ORTHOPAEDICS

A 35 year old male motorcyclist was involved in a motor vehicle accident at 8.00 pm. He
was brought to A+E at 12.00 midnight. U noticed that his right lower limb has multiple
lacerated wounds and he does not respond to calls.
1. What is your immediate mx?
a) exclude cervical injuries
b) clear the airway
c) look for sucking chest wound/ flail chest
d) thorough examination of head and neck. Look for sings of basal skull # :-
i) subconjunctival haemorrhage
ii) panda eye sign –periorbital haemorrhage + oedema
iii) look for rhinorrhoea / orthorrhoea
iv) look for mastoid haematoma

e) assess for signs of shock

f) assess consciousness: Glasgow coma scale
check pupil reaction + size

His GCS is 6. Resp rate 10 bpm , Pulse rate 130 bpm , BP 90/60 mm Hg
His hand is cold & clammy.
2. What is your subsequent mx?
a) Establish airway and ventilation through intubation
Criteria:
1) Pt is unable to protect airway (stuporose)
2) Very low resp. rate which causes inadequate ventilation
3) GCS < 7
Rapid intubation by:-
1) Midazolam for sedation
2) Suxamethonium for paralysis
3) Size 8 ETT
ABG stat

b) Treat shock.
i) Insert 2 large bore IV canullae ( 16 gauge)
ii) Rapid infusion (bolus) of colloid ( normal saline)
iii) Group cross and hold 4 Unit whole blood stat
iv) If BP not stabilised after 2 litre of crytalloid infusion, start whole blood
transfusion
v) Catheterize the pt (continuos bladder drainage)l
Strict monitoring for sn of oliguria/ anuria

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c) Secondary survey (non life threatening injuries)
d) Send to ICU.
- pt must be stabilised b4 transport
- adequate sedation and paralysis to prevent cough and  intracranial pressure

His condition has been stabilized. On thorough examination, there is a depression over
the skull. There is gross deformity over the right thigh and leg with bony protrusions. The
wound is grossly contaminated. U also Pnoticed that his ICP is increasing.
3. What is your next step?
a) Order a skull x-ray to confirm skull #
b) X-ray of pelvis, hip jt, rt knee jt & rt ankle jt (AP + Lat.view)
c) Anti-tetanus prophylaxis ( immune status not known)
0.5 cc anti-tetanus toxoid
250 unit immunoglobulin

d) Wound debridement + thorough wound toilet

Cover with IV Penicillin 2 million unit 6 hrly
IV Metronidazole 800 mg 6 hrly

e) Treat increased ICP.

i) Prop up and hyperventilate to reduce Pa CO2 to 30 mmHg
ii) Osmotic diuresis:
Mannitol 0.5-1.0 g/kg ( 20 % solution) 6 hrly
+
Frusemide
iii) Strict monitoring of ICP. Alert neurosurgeon if ICP> 12 mmHg ( normal <
10mmHg)

4. How do u grade open #? ( Gustilo’s classification )

Grade 1 -<1cm, cleanwound, little soft tissue injury
Grade 2 –1-10cm, moderate soft tissue injury
Grade 3 ->10cm with severe soft tissue damage
3A- Adequate skin coverage
3B- Bony exposure
3C- Neurovascular injury

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X-ray- skull # over rt temporal bone.
Transverse # over rt femoral shaft & rt tibial shaft
ICP continue to rise despite hyperventilation and diuresis. Pulse rate 60, BP 140/90
5. What is your Mx?
i) Suspect extradural/ subdural / inracranial haemorrhage / haematoma
Order CT scan stat
ii) Stabilize long bone # using external fixator to prevent fat embolism.
Monitor for sn of fat embolism.
Major:
1) Petechial rash
2) Resp sym ( dyspnoea, tachypnoea, central cyanosis)
3) Drowsiness, convulsion, coma.

Minor:
1) Tachycardia
2) Pyrexia
3) Retinal changes ( fat/ petachiae)

Continuous ABG monitoring.

Order platelet count to look for thrombocytopenia.
Consider Swanz Ganz catheterization if condition deteriorates.( normal
pul.wedge pressure < 16 mmHg)

Order CXR to look for:-

a) air bronchogram
b) alveolar collapse
c) complete white out of lung field

Subsequently he develops a generalized convulsion. GCS is 3.Fat globules floating in

urine bag.
6. Outline your Mx for controlling the seizure.
Seizure > 3 minutes

IV diazepam 2 mg/min till seizure stop (Max 25mg)
 If seizure persist
IV phenytoin 50mg/min
 If seizure persist
IV lignocaine 50-100mg
 If seizure persist
Barbiturate coma

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EEG monitoring
-continuous ICP monitoring
-continue ICP reduction steps
Rule out :
i) Cerebral oedema
ii) Muscle damage & rhabdomyolysis
iii) Fatal hyperkalemia
iv) Acute renal failure

Monitor serum level of anti-epileptic.

