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Orthopaedics OSCE Session 170811 Limb - Painful or painless o Painless Maybe chronic and not so urgent o Painful: More

re significant If you miss; more sequelae - Normal gait: 4 phases o Heel stri e !n le dorsifle" #equires intact muscle $ %oint In&ol&es mild hip fle"ion $ nee fle"ion o 'tance phase Longest phase (decreases in pain) o Push off o '*ing phase If you ha&e nees *ea ness+ unable to fle" nee *ill circumduct If you ha&e ,N' only *ea nessHip *ea ness.foot drop *ill ha&e to fle" nee more /ea in both hip and nee need to stabili0e LL *ith hands o 'o must push nee bac *ards (to e"tend nee to loc it) ,er&ical mylopathy o 1nstable gait 2end to fall o 2est !s to *al /al in tandem !s them to close eyes 3ut may be cerebellum 4ait painful or painlesso Neurological deficit- 5r other problems If problem in hip o 'hort limb gait 6 limb 7 shorter than the other 6 side of pel&is *ill drop (on side of shortened limb) 'imilar to trendelenberg gait 3ut you ha&e to test if 2rendenlenberg gait ,an be around hip+ abo&e nee+ or belo* nee o Loo from foot+ an le+ nee up*ards Most problem 7 in lo*er limb Hip %oint most common deformity o 8le"ion /hen hip s*ells up+ *ill go into fle"ion Hip *ill be most comfortable in fle"ion o Muscle goes into spasm

Left long enough muscle contractures fle"ion contracture !99 deformity Hip cannot *al *ith hip adducted Patient tries to ele&ate hip o 2here is apparent shortening /hen pel&ic lifts up !bducted deformity Hip *ill compensate by trying to bring do*n Leg appears to be longer Internal rotation In-toeing gait common in paediatrics :"cessi&e femoral ante&ersion from femur ,hildren *al s *ith toes pointing in*ards o 'lo*ly gro*ing out of it :"ternal rotation 5ut-toeing gait scyphy :"amine patient.child 8le" the hip 1sually *ill ha&e only fle"ion 3ut if child (6; -6<) going into e"ternal rotation *hen fle"ing hip 'cyphy

2rue Length &s= !pparent Length - Painful &s= painless gait o 'hort limb gait &s= trendelenberg gait - 2rue &s= apparent o Lie do*n (supine)+ face up*ards 'houlder chest and pel&is nees an les+ all should be placed in straight line o Measure from fi"ed bony point >iphisternum to medial malleolus apparent length o 2rue length ,onditions 'quare the pel&is o ; !'I' perpendicular to body a"is Place both limbs in same position o I=e= affected side adducted+ the normal side must be adducted also Measurement - 8le"ion deformity of hips 2homas? test o Ho* to e"plain- understanding /ith fle"ed hip+ the body *ill be positioned for*ard /hilst you assume the upright position+ you *ill hypere"tend your lumbar spine 2hat 7 compensatory mechanism (bac for hip during fi"ed fle"ion) 2o unmas the deformity+ you must obliterate the lumbar compensation 8le" the normal hip+ until obliterate the lumbar lordosis o If deformity present *ill sho* up on affected side o 'tabili0e pel&is !ble to detect change *ith mo&ement (abduction+ adduction+ etc=) - No real discrepancy of lo*er limb o Hip shortening must be adduction deformity o 2o *al properly+ the hip must tilt up slightly+ - 2rue shortening 7 ;cm+ apparent 7 4cm o !bduction problem - Must ascertain if shorteningo Hip test o !bo&e the nee o 3elo* nee o 4ilia0i?s sign 9epending if the abo&e or belo* nee o !bo&e hip.belo* hip 3rian?s triangle 3ony landmar s o !'I' o 4reater trochanter Perpendicular line from !'I' to greater trochanter o Height abo&e the hip - 2rendelenberg test

