Algorithm 5 : Management of Posterior hip dislocation

Conus medullaris syndrome vs. Cauda equina syndrome

Both of these are orthopedic/neurosurgical emergencies! But in general, CM syndrome is more severe than CE syndrome.

Here's a comparison between the two...

Club foot: Age-wise Management Flowchart

Club foot is one that resembles a golf club. It is also called Congenital Talipes Equino Varus or CTEV.

Figure 1. Dennis-Brown Splint

How to approach Ankle sprain

Hi!

I sprained my ankle and thought of making a video on it 

-Drashtant

Voila! Its a baby bone.

Bone formation is critical to skeletal development as well as maintenance. Bone is a hollow matrix of calcium phosphate a and apatites wherein calcium is under a state of constant turnover balanced by degradation of calcium apatite and absorption of new calcium from the gut as well as breakdown by PTH and Vitamin D. 

Here's how you can remember what your body produces when are forming new bone. Remember that as 

Old FAP

Formation of Bone

• Bone Specific ALP
• Procollagen type I
• Osteocalcein
• Osteonectin

Integrating Trendelenburg

This blog will compel all the signs /symptoms Or test related to 'Trendelenburg'. Let us know if you know more of the 'Trendelenburg' in the comment section so we can integrate it here. 

Trendelenburg's gait: 

A child with unilateral dislocation of hip lurches on the affected side while bearing weight on it. Seen in DDH, poliomyelitis, Superior Gluteal nerve palsy.
Trendelenburg's gait is also known as Abductor gait or lurching gait.

Trendelenburg's test:

Trendelenburg's surgery/procedure:
It is done in GSV and SFJ incompetence. Here flush ligation of SFJ is done. Flush ligation means vein is ligated as close as possible.
Six tributaries also need to be ligated to reduce recurrence rate.
Laterally: Superior circumflex iliac.
                  Superior epigastric vein.
Medially: Superior external pudendal
                   Deep external pudendal
Distally: Accessory anterior saphenous vein
                Posterior medical thigh vein

Stripping is an additional surgery. Should be done till knee, not below knee to avoid Saphaneous nerve.

Brodie Trendelenburg's test: 

It is done to determine the incompetency of the sapheno-femoral valve and incompetency of the communicating vein.
In both the tests, patient is first placed in the recumbent position and his legs are raised to empty the veins. The sapheno-femoral junction is now compressed with the thumb or a torniquet can be used.
1) To check sapheno-femoral valve incompetency, patient is asked to stand up quickly and pressure is released. If varices fill quickly by a column of a blood from above, it indicates incompetency of the sapheno-femoral valve. This is called Trendelenburg test.
2) To test communicating system, pressure is not released but maintain for 1 min. Gradual filling of the veins indicates incompetency of communicating veins.

That's it

-Demotional bloke. 

Lower back pain notes

Hello!

Here are my quick and dirty notes on Low back pain (LBP) mostly seen in ambulatory medicine! I will not be going into evidence-based medicine (EBM) physical examination (PE) findings but I have put a quick note for conditions you can test on PE so you can look them up.

Radiologic features seen in Osteosarcoma mnemonic

Hi!

Radiologic features seen in Osteosarcoma mnemonic:

SARCOMAtous BONE

Features suggestive of fractured patella mnemonic

Hi!

Features suggesting fracture of patella mnemonic :

Bruised PATELLA

Complications of Colles' fracture mnemonic

Hi!

Complications of Colles' fracture mnemonic:
COMPSSS

Orthopaedics: Facebook Septic arthritis Vs Transient synovitis

#Medicowesome
#Orthopaedics

Q) A 4 year old kid comes to OPD with complaints of high grade fever, decreased appetite and pain in right hip. On examination he has dehydration/ tenderness in Scarpa's traingle/ swelling in right hip region, flexion, abduction and external rotation at hip/ absent movements in right hip region. On Xray there is mild increase in medial joint space. Diagnosis is

1) Septic arthritis
2) Transient synovitis
3) Tubercular arthritis
4) Dislocation of hip

Answer is 1) Septic arthritis

Let us dissect this Multiple choice question. Read the question one more time and let's follow up. Put your Sherlock holmes hat and let's see what we can deduce!

