image Q. 47 - White boot

Q.  The below image showing plaster applied is likely to be for which injury?

a. Metatarsal fracture
b. Calcaneum fracture
c. Distal tibia fracture
d. Hip fracture

Answer -
d

The below knee plaster cast as seen in picture is coupled with a wooden scale and this arrangement is known as ' boot and bar' in which a bar or scale  is used to check or maintain the rotation of the limb and the boot it plaster cast is supporting the bar or  helps in giving traction through it.

This old method of conservative treatment is now only reserved to treat cases of mainly hip region like intertrochanteric fracture in cases that are not fit for surgery due to comorbidities.

image Q. 46 - Now you see me

Q.   Which of these is not a plain radiographic technique or radiographic view?


a. Stress view
b. Traction view
c. Subtraction view
d. Weight bearing view

Answer -
c

Stress views are taken with putting external forces over desired anatomical reason  to recreate position of pathological laxity due to any reason. eg. stress view of ankle or knee to demonstrate ligamentous injury etc

Traction views are done to clarify images in  radiographs to show better anatomical details eg. comminuted fractures if seen in normal radiograph don't clearly show fracture details like number and pattern of fracture fragments etc. Traction given to extremity disengages fragments and is helps evaluate fracture pattern better. The only caveat is that it is painful in acute traum settings and may require anaesthesia at times.

Weight bearing views are done in weight bearing structures to simulate loading posture and clearfies things in some disorders eg. weight bearing radiographs for knee, ankle or foot regions.

Subtraction imaging is great tool to know details that conventional overlap of structures hide. digital subtraction helps us look into those sites such as inside joint or behind a complex bony anatomy. This process is not possible in plain radiography and requires advance imaging like CT scan.

Image Q. 45 - Breaking bread

Q.   Which of these is the treatment of a case of pathological lesion in proximal tibia (image below) diagnosed as giant cell tumor?

a. Intralesional phenol
b. Curettage and bone cement
c. denosumab therapy
d. Sandwich procedure

Answer -
d

The case here is of a GCT of  tibia extending till articular margin proximally.

Sandwich procedure in which the articular part of joint is preserved and seperated from cement filling the cavity after extended currettahe by a layer of morsellised bone graft and gelfoam. Gelfoam acts as protective barrier of articular surface from heat of cement and graft later helps reduce joint destruction (the schematic diagram below).

 Denosumab is a RANKL (receptor activator of nuclear kappaB ligand) inhibitor. Giant cells are rich in RANKL that in turn causes osteolysis and destruction, inhibition of which, as done by denosumab, result in improved bone quality and structure.

It has been shown good results in studies but is not an option here for the lesion is larger here and probably in neglected status thus making conservative plan not preferable. The intralesional phenol and currettage with only bone cement is not correct option her for the similar reasons.

image Q. 44 - Death race

Q. The terrible triad of death consists of all except ?

a. Hypotension
b. Coagulopathy
c. Acidosis
d. Hypothermia

Answer -
a

Terrible triad of death results from complication of  polytrauma and comprises of :
hypothermia,
Metabolic acidosis and
coagulopathy.

image Q. 43 - Homeland

Q.   When knee goes from flexion to extension the tibia -


a. Externally rotates
b. Internally rotates
c. Remains neutral
d. Rotates and then comes back
e. Goes into anteroposterior translation

Answer -
a

As the knee is reaching full extension to stand upright ( stance phase), the tibia externally roates to lock the knee and tightens cruciate for stable knee whereas in swing phase it goes into internal rotation relative to native femur.

This phenomenon is called ' screw home mechanism' of the knee.

image Q. 42 - Ablation

Q.   A young adult complains of pain in upper thigh in night and have been advised radio frequency ablation for the management of the problematic condition causing the symptoms. Which might be the most likely etiology ?

a. Ivory osteoma
b. Osteoid osteoma
c. Ostefibrous dysplasia
d. Chondroma
e. Osteoblastoma

Answer -
b.

Osteoid osteoma has characteristic night pain that gets dramatically relieved on taking NSAIDS. The radiograph also depicts localised cortical growth, however, CT scan in thin section around the lesion is better I investigation.

The percutaneous radio frequency ablation is widely considered as treatment of choice in cases if osteoid osteoma. That's why this should be the lesion.
Apart from it , one interesting g clue in the question is night pain. Pain in the night that is drastically improves on taking NSAIDS is characteristic feature of osteoid osteoma.

image Q. 41 - Wad's that ?

Q. The lateral bulging area of upper forearm region, which is often referred to the ' mobile wad' ( colored part in below image) consists of all muscles except?

a. Extensor carpi radialis longue
b. Extensor carpi radialis brevis
c. Extensor pollicis long us
d. Brachioradialis

Answer -
c

The mobile wad or ' mobile wad of Henry' consists of all three muscles except extensor pollicis longus.

The anterior (volar) approach to upper extremity is also called Henry's approach.

image Q. 40 - Opposites attract

Q.  'Reverse arthroplasty' is performed in which joint?

a. Shoulder
b. Elbow
c. Wrist
d. Ankle
e. Hallux

Answer -
a
In certain cases of  shoulder joint arthritis with associated rotator cuff artgropathies is managed well by reverse shoulder arthroplasty. This has biomechanical advantage over conventional shoulder arthroplasty in these settings.

image Q. 39 - Outlaw

Q. Extrusion is named for complete prolapse of intervertebral disc into spinal canal. Apart from it, the extrusion of which of the bones in below radiograph is well described injury?

a. Navicular
b. Calcaneum
c. Cuboid
d. Talus
e. Medial cuneiform

Answer -
d

Total Talar extrusion is rare injury in which the talus is dislocated and is outside with the skin and soft tissue defect and  mostly with gross contamination. The management consists of good lavage, debridement and reposition of talus as per surgeon's descretion and judgement with guarded prognosis.

image Q. 38 - Mass effect

Q.   'Lateral mass' is feature of which bone ?


a. Talus
b. Calcaneum
c. Vertebra
d. Pelvis
e. Sacrum
f. Lateral condyle

Answer -
c

The lateral mass, two in number are features of First vertebra ( Atlas vertebra or C1). This is unique bone as it has no vertebral body and is ring like structure with two lateral mass. Lateral mass is important structure in surgical fixation of fracture around this region

image Q. 37 - Weekend blues

Q.  ' Weekend warrior' injuries mostly involve

a. Muscles
b. Tendon
c. Bone
d. Cardiovascular system
e. Compartments

Answer -
b

Weekend warrior injuries are injuries sustained to unaccustomed, excessive physical activity ( long and demanding activities duribg weekends etc).

Excessive stress give rise to host of musculoskeletal problems most notably tendon injuries like Achilles tenon , patellar tendon etc..