LMCC Orthopedic Review Lecture

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• LMCC Orthopedic Review Lecture
• April, 2004
• Back to Basics
• Dr. P.R. Thurston

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Syllabus

• 1. Diagnosis, Treatment Complications of
  Fractures /Dislocations.
• 2. Diagnosis Treatment of Arthritis.
• 3. Assessment and Management of Low Back Pain.

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• Fractures

Dislocations
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Fractures
A discontinuity in the structural integrity of a
bone.
Definition -

A fracture occurs because the force
applied exceeds the breaking strength of the bone
so that the Load can no longer be transferred
across that zone of the bone.

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Fractures

• All fractures ultimately begin with kinetic
  energy, released by misadventure and applied to
  the human body.
• Some of that energy is absorbed and some is
  transmitted to the surroundings.
• Absorbed energy must be dissipated, ie.
  distributed, through the soft tissues and bones.
• Fractures occur when the bone can not dissipate
  all of the energy absorbed.

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Fractures

• Thus -
• 1 ) A fracture occurs when the energy
  transferred to a bone exceeds the ability of the
  bone to dissipate that energy.
• 2 ) Further energy dissipation produces -
• - comminution.
• - soft tissue damage (open fractures).
• - displacement.
• - other fractures.

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Definitions

• Fracture- A discontinuity in the structural
  integrity of a bone.
• Infraction- An incomplete fracture.
• Dislocation- Complete loss of contact of the
  articular surfaces of a joint.
• Subluxation- Non-concentric joint surfaces.
• Reduction- Returning a fracture or dislocation
  to an anatomical alignment.
• Comminution- Multiple fragments.

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Fractures
Mechanical Properties of Bone

• Bone is a two-phase material -
• Calcium HydroxyApatite Ca10(PO4)6(OH)2
  mineral
• Osteoid Collagen type I and III
  fibrous
• Calcium is strong in compression, but weak in
  tension.
• Osteoid is strong in tension, but weak in
  compression.

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Fractures

• BUT - (for adult bone)
• Calcium is stronger in compression than
  Osteoid is in tension
• And therefore -
• Bone always fails first in tension

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Fractures
For immature bone, this effect is reversed.
The Buckle or Torus fracture occurs because the
bone fails in compression first.
In children, the Osteoid is stronger than the
Mineral phase.
Generally, the dislocation in youth becomes the
fracture in the adult.
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Fractures

• A bone consists of three areas -
• the Diaphysis
• the Metaphysis
• the Epiphysis.

Each region has its own fracture characteristics.
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Fractures

• Bending
• Torque
• Direct
• Traction
• Compression
• Intra-articular
• Pediatric

Oblique
Diaphyseal
Spiral
Transverse
Metaphyseal
Epiphyseal
Mixed
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Bending
Fractures

• Bending produces a transverse fracture line, with
  or without a lip.
• When load is added, the lip becomes a butterfly
  fragment.
• With more loading, the fracture line becomes
  oblique.

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Torque
Fractures

• - Rotatory shear produces a continually changing
  line of failure, giving the typical Bayonet
  Spikes at the ends of the bones.
• The greater the load the longer the fracture.
• These occur only in long bones and are referred
  to as-
• Spiral Fractures

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Torque
Fractures

• piral
• The butterfly segment is different from the
  oblique bending fracture.

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Fractures
If no butterfly, then the ends are Bayonet in
appearance.
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Direct Blow
Fractures

• tapping fractures.
• Fractures of dying momentum.
• Tension produced on the opposite side of the
  bone.
• Comminution produced on the impact side of the
  bone.
• High energy injuries.

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Direct Blow
Fractures
Transverse Fractures Comminution on the opposite
side to a bending fracture, ie. at the point of
impact. The Nightstick Fracture.
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Metaphyseal
Fractures
Traction Avulsion.

• The Metaphysis is subject to all of the
  diaphyseal patterns plus-
• 1) Traction Avulsion.
• 2) Compression.

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Metaphyseal
Fractures
Traction-Avulsion

• are transverse since the tension is equal on
  both sides of the bone.
• are caused by ligament or tendon traction.
• always occur adjacent to joints.

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Fractures
Traction Avulsion.
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Compression
Fractures

• Crush fractures
• Impacted fractures
• Usually comminuted
• Usually axial skeleton
• - Vertebrae
• - Calcanei

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Epiphyseal
Fractures

• The Epiphysis is subject to all of the diaphyseal
  and metaphyseal patterns
  plus-
• 1) Intra-articular Fractures.
• 2) Pediatric Fractures about the Epiphyseal
  plate.

