MPMSU orthopaedics 2020 question paper with answers

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.
  • Mild: Passive stretching and Volkmann’s splint.
  • Moderate: Maxpage operation (soft tissue release).
  • Severe: Bone surgery like carpal excision or forearm shortening.

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: 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.