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Quick Revision Highlights for Distinction

Q1 (PIH) - Key Points to Remember:

• 5 categories: Gestational HTN → Preeclampsia (mild/severe) → Eclampsia → HELLP → Chronic HTN
• Severe features: BP ≥160/110, platelets <1 lakh, Cr >1.1, raised LFTs, pulmonary oedema, CNS symptoms
• MgSO₄ = anticonvulsant of choice (Pritchard: 4g IV + 10g IM loading)
• MgSO₄ antidote = Calcium gluconate 10% IV
• Definitive treatment = delivery

Q2 (Postmenopausal Bleeding) - Key Points:

• TVUS endometrial thickness ≤4 mm = low risk (>4 mm investigate)
• Pipelle biopsy = first-line; Hysteroscopy+D&C = gold standard
• 10% are malignant (endometrial Ca) - always exclude first
• Most common benign cause = atrophic vaginitis

Q3 (Clinical Scenario) - Key Points:

• G2P1+0 + macrosomia + polyhydramnios at 28 weeks = GDM until proven otherwise
• Do 75g OGTT; target FBS <95, 2-hr <120 mg/dL
• Previous LSCS + macrosomia + polyhydramnios = elective repeat LSCS at 38-39 weeks
• Fetus >4.5 kg = absolute indication for LSCS

Q4 Short Notes - Key Mnemonics:

• PALM COEIN: Polyp, Adenomyosis, Leiomyoma, Malignancy | Coagulopathy, Ovulatory, Endometrial, Iatrogenic, Not classified
• Mackenrodt's ligament = most important uterine support
• AMTSL: Oxytocin 10 IU IM within 1 min (main component) + CCT + Uterine massage
• Abruption vs Previa: Painful+concealed+DIC vs Painless+bright red+no DIC
• Choriocarcinoma low risk = Methotrexate monotherapy; high risk = EMA-CO
• Stages of Labour: 1st (0-10 cm), 2nd (delivery of baby), 3rd (placenta), 4th (2 hrs observation)

Q5 (MTP Act) - Key Points:

• Original 1971: up to 12 weeks (1 doctor), 12-20 weeks (2 doctors)
• 2021 Amendment: up to 20 weeks (1 doctor), 20-24 weeks for special categories (2 doctors), beyond 24 weeks = State Medical Board
• Unmarried women now covered for contraceptive failure
• At 12 weeks: MVA (surgical) or Mifepristone + Misoprostol (medical)
• Always offer post-procedure contraception counselling

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GENERAL SURGERY (ORTHOPAEDICS)

Saraswati Medical College Unnao - MBBS III-1, 2nd Terminal Exam

Full Distinction-Level Answers (5 Marks Each)

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1. Anterior Shoulder Dislocation

Definition

Anatomy

• Rotator cuff muscles (SITS: Supraspinatus, Infraspinatus, Teres minor, Subscapularis)
• Glenohumeral ligaments (superior, middle, inferior)
• Glenoid labrum (deepens the socket by ~50%)

Mechanism of Injury

• Indirect (most common): Fall on outstretched hand (FOOSH) with arm abducted, externally rotated and extended
• Direct: Blow to posterior shoulder
• Forced external rotation: Sports (throwing, swimming, martial arts)

Clinical Features

• History: FOOSH mechanism, severe shoulder pain, patient supports arm with opposite hand
• Inspection: Loss of normal rounded shoulder contour - "flattening of deltoid" / squaring of shoulder; prominent acromion ("step deformity"); arm held in slight abduction and external rotation
• Palpation: Hollow beneath acromion; humeral head palpable anteriorly/axilla
• Loss of function: All shoulder movements restricted; particularly internal rotation impossible

Associated Injuries

Investigations

• X-ray shoulder AP + axial/lateral (Y-view): Loss of normal relationship; subcoracoid position of humeral head; Hill-Sachs lesion; greater tuberosity fracture
• MRI: Post-reduction assessment of Bankart lesion, labral tear, rotator cuff integrity

