List of long cases:

1. PLID
2. Knee instability
3. TB hip
4. TB spine
5. Shoulder dislocation
6. GCT
7. Osteosarcoma
8. Ewings sarcoma
9. Metastatic tumours
10.Perthes/ AVN
11.CP
12.Poliomyelitis
13.ACL injury
14.VIC
15.Habitual dislocation of patella
16.Ankylosing spondylitis
17.Chronic osteomyelitis
18.Nonunion
19.Scoliosis

PLID
Mr hamidul, 45 yrs businessman from chandpur, admitted in nitor on
3.3.15 with the complaints of
a.LBP for 1 yr
b. Difficulty in walking for the same duration
c. Tingling, Numbness of Rt lower limb for the same duration

History of present illness: according to the statement of the

patient, he was relatively well 01 yr back. Then he developed low back
pain. The pain initiated during weight lifting. Initial 3-5 days pain was
severe in nature and gradually pain radiate to gluteal region,
posterolateral thigh, leg and dorsum of foot. Pain aggravated by
sneezing, coughing and straining and pain relieved by taking rest in
lying position and analgesic. He also developed difficulty in walking for

last 01 yr. moreover, he developed tingling, numbness of lt lower limb

for the same duration. His symptoms are worsening day by day.
He had no history of wt loss, anorexia, heamoptysis, cough, chest pain
or evening rise of temperature.
He is normotensive, non asthmatic and non diabetic.
His bowel and bladder habit is normal.

History of past illness:NS

Family history: NS
Socioeconomic history: low
Allergic history: NS
Immunization history: immunized as per EPI schedule
On examination:
General exam:
Pulse-72b/min
BP-120/70 mm of Hg
Temp-normal
Anaemia-absent

Local exam:
look from the frontshoulder drooping(axillary type-same side, in shoulder type-opposite
side)
muscle wasting present in lt thigh
patient can walk heel with difficulty
gait

look from the side: lumber lordosis

look from back: list of lt side
no scar mark

slight gluteal muscle wasting

squatting possible
gait-antalgic
pelvic tilting-lt
Feel:
Mild tenderness at lower lumber region
No stepping is present
No wasting of back muscles
Move
Heel walking : not possible
Toe walking: possible
Sensory: paresthesia at L4, L5, S1 dermatome
Motor: EHL(MRC-3/5)Rt
FHL(MRC-5/5)Rt

Jerk: ankle jerk-normal

knee jerk-normal

Special test
SLR:

Right-70o

Left -90o

Cross SLR: (-)ve

Bowstring test: +ve
Fazerstazan test:+ve
Lasegue test:+ve
Sicards test:+ve

KNEE INSTABILITY
Mr hamidul, 45 yrs businessman from chandpur, admitted in nitor on
3.3.15 with the complaints of
a. Giving away of right knee and feeling of insecurity while walking for
01 yr

History of present illness: according to the statement of the

patient, he was relatively well 01 yr back. He gave history of twisting
injury during playing football and heard a pop sound. He could not
continue the game and with the help of other people he was sent to
local clinic. He noticed swelling at his right knee immediately after the
injury. There is no problem on climbing stairs and no history of locking
of right knee.

On examination
Look from the front:
Quadriceps wasting
Gait normal
Feel:
Local temp-normal
Tenderness-joint line absent

Wasting
Neurovascular status-normal
Move:
Knee flexionExtension-

Special test:

Stand on one leg:

Test for hyperextension:
Varus-valgus stress test: at 300 flexion(isolated tear of collateral
ligament)
and knee straight(capsule, collateral and cruciate ligament)
Anteroposterior stability: knee 900 look from the side-posterior sag
Anterior drawer test
ADT with 150 external rotation
ADT with 300 internal rotation
Posterior drawer test
Lachman test
Mc murreyst test
Thessaly test
Pivot shift test

MENISCUS INJURY
Mr hamidul, 25 yrs businessman from chandpur, admitted in nitor on
3.3.15 with the complaints of

a. pain in left knee for 01 yr

History of present illness: according to the statement of the

patient, he was relatively well 01 yr back. He gave history of twisting
injury during playing football. Knee swelling appeared after 12 hr. with
rest his symptoms subsided. Occasionally his knee locks for last 08
months.

