2015 SAQ Flashcards
What is the most common malunion of the talus?
varus (+/- supination, +/- dorsal translation)
What are three techniques to achieve and maintain a proper reduction of the talus?
- exposure of both sides of the talus to assess reduction
- distraction and bridging of medial comminution
- anatomic lateral reduction with fixation in compression
- intraoperative Canale view
- bone graft for large medial defects
Name 5 methods to aid in achieving and maintaining reduction of a proximal tibia fracture?
- Poller blocking screws
- Semi-extended positioning
- Unicortical plate
- Reduction clamps
- Universal distractor
- Avoid anterior start point (vs more posterior)
- Suprapatellar nailing
Define these three terms related to syndactyly
- Complex: Involves fusion of bone or fingernails of adjacent digits
- Complete: Fusion of digits from webspace to fingertips (simple or complex)
- Synonychia: Fusion including a common nail
What are 5 elements to determine if a patient has the capacity to consent for treatment?
- Patient must understand the diagnosis / injury and the nature of the proposed treatment
- They must be aware of common and important risks / benefits of treatment
- They must understand alternative treatment options
- They must understand the prognosis with and without treatment
- Patient should be able to re-phrase or describe the above in their own words
what would be a vaild informed consent component?
- capacity
- informative
- voluntary
- specific to treatment
- appropriately communicated
What are 3 signs of AVN following closed reduction of DDH?
- failure of initial appearance or progression of ossification within 1 year of reduction
- broadening of the femoral neck within 1 year of reduction
- increase in density, +/- fragmentation
- residual deformity of head and neck when ossification complete
What are 3 intraarticular blocks to reduction of DDH when doing it open?
- Labrum
- Ligamentum teres
- Transverse acetabular ligament
- Pulvinar
What are poor radiographic prognostic factors when doing a PAO in an adult?
- Arthritis
- Aspherical femoral head
- Subluxation / Dislocation
- Os acetabuli (calcification of detached labrum)
- Severe dysplasia (CEA <0 degrees, reduced anteversion anlge on CT – may not be correctible)
- Combined CAM / Pincer lesion (requires surgical hip dislocation / scope before)
- Excessive posterior wall coverage (lack of posterior wall sign – may lead to impingement)
- +/- Age >50
What are 3 methods to assess version/rotation after nailing a subtrochanteric fracture?
- Cortical fracture fragment reduction
- Width of corticies equal
- Lesser trochanter profile compared to contralateral side
- Tornetta method (calculated version)
- Use 15 degree anteversion of nail
What are the 5 radiographic features of an atypical femur fracture?
Major:
- No / minimal trauma
- Originates at lateral cortex (and is transverse)
- Complete fractures involve medial spike (or single cortex only)
- No comminution
- Lateral cortical beaking at fracture site (periosteal or endosteal)
Minor:
- generalized increased cortical thickness
- prodromal symptoms
- bilateral incomplete or complete fractures
- delayed fracture healing
- between lesser trochanter and metaphyseal flare
Give 5 principles in managing a medical error
- disclosure to patient
- documentation of error
- take measures to correct error and prevent recurrence of error
- debrief and review with medical team / administration
- provide emotional support
- discuss with CMPA
Give 3 prognostic factors in management of juvenile OCD of knee.
- size of lesion (>2cm diameter)
- open physes
- unstable lesion (signs of dissection, MRI with fluid behind lesion)
- location (lateral > patella > medial)
- acuity
- sclerosis
74 year-old male gets a metal-on-polyethylene THA. Surgeon decides to put in high-offset stem. Give 4 benefits of using high-offset?
- decreased joint reaction forces
- decreased femoropelvic impingement
- increased stability
- increased tensioning of abductors
Patient comes to emergency after an MVC with spinal injury. Give 3 clinical findings of an incomplete spinal cord injury.
- preserved voluntary anal contraction
- preserved perianal sensation
- preserved motor function below the level of injury
36 year-old male come to office with 3-week history of acute onset shoulder pain in non-dominant arm. No history of trauma. Complains of night pain and 1 week of decreased shoulder abduction and external rotation as seen in the physical exam. Has an MRI, which is normal except for increased signal in the supraspinatus and infraspinatus.
What is the most likely diagnosis
What investigation do you want (choose 1)?
