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Orthopaedics Question Bank - Topic-Wise Classification

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🦴 1. FRACTURE

• Define fracture, dislocation and Sprain
• Define and classify fracture
• What is Simple fracture and Compound fracture? / What is closed fracture and compound fracture?
• Enumerate the healing process of a fractured long bone
• Enumerate stages of fracture healing process
• What are the complications of a long bone fracture? (appears multiple times)
• Enumerate some methods of immobilization in a fractured limb (appears multiple times)
• Write down the principles of closed fracture management
• How will you obtain an X-Ray for a patient with a fractured limb?
• What are the investigations you may suggest to an Orthopaedic patient?
• What is pathological fracture? Mention some of its causes / What do you mean by pathological fracture and stress fracture?
• Enumerate some causes of pathological fracture
• Classify Open fracture / Classify open fracture (Gustilo-Anderson)

• Outline the management of Clavicle fracture (appears multiple times)
• What are the structures those may be injured due to clavicle fracture?
• What is Monteggia fracture dislocation and Galeazzi fracture dislocation?
• How will you manage a case of Gustilo-Anderson Type-III fracture of right tibia in a 25-year-old bike rider?
• Classify fracture neck of femur
• How will you differentiate fracture NOF from dislocation of hip joint
• Compartment syndrome (short note)

• A 30-year-old motorbike rider with severe painful swelling of mid thigh, multiple open wounds: diagnosis, treatment, name 2 orthopaedic emergency conditions
• A 55-year-old woman, fall on outstretched hand, swelling and severe pain around left wrist with dinner fork deformity: define injury, evaluate, why old women are more prone (appears twice)
• A middle-year female, fall on outstretched hand, swelling of right forearm just above wrist: enumerate injuries, radiological findings, early and late complications
• A 55-year-old lady, fall on outstretched hand, dinner fork deformity of wrist: most likely diagnosis, reverse type, investigate, treat (appears twice)
• A 10-year-old boy fell on outstretched hand, pain and swelling of right elbow joint: probable diagnosis, manage, probable complications (appears multiple times - across 3 papers)
• An old man fallen from height, trauma to hip region: differentiate fracture NOF from dislocation, classify fracture neck of femur, treat
• A 65-year-old lady, pain and swelling around hip, inability to walk after fall in slippery bathroom: 2 differential diagnoses, diagnose, treat (appears multiple times)

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🦷 2. BONE TUMOR

• Define neoplasm
• Differentiate between benign and malignant neoplasm
• Mention some common sites for primary and secondary bone tumour
• Classify bone tumours (appears multiple times)
• Differentiate between Osteosarcoma and Ewing sarcoma
• What are the radiological findings of GCT? (appears multiple times)
• What are the radiological findings of Ewing's sarcoma?
• GCT (short note)
• Osteoid osteoma (short note)

• A 20-year-old man, painful tender hard swelling in left knee, X-ray shows sun ray appearance in lower end of femur: most probable diagnosis, approach to diagnose, treatment plan (Osteosarcoma scenario - appears multiple times)
• How will you treat a case of osteosarcoma involving distal femur in a 20-year-old man?

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🦠 3. OSTEOMYELITIS

• Define osteomyelitis (appears multiple times)
• Classify osteomyelitis (appears multiple times)
• Write down the pathogenesis of chronic pyogenic osteomyelitis
• Why acute haematogenous osteomyelitis is common in metaphysis of long bone?
• What are the common organisms responsible for osteomyelitis?
• Define acute osteomyelitis? What is sequestrum and involucrum?

• A boy of 6-7 years, high rise of body temperature, pain in upper part of right leg, tender part redden, hot and oedematous, restricted knee movement for 36 hours: diagnosis / differential diagnosis, clinical assessment / evaluation, plan of treatment (appears across multiple papers)
• A 20-25-year-old man, chronic discharging sinus, H/O fracture of right tibia/femur following RTA / open fracture: diagnosis, management plan, complications (appears multiple times - both as osteomyelitis and fracture question)

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📋 4. INTRODUCTION / ORTHOPAEDICS BASICS

• Outline the principles of musculoskeletal history taking
• What is Orthopaedics? What are the branches of Orthopaedics?
• Outline the principles of musculoskeletal clinical examinations
• What are the investigations you may suggest to an Orthopaedic patient?
• How will you obtain an Orthopaedic X-Ray?
• CTEV (short note)

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🔀 5. OTHERS

• Narrate various methods of immobilization in case of a fracture
• Classify dislocation of Shoulder
• How will you manage shoulder dislocation in a 26-year-old man / army recruit? (appears multiple times)
• What is dislocation and subluxation?
• Which joint is commonly dislocated and why?

• 30 patients brought to casualty unit following a bus accident: categorize patients for management (triage), Glasgow coma scale components, cABCDE in trauma care (appears multiple times)
• Define polytrauma
• How will you approach to manage a polytrauma case?
• Write the components of Glasgow coma scale

• What is amputation? Enumerate some of its types
• What are the indications and complications of amputation of a limb? (appears multiple times)
• What is Phantom limb?

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📊 FREQUENCY SUMMARY (High-Yield Topics)

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1. Classify fracture + complications of long bone fracture
2. Osteomyelitis definition, classification, pathogenesis
3. Classify bone tumours + Osteosarcoma vs Ewing sarcoma
4. Distal radius fracture (Colles') / dinner fork deformity scenario
5. Elbow injury in a child (supracondylar fracture scenario)
6. Osteomyelitis in a child (haematogenous) scenario
7. Chronic discharging sinus post-fracture (chronic osteomyelitis) scenario
8. Fracture NOF in elderly / hip injury
9. Glasgow coma scale + Triage (mass casualty)
10. Shoulder dislocation management

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Ward Assessment Exam 01 - Complete Answers

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Question 1

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1a) Principles of Musculoskeletal History Taking

• Chief complaint in patient's own words
• Duration and onset (acute vs. gradual)

• Site - exact location of pain/deformity
• Onset - sudden or gradual, precipitating event
• Character - nature of pain (aching, sharp, throbbing)
• Radiation - does it spread elsewhere?
• Associating symptoms - swelling, stiffness, locking, weakness, numbness
• Timing - constant or intermittent, worse at rest or on activity
• Exacerbating and relieving factors
• Severity - impact on daily activities/function

• Mechanism of injury (direct/indirect force, direction, magnitude)
• Swelling - time of onset (immediate = haemarthrosis; delayed = synovial effusion)
• Deformity, instability, clicking/locking
• Neurological symptoms - tingling, numbness, weakness

• Previous fractures, operations, joint diseases
• Metabolic bone disease, malignancy, steroids use

• Occupation, dominant hand, sport activities
• Family history of arthritis, bone tumours

• Constitutional symptoms (fever, weight loss - suggest infection or malignancy)

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1b) What is Orthopaedics? Branches of Orthopaedics?

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1c) Principles of Musculoskeletal Clinical Examination

• Patient adequately exposed, compare both sides
• Skin: scars, sinuses, redness, bruising
• Shape/Contour: swelling (localised vs. diffuse), wasting, deformity
• Alignment: valgus/varus, shortening, rotation
• Gait: if lower limb affected

• Temperature (warm = inflammation/infection)
• Tenderness - localise precisely (point tenderness vs. diffuse)
• Swelling character: bony hard, firm, fluctuant, pulsatile
• Crepitus on palpation

• Active movement first (patient moves) - tests strength and willingness
• Passive movement (examiner moves) - tests joint integrity and end-feel
• Document in degrees; compare with opposite side
• Note: painful arc, crepitus, locking

• Stability tests (ligament laxity)
• Provocative tests (Lachman, McMurray, etc.)
• Measurement: limb length, girth

• Motor power (MRC grading 0-5)
• Sensation (light touch, pin-prick, proprioception)
• Reflexes
• Peripheral pulses, capillary refill

• Always request X-ray: two views (AP + lateral), include joints above and below

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Question 2

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2a) Define and Classify Fracture

• Closed (Simple): No communication with external environment
• Open (Compound): Fracture communicates with outside through a skin wound

• Complete: Both cortices disrupted
• Incomplete: One cortex intact (e.g., Greenstick in children, Stress fracture, Torus/Buckle fracture)

• Transverse: At right angles to long axis
• Oblique: At angle to long axis
• Spiral: Twisting force
• Comminuted: More than two fragments
• Butterfly fragment: Triangular fragment with transverse force
• Segmental: Two separate fracture levels
• Impacted: One fragment driven into another

• Traumatic: Direct or indirect force
• Stress (Fatigue): Repetitive loading (e.g., march fracture)
• Pathological: Fracture through diseased bone (tumour, osteoporosis, infection, Paget's)

• Avulsion: Fragment pulled off by muscle/ligament
• Compression: Vertebral body collapse
• Depressed: Skull fractures
• Epiphyseal (Salter-Harris): In children, involve growth plate

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2b) Investigations for an Orthopaedic Patient