Tail down sedative and wean off once o fits are noted.

7. How do you treat fat embolism?

i) Heparin to counter thromboembolism.

ii) Steroid to reduce pulmonary oedema.
iii) Aprotinin to prevent aggregation of chylomicron.
iv) 8-16L O2 via face mask.
v) Ventilatory support.
vi) Early operative fixation of long bone fractures.

8. What are the dangers of convulsion lasting longer than 60 minutes:

i) Irreversible cerebral damage.

ii) Lactic acidosis.
iii) Hypoglycemia.
iv) Hyperthermia.
v) Rhabdomyolysis.
vi) Acute renal failure.
vii) Shock.
viii) Aspiration pneumonia.

The patient regained consciousness the next day. Vital signs are stable. However he
complaint that he could not move his R toes. You suspect that it is most probably due to
nerve injury.

9. List down Seddon’s classification of nerve injuries.

1.Neuropraxia - physiological blockage to conduction of electrical impulse.

- no anatomical disruption.
- temporary motor paralysis with incomplete sensory impairment.

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 - complete recovery by 6 weeks.

a) Axonotemesis - anatomical disruption of axon.

- intact nerve sheath.
- Wallerian degeneration.
- axon begin to sprout by 10th day, 1mm/day.
- recovery can be complete / incomplete depending on degree of
fibrosis.

b) Neurotemesis - the nerves is completely divided.

- spontaneous recovery not possible.
- surgical exploration is mandatory.
- even with surgical repair , recovery is never complete.

10. How would you grade motor and sensory dysfunction ?

Medical Research Council Classification :
Motor Sensory
0 Paralysis 0 No sensation
1 Flicker of muscle activity 1 Deep pain only
2 Movement & gravity eliminated 2 Pain , temperature
3 Movement against gravity 3 Able to localise pain
4 movement against resistance 4 Stereognosis + subnormal 2
point discrimination
5 Full power 5 Normal

The patient was kept immobilized for 3 weeks.

11. How would you prevent deep vein thrombosis?

a) Mechanical –
- Graduated elastic compression stocking
- Early mobilization
- Exercise
- Intermittent pneumatic compression
- Elevation of leg
b) Pharmacological - low dose subcutaneous heparin / warfarin

12. How do you prevent pressure sores in dependent areas/

i) Frequent changing of position every 2 hrly.
ii) Inflate glove with water & place over dependent areas.

13. How do you treat established pressure sore?

i) Treat the wound with clean method.

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ii) Rinse with 0.9% NaCl at body temperature.
iii) Moisten the wound . Never use dry dressing as it would cause cell dehydration &
tissue dessication.
iv) Maintain temperature at 32-37C to optimize cell division.
v) Check serum protein, albumin, electrolyte, hematocrit regularly. Correct any
abnormal.
vi) Give additional nutritional support - multivitamin
- adequate protein (2g/kg/day).

He was discharged 2 months later, he came back to you with painless mobility over the
fracture site.

14. What is your diagnosis?

Non-union.

15. How do you differentiate non-union from delayed union?

Non-union: Painless movement.
X-ray = Bone ends are smoothed off, sclerosed.
Fracture gap filled with fibrous tissue forming a pseudoarthresis.
Delayed-union: Fracture site is tender if subjected to stress.
X-ray = Fracture line still visible.

16. What is the cause of non-union?

a) Too large a gap between bone end.
b) Interposition of soft tissue.
c) Excessive distraction due to inadequate fixation.
d) Inadequate blood supply.
e) Septic non-union.

17. What is your Mx for non-union?

Autogenous bone grafting, cancellous bone is taken from iliac crest. The matrix will
serve as a scaffold for new bone formation, stimulated by Bone Marphagenic Protein.

You also notice that there is a discharging sinus over the fracture site.

18. What’s the diagnosis?

Acute traumatic osteomyelitis.

19. What Ix would you order?

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i) Aspirate the pus for gram stain.
ii) Blood culture + sensitivity.
iii) Total white count and ESR
iv) Anti-staphylococcal antibody.
v) X-ray.

20. List 3 X-ray findings to support your .

a) Periosteal reaction.
b) Metaphyseal mottling.
c) Area of increased density and rarefaction.

21. What is your Mx?

a) Supportive - relief pain-NSAID.
b) Regular wound dressing, sterile method.
c) Remove loose or ineffectual implants.
d) Adequate antibiotic coverage.
IV Flucloacillin + Fusidic acid 3 weeks.
Oral 3-6 weeks.
e) Drain abscess.

22. List the factors that predispose to post-traumatic infection.

a) Inadequate debridement.
b) Early closure of the wound.
c) Unfixed / unstable fracture.
d) Wound tension.
e) Tight dressing.
f) Haematoma formation.
g) Use of foreign material implant eg. Internal fixation.

23. What are the complication of osteomyelitis?

General : Septicaemia
Pyaemia
Metastatic abcsess
Local : Septic arthritis
Spontaneous fracture
Deformity
Chronic osteomyelitis.

