MCQ Flashcards

Question 1

Q

What is true about the sesamoids?

Answer

A

the tibial sesamoid is larger

Blood supply - medial plantar artery and plantar arch

Sesamoid complex transmits 50% of the body weight

Question 2

Q

What are the surgical options for a burst fracture?

Answer

A

Anterior decompression with stabilization

Retropulsion with need for decompression

corepectomy with strut grafting

Posterior decompression with fusion

Instrumentation with distraction, get indirect decompression of the canal

Posterior fusion

Progressive kyphotic deformity

Question 3

Q

Compare two incision distal biceps

Answer

A

both can get PIN

same HO

better flexion with two incision

less LABCN with two incision

Question 4

Q

What are approapriate antibiotics for open wounds

Answer

A

Gustilo 1
- cefazolin
- clinda if allergy
Gustilo 2/3
- cefazolin
- gentamycin
- Farm wounds - penicillin or flagyl
Freshwater (A hydrophilia)
- cipro or ceftazidime
Salt water (vibrio)
- Doxycycline
- ceftaxidime or cipro

Question 5

Q

What is true about NF2?

Answer

A

less common
bilateral acoustic neuroma
no scoliosis

Question 6

Q

What are the indications for treatment of a pediatric proxiaml humerus fracture?

Answer

A

Neer-Horowitz classification
- type I is minimally displaced (< 5mm)
- type II is displaced less than 1/3 of the shaft width
- type III is displaced greater than 1/3 and less than 2/3 the shaft width
- type IV is displaced greater than 2/3 the shaft width
> 6 with the following displacement
- >50% displaced
- > 45 deg angulated
- open
- dysvascular

Question 7

Q

Sites of compression of the ulnar nerve at the cubital tunnel

Answer

A

Arcade of struthers
Medial intermuscular septum
Medial epicondyle
Osborne’s ligament
Between heads of FCU (fasica)
Aponeurosis of FDS

Question 8

Q

What structure causes retrograde ejaculation in the anterior approach to the lumbar spine?

Answer

A

Superior hypogastric plexus

Question 9

Q

What are the releases for a valgus knee?

Answer

A

osteophytes

Capsule

IT (extension)

popliteus (flexion)

LCL

Question 10

Q

What is your approach to factor replacement in a hemophiliac

Answer

A

2 hours pre op infuse with clotting factor calculated to attain 100% activity of normal
Then maintained on continuous infusion of factor to maintain levels at >60% throughout the procedure
- Thereafter, levels are checked every 1 or 2 days.
- A 60% level is maintained by continuous infusion until the patient is discharged.
Home infusion of bolus doses is used to maintain levels of 30% to 60% for at least 2 weeks postoperatively.
If vigorous physical therapy is needed the patient is infused to a 30% level just before therapy
Complications
- hemarthorosis at 4-7 days if it occurs
- infection slightly higher
- risk of stiffness so no concern for instability

Question 11

Q

Complications of talar neck fractures

Answer

A

Subtalar OA
AVN
malunion
In that order, no matter the Hawkins classification, but the risk of each one will go up with subsequent grade
Nonunion is a very low risk

Question 12

Q

What is the incidence of bilateral slip in a SCFE?

Answer

A

General population - 20%

Renal osteodystrophy - 80%

Question 13

Q

What injury pattern has the lowest rate of ligament injury in a tibial plateau fracture?

Answer

A

lateral split

Question 14

Q

Which dwarfism does not have an ustable c-spine?

Answer

A

achondroplasia

Question 15

Q

What is the most common cause of heel pain in the pediatric population?

Answer

A

Sever’s

Question 16

Q

Acceptable alignment of a humeral shaft fracture

Answer

A

< 20° anterior angulation
< 30° varus/valgus angulation
< 3 cm shortening

Question 17

Q

What is true about the genetics and etiology of achondroplasia?

Answer

A

FGFR3 point mutation G380R
- AD
- 80% are spontaneous
  - associated with higher paternal age
Leads to abnormal chondroid production in the proliferative zone
- short long bones
- endosteal ossification
- proximal > distal (?why)
Spine
- narrow interpedicular distance (L1-5)
- narrow foramen magnum
  - mortality, apnea, UMN
  - screen all with MRI who have positive sleep study
- thoracolumbar kyphosis
  - brace when young
  - usually will resolve
- lumbosarcral hyperlordosis
- spinal stensosis
  - narrow pedicles
  - hyperplastic discs
MSK
- genu varum
- rhizomelic shortening
- trident hand

Question 18

Q

What structures are released during plantar fascial release

Answer

A

divide supericial fascia of the abductor hallucis
fascia between abductor hallucis and plantar quadratus is released
- releases the nerve between the two
a portion of the plantar fascia is incised
medial heel spur is resected if present

Question 19

Q

Treatment of unstable PIP fracture-dislocations

Answer

A

Extension block pinning (transarticular)
- reducible joint with tenuous stability
- flex the joint slightly and pin the proximal phalax
CRPP
- reducible joint with tenous stability
- larger fragment ammenable to pinning
- not superior to extension pinning
Dynamic distraction and Ex-fix
- unstable pilon or > 50% (B type fracture)
- off-loads the joint and permits early ROM
Volar Plate arthroplasty
- augmented with button
- proected with k-wire
Hemihamate reconstruction arthroplasty (more for volar fractures)
- section of hamate if measured and transplated
- B type fractures can use hemiH or dynamic ex-fix; no studies to compare the two
- 2 week extension splint then ROMAT
- no long term studies
- easier to do in a more chronic situation where you can’t do a DynEx

Question 20

Q

What is the most common complication of a talar neck fracture?

Answer

A

subtalar OA

Question 21

Q

What are the indications for epiphyseodesis in congential scoliosis

Answer

A

Age <5 years
Site of anomaly in lumbar as opposed to thoracic spine
A curve of five segments or less
A progressive curve <40°
Anomalies consisting of hemivertebrae instead of unsegmented bars
Absence of excessive kyphosis
Absence of neurological deficits, including syrinx, diastomatomyelia and tethered spinal cord

Question 22

Q

What are the MRI characteristics and treatment of an ABC?

Answer

A

MRI - cystic, fluid-fluid levels showing blood and solid components
curettage and grafting with cryotherapy

Question 23

Q

Approach to adolescent bunions

Answer

A

best to wait until skeletal maturity to operate
can not perform metatarsal osteotomies if physis is open (cuneiform osteotomy OK)
surgery indicated in symptomatic patients with an IMA > 10° and HVA of > 20°
severe deformity with a DMAA > 20 perform a double MT osteotomy
technique
- soft tissue procedure alone not successful
- similar to adults if physis is closed (except in severe deformity)

Question 24

Q

What is the most sensitive test to detect OM?

Question 25

Q

What is the best treatment for a 20 yo female with JRA and trashed TN, CC and TC joints?

