2023 Flashcards
8F with fibular hemimelia. 4cm projected LLD, 4 ray foot, and valgus ankle. What is most inappropriate at this time?
a. Lengthen short leg
b. Epiphysiodesis long leg
c. AFO for valgus ankle
d. Syme amputation
D
Fibular Hemimelia
- Anteromedial tibial bowing
o Most common cause is fibular hemimelia
- Ankle instability
o Secondary to a ball and socket ankle
- Talipes equinovalgus
- Tarsal coalition (50%)
- Absent lateral rays
- Femoral abnormalities (PFFD, coxa vara)
- DDH
- Cruciate ligament deficiency
- Genu valgum
o Secondary to lateral femoral condyle hypoplasia
- Significant LLD
- Shortening of femur and/or tibia
IMAGING
Radiographs
-fibula is either absent or shortened
-tibial spines are underdeveloped
-intercondylar notch is shallow
-ball and socket ankle joint
>secondary to tarsal coalitions
Indication for MRI in AIS?
a. Thoracic curve with absent abdominal reflexes
b. Thoracic curve with back pain
c. Thoracic curve with 10 degree progression during growth
d. Thoracic curve in patient with restrictive lung disease
B
Most common complication following palmar fasciectomy for Dupuytren’s?
a. Arterial injury
b. Neuropraxia
c. Iatrogenic nerve laceration
d. Infection
B
Eberlin KR, Mudgal CS. Complications of Treatment for Dupuytren Disease. Hand Clin. 2018 Aug;34(3):387-394. doi: 10.1016/j.hcl.2018.03.007. Epub 2018 Jun 8. PMID: 30012298.
Postoperative numbness and paresthesias in the absence of surgical nerve injury (ie, neurapraxia) are common and can occur in up to 46% of patients undergoing fasciectomy
Injury to a digital nerve is relatively uncommon and occurs in fewer than 10% of patients undergoing operative intervention.
A 14 year old boy is undergoing T4 to L4 posterior surgical correction for AIS. While inserting pedicle screws at the apex of the curve via freehand technique, there is a 60% loss in motor evoked potentials. Patient is normothermic, anesthetized by propofol, Hgb 110, MAP 60, with normal oxygenation and ventilation. After verifying that the neuromonitoring is working properly, what is the management?
a) Transfuse 2 units and recheck MEPs
b) Increase MAP to 85 and recheck MEPs
c) Remove pedicle screws at the apex and recheck MEPs
d) Check the extent of neuromuscular blockade and recheck MEPs
B
Black Book:
What is the management of an intraoperative alert while using intraoperative neuromonitoring? [JAAOS 2015;23:648-660]
- Intraoperative pause
- Communicate with anaesthesiologist, surgeon, neuromonitoring team
- Ensure blood pressure is adequate (MAP >80mmHg recommended)
- Ensure oxygen saturation is adequate
- Reverse surgical interventions until baseline achieved
- If alert persists perform wake-up test
What is true about above knee amputation for peripheral vascular disease?
a) 50% increased energy expenditure compared with non-amputee
b) ABI greater than 0.4 is associated with improved soft tissue healing.
c) ITB tenodesis will prevent flexion contracture
d) Abduction contracture is uncommon
B
What is the most important prognostic feature of a soft tissue sarcoma?
a. Tumor size
b. Tumor stage
c. Presence of Mets
d. Tumor grade
C
2024F consensus
Management of brachial plexus sequalae?
A. Derotation osteotomy helps with anterior instability
B. Internal rotation contracture treated with capsular release and subscap release
C. Minority of patients with Erb palsy and chronic muscle imbalance get GH deformity
D. Lat dorsi and teres major transfer is used primarily for help with abduction
B
Subscapularis muscle release is a procedure we found to have few significant complications and was highly effective in increasing active range of motion and restoring shoulder function.
Glenohumeral dysplasia (and posterior shoulder dislocation) is associated with BPBP and may occur as early as 3 months of age [21*]. Approximately 60–80 % of children who do not recover full motor function develop some degree of glenohumeral deformity [22].
Limited shoulder function in children with plateauing of neural recovery could be related to persistent internal rotation contracture, progressive glenohumeral deformity, infantile dislocation, and insufficient abduction and external rotation power.
