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 1 .00 midnight. ! noticed that his right lower limb has multiple lacerated wounds and he does not respond to calls. 1. "hat is your immediate m#$ a% e#clude cervical in&uries b% clear the airway c% loo' (or suc'ing chest wound) (lail chest d% thorough e#amination o( head and nec'. *oo' (or sings o( basal s'ull + ,i% subcon&unctival haemorrhage ii% panda eye sign .periorbital haemorrhage + oedema iii% loo' (or rhinorrhoea ) orthorrhoea iv% loo' (or mastoid haematoma e% assess (or signs o( shoc' (% assess consciousness, /lasgow coma scale chec' pupil reaction + si0e His /12 is 3. 4esp rate 10 bpm 5 6ulse rate 130 bpm 5 76 80)30 mm Hg His hand is cold 9 clammy. . "hat is your subse:uent m#$ a% Establish airway and ventilation through intubation 1riteria, 1% 6t is unable to protect airway ;stuporose% % <ery low resp. rate which causes inade:uate ventilation 3% /12 = > 4apid intubation by,1% ?ida0olam (or sedation % 2u#amethonium (or paralysis 3% 2i0e 8 E@@ A7/ stat b% @reat shoc'. i% Ansert large bore A< canullae ; 13 gauge% ii% 4apid in(usion ;bolus% o( colloid ; normal saline% iii% /roup cross and hold B !nit whole blood stat iv% A( 76 not stabilised a(ter litre o( crytalloid in(usion5 start whole blood trans(usion v% 1atheteri0e the pt ;continuos bladder drainage%l 2trict monitoring (or sn o( oliguria) anuria 1 Cor distribution among the 1HADE2E community onlyEEEEE

c% 2econdary survey ;non li(e threatening in&uries% d% 2end to A1!. - pt must be stabilised bB transport - ade:uate sedation and paralysis to prevent cough and intracranial pressure

His condition has been stabili0ed. Fn thorough e#amination5 there is a depression over the s'ull. @here is gross de(ormity over the right thigh and leg with bony protrusions. @he wound is grossly contaminated. ! also 6noticed that his A16 is increasing. 3. "hat is your ne#t step$ a% Frder a s'ull #-ray to con(irm s'ull + b% G-ray o( pelvis5 hip &t5 rt 'nee &t 9 rt an'le &t ;A6 + *at.view% c% Anti-tetanus prophyla#is ; immune status not 'nown% 0.5 cc anti-tetanus to#oid 50 unit immunoglobulin d% "ound debridement + thorough wound toilet 1over with A< 6enicillin million unit 3 hrly A< ?etronida0ole 800 mg 3 hrly e% @reat increased A16. i% 6rop up and hyperventilate to reduce 6a 1F to 30 mmHg ii% Fsmotic diuresis, ?annitol 0.5-1.0 g)'g ; 0 H solution% 3 hrly + Crusemide iii% 2trict monitoring o( A16. Alert neurosurgeon i( A16I 1 mmHg ; normal = 10mmHg% B. How do u grade open +$ ; Gustilos classification % /rade 1 -=1cm5 cleanwound5 little so(t tissue in&ury /rade .1-10cm5 moderate so(t tissue in&ury /rade 3 -I10cm with severe so(t tissue damage 3A- Ade:uate s'in coverage 37- 7ony e#posure 31- Deurovascular in&ury

Cor distribution among the 1HADE2E community onlyEEEEE

G-ray- s'ull + over rt temporal bone. @ransverse + over rt (emoral sha(t 9 rt tibial sha(t A16 continue to rise despite hyperventilation and diuresis. 6ulse rate 305 76 1B0)80 5. "hat is your ?#$ i% 2uspect e#tradural) subdural ) inracranial haemorrhage ) haematoma Frder 1@ scan stat ii% 2tabili0e long bone + using e#ternal (i#ator to prevent (at embolism. ?onitor (or sn o( (at embolism. ?a&or, 1% 6etechial rash % 4esp sym ; dyspnoea5 tachypnoea5 central cyanosis% 3% Jrowsiness5 convulsion5 coma. ?inor, 1% @achycardia % 6yre#ia 3% 4etinal changes ; (at) petachiae% 1ontinuous A7/ monitoring. Frder platelet count to loo' (or thrombocytopenia. 1onsider 2wan0 /an0 catheteri0ation i( condition deteriorates.; normal pul.wedge pressure = 13 mmHg% Frder 1G4 to loo' (or,a% air bronchogram b% alveolar collapse c% complete white out o( lung (ield 2ubse:uently he develops a generali0ed convulsion. /12 is 3.Cat globules (loating in urine bag. 3. Futline your ?# (or controlling the sei0ure. 2ei0ure I 3 minutes A< dia0epam mg)min till sei0ure stop ;?a# 5mg% A( sei0ure persist A< phenytoin 50mg)min A( sei0ure persist A< lignocaine 50-100mg A( sei0ure persist 7arbiturate coma 3 Cor distribution among the 1HADE2E community onlyEEEEE

EE/ monitoring -continuous A16 monitoring -continue A16 reduction steps 4ule out , i% 1erebral oedema ii% ?uscle damage 9 rhabdomyolysis iii% Catal hyper'alemia iv% Acute renal (ailure ?onitor serum level o( anti-epileptic. @ail down sedative and wean o(( once o (its are noted. >. How do you treat (at embolism$ i% ii% iii% iv% v% vi% Heparin to counter thromboembolism. 2teroid to reduce pulmonary oedema. Aprotinin to prevent aggregation o( chylomicron. 8-13* F via (ace mas'. <entilatory support. Early operative (i#ation o( long bone (ractures.

