• Pain- pain at rest / night pain
• Palpable mass
• Altered functions
• LOW
• LOA
• Pathological fracture

          - fever not prominent

• Clinical evaluation

• 50 – mets (destructive bone lesions)
• 10 – Histiocytosis

• Osteosarcoma- male
• GCT – female

• smoking
• certain jobs
• previous irradiation

• Physical Examination:
• General examination :

• Secondary:

• Primary:

• FBC

• Plain radiograph

• Bone scan

• MRI

• Angiogram

• Tumor staging (Enneking)

• Surgical resection

• Plain Radiograph:

• Epiphysis

• Diaphysis – Round cell tumors (Histiocytosis, leukemia,lymphoma, Ewing,

• Metaphysis

Labels: Management

1.Open fracture (Gustillo Anderson)
grade 1 wound size less than 1cm <6hours minimal soft tissue injury
grade 11 1 – 10cm >8hours moderate
grade 111 >10cm >8hours severe
A Adequate soft tissue cover
B Inadequate
C Vascular injury require repair

2.Physeal injury (Salter Harris)
type 1 epiphyses and growth plate
type 11 epiphyses and growth plate + part of metaphysis
type 111 part of epiphysis and growth plate
type 1V part of epiphysis, growth plate and metaphysis
type V crush injury (crumple of growth plate)

3.Fracture neck of femur (Garden)
grade 1 incomplete #
grade 11 complete #, undisplaced
grade 111 complete #, partially displaced
grade 1V complete # and totally displaced

4.Diabetic foot (Wegener)
grade 0 foot at risk, sensory neuropathy
grade 1 sup ulcer
grade 11 deep ulcer
grade 111 osteomyelitis (bony changes)
grade 1V local gangrene
grade V foot gangrene

5. Ankle fracture (Weber)
A # of fibula below syndesmosis
B # of fibula at the level of syndesmosis
C above the level of syndesmosis

6.MSK Tumor (Enneking)
stage 1(intra compartmental)
A low grade
B high grade
stage 11(extra compartmental)
A low grade tumour
B high grade
stage 111(distant metastasis)

7.Spine fracture (Dennis)
There are 3 columns:
Anterior
Middle
Posterior
Involvement of more than one column is unstable
Instability - pain
- deformity
- neurology deficit

Labels: Orthopaedic notes

presentation:
Painful distal thigh ?prox. leg swelling/mass.

Examination:
-mass examination:
-site
-shape
-size
-tenderness
-temperature changes
-surface
-consistency
-border
-?sinus,ulceration,discharge
-special features
-pulsatile/expansile
-translumination test
-bruit
-relation to adjacent structures
-attachment to skin and underlying muscles
-mobility
-compression effects to neurovascular structure
-knee joint ROM

Common Qs:
1.Differential diagnosis:
-tumor
-osteosarcoma
-infection
-chronic OMof prox tibia
-TB
-TB arthritis - usually the sweeling is diffuse and ROMknee is usually present.

2.Investigations
-Blood:
-Hb - anemia - nonspecific
-TWDC -elevated in infection
-ESR -non specific
-LFT -elevated ALP - suggestive of bone tumor
-Radiological:(Radiological staging)
-Plain x-ray of the affected limb
-osteolytic changes, cortical destruction,periosteal elevation(Codman's triangle), narrow
zone of transistion (both present in tumor and Chronic OM)
-calcification/new bone formation - more toward sbone forming tumor eg osteosarcoma.
-look for joint involvement, skip lesion into femur
-pathological fracture
-Chest x ray - look for secondary
-Other investigation:
-MRI - soft tissue involvement - marrow extension, muscles and neurovascular

involvement
-CT scan - the affected site (for cortical destruction)
- chest especially if plain chest x ray is normal - TRO secondaries
-Bone scan - to detect secondaries
-angiogram if necessary

3.What is next?
-Biopsy.(histological staging)

4.What is tumor staging
- Full radiological staging & biopsy .
-for diagnosis and localization of tumor

5.How do you stage tumor?
-Enneking classification:
-Stage 1 (tumor grade- histology)
a-low grade
b-high grade
-Stage 2 (anatomical extension - radiography)
a-intracompartmental
b-extracompartmental
-Stage 3 -with secondaries elsewhere (radiolography)

