OSPE-Ortho

اللهم يا معلّم موسى علّمني، ويا مفهم سليمان فهّمني، ويا مؤتي لقمان الحكمة وفصل الخطاب آتني الحكمة وفصل الخطاب اللهم اجعل ألستنا عامرة بذكرك، وقلوبنا بخشيتك، وأسرارنا بطاعتك، إنك على كل شيء قدير، حسبنا الله ونعم الوكيل

Updates through https://medatlax.com/Clinical/Level-11/Orthopedics/OSPE/OSPE-Ortho/OSPE-Ortho - will be highlighted yellow - If there is any adjustment or edits please let me know Dr.alkharji@proton.me

collected from previous batches, Dania abuobaid, Alzahraa Ismaeel, Deema alsarawi, ~FA, Mujahid Almuhaydib, and Ola Al-Rayes

Principles of Fracture

Salter-Harris Fractures

Q8/ What is the type of fracture shown in these pictures?

• A- Salter harris fracture II

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Associated Injuries with Fractures

Q6/ For patients with this following fracture, you have to rule out the most associated injury which is:

• A. Spine fracture

QUESTION 9: A case about a patient who fell from a high building. “X-ray showed a calcaneus fracture”, what is the most likely fracture to be associated with this injury?

Fracture Identification and Pain Causes

Q5/ A patient came with pain and the physician ordered X-ray to figure out the cause. According to his X-Ray, what could be the cause of his pain?

• C- Fracture association

QUESTION 10: Patient come with pain and had this x-ray, what could be the cause of pain?

• a. Fracture

Fracture Patterns and Types

Which pattern of fractures is demonstrated in the attached X-ray?

• B. Segmental

Q19- what would be the bleeding source in the injury observed in this x ray?

• The answer: Venous plexus

Fracture Management Considerations

Management Factor

• Neurovascular deficit would affect management

Complications of Fractures

Fat Embolism Case

A 32-year-old man who had sustained a traumatic fracture of the left femoral shaft 20 hours earlier was referred for a sudden deterioration of consciousness. He was unresponsive to verbal stimuli but no focal neurologic abnormalities were found.

Q1. What is the most probable diagnosis?

• Fat embolism (petechial hemorrhage)

Q2: What is the treatment of choice?

• Respiratory support, early recognition, call the anesthesia and transfer to ICU

Stress Fractures

Stress Fracture Characteristics

• Stress fracture
• In Soldiers, athletes,…

Stress Fracture Example

• Callous formation is 2nd metatarsal
• Looks like stress fracture

Principles of Treatment, Traction, Casting, Implants, Splints

Clinical Questions

Q5: 35-year-old male with fracture - Treatment

A 35-year-old male with this fracture, how would you treat it?

• Open reduction and internal fixation

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Q8: 70-year-old female with hip injury

A 70-year-old inactive female presents to the emergency department after falling down in the bathroom. She’s been complaining from hip pain and inability to bear weight. Which of the following is the most appropriate choice of treatment?

• Bipolar hemiarthroplasty

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Q10: 30-year-old with femur fracture - Traction weight

A 30-year-old was involved in a road traffic accident. He sustained a closed femur fracture. The apparatus seen was applied to him. What is the maximum weight that can be used if his weight is 80 kg?

• 8 kg

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Q12: Skeletal traction weight calculation

Assume that a patient weighs 80 kilograms, what is the maximum weight that can be applied in such form of traction? 4.5 kg or less

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Q15: 35-year-old male with fracture - Treatment

35 years old male with this fracture, how would you treat it:

• Open reduction and internal fixation of ulna - Closed reduction of head of radius +/- fixation

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Q17: 5-year-old boy with closed injury - Treatment

A 5-year-old boy sustains an isolated, closed injury. He weighs 55 kg and is otherwise healthy. What is the best treatment option for this patient?

• Fixation and intramedullary nailing

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Q19: Traction weight calculation

Assume that a patient weighs 60 kilograms, what is the maximum weight that can be applied in such form of traction? 4.5

Compartment Syndrome

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Diagnostic Criteria

Which of the following pressures is diagnostic of compartment syndrome?

• Delta pressure of 20 mmHg

Fasciotomy Indications

• High risk patients
  • Prophylactic with major corrective osteotomy of the leg & forearm
  • S&S not resolved within 30-60 min. of appropriate precautions
  • Significant tissue injury
  • Suspicion: Equivocal clinical findings
  • Based on measurements:
    • Delta pressure (DBP - compartment P.) $\le$ 25 mm Hg.
    • Compartment pressure > 30mm Hg.

Case: A man involved in a road traffic accident (RTA) where a car ran over his forearm. X-ray showed fracture of the forearm.

Diagnosis?

• Compartment syndrome

What are the clinical features?

• The 5 P’s:
  • Pallor
  • Paresthesia
  • Pain (out of proportion to injury)
  • Paralysis
  • Pulselessness

Management?

• ABC’s (Airway, Breathing, Circulation)
• Correct hypotension
• Remove circumferential bandages & cast
• Position limb at level of the heart
• Supplemental oxygen
• Fasciotomy (definitive treatment)

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Q22: 30-year-old active patient with femoral neck fracture

30-year-old active patient presents to ER after history of falling down from second floor. Diagnosed with displaced femoral neck - he has only mild controlled hypertension - what is the next step for his management?

• Anatomical reduction and cannulated screws

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Q23: Traction weight calculation

Assume this patient weighs 80 kg. What is the maximum weight that can be applied in such form of traction?

• 8 kg

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Additional Questions

35-year-old male with fracture

A 35-year-old male fell and had this fracture - what is appropriate treatment?

• ORIF

Management of imaging finding

What is the management of the finding in the image?

• Screw fixation

Skeletal traction weight guidelines

A male patient who weighs 80 kg has a fracture, skeletal traction is applied. What is the maximum weight for traction?

