21. Orthopaedics

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  ã Corrections in Maheshwari- ◦ M/C # at birth--> Clavicle ◦ Thurston Holland sign--> Salter harris type 2 ◦ M/C nerve injury in supracondylar # --> ▪ nt! interosseous nerve ▪ Median ▪ adial ▪ lnar ◦ Cast in CT$%--> bove &nee cast 28. Which of the following about facial bone fractures is not true- '!Ma(illary #)s are classi*ied into +e-*ort #s2!+e *ort ,, # which involves *loor o* the orbit is also called blow out # ------ans!Tear drop sign is a *eature o* blow-out *ractures.!Tripod # is the *ractures o* ygo0a1iscussion- 1hingra3 '4567low out # ã only orbit o* eye is involvednot 0a(illary bone6 ã Tear drop sign8- ay *inding6--> (9 Caldwell luc S( 46.Hypophosphatemic rickets: all are true except- '!Secondary hyperparathyroidis0-----ans2!1e*ect in :CT o* &idneys!;o achitic rosary.!8 - lin&ed do0inant1iscussion-hypophosphete0ia-->dentin part is e**ected ã Synovial *luid e(erts an inhibitory e**ect on bone union by dissolving the callus! ã 7rittain<s procedure 9 e(traarticular arthrodesis o* hip joint usually per*or0ed *or tuberculosis o* the hip joint! This involves sub-trochanteric osteoto0y and place0ent o* a tibial cortical gra*t across the osteoto0y site into the ischiu0= and then application o* a hip spica! ,nternal *i(ation is not used! ã unlop!s traction  is used in--> supracondylar *racture hu0erous ã 7owler<s thu0b - perineural *ibrosis due to repeatative co0pression o* digital nerve o* the thu0b while grasping ball! ã ompartment syn#rome - Most co00only a/w supracondylar *racture o* the hu0erous and tibial sha*t! +ac& o* pulse rarely occurs in patients= as pressures that cause co0part0ent syndro0e are o*ten well below arterial pressures and pulse is only a**ected i* the relevant artery is contained within the a**ected co0part0ent ã $olkman!s sign - ,t is possible to e(tend the *ingers only when wrist is *le(ed :-?5 Maheshwari6 ã M/C site o* injury in swi00ers- shoulder ã $(cision o* head o* the radius in children- :ro(i0l 0igration o* the radius resulting in sublu(ation o* the in*erior radio-ulnar joint and instability! ã %ump sign - tenderness with withdrawal grading used in so*t tissue tenderness6 ã &ulge sign - Seen in &nee e**usion also called ballot0ent o* patellae6 ã @anavel<s *our cardinal signs *or tenosynovitis-'!Ainger is uni*or0ly swollen2!Ainger held in slight *le(ion *or co0*ort!Course o* in*la0ed sheath is 0ar&edly tender.!:assive *inger e(tension causes intense pain Highly sensitive *or *le(or tendon in*ection6@anavel<s sign does not include high te0peratre though it 0ay be present! ã ;ight cries are characteristic o*--> Tubercular arthritis ã cro-osteolysis seen in S+$! ã +i0ping in a Child!!!!  0ost co00on cause and they occur in  di**erent age groups!!!!  ◦ Congenital hip dysplasia - B- years= 1( by rtolani test and ltrasound!!!!!!! ◦ +egg-:erthes - .-? years= avascular necrosis o* *e0oral head !!!painless initially!!!! later pain appear!!!!:ain 0ay be re*erred to &nee!!!!!! ◦ Slipped capital *e0oral epiphysis - >'' years obese adolescent= thin& de*icient gonads  ndrogens causes closure o* epiphysis 6 :ain 0ay be re*erred to &nee!!!!!! ã To0 s0ith arthritis o* hip joint is d/t9 :yogenic in*ection ã The only di**erence b/n endochondral and intra0e0branous ossi*ication is the  microen'ironment  in which bone *or0ation occurs! The bones *or0ed can not be distinguished 0icroscopically or 0acroscopically! ▪ ,ntra0e0branous ossi*ication - ,n *lat bones o* the s&ull= bone *or0ation occurs through