8. "hat are the dangers o( convulsion lasting longer than 30 minutes, i% ii% iii% iv% v% vi% vii% viii% Arreversible cerebral damage. *actic acidosis. Hypoglycemia. Hyperthermia. 4habdomyolysis. Acute renal (ailure. 2hoc'. Aspiration pneumonia.

@he patient regained consciousness the ne#t day. <ital signs are stable. However he complaint that he could not move his 4 toes. Kou suspect that it is most probably due to nerve in&ury. 8. *ist down Seddons classification of nerve injuries. 1.Deuropra#ia - physiological bloc'age to conduction o( electrical impulse. - no anatomical disruption. - temporary motor paralysis with incomplete sensory impairment. B Cor distribution among the 1HADE2E community onlyEEEEE

- complete recovery by 3 wee's. a% A#onotemesis - anatomical disruption o( a#on. - intact nerve sheath. - "allerian degeneration. - a#on begin to sprout by 10th day5 1mm)day. - recovery can be complete ) incomplete depending on degree o( (ibrosis. b% Deurotemesis - the nerves is completely divided. - spontaneous recovery not possible. - surgical e#ploration is mandatory. - even with surgical repair 5 recovery is never complete. 10. How would you grade motor and sensory dys(unction $ Medical Research Council Classification ?otor 2ensory 0 6aralysis 0 Do sensation 1 Clic'er o( muscle activity 1 Jeep pain only ?ovement 9 gravity eliminated 6ain 5 temperature 3 ?ovement against gravity 3 Able to localise pain B movement against resistance B 2tereognosis + subnormal point discrimination 5 Cull power 5 Dormal @he patient was 'ept immobili0ed (or 3 wee's. 11. How would you prevent deep vein thrombosis$ a% ?echanical . /raduated elastic compression stoc'ing - Early mobili0ation E#ercise - Antermittent pneumatic compression - Elevation o( leg b% 6harmacological - low dose subcutaneous heparin ) war(arin 1 . How do you prevent pressure sores in dependent areas) i% Cre:uent changing o( position every hrly. ii% An(late glove with water 9 place over dependent areas. 13. How do you treat established pressure sore$ i% @reat the wound with clean method. 5 Cor distribution among the 1HADE2E community onlyEEEEE

ii% iii% iv% v% vi%

4inse with 0.8H Da1l at body temperature. ?oisten the wound . Dever use dry dressing as it would cause cell dehydration 9 tissue dessication. ?aintain temperature at 3 -3>1 to optimi0e cell division. 1hec' serum protein5 albumin5 electrolyte5 hematocrit regularly. 1orrect any abnormal. /ive additional nutritional support - multivitamin - ade:uate protein ; g)'g)day%.

He was discharged (racture site.

months later5 he came bac' to you with painless mobility over the

1B. "hat is your diagnosis$ Don-union. 15. How do you di((erentiate non-union (rom delayed union$ Don-union, 6ainless movement. G-ray L 7one ends are smoothed o((5 sclerosed. Cracture gap (illed with (ibrous tissue (orming a pseudoarthresis. Jelayed-union, Cracture site is tender i( sub&ected to stress. G-ray L Cracture line still visible. 13. "hat is the cause o( non-union$ a% @oo large a gap between bone end. b% Anterposition o( so(t tissue. c% E#cessive distraction due to inade:uate (i#ation. d% Anade:uate blood supply. e% 2eptic non-union. 1>. "hat is your ?# (or non-union$ Autogenous bone gra(ting5 cancellous bone is ta'en (rom iliac crest. @he matri# will serve as a sca((old (or new bone (ormation5 stimulated by 7one ?arphagenic 6rotein. Kou also notice that there is a discharging sinus over the (racture site. 18. "hatMs the diagnosis$ Acute traumatic osteomyelitis. 18. "hat A# would you order$ 3 Cor distribution among the 1HADE2E community onlyEEEEE

i% ii% iii% iv% v%

Aspirate the pus (or gram stain. 7lood culture + sensitivity. @otal white count and E24 Anti-staphylococcal antibody. G-ray.

0. *ist 3 G-ray (indings to support your . a% 6eriosteal reaction. b% ?etaphyseal mottling. c% Area o( increased density and rare(action. 1. "hat is your ?#$ a% 2upportive - relie( pain-D2AAJ. b% 4egular wound dressing5 sterile method. c% 4emove loose or ine((ectual implants. d% Ade:uate antibiotic coverage. A< Clucloacillin + Cusidic acid 3 wee's. Fral 3-3 wee's. e% Jrain abscess. . *ist the (actors that predispose to post-traumatic in(ection. a% Anade:uate debridement. b% Early closure o( the wound. c% !n(i#ed ) unstable (racture. d% "ound tension. e% @ight dressing. (% Haematoma (ormation. g% !se o( (oreign material implant eg. Anternal (i#ation. 3. "hat are the complication o( osteomyelitis$ /eneral , 2epticaemia 6yaemia ?etastatic abcsess *ocal , 2eptic arthritis 2pontaneous (racture Je(ormity 1hronic osteomyelitis. B. "hat is 7rodieMs abscess$ A 1hronic bone abscess surrounded by thic'5 (ibrous tissue 9 sclerotic bone. 4adiologically5 there is a locali0ed radiolucency area in the metaphyses o( long bone. @he > Cor distribution among the 1HADE2E community onlyEEEEE