Management

Immediate (Closed Reduction) - under sedation/analgesia

1. Kocher's method (leverage technique): Adduct, externally rotate, bring elbow across body, internally rotate - NOT recommended now (risk of fracture)
2. Hippocratic method: Traction-countertraction; foot in axilla while pulling arm
3. Stimson technique: Patient prone, 5 kg weight attached to arm, gravity aids reduction over 20-30 minutes
4. Milch technique: Arm abducted overhead, thumb pressure on humeral head; reduces via leverage
5. External rotation method (Leidelmeyer): Elbow at 90°, arm adducted, slow external rotation - safest, least forceful
6. Cunningham technique: Muscle relaxation by massaging biceps/deltoid; no traction needed

Post-Reduction

• Sling immobilisation: 3 weeks (young) to 1-2 weeks (elderly - early mobilisation to prevent stiffness)
• Physiotherapy: rotator cuff strengthening, proprioception exercises
• Recurrence rate: 80-90% in patients <20 years; decreases with age

Surgical

• Bankart repair (arthroscopic): Reattachment of anterior-inferior labrum; indicated for recurrent dislocation
• Latarjet procedure: Coracoid transfer to anterior glenoid rim; for significant glenoid bone loss
• Remplissage: Hill-Sachs lesion filling with posterior capsule/infraspinatus

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2. Glasgow Coma Scale (GCS)

Definition

Components and Scoring

E - Eye Opening (max 4)

V - Verbal Response (max 5)

M - Motor Response (max 6)

Total Score

• Maximum: 15 (fully conscious)
• Minimum: 3 (deeply comatose)

Interpretation

Clinical Significance

• GCS ≤8 → Indication for intubation and mechanical ventilation (cannot maintain airway)
• Serial GCS: worsening by 2 or more points = significant deterioration; urgent CT scan
• Predictor of outcome: Higher initial GCS = better prognosis; GCS 3-5 = poor outcome
• Motor component (M) most prognostically important

Limitations

• Cannot be assessed in: intubated patients (use GCS-T), sedated patients, severe aphasia
• Does not assess brainstem reflexes (pupillary, corneal) - use together with FOUR Score for complete assessment
• Standardised to reduce inter-observer variability (always document E+V+M separately, not just total)

Mnemonics

• Eyes: 1, 2, 3, 4 = None, Pressure, Sound, Spontaneous
• Verbal: 1-5 = None, Sounds, Words, Confused, Oriented
• Motor: 1-6 = None, Extension (decerebrate), Flexion (decorticate), Withdrawal, Localise, Obeys

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3. Dinner Fork Deformity

Definition

Mechanism

• Fall on outstretched hand (FOOSH) with wrist in dorsiflexion
• Most common in post-menopausal women (osteoporosis) and elderly
• Most common fracture in adults >40 years; peak incidence in women 60-70 years

Characteristics of Colles' Fracture (Classic Deformities - "DERD")

Why "Dinner Fork"?

• Viewed from the side: the wrist shows a characteristic dorsal hump at the fracture site with a step-off deformity that resembles the shape of a dinner fork (silver fork) lying face down
• Prominence dorsally = displaced distal fragment
• Concavity proximally = fracture site

Clinical Features

• Swelling, bruising over dorsum of wrist
• Tenderness over distal radius
• Dinner fork deformity (side view) - dorsal bump
• Bayonet deformity (AP view) - radial deviation + shortening
• Restricted wrist movements (especially dorsiflexion)

Associated Injuries

• Ulnar styloid fracture (~50-60% of cases)
• Distal radioulnar joint (DRUJ) disruption
• Nerve: Median nerve (acute carpal tunnel syndrome) - most common nerve complication
• Extensor pollicis longus (EPL) tendon rupture - delayed complication (3-6 weeks post-injury)

Investigations

• X-ray wrist AP + lateral:
  • Dorsal displacement and angulation
  • Radial shortening
  • Loss of normal volar tilt (normally 11-12° volar)
  • Loss of radial inclination (normally 22-23°)
  • Ulnar styloid fracture

