SHORT ESSAY

HAND
 Hand -1
• Male 25 years old right handed male arrived at emergency
room after accidentally he cut his own finger when working.
1. What structure are prevent
flexor tendon from
retracting proximally when
ruptured?
2. What is the source of flexor
tendon nutrition?
3. 3 months after tendon
repair, he complaining that
the adjacent finger cannot
full flexed when grasping
while the repaired finger
can fully flexed, what is the
problem called?
• What structure are prevent flexor tendon from retracting
proximally when ruptured? (max score 35)
- Vincula
- Lumbrical muscle
• What is the source of flexor tendon nutrition (max score
35)
– Vascular system by vincula
– Diffusion by synovial fluid within sheath
• 3 months after tendon repair, he complaining that the
adjacent finger cannot full flexed when grasping while
the repaired finger can fully flexed, what is the problem
called? (max score 30)
– Quadrigia/Quadriga effect
 Hand -2
45 years old right handed male complain about deformity of
his right index finger. He say that 9 months ago, his
deformed finger is only on the distal joint that cannot
extend after being hit by a ball when trying to catch it.
1. What is the the most possible
diagnosis of the previous injury
2. What is the pathoanatomy of
point 1?
3. What is the deformity now?
4. List 3 pathoanatomy of point 3 in
this case ?
• What is the the most possible diagnosis of the previous
injury (max score 20)
Mallet finger
• What is the pathoanatomy of point 1? (max score 20)
Bony avulsion or tendinous disruption of the terminal
extensor tendon
• What is the deformity now? (max score 20)
Swan neck deformity
• List 3 pathoanatomy of point 3 in this case? (max score 40)
- Weakness of volar plate and transverse retinacular
ligament at PIP joint
- Dorsal subluxation of lateral bands
- Resulting PIP hyperextension
- Contracture of triangular ligament maintains deformity
Hand - 3
33 years old right handed
male complaining pain at
his hand after Blowing a
fist to a robber
1. How to do closed
reduction?
2. List 3 Indication for
operation?
3. List 2 operative
management option?
4. What is the
acceptable angulation
for 2nd-5th metacarpal
neck fracture?
• How to do closed reduction? (max score 25)
90 degrees MCP flexion, dorsal pressure through proximal phalanx while
stabilizing metacarpal shaft (Jahss method)
• List 3 Indication for operation? (max score 25)
- Angulation greater than 70 degrees in lateral view
- Rotatory malalignment
- Associated fractures in fith ray of hand
- Open fractures with associated soft tissue injury (excluding human bites)
- Presence of pseudoclawing
• List 2 operative management option? (max score 25)
- Two retrograde crossed Kirschner pins from the lateral or dorsal
(nonarticular)
- Two transverse pins from small to intact ring metacarpal head
- ORIF with a mini-condylar plate
• What is the acceptable angulation for 2nd-5th metacarpal neck fracture? (max
score 25)
– Index and long finger 10°-15°
– Ring finger 30°-40°
– Little finger 50°-60°
 Adult Reconstruction-1
• A 35-year-old-male
complaining pain on the
right knee. Pain especially
during up and down stairs
and unstable knee while
walking.
• He had history of traffic
accident 1 years ago.

• Please describe the MRI finding !

• What is the diagnosis ?
• How do you manage this patient ?
• Please describe type of graft option for this reconstruction surgery?
• Please describe the MRI finding !
Sagittal T2W image demonstrates the disruption of ACL fibers, diffusely
abnormal signal intensity within the ACL, and a discrete band of high
signal
intensity within the proximal ACL. Bone bruises indicates bone marrow/
osteochondral injury as a secondary sign of ACL tear.
• What is the diagnosis ?
Chronic ACL tear of the right knee
• How do you manage this patient ?
ACL reconstruction (open surgery or arthroscopic surgery) with autograft
• Please describe type of graft option for this reconstruction surgery?
- Autograft ( BTB graft, hamstring graft)
- Allograft
- Synthetic graft
 Adult Reconstruction-2

Female, 42 years old came

complaining pain at medial side of
her forefoot. History of daily high
heels usage is admitted. The
clinical pictures is as follows.

• What is your diagnosis?

