2013 Flashcards
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Differences between peds and adult spines (6)
- ligamentous elasticity2. Shallow/horizontal facets3. paraspinal muscle immaturity9. 4. increased water ontent nucleus5. wedge shaped vertebrae6. predisposition to compression fractures7. large head: body ratio8. need peds spine board
Are kids more or les likely to have intraabominal and intrathoracic injuries vs. adults with TL spine trauma
more likely. have a high index of suspicion
What is the treatment for SCIWORA?
brace x 12 weeks (not operative there is nothing to stabilize or decompress)
Management open pelvic fracture in ED? In OR?
ED: packing (don’t explore), pelvic binder, standard open # stuffOR: ex-fix, I+D, colostomy fecal diversion, +/- suprapubic cath placement
FLASHBANG: devastating dyad
combined unstable pelvic # + displaced acetabular #= higher ISS, lower sBP, higher mortality rate, need more transfusions
How do you place an in-fix?
Just an FYI so you know what it is: 6-8mm pedicle screws from AIIS to PIIS, connected with subcutaneous bardon’t say you will do this on the exam. controversial, complications. do an ex-fix
What 3 views do you use to put an AIIS ex-fix pin and what are you looking for in each view?
Tip to remember: 00, 01, 111. Obturator outlet (start point)2. Obturator inlet (interosseous path between inner and outer table)3. Iliac inlet (trajectory above notch - avoid entering GSN)
What is the iliac cortical density and what view do you see it on?
Anterior safe zoneLateral fluoro shotto avoid injury to L5 root + iliac vessels
Approach to open reduction SI joint?
lateral window ilioinguinal approachdon’t have direct visualization from posterior
How would you reduce APC with an ex-fix?
Trick question. don’t use half-pins to get reduction. put the pins in, then reduce with pressure over GT, then fix to clamps + bars (what this JAAOS review suggested)
Name post-injury sequelae of pelvic #? (4)
Dyspareunia (women - symphysis injury)”excretory dysfunction”Erectile dysfunctionChronic pelvic pain
what structures are at risk with portal placement for a shoulder scope?
axillary ncephalic vsuprascapular a + n
What 3 anatomic structures (if they can’t be preserved) are most important when considering a hemipelvectomy?
The three anatomic structures that must be considered are: The sciatic nerve The femoral neurovascular bundle The hip joint (ie, periacetabular region).
Should two of these structures require resection to obtain an adequate margin, then hemipelvectomy should be considered.If you do the hemipelvectomy à pre-plan with anterior or posterior flaps with plastic surgeryALSO, DO MULTIDISCIPLINARY meeting (Psych, Counselling, Rehab, Etc)
Which zones of the pelvis don’t need reconstruction (ok to just resect them)
Iliac wingPubic rami
What are options for reconstruction of a hemipelvectomy involving the acetabulum? (broadly)
Resection arthroplasty (patients can ambulate unassisted, easiest technically)Saddle prosthesis (falling out of favour)Allograft/prosthesis (younger people, high complications)Custom device (expensive, new)
What is the order of physeal closure of the distal tibia?
Central -> anteromedial -> posteromedial -> lateral
Kid comes in and has a complete distal tibia arrest, what do you do?
Fibular epiphysiodesis to prevent lateral impingement(+/- contralateral epiphysiosis or ipsilateral lengthening etc)
Indications for physeal bar resection?
<50% physis involved>2y growth remainingInterpose (fat)
What ligaments comprise the syndesmotic complex?
AITFL: one study states AITFL/fibula = primary restraint to posterior translation of talus in cadaversPITFL 42% of sy`ndesmotic stabilityIOLTTFL (transverse tibiofibular ligament)
Order of innervation of median n. distal to elbow?Order of innervation AIN?
Median nPTFDSPLFCRAIN:FPLFDP to D2-3PQ
How do you distinguish pronator syndrome from CTS on physical exam
Pronator syndrome has palmar cutaneous branch median nerve numbness +/- paresthesias, and negative findings of provocative testing for CTS
3 tests for pronator syndrome?