24. What is Brodie’s abscess?

A Chronic bone abscess surrounded by thick, fibrous tissue & sclerotic bone.
Radiologically, there is a localized radiolucency area in the metaphyses of long bone. The

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infection has been eradicated. However there is a residual scar with a wide gap devoid of
epithelial tissue.

25. What is your Mx?

Thin split thickness skin graft.
Benefit : Can be harvested from any site.
Donor site will heal rapidly.
More rapid epithelialisation.
Higher chance of graft survival.

26. How would you optimize the outcome of skin grafting ?

a) Inspect the graft by 48 hours using sterile technique. Aspirate any fluid at the
undersurface of the graft.
b) Immobilize the area, protected with thick pad of gauze for 5-7 days.
c) Prevent oedema from developing for 4-6 months.

27. List the causes of graft failure.

a) Hematoma formation which prevent epithelialisation.
b) Excessive movement between graft & budding capillary.
c) Colonization by bacteria.
d) Fat attached to the undersurface of graft.

ORTHO

1. Plaster of Paris cast.

a) Name the active substance.
Calcium Sulphate Hemihydrate ( Ca2SO4. 2H2O )

b) Name 3 clinical uses

- Maintain fracture
- Immobile joint
- Correct the deformity ( CTEV )
- Conservative treatment for fracture ( close reduction )
i. To splint distal limb fractures / post-op.
ii. To splint fracture in children.
iii. Splint dislocation of shoulder.
iv. To correct CTEV.

c) List 3 complication and 3 steps to be taken to avoid it.

- Early complication:
o Compartment syndrome

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 o Sensitive / allergy
o Pressure sore
o Nerve compression

- Intermittent:
o Fail to hold the fracture ( malunion / non- union / delayed union )

- Late:
o Iscahemic volkmann’s contracture
o Stiffness
o POP disease / fracture disease

i. Joint stiffness – delayed splintage; use traction until movement is regained, then
only apply
plaster.
– replace cast with functional brace.
ii. Compartment syndrome – do not apply the cast too tightly
– thick padding and splitting of the cast if patient
complains of pain.
iii. Pressure sores – protect bony prominences with thick pad, or avoid them.
– skin must be dry and clean before applying.

d) List 5 instruction to the patient.

i. Report back to hospital immediately if there is pain or pin and needles in the
plastered limb.
ii. Do not rest the cast on firm surface.
iii. Do not hang the splinted limb dependent unless it is in active use.
iv. Exercise the joints and fingers/toes not splinted by the cast.
v. Keep the cast dry and report back if the cast becomes loose/cracked.

2. Photo of improper POP in hand fracture.

a) List 4 mistakes found and comment.
i. The 1st layer must have a stockinet/surgical cotton as padding.
ii. The cast extends up to the fingers. It should extend up to the metacarpal neck
and 2/3 of the way round the circumference of the wrist. Thumb and
metacarpophalangeal joint should be kept free.
iii. The wrist is kept in extreme flexion. It should be held in the functional
position, slightly extended.

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 iv. Metacarpophalangeal joint is held in extension. It should be 90 flexed while
interphalangeal joints are extended to prevent stiffness.

3. *What is the function of the end hole?

-Facilitate in taking out the nail.
*What is the function of the longitudinal hole?
-To prevent rotation.

a) Identify the instrument.

Intramedullary nail.

b) Give 5 indications.
i). Fractures that are unstable and prone to displacement eg. Midshaft fracture of fare
arm.
ii). Pathological fractures of long bone.
iii). Fracture that unite poorly eg. Femoral neck.
iv). Multiple fractures.
v). Fracture in the elderly when early mobilization is preferred.

c) Give advantages of its use.

i). Proper axial alignment.
ii). Early weight bearing.
iii). Can be placed in ‘close’ fashion. (Fracture site need not be opened).

d) What complication will occur 2 weeks after its insertion and how to overcome it?
i). Iatrogenic infection
Strict sterile technique and prophylactic antibiotic.
ii). Implant failure / refracture (after weight bearing).

4. Diagram of ortho bed with skin traction.

a) Draw the correct position of traction, weight & pulley.

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b) What is the principle of its use?
i. Continuous traction & countertraction.
ii. Hold reduction.

c) When is it used?
Used for spiral or oblique shaft fractures which is easily displaced by muscle
contraction.

d) How much weight to use?

10% of body weight.

e) List 5 complications.
i. Pressure sore around malleoli
ii. Common peroneal nerve palsy
iii. Allergic reaction to adhesive
iv. Excoriation of skin
v. Vascular insufficiency

f) List 2 contraindications.
i. Laceration at traction area
ii. Impairment of circulation at the affected area

5. Diagram of skeletal traction & Steinman pin of tibia.

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a) Describe the insertion of the pin & draw on the diagram provided.
Insert 1 inch below and posterior to tibial tuberosity, pin driven from lateral to medial
to avoid common peroneal nerve.

b) Draw and name the nerve that could be damaged.

c) How do you make sure the pin is in right angle?

