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OBSTETRICS & GYNAECOLOGY - Part II

Full Distinction-Level Answers

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Q1. Classify and Define Various Stages of PIH with Their Management (5+5=10)

Classification of PIH (Hypertensive Disorders of Pregnancy)

1. Gestational Hypertension

• Definition: New onset BP ≥140/90 mmHg after 20 weeks of gestation, without proteinuria or end-organ damage, normalizing within 12 weeks postpartum.
• Accounts for ~70% of hypertension in pregnancy.

2. Preeclampsia

• Definition: Gestational hypertension (BP ≥140/90 mmHg after 20 weeks) PLUS proteinuria (>300 mg/24 hr or urine protein:creatinine ratio ≥0.3), OR any evidence of end-organ damage even without proteinuria.

• BP 140-159/90-109 mmHg
• Proteinuria ≥300 mg/24 hrs
• No severe features

• BP ≥160/110 mmHg on two occasions 4 hrs apart
• Thrombocytopenia (platelets <100,000/µL)
• Serum creatinine >1.1 mg/dL
• Transaminases 2x upper limit of normal
• Pulmonary oedema
• New-onset headache unresponsive to medication
• Visual or cerebral disturbances

3. Eclampsia

• Definition: Occurrence of generalised tonic-clonic seizures in a patient with preeclampsia, not attributable to other causes.
• Can occur antepartum (most common ~50%), intrapartum, or postpartum (within 48 hours, up to 4 weeks).

4. HELLP Syndrome

• Severe form of preeclampsia:
  • H - Haemolysis (LDH >600 U/L, schistocytes on smear)
  • EL - Elevated Liver enzymes (ALT/AST >70 U/L)
  • LP - Low Platelets (<100,000/µL)
• Sibai classification: Class I (<50,000), Class II (50-100,000), Class III (100-150,000)

5. Chronic Hypertension

• Pre-existing hypertension before 20 weeks or persisting >6 weeks postpartum.

6. Superimposed Preeclampsia on Chronic Hypertension

• Chronic hypertension + new-onset proteinuria, or sudden worsening of previously controlled hypertension.

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Management of PIH

Mild Gestational Hypertension / Mild Preeclampsia

• Hospitalise or intensive outpatient monitoring
• Bed rest, left lateral position
• Daily BP monitoring, urine protein (dipstick)
• Twice-weekly CBC, LFT, RFT, uric acid
• Daily fetal kick count, weekly NST, fortnightly USG + Doppler
• Antihypertensives if BP persistently ≥150/100 mmHg: oral Labetalol (first-line), Nifedipine (sustained-release), or Methyldopa
• Fetal lung maturity (betamethasone 12 mg IM x2 doses, 24 hrs apart) if <34 weeks
• Definitive treatment = delivery at 37 weeks

Severe Preeclampsia

• Admit to ICU/HDU; IV access, Foley catheter
• Antihypertensive: IV Labetalol 20 mg bolus (repeat every 10 min, max 220 mg), or oral Nifedipine 10-20 mg, or IV Hydralazine 5-10 mg
• Seizure prophylaxis: MgSO₄ (Pritchard regimen) - 4g IV loading over 5-10 min + 10g IM (5g each buttock), then 5g IM every 4 hours
• Aim: BP <160/110 mmHg; UO >25 mL/hr
• Delivery after stabilisation; LSCS if unfavourable cervix
• Monitor MgSO₄ toxicity: DTRs, RR (>12/min), UO (>25 mL/hr); antidote = 10 mL of 10% Ca gluconate IV

Eclampsia

• ABC - protect airway, lateral position, O₂
• IV MgSO₄ (Pritchard/Zuspan regimen) - controls seizures + prevents recurrence
• Control BP as above
• Immediate delivery after stabilisation (LSCS preferred)
• Postpartum MgSO₄ continued for 24-48 hours

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Q2. Causes of Postmenopausal Bleeding, Definition and Management (5+5=10)

Definition

• Menarche to menopause = reproductive years; natural menopause average age: 51 years (India ~45-47 years)

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Causes (5 marks)

Malignant / Pre-malignant (must exclude first)

1. Endometrial carcinoma - most important (accounts for ~10% of PMB; 90% of endometrial Ca presents with PMB)
2. Cervical carcinoma
3. Fallopian tube carcinoma (rare)
4. Ovarian carcinoma with endometrial involvement
5. Endometrial hyperplasia (simple, complex, with/without atypia - pre-malignant)
6. Vaginal / vulval carcinoma