• X-Ray: First-line; always two views (AP + lateral); include joints above and below fracture
• CT scan: Complex fractures (spine, acetabulum, calcaneum), 3D reconstruction for surgical planning
• MRI: Soft tissue injuries (ligaments, cartilage, menisci, rotator cuff, spinal cord), stress fractures, osteomyelitis
• Ultrasound: Soft tissue (tendon tears, effusions, DVT, guide aspiration)
• Bone scan (Technetium-99m): Stress fractures, metastases, osteomyelitis
• PET scan: Bone tumours, metastatic workup

• Blood: FBC (anaemia, infection - WBC), ESR, CRP (infection/inflammation), uric acid (gout), calcium/phosphate/ALP (bone metabolism, Paget's, tumour), LFT, RFT (pre-op)
• Biopsy: Open or needle biopsy for tumours
• Synovial fluid analysis: WBC count, crystals, culture (arthritis, gout, infection)
• Bone marrow aspirate/trephine: For haematological conditions

• Nerve conduction study/EMG: Nerve entrapment, peripheral neuropathy
• DEXA scan: Bone mineral density in osteoporosis
• Arthrography: Joint integrity

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2c) How to Obtain an Orthopaedic X-Ray

1. Two views minimum - AP (anteroposterior) and lateral - a fracture may be visible in one view only
2. Two joints - include the joint above and the joint below the suspected fracture (to detect associated dislocations)
3. Two limbs - in children, X-ray the opposite normal limb for comparison (especially elbow)
4. Two times - repeat X-ray after 10-14 days if initial X-ray is negative but fracture clinically suspected (hairline/stress fractures)
5. Two occasions - before and after reduction/manipulation

• Immobilise the part before moving patient to X-ray
• Good positioning: patient comfortable, part as close to film as possible
• Adequate exposure: bone, surrounding soft tissue, and any plaster visible
• Label: name, date, side (L/R), projection

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Question 3

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3a) Simple Fracture vs. Compound Fracture

• Type I: Clean wound < 1 cm; low energy
• Type II: Wound > 1 cm; moderate soft-tissue damage
• Type IIIA: High energy; adequate soft-tissue cover after debridement
• Type IIIB: High energy; inadequate cover; requires flap
• Type IIIC: High energy + vascular injury requiring repair

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3b) Methods of Immobilization in a Fractured Limb

• Plaster of Paris (POP) cast: Most common; slab or complete cast
• Fiberglass/Synthetic cast: Lighter, water-resistant
• Splints: Thomas splint (femur fracture), wrist splint
• Traction: Skin traction (Buck's) or skeletal traction (Steinmann pin/Kirschner wire) - for femur fractures while awaiting surgery
• Functional bracing: Allows partial movement while stabilising fracture (e.g., humeral shaft fractures)
• Sling: Simple immobilisation for upper limb (arm sling, collar-and-cuff)
• Bandaging: Neighbour strapping for toe/finger fractures

• Intramedullary nailing (IMN): For femur, tibia, humerus shaft fractures
• Dynamic Hip Screw (DHS): For femoral neck fractures
• Plates and screws: For most fractures
• Tension band wiring: Olecranon, patella
• Kirschner wires (K-wires): Temporary fixation (e.g., Colles' fracture)

• External fixator frames (Ilizarov, Hoffmann): For open fractures, infected non-union, pelvic fractures

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3c) Principles of Closed Fracture Management

• Restore anatomical alignment
• Closed reduction: Manipulation under anaesthesia (MUA) - traction and manipulation
• Open reduction: Surgical exposure when closed reduction fails
• Check: restoration of length, alignment, and rotation

• Maintain reduction until union
• Methods: cast, functional brace, traction, internal/external fixation (see above)
• Adequate immobilisation without compromising neurovascular status

• Prevent complications: joint stiffness, muscle wasting, DVT
• Early mobilisation of joints not immobilised
• Physiotherapy: muscle strengthening, gait training
• Return to full function as goal

• Pain control: adequate analgesia
• Treat complications (DVT prophylaxis, wound care)
• Patient education: weight-bearing status, cast care
• Follow-up with serial X-rays to confirm union

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Question 4

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4a) Healing Process of a Fractured Long Bone

• No callus; osteoclast cutting cones cross fracture line directly
• Requires absolute stability

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4b) Classify Open Fracture

• Farmyard and contaminated wounds are automatically Type III regardless of size
• IIIC has highest amputation rate (~50%)
• Management principle: wound debridement within 6 hours ("golden period"), skeletal stabilisation, soft-tissue cover

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4c) Complications of a Long Bone Fracture

• Haemorrhage and shock (femur fracture = up to 1.5L blood loss)
• Neurovascular injury (nerve, artery damage)
• Skin/visceral injury
• Fat embolism (within 24-72 hours of long bone fractures)

• Compartment syndrome - raised pressure in closed fascial compartment; 5 P's (Pain, Pallor, Paralysis, Paresthesia, Pulselessness); requires emergency fasciotomy
• Infection (especially open fractures)
• DVT and Pulmonary Embolism - most dangerous early complication
• Crush syndrome / Rhabdomyolysis
• Wound dehiscence

• Delayed union - fracture healing slower than expected
• Non-union - fracture fails to unite (hypertrophic or atrophic)
• Malunion - heals in abnormal position (angulation, shortening, rotation)
• Avascular necrosis (AVN) - loss of blood supply (e.g., femoral head, scaphoid)
• Joint stiffness
• Muscle wasting and weakness
• Post-traumatic arthritis - if intra-articular fracture
• Osteomyelitis (esp. open fractures)
• Volkmann's ischaemic contracture - from untreated compartment syndrome
• Myositis ossificans - heterotopic bone in muscle
• Sudeck's atrophy (CRPS) - chronic regional pain, osteoporosis, trophic changes
• Growth disturbance (in children: Salter-Harris injuries)
• Refracture

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Question 5

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5a) Probable Diagnosis

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5b) Treatment

• Airway with cervical spine protection
• Breathing - assess ventilation
• Circulation - IV access (two large-bore cannulas), resuscitation with IV fluids/blood (femur fracture = blood loss up to 1.5L)
• Disability - GCS, neurological check
• Exposure - full exposure, log-roll

• Cover wound with saline-soaked sterile dressing
• Do NOT probe or explore in A&E
• IV antibiotics immediately: co-amoxiclav + metronidazole (or cefuroxime); add gentamicin for Type III
• Tetanus prophylaxis

• Thomas splint or traction splint for immediate immobilisation
• Reduces pain, reduces blood loss, prevents further neurovascular damage

• Wound debridement in theatre - thorough irrigation, excision of devitalized tissue
• Skeletal stabilisation: External fixator initially for contaminated/unstable open fractures; convert to intramedullary nail (IMN) once wound clean (within 72 hours if possible)
• Wound closure: Primary closure for Type I/II if clean; delayed primary closure or split skin graft/flap for Type III
• Vascular repair if Type IIIC (consult vascular surgery)

• Serial wound inspection
• Physiotherapy: early mobilisation, quadriceps strengthening
• DVT prophylaxis (LMWH)
• Pain management
• Follow-up X-rays to confirm union

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5c) Two Orthopaedic Emergency Conditions

1. Compartment Syndrome - Raised intra-compartmental pressure compromising circulation; requires emergency fasciotomy within hours to prevent permanent muscle death and Volkmann's ischaemic contracture
2. Open Fracture - Requires emergency debridement and fixation within 6 hours ("golden period") to prevent osteomyelitis

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Summary Table - Exam 01 Key Points to Remember

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Ward Assessment Exam 02 - Complete Answers

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Question 1

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1a) Define and Classify Fracture

• Closed (Simple): Skin intact; no communication with outside
• Open (Compound): Fracture communicates with external environment through a skin wound

• Complete: Both cortices broken
• Incomplete: One cortex intact - Greenstick, Stress/Fatigue, Torus/Buckle (children)

• Transverse - direct blow; right angles to shaft
• Oblique - angular force
• Spiral - twisting/torsional force
• Comminuted - more than two fragments; high-energy
• Segmental - two fracture levels in same bone
• Butterfly fragment - wedge-shaped piece between two main fragments
• Impacted - one fragment driven into other

• Traumatic - direct or indirect force
• Stress (Fatigue) - repetitive loading
• Pathological - through diseased/abnormal bone

• Avulsion fracture - fragment pulled by tendon/ligament
• Compression fracture - axial loading (vertebrae)
• Salter-Harris (epiphyseal) - in children, involving growth plate
• March fracture - stress fracture of 2nd/3rd metatarsal

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1b) Complications of Long Bone Fracture

• Haemorrhage/shock (femur fracture = up to 1.5L blood loss)
• Neurovascular injury
• Skin/visceral injury
• Fat embolism (within 24-72 hours)

