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EXAMINATION SECRETS FOR ORTHOPAEDIC POST

GRADUATES

GAIT
Points to Remember:
To describe gait, in its phases -Stance Phase, Swing Phase
Stance phase (60% of cycle) comprises of Heel Strike
Foot flat
Mid stance
Push off
Swing phase (40% of cycle) comprises of Acceleration
Mid swing
Deceleration
Width of Normal base measures from 2-4 inches
Normal step length in approximately 15 inches
Pelvis and Trunk shift laterally approximately 1 inch during gait
Centre of Gravity oscillates vertically, approximately 2 inches and Centre of
Gravity of body is 2 inches in front of II Sacral Vertebra.
Pelvis rotates by 40 0 forward. During this rotation opposite Hip acts as a fulcrum,
which is in stance phase then.
Number of steps per minutes is called Cadence and normally consists of 90-120
steps/minute.
The period of “Double Support ' is inversely proportional to Cadence

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Commonly Asked Questions on Gait:
1. What are the different types of Orthopaedic Gaits you know of?
These could be:
1. Trendelenburg
2. Waddle
3. Antalgic Gait
4. Stiff Hip Gait
5. Short Leg Gait
6. Stiff knee Gait.

Neurological Gaits (in polio)


 Flat foot gait
 Hand to knee gait
 High step gait
 Calcaneus gait
2. In what stage of Gait, does the defect occur in the Flat Foot Gait?
Due to weak dorsiflexors the foot steps down after the heel strike
and have no push off.
3. How do you differentiate a Limp from a Lurch?
A limp is any deformity of gait, whereas in a Lurch, there occurs
swaying off of Pelvis/Trunk to avoid the w eight
4. What are the different types of Lurching gait ?
An abduction Lurch due to weak Gluteus Medius and an Extension
Lurch due to weak Gluteus maximus.
5. Where is Hand to Knee gait commonly seen?
In cases of Quadriceps weakness. To shift the axis of weight bearing
on line of body weight bearing.
6. What is a Trendelenburg gait?

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A type of Abduction Lurch seen in patients of Abduction weakness
or Mechanisms.
7. What is an Antalgic gait?
Whenever patient has pain during the gait and whines on weight
bearing with a reduced stance phase.
8. What is Waddling gait ?
When the patient has bilateral Trendlenberg Lurch, he moves on
both sides. This type of giat is seen in Bilateral CDH. Rocker
bottom foot etc.
9. What is the gait in a patient of Abduction deformity with Stiff Hip ?
The patient sways to the opposite side to Clear off the ground.
10. What is the gait in a patient with Bilateral hip and knee flexion deformity ?
Crochy gait.
11. What is Kinematic study?
It involves video-based gait analysis, using surface electrodes and deep
muscle electrodes. Every patient is subjected four walks. It helps in
assessing the need for surgery of muscles involved in gait.
12. What is work load on full weight bearing through the hip joint ?
350 lbs/sq.inch
13. When are you on a single limb in your daily activity ?
- Mid stance phase of same side
- Swing phase of opposite side.
14. What are major movements during gait ? Tabular
Propulsion from the limb on the ground with Plantar flexion of foot and toes.
- Extension of hip joint followed by abduction and external rotation for
nece phase.
- Extension of knee joint.

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HIP CASE
Points to remember in examination :
1. HISTORY :
(A) Pain : Commonest symptom
Mostly in front
Radiates to anterior thigh and knee
Night Pain- due to disappearance of protective Muscle spasm at night.
Reflects damage of articular Cartilage.
(B) Limp : Note gait of patient, Independent or Assisted _ Assisted
may be supported or not. If supported, use of stick in which hand.
(C) Trauma : Mode- Collision
Fall from height on buttocks
Fall of heavy object
Direct impact on trochanter
Stumbling/Missing step
Fall on slippery floor
- Ability to walk after trauma, think of - no bony injury
- Impacted Fracture - Inability to walk after trauma
2) INSPECTION
(A) Attitude : A position acquired by patient on standing or in lying in
bed.
Patient with,
Flexion, External Rotation, Shortening

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Age Young : Suspected # or inflammatory pathology
Age Old - Suspected # N/F
Flexion Abduction External rotation - Young patient - Inflammatory
Pathology. Functional Position - Anterior dislocation.
5. MEASUREMENTS
(i) Apparent Length - Measured from Xiphistemum to Medial Malleolus
- No squaring of Pelvis required.
- Both limbs need not be in mirror image position
(ii) True Length : measured from ASIS to Medial malleolus
- Pelvis should be squared i.e. both ASIS should be at the same level
- Both Lower Limbs should be mirror image of each other
Method of Squaring Pelvis
- Fixed adduction deformity - Adduction is the movement that is
possible. Further adduction brings the ASIS of affected wide down.
- Reverse could be done for Abduction deformity
- Girth of Thigh Muscles 6 cms above Patella (maximum muscle mass )
- True shortening could be Supratrochantric or Infratrochantric
- Supra Trochantric Shortening is measured by Bryant's Test Line.
6. SPECIAL TESTS
- Nelation's line : measures upward shift of Greater Trochanter by a
Line from Ischial tuberosity to ASIS
- Requires other Hip for comparison.
- Shoe Maker's Line : confirms shift of Trochanter by a Line from
Greater Trochanter to ASIS extended upwards. In cases of Supra
Trochantric Shortening it passes beneath the umbilicus.
- Morris Bitrochantric Compression Test
- Chienes' Test - for shift of Pelvis
- Narath's sign - for # N.F. or dislocation Hip
- Ober's Test - for iliotibial band contracture

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- Telescoping Test
Before Completion, always comment on condition of opposite Hip, both
knee and spine and see for Hernia sites and purches.

COMMONLY ASKED QUESTIONS IN EXAMINATION OF A HIP


CASE
1. Why does a patient of Hip complain of Pain in knee and Anterior
Thigh ?
This is because of common Nerve supply by Femoral and Obturator
Nerves.
2. What are the causes of Increased Lumbar Lordosis ?
It could be Physiological - as in Pregnancy or Obesity or Pathological -
due to Fixed Flexion deformity of Hip or, Compensatory to Kyphosis
of Thoracic Spine. Spondylolisthesis, Bilateral CDH
3. On Examination from back, Assymetric Gluteal folds give you what
inference ?
This could be due to
- CDH
- Muscular Atrophy
- Pelvic Obliquity
- Limb Length Discrepancy
4. On Inspecting from back, how do you test for Trendlenberg's Test ?
On advising the patient to lift the affected Limb, off the ground. The
PSIS does not move normally. But on keeping the weight on affected
limb the PSIS droops down, when the test is positive.
5. What do you think are prerequisites of doing a Trendlenberg's Test ?
- Patient could stand and bear weight
- He could lift the Limb up for at least 30 secs.
- He should not have any Ankylosis

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- He should not have any Abduction or Adduction deformity

6. How do you Grade Trendlenberg's Test ?


Grade I - 30 secs.
Grade II - 45 secs.
Grade III - 60 secs.
7. What is the basis of Trendlenberg's Test ?
The Hip joint works as a Lever with a Fulcrum- the Neck, a Lever
Arm of abductors.
8. Name conditions where you will find Trendlenberg's Test positive
a) Gluteal Paralysis/Weakness
- Polio
- Muscle dystrophy
- Motor neuron disease
b) Gluteal inhibition
- Pain arising from hip joint
c) Gluteal insufficiency
- #n/Femur
- Coxa Vara
- Perthes disease
- CDH
N.B. Easier way to remember this is
A. Arthritis
B. Bend-Coxa Vara, Perthes, #N/F
C. Congenital- CDH
D. Dislocation
E. Paralysis
9. How do you Palpate for ASIS ( Antero : Superior Iliac Spine )

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Pass your hand from Pubic Symphisis along the inguinal ligaments
upto the Iliac bone. The first most prominent point is the ASIS
10. Why do you mark ASIS ?
In relation to Hip Joint this is the nearest bony point, in the plane of
Hip Joint, although it lies higher than the Centre of Axis of Hip.
11. Name some condition of upward displacement of Greater Trochanter.
- Posterior dislocation of Hip
- Fracture Neck Femur
- SCFE (Slipped Capital Femoral Epiphysis )
- Coxa Vara
- Excisional Arthroplasty
- Perthes disease
12. Name some conditions of Broadening of Greater Trochanter.
- Healing Inter trochanteric Fracture
- Perthes disease
- Tumor
- Osteomyelitis of Trochanter
- AVN Hip
- Congenital coxa vara.
13. Name a condition, where Greater Trochanter is close to ASIS
It is on increase internal rotation of Hip e.g. Posterior dislocation
14. When does G.Trochanter shift away from ASIS ?
In conditions of increased External Rotation e.g. Anterior Dislocation.
Fracture Neck Femur.
15. Where are the Common sites of Cold abscess aroung Hip ?
- Infront and medial to Greater Trochanter
- In Femoral Triangle - In Gluteal Region.
- In Pelvis - Perforatin of accetabulum which may lead to an Ischio
rectal fossa.

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16. Why is Medial Malleolus considered for Measurements ?
a) It is near the midline
b) Easily assesible
17. If one has adduction and other has abduction deformity, how will you
examine.
The Routine methods cannot be used; hence Radiological method used
for measuring individual deformity.
18. What will happen to the ASIS in Abduction deformity and Adduction
deformity ?
The ASIS goes down in Abduction and up in Adduction deformity.
19. What happends to length in Abduction deformity ?
- There is Apparent lengthening in Abduction deformity.
- If the difference of apparent and true length is taken, then apparent
shortening is less than true shortening.
e.g. If the True Length of affected side is 68 cms the unaffected is 72 cms.
The apparent Length be 108 cms on affected and 110 on unaffected.
Hence the difference of True Length is 4 cms and Apparent Length is 2
cms. Hence the difference of True Length is more than the Apparent.
20. Wht happens to the ASIS when you Square the Pelvis in Abduction
deformity ?
- The ASIS of affected side moves up in order to bring both ASIS at
same level
21. What are the compensatory Mechanism in Abduction deformity in the
Spine ?
There occurs a compensatory Scoliosis on the side of the deformity
22. Why does there occur Apparent Lengthening in Abduction deformity
In order to bring both legs to touch the ground, there occurs an
apparent Lengthening.

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23. What happens to Abduction/Adduction in cases of Abduction
deformity ?
- There is no adduction possible but the range of Abduction is full and
vice versa.
24. What is Full Abduction/Adduction in cases of Abductin deformity ?
- The Total Abduction is the degree of abduction possible without
Pelvic movements.
- The free abduction is the abduction which is possible without pelvic
movement, once the pelvis has been squared.
- Fixed abduction deformity is the degree of movement of Abduction,
when the Pelvis squares.
25.What are the different means of measuring Abduction deformity ?
When the limb is kept in squared position draw a vertical line from
ASIS and another line along axis of this and mid line of body will be the
fixed abduction deformity.
M.L.Kothari's angle- In this could be measured without squaring Pelvis
from both the ASIS, in the position of comfort. Then from each ASIS
draw a perpendicular to mid line of body. This angle gives the idea of
Pelvic tilt.
26. What is the meaning of that the Likb is Fixed in Abduction ?
When the Limb is an attitude of abduction and no other movement is
possible.
27. What happens to length in Abduction deformity ?
There is True shortening in the cases of abduction deformity.
28. What could be the falacies in Squaring of Pelvis ?
- Due to fixed pelvic obliquity of scoliosis
- ASIS has been removed by grafting
- Maldeveloped Pelvis
- PPRP

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- Unreduced dislocations
- Malunions of Fracture Ilium
29. What happens to ASIS in Adduction deformity ?
The ASIS moves up and on squaring, by further adduction it moves
down to correct the deformity.
30. What are the Compensatory Mechanism in Adduction deformity ?
The Scoliosis which has convexity towards unaffected side.
31. What is the Free Adduction, Full Adduction and Fixed Adduction ?
Free Adduction = Full adduction - fixed Adduction deformity or, in
other words.
Full adduction = Free + Fixed Adduction
But this movement occurs without Pelvic jog.
32. What is the meaning that Limb is fixed kin Adduction ?
This is the attitude of adduction in which the Limb is fixed and no
other movement is possible.
33. What are the causes of True Shortening ?
True Shortening could be
Supra trochantric as in , # Neck Femur.
coxa vara
S.C.F.E.
Perthes diseas
Loss of cartilage
Infection
Arthritis
Dislocation of Hip
After Girdlestone procedure
Absorption of Head
Infratrochantric
(A) Congenital

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(B) # Shaft Femur.
# Subtrochantric Femur.
( C ) Growth disturbance - Epiphyseal trauma Bone
infection.
34. Name Causes of Supra trochantric lengthening -
Coxa Volga
Coxa Magna
Malunited Fracture, Prosthesis with improperly cut Neck
35. What are Fallacies in Measuring Segmental length ( Infratrochantric )
- When joint line is damaged.
- Effusion of joint
- Inability to keep knee extended.

36. When was the Fixed Flexion Deformity Test described and by whom ?
It was described by Sir Hugh Owen Thomas in 18766
37. What is the first movement to be lost in Hip ?
It kis Extension, i.e. backward movement from zero position.
38. Prereuisites of Thomas ' Tests-
- It should be done on hard Bed.
- Gradual flexion is done.
- Insinuate the hand between back and bed till lordosis obliterated.
- Ask for passively extending the affected Hip, for avoiding oven
flexion.
39. What angle do you measure in Thomas Test ?
The angle substended by Long axis of bone with that of the Bed.
40. What is the basis of Fixed Flexion Deformity Test or Thomas' Test ?
In order to gain the assess to ground due to loss of extension. The
Pelvis tilts forward in saggital plane. By this the lumbar lordosis is
increased as a compessation. While doing Thomas Test, This pelvic

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obliquity is reverted back and this is revealed in the form of fixed
flexion deformity of hip.
41. If there is No Hip Pathology and patient has increased Lumbar
Lordosis, what does it suggest of ?
That the deformity is either in Pelvis or Spine.
42. In a patient with fixed flexion deformity of Hip and Knee. How do
you test for FFD at Hip ?
We ask the patient to lie on the edge of the couch with both the knee
dangling down then measure for FFD of Hip by Thomas' Test
43. What are drawback of Thomas Test ?
- It is not easy to perform in painful hips.
- Obese patient.
- It cannot be easily performed in ankylosed knee
- It is difficult to perform in bilateral case.
44. How do you measure fixed flexion deformity in Bilateral affection ?
In prone position, making the patient to lie with trunk on the couch and
asking him to support his knees on the examiner's hand. Now on
gradually extending the thigh, the resistance is felt. At this point mark
and angle between trunk and thigh.
In supine position lift both the limbs together without flexing the knee
and see for oblitration of lordosis.
45. What are the conditions of false positive Thomas Test ?
In cases of
- Fixed pelvic obliquity as in Scoliosis and Polio.
- Exaggerated lordosis due to
- Preganancy
- Postural abnormalities
- Spondylolisthesis
46. What is free flexion ?

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It is the range of flexion beyond the fixed flexion deformity.
47. What is the range of flexion ?
It is the sum total of fixed flexion + free flexion.
48. How do you measure for rotation ?
From the zero position, where patella is horizontal and great toe
upwards, the internal and external rotation are measured by rolling or
it could be measured by flexing hip and knee by 90 and a outward
rotatory movement is internal rotation and vice versa.
49. What are the prerequisites of Telescopic Test ?
- The hip and knee fixed to 90 0 after taking patient on hard bed
- Adduct Limb by 5-15 0
- Secure the hand posteriorly and over the trochanter- Push and pull
manocuver is done to feel the recoil over the hadn.
50. Why is Limb adducted ?
In order to clear the posterior rim of Acetabulum.
51. In what conditions you get Telescopic Test positive ?
In CDH
Old dislocation
Pathological dislocation
Nonunion # N/Femur
Charcot's joints
Post Girdlestone's arthroplasty
52. What is the basis of Telescopic Test ?
When ever the head is pushed and pulled it being., in the plane other
than acetabulum moves away from the acetabulum to strike over the
hand in posterior fossa.
53. In post traumatic cases, what else do you get ?
We can elicit a crepitus on push and pull due to movements at the
fracture site.

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54. What happen in Ortolanis' Test flexed thigh is abducted and externally
rotated.
The femoral head slides over acetbulum rim, producing a click and
gets reduced.
55. What is Barlow's Test ?
A stage further of Ortolani's on adduction an internal rotation it
redislocates with a click.
56. What are the differential diagnosis of a thickened Trochanter ?
- implant.
- Post Me Murray's osteotomy
- Infection
- II degreeBuritis
57. Why do fixed deformities occur ?
To conceal the deformity
To maintain equilibrium
Make up disparity of limbs
Stabnilise the hip.
58. Which deformity you would prefer to have, if given a choice ?
Flexion, Abduction and External Rotation.
59. Can you Test fixed flexion deformity by flexing the affected hip ?
Yes, we can do it, but it is painful and also flexing the affected hip, the
movement occurs at pelvis.
60. Why do you tell patient to extend the affected hip at the end of
Thomas Test ?
To correct the over flexin done by flexing hip.
61. What is significance of per-rectal examinatin in female ?
- For pus in pouch of Douglas
- Rectal carcinoma
- Prostrusio acetabulei

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- tracture pelvis can be detected.
62. What is maximum Apparent length you can get in T.B. Hip ?
2.5 cms.
63. Where were Medical Research council studies conducted for T.B. ?
Nigeria
Madras
Hosun ( South Korea )
Hong Kong
64. How do you measure for Bilateral adductin deformity ?
Draw midline vertical, and then a perpendicular to t.
- Draw a line joining both ASIS
- In case of deformity they are not parallel, so go on adducting till they
be come parallel and thus gives adductin deformity.
65. What happens to Paraspinal muscles and Gutters in abscess of T.B. ?
Muscles - Prominent
Gutters - obliterated
66. When do you have false negative Telescopy ?
When limb is kin abduction.
67. When do you get false positive Telescopy ?
- Joint laxity
- Soft bed
68. How do you assess bilateral external rotation deformity ?
Make both hips in 90 0 flexion and then assess (Kothari's Test )
69. What is axis deviation of Hip ?
When Hip is flexed it kpoints to opposite shoulder, exception in
slipped capital femoral epiphysis.

T.B. HIP
1. What are the positive findings in favour of your diagnosis ?

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- Age group first three decades
- Pain in hip, referred to knee, night cries may be associated.
- Prolonged history
- Constitutional symptoms of loss of weight, appetite
- There may be a history of contact
- Limp, tenderness at femoral triangle, spasm of muscles
- Typical deformity, as per the stage
- Muscle wasting and apparent shortening ( stage II onwards may appear
)
2. When the Arthritic stage sets in, why there is an apparent
shortening?
Because as the damage of articular cartilage sets in, the spasm of
adductors occurs and this causes the patient to have an adductin deformity.
3. Can a patient instead of flexion, adduction and internal rotation, have
flexion abduction and external rotation in deformed arthritic hip ?
Yes, this could be due to
a) Constant adaptation of the posture for relief of pain
b) Destruction of Ilio femoral- Y Ligament
c) Patient continued to bear weight on affected limb
4. How do you confirm your diagnosis of a case of T.B.Hip ?
A. By blood investigations :
Haemoglobin, total and differential count and ESR which may
show anaemia, lymphocytosis and raised ESR.
B. ELISA Test for specific Anti Tubercular Proteins could also be
done.
C. Radiologically, there may be an osteoporosis dimipuation of
joint space and eroded margins are commonly seen in early
arthritis head and neck may also be destroyed in late stages.

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There may be, a travelling acetabulum or pathologically dislocated
hip, Perthes disease type or Protrusio Acetabuli type appearance.
5. What are the common sites of affectin in the hip ? ( foci)
Initial foci may be in, Metraphyseal, Epiphyseal, Trochantric region,
Babcock's triangle or Acetabular roof.
6. What is the path followed by cold abscess in hip ?
In femoral triangle, medial lateral and posterior aspect of thigh,
ischiorectal fossa or Pelvis.
Rarely it may perforate acetabular roof. The intra pelvic abscess
7. How does a patient, with earlier affection of T.B. hip present to you
?
He may present in a stage of synovitis, where due to position of joint
to have maximum containment, patient may have deformity of
abduction external rotation of flexion.
8. Where else you can get this type of deformity ?
Traumatic synovitis
Rheumatic/Rheumatoid hip
Non specific transient synovitis
Low grade pyogenic Infection
Perthes' disease
Illiopsoas Spasm
Abscess in sheath and
Slipped capital femoral epiphysis.
9. In Arthritic stage, what could be your other provisional diagnosis?
a) Monoarticular Rheumatoid
b) Perthes' disease
c) Old healed low grade Pyogenic arthritis
d) Non union of fracture neck femur.
10. How do you differentiate these conditions ?

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a) In mono articular rheumatoid there is flexion
abduction and external rotation.
b) In Perthes' disease - Adduction and external rotation
c) In Pyogenic arthritis- All movements are painful and
restricted
d) In non union neck femur- crepitus and telescope test
may be positive.
11. What is the Natural Course of disease ?
If untreated, it leads to ankylosis
- In advanced arthritic stage, it is always fibrous ankylosis
- If deformities are not corrected in time, there may be an ankylosis in
bad position of flexion and adduction.
12. How do you treat a case of T.B. hip ?
- Traction to correct deformity, usually bilateral ( Triple drug therapy )
- Hip mobnilizing exercises,
Patient is non weight bearing for first 12 weeks, partial weight bearing for
next 12 weeks and full weight bearing after 24 months.

13. What is the role of Traction ?


Relieves spasm
Prevents deformity and corrects it
Maintains joint space and avoids subluxation, minimizes
development migrating acetabulum.
14. In advanced arthritis, how do you treat these patients?
If there is more than half of articular surface destructed we go for
arthrodesis in 5-10 0 of external rotation, flexin as per age
(upto 30 0 ) and 15 0 of abduction, ( because with fibrosis there is a
tendency towads adduction )
15. When do you operate in T.B. hip ?

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a) If response to conservative treatment is not favourable.
b) Failure to achieve acceptable outcome
16. What surgeries are done usually in T.B. hip and what are their
indication ?
A) Synovectomy and joint debridement
a) Synovial stage
b) Disease not responding favourably
c) Diagnosis is uncertain
B) Osteotomy - Upper femoral corrective for -
flexion adduction
Femoral displacement and corrective- fibrous
ankylosis
C) Arthrodesis - Ischiofemoral - Adduction
deformity
Intra Capsular - painful ankylosed. Hip or severe
destruction of articular surface
Iliofemoral- Abduction deformity
D) Girdlestone excisional arthroplasty - If patient
with fibrous ankylosis
E) Total hip replacement in healed hips.
17. What complications you can get by Synovectomy ?
- Avascular Necrosis
- Fracture of neck of acetabulum
- Slippage of epiphysis in children.

18. What activities movements patient may loose by arthrodesis ?


Bending
Sitting on floor.
Cross legged sitting

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Kneeling
Bicycling
Sexual mechanics in females
19. When was Excision Arthroplasty desceibed :
In 1950 by Girdlestone.
He desceibed excision of femoral head, neck, proximal part of
trochanter and acetabulum rim fo deep infections.
20. Why do you keep limb in abduction after Girdlestone Arthroplasty ?
We maintain an abductin of 30 to 50 0 to achieve length to minimize
shortening.
21. What is the amount of traction you apply ?
Traction of 15 kgs could be given
22. What is its significance ?
It provides space for an adequate layer of fibrous tissue to form over
femoral and acetabular surface ( Pseudarthrosis formatin )
23. When will you prefer doing a T.H.R. in a case of T.B. hip ?
After 10 years of total queiscent period.

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FRACTURE TROCHANTER

1. What are clinical features in favour of # trochanteric femur ?


- Older age group
- Significant trauma, direct injury
- Broad, irregular tender trochanter
- Marked external rotatin and shortening
- Bitrochantric compression and tenderness in trochanteric region
- Transmitted movements are absent

2. How do you classify Trochantric fracture ?


- Boyd and Friffins
- Tronzo's and
- Evan's classification
( for details see chapter on Classification )
3. Which classification do you prefer and why ?
Evan's Classification as it is prognostically important
4. What is a stable fracture ?
- An undisplaced fracture or
- Fracture with no medial comminution.
5. What is an unstable fracture ? why
- Postero medial comminution when present
(Evan's Gr.IC and ID and II )
6. What are different available implants for fixation ?

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- Dynamic hip screw
- Smith Petersen Pin Plate.
- Jewett's nail plate system ( Fixed Nail plate )
- Condylocephalic Nails
- External fixatins.
7. Which implant you consider as ideal and why ?
None of the implant is ideal but the best suited implant is dynamic hip screw
because it has a better hold in the head and sliding devices provide
controlled collapse of fracture without implant protrusion.
8. What is a Calcar ?
A dense vertical plate of bone extending from posteromedial portin of shaft
under lesser trochanter, radiating laterally to greater trochanter rainforces
neck postero inferiorly.
9. How do you do close reduction in # Trochanter ?
Extremity is secured in Traction, traction is exerted in longitudinal axis, on
slightly abducted extremity. Depending on fracture external or neutral
rotation is done.
10. When do you externally rotate limb during Surgery ?
When in a comminuted fracture, lesser trochanter is a largely displaced
fragment.
11. What are the features of instability ?
Shortening
Varus of neck shaft angle
Increase retroversion
12. What are the complications if implant is fixed in this position ?
- Shortening- Pin intrudes into the acetabulum
- Varus and retroversion - Nail cutting through antero superior part. Implant
breaking at nail plate junction.
13. What's the length (exact) of a DHS screw ?

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Within 1.2 cms of subchondral bone.
14. What is the superiority of D.H.S. ?
- It exceeds normal load hence favour penetration.
- 5 times more rigid than condylocephalic nail.
- The maximum load is borned by implant rather than bone, hence early
mobilization. is possible.
15. Where do you place the guide pin ?
2 cms below the base of greater trochanter midway between, anterior and posterior
cortices.
16. What is exact placement of guide pin ?
- Centralized in femoral head.
- Slight posterior on lateral view
- Within 1 cm from articular surfce of femoral head.
17. Why do you prefer a shorter screw by 5 mm than exact measured length ?
A 5 mm shorter screw permits 10 mm of compression. But if it is more than 10 mm
shorter it is insufficient for coverage of screw within barrell.
18. What is a Dimon and Hughston procedure ?
Hughston, describes an unstable intertrochantric fracture as one with communication
of Calcar and Posterior arch or Posterior arch along the shaft. So a medial continuity
restoration is essential for successful fixation. So a transverse osteotomy of shaft is
made and distal portion medialized.
19. What is Sarminto's procedure ?
He advocates an oblique osteotomy of 45 0 followed by medialization.
20. What are Trochantric prosthesis ?
Leinbach's prosthesis is a specially designed prosthesis for # P/T femur
21. What are the indications of using it ?
- Severe osteoporosis.
- Proximal fixation is questionable
- Low activity in life-old age, debility

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- Severe communiution.
22. How do you treat a malunited trochantric fracture ?
They may be, with internal or external rotation and shortening upto 2.5 cms or
Those with internal and external rotation with shortening upto 5 cms. In malunions of
first type, rotation and varus is corrected by subtrochantric osteotomy. No attempt to
compensate length is made.
In second type - Do Tenotomy of Adductors
- Obtain abduction and internal rotation
- Divide with osteotome the union site
- Restore neck shaft angle.
23. How do you conservatively treat a case of fracture trochanter ?
By means of Hamilton Russel Traction.

25
FRACTURE NECK FEMUR
1. Why do you consider that the patient is a case of old fracture of neck femur
?
- Tenderness over mid inguinal point
- Absence of transmitted movement at neck but presence at trochanter
- Telescopic Test positive
- Crepitus is present
2. Why do you get Telescopic Test positive in these cases ?
As the neck is absorbed the trochanter could be pushed or pulled.
3. Which is the commonest deformity to occur and why does and old fracture
neck femur, patient develops an abduction deformity ?
It is Adduction.
It happens so, when he tries to bear weight and become ambulatory
4. Can a patient of # neck femur (old) have an active SLR ?
Yes, it is possible in impacted fractures or when capsular fibrosis, has
occurred.
5. How does a case of fracture neck femur differ from fracture trochanter on
examination ?
Characteristic # Neck Femur # Trochanter
Age Pt.older (than # p/t femur) Younger by decade
Sex. Females : Male is same Male > Females
History Trivial injury R.T.accident
Fall on buttocks direct lateral impact
Ecchymosis Less Moe on lateral
Bruising aspect
Tenderness Mid inguinal point Lateral aspect hip

26
External Lesser than Marked externally
Rotation # /t Femur rotated
Trochanter Normal Brodencd, Tender
Irregular
Transmitted Present Absent
Movements
Telescopic Test Positive in old case Negative
Narath's sign Positive Negative
Chiene's test Convergence towards Coverage to affected
site but angle is less
Bitrochantric Pain at mid inguinal point At trochanter
Compression
Supra trochantric Less than trochanter More
Shortening
Complication Nonunion Malunion
6. In case of fracture neck femur, in a young adult, what are the modalities of
treatment available ?
In a fresh cases, we may prefer
- Multiple pinning
- Dynamic hip screw.
In old cases, we may prefer
- Mayer's Procedure i.e. Quadratus Femoris Muscle Pedicle grafting
with multiple pinning.
- Biological osteosynthesis ( with fibula )
7. How do you reduce a fracture neck femur ?
Lead better's Manoeuvre - Traction in a flexed hip and knee followed by
abduction internal rotation along with extension with a stabilized pelvis.

