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LMCC Orthopedic Review Lecture

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Title: LMCC Orthopedic Review Lecture


1
  • LMCC Orthopedic Review Lecture
  • April, 2004
  • Back to Basics
  • Dr. P.R. Thurston

2
Syllabus
  • 1. Diagnosis, Treatment Complications of
    Fractures /Dislocations.
  • 2. Diagnosis Treatment of Arthritis.
  • 3. Assessment and Management of Low Back Pain.

3
  • Fractures

Dislocations
4
Fractures
A discontinuity in the structural integrity of a
bone.
Definition -

A fracture occurs because the force
applied exceeds the breaking strength of the bone
so that the Load can no longer be transferred
across that zone of the bone.

5
Fractures
  • All fractures ultimately begin with kinetic
    energy, released by misadventure and applied to
    the human body.
  • Some of that energy is absorbed and some is
    transmitted to the surroundings.
  • Absorbed energy must be dissipated, ie.
    distributed, through the soft tissues and bones.
  • Fractures occur when the bone can not dissipate
    all of the energy absorbed.

6
Fractures
  • Thus -
  • 1 ) A fracture occurs when the energy
    transferred to a bone exceeds the ability of the
    bone to dissipate that energy.
  • 2 ) Further energy dissipation produces -
  • - comminution.
  • - soft tissue damage (open fractures).
  • - displacement.
  • - other fractures.

7
Definitions
  • Fracture- A discontinuity in the structural
    integrity of a bone.
  • Infraction- An incomplete fracture.
  • Dislocation- Complete loss of contact of the
    articular surfaces of a joint.
  • Subluxation- Non-concentric joint surfaces.
  • Reduction- Returning a fracture or dislocation
    to an anatomical alignment.
  • Comminution- Multiple fragments.

8
Fractures
Mechanical Properties of Bone
  • Bone is a two-phase material -
  • Calcium HydroxyApatite Ca10(PO4)6(OH)2
    mineral
  • Osteoid Collagen type I and III
    fibrous
  • Calcium is strong in compression, but weak in
    tension.
  • Osteoid is strong in tension, but weak in
    compression.

9
Fractures
  • BUT - (for adult bone)
  • Calcium is stronger in compression than
    Osteoid is in tension
  • And therefore -
  • Bone always fails first in tension

10
Fractures
For immature bone, this effect is reversed.
The Buckle or Torus fracture occurs because the
bone fails in compression first.
In children, the Osteoid is stronger than the
Mineral phase.
Generally, the dislocation in youth becomes the
fracture in the adult.
11
Fractures
  • A bone consists of three areas -
  • the Diaphysis
  • the Metaphysis
  • the Epiphysis.

Each region has its own fracture characteristics.
12
Fractures
  • Bending
  • Torque
  • Direct
  • Traction
  • Compression
  • Intra-articular
  • Pediatric

Oblique
Diaphyseal
Spiral
Transverse
Metaphyseal
Epiphyseal
Mixed
13
Bending
Fractures
  • Bending produces a transverse fracture line, with
    or without a lip.
  • When load is added, the lip becomes a butterfly
    fragment.
  • With more loading, the fracture line becomes
    oblique.

14
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15
Torque
Fractures
  • - Rotatory shear produces a continually changing
    line of failure, giving the typical Bayonet
    Spikes at the ends of the bones.
  • The greater the load the longer the fracture.
  • These occur only in long bones and are referred
    to as-
  • Spiral Fractures

16
Torque
Fractures
  • piral
  • The butterfly segment is different from the
    oblique bending fracture.


17
Fractures
If no butterfly, then the ends are Bayonet in
appearance.
18
Direct Blow
Fractures
  • tapping fractures.
  • Fractures of dying momentum.
  • Tension produced on the opposite side of the
    bone.
  • Comminution produced on the impact side of the
    bone.
  • High energy injuries.

19
Direct Blow
Fractures
Transverse Fractures Comminution on the opposite
side to a bending fracture, ie. at the point of
impact. The Nightstick Fracture.
20
Metaphyseal
Fractures
Traction Avulsion.
  • The Metaphysis is subject to all of the
    diaphyseal patterns plus-
  • 1) Traction Avulsion.
  • 2) Compression.

21
Metaphyseal
Fractures
Traction-Avulsion
  • are transverse since the tension is equal on
    both sides of the bone.
  • are caused by ligament or tendon traction.
  • always occur adjacent to joints.

22
Fractures
Traction Avulsion.
23
Compression
Fractures
  • Crush fractures
  • Impacted fractures
  • Usually comminuted
  • Usually axial skeleton
  • - Vertebrae
  • - Calcanei

24
Epiphyseal
Fractures
  • The Epiphysis is subject to all of the diaphyseal
    and metaphyseal patterns
    plus-
  • 1) Intra-articular Fractures.
  • 2) Pediatric Fractures about the Epiphyseal
    plate.

