Cambridge Core - Surgery - Postgraduate Orthopaedics - edited by Paul A. PDF · HTML; Export citation. Postgraduate Orthopaedics - Title page. pp iii-iii. Postgraduate Orthopaedics Viva Guide for the FRCS Tr and Orth Examination (2) - Download as PDF File .pdf), Text File .txt) or read online. chapter. Cambridge A catalogue record for this publication is available from the British Library Library of Congress Cataloging-in-Publication Data Postgraduate orthopaedics: MCQS and EMQS for the FRCS (Tr & Orth) / edited by Kesavan Sri-Ram. FRCS (Orth) Consultant Orthopaedic Surgeon.
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This is additional material which we weren't able to include in the 3rd edition of Postgraduate osakeya.info have also included some MCQ/EMI questions to . The Postgraduate Orthopaedics ethos is to try and keep costs reasonably priced for candidates. We are not running the course to satisfy a financial motive and. Postgraduate Orthopaedics: MCQs and EMQs for the. FRCS (Tr & Orth). This book helps the orthopaedic surgeon preparing for the written part of the FRCS (Tr .
Before considering surgery a thorough knowledge of local structures is important. The distortion of the normal anatomy results in displacement of the neurovascular structures, and explains the significant risk in Dupuytrens disease surgery. No sensation from tip of acromion to tip of fingers. The prognosis for avulsion of the roots is far worse than just rupture or traction. All of these markers suggest severe trauma and may point to root avulsion.
Numbness on its own is not as worrying as the other signs. Tendon pull must be synergistic. These rules must be appreciated and short cuts will only lead to disaster. Donor muscles must be expendable and have adequate power, ideally MRC grade 5. Joints must be mobile with no contracture. Diabetic cheirarthropathy. This is a poorly understood condition. It is thought to be as a result of a muscular or tendon imbalance with soft tissue disruption. There is a microangiopathy of the dermal and subcutaneous blood vessels.
Loss of function is painless, and progresses from distal to proximal. The prayer sign is an inability to oppose palmar surfaces. Wrist arthrodesis. The Lichtman classification system essentially divides Kienbocks disease into types that can be treated with therapeutic operations such as radial shortening or grafting versus those that need salvage operations such as partial or complete wrist arthrodesis.
One of the deciding factors in the type of fusion is the degree of fixed deformity. In the presence of fixed deformity radial shortening is not an option. It is also not an option in the more uncommon scenario of the ulnar positive wrist. The Lichtman classification, based on radiographs, is as follows: Stage 1 normal may have a linear or a compression fracture Stage 2 sclerosis but no collapse Stage 3A collapse of entire lunate without fixed scaphoid rotation Stage 3B collapse of entire lunate with fixed scaphoid rotation Stage 4 stage III with generalized degenerative changes in the carpus 19 Chapter 2 Hand and wrist: Answers Ulnar shortening osteotomy.
It is uncommon for younger people to present with significant radial shortening as their fractures are usually well managed. In this case there is ulna impaction syndrome. The aim is to reduce this impaction. There is no need to address the DRUJ or replace the distal ulna. The Darrach procedure should be reserved for older patients with rheumatoid disease. It is associated with ongoing discomfort in the proximal stump and certainly not the first choice in this scenario.
Painful nodules are an indication for surgery. The disease is usually in its early phases. The stages, according to Lucks classification, are proliferative, involutional and finally residual. Early surgery will certainly lead to recurrence and can stimulate the disease process. Carpal tunnel surgery must be performed at a separate occasion for a similar reason. Class 1B lesion.
TFCC tears are divided into acute 1 and chronic 2 by the Palmer classification. The majority of isolated TFCC injuries do not require early surgical management. The need for treatment is increased when the lesion is associated with fractures, instability and DRUJ injuries.
She has a claw hand. She has tight intrinsic muscles and her Bunnell test is positive as the intrinsic muscles are more powerful than her extrinsic extensors and flexors. The tight intrinsic muscles are treated with distal releases when fibrotic and a proximal slide when spastic. An intrinsic minus hand is one where there is a loss of function in the ulna and sometimes the median nerve claw.
