Target PG - TNPG 2001 to 2004 Book 2002 ORTHOPAEDICS Author: Dr.J.Mariano Anto Bruno Mascarenhas
Question Stem 219) A 45 year old lady suffering from Ca Breast on Therapy for the malignancy presents to you with a fracture Shaft of Tibia. What will you do ?? Choices given A) Plaster of Paris Application B) Skin Traction C) Skeletal Traction D) Open Reduction and Internal Fixation Answer D) Open Reduction and Internal Fixation Reference Oxford Text Book of Surgery - Chapter 40.4 - management of Bone Tumours Question Analysis Based on Question Category Question Grade Question Type Books Target PG Opinion Concept Clinically Applied point MBBS Straight forward Given in All books Needs Memory Facts The treatment of skeletal metastases from primary carcinomas depends on a variety of factors. A prime goal is to alleviate pain and to render the patient mobile, so that the magnitude and consequences of hypercalcaemia are minimized. The site and size of the metastatic deposit and the threat posed to skeletal integrity or adjacent vital structures, such as the spinal cord, may dictate emergency surgical treatment and/or radiotherapy. Prophylaxis o In the long bones prophylactic nailing, with or without methyl methacrylate cement, is employed to prevent pathological fracture. o In the spine, posterior stabilization with Harrington rods and laminectomy or anterior decompression of the cord may be necessary. Treatment o If the patient has suffered a pathological fracture of a long bone, open reduction and internal fixation is usually required to stabilize the skeleton prior to radiation therapy, hormonal therapy, or chemotherapy directed at eradicating or controlling the lesion. Some tumours regress considerably with appropriate systemic management, and the use of anti-oestrogens in hormonally responsive breast cancer and oestrogens in patients with prostatic carcinoma may produce long-lasting radiographic remission of symptoms and regression of lesions. Radiation therapy is usually very effective for a solitary or even multiple symptomatic lesions, and for those that are likely to cause a fracture if left untreated. In some circumstances, particularly solitary lesions metastatic from the kidney or thyroid, aggressive resective or even ablative surgery is indicated in the hope of obtaining a cure. Interpretation When the patient has already suffered a fracture, (as given in this question) we have to go for ORIF (Open Reduction and Internal Fixation) Remarks Pathological Fractures can also occur due to Chronic Malignant Ulcers eroding the bones Tit Bits The most common causes of pathologic fracture are osteoporosis and metastatic carcinoma. Question Stem 220) Test done in deQuevrain’s disease is Choices given A) Finkelstein’s Test
B) Pump handle Test C) McMurray’s Test D) Gaenslen’s Test Answer A) Finkelstein’s Test Reference Essential Orthopaedics by Maheswari 3rd Edition Page 257 Textbook of Orthopaedics 2nd Edition Ebnezar Page 197 Kalava’s Textbook of Orthopaedics 1st Edition Page 265 Question Analysis Based on Question Category Question Grade Question Type Books Target PG Opinion Fact Clinically Applied point PG Entrance Straight forward Given in All books Needs Memory Facts There are few tests for deQuervain’s disease Ask the patient to make a fist keeping the thumb in palm - the patient will complain of pain just above radial styloid The patient makes a fist and the wrist is made to deviate towards the Ulnar Side - Pain over Radial Styloid. This is the classical Finkelstein’s Test Keep the thumb and Ring Finger in Opposition and press over the heads of the first and fourth Metacarpals with a springing action the patient complains of pain on the outer surface of radial styloid Keep the thumb and Ring Finger in Opposition and ask the patient to extend the thumb against resistance. There will be pain in radial Styloid Interpretation A) Finkelstein’s Test is done in deQuevrain’s Disease B) Pump handle Test is done to find a pathology in Sacro Iliac Joint C) McMurray’s Test is done for diagnosing Meniscal Tears D) Gaenslen’s Test is done to find a pathology in Sacro Iliac Joint Remarks About deQuervain’s disease This is condition characterized by pain and swelling over the radial styloid process. It results from the inflammation of the common sheath of abductor pollicis longus and extensor policis brevis tendons Treated by o Rest o Creep Bandage or POP Slab o Local Injection of Hydrocortisone o Slitting and excising a part of tendon sheath Tit Bits There is another deQuervain disease - Subacute nonsuppurative thyroiditis Question Stem 221) Penicillin is alleged to be useful in which of the following pathology of bone Choices given A) Sarcoidosis B) Caffey’s Disease C) Scleroderma D) Paget’s Disease Answer B) Caffey’s Disease Reference Aplye’s System of Orthopaedics and Fractures 8th Edition Page 343rd Edition Page 271 Orthopaedics Principles and their Application - Samuel Turek - Section on Caffey’s Disease Question Analysis Based on Question Category Question Grade Question Type Books Target PG Opinion Fact Subtle Point Super specialty Straight forward Not given in a UG Needs Memory Book
