1. Which of the following demand urgent MRI?

Acute loss of peri-anal sensation

Cauda equine syndrome consists of lower limb weakness, absent reflexes, impaired sensation
and urinary retention (with overflow perhaps mimicking incontinence)
Complete lumbar disc prolapse may present as cauda equine syndrome with urinary retention
and overflow; spinal canal obstruction is demonstrated by MRI.
MRI is the method of choice for displaying the intervetebral discs, ligamentum flavum and
neural structures, and is indicated for all patients with neurological signs and those who are
considered for surgery.

2. Which is most difficult to assess on plain xray?

Angulation rotation displacement shortening articular surfaces

3. Describe Lisfranc fracture

The Lisfranc joint, which represents the articulation between the midfoot and forefoot, is
composed of the five tarsometatarsal (TMT) joints. The Lisfranc ligament is attached to the
lateral margin of the medial cuneiform and the medial and plantar surface of the second
metatarsal (MT) base. This is the only ligamentous support between the first and the second ray
at midfoot level.
Lisfranc joint injuries are rare, complex, and often misdiagnosed or inadequately treated. Such
injuries can range from simple ligament sprains to complete disruption of the TMT joint.
Lisfranc fracture dislocations and sprains carry a high risk of chronic secondary disability.

Jacques Lisfranc de Saint-Martin (1790-1847), a field surgeon in Napoleon's army serving on the
Russian front, described a new amputation technique across the five TMT joints — one that did
not require any bony osteotomy — as a swift solution to forefoot gangrene secondary to
frostbite. This anatomic landmark became known as the Lisfranc joint, a term that is used today
in the description of a wide spectrum of traumatic injuries to the TMT area of the foot.
The Lisfranc ligament is a solitary ligament that connects the first ray (first metatarsal-medial
cuneiform articulation) to the middle and lateral columns of the foot. Injury to this ligament,
even in isolation, will result in functional instability with loss of longitudinal and transverse arch.
The two major causes of Lisfranc injuries are as follows :
 Low-energy, sports-related injuries
 High-energy motor vehicle and industrial accidents
In low-energy settings, TMT injuries are caused by a direct blow to the joint or by axial loading
along the MT, either with medially or laterally directed rotational forces. In high-energy injuries,
the method of loading is not significantly different, but the energy absorbed by the articulations
results in significantly more collateral damage to bony and soft-tissue structures, creating such
injuries as MT fractures, cuneiform instabilities, and cuboid fractures.
The damage to the tight ligamentous structures of this joint complex creates an unstable foot for
weightbearing.

4. Avascular necrosis in foot?

Talus has a vulnerable blood supply and is a relatively common site for post-traumatic ischaemic
necrosis. Blood vessels enter the bone from the anterior tibial, posterior tibial and peroneal
arteries, as well as anastamotic vessels from the surrounding capsule and ligaments. The head of
the talus is richly supplied by intraosseous vessels. However, the body of the talus is supplied
mainly by vessels that enter the talar neck from the tarsal canal and then run retrograde from
distal to proximal. In fractures of the talar neck, these vessels are divided; if the fracture is
displaced, the extraossesous plexus may be damaged and the body of the talus is at risk of
ischaemia.

5. Bone ossification in elbow

Secondary ossific centres around elbow joint appear at:
C-capitulum 2 yrs
R-radial head 4 yrs
I-internal epicondyle 6 yrs
T-trochlea 8 yrs
O-olecranon 10 yrs
E-external epicondyle 12 yrs

6. Describe Monteggia fracture

Fracture of the ulnar associated with dislocation of radio-capitellar joint.
If the ulnar shaft fracture is angulated with the apex anterior (commonest) then the radial head is
displaced anteriorly; if the fracture apex is posterior, the radial dislocation is posterior; if fracture
apex is lateral then radial head will be laterally displaced.
MOI – Usually fall on hand, if at moment of impact body is twisting, its momentum may
forcibly pronate the forearm. The radial head usually dislocates forwards and the upper third of
the ulnar fractures and bows forward. Sometimes the causal force is hyperextension.
Useful clue is pain and tenderness on lateral side of the elbow. Assess for signs of injury to radial
nerve (wrist drop – failure of extensors of forearm).
Key to treatment is to restore the length of the fractured ulnar; then the dislocated joint can be
fully reduced and remain stable. ORIF with plate and screws usually the case in adults. Radial
head usually reduces once the ulnar has been fixed.
Complications: Nerve injury (usually a neuropraxia), malunion, non-union.