6.How do you treat the tumor?
generally depends on:
- histological diagnosis
-tumor grading
Options:general principles
-surgical resection - localized tumor without mets.
-chemotherapy- tumor with mets. /certain tumor eg Ewing's sarcoma
-radiotherapy- surgically inaccesible tumor eg.pelvis, spine
#sometimes used in combination

Labels: Short cases in orthopaedics

Inspection:
1.Hand
Wasting of thenar muscles , pointing index (Median N. injury)
Wasting of hypothenar muscles, interosseous muscles, claw hand (Ulna N. injury)
Wrist /finger drop (Radial n. injury)
Trophic changes

2.Wrist:
scars

3.Forearm:
muscle wasting anterior forearm (Median n)
posterior forearm (radial N)

4.Elbow
valgus deformity (Tardy ulnar n.)
Palpable ulna N (Leprosy look for other signs of leprosy- collapse nasal
bridge,hypopigmented patch etc)

5.Shoulder
-Deltoid wasting (Brachial plexus injury- look for other signs)

Palpation
1.Sensation loss
-Examine the autonomous sensory area of each nerve
-tip of index (Median N)
-tip of little finger (Ulna N.)
OR
-Medial 11/2 (Ulnar N.)
-Lateral 31/2 (Median N.)
-Anatomical snuff box (Radial N)

2.Power
-Index & middle finger flexors weakness (Median N)
-Thumb abductor
-abductor digiti minimi weakness (Ulnar n)
-MCP,thumb and wrist extensor weakness (radial n)

Secial tests:
-Benediction test (Median n)
-Froment’s sign (Ulna n)

Labels: Short cases in orthopaedics

Examination:
-examination of leg wound
-site
-size
-clean /dirty
-bone exposure
-examination of limb
-shortening/angulation
-examination of external fixator & complications
-EF configuration
-pin tract
-rock the EF - pain? loosening?
-movement of ankle and knee joint - stiffness?
-neurovascular bundle

Common Qs:
1. How to grade open fracture:
-Gustillo-Anderson classification
-wound size,duration of injury, degree of soft tissue injury

2.How to manage open fracture?
-wound debridement- wash copiusly and remove foreign & unhealthy tissue.
-IV antibiotics
-external fixation
-leave wound open
-avoid internal fixation

3.How to differentiate between healty and necrotic muscles?
-5C
-Healthy muscles: color (red), character (turgid, not friable),contractility, circulation (bleeds)

4. Complications of open fracture.
-infection -osteomyelitis
-non union

5.What is the common indications of EF?
-open fracture
-bone lengthening
-pelvic # (open book # - to control bleeding)
-comminuted, intraarticular # d/e radius
-joint fusion (knee)
-infected non union

6.Advantages?
-can be done under LA
-fast procedure
-allow better wound inspection/care
-low infection risk

7.Complications of EF?
-pin tract infection-- OM
-joint stiffness
-non union
-neurovascular injury

Labels: Short cases in orthopaedics

Presentation:
-chronic discharging pus following fracture

Examination:
-inflammed swollen leg
-area of tenderness
-sinus with discharge
-ROM of ankle and knee
-abnormal movement at fracture site

Common Qs:
-gen. examination:
-toxic

1.What is your diagnosis? Diff. for chronic discharge
-Chronic OM of tibia
-Foreign body
-fungal infection
-soft tissue tumor, eg.epithelioma

# Diff. diagnosis of inflamed /swollen leg without ulcer/sinus.
-acute OM
-cellulitis
-DVT
-ruptured Baker's cyst.

2.Investigations:
-TWDC
-ESR/CRP
-Swab/Blood C&S
-plain x-ray

3.What are the X-ray changes in Chronic OM?
-sequestrum
-involucrum
-osteolytic bony lesion/ cortical destruction
-periosteal elevation (eg. Codman's triangle)
-fracture line

4.Management:
-IV antiobiotics
-Debridement (Sequestrectomy/ drainage of abscess)
-protect the bone(back slab) - pathological #
-if fracture is present ( infected non union) - stabilize with ex. fix.
-Local wound dressing.

5.Complications of OM:
-pathological #
-septicemis
-malignant changes(epithelioma , SCC)

Labels: Short cases in orthopaedics

Presentation
-wrist drop
-painless movement of humerus shaft fracture.

