Long Answer Questions
Q1. Pathogenesis and Management of Pott’s Spine
+A. Pott's spine
Pott’s spine, or tuberculosis of the spine, is the most common form of skeletal tuberculosis. The dorso-lumbar region is most frequently affected.
B. PATHOPHYSIOLOGY
Tuberculosis of the spine is always secondary. Bacilli reach the vertebral column via the haematogenous route from a primary focus (lungs or lymph nodes), primarily through Batson’s plexus—a valveless venous network connected to the abdominal visceral plexus.
Types of Vertebral Tuberculosis
- Paradiscal (most common): Involves adjacent vertebrae and the intervening disc.
- Central: Affects a single vertebral body; leads to collapse and wedging deformity.
- Anterior: Infection remains in the anterior body and spreads under the anterior longitudinal ligament.
- Posterior: Involves posterior structures—pedicle, lamina, spinous and transverse processes.
Mechanism of Destruction
- Granulomatous inflammation leads to erosion of vertebral margins and disc degeneration.
- Vertebral collapse causes angular kyphosis or gibbus, especially in the dorsal spine.
- Children show faster and more severe destruction due to weaker bones.
Cold Abscess Formation
- Collection of tubercular pus without classical inflammation.
- Tracks posteriorly (spinal canal), anteriorly (prevertebral), or laterally (paravertebral).
- May follow musculo-fascial planes to cause remote swellings.
Healing
- Lytic lesions are replaced by new bone and vertebral fusion.
- Resultant spinal deformities are permanent.
C. MANAGEMENT
Goals: (i) Disease healing, (ii) Prevention and management of complications like paraplegia.
1. Anti-Tubercular Chemotherapy (ATT)
- Mainstay of treatment—even effective with abscess or paraplegia.
2. Spine Care
Rest:
- Short-term bed rest for pain relief in early stages.
- Prolonged immobilisation if severe destruction is present.
- Supports: Minerva jacket or collar for cervical spine.
Mobilisation:
- Begins after symptom improvement.
- Supports:
- Cervical collar – cervical spine.
- ASH brace – dorso-lumbar spine.
- Brace discontinued after bony fusion. Strenuous activities avoided for 2 years.
3. Treatment of Cold Abscess
- Small abscesses: Resolve with ATT alone.
- Superficial abscesses:
- Aspiration: Done with thick needle via anti-gravity zig-zag tract to prevent sinus formation.
- Evacuation: Drainage, curettage of walls, and primary closure. Psoas abscess via extraperitoneal kidney incision.
4. Surgical Intervention
- Progressive neurological deficit.
- Severe spinal deformity.
- Non-responding abscesses.
5. MRC Trial Recommendations (1973–74)
- Bed rest not mandatory.
- Streptomycin not essential.
- POP jacket not beneficial.
- Debridement not routinely helpful.
Q.2 Describe supracondylar fracture humerus in children under clinical features, management and complications
+A. CLINICAL FEATURES
1. History
- Typically caused by a fall on an outstretched hand.
- Child presents with pain, swelling, deformity, and inability to move the elbow.
2. Examination
- Early presentation:
- Posterior prominence of olecranon due to distal fragment tilt.
- Three-point bony relationship is maintained.
- Late presentation:
- Swelling may obscure deformity.
- Assess for vascular injury – absent radial/ulnar pulses, signs of ischemia (5 P’s).
- Check for nerve injuries:
- Median nerve – pointing index.
- Radial nerve – wrist drop.
3. Radiological Features
- Anteroposterior (AP) view: Proximal shift, medial/lateral tilt, rotation of distal fragment.
- Lateral view: Posterior displacement/tilt and rotation of distal fragment.
B. MANAGEMENT
1. Undisplaced Fractures
- Immobilization with above-elbow slab at 90° flexion.
2. Displaced Fractures
Require hospital admission due to risk of early complications.
a) Closed Reduction and Percutaneous K-wire Fixation
- Most common method for displaced fractures.