/hy positi&e trendelenberg test !ny portion that affects the le&er system Hip %oint 8ulcrum 7 %oint itself Le&er arm 5!+ 'hort nec + bro en nec + 5!+ *ea muscle.painful muscle (glueteus medius+ minimus) 'ometimes patient may compensate 3ody no*s that it is going to drop /ill lean to one side (ipsilateral to site of pathology)

'eptic arthritis of Hip - ,auses o 8emoral puncture (before aspetic technique) infection o Haematogenous spread o Premature babies o Important reason that the dude *ill go into later on Limb-length discrepancy - 'quare the pel&is first for true length >-rays of Hip @oint - !ny %oint o ,ortical bone o ,acnellous bone o 'ubchondrol bone - 9ensity of bone o Normal o 'cloertic bone (uncommon) o 5steoporetic - !llignment o 'hanton line - 9i&ide hip into A o !cetabalum o @oint space 'ubchondral 7 foundation of bone 'hort or long 'loping or &ery sloping 'hort 7 acebalar dysplasia Bery slo*ing acetablar dysplasia 9estruction of subchondral bone 'ubchondral bone Increase in stress (*ith dysplasia) increased sclerosis Increase in shado* 7 increase in shado* 'tress *ill cause crac in subchondral bone 8luid *ill go through crac s+ forming subchondrfal cyst o ,ollate together+ e&entually *ill collapse *hen going bigger In osteoarthritis @oint space Narro* or big

8emur head 'perhical or non-spherical Head non spherical+ something happen to head in gro*ing period o 2hin of de&elopmental conditions 5! in infancy 'cchphy If happens after maturity o 2he head *ill be round o 3ut you *ill ha&e a dent (i=e= ping pong ball *ith dent) o I=e= !BN Nec of femur Medial corte" ,ontinues abo&e lesser trohcnater to become the femoral coulter strongest part of nec after that becomes the &ertical trabeculae o /hen classifying N58 fractures+ need trabeculae pattern 2rabeculae *ill become tension trabeculae o ; *ill meet together in centre of head /ea est part 7 *ard?s triangle @ust inferior of intersection of ; trabeculae pattern 8racture *ill abo&e trochanter+ 'omeho* *ill e"tend along line toe*ards greater torhcnater+ to*ards the /ard?s triangle o 1sual pattern of N58 femur 4ardens different grading o 6 6 corte" o ; ; corte" o A partially displaced o 4 completely displaced Normally: trabeculae pattern in line *ith acebtabular pattern o Head 7 in &arus /hen fracture: both corte" of femur /hole thing *ill go into more &arus o 8irstly: head is &arus 2rochanter pattern no longer same /hat if head becomes more &ulgus (; becomes 6) o I=e= the trochanter pattern become more &ertical 8rom unstable to stabl epositiion Lateral corte" Lesser trohcnater 4reater trochanter

; Cinds of Hip: *hen you are in trouble - ; operations: (operation of last resort) o !rtrodesis of hip (i=e= fused but stable) Painless $ stable

3est position of fusion 3etter to ha&e a shorter leg o !llo*s clearance of ground more easily 'lightly fle"ed better than fully e"tended !bducted better than adducted (*ill get in the *ay) o !bducted+ can tilt pel&is to allo* for compensation Internal rotate &s= e"ternal rotate ( o :"ternal rotation 7 best /al typically *ith e"ternal rotation 4irdle stone (pseudo-arthrodesis) or e"cision arthroplasty (remo&e head) Painless $ unstable hip pain