25
Epiphyseal
Fractures
  • Intra-articular Fractures
  • Always require accurate reduction.
  • Usually require surgical treatment.
  • Are often comminuted.
  • Frequently threaten Post-traumatic Osteoarthritis.

26
Epiphyseal
Fractures
  • Pediatric Epiphyseal Fractures
  • Produce fracture patterns specific to children.
  • Always require accurate reduction.
  • Can produce growth abnormalities.
  • Salter-Harris Classification.

27
Salter-Harris Classification
Fractures
I
II
III
IV
V
28
Salter-Harris Classification
Fractures
1) Fractures interfering with growing
bones. 2) Worse prognosis with increasing
number. 3) Probability of surgery increases with
number.
29
Fractures
  • A fracture can occur in -
  • normal bone subject to abnormal forces.
  • Traumatic Fractures.
  • abnormal bone subject to normal forces.
  • Pathologic Fractures.
  • normal bone subject to cyclic forces.
  • Fatigue or Stress Fractures.

30
Description
Fractures
  • 1) Displacement - Angulation
  • 2 ) Closed or Open.
  • 3 ) Simple or Comminuted.
  • 4 ) Fracture Pattern eg. Spiral, Transverse etc.
  • 5 ) Anatomical Area.
  • 6 ) Mechanism.

31
Fracture Description
  • This fracture is angulated laterally, since it
    points laterally.
  • The distal fragment is tilted medially

32
Description
Medially Displaced Closed Comminuted Short
Oblique Fracture of the Proximal Humerus Caused
by a direct fall
33
Fracture Description
  • 1) The distal fragment is always described with
    relation to the proximal segment.
  • 2) Displacement Translation of bone ends.
  • 3) Angulation Orientation of bone ends.
  • 4) Angulation identifies to where the fracture
    points.
  • 5) For clarity, the tilt of the distal fragment
    is often used to describe angulation.

34
The Periosteal Bridge
  • The Periosteal Bridge is intact on the concave
    side of the fracture.
  • Reversal of the mechanism of the fracture
    tightens the bridge and stabilizes the fracture.

35
The Periosteal Bridge
  • Tightening the periosteal bridge locks the
    fracture together.
  • Holding the bridge tight requires three point
    fixation.
  • It takes a bent cast to produce a straight bone
  • J. Charnley

36
Treatment
  • Closed or Open ( Surgical ).
  • - Both require an understanding of fracture
    healing.
  • - Closed requires reversal of mechanism of
    injury.

37
Indications for Closed Reduction
  • There is significant displacement.
  • Reduction is possible.
  • The reduction, if gained, can be held.
  • The fracture has not been produced by a traction
    force.

38
Indications for Open Reduction
  • 1 ) There is a significant Displacement.
  • 2 ) Open Fractures.
  • 3 ) Intra-articular Fractures.
  • 4 ) Un-reducible Fractures
  • 5 ) Reductions that cannot be maintained in a
    cast.
  • 6 ) Comminuted or Segmental Fractures.
  • 7 ) Floating Joints.
  • 8 ) Fractures with Neurovascular damage.

39
Open Fractures
  • Classification -
  • 1. lt 1 cm., inside-out, little soft tissue
    damage.
  • low potential for infection.
  • 2. 1 cm. 10 cms., outside-in, requires
    debridement, but no flap or skin graft.
  • moderate potential for infection.
  • 3. gt 10 cms., outside-in, high energy,
    devitalized muscle, comminution or bone loss,
    soft tissue loss.

40
Open Fractures
  • Classification -
  • 3A. No loss of soft tissue cover, no flap
    required.
  • 3B. Flap required due to soft tissue stripping.
  • 3C. Associated vascular injury.

41
Type 1. Open Fracture 6 mm, extend debride
42
Degloving Mechanism
Degloving Mechanism
43
Type III C Injuries Vascular Injury
Note pallor of the ankle No pulses
44
Fracture Complications
  • 1. Pulmonary Fat Emboli
  • 2. Compartment Syndromes
  • 3. Cast Disease
  • 4. Stress Fractures
  • 5. Pathologic Fractures

45
Pulmonary Fat Emboli - A.R.D.S.
  • - Long bone fractures, burns, contusions.
  • - Interstitial pneumonitis due to free fatty
    acids
  • - S.O.B. confusion in young adults.
  • - Axillary Subconjunctival Petechiae.
  • - Serum lipase elevated.
  • - pAO2 reduced if lt 50 20 mortality.
  • - Ventillatory support
  • - Dexamethazone.
  • - 5 day course.

