45 year old female complaint of pain and numbness of the right hand,

mainly at night and during working

Carpal tunnel syndrome

Causes

• Idiopathic• Obesity,• Oral contraceptives, • Hypothyroidism, • Arthritis, • Diabetes,.

• Trauma.• Lipoma ,• ganglion, • vascular malformation

Treatment

• Localized corticosteroid injections??????• PT

• CT Release

Triggering thumb or finger

• Called stenosing tenosynovitis . Idiopathic. Or Congenital• Common disorder of later adulthood

characterized by catching, snapping or locking of the involved finger flexor tendon, associated with dysfunction and pain.

Treatment

• Cortisone injection• A1 poly release (surgically)

1 month old baby girl referred to you from LHC with hip click

Developmental dysplasia of the Hip (DDH)

• Etiology / Epidemiology / Natural History• 1/1000 live births, left hip most common • More common in children of central European . • Etiology: multifactorial, genetic, intrauterine mechanical

environment, • DDH Risk factors (five f's)• first born • female • family history • feet( breech position) • fluid(oligohydramnios )

• DDH Clinical Evaluation• Ortolani=out-reduces • Barlow=in-dislocates • Asymmetric gluteal folds • Galeazzi sign: apparent femoral

length discrepancy when the legs are held together with the hips and knees flexed.

• Decreased hip abduction • Ambulatory Patient: flexion

contracture, gluteus medius lurch, toe walking, increased lordosis if bilateral

DDH Associated AnomaliesMetatarsus adductus Hyperextended knees / congenital knee dislocation Torticollis

Treatment Age 0-6 m=Pavlik

harness 6m-18 m= adductors

tenotomy , hip Spica >18m OR and pelvic

osteotomy

< 5 month

>5 month

Osteomyelitis

• Acute, Sub acute, or Chronic.• The mechanism :exogenous or hematogeneus. • Osteomyelitis :pyogenic or non pyogenic • In infants, the infection can spread to the joint

and cause arthritis. • In children, large sub periosteal abscesses can

form because of the periosteum is loosely attached to the surface of the bone

Pathogenesis

• leukocytes enter the infected area, and, in their attempt to engulf the infectious organisms, release enzymes that lyse the bone.

• Pus spreads into the bone's blood vessels, impairing their flow, and areas of devitalized infected bone, known as sequestra,

• Often, the body will try to create new bone around the area of necrosis. The resulting new bone is often called an involucrum

Cause

Age groupMost common organisms• Newborns (younger than 4 mo)S. aureus, Enterobacter

species, and group A and B Streptococcus species• Children (aged 4 mo to 4 y)S. aureus, group A

Streptococcus species, Haemophilus influenzae, and Enterobacter species

• Children, adolescents (aged 4 y to adult)S. aureus (80%), group A Streptococcus species, H. influenzae, and Enterobacter speciesAdultS. aureus and occasionally Enterobacter or Streptococcus species

• Sickle Cell Anemia Salmonella species

Osteomyelitis

• In adults, vertebrae and the pelvis. • In children, affects the adjacent ends of long

bones. • Fungus :The two most common are Blastomyces

dermatitidis and Coccidioide immitis.• In osteomyelitis involving the vertebral bodies,

about half the cases are due to Staphylococcus aureus, and the other half are due to tuberculosis Pott's disease.

Symptoms of osteomyelitis

• Pain and/or tenderness • Swelling and warmth Fever• Nausea• General discomfort, uneasiness, or ill feeling• Sinuses

• Blood tests• Blood culture.• Needle aspiration• Biopsy: • Bone scan: Technetium-99 pyrophosphate

Treating and managing osteomyelitis

• Drainage• Medications:• Splinting or cast immobilization• Surgery:

Duchenne muscular dystrophy (DMD)

• Recessive X-linked form of muscular dystrophy, which results in muscle degeneration, difficulty walking, breathing, and death.

• 1 in 3,600 -4000 boys.• Females and males are affected, though

females are rarely affected and are more often carriers.

• Caused by a mutation in the dystrophin gene,

• male children before age 5 and may be visible in early infancy.• Progressive proximal muscle weakness of the legs and pelvis

associated with a loss of muscle mass is observed first. Eventually this weakness spreads to the arms, neck, and other areas.

• pseudo hypertrophy (enlargement of calf and deltoid muscles), low endurance.

