---

CLINICAL ORTHOPAEDICS - PREVIOUS YEAR QUESTION ANALYSIS

PDF 1: Sub Code 6266 (4th Year BPT, 2011-2026) - 20 MARK Questions

PDF 2: Sub Code 6284 (3rd Year BPT, 2020-2026) - 15 MARK Questions

---

PART A: REPEATED QUESTIONS WITH FREQUENCY COUNT

---

PDF 1 (Sub Code 6266) - 20 MARK REPEATED QUESTIONS

---

PDF 2 (Sub Code 6284) - 15 MARK REPEATED QUESTIONS

---

TOP MOST REPEATED QUESTIONS (Both PDFs Combined)

---

---

PART B: DETAILED ANSWERS TO ALL 20-MARK AND 15-MARK QUESTIONS

---

Q1. FRACTURE NECK OF FEMUR

Definition

Classification (Garden's Classification)

• Grade I - Incomplete/impacted fracture (valgus impaction)
• Grade II - Complete fracture, no displacement
• Grade III - Complete fracture, partial displacement
• Grade IV - Complete fracture, full displacement

• Type I: < 30 degrees (most stable)
• Type II: 30-70 degrees
• Type III: > 70 degrees (most unstable - shear force)

Causes/Aetiology

• Osteoporosis (most common in elderly)
• Trivial fall or twisting injury in elderly
• Direct blow to the greater trochanter
• Pathological fracture - due to tumour metastasis, Paget's disease
• In young adults: high-energy trauma

Clinical Features

• Severe pain in hip/groin region
• Inability to bear weight
• Inability to stand or walk

• Shortening of limb (apparent and true)
• External rotation of affected limb (foot points outward)
• Adduction deformity
• Tenderness over femoral triangle
• Any attempt to rotate the hip is very painful
• Telescopy positive

Investigations

• X-ray hip AP and lateral view - confirms diagnosis
• MRI - detects occult/stress fractures
• Blood investigations: CBC, ESR, serum calcium, phosphorus, alkaline phosphatase

Management

• Bed rest
• Skin traction
• Pain management
• Mobilisation physiotherapy

• Garden Grade I & II (undisplaced): Multiple cancellous screws/cannulated screws fixation
• Garden Grade III & IV (displaced) - Young patient (<60 yrs): Open reduction + internal fixation (ORIF) with dynamic hip screw (DHS) or cannulated screws. Goal: preserve femoral head
• Elderly patient (>60-65 yrs): Hemiarthroplasty (Austin Moore prosthesis or Thompson prosthesis) OR Total Hip Replacement (THR) if OA changes present

Complications

• Avascular Necrosis (AVN) of femoral head - most feared complication (blood supply from lateral femoral circumflex artery and vessels in ligamentum teres is disrupted)
• Deep Vein Thrombosis (DVT)
• Pulmonary embolism
• Fat embolism
• Infection

• Non-union - very common (20-30%)
• Malunion
• Osteoarthritis of hip
• Coxa vara (neck-shaft angle <120 degrees)

Physiotherapy Management

• Pre-operative: Strengthening quadriceps, breathing exercises
• Post-operative: Early mobilisation within 24-48 hours
• Gait training with walking aids
• Hip strengthening exercises (abductors, extensors)
• Balance and proprioception training

---

Q2. SUPRACONDYLAR FRACTURE OF HUMERUS

Definition

Mechanism of Injury

Classification (Gartland's Classification)

• Type I - Undisplaced (only anterior humeral line disrupted)
• Type II - Displaced but with posterior cortex intact (hinged)
• Type III - Completely displaced (posteromedial or posterolateral)
• Type IV - Multidirectional instability (modern addition)

Clinical Features

• Pain, swelling, tenderness around elbow
• Reluctance to move the elbow
• "S" shaped deformity (posterior prominence of olecranon)
• Bruising in the antecubital fossa
• Loss of normal bony landmarks
• Pulses must be assessed (brachial artery)
• Neurological examination essential

Investigations

• X-ray elbow AP and lateral - confirms fracture
• Lateral view: anterior humeral line should pass through middle 1/3 of capitellum; if passes anterior = extension fracture
• Baumann's angle (carrying angle) measured on AP view
• Doppler ultrasound if vascular injury suspected

Management

• Collar and cuff/posterior slab in 90° flexion
• Immobilize 3 weeks then mobilise

• Closed manipulation under general anaesthesia + above elbow plaster cast
• If unstable: percutaneous K-wire fixation

• Closed reduction + percutaneous K-wire fixation (standard treatment)
• Open reduction + K-wire if closed reduction fails
• 3-4 K-wires inserted (lateral entry preferred to avoid ulnar nerve injury)
• Above elbow cast 3-4 weeks post-operatively

• Urgent reduction; if pulse returns - observe; if pulse absent after reduction - surgical exploration of brachial artery required

Complications

• Brachial artery injury - most dangerous; may cause Volkmann's ischaemic contracture
• Nerve injury:
  • Anterior interosseous nerve (branch of median nerve) - most common nerve injury in Type III
  • Radial nerve (posterolateral displacement)
  • Median nerve
  • Ulnar nerve (flexion type)

• Volkmann's Ischaemic Contracture - compartment syndrome due to brachial artery injury → ischaemia of forearm flexors → fibrosis and contracture
• Compartment syndrome

• Cubitus varus (gun-stock deformity) - most common late complication (malunion with internal rotation)
• Cubitus valgus
• Myositis ossificans
• Stiffness of elbow
• Tardy ulnar nerve palsy (in cubitus valgus)

Physiotherapy

• Post-immobilisation: Gentle ROM exercises
• Strengthening of elbow flexors, extensors
• Functional activities of upper limb
• Monitor for compartment syndrome signs

---

Q3. RHEUMATOID ARTHRITIS

Definition

Aetiology / Etiopathology

• Genetic: HLA-DR4, HLA-DR1 association
• Environmental: Smoking (increases anti-CCP antibodies), infections (Epstein-Barr virus, Proteus mirabilis)
• Autoimmune mechanism:
  • CD4+ T helper cells activated
  • B cells produce Rheumatoid Factor (IgM against Fc portion of IgG) and anti-CCP antibodies
  • TNF-alpha, IL-1, IL-6 released → synovial inflammation → pannus formation
  • Pannus (granulation tissue) invades and destroys cartilage and bone

Pathology

1. Synovial membrane becomes hyperplastic
2. Inflammatory cells infiltrate synovium
3. Pannus formation - fibrovascular tissue covering articular cartilage
4. Cartilage erosion and bone destruction
5. Joint space narrowing
6. Periarticular osteoporosis
7. Eventually: fibrous or bony ankylosis

Clinical Features

• Morning stiffness > 1 hour (characteristic)
• Commonly affected: MCPs, PIPs, wrists, knees, ankles
• DIP joints SPARED (distinguishes from OA)
• Rheumatoid hand deformities:
  • Z-thumb deformity (IP hyperextension + MCP flexion)
  • Boutonnière deformity (PIP flexion + DIP hyperextension)
  • Swan neck deformity (PIP hyperextension + DIP flexion)
  • Ulnar drift/deviation at MCPs
  • Mallet finger
  • Trigger finger

• Rheumatoid nodules (subcutaneous, over bony prominences)
• Eye: Keratoconjunctivitis sicca (Sjogren's), scleritis
• Lung: Pleural effusion, pulmonary fibrosis, Caplan's syndrome
• Heart: Pericarditis, valve disease
• Vasculitis
• Felty's syndrome (RA + splenomegaly + neutropenia)
• Anaemia of chronic disease

Investigations

• Rheumatoid Factor (RF): positive in 70-80%
• Anti-CCP antibodies: most specific test
• ESR, CRP raised
• Anaemia (normocytic normochromic)
• X-ray: Periarticular osteoporosis, joint space narrowing, erosions, subluxation
• Synovial fluid analysis: turbid, poor mucin clot

ACR Diagnostic Criteria (2010 - score ≥6 = RA)

1. Joint involvement (0-5 points)
2. Serology - RF/anti-CCP (0-3 points)
3. Acute phase reactants - ESR/CRP (0-1 point)
4. Duration of symptoms (0-1 point)

Management

• NSAIDs: Ibuprofen, Naproxen (for pain and inflammation)
• Corticosteroids: Low-dose prednisolone (bridge therapy)
• DMARDs (Disease Modifying Antirheumatic Drugs): Methotrexate (gold standard), Hydroxychloroquine, Sulfasalazine, Leflunomide
• Biologics: Anti-TNF agents (Adalimumab, Infliximab, Etanercept), IL-6 inhibitors (Tocilizumab)

• Synovectomy (early disease)
• Arthroplasty (joint replacement for severely damaged joints)
• Arthrodesis (for wrist stability)
• Tendon repair

• Passive ROM during flare
• Active assisted and active ROM during remission
• Strengthening exercises
• Splinting to prevent deformities (resting splints at night, working splints during day)
• Hydrotherapy
• Gait training, ADL training
• Patient education: Joint protection techniques

---

Q4. ANKYLOSING SPONDYLITIS

Definition

Aetiology / Etiopathology

• Strongly associated with HLA-B27 (90-95% of patients positive)
• Male predominance (3:1 male:female), onset 15-30 years
• Molecular mimicry theory: HLA-B27 antigen similar to bacterial antigens (Klebsiella pneumoniae)
• Inflammatory reaction starts at entheses (insertion of tendons and ligaments into bone)
• Sacroiliac joints affected first, then lumbar spine, then thoracic, then cervical (ascending pattern)

Pathology

1. Inflammatory erosion at entheses
2. Fibrocartilage replaces inflamed tissue
3. Ossification of fibrocartilage
4. Syndesmophyte formation (vertical bony bridges between vertebrae)
5. Progressive fusion leading to "Bamboo Spine" on X-ray
6. Sacroiliac joint sclerosis then fusion

Clinical Features

• Insidious onset of low back pain and morning stiffness (>1 hour) in young male
• Pain worse with rest, IMPROVES with activity (inflammatory back pain)
• Buttock pain (sacroiliac joint involvement), alternating buttock pain
• Chest pain (costovertebral joint involvement - restricted chest expansion)

• Schober's test <5 cm increase from 10 cm mark - reduced lumbar flexion
• Loss of lumbar lordosis
• Kyphosis (increased thoracic)
• Chest expansion < 2.5 cm
• Occiput-to-wall test - cannot touch wall with occiput
• Tenderness over sacroiliac joints
• Peripheral joint involvement (hip, knee - asymmetric)

• Uveitis (most common extra-articular feature - 25%)
• Aortitis, aortic regurgitation
• Apical pulmonary fibrosis
• IgA nephropathy
• Cauda equina syndrome (rare)
• Fractures of ankylosed spine (high risk)

Investigations

• HLA-B27 - positive
• ESR, CRP raised
• X-ray sacroiliac joints: sclerosis, erosions, fusion
• X-ray spine: Bamboo spine (continuous ossification of annulus fibrosus), squaring of vertebrae, Romanus lesion
• MRI - detects early sacroiliac joint inflammation (sacroiliitis) before X-ray changes

Management

• Spinal extension exercises - to counteract kyphotic tendency (MOST IMPORTANT)
• Deep breathing exercises - to maintain chest expansion
• Hydrotherapy
• Postural exercises - sleep on firm mattress without pillow
• Swimming is ideal exercise
• Maintaining erect posture at all times