46
Compartment Syndromes
  • - increased interstitial tissue pressure.
  • - fractures, burns, tight dressings.
  • normal pressure lt 25 mm. Hg.
  • when the tissue pressure gt venous capillary
    pressure, but less than the arteriolar pressure.
  • 5 Ps
  • - pain.
  • - pallor.
  • - pulselessness.
  • - paresthesias.
  • - paralysis.

47
Compartment Syndrome
Symptom Pain out of proportion to that
expected for the injury. Signs 1. Loss of
function of muscle due to ischemia within
the compartment. 2. Pain with passive
stretch 3. Numbness etc. are LATE findings! 4.
If neuro symptoms present, potential
for full neuro recovery is only 10
48
Rx Compartment Syndrome
Release all compressive dressings / plaster.
Elevate extremity to heart level.
Fasciotomies.
49
Rx Compartment Syndrome
Increased girth. Pallor of the foot. Recent
surgery.
50
4 compartment fasciotomy
51
Compartment Syndrome
Careful monitoring. Recognise it - 5 Ps
Call Orthopaedic Surgeon Pressure measurements

52
Stress or Fatigue Fracture
  • Repeated loading below acute
  • failure threshold.
  • Eventual fatigue failure.
  • Military recruits, runners, aerobics.
  • Tibia, metatarsals, femoral neck.
  • Initial x-ray can be negative.
  • Bone tenderness Bone scan.

53
Pathologic Fractures
  • Failure through abnormally
  • weakened bone
  • Minimal trauma BEWARE
  • Osteoporosis
  • Metastasis
  • Tumour- Benign, Malignant
    (Myeloma).
  • Metabolic Bone Disease

54
Pathologic Fractures
55
Fractures
Ultimately, the treatment of fractures requires
  • an understanding of the mechanism that produces
    them,

56
Fractures
An understanding of the diagnostic tools
available,
57
Fractures
And the current technologies used in their
treatment
58
Dislocations
  • The articular surfaces are no longer in contact.
  • Commonly affects -
  • Shoulders gt PIP joints gt Elbows gt Ankles.
  • Often associated with fractures.
  • Often associated with neurologic injuries

59
Shoulder Dislocations
  • 95 anterior
  • 1 posterior
  • Luxatio erecta
  • Medial
  • Axillary nerve injury
  • Rapid reduction

60
Shoulder Dislocations
  • Conscious sedation.
  • Traction reduction.
  • Immobilization.
  • Recurrent.
  • Voluntary
  • Habitual.
  • Multiaxial instability.

61
Elbow Dislocation
  • Posterolateral.
  • Median nerve injury.
  • Ulnar nerve injury.
  • Rapid reduction.
  • Early mobilization.

62
Back Pain
63
Classification Mechanical (MacKenzie)
  • Postural syndrome
  • normal tissues become painful by the application
    of prolonged stresses (sitting, bending etc)
  • Dysfunction syndrome
  • soft tissues are shortened and stiff. Usually gt30
    year old, poor posture, under exercised, reduced
    mobility
  • Derangement syndrome
  • Disc derangement (tears and herniation)

64
Causes and Classification of Back Pain McNab
  • Spondylogenic
  • Osseus
  • Trauma
  • Infection
  • Neoplasms
  • Inflammatory
  • Metabolic (eg.Pagets)
  • Deformities
  • Soft tissues
  • Muscles
  • SI joints
  • Disc
  • Facets
  • Viscerogenic
  • Vasculogenic
  • Neurogenic
  • Psychogenic
  • Spondylogenic

65
Non operative Treatment of Back Pain
  • Do nothing
  • Activity modification
  • Medications
  • Exercise and physiotherapy
  • Braces
  • Manipulation
  • Massage therapy
  • Traction/inversion therapy
  • Vitamins/Supplements/Diets
  • Weight control
  • Every Suzanne Summers sponsored abs exerciser

66
Degenerative Conditions of the Lumbar Spine
  • Congenital
  • Disc herniation
  • Degenerative Disc Disease
  • Spinal Stenosis
  • Degenerative Spondylolisthesis
  • Degenerative Scoliosis

And when did you first notice that your back had
gone out?
67
Congenital Anomalies
  • Congenital scoliosis

Arthrogryposis
68
Congenital anomalies
  • Spina bifida

69
Anatomy
Extension
Flexion
70
Three joint complex(Kirkaldy Willis, Farfan)
Instability
Lateral n. ent
Central stenosis
71
Disc herniation
Ms J.H. 25 y.o. female presented with cauda
equina syndrome
72
Spinal stenosis
  • Symptoms
  • unilateral radicular pain
  • bilateral claudication
  • better with forward flexion of trunk
  • better walking uphill
  • rare bowel/bladder involvement
  • Signs
  • usually no neuro signs
  • look for pulses
  • stress test
  • Investigations
  • XR
  • CT
  • Myelo-CT
  • MRI

73
Spinal stenosis
Post myelogram CT
AP
lateral
myelogram
74
Degenerative Spondylolisthesis
  • Most common cause of spinal stenosis
  • More common in women, hemisacralization of L5,
    diabetics and women with BSO
  • OA of hip also in 11-17

75
Isthmic spondylolisthesis
76
Severe spondylolisthesis
77
Time for a 10 minute break!
78
Pediatric Orthopedics
  • 1. Developmental Dysplasia of the Hip.
  • 2. Legg-Perthes Disease.
  • 3. Slipped Capital Femoral Epiphysis.
  • 4. Club Feet.
  • 5. Osteomyelitis.
  • 6. Septic Hip.

