Orthopaedic Notes New

7/29/2019 Orthopaedic Notes New

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ORTHOPAEDIC NOTES

Dr.Raju Karuppal

1. Indications of surgical fixation in fracture Clavicle:

1. Nonunion.

2. Neurovascular involvement

3. Fracture of the lateral end near the acromioclavicular joint in an adult

4. A persistent wide separation of the fragments with interposition of soft tissue

5. Floating shoulder.

2. Normal intra compartment pressure is Zero mm of Hg at physiologically inactive state

Fasciotomy is indicated when the pressure reaches at 30 mm of Hg

Deepest muscles are the earliest to get involved

MC muscle involved in Upper limb is FDP

3. recurrent dislocation of shoulder

Classification of recurrent shoulder dislocation is into two types (by Matsen)

TUBS

1. T for traumatic meaning after an accident

2. U for unidirectional meaning either anterior or posterior and unilateral meaning either left or righ

3. B for Bankart lesion is present

4. S for surgery is usually required for stability

AMBRI

1. A for atraumatic meaning mild or no injury causes the initial dislocation

2. M for multi-directional meaning both in anterior and posterior directions

3. B for bilateral meaning both shoulders usually involved

4. R for rehabilitation meaning physiotherapy is the main treatment

5. I for if surgery is required then an inferior capsular shifttype of surgery is done

Dugas test, Hamiltons test, Callaways test are the tests for Anteriorly dislocated of shoulder

Apprehension test is for the assessment of recurrent dislocation of shoulder

4. Avulsion fractures of the lateral aspect of the proximal tibia below the articular surface are called Segon

fractures

Segond fractures may be accompanied by other injuries:

Tear of the anterior cruciate ligament (75-100%).

Injuries of the medial and lateral menisci (66-70%).


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The Pellegrini-Stieda sign is a finding seen on x-rays of the knee. The Pellegrini-Stieda sign is a calcium

deposit seen on the medial (inside) side of the knee, where the MCL attaches to the femur.

5. Baumann's Angle: - humeral capitellar angle: angle between long axis of humeral shaft & a line throug

physis of lateral condyle. Baumans Angle increases in cubitus varus

Q angle is the angle formed by the line of pull of the quadriceps mechanism and that of the patellar

tendon as they intersect at the center of the patella. Clinically, it is represented by the intersection of a li

drawn from the anterior superior iliac spine to the center of the patella with a second line drawn from the

center of the tibial tuberosity to the center of the patella

Bohlers angle: angle formed by intersection of line drawn from most cephalic point on tuberosity to

highest point ofposterior facet .normal range is 20-40 deg

Cobb's angle, a measurement used for evaluation of curves in scoliosis on an AP radiographic projecti

of the spine

6. The most common type of epiphyseal injury is SH type 2. Thurston Holland sign- hallmark of type 2

epiphyseal injury, it is the metaphyseal fragment separated along with the epiphysis seen in x ray

7. The Morel-Lavalle lesion is a rare condition that was first described by the French physician Maurice

Morel-Lavalle The lesion is caused by forces of pressure and shear stress at the borders of

subcutaneous tissue to the muscle fascia or bone as they are seen in run-over accidents. It leads to a

shear of skin and subcutaneous tissue from the neighboring fascia followed by the development of a

blood-filled hollow space at predestined regions of the body. If therapy is insufficient, large areas of

necrosis can form, which will negatively influence operative measures.

8. Fracture dislocation at Tarso metatarsal joint is the Lisfrank fracture

Fracture of the base of first metacarpal bone- bennets fracture

Tibial Plafond fracture pilon fracture

Fracture of radial styloid process chauffers fracture

9. GustilloAnderson classification of open fractures

Grade I

The wound is less than 1cm long. It is usually a moderately clean puncture, through which a spike of bo

has pierced the skin. There is little soft-tissue damage and no sign of crushing injury. The fracture is

usually simple, transverse, or short oblique, with little comminution.

Grade II

The laceration is more than 1 cm long, and there is no extensive soft-tissue damage, flap, or avulsion.

There is slight or moderate crushing injury, moderate comminution of the fracture, and moderate

contamination.

Grade III
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These are characterized by extensive damage to soft-tissues, including muscles, skin, and neurovascul

structures, and a high degree of contamination. The fracture is often caused by high velocity trauma,

resulting in a great deal of comminution and instability.

III A Soft tissue coverage of the fractured bone is adequate

III B Extensive injury to, or loss of soft tissue, with periosteal stripping and exposure of bone, massivecontamination, and severe comminution of the fracture. After debridement and irrigation a local or free

flap is needed for coverage.

III C Any open fracture that is associated with an arterial injury that must be repaired, regardless of the

degree of soft tissue injury.

10. Complications of the Colles fracture include:

malposition-malunion

persistent neuropathies of the median, ulnar, or radial nerves

radiocarpal or radio-ulnar arthrosis

tendon ruptures- EPL

Volkmann's ischemia

finger stiffness

shoulder-hand syndrome

11. separation of the glenoid labrum from the margin of the glenoid cavity called Bankart lesion

Hill Sachs- Defect in the posterolateral aspect of humeral head

12. Malunion is the most common complication of supracondylar fracture in children.

Malunion results:

1. deformity(gun stoke),

2. ulnar nerve neuropathy,

3. high chance of fracture to lateral condyle of humerus on fall

Other complications are: Acute:Compartment syndrome

Myositis ossificansB artery injury

Nerve injury- MC: Median

13. SUPPURATIVE ARTHRITIS usually ends with Bony ankylosis and the TB arthritis end up with fibrous

ankylosis except in Vertebral column

14. Rush pin has a role for temporary bone fixation.


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Skeletal traction is given by putting a Steinmanns pin or a K wire through the bone which is connected

the bohlers stirrup

15. sudden increase in pain in osteochondroma seen in sarcomatous change ,

indications for surgery in osteochondroma are:

bursitis

fracture of osteochondroma

Malignant transformation

Neurovascular compression

Mechanical block to the nearby joint movement

16. vacant glenoid" sign. And Electric bulbs sign on X-ray axillary view in posterior dislocation of shoulder

