All Orthopaedics II Flashcards
posterior column
- quadrilateral surface
- posterior wall and dome
- ischial tuberosity
- greater/lesser sciatic notches
Judet views
45 degree oblique views
obturator oblique
- shows profile of obturator foramen
- shows anterior column and posterior wall
iliac oblique
- shows profile of involved iliac wing
- shows posterior column and anterior wall
roof arc measurements
help to define fracture pattern stability
- considered stable if the fracture line exits outside the weight bearing dome of the acetabulum
- defined as > 45 degrees on AP, obturator and iliac oblique views
- not applicable for associated both column or posterior wall pattern because no intact portion of the acetabulum to measure
what are the indications for acetabular ORIF?
patient factors
- <3 weeks from date of injury
- physiologically stable
- adequate soft-tissue envelope
- no local infection
- pregnancy is not contraindication to surgical fixation
fracture factors
- displacement of roof (>2mm)
- unstable fracture pattern (e.g. posterior wall fracture involving > 40-50%)
- marginal impaction
- intra-articular loose bodies
- irreducible fracture-dislocation
what are the approaches for the acetabulum?
anterior
- ilioinguinal
- iliofemoral
- modified stoppa
posterior
- Kocher-Langenbach
combined
- extended ilifemoral
factors considered for fiaxtion methodology to the acetabulum
- location (column and/or wall) and level (high or low) of the fracture pattern
- amount of displacement
- marginal impaction
- assoicated injury
fixation modalities of the acetabulum
column fixation strategies
- reconstruction bridging plate and screws
- percutaneous column screws
- cable fixation
wall fixation strategies
- bridge plate and screws
- lag screw and neutralization plate
- spring (buttress) plate
responses to initial fluid resuscitation*
- Vital signs
- Estimated blood loss
- Need for more crystalloid
- Need for blood
- Blood preparation
- Need for operative intervention
- Early presence of surgeon
Etiology volar subluxation associated with ulnar drifting of digits
- joint synovitis
- radial hood sagittal fiber stretching
- concomitant volar plate stretching
- extrinsic extensors subluxate ulnarly
- lax collateral ligaments allow ulnar deviation deformity
- ulnar intrinsic contract further worsening the deformity
- wrist radial deviation further worsens
- flexor tendon eventually drifts ulnar
Charcot-Marie-Tooth disease (CMT) cavus foot
- First ray is plantar flexed due to relative unopposed pull of the peroneus longus (peroneus longus > tibialis anterior)
- Hindfoot pulled further into varus because of relative unopposed pull of the posterior tibial muscle (posterior tibial > peroneus brevis).
- Plantar-flexed first ray and hindfoot varus leads to external rotation of distal tibia and fibula
- Intrinsic (extensor digitorum brevis, extensor hallucis brevis, interossei) wasting leads to overpull of extrinsics (EHL, EDL, FHL, FDL), which causes claw-toe deformity
indecations of surgical treatment of Scaphoid fracture?
- ■ proximal pole fractures
- ■ displacement > 1 mm
- ■ 15° scaphoid humpback deformity
- ■ radiolunate angle > 15° (DISI)
- ■ intrascaphoid angle of > 35°
- ■ scaphoid fractures associated with perilunate dislocation
- ■ comminuted fractures
- ■ unstable vertical or oblique fractures
features as cauda equina syndrome
- • saddle anaesthesia
- • loss of bladder reflex: urinary retention
- • loss of bowel reflex: incontinence
- • lower limb motor weakness, paraesthesia and numbness
POOR candidates for TAA
- -Chronic infection
- -Insensate foot
- -severe multiplanar deformity
- -Charcot
- -Talus osteonecrosis
- -Bad soft tissues
- ankle instability
- obesity
- young laborers
TFCC components
- central articular disc
- meniscal homologue
- volar and dorsal radioulnar ligaments
- ulnolunate and ulnotriquetral ligament origins
- floor of the ECU tendon sheath
entry point of the pedicle screw is defined as the confluence of any of the four lines
- Pars interarticularis.
- Mamillary process.
- Lateral border of the superior articular facet.