in(ection has been eradicated. However there is a residual scar with a wide gap devoid o( epithelial tissue. 5. "hat is your ?#$ @hin split thic'ness s'in gra(t. 7ene(it , 1an be harvested (rom any site. Jonor site will heal rapidly. ?ore rapid epithelialisation. Higher chance o( gra(t survival. 3. How would you optimi0e the outcome o( s'in gra(ting $ a% Anspect the gra(t by B8 hours using sterile techni:ue. Aspirate any (luid at the undersur(ace o( the gra(t. b% Ammobili0e the area5 protected with thic' pad o( gau0e (or 5-> days. c% 6revent oedema (rom developing (or B-3 months. >. *ist the causes o( gra(t (ailure. a% Hematoma (ormation which prevent epithelialisation. b% E#cessive movement between gra(t 9 budding capillary. c% 1oloni0ation by bacteria. d% Cat attached to the undersur(ace o( gra(t. F4@HF 1. 6laster o( 6aris cast. a% Dame the active substance. 1alcium 2ulphate Hemihydrate ; 1a 2FB. H F % b% Dame 3 clinical uses - ?aintain (racture - Ammobile &oint - 1orrect the de(ormity ; 1@E< % - 1onservative treatment (or (racture ; close reduction % i. @o splint distal limb (ractures ) post-op. ii. @o splint (racture in children. iii. 2plint dislocation o( shoulder. iv. @o correct 1@E<. c% *ist 3 complication and 3 steps to be ta'en to avoid it. - Early complication, o 1ompartment syndrome 8 Cor distribution among the 1HADE2E community onlyEEEEE

o 2ensitive ) allergy o 6ressure sore o Derve compression Antermittent, o Cail to hold the (racture ; malunion ) non- union ) delayed union % *ate, o Ascahemic vol'mannMs contracture o 2ti((ness o 6F6 disease ) (racture disease

i.

Noint sti((ness . delayed splintageO use traction until movement is regained5 then only apply plaster. . replace cast with (unctional brace. ii. 1ompartment syndrome . do not apply the cast too tightly . thic' padding and splitting o( the cast i( patient complains o( pain. iii. 6ressure sores . protect bony prominences with thic' pad5 or avoid them. . s'in must be dry and clean be(ore applying.

d% *ist 5 instruction to the patient. i. 4eport bac' to hospital immediately i( there is pain or pin and needles in the plastered limb. ii. Jo not rest the cast on (irm sur(ace. iii. Jo not hang the splinted limb dependent unless it is in active use. iv. E#ercise the &oints and (ingers)toes not splinted by the cast. v. Peep the cast dry and report bac' i( the cast becomes loose)crac'ed. . 6hoto o( improper 6F6 in hand (racture. a% *ist B mista'es (ound and comment. i. @he 1st layer must have a stoc'inet)surgical cotton as padding. ii. @he cast e#tends up to the (ingers. At should e#tend up to the metacarpal nec' and )3 o( the way round the circum(erence o( the wrist. @humb and metacarpophalangeal &oint should be 'ept (ree. iii. @he wrist is 'ept in e#treme (le#ion. At should be held in the (unctional position5 slightly e#tended. 8 Cor distribution among the 1HADE2E community onlyEEEEE

iv.

?etacarpophalangeal &oint is held in e#tension. At should be 80 (le#ed while interphalangeal &oints are e#tended to prevent sti((ness.

3. Q"hat is the (unction o( the end hole$ -Cacilitate in ta'ing out the nail. Q"hat is the (unction o( the longitudinal hole$ -@o prevent rotation. a% Adenti(y the instrument. Antramedullary nail. b% /ive 5 indications. i%. Cractures that are unstable and prone to displacement eg. ?idsha(t (racture o( (are arm. ii%. 6athological (ractures o( long bone. iii%. Cracture that unite poorly eg. Cemoral nec'. iv%. ?ultiple (ractures. v%. Cracture in the elderly when early mobili0ation is pre(erred. c% /ive advantages o( its use. i%. 6roper a#ial alignment. ii%. Early weight bearing. iii%. 1an be placed in RcloseM (ashion. ;Cracture site need not be opened%. d% "hat complication will occur wee's a(ter its insertion and how to overcome it$ i%. Aatrogenic in(ection 2trict sterile techni:ue and prophylactic antibiotic. ii%. Amplant (ailure ) re(racture ;a(ter weight bearing%. B. Jiagram o( ortho bed with s'in traction. a% Jraw the correct position o( traction5 weight 9 pulley.

10 Cor distribution among the 1HADE2E community onlyEEEEE

b% "hat is the principle o( its use$ i. 1ontinuous traction 9 countertraction. ii. Hold reduction. c% "hen is it used$ !sed (or spiral or obli:ue sha(t (ractures which is easily displaced by muscle contraction. d% How much weight to use$ 10H o( body weight. e% *ist 5 complications. i. 6ressure sore around malleoli ii. 1ommon peroneal nerve palsy iii. Allergic reaction to adhesive iv. E#coriation o( s'in v. <ascular insu((iciency (% *ist i. ii. contraindications. *aceration at traction area Ampairment o( circulation at the a((ected area

5. Jiagram o( s'eletal traction 9 2teinman pin o( tibia. 11 Cor distribution among the 1HADE2E community onlyEEEEE

a% Jescribe the insertion o( the pin 9 draw on the diagram provided. Ansert 1 inch below and posterior to tibial tuberosity5 pin driven (rom lateral to medial to avoid common peroneal nerve. b% Jraw and name the nerve that could be damaged.

c% How do you ma'e sure the pin is in right angle$ Jo a chec' G-ray o( 'nee &oint. d% "hat is the (unction o( 7ohlerMs stirrup. @o allow a range o( direction (or traction without disturbance o( pin. e% *ist 5 complications. i%. Antroduction o( in(ection into the bone. ii%. Jamage to epiphyseal growth plate. iii%. Jistraction at (racture site. iv%. Aschaemic necrosis o( s'in around the pin. v%. *igamentous damage.