Management

Undisplaced/Minimally Displaced

• Below-elbow POP cast (plaster) in slight volar flexion and ulnar deviation
• Duration: 6 weeks
• Weekly X-rays for 3 weeks (to detect re-displacement)

Displaced (Requires Reduction)

• Closed manipulation under local/haematoma block/GA:
  • Disimpact by accentuating deformity
  • Traction to disimpact
  • Correct dorsal tilt + radial shortening
  • Immobilise in POP cast (Cotton-Loader position: slight flexion + ulnar deviation)
• Below-elbow cast for 6 weeks; X-ray at 1, 2 weeks post-reduction

Unstable / Failed Closed Reduction

• Percutaneous K-wire fixation (Kapandji technique): 2-3 K-wires + POP cast
• External fixation: Ligamentotaxis; for highly comminuted fractures
• Volar locking plate (ORIF): Gold standard for unstable, intra-articular, or displaced fractures; allows early mobilisation

Physiotherapy

• Finger exercises from day 1
• Shoulder and elbow exercises
• After cast removal: grip strengthening, wrist ROM exercises

Complications

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4. Supracondylar Fracture of Humerus

Definition

Classification (Gartland Classification - Extension Type)

Mechanism

• Extension type: Fall on outstretched hand (FOOSH) - olecranon acts as a lever
• Flexion type (rare, 1-3%): Direct blow on posterior elbow (fall on flexed elbow)

Clinical Features

• Painful swollen elbow; child holding arm at side
• S-shaped deformity (extension type) on lateral view
• Loss of normal carrying angle
• IMPORTANT: Check neurovascular status FIRST and document before treatment

Key Landmarks on X-ray

• Anterior humeral line: On lateral X-ray, a line along anterior cortex of humerus should pass through middle third of capitellum (passes anterior in supracondylar fracture)
• Baumann angle: Between capitellar physis and long axis of humerus; normally 70-75°; decreased in supracondylar fracture
• Fat pad signs: Positive posterior fat pad = haemarthrosis = occult fracture

Neurovascular Complications (Distinction Point)

White Pulseless Hand vs Pink Pulseless Hand

• White pulseless: Cold, pale, no Doppler signal → surgical emergency → reduce immediately + vascular surgery exploration if pulse doesn't return
• Pink pulseless: Perfused hand (collaterals) but no pulse → reduce + stabilise → observe; vascular exploration if pulse still absent after reduction

Management

Type I

• Collar and cuff or backslab in 90° flexion for 3 weeks
• No reduction needed

Type II

• Closed reduction under GA:
  • Traction + correct rotation → flex elbow
  • If periosteal hinge intact: above-elbow cast in 90-120° flexion
  • If unstable: percutaneous K-wires

Type III/IV - CRPP (Closed Reduction + Percutaneous K-wire Fixation)

• Standard of care for displaced fractures
• 2 lateral divergent K-wires OR 1 lateral + 1 medial K-wire (medial K-wire risk: ulnar nerve injury)
• Above-elbow cast post-CRPP for 3-4 weeks
• K-wire removal at 3-4 weeks (clinic)

Open Reduction

• Failed closed reduction (rare)
• Open vascular injury requiring exploration
• Irreducible fracture (interposed periosteum/muscle)

Complications

• Volkmann's ischaemic contracture: Most feared complication; compartment syndrome of forearm → muscle necrosis → fibrosis → flexion contracture of wrist + fingers; prevented by careful post-reduction monitoring (5 P's: Pain, Pallor, Paraesthesia, Paralysis, Pulselessness)
• Cubitus varus (gunstock deformity): Most common late complication; malunion with medial tilt; cosmetic deformity; corrected by supracondylar osteotomy
• Malunion / Cubitus valgus: Risk of late tardy ulnar nerve palsy
• Myositis ossificans: Abnormal bone formation in muscle (avoid repeated manipulation)
• Avascular necrosis of capitellum (rare)

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5. Galeazzi Fracture-Dislocation