In 1934, L’Episcopo15 described use of an anterior and posterior incision to transfer the latissimus dorsi and teres major laterally to enhance external rotation.
Difference between adult and pediatric knee injuries.
A. Paeds has higher neurovascular injuries
B. Must be as suspicious of associated soft tissue injuries
C. Same mechanism of injury as adults
D. Accept more intra-articular displacement in pediatric fractures
B
Brutal question.
Consensus
25M with a distal radius fracture with basilar ulnar styloid fracture what is the MOST important stabilizer of the DRUJ?
a. Palmer RU lig
b. dorsal RU lig
c. TFCC (most important with no fracture)
d. Distal band of the interosseus membrane
D
Question implies that the TFCC is no longer functional, making the distal band of the IO the most important stabilizer remaining.
A and B and both part of the TFCC
During the anterior approach to the lumbar spine, which of the following structures lies on the Anteromedial psoas?
A. Ureter
B. genitofemoral nerve
C. vena cava
D. segmental Arteries and veins
B
Difference between one and two screws MM
A. One screw fails more one in torsion
B. More hardware removal for two screws
C. Longer OR time for two
D. No difference in functional outcomes
D
Buckley R, Kwek E, Duffy P, Korley R, Puloski S, Buckley A, Martin R, Rydberg Moller E, Schneider P. Single-Screw Fixation Compared With Double Screw Fixation for Treatment of Medial Malleolar Fractures: A Prospective Randomized Trial. J Orthop Trauma. 2018 Nov;32(11):548-553. doi: 10.1097/BOT.0000000000001311. PMID: 30211788.
There was no difference in the operating room time, SF36, or Ankle Hindfoot Scale at all follow-up time points.
Conclusions: SS medial malleolar fixation provides an equally safe and effective method of fracture care as compared to DS fixation. Twenty percent of patients receiving 2 screws can be expected to crossover to receive SS fixation as a safer alternative.
Shown a picture of a high BMI knee dislocation/medial tibial plateau, told low energy. which is true:
A. If ABI>0.7 no vascular injury
B. If pulse to the foot, no vascular injury
C. Intimal tear is most common and needs CTA
D. 5-10% incidence of vascular injury
C
Gahr P, Kopf S, Pauly S. Current concepts review. Management of proximal tibial fractures. Front Surg. 2023 Mar 23;10:1138274. doi: 10.3389/fsurg.2023.1138274. PMID: 37035564; PMCID: PMC10076678.
In knee dislocations with suspected arterial lesions or in case of an ankle-brachial-index (ABI) of <0.9, (CT-) angiography is mandatory, because even patients with an intact pulse status show intimal lesions in about 9% of cases
Popliteal artery injury ~ 25%. Peroneal nerve injury ~40%)
Breast cancer patient with one isolated bone mets. What is true?
a)No need for biopsy with an isolated bone lesion on a patient known for breast cancer
b) All chemo and immune treatment are not necessarily associated with healing problems
c) Denosumab is inferior to biphosphonate in preventing second skeletal events
d) Breast bone mets are resistant to radiotherapy
B
A – This is false. Could be a second primary.
B – This is true?
C – This is false. Denosumab is superior to bisphosphonates in preventing skeletal events.
D – This is false. Breast cancer bone mets are sensitive to radiotherapy.
55 yo make has a fall and injury in hyperabducted arm position with increased external rotation and weakness on internal rotation as well as pain. He undergoes surgery. 6 months later has another fall and you are shown an MRI with significant tear of subscap, very retracted, some bony edema around anchor but not significant degen changes of glenoid and humeral head. Tx?
A. RTSA
B. Subcoracoid pec major transfer
C. Synovectomy and debridement
D. Arthroscopic revision repair
B
Generally, retraction medial to glenoid and SSc fatty infiltration of stage 3 or more are considered as indicators of irreparability of SSc.
The management of retears should be in the form of salvage procedures.
Reverse shoulder arthroplasty is reserved for older patients or those with arthritic changes. In younger patients, tendon transfer has been the treatment of choice.
