MPMSU orthopaedics 2023 question paper with their answers

Pott’s spine, or tuberculosis of the spine, is the most common form of skeletal tuberculosis. The dorso-lumbar region is the most frequently affected part of the vertebral column.

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Pathophysiology:

Tuberculosis of the spine is always secondary, the causative bacilli reaching the vertebral column via the haematogenous route from a primary focus in the lungs or lymph nodes. Spread occurs predominantly through Batson’s plexus, a valveless paravertebral venous network communicating freely with the visceral plexus of the abdomen, a common site of tuberculosis.

Types of Vertebral Tuberculosis:

1. Paradiscal (most common): Involves the contiguous areas of two adjacent vertebrae and the intervening disc.
2. Central: Affects the body of a single vertebra leading to its collapse, resulting in wedging or concertina deformity.
3. Anterior: Infection remains confined to the anterior part of the vertebral body and spreads beneath the anterior longitudinal ligament.
4. Posterior: Involves the posterior complex—pedicle, lamina, spinous and transverse processes.

Mechanism of Destruction:
Granulomatous inflammation causes erosion of vertebral margins and compromises disc nutrition, leading to degeneration and destruction.
Collapse of weakened vertebrae, especially in the dorsal region, results in angular kyphosis or gibbus deformity.
In children, destruction is more rapid and severe due to the relatively weaker bone structure.

Cold Abscess Formation:
A cold abscess is a collection of tubercular pus without classical signs of inflammation.
Pus may track in multiple directions—posteriorly into the spinal canal (risking neural compression), anteriorly (prevertebral abscess), or laterally (paravertebral abscess).
Tracking along musculo-fascial planes may cause remote swelling.

Healing:
Lytic areas are replaced by new bone, with bony fusion between adjacent vertebrae.
Deformities, once formed, are permanent.

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Management:
The treatment aims to:
(i) achieve healing of the disease, and
(ii) prevent, detect, and manage complications, such as paraplegia.

1. Anti-Tubercular Chemotherapy:
Standard ATT regimens are the mainstay of treatment.
Effective even in the presence of cold abscess or paraplegia.

2. Care of the Spine:

Rest:
Short period of bed rest for pain relief in early stages.
In severe vertebral destruction, prolonged immobilisation may be necessary.
Cervical spine may be supported with a Minerva jacket or collar.

Mobilisation:
Initiated once symptoms improve.
Spine is supported using:

• Cervical collar – for cervical spine.
• ASH brace – for dorso-lumbar spine.

Brace is discontinued once bony fusion occurs.
Strenuous activities are avoided for 2 years.

3. Treatment of Cold Abscess:
Small abscesses may resolve with ATT alone.
Superficial abscesses may require:

• Aspiration: Done using a thick needle. Anti-gravity insertion via a zig-zag tract to prevent sinus formation.
• Evacuation: Includes drainage, curettage of abscess walls, and primary closure without a drain. Psoas abscess is drained extra-peritoneally via a kidney incision.

4. Surgical Intervention:
Indicated in cases with:

• Progressive neurological deficit.
• Severe spinal deformity.
• Non-responding abscesses.

5. MRC Trial Recommendations:
Findings by the Medical Research Council of Great Britain (1973–74) include:

• Bed rest is not mandatory.
• Streptomycin is not essential.
• POP jacket offers no additional benefit.
• Debridement is not a beneficial surgery.

Classification of Femoral Neck Fractures
Fractures of the neck of the femur may be classified on the following basis:

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a) Anatomical Classification
Based on anatomical location:

• Subcapital – fracture just below the head.
• Transcervical – fracture in the middle of the neck.
• Basal – fracture at the base of the neck.

Note: The more proximal the fracture, the worse the prognosis.

b) Pauwel’s Classification
Based on the angle of inclination of the fracture line with the horizontal:

• Type I – Pauwel’s angle < 30°
• Type II – Pauwel’s angle between 30°–50°
• Type III – Pauwel’s angle > 50°

Note: Greater the angle, more unstable the fracture and worse the prognosis.

c) Garden’s Classification
Based on the degree of displacement:

• Stage I: Incomplete fracture with valgus impaction.
• Stage II: Complete but undisplaced fracture.
• Stage III: Complete fracture with partial displacement.
• Stage IV: Complete fracture with full displacement.

Note: Assessed radiologically by observing trabecular alignment.

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Treatment in 60-Year-Old Female

General Principles
Fracture neck of femur is called an “unsolved fracture” due to:

• Interruption of blood supply to femoral head.
• Difficulty in achieving and maintaining reduction.

Age-Based Approach
For a 60-year-old female, treatment choice lies at the borderline of:

• Internal fixation (for younger individuals aiming at preserving the head)
• Prosthetic replacement (for older individuals to avoid complications)

Preferred Management
In most cases, Hemiarthroplasty is preferred due to:

• High risk of non-union and avascular necrosis.
• Faster rehabilitation and better pain relief.