Do a check X-ray of knee joint.

d) What is the function of Bohler’s stirrup.

To allow a range of direction for traction without disturbance of pin.

e) List 5 complications.
i). Introduction of infection into the bone.
ii). Damage to epiphyseal growth plate.
iii). Distraction at fracture site.
iv). Ischaemic necrosis of skin around the pin.
v). Ligamentous damage.

6. Crutches.
a) What is the use for it?
As a walking aid.

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b) Name the parts.
A- Axillary pad
B- Hand grip
C- Suction cap
D- Shank
E- Metal / wood frame

c) What is the level of A, B, C?

A= 3 finger breath bellow axilla.
B= At the level of greater trochanter.
C= 15cm anterolateral from little toe.

d) How should you position the elbow?

Elbow kept 30 flexion.

e) List 4 ways of using it.

i). Walk to the crutch.
ii). Walk through the crutch.
iii). Non-weight bearing.
iv). Partial weight bearing.

7. Specimen : Plate & screw.

a) Identify.

b) List 3 indications.
i). Pathological fracture.

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ii). Fracture prone to malunion.
iii). Intra-articular fracture.

c) List 3 places where it can be used.

i). Femoral neck.
ii). Supracondylar (humerus)
iii). Distal end of tibia.
iv). Patella , olecranon.

d) List 3 contraindications.
i). Open fracture.
ii). Laceration wound at the operation site
iii).Multiple fracture

e) List 3 complications
i). Non-union.
ii). Implant failure.
iii). Iatrogenic infection.
iv). Overdistraction.

8. External fixator.
a) Identify.

b) List 3 indications.
i). Open fracture.
ii). Multiple fractures.
iii). Lengthening of limb.
iv). Non-union.

c) List 3 sites of fracture for its use.

i). Pelvic fracture (open book)
ii). Tibial fracture.
iii). Distal radius comminuted fracture.

d) List 3 contraindications.
i). Very soft osteoporotic bone.
ii). Too small bony fragment to hold pin.
iii).Infected lesion at the site of pin insertion.

e) List 3 complications.
i). Pin track infection.

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ii). Overdistraction of fragment.
iii).Delayed fracture healing. (able to reduce load transmission)

9.Thomas Splint.
a) Measurement:
i). Length : ASIS to heel + 12cm
ii). Circumference : Greatest circumference of thigh + 6cm.

b) Indication:
i). Transfer patient
ii). Temporary immobilization before application of POP.
iii).Fracture of shaft of femur.

c) Position of leg:
Internal rotation.

d) Daily assessment:
i). Movement of big toe.
ii). Sensory over dorsum of first web of foot.

e) Complications:
i). Pressure sore.
ii). Compression of nerve and vessel.

10. Bohler-Braun frame.

a) Indication.
i). Supracondylar fracture of femur.
ii). Ipsilateral fracture of femur and tibia.
iii).Elevation of lower limb to decrease swelling.
iv). Unlocking of knee to reduce stiffness.

b) Mechanism :
Flexion over knee joint relaxes gastrocnemius muscle thus preventing it from puling
fractured part of femur especially in supracondylar fracture of femur.

c) Complications:
i). Nursing care is more difficult as patient is less mobile.
ii). Proximal fragment is mobile in relative to distal fragment which predisposes to
malunion.

11. Photo of left foot of T/M/ . (CTEV)

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a) List the abnormalities seen.
i). Talus points downwards (equinus).
ii). Forefoot shifted medially, adducted, inverted.
iii). Forefoot supinated.
iv). Wasting of calf muscle.
v). Callosities over lateral side of foot.

b) Diagnosis : Congenital talipes equinovarus.

c) What other joint you would want to examine? Give reasons.

i). Knee joint - look for arthrogryposis.
ii). Elbow joint - arthrogryposis multiplex congenita.
iii).Spine - spina bitida.

d) What X-ray would you want to take? In what position of foot?

i). Anteroposterior film.
Foot 30 plantar flexed.
ii). Lateral film.
Foot forced in dorsiflexion.

e) Which bone of foot can be seen at birth?

i). Calcaneum
ii). Tarsal
iii).Cuboid

f) List the deformity to be corrected in order of hieyrhachy.

i). Adduction
ii). Supination
iii).Equinus.

g) When should it be corrected surgically?

By 8 weeks of life in resistant cases.

h) List the surgical procedure.

i). Elongation of tendon Achillis.
ii). Posterior release (of posterior ankle capsule).
iii). Medical release (of talonavicular joint)
iv). Lengthening of tibialis posterior tendon.

