Created by: Edward Ngwenya

GEMP IV ORTHOPAEDICS OSCE 2010

Created by: Edward Ngwenya

Question 1

X-ray of the hand with # of Scaphoid bone (Tut 3 pg 4/ Apley’s pg 329)

 75% of all carpal #’s

 Fall on hand with wrist extended ( dorsiflexion &/ radial deviation)

 Diminished blood supply proximally- resulting in avascular necrosis (AVN)

 Types: 3 points 1) Proximal 2)Waist[Commonest] 3) Scaphoid Tubercle

 Sx: Slight fullness & Tenderness in Anatomical snuff box

 Xray: AP; Lat; & 2 Obliques/

o Break most easily seen after 2 wks

o ?Carpal displacement
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 Rx: Conservative 1) Crepe Bandage- Scaphoid Tubercle

2) Below elbow POP (arm in dorsiflexion; thumb in glass

holding position for 8 wks

- Undisplaced #’s

Operative ORIF - Displaced #’s

If Scaphoid Tender/ #still on Xray post POP

 Complications:1) AVN (5 common sites= Fem head &condyles; humerus head; talus)

2) Non-union

3)OA

Q1 b. X-ray wrist. Label carpal bones

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Question 2

X-ray of Protrusio Acetabuli (Apley’s pg 210)

 Socket is too deep and bulges into the cavity of the pelvis

 2 types;
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 1- Primary

o Slight familial tendency

o Females > Males

o Develops soon after puberty

o Usually No Sx, although limited movements

o Xray: Sunken acetabulum, with inner wall bulging beyond iliopectineal line

Secondary OA may dev later in life

o Tx not required

 2- Secondary

o Secondary to bone ‘softening’d/o – Osteomalasia or Paget’s disease

o Longstanding RA

o Rx: Joint replacement if sever pain; or markedly restricted movements

Question 3

X-ray of Ankle (Tut 5 pg 2; Ap pg 381)

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 MOI: Vast majority d/t ankle twisted & talus tilts & rotates forcefully in tibiofibular
mortise

 X-ray: 3 views- AP; Lat; Mortise view (30’oblique)

 Lauge-Hansen classification (based on adduced MOI)

 Denis-Weber classification

o A. # below syndesmosis + Oblique # of medial malleolus

o B. # at syndesmosis; disruption of ant fibers of tibiofibular ligament

o C. # above syndesmosis

o Add 1, 2, or 3 depending on number of fractures

 Rx: -Conservative- If stable # (only in 1 place) eg Weber A1

Below knee POP with partial weight bearing & crutches 6 wks

-Operative- If unstable (# in 2or more areas)

ORIF

Question 4
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Lady with Rheumatoid Arthritis. Examine hand & discuss Mx (Apl pg 173)

 Affects 3% of the population, Females > Males (3:1); Onset between 40 and 70

 Pathology: Early- Synovitis PJ and tendon sheaths (joint swelling)

Late- Joint destruction and periarticular erosions

Final- Joint + tendon rupture (Deformity)

 Sx: Pain; and Joint stiffness (fingers and wrist)

 O/E:

o MCP & PIP & Wrist swelling; Symmetrical

o Decr joint motility & strength

o Ulna deviation of fingers

o Subluxation of MCP joints

o Swan-neck Or Boutonniere deformity

o Z-deformity thumb

o Trigger finger (Dropped Finger = rupture of Ext tendons)

 Xray:

o Soft tissue swelling

o Periarticular osteopaenia
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o Narrowing of joint space

o Marginal bony erosions

o Articular destruction and deformity

 Rx: Early- Tx Systemic disease (DMA + NSAID’s)

Local synovitis (local methylprednisolone/ synovectomy + physio)

Splints- reduce pain, and improve mobility

Late- Repair isolated tendon rupture/ tendon transfer

Stabilization / Arthroplasty for joint instability Directed at

Reconstruction surgery for Deformities restoring function

 Complications

o Infection

o Tendon rupture (esp wrist)

o Joint rupture

o Secondary OA

Question 5

Xray # Dislocation Hip (Tut 8; Apl pg 361)

 Posterior Dislocation- commonest

 MOI: MVA (striking knee to dashboard)- always do X-ray hip, femur, & knee
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 O/E: leg shortened, adducted, internally rotated

? Sciatic nerve injury

 X-ray: views= Multiple + CT (to exclude # of Acetabular rim / Femoral head)

AP- Femoral head is outside socket and above the acetabulum

 Rx: Manipulation under Anesthesia (MUA)- reduce dislocation- pelvis steadied &
knee flexed at 90’, thigh pulled vertically upwards.

