image Q. 36 - How's your cuff ?

Q.  A prisoner complained of wrist pain following prolonged handcuff application. He also complains of the hand cuffs too tight. What structure might be affected mostly in this case?

a. Extensor tendons
b. Flexor tendons
c. Radial artery
d. Radial nerve
e. Radial styloid

Answer -
c

Radial sensory nerve entrapment at wrist may be the problem here as it is usually caused by lacerations, trauma or tight cuff or wrist bands.

Brachioradialis and ECRL tendons scissor to compress the nerve in pronation position.

The condition is also referred as ' Cheiralgia paresthetica' or ' Wartenberg syndrome'

image Q. 35 - Trapped

Q.   Below image showing the area ( lighted) of possible nerve compression for which nerve often remembered by the acronym FREAS?


a. Ulnar nerve
b. Radial nerve
c. Median nerve
d. Musculoskeletal nerve
e. Lateral antebrachial nerve

Answer -
b

Radial nerve compression site in upper extremity are easily remembered by FREAS
F fibrous sheath
R recurrent leash of vessels
E ECRB ( extensor carpi radialis brevis)
A arcade of Frohse
S supinator distal edge

image Q. 34 - Whereabout

Q.  Cluneal nerves are found near

a. Scapula
b. Pubic symphysis
c. Coccyx
d. Iliac crest
e. Sacrum

Answer -
d

Superior cluneal nerves are adjacent to posterior iliac crest. They are likely to be injured during bone grafting from posterior iliac crest as they lie beginning about 8 cm lateral  to PSIS ( posterior superior iliac spine) - figure below

image Q. 33 - Think pink

Q.  Pink, pulseless hand is complication of


a. Brachial artery thrombus
b. Vascular injury at wrist
c. Elbow fracture
d. Compartment syndrome
e. Carpal dislocations

Answer -
c

Pink and pulseless hand is often associated with supracondylar humerus fracture in children.
The pink hand suggests viability of circulation despite pulselessness. Various opinions regarding management are present.
Cautious observation coupled with vascular studies are advocated and in case of decreased perfusion early explortion is done.

image Q. 32 - Acronym

Q.  All of the following are widely used acronyms in orthopaedics helpful in remembering important facts except?

a. AMPLE
b. TEAM
c. RICE
d. CRITOE
e. MIPO

Answer -
e

AMPLE is part of clinical history taking from patients and stands for

A Allergies
M   Medications (all relevant)
P    Previous medical/surgical history
L    Last meal (Time)
E    Events /Environment about the injury

TEAM is short for Traction, External rotation, Adduction and Medial ( internal) rotation. This is sequence of manouvre of upoer extremity in order to reduce dislocated shoulder in Kocher's method.

RICE is popular short for Rest, Ice, Compression and Elevation and is related to first aid and initial care of acute musculoskeletal injuries. If we apply plaster and provide Protection to the limb it becomes PRICE.

CRITOE is acronym to remember serial of ossification centres around elbow from first to last in chronology.
Stands for - Capitellum , Radius, Internal ( medial) condyle, Trochlea, Olecranon and External ( lateral) condyle.

MIPO, on the other hand is a surgical procedure that is Minimal Invasive Plate Osteosynthesis. 

image Q. 31 - Muscle power

Q.   The two joint muscles ( muscles crossing two joints) are all except?


a. Biceps brachii
b. Biceps femoris
c. Rectus femoris
d. Semimembranous
e. Semitendinosis

Answer -
b

All hamstring muscles ( semimembranous, semitendinosis and biceps femoris) along with rectus femoris are two-joint/ byarticulate muscles.

Other examples are rectus femoris and gastrocnemius in lower limb and biceps brachii and long head triceps in upper limb.

The catch here is as all options are correct, biceps femoris short head is not two joint muscle thus this one is the answer here in the view of unspecified term used.

image Q. 30 - An eye for detail

Q.  What should be next step in a child complaining pain in one of his knee (left) for last three months and could not recall history of any significant trauma and near normal knee radiograph as shown below?

a. Radiographs of both knees every week
b. Pain medication and assurance
c. Plaster for three weeks
d. Examination of hip
e. No treatment required
f. MRI of knee

Answer -
d

In any patient complaining of unexplained knee pain, it is mandatory to evaluate hip region for any problem as the knee pain might be referred or related to hip pathology as anterior be of obturator nerve supplies to the knee and part of hip.

