MPMSU orthopaedics 2024 question paper with their answers

Definition:
Chronic osteomyelitis is conventionally used to refer to chronic pyogenic osteomyelitis. Though its incidence is declining in developed countries, it remains a significant concern in developing nations. Other causes include tuberculosis, fungal infections, etc.

Types of Chronic Osteomyelitis:
a) Chronic osteomyelitis secondary to acute osteomyelitis
b) Garre’s osteomyelitis
c) Brodie’s abscess

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Clinical Features:

1. Presenting Complaints:

• A chronic discharging sinus is the most common presenting symptom.
• History often traces back to an acute osteomyelitis episode during childhood.
• Sinuses may temporarily heal and recur with acute exacerbations.
• Discharge may range from sero-purulent to thick pus.
• History of extrusion of bone fragments from the sinus may be present.
• Pain is usually mild but worsens during exacerbations.
• Generalised symptoms like fever are seen only in acute stages.

2. Examination Findings:

• Chronic discharging sinus: Fixed to underlying bone, with granulation tissue and sometimes visible sequestrum.
• Thickened, irregular bone: Girth of affected bone is increased compared to the normal side.
• Tenderness: Mild, on deep palpation.
• Joint involvement: Adjacent joint may show stiffness due to scarring or secondary arthritis.

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Radiological Appearance:

1. X-ray Findings:

• Thickening and irregularity of cortices
• Patchy sclerosis
• Bone cavities: Rarefied area surrounded by sclerosis
• Sequestrum: Denser than normal bone, with a radiolucent zone
• Involucrum and cloacae may be seen

2. Sinogram:
Helps trace sinus to its origin by injecting radio-opaque dye through a catheter.

3. CT Scan and MRI:
Used in doubtful cases to define cavities and sequestra more precisely.

4. Blood Tests:
ESR may be normal or mildly elevated
Total blood counts are usually normal unless during exacerbations

5. Pus Culture:
Identifies causative organism for targeted antibiotic therapy

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Management:

1. Principles of Treatment:

• Primarily surgical
• Antibiotics are helpful during acute exacerbations and post-operatively
• Surgical aims:
• i) Removal of sequestrum
• ii) Elimination of dead space
• iii) Removal of infected granulation tissue and sinuses

2. Operative Procedures:

• a) Sequestrectomy: Removal of dead bone (sequestrum) through a window in the involucrum
• b) Saucerisation: Converts cavity into a saucer to enable drainage
• c) Curettage: Removal of infected granulation tissue until healthy bone is visible
• d) Excision of Infected Bone: In selected cases (e.g., fibula) or using Ilizarov’s technique
• e) Amputation: Rare, for malignant transformation or intractable cases

3. Post-operative Care:
Use of continuous suction irrigation system with antibiotic solution for 4–7 days

Definition:
Ewing’s sarcoma is a highly malignant tumour commonly seen between the ages of 10–20 years, occasionally up to 30 years.

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Pathology:

1. Bones Affected:

• Long bones in two-thirds of cases (especially femur and tibia)
• Flat bones in one-third of cases (especially pelvis and calcaneum)
• May occasionally have multicentric origin

2. Site:
Most commonly arises in the diaphysis of long bones

3. Gross Pathology:

• Involves large area or entire medullary cavity
• Tumour is grey-white, soft, and pus-like in consistency
• Bone expansion with elevated periosteum and layered sub-periosteal new bone
• Early rupture through cortex and spread to soft tissues

4. Histopathology:

• Sheets of uniform, small lymphocyte-like cells
• Pseudo-rosette formation may be present
• Tumour grows rapidly and metastasises via bloodstream to lungs and other bones

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Clinical Features:

• Age group: 10–20 years
• Presents with pain and swelling
• History of trauma may be present but is usually incidental
• Fever is often associated, making it resemble osteomyelitis

Examination:

• Swelling located in the diaphysis
• Features suggestive of malignant tumour

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Radiological Features:

1. Typical Presentation:

• Lytic lesion in medullary zone of midshaft of long bone
• Cortical destruction
• Onion-peel appearance due to layered new bone formation

2. Atypical Presentations:

• Tumour in metaphysis may resemble osteomyelitis
• Predominant soft tissue component with minimal cortical destruction (resembles soft tissue sarcoma)
• In flat bones: Primarily lytic lesion with little to no new bone formation

1. Flexor Carpi Ulnaris

• The patient is asked to palmar flex the wrist against gravity.
• In doing so, the hand deviates towards the radial side.
• The tendon of flexor carpi ulnaris just above the pisiform does not stand out.
• On performing the same test against resistance, the tendon cannot be felt.

2. Abductor Digiti Minimi

• The patient is asked to abduct the little finger against resistance.
• This is done while keeping the hand flat on the table (to avoid action of flexors of the finger).

3. Interossei

• Palmar interossei: Responsible for adduction (PAD) of fingers at metacarpo-phalangeal joints.
• Dorsal interossei: Responsible for abduction (DAB) of fingers at metacarpo-phalangeal joints.
• These can be tested as follows:

Egawa's Test:
For dorsal interossei (middle finger abductors).
With hand flat on the table (palmar side down), the patient is asked to move the middle finger sideways.