• Compartment syndrome - raised pressure in closed fascial space; 5 P's (Pain, Pallor, Paresthesia, Paralysis, Pulselessness); requires emergency fasciotomy
• Infection (especially open fractures)
• Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)
• Wound dehiscence

• Delayed union - slower healing than expected
• Non-union - failure to unite (hypertrophic or atrophic)
• Malunion - heals with angulation, shortening, or rotation
• Avascular necrosis (AVN) - loss of blood supply (femoral head, scaphoid)
• Joint stiffness and muscle wasting
• Post-traumatic osteoarthritis
• Osteomyelitis - chronic infection of bone
• Volkmann's ischaemic contracture - from untreated compartment syndrome
• Myositis ossificans - heterotopic bone formation in muscle
• Sudeck's atrophy (CRPS) - chronic regional pain syndrome
• Refracture
• Growth disturbance (children - Salter-Harris injuries)

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1c) Pathological Fracture - Definition and Causes

• Fracture with minimal/no trauma
• Pain before injury
• Elderly patient
• Known malignancy
• Unusual fracture site or pattern

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Question 2

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2a) Closed vs. Compound Fracture

• Skin overlying the fracture is intact
• No communication with the external environment
• Lower infection risk
• Less urgent, but neurovascular injury still possible
• Example: Colles' fracture, closed femur fracture

• There is a breach in the skin (or mucous membrane)
• The fracture haematoma communicates with the external environment
• Higher risk of infection, osteomyelitis, delayed/non-union
• Orthopaedic emergency - requires urgent surgical debridement
• Classified by Gustilo-Anderson:
• Type I: wound < 1 cm, clean, low energy
• Type II: wound > 1 cm, moderate soft-tissue damage
• Type IIIA: high energy, adequate soft-tissue cover
• Type IIIB: inadequate cover, requires flap
• Type IIIC: associated vascular injury

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2b) Investigations for an Orthopaedic Patient

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2c) Management of Open Fracture of Right Tibia (RTA, 20-year-old)

• Airway, Breathing, Circulation (IV access, fluids/blood), Disability, Exposure
• Haemorrhage control with direct pressure

• Cover wound with saline-soaked sterile gauze - do NOT probe in casualty
• IV antibiotics within 1 hour: Co-amoxiclav (or Cefuroxime) ± Gentamicin for Type III
• Tetanus prophylaxis (if not up to date)

• Below-knee plaster backslab or splint
• Document neurovascular status before and after splinting

• Wound debridement and irrigation: Thorough excision of all devitalized tissue, copious saline irrigation (minimum 9 litres for Type III)
• Fracture stabilisation:
• External fixator (Orthofix/Ilizarov) - preferred for contaminated/high-energy open tibia fractures
• Convert to intramedullary nail (IMN) once wound is clean (within 72 hours to 2 weeks)
• Wound closure:
• Type I/II: Primary closure or healing by secondary intention
• Type III: Delayed primary closure, split skin graft, or free/rotational flap (plastic surgery input)
• Type IIIC: Emergency vascular repair + fasciotomy of all 4 compartments of leg

• Serial wound inspections
• Continue IV antibiotics for 72 hours, then oral
• DVT prophylaxis (LMWH/compression stockings)
• Physiotherapy - non-weight bearing initially, then gradual mobilisation
• Follow-up X-rays every 6-8 weeks to confirm healing

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Question 3

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3a) How to Obtain an X-Ray for a Fractured Limb

1. Two views - AP and lateral (a fracture may only show in one plane)
2. Two joints - Include joint above and joint below the fracture (to detect associated dislocations)
3. Two limbs - X-ray the opposite limb for comparison (especially in children for growth plate assessment)
4. Two times - Repeat after 10-14 days if initial X-ray negative but fracture clinically suspected (hairline/stress fractures)
5. Two occasions - Before and after any reduction/manipulation

• Immobilise the limb before transport to X-ray
• Adequate analgesia before positioning
• Correct labelling: patient name, date, side, projection
• Ensure soft tissues and joints visible on film
• Assess: bone alignment, cortical integrity, soft tissue swelling, foreign bodies

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3b) Stages of Fracture Healing

Perren's strain theory: <2% strain → bone; <10% strain → cartilage; >10% strain → fibrous tissue. Hence: controlled movement helps, excessive movement hinders healing.

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3c) Methods of Immobilization in a Fracture

• External fixator (Ilizarov, Orthofix, Hoffmann): Open fractures, infected non-union, pelvic fractures, limb lengthening

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Question 4

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4a) Diagnosis

• Dorsal displacement and tilt of the distal fragment
• Radial shortening
• Radial deviation
• Producing the characteristic "dinner fork" deformity

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4b) Evaluation

• Mechanism: FOOSH (Fall On OutStretched Hand) - forced dorsiflexion of wrist
• Dominant hand? Occupation (important for outcome)
• Previous fractures? Osteoporosis? Steroid use?
• Age (elderly women most commonly affected due to osteoporosis)

• Inspection: "Dinner fork" deformity (dorsal prominence of distal fragment); radial deviation; swelling; bruising
• Palpation: Tenderness 2-3 cm proximal to wrist; may palpate dorsal bony step; check ulnar styloid tenderness
• Neurological: Assess median nerve (carpal tunnel - most commonly injured); check thumb, index, middle finger sensation; thenar muscle function
• Vascular: Radial pulse, capillary refill

• X-Ray wrist (AP + lateral) - mandatory; shows:
• Dorsal angulation (>10° posterior tilt; normal = 11° volar tilt)
• Radial shortening (>3 mm)
• Radial deviation of distal fragment
• Ulnar styloid fracture
• Intra-articular extension (increases severity)
• CT scan: If intra-articular extension to better characterise fragments for surgical planning
• Bloods: Pre-operative workup if surgery planned; DEXA scan (osteoporosis assessment)

• Radial inclination (normal = 23°)
• Volar tilt (normal = 11°)
• Radial height (normal = 12 mm)
• Articular step-off (>2mm = significant)

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4c) Treatment

• Plaster of Paris backslab (below-elbow) for 4-6 weeks
• No reduction needed
• Repeat X-ray at 1-2 weeks to check no secondary displacement

• Under haematoma block (local) or Bier's block/general anaesthesia
• Technique: traction → accentuate deformity → reduce → hold in slight flexion and ulnar deviation
• Check post-reduction X-ray in theatre
• Below-elbow POP cast for 5-6 weeks
• Serial X-rays at 1 and 2 weeks to detect re-displacement

• Intra-articular fracture with step-off >2mm
• Comminuted/unstable fractures
• Failed/lost closed reduction
• Young, active patients
• Options: K-wire fixation, volar locking plate (gold standard), external fixator

• Physiotherapy once cast removed: wrist and finger range-of-motion exercises
• Warn about complications (see below)

• Early: Median nerve injury (acute CTS), vascular injury, compartment syndrome
• Late: Malunion (most common), Sudeck's atrophy/CRPS, carpal tunnel syndrome, ruptured EPL tendon, stiff wrist, inferior radio-ulnar joint disruption

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Question 5

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5a) Probable Diagnosis

• Most common elbow fracture in children (5-10 years old)
• Mechanism: FOOSH with elbow in extension
• X-ray: Loss of anterior humeral line (anterior humeral line should pass through middle third of capitellum on lateral view); positive fat pad sign
• Gartland Classification: Type I (undisplaced), Type II (displaced, posterior cortex intact), Type III (completely displaced)

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5b) Management

• Full neurovascular examination: Radial pulse, capillary refill, sensation
• Check for anterior interosseous nerve (AIN) injury (most common nerve injured) - test by "OK" sign (flex tip of thumb and index)
• Check radial nerve (wrist drop) and ulnar nerve (ring/little finger sensation)

• Above-elbow backslab in 90° flexion + collar-and-cuff sling
• 3-4 weeks immobilisation
• No manipulation required

• Closed reduction under general anaesthesia
• Check neurovascular status after reduction
• K-wire fixation if unstable
• Above-elbow cast for 3-4 weeks

• Emergency surgery (same night)
• Closed reduction under GA on a radiolucent table
• Percutaneous K-wire fixation (crossed K-wires or two lateral K-wires - lateral safer for ulnar nerve)
• Above-elbow backslab/cast for 3-4 weeks
• Remove K-wires at 3-4 weeks in clinic
• If closed reduction fails → open reduction

• If hand warm + pink despite absent pulse → reduce and fix; pulse usually returns
• If hand cold + white (ischaemic) → emergency exploration of brachial artery after reduction

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5c) Complications

• Neurovascular injury - most important complication
• Anterior interosseous nerve (AIN) injury - most common nerve injury (PIN function)
• Radial nerve injury (wrist drop)
• Median nerve injury
• Brachial artery injury (intimal tear or laceration)
• Compartment syndrome of forearm

• Volkmann's ischaemic contracture - from unrecognised/untreated compartment syndrome or brachial artery injury; results in fixed flexion deformity of fingers/wrist