79
1. Talipes Equinovarus is the proper name for -
  1. Flat feet
  2. In-toeing
  3. Club feet
  4. Knock knees
  5. Wry neck

80
Talipes Equinovarus is the proper name for -
  • c. Club feet

81
1. Talipes Equinovarus is the proper name for -
  • Flat feet
  • In-toeing
  • Club feet
  • Knock knees
  • Wry neck

Pes Planus
Metatarsus Adductus
Genu Valgus
Torticolis
82
Talipes Equinovarus
  • congenital deformity of the foot
  • Equinus, Inversion, Adduction, Supination
  • 2 per 1000 live births
  • 50 bilateral
  • M gtF 21
  • Serial corrective casts at birth
  • Surgery if resistant
  • EARLY TREATMENT IS ESSENTIAL

83
2. Trendelenburg refers to -
  1. Leg length discrepancy
  2. Gait abnormality
  3. Knee recurvatum
  4. Scoliosis
  5. Hip Contracture

84
2. Trendelenburg refers to -
  • b. Gait abnormality

85
2. Trendelenburg refers to -
  1. Leg length discrepancy Apparent vs Real
  2. Gait abnormality
  3. Knee recurvatum straightens past 1800
  4. Scoliosis lateral curvature, lordosis, kyphosis
  5. Hip Contracture Thomas test

86
3. All of these are signs of D.D.H. except -
  1. Limited Abduction
  2. Ortolani Sign
  3. Asymmetric Skin Folds
  4. Galeazzis Sign
  5. McMurray Sign

87
3. All of these are signs of D.D.H. except -
  • e. McMurray Sign

88
3. All of these are signs of D.D.H. except -
Dislocated
  1. Limited Abduction
  2. Ortolani Sign
  3. Asymmetric Skin Folds
  4. Galeazzis Sign
  5. McMurray Sign

Reducible
Dislocated
Knee height
Torn Meniscus
89
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90
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91
Developmental Dysplasia of the Hip
  • Acetabular dysplasia
  • Femoral anteversion
  • Adduction Contracture
  • 50 bilateral, F gt M 81
  • Test ALL newborns at birth
  • Conservative Rx at birth Pavlik, D.diaper
  • Surgical Rx if resistant

92
4. The most common congenital Spinal abnormality
is -
  1. Scoliosis
  2. Spina Bifida
  3. Torticolis
  4. Klippel Feil Syndrome
  5. Multiple Hereditary Osteochondroma

93
4. The most common congenital Spinal abnormality
is -
  • b. Spina Bifida

94
4. The most common congenital Spinal abnormality
is -
  1. Scoliosis
  2. Spina Bifida
  3. Torticolis Wry Neck
  4. Klippel Feil Syndrome Congenital Fusion
  5. Multiple Hereditary Osteochondroma

95
Spinal Bifida
  • defect of neural tube closure
  • Lumbar spine, commonly low
  • 2 per 1000
  • myelodysplasia
  • Mild to complete paraplegia
  • Occulta, meningocoele, Myelomeningocoele
  • Bowel and bladder dysfunction

96
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97
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98
Polydactyly
5.
99
Syndactyly
6.
100
7.
101
Sprengels Deformity
Omovertebral Bone
102
8. A 6 year old boy with delayed physical
development, convulsions, tetany, weakness,
blue sclera and bony deformities is most likely
suffering from -
  • a. Physical Abuse
  • b. Ehlers Danlos Syndrome
  • c. Osteogenesis Imperfecta
  • d. Multiple Hereditary Exostoses
  • e. Myositis Ossificans

103
8. A 6 year old boy with delayed physical
development, convulsions, tetany, weakness,
blue sclera and bony deformities is most likely
suffering from -
  • c. Osteogenesis Imperfecta

104
8. A 6 year old boy with delayed physical
development, convulsions, tetany, weakness,
blue sclera and bony deformities is most likely
suffering from -
  • a. Physical Abuse
  • b. Ehlers Danlos Syndrome
  • c. Osteogenesis Imperfecta
  • d. Multiple Hereditary Exostoses
  • e. Myositis Ossificans