• 10% of body weight
• 8 kg

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Orthopedic Devices and Principles

Skeletal Traction

1. Skeletal Traction

• Indication: When a strong force is needed (weight more than 4-5 kg) in adults
• Complications: Infection, over distraction of bone fragments

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Synthetic Fiberglass Cast

1. Synthetic Fiberglass

• Disadvantages: Sharp edges, not moldable
• Advantages: Strong, quickly sets

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Thomas Splint

Name of device: Thomas splint

Indication of use: Transport of patient with femoral shaft fracture

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Locked Head Screws and Locked Plate

Name of device: Locked head screws and locked plate

Used in: Osteoporotic bone

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Synthetic Fiberglass Cast

Name of cast: Synthetic Fiberglass Cast

Advantages:

• Strong
• Water resistant

Disadvantages:

• Costly
• Sharp edges

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Hip Spica

Q1) Hip spica

Q2) Indications:

• DDH
• Femoral fracture

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Thomas Splint Applications

Name of splint: Thomas splint

Used for:

• Fixed traction for transport
• Can also be used as balanced traction for treatment

Orthopedic Clinical Examination

Neurological Examination

Dermatomes and Myotomes

What’s the dermatome at the level of the umbilicus?

• D. T10

What’s the myotome of the shown structure (Big toe)?

• C. L5

Which nerve root is responsible for the reflex of the shown structure (Achilles tendon)?

• D. S1

Nerve root examination in reflex testing:

• Picture A: L5, S1
• Picture B: S1, S2

Additional nerve testing:

• C7 testing
• Nerve root of umbilicus: T10

Hand and Peripheral Nerve Testing

OK Sign Test

• What is being tested with the OK sign?
  • AIN (Anterior Interosseous Nerve)
• Loss of OK sign in right hand indicates:
  • Inability to flex DIP of thumb and index
  • AIN (branch of median nerve) injury

During clinical examination with OK sign:

• Interpretation: Loss of OK sign
• Peripheral nerve affected: Anterior interosseous nerve (branch of median nerve)

Froment’s Sign

• What does the positive sign signify?
  • Positive Froment’s sign
  • Ulnar nerve dysfunction

Carpal Tunnel Syndrome (Phalen’s Test)

• Diagnosis when patient holds hands in position:
  • CTS (Carpal Tunnel Syndrome)
• Positive sign criteria:
  • Reproducing symptoms within 1 minute (numbness, tingling, and burning sensation)

Shoulder Examination

Rotator Cuff Testing

Supraspinatus Muscle Testing

• What muscle is being examined?
  • A. Supraspinatus

Jobe Test (Empty Can Test)

• Test being performed:
  • Jobe test
  • Tests: Supraspinatus muscle

Rotator Cuff Strength Testing

• External rotators strength (Image A)
• Internal rotators strength (Image B)

Shoulder Instability Tests

Shoulder Apprehension Test

• Test name: Shoulder apprehension test
• Positive findings: Shoulder instability (previous shoulder dislocation)
• What the test shows: Patient feels pain (apprehension) when pushing the shoulder from behind in this position
• Associated condition: Shoulder dislocation (recurrent most probably)

Biceps Tendon Testing

Biceps Tendinitis Test

• Pain over anterior shoulder during this test indicates:
  • A. Biceps tendinitis

Shoulder Range of Motion

Apley’s Scratch Test

• Range of movement tested in images:
  • Adduction and internal rotation
• Which photograph is abnormal?
  • A

Scapular Testing

Winged Scapula Test

• During wall pushing test:
  • Sign name: Winged scapula
  • Affected nerve: Long thoracic nerve

Hip and Pelvic Examination

Hip Flexor Testing

Thomas Test

• Test name: Thomas test
• Positive findings: Fixed flexion deformity of the hip

Iliopsoas Testing

• Which structure is being examined?
  • Left psoas
• Which muscle is attached to the pointed structure?
  • Iliopsoas
• Which muscle is tested during this test?
  • Left psoas

Iliopsoas Tightness Test

• What does this picture examine?
  • A. Iliopsoas tightness

Hip Abductor Testing

Trendelenburg Test

• Test name: Trendelenburg test
• Positive if: Weak hip abductors, hip dislocation, OA
• True statement regarding Trendelenburg sign:
  • A. Contralateral pelvic tilt, and ipsilateral shoulder tilt towards the affected side

Sacroiliac Joint Testing

Sacroiliac Joint Stress Test

• Test name: Sacroiliac joint stress test
• Positive finding: Sacroiliac joint instability

Lower Limb Examination

Hamstring Testing

Hamstring Muscle Attachment

• Which muscle is attached to the fractured structure?
  • d. Hamstring

Achilles Tendon Testing

Achilles Tendon Examination

• Which tendon is being tested?
  • A. Achilles tendon

Achilles Tendon Rupture Sign

• This sign is seen in:
  • a. Achilles tendon rupture

Radiological Views

Ankle Views

• Mortise view:
  • c. anterior posterior with 15 degree internal rotation

Normal vs Abnormal Findings

Normal vs Abnormal Comparison

• What is shown, indicate what?
  • b. Normal

Upper Limb

Clavicle Fractures

Z-shaped Clavicle Fracture

• Treatment: Surgery

Clavicle Fracture Treatment

• Figure A: Figure-of-eight brace (bandage) and shoulder sling
• Figure B: Shoulder sling

Humerus Fractures

GT (Greater Tuberosity) Fracture

Surgical Neck of Humerus Fracture

Humeral Shaft Fracture

• Clinical Examination: Check for radial nerve injury by asking the patient to extend the wrist and fingers

Distal Humerus Fracture

Forearm Fractures

Galeazzi Fracture

• Treatment: Surgery -

Monteggia Fracture

• Location: Proximal ulna fracture w/ radial head dislocation  fracture of the proximal (or mid‑shaft) ulna with dislocation of the radial head at the elbow.  