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Epiphyseal
Fractures

• Intra-articular Fractures
• Always require accurate reduction.
• Usually require surgical treatment.
• Are often comminuted.
• Frequently threaten Post-traumatic Osteoarthritis.

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Epiphyseal
Fractures

• Pediatric Epiphyseal Fractures
• Produce fracture patterns specific to children.
• Always require accurate reduction.
• Can produce growth abnormalities.
• Salter-Harris Classification.

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Salter-Harris Classification
Fractures
I
II
III
IV
V
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Salter-Harris Classification
Fractures
1) Fractures interfering with growing
bones. 2) Worse prognosis with increasing
number. 3) Probability of surgery increases with
number.
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Fractures

• A fracture can occur in -
• normal bone subject to abnormal forces.
• Traumatic Fractures.
• abnormal bone subject to normal forces.
• Pathologic Fractures.
• normal bone subject to cyclic forces.
• Fatigue or Stress Fractures.

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Description
Fractures

• 1) Displacement - Angulation
• 2 ) Closed or Open.
• 3 ) Simple or Comminuted.
• 4 ) Fracture Pattern eg. Spiral, Transverse etc.
• 5 ) Anatomical Area.
• 6 ) Mechanism.

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Fracture Description

• This fracture is angulated laterally, since it
  points laterally.
• The distal fragment is tilted medially

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Description
Medially Displaced Closed Comminuted Short
Oblique Fracture of the Proximal Humerus Caused
by a direct fall
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Fracture Description

• 1) The distal fragment is always described with
  relation to the proximal segment.
• 2) Displacement Translation of bone ends.
• 3) Angulation Orientation of bone ends.
• 4) Angulation identifies to where the fracture
  points.
• 5) For clarity, the tilt of the distal fragment
  is often used to describe angulation.

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The Periosteal Bridge

• The Periosteal Bridge is intact on the concave
  side of the fracture.
• Reversal of the mechanism of the fracture
  tightens the bridge and stabilizes the fracture.

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The Periosteal Bridge

• Tightening the periosteal bridge locks the
  fracture together.
• Holding the bridge tight requires three point
  fixation.
• It takes a bent cast to produce a straight bone
• J. Charnley

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Treatment

• Closed or Open ( Surgical ).
• - Both require an understanding of fracture
  healing.
• - Closed requires reversal of mechanism of
  injury.

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Indications for Closed Reduction

• There is significant displacement.
• Reduction is possible.
• The reduction, if gained, can be held.
• The fracture has not been produced by a traction
  force.

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Indications for Open Reduction

• 1 ) There is a significant Displacement.
• 2 ) Open Fractures.
• 3 ) Intra-articular Fractures.
• 4 ) Un-reducible Fractures
• 5 ) Reductions that cannot be maintained in a
  cast.
• 6 ) Comminuted or Segmental Fractures.
• 7 ) Floating Joints.
• 8 ) Fractures with Neurovascular damage.

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Open Fractures

• Classification -
• 1. lt 1 cm., inside-out, little soft tissue
  damage.
• low potential for infection.
• 2. 1 cm. 10 cms., outside-in, requires
  debridement, but no flap or skin graft.
• moderate potential for infection.
• 3. gt 10 cms., outside-in, high energy,
  devitalized muscle, comminution or bone loss,
  soft tissue loss.

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Open Fractures

• Classification -
• 3A. No loss of soft tissue cover, no flap
  required.
• 3B. Flap required due to soft tissue stripping.
• 3C. Associated vascular injury.

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Type 1. Open Fracture 6 mm, extend debride
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Degloving Mechanism
Degloving Mechanism
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Type III C Injuries Vascular Injury
Note pallor of the ankle No pulses
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Fracture Complications

• 1. Pulmonary Fat Emboli
• 2. Compartment Syndromes
• 3. Cast Disease
• 4. Stress Fractures
• 5. Pathologic Fractures

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Pulmonary Fat Emboli - A.R.D.S.

• - Long bone fractures, burns, contusions.
• - Interstitial pneumonitis due to free fatty
  acids
• - S.O.B. confusion in young adults.
• - Axillary Subconjunctival Petechiae.
• - Serum lipase elevated.
• - pAO2 reduced if lt 50 20 mortality.
• - Ventillatory support
• - Dexamethazone.
• - 5 day course.

