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|