!nother Hip @oint - ' eletally immature o ,an see the physeal plate o 4ro*ing s eleton Pel&is has A parts: ileum+ ischium+ pubis) Hilgerr line - 'ub-chondrol bone o 'ee uniformly destroyed fracture o Locali0ed usually infection - @oint space 7 intact - Head femur - Nec femur deformity - 'omething happened during gro*ing period of child+ something happened Infection of hip in children (something different) o Infancy different in hip rather than adult 9I9 D51 CN5/ 2H!2 M585'--o Most infection Haematogenous Mostly *ill go to the metaphyseal region Intact (during childhood) o Head 7 before the first year Mainly cartilaginous :n0ymse and lyso0omes *ill N5M N5M the cartilage easily 3efore 6 year+ if you can infection in area *ill destroy area :piphyseal 4ro*th plate *ill pre&ent 3efore first yaer 2rans-epiphyseal &essels across gro*th plate o If ha&e infection+ can cross gro*th plate easily into femoral head d 9estroys it a lot more easily o !nterior epiphyseal Intra-capsule attached to base anteriorly 3ut posteriorly: it is a syno&ial reflection ,ortices and abscess brea s anteriorly

,an become intra-capsular 3ut brea s posteriorly ,an be behind %oint Infancy arthritis causes more damage than adult did you no* that too mofos-

,hronic &s= !cute Infection - ,hronic: 23 o 23: aseptic arthtiris 9estruction of subchondral bone 4ranulation tissue 8urther cause bony destruction $ soft tissue destruction 8emoral head: 4ets destroyed !cetabulum haed: also gets destroyed o /hen you pound chilli in motor Hammer: *andering acetabulum Head gets destroyed !cetabulum gets bigger and bigger o 2P: 8ibrous an lyosis: because of the granulation - Infected Hip: o 9:'2#5Ds cartilage on both sides+ bone on both sides e"posed 3ony an ylsosis of hip Infancy: ' eltal displacement across physeal plate - 6E F 6; years old - ,lassification (bearing on treatment and prognosis) o 'table o 1nstable o /eight-baering (*al ing) &s= non *eight bearing (non-*al er) /al er 7 better prognosis 'ome pain ,hronic o 3it by bit+ allo*s for &essel gro*th Non-*al er 1nstable More acute o 'udden split of epyseal plate 9isruption of &essels - 'e&erity of slip o More it slips se&ere o Less it slips mild - 3est seen on lateral &ie* - Mild AEG+ moderateHEG+ se&ere IHEG :piphyseal plate o Hardly any changes+ any sclerosis acute o ,hronic: increased follicular thic ening on medial corte" 3lurring of margin

3efore epiphyseal slips o 'omething happens in meta-physeal ,hronic ,ysts li e or increased in density in meta-physeal 9iagnosis o 6E F 6< years old ,.5 Pain in hip or groin F JEG+ ;EG Most complain of pain in anterior thigh+ %ust abo&e nee 1sually e"amine nee+ but should e"amine hip as *ell 3ecause: 5bturator ner&e inner&atino (*hich inner&ates hip %oint) o #eferred to the anterior thigh+groin MD 3!LL' !#: 31#NIN4 Mo&ement: /al n *ith limb :"ternal rotated foot /hen fle" the hip+ goes into e"ternal rotation 2reatment: o #educe the fracture and displacement If reduced: must tear all the blood &essls ,auses re-displacement again+ *hich comprimises circulation o 3asically: No traction If goes bac into place good Ne&er force it 3ecause you *ill bloc re&ascularation to femoral head Head: in-situ 8use *ith pins until epiphyseal plate closes >-ray Normal density bone #ight side alignment is bro en 'ubchondral bone of hip and acetabulum intact 7 not infected @oint space 7 deceased Head loo s fairly round :piphyseal line 7 6 dense scloeritc line and lucent line %ust belo* it o 1sually hori0ontal 2his line: is abit &ertical and oblique 2here are changes in metaphyseal region Head is slipped in+ not central ,hronic scipphy o Pistol grip sign /IL9 /IL9 /:'2 the nec and the head machiam pistol head A+ ;+ 6 line: Clein?s line o 9ra* a line from superior border of nec of femur 'hould cut 6.A of femoral head 'hanton line loo s o 'ubchondral bone loo s intact

o 3ut deformed @oint space 7 o !BN of femoral head o 3ecause of inter&ention 5ld !9H- 'urgery head 2hat is not infection o @ust increased sclerosis in area

