45 year old female complaint of pain
and numbness of the right hand,
mainly at night and during working
Carpal tunnel syndrome
Causes
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Idiopathic
Obesity,
Oral contraceptives,
Hypothyroidism,
Arthritis,
Diabetes,.
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Trauma.
Lipoma ,
ganglion,
vascular malformation
Treatment
• Localized corticosteroid injections??????
• PT
• CT Release
Triggering thumb or finger
• Called stenosing tenosynovitis .
Idiopathic. Or Congenital
• Common disorder of later adulthood
characterized by catching, snapping or locking
of the involved finger flexor tendon,
associated with dysfunction and pain.
Treatment
• Cortisone injection
• A1 poly release (surgically)
1 month old baby girl referred to you
from LHC with hip click
Developmental dysplasia of the Hip
(DDH)
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Etiology / Epidemiology / Natural History
1/1000 live births, left hip most common
More common in children of central European .
Etiology: multifactorial, genetic, intrauterine
mechanical environment,
DDH Risk factors (five f's)
first born
female
family history
feet( breech position)
fluid(oligohydramnios )
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DDH Clinical Evaluation
Ortolani=out-reduces
Barlow=in-dislocates
Asymmetric gluteal folds
Galeazzi sign: apparent
femoral length discrepancy
when the legs are held
together with the hips and
knees flexed.
• Decreased hip abduction
• Ambulatory Patient: flexion
contracture, gluteus medius
lurch, toe walking, increased
lordosis if bilateral
DDH Associated Anomalies
Metatarsus adductus
Hyperextended knees / congenital
knee dislocation
Torticollis
Treatment
 Age 0-6 m=Pavlik
harness
 6m-18 m= adductors
tenotomy , hip Spica
 >18m OR and pelvic
osteotomy
< 5 month
>5 month
Osteomyelitis
• Acute, Sub acute, or Chronic.
• The mechanism :exogenous or
hematogeneus.
• Osteomyelitis :pyogenic or non pyogenic
• In infants, the infection can spread to the joint
and cause arthritis.
• In children, large sub periosteal abscesses can
form because of the periosteum is loosely
attached to the surface of the bone
Pathogenesis
• leukocytes enter the infected area, and, in their
attempt to engulf the infectious organisms,
release enzymes that lyse the bone.
• Pus spreads into the bone's blood vessels,
impairing their flow, and areas of devitalized
infected bone, known as sequestra,
• Often, the body will try to create new bone
around the area of necrosis. The resulting new
bone is often called an involucrum
Cause
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Age groupMost common organisms
Newborns (younger than 4 mo)S. aureus, Enterobacter
species, and group A and B Streptococcus species
Children (aged 4 mo to 4 y)S. aureus, group A
Streptococcus species, Haemophilus influenzae, and
Enterobacter species
Children, adolescents (aged 4 y to adult)S. aureus
(80%), group A Streptococcus species, H. influenzae,
and Enterobacter speciesAdultS. aureus and
occasionally Enterobacter or Streptococcus species
Sickle Cell Anemia Salmonella species
Osteomyelitis
• In adults, vertebrae and the pelvis.
• In children, affects the adjacent ends of long
bones.
• Fungus :The two most common are Blastomyces
dermatitidis and Coccidioide immitis.
• In osteomyelitis involving the vertebral bodies,
about half the cases are due to Staphylococcus
aureus, and the other half are due to tuberculosis
Pott's disease.
Symptoms of osteomyelitis
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Pain and/or tenderness
Swelling and warmth Fever
Nausea
General discomfort, uneasiness, or ill feeling
Sinuses
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Blood tests
Blood culture.
Needle aspiration
Biopsy:
Bone scan: Technetium-99 pyrophosphate
Treating and managing osteomyelitis
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Drainage
Medications:
Splinting or cast immobilization
Surgery:
Duchenne muscular dystrophy (DMD)
• Recessive X-linked form of muscular
dystrophy, which results in muscle
degeneration, difficulty walking, breathing,
and death.
• 1 in 3,600 -4000 boys.
• Females and males are affected, though
females are rarely affected and are more often
carriers.
• Caused by a mutation in the dystrophin gene,
• male children before age 5 and may be visible in early
infancy.
• Progressive proximal muscle weakness of the legs and
pelvis associated with a loss of muscle mass is observed
first. Eventually this weakness spreads to the arms, neck,
and other areas.
• pseudo hypertrophy (enlargement of calf and deltoid
muscles), low endurance.
• As the condition progresses, muscle tissue experiences
wasting and is eventually replaced by fat and fibrotic tissue
(fibrosis).