Wrist and Hand Fractures

Colles’ Fracture

• Deformity: Dinner-fork deformity

Scaphoid Fracture

Scaphoid Fracture Treatment

• Treatment: Thumb spica cast

Mallet Finger

• Treatment: Splint (hyperextender) for 6 continuous weeks OR surgical fixation with nail removal after 6 weeks

Lower Limb

Hip and Pelvis Injuries

Hip Fractures

A 70-year-old inactive female presents to the emergency department after falling down in the bathroom. She’s been complaining from hip pain and inability to bear weight. Which of the following is the most appropriate choice of treatment?

• C. Bipolar hemiarthroplasty

Management Question 8

• B) Total hip arthroplasty

Muscle Attachments and Hip Pain

A teenager with acute onset of pain in the right hip during a run. He sustained the injury seen in the x-rays with a white arrow. This injury usually occurs due to a forceful eccentric contraction of which of the following muscles?

• C. Rectus femoris

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• Sartorius

Pelvic Anatomy

Which of the following muscles is attached to the structure pointed by the arrow?

• C. Sartorius

Note: Arrow was pointing at ASIS (Anterior Superior Iliac Spine)

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• A. Hamstring

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Femoral Fractures

Intertrochanteric Fracture

Diagnosis: Intertrochanteric fracture of neck of femur Treatment: Dynamic hip screw or proximal femoral nail

Femoral Shaft Fracture

Diagnosis: Femoral shaft fracture Management:

• IV line, fluids, blood transfusion
• 2 views and 2 joints x-rays (must see hip joint)
• Treatment of choice: Locked intramedullary nail

Knee and Thigh Injuries

Patellar Fractures

Fracture of Patella

Treatment of choice: Open Reduction Internal Fixation (ORIF) because it’s intra-articular with muscle pulling, using wires/screws and tension bands

Ankle and Distal Lower Leg

Syndesmotic Injuries

A 17-year-old male had a high ankle sprain followed by pain in his leg. X-ray films were obtained. According to the attached X-ray, which structure has been injured?

• B. Syndesmosis ligament

A 23-year-old male injured his ankle after a twisting ankle injury 2 days back. What is the most likely pathology based on shown x-ray?

Management Question: What is the management of the finding in the image?

• A. Screw fixation for syndesmosis injury

Ankle Fractures

Ankle Fracture Cases

Answer 1: Ankle fracture (Suprasyndesmotic fracture in distal fibula type C with medial malleolus fracture)

Answer 2: ORIF by plate in fibula and syndesmotic screw, and screw for medial malleolus fixation

• 1: Ankle fracture (transyndesmotic fracture in distal fibula type B and medial malleolus fracture)
• 2: Open reduction internal fixation by plate in fibula and syndesmotic screw and screw for medial malleolus fixation

Twisting Injury Cases

Q1: What is the mechanism of this injury?

• Spiral fracture caused by indirect twisting injury

Q2: What is the treatment of choice?

• Surgical treatment is best
• Conservative options if minimally displaced: Long leg cast for 4-6 weeks, Patella-bearing cast (Sarmiento) or fracture brace
• Average union time is 16±4 weeks
• Operative treatment: Intramedullary (IM) Nailing is the treatment of choice

Tibial Fractures

Tibia and Fibula Fracture

Diagnosis: Segmental and comminuted fracture of tibia and fibula

Tibial Plateau Fracture

Diagnosis: Tibial Plateau fracture Characteristics: Intra-articular Treatment: ORIF CT scan is necessary for evaluation

Sarmiento Brace

Description: Sarmiento brace (patella-bearing cast) used for tibial fractures

Ankle Specific Fractures

General Ankle Fracture

Diagnosis: Ankle fracture Mechanism: Twisting injury Common in: Old people

Mortise View of the Ankle

Foot Injuries

Talus Fractures

Fractured Talus

Complications: If displaced, can lead to avascular necrosis Treatment for displaced: ORIF or percutaneous fixation

Avascular Necrosis in Talus

Q1. What is the diagnosis?

• Fracture talus

Q2. Write complications specific to this fracture?

• Avascular necrosis

Calcaneal Fractures

Calcaneal Fracture

Complications: If displaced, can lead to osteoarthritis of subtalar joint which is painful Evaluation: CT scan to assess displacement Treatment: Conservative management

Calcaneal Fracture Evaluation

Q2: What other image you need for better evaluation of fracture?

1. Calcaneal fracture
2. CT scan to show the displacement

Pelvis

Pelvic Anatomy

What does this view demonstrate?

• Anterior column

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Pelvic Fractures and Radiological Findings

Give 2 abnormalities in this X-ray?

• Fracture of pubic bones
• Disrupted sacroiliac joint on the same side

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Emergency Management of Pelvic Trauma

Give first 2 measurements you need for saving life?

• ATLAS protocol (ABC)
• IV fluid administration
• IV analgesia
• Pelvic sheet application

Spine & Back

Scoliosis Cases

Which of the following is associated with this finding?

• Adolescent Idiopathic Scoliosis

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A 14-year-old girl presented to the clinic after her parents noticed a deformity in her back. Adam’s test was positive. Which of the following pathologies represents this case?

• Idiopathic scoliosis

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A 13 years old patient, she is known to have idiopathic scoliosis. X-ray pelvis was requested for her.

• 1. Mention the name of the sign seen the X-ray.
  • Risser sign
• 2. How it can help in taking decision the management?
  • By assessing potential of growth to evaluate potential deformity progression (e.g. scoliosis)

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Growth Assessment Signs

Rosser’s sign

1-Describe? Rosser’s sign

2-What is clinical importance of this sign? Measure progress of bony fusion of iliac apophysis. The lower the grade, higher the potential for progression.

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Spinal Deformities

What is this deformity?

• Gibbus deformity

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What is the deformity in this picture?

• Gibbus deformity

What is the most common cause?

• TB, congenital POTTS

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Spinal Trauma & Mechanisms

Which of the following is the mechanism of this injury; MOI?

