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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.
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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.
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- He should not have any Abduction or Adduction deformity
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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.
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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.
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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
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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.
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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
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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.
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- 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%
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-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.
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
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
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.
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
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
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 ?
51
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
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.
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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%
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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 ?
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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
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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 ?
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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 ?
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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 ?
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- 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.
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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
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the joint cavity. Either due to effusion or locking patient fails to
extend the joint beyond a certain angle.
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.
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
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
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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
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- 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
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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 ?
83
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.
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
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.
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.
88
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
89
- 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
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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
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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
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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
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- 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 ?
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- 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 :
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
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- 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
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- 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 ?
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- Patchy
- Irregular
- Assymetric
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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 ?
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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 ?
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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
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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
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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
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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.
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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
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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.
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.
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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.
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.
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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.
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.
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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.
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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
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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.
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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.
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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.
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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.
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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.
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There may be evidence of the original benign primary lesion. Radiographs show
a fuzzy infiltration tumor.
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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.
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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 ?
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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 ?
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.
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.
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.
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.
141
DIAGNOSTIC RADIOLOGY
occur in 5%.
142
from an inferior position through the axilla to a superior
plate.
internal rotation.
143
of the shoulder. It is best seen on an axillary view of the
shoulder.
acromioclvicular joint.
144
7. What radiographic view is used to evaluate Impingement
syndrome?
impingement syndrome.
145
The normal anterior fat pad appears as a lucid strip
146
the flexed elbow. Visualization of the posterior fat pad
147
most notably over the radial styloid and triangular
overhanging margin.
148
contralateral iliac crest and pubic and ischial rami.
149
A segond fracture is an avulsion fracture of the capsular
commonly associated.
150
Fractures of the talar neck or talar dome may be seen on
151
of peroneal tendon subluxation.
152
forces.
the fibula.
153
20.What is a Jones fracture?
154
abnormal bone, such as that in osteomalacia or
osteoporosis.
Midfibula Patella
Metatarsals
Radiation Hyperparathyroidism
155
bones, such as the tibia or the femur, they are better
156
Alcohol abuse Lupus erythematosus Caisson’s disease
157
joint spaces; and (4) other degenerative signs.
Degenerative
subchondral sclerosis.
158
periosteum and bone. Where the gap is elevated, bone is
tuberculosis.
159
The earliest sign may be blurring or obliteration of soft-
tissue
a diagnosis of osteomyelitis.
160
Charcot joint, also called neuropathic joint, occurs in
patients
161
visualized. The cervicothoracic junction is a common site
of
traumatic injury.
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.
NUCLEAR MEDICINE
163
drugs extracted by specific organs allows observation of
how
distribution.
164
4. What are the scintigraphic features of osteomyelitis?
phases.
165
Gallium-67 citrate and leukocytes labeled with idium
111 are
osteomyelitis.
166
9. Which is the more sensitive in the detection of stress
fractures plain film or bone scan?
pain.
167
between the ages of 5-7 years and is more common in
bodys.
disease.
168
14. What is reflex sympathetic dystrophy syndrome
(RSDS)?
extremity.
169
Tumours most likely to spread to bone include breast
cancer,
170
COMPUTED TOMOGRAPHY & MACNETIC
RESONANCE IMAGING
171
by CT or MR arthrography is believed to be greatr
than
95%.
172
4. What is the appropriate imaging modality for
evaluating the patient with recurrent low back pain
after lumbar discectomy?
instability.
173
The two types are lytic and degenerative
spondylolisthesis.
174
defects.
175
9. What are the absolute contraindications to MRI?
undergo MRI.
176
reconstruction stabilized with metallic screws usually
can
arthroscopy is 95%.
177
more common than medial discoid menisci.
Complications
178
16. Where is osteochondritis dissecans of the knee
classically located?
179
sensitive imaging modality. Radiographs become
positive
stages of AVN.
scintigraphy.
180
In the tarsal tunnel syndrome the posterior tibial nerve
is
181
Grade 1 tendinitis demonstrates normal morphology
of the
182
Occasionally an increased signal on T2-weighed
images
accumulation.
183
Plain radiographs always should be obtained first to
184
asymptomatic patient with a known malignancy.
185
NON UNION
186
Delayed- The process begins the normal pace but is
Hypertrophic Atrophic
187
Atrophic Hypovascularity of bone
ends
B-> 1cm
C-Infected
Exterior fixation
Bone graft
188
Skin cover- split skin
Friedlander’s techniques –
Debridement+Stabilization
Open #s.
Severity of contamination
Severity of trauma.
these.
189
Cortical Fibula.
Femoral Condyle
Olecleanon
Malleolus
Iliac Crest.
bone.
190
replacement.
Harmon’s Procedure.
191
It is released from the osteoclasts which induces the
activity.
192
17. What is the role of Compression on bone grafting?
193
formation. It is not very useful in atrophic type.