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Compartment Syndromes

• - increased interstitial tissue pressure.
• - fractures, burns, tight dressings.
• normal pressure lt 25 mm. Hg.
• when the tissue pressure gt venous capillary
  pressure, but less than the arteriolar pressure.
• 5 Ps
• - pain.
• - pallor.
• - pulselessness.
• - paresthesias.
• - paralysis.

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Compartment Syndrome
Symptom Pain out of proportion to that
expected for the injury. Signs 1. Loss of
function of muscle due to ischemia within
the compartment. 2. Pain with passive
stretch 3. Numbness etc. are LATE findings! 4.
If neuro symptoms present, potential
for full neuro recovery is only 10
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Rx Compartment Syndrome
Release all compressive dressings / plaster.
Elevate extremity to heart level.
Fasciotomies.
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Rx Compartment Syndrome
Increased girth. Pallor of the foot. Recent
surgery.
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4 compartment fasciotomy
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Compartment Syndrome
Careful monitoring. Recognise it - 5 Ps
Call Orthopaedic Surgeon Pressure measurements

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Stress or Fatigue Fracture

• Repeated loading below acute
• failure threshold.
• Eventual fatigue failure.
• Military recruits, runners, aerobics.
• Tibia, metatarsals, femoral neck.
• Initial x-ray can be negative.
• Bone tenderness Bone scan.

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Pathologic Fractures

• Failure through abnormally
• weakened bone
• Minimal trauma BEWARE
• Osteoporosis
• Metastasis
• Tumour- Benign, Malignant
  (Myeloma).
• Metabolic Bone Disease

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Pathologic Fractures
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Fractures
Ultimately, the treatment of fractures requires

• an understanding of the mechanism that produces
  them,

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Fractures
An understanding of the diagnostic tools
available,
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Fractures
And the current technologies used in their
treatment
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Dislocations

• The articular surfaces are no longer in contact.
• Commonly affects -
• Shoulders gt PIP joints gt Elbows gt Ankles.
• Often associated with fractures.
• Often associated with neurologic injuries

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Shoulder Dislocations

• 95 anterior
• 1 posterior
• Luxatio erecta
• Medial
• Axillary nerve injury
• Rapid reduction

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Shoulder Dislocations

• Conscious sedation.
• Traction reduction.
• Immobilization.
• Recurrent.
• Voluntary
• Habitual.
• Multiaxial instability.

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Elbow Dislocation

• Posterolateral.
• Median nerve injury.
• Ulnar nerve injury.
• Rapid reduction.
• Early mobilization.

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Back Pain
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Classification Mechanical (MacKenzie)

• Postural syndrome
• normal tissues become painful by the application
  of prolonged stresses (sitting, bending etc)
• Dysfunction syndrome
• soft tissues are shortened and stiff. Usually gt30
  year old, poor posture, under exercised, reduced
  mobility
• Derangement syndrome
• Disc derangement (tears and herniation)

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Causes and Classification of Back Pain McNab

• Spondylogenic
• Osseus
• Trauma
• Infection
• Neoplasms
• Inflammatory
• Metabolic (eg.Pagets)
• Deformities
• Soft tissues
• Muscles
• SI joints
• Disc
• Facets

• Viscerogenic
• Vasculogenic
• Neurogenic
• Psychogenic
• Spondylogenic

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Non operative Treatment of Back Pain

• Do nothing
• Activity modification
• Medications
• Exercise and physiotherapy
• Braces
• Manipulation
• Massage therapy
• Traction/inversion therapy
• Vitamins/Supplements/Diets
• Weight control
• Every Suzanne Summers sponsored abs exerciser

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Degenerative Conditions of the Lumbar Spine

• Congenital
• Disc herniation
• Degenerative Disc Disease
• Spinal Stenosis
• Degenerative Spondylolisthesis
• Degenerative Scoliosis

And when did you first notice that your back had
gone out?
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Congenital Anomalies

• Congenital scoliosis

Arthrogryposis
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Congenital anomalies

• Spina bifida

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Anatomy
Extension
Flexion
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Three joint complex(Kirkaldy Willis, Farfan)
Instability
Lateral n. ent
Central stenosis
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Disc herniation
Ms J.H. 25 y.o. female presented with cauda
equina syndrome
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Spinal stenosis

• Symptoms
• unilateral radicular pain
• bilateral claudication
• better with forward flexion of trunk
• better walking uphill
• rare bowel/bladder involvement

• Signs
• usually no neuro signs
• look for pulses
• stress test
• Investigations
• XR
• CT
• Myelo-CT
• MRI

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Spinal stenosis
Post myelogram CT
AP
lateral
myelogram
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Degenerative Spondylolisthesis

• Most common cause of spinal stenosis
• More common in women, hemisacralization of L5,
  diabetics and women with BSO
• OA of hip also in 11-17

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Isthmic spondylolisthesis
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Severe spondylolisthesis
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Time for a 10 minute break!
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Pediatric Orthopedics

• 1. Developmental Dysplasia of the Hip.
• 2. Legg-Perthes Disease.
• 3. Slipped Capital Femoral Epiphysis.
• 4. Club Feet.
• 5. Osteomyelitis.
• 6. Septic Hip.