• NSAIDs (first-line): Indomethacin, Diclofenac - also diagnostically useful
• DMARDs: Sulfasalazine (for peripheral joints)
• Biologics (anti-TNF): Etanercept, Adalimumab, Infliximab (for axial disease not responding to NSAIDs)
• IL-17 inhibitors: Secukinumab, Ixekizumab

• Spinal osteotomy for severe deformity
• Hip replacement for hip involvement
• Posterior spinal fusion rarely

---

Q5. COLLE'S FRACTURE

Definition

• Dorsal displacement and angulation
• Radial shortening
• Dorsal comminution
• Supination deformity of the distal fragment
• Often associated with ulnar styloid fracture

Mechanism

Classic Deformities

• Dinner fork deformity - dorsal displacement seen from the side
• Bayonet deformity - radial displacement seen from front
• Radial shortening → ulnar styloid appears prominent
• Supination of distal fragment

Clinical Features

• Pain and swelling at wrist after fall
• Tenderness over distal radius

• Dinner fork deformity - wrist looks like dinner fork in profile
• Radial deviation of hand
• Loss of radial angulation (normally 25° volar, 25° radial)
• Radial shortening (normally radius extends 1 cm beyond ulna)
• Tenderness over distal radius

Investigations

• X-ray wrist - AP and lateral view:
  • Reversed radial angle (instead of 25° volar tilt → 10° dorsal tilt)
  • Reversed radial inclination (instead of 25° radial inclination → loss or reversal)
  • Radial shortening
  • Dorsal displacement and comminution

Management

1. Haematoma block (local anaesthetic) or IV sedation
2. Closed reduction - traction + disimpaction → manipulation (palmarly angulate + ulnar deviate)
3. Check reduction under X-ray
4. Apply Colle's cast (below elbow POP) in:
   • Wrist: slight flexion (15°), ulnar deviation
   • Forearm: pronation
5. Cast for 6 weeks
6. Physiotherapy after cast removal

• External fixation
• Percutaneous K-wire fixation
• Open reduction and internal fixation (ORIF) with volar locking plate (most common now)

Complications

• Carpal tunnel syndrome
• Tendon rupture (Extensor Pollicis Longus - most common)
• Shoulder-hand syndrome (Sudeck's atrophy)
• Distal radio-ulnar joint injury

• Malunion (most common complication)
• Sudeck's atrophy / Complex Regional Pain Syndrome (CRPS)
• Rupture of EPL tendon
• Stiffness of wrist/fingers
• Carpal tunnel syndrome (median nerve compression)
• Radiocarpal osteoarthritis

Physiotherapy

• During cast: Shoulder, elbow, and finger exercises (to prevent stiffness)
• After cast removal: Wrist ROM exercises (flexion, extension, supination, pronation)
• Grip strengthening
• Oedema management - elevation, retrograde massage
• ADL retraining

---

Q6. TOTAL HIP REPLACEMENT (THR)

Definition

Indications

• Osteoarthritis hip (most common indication)
• Rheumatoid arthritis
• Avascular necrosis of femoral head
• Failed hemiarthroplasty
• Fracture neck of femur in elderly (>65 years) with pre-existing arthritis
• Ankylosing spondylitis
• Paget's disease of hip
• Tumour around hip
• Developmental dysplasia of hip (DDH) - failed conservative

Contraindications

• Active infection (absolute)
• Neurological conditions causing abnormal gait
• Young active patient (relative)
• Skeletal immaturity
• Inadequate bone stock
• Severe obesity (relative)

Types of Prosthesis

• Cemented: Methyl methacrylate cement used for fixation - better for elderly osteoporotic bone
• Uncemented (cementless): Press-fit or biologic fixation (osseointegration) - preferred for younger patients
• Hybrid: Cemented stem + uncemented cup

Surgical Approaches

• Posterior (Moore's) approach - most common
• Anterolateral (Watson-Jones) approach
• Direct lateral (Hardinge) approach
• Anterior approach (minimally invasive)

Pre-operative Management (Physiotherapy)

• Assessment of gait and functional mobility
• Strengthening of hip abductors, extensors, quadriceps
• Breathing exercises to prevent post-op chest complications
• Teaching post-operative precautions (hip precautions)
• Walking aids training

Post-operative Management

• Elevation of limb
• Ice therapy
• Ankle pumps (DVT prevention)
• Quadriceps setting, gluteal setting
• Breathing exercises

• Sitting up in bed
• Standing with walking frame (weight bearing as tolerated)
• Hip precautions: Avoid hip flexion >90°, avoid internal rotation and adduction past midline (for posterior approach)

• Active ROM exercises (within precaution limits)
• Strengthening: Hip abductors, extensors, quadriceps
• Gait training: Walker → crutches → cane
• Stair climbing

• Hip strengthening programme
• Return to activities of daily living
• Full weight bearing by 6-12 weeks

Complications

• DVT and Pulmonary Embolism (most common serious complication)
• Infection
• Dislocation of prosthesis (most common early complication)
• Nerve injury (sciatic nerve palsy)

• Aseptic loosening (most common late complication - leading cause of revision)
• Infection (periprosthetic joint infection)
• Heterotopic ossification
• Implant wear (polyethylene wear)
• Periprosthetic fracture
• Leg length discrepancy

---

Q7. BRACHIAL PLEXUS INJURY

Anatomy of Brachial Plexus

• Roots → Trunks (Upper C5-C6, Middle C7, Lower C8-T1)
• Trunks → Divisions (Anterior and Posterior)
• Divisions → Cords (Lateral, Medial, Posterior)
• Cords → Terminal branches (Musculocutaneous, Median, Ulnar, Radial, Axillary)

Aetiology / Causes

• Excessive lateral flexion of neck during delivery
• Shoulder dystocia
• Traction during breech delivery

• Motorcycle accidents (most common - violent shoulder depression with neck lateral flexion)
• Stab wounds
• Gunshot wounds
• Iatrogenic (surgery, radiotherapy)
• Tumour infiltration (Pancoast tumour)

Classification

• Preganglionic (avulsion): Root avulsed from spinal cord - no recovery possible; associated with Horner's syndrome (C8-T1 avulsion)
• Postganglionic: More peripheral, better prognosis

1. Erb's Palsy (Upper trunk C5-C6 injury):
   • Waiter's tip position: Shoulder adducted + internally rotated, elbow extended, forearm pronated, wrist flexed
   • Muscles affected: Deltoid, Supraspinatus, Infraspinatus, Biceps, Brachialis, Brachioradialis
   • Sensory loss: Outer arm/forearm (C5-C6 dermatome)
2. Klumpke's Palsy (Lower trunk C8-T1 injury):
   • Claw hand deformity
   • Intrinsics of hand paralysed
   • If T1 involved: Horner's syndrome (ptosis, miosis, anhidrosis, enophthalmos)
   • Sensory loss: Inner arm, forearm, medial hand (C8-T1)
3. Total Brachial Plexus Palsy (C5-T1):
   • Flail limb (complete loss of motor function)
   • Complete sensory loss in entire upper limb
   • Horner's syndrome if T1 involved

Clinical Features

• Detailed neurological examination
• Motor: MRC grading of each muscle group
• Sensory: Dermatome mapping
• Reflexes: Biceps (C5-C6), Brachioradialis (C6), Triceps (C7)

Investigations

• X-ray: Cervical spine, shoulder, chest (for fractured transverse processes = preganglionic)
• EMG/NCS: After 3 weeks - assesses type and extent of injury
• MRI cervical spine: Shows pseudomeningoceles = root avulsion (preganglionic)
• CT Myelogram: Confirms root avulsion

Management

• Physiotherapy: Prevent deformity, maintain joint mobility
• Splinting: Shoulder abduction splint to prevent contracture; wrist-hand orthosis
• Sensory re-education
• Electrical stimulation of denervated muscles

• Neurolysis (release from scar tissue)
• Direct nerve repair (end-to-end anastomosis)
• Nerve grafting (sural nerve graft) - for gaps
• Nerve transfers (neurotization): For avulsion injuries
  • Intercostal nerves → musculocutaneous nerve (to restore elbow flexion)
  • Spinal accessory nerve → suprascapular nerve (to restore shoulder abduction)

• Tendon transfers
• Muscle transfers (free functional muscle transfer)
• Shoulder fusion (arthrodesis)
• Elbow fusion

• Passive ROM all joints (prevent contractures)
• Active-assisted exercises as recovery occurs
• Sensory re-education
• Functional training (one-handed ADL for complete palsy)
• Biofeedback and EMG-guided exercise
• Sling support for shoulder subluxation
• Pain management (neuropathic pain: Gabapentin, Pregabalin, TENS)

---

Q8. OSTEOMYELITIS

Definition

Classification

Causes / Organisms

• Staphylococcus aureus - most common in all age groups
• Streptococcus (neonates)
• Salmonella - in sickle cell disease
• Pseudomonas - in IV drug users and puncture wounds
• Mycobacterium tuberculosis - TB osteomyelitis

Pathogenesis (Acute Haematogenous)

1. Bacteria seed metaphysis via blood
2. Bacteria multiply in sinusoidal vessels (sluggish flow, no phagocytes)
3. Acute inflammatory response
4. Pus formed → increased intraosseous pressure
5. Pus tracks through cortex → Subperiosteal abscess
6. Periosteum stripped → Involucrum (new bone formation around)
7. Blood supply cut off → Sequestrum (dead bone)
8. Cloaca (opening in involucrum)
9. Sinus tract forms

Clinical Features

• High fever (38-40°C), rigors, toxaemia
• Severe localised bone pain (site tenderness)
• Swelling, redness, warmth over affected bone
• Metaphysis most commonly affected (distal femur, proximal tibia, proximal humerus)
• Child refuses to use limb (pseudoparalysis)
• Septic joint if infection extends to joint

• Recurring discharge from sinus (sinus tract)
• Pathological fracture
• Growth disturbance in children
• Squamous cell carcinoma of sinus tract (Marjolin's ulcer - rare)

Investigations

• Blood: Raised WBC, ESR, CRP; Blood cultures (positive 50%)
• X-ray: Normal in first 7-10 days; then periosteal reaction, bone destruction, sequestrum, involucrum (late)
• MRI - gold standard early (shows medullary oedema within 24-48 hours)
• Bone scan (Tc-99m) - elevated uptake early
• Biopsy + culture - definitive

Management

• IV antibiotics (high dose, 4-6 weeks total; IV initially 2 weeks)
• Empirical: Cloxacillin/flucloxacillin (anti-staphylococcal); adjust per culture
• Analgesics, antipyretics
• IV fluids
• Immobilisation: splint/cast to prevent deformity and pathological fracture

• Aspiration (diagnostic and therapeutic)
• Surgical drainage (if pus confirmed - incision + drainage, sequestrectomy)
• Sequestrectomy (removal of dead bone)
• Saucerization (scooping out of bone cavity)
• Cancellous bone graft (to fill cavity after sequestrectomy)
• Antibiotic-impregnated beads (local delivery)
• Wound closure or secondary healing

• Prevent joint stiffness and muscle wasting (gentle ROM, isometrics)
• Non-weight bearing/protected weight bearing
• After healing: strengthening, gait training

