be the the discu discussi ssion on if if X-ray X-ray is norm normal? al? 2. If the the X-ra X-ray y is art arthri hritic tic wit with h joint joint nar narrow rowing ing?? 3. If the the X-r X-ray ay is is a tumo tumoro rous us con condi diti tion on??

 

PEARLS   xvii

• Keep Keep your your mind mind op open en till till the ent entire ire que questi stion on is is asked asked.. • Whi While le aske asked d to dem demons onstra trate te a cli clinic nical al sign sign,, try try to sta stand nd always on the right side of the patient. • Dem Demons onstra trate te the the sign signss you you are are asked asked to do do in the mos mostt classical way and not not the cursory cursory way way because because this ½ hour (or) (or) 1 hour assessment will reflect reflect your entire (3/2 years) training. • Pos Postgr tgradu aduate ate pr prese esenta ntatio tion n and dis discus cussio sion n of cli clinic nical al cases should involve facts and not controversies. • It is usu usual al and exp expect ected ed tha thatt a qu quest estion ion is ask asked ed previous answer. Examination Examin ation is not a war but a plot—  by you. you. You have to pull the examiner to your fold rather than otherwise.

 

Short Cases

 

2

SHORT CASES IN ORTHOPAEDICS

1. CONGENITAL TALIPES EQUINOVARUS (CTEV)

A

B

Figs 1A and B:  Unilateral club foot (Right side)

Fig. 2:  Same patient after surgery

 

SHORT CASES   3

A

B

Figs 3A and B:  (A) Recurrent club foot following surgery; (B) Bilateral club foot neglected for 10 months

A

B

Figs 4A and B:  Another such deformity since birth

 

4

SHORT CASES IN ORTHOPAEDICS

LIST OF FINDINGS IN CLUB FOOT ABOVE DOWNWARDS

              

Internal tibial torsion Calf atrophy Lateral malleolus prominent Medial malleolus less prominent Inner border of foot shorter/outer border of foot longer Abnormal creases posterior and medial Tendo calcaneus taut Adduction of forefoot Callosity present on lateral side foot Inversion at subtalar joint Heel small and elevated Cavus Inward curling of toes Bilateral in 50% Examine hips and spine always. 1. What What is the eti etiolo ology gy of this this con condit dition ion?? • Abn Abnorm ormal al uteri uterine ne posit position ion (mos (mostt accept accepted) ed) • Pri Primar mary y ger germ m plas plasm-t m-tala alarr def defect ect • Pri Primar mary y soft soft tis tissue sue abn abnor ormal mality ity.. 2. Pathol Pathologi ogical cal ana anatom tomy y of this this condi conditio tion? n? • Talu Talus—p s—plant lantar ar flexed flexed,, neck neck elongat elongated ed and and rotate rotated d • Ca Calc lcan aneu eus— s—in inve vert rted ed • Na Navi vicu cula la—r —rot otat ated ed • So Soft ft ti tiss ssue ue co cont ntra ract ctur ures es • Tendo Achil Achilles, les, tibi tibialis alis poste posterior rior,, Flexor Flexor hallu hallucis cis longus (FHL), Flexor digitorum longus (FDL), Abductor hallucis

 

SHORT CASES   5

• Lig Ligame aments nts—sp —sprin ring g ligamen ligament, t, planta plantarr fascia fascia • Cap Capsul sules— es—sub subtal talar/ ar/mid midtar tarsal sal joint joints. s. 3. Wha Whatt are are the dif differ ferent ential ial dia diagno gnoses ses?? • My Myel elom omen enin ingo goce cele le • Arth thrrogr gry yposi siss • Po Polliomy myel eliiti tiss • Ce Cerreb ebrral pal alsy sy • Co Cons nstr tric icti tion on ba band ndss • Ti Tibi bial al he hemi mime meli lia. a. 4. Wha Whatt is the the most most comm common on as assoc sociat iated ed anoma anomaly? ly? • Urogenital. 5. What What is is the the mana manage geme ment nt?? • Dep Depend endss on the the age age of the the child child and typ typee of the the CTEV • Ponse Ponsetti’s tti’s metho method d of of serial serial cast corr correcti ection, on, every every

week (sequence of manipulation→  fore foot cavus→ adduction→ varus-equinus). 6. What What are are the the surg surgic ical al opt optio ions ns?? • Pos Poster terome omedia diall soft soft tis tissue sue rel releas easee • Ex Exte tens nsil ilee re rele leas asee • Cor Correc rectiv tivee osteo osteotom tomy y of the cal calcan caneum eum

• Trip Triple le ar arth thro rode desi siss • JES JESS/I S/Ili lizar zarov ov appar apparatu atuss applica applicatio tion. n. 7. What is the the single single most impor important tant tendo tendon n to rele release ase in posteromedial soft tissue release? • Ti Tibi bial alis is pos poste teri rior or..

 

6

SHORT CASES IN ORTHOPAEDICS

2. OSTEOSARCOMA      

Age group—younger age usually (sometimes middle age—parosteal) Swelling, pain (pain starts first) Region—around the knee Step by step approach. Clinical examination, local staging, systemic staging, Histopathology Usually soft in consistency/fast growing/vascular Clinically candidate can only tell it is a malignant bone tumor most probably it may be osteosarcoma. 8. What is the the common common prese presentati ntation on of of osteo osteosarc sarcoma? oma? • 10 100% 0% ca case ses— s—sw swel elli ling ng • 75%—pain.

Questions on local staging 9. How wil willl you you sta start rt inv invest estiga igating ting?? • X-ray a. Periosteal reaction (elevation)  b. Bone destruction c. Cortical erosion d. Pathological fracture e. Soft tissue involvement. 10. Elev Elevatio ation n of perio perioste steum um is speci specifica fically lly call called ed in this this case? • Cod Codman man’s ’s triang triangle le (not (not patho pathogno gnomon monic ic of  osteosarcoma).

11. Sunray Sunray spi spicul cules— es—how how it is for formed? med? a. They are are formed formed along along the blood blood vessel vesselss of  periosteum as it is elevated from the bone by the tumor

 

SHORT CASES   7

 b.. It is al  b also so hy hypo poth thes esiz ized ed to be fo form rmed ed by th thee Sharpey’s fibres of the periosteum. 12. Wha Whatt is the best best inve investi stigat gation ion for for local local stagi staging? ng? • Mag Magnet netic ic res resona onance nce ima imagin ging g (MRI (MRI). ). 13. Ho How w is os oste teos osar arco coma ma sta stage ged? d? • Low grade A—Intracompartmental B—Extracompartmental • High grade A—Intracompartmental B—Extracompartmental • Metastasis. 14. Wha Whatt is is a sa sate tell llit ite e les lesio ion? n? • It is a small small nodu nodule le separa separate te from from prima primary ry focifociembedded in medullary sinusoids with no reaction—not even detected by Tc 99 scan differentiated from secondary as there are no metastasis. • 50% pic picked ked by MRI, MRI, 50% 50% at at autop autopsy sy only only.. • Assoc Associated iated with poor prog prognosis nosis.. Recurr Recurrence ence can

follow after amputation also. 15. What What is the the best best invest investiga igatio tion n of choic choice e to pick pick up satellite, lesions? • Mag Magnet netic ic res resona onance nce ima imagin ging g (MRI (MRI). ). 16. How many many perce percent nt of sate satelli llite te nodule noduless picked picked by MRI? • About 50%. 17. What What is the the impor importan tance ce of sat satell ellite ite nodu nodules les?? • To pla plan n the the leve levell of res resec ecti tion on..

 

8

SHORT CASES IN ORTHOPAEDICS

18. What is the the common commonest est sec seconda ondary ry of of osteo osteosar sarcoma coma?? • Lungs. 19. What What are the the charact characteri eristi stics cs of lung lung seconda secondarie ries? s? • These ar are multiple, basal, bilateral, subpleural (mnemonic → MBBS). 20. What What is the the use use of ches chestt comput computed ed tomog tomograp raphy? hy? • Che Chest st comput computed ed tomog tomograp raphy hy more more specif specific ic to pick pick up during secondaries. 21. If the the chest chest X-ra X-ray y is norm normal, al, stil stilll will will you order order computed tomography chest? • Yes Yes,, comput computed ed tomog tomograp raphy hy scan scan can can pick pick up up micrometastasis. BIOPSY

22. What What are are ty types pes of bi biop opsy sy?? a. Fine needl needlee aspirat aspiration ion cytol cytology ogy (FNA (FNAC) C)  b.. Core needle biopsy—Ideal  b c. Ope pen n bi biop opsy sy.. 23. Why co core re nee needl dle e biop biopsy sy is is idea ideal? l? • You get a bit bit of tissu tissuee for for diagn diagnosis osis with mini minimum mum

contamination of track • The There re is is less less blee bleedin ding g and and less less seedi seeding. ng. 24. In open open biops biopsy, y, what what is is the prec precaut aution ion you will will tak take? e? 1. Avo Avoid id cros crossin sing g compa compartm rtment entss 2. Incis Incision ion placed placed in such such a way that it it is includ included ed in the final surgery incision 3. Cut the the window window in an oval oval shaped shaped not not in a stress stress increasing manner 4. Achieve Achieve perfect perfect hemosta hemostasis sis in in the form of bone bone wax wax 5. No dr drain.

 

SHORT CASES   9

25. What is the diag diagnost nostic ic hist histopat opatholog hological ical appea appearanc rance e of osteosarcoma • Pre Presen sence ce of mal malign ignant ant ost osteoi eoid. d. 26. What What are the the histolo histologic gical al types types of oste osteosa osarco rcoma? ma? Types of osteosarcoma a. Os Oste teob obla last stic ic  b.. Fibro  b Fibroblasti blasticc c. Ch Chon ondr drob obla last stic ic d. Tel Telang angie iecta ctati ticc

e. Sm Smal alll cell cell typ type. e. 27. Wha Whatt are are the the trea treatm tment ent op opti tion ons? s?

• Stage Stage IA—I IA—Intr ntraco acompa mpartm rtmenta entall low low gra grade de → Limb salvage • Stag Stagee IB—E IB—Extra xtracomp compartm artmental ental low grad gradee →  Ablation • Sta Stage ge IIA—In IIA—Intra tracom compar partme tmenta ntall high high grade grade → Limb salvage • Sta Stage ge IIB—Ex IIB—Extra tracom compar partme tmenta ntall high grad gradee →  Ablation • Stag Stagee III—M III—Met etas asta tasi siss chemo/radiotherapy.

→

  Palliative ablation/

28. What What is a com compa part rtme ment nt?? • Bo Bone ne is is a com compa part rtme ment nt.. • Eac Each h muscl musclee group group is a com compar partme tment. nt. 29. If you you plan plan for for limb limb salvag salvage, e, how how will will you pro procee ceed? d? • If the the case case is is planned planned for limb salva salvage, ge, patie patient nt is

put on chemotherapeutic drugs before any surgical procedure is undertaken. This is called Neoadjuvant chemotherapy.

 

10

SHORT CASES IN ORTHOPAEDICS

30. What What are the the advan advantag tages es of neoa neoadju djuvan vantt chemochemotherapy? 1. Contr Controls ols micro micrometas metastasis tasis and metast metastasis asis durin during g

surgery

2. 3. 4. 5. 6.

31.

32. 33.

34.

Tumorr re Tumo regr gres essi sion on Decr De crea ease se vascu vascula lari rity ty Tumor beco becomes mes more more firm firm and and easy easy to dissec dissectt It gives gives time time to fabric fabricate ate a custom custom pros prosthesi thesiss When chemot chemotherap herapy y is given given before before surge surgery, ry, the the resected specimen can be sent for study of necrotic necrot ic material and chemotherapeutic drugs can be

changed if no necrosis, i.e. the tumor has not responded. Whatt are the Wha the commo common n chemoth chemothera erapeut peutic ic agent agentss used in osteosarcoma? • Cis Cispla platin tin,, adriam adriamyci ycin n and ifosp ifospham hamide ide.. Whatt is adju Wha adjuva vant nt che chemot mother herap apy? y? • Giv Given en aft after er sur surgic gical al abl ablati ation. on. What stag stage e of cyc cycle le of tumor tiss tissue ue is amena amenable ble for for chemotherapy? • G2 mul multip tiplyi lying ng mit mitoti oticc sta stage. ge. How to to suspec suspectt osteo osteosar sarcom coma a clini clinical cally? ly? • Young age →  1st and 2nd decade • No joint invo involveme lvement nt (may (may have extra extra-art -articul icular ar restriction) • No con const stit itut utio iona nall sympt symptom oms. s.

35. Oste How dimfferen diffe tiate te Ewing’ Ewing’ss from fro minosteosa oste osato rco a rentia Ew g’s sosarco arcrcoma? omama?

 

Site—appendicular skeleton

50% axial 50% appendicular

Cons Co nsti titu tuti tion onal al sym sympt ptom omss abse absent nt

Pres Pr esen entt (++ (++))

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36. Can we get get ost osteos eosarc arcoma oma at old age age?? • Yes Yes/us /usual ually ly sec second ondary ary ost osteos eosarc arcoma oma • Class Classical ical osteo osteosarco sarcoma ma in in old old age age due to irrad irradiiation, Paget’s, consisting congenital conditions like hereditary, multiple exostosis and fibrous displasia • The They y are are typi typical cally ly high highly ly mali maligna gnant. nt. 37. Having Having diagn diagnose osed d osteosa osteosarco rcoma ma clinic clinicall ally, y, what what investigation you will order next? • Pla Plain in X-ray X-ray of of bone bone with with joint joint abov abovee and belo below w 38.

39. 40.

41.. 41

42.

• We see see permeati permeative ve lesion lesion with cort cortical ical destr destructi uction. on. What are the the differ difference encess between between multi multicent centric ric origin and multiple secondaries? • Mult Multicent icentric ric orig origin—m in—multi ultiple ple areas with lesio lesions ns similar to primary (Codman’s, etc.) with no lung lesions • Mult Multiple iple secon secondari daries—o es—osteol steolytic ytic lesio lesions ns only. Where will be the the bone bone secon secondari daries es seen seen comm commonly only?? • To the ver erte teb bra ra.. Whatt is the rol Wha role e of tra trauma uma in inci incidenc dence? e? • Tra Trauma uma hist history ory is is only only incide incidenta ntall and have have no no etiological importance in this condition. Whatt is the comm Wha common on stage stage of of present presentati ation on of osteosarcoma? • St Stag agee II II B (E (Enn nnek ekin ing) g)—7 —70% 0% • St Stag agee II III— I—20 20%. %. Whatt is the pro Wha progno gnosis sis of oste osteosa osarco rcoma? ma? • Pro Progno gnosis sis has has improv improved ed drama dramatic ticall ally y with with adjuvant chemotherapy. • 5 years years survi survival val in in case case of limb limb salva salvage ge is 85% 85% with adjuvant chemotherapy.