The patient presents with a monkey grip. Quadrigia effect. Though this was a bony avulsion it must be thought of like any other FDP tendon injury. In this case because of the proximal migration of the tendon it was probably repaired tightly with an adhesed improperly tensioned FDP.
Because the adjacent remaining fingers share a common muscle belly, they cannot flex entirely quadrigia effect. There is not always a scaphoid fracture. To understand carpal instability it is essential to appreciate the ligamentous attachments both between the individual carpal bones as well as the extrinsic ligaments that support the wrist.
Superficial palmar arch. The superficial palmar arch is a continuation of the ulna artery. This explains why even with significant lacerations to the ulna artery a hand can be well perfused.
Mucoid cyst. This is a common lesion that arises from the osteoarthritic DIP joint. There is usually a disruption of the joint and a cyst develops. They cause deformity of the nail because of pressure on the germinal matrix. If they are large it may be necessary to perform a local flap at excision transposition. Nerve stimulation therapy. If symptoms are not severe and there is not significant and progressive neuropathy then non-operative management must be considered.
This includes splintage, hand therapy, steroid injection and even yoga has been proven to be beneficial. Alternatively a patient could be referred for either open or endoscopic release.
Scaphoid extension. In rheumatoid arthritis the inflammation of the synovium sets off a sequence of events that start with correctable deformity and eventually lead to fixed deformity and destruction of the joints. There is erosion of the radio-scapho-capitate ligament with flexion of the scaphoid. The carpus supinates as it moves in an ulna direction. Rather than the ulna becoming prominent it is the carpus that slips away from it.
Nail patella syndrome. This syndrome is a result of an abnormality on chromosome 9. Patients may have subluxed or dislocated radial heads and never realize they have a problem until they have an X-ray. The syndrome can include abnormalities of the patella and nail growth, generalized ligamentous laxity and bony exostoses.
The exception to this rule is if there is visible triggering under a local anaesthetic block it may be necessary to address this. Sonic hedgehog protein. Eight weeks after fertilization, all limb structures are present. It is between 4 and 8 weeks where the majority of congenital disorders in the hand occur.
There are many factors involved in limb development; however, there are three key zones responsible for proximodistal, anteroposterior and dorsoventral development. These are the apical ectodermal ridge, zone of polarizing activity and Wnt pathway respectively. These in turn produce fibroblast growth factors, sonic hedgehog protein and LMX1, which all work in a coordinated manner to ensure the normal development of the limb. Extensor carpi ulnaris ECU subluxation and tenosynovitis.
VaughnJackson syndrome. De Quervains disease.
This question is really a test of the seven extensor compartments. Each compartment has its own unique anatomy and pathology in turn. Rowers and drummers have ECU subluxation and tenosynovitis. It is common for young mothers to develop tenosynovitis of the first extensor compartment but the condition is not exclusive to them.
Vaughn-Jackson syndrome is the attritional rupture of the extensor digiti minimi EDM in rheumatoid arthritis. The compartments are as follows: First abductor pollicis longus and extensor pollicis brevis tendons Second extensor carpi radialis longus and extensor carpi radialis brevis tendons Third extensor pollicis longus tendon Fourth three tendons of extensor digitorum muscle and the extensor indicis tendon Fifth extensor digiti minimi tendon Sixth extensor carpi ulnaris 2.
Herpes simplex virus type 1. Pasteurella multocida. The most common cause of hand infections is probably still Staphylococcus aureus. However, because the hands come into contact with specific things it is important to recognize a few important infections. A fight bite often presents with a small wound and a history of punching. Eikenella corrodens comes from the human mouth.
Dentists and healthcare workers are exposed to the herpes virus. The typical organism in cat bites is Pasteurella. The organisms in necrotizing fasciitis are multiple and usually include clostridia and Group A b-streptococci. V-Y plasty advancement. Cross finger flap. Knowing the plastic surgery reconstructive ladder is essential for the management of fingertip injuries.