Definition

"Reverse Monteggia" vs Galeazzi

• Monteggia: Proximal ulna fracture + radial head dislocation
• Galeazzi: Distal radius fracture + DRUJ dislocation (inverse)
• Mnemonic: "MUGR" - Monteggia = Ulna + radial head dislocation; Galeazzi = Radius + ulnar dislocation

Mechanism

• Axial loading with pronation (fall on outstretched hand with hyperpronation)
• Sports, motor vehicle accidents
• Much less common than Monteggia; accounts for ~3-7% forearm fractures

Clinical Features

• Pain, swelling over distal forearm
• Localised tenderness at fracture site (distal 1/3 radius)
• DRUJ instability: dorsal prominence of ulnar head; ballottement of ulnar head (piano key sign)
• Restriction of forearm rotation (pronation/supination)
• Wrist pain

Investigations

• X-ray forearm AP + lateral (must include wrist AND elbow):
  • Radius fracture at junction of middle/distal thirds
  • Widening of DRUJ (>5 mm suggests disruption)
  • Ulnar head dorsal subluxation on lateral view
  • Radial shortening (>5 mm = DRUJ disruption likely)
  • Ulnar styloid fracture (associated in ~50%)
• CT wrist: To confirm DRUJ disruption if X-ray inconclusive

Management

Adults - ORIF (Open Reduction Internal Fixation)

• Standard of care - ORIF of radius + assessment of DRUJ
• 3.5 mm dynamic compression plate (DCP) applied to volar (Henry) or dorsal surface of radius
• After radius fixation:
  • DRUJ reduces in most cases (90%)
  • Test DRUJ stability under fluoroscopy (forearm rotation)
  • If stable: above-elbow cast in neutral/supination for 4-6 weeks
  • If DRUJ still unstable: Kirschner wire through DRUJ in supination OR repair of TFCC (triangular fibrocartilage complex)

Children (rare)

• May be managed with closed reduction + long-arm cast in supination
• ORIF if unstable

Complications

• DRUJ instability: Most common; chronic wrist pain; limitation of rotation
• TFCC tear: Triangular fibrocartilage complex disruption
• Interosseous membrane injury: Affects forearm stability
• Superficial radial nerve (Wartenberg's nerve) injury: Paraesthesia dorsum thumb/index
• Malunion / non-union: If inadequately treated by conservative means
• Radio-ulnar synostosis: If periosteum stripped excessively

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6. Fracture Clavicle

Definition

Anatomy

• S-shaped bone connecting sternum to acromion
• Serves as a strut between trunk and upper limb
• No intramedullary canal (unlike other long bones)
• Middle third is the weakest point (transition between curves; no muscle attachment)

Mechanism

• Fall on outstretched hand or direct blow to lateral shoulder - most common (indirect)
• Sports (rugby, cycling, equestrian, motorsports)
• Motor vehicle accidents
• Neonatal clavicle fracture: Birth injury (shoulder dystocia, large baby)

Classification (Allman/Craig Classification)

Clinical Features

• History of fall on outstretched hand / shoulder
• Localised swelling, bruising, tenderness over clavicle
• Step deformity: Palpable bony step at fracture site
• Drooping of shoulder: Due to weight of arm pulling distal fragment inferiorly
• Patient supports elbow with opposite hand, tilts head to affected side (relaxes SCM)
• Tenting of skin: Proximal fragment may tent skin (risk of open fracture)

Associated Injuries

• Pneumothorax / Haemothorax: Especially in high-energy trauma
• Subclavian artery/vein injury: Rare but serious
• Brachial plexus injury (C5-C6 most vulnerable): Especially in displaced fractures
• Rib fractures: Associated in polytrauma

Investigations

• X-ray clavicle AP and 15° cephalic tilt view
• CT scan: Medial third fractures (sternoclavicular assessment)
• MRI/arteriogram: If vascular injury suspected

Management

Conservative (Most Middle-Third Fractures)

• Broad arm sling (body bandage): Most widely used; supports arm weight; 6 weeks
• Figure-of-eight bandage: Retracts shoulders, may help hold reduction; NOT superior to sling; associated with neurovascular complications; less used now
• Analgesics (NSAIDs, paracetamol)
• Gradual pendulum exercises from week 2-3
• Return to sports: 8-12 weeks (non-contact), 12-16 weeks (contact)

