2019 Flashcards
Which of the following is associated with persistent bowel / bladder dysfunction but improved ambulation at 3 months post injury:
a. ASIA A
b. Conus medullaris syndrome
c. Anterior cord syndrome
d. Brown-Sequard Syndrome
B
Conus medullaris syndrome has a mixture of UMN & LMN findings
Tendency for the nerve roots at the site of a SCI to recover = root escape
Greater apparent neurologic improvement rate of the conus is most likely because of the greater proportion of lower to upper motor neurons
93% of conus patients had a neurologic recovery of 1 ASIA score or more
14 yo child with CP, is ambulatory with jump gait, hip flexion contracture of 15 degrees, knee flexion contracture of 35 degrees, ankle plantar flexion contracture of 10 degrees. How would you correct this?
a. Medial hamstring release only
b. Medial hamstring release and distal femoral extension osteotomy
c. Medial hamstring release and anterior distal femur hemiepiphysiodesis
d. Medial and lateral hamstring release
B
This patient has a jump gait with true ankle equinus!
Jump gait more common in patients with diplegia
true= equinus relative to the tibia
apparent= foot is NOT in equinus, just looks like it. due to knee flexion contractures, and hip flexion contractures.
14 years - minimal to no growth potential left - cannot use guided growth (need ≥ 2 years of growth left)
Medial hamstring release alone used only in mild knee flexion contractures (<5°)
Technique
Fractional lengthening at the myotendinous junction is ideal
Complications
Hamstring contractures often recur, especially in jump gait
Supracondylar femur extension osteotomy +/- patellar tendon advancement or shortening
Indications
For knee flexion deformities of 10-30°, with severe quadriceps lag close to or already at skeletal maturity.
A normal popliteal angle is about 25°, and popliteal angles > 50° or knee contractures suggest significant hamstring tightness that should be treated with hamstring lengthening or other procedures.
CONTRAINDICATION
> 30 DEGREES= RESULTS IN INCREASE CARTILAGE PRESSURE, RISK OF OVER TENSIONING THE NEURO VASCULAR STRUCTURES
Can get them to under 30 degrees first with botox, ex-fix, casting, TSF
Equinus: TAL or gastroc recession
Medializing calcaneal osteotomy described as having a “safe zone” what is true about it?
a. Osteotomy inside the safe zone decreases rate of ALL nerve injuries to < 10%
b. Medial and lateral plantar (calcaneal?) nerves are still at risk even with osteotomy in the safe zone
c. Sural nerve injury > 10%
d. Some shit about medial vs lateral plantar nerve always at risk
B
Safe Zone for Neural Structures in Medial Displacement Calcaneal Osteotomy: A Cadaveric and Radiographic Investigation. FAI 2015
Conclusions:
-The safe zone extended 11.2 ± 2.7 mm anterior to the described landmark line.
-Provides reliable clearance of the medial plantar, lateral plantar, and sural nerves.
-The MC and LC nerves were always at risk during medial displacement calcaneal osteotomy
-There were more injuries to the MC & LC nerves using a traditional open approach compared to a percutaneous osteotomy with a side-cutting burr.
-Open technique = 30% risk to MC & LC nerves.
Which of the following is associated with atlanto-occipital dissociation
a. Basion dens interval > 12 mm
b. Space available for the cord < 13 mm
c. PADI < 15 mm
d. Basion axis interval < 12 mm
A
REF: Miller’s orthopaedics
For atlantooccipital dislocation
Power’s ratio
> 1 indicates instability of the atlanto-axial joint
Good for anterior dislocations, can miss posterior dislocations
Basion-axial interval (BAI)
Normal 4-12 mm
> 12 mm suggest AO dissociation
Basion dental interval (BDI)
Normal <12 mm
> 12 mm suggest AO dissociation
All are MAJOR criteria for atypical femur fracture based on the ASBMR 2013 consensus EXCEPT?
a. Generalized diaphyseal cortical thickening
b. Non-communited
c. Lateral beaking (revised to major criteria in future paper)
d. Complete fracture extend through both cortices and may be associated with a medial spike
A
Major
-No or minimal trauma (fall from standing height or less)
-Fracture line originates at the lateral cortex and is substantially transverse in its orientation, although it may become oblique as it progresses medially
-Complex fractures extend through both cortices and may be associated with a medial spike
-Non-comminuted or minimally comminuted
-Localized periosteal or endosteal thickening of the lateral cortex is present at the fracture site (“lateral beaking” or “flaring”)
Minor
-Generalized increase in cortical thickness of diaphysis (A is false - minor, not major criteria)
-Unilateral or bilateral prodromal symptoms
-Bilateral incomplete or complete fractures
-Delayed healing
Elbow physical - all are true except?