---

Q9. CONGENITAL TALIPES EQUINOVARUS (CTEV / CLUB FOOT)

Definition

• C - Cavus (high arch)
• A - Adductus (forefoot adduction)
• V - Varus (heel inversion)
• E - Equinus (plantarflexion)

Incidence & Aetiology

• 1 in 1000 live births; male:female = 2:1; bilateral in 50%
• Multifactorial: genetic + environmental (intrauterine malposition)
• Associated conditions: Spina bifida, arthrogryposis, amniotic band syndrome

Classification

• Idiopathic CTEV (most common)
• Postural/positional CTEV (easily correctable, good prognosis)
• Syndromic/teratological CTEV (most rigid, associated with neuromuscular conditions)
• Scoring: Pirani score (0-6) and Dimeglio score assess severity

Clinical Features

• Foot in equinus, varus, adduction, cavus
• Soft tissues on medial/posterior aspect are tight
• Tibialis anterior, Achilles tendon, plantar fascia contracted
• Lateral aspect of foot convex
• "Banana-shaped foot"
• Child walks on dorsolateral aspect
• Calf muscle wasting

Management

1. Serial casting every week for 4-6 weeks (correcting CAVE - Cavus first, then Adductus, then Varus, then Equinus last)
2. Percutaneous tenotomy of Achilles tendon - in 90% (to correct equinus)
3. Foot Abduction Brace (FAB) - Denis-Browne splint: wear 23 hours/day for 3 months, then night/nap use until age 4-5 years (critical to prevent relapse)

• Posteromedial soft tissue release (Turco procedure)
• Achilles tendon lengthening
• Tibialis anterior tendon transfer (for residual dynamic supination)
• Calcaneal osteotomy (for relapse in older child)
• Triple arthrodesis (for severe neglected cases >12 years)

• Post-cast stretching
• Strengthening of peroneal and dorsiflexor muscles
• Gait training
• Brace compliance education

---

Q10. AMPUTATION

Definition

Indications

• "4 D's": Dead limb (ischaemia/gangrene), Deadly limb (sepsis/tumour), Dangerous limb (gas gangrene), Damned nuisance limb (severe pain, non-functioning)
• Peripheral vascular disease / Diabetes (most common cause overall)
• Trauma (crush injuries, blast injuries)
• Malignant tumours
• Congenital deformities
• Osteomyelitis (uncontrolled)
• Frostbite/Thermal injuries

Levels of Upper Limb Amputation

1. Forequarter (interscapulothoracic)
2. Shoulder disarticulation
3. Trans-humeral (above elbow)
4. Elbow disarticulation
5. Trans-radial (below elbow)
6. Wrist disarticulation
7. Transcarpal
8. Transmetacarpal
9. Finger/Thumb amputation

Levels of Lower Limb Amputation

1. Hemipelvectomy
2. Hip disarticulation
3. Trans-femoral (above knee - AKA)
4. Knee disarticulation
5. Trans-tibial (below knee - BKA) - preferred (better prosthetic outcome)
6. Ankle disarticulation (Syme's amputation)
7. Transmetatarsal
8. Toe amputation

Principles of Ideal Stump

• Length: Sufficient for prosthetic fitting (mid-tibial for BKA, mid-femoral for AKA)
• Shape: Cylindrical (not conical)
• Skin: Adequate soft tissue coverage, no redundant skin
• Scar: Well-healed, non-adherent, not over bony end
• Bone: Smooth end, no sharp spurs, cortical rim
• Muscles: Myoplasty (myodesis) - muscles sutured to bone or each other
• Vessels: Ligated well away from end
• Nerves: Cut sharply and allowed to retract (prevent neuroma)
• Pain-free: No tenderness, no neuroma

Types of Amputation

• Open (guillotine): Emergency, no skin closure, for infection
• Closed (flap): Planned, skin closure, primary healing
• Revision/Refashioning: Improving an existing stump

Complications

• Haemorrhage
• Haematoma
• Infection
• Flap necrosis
• Stump oedema

• Phantom limb pain (most distressing)
• Phantom limb sensation
• Stump neuroma
• Adherent scar
• Bony spurs
• Flexion contracture (most common - knee flexion after BKA, hip flexion after AKA)
• Skin breakdown over prosthetic interface
• Revision surgery required

Management

• Patient counselling + psychological support
• Physiotherapy: Strengthening of intact limbs, breathing exercises
• Explanation of post-op rehabilitation plan

• Elevation of stump (first 24-48 hours)
• Early mobilisation
• Stump bandaging (figure of 8) - to shape stump for prosthesis
• TENS/mirror therapy for phantom pain

• Strengthening of stump muscles and residual limb
• Hip extension strengthening (for BKA) to prevent flexion contracture
• Gait training with prosthesis
• Balance and proprioception training
• ADL training
• Prosthetic education

---

Q11. SCOLIOSIS

Definition

Classification

1. Structural Scoliosis (true scoliosis with rotation):
   • Idiopathic (most common - 80%): Infantile (0-3yr), Juvenile (3-10yr), Adolescent (>10yr)
   • Congenital (failure of formation/segmentation)
   • Neuromuscular (cerebral palsy, polio, muscular dystrophy)
   • Neurofibromatosis
2. Non-structural/Functional (no rotation, corrects on bending):
   • Postural
   • Secondary to leg length discrepancy
   • Sciatic scoliosis (pain)

Clinical Features

• Uneven shoulder levels (one higher)
• Prominent scapula on convex side
• Waist asymmetry
• Pelvic tilt
• Trunk shift

• Rib hump (ribcage prominence) on convex side = rotational component = structural scoliosis

• Cardiopulmonary compromise (curves >70°)
• Back pain
• Cosmetic disfigurement

Investigations

• X-ray full spine (PA standing view): Measure Cobb's angle
• Cobb's Angle: Angle between lines drawn along superior endplate of uppermost vertebra and inferior endplate of lowermost vertebra of the curve
  • <10°: Normal variant
  • 10-25°: Mild
  • 25-40°: Moderate

  • 40°: Severe

• Risser's sign: Graded 0-5, indicates skeletal maturity (apophysis of iliac crest ossification)
• MRI: If neurological symptoms or atypical curve pattern

Management

• Physiotherapy: Schroth method, core strengthening
• Observation with regular X-rays

• Bracing (Milwaukee brace / Boston brace / TLSO) - 23 hours/day
• Goal: Prevent progression, not correction
• Physiotherapy with bracing

• Surgical correction: Posterior spinal instrumentation and fusion (Harrington rod, pedicle screws + rods)
• Goal: Correct curve and fuse to prevent progression

• Schroth 3D exercise method
• Core stabilisation
• Respiratory exercises
• Postural education
• Hydrotherapy

---

Q12. ANTERIOR CRUCIATE LIGAMENT (ACL) INJURY

Anatomy

Mechanism

• Non-contact (70%): Sudden deceleration, cutting/pivoting, landing from a jump
• Contact (30%): Valgus force + internal rotation (dashboard injury), direct blow

Clinical Features

• "Pop" sound at time of injury
• Immediate swelling (haemarthrosis within 2-4 hours - indicates ACL tear)
• Unable to continue activity
• Feeling of knee "giving way"

• Anterior Drawer Test: Knee at 90° flexion - anterior translation of tibia on femur
• Lachman Test (most sensitive - 87%): Knee at 20-30° flexion - anterior tibial translation
• Pivot Shift Test: Internal rotation + valgus + extension - clunk as tibia subluxes anteriorly

Investigations

• MRI - gold standard (confirms ACL tear, associated injuries: meniscus, MCL)
• X-ray: Look for Segond fracture (avulsion of lateral tibial plateau = ACL tear), tibial spine avulsion

Management

• RICE (Rest, Ice, Compression, Elevation)
• NSAIDs
• Knee brace (functional brace)
• Physiotherapy: Quadriceps strengthening, hamstring strengthening, proprioception

• ACL Reconstruction (not repair - due to poor healing capacity)
• Graft options:
  • Patellar tendon (BPTB) graft - bone-to-bone healing, gold standard for high-demand athletes
  • Hamstring tendon (4-strand semitendinosus-gracilis) graft - most commonly used
  • Quadriceps tendon graft
  • Allografts
• Arthroscopic procedure
• Graft fixation with interference screws, Endobutton, etc.

• Phase 1 (0-2 weeks): Swelling control, ROM, quadriceps activation
• Phase 2 (2-6 weeks): Progressive ROM, closed kinetic chain exercises, PWB → FWB
• Phase 3 (6-12 weeks): Strength, balance, proprioception
• Phase 4 (3-6 months): Return to running, agility
• Phase 5 (6-12 months): Return to sport (requires: 90% limb symmetry index)

---

Q13. OSTEOARTHRITIS KNEE (OA KNEE)

Definition

Causes / Risk Factors

• Primary (idiopathic): Age, female sex, obesity, genetic predisposition
• Secondary:
  • Previous injury (meniscal tear, ligament injury, fracture)
  • Infection (septic arthritis)
  • Avascular necrosis
  • Inflammatory arthritis (RA)
  • Osteochondrosis

Classification (Kellgren-Lawrence X-ray grading)

• Grade 0: Normal
• Grade 1: Doubtful - minor osteophyte
• Grade 2: Mild - definite osteophyte, possible joint space narrowing
• Grade 3: Moderate - definite joint space narrowing, multiple osteophytes, sclerosis
• Grade 4: Severe - bone-on-bone, large osteophytes, deformity

Clinical Features

• Gradual onset of knee pain (worse on activity, relieved by rest - distinguishes from RA)
• Morning stiffness < 30 minutes (unlike RA > 1 hour)
• Crepitus on knee movement
• Decreased ROM (especially flexion)
• Varus deformity (medial OA most common)
• Bony enlargement (osteophytes - palpable)
• Quadriceps wasting
• Antalgic gait

Investigations

• X-ray AP and Lateral, weight-bearing:
  • Joint space narrowing (medial compartment mainly)
  • Subchondral sclerosis
  • Osteophytes (lipping)
  • Subchondral cysts
• MRI: Cartilage assessment, meniscal and ligament evaluation
• Blood: ESR, CRP normal (distinguishes from RA); X-ray confirms

Management

• Quadriceps strengthening (most important)
• Hamstring stretching
• Low-impact aerobic exercise (swimming, cycling)
• Weight loss (most effective intervention)
• Walking aids (cane on contralateral side)
• Patellofemoral taping (Lateral release taping/McConnell taping)
• Knee brace/splint

• Paracetamol (first line analgesic)
• Topical NSAIDs, Oral NSAIDs
• Intra-articular corticosteroid injections
• Intra-articular hyaluronic acid (viscosupplementation)
• Glucosamine + Chondroitin (controversial)

• Arthroscopy + Lavage: Debridement for mechanical symptoms (limited evidence)
• Unicompartmental Knee Replacement (UKR): For isolated compartment disease
• High Tibial Osteotomy (HTO): For young patient with varus deformity + medial OA (offloads medial compartment)
• Total Knee Replacement (TKR): Gold standard for severe OA - most effective

---

Q14. LOW BACK PAIN

Definition

Causes / Aetiology

• Muscle strain/ligament sprain
• Disc degeneration / Prolapsed Intervertebral Disc (PIVD)
• Facet joint osteoarthritis
• Spondylolisthesis
• Spinal stenosis

