QUEST.6

This patient fell from a tree

a. What is the diagnosis? (2)

b. What would be your management for this injury in casualty? (3)

P381

A. Right sided fractures of medial and lateral malleoli with a dislocation (or subluxation) of the ankle joint

B. Airway, breathing and circulation resuscitation according to ATLS principles, exclude c-spine injury

Analgesia

Assess and make a note of the neurovascular status of the limb

Reduce dislocation immediately (in casualties) under sedation

Immobilize limb

Elevate limb

Look for other injuries and fractures (esp. of spine, pelvis and hip)

Reassess the neurovascular status of the limb and make a note of it

Refer for definitive treatment

QUEST. 7

She slipped and fell at work

a. Describe the classification used for this injury (3)

b. How would you manage this injury?(2)

P381

A. Two types of classifications can be used for ankle fractures. The Lauge-Hansen classification is based on the adduced mechanism of injury, which is useful in planning how to reduce the fracture. The Danis-Weber classification focuses on the level of the fibular fracture. Fractures distal to tibiofibular joint leaves the syndesmosis intact. Fractures proximal to the tibiofibular joint damages the syndesmosis.

Danis-Weber A: Fibula # below syndesmosis and an oblique # of the medial malleolus

Danis-Weber B: Fibula # at syndesmosis often with a # of the medial malleolus with disruption of the medial ligament

Danis-Weber C: Fibula # above syndesmosis, tibiofibular ligament torn, unstable # subluxation of ankle joint

B. Airway, breathing and circulation resuscitation according to ATLS principles, exclude c-spine injury

Analgesia

Assess and make a note of the neurovascular status of the limb

Reduce dislocation immediately (in casualties) under sedation

Immobilize limb

Elevate limb

Look for other injuries and fractures (esp. of spine, pelvis and hip)

Reassess the neurovascular status of the limb and make a note of it

Refer for definitive treatment

QUEST.8

This patient fell while playing soccer

a. What is the diagnosis? (2)

b. How would you treat this patient? (1)

c. What is a Colles fracture (2)

P327 and P324

A. Right sided distal Radius fracture. Salter-Harris type (1)

B. Acute management: Resuscitate, analgesia, immobilize limb, elevate limb

Definitive management: Closed reduction under anaesthesia

Full-length, well-moulded cast with the wrist slightly flexed and ulnar deviated and elbow at 90’ flexion. Placement is checked after 5 days. The cast is kept for 4 weeks. Throughout this period hand and shoulder exercises are encouraged

C. Colles #: Transverse fracture of radius just above wrist, with dorsal displacement of distal fragment, the fragment may also displace radially. Commonly seen in elderly woman with osteoporosis.

QUEST.9

This patient fell at home

a. What is the diagnosis? (2)

b. How would you manage this injury in casualty? (3)

P376

A. Left sided dislocation of the knee joint (anterior) with torn cruciate and lateral ligaments

B. Airway, breathing and circulation resuscitation according to ATLS principles, exclude c-spine injury

Analgesia

Assess and make a note of the neurovascular status of the limb

Reduce dislocation immediately (in casualties) under sedation

Immobilize limb

Elevate limb

Look for other injuries and fractures (esp. of spine, pelvis and hip)

Reassess the neurovascular status of the limb and make a note of it

Refer for definitive treatment

QUEST. 10

This patient fell from a swing

a. What is the diagnosis? (1)

b. How would you treat this patient? (2)

c. Mention two complications that can occur in this injury (2)

P321

A. Right sided Fractures of the distal radius and ulna

B. Acute management: Resuscitate, analgesia, immobilize limb, elevate limb

Definitive management: Closed reduction under anaesthesia

Full-length, well-moulded cast with the wrist in neutral position, extending to metacarpal heads. The elbow at 90’ flexion. Placement is checked after 5 days and cast kept for 6-8 weeks. Throughout this period hand and shoulder exercises are encouraged

C. Early complications: Nerve injury (posterior interosseous nerve) and compartment syndrome

Late complications: Delayed union, malunion, non-union

QUEST. 11

This 8 year old boy fell from a bicycle

a. What is the diagnosis? (2)

b. How would you manage this patient? (3)