7. Describe Colles
Transverse fracture of the radius just above the wrist, with dorsal displacement of the distal
fragment.
6 features:
Dorsal angulation and displacement
Radial angulation and displacement
Ulnar styloid fracture
Impaction and shortening
Most common of all fractures in older people, usually osteoporotic.
Patient is usually an older woman with a history of falling on outstretched hand. MOI - Force is
applied in the length of the forearm with the wrist in extension. Bone fractures at the
corticocancellous junction and the distal fragment collapses into extension, dorsal displacement,
radial tilt and shortening.
Classic dinner fork deformity with prominence on the back of the wrist and a depression in the
front.
Tx:
Undisplaced – dorsal splint for 1-2 days then complete cast. X-ray at 10-14 days.
Displaced – Must be reduced under anesthesia (haematoma block, Bier’s block or axillary
block). Grasp hand and apply traction in length of bone, distal fragment pushed into place by
pressing on the dorsum while manipulating the wrist into flexion, ulnar deviation and pronation.
Dorsalplaster slab applied from just below elbow to metacarpal necks, 2/3 of the way around the
circumference of the wrist.
Fracture unites in approx 6 weeks.

8. Management of elderly woman with displaced intracapsular fracture

Garden 1 or 2: Possibility of preservation of femoral head, therefore cannulated screws may be
used.
Garden 3 or 4: Vascularity compromised
Elerderly female: Surgery for pain relief
Unipolar hemiarthroplasty (Austin Moore prosthesis)
9. What is hangman fracture
Bilateral fractures of the pars articularis (pedicles) of C2 and the C2/3 disc is torn; the
mechanism is extension with distraction.
One cause of death in MVAs where the forehead strikes the dashboard. Neurological damage,
however, is unusual because the fracture of the posterior arch tends to decompress the spinal
cord. Nevertheless, the fracture is potentially unstable.
Undisplaced fractures are treated in a semi-rigid collar or halo-vest until united. Displaced
fractures may need reduction before immobilization in a halo-vest for 12 weeks.

10. Descending order of bone fractures with most blood loss

Pelvis (2-6 units may be lost)
Femur (2-4 units)
Humerus (1-4 units)
Ribs (2-4 units)
Knee joint (2-4 units)

11. Signs of fatty embolism

Early warning signs (usually within 72 hours) are a slight rise of temperature and pulse rate. In
more pronounced cases there is breathlessness and mild mental confusion or restlessness.
Pathognomonic signs are petechiae on the trunk, axillae and in the conjunctival folds and retinae.
In more severe cases there may be respiratory distress and coma, due both to brain emboli and
hypoxia from involvement of the lungs. The features at this stage are essentially those of ARDS.
Urinalysis may show fat globules and blood PO2 should be monitored.
Management is supportive.

12. Why take open mouth xray

Although called the 'odontoid peg' view the odontoid peg is often obscured on this view by
overlapping structures such as the teeth or occiput. Many refer to this view as the 'open mouth'
view. Its primary purpose is to view lateral mass alignment.

Even if a fracture of the odontoid peg is present it is often not visible with this view. If a peg
fracture is not visible, but is suspected clinically by a senior clinician, then further imaging with
CT should be considered.
13. Where does Osgood-Schlatter affect?
Also called Tibial tubercle Apophysitis
Characterized by pain and swelling of the tibial tubercle. Fairly common complaint amongst
adolescents, particularly those engaged in strenuous sports. It is a traction injury of the
incompletely fused apophysis into which part of the patellar ligament is inserted.
On exam, the tibial tuberosity is unusually prominent and tender. Xraysshow displacement or
fragmentation of the tibial apophysis.
Spontaneous recovery is usual.