8. Why is it important to reduce a fresh case immediately ?

27
- In order to reduce, chances of Avascular Necrosis and Nonunion
9. Why do you, not prefer classifying an old fracture neck femur by
Garden's Classification ?
- In old fractures, with gradual resorption of neck and ligaments
laxity the head alignment changes.
10. When does neck start resorption ?
By third week.
11. Why does the neck get resorbed ?
As it is an intra-articular part of bone, which is cancellous and least
vascular hence the creeping substitute is delayed and poor
12. Why there is increase incidence of Non union in fracture neck femur
and what is the incidence ?
- Due to loss vascularity
- Intra- articular portion
- Increased micromotions
Its incidence is upto 40%
13. What is the fracture line in fracture neck ?
- Spiral.

14. Who gave the first implant fixation for fracture neck femur.
- Von Langenback.
15. What are the different complications with their pecentage incidence,
in a case of fracture neck femur treated by.
DHS Multiple planning
AVN 33% 19%
Nonunion 52% 14%

16. What is Garden's Index ?

28
-Compression Trabeculae forms an angle of 160 0 in AP and 180 0
in lateral view. This ratio is known as Garden's Index.
17. What is its significance ?
It gives the idea of anatomic reduction in cases of fracture neck
femur.
18. What is the role of Anteversion, Retroversion in a good reduction ?
With retroversion there is intoeing and increased incidence of
dislocation.
19. Which fixation device is preferable and why, amongst the nail and
plate systems ?
Jewett D.H.S.
- Trephine tip Controlled collapse
- causes uncontrolled impaction
- Prevents early No penetration
- penetration
- Varus promoting Better reduced
- forces less strongly reduced
- Fracture disimpaction Rotation
during insertion
20. Why do you do Prosthetic Replacement in old patients ?
- In osteoporotic bone hold of implant is poor
- Early mobilization could be achieved.
More chances of AVN and Nonunion
21. What are Indications for Prosthesis (Austin Moore's
Relative Absolute
Advanced Age - Loose initial fixation
Osteoporosis - No satisfactory reduction
Fracture dislocation - Malignancy
Patient invalid to walk - AVN hip

29
22. What is Singh and Maini's Index ? What is its significance ?
The arrangement of the trabeculae in th head and neck of femur is in form of
Principle tension.
Principle compression
Secondary Tension
Secondary Compression
and Tensile Trabeculae. Their loss is seen in Osteoporosis as Gr.6 Normal
of
Gr. 5 Loss of Secondary Trabeculae Gr. 2-P compression lost.
Gr. 4 Loss of Traction Trabeculae Gr. 1 Few trabeculae left.
Gr. 3 Principle Tension lost.
23. What is Ward's Triangle or Babcock's Triangle ?
Ward's Lateral to Principle Compression and below tension trabeculae this
area is rarely avoided during fixation.
Babcocks' Inferior sector of head where implant fixation is poor.
24. What Reduction will you prefer, Varus or valgus alignment ?
Valgus alignment- As it is responsible for controlled collapse and reduces
bending movement by Shear.
25. What is Southern America or Philadelphia Approach ? Why is kit so called ?
A posterior approach of hip exposure used in Southern America hence
(Philadelphia ) for the first time hence it is so called.
26. Why do you prefer Bipolar over Austin Moore's Prosthesis ?
- 3 point fixation is better due to long stem and straight implant
- It reduces frictin and impact forces at prosthesis and cartilage interface
- Could be converted into THR.
27. What are the commonest complication of Bipolar Prosthesis ?
- Loosening
- Pain
- Increase dislocation

30
- Acetabular wear
28. What is the major controversy regarding motin in Bipolar ?
It acts as a unipolar presthesis despite being a Bipolar
29. What is advantage of using Bipolar ?
- Could be converted into THR
- Less chances of Protrusle acetabuli
- Eliminates shear forces.
30. What is three point fixatin of a Prosthesis ?
A) Medial cortex of shaft touched by the stem. (B) Head of the Prosthesis (C)
Trochanter.
31. Wht is a centrally placed Prosthesis on X-rays ?
A line drawn from centre of acetabulum should pass through the centre of
Prosthesis and the collar.
32. When do you do T.H.R. in fracture neck femur ?
- When acetabulum is also involved as in primary osteoarthritis
- Failed implant in old age patients.
33. What is Mc Murray's Osteotomy ? Define
Subtrochantric medial displacement oblique osteotomy.
34. How do you fix a Mc.Murry's Osteotomy ?
With a Van Wright's Plate
35. What is the Postop Regimen with this Osteotomy ?
2 months spica in 40 0 abduction followed by 2 months with 20 0 abduction
followd by 2 months exercises in bed.
36. What are disadvantages of Mc Murray's Osteotomy ?
- Shortening
- Compromise of medullary canal
- could not be converted into THR
- Union is rarely seen.

31
37. Why is Mc Murray's Osteotomy Biomechanically unstable ? How do you
stabilize it ?
Medialization may increase with increase of valgus, hence an internal
fixation is always necessary.
38. Who discovered Bipolar Prosthesis ?
James Batman.
39. Which was the first Prosthesis to be used for neck femur ?
Heygroves (1920) used ivory endoprosthesis.
40. Describe evolution of Prosthesis ?
Heygrove (1920)- Ivory
Judet (1948) Acrylic
Moore and Bohlman (1940) first metallic prosthesis
Thomson (1954)
Austin Moore (1955)
Bipolar of Batman (1978)
41. Why does a patient with old frcture neck femur use stick in opposite hand ?
To reduce the loading of the hip joint, by redistribution of the weight by
shift of fulcrum.
42. What is the Postop Regimen with D.H.S. ?
- Sitting in bed-Day II with knee and hip mobilization
- Crutch walking I Week
- Partial weight bearing VI weeks
- Total weight bearing VIII weeks onwards
43. What is the Postop Regimen with Prosthesis ?
-Patient could be made to stand as soon as possible as he is postoperatively
stable
-Ambulation as tolerated
-Abduction pillow maintained initially.
44. What is the theory of Tamponade Effect for fracture neck femur ?

32
Hematoma collected in the capsule due to intracapsular fractures will
damage the already tenuous circulation (Deyerle )
45. Describe in short the blood supply of neck femur ?
Profundafemoris artery
Medial Circukflex femoal Lateral Circumflex femoral(Extra Capsular
Ring )
Medial ascending, posterior, lateral Anterior ascending (Intra
Articular ring of Chung )
46. What is Garden's Classification ?
I. Incomplete undisplaced
II. Complete impacted undisplaced
III. Partially displaced
IV. Totally displaced.
47. What is Pauwel's Classification ? What classification you prefer in cases ?
Angle of fracture line with an imaginary horizontal line. It may be
I. 30 0 Sub capital
II. --50 0 -- Transcervical
III. -- 70 0 -- Basal
This is preferred classification for lold cases.
48. How do you classify fracture neck femur in children ?
Transcapital Epiphiseal injuries are classified by Collona's Classification as
I -- Transepiphyseal
II - Transcervical
III - Cervicotrochantric
IV -- Intertrochantric
49. Of the different types of fracture neck femur, which will unite the best and
why ?
Basal, as it has minimal interference of bnlood supply
50. What is the neck shaft angle of adult hip ?

33
130 0
51. What is neck shaft angle in Paediatric Hip ?
It is 150 0
52. What is preventive orthopaedics in an old case of 65 years ?
To prevent fractures in old patients by general awareness and treatment of
other aiments for e.g. treatment of cataract hypertension, avoid slippery floor, use
slippers at night, keep a torch near bed, use of stick.

52. What are prerequisites of Telescopic Test ?


- Hard Bed Rest
-
Hip and knee flexed to 90 0
- Slight adduction of 15 0 to negotiate through posterior lip of

34
TOTAL HIP REPLACEMENT
1. What is artritis ?
Arthritis in inflammation of the joint; in this case, inflammation of the hip
jolint
2.. What are the causes of arthritis ?
 Noninflammatory : This category includes idopathic and post traumatic
arthritis, congenital deformities ( e.g. congenital hip dysplasia ) and
avascular necrosis.
 Inflammatory : The most common is rhcumatoid arthritis; other include
mixed connective tissue disease, lupus erythematosus, and psoriatic arthritis.
3. What are the clinical manifestations of hip arthritis ?
Pain is the main symptom, but the patient also may demonstrate decreased
walking distance, decreased range of motion, inability to sleep and limp.
4. Why do patients commonly complan of groin pain ?
The obturator nerve runs directly by the hip joint, therefore, it is irritated by
the arthritis.
5. What are the common radiographic findings ?
The most common findings are narrowing of the hip joint space, osteophyte
formation, and subchondral cysts.
6. Why do the osteophytes form ?
Once the articular cartilage begins to degenerate, the ability of the cartilage
to distribute stress begins to fail, and stress on the bone increases. The bone
responds to increased stress by laying down increased bone ( Wolff's law ) Thus,
more surface area is produced to cover the increased stress.
7. Why do subchondral cysts form ?

35
8. What conservative approach should be tried before recommending THR ?
Most authors agree that anti-inflammatory agents, can decrease degenerative
activity, and weight loss ( if appropriate ) should be tried for at least 6 months
before surgery is recommended.
9. On which side of the patient should the cane be used :
The cane should be in the hand opposite the involved hip to decrease the
reactive force on the joint.
10. Besides THR, what other surgical procedures are sometimes offered
?
Femoral osteotomies. Hip arthroscopy (unlike knee arthroscopy ) has
been shown to be of little benefit.
11. What are the most popular surgical approaches to the hip ?
The most popular are posterior, transtrochantric, direct lateral, and
anterior approaches. The posterior and direct lateral approaches are now the
most popular
12. What characteristics do modern cemented components have in
common ?
 They are made of super alloys (cobalt-chrome or titanium alloys )
 They have smooth edges with no sharp comers
 They fill at least one-half of the diameter of the femoral canal
 They have some sort of texturing proximally to encourage cement
attchment to stem
 They have cobalt chrome heads for articulation.
13. Describe the modern cement technique :
Modern cement technique consists of distal femoral plugging, use of a
cement gun to fill the canal from distal to proximal, and pressurization of the
cement. In addition, most surgeons recommend either vacum mixing or
centrifugation to decrease porosity of the cement. Metal backing of the
polyethylene acetabular component does not appear to help long-term results.

36
14. Why did cementles prosthesis come into vogue in the mid 1980s ?
Although cemented hips did well for older people, many studies, showed
less than optimal results for younger people.
15. What size should the pores be to facilitate bone ingrowth ?
Most authors agree that the pore size should be between 200-500 microns.
16. How much porous in-growth is enough ?
No one knows. Certainly, the more porous the surface, the more likely
ingrowth will loccur. However, the more porous surface that is available, the
more likely there is to be stress shielding, and the harder it would be to
remove a well-fixed stem if the need should arise.
17. Why are cementless acetabular components so popular ?
Although cement techniques on the femoral side have greatly
improved the long term results, the results of cemented acetabular
components have failed to show similar improvements.
18. What design characteristics should a cementless acetabular
component have ?
The component should be circular in shape, fully porous coated, and
placed in a press-fit (tight) fashion. The necessity and advisability of screw
reinforcement is under debate.
19. What size head and liner should be used ?
Most experts agree that a 26 or 28 mm head provides the least amount
of wear. AT least 6 mm of polyethylene in the socket should be available.
20. What is the Dorr classificatin of bone stock ?
While looking at a lateral radiograph of the proximal femur. Dorr
classified the amount of funnelization of the metaphysis. A maximal funnel
represented good bone stock and was classified as A. If no funnel was
present, the classification was C. The intermediate classification was B.
Cementless THR results directly correlated with the classification ( A is
optimal )

37
COMPLICATIONS OF TOTAL HIP REPLACEMENT
INTRAOPERATIVE COMPLICATIONS
1. What is the vascular effect of insertion of the cement ?
The cement is a potent vasodilator and thus causes hypotension ( and
can cause immediate death ). It is important that the
patient remain well hydrated throughout the procedure.
2. What nerves can be injured ? What are the common
mechanisms of injury during total hip replacement (
THR) ?
The most common nerve injury is to the sciatic nerve. Injury is usually
caused by retractors on the nerve, but it may result from lengthening
a shortened extremity. The femoral nerve can be injured by an
anterior retractor. The obturator nerve is rarely injured but may be at
risk from a poorly placed retractor.
3. When putting in screws for an acetabular component, what quadrant
is to be avoided ?
In the anterior superior quadrant ( some say the anterior quadrant) the
femoral vein and artery are located immediately on the other side of the
bone of the acetabular and may be easily injured by a drill or screw.
4. What factors lead to intraoperative femoral fractures ?
The most common factors are (1) failure to ream straight down the canal
(2) attempts to put too large a component down the canal (3) attempts to
pount the component down the canal too rapidly, without allowing the
viscoclastic nature of the bone to accept the component (bone expands

38
with time ) and (4) failure to appreciate preoperative deformities or distal
tightness of the canal.
IMMEDIATE POSTOPERATIVE PERIOD IN THE HOSPITAL
5. What is the incidence of thrombophlebitis in untreated patients ?
The incidence in most studies is around 50%
6. What measures are available to decrease the incidence of
thrombophlebitis ?
Early mobilization
Sequential compression stockings
Anticoagulation ( warfarin, aspirin, heparin, dextran)
7. What position should the patient avoid to minimize the possibility of posterior
dislocation of the THR ?
The patient should avoid flexion and internal rotation of the hip.
8. What are the most common organisms causing infections in THR ?
The two most common organisms are Staphylococcus epidermidis and
staphylococcus ureus. Whereas S.areus was previously the more common of
the two, most authors believe that S. epidermidis is more common now.
9. What known factors decrease the incidence of infection ?
The factors known to decrease infection rates are (1) prophylactic antibiotics,
(2) decreased traffic in the patient's room, and (3) rapid filtration of the air.
Ultravoilet light, exhaust suits, and laminar flow also may decrease infections
rates.
10. How long may it take for preoperative infection to manifest clinically ?
It may take as long as 1 year before a low virulent organism finally manifest
itself.
LONG TERM COMPLICATIONS

11. What is the most common long-term complication ?


Loosening that causes pain is the most common complication.

39
12. How can one determine if a component is loose on radiographs ?
Radiographic evidence of loosening includes (1) migration of the component,
(2) fracture of the cement, and (3) 2 mm Incent line completely surrounding
the prosthesis.
13. What is osteolysis ?
Osteolysis is a severe absorption of bone around the prosthesis mediated by
collagenases, prostaglandins, and proteases.
14. What is thought to be the initiating factor in osteolysis ?
Debris from polyethylene wear is thought to be initiating factor. When the
polyethylene of the acetabular line wears, it goes down to the femur, around
the edges of the cup, or through th screw holes of the cup.
15. How can one minimize polyethylene debris ?
Four factors minimize polyethylene debris (1) proper head size (26-28 mm)
(2) maximal polyethylene thickness ( atleast 6 mm ); (3) better metal for the
head. possibly zirconium or ceramic, and (4) better grde of polyethylene.
16. How can late hematogenous infections be prevented ?
Preventive strategies include (1) prophylactic antibiotics for dental work,
nonclean opertions, and urologic manipulations, and (2) aggressive treatment
of systemic infections.
17. How can heterotopic bone be prevented in high risk patients?
The best and easiest method of prevention is radiation. A single dose of 600
rads 2-3 days after surgery is recommended. Indomethacin also may be used.

40
SPINE CASE
EXAMINATION OF SPINE CASE
1. Trauma - direct or indirect (rotational)
e.g. - lifting weight from beat position
Seat belt injuries.
diving in shallow waters.
2. Pain -- describe, site, onset, nature radiation aggravating or relieving
factors
Nature - Dull pain -- inflammatory
Sudden sharp -- Prolapse disc
Radiating - Sciatica
3. Deformity -- may be since childhood or due to some pathology
4. Loss of Power/Weakness - sudden or gradual

INSPECTION

1. Attitude and Deformity


2. From side : Forward bending
(i) Kyphosis - Knuckle - single vertebrae - T.B.spine
Angular - 2-3 vertebrae - Late TB and Scoliosis
Round and fixed - Senile - Osteroporosis, osteomalacic Sheurmann's
Ankylosing spondylitis - forward stopping gait.
(ii) Lordosis - increased or flattening or reversal
Loss of Lordosis - PIVD
Osteoarthritis

41
Infection
Spinal Stenosis
Increased- Normal in women.
spondylolisthesis
Fixed Flexion at Hip
Secondary to Thoracic Kyphotic deformity, Bilateral C.D.H.
3. From Behind
- Position of head
- Level of shoulder
- Position of Scapulae
- Laterl Margin of body
- Prominence of Iliac Crest
- Scoliosis- Check if it is structural- Not corrected by Bending
- Postural-Corrects on Bending
- (commonly ) due to protective response of PIVD
- Check Skin for
I. Scars
sinuses
Vessels
Café au Lait spots
Lipoma
Tuft of Hair
Swelling - Maningocele
Paravertebral abscess
[a;[atopm/
- Done in standing and in prone position.
PALPATION
Always start with Local Temperature and Tenderness
Tenderness

42
- Between Spine of Lumbar Vertebrae - PVID
- Over Lumbar Muscles - Mechanical back pain
- Over Sacro Iliac joint S.I.Infection Mechanical
- Over Vertebral Spine- Infection
- Traumatic
- Pathological

Methods :
1. Direct Pressure -- Positive kin Pathology of spinous process or
advanced pathology of vertebral body
2. Twist- Positive in Pthology of body
3. Deep Thrust - By fist
2. - Defect in Spinous procss - Spina bifida
LQMIN3D5OMY
- Step Deformity - Spondylolisthesis
- Kyphotic Deformity -
Knuckle- collapse of single vertebrae
Angular- collapse of 2-3 vertebrae
Round - Scheurmann's disease
T.B.
Senile kyphosis
Prominent spinous process and its significance
- Fracture Dislocation - Lower one prominent
- Compression Fracture - Upper one prominent
- Tuberculosis- Upper one
- Spondylolisthesis - Lower one
3. Soft Tissue Palpation
- Supraspinous Ligaments
- Paraspinal Muscle - Only superficial group Rigidity Wasting

43
sites of Pott's abscess- Renal angle, Petit's Triangles, Iliac fossa
PERCUSSION
Over Spinous process
Over Muscle PIVD
Painful spinous condition

MOVEMENTS
Flexion- Normal 90 0
a)Finger- Floor distance ignores Hip movements indicates Thoracic Lumbr
movements.
b) Finger to an Approximate Level e.g. upto midtibia
c)Mark TI and SI in standing position increase in distance TI-LI upto 8 cms and LI-
SI, 8-10 cms ( on flexion) Less than 3 cms pathological
d) Schrober's Method - For Lumbar flexion, Dimple of Venus to 10 cms above it
Note increse in flexion.
For Thoracic Movements
T1 to a Point at 30 cms distance - Very gross restriction ankylosing spondylitis
(Spine moves as one unit on Ankylosing Spondylitis )
- Less than complete in all direction- due to Pain
- Anterior flexion limited - Lower disc disgeneration
- Restricted Lateral flexion- Listhiesis

Extension -
N-15 0
- Decrease in LI-SI distance with Tape measures
- Middle finger Tip reaches upto PSIS
Lateral Flexion -
- Middle finger Tip Reaches kne level
Rotation in sitting position

44
N-45 0
Angle between plane of shoulder and Pelvis
SPECIAL TESTS
A. Straight leg raising test
See for painl in leg or back
SLR will stretch spinal cord cauda, sciatic nerve
B. Lessageu's Test -
Frost described it in 1881
Dedicated to Lessague
Procedure - Supine patient
Leg flexed at hip, then gradually extend
See for pain.
C. Braggard-Dorsiflex the foot, causes increased pull on sciatic.
D. Frajerstajn Test - Cross sciatic reflex or well leg raising test
E. Bowstgring Test -- after SLR flex the knee and apply from pressure
over popliteal fossa - Radiating pain and paraesthesia on leg.
F. Reverse Lesague Test
In Prone position
Knee flexed in turn - Pain due to stretching of Femoral Nerve Root.
Suggests - High Lumbar disc.
G. Kerning's Test - After flexion of hip and knee on passive extension of
knee patient gets severe pain in involved region.
H. Test to increase Intrathecal Pressure
a) Milgram's Test - SLR 2" above ground 30 0 sec. If < 300 Disc
prolapse
Trapping of Cord
b) Naffezier's Test- Jugular Compression in seated position
Pain in Lumbar Region- Disc Prolapse
c) Valsalva Manoeuvre - Pain in back, radiating down in leg.

45
TEST FOR SI JOINT
a) Pelvic Rock Test
b) Ganselen's Test
c) Pump Handle Test
d) Faber's Test
e) Forward bending and Rotation painful

MOTOR NEUROLOGY
See for Nutrition
Tone
Power
Co- ordination
Involuntary movements
T12 LI L@ L# Iliopsos - Hip Flexion
L2L3L4- Quadriceps - Knee Extension
Gluteus Medius - Hip Abduction
L4- Tibialis Anterior - Dorsiflexion, Eversion ?
L5- Exterior Hallucis - Dorsiflexion
S1 Peroneus Longus and brevis- Eversion
Gastrosoleus - Plantar flexion
Sensory
Superficial Deep
Pain Joint Sense
Touch Deep Pressure
Temperature Vibration
2 point discreminatin
REFLEXES
Superficial- reflexes of UMN type so lost in UMN Lesion

46
a) Abdominal ( T7-L1)
b) Cremastric (T13)
c) Anal (S2,S3,S4)
d) Bulbo Cavernousus (S2,S3,S4)
e) Plantar (S1)
Deep - LMN reflexes, front Anterior Horn cells
a) Patellar (L2, L3,L4)
b) Ankle (s1)
EXAMINING A SCOLIOSIS PATIENT

History :
- When the curve was first noticed, Progression of curve.
- Past illness
- General development- lacks energy
- Loss of appetite
General Examination to tule out - Osteogenesis Imperfecta
Pinched face - Down's syndrome
Tapering ears - Hurler's syndrome
Thin chin - Marfan's syndrome
Poorly developed mandible - Pectus Excavatum
Assymetry of skull
Pigmentation of skin
Navei
Hairy patch
Malformed limbs
Hypoplasia of thumb
Shoulder - Poorly compensated curve have raised convex side
Scarpula- Raised and rotated forward and outward.

47
Flant Creases - Chaklin'ssign - on Rotation of Lumbar spine there is bulging of
lumbar muscle and fullness of loin on convex
Hip - On Rotation of Lumbar spine the convace side loin sinks in and hip appears
prominent. If curve is low with inadequate compensatin pelvis tilts on convace side
and hip on opposite side is higher.
Spine - Note the type of curve
- Note any associated kyphosis
Rotation - More prominent protrusion of Rib or Lumbar muscle on flexion is
sign of fixed Rotation deformity
Flexibility is tested byu
(a) Correctible on flexion, if they do not they are rigid.
(b) Straightening of curve on lifting the patient by
holding from neck
(c) Pushing from convex side and supporting the
convace side.
List - Recorded by plumb line, when a vertical line is dropped from C, and it falls
in centre. In a thoracic curve, plumb line may fall on concave side if there is no
lumbar compensation and convex side if there is too much compensation.

Depending on the side plumb line falls,


List is said to be Rt/Lt side.
Raised shoulder on Convex - Poor compensated curve
Raised scapula on Concave

Detailed neurology
Leg Measurement for LLD
Measurement of Angles on X-ray
Cobb's - Top of bottom vertebrae identified and the angle between their
perpendiculars is cobb's angle

48
Mehta's- Rib vertebral angle difference. Apex vertebrae in A.P draw its perpendicular
to inferior surface. The corresponding ribs on convex and concave sides are
identified and lines drawn in the axis which meets perpendicular. The Angle on each
side is measured.
If it is < 20 0 difference - Resolving type
If it is > 20 0 progressive typeMo1 & Nash - Noting the position of pedicle AP film
gives idea of rotation and graded from I to IV

PROLAPSE DISC AND LUMBAR CANAL STENOSIS

1. What is the corelation of Vertebral Level to the Neurological


Level ?

C1-C7, Add1
T1,T6 Add 2
T7-T9 Add 3
T10 Corresponds to L1L2
T11 Corresponds to L3L4
T12 Corresponds to L5,L1
2. What are the features of an UMN Lesion ?
Increased tone
Exaggerated Deep tendon reflex About sup; reflexes
Plantar upgoing
Clonus may be present
Bladder Dribbling ( Automatic )
3. What are the features of a LMN Lesion ?
Flaccidity

49
D.T.R. sluggish
Superficial - present
No colnus
Bladder - Retention overflow (Atonomus )
4. What are the different stages of a Plantar reflex ?
Flexion of toes
Dorsiflexion of ankle
Inversion of foot

Extension of big toe


Fanning out of other toe
Flexion of hip and knee
5. What are other ways of ellisting a Plantar reflex ?
Along Medial border of Tibia - Oppenheim's Test
Squeezing heel cord - Gordon's sign
Squeezing calf muscles
Stroking lateral Malleolus
6. What are the types of clonus ?
Illustained - less than 5 strokes of flexion and extension usually.
Not of clinical significance
Sustained - more than 5 strokes
7. Why does a clonus occur ?
Due to hyperactive stretch reflex because of absence of inhibitory
reticular cell synapses.
8. What is a reflex are ?

50
Polysynaptic are arising from the golgi tendon organs to postrior
horn cells.
9. When do you get absence of joint positin sensation, what does it
suggest ?
It means there is total involvement of posterior and lateral
column tracts and hence the prognosis of improvement should be
guarded.
10.Why does an L4L5 disc has involvement of L5 Root ?
The root of L4L5 line in the same sheath and this occurs because
the root of L5 crosses over the disc to come out of formina at L5
vertebra, and so on.
17. What are indications of poorly compensated curve in scoliosis
?
18. What are the Paraspinal Muscles of Bank ?
Superficial > Erector spinae > Ilio costalis, Longisimus
Intermediate > Transverse > semispinalis ( rotatores
multifides )
spinalis
deep -> Interspinalis
Intertransversii
19. What is the total No.of disc ?
23 in Number 23 Number of disc present
20. What is the total No.of Nerve Roots ?
31 pairs.
21. What is the Nerve supply of disc ?

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It is avascular
22. What is the Nerve supply of disc Through sinovertebral
nerves
Nerves are branches of sinovertebral nerves
23. What is the commonest site of disc prolapse ?
L5,S.1 disc is commonest followed by L4-L5 disc
24. What are the stages of Disc Prolapse ?
Normal Bulge B
Protrusion P
Extrusion E
Sequestration S
25. What is the Natural History of disc degeneration ?
Stage of Dysfunction > synovitis
26. What is the Normal canal diameter in spine ?
Cervical - 15-22 m.m
Thoracic 15-22 m.m
Lumbar (L1-L3) 15-23 m.m
(L4-L5) 16-27 m.m.
27. Why does a disc prolapse more in Lumbar region ?
1) Due to instability of these
a) Hip Extensors -> for heavy exertion
b) Paraspinal -> Lighter task
c) Abdominals -> Balance
2) Motion at disc -> Load in front of annulus disc moves
posteriorly -> Rupture

52
28. What is a Lateral recess ?
It is a space bound laterally by pedicle dorsally by facet joints,
ventrally by body. In lower lumbar area it is 3-4 mm space.
If reduced, causes stenosis
29.How does Facetal Huypertrophy affect the Nerve Roots ?
It reduces the distance from body to articular surface, because
of this nerve root which passes is compressed.
30.What are the features of completion of Discectomy on table ?
Fresh bleeding from the disc space due to exposed cancellous bone.
31.What is an Autonomic and Automatic Bladder ?
AUTONOMOUS AUTOMATIC
- Cauda Lesion Sympathetic efferent cut
- LMN UMN
Detrusor Int.
Detrusor Internal spnineter Tone Sphincter Tone
Tone cut Tone increased increased descresed
Contraction Int.Sphincter Open
External Sphincter open Ext. sphincter Close
Dribbling Fullness of bladder local reflex
arc.
32.How do you conservatively manage a disc case ?
Rest- Hip knee flexed- Relaxes sheath and root decrease lordosis
Tractio- 15 lbs bilateral
Heat - massage - relieves spasm

53
Rotatory manipulation- usually not done due to risk of injury to
cord.
33.What are the signs of increased root presure ?
1. Lesague's test ( 1864)
2. Bowstring test
3. Anvil's test
4. Well leg raising test- Frajerstaian test (1901)
5. Reverse SLR - Femoral stretch test
34.What are steps of disc excision :
- Midline incisi9on
- Paraspinal muscles stripped from Lamina
- Lamina identified
- Ligamentum flavum excised
- Nerve root retracted
- Disc herniation identified and removed
35.What is chemonuclcolysis ?
Injection of chymopapain, causes dissociation of
mucopolysaccharide and reduces intradiscal pressure.
36.What is micro discectory
Hijikata described it for minimal disc hermiation and
protruded disc done through operating microscope, and
laminae are not removed in this.
37. Complications of lumbar disc surgery.
Cauda equina syndrome
Thrombophlebitis

54
Pulmonary embolism
Wound infection
Postop- discitis
Dural tear
Nerve root injury
Pyogenic spondylitis

38. What is Postop. Regimen after discetomy ?


Turn in bed - same day
Walk by III day
Sitting minimised and walking increased
Exercises 6-8 weeks
Sitting job 4-6 weeks.
39.What is the success rate in discectomy ?
93% patients have relief of leg pain
80% patients have rerlief of low back pain.
40. What is the role of epidural steroids ?
- It reduces acute pain and inflammation
- Reduces fibrosis and wear and tear in disc
- used in acute low back pain
41. What do you understand by PLIF ?
Cloward described posterior lumbar interbody fusion, in disc
disease and spondylolisthesis, it involves bi8lateral
laminectomy, inter vertebral rims removed with grafts placed
and advanced medially.