• Explain the pathomechanism!
• Please describe the classification of this disease?
• Please mention the risk factors for this disease?
– What is your diagnosis?
Bilateral Hallux valgus
– Explain the pathomechanism!
- Valgus deviation of hallux
- Attenuated medial structure
- Varus metatarsal head deviation
- Sesamoid subluxation
- Hallux pronation
- Lateral contracture
– Please describe the classification of this disease!
– Please mention the risk factors for this disease?
Adult Reconstruction-3

A 35-year-old-female had motorcycle

accident. Her knee was hit by another
motorcycle from front.
• Please describe the clinical and x-ray
findings?
• What are possible clinical diagnosis?
• What are the complications ?
• Please describe the reduction techique?
• Please describe the clinical and X-ray findings? (25)
Clinical : left hip in flexion, abduction and external rotation
Xray : anterior hip dislocation with inferior (obturator) direction,
proximal femur in abduction, flexion and external rotation,
broken shenton’s line
• What are possible clinical diagnosis? (25)
Anterior dislocation of the left hip joint
• What are the complications ? (25)
Early : neurovascular injuries (rare)
Late : femoral head osteonecrosis (4%),
posttraumaticarthritis (24-37%)
recurrent dislocation (2%)
• Please describe the reduction technique? (25)
Reverse Bigelow technique :
- Supine position with general anesthesia
- Apply traction of the affected limb inline with tge deformity
- The hip is then adducted, sharply internal rotated and extended
- Check hip stability, reducible with stable hip  short period of bed rest is advised and
followed with protected weight bearing
for 4-6 weeks
Reducible with unstable hip  skeletal traction for 4-6 weeks and followed with protected
weight bearing
Unreducible  open reduction
Oncology-1
1.Describe about surgical margin in
musculoskeletal tumor (30)

2.Which type of surgical margin relataed

to the picture above and what is the
possible diagnosis (35)

3.How do you manage surgically

according to your diagnosis (35)
1. Surgical Margin defined as the plane of dissection as it
relates to the location of the neoplasma. There is 4 possible
surgical margin : (30)
a. Intralesional
b. Marginal
c. Wide
d. Radical

2. Possible diagnosis is Giant Cell Tumor of the bone

According the the diagnosis , intralesional surgery (35)

3. Curretage, intralesional adjuvant, filling defect (graft or

cement) with or without augmentation. (35)
Oncology - 2
1.What is the step of Greenspan for
read the lession in extremity(35)

2.What is the possible diagnosis

according to the x-ray and explain
why(30)

3.What the meaning of periosteal

reaction(35)
1. Radiological step (35)
• Site of lession ( Metadiaphyseal or epimetaphysis or epimetadiaphyisis)
• Lession multiplicity ( single or multiple )
• Type of bone destruction ( geographic, permeative, moth-eaten )
• Periosteal respons
• Margin ( transition area )
• Type of bone matrix ( oteolitik or osteoblastic )
• Soft tissue realation

2. Primary bone tumor suspect osteosarcoma (30)

Sign of malignancy : permeative, periosteal reaction, wide margin,
osteoblastic
Sign of childhood. : opening epyphiseal growth

3. Periosteal reaction is the formation of new bone in response to injury or

other stimuli of the periosteum. Sunburst is specific for respon to
sarcoma. (35)
Oncology - 3
Diagnosis : Pathologic fracture
subtroanteric femur Dextra due to
Breast carcinoma

1.Describe about Mirels classification

(35)

2.Describe about at least 3 tumor

marker (35)

3.Describe about “seed and soil”

theory (30)
1. Mirel Score (35)
2. TUMOR MARKER (35)
 2. SEED AND SOIL THEORY (30)

Mechanism of bone metastases follow the philosophy of

“seed and soil theory”
Seed : primary tumor itself
Soil : microenvironment in end organ
There is propensity for every tumor to metastasize in
specific end organ. For example : breast carcinoma
have trend to metastasize in lymph node, lung and bone
Spine-1

• A 47-year-old man has with chief complain

back pain for 6 months. Night pain are
noted and pain in change of position.
Motoric power of lower extremities are 4/5.
MRI of thoracal spine is showed in this
figure.
• Please describe at least 2 abnormality
finding in MRI ! (40)
• Why the kyphotic deformity happened ? (30)
• What is your diagnosis ? (30)
• Please describe at least 2 abnormality finding in MRI ! (40)
• (1) Abcess at anterior T4,
• (2) Hyperintense in T2 dan T4 vertebral body,
• (3) interspinous space distraction atT2-3, T3-4
• (4) buldging mass at posterior part of T2, T3 and T4 vertebral bossy
• (5) destruction of T2 - T3 vertebral body
• Why the kyphotic deformity happened ? (30)
• Fracture compression of T2 and missing of T3 vertebral body
• What is your diagnosis ? (30)
• Spinal infection ( TB )
 Spine-2