Posterior dislocation of shoulder is rare,

the causes are- congenital

electric shock

epilepsy

17. Floating knee: Concomitant ipsilateral fractures of the femur and tibia

Floating elbow-Concomitant ipsilateral fractures of the distal humerus and distal forearm

Floating shoulder: Concomitant ipsilateral fractures of the clavicle and scapular neck

18. Gait cycle:

STANCE PHASE = LIMB LOADING

STANCE ( support) PHASE - Begins when the heel of the forward limb makes contact with the

ground and ends when the toe of the same limb leaves the ground.

a. Heel Strike - heel of forward / reference foot touches the ground

b. Mid Stance - foot is flat on the ground and the weight of the body is directly over the

supporting limb.

c. Toe Off - Only the big toe of the forward / reference limb in contact with the ground.

60% OF GAIT CYCLE

SWING PHASE = LIMB ADVANCEMENT

SWING ( unsupported ) PHASE - Begins when the foot is no longer in contact with the ground.

The limb is free to move.


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a. Acceleration - the swinging limb catches up to and passes the torso

b. Deceleration - forward movement of the limb is slowed down to position the foot for hee

strike

MUSCLE ACTIVITY DURING GAIT

INTERVAL JOINT POSITION MUSCLE ACTIVITY

Acceleration to Heel

Strike

Hip Flexed

Gluteus Maximus

Hamstrings

Gluteus medius & minimus

Knee Flexed Quadriceps femoris

Ankle Neutral Anterior crural muscles

Heel Strike to Midstance

Hip Neutral Gluteus medius & minimus

Knee Extended Quadriceps femoris

Ankle Dorsiflexed Gastrocnemius; soleus

Tarsal InvertedTibialis anterior

Tibialis posterior

Midstance to Toe Off Hip Extended -

Knee Flexed Gastrocnemius

Ankle Plantar

flexedGastrocnemius; soleus

Tarsal EvertedFibularis longus

Fibularis brevis

Toe Off to Acceleration Hip Flexed

Iliopsoas

Adductors longus, brevis,

magnus

Knee Flexed Gastrocnemius

Ankle Neutral Anterior crural muscles

Tarsal Neutral -

19. Radial head excision contraindicated in children because


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Maximum growth of radius is at pxoxiaml end

It can cause valgus instability and valgus deformity

20. Stroncium Ranilate acts by Increasing the osteoid formation and Decreasing the osteoclast mediated

resorption of bone

21.

# neck of talus Aviators fracture

2 nd metatarsal # - March fracture

5th metatarsal base # - bar room fracture/ Boxer;s fracture

Stress fracture of fibula Runners fracture

(ref: Essentials of Skeletal Radiology (3rd. Ed.), page916

22. Fracture consist of both pubic rami plus posterior fracture ofSI complex orsacrum:

- there is vertically oriented fracture through anterior and posterior pelvis together with superior

displacement of lateral "acetabulum-containing" fragment of pelvis;

Ischeal tuberosity fractures are usually avulsion fracture.

23.Articular cartilage is a highly organized avasculartissue composed of chondrocytes embedded within a

extracellular matrix of collagens, proteoglycans and noncollagenous proteins.

Its primary functions are:

To enable the smooth articulation of joint surfaces,

To cushion compressive, tensile and shearing forces.

Hyaline cartilage has one of the lowest coefficients of friction known for any surface to surface contact. Cartilag

is unique as it is an avascular, aneural tissue, in which cells survive for a lifetime, without intercellular

connections. Articular cartilage is hyaline type cartilage

24. De Quervain syndrome; also known as washerwoman's sprain, radial styloid tenosynovitis. De

Quervain's tenosynovitis is inflammation oftendons on the side of the wrist at the base of the thumb.

These tendons include the extensorpollicis brevis and the abductor pollicis longus tendons.

Finkelstein's Test. The patient is asked to make a fist with the thumb tucked inside the palm. Stabilize

the patient's distal forearm with one hand, and ulnar deviate the wrist with your other hand. Sharp pain

induced in the area of the f irst wrist tunnel (radial side) strongly points toward de Quervain's disease.

Finsterer's Test. This is a two-phase test for Kienbock's disease: (1) If the normal prominence of the

middle knuckle during clenching the fist firmly is not produced, the test is initially positive. (2) If percussio

of the 3rd metacarpal just distal to the dorsal aspect of the midpoint of the wrist elicits abnormal

tenderness, the sign is confirmed.
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25. Galeazzi'stest- affected thigh is shortened when the knees & hips are flexed to 90 degrees .

The Galeazzi test, also known as the Allis sign, is used in the assessment ofcongenital

dislocation/developmental dysplasia of the hip. It is performed by flexing an infant's knees in the

supine position so that the ankles touch the buttocks. If the knees are not level then the test is positive,

indicating a potential congenital hip malformation

Von Rosen's sign : With the baby lying supine and the pelvis steadied with one hand, the hip being

tested is gently adducted and backward pressure is applied to the head of the femur. If the hip is

dislocatable, a clunk will be felt and sometimes heard (Von Rosen's sign). If the hip is gently abducted

will usually relocate

Tinel's sign is a way to detect unmyelinated nerves. It is performed by lightly tapping (percussing) over

the nerve to elicit a sensation of tingling or "pins and needles" in the distribution of the nerve.It takes its

name from French neurologist Jules Tinel (1879-1952).