1) A 4 year old kid.
2) Toxic due to dehydration.
3) In his right hip we have - Flexion, abduction, and external rotation. This collectively is called as FABER! Big clue here.
4) Absent movements

Looking at the option given, we can definitely eliminate dislocation of hip. It has FADIR - Flexion, Adduction and internal rotation.
Coming to TB. Now if try to recollect the 5 stages of TB you will find that 1st stage is FABER and next two stages are FADIR! 5th stage is Fibrous ankylosia known as TB arthritis. 4th stage has Wandering Acetabulum (It is a misnomer because both acetabulum and femur head is destroyed so actually remaining part of femur wanders! - also known as - Pestle and Mortar type)

Now two options left - Transient synovitis and Septic arthritis. Well you know Septic arthritis is an emergency condition. Even if you don't know any thing about other option, you can still get it correct. Child is toxic and absent movements points out toward emergency condition.

Both Transient synovitis and septic arthritis causes FABER which leads to more space in the joint leading to more inflammation and swelling. Any swelling disease in Orthopedics is approached as
"XMAS"
X- Xray
M-MRI
A-Arthroscopy which is USG guided.
S-(for)Swelling diseases

Wait! What would be treatment modalitis for both of them?
Ofcourse surgery followed by 6 weeks of Antibiotics for Septic arthritis
Whereas Transient synovitis as name suggest is less severe so we do conservative treatment.

Remember:
Septic arthritis - Absent movements
Transient synovitis - Decrease movements

True or False #10

Hallux valgus is also known as bunion. T or F

T

●Hallux valgus (HV) deformity (ie, bunion) is a common, potentially debilitating deformity consisting of lateral deviation of the hallux on the first metatarsal . The etiology is unknown. The deformity is more common among women and shod populations.

●Although HV is easily recognized by clinical examination, radiographs may be necessary to determine the presence of articular damage . Neither radiographic nor clinical appearance provides the basis for surgical referral, which is determined by patient pain and disability.

●There is little evidence that conservative treatments are useful in the treatment of HV. Nevertheless, we suggest patients without debilitating symptoms avail themselves of conservative therapies before being referred for surgery.

Possible treatments include:

•Shoe modification: wide, low-heeled shoes, or specially altered shoes with increased medial pocket for first metatarsophalangeal (MTP) joint to minimize deforming forces

•Orthoses to improve support and alignment

•Night splinting to improve toe alignment

•Stretching and/ormobilization/manipulation to maintain joint mobility

•Medial bunion pads to prevent irritation

•Ice applied after activity to reduce inflammation
•Analgesics: acetaminophen or NSAIDs

●We suggest that patients with severe pain or dysfunction and those whose symptoms do not improve under a conservative treatment regimen be referred for surgical repair.

Approximately 150 surgical procedures for the correction of HV deformity have been described. Few prospective, randomized trials evaluating these procedures have been performed. Patients should be referred to a foot surgery specialist with experience repairing HV deformity.

●Managing patient expectations about surgery is important. Patients should understand that 10 to 25 degrees of valgus angulation is normal at the MTP joint, and that resolution of postoperative pain and swelling may require several months. Most patients will remain unable to fit into narrower shoes.

Do not forget to look up pictures of how a bunion looks.

Over and out.

Mnemonics for special orthopedic tests

1) TEST: BRUDZINSKI 'S SIGN --

   *Description: Flexion of neck elicits reflexive flexion of knee.

   *Significance: suggests meningitis.

   * Mnemonic : a) Imagine as if the patient is in SKI position on the bed (neck and knee flexed) .
     b) The neck is stiff from the freezing in the snow.

2) DIX HALLPIKE MANEUVER --

   *Significance : suggests BPPV.

   *Mnemonic : Spike your drink and see the hall spin around you (vertigo) .

3) FINKELSTEINS 'S TEST :

  * Significance : for dequervain's tenosynovitis .

  *Mnemonic : a) Ask the patient to flick a coin of ten.
     b) The head's side of the coin has de (the) queen embossed on it.

4) HAWKIN'S TEST : 
   *Description : Internally rotate the shoulder to produce pain if rotator cuff pathology.
   *Mnemonic :Imagine a hawk flying in circles (rotate) , waiting to attack the shoulder of its prey.

5) LHERMITTE'S SIGN: 
   *Description : Passive forward flexion of head causes electric sensation down the spine.

   *Mnemonic : Imagine a hermit (sadhu)  giving his blessings (aashirwaad)  which induces some electric power down your body.

6) LACHMAN TEST:

   *Significance : indicates anterior cruciate ligament injury.

   *Mnemonic : Imagine anterior cruciate ligament to be a latch which keeps the tibia and femur locked to each other.

7) O'BRIEN TEST:
    *Description : With shoulder at 90 degrees flexion, instruct patient to point thumb at ground and resist downward force. Repeat with palm facing upwards.

  *Significance : Pain suggests labral tear.
   *Mnemonic : a) This is a story of O'Brien who worked as a labourer.
     b) He got thumbs down for his work.
     c) So he had to beg (with palms facing upwards) to make end's meet.