• Ankylosing spondylitis
• Rheumatoid arthritis
• Infective: TB spine, pyogenic spondylitis

• Primary (osteosarcoma, myeloma)
• Secondary/Metastatic (breast, prostate, lung, kidney, thyroid)

• Renal colic, aortic aneurysm, pelvic pathology

Clinical Features

• Pain in lumbar region (localised or radiating)
• Sciatica: Radiation along sciatic nerve distribution (L4-S1) - buttock → posterior thigh → calf/foot (PIVD or spinal stenosis)
• Pain worse on bending/lifting/prolonged sitting
• Morning stiffness

• Tenderness over spinous processes or paravertebral muscles
• Reduced lumbar movements (flexion, extension, lateral flexion)
• Straight Leg Raise (SLR) test: Positive in disc prolapse (pain at <60°)
• Crossed SLR: More specific for central disc prolapse
• Neurological signs (dermatomal sensory loss, weakness, reduced reflexes in nerve root compression)

Investigations

• X-ray lumbar spine: Disc space narrowing, osteophytes, alignment
• MRI lumbar spine (gold standard): Disc prolapse, nerve root compression, spinal stenosis
• CT scan: Bony detail, spinal stenosis
• Bone scan: Metastases, infection, stress fracture
• Blood: CBC, ESR, CRP, PSA (if suspected metastasis)

Management

• Physiotherapy (cornerstone):
  • McKenzie extension exercises (for disc prolapse with centralisation)
  • Core stabilisation (transversus abdominis, multifidus activation)
  • Back school: Ergonomics, posture education
  • Mobilisation and manipulation
  • Traction (lumbar)
  • Electrotherapy: TENS, ultrasound, IFT
  • Hot packs
• Medical:
  • NSAIDs (Ibuprofen, Diclofenac)
  • Muscle relaxants (Cyclobenzaprine)
  • Neuropathic pain: Gabapentin, Pregabalin (for radiculopathy)
  • Epidural steroid injections (for radiculopathy not responding to conservative)

• Microdiscectomy: For disc prolapse with neurological deficit not resolving
• Laminectomy/Decompression: For spinal stenosis
• Spinal fusion: For spondylolisthesis, instability

---

Q15. INTERVERTEBRAL DISC PROLAPSE (IVDP)

Definition

Anatomy

• Disc: Nucleus pulposus (central - gel-like) + Annulus fibrosus (outer - fibrocartilage rings)
• Most common levels: L4-L5 and L5-S1 (90% of lumbar disc prolapse)
• Cervical: C5-C6, C6-C7 most common

Stages of Disc Disease

1. Nuclear degeneration (desiccation)
2. Annular tears / Disc protrusion
3. Disc prolapse (herniation through annulus)
4. Sequestration (free fragment in canal)

Clinical Features (Lumbar IVDP)

• L4-L5 disc: L5 nerve root compression
  • Pain: Posterolateral thigh, lateral leg, dorsum of foot, big toe
  • Weakness: EHL (extensor hallucis longus - big toe extension), foot dorsiflexion
  • Sensory loss: Dorsum of foot, big toe
  • Reflex: Usually normal (or reduced knee jerk)
• L5-S1 disc: S1 nerve root compression
  • Pain: Posterior thigh, calf, lateral foot/sole, little toe
  • Weakness: Plantarflexion, eversion
  • Sensory loss: Lateral foot, sole, little toe
  • Reduced ankle jerk reflex
• SLR positive (Lasègue's test): <60° - most important test
• Cauda Equina Syndrome (emergency): Bilateral radiculopathy + saddle anaesthesia + bladder/bowel dysfunction → requires emergency surgery

Management

• Bed rest (short term 2-3 days only)
• NSAIDs, analgesics
• Physiotherapy:
  • McKenzie extension exercises
  • Core stabilisation
  • Traction
  • Neural mobilisation (sciatic nerve mobilisation)
  • TENS, heat

• Microdiscectomy (gold standard)
• Indications: Cauda equina syndrome (emergency), neurological deficit not improving, intractable pain >6-8 weeks

---

Q16. TUBERCULOSIS OF SPINE (POTT'S SPINE)

Definition

Pathogenesis

• Haematogenous spread from primary focus (usually lung)
• Involves the vertebral body (anterior subchondral region)
• Spreads to adjacent disc (avascular - via granulation tissue in TB, unlike pyogenic osteomyelitis)
• Disc destruction and vertebral collapse → Kyphosis/Gibbus deformity
• Cold abscess formation (pus tracking along fascial planes)

Cold Abscess

• Pus without signs of acute inflammation (cold, non-tender)
• In thoracic spine: Paravertebral abscess → tracks along psoas muscle → Psoas abscess → appears in iliac fossa, groin
• In cervical spine: Retropharyngeal abscess

Clinical Features

• Insidious onset back pain
• Stiffness of spine
• Low-grade fever, evening rise, night sweats, weight loss
• Gibbus deformity (angular kyphosis)
• Neurological symptoms (paraplegia - Pott's paraplegia) if cord compressed

• Gibbus deformity (sharp angular kyphosis at affected level)
• Local tenderness
• Cold abscess (fluctuant, non-tender swelling)
• Cord signs: Spasticity, hyperreflexia, clonus, extensor plantar

Investigations

• X-ray spine: Disc space narrowing (early), vertebral collapse, kyphosis, paravertebral shadow (abscess)
• MRI (gold standard): Shows extent of cord compression, abscess, marrow involvement
• CT guided biopsy: Definitive diagnosis
• AFB smear + culture
• Mantoux test, IGRA
• ESR raised, lymphocytosis

Management

• HRZE regimen:
  • Intensive phase (2 months): Isoniazid (H) + Rifampicin (R) + Pyrazinamide (Z) + Ethambutol (E)
  • Continuation phase (7-10 months): Isoniazid + Rifampicin
  • Total duration: 9-12 months (18 months for extensive disease)
• Supplemental Pyridoxine (Vitamin B6) with Isoniazid
• Adequate nutrition, rest

• Pott's paraplegia with progressive neurological deficit
• Spinal instability
• Large abscess not responding to medical treatment
• Diagnostic biopsy when needed

• Anterior debridement (removal of diseased tissue) + bone graft + stabilisation
• Posterior instrumented fusion (pedicle screws + rods)
• Drainage of psoas abscess

• Bed rest in acute stage
• Spinal brace (TLSO) during mobilisation
• Breathing exercises (prevent chest complications)
• After control of disease: Spinal extension strengthening
• Gait training
• Neurological rehabilitation if paraplegia present

---

Q17. RECURRENT DISLOCATION OF SHOULDER

Definition

Anatomy of Instability

• Bankart lesion: Detachment of anterior labrum + inferior glenohumeral ligament from anterior glenoid rim (90% of cases)
• Hill-Sachs lesion: Posterosuperior humeral head impaction fracture (engagement notch)
• Subscapularis stretching
• Anterior capsule redundancy

Predisposing Factors

• First dislocation at young age (<20 years) → highest recurrence rate (>90%)
• First dislocation inadequately immobilised
• Bony Bankart lesion
• Large Hill-Sachs lesion
• Generalised ligamentous laxity

Clinical Features

• History of initial dislocation followed by repeated episodes
• Episodes occur with less and less force over time
• Patient may be able to self-reduce
• Apprehension sign: Shoulder in 90° abduction + external rotation → patient appears apprehensive/in pain (positive = anterior instability)
• Relocation test: Pressure on humeral head from behind relieves apprehension (positive)
• Examination of ligamentous laxity (Beighton score)
• Sulcus sign (inferior laxity)

Management

• Strengthening of rotator cuff and periscapular muscles
• Proprioception training
• Activity modification

1. Bankart repair (Arthroscopic): Reattachment of labrum to glenoid rim using suture anchors - gold standard for soft tissue Bankart lesion with adequate glenoid bone stock
2. Latarjet procedure: Transfer of coracoid process (with conjoined tendon) to anterior glenoid - provides bone graft + sling effect; indicated for significant glenoid bone loss (>20-25%)
3. Remplissage: Fill Hill-Sachs lesion with infraspinatus tendon/capsule (done with Bankart repair if engaging Hill-Sachs)
4. Putti-Platt procedure: Shortening of subscapularis and anterior capsule (historical)

Physiotherapy Post-op (Bankart repair)

• Phase 1 (0-4 weeks): Immobilisation in sling, pendulum exercises, elbow/wrist/hand exercises
• Phase 2 (4-8 weeks): Active ROM, avoid aggressive ER (protect repair)
• Phase 3 (8-12 weeks): Strengthening - rotator cuff, scapular stabilisers
• Phase 4 (3-6 months): Return to sport - sport-specific training, plyometrics
• Return to contact sport: 6-9 months

---

Q18. TOTAL KNEE REPLACEMENT (TKR)

Definition

Indications

• Severe OA of knee (most common)
• Rheumatoid arthritis with severe joint destruction
• Post-traumatic arthritis
• Avascular necrosis
• Failed high tibial osteotomy
• Psoriatic arthritis

Pre-operative Physiotherapy

• Strengthening of quadriceps, hamstrings
• Breathing and coughing exercises
• Teaching postoperative exercises
• Instructions for gait aids use

Post-operative Physiotherapy

• Active knee flexion and extension exercises
• CPM (Continuous Passive Motion) machine - helps achieve early ROM
• Goal: Achieve 90° flexion by discharge (Day 3-5)
• Straight leg raises

• Progressive strengthening
• Stationary cycling
• Pool therapy

• Goal: 120° flexion, full extension
• Low-impact activities encouraged (swimming, cycling)
• Avoid high-impact sports

Complications

• DVT/PE
• Infection (periprosthetic joint infection - most serious)
• Stiffness (most common - flexion contracture)
• Aseptic loosening (late)
• Instability
• Peroneal nerve palsy (from valgus correction)
• Patellar problems (maltracking, clunk)
• Fracture around implant

---

SUMMARY TABLE OF MOST IMPORTANT QUESTIONS TO STUDY

---

1. Focus heavily on the top 6 topics (marked ★★★★★) - they appear almost every year
2. Know the full format: Definition → Aetiology → Pathology → Clinical Features → Investigations → Management → Complications → Physiotherapy
3. For 20-mark questions: Write 4-5 pages with detailed subheadings
4. For 15-mark questions: Write 3-4 pages, slightly more concise but all key points covered
5. Draw diagrams wherever possible (classification tables, anatomy sketches) - they add marks

---

CLINICAL ORTHOPAEDICS - 5 MARK QUESTIONS ANALYSIS

(Both PDFs Combined - Treated as One Subject)

---

SECTION 1: ALL 5-MARK QUESTIONS WITH FREQUENCY COUNT

---

PDF 1 (Sub Code 6266) - 5 MARK QUESTIONS (8×5 = 40)

---

PDF 2 (Sub Code 6284) - 5 MARK QUESTIONS (10×5 = 50)

---

SECTION 2: MASTER FREQUENCY TABLE (Both PDFs Combined - 5 Mark Questions)

---

SECTION 3: DETAILED 5-MARK ANSWERS

---

Q1. EWING'S SARCOMA (Asked 9 times - Highest frequency)

