Orthopedic

Questions

2010/2011
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1) 2) 3) 4) 5) 6) 7) 8) 9)

What are the differences between delayed union and non-union? What is Spondylithiasis? What are its subtypes? What are the steps to read an X-ray? What are the complications of anterior hip dislocation? What are the early complications of fracture? What are the late complications of fracture? What is carpel tunnel syndrome? How to diagnose it? What are the differences between sciatica and pseudo sciatica? What is the management of acute osteomyelitis?

10) What are the signs of osteoarthritis on X-ray? 11) What are the radiological signs of Osteosarcoma ? 12) What is the pathogenesis of acute osteomyelitis ? 13) What are the anatomical supports of the shoulder joint (muscles and ligaments)? 14) What are the differences between neurological claudication and vascular claudicating? 15) What are the radiological lines of the hip joint? (The same of DDH) 16) What is the compartment syndrome? How to diagnose it? 17) What are the normal curves of the spine? What is scoliosis? 18) How would u differentiate between complete and partial supraspinatous tendon tear? 19) What are the predisposing factors for DDH? 20) describe meniscial injuries and their primary treatment 21) describe the treatment of septic arthritis 22) describe fractures in term of mechanism of injury 23)describe gait phases and give 3 examples of 3 abnormal types of injury

+ Look for the last 3 questions in the end

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1. Delayed union is when there are no signs of healing on the x-ray after the expected time of fracture healing with Persistence of pain and tenderness at site of fracture. Non-union is when there are no signs of healing on the x-ray after double the expected time of fracture healing and there is no pain and there is pseudoarthrosis (movement at fracture site). Hypertrophic theres osteogenesis. Atrophic no osteogenesis.

2. Spondylithiasis means vertebral displacement. This is usually prevented by the normal laminas and facets which prevent slippage and sliding of a vertebral bone on the one below it. The most common sites are the L4-L5 and the L5-S1. Caused by bilateral defect in the pars interarticularis. Three main types are found: a- Dysplastic: this is seen in children and usually painless. It is sometimes associated with scoliosis b- Isthmic: most common one and it is found in adults. It is associated with back pain radiating downwards toward the lower limbs. It is aggravated by excersize and sliding a finger by physical examination may reveal a step on the level of involvement c- degenerative: its a type found in women over 40 and is characterized by long standing backache due to facet joint arthritis or osteoporosis d- traumatic e- iatrogenic 3. Patients profile identification of X-rayed part is the x-ray of good quality judging by the soft tissue and bone contrast rule of 2: 2 areas, sites, occasions, views, joints, and sides identify the cortex of the bones involved and any abnormality in them. 4. complications of anterior hip dislocation: According to apleys only avascular necrosis is the complication. But read this very good for both anterior and posterior dislocation Complications AVN of the hip o AVN is common, occurring in 8-13% of patients. o Early diagnosis and treatment of dislocations decreases the incidence of AVN.

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Other complications of hip dislocation are the following: o Osteoarthritis o Heterotopic calcification o Recurrent dislocation o Ligamentous injury of the knee, other fractures o Complications of immobilization (DVT, pulmonary embolus, decubiti, pneumonia)
o o

Sciatic nerve injury (posterior dislocation) Injury to the sciatic nerve occurs in 10-14% of posterior dislocations during the initial trauma or during relocation. Femoral-nerve injury Anterior dislocations are occasionally associated with injury to the femoral artery or nerve. Femoral-artery injury (in anterior dislocations)

5. Early complications of fractures: Visceral, vascular and nerve injuries Compartment syndrome, PE, fracture blisters, infection, heamarthrosis, fat embolism and gas gangrene. 6. Late complications include: delayed union, non-union, mal-union, avascular necrosis, join instability, growth disturbance and osteoarthritis. 7. CTS is when the median nerve is entrapped and compressed under the flexor retinaculum. Causes Dm,hypo/hyperthyroidism, amyloidosis,pregnancy, obesity, repetitive trauma. This causes pain, numbness and tingling in the lateral aspect of the hand especially the lateral 3.5 fingers. Muscle wasting is found (thenars primarily) which is a result of denervation.

