Thursday, December 15, 2011

DNB December 2011

DNB Final 2011 December Orthopedic Question papers

PAPER I

1. Describe the pathology, clinical features and principles of treatment of a neuropathic joint.

2. Describe the pathophysiology of Polytrauma patient and discuss the principles of Damage Control Orthopedics.

3. Discuss the etiopathology, diagnosis, prophylaxis and treatment of D.V.T.

4. Describe the pathology, diagnosis and broad principles of management of ankylosing spondylitis.

5. Discuss the pathophysiology and principles of treatment of Heterotopic ossification.

6. Discuss the surgical options in the treatment of mild medial compartment osteoarthrosis of knee in a 40 years old man.

7. a. Autonomic dysreflexia in Spinal Cord lnjury

b. Femoro-acetabular lmpingement Syndrome

8. Describe the pathology of avascular necrosis of femoral head and outline the principles of management in Ficat 3 stage of femoral head in a 30 years old man.

9. a. Pigmented villonodular synovitis

b. Carpal Tunnel Syndrome

10. a. Transient migralory osteoporosis

b. Early tendon transfer in Radial Nerve Palsy

PAPER II

1. Define osteomyelitis. Discuss the pathology, clinical features, diagnosis and treatment of acute osteomyelitis in a child.

2. List the causes of limp in an 8 years old child. Describe the differentiating features of septic arthritis with transient synovitis.

3. What is Kienbock's disease? Write briefly its etiology, diagnosis, clinical staging and management.

4. Describe "JAIPUR FOOT". Discuss the difference with 'SACH FOOT'& -MADRAS FOOT"?

5. a. SOMI brace

b. lnterferential Therapy (lFT)

6. Define ulnar claw hand. Discuss the tendon transfer for ulnar claw hand following ulnar nerve injury.

7. a. Radial Club Hand

b. Congenital Vertical Talus

8. Describe the flexor zones of hand. Discuss the principles of acute tendon repair (zone-wise).

9. a. Renal Rickets.

b. Salter's Osteotomy

10. a. Strength Duration Curve

b. Congenital Torticollis

PAPER III

1. Classify distal radius fractures. Describe radiological indices of wrist. Discuss the treatment principles of extra-articular distal radius fractures.

2. Classify infected nonunion. Discuss the treatment of infected nonunion of tibia.

3. Discuss the diagnosis and management of Anterior cruciate Ligament (ACL) lnjury.

4. Discuss the differences between :-

a. Machine screw and ASIF screw

b. DCP, LCDCP, Locking plate

c. Static compression and Dynamic compression

5. Classify proximal tibial fractures. Outline the management of type lV, V, and Vl fractures.

6. a. Fracture head of femur

b. Classification of Calcaneal fracture

7. Discuss the management of osteoporotic spinal fractures.

8. Describe the blood supply of talus. classify "Talar neck fractures". Discuss treatment and list complications.

9. Describe the structure of physis. Classify physeal injury. Outline the treatment of physeal injury and enumerate the compiications.

10. Define and classify Montegia fracture dislocation. Discuss the treatment principles of neglected Montegia fracture dislocation in a 10 years old child.

PAPER IV

1. Describe the extensor mechanism of knee and the factors that predispose to recurrent dislocation of patella.

2. Draw a cross section of peripheral nerve and label the structures. Describe Sunderland's classification of nerve injury.

3. a. Plaster Cast Syndrome

b. Bone morphogenic protein

4. Describe Stress, Strain, and Young's Modulus of Elasticity in relation to Orthopedic implants.

5. Describe 'free vascularized bone transplant. Discuss the principles of technique and applications in Orthopaedic practice.

6. Discuss the role of parathyroid glands in calcium metabolism.

7. Discuss the principles of application of Functional Cast Bracing in ' the management of diaphyseal fractures of long bones.

