List of long cases:

1. PLID
2. Knee instability
3. TB hip
4. TB spine
5. Shoulder dislocation
6. GCT
7. Osteosarcoma
8. Ewing’s sarcoma
9. Metastatic tumours
10.Perthes/ AVN
11.CP
12.Poliomyelitis
13.ACL injury
14.VIC
15.Habitual dislocation of patella
16.Ankylosing spondylitis
17.Chronic osteomyelitis
18.Nonunion
19.Scoliosis

PLID

Mr hamidul, 45 yrs businessman from chandpur, admitted in nitor on

3.3.15 with the complaints of

a.LBP for 1 yr

b. Difficulty in walking for the same duration

c. Tingling, Numbness of Rt lower limb for the same duration

History of present illness: according to the statement of the

patient, he was relatively well 01 yr back. Then he developed low back
pain. The pain initiated during weight lifting. Initial 3-5 days pain was
severe in nature and gradually pain radiate to gluteal region,
posterolateral thigh, leg and dorsum of foot. Pain aggravated by
sneezing, coughing and straining and pain relieved by taking rest in
lying position and analgesic. He also developed difficulty in walking for
last 01 yr. moreover, he developed tingling, numbness of lt lower limb
for the same duration. His symptoms are worsening day by day.

He had no history of wt loss, anorexia, heamoptysis, cough, chest pain

or evening rise of temperature.

He is normotensive, non asthmatic and non diabetic.

His bowel and bladder habit is normal.

History of past illness:NS

Family history: NS

Socioeconomic history: low

Allergic history: NS

Immunization history: immunized as per EPI schedule

On examination:

General exam:

Pulse-72b/min

BP-120/70 mm of Hg

Temp-normal

Anaemia-absent

Local exam:
look from the front-

shoulder drooping(axillary type-same side, in shoulder type-opposite

side)

muscle wasting present in lt thigh

patient can walk heel with difficulty

gait
look from the side: lumber lordosis

look from back: list of lt side

no scar mark

slight gluteal muscle wasting

squatting possible

gait-antalgic

pelvic tilting-lt

 Feel:

 Mild tenderness at lower lumber region

 No stepping is present

 No wasting of back muscles

 Move

 Heel walking : not possible

 Toe walking: possible

 Sensory: paresthesia at L4, L5, S1 dermatome

 Motor: EHL(MRC-3/5)Rt

 FHL(MRC-5/5)Rt

 Jerk: ankle jerk-normal

 knee jerk-normal

 Special test

 SLR: Right-70o

Left -90o
Cross SLR: (-)ve

Bowstring test: +ve

Fazerstazan test:+ve

Lasegue test:+ve

Sicard’s test:+ve

KNEE INSTABILITY

Mr hamidul, 45 yrs businessman from chandpur, admitted in nitor on

3.3.15 with the complaints of

a. Giving away of right knee and feeling of insecurity while walking for
01 yr

History of present illness: according to the statement of the

patient, he was relatively well 01 yr back. He gave history of twisting
injury during playing football and heard a pop sound. He could not
continue the game and with the help of other people he was sent to
local clinic. He noticed swelling at his right knee immediately after the
injury. There is no problem on climbing stairs and no history of locking
of right knee.

On examination

Look from the front:

Quadriceps wasting

Gait normal

Feel:

Local temp-normal

Tenderness-joint line absent

Wasting

Neurovascular status-normal

Move:

Knee flexion-

Extension-

Special test:

Stand on one leg:

Test for hyperextension:

Varus-valgus stress test: at 300 flexion(isolated tear of collateral
ligament)

and knee straight(capsule, collateral and cruciate ligament)

Anteroposterior stability: knee 900 look from the side-posterior sag

Anterior drawer test

ADT with 150 external rotation

ADT with 300 internal rotation

Posterior drawer test

Lachman test

Mc murrey’st test

Thessaly test

Pivot shift test

MENISCUS INJURY
Mr hamidul, 25 yrs businessman from chandpur, admitted in nitor on
3.3.15 with the complaints of
a. pain in left knee for 01 yr

History of present illness: according to the statement of the

patient, he was relatively well 01 yr back. He gave history of twisting
injury during playing football. Knee swelling appeared after 12 hr. with
rest his symptoms subsided. Occasionally his knee locks for last 08
months.