Card Test:
For palmar interossei (adductors).
A card is inserted between two extended fingers.
The patient is asked to hold the card tightly while the examiner tries to pull it out.
In case of weak palmar interossei, it is easy to pull the card out.

First Dorsal Interosseous Muscle:
Can be separately tested by asking the patient to abduct the index finger against resistance.

4. The Lumbricals

• Mainly responsible for flexion at the metacarpo-phalangeal joints.
• Their isolated action cannot be tested.

5. Adductor Pollicis (Froment’s Sign / Book Test)

• The patient is asked to grasp a book between the thumb and index finger.
• Normally, the thumb remains extended due to adductor pollicis and first dorsal interosseous.
• In ulnar nerve injury, adductor pollicis is paralysed.
• The patient uses the flexor pollicis longus (median nerve), causing flexion at the inter-phalangeal joint of the thumb.
• This becomes more noticeable if the examiner tries to pull the book out.
• This is known as Froment’s sign or Book Test.

Definition

A condition characterised by pain and swelling over the radial styloid process due to inflammation of the common sheath of:

• Abductor pollicis longus
• Extensor pollicis brevis

Clinical Features

• Localised tenderness over the radial styloid process
• Pain is aggravated by:
  • Adducting the thumb across the palm and forcing ulnar deviation
  • Radial deviation against resistance (Finkelstein’s test)
• A palpable thickening of the tendon sheath may be present

Treatment

Early Stage:

• Rest to the wrist with crepe bandage or slab
• Analgesics
• Ultrasonic radiation therapy

If not relieved:

• Local infiltration of hydrocortisone

Chronic cases:

• Surgical intervention: Slitting and excision of part of the tendon sheath

Definition:
Osteoporosis is the most common metabolic bone disease characterized by diffuse reduction in bone density due to decreased bone mass, caused when bone resorption exceeds bone formation.

Causes:
Common causes include senility (in males), menopause (in females), immobilization, protein deficiency, endocrinal disorders (e.g., Cushing's), and long-term steroid therapy.

Clinical Features:
Usually asymptomatic until fractures occur. Common fracture sites: dorso-lumbar spine, Colles' fracture, and neck of femur. May show slight loss of height and increased kyphosis.

Radiological Features:
Loss of vertebral height, cod-fish appearance of vertebrae, ground glass bone appearance, and changes in femoral neck trabeculae (Singh’s index).

Treatment:
Includes medical (high protein diet, calcium, vitamin D, estrogens, androgens, bisphosphonates like alendronate, calcitonin, teriparatide) and orthopaedic (weight-bearing exercises, spinal bracing) measures to prevent fractures and alleviate pain.

Definition:
A fracture at the distal end of the radius (about 2 cm proximal to the articular surface) with characteristic dorsal displacement of the distal fragment. Most common in people >40 years, especially postmenopausal women.

Cause:
Fall on an outstretched hand.

Displacements:

• Dorsal displacement & tilt
• Lateral displacement & tilt
• Impaction
• Supination

Clinical Features:

• Pain, swelling, deformity
• Dinner fork deformity
• Radial styloid at same or higher level than ulnar styloid

Diagnosis:
X-ray: Dorsal/lateral tilt of distal radius articular surface

Treatment:

• Undisplaced: Plaster cast for 6 weeks
• Displaced: Closed reduction + Colles’ cast
• Comminuted/unstable: K-wire fixation, external fixator, or LCP plating

Complications:

1. Finger stiffness
2. Malunion → dinner fork deformity
3. Inferior radio-ulnar joint subluxation
4. Carpal tunnel syndrome
5. Sudeck’s osteodystrophy
6. Extensor pollicis longus rupture

Definition:
Spontaneous dislocation of the hip occurring before, during, or shortly after birth. Common in Western countries; rare in India due to cultural carrying practices.

Aetiology:

• Hereditary joint laxity.
• Hormone-induced laxity (maternal relaxin affecting female fetus joints).
• Breech malposition increases risk.

Pathology:
Two types:

1. Dislocated at birth (faulty acetabulum development).
2. Dislocatable after birth (joint laxity).

Changes include displaced femoral head, shallow acetabulum, hypertrophied ligamentum teres, and shortened hip muscles.

Clinical Features:
More common in first-born females, left side, 20% bilateral.
Signs vary by age: asymmetrical groin creases, limited abduction, hip click, peculiar gait.

Diagnosis:

• Clinical tests: Barlow’s and Ortolani’s tests for instability.
• Older children show limited abduction, thigh asymmetry, positive Trendelenburg’s and Galeazzi’s signs.
• X-rays show delayed femoral head ossification, sloping acetabulum, and disrupted Shenton’s line.

Treatment:
Aim: Reduce and maintain femoral head in acetabulum till stability and normal acetabulum form.
Methods: Closed reduction (birth–2 years), traction, open reduction if needed.
Maintenance: Plaster cast or splints.
Surgery (acetabular reconstruction) for delayed cases or older children (Salter’s, Chiari’s, Pemberton’s osteotomies).
Treatment depends on age and severity.