• Flexion distraction injury

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You are evaluating a 17 years old adolescent girl who was in an unrestrained motor vehicle accident. Imaging is demonstrated. And she has significant posterior midline neck pain. What is the diagnosis and MOI?

• Jumped facet Hyperflexion

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A case about a patient who fell from a high building. “X-ray showed a calcaneus fracture”, what is the most likely fracture to be associated with this injury?

• Spinal fracture

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Spondylolisthesis

Lady came to the clinic complaining of long standing low back pain

Description Lateral x-ray of lumbar spine showing a fracture in the pedicle & slipped L4 over L5

Diagnosis: Spondylolisthesis

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Diagnosis: Spondylolisthesis Next step? Oblique view - to see Scotty dog

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Findings? X-ray of cervical spine should include all C vertebrae and T1. Anterior slippage of C4 over C5 and pars-interarticularis fracture (decapitated scotty dog)

Diagnosis? Pars interarticularis fracture (decapitated scotty dog)

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Anterior displacement of L4 over L5, pars interarticularis disruption, osteopenia

Nerve compression may cause inability to control bowel and bladder sphincter, chronic pain and numbness

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Scheuermann’s Disease

Describe: Schmorl’s Node etc.

Diagnosis: Scheuermann’s Disease

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Chronic Back Pain Cases

A 36-year old patient presented with low back pain for two years that has recently increased.

Q15: Write TWO abnormal findings you can see on the x-ray

• Slipped lumbar spine – over the other lumbar spine “Not sure what is the vertebrae number”

Q16: What is the most probable complication?

• Nerve root injury

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Other Cases

MRI of spine fracture at top of spine

Cervical Facet Dislocations Same as pic A but the choices didn’t have C2-C3 dislocation.

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Young patient presents with limbing leg length discrepancy x-ray is shown. What is the diagnosis?

• Fibrous dysplasia

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Segmental

Knee Examination and Pathology

Meniscal Injuries

Meniscal Tear Identification

What pathology is seen in this MRI of an 18-year-old male who twisted his knee?

• Posterior horn meniscal tear
• Bucket-handle meniscal tear

What is the significance of the double PCL sign?

• Indicates bucket-handle meniscal tear

What does the white arrow indicate in this image?

• Posterior meniscus horn

What is the diagnosis shown in these images?

• Posterior meniscus horn tear

Clinical Correlation

In an 18-year-old male who twisted his knee during sports, which physical finding is most likely to be found on MRI?

• Joint line tenderness

Cruciate Ligament Injuries

Posterior Cruciate Ligament (PCL)

What does this sign indicate?

• Posterior cruciate ligament injury

What is the clinical significance of the posterior sag sign?

• Seen in PCL injury

Anterior Cruciate Ligament (ACL)

What special test is being performed in this image?

• Anterior drawer test

What is the name of this test and what does it indicate when positive?

• Name: Lachman test
• Positive meaning: Tear (instability) of the ACL

What is the imaging modality and diagnosis?

• Modality: MRI
• Diagnosis: ACL tear

What finding is shown in this MRI?

• Torn ACL

What special test would you perform during clinical examination to confirm ACL instability?

• Valgus stress test
• Most probable diagnosis: Tear (instability) of the ACL

Knee Dislocations and Traumatic Injuries

Knee Dislocation Cases

Case 1: 28-year-old parachute jumper

• Injury mechanism: Severe injury to left knee while landing in wrong position with force

What is the diagnosis?

• Anterior knee dislocation

What are TWO expected serious associated injuries?

• Popliteal artery injury
• Common peroneal nerve injury

Case 2: 27-year-old male who fell from first floor balcony

• Presentation: Pain and inability to move left knee

Special Clinical Tests

Patellofemoral Examination

What test is being performed and what conditions does it diagnose?

• Test: Patellofemoral grind test (examiner resists patellar motion while quadriceps tightens)
• Diagnoses: Chondromalacia, osteoarthritis

Collateral Ligament Testing

What would be indicated for a patient with potential collateral ligament injuries?

• Hinged knee splint
• Collateral ligament injuries

Pediatric and Growth-Related Conditions

Osgood-Schlatter Disease

What is shown in this image and how should it be managed?

• Diagnosis: Osgood-Schlatter disease (tendon avulsion injury - partial avulsion)
• Characteristics: Not painful, might be tender
• Nature: Benign lesion
• Management: Ignore unless very tender and painful, reassure patient
• Treatment: Conservative

Video References

Lachman Test Demonstration

• Lachman Test Video
• Test name: Lachman test
• Structure tested: ACL

Acute Joint Dislocations

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Shoulder Dislocations

Anterior Shoulder Dislocation

What is the diagnosis shown in the image?

• Anterior Shoulder Dislocation

What is the most common complication of anterior shoulder dislocation?

• Axillary nerve injury

Hill-Sachs Lesion

What does this photo show?

• Hill-Sachs lesion

18-year-old male presented after sport injury and unable to do internal rotation of right shoulder. What is the name of the injury seen in the figure?

• Hill-Sach’s defect

18-year-old male presented after sport injury and unable to internally rotate his left shoulder. What is the diagnosis?

• Hill-Sachs lesion

A case scenario about a male with anterior shoulder dislocation. What does the figure 1b show?

• Hill-Sachs lesion

reverse - Hill sachs lesion

What do you see in this image?

• Hill sachs lesion

Associated Injuries

What is the associated injury in anterior shoulder dislocation?

• Lesser tuberosity fracture

18-year-old male presented after sport injury and unable to internally rotate his left shoulder. What is the likely finding?

• Lesser tuberosity fracture

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Hip Dislocations

Posterior Hip Dislocation

A 22-year-old man involved in RTA presented to emergency room with pain at left hip, the lower limb was adducted and internally rotated. What is the diagnosis?

• Posterior hip dislocation

What are TWO common complications of posterior hip dislocation?

• Sciatic nerve injury
• Avascular necrosis of femoral head

Posterior dislocation of the right hip position shows?