Radiograph of knee or MRI of knee may also be right option but only after assessing hip as we might require radiograph/ MRI of hip and not knee in many cases.

Assurance and no treatment are not option as they are only prescribed if required and after ruling out any significant disorders of either hip or knee.

The pelvic radiograph ( below) of the same patient showed hip joint decreased space suggesting underlying pathology in ipsilateral ( left side) hip joint highlighting the importance of this question and its answer.

image Q. 29 - Let's play

Q.   All of these prefixes are used for well known sports related injuries except?


a. Runner's
b. Jumper's
c. Gamekeeper's
d. Thrower's
e. Bowler's
f. Stryker's

Answer -
e,f

All the other options are well described sports injury patterns -

Runner's fracture - spiral fracture distal fibula

Jumper's knee - Patellar tendinitis

Gamekeeper's thumb - injury to ulnar collateral ligament of thumb

Thrower's elbow - medial ligamentous strain of elbow, also referred as golfer's elbow or javelin thrower's elbow with strain to ulnar collateral ligament of elbow.

There is no well described injuries with bowler's or stryker's.
There  however is 'stryker's notch' radiographic view for shoulder region to assess recurrent instability due to glenohumeral defects.

image Q. 28 - My foot !!!

Q.  Which of these bone is injured in  'snowboarders fracture' ?


a. Talus
b. Calcaneum
c. Navicular
d. Distal tibia
e. Distal fibula
f. Cuboid

Answer -
a

Common fractures of Talus is neck fractures also called Aviator's fracture due to historical evidence of increased injury in pilots due to strike of foot over foot pedal/ rudders while  landing jerks.

An uncommon injury of lateral process of Talus is known as 'snowboarder's fracture'.

Cuboid fracture on the other hand if comminuted due to axial forces during injury is also termed ' nutcracker fracture'.

image Q. 27 - Bone piece

Q.  Hamulus is anatomical part associated with which bone/ region?

a. Carpal bones
b. Elbow region
c. Tarsal bones
d. Shoulder girdle

Answer -
a

Hamulus or hook is part of hamate, and that is carpal bone ( pointed by arrow in below image as end on projection of hamate hook).

Hook if hamate is characteristic feature of hamate and clinically significant for fracture or its association to Guyon's canal.

image Q. 26 - Muscle power

Q.  The number of muscles attached over the marked bone is ?


a. Five
b. Three
c. One
d. Zero

Answer-
d

The talus has no muscle origin or insertion. The talus is mostly covered with articular cartilage to the tune of 60%.

image Q. 25 - Landmarks

Q.  Which among these is not a part of tibia bone?

a. Plafond
b. Plateau
c. Eminence
d. Gerdy tubercle
e. Adductor tubercle

Answer-
e

The plateau are flat articular  region of proximal tibia on either side of tibial eminence or tibial spine. There are thus medial and lateral tibia plateau. The plafond is distal tibial articular portion. ( see image). So first three options are part of proximal tibia.

Gerdy tubercle is situated at lateral aspect of tibia and is attachment site for iliotibial band.

Adductor tubercle, however,  is part of distal femur above medial cobdyle and is associated with attachment for fibres of adductor magnus. This is important clinical/surgical landmark.

image Q. 24 - Hard drive

Q.    The below mentioned fracture is known as all except?


a. Backfire fracture
b. Barton fracture
c. Hutchinson fracture
d. Chauffeur fracture

Answer-
b

The radiograph depicts fracture of radial styloid. This fracture is also known as Chauffeur or backfire fracture as sudden backfire during start of vehicle may injure the wrist over the car steering to driver ( here association given to a chauffeur driving the car).

Hutchinson fracture is another name for it.

Barton fractures on the other hand are volar or dorsal lip injury of distal radius with interarticular element and are better seen on lateral radiograph of wrist. 

image Q. 23 - Radius injury

Q.  The below image shows fracture of radius diaphysis with deformity. All the deformities require correction by performing opposite action except


a. Shortening
b. Angulation
c. Displacement
d. Bowing
e. Rotation

Answer -
d

The length, alignment and rotation are corrected for good union and outcome.
Radial bowing, however is anatomical characteristic of radius and requires no correction; and in fact the aim of all the treatment is to restore or maintain the normal bowing of radius.