On examination
Look from the front:
Quadriceps wasting
Gait normal
Feel:
Local temp-normal
Tenderness-joint line present
Wasting
Neurovascular status-normal
Move:
Knee flexion-full
Extension-slightly limited

Special test:
Knee effusion-+ve
Varus-valgus stress test: at 300 flexion(isolated tear of collateral
ligament)
and knee straight(capsule, collateral and cruciate ligament)
Anteroposterior stability: knee 900 look from the side-posterior sag

Anterior drawer test

ADT with 150 external rotation
ADT with 300 internal rotation
Posterior drawer test
Lachman test
Mc murreyst test +ve
Apleys grinding test+ve
Thessaly test+ve
Pivot shift test
TB HIP
Mr hamidul, 45 yrs businessman from chandpur, admitted in nitor on
3.3.15 with the complaints of
a.Pain in right hip for 01 yr
b. Difficulty in walking for the same duration
history of present illness: according to the statement of the patient
he developed pain in his rt hip for 01 yr and he faces difficulty in
walking for the same duration. Pain is insidious in onset with aching in
groin and thigh, continuous, dull aching and increased at night, which
make him awake from sleep. It is aggravated by movement but
relieved with analgesic. He also complains of limping for last 01 yr. He
has history of evening rise of temperature, night sweat and wt loss.
On examination:
Hip is flexed, adducted and internally rotated.
Muscle wasting present
Hip movement-all movement are restricted.
x ray:

general rarefaction but normal joint line and space

femoral epiphysis may be enlarged
bone abscess may be visible
destruction of acetabular roof-wandering acetabulum
destruction of femoral head
destruction of both(usually)
joint may be subluxed or even dislocated
with healing bones recalcify
TB spine:

Mr hamidul, 45 yrs businessman from chandpur, admitted in nitor on

3.3.15 with the complaints of
a. back pain for 01 yr and generalized weakness for 01 yr
b. Difficulty in walking for 06 months
history of present illness: according to the statement of the patient
he developed back pain for 01 yr and he faces difficulty in walking for
the same duration. Pain is insidious in onset with continuous, dull
aching and increased at night, which make him awake from sleep. It is
aggravated by movement but relieved with analgesic. He also
complains of abnormal sensation and weakness in his both lower limb
for last 01 yr. He has history of evening rise of temperature, night
sweat and wt loss.
On examination:
Look: patient cant stand comfortably
Gait: clumsy
He can squat
Feel:
SLR: normal

Sensory: diminished from L2 level

Motor: all muscle of lower limb weak: mrc-3/5
Tone- increased
Jerks-exaggerated
Clonus-present
Pump handle test
Hip movement
Move: movement of spine is normal
x ray:
early:
local osteoporosis of two adjacent vertebrae and narrowing of intervertebral
disc, fuzziness of the end plate.
Progressive: sign of bone destruction and collapse of adjacent vertebral
bodies. Paraspinal soft tissue shadow
Chest x ray.
MRI
CT scan
Mantoux test
ESR
FNAC
d/d:
pyogenic infection
malignant disease
parasitic infection

RECURRENT SHOULDER DISLOCATION

Mr hamidul, 25 yrs businessman from chandpur, admitted in nitor on

3.3.15 with the complaints of
a. dislocation of rt shoulder during overhead activities for 5 times in
last 03 months

history of present illness: according to the statement of the patient

he developed recurrant dislocation of rt shoulder for last 05 yrs. In last
yr his shoulder dislocated for 05 times during overhead activities. 05
yrs back his shoulder dislocated during playing and fall on ground. It
was painful and reduced by an orthopaedic surgeon. He immobilized
his shoulder for only 01 wk.
On examination:
shoulder
Look: normal

Feel: deltoid wasting 1 cm

Local temp-normal
Tenderness-normal
Move: movement of shoulder is normal
Special test: apprehension test-+ve
Fulcrum test:apley 355
Drawer test:apley 355
x ray:
Hill sachs lesion-AP view with abduction and internal rotation
MRI