Carpel tunnel syndrome

How to diagnose History Physical exam: tinnel's test: tapping on the median nerve Compression on the wrist elicit parasthesia Phalen's sign: elicit parasthesia by maximum flexion on wrist joint Inspect for any thinner wasting and do abduction against resistance at thumb Nerve conduction study and EMG

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8. Sciatica is pain numbness and parasthesia in the lower back radiating down to the back of the thigh due to sciatic nerve compression. It may be caused from the compression of the roots in the spinal cord(problem of the spinal cord). Pseudo sciatica is only pain of the same characteristics but sparing the parasthesia and numbness and it is usually not a spinal cord issue. Compression of the peripheral parts of the sciatic nerve caused by pathology outside the spinal cord. 9. Management of acute osyomyletitis 1. History and physical exam 2. Imaging: first 2 weeks, bone scan, then x-ray(Periosteal elevation, cortical disruption and medullary involvement) 3. Investigations: cbc, blood culture, aspiration of pus from subperiosteal abcess if present ( lab and culture) 4. Analgesia, Rest, Start antibiotic IV for one to two weeks followed by 2 to 3 weeks oral antibiotics 5. If there is no improvement in the first 24 hours: open and drain Management of osteomyelitis like any infection is the administration of antibiotics. Specific antibiotics are given after culture results but we start empirical therapy based on clinical presentation. Some of these are: MRSA vancomycin Old children and previously healthy adults with staph flucoxacillin <4 years 3rd generation cephalosporin Drug abusers and HIV more specific due to their special condition. 10. Narrowing of joint space Subchodral cyst formation and sclerosis Osteophyte formation Condrocalcinosis 11. Osteolytic lesions which are areas of alternating lysis and increase in bone density. Tumor margin poorly recognized Cortex maybe breached and this is called sunburst appearance Sometimes Codmans triangle is seen which is caused by new formation bone angulations with the cortex and periosteum.

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12. Infection of bone medulla and marrow with pathogens that may arrive via blood, trauma or due to impaired host defenses. This causes an inflammatory reaction and later suppuration with pus and then necrosis due to rise in interoseous pressure which causes vascular stasis 13. The shoulder is supported by a number of muscles and ligaments: Glenoid capsule, labrum, muscles include rotator cuff( infraspinatous, supraspinatous, subscapularis, teres minor) deltoid, levator scapulae, trapezius. Also some ligaments help in its stability like coracoacromial, coracoclavicular(trapezoid and conoid ligament), acromioclavicular ligament and last superior, middle, and inferior glenohumeral ligaments. 14. What are the differences between neurological claudication and vascular claudicating? According to Marridi : Both come with movement and increase with movement duration Vascular claudication is caused by arteriosclerosis which causes hypoperfusion to the muscles of the lower limb which causes hypoxia in the muscles when moving which leads to lactic acid accumulation in muscle which leads to pain. Vascular claudication is relieved by rest ( stopping movement, in mild cases just by standing still). Neuro claudication is caused by compression on nerve root or spinal cord (decrease in space in spinal canal --- lumbar spine stenosis---). Neruo claudication is relieved by flexion of the lumbar spine even while continuation of movement (has a special gait where there is flexion of lumbar spine while walking) Characteristic of this is pain while going down the stairs and no pain while going up the stairs. According to emedicine: NC pain is exacerbated by standing erect and downhill ambulation and is alleviated with lying supine more than prone, sitting, squatting, and lumbar flexion. NC, unlike vascular claudication, is not exacerbated with biking, uphill ambulation, and lumbar flexion and is not alleviated with standing. LSS patients compensate for symptoms by flexing forward, slowing their gait, leaning onto objects (eg, over a shopping cart) and limiting distance of ambulation. 15. Acetabular index is the angle formed by the hilgenreiners line and the upper border of the roof line of the acetabulum. This is usually less the 30 degrees Hilgenreiners line is the horizontal line which passes through the triardiate cartilages.