- Reduction done with 30-40° elbow flexion and supinated forearm.
- K-wires inserted percutaneously under image guidance.
- Posterior slab applied for 3 weeks.
- Follow-up X-rays at 48 hours and 1 week.
b) Open Reduction and K-wire Fixation
- Indicated when closed reduction fails or fracture redisplaces.
- Also used for open fractures or brachial artery exploration.
c) Continuous Traction
- Used in late presentation with swelling or open wounds.
- Methods: Smith’s traction (K-wire through olecranon), Dunlop’s traction (skin traction).
- Rarely used in modern practice.
C. COMPLICATIONS
1. Immediate Complications
- Brachial artery injury:
- Compression or transection may lead to ischemia or gangrene.
- Requires vascular repair.
- Nerve injury:
- Median nerve most commonly affected.
- Usually recovers spontaneously.
2. Early Complications
- Volkmann’s Ischemia:
- Ischemia of forearm flexors due to brachial artery occlusion.
- Symptoms: Severe pain, stretch pain, inability to move fingers, tender forearm.
- Treatment:
- Remove tight bandages.
- Elevate limb, encourage finger movement.
- Fasciotomy if no improvement in 2 hours.
3. Late Complications
- Malunion:
- Results in cubitus varus (gunstock deformity).
- Treatment: Corrective supracondylar osteotomy if severe.
- Myositis Ossificans:
- Ectopic bone formation from aggressive physiotherapy or massage.
- Treatment: Rest and gentle mobilization; late cases may need excision.
- Volkmann’s Ischemic Contracture (VIC):
- Fibrosis of forearm muscles causing wrist/finger deformity.
- Treatment:
- Mild – Passive stretching and Volkmann’s splint.
- Moderate – Maxpage operation (soft tissue release).
- Severe – Bone surgery like carpal excision or forearm shortening.
Short Answer Questions
Q.1 Tardy Ulnar Nerve Palsy?
+A. Tardy ulnar nerve palsy
Tardy ulnar nerve palsy refers to a delayed onset of ulnar nerve dysfunction, often occurring months or years after an initial injury around the elbow. It is commonly seen in children with old lateral condyle fractures leading to cubitus valgus deformity.
B. CAUSE
- Old lateral condyle fractures (especially in children).
- Cubitus valgus deformity.
- Chronic stretching or compression of the ulnar nerve at the elbow (cubital tunnel).
- Rarely due to direct trauma to the ulnar nerve.
C. PATHOPHYSIOLOGY
- Progressive traction/stretching of the ulnar nerve due to valgus deformity of the elbow.
- Leads to nerve fibrosis, ischemia, and demyelination over time.
D. CLINICAL FEATURES
- Gradual onset of numbness or tingling in the ring and little fingers.
- Claw hand deformity (more prominent in ring and little fingers).
- Weakness in hand grip.
- Wasting of hypothenar muscles and interossei (especially first dorsal interosseous).
- Positive Froment’s sign (compensatory thumb flexion when pinching paper).
E. DIAGNOSIS
- Clinical Evaluation: Motor and sensory examination.
- NCS/EMG: To confirm and assess severity.
- X-rays: Elbow imaging to assess for cubitus valgus or old fractures.
F. TREATMENT
- Conservative (Mild Cases):
- Activity modification.
- Splinting and physiotherapy.
- Surgical (Advanced/Severe Cases):
- Ulnar nerve decompression (in situ or anterior transposition).
- Corrective osteotomy for cubitus valgus deformity.
- Neurolysis in cases with scar tissue involvement.
Q.2 Ortolani’s Test
+A. ORTOLANI’S TEST
This test is used to detect developmental dysplasia of the hip (DDH) in infants and is similar to the second part of Barlow’s test.
- Hips and knees are flexed.
- Gradual abduction of the hips is performed.