26. Complications of scaphoid fractures are:

Nonunions

Avascular Necrosis

Arthritis

Lunate is the most commonly dislocating carpal bone

27. Discoid meniscus is a rare human anatomic variant that usually affects the lateral meniscus of the kne

A discoid meniscus is a congenital anomaly of the knee found in 3% of the population. It typically affects

the lateral meniscus and may be found bilaterally (20%). Instead of the narrow crescent shape, as seen

a normal meniscus above, a discoid meniscus is thickened, and has a fuller crescent shape

The Watanabe classification of discoid lateral meniscus is: (A) Incomplete Tear, (B) Complete Tear, a

C) Wrisberg-ligament variant.

28. When a patient gets up to gain an erect posture the knee joint must maintain a position of full extension

This is achieved by locking at the knee joint which occurs from internal rotation of femur on the fixed tibi

The Muscle which helps in locking is Quadreceps femoris.

How does the locking occurs: The articular surface of the medial femoral condyle is prolonged

anteriorly,when compared to articular surface of lateral condyle. As the knee comes in to full

extension,lateral condylar articular surface is fully used up but part of the medial condylar surface remai

unused.at this stage the femur rotates internally until the remaining articular surface of the medial condy

is in contact.

Unlocking of knee is required when flexion is initiated from a fully extended position. Unlocking is brough

about by the action of Popliteus muscle
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Plica Syndrome occurs when the plica (membranes that separate the knee into compartments during

fetal development. These plica normally diminish in size during the second trimester of fetal developme

In adults, they exist as sleeves of tissue called "synovial folds," or plica becomes irritated or inflamed

29.Operative correction congenital Talipes equino varus is basically the posteromedial release(Turco;sprocedure)

30. Plantar calcaneonavicular ligament is the (spring) ligament.

The ankle joint is bound by the strong deltoid ligament and three lateral ligaments: the anterior talofibula

ligament, the posterior talofibular ligament, and the calcaneofibular ligament.

The deltoid ligamentsupports the medial side of the joint, and is attached at the medial malleolus

the tibia and connect in four places to the sustentaculum tali of the calcaneus, calcaneonavicular ligament,

the navicular tuberosity, and to the medial surface of the talus. The anteriorandposterior talofibular ligaments support the lateral side of the joint from the he

fibula to the dorsal and ventral ends of the talus.

The calcaneofibular ligamentis attached at the lateral malleolus and to the lateral surface of the

calcaneus.

31. The coronary ligament of the liverrefers to parts of the peritoneal reflections that hold the liver to the

inferior surface of the diaphragm

The coronary ligaments of the knee (also known as meniscotibial ligaments) are portions of the join

capsule which connect the inferior edges of the fibrocartilaginous menisci to the periphery of the tibial

plateaus.

32. .Non union is the most common complication of fracture NOF

Other complications are:

AVN

OA Hip

33. walking cycle has two phases-swing phase and stand phase

34. most common type of meniscal tear is Longitudinal tear

35. Lachmans test- most specific test for ACL tear. The Lachman test is recognized by most authorities as

the most reliable and sensitive clinical test for the determination of anterior cruciate ligament integrity. P

the patient's knee in about 20-30 degrees flexion, also according to Bates' Guide to Physical Examinatio
http://en.wikipedia.org/wiki/Deltoid_ligamenthttp://en.wikipedia.org/wiki/Anterior_talofibular_ligamenthttp://en.wikipedia.org/wiki/Anterior_talofibular_ligamenthttp://en.wikipedia.org/wiki/Posterior_talofibular_ligamenthttp://en.wikipedia.org/wiki/Calcaneofibular_ligamenthttp://en.wikipedia.org/wiki/Medial_malleolushttp://en.wikipedia.org/wiki/Sustentaculum_talihttp://en.wikipedia.org/wiki/Calcaneushttp://en.wikipedia.org/wiki/Calcaneonavicular_ligamenthttp://en.wikipedia.org/wiki/Navicular_tuberosityhttp://en.wikipedia.org/wiki/Liverhttp://en.wikipedia.org/wiki/Peritonealhttp://en.wikipedia.org/wiki/Thoracic_diaphragmhttp://en.wikipedia.org/wiki/Meniscus_(anatomy)http://en.wikipedia.org/wiki/Tibiahttp://en.wikipedia.org/wiki/Flexionhttp://en.wikipedia.org/wiki/Deltoid_ligamenthttp://en.wikipedia.org/wiki/Anterior_talofibular_ligamenthttp://en.wikipedia.org/wiki/Anterior_talofibular_ligamenthttp://en.wikipedia.org/wiki/Posterior_talofibular_ligamenthttp://en.wikipedia.org/wiki/Calcaneofibular_ligamenthttp://en.wikipedia.org/wiki/Medial_malleolushttp://en.wikipedia.org/wiki/Sustentaculum_talihttp://en.wikipedia.org/wiki/Calcaneushttp://en.wikipedia.org/wiki/Calcaneonavicular_ligamenthttp://en.wikipedia.org/wiki/Navicular_tuberosityhttp://en.wikipedia.org/wiki/Liverhttp://en.wikipedia.org/wiki/Peritonealhttp://en.wikipedia.org/wiki/Thoracic_diaphragmhttp://en.wikipedia.org/wiki/Meniscus_(anatomy)http://en.wikipedia.org/wiki/Tibiahttp://en.wikipedia.org/wiki/Flexion


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the leg should be externally rotated. The examiner should place one hand behind the tibia and the other

on the patient's thigh. It is important that the examiner's thumb be on the tibial tuberosity. On pulling

anteriorly on the tibia, an intact ACL should prevent forward translational movement of the tibia on the

femur("firm endpoint").