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1. Talipes Equinovarus is the proper name for -

1. Flat feet
2. In-toeing
3. Club feet
4. Knock knees
5. Wry neck

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Talipes Equinovarus is the proper name for -

• c. Club feet

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1. Talipes Equinovarus is the proper name for -

• Flat feet
• In-toeing
• Club feet
• Knock knees
• Wry neck

Pes Planus
Metatarsus Adductus
Genu Valgus
Torticolis
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Talipes Equinovarus

• congenital deformity of the foot
• Equinus, Inversion, Adduction, Supination
• 2 per 1000 live births
• 50 bilateral
• M gtF 21
• Serial corrective casts at birth
• Surgery if resistant
• EARLY TREATMENT IS ESSENTIAL

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2. Trendelenburg refers to -

1. Leg length discrepancy
2. Gait abnormality
3. Knee recurvatum
4. Scoliosis
5. Hip Contracture

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2. Trendelenburg refers to -

• b. Gait abnormality

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2. Trendelenburg refers to -

1. Leg length discrepancy Apparent vs Real
2. Gait abnormality
3. Knee recurvatum straightens past 1800
4. Scoliosis lateral curvature, lordosis, kyphosis
5. Hip Contracture Thomas test

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3. All of these are signs of D.D.H. except -

1. Limited Abduction
2. Ortolani Sign
3. Asymmetric Skin Folds
4. Galeazzis Sign
5. McMurray Sign

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3. All of these are signs of D.D.H. except -

• e. McMurray Sign

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3. All of these are signs of D.D.H. except -
Dislocated

1. Limited Abduction
2. Ortolani Sign
3. Asymmetric Skin Folds
4. Galeazzis Sign
5. McMurray Sign

Reducible
Dislocated
Knee height
Torn Meniscus
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Developmental Dysplasia of the Hip

• Acetabular dysplasia
• Femoral anteversion
• Adduction Contracture
• 50 bilateral, F gt M 81
• Test ALL newborns at birth
• Conservative Rx at birth Pavlik, D.diaper
• Surgical Rx if resistant

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4. The most common congenital Spinal abnormality
is -

1. Scoliosis
2. Spina Bifida
3. Torticolis
4. Klippel Feil Syndrome
5. Multiple Hereditary Osteochondroma

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4. The most common congenital Spinal abnormality
is -

• b. Spina Bifida

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4. The most common congenital Spinal abnormality
is -

1. Scoliosis
2. Spina Bifida
3. Torticolis Wry Neck
4. Klippel Feil Syndrome Congenital Fusion
5. Multiple Hereditary Osteochondroma

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Spinal Bifida

• defect of neural tube closure
• Lumbar spine, commonly low
• 2 per 1000
• myelodysplasia
• Mild to complete paraplegia
• Occulta, meningocoele, Myelomeningocoele
• Bowel and bladder dysfunction

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Polydactyly
5.
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Syndactyly
6.
100
7.
101
Sprengels Deformity
Omovertebral Bone
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8. A 6 year old boy with delayed physical
development, convulsions, tetany, weakness,
blue sclera and bony deformities is most likely
suffering from -

• a. Physical Abuse
• b. Ehlers Danlos Syndrome
• c. Osteogenesis Imperfecta
• d. Multiple Hereditary Exostoses
• e. Myositis Ossificans

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8. A 6 year old boy with delayed physical
development, convulsions, tetany, weakness,
blue sclera and bony deformities is most likely
suffering from -

• c. Osteogenesis Imperfecta

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8. A 6 year old boy with delayed physical
development, convulsions, tetany, weakness,
blue sclera and bony deformities is most likely
suffering from -

• a. Physical Abuse
• b. Ehlers Danlos Syndrome
• c. Osteogenesis Imperfecta
• d. Multiple Hereditary Exostoses
• e. Myositis Ossificans

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9. A 6 year old boy with delayed physical
development, a rachitic rosary, weakness and
bony deformities is most likely suffering from -