GCT RADIUS

Mr hamidul, 25 yrs businessman from chandpur, admitted in nitor on

3.3.15 with the complaints of
a. pain and swelling around his rt wrist for 02 months

history of present illness: according to the statement of the patient

he developed pain and swelling around his right wrist for 02 months
On examination:
Wrist
Look: swollen, mass 3x3 cm

Feel:
Local temp-raised
Tenderness-absent
Palpable mass 3x3 cm, surface smooth, margin ill defined, bony hard in
consistency, free from skin, fixed with bone.
Move: movement of wrist is normal

x ray:
radiolucent area located eccentrically bounded by subchondral bone plate
soap bubble appearance
cortex thin
MRI

OSTEOSARCOMA thik korte hobeapley 207

Mr hamidul, 25 yrs businessman from chandpur, admitted in nitor on
3.3.15 with the complaints of
a. pain and swelling around his rt knee for 02 months

b. fever, anorexia and wt loss for the same duration

history of present illness: according to the statement of the patient

he developed pain and swelling around his right knee for 02 months.
Pain is continuous, severe increased in night, aggravated by movement
and relieved with medication. Swelling is rapidly increasing. Moreover
he developed fever, anorexia and wt loss for last 02 months.
On examination:
Wrist
Look: swollen, mass 3x3 cm

Feel:
Local temp-raised
Tenderness-absent
Palpable mass 3x3 cm, surface smooth, margin ill defined, bony hard in
consistency, free from skin, fixed with bone.
Move: movement of wrist is normal

x ray:
radiolucent area located eccentrically bounded by subchondral bone plate
soap bubble appearance
cortex thin
MRI

HABITUAL DISLOCATION OF PATELLA

PARTICULARS OF THE PATIENT

Name-Abdul Jalil
Age- 30 yrs
Sex-male
Occupation-Medical asst
Address-Netrokona
Date of admission-28-08-15
Date of examination-08-09-15

CHIEF COMPLAINTS:
a. displacement of right knee cap when he flexes his
knee and it relocates automatically since his
childhood.

HISTORY OF PRESENT ILLNESS: according to

the statement of the patient his right patella displaces
every time when he flexes his knee and it relocates
automatically since his childhood. He has no definite
history of trauma. There is no pain when he flexes his
knee.

HISTORY OF PAST ILLNESS: nothing significant

TREATMENT HISTORY: nothing significant
FAMILY HISTORY: none of his family member
suffered from this type of illness.
PERSONAL HISTORY: nonsmoker, non alcoholic.

ON EXAMINATION:
General examinationBody built- average.

Anaemia-

Decubitus on choice
Nutritional status- average

Cyanosis

Pulse-72 beat/min
NAD

Jaundice-

BP-120/80 mm of Hg

Oedema-

Temp-normal
Heart/lung-NAD
Local examination:

Lymph NodeDehydration-

Rt knee

Look:
Patella is laterally placed.
Genu recurvatum-absent
Genu valgus-absent
Quadriceps wasting-present
Gait-normal
Squat-possible, in this position patella is
displaced more laterally

Feel:
Local temp-normal
Tenderness-absent
Patellofemoral joint-normal
Apprehension test-negative.

Q angle-70
Patellar tracking test-+ve
Patellar grinding test-negative
Patellar tilt test-negative.
Features of ligament laxity-absent
Quadriceps wasting-present 7 cm at 18 cm
above joint line on right side
Contracture of quadriceps-absent
Tibial torsion-absent.

