General Orthopaedics tested viva question

De-Quervan's tenosynovitis 

 based on clinical scenario , diagnose this 

what test do you do ? , they ask.

  most important clinical test - Finketstein test 

 ,

 how do you treat ? 

    always explain role of immobilization 

   pain management 

 steroid injection 

 surgery - tell what you do ? 

Ricket's 

 x-ray diagnosis 

 investigations 

treatment 

tumor x-ray 

 Osteosarcoma , GCT , Metastasis , Ewing's  sarcoma are very frequent , master them.

Osteomyelitis 

 diagnosis 

investigation 

treatment 

          needs to be mastered in every portion of bone . 

GCT - histopathology slide was tested during our time . have a look . 

Ankylosing Spondylitis 

 a very favorite topic of CPSP Pakistan. 

recognise on X-ray 

Treatment of the condition - Flexion contracutre of both hips 

Preoperative preparation 

caution during surgery to be taken 

 

         

Tested question in viva in Paediatric orthoapedics

Club foot

 identify in photo


 councelling to parents about this condition


 meaning of familial condition


 treatment


Cerebral Palsy

 adductor tightness, equinus defomity

 its diagnosis

 types

 treatment


SCFE

 diagnosis on a photo

 x-ray elaboration of SCFE

Classify it

what lab investigations to be sent will be asked

managment





AMC

 diagnosis on photo

x-ray of hip and knee which shows both dislocated

its treatment

surgical steps for flexion contracutre release of knee was asked during our time



Scoliosis

diagnosis

risk factors for scoliosis progression

measure the deformity on X-ray

its management



DDH

X-RAY recognition

different lines to be known

   Hilgenreiners , Perkin lines

 acetabular angle and centre edge angle importance

Approach to management


 ( i remember exactly the same question , long ago. )


Congenital pseudoarthrosis of tibia

its a very important question , diagnosis in x-ray

classification very important

treatment


PFFD / Fibular deficiency

Radial Club hand  are important too. 

Already tested viva questions in trauma

Acetabular fracture

      diagnosis on plain x-ray

      classification

    approach to management

    about corona mortis


Compartment syndrome management of forearm

 (equllay important in foot and hand )

  diagnosis on plain x-ray

      based on soft tissue shadow enlargement

  approach to management



 AC joint dislocation

       diagnosis on x-ray

         type

         approach to management


 
Lisfranc Injury

    classification

       types

       management


 Supracondylar fracture


    classification

     types

    management

        they also ask if no pulsation distally on radial and ulnar arteries approach to management



ACL injury


   X-RAY FEATURES

       segond sign importance


Neck of femur fracture both in adults and paediatric cases

 diagnosis

 blood supply peculiarity

 chances of AVN

 approach to treatment



Thompsons and Austin-Moore prosthesis

 identify

  tell hip approaches

 Disadvvantage of lateral approach

 Steps of hemiarthroplasty




identify Arthroscopy instruments

tell uses

Tell different portals of ACL reconstruction and their importance

 read MRI  for ACL injury

tell the treatment for ACL injury


Identify the fracture on humerus

 tell principle of fixation

 Neutralization mode plate  fixation and lag screw fixation steps had to be explained for  a fracture in

that i was asked .

mention each steps

 name the instruments for giving compression during DCP.

Wist Special tests

Shuck test

 Ist MCP joint stability

 > 2 mm translations +ve

Grind test

    Ist MCP

         axial load and make round

Watson test

   From DF and ulnar deviation to palmar flexion and radial deviation

    thumb on scaphoid tubercle (just proximal to thenar region )


  S-L Ballotment   (scaphoid shuck and S-L Ballotment )

 L- T ballotment

TFCC compression

     axial compression

     radial to ulnar deviation

Piano key test - press with thumb on ulnar head

Other tests - DRUJ compression test

            hold distal radius and ulnar with 2 fingers and pronate and supinate them

           midcarpal instability

              TFCC like 

approach to C-spine examination

Gait , Romberg sign

Sitting

        Look - Head , neck , sides and face

        feel temperature

feel - soft tissues - anterior / posterior , deeper structures

movement

Tests

 Spurling

 Axial compression

 Hyperabduction

  Sensation

  myotome

   reflexes

  Lhermitte's

 Lying position

       Reflexes

       Clonus

        Babinski's

     Upper limb tension signs for brahial plexus tension tests

              ULT1 - patient supine

                          examines axilla , hand on shoulder not to let elevate shoulder

                          shoulder abduction to 90 degrees , forearm supination , wrist and fingers extended

                           head same side - relief ; head opposite side - pain on antecubital region


              UL 2 - Median nerve variant

                          examiner on head end , thigh depresses shoulder

                         pain if illicited suggestive of Compression

                  radial nerve variant - examiner same position

                           shoulder - IR

                           hand and fingers - PF


               ULT3

                  Ulnar nerve - examine axilla

                  arm of patient overlying pelvis
           
                 flex elbow , Dorsiflexion of wrist and finger , abduct and maximum external rotation

                    pain suggestive of tension sign .
 