Answer

A

triple arthrodesis

Question 26

Q

What is the nonopertive treatment of spondylolisthesis?

Answer

A

Asx - non-op, full contact

Sx low grade - PT for pelvic tilt, core strength and hamstring stretches (know the risks and monitor)

Acute - TLSO, better than activity mod alone

Question 27

Q

What are the sensitivity/specificity/PPV/NPV

Answer

A

sensitivity = (true positive) / (true positive + false negative)
- proportion of individuals who truly have a designated disorder who are so identified by test
specificity = (true negative) / (true negative + false positive)
- proportion of individuals who are truly free of a designated disorder who are so identified by test
PPV = (True positive) / (True + False positives)
- proportion of individuals with a positive test who have the disease
NPV = (true negative) / (true + false negatives)
- proportion of individuals with a negative test who are free of the disease

Question 28

Q

What is the typical presentation of a glomus tumor

Answer

A

Small red-blud nodule on gross histoloy
typically in the nailbed
- can occur in other places
- riding or discoloration of the nailbed
20-40 yo
F>M in subungual region only
Triad
- paroxysmal pain
- cold intolerance
- localized tenderness
XR
- may not be helpful
- scalloped osteolystic defect with sclerotic border
MRI
- diagnostic

Question 29

Q

What are indications for surgery of a clavicle fracture?

Answer

A

unstable Group II fxs (Type IIA, Type IIB, Type V)

open fxs
displaced fracture with skin tenting
subclavian artery or vein injury
floating shoulder (clavicle and scapula neck fx)
symptomatic nonunion
posteriorly displaced Group III fxs

displaced Group I (middle third) with >2cm shortening

Question 30

Q

What is the effect of overstuffing a radial head arthroplasty

Answer

A

increased load
limit mobility

Question 31

Q

Anatomy of the blood supply to the hand

Answer

A

Superficial arch
- deep to palmar fascia
- distal to the to the deep arch
- at the level of a line drawn across the palm parallel to the distal edge of the fully abducted thumb
- predominant supply is ulnar artery
  - 1st branch
    - is the deep branch that provides the minor supply to the deep palmar arch
  - 2nd branch
    - is the ulnar digital artery of the little finger
  - 3rd, 4th, 5th, and 6th branches
    - are the common palmar digital arteries
Location compared to nerves
- in the palm, the digital arteries are volar to the digital nerves
- in the digits, the digital arteries are dorsal to the digital nerves
- in the digits, the neurovascular bundle is volar to Cleland’s ligament (ceiling, grayson = ground)
Deep Arach
- deep to the flexor tendons (FDS, FDP)
- proximal to the superficial arch
- at the level of the base of the metacarpals
- predominant supply is the deep branch of the radial artery
  - princeps pollicis
    - runs between 1st dorsal interosseus and adductor pollicis
  - branch to the radial side of the index finger
    - the proper digital artery to the radial side of the IF arises directly from the deep arch
  - branches to the 3 common digital arteries in the 2nd, 3rd, and 4th web spaces
- The deep arch is complete (branches to all digits) in 97% of individuals

Question 32

Q

What are the 5 mechanisms of wear in TJA

Answer

A

Adhesive wear
- most important in osteolytic process
- microscopically PE sticks to prosthesis and debris gets pulled off
abrasive wear
- cheese grater effect of prosthesis scraping off particles
third body wear
- particles in joint space cause abrasion and wear
volumetric wear
- main determinant of number of particles created
- directly related to square of the radius of the head
- volumetric wear more or less creates a cylinder
- V=3.14rsquaredw
- V is volumetric wear, r is the radius of head, w is linear head wear
- head size is most important factor in predicting particles generated
Linear wear
- is measured by the distance the prosthesis has penetrated into the liner

Question 33

Q

What is the treatment for the different stages of PTTI?

Answer

A

Grade 1 - debridment and tendon augmentation

Grade 2 - FDL transfer, medial calcaneal osteotomy, TAL, +/-cotton, +/-evans

Grade 3 - subtalar arthrodesis

Grade 4 - Subtalar arthrodesis with deltoid recon if ankle is flexible

TTC if ankle valgus is fixed

Question 34

Q

Most common presentation of discitis in peds

Answer

A

> 9 back pain

3-9 abdo pain**

< 3 limp, posivite log roll

Question 35

Q

What is ture about NOF?

Answer

A

cortical

metaphyseal/diaphyseal

1-3cm

bubbly - not loculated

Eccentric

Question 36

Q

What is Morquio syndrome?

Answer

A

Mucopolysacharidosis

accumulation of keratn sulfate

presents at 18-24 months, proportionate dwarfism

normal intellegence, waddling gait, genu valgum, thoracic kyphosis, corneal clouding

XR - thick skull, wide ribs, vertebral beaking, coxa vera, unossified femoral head

*** Flex - ex views for C1-C2 instability

Question 37

Q

Complications associated with CTR

Answer

A

inadequate release (most common)
motor branch disection
hypertrophic scar
pillar pain - pain over trapeizium and hamate prominence
- can result from division of the palmar cuteanous branch
- some sources quote this as more common
adhesions
laceration superificial palmar arch
hematoma
recurrence

Question 38

Q

What is the treatment for chronic achilles tear?

Answer

A

Type 1: gap < 2cm = end-to-end repair
Type 2: gap 2 to 5 cm = V-Y lengthening +/- tendon transfer
Type 3: gap >5cm = (FHL) tendon transfer alone +/- V-Y advancement

Question 39

Q

What are the common causes of wear in a metal on poly hip?

Answer

A

Mode 1 - bearing surface (adhesive, abrasive; MOST COMMON)

Mode 2 - bear on non-bearing; neck on poly

Mode 3 - 3rd body wear (poly, debris)

Mode 4 - non-bearing with non-bearing; backside wear (trunionosis)

Question 40

Q

What are the primary and secondary lesions associated with swan neck deformity

Answer

A

Primary
- trauma
- generalized ligament laxity
- rheumatoid arthritis
Secondary
- mallet injury
  - leads to transfer of DIP extension force into PIP extension forcee
FDS rupture
- leads to unopposed PIP extension with an intact FDP
intrinsic contracture
- tethering of the lateral (collateral) bands by the transverse retinacular ligament as a result of PIP hyperextension.
- if the lateral (collateral) bands are tethered, excursion is restricted and the extension force is not transmitted to the terminal tendon, and is instead transmitted to the PIP joint
MCP joint volar subluxation
- caused by rhuematoid arthritis