On examination

Look from the front:

Quadriceps wasting

Gait normal

Feel:

Local temp-normal

Tenderness-joint line present

Wasting

Neurovascular status-normal

Move:

Knee flexion-full

Extension-slightly limited

Special test:

Knee effusion-+ve
Varus-valgus stress test: at 300 flexion(isolated tear of collateral
ligament)

and knee straight(capsule, collateral and cruciate ligament)

Anteroposterior stability: knee 900 look from the side-posterior sag

Anterior drawer test

ADT with 150 external rotation

ADT with 300 internal rotation

Posterior drawer test

Lachman test

Mc murrey’st test +ve

Apley’s grinding test+ve

Thessaly test+ve

Pivot shift test

TB HIP

Mr hamidul, 45 yrs businessman from chandpur, admitted in nitor on

3.3.15 with the complaints of

a.Pain in right hip for 01 yr

b. Difficulty in walking for the same duration

history of present illness: according to the statement of the patient

he developed pain in his rt hip for 01 yr and he faces difficulty in
walking for the same duration. Pain is insidious in onset with aching in
groin and thigh, continuous, dull aching and increased at night, which
make him awake from sleep. It is aggravated by movement but
relieved with analgesic. He also complains of limping for last 01 yr. He
has history of evening rise of temperature, night sweat and wt loss.

On examination:

Hip is flexed, adducted and internally rotated.

Muscle wasting present

Hip movement-all movement are restricted.

x ray:
general rarefaction but normal joint line and space

femoral epiphysis may be enlarged

bone abscess may be visible

destruction of acetabular roof-wandering acetabulum

destruction of femoral head

destruction of both(usually)

joint may be subluxed or even dislocated

with healing bones recalcify

TB spine:

Mr hamidul, 45 yrs businessman from chandpur, admitted in nitor on

3.3.15 with the complaints of

a. back pain for 01 yr and generalized weakness for 01 yr

b. Difficulty in walking for 06 months

history of present illness: according to the statement of the patient

he developed back pain for 01 yr and he faces difficulty in walking for
the same duration. Pain is insidious in onset with continuous, dull
aching and increased at night, which make him awake from sleep. It is
aggravated by movement but relieved with analgesic. He also
complains of abnormal sensation and weakness in his both lower limb
for last 01 yr. He has history of evening rise of temperature, night
sweat and wt loss.

On examination:

Look: patient cant stand comfortably

Gait: clumsy

He can squat

Feel:

SLR: normal
Sensory: diminished from L2 level

Motor: all muscle of lower limb weak: mrc-3/5

Tone- increased

Jerks-exaggerated

Clonus-present

Pump handle test

Hip movement

Move: movement of spine is normal

x ray:

early:

local osteoporosis of two adjacent vertebrae and narrowing of intervertebral

disc, fuzziness of the end plate.

Progressive: sign of bone destruction and collapse of adjacent vertebral

bodies. Paraspinal soft tissue shadow

Chest x ray.

MRI

CT scan

Mantoux test

ESR

FNAC

d/d:

pyogenic infection

malignant disease

parasitic infection

RECURRENT SHOULDER DISLOCATION

Mr hamidul, 25 yrs businessman from chandpur, admitted in nitor on
3.3.15 with the complaints of

a. dislocation of rt shoulder during overhead activities for 5 times in

last 03 months

history of present illness: according to the statement of the patient

he developed recurrant dislocation of rt shoulder for last 05 yrs. In last
yr his shoulder dislocated for 05 times during overhead activities. 05
yrs back his shoulder dislocated during playing and fall on ground. It
was painful and reduced by an orthopaedic surgeon. He immobilized
his shoulder for only 01 wk.