Examination:
-Motor:
Wrist drop
Inability to extend the extensor pollicis, wrist, fingers.
Wasting of 1st web space dorsally

-Sensory:
Loss of sensation over the dorsum aspect of the forearm, anatomical snuff box.

-Reflexes:
Nil

Find cause:
-evidence of fracture at the humerus
-non union
-malunion
-laceration scar at dorsum aspect of the arm.

Rule out:
-Median n. injury
-Ulna n. injury

Common questions:
1.What is non union.
-when bone/fracture fails to unite within expected time, with the evidence of cessation of fracture
healing.

2.Type of non union.
-Hypertrophic and atrophic

3.Features of non and delayed union
-clinical and radiological
-clinical: Painless movemennt at fracture site.
-Radiological: Present of fracture line, sclerosis of fracture ends, closure of the medullary cavity,
tapering of bone ends

4.Causes of non union.
-5 i's
-interposition, infection,intact fellow bone,inadequate immobilization,insufficiency of blood
supply.

5.Treatment of non union.
-ORIF & bone graft.

Labels: Short cases in orthopaedics

Presentation:
Lower limb deformity, with pain or short limb gait

Examination:
-short limb gait
-Leg deformity , medial or lateral angulation
-shortening
-swelling at # site - painless and no abnormal movement
-ankle and knee joints - normal ROM
-Neurovascular - normal

Common Qs:
1.How to differentiate between non union ,delayed and malunion.

2.Causes:
-improper reduction - neglected,bomoh, unexperienced doctor.
-improper immobilization - early removal of POP, early weight bearing

3.How much angulation allowed?
-5-10 degrees.

4.Treatment:
-Corrective osteotomy& ORIF

5.Complications?
-Early OA knee and ankle - malalignment
-early back pain - shortening

Labels: Short cases in orthopaedics

Presentation
-Cubitus varus of the elbow


Examination:
-Elbow examination
-varus deformity
-limited ROM - both flexion and extension
-usually normal pronation and supination
-intact triangular bony prominence at the elbow.

Rule out complications:
Median n or Radial n palsy.

Common Qs.
1.How to differentiate between supracondylar # with elbow dislocation
-intact triangular in supracondylar #.

2.Cause of disruption of triangular
-displaced medial or lateral humeral condyles
-unreduced elbow dislocation.

3.Common nerve injured
-Median n.

4.Types of #
-Extension and flexion type. Extension type more common

5.Treatment:
-Corrective osteotomy

6.When?
-when pt. regained full extension.

7.What is the dilemma of treating fresh # conservatively.
-too much flexion- vascular compromise
-minimal flexion- # displacement.

8.Solution
-PC K-wiring.

Labels: Short cases in orthopaedics

Presentation
-short limb gait

Examination:
-gait
-supine position
-Galleazi test
-Bryan triangle
-measurement:
-true length - square the pelvis
-apparent length - parallel the limb

Common Qs:
1. what is the effect of fixed adduction/abduction deformity?
-apparent shortening/lengthening of the limb.

2.What are the causes of apparent shortening?
-spine and pelvic problem
-spine (eg.scoliosis) pelvis ( eg. fixed adduction deformity)

3.Give example of equal true length but shortening of apparent length?
-# hemipelvis.
-scolisosis

4.How do you manage apparent shortening?
-treat the cause eg treat scolisosis, pelvic fracture etc.

5.How to treat true shortening?
-<2cm - no treatment, compensated by pelvis.
-2-5cm - Shoe raise
->5cm - (Bone lengthening eg,Illizarov fixator, bone grafting )
-in children, consider epiphysiodesis(of the contralateral side)

6.What are the complications of limb length inequality?
-early osteoarthritis of the affected joint
-early low back pain.
PDF Creator - PDF4Free v2.0 http://www.pdf4free.com

Labels: Short cases in orthopaedics

Presentation:
-Painful knee joint
-Deformity

Examination:
-Varus deformity
-antalgic gait
-measure intercondylar distance
-knee examination
-swelling
-crepitus
-limited ROM
-contracture
-varus stress test positive
-joint line tenderness
-can feel osteophytes, sometimes
-check hip & ankle too.