If there is a bigger lesion with exposed bone then the type of lesion and location must be carefully assessed. Sarcoma and other malignancies in the hands are rare. Benign tumours and skin cancers are not. Prior to and after the excision of any lesion from the hand the surgeon must have a wide differential diagnosis at hand. Many systemic conditions manifest in a pathognomonic manner in the hands.
Certain key facts have been provided about each of the conditions. The reader is reminded that other arthritides must be considered in hand pathology. ParsonageTurner syndrome. Anterior interosseous nerve palsy. MannerfeltNorman syndrome. The various compression neuropathies can be a bit tricky.
The key to the anterior interosseous nerve is that it is a pure motor palsy. Pronator syndrome is a sensory deficit. MannerfeltNorman syndrome refers to an attrition rupture of the flexor pollicis longus 22 Chapter 2 Hand and wrist: Answers due to scaphotrapezial synovitis. This question could also be asked in terms of special investigations and special tests in clinical examination. Radial shortening.
Proximal row carpectomy. Wrist fusion. The clues of dorsal wrist pain and Lichtman classification lead the reader to Kienbocks disease. The question is a discriminator between treatment and salvage of the disease as well as differentiating fixed and mobile deformity 3A vs. Intrinsic plus hand. Boutonnire deformity. This questions tests knowledge of special signs.
Intrinsic tightness as shown by the Bunell test must be differentiated from the intrinsic minus hand, e. A Boutonnire deformity is usually due to central slip rupture while a swan neck deformity can have many causes.
Hamate hook fracture. Ulnocarpal abutment. Scaphoid lunate advanced collapse. When evaluating wrist pain it is worth dividing it into dorsal, radial and ulnar-sided wrist pain. Once age and location has been taken into account the diagnosis will be narrowed down. At this stage radiographs and diagnostic injections will probably provide a definite answer. The ring sign is one of many signs that reveal widening of the scapholunate ligament and flexion of the scaphoid. This training will result in a self-sustaining program by Discussion The manual therapy Residency education model allowed for advancement of the participating physiotherapists professional development utilizing evidence-based practice.
This was done without altering the current education system within the country, or accessing expensive equipment. Concluding remarks The Residency program was developed and established with the cooperation of a local education institution and a non-profit corporation in the United States. This collaboration has facilitated the advancement of orthopedic clinical standards in the country and will, hopefully, one day serve an as a template for future programs.
Keywords: Residency program, Kenya, clinical reasoning, physiotherapy, manual therapy Introduction In the year , it was estimated that there were million moderately or severely disabled people living in developing countries 1. This number is projected to grow to million in 1. Although there are limited numbers of physiotherapists available to provide services in these countries, there is a possibility to maximize the potential and skills of the physiotherapists who do exist for the benefit of those in need of services.
However, there are very few opportunities for long-term, comprehensive postgraduate clinical education in developing countries because of fiscal and human resource constraints. Therefore, physiotherapists have little opportunity to improve clinical reasoning and treatment skills 2. To promote the profession of physiotherapy in Kenya, an orthopaedic Residency program was developed in Nairobi, Kenya.
Background Physiotherapists in Kenya currently have the opportunity to earn a 3-year diploma or a Bachelor of Science degree in the field of physiotherapy 3. According to the World Confederation for Physical Therapy, education for entry-level therapists should include a minimum of 4 years of university level courses 4.
In addition, physiotherapists should be committed to pursuing educational opportunities following entry-level education to promote the development of the profession 4. Access to advanced instruction, fundamental to promoting educational development, is limited in Kenya. One factor restricting advanced instruction has been the shortage of physiotherapists with advanced degrees and specialty training to offer educational opportunities following entry-level education 2.
Development of the Residency Program To assist with the progression of clinical reasoning and skill development, an Orthopaedic Manual Therapy Residency Residency program was introduced in Nairobi, Kenya in 5.
The Foundation is a non-governmental organization formed for the purpose of funding humanitarian efforts in Africa 5. The Foundation provides the recruitment and transportation of qualified instructors from universities and clinics throughout the US to Nairobi, Kenya.