• a. Physical Abuse
• b. Rickets
• c. Scurvy
• d. Osteitis Deformans
• e. Myositis Ossificans

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9. A 6 year old boy with delayed physical
development, a rachitic rosary, weakness and
bony deformities is most likely suffering from -

• b. Rickets

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9.
108
9.
109
Etiology Alkaline
Calcium Phosphate Urea
Phosphatase Vita
min D Up Down Normal
NormalDeficiency Rickets
Renal Up
Down Up UpInsufficiency (Renal
Rickets) Renal Up
Down Down NormalTubular
Insufficiency (HypoPhosphatemia)
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10. This is -

• a. Osteomyelitis
• b. Osteomalacia
• c. Osteoporosis
• d. Osteitis Deformans
• e. Leprosy

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10. This is -

• d. Osteitis Deformans

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10. This is -

• a. Osteomyelitis
• b. Osteomalacia
• c. Osteoporosis
• d. Osteitis Deformans
• e. Leprosy

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Osteitis DeformansPagets Disease

• 4 of pop. Over 40 yrs.
• accelerated bone turnover
• often assymptomatic
• monostotic gt polyostotic
• loss of stature
• AV shunting
• pathologic bone

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11. A child with knee pain has a ____ problem
until proven otherwise.

• a. Knee
• b. Femoral
• c. Tibial
• d. Hip
• e. Patella

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11. A child with knee pain has a ____ problem
until proven otherwise.

• d. Hip

Obdurator Nerve
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11. All of the following are part of the
differential of hip pain in a 6 year old, except
-

• a. Femoral Osteomyelitis
• b. Septic Hip
• c. Transient Synovitis
• d. Legg-Perthes Osteochondritis
• e. Slipped Capital Femoral Epiphysis

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11. All of the following are part of the
differential of hip pain in a 6 year old, except
-

• e. Slipped Capital Femoral Epiphysis

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11. All of the following are part of the
differential of hip pain in a 6 year old, except
-

• a. Femoral Osteomyelitis
• b. Septic Hip
• c. Transient Synovitis
• d. Legg-Perthes Osteochondritis
• e. Slipped Capital Femoral Epiphysis

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Ages for Hip Disease

• D.D.H. Birth
• Septic Hip Birth 11
• Legg-Perthes 3 11
• Transient Synovitis 3 11
• S.C.F.E. 11 - 16

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12. Osteomyelitis in children is produced by
what route of infection?

• a. Direct extension from another focus
• b. Hematogenous spread
• c. Perforating wounds
• d. Lymphatic spread
• e. Septic hip

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12. Osteomyelitis in children is produced by
what route of infection?

• b. Hematogenous spread

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Osteomyelitis

• Acute infection,metaphyseal
• 90 Staph.,20 mortality
• 100 growth abnormality
• Periosteal elevation, osteolysis
• Sequestrum, Involucrum

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13.
124
13.
Paronychia
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14.
126
14.
Felon
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15. All of these are findings of a Herniated
L5-S1 disc, except -

• a. Absent Achilles reflex
• b. Lateral foot numbness
• c. Sciatica
• d. Low back pain
• e. Extensor Hallucis Longus weakness

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15. All of these are findings of a Herniated
L5-S1 disc, except -

• e. Extensor Hallucis Longus weakness

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15. All of these are findings of a Herniated
L5-S1 disc, except -

• a. Absent Achilles reflex S1
• b. Lateral foot numbness S1
• c. Sciatica S1
• d. Low back pain
• e. Extensor Hallucis Longus weakness L5
• f. Knee jerk L4

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16. Avascular necrosis of the femoral head is
associated with all of the following except -

• a. Steroid use
• b. Alcohol
• c. Deep sea diving
• d. Lipid storage disease
• e. Diabetes

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16. Avascular necrosis of the femoral head is
associated with all of the following except -

• e. Diabetes

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16. Avascular necrosis of the femoral head is
associated with all of the following except -

• a. Steroid use
• b. Alcohol
• c. Deep sea diving
• d. Lipid storage disease
• e. Diabetes

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17.
8 year old boy
What is the Diagnosis?
134
17.
8 year old boy
Legg Perthes Osteochondosis
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Legg-Perthes Disease

• Osteochondrosis (avascular necrosis)
• Proximal Femoral Epiphysis
• Necrosis, revascularization, fragmentation,
  healing
• 3 11 yrs., M gt F 41, 15 bilat.
• Subluxation laterally, Coxa plana, Coxa magna
• Osteoarthritis 50 yrs.

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Osteochondroses
18.