- Pronator compression testApply pressure prox and lat to prox edge of PT muscle belly on volar forearmPositive test=reproducing pain or paresthesias within 30 seconds of compression2. Resisted pronation & supinationSee if reproduce sx from compression by PT or lacertus fibrosis3. Resisted flexion of PIP of middle fingerSx if compressed by heads of FDS; may be positive in those with CTS too4. proximal volar forearm tinel
How can you differentiate FPL tendon rupture from AIN syndrome?
Evaluate the tenodesis effect
* If tendons are intact and wrist is passively extended the thumb IP joint and DIP joint of the index finger assume a flexed position
* These joints extend when the wrist is passively flexed
Perform electrodiagnostic studies (EMG/NCV testing)
* Affected muscles in AIN syndrome may exhibit fibrillations, sharp waves, abnormal latency, abnormal compound motor action potentials on EMG/NCV testing
When can you consider an ORIF + intramedullary fibular strut graft in PHF non-union surgery?
Severe osteopeniaProbably don’t say this on exam if you’ve never seen it
All of the following statements regarding the use of chemotherapy for sarcoma are true EXCEPT? Adjuvant chemotherapy is indicated in the surgical treatment of Ewing’s sarcoma Chemotherapy provides the only intervention aimed at controlling micrometastatic disease Doxorubicin functions by inhibiting Topoisomeras II Methotrexate is in the family of Anthracycline agents
Answer: DAnthracyclines end in –rubicin. Methotrexate is an Antimetabolite agent. It inhibits folate.
Name the six characteristics of tumor cells that permit them to proliferate and metastasize
Evading apoptosis Self-sufficiency in growth signals Insensitivity to anti-growth signals Tissue invasion and metastasis inactivation Limitless replicative potential Sustained angiogenesis
Risk factors for neonatal septic arthritis? (4)
Invasive proceduresNICU treatmentPremature/immunocompromisedBreech (??)
Presentation of neonatal septic arthritis? (5)
Limited movementEdema (butt or leg)Different resting position of hipAnorexiaIrritableLethargicTo note: neonates are often afebrile and labs are unreliable. You can’t use Kocher criteria in neonates
What are your options for irreparable RCT tendon transfers? What factors predict a poor outcome?
Lat dorsi : to restore ERLargest potential excursion in shoulderTransfer tendon to GTPoor outcome associated with:
* Subscap or deltoid dysfunction
* OA of GH or AC joint
* Teres minor loss of function
Pec major: to restore IRTrapezius transfer:Another option for ER but need an allograft to improve excursion… don’t say you will do this probably
name 4 reasons to have an extensor lag in rheumatoid hand
nerve, ligament, tendon, jointPIN neuropathyextensor tendon ruptureextensor tendon subluxation (torn radial sagittal band)MCP volar subluxation
what is the difference between adult and pediatric popliteal cysts?
children = no communication with joint and idiopathic or traumaadults secondary to joint pathology
List 5 nerves at risk during shoulder surgery
SuprascapularAxillaryMusculocutaneoussubscapularspinal accessory (close to GH joint with shoulder in abduction + ER)
What is the Goutallier staging system
0: normal1: fat streak2: more muscle than fat3: equal fat and muscle4: more fat than muscleFatty infiltration and rotator cuff atrophy = associated with increased re-tear rates and worse functional outcomes after RCT repair0-1 = Fuchs 12 = Fuchs 23-4 = Fuchs 3
What is the Tangent sign and what is its implication?
line between superior aspect of coracoid and superior border of scapular spinenormally supraspinatus crosses the line.if supraspinatus is found below the line, it is highly correlated with grade III fatty atrophyFatty infiltration and rotator cuff atrophy = associated with increased re-tear rates and worse functional outcomes after RCT repair
What 3 things are you going to forget to do on your physical exam when investigating a bone lesion?