P368 and P283

A. Right sided mid-shaft oblique fracture of the femur

B. Acute management: Resuscitate, analgesia, immobilize limb

Definitive management: Balanced skin traction using a Thomas’s splint for 2 – 4 weeks followed by a spica for another 6 weeks. Or Thomas’s traction for 9 weeks (one week for every year of life plus one week)

Look for and prevent complications

QUEST. 12

This patient was knocked down by a car a. What is the diagnosis? (2)

b. Mention 3 early complications you would

look for (3)

P309

A. Right sided spiral (comminuted) fracture of the shaft of the humerus

B. Early complications

1. Nerve injury – Most commonly the radial nerve

2. Blood vessel injury – Most commonly the brachial artery

3. Compartment syndrome

4. Fat embolism

QUEST.13

This patient was assaulted

a. What is the diagnosis? (1)

b. How would you manage this injury? (2)

c. Which nerve would worry you? (2)

P306

A. Right sided anterior dislocation of the shoulder joint

B. Airway, breathing and circulation resuscitation according to ATLS principles, exclude c-spine injury

Analgesia

Assess and make a note of the neurovascular status of the limb

Reduce dislocation as soon as possible (in casualties) under sedation or (in theatre) under general anaesthesia

Reassess the neurovascular status of the limb and make a note of it

Immobilize the limb with a sling for two to four weeks

Methods for reduction: modified Hippocratic method, kocher’s method, Stimson’s method, Milsch’s method and as a last resort open reduction

C. Axillary nerve, test by asking the patient to abduct the shoulder and then feeling for slight contractions of the deltoid muscle. Other nerves that may occasionally get injured include: posterior cord of the brachial plexus, the median nerve and the musculocutaneous nerve

QUEST. 14

Comment on this X-Ray (5)

P338

This is a AP x-ray of the right hand and wrist

There is a artifact present on the ring finger (most likely a ring) that should have been removed before the x-ray was taken

There is a soft tissue injury (laceration) on the ulnar side of the pinky finger

There is a transverse fracture of the distal phalanx of the pinky finger

There seems to be a periosteal reaction on the radial side of the distal phalanx of the pinky finger

There are slight peri-articular osteopenia especially around the metacarpal-phalangeal joints

The other soft tissues, bones and joints seem to be normal

QUEST. 15

a. What is the

diagnosis? (1) b. How would you treat

this patient ? (2) c. Mention 2 early

complications (2)

P317

A. Left sided posterior dislocation of the elbow joint

B. Airway, breathing and circulation resuscitation according to ATLS principles, exclude c-spine injury

Analgesia

Assess and make a note of the neurovascular status of the limb

Reduce dislocation as soon as possible (in casualties) under sedation or (in theatre) under general anaesthesia

Reassess the neurovascular status of the limb and make a note of it

Check joint for stability by putting it through full range of movement

Immobilize the limb with a above elbow cast for one week and a sling for two to four weeks

C. Early complications: Vascular injury – brachial artery, Nerve injury – median nerve or the ulna nerve

CLINICAL QUESTIONS:16-25

PART 2

a. What test is being demonstrated? b. What does it show in this patient?

QUEST.16

(2) (3)

P203

A. Thomas’ test

Both hips are flexed simultaneously to their limit, holding the healthy hip firmly in this position, the other limb is lowered gently; with any flexion deformity the knee will not rest on the couch

B. The right knee does not touch the examination bed, which it should be able to do if the hip joint was normal. Thus a positive Thomas’ test. This patient has a fixed flexion deformity (flexion contracture) of the right hip. There is a limitation of extension of the right hip.

a. What is the diagnosis? (2) b. Mention three deformities you get in this condition ? (3)

QUEST.17

P241

A. Congenital talipes equinovarus (idiopathic club-foot)

B. Three components

1. Heel in equines (pointing downwards)

2. The entire hindfoot in varus (tilted toward the midline)

3. The midfoot and forefoot adducted and supinated (twisted medially and the sole turned upwards)

a. What is this implant used for ? (3) c. Give 1 absolute contra indication to its use?(2)

QUEST.18

P129 and P219

A. This is a polyethelene socket and metal (titanium or stainless steel) femoral head and neck implant

It is used in arthroplasty operations of the hip joint

This specific implant is used in total hip replacement procedures

B. Absolute contra indications for THR

No consent, patient refusal

Allergy to materials used in the implant

Active infection of the hip joint

Severe uncontrolled systemic disease

Unfit for general anaesthesia

This foot was subjected to blunt trauma. a. What is your clinical diagnosis? b. Give the cardinal signs of this condition?