14. Describe gamekeepers thumb

Torn ulnar collateral ligament of the thumb metacarpophalangeal joint.
Used to be seen in gamekeepers who twisted the necks of little animals.
Now seen in skiers who fall onto extended thumb, forcing it into hyperabduction. A small flake
of bone may be pulled off at the same time.
Ulnar side of the joint is swollen and very tender.
X-ray to rule out fracture.
Inject local anaesthetic into the tissues along the inner aspect of the joint and stress the thumb in
abduction with the MCP flexed at 30 degrees. If there is no undue laxity compared with other
side, a serious injury can be excluded.
If there is significant laxity, this is at least a partial rupture.
Repeat test with thumb fully extended: if still significant laxity, most likely a complete rupture.
Ligament may become jammed proximally under the adductor pollicis tendon.
Partial tears can be treated by immobilization in a cast or splint for 4 weeks.
Complete tears need operative repair

15. Why are medial meniscal tears more common?

The meniscus consists mainly of circumferential fibres held by a few radial strands. It is
therefore more likely to tear along its length than across its width. The split is usually initiated by
a rotational grinding force, which occurs for eg when the knee is flexed and twisted while taking
weight, hence the frequency in footballers. The medial meniscus is much less mobile than the
lateral, and it cannot accommodate easily to abnormal stresses because of its attachements to the
capsule, therefore meniscal lesions are more common on the medial side.

16. Most common race for osteoporosis

White/Caucasian race

17. Tests for acl tear

With knee flexed at 90 degrees, and feet resting on exercising bunk, foot anchored by examiner
sitting on it provided this is not painful, and the upper end of the tibia is grasped firmly and
rocked backwards and forwards to see if there is any anteroposterior glide ‘The Drawer Test’.
Excessive anterior movement (a positive anterior drawer sign) denotes ACL laxity and the
reverse for PCL.

18. Which nerve causes foot drop

Sciatic nerve
Common peroneal nerve

19. Hand infection- organism, complications, spread

Infection of the hand is frequently limited to one of the several well-defined compartments:
under the nail fold (paronychia), the pulp space (felon) and in the subcutaneous tissues
elsewhere, the deep fascial spaces, tendon sheaths and joints. Usually the cause is staphylococcus
which has been implanted during fairly trivial injury.
The response to infection is an acute inflammatory reaction with oedema, suppuration, and
increased tissue tension. In closed tissue compartments eg pulp space or tendon sheaths,
pressures may rise to levels where local blood supply is threatened, with the risk of tissue
necrosis. In neglected cases, infection can spread from one compartment to another and the end
result may be a permanently stiff useless hand. There is also a danger of lymphatic and
haematogenous spread.

20. First clinical finding of compartment syndrome

6 P’s
Pain most common and consistent sign, described as out of proportion to the normal clinical
course
Paraesthesia
Pallor
Perishing cold
Pulselessness
Paralysis

21. Most common injured ankle ligament

In more than 75% of cases it is the lateral ligament complex that is injured, in particular the
anterior talofibular and calcaneofibular ligaments.

22. Supracondylar fracture complications

Early
Vascular injury
Nerve Injury: Median or ulnar nerve
Late
Stiffness: comminuted fractures of the elbow always result in some degree of stiffness
Heterotropic ossification

23. Most common organism for osteomyelitis in scd

Most common organism for both adults and children is staph aureus.
Patients with sickle cell disease are prone to Salmonella typhi infection.

24. Which is not a characteristic of bone malignancy

 25. Bigelow’s ligament

Attaches to the AIIS and then fans out to attach along the intertrochanteric line of the femur. The
iliofemoral ligament is the strongest ligament in the body, and checks extension, adduction (superior
fibers), and abduction (inferior fibers). In addition, because this ligament limits hip extension, it allows
maintenance of the upright posture by reducing the need for muscle contractions.