55
42.What are the causes of lumbar failed back syndrome
Failure to remove disc
Overlooked second rupture
Further extrusion
Adhesive arachnoiditis
Stenosis
Scaning
Foreign body
Wrong level wrong site
Nerve injury
43.What are the causes of spinal stenosis ?
Cogenital - Achondroplasia
- Idiopathic
- Acquired - Trauma
- Degeneration
- Listhesis
- Metabolic - Paget's disease, Fluorosis
44. What is common cause of stenosis ?
Acquired degenerative spinal stenosis.
45. What is D/D of spinal stenosis ?
Disc herniation
Cauda equina syndrome
Peripheral neuropathy
Vertebral tumors

56
46. What is neurological ciaudication how it differs from
vascular ?
Vascular Neurological
Fixed distance -Claudication distance gradually increase
Pain relief even on - Sitting only gives relief
Standing for a while - Numbness ache or sharp pain
Cramp like pain
tightness in falf
47. When do you label stenosis on radiology ?
When diameter is < 10-12 mm in sagittal measurement
47. What is length of spinal cord ?
72 cms + 10 cms in an adult
48. Define bed sores and give their classification
There are ulcers caused due to neurotrophic necrosis at
pressure points, caused by lowered resistance, loss of
sensation and skin maceration due to
II I + S/c fat involved
III II + muscles involved
IV III + bone and deep structures involvement as
osteomyelitis and septic arthritis.
50. Define lumbar canal stenosis
It is abnormal lateral and saggital diametric narrowing of
vertebral canal causing cauda equina compression
51. What are the indications of myelography in lumbar disc
disease ?

57
- Disc herniation
- suspicion of intraspinal lesion
- Questionable diagnosis
- Previously operated spine
52. What are the indications of CT scan ?
Better for bony architecture, discriminates neural
compressions caused by either soft tissue or bony changes.
52. Indication of MRI
88% accurate
Better visualization of both soft tissue of bony deformities.
Superior in- disc degeneration
- tumor
- infection
Low intensity T1 mode -- for intramedullary lesion
High intensity T2 mode - extra osseous lesion
54. What are the causes of low back pain ?
Spinal- disc hermiation, stenosis, lysthesis
Rheumatological- Rh. Arthritis, ankylosing spondylitis
Tumors - Primary/metastatic
Infection - Bacterial tuberculosis
55. What is the role of electromyography in patients of disc. ?
It is done to differentiate radicular symptoms from neuropathy or
IMN lesion or myopathy if present
56. What is spondylolisthesis ?
A forward slip of one vertebra over another

58
57. What is spondylolysis
It is a clinical entity in which pars inter articularis is disrupted. It
may be described as a fracture non union or stress fracture. It
may not be associated spondylolisthesis
58.What are the 5 classes of spondylolisthesis ?
Congenital, isthemic, traumatic, pathological and degenerative
59. What is the Meyerding's grading of spondylolisthesis ?
I. 25% slip
II. II 50% slip
III. III 75% slip
IV. IV More than 75%
60. What is etiology of inshimic spondylolisthesis ?
a. Birth fracture of pars
b. Stress fracture
c. Failure of fusion
d. Hereditary
e. Impingement of articular process pinch like
compression of L5 between L4 and sacrum.
61. What is the most common class of spondylolisthesis ?
Degenerative, female : male = 5:1
4 to 10% of total population
62.What is a slip angle ?
It is the angle of lumbosacral overhang to reference in which is
parallel lto and plate of L5 vertebral body. Second line drawn
through end plate of sacrum. Normal slip angle is 0

59
63. What is the best radiographic evaluation for spondylolysis
and listhesis ?
AP and lateral films are helpful but listhesis is seen best in
oblique views.
64. What is the scotty dog sign sen on oblique radiograph ?
Scotty dog sign describes the appearance of facet joint and pars
interarticularis on oblique radiograph. The scotty dog neck
represents the pars defect. It is broken in isthemic
spondylolesthesis. The gap in the injury if acute may show
narrow irregular edges, whereas long standing lesions may even
show a psued arthrosis.
65.What are the clinical features of spondylolisthesis ?
i) Pain-low grade irritation relieves by sitting
ii) Para spinal muscle spasm
iii) Stiffness -Hamstring spasm cause waddling
iv) Gait Pelvic waddle increase lordosis
v) Neurology - some cases may show signs of route
compression.
In children initially there is discomfort in back they may
have poor posture.
66.What is lumbar index ?
The degree of trapizoidal deformation of lumbar vertebra
Height of posterior border
_________________X 100
Height of anterior border

60
67.What is Ulman's sign ?
Seen on lateral view when interior surface of sacrum projected to
anterior inferior border of L5
68.What are principles of treatment in children with spondylosis
?
i. Slip increases during 1st few years.
ii. Upto 15% no symptoms no treatment only
exercise.
iii. More than 50% with symptoms, surgery is
indicated
iv. More than 50% without symptoms, surgery
is indicated
v. Persistant symptoms, progressive slip, early
surgery is indicated
vi. Fusion alone done to get relief from pain.
vii. Decompression if neurological symptoms
are present.
69. What patients are at risk for progression of lysthesis ?
i) Early onset
ii) Female
iii) Recurrent
iv) Postural deformity
v) Increase slip angle
vi) Congenital
70. What is role of reduction in lysthesis ?

61
i) Done for displacements less than 50% slip
ii) Method 90-90 traction or halopelvic traction with
pantaloon spica cast.
iii) Hazardous due to bladder and rectal incontinence.

62
POTT'S SPINE
1. How do you classify Pott's Paraplegia ?
I. Negligible - Patient unaware/Detectable Plantar
extrensor and or Clonus
II. Mild - Patient aware/manages to walk
III. Moderate - Non ambulatory, Paralysis in extension
sensory, deficit < 50%

63
IV. Severe-III + Flexor spasm/Paralysis in flexion Flaccid,
Sphincter involved
A. Early onset due to inflammation granulationl,
abscess, Ischemia
B. Late onset - Recurdescence or mechanical
(associated with healed disease )
2. What are flexor spasms ?
Sudden forceful spasm of the flexors of lower limb due to
complete involvement of cord and formation of local reflex are,
on slight stimulation.
3. What is 'K' angle ?
Line along posterior margins of bodies of healthy vertebrae
above below, is the angle of Kyphosis
If < 600 progonosis is better.
( A Kyphosis of more than 30 0 has 3 or more vertebral
involvement )
4. What are common sites of involvement in the vertebral column ?
- Dorsal
- Lumbar
- Cervical and Dorso Lumbar
- Lumbosacral
5. What are the sites in a vertebra ?
a) Paradiscal c) Appendical
b) Central d) Anterior
6. What is the first sign of involvement in a vertebra ?

64
Paradiscal- Narrowing of disc, osseous destruction seen as
porosis.
7. What are the sites of tracking of Potts abscess ?
Below diaphram Above diaphram
Renal angle along the inter costal
Petit's Triangle Vessels any where along
Inguinal Fossa the chestwall
Scarpa's Triangle
8. What are Radiological features in Pott's Spine ?
Paravertebral abscess - below D4-Bird Nest appearance
Upper thoracic V shape shadow
Thoracic Tense Paravertebral abscess- Scalloping effect with
healthy disc giving saw tooth appearance
- Kyphosis - Areas of destruction of vertebrae- Scoliosis
may be rare.
9. How does kyphosis develop in Pott's Spine ?
Due to dimination of disc space and destruction of body, there is
wedging with forward angulation causing a Kyphotic deformity.
10.What is L:M ratio ? How is it important in Pott's Spine ?
Lymphocyte : Monocyte ratio normally is 4:1 and is reversed in
Pott's spine.
11.What other investigations you'd like kto get in a case of Pott's
spine ?
A) C.T.scan - in Posterior spinal disease
in Cranio Vertebral

65
in Sacral
in Destructive lesion in Sacroiliac joint
Better assess of bony and soft tissue.
12.What is Costo Transversectomy ? What is its indication ?
--A Semicircular incision made from midline 6 cm proximal to
diseased area 10 cm from midline.
-- Two to four Ribs, S cms from Transverse process
 Abscess is sucked.
Indication -- A frant abscess
13.When do you operate in cases of Pott's spine ?
- No recovery on conservation
- Develop Neurological compliction during therapy
- Worsening of Neurology
- Recurrence after initial healing by conservation
- Advanced cases with flexor spasm, sphincter involvement.
14.What is Middle Path Regimen ?
- Rest. drugs, gradual mobilization, abscess aspiration
- If neural complication do not show improvement in 3-4
weeks we consider for decompression.
15.What is Anterior Decompression ?
Through Transthorcic approach., ( Left thoracotomy ) and
traspleurally lung is freed, plane between abscess and aorta is
made and debrima removed (described by Krikaldy Willis,
1965)
16.What is an Anterolateral Decompression ?

66
If on Costotransversectomy no abscess comes out - and anterior
exploration done through medial end by removal of rib and
transverse process then approaching into abscess cavity large
sequestra, necrotic debris is curetted. We do not excise pedicles
in this procedure.
17.What is the Spinal Tumor Syndrome ?
A small tuberculoma or extrtadural granuloma responsible for
neurological compliction without radiological evidence of
tuberculosis of vertebra are considered as spinal tumor
syndromes.
18.What is the natural course of healing in Tuberculosis ?
- Bony ankylosis - if disc space completely destroyed
- Intercorporal fusion - Bone block formation
- Ivory vertebra - Early healing, disease focus surrounded by
sclerotic bone.
19.Causes of Neurological Complication in Carie Spine ?>
Inflammatory - Oedema, Abscess, Granulation, Caseation
Mechanical- Debris, Sequestra, Constriction
Intrinsic - Prolonged streching of cord, Dislocation
Spinal Tumor Syndrome - Diffuse extradural granuloma
20.When is Myelography indicated in Pott's spine ?
Multiple vertebrai lesion
Spinal Tumor Syndrome
No recovery after decompression
21.What happens to cord in unrelieved compression ?

67
Loss of Neurons
Gliosis
Loss of Myelin
Syringomyclic changes
22.What are the causes of Relapse or Recurrence ?
- Severe Kyphosis
- Reactivation of Lesion
- Resistant organism
23.What the features of healing Radiologically ?
- Intactness of space by fibrous replacement
- Spontaneous interbody bone/fusion mixed
- Regeneratin of bodies.
24.When do you predict better prognosis of cord involvement ?
Degree - Partial (Duration - Shorter )
Type (A) Early onset
Speed of onset-Slow
Age- Young
General condition - Good
Vertebral disease - Active
Kyphosis - < 60 0
25.Why is Laminectomy in Pott's spine contraindicated ?
Inadequacy for decompression
- Increase instability causing pathological dislocation
- Increased Kyphosis.
26.What are the advantages of costo-transyersectomy ?

68
- It attacks the main cause of paraplegia.
- Reduces the pressure on cord.
- Reduced toxicity of focus
- Drainage of pus is away from cord.
- Does not weaken the spine
27.What is Whitman frame ?
It is a retention splint used in children of Pott's spine
28.What are presentations of Psoas Abscess ?
- Pseudo Hip flexion deformity ( with full range of rotation )
- Lump in Iliac fossa.
- It is as a rule associated with detectable disease below D-
10 vertebra. to sacrum, sacro iliac joint
29.What is Routine Distribution of Spinal T.B.?
Dorsal - 42%
Lumbar - 26%
Dorso Lumbar - 12%
Cervical - 12%
30.Why does narrowing of disc space occur in Praadiscal Lesion ?
- Atrophic changes due to lack of nutrition to pulposus. and for
prolpse of pulposus in vertebral body.

69
KNEE CASE
History :
1. Trauma
- Blow over lateral side of knee in weight bearing position,
MCL affected
- Blow on medial side in weight bearing position, LCL
affected
- Blow over anterior side in flex position, posterior cruciate
affected
- Knee is forcefully huyperextended, anterior cruciate
affected
- Femur internally rotated on tibia - medial meniscus injury
- Femur externally rotated on tibia - lateral meniscus
2. Locking of knee joint,
means joint can flex freely but cannot be extended beyond a
certain limit. Seen is meniscal injury, loose bodies.
3. Pain - Remember causes according to site
4. Swelling - immediate or insiduous onset (Gradually )
5. Giving way, clicking suggests mechanical disorder

INSEPCTION ;
1. Attitude :
Generally knee is kept in the flexed position. This is the
optimum position of the joint to accommodate maximum fluid in

70
the joint cavity. Either due to effusion or locking patient fails to
extend the joint beyond a certain angle.

2) Note abnormalities of valgus, varus, recurvatum.


In late stages of arthritis, triple displacement of flexion, posterior
subluxation lateral rotation of tibia due to hamstring contraction
may occur. Triple deformity indicates destruction of cruciate and
collateral ligament.
(ALWAYS NOTE THE POSITION OF PATELLA )
3. Gait- antalgic or circumducted
4. Swelling- effusion- horse shoe shaped above patella and on either
side of ligamentum patellae oblitrating normal depressions.
Cellulitis - extends over patella and its ligament, it is generalised
5. SWELLING CONFINED TO LIMITS OF SYNOVIAL
CAVITY AND SUPER PATELLA POUCH
1. Effusion
2. Haemarthrosis
3. Pyarthrosis
4. Space occupying lesion
SWELLING EXTENDING BEYOND THE JOINT
1. Infection of joint, tibia, femur
2. Tumors - major injury
LOCALISED
Anteriorly pre-patellar bursitis, infra-patellar bursitis
Medially cyst of medial meniscus, exostosis

71
Laterally cyst of lateral meniscus
Posteriorly semi membranous bursitis ( between gastrocnemius
and semi membranosus tendon ) Moront Baker cyst ( appears on
extension, disappears on flexion )

5. Dissolouration
6. Scar Sinuses
7. Muscular Wasting.
PALPATION
Always start by noting temperature and tenderness.

Swelling - for diagnosis of effusion, patellar tap, fluid shift and


fluctuation tests are done - For patellar tap, 25-30 ml fluid in joint is
required. For fluid shift 10-15 ml is required.

Synovial Membrane - Start coming down on either side of knee,


feel for the edges of thickened synovium in supra patellar pouch and
roll under the fingers.

Palpation of bony component :


MOVEMENTS
1. Flexion 0-130 degrees measured by Goniometer. Useful for
assessing gradual progress of treatment

72
2. Extension upto 0 degree - increased extension seen in girls, joint
laxity, patella alta, condromalacia patellae, recurrent dislocation
patella, tear of anterior cruciate with medial component.
3. Abduction and Adductioin - Absent in a straight knee, so are the
rotations.
MEASUREMENTS
1. Limb length
2. Quadriceps mass
3. For genu valgum - intermalleolar distance both patella
should be vertical while taking the measurement
4. For genu varum - the distance between the knees is
measured in standing positions.
Q. In genu valgum bow do you assess whether the deformity is the
femur or tibia or in both ?
Ans : Ask patient to flex the knee if valgus gets corrected the deformity
is femoral. Explanation - in extension a relatively flat surface of femur
is in contact with the tibial condyles, but with full flexion, a more
curved posterior femoral condyle comes in contact with the tibia and
the deformity disappears. If on knee flexioin if the deformity is
kpartially corrected then both tibial and femoral component are
responsible.
If no correction on flexion, then tibia is exclusively present.
4. Q-Angle ( 9 to 15 degrees )
SPECIAL TESTS
For Meniscus -

73
Mc Murray's test
Apley Grinding test

Ligamentous instability
valgus stress test
Varus stress test
Anterior drawer test
Postrior drawer test
Lachman test

For Rotatory instabilities -


Slocum anterior drawer test
Jerk test of Hughston and Lossey
Lateral pivot shift test of Mcintosh
External rotation recurvtum test

For Patellar dislocations -


Aprehension test of Fairbank

74
RECURRENT DISLOCATION OF PATELLA
1. What is Q angle ?
The angle subtended by the quadriceps pull on the tibial
tuberosity or centre of patella.
It is measured by a line drawn from ASIS to mid kpoint of patella
and another from tibial tuberosity. The angle so formed is Q
angle.
Normally 9-15 0 More in males.
2. What are predisposing factors of dislocation ?
Bony Soft tissue
Genu valgus Vastus medialis oblique dysplasia
Patella alta
Shallow groove Tight lateral retinaculum
Extrnal tibial torsion Patellar hypermobility
Femoral ante version Generalised ligament laxity

3. What is apprehension test of dislocation ?


In recurrent dislocation of patellary attempt to subluxate the
patella laterally is resisted by the patient.
Described by Fairbank
4. What is habitual dislocation of pattella ?

75
When the patella dislocates with every flexion of the knee joint
and is replaced by the extension it is habnitual dislocation of
patella. Seen more commonly in adolescent females.
5. What is treatment of patellar dislocation ?
Proximal alignment e.g. Campbell's procedure
Distal alignment e.g. Hauser's procedure
Combined e.g. Roux Goldwith procedure
6. What is Insall Solvetti ratio ?
Ratio of patellar articular surface to length of ligamentum
patellae. Normally, one if it is more it is patella baja if less it is
alta.
7. What special radiograph you would advice ?
Skyline view of the knee to know about medial surface of patella
and lateral condyle of femur in patellar dislocations.
8. What is Patellar Traking and Maltraking ?
After doing a total knee replacement, the patellar movement are
chacked by flexion - extension in the intercondylr norch. A
normal tract of patellar movements is known as patellar Tracing
and any deviation from normal is ialtracing.
9. Why is kpatellar tap false negative in flexion ?
Because in flexion the synovial capsule flatterns over the
condyles and fluid slufto to periphery.
10. What is D/D of Moront Baker cyst ?
Poplateteal artery aneurysm
Lipoma

76
Bursitis
Lymph nodes
Ganglion
11. Is moront Baker cyst always in Midline ?
It lies between medial head of Gastrocnemius and
semimembranosus tendon. It was first described for Tubercular
infection in 1877.
12. How do you look for posterior subluxation of Tibia ?
By blending both knee's and hip at 90 0 of the ground and looking
for any posterior sagging.
`13. What is Triple deformity in T.B. knee ?
- Flexion of joint
- Posterior subluxation or lateral subluxation
- Abduction of Tibia
14. What are the features of T.B. knee clinically ?
a. Swelling, unilateral, warm,
b. Tenderness
c. Synovial Hypertrophy - feels boggy, can be rolled between
fingers
d. knee may have Trible deformity
e. Muscle wasting

15.How do you see for Synovial Thickening ?


- It is felt better medially as vastus medialis is muscular till
the end, so gets wasted easily.

77
- It can be rolled between two fingers.

CUBITUS VARUS
1. What is the normal carrying angle of elbow ?
10-15 0 (Upto 18 0 in female )
2. What is the cause of cubitus varus ?
- Malunited supracondylar fracture of humerus
- Congenital
3. What re radiological features of a malunited supracondylar
humerous ?
4 What is Baumann's angle ?
Draw a perpendicular line to the metaphysio epiphyseal line and
another line along the long axis of humerus, normal it is 8 to 11
degrees.
5. Which nerves are usually palsied with malunited supracondylar
femur ?
Median nerve palsy
Tardy ulnar nerve palsy

78
6. What is 3 point relation at elbow ?
Normally epicondylar tip and olecrenon in extension are in 90 0 in
flexed position they form isosceles triangle.
Falacies - # of epicondyle, or olecrenon.
Maintained in supracondylar fracture
7. What is cubitus rectus ?
When there is no varus or valgus angulation
8. What are the patpatory findings in malunited supracondylar region
?
Ridges are blunted
Contoured rounding of lower end
Widened elbow region
Cubitus varus
Hyperextension
9. What is shoulder compensatin in cases of cubitus varus ?
There occur 3 deformities in malunited supra condylar fractures. A
coronal tilt An anterro posterior displacement and angulation - This
angulation of elbow is compensated at houlder by internal rotatin to
keep the alingment of elbow normal.
10. What do the other two deformities manifest as ?
Coronal tilt - varus
Anteroposterior displacement - Hyperextension
11. What are normal movements at elbow ?
Flexion 0-145 0
Extension 145 0 - 0

79
Supination Pronation -90 0
12. What is treatment of cubitus varus ?
French osteotomy - medial wedge osteotomy
Modified French osteotomy
13. What is modified french osteotomy ?
Belmore's modification of osteotomy to correct the angular tilt, in
this the wedge is removed after passing of 2 screws in proximal and
distal end and with tension banding the angulation is corrected.
14. What other osteotomy you know of ?
A. Grazino's osteotomy
B. Step cut osteotomy
15. What are the features of an untreated supra cndylar fracture ?
- Cubitus varus
- Tardy ulnar Nerve palsy
- Proximal migratin of Radius
- Superior Radio unlar instability
16. What are the parts of Lateral condyle ?
Lateral Epicondyle
Capitulum
Part of trochlea.

80
1. Define osteomyelitis ?
Infective inflammation of cortex along with its medulla i.e. all the
layers of bone.
2. What are the different types of osteomyelitis ?
Acute haematogenous - Systemic iliness less than 10 days
Sub acute - Established radiology more than 10 days
3. What is acute haematogenous osteomyelitis ?
Acute infection in medullary canal
Increased osteolytic activity associated with hyperemia, increased
local compromise with fat necrosis

81
Pathogen pass through these channel producing periosteal abscess. End
result depends on virulence, host condition and local melieu.
4. Why is metaphysis commonly involved site ?
Hair pin bend
Tortuous course
Sluggish blood flow
Nidus for bacteria
Rapidly growing end
Site for microfracture occuring during physiological loading.
5. What is natural history of untreated osteomyelitis ?
Local abscess
Patchy bone resorption
Periosticitis
Nutrient vessel occlusion
Periosteal new bone formatin
6. When do you call an osteomyelitis to be chronic ?
Period more than 3 months
Sequestrum formation
Chronic discharging sinus
Reactive new bone formation
7. What is a sequestrum ?
A dead detached piece of bone lying in a osteolytic cavity
surrounded by infected granulation tissue and reactive new bone
formation.
7. What are different types of sequestrum ?

82
Flake like sequestrum
Tubular sequestrum
Ring sequestrum
Coraliform sequestrum
Coloured sequestrum
Ivory sequestrum
Coarse sand like sequestra
Bombay Nigra sequestrum
Feathery sequestrum
Kissing sequestrum
Muscle sequestrum
9. What are common pathogens in osteomyelitis ?
Staphylococcus aureus.
10. What are the clinical presentation of chronic osteomyelitis ?
Skin - sinuses - healed and active - fixed to bone unhealthy, shinny.
Bone irregular.
Painful and tenderness on deep pressure
Muscular atrophy
11. What is Cierny and Mader (1981) classification of Osteomyelitis
?
I. Medullary osteomyelitis - haematogenously infected nonunion
II. Superficial osteomyelitis
III. Localized infection, with sequestration, cavitatin
IV . Osteomyelitis includes infected non union, septic joints.
12. What is a Brodie's abscess ?

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Subacute osteomyelitis mainly involves lower end of tibia or upper
tibia and femur, patient complains of pain dull aching. Radiologically
lower end of tibia has an osteoloytic lesion with sclerotic margins with a
fluid level. Which may be sterile.

13. What are the conditions where you get bilateral osteomyelitis ?
Salmonetta osteomyelitis as a secondary infection in sickle cell
anaemia.

14. What is sclerosing osteomyelitis of Garre ?


Low grade infection causing sclerosis patchy, in long bones on
diaphysis. A subacute form of osteomyelitis. D/D Ewing's Sarcoma.
15. What is treatment of Brodies abscess ?
Multiple drll holes are made for decompression, as patient has main
complain of pain.
16. What are the different modes of treating chronic ostomyelitis ?
Curettage and debridement
Sauccrizatin with or without filling of cavity
17. What are the methods of closing cavities ?
Bone grafts
Muscle flaps
Gentamicin beads, Tobramycin beads.
18. What is Carel and Dakins' method of treatment ?
Closed suction irrigation done in chronic osteomyelitis
19. What is Bier's method of treatment ?

84
Oldest treatment method it used Maggots and liquid paraffin seals
for scavenging of osteomyelitic cavity.
20. What is silver ionizing method ?
Iontophoresis using silver ion electrodes and pulse of electric
current.
21. What is Haltstead's procedure ?
Electromagnetic induction method of treatment of chronic
infection, started in 1984
22.What is Papenau Rhinelanders' technique ?
It is a 4 stage procedure done in infected non union comprising.
I. Debridement
II. Saucerization
III. Bone grafts
IV. External fixatin
V. Myocutaneous flap
23. What is D/D/ of chronic ostromyelitis ?
Osteoid osteoma
Ewing's Tumor
Histocytic Eosinphilic Granulema
24. What are the complications of chronic osteomyelitis ?
Shortening or lengthening
Generalised septicemia, bacteria
Pathological fractures
Secptic arthritis
Joint stiffness

85
Secondary skin infections
Amyloidosis
Squamous cell carcinoma in the sinus

25. What is the cause of death in osteomyelitis ?


Amyloidosis of kidney
Thrombo embolism
Squamous cell Ca.

26. What are the radiological features of chronic osteomyelitis ?


Soft tissue wasting
Sequestrum in an osteolytic cavity with involucrum
Bony irregularity
Loss of corticomedullary differentiatin at sites Periosteal reaction may be
present.

27. Why does bony irrregularity occur ?


Due to periosteal reaction and improper remodelling following healing
of osteomyelitic sinus and cavities.
28. What are the Stndard imaging methods in diagnosis your know of ?
Tc 99- Gallium 67, Indium 111 scans are done
Tc 99 - for osteoblastic activity, because uptake within 1 hour.
1 Phase - flow study
II phase - differentiate nonosseous and osseous tissue by uptake
III phase - acute osteoblastic activity seen in disease state

86
29. Describe the role of CT/MRI in acute osteomyelitis ?
CT- used in acute osteomyelitis detectin of enterosseous gas which is
decreased density of infected bone.
MRI - superior to CT as it displays both soft tissue and bone marrow,
detects early Bone marrow edema
- Sequestrum formation.
- Periosteal reaction
- Bony changes.
30. What is Methylene blue used for ?
It stains and differentiates dead tissue from live during sinus excision.
Dead tissue stains blue whereas living tissue reacts with it to give gray
colour.
31. How does a sequestrum differ from living bone ?
Sequestrum - Colour, ivory pale white
Rough from one side - Dull note on percussion
Smooth from other side - More dense on X-ray
Which lies in pus - Haversian canal closed
Heavier than water so in water it sinks.
Living bone- bleeds on removing smooth surface, floats in water.

INFANCY CHILDHOOD ADULT


1) Secondary to umbilical Haematogenous Open fracture

87
infection
2) Constitutional symptom less More Moderate
3) Site -Intrarticular Metaphyseal Diaphyseal
Metaphyseal
Epiphyseal
4) Local Temperature
- Very little raised Raised Moderately
5) Periosteum perforated Subperiosteal pus Adherent
by pus periosteum
6) Joint ffection frequest Less frequent In late case due
communication vessels to muscular adhesion
pass through epiphysis
and growth plate
7) Sequestrum -Less Very common Smaller, thin
8) Chronic conversion- less More More
9) Shortening Lengthening No effect.