Benign Causes (majority ~90% of PMB)

1. Atrophic vaginitis / endometritis - most common benign cause; due to oestrogen deficiency
2. Endometrial / cervical polyp
3. Hormone Replacement Therapy (HRT) - breakthrough bleeding
4. Tamoxifen therapy (antiestrogen with agonist effect on endometrium)
5. Uterine fibroids (though usually regress postmenopause)
6. Bleeding diathesis / anticoagulant therapy (warfarin)
7. Cervical ectropion / cervicitis
8. Trauma - post-coital

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Management (5 marks)

Initial Assessment

• Detailed history: duration, amount, associated symptoms (pain, discharge, weight loss)
• Obstetric/menstrual history, HRT/tamoxifen use, family history (Lynch syndrome, BRCA)
• General & pelvic examination: speculum (polyp, cervical lesion), bimanual (uterine size)
• Exclude non-genital causes (urethral, rectal)

Investigations

Treatment

• Atrophic vaginitis: Local oestrogen cream (estriol), lubricants
• Endometrial polyp: Hysteroscopic polypectomy
• Simple hyperplasia without atypia: Progestins (Medroxyprogesterone acetate 10 mg/day cyclically x 3-6 months); repeat biopsy
• Atypical hyperplasia: TAH+BSO (due to 30% risk of co-existing carcinoma)
• Endometrial carcinoma: TAH + BSO + pelvic lymph node dissection (staging surgery); adjuvant radiotherapy for advanced stages
• HRT-related: Adjust regimen or discontinue

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Q3. G2P1+0 at 28 Weeks for ANC (H/o LSCS for Large Baby 4.2 kg, Polyhydramnios) - Approach and Management (5+5=10)

Analysis of the Clinical Scenario

• G2P1+0 (2nd pregnancy, 1 previous delivery with no living child issue from first - or 1 living child)
• 28 weeks gestation, first ANC visit (late booking - red flag)
• Previous LSCS for macrosomic baby (4.2 kg)
• Apparent Polyhydramnios

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Approach (5 marks)

History

• LMP, EDD, POG confirmation
• H/o previous pregnancy: type of LSCS, indication, uterine incision (lower segment vs classical), any complications
• Symptoms of diabetes: polyuria, polydipsia, excessive weight gain, recurrent infections (vulvovaginitis, UTI)
• Family history of diabetes, hypertension
• Current medications

Physical Examination

• Weight, BMI, BP
• Symphysio-fundal height (SFH): will be larger than dates (polyhydramnios + macrosomic fetus)
• Fluid thrill, difficult fetal palpation (polyhydramnios signs)
• Fetal presentation: may be unstable due to excess fluid
• Urine for sugar and protein

Investigations for GDM Diagnosis

1. Fasting plasma glucose and 75g OGTT (ADA/WHO criteria):
   • Fasting ≥126 mg/dL OR
   • 2-hr post-load ≥200 mg/dL OR
   • HbA1c ≥6.5% = Diabetes in pregnancy
   • Fasting 92-125 + 2-hr 153-199 = GDM
2. HbA1c (baseline glycaemic control)
3. Urine R/M + culture (UTI common in GDM)
4. Thyroid function tests (associated thyroid dysfunction)
5. Renal function + LFTs (baseline)
6. Detailed anomaly scan + echocardiography - fetal macrosomia, congenital heart defects, neural tube defects more common in GDM

Investigations for Polyhydramnios

• Amniotic Fluid Index (AFI): Polyhydramnios = AFI >24 cm or single deepest pocket >8 cm
• Causes to rule out: fetal anomalies (oesophageal atresia, anencephaly, duodenal atresia), Rh isoimmunisation, twin-to-twin transfusion, GDM (idiopathic 60%)

Previous LSCS Assessment

• Review operative notes (incision type - LSCS scar)
• USG: scar thickness (lower uterine segment) - adequate if >3 mm
• Risk of scar dehiscence/rupture: increased with polyhydramnios (over-distension) and macrosomia

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Management (5 marks)

Immediate

1. Confirm GDM diagnosis by OGTT; consult endocrinologist
2. Fetal surveillance: anomaly scan, fetal echo
3. Assess AFI, fetal growth

