MPMSU orthopaedics 2021 question paper with answers

A. Introduction

After the spine, the hip is the most commonly affected joint. Usually occurs in children and adolescents, but can affect any age group.

B. Pathology

• Initial lesion: Most commonly in bone adjacent to joint (acetabulum or head of femur) → osseous tuberculosis. Less commonly in synovium (synovial tuberculosis) but soon cartilage and bone also involved. Pure synovial TB is rare in the hip.
• Natural history:
  • Granulation tissue from bony focus erodes cartilage or bone and enters the joint.
  • Early stage → synovial hypertrophy and joint effusion.
  • Hypertrophied synovium (pannus) gradually destroys cartilage.
  • Joint cavity filled with pus + granulation tissue.
  • Articular bone ends become exposed and eroded; multiple cavitations common.
  • Head of femur or acetabulum may undergo partial absorption.
  • Constant pull of muscles may cause displacement of head of femur upwards and backwards → wandering acetabulum.
  • Later: pus may perforate capsule → cold abscess in groin/trochanteric region or pelvic abscess.
• Healing: Untreated disease → fibrosis and ankylosis of hip, usually in a deformed position.

C. Clinical Features

• Onset: insidious, chronic course.
• General ill-health in children: pallor, weakness, anorexia.
• Stiffness of hip → limp.
• Pain: often absent early; if present → referred to knee.
• Night cries (“starting pain”): sudden severe pain at night due to rubbing of raw surfaces.
• Abscess/sinuses: cold abscess or discharging sinus in advanced stage.

D. Examination

• Gait: Early → stiff-hip gait (lumbar spine compensates). Later → antalgic gait (avoids weight-bearing).
• Muscle wasting: thigh and gluteal muscles.
• Swelling: due to cold abscess.
• Sinuses: discharging or healed scars around groin/trochanter.
• Deformity: flexion, adduction, internal rotation.
• Shortening:
  • Stage I → apparent lengthening (true length normal).
  • Stage II & III → apparent + true shortening.
• Movements: restriction in all directions with spasm; late → ankylosis (fibrous/bony).
• Dislocation: head may be palpable in gluteal region.
• Telescopy test: demonstrates instability of femoral head.

E. Stages of Tuberculosis of the Hip

• Stage I – Synovitis
  • Effusion in joint.
  • Hip in flexion, abduction, external rotation.
  • Apparent lengthening; true length equal.
  • Rarely diagnosed at this stage.
• Stage II – Arthritis
  • Cartilage destruction begins.
  • Muscle spasm → deformity: flexion, adduction, internal rotation.
  • Apparent shortening; true length equal.
• Stage III – Erosion
  • Destruction of cartilage, head and/or acetabulum.
  • Pathological dislocation/subluxation.
  • Deformity exaggerated.
  • True shortening + apparent shortening present.

F. Investigations

• X-ray pelvis with both hips (AP + lateral views):
  • Early haziness of articular bone ends.
  • Lytic lesions in head of femur/acetabulum.
  • Reduced joint space (uniform or irregular).
  • Irregular articular outline.
  • Advanced disease → destruction of head or acetabulum, pseudo-acetabulum, wandering acetabulum, pestle-and-mortar deformity.
  • Healing → sclerosis.
• MRI / bone scan: more sensitive, detects early lesions.
• Biopsy: in doubtful cases; synovial or bone sample for histopathology.

G. Differential Diagnosis

• Other hip arthritis:
  • Low-grade septic arthritis.
  • Rheumatoid arthritis (uniform joint space narrowing).
• Extra-articular lesions:
  • Inguinal lymphadenitis.
  • Psoas abscess (hip movements free except extension).
• Other childhood hip disorders:
  • Congenital dislocation of hip.
  • Congenital coxa vara.
  • Perthes’ disease (5–10 yrs; limp; joint space widened, minimal restriction).
• Osteoarthritis: older age group, terminal restriction of movement, pain + crepitus.

H. Treatment

Principle: Control disease activity and preserve hip function.

