2015 SAQ

Question 1

What is the most common malunion of the talus?

Answer 1

varus (+/- supination, +/- dorsal translation)

Question 2

What are three techniques to achieve and maintain a proper reduction of the talus?

Answer 2

• 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

Question 3

Name 5 methods to aid in achieving and maintaining reduction of a proximal tibia fracture?

Answer 3

1. Poller blocking screws
2. Semi-extended positioning
3. Unicortical plate
4. Reduction clamps
5. Universal distractor
6. Avoid anterior start point (vs more posterior)
7. Suprapatellar nailing

Question 4

Define these three terms related to syndactyly

Answer 4

• 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

Question 5

What are 5 elements to determine if a patient has the capacity to consent for treatment?

Answer 5

1. • Patient must understand the diagnosis / injury and the nature of the proposed treatment
2. • They must be aware of common and important risks / benefits of treatment
3. • They must understand alternative treatment options
4. • They must understand the prognosis with and without treatment
5. • Patient should be able to re-phrase or describe the above in their own words

Question 6

what would be a vaild informed consent component?

Answer 6

1. capacity
2. informative
3. voluntary
4. specific to treatment
5. appropriately communicated

Question 7

What are 3 signs of AVN following closed reduction of DDH?

Answer 7

1. • failure of initial appearance or progression of ossification within 1 year of reduction
2. • broadening of the femoral neck within 1 year of reduction
3. • increase in density, +/- fragmentation
4. • residual deformity of head and neck when ossification complete

Question 8

What are 3 intraarticular blocks to reduction of DDH when doing it open?

Answer 8

1. Labrum
2. Ligamentum teres
3. Transverse acetabular ligament
4. Pulvinar

Question 9

What are poor radiographic prognostic factors when doing a PAO in an adult?

Answer 9

1. • Arthritis
2. • Aspherical femoral head
3. • Subluxation / Dislocation
4. • Os acetabuli (calcification of detached labrum)
5. • Severe dysplasia (CEA <0 degrees, reduced anteversion anlge on CT – may not be correctible)
6. • Combined CAM / Pincer lesion (requires surgical hip dislocation / scope before)
7. • Excessive posterior wall coverage (lack of posterior wall sign – may lead to impingement)
8. • +/- Age >50

Question 10

What are 3 methods to assess version/rotation after nailing a subtrochanteric fracture?

Answer 10

• 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

Question 11

What are the 5 radiographic features of an atypical femur fracture?

Answer 11

Major:

1. • No / minimal trauma
2. • Originates at lateral cortex (and is transverse)
3. • Complete fractures involve medial spike (or single cortex only)
4. • No comminution
5. • Lateral cortical beaking at fracture site (periosteal or endosteal)

Minor:

1. • generalized increased cortical thickness
2. • prodromal symptoms
3. • bilateral incomplete or complete fractures
4. • delayed fracture healing
5. • between lesser trochanter and metaphyseal flare

Question 12

Give 5 principles in managing a medical error

Answer 12

1. • disclosure to patient
2. • documentation of error
3. • take measures to correct error and prevent recurrence of error
4. • debrief and review with medical team / administration
5. • provide emotional support
6. • discuss with CMPA

Question 13

Give 3 prognostic factors in management of juvenile OCD of knee.

Answer 13

1. • size of lesion (>2cm diameter)
2. • open physes
3. • unstable lesion (signs of dissection, MRI with fluid behind lesion)
4. • location (lateral > patella > medial)
5. • acuity
6. • sclerosis

Question 14

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?

Answer 14

• decreased joint reaction forces
• decreased femoropelvic impingement
• increased stability
• increased tensioning of abductors

Question 15

Patient comes to emergency after an MVC with spinal injury. Give 3 clinical findings of an incomplete spinal cord injury.

Answer 15

• preserved voluntary anal contraction
• preserved perianal sensation
• preserved motor function below the level of injury

Question 16

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)?

Answer 16

• Brachial neuritis
• EMG

Question 17

Describe the orthotic for the subtle cavus foot (4 things)

Answer 17

• full length
• recessed first metatarsal
• lateral wedge (forefoot)
• lowered medial arch
• heel cushion

Question 18

They showed a diagram like this and asked you to name the layers of cartilage?