Anterior Drawers test :The test is performed as follows: the patient is positioned lying supine with the h

flexed to 45 and the knee to 90. The examiner positions themselves by sitting on the examination tabl

in front of the involved knee and grasping the tibia just below the joint line of the knee. The thumbs are

placed along the joint line on either side of the patellar tendon. The index fingers are used to palpate the

hamstring tendons to ensure that they are relaxed; the hamstring muscle group must be relaxed to ensu

a proper test. The tibia is then drawn forward anteriorly. An increased amount of anterior tibial translatio

compared with the opposite limb or lack of a firm end-point indicates either a sprain of the anteromedial

bundle of the ACL or a complete tear of the ACL.

An instrument called a "KT-1000" can be used to determine the magnitude of movement in mm.

36. Subacromial bursitis is a condition caused by inflammation of the bursa that separates the superior

surface of the supraspinatus tendon (one of the four tendons of the rotator cuff) from the overlying corac

acromial ligament, acromion, coracoid (the acromial arch) and from the deep surface of the deltoid

muscle

Causes:

Primary inflammation

Autoimmune inflammatory conditions (rheumatoid arthritis)

Crystal deposition (Gout or Pseudo gout)

Calcific loose bodies (rheumatoid arthritis)

Infection

More commonly,as a result of complex factors, thought to cause shoulderimpingementsymptoms.

These factors are broadly classified as:

Intrinsic (intratendinous)

Extrinsic (extratendinous).

They are further divided into primary or secondary causes of impingement. Secondary causes are thoug

to be part of another process such as shoulder instability or nerve injury

Impingement syndrome, also called painful arc syndrome is a clinicalsyndromewhich occurs when

the tendons of the rotator cuffmuscles become irritated and inflamed as they pass through the
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subacromial space, the passage beneath the acromion. This can result in pain, weakness and loss of

movement at the shoulder

Causes: Anything which causes further narrowing of subacromial space can result in impingement

syndrome.

This can be caused by:

Bony structures such as subacromial spurs

Osteoarthritic spurs on the acromioclavicular joint

Variations in the shape of the acromion.

Thickening or calcification of the coracoacromial ligament

Loss of function of the rotator cuff muscles

Subacromial bursitis

Frozen shoulderis when the shoulder is painful and loses motion because of inflammation.

Most of the time there is no cause for frozen shoulder. However, risk factors include:

Cervical disk disease of the neck

Diabetes

Shoulder injury

Shoulder surgery

Open heart surgery

Hyperthyroidism

37. Arteries of the knee

The femoral artery and thepopliteal arteryhelp form the arterial network surrounding the knee joint

There are 6 main branches:

1. Superior medial genicular artery

2. Superior lateral genicular artery

3. Inferior medial genicular artery

4. Inferior lateral genicular artery
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5. Descending genicular artery

6. Recurrent branch of anterior tibial artery

The medial genicular arteries penetrate the knee joint

The middle genicular artery is a small branch, arisingopposite the back of the knee-joint. It pierces the oblique

popliteal ligament, and supplies the ligaments and synovial membrane in the interior of the articulation.

38. Osteporosis:

Symptoms occurring late in the disease include:

Bone pain or tenderness

Fractures with little or no trauma

Loss of height (as much as 6 inches) over time

Low back pain due to fractures of the spinal bones

Neck pain due to fractures of the spinal bones

Stooped posture orkyphosis, also called a "dowager's hump"

Tests

Bone mineral density testing-DEXA scan).

A special type ofspine CT , quantitative computed tomography (QCT),that can show loss of bone mineral densi

In severe cases, a spine or hip x-ray may show fracture or collapse of the spinal bones.

Treatment

The goals of osteoporosis treatment are to:

Control pain from the disease

Slow down or stop bone loss

Prevent bone fractures with medicines that strengthen bone

Minimize the risk of falls that might cause fractures

Medications are used to strengthen bones when:

Osteoporosis has been diagnosed by a bone density study.
http://wiki/Descending_genicular_arteryhttp://wiki/Anterior_tibial_recurrent_arteryhttp://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A003180/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000001/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A003025/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A001240/http://pubmedhealth/n/pmh_adam/A003787/http://pubmedhealth/n/pmh_adam/A003806/http://wiki/Descending_genicular_arteryhttp://wiki/Anterior_tibial_recurrent_arteryhttp://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A003180/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A000001/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A003025/http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A001240/http://pubmedhealth/n/pmh_adam/A003787/http://pubmedhealth/n/pmh_adam/A003806/


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Osteopenia (thin bones, but not osteoporosis) has been diagnosed by a bone density study, if a bone

fracture has occurred.

BISPHOSPHONATES

Bisphosphonates are the primary drugs used to both prevent and treat osteoporosis

Alendronate

Ibandronate

Risedronate

CALCITONIN

Calcitonin is a medicine that slows the rate of bone loss and relieves bone pain. It comes as a nasal spray o

injection.

HORMONE REPLACEMENT THERAPY

Estrogens orhormone replacement therapy (HRT)

PARATHYROID HORMONE

Teriparatide is approved for the treatment of severe osteoporosis

RALOXIFENE(selective estrogen receptor modulator (SERM)

Raloxifeneis used for the prevention and treatment of osteoporosis. Raloxifene is similar to the breast canc

drug tamoxifen.

39. The clay-shoveler's fracture is an oblique fracture of a lower cervical spinous process, commonly C7

Hangmans fracture: Traumatic spondylo listhesis of Axis

Chance fracture- horizondal fracture through the spinous process

40. Simmonds-Thompson test is to test for the rupture of the achilles tendon.The patient lies face down

with feet hanging off the edge of the bed. If the test is positive, there is no movement of the foot on

squeezing the corresponding calf, signifying likely rupture of the achilles tendon.

