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FRCSC Netting > JAAOS Sep2016 > Flashcards

JAAOS Sep2016 Flashcards

1
Q

3 Goals of surgical treatment DDH hip

A

Obtaining a stable concentric reduction
Limiting risk of osteonecrosis
Limiting need for secondary procedures

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2
Q

OUTCOMES OF SURGICAL MANAGEMENT DDH Largely predicated on what 3 domains

A

Functional-McKay Criteria
Development of Osteonecrosis
Radiographic assessment-Severin Classificaiton

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3
Q

WHAT ARE 5 FACTORS ASSOCIATED WITH SUCCESSFUL CLOSED REDUCTION in DDH?

A

-use of preoperative traction
- fluoroscopic assessment of reduction
(arthrogram showing less than 5-6mm of medial dye pool or less than 16% of the size
of the femoral head)
- adductor tenotomy
- postoperative radiographic confirmation of reduction
- procedure timing

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4
Q

WHAT IS THE SAFE ZONE in DDH?

A

90-100 deg of flexion and <55 deg abduction

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5
Q

WHAT ARE 3 RISK FACTORS FOR OSTEONECROSIS following medial open reduction in DDH

A

younger age at time of procedure (<12 months)
need for further surgery
postoperative hip abduction angle >60deg

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6
Q

What are Indications for distal femoral traction pin (5)

A

Pelvic fracture with displaced hemipelvis (ie vertical shear injuries)
acetabular fracture with subluxation, incarcerated fragment, medicalization of femoral head
proximal 1/3 femur fracture
pediatric femur fractures
any condition that precludes a proximal tibia pin (stemmed TKA, unstable ligamentous knee
injury, comminuted tibial plateau fracture)

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7
Q

Contraindications to distal femoral traction (fracture patterns/characteristics)

A

undisplaced acetabular fractures that are stable
acetabular fractures thru the weight bearing dome as they are often irreducible and traction has
limited utility

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8
Q

Where should the distal femoral pin placement

A

medial to lateral >0.7cm proximal to the adductor tubercle near the metaphyseal flare
(basically at the top of the patella)
- avoid intraarticular placement
- can place eccentrically to allow for rodding of the femur with the pin in place

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9
Q

Indications and contraindications to prox tibia pin

A

Distal 2/3 distal femoral shaft fractures
Contraindications:
- ligamentous knee injuries
- tibial plateau fractures

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10
Q

proximal tibia pin dangers (3) and optimal placement?

A

dangers - physis, peroneal nerve, anterior tibial artery

- optimal placement is 2.5cm posterior and 2.5 cm distal to the tibial tubercle

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11
Q

Calcaneal pin use and position?

A

used to temporize tibial shaft fractures
o 2cm distal and 2cm posterior from the medial malleoli
o 3.1 cm radius of from the post-inf calcaneus

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12
Q

Inmates have what disadvantages compared to general population

A
  • lower socioeconomic status
  • are/were unemployed
  • less educated
  • less access to healthcare
  • accumulated untreated injuries before incarceration
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13
Q

What are some health issues facing inmates (4)

A

1) SUBSTANCE ABUSE
a. 67% reg use drugs
b. 38-74% smoke
2) MENTAL ILLNESS
a. 33-50% have a psych diagnosis
b. 25% have substance abuse disorder PLUS mental illness
3) INFECTIOUS DISEASES
a. HIV 1.3%
b. HBV 2.7%
c. HCV 9.8%
i. Compared with 0.4% HIV and combined HBV/HCV 1.1% in the gen
population.

d. MRSA – twice the general population
4) INJURIES
a. 32% report an injury while incarcerated

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14
Q

Name 6 factors affecting delivery of health care to inmates

A
  • safety and security often take precedence over health care needs
  • inmate transfers
  • non-compliance, lack of cooperation of patients
  • delay and interruption of care
  • referral process burdened by admin and security protocols
  • lack of services i.e rehab is non-existent
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15
Q