• By age 10, braces may be required to aid in walking but
most patients are wheelchair dependent by age 12.
• Cardiomyopathy (DCM) , congestive heart failure
or arrhythmias
• A positive Gower's' sign
• creatinine kinase (CPK-MM)
• An electromyography (EMG) shows destruction of
muscle tissue Genetic testing :genetic errors in
the Xp21 gene.
• A muscle biopsy or genetic test (blood test)
confirms the absence of dystrophin,
• DNA test.
DNA testing confirms the diagnosis in most
cases.
• Muscle biopsy
A small sample of muscle tissue is extracted
(usually with a scalpel instead of a needle) and a
dye is applied that reveals the presence of
dystrophin. Complete absence of the protein
indicates the condition.
• Prenatal tests
Treatment
• Comprehensive multi-disciplinary care
• Corticosteroids such as Prednisolone and
deflazacort increase energy and strength
• beta2-agonists increase muscle strength but do
not modify disease progression. .
• Physical therapy
• Orthopedic appliances (braces and wheelchairs)
• Appropriate respiratory support
55 years old female
Osteoarthritis
• Idiopathic, primary
• secondary.
• Osteoarthritis causes the formation of hard,
bony enlargements of the small joints of the
fingers Heberden's node,
• Another common bony knob (node) occurs at
the middle joint of the fingers a Bouchard's
node
•
• Osteoarthritis commonly affects the hands,
feet, spine, and large weight-bearing joints,
such as the hips and knees
• Crystal deposits in the cartilage can cause
cartilage degeneration and osteoarthritis.
• Uric acidcrystals cause arthritis in gout,
• Calcium pyrophosphate crystals cause
arthritis in pseudo gout
signs you should be aware of include:
• crepitus
• restricted movement or range of motion
• bony enlargement
• The symptoms include:
• persistent knee pain
• short-lived morning stiffness
• functional limitation
Management
• protect your joints (for
example, walking is
better for the joints
than running).
• diet and aerobic fitness
exercises
• Range of motion
Quadriceps strengthening
• Patellar taping
• Lateral heel wedges
• knee brace for valgus
deformity
• NSAID
• Intra articular
corticosteroids
• intra-articular
hyaluronic acid
• Arthroscopy
• Osteotomy
Replacement
5 year old child
Definitions
 Rickets : softening of bones in children due
to deficiency or impaired metabolism of
vitaminD, calcium or phosphorus, leading to
fractures and deformity.
 Predominant cause is vit. D deficiency.
Rachitic Changes
Head
craniotabes(soft skull)
frontal bossing
Widening of suture
persistent fontanelae
Delayed dentition &
caries
Rachitic Changes
Abdomen
 Prominent
muscle weakness
 Floppy baby, delayed walking
Pelvis
 Narrow inlet
Rachitic Changes
Widening of wrist, knee and ankle due to
physeal over growth
Rachitic Changes
Chest
Rachitic rosary
Harrison groove
Pigeon chest
Respiratory infection and
atelectasis
Rickets
• Vitamin D 1,25-OH helps
calcium and phosphorous
absorption from the intestine,
increases kidney reabsorption
of phosphorus, and it causes
calcium and phosphorus to be
released from the bone.
Increasing the concentrations
of calcium and phosphorus in
extracellular fluid causes
osteoid cells to calcify.
Parathyroid hormone
increases the 1-hydroxylation
step of vitamin D metabolism
and thereby helps regulate
calcium metabolism
• Ultraviolet light in the skin
changes cholesterol to Vitamin
D3 (i.e. cholecalciferol).
Vitamin D3 then is
hydroxylated in the liver to
make Vitamin D 25-OH (i.e.
calcidiol, the circulating
reserve metabolite). It then
undergoes hydroxylation again
in the kidney to Vitamin D
1,25-OH (i.e. calcitriol, the
active metabolite).
Management
Blood tests
Serum cacium
Serum alkaline phosphatase
Serum phosphorus
Bone x-ray
Other tests
ALP (alkaline phosphatase) isoenzyme
Calcium (ionized)
PTH
Urine calcium
Bone biopsy (rarely done)
Management
Target of therapy
Serum calcium : low - N
Serum alkaline phosphatse : high – N
Serum phosphorus : high – N
Management
Treatment
Vit-D deficiency state
Vit D 1,000 – 10,000 IU For 4 – 6 wks.
Vit D 300,000 IU For < 1yr of age.
Vit D 600,000 IU For > 1yr of age.
IM once OR 2 – 4 doses/day orally.
All protocols followed by 400 IU/day
Calcium 1g/day.
