image based Q. 68 - Cast split

Q.  How much pressure should we expect to drop if plaster of Paris cast is cut in below case?

a. 20%
b. 50%
c. 10%
d. 30%
e. 60%

Answer -
d

 The picture depicts unilateral cutting of cast (i.e. univalving).

Cast splitting relieves pressure in the setting of suspected compartment syndrome in the given degrees.

Univalving - 30% pressure drop and bivalving leads to 60% pressure drop.

image based Q. 67- Castaway

Q.  A baby undergoing corrective casting for the correction of clubfoot has been applied 13 plasters but correction doesn't seem to improve lately and there is swelling of foot on each cast removal. The parents also complain of slipping of the cast noticeable for last few occasions. Which among these would be best option to treat such case?


a. Modification of casting technique
b. Apply loose plaster next time
c. Apply more pressure on casting for speedy correction
d. Do not apply cast
e. Prepare the child for surgical correction

Answer -
d

Slippage of cast and static correction with swollen and often painful foot suggests 'atypical clubfoot'.

The loose and improperly moulded cast leads to slipping of feet inside and that impinges over toes leading to swelling and pain. Thus loose plaster or extra pressure won't help here (option b and c).

Modification of casting is not acceptable as casting follows standard prescribed methodology.

Surgical option is not required for correction in most cases and is limited for certain indications only.

Leaving foot free without cast for 6-8 weeks or till swelling and edema is reduced ( i.e. cast holiday) is best option.

 Casting is resumed after abovementioned status is achieved.

image based Q. 66 - Identity crisis

Q.  A case of psychiatric disorder named BIID ( body identity integrity disorder) is presented to orthopaedic clinic for opinion regarding which feature?


a. Charcot's joint
b. Self mutilation
c. Factitious illness
d. Fake joint pains
e. Amputation
f. Excessive fitness consciousness

Answer -
e

The patient with BIID consults orthopaedicians for amputation of his/her normal limb. The disorder consists of patient's perception of his/her normal limb (certain part or whole) as abnormal, alien or worst belonging to someone else rather than his/her own.
The patient can exactly delineate the level from which that body part appears alien to him/her. The patient bears so much psychological burden that he/she wishes to happily remove it and are often 'cured' after the consented amputation. Thus amputation has a therapeutic effect in these individuals.

image based Q. 65- Preventing HO

Which of these therapy is not  helpful in reducing chances of heterotrpic ossification after major trauma in vulnerable places?


a. Naproxen
b. Etodolac
c. Radiation
d. Indomethacin

Answer -
a

Indomethacin has been linked to decreased chances of HO after major trauma and

recent research has shown etodolac also work similarly in sports injuries.

Radiation in single dose also has been associated with same objectives.

image based Q.64 - Matter of heart

One of the patient of orthopaedics was cancelled for surgery due to a transient condition mimicking acute myocardial infarction. The name the  condition takes origin from a Japanese pot used to catch which one of the seafood?


a. Oyster
b. King Crab
c. Octopus
d. Molluscs
e. Turtles

Answer -
c

A temporary acute stressful condition mimicking acute MI with ST elevation is known as 'Takotsubo Cardiomyopathy'.

 The Japanese pot 'tako-tsubo' is used by fishermen to trap octopus.

The condition is also called 'broken heart syndrome', 'Stress cardiomyopathy', Transient atypical ballooning syndrome' etc.

image based Q. 63. Going Places

Q. Given places have interesting history of their connection with orthopaedic milestones/events. Which two of these are non-operative with huge economical benefit to society at large?


a. Florida
b. Iowa
c. Uganda
d. South Carolina
e. Kurgan

Answer -
b,c.

Moore developed his posterior approach to hip joint for arhroplasty in South Carolina, henceforth the posterior approach to hip joint is also referred to 'southern approach' at times.

Iowa has been working place of renowned Dr Ponseti, who worked entire life in perfecting corrective casting techniques for treating clubfeet. His approach now is most preferred conservative method for clubfoot management.

Florida has witnessed many stalwarts like Dr Dror Paley, who has been instrumental in disseminating art and science of deformity corrections internationally.