Also check 

https://orthonp.blogspot.com/2020/04/algorithm-6-for-osteonecrosis-of.html

Calcific Tendinits

Calcium hydroxyappatite crystals , supraspinatus tendon 1.5-2 cm away from insertion

Investigations

 X-ray

 Ultrasound - more sensitive for diagnosis and treatment

Treatment

 Ist line - non-operative

 needling and lavage under USG guidance

 ESWL

 Surgery for symptoms progressing , absence of conservative treatment 

Frozen Shoulder

ROM Restriction , no initiating factor , global stiffness , affects external rotation

Plain X-ray normal


Stages

 1. Painful Freezing

 2. Progressive stiffness

 3. Resolution

O/e

 diffuse tenderness

 motion - active / passive both restricted

Investigations

 X-ray - to differentiate primary and secondary frozen syndrome

Bone scan - to differentiate from Reflex Sympathetic dystrophy

MRI - to rule out other pathology

Arthrosocopy - It has both therpeutic and diagnostic value.



Management

Analgesics

USG , TENS

Steroids -Intra-articular

Stretching exercises

Manipulation under anaestheisa

   sequence - flexion , extension , abduction , adduction ,external rotation , internal rotation


Arthroscopic Release

 rotator interval , MGHL , coracohumeral ligament ,


Rehabilitation

supervised ROM exercise

A brief about SLAP tears

Superior Labral Anteroposterior Tears

Associated with glenohumeral instability and rotator cuff tears

Investigations

 MR Arhtrography

Treatment

 Repair or resect Arthroscopically

Paediatric Clinical Cases -A brief review , must know .

Klippel-Feil Syndrome

Clinical Examination

Short webbed neck , no neck appearance  , head on top of shoulder with restricted ROM

Spinal Examination

 Sprenge'ls deforomity

 Torticollis ,

 Scoliosis , kyphosis

 Congenital heart disease

( Risk of atlantoaxial instability )

Not to forget Neurological examination

Sprengel's deformity

 Trapezius , Rhomboids, Levator Scapulae may be absent


Pseudoarthrosis of Clavicle

Inspection

          swelling on shoulder

          mobile end , painless

          shoulder motion


       X-ray - sclerosed ends

     managent - conservative



Gunsotck Deformity

Scars

lumps of HMEs

Abduction , thumb up - clearly seen

 Measure carrying angle

 ROM

Able to reach his face or not

Instability


Treatment

Painless

 mass present posteriorly around lateral epicondyle

 Attitude - pronated

ROM - both restricted supination and loss of  full extension





Radial Head Dislocation

Posterior - always congenital

                  radius head thin , elongated , and posterior ulnar border round.

                 restriction -- extension , forearm rotation


Congenital  anterior dislocation - often associated with other congenital conditions

          Radial head rounded , deficient  capetullm and a long radius
             
            restriction - flexion and supination

Lateral Dislocation- Cubitus Valgus



Association - Ehler-Danlos syndrome

                      Arthrogryposis



Manasgement

 Conservative

 Surgery - shortening of radius

                 excision of radius head






Radioulnar Synostosis

Attitude

loss of supination and pronation




Madelung's deformity


female

b/l prominent ulnar styloid and restricted supination , DF , Radial deviation

 Wrist deviation - ulnar and volar ward

Aetiology

 Post trauma

 HME, Achondroplasia

 Chromosomal - Turner's syndrome

 Idiopathic or primary

Surgery

 age and growth remaining

 severity - deformity

severity of symptoms

 operations

        Osteotomy , Epiphysiodesis

        Improve ROM  - Sauve Kapandji

                                    Darrach

        Both wrist fusion and Ostoetomy




Trigger Thumb 

Interphalangeal joint of thumb flexed , b/l

No other anomalies

Extension limited

At base , node mobile with flexion / extension of the joint

Treatment

 Surgical release of A1 pulley

Infants - - stretching

Congenital Absence of limbs or Part of limb

 1. failure of formation

  2. failure of differentiation

  3. failure of duplication

4. overgrowth

 5. Constriction band syndrome

 6.Miscellaneous

 7.Generalized skeletal abnormailities


Failure of Formation

 Transverse

 Longitdinal
       

      Preaxial - Hypoplasia of thumb/ radius

       central - cleft of hand

     Post - axial - ulnar hypoplasia

         intercalated arrest - phocomelia


LLD

 Depends on predicted LLD at skeletal maturity

 Current LLD

   Clinical

   Radiological

       orthoroentgenoraphy

       parallel beam scanogram

       CT scanogram

     Predicted LLD at maturity

      Menalus rule of thumb

     Moseley straight line method

     Eastwood and cole method

     Paley's multiplier method

Patient perception


   how tall is child ?

  how tall are family members ?