 

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43. Any otherrof othe imp import ortant ant fact factor or other other than than stag stage e and adequacy resection? • Yes • Tum Tumor or size; size; small smaller er the the tumor— tumor—bet better ter is is the prognosis. • Res Respon ponse se to to chem chemoth othera erapy py is bett better. er. • Tum Tumor or necro necrosis sis afte afterr chemot chemother herapy apy is is the only only significant variable. 44. What What is MDR MDR 1 and and P-Gl P-Glyc ycop opro rote tein? in? • MDR 1 is is Multi Multidru drug g Resis Resistan tantt 1 gene gene.. • It codes codes for 170 KDA Memb Membrane rane prot protein ein call called ed PPGlycoprotein. This decreases the intracellular concentration of many cytotoxic drugs by energy efflux pump. • This is of of signific significance ance in osteosa osteosarcoma rcoma and other tumors. 45. What What is the natu natural ral cour course se of oste osteosa osarco rcoma ma after after diagnosis if left untreated? • It breach breaches es the the cortex cortex and the soft tissu tissues es interi interior or of muscles, nerves, vascular structures and distant metastasis and not by lymphatics. This is  because bone has no lymphatics. 46. What What are are the the inves investig tigati ations ons pos possib sible? le? • X-ray • CT (Co (Comp mput uted ed tom tomog ogra raph phy) y) • MRI • Angiography • Th Thaall lliu ium m st stud udy. y.

47. What What is Mi Micr crom omet etas asta tasi sis? s? • Whe When n X-ray X-ray ches chestt and CT scan scan are are norma normall with with no other demonstrable secondaries in isotope

 

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scan, patient is suspected to have micrometastasis. • 35% norm normal al X-ray X-rayss will will have have CT chest chest posi positiv tivee for secondaries. 48. X-ray X-ray shows shows sing single le lobe lobe of lung lung invo involve lved. d. Why you you need CT? • Ot Othe herr lung lung mic micro rome meta tast stas asis is.. 49. Open Open biops biopsy. y. How How is is it dan dange gero rous us?? • Contaminati tio on • He Hemo most stas asis is is mu must st • Bo Bone ne ce ceme ment nt fo forr bon bonee • Ge Gell fo forr sof softt tis tissu sue. e. 50. What bear bearing ing the the biopsy biopsy site have over trea treatmen tment? t?

• Since Sinc e osteos osteosarco arcoma machemotherapy patient pati ent shoul should dthey be appro be ap proached ached positively, i.e. with live longer, we should not hamper the chance of limb salvage. • It is is better better to do do a cor coree needle needle bio biopsy psy wher wheree dissemination chance is less and if needle specimen is inadequate, open incisional biopsy is planned so that the scan with margin is removed in definitive surgery.

51. How to diagn diagnose ose and subty subtype pe osteo osteosar sarcom coma? a? • Dem Demons onstra tratio tion n of mali maligna gnant nt oste osteoid oid.. • The There re are 5 type typess histo histolo logic gicall ally: y: – Osteoblastic – Chondroblastic – Fibroblastic – Telangiectatic

– Small cell.

 

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52. What What are the type typess of medull medullary ary lesi lesion on in oste osteoosarcoma? • Thr Three ee types types:: Scler Scleroti otic, c, Lyti Lytic, c, Mixed Mixed.. 53. What What is clas classic sical al pictu picture re of ost osteos eosarc arcoma oma?? • Site Site—Met —Metaphy aphysis, sis, Codm Codman’s an’s tria triangle, ngle, sunra sunray y

spicules, usually no pathological fracture. 54. Is Codm Codman’ an’ss tria triangl ngle e path pathogn ognomo omonic nic?? • No No.. It can occur occur in in other other condi conditio tions ns also also where where periosteum is elevated. 55. What What is the cau cause se of Sunra Sunray y spic spicule ules? s? Two theories 1. Calc Calcifica ifications tions along along the the attachmen attachmentt of Sharpey’ Sharpey’ss

from periosteum the cortex 2. fibres Calcifica Calc ifications tions along the along the to peri periostea osteal l blood blood vessels. vessels. 56.. Why oste 56 osteosar osarcoma coma is more more common common in metameta-

physis? • Grow Growth th based based on Johns Johnson’s on’s theo theory ry of of field field selection, proliferative primitive spindle cells lodged in metaphysis • Prol Prolifera iferative tive prim primitive itive roun round d cells cells are lodge lodged d in

diaphysis • It is is not not just just du duee to the blo blood od supp supply ly of of the the metaphysis. 57.. How 57 How wil willl you you co conf nfir irm? m? • Cor Coree nee needle dle bi biops opsy—d y—diag iagnos nostic tic.. 58. What What are are the the compon component entss of lim limb b salva salvage? ge? • Wi Wide de ex exci cisi sion on of th thee tum tumor or

• Fo Foll llow owed ed by by reco recons nstr truc ucti tion on

 

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• In adults adults,, knee joint joint fusi fusion, on, endop endopros rosthe thesis sis,, allograft, ilizarov, rotation plasty • In chil childre dren n expan expandab dable le pros prosthe thesis sis.. 59. Whe When n secon secondar dary y oste osteosa osarco rcoma ma occu occurs? rs?

• In premal premalignan ignantt disease diseasess like like Paget Paget’s, ’s, irra irradiat diated ed  bone, diaphyseal achalasia, enchondromatosis enchondromatosis,, secondary OS can occur • Sk Skel elet etal al—s —sec econ onda dari ries es.. 60. When When wil willl you you do do biop biopsy sy?? • Wh When en the the pri prima mary ry not not det detec ecte ted. d.

61. Whe When n will will you you do pro prophyl phylact actic ic fixa fixatio tion? n?

• Mirel’s Mirel’s scorin scoring g system system 4 variab variables-1 les-1,, 2, 3 points points in that order V e r ia ble

Score 1

Sc o r e 2

Sc o r e 3

1. Location of of th the lesion ................

upper limb

l ow e r limb

peritrochanter........

2. Degree of pain

mild

mo d e r a t e s e v e r e

lytic

blastic

caused lesion by the 3. Type of lesion .......................

4. Size of the lesion < 1/3 ............................

mixed

1/3 = 2/3 > 2/3

8/12 = 15% risk of fracture 9 or above indication for prophylactic fixation.

 

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A

B

Figs 5A and B:  A case of osteosarcoma of distal tibia

 

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A

B

Figs 6A and B: X-ray of the above patient with sunray appearance

Fig. 7:  A girl with osteosarcoma of lower femur 

 

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A

B

Figs 8A and B: X-ray of the above patient

Fig. 9: MRI of the above patient

 

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3. ERB’S PALSY 1. De Defo form rmit ity y is is prese present nt sin since ce bir birth th 2. His Histor tory y of dif diffic ficult ulty y in 2nd sta stage ge of of labo labor. r. Child unable to flex the elbow, supinate the forearm. Flexion of finger is possible with attitude of waiter’s tip receiving position (see Fig. 10A). 62. Wha Whatt is pro progno gnosti sticc indic indicato atorr in Erb’ Erb’s? s? • Biceps Biceps recover recovery y within within 3–6 mont months hs of of delive delivery ry is is of good prognosis. 63. What is the the posit position ion of of limb limb to be kept kept in infa infants? nts? • Abd Abduct uction ion and and exter external nal rota rotatio tion n of uppe upperr limb, limb, this will relaxed brachial plexus. 64. Wha Whatt is the typ typica icall findin finding g in adul adultt X-ray X-ray?? • Be Beak akin ing g of of acr acrom omio ion. n. 65. What are the recon reconstr structi uction on procedu procedures res avai availabl lable? e? 1. Shoulder Shoulder arthro arthrodesis desis in in functiona functionall position position.. 2. Muscl Musclee transfer transfer to to augment augment elbow elbow flex flexion. ion.

A

B

Figs 10A and B: A lady with a left side Erb’s palsy and her X-ray

 

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4. EXOSTOSIS 66. How to tel telll any any mass mass as exo exosto stosis sis?? • Sit Site—B e—Bony ony swe swelli lling ng aro around und the joi joint nt • Age grou group— p—Ske Skelet letall ally y immatu immature re age age group group • Abno Abnormal rmality ity of the the host host bone, bone, e.g. shor shorteni tening, ng,

dysplasia (Theories of exostosis—periosteal defect theory and others). 67.. Is Ex 67 Exos osto tosi siss a tu tumo mor? r? • It is not a tumo tumor. r. It is a devel developm opmenta entall anomaly anomaly.. 68. Why clinic clinicall ally y exostos exostosis is appears appears large largerr than X-ray?

• Beca Becaus usee of of the the ca cart rtil ilag agee cap cap.. 69. Wha Whatt are are the the compli complicat cation ionss of exo exosto stosis sis?? 1. Mechan Mechanical ical block block for for joint joint movement movement with with adjoining joint

2. Adv Advent entiti itious ous burs bursaa and pai pain n 3. Frac Fracture ture of exosto exostosis sis stalk and pain 4. Mal Malign ignant ant tran transfo sforma rmatio tion. n. 70. What What are are the the cause causess of pai pain n in exos exostos tosis? is? 1. Ad Adve vent ntit itio ious us bur bursa sa 2. Fr Frac actu ture re of st stal alk k 3. Ma Mali lign gnan ancy cy.. 71. What What is the the malig malignan nancy cy that that usual usually ly arise arisess from from exostosis? • Cho Chondr ndrosa osarco rcoma ma (se (secon condar dary). y).

 

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72. How to ident identify ify the mali malignany gnany of carti cartilagi laginous nous origin? • It is diff difficul icultt even even for for an exper experience ienced d patholo pathologist. gist. 73. The cytol cytologi ogical cal featu features res sugge suggesti sting ng malignan malignancy cy are: are:

1. 2. 3. 4. 5.

Water and Water and calci calcium um conte content nt > 85% 85% DNA DN A > 5. 5.55 mic micro rogr gram am Protei Pro tein n > 350 mic micro rogra gram m Kerati Ker atin n sulph sulphate ate dec decrea reased sed Hexosa Hex osamin minee < 75 mic microg rogram ram..

74. What What are the the other other caus causes es of of seconda secondary ry chond chondrorosarcoma?

• Fi Fibr brou ouss dys dyspl plas asia ia.. 75. Which Which has has more more pred predilec ilection tion for mali malignanc gnancy— y— solitary or multiple? • Multiple. 76. What is the the import importance ance of the the tthick hickness ness of the the cartilaginous cap? • Thi Thickne ckness ss > 6 mm wil willl have have more more changes changes of  malignancy. 77. What What are the othe otherr indica indicator torss of malig malignanc nancy? y? 1. Haz Hazine iness ss of out outer er cor cortex tex 2. Irr Irregu egular lar matr matrix ix insid insidee the tumor tumor 3. Car Cartil tilage age cap thi thickn ckness ess.. 78. How the the upper upper fibula fibularr exosto exostosis sis expo exposur sure e is done? done? 1. Expo Exposure sure is for for the the common common pero peroneal neal nerve

2. Nerv Nervee is first first protecte protected. d. Then exosto exostosis sis is resecte resected. d.

 

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A

C

B

Figs 11A to C: (A) Exostosis lower femur; (B) X-ray; (C) Exposure

A

B

Figs 12A and B: (A) An X-Ray of the leg seen on the side sid e shows an exostosis arising from the tibia pressing on the fibula; (B) Exostosis from posterolateral side of leg clinical diagnosed arise from fibula, if you tell this swelling arises from the tibia then you have already seen the X-ray shows it actually arise from the tibia pressing on the fibula

 

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A

D

B

E

C

F

Figs 13A to F:  Another case multiple exostosis of right upper arm, right femur and right tibia

Fig. 14:  An exostosis from left clavicle

 

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5. OSTEOMYE OSTEOMYELITIS LITIS Clinical Findings

Fig. 15:  Osteomyelitis of femur 

Fig. 16:  Another similar case of osteomyelitis

 

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Fig. 17:  Osteomyelitis of tibia

Clinical Findings       

Sinus with discharge Warmth in the region around the sinus Thickening of bone Tenderness Growth disturbance— disturbance—shortening/leng shortening/lengthening thening Pathological fracture Deformity.

79. Defi Defini niti tion on of oste osteom omye yeli liti tis? s? • Osteo Osteomyel myelitis itis is infla inflammat mmation ion of bone and

marrow (usually blood borne). 80. Why Why in me meta taph phys ysis is?? 1. Vascu Vascularit larity y and hairp hairpin in loop loop of capi capillari llaries es 2. Ma Macr crop opha hage ge activ activit ity y 3. Sl Slow owin ing g of of blo blood od..

 

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81. What What are are the the stage stagess of of osteo osteomye myelit litis? is? 1. Int Intram ramedu edulla llary ry abs absces cesss 2. Subp Subperios eriosteal teal absce abscess ss from from erosion erosion of cortex cortex 3. Str Stripp ipping ing of the the perio perioste steum um 4. Dia Diaphy physea seall seq seques uestru trum m 5. Peri Periosteu osteum m forming forming new new bone call called ed involuc involucrum. rum. 82. How How to to iden identi tify fy se seque quest stru rum? m? Sequestrum is identified by 1. Iv Ivor ory y whi white te co colo lorr 2. Smo Smooth oth sid sidee (on (on the pus pus)) 3. Rou Rough gh side side (Gran (Granula ulatio tion n side) side) 4. Du Dull ll note note on drop droppin ping g down down 5. Sinks in water water whereas whereas a normal normal bone bone will will float. float.

A

B

Figs 18A and B:  Patient femur infected plate and screws removed with sequestrum the right osteomyelitis

83. What are are types types of of osteom osteomyel yeliti itiss in adult adult (Cier (CiernynyMadder)? Types of osteomyelitis in adult A. Med Medul ulla lary ry

B. Sup Superf erfici icial al cort cortex ex

 

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C. Localized cortical and medullary D. Diffuse cortical and medullary (unstable) Host classified as A—Healthy BS—Compromise due to systemic factors BL—Compromise due to local factors BLS—Compromise due to both local and systemic factors C—Treatment worst than disease. 84. Any spe specif cific ic ost osteom eomyel yeliti itiss you you know? know? 1. Tu Tube berc rcul ulou ouss OM 2. Sa Salm lmon onel ella la OM. OM. 85. Wha Whatt are the the areas areas in in which which metaphys metaphysis is is int intrara-

articular? • Sh Shou ould lder er,, hip hip an and d elb elbow ow.. 86. What are are the usua usuall investi investigat gations ions of of osteom osteomyel yeliti itis? s? 1. X-ra X-ray y to see see the cavity cavity and sequest sequestrum rum and and to see formation of mature involucrum 2. Sino Sinogram gram in chron chronic ic osteo osteomyeli myelitis. tis. 87. Wha Whatt is the impo importa rtance nce of of involuc involucrum rum from from management perspective? • It is impo importa rtant nt to wait wait for for matur maturati ation on of the involucrum. Premature opening of window to remove the sequestrum will end in pathological fracture. 88. What What is is the the impo importa rtance nce of sin sinogr ogram? am? • To curet curette te or rem remove ove a seq seques uestru trum m it is bet better ter to to open the window at the site of the sinus rather

than normal bone to not to weaken the cortex in the already diseased bone.

