HPI - Patient under Anti Tubercular drugs for last 14 months.
After 6 months of Category 1 treatment for New Pulmonary TB, he again had sputum positive. This was drug resistance. So he was on DR TB treatment for last 8 months.
He developed weakness of limbs for last 2 months.
But weakness is more on upper limbs than lower limbs.
How would you treat this TB patient with progressive weakness?
HPI - The patient has had hip pain ever since a revision THA 17 years ago. The patient reports the pain has worsened the last 30 day.
How would you treat the left (revised) hip?
HPI - No history of ankle or foot trauma.
Started complaining of pain in the ankle and midfoot in 2009, which slowly progressed.
MRI shows a 8mm x 8mm lesion in the talar dome.
How would you treat the osteochondral lesion of the talus?
HPI - During sports activities (basketball) a 17 years old male injured his left knee. He came to my office two weeks later.
How would you treat this patient initially?
HPI - CA and head truma
Would you obtain additional imaging?
HPI - Fall on the ground with pain and deformity of the LT knee. Pt. presents with the injury films show. Closed reduction was performed. See closed reduction below.
What would you do for definitive treatment of the distal femur physeal following the closed reduction films below?
HPI - h/o Bipolar 5 years ago for a femoral neck fracture
sustained a fall 6 months after surgery sustaining a periprosthetic fracture. It was fixed with a locking plate, screws, and cerclage wires.
Has not been able to bear weight for last 4-5 months. No h/o fever or recent trauma.
What is your choice for surgical management of this case?
HPI - 71 year old male who fell on out-stretched hand. Active, otherwise healthy. Patient lives alone and is widowed.
How would you treat this patient?
HPI - 30 year old male status post trauma with right femur fracture
How would you treat this fracture?
HPI - Since childhood
How would you treat this 13 years old boy with neglected DDH?
HPI - Dec 6th, 2015 - Deep laceration to palm of hand (zone III/IV). Ruptured all 8 flexor tendons (except for thumb), severed median and ulnar nerves.
Dec 15th, 2015 - Six-hour long repair; nerve grafting. Immobilized post-op for one week, then transitioned to a splint + passive-active motion.
January 5th, 2016 - Sutures removed, active motion allowed.
February 18th, 2016 - Decent range of motion, a lot of scarring in the palm present. The middle finger is doing best, able to touch the palm. Very good range of motion at all DIP joints. (Please see the attached video).
February 19th, 2016 - At 8 weeks and 2 days post-repair, sudden loss of middle finger tip flexion (DIP). Most likely re-rupture. The range of motion at PIP joint worsens as well. Previous best finger now becomes the worst with the least ROM.
March 1st, 2016 - At about 10 weeks post-repair, able to bend the tip of middle finger if and only if the PIP joint is held down. (Again, video attached). Most likely it was possible all along, just haven't tried/put enough force into it.
What is the possible cause of this new onset middle-finger DIP stiffness?
HPI - Untreated Hoffa's fracture from a car accident February 2014
How would you treat this distal femur nonunion?
HPI - Simple trip and fall whilst mobilising
HPI - pain and swelling staretd gradually two monthes earlier
pain excaserbate with standing walking activity and settle with rest and pain killer
What is the most likely diagnosis?
HPI - ski injury
HPI - Condition started 1 month ago after fall on to the RT hip , with pain, tenderness and limited mobility of the affected hip ,
How would you treat this patient? (HWR = hardware removal)
HPI - Had a tibial fracture on the other side
What is your recommended treatment and why?
HPI - History of injury to left wrist 06 months back while playing handball. Had mild pain following injury but did not went for medical help.
Has mild pain left wrist on excessive activities, load lifting and on extreme of forearm movements.
Right hand dominant female.
HPI - Road side accident 3 days back
How will you treat this patient?
HPI - Pain and swelling in the left mid finger since 9 months. Initially mobile pip jt but now the motion is restricted.had gone to seek medical advice for similar condition 8 months back where she was given dmards and antiinflammatory for 8 weeks. Her past ra factor s uric acid tc dc esr are within the normal range. Her consistent lab findings are decreased haemoglobin 7.6 initialy to 9 gm% now.
HPI - Simple fall 18 months ago which was treated non-operatively.
Able to perform normal daily activities.
What is your recommended treatment?
HPI - Patient presents with 3 months of forearm pain and edema. There is pain with any type of motion.
How would you stabilize the radius?
HPI - Patient 36 yo, male. 4 months ago ACL anatomic ligamentoplasty and partial meniscectomy of lateral meniscus. Due to knee stiffness, 2 manipulations under anesthesia were necessary.
Do you think this is a complete rupture or a partial rupture?
HPI - Pain full right feet for one week following hard exercise
no history of major trauma
What is the most likely diagnosis based on the information provided?
HPI - Right ankle injury ankle 1 day earlier
After closed reduction and application of posterior splint (see Postoperative P1 images below) what would you do for definitive management?
HPI - Pain Bilateral hip joint since 5yrs
What was the likely underlying etiology?
HPI - Condition from birth.Now having difficulties in wearing closed shoes on the right foot
What Manske and Halikis Classification would you assign this?
HPI - Dashboard injury followed by severe pain, loss of movement in the Lt. Hip and inability to walk.