Two commonly used options for tendon transfer in irreparable SSc tears are PM transfer and LD transfer.
reversed shoulder arthroplasty has been established as the preferred treatment option for older, low-demand patients with arthropathy, providing reliable improvements in pain and function. In younger patients without significant arthropathy, musculotendinous transfers are the treatment of choice. The pectoralis major transfer is historically the most frequently performed procedure and provides improved range of motion and pain relief, but fails to adequately restore strength and shoulder function. The latissimus dorsi transfer has gained increased interest over the last few years due to its biomechanical superiority, and early clinical studies suggest improved outcomes as well. More recently, anterior capsular reconstruction has been proposed as an alternative to musculotendinous transfers, but clinical data are completely lacking
What radio graphic measure is most predictive of scoliosis correction for main thoracic and thoracolumbar curves in AIS?
A. Push-prone (PP)
B. Traction under anesthesia (TUGA)
C. No differences
D. supine bending x-rays
B
It has been suggested that fulcrum bend radiographs predict curve correction in adolescent idiopathic scoliosis (AIS).2,3 However, it has been shown that traction radiographs taken under general anesthesia (GA) are better at predicting flexibility of the scoliosis curve than the fulcrum bending radiographs.
Pec Major anatomy question, which is true?
- clavicular head insertion posterior to sternal on humerus,
- vasc supply lateral thoracic which is a branch from anterior intercostal,
- sternal head more likely to rupture because of orientation of fibres
- both medial and lateral pectoral nerve are from medial cord
C
CONGENITAL SCOLIOSIS XR Left side thoracic curve with wedge? What is most important in your workup?
a. Echocardiogram
b. Renal Ultrasound
c. EMG
d. Bracing
A
2024F consensus
What is the most common site of PIN compression?
a. Arcade of Froshe
b. ECRB
c. Anconeus epitrochlearis
d. Leash of Henry
A
Possible areas of compression of the PIN in the radial tunnel include (from proximal to distal) fibrous bands anterior to the radiocapitellar joint, the leash of Henry (radial recurrent artery anastomosis), medial edge of ECRB, the arcade of Frohse (proximal edge of the supinator), and distal edge the supinator. The most common site of compression is the arcade of Frohse.[11] A risk factor for developing radial tunnel syndrome is repetitive prono-supination with the elbow at 0 to 45 degrees of flexion.[1] This type of repetitive motion increases pressure in the radial tunnel, with resultant nerve irritation.
In elderly patients with distal humerus fracture treated non-op, what is TRUE (repeat)
- 2/3 will have good outcome with 20-130 ROM
- 1/3 will have good outcome with 40-90 ROM
- Will not do well as the cast is not tolerated and cause stiffness
- High non-union rate of 80%
A
Desloges W, Faber KJ, King GJ, Athwal GS. Functional outcomes of distal humeral fractures managed nonoperatively in medically unwell and lower-demand elderly patients. J Shoulder Elbow Surg. 2015 Aug;24(8):1187-96. doi: 10.1016/j.jse.2015.05.032. PMID: 26189804.
At a mean of 27 ± 14 months of follow-up, 68% (13 of 19) of patients reported good to excellent subjective outcomes.
When the injured was compared with the uninjured side, extension (22° ± 11° vs 8° ± 12°; P = .025) and flexion (128° ± 16° vs 142° ± 7°; P = .002) were significantly worse in the injured elbows
Study had 74% union rate
Regarding periprosthetic proximal humerus fracture treatment which one of the followings is TRUE?
- Periprosthetic fracture will heal in the same rate as non-periprosthetic fracture
- It will require surgical treatment most of the times
- The humeral and glenoid components have to be revised
- With significant bone loss it can be managed with proximal humerus Allograft-prosthetic composite (APC) and long stem
D
A. Evidence provided from orthobullets
- Overall union rate of peri-prosthetic humerus fractures is <50%
B. Evidence provided from Black-Book.
- Broken down by intraoperative fractures vs post-operative fractures
- Three types of fracture via Wright/Cofield
- A – If component is not loose, tiral non-op
- B – Generally OR
- C – Trial non-op
C. Revise components if they actually need revision, if loose or perhaps don’t match up with revision component, etc.
D. In rTSA good evidence for APC/ long stem components.
When doing ORIF for a comminuted distal radius fracture in 22 years old the DRUJ was found to be reducible but unstable & ulna is dislocating dorsally. There is just a very small ulnar tip fracture. What is the BEST option?