Surgical - ORIF (Indications)

Complications

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7. Principles of Triage

Definition

Goals of Triage

• Do the greatest good for the greatest number
• Identify immediately life-threatening but salvageable conditions
• Allocate limited resources rationally and efficiently
• Continuously reassess and re-triage (dynamic process)

Triage Categories - START System (Simple Triage and Rapid Treatment)

Colour-Coded Priority System:

START Triage Algorithm (Primary Triage)

Can patient WALK?
    YES → GREEN (minimal)
    NO ↓
Check BREATHING:
    None → Open airway:
        Still none → BLACK (deceased)
        Starts → RED (immediate)
    Present: Rate?
        >30/min → RED
        ≤30/min ↓
Check PERFUSION (radial pulse or cap refill):
    Absent (cap refill >2s) → RED
    Present ↓
Check MENTAL STATUS:
    Cannot follow commands → RED
    Follows commands → YELLOW

SALT System (Sort, Assess, Lifesaving Interventions, Treatment/Transport)

• More comprehensive; used in USA
• Sort: Walk → Wave → Still (decreasing priority)
• Assess: Breathing, obstructed airway, bleeding, need for lifesaving interventions

JumpSTART (Paediatric Triage)

• Modified START for children: checks for pulse before declaring BLACK (children more likely to respond to airway opening)

Military Triage (NATO) - Additional Category

• T1: Immediate
• T2: Delayed
• T3: Minimal
• T4: Expectant
• T5: Dead
• Additional concept: Expectant (T4) - injuries incompatible with survival given available resources; differs from civilian where all attempts are made

Hospital-Level Triage

• SIEVE (Primary, scene): Rapid; walking / breathing / respiratory rate / perfusion
• SORT (Secondary, hospital): Based on physiological parameters (GCS + BP + RR = Revised Trauma Score)

Key Principles

1. Speed: Assessment < 30 seconds per patient at scene
2. Reassessment: Conditions change; re-triage frequently (dynamic triage)
3. Documentation: Triage tag attached to patient (colour-coded)
4. No triage without resources: Triage is meaningless unless treatment/transport follows
5. Triage Officer: Senior experienced clinician; should NOT personally treat (must oversee entire process)
6. Reverse triage: In some scenarios (e.g. NBC warfare), walking wounded triaged first (can decontaminate themselves)

Disaster Triage Context

• Mass Casualty Incident (MCI): >3 patients exceeding local resources
• Coordinate with: Police (security), Fire brigade (extrication), EMS (transport), Hospital (receiving)
• Incident Command System (ICS) activated for large MCIs

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8. Muscle Power Grading

Definition

MRC Scale for Muscle Power Grading

Grade 4 Subdivisions (4-, 4, 4+)

• 4-: Movement against slight resistance
• 4: Movement against moderate resistance
• 4+: Movement against strong (near-normal) resistance

Method of Testing

1. Patient positioned appropriately (isolate the muscle/joint being tested)
2. Assess passive ROM first (no contracture)
3. Gravity eliminated position (for grades 0-2): limb supported on horizontal surface
4. Against gravity position (grades 3-5): vertical movement
5. Resistance applied (grades 4-5): manual resistance by examiner
6. Compare bilaterally (right vs left)
7. Document: muscle name + grade, e.g. "Right deltoid: Grade 4"

Clinical Applications

Upper Motor Neuron (UMN) vs Lower Motor Neuron (LMN) Lesions

Peripheral Nerve Injury Assessment (Seddon's Classification)

• Neuropraxia: Grade 3-4; axon intact; full recovery expected
• Axonotmesis: Grade 0-2; axon disrupted, endoneurium intact; recovery likely (1 mm/day)
• Neurotmesis: Grade 0; complete nerve division; surgical repair needed

Common Clinical Examples

Functional Significance

• Grade 0-1: Complete functional loss; dependent for all activities
• Grade 2: Very limited function; gravity remains major obstacle
• Grade 3: Functional threshold - can use limb for gravity-assisted activities
• Grade 4: Useful function with some compensation
• Grade 5: Normal function

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9. Acute Osteomyelitis

Definition

Pathogenesis

Route of Infection

1. Haematogenous (most common, especially children): Bacteraemia seeds metaphysis; slow sinusoidal blood flow in metaphysis allows bacterial seeding
2. Direct inoculation: Open fracture, penetrating wound, surgery
3. Contiguous spread: From adjacent soft tissue or joint infection

Why Metaphysis?