8. Discuss ceramics as bearing surface in Total Hip Arthroplasty.

9. a. Biodegradable lmplants

b. Principles and applications of lnterlocking Nailing

10. a. Unicameral Bone Cyst

b. Parosteal Osteosarcoma

Wednesday, December 14, 2011

Has the IOACON lost its charm?

Has the IOACON lost its charm?

After attending the last three IOACONs(Annual Meeting of the Indian Orthopaedic Association) in succession, I found that there is a gradual decline in the no of delegates attending the prestigious meeting of the Indian Orthopaedic Association. The past presidents, including Prof Johari had made serious amendments, so that IOACON still remains the most popular meeting among Indian Orthopaedic Surgeons. Prof Rajasekharan in 2010 put forward a questionnaire to everyone to suggest changes at IOACON and he has tried to implement many of them. Some of the biggest issues of IOACON 2010 at Jaipur were that most of the people were not present in the halls, even when highly respected international faculty delivered their lectures. This became such a serious issue that even local newspapers ran full page news covering photographs with empty halls and many orthopaedic surgeons standing in queue for gift vouchers and bags at various pharma stalls.

The faculty selection has been a considerable debate over the years at the most prestigious conference. It has been a common practice that state chapters recommend the faculty and forward it to the national executive. This leads to considerable bias. Prof Rajasekharan suggested a feedback system where all delegates are required to provide feedback for faculty talks, so that those with higher points were given preference at the next IOACON. Though this has been proposed at the last conference, it has still not been implemented.

The significant decline in the number of foreign faculty and delegates is also a serious issue. There has been a significant decline in foreign faculty. While most associations, have a tie up with the AAOS, the tie up of IOA and the AAOS looks weak. In National Meetings of other associations, there is a separate session or even one day dedicated for the AAOS Instructional Course Lectures and most of them are overbooked. It is time that the IOA invites the AAOS and provide them a session or a hall for the prestigious ICLs. I am sure that this step will bring back some of the lost zeal of IOACON. The lack of involvement of AAOS in the IOACONs led Alkem pharmaceuticals to conduct the AAOS India Trauma Conclave in 4 cities, which was again overbooked and a huge success for Alkem laboratories.

The only session where he had the best of foreign faculty was the ACE Trauma symposium, the brainchild of Prof Mohit Bhandari and Dr Parag Sancheti. We saw some the world’s best faculty, Prof Joel Matta, Prof Thomas Einhorn, Dr Vinod Dasa from USA, Dr Mohit Bhandari, Dr Brad Pretisor, Dr Femi Ayeni from Canada, Dr Susan Liew from Australia, Dr Karthik Hariharan from UK. The greatest part of the meeting was that all the talks delivered were based on Current Best Evidence and a great emphasis was placed on Evidence Based Orthopaedics. The halls ran full until the last talk at 6pm in the evening. Next year, we are going to have ACE Trauma, ACE Spine, ACE Joint Reconstruction, ACE Sports Medicine, so that emphasis is placed on current best evidence.

This drawback of IOACON has led to success of speciality meetings. For eg, there were more than 7 joint replacement major meetings last year like the ROC, JRSOA, IAA, Current concepts in arthroplasty, ISHK and MIOT meetings. Others like IASCON conduct live arthroscopy workshops with experts in the respective fields. The foot and ankle meeting by Dr Selene G Parekh from Duke University also is very popular because of the fairly good no of international faculty. In Spine, the ASSICON and the Ganga Hospital Courses run packed.

I remember in 2003(Chennai), 2004(Agra), 2005(Mumbai), at least the main hall was usually full. But since 2009, the no of delegates in the main hall has also decreased. Will the new leadership with Prof Rajasekharan, Dr SKS Marya, change the scenario of our prestigious meeting?

The other major issue was the website, which has been revamped to provide a new website. The current one looks very impressive but nowhere can we compare it with the largest educational resource, the AAOS website. I am sure that Prof Rajasekharan would have visited the AAOS web a no of times. It is time that we do a bit of introspection.