Facts INFANTILE CORTICAL HYPEROSTOSIS or CAFFEY’s DISEASE is a condition of unknown cause that must be differentiated from hyperphosphatasia with osteoectasia. The disorder is usually recognized in the first 3 months of life. The course is o febrile, with o marked swelling of soft tissues over the face and jaws, and o progressive cortical thickening of long bones and flat bones. o When Scapula is involved it is often unilateral Radiology o Periosteal new bone formation which has a laminated appearence Lab Investigations include o Anemia o Leucocytosis o Increased ESR o Alkaline phosphatase activity is usually mildly increased. The condition has exacerbations and remissions with spontaneous regression after several years Differential Diagnois. o Hypervitaminosis A o Scurvy o Osteomyelitis o Syphilitic Hyperostosis o Ewings and other tumours o Subperiosteal Haemorrhage following Trauma Treatment o Corticosteroids can relieve symptoms during exacerbations. o Since infectious etiology is postulated, Antibiotics are given o Vitamins are discontinued to help in finalizing the diagnosis Interpretation A) Sarcoidosis is treated by Prednisolone B) Caffey’s Disease is often treated by Antibiotics and Vitamin Withdrawal C) Scleroderma is treated by Symphathectomy D) Treatment of Paget’s Disease consists of Pain Relief, Deformity prevention, countering high output cardiac states, decreasing the tendency to fracture, prevention and treatment of hypercalcemia and reduce the probability of sarcomatous transformation Remarks If a 6-month-old infant has fever, irritability, and swelling of his mandible and laboratory studies show anemia and an elevated erythrocyte sedimentation rate (ESR), you can diagnose Caffey’s Disease Another Caffey’s Syndrome is the battered Baby Syndrome Tit Bits Caffey’s theory is associated with Perthe’s Disease (COxa Plana, Leg-Clve-Perthes’ Disease, Pseudocoxalgia) and states that the avascular necrosis of Femur is supposed to result from the Intra Epithelial Compression of Vascular Supply to Femoral Ossific nucleus Episodic symptomatic hypocalcemia occurs in the Kenny-Caffey syndrome, which is characterized by medullary stenosis of the long bones, short stature, delayed closure of the fontanel, delayed bone age, and eye abnormalities. Idiopathic hypoparathyroidism and abnormal PTH levels have been found. Autosomal dominant and autosomal recessive modes of inheritance have been reported. Question Stem 222) Which of the following is an epiphysial tumour Choices given A) Osteochondroma B) Ewing’s Sarcoma C) Osteolastoma D) Chondromyxoid fibroma
Answer C) Osteoclastoma Reference Essential Orthopaedics by Maheswari 3rd Edition Page 216 Textbook of Orthopaedics 2nd Edition Ebnezar Page 372 Kalava’s Textbook of Orthopaedics 1st Edition Page 223 Question Analysis Based on Question Category Question Grade Question Type Books Target PG Opinion Fact Subtle Point PG Entrance Straight forward Given in All books Needs Memory Facts The main tumours of bone and the places where they are commonly found are Tumour Position Location Osteoma Frontal / Facial Bones Osteoid Osteoma Diaphysis Long Bones Osteochondroma Metaphysis Long Tubular Bones Chondroma Metaphysis Phalanges (Enchondroma, Chondromyxoma) Periosteal Chondroma Long Tubular Bones Metaphysis Epiphysis (Apophysis Metaphysis) Benign Osteoblastoma Metaphysis / Diaphyis (Never in Epiphysis) Aneurysmal Bone Cyst (ABC) Metaphysis Unicameral Bone Cyst Metaphysis (Adjacent to Epiphysis) Benign Giant Cell Tumour (GCT) Epiphysis Chondromyxoid Fibroma Chondroblastoma Tubular Bones of Lower Limb Lower Limb, Post of Spine Long Bones, Vertebral Arch Upper End of Humerus Femur, Distal Radius