Note: Other causes: Associated abnormalities :

- Poliomyelitis i). Motor weakness
- Cerebral palsy ii). Sensory loss

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- Post-meningitis iii).Hypertonia / hyperreflexia
iv). Hydrocephalus

GOUT

12. Picture of hand

a) List 2 abnormalities.
i). Swelling of the joints.
ii). Presence of tophi.

b) Diagnosis : Gouty arthritis.

c) List 2 investigations to confirm diagnosis.

i). Synovial fluid examination
Needle shaped, negative birefringent crystals.
ii). Serum uric acid level.

d) Give 2 drugs for acute management.

i). Colchicine
ii). Indomethacin.
iii).IM ACTH.

e) Give 2 drugs for long term management.

i). Allopurinol (Xanthine Oxidase Inhibitor)
ii). Probenicid (Uricosuric drug)

13. Clinical station.

Take history from a 28/M/ with knee swelling 1 month after playing football.
i) Localization of pain.
ii) Pain occur immediately after injury or after an interval.
iii) Type of injury? Direct force over knee joint or twisting injury. Lateral / medial part
of knee?
iv) History of locking in partial flexion. } meniscal
v) History of giving away. } tear
vi) Unable to go upstairs (post. Cruciate) or unable to come downstairs (ant. Cruciate)

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14. Colles (radius) fracture:
a) Components :
i). 2cm proximal to wrist joint.
ii). Dorsal displacement of distal fragment.
iii).Radial deviation.
iv). Supination.
v). Impaction.

b) Splinting :
i). 15 palmar flexion.
ii). Slight ulnar deviation.

c) Complications :
i). Median nerve neuropathy.
ii). Reflex sympathetic dystrophy.
iii).Malunion (Delayed union & non-union of radius do not occur).
iv). Stiffness of shoulder (neglect)
v). Sudeck’s atrophy.
vi). Rupture of tendon of extensor pollicis longus. (causing mallet thumb)

15. Malet Finger

a) Causes :
i). Extensor tendon stretch.
ii). Extensor tendon rupture.
iii).Bony avulsion.

b) Clinical feature :
i). Terminal interphalangeal joint is held flexed.
ii). Loss of active movement of extension of the joint.
iii).Passive movement is normal.

c) Splinting :
Terminal joint held in extension for 6 weeks.

d) Complications :
i). Deformity
ii). Subluxation
iii).Nail bed injury.

16. Trigger finger.

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a) Causes :
i). Thickening of fibrous tendon sheath.(Tender nodule can be felt)
ii). Rheumatoid tenosynovitis.

b) What causes triggering?

As the flexor tendon is trapped at the entrance to its sheath, forced extension will cause it
to pass through the constriction with a snap.

c) Which finger is commonly affected?

i). Ring finger.
ii). Middle finger.

d) Treatment :
i). Intralesional methylprednisolone.
ii). Incision of fibrous sheath, until tendon moves freely.

17.

a) Identify :
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 Scaphoid bone.

b) Name the fracture :

A = fracture through the neck of scaphoid
B = fracture through the waist of scaphoid
C = fracture through proximal pole.

c) Which fracture give rise to progressive avascular necrosis?

C (blood supply of scaphoid diminishes proximally).

d) List 3 clinical features.

i). Fullness of anatomical snuff box.
ii). Localized tenderness over anatomical snuff box.
iii).Pain on gripping and dorsiflexion.

e) What X-ray views would you take?

i). Anteroposterior.
ii). Lateral.
iii).Oblique.

f) What sign would you look for in X-ray?

Abnormal sclerosis over proximal fragment.
g) What is the position of splinting?
Glass-holding position.
i). Wrist held dorsiflexed.
ii). Thumb and fingers slightly flexed at metacarpophalangeal & interphalangeal joints.

h) List 3 complications.
i). Avascular necrosis of proximal fragment.
ii). Non-union (after 6 months).
iii).Osteoarthritis of wrist.

i) How do you treat non-union?

i). Periodic splintage.
ii). Excision of radial styloid.
iii).Arthrodesis of wrist.

18. Supracondylar fracture in a child.

a) What is the common mechanism of injury?
Fall on outstretched hand causing posterior displacement.

b) Which nerve & vessel is commonly injured?

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 Median nerve & Brachial artery.

c) What is Baumann’s angle?

The angle between longitudinal axis of humerus and a line through capiteller physis.
Normally less than 80.

d) What is the treatment of choice?

Dunlop traction.
i). Skin traction with 0.5kg-1kg weight.
ii). Shoulder abducted 45.
iii).Elbow flexed 45.

e) Complications:
i). Myositis ossificans.
ii). Elbow stiffness.
iii).Malunion.
iv). Varces deformity.
v). Volkmann’s ischaemic contracture.

19. Anterior dislocation of shoulder.

a) Predisposing factor:
i). Shallow glenoid socket.
ii). Wide range of movement.
iii). Glenoid dysplasia.
iv). Ligamentous laxity.

b) List 2 lesions which predispose to recurrent dislocation.

i). Bankart lesion (A flake of bone detachted from anterior edge of glenoid).
ii). Hill Sach’s lesion ( A depression over posterosuperior part of humeral head).

c) List 5 clinical features.

i). Fullness over infraclavicular fossa.
ii). Very prominent acromion.
iii). Flattened lateral outline of shoulder.
iv). Greatly decreased range of movement.
v). Severe pain on movement.
vi). Head of humerus can be felt over axilla.

d) What is the method of reduction?