• As the condition progresses, muscle tissue experiences wasting and is eventually replaced by fat and fibrotic tissue (fibrosis).

• By age 10, braces may be required to aid in walking but most patients are wheelchair dependent by age 12.

• Cardiomyopathy (DCM) , congestive heart failure or arrhythmias

• A positive Gower's' sign• creatinine kinase (CPK-MM) • An electromyography (EMG) shows destruction

of muscle tissue Genetic testing :genetic errors in the Xp21 gene.

• A muscle biopsy or genetic test (blood test) confirms the absence of dystrophin,

• DNA test. DNA testing confirms the diagnosis in most cases.• Muscle biopsy A small sample of muscle tissue is extracted

(usually with a scalpel instead of a needle) and a dye is applied that reveals the presence of dystrophin. Complete absence of the protein indicates the condition.

• Prenatal tests

Treatment

• Comprehensive multi-disciplinary care• Corticosteroids such as Prednisolone and

deflazacort increase energy and strength • beta2-agonists increase muscle strength but do

not modify disease progression. .• Physical therapy • Orthopedic appliances (braces and wheelchairs)• Appropriate respiratory support

55 years old female

Osteoarthritis

• Idiopathic, primary • secondary.• Osteoarthritis causes the formation of hard,

bony enlargements of the small joints of the fingers Heberden's node,

• Another common bony knob (node) occurs at the middle joint of the fingers a Bouchard's node

•

• Osteoarthritis commonly affects the hands, feet, spine, and large weight-bearing joints, such as the hips and knees

• Crystal deposits in the cartilage can cause cartilage degeneration and osteoarthritis.

• Uric acidcrystals cause arthritis in gout,• Calcium pyrophosphate crystals cause

arthritis in pseudo gout

signs you should be aware of include:

• crepitus• restricted movement or range of motion• bony enlargement

• The symptoms include:• persistent knee pain• short-lived morning stiffness• functional limitation

Management

• protect your joints (for example, walking is better for the joints than running).

• diet and aerobic fitness exercises

• Range of motion Quadriceps strengthening

• Patellar taping

• Lateral heel wedges • knee brace for valgus

deformity• NSAID• Intra articularcorticosteroids• intra-articular

hyaluronic acid

• Arthroscopy

• Osteotomy

Replacement

5 year old child

Definitions Rickets : softening of bones in children due

to deficiency or impaired metabolism of vitaminD, calcium or phosphorus, leading to fractures and deformity.

Predominant cause is vit. D deficiency.

Rachitic Changes

Headcraniotabes(soft skull) frontal bossing Widening of suture persistent fontanelaeDelayed dentition & caries

Rachitic Changes

Abdomen Prominent

muscle weakness Floppy baby, delayed walking

Pelvis Narrow inlet

Rachitic ChangesWidening of wrist, knee and ankle due to

physeal over growth

Rachitic Changes

Chest Rachitic rosaryHarrison groovePigeon chestRespiratory infection and

atelectasis

Rickets• Vitamin D 1,25-OH helps calcium

and phosphorous absorption from the intestine, increases kidney reabsorption of phosphorus, and it causes calcium and phosphorus to be released from the bone. Increasing the concentrations of calcium and phosphorus in extracellular fluid causes osteoid cells to calcify. Parathyroid hormone increases the 1-hydroxylation step of vitamin D metabolism and thereby helps regulate calcium metabolism

• Ultraviolet light in the skin changes cholesterol to Vitamin D3 (i.e. cholecalciferol). Vitamin D3 then is hydroxylated in the liver to make Vitamin D 25-OH (i.e. calcidiol, the circulating reserve metabolite). It then undergoes hydroxylation again in the kidney to Vitamin D 1,25-OH (i.e. calcitriol, the active metabolite).

Management

Blood testsSerum caciumSerum alkaline phosphataseSerum phosphorus

Bone x-rayOther tests

ALP (alkaline phosphatase) isoenzymeCalcium (ionized)PTHUrine calciumBone biopsy (rarely done)

Management

Target of therapySerum calcium : low - NSerum alkaline phosphatse : high – NSerum phosphorus : high – N

ManagementTreatmentVit-D deficiency stateVit D 1,000 – 10,000 IU For 4 – 6 wks.Vit D 300,000 IU For < 1yr of age. Vit D 600,000 IU For > 1yr of age.

IM once OR 2 – 4 doses/day orally.