- Mid transverse process
Musculoskeletal Infection Society (MSIS) Diagnotic Criteria for prosthetic joint infections
Major criteria (diagnosis can be made when [1] major criteria exist)
- sinus tract communicating with prosthesis, or
- pathogen isolated by culture from 2 separate tissue/fluid samples from the affected joint
Minor criteria (diagnosis can be made when [4/6] of the following minor criteria exist)
- elevated ESR (>30mm/h) or CRP (>10mg/L)
- elevated synovial WBC (>1,100cells/ul for knees, >3,000cells/ul for hips)
- elevated synovial PMN (>64% for knees, >80% for hips)
- purulence in affected joint/ this finding alone is insufficient /fluid from metal-metal articulation, gout, etc. can resemble pus
- pathogen isolation in 1 culture
- >5 PMN per hpf in 5 hpf at x400 magnification (intraoperative frozen section of periprostehtic tissue)
Post-traumatic arthritis after tibial plateau #, rate increases with
- meniscectomy during surgery
- axial malalignment
- intra-articular infection
- joint instability
Indicators of adequate resuscitation
- MAP > 60
- HR < 100,
- Urine Output 0.5-1.0 ml/kg/hr (30 cc/hr),
- serum lactate levels (most sensitive indicator as to whether some circulatory beds remain inadequately perfused (normal < 2.5 mmol/L)
- Gastric mucosal ph (Normal >7.3),
- base deficit normal -2 to +2
risk factors of clavicle non-union
- fracture comminution (e.g, Z deformity)
- fracture displacement
- female
- advancing age
- smoker
Distal humerus anatomical alignment
30˚ anterior, 6˚ valgus, 5˚ IR
Achilles tendon injury
Non-surgical treatment of Achilles tendon
GMFCS FOR CP
McKee (JSES 2009) RCT of TEA vs ORIF for elderly patients with intra-articular distal humerus fractures
- Improved functional outcomes as measured by DASH and MEPS in TEA (at early time points, equal later)
- Decreased OR time in TEA
- No difference in re-operation rate
- No difference in ROM (trend towards TEA)
- No difference in complications
JAAOS 1998 Amputations of the Fingers and Hand: indications fro Replantation Indications
- Loss of a thumb
- Multiple digit amputation
- Amputations at or proximal to the palm
- Pediatric finger amputations at any level
- Single digit amputation in flexor tendon zone 1
Contra-indications for reimplantation
- Single digit amputations through zone II
- Severe crush
- Mangling
- Heavy contamination
- Segmental injuries
- Prolonged warm ischemia time
- • Warm ischemia time should not exceed 12 hours for digits and 6 hours for amputated parts with substantial muscle
- • Cold ischemia time 24 hours for digits and 10-12 hours for limbs
What is ISIS?
Bhandari M (JOT 2005) IM Nailing following external fixation in femoral and tibial shaft fractures
- “Increased rate of infection with external fixation > 28 days, requires pin holiday to decrease risk”
- Pin holiday of > 14 days has increased infection risk vs < 14 days
How do you manage Stiffness after TKA?
When is it safe to perform a percutaneous sacroiliac (SI) screw?
1cm distance between the S1 and S2 neuroforamina
The Hawethorne effect is minimized by which of the following?
Blinding subjects to treatments being compared
Which of the following is the correct mechanism of action of Forteo?
Activates osteoblasts, stimulating new bone formation
. What is the NOT associated with a lesser arc injury
Volar radiolunate ligament tear
ways to minimize the risk of Nerve injuries following elbow arthroscopy
- Ensuring joint is maximally insufflated with fluid at all times
- Drawing out surface landmarks at start of procedure
- Using a needle to landmark portals prior to making an incision and inserting instruments
lateral position in acetabular ORIF Indications
- posterior wall and lip fxs (can use skeletal traction when using lateral position)
- allows for femoral head dislocation
- position of choice for joint arthroplasty
- allows buttock tissue to “fall away” from the field
prone position acetabular ORIF indications
- for transverse fx (flex the knee to prevent stretching of sciatic nerve)
- femoral head is maintained in reduced position throughout procedure
- improves quadrilateral surface access
- improved access to cranial and anterior aspect of posterior wall fractures
infection post-ACL reconstruction
Septic arthritis following ACL reconstruction may appear at any time after surgery, but typically presents either acutely (<2 weeks after surgery) or subacutely (2 weeks to 2 months after surgery). Late presentation (>2 months postoperatively) is relatively infrequent
What is the problem with modular necks in THA?
Associated with soft tissue complications (pseudotumors)
Guyon canal
Ulnar and proximal edge is Pisiform, radial distally by hook of hamate):
a. Zone 1 – Proximal to superficial sensory and deep motor branch – COMBINED SENSORY AND MOTOR LOSS
b. Zone 2 – Includes the deep motor branch – WEAKNESS IN INTRISINCS, NORMAL SENSATION
c. Zone 3 – Includes the Superficial sensory branch – SENSORY LOSS IN HYPOTHENAR EMINENCE, LITTLE FINGER and ULNAR ASPECT OF RING FINGER
plate working distance
length from the fracture to the closest screw on either side of the fracture decreasing the working distance increases the stiffness of the fixation construct
post-op stiffness after TKA
Patient has an open Grade IIIa fracture, what is true?
There is an increased risk of infection with delayed closure
regarding non-displaced scaphoid fractures
Patients will return to work faster with surgery