3. 1rutches. a% "hat is the use (or it$ As a wal'ing aid.

1 Cor distribution among the 1HADE2E community onlyEEEEE

b% Dame the parts. A- A#illary pad 7- Hand grip 1- 2uction cap J- 2han' E- ?etal ) wood (rame c% "hat is the level o( A5 75 1$ AL 3 (inger breath bellow a#illa. 7L At the level o( greater trochanter. 1L 15cm anterolateral (rom little toe. d% How should you position the elbow$ Elbow 'ept 30 (le#ion. e% *ist B ways o( using it. i%. "al' to the crutch. ii%. "al' through the crutch. iii%. Don-weight bearing. iv%. 6artial weight bearing. >. 2pecimen , 6late 9 screw. a% Adenti(y. b% *ist 3 indications. i%. 6athological (racture. 13 Cor distribution among the 1HADE2E community onlyEEEEE

ii%. Cracture prone to malunion. iii%. Antra-articular (racture. c% *ist 3 places where it can be used. i%. Cemoral nec'. ii%. 2upracondylar ;humerus% iii%. Jistal end o( tibia. iv%. 6atella 5 olecranon. d% *ist 3 contraindications. i%. Fpen (racture. ii%. *aceration wound at the operation site iii%.?ultiple (racture e% *ist 3 complications i%. Don-union. ii%. Amplant (ailure. iii%. Aatrogenic in(ection. iv%. Fverdistraction. 8. E#ternal (i#ator. a% Adenti(y. b% *ist 3 indications. i%. Fpen (racture. ii%. ?ultiple (ractures. iii%. *engthening o( limb. iv%. Don-union. c% *ist 3 sites o( (racture (or its use. i%. 6elvic (racture ;open boo'% ii%. @ibial (racture. iii%. Jistal radius comminuted (racture. d% *ist 3 contraindications. i%. <ery so(t osteoporotic bone. ii%. @oo small bony (ragment to hold pin. iii%.An(ected lesion at the site o( pin insertion. e% *ist 3 complications. i%. 6in trac' in(ection. 1B Cor distribution among the 1HADE2E community onlyEEEEE

ii%. Fverdistraction o( (ragment. iii%.Jelayed (racture healing. ;able to reduce load transmission% 8.@homas 2plint. a% ?easurement, i%. *ength , A2A2 to heel + 1 cm ii%. 1ircum(erence , /reatest circum(erence o( thigh + 3cm. b% Andication, i%. @rans(er patient ii%. @emporary immobili0ation be(ore application o( 6F6. iii%.Cracture o( sha(t o( (emur. c% 6osition o( leg, Anternal rotation. d% Jaily assessment, i%. ?ovement o( big toe. ii%. 2ensory over dorsum o( (irst web o( (oot. e% 1omplications, i%. 6ressure sore. ii%. 1ompression o( nerve and vessel. 10. 7ohler-7raun (rame. a% Andication. i%. 2upracondylar (racture o( (emur. ii%. Apsilateral (racture o( (emur and tibia. iii%.Elevation o( lower limb to decrease swelling. iv%. !nloc'ing o( 'nee to reduce sti((ness. b% ?echanism , Cle#ion over 'nee &oint rela#es gastrocnemius muscle thus preventing it (rom puling (ractured part o( (emur especially in supracondylar (racture o( (emur. c% 1omplications, i%. Dursing care is more di((icult as patient is less mobile. ii%. 6ro#imal (ragment is mobile in relative to distal (ragment which predisposes to malunion. 11. 6hoto o( le(t (oot o( @)?) . ;1@E<% 15 Cor distribution among the 1HADE2E community onlyEEEEE

a% *ist the abnormalities seen. i%. @alus points downwards ;e:uinus%. ii%. Core(oot shi(ted medially5 adducted5 inverted. iii%. Core(oot supinated. iv%. "asting o( cal( muscle. v%. 1allosities over lateral side o( (oot. b% Jiagnosis , 1ongenital talipes e:uinovarus. c% "hat other &oint you would want to e#amine$ /ive reasons. i%. Pnee &oint - loo' (or arthrogryposis. ii%. Elbow &oint - arthrogryposis multiple# congenita. iii%.2pine - spina bitida. d% "hat G-ray would you want to ta'e$ An what position o( (oot$ i%. Anteroposterior (ilm. Coot 30 plantar (le#ed. ii%. *ateral (ilm. Coot (orced in dorsi(le#ion. e% "hich bone o( (oot can be seen at birth$ i%. 1alcaneum ii%. @arsal iii%.1uboid (% *ist the de(ormity to be corrected in order o( hieyrhachy. i%. Adduction ii%. 2upination iii%.E:uinus. g% "hen should it be corrected surgically$ 7y 8 wee's o( li(e in resistant cases. h% *ist the surgical procedure. i%. Elongation o( tendon Achillis. ii%. 6osterior release ;o( posterior an'le capsule%. iii%. ?edical release ;o( talonavicular &oint% iv%. *engthening o( tibialis posterior tendon. Dote, Fther causes, - 6oliomyelitis - 1erebral palsy 13 Cor distribution among the 1HADE2E community onlyEEEEE Associated abnormalities , i%. ?otor wea'ness ii%. 2ensory loss