Move:
Rt kneeFlexion-1400
Extension-00
Lt knee-normal
Other systemic examination-NAD
SALIENT FEATURE

Abdul Jalil,30 yrs of age Med Asst, from

Netrokona admitted in Nitor with the
complaints of displacement of right knee cap when he
flexes his knee and it relocates automatically since his
childhood. He has no definite history of trauma. There is
no pain when he flexes his right knee. Patella is laterally
displaced. . There is no genu valgus. Q angle is 70.
Patellar tracking test is positive. Patellar grinding test is
positive. Tibial torsion is absent. Ligamentous laxity is
absent. Knee movement is normal.
Provisional diagnosis-

Habitual dislocation of Patella

Differential diagnosis
Congenital dislocation of patella
Recurrent dislocation of patella

Investigation

X ray both knee joint-AP. Lateral and Skyline

view
Other routine investigation

Ankylosing spondylitis
PARTICULARS OF THE PATIENT
Name-Sumon
Age- 20 yrs
Sex-male
Occupation-unemployed
Address-Jhalokathi
Date of admission-07-09-15
Date of examination-08-09-15

CHIEF COMPLAINTS:
a. Pain in both hip for 01 yr and difficulty in walking
for the same duration.
b. Inability to stand straight for last 08 months.

HISTORY OF PRESENT ILLNESS: according to

the statement of the patient, he was reasonably well 01 yr
back. Then he developed pain at his both hip more in the
right for last 01 yr. Pain is constant dull aching,
aggravated by walking and relieved by taking rest. He
also complains of inability to stand straight for last 08
months. Moreover, he complains of anorexia, weight loss
and occasional rise of temperature for last 01 yr. He has
no history of cough, haemoptysis or contact with a TB
patient.
HISTORY OF PAST ILLNESS: nothing significant
TREATMENT HISTORY: he took anti TB for 06
months which was stopped 03 months back. Now he is
taking salazine for last 03 months and his condition
improved.
FAMILY HISTORY: none of his family member
suffered from this type of illness.
PERSONAL HISTORY: he was smoker but stopped
after the disease, non alcoholic.
IMMUNIZATION HISTORY: immunized as per EPI
schedule.

ON EXAMINATION:
General examinationBody built- average.

Anaemia-mild

Nutritional status- poor

Cyanosis

Pulse-72 beat/min
NAD

Jaundice-

BP-120/80 mm of Hg

Oedema-

Temp-normal

Lymph Node-

Heart/lung-NAD

Dehydration-

Local examination:
Look:
Patient cant stand straight.
Spine is bowed.
He cant walk without support.
Wasting of both gluteal muscles and both
thigh muscles
He cant squat

Feel:
Local temp-normal at both hip region
Tenderness-absent
Thomas test-bil FFD 300, further flexion upto
700
LLD-nil
Lumber spine excursion-3 cm
Wall test-positive
Ceiling test-negative
Chest expansion-2 cm

Move:
Flexion
Adduction
Abduction
External
rotation

Right hip
300-700
00
00
00

Left hip
300-700
00
00
50

Internal
rotation

00

50

Pump handle test-positive bilaterally

Other systemic examination-NAD
SALIENT FEATURE
Sumon ,20 yrs of age from Jhalokathi
admitted in Nitor on 07.09.15 with the
complaints of pain in both hip for 01 yr. Pain is
dull aching, aggravated by walking and relieved after
taking rest. Occasionally pain is associated with mild rise
of temperature. Moreover, he complains of inability to
stand straight for last 08 months. He was treated with
antitubercular for 06 months but he was not improved.
Now he is taking salazin for last 02 months and his pain
decreased but deformity persisted. He has anorexia and
weight loss but no history of cough, haemoptysis or night
sweat. None of his family member suffered from this sort
of illness. He is of poor nutritional status. His vital
parameters are within normal limit. He cant stand
straight. There is kyphosis. He cant walk without
support. His thigh and gluteal muscles are wasted. He
cant squat. Thomas test is positive and bil FFD is 300.

Further flexion is upto 700. All other movements are

severely restricted. LLD is nil. Chest expansion is 2 cm.
lumber excursion is restricted. Wall test is positive. Pump
handle test is positive.
Provisional diagnosis-

Ankylosing spondylitis involving both

hip, spine and SI joint
Differential diagnosis
TB hip
Rheumatoid arthritis
Investigation
CBC
CRP
ESR
HLAB27
RA test
MT

CXR
Sputum for AFB
X ray pelvis A/P view including both hip joint
X ray lumbo sacral spine A/P and lateral view
Xray dorsolumbar spine A/P and lateral view