- palpate lymph nodes2. palpate thyroid3. prostate exam or breast exam
Open biopsy principles according to JAAOS
Not the best list but here are theirs from 2014 artcile:incision:
* longitudinal, centered over lesion
* as small as necessary
* planned carefully for later excision if necessary
tourniquet/exsanguination:
* can be used
* compressive exsanguination before tourniquet (eshmark) is discouraged
biopsy:
* careful surgical dissection (…)
* avoid neurovascular structures
* unicompartmental
diagnosis:
* sufficient tissue for fresh frozen section
* relevant clinical info should be provided to the pathologist
closure and postop:
* meticulous hemostasis
* layered tension-free closure
* drain can be used but exit in line with incision
For metastatic pathological fracture, what is the best filler of the bone defect?1. allograft bone2. autograft bone3. synthetic graft4. PMMA cement5. bone wax
- pmma cementdecreased post-op pain and improved post-op functionn
If you’re nailing for a pathological fracture and cementing, what order do you put your screws/cement in?
locking screws first, then cement (so you don’t miss the nail)for plates you can cement first (good purchase in cement)
intertroch lesionmild painLytic80% of bonemirel’s score = ?plan?
3 + 1 + 3 +3 = 10prophylactic fixation + irradiationJust remember the 2’s:lower limb (not peritroch)moderate painmixed blastic/lytic1/3-2/3<= 7 radiate>=9 prophylactic fixation + irradiate
All of the following are principles of open biopsy EXCEPT
- Maintaining meticulous hemostasis
- Longitudinal incision centered over lesion
- Routine compressive exsanguination before tourniquet inflation
- Dissection around neurovascular structures
Answer: CAlthough tourniquet use is acceptable, exsanguination (such as with an Esmarck bandage) is not recommended
Your management of an extraarticular metastatic lesion located within the distal humerus, 4cm from the olecranon fossa includes in addition to tumor resection:
- Retrograde IM nailing with PMMA
- Total elbow arthroplasty
- Elbow arthrodesis
- Dual plate distal fixation with PMMA
Answer: DLesion is extra-articular, so no need to replace elbow. Lesion is too distal for a retrograde IM nail. Consider it like a distal humerus fracture and fix with 90-90 or parallel plate fixation + PMMA.
You plan to perform a surgical intervention for a proximal humeral lesion involving the surgical neck and proximal meta-diaphysis in a 55 year old patient with metastatic thyroid carcinoma. LIST THREE possible operative procedures that could be performed in this patient.
- Open lesion resection, insertion of PMMA, fixation with long proximal humerus locking plate
- Open lesion resection, insertion of PMMA, fixation with antegrade intramedullary humeral nail.
- Open lesion resection, insertion of proximal humerus endoprosthesis with tuberosity reattachment.
dumb article but here’s a question:list 6 risks of playing on artificial turf vs. grass
artificial turf may be a risk factor for: turf toe, ankle ligamentous injury, high ankle sprain, knee injuryhigher risk to lose consciousness when concussed on artificial turf (harder)infection/abrasions more common on artificial turf (s. aureus, GAS, MRSA)
Which of the following statements regarding the epidemiology of hip arthritis is true?
- The prevalence of hip arthritis in the United States will be relatively stable over the next 20 years
- The number of people under the age of 65 requiring hip surgery for OA will increase
- Medical costs for hip osteoarthritis are declining
- Arthroplasty surgeons are significantly more intelligent compared to trauma/foot & ankle surgeons
Answer: B
List 3 specific complications to total elbow arthroplasty?
Infection 3-11%Aseptic loosening 2-9%Triceps insufficiency: 1-5% in RA patients
What is the ideal patient for a total wrist arthroplasty (instead of a fusion)?