(repeat)
- Place a radioulnar pin in full pronation
- Repair the ulnar styloid with a tension band wire and start ROM 1-2 weeks later
- Cast above elbow in supination for 6 weeks
- Repair the TFCC (open or arthroscopically) and start ROM 1-2 weeks later
C
2024F consensus
Patient with OI, which type is autosomal recessive
a)1
b)2
c)3
d)4
C
Consensus
a)1: AD
b)2: AR
c)3: AR
d)4: AD
A study done comparing Volar locking plates and cast immobilization for DRF. 200 patients were enrolled. DASH scores were 5 points higher for VLP compared to cast, p<0.01. The MCID for DASH is 10 points. 250 people needed for power of 80%. What is true?
a) clinically significant because p< 0.05
b) clinically not significant because underpowered
c) Clinically not significant because MCID is higher than 5
d) because only had 200 participants, a type I error was made”
C
MCID was 10, our study showed a difference of 5… statistically significant, but not clinically meaningful.
AOFE, what is false (All of the following except):
a. Achondroplasia is AR with FGFR3 Mutation
b. SED congenita is AD with T2 collagen defect
c. Pseudoachondroplasia often have both genu valgum and genu varum
d. Hypochondroplasia is AD, presents later
A
Young female polytrauma patient. Given X-rays that show an open book pelvis, femoral shaft and midshaft humerus fractures. After resuscitation, her pH is 7.2, Lactate 7, BE -11. What is the most appropriate treatment at this time?
a. ORIF pelvis, IMN femur, ORIF humerus
b. Ex fix pelvis, IMN femur, splint humerus
c. ORIF Pelvis, IMN femur, splint humerus
d. Ex fix pelvis, ex fix femur, splint humerus
D
All are a cause for patella instability recurrence except?
a. Miserable malallignment syndrome
b. Trochlear dysplasia
c. Decreased TT-GT
d. Augmented angle Q
C
In recurrence, the most evidence I could find was for Trochlear dysplasia.
Miserable malalignment syndrome is a risk factor
- a term named for the 3 anatomic characteristics that lead to an increased Q angle
- femoral anteversion
- genu valgum
- external tibial torsion / pronated feet
Trochlear dysplasia is an osseous risk factor
Decreased TT-GT is opposite of what would be expected in instability.
CT scan
- TT-TG distance
- measures the distance between 2 perpendicular lines from the posterior cortex to the tibial tubercle and the trochlear groove
- >20mm usually considered abnormal
Augmented Q angle – not sure what augmented means, but obviously increased is bad.
Called to see a patient in ICU with a obnubilated patient comminuted radius fracture. What is the most suspicious finding for compartment syndrome?
a. Patients freaks with raising of middle finger to put oxygen probe on
b. Compartment pressures of 40 and diastolic pressure of 75
c. Firm compartments with blistering and bruising
D. Story that patients was down for 24 hours before being brought in
B
XR of a SH3 medial mal/transphyseal distal fibula injury. what is the mechanism?
a) Supination/plantar flexion
b) supination/external rotation
c) supination/inversion
d) pronation/eversion/external rotation
C
Regarding the epidemiology of lumbar burst fractures, which of the following statements is TRUE?
a) Burst fractures most common thoracolumbar fractures.
b) 20% of lumbar burst fractures will have an associated neurological deficit.
c) Most commonly occur in females in the 2nd and 3rd decade of life.
d) Fall from height 80% of burst fracture
B
consensus
Myositis ossificans which is true?
1) Mature lesion can adhere to bone
2) X ray findings are present within a few days of symptom onset
3) Those that present late still have pain
4) In the acute phase there is significant edema on MRI
D
NOT CONSENSUS (A), but D is absolutely the right answer here.