 

28

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89. What What are are the the cause causess of per persis sisting ting sin sinus? us? 1. No Nonde ndepen pendan dantt dra draina inage ge 2. Epi Epithe theli liali alizat zatio ion n of tract tract 3. Low gra grade de infe infecti ction on of of tract tract

4. 5. 6. 7.

Resist Resi stan antt bact bacter eria ia Immuno Imm unocom compro promis mised ed hos hostt Presen Pre sence ce of of fore foreign ign bod body y Specific Speci fic infec infection tion like tuber tuberculo culosis. sis.

90.. Wha 90 hatt is is MOT OTT T? • Myc Mycob obact acteri eriaa other other than than tuber tubercul culosi osis. s. 91. What is the the invest investigati igation on of of choice choice in acute acute osteomyelitis? • Thr Three ee phase phase bone bone scan—i scan—itt differe differenti ntiate atess acute acute osteomyelitis and cellulitis. Former will have activity in delayed images and latter has normal activity in delayed images. Osteomyelitis of Humerus in a Girl

Fig. 19:  Now the disease is quiescent. It is better  to leave her alone

 

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Fig. 20:  Same patient

A

B

Figs 21A and B: X-ray for the above patient

 

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Fig. 22:  Sinus of thigh—osteomyelitis of right femur 

A

B

Figs 23A and B:  Osteomyelitis of distal tibia with deformity

 

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6. WINGING OF SCAPULA 92. Diff Differ eren enti tial al di diag agno nosi sis? s? 1. Weakn Weakness ess of of serratus serratus anter anterior— ior—Invol Involvement vement of  long thoracic nerve of bell 2. Sp Spre reng ngel el’s ’s shou should lder er 3. De Delt ltoi oid d fibr fibros osis is.. • Serratus anterior holds the medial border border of  of  scapula on to the chestwall. So when it is weak, the medial border becomes more prominent or winged-long thoracic nerve of bell involvement. • Spreng Sprengel’s—S el’s—Scapul capulaa is smaller smaller and elevated elevated (Appears to be winged). • Deltoi Deltoid d fibrosis—Ther fibrosis—Theree is a fixed abductio abduction n deformity of the shoulder. So when the arm is  brou  br ought ght to the si side de of che chestw stwal all, l, sc scap apul ulaa ap appe pear arss winged (abduction reduces winging).

A

B

Figs 24A and B:  (A) Pushing the wall →  winging; (B) No winging on adduction rules out deltoid fibrosis. This is a case of weakness of right serratus anterior due to viral infection of  the long thoracic nerve of Bell

 

32

A

SHORT CASES IN ORTHOPAEDICS

B

Figs 25A and B: Abduction causes prominence of scapula even from front

A

B

  Figs 26A and B:  Abduction does not reduce winging

All the above photographs are of one gentleman with right side long thoracic nerve palsy.

 

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7. CUBITUS VARUS   

History of injury to the elbow History of massage/splinting Patient usually brought for cosmetic purpose.

On Examination   

Deformity (Gunstock) Thickening of supracondylar region of humerus Range of motion (ROM)—Flexion is restricted usually.

Clinically diagnosed as cubitus varus due to malunited supracondylar fracture with or without myositis ossificans. 93. What are are the area areass to be seen seen for myosi myositis tis ossificans?

• Br Brac achi hial alis is and and tri trice ceps ps.. 94. Other Other joints joints invo involve lved d in myosit myositis is ossif ossifica icans? ns? • Hip. 95. What are the inves investiga tigation tionss and and treatm treatment ent you will order?

• X-ray X-ray of of both both elbow elbows—A s—AP P in exte extensi nsion— on—to to compare the carrying angle. 96. What What is cub cubit itus us rec rectu tus? s? • Whe When n correc correctio tion n of the the varus varus to to valgus valgus is is attempted if the lateral wedge of bone is taken less then it results in neutral and not valgus. 97. Wha Whatt is th the e caus cause e of of the the var varus us??

1. fracture. Medial tilt Medial tilt of the distal distal fragme fragment nt of the

 

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2. Increased bone formation on the lateral side probably due to the weight of the limb. 98. What What are are the the trea treatm tment ent opti option ons? s? Plan: Corrective osteotomy and internal fixation

• Fr Fren ench ch os oste teot oto omy • St Step ep cu cutt ost osteo eoto tomy my.. 99. The pati patient ent is is in skelet skeletall ally y immatu immature re age age group. group. Will you not allow for remodelling? • Thi Thiss defor def ormit mity y is in the the corona coronall plane. plane.

Remodelling can only occur in the plane of  movement of the joint, i.e. flexion and extension. In elbow, there is no movement in the coronal plane. Hence remodelling is not possible and hence the osteotomy.

  Fig. 27A: Gunstock deformity on the left side

 

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  Fig. 27B: On flexion the deformity disappears

 Fig. 28: The gunstock deformity on the left side in another case

 

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8. CUBITUS VALGUS

  Fig. 29: Cubitus valgus  

History of injury History of massage.

On examination: Deformity of valgus > normal side  Irregularity over lateral condyle  Abnormal mobility may or may not be present  Patient may have ulnar neuritis  ROM—Reasonabll ROM—Reasonablly y maintained. Plan: 100. What What will will you you see see in the the X-r X-ray ay?? • Co Conf nfir irm m the the ma mal/ l/no nonu nuni nion on • Usual Usually ly it it is diffi difficult cult to identi identify fy the the fractu fracture. re.

 

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9. TARDY ULNAR NERVE PALSY 101. How will will you prev prevent ent tard tardy y ulnar ulnar nerve nerve pal palsy? sy? • Ant Anteri erior or trans transpo posit sition ion of of ulnar ulnar nerve nerve..

  Fig. 30: Tardy ulnar nerve palsy

102. When When will will you you do bo bony ny cor corre rect ctio ion? n? • Os Oste teot otom omy y at at sec secon ond d stag stage. e.

• Bone graft grafting ing to unite unite the later lateral al condy condyles les with minimal fixation. 103. Why Why do yo you u need need an an oste osteot otom omy? y? • To reduc reducee undue undue loadi loading ng of medi medial al side side of joint joint..

To reduc reducee undue undue loadi loading ng of medi medial al side side of joint joint.. 104. What What is th the e type type of of oste osteot otom omy? y? • St Step ep cu cutt ost osteo eoto tomy my..

 

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105. Wha Whatt is the cau cause se of thi thiss condi conditio tion? n?

• Associ Associate ated d with prog progres ressiv sivee cubitus cubitus valgu valguss due to epiphyseal arrest of the lateral condyle and progressive growth of medical epiphysis. Commonly after epiphyseal injury involving lateral condyle, or humerus. 106. Wha Whatt will will the the pati patient ent co compl mplai ain? n?

• The pati patient ent comp complai lain n numbne numbness ss of medi medial al one one and half fingers and weakness of fingers (intrinsic weakness). 107. Before Before atte attempt mpting ing any any treat treatment ment what will will you you order or do?

• Ne Nerv rvee cond conduc ucti tion on stu studi dies es.. 108.. What 108 What is is the the trea treatm tmen ent? t? • Earl Early y cases—a cases—anteri nterior or transp transpositi osition on of of ulnar ulnar nerve physiotherapy to the finger should be decided not later than three months of injury.

• Later Later cases— cases—as as for for ulna ulnarr claw claw hand hand—ten —tendon don transfers. 109. Wha Whatt is cubi cubita tall tunne tunnell syndr syndrom ome? e?

• The groo groove ve behin behind d the medi medial al epico epicondyl ndylee may be shallow in some individuals. So after a trauma may not be related to this region but a supracondylar fracture, etc. the patient may experience numbness and weakness of the region of the ulnar nerve.

 

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110. What What is the tre treatm atment ent for thi thiss syndro syndrome? me? • Exten Extension sion splin splint—neu t—neurovi rovitami tamins—fo ns—forr a peri period od of  three months from injury. Nerve conduction studies are done and the slowing or no conduction is confirmed and anterior transposition of ulnar nerve is done. 111. What What is the the compl complica icatio tion n of this this sur surger gery? y? • Tem Tempor porary ary to to perman permanent ent loss loss of of ulnar ulnar nerve nerve function is a known complication.

 

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10. LATERAL CONDYLE NONUNION

  Fig. 31: Lateral condyle fracture of left elbow

History of injury/indigenous treatment and massage  Deformity of elbow in the form of cubitus valgus  Bony irregularity/abnormal irregularity/abnormal mass of the elbow over the lateral condyle  Relative mobility of the mass to be tested against the humerus. Treatment: Same as for cubitus valgus. 112 11 2. If you you have later lateral al condyl condyle e fractur fracture e with with no abnormal mobility but X-ray shows no callus. How will you explain? • Pat Patien ientt is is havi having ng fib fibro rous us uni union. on. 113. 11 3. Why shoul should d this frac fractur ture e have have so commo common n to undergo process of nonunion? 

• The frac fractur turee ends ends are not not oppose opposed d to each each other other.. In fact the distal fragment rotates 180° and both fracture surfaces are facing laterally.

 

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11. MALUNITED INTERCONDYLAR FRACTURE Patient presents with stiffness of elbow, History of injury/ indigenous treatment.

114. What What will will be be the the usual usual vi viol olen ence ce?? Fall on the point of elbow. On examination: • Int Interc ercond ondyla ylarr dis distan tance ce wid widene ened d • Ra Rang ngee of mov movem emen ents ts res restr tric icte ted d • Fix Fixed ed fle flexio xion n defo deformi rmity ty pre presen sentt

• Ma May y or or may may no nott be be myo myosi siti tis. s. 115. Wha Whatt is the the tre treat atme ment nt of of choi choice ce?? • The bony bony unio union n is asses assessed sed and and confi confirme rmed d with with radiographs. • Art Arthro hrolys lysis is can can be done done to to impro improve ve the the range range of  movement.

 

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12. UNREDUCED DISLOCA DISLOCATION TION OF ELBOW History of injury.  Indigenous treatment usually in extension  Difficulty in movement of elbow. On examination:   

Fracture disease + over entire upper limb Skin shiny/loss of hair + Triceps standing out (Tendo Achilles sign of triceps).

Fig. 32:  Look for ulnar nerve palsy

116. Wha Whatt are are the the trea treatm tment ent opti option ons? s?

• Open Op en reduc reductio tion n of the the dislo dislocat catio ion n and mobilization. 117. Any othe otherr proced procedure uress to reduc reduce e instab instabili ility? ty?

• Ante Anteri rior or bone bone bloc blockk-su surg rger ery y • Ant Anteri erior or tran transpo sposit sition ion of tric triceps eps..

 

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13. POST-TRAUMATIC STIFFNESS OF ELBOW • Hi Hist stor ory y of of inj injur ury/ y/in indi dige geno nous us ma mass ssag agee

A

B

Figs 33A and B:  Reaching the mouth; (B) Available extension

Fig. 34:  Another case attempting to reach the mouth

 

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Fig. 35: X-ray of the above patient

118. Should Should the they y alwa always ys hav have e a bon bony y injur injury? y? • Ma May y or may may not not hav havee bony bony inj injur ury. y. 119. Wha Whatt are are the the comm common on fin findin dings gs??

• Range Range of of movem movement ent of elbo elbow w restr restrict icted. ed. • Irr Irregu egular larity ity of of any of the the bony bony promi prominenc nence. e. (Lateral supracondylar ridge, lateral condyle, radial head, olecranon, medial epicondyle, medial supracondylar ridge in that order is palpated).

 

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120. What What are are the the trea treatm tment ent opti option ons? s? Conservative treatment: • Indomethacin • Lo Low w do dose se ra radi diat atio ion n • Ac Acti tive ve mobi mobili liza zati tion on.. 121. 12 1. If no impro improveme vement nt with with this cons conserva ervative tive trea treatment tment,, what is your plan? Adhesiolysis.

 

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14. ARTHRITIS OF ELBOW   

Pain and swelling History of injury (May or may not be)

History of fever/Morning stiffness. On examination:  Tenderness and diffuse swelling on either side of  olecranon (Common site to look for synovial swelling).  Tenderness over radial head, lateral condyle, on either side of olecranon.  To see axillary and supraclavicular nodes



To see other joint movements.

122. What What is your your clin clinic ical al diag diagno nosi sis? s? • Tub Tuberc erculo ulosis sis/Rh /Rheum eumato atoid id arth arthrit ritis is 123.. How 123 How will will yo you u proc procee eed? d? • Inv Invest estiga igatio tion n for abov abovee two dise disease ases. s. The X-ra X-ray y and blood investigation. 124. What What are are the the trea treatm tment ent opti option ons? s? • Syno Synovect vectomy omy or exci excision sion elbo elbow w and and antiantitubercular therapy (ATT)—for tuberculosis

• Synove Synovecto ctomy my and anti antirhe rheuma umatic tic drug drugss and joint joint replacement—for rheumatoid arthritis (RA). 125. Joint Joint repl replace acement ment sho should uld not be done done in? • Mai Main n contra contraind indica icatio tion n is active active infect infection ion..

 

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15. CONGENITAL RADIOULNAR SYNOSTOSIS Child brought with complaints of inability to receive objects (supinate)—usually bilateral. On examination:

  

Restricted supination (Rotation) Hypermobility Hypermobili ty of wrist joint Forearm fixed in pronation.

126 12 6. What are the the types types of of congenit congenital al radiouln radioulnar ar synostosis? Three types: 1. Upper radi radius us imperfe imperfectly ctly forme formed d no head and fused with ulna 2. Ill formed formed head/r head/radius adius attac attached hed by a thick thick introsseous ligament near the coronoid 3. Head is present present malf malformed ormed—fuse —fused d with with upper upper ulna 80% bilateral. 127. What What is is the the diff differe erenti ntial al dia diagno gnosis sis?? • Di Diffe fferen rentia tiall diagno diagnosis sis:: Pulled Pulled elb elbow. ow. 128. What What are are the the trea treatm tment ent opti option ons? s? • Leave alon alonee the child if the the child child is comfor comfortabl table. e. Usually they have hypermobility of the wrist joint and can adjust to all movements except the supination. • If the the parents parents pref prefers ers a surg surgery ery to to correc correctt deformi deformity ty only—inspite of thorough explanation regarding a poor outcome—only a corrective osteotomy and fixation with forearm in supination can be done.

 

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16. FRACTURE MEDIAL EPICONDYLE



History of injury On examination:  Look for any irregularity of medial epicondyle  Carefully see for any involvement of ulnar nerve. 129. What What are are the the trea treatm tment ent opti option ons? s? • Non-union → small fragment → excision • Non-union → large fragment → fixation. 130. What What will will the pat patien ientt compla complain in in an ulnar ulnar ner nerve ve involvement? • The pati patient ent comp complai lain n numbne numbness ss of medi medial al one one and half fingers and weakness of fingers (intrinsic weakness). 131. Before Before atte attempt mpting ing any any treat treatment ment what will will you you order or do?

