Viva topics Grilling - Ac. Osteomyelitis,CTEV,CP, Gait Analysis ,ABC,Supracondylar fracture, Perthes Disease , Bone
Viva 1
A child has hx of fever, malaise & painful walking on his right side.
How to approach patient ?
Assess in line of Septic Arthritis and Acute Osteomyelitis
How do you manage ?
Detailed Hx. taken including Treatment Hx., Past Hx. -allergy to Amy medications if any
Examination- BP , pulse , Temperature
Local examination
Gait
Inspection
Resting Posture of Hip (FABER )
ROM
local tenderness
Inv.
AP / Lateral radiographs of hip - to r/o fractures , any structural abnormality
USG - hip effusion 7 mm
note -
Predictive markers of hip sepsis
1. Temperature> 38 .5 deg. Celcius
2. WBC > 12,000 cells /mm3
3. ESR > 40
4. NWB
Based on above findings , chances of hip sepsis (combination increases accuracy of diagnosis)
1 = 3 % , 2= 40 % , 3 = 93 % , 4= 96.6 %
What's the treatment ?
Surgery
Anterolateral Approach to hip
Remove ellipse of capsule , allow free drainage
Samples for c/s
Irrigation
Hip Spicas - post operative -to prevent subluxation and dysplasia
Approximate Abx. - Initially broad spectrum abx then adjusting
Prolonged course
Guided by Serial infiammation markers
Larger f/u - to assess growth and development of acetabulum
Viva 2
Photograph of a normal child with a club foot deformity .Describe it.
Describe the deformity as Cavus & adductus of mid foot , Varus and Equinus Hindfoot.
How do you classify severity of the deformity ?
Pirani Score
Midfoot - Severity of Medial Crease
- Coverage of talar head
- Curvature of lat border
Hindfoot - Rigidity of Equinus
-Severity of posterior crease
-Degree of emptyness of heell
All deformities are given points 0, 0.5 and 1.
They are sum up. Maixum is 6 and lowest 0. Higher the score , severe the deformity.
How to manage club foot in babies ?
History in depth including history of deformity in Parents
Examination
Classify - syndromic vs Idiopathic
Investigations- X-ray of feet
Treatment
Ponseti cast
Pirani casts are above knee casts with foot areas moulded into corrected position .
Start with manipulation & serial cating
Ist cast.
Dorsiflexion of foot
- 1st ray unlock forefoot and mid foot.
- Elevation & Ist ray supination
2nd Cast
-Abduct at mid foot level, using hand of talus fulcrum
Midfoot corrects after 4 to 5 casts
Achilies tenotomy for residual Equinus
Final cast for further 3 weeks .
Denis Browne boots with a bar (23 hours a day for 3 months , then night time until 5 years. It holds foot at 70 degrees ER.
It also avoids need of surgical release .
25 % require TA transfer laterally for Inversion in swing after age of about 5 years.
Be clear that , different treatment is required for grown up child , requires bony procedures.
Viva 17
What is Cerebral Palsy ?
Neuromuscular disorder cused by non Progressive leison to immature developing brain before age of 2 yrs ( although neurological injury non Progressive ,MSK features evolve )
Types-
Anatomical - Hemiplegia (40 %) , Diplegia (30 % ) , Total Body Involvement (30 % )
Physiological
Spastic (60 %), Dystonic (20%) , Ataxic (10 %),
Hypotonic (10%)
GMFCS Classification is also there.
What is Spasticty?
Velocity dependent increased tone of muscles . Represents as increase response to stretch reflex.
Management of spasticity
1.Multidisciplinary approaches- family and patient in goal planning decissions about treatment ,Exploring expectations.
2.Non-operative
PT -Physiotherapy
Botulinum toxin -
Cl. Botulinum toxin prevents release of Acetylcholine at NMJ .
Effective for 3 to 6 months Combined with plasters & targeted PT/ Orthotics to maintain stretch .
Baclofen Pump and Injections
GABA Agonist / inhibitory neurotransmitter
It acts centrally and peripherally to decrease spasticity
Intrathecal injections - can increase dose and reduce systemic side effects
Orthoses
3. Surgery
SEMLS- Avoid Birthday Operation
1.Soft tissue lengthening to tight muscles.
2.Muscle transfer
3.Osteotomy
What is Gait Analysis?
Systemic discription , assessment and measurement of quantities that characterizes human locomotion.
Involves Kinematics ( movement of individual parts of body) & kinetics (forces how they interact and & produce the movement ) as well EMG and energy consumption .
Gait analysis-
2 D Video
3D computer analysis
- Breaks movement of individual parts into graphic form . -Use force plates, measures ground reaction force & EMG records muscle firing patterns
-Gait analysis looked at in conjuction with a Static detailed physical examination.
Viva- 3
You got an X-ray
Reads like
AP Radiograph of skeletally immature child showing a multiloculated lytic lesion in proximal metaptysis. The zone of transition in Sharp indicating benign lesion & no associated periosteal reaction .
Fallen Fragment inside ? , see it .
What is your Diagnosis ? (Prof.)
X-ray is suggestive of
Simple Bone Cyst
ABC
Infection
He presensts after few weeks with severe pain . What might have happened?