Glycaemic Control

1. Dietary modification first: low glycaemic index, 1800-2200 kcal/day, 3 main meals + 3 snacks, restricted simple carbs
2. Insulin therapy if targets not met in 1-2 weeks:
   • FBS target: <95 mg/dL
   • 1-hr postprandial: <140 mg/dL
   • 2-hr postprandial: <120 mg/dL
   • Insulin: Intermediate-acting (NPH) + rapid-acting (Regular) in split doses
   • Metformin may be used in India (FOGSI guidelines) if insulin not accepted
3. Self-monitoring of blood glucose (SMBG): 4-6 times/day

Fetal Monitoring

• NST weekly from 32 weeks
• Fetal growth scan every 3-4 weeks
• Doppler at 32-34 weeks (middle cerebral artery, umbilical artery)
• BPP if NST non-reactive

Management of Polyhydramnios

• If symptomatic (severe respiratory distress, preterm labour risk): therapeutic amniocentesis (amnioreduction) - drain 1-1.5 L slowly
• Indomethacin (cyclo-oxygenase inhibitor - reduces fetal urine output, closes DA) - use cautiously before 32 weeks
• Treat underlying cause (GDM control)

Timing and Mode of Delivery

• Repeat LSCS is the safest option given:
  • Previous LSCS scar
  • Likely macrosomic fetus
  • Polyhydramnios (risk of cord prolapse with VBAC)
• Elective LSCS at 38-39 weeks if well-controlled GDM without macrosomia (>4.5 kg = absolute indication for LSCS)
• Paediatrician/neonatologist present at delivery
• Post-delivery: neonatal blood glucose monitoring (hypoglycaemia within 2 hours); baby may need NICU care

Postpartum

• OGTT at 6 weeks postpartum (30-50% develop T2DM later)
• Counsel on contraception, lifestyle modification
• Breastfeeding encouraged (reduces future diabetes risk)

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Q4. Short Notes (8 × 5 = 40)

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a) Supports of the Uterus

Primary (Active) Supports - Pelvic Floor

• Levator ani muscles (pubococcygeus, iliococcygeus, puborectalis) - most important mechanical support; form the pelvic diaphragm
• Perineal body - central tendinous structure of the perineum, anchors several muscles

Secondary (Passive) - Ligamentous

Factors Maintaining Normal Position

• Anteversion + anteflexion (normal axis)
• Intrabdominal pressure directed toward pelvic floor not cervix
• Vaginal tone

Clinical Relevance

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b) Maternal Mortality Ratio (MMR) and Its Causes

Definition

India's MMR (NFHS/SRS data):

• MMR 2018-20: 97/1,00,000 live births (SRS)
• Target: SDG Goal 3.1 = <70/1,00,000 LB by 2030

Causes of Maternal Mortality

1. Haemorrhage (PPH, APH) - single most common cause globally and in India (~27%)
2. Hypertensive disorders (eclampsia, preeclampsia) - ~14%
3. Sepsis/infection - ~11%
4. Obstructed labour - ~8%
5. Unsafe abortion - ~8%
6. Embolism (amniotic fluid, pulmonary thromboembolism)

• Anaemia (very common in India - contributing to PPH deaths)
• Cardiac disease in pregnancy
• Hepatitis, malaria, tuberculosis
• Diabetes

Preventable Factors (3-delay model):

• Delay 1: Decision to seek care (lack of recognition of danger signs)
• Delay 2: Reaching care (transport, distance)
• Delay 3: Receiving adequate care (poor facility quality)

Reduction Strategies:

• JSY/JSSK (Janani Suraksha/Shishu Suraksha Yojana)
• PMSMA (Pradhan Mantri Surakshit Matritva Abhiyan)
• Skilled birth attendance (SBA training)
• EmONC facilities
• AMTSL to reduce PPH (see Q4e)

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c) Causes of Female Infertility

• Primary infertility: Never conceived
• Secondary infertility: Previous conception/pregnancy

Causes (Categorised)

1. Ovulatory Factors (~30-40%)

• PCOS (most common) - oligo/anovulation, LH:FSH ratio >2:1
• Hypothalamic dysfunction: functional hypothalamic amenorrhoea (weight loss, exercise, stress)
• Hyperprolactinaemia: pituitary adenoma, drugs (dopamine antagonists); elevated prolactin suppresses GnRH
• Thyroid disorders: hypothyroidism (raises TRH → TSH + prolactin), hyperthyroidism
• Premature ovarian insufficiency (POI): FSH >25 IU/L before age 40; autoimmune, iatrogenic (chemotherapy, radiation), genetic (Turner syndrome)
• Diminished ovarian reserve: raised FSH, low AMH, low antral follicle count (AFC)