• Freibergs Disease
• Osgoode-Sclatters
• Scheuermanns
• Kienbocks
• Osteochondritis Disecans

2nd Metatarsal Head
Tibial Tubercle
Spine
Carpal Lunate
Lateral Femoral Condyle
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19. Diagnosis?
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19. Gout
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Gout

• Urate crystalopathic arthritis
• Crystals in periarticular tissues
• Inconsistant elevated serum urate
• Allopurinol and colchicine
• Tophi in periarticular soft tissues
• Deposits in non-articular cartilage
• Juxta-articular erosions

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20.
L4
L5
Spondylolytic Spondylolisthesis
141
Spondylolisthesis

• Lumbosacral junction defect
• Spondylolysis of Pars Interarticularis
• Traumatic or congenital
• Acute immobilize
• Chronic - surgery

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21. The Salter- Harris Classification is used
to assess the severity of -

• a. Epiphyseal Fractures
• b. Developmental Dysplasia of the Hip
• c. Legg Perthes Disease
• d. Club Foot
• e. Osteomyelitis

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21. The Salter- Harris Classification is used
to assess the severity of -

• a. Epiphyseal Fractures

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I
II
III
IV
V
145
22. What is this deformity?
146
22. A Diner Fork Deformity
Probable Diagnosis?
147

1. Colles Fracture

148
22. Colles Fracture

• distal radial fracture
• FOOSH
• occurs at all ages
• commonly 60 yrs.
• osteoporosis
• intra-articular

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CR K-Wires
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External vs Internal Fixation
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23. The common complication of this fracture
is -
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23. Proximal pole Avascular Necrosis
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154
24. This is a -
a. Buckle Fracture b. Greenstick Fracture c.
Stress Fracture d. Pathologic Fracture e. Growth
Arrest line
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24. This is a -
a. Buckle Fracture
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24.
This is a -
a. Buckle Fracture b. Greenstick Fracture c.
Stress Fracture d. Pathologic Fracture e. Growth
Arrest line
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24.
Greenstick Fractures
158
25. Is this fracture treated by Closed or Open
Reduction?
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ORIF
25.
160
25. Fractures of Necessity
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26. What is the Diagnosis?
162
26. Posterolateral Dislocation of the Elbow
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26. Reduction by traction.
TRACTION
164
27. What is the Diagnosis?
165
27. Anterior Dislocation of the Shoulder
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27. Reduction by traction
167
28.
This is a -
a. Supracondylar b. Olecranon c.
Dislocation d. Forearm e. Radial Head
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28.
This is a -
a. Supracondylar
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28. Supracondylar Fracture
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29. The complications of a Supracondylar
fracture in children include all of the
following except -

• a. Malunion
• b. Volkmanns Ischemic Contracture
• c. Compartment Syndrome
• d. Cubitus Varus
• e. Peripheral Nerve Injuries
• f. Pulmonary Fat Embolus

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29. The complications of a Supracondylar
fracture in children include all of the
following except -

• f. Pulmonary Fat Embolus

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29. The complications of a Supracondylar
fracture in children include all of the
following except -

• a. Malunion
• b. Volkmanns Ischemic Contracture
• c. Compartment Syndrome
• d. Cubitus Varus
• e. Peripheral Nerve Injuries
• f. Pulmonary Fat Embolus

173
30. The only sign of a Compartment Syndrome
that is always present is -

• a. Pain
• b. Pallor
• c. Pulselessness
• d. Paresthesias
• e. Paralysis

174
30. The only sign of a Compartment Syndrome
that is always present is -

• a. Pain

175
30. The only sign of a Compartment Syndrome
that is always present is -

• a. Pain
• b. Pallor
• c. Pulselessness
• d. Paresthesias
• e. Paralysis

176
31. Compartment pressures indicating the need
for fasciotomy -

• a. 0 15 mms. Hg
• b. 15 25 mms. Hg
• c. gt 25 mms. Hg
• d. gt 50 mms. Hg
• e. gt 75 mms. Hg

177
31. Compartment pressures indicating the need
for fasciotomy -

• c. gt 25 mms. Hg

178
Compartment Syndrome

• fractures, crush injuries, burns
• collapse of venous return compartment pressure gt
  25 mms. Hg
• engorgement of muscle within
• necrosis of muscle tissue
• Volkmanns Ischemic Contracture
• Fasciotomy

179
32. A 20 yr. old male with a fractured femur
has findings of confusion, tachypnea and
conjunctival petechia. The most likely diagnosis
is -