A: Possibly true: as lesion progresses, pattern of mature, lamellar bone develops. Have areas of internal fat. Will run in parallel with long axis of muscle. Once lesion has matured there is a radiolucent cleft between the mass and adjacent bone, differentiates from parosteal sarcoma. (See x-ray). Mature lesions ARE SOMETIMES adherent to adjacent bone
B: False, early stage has no calcifications on x-ray
C: False, “Symptoms often abate as the lesion matures. Consequently, patients who present late may not have significant symptomatology.”
D: True. T2 weighted MRI demonstrates marked inflammatory edema about the mass. MRI is the best single modality. Appearance can vary depending on the stage. Acute phase = heterogeneous intensity on T1 (blood), T2 hyperintensity, lack of lesion enhancement. Different from abscess which will have uniform high signal intensity on T2, low signal intensity on T1 and peripheral enhancement. MO can appear similar to a soft tissue sarcoma. (see MRI)
In tuberculosis of the spine, all of the following are part of treatment except:
a. In healed disease, bracing is of little use in the presence of spinal deformity
b. Deformity correction is more difficult in active vs. healed disease
c. Antibiotic regimen for tuberculosis is mult-drug
d. Treatment in active disease comprises of transpedicular decompression and posterior fixation
B
JBJS 2020 TB of the spine
https://journals-lww-com.ezproxy.lib.ucalgary.ca/jbjsjournal/fulltext/2020/04010/tuberculosis_of_the_spine.10.aspx
Surgical correction of spinal deformity is easier to perform in active disease than in healed disease.
Type III supracondylar fracture. 2 crossed pins are used. Post op ulnar nerve palsy. What is true?
A. Remove the medial pin and put it medially in a better position.
B. Remove the medial pin and put a second radial pin.
C. Remove the medial pin and perform an ulnar nerve transposition and put the medial pin again.
D. No intervention as it will likely improve on its own.
D
2024F consensus
AP X-ray of wrist with “piece of pie” sign. What is the diagnosis?
a. Perilunate dislocation
b. Lunate dislocation
c. Kienbock
d. SL dissociation
B
Tucker et al 2013 BMJ Case reports. Radiological signs of a true lunate dislocation.
“The piece of pie” classical triangular shape of the lunate represents the lunate on true AP x-ray for a true lunate dislocation
Also referred to as the Napolean Hat where the lunate looks triangular instead of trapezoidal
What is a contraindication to cervical disc replacement?
a. Osteoporosis
b. Remaining disc height of 5mm
c. Posterior structures intact
d. Posterior facet OA
A
D is consensus, but it is this would only be correct if it said “severe posterior facet OA”
Question regarding outcomes of “Hip ATTACK” trial
a. CVA rates same in both groups
b. MI rates greater in early (<6h) group
c. Delirium rates same in both groups
d. Mortality rates same in both groups
D
Shown x-ray with convex left short segment, acute, upper thoracic scoliosis and a second x-ray with pseudarthrosis of distal 1/3 tibia shaft. What is the most likely diagnosis?
a. NF
b. OI
c. Fibrous dysplasia
d. Langerhans cell histiocytosis
A
Given an XR of a remote distal tibia malunion - which of the following is true regarding supramalleolar osteotomies?
a. Lateral opening wedge is the preferred approach
b. Given the deformity is <20 degrees a insular osteotomy is not indicated
c. 25% loss of cartilage in the tibiotalar joint is a contraindication to SMO
d. Correcting the deformity proximal to the joint line will cause medialization of the joint line
D
Terrible Triad, LUCL needs to be protected. Which is ok?
a. No extension except in supination
b. no extension except in pronation
c. ok to flex and extend, pronation all time
d. ok to flex and extend, supination all times
D
Deltoid Ligament Question:
a. Need both superficial and deep ruptured to cause valgus instability
b. Superficial controls external rotation of the talus
c. Deep is a single band that originates on the posterior colliculus
A
Related to vertebral artery injury in trauma, which is TRUE?
A. Highest risk of injury at C6
B. Most patients are symptomatic
C. Higher risk at V3
D. MRA is more sensitive than CTA at detecting injury
A
35 yo with complete pantalar dislocation (tibiotalar, subtalar and talonavicular, no fracture). What is the most common complication?