Answer 18

• Superficial / Tangential
• Transitional / Middle
• Deep / Basal
• Calcified Cartilage
• Subchondral bone

Question 19

When performing a Chopart amputation, what two things can you do to prevent equinus?

Answer 19

1. • TAL
2. • Tibialis anterior transfer to talar neck

Question 20

What are 6 types of spondylolisthesis by etiology?

Answer 20

1. • dysplastic / congenital
2. • isthmic (a: lytic stress #, b: elongation, c: acute pars #)
3. • degenerative
4. • traumatic (non-pars #)
5. • pathologic
6. • iatrogenic

Question 21

What are three important prognostic factors in soft tissue tumors?

Answer 21

• size >5cm
• deep to fascia
• mets
• high grade
• extracompartmental

Question 22

Name 3 clinical and radiographic signs for thoraco-lumbar spine instability?

Answer 22

1. • neurologic deficit (spinal cord injury, radiculopathy, CES)
2. • distraction injury (widened intraspinous/intralaminar spaces)
3. • translation >4.5mm
4. • kyphosis >22 degrees
5. • rotational deformity
6. • dislocation
7. • incapacitating pain
8. • step deformity on exam
9. • anterior / posterior elements destroyed or unable to function (Panjabi & White)

Question 23

Name 5 or 6 orthopaedic manifestations of Marfan syndrome (from the diagnostic criteria)

Answer 23

Major:

1. Pectus excavatum requiring surgery
2. • Pectus carinatum
3. • In-creased arm span to height ration >1.05
4. • Scoliosis >20 degrees
5. • Spondylolisthesis
6. • Arachnodactyly (thumb and small finger overlap when grasping contra lateral wrist, or thumb in palm with full nail exposed)
7. • Acetabular protrusio
8. • Pes planus (due to medial displacement of medial malleolus)
9. • Dural ectasia

Minor:

1. • Pectus excavatum (moderate)
2. • Joint hypermobility / Ligamentous laxity
3. • High arched palate
4. • Facial features

Question 24

What are 6 MODIFIABLE risk factors for nonunion?

Answer 24

• 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

Question 25

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?

Answer 25

• 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

Question 26

What are 3 poor prognostic factors in chondrosarcoma?

Answer 26

1. • metastatic disease
2. • central / axial location
3. • high grade
4. • increased telomerase activity (on PCR)
5. • size (>10 cm)
6. • extracompartmental

Question 27

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?

Answer 27

1. • Gastrocnemius
2. • Soleus
3. • Tibialis anterior
4. • 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)

Question 28

Name 5 nerves with a contribution from the posterior cord of the brachial plexus

Answer 28

1. • Axillary
2. • Radial
3. • Upper subscapular
4. • Lower subscapular
5. • Thoracodorsal

Question 29

What are 6 risk factors for recurrent patellar instability?

Answer 29

1. • increased TT-TG >20
2. • patella alta
3. • trochlear dysplasia
4. • generalized ligamentous laxity
5. • increased Q angle (+ miserable malalignment)
6. • hypoplastic lateral femoral condyle
7. • VMO weakness / dysplasia
8. • MPFL tear
9. • excessive patellar tilt

Question 30

Name 8 radiographic signs of aortic rupture.

Answer 30

1. • Widened mediastinum
2. • Hemothorax (left)
3. • Apical cap
4. • Loss of AP window
5. • Loss of aortic contour / knob
6. • Tracheal deviation to right
7. • Deviation of NG to right
8. • Depression of left bronchus
9. • Fractured 1st / 2nd rib or clavicle

Question 31

Name 3 non-femoroacetabular hip impingement syndromes

Answer 31

1. • Ischiofemoral impingement
2. • AIIS / subspine impingement (with the femur)
3. • Iliopsoas impingement (@acetabular rim / hip capsule)
4. • Snapping IT band

Question 32

Young 26F has a femoral neck fracture

1) Describe your reduction manoeuvre
2) Name 2 radiographic parameters of adequate reduction