Question 41

Q

Brachial plexus palsy: preganglionic vs postganglionic

Answer

A

preganglionic
- avulsion proximal to dorsal root ganglion
- involves CNS which does not regenerate – little potential recovery of motor function (poor prognosis)
- lesions suggesting preganglionic injury:
  - Horner’s syndrome
    - disruption of sympathetic chain
  - winged scapula medially
    - loss of serratus anterior (long thoracic nerve),rhomboids (dorsal scapular nerve)
  - presents with motor deficits (flail arm)
  - sensory deficits
  - absence of a Tinel sign or tenderness to percussion in the neck
  - normal histamine test (C8-T1 sympathetic ganglion)
    - intact triple response (redness, wheal, flare)
  - elevated hemidiaphragm (phrenic nerve
  - rhomboid paralysis (dorsal scapular nerve)
  - supraspinatus/infraspinatus (suprascapular nerve)
  - latissimus dorsi (thoracodorsal)
  - evaluation
    - EMG may show loss of innervation to cervical paraspinals
postganglionic
- involve PNS, capable of regeneration (better prognosis)
- presentation
  - presents with motor deficit (flail arm)
  - sensory deficits
- evaluation
  - EMG shows maintained innervation to cervical paraspinals
  - abnormal histamine test
    - only redness and wheal, but NO flare

Question 42

Q

What is true about the use of BMP-2 in open tibia fractures?

Answer

A

BEST

decreased need secondary intervention or subsequant bone grafting

increased healing rate

decreased infection in grade III only

Question 43

Q

Why do you not get lunate AVN with volar dislocation?

Answer

A

radioscaphoid ligament - ligament of testut is intact in all 4 stages of dislocation

Question 44

Q

What is true about anterior subcutaneous transposition and simple decompression for the ulnar nerve?

Answer

A

same functional outcome with higher infection rates with transposition (conchrane review from 2012)

Question 45

Q

Intrinsic tendon thumb insertions

Question 46

Q

What is the most common reason for sudden death in an RA patient?

Answer

A

basilar invagination

Question 47

Q

what is the treatment for schermans kyphosis

Answer

A

< 60 - observe

60-80 and risser < 3 - milwakee brace

>75 in skeletally mature - PSF

Question 48

Q

What additional tests and consults are required for congential scoliosis

Answer

A

Cardiac
- cardiology consult
- echocardiogram
Renal: common to have kidney issues
- renal ultrasound (at minimum)
Neurologic
- spine MRI
  - syrinx
  - tethering
- neurosurg referral

Question 49

Q

What are the surgical priorities of tendon transfers?

Answer

A

elbow flexion (musculocutaneous n.)
shoulder stabilization (suprascapular n.)
brachiothoracic pinch (pectoral n.)
sensation C6-7 (lateral cord)
wrist extension and finger flexion (lateral and posterior cords)

Question 50

Q

What is the most common level of hip dislocation in myelomeningocele?

Question 51

Q

What is an important consideration for myelomeningocele?

Answer

A

Latex allergy

Question 52

Q

What is the true regarding the treatment of OCD of the knee

Answer

A

Stable lesions in a skeletally immature patient should not be treated surgically
Unstable lesions should be treated
- reduce pain
- reduce OA - this is only theoretical
Should be give PT
Nothing to show that OATS or ACI are any better than microfracture
- microfracture should be first line of treatment
Outcomes of microfracture
- Age
- Duration of symptoms
- Lesion size
- Body mass index
- Preoperative activity level >4 (Tegner)
- Previous surgery (microfracture)
- Repair cartilage volume >66%
  - MRI results of defect fill

Question 53

Q

What is your management for an anterior SC dislocation?

Answer

A

> 3 weeks = leave it
< 3 weeks
- closed reduction under anesthesia
- figure 8 brace if acceptable
- leave it if unable to reduce
chronic and painful
- medial clavicle resection

Question 54

Q

What is the most important determining factor in AVN associated with pedicatric femoral neck fracture?

Answer

A

Age 3-8 (after 8 have the ligamentum teres; after 14 have metaphyseal flow)

Dalbet classification
- Type I
  - Transphyseal (IA, without dislocation of epiphysis from acetabulum; IB, with dislocation of epiphysis)
  - 90-100% AVN
- Type II
  - Transcervical 40-50%
  - 50% AVN
  - 15% nonunion
- Type III
  - Cervicotrochanteric (or basicervical) 30-35%
  - 25% AVN
  - 15-20% nonunion
- Type IV
  - Intertrochanteric
  - 10% ANV
  - 5% Nonunion

Question 55

Q

What are the common principles for tendon transfers?

Answer

A

donor must be expendable and of similar excursion and power
one tendon transfer performs one function
synergistic transfers rehabilitate more easily
it is optimal to have a straight line of pull
one grade of motor strength is lost following transfer
only cross one joint
Other concepts
- appropriate excursion
  -

3 cm excursion - wrist flexors, wrist extensors
5 cm excursion - EDC, FPL, EPL
7 cm excursion - FDS, FDP

* appropriate tensioning

Question 56

Q

What is true about the pathology of RA

Answer

A

RF is an IgM antibody associated with RA a number of other autoimmune disorders
- attackes IgG
- monoclonal cells are the primary mediator of tissue destruction
  - present in 1-2% of the general population
prognostic value more than diagnostic value
Diagnositc criteria
- morning stiffness and swelling
- subcutaneous nodules
- positive laboratory tests
  - anti-CCP is the most sensitive
- radiographic findings

Question 57

Q

What are indications for total patellectomy

Answer

A

failed ORIF
infection
tumor
PF OA
47% of the strength of the quads is lost
should reinforce with VMO over the defect (shown to have better outcomes)

Question 58

Q

What are indications to perform corrective valgus osteotomy for coxa vara?

Answer

A

Hilgenreiner’s physeal angle > 60
- <45 unlikely to progress
- >60 will likely progress
Neck-shaft angle < 110
trendelenberg
pain
evidence of progression with serial exams

Important considerations - may need to transfer aductor tubercle to increase tension, monitor for LLD

Question 59

Q

What is the pathoanatomy of a SLAC wrist?

Answer

A

chronic SL ligament injury creates a DISI deformity
scaphoid is flexed and lunate is extended as scapholunate ligament no longer restrains this articulation
scapholunate angle > 70 degrees
lunate extended > 10 degrees past neutral
Resulting forces
- abnormal distribution of forces across midcarpal and radiocarpal joints
- malalignment of concentric joint surfaces
- initially affects the radioscaphoid joint and progresses to capitolunate joint

Question 60

Q

What is the incidence of neuraxial abnormalities with juvinille scoliosis?

Answer

A

Children 3-10 yo
high incidence of neural axis abnormalities (18-25%)
- syringomyelia
  - cyst or tubular cavity within spinal cord (due to increase CSF from tumor, arnold chiari..etc, need to drain it and treat underlying cause)
  - can be seen in a scoliotic curve without rotation
  - can manifest as an asymmetric umbilicus reflex
- Arnold-Chiari syndrome
  - cerebellar tonsil are elongated and protruding through the opening of the base of the skull and blocking CSF flow)
- tethered cord
- dysraphism
- spinal cord tumor

Question 61

Q

What is the enneking tumour grading system?

