NBE CME programme for DNB consultants - National Board Of ...

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NBE CME programme for DNB consultantsORTHOPEDICSManagement of neglected fracture neck of femurHistoryAge of the patient- it concerns the line of management. Treatment line may be different in children,youngadults and elderly people.Sex - Child bearing age in females has a relationship with treatmentProfession- employed, unemployed, farmer / labourer, office going person / quality of life. This tooconcerns the line of treatment.Mode of trauma - Was the Trauma high velocity? or trivial, as is generally seen in osteoporoticelderly patients. High energy trauma has worse prognosis for fracture healing.Duration of injury-neglected fractures of longer duration may have more shortening and may requiretraction to achieve limb length equalization.Ability - o stand and bear weight after the injury (it is very important point- Studentsgenerally forgetto note in examination)Neurological status- Was patient able to move his toes just after the injury?History of pain - preceding the fracture ? Presence of hip sympomatology before injury could becrucial, because presence of degenerative disease or associated pathology has implication ontreatment options. Like wise metabolic diseases causing a traumatic fracture may have implicationson fracture healing.Treatment - The details of treatment taken by the patient should be enquired into. History of massageor tight bandages by local quacks/osteopaths should always be asked and their complications belooked into if so. A number of femoral neck fractures are actually posterior dislocation of hip beforethey were managed by local osteopaths. Thus the patient may have fracture neck of femur secondaryto posterior dislocation of hip consequent upon manipulation done by osteopath.Clinical examination -Examination in supine; and standing particularly if patient comes walkingshould be known to the candidate. Heal of the ground, knee flexion, exaggerated lumber lordosisrequire discussion.Attitude - Student must express about the attitude of the limb, shortening on inspection, level ofanterior superior iliac spines, level of two medial malleoli, wasting of muscles, and extent ofexternal rotation. A mention of attitude of hip in adduction to should be looked into.Palpation - Local temperature in scarpas triangle,, Tenderness in scarpas triangle, trochantericregion, gluteal region. Femoral pulsations, their volume on two sides. Resistance in femoraltriangle in an attempt to know the status of femoral head. Plapation of greater trochanter is equallyimportant to rule out associated pathology if any besides fracture itself. Gluteal region too msut bepalpated for any kind of abnormal mass. A mention of shortening above trochanter by palpatoryBriant’s method is equally important before it is finally ascertained on drawing Briant’s triangle andperforming true and apparent measurements. The candidate must look for status of inguinallymph nodes in local examination as well.Measurements - Both true and apparent measurements must be discussed.Briants,Triangle,shortening above / below trichanter should be discussed.Deformity - Methods to detect and measure a deformity like flexion deformity of the hip (fixed orotherwise) must be looked into in a neglected fracture neck of femur. Methods tomeasure the deformities should be discussed with the candidate.Movements - The range of movements both active and passive, pain free or painful should bediscussed.86
NBE CME programme for DNB consultantsStraight legRaising test-Both active and passive.Telescopic test- How to perform and its importance?Gait of the patient should be looked into both from front and . If the patient caries stick/lathi in hand,this too should be discussed. How to look for Trenddenienberg gait?Differential diagnosis - Is the fracture extracapsular or intracapsular? Posterior dislocation of thehip? Infective pathology like tuberculosis of hip?Investigations- X-Rays - Both antero-posterior view and Frog leg view or lateral view of the hip mustbe taken. On antero-posterior radiograph the candidate should comment upon shenton’s line,prominence of lesser trochanter in terms of external rotation and proximal migration, prominenceof greater trochanter vis a vis flexion deformity of hip, proximal displacement of distal fragment, typeof fracture is terms of Pauwel’s and Garden’s classification. Status of head of femur in terms of itsviability and joint line must be discussed besides Singh’s index to grade osteoporosis. Rotation ofhead of femur like varus position, absorption of neck of femur and saggital relationship of proximaland distal fragments should be looked into.MRI - To discuss viability of head femur.Computed Axial Tomography- It is effective in evaluating non union.Treatment - Patients age, morphological features of the fracture, femoral head viability, extent offemoral neck resorption, shortening bone quality and status of auricular cartilage are some importantfactors that need to be discussed.The candidate must know biological procedures which could be taken up in youngerpatients.Ostocotmy of hip eg. Mcmurray and Valgus osteotomies and their pricinple.Fibular graftingand osteosynthesis.Excision arthroplasty in ederly poor females unfit for major surgery, fusion ofhip in poor young labourers with femoral heads; and hemi & total hip arthroplasty in elderly patientswith poor bone stock or avasular necrosis of femoral head should be discussed vis a vis priciplesof treatment.PIVDHistory -Importance of age- Most disc prolapses occur between the age 20 to 40 when the nucleusis juicy and fleshy; Relatively sudden onset of pain with radiation to one or both lower limbs; Reliefof pain on rest and increase of pain on activity; Definite increase of pain on coughing and sneezingwhich raises epidural venous pressure; History of remissions and exacerbations should be elicited;History of weakness and numbness in the lower limbs;Hesitancy of micturition and retentionindicating impending cauda equinqa syndrome; History of neurogemic claudication; past history ofsimilar episodes of pain;Profession e.g. heavy manual labourer.Clinical examination -Spinal asymmetry. Compare the levels of shoulders, rib cage on both sides;Ability to differentiate between spinal list and scoliosis. Relation of the type of list to the anatomicallocation of the prolapse whether shoulder or axillary type; Spinal mobility. Schober’s test. If selectiverestriction of flexion and lateral flexion with normal extension could be demonstrated, it is highlysuggestive of a prolapse; Muscular spasm; Spinal tenderness.Root tension signs viz. SLR- Lasegue’s sign Braggad’s sign;Crossed / Contra lateral SLR; Bowstringsign;Reverse SLR or Femoral stretch sign for higher lumbar prolapses; False positive or falsenegative SLR; Neurological examination of lower limbs; Muscular wasting indicating rootinvolvement; EHL weakness in L5 roots involvement; Quadriceps wasting in L3 root involvement;Gluteal wasting / weakness in S;Check dermatomal sensory loss and detailed dermatomal mappingshould be demonstrated; Perianal / saddle anesthesia to be particularly looked for in cases ofImpending cauda equina compression.Inappropriate signs to check malingering -Flip Test; Burn’s TestAlways check SI joints;Peripheral pulse to rule out vascular occlusive disorders87
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