THEN X-ray to exclude #

THEN traction for3 wks

THEN Physio as soon as pain allows

 Complications:

o Sciatic nerve injury (splint ankle to avoid foot drop)

o AVN (Femoral head replaced/ Arthrodesis-younger/ Total hip replc- Older)

o OA (d/t cartilage damage, retained fragments in joint, or Ischemic necrosis)

Question 6

Malunion (Tut 1 pg 3; Apl pg 298)

 Fragments join in an unsatisfactory position (unacceptable angle, angulation, rotation,

or shortening)
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 Cause:

o Obvious deformity

o Rotational deformity of long bones

 X-ray: to check position of # whilst uniting (NB in first 3 wks)

 Rx:

o Adults

 Reduce # as near to anatomical position as possible

 Apposition NB for healing

 Alignment & rotation are NB for Fx

 Angulation > 10-15 in a long bone will lead to noticeable rotational

deformity – may need ORIF/ Osteotomy/ re-manipulation

o Children

 Angular deformities near bone ends will remodel with time

 Rotational deformities will not remodel

o Shortening of limb < 2cm is acceptable (Tx with shoe raise/ limb lengthening)

o Misalignment > 15’leads to asymmetrical joint loading & late dev of

secondary OA (Particularly in large weight-bearing joints)

Question 7

Monteggia and Galiazzi #’s ( Tut 3 pg 1-2; Apl pg 323)

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 Monteggia- # of ulna (proximal 1/3) & dislocation of proximal end of radius (radio-
ulna & radiocapitellar joint)

 MOI: fall on hand & forced pronation of forearm

 Rx: Conservative- If stable= POP 6 wks – complication=limit elbow flexion

Surgical: - If unstable= ORIF

 Galeazzi- # of radius (distal 1/3) & dislocation of distal radio-ulna joint (More
common)

 Rx: Restore length

o Children: Closed reduction

o Adults: ORIF

Reduced & Stable= Arm rested a few days

Reduced but unstable= Fix with Kirschner wires (K-wires) & splint with above-
elbow POP for 6 wks
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Question 8

X-ray Salter Harris Classification (Tut 6 pg 2; Apl pg 273)

 Injury in the physis (growth plate) = 10% of childhood #’s; M>F

 MOI : falls or traction injuries- MVA; Sports

 Sx: Pain and tenderness near joint

 Salter Harris Classification

o Type 1- Transverse # through hypertrophic (calcified zone)of the plate

(Separation of the epiphysis)- .’. growth not disturbed

o Type 2- # through the physis & metaphysis (Commonest type)

o Type 3- # along the physis & veers off through into joint, splitting
epiphysis

o Type 4- Vertical # through epiphysis & adjacent Metaphysis

o Type 5- crushing of the physis without visible #

* Tx: - Undisplaced #: POP 2-4 wks

Displaced #: Reduce ASAP! Type 1 & 2- Closed reduction + POP 3-6wks

Type 3 & 4- MUA + POP 4-8 wks

If unsuccessful= ORIF + POP 4-6 wks

* Complications

- Premature Fusion: d/t type 3,4, & 5 #’s = Growth arrest

- Deformity (usually Tx by Osteotomy)

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Question 9

Bow legs (Genu Varum) and knock knees (Genu Valgus) (Tut 12; Apl pg 226)

 End of growth knees are normally 5-7 degrees valgus

 Bilateral genu varum- measured by taking distance betwn Knees with legs straight,
and medial malleoli just touching (n<6cm)

 Bilateral genu valgus- measured by taking distance betwn medial malleoli with legs
straight, and knees just touching (n<8cm)

 In children deformities correct by age 10-12yrs, Rx not necessary only operative

correction if >10yrs (Epiphyseodesis-staple one side of physis to stop growth/
Osteotomy @ later stage)

