Clinical Orthopedics - Important Questions & Answers

Tamil Nadu Dr. MGR Medical University | BPT 3rd Year | Regulation 2017-18 Onwards

SECTION A: LONG ANSWER QUESTIONS (10 Marks Each)

Q1. Classify fractures and describe the clinical features, complications, and physiotherapy management of Colles' fracture.

• Dinner fork deformity (dorsal displacement of distal fragment)
• Pain, swelling, and tenderness at wrist
• Loss of normal radial prominence
• Restricted wrist movements
• "Bayonet" appearance on X-ray: dorsal tilt, radial shift, and supination of distal fragment

• Immediate: Median nerve injury (carpal tunnel syndrome), rupture of EPL tendon
• Late: Malunion, Sudeck's osteodystrophy (CRPS I), stiffness, weakness

• Finger exercises (active ROM) to prevent stiffness
• Shoulder and elbow active movements
• Elevation to reduce edema
• Isometric exercises for forearm muscles

• Wrist active and assisted ROM exercises (flexion, extension, pronation, supination)
• Hydrotherapy/warm water soaks to ease stiffness
• Grip strengthening exercises
• Interferential therapy (IFT) / TENS for pain relief
• Ultrasound therapy for scar tissue and tendon mobility
• Functional activities and activities of daily living (ADL) training

• Progressive resistive exercises (PRE) for wrist and grip
• Fine motor and proprioception training

Q2. Define osteomyelitis. Classify it and describe the clinical features and physiotherapy management of acute and chronic osteomyelitis.

• Hematogenous: Blood-borne; common in children (metaphysis of long bones)
• Secondary to contiguous focus: Post-traumatic/post-surgical
• Chronic osteomyelitis: Long-standing, with sequestrum and involucrum formation
• Brodie's abscess: Subacute sclerosing variety

1. Bacteria lodge in metaphyseal sinusoids
2. Inflammatory exudate forms → pressure builds up
3. Pus tracks under periosteum → periosteal stripping → avascular necrosis
4. Dead bone = sequestrum; new bone laid around = involucrum

• Sudden onset high fever, malaise, toxemia
• Severe local pain, exquisite tenderness over bone
• Soft tissue swelling, warm skin
• Refusal to move the limb (pseudoparalysis in children)
• ESR/CRP raised; blood culture positive

• Sinus discharging pus with sequestrum
• Persistent dull aching pain
• Swelling and thickening of bone
• Intermittent exacerbations

• Complete rest and immobilization of affected limb
• Splinting to prevent deformity and reduce pain
• Elevation to reduce edema
• TENS/IFT for pain control
• Breathing exercises and chest physiotherapy

• Gentle active ROM exercises of adjacent joints
• Muscle strengthening (isometrics initially)
• Graduated weight bearing as per surgeon's advice

• Pulsed ultrasound over chronic sinus tracts
• Contrast bath for circulation
• Progressive strengthening and ADL training
• Gait re-education and mobility training
• UV therapy (bactericidal effect over sinus openings)

Q3. Describe the etiology, pathology, clinical features, investigations, and physiotherapy management of osteoarthritis of the knee joint.

• Primary (idiopathic): Age-related degeneration (most common in >50 years, females more)
• Secondary: Trauma, obesity, metabolic disorders, previous infection, malalignment

1. Articular cartilage softening and fibrillation (earliest change)
2. Cartilage erosion and loss → subchondral bone exposure
3. Subchondral sclerosis and cyst formation
4. Marginal osteophyte formation
5. Synovial thickening and mild inflammation
6. Capsular contracture and muscle wasting

• Pain: activity-related, relieved by rest; later rest pain too
• Morning stiffness: <30 minutes
• Crepitus on joint movement
• Joint line tenderness
• Bony swelling (osteophytes), deformity (varus in medial OA)
• Reduced ROM, quadriceps wasting
• Effusion in acute exacerbations

• X-ray: Joint space narrowing, subchondral sclerosis, osteophytes, subchondral cysts
• ESR: Normal (differentiates from RA)
• MRI: Cartilage assessment

• TENS/IFT: Pain relief
• Pulsed ultrasound: Anti-inflammatory, reduce swelling
• SWD/MWD: Deep heat, improve circulation
• LASER: Reduce inflammation, pain modulation

• Quadriceps strengthening (isometrics initially → progressive resistance)
• Hamstring stretching
• SLR exercises
• Cycling and hydrotherapy (reduces joint loading)
• Gait training and posture correction

• Joint mobilization (Maitland grades I-II for pain)
• Muscle energy techniques
• Patellofemoral mobilization

• Weight reduction advice
• Activity modification and joint protection
• Assistive devices (walking stick - contralateral hand)
• Orthosis: Knee brace, foot orthotics for malalignment

Q4. Classify dislocation of the shoulder. Describe the clinical features and physiotherapy management of anterior shoulder dislocation.