• Cubitus varus (Gunstock deformity) - most common late complication; medial tilt of forearm; cosmetically unsatisfactory but little functional loss; treated with lateral closing wedge osteotomy
• Cubitus valgus - lateral tilt; rarer
• Stiffness of elbow
• Tardy ulnar nerve palsy - from progressive cubitus valgus; late ulnar nerve injury
• Myositis ossificans
• Avascular necrosis of lateral condyle (if lateral condyle fracture)

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Question 6

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6a) Two Differential Diagnoses

1. Fracture of the Neck of Femur (NOF) - most likely in elderly female
2. Dislocation of the Hip Joint - traumatic (less common in this mechanism)

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6b) Diagnosis

• Mechanism: Low-energy fall (suggests osteoporotic fracture NOF vs. high-energy needed for dislocation)
• Inability to weight-bear
• Prior hip pain, steroid use, osteoporosis
• Comorbidities (cardiovascular, respiratory - for anaesthetic risk)

• X-ray pelvis (AP) + lateral hip: Confirms fracture site, displacement (Garden classification for NOF)
• CT scan: If fracture not visible on X-ray but clinically suspected; also for hip dislocation to check for associated acetabular fracture/intra-articular fragments
• MRI: Most sensitive for occult fracture (if X-ray and CT negative but high clinical suspicion)
• Bloods: FBC, U&E, clotting, group and save (pre-operative)
• ECG, Chest X-ray: Anaesthetic assessment

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6c) Treatment

• IV access, analgesia (IV morphine or femoral nerve block)
• IV fluids
• NBM for surgery
• DVT prophylaxis (TED stockings, LMWH)

• Internal fixation with cancellous screws or dynamic hip screw (DHS) - preserves femoral head
• Aim to fix within 24-36 hours

• Elderly (>65 years): Hemi-arthroplasty (Austin Moore or Thompson prosthesis - replace femoral head only) or Total Hip Replacement (THR) if fit and mobile
• Young patient (<65 years): ORIF - attempt to preserve femoral head

• Early mobilisation (next day with physiotherapy) - reduces mortality
• DVT prophylaxis for 35 days
• Osteoporosis assessment and treatment (bisphosphonates, calcium + Vit D)
• Falls assessment and prevention

• Every 10 hours delay → increased 30-day mortality
• Aims: early mobilisation to prevent complications (pneumonia, DVT, pressure sores, UTI)

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Question 7

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7a) Dislocation and Subluxation

• Examples: Shoulder dislocation, hip dislocation, elbow dislocation

• Examples: Subluxation of radial head (Pulled elbow in children), subluxation of patella, AC joint subluxation

• In dislocation: complete loss of joint contact
• In subluxation: partial contact retained
• Both cause pain, swelling, deformity and restricted movement

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7b) Most Commonly Dislocated Joint and Why

1. Large head, shallow socket - The large humeral head articulates with the small, shallow glenoid cavity (labelled "golf ball on a tee")
2. Wide range of movement - The price of greatest mobility is reduced stability
3. Weak inferior capsule - The inferior portion of the joint capsule is the weakest area
4. Reliance on muscles - Stability depends heavily on the rotator cuff muscles (SITS: Supraspinatus, Infraspinatus, Teres minor, Subscapularis); if these fail, dislocation occurs easily
5. Frequency of falls on outstretched arm - Very common mechanism in all ages

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7c) Classification of Shoulder Dislocation + Management

• Acute, Recurrent, Habitual, Chronic/Irreducible, Congenital

• Traumatic, Atraumatic (generalized laxity), Voluntary

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• Confirm diagnosis clinically (loss of deltoid contour, arm held in external rotation)
• X-ray (AP + axillary lateral) - confirm dislocation direction; exclude fracture (Hill-Sachs lesion = compression fracture of posterolateral humeral head; Bankart lesion = avulsion of glenoid labrum)
• Neurovascular assessment: Axillary nerve (badge area sensation over lateral deltoid - most commonly injured); axillary artery

1. Cunningham Technique - patient seated; massage deltoid; gentle traction on arm - no sedation needed, quick
2. Kocher's Manoeuvre - traction, external rotation, adduction, internal rotation
3. Hippocratic Method - traction on arm while countertraction applied with foot in axilla
4. Milch Technique - gradual abduction and external rotation to 90°; gentle pressure on humeral head
5. Stimson's Method - prone position, weights on wrist; gravity reduces the shoulder

• Confirm reduction: X-ray AP + axillary (check ball back in socket)
• Check neurovascular status (axillary nerve)
• Broad arm sling / shoulder immobiliser for 3-4 weeks
• Analgesia and ice
• Physiotherapy: Rotator cuff strengthening after immobilisation

• High risk of recurrent dislocation (up to 90% in under 25 years)
• After recurrent dislocations → surgical stabilisation:
• Bankart repair (arthroscopic reattachment of anterior labrum to glenoid)
• Latarjet procedure (bone block) if significant glenoid bone loss

• <20 years: ~90% recurrence
• 20-40 years: ~60% recurrence

• 40 years: ~15% (but risk of rotator cuff tear increases)

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Quick Revision Table - Exam 02 Key Facts

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Ward Assessment Exam 03 - Complete Answers

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Question 01

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01a) Three Differential Diagnoses

1. Acute Haematogenous Osteomyelitis (AHO) - Most probable (child, fever, metaphysis of long bone, hot swollen leg)
2. Septic Arthritis of the knee - also presents with fever, hot joint, restricted movement; must always be excluded
3. Ewing's Sarcoma - bone tumour in children; fever, raised ESR, "onion skin" X-ray; can mimic infection

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01b) Clinical Evaluation

• Onset and duration of fever (rapid onset suggests pyogenic infection)
• Site of pain and whether it has moved
• Recent infection: skin boil, sore throat, dental infection, otitis media - source of bacteraemia
• Trauma - even trivial injury may precipitate infection in vulnerable metaphysis
• Immunisation status
• Any joint swelling or inability to bear weight
• Previous similar episodes

• Temperature: high fever (38-40°C)
• Look sick, toxic, irritable
• Pulse and respiratory rate (systemic sepsis)
• Lymphadenopathy

• Look: Swelling, redness, overlying skin changes; compare with opposite limb
• Feel: Localised point tenderness over the metaphysis of the femur/tibia (most important sign); increased warmth; oedema; soft tissue fluctuance (if subperiosteal abscess has formed)
• Move: Restricted movement - especially of adjacent joint (knee); pain on passive movement of joint (if septic arthritis developing)
• Measure limb girth and length

• Blood: FBC (↑WBC, neutrophilia), ESR (↑), CRP (↑ - sensitive early marker), Blood culture (positive in ~50% - do before antibiotics)
• X-ray of the right femur (AP + lateral): Normal in first 10-14 days; later shows periosteal reaction, lytic lesion
• Ultrasound: Shows subperiosteal pus/fluid collection; guides aspiration; detects early joint effusion
• MRI: Most sensitive early imaging; shows bone oedema (low T1, high T2/STIR), soft tissue extension, joint involvement - investigation of choice
• Bone scan (Technetium-99m): Hot spot; useful if site uncertain
• Aspiration/pus culture: If abscess suspected; identifies causative organism

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01c) Treatment Options for Acute Haematogenous Osteomyelitis

• Hospital admission
• IV fluids and electrolyte correction
• Adequate analgesia
• Limb splintage for pain relief (backslab)
• Regular monitoring of temperature, pulse, WBC, CRP, ESR

• Start IV antibiotics immediately after blood culture (do NOT wait for culture results)
• Empirical choice (guided by most likely organism):
• Children 5-12 years: Staphylococcus aureus is overwhelmingly the most common; start IV Flucloxacillin (if MSSA) or IV Cefazolin
• If MRSA suspected: IV Vancomycin or IV Clindamycin
• Salmonella in sickle cell patients
• Duration: IV for 2-3 weeks, then oral for 4-6 weeks (total 4-6 weeks minimum)
• Monitor CRP response - if not falling within 48-72 hours, consider surgery

• Failure to respond to antibiotics within 48-72 hours
• Evidence of subperiosteal abscess on USS/MRI
• Pus on aspiration
• Chronic or established infection

• Drainage and debridement - incision over the affected metaphysis
• Drill holes through periosteum into cortex to decompose intramedullary pressure
• Drain subperiosteal pus
• Send samples for culture and histology
• Wound irrigation; leave drain in situ
• Post-op antibiotics continued

• Excellent if treated early (within 48-72 hours of onset) with antibiotics alone
• Delayed treatment → progression to chronic osteomyelitis, growth disturbance, septic arthritis, pathological fracture

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Question 02

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02a) Provisional Diagnosis

• Young adult male
• History of open fracture (compound fracture) - direct inoculation of bacteria at time of injury
• Chronic discharging sinus - a sinus through which necrotic bone (sequestrum) and pus drain to the skin surface

