1. 45 year old female complaint of pain and numbness of the right hand, mainly at night and during working

2. Carpal tunnel syndrome

3. Causes Idiopathic Obesity, Oral contraceptives, Hypothyroidism, Arthritis, Diabetes,. Trauma. Lipoma, ganglion, vascular malformation

4. Treatment Localized corticosteroid injections?????? PT CT Release

6. Triggering thumb or finger Called stenosing tenosynovitis. Idiopathic. Or Congenital Common disorder of later adulthood characterized by catching, snapping or locking of the involved finger flexor tendon, associated with dysfunction and pain.

7. Treatment Cortisone injection A1 poly release (surgically)

8. 1 month old baby girl referred to you from LHC with hip click

9. Developmental dysplasia of the Hip (DDH) Etiology / Epidemiology / Natural History 1/1000 live births, left hip most common More common in children of central European. Etiology: multifactorial, genetic, intrauterine mechanical environment, DDH Risk factors (five f's) first born female family history feet( breech position) fluid(oligohydramnios )

10. DDH Clinical Evaluation Ortolani=out-reduces Barlow=in-dislocates Asymmetric gluteal folds Galeazzi sign: apparent femoral length discrepancy when the legs are held together with the hips and knees flexed. Decreased hip abduction Ambulatory Patient: flexion contracture, gluteus medius lurch, toe walking, increased lordosis if bilateral DDH Associated Anomalies Metatarsus adductus Hyperextended knees / congenital knee dislocation Torticollis

11. Treatment  Age 0-6 m=Pavlik harness  6m-18 m= adductors tenotomy, hip Spica  >18m OR and pelvic osteotomy

12. 5 month

14. Osteomyelitis Acute, Sub acute, or Chronic. The mechanism :exogenous or hematogeneus. Osteomyelitis :pyogenic or non pyogenic In infants, the infection can spread to the joint and cause arthritis. In children, large sub periosteal abscesses can form because of the periosteum is loosely attached to the surface of the bone

15. Pathogenesis leukocytes enter the infected area, and, in their attempt to engulf the infectious organisms, release enzymes that lyse the bone. Pus spreads into the bone's blood vessels, impairing their flow, and areas of devitalized infected bone, known as sequestra, Often, the body will try to create new bone around the area of necrosis. The resulting new bone is often called an involucrum

16. Cause Age groupMost common organisms Newborns (younger than 4 mo)S. aureus, Enterobacter species, and group A and B Streptococcus species Children (aged 4 mo to 4 y)S. aureus, group A Streptococcus species, Haemophilus influenzae, and Enterobacter species Children, adolescents (aged 4 y to adult)S. aureus (80%), group A Streptococcus species, H. influenzae, and Enterobacter speciesAdultS. aureus and occasionally Enterobacter or Streptococcus species Sickle Cell Anemia Salmonella species

17. Osteomyelitis In adults, vertebrae and the pelvis. In children, affects the adjacent ends of long bones. Fungus :The two most common are Blastomyces dermatitidis and Coccidioide immitis. In osteomyelitis involving the vertebral bodies, about half the cases are due to Staphylococcus aureus, and the other half are due to tuberculosis Pott's disease. Pott's disease

18. Symptoms of osteomyelitis Pain and/or tenderness Swelling and warmth Fever Nausea General discomfort, uneasiness, or ill feeling Sinuses

19. Blood tests Blood culture. Needle aspiration Biopsy: Bone scan: Technetium-99 pyrophosphate

20. Treating and managing osteomyelitis Drainage Medications: Splinting or cast immobilization Surgery:

21. Duchenne muscular dystrophy (DMD) Recessive X-linked form of muscular dystrophy, which results in muscle degeneration, difficulty walking, breathing, and death. 1 in 3,600 -4000 boys. Females and males are affected, though females are rarely affected and are more often carriers. Caused by a mutation in the dystrophin gene,dystrophingene

22. male children before age 5 and may be visible in early infancy. Progressive proximal muscle weakness of the legs and pelvis associated with a loss of muscle mass is observed first. Eventually this weakness spreads to the arms, neck, and other areas. pseudo hypertrophy (enlargement of calf and deltoid muscles), low endurance. As the condition progresses, muscle tissue experiences wasting and is eventually replaced by fat and fibrotic tissue (fibrosis). By age 10, braces may be required to aid in walking but most patients are wheelchair dependent by age 12.