PFFD

   Gait - Squat

   Short Femur

        Scars

        shoe raise

Knee - ACL / PCL


Leg

   Shaft of Fibula

Foot

    Size, toes , functional or not

Ankle - Lateal and medial malleolus






























































               

Long Head of Biceps Tendon Injury

Pain on anterior shoulder


Investigations

 Plain radiography to see bicipital groove and outlet view


USG ,

MRI with Gadolinium with enhanced arthrography to identify SLAP tears

 Arthroscopy



Treatment

 PT

  strengthening rotator cuff muscles

Intra-articular tendinosis

         Debridement - 25-50 %

          Tenotomy or tenodesis for > 50 %

Subluxation / dislocation

        tenotomy or tenodesis 

Neurological Problems around shoulder

Suprascapular Nerve (C5,6 ) Injury

Compression

     due to Ganglion , Labral tears


   Above spinoglenoid notch - Supra/infra-scapular muscles

   Below spinoglenoid notch with infracspinatus muscle

Clinical features

    Lateral shoulder pain

     Wasting of supraspinatus /infraspinatus muscles

      Loss of abduction and external rotation


Management

    EMGs

    NCS



Treatment

     Trapezius muscle splitting approach

       decompress notch

     arthroscopic debridement of notch







Long Thoracic Nerve (C5-7 )

           Neuorolysis

           Pectoralis Major transfer



Spinal Accessory Nerve Injury

    Mx

        Non-operative after more than 12 months with good compensation


        Options - Neurolysis ,direct repair with nerve grafting , muscle transfer ,scapulothoracic fusion





Thoracic Outlet Syndrome

   Causes


          Cervical rib, anomalous scalenius


Types

        Neurogenic - Upper Plexus Type

                               Lower Plexus Type

        Vascular

    sites of compression

       as plexus passes over first rib

       under clavicle by subclavian tendon

        underneath coracoid process


  Provocative

     Adson , Wright ,Roos


 Investigations

        Plain radiographs of Chest  and Spine

         CT- for suspected bony anomaly

        MRI - for cervical pathology , tumor or radiation plexitis

        Doppler arteriography /Venography

        EMG and NCS


Treatment

     Physiotherapy 

      Ist rib resection , release or excision of scalene anterior and middle muscles

      via transaxillary or supraclavicular approach

     Venous thrombolysis or arterial thrombectomy and vascular reconstruction





       

Recurrent instability management

Principles of treatment



 structural instability - traumatic or atraumatic

                   operative management

  non-structural instability - muscles patterning

                 non -operative management


Structural abnormality

  Anatomical repair

         Bankart repair

             reattachment of bankart lesion to margin of glenoid by open or arhtroscopic technique



          if Hill-sach lesion , transfer infraspinatus to fill defect to prevent redislocation


 Non anatomical repairs

           Laterjet procedure

                coracoid transfer to anterior glenoid rim with conjoined tendon

            Magnuson -stock - advancement of subscsapularis

           Putti - Platt - imbrication and shortening of subscapularis

            Glenoid or humeral osteotomies - if there's excessive anteversion of GH joint.


Strucutral posterior instability

            Reverse Bankart procedure and capsular shift

            Reverse Putti-platt

           
            Boyd-sisk -transfer of long head of biceps to posterior glenoid

             
            Reverse Hill  Sachs - transfer of subscapularis to lesser tuberosity


Non structural instability and muscle patterning

            multidisciplinary approach

             EMG

            muscle patterning , exercises ,endurance , co-ordination



 
       













 

Shoulder dislocation

Swelling

Head palpable

position of extremity

Anterior test

      Duga's test

      Ruler test

      Callaway test


Neurological impairment

Instability

      Fulcrum test

     apprehension

      Jobe's relocation test

      Jerk test

      Drawer test

       Sulcus test

Investigations

      AP view

      Scapular view

       lateral view

                       information about direction of dislocation , fracture , blocks for relocation


     Stryker notch view - for humeral head defects

     
     West point axillary view - shows notch defects


       CT scan - shows detailed anatomy

       MRI - associated rotator cuff tear and labral tears


        Arhtroscopy -  invasive

                                difficult atraumatic structural and muscle pattern in non structural cases


        EMG - atraumatic complex instability situation


Treatment

 Urgent reduction

 1. Stimson method - prone , downward traction

 2. Kocher method - Redislocation rates higher

 3. Spaso technique - supine and ER and long traction

 4. Hippocratic

 5. Traction and countertraction


Open reduction for old dislocation

 Intelligent neglect - for old dislocation with good functional range


Post reduction check congruency , stability , immobilize

Later assess apprehension , cuff muscles


Complication

       Recurrence - as high as 90 % in < 20 years

                           in external rotation immobilization - low recurrence rate







                   

Calssfication of Shoulder Instability

Thomas and Masten in 1989

TUBS - traumatic unidirectional Bankart lesion treated with surgery


AMBRI - atraumatic multidirectional bilateral

                bilateral treated with rehabilitation

              responds with inferior capsular shift and closure of rotator cuff interval



Stanmore classification

Type I - true TUBS , structural

Type II- true AMBRI , strucutral

Type III - muscular patterning

Acromiocalvicular Joint Arthritis

Investigations

                    Zanca view to show AC joint


                    Lignocaine injection inside the joint


Treatment

                   Open /Arthroscopic excision

                    (5 -1 cm lateral end of clavicle excision done )

