ANTERIOR CRUCIATE LIGAMENT [AIIMS MAY 2013]

Q . ANTERIOR TRANSLATION OF TIBIA OVER FEMUR OCCURS IN EXTENDED KNEE BUT NOT AT 90 DEGREE FLEXION THEN INJURED IS……

[A] Anteromedial fibre of anterior cruciate ligament

[B] posterolateral fibre of anterior cruciate ligament

[C] posterior cruciate ligament

[D] anterior horn of medial meniscus

ANS = [B] [ Ref apley’s system of orthopedics and fractures ]

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REFLEX SYMPHATHETIC DYSTROPHY = CRPS I = SUDECK’S DYSTROPHY { AIIMS 2013}

Q1] A old female patient with history of colles fracture presents with wrist and finger joint stiffness + pain + swelling in hand……. [AIIMS MAY 2013]

[A] CAUSALGIA

[B] SUDECKS DYSTROPHY

Earlier both these terms were used to define same features . Currently a classification system is used to differentiate these two based on inciting injury as both of these describe same signs and symptoms. see the figure below to get to this fact….

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so the ans here is [B] sudecks dystrophy as history is suggestive of # as a inciting event and no any definite nerve injury is apperant from symptoms. NOTE : if Electromyography or nerve conduction studies show a nerve lesion then condition is not CRPS I. Along with SAME SYMPTOMES  if a nerve lesion is apperent by signs/ symptoms/Nerve studies, the ans will be [A]= causalgia = CRPS II.

LETS SEE A SIMILAR Q FROM AIIMS NOV 2000

Q2] A lady presents with swelling of hands and shiny skin. She has history of fracture radius and kept on pop cast for 4 weeks. then most likely diagonosis is……[AIIMS NOV 2000]

[A] myositis ossificans

[B] Rupture of extensor pollicis longus tendon

[C] Reflex sympthetic dystrophy

[D] Malunion

ans = [C] RSD = CRPS I = SUDECK’S DYSTROPHY

Now lets know some important points about RSD = CRPS I = SUDECK’S DYSTROPHY

[1] the most distinctive and dramatic feature of this syndrome is = severe pain.

[2] pain often burning nature is one of the first symptom.

[3] exact pathophysiology is unknown but increased symphathetic nervous system activity charecterises this syndrome.

[4] the most common radiographic finding= localised osteopenia[ delhi 99]

[5]It has bad prognosis. Mx consists initialy of pharmacological sympathetic block by local anesthetic agents….which ultimately may require surgical sympheteic blockade eg stellate ganglion block for upper limb.

RSD NATURAL HISTORY  IS DIVIDED INTO THREE stages. see the diagram below to understand this:

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references :

[1] CSDT 11ed /page 844  [2] Current diagonosis and treatment in orthopedics pg 117/ 3rd ed.

AIIMS MAY 2013 QUESTIONS

1 KLUVER BUCY SYNDROME http://pguploads.com/2013/03/16/amygdal/

2. EYE Q = NHL OF ORBIT / METS TO ORBIT http://pguploads.com/2013/05/14/nhl-of-orbit-mets-to-orbit-aiims-may-2013/

3 . psychiatry ..jean piaget http://pguploads.com/2013/05/15/out-of-sight-is-not-out-of-mind-or-object-permanence-in-jean-piagets-development-theory-aiims-may-2003/

4. sudecks dystrophy http://pguploads.com/2013/05/15/reflex-symphathetic-dystrophy-cprs-i-sudecks-dystrophy-aiims-2013/

5 . isochromosome http://pguploads.com/2013/05/14/q-how-is-isochromosome-formed-aiims-may-2013/

6 .seizure related qs in aiims 2013 http://pguploads.com/2013/05/14/seizure-related-qs-in-aiims-may-2013/

7. PSM Q’S http://pguploads.com/2013/05/16/psm-qs-aiims-may-2013/

LUMBAR DISC HERNIATION

Peak age group = 35 -45 years

Most common location L4-L5 & L5- S1 [ NOTE : L4 -L5 > L5-S1 ]

Disc herniation can be central / paracentral and lateral. Most disc herniation that cause unilateral radicular symptoms are paracentral herniations [ ref : CODT page 231/ 3ed]

Lumber disc herniation can produce symptoms by compression of exiting nerve root or traversing nerve root at that disc level.( now have a look at the figure given below to understand what are these )

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so we can say that : at L3- L4 disc, L3 root will be exiting nerve and L4 root wiil be traversing nerve root….similarly at L4-L5 disc, L4 root will be exiting and L5 root will be traversing root and so on..