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CTEV
( congenital talipes equini varus )
1. What are the different types of Club Feet ?
- Congenital
- Acquired - may be due to any cause - bony, muscular,
neurological
2. What are the causes of Acquired Club Feet ?
- Polio
- Muscular
- Post traumatic
3. What are the Aetiological factors in club feet ?
-Neurogenic
Osteogenic
Musculogenic
Idiopathic
4. What are the varieties of Club Feet ? Who classified them ?
Cummin classified them as,
- Supple
- Recurrent
- Rigid

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- Neglected
- Resistant
- Relapsed
5. What are poitive features in a Congenital Club Foot and how
it differs from Acquired ?
- Small heel
- Pendulous calf.
- Medial attachment of Tendo Achillis on the Calcancum
- Foot size smaller if unilateral
6. What is ' Locked Cuboid ' sign of Ingram in CTEV
Cuboid is in abnormal position where medially there are
collaterals and laterally is articular surface of calcaneum and
is also locked by ugin capsule
7. Where does the major defect lie kin CTEV ?
In subtalar joint.
In talocalcaneonavicular joint complex.
8. What is a Varus of foot ?
Hind foot inward and fore foot adducted.
9. According to Le ' Noir's Hypothesis according to what
joint, what deformity occurs.
Equinus at ankle, inversin at the subtalar joint and adduction
on the CHOPART AND LISFRANC'S JOIINT
10. What are the methods of conservtive management in
CTEV ?
Manipulation

90
Strapping and
Plaster of Paris (POP) Cast
11. How does strapping help in early age ? What is the latest
concept regarding it ?
- Non rigid retention thereby prevents the wasting of the
muscles
- This should not be done as a deformation of the cartilage
occurs and deformed cartilage does not grow.
12. What is the method of applying P.O.P. and Changing
POP ?
- Manipulate the foot
- Hold the foot in corrected position while applying POP
- Retain the poition till the cast sets.
13. How do you confirm your finding whether a foot is
completely corrected ?
Radiologically the Talocalcalcaneal angles and the
Talometatarsalangle
14. Which deformity recurrs first ?
Equinus.
15. What are Robert Jones shoes ?
a- Pronator shoes
b- High counter
c- Medial border contamination bar and is straight
d- Heel is flat
e- Lateral border outflare

91
16. What is a Dennis Brown Splint ?
- It is post correction retentive splint given to child before
walking and at night after commencement walking
- It consists of metal br with two L shaped aluminium pieces
to which the limb is attached using adhesive plater.
17. Why do you give an Above Knee POP in 90 0 flexion ?
- To avoid the plaster of paris cast slipping out
- To relax the gastrocnemius, soleus which aid in correction
of equinus.
18. What are the steps in manipulation ?
Adduction
Varus
Equinus
19. What medial soft tissue structures are tight in CTEV ?
Tendinous Ligaments
- Tibialis posterior - Deltoid ligaments
- FHL (Flexor Hallucis longus ) - Spring ligaments
- FDL (Flexor Digitorum longus)- Capsule of the
subtalali joint
- Abductor Hallucis Brevis - Talonavicular joint
20. What are the criteria for selecting a patient for Surgery in CTEV ?
A. Variety
- Rigid
- Recurrent
- Relapsed

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- Residual
- Neglected
B. Foot size more than 8-9 cms (Simon)
C. Patient able to withstand anaesthesia.
20. What are the different soft tissue procedures you know of ?
- Posterior release
- Posteromedial release
- Complete subtalar release
- Tarsometatarsal capsulotomy
21. Osteotomy - Metatarsal, Calcaneal, Talar neck
22. Arthrodesis - Triple, calcaneo cuboid.
23. What is the Postop Regimen in cases of PMCSTR ?
- Immediate post operative cast.
- Removal of striches with reappliaction of cast in fully
corrected position.
- After 3 months the patient is prescribed either plastic splints
or Robert Jones shoes.
24. What is Simon's procedure ?
Complete 4 quadrant subtalar release
25. What is Turco's procedure ?
Posteromedial soft tissue release with internal fixation using K-
wires.
26. Name two Indian Surgeons and their contribution in CTEV.
Prof. B. Mukhopadhyaya - Patna procedure - complete PMSTR

93
Prof. R.L.Mittal - rotational skin flap reconstruction to correct
posteromedial skin contractures.
27. What is a Rocker Bottom Foot ?
Vertical talus with hind foot equinus and forefoot dirsoflexion qcquired
in club foot by improper regimen of manipulation.
28. What is Arthrogryposis Congenita Multiplex ?
It is a non- progressive congenital disorder with multiple skeletal
deformities caused due to replacement of muscle by tight fibrous tissue
bands.
29. What are the associated Congenitl Anomalies you should see for in
CTEV ?
- Spina bifida
- Congenital absence of fibia
- Conenital Dislocation of Hip
- Congenital constrictin bands
- Cleft palate
30. What are the Aetiological Hypothesis in CTEV
Hippocrates - Intra uterinc moulding
Irani and Sherman - Defective development of Talar ahalage
Issac - defective intra uterine development of muscles
Adams - decresed intra uterine oxygen
31. How long do you follow a kpatient of CTEV ?
Till the patient attains skeletal maturity
31. What are Non Invsive Surgery done in CTEV ?
- Ilizarov Ring Fixatin

94
- Jess- Controlled differnetial distraction by B.B. Joshi's
External stabilizing system
32. What Tendon transfers could be done for CTEV.
Tibialis Anterior to medial cuneiform.

POLIO
( POST POLIO RESIDUAL PARALYSIS )
1. What strains of Polio Varus you know of ?
I. Brunhide
II. Lensing
III. Lcon
2. What is the type Polio varus ?
RNA virus
Entero virus
3. What is Convalescent Management to prevent deformity in Polio ?
- Muscle spasm prevention
- Standing reflex stimulated.
- Thigh kept in Abduction, neutral rotation at hip knee
flexed.
- Hubbard Tank bath.
4.. What are the principles of Tendon transfer ?
- Muscle to be transferred should have power grade IV

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- Phasic transfers are preferred
- Range of excursion of tendon should be pproximately
normal to the muscle to be replaced.
- Every muscle losses I grade of power on transfer
- Neurovascular function should be maintained
- Paratenon and sheath should not be excised.
5. What isw a Phasic and Non Phasic Transfer ?
Phasic - when transferred in same phase of gait
Non phasic - when transferred in other phase of gait.
6. What to you understand by Evertor insufficiency and Inventor insufficiency ?

Evertor insufficiency - loss of power of peroneus longus or brevis invertor


insufficiency - Tibialis anterior and posterior.

7. What are the muscles affected in lower limb in polio ?


Tibialis anterior, peroneii, quadriceps, gluteii then triceps.

8.What are the causes of Pelvbic Obliquity ?


Supra pelvic - scoliosis
Pelvic - Maldevelopment
Infrapelvic - tight iliotibial band, limb length discrepancy

9. dWhat are the effects of Pelvic Obliquity ?


Flexion abductin external rotation at hip ?
- Genu valgum
- Flexion contracture of knee
- Varus of foot
- External tibial torsin
- Lordosis

96
- Scoliosis
10. What are the procedures to correct pelvic obliquty ?
Sectioning of ITB with Souttar's or Yount's procedure
11. What is the yount's procedure ?
Selective iliotibial band release either open or by close tenotomy.
12. What is Biceps Femoris Transfer (Caldwell's procedure ) done for ?
In cases of quadriceps weaknew
13. What are the Bony procedure done for Recurvatum Deformity ?
A supra condylar femoral osteotomy could be done in these cases.
14. What is the treatment principle for a Caliper in foot deformity or where do
you use T strap or Iron bar ?
The side of correction of foot requires a "T" strap and the side of deformity
requires double iron bars.
15. What is the treatment of Calcaneus Foot ?
In immature foot :

Tendon transfer of tibialis anterior to calcaneum Peabody transfer


Mitchell osteotomy along with tendon transfer

In mature foot :
Elimsle, Reverse Lambrinudi or Tripe Fusion procedure could be done.
16. What is modified jones procedure ?
Fusion of Great toe Inter phalangeal joint with exterior hallucis longus to
metatarsal neck.
17. What is a Pea body Transfer ?
Transfer of tibialis anterior to calcaneum in calcaneus deformity.
18. What is Irvin's regimen ?
Irvin's regimen consists of
- Steindler's Fasciotomy

97
- Jone's transfer
- Triple arthrodesis
- Transfer of Peroneus Longus and Brevis done in calcanco cavo valgus
deformity.
19. What is modified Elmsille's transfer ?
It is a two stage procedure in
Stage I - together with plantar soft tissue release a bony wedge is excised
from mid tarsal joint. Foot is dorsiflexed for four weeks.
Stage II - a bony wedge from under surface of Talus and upper surface of
calcancum is made to correct calcaneus deformity.
20. What are the muscles responsive for Varus Equinus and Valgus ?
Varus - Peroncii weakness
Valgus - Invertor weakness
Equinus - Triceps suri weakness
21. What is Arthrodesis ?
When foot deformity persists or recur after skeletal maturity and tendon transfer
not possible the joints are fused in functional position.
22. In a 10 year old child with Polio why do you not prefer- Triple Arthrodesis
?
Because bones are still cartilagenous and so chances of pseudarthrosis are more.
23. What are the different methods of sub talar Arthrodesis ?
- Grice green's extra articular fusion
- Dennyson fulford's Arthrodesis
- Batchelor's Arthrodeses
24. What are the different methods to do Triple Arthrodesis ?
- Ryerson's
- Hoke's
- Dunn's
- Lambrinudi

98
- Reverse Lambrinudi
25. What is disadvantage of Pantalar Arthrodesis in Indian condition ?
It is not an ideal arthrodesis for bear foot walking
26. What is a zero position ?
It is that position where all the muscles of joint form a common axes of cone
and are neutral.
27. When does hip become dislocable in polio ?
Weak abductors and extensors
Pelvic obliquity causing valgus and femoral anteversion
28. What deformity could occur in shoulder in polio ?
- Deltoid paralysis
- Senatus anterior paralysis (Abduction insufficiency )
29. Why is Calcaneus considered as an emergency ?
It is a progressive deformity due to gross muscular imbalance
30. What are the Bone Block procedure ?
Placing extra articular bone graft to curtaii certain motion in joints while other
movements are possible.
31. What is Souttar's Release ?
An anterior soft tissue release through an iliofemoral incision cutting all the
muscles of iliac-crest mainly flexors and abductors.
32.. What are the conditions where there is flaccid muscular weakness without
sensory involvement ?
- Multiple sclerosis
- Motor neuron disease
- Muscular dystrophies
- Myesthenia gravis
33. Why there is no Sensory involvement in polio ?
Because it is a disease of anterior horn cells
34. What is the type of involvement of pilio ?

99
- Patchy
- Irregular
- Assymetric

HANSEN'S ULNAR NERVE NEURITIS


1. What is the level of involvement of Unlar Nerve in Hansen's disease ?.
It is high ulnar nerve neuritis

2. Why is Ulnar Nerve most commonly involved ?


- Bony bed
- Superficial
- Low temperature
- Extensor aspect of joint moves with every motion
3. What is the deformity in post Hansen's Ulnar Neuritis ?
Reversal of grasp.
4. What do you understand by Intrinsic Minus deformity ?

100
Muscle imbalance caused by hypoactivity of intrinsics of hand
5. What is your diffrential diagnosis in this conditioin ?
- Volkman's Ischemic contracture
- Post traumatic clawing
6. What is your diffrential diagnosis in this condition ?
Tuberculoid and lepromatous type.
7. What is Rideley Jopling's classification ?
I. Tuberculoid
II. . Borderline Tuberculoid
III. Borderline
IV. Borderline lepromatious
V. Lepromatious
8. What is Volkmann's Test ?
Extension of fingers is possible with palmer flexed hand in cases of
V.I.C. not in ulnar neuritis.
9. What is Medical Decompression in Hanseniosis ?
By Prednisolone
30 mg. per day X ! week
20 mg. per day X II week
10 mg per day X III week
10.What are the criteria of Surgical decompression ?
Patient who do not respond to medical decompression.
Bacterial index less than 1.0
11.What is a Morphologiccal Index ? What is a Bacteriological
Index ?

101
Morphological - Solic staining bacilli in a smear gives idea of
viability and progress of treatment.
Bacteriological - Total no.of positive bacilli in field.
No.of smear
If < 2 = pauci
>2 = multi bacillary
12.What is Lepra Reaction ?
Hypersensitivity reaction : They are of 2 types
Early ( within 48 hrs.) Fernandez reaction
Late (3-4 weeks ) Mistudi reaction
13.What are Anti Hansen's drugs and their regimen ?
According to Indian leprologist associatin in multibacillary.
- Rifampicin 600 mg. per day x 2 wks then 600 mg/month
- Dapsone 100 mg. per day
- Clofazamine 100 mg alternate day or 50 mg. per day.
In paucibacillary
- Rifampicin 600 mg per month x 6 months
- Dapsone 100 mg per day x 6 months
14.What is the treatment of Intrinsic Minus deformity ?
- Brand's EF4T - using ECRL done in mobile interphalangeal
joints
- Bunnel's FF4T - using FDS done in stiff hands, with poor IQ
patient
- Folwer's Extensor digiti minimi and indices used.
15.What is the treatment of Loss of Oppnen's function ?

102
Ring finger (Flexor Digitorum Superficialis ) is cut from radial side
and transferred to thump FDS of RF - Thumb
16.What Tendon's could be used for graft ?
Plantaris, Palmaris, Fascia lata
17.Why is ECRB ( Extensor Carpi Radialis Brevis ) not used in
transfer in Bunnels ?
As it is centrally placed tendon and causes weak dorsiflexion.
18.What is significance of use of Tendon Fasica Lata as a graft ?
- Easily rolled
- Sufficient strength
- Sufficient size available
19.What is the Postop Regimen after Bunnel's or Brand's operation ?
What is a knukle Bender Splint ?
Initially immobilize in James position, followed by physiotherapy,
passively using cylinder POP for fingers then re-education of
function.
20.Why do you stitch all the tendons on Medial border of fingers
except of Index finger in Brand's operatin ?
To get better grip by enhanced abduction of fingers.
21.What is EF4T and FF4T procedure ?
Extensor to flexor four tailed nonphasic transfer and flexor to flexor
four tailed phasic transfer.
22.What is treatment of Trophic Ulcer of foot in Hansen's ?
-Debridement
Non weight bearing ambulatin

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MSGP solutin dressings
Keeping local temperature warm.
23.What is MSGP solution ?
Magnesium sulfate
Glycerine, proflavine solutin used for treatment of plantar ulcers.
24.What are the other sites of nerve involvement in Hansen's
Common peroneal nerve
- Radial nerve
- Median nerve and posterior tibial
25.What is Epeneurolysis, Perineurolysis ?
Epincurotomy - incise sheath
Epi neurolysis - Epineurium dissected Interfasicular neurolysis
26.What is CLAW HAND /
High/Low ulnar paralysis results in deformity known as claw hand.
This results in INTRINSIC minus hand i.e. paralysis of lumbricals,
and interossei ( and other short muscles of hand if median nerve is
also involved )
This is characterised by variable degree of huyperextrensin of
metacarpophalangeal joints ( in absence of normal intrinsic muscles
) acted by FDS and FDP
27.Why does claw hand develop ?
It is an attempt for mimicking the normal mechanism of grasp in
which object is grapsed by the wrong sequence of flexion of
proximal and distal interphalangeal joints ( in absence of normal
intrinsic muscles ) acted by FDS and FDP

104
28.Describe grasp mechanism ?
Grasp of an object is attempted by the "CUPPED LUMBRICAL
POSITION' i.e. metacarpophalangeal joints flexed and I.P joints
extended and tips of one or more fingers are brought together into
oppositioin of thumb.
When cupped lumbrical positin is attempted METACARPAL
ARCH is markedly prominent, without arch it is not possible to
perform the act like firm grasping of object or forming bolus of rice
and other fine dexterous activities.
29.How will you measure deformity of finger joints ?
By measuring - Unassisted Angle
- Assisted Angle
- Carrying Angle
Unassisted Angle - contracture -Deformity
This is measured by goniometer, by asking the patient to flex his
metacarpophalangeal joint and to attempt extension at
interphalangeal joint obviously larger the angle greater is the
adaptatin and lesser is the likelihood of a complete correction.
30.What are the prerequisite of any Tendon Transfer Surgery in
Hand ?
Hand should be reasonably supple
Contractures should be overcome by physiotherapy- wax bath prior
to surgery.
There should be no ankylosis of joints
There should be no infection like scabies

105
Sufficient muscle power of available tendon undergoing transfer
31.Describe other Tendon Transfers in Intrinsic minus Hand
Palmaric Lengus
Many tail graft - Weak transfer used in hyupermobile hand
Very easy to reeducate
Disadvantage - Absent in 20% individuals
Modified Bunnell's op - FDS of Ring finger to Dorsal Digital Expansion
FOWLER'S - Extensor Digiti Minimi,
Anterior to transverse MC ligament through introsseous
space to Dorsal Expansion
RIORDAN'S (ecr Longus ) Tenodesis, Extensor Carpi Radialis
Longus
Bracheoradialis fourtail via introsseous space to Dorsal expansion
indicated in triple nerve lesions
32. What are ideal Tendon grafts available
A. Plantaris Tendon - Slender
can easily split into 4 tails
Easily removed
No significant function loss
Disadvantage - may be absent
B. Fascia Lata - Easily Available
Loss if of no inconvenience
Fibres run longitudinal
Thickness can be varied
Disadvantage - If fibres are in oblique fashion getting tails may be
difficult.
C. Extensor Digitorum to toes

106
for use as free grafts
Disadvantage - toe dropping
33. Why Bunell modified original Stills operation ?
In Buneli modified procedure, FD superficialis tendons is harvested
into four tails and passed through lumbrical canals to be stitiched on
dorsal expansion.

This is a modification of original operation in which all 4, FDS


tendons were transferred to Dorsal expansion leading to intrinsic plus
deformity by over correction.
34. Which FDS Tendon is used in Modified Bunnell's operation ?
Ring fingers Flexor Digitorium Superficialis is used
Index fingers - strong - Intrinsic plus deformity
Little finger - very weak
Index finger - strong
weakens pinch and side grasp
35. How tendons (tail) are sutured to dorsal expansion ?
All tendon tails are sutured on laterals at except Index finger to facilitate
side pinch. Tensioning is of utmost importance
- Karat's method - Range of excursion is 4-6 m
- Pulling one tail to cause just excursion in other finger

DNB candidate is expected to get a short case of leprosy, most probably


cases are claw hand, fott drop, and ulnar/peroneal entrapment neuritis.
Candidate is expected to have a basic idea about classification of leprosy
treatment regime, criteria for selecting patient for surgery and relevant
clinical examination.

107
36. What are the indications for a nerve decompression ?
1. Recent and incokplete paralysis of nerve unrelieved by steroids or
conservative treatment
2. Pain- This indication is valid even if there is no motor function left.
3. Nerve Abscesses.
4. Progression of weakness or deficit in spite of conservtive treatment,
Surgical decompression aim at relieving compression and eliminating
antomical constrictions.
37. What is the most commonly involved nerve ?
Ulnar nerve is the most commonly involved nerve (59.9% of all the
nerves ) involved in leprosy )
The combination most frequently encountered is high ulnar and lower
median nerve paralysis.
Results about decompression are best in Ulnar-nerve ( Fritshi ),
whereas better results have been documented in case of post tibial
nerve by F.H. Anita.
38. How will you attempt Decompression ?
Epiniurotomy is longitudinal incision in expineriruism

In Hemi Circumferential neurolysis epineurium is dissected away


from superficial hemicircumference of nerve leaving the blood supply
undamaged below and the surface fasicles visible above.

Inter Fascicular neurolysis is a radical surgery in which fasicles are


dissected and freed from each other. This cannot be recommended
routinely as there is danger of further damage to nerve.
39. What is extraneural decompression ?

108
It is achieved by Medial Epicondylectomy. The epicondyle along with
adjacent part of medial supratrochlear ridge is removed. The raw bone is
covered with muscles and the unlar nerve is laid just anterior to the
fulcrum of joint.

The olecranon ligament is cut thus removing main external constriction


and also the pivot about which nerve is subjected to repeated sharp
angulation with every flexion and extension of elbow.

40. What is the advantage of anterior transpositioning of the ulnar nerve ?


In this procedure the nerve is transposed anterior to the medial epi
condyle and is buried in muscles of common flexor origin. It eliminates
trauma of repeat angulatin stretches, the bony bed and a deeper vascular
bed atleast in lower part of nerve.

FOOT DROP
41. What is the cause of footdrop in Hanseniosis ?
The common Peroneal nerve has definite and predictable pattern of nerve trunk
involvement. Usually the nerve is affected in toto at this level. Infrequently the
paralysis is incomplete involving anterior tibial nerve in which case there is
only loss of dorsiflexion whereas in former condition there is loss of
dorsiflexors, and evertors. Thus there is lateral drop in additin to equinus
leading to ulceration on lateral borders and metatarsal heads.

109
42. How will you differentiate footdrop of Polio and Leprosy ?
Dquinus of polio is rarely seen in leprosy as the foot is continuously used in
plantigrade position leading to stretching of plantar flexors.

43. What do you mean by established foot drop ?


Foot drop persisting for a period of greater than one year in spite of
conservative treatment.

44. What is its significance ?


After this limit one has to attempt muscle transfer to correct the existing
deformity.

45. Which muscle transfer is routinely used ?


Tibialis posterior is routinely transferred either by interrosseous route or
circumtibial route to dorsum of foot.

46. What precaution would you take ?


In circumtibial transfer tunnelling should be done anteriorly and properly to
gain maximum mechanical advantage.
Attaching transferred tendon to metatarsal head has high incidence
of fracture, There it is best sutured to dorsiflexors.
47.How will you achieve reeducation of muscle ?
Tibialis posterior stabilises subtalar joint during weight bearing, but the
command to elevate foot elicits immediate response from tibialis posterior as it may
be related to common lumbar segments 4 and 6

110
In preoperative period he is showed how to use tibialis posterior
with weight attached to foot so that he has no problem in
postoperative period.

NERVE ENTRAPMENTS OF HAND AND WRIST


1. What is the most commonly encountered compressive
neuropathy of the upper extremity ?
The most common compressive ueuropathy of the upper extremity is
carpal tunnel syndrome or median nerve compression at the wrist.

111
The carpal tunnel is a narrow, fibrooseous canal rigidly bound by the
carpal bones and foofed by the transverse carpal ligament. This
tunnel contains the median nerve and the nine extrinsic flexors of the
fingers and thumb with theeir synovial sheaths. Carpl tunnel
syndrome is most commonly encountered during middle or
advanced age > 80% of patients are more than 40 years old at the
time of diagnosis. It is twice as frequent in women.

2. What are the most common causes of carpal tunnel syndrome ?


Median nerve compression may occur with decreased canal size or
increased volume of the contents in the canal. Consequently, a
multitude of clinical entities can give rise to the condition.
Nonspecific tenosynovial proliferation in otherwise healthy
individuals is the most common cause of increased canal contents.
The pnemonic PRAGMATIC can be used to remember the other
common causes of carpal tunnel syndrome

P == Pregancy
R==Rheumatoid arthritis
A = Arthritis ( degenerative )
G = Growth hormone abnormalities ( acromegaly )
M = Metabolic (hupothyroidism, gout, diabetes melitis )
A = Alcoholism

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T = Tumors
I = Idiopathic
C = Connective tissue disorders (amyloidosis, hemochromatosis )
3. What are the most common symptoms associated with carpal
tunnel syndrome ?
The median nerve is responsible for sensory innervation of the thumb
and index and long fingers as well as the radial border of the ring
finger. It also supplies the thenar musculature at the base of the thumb
and the two radial lumbrical muscles. The most frequent complaint is
numbness., which typically involves the fingers innervated by the
median nerve. Patients also may complain of numbness and tingling in
the entire hand. Pain also may occur over the same distribution or more
proximally in the forearm as the result of median nerve compression in
the carpal tunnel. Nocturnal symptoms are common and frequently
awaken patients from sleep. Clumisiness or lack of dexterity with the
hand is a f requent complaint because of sensory loss or weakness of
the thenar musculature.

4. Name the provocative tests used to substantiate the diagnosis of


carpal tunnel syndrome
A median nerve percussion test is performed by percussion with a
finger or reflex hammer over the median nerve in the wrist or palm.
A positive test produces parethesias in the median nerve distribution
( Tinel's sign ) Phalen's test is performed with the wrist in full,
unforced flexion, which is achieved by putting the dorsum on one

113
hand against the dorsum of the other while the fingers are held
dependent. This position increases carpal canal pressures and
decreases local median nerve blood flow. A positive test produces
paresthesias or sensory disturbances mimicking the patient's
symptoms within 60 seconds.

5. What other diagnostic studies should be performed when


evaluating a patient for carpal tunnel syndrome ?
Laboratory studies should be obtained to screen for diabetes melitus,
gout, and renal, thyroid, and collagen vascular diseases.
Radiographs of the wrist should be obtained to document a fracture,
tumor, or arthritis as a possible cause of median nerve compression.
Finally electrodiagnostic studies are the most sensitive and objective
tests for the diagnosis of carpal tunnel syndrome. They always
should be obtained before surgical treatment of carpal tunnel
syndrome to corroboratic the diagnosis, to tule out other disorders,
and to provide baseline nerve function data. Up to 10% of patients
with clinically evident carpal syndrome, however, produce normal
electrodiagnostic results.
6. Describe the most common complication resulting from carpal
tunnel release. The results from surgical decompression of the
median nerve at the carpal tunnel are reliably good. The
complication rate is low, ranging from 2-15 % Complications
include incomplete release of the transverse carpal ligament,
injury to the palmar cutaneous branch or recurrent motor branch

114
of the median nerve, reflex sympathetic dystrophy, finger
stiffness, decreased strength, and persistent t4enderness in the
palmar scar.
7. What is Guyon's canal ?
What is Guyon's canal ?
Guyon's canal is a fibroosseous tunnel bound by the hamate and
pisiform. The roof is the transverse carpal ligament. The ulnar
artery and nerve pass through Guyon's canal. Unlike the carpal
tunnel, no tendons pass through Guyon's canal.
8. What causes compressive neuropathies in Guyon's canal ?
1. Trauma 2. Ganglia 3 Lipomas, and 4. Fractures of the hamate or
pisiform. The most common traumatic mechanism is pressure from
bicycling. Sensory neuropathy is usually from a distal canal lesion,
whereas motor weakness is from a lesion proximal to or within the
canal.
9. What is bowler's thumb ?
Bowler's thumb is a traumatic neuropathy of the ulnar digital nerve
to the thumb. It is due to repeated frictin or compression of the
nerve by the edge of the thumb hole at the bowling ball. Early ball
adjustment is necessary. The size, fit, spacing and angulation of the
holes should be altered. On rare occasions, transposition or
neurolysis is required for relief of severe symptoms.
10.Can posterior interosscus nerve (PIN) compression occur at the
wrist ?

115
Yes, Repeated forceful wrist dorsiflexion (such as in gymnastics )
may irritate the PIN. The diagnosis is one of exclusion.l Carpal
instability, ganglia, and dorsal osteophytes must be excluded. Rest,
splinting, and NSAIDs should alleviate the symptoms.
11.How does palmar cutaneous nerve compression occur ?
Blunt traumka results in transient neurapraxia. Patients have pain
over the thenar eminence and may have a Tinel's sign at the
proximal edge of the transverse carpal ligament. Conservative
treatment usually suffices.
12.What is intrinsic plus deformity ?
A flexion at metacarpophalangeal joint and extension at
interphalangeal joint. Seen as a complication of overcorrected
Bunnel's procedure or in Rheumatoid hand.

BONE TUMORS

1. Describe Enneking’s system of staging for tumors of the


musculoskeletal system
There are three criteria for Enneking’s classification : Histologic grading
anatomic site, and presence of metastasis, either regional or distant. For
Histologic grading. 0 equals benign, I equals low-grade maligenancy,
and 2 equals high-grade malignancy. An osteosarcoma is classified as
grade 2.
The anatomic site may be either intercompartmental or
extracompartmental. The third distinct category is presence or absence
of metastasis. Malignant tumors are then classified as 1A

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1B,2A,2B,3A,3B. All grade 3 lesions are high-grade malignancies,
either intercompartmental or extracompartmental.
2. Discuss the principles for biopsy of musculoskeletal tumors.
The biopsy specimen must be excised en block if the tumor is malignant
and limb salvage or amputation is contemplated. No transverse incidions
should be made during biopsy. No important neurovascular structures
should be exposed or dissected. The biopsy should traverse only one
compartment. If a bony tumor has a soft-tissue extension, the bone
should not be violated, and the specimen should be taken from the soft
tissue only at the periphery. If bone must be violated, a circular hole or
oblong windows should be fashioned to lessen the likelihood of
pathologic fracture, if the tumor is a sarcorma, a pathologic fracture
usually causes loss of limb.
3. What are the common benign bone forming tumors in the
musculoskeletal system ?
Osteoid osteoma and osteoblastoma.
4. What is osteoid Osteoma ?
Osteoid osteoma is a benign osteoblastic lesion characterized by a well
demarcated core (nidus) of usually less than 1 cm and by a distinctive
surrounding zone of reactive bone formation.
5. What are the signs and symptoms of osteoid osteoma ?
Pain is khighly characteristic of osteoid Osteoma. The pain is
intermittent and vague but gradually increases in severity and usually
occurs at night. Aspirin usually relieves the symptoms completely.