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02b) Management Plan

• Blood: FBC (↑WBC), ESR (markedly ↑), CRP, blood culture
• X-ray tibia (AP + lateral): Shows sequestrum (dense dead bone fragment), involucrum (new reactive bone around sequestrum), cloaca (holes in involucrum for pus drainage), Brodie's abscess (if subacute)
• CT scan: Best for identifying sequestrum location and extent; guides surgical planning
• MRI: Bone marrow involvement; soft tissue extension
• Sinogram (fistulogram): Inject contrast down sinus to delineate tract and depth
• Sinus swab culture: Identifies causative organism (note: surface swab often colonised with multiple organisms; deep tissue biopsy culture is more reliable)
• Biopsy of sinus tract: Exclude squamous cell carcinoma (Marjolin's ulcer - rare late complication)

• Prolonged antibiotic therapy - guided by culture and sensitivity
• Common organisms: S. aureus (most common), gram-negative rods (E. coli, Pseudomonas), anaerobes
• IV antibiotics for 4-6 weeks, then oral for 3-6 months
• MRSA: Vancomycin; Gram-negatives: Ciprofloxacin (excellent bone penetration)

• Non-weight bearing during active infection
• Physiotherapy: range of motion and strengthening once infection controlled
• Nutritional support (high protein diet)

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02c) Complications

• Non-union of fracture - chronic infection prevents bone healing
• Malunion / shortening - bone loss from debridement
• Pathological fracture - weakened bone snaps under normal stress
• Recurrence of osteomyelitis - even after apparent cure
• Septic arthritis - spread to adjacent joint
• Amyloidosis (secondary) - from long-standing chronic infection (rare); affects kidneys → proteinuria/renal failure
• Marjolin's ulcer - squamous cell carcinoma arising in chronic sinus tract (rare but aggressive; suspect if non-healing ulcer suddenly enlarges)
• Ankylosis of adjacent joint - stiffness from prolonged immobilisation

• Septicaemia (bacteraemia)
• DVT and pulmonary embolism
• Anaemia of chronic disease
• Renal amyloidosis

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Question 03

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03a) Define Osteomyelitis

• Bone destruction
• Necrosis (sequestrum formation)
• New bone formation (involucrum)
• Sinus tract formation in chronic cases

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03b) Classification of Osteomyelitis

• Pyogenic (bacterial): S. aureus (most common), Streptococcus, gram-negatives
• Non-pyogenic: Mycobacterium tuberculosis (TB osteomyelitis), Salmonella, fungi, Brucella

• Based on Anatomic type (I-IV) and Physiologic class (A, B, C host)

• Neonates (<1 month): S. aureus + gram-negatives; multiple bones; hip involvement common
• Children (1-16 years): S. aureus predominant; metaphysis of long bones
• Adults: S. aureus; vertebral bodies common; contiguous or vascular routes common

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03c) Pathogenesis of Chronic Pyogenic Osteomyelitis

• Bacteria (usually S. aureus) enter the bloodstream from a remote focus (boil, sore throat, dental infection)
• Bacteria seed the metaphysis of long bones (see Q4a for why)

• Bacteria multiply in the metaphyseal sinusoids
• Acute inflammatory reaction: neutrophil infiltration, oedema
• Intramedullary pressure rises rapidly (bone cannot expand like soft tissue)
• Rising pressure causes ischaemia of the endosteal blood supply

• Elevated pressure → thrombosis of nutrient vessels → ischaemia → bone necrosis
• Dead bone = sequestrum (dense, avascular fragment of dead cortical bone surrounded by pus)
• Sequestrum is not reabsorbed because it has no blood supply; it acts as a nidus for persistent infection (bacteria inside are protected from antibiotics and host immune cells)

• Pus tracks along the medullary canal and breaks through the cortex
• Strips the periosteum → lifts it off the bone → periosteum responds by forming new reactive bone
• This new periosteal bone surrounding the dead shaft = involucrum
• Involucrum has openings (cloaca) through which pus and pieces of sequestrum discharge to the skin surface → forming the discharging sinus

• The sequestrum persists indefinitely because antibiotics cannot penetrate avascular dead bone
• Involucrum forms a shell of new bone around the infected area
• Pus drains through the sinus → periodic flare-ups → more bone destruction
• Without surgical removal of sequestrum, infection never fully resolves

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Question 04

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04a) Why Acute Haematogenous Osteomyelitis is Common in the Metaphysis

• The metaphyseal vessels make sharp hairpin loops before emptying into venous sinusoids
• Blood flow in these sinusoids is slow and turbulent (compared to diaphyseal vessels)
• Slow flow → bacteria have more time to adhere to vessel walls and seed the bone

• The metaphyseal sinusoids lack phagocytic lining cells (unlike sinusoids in the liver/spleen)
• Bacteria entering these spaces are not efficiently cleared by phagocytes
• This creates a sanctuary for bacteria to multiply unopposed

• The metaphysis is the most vascular region of growing bone
• High blood flow = higher chance of bacteria being deposited

• Metaphyseal vessels are essentially end-arteries with no anastomoses
• Once thrombosed (by infection or pressure), the area becomes rapidly ischaemic and avascular
• No collateral circulation → rapid necrosis

• Minor, often unnoticed trauma in active children creates micro-haematomas
• These serve as a nidus for bacterial seeding during bacteraemia
• Explains why even trivial injury can precipitate osteomyelitis

• In children, the growth plate (physis) is avascular and acts as a barrier
• Prevents spread to the epiphysis (except in neonates where transphyseal vessels exist → hence neonatal osteomyelitis commonly involves the joint)

• Distal femur, proximal tibia (fastest growing in body)
• Proximal humerus
• Proximal femur, proximal radius

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04b) Common Organisms Responsible for Osteomyelitis

1. Staphylococcus aureus - single most common cause at all ages (40-50% of all cases)
2. Streptococcus pyogenes (Group A)
3. Streptococcus pneumoniae
4. Gram-negative bacilli: E. coli, Pseudomonas, Klebsiella, Proteus
5. Salmonella (sickle cell)
6. Mycobacterium tuberculosis (in TB-endemic countries like Bangladesh)
7. Haemophilus influenzae (children, unvaccinated)

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04c) Define Acute Osteomyelitis; What are Sequestrum and Involucrum?

• Sudden onset of high fever and systemic toxaemia
• Severe localised bone pain and tenderness
• Local swelling, redness, and warmth over the affected metaphysis
• Duration of symptoms less than 2 weeks before treatment
• Without necrosis of bone (bone is still alive at this stage if treated early)

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• Formed because thrombosis of medullary vessels causes bone death
• It is dense and sclerotic on X-ray (no remodelling as avascular)
• Surrounded by pus and infected granulation tissue
• Acts as a permanent nidus for infection - antibiotics cannot penetrate dead bone
• Must be surgically removed (sequestrectomy) for cure of chronic osteomyelitis

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• Formed by the periosteum being lifted off the bone by pus and responding with new bone deposition
• Represents the body's attempt to contain and wall off the infection
• Perforated by cloacae - holes through which pus and sequestrum fragments discharge to the sinus tract and skin
• Gives the bone an "onion skin" or irregular expanded appearance on X-ray

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Exam 03 - Key Points to Memorise

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Ward Assessment Exam 04 - Complete Answers

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Question 01

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01a) Define Neoplasm

• This classic definition is attributed to Willis (1952)
• Neoplasms result from mutations causing uncontrolled cell proliferation
• May be benign (localised, non-invasive) or malignant (invasive, metastatic)
• Also called a "tumour" (Latin: swelling), though tumour technically refers to any swelling

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01b) Differences Between Benign and Malignant Neoplasm

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01c) Common Sites for Primary and Secondary Bone Tumours

• Most common overall bone tumour in adults >40 years
• Primary sources (mnemonic: BLT with a Kosher Pickle):
• Breast (most common in females)
• Lung
• Thyroid
• Kidney (renal cell carcinoma)
• Prostate (most common in males)
• Common sites of metastasis: Vertebral column (most common), pelvis, ribs, skull, proximal femur, proximal humerus - all axial skeleton and proximal long bones (red marrow-bearing areas)
• Breast/lung/kidney/thyroid → lytic lesions
• Prostate → sclerotic (blastic) lesions

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Question 02

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02a) Classification of Bone Tumours

• Benign: Osteoma, osteochondroma, enchondroma, osteoid osteoma
• Locally aggressive (borderline): Giant Cell Tumour, Desmoplastic fibroma
• Malignant (primary): Osteosarcoma, Ewing sarcoma, Chondrosarcoma, Multiple myeloma
• Malignant (secondary/metastatic): From breast, lung, prostate, kidney, thyroid

• Children/adolescents: Osteosarcoma, Ewing sarcoma, Osteochondroma
• Adults 20-40 years: GCT, Chondrosarcoma
• Adults >40 years: Chondrosarcoma, Metastases, Multiple myeloma

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02b) Osteosarcoma vs. Ewing Sarcoma

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02c) Radiological Findings of Ewing's Sarcoma