I would still recommend the IOACON for the younger generation of orthopaedic surgeons and postgraduates, because it is a good platform for trainees and junior surgeons to present papers and posters in big halls(although there is no audience). They can overcome stage fear and they can gain some practice sessions

Dr Hitesh Gopalan U

Editor, Orthopaedic Principles

Expert Advisory Panel, Ortho-Evidence, India

Friday, November 18, 2011

Tibial Pilon Fractures-An Update

TIBIAL PILON FRACTURES- An Update

Siddharth Sharma, Hitesh Gopalan U

HISTORY

· ‘Pilon’ is a french word meaning ‘pestle’ and this term was coined by Etienne Destot in 1911 to describe fractures occurring within 5 cm of the ankle joint.

· ‘Plafond’ means ‘ceiling’. This term was coined by Bonnin in 1950, in allusion to the tibio-talar articular cartilage injury that occurs with these injuries.

DEFINITION & RELEVANT ANATOMY

Although the common feature of all tibial pilon fractures is involvement of the distal tibial articular surface, two distinct injury patterns can be identified:

SNo.

FEATURE

AXIAL LOAD INJURIES

ROTATIONAL INJURIES

1

Mode of injury

High velocity trauma with axial compression

Low velocity rotational forces

2

Tibial fracture pattern

Variable comminution and impaction of the distal tibial articular surface and metaphysis

Minimal or no comminution, no impaction and no metaphyseal involvement.

3

Fibular fracture pattern

Variable

Variable

4

Displacement of talus

Proximal displacement

Lateral displacement

5

Soft tissue injury

Severe

Minimal

6

Prognosis

Less favourable

More favourable

Rotational injuries involving the tibial pilon can be regarded as being a continuum of ankle fractures and are managed as per the principles that guide ankle fracture fixation.

EPIDEMIOLOGY

1. INCIDENCE

a. Account for less than 10% of all lower extremity fractures.

b. Incidence is increasing owing to the use of seatbelts and airbags, which have decreased the incidence of fatal chest and abdominal injuries in high velocity motor vehicle accidents.

2. AGE: average age is 35 – 40 years.

3. SEX: males are more commonly involved.

CLASSIFICATIONS

1. REUDI – ALLGOWER CLASSIFICATION

CATEGORY

DISPLACEMENT

COMMINUTION

TYPE I

Undisplaced

Cleavage fracture, no comminution

TYPE II

Displaced

Minimally comminuted

TYPE III

Displaced

Highly comminuted

2. AO/OTA CLASSIFICATION OF TIBIAL PILON FRACTURES

TYPE A – EXTRA ARTICULAR FRACTURES

A1

Metaphyseal Simple

A2

Metaphyseal Wedge

A3

Metaphyseal Complex

TYPE B – PARTIAL ARTICLUAR FRACTURES

B1

Pure Split

B2

Split Depression

B3

Multifragmentary Depression

TYPE C – TOTAL ARTICULAR FRACTURES

C1

Articular Simple, Metaphyseal Simple

C2

Articular Simple, Metaphyseal Multifragmentary

C3

Articular Multifragmentary

Inter – rater reliability is better with the AO/OTA classification.

3. TSCHERNE & GOETZEN CLASSIFICATION OF SOFT TISSUE INJURY

GRADE

SKIN INJURY

MUSCLE INJURY

GRADE 0

None

None

GRADE 1

Significant abrasion or contusion

None

GRADE 2

Deep abrasion with local contusion

Mild

GRADE 3 (Includes compartment syndrome and arterial injuries)

Extensive contusion or crushing with subcutaneous avulsion

Severe

CLINICAL FEATURES

1. MODE OF INJURY:

a. Axial compression injuries: are high velocity injuries and occur with motor vehicle accidents. There is rapid loading of the bone and release of large amount of energy at failure, which gets disseminated to the soft tissues.

b. Rotational injuries: occur as a result of torsional forces applied to the ankle. Loading in these cases is slow and less amount of energy is released at failure, therefore there is minimal soft tissue disruption.