117
Examination occasionally reveals swelling of the soft tissues, and
paopation generally reveals local tenderness.
6. Discuss the etiology of osteoid osteoma
Osteoid osteomas are usually less than 1 cm diameter and located near
the articular surface or the cortex. They are most often found in the tibia
and the femur. They occur with a male-to- ffemale ratio of 2:1. The
usual ages are between 10 to 25 years.
7. What is the treatment for osteoid Osteoma ?
Surgical treatment of osteoid osteoma involves excisin of the portion of
the cortex that contains the nidus. Some cases require removal only of
the inner nest of osteoid osteoma with through curettage of the lesion.
8. What is an osteoblastoma ?
Osteoblastoma, although histologically related to osteoid osteoma, is a
progressively growing lesion of larger size; although sometimes painful,
it kis characterized by the absence of reactive bone formation.
9. What is the clinical and radiographic presentation of an osteoblastoma
?
The pain is usually inconsistent. The lesions are greater than 2 cm in size
and grow rapidly. Radiographs reveal perifocal osseous reaction.
Osteoblastomas most commonly involve the verterbral columns and the
long bones, including the humerus, femur, and tibia.
10. What is the treatment for an osteoblastoma ?
Conservative surgical treatment consists of curettage with or without
bone graft. For lesins in the small bones of the feet, fibula and rib,
rresection of the entire bone generally yields a cure.

118
11. Name the benign cartilage- forming tumors found in the
musculoskeletal system.
Osteochondroma
Enchondroma
Chondroblastoma
Chondromyxoid fibroma.
12. What is an osteochondroma ?
An osteochondroma is a cartilage- crapped bony protrusion on the
external surface of the bone
13. Describe the clinical picture of patients with an osteochondroma.
An osteochondroma is usually symptomless unless it is kpalpable. Nerve
or artery compression caused by an enlarging osteochondroma may incite
symptoms. Tumors occur at sites with developing cartilage, such as the
end of long tubular bones. They usually grow adjacent to the cortex near
the epiphyseal cartilage plate, which is the zone of enchondral growth.
Lesions appear to grow away from the physeal line and usually increase
in size during growth spurts at puberty. The most common sites are the
distal metaphysis of the femur, the proximal metaphysis of the tibia, the
proximal end of the humerus, the distal radius, and the distal tibia. The
radiographic appearance suggests a boney excrescene jutting from the
skeleton, much like a mushroom. On gross appearance,
osteochondromas have a cartilaginous cap that varies in size from 1-40
cm.
14. What is the treatment for osteochondroma ?

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The treatment is surgical excision if the exostosis becomes large enough
to cause pain or disfigurement.
15. What complications are seen with osteochondromas ?
Chondrosarcoma may arise from the cartilage cap. This rare complication
is estimated to occur in 1-2% of cases.
16. What is an enchondroma ?
Enchondroma is a benign cartilage growth that develops within the
medullary cavity of a single bone.
17. Describe an enchondroma
Enchondroma affects both sexes equally. The tumor usually arises in the
third or fourth decade of life. Most tumors lie centrally within the bone
or subperiosteally. Enchondroma is the most common tumor arising in
thehand, an about 35% of all such lesions occur in the small tubular bones
of the hand, The femur, humerus, and ribs are less commonly affected.
Radiographs reveal lytic lesions with some stippling of calcification.
18. What is the treatment ?
Surgical intervention is clearly the preferred treatment. If the cortex
reveals expansion and thinning, curettage and bone grafting are the
treatment of choice.
19. What is the name of the syndrome of multiple
enchondromatoisis ?
The syndrome of multiple enchondromatosis is termed Illier’s
disease.
20. What is Maffucci’s disease ?

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This disease process, described by Maffucci, consists of soft tissue
hemangiomas and multiple enchondromatosis.
21. What is a chondroblastoma ?
A chondroblastoma is a primary, usually benign bone tumor of immature
cartilage cell with preferential localization in the epiphysis.
22. Discuss the clinical picture of a patient with chondroblastoma.
Patients usually have minimal symptoms, but pain and swelling may be
represent in the tumor area. Because chondroblastoma most notably occurs
in the epiphysis, some loss of joint function and muscle wasting are often
noted. Pathologic fracture is rare but may occur. The male to female ratio
is approximately 2:1 Most commonly this tumor affects patients from ages
10-30 years. Typically chondroblastomas from within the epiphyseal region
of the long bone, sometimes with extension into the metaphysis. The most
common locations, in descending order, are the femur, humerus, tibia, and
tarsal bones. The radiographic appearance is a lytic, round, or oval lesion
located in the epiphysis or extending into the neighbouring metaphyseal
region of the long bone.

22. What is the differential diagnosis of a chondroblastoma ?


Enchondroma Fibrous dysplasia
Chondrosarcoma Infection
Giant cell tumor Chondromyxoid fibroma

23. What is the treatment of a chondroblastoma ?


24. Treatment includes curettage and bone grafting, with a recurrent rate of
25%
25. What is a chondromyxoid fibroma ?
A chondromyxoid fibroma a benign tumor of bone characterized by
chondroid and myxoid growth in a llobular pattern.

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26. Describe the clinical findings in a patient with chondromyxoid fibroma.
Chondromyxoid, fibromas occur usually in the lower extremity in the distal
metaphysis of the femur, fibula, and tibia. Radiographic findings include a
well-defined lytic border with a sclerotic lesion that sometimes is described
as’ bite like.

27. What is the differential diagnosis of chondromyxoid fibroma ?


Giant cell tumor of bone Chondroblastoma
Unicameral bone cyst Fibrous dysplasia
Enchondroma Ancurysmal bone cyst.
28. What is the treatment for chondromyxoid fibroma ?
Treatment includes surgical resectin with bone grafting. Approximately 10-
15% of tumors recur.
29. What is a giant cell tumor of bone ?
Giant cell tumor lof bone is an aggressive lesion characterized by well
vascularized tissue made up of plump, multinucleated giant cells.
30. Describe the patient who presents with a giant cell tumor of bone.
Patients have physical findings related to the involved bone, including
intermittent aching painl local swelling, tenderness, and limited motion.
Eighty percent of the giant-cell tumors kbone occur in patients older than 20
years. The average is approximately 35 years. Women are affected slightly
more often than men (3:2 ratio ) Seventy five percent of giant cell ltumors
are situated at or near the articular end of a long tubular bone, including the
distal femur, proximal tibia and fibula, and distal radius.
31. What is the radiographic appearance of a giant cell tumor of bone ?
Giant cell tumors are slightly concentric to the long axis of the tubular bone near
the epiphyseal end. Trabeculation is found near the periphery of the lesion.
Pathologic fractures may occur after cortical erosion. The overlying cortex is
usually thin with a well- developed sclerotic outline.

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32. What is the differential diagnosis of a giant cell tumor lof bone ?
Chondroblastoma Brown’s tumor of hyuperparathyroidism
Non ossifying fibroma Fibrosarcoma
Chondromyxoid fibroma Osteogenic sarcoma.

33. What is the microscopic appearance of a giant cell tumor ?


The hallmark of a giant cell tumor is the presence of a large numbers of giant
cells, which are separated by stromal cells with an indistinct cellular outline.
34. Describe the clinical behavious of giant cell tumors.
Giant cell tumors can be classified as benign, semimalignant, and malignant. The
local recurrence rate is approximately 30% after surgical curettage. The tumor
recurs usually within the first 2 years after surgery. Because of its proximity to
the articular cartilage, it is difficult to perform an interlesional excision of a giant
cell without leaving tumor cells behind.
35. What is a chondrosarcoma ?
A chondrosarcoma is a malignant tumor in which the basic neoplastic tissue is
fully developed cartilage, directly formed by sarcomatous stroma.
36. Describe the types of chondrosarcomas.
1. Primary chondrosarcoma may arise in previously normal bone.
2. Secondary chondrosarcoma develops from a pre-existing benign cartilage
tumor, such as an enchondroma.
37. Deswcribe the clinical findings in a patient with chondrosarcoma.
Pain is the most common symptom in patients with chondrosarcoma. Tenderness
is usually present with pain. A painless tumor mass of a long-standing nature
may be the presenting symptom. Chondrosarcoma is seen in a wide age group
ranging from 11-70 years. The most common sites are the pelvis, femur, ribs,
and shoulder gridle.
38. What is the radiographic appearance of a chondrosarcoma ?

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There may be evidence of the original benign primary lesion. Radiographs show
a fuzzy infiltration tumor.

ARTHRITIS OF THE ELBOW


1. What are the presenting complaints of a patient with osteoarthritis of the
elbow ?

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1. Impingement pain at the end of motion, usually greater in extension that in
flexion.
2. Pain after a snort period of carrying heavy objects, such as a shopping bag or
suit case.
3. Increasing pain proportionate with use of the elbow.
4. Progressively worsening motion inthejoint.
2. Describe the epidemiology and presenting history.
Most patients present between the third and eighth decades of life and have a
history of previous severe fracture or dislocation of the elbow, repetitive trauma
to the elbow, or an occupation that requires heavy physical exertion with the
upper extremities, such as squeezing a hammer or operating a jackhammer.
3. What are the findings of the physical examination ?
A flexion contracture is usually present with additional loss of flexion. Bony
crepitance is palpable with flexion/extension and pronation/supination.
Tenderness is elicited on forced extension and flexion at the terminal ranges of
motion.
4. What is the radiographic appearance of osteoarthrosis of the elbow ?
Anteroposterior and lateral views of the elbow typically demonstrate
osteophytes of the olecranon and coronoid as well as in the coronoid and
olecranon fossa. Loose bodies are frequently present.
4. List the surgical procedures available for osteoarthrosis of the elbow.
1. Elbow arthroscopy with synovectomy and removal of loose bodies is
indicated
When an identifiable loose body restricts range of motion and cause pain.
Synovectomy in the rheumatoid elbow is indicated only in the early stages
of disease.
2. Anterior capsulectomy is kindicated when severe flexion contracture has
developed, but the arthrosis is not severe.

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3. For open decompression of impinging areas, various procedures have been
described.
4. Interposition/distraction arthroplasty
5. Total elbow arthroplasty.
6. Excisional arthroplasty.
7. Arthrodesis.
6. What is total elbow arthroplasty ?
Total elbow arthroplasty involves replacement of the articulating surfaces of the
distal humerus and the proximal ulna of the elbow. The radial head is not
included in the reconstruction.
7. When is total elbow contra indicated ?
Active infection in the joint is an absolute contraindication. Relative
contraindications are young patients with an active life style or heavy laborers
unwilling or unable to alter their lifestyle.
8. Describe the available biomechanical designs of total elbow arthroplasty.
What are their relative benefits and disadvantages ?
1. The fully constrained design incorporates a direct link between the ulna and
humeral components. This design allows little dissipation of forces with
range of motion at the elbow joint. The forces therefore are transmitted
through the implant-cement-bone interface, which results in mechanical
loosening and an unacceptably high failure rate. Fully constrained total
elbow prostheses, which were the original design, are no longer indicated.
2. The semiconstrained design is also termed ‘loose hinge’ because of amount
of motion allowed in the joint. These devices have an axle and hinge but
allow approximately 10 0 of varus, valgus, and rotational laxity in their
articulation. The semi-constrained design has lessened dramatically the
mechanical loosening rate and is currently the preferred design for most
elbow arthroplastics.

126
3. The nonconstrained design resurfaces the distal humerus and proximal ulna
with anatomic contours. There is no hinge or snap-fit articulation. Stems are
attched to improve fixation to bone. Nonconstrained designs are also
referred to as ‘ resurfacing’ and ‘minimally constrained’ arthroplasty
because of their conforming nature. This design has the lowest rate of
mechanical loosening. Instability is the main disadvantage; dislocation,
subluxation, or maltracking is a problem in 5-20% of cases. Nonconstrained
prostheses require meticulous soft-tissue balancing to succeed.
9. What are the major complications of total elbow arthroplasty ?
1. Loosening 9largely overcome by the use of intramedullary stems and
avoidance of fully constrained systems )
2. Instability, including dislocations, subluxations, or maltracking
(predominantly with the nonconstrained designs )
3. Infection
4. Ulnar nerve injury
10. Identify the three main technical considerations in elbow arthroplasty.
1. Arthroplasty is usually performed through a posterior approach. The ulnar
nerve must be explored and transposed anteriorly.
2. Careful attention must be given to soft-tissue balancing, especially with the
minimally constrained design.
3. The ulnar aspect of the lateral collateral ligament must be rrepaired to
prevent post operative instability.
11. What are the results of total elbow arthroplasty ?
Ninety percent of patients are highly satisfied kwith pain relief. Overall, motion
is increased 90% in flexion, 0% in extension, and 60-70% in pronation
andsupination. Survivorship analysis predicts a failure rate of approximately
20% at 10 years.
12. What is excisional arthroplasty of the elbow ? What are the relative
indication ?

127
Excisional arthroplasty is removal of the intra-articular osseous structures of the
elbow joint. It is usually performed after a failed total elbow arthroplasty.
Results are better when the condyles of the humerus are present. If a fail elbow
results, usually the elbow becomes non-functional.
13. What are the indications for arthrodesis of the elbow ?
Arthrodesis of the elbow is an unsatisfied operation for both the patient and the
surgeon. It is usually performed for intractable sepsis about the elbow or when
no other reconstruction technique is possible. There is no optimal position of
flexion in which to fuse the elbow, and significant limitations in accomplishing
activities of daily living usually follow arthrodesis of the elbow.
14. What are the main differences in the presenting complaints of patients with
rheumatoid arthritis versus osteoarthritis of the elbow ?
Patients with rheumatoid arthritis complain of pain with instability in the joint,
which, in 90% of cases, is exacerbated by involvement of the ipsilateral
shoulder and wrist. The patient afflicted with osteoarthritis complain of loss lof
motion with pain, which restricts the ability to work and to perform activities of
daily living.
15. What is the normal history of rheumatoid arthritis in the elbow ?

1. Synovitis is the first, prominent pathologic kprocess. Biomechanics remain


normal. Osteoporosis is present but without gross articular destruction.
2. Joint narrowing occurs with progressive worsening of the osteoporosis.
3. Joint architecture is distorted with loss of lcontour of the joint Osteoporosis
worsens. Subchondral cysts form and clinical complaints of instability
begins.
4. Finally, gross joint destruction results in loss of articular surfaces and gross
instability of the joint.
16. What are the surgical optins for treatment of rheumatoid arthritis of the
elbow ?

128
1. Radial head excision
2. Inter position arthroplasty
3. Distraction arthroplasty
4. Total elbow arthroplasty
17. Name three available surgical procedures for treatment of rheumatoid
arthritis of the elbow.
1. Arthroscopic synovectomy.
2. Radial head resectin with or without Silastic head implant.
3. Total elbow arthroplasty.
18. What are the indications, and disadvantages of radial head resection ?
Resection is recommended for pain relief when a radiocapitellar joint is
involved and the ulnohumeral involvement is relatively mild or moderate. This
procedure is recommended for pain relief and not for increased motion. Motion
postoperatively is highly variable, with 50% of cases unchanged, 30%
improved. And 20% exacerbated. Follow up at 5 years shows an
approximately 75% success rate. Radial head resection is not offered as a long-
term solution to the rheumatoid patient, because the diseases process most likely
will progress in the joint.
19. What is the current role of Silastic radial head replacement in elbow surgery
?
Although Silastic radial head replacement is advocated by a few authors, the
increasing concern about silicone particular synovitis and lymphadenitis with a
subsequent autoimmune response has lessend the enthusiasm. The procedure is
currently not recommended by most elbow surgeons.
20. What is interposition/distrctin arthroplasty of the elbow ? What are its
indications ?
Interposition arthroplasty refers to resecting the diseased articulating surfaces
and filing the joint with interposed materials, thereby relieving pain. Many
materials have been tried in the past, such as ivory ;egs, lanolin, and ccluloid.

129
Most recently, materials such as muscle flaps, fascia, skin, gel foam and fat
have been used. External fixators are placed at the elbow to allow distraction
technique is not universally accepted and because of its technical complexity is
used by relatively few surgeons. Interposition arthroplasty is preferred in a
heavy labourer. Disadvantages include unpredictable pain relief and
unpredictable effects on instability. This procedure is used in select patients
who want to avoid elbow arthrodesis or total elbow arthroplasty.

21. What is Arthrolysis ?


It is a treatment for stiff elbow, described by Dr. S. Bhattacharya, it involves
release of all the soft tissue and removal of debris of the joint, through medial
and lateral incision and followed by a vigorous physiotherapy.

ORTHOSES
Science which deals with appliances used for preventin of a
deformity, correction of a deformity, creating a support and
dynamics.

SPINAL, ORTHOSES
FUNCTION Supportive and corrective
Relieves pain, support muscles and unstable joints,
immobilises vertebral column in best functional position.
TYPES
Supportive – e.g. belts/corsets
Corrective – e.g. Milwaukee brace
(A) Neck

130
CERVOCA; CP;;AR – HISTORY –devised by Thomas, he
used sheep skin
PRINCIPLE – Any item which maintains neck in physiological posture
MODIFICTION – Polypropylene
- Shoulder strap.
B) THRACIC SPINE
No brace or corset needed, stability by rib cage for Thoraco
Lumbar/Lumbo sacral area -> Taylor’s Brace may be used.
C) LUMBAR SPINE
BRACE - frame of metal encircles body e.g. Thomas, Taylors,
Goldwaith
CORSET – back support strengthened by few metallic bars but no
frame, used where do not require perfect mobilisation.
BELT - No stiffner, soft material goes across the body
TAYLOR’S BRACE – (1863 c.f. Taylor )
Anterior hyuper extension, rigid orthoroses with a metal frame having
firm foundation on pelvis by a pelvic band and a pelvic corset. The
postero lateral part is made of metal alongwith upright attached metals
supportive on each side of spinous process acting as back levers,
alongwith horizontal cross bar extending laterally and anteriorly in
thoracic region and infra axillary. Abdominal support and shoulder
support is also provided.
INDICATION - Treatment of T.BSpine
SITE - Thoraco lumbar

131
ADVANTAGE - Limits forward flexion, extension and lateral flexion
with some degree of rotation
DISADVANTAGE - Increase lumbosacral joint movements.
ANTERIOR HYUPER EXTENSION BRACE (baker 1942) :
Rectangular frame fits on front of thorax.
MOULDED SPINAL ORTHOSIS : fits in contour of trunk, distribute
weight over large area made of POP or plastizott.
CORRECTIVE SPINAL ORTHOSIS
MILWAUKEE’S BRACE
(Blount and Schemidt )
INDICATIONS – Scoliosis, Ankylosing Spondylitis, Tuberculosis.
FEATURES – Moulded leather corset
Metal side bars two metal vertical bar posteriorly
Pass upward to a ring which is 20 0 to horizontal
anteriorly, with submental pad
Leather strap on posterior bar on convex side.
ADVISE TO PATIENT – wear cotton, keep clean, skin massage,
continuous waring
COMPLICATION – Meralgia
CORSET – Supportive spinal orthosis, fabric orthosis kwith posterior
metal strips only restricts movements subjective support does not
immobilise.
LUMBO SACRAL CORSET - 20 to 40 cm in width extends upto
thoraco lumbar junction, fulcrum strap passes around pelvis, metal
strips incorporated for strength and rigidity.

132
REQUISITES – Does not interfere with movements of hip and pelvis,
does not ride upwards, comfortable, Posterior metals along the curve of
spine.
THORACO LUMBAR CORSET – Fabric orthosis with added shoulder
strap extends over scapulae.
LOWER LIMB ORTHOSIS
FUNCTION : Relieves weight bearing and pain, control deformity and
movements.
TYPES : Weight relieving used where decreased weight transmission is
needed through the bone. Body weight supported on a ring top. Weight
transmission through metal bars. Non weight relieving- ring merely
locates upper end of side bar.
TERMINOLOGY OF ORTHOSIS IN LOWER LIMB – Hip, knee,
ankle and foot are denoted as H.K.A and F respectively.
F – Free Movements free
A – Assisted – Movements withexternal force
R – Resisted – Decrease some movement by external force
S – Stop- Static inclusion
H. Hold – To hold part in specific positin
V- Variable – adjustable attachment.
L. Lock- for locking
PARTS OF STANDARD KAFO – Leather top- cuff, ring bucker top
Metal Bars.
Knee pieces – anterior and posterior
Ankle strap

133
Clongs/ Boots.
HKAFO - Orthosis crosses the hip, so a pelvic band is needed. The
band provides movement only with flexion and extension.
LSHKAFO – add a lumbo sacral support
LOCKS - At level of knee joint it has ring lock system. The axis of
joint is eccentric prevents anterior edging when joint is flexed. Ring
pulled up to allow knee to flex and push down when extended.
SPRING RING LOCK – automatic rods with coaxial springs released
during extension. Swiss lock – most commonly used nowadays. A bar
lock type system locks on extension by pulling on a strap attached to
posterior bar.
NON LOCKING ORTHOSIS – Posterior offset knee joints for
cosmetic appliances in flial lower limb. Access of movement of joint
posterior to flexion extension of knee. Used also in children.

OTHER KNEE ATTACHMENTS – Anterior strap for mild fixed


flexion deformity. Posterior strap for recurvatum.
ANKLE JOINT AND FOOT – Constructs are made to allow flexion
extension or limit both requires stirrups heal sockets. Access of
movement of appliance does not correspond with that of ankle.
For example – Varus inside iron and outside T strap is used and reverse
for a valgus deformity. Add a strap for rotation.
EQUINUS – Toe raising devices are used to abolish high stepping
GAIT and tripping over uneven ground. Back stop constructs, control
plantar flexion.

134
CARE OF ORTHOSIS
Avoid dropping
Examine pressure points
Ciean the dirt
Oil the joints
Keep heal and sole proper and repaired.

1. Define Orthosis
It is an appliance when added to the patient to enable better use to be
made of the part of body to which it is fitted.
2. Define Prosthesis
An appliance which is added for a missing part of the body in a
patient.
3. What are functions of Orthoses ?
It provides stability
Overcomes Weakness
Relieves pain
Controls deformity
4. What are prerequisites of Orthoses ?
It must be strong
Light
Simple
Easy to apply
And manipulation is possible.
5. What is a Caliper ?

135
It is an orthoses for lower limb used permanently or short duration
of time for stability of weak limb
Relieve weight bearing
Relieve pain
Restrict movements of joint
6. How does a weight relieving KAFO differ from Non-weight
Relieving ?
The body weight in weight relieving type is transmitted from Ischial
tuberosity to padded ring or lether top through metal side bars to the
shoe.
7. What is a Surgical Shoe and how it differs from a boot ?
SHOE BOOT
- Deformity limited to forefoot - Hind foot
- Less better - Grip better
- UptoMid Tarsal joints - Lacing extend upto toes
For entry of foot.
A. Collars.
8. What are the pressure points of a cervical collar ?
Pressure must be taken against
(a) Occiput
(b) (b) Lower margin of mandible
9. Why are collars not proper means of immobilization ?
They do not provide absolute immobility of cervical spine, unless
purchase is taken on the skull and dorsal vertebrae.
10.How do you measure size of collar ?

136
- Circumference of neck
- Distance between angle of jaw and clavicle.
11.For what vertebral level immobilization, collars are used ?
For Lesion between C3-C7 vertebra and these are the common level
of lesion also.
12.What are principles of use of Cellars ?
They provide some degree of distraction between vertebra and
provide shaping of vertebral column
13.What are complications of collars ?
- Redness over clavicles and angle of jaw
- Roughening of skin and dermatitis
14.What is a Four Post Cervical Collar ?
It is used for better immobilization is cervical lesions, as it as
- Occipital support
- Cupped plate for chin rest
- Back andchest support with straps for shoulder
15.What is SOMI Brace ?
Sterno, Occipito, Mandibular Immobilizing brace. This also has
similar principle as Four Post collar. It has no back plate so patient
can be flat without discomfort.

137
CORSETS AND BRACES

1. Define Corsets
An appliance madeof fabric with metal stiffeners but without a metal
frame and almost encircles the body.
2. What is a brace ?
An appliance consisting of metal frame which encircles or largely
encircles body and may be supplemented by fabric.
3.What is an essentials feature of brace ?
- It encircles body
- Gains firm basis round the pelvis, with metal extensions in various
directions.
4. How does a corset function ?
It does not provide much corrective forces but relies on its efficiency on
tightness.
5. What are contraindications of use of corsets ?
- Hiatus Hernia
- Pregnancy

138
- Defect of Diaphragm or pelvic floor because there occurs
redistribution of body weight because of intra abdominal
compression.
6. What is principle of use of corset ?
- The Redistribution of body weight occurs, the soft
abdominal wall is approximated to Rigid Vertebral column
thus shifting the centre of Gravity towards spine.
- The compression of Abdomen tends to lengthen the abdomen and it
decreases the ability to flex the spine.
7. For a Lumbar Corset, what should be the size of inseris ?
It should be ideally 13 cms at upper margin and 8 cm over sacrum.
8. What should be the height of a Lumbar Corset ?
It should be measured from symphisis pubis to costal margin.
9. What is a Goldwaith Corset ?
Fabric with steel inserts at 10 cms and rigid stiffners at sacroiliac joint
and lumbar spine. It restricts rotation and forward or lateral flexion by
tension material.
10.How do spinal braces function ?
A firm foundation is achieved by strapping round the pelvis just above
Greater Trochanter by metal straps hinged to Lumbar frame. The frame
extends up the spine is know back lever. Fabric support is added and it
acts as a corset. Straps from this encircle shoulder and this combination
greatly restricts flexion of lumbar spine.

11.What are the limitatioin of spinal braces. ?

139
- Direct fixation to bone is kimpossible
- Movement of soft tissue and skeleton cannot be prevented.
- Skin is not able to withstand forces applied to it.
12.What is a Goldwaith Brace ?
It has encircling bars fixed to the posterior frame in two third of
circumference.
13.What is the ideal height of Taylor’s Brace ?
The shoulder extends from D3 vertebra to the pelvic band at public
symp.
14.What are moulded braces ?
Braces made to a plaster cast and reinforced with Leather and metal
or Polyethylene braces made on the patient.

140
APPLIANCES FOR NERVE PALSIES
(A)

1. For Median Nerve Palsy, what would you prescribe as Orthoses ? Why
?
The main practical problem is loss lof abduction and opposition of thumb
and most patients can carry out most tasks provided the thumb can be
maintained in that position so opponens splints are used, which has two
spring wires joined by a plastic though and Aluminum straps. The two
parallel parts of wire be on either side of Index finger at level of proximal
phalanx and Distal Inter phalangeal joint at one end and on Proximal
phalanx of thumb.

2. For Ulnar Nerve Palsy, what would you prescribe and why ?
In hand there is hyperextension of Meta carpophalangeal joint and flexion
of Interphalangeal joint, so a " Knuckle duster splint is used which has two
metal strips of 1 inch wide flat dorsum and palmar side at Level of
Proximal phalanx and metacarpals respectively.

3. In combined palsy of Median and Ulnar Nerve what modification


would you advice ?
A thumb abductor along with knuckle duster splint is ued.
4. What splint is used for Radial palsy and why ?
If the wrist can be held in slight dorsiflexion, intrinsic muscles well extend
interphalangeal joint and meta carpo phalangeal joint in flexion, thus
providing sufficient tendon excursion. So we use cock-up splints which
may be static or dynamic. The dynamic splint - helps to improve grip by
improving flexion of fingers in dorsiflexed wrist.

5. What is a foot drop splint ?

141
DIAGNOSTIC RADIOLOGY

1. What are the usual radiographic views for evaluating


shoulder problems?

The anteroposterior view is the most common; it may be

taken ina neutral position or in internal and external


rotation.

A transthoracic latral view or axillary view assesses

positioning of the humeral head in the glenoid.

2. Which is morecommon- anterior or posterior dislocations


of the shoulder/

Anterior dislocations are much more common, occurring


in

approximately 95% of cases, whereas posterior


dislocations

occur in 5%.

3. What radiographic examination best differentiates


anterior and posterior dislocations?

Anterior and posterior dislocations are best differentiated


by

an axillry view of the shoulder. The x-ray beam is


directed

142
from an inferior position through the axilla to a superior

plate.

4. What is a hills-Sachs lesion?


A Hill- sachs lesion is a defect of the posteriolateral
aspect of

the humeral head. It occurs with anterior dislocation of


the

shoulder when the posterior superior surface of the


humeral

head impinges on the anterioinferior portion of the


glenoid.

The Hill-Sachs deformity is easily visualized by

antroposterior view of the shoulder with the arm in full

internal rotation.

5. What is a Bankart lesion?

A Bankart lesion is an avulsion of the anterior capsular

structures with a fragment of bone. This lesion is the

hallmark of radiographic findings for recurrent


dislocations

143
of the shoulder. It is best seen on an axillary view of the

shoulder.