• Ne Nerv rvee cond conduc ucti tion on stu studi dies es.. 132. What is the  treatment? 132 • Earl Early y cases— cases—wai waitt for for 3 mont months hs treat treating ing with conservative methods anterior transposition of  ulnar nerve physiotherapy to the finger should be decided not later than 3 months of injury. • Late Laterr cases— cases—as as for for ulna ulnarr claw claw hand hand—ten —tendon don transfers. 133. What What is cubi cubita tall tunne tunnell syndr syndrom ome? e? • The groo groove ve behin behind d the medi medial al epico epicondyl ndylee may be shallow in some individuals. So, after a trauma may not be related to this region but a

 

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supracondylar fracture, etc. The patient may experience numbness and weakness of the region of the ulnar nerve. 134. What What is the tre treatm atment ent for thi thiss syndro syndrome? me? • Ext Extens ension ion splin splintt and neurov neurovita itamin mins—f s—for or a period period of 3 months from injury. Nerve conduction studies are done and the slowing or no conduction if  confirmed, anterior transposition of ulnar nerve is done. 135. What What is the the compl complica icatio tion n of this this sur surger gery? y? • Tem Tempor porary ary to to perman permanent ent loss loss of of ulnar ulnar nerve nerve function is a known complication.

 

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17. MALUNION OF BOTH BONES FOREARM      

History of injury History of native treatment and massage Angulation present Rotations restricted Patient will have stiffness of fingers Patient may have Volkmann’s ischemic contracture (VIC)—should look for Volkmann’s sign.

A

B

Figs 36A and B:  Malunion with still acceptable function

B

A

C

Figs 37A to C:  Malunion with still acceptable function

 

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136. What What are are the the trea treatm tment ent opti option ons? s? • Cor Correc rectiv tivee osteotom osteotomy, y, realign realignmen ment, t, bone bone graftin grafting g and fixation are indicated if the patient has functional disability, e.g. reaching his mouth.

A

B

C

Figs 38A to C: Malunion with poor function, he needed

corrective osteotomy and fixation

 

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18. GALEAZZI FRACTURE DISLOCATION    

History of injury Deformity of radius Prominence of ulna May or may not be transmitted mobility according to union.

Pathology  

Shortening and angulation of radius Disruption of distal radioulnar joint (DRUJ).

136a. What What are the the treat treatment ment optio options? ns? • Ope Open n redu reducti ction on int intern ernal al fix fixati ation on

If necessa necessary ry trans transfix fixati ation on of dist distal al ulna ulna with with radius • Sta Stabil biliza izatio tion n of DRU DRUJJ with with K wire. wire.

 

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19. SUDECK’S OSTEODYSTROPHY (RSD)    

Radiological term extended to a clinical condition Spotty decalcification is distinguished from generalized osteoporosis Shoulder hand syndrome its another for this condition Reflex sympathetic dystrophy (RSD) is a group of  conditions occurring after trauma classified classi fied into minor causalgia, major causalgia, minor traumatic injury,

 

 

major post-traumatic injury This is caused by exaggerated response to posttraumatic conditions Pain, and and tenderness out of proportion to thehyperesthesia physical findings in non anatomic sites not connected to original injures Early stages—There is redness and warmth Later stage—Pallor, dry shining skin and coolness.

137. What What are are th the e sta stage gess of of RSD RSD?? There are 3 stages • Sta Stage ge 1: 1: Burn Burning ing,, achin aching g and and pain pain..

• Stage Stage 2: 2: Edema, Edema, cold cold glo glossy ssy skin skin and joi joint nt stiffness. • Sta Stage ge 3: Progr Progressi essive ve atrop atrophy hy of skin skin and and muscle muscle and significant joint contracture. From 2nd stage Sudeck’s is prominent. Shoulder hand syndrome is a variety of this condition. 138. What What are are the the trea treatm tment ent opti option ons? s? • Initia Initially lly physi physiother otherapy, apy, calci calcium, um, calci calcitonin tonin can be tried along with analgesics. • La Late terr on sy symp mpat athe heti ticc bloc block. k.

 

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• Progres Progressive sive loa loading ding of extrem extremity ity and and progr progressi essive ve resistant exercises.

139. What What is the the cau cause se of of the the sympt symptom oms? s? • Sh Shor ortt circ circui uiti ting ng of of nerv nerves es • He Henc ncee the the nona nonana nato tomi micc pain pain..

A

B

Figs 39A and B: Sudeck’s osteodystrophy

140. What What is is the the XX-ra ray y fin findi ding ng?? • Sp Spec eckl kled ed deca decalc lcif ific icat atio ion. n.

 

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20. VOLKMANN’S ISCHAEMIC CONTRACTURE   

History of trauma Native treatment and massage Difficulty in using the limb.

A

B

Figs 40A and B:  During acute ischemia

Fig. 41:  Volkmann’s ischemic contracture (VIC)

 

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On examination:  Wrist and fingers in flexion  Look for sensations ulna/median nerve  Dorsiflexion of wrist increases the deformity  Skin will have atrophic changes, dry and scaly  In the case of forearm VIC, fingers can be atleast partially extended when the wrist is flexed (Volkmann’s sign). (This is because when the wrist is extended, the shortened muscle tendon unit stretches over the fingers causing extension.)  Atrophy of forearm muscles, nail atrophic. 141.. What 141 What is the the pat patho holo logy gy?? • Sequ Sequel el to Volk Volkmann mann’s ’s ischem ischemia, ia, muscl musclee underg undergoes oes ischemic necrosis and replaced by fibrous tissue which causes flexion-contracture of wrist and

fingers. There may be peripheral nerve involvement with sensory loss and motor paralysis of  hand and forearm. 142. What What is is Vol Volkma kmann’ nn’ss sig sign? n? • The flexi flexion on deform deformiti ities es of the finge fingers rs is beco becoming ming partially correctable with a flexed wrist • The defor deformit mities ies becom becomee more more pronou pronounce nced d when the wrist is dorsiflexed. 143. What What are are the the trea treatm tment ent opti option ons? s? • Pas Passiv sivee str stretc etchin hing g and spl splint inting ing

• • • •

Soft tissu tissuee (muscle (muscle)) slidin sliding g operat operation ion (Max page) Shorteni Shor tening ng of of forear forearm m bones— bones—Garr Garre’s e’s proc procedur eduree Carp Ca rpal al bo bone ne exc excis isio ion n Neur Ne urol olys ysis is of of nerv nerves es..

 

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144. 14 4. What nerv nerve e is comm commonly only invo involved lved in VIC VIC of forearm? • Median ne nerve. 145. Why? • It runs runs in the the centr centree of the the maximu maximum m infarc infarcted ted zone of muscle supplied s upplied by anterior interosseous

artery. • This This muscl musclee can can someti sometimes mes cal called led as ‘muscle sequestrum’ as it is separated by fibrous tissue from the normal muscle. 146. What What is is Vol Volkma kmann’ nn’ss sig sign? n? • On flexi flexing ng the the wrist wrist passi passive ve exten extensio sion n of finger fingerss is possible.

 

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21. OSTEOCLASTOMA Cause of pain, difficulty difficult y in walking or using the upper limb or presents with abnormal mobility (pathological fracture).  Difficulty in using limb after trivial fall (pathological fracture).  Age : Middle age group (20–40).  Incidence more in females. 147. What What is the the common common prese presenta ntatio tion n of osteo osteocla clasto stoma? ma? • Swe Swelli lling ng arisi arising ng from from the the bone bone near near a joint joint especially around the knee or distal end of radius (End of long bone) may be painless to startwith. 148. Can weically we dialy diagno gnose osteocl oste oclast astoma omabeclin clinica ically lly? ? • Clin Clinical ise it t should sho uld not diagnosed diagn osed as

osteoclastoma. • It is be bett tter er to sa say y as as benign bone tumor   most probably giant cell variant osteoclastoma. 149. How wil willl you you diagn diagnose ose ost osteoc eoclas lastom toma? a? • In X-ray X-ray we can can see expan expansil silee eccentr eccentric ic lesio lesion, n, in the end of long bone. 150. What What are are the the type typess of of osteo osteocla clasto stoma? ma? • Agg Aggres ressiv sive—N e—No o sclero sclerosis sis betwe between en tumor tumor and and host  bone (Surrounding bone has no time to react). • No Nonag naggre gressi ssive— ve—Scl Sclero erosis sis pr prese esent. nt. 151. What What are are the the trea treatm tment ent opti option ons? s? Intralesional

• Curettage • Ad Adjuv juvant ant cr cryo yothe thera rapy py/ca /caut utery ery

 

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• In packi packing ng with with bone bone ceme cement— nt—heat heat pro produc duced ed during the setting of cement kills residual cells • Pack Packing ing the defect defect with bone graf graftt or subs substitu titute te • Exci Excision sion if the the bone bone is expen expendabl dable. e. If the lesio lesion n is too big-excision and reconstruction. Reconstruction includes arthrodesis, arthroplasty. • Rad Radiot iother herapy apy for for inacc inaccess essibl iblee lesion lesions. s. 152. Wha Whatt is signi signifi fica cant nt bone bone defe defect ct??

• A defect defect in in bone bone > 1.5 time timess the diam diamete eterr of bone bone never heals by itself (JA Key). 153. What What is the the appear appearanc ance e of an aggr aggress essive ive tumor tumor in X-ray? • Does Doesn’t n’t have scle sclerosi rosiss of marg margin in becau because se it it doesn’t allow time for the surrounding bone to react. 154. What What are are the the X-ra X-ray y findi finding ngss in GCT GCT?? • Ecc Eccentr entric ic expan expansile sile lesi lesion on with with typic typical al soap soap  bubble appearance • Thinn Thinning ing of cort cortex ex with/w with/withou ithoutt sclero sclerosis sis of  margin • Tu Tumo morr does doesn’ n’tt ente enterr the the join jointt • Us Usua uall lly y no ca calc lcif ific icat atio ion. n. 155. What What are are the gia giant nt cell cell var varia iants nts?? • Ost steo eocclas asto toma ma • Fi Fibr brou ouss cor corti tica call def defec ectt

• Nono Nonoss ssif ifyi ying ng fibr fibrom omaa • Ch Chon ondr drom omyx yxoi oid d fibro fibroma ma • Bro Brown’ wn’ss tumor tumor of of hyperp hyperpara arathy thyroi roidis dism m

 

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• Ost steo eob blast sto oma • So Soli lita tary ry bo bone ne cy cyst st • An Aneu eury rysm smal al bo bone ne cy cyst st

Recent Rec ently, ly, gian giantt cell cell rich rich oste osteosa osarco rcoma. ma. 156. How will will you diag diagnos nose e gaint gaint cell cell tumo tumorr (GCT)? (GCT)? • Pr Pres esen ence ce of gi gian antt cel cells ls.. 157. What What is the tumo tumorr cell cell of of giant giant cel celll tumor tumor?? • Fibr Fibrous ous strom stromal al cell (undi (undiffere fferentiat ntiated ed spin spindle dle cells). 158. What What is eg egg g shel shelll crac crackl kling ing?? • It is due due to fract fracturi uring ng of oste osteocl oclast astoma oma by by deep deep palpation. 159. What What is the the cel celll of ori origi gin n of GCT GCT?? • Unknown.

A

B

Figs 42A and B: Osteoclastoma of right lower tumor 

 

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Fig. 43:  GCT of distal femur same patient in Figure 42

A

B

C

Figs 44A to C:  X-ray and CT Scan of the above case

A

B

C

Figs 45A to C:  Recurrent GCT after distal radius excision and fibular grafting

 

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22. NEGLECTED SHOULDER DISLOCATION DISLOCATION 160. What What is th the e natu nature re of inj injur ury? y? • Fa Fall ll on ou outt stre stretc tche hed d han hand. d.

A

B

Figs 46A and B:  (A) Loss of contour of shoulder; (B) Cannot touch opposite shoulder 

Fig. 47:  Flattening of shoulder (Patient should sit with both shoulders bare)

 

SHORT CASES   63

161. What What are are the the clin clinic ical al fin findin dings gs?? On examination: • Los Losss of cont contour our of shou shoulde lder/f r/flat latten tening ing • Anter Anterior ior axil axillary lary fold is at lowe lowerr level level (Brya (Bryant’s nt’s sign) • Pat Patien ientt is not not able able to touch touch oppo opposite site shou shoulde lderr (Dugas test)

• Vertica Verticall circum circumfere ference nce at at axilla axilla is increa increased sed (Callaway sign) • Hamil Hamilton ton ruler ruler test posit positive, ive, i.e. ruler kept on lateral lateral condyle will not touch the acromion normally  because of resistance of head of humerus. In a dislocated case, the ruler touches the acromion.

Fig. 48:  A case of fracture-dislocation shoulder 

162. What What are are the the trea treatm tment ent opti option ons? s? • Depends on on ag age • Ope Open n reduc reductio tion n (if (if patie patient nt is is young young))

• Mob Mobili ilizat zation ion (if old pat patien ient). t).

 

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23. FRESH DISLOCATED ELBOW History of injury and deformity Difficulty in moving the limb. On examination:  

  

Triceps is taut and standing out (Tendo-Achilles sign of triceps) Three bony points altered relationship between olecranon, medial epicondyle and lateral condyle of  humerus. Flexion of elbow restricted Olecranon protrudes abnormally out Test other bony point like the entire lower humerus, medial epicondyle, lateral condyle, radial head and look for ulnar nerve involvement.

163. 16 3. What is is the trea treatme tment nt in fresh fresh and and neglect neglected ed dislocated elbow?

• For For fr fres esh h di disl sloc ocat atio ion n → closed reduction • Abo Above ve elbow elbow sla slab b in 90° 90° flexi flexion on for for 3 week weeks. s. 164. 16 4. What are are the trea treatme tment nt option optionss for negle neglecte cted d dislocated elbow?

• Open Open reductio reduction—Po n—Poster sterior ior appr approach oach—pr —protec otecting ting the ulnar nerve • Tra Transp nsposi ositio tion n of tric triceps eps ante anterio riorly rly • Bo Bone ne bl bloc ock k sur surge gery ry..

 

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A

B

Figs 49A B:  (A)case Caseofoffresh dislocated elbow (neglected); (B)and Another dislocated elbow

 

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24. NONUNION OF BOTH BONE FOREARM    

History of injury to forearm History of immobilisati immobilisation on Cause of difficulty in using forearm especially rotation Stiffness of hand and wrist



May or may not have VIC/atrophic changes of hand.

On examination:  Deformity of forearm more obvious if fracture is in ulna (subcutaneous)  Loss of transmitted mobility on radial head on  

supination/pronation Defect or abnormal mobility in ulna Look for scars over site of fracture (May have loss of   bone or primarily open fracture).