All protocols followed by 400 IU/dayCalcium 1g/day.

MCQ

1-Acute osteomyelitis is commonly caused by:• a. Staph aureus.• b. S. pyogenes.• c. H. influenzae.• d. Salmonella.

1-Acute osteomyelitis is commonly caused by:• a. Staph aureus.• b. S. pyogenes.• c. H. influenzae.• d. Salmonella.

2-Acute osteomyelitis usually begins at:• a. Epiphysis.• b. Metaphysis.• c. Diaphysis.• d. Any of the above

2-Acute osteomyelitis usually begins at:• a. Epiphysis.• b. Metaphysis.• c. Diaphysis.• d. Any of the above

3- What is not True of acute pyogenic osteomyelitis:

• a. Trauma is a predisposing factor.• b. Common infecting agent is Staph. Aureus.• c. Infection is usually blood borne.• d. All are true.

3- What is not True of acute pyogenic osteomyelitis:

• a. Trauma is a predisposing factor.• b. Common infecting agent is Staph. Aureus.• c. Infection is usually blood borne.• d. All are true.

4-Tuberculosis of the spine most likely originates from:

• a. Intervertebral disk.• b. Cancellous vertebral body.• c. Ligamentous structures.• d. Paravertebral soft tissue.

4-Tuberculosis of the spine most likely originates from:

• a. Intervertebral disk.• b. Cancellous vertebral body.• c. Ligamentous structures.• d. Paravertebral soft tissue.

5-The single most important factor in fracture healing is:

• a. Correct bone alignment.• b. Accurate reduction.• c. Immobilization.• d. Organization of clot.

5- The single most important factor in fracture healing is:

• a. Correct bone alignment.• b. Accurate reduction.• c. Immobilization.• d. Organization of clot.

6- If an unstable hip is detected at birth themanagement policy is:• a. Do nothing and re-examine every six months as

only minority of hips develop into a persistent dislocation.

• b. Use a splint to keep the hip joint in 45° flexion and adduction.

• c. Use a splint to keep the hip joint in 90° flexion and abduction.

• d. Advise operative stabilization

6- If an unstable hip is detected at birth themanagement policy is:• a. Do nothing and re-examine every six months as

only minority of hips develop into a persistent dislocation.

• b. Use a splint to keep the hip joint in 45° flexion and adduction.

• c. Use a splint to keep the hip joint in 90° flexion and abduction.

• d. Advise operative stabilization

7- Anterior dislocation of shoulder may be complicated: By

• a. Brachial plexus injury.• b. Tear of rotator cuff.• c. Fracture head of humerus.• d. All of the above

7- Anterior dislocation of shoulder may be complicated by:

• a. Brachial plexus injury.• b. Tear of rotator cuff.• c. Fracture head of humerus.• d. All of the above

8- The most common form of supracondylar fracture humerus in children is of which type:

• a. Flexion.• b. Extension.• c. Combination of A & B• d. None of the above

8-The most common form of supracondylar fracture humerus in children is of which type:

• a. Flexion.• b. Extension.• c. Combination of A & B• d. None of the above

9- What is True of Sudeck's atrophy of hand:• a. Hand is painful and swollen.• b. Osteoporosis of carpals and metacarpals.• c. There is increased blood flow to para-

articular areas.• d. Cervical sympathectomy may be of help.• e. All are true

9- What is True of Sudeck's atrophy of hand:• a. Hand is painful and swollen.• b. Osteoporosis of carpals and metacarpals.• c. There is increased blood flow to para-

articular areas.• d. Cervical sympathectomy may be of help.• e. All are true

10- Limb shortening with adduction and internal rotation occurs in which type of hip dislocation:

• a. Anterior.• b. Posterior.• c. Central.• d. All of the above

10- Limb shortening with adduction and internal rotation occurs in which type of hip dislocation:

• a. Anterior.• b. Posterior.• c. Central.• d. All of the above

11- Which of the following is not True of intertrochanteric fracture of femur:

• a. Limb shortening.• b. Malunion.• c. Avascular necrosis of femoral head.• d. Internal fixation is preferred

11- Which of the following is not True of intertrochanteric fracture of femur:

• a. Limb shortening.• b. Malunion.• c. Avascular necrosis of femoral head.• d. Internal fixation is preferred

12- Idiopathic scoliosis is a• a. lateral curvature of the spine• b. rotation of the spine• c. lateral curvature with rotation of the spine• d. flexion deformity of the spine• e. congenital disease with hemivertebrae

