Exam Recall Series (NEET-PG '23) - Orthopaedics

NEET PG 2023 Orthopedics Recall

In this video, Dr. Basili recalls the questions that were asked in the NEET PG of 2023 for Orthopedics. He mentions that most of the questions were previously asked and heavily relied on previous year questions.

Correct Pair for Image Shown Below

• The image is a splint used for radial nerve injuries.

• The splint is called an up-splint.

• There are two varieties of up-splints: static and dynamic.

• The advantage of using a dynamic cock-up splint over a static one is that it allows the patient to continue using their flexors, preventing disuse atrophy.

Humerus Fracture and Radial Nerve Injury

• When the radial nerve is injured at the spiral groove in Holstein Lewis fracture, the patient will have wrist drop.

• Whenever there is wrist drop, there will also be finger drop and thumb drop as well as sensory loss.

• Up-splints are used when patients have wrist and finger drops due to radial nerve palsy.

• Dynamic cock-up splints use strings or rubber bands to extend fingers on behalf of lost extensors.

Recap

Dr. Basili emphasizes that these recall questions are based on student memory and may not match with what others marked as correct answers. However, understanding what examiners ask helps prepare for future exams.

Deformity and Diagnosis

In this section, the speaker discusses a deformity called partial glowing of hand and explains how to treat it with a knuckle bender splint. The speaker also presents a clinical case of a female patient complaining of tingling and numbness in her fingers, and explains how to diagnose carpal tunnel syndrome.

Partial Glowing of Hand

• Partial glowing of hand is a deformity where the patient has hypothenar wasting, extension of the mCP, and reflection of the PIP and DIP.

• Knuckle Bender Splint is used to bend the knuckles so that it can counteract the action of the muscles that are contracting.

• The Knuckle Bender Splint is used in patients with claw hand to bend the knuckles so that they don't go into extension as they would in flowing off hand.

Carpal Tunnel Syndrome Diagnosis

• A female patient complains of tingling and numbness in her lateral three-and-a-half fingers.

• She usually wakes up at night because of pain but gets relief by hanging her hands at the edge of the bed.

• This is a classical complaint for patients with carpal tunnel syndrome.

• The correct diagnosis pair is carpal tunnel syndrome Durkin's test.

Carpal Tunnel Syndrome Overview

In this section, the speaker provides an overview of carpal tunnel syndrome, including its causes, symptoms, associations, and diagnostic tests.

Causes

• Carpal tunnel syndrome is an idiopathic condition where there is pressure over the median nerve in the carpal tunnel.

• Why it occurs is unknown.

Symptoms

• Patients complain about pain in their hands at night particularly in their median nerve distribution area (lateral one two three-and-a-half).

• They also complain of tingling, numbness, pins and needle-like sensation in the middle of the night.

Associations

• Carpal tunnel syndrome is usually found in middle-aged females.

• Patients with carpal tunnel syndrome get up because of the pain and do quite a lot of things to relieve it.

Diagnostic Tests

• The best clinical test is to press on the median nerve at the wrist (Phalen's test or reverse Phalen's test).

• Other tests include Durkin's test.

Clinical Diagnosis and Management

In this section, the speaker discusses clinical diagnosis and management of knee pain and patella fractures.

Knee Pain Diagnosis

• Patients may complain of knee pain for months without any history of trauma.

• Radiographs can help diagnose bipartite patella, which is a congenital anomaly where the patella has an accessory ossification nucleus that does not fuse with the primary nucleus.

• Bipartite patella is usually bilateral and asymptomatic, but patients may experience chronic pain.

Patella Fracture Diagnosis

• Patellar fractures have ragged or jagged edges on radiographs.

• Smooth edges on radiographs indicate bipartite patella rather than a fracture.

Patella Fracture Management

• Tension band wiring is required for an avulsion fracture of the upper pole of the patella.

• Cast placement is required for a fracture requiring conservative treatment.

• Interfragmentary screw fixation is required for an avulsion fracture of the patella.

Differentiating Between Bipartite Patella and Patellar Fractures

In this section, the speaker explains how to differentiate between bipartite patella and patellar fractures using radiographs.

Identifying Bipartite Patella

• Smooth edges on radiographs indicate bipartite patella rather than a fracture.

• The accessory ossification center in bipartite patella can be located at different parts of the patella, including lower pole, lateral side, or superior lateral pole.

• More than 50% of cases are bilateral and asymptomatic.

Identifying Patellar Fractures

• Ragged or jagged edges on radiographs indicate a fracture rather than bipartite patella.

• Patients with fractures will have a history of trauma.

• Patellar fractures require different management techniques depending on the location and severity of the fracture.

Patellar Fracture

This section discusses the most common type of patellar fracture, its treatment, and other possible treatments.

Patellar Fracture Treatment

• A device that converts destructive forces into compressive forces is used to treat a transverse patellar fracture.

• The most common treatment for patellar fractures is tension band wiring.

• If the patellar fracture is undisplaced, it can be managed conservatively with a leg cylinder cast.