- A ‘click of entrance’ is felt when the dislocated femoral head re-enters the acetabulum.
B. FINDINGS IN AN OLDER CHILD
1. Physical Signs
- Limitation of hip abduction.
- Asymmetrical thigh folds.
- Higher buttock fold on the affected side.
2. Galeazzi’s Sign
- Hips flexed to 70°, knees flexed.
- The knee on the affected side appears lower.
3. Ortolani’s Test
- May still be positive in some older children.
4. Trendelenburg’s Test
- Performed in older children.
- The child stands on the affected leg.
- The opposite anterior superior iliac spine (ASIS) dips down.
5. Other Findings
- Shortening of the limb.
- Slight external rotation of the limb.
- Presence of lumbar lordosis.
6. Telescopy Test
- Positive in dislocated hips.
- Piston-like movement of the femur felt at the hip.
- Greater trochanter moves under the fingers.
7. Gait Abnormalities
- Unilateral dislocation: Trendelenburg gait with lurch toward the affected side.
- Bilateral dislocation: Waddling gait with alternate lurching.
Very Short Answer Questions
Q.1 Smith’s Fracture
+A. Smith's fracture
Smith’s fracture is an uncommon fracture of the distal radius, often considered the reverse of Colles’ fracture. It is more frequently seen in adults and the elderly.
It is clinically significant due to the need to differentiate it from Colles’ fracture, which involves the same anatomical site.
B. KEY DIFFERENCE FROM COLLES’ FRACTURE
- In Smith’s fracture, the distal fragment is displaced and tilted ventrally (anteriorly).
- In Colles’ fracture, the distal fragment is displaced dorsally (posteriorly).
C. TREATMENT
- Closed reduction followed by plaster cast immobilization for 6 weeks.
D. COMPLICATIONS
- Complications are similar to those seen in Colles’ fracture.
Q.2 Ewing’s Sarcoma
+A. Ewing's Sarcoma
Ewing’s sarcoma is a highly malignant bone tumour that typically affects individuals between 10–20 years of age, occasionally seen up to 30 years.
B. PATHOLOGY
1. Bones Affected
- Common in long bones (two-thirds of cases), especially femur and tibia.
- Flat bones (one-third): pelvis, calcaneum.
- May have a multicentric origin.
2. Site
- Most commonly arises in the diaphysis of long bones.
3. Gross Pathology
- Involves large areas or entire medullary cavity.
- Grey-white soft tissue, may resemble pus.
- Causes bone expansion, periosteal elevation, and subperiosteal new bone formation (layered).
- Early rupture of cortex with extension into soft tissues.
4. Histopathology
- Uniform small round cells resembling lymphocytes.
- Pseudo-rosettes may be seen (tumour cells around clear area).
- Spreads rapidly via bloodstream to lungs and other bones.
C. CLINICAL FEATURES
- Seen between 10–20 years of age.
- Pain and swelling are common.
- May follow trauma (usually incidental).
- Fever is often present, mimicking osteomyelitis.
On Examination
- Swelling over the diaphysis.
- Clinical features suggest malignancy.
D. RADIOLOGICAL FEATURES
Typical Presentation
- Lytic lesion in medullary zone of midshaft of a long bone.
- Cortical destruction and layered periosteal new bone formation (“onion-peel” appearance).
Atypical Presentation
- May involve metaphysis, resembling osteomyelitis.
- May present as a soft tissue mass with little bone involvement.
In Flat Bones
- Predominantly lytic with minimal new bone formation.
E. DIFFERENTIAL DIAGNOSIS
Distinguished from Chronic Osteomyelitis by:
- Absence of sequestrum.
- Lack of well-defined cloacae.
- Irregular periosteal reaction.
- Common diaphyseal location (vs metaphyseal in osteomyelitis).
F. TREATMENT
Ewing’s sarcoma is radiosensitive and initially responsive to therapy but has a high recurrence rate and frequent distant metastases.