LETS MOVE ON :

Now we need to understand that lateral disc herniation will affect exiting nerve root at that level. In the figure given below L4 nerve root is compressed  by lateral herniation of L4-L5 DISC.

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NOW LETS UNDERSTAND EFFECT OF MORE COMMNER VARIETY ie PARACENTRAL/CENTRAL DISC HERNIATION ( SEE THE FIGURE BELOW)

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So its now clear that until the q mentions any specific type of herniation we assume it as paracentral ans so we can draw inference for q solving purpose that:

L3-L4 DISC HERNIATION = L4 ROOT WILL BE AFFECTED

L4-L5 DISC HERNIATION = L5 ROOT WILL BE AFFECTED

L5-S1 DISC HERNIATION = S1 ROOT WILL BE AFFECTED

But always keep in mind that q may be twisted by asking lateral disc herniation and in such condition root affected will be one level up!!!!!!!!

NOW WE SHOULD LEARN THE EFFECTS OF L5 ROOT COMPRESSION BY L4-L5 DISC HERNIATION ( SEE THE FIGURE BELOW)

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Q] After lifting something heavy from ground a patient complains of back pain which is radiating to lateral leg and great toe of lower limb. most probable diagonosis is …[AIIMS MAY 2012]

A]L5-S1 DISC PROLAPSE

B]L4-L5 DISC PROLAPSE

C]L3-L4 DISC PROLAPSE

D]L5 FRACTURE

ANS= [B] L4- L5 PROLAPSE : Will cause L5 radiculopathy so back pain ( occuring at level of prolapse) will radiate to distribution of L5 root ie lateral side of leg and dorsum of foot. Furthur it will lead to sensory loss at these sites and weakness of extensor hallucis longus and other dorsiflexors. EHL is exclusively supplied by L5 root.

NOW LETS DROP DOWN OURSELVES ONE LEVEL DOWN AND SEE THE EFFECTS OF S1 NERVE ROOT COMPRESSION by L5-S1 DISC PROLAPSE(see the figure below)

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Now we can summarise the effect of disc herniations at various levels ( assuming it to be of most common type ie paracentral)

1. L3-L4 DISC HERNIATION = L4 ROOT COMPRESSION = SENSORY LOSS over great toe and medial side of leg, MOTOR LOSS consisting of weakness of knee extensors , KNEE JERK becomes sluggish or absent.

2. L4-L5 DISC HERNIATION = L5 ROOT COMPRESSION = SENSORY LOSS over lateral side of leg and dorsum of foot , MOTOR LOSS consisting of weakness of EHL and foot dorsiflexors, ANKLE JERK is normal.

3. L5-S1 DISC HERNIATION = S1 ROOT COMPRESSION = SENSORY LOSS over lateral side of foot , MOTOR LOSS consisting of weakness of planter flexors , ANKLE JERK is sluggish or absent.

NOTE POINTS :

1. Straight leg raising test is performed when disc herniation is suspected . Pain on elevating affected leg ( lesegue sign +ve) is positive in more then 90% patients. Pain on opposite leg is elevated ( cross lesegue + ve ) is present in about 20 % patients.

2. MRI is study of choice for diagonosis of a herniated disc.

3. only < 10 % patients require surgial management which consists of Discectomy , Microdiscectomy, Chemonucleolysis .

SAMPLE Q : A patient presents with sensory loss over lateral leg and dorsum of foot along with weakness of extensor hallucis longus and normal ankle jerk then diagonosis among following is/are….