A sagittal CT scan of a 77-year-old woman who has been

experiencing back pain for about 1 month. No history of
trauma, No muscle weakness and sensory disturbances.
• Please describe the abnormal radiologic finding at L1 ?
(25)

• What is your diagnosis ? (25)

• Explain biomechanically, why the kyphotic deformity

tend to progress in severe osteoporotic spine ? (25)
• What is AAOS Clinical Practical Guidance
recommendation about vertebroplasty ? (25)
• Please describe the abnormal radiologic finding at L1 ? (25)
• Fracture of superior endplate and posterior wall of L1 / burst
fracture / osteoporotic bone
• What is your diagnosis ? (25)
• Burst fracture L1 with osteoporosis
• Explain biomechanically, why the kyphotic deformity tend to
progress in severe osteoporotic spine ? (25)
• Kyphotic deformity will increase the lever arm of central body
gravitation, and as a result the progression of kyphotic deformity
will occur
• What is AAOS Clinical Practical Guidance recommendation
about vertebroplasty ? (25)
• Contra indication / AAOS CPG recommend against vertebroplasty to
treat the fractures
Spine-3

21-year-old female complain about severe back pain

after her car hit a tree. There is no neurologic deficit.
The sagittal CT of lumbar spine is showed in figure.
• What is the mode of injury? (25)
• What is the diagnosis? (25)
• What is the most possible complication of this type
injury? (25)
• What is the best choice of treatment? (25)
• What is the mode of injury ? (25)
• Flexion distraction / seat belt injury
• What is your diagnosis ? (25)
• Chance fracture (bony type)
• What is the most possible complication of this
type of injury ? (25)
• Visceral organ injury
• What is your best choice for treatment ? (25)
• Posterior stabilization and fusion (arthrodesis)
 Pediatric -1
A 4 years old boy cannot move his left elbow
after a fall onto his left hand while the elbow is
flexed
• What is your diagnosis and please classify
the fracture (25)
• How do you manage this problem
(25)
• If your answer on no 2 is surgical
intervention, what approach do you use and
why? (25)
• What complication may occur in the future
(25)
• What is your diagnosis and please classify the fracture (25)
Lateral condyle fracture Milch 2
• How do you manage this problem (25)
Open reduction and internal fixation using K wire
• If your answer on no 2 is surgical intervention, what approach do you use
and why? (25)
Lateral/ Kocher approach of elbow because has the lowest
incidence of
avascular necrosis
• What complication may occur in the future (25)
a. avascular necrosis
b. delayed union and non union
c. cubitus valgus
 Pediatric-2
A two year old baby came to your clinic with

a deformities on both of his feet

• Please mention three (3) differential

diagnosis that may produce such
deformities (40)

• An idiopathic clubfoot is best managed

by Ponseti protocol. Could you describe
in brief the protocol of Ponseti (60)
• Please mention three (3) differential diagnosis that may produce such
deformities (40)
Idiopathic/ primary CTEV
Spina bifida
Aryhrogryposis multiplex congenita
• An idiopathic clubfoot is best managed by Ponseti protocol. Could you
describe in brief the protocol of Ponseti (60)
Manuver of Ponseti Protocol
Elevate/ supinate the first metatarsal to corect cavus
With the head of Talus as the fuclrum, abduct the rest of the foot to
correct adductus, varus and equinus
If at the end of serial plaster the ankle is unable to reach 15 degree
dorsiflexion then ATL is necessary
Foot abduction orthosis 23 hours a day in the first 3 months followed by
12 hours a day until the age of 4 years
Pediatric-3

An 8 year old boy came with a swollen

wrist after a fall in a soccer play.
• Please name your diagnosis and
classification (30)

• Please describe the configuration

and extension of fracture line in
growth plate injury according to
Salter Harris (40)

• How do you treat this

condition? (30)
Please name your diagnosis and classification (30)
Fracture of distal radius Salter Harris II
Please describe the configuration and extension of fracture line in growth
plate injury according to Salter Harris (40)
• SH I describes as transverse fracture through the growth plate (also
referred to as the physis)
• SH II describes as fracture through the growth plate and metaphysis but
sparing the epiphysis
• SH III describes as fracture through the growth plate and epiphysis but
sparing the metaphysis
• SH IV describes as fracture through all three elements of the bone, the
growth plate, metaphysis and epiphysis
• SH V describes as a compression fracture of the growth plate (resulting
in a decrease in the perceived space between epiphysis and metaphysis
on x-ray)
How do you treat this condition? (30)
Open reduction and internal fixation with K wire