Analysis Case Orthopaedics Pro Exam

Short Case
ACL injury
⁃ which one is more sensitive? ant. drawer or lachman
⁃ other lachman test that you know? modified lachman (put examiner’s leg under pt’s
thigh)
⁃ where to look for knee effusion? para-patellar gutter
⁃ where to look for posterior sagging? in flex 90 degree, look from side, look at tibial
tuberosity sagging posteriorly in relation to femoral condyle
⁃ where’s scar for arthroscopy?

⁃ how to investigate? xray (segond fracture), MRI (degree of tear) and diagnostic
arthroscopy
⁃ how to repair?
⁃ incomplete: conservative (physiotherapy)
⁃ complete: ACL reconstruction using autograft (harmstring muscle tendons;
semimembranous, gracilis; patellar tendons, quadriceps)

PCL tear

Meniscus injury

Patellar instability
⁃ inverse J sign + positive grinding test
⁃ causes (trauma to the knee/patella, recurrent dislocation secondary to malalignment,
hemarthrosis, hypermobility syndrome, medial patellofemoral ligament insufficiency)

⁃ xray knee joint (AP, lateral, skyline view x-ray)

⁃ describe skyline xray (lateral patellofemoral angle, lateral displacement, congruence
angle)
⁃ type of brace, mechanism of brace

DFU (inspection of ulcer)

⁃ skin: dry, loss of hair, brittle nails, high arched foot, claw toes, rocker bottom foot,
migration fat pad distally, onychomyosis, tinea pedis
⁃ palpation: coldness, artherosclerotic bounding pulse,
⁃ focus kat ulcer dulu, then buat sensation,
⁃ xray of foot: OM changes, osteolysis, fractures, dislocations, medial arterial
calcification, soft-tissue gas and Charcots joint
⁃ does the ulcer looks healthy? why?
⁃ why DPA and PTA not palpable?
⁃ sorbitol pathyway in diabetic neuropaty: hyperglycemia (glucose converted into
sorbitol, later become fructose [has oxidative and osmotic effect] reduce in myo-inositol and
NADPH, both lead to nerve ischemia and dysfunction)
⁃ management in hospital
⁃ diabetic control: investigation, assess insulin technique, diet control, lifestyle
modification
⁃ wound care: dressing, teach to dressing by himself, refer to nearest KK
⁃ foot care: daily foot inspection, pressure relieving insole footwear (healing sandal,
rocker bottom shoes
⁃ infection: antibiotic
⁃ vascular insufficiency: refer vascular surgeon, for angiogram, vascular reconstructive
surgery
⁃ reduce risk of recurrence

Lipoma/Liposarcoma at left forearm

⁃ lump examination
⁃ slippery test
⁃ where it is attached/originated?
⁃ ddx
⁃ complication of lipoma ; recurrence after excision, liposarcoma

Trigger finger (stenosing tenosynovitis)

⁃ ddx: locking (dupuytren contracture, post-traumatic tendon entrapment of MCP head,
flexor tendon sheath tumour
⁃ ddx: pain at MCP (Thumb only-DeQuervains, MCP joint sprain, MCP joint OA)
⁃ pathophysiology: inflamation and subsequent narrowing of the A1 pulley of the
affected digit, typically the third or fourth
⁃ risk factor: pregnancy, DM, RA, amyloidosis, hypothyroidism, CKD
⁃ grade (Green classification)

⁃ ix:
⁃ mx:
⁃ non-operative: night splinting, activity modification, NSAID , steroid injection
⁃ operative: release of A1 pulley: endoscopic or open

