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Short Cases in
ORTHOPAEDICS
Short Cases in
ORTHOPAEDICS
for PG Practical Examination
S Kumaravel
MS (Ortho) D (Ortho) DNB (Ortho) (PhD) MNAMS
Associate Professor
Department of Orthopaedics
Government Thanjavur Medical College and Hospital
Thanjavur, Tamil Nadu, India
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ISBN: 978-93-5090-083-3
Printed at
Preface
1. CONGENITAL TALIPES
EQUINOVARUS (CTEV)
A B
A B
A B
2. OSTEOSARCOMA
Age group—younger age usually (sometimes middle
age—parosteal)
Swelling, pain (pain starts first)
Region—around the knee
Step by step approach. Clinical examination, local
staging, systemic staging, Histopathology
Usually soft in consistency/fast growing/vascular
Clinically candidate can only tell it is a malignant bone
tumor most probably it may be osteosarcoma.
8. What is the common presentation of osteosarcoma?
• 100% cases—swelling
• 75%—pain.
BIOPSY
22. What are types of biopsy?
a. Fine needle aspiration cytology (FNAC)
b. Core needle biopsy—Ideal
c. Open biopsy.
23. Why core needle biopsy is ideal?
• You get a bit of tissue for diagnosis with minimum
contamination of track
• There is less bleeding and less seeding.
24. In open biopsy, what is the precaution you will take?
1. Avoid crossing compartments
2. Incision placed in such a way that it is included
in the final surgery incision
3. Cut the window in an oval shaped not in a stress
increasing manner
4. Achieve perfect hemostasis in the form of bone wax
5. No drain.
SHORT CASES 9
A B
A B
3. ERB’S PALSY
1. Deformity is present since birth
2. History of difficulty in 2nd stage of labor.
Child unable to flex the elbow, supinate the forearm.
Flexion of finger is possible with attitude of waiter’s tip
receiving position (see Fig. 10A).
62. What is prognostic indicator in Erb’s?
• Biceps recovery within 3–6 months of delivery is
of good prognosis.
63. What is the position of limb to be kept in infants?
• Abduction and external rotation of upper limb, this
will relaxed brachial plexus.
64. What is the typical finding in adult X-ray?
• Beaking of acromion.
65. What are the reconstruction procedures available?
1. Shoulder arthrodesis in functional position.
2. Muscle transfer to augment elbow flexion.
A B
Figs 10A and B: A lady with a left side Erb’s palsy and her X-ray
20 SHORT CASES IN ORTHOPAEDICS
4. EXOSTOSIS
66. How to tell any mass as exostosis?
• Site—Bony swelling around the joint
• Age group—Skeletally immature age group
• Abnormality of the host bone, e.g. shortening,
dysplasia
(Theories of exostosis—periosteal defect theory
and others).
67. Is Exostosis a tumor?
• It is not a tumor. It is a developmental anomaly.
68. Why clinically exostosis appears larger than
X-ray?
• Because of the cartilage cap.
69. What are the complications of exostosis?
1. Mechanical block for joint movement with
adjoining joint
2. Adventitious bursa and pain
3. Fracture of exostosis stalk and pain
4. Malignant transformation.
70. What are the causes of pain in exostosis?
1. Adventitious bursa
2. Fracture of stalk
3. Malignancy.
71. What is the malignancy that usually arises from
exostosis?
• Chondrosarcoma (secondary).
SHORT CASES 21
A B C
Figs 11A to C: (A) Exostosis lower femur; (B) X-ray; (C) Exposure
A B
Figs 12A and B: (A) An X-Ray of the leg seen on the side shows
an exostosis arising from the tibia pressing on the fibula;
(B) Exostosis from posterolateral side of leg clinical diagnosed
arise from fibula, if you tell this swelling arises from the tibia
then you have already seen the X-ray shows it actually arise
from the tibia pressing on the fibula
SHORT CASES 23
A B C
D E F
Figs 13A to F: Another case multiple exostosis of right
upper arm, right femur and right tibia
5. OSTEOMYELITIS
Clinical Findings
Clinical Findings
Sinus with discharge
Warmth in the region around the sinus
Thickening of bone
Tenderness
Growth disturbance—shortening/lengthening
Pathological fracture
Deformity.
79. Definition of osteomyelitis?
• Osteomyelitis is inflammation of bone and
marrow (usually blood borne).
