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JAAOS Summaries > 2019 (Jan-Sept) > Flashcards

2019 (Jan-Sept) Flashcards

1
Q

Where does the deltoid ligament typical rupture

A

Off the medial malleolus side

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2
Q

1mm of lateral deviation of the talus = what decrease in contact

A

42% reduction in tibiotalar contact

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3
Q

What are the two things you look for on plain XRs for deltoid rupture?

A

> 4mm of medial clear space widening

>1mm more than superior tibiotalar space

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4
Q

If reduced on WB views of ankle do you still need a stress?

A

Yes - doesn’t maximally stress syndesmosis

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5
Q

Does MRI help with deltoid ruptures

A

No - not useful to make surgical decision

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6
Q

When should you repair deltoid?

A

Controversial
Right now algorithm:
Fix fibular +/- syndesmosis PRN
If persistent widening on ER stress and talar tilt on EVERSION stress consider it

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7
Q

What are you looking for on Eversion stress test of ankle

A

Valgus tilt of talus greater than 7 degrees

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8
Q

What’s the literature on deltoid repair vs. no?

A

Literature to support either side

  • One RTC shows no difference but lacked power, short FU and lacked ability to test medial instability
  • Perhaps better for preventing medial widening and better pain IF the syndemosis was also fixed
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9
Q

Name five diagnostic tests for ACJ pathology

A
  1. TTP over ACJ
  2. O’Brien test
  3. Paxino test
  4. Cross-body adduction
  5. AC resisted extension

 ACJ TTP – best screening test to r/o ACJ pathology
 O’Brien/cross-body adduction/AC resisted extension useful in confirming ACJ pathology if positive

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10
Q

Describe the Paxino test

A

Pt sitting with arm resting @ side

Create shearing force over ACJ by applying thumb pressure over PL acromial corner and counterpressure with index and middfle fingers over distal clavicle

Positive if pain occurs @ ACJ

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11
Q

Describe the O’Brien test as it applies to ACJ pathology

A

FF of arm to 90 deg with elbow extended and arm adducted 10 deg

Examiner applies downward force and patient resists first with forearm IR/pronated (thumb points down) and then with arm ER/supinated

ACJ pain exacerbated by pronated position but alleviated with supinated position

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12
Q

Name five diagnostic tests for LHBT pathology

A
  1. Palpation of LHBT
  2. Speed’s test
  3. Yergason test
  4. Upper Cut test

 TTP at biceps – not reliable test for detecting or r/o biceps pathology
 Speed’s/Yergason/Upper Cut tests – good confirmatory test
 Upper cut test – highest clinical utility as screening and confirmatory test
 Combining Speed and upper cut test significantly improves predictability of detecting biceps pathology

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13
Q

Describe the Upper Cut test

A

Pt makes fist while flexing elbow to 90 deg, and supinating forearm

Examines places hand over first and resists pt bringing their hand up and toward examiner’s chin (boxing uppercut motion)

Pain/painful pop @ anterior shoulder indicates positive test

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14
Q

Name nine diagnostic tests for SLAP tears

A
  1. O’Brien tetst
  2. Crank test
  3. Anterior slide test
  4. Biceps Load I test
  5. Biceps Load II test
  6. Modified Dynamic Labral Shear
  7. Labral tension
  8. Resisted Supination External Rotation
  9. Forced Shoulder Abduction and Elbow Flexion
  • Only test to show consistency as screening test was modified dynamic labral shear test
  • Combining anterior slide and crank tests improves ability to rule in SLAP tear
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15
Q

Describe the O’Brian test as it applies to SLAP tears

A

FF arm 90 deg with elbow extended and arm adducted 10 deg

Examiner applies downward force and patient resists first with forearm IR/pronated (thumb points down) and then with forearm ER/supinated

GHJ pain with pronated position that decreases with supinated position is positive test

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16
Q

Describe the Crank test for SLAP tears

A

Pt seated and examiner positions arm @ 160 deg FF in scapular plane

GHJ axially loaded with passive IR/ER of humerus

Positive if pain with/out a click develops

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17
Q

Describe the Anterior Slide test for SLAP tears

A

Pt places hands on hips with thumbs pointed posteriorly

Examiner places one hand across top of shoulder (index finger extends over anterior acromion)

Examiner’s other hand placed behind elbow, and applies antero-superior force to elbow while pt resists this force
Pain and/or click @ anterior shoulder is positive test

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18
Q

Describe the Biceps Load I test

A

Designed for patients with anterior instability and a SLAP tear

Pt supine, and examiner grasps pt’s wrist and elbow, and abducts arm to 90 deg

Examiner ER arm until apprehension felt and resists pt’s attempted elbow flexion

Positive test if apprehension does not change or if increased pain with resisted elbow flexion

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19
Q

Describe the Biceps Load II test

A

Designed to assess potential isolated SLAP pathology

Patient supine, and examiner places shoulder in 120 deg abduction, elbow in 90 deg flexion, forearm in supination, and then ER shoulder