Question 62

Q

Principles of medical ethics

Answer

A

Respect for autonomy - the patient has the right to refuse or choose their treatment
Beneficence - a practitioner should act in the best interest of the patient
Non-maleficence - “first, do no harm”
Justice - concerns the distribution of scarce health resources, and the decision of who gets what treatment (fairness and equality)
Respect for persons - the patient (and the person treating the patient) have the right to be treated with dignity.
Truthfulness and honesty - the concept of informed consent has increased in importance since the historical events of the Doctors’ Trial of the Nuremberg trials and Tuskegee syphilis experiment.

Question 63

Q

What are the features of Marfan?

Answer

A

Fibrillin Gene

Ortho - arachnodactyly, scoliosis, protrusio, laxity, dislocations, pes planovalgus

Non-ortho - aortic root dilations, aortic disection, mitral valve prolapse, pectus excavatum, pneumothorax, dural exctasia, meningocele

Question 64

Q

What are the sites of compression of the ulnar nerve in the cubital tunnel?

Answer

A

*Arcade of struthers

*Aponeurosis of FCU

*MCL and osborne’s ligament

medial head of triceps

intermuscular septum

medial epicondyle

anconeus epitrochleris

Answer 61

A

Stage I SLAC wrist - scaphoid and syloid
- PA radiograph shows radial styloid beaking, sclerosis and joint space narrowing between scaphoid and radial styloid
Stage II SLAC wrist - scaphoid and entire DR
- PA radiograph shows sclerosis and joint space narrowing between scaphoid and the entire scaphoid fossa of distal radius
Stage III SLAC wrist - capitate and lunate
- PA radiograph shows sclerosis and joint space narrowing between the lunate and capitate, and the capitate will eventually migrate proximally into the space created by the scapholunate dissociation

Answer 62

A

CT - better than MRI to look for the nidus

Answer 63

A

Dorsal IP dislocation
late deformity
- swan neck - due to volar plate injury
- flexion deformity - resolves with PT
Blocks to reduction
- volar plate
- If open injury - FDP dislocation
Treatment
- buddy tape for 3-6 weeks if reducible
- open to get reduction
  - dorsal approach between central slip and lateral bands

Answer 64

A

Pediatric Odontoid fracture

Mechanism of injury
- high velocity flexion
- anterior displacement through the synchondrosis
Acutely
- Usally seen on lateral
- Can get CT to assess
- Flex-ex views if appropriate
- MRI - static if chronic to assess cord
  - Then can do dynamic MRI to assess stability of the fragment
Treatment
- Reduction with Halo or Minerva for 3 months
  - Acute
  - Confirm reduction with XR
  - Confirm healing with fle-ex views
- Usually heals with NO issues
Posterior C1/2 fusion (chronic)
- If no decompression necessary
- Brooks/Gallie - if young
- C1/2 lateral mass screws if older
Posterior Occiput-C2 fusion (unstable os odontoidium)
- For chornic injuries that you need to decompress posteriorly
- Otherwise hard to get your bone graft in

Answer 65

A

lateral Bending
then torsion

Answer 66

A

Vaughan-Jackson syndrome (RA)
- describes the rupture of the hand digital extensor tendons which occur from the ulnar side of the wrist first then moves radially
pathoanatomy
- results when DRUJ instability results in dorsal prominence of the ulnar head which results in an attritional rupture of the extensor tendons
- EDM is the first extensor ruptured.
treatment
- EIP to EDC transfer and distal ulna resection

Answer 67

A

Age - younger age better prognosis
Lesion size less than 4cm2 show better prognosis
Activity level- High impact athletes have worse prognosis though still improved
Increased body weight- worse prognosis
Patello-femoral lesions worse
Better fill of defect on MRI correlated to better clinical results

Answer 68

A

pain out of proportion
systemic
bullae
Fascial edema from infection occludes arterial flow
- promotes spread of infection
- dishwater pus
- Nectrotic skin follows
Most commonly GAS
- diabetic, HIV and malignancy at higher risk (but 50% in healthy patients)

Answer 69

A

myelomeningocele

tethered cord

arthrogryposis

Answer 70

A

number failed divided by the number still being followed

Answer 71

A

Benzodiazepine
- works systemically to reduce spasms and anxeity
- used with caution due to effects of sedation
Bacolfen
- works centrally to decrease GABA receptors
- works to inhibit Ca influx from pre-synapic vessels
- drug of choice for spinal cord pathology in adults
Dantrolene
- works peripherally on the muscles to decrease the release of Ca from the sarcoplasmic reticulum
Botox - not given centrally
- injected into the muscle
- works locally to block release of Ach from pre-synaptic vessels
Tizanidine - new with less sedation than some of the older medications

Answer 72

A

2 screws have higher load to failure
anterior plate with 2 screws is not as stable as native pelvis

Answer 73

A

Rib Phase 1 (>2 will progress)

RVAD/Mheta < 20 (90% will resolve spont)

Cobb < 25

Double major curves progress

Answer 74

A

posterior radial collateral artery

Answer 75

A

neutral dorsiflexion

5 valgus

10 ER

Answer 76

A

Hard palate-arch of the atlas

Lower border of the mandible-C2-3

Hyoid bone-C3

Thyroid cartilage-C4-5

Cricoid cartilage-C6

Carotid tubercle-C6

Answer 77

A

blocks ACTH from release at the pre-synapic vesicles

Answer 78

A

skin overgrowth and boney deformation
genetic mosacism
- often get overgrowth (hemihypertrophy)
- megalospondylodysplasia
at risk of developing tumors

Answer 79

A

Partial ruptures

Proximal tears ( in the muscle or musculotendonous junction)

Sedentary patient

Answer 80

A

<1mm = cast

> 1mm and large = screw

> 1mm and small = k-wire (wagner pinning)

(one=oblique ligament, one=counter tendons)

Answer 81

A

Usually will resolve will closed reduction

Chronic nerve palsy is very rare, pateients complain of weakened power grip due to inability to extend wrist (can treat initially with PT to maintain ROM and then with tendon transfers)

Answer 82

A

Presents with pain with flexion, especially deep flexion
- after activity
- mechanical symptoms
Able to make diagnosis from MRI
Classification
- anterior to ACL
- between ACL and PCL
- posteior to PCL
Treatment
- arthroscopic vs image guided aspiration
- both have good outcomes with limited reported recurrence

Answer 83

A

genus of Gram-negative, aerobic but facultatively anaerobic bacteria
occur in domestic pet bites (dog and cat)
it is not difficult to isolate
treatment
- tetanus, I&D
- clavulin, cipro/flouroquinolone, septra