• Most common in 10-15 years
• Rare in Black population
• Second most common malignant bone tumour in children (after osteosarcoma)
• Commonly affects: Diaphysis of long bones (femur most common), pelvis, ribs, fibula

• Small round blue cell tumour (SRBCT)
• Chromosomal translocation: t(11;22)(q24;q12) - EWS-FLI1 fusion gene (present in 85%)
• Sheets of uniform small round cells with little cytoplasm
• PAS positive (glycogen-rich cells)

• Painful swelling over affected bone (dull aching pain, progressively worsening)
• Soft tissue mass palpable
• Fever and raised ESR (mimics osteomyelitis - "Great Mimic")
• Pathological fracture
• Systemic symptoms: weight loss, malaise

• X-ray: "Onion peel/Onion skin" periosteal reaction (multiple layers of new bone) - classic
• "Sunray" appearance less common than osteosarcoma
• Codman's triangle (periosteal elevation)
• Permeative bone destruction
• MRI: Extent of tumour, soft tissue involvement
• Bone scan: Metastasis detection
• Biopsy: Histology confirmation (FNAC/core biopsy)
• t(11;22) molecular testing

• Multi-modal treatment (combination):
• Chemotherapy (neoadjuvant - before surgery): VAC/IE regimen (Vincristine, Adriamycin/Doxorubicin, Cyclophosphamide + Ifosfamide, Etoposide) - 4-6 cycles
• Surgery: Wide excision / Limb salvage surgery (preferred) OR amputation
• Radiotherapy: For unresectable tumours, pelvis, spine (Ewing's is radiosensitive - unlike osteosarcoma)
• Adjuvant chemotherapy after surgery

---

Q2. SEPTIC ARTHRITIS (Asked 9 times)

• Staphylococcus aureus - most common (all ages)
• Streptococcus - children, adults
• Neisseria gonorrhoeae - sexually active young adults (most common cause in adults in some populations)
• H. influenzae - < 2 years (now rare with vaccination)
• Gram negatives - neonates, elderly, immunocompromised

1. Haematogenous spread (most common)
2. Direct inoculation (trauma, surgery, injection)
3. Contiguous spread (from adjacent osteomyelitis)

• Acute onset severe joint pain
• Joint swollen, warm, red, tender (cardinal signs of inflammation)
• Joint held in position of ease (hip: flexion/abduction/ER; knee: flexion)
• High fever, toxaemia, rigors
• Refusal to move joint (pseudoparalysis in infants)
• Most common joints: Hip (children), Knee (adults)

• Joint aspiration (most important - diagnostic + therapeutic):
  • Turbid/frank pus
  • WBC > 50,000 cells/mm³ (usually > 100,000 in septic arthritis)
  • Glucose low, protein high
  • Culture and sensitivity
• Blood: Raised WBC, ESR, CRP; Blood cultures
• X-ray: Early - soft tissue swelling, joint space widening; Late - joint destruction
• MRI/Ultrasound - detects effusion early, guides aspiration (especially hip)

1. Joint aspiration/washout (diagnostic + removes pus)
2. IV Antibiotics (start empirically after aspiration):
   • Flucloxacillin/Cloxacillin (anti-staphylococcal)
   • If MRSA suspected: Vancomycin
   • Adjust per culture sensitivity
   • IV for 2 weeks → Oral for 4 more weeks
3. Surgical drainage (arthrotomy) if:
   • Hip joint (mandatory - cannot be drained adequately by aspiration)
   • No response to aspiration + antibiotics in 24-48 hours
   • Frank pus on aspiration
4. Joint immobilisation (traction or splint in functional position)

• After acute phase: Gentle ROM to prevent stiffness
• Strengthening exercises
• Gait training

---

Q3. PLANTAR FASCIITIS (Asked 7 times)

• Overuse/repetitive stress (running, prolonged standing)
• Obesity (increased load)
• Flat foot (pes planus) - increased stretch on fascia
• Tight Achilles tendon (limited dorsiflexion)
• Cavus foot
• Change in activity level (sudden increase in running)
• Hard surfaces

• Pain at the heel (medial plantar heel)
• Classic: "First step pain" - worst pain with first steps in the morning or after prolonged rest (called "post-static dyskinesia")
• Pain reduces after walking a few steps, but returns with prolonged activity
• Tenderness at the medial calcaneal tubercle (plantar aspect)
• Pain on passive dorsiflexion of toes (stretches plantar fascia)
• Windlass test positive (dorsiflexion of great toe increases arch and stretches fascia - reproduces pain)

• Clinical diagnosis
• X-ray: May show calcaneal spur (heel spur) at origin - but spur is not the cause of pain; found in 50% of asymptomatic people too
• USS/MRI: Thickened plantar fascia (>4mm), if diagnosis uncertain

1. Rest and activity modification
2. Stretching exercises (most important):
   • Plantar fascia stretch (towel/belt stretch before first step every morning)
   • Achilles tendon/calf stretch
3. Footwear modification: Well-cushioned shoes, heel cups, arch supports
4. Night splints (dorsiflexion night splint - maintains stretch during sleep)
5. Orthoses (custom insoles)
6. Ice therapy after activity
7. NSAIDs (oral or topical)
8. Corticosteroid injection (into plantar fascia origin) - for persistent cases (caution: may rupture fascia)
9. Extracorporeal Shock Wave Therapy (ESWT) - for chronic cases > 6 months
10. Surgical: Partial plantar fasciotomy (endoscopic) - last resort, only if conservative fails 12 months

---

Q4. CARPAL TUNNEL SYNDROME (Asked 7 times)

• Idiopathic (most common - especially in middle-aged women)
• Pregnancy (fluid retention)
• Hypothyroidism, diabetes, acromegaly
• Rheumatoid arthritis (synovial thickening)
• Wrist fracture (Colle's fracture - post-traumatic)
• Repetitive wrist movements (occupational)
• Ganglion, lipoma, tenosynovitis

• Pain and tingling in thumb, index, middle, and radial half of ring finger (median nerve distribution) - classic
• Symptoms worse at night (wakes from sleep)
• Shaking hands relieves symptoms (flick test)
• Symptoms with prolonged wrist flexion/extension (driving, typing)
• Late: Weakness of grip, thenar muscle wasting (ape thumb deformity)
• Thenar muscles wasted (LOAF muscles affected: Lumbricals 1&2, Opponens pollicis, Abductor pollicis brevis, Flexor pollicis brevis)

• Phalen's test: Wrist in full flexion for 60 seconds → reproduces symptoms (sensitive ~75%)
• Tinel's sign: Percussion over carpal tunnel → tingling in median nerve distribution
• Durkan's test (carpal compression test): Direct compression over carpal tunnel for 30 seconds

• Nerve conduction studies (NCS) - gold standard; shows delayed conduction of median nerve at wrist
• EMG: Shows denervation changes in severe cases
• X-ray wrist: Bony causes

• Wrist splint (in neutral position, especially at night) - first line
• Activity modification
• NSAIDs
• Corticosteroid injection into carpal tunnel (temporary relief, diagnostic)
• Treatment of underlying cause (hypothyroidism, RA)

• Carpal tunnel release (CTR) - divides flexor retinaculum
• Open or endoscopic
• Indicated if: Conservative fails, thenar wasting, severe NCS changes
• Excellent results (>90% success)

• Tendon gliding exercises
• Nerve gliding exercises (median nerve mobilisation)
• Strengthening after surgical release

---

Q5. SYME'S AMPUTATION (Asked 7 times)

• Severe foot infections (diabetic foot, gas gangrene)
• Crush injuries of the foot
• Congenital deformities (absent/severely deformed foot)
• Failed forefoot amputation
• Peripheral vascular disease (if heel pad viable)
• Severe Charcot arthropathy of foot

1. Heel flap raised (plantar skin preserved - heel pad)
2. Ankle disarticulated
3. Malleoli shaved flush
4. Heel pad (posterior skin flap) brought forward and sutured
5. Results in bulbous stump that can be end-bearing

• End-bearing stump (can bear weight without prosthesis for short distances)
• Excellent proprioception (heel pad)
• Better energy expenditure than transtibial amputation
• Suitable for diabetic and peripheral vascular patients (good blood supply to heel)
• Good cosmesis

• Bulbous stump (cosmetically not ideal)
• Requires special prosthesis (Syme's prosthesis with removable window)
• Not suitable if heel pad compromised

• Stump dressing and shaping
• Strengthening of residual limb muscles
• Prosthetic training
• Gait re-education

---

Q6. MULTIPLE MYELOMA (Asked 7 times in PDF1)

• Most common primary bone tumour in adults (>40 years)
• Mean age: 65 years; Male > female
• Most common sites: Vertebrae, ribs, skull, pelvis, proximal femur

• Clonal plasma cells secrete M-protein (IgG most common, then IgA)
• Plasma cells secrete RANKL → osteoclast activation → bone resorption (no new bone formation - "punched out" lesions without sclerosis)
• Bence-Jones proteins (free light chains - kappa or lambda) excreted in urine → renal tubular damage

• C - Hypercalcaemia (bone resorption) → polyuria, constipation, confusion
• R - Renal failure (Bence-Jones proteins, hypercalcaemia, amyloidosis)
• A - Anaemia (bone marrow infiltration) → fatigue, pallor
• B - Bone pain and lesions (pathological fractures especially vertebral)
• Recurrent infections (immunoparesis - suppressed normal immunoglobulins)
• Hyperviscosity syndrome (headache, visual disturbances, bleeding)
• Vertebral collapse → kyphosis, spinal cord compression

• Blood: Anaemia (normocytic), raised ESR (often >100 mm/hr), raised total protein, hypercalcaemia
• Serum electrophoresis: M-spike (monoclonal band)
• Immunofixation: Confirms type of M-protein
• Urine: Bence-Jones proteins (BJP)
• Bone marrow biopsy: Plasma cells > 10% (diagnostic)
• X-ray: "Punched out" lytic lesions (no periosteal reaction, no sclerosis - characteristic), "Raindrop skull" (skull X-ray)
• MRI: Better assessment of marrow involvement
• Beta-2 microglobulin: Prognostic marker

• Chemotherapy: VMP (Bortezomib + Melphalan + Prednisolone), VRd (Bortezomib + Lenalidomide + Dexamethasone)
• Autologous Stem Cell Transplantation (ASCT) - for eligible patients (<70 years, good performance status)
• Bisphosphonates (Zoledronic acid, Pamidronate): Reduce bone pain, prevent pathological fractures
• Radiotherapy: For localised painful lesions, cord compression
• Surgical: Stabilisation of pathological fractures, spinal decompression
• Supportive: EPO for anaemia, dialysis for renal failure, IV fluids for hypercalcaemia

---

Q7. FLAT FOOT (PES PLANUS) (Asked 6 times)

1. Flexible (Mobile) Flat Foot - arch visible when non-weight bearing, disappears on weight bearing; most common; usually physiological in children <5 years
2. Rigid (Structural) Flat Foot - arch absent even on non-weight bearing; always pathological

• Physiological: Children under 5 years (fat pad in medial arch, ligamentous laxity - normal)
• Tibialis posterior tendon dysfunction (most common cause in adults)
• Congenital ligamentous laxity (Ehlers-Danlos, Marfan's)
• Neuromuscular: Cerebral palsy, polio (weak tibialis posterior)
• Tarsal coalition (bony bar between tarsal bones - causes rigid flat foot)
• Rheumatoid arthritis
• Obesity