26. Hoffas Fat Pad

The infrapatellar fat pad (IFP), also known as Hoffa's fat pad, is an intracapsular, extrasynovial structure
that fills the anterior knee compartment, and is richly vascularized and innervated. Its degree of
innervation, the proportion of substance-P-containing fibres and close relationship to its posterior synovial
lining implicates IFP pathologies as a source of infrapatellar knee pain. Though the precise function of the
IFP is unknown, studies have shown that it may play a role in the biomechanics of the knee or act as a
store for reparative cells after injury.

Infrapatellar fat pad syndrome, also called Hoffa's disease, involves pain below the kneecap (patella) due to
the thigh bone (femur) and shinbone (tibia) pinching fatty tissue below the patella. The fat pad is meant to
protect the patella from injury.
SYMPTOMS
 Pain below the patella.
 Pain that gets worse with physical activity, including sports or when completely straightening the knee.
 Swelling of the knee (sometimes).
 Tenderness and swelling (sometimes) on either side of the tendon connecting the kneecap and shinbone
(patellar tendon).
CAUSES
Hoffa's disease may be caused by severe injury (acute trauma) or ongoing (chronic) stress on the fat pad below
the kneecap. This often occurs during activities that require full bending or full extension of the knee. The fat
pad is pinched between the thigh bone and shinbone, and becomes inflamed, causing pain.

27. C-shaped medial meniscus

Medial meniscus lies outside the synovial cavity but within the joint capsule.

It is C-Shaped (forms a semi-circle) and is attached to the medial collateral ligament and
interarticular area of the tibia. It acts as a cushion or shock absorber and lubricates the articular
surfaces by distributing synovial fluid in a windshield-wiper manner.

The lateral meniscus is nearly circular. It is separated from the fibular or lateral collateral
ligament by the tendon of the popliteal muscle and aids in forming a more stable base for the
articulation of the femoral condyle.

28. Popeye’s Arm

Rupture of the tendon of the long head of the biceps usually accompanies rotator cuff disruption,
but sometimes the biceps lesion is paramount.

Patient usually over age 50. While lifting he/she feels something snap in the shoulder and the
upper arm becomes painful and bruised.

Then asked to flex elbow, the detached belly of the biceps forms a prominent lump in the lower
part of the arm. Isolated tears in elderly patients need no treatment. However, if the rupture is
part of a rotator cuff lesion, and especially if the patient is young and active, this is an indication
for anterior acromioplasty; at the sametime the distal tendon stump can be sutured to the bicipital
groove.

29. Bennet’s fracture

Occurs at the base of the first metacarpal bone and is commonly due to punching; however the
fracture is oblique, extends into the carpometacarpal joint and is unstable. The thumb looks short
and the carpometacarpal region swollen. X-rays show that a small triangular fragment has
remained in contact with the medial edge of the trapezium, while the remainder of the thumb has
subluxed proximally, pulled upon by abductor pollicis longus tendon.

Treatment: Reduce and hold with plaster or internal fixation with K-wires

30. Boxer’s Fracture

A blow may fracture the metacarpal neck, usually of the 5th finger and occasionally one of the
others. There may be local swelling with flattening of the knuckle. X-rays show an impacted
transverse fracture with volar angulation of the distal fragment

Treatment: Hand immobilized in a gutter splint with the MCP joint flexed and IP joints straight
for 1-2 weeks then the hand is mobilized.

31. Termination of the spinal cord: L1/L2

32. First bone to be developed in a baby

In weeks 9-12 in utero, the first bone (the clavicle) ossifies by a process of intramembranous
deposition of calcium.

33. Bone in elbow joint to be ossified at age 6

Medial (internal) epicondyle

CRITOE

34. Sequestrum/involucrum

Sequestra: Separated pieces of dead bone

Involucrum: Thickening new bone forming a casement, enclosing sequestrum and infected
tissue.

35. Osteoarthritis

36. Thurston Holland fragment

Triangular metaphyseal fragment of bone seen in salter harris type 2 fractures.

37. Garden Classification

Stage 1 Incomplete impacted fracture, including the so-caled abduction fracture in which the
femoral head is tilted into valgus in relation to the neck

Stage 2 Complete but undisplaced fracture

Stage 3 Complete fracture with moderate displacement

Stage 4 Severely displaced fracture

38. Painful arc syndrome