Podcast 024: Orthopaedic Surgery With Dr Saqib Noor

Bones are the putative skeleton of the human body, so it’s important that they’re not broken. Hold on! They actually are the skeleton! That means we need orthopaedic surgery to fix them.

In this episode, Dr Saqib talks about orthopaedic surgery, charitable work and international inequalities in health care.

Podcast

About the guest speaker

Dr Saqib Noor is an orthopaedic surgeon and creative genius.

Dr Saqib has written a book, Surgery on the Shoulders of Giants, describing his life changing experiences as a surgeon in austere settings (http://mybook.to/SotSog) and has used these experiences to help start a new project dedicated to improving global surgery worldwide – One Surgery (https://one.surgery).

Music credits

Opening and closing themes by Lily Chen.

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Salter-Harris Injuries

Salter-Harris is a classification of fractures involving the growth plate. The relevant mnemonic is SALTR.

  1. Solo: only through the growth plate
  2. Above: through the growth plate and above it into the metaphysis, which is the bit of bone towards the shaft of the bone
  3. Lower: through the growth plate and below it, more towards the extreme end of the bone
  4. Through: through the growth plate, as well as above and below it
  5. Rammed: a crush injury that squishes the growth plate

Here is some sage advice.

If you ever have trouble memorising acronyms, there is a simple fix. And that is the power of group study sessions.

Abdominal And Hip Signs In Children

There are many signs of peritoneal irritation.

Rovsing Sign

Palpation of the left lower quadrant elicits pain in the right lower quadrant.

Indication: suspected appendicitis, peritoneal irritation.

Obturator Sign

Passively flex the supine patient’s hip and knee and internally rotate the hip to elicit pain.

Indication: suspected pelvic appendicitis, irritation to obturator muscle.

Psoas Sign

2 options:

  1. Ask the supine patient to flex the hip against resistance to elicit pain.
  2. Ask the supine patient to roll onto their side and passively extend the hip, which stretches the psoas and elicits pain.

Indication: suspected retrocaecal appendicitis, irritation to psoas muscle.

Galeazzi Sign

Have the infant supine, with the hips at 45 degrees and knees at 90 degrees. Look at the height of the knees for asymmetry.

Indication: suspected hip dislocation or congenital femoral shortening.

McBurney’s Point

Pain at the point 1/3 along the line from the ASIS to the umbilicus.

ASIS means anterior superior iliac spine, not a government spy organisation.

That’s the lateral 1/3 point closest to the ASIS.

Indication: suspected appendicitis.

Dunphy’s Sign

When coughing equals pain.

Indication: suspected appendicitis.

References

  1. Gooding, F. (2018). Rovsing’s sign • LITFL • Medical Eponym Library. [online] LITFL • Life in the Fast Lane Medical Blog. Available at: https://lifeinthefastlane.com/eponymictionary/rovsings-sign/ [Accessed 8 Apr. 2018].
  2. MDforAll (2010). Obturator Sign. Available at: https://www.youtube.com/watch?v=jV80jcnhNtA [Accessed 8 Apr. 2018].
  3. MDforAll (2010). Psoas Sign. [image] Available at: https://www.youtube.com/watch?v=n0a0PCwsVQ4 [Accessed 8 Apr. 2018].
  4. Fulford, D. (2018). Galeazzi Test • LITFL • Medical Eponym Library. [online] LITFL • Life in the Fast Lane Medical Blog. Available at: https://lifeinthefastlane.com/eponymictionary/galeazzi-test/ [Accessed 8 Apr. 2018].
  5. Hardin, D. (1999). Acute Appendicitis: Review and Update. [online] American Family Physician. Available at: https://www.aafp.org/afp/1999/1101/p2027.html [Accessed 8 Apr. 2018].

Schober Test

Purpose

The Schober test checks the lumbar flexion range of motion.

Suppose the spine is straight. If it bends forward, like in lumbar flexion, the posterior surface of the back should stretch out to accommodate the movement.

For example, if you have a circle drawn with a thick line, the circumference of the outer side of the line is greater than the circumference of the inner side of the line.

If the posterior back doesn’t stretch out all that much, it means the range of lumbar flexion is limited.

Steps

  • Patient has back facing you
  • Find the level of the posterior superior iliac spine
    • PSIS is roughly at L5-S1 level
  • Make a mark 10cm above that and another mark 5cm below it
    • Memory aid: the higher number is higher up
    • The distance between the points is 15cm
  • Tell patient to touch toes
    • Patient bends over, which is lumbar flexion
  • If the distance between the points is <20cm, there is limited lumbar flexion
    • Alternatively, means the increase in distance from the lumbar flexion movement is <5cm

References

  1. Physiopedia. (n.d.). Schober test. [online] Available at: https://www.physio-pedia.com/Schober_test [Accessed 2 Feb. 2018].
  2. General Practice Notebook. (n.d.). Schober’s test. [online] Available at: https://www.gpnotebook.co.uk/simplepage.cfm?ID=1422917656 [Accessed 2 Feb. 2018].