 Conditions (4 conditions of bilateral bow legs)

o Bone dysplasia

 Assoc with intractable deformities, likely to need op

o Blount’s disease

 Progressive bow-leg deformity with abnormal growth of posteromedial

part of proximal tibia

 Abnormal flattening/ slopping of medial half of epiphysis

 Rx- will need operative correction

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o Rickets / other metabolic diseases – osteomalacia in adults

 Incomplete mineralization of bone d/t inadequate absorption &/

utilization of calcium

 Causes: Vit D deficiency/ its active metabolites

 Sever calcium deficiency

 Hypophosphataemia

 Inv: Decr serum calcium & phosphate; Incr ALP

 Rx: Vit D administration in the form of Calciferol 400-1000 IU dly

Sever deformities= correction osteotomies

o Congenital genu varum

o Genu Deformity in adults

 Secondary to RA (valgus) or OA (varus) esp if unilateral/

asymmetrical.

 Rx- if assoc with instability- Joint reconstruction/ osteotomy

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Question 10

Differential Dx of Bony deformities of distal leg?

1) Congenital

2) Metabolic (R/ Osteomalasia)

3) Malignancy

4) Trauma (Physis/ # Malunion)

5) Paget’s

6) Infection

7) Inflammatory (Arthritis)

Question 11

Differential Dx of joint deformity?

1) Trauma

2) Skin contracture

3) Fascial contracture

4) Muscle imbalance

5) Joint instability

6) Joint destruction

Question 12

Osgood-Schlatter’s disease (Ostoechondritis) (Tut 10 pg 4; Apl pg 235)

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 Painful swelling of tibia tubercle

 d/t Traction injury of apophysis into part where patellar ligament is inserted

 Sx; Adolescent in strenuous sports= unusual tenderness & prominent tibial tuberosity

 Active extension against resistance = Painful

 X-ray: displacement/ fragmentation of tibial apophysis

 Rx; Spontaneous recovery in most, but no cycling / football

Question 13

Lateral spine disc narrowing

Question 14

Ladies feet with bunions- identify & Tx (Tut 13; Apl pg 245)

Question 15

X-ray rule of two’s

1) 2 view (AP + Lat)

2) 2 joints (Above & below)

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3) 2 limbs (esp Child)

4) 2 injuries (Calcaneous + Femur = Pelvis + Spine)

5) Twice (before & after reducing)

Question 16

Tendon injury hand (Tut 8; Apl pg 339)

 Check for #, skin damage, circulation, sensation, & motor movement

 Note hand & finger posture

 FDP tested by holding proximal finger joint straight & asking pt to move distal part

 FDS tested by asking pt to flex one finger @ a time while extending other digits

 Zone injury

o I- Distal to insertion of FDS

o II- Betwn distal palmar crease & insertion of FDS

o III- Betwn end of carpal tunnel & beginning of flexor sheath

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o IV- Within the carpal tunnel

o V- Proximal to carpal tunnel

 Zone III injuries= worst outcome

 Amputation is a last resort

Question 17

A child with a very tender tibia. X-ray shows sunburst phenomena ( Sunray Spicules)
(Tut 13 pg 3; Apl pg 91)

 Highly malignant tumor from within bone & spreading rapidly outwards to
periosteum & soft tissues.

 Predominantly children & adolescents

 Most commonly long bone metaphysis (esp knee & proximal end of humerus)

 Sx; Constant pain, worse at night, gradually Incr severity

 Inv: Incr ESR & ALP; Biopsy=diagnostic; CT Chest= Pulm lung mets

 X-ray:

o Completely osteolytic/ alternating areas of lysis & Incr bone density

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o Poorly defined margins with sunburst phenomena

o Codman’s triangle: where tumor emerges from cortex reactive new bone
forms in angle betwn periosteum & cortex

 Rx: Multi agent Chemo 8-12 wks

o Then wide resection if no skip lesions

o Replace segment with large bone graft/ custom implant

o Amputation in some cases

Question 18

Child with club-foot (Congenital talipes equinovarus) (Tut 12; Apl pg 241/2)