6ost-meningitis

iii%.Hypertonia ) hyperre(le#ia iv%. Hydrocephalus

/F!@ 1 . 6icture o( hand a% *ist abnormalities. i%. 2welling o( the &oints. ii%. 6resence o( tophi. b% Jiagnosis , /outy arthritis. c% *ist investigations to con(irm diagnosis. i%. 2ynovial (luid e#amination Deedle shaped5 negative bire(ringent crystals. ii%. 2erum uric acid level. d% /ive drugs (or acute management. i%. 1olchicine ii%. Andomethacin. iii%.A? A1@H. e% /ive drugs (or long term management. i%. Allopurinol ;Ganthine F#idase Anhibitor% ii%. 6robenicid ;!ricosuric drug%

13. 1linical station. @a'e history (rom a 8)?) with 'nee swelling 1 month a(ter playing (ootball. i% *ocali0ation o( pain. ii% 6ain occur immediately a(ter in&ury or a(ter an interval. iii% @ype o( in&ury$ Jirect (orce over 'nee &oint or twisting in&ury. *ateral ) medial part o( 'nee$ iv% History o( loc'ing in partial (le#ion. S meniscal v% History o( giving away. S tear vi% !nable to go upstairs ;post. 1ruciate% or unable to come downstairs ;ant. 1ruciate% 1> Cor distribution among the 1HADE2E community onlyEEEEE

1B. 1olles ;radius% (racture, a% 1omponents , i%. cm pro#imal to wrist &oint. ii%. Jorsal displacement o( distal (ragment. iii%.4adial deviation. iv%. 2upination. v%. Ampaction. b% 2plinting , i%. 15 palmar (le#ion. ii%. 2light ulnar deviation. c% 1omplications , i%. ?edian nerve neuropathy. ii%. 4e(le# sympathetic dystrophy. iii%.?alunion ;Jelayed union 9 non-union o( radius do not occur%. iv%. 2ti((ness o( shoulder ;neglect% v%. 2udec'Ms atrophy. vi%. 4upture o( tendon o( e#tensor pollicis longus. ;causing mallet thumb% 15. ?alet Cinger a% 1auses , i%. E#tensor tendon stretch. ii%. E#tensor tendon rupture. iii%.7ony avulsion. b% 1linical (eature , i%. @erminal interphalangeal &oint is held (le#ed. ii%. *oss o( active movement o( e#tension o( the &oint. iii%.6assive movement is normal. c% 2plinting , @erminal &oint held in e#tension (or 3 wee's. d% 1omplications , i%. Je(ormity ii%. 2ublu#ation iii%.Dail bed in&ury. 13. @rigger (inger. 18 Cor distribution among the 1HADE2E community onlyEEEEE

a% 1auses , i%. @hic'ening o( (ibrous tendon sheath.;@ender nodule can be (elt% ii%. 4heumatoid tenosynovitis. b% "hat causes triggering$ As the (le#or tendon is trapped at the entrance to its sheath5 (orced e#tension will cause it to pass through the constriction with a snap. c% "hich (inger is commonly a((ected$ i%. 4ing (inger. ii%. ?iddle (inger. d% @reatment , i%. Antralesional methylprednisolone. ii%. Ancision o( (ibrous sheath5 until tendon moves (reely.

1>.

a% Adenti(y , 18 Cor distribution among the 1HADE2E community onlyEEEEE

2caphoid bone. b% Dame the (racture , A L (racture through the nec' o( scaphoid 7 L (racture through the waist o( scaphoid 1 L (racture through pro#imal pole. c% "hich (racture give rise to progressive avascular necrosis$ 1 ;blood supply o( scaphoid diminishes pro#imally%. d% *ist 3 clinical (eatures. i%. Cullness o( anatomical snu(( bo#. ii%. *ocali0ed tenderness over anatomical snu(( bo#. iii%.6ain on gripping and dorsi(le#ion. e% "hat G-ray views would you ta'e$ i%. Anteroposterior. ii%. *ateral. iii%.Fbli:ue. (% "hat sign would you loo' (or in G-ray$ Abnormal sclerosis over pro#imal (ragment. g% "hat is the position o( splinting$ /lass-holding position. i%. "rist held dorsi(le#ed. ii%. @humb and (ingers slightly (le#ed at metacarpophalangeal 9 interphalangeal &oints. h% *ist 3 complications. i%. Avascular necrosis o( pro#imal (ragment. ii%. Don-union ;a(ter 3 months%. iii%.Fsteoarthritis o( wrist. i% How do you treat non-union$ i%. 6eriodic splintage. ii%. E#cision o( radial styloid. iii%.Arthrodesis o( wrist. 18. 2upracondylar (racture in a child. a% "hat is the common mechanism o( in&ury$ Call on outstretched hand causing posterior displacement. b% "hich nerve 9 vessel is commonly in&ured$ 0 Cor distribution among the 1HADE2E community onlyEEEEE

?edian nerve 9 7rachial artery. c% "hat is 7aumannMs angle$ @he angle between longitudinal a#is o( humerus and a line through capiteller physis. Dormally less than 80. d% "hat is the treatment o( choice$ Junlop traction. i%. 2'in traction with 0.5'g-1'g weight. ii%. 2houlder abducted B5. iii%.Elbow (le#ed B5. e% 1omplications, i%. ?yositis ossi(icans. ii%. Elbow sti((ness. iii%.?alunion. iv%. <arces de(ormity. v%. <ol'mannMs ischaemic contracture. 18. Anterior dislocation o( shoulder. a% 6redisposing (actor, i%. 2hallow glenoid soc'et. ii%. "ide range o( movement. iii%. /lenoid dysplasia. iv%. *igamentous la#ity. b% *ist lesions which predispose to recurrent dislocation. i%. 7an'art lesion ;A (la'e o( bone detachted (rom anterior edge o( glenoid%. ii%. Hill 2achMs lesion ; A depression over posterosuperior part o( humeral head%. c% *ist 5 clinical (eatures. i%. Cullness over in(raclavicular (ossa. ii%. <ery prominent acromion. iii%. Clattened lateral outline o( shoulder. iv%. /reatly decreased range o( movement. v%. 2evere pain on movement. vi%. Head o( humerus can be (elt over a#illa. d% "hat is the method o( reduction$ PocherMs method. i%. Elbow (le#ed 805 held close to body. 1 Cor distribution among the 1HADE2E community onlyEEEEE

ii%. Arm >5 laterally rotated. iii%.Elbow li(ted (orward. iv%. Arm rotated medially. e% "hich nerve + vessel is commonly in&ured$ A#illary nerve + A#illary artery.