Plan: ORIF with plate and screws, square nail and bone grafting Square nail is otherwise called ‘Talwalkar‘s nail’ 165. How wil willl you you ident identify ify rot rotati ation on in in nonuni nonunion? on? • In nonun nonunion ion there is no no spike spikess to inte interdig rdigitate itate.. • Ends are scl scleros erosed ed so rot rotatio ation n is matc matched hed by interosseous border. 166. In fresh fresh case casess which which is the the first first bone bone you you will will fix— fix— radius or ulna? • Le Less ss com commi minu nute ted d bon bonee firs first. t. 167. What What is the the commo common n compli complicat cation ion of of a both both bone bone fracture surgery? • Pos Poster terio iorr inte interos rosseo seous us nerv nervee pals palsy y • To Tour urni niqu quet et pa pals lsy. y.

 

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25. BRACHIAL PLEXUS INJURY

Fig. 50:  Cut injury involving shoulder—injuring the brachial plexus

History of Road Traffic Accident.  Head separated violently from shoulder resulting in stretching of nerve or deep cut in the shoulder region  Thrown from two wheeler or fall from height  Handedness of individual is important History of pre-existing pain neck  Should ask if weakness was static/worsening/improving  Occupation—manual labour or clerical  Activities done at present

 

68

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Past history of hospitalization, epilepsy, congenital disorders.

On examination: patient will not be able to move his entire upper limb.

Attitude: Waiter’s tip receiving position in Erb’s palsy totally flail upper limb in total brachial plexus injury.  Wasting of deltoid supraspinatus, infraspinatus and Pectoralis major  Atrophic changes of hand  Hair loss  Dermatomal pattern  C1—purely motor  Examine for motor power of upper limb—shoulder, elbow, wrist and hand (Should not be examined for separate nerves)    

Sensation tested according to the dermatome Reflexes elicited—Biceps, triceps, supinator Autonomous—Ciliospinary reflex, Horner’s syndrome Muscle power—Muscles of scapula—Serratus anterior, rhomboids.

Power of the above Case   

Shoulder abduction—weak abduction—wea k Elbow flexion—0 Supination—0.

168.. What 168 What is wr wrin inkl kle e tes test? t? • Put the the hand hand in wat water er for for five five minut minutes, es, app appeaea-

rance of wrinkles show intact of nerves.

 

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A

B

Figs 51A and B:  A case of partial brachial plexus

169.. Wh 169 What at is is axon axonal al ref refle lex? x?

• The skin skin is is scratc scratched hed thro through ugh a drop dr op of  o f  histamine. A sequence of vasodilatation, wheel and flare are noted. • If the the nerve nerve is injure injured d proxi proximal mal to gangli ganglion on with with anesthesia in the region the above reflex is noted. • If the the nerve nerve is inju injured red dist distal al to the gang ganglio lion n with anesthesia the flare is absent in the sequence. 170.. Wh 170 What at is sw swea eatt tes test? t?

• Presence Presence of sweat sweating ing after testi testing ng with with Quin Quinizar izarin in dye indicates nerve intact. 171. How How will will you you dia diagn gnos ose e a cas case? e? • Com Comple plete, te, inco incomp mplet letee brach brachial ial ple plexus xus • Open, cl closed • Re Reco cove vere red, d, not not re reco cove vere red d • Pre Pregan gangli glioni onicc and postga postgangl nglion ionic ic lesion lesions. s.

 

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172. What What are are the inv invest estiga igatio tion n you wil willl order order?? • X-r X-ray ay cervic cervical al spine—A spine—Ante nterop ropost osterio erior, r, Lateral Lateral-Look for fracture of transverse process • Mye Myelog logram ram aft after er 6 week weekss (Pseud (Pseudome omenin ningoc gocele ele effect) • MRI

• Ele Electr ctron oneur eurom omyog yograp raphy hy (EN (ENMG) MG).. 173. What are the poor poor prog prognost nostic ic indic indicato ators rs in in brachia brachiall plexus? • All the fiv fivee nerve nervess invol involved ved (C5 – T1) T1) • First nerve nervess involv involved ed (Nerv (Nervee to levat levator or scapu scapula, la, rhomboids) • Su Supr prac acla lavi vicu cula larr anes anesthe thesia sia • Pa Pain in in an anes esth thet etic ic li limb mb • Ho Horn rner er’s ’s sy synd ndro rome me • Avu Avulsi lsion on of of transv transvers ersee proce process ss in X-ra X-ray. y. 174.. Ho 174 How w to te test st sup supin inat ator or??

• I will will extend extend the the shoul shoulder der and elbo elbow—s w—so o that that only only supinator not biceps longus will act. 175. How to to differe differenti ntiate ate peri peripher pheral al nerve nerve and and plexus plexus injuries? • Peri Peripher pheral al nerve injur injury y patter pattern n follo follows ws innervation of nerve. • Plexu Plexuss injury injury invol involves ves root or trunk derm dermatoma atomall pattern. For example consider—C5C6 injury and musculocutaneous nerve injury. In C5C6 root injury, patient will have sensory loss over outer aspect of arm and shoulder and lateral aspect of forearm and hand. Patient will also have

 

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loss of abduction of shoulder, flexion of elbow. Weakness of dorsiflexion of hand, supination of  forearm. But in musculocutaneous nerve injury which has C5C6 root value patient will have only sensory loss over lateral aspect of forearm and weakness weakness of elbow flexion only. 176. How to test test aut autono onomous mous ner nervou vouss syst system? em? • Al Aliiza zarrin inee te test st • Loo Lookin king g for for skin skin chan changes ges los losss of hai hairr • Wrinkle te test.

177. Ca Can n you you te test st su subc bcla lavi vius us??

• It is diff difficu icult lt to test subc subclav lavius ius.. It is one one of the the accessory inspiratory muscles. • It is a should shoulder er girdl girdlee muscle muscle arisi arising ng from from the the undersurface of clavicle going on to first rib and cartilage. • In Inne nerv rvat ated ed by C5 C5,, C6 C6 roo roots ts.. 178. Wha Whatt are the the compo componen nents ts of Horn Horner’ er’ss syndro syndrome? me?

• Ptosis, Ptosis, Mios Miosis, is, enop enophtha hthalmo lmos, s, anhidr anhidrosi osis, s, no ciliospinal reflex. 179. 17 9. How How to to cla class ssif ify? y? • Le Leff ffer ert’ t’ss clas classi sifi fica cati tion on.. 180. What What els else e wil willl you you ex exam amin ine? e? • Exam Examine ine pass passive ive move movement mentss of join joints ts of of the the same same side, cervical spine and opposite upper limb. 181. What What are are the oth other er caus causes es of of plexus plexus inj injurie uries? s? • Lat Lathyr hyrism ism,, irradi irradiati ation, on, neur neuroto otoxin xins. s.

 

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182. What What are the contr contract actures ures in plexu plexuss injuri injuries? es? • Sho Should ulder— er—Add Adduct uction ion,, interna internall rotatio rotation n • El Elbo bow— w—Fl Flex exio ion, n, pron pronat atio ion n

• Fi Fing nger ers— s—Fl Flex exio ion. n. 183. Wha Whatt is the the relat relation ionshi ship p bet betwee ween n progno prognosis sis and recovery time?

• In infant infants, s, good good prog prognosis nosis—if —if bice biceps ps recov recovers ers in less than 3 months—good recovery. • If it occu occurs rs 3–6 3–6 month monthss partia partiall recove recovery. ry. • If not not recov recovered ered even afte afterr 6 mont months— hs— diff difficu icult. lt. 184. In Erb’s Erb’s pals palsy, y, good good recov recovery ery in in what les lesion ion?? • Po Post st gan gangl glio ioni nicc C5C6 C5C6.. 185. What What is the EMG in in 1st 1st hour hour afte afterr injur injury? y? • Normal. 186. When When will will you you do nerv nerve e proce procedur dures es?? • Nerv Nervee proc procedur edures—N es—Nerve erve sutu suturing ring/gra /graftin fting/ g/ repair within 2 years. 187. Why so? • Neu Neurom romusc uscula ularr juncti junction on degen degenera erates tes with within in 2 years • Aft After er 2 years years—Te —Tendo ndon n transf transfer er and and muscle muscle transfer can be done • Joi Joint nt fusi fusion on of of joint jointss like like shoul shoulder der.. 188. What What are are the way wayss of of nerv nerve e repa repair? ir? • Mobi Mobiliza lization tion,, nerve nerve graf grafting ting,, joint joint posi position tioning. ing. 189. What What is the class classifi ificat cation ion of brach brachial ial plexu plexuss injury? injury? Leffert’s classification 1. Open

 

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2. Closed

• Supra Supraclavic clavicular— ular—suprag supraganglio anglionic, nic, infraganglionic • Inf Infrac raclav lavic icula ularr • Pos Postan tanest esthet hetic ic palsy palsy 3. Ra Radi diat atio ion n in inju jury ry 4. Ob Obst stet etri ricc pa pals lsy. y. 190. When When is Tine Tinel’ l’ss sign sign not not use useful ful?? • Neu Neurop ropraxi raxia, a, cut cut injurie injuriess without without any nerv nervee repair. 191. When When will will you int interf erfere ere in Tin Tinel’ el’s? s? • No pr prog ogre ressi ssion on of Ti Tine nel’ l’ss • No Nona nana nato tomi mica call progr progres essi sion on • Sl Slow ow pr prog ogre ress ssio ion. n. 192. Imaging Imaging of of choice choice to identi identify fy suspe suspect ct lesio lesion n of brachial plexus? • MRI. 193. What What are are the the trea treatm tment ent opti option ons? s? • Init Initial ial phase phases—Sp s—Splin linting ting,, pain contr control, ol, preve preventio ntion n of contractures • Lat Latee phase—M phase—Musc uscle le streng strengthe thenin ning, g, reeduc reeducati ation on of  muscles, modication of splints TENS to control pain. Acute phase— 1. Pre Pregan gangli glioni onic—n c—no o surge surgery ry

2. • • • •

 

Postgangl Postga nglion ionic— ic—ner nerve ve sut suturi uring ng Latee phas Lat phase—m e—musc uscle/ le/ten tendon don tra transf nsfer er Should Sho ulder— er—tra transf nsfer er of tra trapez pezius ius/ar /arthr throde odesis sis Elbo El bow— w—la lati tiss ssim imus us do dors rsii Reeduc Ree ducati ation on of tra transf nsferr erred ed musc muscles les..

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26. TORTICOLLIS    

Contracture of sternocleidomastoi sternocleidomastoid d Occiput turned to same side and chin to opposite side Later—facial asymmetry and visual disturbance Child—congenital, infection, muscle, primary visual problem, trauma to spine are the causes to be ruled out.

194. What What are are the the trea treatm tment ent opti option ons? s? • Spli Splinting nting with coll collar ar passi passive ve gentl gentlee stretch stretching ing • In resist resistant ant cases cases unipo unipolar lar or or bipola bipolarr releas releasee —  bee f o r e v i s u a l a r e a f i x a t i o n i n b r a i n ( e a r l y  b childhood).

Fig. 52:  A child with left side sternomastoid contracture seen from front and back

 

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27. CEREBRAL PALSY Cerebral palsy is a nonprogressive neurological disorder. Types   

Prenatal Natal Postnatal.

Patient will have variable degree of mental retardation, difficult in muscle coordination. Difficulty in walking and doing activities of daily living.

Fig. 53: Cerebral palsy

 

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195. What What questio questions ns will will you you ask in in the birt birth h histor history? y? • An Ante tena nata tall hi hist stor ory y – Drugs – Antiemetics – An Anti tico conv nvul ulsa sant nt – Di Diab abet etic ic mo moth ther er

• B th spit atital – irHosp Ho al or ho home me – Del Delaye ayed d 2nd 2nd sta stage ge of lab labor. or. 196. Wha Whatt is the impo importa rtance nce of the the firs firstt cry? cry? • The pulm pulmonary onary circ circulati ulation—p on—pressur ressuree (Pul (Pulmonar monary y resistance) is reduced as the solid lung becomes aerated. 197. Wha Whatt are are the deta detaile iled d mile milesto stones nes?? • Social Social smile smile,, lying lying prone, prone, crawl crawling ing,, sitting sitting,, standing, walking normal, hearing, speeching  bowel or bladder control. 198. Wha Whatt are the type typess of pati patient ent/chi /childr ldren en with with CP? CP? • Var Vario ious us types types are are shown shown in Figu Figures res 54 54 to 56. 56.

Fig. 54: Group A—Can do activities of daily living by themselves

 

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Fig. 55:  Group B—Can do activities of  daily living with help

Fig. 56:  Group C—Completely depend on others for daily living, bed ridden

 

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199. What What is the the diagn diagnost ostic ic typi typing ng for for treat treatment ment?? • No Norm rmal al in inde depe pend nden entt chi child ld • Mil Mild d MR need needss help help for for many many of her acti activit vities ies • To Tota tall lly y be bed d ri ridd dden en On examination: • Ge Gene nerral at atti titu tude de • Whe Whethe therr coop coopera eratin ting g for for exami examinat nation ion • IQ of the child

• • • • •

A

Spine examina Spine examination tion,, stabili stability ty in in sitting sitting and stand standing ing Defo De form rmit itie iess of of spi spine ne Scolio Sco liosis sis in in sitting sitting pos positi ition on is sign signifi ifican cantt Scol Sc olio iosi siss exist existss with with lord lordos osis is Powerr of all limb musc Powe muscles les and and contr contractu actures res of  of   joints.

B

Figs 57A and B: Patients with cerebral palsy require help for their activities

 

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200. What What is the the preca precauti ution on durin during g muscle muscle tes testin ting? g? • Do not allo allow w the the child child to recrui recruitt other other muscl muscles. es.

201. Spastic Spastic musc muscle le is is not not a stro strong ng muscl muscle e why? why? • Bec Becaus ausee power power invol involves ves volu volunta ntary ry act act of the muscle not spastic contractions (MRC grading). 202. What What is the the maxim maximum um power power you can can give give in case case of a fixed deformity? • For fixe fixed d deform deformitie ities, s, power power for for rever reverse se moveme movement nt is given at grade 1 MRC grading only. For example,

in equines the ankle dorsiflexor assessed by palpating contraction ofpower tibialisisanterior. 203. How How will will yo you u ass asses esss equi equinus nus?? • Eq Equi uinu nuss or or For Foref efoo oott dro drop. p. 204.. How 204 How to Do Dors rsif ifle lex? x? • Do Dorsi rsifle flex x holdin holding g up the the talar talar head head with with thumb. thumb. 205. What What are are the the inve invert rtor orss of ankl ankle? e? • Tibi Tibialis alis anter anterior ior is the the inverto invertorr in dors dorsiflex iflexion ion of  ankle • Tibi Tibialis alis post posterio eriorr is the invert invertor or in in plantar plantar flex flexion ion of ankle. 206. Why to tes testt hip hip abduct abduction ion in knee knee flex flexion/ ion/knee knee extension? • The hamstr hamstrings ings are rela relaxed xed in flexi flexion on of of knee knee and

hence you get more abduction of hip in knee flexion. 207. Gait Gait in Ce Cere rebr bral al pa pals lsy? y? • Scissoring.