23. Cardiomyopathy (DCM), congestive heart failure or arrhythmias A positive Gower's' sign creatinine kinase (CPK-MM) An electromyography (EMG) shows destruction of muscle tissue Genetic testing :genetic errors in the Xp21 gene. A muscle biopsy or genetic test (blood test) confirms the absence of dystrophin,

24. DNA test. DNA testing confirms the diagnosis in most cases. Muscle biopsy A small sample of muscle tissue is extracted (usually with a scalpel instead of a needle) and a dye is applied that reveals the presence of dystrophin. Complete absence of the protein indicates the condition. Prenatal tests

25. Treatment Comprehensive multi-disciplinary care Corticosteroids such as Prednisolone and deflazacort increase energy and strength beta2-agonists increase muscle strength but do not modify disease progression.. Physical therapy Orthopedic appliances (braces and wheelchairs) Appropriate respiratory support

26. 55 years old female

27. Osteoarthritis Idiopathic, primary secondary. Osteoarthritis causes the formation of hard, bony enlargements of the small joints of the fingers Heberden's node, Another common bony knob (node) occurs at the middle joint of the fingers a Bouchard's node

28. Osteoarthritis commonly affects the hands, feet, spine, and large weight-bearing joints, such as the hips and knees

29. Crystal deposits in the cartilage can cause cartilage degeneration and osteoarthritis. Uric acidcrystals cause arthritis in gout, Calcium pyrophosphate crystals cause arthritis in pseudo gout

30. signs you should be aware of include: crepitus restricted movement or range of motion bony enlargement The symptoms include: persistent knee pain short-lived morning stiffness functional limitation

31. Management protect your joints (for example, walking is better for the joints than running). diet and aerobic fitness exercises Range of motion Quadriceps strengthening Patellar taping Lateral heel wedges knee brace for valgus deformity NSAID Intra articular corticosteroids intra-articular hyaluronic acid

32. Arthroscopy Osteotomy

33. Replacement

35. 5 year old child

37. Definitions  Rickets : softening of bones in children due to deficiency or impaired metabolism of vitaminD, calcium or phosphorus, leading to fractures and deformity.  Predominant cause is vit. D deficiency.

38. Rachitic Changes Head  craniotabes(soft skull)  frontal bossing  Widening of suture  persistent fontanelae  Delayed dentition & caries

39. Rachitic Changes  Abdomen  Prominent  muscle weakness  Floppy baby, delayed walking  Pelvis  Narrow inlet

40. Rachitic Changes  Widening of wrist, knee and ankle due to physeal over growth

41. Rachitic Changes  Chest  Rachitic rosary  Harrison groove  Pigeon chest  Respiratory infection and atelectasis

42. Rickets Vitamin D 1,25-OH helps calcium and phosphorous absorption from the intestine, increases kidney reabsorption of phosphorus, and it causes calcium and phosphorus to be released from the bone. Increasing the concentrations of calcium and phosphorus in extracellular fluid causes osteoid cells to calcify. Parathyroid hormone increases the 1-hydroxylation step of vitamin D metabolism and thereby helps regulate calcium metabolism Ultraviolet light in the skin changes cholesterol to Vitamin D3 (i.e. cholecalciferol). Vitamin D3 then is hydroxylated in the liver to make Vitamin D 25-OH (i.e. calcidiol, the circulating reserve metabolite). It then undergoes hydroxylation again in the kidney to Vitamin D 1,25-OH (i.e. calcitriol, the active metabolite).

43. Management  Blood tests  Serum cacium  Serum alkaline phosphatase  Serum phosphorus  Bone x-ray  Other tests  ALP (alkaline phosphatase) isoenzyme  Calcium (ionized)  PTH  Urine calcium  Bone biopsy (rarely done)

44. Management  Target of therapy  Serum calcium : low - N  Serum alkaline phosphatse : high – N  Serum phosphorus : high – N

45. Management Treatment Vit-D deficiency state  Vit D 1,000 – 10,000 IU For 4 – 6 wks.  Vit D 300,000 IU For < 1yr of age.  Vit D 600,000 IU For > 1yr of age.  IM once OR 2 – 4 doses/day orally. All protocols followed by 400 IU/day  Calcium 1g/day.