8) SPURLING TEST    

    *Significance : Tingling or pain along cervical nerve root suggests cervical radiculopathy.

    *Mnemonic :a) Spurling test is for spine.
     b)  Imagine if there are spurs formed in spine, they will compress the spinal cord causing radiculopathy.

9) McMURRAY'S TEST :

   *Significance : positive test suggests meniscal tear.

  * Mnemonic : a) Tennis players are very vulnerable to meniscal tear.
     b) Imagine Andy Murray to be suffering from meniscal tear.
     c) Also Mc Murray and meniscus both have M and C.

10) PHALEN 'S TEST :
 
   *Description : Instruct patient to bring dorsal aspect of hands together.  
    *Significance : Tingling or paresthesia in lateral 3.5 fingers suggests carpal tunnel syndrome.

    * Mnemonic : a) Imagine a felon who is handcuffed with dorsal aspect of his hands together.
   b)  The handcuffs are tight and compressing his median nerve causing tingling and numbness.

Submitted by Abuzar Asif

The basics: Osteomyelitis

Osteomyelitis is an infectious disease that attacks the bones, specifically the bone marrow. It can have several etiologies: infection from an open fracture, postoperative infection, spread of a blood-borne infection such as pharyngitis, otitis etc. The causative organisms are most often staphylococcus aureus and group A streptococcus.

It is manifested by episodes of fever, often excruciating pain and functional impotence in the affected limb.

It is prevalent among the poor, especially children. In Haiti, it represents a real cause of morbidity and mortality.

It can eventually cause various complications such as: chronic osteomyelitis, pathological fracture by weakening of the bone, length difference in limbs etc.

This mnemonic was written by our Medical Student Guest Author, Rebecca St Louis

She originally wrote this for us in French:

*Ostéomyélite aigüe*

L'ostéomyélite est une maladie infectieuse attaquant les os plus précisément la moëlle osseuse. Elle peut avoir plusieurs étiologies: infection à partir d'une fracture ouverte, infection post-opératoire, propagation d'une infection hématogène comme une pahryngite, une otite etc. Les germes en cause sont le plus souvent le staphylocoque auréus et le streptocoque du groupe A.

Elle se manifeste par des poussées de fièvre, par une douleur souvent atroce et une impotence fonctionnelle au niveau du  membre atteint.

Elle est prévalente chez les pauvres surtout les enfants. En Haïti, elle représente une véritable cause de morbidité et de mortalité.

Elle peut occasionner àla longue diverses complications telles que: ostéomyélite chronique, fracture pathologique par fragilisation de l'os, différence de longueur au niveau des membres etc.

De ce fait, contribuer à l'abaissement de l'incidence de cette pathologie est d'une importance capitale. Voilà pourquoi nous encourageons les parents:
- à promouvoir l'application des règles d'hygiène par les enfants dès les premières années.
-à penser rapidement à faire sougner leurs enfants en cas d'infections hématogènes.

USMLE Step 3 CCS: Fracture of the hip / femur

Hello!
Here are orders for the hypothetical case - let me know if I missed out on something! :)

Causative microbes in acute osteomyelitis

 

Hello Awesomites!
Let's discuss some facts about Common microbes involved in Acute Osteomyelitis.

Staphylococcus aureus is the most common infecting organism found in older children and adults with osteomyelitis.

Gram negative bacteria - vertebral body infections in adults.

Pseudomonas  - intravenous drug abusers.

Fungal osteomyelitis - chronically ill patients receiving long-term intravenous therapy or parenteral nutrition.

Salmonella osteomyelitis - Sickle cell hemoglobinopathies - tends to be diaphyseal.

Infants -S. aureus (most common),group B streptococcus & gram-negative coliforms . 
Group B streptococcus - otherwise healthy infants 2 to 4 weeks of age.

Animal Bite - Pasteurella

Human Bite - Eikinella

That's all!
Thank you.

MD Mobarak Hussain (Maahii)

Saucerization and Arthrodesis

Hello :)

I was fascinated with this two terms :- Saucerization in Osteomyelitis and Arthrodesis (I studied it in treatment of foot drop).

SAUCERIZATION

-Extension of surgical debridement
-Debrided wounds left open widely through excision of overhanging soft tissue and bone
-Wounds drain freely (otherwise If we close it the pus will keep on collecting)
-Abscesses do not form
-Limited to areas where it causes acceptable loss of function e.g. Tibia and femur

Arthrodesis

The term arthrodesis refers to surgical fusion of a joint.
The indications for this are pain & instability in a joint and, in some situations, following the failure of joint replacement.