105
9. A 6 year old boy with delayed physical
development, a rachitic rosary, weakness and
bony deformities is most likely suffering from -
  • a. Physical Abuse
  • b. Rickets
  • c. Scurvy
  • d. Osteitis Deformans
  • e. Myositis Ossificans

106
9. A 6 year old boy with delayed physical
development, a rachitic rosary, weakness and
bony deformities is most likely suffering from -
  • b. Rickets

107
9.
108
9.
109
Etiology Alkaline
Calcium Phosphate Urea
Phosphatase Vita
min D Up Down Normal
NormalDeficiency Rickets
Renal Up
Down Up UpInsufficiency (Renal
Rickets) Renal Up
Down Down NormalTubular
Insufficiency (HypoPhosphatemia)
110
10. This is -
  • a. Osteomyelitis
  • b. Osteomalacia
  • c. Osteoporosis
  • d. Osteitis Deformans
  • e. Leprosy

111
10. This is -
  • d. Osteitis Deformans

112
10. This is -
  • a. Osteomyelitis
  • b. Osteomalacia
  • c. Osteoporosis
  • d. Osteitis Deformans
  • e. Leprosy

113
Osteitis DeformansPagets Disease
  • 4 of pop. Over 40 yrs.
  • accelerated bone turnover
  • often assymptomatic
  • monostotic gt polyostotic
  • loss of stature
  • AV shunting
  • pathologic bone

114
11. A child with knee pain has a ____ problem
until proven otherwise.
  • a. Knee
  • b. Femoral
  • c. Tibial
  • d. Hip
  • e. Patella

115
11. A child with knee pain has a ____ problem
until proven otherwise.
  • d. Hip

Obdurator Nerve
116
11. All of the following are part of the
differential of hip pain in a 6 year old, except
-
  • a. Femoral Osteomyelitis
  • b. Septic Hip
  • c. Transient Synovitis
  • d. Legg-Perthes Osteochondritis
  • e. Slipped Capital Femoral Epiphysis

117
11. All of the following are part of the
differential of hip pain in a 6 year old, except
-
  • e. Slipped Capital Femoral Epiphysis

118
11. All of the following are part of the
differential of hip pain in a 6 year old, except
-
  • a. Femoral Osteomyelitis
  • b. Septic Hip
  • c. Transient Synovitis
  • d. Legg-Perthes Osteochondritis
  • e. Slipped Capital Femoral Epiphysis

119
Ages for Hip Disease
  • D.D.H. Birth
  • Septic Hip Birth 11
  • Legg-Perthes 3 11
  • Transient Synovitis 3 11
  • S.C.F.E. 11 - 16

120
12. Osteomyelitis in children is produced by
what route of infection?
  • a. Direct extension from another focus
  • b. Hematogenous spread
  • c. Perforating wounds
  • d. Lymphatic spread
  • e. Septic hip

121
12. Osteomyelitis in children is produced by
what route of infection?
  • b. Hematogenous spread

122
Osteomyelitis
  • Acute infection,metaphyseal
  • 90 Staph.,20 mortality
  • 100 growth abnormality
  • Periosteal elevation, osteolysis
  • Sequestrum, Involucrum

123
13.
124
13.
Paronychia
125
14.
126
14.
Felon
127
15. All of these are findings of a Herniated
L5-S1 disc, except -
  • a. Absent Achilles reflex
  • b. Lateral foot numbness
  • c. Sciatica
  • d. Low back pain
  • e. Extensor Hallucis Longus weakness

128
15. All of these are findings of a Herniated
L5-S1 disc, except -
  • e. Extensor Hallucis Longus weakness

129
15. All of these are findings of a Herniated
L5-S1 disc, except -
  • a. Absent Achilles reflex S1
  • b. Lateral foot numbness S1
  • c. Sciatica S1
  • d. Low back pain
  • e. Extensor Hallucis Longus weakness L5
  • f. Knee jerk L4

130
16. Avascular necrosis of the femoral head is
associated with all of the following except -
  • a. Steroid use
  • b. Alcohol
  • c. Deep sea diving
  • d. Lipid storage disease
  • e. Diabetes

131
16. Avascular necrosis of the femoral head is
associated with all of the following except -
  • e. Diabetes

132
16. Avascular necrosis of the femoral head is
associated with all of the following except -
  • a. Steroid use
  • b. Alcohol
  • c. Deep sea diving
  • d. Lipid storage disease
  • e. Diabetes

133
17.
8 year old boy
What is the Diagnosis?
134
17.
8 year old boy
Legg Perthes Osteochondosis
135
Legg-Perthes Disease
  • Osteochondrosis (avascular necrosis)
  • Proximal Femoral Epiphysis
  • Necrosis, revascularization, fragmentation,
    healing
  • 3 11 yrs., M gt F 41, 15 bilat.
  • Subluxation laterally, Coxa plana, Coxa magna
  • Osteoarthritis 50 yrs.