• Internal rotation of the lower limb

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Knee Dislocations

Patellar Dislocation

What is the diagnosis?

• Lateral patellar dislocation

What is the treatment?

• Reduction & immobilization in above knee cast

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Ankle Injuries

Syndesmotic Injury

A 23-year-old male injured his ankle after a twisting ankle injury 2 days back. What is the most likely pathology based on the shown x-ray?

• Syndesmotic ligament injury

Chronic Shoulder, Hand & Foot Disorders

Shoulder Disorders

Q21 - What causes pain during overhead activities when MRI shows rotator cuff muscle tear?

• Subscapularis and infraspinatus muscle tears
• Note: Supraspinatus was not included in the answer choices

Q34 - What impingement syndrome is most likely associated with abduction and external rotation?

• Impingement during overhead activities

Q35 - What condition is associated with a prominent coracoid process?

• Prominent coracoid process

Question 56 - A 45-year-old male with anterior shoulder dislocation. Which injury is demonstrated in the attached MRI?

• d. Supraspinatus tear

Foot Disorders

Q31 - In a foot X-ray showing possible hallux valgus, which measurement is abnormal?

• Lateral deviation of intermetatarsal angle by 14°

Q32 - In a case of painful bunion, what deformity is observed in the big toe?

• Pronation of the great toe + lateral deviation (valgus)

Q5 - A 55-year-old patient has significant foot pain. What pathology is shown on the X-ray?

• Hallux rigidus

Elderly patient foot pain diagnosis

• Diagnosis: Hallux rigidus

Question 20 - An elderly patient came with foot pain. What is the diagnosis?

• Hallux rigidus

Key Points Summary

Hallux Rigidus

• Arthritic condition affecting the big toe joint
• Causes stiffness and pain in the great toe
• Characterized by osteophyte formation and joint space narrowing on X-ray

Hallux Valgus (Bunion)

• Lateral deviation of the great toe
• Associated with increased intermetatarsal angle (>14°)
• Often accompanied by pronation of the great toe

Rotator Cuff Pathology

• Common cause of shoulder pain during overhead activities
• May involve tears in subscapularis, infraspinatus, or supraspinatus muscles
• Diagnosis confirmed with MRI imaging

Shoulder Disorders

Question: A case scenario that was suggestive of an anterior shoulder dislocation in a 45-year-old male. Which of the following injuries is demonstrated in the attached MRI?

• Answer: Supraspinatus tear

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Hand and Finger Disorders

Question: De Quervain’s Tenosynovitis is known as the inflammation of which extensor compartment of the hand? Question: This test is used to assess tendonitis in which compartment?

• Answer: 1st compartment

Question: What is the name of the deformity in the distal interphalangeal joints and what is the cause?

• Answer: Heberden’s nodes
• Cause: Osteophytes in case of osteoarthritis

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Elbow Disorders

Question: A 30-year-old carpenter presented with pain at the outer aspect of his elbow since 4 weeks. Clinically he has pain on resisted wrist extension. Local steroid injection was decided.

What is the lesion pathology located?

• Lateral epicondyle (origin of wrist extensor muscles) - tennis elbow

Where do you have to inject exactly?

• Distal to the epicondyle at maximum area of tenderness

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Hip Disorders

Question: A 40-year-old female reports a painful snapping in her hip in which she’s able to hear it. The snapping is associated with a clicking sensation. She’s been on conservative treatment for 5 years with no signs of improvement. Which of the following is the treatment of choice for her condition?

• Answer: Arthroscopic debridement for synovial chondromatosis

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Foot Disorders

Question 1: What is the deformity called in this picture?

• Answer: Hallux Valgus

Question 2: Patient complaint of severe pain and it was inflamed, what is the possible treatment?

• Answer: Surgery (Re-align 1st metatarsal, correct valgus deformity of big toe, and soft tissue balancing)

X-rays

Introduction

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Rheumatology-related Imaging

Gout

• Tophus formation visible on radiograph

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Hip and Pelvis

Bilateral Neck of Femur Fracture

Findings:

• Adult patient
• Osteoporotic bone changes
• Bilateral fracture neck of femur

Recommended additional imaging:

• CT scan for further evaluation

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Knee and Patella

Patellar Subluxation

Findings:

• Skyline view of the patella
• Subluxation of patella with trochlear dysplasia

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Advanced Imaging

CT Scan for Joint Assessment

Clinical application:

• CT scan is essential to assess the joint line before starting the management plan
• Provides detailed anatomical information for surgical planning

Peripheral Nerve

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Posterior Interosseous Nerve Questions

Which nerve is responsible for this action?

• Posterior interosseous nerve

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If a patient is unable to perform this sign, which nerve is affected?

• Posterior interosseous nerve

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Anterior Interosseous Nerve Questions

Which of the following nerves is responsible for this action? (Ok sign)

• Anterior interosseous nerve

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Which nerve is shown in this image?

• Median nerve

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Nerve Root Injuries

What nerve root injury is present in Erb’s palsy?

• C5, C6

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A weakness in elbow flexion. The herniation would be in?

• C5, C6

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Dermatomes and Myotomes

What’s the dermatome at the level of the umbilicus?

• T10

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What’s the myotome of the shown structure (Big toe)?

• L5

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Which nerve root is responsible for the reflex of the shown structure (Achilles tendon)?

• S1

Pediatric Fractures

Supracondylar Fractures

Clinical Presentation

• What is the characteristic finding in supracondylar fractures? Supracondylar fracture in children with fat pad sign

Treatment Protocol

• What are the treatment options for supracondylar fractures?
  • If not displaced: Back slab above elbow (flexed elbow)
  • If displaced: Closed reduction and fixation with K-wires and slab

Emergency Room Management: Back slab with flexion in 30 degrees and send for AP and L x-rays

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Radial Head Dislocation

Clinical Diagnosis

• How is radial head dislocation diagnosed? Possible dislocation of the head of radius
  • Draw a line from the neck of the radius - it won’t pass through the capitellum center

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Bucket-Handle Fracture

Clinical Features

• What is a bucket-handle fracture? Twisting injury
• What is the clinical significance of bucket-handle fractures? Non-accidental injury (child abuse)

Management Protocol

• What is the immediate management priority? Inform the social worker is the first thing to do

Pediatric Deformity

SCFE (Slipped Capital Femoral Epiphysis)

Case: A child was stated to be stuck in external rotation and abduction, with an X-ray shown.