Answer 84

A

unstable CMC joint

Answer 85

A

Patient Selection

Timing of surgery

Prioritization of restoration

Answer 86

A

type I : < 5mm
type II : < 1/3 of the shaft width
type III : > 1/3 and < 2/3 the shaft width
type IV : > 2/3 the shaft width

Answer 87

A

Stage 1 - radial syloidectomy and scaphoid stabilitzation
Stage 2 - proximal row carpectomry
- CI if there is severe capitate OA
Stage 3 - four corner fusion
- no evidence to show superior to proximal row carpectomy
Wrist Fusion
- option for pancarl OA
- good pain control and return of grip with loss of motion

Answer 88

A

Indications
- spondylolisthesis (low grade)
- degenerative scoliosis
- severe instability
- pseudarthrosis
- recurrent disk herniation
- painful degenerative disk disease
Contraindications
- epidural fibrosis
- active infection
- conjoined nerve roots
  - restrict access to the disk space
- severe disk space collapse
- severe ankylosis
- osteoporosis

Answer 89

A

Hurler
- most severe
- α-L-iduronidase
- Dermatan sulfate, heparan sulfate
Hunter
- Iduronate-2-sulfatase
- Dermatan sulfate, heparan sulfate
San Filipino
- most common
- Heparan sulfate, chondroitin sulfate
Morqouio
- Keratan sulfate, chondroitin sulfate

Answer 90

A

Synovial cutaneous fistula
- avoid by immobilization to allow portal skin healing and closure
Neurovascular injury from portal placement
Anterolateral portal
- risks dorsal intermediate cutaneous branch of superficial peroneal nerve
- most common neurovascular injury
Anteromedial portal
- risks saphenous nerve and vein
Anterocentral portal
- risks dorsalis pedis artery
Posterolateral portal
- risks sural nerve and small saphenous vein
Posteromedial portal
- risks posterior tibial artery

Answer 91

A

Osteoporosis
- reduced bone mass
- Type 1 - postmenopausal
  - trabecular
  - distal radius, VB (and IT hip)
  - reduced Vit D and intake
- Type 2 - elderly
  - trabecular>cortical
  - hip/pelvis (femoral neck)
  - reduced Ca intake
- pain at fracture
- Labs
  - Ca, ALP and urinary Ca are normal
- Tetracycline labelling - normal
- Osetopenia - 1-2.5 SD below 25 yo
- Osteoporosis - >2.5 SD below 25yo
Osteomalacia
- reduce bone mineralization
- generalized bone pain
- appedicular fractures, deformity and looser zones
- Labs
  - will be altered based on etiology (rickets, hyperparathyroid, hypophosphatasia)
- abnormal tetracycline labelling

Answer 92

A

Trasylol, or aprotinin; Historic drug used to prevent blood loss by inhibiting fibrinolysis. Was taken off the market in 2008 due to complications including death

Answer 93

A

Movement Restriction
- More motion below C2
- Controversial - most motion at C2/3 and least at C7/T1
- Some say allows 70% of flexion
Contraindications
- absolute
  - cranial fracture
  - infection
  - severe soft-tissue injury at the proposed pin sites
- relative
  - severe chest trauma
  - obesity, advanced age
  - recent evidence demonstrates an unacceptably high mortality rate in patients aged 79 years and older (21%)
  - barrel-shaped chest
Indications for CT
- possible fracture
- child
Adults
- total of 4 pins
  - 2 posterior pins
    - 1 cm above the pinna
  - 2 anterior pins
    - lateral 1/3 of the eyebrow
    - this is anterior/medial to temporalis fossa
    - this is lateral to supraorbital nerve
- tighten to 4-8 inch-pounds of torque
  - (not foot pounds..)
- have patient return on day 2 to tighten again
Pediatrics
- more pins, less torque
- total of 6-8 pins
- lower torque (2-4 in-lbs or “finger-tight”)
  *

Answer 94

A

Sciatic (Peroneal division)
most often damaged by retractors
- 70% of people will have subclinical findings
Risk factors
- Women
- DDH
- Revsion surgery
Do to the large size of the nerve and the proximal from the end organ recovery is rare
Treatment is supportive
Prevention is the best stragtegy

Answer 95

A

antiprotrusio cage with screws

liner secured PMMA

3 rods to reconstruct posterior column of the acetabulum

Answer 96

A

A; L (lesser), G (greater)
- Occurs in trochanteric region
- Commonly associated with osteolysis and often requires treatment that addresses the osteolysis
- Often will require ORIF with claw plate if adequate bone stalk
B1
- Fx around stem or just below it with a well fixed stem
- Often unreconized B2 - make sure you assess the XR adequatly
- ORIF using cerclage cables and locking plates
B2
- Fx around stem or just below it, loose stem, but good proximal bone stock
- Revision of the femoral component to a long porous-coated cementless stems (fluted, tapered)and fixation of the fracture fragment. Revision of the acetabular component if indicated.
- Bypass # - 1.5cm
- May need ETO to get the component out, fix with circlage wires
B3
- Fx around stem or just below with proximal bone that is poor quality or severely comminuted
- Femoral component revision with proximal femoral allograftn (young) or proximal femoral replacement (old and low demand)
- Consider the demand of your patient - femoral replacement only for low demand patients
C
- Fx occurs well below the prosthesis
- ORIF and with plate

Answer 97

A

better forefoot aduction

Answer 98

A

observational
- researchers observe patient groups without allocation of intervention
- may be either prospective or retrospective
- may be descriptive or analytic
  - descriptive
    - useful for obtaining background information for more advance studies
    - examples
      - case reports
      - case series
      - cross-sectional studies
  - analytic
    - explores the association between a given outcome and a potentially related variable
    - examples
      - case-control
      - cohort
      - meta-analysis
experimental
- researchers allocate treatment
- allows the evaluation of efficacies of therapeutic interventions
- examples
  - double-blinded, prospective, randomized clinical trial is the gold standard for evidence based medicine

Answer 99

A

For a given leg circumfrance, a wider cuff means a lower pressure
ischmeic injury to nerves can occur, thought that muscles are more sensitive than nerves
- > 2 hrs
- 350mmhg - lower
- 250 mmhg - upper
EMG findings in 70% of patients 5 months later
- slower recovery
muscles can recover from periodic ‘rest’ during surgery but nerves do not
Consider the SBP to use the smallest measured pressure
How to reduce tourniquette damage
- wider cuff
- cool extremity
- 2 cuffs, alternate use
- pad the extremity
- don’t use prep

Answer 100

A

PIP subluxation inhibits the gliding arc of the joint and portends a poor clinical outcome (therefore, congruent joint reduction is the most important factor)

articular surface reconstruction is desirable, but not necessary for a good clinical outcome