a. Tennis elbow symptoms CAN be elicited with resisted long finger extension
b. NPV of Milking maneuver is poor
c. Chair Push-up test more sensitive that pivot shift
d. Moving valgus stress test is sensitive
B
-Resisted middle finger extension recruits ECRB which can cause pain from lateral epicondylitis as well as radial tunnel syndrome
-Typically used for radial tunnel syndrome
Special tests:
-Manual valgus stress test: sensitivity 19%, specificity 100%
-Moving valgus stress test: sensitivity 100%, specificity 75%
-Chair push up test: sensitivity 87.5%
-Pivot shift test: sensitivity 37.5%
When performed under anesthesia = ~100% sensitive
-Milking maneuver: sensitivity 87.5%, NPV 100%
Most SENSITIVE: Moving valgus stress test
Most SPECIFIC: Manual valgus stress test
What is true about congenital radioulnar synostosis
a. Supination contracture
b. Does not improve with resection
c. Is typically distal or medial forearm
d. 2:1 male to female ratio
B
Ref: Orthobullets
-3:2 male to female
-Fixed forearm pronation ~30° (this is position of arm in utero)
-Considered failure of differentiation
-Usually proximal
-60% bilateral
-If patient presents with limited ROM but normal radiographs, MRI to r/o cartilaginous synostosis
Classification
Type 1 - Complete proximal synostosis with no formation of radial head
Type 2 - Rudimentary radial head present (often dislocated posteriorly)
Management:
Generally non-op if unilateral deformity and not limiting
Resection of Synostosis is bad, don’t do this —> will recur
Operative Options:
Derotation Osteotomy
High risk of compartment syndrome
Higher risk if >85° correction
8 yo male with a monteggia fracture Bado II with posterior radial head dislocation and PIN neuropathy describe your initial management
a. Closed reduction with 100 degrees flexion and pronation
b. Closed reduction with 100 degrees flexion and supination (anterior dislocations)
c. Open reduction of ulna, nerve exploration, closed reduction of radial head
d. Closed reduction in extension with pronation
D
Ref: Wheelless
Treatment:
-For type I, III, and IV Monteggia injuries, immobilize elbow in 100° of flexion w/ forearm fully supinated x 6 weeks
-For type II injuries, immobilize elbow extended x 4 weeks
All the following increase the rate of DVT in ankle surgery except:
a. BMI > 30
b. Age > 40
c. Tourniquet use
d. TXA
D
Type III supracondylar fracture humerus what is true?
a. Limited remodeling for translational deformity
b. Splinting in 120 degrees of flexion to maintain reduction is acceptable
c. Equivalent outcomes with lateral and crossed pinning
d. These require emergent surgical management
C
2024F consensus
Which accurately describes the anatomy of the distal humerus?
a. 30 deg anterior angulated, 6 deg valgus, internal rotation
b. 30 deg anterior angulated, 6 deg varus, internal rotation
c. 10 deg anterior, 6 deg valgus, 5 deg internal rotation
d. 10 deg anterior, 6 deg varus, 5 deg external rotation
A
All are true regarding chondroblastoma, EXCEPT:
a. MRI will not have surrounding edema
b. Found in long bone apophysis
c. Will appear lytic and have a well defined sclerotic border
d. Can have secondary ABC
A
JAAOS 2013 21(4):225
Chondroblastoma:
-15-32% have secondary ABC
-Classic XR appearance:
Well-defined eccentric oval or round lytic lesion involving the epiphysis adjacent to an open physis, often with a sharp sclerotic border, +/- calcifications
-MRI: Chondroblastoma usually is hypointense on T1-weighted images and variably ranges from hypointense to hyperintense on T2-weighted images, with or without peripheral lobulation and the associated marrow and soft-tissue edema that enhances after administration of contrast material. Bone scan shows increased uptake but seldom is needed for diagnosis.
-Management: curettage and bone grafting, some early results for RFA in small lesion
What is the best Xray to take for hindfoot alignment?
a. Saltzman
b. Broden
c. Canale
d. Mortise
A
Regarding glenoid fractures, which is true:
a. Patients with extra-articular fractures do well with non-operative treatment
b. Stable injuries if no other fractures or ligamentous injuries
c. Usually plated through a deltopectoral approach
d. Patients with > 1 cm medialization should be treated operatively
B
A - conditionally true, but not always
C - incorrect - Judet
D - 2.5cm traditional number
What is true about far cortical locking screws?
a. Stiffer construct
b. Produces asymmetric callous
c. Produces more callous volume
d. Produces callus with less mineralization
C
Kaplan Meier survivorship for THA implant, what is true?
a. Death not related to implant removes you from analysis
b. Patient starts survivorship curve after OR and continues until a predetermined event occurs or patient is censored
c. Plotted at predetermined time intervals
d. Too much weed
B
Censorship - elimination of a data point due to loss of follow-up, or they survived past the end of the study (when calculating the survivorship, their data would be used for each time point calculation up until the point they were censored. At that given time point and beyond, they would not be considered “at risk” of the event occurring because their endpoint is unknown and therefore would not be included in the analysis
A) Incorrect as their data would be used in analysis up until their censorship, and then excluded thereafter…
Survivorship is calculated and plotted each time the event-of-interest occurs (ie: each time a joint fails) - not predetermined
Regarding burnout in orthopaedic surgeons, what is true?
A. Overworking, fatigue, and being a program director is a risk factor
B. Is higher among surgeons in their first 5 years and their last 5 years of practice
C. Junior residents have more suicidal ideation
D. Is not associated with making more medical errors
A