2. Tubal/Peritoneal Factors (~30-40%)

• Tubal occlusion: Post-PID (Chlamydia, N. gonorrhoeae), post-septic abortion, post-surgical
• Endometriosis (chocolate cysts, peritubal adhesions, altered peritoneal environment)
• Pelvic adhesions: previous surgery (myomectomy, appendicectomy)
• Hydrosalpinx: toxic to embryo (backflow into uterine cavity)

3. Uterine/Cervical Factors (~10%)

• Uterine anomalies: septate (most common), bicornuate, unicornuate uteri
• Fibroids: submucosal > intramural (distort cavity)
• Asherman's syndrome: intrauterine adhesions post-D&C/myomectomy/endometritis
• Cervical stenosis: post-LLETZ/conization
• Cervical hostility: inadequate mucus (anti-sperm antibodies, cervicitis)

4. Vaginal Factors

• Vaginismus, vaginal agenesis, imperforate hymen

5. Unexplained Infertility (~10-15%)

• All investigations normal; possible subtle ovulatory dysfunction, implantation failure, sperm-egg interaction defects

6. Systemic Causes

• Diabetes, obesity (insulin resistance → androgen excess)
• Autoimmune disease (antiphospholipid syndrome → implantation failure)

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d) Choriocarcinoma - Management

• Marked elevation of β-hCG
• Absence of chorionic villi (distinguishes from hydatidiform mole)
• Early haematogenous spread (lungs, brain, liver, vagina)

FIGO Staging (I-IV)

• Stage I: Confined to uterus
• Stage II: Extends to other genital structures
• Stage III: Lung metastases
• Stage IV: All other metastases (brain, liver - worst prognosis)

WHO Prognostic Scoring (Risk Stratification):

Management

Low-Risk GTN (Score 0-6, Stage I-III)

• Single-agent chemotherapy:
  • Methotrexate (MTX): 50 mg/m² IM weekly, or MTX 0.4 mg/kg/day x5 days with folinic acid rescue
  • Actinomycin-D: 1.25 mg/m² IV every 2 weeks (if MTX resistance/contraindicated)
• Cure rate: >95%
• hCG monitored weekly; 3 consecutive normal levels = remission
• Consolidation: 2-3 more courses after normalisation

High-Risk GTN (Score ≥7, Stage IV)

• Multi-agent chemotherapy:
  • EMA-CO regimen: Etoposide + Methotrexate + Actinomycin-D (alternating courses) + Cyclophosphamide + Oncovine (vincristine)
  • Alternative: EMA-EP (Etoposide + Cisplatin)
• Cure rate: ~85-90% even with metastases
• Brain metastases: Whole brain radiotherapy + EMA-CO; intrathecal MTX
• Hepatic metastases: Hepatic arterial infusion

Role of Surgery

• Hysterectomy: May be primary treatment in low-risk GTN in women who have completed family (reduces chemotherapy courses); emergency for uncontrolled haemorrhage
• Resection of isolated drug-resistant metastasis

Fertility Preservation

• Chemotherapy does NOT impair fertility
• Contraception for 12 months after hCG normalisation before attempting pregnancy
• Subsequent pregnancies: no increase in congenital anomalies

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e) AMTSL (Active Management of the Third Stage of Labour)

Definition

Components of AMTSL (WHO/FIGO recommendations):

• Oxytocin 10 IU IM within 1 minute of delivery of the baby (before delivery of placenta)
• Given after excluding second baby
• Oxytocin is the uterotonic of choice (WHO 2012)
• If oxytocin unavailable: Misoprostol 600 µg sublingually or rectally
• Ergometrine (carbetocin in some protocols): additional uterotonic if needed

• Wait for uterine contraction
• Counter-pressure on uterus suprapubically (guard uterus)
• Steady downward and backward traction on cord
• Do NOT pull cord without uterine contraction (risk: uterine inversion)
• No longer mandatory if oxytocin given (WHO 2012 update)

• After placenta delivered: sustained uterine massage to promote contraction
• Fundal massage within 15 minutes of delivery
• No longer recommended routinely post-oxytocin administration (WHO 2012) - only if uterus not well contracted

• Now incorporated into current practice: clamp cord at 1-3 minutes (benefits newborn iron stores + neurodevelopment); does not increase PPH

Benefits of AMTSL:

• Reduces PPH incidence by 60%
• Reduces need for blood transfusion
• Reduces duration of third stage (normally up to 30 min; AMTSL reduces to 5-10 min)

