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2659. Correct Answer: C) Stage of
advanced arthritis
Explanation:
Presence of hip pain and true shortening of the limb is suggestive of Stage-III TB hip, known as Stage of advanced arthritis.
Babulkar and Pandey Clinico-Radiological Classification of TB Hip
Babulkar and Pandey Clinico-Radiological Classification of TB Hip stages:
Stage 1:
Synovitis
Clinical findings :
Irritable hip
Increased FABER (Flexion, Abduction, External Rotation)
Apparent lengthening due to FABER (Position of ease due to synovitis)
Terminal movements are restricted by 25%
X ray findings:
Normal or haziness of the articular margins
Stage 2 early arthritis:
Clinical features:
. Early joint pain, stiffness
. Increased FADIR ( Flexion,adduction, internal rotation)
. Apparent shortening due to FADIR
. Gluteal and quadriceps shortening
. ROM restricted by 50%
X ray findings
. Osteopenia and narrowing of joint space
Stage 3 late arthritis
Clinical features
Marked FADIR
True shortening
Gross restriction of movements
X ray :
Marked subchondral erosion and destruction.
Stage 4 severe arthritis:
. Marked FADIR
. Gross shortening
X ray :
Wandering and travelling acetabulum
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2568. Explanation
Correct Answer: D) Neuropraxia
Explanation:
Given clinical scenario is suggestive of Saturday night palsy, which is caused by compression of the radial nerve against the humerus.
The compression produces a temporary conduction block without disruption of the axon. This type of nerve injury is called neuropraxia (neurapraxia).
Radial nerve dysfunction causes weakness of the wrist and finger extensors, resulting in the characteristic wrist drop.
Neurotmesis (Option A): Complete
transection of both the axon and surrounding connective tissue sheaths (requires surgical repair).
Neurolysis (Option B): A surgical procedure to release a nerve from scar tissue or adhesions, not a category of nerve injury.
Axonotmesis (Option C): Disruption of the internal axon and myelin sheath leading to Wallerian degeneration, though the outer nerve sheaths remain intact.
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2567. Explanation
Correct Answer: B) Synovial Fluid
Analysis
Explanation:
Acute gout can be diagnosed with certainty by identifying urate crystals in synovial fluid, bursa or aspirate of tophus. In acute gout synovial fluid is highly inflammatory, with white blood cell counts of β₯2,000 cells/mm3.
Even when uric acid crystals are seen, the joint fluid should also be examined for the simultaneous presence of other crystals, especially calcium pyrophosphate crystals, and should undergo Gram stain and culture to rule out co-infection.
Gout
Inflammatory arthritis caused by the deposition of monosodium urate crystals in joints and tissues due to hyperuricemia
Clinical Presentation:
Acute Gouty Attack- Sudden onset of intense joint pain, typically affecting the big toe, but can also involve other joints such as the ankle, knee, wrist, or elbow
Chronic Gout- Recurrent attacks of joint inflammation, development of tophi (deposits of urate crystals) in joints and soft tissues
Diagnosis:
Medical History- History of recurrent joint pain, sudden onset, and self-limiting nature of attacks.
Physical Examination- Joint examination revealing signs of inflammation (redness, swelling, warmth)
Synovial Fluid Analysis-Detection of monosodium urate crystals in synovial fluid aspirated from an affected joint.
Serum Uric Acid Level- Elevated serum uric acid levels (>6.8 mg/dL) may support the diagnosis, but levels can be normal during an acute attack. Repeated estimations of serum uric acid levels is of great value.
Treatment:
Acute Attack- Nonsteroidal anti-
inflammatory drugs (NSAIDs), colchicine, corticosteroids for pain relief and inflammation control
Long-term Management-
Lifestyle modifications (dietary changes, weight loss), medications to lower uric acid levels (allopurinol, febuxostat) to prevent further attacks.
Serum Uric Acid Level (Option A):
Serum uric acid levels are often normal during an attack of acute gout, repeated estimations of serum uric acid levels is helpful.
Urine Uric Acid Levels (Option C):
Urine uric acid levels are not typically used as a diagnostic test for gout.
Although increased urinary excretion of uric acid may be observed in some cases of gout, it is not a specific or reliable marker for diagnosing the condition.
X-Ray Changes (Option D): X-ray changes, such as the presence of joint erosions or bone damage, may occur in advanced stages of gout (chronic gout) or if there have been recurrent episodes of inflammation over time.