the di**erentiation o* osteoprogenitor cells *ro0 0esoder0 and is acco0panied by vascularisation ▪ $ndochondral ossi*ication - steoprogenitor cells di**erentiate into chondrocytes and establish a cartilage 0odel o* long bones which is used as a sca**olding *or bone *or0ation! ã (soriatic arthropathy - ◦ :resentation is li&e a polyarthritis but with distal ,: joints o* hands involved6 ◦ Classic s&in lesions ◦ adiography- 1,: involve0ent= including the classic D pencil-in-cup D de*or0ityE 0arginal erosions with adjacent bony proli*eration Dwhis&eringD6E s0all-joint an&ylosisE osteolysis o* phalangeal and 0etacarpal bone= with telescoping o* digitsE and periostitis and proli*erative new bone at sites o* enthesitis! There is cup-li&e erosions and bony proli*eration with e(pansion at the base o* the ter0inal phalanges and tapering o* the pro(i0al phalanges! ◦ (9 Steroids ã )harpey!s fibres   bone fibres = or perforating fibres 6 are a 0atri( o* connective tissue consisting o* bundles o* strong collagenous *ibres connecting periosteu0 to bone ! ã 11H- M/C in girls= on le*t side= breech presentation0ore in e(tended breech6= *irst born child = CS ã *li+aro's techni,ue principle - osteogenesis reFuires dyna0ic state--> either a controlled distraction or a controlled co0pression ã G,;T ,;%+%$M$;T ,; ;$ +,C 1,S 1$ S ◦ SI ,;MI$+, a**ects upper li0bs jts- glenohu0eral jt= elbow and wrist ◦ T7$S 1 S+,S a**ects lower li0b jts- &nee= hip and an&le ◦ 1,7$T$S M$++,TS a**ects Tarsal and Tarso 0etatarsal joint! ã ,;1,CT,;S A :$; $1CT,;  $ D; CSTD 9 ◦ ;on union ◦ pen *racture ◦ Co0pro0ise in neurovascular structures ◦ rticular *racture ◦ Salter harris ,,, ,% % ◦ Trau0a ã ustilo an# n#erson classification of open fractures ã Type ,9 clean wound s0aller than ' c0 in dia0eter= appears clean= si0ple *racture pattern= no s&in crushing! ã Type ,,9 a laceration larger than ' c0 but without signi*icant so*t tissue crushing= including no *laps= degloving= or contusion! Aracture pattern 0ay be 0ore co0ple(! ã Type ,,,9 an open seg0ental *racture or a single *racture with e(tensive so*t tissue injury! lso included are injuries older than ? hours! Type ,,, injuries are subdivided into three types9 ã Type ,,,9 adeFuate so*t tissue coverage o* the *racture despite high energy trau0a or e(tensive laceration or s&in *laps! ã Type ,,,79 inadeFuate so*t tissue coverage with periosteal stripping! So*t tissue reconstruction is necessary! ã Type ,,,C9 any open *racture that is associated with vascular injury that reFuires repair!Major advantage o* open redction is shorter period o* i00obilisation! He0ato0as at the site o* *racture 0ay be i0portant *or early healingE open reduction which generally involves re0oving the clots in the *ield= could contribute  to a delay in bone healing and to non-union! ã Goint disease with synovial *luid having nor0al to slightly elevated neutrophil count and nor0al 0ucin clot study-->steoarthritis and neuropathic arthropathy are the two nonin*la00atory joint diseases! ,n*la00atory joint diseases have high neutrophil count and poor 0ucin clot test6 ã Third degree sprain- o omplete  tear o* liga0ent o *ten the pain is minimal o He0arthrosis is noticed within 2 hours o Goint will open upi* liga0ent is stressed o eFuires surgical repair ã M/C involved 0uscle in %,C--> *le(or pollicis longus=*le(or digitoru0 pro*undus ã Aracture o* lateral condyle o* hu0erous is a type ,% epiphysial injury= accurate reduction is i0portant i* nor0al growth o* the elbow is to be e(pected= and it is treated by  ,A