Common Qs:
1.what is OA?
-Degenerative dis. of the synovial joint affecting the cartilage

2.Classification?
-primary& secondary
-primary - no obvious cause, old age
-secondary - trauma, septic arthritis, RA, osteochondritis, avascular necrosis.

3.Radiological features:
-deformity, reduced jt. space, osteophytes,sclerosis, subchondral cyst.

4.Most commonly affected jt?
-knee jt

5.Treatment?
-conservative
- medical - NSAIDs
- non medical - rest, reduce weight, cane, use public transport, physiotx.
-surgery- osteotomy, TKR.

6.Indication for surgery?
-Severe intolerable pain- pain at rest, pain that affect normal fc.

Labels: Short cases in orthopaedics

Presentation
-painless bony swelling/mass

Examination
-consistency -bony hard
-painless- if tender ?malignant change
-around metaphyseal region
-look for compressive effects
-nerve -numbness distally
-vessels - pulses
-tendons - ROM adjacent joint
-look for other exostosis

Common Qs:
1.What is exostosis
-osteochondroma
-benign cartilage tumor arising from epiphyseal-metaphyseal region
-due to ?developmental disorder

2.How to diagnose ? need biopsy?
-clinical & radiological - typical
-biopsy - not needed

3.What are the radiological changes?
-usually pedunculated bonymass with cartilage cap
-arise from metaphysis
-has common medullary canal, cortex is continuous

4.Types?
-pedunculated
-sessile

5.Can turn malignant? what type of Ca?
-Yes, single - 1% ,multiple -10%
-Chondrosarcoma.

6.Symptoms and signs of malignant change?
-Suddenly becomes : painful , increase in size progressively, compressive effect.

7.any investigation can be done ?
-Yes, MRI - see size of cartilage cap. >2.5 cm.

8.Treatment
-small & asymptomatic - leave alone
-cosmetically not acceptable, pain or presence of compressive effects: excision.

Labels: Short cases in orthopaedics

Presentation:
-painless ulcer at plantar aspect of the foot

Examination:
-examination of ulcer
-site
-shape
-size
-depth
-clean (granulating) dirty ( pus/slough)
-associated lesions
-trophic changes
-callosities
-dry
-fissures
-predisposing factors
-numbness
-pulses- DP/PT
-deformity - prominent metatarsal bone

Common Qs:
1.Classification of DF.
-Wegener's

2.What is the pathophysiology of DF ulcer
-neuropathy -sensory (numbness), motor (small muscles imbalance- deformity) & autonomic
(dryness)
-angiopathy - small and medium size vessels(calcification,atherosclerosis)
-infection - polymicrobial
-trauma

3.How to assess foot circulation.
-ABSI
-Transcutaneous Oxymetry
-Angiography
-Doppler study
-Pulse oxymetry

4.How to manage DF ulcer
-dressing
-antibiotics
-debridement
-total contact cast
-rest/non wight bearing
-local amputation
-major amputation- BKA, AKA

5.Explain foot care in Diabetic pts.
a.proper foot wear:
-soft
-well covered
-wide toe box
-avoid high heel
b.regular foot inspection
c.correct nail cut
d.maintain moisture - cream
e.avoid wetness of webspaces
f.wear foot wear in house

Labels: Short cases in orthopaedics

Presentation
-Finger tips numbness

Examination:
-wasting of thenar muscles
-reduced sensation at Median n. distribution
-Phalen sign positive
-Tinel sign positive
-intact sensation over the thenar eminence
-Benediction sign positive. (severe case)
-Normal forearm muscles.

Rule out
-Ulnar n palsy
-Radial n palsy

common Qs:
1.What is CTS
-Entrapment sd ofMedian n within carpal tunnel./palmar flexor aponeurosis.

2.Causes of CTS:
-tenosynovitis
-tumor (lipoma, ganglion)
-pregnancy
-acromegaly.
-DM

3.Diagnosis?
-Nerve conduction study .Findings suggest delayed nerve conduction.

4.Treatment?
-conservative - NSAIDs, cock up splint.
-surgery - carpal tunnel release.

5.Types of nerve injury? Elaborate.
-neuropraxia
-neurotemesis
-axonotmesis

6.What isWallerian degeneration?
-degeneration of nerve following injury characterised by nerve degeneration of nerve distally to
the end & proximally to the nearest node of Ranvier.

Labels: Short cases in orthopaedics