 

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208. Wha Whatt are are the mai main n points points in in a cereb cerebral ral pal palsy sy (CP) (CP) child examination? • Hig ighe herr fun funct ctiion • Mu Musc scle le gr grou oup p sp spas asti tici city ty • Deformities • Si Sitt ttiing bala lanc ncee • Gait. 209. How will will you asse assess ss the the power power of of muscle muscless in a CP a child? • Spa Spasti sticc muscle muscle is is not a stron strong g muscle muscle.. Streng Strength th is measured as power and spasticity is involuntary involuntary.. Hence spasm is not power. Only when the child understands and does the movements voluntarily then we can assess the power of the muscles in a CP child. 210. Wha Whatt is the the maxim maximum um power power give given n to the the muscl muscle e which has a reverse deformity? • In fixed fixed fle flexio xion n defor deformit mity y maxim maximum um power power of  extensor is only 1/5. 211. What What is is bir birth thday day sy syndr ndrom ome? e? • If child child is is not asse assessed ssed prop properl erly y by the the team team of  spastic care, then the child will spend each  birthday in hospital hospital for some surgery. Hence it is

 better to stage. assess the child and do all surgeries s urgeries in a single 212. What What is re reci cipro proca cati ting ng gai gait? t? • As the the chil child d is mad madee to wal walk k with with suppo support rt then he can alternately bring one lower limb in front of other.

 

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213. What is the the role role of of tendon tendon lengt lengtheni hening ng in in deformi deformity ty correction? • Open tend tendon on leng lengtheni thening ng is not not advis advised ed nowadays • Clo Closed sed tendon tendon lengt lengthen hening ing,, fractio fractional nal lengt lengthen hening ing is the in thing in CP.

Fig. 58: Tendon lengthening

214. Wha Whatt is the the mea measur sure e of equi equinus nus??

• Th Thee heel heel to to grou ground nd dis dista tanc nce. e. 215. Wha Whatt are are the rec recent ent adv advanc ances es in CP?

• • • • •

Recent Rece nt ad adva vanc nces es in CP Nott just No just len length gtheni ening ng of ten tendo dons ns Abil Ab ilit ity y as asse sess ssme ment nt Occu Oc cupa pati tion onal al th ther erap apy, y, Physiotherapy

 

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• Spasm reli relieving eving ortho orthosis sis spasm reli relieving eving brac bracee (footwear)—given upto tip of toe for lower limb, initialization of spasm is relieved • Intra Intratheca thecall bacl baclofen ofen depo depot—no t—no sedat sedation, ion, pati patient ent attender can control dose • Gai Gaitt analy analysis sis befo before re and and afte afterr surge surgery ry • Sele Select ctiv ivee dors dorsal al rhi rhizo zoto tomy my • Fra Fracti ctiona onall leng lengthe thenin ning g of of tend tendons ons • Ner Nerve ve block blockade ades. s. Region Regional al nerve nerve bloc blocks ks can can be tried first before neurectomy • Blo Block ck with with ligno lignocai caine ne and look look whet whether her spasm spasm is relieved or not, then neurectomy is done. (Phenol may be used for permanent neurectomy) • All sur surgic gical al proc procedu edures res in one one stag stagee • Hel Helps ps in in rehab rehabil ilita itatio tion n of the chil child d • Av Avoi oid d bir birth th da day y syn syndr drom omee • Bot Botuli ulinum num tox toxin— in—cos costly tly but use useful ful.. 216. What are the proc procedur edures es in in CP, done by ortho orthopedi pedicc surgeons?

• Hip—Ad Hip—Adduc ductor tor tenot tenotomy omy,, obturat obturator or neurec neurectom tomy y • Kn Knee ee—h —ham amst stri ring ng re rele leas asee • Foot → valgus - leave alone Varus—osteotomy • Fra Fracti ctiona onall lengt lengthen hening ing of ten tendon dons. s. 217. Where Where tendotendo- Achi Achille lless length lengtheni ening ng shoul should d not be done? • Equ Equinu inuss correc correctio tion n should should not not be done done when when quadriceps power is less than three.

 

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218. How will will you you diffe differen rentia tiate te the the cause cause of of equine equiness soleus or gastrocnemius? • Sil Silfve fversk rskio iold ld test—T test—The he equin equinus us is mainl mainly y due to gastrocnemius only if equines gets corrected in knee flexion. If there is no correction then it is both

gastrocnemius or soleus causing equines. 219. Impo Import rtan ance ce of of the the firs firstt cry? cry? • Air ent enters ers the ers erstwh twhile ile sol solid id lun lung. g. • The pul pulmon monary ary oxy oxygen genati ation on occ occur urs. s. • Pre Pressu ssure re on the left left side side of of heart heart becom becomes es more more than right side. • Fun Functi ctiona onall closur closuree of forame foramen n ovale ovale occurs. occurs. 220.. Wh 220 What at is AP APGA GAR R scor scorin ing? g?

• Appearance • Pulse-Rate

• Grimaces • Activity • Respiration.

Fig. 59: Inability to walk in a child with cerebral palsy

 

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28. WRIST DROP

Fig. 60:  Clinical sign due to weakness of dorsiflexor  of wrist and extensor of finger 

Clinical Findings is as Seen in Figure 60

Anesthesia present over 1st web space over the dorsal aspect. The entire course of radial nerve is palpated and to looked for tenderness (Nerve ends at the level of lateral condyle and continues as posterior interosseous nerve to midpoint of wrist). Treatment  Initial—splinting in volar cock-up splint, electroneuromyography

 

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221. Wha Whatt is Hols Holste tein in Lewis Lewis synd syndro rome me??

• Post manip manipulat ulation ion radi radial al nerve pals palsy y in in humeru humeruss fracture.

• Lower Lower fragm fragment ent with with later lateral al spike spike catc catches hes the the nerve inside fracture. 222. Wha Whatt is the trea treatme tment nt of Holst Holstein ein Lewis Lewis synd syndrom rome? e?

• Immedi Immediate ate expl explora oratio tion n and relea release se of nerve nerve and and reduction and fixation of fracture. 223. What What is the the treat treatmen mentt of open open inju injury ry of of the ner nerve ve (Neurotmesis)?

• Debr Debrid idem emen entt of of the the wo woun und. d. • Sec Second ondary ary nerve nerve repa repair ir in centr centree of special specialisisation of peripheral nerve surgery. 224. Whe When n will will you you do ner nerve ve repa repair/ ir/gra grafti fting? ng?

• Nerve Nerve repai repair/gr r/grafti afting ng less less than than 2 years years (whe (when n myoneural junction is still viable) 225. When will will you do tendo tendon n transf transfer er more more tha than n 2 years.

• Median Median nerv nervee muscle muscless are tran transfe sferre rred d to hand hand • Pro Pronat nator or tere teress to wri wrist st dors dorsifl iflexi exion on • Flexo Flexorr digito digitorum rum superf superficia icialis lis (FDS (FDS)) of of ring ring finger finger to all finger extensors • Pal Palmar maris is long longus us for for thum thumb b exten extensio sion. n. 226. What What is is auto autonom nomou ouss zo zone ne?? • It is that that part part of skin skin supp supplie lied d only only by the the nerve nerve in question and not by any other nerve.

 

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227.. What 227 What is ma maxi xima mall zon zone? e? • If the the other other nerve nerves, s, e.g. e.g. the media median n and ulna ulnarr are are completely blocked, still some area of these nerves will retain sensation. This is due to the supply of  radial more than its anatomic area. 228. What What is anato anatomic mical al area area of this (ra (radia dial) l) nerve nerves? s? • This area is descr described ibed in anato anatomy my book bookss as supplied by radial nerve that is the dorsum of  hand and fingers.

 

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29. CLAW HAND

A

B

Figs 61A and B: Two different cases of claw hands

 

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Fig. 62: See the flexion of the left thumb of this patient is on the right side wearing watch. ‘Claw’ is the hyperextension of MCP and hyperflexion at IP ulnar claw—leprosy, ulnar nerve injury

229.. Caus 229 Cause e of of cl claw aw ha hand nd.. • In Intr trin insi sicc min minus us ha hand nd.. 230. What What is the the auton autonomo omous us regio region n of ulna ulnarr nerve? nerve? • Med Medial ial sid sidee of the the distal distal phal phalanx anx of of the litt little le

finger. 231. Why claw claw hand dev develo elops? ps? (Int (Intrins rinsic ic minus minus)? )? • Intri Intrinsic nsic muscl musclee flex metac metacarpo arpophal phalangea angeall joint (MCP) and extend the interphalangeal (IP). • When int intrins rinsic ic muscl muscles es are are paral paralysed ysed ther theree is unopposed action of long flexors and extensors. Long flexors cause IP flexion • Ext Extens ensors ors cau cause se MCP ext extens ension ion..

 

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232. What What is the the tre treat atme ment nt of of claw claw hand? hand? • Phy Physio siothe therap rapy y to keep keep the join joints ts suppl supplee • Paul Bran Brand d I—Exte I—Extensor nsor carpi radi radiali aliss brevis brevis (ECR (ECRB) B) • Paul Bran Brand d II—Ext II—Extensor ensor carp carpii radia radialis lis long longus us (ECRL) • To Tota tall claw claw—4 —4 tai taill tran transf sfer er.. 233. Why in Paul Paul Bra Brand nd II— II—ECR ECRL L is use used? d? • Be Beca caus usee ECRB ECRB was was a bul bulky ky mus muscl cle. e. 234. Where Where in Indi India a this this pionee pioneering ring work was done and by whom? • Wo Work rk do done ne in in CMC CMC Vel Vello lore re by Professor Professor PaulBrand and Professor AJ Selvapandian. 235.. Wh 235 What at is ul ulna narr para parado dox? x?

• When When the nerve nerve lesi lesion on is prox proxima imall the defor deformit mity y is less. • Whe When n the nerve nerve lesi lesion on is dista distall the defo deformi rmity ty is

more. RELATED RELA TED QUESTIONS QUESTI ONS 236. What What is is intr intrin insi sicc plus plus hand hand?? • When pat patient ient flex flexes es active actively ly his his finger, finger, fing finger er goes goes for extension-action through lumbricals. 1. Com Compl plica icatio tion n of ampu amputat tation ion 2. Sever Severance ance of of Flexor Flexor digito digitorum rum profu profundus ndus (FDP) (FDP) 3. Lo Loos osee gra graft ft of FD FDP P 4. Av Avul ulsi sion on of FD FDP. P. 237. What What is is quad quadri riga ga ef effe fect ct?? • Tig Tight-r ht-repai epairr or shorter shorter graft graft—re —repai paired red finger finger goes goes

for flexion faster than other fingers in the same musculotendinous group.

 

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Fig. 63:  Clawing

238. What What is is auto autonom nomou ouss zo zone ne?? • It is that that part part of skin skin supp supplie lied d only only by the the nerve nerve

in question and not by any other nerve. 239.. Wh 239 What at is ma maxi xima mall zon zone? e? • In the the other other nerves nerves,, e.g. e.g. the medi median an and and radial radial are  blocked still some of the area area of those nerves nerves will will retain sensation. This is due to the supply of  ulnar more than its anatomical area. This is called the maximal zone of ulnar. 240. What What is is ana anato tomi mica call are area? a? • Thi Thiss is descri described bed in in anatom anatomy y books books as to medi medial al 1½ fingers and adjoining hand (the volar aspect).

 

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30. RADIAL CLUB HAND Congenital—bilateral Child has extreme radial deviation of wrist, thumb touching forearm.

Contracture of radial side of wrist. X-ray: Partial/total absence of radius (Tetralogy of Fallot— absence of radius). 241. Wha Whatt surgi surgical cal tre treatm atment ent you wil willl offer offer??

• Initial Initi al splin splinting, ting, later r excisio excision n of of lunate luna te and and wrist wrist arthrodesis withlate centralization ulna.

Fig. 63A:  A child with radial club hand

 

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31. COMPOUND PALMAR GANGLION      

Swelling on either side of flexar retinaculum Cross fluctuation + Not much of tenderness Usually TB, osteoporosis of carpal bone Crepitus from the “Melon seed bodies “ ‘TB tenosynovitis of ulnar bursa’—chronic cases hour glass swelling above and below the carpal ligaments



Finger tightly flexed. 242. Wha Whatt is Ka Kana nave vel’ l’ss si sign? gn? • Tend Tendern erness ess over over the ulna ulnarr aspect aspect of of palm— palm—in in cases of ulnar bursa inflammation. • In Inve vest stig igat atio ions ns as fo forr TB. TB. 243 24 3. What is the the treatme treatment nt for for compound compound palma palmarr ganglion?

• An Anti titu tube berc rcul ular ar tr treat eatme ment nt..

Fig. 63B:  Case of compound palmar ganglion of wrist

 

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32. NEUROPATHIC JOINT        

Elbow, knee and sometimes ankle Acquired in the 4th decade  Joint is excessively swollen, not much of pain, crepitus, abnormal mobility Patient may have findings of laminectomy, syringomyelia, meningocele Sensory examination should be thorough. Any swollen painless joint should be suspected for neuropathy X-ray—excessive degeneration with loose bodies Rule out tabes dorsalis (VDRL), syringomyelia, (MRI) spine (laminectomy).

Treatment

Splinting  More prone for infection—loss of limb. 244. Wha Whatt treatm treatment ent you you will will never never do do or tell tell in this this case case?? • Art Arthro hropla plasty sty not not to be told/ told/fus fusion ion may may be tried tried • Cont Contraind raindicati ication on for arth arthropl roplasty asty or fusi fusion on may may also be difficult • Mo More re pr pron onee for for in infe fect ctio ion. n. 

Fig. 63C:  Case of neuropathic ankle joint

 

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33. CARPAL TUNNEL SYNDROME   

Patient will complaint of paresthesia over palm more over thenar aspect Phalen’s test positive—Flexion of wrist for 30 seconds reproduces symptoms Most common in myxedema, pregnancy.

245.. What 245 What is is the the trea treatm tmen ent? t? • Ini Initia tial—d l—diu iuret retics ics,, control control of of myxede myxedema. ma. 246. What What is the trea treatme tment nt in in resis resistan tantt cases cases?? • Res Resist istant ant case casess can be b e subjec sub jected ted to t o nerve ner ve conduction tests and carpal tunnel release can be done.

Fig. 63D:  Carpal tunnel syndrome with wasting of left thenar muscles

 

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34. DUPUYTREN’S CONTRACTURE     

Fibrosis and contracture of MCP joint Thickening of palmar fascia—little and ring finger Feel of nodularity of affected finger Fibrous strand cross the crease into the affected finger Grading of Dupuytren’s.

Treatment 

Splinting, open release.