MANAGEMENT OF SPINAL DEFORMITY IN ADULT PATIENTS WITH NM DISEASE
Goals of tx: (5)

A 
enhance sitting balance
enhance posture
improve lung and GI function
reduce pain and deformity
avoid complication
-increased rates of complication and revision surgery in this
population
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16
Q

SPINAL DEFORMITY IN ADULT PATIENTS WITH NM DISEASE

Etiology (4)

A

Parkinsons

  • Cerebral palsy
  • MS
  • Myopathies (endocrine, paraneo etc)
17
Q 
NEUROMUSCULAR SYSTEM CHANGES
WITH AGING (8)
A

proprioceptive disintegration

  • dystonia
  • rigiditiy
  • polypharmacy
  • soft tissue changes
  • degenerative spinal changes
  • sarcopenia
  • decreasing cognitive function
18
Q

SPINAL DEFORMITY IN ADULT PATIENTS WITH NM DISEASE

Classification (4)

A

ANTEROCOLLIS (DROPPED HEAD SYNDROME)
a. Minimum of 45 deg of cervical flexion which may be partially overcome passively or
actively
PISA SYNDROME (PLEUROTHOTONUS)
a. Defined by >10 deg of lateral thoracic flexion that can be corrected passively or by
supine positioning
SCOLIOSIS
CAMPTOCORMIA (bent spine syndrome)
a. Defined as >45 deg of thoracolumbar flexion with almost complete resolution in the
supine position

19
Q

SPINAL DEFORMITY IN ADULT PATIENTS WITH NM DISEASE

Non-surgical Options (6)

A
  • optimize medical management (levodopa can worsen camptocormia and pisa syndrome)
  • PT
  • Bracing with thoracolumbar anterior distraction
  • Botox iliopsoas injection
  • Lidocaing external oblique injection
  • Deep Brain Stimulation
20
Q 
SPINAL DEFORMITY IN ADULT PATIENTS WITH NM DISEASE
Surgical options (2) and considerations (3)
A

-NOT offered unless there is radiculopathy or myelopathy
- SHORT fusion constructs and decompressions are recommended in pts who have low
motivation to walk
- LONG contructs and major deformity correction are recommended in patients who are highly
motivated to walk AND have minimal major comorbidities.
- Patients are often osteoporotic so this is a major consideration
- Rehab is also a problem due to poor ambulation

21
Q

SPINAL DEFORMITY IN ADULT PATIENTS WITH NM DISEASE

Complications with surgery and %

A
  • medical complication rate of 16.7 % in PD patients (delirium, PE, ACS, Ileus, UTI etc)
  • delirium – rates as high as 66%. Associated with inc LOS and dec outcome scores at 6/12
  • PJK – rates of 4-16% reported in elderly patients
  • Instrumentation failure – as high as 29%
  • Revision – reported rates from 50-86%
22
Q

SPINAL DEFORMITY IN ADULT PATIENTS WITH NM DISEASE

Surgery, correction goals:

A

i. Pelvic tilt <25 deg
ii. C7-S1 SVA <5cm
iii. PI – LL <10 deg

23
Q

ICL – UPDATE IN PEDIATRIC MSK INFECTIONS

etiology: primary and secondary

A

Primary - due to hematogenous spread or direct innoculation

Secondary - due to spread of OM

24
Q

ICL – UPDATE IN PEDIATRIC MSK INFECTIONS

most common organism?

A

S Aureus is the dominant causative agent

25
Q

ICL – UPDATE IN PEDIATRIC MSK INFECTIONS

Other organisms to consider in puncture wounds, exotic countries, sickle cell

A

Pseudomonas in puncture wounds
TB - children are more likely to have extrapulmonary involvment
Salmonella in sickle cell

26
Q

ICL – UPDATE IN PEDIATRIC MSK INFECTIONS

consider in refractory infections?