Normal density bone - 'henton line normal on right side+ abnormal on left side - 'ubchondral bone 7 partially destroyed o Many cystic changes in femoral head and on femoral side Bery &ertical+ oblique acetabulum o Most li ely: !BN of femoral head 'e&ere 5! due to acetebular dysplasia o Not infection ,ollapse of acebatulum Narro* %oint space Head not &ery spherical ,ystic $ scloertic changes 2ypical of se&ere 5! of head #esult of dysplastic hip or o /hen becomes se&ere+ no *ay of telling priomary cause Head 7 spherical o 'ubchondrol fracture line ,resenteric line plastar o 3ric s: people put palster one+ put cement o 4aps bet*een bonding 9ebonding from subchondral bone 'ub-chondral fracture line.cresenteric line o Means: the head is going to collapse &ery soon (pre-collapse head) o Bery e"tensi&e ,an see cystic $ sclerotic changes in head 6 of prognostic sign 'e&ere 5! of hip o Head 7 almost collapsed @oint space: o Not infection o 3ut se&ere 5! of hip

8racture Nec of femur - 3ase of femur - :>92#!7,!P'1L!# 8i"ed - 'cre* *ere placed in nec pre&iously o 'cre*s *ere displaced *rong *ay

!&ascular necrosis of femoral head /hen can prognosticate after fracture of nec o !BN Li ely hood of !BN o Minimum of 6K months F ; years: before you can prognosticate after the head of the femur 3efore you can gi&e diagnosis 2a es sometimes for bone changes to sho* up

Patient *ith: - ,entral dislocation Hip fl"ed !bducted 4oes to*ard acetaubulum Posture of limb: *hen fracture nec of femur and dislocated head - 8racture nec : shortened e"ternally and abducted - 8le"ed+ shortened and e"ternally rotated fracture nec of femur postuer 9islocation: o 2o come out posteriorly: Hip must go adducted and internally rotated Position of modesty

:arly you reduce it+ the better it is

#eduction: - 9one under 4! o /HD- ! lot of spasm of muscle 9islocated morsque - 2he acetabulum - 'ubchondral bone destroyed - 9estroyed subchondral bone thin of infection o 'eptic arthtiris of hip after hip replacement Implant 7 loose+ ta en out - 9islocation of hip: complication o Hemi-arthroplasty or o 2otal hip replacement - ,auses of hip dislocation o /hen it dislocate !cute ,hronic o Patient factor More prone to dislocation (some patient?s) Muscle imbalance Hemiplegia 'tro e

o o

Par insonism 'urgeon factor Intra-5p :stablish mechanics of hip o Maintani correct tension o Maintain correct stresses If head+ or nec too short the li&er become narro* and loose Pull too tight painful Nec 2oo short loose Head too small 3et*een ;: choose 6 that is bigger+ because it is more stabl0e !nte&ersion of head Head is usually ante&erted o If put retro-&erted: can pop out easily !nother reason *hy Post-5p Poor muscle tone under 4! o 3efore patient a*a e+ eep legs *ide apart Put adduction pillo* 5nly *hen regains o 2hen put adduction pillo* Patient &ery restless #ehabilitation: Hip must be ept abducted at all times Not ad&iced to sit on floor+ squat+ get in and out of car+ get out (using bad leg first) 4et in: use good leg ,omes out :"treme o 8le"ion I JE o !dducted 9on?t cross leg o Internal rotation :n&iromental factor 2rauma

5blique &ie* of the pel&is - 4<o right and left - >-ray of pel&is !P o #ight face for*ard - 4ood to ascertain fracture of acetabulum o 6 side: see anterior column o 6 side: see posterior column 8racture of !nterior column - Normal