Osteogenic Sarcoma Metaphysis Tubular Bones Parosteal Osteogenic Sarcoma Metaphysis Long Tubular Bones Chondrosarcoma Metaphysis / Diaphysis Proximal Femoral Shaft Clear Cell Chondrosarcoma Proximal Femoral Shaft Ewing’s Sarcoma Diaphysis Long Bones Fibrosarcoma Diaphysis / Metaphysis Long Bones Histolytic Lymphoma Medulla, Epi, Meta Long Bones Multiple Myeloma Medulla Liposarcoma Long bones of Extremities Adamantinoma Jaw, Tibia Chordoma Skull, Spheno- Occipital Interpretation Self Explanatory Remarks There is also another way to remember this Location Benign Malignant Diaphysis Osteoid Osteoma Ewing’s Sarcoma Adamantinoma Lymphoma Chondrosarcoma Metaphysis Non Ossifying Fibroma Osteosarcoma Osteoblastoma Osteochondroma Chondromyxoid Fibroma Epiphysis Chondroblastoma Giant Cell Tumour (GCT) Tit Bits
Remember that Osteoclasts are NOT the tumour cells in this Tumour and the Malignant cells are the SPINDLE CELLS Question Stem 223) Nerve injury that causes pointing index deformity is Choices given A) Radial Nerve B) Ulnar Nerve C) Median Nerve D) Facial Nerve Answer C) Median Nerve Reference Essential Orthopaedics by Maheswari 3rd Edition Page 54 Textbook of Orthopaedics 2nd Edition Ebnezar Page 175 Kalava’s Textbook of Orthopaedics 1st Edition Page 214 Question Analysis Based on Question Category Question Grade Question Type Books Target PG Opinion Concept Basic point MBBS Straight forward Given in All books Needs Analysis Facts In case of a Median Nerve lesion, the nerve supply to the lateral half of FDP (Flexor Digitorum Profundus) is lost and that means there loss of flexion of the Distal Interphalangeal (DIP) Joint of the Index Finger (and to a certain extent) the Middle Finger Now when you ask the patient to clasp his hand, (Ochner’s Clasping Test) there is flexion in all other joints of the hand except the Distal Interphalangel Joint and the Index Finger “points” instead of being flexed this is called as Pointing Index Sign Interpretation A) Radial Nerve lesions lead to Wrist Drop, Thumb Drop and Finger Drop B) Ulnar Nerve lesions lead to Claw hand and Froment’s sign in the book test. Other tests are Egawa’s test, Card Test C) Median Nerve can be tested by the Pen Test. The signs are D) Facial Nerve lesions lead to bell’s palsy Remarks As the patient is unable to flex the Distal Interphalangeal Joint the Index and (to a certain extent) the middle finger are extended and this gives rise to the Benediction Attitude, the attitude the priest (clergyman) keeps his hand when blessing Tit Bits Refer to Question Number 222 in TNPG 2003 Question Paper for more info Question Stem 224) Osgood Schlatter disease affects Choices given A) Acromion of Scapula B) Tibial Tubercle C) Greater Trochanter of Femur D) Medial Part of Clavicle Answer B) Tibial Tubercle Reference Essential Orthopaedics by Maheswari 3rd Edition Page 269 Kalava’s Textbook of Orthopaedics 1st Edition Page 327 Question Analysis Based on Question Category Question Grade Question Type Books Fact Subtle Point PG Entrance Straight forward Given in All books Facts
Target PG Opinion Needs Memory
Osgood-Schlatter's disease is a common and easily recognizable stress injury to the extensor mechanism in the adolescent. The resulting concentration of stress from the quadriceps muscle pull, through the patella tendon to tibial tubercle apophysis results in chondro-osseous failure and separation because of the repetitive traction This type of stress fracture is commonly seen in children between the ages of 10 and 12. Patients often present with an insidious onset of anterior knee pain that is directly related to their activity level. Pain is often bilateral, and patients will point directly to the tibial tubercle as the source of their pain; palpation elicits exquisite tenderness. The hamstring muscles are frequently tight. Radiographic evaluation shows fragmentation of the tibial tubercle apophysis. If left untreated, the avulsed fragments never heal to the main body of the tubercle; chronic pain may ensue. Interpretation Osgood-Schlatter's disease is a Stress fractures of the tibial tubercle Remarks Treatment is directed to the relief of stress to the extensor mechanism. Athletic activity usually has to be reduced or stopped. o The most effective treatment is to use a cylinder cast to immobilize the knee and reduce the activity level. o Cold compresses, non-steroidal anti-inflammatory medication, and hamstring stretching are important. o After 6 weeks the cast is removed and active range of motion exercises are begun. o No sports are allowed until all motion and equal girth in the injured limb is equal to that of the opposite side. With successful treatment and