Kurgan, a place in Russia (earlier USSR) was made famous by one Dr Gavriil A. Ilizarov, who invented his method of distraction osteogenesis which has since been benefited society by its versatility and effectiveness in myriad musculoskeletal disorders.

Rural Uganda is place where high cost of braces for clubfeet inspired Michael Steenbeek to make light and inexpensive brace out of locally available material for clubfeet now widely used as Steenbeek foot abduction brace (SFAB) that cost a fraction ( approx USD 7) as compared to other braces (in the range USD 400 and beyond).

image based Q.62- Guess who part 1

Q. Identify the notable personality in Orthopaedics credited for his path breaking work ?



a. Martin Kirschner
b. John Charnley
c. Gerhardt Kuntscher
d. Gavriil Ilizarov
e. Abraham Colles

Answer -
d.

Gavriil A. Ilizarov was a russian doctor who discovered the principal of distraction osteogenesis with ring fixators now popularly known as Ilizarov fixators. The technique has wide and versatile implications for various disorders. He made a small city Kurgan a world renowned centre and is often referred with epithets like  'magician from Kurgan' among others.

Martin Kurschner is known for smooth metallic wires with pointed ends 'K- wire' or Kirschner wire. These are one of the most widely used implants in orthopaedics.

John Charnley is hailed as pioneer of joint replacement arthroplasty.

Gerhardt Kuntscher, a German doctor has been instrumental in paving path for intramedullary nailing initiated with his version of nail known as K- nail or Kuntscher's cloverleaf intramedullary nail.

Abraham Colles is known for an eponymous fracture that results from fall in elderly and involves distal radius with specific deformity.

image based Q.61 - Bracing up

Q. Which of these places is not associated with orthosis/brace to its name?


a. Malibu
b. Miami
c. Philadelphia
d. Nebraska
e. Yale

Answer -
d

Most of the mentioned places have cervical orthosis in their name;
Malibu brace,
Miami brace,
Philadelphia collar,
Yale brace etc.
 
 except Nebraska.


 May other notable braces are -

-  Boston brace thoracolumbar disorder,
  -Milwaukee brace for scoliosis ,
 -UCLA (University of California Los Angeles) foot braces etc.

image based Q.60 - Imperfect match

Q.- Which one of these is mismatched? (These are disorders matched with relevant instruments used to measure/diagnose/treat them).


a. Dynamometer - Grip strength
b. RIA (reamer irrigator aspirator) - Fracture nonunion
c. KT 1000 - Ligament testing
d. MARS - Infection

Answer -
d

MARS or metal artifact reduction sequence is specialised MRI scan used to perform in condition when metallic implants is in situ.

KT 1000 is used in diagnosing ligament injuries like ACL, PCL etc.

RIA is used to extract bone marrow from medullary cavity of long bones through reaming and is helpful in nonunion.

Dynamometer is used for measuring hand grip strength eg. Jamar dynamometer

image based Q.- 59 - Hip secret

Which among these has least clinical implication on  hip joint structure or function ?


a. Pulvinar
b. Quadrilateral plate
c. Sourcil
d. Teardrop
e. Cam bump

Answer -
e

Pulvinar is fibrofatty tissue over part of acetabulum fossa and quadrilateral plate bony part overlying the acetabular roof that makes for medial part of acetabulum; so both these are related to joint.

Sourcil is identified subchondral part of edge of acetabulum, sclerosis of which denotes stress and defective aetabular labrum thus indicates hip dysplasia.

Teardrop is radiological landmark made by projection of bony ridges running along floor of acetabular fossa and thus may have certain bearing on hip joint anatomy and function.

Cam lesion are structural deformity of head neck junction often with a bump seen radiologically and is responsible for femoro-actabular impingement (FAI). These have later bearing as precursor to hip arthritis but may be closest option here.

(The option c, d and e depicted here)

image based Q. 58- Thanks to NASA

Q. Which among these technology used in Orthopaedics has been inspired by working of NASA in space missions?

a. Carbon fibre
b. PEEK (polyether ether ketone) material
c. Low level laser therapy (LLLT)
d. Tentalum ( rare earth metal)

Answer -

LLLT used for alleviation of pain and inflammation has been inspired by astronauts as they used low lights LEDs in the space.