Biceps brachi rupture causes Popeye deformity

41. Tendo Achillis tendinitis can be:

Non insertional tendinitis: The main complaint associated with Achilles tendonitis is pain behind the

heel. The pain is often most prominent in an area about 2-4 centimeters above where the tendon attach
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to the heel. In this location, called the watershed zone of the tendon, the blood supply to the tendon

makes this area particularly susceptible

Insertional tendinitis: Due to overuse

Haglund's deformity may be related to this condition

42. Jons tendon transfer for radial nerve injury,

Palmaris longus to substitute EPL

Pronator teres to substitute ECRB

FCU to substitute ED

43. spinal shock UM type palsy

Spinal shock is the loss ofsensation accompanied by motorparalysis with initial loss but gradual recovery o

reflexes, following a spinal cord injury (SCI) -- most often a complete transection. Reflexes in the spinal cord

caudal to the SCI are depressed (hyporeflexia) or absent (areflexia), while those rostral to the SCI remain

unaffected

44. In cervical injury traction is given to Disengage inter locked articular process

45. As per 1987 Criteria for the Classification of Acute Arthritis of Rheumatoid Arthritis -The 14 possible are

are right or left PIP, MCP, wrist, elbow, knee, ankle, and MTP joints

In 2010 the 2010 ACR / EULAR Rheumatoid Arthritis Classification Criteria were introduced.These new

classification criteria overruled the "old" ACR criteria of 1987 and are adapted for early RA diagnosis. Th

"new" classification criteria establish a point value between 0 and 10. Every patient with a point total of 6

or higher is unequivocally classified as an RA patient, provided he has synovitis in at least one joint and

given that there is no other diagnosis better explaining the synovitis. Four areas are covered in the

diagnosis:

Joint involvement, designating the

Metacarpophalangeal joints,

Proximal interphalangeal joints,

Interphalangeal joint of the thumb,

Second through thirdmetatarsophalangeal joint

Wrist as small joints,

Elbows,hip joints

Kneesas large joints:
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Involvement of 1 large joint gives 0 points

Involvement of 2-10 large joints gives 1 point

Involvement of 1-3 small joints (with or without involvement of large joints) gives 2 points

Involvement of4-10 small joints (with or without involvement of large joints) gives 3 points

Involvement of more than 10 joints (with involvement of at least 1 small joint) gives 5 points

serological parameters including the rheumatoid factoras well asACPA "ACPA" stands for "anti-

citrullinated protein antibody":

Negative RF andnegative ACPA gives 0 points

Low-positive RF orlow-positive ACPA gives 2 points

High-positive RF orhigh-positive ACPA gives 3 points

Acute phase reactants: 1 point for elevated erythrocyte sedimentation rate, ESR, or elevated CRPvalue

(c-reactive protein)

Duration ofarthritis: 1 point for symptoms lasting six weeks or longer

46. Radiological signs in scurvy are Wimberger line,Pelken Spur,Frenkels line

47. The position of lower limb in Synovitis hip joint is Flexion abduction external rotation

The position of lower limb in OA hip joint is Flexion adduction external rotation

The position of lower limb in Posterior dislocation hip joint is Flexion adduction internal rotation

48. Trendelenburg's sign is found in people with weak or paralyzedabductormuscles of thehip, namely

gluteus mediusandminimus. It is named after the German surgeon

Sup GLUTEAL N (innervating the glu medius, which is the abductor of hip joint)

49. Most common complication of fracture lateral condyle of humerus is non union

50. Acramans zonal effect in HPR and Spotted veil in X Ray is in Myositis ossificans

Heterotopic ossification two types

1.Dystrophic:serum ca and ALP are not non specific .but ALPmis the single most important

investigation, as it is the measure of Osteoblastic activity

2.Metastaic :Serum ca level is very important investigation
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51. Treatment of the Fracture neck of femur:

in young patients is - Closed pinning with screws

Old age: hemiarthroplasty

Any age with OA THR

52. Classification of supracondylar fracture in children:

- 2 types: extension type (95%) & flexion type;

Most common type of supracondylar fracture of humerus is Extension type

Gartland classification for extension fractures:

- recognizes that anterior cortex fails first w/ resultant posterior displacement of distal fragme

- type I: non-displaced frx;

- type II: displaced with intact posterior cortex;

- type III: displaced with no cortical contact

53. Names of the surgeries:

Genu valgum deformity - Mc Evens femoral osteotomy

Perthes disease Varus derotation surgery by Axer

C. Clubfoot deformity Turcos Posteromedial release

Hip diseases- Watson Jones operation

54. In C5-6 disc prolapse,nerve injury seen is C6.

C5-6 disc prolapse is the commonest site of IVDP at cervical spine

55. Pulled elbow is the is slippage of the head of the radius under the annular ligament. The distal attachme

of the annular ligament covering the radial head is weaker in children than in adults, allowing it to be mo

easily torn. This condition has been described by HUGH OWEN THOMAS( Hence called Thomas Elbo

56. Follows a fall from height There is more association of the fractures of Calcaneum,vertebra and Base o

skull. This areas are important in the skeletal survey

57. Osteomyelitis

Subacute osteomyelitis is a distinct form of osteomyelitis, and Brodie abscess is one type of subacute

osteomyelitis.

Treatments:

Prolongedantibiotic therapy

Surgical debridement. Open surgery is needed for chronic osteomyelitis, whereby the involucru

is opened and the sequestrum is removed or sometimes
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Hyperbaric oxygen therapy in treatment ofrefractory osteomyelitis

Ilizarov technique

58. Crush syndrome results from Massive crushing of muscles release of large amount of myohemoglobin

in to the circulation,which is excreted in the urine (Myohemoglobinuria)

59. Slipped capital femoral epiphysis

Symptoms

Difficulty walking, walking with a limp

Knee pain

Hip pain

Hip stiffness

Outward-turning leg - Axis deviation

Restricted hip movements

Treatment

Surgery to stabilize the bone with pins or screws will prevent further slippage or displacement of the bal

of the hip joint.