1. "Onion skin" (laminated/lamellated) periosteal reaction - most characteristic; multiple parallel layers of new periosteal bone laid down as tumour repeatedly breaks through periosteum
2. Codman's triangle - triangular elevation of periosteum at the edge of the tumour, forming a reactive periosteal triangle; also seen in osteosarcoma
3. Permeative (moth-eaten) lytic pattern - widespread bony destruction with ill-defined margins; infiltrating through the diaphysis
4. Soft tissue mass - large extraosseous soft tissue extension visible even on plain X-ray
5. Diaphyseal location (unlike osteosarcoma which is metaphyseal)
6. Mixed lytic and sclerotic appearance in some cases

• Extent of cortical destruction
• Soft tissue mass with heterogeneous density
• Identifies skip lesions

• Best for soft tissue extension and bone marrow involvement
• Low T1, high T2/STIR signal
• Guides surgical planning and biopsy

• Intense uptake at primary site
• Detects skip lesions and metastases

• Ewing's sarcoma has a large soft tissue mass disproportionate to bone change
• Onion skin periosteal reaction vs. periosteal elevation in osteomyelitis
• MRI: marrow replacement vs. marrow oedema

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Question 03

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03a) Most Probable Diagnosis

• Young patient (peak age 10-20 years)
• Painful, hard, tender swelling around the knee
• "Sunburst" periosteal reaction on X-ray at the lower end of femur (most characteristic radiological sign of osteosarcoma)

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03b) Diagnostic Approach

• Duration and progression of pain (initially intermittent, then constant, worse at night)
• Swelling - when noticed, rate of growth
• Previous trauma (often falsely attributed; tumour pre-exists)
• Constitutional symptoms: weight loss, anorexia, fever
• Family history of cancer; previous radiation therapy

• General: Pallor, weight loss, lymphadenopathy (uncommon in osteosarcoma)
• Local:
• Inspection: Swelling of distal thigh/around knee; dilated surface veins; skin shiny
• Palpation: Hard, bony swelling; tender; warm; fixed to bone, may be mobile over skin
• Movement: Knee range of motion restricted; joint effusion may be present
• Examine for pathological fracture
• Assess neurovascular status of limb

• FBC (anaemia in advanced disease)
• ESR, CRP (raised)
• Alkaline phosphatase (ALP) - markedly elevated; correlates with tumour activity and prognosis (osteoblastic tumour)
• Lactate Dehydrogenase (LDH) - elevated; poor prognostic marker
• Calcium, Phosphate
• Liver function, Renal function (pre-treatment workup)

• X-ray (AP + lateral): Metaphyseal lytic/sclerotic lesion; cortical destruction; sunburst periosteal spiculation; Codman's triangle; soft tissue extension
• MRI of whole bone (limb): Gold standard for local staging; shows intramedullary extent, soft tissue mass, neurovascular involvement, skip lesions; essential for surgical planning
• CT chest: Lung metastases (most common distant metastasis)
• Bone scan: Whole body; skip lesions, distant bone metastases
• PET-CT: Staging; assess chemotherapy response

• Biopsy - MUST be performed by the treating surgeon (or at the treating centre); poorly placed biopsy can compromise limb salvage
• Needle biopsy (core needle biopsy) - preferred; less contamination
• Incisional biopsy - if core biopsy inconclusive
• Histology shows: Pleomorphic osteoblasts producing osteoid (unmineralised bone matrix); high mitotic rate

• Stage IA: Low grade, intracompartmental
• Stage IB: Low grade, extracompartmental
• Stage IIA: High grade, intracompartmental
• Stage IIB: High grade, extracompartmental (most osteosarcomas)
• Stage III: Any grade with metastasis

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03c) Treatment Plan for Osteosarcoma

• Given BEFORE surgery for 2-3 cycles (approximately 8-12 weeks)
• Regimen: MAP protocol - Methotrexate (high-dose) + Adriamycin (doxorubicin) + Cisplatin
• Benefits:
• Reduces tumour size (downsizing) - increases chance of limb salvage
• Treats micrometastases (20% have metastases at diagnosis)
• Allows assessment of tumour chemosensitivity (histological response guides prognosis)

• Limb-salvage surgery (preferred in 85-90% of cases):
• Wide excision of tumour with adequate margins (>2-3 cm or one tissue plane)
• Reconstruction with: endoprosthesis (modular tumour prosthesis), allograft, or allograft-prosthesis composite
• Requires: no neurovascular involvement, no pathological fracture (relative contraindication), adequate soft tissue coverage
• Amputation (10-15% of cases):
• Indications: involvement of neurovascular bundle, pathological fracture, failed limb salvage, inadequate margins, infection
• Below-knee or above-knee depending on tumour level

• Same MAP regimen for 4-6 more cycles after surgery
• Histological response: >90% necrosis = good responder; better prognosis

• Radiotherapy has no role in primary treatment
• Used for palliative control of unresectable/metastatic disease only

• Localised disease: 5-year survival ~65-75%
• Metastatic disease: 5-year survival ~20-30%

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Question 04

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04a) Categorization of Patients for Management (Triage)

• Airway obstruction
• Respiratory rate <10 or >30/min
• No radial pulse, or capillary refill >2 seconds
• Unresponsive (not obeying commands)
• Uncontrolled haemorrhage
• GCS ≤8

• Vital signs stable
• Significant but non-life-threatening injuries (closed long bone fractures, burns 20-60%)

• Walking; minor lacerations, sprains, fractures

• No spontaneous breathing after airway opened
• Massive burns >60%
• Unsurvivable head injury

• Designate a Triage Officer (most experienced clinician)
• Set up 4 zones: Triage zone, Treatment zone, Transport zone, Casualty clearing station
• Call for backup: additional medical staff, blood bank, theatre teams
• Regular re-triage as patient conditions change

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04b) Indications of Amputation

• Peripheral vascular disease with critical limb ischaemia (non-reconstructable)
• Diabetic foot with gangrene (most common indication in developed world)
• Buerger's disease (thromboangitis obliterans)
• Traumatic arterial injury with irreversible ischaemia
• Frostbite/severe burns with dry gangrene

• Gas gangrene (Clostridium perfringens) - life-threatening; emergency amputation
• Necrotising fasciitis uncontrolled by debridement
• Chronic osteomyelitis unresponsive to treatment with useless limb
• Septic arthritis causing joint destruction

• Traumatic amputation (completion/revision)
• Mangled limb (Mangled Extremity Severity Score MESS ≥7 predicts amputation)
• IIIC open fractures with failed vascular reconstruction
• Crush injury with non-viable muscle

• Malignant tumours (osteosarcoma, soft tissue sarcoma) not amenable to limb-salvage
• Benign but destructive lesions
• Congenital deformity (non-functional limb)
• Failed total joint replacement with sepsis
• Painful non-functional limb (burns, spastic paralysis)

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04c) Complications of Amputation

• Haemorrhage - primary (during surgery) or reactionary (within 24 hours)
• Wound infection
• Shock (from blood loss)
• DVT/PE

• Wound breakdown / dehiscence - poor blood supply at amputation level
• Infection / wound sepsis - especially in diabetics/vascular patients
• Flap necrosis - ischaemic skin flap
• Gas gangrene (if not all necrotic tissue removed)
• Haematoma under stump flap
• Joint contracture at adjacent joint (flexion deformity) - prevented by physiotherapy and positioning

• Phantom limb pain - patient feels pain in the amputated part (see Q6c below)
• Phantom limb sensation - non-painful awareness of amputated limb
• Stump pain - local pain from neuroma, bursitis, infection
• Neuroma - bulbous painful swelling at cut nerve end; treated by excision or burying nerve deeper
• Bursitis - over bone prominence (bursa over end of tibia)
• Bone overgrowth (especially in children) - requires revision surgery
• Poor stump shape - conical, adherent scar, skin irregularities; affects prosthetic fitting
• "Choke syndrome" - venous congestion of stump

• Pressure sores from ill-fitting prosthesis
• Skin problems: eczema, contact dermatitis, cysts

• Depression and psychological adjustment difficulties
• Reduced mobility and cardiovascular fitness (especially bilateral amputees)
• Increased energy expenditure for walking (above-knee amputation = 60-80% more energy)

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Question 05

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05a) Define Polytrauma

• Hypotension (SBP ≤90 mmHg)
• Unconsciousness (GCS ≤8)
• Acidosis (BE ≤-6)
• Coagulopathy (PTT ≥40 sec)
• Age ≥70 years

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05b) Management of Polytrauma (ATLS - Advanced Trauma Life Support)

• Open airway: jaw thrust (if C-spine injury suspected - do NOT tilt head)
• Clear secretions, blood, foreign bodies
• If unconscious (GCS ≤8): Definitive airway - endotracheal intubation
• Apply cervical spine collar - assume C-spine injury until proven otherwise
• Jaw thrust > chin lift in trauma