reduction in pain, the athlete can return to sports; however, the underlying pathophysiology must be discussed with the athlete so that they understand the need for activity modification. If both legs are affected, immobilization of just one limb allows the other to rest sufficiently, and the symptoms abate. Completion of growth often renders the athlete asymptomatic. o He or she will be left with the minor cosmetic deformity of an enlarged tibial tubercle. Some patients continue to have significant pain and tenderness over the tibial tubercle, with an ununited ossicle in the patella tendon. Resection of the ossicle and surrounding bursa is necessary to relieve symptoms. However, the bony prominence of the tubercle is unchanged by the surgery. Tit Bits Refer to Q.No 228 in TNPG 2003 Paper for more information about Osteochondritis Question Stem 225) Galleazi fracture is # - # low 1/3rd radius + inf RU jt dislocation Choices given A) Fracture of Upper Ulna with Disruption of Superior Radio-Ulnar Joint B) Fracture of Lower Ulna with Disruption of Inferior Radio-Ulnar Joint C) Fracture of Upper Radius with Disruption n of Superior Radio-Ulnar Joint D) Fracture of Lower Radius with Disruption of Inferior Radio-Ulnar Joint Answer D) Fracture of Lower Radius with Disruption of Inferior Radio-Ulnar Joint Reference Essential Orthopaedics by Maheswari 3rd Edition Page 93 Textbook of Orthopaedics 2nd Edition Ebnezar Page 96 Kalava’s Textbook of Orthopaedics 1st Edition Page 63 Question Analysis Based on Question Category Question Grade Question Type Books Target PG Opinion Concept Clinically Applied point MBBS Straight forward Given in All books Needs Memory Facts Galeazzi Fracture is common in Adult and Rare in Children This is treated by Open Reduction and Internal Fixation and thus this fracture is called as the fracture of Necessity Interpretation
Self Explanatory Remarks Galeazzi Test (Allis Sign) is used for detecting UNILATERAL Congenital Dislocation of Hip The Child is made to lie of a level table in Supine Position. In case of CDH ( Congenital Dislocation of Hip) when the knees are flexed keeping the feet level, the knee of the affected side will be at a lower level Tit Bits You can remember the two fractures using the Mnemonic o Medial Bone - Monteggia If you know tamil, Remember as o Monteggia - Ma for (Melae - Up in Tamil) and Galeazzi - Ga for Gelae - Below in Tamil) Refer to Q.No 222 in TNPG 2004 Paper for more information about named Fractures and Q.No 227 in TNPG 2004 for Monteggia Fracture Question Stem 226) Sprengel Shoulder is associated with a defective scapula Choices given A) Talus B) Femur C) Radius D) Scapula Answer D) Scapula Reference Essential Orthopaedics by Maheswari 3rd Edition Page 204 Textbook of Orthopaedics 2nd Edition Ebnezar Page 257 Kalava’s Textbook of Orthopaedics 1st Edition Page 148 Question Analysis Based on Question Category Question Grade Question Type Books Target PG Opinion Concept Basic point PG Entrance Straight forward Given in All books Needs Memory Facts Failure of the scapula to descend to its normal location is termed Sprengel deformity. The scapula is located at an abnormally high position with respect to the child's neck and thorax. This abnormality occurs with varying degrees of severity. Webbing of the skin between the neck and scapula and a low posterior hairline may be associated findings. In the severe form, a bone (omovertebral) may connect the scapula with the cervical spine and prevent scapulothoracic movement. There may also be associated muscle anomalies that further limit strength and stability of the shoulder girdle. In severe cases, the scapula is very high, producing a significant cosmetic deformity with markedly limited shoulder range of motion, particularly forward flexion and abduction. In the mild form, the scapula is slightly high riding with less than normal motion. Interpretation This is a deformity of Scapula Remarks The best outcome in severe Sprengel deformity is achieved by surgically repositioning or, occasionally, partially resecting the scapula. An osteotomy of the clavicle is frequently necessary to bring the scapula to a more normal position. This improves the cosmetic appearance and will increase shoulder motion, especially abduction. Tit Bits A Klippel-Feil anomaly, congenital fusion of one or more of the cervical spine vertebra, may also occur with Sprengel deformity. Question Stem 227) Osteomalacia is associated with Choices given A) Decrease in osteoid volume.