On examination:

shoulder

Look: normal

Feel: deltoid wasting 1 cm

Local temp-normal

Tenderness-normal

Move: movement of shoulder is normal

Special test: apprehension test-+ve

Fulcrum test:apley 355

Drawer test:apley 355

x ray:

Hill sachs lesion-AP view with abduction and internal rotation

MRI

GCT RADIUS
Mr hamidul, 25 yrs businessman from chandpur, admitted in nitor on
3.3.15 with the complaints of

a. pain and swelling around his rt wrist for 02 months

history of present illness: according to the statement of the patient

he developed pain and swelling around his right wrist for 02 months

On examination:

Wrist

Look: swollen, mass 3x3 cm

Feel:

Local temp-raised

Tenderness-absent

Palpable mass 3x3 cm, surface smooth, margin ill defined, bony hard in
consistency, free from skin, fixed with bone.

Move: movement of wrist is normal

x ray:

radiolucent area located eccentrically bounded by subchondral bone plate

soap bubble appearance

cortex thin

MRI

OSTEOSARCOMA –thik korte hobeapley 207

Mr hamidul, 25 yrs businessman from chandpur, admitted in nitor on
3.3.15 with the complaints of

a. pain and swelling around his rt knee for 02 months

 b. fever, anorexia and wt loss for the same duration

history of present illness: according to the statement of the patient

he developed pain and swelling around his right knee for 02 months.
Pain is continuous, severe increased in night, aggravated by movement
and relieved with medication. Swelling is rapidly increasing. Moreover
he developed fever, anorexia and wt loss for last 02 months.

On examination:

Wrist

Look: swollen, mass 3x3 cm

Feel:

Local temp-raised

Tenderness-absent

Palpable mass 3x3 cm, surface smooth, margin ill defined, bony hard in
consistency, free from skin, fixed with bone.

Move: movement of wrist is normal

x ray:

radiolucent area located eccentrically bounded by subchondral bone plate

soap bubble appearance

cortex thin

MRI

HABITUAL DISLOCATION OF PATELLA

PARTICULARS OF THE PATIENT

Name-Abdul Jalil
Age- 30 yrs
Sex-male
Occupation-Medical asst
Address-Netrokona
Date of admission-28-08-15
Date of examination-08-09-15

CHIEF COMPLAINTS:
a. displacement of right knee cap when he flexes his
knee and it relocates automatically since his
childhood.

HISTORY OF PRESENT ILLNESS: according to

the statement of the patient his right patella displaces
every time when he flexes his knee and it relocates
automatically since his childhood. He has no definite
history of trauma. There is no pain when he flexes his
knee.
HISTORY OF PAST ILLNESS: nothing significant
TREATMENT HISTORY: nothing significant
FAMILY HISTORY: none of his family member
suffered from this type of illness.
PERSONAL HISTORY: nonsmoker, non alcoholic.

ON EXAMINATION:
General examination-
Body built- average. Anaemia-
Decubitus –on choice
Nutritional status- average Cyanosis –
Pulse-72 beat/min Jaundice-
NAD
BP-120/80 mm of Hg Oedema-
Temp-normal Lymph Node-
Heart/lung-NAD Dehydration-
Local examination:
Rt knee

Look:
Patella is laterally placed.
Genu recurvatum-absent
Genu valgus-absent
Quadriceps wasting-present
Gait-normal
Squat-possible, in this position patella is
displaced more laterally

Feel:
Local temp-normal
Tenderness-absent
Patellofemoral joint-normal
Apprehension test-negative.
Q angle-70
Patellar tracking test-+ve
Patellar grinding test-negative
Patellar tilt test-negative.
Features of ligament laxity-absent
Quadriceps wasting-present 7 cm at 18 cm
above joint line on right side
Contracture of quadriceps-absent
Tibial torsion-absent.

Move:
Rt knee-
Flexion-1400
Extension-00
Lt knee-normal
Other systemic examination-NAD
SALIENT FEATURE
Abdul Jalil,30 yrs of age Med Asst, from
Netrokona admitted in Nitor with the
complaints of displacement of right knee cap when he
flexes his knee and it relocates automatically since his
childhood. He has no definite history of trauma. There is
no pain when he flexes his right knee. Patella is laterally
displaced. . There is no genu valgus. Q angle is 70.
Patellar tracking test is positive. Patellar grinding test is
positive. Tibial torsion is absent. Ligamentous laxity is
absent. Knee movement is normal.