• Expose chest; look, listen, feel
• Treat immediately life-threatening: Tension pneumothorax (needle decompression → chest drain), Open pneumothorax (occlusive dressing), Massive haemothorax (chest drain)
• Give high-flow O₂ (15L/min via reservoir mask)
• SpO₂ target >95%

• Identify and control haemorrhage - direct pressure, wound packing, tourniquet for limbs
• Two large-bore IV cannulas (14-16G) in antecubital fossae
• Take blood: FBC, U&E, clotting, group & cross-match, ABG, blood sugar
• Fluid resuscitation: permissive hypotension (target SBP 80-90 mmHg until haemorrhage controlled) - avoid dilutional coagulopathy
• Massive haemorrhage protocol: 1:1:1 ratio (packed red cells : fresh frozen plasma : platelets)
• FAST (Focused Assessment with Sonography for Trauma) scan - detect haemoperitoneum, haemothorax, pericardial tamponade

• GCS score (see Q5c)
• Pupillary response: size, reactivity, asymmetry
• Blood sugar (hypoglycaemia mimics brain injury)
• Look for lateralising signs (hemiplegia = intracranial bleed until proven otherwise)

• Fully expose patient (cut clothing)
• Log-roll with spine control; examine back, buttocks, perineum
• Prevent hypothermia ("lethal triad": hypothermia + acidosis + coagulopathy) - warm blankets, warm IV fluids, warm environment

• After primary survey stabilised
• Full physical examination: head, face, C-spine, chest, abdomen, pelvis, limbs, neurological
• AMPLE history: Allergies, Medications, Past history, Last meal, Events/mechanism

• Trauma CT (CT head, CT chest, CT abdomen/pelvis - "trauma pan-scan")
• Pelvis X-ray, CXR
• FAST ultrasound

• Damage control surgery: control bleeding and contamination first; not definitive repair
• ICU admission for monitoring
• Early involvement of: Neurosurgery, Cardiothoracic surgery, Vascular surgery, Orthopaedics

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05c) Components of the Glasgow Coma Scale (GCS)

• Minimum: 3 (deep coma or death)
• Maximum: 15 (fully conscious)

• 13-15: Minor injury
• 9-12: Moderate injury
• ≤8: Severe injury; indicates need for definitive airway (intubation)
• ≤8 = "intubate" (cannot protect own airway)

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Question 06

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06a) Giant Cell Tumour (GCT)

• Age: 20-40 years (adults; unusual in children before epiphyseal closure)
• Sex: Slightly more common in females
• Among the most common bone tumours (4-5% of primary bone tumours)

• Always involves the epiphysis and extends to the subchondral bone
• Distal femur (most common), proximal tibia, distal radius (3rd most common but produces worst morbidity), proximal humerus
• Can also occur in vertebrae and sacrum

• Pain and swelling around the joint
• Pathological fracture in ~10% at presentation
• May have joint effusion

1. Eccentric location in the epiphysis
2. Lytic (osteolytic) lesion - no calcification, no sclerotic margin
3. "Soap bubble" appearance - thin bony trabeculae within the lytic area
4. Extends to the subchondral plate (right up to the articular surface)
5. Expansile - cortex expanded and thinned, sometimes breached
6. No periosteal reaction (distinguishes from osteosarcoma)
7. Defined by Campanacci grade: I (latent), II (active), III (aggressive - cortical breach)

• Large multinucleated giant cells (osteoclast-like; 50-100 nuclei) evenly distributed throughout
• Mononuclear stromal cells (fibroblast-like) are the true neoplastic cells
• No matrix production (distinguishes from osteosarcoma)

• Extended curettage (aggressive intralesional curettage) with high-speed burr + adjuvant (phenol, liquid nitrogen, cement) → bone graft or PMMA cement to fill cavity
• Recurrence rate: ~15-25% after curettage (high)
• Wide excision (distal radius): for expendable bones; reconstructed with fibular autograft
• Denosumab: Anti-RANKL antibody; reduces osteoclast activity; used for unresectable, recurrent, or metastatic GCT; allows downsizing before surgery
• Lung metastases occur in 1-3% ("benign metastasising GCT")
• Malignant transformation (~1-2%) - especially post-irradiation (avoid radiotherapy)

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06b) Osteoid Osteoma

• Age: 5-25 years (children and young adults)
• Sex: Male predominance (2-3:1)
• ~10% of benign bone tumours

• Cortex of long bones: proximal femur (most common - especially femoral neck), tibia, fibula
• Spine: posterior elements (lamina, pedicle) - causes painful scoliosis
• Rarely: carpals, tarsals, phalanges

• Hallmark: Constant, boring pain, worse at night, dramatically relieved by aspirin or NSAIDs (prostaglandin E2 produced by the nidus responds to NSAIDs) - this is pathognomonic
• Point tenderness
• If in spine: painful scoliosis (concavity toward lesion)
• If in long bone: adjacent joint synovitis; leg length discrepancy in children

• Central nidus (< 1 cm; lucent or partly calcified) surrounded by dense fusiform cortical sclerosis
• The sclerosis can be so dense it obscures the nidus
• Nidus = small round lucency, sometimes with central calcification

• Investigation of choice - best demonstrates the nidus; small lucent area with central calcification ("target lesion") within dense sclerosis

• "Double density sign" - intense hot spot at nidus within surrounding reactive uptake; very sensitive

• Nidus shows low T1 and high T2 signal; surrounding marrow oedema; may overestimate extent

• Nidus: interlacing trabeculae of osteoid and woven bone surrounded by vascular fibrous stroma, osteoblasts, osteoclasts
• NO atypia; no malignant features

• NSAIDs: Many cases resolve spontaneously over 3-7 years; NSAIDs control symptoms (prostaglandin inhibition)
• CT-guided radiofrequency ablation (RFA): Treatment of choice; minimally invasive; >90% success rate; destroys the nidus thermally via CT-guided needle
• Surgical excision: If RFA unavailable or contraindicated; intralesional excision/curettage of the nidus

• Osteoid osteoma: < 2 cm; responds to NSAIDs; cortical
• Osteoblastoma: > 2 cm; does NOT respond to NSAIDs; more aggressive; spinal predominance

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Exam 04 - Key Facts to Memorise

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• Army Medical College Bogura branding
• All 4 exam subjects listed

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OSCE Stations — Complete Answers

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🔵 STATION 03 (Version A) — Wrist X-Ray

a) Identify the X-Ray (1)

(If the image shows a triangular/pie-shaped lunate on AP and anterior displacement on lateral — this is classic lunate dislocation)

b) Three Radiological Features (3×0.5)

1. Disrupted carpal alignment — the normal smooth arcs (Gilula's arcs) of the carpal bones are broken
2. Triangular/pie-shaped appearance of the lunate on AP view (normally trapezoidal) — "piece of pie" sign
3. Increased scapholunate gap (>3 mm) = "Terry Thomas sign" — suggests scapholunate dissociation

c) Three Probable Diagnoses (3×0.5)

1. Lunate dislocation (most probable — lunate dislocates anteriorly; all other carpals maintain position relative to radius)
2. Perilunate dislocation (lunate stays; rest of carpus dislocates posteriorly)
3. Scapholunate dissociation (isolated ligament injury with widened gap)

d) How to Confirm the Diagnosis (1)

• Lateral X-ray of wrist (most important) — on lateral view, lunate dislocation shows the "spilled teacup" sign: lunate tilts and faces anteriorly, displaced volar to the radius; in perilunate dislocation, the lunate aligns with the radius but capitate is displaced posteriorly
• CT scan of wrist — best for identifying exact displacement and any associated fractures (especially scaphoid)
• MRI — evaluates ligamentous injuries (scapholunate, lunotriquetral ligaments)

e) One Treatment Option for Most Probable Diagnosis (1)

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🔵 STATION 03 (Version B) — Elbow X-Ray (Lateral, "L" labelled)

Q1. Radiological Findings + Radiological Dx

• Lateral X-ray of left elbow
• Positive posterior fat pad sign (elevated posterior fat pad = "sail sign") — indicates intra-articular haemarthrosis
• Loss of the anterior humeral line — line along anterior humeral cortex should pass through middle third of capitellum; in this X-ray the line passes anterior to the capitellum, indicating posterior displacement
• Disruption of the normal carrying angle / alignment at the elbow
• Posterior displacement of the distal humeral fragment

Q2. Four Common Fractures from Fall on Outstretched Hand (FOOSH)

1. Supracondylar fracture of humerus (children) — most common elbow fracture in children
2. Colles' fracture (distal radius) — most common in adults/elderly
3. Scaphoid fracture — young adults; snuffbox tenderness; may not show on initial X-ray
4. Fracture of the clavicle — indirect force transmitted through shoulder

Q3. How to Treat This Case (Supracondylar Fracture)

• Document neurovascular status (radial pulse, AIN function — "OK sign") before and after reduction
• If pulseless + cold ischaemic hand → emergency vascular exploration after reduction

Q4. Four Complications

1. Anterior interosseous nerve (AIN) injury — most common nerve injury; "OK sign" lost (can't flex tip of thumb + index)
2. Brachial artery injury — most dangerous vascular complication; threatened limb
3. Volkmann's ischaemic contracture — from unrecognised compartment syndrome; fixed flexion deformity of fingers/wrist
4. Cubitus varus (gunstock deformity) — most common LATE complication; medial tilt; cosmetic; treated with lateral closing wedge osteotomy

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🔵 STATION 10 — Right Hip X-Ray (AP pelvis)

a) Read the X-Ray with Radiological Findings

• AP X-ray of the right hip/pelvis (labelled "R")
• The femoral head is displaced superiorly and laterally out of the acetabular socket
• Empty acetabulum visible
• The femoral head appears smaller/more opaque than the left (foreshortening due to displacement)
• Limb is shortened
• No obvious fracture of the femoral head or acetabulum visible (though CT needed to exclude)

b) Radiological Diagnosis

c) Who is Most Commonly Affected and Why?