(% *ist 3 late complications. i%. 2houlder sti((ness with loss o( lateral rotation and abduction. ii%. 4ecurrent dislocation. iii%.4ecurrent sublu#ation. Dote , An posterior dislocation5 coracoid is prominent. Arm held medially rotated.

0. Jiabetic Coot , a% @ypes , i%. Aschaemic . dry5 s'inny5 pulseless. ii%. An(ective . oedematous. iii%.Deuropathic . ?otor L paralysis 2ensory L clawed (oot callosities. Autonomic L @rophic changes L 7rittle nail 5 loss o( hair. b% An'le-7rachial systolic inde#, D 1.0 0.5-0.8 L moderate ischaemia 0.3-0.5 L mar'ed ischaemia = 0.3 L gangrene. Amputate. c% 1omplications, i%. An(ection , - cellulitis - abscess - osteomyelitis ii%. /angrene . wet ) dry. iii%.1harcoatMs &oint. d% *evels o( amputation ,

Cor distribution among the 1HADE2E community onlyEEEEE

i%. @oe disarticulation. ii%. ?etatarsophalangeal disarticulation. iii%.@ransmetatarsal amputation. iv%. 1hopart amputation ;through calcaneo-cuboid)talus &oint%. v%. *is(ranc ;tarso-metatarsal%. vi%. 2ymeMs an'le disarticulation. 1. 1ongenital dislocation o( hip. a% 1auses , i%. /enerali0ed &oint la#ity ;autosomal dominant%. ii%. Acetabular dysplasia. iii%.7reech with e#tended leg. iv%. ?aternal hormone O rela#in5 estrogen5 progesterone. b% Dame clinical test (or neonates. i%. FrtolaniMs test. ii%. 7arlowMs test. c% 1linical (eatures , i%. Asymmetrical s'in creases. ii%. *eg is short. iii%.*eg in e#ternal rotation. iv%. 6ositive trendelenburgMs test. d% *ist 3 radiological (indings. i%. *oss o( 2hentonMs line. ii%. Epiphysis lies in the outer :uadrant o( 6er'inMs line. iii%.An B5 abduction5 (emoral sha(t point away (rom acetabulum. e% "hat is 6er'inMs line$ i%. Hori0ontal line through triradiate cartilage. ii%. <ertical line through A2A2. (% "hen does triradiate cartilage (use$ ?ale 13-18 years old. Cemale 1 -1B years old. g% *ist 3 modes o( treatment. i%. <on 4osenMs 2plint ii%. 6auli' Harness iii%.Abduction pillow 3 Cor distribution among the 1HADE2E community onlyEEEEE

h% How do you treat persistent dislocation$ i%. 1losed reduction with gallowMs traction + concentric reduction with hip spica. ii%. Fpen operation - 6ericapsular reconstruction o( acetabular roo(. - Anominate osteotomy. i% *ist 3 complications. i%. Avascular necrosis. ii%. *imping O waddling gait ;i( bilaterally dislocated% iii%.Hampering se#ual intercourse in (emale patient. 6ositive @rendelenburgMs test. i%. Jislocation ) 2ublu#ation o( hip. ii%. "ea'ness o( abductors o( hip &oint ;/luteus medius + minimus% Tsuperior gluteal nerveU. iii%. 2hortening o( (emoral nec'. iv%. 6ain(ul disorder o( hip. . 6erthesMs Jisease. a% *ist 3 clinical (eatures. i%. *imping ii%. *imited abduction 9 internal rotation. iii%.4etarded growth o( trun' 9 limbs. b% *ist 5 G-ray abnormalities. i%. "idening o( &oint space. ii%. Asymmetry o( ossi(ication center. iii%.Ancreased density o( ossi(ic nucleus. iv%. Clattening o( epiphysis. v%. "idening o( metaphysis. vi%. ?ushroom shaped (emoral head. vii%.2agging rope sign. ;sclerotic line crossing (emoral head% c% *ist 3 i%. Arritable hip ;transient synovitis%. ii%. 1retinism. iii%.2ic'le cell disease. iv%. /aucherMs disease. v%. ?or:uioMs disease. d% *ist B adverse radiological signs. i%. !ncovering o( epiphysis. ii%. 1alci(ication in cartilage. B Cor distribution among the 1HADE2E community onlyEEEEE

iii%./ageMs sign ;4adiolucency at lateral edge o( epiphysis%. iv%. 2evere metaphyseal absorption. e% *ist 3 methods o( treatment. i%. 7roomstic' plaster. ii%. 2upervised neglect. iii%.1ontainment - hips held widely abducted in plaster. - varus osteotomy o( (emur. - inominate osteotomy o( pelvis. ;Aim to contain head o( (emur inside acetabulum.% (% *ist 5 complications. i%. Avascular necrosis. ii%. Fsteoarthritis o( hip &oint. iii%.2hortening o( limb. iv%. v%. E47 J!1HEDDE ;155 13% Derve paralysed ?uscle paralysed Action paralysed 1linical picture 1. 2uprascapular 2upraspinatus Abduction o( *imb hang nerve. shoulder. limply. ?edially rotated. . Derve to 2ubclavius Jepression o( subclavius. shoulder. 3. 7iceps brachii 2upinate + (le# 6ronated. ?usculocutaneou (orearm. E#tended at s nerve. 7rachialis Cle#ion o( elbow. 1oracobrachialis (orearm Cle#ion o( shoulder. B. A#illary nerve. Jeltoid Abduction o( *oss o( sensation shoulder. down lateral side @eres minor *ateral rotation o( o( arm. shoulder. !nopposed by 6ectoralis ma&or.