• Anterior (Subcoracoid/Subglenoid): Most common (95%) - FOOSH with abduction and external rotation
• Posterior: Uncommon - epileptic seizures, electric shock
• Inferior (Luxatio erecta): Rare
• Superior: Very rare

• Loss of deltoid contour (squared-off shoulder/step deformity)
• Prominent acromion
• Head of humerus palpable anteriorly below coracoid
• Arm held in slight abduction and external rotation
• Restricted ROM, pain
• Apprehension test positive
• Complications: Axillary nerve injury (loss of sensation over regimental badge area), rotator cuff tear, Hill-Sachs lesion, Bankart lesion, recurrent dislocation

• Immobilization in a sling (3 weeks)
• Pendulum exercises (Codman's)
• Isometric exercises for rotator cuff (ER/IR)
• Ice application for pain and swelling

• Active-assisted ROM (flexion, abduction, IR - avoid ER)
• Scapular stabilization exercises
• IFT/TENS for pain
• Ultrasound over soft tissue healing

• Progressive resistive exercises for rotator cuff and deltoid
• External rotation strengthening (key stabilizer)
• Proprioceptive training
• Functional activities and sport-specific exercises

• Full strength and ROM restoration
• Proprioception and neuromuscular control
• Preventive exercises for recurrence

SECTION B: SHORT NOTES (5 Marks Each)

Q5. Sudeck's Osteodystrophy (CRPS Type I)

• Also called Complex Regional Pain Syndrome (CRPS) Type I / Reflex Sympathetic Dystrophy
• Follows minor trauma, Colles' fracture, or surgery
• Pathology: Abnormal sympathetic nervous system response → vasomotor instability
• Stages:
  • Stage 1 (Acute - 0-3 months): Burning pain, warm red swollen hand, hypersensitivity
  • Stage 2 (Dystrophic - 3-9 months): Pain persists, cold cyanotic skin, brawny edema, stiffness
  • Stage 3 (Atrophic - >9 months): Irreversible stiffness, atrophy, skin thinning, X-ray shows patchy osteoporosis
• PT Management: TENS, IFT, contrast baths, desensitization, mirror therapy, graded motor imagery, active ROM, stress loading

Q6. Carpal Tunnel Syndrome

• Compression of the median nerve at the wrist within the carpal tunnel
• Causes: Pregnancy, hypothyroidism, RA, Colles' fracture, repetitive strain
• Clinical features: Tingling and numbness in median nerve distribution (lateral 3.5 fingers), nocturnal pain, thenar wasting (late)
• Tests: Phalen's test, Tinel's sign, carpal compression test
• PT Management: Wrist splinting in neutral (especially night), nerve gliding exercises, ultrasound, TENS, ergonomic advice; surgery (carpal tunnel release) in severe cases

Q7. Prolapsed Intervertebral Disc (PIVD) / IVDP

• Herniation of nucleus pulposus through a tear in annulus fibrosus, most common at L4-L5 and L5-S1
• Types: Protrusion, extrusion, sequestration
• Features: Low back pain with sciatica, positive SLR test, dermatomal sensory loss, weakness
• PT Management:
  • Acute: Rest, traction (lumbar), hot pack, TENS
  • Subacute: McKenzie protocol (extension exercises for posterior prolapse), core stabilization
  • Chronic: Back school, posture correction, ergonomic advice, Williams flexion exercises (anterior prolapse), strengthening

Q8. Scoliosis - Classification and PT Management

• Lateral curvature of the spine with rotational deformity
• Classification:
  • Structural: Idiopathic (most common), congenital, neuromuscular
  • Non-structural (Postural): Leg length discrepancy, muscle spasm
• Cobb's angle: Used to measure severity (<25° mild, 25-45° moderate, >45° severe)
• PT Management: Schroth method (3D breathing + postural correction), corrective exercises, Milwaukee brace for growing children (Cobb's 25-45°), spinal fusion surgery for >45°