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CTEV (Clubfoot) Deformities

Varus Hindfoot Deformity

Q1: What is the deformity showing in this CTEV patient?

• C. Varus hindfoot

Q2: What is the deformity in the photo in this CTEV patient?

• C. Varus midfoot or hindfoot

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Genu Valgum

Q1: What do you see in this image?

• A. Genu valgum, Coronal view

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Medial Femoral Torsion (Anteversion)

Clinical Case

Patient: A 6-year-old girl, brought by her mother to the clinic complaining of awkward walking for 4 years.

Q1: Describe what each clinical picture shows

• Patient stands with medial rotation of the femur (“kissing patella”)

Q2: At what level is the deformity occurring?

• Medial femoral torsion (“Anteversion”)
• Starts at the age of 3 years and peaks at 4-6 years

Finding:

• Stands with knees medially rotated (kissing patellae)
• Sits in “W” position
• Runs awkwardly (egg-beater)

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Asymmetrical Deformities

Diagnosis: Asymmetrical deformity

Pediatric Neuromuscular Disorders

Clinical Case Presentation

You were called to the nursery department to examine a newborn baby not moving his upper limb.

Diagnosis

Erb’s Palsy (Neonatal Brachial Plexus Injury)

Affected Muscle Groups

• Shoulder abductors
• External rotators
• Biceps

Clinical Features

Erb’s palsy is a type of neonatal brachial plexus injury that affects the upper trunk (C5-C6 nerve roots), resulting in weakness or paralysis of the shoulder and elbow muscles while preserving wrist and hand function.

Pediatric Congenital

Developmental Dysplasia of the Hip (DDH)

Radiological Findings

What are the four main radiological findings in DDH?

• Acetabular index more than 25°
• Broken Shenton’s line
• Smaller size of femoral head ossification center
• Lateralization of femoral head to perpendicular line

A case scenario that was suggestive of developmental dysplasia of the hip in an 18-month-old girl. Which of the following radiological signs represents this case?

• Wide acetabular index (also referred to as increased acetabular index)

Clinical Cases

A 15-month-old child was brought to the clinic because of painless limping. There is no history of trauma. The pelvic x-ray is shown.

Q1: Write two abnormalities seen on the X-ray.

• Lateralization of the ossifying centre
• Acetabular angle more than 27°
• Broken Shenton line
• Shortening of the line from greater trochanter to the horizontal line

Q2: What is the most probable diagnosis?

• Developmental dysplasia of the hip (DDH)

10 months old child presenting with this condition:

• Right DDH

Physical Examination

Q11/ The test that is shown in the following picture is used in which of the following conditions?

• Developmental hip dysplasia

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Perthes Disease (Legg-Calve-Perthes)

Clinical Presentation

Q4/ 7 years old boy, noticed by his parents that he had limping over last 3 months. x-ray obtained. What’s the diagnosis?

• Perthe’s disease

Diagnosis: Legg-Calve-Perthe’s Disease

• Collapse – Fragmentation - flattening (coxa plana)

A 7 year old boy presented to emergency room with painful limping right lower limb. Clinically he has limitation of abduction and internal rotation movement at his right hip.

Q1: Mention two abnormal findings:

• Collapse and fragmentation of epiphysis
• Sclerosis

Q2: What is the most probable diagnosis?

• Legg-Calve-Perthe’s disease

X-ray findings in Perthes disease:

• Fragmentation and collapsed epiphysis
• Sclerosis
• May initially look normal in x-ray

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Slipped Capital Femoral Epiphysis (SCFE)

Clinical Presentation

A 13-year-old overweight boy presented to the clinic with pain in his left thigh and knee for one month. He was limping. There was no swelling and no tenderness in the thigh and knee. The hip was held in external rotation and showed limitation of internal rotation.

Q1. What is the diagnosis?

• Slipped capital femoral epiphysis (SCFE)

Q2. What is the treatment of choice?

• Fixation in situ without manipulation, and fix the other limb because there is 1/3 of cases have recurrence in the other joint

14 years old boy, limping, obese, hypogonadism

X-ray: AP and Frog lateral

Presentation: Acute: painful, Chronic: painless

Diagnosis: Slipped Capital Femoral Epiphysis (SCFE)

Signs:

• Hip externally rotates when flexed
• Limited internal rotation

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Clubfoot (Congenital Talipes Equinovarus - CTEV)

Clinical Presentation

What is the diagnosis?

• Congenital Talipes Equino Varus (CTEV)

Which of the following is the initial management of this case?

• Serial casting for clubfoot

Treatment:

• Ponseti method of serial casting for 4-6 weeks followed by tenotomy of Achilles tendon
• If failed >> surgical release

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Other Pediatric Conditions

Cubitus varus

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Talipes Calcaneovalgus

Q.1: What is the deformity called in this picture?

• Talipes Calcaneovalgus

Q.2: This deformity is associated with?

• DDH

Diagnosis: Talipes Calcaneovalgus

Pediatric Fractures

An 8-month-old girl was brought by her mother with history of falling down the stairs while carrying her baby 2 days before. She noticed that her baby is not moving her right lower limb since then, with pain on changing diapers.

Q1: How would you treat this fracture?

• Conservative treatment with hip spica

Q2: What is a major concern in such a case?

• Non-accidental injury

Q.3: What should you consider in this case?

• Child abuse

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An 8-month-old boy was irritable. During assessment, he was afebrile with restricted motion due to pain. X-ray flms were obtained. What is the next step of management?