FIXATION POSITIONS
The optimum positions for arthrodesis in different joints are as follows:

1. SHOULDER:
-In such a position that the hand can comfortably reach the mouth.
-The person will be able to perform the day-to-day activity like eating.combing,scratching the back,cleaning.
-Arthrodesis of shoulder joint is usually reserved for a flail joint as may follow a brachial plexus injury.
-Stabilization of this joint may lead to improvement in the remaining distal function of the arm.

2. ELBOW: 90° of flexion.
(Suppose you won't be able to flex it 90 degree ,then what will happen? Try eating food with that position. You won't be able to do that without this.)

3. WRIST: A few degree of extension
4. THUMB:
-MCP joint in 20° of flexion.
-IP joint in slight flexion.
5.FINGERS:
MCP joints in 20° -30° of flexion.
 (These joints are rarely fused).
 Proximal IP joints in 40° -45° of flexion (less in middle & index fingers)

To show the importance of fixation 

-Upasana Y. :)

Casts (Colle's Cast)

Hello :)

These days, I am attending orthopaedics posting. And I am loving it.
I saw casting. Following questions were asked to me during the procedure.

Q. Define Casts and Slabs.
A. Cast & slab are methods of a temporary immobilization for a wide variety of musculoskeletal conditions not only for disorders of bones but also for many other disorders related with tendons, muscles and soft tissues

Cast: are circumferential immobilizers which is surrounding the whole circumference of the limb
Slab: are non-circumferential immobilizers which is only support apart of the circumference of the limb.

Q. Define Traction and Splints.
A. TRACTION -Traction is a method of restoring alignment to a fracture through gradual neutralisation of muscular forces. Traction is applied to the limb distal to the fracture, so as to exert a continuous pull in the long axis of the bone.

SPLINT - A device used for support or immobilization of a limb or the spine. Any material used to support a fracture is known as splint.

Q. What is Colle's Fracture?
A. It is not just fracture lower end of radius but a fracture dislocation of the inferior radioulnar joint.

Q. Do you know anything regarding Colles Cast.
A. It is a type of Immobilization method. It is the Below elbow cast (10 – 20 degree palmar flexion, 15 – 20 degree ulnar deviation) .

So, Colle`s cast :- It is a below elbow cast in supination.

 Ideally it has to meet the following 4 criteria :
-Firm fit at the dorsum
-Firm fit at the volar fracture apex
-Just snuggly fitting at the forearm
-Metacarpophalangeal joints should be free to move.

That's all for today.

-Upasana Y. :)

Composition of Bone cement

Hello :)

Today I saw a case of Infected AMP implant. Following questions were asked to me regarding bone cement.
Q. Composition of bone cement.

A. Bone cement consist of :- Powder and liquid.

POWDER
1. Polymer : Polymethylmethacrylate (PMMA)
2. Initiator : Benzoyl peroxide (BPO)
3. Radio-opacifier : Barium sulphate , Zirconia
4. Antibiotic :- Gentamicin (commonly)

LIQUID
1. Monomer : Methylmethacrylate (MMA)
2. Accelerator : N,N Dimethy Paratoluidine (DMPT)
3. Stabilizer : Hydroquinone

Q.Antibiotics used as additives for PMMA bone cement.
A. Antibiotics commonly used as additives for PMMA bone cement include:
- vancomycin, (MRSA)
-gentamicin,
-meropenem,
-in addition to tobramycin.

Also, successful non-antibiotic bactericides that have been used as bone cement additives include:-
- Quaternary ammonium compounds (benzalkonium chloride and cetylpyridinium chloride)

That's all for today.
-Upasana Y. :)

Image Based MCQ on Fracture

Hello awesomites!
Yesterday we posted an Image based MCQ on Fracture of forearm bones and here's the answer for it.
Q. The X-ray of forearm in AP and Lateral views as shown in the image is diagnostic of

A. Galeazzi fracture-dislocation
B. Barton fracture
C. Monteggia fracture-dislocation
D. Colles fracture

Ans: c) Monteggia fracture-dislocation

Monteggia fracture-dislocations is defined as fracture of the ulnar shaft along with concomitant dislocation of the radial head.

Mechanism: Monteggia fracture-dislocations occur as the result of a fall onto an outstretched hand (FOOSH).

Classification: The Bado classification is used to subdivide the Fracture dislocation into four types.

Type I: anterior dislocation of radial head (Most common)
Type II: posterior dislocation of radial head
Type III: lateral dislocation of radial head
Type IV: anterior radial head dislocation as well as proximal third ulnar and radial shaft fractures

That's all!
Thanks for your active participation.

MD Mobarak Hussain (Maahii)