Q9. Rheumatoid Arthritis - PT Management

• Systemic autoimmune disease causing symmetrical polyarthritis
• Hands (MCP, PIP) affected; morning stiffness >1 hour; positive RF, anti-CCP antibodies
• Deformities: Ulnar deviation, swan neck, boutonniere, Z-thumb
• PT Management:
  • Rest splints for acute flares, resting hand position
  • Active ROM exercises during remission
  • Hydrotherapy and warm paraffin wax bath
  • Strengthening exercises (avoid overloading inflamed joints)
  • Joint protection education (principles: reduce force, distribute load, use large joints)
  • Functional splints and assistive devices
  • Aerobic exercises (cycling, swimming)

Q10. Spinal Cord Injury (SCI) - Rehabilitation

• Complete vs. Incomplete injury (ASIA classification: A-E)
• Levels: Cervical → Tetraplegia; Thoracic/Lumbar → Paraplegia
• PT Goals:
  • Prevent secondary complications: pressure sores, contractures, DVT, respiratory infections
  • Maximize remaining function
  • Wheelchair mobility and transfers
• Management:
  • Positioning and regular turning (every 2 hours)
  • Passive ROM, stretching to prevent contractures
  • Strengthening of intact muscles
  • Respiratory exercises
  • Mat activities, balance training, gait training (with FES, orthotics, walkers)
  • Bladder and bowel training (in coordination)
  • Community re-integration

Q11. Periarthritis of the Shoulder (Frozen Shoulder / Adhesive Capsulitis)

• Idiopathic fibrosis and contracture of glenohumeral joint capsule
• Stages:
  • Painful (0-3 months): Gradual increasing pain
  • Freezing (3-9 months): Pain + severe restriction
  • Frozen (9-15 months): Stiffness, pain reduces
  • Thawing (15-24 months): Gradual recovery
• PT Management:
  • Pendulum (Codman's) exercises
  • Passive and active-assisted ROM
  • Maitland mobilization (grades I-IV)
  • Heat/SWD before exercises, ice after
  • Ultrasound and IFT
  • Stretching of inferior and posterior capsule
  • Hydrodilatation (injection) for refractory cases

Q12. Fractures - General Healing and Complications

1. Hematoma formation (0-48 hrs)
2. Fibrocartilaginous callus (2-4 weeks)
3. Bony callus formation (4-8 weeks)
4. Bone remodeling (months-years)

• Immediate: Hemorrhage, vascular injury, nerve injury, visceral injury
• Early: Infection, fat embolism, DVT, pulmonary embolism, compartment syndrome
• Late: Malunion, non-union, delayed union, avascular necrosis, Volkmann's ischemic contracture, refracture, joint stiffness

• Maintain ROM of adjacent joints
• Prevent muscle wasting (isometric exercises)
• Reduce edema (elevation, ice)
• Post-union: Progressive weight bearing, strengthening, gait training

SECTION C: SHORT ANSWER QUESTIONS (2 Marks Each)

KEY TOPICS TO PRIORITIZE (Based on Past Paper Pattern)

1. Colles' fracture - PT management
2. Osteoarthritis - knee PT management
3. Anterior shoulder dislocation
4. Osteomyelitis (acute and chronic)
5. Fracture - classification and complications
6. Scoliosis - assessment and PT
7. Rheumatoid arthritis - PT management

• Sudeck's osteodystrophy
• Carpal tunnel syndrome
• Frozen shoulder / Periarthritis
• PIVD/Sciatica
• Volkmann's ischemic contracture
• Pott's disease (spinal TB)
• Amputation - stump care and prosthetics
• Spinal cord injury rehabilitation
• Compartment syndrome
• Hallux valgus

Study Tips:

• Each long answer should follow the pattern: Definition → Classification → Etiology → Pathology → Clinical Features → Investigations → Physiotherapy Management (Aims + Phases)
• For PT management, always structure into: Electrotherapy + Exercise Therapy + Manual Therapy + Functional Training + Education
• Know the 3 sections of exam paper: 2 Long Essays (10 marks each) + 10 Short Notes (5 marks each) + 10 Short Answers (2 marks each)
• Refer past papers from MGR University BPT Clinical Orthopedics Papers for exact question patterns