6. What is the radiographic appearance of an


acromioclavicular dislocation?

An acromioclavicular dislocation is a disruption of the

coracoclavicular and acromioclavicular ligaments. The


space

between he clavicle and the coracoid is widened.

Dissociation of the acromioclavicular joint is complete,


and

the clavicle is displaced superiorly in comparison with


the

acromion. The best view to visualize and


acromioclavicular

dislocation is attained with the patient holding 10-15


pounds

of weight in each arm. Anteroposterior radiographs are


then

taken simulataeously of the affected and nonaffected

acromioclvicular joint.

144
7. What radiographic view is used to evaluate Impingement
syndrome?

The supraspinatus outlet view is used to evaluate

Impingement syndrome. In this view the patient is


positioned

for the scapular lateral radiograph, and the tube is angled

inferiorly at approximately 10. This view shows the

morphology of the acromion for the treatment of

impingement syndrome.

8. What are the most common views for evaluating elbow


symptoms?

Anteriposterior and lateral radiographs are most


commonly

used.Fractures are common around the radial head with

trauma. Loose bodies may be identified in the olecranon

fossa or anteriorly in the anterior joint. Osteochondritis

dissecans may bye seen as irregularities along the


capitellum.

9. Is it normal to visualize the anterior fat pad on latral


radiographs of the flexed elbow?

145
The normal anterior fat pad appears as a lucid strip

paralleling the anterior margin of the supracondylar


region. If

the anterior fat pad has assumed a “sail-shaped”

configuration, the elbow capsule is disteneded. This


finding

signifies recent trauma, most likely aheamarthrosis. The

normal anterior fat pad appears as a lucid strip


paralleling the

anterior margin of the supracondylar region. If the


anterior

fat pad has assumed a “sail-shaped” configuration, the


elbow

capsule is disteneded. This finding signifies recent


trauma,

most likely aheamarthrosis.

10. It it normal to visualize a posterior fat pad on


lateral
radiographs of a flexed elbow?

The posterior fat pad is not visible on routine lateral


views of

146
the flexed elbow. Visualization of the posterior fat pad

idicates capsular distension, most likely due to


hemarthrosis

and often caused by a nondisplaced radial head fracture.

11. What radiographic examination is invaluable for


evaluating patients with rheumatologic diseases?

An anteropostrior radiograph of the hand shows many


joints

of the wrist and phalanges. Rheumatoid arthritis has a

predilection for an entire wrist and metacarpophalangeal

joint. Osteoarthritis generally affects the interphalangeal

joints and the first carpometacarpal joint. Erosive

osteoarthritis is characterized by interphalangeal joint

destruction with subluxation and severe erosions.

Raqdiographs of patients with calcium pyrophosphate

dehydrate deposition disease (CPDD) may show small

subchondral cysts and interarticular soft-tissue


calcification,

147
most notably over the radial styloid and triangular

fibrocargilage. Erosions in gout may show a


characteristic

overhanging margin.

12. What radiographic studies should be taken for


evaluation of hip disease?

An anteroposterior view of the pelvis, not just the


affected

hip, should be taken. This view gives clues to the


diagnosis

of other disease processes by visualizing the pelvic


bones,

lower portion of the spine, sacroiliac joint, and pubic

symphisis. Join changes may give clues to diagnoses


such as

ankylosing spondylitis and rheumatoid arthritis. Bone

destruction commonly occurs in the pelvis of patients


with

metastatic disease or multiple myeloma. Fractures


generally

occur in the ring of the pelvis and can be seen in the

148
contralateral iliac crest and pubic and ischial rami.

13. What are the standard radiographs for evaluation of


knee pathology?

The standard radiographs are antroposterior and lateral


views

of the knee, which show the metaphyseal bone of the


femur

and fibula joint surfaces and the surrounding soft tisues.


A

tunnel view shows the inercondyalr notch and may


visualize

loose bodies not seen on the anteroposterior radiographs.


It is

alos the best view to see osteochondritis dissecans of the

medial or lateral femoral condyles. A sunrise or


Hughston

view shows subluxation of dislocations of the patella


from

the trochlear groove.

14. What is a Segond fracture?

149
A segond fracture is an avulsion fracture of the capsular

ligament on the lateral side of the tibia, best seen on the

anteroposterior view of the knee. It is highly suggestive


of an

anterior cruciate ligament tear, because the two are

commonly associated.

15. Which radiographs are used in evaluation of the


ankle injuries?

Anteroposterior and lateral radiographs are used in

conjuction with a mortise view, an oblique view with

approximately 20-30 of internal rotation that attempts to

show the ankle mortise. The medial and lateral malleolus


are

on the same plane in the mortise view, which can be used


to

evaluate the congruity of the talus as it sits adjacent to


the

medial and lateral malleolus and the tibial plafond.

16. What talar abnormalities are seen on ankle


radiographs?

150
Fractures of the talar neck or talar dome may be seen on

ankle radiographs. Dome fractures are usually related to

inversion or eversion injuries and occur on the


superolateral

or superomedial portion of the talar dome. The


radiographic

appearance suggests a small, separated fracture. Dome

fractures are sometimes best visualized on an


antroposterior

film in full plantar flexion.

17. What radiographic abnormality is seen in patients


with peroneal tendon dislocations?

Peroneal tendon dislocations involveavulsion of the

osteocartilaginous attachment of the peroneal tendon


sheath

to the fibula. The result is a small avulsion fracture that is

best seen on the posterolateral cortner of the distal fibula.

This fracture is the hallmark of the radiographic


appearance

151
of peroneal tendon subluxation.

18. D escribe the radiographic features of an inversion


injury
With inversion injuries of the foot and ankle, avulsive
forces

affect the lateral structures and compressive forces affect


the

medial structures, lateral injuries may consist of a sprain


of

avulsion of the lateral ligamentous complex, neither of


which

is apparent on radiographs. If, however, a fracture is

involved, it is usually a transverse fracture in which the

ligaments have been avulsed with bone. Fractures appear


on

the anteroposterior and oblique views, medial injuies


with

inversion sprains may show an obliue fracture of the


medial

malleolus. In general, oblique fractures are usually du to

compressive forces and transverse fractures to avulsion

152
forces.

19.Describe the radiographic appearance of an eversion


injury of the ankle

With eversion injuries of the foot, avulsive forces act on


the

medial structures and compressive forces on the lateral.

Depending on the rotation involved, a sprain or avulsion


of

the medial deltoid ligament may occur, neither is


apparent on

radiographs. However, if a fracture is involved, it is


usually a

transverse fracture of the medial malleolus below the


ankle

mortise. Latral injuries consist of an oblique or spiral


fracture

of the lateral malleolus with rupture of the syndesmosis.


The

tibiofibular ligament may rupture with a without a


fracture of

the fibula.

153
20.What is a Jones fracture?

A Jones fractureis a transverse fracture of the proximal


fifth

metatarsal shaft. The fracture is located approximately


1.5-

2cm distal to the tip of the metatarsal and usually is a


stress

fracture. It is differentiated from a styloid fracture, which

occurs in the metaphysic, on an oblique view of the foot.


The

normal apophysis may not be entirely fused in children


and

may give the appearance of a fracture.

21.What types of stress fractures are seen?

Stress fractures generally can be divided into two


categories:

fatigue fractures and insufficiency fractures. Fatigue


fractures

are due to repetitive prolonged stress on normal bone.

Insufficiency fractures result from normal stresses on

154
abnormal bone, such as that in osteomalacia or
osteoporosis.

22.Name the common sites for fatigue stress fractures


Tibial shaft Calcaneus

Midfibula Patella

Pubic ramus pars interarticularis

Metatarsals

23.Name the major predisposing conditions for


insuffieiency fractures.

Osteomalacia Fibrous dysplasia

Paget’s disease Osteoporosis

Radiation Hyperparathyroidism

24.What is the radiographic appearance of a stress fracture?

Stress fractures generally are seen as transverse fractures


in

the shaft of the bone. Stress fractures of the metatarsals


may

be seen as a slight, thin, radiolucent line, whereas in


larger

155
bones, such as the tibia or the femur, they are better

visualized. Some fractures h\show no lines, but only


signs of

healing, such as new bone formation. Often callus


formation

is abdundant in metatarsal fractures but minimal in


fractures

of the tibia and femur.

25.What is avascular necrosis?

Avascualr necrosis, also known as osteonecrosis, is bone

death caused by vascular insult. The vessels may be


damaged

directly by trauma or occluded by emboli or elevated


marrow

pressure. The most common sites include the hips,


shoulder,

medial femoral condyle, and talus.

What are the common causes of avascular necrosis?

Steroids Sickle-cell disease Emboli

156
Alcohol abuse Lupus erythematosus Caisson’s disease

Congenital Radiation therapy


Pancreatitis,Fracture
Problems and Gaucher’s m
disease.

26.Which radiographic features suggest a slow-growing or


benign process?

 Preservation of cortical margin


 Well-Demarcated boundary of the lesion
 Sclerotic margin
 Solid, uninterrupted periosteal reaction
 Little or no soft-tissue mass, except in acute
osteomyelitis

27.What are the radiographic findings in patients with


osteonecrosis?

In the early stages radiographs may be nondiagnositc;


bone

scans may be the only positive test. In the later stages,

radiographic chanes include (1) bone cysts with sclerotic

changes in the bone (2) subchondral collapse, with or

without flattening of the articular surface; 93) narrowing


of

157
joint spaces; and (4) other degenerative signs.
Degenerative

changes may be minimal but generally progress to


include

joint space narrowing, osteophytes, subchondral cysts,


and

subchondral sclerosis.

28.List the common radiographic features of a malignant


bone lesion.
 Cortical erosion and destruction
 Irregular periosteal reaction, including sunburst,
onion peeling, and Codman’s triangle.
 Indistinct boundaries of the lesion, which seems to
permeate into the adjacent soft tissue and bone.
 Absence of sclerotic margin.
 Associated soft tissue mass

29.What is Codman’s triangle?

Codman’s triangle is a radiographic patern, usually found


in

patients with infection or tumor. When infection or


tumor

elevates the periosteum of the bone, a gap occurs


between the

158
periosteum and bone. Where the gap is elevated, bone is

formed, creating a triangular shape on radiograqphs.

Codman’s triangle, which denots soft=tissue extension of


the

tumor or infectious process, was first described in 1914


by

Rubbert. Although long considered to be a manifestation


of

malignancy, codman’s triangle may result from any


disorder

that lifts the periostum, whether benign or malignant.

30.What is a pathologic fracture?

A pathologic fracture occurs when the bone has been

weakened by infection, neoplasm, or metabolic bone


disease.

Common causes include benign tumors, osteomyelitis,


and

tuberculosis.

31.What are radiologic features of acute osteomyelitis?

159
The earliest sign may be blurring or obliteration of soft-
tissue

fat planes. Soft-tissue changes are followed by

intramedullary destruction, usually in a permeative


pattern.

Subsequent findings are cortical destruction, endosteal

scalloping, and periosteal reaction. Radiographic changes


lag

behind onset of infection by 10-14days.

32.What is the study of choice in diagnosis of suspected


acute osteomyelitis?

Initial radiographic findings may be nonspecific. A 3-


phase

bone scan is useful in diagnosing early acute


osteotomyelitis.

Increased acitivity on perfusion, blood pool, and delayed

images in the areas of bony involvement are compatible


with

a diagnosis of osteomyelitis.

33.What is a Charcot joint?

160
Charcot joint, also called neuropathic joint, occurs in
patients

who have neurologic neurophathy secondary to diabetes

mellitus, paraplegia, syphilis, leprosy, and various other

peripheral neuropathies. Patients generally have lost

sensastions of pain and proprioception, but motion is

maintained. Subtle fractures occur, along with significant

degenerative changes. Radiographic features include


joint

destruction, significant amounts of bony debris from

fractures an loose bodies, and disorganization of the joint

with subluxation and dislocation.

34.What is the initial film to obtain in evaluating a patient


for cervical spine trauma?

The first film to obtain is a cross-table lateral view, All


seven

cervical vertebrae and the upper thoracic vertebrae need


to be

161
visualized. The cervicothoracic junction is a common site
of

traumatic injury.

35.If the cross-table lateral view is normal, is further


imaging needed?

Yes. Minimal evaluation of the cervical spine must


include a

latral view, an anteropostrior view, and a view of the

odontoid. Significant injuries may not be visible on the

lateral film because of their orientation.

36.what is the Salter-Harris classification for epiphyseal


fractures?

Type I Epiphyseal plate separation- the fracture


line
is in the cartilage and is not visible
radiographically.

Type II A fragment from the metaphysic is


associated with the epiphyseal plate
fracture,
this is the most common injury.

Type III The fracture runs through the epiphysis


and
growth plate.

162
Type IV A vertically oriented fracture extends
through the epiphysis and growth plate
into
the metaphysic, growth arrest and joint
deformities are possible complications.

Type V – Crushing injury to the epiphyseal plate; a


frequent complication is shortening or
ngulation of the bone due to premature
closure of the epiphyseal plate.

NUCLEAR MEDICINE

1. What is nuclear medicine?

Nuclear medicine imaging studies physiology through

administration of radiolabelled drugs. Selection of


radiolabelled

163
drugs extracted by specific organs allows observation of
how

the organs function through recorded images of activity

distribution.

2. What is a bone scan ?

A bone scan uses a physiologic marker to detect

abnormalities of bone metabolism. The imaging agents


used

are radiolabelled phosphorus based compounds.


Depending

on the clinical indication, imaging may include the whoe

body or be limited to a specific region.

3. What is a 3-phase bone scan?

A 3-phase bone scan consists of the following:

1. A radionuclide angiogram centred over the area of


interest and performed during injection;

2. Blood pool images of the area of interest obtained


after injection; and

3. Delayed images obtained 2-3 hours after injection.

164
4. What are the scintigraphic features of osteomyelitis?

A 3- phase bone scan is needed for evaluation of possible

osteomyelitis. If osteomyelitis is present, the


radionuclide

angiogram reveals focally increased blood flow. Blood


pool

and delay images also show increased acitivity, which is

more focal on the delayed scans.

5. What scintigraphic features distinguish osteomyelitis


from cellulites?

On a 3-phase bone scan cellulites presents as increased

acitivity on the perfusion (radionuclie angiogram) and


blood

pool images. Normal acitivity is demonstrated on


delayed

images. Osteomyelitis has abnormal activity in all three

phases.

6. What additional nuclear medicine examinations may be


performed if bone scan findings for osteomyelitis are
equivocal?

165
Gallium-67 citrate and leukocytes labeled with idium
111 are

useful in the diagnosis of inflammatory and infectious

disease of soft tissue and bone. Labelled white blood


cells

have a lower sensitivity than gallium in detecting chronic

osteomyelitis.

7. Name three bones that are studied more effectively with


nuclear medicine than with plain film in cases of trauma.

Nuclear medicine is more effective than plain film for


studies

of the three S’ssternum, scapula, and sacrum.

8. What does the H-shaped patern of increased activity in


the sacrum indicate?

Bilateral linear areas of increased acitivity in the sacral


alae

with tranverse increased activity in the mid sacrum are

characteristic of sacral insufficiency fractures.


Osteoporosis

is the most common underlying etiology.

166
9. Which is the more sensitive in the detection of stress
fractures plain film or bone scan?

Bone scan is more sensitive in the detection of stress

fractures. If the stress injury is acute, angiogram and


blood

pool imaes show increased uptake. In both acute and

subacutes stress fractures, delayed images show


increased

uptake. The activitiy is focal and corresponds to the area


of

pain.

10. What are the scintigraphic finds of osteiis pubis?

Bilateral increased activity at the pubic rami by the

symphysis is demonstrated with osteitis pubis.

11. What is Legg-Perthes disease?

Legg- Perthes disease refers to primary avascular


necrosis of

the capital femoral epihpysis. It occurs most frequently

167
between the ages of 5-7 years and is more common in
bodys.

In early disease, radionuclide scanning is used to


evaluate the

vascular supply to the femoral head. Scintigraphic


studies

show a cold area in the proximal femoral epiphysis with


early

disease.

12. Name the other common sites of avascular


necrosis.

Other common sites of avascular necrosis include the


femoral

head, lunate, scaphoid, body of the talus, and knee.

13. Are the scintigraphic features always the same with


osteonecrosis?

No. Scintigraphic findings vary with the stage of disease.


In

early disease, decreased uptake is seen. With repiarative

process and degenerative changes, increased activity is


noted.

168
14. What is reflex sympathetic dystrophy syndrome
(RSDS)?

Reflex sympathetic dystrophy is a syndrome


characterized by

pain, vasomotor instability, swelling, and dystrophic skin

changes. Patients frequently report a history of trauma or

injury. RSDS may follw a self limited course or become

chronic and irreversible. RSDS usually involves the


upper

extremity.

15. What are the scintigraphic features of RSDS?

Three-phase bone scan shows increased blood flow to the

affected limb with increased activity on blood pool


imags.

On delayed images, increased juxtaarticular activity is


noted

around all the joins.

16. Name the primary cancers that most frequently


meatastasize to bone.

169
Tumours most likely to spread to bone include breast
cancer,

lung cancer, prostaqte cancer, lymphoma, renal cell

carcinoma, and thyroid cancer, both papillary and


follicular.

Bone scans are more sensitive than plain films in

identification of metastatic disease. Whole bone images


show

multipl areas of abnormal increased activity.

17. What is a superscan?

Diffuse increased uptake or activity is noted throughout


the

skeleton, along with a lack of renal activity and nearly

complete absence of soft tissue activity.

170
COMPUTED TOMOGRAPHY & MACNETIC
RESONANCE IMAGING

1. A complex fracture of the hp is best visualized with


what imaging modality?

CT provides the Orthopaedic surgon with the greatest

amout of information about the extent of freactures,

displacement, and fracture fragments within the joint

space. Three-dimensional CT images may also


enhance

the anatomic depiction of the fractures.

2. What is the most sensitive imaging modality for


evaluation of glenoid labral tears?

CT arthrography or MR arthrography are probably


more

sensitive in detecting glenoid labrum tears than


routine

MRI alone. Sensitivity for detection of glenoid labral


tears

171
by CT or MR arthrography is believed to be greatr
than

95%.

3. What is the imaging procedure of choice for


identifying a suspected lumbar disc herniation?

This issue is controversial. There is little


disagreement,

however, that MRI is more sensitive in identifying


early

changes in degenerative disc disease and offers the


added

advantage of direct sagittal, imaging. CT, however, is


a

highly sensitive test for identifying a suspected lumbar

disc herniation and is generally less expensive than


MRI.

CT offers the added advantage of superior cortical


detail.

In some instances, the examinations are


complementary,

and both may be needed.

172
4. What is the appropriate imaging modality for
evaluating the patient with recurrent low back pain
after lumbar discectomy?

Contrast-enhanced MRi is more accurate than CT in

differentiating recurrent nonenhancing lumbar disc

herniation from enhancing postoperative epidural scar.

Other etiologies of recurrent low back pain may


include

spinal stenosis, which is effectively evaluated with


MRI,

and araqchnoiditis, which also is evaluated mjore

effectively with MRI than with CT.

5. Patient who has undergone a bone fusion of the


lumbar
spine?

CT is the modality of choice. Plain radiographs in


flexion

and extension are also useful to define the degree of

instability.

6. What are the two types of spondylolishesis?

173
The two types are lytic and degenerative
spondylolisthesis.

Lytic spondylolisthesis is due to bilateral fractures or

congenital defects in the pars interarticularis


(classically

described as the “colar on the neck of the Scottie dog”


on

oblique plain radiographs of the lumbar spine). Lytic

spondylolisthesis results in posterior displacement of


the

superior vertebral body with respect to the inferior

vertebral body. Degenratvie spondylolisthesis is due


to

degenerative erosion of the superior facet of the


inferior

vertebral body. Such erosion allows forwards


movement

of the inferior facet of the superior vertebral body and

results in spondylolisthesis. CT scanning can


document

the degree of displacement and the pars intraarticularis

174
defects.

7. A suspected soft-tissue mass in the extremity is best


evaluated first with what imaging modality?

With direct multiplanar imaging capabilities and


excellent

soft-tissue discrimination, MRI is the initial imaging

modality of choice in evaluating soft tissue masses in


an

extremity. CT usually is reserved for cases that require


a

clearet depiction of bony deaisl.

8. What pulse sequences are most commonly used in


magnetic resonance imaging (MRI) of the
muscaloskeletal system?

Conventional spin-echo. TI-weighted, proton density,


and

T2- weighted images are used most often. Gradient-


echo

and inversion recovery (STIR) images are also


common.

175
9. What are the absolute contraindications to MRI?

Patients with an internal cardia pacemaker, brain

aneurysm clip, metallic foreign body in the eye,


cochlear

implant, and surgically implanted drung infusion


pumps,

neurostimulators, or bone growth stimulators cannot

undergo MRI.

10. may a patient who has a metallic hip or knee


prosthesis undergo an MRI examination?

Yes. Metallic distortion artifact may cause signal void


on

MR images of anatomic structures in the immediate


region

of the metal implant. If the patient has a hip or knee

prosthesis in place, the contralateral hip or knee can be

readily imaged with MRI. Orthopaedic screws or wire

usually do not cause significant distortion of the MR

signal. For example, an anterior cruciate ligament

176
reconstruction stabilized with metallic screws usually
can

be well visualized with MRI.

11. What is the accuracy rate of MRI in detecting


meniscal tears of the knee?

The accuracy rate of MRI in detecting meniscal tears


is

greater than 90% in most series. With three-


dimensional

imaging the rate of concurrence between MRI and

arthroscopy is 95%.

12. What is the normal MRI appearance of a meniscus?

The intact meniscus demonstrates homogeneous low

signal intensity on all pulse sequences.

13. What is discoid meniscus of the knee? What are the


complications of a discoid meniscus?

A discoid meniscus is a dysplastic meniscus that has a

broad, disclike configuration. Lateral discoid menisci


are

177
more common than medial discoid menisci.
Complications

include tears and cysts.

14. What is the appearance of an anterior cruciate


ligament (ACL) tear on MRI?

A complete tear results in nonvisualization of the


normal

low-signal intensity ACL.

15. Which pathologic findings of a latral patellar


dislocation may be demonstrated with MRI?

Torn medial retinaculum

Osteochondral fracture of the patella

Impaction bone bruise of the lateral femoral condyle


Lateral subluxation of the patella

Joint effusion and dysplastic patella without a medial


facet

Shallow or hypoplastic femoral groove.

178
16. Where is osteochondritis dissecans of the knee
classically located?

Osteochondritis dissecans of the knee is classically


located

in the non weight bearing lateral aspect of the medial

femoral condyle. It is usually seen in men and up to


50%

of patients may have a history of trauma. Early

osteochondritis dissecans is best visualized with MRI.

17. What is the imaging procedure of choice for early


detection of avascular necrosis (AVN) of the femoral
head/

MRI is reported to be the most sensitive imaging


modality

for differentiating AVN from non AVN of the femoral

head with a specificity of 98% and a sensitivity of


97%. In

addition to MRI, nuclear scintigraphy with


technetium-

99m- labeled phosphate compound is the second most

179
sensitive imaging modality. Radiographs become
positive

in later stages of AVN. Early diagnosis is critical


because

all treatment procedures are more successful in the


initial

stages of AVN.

18. What imaging study is appropriate when a


nondisplaced femoral neck fracture is suspected
clinically but radiographs are negative?

MRI is useful in identifying nondisplaced femoral


neck

fractures that cannot be detected on routine


radiographs.

Although bone scintigraphy is also useful, it is not as

specific. MRI is able to depict the morphology of the

nondisplaced fracture more accurately than bone

scintigraphy.

19. What nerve is entrapped or compressed in the tarsal


tunnel syndrome?

180
In the tarsal tunnel syndrome the posterior tibial nerve
is

entrapped or compressed. Etiologies of this


compression

neuropathy that can be effectively imaged with MRI

include neuromas, ganglion, cysts, lipomas, varicose

veins, and tenosynovitis.

20. The rotator cuff comprises which muscles?

The SIT muscles (supraspinatus, infraspinatus, teres

minor) and the subscapularis muscle.

21. Which tendon of the rotator cuff is most likely to


tear first?

The tear usually begins along the anterolateral leading

edge of the supraspinatus tendon at its insertion into


the

greater tuberosity of the humerus.

22. How are abnormal tendons of the rotator cuff


classified on MRI?

There are three grades of abnormal rotator cuff


tendons.

181
Grade 1 tendinitis demonstrates normal morphology
of the

tendon with high signal intensity on T1-weighted


images

and normal low signal intensity on T2-weighted


images.

Grade 2 lesions are partia-thickness tears on either the

articular or bursal surface of the tendon and are seen


as

high signal intensity lesions on T2-weighted images.

Grade 3 lesions are full-thickness tears that show a


high

signal intensity gap in the tendon on T2-weighted


images.

23. What is the most common appearance of avascular


necrosis of the scaphoid on MRI?

The most common appearance of AVN of the


scaphoid is

low signal intensity on both T1 and T2-weighted


images.

182
Occasionally an increased signal on T2-weighed
images

may be noted because of marrow edema and local


fluid

accumulation.

24. What is the imaging procedure of choice to identify


a suspected lesion of the brachial plexus?

The procedure of choice is MRI

25. What is the first imaging modality to order in


screening for pathology of the cervical or thoracic
spine?

MRI provides the most information in a single


imaging

examination for pathology of the cervical and thoracic

spine. Both the extradual structures, including the


vertebra

and intervertebral discs, and the intradural anatomy,

including the spinal cord, are clearly depicted on MRI.

26. For evaluating congenital abnormalities of the


pediatric spine, what is the first imaging study to
order?

183
Plain radiographs always should be obtained first to

evaluate bony anantomy for such abnormalities as


spina

bifida, butterfly vertebra, or other congenital bony

abnormalities. MRI is commonly used next for


evaluating

the neural elements of the spine for abnormalities such


as

myelomeningocele, tethered cord, syrink,

diastematomyelia, and other congenital abnormalities


of

the neural elements.

27. What is the best imaging modality for evaluating


bone marrow?

MRI directly images bone marrow and is highly


sensitive

in detecting early disease such as metastases,


lymphoma,

and myeloma. Nuclear bone scintigraphy is the best

modality in screening for metastic disease in the

184
asymptomatic patient with a known malignancy.

28. Is MRI able to differentiate confidently between


benign and malignant lesions of soft tissue and bone?

No. No specific characteristic of MR signal intensity

determines whether the lesion is benign or malignant.


If

the mas is extensive and has poorly circumscribed


margins

involving soft tissue, bone, and the neurovascular


bundle,

it is more likely to be malignant.

185
NON UNION

1. Define Non union.


It is a stage of fracture healing when the process of

healing has come to a stand still with no exterior


union

between the bone ends.

2. What is Slow Union and Delayed Union?

Slow Union- There is an initial delay in the union

process to begin with but then the progress is


normal

and results in union.

186
Delayed- The process begins the normal pace but is

delayed or halted and then progress to ultimate


union.

3. What are Radiological Features of Non Union?

Depends on the type of Non Union.

Hypertrophic Atrophic

No element of cortex between Cap may be


present

Two fragments ends are tapered


and

Hypertrophy of bony ends sclerosed

Evidence of Callus Gap between the


two
Ends
Medullary canal is open Medullary canal
is
Closed
In both fragments.

4. What are the different types of Non Union ? an what are


their cause?

Hypertrophic - Improper immobilization

187
Atrophic Hypovascularity of bone
ends

Oligotrophic Non rigid retension.

5. What is Ilizarov’s Classification of Non Union?

Paley’s modification of Ilizarov’s classification

A1-<1cm Bone loss – Stiff.

A2- Mobile lacks with defect

A2- Fixed Lacks without defect

B-> 1cm

B1-With 2cms defect

B2- loss of bone

C-Infected

6. What are the treatment modalities of Infected Non


union?

Rheinlander’s method- Debridement

Exterior fixation

Bone graft

188
Skin cover- split skin

Harmon’s Posterior- Lateral bone grafting.

Friedlander’s techniques –
Debridement+Stabilization

Followed by open bone grafting

Ilizarov’s ring fixation.

7. What are the causes of Infected Non Union?

Open #s.

Closed # ORIF followed by infection

Severity of contamination

Severity of trauma.

Delayed inappropriate treatment

8. What is a Bone Graft?

It is a bone transplant used to provide stability or


repair

of structural defect or induce osteogenesis or all of

these.

9. What are the common sites of taking out bone grafts?

189
Cortical Fibula.

Medial surface of tibia

Cancellous Iliac crest

Post superior iliac spine

Femoral Condyle

Olecleanon

Upper end of tibia

Head of Femur (if excised)

Malleolus

Corticocancellous Metaphysis of Tibia

Iliac Crest.

10. How does a Cortical Bonegraft incorporate?

It never incorporates. The grafts get resorbed and

slowly replaced by the new bone from the


surrounding

bone.