Glenohumeral Arthritis

Primary degenerative Glenohumeral Arthritis  - capsular contracture

           Anterior / Posterior subluxation , Posterior glenoid wear



 Secondary Degenerative Glenohumeral Arthritis

          Inflammatory arthritis

          Cuff tear arthropathy

          Capsulorraphy arthropathy

                   opposite side arthritis

           Neulpathic arthritis



Investigations

          X-ray - AP , Axillary views

         CT -glenoid bone stoks and zone of wear and orientation

          USG/  MRI - squality of rotator cuff repair



Treatment

         Non operative

            ROM , Strengthening exercises , NSAIDs, analgesics, steroid injections


       Shoulder Arthroplasty

Rotator Cuff Tear

Partial thickness tear based on location

 Bursal side tear

 Intratendinous tear

 Articular side

based on depth ; E'l Man's

 3 mm

  3-6 mm

  > half of tendon

Anatomical classification

 C - shaped

 U-shaped

 L-shaped

 Longitudinal

Pain at deltoid  side


Investigations

 Plain radiographs

    sclerosis on undersurface of acromion

     Traction spurs in coracoacromial line

     upward displaced humeral head

    acetabularized coracoid , acromion and glenoid

    degenerative calcification of cuff


Cuff tendon imaging


   USG - dynamic evaluation of cuff

   MRI - detects cuff tear and assesses cuff vasculature


  Treatment

 
   Partial thickness tear


 Non - operative


   activity modification

    stretching and  strengthening

    anti-inflammatory medications

   Surgery - Principles
 
              > 50 % tears (large )

             failure of conservative management from 3 -6 months

  during surgery  ,

        assess thickness of tear

       release of capsular contracture

       reinduce healing - debridement of tendon

       subacromial decompression

        Reattach tendon to its anatomical alignment

      protect repair

 


Full thickness tear

   NSAIDs, Rest

  Stretching , Strengthening

  Open /Mini-open or Arthroscopic technique

   Repair back to Greater tuberosity

     Crescent tear , U-shape tear

  Side -side repair

       long tear



 Irrepairable rotator cuff tear

  large gap in supraspinatus insertion

 latissimus dorsi transfer for posteriosuperior defects

  Pectoralis and teres major transfer for anterosuperior defects



  Deltoid and rotator cuff non function

    Glenohumeral Arthrodesis














   

Impingement with Incomplete tear of Rotator Cuff

1. Subacromial Impingement

    Intrinsic - Degneration tendinopathy

    Extrinsic - Due to coracoacromial arch



Acromion types

Type I - Acromion flat

        II - Curved

       III - Hooked

Types ; Neer Calssification

Stage1 - Edema and haemorrhage ; < 25 years

         2- fibrosis ; 25-40 years

          3 - tendon rupture > 40 years


Treatment

    Antiinflammation

   Steroids

   PT

   Strengthening exercises

 


2. Subcoracoid Impingement

   contact between subscapularis and coracoid

   Treatment - Arthroscopic or open coracoplasty



3. Internal Impingement

 contact of posterior rotator cuff with posterosuperior glenoid when ar mabducted extended and   

  externally rotated.


 Treatment

      PT - Rotator cuff strengthening exercises

      Surgery -  Removal of posterosuperior glenoid osteophytes and posterior release

Shoulder Arthroscopic Portals

Posterior (Viewing )

 2 cm medial and posterior to posterolateral corner of Acromion


Anterior

 lateral and inferior to coracoid process


Lateral

 anterior 1/3rd of lateral border of acromion and 2 cm inferior


Additional - Naeviser

                    Anterolateral

                    Posterolateral

                   Anteroinferior

                  Posteroinferior 

Bony Exostosis (Osteochondrosis )

Most common bone tumor in children

Solitary or Multiple

Aberrant cortical overgrowth adjacent to growth plate leading to eccentric bony growth


disturbances of growth plate development or localized bone disturbances

    First type

           HME - AD inheritance

          MED - AD inheritance


           Dsyplasia Epiphysealis Hemimelica (Trevor Disease ) occurs in infants and young children

       

     second type

           Fibrous dysplasia



Management

        X-ray characteristic

       CT scan - of pelvis , shoulder and spine


       MRI

         1.  assessing continuity of parent bone with cortical and medullary bone in an

            osteochondroma

         2.   catiliage cap size ,

         3.   impingement syndrome ,

          4. and arterial and venous   compromise




Angiogram

       AV compression


Treatment


     Solitary - Symptomatic

           very large - avoid in skeletally immature (restricts growth  )

           
    Multiple - treatment of symptomatic ones

     Angular deformity

         timed hemiphyseal stappling

         corrective osteotomy

        surgical decompression of neurovascular compromise











     