uremitting pain with pancarpal wrist arthritis, refractory to nonsurgial management.low-demand lifestyle (like RA patients)interested in motion-preserving treatment option to allow ADL
List 4 contraindications to total wrist arthroplasty
- Young active patient
- Soft tissue infection/septic wrist joint
- Insufficient neuromuscular control
- Prior surgical procedure that would limit implant fixation into carpus
True or false: total wrist arthroplasty is the standard of care for wrist arthriti
- False – it is total wrist arthrodesis
With regard to total wrist arthroplasty
- Most common mechanism of failure is implant breaking
- Radial stem loosening is rare If distal stem is needed use 2nd metacarpal to ensure proper alignment
- Other
Answer – B(Most common mechanism of failure is implant breaking) Wrong – only in silicone implants, soft tissues and loosening more common3rd metacarpal aligns with radiusAseptic loosening of wrist implants is usually at the metacarpal side of the prosthesis.Steven R. Papp, George S. Athwal, and David R. PichoraThe Rheumatoid WristJ. Am. Acad. Ortho. Surg., February 2006; 14: 65 - 77.The prosthesis should be aligned distally with the third metacarpal and proximally with the ulnar border of the radius.There were two revisions (modern implant from Ranawat), one for pain and one for loosening. Radiographs showed nonprogressive radiolucent lines in the bone around 9 implants; in three instances, components were noted to have perforated the metacarpal and migrated, but the wrist remained painless.Carlson, JR and BP SimmonsTotal wrist arthroplastyJ. Am. Acad. Ortho. Surg., Sep 1998; 6: 308 - 315B is the only true one. Just remember that the 2nd metacarpal is the index finger, the 3rd metacarpal is the long finger
According to JAAOS article: what DOES WORK and is STRONGLY RECOMMENDED for non-op OA? (2013, might not be up to date)
Patients with OA of the knee should do “Self-Management Programs” * Do Physical Activity * Do Leg Strengthening Exercises * Do Low-Impact Aerobic Exercises * Do Neuromuscular Education * Patients with OA of the knee with a BMI over 25 should lose weight. That’s it !!!WHAT DOES NOT WORK and CANNOT BE RECOMMENDED * * Arthroscopic lavage and debridement The following are INCONCLUSIVE * Electrotherapeutic modalities * Manual therapy (Massage?) * Valgus off-loading brace (but the people wearing these in the ads look so happy!) * Lateral wedge in-soles * Glucosamine and Chondroitin Sulfate * Hyaluronic Acid * NSAIDs (oral or topical) * * Acetaminophen, Opioids or pain patches * Intra-articular steroids * PRPP injections * Needle lavage * Partial menisectomy of patients with OA that have a chronically torn meniscus * HTO for medial compartment OA * Interposition arthroplasty
Which of the following has received a STRONG recommendation from the AAOS guidelines of treatment for knee osteoarthritis?
- Use of topical or oral NSAIDs for pain control
- Performing high-impact aerobic physical activity
- High tibial osteotomy for treatment of unicompartmental disease
- Weight loss if the patient’s body mass index is over 25
Answer: D[Not B…its low-impact, not high impact]
Which of the following has received a STRONG recommendation from the AAOS guidelines of treatment for knee osteoarthritis?
- Avoidance of physical activities
- Intra-articular injection of cortisone
- Use of a valgus (off-loading) brace
- Recommend against the use of acupuncture for pain control
Answer: D
Can you use epinephrine in finger + hand local anesthesia?
yes
* Even accidental high dose epi finger injection has never been associated with finger necrosis
* The whole idea of epi being dangerous started in the 1920s-1940s with procaine (very acidic)
however
* Caution in all low-flow finger perfusion states – e.g. Buerger, renal failure, connective tissue diseases like severe scleroderma
List 4 benefits of wide-awake surgical procedures in hand/wrist surgery
- Flexor tendon repair – low rupture rate as patients actively fully flex/extend fingers intraop
- Tendon transfer – appropriate tension on repair achaived
- Elective surgery – no tourniquet = no sedation & monitoring
- Cheaper (less staff and OR needed)
List 8 principles of tendon transfer
Functional loss associated with donor tendon should be minimized, to maximize functional gains after transfer; EXPENDABLE DONOR TENDON with INTACT innervation
Strength of proposed muscle for transfer must be normal/near normal and under voluntary control; 4/5 OR 5/5 STRENGTH
Tendon EXCURSION of donor unit must be SUFFICIENT to restore lost function of recipient unit Direction of pull/vector of recipient tendon should be IN LINE with donor muscle; CROSS ONLY ONE JOINT
Single transferred tendon should perform ONE INTENDED FUNCTION
Soft-tissue bed must be stable and allow for tendon gliding with pliable, UNSCARRED overlying skin
JOINTS controlled by transferred tendon must have nearly FULL PASSIVE ROM
Tendons with IN-PHASE FUNCTIONS should be used
Radial nerve palsy transfers
Know this one:PT to ECRBPL to EPLFCR to EDCThis is the other one:FDS4 to EPLFDS3 to EDC
median nerve tendon transfers
Opponensplasty: (to APB) options * EIP to APB FDS D4 to APB * PL to APB Thumb IP flexion: (to FPL) options BR to FPL * ECRL to FPL * ECU to FPL Index DIP flexion: ECRL to FDP
Ulnar nerve tendon transfers for clawing and power pinch strength
I am not learning this…Clawing:
* FDS (cut it at insertion and loop it around A1 and tie it on itself so that it becomes an MCP flexor) = Zancolli lasso
* Modified stiles-bunnell
* Brand
Power pinch weakness = adductorplastyECRB to APorFDS D3 to AP
Describe the vascularity of the scaphoid
Major blood supply = dorsal carpal branch (branch of radial artery)Enters scaphoid in nonarticular ridge on dorsal surfaceSupplies 80% of scaphoid via retrograde blood flowMinor blood supply Superficial palmar arch (branch of volar radial artery)Enters distal tubercle and supplies distal 20% scaphoid
true or false
* MRI has inconsistent effectiveness to predict ON of proximal pole
true
4 risk factors for digit replant failure?