The process may taken upto 2 years for complete

190
replacement.

11. What is the role of cancellous bone graft?

It provides the osteogenic bone morphogenic


protein.

It provides the lattices network for


neoosteosynthesis

and creeping substitution.

12. What is Phemister Bone grafting? Who modified


this procedure?

It is a type of corticacancellous superiorteal bone

grafting done is cases of delayed union without

disturbing the fibrous union at the fracture site.


This

procedure was modified by Forbe.

13. When the skin and soft tissue on anterior aspect of


Tibia is not good. How do you bone graft?

Harmon’s Procedure.

Posterior Bone Grafting.

14. What is the role of Bone Morphogenic Proteins?

191
It is released from the osteoclasts which induces the

conversion of IOPC to DOPC to produce


osteoblastic

activity and hence bone formation.

15. What is Pizoelectric Effect in Union?

Each bone acts as a dipole and on break in


continuity of

bone there occurs positive and negative charge


around

the surface of bone and this causes increased


osteogenic

activity.

16. What is a IOPC and DOPC?

Induced osteoprogenitor Cell and Dependent

osteoprogenitor Cells. These are responsible for the

Osteoblastic activity. IOPC are mesenchymal and

converted to DOPC by bone morphogenic proteins,

which are released by dead osteoid cells.

192
17. What is the role of Compression on bone grafting?

According to Wolff-compression induces


Osteogenesis

and hence a good compression enhances bone


healing.

18. What is the law of Distraction Compression


Osteosynthesis?

According to Ilizarov (1951) ‘When a living tissue


put

under steady traction in the line of tension vector,


there

occurs increase in Osteogenicity and also the soft


tissue

and Neuro vascular tissue becomes active in


Metabolic

and proliferative pathway.

19. What is Percutaneous Bone Marrow Grafting?

We harvest 10-15ml Bone Marrow from Iliac crest


and

put in the site of delayed union to induce new bone

193
formation. It is not very useful in atrophic type.

20. What are the Latest Trends in treatment of Non


union?

Phoe’s Technique- Vascularized Bone grafts.

Electro stimulation- Magnetic

Percutaneous bone marrow (PCBMG)

Pulverised bone grafts with PCBMG.

WARD ROUND

During the examination, student are taken for a


Ward

round, where the questions are asked on the


patients.

The common questions are asked on Thomas splint,

Bohler Braun splint, Traction system, skeletal


tractions,

194
care of the bladder, Post operative infections,
Dressing

trolley, External fixtors, Ilizarov, JESS, POP

techniques, Paraplegia, Nursing, Bed sores. During

course of discussion the questions are sometimes


asked

on the history of Orthopaedics.

1. What are the contradictions of negative suction


drainage?

While doing suction irrigation

When Local depo- medrol is injected

Dural Tear has occurred

At Bone graft donor site.

2. Who used Plaster of Paris Bandages for the first


time?

Matheius

3. What is difference between commercial and


Home made Pop Bandage?

195
They have starched Resin treated bandages
called

leno and Plaster is impregnated by steam


autoclave

with a volatile solvent.

4. How many squares are ideal per square cm in a


P.O.P. Bandage?

16

5. What are various sites of application of skeletal


traction?

Head Crutchfield prongs

Olecranon

Metacarpals

Ribs

Torchanter

Lower End femur

Upper End tibia

Lowr End tibia

Calcaneum

196
6. What is Charnley’s traction Unit?

An upper tibial pin incorporated in a Below knee

POP cast, used for ipsilateral fractures of lower


limb.

7. Why do you keep master padding?

It maintains normal anterior bowing of Femur

It helps to keep the muscles in optimum position

Relaxation

It is a biofilm consisting of Polysaccharides and

bacteria, they are formed as as slimy layer and


are

impervious to anti bacterial penetration.

8. What is Leukergy?

It is the phenomenon in which WBC


agglomerate in

peripheral venous blood. It is positive if at least


there

leukocytes are in close proximity, and distance


of

197
nuclei being less than diameter of one cell. The

result is graded 0-3 according to the percentage


of

aggregated cells.

9. What are fixed Traction and Balanced Traction?

Fixed traction is one where counter traction is

obtained by applying force against a fixed point

proximal to attachments of muscles in spasm.

Balanced traction is one, where traction is


balanced

by a countertraction, through weight of body


under

gravity.

10. What is the size of master padding used with


Thomas Splint?

It should measure roughly 6 x 9 inches and 2


inches

thick when compressed.

11. What is a Glycocalyx?

198
It is a biofilm consisting of Polysaccharides and

bacteria which is formed as a slimy layer and is

impervious to antibacterial penetration.

12. What is the role of applying traction?

It overcomes effect of deforming force

Relieves pain and spasm.

Controls movements of damaged part.

13. How do you measure the length of Thomas


splint?

Measure the distance from crotch to heel and


add 6 t

to 9 inches, this is the length of inner side bar.

14. What are the contra indications to Skin


traction?

Abrasions

Lacerations

Impaired circulation

Dermatitis

199
Shortening of fragments.

15. What is the maximum Traction applied by


skin traction?

6.7 kg.

16. What is the function of Bohler’s strirrup?

It allows direction of traction to be varied


without

turning the pin in the bone.

17. What is the complication of Prolonged


traction through upper tibial pin?

It predisposes to knee stiffness from fibrosis of

extensor mechanism.

18. How do you insert Steinmann pin?

Local Anaesthesia

Aseptic precautions

Paint the skin and Drape it

Ask assistant to hold limb in the same degree of

200
latral rotation as normal limb to ensure that
lateral

end does not press on mattress to cause medial

rotation deformity.

Drill through first cortex, then Hammer into the

other cortex.

Tincture benzoin seal is used as it sticks to skin


and

metal.

19. By means of traction, how can you correct an


abduction deformity?

By use of Roger Anderson well legged traction,


so

that the affected lmb is pushed up. Reversing

arrangement can be used for adduction


deformity.

20. How can you correct a fixed flexion


deformity by Taction?

By Agnes Hunt traction.

21. Why is plaster of Paris so called?

201
When henry III visited paris in 1254, he admired
the

smoother whiteness of walls and popularized the


use

of plaster of paris for walls in England.

22. What are water resistant P.O.P. Csts?

They use Melamine synthetic resin with plaster


of

Paris to form water Resistant casts. In World

orthopaedic history, it is expected that you will

know, about

1. Hugh owen Thomas


. 2. Robert Jones
3. Watson Jones
4. Girdlestone
5. Lorenz Bohler
6. Lucas champanare
7. John charnley
8. Harry platt
9. Vitore putti
10. .Smith Petersen
11.Austin moore
12.Judet Brothers
13.Rush Brothers

202
14. McMurray
15.y.Cotrel
16.J.I.P.James
17.Sarmiento
18.Huckstep
19. Pulvertaft
21. Harrington
22. Sterling Bunnel
23. R.Duthie
24. L.Guttmann

1. Hugh Own Thomas (1876-1891) son of a


Bone setter.

Thomas’ Bed knee splint.

Thomas’ Test

Pulled Elbow

Cervical collar

Metatarsal bar.

Heel Wedges.

2. Robert Jones (1857-1933) – Nephew of H.O.


thomas’

Founder of british Orthopaedic Association.

He made orthopaedics a speciality and


propagated

203
works of H.O. Thomas’.

He propounded Rules of tendon Trasnfer.

3. Abraham colles (1773-1843) – Youngest


President of Royal College.

Fracture lower third radius described exactly


even

before X-ray invention.

Role of mercury in veneral disease.

4. John Lister

Lord Lister performed his first operation


using

Antiseptic Surgery in 1865.

5. Wilhelm roentgen (1845-1923)

X-ray in 1895.

6. T.G. Morton (1846)

Anaesthesia

Morton’s Metatarsalgia, first Laprotomy for

Acute Appendicitis.

204
7. Langenback (1850)

Nailed hip Fracture for the first time.

8. Lane (1894)

Used steel for instruments and implants.

9. Percival Pott 91714-1788)

a. Pott’s Puffy Tumor in skull


b. Pott’s Paraplegia
c. Pott’s Fracture dislocation
d. Pott’s spine and disease.

10. Sir Bengamin Brodie (1783-1862)

Brodie’s Abscess.

He introduced Fellowhsip examinations


( 1843)

First President of General medical


council.

11. Sir James Paget (1814-1899)

He started as curator of Museum and

Demonstrator in Anatomy until he became

205
Consultant in 1847.

President of Royal Society in 1875.

He was not a brilliant operator but good


clinician

and orator.

He identified muscle clacification due to


Trichina

spiralis

Osteitis deformans.

Carpal tunnel syndrome.

12. W.J. Little (1810-1894)

Cerebral palsy.

Tenotomy of Tendoachillis in CTEV.

He had himself left Talipes Equino varus

deformity.

13. Madame Auguste Dejer ine- klumpke


(1859-1927)

First Woman doctor in paris.

206
Brachial plexus Raqdicular paralysis.

14. Rober William smith (1870-1873)

Neuro fibromatosis before description by von

Reck Lunghausen (in 1882)

He gave description of Madelung’s deformity

even before madlung.

Smith’s fracture dislocation.

15. Ambrose Pare

Ligation of vessels.

Many Surgical instruments.

Prosthesis for amputation.

Surgeon of Four Kings of France

Rupture Tendo achillis was first described by


him.

Father of French Surgery.

16. Richard Voa Volkann (1830-1889)

‘Pen’ name Richard Leander

207
Volkmann’s Canal in Bone marrow

Ischaemic contracture

Volkamann’s Ligament.

17. Giovanni Battista montaggia (1762-


1815)

Started as a Surgical pathologist

Described Fracture dislocation in pre x-ray


era.

18. B.G. Dupytern (1777-1835)

Contracture

Fracture around ankle

Sub ungal Exostosis

Congenital dislocation of hip.

Depositis and formation of callus.

19. Paul of Aegina (625-690)

First Laminectomy

Ganglion described, for the first time.

20. T.P.McMurray

208
Followed, Robert Jones at Liver pool

Wrote Text on Orthopaedics.

Articule on internal derangement of knee

Originator of osteotomy of hip for Arthritis of


hip.

21. Sir William Macewan (1848-1924)

Devised osteotome used for Genu valgum of


Rickets.

22. Bonegrafting

1682 Jobi Meckren 1st prson.


1683 Fred Albee used cortical Grafts

1931 Phemister – Cancellous Graft.

1932 Ghromley – Iliac Graft.

23. Sir William Arbithnot Lane (1856-


1938)

Internal Fixation.

Long bone instruments

Used liquid paraffin for dressings

209
Public Health Eduction

24. Bunnel

For his work on Tendon Transfer in hand, in

Hanseniosis.

25. Charnley

Charnley’s book on conservative


Management of

Fractures

Charnley’s Total hip Replacement

Charnley’s Arthrodesis clamp for ankle and


knee.

Charnley’s Operative procedure for ankle,

Tendoachillis, hip osteotomy etc.

INDIAN ORTHOPAEDICS.

1. Dr. B.N. Sinha

Founder president of Indian


orthopadics

Association.

210
2. Dr. b.Mukhopadhya

Founder Secretary of Indian


orthopaedic

Association (IOA)

First Surgeon to give Hunterian


Lecture.

Known for work on CTEV, T.B. of


Bone

and joint and infection’s

3. Dr. P.K. Duraiswamy

First Indian to get Robert Jones


Medal for

his Experimental Work on Chick

Embryo.

4. Dr. K.T. Dholakia

First Indian to become President of

SICOT

First T.H.R. in India.

211
5. Dr. A.K. Gupta

Known for his work on Rickets and

Fracture Neck Femur in children.

Founder member of I.O.a.

6. Dr. K.S. Grwal

Leading spine Surgeon.



Founder Member of IOa, Established

Orthopaedics Surgeon in North India.

7. Dr. balu Sankaran

First Chairman of ALIMCO India.

8. Dr. M. Natrajan.

Established First Government

Rehabilitation and Trauma Service in

India.

Madras Foot.

9. Dr. S.M. Tuli

212
T.B. of Bone and Joints and
pionecered

middle path treatment regimen.

10. Dr. P.S. Maini

Hip Replacements, Arthritis of Hip.

Singh and Maini Index of


Osteoporosis.

11. Dr. Varghese Chacko

Known for his work on Perthe’s


disease.

12. Dr. Min Mehta

First Indian as well as Asian lady to

receive Robert Jones gold Medal.

Her work on infantile Scoliosis 9rib

vertebral Angle) is widely acclaimed.

13. Dr. P.K. Sethi

Internationally acclaimed for Jaipur


foot.

Received magsaysay awaqrd.

213
Established Rehabilitative
orthopaedic

Services in Rajasthan.

14. Dr. Amulya K. Saha.

For his work on shoulder, zero


position

and Osteotomy of Humerus.

15. Dr. B.B. Joshi

Internationally renowned hand


surgeon

established Joshi’s External


stabilizing

system.

16. Dr. Shailendra Bhattacharya

Internationally known for his


operation

on stiff Elbow Arthrolysis.

17. Dr. T.K. Shanmugasundram

For T.B. Hip, Polio surgery.

214
18. Dr. D.P. Bakshi

For Total Elbow Replacement and

Avascular necrosis of Hip Treated by

Muscle Pedicle Graft.

19. Dr. S.S. Yadav

Extensive work on fibular Grafting.

This list is not complete. We may


have

missed many more Eminent


orthopaedic

surgeons who have made significant

contribution for the benefit of the

speciality.

215
SUTURE MATERIALS

1. Classify Sutures,

Absorbable Non Absorbable

A. Mobofilament 1. Surgical gut 1. Polyamide

(Plain/Chromic catgut) 2. Polypropylene

2. Collagen 3. Steel.

(Plain/Chromic) 4. Polyester.

216
B. Multilament 1. Polyglycolic 1. Surgical silk

2. Polyglactin 2. Polyester Braided

3. Polyamide
Braided.

4. Steel.

2.In how many days does a Gut get reabsorbed?

Tensile strength is lost in 15 days.

Absorbed in 6-120 days by proteolytic enzymes.

3.From where do you get Absorbable sutures (non synthetic)?

Cattle/Beef cattle, sheep.

4. What are synthetic absorbable sutures?

Dxon (Green) Homopolymer glycolide


90days

Vicryl (Violet) Compolymer Glycolide


70days

PDS (white)
180days

5. What do you know about Silk, linen and cotton?

Silk Linen Cotton

217
Cocoon of silk larvae Made of flex and cellulose Seed
of

cotton

Protein covered with wax Gains 10% strength when


handling not good wet.

Strength lost after 2 years used as ligature for


Weaker

than silk

Knots easy Pedicles.

6. What are advantages of Nylon?

They are polyamides

Minimally reactive’

Nylon has memory knott security is low.

7. What are prolene?

Dyed Polymer, Polyprolene monofilament

Low tissue reaction

High tensile strength.

8. Describe in brief history of Sutures?

218
5000- 3000 B.C. Eye needle invented.

Sushruta Samhita – Described straight, triangular, round

body needles.

Albucasis (936 A.D.) – Described double sutures.

J. Lister – Carbolic crusades

Invented chromic catgut.

9. What are Principles of Suture Selection?

a. Skin, Tendons heal slowly- non absorbable

b. Muscle, peritoneum Absorbable.

c. Tissue contamination Avoid Multifilament

d. Cosmesis Use inert monofilament

e. Close Subcutaneous Polyamides

f. Cardiovascular Surgery Polyprolene, polyester

g. pancreaqtic Surgery Non absorbable.

h. Micro Surgeon 10.0 to 8.0 Polyamide


Monofilament

i. Orthopaedic Surgery Absorbable – Muscle, fascia.

219
Polyester -THR, Scoliosis

Steel Wire – Tendon

j. post irradiation Polypropylene.

10. What are the Ideal Suture sizes?

a. Peritoneum 20/3.0 Absorbable

b. Muscle 1.0/0.1 Absorbable

c. Linea Alba 1.0 Silk

d. Tendon 4.0 Polyester

e. Hernia Repair 1.0/1

11. What are the advantages of Eyeless needles?

Less Trauma to sot tissue’

No accidental unthreading

Faster and efficient Surgery

Sterility maintained

Uniform strength.

12. What are the types of Needles?

220
A. Round Body Taper cut, Trocar point

B. cutting Needles Conventional, Slim blade

C. Micropoint needles

221
O.T. TECHNIQUES AND INFECTIONS

1. What are Recommendations for an ideal O.T. condition?

Person entering, should wear pant Suit with ankle


closure, shoe and head cover

Standard drapes with pure size 100M should be used. ‘

Laminar flow has an -------------

UV radiation

HEPA fillers clears 99.9% particles

Air bacteria count 50 to 500 colony, meter cubic

Humidity more than 50%

Air Temperature 21.1 to 21.4

3-5 minutes scrub

Double gloves security, cut resistant gloves ideal.

2. In What conditions there is increae infection susceptibility?

It happens in condition of decrease hos defence as,

Congenital

222
Old age

Obesity

Diabetes

Implant Surgery

Rheumatoid Arthritis.

3. In a patient of Polytrauma, whaqt are the sites of Bacterial


colonization?

I/V Cannula

Tracheostomy

Indwelling catheter

Pneumonitis

4. What is the role of antibiotic after inoculation?

Prevents overt clinical signs, but infection may persist.


An

ideal concentration of 4 times its MIC level is required.

5. What is the ASA classification?

It is Risk Index Score.

1. Healthy patient.

223
2. Mild systemic disease.
3. Mild disease with functional impairment
4. Sever systemic Disease
5. Morbound patient.
3,4,5 are major risk factors in post
operative infection.

6. What are the causes of contamination in O.T?


Bacteria reach by air, direct sedimentation.

OIncrease in activity of surgery team

Maximum concentration is during inde\uction positioning,

extubation

Increase electrocoagulation, tissue damage, suture use.

General decrease in resistance due to blood loss.

224
STERILIZATION

1. Classify Sterilizing Agents.

METHOD FROCESS.

A. Physical

Dry Heat Flaming

Most Heat Boiling

B. Radiation

Non lonising VV Rays

Lonising Gamma Rays

Gases Ethylene oxide

C. Chemical

Alcohol Ethanol

Aldehyde Formaldehyde

225
Halogen Chlorine

Phenol Carbolic Acid, Cresols.

2. What is Temperature and Pressure used in Autoclave?

Temprature of 121 C is achieved by pressure of 1516/sq.


inch

for 20 minutes (for gloves 516x109 C for 30min)

3. What Wavelength of UV Rays are used?

240 to 280 m is the bactericidal range.

4. What is Cidex?

Glutaraldehyde, it is used for rubber, plastics. It has to be


used

within 15 days of formation.

5. What dilution of savlon is used?

1:1 with water.

6. how many formation tablets are required in a chimko


box?

4 to 10 tablets for 24 hours. They provide formalin


vapours.

7. What agent is used to sterilize sutures, Blades needles?

226
InLysol for 1-2 hours.

8. What is minimum time for Boiling Instruments?

15-20 minutes.

VOLKMAN’S ISCHAEMIC CONTRACTURE

1. Why is Median Nerve most commonly involved in


V.I.C.?

The median nerve runs near the centre of the ellipsoid

Seddon’s area and so exhibits profound ischemia.

2. what is Seddon’s area of affection?

Area where infarct takes place in form of an ellipsoid


with

its axis in the line of anterior interrous artery and its

227
central line a little above middle of forearm. The
greatest

damage is at centre and usually falls on FDP and FPL.

3. What else do you know about Volkmann?

Volkmann’s Canal in bone’’

Volkmann’s contracture.

Volkmann’s test for differentiating VIC from Intrinsic

minus hand.

4. What is D/D of V.I.C.?

Muscle degeneration due to sepsis

Compartment syndrome due to Drugs e.g Alcohol

Haemophilia with bleeding in forearm.

5. What is the deformity in V.I.C.?

Fully developed picture has,

Wrist flexed.

Fingers extended at MCP joints.

Fingers flexed at IP joints.

228
Forearm pronated

Elbow flexed.

6. What is Garee’s operation in V.I.V.?

Shortening of bones by 2-2.5 cms. But it has

complications of nonunion due to trophic changes of

forearm.

7. What is maxpages’ operation?

Muscle slide through a straight incision from medial

epicondyle to 10cm on medial aspect of forearm, and

muscles are erased from bone. fingers are


hyperxtended.

8. While testing in V.I.C. how do you relax FDP and


then stretch FDS?

By flexing Distal interphalangeal joint FDP is relaxed


and

so FDS could be tested.

9. What are the recent trends in treating V.I.C.?

a. Reconstructive procedure.
b. Tendon transfers.

229
c. Muscle Transplanting.
d. Pedicle grafting for Nerve lesions.

10. How long do your wait before operating a case of


V.I.C.?

Three months, because within 2-3 months extensor


muscle

recover well, with few flexors and also, nerve heal


well

from ischemia within three months.

11. What is a muscle sequestrum?

The muscle degeneration occurs in centre and cellular

activity and fibrosis occurs at periphery surrounded by


a

sheath of fibrous tissue. This degenerated muscle fibre

mass is a sequestrum.

FRACTURE FIXATION

1.How does a butterfly fracture occur?

A combination of bending and axial compression causes

230
oblique, transverse and butterfly fractures. A Bending force
causes

deformation to concave and convex side of the bone. The


convex

side has Tension force and concave has compression force.


Adding

of axial force causes further compression on concave side and


at

convex side it subtracts tension force so the fracture line starts

from convex side initially as compression failure, obliquely


then

becomes transverse due to tension failure. The butterfly


fragment

occurs due to this change from oblique to transverse.

2. What is effect of Torsion?

High shear and Tension stress develops in response to


torsion.

The bone tends to be weaker in shear and a spiral fracture

initiates, parallel to axis and at bone surface, then tension


force

231
causes the progression at 45degree plane.

3. Define shear, tension and compression forces?

The forces acting on bone or ‘Bone Loading’ is either in a


plane

perpendicular to its axis i.e. normal force or along the axis


i.e.

axial foce, or parallel to the surface i.e. shear. The normal


and

axial force may be either in the form of compression


(pressing

together) or tension (pulling apart)

4. What are stress risers?

Stress is an internal force which resists deformation. At a


point

where this stress is appreciably higher than elsewhere is


called

as stress risers. They are concentrated around discontinuity,

such as holes. Sharp angles, grooves, threads. These greatly

weaken a structure. A fracture may thus initiate at a screw


hole

232
in a bone or a window for bone graft. Other examples are

pathological fractures, Refracture near Callus and Fracture


at

the end of rigid bone plate.

5. What is a stable fixation and a rigid fixation?

A stable fixation is lack of motion at fracture site, even


during

joint movement and a fixation which does not allow any

deformation under load is called rigid fixation.

6. What is Implant corrosion?

Gradual degradation by electrochemical attack on metals,


which

may be either.

Galvanic

Crevice – Depened on oxide film.

Pitting – localized reaction of crevice corrosion.

Fretting – Results from oscillating movement.

Stress – Mechanical and chemical effect causes surface

233
rupture

Intergranular corrosion or

Purely chemical – due to acidic pH, usually associated


with
infection

Corrosion weakens the implant, changes the surface and

releases metal ions on body.

7. What is 316L stainless Steel ?

It is an iron based alloy with

Chromium self regenerating surface protection

Molybednum decreases rate of dissolution of chromium and

pitting corrosion

Nickel, manganese and silicon are used for manufacture

facilitation

Carbon – increases strength.

8. Compare stainless steel from Titanium as a metal for


implant.

Titanium – Lacks potrentially toxic ions

234
Less allergic

Can be kept for long time.

Steel Cheap

High elastic modular and ductility

9. What is Implant Failure?

Brittle, plastic or fatigue failures are types of mechanical

failures occur in implant due to stress risers like scratches,

bends and clamping.

Plastic – Implant bends permanently because of loading


beyoud

yield strength of material causing loss of alignment of


fracture.

Fatigue – Load is greater than the endurance limit, due to


cyclic

loading.

Brittle – a screw head, made of material of failure. Poor

conductivity may cause brittle failure.

10. Define pitch and Lead in a screw.

235
Pitch – Distance between adjacent threads.

Lead – Distance a screw travels on a complete turn.

11. what is the weakest portion of screw?

The core diameter is the weakest part.

12. What is ‘Run out’?

The transitional area between thread and shaft. It is the area


of

stress concentration. It is the point where screw may break

during incorrect insertion.

13. What is an ideal drill bit used for bones?

It had cutting end which is conical in shape and has two


cutting

edges, which act as wedge. The cutting edge angle should


be

90-100 and Helix angel of 24 (angle between one cutting


edge

and centre) for high clearance and rapid advance of drill.

14. What is lag screw?

236
A method to achieve compression between two bone
fragments,

producing pressure across fracture line, by providing


purchase

and distal fragment, while able to turn freely in proximal

fragment threads in proximal cortex do little to improve

purchase. Compression between fragments increase friction

which reduces interfragmentary motion. It could be applied


to

all types of screw e.g. cortical screw in diaphysis, when


over

drille din near cortex.

For effective compression lag screws must be inserted


though

centre and at right angles, and a minimum number of two


screw.

15. What is role of compression plate?

a. Compaction of fracture
b. Reduction of space between fragment
c. Protection of blood supply through enhanced stability
d. Fraction to avoid torsion or shear slide.

237
16. What is static and dynamic compression?

a. Plat applied under tension produces static compression,

b. which is constantly existing when limb is at rest or

c. functioning.

d. Dynamic – a phenomenon by which a plate can transfer

e. functional forces into compressive forces at fracture site.

17. How do you achieve compression?

a. Self compressing plates e.g. DCP.


b. Tensioning Devices
c. Eccentric placement of a screw

18. How close to the fracture, a screw is applied?

As a rule, it should not be placed coser than one centimeter


or

else closer than this, it may split along the hole, and loosen
the

fixation.

19. what is “stress protection” phenomenon?

Aftr fracture healing, the screws remain tight and support

238
loading over the bone causing osteopenia and these occur

directly beneath the plate. This phenomenon is stress


protection.

20. What are indications of plate removal?

Refracture immediately adjacent to plate due to stress


protection

phenomenon

Possibility of corrosion

Infection

Implant Bothers patient mechanically.

21. What are ideal plating sites in various long bones?

They should be along the tension side.

In femur – antero lateral.

Tibia – Lateral

Humerus- Posterior

Radius- Anterior in lower third and dorsal in mid third.

Ulna – subcutaneous dorsal surface or anteriorly.

239
22. for what fracture Kuntscher nail was first used?

For subtrochantric fracture in November 1939.

23. What are disadvantages of retrograde nailing in femur?

There is no control on exit of nail and if placed more medial


the

blood supply to head of femur may be jeopardized.

24. What are advantages of Reaming?

Enlarges medullary canal for adequate working length.

Facilitates insertion of nail of larger diameter.

Improves nail bone contact which enhances rotational


stability

Nail sliding is easier and if reamed to 2mm more the bow of

bone is sell accommodated without developing higher


stress.

25. What are side effects of reaming?

Destroys medullary circulation causing necrosis of inner


cortex.

Extruded products of reaming decrease callus forming.

Heat of pressure caused due to reaming.

240
Causes infection of medullary fat into transcortical vessels
and

venous system.

Decreases thickness of cortex and reduces torsion strength.

26. What is working length of nail?

Length of two points on two sides of fracture, where bone

firmly grips metal. It is the length carrying majority of load

across the fracture.

27. How do you remove a broken nail in a united fracture?

Expose proximal half of nail and remove it

Pass a ball tipped guide wire till the proximal end is broken.

Remove the proximal canal upto broken end.

Pass two or more guide wire into distal end of nail and
hammer

out the nail.

28. How do you remove broken nail in ununited fracture ?

Proximal half is removed easily, as above.

241
For Distal create a window in the bone distal and tip of nail
and

hammer out the nail.

FUNCTIONAL CAST BRACING

Functional Cast Bracing is a closed method of treating


fractures

based on the belief that continuing function while a fracture is

uniting (1) encourages osteosynthesis, (2) promotes healing of

242
tissues and (3) prevens the joint stiffness thus accelerating

rehabilitation.

Defenition : The fracture brcace is an external splint which can


be

applied to a fractured limb in such a way to provide adequate

support for the fracture whilst permitting maximum function


of the

limb until union is complete.

In most instance fracture brace should eb regarded as the


second

stage of management of fracture. Bracing does not reduce the


time

a fracture takes to unite, the benefits of this method of


treatment

are the reduction in disability caused by prolonged


immobilization.

WHEN TO APPLY ?

Functional braces usually are not applied at the time of injury.

Conventiaonal cast which immobilize the joints above and


below

243
the fracture or traction may be needed initially. Care being
taken

during this time to correct any angulation or rotational


deformity.

Minor movements at the fracture site should be painless.

Any deformity should disappear once the deforming force is

removed.

There should be reasonable resistance to telescoping.

Shortening should not exceed ¼ inch for tibia and ½ inch for

femur.

Contraindications for bracing

(1) mentally retarded patients.