80. Why in metaphysis?
1. Vascularity and hairpin loop of capillaries
2. Macrophage activity
3. Slowing of blood.
26 SHORT CASES IN ORTHOPAEDICS
A B
A B
A B
6. WINGING OF SCAPULA
92. Differential diagnosis?
1. Weakness of serratus anterior—Involvement of
long thoracic nerve of bell
2. Sprengel’s shoulder
3. Deltoid fibrosis.
• Serratus anterior holds the medial border of
scapula on to the chestwall. So when it is weak,
the medial border becomes more prominent or
winged-long thoracic nerve of bell involvement.
• Sprengel’s—Scapula is smaller and elevated
(Appears to be winged).
• Deltoid fibrosis—There is a fixed abduction
deformity of the shoulder. So when the arm is
brought to the side of chestwall, scapula appears
winged (abduction reduces winging).
A B
A B
A B
7. CUBITUS VARUS
On Examination
Deformity (Gunstock)
Thickening of supracondylar region of humerus
Range of motion (ROM)—Flexion is restricted usually.
Clinically diagnosed as cubitus varus due to malunited
supracondylar fracture with or without myositis ossificans.
93. What are the areas to be seen for myositis
ossificans?
• Brachialis and triceps.
94. Other joints involved in myositis ossificans?
• Hip.
95. What are the investigations and treatment you will
order?
• X-ray of both elbows—AP in extension—to
compare the carrying angle.
96. What is cubitus rectus?
• When correction of the varus to valgus is
attempted if the lateral wedge of bone is taken
less then it results in neutral and not valgus.
97. What is the cause of the varus?
1. Medial tilt of the distal fragment of the
fracture.
34 SHORT CASES IN ORTHOPAEDICS
Fig. 28: The gunstock deformity on the left side in another case
36 SHORT CASES IN ORTHOPAEDICS
8. CUBITUS VALGUS
History of injury
History of massage.
On examination: Deformity of valgus > normal side
Irregularity over lateral condyle
Abnormal mobility may or may not be present
Patient may have ulnar neuritis
ROM—Reasonablly maintained.
Plan:
13. POST-TRAUMATIC
STIFFNESS OF ELBOW
• History of injury/indigenous massage
A B
History of injury
On examination:
Look for any irregularity of medial epicondyle
Carefully see for any involvement of ulnar nerve.
129. What are the treatment options?
• Non-union → small fragment → excision
• Non-union → large fragment → fixation.
130. What will the patient complain in an ulnar nerve
involvement?
• The patient complain numbness of medial one
and half fingers and weakness of fingers
(intrinsic weakness).
131. Before attempting any treatment what will you
order or do?
• Nerve conduction studies.
132. What is the treatment?
• Early cases—wait for 3 months treating with
conservative methods anterior transposition of
ulnar nerve physiotherapy to the finger should be
decided not later than 3 months of injury.
• Later cases—as for ulnar claw hand—tendon
transfers.
133. What is cubital tunnel syndrome?
• The groove behind the medial epicondyle may be
shallow in some individuals. So, after a trauma
may not be related to this region but a
SHORT CASES 49
A B
A B C
A B C
Pathology
Shortening and angulation of radius
Disruption of distal radioulnar joint (DRUJ).
136a. What are the treatment options?
• Open reduction internal fixation
• If necessary transfixation of distal ulna with
radius
• Stabilization of DRUJ with K wire.
SHORT CASES 53
A B
A B
On examination:
Wrist and fingers in flexion
Look for sensations ulna/median nerve
Dorsiflexion of wrist increases the deformity
Skin will have atrophic changes, dry and scaly
In the case of forearm VIC, fingers can be atleast
partially extended when the wrist is flexed
(Volkmann’s sign). (This is because when the wrist is
extended, the shortened muscle tendon unit stretches
over the fingers causing extension.)
Atrophy of forearm muscles, nail atrophic.
141. What is the pathology?
• Sequel to Volkmann’s ischemia, muscle undergoes
ischemic necrosis and replaced by fibrous tissue
which causes flexion-contracture of wrist and
fingers. There may be peripheral nerve involve-
ment with sensory loss and motor paralysis of
hand and forearm.
142. What is Volkmann’s sign?
• The flexion deformities of the fingers is becoming
partially correctable with a flexed wrist
• The deformities become more pronounced when
the wrist is dorsiflexed.
143. What are the treatment options?
• Passive stretching and splinting
• Soft tissue (muscle) sliding operation (Max page)
• Shortening of forearm bones—Garre’s procedure
• Carpal bone excision
• Neurolysis of nerves.
SHORT CASES 57
21. OSTEOCLASTOMA
Cause of pain, difficulty in walking or using the upper limb
or presents with abnormal mobility (pathological fracture).
Difficulty in using limb after trivial fall (pathological
fracture).
Age : Middle age group (20–40).
Incidence more in females.