- Brachial neuritis
- EMG
Describe the orthotic for the subtle cavus foot (4 things)
- full length
- recessed first metatarsal
- lateral wedge (forefoot)
- lowered medial arch
- heel cushion
They showed a diagram like this and asked you to name the layers of cartilage?
- Superficial / Tangential
- Transitional / Middle
- Deep / Basal
- Calcified Cartilage
- Subchondral bone
When performing a Chopart amputation, what two things can you do to prevent equinus?
- TAL
- Tibialis anterior transfer to talar neck
What are 6 types of spondylolisthesis by etiology?
- dysplastic / congenital
- isthmic (a: lytic stress #, b: elongation, c: acute pars #)
- degenerative
- traumatic (non-pars #)
- pathologic
- iatrogenic
What are three important prognostic factors in soft tissue tumors?
- size >5cm
- deep to fascia
- mets
- high grade
- extracompartmental
Name 3 clinical and radiographic signs for thoraco-lumbar spine instability?
- neurologic deficit (spinal cord injury, radiculopathy, CES)
- distraction injury (widened intraspinous/intralaminar spaces)
- translation >4.5mm
- kyphosis >22 degrees
- rotational deformity
- dislocation
- incapacitating pain
- step deformity on exam
- anterior / posterior elements destroyed or unable to function (Panjabi & White)
Name 5 or 6 orthopaedic manifestations of Marfan syndrome (from the diagnostic criteria)
Major:
- Pectus excavatum requiring surgery
- Pectus carinatum
- In-creased arm span to height ration >1.05
- Scoliosis >20 degrees
- Spondylolisthesis
- Arachnodactyly (thumb and small finger overlap when grasping contra lateral wrist, or thumb in palm with full nail exposed)
- Acetabular protrusio
- Pes planus (due to medial displacement of medial malleolus)
- Dural ectasia
Minor:
- Pectus excavatum (moderate)
- Joint hypermobility / Ligamentous laxity
- High arched palate
- Facial features
What are 6 MODIFIABLE risk factors for nonunion?
- Smoking
- Malnutrion
- Ca / Vit D deficiency
- Corticosteroid use
- Hypothyroidism
- Diabetic control
- NSAID use
- Excessive soft tissue stripping during surgery
- Infection
- Poor compliance
- Inadequate stability
- Fracture gap
- Obesity
- Alcohol use
Patient has a type II tibial eminence fracture.
What is the main block to reduction?
Name 2 complications if unable to achieve proper reduction of the fragment?
- What is the main block to reduction:
- anterior horn of medial meniscus (also intermeniscal ligament, fracture debris)
- Name 2 complications if unable to achieve proper reduction of the fragment:
- ACL instability
- Decreased ROM (lack extension)
- Arthrofibrosis
What are 3 poor prognostic factors in chondrosarcoma?
- metastatic disease
- central / axial location
- high grade
- increased telomerase activity (on PCR)
- size (>10 cm)
- extracompartmental
A 9-year old patient with CP comes in with a foot in equinovarus.
1) What are the contributory muscles to this deformity
2) What test can be done to differentiate which part of the foot is driving the deformity?
3) Treatment options?
- Gastrocnemius
- Soleus
- Tibialis anterior
- Tibialis Posterior
confusion test: helps to distinguish TA vs TP as the primary muscle involved
- patient performs active hip flexion against resistance while seated
- tib ant will normally fire during hip flexion causing dorsiflexion
- if the foot dorsiflexes AND supinates, then tib ant is likely contributing to varus (more than tib post) à split tib ant transfer
3)
- TAL or gastroc recession
- Split tib ant (with tib post lengthening) OR split tib post transfer
- calcaneal osteotomy or triple arthrodesis (if not flexible)
Name 5 nerves with a contribution from the posterior cord of the brachial plexus
- Axillary
- Radial
- Upper subscapular
- Lower subscapular
- Thoracodorsal
What are 6 risk factors for recurrent patellar instability?
- increased TT-TG >20
- patella alta
- trochlear dysplasia
- generalized ligamentous laxity
- increased Q angle (+ miserable malalignment)
- hypoplastic lateral femoral condyle
- VMO weakness / dysplasia
- MPFL tear
- excessive patellar tilt
Name 8 radiographic signs of aortic rupture.