Thomas Test

Purpose

The Thomas test looks for hip pathology, namely of issues with hip flexor tightness. This is called a fixed flexion deformity.

For example, there could be a problem with the iliopsoas muscle.

Steps

  • Patient is supine on bed
  • Tell patient to bring knees to chest
    • Patient flexes both knees and hips
    • But not excessively so, otherwise it could give a false positive result
  • Lower one leg straight onto the bed
    • If the thigh is on the bed, it is a normal result
    • If the thigh is off the bed, the patient has a fixed flexion deformity of that side

References

  1. Patel, M. (2011). Thomas test. [online] OrthopaedicsOne. Available at: https://www.orthopaedicsone.com/display/Main/Thomas+test [Accessed 31 Jan. 2018].
  2. Physical Therapy Haven. (2018). Thomas Test. [online] Available at: http://www.pthaven.com/page/show/157779-thomas-test [Accessed 31 Jan. 2018].
  3. General Practice Notebook. (n.d.). Thomas’ test. [online] Available at: https://www.gpnotebook.co.uk/simplepage.cfm?ID=120913935 [Accessed 31 Jan. 2018].

Types Of Multiple Sclerosis

Time heals all wounds except relapsing-remitting MS.

And primary-progressive MS.

And secondary-progressive MS.

And whole bunch of other age-related illnesses, like glaucoma, age-related macular degeneration and malignancy.

At least time is good for adhesive capsulitis, alternatively known as frozen shoulder!

Multiple sclerosis

MS is a chronic disease involving immune-mediated attacks on the central nervous system. Demyelination causes mayhem.

As a parallel, Guillan-Barre acutely affects the peripheral nervous system. When it’s chronic, it’s called chronic inflammatory demyelinating polymyopathy.

Symptoms

Neurological symptoms ensue after the disease has passed a threshold.

  • Optic neuritis, characterised by painful visual loss in an eye
  • Numbness, weakness
  • Ataxia, spasticity
  • Fatigue
  • Pain
  • Sexual and urinary dysfunction, such as detrusor overactivity causing urgency

Clinically isolated syndrome is a one-off presentation of demyelination that can progress to MS.

Investigations

MRI can show brain lesions.

CSF analysis can show inflammation.

Evoke potential measurement can show demyelination.

Treatment

Ongoing: immunotherapy agents.

Acute relapse: high-dose corticosteroids.

Spasticity: baclofen

Spasms: benzodiazepines

Mobility: fampridine

Paroxysmal symptoms: carbamazepine

Urinary symptoms: oxybutynin

Pregnancy

The risk of MS relapse is lower during pregnancy and higher in the first 3 months after giving birth.

Summary of major demyelinating illnesses

Central nervous system: clinically isolated syndrome (acute), MS (chronic)

Peripheral nervous system: Guillan-Barre (acute), CIDP (chronic)

References

  1. MS Australia. (2001). Types of MS | MS Australia. [online] Available at: https://www.msaustralia.org.au/about-ms/types-ms [Accessed 20 Jan. 2018].
  2. National Multiple Sclerosis Society. (n.d.). Definition of MS. [online] Available at: https://www.nationalmssociety.org/What-is-MS/Definition-of-MS [Accessed 20 Jan. 2018].
  3. Johns Hopkins Medicine. (n.d.). Guillain-Barre and CIDP. [online] Available at: https://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/peripheral_nerve/conditions/guillain_barre_and_cidp.html [Accessed 20 Jan. 2018].
  4. Multiple sclerosis. In: eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited (eTG November 2017 edition); 2017 Nov.

American Compact Disc

Colles and Smith fractures are both fractures of the distal radius.

Colles fracture

  • Dorsal angulation of the fractured fragment
  • Memory aid: CD

Smith fracture

  • Volar angulation of the fractured fragment
    • Volar means palmar
  • Memory aid: VS almost looks like US, which is quite American

And that’s how an American CD is made.

References

  1. Luijkx, T. and Desai, P. (2018). Colles fracture. [online] Radiopaedia. Available at: https://radiopaedia.org/articles/colles-fracture [Accessed 15 Jan. 2018].
  2. Luijkx, T. and Gaillard, F. (2018). Smith fracture. [online] Radiopaedia. Available at: https://radiopaedia.org/articles/smith-fracture [Accessed 15 Jan. 2018].