QUEST.19

(2) (3)

P294

A. Compartment syndrome (crush syndrome???)

B. Cardinal signs of compartment syndrome

1. Pain – out of proportion to injury, pain on passive stretching (bursting pain)

2. Par aesthesia (pins and needles)

3. Paralysis

Late signs

4. Pallor, color changes (purple)

5. Pulselessness

a. Name the classification used for growth plate injuries ? b. Classify the injury shown using this classification system

QUEST.20

(2) (3)

P273

A. Salter-Harris classification

B. Salter-Harris type 4

Vertical fracture through the epiphysis, physis and the adjacent metaphysis

a) What is the name of this plaster of paris? b) What fracture is it typically used to treat? c) After application of such a plaster, what specific nerve would you test

QUEST.21

(2) (2) (1)

P309

A. Modified shoulder splint cast

U-slab

B. Humerus shaft fracture

C. Radial nerve

Palsy of the nerve causes wrist-drop and paralysis of the metacarpophalangeal extensors

Write down the levels of the following dermatomes (5)

QUEST.22

P98

A. L1

B. L1

C. L2

D. L5

E. S1

a) What is the device called? b) Give one indication for its use c) How do you manage a patient with such a device in the ward?

(1) (2) (2)

QUEST 23

P288

A. External fixator

B. Indications:

1. Fractures associated with severe soft tissue injury, so wound can be left open for inspection, dressing or definitive coverage

2. Severely comminuted and unstable fractures

3. Fractures of the pelvis

4. Fractures associated with nerve and/or vessel injuries

5. Infected fractures

6. Ununited fractures

C. Meticulous pin site care, start anti-biotics immediately if infection is suspected, early mobilization and exercises

a) What surgical procedure has been performed on this arm? b) For what clinical condition has it been performed? c) What are the clinical signs of this condition?

QUEST.24

(1) (1) (3)

P294

A. Fasciotomy

B. Compartment syndrome

C. Cardinal signs of compartment syndrome

1. Pain – out of proportion to injury, pain on passive stretching (bursting pain)

2. Par aesthesia (pins and needles)

3. Paralysis

Late signs

4. Pallor, color changes (purple)

5. Pulselessness

a) What is the name of this splint? b) Give the main indication for its use d) What is the maximum allowed weight for a child treated in GALLOWS traction?

QUEST.25

(2) (2) (1)

P284

A. b. Thomas’ splint

c. Skeletal traction with a splint and a knee flexion piece.

Perkin’s splint

B. Rarely used today.

1. Femur fractures in children where skin traction will not be adequate

2. Femur fractures in adults and children where there are contra indications for general anaesthesia and thus cannot be treated by ORIF

3. Femur fractures in adults and children where an ORIF is contra indicated because of lack of surgical skills or adequate facilities

C. 12kg (or 2 years)

QUEST.6

This patient fell from a tree

a. What is the diagnosis? (2)

b. Mention three other fracture you will exclude in this patient (3)

P386

A. Right sided intra articular fracture of the calcaneus with flattening of Bohler’s angle which is normally 25-40’

B. Fractures of the calcaneus are strongly associated (>20%) with fractures of the spine, pelvis or hip (whole axial skeleton) and these should be excluded

QUEST.9

This patient fell from a motor-bike

a. What is the diagnosis? (2)

b. How would you manage this injury in casualty? (3)

P381

A. Right sided fracture of the lateral malleolus (and medial malleolus?) with dislocation of the ankle joint

B. Airway, breathing and circulation resuscitation according to ATLS principles, exclude c-spine injury

Analgesia

Assess and make a note of the neurovascular status of the limb

Reduce dislocation immediately (in casualties) under sedation

Immobilize limb

Elevate limb

Look for other injuries and fractures (esp. of spine, pelvis and hip)