Answer 101

A

MRI to rule out hematoma/edema/cord transection or missed ligamentous injury

Immoblization (c-collar) 2-3 weeks

monitor

Answer 102

A

EPL control IP flexion

Answer 103

A

latent presentation can occur

delayed is often more severe

worse at presentation=worse prognosis

MRI - can indicate full transection, hemorhage, edema or nothing (the less injury means better prognosis)

Answer 104

A

chronic MCL deficiency leads to calcification next to medial femoral epicondyle

Answer 105

A

LCP

I - spherical congruency

II - spherical congruency with <2mm loss and starting to have changes

III - aspherical congruency with > 2mm and changes

IV - aspherical congruency with flat head and abnormal neck; mild OA

V - aspherical incongruency; abormal head with severe OA

Answer 106

A

A - Observe, casting

B, B/C - containment in fragmentation phase

Later can do abduction/ext or chiari as salvage procedures

Answer 107

A

hardware irritation
hardware migration is rare
stiffness
- strength
- pain
- not associated with immobilization
Nonunion
deep infection
association with OA is unclear

Answer 108

A

Burst - anterior and middle column invovlement with retropulsion into the canal

Neurological deficits
Unstable pattern

Posterior injury
Progressive kyphosis

30 kyphosis
>50% height
>50% canal comprimise

****There is no association of retropulsion with neurological comprimise; the retropulesed fragment if not causing neuro deficiet can be left as the fragment will eventually resorb

Answer 109

A

human synovial cells - special cells in the lining of the synovium

Answer 110

A

Medial - peroneals, EDB, TN capsule

Lateral - FHL, FDL, Tib post

Answer 111

A

Patients change their outcome based on the treatment they receive

Answer 112

A

When they have a new physician

Answer 113

A

pre-op ROM

Answer 114

A

forearm full supination; supination + extension

flexion + valgus force + axial load = rotatory supination torque on forearm

Answer 115

A

A benign chondrogenic lesion caused by an abnormality of chondroblast function in the physis
- chondroblasts escape the physis and proliferate in metaphysis
2nd most common benign cartilage lesion (osteochondroma is most common)
Age & location
- age range is 10-60 years
- occurs in medullary cavity in diaphysis or metaphysis
- hand is most common location (60%)
  - presentation as pathological fractures common
- other locations include the femur (20%) and proximal humerus (10%)
solitary enchondroma
- 1% chance of malignant transformation (chondrosarcoma)
Ollier’s disease (multipe enchondromatosis)
- no genetic predisposition has been identified
- multiple enchondromas in long bone diaphysis
- 10-30% chance of malignant transformation into chondrosarcoma
- however associated with high rate of both skeletal and non-skeletal malignancies
- involved bones are dysplastic
Maffucci’s syndrome
- no genetic predisposition has been identified
- multiple enchondromas and soft-tissue angiomas
- 100% chance of malignant transformation into chondrosarcoma
- increased risk of visceral malignancies (astrocytoma, GI malignancy)

Answer 116

A

Inflammation
- Hematoma forms and provides source of hemopoieitic cells capable of secreting growth factors.
- Osteocytes undergo apoptosis, macrophages, neutrophils and platelets release several cytokines
  - this includes PDGF, TNF-Alpha, TGF-Beta, IL-1,6, 10,12
  - lack of TNF-Alpha (ie. HIV) results in delay of both enchondral/intramembranous ossification
- Fibroblasts and mesenchymal cells migrate to fracture site and granulation tissue forms around fracture ends
- during fracture healing granulation tissue tolerates the greatest strain before failure
- Osteoblasts and fibroblasts proliferate
- inhibition of COX-2 (ie NSAIDs) causes repression of runx-2/osterix, which are critical for differentiation of osteoblastic cells
Repair
- Primary callus forms within two weeks
  - the mechanical enviroment drives differentiation of either osteoblastic (stable enviroment
    - <2% strain = osteoblasts = intramembranous
      2-10% strain = chondrocytes = enchondral
  - cartilage production provides provisional stabilization
  - Type II collagen (cartilage) is produced early in fracture healing and then followed by type I collagen (bone) expression
  - Amount of callus is inversely proportional to extent of immobilization
Remodeling
- Begins in middle of repair phase and continues long after clinical union
- chondrocytes undergo terminal differentiation
- complex interplay of signaling pathways including, indian hedgehog (Ihh), parathyroid hormone related peptide (PTHrP), FGF and BMP
- type X collagen types is expressed by hypertrophic chondrocytes as the extraarticular matrix undergoes calcification
- proteases degrade the extracellular matrix
- cartilaginous calcification takes place at the junction between the maturing chondrocytes and newly forming bone
- subsequently, chondrocytes become apoptotic and VEGF production leads to new vessel invasion
- newly formed bone (woven bone) is remodeling via organized osteoblastic/osteoclastic activity
- Shaped through
  - Wolff’s law: bone remodels in response to mechanical stress
  - piezoelectic charges : bone remodels is response to electric charges: compression side is electronegative and stimulates osteoblast formation, tension side is electropostive and simulates osteoclasts

Answer 117

A

<5 yo

no kyphosis

<5 segments

hemivertebrae (NOT unsegmented bars)

absence of neurological deficiet

Answer 118

A

LCP - lateral pillar

A - no involvement

B - > 50% lateral pillar height

B/C - lateral pillar at 50%

C - < 50% lateral pillar height

Answer 119

A

NO EDGE LOADING
Functional loads will not result in pain during normal ROM
Small change in direction of functional loads will not result in sudden shift in the joint

Answer 120

A

AP
- Radial height
  - 13 mm
  - _<5 mm shortening _
- Radial inclination
  - 23 degrees
  - _change <5° _
- Articular stepoff
  - congruous
  - _<2 mm stepoff _
LAT
- Volar tIlt
  - 11 degrees
  - dorsal angulation <5° or within 20° of contralateral distal radius

Answer 121

A

IR view

stryker notch

Answer 122

A

attach heel pad to anterior tibia

Answer 123

A

Immune repsonse to heparin 4-10 days following initiation
- less response to LMWH, but present
- type 1 is not immune mediated
skin lesions, chills, fever, dyspnea, chest pain
HIT as likley diagnosis
- timing (4-10 days following start)
- >50% drop in platelets
- presence of DVT with heparin
start WU if >50% drop in platlets
- functional assay
- immunoassay
- U/S to rule out DVT
- CT PE
treatment
- stop heparin/LMWH
- don’t use warfarin until platelets normal
- Dabigatron or direct platelet inhibiter a good options
- avoid platelet transfusion