Pathological fracture
How do you manage ?
Detailed histroy
Examination
Investigations
Manage expectantly
(# stimulates new bone formation, bear this in this chapter )
Patient treated expectantly but lesion persists . How to manage ?
Follow up and see
Aspiration of cyst done-If expectant non operative measures fail
Inject steroid on bone graft, marrow to try and stimulate new bone formation.
-If it fails , repeated attempt is worthwhile.
Surgery - Curette out lining of cyst through a cortical window and Stabilizing bone to prevent fractures
Flexible IM nails across lytic area.
If cavity adjacent to growth plate , important not to damage physis.
Viva 4
You got an X ray Gartland type IIIA , supracondylar fracture .
Questions
How do you manage the case ?
Hx. - MOI , Other injuries ,drug allergy
Examn . - assess presence of open injury
Assess distal NV (Hand colour , capillary refill of finger tips , radial pulse ,sensation in specific dermatomes , motor function in ulnar ,median ,radial and AIN nerves )
Treatment
Analgesia
Temporary back slab
Consenting
OT set up with C-arm back up
CR -technique
Continuous traction in 20 degrees flexion , several minutes.
-- correct valgus /varus and rotational deformity
-flex arm
-Pronate forearm to lock fragments
-Insert a lateral wire 1.6 mm k wire first
Extend arm a bit to plan a mini open approach to medial side .
Bend and cut wires in clinic in 3 to 4 weeks time.
Splint arm in back slab in near extension
Reassess perfusion of hand and watch for compartment syndrome
Not able to feel pulse after pinning. What to do ?
Assess colour of hand and warmth , capillary refill time
for a pink and warm hand , with adequate Capillary refill of finger tips , I would monitor situation with a regular review.
Artery in spasm (if) will lead to loss of pulsation.
If hand white and CR reduced , remove splint, extend elbow and see situation.
If not contatct vascular /plastic surgery for urgent review as artery has been caught up in fracture and has been occluded by rdeuction.
If requires exploration anteriorly.
Viva 5
You are shown an AP Pelvis of skeletally immature child with flattening of femoral head with deformity suggestive of Perthes disease.
What is underlying disease ? Who gets it ?
Idiopathic AVN of Proximal femoral epiphysis in childhood .
Unknown actiology, sequeale of acetabulum procedure
Boys & Girls = 4: 1, Bilateral -20%
Classification
Based on Staging
1. Initial Avascular event (crescent sign presenting subchondral fracture )
2. Fragmentention
3. Resolutions and re-ossification
4. Remodelling
Herring’s classification
Piller height on AP radiograph during fragmentation .
>50% maintained
<50 % maintained
Caterall’s classification - depending on head involved on lateral Radiograph
Also Added head at risk sign .
Clinically
Obese
Progressive and decrease ROM
Abduction contracture
ER with flexion
Radiographically
Horizontal Physis
Lateral Subluxation of epiphysis
Lateral calcification
Diffuse Metaphyseal Sign
+ Gaze Sign-inverted V shaped lucency in lateral Metaphysis
Stullberg's classification based on shape of femoral head
I- normal
II - head spherical which is spherical (magna / Bevel ) fits in socket which is congruent
III - mushroom head congruent
IV - flat head and flat socket careongruemt mont
V - flat head incongruent .
What is the Principle of management ?
Goals
Symptomatic Parf
Containment of femoral head
Restore ROM
Goals achieved by non operative and operative measures.
Management based individual basis taking into accounting their age, clinical signs & radiological appearances on X-ray .
Viva 5
What is bone ?
Bone is a dynamic form of specialized connective tissue
Cells - 10 %
Osteoblasts
Osteoclasts
Osteocytes
ECM - 90 %
Organic
Collagen- type I
Inorganic
Calcium phosphate
Osteocalcium phosphate
Function of Bones
Movement
support & polkrotect internal organs
Production - WBC/ RBCs
Storage of Calcium and Phosphate
Osteoblasts short explanation
Derived from undifferentiated mesenchymal cells
Bone forming ,lay down osteoid ( type I collagen )
Contains RANK Receptor activator of nuclear factor kappa - B
Osteocytes osteoblasts that have beame trapped in bone
About Osteocytes
Osteoblasts that have become trapped in bone matrix ( making upto 90 % of cells in bone ) ,
Important role in homeostasis of calcium and phosphate
Jolius Wolff , German anatomist FIRST described metabolic change in bone according to demand and hence name as Wolff's law.
Wollf's Law
If loading on bone increases , bone remodels itself over time to become stronger to resist load.
About Osteoclasts
Monocyte call lineages that multinucleated giant cells that resorb bone
Location - Small pits called Howship Lacunae, bonee surfaces. & lead culting cones.
Ruffled brush border , increase surforce area, create ? low PH to disolve inorganic constituents
Enzymes Release - tartarate resistant acid phosphatase - break down organic matrix components,
inhibitors to Osteoclast are Osteoproteogerin.
Bone | Perthes disease |Supracondylar Fracture | ABC | Gait Analysis |Cerebral Palsy (CP )|Congenital Talipes Ewuinovarus (CTEV)|Septic Arthritis |Acute Osteomyelitis|