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2566. Explanation
Correct Answer: B) Osteogenesis Imperfecta
Explanation:
Multiple long bone fractures seen on an ultrasound during the 13th week of pregnancy are typically indicative of osteogenesis imperfecta, a genetic disorder.
Osteogenesis Imperfecta:
Osteogenesis imperfecta is a genetic condition that affects bone strength and causes brittle bones. Hearing issues, dental deformities, and discolored sclera (the whites of the eyes) are further signs of osteogenesis imperfecta.
Ultrasound imaging can detect multiple long bone fractures in a fetus with osteogenesis imperfecta.
Defective Type 1 collagen.
Genetic Disorders and Prenatal Screening:
Prenatal screening tests can detect genetic disorders such as osteogenesis imperfecta during pregnancy.
Most commonly COL1A1 and COL1A2.
Radiological features:
Wormian bones: Supernumerary bones of the skull that form as a result of extra-ossification centres during development in utero. These are classic osteogenesis imperfecta and are usually within and surrounded by the suture lines.
Frontal and mastoid sinus
enlargement: Observed in some patients.
Thin cortices of long bones:
General demineralization and thinning of bone cortices
Frontal and mastoid sinus enlargement: Observed in some patients
Reduction in bone density: Notable in severe forms of osteogenesis imperfecta.
Codfish vertebra: Biconcave appearance of vertebrae (esp. Lumbar vertebrae) noted in imaging studies.
Fracture deformities: Mid-diaphyseal deformities (e.g., apex anterior) due to fragility fractures.
Protrusio acetabuli: Common hip finding.
Shepherd's crook deformity:
Common in femurs and is classically associated with fibrous dysplasia
Radiolucent scalloping with radio-dense rims: "Popcorn" appearance in metaphyses.
Trumpet-like metaphysis:
Characteristic deformity seen in radiology.
Management of Osteogenesis Imperfecta
Physiotherapy & Mobility Aids:
Ξ Walking aids and orthotics to maximize mobility and reduce fracture risk.
Pharmaceutical Agents:
Bisphosphonates:
IV Zoledronate:
Commonly used in children to enhance bone strength by inhibiting osteoclastic bone resorption.
Increases cortical thickness.
Cycles of intravenous bisphosphonates reduce bone pain and fracture incidence.
Surgical Intervention:
Sheffield Procedure:
Used in children with bowed long bones.
O Involves the insertion of expanding intramedullary rods or telescopic rods to improve weight-bearing and correct deformities
Sofield-Miller or Kebab Osteotomy:
Involves multiple osteotomies of bowed long bones in children to correct severe deformities and enhance bone stability.
Intramedullary fixation systems are often utilized to stabilize load-bearing bones.
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2565. Explanation:
Dyspnea, and the presence of petechiae all over the body in a male patient who has broken a long bone in a car accident could be signs of the hazardous medical disorder known as fat embolism syndrome (FES)
Fat embolism syndrome (FES) is a serious medical condition that can occur after a bone fracture or other traumatic injury.
Symptoms of FES include dyspnea, decreased oxygen saturation, and petechiae all over the body.
Air embolism (Option B) :occurs when air bubbles obstruct blood flow, risking organ damage or death.
Venous thromboembolism (VTE)
(Option C): forms blood clots in veins, often traveling to the lungs, leading to pulmonary embolism and potential fatality.
Pulmonary hypertension (PH)
(Option D): causes high blood pressure in lung arteries, straining the heart and leading to eventual failure
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2564. Correct Answer: A) Physiological conduction block
Explanation:
Neuropraxia is characterised by a physiological conduction block without structural disruption of the axon or surrounding connective tissue.
It is the mildest form of peripheral nerve injury.
Commonly caused by compression or mild traction injury.
There is a temporary interruption of nerve conduction without structural damage.
Features:
Physiological conduction block occurs.
The axon remains intact.
Ξ No Wallerian degeneration occurs.
Clinical manifestations:
Temporary motor weakness and sensory loss may occur.
Recovery is usually complete within days to weeks.
Examples:
Ξ Saturday night palsy
Transient nerve compression injuries.
Axonal disruption (Option B) occurs
in axonotmesis and neurotmesis, associated with Wallerian degeneration distal to injury
Nerve trunk damage (Option C):
Severe injury involving the entire nerve trunk is seen in neurotmesis, and recovery is poor without surgical repair
Perineurium damage (Option D):
Damage to the perineurium suggests more severe nerve injury than neuropraxia and is associated with axonotmesis or neurotmesis.