>-rays of nee > #ays of Cnee - Lateral - Medial - Patellar+ femoral compartment History of patient *hich compartment affected - !ffects o Physiotherapy o 'urgical therapy !nything that increases patellar-femoral pressure - /hene&er nee is fle"ed o 'quatting o 2ight hamstring o ,ontractures of bac of nee o Cnee fle"ed completely L squat position o Pain *hen getting up from sitting position+ to standing position Problem *ith squatting and impact e"ercises Doung man: problems *ith squat %ump - Medial o Pain usually on medial aspect of %oint space o Pain usually on *eight bearing 'tiffness in morning 4ets better *ith e"ercise :"cessi&e e"ercise to much pain - Lateral 'e&ere 5! of %oint o /hene&er: nees are painful '*ollen+ inflamed ,apsule !ll get fle"ion contracture *hen present: long period of time o Physiotherapy useful for stretching hamstring 'e&ereity of deformity o Mild o Moderate o 'e&ere Lateral compartment or collateral ligament starting to stretch out (on >-ray) Ligaments *ill stretch out Cnee *ill get: 8le"ure contracture Barus thrust ( nee buc les laterally) Posterior dislocation o 9islocated nee o 5&erlapping N5 articulation bet*een tibia and femur

o o

2here is o&erlap denotes dislocation o /hether anterior or posterior 9epending on *here tibial is In relation to fibula or *hole thing 9islocated nee High energy trauma !ssociated *ith significant in%ury o High neuro&ascular in%ury F <EG incidence /hy Popliteal space a lot of space Popliteal artery fi"ed on both ends 6 abo&e nee o 8emoral artery into hunter?s canal (pierces medial inter-muscular septum to go from front to bac ) 6 belo* nee o Popliteal artery trifurcates (6 in front of interossous membrane and anterior tibial+ 6 peroneal artery to the fibular+ 6 posterior tibial) ; anchor point *ith high energy displacement o ,omplete disruption of artery o Partial disruption of artery o Intimal tear ;4 F 4K hours later In%uries to niee !ll 4 ligaments o !,L o P,L o ; laterals ,artilages o Partillar 5steo-something fractures

Mids*ipe nee - Barus 7 5! - Bulgus 7 #! until pro&en other*ise - !l*ays e"amine *hen standing o /hen bear *eights accentuate deformity - Mids*ipe o If #!: 8ingers ha&e changes.s*ollen o #ic et?s: 'he *ill be short as *ell o !bnormal %oint: :"cessi&ely mobile %oint Neuropathic %oint 9iabetes 'yphillis Lump in #ight Leg - 2umour

o Ho* often is tumour in foot (&ery &ery &ery rare) !bscess o Medial aspect of 6st meta-tarsal 1sually tissue around area 7 not area as*ells first o 2ypically o&er dorsum: *hen s in is most la" Pain $ s*elling o&er first metatarsal %oint o 4outy arthritis o /ith gouty tophi 2ophi becomes so big that ulcerates 'ee center s in necrosis o 'lough o 'urrounding bandaged granulation tissue ' in o 2urned abit ' in abit dead o ! lot of s*elling /hite stuf8: o 2ophi

8oot >-#ay - ,harcot?s o >-ray

8oot >-ray.,linical :"am - 8orefoot o Normal - Midfoot o 2otally disorgani0ed 8racturse Pieces of bone 9islocated %oint 8racture M nec of metatarsal 8racture M tarsal-metatarsal %oint Lis-fran %oint - Hindfoot 6st+ ;nd+ Ard+ 4th+ <th - ;nd loc and ey %oint o ;nd acts li e a ey into the rest as a %oint Loc and ey acts as stability of %oint - 'pace bet*een each of tarsal bone 7 same o Parallel to tarsal bone Placed in same order o Loc and ey and alignment to tarsal bone