6ronator. E#tensor o( elbow.

5 Cor distribution among the 1HADE2E community onlyEEEEE

Derve paralysed ?uscle paralysed Action paralysed 1linical picture !nopposed by Plump'e ;185 @1% All the small Cle#ion at Hypere#tension E#tensor 1. ?edian nerve muscle o( hand metacarpophalang o( digitorum ;lumbrical%. eal &oint. metacarpophalang E#tension at eal &oint. . !lnar nerve interphalangeal Cle#ion o( Cle#or digitorum &oints. interphalangeal pro(undus + &oints. super(icialis. *ong thoracic 2erratus anterior 4otation o( Ji((iculty raising nerve ;155 35 >% scapula. the arm above the head. Application o( "inging o( scapula to chest scapula. wall.

4adial nerve ;15-@1% 6osterior cord Derve branches ?uscle paralysed 1linical picture A#illa ;crutch% 1. 6osterior @riceps5 !nable to e#tend 1. cutaneous anconeus. (orearm 9 wrist nerve o( arm. *ong e#tensor o( &oint + (inger . Derve to long wrist &oint and &oint. head o( (ingers. "rist drop. triceps. 7rachioradialis. Dot much sensory 3. Derve to 2upinator. loss. medial head o( triceps. . 2piral /roove ;sha(t o( humerus% 1. *ower lateral *ong e#tensor o( cutaneous wrist and (inger nerve o( arm. ;triceps not . 6osterior a((ected%. cutaneous nerve o( (orearm. 3. Derve to lateral head o( triceps. "rist drop. 2ensory loss over dorsal lateral 31) .

4esidual (#. Jistal phalanges can be e#tended by lumbrical 9 interossei ;i( pro#imal phalan# is passively e#tended%. 2upination by biceps.

3 Cor distribution among the 1HADE2E community onlyEEEEE

B. Derve to medial head o( triceps + anconeus. Anterior 1. Derve to compartment o( brachioradiali (orearm s . Derve to e#tensor carpi radialis longus 1ubital (ossa 1. Jeep branch !ot paralysed , ;pro#imal radius o( radial nerve 2upinator. dislocation o( -E#tensor E#tensor carpi radial head% carpi radialis radialis longus. brevis. undamaged -2upinator -All e#tensor o( (orearm. ;stab wound% . 2uper(icial 2ensory loss over branch dorsal 31) or ;sensory%. patchy loss o( sensation.

!o wrist drop. ;e#tensor carpi radialis longus 'eep wrist e#tended% +Cinger drop without wrist drop 6osterior interosseous nerve ;no sensory loss%. ?ontegia (racture ;ulnar (racture + dislocation o( radial head%. 2upinator (ossa 2upinator paralysed Do supination i( elbow held e#tended. 7ut supination possible i( elbow held (le#ed ;by biceps brachii%. ?edian nerve ;15-@1% ?edial + lateral cord. An&ury ?uscle paralysed 1linical 4esidual (#.

> Cor distribution among the 1HADE2E community onlyEEEEE

Elbow

1. 6ronator teres. . *ong (le#or o( wrist. 3. *ong (le#or o( (inger ;digitorum super(icialis% 7enedictMs sign. B. Cle#or carpi radialis.

2upinated. "rist (le#ion is wea'. 2ome (le#ion possible by (le#or carpi ulnaris. Do (le#ion o( "ea' (le#ion at interphalangeal &oint metacarpophalangeal o( inde# $ %iddle &oint by interossei. (inger. !nopposed by (le#or Adducted. carpi ulnaris. *oss o( (le#ion o( terminal phalan# o( thumb.

"rist

5. Cle#or policis longus" ;very sensitive + speci(ic (or Clat thenar eminence. @humb laterally elbow in&ury%. rotated5 opposition Abductor pollicis 3. @henar muscle, longus is supplied by - Fpponens pollicis. possible. @humb adducted. radial nerve. - Abductor pollicis !nable to (le# brevis metacarpophalangeal - Cle#or pollicis &oint o( thumb. brevis 6en test. >. Cirst lumbricals ;not involved% 1. @henar muscles *aterally rotated + adducted. Fpposition impossible. . Cirst lumbricals E#tension at metacarpophalangeal &oint. Cle#ion at interphalangeal &oints. Ande# + ?iddle (inger lag behind when ma'ing a (ist.

!lnar nerve ;185 @1% ?edial cord. 8 Cor distribution among the 1HADE2E community onlyEEEEE

An&ury Elbow

?uscle paralysed 1. Cle#or carpi ulnaris.