Kocher’s method.
i). Elbow flexed 90, held close to body.
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ii). Arm 75 laterally rotated.
iii).Elbow lifted forward.
iv). Arm rotated medially.

e) Which nerve + vessel is commonly injured?

Axillary nerve + Axillary artery.

f) List 3 late complications.

i). Shoulder stiffness with loss of lateral rotation and abduction.
ii). Recurrent dislocation.
iii).Recurrent subluxation.

Note : In posterior dislocation, coracoid is prominent. Arm held medially rotated.

20. Diabetic Foot :

a) Types :
i). Ischaemic – dry, skinny, pulseless.
ii). Infective – oedematous.
iii).Neuropathic – Motor = paralysis
Sensory = clawed foot callosities.
Autonomic = Trophic changes
= Brittle nail , loss of hair.

b) Ankle-Brachial systolic index:

N  1.0
0.5-0.9 = moderate ischaemia
0.3-0.5 = marked ischaemia
< 0.3 = gangrene.  Amputate.

c) Complications:
i). Infection : - cellulitis
- abscess
- osteomyelitis
ii). Gangrene – wet / dry.
iii).Charcoat’s joint.

d) Levels of amputation :

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i). Toe disarticulation.
ii). Metatarsophalangeal disarticulation.
iii).Transmetatarsal amputation.
iv). Chopart amputation (through calcaneo-cuboid/talus joint).
v). Lisfranc (tarso-metatarsal).
vi). Syme’s ankle disarticulation.

21. Congenital dislocation of hip.

a) Causes :
i). Generalized joint laxity (autosomal dominant).
ii). Acetabular dysplasia.
iii).Breech with extended leg.
iv). Maternal hormone ; relaxin, estrogen, progesterone.

b) Name clinical test for neonates.

i). Ortolani’s test.
ii). Barlow’s test.

c) Clinical features :
i). Asymmetrical skin creases.
ii). Leg is short.
iii).Leg in external rotation.
iv). Positive trendelenburg’s test.

d) List 3 radiological findings.

i). Loss of Shenton’s line.
ii). Epiphysis lies in the outer quadrant of Perkin’s line.
iii).In 45 abduction, femoral shaft point away from acetabulum.

e) What is Perkin’s line?

i). Horizontal line through triradiate cartilage.
ii). Vertical line through ASIS.

f) When does triradiate cartilage fuse?

Male 16-18 years old.
Female 12-14 years old.

g) List 3 modes of treatment.

i). Von Rosen’s Splint
ii). Paulik Harness
iii).Abduction pillow

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h) How do you treat persistent dislocation?
i). Closed reduction with gallow’s traction + concentric reduction with hip spica.
ii). Open operation - Pericapsular reconstruction of acetabular roof.
- Inominate osteotomy.

i) List 3 complications.
i). Avascular necrosis.
ii). Limping ; waddling gait (if bilaterally dislocated)
iii).Hampering sexual intercourse in female patient.

Positive Trendelenburg’s test.

i). Dislocation / Subluxation of hip.
ii). Weakness of abductors of hip joint (Gluteus medius + minimus) [superior gluteal
nerve].
iii). Shortening of femoral neck.
iv). Painful disorder of hip.

22. Perthes’s Disease.

a) List 3 clinical features.
i). Limping
ii). Limited abduction & internal rotation.
iii).Retarded growth of trunk & limbs.

b) List 5 X-ray abnormalities.

i). Widening of joint space.
ii). Asymmetry of ossification center.
iii).Increased density of ossific nucleus.
iv). Flattening of epiphysis.
v). Widening of metaphysis.
vi). Mushroom shaped femoral head.
vii).Sagging rope sign. (sclerotic line crossing femoral head)

c) List 3  
i). Irritable hip (transient synovitis).
ii). Cretinism.
iii).Sickle cell disease.
iv). Gaucher’s disease.
v). Morquio’s disease.

d) List 4 adverse radiological signs.

i). Uncovering of epiphysis.
ii). Calcification in cartilage.

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iii).Gage’s sign (Radiolucency at lateral edge of epiphysis).
iv). Severe metaphyseal absorption.

e) List 3 methods of treatment.

i). Broomstick plaster.
ii). Supervised neglect.
iii).Containment - hips held widely abducted in plaster.
- varus osteotomy of femur.
- inominate osteotomy of pelvis.
(Aim to contain head of femur inside acetabulum.)

f) List 5 complications.
i). Avascular necrosis.
ii). Osteoarthritis of hip joint.
iii).Shortening of limb.
iv).
v).