• a. Pneumonia
• b. Pulmonary Fat Emboli
• c. Cerebral Contusion
• d. Cardiac Contusion
• e. Transient Stress Reaction

180
32. A 20 yr. old male with a fractured femur
has findings of confusion, tachypnea and
conjunctival petechia. The most likely diagnosis
is -

• b. Pulmonary Fat Emboli

181
32. Pulmonary Fat Embolus

• 2 - long bone s 10 - multiple s
• tissue thromboplastin ---gt extrinsic cascade VII
• A.R.D.S. - aterial hypoxemia
• petechia across chest, in axillae and conjunctiva
• early fixation decreases PFE, but increases
  infection rates
• no current lab tests or treatment protocol

182
33. Name the Fracture -
183
33. Monteggia Fracture
184
33. Monteggia Fracture
185
33. Monteggia Fracture
186
34. Name this fracture -
187
34. Name the fracture -
Galeazzi Fracture
188
GaleazziFracture
34.
189
35. The commonest complication of this
fracture is -
190
35. A Radial Nerve Palsy
191
36. Does this fracture require surgery?
192
36. Does this fracture require surgery?
Yes
193
37. Does this fracture require surgery?
194
37. Does this fracture require surgery?
No
195
38. This patient most likely has a fracture
of the --------.
196
38. This patient most likely has a fracture
of the --------.
Hip
197
38. This patient most likely has a fracture
of the hip.
External Rotation Shortening Hip Flexion
198
38.
199
39. Whats the Diagnosis?
200
39. Sub-Capital Hip Fracture.
201
40. All of the following are complications of
this fracture except -
a. Malunion b. Avascular necrosis c. Fat
emboli d. Non-union e. Thrombophlebitis
202
40. All of the following are complications of
this fracture except -
c. Fat emboli
203
40. Blood Supply of Femoral Head
204
40. Save Head versus Replacement
205
40. Subcapital Hip Fractures
Garden Classification
1. Abduction 2. Minimally displaced 3. 50
Displaced 4. Completely Displaced
206
40. Subcapital Hip Fractures
Properties
1. Avascular Necrosis - 30 2. Malunion -
30 3. Non-union - 30 4. Surgery required 5.
Older population 6. Pathologic - Osteoporotic

207
41. Whats the Diagnosis?
208
41. Intertrochanteric Hip Fracture
209
41. Intertrochanteric Fractures
210
41. Intertrochanteric Fractures
Properties

• 1. Varus deformity
• 2. Well - Healing
• Traumatic Osteoporosis
• Surgery required
• Mid-range Age population

211
42. What is the Diagnosis?
212
42. What is the Diagnosis?
Subtrochanteric Hip Fracture
213
42. Subtrochanteric Fractures
Properties

1. Non-union
2. Traumatic
3. Surgery required

214
43.Surgery or not?
215
43.Surgery or not?
Yes
216
44. Surgery or not?
217
44. Surgery or not?
Yes
218
44. Ankle Fractures
Eversion Injuries
219
44. Ankle Fractures
Inversion Injuries
220
45. What is the approach to this fracture?
23 y.o. male Basketball injury Open fracture
Numbness dorsum toes
221
45.
Reduce dislocation Sterile dressing Splint
extremity Re-check NV status IV Antibiotics
Tetanus Surgery
222
46. Surgery or not?
223
46. Surgery or not?
Yes
224
47. Surgery or not?
225
47. Surgery or not?
Yes
226
47. Surgery or not?
Yes
227
48. A 45 yr. old male, who was previously in good
health, has sudden onset of transverse low back
pain and right sided sciatica to his foot, after
chopping wood at the cottage. Upon arising the
following morning, he notices numbness on the
outer border of his right foot and some
weakness in the right leg. He has no bowel or
bladder problems. The most likely diagnosis
would be-

• a. Lumbar Muscular Strain.
• b. Herniated Lumbar Disc.
• c. Herniated Lumbosacral Disc.
• d. Cauda Equina Syndrome.
• e. Spinal Stenosis.

228
48. A 45 yr. old male, who was previously in good
health, has sudden onset of transverse low back
pain and right sided sciatica to his foot, after
chopping wood at the cottage. Upon arising the
following morning, he notices numbness on the
outer border of his right foot and some
weakness in the right leg. He has no bowel or
bladder problems. The most likely diagnosis
would be-

• c. Herniated Lumbosacral Disc.