60. Ulnar nerve injury

Froment's sign: when the patient is asked to adduct the thumb (such as holding a pencil in the web

space), patient will instead hyperflex the IP joint to compensate for loss of the adductor

wartenberg's sign (little finger abduction) due to unopposed ulnar insertion ofextensor digiti quinti; litt

finger more often has more severeclaw deformity, as opposed to ring finger, because of inherent

increased laxity in little finger MP joint volar plate; in addition, approx 50% of pts have median nerve

cross innervation tolumbricalsto ring finger,

thus preventing claw deformity of the ring finger;

- Clawing- also known as Duchenne's sign;

Operative Procedures:
http://wiki/Hyperbaric_oxygen_therapyhttp://en.wiktionary.org/wiki/refractoryhttp://pubmedhealth/n/pmh_adam/A003199/http://pubmedhealth/n/pmh_adam/A003187/http://pubmedhealth/n/pmh_adam/A003179/http://pubmedhealth/n/pmh_adam/A003261/http://ortho/extensor_digiti_minimi_qunitihttp://ortho/extensor_digiti_minimi_qunitihttp://ortho/intrinsic_weakness_and_claw_handhttp://ortho/intrinsic_weakness_and_claw_handhttp://ortho/median_nervehttp://ortho/lumbricalshttp://ortho/lumbricalshttp://ortho/lumbricalshttp://ortho/intrinsic_weakness_and_claw_handhttp://ortho/intrinsic_weakness_and_claw_handhttp://ortho/intrinsic_weakness_and_claw_handhttp://wiki/Hyperbaric_oxygen_therapyhttp://en.wiktionary.org/wiki/refractoryhttp://pubmedhealth/n/pmh_adam/A003199/http://pubmedhealth/n/pmh_adam/A003187/http://pubmedhealth/n/pmh_adam/A003179/http://pubmedhealth/n/pmh_adam/A003261/http://ortho/extensor_digiti_minimi_qunitihttp://ortho/intrinsic_weakness_and_claw_handhttp://ortho/median_nervehttp://ortho/lumbricalshttp://ortho/intrinsic_weakness_and_claw_handhttp://ortho/intrinsic_weakness_and_claw_hand


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Adductor pollicis deficit:

- adductor pollicis substitution by FDSof long finger passed thru interosseous membrane, over & under

ECU as distal pulley;

Byles procedure: transfer ofBR(reroute around 3rd MC toadductor pollicis);

- intrinsic muscles deficit:

APL transfer to first dorsal interosseous

MP joint arthrodesis

61. Mechanism of violence in burst fracture is axial Compression violence

axial Compression violence alone or along with flexion , rotation or lateral flexion

CHANCE FRACTURE- Horizondal avulsion injuru of vertebral bodies

MC force involved in the fracture of the spine is Flexion

62. Gardens Classification of fracture femoral neck is:

Type I = Partial fracture

Type II = Complete fracture and undisplaced

Type III = Complete fracture with partial displacement

Type IV = Complete fracture and fully displaced

63. Brachial pluxes injury can be pre ganglionic or post ganglionic

Pre ganglionic lesions=

o Poor prognosis,

o Surgically irreparable

o Histamine test is +ve

64. Medial meniscus injury is more common than Lateral meniscus, because of various reasons. The most

important is the medial meniscus is less mobile due to its attachment to the MCL.

The ligaments in relation to menisci are:

1. Menisco femoral ligaments

2. Coronary Ligament Attach periphery of meniscus to tibial condyle

3. Transverse ligaments Attach the anterior edges of the medial and lateral meniscus

Ligament of Wrisberg & Humphrey are the menisco femoral ligaments.They are extendingfrom the

posterior part of the lateralmeniscus and ends on the femoral medial condyle in association with the PC
http://ortho/adductor_pollicishttp://ortho/flexor_digitorum_superficialishttp://ortho/flexor_digitorum_superficialishttp://ortho/extensor_carpi_ulnarishttp://ortho/brachioradialishttp://ortho/brachioradialishttp://ortho/brachioradialishttp://ortho/adductor_pollicishttp://ortho/adductor_pollicishttp://ortho/adductor_pollicishttp://ortho/intrinsic_weakness_and_claw_handhttp://ortho/abductor_pollicis_longushttp://ortho/arthrodesis_of_the_mp_joint_and_finger_joints_1http://ortho/arthrodesis_of_the_mp_joint_and_finger_joints_1http://ortho/adductor_pollicishttp://ortho/flexor_digitorum_superficialishttp://ortho/extensor_carpi_ulnarishttp://ortho/brachioradialishttp://ortho/adductor_pollicishttp://ortho/intrinsic_weakness_and_claw_handhttp://ortho/abductor_pollicis_longushttp://ortho/arthrodesis_of_the_mp_joint_and_finger_joints_1


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Lig of Humphrey =Anterior menisco femoral lig.

Lig of Wrisberg = Posterior menisco femoral lig

Locking and giving way are very commonly seen with meniscus tear

Indications for meniscus tearrepair are:

Peripheral tear-RR RW Zone

Acute tears should be repaired

Longitudinal tears should be repaired

Associated ACL injury

65.Airplane splint is used in Brachial plexus palsy to prevent the deformities

66. Lateral condyle humerus excition can cause lateral instability of elbow with cubitus valgus deformity

67. . There are two types of traction: skin traction and skeletal traction.

Maximum weight that can be used in skin traction is 1/10 of body Wt.

Bryant's traction - in young children who have fractures of the femur

Buck's traction - hip fractures

Dunlop's traction - humeral fractures in children

Russell's traction- Fracture femur

68. Subperiosteal new bone formation is not a feature of Eosinophilic granulomaPeriosteal reaction can result from a large number of cause:

1.Trauma - bone healing in response to fracture, subperiosteal hematomas

2.chronic irritation due to a medical condition such as hypertrophic osteopathy,

3.osteomyelitis,

4.cancerof the bone.