MCQ
1-Acute osteomyelitis is commonly caused by:
• a. Staph aureus.
• b. S. pyogenes.
• c. H. influenzae.
• d. Salmonella.
1-Acute osteomyelitis is commonly caused by:
• a. Staph aureus.
• b. S. pyogenes.
• c. H. influenzae.
• d. Salmonella.
2-Acute osteomyelitis usually begins at:
• a. Epiphysis.
• b. Metaphysis.
• c. Diaphysis.
• d. Any of the above
2-Acute osteomyelitis usually begins at:
• a. Epiphysis.
• b. Metaphysis.
• c. Diaphysis.
• d. Any of the above
3- What is not True of acute pyogenic
osteomyelitis:
• a. Trauma is a predisposing factor.
• b. Common infecting agent is Staph. Aureus.
• c. Infection is usually blood borne.
• d. All are true.
3- What is not True of acute pyogenic
osteomyelitis:
• a. Trauma is a predisposing factor.
• b. Common infecting agent is Staph. Aureus.
• c. Infection is usually blood borne.
• d. All are true.
4-Tuberculosis of the spine most likely
originates from:
• a. Intervertebral disk.
• b. Cancellous vertebral body.
• c. Ligamentous structures.
• d. Paravertebral soft tissue.
4-Tuberculosis of the spine most likely
originates from:
• a. Intervertebral disk.
• b. Cancellous vertebral body.
• c. Ligamentous structures.
• d. Paravertebral soft tissue.
5-The single most important factor in fracture
healing is:
• a. Correct bone alignment.
• b. Accurate reduction.
• c. Immobilization.
• d. Organization of clot.
5- The single most important factor in fracture
healing is:
• a. Correct bone alignment.
• b. Accurate reduction.
• c. Immobilization.
• d. Organization of clot.
6- If an unstable hip is detected at birth the
management policy is:
• a. Do nothing and re-examine every six months as
only minority of hips develop into a persistent
dislocation.
• b. Use a splint to keep the hip joint in 45° flexion
and adduction.
• c. Use a splint to keep the hip joint in 90° flexion
and abduction.
• d. Advise operative stabilization
6- If an unstable hip is detected at birth the
management policy is:
• a. Do nothing and re-examine every six months as
only minority of hips develop into a persistent
dislocation.
• b. Use a splint to keep the hip joint in 45° flexion
and adduction.
• c. Use a splint to keep the hip joint in 90° flexion
and abduction.
• d. Advise operative stabilization
7- Anterior dislocation of shoulder may be
complicated: By
• a. Brachial plexus injury.
• b. Tear of rotator cuff.
• c. Fracture head of humerus.
• d. All of the above
7- Anterior dislocation of shoulder may be
complicated by:
• a. Brachial plexus injury.
• b. Tear of rotator cuff.
• c. Fracture head of humerus.
• d. All of the above
8- The most common form of supracondylar
fracture humerus in children is of which type:
• a. Flexion.
• b. Extension.
• c. Combination of A & B
• d. None of the above
8-The most common form of supracondylar
fracture humerus in children is of which type:
• a. Flexion.
• b. Extension.
• c. Combination of A & B
• d. None of the above
9- What is True of Sudeck's atrophy of hand:
• a. Hand is painful and swollen.
• b. Osteoporosis of carpals and metacarpals.
• c. There is increased blood flow to paraarticular areas.
• d. Cervical sympathectomy may be of help.
• e. All are true
9- What is True of Sudeck's atrophy of hand:
• a. Hand is painful and swollen.
• b. Osteoporosis of carpals and metacarpals.
• c. There is increased blood flow to paraarticular areas.
• d. Cervical sympathectomy may be of help.
• e. All are true
10- Limb shortening with adduction and
internal rotation occurs in which type of hip
dislocation:
• a. Anterior.
• b. Posterior.
• c. Central.
• d. All of the above
10- Limb shortening with adduction and
internal rotation occurs in which type of hip
dislocation:
• a. Anterior.
• b. Posterior.
• c. Central.
• d. All of the above
11- Which of the following is not True of
intertrochanteric fracture of femur:
• a. Limb shortening.
• b. Malunion.
• c. Avascular necrosis of femoral head.
• d. Internal fixation is preferred
11- Which of the following is not True of
intertrochanteric fracture of femur:
• a. Limb shortening.
• b. Malunion.
• c. Avascular necrosis of femoral head.