50. MCQ 1-Acute osteomyelitis is commonly caused by: a. Staph aureus. b. S. pyogenes. c. H. influenzae. d. Salmonella.

51. 1-Acute osteomyelitis is commonly caused by: a. Staph aureus. b. S. pyogenes. c. H. influenzae. d. Salmonella.

52. 2-Acute osteomyelitis usually begins at: a. Epiphysis. b. Metaphysis. c. Diaphysis. d. Any of the above

53. 2-Acute osteomyelitis usually begins at: a. Epiphysis. b. Metaphysis. c. Diaphysis. d. Any of the above

54. 3- What is not True of acute pyogenic osteomyelitis: a. Trauma is a predisposing factor. b. Common infecting agent is Staph. Aureus. c. Infection is usually blood borne. d. All are true.

55. 3- What is not True of acute pyogenic osteomyelitis: a. Trauma is a predisposing factor. b. Common infecting agent is Staph. Aureus. c. Infection is usually blood borne. d. All are true.

56. 4-Tuberculosis of the spine most likely originates from: a. Intervertebral disk. b. Cancellous vertebral body. c. Ligamentous structures. d. Paravertebral soft tissue.

57. 4-Tuberculosis of the spine most likely originates from: a. Intervertebral disk. b. Cancellous vertebral body. c. Ligamentous structures. d. Paravertebral soft tissue.

58. 5-The single most important factor in fracture healing is: a. Correct bone alignment. b. Accurate reduction. c. Immobilization. d. Organization of clot.

59. 5- The single most important factor in fracture healing is: a. Correct bone alignment. b. Accurate reduction. c. Immobilization. d. Organization of clot.

60. 6- If an unstable hip is detected at birth the management policy is: a. Do nothing and re-examine every six months as only minority of hips develop into a persistent dislocation. b. Use a splint to keep the hip joint in 45° flexion and adduction. c. Use a splint to keep the hip joint in 90° flexion and abduction. d. Advise operative stabilization

61. 6- If an unstable hip is detected at birth the management policy is: a. Do nothing and re-examine every six months as only minority of hips develop into a persistent dislocation. b. Use a splint to keep the hip joint in 45° flexion and adduction. c. Use a splint to keep the hip joint in 90° flexion and abduction. d. Advise operative stabilization

62. 7- Anterior dislocation of shoulder may be complicated: By a. Brachial plexus injury. b. Tear of rotator cuff. c. Fracture head of humerus. d. All of the above

63. 7- Anterior dislocation of shoulder may be complicated by: a. Brachial plexus injury. b. Tear of rotator cuff. c. Fracture head of humerus. d. All of the above

64. 8- The most common form of supracondylar fracture humerus in children is of which type: a. Flexion. b. Extension. c. Combination of A & B d. None of the above

65. 8-The most common form of supracondylar fracture humerus in children is of which type: a. Flexion. b. Extension. c. Combination of A & B d. None of the above

66. 9- What is True of Sudeck's atrophy of hand: a. Hand is painful and swollen. b. Osteoporosis of carpals and metacarpals. c. There is increased blood flow to para- articular areas. d. Cervical sympathectomy may be of help. e. All are true

67. 9- What is True of Sudeck's atrophy of hand: a. Hand is painful and swollen. b. Osteoporosis of carpals and metacarpals. c. There is increased blood flow to para- articular areas. d. Cervical sympathectomy may be of help. e. All are true

68. 10- Limb shortening with adduction and internal rotation occurs in which type of hip dislocation: a. Anterior. b. Posterior. c. Central. d. All of the above

69. 10- Limb shortening with adduction and internal rotation occurs in which type of hip dislocation: a. Anterior. b. Posterior. c. Central. d. All of the above

70. 11- Which of the following is not True of intertrochanteric fracture of femur: a. Limb shortening. b. Malunion. c. Avascular necrosis of femoral head. d. Internal fixation is preferred

71. 11- Which of the following is not True of intertrochanteric fracture of femur: a. Limb shortening. b. Malunion. c. Avascular necrosis of femoral head. d. Internal fixation is preferred

72. 12- Idiopathic scoliosis is a a. lateral curvature of the spine b. rotation of the spine c. lateral curvature with rotation of the spine d. flexion deformity of the spine e. congenital disease with hemivertebrae