12- Idiopathic scoliosis is a• a. lateral curvature of the spine• b. rotation of the spine• c. lateral curvature with rotation of the spine• d. flexion deformity of the spine• e. congenital disease with hemivertebrae

13- A trigger finger is• a. an inflamed index finger• b. an atrophic index finger in a median nerve

palsy• c. due to stenosing tenovaginitis affecting one of

the flexor tendons in the palm• d. an essential feature of the carpal tunnel

syndrome• e. a component of syndactyly

13- A trigger finger isa. an inflamed index fingerb. an atrophic index finger in a median nerve palsyc. due to stenosing tenovaginitis affecting one of

the flexor tendons in the palmd. an essential feature of the carpal tunnel

syndromee. a component of syndactyly

14-The most severe growth disturbance results from which of the following types of epiphyseal injuries:

• a. Separation of the epiphysis at the metaphyseal side of the epiphyseal plate

• b. Separation of the epiphysis with a triangular fragment of the metaphysic

• c. Intra-articular fracture involving the articular cartilage epiphysis and epiphyseal plate

• d. Intra-articular fracture extending from the joint surface through the epiphysis and epiphyseal plate to the metaphysic

• e. Crashing injuries compressing the epiphyseal plate without displacement

14-The most severe growth disturbance results from which of the following types of epiphyseal injuries:

• a. Separation of the epiphysis at the metaphyseal side of the epiphyseal plate

• b. Separation of the epiphysis with a triangular fragment of the metaphysic

• c. Intra-articular fracture involving the articular cartilage epiphysis and epiphyseal plate

• d. Intra-articular fracture extending from the joint surface through the epiphysis and epiphyseal plate to the metaphysic

• e. Crashing injuries compressing the epiphyseal plate without displacement

15- Tears of the meniscus of the knee result from which of the following strain:

• a. Hyperextension• b. Abduction• c. Adduction• d. Rotation• e. Combined flexion and rotation

15- Tears of the meniscus of the knee result from which of the following strain:

• a. Hyperextension• b. Abduction• c. Adduction• d. Rotation• e. Combined flexion and rotation

16- In a football game, an athlete felt severe pain in his Rt knee while turning to the left side with the joint flexed and taking the body weight. Soon after, the joint became swollen and painful but recovery followed rest for 3 weeks. Thereafter, the patient suffered from recurrent locking with pain and a feeling of "giving way" in the joint. The most probable diagnosis is:

• a. Solitary loose body• b. Fracture of the tibial spine• c. Rupture of the medial ligament• d. Rupture of the medial semillunar cartilage• e. Fracture of the patella

16-In a football game, an athlete felt severe pain in his Rt knee while turning to the left side with the joint flexed and taking the body weight. Soon after, the joint became swollen and painful but recovery followed rest for 3 weeks. Thereafter, the patient suffered from recurrent locking with pain and a feeling of "giving way" in the joint. The most probable diagnosis is:

• a. Solitary loose body• b. Fracture of the tibial spine• c. Rupture of the medial ligament• d. Rupture of the medial semillunar cartilage• e. Fracture of the patella

17- The signs of fractured shaft of a bone do not include:

• a. Swelling• b. Deformity• c. Loss of all movements in the limb• d. Acute localized bone tenderness• e. Abnormal mobility in the line of the bone

17- The signs of fractured shaft of a bone do not include:

• a. Swelling• b. Deformity• c. Loss of all movements in the limb• d. Acute localized bone tenderness• e. Abnormal mobility in the line of the bone

18-What is the most common benign soft-tissue tumour in adults?

1. Fibroma2. Lipoma3. Hemangioma4. Schwannoma

18-What is the most common benign soft-tissue tumour in adults?

1. Fibroma2. Lipoma3. Hemangioma4. Schwannoma

19-What is the most common site of metastasis for sarcomas? A. liver

B. brainC. LungD. skeleton

19-What is the most common site of metastasis for sarcomas? A. liver

B. brainC. LungD. skeleton

20-Intestinal absorption of calcium is dependent upon:

• a. Vitamin D• b. Parathoraone• c. Calcitonin• d. All of the above• e. None of the above

20-Intestinal absorption of calcium is dependent upon:

• a. Vitamin D• b. Parathoraone• c. Calcitonin• d. All of the above• e. None of the above