• Conservative:
  • Anti-tubercular therapy (ATT) – cornerstone.
  • Hip care: immobilisation in skin traction → relieves pain, corrects deformity, prevents progression.
  • General measures: good nutrition, rest.
• Operative options:
  • Joint debridement: removal of pus, necrotic tissue, thickened synovium.
  • Girdlestone arthroplasty (excision arthroplasty): removal of head and neck femur → painless, mobile but unstable hip.
  • Arthrodesis: stable but stiff hip in functional position.
  • Corrective osteotomy: for ankylosis in non-functional position.
  • Total Hip Replacement (THR): in selected cases of healed TB with destroyed hip.

I. Plan of Treatment

• Stage I & early II: ATT + traction → mobilisation, physiotherapy.
• Late II & III: ATT + traction → if joint salvageable → mobilisation; if destroyed → excision arthroplasty / arthrodesis / THR (case selection).

A. Introduction

• Seen in the growing skeleton.
• Injury to the growth plate (physis) may result in deformities due to irregular growth.
• Shortening may occur because of premature epiphyseal closure.

B. Salter–Harris Classification of Epiphyseal Injuries

• Type I
  • Separation of the epiphysis from metaphysis through the growth plate.
  • Example: Radial neck epiphysis separation.
  • Treatment: Closed reduction.
  • Prognosis: Good.
• Type II
  • Fracture line passes through the growth plate and exits through the metaphysis.
  • Example: Lower end of radius epiphysis.
  • Treatment: Closed reduction.
  • Prognosis: Good.
• Type III
  • Fracture line passes through the growth plate and exits through the epiphysis into the joint.
  • Example: Medial malleolus epiphysis.
  • Treatment: Open reduction.
  • Prognosis: Growth disturbance can occur.
• Type IV
  • Fracture line passes through the metaphysis, growth plate, and epiphysis, involving the joint.
  • Example: Lateral condyle of humerus.
  • Treatment: Open reduction.
  • Prognosis: Growth disturbance is common.
• Type V
  • Crush injury of the growth plate.
  • Example: Lower tibial epiphysis injury.
  • Treatment: Conservative.
  • Prognosis: Growth disturbance always occurs.

C. Management of Epiphyseal Injuries

Goals

• Achieve and maintain anatomical reduction.
• Avoid damage to germinal layer of physis.

Factors Influencing Outcomes

• Amount of residual deformity.
• Location of injury.
• Age of patient.
• Time since injury.
• Remodelling potential = location of injury + patient’s age.

D. Treatment According to Salter–Harris Type

• Type I
  • Undisplaced, stable → non-operative (cast).
  • Displaced → anatomical reduction required.
  • Unstable → fixation with smooth K-wires if needed.
• Type II
  • Minimally displaced, stable → conservative.
  • Acceptable angulation depends on remodelling potential + age.
• Type III
  • Fixation with 1–2 screws through epiphysis (parallel to physis).
  • Treatment goals:
    • Restore joint congruity.
    • Allow uncomplicated healing.
    • Prevent secondary displacement.
    • Minimize physeal damage.
• Type IV
  • Fixation:
    • One screw through epiphysis.
    • One or two screws through metaphysis (parallel to physis).
  • Treatment goals:
    • Restore joint congruity.
    • Restore physeal anatomy.
    • Reduce metaphyseal fracture.
  • Special notes: Avoid implants crossing physis. If unavoidable → use smooth, smallest diameter, and remove early.
  • In unstable/multifragmentary fractures or older children with closing physis → fixation required.
• Type V
  • No role for reduction.
  • Symptomatic treatment (immobilization, physiotherapy).
  • Long-term follow-up for deformity/limb length discrepancy.
  • Prognosis: Poor (inevitable growth disturbance).

E. Complications

Growth Arrest

• Most common complication.
• Leads to shortening or angular deformity.
• Caused by bony bar across physis.
• Common in distal femur and distal tibia injuries.

Types

• Complete → entire physis closes prematurely.
• Partial → part of physis closes prematurely.

Subtypes of Partial Growth Arrest

• Central: surrounded by normal physis → limb length discrepancy; eccentric → angulation.
• Peripheral: causes angulation + shortening.
• Linear: growth ceases symmetrically (e.g., SH Type V).

F. Management of Leg Length Discrepancy (at maturity)

• Up to 2 cm → shoe lift.
• 2–5 cm → contralateral epiphysiodesis.
• >5 cm → limb lengthening (intramedullary nails, external fixators).