229
49. Your initial approach to this problem would
include some or all of the following-

• a. Bedrest.
• b. Anti-inflammatories.
• c. Muscle Relaxants.
• d. Spinal X-rays.
• e. Physiotherapy.
• f. Orthopedic/Neurosurgical referral.
• g. CT-Myelogram or MRI
• h. Discectomy

230
49. Your initial approach to this problem would
include some or all of the following-

• a. Bedrest.
• b. Anti-inflammatories.
• c. Muscle Relaxants.
• d. Spinal X-rays.
• e. Physiotherapy.
• f. Orthopedic/Neurosurgical referral.
• g. CT-Myelogram or MRI
• h. Discectomy

?
231
50. During the work-up for this problem, the
patient complains that he has unaccountably
soiled his underwear, without knowing it. Your
response to this would be to-

• a. Reassure the patient that this is not serious
• b. Order an urgent MRI
• c. Get an urgent referral to Neuro/Orthopedics
• d. Place the patient on immediate bedrest.

232
50. During the work-up for this problem, the
patient complains that he has unaccountably
soiled his underwear, without knowing it. Your
response to this would be to-

• c. Get an urgent referral to Neuro/Orthopedics

233
50. During the work-up for this problem, the
patient complains that he has unaccountably
soiled his underwear, without knowing it. Your
response to this would be to-

• a. Reassure the patient that this is not serious
• b. Order an urgent MRI
• c. Get an urgent referral to Neuro/Orthopedics
• d. Place the patient on immediate bedrest.

234
51. A lumberjack felling a tree is unfortunately
struck on the back by the tree, knocking him to
the ground and injuring his left lower extremity.
In the ER, his left hip is in flexion, adduction
and internal rotation. The most likely diagnosis
is-

• a. Fracture of the Hip.
• b. Fracture of the Femur.
• c. Anterior Hip Dislocation.
• d. Posterior Hip Dislocation.
• e. Fracture of Pelvis.

235
51. A lumberjack felling a tree is unfortunately
struck on the back by the tree, knocking him to
the ground and injuring his left lower extremity.
In the ER, his left hip is in flexion, adduction
and internal rotation. The most likely diagnosis
is-

• d. Posterior Hip Dislocation.

236
52. Which of the following signs and symptoms
are consistent with a torn medial meniscus of
the knee-

• a. Inability to squat
• b. Pain on descending stairs
• c. Locking
• d. Recurrent effusions
• e. All of the above.

237
52. Which of the following signs and symptoms
are consistent with a torn medial meniscus of
the knee-

• a. Inability to squat
• b. Pain on descending stairs
• c. Locking
• d. Recurrent effusions
• e. All of the above.

238
A 35 yr. old male falls jogging and sustains an
undisplaced lateral malleolar fracture of the
ankle. He is treated in a Below-knee Walking
cast, but returns to the ER 24 hrs. later
complaining of increased, persistent, burning
pain at the ankle. Your response to this
situation would be to-

• a. Re-X-ray the ankle.
• b. Remove the cast.
• c. Measure the compartment pressures.
• d. Instruct the patient to elevate the limb
  and prescribe an anti-inflamatory.

239
53.. A 35 yr. old male falls jogging and sustains
an undisplaced lateral malleolar fracture of the
ankle. He is treated in a Below-knee Walking
cast, but returns to the ER 24 hrs. later
complaining of increased, persistent, burning
pain at the ankle. Your response to this
situation would be to-

• b. Remove the cast.

240
A 35 yr. old male falls jogging and sustains an
undisplaced lateral malleolar fracture of the
ankle. He is treated in a Below-knee Walking
cast, but returns to the ER 24 hrs. later
complaining of increased, persistent, burning
pain at the ankle. Your response to this
situation would be to-

• a. Re-X-ray the ankle.
• b. Remove the cast.
• c. Measure the compartment pressures.
• d. Instruct the patient to elevate the limb
  and prescribe an anti-inflamatory.

241
54. The most common dislocations of the shoulder
are-

• a. Medial.
• b. Posterior.
• c. Luxatio Erecta.
• d. Anterior.

242
54. The most common dislocations of the shoulder
are-

• d. Anterior.

243
55. Metastatic lesions to bone, of the
following tumours, usually produce lytic
defects except-

• a. Thyroid.
• b. Pancreas.
• c. Prostate.
• d. Kidney.
• e. Lung.

244
55. Metastatic lesions to bone, of the
following tumours, usually produce lytic
defects except-

• c. Prostate.

245
55. Metastatic lesions to bone, of the
following tumours, usually produce lytic
defects except-

• a. Thyroid.
• b. Pancreas.
• c. Prostate.
• d. Kidney.
• e. Lung.

246
Th - Tha Thats all folks!