A

MRSA

27
Q

ICL – UPDATE IN PEDIATRIC MSK INFECTIONS

Labs? (6)

A

LABORATORY MARKERS

  1. WCC
  2. CRP (CRP>200 95% sensitivity)
  3. ESR (>20 94% sensitivity)
  4. Plasma procalcitonin
  5. Blood cultures
  6. Joint aspirate/bone aspirate (>100K, 90% PMN) highly suggestive
28
Q

ICL – UPDATE IN PEDIATRIC MSK INFECTIONS

A

Periosteal reaction
Osteolysis
Joint space widening
Soft tissue changes

29
Q

ICL – UPDATE IN PEDIATRIC MSK INFECTIONS

Differential of limb pain and fever, not infectious (3)

A
  1. TRANSIENT SYNOVITIS
  2. JIA
  3. NEOPLASM
30
Q

Kocher criteria is what?

A 
Predictor of pediatric septic joint
KOCHER CRITERIA
i. Fever
ii. NWB
iii. ESR >40
iv. WBC >12
1. 0/4 - 0%
2. 1/4 - 3%
3. 2/4 - 40%
4. 3/4 - 93%
5. 4/4 - 99%
ii. CRP >20 mg/L (Caird et al) - strong independent predictor
iii. MOST IMPORTANT ARE ELEVATED CRP and WB
31
Q

JIA, what is it?

Age, presents how, where, dx criteria?

A

Age of onset most commonly 7-12

b. Common triad FEVER, RASH, JOINT INVOLVEMENT
c. Often Migratory and polyarticular
d. Knee most common (in 2/3rds) followed by ankle
e. DIAGNOSTIC CRITERIA
i. Fever for 2 weeks
ii. Joint effusion for 6 weeks
a. Joint aspirate
i. 25,000 - 100,000 wcc with >75%PMNs
ii. Intermediate glucose level

32
Q

Neoplastic conditions mimicking infection in paedeatrics

A

Leukemia

b. Osteosarc
c. Ewings
d. Chondroblastoma
e. Primary Lymphoma of bone
f. Metastatic neuroblastoma

33
Q

ICL – UPDATE IN PEDIATRIC MSK INFECTIONS

Indications for surgery? (Septic joint and in OM)

A 
Septic arthritis
o I+D plus abx
OM
o Generally the mainstay of tx is antibiotics
o Surgical indications include
 Subperiosteal abcess
 Evidence of bone necrosis
 Direct invasion of the growth plate
 Contiguous spread to joint
 Failure of medical management
34
Q 
ICL – UPDATE IN PEDIATRIC MSK INFECTIONS
Complications general(6) OM (4)
A 
 Persistent bacteremia
 DVT
 Septic PE
 Pathological fracture
 Growth arrest
 LLD/Angular deformity
 OM long term complications:
o Osteonecrosis
o Chronic osteomyelitis
o Gait abnormalitiies
o Premature arthritis
35
Q

GREEN RESEARCH ARTICLE
THE USE OF MRI IN EVALUATING KNEE PAIN IN PATIENTS AGED 40 YRS AND OLDER
Inclusion Criteria:
- patients over 40 yrs old
- referred for evaluation of knee pain in 2012
What were the results?

A
  • pre-referral use of MRI in 22%
  • Plain xrays ordered pre-MRI in 58%, of these 13% had WB views
  • 17% had >50%loss of joint space
  • 48% of MRIs did NOT contribute to treatment recommendations
  • in patients with>50% joint space narrowing and MRI was considered unnecessary in 95%
36
Q

PREVALENCE OF OBESITY IN PATIENTS WITH LCP
Neal et al
Problem: There is no recent evidence on the prevalence of obesity in patients with LCP
Study Type: Retrospective Cohort study, 150 patients
Inclusion Criteria:
- Any patient presented with LCP over a 5 yr period
Results? (5)

A

-2% underweight
- 50% normal weight
- 16% overweight
- 32% obese (compared with 18% obesity rate for normal population)
- obesity was associated with later walderstrom stage at presentation, Lower median household
income and greater use of government funded health insurance
- Obese patients had a 2.8X lower likelihood of receiving a bony procedure

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