2. ASSOCIATED INJURIES

a. Incidence of concomitant injuries: 27 – 51%

b. Incidence of bilateral tibial pilon fractures: 0 – 8%

c. Ipsilateral talus and calcaneal fractures: extremely uncommon with axial loading fracture patterns. This is because most of the energy gets absorbed in the distal tibia and this protects the talus and calcaneum.

3. SOFT TISSUE INJURY

a. Severe soft tissue injury occurs with axial loading fracture patterns.

b. Tense soft tissue swelling is palpable and may also be appreciated by absence of wrinkles; conversely the re-appearance of wrinkles indicates healing of the tissues (wrinkle test).

c. Blisters indicate soft tissue injury and can be categorized as:

i. Clear fluid filled blisters

ii. Blood filled blisters

Although both types are caused by separations at the dermo – epidermal junction, blood filled blisters indicate severe soft tissue injury.

4. NEUROVASCULAR INJURIES

a. CT angiography demonstrated vascular injury in 52% of cases in a recent study.

b. Tibialis anterior artery is the most commonly involved .

DIAGNOSIS

1. RADIOGRAPHS: obtain Antero-posterior, Lateral and Mortise views (AP radiograph with the ankle in 15 degrees internal rotation) in all cases, full leg radiographs to rule out proximal extension, contralateral ankle radiograph as template for preoperative planning.

2. CT SCAN: helps in determining the degree of articular involvement, impaction and comminution and is also a useful adjunct to assess the quality of reduction.

GOALS OF TREATMENT

1. To obtain an anatomical articular reduction.

2. Restoration of axial alignment.

3. Maintenance of joint stability.

4. Achieve fracture union.

5. Regain functional and pain-free weight bearing and motion

6. Avoiding infections and wound complications.

It may be impossible to achieve all these goals in all cases and therefore treatment should be individualised.

EMERGENCY MANAGEMENT

1. Stabilize the patient as per the Advanced Trauma Life Support (ATLS®) protocols as most of these injuries are high velocity motor vehicle accidents.

2. Life threatening head, abdominal, chest or other injuries take precedence in management.

3. Talus should be reduced immediately and the ankle should be immobilized in a bivalved cast or slab and elevated.

4. If the talus cannot be reduced, a calcaneal Steinmann pin can be used to deliver 10 pounds (approx. 4.5 kgs) of traction over a Bohler frame.

5. Alternatively, a joint spanning external fixator can be used to achieve and maintain provisional reduction of the fracture as well as talus.

INDICATIONS OF CONSERVATIVE TREATMENT

The overwhelming majority of Pilon fractures need operative treatment. Indications of conservative management are limited and include:

1. Minimally displaced ‘A’ or ‘C1’ fractures.

2. Moribund and medically unfit patients.

TIMING OF ORIF

Open reduction and internal fixation of Pilon fractures should be delayed for several reasons:

1. It has been shown that the trans-cutaneous oxygen concentration at the fracture site drops after injury and remains low up to 10 days after injury.

2. Incisions that are placed through compromised soft tissue envelopes may end up in wound dehiscence, necrosis and infection.

3. Soft tissue swelling may preclude closure of the surgical wound and tightly applied sutures can worsen the soft tissue compromise.

SURGICAL APPROACHES FOR PILON FRACTURES

APPROACH

TECHNIQUE

ADVANTAGE

DISADVANTAGE

ANTEROMEDIAL & LATERAL(CLASSICAL)

Separate incisions for tibial and fibula

Good visualization of fracture site

Wound breakdown, hardware prominence

DIRECT LATERAL

Both tibia & fibula approached through a single incision centred over posterolateral border of fibula

· Excellent exposure with fewer wound complications.