Answer 124

A

scaphoid flexion

triquetrum extesion

volar flexion lunate

No LT widening

SL angle <30

break in gilula’s arc with superior migration of triquetrum

Answer 125

A

Stage 2 SNAC

Stage 2 SLAC

Stage IIIb, IV Keinbochs

failed implant

severe trauma to lunate

Answer 126

A

in situ arthrodesis, anterior/posterior or posterior alone
- indications
  - unlateral unsegmented bars with minimal deformity
- As risk for crackshaft and may not prevent progression in children
hemiepiphysiodesis
- indications
  - intact growth plates on the concave side of the deformity
  - Cannot use in a patient with unsegmented bars
  - <5 yrs. with curve <40-50
- mixed results
osteotomy
- osteotomy of bar
- for more severe; rigid deformities
hemivertebrectomy
- hemivertebrae with progressive curve causing truncal imbalance and oblique takeoff
  - often caused by a lumbosacral hemivertebrae
- <6 yo
- flexible curve > 40 degrees
- Difficulty procedure requiring both anterior and posterior exposure
spinal column shortening resection
- indications
  - deformities that present late and have severe decompensation
  - rigid, severe deformities
  - pelvic obliquity, fixed

Answer 127

A

Proximal anterolateral
- 2cm proximal, 1cm anterior to lateral epicondyle
- Radial n.
Distal anterolateral
- 1 cm anterior and 1-3cm distal to lateral epicondyle
- 1st portal for supine position
- See radial head, medial side of elbow, coronoid, trochlea, brachialis insertion, coronoid fossa
- Radial and lateral antebrachial cutaneous
Direct lateral (or midlateral)
- “soft spot” portal (in triangle formed by olecranon, radial head, epicondyle)
- Initial site for joint distension before scope is inserted, viewing posterior compartment (capitellum, radial head, radioulnar articulation)
- relatively safe, lateral antebrachial cutaneous nerve
Anteromedial
- 2 cm anterior and 2cm distal to medial epicondyle.
- Place under direct visualization.
- medial antebrachial cutaneous and median
Proximal medial (or superomedial)
- 2cm proximal to medial epicondyle, anterior to intermuscular septum
- viewing entire anterior compartment, radial head, capitellum, coronoid, trochlea
- ulnar and median
Straight posterior (transtriceps)
- 3cm proximal to olecranon, triceps midline (musculotend. junction)
- Elbow partially extended, good for removing impinging olecranon osteophytes and loose bodies from posteromedial compartment
- posterior antebrachial cutaneous and ulnar nerve
Posterolateral
- 2-3 cm proximal to olecranon and just lateral to triceps
- center of anconeus triangle
- Elbow 20-30deg flexion (to relax triceps)
- Best access to posterior compartment, radiocapitellar joint (debridement of OCD capitellum), olecranon fossa and posterior structures
- posterior antebrachial cutaneous and medial brachial cutaneous and ulnar

Answer 128

A

thumb hypoplasia/radial clubhand

VACTERL
Holt-Oram
thrombocytopenia-absent radius (TAR)
Fanconi anemia

Answer 129

A

Regain elbow flexion

Stindler’s flexorplasty

latissiumus dorsi/pec major to biceps

Answer 130

A

Low ALP
High Ca
Normal PTH

Answer 131

A

the common carotid artery as well as the internal carotid artery
internal jugular vein
the vagus nerve (CN X)
the deep cervical lymph nodes

Answer 132

A

Idiopathic vs dystrophic
- idiopathic is more common
- overall, idiopathic will become dystrophic in 65%
- younger age=higher risk
- dystropic progress faster
usually thoracic kyphoscoliosis (type II curve)
- type I curve < 50 deg kyphosis
short, segmented, sharp curve with distorted ribs
XR
- short, segemented
- sharp curve
- vertebral scalloping
- rib pencilling (suseptible to dislocation)
- enlarged foramina
MRI
- dural ectasia
- dumbell lesion
- paraspinal mass
- vertebral scalloping
TX = bracing ineffective
- early in young children (cobb <20)
- >20 = fusion

Answer 133

A

figure of 8 wires with cannulated screws

interfrag screws for comminution

Answer 134

A

vastus medius, adductor magnus, sartorius

femoral artery, femoral vien, saphenous nerve, nerve to vastus medialis

Answer 135

A

43% - osteochondroma
30% - idiopathic
15% - rib resection
12% - soft tissue

Answer 136

A

of people patients who developed the disease in a set period of time

Answer 137

A

5 deg valgus

Answer 138

A

Penecillin

Answer 139

A

>25% deficit
- Infraspinatous sewn into defect (remplissage)
>40%
- Allograft for young patient
- hemi for older patient

Answer 140

A

young, middle age men
- or women in 3rd trimenster
Presents with rapid development of pain and reduced ROM
Differential
- regional migratory OP
- AVN
- neoplasia
usually in the hip; ONLY lower extremity
- thought to be similar to an AVN process that stops
blood tests will be normal but should be done to rule out other causes
XR
- will show demineralization over 3-6 weeks
- 2 years to return, but never collapses
MRI
- will rule out AVN

Answer 141

A

medial talar dome
- usually no history of trauma
- more common
- more posterior
- larger and deeper than lateral lesions
lateral talar dome
- usually have a traumatic history
- more superficial and smaller
- lower incidence of spontaneous healing
- more anterior

Answer 142

A

medial sural cutaneous nerve

Answer 143

A

No increase mortalilty at 3 years

Better function outcome with THA

Increased risk of complications with THA

Reduced risk of re-operation with THA

Answer 144

A

Fibrous Bands

Recurrent radial artery - lesh of henry

Tendonous ECRB

Arcade of Frosch (proximal supinator) (MOST)

Distal supinator (least)

Answer 145

A

dilution of plasma from water retention and therefore low NA
hyponatremia = headache, N/V, confusion
- but do not become volume deplete
treated with water restriction
Must be differentiated from cerebral salt wasting
- loose Na in the urine due to renal insufficiency and become hyponatriemic and hypovolemic
- treat with aggressive fluid resucitaiton

Answer 146

A

commonly ruptured off the femoral insertion

Failed Non-op
Excessive > 10o laxity in Full extension (Associated posteromedial injury)
Associated Cruciate or Meniscal Injuries
Entrapment of MCL ligament inside compartment
Stener lesion - can lay over top of pes tendon if comes off the tibia = much less likely to heal

Answer 147

A

Approach for Surgery
- kocher will allow you to see LUCL
- EDC split will all you to see more anterior
- Arm held in pronation to protect the PIN, 2.6cm distal to the RC joint
indications
- for comminuted fracture with 3 or more fragments
- technique include two type of metal prosthesis, both are in use
  - monopolar prosthesis are better at resisting residual instability
  - pressfit that acts as a stiff spacer
    - risk of loosening
  - bipolar prosthesis that is cemented into the neck of the radius
    - risk of dislocation
  - silicon replacements are no longer used
Sizing radial head
- Size the contralateral head pre-op
- Size to original radial head - thickness and cup
- Trial reduction with visual inspection - most reliable
  - Proximally should line up with less sigmoid notch
  - Lateral UH joint are opposed
    - gapping 0.9mm = 2mm overstuffing
- Flouro
  - Medial and lateral UH joint lines (can’t see this until >6mm)
  - Look for congruency of the medial UH joint
Repair the LCL using the docking technique
- this is one of the most important parts of the technique
complications
- overstuffing of joint that leads to capitellar wear problems and malalignment instability