Achondroplasia

Normal IQ , co-operative

Head and face

            large head , frontal bossing

            mid face hypoplasia

           dental malocclusion

Skeletal features

           disproportionate short stature

                                      normal trunk length with rhizomelic shortening of proximal limbs with

                                      redundant skin folds

          brachydactyly and trident hands

          lumbar lordosis

          hyperextension knees

           limited elbow extension and rotation

         bowed legs


Radiologically

        1. small skull base

         2.progressive interpedicular narrowing L-S spine

        3.short pedicles leading to spinal stenosis

        4.short femoral neck and metaphyseal flaring with inverted V-shape distal physis

         5. small sacrosciatic notch , flat roofed acetabulum


Orthopaedic problems

          1.craniocervical junction abnormailities

          cord compression

                                 risk of contact sports , car accident and intubation

           2.lumbar stenosis with neurological claudication

           3. kyhposis




Management

Growth hormone treatment under evaluation

management of complications

Arthrogryposis

Curved joints

Classical Arthrogryposis multiplex congenita 

              limbs involved , muscles absent or deficient

 Arhtrogryposis  associated with neuropathic (brain, spinal cord, perpheral nervous system - nerves )

                                                     or myopathic (congenital muscular dystrophy )

Arthrogryposis associated with other syndromes or anomalies such as diastrophic dysplasia , 

Aetiology - Unknown 

                    Fetal Akinesia 

                   Hereditary

On examination 

 Involved limbs - tubular shape, thin subcuatneous tissue absent skin crease 

                              symmetrical , severe distally typically hands and feet 

                           dislocated hip joints , ocasionally knees 

                            trunk - rarely affected , scoliosis 

                            muscle groups absent 

  Normal  IQ 

Management 

     Paediatrician , Orthopaedic surgeon, geneticist , psychologist , physiotherapist , ocupational 

   therapist 

Orthopaedic management 

      Optimize function , keep children independent , 

      Goal - improve function of the limb, rather than a joint, 

            e.g. elbow extension deformity ; 

            PT

            Tendon transfer 

        

        Time 

          Within the first year -

                                 splint , stretching

                                correct major defomities (e.g. Hip dislocation - ORIF in first year )

          Later , limited to maintain mobility and imrove function ; Tendon transfer 

Practical Examination - Cerebral Palsy

Examination in order

General

 presence of wheelchair  , walking aid , communication devices  , orthosis e.g. AFO , KAFO , Wrist

Splint , Spinal Brace

Look at trunk for gastroscopy or a baclofen pump


Pattern of involvement

 Anatomical

    monoplegic

    diplegic

    hemiplegic

     quadriplegic

   

 movement disorder

     spastic

     ataxic

     dyskinetic

                 athetoid - slow writhing movement of fingers , hand or lower limb

                 dystonic - involuntary sustained contraction

                  chorea - random movement of limbs more on rest position

                  ballismus and hemiballismus

                                           infrequent jerky movements , purposeless

                    mixed


Standing -

           posture - UL ,

                          scoliosis - C-curve neck to LS junction

                    (      idiopathic curve with a rib hump )

         

        walking
 
                        aids,

                        head steady or moves up and down / sidewise

                         shoulder and upper body - excessive movement

                          upper limbs - posture

                                                 swinging or held stiff
                     
                           Trunk - flexion , lordosis , lateral tilt

                         Pelvis - level or tilted

                         lateral movement when walking

                         Trendelenburg


                          Lower limbs - position of hip , knee, ankle - walking

                         Foot - Foot progression angle , foot shape ,

                                   describe initial contract , foot flat and lift off.


Lying position

                 Hip examination

                  dislocated ?

                             Contractures

                   

                                 Flexion and Adduction contractures
 
                                 limitation of extension and abduction eventually flexion contracture and 

                                  adduction contracture



                         Knee

                                    contractures

                                              measure popliteal angle

                     Ankle

                               Silfverskiold test

                                  midfoot break on DF , heel neutral

                    Foot

                    deformity , callosity , bony prominences , ulceration



             Prone position

                 Rotational profile

                 Dunken Ely test



























                       





















   

Overriding 5th toe

At birth or during childhood

cosmetic deformity

pressure problems , caught on with socks on

Memorandum

  5th toe MTP - hyperextended

               IP joints flexion

               Deviation - medially , overrides 4th toe , nail laterally facing , hypoplastic


skin - dorsum contracted , MTP - Subluxed dorsomedailly , +/- bunionette


Management


            strapping

             stretching

              Surgery - Butler Procedure


                                Rocket incision over little digit centred over ED . derotate toe

Contracted tendon and capsule released.

Practical Examination Pes Cavus / Flat feet

know is it painful or not ?

and where is pain ?

         Talocalaneal coalition - medial side pain

         Calcaneonavicular Coalition - lateral side pain


Look -

           Standing - forefoot abducted , adducted - skew foot )

          hind foot - valgus

              bottom of foot - conved plantar surface - in rocker bottom foot

        shoulde be able to pass 2 fingers on medial arch.

        quickley see on lower back to see if there are any tell-tale signs.