· Minimal risk of injury to superficial peroneal nerve

· Difficult to address fractures of the posterior aspect of the tibial pilon

· Difficult to address medial comminution

ANTEROLATERAL

Both tibia and fibula can be approached by skin incision centred over anterior border of fibula

Excellent exposure with fewer wound complications

· Iatrogenic damage to superficial peroneal nerve and anterior perforating peroneal artery.

· Difficult to address medial comminution

POSTEROLATERAL

Utilizes the interval between peroneal tendons and flexor hallucis longus

· Provides good exposure for fractures that have posterior displacement & comminution

· Also useful when skin condition rules out anterior approaches

· Difficult to address anterior displacement or comminution

· Incidence of wound complications is same as with other approaches.

MINIMALLY INVASIVE PLATE OSTEOSYNTHESIS (MIPO)

Limited incisions, indirect reduction techniques, bridge plating principle used

Minimizes further damage to the compromised bone & soft tissues

Articular comminution is difficult to address

The choice of surgical approach is dictated by the soft tissue status, fracture displacement and the location of articular comminution.

INITIAL MANAGEMENT

It is aimed at reduction of gross displacement of the talus and elevation of the limb. This can be accomplished by:

1. Plaster slab or bivalved cast.

2. Calcaneal pin traction and elevation on a Bohler frame.

3. Spanning external fixator.

CHOICE OF OPERATIVE PROCEDURES

1. SINGLE STAGE MANAGEMENT

It is preferred for displaced fractures with minimal, closed, soft tissue injury.

2. MULTIPLE STAGE MANAGEMENT

Majority of Pilon fractures have moderate – severe soft tissue injury, with or without compounding and are best managed by staged treatment protocol, as follows:

· Stage 1: Closed reduction and external fixation: This may be accomplished by any of the following methods:

o Ankle spanning External Fixator:

§ Utilizes pins placed in the tibia and in the calcaneum & /or talus.

§ Advantages: zone of injury is spanned, quick and easy to apply, holds out to talus to length, no further injury to soft tissues and does not preclude other treatments.

§ Disadvantage: ankle joint movements are lost, although this may not have much bearing on the final outcome.

o Non-spanning External Fixator:

§ Pin fixators, Ilizarov fixators and hybrid fixators (employing pins and wire constructs)

§ Advantage: ankle movements are preserved

§ Disadvantage: at least 2 cm of the distal tibia must be intact to allow such a fixation, safe corridors for the distal tibia are limited and higher incidence of pin, wire and wound complications as the fixation passes through the zone of injury.

o Articulated (Hinged) ankle spanning External Fixators:

§ Utilizes a hinge that connects the tibial pins with the hindfoot pins.

§ Advantages: Allows reduction of the displaced talus and also permits limited ankle movements while bridging the zone of injury.

§ Disadvantages: Needs precise pin placement; the hindfoot clamp straddles the neurovascular bundle and the subtalar joint and the calcaneal pin can injure the medial calcaneal branch of the tibial nerve.

· Stage 2 - Definitive Treatment: is begun when soft tissues have healed and there is no evidence of infection in case of open fractures. The different treatment options include:

o Plate Fixation of Tibia:

§ The articular fragments must be reduced under vision anatomically and rigidly fixed with interfragmentary screws.

§ The metaphyseal fractures are dealt with by bridging fixation. Minimal soft tissue dissection, indirect reduction techniques and maintenance of length, alignment and rotation are the goals of treatment.

§ Choice of implants: low profile plates that are contoured to the distal tibia are preferred. The use of precontoured angle stable plates (distal tibial locking compression plates) offers several advantages in complex fractures and osteoporotic bone.

o External Fixation as a definitive modality of treatment:

§ The most important step is to reduce the articular fracture anatomically and if needed, this can be accomplished by limited open reduction and interfragmentary screw fixation.