• Flat medial arch visible on weight bearing
• Heel in valgus (eversion)
• Toe-out posture
• "Too many toes" sign (when viewed from behind, more toes visible on lateral side)
• Bilateral calf tenderness (in posterior tibial tendon dysfunction)
• Pain (if symptomatic) - medial arch, heel, ankle, knee, back

• Clinical diagnosis
• X-ray weight-bearing: Talo-calcaneal angle (Kite's angle) increased (>35°), talus vertical, loss of calcaneal inclination angle
• MRI: If tibialis posterior tendon pathology suspected

• Reassurance - most resolve by age 5-8 years
• No treatment needed

• Insoles/Arch supports (medial arch support orthosis) - first line
• Footwear modification (Thomas heel - extended medial heel counter)
• Physiotherapy:
  • Tibialis posterior strengthening (heel raises in supination)
  • Intrinsic foot muscle exercises (towel curling, marble picking)
  • Gastrocnemius-soleus stretching
  • Proprioception training

• Tibialis posterior tendon reconstruction
• Calcaneal osteotomy (medial displacement)
• Subtalar arthroereisis
• Triple arthrodesis (rigid flat foot)

---

Q8. MYOSITIS OSSIFICANS (Asked 6 times)

1. Myositis Ossificans Traumatica (most common) - localised, following single significant trauma
2. Myositis Ossificans Progressiva (Fibrodysplasia Ossificans Progressiva - FOP) - rare genetic disorder, progressive, fatal

• Direct blow/contusion to muscle (especially anterior thigh - quadriceps)
• Haematoma formation after trauma
• Repeated minor trauma
• Post-operative (after hip replacement - most common)
• Aggressive physiotherapy (kneading/manipulation) in early stage
• Burns, spinal cord injury (neurogenic myositis ossificans)

• Painful hard mass in muscle after trauma
• Swelling, warmth, reduced ROM of adjacent joint
• Pain on movement
• Eventually palpable bony hard lump
• In brachialis: Progressive loss of elbow flexion

• X-ray (3-4 weeks after injury): Shows calcification/ossification in muscle - "eggshell" appearance (peripheral denser than centre - distinguishes from osteosarcoma where centre is denser)
• MRI/CT: Early diagnosis, shows location and extent
• Bone scan: High uptake in early active phase; reduces as mature

• Avoid aggressive massage and forceful passive stretching in acute haematoma stage
• RICE initially (Rest, Ice, Compression, Elevation)
• NSAIDs (Indomethacin, Celecoxib - reduce risk in high-risk cases)

• Gentle, pain-free active ROM exercises (NOT passive)
• NSAIDs (Indomethacin) - reduce ossification progression
• Wait for maturation (9-12 months) before surgical intervention
• Radiotherapy (low dose) - for prevention in high-risk surgical cases (hip replacement)

• Excision only when ossification is mature (bone scan normalised, >12 months)
• Indications: Significant functional loss, nerve/vessel compression
• Do NOT excise early (very high recurrence)

---

Q9. RHEUMATOID HAND (RA HAND) (Asked 5 times)

• Most characteristic
• MCPs deviate ulnarward due to:
  • Attenuation of radial collateral ligament and radial sagittal band
  • Pull of long flexors (ulnar direction)

• PIP hyperextension + DIP flexion
• Cause: Intrinsic muscle tightness OR long extensor tendon contracture
• Tests: Bunnell's intrinsic tightness test

• PIP flexion + DIP hyperextension
• Cause: Rupture of central slip of extensor tendon → lateral bands slide volar to PIP axis

• MCP flexion + IP hyperextension (or MCP hyperextension + IP flexion)
• Two types: Type I (intrinsic-plus) and Type II (intrinsic-minus)

• Extensor tendon rupture (especially of little finger) - Mannerfelt lesion

• Flexor tenosynovitis causes triggering

• Volar subluxation of wrist
• Caput ulnae syndrome (prominent ulnar head + piano key sign + extensor tendon rupture)
• Carpal bone destruction

• Early RA: DMARDs, physiotherapy, splinting to prevent deformity
• Established deformity:
  • Swan neck: PIP fusion or Swanson's silicone implant
  • Boutonnière: Central slip repair, PIP fusion
  • Ulnar drift: MCP joint arthroplasty (Swanson)
  • Wrist: Wrist fusion (arthrodesis) for severe destruction

• Resting splints (night) to prevent deformity progression
• Working splints during activities
• Joint protection education
• ROM exercises during remission
• Grip strengthening within pain limits

---

Q10. TORTICOLLIS (WRYNECK) (Asked 5 times)

1. Congenital Muscular Torticollis (CMT):
   • Most common type
   • SCM fibrosis/shortening from birth
   • Aetiology: Birth trauma, ischaemia of SCM, intrauterine malposition
   • Palpable SCM mass (fibrous tumour) in newborns
2. Acquired Torticollis:
   • Acute wry neck (Atlanto-axial rotatory subluxation): Sudden onset in children after URTI or minor trauma
   • Ocular torticollis: Compensatory head tilt for extraocular muscle palsy
   • Spasmodic torticollis (cervical dystonia): Neurological - repetitive involuntary SCM contraction
   • Bony torticollis: Atlanto-axial instability, os odontoideum, Klippel-Feil syndrome
   • Post-irradiation, post-inflammatory (Grisel's syndrome)

• Head tilted to affected (ipsilateral) side
• Chin rotated to opposite (contralateral) side
• Restricted cervical rotation toward affected side
• In congenital: Palpable SCM mass, facial asymmetry (plagiocephaly - if untreated)
• In acute: Sudden painful restriction

• < 1 year: Physiotherapy - SCM stretching (turn chin toward affected side + tilt head to opposite side), strengthening contralateral SCM
• 1-4 years (if persistent): Physiotherapy continues + Botulinum toxin injection
• > 4-5 years (failed conservative): Surgical - SCM release:
  • Unipolar release (lower end)
  • Bipolar release (upper and lower ends) - for severe cases
  • Z-plasty of SCM

• Botulinum toxin injection (into SCM and other affected muscles) - most effective
• Physiotherapy
• Surgical: Selective denervation

---

Q11. OSTEOSARCOMA (Asked 5 times)

• Peak incidence: 10-20 years (adolescents), second peak >60 years (secondary/Paget's)
• Male > Female (1.5:1)
• Common sites: Distal femur (most common), proximal tibia, proximal humerus - metaphysis of long bones

• Central (classic/conventional): Intramedullary, most common
• Parosteal: Surface tumour, low grade
• Periosteal: Surface, intermediate grade
• Telangiectatic: Cystic, very aggressive
• Secondary: In Paget's disease, post-radiation

• Progressive, constant pain (worse at night - unlike mechanical pain)
• Soft tissue mass/swelling (hard, warm, tender)
• Dilated surface veins
• Pathological fracture
• Advanced: Fever, weight loss, pulmonary metastases (lung most common site)

• X-ray:
  • Lytic or sclerotic or mixed lesion in metaphysis
  • "Sunray/Sunburst" periosteal reaction (spiculated new bone perpendicular to cortex)
  • Codman's triangle (periosteal elevation at tumour margins)
  • Soft tissue extension
• MRI: Local staging (extent of medullary involvement, soft tissue, neurovascular)
• CT chest: Pulmonary metastases (present in 20% at diagnosis)
• Bone scan: Skip lesions, other bone metastases
• Biopsy (incisional/core needle): Histology - malignant spindle cells producing osteoid
• Serum Alkaline Phosphatase (SAP): Raised (correlates with extent)
• LDH: Raised (poor prognostic marker)

1. Pre-operative chemotherapy (neoadjuvant): MAP regimen - Methotrexate (high dose), Adriamycin (Doxorubicin), Cisplatin - 8-12 weeks
2. Surgery: Limb salvage surgery (preferred) - wide excision with en-bloc resection; OR Amputation (if limb salvage not possible)
3. Post-operative chemotherapy (adjuvant): Same drugs - 6-12 months

• Radiotherapy: Osteosarcoma is radioresistant (unlike Ewing's)

---

Q12. PRINCIPLES OF TENDON TRANSFER (Asked 5 times)

• Irreparable nerve injury with permanent muscle paralysis
• Poliomyelitis (classic indication)
• Leprosy (ulnar/radial nerve palsy)
• Traumatic nerve injury

1. P - Passive mobility: Joint must have full passive ROM before transfer (no contractures)
2. A - Adequate motor (Available donor): Donor muscle must have MRC grade ≥ 4 (preferably 5)
3. S - Synergistic: Ideally, donor should be synergistic to recipient (e.g., wrist extensors with finger extensors)
4. S - Straight line pull: Tendon must run in a straight line without sharp angles (may use pulley)
5. Expendable donor: Donor removal must not significantly compromise existing function
6. Equal amplitude: Donor and recipient should have similar excursion
7. One tendon - one function: Each transferred tendon should perform only one function
8. Adequate skin and soft tissue: Tendon must glide in a bed of healthy, non-scarred tissue

1. Immobilisation phase (0-4 weeks): Splinting in position of slack; no tension on repair
2. Re-education phase (4-8 weeks): Gentle active mobilisation; biofeedback; train patient to activate donor in new role
3. Strengthening phase (8-12+ weeks): Progressive resistance, functional activities, sport-specific if needed

• Radial nerve palsy: PT (pronator teres) → ECRB; FCU → EDC; PL → EPL
• Ulnar nerve palsy: FDS → lateral bands (to correct claw); EIP → ADM
• Median nerve palsy: EIP → APB (to restore thumb opposition - Camitz procedure)

---

Q13. AVASCULAR NECROSIS (AVN) (Asked 5 times)

• Femoral head (most common)
• Humeral head
• Scaphoid (proximal pole)
• Talus
• Femoral condyle

• Traumatic: Fracture neck of femur (disrupts blood supply), dislocation of hip
• Non-traumatic:
  • Corticosteroid use (most common non-traumatic cause) - fat embolism hypothesis
  • Alcohol excess
  • Sickle cell disease
  • Systemic lupus erythematosus (SLE)
  • Caisson disease (decompression sickness - nitrogen bubbles)
  • Gaucher's disease
  • Idiopathic

• Blood supply interrupted → bone cells die (osteocytes die within 12-48 hours)
• Subchondral bone weakens
• Microfractures → Subchondral crescent sign on X-ray
• Articular cartilage (avascular normally) survives initially
• Eventually: Subchondral collapse → articular incongruity → OA

• Insidious onset of joint pain
• Progressive loss of ROM
• Antalgic gait (hip AVN)
• Eventually: Osteoarthritis features

• Stage I: Normal X-ray, MRI changes (oedema)
• Stage II: Sclerosis/cysts on X-ray, no crescent
• Stage III: Crescent sign (subchondral fracture) - characteristic
• Stage IV: Femoral head collapse, joint space narrowing, OA

• X-ray: Normal early; later sclerosis, "crescent sign", collapse
• MRI - gold standard (earliest detection): "Double line sign" (inner bright and outer dark band around necrotic segment)
• Bone scan: Cold spot (photopenic) early, hot spot later