• Richly vascularised
• Sinusoidal blood flow (slow velocity)
• Deficient phagocytic activity
• Terminal capillary loops (no anastomoses in children)
• Growth plate acts as a barrier

Common Organisms by Age

Common Sites

• Children: Metaphysis of long bones: distal femur > proximal tibia > proximal humerus > proximal femur
• Adults: Vertebral column (lumbar > thoracic > cervical)
• Neonates: Can cross growth plate → spreads to epiphysis + adjacent joint (septic arthritis)

Clinical Features

Local (Classical Triad)

• Pain: Constant, throbbing; worse at night; point tenderness over metaphysis
• Swelling: Soft tissue oedema; then brawny oedema
• Loss of function: Child refuses to weight-bear; "pseudoparalysis" in infants

Systemic (Sepsis features)

• Fever (38-40°C), rigors
• Malaise, irritability (especially infants)
• Tachycardia

Important Sign

• Point tenderness over metaphysis (highly specific)
• Pseudo-paralysis in infants - limb held still due to pain (must not be confused with nerve palsy)

Investigations

Pathological Stages (Cierny-Mader)

1. Early (<72 hrs): Bacterial seeding → acute inflammation → pus under periosteum (subperiosteal abscess)
2. 4-7 days: Periosteum stripped → devascularisation of bone → ischaemia
3. >7-10 days: Dead bone fragment (sequestrum); periosteum forms new bone shell (involucrum); pus may track to skin through a sinus (cloaca/sinus)
4. Chronic osteomyelitis: If inadequately treated; sequestrum + involucrum established

Management

Medical (Antibiotic Therapy) - When Appropriate

• Diagnosis within 2-3 days of onset
• No dead bone (sequestrum) on imaging
• No adjacent septic arthritis
• Clinical improvement within 24-48 hours of antibiotics

• Children >1 year: IV Flucloxacillin (anti-staphylococcal) 50 mg/kg/day in 4 divided doses OR IV Cefazolin
• Children <1 year / Neonates: IV Flucloxacillin + Gentamicin (Gram-negative cover)
• MRSA suspected (IV drug user, healthcare contact): IV Vancomycin 15 mg/kg every 6-8 hours
• Sickle cell patient: Cover Salmonella - IV Ceftriaxone + Flucloxacillin
• IV antibiotics for 2-3 days until clinical improvement, then step down to oral (switch to oral Flucloxacillin/Co-amoxiclav)
• Total duration: 4-6 weeks (minimum; 6 weeks for vertebral osteomyelitis)

Supportive

• Limb splinting (rest; POP backslab)
• Adequate analgesia
• Nutritional support

Surgical (Indications)

• No response to IV antibiotics within 48-72 hours
• Identifiable subperiosteal or intraosseous abscess
• Sequestrum formation (dead bone requiring removal)
• Adjacent septic arthritis
• Deteriorating systemic condition despite antibiotics

• Incision and drainage of subperiosteal abscess
• Bone drilling / cortical windowing (if intraosseous pus)
• Debridement of necrotic tissue
• Wound lavage; may be packed open or closed with drain
• Bone biopsy + tissue culture at time of surgery (definitive organism identification)

Prognosis

• With prompt appropriate treatment: 90% cure rate (Bailey & Love)
• Delayed treatment → chronic osteomyelitis (recurrent discharge, sequestrum, sinus)
• In children: growth plate damage → limb length discrepancy, angulation deformity

Complications

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Quick Summary Table for All 9 Topics