ERB DUCHENNE (C5, C6)

Nerve paralysed Muscle paralysed Action paralysed Clinical picture Unopposed by

1. Suprascapular Supraspinatus Abduction of Limb hang Pectoralis major.
nerve. shoulder. limply.
Medially rotated.
2. Nerve to Subclavius Depression of
subclavius. shoulder.
3. Biceps brachii Supinate + flex Pronated. Pronator.
Musculocutaneou forearm. Extended at Extensor of
s nerve. Brachialis Flexion of elbow. elbow.
Coracobrachialis forearm
Flexion of
shoulder.
4. Axillary nerve. Deltoid Abduction of Loss of sensation
shoulder. down lateral side
Teres minor Lateral rotation of of arm.
shoulder.

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 Nerve paralysed Muscle paralysed Action paralysed Clinical picture Unopposed by
Klumpke (C8,
T1) All the small Flexion at Hyperextension Extensor
1. Median nerve muscle of hand metacarpophalang of digitorum
(lumbrical). eal joint. metacarpophalang
Extension at eal joint.
2. Ulnar nerve interphalangeal Flexion of Flexor digitorum
joints. interphalangeal profundus +
joints. superficialis.
Long thoracic Serratus anterior Rotation of Difficulty raising
nerve (C5, 6, 7) scapula. the arm above the
head.
Application of Winging of
scapula to chest scapula.
wall.

Radial nerve (C5-T1) Posterior cord

Nerve branches Muscle paralysed Clinical picture Residual fx.
Axilla (crutch) 1. Posterior Triceps, Unable to extend 1. Distal
cutaneous anconeus. forearm & wrist phalanges can
nerve of arm. Long extensor of joint + finger be extended
2. Nerve to long wrist joint and joint. by lumbrical
head of fingers. Wrist drop. & interossei
triceps. Brachioradialis. Not much sensory (if proximal
3. Nerve to Supinator. loss. phalanx is
medial head passively
of triceps. extended).
2. Supination by
biceps.
Spiral Groove 1. Lower lateral Long extensor of Wrist drop.
(shaft of cutaneous wrist and finger Sensory loss over
humerus) nerve of arm. (triceps not dorsal lateral
2. Posterior affected). 31/2.
cutaneous
nerve of
forearm.
3. Nerve to
lateral head of
triceps.
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 4. Nerve to
medial head
of triceps +
anconeus.
Anterior 1. Nerve to
compartment of brachioradiali
forearm s
2. Nerve to
extensor carpi
radialis
longus
Cubital fossa 1. Deep branch Not paralysed : No wrist drop.
(proximal radius of radial nerve Supinator. (extensor carpi
dislocation of -Extensor Extensor carpi radialis longus
radial head) carpi radialis radialis longus. keep wrist
brevis. →undamaged extended)
-Supinator #Finger drop
-All extensor without wrist
of forearm. drop  Posterior
(stab wound) 2. Superficial Sensory loss over
interosseous
branch dorsal 31/2 or nerve (no sensory
(sensory). patchy loss of loss).
sensation. Montegia fracture
(ulnar fracture +
dislocation of
radial head).
Supinator fossa → Supinator paralysed → No supination if elbow held extended.
But supination possible if elbow held flexed
(by biceps brachii).

Median nerve (C5-T1) Medial + lateral cord.

Injury Muscle paralysed Clinical Residual fx.

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Elbow 1. Pronator teres. Supinated.
2. Long flexor of Wrist flexion is weak. Some flexion possible
wrist. by flexor carpi ulnaris.
No flexion of Weak flexion at
3. Long flexor of interphalangeal joint metacarpophalangeal
finger (digitorum of index & middle joint by interossei.
superficialis)  finger. Unopposed by flexor
Benedict’s sign. Adducted. carpi ulnaris.
4. Flexor carpi
radialis. Loss of flexion of
terminal phalanx of
5. Flexor policis thumb.
longus# (very
sensitive + specific for Flat thenar eminence.
elbow injury). Thumb laterally
6. Thenar muscle: rotated, opposition Abductor pollicis
- Opponens pollicis. possible. longus is supplied by
Thumb adducted. radial nerve.
- Abductor pollicis
brevis Unable to flex
- Flexor pollicis metacarpophalangeal
brevis joint of thumb.
 Pen test.
7. First 2 lumbricals
(not involved)
Wrist 1. Thenar muscles Laterally rotated +
adducted. Opposition
impossible.
2. First 2 lumbricals Extension at
metacarpophalangeal
joint.
Flexion at
interphalangeal joints.
Index + Middle finger
lag behind when
making a fist.

Ulnar nerve (C8, T1) Medial cord.