Provisional diagnosis-
Habitual dislocation of Patella

Differential diagnosis
Congenital dislocation of patella
Recurrent dislocation of patella

Investigation
X ray both knee joint-AP. Lateral and Skyline
view
Other routine investigation

Ankylosing spondylitis
PARTICULARS OF THE PATIENT
Name-Sumon
Age- 20 yrs
Sex-male
Occupation-unemployed
Address-Jhalokathi
Date of admission-07-09-15
Date of examination-08-09-15

CHIEF COMPLAINTS:
a. Pain in both hip for 01 yr and difficulty in walking
for the same duration.
b. Inability to stand straight for last 08 months.
HISTORY OF PRESENT ILLNESS: according to
the statement of the patient, he was reasonably well 01 yr
back. Then he developed pain at his both hip more in the
right for last 01 yr. Pain is constant dull aching,
aggravated by walking and relieved by taking rest. He
also complains of inability to stand straight for last 08
months. Moreover, he complains of anorexia, weight loss
and occasional rise of temperature for last 01 yr. He has
no history of cough, haemoptysis or contact with a TB
patient.
HISTORY OF PAST ILLNESS: nothing significant
TREATMENT HISTORY: he took anti TB for 06
months which was stopped 03 months back. Now he is
taking salazine for last 03 months and his condition
improved.
FAMILY HISTORY: none of his family member
suffered from this type of illness.
PERSONAL HISTORY: he was smoker but stopped
after the disease, non alcoholic.
IMMUNIZATION HISTORY: immunized as per EPI
schedule.
ON EXAMINATION:
General examination-
Body built- average. Anaemia-mild
Nutritional status- poor Cyanosis –
Pulse-72 beat/min Jaundice-
NAD
BP-120/80 mm of Hg Oedema-
Temp-normal Lymph Node-
Heart/lung-NAD Dehydration-
Local examination:
Look:
Patient can’t stand straight.
Spine is bowed.
He can’t walk without support.
Wasting of both gluteal muscles and both
thigh muscles
He can’t squat
Feel:
Local temp-normal at both hip region
Tenderness-absent
Thomas test-bil FFD 300, further flexion upto
700
LLD-nil
Lumber spine excursion-3 cm
Wall test-positive
Ceiling test-negative
Chest expansion-2 cm

Move:
Right hip Left hip
Flexion 300-700 300-700
Adduction 00 00
Abduction 00 00
External 00 50
rotation
Internal 00 50
rotation

Pump handle test-positive bilaterally

Other systemic examination-NAD
SALIENT FEATURE
Sumon ,20 yrs of age from Jhalokathi
admitted in Nitor on 07.09.15 with the
complaints of pain in both hip for 01 yr. Pain is
dull aching, aggravated by walking and relieved after
taking rest. Occasionally pain is associated with mild rise
of temperature. Moreover, he complains of inability to
stand straight for last 08 months. He was treated with
antitubercular for 06 months but he was not improved.
Now he is taking salazin for last 02 months and his pain
decreased but deformity persisted. He has anorexia and
weight loss but no history of cough, haemoptysis or night
sweat. None of his family member suffered from this sort
of illness. He is of poor nutritional status. His vital
parameters are within normal limit. He can’t stand
straight. There is kyphosis. He can’t walk without
support. His thigh and gluteal muscles are wasted. He
can’t squat. Thomas test is positive and bil FFD is 300.
Further flexion is upto 700. All other movements are
severely restricted. LLD is nil. Chest expansion is 2 cm.
lumber excursion is restricted. Wall test is positive. Pump
handle test is positive.
Provisional diagnosis-
Ankylosing spondylitis involving both
hip, spine and SI joint

Differential diagnosis
TB hip
Rheumatoid arthritis

Investigation
CBC
CRP
ESR
HLAB27
RA test
MT
CXR
Sputum for AFB
X ray pelvis A/P view including both hip joint
X ray lumbo sacral spine A/P and lateral view
Xray dorsolumbar spine A/P and lateral view