KMTC secures housing for instructors, provides teaching space for the program, and grants a Higher Diploma in Orthopaedic Manual Therapy to successful graduates of the Residency program.
The mission of the Higher Diploma Program is to graduate advanced orthopedic practitioners who can lead their communities and local profession in the advancement of clinical care and education. Multiple steps were taken to establish a long-term educational program, including comprehensive didactic education and clinical mentoring, to improve clinical practice and health-care delivery by physiotherapists in Kenya.
During the development of the program, meetings were held with key stakeholders; the Foundation, the director of the KMTC, and the head of the department of physiotherapy education. Discussions centered on a shared vision and mission for the program. Common goals for the program were agreed upon. In addition, details regarding what each stakeholder could provide to ensure the success of the program were examined.
Following the development of the mission for the program and drafting of a Memorandum of Understanding, the goals and scope of the program were shared with the University of Nairobi and Kenyatta University to ensure that misunderstandings did not ensue.
In addition, the program was presented to the Ministry of Health. Once the program was accepted by all parties, the development of the content was addressed by the Foundation and physiotherapy faculty at KMTC. Program Content The physiotherapists participating in the Orthopaedic Manual Therapy Residency program have a 3-year technical diploma in physiotherapy and have reported no previous access to continuing education throughout their careers.
The residents complete six modules over 18 months. The online didactic portion of the program utilizes the Clinical Practice Guidelines and Current Concepts in Orthopedics, 3rd edition American Physical Therapy Association as background reading and preparation for participation in onsite modules 6. Each module takes place during 10 days of onsite education and mentoring provided by physical therapy instructors from the US.
Instructor qualifications include currently a faculty member teaching in the area of orthopedics within an accredited physical therapy program or having an advanced certification in both orthopedics and manual therapy. The purpose of each module is to provide the residents with the didactic education and clinical skills consistent with the orthopedic curriculum provided by professional doctorate in physical therapy programs in the US.
In addition to onsite modules and online resources, residents receive clinical mentoring focused on integrating the knowledge and skills learned during the Residency program into clinical practice. To allow for mentoring of these residents, KMTC contracts with providers to allow the residents to practice as students within local facilities. To progress in the program, residents must achieve adequate performance on written and practical examinations provided at the completion of each module.
Following completion of the month Residency program, residents must successfully pass a comprehensive written examination and a live patient practical examination to earn the Higher Diploma.
Participants Since , 51 volunteers from the US have provided instruction in the Residency program as didactic instructors and clinical mentors to the Residents. The first cohort of the program graduated in December , and the second cohort graduated in December Currently, four additional cohorts are in progress of completing the Residency program for a total of 90 Residents.
Although significant support has been provided through the Foundation to institute the program, a train-the-trainer program has been established. Six graduates are currently being trained to continue the Residency program and are serving as teaching assistants for the on campus modules. Mentoring is being provided to the teaching assistants to allow progression of their understanding of the content and effective delivery skills for teaching both didactic and procedural knowledge.
The training of graduates to provide ongoing education will result in a self-sustaining program by The Foundation has provided the costs associated with airfare from the US to Kenya for volunteers. Furthermore, the Foundation has sought professionals with specialty training in manual therapy to provide mentoring for the residents in their current clinical setting focused.
This mentoring focuses on integrating the knowledge and skills learned during the Residency program into clinical practice. KMTC provides the resources and facilities needed for the onsite modules. These include a large gym space with standard treatment tables and exercise equipment and audiovisual equipment. KMTC also arranges lodging and transportation for the volunteer instructors and mentors.
As a gift from the Foundation to successful graduates, a messenger bag with an inclinometer, two goniometers, pinwheel, reflex hammer, exercise band, stethoscope, pulse oximeter, and blood pressure cuff is provided at graduation. This provides the graduates with some tools for to providing treatment to patients.
In addition, the Foundation hoped to determine obstacles to the integration the newly acquired knowledge and skills gained through the Residency into clinical practice.