• d. Internal fixation is preferred
12- Idiopathic scoliosis is a
• a. lateral curvature of the spine
• b. rotation of the spine
• c. lateral curvature with rotation of the spine
• d. flexion deformity of the spine
• e. congenital disease with hemivertebrae
12- Idiopathic scoliosis is a
• a. lateral curvature of the spine
• b. rotation of the spine
• c. lateral curvature with rotation of the spine
• d. flexion deformity of the spine
• e. congenital disease with hemivertebrae
13- A trigger finger is
• a. an inflamed index finger
• b. an atrophic index finger in a median nerve
palsy
• c. due to stenosing tenovaginitis affecting one of
the flexor tendons in the palm
• d. an essential feature of the carpal tunnel
syndrome
• e. a component of syndactyly
13- A trigger finger is
a. an inflamed index finger
b. an atrophic index finger in a median nerve palsy
c. due to stenosing tenovaginitis affecting one of
the flexor tendons in the palm
d. an essential feature of the carpal tunnel
syndrome
e. a component of syndactyly
14-The most severe growth disturbance results from which
of the following types of epiphyseal injuries:
• a. Separation of the epiphysis at the metaphyseal side of
the epiphyseal plate
• b. Separation of the epiphysis with a triangular fragment of
the metaphysic
• c. Intra-articular fracture involving the articular cartilage
epiphysis and epiphyseal plate
• d. Intra-articular fracture extending from the joint surface
through the epiphysis and epiphyseal plate to the
metaphysic
• e. Crashing injuries compressing the epiphyseal plate
without displacement
14-The most severe growth disturbance results from which
of the following types of epiphyseal injuries:
• a. Separation of the epiphysis at the metaphyseal side of
the epiphyseal plate
• b. Separation of the epiphysis with a triangular fragment of
the metaphysic
• c. Intra-articular fracture involving the articular cartilage
epiphysis and epiphyseal plate
• d. Intra-articular fracture extending from the joint surface
through the epiphysis and epiphyseal plate to the
metaphysic
• e. Crashing injuries compressing the epiphyseal plate
without displacement
15- Tears of the meniscus of the knee result
from which of the following strain:
• a. Hyperextension
• b. Abduction
• c. Adduction
• d. Rotation
• e. Combined flexion and rotation
15- Tears of the meniscus of the knee result
from which of the following strain:
• a. Hyperextension
• b. Abduction
• c. Adduction
• d. Rotation
• e. Combined flexion and rotation
16- In a football game, an athlete felt severe pain in his Rt
knee while turning to the left side with the joint flexed
and taking the body weight. Soon after, the joint became
swollen and painful but recovery followed rest for 3
weeks. Thereafter, the patient suffered from recurrent
locking with pain and a feeling of "giving way" in the joint.
The most probable diagnosis is:
• a. Solitary loose body
• b. Fracture of the tibial spine
• c. Rupture of the medial ligament
• d. Rupture of the medial semillunar cartilage
• e. Fracture of the patella
16-In a football game, an athlete felt severe pain in his Rt
knee while turning to the left side with the joint flexed
and taking the body weight. Soon after, the joint became
swollen and painful but recovery followed rest for 3
weeks. Thereafter, the patient suffered from recurrent
locking with pain and a feeling of "giving way" in the joint.
The most probable diagnosis is:
• a. Solitary loose body
• b. Fracture of the tibial spine
• c. Rupture of the medial ligament
• d. Rupture of the medial semillunar cartilage
• e. Fracture of the patella
17- The signs of fractured shaft of a bone do
not include:
• a. Swelling
• b. Deformity
• c. Loss of all movements in the limb
• d. Acute localized bone tenderness
• e. Abnormal mobility in the line of the bone
17- The signs of fractured shaft of a bone do
not include:
• a. Swelling
• b. Deformity
• c. Loss of all movements in the limb
• d. Acute localized bone tenderness
• e. Abnormal mobility in the line of the bone
18-What is the most common benign
soft-tissue tumour in adults?
1.
2.
3.
4.
Fibroma
Lipoma
Hemangioma
Schwannoma
18-What is the most common benign
soft-tissue tumour in adults?
1.
2.
3.
4.
Fibroma
Lipoma
Hemangioma
Schwannoma
19-What is the most common site of
metastasis for sarcomas?
A.
B.
C.
D.
liver
brain
Lung
skeleton
19-What is the most common site of
metastasis for sarcomas?
A.
B.
C.
D.
liver
brain
Lung
skeleton
20-Intestinal absorption of calcium is
dependent upon:
• a. Vitamin D
• b. Parathoraone
• c. Calcitonin
• d. All of the above
• e. None of the above
20-Intestinal absorption of calcium is
dependent upon:
• a. Vitamin D
• b. Parathoraone
• c. Calcitonin
• d. All of the above
• e. None of the above