WARD ROUND
194
care of the bladder, Post operative infections,
Dressing
Matheius
195
They have starched Resin treated bandages
called
16
Olecranon
Metacarpals
Ribs
Torchanter
Calcaneum
196
6. What is Charnley’s traction Unit?
Relaxation
8. What is Leukergy?
197
nuclei being less than diameter of one cell. The
aggregated cells.
gravity.
198
It is a biofilm consisting of Polysaccharides and
Abrasions
Lacerations
Impaired circulation
Dermatitis
199
Shortening of fragments.
6.7 kg.
extensor mechanism.
Local Anaesthesia
Aseptic precautions
200
latral rotation as normal limb to ensure that
lateral
rotation deformity.
other cortex.
metal.
201
When henry III visited paris in 1254, he admired
the
know, about
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
Thomas’ Test
Pulled Elbow
Cervical collar
Metatarsal bar.
Heel Wedges.
203
works of H.O. Thomas’.
4. John Lister
X-ray in 1895.
Anaesthesia
Acute Appendicitis.
204
7. Langenback (1850)
8. Lane (1894)
Brodie’s Abscess.
205
Consultant in 1847.
and orator.
spiralis
Osteitis deformans.
Cerebral palsy.
deformity.
206
Brachial plexus Raqdicular paralysis.
Ligation of vessels.
207
Volkmann’s Canal in Bone marrow
Ischaemic contracture
Volkamann’s Ligament.
Contracture
First Laminectomy
20. T.P.McMurray
208
Followed, Robert Jones at Liver pool
22. Bonegrafting
Internal Fixation.
209
Public Health Eduction
24. Bunnel
Hanseniosis.
25. Charnley
Fractures
INDIAN ORTHOPAEDICS.
Association.
210
2. Dr. b.Mukhopadhya
Association (IOA)
Embryo.
SICOT
211
5. Dr. A.K. Gupta
8. Dr. M. Natrajan.
India.
Madras Foot.
212
T.B. of Bone and Joints and
pionecered
213
Established Rehabilitative
orthopaedic
Services in Rajasthan.
system.
214
18. Dr. D.P. Bakshi
speciality.
215
SUTURE MATERIALS
1. Classify Sutures,
2. Collagen 3. Steel.
(Plain/Chromic) 4. Polyester.
216
B. Multilament 1. Polyglycolic 1. Surgical silk
3. Polyamide
Braided.
4. Steel.
PDS (white)
180days
217
Cocoon of silk larvae Made of flex and cellulose Seed
of
cotton
than silk
Minimally reactive’
218
5000- 3000 B.C. Eye needle invented.
body needles.
219
Polyester -THR, Scoliosis
No accidental unthreading
Sterility maintained
Uniform strength.
220
A. Round Body Taper cut, Trocar point
C. Micropoint needles
221
O.T. TECHNIQUES AND INFECTIONS
UV radiation
Congenital
222
Old age
Obesity
Diabetes
Implant Surgery
Rheumatoid Arthritis.
I/V Cannula
Tracheostomy
Indwelling catheter
Pneumonitis
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.
extubation
224
STERILIZATION
METHOD FROCESS.
A. Physical
B. Radiation
C. Chemical
Alcohol Ethanol
Aldehyde Formaldehyde
225
Halogen Chlorine
4. What is Cidex?
226
InLysol for 1-2 hours.
15-20 minutes.
227
central line a little above middle of forearm. The
greatest
Volkmann’s contracture.
minus hand.
Wrist flexed.
228
Forearm pronated
Elbow flexed.
forearm.
a. Reconstructive procedure.
b. Tendon transfers.
229
c. Muscle Transplanting.
d. Pedicle grafting for Nerve lesions.
mass is a sequestrum.
FRACTURE FIXATION
230
oblique, transverse and butterfly fractures. A Bending force
causes
231
causes the progression at 45degree plane.
232
in a bone or a window for bone graft. Other examples are
may be either.
Galvanic
233
rupture
Intergranular corrosion or
pitting corrosion
facilitation
234
Less allergic
Steel Cheap
loading.
235
Pitch – Distance between adjacent threads.
236
A method to achieve compression between two bone
fragments,
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?
c. functioning.
else closer than this, it may split along the hole, and loosen
the
fixation.
238
loading over the bone causing osteopenia and these occur
phenomenon
Possibility of corrosion
Infection
Tibia – Lateral
Humerus- Posterior
239
22. for what fracture Kuntscher nail was first used?
240
Causes infection of medullary fat into transcortical vessels
and
venous system.
Pass a ball tipped guide wire till the proximal end is broken.
Pass two or more guide wire into distal end of nail and
hammer
241
For Distal create a window in the bone distal and tip of nail
and
242
tissues and (3) prevens the joint stiffness thus accelerating
rehabilitation.
WHEN TO APPLY ?
243
the fracture or traction may be needed initially. Care being
taken
removed.
Shortening should not exceed ¼ inch for tibia and ½ inch for
femur.
