Trauma Amputations, Prosthetics and Joint Replacement Surgery MCQs

This obese patient has neuropathic pain along the distribution of the median nerve that is consistent with carpal tunnel syndrome (CTS). The patient presents with classic signs of hypothyroidism: constipation, fatigue, bradycardia, hyporeflexia, and lower limb edema (which is usually myxedematous and non-pitting, but pitting edema can also occur due to excessive albumin in extracellular spaces). While the precise etiopathology is uncertain, it is assumed that the excess deposition of glycosaminoglycans, hyaluronic acid, and mucopolysaccharides in hypothyroidism causes myxedema. These characteristic depositions can subsequently cause compression of the carpal tunnel. With thyroid hormone replacement and return to a euthyroid state, symptoms should improve within weeks to months. Reference: Basic & Clinical Pharmacology, Fourteenth Edition By Bertram G. Katzung Pg no. 699

Pain during abduction with limitation of movement is suggestive of supraspinatous tendonitis. Palpation or compression around the greater tubercle of the humerus is particularly tender. Glenohumeral joint OA is very rare. Though Rotator cuff tendinitis is often accompanied by a sub acromial bursitis, the more likely answer here is supraspinatus tendinitis, considering the recurrent overhead abduction as in a tennis player. Tennis elbow causes pain the elbow. Reference: Harrison's Principles of Internal Medicine 21 st Ed, Ch: 375, Pg: 2878

The classical definition of compartment syndrome is an intracompartmental pressure of 30mm of Hg or above. However, this is not true for hypotensive patients. The best way to diagnose compartment syndrome in a hypotensive patient is to calculate the delta P value. Diastolic blood pressure minus intracompartmental pressure is called delta p, If delta p is less than 30 mm hg patient requires immediate fasciotomy for compartment syndrome Reference- Maheshwari ortho 5th edition, page number 47

This is a case of pulled elbow also called the nursemaid’s elbow. It is a subluxation of radial head caused due to an axial pull distal to the elbow. Seen in children Clinical features Minimal inflammation Pronated forearm X ray - normal Treatment - flexion and supination of the forearm will reduce the radial head and correct the subluxation. Reference: J. Maheshwari's 5th Edition of Essential Orthopaedics page no. 105

DISCUSSION: The anterior approach to the hip joint involves identifying the plane between the tensor fascia lata and the sartorius muscles. In the anterolateral approach to hip, we use the plane between TFL and Gluteus medius. Reference: Berry, D. J. (2001). PRIMARY TOTAL HIP ARTHROPLASTY. In M. W. Chapman (Ed.), Chapman's Orthopaedic Surgery (3rd ed., pp. 2749–2759). Lippincott Williams & Wilkins

The plane of dissection in anterolateral approach to hip is between TFL and gluteus medius Incision: Curvilinear incision centered over the greater trochanter running posteriorly along the shaft of the femur with hip in 30–40° of flexion starting 2–3 cm behind the ASIS. Soft tissue dissection: Plane is developed between the TFL and the gluteus medius (protects the inferior branch of the superior gluteal nerve). TFL is then retracted medial and anterior, and the gluteus medius retracted posterior and lateral exposing gluteus minimus posteriorly and rectus anteriorly. Reference: Manish kumar varshney 1st edition page no 1094.

DISCUSSION: Increased pain, swelling, erythema, and drainage 2 weeks removed from the primary arthroplasty are all signs of a probable infection. Erythrocyte sedimentation rate and C-reactive protein may not be helpful as they are elevated postoperatively even in the absence of infection. Even in the absence of infection, persistent wound drainage is an indication for surgical debridement to prevent subsequent infection. When a postoperative infection is easily recognized by clinical examination, there is no need to wait for a positive culture before proceeding with debridement. Reference: Burke, D. W., & O'Flynn, H. (2001). PRIMARY TOTAL KNEE ARTHROPLASTY. In M. W. Chapman (Ed.), Chapman's Orthopaedic Surgery (3rd ed., pp. 2869–2896). Lippincott Williams & Wilkins.

In most instances of hemarthrosis, the first line of management is aspiration of joint, which will relieve the pressure within the joint and provide pain relief to the patient. However, this is contraindicated in hemophilia, as even if we aspirate a joint and remove all the blood, it will re-accumulate within few hours. This is because, the deficiency of clotting factor 8 will not allow clot formation and there will be continued bleeding into the joint. Reference: Miler's 8th Edition of Review of Orthopaedics, page no. 699