136
Osteochondroses
18.
  • Freibergs Disease
  • Osgoode-Sclatters
  • Scheuermanns
  • Kienbocks
  • Osteochondritis Disecans

2nd Metatarsal Head
Tibial Tubercle
Spine
Carpal Lunate
Lateral Femoral Condyle
137
19. Diagnosis?
138
19. Gout
139
Gout
  • Urate crystalopathic arthritis
  • Crystals in periarticular tissues
  • Inconsistant elevated serum urate
  • Allopurinol and colchicine
  • Tophi in periarticular soft tissues
  • Deposits in non-articular cartilage
  • Juxta-articular erosions

140
20.
L4
L5
Spondylolytic Spondylolisthesis
141
Spondylolisthesis
  • Lumbosacral junction defect
  • Spondylolysis of Pars Interarticularis
  • Traumatic or congenital
  • Acute immobilize
  • Chronic - surgery

142
21. The Salter- Harris Classification is used
to assess the severity of -
  • a. Epiphyseal Fractures
  • b. Developmental Dysplasia of the Hip
  • c. Legg Perthes Disease
  • d. Club Foot
  • e. Osteomyelitis

143
21. The Salter- Harris Classification is used
to assess the severity of -
  • a. Epiphyseal Fractures

144
I
II
III
IV
V
145
22. What is this deformity?
146
22. A Diner Fork Deformity
Probable Diagnosis?
147
  1. Colles Fracture

148
22. Colles Fracture
  • distal radial fracture
  • FOOSH
  • occurs at all ages
  • commonly 60 yrs.
  • osteoporosis
  • intra-articular

149
CR K-Wires
150
External vs Internal Fixation
151
23. The common complication of this fracture
is -
152
23. Proximal pole Avascular Necrosis
153
(No Transcript)
154
24. This is a -
a. Buckle Fracture b. Greenstick Fracture c.
Stress Fracture d. Pathologic Fracture e. Growth
Arrest line
155
24. This is a -
a. Buckle Fracture
156
24.
This is a -
a. Buckle Fracture b. Greenstick Fracture c.
Stress Fracture d. Pathologic Fracture e. Growth
Arrest line
157
24.
Greenstick Fractures
158
25. Is this fracture treated by Closed or Open
Reduction?
159
ORIF
25.
160
25. Fractures of Necessity
161
26. What is the Diagnosis?
162
26. Posterolateral Dislocation of the Elbow
163
26. Reduction by traction.
TRACTION
164
27. What is the Diagnosis?
165
27. Anterior Dislocation of the Shoulder
166
27. Reduction by traction
167
28.
This is a -
a. Supracondylar b. Olecranon c.
Dislocation d. Forearm e. Radial Head
168
28.
This is a -
a. Supracondylar
169
28. Supracondylar Fracture
170
29. The complications of a Supracondylar
fracture in children include all of the
following except -
  • a. Malunion
  • b. Volkmanns Ischemic Contracture
  • c. Compartment Syndrome
  • d. Cubitus Varus
  • e. Peripheral Nerve Injuries
  • f. Pulmonary Fat Embolus

171
29. The complications of a Supracondylar
fracture in children include all of the
following except -
  • f. Pulmonary Fat Embolus

172
29. The complications of a Supracondylar
fracture in children include all of the
following except -
  • a. Malunion
  • b. Volkmanns Ischemic Contracture
  • c. Compartment Syndrome
  • d. Cubitus Varus
  • e. Peripheral Nerve Injuries
  • f. Pulmonary Fat Embolus

173
30. The only sign of a Compartment Syndrome
that is always present is -
  • a. Pain
  • b. Pallor
  • c. Pulselessness
  • d. Paresthesias
  • e. Paralysis

174
30. The only sign of a Compartment Syndrome
that is always present is -
  • a. Pain

175
30. The only sign of a Compartment Syndrome
that is always present is -
  • a. Pain
  • b. Pallor
  • c. Pulselessness
  • d. Paresthesias
  • e. Paralysis

176
31. Compartment pressures indicating the need
for fasciotomy -
  • a. 0 15 mms. Hg
  • b. 15 25 mms. Hg
  • c. gt 25 mms. Hg
  • d. gt 50 mms. Hg
  • e. gt 75 mms. Hg

177
31. Compartment pressures indicating the need
for fasciotomy -
  • c. gt 25 mms. Hg

178
Compartment Syndrome
  • fractures, crush injuries, burns
  • collapse of venous return compartment pressure gt
    25 mms. Hg
  • engorgement of muscle within
  • necrosis of muscle tissue
  • Volkmanns Ischemic Contracture
  • Fasciotomy