244
2. Fractures around knee 3 weeks.
245
fibula fracture. Even fracture in tibia with intact
fibula
246
cases who had compound. Fracture and ORIF hs been
8. Forearm Fractures.
1. In both bones fracture.
2. After internal fixation, if the fixation is not rigid.
2.Postoperative infection
8. Distraction of fragments.
9. Skin necrosis.
247
TECHNIQUES
Indieations :
supracondylar fracture
2. For fractures proximal one third of tibial tibial shaft
248
4. Those condylar fracture of femur and tibia in which open
reduction and internal fixation are not indicated.
II. Material ;
axis.
compressed by cast.
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
III. Technique :
the hinge free, then long bar of thigh portion and short bar of
leg
250
movement of hinge and not interfered by knee movements.
The
itching.
251
So a line is drawn vertically along mid of patella along medial
and
then 2cm. below and parallel to these lines other two lines are
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
brace.
252
Stockinette of appropriate size is applied from groin to toe and
from ischial tuberosity level to the just above the knee and it is
253
clearance permits patient to walk or sit in the cast brace
without
the patella center over the stockinette and after keeping the
254
flexion of knee.
oedema.
necessary.
is allowed.
255
ANKLE BRACE
I. Indications :
2. Bilateral fractures.
4. Compound fractures.
2. Stockinette.
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
2. No anaesthesia is required.
257
above the proximal end of patella and was firmly moulded
over
258
around the lateral and medial malleoli for permitting
complete
surface.
paris bandages.
259
After Twenty four hours of application when the plaster is
with the help of axillary Crutches, then with the help of a stick
and
possible.
Follow up :
260
examined for range of movements, and to see whether brace is
that the cast was loose and not providing required stability, the
union.
261
examination at regular interval of 4 to 6 weeks to see
etc.
Removal of Brace :
262
considered as positive sign for clinical union. In patients
who
4 weeks.
Complications :
1. Swelling of fot.
2. Angulation.
263
treating fractures shaft femur but can also be used as
supplement
Material required :
4 - 2
5 - 6
(2) Stockinette.
(3) Cast padding.
Indications :
264
1. Mid 3rd and lower 3rd fractures shaft femur.
Contradications :
Technique :
265
Patient is place don the Wastson jones fracture table and
fracture
266
Post Application management :
start active knee, hip and leg raising exercises and is allowed
Complications :
1. Alergic reactions.
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.
268
1. Hip Brace- Consists of single uniaxial joint, thigh upright
and
2. Stockinette.
10-12 rolls.
5. Screw driver.
Technique :
269
3. The hip joint axis roughly corresponds to level just above
the
trochanter.
6. Then the hip brace is placed on the lateral aspect with the
270
uniaxial joint at level just superior and anterior to the hip axis
and
pelvic casts.
support discarded.
271
at regular interval to see the progress of union. Brace is
united.
Complications :
3. Lossening of brace.
4. Breaking of brace
Contriandications :
2. Delayed/ Nonunion.
3. compound.
4. Bilateral fractures.
272
HUMERAL SLEEVE
For Children :
For Adults :
273
c. Cast padding 10cmx3M. One.
3. Technique :
2.5cm. Below axilla and laterally it extends upto the point just
moulded well over the shape of the soft tissue structures over
the
274
arm. Sleeve must allow the complete range of motion of the
flabby extremities.
4. Follow Up :
275
examination should be done 3-4 weeks interval and in each
visit of
evaluated.
clinically.
7. Complications :
276
2. Minor angulatory deformity : Upto 25 acceptable will not
WRIST BRACING
end ulna.
the small plaster of the hand. Two blades are joined together in
the
277
form of an uniaxial joint which is freely mobile in one axis. (in
the
ulnar side and the plastr is given in full supination and ulnar
deviation.
278
distal. The proximal portion of the plaster is applied over
the
30degree.
joint.
279
rnage of finger movements.
5.Follow- Up :
280
fracture has united clinically.
Indication :
fixation.
Materials :
1. Stockinette.
2. Castpadding.
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3. Cotton roll
Methods :
by the side of the chest. An assistant holds the elbow and the
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sprinkles an antibiotic/antifungal poweder over the fo4rearm
and
the condyles, over the distal end just proximal to the wrist and
strip
end the plaster is moulded over both the latral and medial
condyles
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plaster is moulded over the wrist to allow upper grip.
full extension. The slab now is applied oer the dorsal aspect of
the sharp edges and pointed ends of the plaster are rounded off
away and the elbow and hand are ceaned. An idal OCB is light
After Treatment :
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movement from 30 short of full extension and a wrist ROM
from
function brace.
aesthetic and because both the elbow and wrist joints are free
Material :
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1. Plaster of Paris Bandages 4x4(approx)
2. Stockinette One
4. Screw Driver.
Indications :
After the fragments have become sticky and there has occurred
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.
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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.
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DISABILITY EVALUATION
1. Define Disability ?
b. Awkwardness 20%
c. Wakness 20%
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d. Insecurity 10%
Similarly muscle power also has .30, for shoulder elbow and
wrist.
I 80%
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II 60%
III 40%
IV 20%
V 0%
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
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5. What are draw backs of McBride Formula?
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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 ?