73. 12- Idiopathic scoliosis is a a. lateral curvature of the spine b. rotation of the spine c. lateral curvature with rotation of the spine d. flexion deformity of the spine e. congenital disease with hemivertebrae

74. 13- A trigger finger is a. an inflamed index finger b. an atrophic index finger in a median nerve palsy c. due to stenosing tenovaginitis affecting one of the flexor tendons in the palm d. an essential feature of the carpal tunnel syndrome e. a component of syndactyly

75. 13- A trigger finger is a. an inflamed index finger b. an atrophic index finger in a median nerve palsy c. due to stenosing tenovaginitis affecting one of the flexor tendons in the palm d. an essential feature of the carpal tunnel syndrome e. a component of syndactyly

76. 14-The most severe growth disturbance results from which of the following types of epiphyseal injuries: a. Separation of the epiphysis at the metaphyseal side of the epiphyseal plate b. Separation of the epiphysis with a triangular fragment of the metaphysic c. Intra-articular fracture involving the articular cartilage epiphysis and epiphyseal plate d. Intra-articular fracture extending from the joint surface through the epiphysis and epiphyseal plate to the metaphysic e. Crashing injuries compressing the epiphyseal plate without displacement

77. 14-The most severe growth disturbance results from which of the following types of epiphyseal injuries: a. Separation of the epiphysis at the metaphyseal side of the epiphyseal plate b. Separation of the epiphysis with a triangular fragment of the metaphysic c. Intra-articular fracture involving the articular cartilage epiphysis and epiphyseal plate d. Intra-articular fracture extending from the joint surface through the epiphysis and epiphyseal plate to the metaphysic e. Crashing injuries compressing the epiphyseal plate without displacement

78. 15- Tears of the meniscus of the knee result from which of the following strain: a. Hyperextension b. Abduction c. Adduction d. Rotation e. Combined flexion and rotation

79. 15- Tears of the meniscus of the knee result from which of the following strain: a. Hyperextension b. Abduction c. Adduction d. Rotation e. Combined flexion and rotation

80. 16- In a football game, an athlete felt severe pain in his Rt knee while turning to the left side with the joint flexed and taking the body weight. Soon after, the joint became swollen and painful but recovery followed rest for 3 weeks. Thereafter, the patient suffered from recurrent locking with pain and a feeling of "giving way" in the joint. The most probable diagnosis is: a. Solitary loose body b. Fracture of the tibial spine c. Rupture of the medial ligament d. Rupture of the medial semillunar cartilage e. Fracture of the patella

81. 16-In a football game, an athlete felt severe pain in his Rt knee while turning to the left side with the joint flexed and taking the body weight. Soon after, the joint became swollen and painful but recovery followed rest for 3 weeks. Thereafter, the patient suffered from recurrent locking with pain and a feeling of "giving way" in the joint. The most probable diagnosis is: a. Solitary loose body b. Fracture of the tibial spine c. Rupture of the medial ligament d. Rupture of the medial semillunar cartilage e. Fracture of the patella

82. 17- The signs of fractured shaft of a bone do not include: a. Swelling b. Deformity c. Loss of all movements in the limb d. Acute localized bone tenderness e. Abnormal mobility in the line of the bone

83. 17- The signs of fractured shaft of a bone do not include: a. Swelling b. Deformity c. Loss of all movements in the limb d. Acute localized bone tenderness e. Abnormal mobility in the line of the bone

84. 18-What is the most common benign soft-tissue tumour in adults? 1.Fibroma 2.Lipoma 3.Hemangioma 4.Schwannoma

85. 18-What is the most common benign soft-tissue tumour in adults? 1.Fibroma 2.Lipoma 3.Hemangioma 4.Schwannoma

86. 19-What is the most common site of metastasis for sarcomas? A.liver B.brain C.Lung D.skeleton

87. 19-What is the most common site of metastasis for sarcomas? A.liver B.brain C.Lung D.skeleton

88. 20-Intestinal absorption of calcium is dependent upon: a. Vitamin D b. Parathoraone c. Calcitonin d. All of the above e. None of the above

89. 20-Intestinal absorption of calcium is dependent upon: a. Vitamin D b. Parathoraone c. Calcitonin d. All of the above e. None of the above