- Widened mediastinum
- Hemothorax (left)
- Apical cap
- Loss of AP window
- Loss of aortic contour / knob
- Tracheal deviation to right
- Deviation of NG to right
- Depression of left bronchus
- Fractured 1st / 2nd rib or clavicle
Name 3 non-femoroacetabular hip impingement syndromes
- Ischiofemoral impingement
- AIIS / subspine impingement (with the femur)
- Iliopsoas impingement (@acetabular rim / hip capsule)
- Snapping IT band
Young 26F has a femoral neck fracture
1) Describe your reduction manoeuvre
2) Name 2 radiographic parameters of adequate reduction
- Leadbetter
- Flexion, adduction, internal rotation
- Followed by traction, circumduction to an extended and abducted position
parameters of adequate reduction:
- Double S shaped countour on lateral
- Reduction of medial calcar (with no displacement)
- Garden alignment index – trabecular lines on AP / lateral (aim for 160 / 180, acceptable 155 to 180 degrees
- No varus neck shaft angle (neutral to 15 degrees valgus – 130 to 150)
- Anterior posterior angulation <10 degrees
Patient presents with loss of extension after TKA, in the absence of infection, give 4 causes
- tight extension gap
- posterior capsular contraction / posterior osteophytes
- poor rehabilitation
- extensor mechanism injury
- arthrofibrosis
- poor preop ROM
- HO
- +/- patella maltracking
Patient presents with loss of flexion after TKA, in the absence of infection, give 4 causes
Loss of flexion:
- tight flexion gap
- infrapatellar contraction syndrome
- increased anterior slope
- overstuffed patellafemoral joint
- elevated joint line (>10-16 mm)
- arthrofibrosis
- poor rehabilitation
- poor preop ROM
- posterior osteophytes
- +/- patella maltracking
12 year-old girl has recurrent lateral ankle pain 6 months post sprain. MRI does not show tear of fibular ligaments. Name 6 other causes of chronic pain.
- tarsal coalition
- syndesmotic injury
- talar osteochondral fracture or OCD
- peroneal tendon subluxation / tears
- occult fracture (lateral malleolus / medial malleolus / lateral process talus / anterior process calc / 5th metatarsal)
- superficial peroneal nerve injury
- anterolateral impingement
- sinus tarsi syndrome (fibrosis in sinus tarsi space)
- subfibular impingement
What are 3 principles to preventing patellar maltracking in TKA?
- avoid internal rotation of femoral / tibial components
- medialize patellar resurfacing component
- avoid medializing femoral component
- avoid posterior referencing with hypoplastic lateral femoral condyle / valgus knee
- avoid overstuffing patellofemoral joint (tensions lateral retinaculum)
- correct mechanical axis (avoid valgus >7 degrees)
Patient with a type 3 bunionette, what 3 things would you do surgically?
- lateral condyle resection
- medial soft tissue release
- mid-diaphyseal metatarsal osteotomy (oblique or transverse depending on plantar callosity)
- lateral soft tissue imbrication
Types:
1 – lateral exostosis –>eminence resection + lateral imbrication
2 – congenital bow, normal IMA (up to 8 degrees) –> distal chevron + eminence only
3 – increased IMA –> diaphyseal osteotomy + eminence + lateral imbrication +/- medial release
Causes of hallux varus after hallux valgus surgery?
- excessive eminence resection
- excessive lateral soft tissue release
- overtightening medial capsule
- resection of fibular sesamoid
- overcorrection IMA
- excessive lateral translation with distal osteotomy
- overcorrection of hallux valgus interphalangeus
How do you determine risk for pathologic fracture in metastases?
- size of lesion
- location (upper extremity / lower extremity / peritrochanteric, diaphyseal / metaphyseal)
- lesion characteristic (lytic / blastic / mixed)
- pain (minimal / moderate / functional)
4 reasons to CRPP a distal radius fracture in a child
- ipsilateral supracondylar fracture
- salter harris III / IV
- inability to obtain or maintain an acceptable reduction
- open fracture
- soft tissue injury precluding cast / splinting
- vascular injury requiring repair
4 reasons to acutely fix a scaphoid fracture
- displaced (>1mm)
- proximal pole
- unstable fracture (comminuted / vertical / oblique fracture)
- associated perilunate injury
- associated DISI deformity (SL >60 and RL >15, Intrascaphoid angle >35)
- open fracture
Benefits of surgery vs cast in scaphoid #
- decreased time to union
- decreased length of immobilization
- earlier return to work / activity
- decreased rate of nonunion