Gait

 Tip toeing - flexible - heel varus ; medial arch prominent

 Tarsal Coalition - arch doesnot form , heel valgus


Sit - legs dangling

       check shoes

       more wear on medial side; if no wear ask if they are new.


Check Achilles tendon tightness -- stiff flat foot

ROM - Ankle and subtalar joint

            subtalar joint stiffness - difficult to illicit - patients will have ball and socket joint by   


            remodelling

 use IF/ Thumb to stabilize or at least to check talus body movement while  assessing subtalar joint



check neurovascular structures

Practical Examination - In-toeing and Out-toeing

After proper exposure from umbilicus to toes with an inner  wear


Check height and weight which might clue bony displasia or metabolic diseases


Gait - see foot progression angle (Angle between foot print and line of walking )

           normal angle is -5 to +20 degrees

          -5 to -10 mild , -10 to - 15 moderate

           > -15 degrees severe


Look - Leg length discrepancy , any noticeable deformities or muscles wasting

           Check Trendelenburg test during standing position


Feel - any tenderness on soft tissue or bony tenderness

Movement


Special test on prone position with a pillow on chest

 Hip rotation

          Knee in 90 degree flexion , check Hip IR and ER

      Normally Hip IR < 70 degrees , ER < 30 degrees

         meausre Anteversion angle

            Birth ; 40 degrees

            9 years  ; 20 degrees

           16 years ; 16 degrees


    Thigh foot angle

      normally ; 0-20 degrees

      measure tibial and hind foot rotational status


  Transmalleolar thigh angle

         measures tibial torsion only

        normally 0 -40 degrees  .



suspect any pathology when there is

  pain , limp , LLD , asymmetry , rapid changes in rotational profile.








   

Rehabilitation phase weight bearing

It depends on quality of bone , gemoetry of fracture and type of implant used.


Wight bearing not allowed immediately in

  Uncemented THR

  Plate fixation

  Locking Plate

Wight bearing allowed immediately

  Nailing

  TBW

   External Fixator application

   Cemented THR

   Pedicle Screw fixation

   Dissectomy




Note - THR Prosthetic dislocation - skin traction role

            gives splintage to soft tissues strain  .

Practical Examination - Flexor Tendon Injury

Examination depends on the question given. May be examination of the whole extremity or just the

hand . Be careful !

Exaimination begins after asking 2 questions as allowed . Relevant questions might be after your 

own  introduction .

 1. what happened ?

 2.when did it happen ?

one can ask hand dominance and profession during examination to be clever .

Then get permission from patients


If command is to examine the whole upper extremity go as below


Look - Normal alignment of Right Upper extremity

            shoulder at slight abduction

           elbow flexed, forearm supinated with palm facing up

            cascade of fingers not maintained , index finger is extended while others are in flexion

           no wasting of muscles on arm , forearm , hand on volar and dorsum side

          on hand , there is a transverse scar around 1 cm proximal to metacarpophalangeal joint ,

           healed.

           color of all fingers look pink on finger tips as  well as nail bed

Feel - temperature normal

          no soft tissue , bony tenderness

          sensation- ulnar / median / radial nerve is intact

                           digital nerve sensation - intact


Pulsation - Allen's test for fingers

                  tinel's test for nerve injuries

Lymph nodes palbable or not 

Movement - screening quickly active motion of shoulder , elbow and wrist

                   Finger passive active and passive test at PIP , DIP and MCP

Tests for

 FDP of all fingers , FDS of all fingers , Extensor , Adductor ,abductors of fingers


Mention diagnosis as

 Flexor Tendon Injury Rt. RF Zone III (Mention the duration of injury in weeks )



Investigations

MRI - to confirm diagnosis

           to document the injury

           proximal tendon level will be identified in old cases

X-ray - to see joints ,
 
            if there is bony injury as well


Treatment

 Physiotherapy to make skin supple , prevent joint stiffness


Surgery

    Primary Repair - done within a week

     Delayed Primary Repair - done within 14 days

    Secondary Repair - 2-5 weeks

    Delayed Secondary - after 5 weeks .
   

Different deformities around foot and muscle imbalance

 Joint                                       Muscle Imbalance                                                             Deformity

Ankle                                      Triceps Surae - Strong                                                   

                                                 TA weak                                                                           Equinovarus

     
                                               Reverse                                                                              Calcaneovarus




Subtalar Joint                       Invertors strong/Evertors weak                                            Cavovarus


                                              Reverse                                                                                Cavovalgus

Pes Cavus

If same problem in family runs , think of some neurological diseases, Also ask if its progressive .Ask

if they have any vision problem .

Look 

 Back 

 Toes callsities under metatarsal heads , lateral border of foot 

  Exagerrated Cavus 

 Foot drop 

 leg muscles wasting 

 hindfoot varus /valgus , equinus,forefoot plantaris , Ist ray PF 

 footwear problems 

 Feel - temperature, tenderness , deformity correctible or not 

 Neurovascular examination 

    sensation 

   motor - tone , power , reflexes . 