"rist

1linical *oss o( tightening o( tendon over pisi(orm while ma'ing a (ist. Cle#ion o( wrist results in . Cle#or digitorum abduction. pro(undus ;ring + little !lnar parado#. (inger%. Do (le#ion de(ormity over distal interphalangeal &oint. 3. Adductor pollicis. CromentMs sign. B. Anterossei ;all%. !nable to adduct (ingers. 5. *umbrical ;ring + little Hypere#tension o( (inger%. metacarpophalangeal &oint. Cle#ion o( interphalangeal &oint. ;7ut minimi0ed by paralysis o( (le#or digitorum pro(undus.% 2mall muscles o( hand e#cept ?ore obvious ulnar claw thenar eminence. hand.

1auses , 1. Cracture o( lateral humeral condyle. . /alea00i (racture ;lower 1)3 o( radius in(erior radioulnar sublu#ation%. 3. *eprosy with ulnar neuritis. B. !lnar tunnel syndrome. 5. *aceration at wrist &oint. 7a'erMs 1yst 1. Noint is abnormal ;FA V 4A%. . 6ainless. 3. 7elow &oint line. B. 1ompressible. be pushed into 5. 1annot e#ercise. 4#., Aspiration time. 1an be Hydrocortisome in&ection most will recur. 2ynovectomy. 8 Cor distribution among the 1HADE2E community onlyEEEEE 2emimembranous 1yst 1. Noint is normal. . 6ainless. 3. Above &oint line. B. Don-compressible.;Cluid cannot 5. &oint% "aiting policy . disappear with e#cised but

1harcotMs Noint 1. Jiabetic neuropathy . 2yringomyelia 3. *eprosy B. @abes dorsalis

/ustillo 1lassi(ication A = 1cm *ow energy impact. AA = 10cm ?oderate energy impact. AAA 10cm High energy5 high velocity impact. 2egmental (racture. Deurovascular in&ury. Fpen I 8 hours. AAA A Ade:uate so(t tissue coverage. AAA 7 ?assive so(t tissue destruction. 7ony e#posure. AAA 1 <ascular in&ury. Enne'ing 2taging o( 1 7one @umour. 2tage A *ow grade. Aa Antracompartmental. Ab E#tracompartmental. 2tage AA High grade. AAa Antracompartmental. AAb E#tracompartmental. 2tage AAAa Any grade. Antracompartmental. ?etastasis. AAAb Any grade. E#tracompartmental. ?etastasis. 2taging 30 Cor distribution among the 1HADE2E community onlyEEEEE

Deoad&uvant chemo ;?ultiagent 8-1 wee's% 2urgery a% ?arginal . resection through reactive 0one o( tumor. b% "ide . entire tumor + cu(( o( D tissue. c% 4adical . entire tumor + compartment. Ad&uvant chemo 3-1 months. E#ternal beam radiation (or Ewing5 ?yeloma5 ?etastatic bone disease. JonMt (orget to as' in history , ;FA% Cunctional level . "hat pt can 9 cannot do$ 1an he go to wor'$ 1an he go to school$ 1an he pray$ + Joes he need wal'ing aid$ "hat type$ 2ocial h# , 2ingle ) double storey house. How many (lights o( stairs. "hereMs his bedroom$ Deed to climb upstairs$ @oilet . what type . sitting ) s:uating$ Any side handles$ <ascular claudication 1. 6ain , Jistal6ro#imal 1al( pain . Ampotence ;*ericheMs syndrome% 3. 1laudication distance is constant. B. 4elie( by standing. 5. Aggravated by raising leg ;7uergerMs test%. 3. 7icycling . symptom develop. >. *ying (lat . relie(. 8. /love 9 stoc'ing sensory loss. 8. 6ulselessness. Deurogenic claudication 1. 6ain , 6ro#imalJistal @high pain. . Dil. 3. <ariable. B. 4elie( by sitting V bending. 31 Cor distribution among the 1HADE2E community onlyEEEEE

5. 3. >. 8. 8.

;Aggravated by e#tension o( bac'%. Dil. *ying may e#acerbate. 2egmental sensory loss. 6ulse is present. 21F4E 5 B 3 1 1 1 1

Cat Embolism. ;2chon(eldMs inde#% 6etechiae Ji((use alveolar in(iltrate ;1G4% Hypo#aemia ;A7/% T6aF = 30U 1on(usion Cever I 38 H4 I 1 0 44 I 30 2core I 5 is diagnostic.

2'in /ra(t. 2plit thic'ness gra(t. 1. @hin . cut to the level o( subpapillary vascular ple#us. . ?edium . cut to the layer o( dermal ple#us. 3. @hic' . W o( dermis. Advantage , 1. Jonor site heal by themselves . allows harvesting o( any site o( gra(t. . @hin gra(t , Higher chance o( survival Epitheliali0e more rapidly. 3. @hic' gra(t , ?ore closely resemble donor site in terms o( colour5 te#ture 9 hair distribution. Jisadvantage , "ound contraction. Cull thic'ness gra(t. -Cull thic'ness o( dermis. Advantage , 1. 6rovide more padding5 better colour match5 nearly normal hair pattern. . Do wound contraction. Jisadvantage , 1. Jonor site cannot heal spontaneously. . ?ust be placed in vasculari0ed recipient site. 3. Ancreased thic'ness re:uires more nourishment prior to establishment o( vascular integrity. ;1annot survive on bare tendon V bare cartilage% A#ial 2'in Claps. 3 Cor distribution among the 1HADE2E community onlyEEEEE

7lood supply (rom direct cutaneous artery eg. 2capular (lap. Advantage , 1. Hair growth5 sebaceous secretion5 sweating 9 sensation are well preserved. . ?ore durable than s'in gra(t. 3. Claps grow in proportion to total body growth. Jisadvantage , 1. E#cessive bul'. . 4elative ischaemia.

33 Cor distribution among the 1HADE2E community onlyEEEEE