Reassess the neurovascular status of the limb and make a note of it

Refer for definitive treatment

QUEST. 14

This patient was involved in a car accident a. What view is this? (1)

b. Describe how would you read this x-ray (4)

P345

A. Lateral X-ray of the C-spine

B. Make sure that the X-ray is adequate – able to see C1-T1(junction of C7&T1)

Start from anterior and work towards posterior

Look for any obvious soft tissue abnormality (swelling) or an obvious bony deformity)

Evaluate the anterior soft tissue line, measure the amount of soft tissue in front of the vertebral bodies

Evaluate the anterior vertebral body line – the line should follow the normal cervical lordosis without any steps

Evaluate the vertebral bodies, look at the shape of the vertebral bodies, look for fractures and/or compressions, osteophytes and other abnormalities

Evaluate the intervertebral disc spaces, these should be equal

Evaluate the posterior vertebral body line – the line should follow the normal cervical lordosis without any steps

Evaluate the spinous laminar line

Look for convergence of the spinous processes at an imaginary point (normal)

a. Name the pathology? b. What must be examined in addition to the feet? c. Which muscle is responsible for plantar flexion of the first metatarsal?

QUEST.17

A. Pes Cavus

High longitudinal arch, heel in varus, first metatarsal drop

B. Full neurological examination, look for spastic diplegia, old poliomyelitis

Full orthopaedic examination, many cases are associated with spina bifida occulta

C. Tibialis anterior muscle

a) Describe the pathology shown b) What are these called c) Who classically develops this condition? d) Differentiate between this condition and Rheumatoid Arthritis in the hands

QUEST.22

P43 and P26 A. Osteoarthritis of the hands, this is polyarticular (generalized) osteoarthritis affecting most obviously the distal interphalangeal joints B. There are Heberden’s nodes present affecting the DIP joints Bouchard’s nodes affect the PIP joints C. Classically middle-aged and elderly woman are affected D. OA vs RA

Osteoarthritis in the hands:

Usually affects the distal joints of the hands – DIP, CMC of the thumb

Usually with osteophytes on imaging

Usually no deviation of fingers

Periarticular osteopenia uncommon

Periarticular erosions uncommon

Rheumatoid arthritis in the hands:

Usually affects the proximal joints of the hands – MCP, PIP

Usually no osteophytes on imaging

Usually ulnar deviation of fingers, and radial deviation of metacarpals

Periarticular osteopenia common

Periarticular erosions common

QUEST. 10

This patient fell from a swing

a. What is the diagnosis? (1)

b. How you treat this patient? (2)

c. Mention two complications that can occur in this injury (2)

P321

A. Left sided fractures of the distal radius and ulna. Bayonet type fracture. With shortening and apex volarly displaced

B. Acute management: Resuscitate, analgesia, evaluate neurovascular status and make a note of it, immobilize limb, elevate limb

Definitive management: Closed reduction under anaesthesia, hyperextension (worsen deformity) then push distal fragment distally, then reduce fracture. Evaluate neurovascular status and make a note of it

Full-length, well-moulded cast with the wrist in neutral position, extending to metacarpal heads. The elbow at 90’ flexion. Placement is checked after 5 days and cast kept for 6-8 weeks. Throughout this period hand and shoulder exercises are encouraged

C. Complications

Nerve injury – median nerve

Compartment syndrome

Blood vessel injury – radial artery

Delayed union, malunion, non-union

a. What is the diagnosis? b. How will you treat this injury? c. Mention two early complications of this injury

QUEST.17

P317

A. Left sided supra-condylar fracture of the humerus

B. Airway, breathing and circulation resuscitation according to ATLS principles, exclude c-spine injury

Analgesia

Assess and make a note of the neurovascular status of the limb

ORIF under general anaesthesia

Reassess the neurovascular status of the limb and make a note of it

C. Early complications: Compartment syndrome, Vascular injury – brachial artery, Nerve injury – median nerve or the ulna nerve