5.as part ofthyroid acropachy,

6.a severe sign of the autoimmune thyroid disorderGrave's disease.

7.Menkes kinky hair syndrome

8. hypervitaminosis A.

It can take about three weeks to appear.

69. Subtrochanteric fracture fixation methods

EXTRAMEDULLARY fixation methods = DHS & Condylar butress plate
http://en.wikipedia.org/w/index.php?title=Bryant%27s_traction&action=edit&redlink=1http://en.wikipedia.org/wiki/Femurhttp://en.wikipedia.org/w/index.php?title=Buck%27s_traction&action=edit&redlink=1http://en.wikipedia.org/wiki/Hip_fracturehttp://en.wikipedia.org/w/index.php?title=Dunlop%27s_traction&action=edit&redlink=1http://en.wikipedia.org/wiki/Humeralhttp://en.wikipedia.org/w/index.php?title=Russell%27s_traction&action=edit&redlink=1http://en.wikipedia.org/wiki/Hypertrophic_osteopathyhttp://en.wikipedia.org/wiki/Osteomyelitishttp://en.wikipedia.org/wiki/Cancerhttp://en.wikipedia.org/wiki/Acropachyhttp://en.wikipedia.org/wiki/Grave's_diseasehttp://en.wikipedia.org/wiki/Menkes_kinky_hair_syndromehttp://en.wikipedia.org/wiki/Hypervitaminosis_Ahttp://en.wikipedia.org/w/index.php?title=Bryant%27s_traction&action=edit&redlink=1http://en.wikipedia.org/wiki/Femurhttp://en.wikipedia.org/w/index.php?title=Buck%27s_traction&action=edit&redlink=1http://en.wikipedia.org/wiki/Hip_fracturehttp://en.wikipedia.org/w/index.php?title=Dunlop%27s_traction&action=edit&redlink=1http://en.wikipedia.org/wiki/Humeralhttp://en.wikipedia.org/w/index.php?title=Russell%27s_traction&action=edit&redlink=1http://en.wikipedia.org/wiki/Hypertrophic_osteopathyhttp://en.wikipedia.org/wiki/Osteomyelitishttp://en.wikipedia.org/wiki/Cancerhttp://en.wikipedia.org/wiki/Acropachyhttp://en.wikipedia.org/wiki/Grave's_diseasehttp://en.wikipedia.org/wiki/Menkes_kinky_hair_syndromehttp://en.wikipedia.org/wiki/Hypervitaminosis_A


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Intramedullary fixation methods = Russel Tayler nail,Gamma nai &Ender nail

70. Locking and giving way are very commonly seen with meniscus tear

Indications for meniscus tearrepair are:

1. Peripheral tear-RR RW Zone2. Acute tears should be repaired

3. Longitudinal tears should be repaired

4. Associated ACL injury

71. Organism causing Osteomyelitis

Age group Most common organisms

Newborns (younger than 4 mo)S. aureus,Enterobacterspecies, andgroup Aand BStreptococcus

species

Children (aged 4 mo to 4 y)S. aureus,group AStreptococcus species, Haemophilus influenzae,

andEnterobacterspecies

Children, adolescents (aged 4 y

to adult)

S. aureus (80%), group AStreptococcus species, H. influenzae, and

Enterobacterspecies

Adult S. aureus and occasionallyEnterobacterorStreptococcusspecies

Sickle Cell Anemia Patients Salmonella species

Commonest organism causing osteomyelitis in children under 3 years is Staphylococcus aureus

72. In COMPARTMENT SYNDROME the deepest muscles are first to get involved

73. . Brachialis is a muscle with dual nerve supply

Brachialis is supplied by Radial and musculocutaneous nerve

74. Ulnar nerve

It is the terminal branch of the medial cord, root value C8, T1 but sometimes it is joined by fibers of C7

which arises from the lateral cord.

It runs along the medial border of the axillary artery up to the medial aspect of the brachial artery to the

middle of the arm were it pierces the medial intermuscular septum to enter the extensor

compartment of the arm.

75. Aaaaa
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76. Spinal tumors areneoplasms located in the spinal cord. They are mostlymetastases from primary

cancers elsewhere (commonly breast, prostateandlung cancer).

Primary tumors may be benign (e.g. hemangioma) or malignant in nature.

Depending on their location, the spinal cord tumors can be:

Extradural - Metastasis, meningioma

Intradural - neuro fibroma

Intramedullary - ependymoma,neuro fibroma

Commonest intramedullary spinal tumour is:Ependymoma

77. Tennis elbow is an overuse injury occurring in the lateral side of the elbow region, but more specifically,

occurs at common extensor tendon that originates from the lateral epicondyle.

Tests for Tennis elbow are Cozen & Mills

The pathology of tennis elbow is Angio fibroblastic hyperplasia at the origin of the extensor carpi radiali

brevis

78.A fat embolism is a type ofembolism that is often caused byphysical traumasuch as fracture of long

bones, soft tissue trauma and burns

The pathogenesis occurs due to both mechanical obstruction and biochemical injury. The

microemboli cause pulmonary and cerebral microvasculature occlusion. It is aggravated by local platele

and erythrocyte aggregation. The release of free fatty acids from the fat globules causes local toxic injur

to endothelium. The vascular damage is aggravated by platelet activation and recruitment of

granulocytes.

Clinical Manifestations are

Neurological (Brain)

Dematological

Ocular

Respiratory

79. Bone tumour metastasizing to bone is Ewing's sarcoma

80. Giant-cell tumor of the bone is characterized by the presence ofmultinucleated giant cells (osteoclast

like cells).