• Stage I-II: Conservative - activity modification, non-weight bearing, bisphosphonates; Core decompression (drilling to reduce intraosseous pressure and promote revascularisation)
• Stage III: Core decompression + bone grafting; Vascularised fibula graft
• Stage IV: Total Hip Replacement (definitive)

---

Q14. TB SPINE (POTT'S SPINE) / POTT'S DISEASE (Asked 4 times)

• Haematogenous spread from primary focus (lung, lymph nodes)
• Starts in subchondral region of vertebral body
• Spreads to adjacent disc and vertebra
• Disc destruction (avascular disc - infected via granulation tissue)
• Vertebral collapse → Gibbus deformity (angular kyphosis)
• Cold abscess formation (pus with no inflammatory signs):
  • Thoracic: Paravertebral abscess → tracks down to psoas muscle (Psoas abscess) → points in inguinal/iliac fossa

• Insidious onset back pain with stiffness
• Low-grade fever, evening rise of temperature, night sweats, weight loss
• Gibbus deformity (sharp angular kyphosis)
• Cold abscess (fluctuant, non-tender swelling)
• Pott's paraplegia (in 10-30%): Spinal cord/cauda equina compression
  • Early: Spastic paraplegia (cord compression by abscess/granulation tissue)
  • Late: Flaccid (cord damage from vascular occlusion, bone collapse)

• X-ray spine: Disc space narrowing (early), vertebral collapse, kyphosis, paravertebral shadow
• MRI (gold standard): Best for cord compression, abscess extent, marrow involvement
• CT-guided biopsy: Definitive diagnosis
• AFB smear, CBNAAT/GeneXpert, culture
• Mantoux test positive, IGRA
• ESR raised

1. Anti-tubercular therapy (ATT):
   • HRZE × 2 months (Isoniazid, Rifampicin, Pyrazinamide, Ethambutol)
   • HR × 7-10 months continuation
   • Total: 9-12 months (18 months for extensive disease)
2. Immobilisation: Spinal brace/TLSO during ambulation
3. Surgical (indications): Progressive neurological deficit, spinal instability, large undraining abscess, failed conservative
   • Anterior debridement + bone graft + posterior instrumentation

---

Q15. KLUMPKE'S PALSY (Asked 4 times)

• Birth injury: Excessive abduction of arm during breech delivery
• Adult: Sudden upward traction of arm (grabbing to prevent fall), cervical rib, Pancoast tumour

• Ulnar nerve (intrinsics)
• Median nerve (hand intrinsics)
• T1 sympathetic fibres (if T1 involved)

• Claw hand deformity (hyperextension at MCPs + flexion at IPs) - intrinsic muscle paralysis
• Paralysis: All intrinsics of hand (interossei, lumbricals, thenar, hypothenar)
• Weakness: Long flexors (FDP, FDS) - weakness of grip
• Sensory loss: Medial aspect of arm, forearm, hand (C8-T1 dermatome) - ulnar border of hand and forearm
• Horner's syndrome (if T1 involved): Ptosis (drooping eyelid), miosis (constricted pupil), anhidrosis (no sweating), enophthalmos

• Splinting: Lumbrical bar splint (to prevent claw deformity - holds MCPs in flexion)
• Physiotherapy: Passive ROM to prevent contractures, strengthening as recovery occurs
• Sensory re-education
• Surgical if no recovery in 3-6 months: Nerve repair, grafting, transfer

---

Q16. ADHESIVE CAPSULITIS (FROZEN SHOULDER) (Asked 4 times)

• Primary (Idiopathic): No known cause; most common
• Secondary: Associated with systemic disease (diabetes - most common, thyroid disease, cardiac disease, Parkinson's), or following prolonged immobilisation

1. Freezing Stage (Painful phase - 3-9 months): Increasing pain, gradual loss of motion, capsular inflammation
2. Frozen Stage (Stiff phase - 9-15 months): Pain decreases, maximal stiffness, dense capsular adhesions
3. Thawing Stage (Resolution - 15-24 months): Gradual spontaneous recovery of motion

• Gradual onset pain (often at night)
• Progressive loss of all shoulder movements (especially ER - first and most lost)
• Pattern of restriction: ER > Abduction > IR (capsular pattern)
• Deltoid wasting in late stages
• Pain at end of available ROM
• Scapulohumeral rhythm: Normal initially, lost later
• Duration: 18-24 months typically (self-limiting in 90%)

• Clinical diagnosis
• X-ray: Normal (rules out other pathology); may show osteoporosis
• MRI: Thickened contracted capsule, especially at rotator interval
• Arthrography: Reduced joint volume (<10ml vs normal 20-30ml)

1. Physiotherapy (cornerstone):
   • Pendulum exercises (Codman's exercises) - early
   • Active and assisted ROM (within pain limits)
   • Capsular stretching (especially ER and abduction)
   • Joint mobilisation techniques (Maitland, Mulligan)
   • Heat before, ice after exercise
   • TENS, ultrasound
2. Medical:
   • NSAIDs (analgesic and anti-inflammatory)
   • Intra-articular corticosteroid injection - most effective for pain relief (early stage)
   • Oral steroids (short course) for very acute pain
3. Manipulation Under Anaesthesia (MUA): Forced stretching under GA - used for refractory frozen stage
4. Hydrodilatation (Arthrographic distension): Injection of saline + steroid into joint capsule to distend and rupture adhesions
5. Arthroscopic capsular release: For failed conservative treatment

---

Q17. SUDECK'S ATROPHY / RSD / CRPS (Asked 4 times)

• Trauma (most common - fracture, especially Colle's fracture)
• Surgery
• MI, stroke
• Minor injury, immobilisation
• Spontaneous (10%)

1. Acute stage (1-3 months): Burning pain, swelling, redness, warmth, hyperhidrosis
2. Dystrophic stage (3-6 months): Pain continues, skin becomes cool, cyanotic, stiff, livedo reticularis, brittle nails
3. Atrophic stage (>6 months): Irreversible atrophy of skin, subcutaneous tissue, muscle wasting, contractures, severe osteoporosis

• Burning, severe pain (allodynia - pain from non-painful stimulus)
• Hypersensitivity to touch
• Swelling, colour changes (red/blue)
• Temperature changes (warm initially, later cold)
• Sweating changes
• Trophic changes: Shiny skin, brittle nails, hair loss
• Osteoporosis

• X-ray: Patchy osteoporosis ("moth-eaten" or "spotty" osteoporosis - characteristic of Sudeck's)
• Bone scan: Increased uptake (Stage 1-2), decreased (Stage 3)
• MRI: Bone marrow oedema

• Physiotherapy (central): Desensitisation, mirror therapy, graded motor imagery, gentle ROM, TENS, contrast baths (alternating hot/cold)
• Medical: NSAIDs, Gabapentin/Pregabalin (neuropathic pain), Bisphosphonates, Calcitonin, Corticosteroids (early stages)
• Sympathetic nerve block (stellate ganglion block for upper limb, lumbar sympathetic block for lower limb)
• Spinal cord stimulation (refractory)

---

Q18. SCAPHOID FRACTURE (Asked 4 times)

• Waist (most common - 70%) - moderate AVN risk
• Proximal pole (15-20%) - highest AVN risk
• Distal pole/Tubercle (10%) - lowest AVN risk

• Fall on outstretched hand with wrist dorsiflexed
• Pain in anatomical snuff box
• Swelling in "anatomical snuff box" region
• Anatomical snuff box tenderness (between EPL and EPB/APL tendons) - pathognomonic
• Pain on axial compression of thumb
• Reduced wrist movement

• X-ray (AP, Lateral, oblique views): May be normal initially (up to 20% missed initially)
• If X-ray normal but clinically suspected → MRI or CT scan
• MRI: Gold standard for occult fractures (shows marrow oedema within 24 hours)
• CT: Better for displacement assessment, union assessment

• Thumb spica cast (below elbow, includes thumb MCP) for 8-12 weeks
• 6-8 weeks for distal pole, 8-12 weeks for waist
• Or percutaneous headless screw fixation (Herbert screw) - allows earlier return to activity

• Surgical: ORIF with Herbert screw
• Proximal pole AVN: Vascularised bone graft (1,2-intercompartmental supraretinacular artery graft)

• AVN of proximal pole (most important - 13-40% of waist fractures)
• Non-union (10-30% if untreated)
• OA wrist (SNAC wrist - Scaphoid Non-union Advanced Collapse)

---

Q19. FOOT DROP (Asked 4 times)

• Common peroneal (fibular) nerve palsy - most common cause; nerve compressed at fibular neck (prolonged squatting, tight plaster cast, crossing legs, trauma around knee)
• L4-L5 disc prolapse (L5 radiculopathy) - nerve root cause
• Sciatic nerve injury
• Peripheral neuropathy (diabetes, alcoholism - bilateral foot drop)
• Central causes: Stroke, MS, brain tumour

• Compartment syndrome of anterior compartment
• Anterior tibial tendon rupture

• Inability to dorsiflex foot - cannot lift forefoot
• Steppage gait (high-stepping gait) - exaggerated hip and knee flexion to lift foot off ground
• Slapping of forefoot on ground (footslap)
• Sensory loss: Dorsum of foot and first web space (L5 / deep peroneal nerve)
• If superficial peroneal involved: Eversion also weak + lateral leg sensory loss
• Wasting of anterior compartment muscles

• EMG/NCS: Confirms nerve injury and level
• X-ray knee: If bony cause
• MRI: Nerve compression, disc prolapse, spinal cord pathology

• AFO (Ankle Foot Orthosis): Maintains foot in dorsiflexion for walking; prevents equinus contracture - most important management
• Physiotherapy: Strengthening of dorsiflexors, proprioception, gait training
• Electrical stimulation of peroneal nerve (functional electrical stimulation - FES)
• Treat cause (remove plaster, treat underlying neuropathy)

• Nerve decompression/repair (if structural cause)
• Tibialis posterior tendon transfer (through interosseous membrane to dorsum of foot) - for permanent foot drop with adequate tibialis posterior strength
• Ankle arthrodesis (if tendon transfer not possible)

---

Q20. SUPRASPINATUS TENDINITIS (Asked 4 times)

• Impingement (most common): Repeated compression of supraspinatus between greater tuberosity and coracoacromial arch during shoulder abduction (60-120°)
• Degenerative changes (age-related)
• Repetitive overhead activities (swimming, throwing, painting)
• Calcific deposits in tendon

• Pain in shoulder, radiating to deltoid region
• Painful arc of abduction: 60°-120° (pain during this arc, free before and after - classic)
• Tenderness over greater tuberosity
• Painful on resisted abduction
• Reduced full abduction (chronic)
• Neer's impingement sign: Forward flexion with internal rotation → pain
• Hawkins-Kennedy test: Shoulder at 90° flexion, internal rotation → pain

• X-ray: Usually normal; calcific deposits if calcific tendinitis
• USS: Thickened tendon, calcification, partial/full thickness tear
• MRI: Best - shows extent of tendon damage

1. Rest, activity modification
2. NSAIDs
3. Physiotherapy:
   • Strengthening of rotator cuff muscles (especially infraspinatus/teres minor for ER)
   • Scapular stabilisation exercises
   • Postural correction
   • Ultrasound therapy
4. Subacromial corticosteroid injection - effective for pain
5. Extracorporeal Shock Wave Therapy (ESWT) - for calcific tendinitis
6. Surgical: Subacromial decompression (acromioplasty) if conservative fails >6 months