147. What is the common presentation of osteoclastoma?
• Swelling arising from the bone near a joint
especially around the knee or distal end of radius
(End of long bone) may be painless to startwith.
148. Can we diagnose osteoclastoma clinically?
• Clinically it should not be diagnosed as
osteoclastoma.
• It is better to say as benign bone tumor most
probably giant cell variant osteoclastoma.
149. How will you diagnose osteoclastoma?
• In X-ray we can see expansile eccentric lesion, in
the end of long bone.
150. What are the types of osteoclastoma?
• Aggressive—No sclerosis between tumor and host
bone (Surrounding bone has no time to react).
• Nonaggressive—Sclerosis present.
151. What are the treatment options?
Intralesional
• Curettage
• Adjuvant cryotherapy/cautery
SHORT CASES 59
• Osteoblastoma
• Solitary bone cyst
• Aneurysmal bone cyst
• Recently, giant cell rich osteosarcoma.
156. How will you diagnose gaint cell tumor (GCT)?
• Presence of giant cells.
157. What is the tumor cell of giant cell tumor?
• Fibrous stromal cell (undifferentiated spindle
cells).
158. What is egg shell crackling?
• It is due to fracturing of osteoclastoma by deep
palpation.
159. What is the cell of origin of GCT?
• Unknown.
A B
A B C
A B C
A B
A B
A B
2. Closed
• Supraclavicular—supraganglionic, infra-
ganglionic
• Infraclavicular
• Postanesthetic palsy
3. Radiation injury
4. Obstetric palsy.
190. When is Tinel’s sign not useful?
• Neuropraxia, cut injuries without any nerve
repair.
191. When will you interfere in Tinel’s?
• No progression of Tinel’s
• Nonanatomical progression
• Slow progression.
192. Imaging of choice to identify suspect lesion of
brachial plexus?
• MRI.
193. What are the treatment options?
• Initial phases—Splinting, pain control, prevention
of contractures
• Late phase—Muscle strengthening, reeducation of
muscles, modication of splints TENS to control
pain.
Acute phase—
1. Preganglionic—no surgery
2. Postganglionic—nerve suturing
• Late phase—muscle/tendon transfer
• Shoulder—transfer of trapezius/arthrodesis
• Elbow—latissimus dorsi
• Reeducation of transferred muscles.
74 SHORT CASES IN ORTHOPAEDICS
26. TORTICOLLIS
Contracture of sternocleidomastoid
Occiput turned to same side and chin to opposite side
Later—facial asymmetry and visual disturbance
Child—congenital, infection, muscle, primary visual
problem, trauma to spine are the causes to be ruled out.
194. What are the treatment options?
• Splinting with collar passive gentle stretching
• In resistant cases unipolar or bipolar release —
before visual area fixation in brain (early
childhood).
Types
Prenatal
Natal
Postnatal.
Patient will have variable degree of mental retardation,
difficult in muscle coordination.
Difficulty in walking and doing activities of daily living.
A B
Treatment
Initial—splinting in volar cock-up splint, electroneuro-
myography
SHORT CASES 85
Fig. 62: See the flexion of the left thumb of this patient is on the
right side wearing watch. ‘Claw’ is the hyperextension of MCP
and hyperflexion at IP ulnar claw—leprosy, ulnar nerve injury
RELATED QUESTIONS
236. What is intrinsic plus hand?
• When patient flexes actively his finger, finger goes
for extension-action through lumbricals.
1. Complication of amputation
2. Severance of Flexor digitorum profundus (FDP)
3. Loose graft of FDP
4. Avulsion of FDP.
237. What is quadriga effect?
• Tight-repair or shorter graft—repaired finger goes
for flexion faster than other fingers in the same
musculotendinous group.
90 SHORT CASES IN ORTHOPAEDICS
Treatment
Splinting, open release.
Figs 66A and B: Foot drops; (A) In a child on his left side;
(B) An adult on his right foot
History of injury to leg or spine or surgery knee or tumor
Cause of difficulty in lifting toes of the ground
Patient cannot walk with heel strike.
SHORT CASES 99
On examination:
Foot in equinus
Tibialis anterior is weak
Peroneus long as not acting.
Loss of sensation of autonomous area of common peroneal
nerve.
Common peroneal nerve sites are inspected palpated for
scar, nerve thickening and swelling over the area.
Tinel’s sign is tested in injuries.
With injuries (except in neuropraxia) neurological
recovery can be assessed
X-rays of ankle and knee are taken
Muscle and nerve conduction study are done.
251. What is the treatment?
• Immediately dynamic foot drop splint is given.