A. Loss of Plantar sensation
B. Post traumatic arthritis
C. Recurrent instability
D. Avascular necrosis
D
Consensus D
5 year old with 3 months limp, no/min pain. Shown X-rays of bilateral hips with what looks like pillar B/C bilaterally. What most likely would point towards a diagnosis other than LCP?
A:Age
B:No pain
C:Whole head involvement
D: Bilateral synchronous involvement
D
What is true regarding pronator syndrome?
A: Not associated with carpal tunnel
B: Night time symptoms
C: Tinel at the wrist
D: Dysesthesias in the palm
D
What is true in regards to ACI?
a. Less than 30% of ACI and microfracture treated OCD lesions show radiographic features of OA at 15 years of follow up
b. ACI and microfracture have equivalent long term outcomes
c. A contraindication to ACI is 25% articular chondral loss
B
A patient <50 years old with a femoral neck
a. When treated at a level 1 trauma center failure rate is rare (less than 10%)
b. Fixed angle devices are better than a multi screw construct
c. Associated femoral shaft fracture decreases union rate of the femoral neck fracture
d. Displaced and undisplaced fracture have the same rate of union
B
Infantile scoliosis. What is true?
- More than 75% resolve:
- Right sided curves most common
- RVAD>10 deg associated with higher risk of progression
A
JPO 2019 The Natural History of Early-onset Scoliosis
1. JPO 2019 in patients who do not have rib overlap (phase 1 ribs), quantification of the rib vertebral angle difference of Mehta can help sort patients who are unlikely to progress, with rib vertebral angle difference <20 degrees, from those who are likely to worsen.
10 year old boy soccer competitive, ACL rupture, most appropriate?
A)Bone tendon bone
B)Anatomic tunnel (femoral and tibial) plus LET
C)All epipheseal tunnel
D)Extra articular using IT band
C
2024F consensus
Sinus tarsi vs. extensile lateral, what is true of the sinus tarsi approach:
a. more sural nerve injury
b. better posterior facet reduction
c. worse outcomes
d. shorter operative time
D
63M with OPLL and cervical myelopathy symptoms. They provide you with XRs and CT that show you he has OPLL and that he has no kyphosis. What is the most appropriate management option:
a. ACDF
b. Anterior corpectomy and interbody cage fusion
c. Multilevel posterior laminoplasty
d. Posterior laminectomy and fusion
D
What are the deforming forces in a Bennet fracture? (repeat 2019)
a. APL,Adductor Pollicis, EPL
b. APB, Adductor pollicis, EPL
c. EPB, APL, EPL
d. Some other wrong combination
A
Desmoid tumours are locally aggressive soft tissue tumors. What is true regarding them?
- Multifocal involvement is associated with Gardner syndrome
- Like other soft tissue tumors, they are painless
- They have metastatic potential
A
Which of the following is true regarding distal tib/fib fractures?
a. Spiral fractures are associated with intraarticular extension 10% of the time
b. Non-union rates are high if you plate an associated distal fibula fracture
c. Compared to infrapatellar nailing, suprapatellar nailing has a lower rate of malreduction
d. Compared to infrapatellar nailing, suprapatellar nailing has a higher rate of anterior knee pain.
C
Which of these is not a risk factor for navicular stress fracture:
A) pes planus
B) metatarsus adductus
C) equinus contracture
D) anterior ankle impingement
A
68M with 3 months of left hip pain now with difficulty walking. CT and plain film show large lytic lesion in the left femoral neck. Biopsy confirms multiple myeloma. All of the following are true except:
A) Hypercalcemia associated with MM can be treated with bisphosphonates
B) Lesions can sometimes be cold on bone scan
C) Mirel score greater than 9 is an indication fo prophylactic fixation
D) Appropriate management includes radiation of the lesion followed by CMN
D
Patient got into a motocycle accident, Gustillo 3B tibia fracture with 4 cm bone deficit. Appropriate orthopedic management was done (I/D, intramedullary nail, soft tissue coverage). Which of the following is not a risk factor for non-union.
a. BMI > 35
b. Tobacco cessation is shown to decrease non-union rates
c. Cortical deficit
d. High energy mechanism
A
2024F consensus
Shoulder fusion - all are contraindications except:
a. Bilateral
b. Charcot
c. Brachial plexus injury
d. Non functional serratus
C