 Position: Heel point downwards (equinus)

o Entire hind foot varus (tilted towards midline)

o Mid-foot & fore-foot adducted & supinated (twisted medially & sole turns
upwards and faces postero-medially)

 1-2/1000 births; Boys>girls (2:1); 33% bilateral

 Assoc with Myelomeningocoele & arthrogryposis

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 O/E: Skin & soft tissues of calf & medial side of foot are short developed

o Heel is small & high, deep creases posteriorly & medially

o Assoc abnormalities: Congenital hip dislocation & spina bifida

 X-ray: Tarsal bones are incompletely ossified .’. anatomy difficult to define

o Tarsal ossific centers helpful in assessing progress

 Rx: Aim = Produce & maintain a plantigrade, supple foot that will Fx well. Relapse
common

o Conservative

 Start early (day after birth)

 Repeated manipulation & strapping/ Serial POP- may need surgical

Achilles tendon release

o Operative

 Resistant cases

 Complete release of joint tethers

 Lengthening of tendons

 Foot immobilized in POP- Achilles tendon release may be needed

 K-wires may be used to augment & hold

 Pt given hobble boots (Dennis Brown) / customized orthosis- maintain

correction

 Late presentation= Cuboid enucleation (Delwyn Evans)

 OR gradual circular correction with ext fixation (Lizarov method)

 Sever deformed, stiff & painful= Correction osteotomies & fusion

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Question 19

Compartment Syndrome (Apl pg 294)

 # of arm or leg

 Pathophysiology: Bleeding, Edema, or Inflammation (infection) = Incr pressure

within one of osteofascial compartments = reduced capillary flow = muscle Ischemia
= further edema = Incr pressure = > Ischemia (Cylce end after 12hrs or less in
necrosis of nerve and muscle within compartment). Nerve capable of regeneration,
but muscle not! .’. replaced by inelastic fibrous tissue (Volkmann’s ischemic
contracture)
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 Sx: High-risk injuries= #’s of elbow, forearm, & proximal 1/3 tibia.

o 5 P’s: Pain, Paraesthesia, Pallor, Pulselessness, Paralysis

o Earliest = Pain!! (Bursting sensation)

 Rx: Fasciotomy (opening all 4 compartments through medial and lateral incisions)

Wound left open & inspected 2 days after- if necrosis= debride & suture wound.

Question 20

Traction devices (Apl pg 283)

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1) Sustained traction

Traction applied to the limb distal to the #, to exert continual pull in the long axis
of the bone

a. Traction by gravity

i. # of humerus: Forearm supported in sling/ U slab

b. Balanced traction

i. Skin traction (max 4-5 kg)

ii. Skeletal traction – Thomas’s splint for the femur

Braun’s frame for the tibia

iii. Skull traction (Cone’s calipers)

1. 2 kg for skull and 1kg added for every C-level.

2. Indication

a. # dislocation of cervical bones

b. Pt with RA (Atlanto-axial Subluxation)

3. Complications

a. Infection of pin site

b. Bed ridden .’. 1. Bed sore 2. DVT

c. Fixed traction

i. Gallow’s traction- Femur # young child: traction achieved by

suspending legs from overhead beam. (risk of constriction of
circulation ,’, must never be used for children over 12kg’s in
weight)
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2) Cast splintage

a. POP- safe, speed of union same as traction, holding of reduction good

b. d/a: plaster cannot move & liable to stiffen. As swelling resolves,

adhesions form which bind muscle fibres to each other & bone ,’,
minimized by delaying application of POP (traction used 1st)

c. Complications

i. Tight cast (if limb swells) –Rx= Split cast

ii. Pressure sores (over bony prominences) –Rx= Padding

iii. Skin abrasions & lacerations (when removing cast) –Rx= ? ligation

iv. Loose cast (once swelling subsides) –Rx= Replace

3) External fixation

a. Bone is transfixed above and below # with screws/ pins/ tension wires &
these are then clamped to a frame

b. Indication

i. Open #’s
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ii. Severely comminuted & unstable #’s which can be held until
healing commences

iii. Pelvic #’s

iv. Infected #’s

v. Ununited #’s, where dead/sclerotic fragments can be excised &

remaining ends brought together by ext fixation.