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f) PALM-COEIN Classification

PALM - Structural Causes:

COEIN - Non-Structural Causes:

• HMB (Heavy Menstrual Bleeding): >80 mL/cycle or flooding/clots
• IMB (Intermenstrual Bleeding)
• PCB (Postcoital Bleeding)
• Oligomenorrhoea, amenorrhoea, dysmenorrhoea

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g) Difference Between Abruptio Placentae and Placenta Previa

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h) Stages of Labour

Stage 1 - Cervical Dilatation

• Primigravida: ~12-18 hours (average)
• Multigravida: ~6-8 hours

Stage 2 - Expulsive Stage

• Primigravida: up to 1 hour (or 2 hours with epidural)
• Multigravida: 30 minutes (or 1 hour with epidural)

1. Engagement (biparietal diameter passes pelvic brim)
2. Descent
3. Flexion (chin on chest, suboccipitobregmatic diameter = 9.5 cm presents)
4. Internal rotation (occiput rotates anteriorly to lie under symphysis pubis)
5. Extension (head extends as it passes under pubic arch, crowning occurs)
6. Restitution (head rotates back to original position)
7. External rotation (shoulders align with AP diameter of outlet)
8. Expulsion of the body

Stage 3 - Placental Stage

• Calkin's sign: uterus becomes globular and firm
• Cord lengthening (Dührssen's sign)
• Gush of blood
• Uterus rises in abdomen (placenta descends into lower segment)

Stage 4 - Postpartum Observation

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Q5. MTP Act - Definition, Amendments, and Counselling of 20-year Primigravida at 12 Weeks (2+3+5=10)

What is the MTP Act? (2 marks)

• Protect the life of the pregnant woman
• Prevent the birth of seriously handicapped children
• Prevent pregnancies resulting from rape or contraceptive failure

• Termination permitted up to 12 weeks by a registered medical practitioner (RMP) alone
• Between 12-20 weeks: opinion of 2 RMPs required
• No time limit if risk to life of the woman is present
• Approved facilities only (Government hospital or MTP-certified private clinic)
• No gestational limit for pregnancies threatening the woman's life or substantial fetal abnormality

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Amendments to the MTP Act (3 marks)

MTP (Amendment) Act 2021 (effective September 24, 2021) - Major changes:

1. Survivors of sexual assault/rape
2. Minors
3. Change of marital status (widowhood, divorce)
4. Women with physical disabilities (≥40% disability)
5. Women with mental illness
6. Fetal malformation incompatible with life or with serious handicap
7. Humanitarian settings/emergencies

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Role of Gynaecologist in Counselling (5 marks)

Legal Assessment

• At 12 weeks, she falls WITHIN the legal limit (up to 20 weeks - 1 RMP sufficient)
• MTP is legally permissible with a single RMP opinion
• She may be unmarried - this is now covered under the amended Act (contraceptive failure provision extended to unmarried women)

Counselling Framework (Non-directive, Non-judgmental, Confidential)

• Private, confidential setting; reassure no coercion
• Maintain confidentiality (legal requirement under amended Act)

• Clinical examination + USG confirmation (gestational age, rule out ectopic, confirm intrauterine pregnancy)
• At 12 weeks: medical or surgical method can be offered

• Is the decision free and voluntary?
• Reason for seeking MTP (contraceptive failure, unwanted, rape, fetal anomaly, etc.)
• Support system at home

• Incomplete abortion (need repeat procedure)
• Haemorrhage
• Infection (endometritis)
• Uterine perforation (surgical methods)
• Cervical injury
• Asherman's syndrome (rare)
• Psychological effects (counsel that normal grief/guilt is expected; support available)

• Counsel on contraception to prevent repeat unwanted pregnancy
• Options: OCP (can start same day), DMPA (injectable, 3-monthly), Cu-IUD (can be inserted at time of surgical MTP), implant, condoms
• Strongly advise consistent contraceptive use

• Written informed consent is mandatory
• She must understand the procedure, alternatives (continuing pregnancy, adoption), risks
• If minor: parental consent or court order required (although 2021 Act protects minors)

• Review in 1-2 weeks to confirm complete termination (clinical/USG + hCG decline)
• Emotional support/counselling follow-up

Important Ethical Points

• The gynaecologist has the right to conscientious objection but must refer to another provider
• No punitive action if MTP performed in good faith per the Act
• The woman's autonomy and right to reproductive choice must be respected

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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