Movement 

     Active and passive 

Special tests 

    Varus Coleman block test 

     Silfverskiold test for Equinus deformity 

 How to proceed ? 

X-ray - Weight bearing lateral x-ray 

          to see calcaneal pitch (N< 30 degrees ) and lateral Meary's (N 0-5T degrees )

              normal - 20-30 degrees

               low - Pes Planus

               high - Pes Cavus 

PA - meary's angle N - 0 degrees

         it gives the apex of angle in Pes Planus and Pes Cavus 

Blood - Muscle enzymes 

              Genetic Screening 

Neurophysiology for underlying neurology 

What are causes of Pes Cavus ? 

Congenital 

           Idiopathic 

            CTEV 

            Arthrogryposis 

Acquired 

             Trauma 

             Neuromuscular 

                  Muscular Dystrophy 

                  HMSN 

                  

                

  HMSN (CMTD )

         Weak Tibialis Anterior 

              Normal Peroneus Longus leading to first Metatarsal drop 

          Weak Peroneus Brevis

                 leading to Varus hindfoot with normal Tibialis Posterior. 

          Weak TA 

               normal extensors leading to clawing 

            tight plantar fascia  leading to  Windlasss effect 

         Spina Bifida 

           Weak triceps Surae leads to Calcaneal Deformity

             owing to unopposed Dorsiflexion and reciprocally PF forefoot 

            Varus heel (Subtalar inversion ) locks midtarsal joints leading to rigid foot. 

              Excessive pressure leading to callosities . 

Treatment 

 Conservative 

 Operation 

     symptomatic 

    orthotics 

Release of plantar Fascia 

DF osteotomy  - Ist ray +/- 2nd 

Calcaneum sliding and closing wedge osteotomy 

 Transfer peroneum longus to brevis at level of distal fibula 

Clawing of toes leading to flexion of extension aponeurosis 

Jones Procedure 

Triple Arthrodesis 

           

          

  

Tibial Bowing

Posteromedial Bowing - Physiological



Anteromedial Bowing -

    Fibular Hemimelia

     Ankle Instability

    Foot - Equinovarus +/- absence of lateral rays

   Tarsal Coalition

   Ball and socket ankle joint

    Femoral shortening

Treatment

     Bracing
     
     Amputation

    Ankle Recontruction

        depends on LLD , Foot and ankle involvement

  Anterolateral Bowing

      50 % - Neurofibromattosis , Ehlers-Danlos syndrome , and amniotic band syndrome

Nail Patella Syndrome

Positive Family history

 Late childhood or early adulthood knee pain or recurrent dislocation of patella


Features

 Finger nail dysplasia

 Hypoplastic patella

 Presence of conical iliac horns

 hypoplasia of radial head

 40 percents have immune related nephropathy

Clinically

 tenderness on patella , features of early arthritis at younger age

 impression - Chonromalacia Patella
                     
                      Naile Patella Syndrome

                        (Elbow ROM -restricted )
                      

Clinical case Osgood Schlatter Disease

Perform the examination as in Genu Valgum


Key findings

 Look - Swelling on anterior tibial tuberosity

Feel - Temperature

           Bony hard in consistency


          tenderness

Movement

      Tightness of quadriceps and patellar tendon

Distal  neurovascular structures

     Sensory , motor examination - normal

    DPA, PTA - normal

Examine -Ankle and Hip

Shoes exmination



Investigation


 X-ray Knee - Fragmentation of Tibial Tuberosity.

Management

      Reassure

   Non operative

       Cast


 Why this happens ?

 Growt spurt in this age causes bone to grow longer than soft tissues such as quadriceps . 

Short Case Clinical Examination - Genu Valgum

  Important imformation from the patients in the short case might be

    Age of the patient

   Family History


                HME , Rickets and bony dysplasias might run in family .


   Deformity


O/e

   after exposure of both lower extremities from umbilicus to toes with an underwear


Gait  and Squatting - comment .They may have circumduction gait.

Standing - Genu Vlagum deformity

                  Quadriceps normal


                  Patella facing forward , forefoot normal



Side - any scars or not around knee

          knee in extension

          hip,  thigh , leg , ankle and foot normal alignment


Back

            Popliteal swelling ,

            thigh and calf normal looking normal

            heel in normal varus


              dont forget to measure Intermalleolar distance

              and Genu Valgum in standing

         

After Lying down

Palpation

          normal temperature compared to opposite side

          no soft tissue and bony tenderness

                 feel patella , facets of articular surface of femur with patella , medial condyle of femur ,                       joint line, medial condyle of tibia , MCL, Popliteal artery pulsation, lateral condyle of                           femur , joint line , lateral tibial condyle , fibular head

         Patella test - Glide , Apprehension , Clarke TEST

Movement

           Knee Flexion , Extension

            Deformity disappears after flexing knee



Measurement

  Leg length measurement and Q angle measurement in supine position


Special tests for MCL and LCL done .


Neurovascular examination

sensation , pulsation of DPA and Anterior tibial artery


Lateral positioning

 Ober's test done


At last or in the beginnning frontal bossing , tooth examination and ligamentous laxity quickly checked.