c. Complications

i. Damage to soft tissue structures (nerves/vessels/ ligaments)

ii. Over-distraction (if there’s no contact with fragments, union may

be delayed/prevented)

iii. Pin-track infection (administer Ab’s if occurs)

Question 21

X-ray OA of knee, focused @ skyline view of patella. Describe. (Apl pg 231)

 Knee = one of commonest sites for OA

 Often predisposing factor: Injury, torn meniscus, ligamentum instability, deformity

 If unidentified cause, often presents bilaterally + Heberden’s nodes

 Cartilage breakdown often in area of excessive loading (long standing varus=medial)

 Sx: pt >50yrs, overweight, long-standing bow-leg deformity

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o Pain! Worse after use. At rest joint = stiff. Swelling common

 O/E: Obvious deformity (often varus)/ scar of previous operation + limited movement

 X-ray: weight bearing view NB!

o Decreased joint space

o Subchondral sclerosis

o Subchondral cysts

o Periarticular osteophytes

 Rx:

o Conservative: Analgesics; quadriceps exercise; application of warmth (physio)

o Operative: indications= 1. Pain not responding to conservative mx 2.

Progressive deformity & instability

 Arthroscopic washouts + trimming of degenerative meniscal tissue &

osteophytes

 Realignment osteotomy (upper tibial valgus osteotomy)- young

 Replacement Arthroplasty – Older pts

Question 22

X-ray Colles’ # (Tut 2; Apl pg 324)

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 Transverse # of radius just above wrist + dorsal displacement & angulation of distal
fragment.

 Common in older people

 MOI: Falling on outstretched hand

 Sx: Undisplaced= Pain & swelling (little/ no deformity)

Displaced= distinct dorsal tilt above wrist (Dinner folk deformity)

 X-ray: radius # at corticocancellous junction (2cm from wrist)

o Distal fragment shifted & tilted dorsally & towards radial side

 Rx:

o Undisplaced

 Dorsal splint for 1-2 days until swelling resolves, then POP 4 wks, then
Physio

o Displaced

 Reduce under anesthesia (Haematoma block, Bier’s block/ Axillary

block)

 # Often displaces ,’, re-manipulate

o Comminuted/ Unstable

 Percutaneous K-wire fixation with Plaster / Ext fixate

Question 23

X-ray Avascular Necrosis of femoral head

 Dead bone = no blood supply ,’, doesn’t undergo renewal, after period of repeated
stress it collapses. Changes occur in 4 stages:

o Stage 1- Bone death without structural damage

 Within 48hrs post infection = marrow necrosis & cell death, but bone
may show no changes macroscopically for wks -months

o Stage 2-Repair & early structural failure

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 Days / wks after infarction = surrounding living bone shows vascular

rxn, new bone laid upon dead trabeculae, Incr in bone mass shows on
X-ray as exaggerated density.

o Stage 3- Major structural failure

 Necrotic portion starts to crumble & bone outline becomes distorted

o Stage 4- Articular destruction

 Cartilage, being nourished mainly by synovial fluid, is preserved.

However sever distortion leads to cartilage breakdown + secondary
OA

 Sx: Pain, stiffness

 X-ray: subarticular segment of increased bone density (d/t reactive new bone
formation in surrounding living tissue, which increases total mass of calcified bone)

 Must do MRI –reliable in picking up early osteonecrosis

 Rx:

o Conservative: Stage 1-2, weight relief, splintage

o Operative: Stage 4-5, decompression, realignment osteotomy

Question 24

X-ray # neck of femur ( Garden classification)

 MOI: Fall directly onto greater trochanter; young pt’s= fall from heights
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 Early (most common), osteoporotic, less force needed

 Garden’s classification

o I incomplete impacted #

o II complete, but Undisplaced

o III complete + moderately displaced

o IV complete + sever displacement

 If displaced ant- medial rotation

 If displaced post- lateral rotation

 Rx: younger pts- ORIF

Older pts- Hip replacement

 Complications

o AVN (if capsular)

o Pneumonia; Thromboembolism; bed sores

o Non-union (<50 yrs- bone graft; >50yrs –prosthetic replacement-head/total)