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Perkins line is the vertical line from the outer edge of the acetabulum. Van rosens line is the line drawn when the hip is abducted in 45 degree manner. This should pierce the middle of the acetabulum. Shentons line is the curve drawn that marks the neck of the femur, inferior rami of ischium and the lower border of the acetabulum. 16. Compartment syndrome is when the pressure in the fascia underlying the muscles increasers due to fractures or fluid accumulation. This causes hematogenous stasis and compression on the nerves in the compartment. 5 Ps Pain Pallor Parasthesia Pulseless Paralysis are the clinical features. Usually this is diagnosed by clinical history and sometimes by catheter insertion in the compartment and measurement of the pressure. 17. Lordosis in lumber and cervical vertebrae is normal Kyphosis of thoracic and sacral vertebrae is normal Scoliosis is the deviation of the vertebral column axis laterally. This may be due to muscular or spinal causes. 18. 3 main points 1 Acutely theres pain in both. With time, in partial tear pain will continue and in complete tear the pain will subside(but not gone completely) 2 In partial tear, theres pain in the 1st 30 degrees of abduction, but it can be done. In complete tear, initiation of abduction is not possible, so the patient will either help himself with the other arm or bend laterally so that it can overcome the initiation angle of abduction. 3 Upon giving local anasthetics , in partial tear, is it possible to abduct the arm normally, whereas in complete tear, no abduction is possible.

19. DDH risk factors: 1- Females 2- Normal vaginal delivery or instrumental one 3- Breached position in delivery 4- Polyhydrominas 5- Family hx 6- Hormonal changes in the last trimester of pregnancy 7- Trauma or history of drop after birth 8- Cultures such as SAMI people 9- First baby

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21 - Diagnosis and Management of septic arthritis? History PE Investigations aspiration synovial fluid, culture, esr crp Management x ray(soft tissue swelling,widening of joint spaces and osteoporosis for the 1st 2 weeks,after that narrow joint space), ultrasound, mri,bone scan, ct Treatment Analgesics, splinting, antibiotics, drainage 22 - Classify fractures according to mechanism of injury? Direct- direct blow, crush Indirect- twisting, bending, avulsion PathologicalStress- minor repetitive(tibia,fibula,neck of femur Iatrogenic23 - What is the normal walking cycle and give 3 examples of gaits? Stance and Swing Stance 60% of the cycle, comprises of Heel stride, flat foot, lift off 3 examples antalgic, wide base gait, stumping gait, waddling gait 24 - What are the radiological and physical signs of anterior shoulder dislocation? Physical pain, limitation of movement, Anterior bulging with loss of deltoid contour, Humeral head is palpable anteriorly, A Bankart lesion - when the
anterior/inferior portion of the labrum is torn away from the glenoid fossa

X ray hill sachs lesion,humeral head anteriorly on axillary view, 25 - Diagnosis and management of meiniscial tear? History trauma, pain, swelling emerges the day after, giving away or locking PE Slightly flexed, swelling, limitation of movement,quadriceps wasting in prolonged cases, Apleys test positive Management - X-ray(normal), MRI , arthroscopy(diagnostic and therapeutic) Most meniscal tears do not heal without intervention. -Conservative treatment of meniscal injuries begins with RICE (Rest, Ice, Compression, and Elevation). - Arthroscopy (a7san wa7deh) - Surgical

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26 - What are the principles of fracture management? -ABC -Reduction (open or closed), Maintenance(Casting, traction, internal w external fixation), Mobilisation of the surrounding joint

M3 ta7yat Sa3d Abd Allah, Kosai Al-Yafawi, and Abdel Rahman Marridi Abdullah Ashraf Refikoglu and Sameh Abu Remeileh

Note that recently the mode of the exam was changed to MCQs, but still with these questions you can get an idea of what they might ask Good Luck to everyone

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