What Pipkin Classification is this fx?
HPI - Restrained driver in an MVC, transferred from outside hospital approximately 5 hours after injury.
What is your recommended treatment for this femoral neck NONUNION (see Postoperative P1 images below)?
HPI - Fall from standing position on a ramp (inclined plane)
What is the best treatment?
HPI - Patient presents with slow and progressive swelling of left thigh that started 9 months ago. The swelling only in left thigh .Equal lower limb length
HPI - History of fracture lateral Malleolus 10 months ago. Treated with ORIF by one third tubular plate and syndesmotic screw. Pt now complains of pain with ambulation
How would you treat this failed ORIF at this time?
HPI - 58M, s/p motorcycle accident 5 weeks ago.
Isolated LEFT shoulder injury.
Has pain and limited function of left shoulder.
Was seen in ER were he was told x-rays where normal, and now follows up after PMD ordered MRI of shoulder.
Shoulder was normal prior to accident.
What x-ray view would have aided in the initial treatment of this patient?
HPI - Inability to weight bear for the last year
Increasing left hip pain over the previous 5 years
Previous left hip surgery in a foreign country > 15 years ago - had mild ongoing hip pain ever since
What type of implant is this?
HPI - History of swelling and discharging wound over the left gluteal region at the age of 2 months. Treated only with dressings. No surgical decompression done. Started walking with a painless limp at 1.5 years of age. Affected limb noted to be shorter.
How would you classify this lesion?
HPI - at the first time pev and then post op pes cavus
The patient is a 4.5 years old male who presents with a postoperative cavus deformity.
Four years ago by report he presented with a pes deformity that was treated with ponseti casting 5 times. This was followed by a posteromedial release when he was in sixth month old.
Now he presents a very rigid foot with pes cavus .
we talk about right foot.
What do you think was the reason the patient presented with Pes Planovalgus that was treated with surgery 4 years ago?
HPI - THR done about 20 years before in USA, patient now in Egypt.
Now, pain and limited movements on right side
What do you think the cause of the patient's symptoms is?
HPI - open floating elbow injury due to MVA
crush between road and car
no other associated injuries like head or chest injuries
How would you treat this injury?
HPI - 13 year-old male experienced trauma two weeks ago and suffered both bone fracture. The patient was initially treated in a long let cast.
Based on the 2 week xrays, how would you treat this pediatric tib-fib fracture?
HPI - Traffic accident 1 year ago
1.- Left femur: Bifocal fracture (shaft and femoral neck) treated with long gamma nail.
2.- Right femur: femoral shaft fracture treated with long femoral nail.
What is your preferred treatment for femoral neck and shaft fracture?
HPI - Trauma. Bicyclist struck by car.
How would you classify this injury?
HPI - 1st surgery 3 Months ago open fracture middle phalanx index finger treated with a mini plate. It resulted in skin necrosis and non union.
2nd surgery reverse cross finger flap and K wire fixation.
How would you have treated this OPEN middle phalanx fracture on INITIAL presentation (see preoperative images above)?
HPI - 10 days old injury left middle finger, treated with finger splint
Would you get a CT scan to determine proper treatment?
HPI - Patient presented with history of pain and pain on the lateral side of both elbows 2 years ago and was missed diagnosed as lateral epicondylitis and was treated with local injection of cortisone.
HPI - 59F with a history of THA revision for loosening, and two subsequent debridements at outside institution complains of L thigh pain and deformity after feeling a snap getting out of bed 3 days ago. Has been non-weight bearing on that side for 1 year per her orthopaedist's recommendations. Started on IV vancomycin 3 weeks ago for "osteomyelitis" of the femur. Lives with husband and daughter. Works as a secretary.
How would you treat the patient at this time (on Vanco for 3 weeks)?
HPI - Motor Vehicle Collision, trauma alert. Hemodynamically stable on presentation. Injuries include rib fractures, small lung contusion, left acetabular fracture, right sided pelvic ring disruption, and left distal radius fracture.
What fracture type is depicted in the preoperative images?
HPI - Run over by a 4 wheeler on 27.12.15. Isolated injury to left leg. Clinical and xrays attached to show the extent of the wound.
How would you treat this acutely following the initial debridement and exploration?
HPI - Grade 1 Open Distal Femoral Fracture Dec 2014. ORIF with short retrograde nail. Failure of Fixation March 2015. Exchange Retrograde Nail with synthetic bone grafting March 2015.
Referred from another centre with ongoing pain now 1 year since original injury/fixation.
CRP 11. ESR 18. No definitive evidence of infection at present.
How would you treat this potentially infected distal femoral non-union at this time (P1 xrays below)?
HPI - Patient was skiing when he fell with a twisting mechanism to left ski, had immediate and severe pain in knee. Went to ER where radiographs done. MRI done shortly after.
MRI report is shown below.
In addition to the plain radiographs above, what additional imaging studies would you obtain to dictate treatment?
HPI - Patient with Parkinson disease, many falls. Fell 2 years ago with a diaphyseal radius fracture operated with a volar plate and healed. Fell again and new fracture on the proximal side of the plate. Non dominant extremity. Xrays show old distal radius fracture with malunion on ipsilateral side of undeterminate age
How would you treat this patient at this time (fx adjacent to hardware)?