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 Injury Muscle paralysed Clinical
Elbow 1. Flexor carpi ulnaris. Loss of tightening of tendon
over pisiform while making a
fist.
Flexion of wrist results in
2. Flexor digitorum abduction.
profundus (ring + little Ulnar paradox.
finger). No flexion deformity over
distal interphalangeal joint.
3. Adductor pollicis. Froment’s sign.
4. Interossei (all). Unable to adduct fingers.
5. Lumbrical (ring + little Hyperextension of
finger). metacarpophalangeal joint.
Flexion of interphalangeal
joint.
(But minimized by paralysis
of flexor digitorum
profundus.)
Wrist Small muscles of hand except →More obvious ulnar claw
thenar eminence. hand.
Causes :
1. Fracture of lateral humeral condyle.
2. Galeazzi fracture (lower 1/3 of radius inferior radioulnar subluxation).
3. Leprosy with ulnar neuritis.
4. Ulnar tunnel syndrome.
5. Laceration at wrist joint.

Baker’s Cyst Semimembranous Cyst

1. Joint is abnormal (OA @ RA). 1. Joint is normal.
2. Painless. 2. Painless.
3. Below joint line. 3. Above joint line.
4. Compressible. 4. Non-compressible.(Fluid cannot
be pushed into
5. Cannot exercise. joint)
Rx.: Aspiration 5. Waiting policy – disappear with
time. Can be
Hydrocortisome injection excised but
most will recur.
Synovectomy.

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Charcot’s Joint
1. Diabetic neuropathy
2. Syringomyelia
3. Leprosy
4. Tabes dorsalis

Gustillo Classification
I < 1cm Low energy impact.
II < 10cm Moderate energy impact.
III  10cm High energy, high velocity impact.
Segmental fracture.
Neurovascular injury.
Open > 8 hours.
III A Adequate soft tissue coverage.
III B Massive soft tissue destruction.
Bony exposure.
III C Vascular injury.

Enneking Staging of 1 Bone Tumour.

Stage I Low grade.
Ia Intracompartmental.
Ib Extracompartmental.
Stage II High grade.
IIa Intracompartmental.
IIb Extracompartmental.
Stage IIIa Any grade.
Intracompartmental.
Metastasis.
IIIb Any grade.
Extracompartmental.
Metastasis.

Staging


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 Neoadjuvant chemo (Multiagent 8-12 weeks)

Surgery
a) Marginal – resection through reactive zone of tumor.
b) Wide – entire tumor + cuff of N tissue.
c) Radical – entire tumor + compartment.

Adjuvant chemo 6-12 months.
External beam radiation for Ewing, Myeloma, Metastatic bone disease.

Don’t forget to ask in history : (OA)

Functional level – What pt can & cannot do?
Can he go to work?
Can he go to school?
Can he pray? #
Does he need walking aid? What type?
Social hx : Single / double storey house.
How many flights of stairs.
Where’s his bedroom? Need to climb upstairs?
Toilet – what type – sitting / squating? Any side handles?

Vascular claudication
1. Pain : Distal→Proximal
Calf pain
2. Impotence (Leriche’s syndrome)
3. Claudication distance is constant.
4. Relief by standing.
5. Aggravated by raising leg (Buerger’s test).
6. Bicycling – symptom develop.
7. Lying flat – relief.
8. Glove & stocking sensory loss.
9. Pulselessness.

Neurogenic claudication
1. Pain : Proximal→Distal
Thigh pain.
2. Nil.
3. Variable.
4. Relief by sitting @ bending.
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5. (Aggravated by extension of back).
6. Nil.
7. Lying may exacerbate.
8. Segmental sensory loss.
9. Pulse is present.

Fat Embolism. (Schonfeld’s index)

SCORE
Petechiae 5
Diffuse alveolar infiltrate (CXR) 4
Hypoxaemia (ABG) [PaO2 < 60] 3
Confusion 1
Fever > 38 1
HR > 120 1
RR > 30 1
Score > 5 is diagnostic.

Skin Graft.
Split thickness graft.
1. Thin – cut to the level of subpapillary vascular plexus.
2. Medium – cut to the layer of dermal plexus.
3. Thick – ¾ of dermis.
Advantage :
1. Donor site heal by themselves – allows harvesting of any site of graft.
2. Thin graft : Higher chance of survival
Epithelialize more rapidly.
3. Thick graft : More closely resemble donor site in terms of colour, texture & hair
distribution.
Disadvantage : Wound contraction.

Full thickness graft.

-Full thickness of dermis.
Advantage :
1. Provide more padding, better colour match, nearly normal hair pattern.
2. No wound contraction.
Disadvantage :
1. Donor site cannot heal spontaneously.
2. Must be placed in vascularized recipient site.
3. Increased thickness requires more nourishment prior to establishment of vascular
integrity. (Cannot survive on bare tendon @ bare cartilage)

Axial Skin Flaps.

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Blood supply from direct cutaneous artery eg. Scapular flap.
Advantage :
1. Hair growth, sebaceous secretion, sweating & sensation are well preserved.
2. More durable than skin graft.
3. Flaps grow in proportion to total body growth.
Disadvantage :
1. Excessive bulk.
2. Relative ischaemia.

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