Fig. 64: Dupuytren’s contracture with involvement of PIP  joint of little fingure bilaterally bilater ally

 

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35. SPINA VENTOSA   

Swelling of phalanges Spina—“ache” as produced by spike/thorn Ventosa—fusiform.

247. What What is the cau cause se and and treat treatmen mentt for for this? this? • TB osteo osteomyeli myelitis tis and antianti-tuber tuberculo culous us treat treatment ment should be started followed by curettage. 248. What What differ different ential ial dia diagno gnosis sis you you will will think think of? of? • En Ench cho ond ndro roma mata ta..

Fig. 64A:  A case of spina ventosa

 

SHORT CASES   97

36. MALLET FINGER (BASE BALL FINGER)

Fig. 65: Mallet finger 

Characterized by flexion of DIP joint due to avulsion of long extensors from the distal insertion/passive extension is possible in early cases. 249. What What woul would d be the the X-r X-ray ay pic pictu ture re?? • Av Avul ulsi sion on of dis dista tall pha phala lanx nx.. 250.. What 250 What is is the the trea treatm tmen ent? t? • Vola Volarr splint splinting ing with DIP joint exte extensio nsion—6 n—6 week weekss in early cases • Repa Repair ir and and sutur suturing ing by a transve transverse rse elli elliptic ptical al incision, if presented late.

 

98

SHORT CASES IN ORTHOPAEDICS

37. FOOT DROP

A

B

Figs 66A and B: Foot drops; (A) In a child on his left side; (B) An adult on his right foot   

 

History of injury to leg or spine or surgery knee or tumor Cause of difficulty in lifting toes of the ground Patient cannot walk with heel strike.

SHORT CASES   99

On examination:   

Foot in equinus Tibialis anterior is weak Peroneus long as not acting.

Loss of sensation of autonomous area of common peroneal nerve. Common peroneal nerve sites are inspected palpated for scar, nerve thickening and swelling over the area. Tinel’s sign is tested in injuries.  With injuries (except in neuropraxia) neurological recovery can be assessed  X-rays of ankle and knee are taken  Muscle and nerve conduction study are done. 251.. What 251 What is is the the trea treatm tmen ent? t? • Imm Immedi ediate ately ly dynam dynamic ic foot foot drop drop spli splint nt is given given..

Observation (Neuropraxia) • Int Interv ervent ention ion (no (no improve improvemen ment, t, nonanat nonanatomi omical cal Tinel’s). Reconstruction Reconstruct ion procedures: • If patien patientt present presentss after after one year, neuro neuromuscu muscular lar  junc  ju ncti tion on is al alre read ady y da dama mage ged— d—“S “Sri rini niva vasa san’ n’ss procedure (transfer of tibialis posterior to dorsum with TA lengthening). 252. How will will you diff differe erentia ntiate te a musc musculot ulotendi endinous nous injury or a nerve injury? • The cont contrac ractio tions ns of the the muscl musclee can be be palpat palpated ed in case of a tendon injury and not in nerve injury, as the patient attempts to dorsiflex the ankle.

 

100 SHORT CASES IN ORTHOPAEDICS

253. What What is is auto autonom nomou ouss zo zone ne?? • It is that that part part of skin skin supp supplie lied d only only by the the nerve nerve in question and not by any other nerve. 254.. What 254 What is ma maxi xima mall zon zone? e? • In the the other other nerve nervess are bloc blocked ked stil stilll some some of the the area of those nerves will retain sensation. This is due to the supply of nerve in question more than

its anatomical area. 255. Wha Whatt is is ana anato tomi mica call are area? a? • Thi Thiss is descr describ ibed ed in boo books ks as to dor dorsum sum,, medial medial half and lateral ½ of sole.

 

SHORT CASES   101

38. BAKER’S CYST       

Patient has pain in the knee (anterior and posterior) Difficulty in squatting Cystic swelling, lesion in popliteal region On flexion, less prominent On extension, more prominent Associated with degenerative joint disease of knee Popliteal cyst is the other name.

256. How will will you you treat treat if patie patient nt is les lesss than than 6 years? years? • Observe. 257. 25 7. What is the the treat treatment ment in rheumat rheumatoid oid arthr arthritis itis patient? • Pop Poplit liteal eal cyst cyst exci excisio sion n and synov synovect ectomy omy.. 258. What What is the trea treatme tment nt if the the patient patient has has associ associate ated d findings for deep venous thrombosis (DVT)? OR What is the treatment in suspected DVT

patient? • Rup Ruptur tured ed popli poplitea teall cyst may may mimic mimic DVT— DVT—mus mustt do ultrasound of the region to find if the sac is

ruptured and treat for DVT. 259. Wh 259. What at is fl fluc uctu tuat atio ion? n? • Disp Displaci lacing ng a flui fluid d inside inside a sac sac is call called ed fluctuation. 260. What What is is cro cross ss fl fluct uctua uati tion? on? • Fluctuation → In more than one plane is called cross fluctuation.

 

102 SHORT CASES IN ORTHOPAEDICS

261. What What is is pse pseudo udofl fluc uctu tuat atio ion? n? • Fluctuation →  In only one direction is called pseudofluctuation (e.g. muscle mass).  A Popliteal cyst

A

C

B

D

Figs 67A to D: Popliteal cysts

 

SHORT CASES   103

39. MADUROMYCOSIS  

History of bare foot walking Agricultural laborer

 

Swelling and pigmentation of foot and ankle Multiple sinuses discharging fungal granules.

262. What What are are th the e X-r X-ray ay fi findi nding ngs? s? • Mul Multip tiple le osteo osteolyt lytic ic lesio lesions ns in the the tarsal tarsals. s.

263.. What 263 What is is the the trea treatm tmen ent? t? • An Anti tifu fung ngal al Amp Ampho hote teri rici cin nB • Debridement

• Amp Amputa utatio tion n in res resist istant ant cas cases. es. 264. Why Hi Hist stor ory y of bar bare e foot foot wal walkin king? g? • Com Common mon in in farmer farmerss and bare barefoo foott walker walkerss which which favor inoculation of spore.

A

B

Figs 68A and B: (A) X-ray of the patient with mycetoma foot; (B) Above patient with mycetoma

 

104 SHORT CASES IN ORTHOPAEDICS

40. GENU VALGUM

  

A condition where the limb distal to the knee is deviated outwards Intermalleolar distance increased to at least 10 cm Medial joint laxity present. In children with stunted growth vitamin D levels, calcium, phosphorus estimation, USG abdomen for renal and neurological problem is must.

265. Whe Where re is is defor deformit mity y whethe whetherr in tibi tibia a or fem femur? ur? →

• Di sapp r sapp onppea flex fl exio n fle  deformity is in femur • Disa Did Di d ppea nottear no di disa ear rion on flexi xion on → deformity is in tibia. 266.. Trea 266 Treatm tmen entt of of choi choice ce?? • Vit Vitami amin n D suppl suppleme ementa ntatio tion n if ric ricket ketss • Mac Macewa ewan’s n’s—o —oste steoto otomy my to correct correct defor deformit mity. y.

A

B

Figs 69A and B:  Two cases of genu valgus

 

SHORT CASES   105

41. GENU VARUM



By the nomenclature limb distal to the knee, i.e. legs moving towards the midline Usually bilateral Intercondylar distance is measured in standing and lying down positions Used to assess progression It is physiological usually—manifested usually—manifested by 1½ years and



corrected years Blount’s, osteoarthrosis of knee. Also seen by in 3rickets,

   

A

B

C

D

Figs 70A to D:  There can be flexion deformity also

 

106 SHORT CASES IN ORTHOPAEDICS

A

B

Figs 71A and B:  No deformity in flexion → appears on extension only →  deformity is in femur right

Fig. 72:  Case of bilateral osteoarthritis

 

SHORT CASES   107

Fig. 73:  X-ray on the above case

267. Where Where is the de defo formi rmity ty?? • If it it disa disapp ppea ears rs on fl flex exio ion n → deformity is in femur →

• If ittibia. did not did not disap disappea pears rs on on flexi flexion on in it

 deformity is

268.. Trea 268 Treatm tmen entt opt optio ions ns?? • Sp Spli lint ntin ing g in in chil childr dren en • Ca Calc lciu ium m an and d vi vita tami min n D. 269. Wha Whatt is the the indicat indication ion for for high high tibia tibiall osteot osteotomy omy in in

OA knee? • Un Unic icom ompa part rtme ment ntal al dis disea ease se

• Youn Young g pat patie ient nt < 65 65 yea years rs • Go Good od ra rang ngee of mo move veme ment nt.. 270. Who is the aut author hor of abo above ve sur surger gery? y? • Coventry. 271. What What is the the advan advantag tage e of late lateral ral appr approac oach h for the above surgery? • The probl problem em of of laxity laxity of the the latera laterall ligamen ligaments ts is is

taken care by reefing.

 

108 SHORT CASES IN ORTHOPAEDICS

272. What What is the the indica indicatio tion n for tota totall knee knee replac replaceme ement nt OA knee? • Tr Tric icom ompa part rtme ment ntal al dis disea ease se • Ol Olde derr pat patie ient nt > 65 65 yea years rs • Po Poor or ra rang ngee of of mov movem emen ent. t. 273. Where Where will will you you see for syno synovia viall thicke thickening ning?? • Ant Antero eromed medial ial asp aspect ect of kne kneee joint joint.. • Als Also o grip grippi ping ng the the side sidess of pat patell ella. a. 274. Why Ante Anterom romedi edial al asp aspect ect of knee joi joint? nt? • Beca Because use in in any syno synovial vial effu effusio sion n or infla inflamma mmation tion or immobility due to pain vastus medialis obliqus is the first muscle to get wasted. By rolling over

this feel. site synovial reflection is felt with a craggy

275 27 5. Why should should you prese preserve rve patel patella la in fractu fracture re patella, what is the necessity of bone, e.g. even horses do not have patella? • Pate Patella lla give givess lever lever arm for the quad quadrice riceps ps to to contract. If there is no patella then the excursion of quadriceps tendon is reduced and flexion is

reduced. • Pat Patell ellaa is is essen essentia tiall for for bi biped peds. s. • In this this era era of tota totall knee knee arthrop arthroplast lasty y (T (TKA) KA) preserving patella is a must—though with a nonanatomical reduction. 276. What What is mec mechani hanical cal axi axiss devia deviatio tion n (MAD)? (MAD)? • Line join joining ing the centr centree of head of femur femur to the the

centre of ankle joint is the mechanical line. Any deviation is called mechanical axis axis deviation.

 

SHORT CASES   109

42. RESIDUAL POLIOMYELITIS Patient presents complaints—for deformity, weakness. History of the Patient  Delivery, vaccination, development, childhood fever— intramuscular injections during fever  Splintage previous orthosis  Present occupation.

General Examination       

  

Gait—Patient walks alone/support/caliper Neurological examination examinatio n muscle power of upper and lower limb Shoulder—Extension, flexion, abduction, adduction, internal rotation, external rotation Elbow—Flexion, Elbow—Flexi on, extension Wrist—Dorsiflexion, Wrist—Dorsif lexion, plantarflexion Small joints of hand MCP and IP Hip level of ASIS/attitude, fixed deformities, Range of  movement—active and passive—Extension, flexion, abduction, adduction, internal rotation, external rotation Knee—Flexion, extension Ankle—Dorsiflexion, Ankle—Dorsifl exion, plantarflexio plantarflexion n Toes—Dorsiflexion, Toes—Dorsiflexi on, plantarflexion, spine deformity— region and length.

Measurements 

Apparent and true measurements.

 

110 SHORT CASES IN ORTHOPAEDICS

SPECIAL TESTS

Abduction contracture of hip—Ober’s test a diagnostic test that assesses the degree of tautness in the iliotibial band. The

patient in a side lying position with hips at zero degree flexion and the leg is passively adducted. Tightness and knee not touching the couch indicates iliotibial band syndrome.

A

B

C

D

Figs 74A to D:  (A) Residual poliomyelitis of right lower limb standing with quadriceps gait; (B) the same patient trying to passively extend his knee; (C) his pelvis X-rays; (D) another  patient with left upper limb polio

 

SHORT CASES   111

277. What What are the the possib possible le surgi surgical cal trea treatme tment nt of polio polio?? • De Defo form rmit ity y corr correc ecti tion on • Mu Musc scle le bal alaanc ncin ing g • To st stab abil iliz izee a fl flai aill join joints ts • To corr correct ect li limb mb leng length th disc discrep repanc ancy. y. 278. What What are are the the cause causess of def deform ormity ity in polio polio?? • Unt Untrea reated ted unsp unspli linte nted d positi positioni oning ng of limb limb • Musc Muscle le imba imbalan lance— ce—over over act action ion of of un affec affected ted muscle. 279. What are the prer prerequis equisites ites and princ principle ipless of of tendon tendon transfer? 6S • Supple jo joints • Sa Same me po powe werr do dono norr te tend ndon on • Transfer • Straight li line • Sup Suppl ply—n y—nerv ervee and and mus muscle cle int intact act • Sta Stable ble inse inserti rtion on into into bone bone prefe preferab rable. le. 280. 28 0. What a proper proper tendon trans transfer fer is intende intended d to achieve? • Rem Remove ove a stron strong g muscl musclee or str streng engthe then n a weak weak muscle • Dy Dyna nami micc cor corre rect ctio ion n

• Sta Stabil iliz izee a jo join intt • Mak Makee a pati patient ent to to walk walk arou around nd with with a near near normal gait preferably without calipers. 281. Which Which is the the commo commones nestt muscle muscle to to get par paraly alysed sed?? • Ti Tibi bial alis is an ante teri rior or..

 

112 SHORT CASES IN ORTHOPAEDICS

282. Which Whi commone monest st musc muscle le to to get get spare spared? d? • Pech roniseithe . com 283. Why? • Tib Tibial ialis is anteri anterior— or—get get suppl supplied ied only only from from L4 • Pero Peronei— nei—get get supp supplie lied d from from more more number number of root rootss L5 S1 S2. 284. Whi Which ch is the the easy easy muscl muscle e to teac teach h after after trans transfer fer??

• Pe Perron oneu euss br brev evis is.. 285. Is arthro arthrodes desis is an altern alternati ative ve for tendo tendon n transfe transfer? r? • No it it can be consi consider dered ed to be done done with with a ten tendon don transfer. Arthrodesis is not an alternative to tendon transfer.

 

SHORT CASES   113

43. NONUNION FRACTURE BOTH BONE LEG A cause of deformity of the leg/history of injury to patients leg in a road-accident.  History of indigenous treatment  Now after 6 months the patient cannot weight bear on   

the On limb. examination the leg is deformed there is a valgus deformity M/3 D/3 junction Abnormal mobility present there Shortening of 2 cm.