Carbon fibre is strong but light material used for making various implants and prosthesis.

PEEK is newer materials widely used in Orthopaedics implants like spine surgery etc..

Tentalum is rare earth metal used in hip arthroplasty procedures.

image based Q. 57 - Renamed

Q. Which of these is an atypical cartilaginous tumor (ACT) ?


a. Chondrosarcoma
b. Chondromyxoid fibroma
c. Chondroblastoma
d. Giant cell lesion

Answer -

Chondrosarcoma grade 1, have been recently renamed as 'atypical cartilaginous tumor' by WHO. These are usually do not turn into malignant chondrosarcoma but may be locally aggressive.

image based Q. 56- Angles inside heel

Q. All of these are angles can be related to the below fracture except?


a. Tuber angle
b. Neutral angle
c. Bohler angle
d. Critical angle
e. Gissane angle

   

Answer -
b

The angles related to calcaneum are asked here. Critical angle and Gissane angle are synonyms and similarly tuber and Bohler angles are synonymous. The area underneath lateral talar process is composed of sparse bone and is called 'neutral triangle'. It thus is similar to Ward's triangle in hip where bone density is minimal.

image based Q.55. Nerve name

Q. Furcal nerve is which of the given option?

a. L 1
b. L 2
c. L 3
d. L 4
e. L 5

Answer .
Furcal nerve is formed by anomalous contribution from L 4 nerve as it's ventral branch.

image based Q.54- Elbow surgery

Q. Which position of forearm is safer to keep while operating on below anatomical site of forearm bones ?


a. Pronation
b. Supination
c. Flexion
D. Extension

Answer -

The proximal forearm region especially radius has posterior interosseous nerve (PIN) as adjacent structure , pronation of forearm is supposed to put the nerve away from operating field during common surgical approaches.

image based Q.53- Hip pointers

Q. 'Hip pointers' are referred to injuries to which underlying structures?


a. Acetabular labrum
b. Trochanter tips
c. Ischial tuberosity
d. Prominent gluteal region
e. Iliac crest

Answer -

Iliac crest contusion are also called 'hip pointers'. Diagnosis requires clinical correlation and use of MRI in doubtful cases.

image based Q.52-Eelbow fracture

Q. Which among these may not be a classic feature associated with below mentioned fracture in a child ?


1. Sail sign
2. Pucker sign
3. Fish tail sign
4. Crescent sign
5. 'OK' sign

Answer -
 c

The radiograph shows supracondylar fracture of humerus in a child (extension type).

'Sail sign' represents black shadow over the distal humerus cortex and is also referred as 'fat pad sign' that is more extensive in shape.

'Pucker sign' is a clinical sign of displaced extension type supracondylar fracture, when proximal fragment is displaced anteriorly by penetrating brachialis muscle and presents as anterior puckering of skin.

'Crescent sign' is overlapping of normal capitellum epiphysis with olecranon part of ulna, represnting malrotated fracture.

Anterior interosseous nerve is commonest nerve injury associated that presents with inability to oppose index and thumb to form a 'OK' sign.

'Fish tail' sign represents osteonecrosis of trochlea that gets resorbed and distal humerus takes shape of a fish tail on radiograph.

image based Q. 51- Hip structure

Q. Which of these structure is used by some surgeons as guide to place acetabular component rightly during total hip replacement surgery?

1. Pulvinar
2. Actabular labrum
3. Transverse acetabular ligament
4. Capsular attachment

Answer -
Transverse acetabular ligament (TAL) is used out of all options to place acetabular component in right version and inclination.

image based Q. 50 - Injury to growth plates

Q- Regions of physis not interfered in below injury are all except?




a. Endochondral ossification
b. Germinal Zone
c. Proliferative Zone
d. Articular surface
e.Hypertrophic Zone

Answer -
a and e

The metaphyseal fragment in the given image (Arrow) suggeste type 2 Salter -Harris physal injury. The fragment is called Thurston- Holland sign/fragment. 
All except a and e are not involved thus the prognosis is better in these fractures while managed by simple closed reduction and splinting.

image based Q. 49- drug reaction

Q. The in-patient in Ortho ward undergoing treatment for chronic infection noticed erythema, flushing, rashes over face and upper torso. Which of these agent/drug might be responsible for the adverse reaction ?


a. Linezolid
b. Aztreonam
c. Daptomycin
d. Vancomycin

Answer -
d.