B. Prepare for admission

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Pediatric Deformities

Unilateral genu valgum of the left knee in a child

Most common cause?

• A previous fracture to the distal femur with malunion

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Additional Resources

Video Reference: https://youtu.be/kZm5VEHKMPQ

A- name of the test: varus stress test B- structure: LCL

Limping and Gait Analysis

Trendelenburg Gait Pattern

Visual Assessment

What is the Trendelenburg sign?

The Trendelenburg sign is characterized by:

• Contralateral pelvis drop (the pelvis on the opposite side drops downward)
• Ipsilateral shoulder lean (the shoulder on the affected side leans toward the involved hip)

Clinical Significance

The Trendelenburg sign indicates:

• Weakness of the hip abductor muscles, primarily the gluteus medius and gluteus minimus
• Inability to maintain pelvic level during single-leg stance
• Commonly associated with conditions affecting the hip joint or surrounding musculature

Underlying Conditions

• Hip osteoarthritis
• Hip dysplasia
• Gluteal muscle weakness or denervation
• Greater trochanteric pain syndrome
• Post-hip surgery or trauma

Assessment Notes

During gait assessment, observe for:

• Pelvic drop during stance phase
• Lateral trunk lean toward the affected side
• Compensatory mechanisms to maintain balance
• Severity often correlates with degree of muscle weakness

Osteomyelitis

Clinical Cases and Questions

What anatomical structure is indicated by the blue arrow in a patient with chronic osteomyelitis?

• a. Involucrum
• b. Sequestrum

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16- The blue arrow show?

A. Involucrum

What is the appropriate treatment for subacute osteomyelitis? (2-month history of knee pain with limping and occasional swelling)

• IV antibiotics and surgical drainage

What is the most likely diagnosis for a patient with long history of knee pain and a sinus draining pus?

• Chronic necrotizing osteomyelitis

What are the characteristic findings and diagnosis for a 7-year-old with painful swollen lower thigh and recurrent fever?

Q1: Abnormal x-ray findings:

• Cavitation
• Periosteal reaction
• Involucrum
• Sequestration

Q2: Diagnosis:

• Chronic osteomyelitis

What is the diagnosis for this acute osteomyelitis case?

• Acute osteomyelitis

What neonatal infection source can cause osteomyelitis?

• A source of infection at the umbilicus
• Could cause osteomyelitis in neonates

Acute Osteomyelitis

Clinical Features

• Fever
• Tenderness
• Acute onset
• Often history of trauma or infection source

Diagnosis

• Clinical presentation
• X-ray findings (may be normal early)
• Laboratory studies

Chronic Osteomyelitis

Radiological Features

• Rarefaction surrounded by sclerosis
• Cavities and sequestra

Key Pathological Features

• Sequestrum: Dead bone fragment that becomes separated from healthy bone
• Involucrum: New bone formation surrounding the sequestrum
• Cavitation: Bone destruction forming cavities
• Sinus formation: Draining tracts to skin surface

Differential Diagnosis

• Tumor
• Infection

Treatment

Medical Management

• Antibiotics (IV initially, then oral based on cultures)

Surgical Management

• Sequestrectomy - removal of dead bone fragments
• Surgical debridement - removal of infected tissue
• May use local antibiotic beads for targeted delivery

Diagnostic Tools

• Sinogram - to show extent of sinus tracts
• Imaging studies (X-ray, CT, MRI)

Clinical Features for Diagnosis

• History: fever, tenderness
• Physical: swelling, warmth, draining sinuses (chronic)
• Laboratory: elevated inflammatory markers

Osteo Infections (Osteomyelitis, Septic Arthritis, TB)

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Q8/ An adult male presented to the clinic complaining of Right thigh pain & fever for 6 weeks. He didn’t seek any medical advice. On examination, He is febrile 38 with swelling around the proximal tibia. WBC was 12500, ESR 40 & CRP 5. The osteolytic lesion seen in the x-ray is known as:

• Brodie’s abscess. - IV antibiotics and surgical drainage, with oral antibiotics 4-6 weeks

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Q16/ An 8-year-old girl presented with a limp. Two years earlier, she had had mild trauma followed by a “bone infection”. Examination revealed a small, pus-secreting wound on the anterior aspect of her left thigh. Her blood count was normal, but her erythrocyte sedimentation rate was 48 mm. According to this radiograph, What do The White Arrows indicate?

• C- Sequestrum

Osteoarthritis

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Q9: A 45-year-old male complained of left knee pain for 3 years that didn’t improve with conservative treatment. His x-ray is shown in Figure A. He underwent the procedure, as seen in Figure B. What is the aim of this procedure?

• B. Redistribute the patient’s weight.

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Q22: A 55-year-old male was diagnosed with right knee osteoarthritis. He was asking about partial (Unicompartmental) knee arthroplasty. What is the absolute contraindication for this procedure?

• D. Rheumatoid Arthritis

(It may be relative contraindication not absolute?CC)

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Q67: A 70-year-old male came with a history of knee pain, and his x-ray in the picture. What is appropriate treatment for him?

• A. Total knee replacement

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Radiographic Findings and Diagnosis

Describe the findings:

• Joint space narrowing
• Subchondral sclerosis
• Osteophytes formation

Diagnosis: Osteoarthritis

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Clinical Case Analysis

A 60-year-old overweight lady presented to clinic with chronic pain in both knees. A standing AP x-ray of both knees is shown.

Q1: Mention TWO findings on this X-ray

• Narrowing of the joint space
• Osteophytes

Q2: What is the diagnosis?

• Bilateral knee osteoarthritis

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X-ray Interpretation and Management

AP & Lateral x-ray of the knee joint showing narrowing of joint space & sclerosis

Diagnosis?

• Knee Osteoarthritis

Management?

• Exercise & analgesics
• Intra-articular injection
• Knee arthroplasty (depends on the case)

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Metabolic Bone Disorders

Bone Cell Identification

Which cells are multinucleated with a rough border facing the bone?