B) Derease in osteoid surface. C) Increase in osteoid maturiaton time D) Increase in mineral apposition rate. Answer C) Increase in Osteoid Maturation Time Reference Harrison 15th Edition Chapter 340 System of Orthopaedics and Fractures Apley 8th Edition Page 119 Textbook of Orthopaedics 2nd Edition Ebnezar Page 289 Question Analysis Based on Question Category Question Grade Question Type Books Target PG Opinion Concept Basic point MBBS Twisted Given in All books Needs Analysis Facts Failure of mature bone to mineralize is called osteomalacia. In rickets, defective growth of bone results from retardation or suppression of normal growth of epiphyseal cartilage and of normal calcification. Cartilage cells fail to complete their normal cycle of proliferation and degeneration, and subsequent failure of capillary penetration occurs in a patchy manner. The result is a frayed, irregular epiphyseal line at the end of the shaft. Failure of osseous and cartilaginous matrix to mineralize in the zone of preparatory calcification, followed by deposition of newly formed uncalcified osteoid, results in a wide, irregular, frayed zone of nonrigid tissue (the rachitic metaphysis) A characteristic feature of these disorders is therefore an increase in osteoid volume and thickness (the latter being normally <12 to 14 um) and a decrease in calcification of the mineralization front. This can be detected in unmineralized sections by the fluorescence of previously ingested tetracyclines or by special stains. Interpretation A) Osteomalacia is associated with Increase in osteoid volume. B) Osteomalacia is associated with Increase in osteoid surface. C) Osteomalacia is associated with Increase in osteoid maturiaton time D) Osteomalacia is associated with decrease in mineral apposition rate. Remarks See the choices. Choice 3 stands out. Obviously the rate of maturation is delayed and that means the time is increased Tit Bits Mineralization is also lacking in subperiosteal bone; pre-existing cortical bone is resorbed in a normal manner but is replaced by osteoid tissues over the entire shaft, which fails to mineralize. If this process continues, the shaft loses its rigidity, and the resultant softened and rarefied cortical bone is readily distorted by stress; deformities and fractures result. Question Stem 228) Kinebock's disease is due to avascular necrosis of Choices given A) Patella B) Talus C) Scaphoid D) Lunate Answer D) Lunate Reference Apley 8th Edition Pg-101 Stedman's Pg- 516 Schwartz Page 1931 Question Analysis Based on Question Category Question Grade Question Type Books Fact Subtle Point PG Entrance Straight forward Given in All books
Target PG Opinion Needs Memory
Facts Osteochondritis is defined as derangement of growth or ossification occurring in an epiphysis Bone Disease Eponym Epiphysis Type Scaphoid Preisser Primary Lunate Kienbock Primary Crushing Patella Kohler Primary Talus Mouchet Primary Tarsal Navicular Kohler Primary Crushing Vertebra-Ring Epiphysis Schewermann Secondary Crushing Vertebra - Central body nucleus Calve Crushing Head of Hmerus Hass Secondary Capitellum Panner Secondary Crushing Head of Radius Brailsford Secondary Pubic Symphysis VanNeck Secondary Ischiopubic Junction Oldsberg Secondary Head of Femur LegCalvePerthes Secondary Crushing Patella Lower Pole Sinding Larsen Johnson Secondary Traction Tibial Tuberosity Osgood Schlatter Secondary Traction Calcaneum Sever Secondary Traction Metatarsal Head Freiberg Secondary Crushing Femoral Condyle Osteochondritis Dessican Splitting Interpretation Self Explanatory Remarks Questions from this topic has been repeatedly asked. Now every serious contender know these facts and so this has become a non decider Question Tit Bits If you know tamil, you can also use the mnemonic we had in our college days for this condition - “Lunke” Lunate - Kienbock