Short Notes in Orthopaedics

Complications arising from fixation of unstable proximal femur fracture with PFN having 2 screws . 1.Z-effect   lateral migration of caudal screw , varus collapse and perforation of femoral head by superior screw 2. Reverse Z-effect   lateral  migration of superior screw , varus collapse and femoral head cut by inferior screw Causes  varus fixation of fractures , severe medial communition , inappropriate entry point and poor bone   quality. Intaoperative Procedures to stabilize unstable IT fractures  Osteotomies and fixed with nail plate   Design (Smith -Peterson nail plate  )     e.g. 1. Dimon  -Hughston medial displacement Osteotomy            2. Sarmiento Valgus Osteotomy            3. Wayne -County lateral displacement Osteotomy No evidence are there to support these osteotomies combined with sliding hip screw fixation .

Advantages 1.Ability to fix majority of fractures 2. Short surgical time and less blood loss   for unstable Intertrochanteric fractures , (no difference compare to DHS fixation for stable IT fracture 3. smaller moment arm - to bear tensile forces and lesser calcar strain  DHS - produces 1.5 times calcar strain of a normal femur  IM < 10 percent of strain 4.Better controlled collapse as bending moment at lag screw for nail is lesser than DHS . 5. Biomechanically nail construct are more stiff so more stable than DHS for torsion and bending       stress. Disadvantages   1. Abductor injury while insertion   2. difficult revision by arthroplasty if it fails    3. anterior thigh pain due  to impingement of nail tip   4. curative mismatch of nail and femora produces iatrogenic fractures   5. stress concentration at nail tip leads to fracture   6. implants are costlier .

Findings Small foot , stretched skin  on dorsolateral region and thrown into creases along medial aspect scars and callosities head of talus palpable lateral convex border and medial concavity with furrows heel rotated medially and drawn up ancilliary   genu valgum ,   extrinsic  / intrinsic type gait - stumbling ROM -   ankle , knee , inversion , eversion at subtalar joint other examination  hip for DDH   Spine for Dysrahism   Cerebral Palsy   Polio - tight iliotibial band     cleft lip , palate , exomphalos  and congenital hernia correctible or not Impression -                    Primary or Idiopathic Secondary Clubfoot                     Recurrent Club Foot       Deformities in club Foot  equinus at ankle  varus and internal rotation  forefoot adduction and supination midfoot cavus others -  internal rotation of tibia  atrophy of claves and smaller circumference than others  small foot How do you look for equinus , v

Young boy or a girl height stunted Ratio of upper and lower body height proportion normal or not (normally 1:1) LE reaches upto middle thigh or down ? proportion of arm and forearms looks normal fingers shape is normal lower extremity look shorter alignment of LE on a photo shows multiplanar deformity of leg with anterior bowing and areas of flattening anateroposteriorly on leg knee and hip are at flexion attitude , Intelligence - normal Eye sight - normal head ,neck examination - frontal bossing , sclera color , dentition , neck webbing , chest any signgs or deformity , belly protuded or not , umbilical hernia or not , back - kyphoscoliosis or not , dimpling of hair or not , any swellings on upper or lower extremities gives  a clue to plan and proceed further Impression Rickets Osteogenesis Imperfecta    will have history of reccurent fractures with trivial trauma ,     family history     eyes color might be different , poor dentition Pol

Contour paraspinous muscles  Errector Spinae or    Sacrospinalis - Multifidus , Longissimus , Iliocostalis from medial to lateral Symmetry Pelvic Obliquity Step off deformity   Spondylolisthesis - body of involved vertebrae and rest of spine above slide forward Lateral - Normal lordosis ,                 hyperlordosis - flexion contracture of hip               flat back syndrome                        compression fracture of lumbar vertebrae                Gibbus - - sharp angular kyphosis kyphotic deformity                               TB Gait - antalgic heel walk - 10 steps ,  L4 testing at L 3-4 toe walking L5 - S1 testing ROM - flexion 80- 90 , 10 cm to floor extension 20 - 30 degrees  lateral bending - 20 to 30 degrees  rotation - 30 to 40 degrees measurement - Schober test Palpation spinous process counting L4-5 , level of iliac crest paraspinous muscles - tender , tone posterior facet joints muscle testing          fle