Fig. 75:  A gap nonunion (the above patient’s X-ray)

 

114 SHORT CASES IN ORTHOPAEDICS

286. What What will will you you see see in the the X-r X-ray ay?? • En Ends ds of of the the frac fractu ture re scl scler eros osed ed.. • No evi eviden dence ce of of callu calluss there there is a gap gap.. 287. Clas Classi sifi fica cati tion on?? • Hypertrophic,

• Atr tro ophi hicc ty types es..

A

B

Figs 76A and B:  An example of hypertrophic nonunion in another patient

288.. What 288 What is is the the trea treatm tmen ent? t? • Inter Internal nal fixat fixation ion with with interl interlocki ocking ng nail nail or or plating plating after freshening of fracture with posterolateral  bone grafting. 289. If this this case case is an an infect infected ed nonuni nonunion on how how will will you you proceed? • Deb Debrid rideme ement nt of the inf infect ected ed sit sitee • Iliza Ilizaro ro fram framee applic applicatio ation n and and bone bone trans transport port..

 

SHORT CASES   115

Fig. 77:  Infected gap nonunion

Fig. 78:  Nonunion with deformity

 

116 SHORT CASES IN ORTHOPAEDICS

Fig. 79:  X-ray of above case

290. Why in in the non non union union of tib tibia ia ther there e is diff difficu iculty lty in eliciting abnormal mobility in both planes? • As there there are are two two bones bones in in the leg the fibu fibula la almo almost st always unite faster and hence restricts movement in the form of abnormal mobility.

A

B

C

Figs 80A to C:  Nonunion treated with Ilizaro

 

SHORT CASES   117

A

B

Figs 81A and B:  Postoperative

291. What What is is the the adv advant antage agess of of Iliz Ilizaro aro?? • Imme Immediat diatee weight weight-bea -bearing ring can be allo allowed wed in infected fracture also. Addresses all issues of  fracture like shortening, bone loss, deformity, nonunion.

 

118 SHORT CASES IN ORTHOPAEDICS

44. NONUNION PATELLA   

Case of difficulty in walking History of injury mostly direct on the patella 8 months  back Indigenous splintage and over the counter (OTC) drugs.

On examination:  Extension is weak  

Extensor lag present A palpable gap present over the patella.

292. What What will will you you see see in the the X-r X-ray ay?? • Ga Gap p seen seen in in the the frac fractu ture re sit site. e. 293.. What 293 What is is the the trea treatm tmen ent? t? • Wha Whatev tever er time time it pres present entss the best best trea treatme tment nt is to to retain the patella. 294. What What is the the differ differenc ence e betwee between n extens extensor or lag lag and fixed flexion deformity? • In extensor extensor lag passi passive ve extensio extension n of final degre degrees es is possible. It is not possible in fixed flexion deformity.

 

SHORT CASES   119

C

D

E

Figs 81C to E:  A case of neglected fracture of patella

 

120

SHORT CASES IN ORTHOPAEDICS

45. CONGENITAL PSEUDARTHROSIS OF TIBIA

Fig. 82: Congenital pseudarthrosis     

Cause of deformity of the leg in the form of anterior  bowing  bow ing The deformity may be seen from birth History of indigenous treatment History of surgery Deformity and abnormal mobility m/3 of leg.

 

SHORT CASES   121

Fig. 83: X-ray of congenital pseudarthrosis

295. What What will will you you see see in the the X-r X-ray ay?? • Ti Tibi bial al sh shaf aftt is is thin thinne ned d out out • Fi Fibu bula la is th thic icke kene ned. d. 296. What What are are the the type typess of thi thiss lesi lesion? on? Boyd classification Six types 1. De Defe fect ct

2. Hou Hourgl rglass ass 3. Cy Cyst st 4. Scl Sclero erosis sis 5. Dysp Dysplasia lasia of fibula fibula 6. Intra Intraosseo osseous us fibroma. 297. What What are are the the trea treatm tment ent o opti ption ons? s? • Idea Ideall treatm treatment ent and and that that gives gives some some hope hope is is

with ilizaro • resection Other Oth er option optand ionss transport are vascul vasculari arised sed fibular fibul ar graft graft • Bon Bonee graft grafting ing and int intern ernal al fixa fixatio tion. n.

 

122 SHORT CASES IN ORTHOPAEDICS

46. OSGOOD SCHLATTER’S DISEASE

Figs 84A and B:  Adolescent boy cause of pain over the tibial tuberosity   

Swelling and prominence over the tibial tuberosity Tenderness over the tibial tuberosity Flexion almost full except mild restriction in the extreme flexion.

298. What What will will you you see see in the the X-r X-ray ay?? • Frag Fragmenta mentation tion of the the tibia tibiall tubero tuberosity sity apop apophysis hysis.. 299.. What 299 What is is the the trea treatm tmen ent? t? 1. Exte Extensio nsion n splints splints and non-stero non-steroids ids antiantiinflammatory drugs (NSAIDs) 2. Exci Excision sion of of the fragmen fragment, t, if pain pain is severe and not not responding to conservation.

 

Things to be Taken

 

124 SHORT CASES IN ORTHOPAEDICS

THINGS TO BE TAKEN TO THE CLINICAL EXAMINATION HALL

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

White coat White coat wit with h numbe numberr writt written en legi legibly bly Inch In ch ta tape pe (a (avo void id st stee eel) l) Tuni Tu ning ng Fo Fork rk-1 -128 28 Hz Tuni Tu ning ng Fo Fork rk-2 -256 56 Hz Knee ha hammer Skin Sk in ma mark rkin ing g pen penci cill Goniometer Plumb lime Test tu tubes Cotton wi wisp Pins Pad Scale ru ruler Stet St etho hosc sco ope Coins Stopwatch.

 

Cases Seen in Ward Rounds

 

126 SHORT CASES IN ORTHOPAEDICS

CASES AND APPLIANCES YOU MAY BE ASKED IN WARD ROUNDS IN DNB AND NOTES FOR THEM WARD PROCEDURES 1. The BB Splint or Bohler–Braun splint

Fig. 85: BB splint

It has a limb rest with a genu corresponding to the knee. In the above picture the left lower limb is kept in BB splint with upper tibial pin traction.

 

CASES SEEN IN WARD ROUNDS   127

2. The Stryker frame

Fig. 86: Stryker frame

It has two boards to rotate the patient. It has a pulley in the upper end. In the above picture the patient is kept in the Stryker frame with skull tongs traction. 3. Calcaneal pin traction

Fig. 87: Calcaneal pin applied

 

128 SHORT CASES IN ORTHOPAEDICS

4. One and half hip spica

Fig. 88: Hip spica for pediatric femur fracture

REGION WITH CONDITION SHOULDER (ROTATOR CUFF TEAR)

A

B

C

Figs 89A to C: (A) Patient attempting active abduction—which he is not able to do; (B) He can touch the opposite shoulder; (C) Patient can passively lift his shoulder to abduction

 

CASES SEEN IN WARD ROUNDS   129

6. An Ano oth ther er su such ch pa pati tien entt

Fig. 90: Patient is trying to abduct his shoulder 

7. Pos Postt sho shoul ulde derr hem hemia iart rthr hrop opla last sty y

Fig. 91: Patient with post shoulder hemiarthroplasty

 

130 SHORT CASES IN ORTHOPAEDICS

8. An ost osteo eoto tomy my do done ne fo forr Erb’ Erb’ss pal palsy sy

A

B

Figs 92A and B: Erb’s osteotomy

ARM 1. Malunited humerus fracture

A

B

Figs 93A and B: Humerus fracture (Malunited)

 

CASES SEEN IN WARD ROUNDS   131

2. Wounds for nail entry, proximal and distal locking for humerus fracture fixed with an interlocking nail.

Fig. 94: Humerus fracture (proximal and distal locking)

A

B

Figs 95A and B: Immediate—postoperative closed

ILN of humerus of above case

 

132 SHORT CASES IN ORTHOPAEDICS

3. Another similar case (2-year follow-up)

Fig. 96: Humerus tracture (after 2-year follow-up)

ELBOW

A

B

Figs 97A and B:  Dislocated elbow

 

CASES SEEN IN WARD ROUNDS   133

Fig. 98:  Fracture olecranon (see the olecranon retained in fossa)

A

B

Figs 99A and B:  Prominent implants under the skin

 

134 SHORT CASES IN ORTHOPAEDICS

Fig. 100:  Puckering in supracondylar  fracture of humerus type III

A

B

Figs 101A and B: A case of flexion type t ype of supracondylar fracture of humerus—presented late with ankylosed elbow with ulnar  nerve palsy

 

CASES SEEN IN WARD ROUNDS   135

Fig. 102:   Extension osteotomy, arthrolysis and anterior  transposition of ulnar nerve done in one stage (for above case)

WRIST AND HAND

Fig. 103: An extensor tendon injury

 

136 SHORT CASES IN ORTHOPAEDICS

A

C

B

Figs 104A to C: Volar barton fracture—after fixation degree of volar and dorsiflexion after surgery

A

B

Figs 105A and B:  Tuberculosis of wrist—lower end of ulna

 

CASES SEEN IN WARD ROUNDS   137

A

B

Figs 106A and B:  Carpometacarpal dislocation of third metacarpal

Fig. 107:  Heberden’s nodules osteoarthritis of small joints

 

138 SHORT CASES IN ORTHOPAEDICS

Fig. 108:  PIP joint dislocation of ring finger neglected

A

B

Figs 109A and B:  A rheumatoid hand

 

CASES SEEN IN WARD ROUNDS   139

Fig. 110:  The ulnar deviation of PIP of right middle finger 

Fig. 111:  Trigger finger 

 

140 SHORT CASES IN ORTHOPAEDICS

Fig. 112:  Dorsal capsulotomy of MCP joints for a stiff hand

Negative ulnar variance with snapping distal ulnar 

A

B

C

Figs 113A to C:  Prominent ulnar head in

supination

→

  Snaps in pronation

 

CASES SEEN IN WARD ROUNDS   141

A

B

C

D

Figs 114A to D:   Wrist dislocation fusion done for the same

A

B

Figs 115A and B:  Colles’ fracture

 

142 SHORT CASES IN ORTHOPAEDICS

A

C

B

Figs 116A to C:  Level of styloids, stiffness of hand joints and dinner fork deformity

A

B

C

Figs 117A to C:  Another case of old malunion distal radius

HIP

Fig. 118:  Old Perthes disease

 

CASES SEEN IN WARD ROUNDS   143

Fig. 119:  Fracture of acetabulum with fracture femur shaft

THIGH

A

B

Figs 120A and B:  Infected fracture femur →  Antibiotic Loaded Acrylic Cement laden nail for the same case

 

144 SHORT CASES IN ORTHOPAEDICS

A

B

C

D

Figs 121A to D:  Infected fracture femur treated with Ilizaro X-ray of the same case

Fig. 122:  Floating knee treated with knee spanning Ilizaro apparatus

 

  145

CASES SEEN IN WARD ROUNDS

KNEE

A

B

C

Figs 123A to C:   Painful swelling over medial collateral ligament, X-ray of the same case showing calcification of  ligament

Fig. 124:  Patellofemoral arthritis—osteophyte seen on the lateral aspect of the fibula

 

146 SHORT CASES IN ORTHOPAEDICS

Fig. 125:  Quadriceps lengthening done for congenital dislocation of both knees—(now after 50 years)

A

B

Figs 126A and B:  Bilateral genu varus (more on right side)

 

CASES SEEN IN WARD ROUNDS   147

A

B

Figs 127A and B:  The knee deformity patient also had chest deformity pigeonchest and stunted growth

A

B

Figs 128A and B: X-ray of the above case—  possibility of Rickets

 

148 SHORT CASES IN ORTHOPAEDICS

Fig. 129:  Another patient with bilateral genu valgum (Rickets)

A

B

C

D

Figs 130A to D:  Dislocation knee, treated with reduction and stabilization. Arterial injury is notorious complication

 

CASES SEEN IN WARD ROUNDS   149

A

B

Figs 131A and B:  Post-patellectomy status–on left side, extension is almost full

Fig. 132:  Flexion deformity knee treated with Ilizaro

 

150 SHORT CASES IN ORTHOPAEDICS

Fig. 133:  Soft tissue swelling from upper part of  medial collateral ligament

A

B

Figs 134A and B:   Hemophilic arthritis (see the wide intercondylar notch). In AP view X-ray condyles magnified and distorted due to associated flexion deformity

 

CASES SEEN IN WARD ROUNDS   151

Poor fixation of upper tibia fracture—causing delayed mobilization

A

B

Figs 135A and B:  (A) No plate plate was used for an upper tibial tibial fracture; (B) Locking compression plate for a similar fracture expected to achieve early mobilization

Foot and Ankle

A

B

Figs 136A and B:  Communited distal tibia fracture

 

152 SHORT CASES IN ORTHOPAEDICS

Fig. 137:  Pronation abduction injury ankle

See the lateral cortical comminution in fibula and the avulsion fracture of the medial malleolus

A

B

C

Figs 138A to C:  Post-traumatic equinus contracture

Patient cannot dorsiflex actively or passively

 

CASES SEEN IN WARD ROUNDS   153

Fig. 139:  X-ray of the above patient—see the forefoot—  equinus—a fit case for lambrinudi arthrodesis

A

B

Figs 140A and B: Another such patient with equinus contracture

 

154 SHORT CASES IN ORTHOPAEDICS

Fig. 141:  Loss of toes after an end arteritis

RETROCALCANEAL BURSITIS

Fig. 142:  See the prominent swelling over and near the attachment of tendocalcaneus-pointed tenderness

*Must rule out—Rheumatoid Artheritis *Main stay of treatment are Wax bath and NSAIDs *Excision of the bursa in resistant cases, with trimming posterior end of calcaneum.

 

CASES SEEN IN WARD ROUNDS   155

Closed TA rupture

A

B

Figs 143A and B:  (A) Squeeze test; (B) Palpable gap

300. 30 0. How How to to dia diagn gnos ose? e? • Hi Histo story ry of sudde sudden n giving giving way way in pers persons ons abov abovee

• •

• •

50 years of age. Palpable Palp able gap in the the substa substance nce of Tendo Tendo Achi Achilles. lles. Patient Pati ent can can still still attem attempt pt a plan plantar tar flexi flexion on by by contracting the long flexors but it is not powerful at all. Pati Pa tien entt cann cannot ot wal walk k on to toes es.. Squeezing Sque ezing the calf calf will not cause plan plantar tar flexi flexion on of the foot.

301. What What are are th the e oth other er te test sts? s? • Obri Obrien’s en’s test needl needlee is intro introduced duced into the distal distal end and then the above test is demonstrated (squeezing of calf muscles).

 

156 SHORT CASES IN ORTHOPAEDICS

302. What What is the the anoth another er diagn diagnosi osiss which which may may mimic mimic but but is not so devastating? • Pl Plan anta tari riss tend tendon on rup ruptu ture re.. • Post Posterom eromedia ediall and and the pai pain n and hema hematoma toma is less. less. • Mor Moree import important ant ther theree is no gap gap felt felt over over the the Tendo Tendo Achilles.

Fig. 144: Another case of TA