crush injuryimproper treatment of amputated digitsmokinghigh platelets
What do you suspect in a kid with a nail bed injury and what are its complications?
Seymour fracture :Distal phalanx physeal fracture + nailbed injuryExplore to ensure no interposed tissue at fracture site (take off nail), I+D, Abx, reduce #, nail bed repairFailure to do this = nail deformity, physeal arrest, osteomyelitis
Complications of nail injuries?
nail ridge deformity from uneven nail bed after repair or uneven distal phalanx cortex hook nail split nail cold intolerance sensory loss neuroma
Question(2008) Virchows triad except a. Stasis b. Endothelial injury c. Hypercoagulable d. Thrombocytosis
Answer: dVirchow = Stasis, hypercoagulable, endothelial injury
What is the most common inherited thrombophilia? Factor VIII deficiency Factor V Leiden Prothrombin G20210A Protein C deficiency Protein S deficiency
Factor V leidenProthrombin G20210A is 2nd more common
All are risk factors for venous thrombosis in athletes except: dehydration trauma immobilization travel hereditary thrombophilia OCP Male Running a marathon then air travelling >4h
MaleOthers are all risk factorsThere’s a whole article on venous thrombosis in athletes..
All of these are risk factors for wrong site spine surgery except:
- emergency surgery
- morbid obesity
- anatomic variation secondary to deformity or previous surgery
- time pressure to start or finish surgery
- unfamiliar equipment or setup
- solo surgeon
- multiple procedures during single surgery
- communication breakdown
solo surgeon is not a risk factormultiple surgeons in the surgery is a risk
2014
2014
Regarding subscap tears. All except:
- Release CHL to increase excursion of the tendon
- The axillary nerve and artery are found along the inferolateral border of the subscap approximately 3-5mm medial to the musculotendinous junction
- Isolated tears are more often seen in older patients
- Acute surgery for traumatic ruptures leads to better outcomes
- The comma sign is a sign of a torn subscapularis tendon and represents an arc formed by the SGHL and CHL
- isolated tears are most often seen in older patients = FALSEisolated tears mostly in younger patients an traumatic ER mechanism
All of these components of an osteochondral allograft elicit an immune response EXCEPT: articular cartilage subchondral bone marrow components
- articular cartilage
These are alll factors that increase the likelihood of having a successful single-stage revision for PJI except:
- TKA
- known bacteria and gram +ve
- antibiotics tailored to bacteria given for 12 weeks
- not polymicrobial infection
- optimal patient factors (medical and surgical)
- TKATHA has better success rate
What is the result of a too _____ femoral tunnel while doing MPFL reconstruction?1. anterior2. proximal3. distal
too anterior = overload of medial PF cartilagetoo proximal = graft lax in extension, tight in flexion = knee paintoo distal = tight in extension, lax in flexion = loss of extension
DM increases the incidence of all of these conditions EXCEPT:
- adhesive capsulitis
- dupuytren
- CTS
- flexor tenosynovitis
- DISH
- limited joint mobility
- CRPS
- keeping all your limbs
8.5% lifetime risk of amputation