• The hip joint has strong capsule and ligaments — enormous force is needed to dislocate it
• Dashboard injury is the classic mechanism for posterior dislocation: knee hits dashboard → force transmitted along femoral shaft → posterior force on femoral head drives it out posteriorly through the posterior capsule
• Males > females due to higher exposure to high-energy trauma (motor vehicle accidents, sports)

d) Three Clinical Features the Patient May Present With

1. Limb held in flexion, adduction, and internal rotation (posterior dislocation — classic position; mnemonic: "FLAIR" = Flexed, aLready Internally Rotated and Adducted)
2. Inability to weight-bear; severe hip pain
3. Apparent shortening of the limb on the affected side

e) Definitive Treatment

• Post-reduction: check X-ray (confirm reduction); CT scan to exclude intra-articular fragments/acetabular fracture
• Skin traction for 2–4 weeks; non-weight bearing → graduated mobilisation
• Open reduction if closed reduction fails (interposed soft tissue/bony fragment)

f) What Happens if Left Untreated?

1. Avascular necrosis (AVN) of the femoral head — most serious complication; blood supply (medial femoral circumflex artery) disrupted; risk increases dramatically if reduction delayed >6 hours; leads to femoral head collapse and devastating arthritis
2. Post-traumatic osteoarthritis — progressive joint destruction
3. Sciatic nerve palsy — permanent foot drop, sensory loss if nerve damage not relieved
4. Myositis ossificans — heterotopic bone formation around hip
5. Chronic dislocation — fixed deformity; very difficult late reconstruction

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🔵 STATION 04 — Long Bone X-Ray (Tibia/Fibula)

Q1. Radiological Findings + Radiological Dx

• AP X-ray of the left tibia and fibula
• Periosteal reaction — layered new bone formation along the cortex (involucrum)
• Dense fragment within the medullary canal — sequestrum (dead avascular cortical bone; denser than surrounding live bone because it has no remodelling)
• Areas of lysis (lucency) surrounding the sequestrum — represents pus and granulation tissue
• Cortical thickening and sclerosis of the tibial shaft
• Cloaca may be visible — holes in the involucrum through which pus drains
• Soft tissue swelling/thickening

Q2. What is a Sequestrum?

• It is white/dense on X-ray (no remodelling because no blood supply)
• Surrounded by pus and infected granulation tissue
• Acts as a permanent nidus for persistent infection — bacteria inside the sequestrum are protected from antibiotics and host immune cells because there is no blood supply
• Must be surgically removed (sequestrectomy) for cure — antibiotics alone cannot eradicate infection within avascular dead bone

Q3. How is Sequestrum Formed?

1. Bacteria (usually S. aureus) enter bone via haematogenous spread and seed the metaphysis
2. Inflammatory reaction → intramedullary pressure rises (bone is rigid and cannot expand)
3. Raised pressure causes thrombosis of the medullary and periosteal blood vessels → ischaemia
4. Ischaemia leads to bone necrosis — the affected cortical bone dies
5. Dead bone separates from living bone → forms the sequestrum (dense, avascular fragment)
6. The sequestrum is surrounded by pus and cannot be reabsorbed (no blood supply = no osteoclast activity = no remodelling)
7. It persists indefinitely → nidus for chronic infection → ongoing suppuration

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🔵 STATION 05 — Bandaging Materials (4 objects A, B, C, D)

Q1. Identify the Objects + Q2. Two Uses of Each

Memory tip: A = Plaster; B = Gauze; C = Wool; D = Crepe — "Patients Get Well Quickly" (with Crepe!)

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🔵 STATION 06 — Right Shoulder X-Ray

Q1. Radiological Findings

• AP X-ray of the right shoulder (labelled "R")
• Humeral head displaced anteriorly and inferiorly — no longer in the glenoid fossa
• "Empty glenoid" sign — glenoid fossa is visible without the humeral head
• Humeral head lies below the coracoid process (subcoracoid position — most common anterior dislocation type)
• Loss of normal rounded shoulder contour
• May show Hill-Sachs lesion (compression fracture of posterior-lateral humeral head) on internal rotation view
• Look for: greater tuberosity fracture (associated in ~15% of cases)

Q2. Diagnosis

Q3. Clinical Attitude (Position) of the Patient

• Slight abduction and external rotation of the arm
• Loss of the normal rounded deltoid contour — shoulder looks "squared off" or flat
• Prominent acromion — step deformity visible/palpable
• Patient holds the arm away from body, supported with the other hand
• Reluctance to move the arm; any movement extremely painful
• Fullness/bulge anteriorly (below clavicle / coracoid) where the humeral head has displaced

Q4. Management Techniques

• Check axillary nerve (sensation over lateral deltoid — "badge area") — most commonly injured nerve
• Check axillary artery (rare)
• X-ray AP + axillary lateral BEFORE reduction to confirm direction and exclude fracture

• Confirm reduction: X-ray (AP + axillary)
• Re-check axillary nerve function
• Broad arm sling / shoulder immobiliser for 3–4 weeks
• Ice, analgesia (NSAIDs, opioids if needed)
• Physiotherapy: rotator cuff strengthening (supraspinatus, infraspinatus, teres minor, subscapularis) after immobilisation

• Young patients (<25 years) → up to 90% recurrence
• Bankart repair (arthroscopic reattachment of anterior labrum to glenoid)
• Latarjet procedure (bone block) if significant glenoid bone loss

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🔵 STATION 07 — Wrist X-Ray (AP + Lateral views)

Q1. Describe X-Ray + Radiological Diagnosis

• AP and lateral X-ray of the right wrist
• Fracture of the distal radius within 2.5 cm of the articular surface (extra-articular)
• Dorsal (posterior) displacement of the distal fragment
• Dorsal angulation (posterior tilt of articular surface — normal is 11° volar tilt)
• Radial shortening — radius shorter relative to ulna
• Radial deviation of the distal fragment
• Possible ulnar styloid avulsion fracture (often associated)
• On lateral view: "dinner fork" deformity — dorsal step at the fracture site

Q2. Structures That Can Be Injured

1. Median nerve — most commonly injured nerve; runs through the carpal tunnel just distal to the fracture; acute carpal tunnel syndrome (numbness/tingling in thumb, index, middle finger; weakness of thenar muscles)
2. Ulnar nerve — less common; can cause medial 1½ fingers numbness
3. Extensor Pollicis Longus (EPL) tendon — delayed rupture (weeks later) at Lister's tubercle; patient unable to extend thumb IP joint
4. Distal radio-ulnar joint (DRUJ) — disrupted by avulsion of ulnar styloid; causes wrist instability and long-term pain
5. Radial artery — rarely damaged; in severe displacements

Q3. Treatment

• Below-elbow POP backslab → convert to full cast → 5–6 weeks
• Repeat X-ray at 1 and 2 weeks to detect secondary displacement

• Closed reduction + below-elbow POP cast:
• Anaesthesia: haematoma block (lidocaine into fracture haematoma) or Bier's block (IV regional anaesthesia)
• Technique: traction → accentuate deformity → reduce → hold in slight flexion and ulnar deviation
• Post-reduction X-ray in theatre to confirm
• Below-elbow cast for 5–6 weeks
• Serial X-rays at 1 and 2 weeks

• Intra-articular step-off >2 mm
• Comminuted/highly unstable fracture
• Failed/lost closed reduction
• Young active patient
• Methods: volar locking plate (gold standard), K-wire fixation, external fixator

Q4. Reverse Type of This Fracture

• Volar (anterior) displacement of the distal radial fragment (opposite to Colles')
• Mechanism: fall on a flexed wrist (back of hand strikes ground) or direct blow to dorsum of wrist
• X-ray: distal fragment displaced and angulated volarly (anteriorly)
• Treatment: usually ORIF with volar locking plate (unstable; closed reduction rarely holds)

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OSCE Quick Summary Table