179
32. A 20 yr. old male with a fractured femur
has findings of confusion, tachypnea and
conjunctival petechia. The most likely diagnosis
is -
  • a. Pneumonia
  • b. Pulmonary Fat Emboli
  • c. Cerebral Contusion
  • d. Cardiac Contusion
  • e. Transient Stress Reaction

180
32. A 20 yr. old male with a fractured femur
has findings of confusion, tachypnea and
conjunctival petechia. The most likely diagnosis
is -
  • b. Pulmonary Fat Emboli

181
32. Pulmonary Fat Embolus
  • 2 - long bone s 10 - multiple s
  • tissue thromboplastin ---gt extrinsic cascade VII
  • A.R.D.S. - aterial hypoxemia
  • petechia across chest, in axillae and conjunctiva
  • early fixation decreases PFE, but increases
    infection rates
  • no current lab tests or treatment protocol

182
33. Name the Fracture -
183
33. Monteggia Fracture
184
33. Monteggia Fracture
185
33. Monteggia Fracture
186
34. Name this fracture -
187
34. Name the fracture -
Galeazzi Fracture
188
GaleazziFracture
34.
189
35. The commonest complication of this
fracture is -
190
35. A Radial Nerve Palsy
191
36. Does this fracture require surgery?
192
36. Does this fracture require surgery?
Yes
193
37. Does this fracture require surgery?
194
37. Does this fracture require surgery?
No
195
38. This patient most likely has a fracture
of the --------.
196
38. This patient most likely has a fracture
of the --------.
Hip
197
38. This patient most likely has a fracture
of the hip.
External Rotation Shortening Hip Flexion
198
38.
199
39. Whats the Diagnosis?
200
39. Sub-Capital Hip Fracture.
201
40. All of the following are complications of
this fracture except -
a. Malunion b. Avascular necrosis c. Fat
emboli d. Non-union e. Thrombophlebitis
202
40. All of the following are complications of
this fracture except -
c. Fat emboli
203
40. Blood Supply of Femoral Head
204
40. Save Head versus Replacement
205
40. Subcapital Hip Fractures
Garden Classification
1. Abduction 2. Minimally displaced 3. 50
Displaced 4. Completely Displaced
206
40. Subcapital Hip Fractures
Properties
1. Avascular Necrosis - 30 2. Malunion -
30 3. Non-union - 30 4. Surgery required 5.
Older population 6. Pathologic - Osteoporotic

207
41. Whats the Diagnosis?
208
41. Intertrochanteric Hip Fracture
209
41. Intertrochanteric Fractures
210
41. Intertrochanteric Fractures
Properties
  • 1. Varus deformity
  • 2. Well - Healing
  • Traumatic Osteoporosis
  • Surgery required
  • Mid-range Age population

211
42. What is the Diagnosis?
212
42. What is the Diagnosis?
Subtrochanteric Hip Fracture
213
42. Subtrochanteric Fractures
Properties
  1. Non-union
  2. Traumatic
  3. Surgery required

214
43.Surgery or not?
215
43.Surgery or not?
Yes
216
44. Surgery or not?
217
44. Surgery or not?
Yes
218
44. Ankle Fractures
Eversion Injuries
219
44. Ankle Fractures
Inversion Injuries
220
45. What is the approach to this fracture?
23 y.o. male Basketball injury Open fracture
Numbness dorsum toes
221
45.
Reduce dislocation Sterile dressing Splint
extremity Re-check NV status IV Antibiotics
Tetanus Surgery
222
46. Surgery or not?
223
46. Surgery or not?
Yes
224
47. Surgery or not?
225
47. Surgery or not?
Yes
226
47. Surgery or not?
Yes
227
48. A 45 yr. old male, who was previously in good
health, has sudden onset of transverse low back
pain and right sided sciatica to his foot, after
chopping wood at the cottage. Upon arising the
following morning, he notices numbness on the
outer border of his right foot and some
weakness in the right leg. He has no bowel or
bladder problems. The most likely diagnosis
would be-
  • a. Lumbar Muscular Strain.
  • b. Herniated Lumbar Disc.
  • c. Herniated Lumbosacral Disc.
  • d. Cauda Equina Syndrome.
  • e. Spinal Stenosis.

228
48. A 45 yr. old male, who was previously in good
health, has sudden onset of transverse low back
pain and right sided sciatica to his foot, after
chopping wood at the cottage. Upon arising the
following morning, he notices numbness on the
outer border of his right foot and some
weakness in the right leg. He has no bowel or
bladder problems. The most likely diagnosis
would be-
  • c. Herniated Lumbosacral Disc.