Pt flexes elbow against resistance

Positive if pain with resisted elbow flexion

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20
Q

Describe the Modified Dynamic Labral Shear test for SLAP tears

A

Examiner flexes elbow to 90 deg and abducts arm to 120 deg while maximally ER arm

Examiner lowers arm to 60 deg abduction

Positive test with pain/painful click along posterior joint line bw 120-90 deg abduction

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21
Q

Name the Beighton criteria for joint hyper mobility

A
  1. Passive DF for fifth finger > 90 deg
  2. Passive flexion of thumb to forearm
  3. Hyperflexion of elbows > 10 deg
  4. Hyperflexion of knees > 10 deg
  5. Forward flexion of trunk with knees fully extended and palms resting on floor

Score greater than or equal to 5 indicates joint hyper mobility

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22
Q

Name four tests for anterior instability of the GHJ

A
  1. Anterior apprehension
  2. Jobe relocation and surprise
  3. Anterior drawer test
  4. Anterior load and shift
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23
Q

Name four tests for posterior instability of GHJ

A
  1. Jerk test
  2. Kim test
  3. Posterior drawer
  4. Posterior load and shift
24
Q

Describe the Jerk test for posterior instability of GHJ

A

Pt sitting, examiner holds scapula with one hand while pt’s arm abducted to 90 deg and IR to 90 deg

Pts arm is axially loaded at elbow while applying horizontal adduction force

Positive if pain with/out clunk

25
Q

Describe the Kim test for posterior instability of GHJ

A

Pt sitting with arm in 90 deg abduction, examiner holds elbow and applies axial force/45 deg of upward diagonal elevation while pushing postero-inferiorly on upper arm

Positive if pain with/out clunk

26
Q

Name two tests for inferior instability of GHJ

A
  1. Sulcus sign

2. Gagey test

27
Q

Describe the Gagey test

A

Examiner’s forearm pushing down on shoulder girdle, examiner lifts pt’s relaxed upper limb into abduction with other hand

Abduction > 105 deg or apprehension limiting passive abduction positive for interior laxity

28
Q

Sulcus sign grading scheme

A

Sulcus Grading
I – Acromiohumeral interval < 1cm
II – Acromiohumeral interval 1-2 cm
III – Acromiohumeral interval > 2cm

29
Q

Hawkin’s Scale for GHJ translation

A

0 – Little or no translation (<25% of humeral head diameter)
1 – Humeral head moves onto glenoid rim
2 – Humeral head can be dislocated by spontaneously reduces
3 – Humeral head does not relocate when pressure removed

30
Q

Pathology of internal impingement in overhead throwing athletes

A

o Late cocking phase of throwing can translate GT/articular RC surface to impinge against posterosuperior glenoid
 Partial-/full-thickness RC tears, posterosuperior labral tears
oSecondary to subtle anterior shoulder instability and posterior capsule/posterior band IGHL contracture
 Increased ER at expense of decreased IR

31
Q

Name six diagnostic tests for the cervical spine

A
  1. Spurling test
  2. Axial Manual Traction Test
  3. Shoulder Abduction Test
  4. Valsalva Test
  5. Upper Limb Tension Test

Upper limb tension test
• Only useful screening test

Spurlilng/axial manual traction/shoulder abduction/Valsalva tests
• Useful in confirming cervical spine pathology

32
Q

Describe the Upper Limb Tension Test

A

Pt supine

Examiner sequentially depresses scapula, abducts shoulder, supinates forearm, extends wrist and fingers, ER shoulder, extend elbow, and laterally flex neck away and then over to affected side

Positive if
• Radicular sxs reproduced
• Side-to-side difference >10 deg observed in elbow extension upon test completion
• Sxs increased with CL lateral flexion of neck or decreased with ipsilateral lateral flexion

33
Q

Name four diagnostic tests for scapular dyskinesia

A
  1. Kibler Assessment
  2. Scrapula Retraction Test
  3. Lateral Scapular Slide Test
  4. Scapular Assistance Test

Interpret these tests with caution secondary to
• Challenges with assessing scapulothoracic motion beneath overlying muscles and SC tissues,
• Three rotational movements and two translations of scapula
• Their weak association with clinically relevant shoulder pathology

34
Q

Describe the Kibler Assessment Scapular Dyskinesis

A

Visual assessment by inspecting bilateral scapular motion during shoulder elevation and lowering in scapular and sagittal planes for any asymmetry in position or motion

I – Prominent inferior medial scapular border
II – Prominent entire medial scapular border
III – Excessive superior migration of superior medial scapular border
IV – Normal and symmetric scapular motion (posterior tilting, ER, upward motion of scapula during arm elevation)

35
Q

Name three tests for subacromial impingement

A
  1. Neer test
  2. Neer sign
  3. Hawkin’s test
  • When evaluating for subacromial bursitis or RC tears, all three tests are useful screening tests for r/o these pathologies if negative
  • If positive, possibility of other shoulder pathologies still exists
  • Neer test only test to reliably predict subacromial bursitis alone or partial thickness rotator cuff tear (RCT)
36
Q