Answer 32

1. • Leadbetter
2. • Flexion, adduction, internal rotation
3. • Followed by traction, circumduction to an extended and abducted position

parameters of adequate reduction:

1. • Double S shaped countour on lateral
2. • Reduction of medial calcar (with no displacement)
3. • Garden alignment index – trabecular lines on AP / lateral (aim for 160 / 180, acceptable 155 to 180 degrees
4. • No varus neck shaft angle (neutral to 15 degrees valgus – 130 to 150)
5. • Anterior posterior angulation <10 degrees

Question 33

Patient presents with loss of extension after TKA, in the absence of infection, give 4 causes

Answer 33

1. • tight extension gap
2. • posterior capsular contraction / posterior osteophytes
3. • poor rehabilitation
4. • extensor mechanism injury
5. • arthrofibrosis
6. • poor preop ROM
7. • HO
8. • +/- patella maltracking

Question 34

Patient presents with loss of flexion after TKA, in the absence of infection, give 4 causes

Answer 34

Loss of flexion:

1. • tight flexion gap
2. • infrapatellar contraction syndrome
3. • increased anterior slope
4. • overstuffed patellafemoral joint
5. • elevated joint line (>10-16 mm)
6. • arthrofibrosis
7. • poor rehabilitation
8. • poor preop ROM
9. • posterior osteophytes
10. • +/- patella maltracking

Question 35

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.

Answer 35

1. • tarsal coalition
2. • syndesmotic injury
3. • talar osteochondral fracture or OCD
4. • peroneal tendon subluxation / tears
5. • occult fracture (lateral malleolus / medial malleolus / lateral process talus / anterior process calc / 5th metatarsal)
6. • superficial peroneal nerve injury
7. • anterolateral impingement
8. • sinus tarsi syndrome (fibrosis in sinus tarsi space)
9. • subfibular impingement

Question 36

What are 3 principles to preventing patellar maltracking in TKA?

Answer 36

1. • avoid internal rotation of femoral / tibial components
2. • medialize patellar resurfacing component
3. • avoid medializing femoral component
4. • avoid posterior referencing with hypoplastic lateral femoral condyle / valgus knee
5. • avoid overstuffing patellofemoral joint (tensions lateral retinaculum)
6. • correct mechanical axis (avoid valgus >7 degrees)

Question 37

Patient with a type 3 bunionette, what 3 things would you do surgically?

Answer 37

1. • lateral condyle resection
2. • medial soft tissue release
3. • mid-diaphyseal metatarsal osteotomy (oblique or transverse depending on plantar callosity)
4. • 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

Question 38

Causes of hallux varus after hallux valgus surgery?

Answer 38

1. • excessive eminence resection
2. • excessive lateral soft tissue release
3. • overtightening medial capsule
4. • resection of fibular sesamoid
5. • overcorrection IMA
6. • excessive lateral translation with distal osteotomy
7. • overcorrection of hallux valgus interphalangeus

Question 39

How do you determine risk for pathologic fracture in metastases?

Answer 39

1. • size of lesion
2. • location (upper extremity / lower extremity / peritrochanteric, diaphyseal / metaphyseal)
3. • lesion characteristic (lytic / blastic / mixed)
4. • pain (minimal / moderate / functional)

Question 40

4 reasons to CRPP a distal radius fracture in a child

Answer 40

1. • ipsilateral supracondylar fracture
2. • salter harris III / IV
3. • inability to obtain or maintain an acceptable reduction
4. • open fracture
5. • soft tissue injury precluding cast / splinting
6. • vascular injury requiring repair

Question 41

4 reasons to acutely fix a scaphoid fracture

Answer 41

1. • displaced (>1mm)
2. • proximal pole
3. • unstable fracture (comminuted / vertical / oblique fracture)
4. • associated perilunate injury
5. • associated DISI deformity (SL >60 and RL >15, Intrascaphoid angle >35)
6. • open fracture

Question 42

Benefits of surgery vs cast in scaphoid #

Answer 42

• decreased time to union
• decreased length of immobilization
• earlier return to work / activity
• decreased rate of nonunion