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. - 

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 

USG - hip effusion 7 mm 

Inv. 

AP / Lateral radiographs of hip - to r/o fractures , any structural abnormality

Predictive markers of hip sepsis 

Temperature> 38 .5 deg. Celcius 

WBC > 12,000 cells /mm3 

ESR > 40 

NWB 

X 1 = 3 % , x 2= 40 % ,x 3 = 93 % ,x 4= 96.6 % 

Sx . 

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 

Serial infiammation markers

Larger f/u - growth and development of acetabulum 

Viva 2 

photograph of a normal child with a club foot deformity 

 Cavus & adductus of mid foot , Varus and Equinus Hindfoot ,  

classification of severity of the deformity 

Pirani 

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

How to manage club foot in babies ? 

(different treatment for grown up child , require bony procedures )

Hx-of deformity in Parents

Examination

Classify - syndromic vs Idiopathic 

Ponseti cast 

Start with manipulation & serial cating

Ist cast. 

DF - 1st ray unlock forefoit and mid foot. 

- Elevation & Ist ray supination

2nd Cast

-Abduct at mid foot level, using hand of talus fucrum 

Above knee casts - moulding into corrected position . 

Midfoot corrects after 4 to 5 casts 

Achilies tenotomy for residual Equinus 

Final cast for further 3 weeks .

Babies - 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. 

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 umber fry nen pagresive, ask

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Types-

Anatomical - Hemiplegia (40 %) , Diplegia (30 % ) , Total Body Involvement (30 % ) 

Physiological 

 Spastic (60 %), Dystonic (20%) , Ataxic (10 %) 

Hypotonic (10%) 

GMFCS

What is Spasticty?

Velocity dependent increased tone of muscles . Represents as increase response to stretch reflex.

Management of spasticity 

Multidisciplinary approaches-

family and patient in goal planning 

decissions abt treatment 

Exploring expectation 

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 

  Acts - centrally and peripherally to decrease spasticity 

 Intrathecal injections - can increase dose and reduce systemic side effects

  Surgery 

SEMLS- Avod Birthday Operation 

soft tissue lengthening to tight muscles. 

Muscle transfer

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 platesn, measures ground reaction force & EMG records muscle firing patterns

Gait analysis looked at in conjuction with a Static detailed physical examination. 

Vivo- 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 . 

Diagnosis 

 

Simple Bone Cyst 

ABC 

Infection 

HE presensts after few weeks with severe pain . 

 What you think has happened?

Pathological fracture 

 A fallen fragment sign 

How do you manage ? 

 Thorough hx. 

 Examination 

  Manage expectantly 

  # stimulates new bone formation.

Pt. treated expectantly but lesion persists . How to manage ? 

If expectant non operative measures fail

Aspiration of cyst done .

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.

Viven-19iva 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 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 contrat vascular /plastic surgery for urgent review as artery has been caught up in fracture and has been occluded by rodeuction.

If requires exploration anteriorly.

Viva 4 

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 acetabulon procedure

Boys & Girls = 4: 1, Bilateral -20%

Classification

1. Initial l Aversvascular event (crescent sign presenting subchondral fracture )

2. Fragmentention

3. Resolutions and re-ossification

4. Remodelling

Herring’s classification 

Piller height on AP radiograph 3 during fragmentation .

3 >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 l V shaped lucency in lat. 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 .

Principles of mx. 

Goals

Symptomatic Parf

Containment

Restore ROM,

goals achieved by non operative and operative measures.

Management based individual basis taking into accounting their age, chalinic signs & radiological appearances on X-ray .

Vivo.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

Differences

Osteoblasts 

Derived from undifferentiated mesenchymal cells

Bone forming ,lay down osteoid ( type I collagen ) 

Contains RANK Receptor activator of nuclear factor kkappa - B

Osteocytes osteoblasts that have beame trapped in bone

Osteocytes - osteoblasts that have become trapped in bone matrix ( making upto 90 % of cells in bone ) , important role in homeostasis of calcium and phosphate 

wolffis hid German anatomist/engem by Jullim Dolf. of londing on tone ter, home remiadal Hot iver time to become trueer & east land

Osteoclasts 

Monocyte call lineages that multinucleated giant cells that resorb bone

Location - Small pits called Howship Lacunae, bonee surfaces. & lead culting cones.

Ruffle

d brush border , increase surforce area, create ? low PH to disolve inorganic constituents 

Enzymes Release - tartarate resistant acid phosphatase - break down organic matrix components,

inhibitors- osteoproteogerin 

Wolff’s law 

German Anatomist /Surgeon by Julius Wolff 

If loading on bone increases , bone remodels itself over time to become stronger to resist load. 

Bone | Perthes disease |Supracondylar Fracture | ABC | Gait Analysis |Cerebral Palsy (CP )|Congenital Talipes Ewuinovarus (CTEV)|Septic Arthritis |Acute Osteomyelitis|