On x-ray, giant-cell tumors (GCTs) are lytic/lucent lesions that have a epiphyseal location and grow to th

articular surface of the involved bone. Radiologically the tumors may show characteristic 'soap bubble'

appearance] They are distinguishable from other bony tumors in that GCTs usually have a non-sclerotic
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and sharply defined border. 5% of giant-cell tumors metastatise, usually to lung, which may be benign

metastasis

Osteoclastoma is common in age group of: 20 to 40 years

81. Name of cast and its use

Risser/turn buckle cast used for scoliosis

U cast/hanging cast- #humerus

Minerva cervical spine injury

PTB cast - #tibia

82. The most common cause of a sprained ankle is injury of: Anterior Talofibular ligament

83. Flexion abductionposition of proximal fragment in subtrochanteric fracture is due to the pull of iliopsoas

anteriorly and the gluteus medius laterally

84. Scurvy characterized by metaphyseal enlargement . In spondylo-epiphyseal dysplasia and rickets the

epiphysis is the main area of involvement.

85. Colles fracture has six components - Proximal impaction, Lateral rotation, Dorsal angulation, dorsal

tilt,lateral angulation ,lateral tilt

86. Bryants triangles A triangle drawn in order to determine the upward displacement of the trochanter in

fracture of the neck of the femur. Its dimensions are changed in supratrochanteric pathology

87. In Hemophilia, pseudotumour is most often found in Ilio psoas

88. Osteogenesis imperfecta hallmark is h/o multiple fracture with deformities

89. Injury of median nerve at wrist is best detected by Action of abductor pollicis brevis because it is solely

supplied by the median and can test very easily and reliably

90. Excition of olecranone is indicated in:

Non articular fractures

Fracture in elderly

Fracture with extensive comminution(orif not amenable)

Old ununited fracture

91. Multiple exostosis usually presents at: Puberty because its the time of maximum bone growth.

92. Gate control theory asserts that activation of nerves which do not transmit pain signals, called

nonnociceptive fibers, can interfere with signals from pain fibers, thereby inhibiting pain.

Afferentpain-receptive nerves, those that bring signals to the brain, comprise at least two kinds of fibers

a fast, relatively thick, myelinated"A" fiberthat carries messages quickly with intense pain, and a smal

unmyelinated, slow"C" fiberthat carries the longer-term throbbing andchronic pain. Large-diameter A
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fibers are nonnociceptive (do not transmit pain stimuli) and inhibit the effects of firing by A and C

fibers.Theperipheral nervous system has centers at which pain stimuli can be regulated. Some areas in

the dorsal horn of the spinal cordthat are involved in receiving pain stimuli from A and C fibers, called

laminae, also receive input from A fibers. The nonnociceptive fibers indirectly inhibit the effects of the

pain fibers, 'closing a gate' to the transmission of their stimuli. In other parts of the laminae, pain fibers

also inhibit the effects of nonnociceptive fibers, 'opening the gate'.

93. Maximum shortening of limb is seen in Posterior dislocation hip due to the proximal migration of the fem

when it is out of the acetabulam.

94. Collapsed dorsal vertebra with disc space narrowing is the radiological sign infection of spine

95. Synovial fluid is a viscous, non-Newtonian fluid

Synovial tissue is a vascularized connective tissue that lacks a basement membrane.

Two cell types (type A and type B) are present:

Type B produces synovial fluid.

Synovial fluid is made of hyaluronic acid and lubricin, proteinases, and collagenases.

Synovial fluid exhibitsnon-Newtonian flowcharacteristics; the viscosity coefficient is not a constant and the

fluid is not linearly viscous. Synovial fluid has thixotropiccharacteristics; viscosity decreases and the fluid

thins over a period of continued stress.

Normal synovial fluid contains 34 mg/mlhyaluronan which is synthesized by the synovial membrane and

secreted into the joint cavity to increase the viscosity and elasticity of articular cartilages and to lubricate the

surfaces between synoviumand cartilage

Synovial fluid contains lubricinsecreted by synovial cells. Chiefly, it is responsible for so-called

boundary-layer lubrication, which reduces friction between opposing surfaces of cartilage.

96. Deep heat is produced when energy is converted into heat as it passes through body tissues.Energy

sources include

high-frequency currents (shortwave diathermy)

electromagnetic radiation (microwaves)

ultrasound (high-frequency sound).

The best method for large-area deep heating is shortwave diathermy. This modality is useful for various

indications.

97. fixed flexion deformity of a joint Complete extension is not possible

98. Hunterdescribed the 4 classic stages of natural bone repair:
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Inflammation

Soft callus

Hard callus

Remodeling.

The inflammation stage begins soon after injury and appears clinically as swelling, pain,

erythema, and heat.

After the initial inflammatory phase, the soft callus stage begins with an infiltration of fibrous

tissue and chondroblasts surrounding the fracture site.

Soft callus is then converted into rigid bone, the hard callus stage, by enchondral ossification an

intramembranous bone formation.

Once the fracture has united, the process of remodeling begins. Fibrous bone is eventually

replaced by lamellar bone.

This process has been called secondarybone union or indirect fracture repair, it is the natural and

expected way fractures heal.

Anatomic reduction and absolute stabilization of a fracture by internal fixation alter the biology of fractur

healing. Absolute stability with no fracture gap (eg, via ORIF using interfragmental compression and

plating) presents a low strain and results in primary healing (cutting cone) without the production of

callus.

99. CARPEL TUNNEL SYNDROME is the most common peripheral nerve compression neuropathy

100. A popular form of muscle stimulation, Faradic current( intermittent and nonsymmetrical alternaticurrent) is an alternating current that affects the muscle only and causes no reaction in the skin.

Galvanic current is using for nerve stimulation

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