• If it's a displaced transverse structure or a comminuted fracture with multiple fragments, tension band wiring or removal (telectomy) may be necessary.

Spotter Question on Radiograph Diagnosis

This section discusses how to approach spotter questions and diagnose an epiphyseal lesion in an adult skeleton at the distal end of the radius.

Diagnosing Epiphyseal Lesions

• When diagnosing an epiphyseal lesion in an adult skeleton at the distal end of the radius, giant cell tumor should come to mind first.

• Chondroblastoma occurs in skeletally immature patients (children), while giant cell tumors occur in skeletally mature patients (adults).

• Differentiate between chondroblastoma and giant cell tumor based on growth rate. If the growth plate is visible, mark chondroblastoma; if not visible, mark giant cell tumor.

• Look at X-rays carefully when answering spotter questions. In this case, there was only one clinical point mentioned - swelling in forearm - and options were given for diagnosis: giant cell tumor, aneurysmal bone cyst, chondroblastoma, osteochondroma.

Aneurysmal Bone Cyst and Other Lesions

In this section, the speaker discusses different types of bone lesions and how to identify them on an X-ray.

Identifying Aneurysmal Bone Cysts

• Distal femur with a visible growth plate is immature skeleton.

• Multiloculated lesion in the metaphysis is aneurysmal bone cyst.

Chondroblastoma vs. Giant Cell Tumor

• Tibia, fibula, and talus around the ankle.

• Multiloculated lesion in the metaphysis is either chondroblastoma or giant cell tumor.

• If it's a child, it's chondroblastoma. If it's an adult, it's giant cell tumor.

Osteochondroma and Giant Cell Tumor

• X-ray of the knee joint shows mature skeleton with a visible growth plate.

• Lesion around the metaphysis with a pedicle and cartilaginous cap is osteochondroma.

• Giant cell tumor appears as a growth in each exam.

Spotter Question: Deformity in Lower Limbs

In this section, the speaker presents a spotter question about diagnosing lower limb deformities based on skin changes and X-rays.

Diagnosing Lower Limb Deformities

• Child with deformity in lower limbs and hypo-pigmented patches on skin.

• X-ray of pelvis with both lower limbs shows immature skeleton with visible growth plates.

• Options for diagnosis include fibrous dysplasia, non-osseous fibroma, Paget's disease, or osteogenesis imperfecta.

• Can rule out Paget's disease because it occurs in elderly population.

• Osteogenesis imperfecta is characterized by blue sclera and fragile bones.

McCune Albright Syndrome

This section discusses the three P's of McCune Albright Syndrome and the biopsy finding in fibrous dysplasia.

Three P's of McCune Albright Syndrome

• Polyostotic fibrous displaces involving multiple parts of the bone or multiple bones

• Pigmentation on the skin in the form of cafe au lait spots

• Precocious puberty

Biopsy Finding in Fibrous Dysplasia

• The biopsy finding is a Chinese letter pattern appearance.

Vitamin Deficiency and Deformities

This section discusses how to identify vitamin deficiencies based on deformities, specifically focusing on rickets.

Identifying Rickets

• Bilateral genu varum deformity is a sign of rickets.

• Swelling around joints occurs due to cupping, splaying, fraying, and widening around the wrist.

• A dense white line known as the white line of Frankel appears on x-rays after treatment with vitamin D and calcium.

Differentiating Between Vitamin C and D Deficiencies

• The white line of Frankel can also appear in scurvy (vitamin C deficiency).

• Clinically, collagen abnormalities causing bleeding disorders are present in vitamin C deficiency patients while radiologically there will be a ring in epiphysis for vitamin D deficiency.

Deformities of the Knee

In this section, the speaker discusses deformities of the knee and provides six multiple-choice questions related to these deformities.

Causes of Bilateral Genovarium Deformity

• The most common cause in children is rickets.

• In adults, it is idiopathic more than rickets.

Causes of Bilateral Genome While Gum Deformity

• It is actually idiopathic more than rickets.

Causes of Wind Swept Deformity

• In children, it occurs because of rickets.

• In adults, it is rheumatoid arthritis more than osteoarthritis.

MCQ Questions Related to Deformities of the Knee

• What is the most common cause of bilateral genovaram in children? The answer is rickets.

• What about bilateral genome while gum deformity? It is actually idiopathic more than rickets.

• What are the causes of wind swept deformity? In children, it occurs because of rickets and in adults because of rheumatoid arthritis.

• What is the most common cause of bilateral genovaram in adults? The answer is osteoarthritis.

• What causes bilateral genome while gum deformity in adults? It's rheumatoid arthritis more than osteoarthritis.

• Which disease patients have put vitamin C and D deficiency not to be confused with buttons fracture which is an intra-articular fracture of the distal end radius? No answer provided for this question.

Importance of Mastering Previous Year Topics

• Most of the questions were from previous year topics, so mastering them is essential for any preparation of any exam in any part of the world.

Final Words

• Don't be disheartened if you got the questions wrong. You still have time to recover and improve. The ionized is coming around the corner, and I wish you all the best.