1. Local Tumour Control
- Radiotherapy – 6000 rads.
2. Systemic Metastasis Control
Combination Chemotherapy:
- Vincristine
- Cyclophosphamide
- Adriamycin
Given in 3–4 week cycles for 12–18 cycles.
G. PROGNOSIS
- Poor prognosis due to early metastasis.
- 5-year survival has improved from 10% to 30–40% with combined chemotherapy.
Q.3 Rickets
+A. Rickets
Rickets is a disease of the growing skeleton, characterised by defective mineralisation of the growth plates. This results in softening of bones and skeletal deformities.
B. CAUSES
- Type I: Due to vitamin D deficiency or metabolic defect in its activation.
- Type II: Caused by extracellular phosphate deficiency due to:
- Defective tubular phosphate reabsorption.
- Reduced phosphate intake.
- Nutritional deficiency is the most common cause in developing countries due to poor socio-economic status.
C. CLINICAL FEATURES
Usually seen around 1 year of age but may occur in older children with malabsorption syndromes.
- Craniotabes: Soft skull bones with a ping-pong ball feel.
- Skull bossing: Frontal and parietal bone prominence (after 6 months).
- Broadening of long bone ends: Especially at wrist and knees (6–9 months).
- Delayed tooth eruption.
- Harrison’s sulcus: Horizontal depression at diaphragm insertion site.
- Pigeon chest: Prominent sternum.
- Rachitic rosary: Beading at costochondral junctions.
- Muscular hypotonia: Causes pot belly, visceroptosis, and lumbar lordosis.
- Deformities: Knock knees or bow legs after walking begins.
D. RADIOLOGICAL FEATURES
Best seen at distal radius and ulna; X-rays of wrists and knees (AP view) are screening tools.
- Delayed appearance of epiphyses.
- Widened epiphyseal plates: >2–4 mm due to uncalcified osteoid.
- Cupping of metaphysis: Absence of provisional calcification zone, irregular metaphyseal ends.
- Splaying of metaphysis: Due to pressure from accumulated cartilage cells.
- Rarefaction of diaphyseal cortex (late feature).
- Bone deformities in older children: Knock knees, bow legs, coxa vara.
E. OTHER INVESTIGATIONS
- Serum calcium: Normal or low
- Serum phosphate: Low
- Serum alkaline phosphatase: High
F. TREATMENT
1. Medical Treatment
- Vitamin D: 6,00,000 units orally as a single dose.
- Repeat X-rays in 3–4 weeks for healing line (sclerosis at metaphysis).
- If no healing line → repeat dose.
- If still unresponsive → refer to nephrologist/endocrinologist for refractory rickets.
- Maintenance dose: 400 I.U./day Vitamin D.
2. Orthopaedic Treatment
Aimed at correcting skeletal deformities.
a) Conservative Methods
- Mild deformities often correct after medical therapy.
- Mermaid splints or orthopaedic shoes may help knee deformities.
b) Operative Methods
- Moderate/severe deformities require surgical correction after 6 months of medical therapy.
- Corrective osteotomy is done depending on type of deformity.
Q.4 Non-union of Fracture
+A. Non-union of fracture
Non-union is a condition in which a fractured bone fails to unite even after an extended period, typically more than 6 months.
Characteristics:
- Persistent mobility at the fracture site.
- Chronic pain at the site of fracture.
- Absence of radiological evidence of healing.
B. TYPES OF NON-UNION
1. Atrophic Non-union
- Minimal or no callus formation.
- Due to poor biological activity at the fracture site.
2. Hypertrophic Non-union
- Abundant callus formation without bridging the fracture gap.
- Indicates good biological activity but inadequate mechanical stability.
C. COMMON SITES
- Neck of femur
- Scaphoid
- Distal tibia
- Lateral humeral condyle
D. TREATMENT
- Internal fixation: To provide mechanical stability.
- Bone grafting: To enhance biological healing at the fracture site.
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