Mid-tarsal bone.%oint 7 normal - 8orefoot or tarsal-phalangeal %oint - Loo s more chronic and sclerotic - 9on?t see the tarsal bone etc

Infection o Infection of all the phalan"+ abit unusal Lac of bone o Bery unstable o ,ould be a charcot %oint

Punched out ulcer: reser&ed for patient *ith syphilis - Huge ulcer *ith dorsum of forefoot o 8rom ;nd F 4th - /ell demarcated o 'loughing of surgeon - :dges not raised+ but flat - :dges are fairly *ell demarcated o 3ase: granulation tissue 2endon e"posed *ill not heal Infection not continue Must e"cise the tendon Let the granulation tissue gro* - 'ome s*elling of soft tissue Ho* to tell if %oint s*ollen or not o ' in creases ,ellulitis treated: /rin ling of s in s*elling has gone done 3lister o If blister indication of compromised s*elling ' in supply comes from underlying muscle !bo&e muscle 7 deep fascia+ subcutaneous plane $ fat o 1nderlying muscles send blood to s in ! lot of s*elling: Plane bet*een subcutaneous $ deep fascia plane 7 compromised 3listers 7 *ith infection Necroti0ing fascilitis 2hat plane 7 in&ol&ed and that plane circulation in&ol&ed o Patient *ith fractures $ blisters in plaster cast ,ompartmental syndrome ,irculation is affected too o 'e&ere s*elling or compromised s*elling

Hands - Position 'tic out hand 9orsum faceing you Palmar facing you Normal cascade of hand o 8le"ion tone and e"tensor tone different

Loo out for Posture of hand Ner&e in%ury 9eformity of hand 2endon in%ury I=e= 6 finger dropped do*n only Lumps and bumps 'tart rom loo ing from top to bottom o Loo M lo*er arm+ *rist %oint+ carpal area+ meta-carpal area+ M,P@+ PIP@+ 9IP@ /rist %oint '*ollen or not o Locali0ed.diffused 'hould be able to see o #adial+ ulnar head o #adial tubercle o #adial styloid process In Picture '*elling of *rist %oint o Locali0ed: on dorsum of *rist 4anglion o 4enerali0ed: 2rauma Infection (usually 6 side) o 3ilateral #! Immunological chronic infection Metabolic etc M,P@ 7 s*ollen 'ome s*elling of *rist %oint both sides PIP@ of middle finger and inde" finger Multiple %oint s*elling Nodule o 9ifferentials #! 4out o

:lbo* - 5lecranon bursa o 'olid o 8luid Hand 7 multiple nodular s*ellings - PIP+ M,P@ $ /rist %oint Median ner&e - /asting of thenar muscles o Patient to close muscles #adial ner&e - /rist drop or finer drop

1lnar -

Ner&e ,la* /asting of 6st dorsal interossi ,la*ing of Hyper-e"tension of of M,P@ and fle"ion of PIP@

9#,1M! - ; ; types of ,la* - Normal cla* - Parado"ical hand o /asting of 6st dorsal interossi o Patient unable to !bduct o /hy cla* hand less ob&ious Normal posture *hen fle"or tone (all finger fle"ed) High ulnar lesion ,annot fle" - 2henar $ hypothenar muscle both hands o Possible: cer&ical spondyloosis Median ner&e to ulnar ner&e (,H+ ,N+ ,K+ 26) - Location o 3rain 'agiital aera o 'pinal cord 3oth sides of ner&e root: sphingomylitia o 9iabetes o Leprosy: hansen?s disease 'houlder - #ound+ not angular - 9islocated shoulder o !ble to see acromion (&ery sharp) o 1nable to abduct the shoulder o /asting of deltoid o /asting of supra-spinatus and infra-spinatus - Patient has brachial ple"us in%ury o Doung man brachial ple"us o 5ld man massi&e rotator cuff tear 'imple Lipoma of bac of head