• Osteoclasts - These are the bone-resorbing cells characterized by their multinucleated appearance and ruffled border

Osteoporosis and Pathological Fractures

Clinical Case Study

A 50-year-old male tripped over the edge of carpet at home. He heard a crack and is unable to walk. He gave history of progressive weight loss. On clinical examination, he was in pain with a deformity at upper right thigh. He looks pale.

What are the key x-ray findings?

• Decreased bone density in the right proximal femur
• Fracture in the neck of the femur
• AP view of the right proximal femur

What is the diagnosis?

• Pathological fracture due to osteoporosis

Rickets

Radiological Features

What are the characteristic x-ray findings in rickets?

• Widening of the epiphyseal plate
• Cupping of the metaphysis
• Irregular metaphyseal ends
• Widened physis

Pediatric Case Study

A 5-year-old boy was brought to the clinic because of a progressively increasing deformity in his left leg for 6 months.

What are the abnormal x-ray findings?

• Widening of epiphyseal plate
• Cupping of metaphysis

How will you treat the underlying cause?

• Vitamin D supplementation

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Bone Tumors

Benign Bone Tumors

Non-Ossifying Fibroma

What does this picture show?

• A- Non-ossifying fibroma

Clinical Features:

• Found in children
• Incidentally discovered
• Asymptomatic
• Cortical defect

Osteochondroma

What is the diagnosis?

• X-ray showing bony tumor growing away from the epiphysis
• Diagnosis: Osteochondroma

Clinical Features:

• Pain since 2 years in proximal humerus
• Malignant transformation is rare (<1%)
• Treatment: Monitor with ESR, follow-up every 6 months-1 year
• Surgery considered if severe pain (suggesting malignant transformation)
• Surgical risk: Drop hand due to radial nerve injury

Osteoid Osteoma

Clinical Features:

• Night pain
• Bone forming tumor
• Pain relief with aspirin or ibuprofen
• Common in spine
• X-ray may not show anything initially

Radiological Features:

• Sclerotic lesion inside osteolytic lesion (nidus)
• CT shows nidus better

Treatment:

• Excision
• Radio-ablation for spinal lesions

Fibrous Dysplasia

Clinical Scenario:

• Young patient presented with limping and leg length discrepancy
• Diagnosis: Fibrous dysplasia

Malignant Bone Tumors

Osteosarcoma

Typical Presentation:

• Age: 10-20 years
• Pain and mass
• Location: Metaphysis of long bone

Characteristic Radiological Findings:

• Sunburst (Sunray) appearance
• Codman’s triangle
• Periosteal reaction
• Bone eating appearance

Clinical Cases:

1. 14-year-old patient with pain and swelling at lower right thigh

   • Most important X-ray findings: Sun ray appearance, Codman’s triangle
   • Diagnosis: Osteosarcoma

2. 14-year-old patient complaining of pain and swelling at lower R thigh

   • Findings: Codman’s triangle, Sun burst appearance
   • Diagnosis: Osteosarcoma

Codman trinagle

Ewing Sarcoma

Clinical Features:

• Occurs in children
• Throbbing pain
• Can be confused with chronic osteomyelitis
• Poor prognosis

Clinical Cases:

1. 11-year-old presented with symptoms - diagnosis on imaging

   • Diagnosis: Ewing sarcoma

2. Case scenario provided with picture

   • Diagnosis: Ewing sarcoma

Giant Cell Tumor

Clinical Features:

• Benign but aggressive
• Eccentric and close to the joint line
• Behavior patterns: Benign, local aggressive, high aggressive
• Occurs after fusion of physis
• Extends to sub-articular region

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Bone Cysts

Simple Bone Cyst

Clinical Features:

• Benign
• Children
• Fracture is the first symptom
• Aspiration yields clear fluid
• Surgery for recurrent cases or very large fractures in lower limb

Radiological Features:

• Fills medullary cavity
• Does not expand bone

Clinical Case:

• 12-year-old boy fell and developed severe thigh pain
  • AP view of femur showing well demarcated radiolucent lesion without fracture
  • Diagnosis: Simple (solitary) bone cyst
  • Treatment: Curettage and grafting

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Aneurysmal Bone Cyst

Clinical Features:

• Eccentric, ballooning appearance
• Bloody content
• Found in young adults

Radiological Features:

• Located at metaphyseal side of physis
• Expansile

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Metabolic and Other Conditions

Multiple Myeloma

Clinical Features:

• Age: 45-65 years
• Generalized bone pain
• Involves bone marrow

Radiological Features:

• Multiple punched-out lesions
• Osteopenia, osteoporosis

Clinical Cases:

1. 60-year-old man complaining of generalized bone pain, mostly in left thigh

   • Sign: Multiple punched out lesions
   • Diagnosis: Multiple Myeloma

2. Radiological description

   • Lesion: Multiple punched-out lesions
   • Associated finding: Osteoporosis
   • Diagnosis: Multiple myeloma

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Brown Tumor

Clinical Features:

• Associated with hyperparathyroid disease
• Check PTH levels
• Differential diagnosis: infection, malignancy, hyperparathyroidism

Metastatic Bone Disease

Clinical Features:

• Above 50 years old
• Metastasis is differential diagnosis
• Can present as pathological fracture

Radiological Features:

• Osteolytic lesion
• Moth eaten appearance

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General Radiological Features

Zone of Transition

Which of the following is correct regarding this image?

• C. Narrow zone of transition or cortical thinning not sure?

Differential Diagnosis by Age

• Children: Ewing sarcoma (when sun-ray appearance and Codman’s triangle present)
• Adults: Osteosarcoma (when sun-ray appearance and Codman’s triangle present)
• Elderly: Consider metastatic disease

Common Presentations

• Many bone tumors present as injury
• Pain is a common symptom across most tumor types
• Location and age are key diagnostic factors
• Radiological appearance helps narrow differential diagnosis