229
49. Your initial approach to this problem would
include some or all of the following-
  • a. Bedrest.
  • b. Anti-inflammatories.
  • c. Muscle Relaxants.
  • d. Spinal X-rays.
  • e. Physiotherapy.
  • f. Orthopedic/Neurosurgical referral.
  • g. CT-Myelogram or MRI
  • h. Discectomy

230
49. Your initial approach to this problem would
include some or all of the following-
  • a. Bedrest.
  • b. Anti-inflammatories.
  • c. Muscle Relaxants.
  • d. Spinal X-rays.
  • e. Physiotherapy.
  • f. Orthopedic/Neurosurgical referral.
  • g. CT-Myelogram or MRI
  • h. Discectomy

?
231
50. During the work-up for this problem, the
patient complains that he has unaccountably
soiled his underwear, without knowing it. Your
response to this would be to-
  • a. Reassure the patient that this is not serious
  • b. Order an urgent MRI
  • c. Get an urgent referral to Neuro/Orthopedics
  • d. Place the patient on immediate bedrest.

232
50. During the work-up for this problem, the
patient complains that he has unaccountably
soiled his underwear, without knowing it. Your
response to this would be to-
  • c. Get an urgent referral to Neuro/Orthopedics

233
50. During the work-up for this problem, the
patient complains that he has unaccountably
soiled his underwear, without knowing it. Your
response to this would be to-
  • a. Reassure the patient that this is not serious
  • b. Order an urgent MRI
  • c. Get an urgent referral to Neuro/Orthopedics
  • d. Place the patient on immediate bedrest.

234
51. A lumberjack felling a tree is unfortunately
struck on the back by the tree, knocking him to
the ground and injuring his left lower extremity.
In the ER, his left hip is in flexion, adduction
and internal rotation. The most likely diagnosis
is-
  • a. Fracture of the Hip.
  • b. Fracture of the Femur.
  • c. Anterior Hip Dislocation.
  • d. Posterior Hip Dislocation.
  • e. Fracture of Pelvis.

235
51. A lumberjack felling a tree is unfortunately
struck on the back by the tree, knocking him to
the ground and injuring his left lower extremity.
In the ER, his left hip is in flexion, adduction
and internal rotation. The most likely diagnosis
is-
  • d. Posterior Hip Dislocation.

236
52. Which of the following signs and symptoms
are consistent with a torn medial meniscus of
the knee-
  • a. Inability to squat
  • b. Pain on descending stairs
  • c. Locking
  • d. Recurrent effusions
  • e. All of the above.

237
52. Which of the following signs and symptoms
are consistent with a torn medial meniscus of
the knee-
  • a. Inability to squat
  • b. Pain on descending stairs
  • c. Locking
  • d. Recurrent effusions
  • e. All of the above.

238
A 35 yr. old male falls jogging and sustains an
undisplaced lateral malleolar fracture of the
ankle. He is treated in a Below-knee Walking
cast, but returns to the ER 24 hrs. later
complaining of increased, persistent, burning
pain at the ankle. Your response to this
situation would be to-
  • a. Re-X-ray the ankle.
  • b. Remove the cast.
  • c. Measure the compartment pressures.
  • d. Instruct the patient to elevate the limb
    and prescribe an anti-inflamatory.

239
53.. A 35 yr. old male falls jogging and sustains
an undisplaced lateral malleolar fracture of the
ankle. He is treated in a Below-knee Walking
cast, but returns to the ER 24 hrs. later
complaining of increased, persistent, burning
pain at the ankle. Your response to this
situation would be to-
  • b. Remove the cast.

240
A 35 yr. old male falls jogging and sustains an
undisplaced lateral malleolar fracture of the
ankle. He is treated in a Below-knee Walking
cast, but returns to the ER 24 hrs. later
complaining of increased, persistent, burning
pain at the ankle. Your response to this
situation would be to-
  • a. Re-X-ray the ankle.
  • b. Remove the cast.
  • c. Measure the compartment pressures.
  • d. Instruct the patient to elevate the limb
    and prescribe an anti-inflamatory.

241
54. The most common dislocations of the shoulder
are-
  • a. Medial.
  • b. Posterior.
  • c. Luxatio Erecta.
  • d. Anterior.

242
54. The most common dislocations of the shoulder
are-
  • d. Anterior.

243
55. Metastatic lesions to bone, of the
following tumours, usually produce lytic
defects except-
  • a. Thyroid.
  • b. Pancreas.
  • c. Prostate.
  • d. Kidney.
  • e. Lung.

244
55. Metastatic lesions to bone, of the
following tumours, usually produce lytic
defects except-
  • c. Prostate.

245
55. Metastatic lesions to bone, of the
following tumours, usually produce lytic
defects except-
  • a. Thyroid.
  • b. Pancreas.
  • c. Prostate.
  • d. Kidney.
  • e. Lung.

246
Th - Tha Thats all folks!
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