Hemiarthroplasty

• Unipolar prosthesis: Single-piece head and stem.
• Bipolar prosthesis: Two-piece head allows dual motion, offers mechanical advantage.

Appropriate for: Elderly patients with displaced or late-presenting fractures.

Alternative Options (Less Preferred at This Age)

• Internal fixation (if patient is physiologically young and bone quality is good): Cancellous screws, DHS.
• Meyer’s Procedure: For late presentation with vascular femoral head.
• Osteotomy (McMurray’s): Rarely used now.

Open Fracture
An open fracture is defined as a fracture in which there is a break in the overlying skin and soft tissues, such that the fracture communicates with the external environment.

This exposure of the fracture to the outside world increases the risk of infection, especially in externally open fractures.

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Types of Open Fracture
Open fractures may occur in two ways:

a) Internally Open Fracture (from within)
In this type, the sharp end of the fractured bone pierces the skin from the inside, leading to a break in the skin and exposure of the fracture to the external environment.

b) Externally Open Fracture (open from outside)
Here, the object causing the injury first lacerates the skin and soft tissues, and then breaks the underlying bone, resulting in an open fracture.

Note: Externally open fractures are generally at a greater risk of infection than internally open ones due to the higher degree of contamination from the external source.

Volkmann’s Ischaemic Contracture
Volkmann’s Ischaemic Contracture is a sequel of Volkmann’s ischaemia. The ischaemic muscles are gradually replaced by fibrous tissue, which contracts and pulls the wrist and fingers into flexion.

If peripheral nerves are also involved, there may be sensory loss and motor paralysis in the forearm and hand.

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Clinical Features

• Marked atrophy of the forearm.
• Flexion deformity of the wrist and fingers.
• Dry, scaly skin over the forearm and hand.
• Atrophic changes in nails.
• Volkmann’s Sign:
  Fingers can be extended fully at the interphalangeal joints only when the wrist is flexed.
  On extending the wrist, the fingers flex at the interphalangeal joints.
  This happens because the shortened flexor muscle-tendon unit gets stretched over the front of the wrist, causing finger flexion.
• Hypoaesthesia or anaesthesia of the hand may be present.

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Treatment

• Mild deformities:
  Treated by passive stretching of contracted muscles using a turn-buckle splint (Volkmann’s splint).
• Moderate deformities:
  Managed with soft tissue sliding operation, where the flexor muscles are released from their origin at the medial epicondyle and ulna (Maxpage operation).
• Severe deformities:
  Require bone operations such as:
  • Shortening of forearm bones
  • Carpal bone excision

Osteoid Osteoma
It is the commonest true benign tumour of the bone.

Pathologically, it consists of a nidus of tangled arrays of partially mineralised osteoid trabeculae surrounded by dense sclerotic bone.

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Clinical Presentation

• Commonly occurs between the ages of 5–25 years.
• Lower extremity bones are more often affected, tibia being the most common.
• Typically located in the diaphysis of long bones.
• Posterior elements of the vertebrae are also a frequent site.
• Presents as a nagging pain, worse at night, relieved by salicylates.
• Minimal or no clinical signs, may show mild tenderness or palpable swelling if superficial.

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Diagnosis

• Usually confirmed by X-ray, showing zone of sclerosis surrounding a radiolucent nidus (<1 cm).
• If nidus is obscured by sclerosis, it may be detected using CT scan.

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Treatment

• Complete excision of the nidus along with sclerotic bone.
• Prognosis is good.
• It is not a pre-malignant condition.

• Chronic discharging sinus fixed to the underlying bone, often with sprouting granulation tissue and possible visible sequestrum at the sinus opening.
• Thickened and irregular bone compared to the normal side.
• Mild tenderness on deep palpation.
• Stiffness of the adjacent joint due to scarring or associated arthritis.

Clinical Features:

• Swollen gums, gingivitis
• Abnormal bleeding tendencies:
  • Perifollicular haemorrhages (especially on thighs)
  • Petechiae, spontaneous bruises
• In infants:
  • Lassitude, anaemia
  • Painful limbs due to sub-periosteal haematoma
  • Scorbutic rosary (beading of ribs)

Radiological Features:

• Ground-glass appearance of bones
• White line of Frankel (dense provisional calcification line at metaphysis)
• Trümmerfeld zone (lucent band beneath Frankel’s line)
• Pelkan’s spur (metaphyseal beaking)
• Sub-periosteal haemorrhages causing lifting of periosteum

1. Sunray Appearance:

• Seen in osteogenic sarcoma (osteosarcoma).
• Radiating spicules of bone extend in a sunburst or sunray pattern from the cortex.
• Caused by aggressive periosteal reaction due to rapid tumor growth, leading to perpendicular bone formation.

2. Onion Peel Appearance:

• Characteristic of Ewing’s sarcoma.
• Lamellated periosteal reaction, with new bone laid in concentric layers like an onion.
• Seen on X-ray as multiple parallel lines along the shaft of the affected bone.

These appearances are helpful in the radiological diagnosis of malignant bone tumors.