         

What is your diagnosis ?

Genu Valgum deformity .


What might be the underlying cause ?

 Physiologic Genu Valgum in 2-6 years

Trauma

 Rickets

 Infection

Bony Dysplasia

Ligamentous Laxity, Down's Syndrome , Hereditary Multiple Expostosis



How to proceed ?

X-ray in standing position leg alignment X-ray

   Tibiofemoral angle as per Selenius curve

     normal is 6 +/- 2 degrees

    following two points important for Genu Varum
                Metaphyseal diaphyseal angle of Levine and Drennan 

                            normal < 11 degrees , abnormal > 16 degrees 

                         Important to know in Tibia Vara to distinguish from Physiologic Bowing. (> 11 degrees indicates Tibia Vara

                   Metaphyseal epiphyseal angle normal < 20 degrees


Serum Ca, Phosphorous level , Vit. D level for Rickets


How to treat  ?

Treatment

  Observe

   Medical Treatment

  Bracing - STILL PRACTICED ,

   Surgical Treatment

         Guided growth

                  staples , advantage - reversible

        Osteotomy to correct the deformity















                   

Trigger Thumb

Interphalangeal joint of thumb flexed , b/l

No other anomalies

Extension limited

At base , node mobile with flexion / extension of the joint

Treatment

 Surgical release of A1 pulley

Infants - - stretching

Coxa Vara

Coxa Vara

 Painless limp , LLD - gradually worsening

 Unilateral or B/l in 30 -50 % cases

 Prominent trochanters

 Pelvic tilt - LLD

 Trendelenburg test or delayed trendelenburg

 Waddling B/l

 High GT - supratrochanteric shortening

 Decreased abduction

  (decreased articular trochanteric distance )

Decreased IR ( due to decreased antversion )


may have out -toeing

rule out cervical instability causing limping


Types                         Pathology                                   Site                                                   Progression

Congenital               Dysgenesis                             Subtrochanteric                                        progresses


Developmental        Growth abnromality                physological                                           resolves


Acquired             Dysplastic;Fibrous dysplasia            metaphysis                                         progresses


                          metabolic ; rickets                            Physis                                                   progresses

                          vascular ; sepsis & CPD                   Physis and epiphysis                            progresses

                          Trauma                                             Physis  ;SUFE,

                                                                                 Metaphysis,Subtrochanteric                may resolve                           


Management

HEA
 
 > 60 degrees - surgery

 45- 60 degrees - wait and watch

 Goals of surgery

       neck shaft angle >/== 140 degrees

       correct version

       ossification and healing of inferomedial fragment

       restore Articular Trochanteric distance and abductor mechanism

       to resotre length- tension relationship

        abduction tenotomy

        Osteotomy - 3 types

                       1. Pauwel's Y-shpaed

                        2. Langenskiold Intertrochanteric Osteotomy

                       3. Borden subtrochanteric Osteotomy

Median Nerve Examination

Not to miss following points during the examination

Attitute of the limb or hand

cascade of fingers


Look -
           any scars on arm , forarm

       wasting on forearm and thenar region


Feel - temperature

           any soft tissue or bony tenderness

           tinel's sign ,scar tenderness , scar pliability

           lymph nodes



Movement

          active and passive -rapidly test it

Measurement if any angulation or bony deformity or bony shortening


Neurovascular examination

sensation of autonomous zones of hand and  direct the examination to the nerve affected

Power of muscles - Examine both the weaker muscles and donor group of muscles


Forearms - Brachioradialis , Pronator Teres , Supinator

           
Wrist      FCU, FCR , PL,Pronator Quadratus , ECRL


Hand       FDS

                FDP , FPL

               Lumbricals

              Opponens Pollicis

              Abductor Pollicis Brevis

             FPB


Reflexes

Pulsation and Allen's test




History of injury, scars or muscle wasting supplied by median nerve , loss of sensation and muscle

weakness suggest median nerve injury.

How do you treat them ?

It's treated same as other nerve injuries. See on previous section for nerve injuries management.


Its true for all other nerves.


If time period of nerve repair does not allow then tendon transfer is an option.



What are choices for tendon repairs in Median nerve injury ?


High Median Nerve Injury


losses - Forearm pronation

             radial flexion of wrist

             thumb flexion

            2nd and 3rd finger flexion

            opponens function of thumb

           
Choices of tendon to supplement the function
           

        Brachiolradialis to FPL

        EIP to Opponens Pollicis

        FDP to 2nd and 3rd finger

       sensory flap for thenar region



pnemonic for tendon options - BEF


Low Median Nerve Injurry 

losses - Opposition

            sensation of thenar region

Donor tendons
   
 EIP , PL and FDS RF

Mnemonic  -      PEF



Never forget Post operative physiotherapy after tendon transfer.

          suture removal after 3 weeks

          splint removal in 3 weeks

          start training like pen holding in 3 weeks

          eating with the hand after 4 weeks

          heavy work not done till 2 months after surgery