Question 25

Slipped upper femoral epiphysis (SUFE) (Tut tut 12; Apl pg 214)

 Epiphysiolysis- displacement of proximal femoral epiphysis

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 Insufficiency # through hypertrophic zone of growth plate

 Uncommon; boys>girls; very tall, fat children with delayed gonadal development

(imbalance betwn growth hormone-stimulate growth & gonadal hormones-promote

physial fusion)

 d/t trauma/ underlying abnormality

 Sx; sudden onset groin pain, ant part of thigh/ knee & limp

o Leg internally rotated, 1-2cm short & limited abd & med rotation

 X-ray; epiphyseal plate too wide & ‘woolly’

o Trethowan’s sign (line from sup surface of neck remains sup to head instead
of passing through it.

o Lat view- femoral head tilted backwards

 Rx: Avoid manipulation

o Minor displacement (<1/3width) – pin screws

o Moderate displacement (1/3-1/2) – Pinning alone / osteotomy

o Sever displacement (>1/2) – fix epiphysis in displaced position & osteotomy

 Complications

o AVN

o Coxa vara

o Slipping at opposite hip (33% of cases)

o Secondary OA

DDx- if pt was old= neck of femur (Subcapital)

Question 26
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X-ray C-spine with dislocation, all views. Approach.

1- Name

2- Date

3- Penetration

4- Rotation

5- Type of view: Lat stated if adequate= Must see C1-C7 + T1

A. Alignment 1. prevertebral soft tissue line 2. Ant vertebral line 3. Post vertebral line

B. Bone (size; shape; height; ?Fractures)

C. Cartilage (Disc spaces- compare above & below vert)

E. Soft tissue (Swelling C5 <2/3 width of vertebral body= normal)

F. Foreign Body (NG tube, etc)

Question 27
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Tourniquet (Apl pg 123)

 Many operations on limbs can be done more rapidly & accurately if bleeding is
prevented by application of a tourniquet.

 Only a Pneumatic cuff is suitable with wool underneath (to distribute pressure)

 Rubber bandage = dangerous – pressure beneath bandage cannot be controlled ,’, risk
of damage to underlying nerves & muscle.

 Adequate exsanguinations of tissue achieved by elevating limb for 1min before

inflating cuff.

 Tourniquet pressure should not exceed 150 mmHg above systolic for lower limb

100 mmHg above systolic for upper limb

 Tourniquet time should not exceed 2hrs

Question 28

X-ray Pelvis: Shenton’s line (Apl pg 205)

 X-ray pelvis: need AP showing both hips

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o Compare both side- size, shape, position of femoral head

o Shenton’s line: from inf border of femoral neck – inf border of pubic ramus.
Any interruption in line suggests abnormal position of femoral head.

 Perthe’s disease (coxa plana) (tut 12, Apl pg 210)

o Childhood d/o with necrosis of femoral head; 4-8 yrs; boys (4:1)

o Up to 4 months femoral head supplied by Metaphyseal vessels, Lat epiphyseal

vessels, and scanty vessels.

o Metaphyseal supply declines until 4 yrs (disappears)

o By 7 yrs = vessels in Ligamentum teres have developed

o Betwn 4-7 blood supply depends on Lateral epiphyseal vessels (susceptible to

pressure & stretching in retinacula d/t effusion)

o Cause= Effusion into joint post trauma/ non-specific synovitis

o Stage 1- Bone death

o Stage 2- Revascularization & repair

o Stage 3- Distortion & remodeling (Epiphyseal collapse ,’, distorted growth of

head & neck)- coxa plana (flattened epiphysis)/ Coxa magna (Enlarged)

o X-ray: disruption of Shenton’s line

o DDx- non-specific transient synovitis (irritable hip)

o Rx; Bed rest with skin traction applied to affected leg 3 wks (pain resolves)