usig two @-Jires ã $arliest diagnosis o* acute osteo0yelitis--> 7one scanit shows increased blood *low to the bone at the site o* in*ection! ã Sub-0etaphyseal translucency is the classic radiologic *inding in child with leu&ae0ia! ã nkylosing spo#ylitis- o Seronegativenegative rheu0atoid *actor6 o H+ 7-24 positive o ,nvolves pri0arily young 0an between '5-B yrs o C/A-  ,nsidious onset o* 0orning sti**ness in lower bac& that persists *or >0ths and i0proves as day progresses or with e(ercise  Sclerotic changes in the sacroiliac area are the *irst radiographic evidence o* disease! :atients have di0inished anterior *le(ion o* the spine= which is docu0ented with the )chober test 0easure the ability o* a patient to *le( his/her lower bac&6! $ventually the vertebral colu0n *uses to produce the classic bamboo spine/ o Seru0 ; is negative because it is not a collagen vascular disease or a variant o* rheu0atoid arthritis!:atric& test- done *or sacroilitis!!!!!!! ã %arious tests- o 0inkelsein test/--1  chronic stenosing tenosynovitis de Kuervain)s test6 o  currey test--1  evaluation o* &nee *or meniscal  tears o 3rtolani test--1  evaluates newborns *or congenital hip dislocation ã ite5s angle:  > 5 degree reduced in CT$%6 o @ite inde(- Telocalcaneal angles in : and +ateral views ã &ohler5s angle--1 educed in 0ost # o* calcaneu0 o angle b/n talus and calcaneu0 o ;--> 5 degree ã &or#en!s 'iew--1 diagnosis o* Calcaneal *ractures! ã 3bli,ue popliteal ligament  is e(tra-articular in &nee joint! ã ,liac crest are the co00onest site *or ta&ing bone gra*ts! o Jhen the gra*t is reFuired *or osteogenic  purposeas in non-union6= cancellous  bone gra*ts are pre*erred! ,t is available in plenty *ro0 iliac crests and upper end o* tibia! o Jhen gra*t is used *or providing stabilityas *or *illing bone gaps6= cortical gra*t is used! Aibulae are the co00on source o* cortical bone gra*ts! ã Aracture o* the clavicle- o Co00on *racture o* all the age groups o Co00on site is junction o* 0iddle L outer thir# o uter *rag0ent displaces me#ially an# #ownwar#s  because o* the gravity and pull by the pectoralis 0ajor 0uscle attached to it  o Shoulder sti**ness is a co00on co0plication ã vascular necrosis a*ter trau0a is seen in- o Head o* *e0ur o :ro(i0al pole o* scaphoid o 7ody o* talus o :ro(i0al pole o* lunate &asic science an# anatomy-. alcium ion transport me#iate# by- '!steoblast2!steocyte---------------ans!steoclast.!ll1iscussion- ã 3steoblasts- ▪ :rinciple bone *ro0ing cell! steoblasts are 0odi*ied *ibroblasts! ▪ ich in al&! :hosphate! ▪ ;or0al osteoblasts are able to lay down type-' collagen and *or0 new bone! ▪ Aor0 ru**led borders ã 3steocyte - ▪ Spent osteoblast ▪ ole in osteolysis 0ain role--> though all are involved6 ▪ ,nvolved in Ca and other 0ineral transport ã 3steoclasts- ▪ steoclasts= on the other hand= are 0e0bers o* the 0onocyte *a0ily! ▪ ich in T : Tartarate resistant acid phophate6 ▪ 7one resoption ▪ +ie on houship lacune ▪ u**led borders e(ist on osteoclast 2. ells in howships lacunae- '!steoblast2!steocyte!steoclast--------------ans.!ll 7. uyons canal is for '!Median nerve2!lnar nerve---------------ans! adial nerve.!:,;1iscussion- ã uyton<s canal- ◦ Content- wrist--> ulnar nerve= ulnar artery ◦ Medially--> pisi*or0 and ha00ate *or0 the boundryHandlebar palsy- lnar nerve co0pressed 4. er#ys tubercle is- '!ttach0ent o* iliotibial band---------------------ans2!nterior aspect o* lower end *e0ur!:osterior aspect tibia .!Medial aspect tibia1iscussion-
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