---

Q21. ULNAR CLAW HAND (Asked 4 times)

• All intrinsics except LOAF muscles (which are median nerve)
• Hypothenar muscles, 3rd and 4th lumbricals, interossei, adductor pollicis

• Paralysis of 3rd and 4th lumbricals + interossei
• Lumbricals flex MCPs and extend IPs → when paralysed: MCPs hyperextend, IPs flex
• Long flexors (FDP, FDS) unopposed → further flex IPs
• Clawing more severe in ring and little fingers (as index and middle lumbrical supplied by median nerve)

• Clawing of ring and little fingers (more prominent in distal ulnar palsy)
• Froment's sign: Paper held between thumb and index with adductor pollicis paralysed → patient uses FPL (flexes IP of thumb) - positive Froment's
• Weakness of hand grip
• Sensory loss: Little finger + medial half of ring finger + ulnar border of palm
• Hypothenar wasting, first dorsal interosseous wasting (most visible)
• Card test (Egawa test): Spreading fingers not possible

• Lumbrical bar splint (knuckle bender splint): Prevents MCP hyperextension, corrects functional position
• Physiotherapy: Passive ROM to prevent contractures

• FDS tenodesis (Brand procedure): FDS tendons used to prevent MCP hyperextension
• Bunnell's procedure
• Zancolli's lasso procedure: FDS threaded through A1 pulley to flex MCPs

---

Q22. SPONDYLOLISTHESIS (Asked 4 times)

1. Dysplastic (Congenital): Congenital defect in facets - rare
2. Isthmic (most common): Defect in pars interarticularis (spondylolysis) - common in young athletes
3. Degenerative: Disc and facet degeneration in elderly; no pars defect
4. Traumatic: Acute fracture
5. Pathological: Paget's disease, TB, tumour

• Grade I: 0-25% slip
• Grade II: 25-50% slip
• Grade III: 50-75% slip
• Grade IV: 75-100% slip
• Grade V (Spondyloptosis): >100% slip

• Low back pain (worse on activity, extension)
• Buttock pain, referred leg pain
• "Step deformity" at lumbar spine (if significant slip - visible step)
• Tight hamstrings (limited straight leg raise, crouching posture)
• Neurological signs (cauda equina if severe)
• Antalgic gait

• X-ray Lateral: Anterior vertebral slip; "Scotty dog" sign on oblique view - collar on dog's neck = spondylolysis
• CT: Pars defect detail
• MRI: Disc degeneration, nerve compression

• Rest, NSAIDs
• Physiotherapy: Core stabilisation, flexion exercises (Williams), extension (McKenzie)
• Spinal brace/corset (for isthmic in young)
• Activity modification

• Spinal fusion with instrumentation (posterior instrumentation + posterolateral fusion)
• ± Decompression (if stenosis)

---

Q23. CLASSIFICATION OF BONE TUMOURS (Asked 4 times)

• Primaries: Breast, Prostate, Lung, Kidney, Thyroid (BPLKiT)
• Commonly: Lytic (breast, lung, kidney, thyroid); Sclerotic (prostate)

• Stage I: Low grade
• Stage II: High grade
• Stage III: Any grade with metastasis
• A: Intracompartmental; B: Extracompartmental

---

Q24. RADIAL NERVE PALSY (Asked 4 times)

• High (axilla level): Misuse of crutches (crutch palsy), fracture shaft of humerus (Holstein-Lewis fracture)
• Mid-humeral (spiral groove - most common): "Saturday night palsy" (compression against arm of chair while intoxicated), fracture of shaft of humerus (Holstein-Lewis)
• Elbow level: Posterior interosseous nerve (deep branch): Resistant epicondylitis, Radial tunnel syndrome, Monteggia fracture

• Wrist drop (inability to extend wrist)
• Finger drop (inability to extend fingers at MCP joints)
• Thumb drop (loss of extension and abduction)
• Weakness of supination (biceps can still supinate)
• Sensory loss: Posterior arm, forearm, and dorsum of hand (first web space - most consistent - dorsal digital nerve to first web space)

• EMG/NCS: Confirms level and severity

• Splinting: Cock-up splint (wrist extension splint) - holds wrist in 30-40° extension + MCP extension to allow functional grip
• Physiotherapy: Prevent contractures (passive ROM), strengthen when recovery begins
• TENS, EMG biofeedback
• Surgical if no recovery in 3-6 months:
  • Nerve repair/graft
  • Tendon transfer (standard): PT → ECRB; FCU → EDC; PL (or FDS) → EPL/APL

---

Q25. OSTEOCHONDRITIS DISSECANS (Asked 3 times)

• Medial femoral condyle (most common - posterior aspect) - knee
• Capitellum of humerus - elbow (especially gymnasts, throwers)
• Talus - ankle

• Grade I: Intact articular surface, subchondral bone change
• Grade II: Partial separation
• Grade III: Completely detached but in place
• Grade IV: Loose body in joint

• Pain with activity (especially knee flexion)
• Intermittent swelling of joint
• Locking (if loose body present)
• Wilson's test (knee): Knee in 90° flexion, internal rotation, extend knee → pain at 30° (tibial spine impinges on OCD lesion); relieved by external rotation - positive in knee OCD
• Tenderness over medial femoral condyle

• X-ray: "Crater" in medial femoral condyle; loose body
• MRI: Best - shows extent of separation, viability of fragment

• Stable lesions in skeletally immature: Conservative - restrict activity 3-6 months (spontaneous healing potential)
• Arthroscopic surgery:
  • Stable: Drilling (to promote revascularisation)
  • Unstable: Fixation with Herbert screws/pins
  • Detached loose body: Removal + microfracture/mosaicplasty of crater

---

Q26. MONTEGGIA FRACTURE DISLOCATION (Asked 3 times)

• Type I (most common - 60%): Anterior ulna angulation + anterior radial head dislocation
• Type II: Posterior angulation of ulna + posterior radial head dislocation
• Type III: Lateral radial head dislocation + ulna metaphyseal fracture
• Type IV: Anterior dislocation of radial head + fractures of both radius and ulna

• Pain and deformity of forearm
• Radial head may be palpable anterolaterally
• Posterior interosseous nerve (PIN) palsy in 10-20%: Loss of finger extension (wrist extension partially preserved due to ECRL intact)
• Compartment syndrome possible

• X-ray: Ulna fracture + radial head dislocation
• Key rule: A line through radial shaft should pass through capitellum on ALL views - if not, radial head is dislocated

• Closed reduction of radial head + cast immobilisation (good results)

• ORIF of ulna (plate and screws) + closed reduction of radial head
• If radial head does not reduce: Open reduction of radial head
• If irreducible/chronic: Radial head excision (or replacement)
• PIN palsy: Usually recovers after radial head reduction; explore if no recovery in 3-6 months

---

Q27. POSTERIOR DISLOCATION OF HIP (Asked 3 times)

• Severe pain in hip
• Limb shortened + internally rotated + adducted (characteristic position - opposite of neck of femur fracture which is ER)
• Prominent femoral head palpable in buttock
• Unable to move hip
• Check for sciatic nerve injury

• Sciatic nerve injury (10-20%) - most common
• Avascular necrosis of femoral head (10-30%) - incidence increases with delay in reduction
• Osteoarthritis (late)
• Myositis ossificans
• Associated fracture of acetabulum or femoral head

• X-ray AP pelvis + hip: Femoral head displaced superior and lateral to acetabulum (posterior dislocation), smaller femoral head shadow (as closer to X-ray plate)
• CT scan: Post-reduction (assess acetabular fracture, femoral head fracture, intra-articular fragments)

• Emergency closed reduction (within 6 hours - before AVN develops):
  • Bigelow's technique: Traction + flexion → IR → abduction → ER
  • Stimson's technique: Prone, knee flexed 90°, downward traction on tibia
  • Under sedation/GA
• Post-reduction: CT scan, traction for 2-4 weeks, then mobilise
• Open reduction: If closed fails or bony fragments blocking reduction

---

Q28. ANTERIOR DISLOCATION OF SHOULDER (Asked 3 times)

• Indirect (most common): Fall on outstretched hand with shoulder in abduction + external rotation
• Direct: Posterior blow to shoulder

• Severe shoulder pain
• Loss of normal shoulder contour - deltoid flattened, step deformity
• Acromion prominent (sharp corner)
• Arm held in slight abduction and ER
• Dugas test positive: Patient cannot touch opposite shoulder with affected hand while elbow touching chest
• Fullness of anterior axillary fold (subcoracoid position of head)
• Check for axillary nerve (sensation over deltoid patch) and brachial plexus

• Axillary nerve injury (most common nerve injury - tests: Regimental badge area sensation)
• Rotator cuff tear (in elderly >40 years)
• Brachial plexus injury
• Vascular injury (axillary artery)
• Recurrent dislocation (Bankart lesion, Hill-Sachs lesion)

• Hippocratic method: Traction + countertraction + ER then IR
• Kocher's method: Traction → ER → adduction → IR
• Stimson's technique: Prone, 5-10 lb weight hanging from wrist → gravity reduction
• All under sedation/analgesia
• Post-reduction X-ray to confirm

• Arm sling 3-6 weeks (younger patients longer)
• Physiotherapy: Rotator cuff strengthening, ER strengthening
• Young patients: Consider early stabilisation surgery (high recurrence rate)

---

Q29. FRACTURE CLAVICLE (Asked 3 times)

• Group I: Middle 1/3 (most common - 80%)
• Group II: Lateral 1/3 (distal - 15%; risk of non-union)
• Group III: Medial 1/3 (5%)

• Pain, swelling, tenderness at fracture site
• Drooping of shoulder
• Deformity - proximal fragment displaced upward (SCM pull), distal fragment downward (arm weight)
• Skin tenting
• Check neurovascular status (brachial plexus, subclavian vessels)

• Broad arm sling (most common) OR figure-of-8 bandage for 4-6 weeks
• Pain relief: NSAIDs
• Physiotherapy: Shoulder ROM after 4-6 weeks, strengthening

• Open fracture
• Neurovascular compromise
• Severely displaced (>2 cm shortening)
• Floating shoulder (clavicle + scapula fracture)
• Non-union (lateral 1/3 especially)
• Polytrauma patient

---

Q30. CLUB FOOT (CTEV - Brief 5-mark version) (Asked 3 times)

• Incidence: 1 in 1000 births; M:F = 2:1; bilateral 50%
• Pirani score/Dimeglio score for severity
• Treatment: Ponseti method (gold standard):
  • Serial casting (correct CAVE order: Cavus → Adductus → Varus → Equinus)
  • Percutaneous Achilles tenotomy (in 90%)
  • Denis-Browne foot abduction brace (23 hrs/day for 3 months, then nights until age 4-5)
• If neglected: Posteromedial soft tissue release, triple arthrodesis

---

SUMMARY: TOP 10 MOST IMPORTANT 5-MARK TOPICS

---

• Write approximately 1 to 1.5 pages
• Follow format: Definition → Causes → Clinical Features → Investigations → Management
• Use bullet points and sub-headings (examiners love structure)
• Include 1-2 key X-ray findings or special tests where relevant
• For surgical topics, always end with physiotherapy role
• Total time budget: ~8 minutes per 5-mark question