A] LATERAL DISC PROLAPSE L4-L5

B] PARACENTRAL DISC PROLAPSE L4- L5

C] LATERAL DISC PROLAPSE L5-S1

D] PARACENTRAL DISC PROLAPSE L5-S1

ANS = going with symptoms , L5 root is affected so it can be due to both [B] and [C].

ROTATOR CUFF : ANATOMY , PATHOLOGY ,ORTHOPEDICS

Q1] Rotator cuff/ musculotendinous cuff of shoulder is a fibrous sheath formed by four flattened tendons which blend with capsule of shoulder joint and enforces it. Which of the following statements is false about rotator cuff….

A] All four muscle arise from scapula and are inserted into tuberosity of humerous.

B] All four muscle do external rotation of arm.

C] Rotaror cuff gives strength to capsule of shoulder joint all around except inferiorly.

D] Rotator interval is space between supraspinatous and subscapularis.

ANS [B] SEE THE TABLE BELOW

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Q2] Which part of rotator cuff is  in greatest tension during overhead abduction and hence is most commonly affected tendon in rotator cuff tendinitis/tear…

A] SUPRASPINATUS

B] INFRASPINATUS

C] TERES MINOR

D] SUBSCAPULARIS

ANS [A] SEE FIGURE BELOW

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Q3] All of following specificaly indicate complete rotator cuff tear in a patient presenting with shoulder pain except….

A] Neer impingement sign positive

B] JOBES test positive

C] Contrast flooding subacromial bursa when injected into glenohumeral joint during arthrography.

D] Hyperintense signals on T2 MRI that extends throughout tendon.

E] Diffusely hypoechoic tendon on USG.

ANS: [A] , [B], [E]

[A] = NEER IMPINGEMENT SIGN IS +VE in any cause of anterosuperior impingement as in subacromial bursitis or partial tendon tear.

[B] JOBES TEST can be +ve in partial tears also.

[E] normally tendon is echoic structure whereas fluid is hypoechoic so diffusely hypoechoic tendon denotes tendinitis and not tear.

NOTE : ON T2 WATER IS HYPERINTENSE IE WHITE SO TENDON TEAR APPEAR AS HYPERINTENSE SIGNAL.

SEE FIGURE BELOW:

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NOTE POINTS: 1] LIFT OFF TEST IS DONE TO ASCESS ISOLATED SUBSCAPULARIS TEAR= “FORGOTTEN TENDON” [AI 2010]

2] SHOULDER JOINT CAPSULE HAS 2 OPENINGS ONE FOR LONG HEAD OF BICEPS AND BY OTHER IT COMMUNICATES WITH SUBSCAPULAR BURSA.

3] THOUGH JOINT CAPSULE IS LEAST REINFORCED INFERIORLY ,MOST COMMON TYPE OF SHOULDER DISLOCATION IS ANTERIOR OF SUBCORACOID TYPE.

4]In subacromial bursitis pressure over deltoid below acromian in adducted arm produces pain but this pain dissapears when same test is repeated in abducted position . This sign is clled as DAWBARNS SIGN.

References [1]. CODT 3ed page 191. [2] BDC vol 1 page 79 4th ed [3] campbells orthopedics 11th ed page 2607 [4] @medscape

HAMMER TOE vs CLAW TOE vs MALLET TOE

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HAMMER TOE DEFORMITY:

It is most common deformity of lesser toes.

primary defect is flexion deformity at proximal interphalyngeal joint secondrarily associated with hyperextension at metatarsophalyngeal joint and distal interphalyngeal joint. MTP JOINT BECOMES UNSTABLE DUE TO OVERUSE IN THIS CONDITION.

cause: long 2 nd ray,  rheumatoid arthiritis.

presentation:   pain / callosity over dorsal aspect of PIP joint + charecteristic deformity ( see figure above).

CLAW TOE :

dorsiflexion at MTP joint associated with flexion at DIP and PIP joint.

( note that CURLY TOE ) is combined flexion at all three joints).

presentation : pain / callosity at dorsal PIP joint + pain callosity at toe tip + characteristic deformity.

MALLET TOE:

flexion deformity at DIP JOINT.