The rapid infusion of Vancomycin is reported to cause above symptoms alongside hypotension and shock-like state, also referred to as "red neck syndrome".

image based Q.48- Elbow ligaments

Q. Which of these is not a part of lateral elbow ligaments depicted in below pic?



a. Radial collateral ligament
b. Lateral ulnar collateral ligament
c. Cooper's ligament
d. Accessory ligament

Answer -
C
The lateral ligament complex of elbow consists of four ligaments - LUCL( lateral ulnar collateral ligament), Accessory ligament, Radial collateral ligament, and Annular ligament. - mnemonic LARA.

Medial ligaments, on other side, are three in number - Anteromedial collateral ligament, Posteromedial collateral ligament and transverse or Cooper's ligament.

Image based Q. 47- Absent bone

Q. Which of the basic blood investigation is deranged in one syndrome associated with absent bone in below patient (i.e. radius)?



1. Red blood cells
2. Monocytes
3. Eosinophils
4. Platelets

Answer -
D

TAR syndrome that is Thromocytopenia and Absent Radius is a peculiar congenital disorder associated with variable absence of radius bone and thrombocytopenia presenting as heammorhagic complications.

image based Q. 46 - Two surfaces

Q. - 

‘Tribology’ is science of interactive surfaces in relative motion. Joint replacement prosthesis are often  studied in this. It incorporates concepts of all except?

1.       Lubrication

2.       Friction

3.       Fabrication

4.       Wear

Answer - 3,

Wear, lubrication and friction are key components of study of tribology

image based Q. 45- Absent bone

Q. - Anomaly with absence of this bone may be related to which of these gene locus?

1.       BMP (Bone Morphogenic Protein) receptor

2.       TGF beta 1

3.       PIT- X1

4.        RUN X 2

 Answer -

 The bone depicted here is clavicle.

Congenital absence of this bone is  a feature of disorder called ‘Cleidocranial dysplasia’ . 

RUNX 2 is reported to be linked with Cleidocranial dysplasia, the disorders with absent clavicle.

image based Q. 44 - Finger deformity

Q. The below case had radial  and palmar deviation of little finger noticed from early in life? Which of the option fits as the anomaly in this case?


1. Camptodactyly
2. Clinodactyly
3. Delta phalynx
4. Kirner deformity

Answer-

The Kirner deformity consists of radiovolar deviation of finger usually the little one.

The cantodactyly is flexion deformity at pip joint as a result of saggital plane angulation while clinodactyly is coronal plane sidewise deviation.

Delta phalynx is different anomaly diagnosed radiologically as the phalynx usually thumb has a separate wedge shaped extra bone.

image based Q. 43 - child with bowed legs

Q. Which among the below test would be necessary for further clinical evaluation of the given case?




1. Hip external rotation
2. Knee extension
3. Knee flexion
4. Foot thigh angle

Answer -


Knee flexion would determine whether the bowing (genu varum) is due to femoral or tibial cause. Femur causes usually get corrected on knee flexion, while the tibial causes persist in deformity.

Hip external rotation is important in slipped capital femoral epiphysis cases where external rotation in affected side is more (one of very few conditions as most hip pathologies have restricted motion)

Hip thigh angle is measured to ascertain anteversion deformities of proximal femur in children with in-toeing gait..

image based Q. 42- Implant composition

 Q.  The implant used in given picture is composed of all except ?


1. Nickel
2. Vanadium
3. Titanium
4. Aluminium

Answer - 
Nickel



The picture depicts an intramedullary  nail used in pediatric femur fracture fixation thus appears as TENS. TENS stands for Titanium Elastic Nailing System. The implant is made of titanium  which is commonly composed of Titanium along with Aluminium and Vanadium (Ti-Al-6V).

Stainless steel implants used in orthopaedics are mostly made of steel grade 316L. here L stands for Low carbon. It has many alloys and nickel is one of them


Nickel is common cause behind metal hypersensitivity to metal implants.