Observation (Neuropraxia)
• Intervention (no improvement, nonanatomical
Tinel’s).
Reconstruction procedures:
• If patient presents after one year, neuromuscular
junction is already damaged—“Srinivasan’s
procedure (transfer of tibialis posterior to dorsum
with TA lengthening).
252. How will you differentiate a musculotendinous
injury or a nerve injury?
• The contractions of the muscle can be palpated
in case of a tendon injury and not in nerve injury,
as the patient attempts to dorsiflex the ankle.
100 SHORT CASES IN ORTHOPAEDICS
A Popliteal cyst
A B
C D
39. MADUROMYCOSIS
History of bare foot walking
Agricultural laborer
Swelling and pigmentation of foot and ankle
Multiple sinuses discharging fungal granules.
262. What are the X-ray findings?
• Multiple osteolytic lesions in the tarsals.
263. What is the treatment?
• Antifungal Amphotericin B
• Debridement
• Amputation in resistant cases.
264. Why History of bare foot walking?
• Common in farmers and barefoot walkers which
favor inoculation of spore.
A B
A B
A B
C D
A B
General Examination
Gait—Patient walks alone/support/caliper
Neurological examination muscle power of upper and
lower limb
Shoulder—Extension, flexion, abduction, adduction,
internal rotation, external rotation
Elbow—Flexion, extension
Wrist—Dorsiflexion, plantarflexion
Small joints of hand MCP and IP
Hip level of ASIS/attitude, fixed deformities, Range of
movement—active and passive—Extension, flexion,
abduction, adduction, internal rotation, external
rotation
Knee—Flexion, extension
Ankle—Dorsiflexion, plantarflexion
Toes—Dorsiflexion, plantarflexion, spine deformity—
region and length.
Measurements
Apparent and true measurements.
110 SHORT CASES IN ORTHOPAEDICS
SPECIAL TESTS
Abduction contracture of hip—Ober’s test a diagnostic test
that assesses the degree of tautness in the iliotibial band. The
patient in a side lying position with hips at zero degree flexion
and the leg is passively adducted. Tightness and knee not
touching the couch indicates iliotibial band syndrome.
A B
C D
A B
A B C
A B
WARD PROCEDURES
A B C
A B
Figs 92A and B: Erb’s osteotomy
ARM
A B
Figs 93A and B: Humerus fracture (Malunited)
CASES SEEN IN WARD ROUNDS 131
A B
ELBOW
A B
A B
A B
A B C
A B
A B
A B
A B C
A B
C D
A B
A B C
A B C
HIP
THIGH
A B
A B C D
KNEE
A B C
A B
A B
A B
A B C D
A B
A B
Figs 135A and B: (A) No plate was used for an upper tibial
fracture; (B) Locking compression plate for a similar fracture
expected to achieve early mobilization
A B
A B C
A B
RETROCALCANEAL BURSITIS
Fig. 142: See the prominent swelling over and near the
attachment of tendocalcaneus-pointed tenderness
*Must rule out—Rheumatoid Artheritis
*Main stay of treatment are Wax bath and NSAIDs
*Excision of the bursa in resistant cases, with trimming
posterior end of calcaneum.
CASES SEEN IN WARD ROUNDS 155
Closed TA rupture
A B
Localised Gigantism
Plexiform neurofibroma of foot involving the second and
third toes. This patient was not able to wear shoes to
school. Both cosmetic and functional problem settled with
ray amputation of the toes. Preoperative assessment
included a search for any other evidence of neurofibromata,
MRI of the part and an arterial doppler.
B
Figs 145A and B: Postoperative
158 SHORT CASES IN ORTHOPAEDICS
A B
A B C
A B
A B
A B C D
A B
PAEDIATRIC CASES
A B C
A B
A B
A B
A B C
A B C
A B
Figs 169A and B: Operated patient with deformity of his left
shoulder and no useful function of the shoulder. His X-ray
showed a loosened implant with deformity and nonunion
A B
Figs 170A and B: (A) Broken nail—probably due to → leaving
a distal locking hole close to the fracture free which is a stress
raiser which has coupled with premature weight bearing;
(B) Broken plate—probably due to premature weight bearing
CASES SEEN IN WARD ROUNDS 171
A B
A B
A B
Fig. 177: Lymphedema of old flap area. Should rule out a deep
vein thrombosis. Treatment is strict elevation and antiedema
measures
A B C D
A B C
A B
C D
A B
A B
Figs 183A and B: Abdominal flap for a soft tissue defect of forearm
OSTEOMALACIA
A B C
Figs 186A to C: The patient with osteomalacia—
champagne pelvis
A B C
SPINE
A B
A B C