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2563. Explanation
Correct Answer: A) Emergency
fasciotomy
Explanation:
The patient has acute compartment syndrome with critically elevated intracompartmental pressure (90 mmHg), requiring emergency fasciotomy to relieve pressure, restore perfusion, and prevent irreversible muscle and nerve damage.
It is referred to as increased pressure within a closed osteofascial compartment, causing compromised circulation and tissue perfusion.
Raised compartment pressure causes:
Compromised tissue perfusion
Muscle ischemia
Nerve injury
Irreversible tissue necrosis if untreated
Clinical features:
β
Severe pain out of proportion to injury
Pain on passive stretch
O Tense swollen compartment
Paresthesia and paralysis in late stages
Management: Emergency fasciotomy is the treatment of choice
Relieves pressure within compartment
γ Restores circulation to muscles and nerves
Prevents permanent disability and limb loss.
Fasciotomy:
Two longitudinal incisions are given, one on the medial side and one on the lateral side.
The skin, subcutaneous fat, and fascia are incised during fasciotomy.
The muscle bulges through the fascia after decompression
Observation and limb elevation (Option B): Observation is inappropriate in established compartment syndrome with markedly elevated compartment pressure. Delay in decompression can lead to irreversible ischemic damage.
Closed reduction and cast application (Option C): Applying a cast may further increase compartment pressure and worsen ischemia if a fasciotomy is not performed first.
Fracture fixation alone (Option D): It does not relieve elevated intracompartmental pressure.
Surgical decompression is mandatory before definitive fracture management
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2562. Explanation
Solution VERY DIFFICULT
Correct Answer: D) External fixation
for both femur and tibia
Explanation:
This child has polytrauma with hemodynamic instability, indicated by:
Multiple bilateral long-bone fractures
Positive London sign (suggestive of significant blunt abdominal trauma)
Unstable vitals
In such patients, the preferred approach is Damage Control Orthopedics (DCO).
In such patients, the preferred approach is Damage Control Orthopedics (DCO).
Aim:
Quickly stabilize fractures
Minimize operative time
O Reduce blood loss
Avoid the "second hit" phenomenon caused by major definitive surgery in an unstable patient.
External fixation is preferred as: (Option D)
Rapid to apply
Ξ Causes minimal physiological stress
Helps control pain and bleeding
Facilitates ongoing ICU resuscitation and monitoring.
Intramedullary nailing/plating:
Are definitive surgeries and are delayed until the patient is fully stabilized, as they can worsen:
(Option A, B, and C ruled out)
Shock
Acidosis
Coagulopathy
Hypothermia
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2560. Explanation
Correct answer A. Proximal tibia
β’ Blount disease is characterized by pathological tibial varus deformity often seen in young children and is linked with abnormal growth of the media part of the proximal tibial growth part
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2559. Explanation
Correct Answer: A) Osteoarthritis
Explanation:
OA typically affects the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints, especially in the hands. It often spares the metacarpophalangeal (MCP) joints and wrists, making it characteristic of OA in the hands.
Rambo
Osteoarthritis (OA):
It is the most common form of arthritis in the world.
It mainly affects the hips, knees, spine, hands and feet.
Clinical manifestations
Symptoms:
.
Pain (Nature and severity are variable)
Joint stiffness (short-lasting stiffness after a period of inactivity)
Fatigue
Sleep disturbance
Reduced functional ability and activities
Rambo
Signs:
Tenderness of the joint
Bony swelling
Reduced range of movement with pain at the end of the range
Crepitus on movement of the joint
Weakness and wasting of muscles around the joint
Signs of inflammation (mild)
In severe cases - deformity and instability
Varus deformity and fixed flexion deformity of the knee
Varus deformity
Commonly affected joints in the hand: Distal interphalangeal joints (DIPs) and the thumb base
Classical findings in hand:
Heberden's nodes (posterolateral swellings of DIP joints)
Bouchard's nodes
(posterolateral swellings of PIP joints)
Squaring at the base of the thumb (first CMC joints)
Kashin Beck disease:
An extremely rare polyarticular form of OA.
Seen in the people of Northern China and Eastern Siberia.
Symptoms:
Joint pain
Polyarticular swelling
Deformity from childhood
Short stature
X-ray:
Distorted epiphyses and tubular long bones.
Rheumatoid Arthritis (Option B):
Affects MCP joints and wrists symmetrically, not typically sparing them.
Psoriasis (Option C): Psoriatic
arthritis can affect DIP joints but often involves other joints, including MCP joints.
Rambab
Hyperparathyroidism (Option D):
Causes bone changes but does not specifically affect DIP and PIP joints in the same pattern as OA.
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