Describe the Neer sign and test

A

Neer Sign
Performed by preventing scapular motion with one hand while other hand of examiner passively forward flexes arm

Positive if pain at anterior edge of acromion

Neer Test
Diagnosis confirmed when pain relieved with injection of 1% Xylocaine beneath anterior acromion

37
Q

Name four tests for supraspinatus assessment

A
  1. Jobe test
  2. Full can test
  3. Drop arm test
  4. Painful arc
  • Jobe test useful as both screening and confirmatory test but only for massive/large RCT
  • Full can test has similar utility when finding is weakness
  • Drop-arm test is specific for detecting partial- and full-thickness RCT
  • Painful arc test is a valuable screening test
38
Q

Name three tests for infraspinatus/teres minor assessment

A
  1. Resisted ER
  2. Hornblower test
  3. ER Lag sign (dropping sign)

Infraspinatus
• Weakness in ER is good screening test for infraspinatus tears
• ER lag sign is good confirmatory test for full-thickness infraspinatus tears

Teres Minor
• Pattie/Hornblower useful as both screening and confirmatory test for teres minor tear
• ER lag sign > 40 deg highly specific and sensitive for teres minor tear

39
Q

Name six tests for subscapularis assessment

A
  1. Belly press
  2. Belly-off
  3. Lift-off
  4. Bear hug
  5. IR lag sign
  6. IR resistance at abduction and ER
  • Belly-off test is excellent screening and confirmatory test
  • Belly press, liftoff, and bear hug tests all useful confirmatory tests
  • Bear hug more sensitive than belly press for partial SSC tears
  • Lift-off test difficult to complete in setting of pain or restricted ROM
40
Q

When does rotator cuff rehears normally occur post op

A

Retears occur early.

( often by 3 months, rates drop off after 6 mo )
Tendon healing is prolonged ( 6 mo to a year) therefore repairs need to be strong enough to last this long.

41
Q

Where do rotator cuff tenders typically retear?

A

weak link = suture tendon interface caused by poor tissue quality of the tendon

42
Q

Which of the following factors of mechanical augmentation creates the biggest increase in load to failure in rotator cuff tendon repair?

A) stitch configuration
B) size of instrument throwing suture
C) shape of instrument throwing suture
D ) size of tissue bite

A

A) stitch configuration

Ponce et al – compared stitch configuration, size and shape of instrument, size of tissue bite and stich configuration had the biggest increase in load to failure

But still have weakness in tendon suture interface – therefore strategies to improve RCR integrity with mechanical or biological means

43
Q

Do dermal autografts (Acellular Dermal Matrices) improve outcomes after RCR?

A

Consensus

RCR augmented with ADM appear to have higher rate of structural integrity on post op imaging

44
Q

Effect of Marrow Venting Procedures (Microfracture) on RCR ?

A

Consensus
Beneficial in improving healing rates on large and massive tears but may not make a different for small-medium size tears

45
Q

Effect of PRP on RCR?

A

No true consensus

Mixed results – some show benefit some don’t
? cause for inconsistency as not all PRP is the same.
Large table in paper with no overt consensus.

46
Q

Effect of Bone Marrow Aspirate on RCR?

A

2 studies available – poor scientific rigor ( no control ) There was some positive effects in the studies but consensus was not strong enough evidence for a conclusion supporting.

47
Q

Effect of Adipose – Derived Stem Cells on RCR ?

A

Only one study – authors found no real difference clinically however struc integ higher on post op MRI

Need more evidence before any recommendations can be made

48
Q

Patient factor indications to augment rotator cuff repair (predictors of failure to heal)

A 
age > 65 
multiple tendon involvement > 1 
large tear > 2 cm 
retraction > 2 cm 
high grade fatty infiltration (Goutallier > 2)
49
Q

What is the primary restraint to talus ER and lateral displacement

A

Deltoid ligament

50
Q

Who is at highest risk for false positive for measuring medial clear space evaluation on standard XR

A

Tall males (on ave 1mm more)

51
Q

What is cutoff for medial clear space (MCS)

A

> 5mm

52
Q

Three ways to judge instability in lateral malleolus fractures

A

Manual stress XR
Gravity stress XR
Weight bearing XR

53
Q

What did Sanders et al. study show on unstable weber B fractures?

A

81 patients with unstable weber B, randomized to op vs non op

Good: No functional differences @ 1 years

Bad: 20% nonop group showed signs of mal alignment at 1 year and had delayed union

54
Q

1 advantage and 1 disadvantage of PL plating of fibula for weber B fractures

A

Pro: biomechanically most stable

Con: Peroneal irritation

  • usually from distal oblique screw in plate
  • Suggest placing plate 1cm from tip of mal +/- using 2.0 or 2.4mm screw below plate
55
Q

IM fixation for Weber B indications

A

Poor soft tissue

High risk for wound complications

56
Q

Advantage of IM fixation of Weber B fixation

A
  • Soft tissue friendly

- Greater torque resistance than 1/3 tubular + lag

JAAOS Summaries (8 decks)

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