§ External fixators can be in the form of Ilizarov fixators, tubular external fixators or modular fixators.

o Fibular fixation:

§ Most authors recommend that this should be done at the time of the initial operation.

§ If the fibular fracture pattern is simple, it is fixed first. This permits easy reduction of the tibial fracture. However, in comminuted fibular fracture patterns, the tibia is fixed first.

§ Fixation can be accomplished with one third tubular plates, reconstruction plates or 3.5 mm dynamic compression plates depending on the size of fibula.

Surgical Approaches:

· Although historically a single “utilitarian” approach was popular in the reconstruction of the tibial plafond, a variety of surgical approaches are currently used to treat these fractures.

· Less dissection and soft tissue retraction, as well as optimal implant placement, is possible using more direct approaches.

· As with other complex injuries, the selection of an approach should be based on the personality of fracture and location of major fracture fragments.

· These more customized approaches should adhere to the following principles:

- Effective soft tissue handling

- Maintenance of a reasonable skin bridge between incisions (especially if these incisions are long or extensile)

· Placing skin incisions directly over bone should be avoided if possible. Thus, if skin problems occur, resultant tissue defects can be reconstructed with a simple skin graft or fasciocutaneous flap as opposed to a free soft tissue transfer.

· Howard et al recently reported a series of 46 plafond fractures in 42 patients in which 106 skin incisions were used, creating 60 skin bridges. The mean skin bridge size was 5.9 cm; only 16% were greater than 7 cm.

· All incisions other than two healed uneventfully, and no deep infections or skin bridge compromises were recorded.

COMPLICATIONS

1. WOUND DEHISCENCE & INFECTION

i. Incidence was found to be higher in fractures that are managed by single stage open reduction and internal fixation (67% in one series).

ii. With the use of staged protocol, this complication occurs in < 10% of all cases.

2. DELAYED UNION & NON UNION

i. Incidence is 5% regardless of the modality of treatment used.

ii. High energy comminuted fractures, presence of severe soft tissue injury, aggressive soft tissue dissection and infection predispose to these complications.

3. MALUNION

i. Some amount of malunion is expected to occur after high energy comminuted fracture patterns.

ii. Reported rates in recent series: 4 – 25%

iii. Angular malunion is most common and incidence is higher in cases treated with external fixation and those where fibula was not fixed.

4. ANKLE ARTHROSIS

i. Precise incidence not known, rates up to 50% have been reported.

ii. It is thought that the damage to articular cartilage at the time of trauma is the main determinant of arthrosis, although joint incongruity also plays an important role.

iii. Avascular necrosis of talus and infection are less common causes of arthrosis.

iv. Significant arthrosis develops within 1-2 years of injury and its clinical severity does not correlate with the radiological appearance.

REFERENCES

1) Canale ST, Beaty JH. Fractures of the lower extremity. In Campbell's Operative Orthopedics. 11th ed. Philadelphia: Elsevier; 2007. p. 3193 - 217.

2) Reid JS. Pilon fractures update. Current Orthopaedic Practice2009;20(5):527-33

3) Wade AM, Crist BD, Khazzam M, Della Rocca GJ, Calhoun JH. Pilon fractures. Current Orthopaedic Practice2008;19(3):242-8

4) LeBus GF, Collinge C. Vascular abnormalities as assessed with CT angiography in high-energy tibial plafond fractures. J Orthop Trauma. 2008; 22:16–22.

5) Barei DP. Pilon fractures. In: Buchholz RW, Heckman JD, Court-Brown CM, Tornetta P editors. Rockwood and Green’s Fractures in Adults. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2010. p. 1928-71.

6) Howard JL, Agel J, Barei D, et al. Challenging the dogma of the 7-cm rule: a prospective study

evaluating incision placement and wound healing for tibial plafond fractures. Orthopaedic Trauma Association annual meeting, Phoenix, AZ, October 5-7, 2006