 Containment if bad prognosis (Keep femoral head seated within

acetabulum)

o Bad prognostic factors

 Onset > 6yrs

 Involving whole femoral head

 Sever Metaphyseal rarefaction

 Lateral displacement of femoral head

 TREAT WITH CONTAINMENT

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Question 29

Femur greater trochanter muscle insertion

1. Gluteus maximus

2. Gluteus minimus

3. Piriformis

4. Obturator int

5. Superior gemelli

6. Inferior gemelli

7. Vastus lateralis

Question 30

Total hip replacement indications

1. X-ray features of progressive joint destruction

2. Intractable pain

3. Decreased function- ie: range of movement and ADL’s

4. Post traumatic

5. OA Elderly

Question 31

X-ray spiral #
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a) Stable/ unstable (Use LARA principle)–Length, Alignment, Rotation, Angulation

b) Name type of injury

Question 32

Anatomy of lesser trochanter- muscle attachments & action

Anterior muscles of thigh (Flex hip; Ext Knee)

1. Iliopsoas -Chief flexor of thigh, prevents hyperextension hip when standing

2. Pectineus - adducts & flexes thigh + assists with medial rotation

Question 33

C-arm (X-ray machine used in theatre)

Question 34

Cystic lesion pelvis. Differential Dx (Apl pg 84)

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Cell type Benign Malignant

Bone Osteoid osteoma Osteosarcoma

Cartilage Chondroma Chondrosarcoma

Osteochondroma

Fibrous tissue Fibroma Fibrosarcoma

Marrow Haemangioma Angiosarcoma

Uncertain Giant cell tumor Malignant giant cell tumor

Question 35

# pelvis (Tut 4; Apl pg 356)

 Isolated #/ Pelvic ring #/ Acetabulum #

 Pelvic ring

 Innominate bones of sacrum form ring,held together by weak symphseal joint ant;
strong sacroiliac (SI) & iliolumber ligaments post.

 Break one bone = disruption of second point

 MOI:

o Anterioposterior compression

 Frontal collision betwn pedestrian / car

 Disruption of symphysis = “open book” injury

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 < 2cm = stable

 >2cm = unstable (displacement of SI joint)

o Lateral compression

o Vertical shear

o Combination injuries

 Rx:

o Stable: 6 wks bed rest + post sling/ elastic girdle to “close book”

o Unstable: External fixation with pins in both iliac blades connected to anterior
bar for 8-12 wks

 Acetabular # (Apl pg 359)

Question 36

Anatomy of shoulder joint

-ligaments

- impingement syndrome
 Created by: Edward Ngwenya

Question 37

Pott’s dsease

Question 38

Foot drop DDx

1. Peripheral neuropathy

2. Peroneal nerve injury

3. Sciatic nerve injury

4. Muscle/ tendon injury

 Created by: Edward Ngwenya

Question 39

Tibial Plateau # (Tut 3; Apl pg 371)

 MOI; Strong bending forces combined with axial loads (car striking leg against
bumper)/ fall from height where knee if forced into valgus/varus

 Nearly always adults

 Sx; swollen joint, doughy feel of haemarthrosis, diffuse tenderness on side of #

 X-ray: Multiple view (sometimes CT) to show full extent

 Schatzker’s classification

o Type 1 simple split of lateral condyle Rx-conservative: aspirate

haemarthrosis, Hinged cast brace fitted, heals in 8-9wks

o Type 2 split of lat condyle + central area of depression Rx-ORIF

o Type 3 Depression of Lat condyle with intact rim Rx: Conservative

o Type 4 # of medial condyle Rx: ORIF with buttress plates

o Type 5 # of both condyles, central portion of metaphysis still connected to

tibial shaft Rx: ORIF with plates & screws

o Type 6 Combined condylar & subcondylar # Rx: ORIF with plates &
screws

 Complication

o Compartment syndrome (Esp bicondylar #’s)

o Deformity (varus/valgus)

o Joint stiffness

o Secondary OA
 Created by: Edward Ngwenya

EXAMINATION

A. KNEE EXAM

Collateral ligaments

B. HIP EXAM

Thomas & Galleatzi tests

C. FOOT EXAM (Hallux valgus) + take history

D. SHOULDER EXAM-has recurrent dislocation & wasted deltoids

E. HAND EXAM – Nerve pathology, do reflexes & know the different levels

F. GAIT EXAM

G. STRAIGHT LEG RAISING TEST

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GOOD LUCK & God bless!

SI PASSA SONKE NGENKANI!!

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