(2) Unco-operative patients.
(3) Patients with peripheral vascular disease and
peripheral neuropathy.
(4) Very obese patients.
(5) Skin loss or any skin problems.
(6) Galleazi fracture dislocation
(7) Montaggia fracture dislocation.

TIME OF BRACE APPLICATION.

1. Fracture shaft femur 4 to 6 weeks.

244
2. Fractures around knee 3 weeks.

3. Fracture shaft tibia 2-3 weeks.

4. Fracture around ankle 2 weeks

5. Fracture Humerus Days 1 or 10-15 days.

6. Fracture Radius and ulna -2 to 3 weeks.

7. Fracture lower end radius – Same day or 7-10 days.

8. Fractures around Elbow – 2 to 3 weeks.

FRACTURES TO BE TREATED BY CAST BRACING

1. Ankle fractures : Should not be treated by bracing.


Ideal

2. treatment is open reduction and internal fixation


and

below knee POP cast.

3. Tibial Fractures : Ideal fracture for bracing is


closed

spiral fracture of middle third of tibia with


associated

245
fibula fracture. Even fracture in tibia with intact
fibula

can alos be treated by tibial brace.

4. Fractures involving Knee joint : ideal treatment is


of

course ORIF but knee brace can be used is


severally

communited intraarticular fracture and can also be

applied postopertively for mobilization of joint.

5. Fracture Shaft Femur :

a. Fracture in middle and distal


third are quite amenable to
bracing.
b. Even fractures of proximal
femur where fixation is
inadequate and where the
fracture has been treated by
tr5action, can also be treated
by bracing.
6. Fracture humerus : Shaft fracture are best treated
by a brace.
7. Supracondylar fracture : brace is indicated in those

246
cases who had compound. Fracture and ORIF hs been

done and where mobility from day one is important.

8. Forearm Fractures.
1. In both bones fracture.
2. After internal fixation, if the fixation is not rigid.

9. Colle’s Fractures : are tr4eated by wrist brace.

DISADVANTAGES OF OPERATIVE TR4EATMENT

1. Simple fracture is converted into an open fracture.

2.Postoperative infection

3. Reaming has adverse effects on fracture healing.

4. Failure of operative treatment is more difficult to salvage.

5. Other risks of Anaesthesia and surgery.

6. Implant failure, Bent Nails, Migrated Nails, broken, Plates


loosening of implant etc.

7. Delayed union and non-union.

8. Distraction of fragments.

9. Skin necrosis.

247
TECHNIQUES

1. FUNCTIONAL CAST BRACING FOR KNEE JOINT :

Indieations :

1. For fractures distal one third of femur shaft including

supracondylar fracture
2. For fractures proximal one third of tibial tibial shaft

3. Comminutd fractures of condyles of tibia and femur.

248
4. Those condylar fracture of femur and tibia in which open
reduction and internal fixation are not indicated.

II. Material ;

1. Brace : An unicentric brace of two sizes bigger one for


adult

and smaller on for children madeup of Aluminium. The

wings are made of thin malleable in to enable essy


alternation

accoding to the variation of thigh and leg.

2. Alignment Jig : to hold the brace and maintain the


correct

axis.

3. Stockinette : Of appropriate size and about 4 feet length


is

required as the initial compressive material.

4. Sofroll : to protect the skin over bony prominence to be

compressed by cast.

5. Plater of Paris Bandages : good quality of fast setting

249
commercial bandages of 4” & 6’ are required in 6-6
numbers

each
.
6. Screw driver and bar bender : for opening the screw, to
free

the hinge, and to bend the bar of brace in required angle.


.
7. Spirit and antifungal powder : To clean the whole skin
area

of thigh and leg and to prevent the itching and infection.

III. Technique :

First of all, the central and side screws of hinge is opened to


make

the hinge free, then long bar of thigh portion and short bar of
leg

portion of brace is bend in such a manner that after application


it

should be about 4-5cm. apart from knee on both ides and

approximately 8-10cms. Proximal and distal portion of bar


from

hinge should be free from knee on both sides to make easy

250
movement of hinge and not interfered by knee movements.
The

bending levers should be at equal level on both bar on both


ends.

The wings of thigh and leg portions is curved according to


required

need to contact fully and smoothly.

Whole extremity from groin to toe is thoroughly cleaned with


spriti

and an antifungal powder is spread all over the area to prevent


any

itching.

If there is any remaining wound e.g. tibial pin extraction


wound it

should be cleaned and dressed properly.

Marking of joint axis- The knee axis roughly correspond to the

level of adductor tubercle or middle point of patella and about

2cm. posterior to the midline in sagital plane.

251
So a line is drawn vertically along mid of patella along medial
and

lateral sides of knee then on both side horizontal line are


drawn

perpendicular to above line at the mid level of knee is sagital


plane

then 2cm. below and parallel to these lines other two lines are

drawn on both sides. The irteresting points are actual position


for

hinges of brace. Another line over patella is drawn above

downward and central point of patella is marked.

Then keeping the brace with hinges exactly on same plane as

marked above, the central bar of jig is kept just ove the cener
of

patella and side bars on both sides over the hinge of brace and
with

maintaining the position all screws of jig are tightened to hold


the

brace.

252
Stockinette of appropriate size is applied from groin to toe and

second layer is again applied extending from mid of thigh to


mid

of leg. To avoid wrinkling a sling is passed from lateral


portion of

stockinette and keeping tight by the patient.

The patient is brought at the edge of table and the limb is


abducted

by an assistant and holding it, in neutral position.

Thigh portion of cast is applied by 6” plaster bondages


extending

from ischial tuberosity level to the just above the knee and it is

firmly moulded in upper thigh by applying pressure

anteropostriorly and side by help of another assistant.

Clearance of 1cm is allowed above the brim of cast on medial


side

to prevent the impingement in the perineum. This amout of

253
clearance permits patient to walk or sit in the cast brace
without

discomfort and avoids skin irritation.

The below knee portion of cast is completed after well padding


the

ankle by sofroll and taking care to avoid any wrinkling. The


leg

should be in neutral position, leg cast should extend from just

below the knee to the toe and normal planter arch is


maintained

before setting the plaster.

Now brace is applied with jig is exact position, after again


marking

the patella center over the stockinette and after keeping the

additional sofroll layers beneath the wings of brace with


maintaing

this position the cast is completed by incorporating the brace.

Trimming of cast is done, above and below the knee to allow


full

254
flexion of knee.

The outer layer of stockinette is splitted around all over the


knee

and incorporated within the finishing layer of plaster.

Not the central screw of hinge is tightened and plaster is


allowed to

set for atleast 24 hours. With limb keeping elevated to avoid

oedema.

To avoid effusion in knee a compressive bandage is usually

necessary.

From second day by releasing the screw the active knee


movement

is allowed.

255
ANKLE BRACE

I. Indications :

1. Fracture middle and lower third tibia.

2. Bilateral fractures.

3. Fracutres in Elderly people.

4. Compound fractures.

II. Material Required :

1. Plaster of Paris bandages -4”x4 (approx)

2. Stockinette.

3. Metallic joint incorporated in leather shoes.

4. Screw driver.

III. Technique :

256
1. a bellow the knee plaster of paris patellar tendon bearing
brace

is applied with the patient on the edge of table with his hip
and

knee flexed at 90degree.

2. No anaesthesia is required.

3. Single layer of stockinette is put on the leg and pads of


foam are

plaed on bone prominances to avoid pressure sores.

4. Plaster of paris bandgs are wrapped from ankle to Tibial

tuberosity and moulded on bony prominence of tibia along


its

entire length. The posterior and superior portion of the cast


is

moulded to produce a triangular shape at the ton Before this

portion of the cast is completely set the knee is extended to


40

of flexion and is helf in this position by resting the heel on

surgeon’s lap. Further plaster of paris bandages are applied

257
above the proximal end of patella and was firmly moulded
over

patellar tendon and popliteal fossa so as to produce a


countour

similar to that of patellar tendon bearing prosthesis.


Moulding is

maintained and continued till plaster became dry.

Proximally the anterior trim was extended to expose only


the

proximal portion of the patella and this part of the cast is


closely

contoured to the condyles of femur extending as far


posteriorly

as possible. The posterior wall of plaster cast should not be


very

high otherwise it irritates the hamstring tendons during


walking

and prevent full flexion of knee. The posterior portion of the

cast is cut down to the level of mid popliteal region. The


distal

portion of cast is trimmed to preserve saug molding of cast

258
around the lateral and medial malleoli for permitting
complete

plantar and dorsiflexion of ankle.

5. Metalic ankle joint with two metallic sleeves is incorporated

exactly across the brace line of heel of shoes on its plantar

surface.

6. This preassembled shoe with upright and mechanical ankle


joint

is put on the foot of fractured leg having the plaster of paris

patellar tendon bearing brace. The medial upring of the joint


is

carefully placed exactly opposite to the apex of medial ma

lleolus and lateral upright is placed slightly posterolateral so


t

hat norm toe out of 10 is maintained during walking. The

proximal metallic sleeves are then incorporated with plaser


of

paris bandages.

Post Application Management :

259
After Twenty four hours of application when the plaster is

completely dried, paint is encouraged to move the freed ankle


and

knee joints and to start weight bearing on the affected limb,


first

with the help of axillary Crutches, then with the help of a stick
and

is finally encouraged to discard all type o9f support as son as

possible.

Follow up :

Once the patient has started full weight bearing without


support.

Skiagram is taken to check the position of fragments after


weight

bearing. Patients are encouraged to return to their jobs, with


the

instruction to keep the limbs elevated while sitting. Each


patient is

reviewed every two weeks. On subsequent visits, patient is

260
examined for range of movements, and to see whether brace is

providing sufficient stability to fracture fragnments. If it is


ofund

that the cast was loose and not providing required stability, the

plaster brace is reapplied.

At the time of review the clinical union is assessed by two test.

(1) Afer holding the heel of fractured leg it is first


pulled

and then pressed vertically. Absence of pain at


fracture

site inicates that fracture has united.

(2) The knee of fractured leg is held in left hand and


ankle

in right hand. On rotating the ankle externally or

internally and also the knee in the same direction,

produces no pain at fracture site is diagnostic of


clinical

union.

Cast brace is removed for clinical and radiological

261
examination at regular interval of 4 to 6 weeks to see

progress of union and then reapplied. Usually 2 to 3

applications are needed in majority of the cases.

Further observations are recorded for any residual


limitations

of knee and ankl movements, limp, pain, shortening or

swelling, walking ability, angulation, rotational


deformity

etc.

Removal of Brace :

Before discarding the brace, a skiagram is taken to see


the

callus formation. A clinical union is assessed by the


positive

tests and no pain at fracture site, and is confirmed by


direct

clinical examination after removal of brace. Absence of

tenderness and abnormal mobility at fracture site are

262
considered as positive sign for clinical union. In patients
who

have pain at fracture site on weight bearing but clinically

fracture had united, were given leg sleeve for a period of


2 to

4 weeks.

Complications :

1. Swelling of fot.

2. Angulation.

3. Loosening of nuts and bolts.

4. Loosening /Breaking of brace.

FUNCTIONAL THIGH SLEEVE

Application of functional thigh sleeve is a conservative


method of

263
treating fractures shaft femur but can also be used as
supplement

after intramedullary nailing. It provides stabilizing influence at

fracture site and allows negligible movements at fracture site

which are desirable. At the same time it allows early weight

bearing and movement at knee and hip joints. Weight is


transitted

from femoral condyles to ischial tuberosity and anterior


superior

iliac spine through the sleeve but more than 60 percent of


weight is

transmitted through muscle mass surrounding the fracture site.

Material required :

(1) Plaster of paris bandages (fast setting)

4 - 2
5 - 6

(2) Stockinette.
(3) Cast padding.

Indications :

264
1. Mid 3rd and lower 3rd fractures shaft femur.

2. Post intramaeullary nailing of shaft femur.

Contradications :

(1) If fracture is wobbling.

(2) Upper 3rd shaft femur fractures.

(3) Sub-Trochentric fractures.

(4) Suppra condylar fracture shaft femur.

(5) Bilatral fractures shaft femur

(6) Floating knee.

Technique :

Thigh sleeve is applied usually 4 weeks afer the injury when


the

fracture has become sticky and intrinsic stability has been

achieved. Aftr spreading antifungal poweder stockinette is


rolled

up from below the knee upto the groin.

265
Patient is place don the Wastson jones fracture table and
fracture

limb is abducted in a neutral position. The plaster of paris

bandages are wrapped and thigh sleeve applied, which extends

from inferior pole of patella anteriorly and midpopliteal level

posteriorly upto ASIS anteriorly and Ischial tuberosity


posteriorly.

The sleeve is strengthened by incorporating 4 slabs (anterior,

posterior medial and lateral). The sleeve is firmly moulded in


the

upper thigh by applying pressure anteroposteriorly and side to


side

by help of an assistant. In the lower part of thigh, sleeve is well

moulded over patella and femoral condyles. Clearnace of


about

half an inch is allowed on brim of the sleeve an medial side to

prevent the impingement on the perineum. This pemits patient


to

walk or sit comfortably and avoids skin irritation.

266
Post Application management :

After 24 hrs. of application of thigh sleeve, patient is advised


to

start active knee, hip and leg raising exercises and is allowed

partial weight baring with axillary crutches. The patient is

reviewed every 2 week and assessed clinically. Every 4 weeks,

sleeve is removed a skiagram taken and fracture site assessed


for

clinical and radiological union. Any breakage or lossening of

sleeve calls for change. Sleeve is discarded when the fracture


is

united clinically as well as radiologically.

Complications :

1. Alergic reactions.

2. Angulation : Anerioposterior angulation, varus angulation


valgus angulation.

3. shortening.

4. Rotational deformity.

267
5. lossening and sliping of thigh sleeve- it is prevented by
giving a shoulder strap.

HIP BRACE

1 Indications :

1. Subtrochantric fractures.

2. Trochanteric fractures.

3. Upper 1/3 Femur

4. Post operative after IM nailing

III. Materiaql Required :

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1. Hip Brace- Consists of single uniaxial joint, thigh upright
and

pelvic upright to which pelvic band is attached.

2. Stockinette.

3. Cast padding – to protect skin over bony prominences.

4. Plaster of paris bandge 6’ (fast seeting commercial


bandages 6’-

10-12 rolls.

5. Screw driver.

Technique :

1. Hip brace is applied 4 to 6 weesk after the injury, during


which

the fracture site becomes sticky and intrinsic stability is


achieved.

2. Stocknette is rolled up from just below the kne joint to


above

the groin and cast padding applied over the bony


prominences

as well as lower abdomen and back.

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3. The hip joint axis roughly corresponds to level just above
the

greater trochanter and lies about 1-2cm. anterior to the


greater

trochanter.

4. Thigh portion of the cast is applied by 6’ plaster bandages

extending from ischial tuberrosity level to superior broder


of

patella and it is firmly moulded in upper thigh by applying

pressure in anteroposteriorly and side to side by assistant.


The

cast is well moulded over femoral condyles and patella.

5. Pelvic portion of the cast is applied with 6’ bandages


extending

from just below the xiphisternum to iliac crest level, prior to

application of pelvic portion abundant cotton is kept on

abdomen to accommodate, for the abdominal movements


which

occur with respiration.

6. Then the hip brace is placed on the lateral aspect with the

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uniaxial joint at level just superior and anterior to the hip axis
and

it is incorporated by wrapping POP bandages in the thigh and

pelvic casts.

7. Active hip and knee movements are started after 24 hours


when

the cast brace is completely dried and partial weight bearing

with axillary crutches is allowed. Gradually the patient is

encouraged to walk with stick and finally all types of


external

support discarded.

8. Patient is reviewed every two weeks and on subsequent


visit

patient is examined for range of movements and to see if the

brace is providing sufficient stability. If the brace is loose


and

not providing the required stability it is changed.

9. Cast brace is removed for clinical and radiological


examination

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at regular interval to see the progress of union. Brace is

discarded when the fracture is clinically and radiologically

united.

Complications :

1. Moderate oedema distal to brace.

2. Minor angulatory deformity

3. Lossening of brace.

4. Breaking of brace

5. Lossening of nuts and bolts

Contriandications :

1. unco-operative/Mentally retarded patient.

2. Delayed/ Nonunion.

3. compound.

4. Bilateral fractures.

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HUMERAL SLEEVE

1. Indications : All diphyseal fractures of Humerus – Middle


1/3.

2. Materials : Stockinet, Plaster of Paris Bandage cast padding.

For Children :

a. King (Stockinet) 10” length One

b. P.O.PP. Bndages 10cmx2.7cm Two

c. Cast padding 10cmsx2.7m One.

For Adults :

a. Stockinets 14” One

b. P.O.P. Bandage 10cmx2.7M. Three

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c. Cast padding 10cmx3M. One.

3. Technique :

Stockinet is applied to the arm from shoulder to elbow, give a

proper stretch to stockinet and apply cast padding evenly over


the

boney prominences. P.O.P. Bandags application started


medially

2.5cm. Below axilla and laterally it extends upto the point just

below the acromion process, application of P.O.P. Bandages

wound be evenly, Lower down it extend midially 1.3cms.


above

medial epicondyle of humerus. Laterally it should extend just

above the lateral epicondyle. During application of sleeve


minor

correction in alignment of fracture can be carried out and it is


to be

moulded well over the shape of the soft tissue structures over
the

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arm. Sleeve must allow the complete range of motion of the

shoulder and elbow joint.

A shoulder harness some time may be applied to the proximal

portion of sleeve and looped around the neck to prevent


slippage of

sleeve downward. This is likely to occur in Patient’s large and

flabby extremities.

4. Follow Up :

After sleve application check x-ray to be taken and see the

alignment and call the patients to next day for neurovascular

revaluation. After 1 week check the alignment readiologically.


At

this time pendulum exercises of shoulder in extension (other


joint

movement) startd just after the sleeve application). Again


check x-

rays is to be taken after 1 week alignment is satisfactory re-

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examination should be done 3-4 weeks interval and in each
visit of

patient clinically as well as radiologically assessment to be


done.

Functions a range of motion were continually stressed and

evaluated.

5. Removal of Sleeve : is undertaken after the fracture is


united

clinically.

6. Time of Application of Sleeve : This will depend upon the


soft

tissue damage, type of fracture, swelling in the arm usually


it

should be applied on 10th or 15th days after injury.

7. Complications :

1. Moderate oedema distal to sleeve may occur after

application. Elevation of forearm on pillow during

recumbency, exercise of fingers of the hand decreases


the

oedema with in three weeks.

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2. Minor angulatory deformity : Upto 25 acceptable will not

interfere in functioning of the arm, for cosmetic purpose

specially to ladies it may look ugly.

WRIST BRACING

1. Indications : colles fracture, fracture lower and Rdius,


lower

end ulna.

2. Material : plaster of Paris bandage (3”x2/4”x2”) Sofrol.

Metallic wrist brace, stockinet.

Metallic Wrist Brace : Brace is made of aluminium and it


consists

of two blades. The proximal blade is longer and to be


incorporated

in the proximal of plaster and distal is smaller to be


incorporated in

the small plaster of the hand. Two blades are joined together in
the

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form of an uniaxial joint which is freely mobile in one axis. (in
the

axis of palmer and dorsal flexion of the wrist).

Plaster : The functional bracing of the colles fracture


constitutes

two piece plaster applied on the forearms and in the hadn.


These

two pieces are joined by a metallic joint which was placed on


the

ulnar side and the plastr is given in full supination and ulnar

deviation.

3. Procedure : The brace is applied immediately after

reductionin cases where there is no swelling. If there is

swelling, brace can be applied when swelling has


subsided

from 0-10 days after deduction. The plaster is now


applied

over the forearm and hand, keeping forearm in full

supination. The plaster has two components proximal


and

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distal. The proximal portion of the plaster is applied over
the

forearm with a supracondylar extension, to prevent

supination and pronation, but permitting complet elbow

flexion movement, full extension restricted upto last

30degree.

Dostally plaster extends upto the level of wrist on palmar

aspect on radial side and on dorsal aspect plaster is


extended

in the form of a good covering the proximal part of the

dorsum of the hand and on the ulnar side it is upto the


wrist

joint.

Distal portion is applied over the hand. A well moulded

plaster of paris, piece encircling the distal part of the


hand,

just proximal to knuckle dorsally and upto distal palmar

crease on the palmar aspect is appled, so as to permit full

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rnage of finger movements.

The proximal blade of metallic brace is long and is

incorporated in the forearm and the distal small blade is

incorporated in the hand. Brace is applied over the ulnar

aspect of the wrist.

4. Aims of Wrist Brace :

A. It allows elbow flexion, and extension restricted to


around 30

B. It prevents supination and pronation.

C. It permits full palmar flexion and allows


dorsiflexion of the wrist to neutral.

D. Permits full range of finger movements.

5.Follow- Up :

Patients with functional wrist brace are followed upto six

week. After six weks, cast brace can be removed, once


the

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fracture has united clinically.

OLECRANO – CONDYLAR BRACE (OCB)

Indication :

1. Fracture both bones forearm (BBFA) in position.

2. Displaced fractures BBFA treated conservatively by

closed reduction and above elbow POP cast can be


given

an OCB after 3 weks.

3. All operated cases of fracture BBFA, Monteggia


fracture

dislocation and Galeazzi fracture, if not sure of rigid

fixation.

4. Isolated fracture Ulna in position.

Materials :

1. Stockinette.

2. Castpadding.

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3. Cotton roll

4. Plaster of Paris bandages 4”x3 (approx)

Methods :

Ideally the brace should be applied in the anatomical position


of

the upper limb i.e. keeping the forearm in full supination,


where

full range of elbow joint movement is possible, but it could


well be

applied in the functional position of the upper limb. i.e.


keeping the

forearm in midprone position.

The patient is seated comfortably on the coach with his upper


limb

by the side of the chest. An assistant holds the elbow and the

lateral three fingers, keeping it in cunctional position with the

elbow in 90 flexion. The surgeon after donning the full plaster


gear

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sprinkles an antibiotic/antifungal poweder over the fo4rearm
and

then rolls over a length of stockinette distal to proximal and

extends it proximal to the Elbow joint. A layer or two of cast

padding is applied at the proximal end over the olecranon and


both

the condyles, over the distal end just proximal to the wrist and
strip

along the subcutaneous boarder of ulna. Required numbrs of

plaster bandages are soaked into water and a forearm cast is

quickly applied leaving the wrist and elbow free. At the


proximal

end the plaster is moulded over both the latral and medial
condyles

and over the tip of the olecranon. Particular attention should be

given in this moulding as this keeps the plaser braced to the


limb

and is the key to a successful brace. Care should be taken that


the

plaster does not cut into the flexion crease of elbow.


Similarly the

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plaster is moulded over the wrist to allow upper grip.

A sufficiently thick slab is made with plaster bandages which

extends distally from the knuckles to 2” proximal to the point


of

elbow. The patient is asked to keep the wrist in about 30 short


of

full extension. The slab now is applied oer the dorsal aspect of

limb and is held in position by plaster bandages. As the cast


sets in

the sharp edges and pointed ends of the plaster are rounded off

with small strips of plaster bandges, the extra stockinette is cut

away and the elbow and hand are ceaned. An idal OCB is light

weight yet strong enough.

After Treatment :

Active movments of elbow and wrist are commenced after one


day

as the plaster becomes completely dry. The OCB permits an


elbow

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movement from 30 short of full extension and a wrist ROM
from

full palmar flexion to 30 Dorsiflexion, but it does not allow

pronation and supination. Thus OCK is a resistricted motion

function brace.

The patient compliance is usually good as he regains the


maximum

ROM within the confines of brace in a fortnight or so. The


brace is

aesthetic and because both the elbow and wrist joints are free

patient can carry out his routine works unhindered.

The brace is usually worn until there is evidence of sound


union.

Any breakage or lossening in between calls for a repair

or removal and reapplication.

ELBOW CAST BRACE

Material :

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1. Plaster of Paris Bandages 4x4(approx)

2. Stockinette One

3. Brace with Padding (which has to be moulded to the


Contoors)

4. Screw Driver.

Indications :

1. Intercondylar fracture Humerus.

2. Badly comminuted fracture Lowre end Humerus which


can not be fixed.

3. Side sweep injuries of Elbow.

4. Fracture BBFA Upper third, after I.M. Nailing.

Ideal time for application :

After the fragments have become sticky and there has occurred

some callus formation (2 to 3 weeks)

Technique ;

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1. A double stockinette is applied extending from the hand
to the shoulder after preparation of skin and dusting
mycoderm poweder.

2. The patient is sitting while an Assistant keeps the


stockinette pulled and holds the limb so that the :

a. Shoulder is in slight abduction to facilitate


application of cast.
b. The elbow is kept in extension.
c. Forearm in Midprone position.

3. The two humoral condyles, the olecranon and the joint


line are marked by the marking pencil.

4. A well moulded cast is applied (using one POP bandge)


overall the arm extending from the insertion of
deltoid/anterior Axillary crease to just above the
condyles.

5. anteriorly this cast is curved proximal to the Elbow joint


so as to permit full felexion.

6. Next a well moulded cast is applied over the forearm so


as to extend proximally from the level of radial head to
the wrist joint.

7. The brace is now so moulded so as to fit to the contours


of the arm and forearm and so that it does not hinder the
Elbow movement. The hinge of the brace is kept just
anterior to the axis of the Elbow joint.

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8. Long arm of the brace are kept proximally or distally
depending on the fracture site, so that the arm of the
brace extend beyond he fracture site.

9. Now keeping the brace in the required position POP


bandges are firmly applied over the arm and forearm
with the precaution that the brace does not slip from the
required position.

Post application Management :

No movements are allowed for 24 hours after application. The


patient is then asked to gradually start mobilizing the Elbow
joint and as the range of movement improves oto perform all
the routine work possible. The patient is instructed to lock the
brace when sleeping and to kep the limb elevated.

The brace is worn till there is sound union of fracture.


Alternatively functional humeral sleeve or an OCB may be
given after some time depending on indication

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DISABILITY EVALUATION

1. Define Disability ?

Inability to meet certain standard of physical, social,

occupational and economic competence.

2. What are the Types of Disability?

Temporary total disability – during the time of treatment.

Temporary partial disability – Recovery has reached the stage


of improvement.

Permanent disability – permanent damage or to loss of use of


some part of body after maximum improvement from
treatment.

3. What is the McBride Formula?

It is based on functional factors of loss in respect of 100%


incapacity and rated as :

a. Delayed action 10%

b. Awkwardness 20%

c. Wakness 20%

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d. Insecurity 10%

e. Diminished Endurance 20%

f. Lowe safety factor 10%

g. Adverse influence to employment 10%

4. What is the Kessler’s Formula?

He used Loss of function as basis for disability evaluation,


involving

Loss of range of motion of a limb (100%)

Loss of muscle strength (90%)

Loss of coordination and control (90%)

e.g. if there is loss of 50% functions of shoulder abduction.


Then loss of R.O.M. of shoulder will be 50x.30=15% (30
being 1/3 part of a limb, having shoulder, elbow and wrist
joint).

Similarly muscle power also has .30, for shoulder elbow and
wrist.

Suppose a patient has

Gr. 0 Power 100% loss.

I 80%

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II 60%

III 40%

IV 20%

V 0%

Add different group, then multiply by .30 and average value is


obtained.

For co-ordination, each activity has 9% value.

After obtaining the value for Rom, Muscle power and co-
ordination they are added as :

a + b (90 – a) = x

90

a = higher value

b = lower value

x = Total value of loss.

This is calculated separately for UL. Hand, LL components


and then average is taken.

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5. What are draw backs of McBride Formula?

Individual value is purely arbitrarily taken

Allotment of disability is totally on personal judgment hence


too subjective.

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293
294
0

295
296
297
0

298
299
300
0

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6. What to you understand by Evertor insufficiency and Inventor
insufficiency ?

Evertor insufficiency - loss of power of peroneus longus or brevis invertor


insufficiency - Tibialis anterior and posterior.

7. What are the muscles affected in lower limb in polio ?


Tibialis anterior, peroneii, quadriceps, gluteii then triceps.

8.What are the causes of Pelvbic Obliquity ?


Supra pelvic - scoliosis
Pelvic - Maldevelopment
Infrapelvic - tight iliotibial band, limb length discrepancy

9. dWhat are the effects of Pelvic Obliquity ?


Flexion abductin external rotation at hip ?
- Genu valgum
- Flexion contracture of knee
- Varus of foot
- External tibial torsin
- Lordosis
- Scoliosis
10. What are the procedures to correct pelvic obliquty ?
Sectioning of ITB with Souttar's or Yount's procedure
11. What is the yount's procedure ?
Selective iliotibial band release either open or by close tenotomy.
12. What is Biceps Femoris Transfer (Caldwell's procedure ) done for ?
In cases of quadriceps weaknew
13. What are the Bony procedure done for Recurvatum Deformity ?
A supra condylar femoral osteotomy could be done in these cases.
14. What is the treatment principle for a Caliper in foot deformity or
where do you use T strap or Iron bar ? 302
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