Look skin  , vertebral alignment , dimpling, tuft of hair Head , eyes , fact , neck , suprascapular/infrascapular region , hair level , Feel - Temperature, tenderness, spasm Sensory Examination upper limb  / upto c 8 power of muscles in upper extremities Pulsation Reflexes - Homan,s                     spine - humeral                    radial reflex                    cross adduction thigh                   clonus Special test - Gait, Rhomberg test, Spurling ,Lhermitte test,  Distraction test , valsalva test rule out problem of shoulder , brachial plexus and extra rib as they mimic the same sometimes. functional like in torticollis flow like from standing (front , sides and back ) , walking , squatting and sitting so as not to discomfort patients .

Torticollis Look Anterior  - head position - centre or deviated to one side with rotation                        decrease head and shoulder distance on one side                        facial aymmetry present or not ?                         eyes - nystagmus ?                                 taut sternocleidomastoid muscle                                         chest - muscles wasting present or not ?  Side -             ear close or touching the shoulder                        l ordosis                                   comment on deltoid contour and elbow extended  Back -                         b/l shoulder symmetrical                          normal hairline                          scapula at same level                          occiput flat or nomal ?  Gait / Squatting - Normal or not ?  Feel - comment of taut sternocleidomastoid muscles,               palpate on sternum, clavicle , AC joint, Scapula and Proximal humerus               palpate on C-spine  Movement      

Look Leg cylindrical Dorsum - swelling on dorsolateral region lateral to ankle joint skin - callosity forefoot - adduction toes alignment - normal midfoot - cavus lateal border convex hindfoot varus whole foot -shortened foot wears - worn out no torticollis , hip flexion normal spin - no patch of hair , scoliosis and dimpling feel - temperature normal ,          no tenderness  movement - active  active passive deformity correctable or not puslation - intact sensation intact motor power - muscles normal reflexes - achillies tendon reflex , babinski's reflex LLD , Lymph nodes            

Pratap Aryal   14 years   / boy    hospital no 017-1121000 , charikot , Nepal C/O – Lt elbow deformity for 11 years History of fall injury at the age of 3 years , and sustained injury around elbow . casted after 12 hours for 3 weeks ( no documents to know the fractured part in elbow ) Deformity noticed which remained static . No disabilities but he is not feeling well with the deformity Personal History – He is a right hand dominant boy studying in class 8. O/E Introduction of ownself Exposure upto Shoulder Maintain privacy of the patient Inspection   Attitude of the Lt upper extremity   Internally rotated   Alignment   - cubitus varus deformity Deformity is exaggerated in shoulder abduction No wasting of muscles on arm forearm and hand Normal overlying skin Palpation   Overlying temperature – normal Skin texture – normal No tenderness of soft tissue and bone Lateral condyle , olecranon process and medial condyle at same li

Patient whole body  was exposed maintaing privacy. Standing Gait pattern - Normal Attitude of the body on standing position - Left side listing , right shoulder up  , pelvic obliquity , no no wasting of thigh , calf muscles , knee at same level , patella facing forward  similarly comment attitude from the sides and back . Regional examination from front sides and back  T L Scoliosis with convextiy on lt side which disappers on bending right Movemenets  flexion touches upto toes  extension 20 degrees  side bending - upto just below knee  rotation - 35 degrees  Schober's test      4.5 cm excursion     Trendelenburg test  Lying position on supine     SLRT , Cross leg SLRT , Lasegue's test , Bowstring sign , FABER test , FADIR Test   , Neurology Lying on Prone position                 overlying skin normal               Temperature normal               percussion pain - L 5 - S 1 +             FemoralFemoral  stretching test

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 

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 v

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 lat

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 

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                   radi

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 

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

Superior Labral Anteroposterior Tears Associated with glenohumeral instability and rotator cuff tears Investigations  MR Arhtrography Treatment  Repair or resect Arthroscopically

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 c

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 

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                

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    

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. Koch