Ulnar Nerve Palsy

⁃ partial claw hand
⁃ causes:
⁃ elbow: compression; OA, fracture of medial epicondyle, pronator teres syndrome
⁃ wrist: compression; ganglion cyst, lipoma, trauma; hook of hamate fracture,
rheumatoid arthritis
⁃ what is ulnar paradox? the higher lesion causes partial claw hand while the lower lesion
causes complete claw hand [the higher the lesion, the less claw the hand is]
⁃ type of nerve injury
Carpal tunnel syndrome
⁃ symptoms: pain over wirst joint, numbness over the hand especially at night
⁃ signs: muscle wasting, tinel sign positive
⁃ how to make muscle wasting more obvious?
⁃ ix: nerve conduction study
⁃ mx:
⁃ non-surgical - steroid injection, painkiller, physiotherapy, activity modification (avoid
triggering occupation)
⁃ surgical - carpal tunnel release
⁃ how to differentiate CTS and other median nerve injury?
⁃ in CTS, sensation over thenar muscle is intact because the palmar cutaneous branch of
median nerve is above the flexor retinaculum.
⁃ what are the other syndrome, with higher lesion of median nerve? - pronator teres
compression syndrome [has pain over palmar triangle, phalen and tinnel sign negative]
⁃ where do you think the lesion if there is wrist drop?
⁃ Bilateral CTS is common, although the dominant hand is usually affected first and more
severely than the other hand. [medscape]

Tenosynovitis (De Quervein or Flexor Pyogenic)

⁃ causes of de quervain
⁃ treatment

Lower limb discrepancy

⁃ type of gait: short limb gait
⁃ Allis test
⁃ apparent and true length
⁃ where is the pathology? - above knee
⁃ how to confirm is it above or below knee fracture? palpate and look the level of both
patella (if same, fracture below knee)
⁃ why pt with hx of fracture has recurrent pain? OM or OA. why OA? misalignment at
distal end of femur fracture cause unequal stress at knee joint
⁃ how to measure bryant triangle?
⁃ how do you know it is a greater trochanter?

⁃ investigation: x-ray of hip

⁃ if this patient had AVN of NOF, what do you expect to see on x-ray? osteopenia,
osteosclerosis, crescent sign or cortical collapse

Lump and bumps

Ilizarov
⁃ complication of ilizarof: pin site insertion, OM, nerve injury
⁃ where is the fracture?
⁃ why patient on brace?
⁃ what we need to keep LL like that?
⁃ indication
⁃ factors of non-union
⁃ what nerve and arteries affected
⁃ if the arteries affected, what do you expect the changes? 6P; pain, pallor, paraesthesia,
paralysis, pulselessness, perishingly cold
⁃ complication and how to prevent

Long case
Bilateral knee OA
⁃ 5 ddx : RA, Gouty arthritis, SLE with arthritis
⁃ indication TKR
⁃ how TKR was done
⁃ pre-op advice pt TKR
⁃ complication TKR

Lower Limb Discrepancy secondary to AVN

⁃ hx: function before and after MVA, how it affect pt’s life, pt’s emotion and acceptance,
how he goes to work at at home, stairs, family supports
⁃ causes of AVN
⁃ hip examination
⁃ diagnosis
⁃ interpret x-ray
⁃ long term complication - osteoarthritis, back/spine pain
⁃ AVN
⁃ mechanism (traumatic and non-traumatic) - tissue death due to diminished blood
supply and hypoxia
⁃ common sites (femoral head, hip, scaphoid, body talus)
⁃ what we can do about limb shortening (shoe lift)
⁃ causes of limb length discrepancy

Perthes disease
⁃ common in boy 5:1, age 4-8 years old, idiopathic
⁃ risk factor:
• low birth weight
• positive family history
• abnormal birth presentation
• second hand smoke
• Asian, Inuit, and Central European decent
⁃ x-ray findings
⁃
Hip OA
⁃ how to assess control of pain? - sleep pattern
⁃ if HO in rural area, what ix to send?
⁃ changes in x-ray
⁃ what injection to the knee?
⁃ what limitation pt will have after TKR?

Chronic OM
⁃ OM changes in x-ray
⁃ if pt had internal fixator come with sign of chronic OM, what to do? - remove the
implant

Patellar fracture
⁃ palpate feel like wires - tension band wiring of the patella
⁃ old fractures vs new fractures

Non-union
⁃ sign and symptoms
⁃ factor: smoking
⁃ ddx
⁃ advice to stop smoking
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