Answer 148

A

Nonoperative
- double ring splint
- indications
  - can prevent hyperextension of PIP
Volar plate advancement and PIP balancing with central slip tenotomy
- indications
  - progressive deformity
- technique
  - address volar plate laxity with volar plate advancement
  - correct PIP joint muscles imbalances with either
    - FDS tenodesis indicated with FDS rupture
    - spiral oblique retinacular ligament reconstruction
    - central slip tenotomy (Fowler)
DIP Arthrodesis
- Dorsal approach
- Extensor tenodesis with capsulotomy

Answer 149

A

2-3%, 9% with re-operation
- can get ENT for second procedure
- use the same side
likley cause is impingement between ET tube cuff and retractors and continuous compression against the esohpagus
Presents with post-op hoarsness or vocal cord paralysis
- don’t forget to include esphophageal rupture in your diagnosis
if you see it, watch over time
if not improved over 6 weeks than ENT consult to scope patient and inject teflon

Answer 150

A

smoking
advancing age
female
comminution
> 100% displacement

> 2cm shortened
location = lateral 1/3 fractures - medial to CC ligaments are most unstable and have highest risk of nonunion

Answer 151

A

the number to prevent one bad outcome

Answer 152

A

Dorsal PIP dislocation

Type I-Stable
- <30%; stable
Type II-Tenuous
- 30-50%-if reducible in flexion, dorsally based extension block splint
Type III-Unstable
- >50%-ORIF, hamat autograft, or volar plate arthroplasty
Becomes unstable after 40% because they loose the attachments of the collaterals

Answer 153

A

No difference in complication rate
Negligable data to suggest TEA decreases reoperation
Main difference is that TEA has improved functional outcomes (Level 1 evidence)

Answer 154

A

Loosening (36%)
- pins placed more cranial = more loosening
  - just above pinna at equator of head
  - 0.5cm above brow
- ring should be closer to head
- pins should engage at 90 deg angle
- metal rings better than graphite ring
Infection (20%)
- especially with anterior pin in temporalis fossa because
- treat infection with oral antibiotics if pin not loose
- if infection with loose pin then remove pin
Discomfort (18%)
- treat by loosening skin around pin
Dural puncture (1%)
Crainal nerve VI palsy

Answer 155

A

Choosing interventions known to be beneficial on the basis of evidence of effectiveness.
Minimizing the use of marginally beneficial tests, such as the diagnostic zebra-hunt.
Minimizing the use of marginally beneficial interventions, such as the latest generations of antimicrobials for common infections.
Seeking the least costly tests or treatments that will accomplish the diagnostic or therapeutic goal.
Using the natural queue, treating patients in order of appearance unless morally relevant considerations of need and benefit require modification of this approach. - apparently this is flawed
Ranking patients with whom you have an established patient-doctor relationship ahead of unknown or future patients.
Supporting rather than opposing reasonable efforts to conserve health care resources.
Avoiding manipulation of the rules of the health care system to give unfair advantage to your own particular patients.
Resolving conflicting claims for scarce resources justly, on the basis of morally relevant criteria of need and benefit.
Employing fair and publicly defensible procedures for resolution of conflicting or competing claims.
Seeking resolution of unacceptable shortages at the level of hospital management (meso allocation) or through political action at the level of government (macro allocation).
Informing your patients of the impact of cost constraints on care in a humanistic way, as a matter of respect for persons. Embittered blaming of administrative or governmental systems during discussions with the patient at the point of treatment should be avoided.
Developing guidelines for individualization in the face of uncertainty in order to promote a reasonable balance between individual choice and systemic cost control.

Answer 156

A

90% resolve by 2 years

Recovery of biceps by 2 months is good prognosis

Answer 157

A

typically none at birth. After a period of normal growth
coarse facial features
fullness of skin/brows
enlarged tongue
retained epicanthal folds
short neck
hydrocephalus
corneal clouding
inguinal/umbilical hernias
hepatosplenomegaly
otitis media, conductive hearing loss
chronic resp tract infections
cardiac d/o, carpal tunnel syn.

Answer 158

A

palmar cutaneous branch of the median nerve

Answer 159

A

monitor, most will resolve on their own

EMG at 3 months to assess recovery with operative exploration if no evidence of recovery

NOTE - stabs wounds should be explored eariler, and post-surgical can consider EMG eariler

Answer 160

A

multiple hereditary exostosis (MHE)

mutations affect the prehypertrophic chondrocytes of the physis
genetics
- autosomal dominant
- mutations in EXT1, EXT2, and EXT3 genes (tumor suppressor genes)
EXT1 mutation have a more severe presentation compared to patients with the EXT2 mutation including
- higher rate of chondrosarcoma
- more exostoses
- more limb malalignment with less forearm and knee range of motion
- more pelvic and flatbone involvement
prognosis
- 5%-10% malignant transformation to chondrosarcoma in patients with MHE
- proximal lesions more likely to undergo malignant transformation than distal lesions
- most common location of secondary chondrosarcoma is the pelvis (usually occur as low-grade chondrosarcomas)

Answer 161

A

Glut med split with hardinge

Answer 162

A

EIP to EPL
EIP to EDC5
EDC4/5
- EIP to EDC5
- 3/4 side-side
EDC3/4/5
- 2/3 side-side
- EIP - 4/5 side-side
EDC2/3/4/5 without EIP
- use FDS

Answer 163

A

reduced joint is the most important thing
anatomic reduction is less important

Answer 164

A

Member of the Scleroderma family
Calcinosis
Raynaud phenomenon
Esophageal dysmotility
Sclerodactyly
Telangiectasia

Answer 165

A

Pros
- decrease pressure sore
- better ability to conform to limb
Cons
- low strength to weight ratio
- poor resistance to water

Answer 166

A

posterior malleolus fracture

Answer 167

A

lower need for future bone graft

lower rate subsequent soft tissue

lower infection rate (only in Gustilo 3 pattern)

Answer 168

A

Open fracture
High-velocity gunshot or penetrating injury
Vascular injury
Nerve deficit after closed reductiona Distal third (Holstein-Lewis) fractures

Answer 169

A

Serratus anterior - medial
- long thoracic (C5, 6, 7)
Trapezius - lateral
- accessory
Rhomboids - lateral
- dorsal scapular
Treatment
- trapezium strengthening
- eden lange transfer - lateralize levator scapulae and rhomboids
- scapulothoracic fusion

Answer 170

A

limited soft tissue viability
lack of soft tissue coverage
severe contamination
Note - bead pouch or abx PMMA can significantly decreased risk of infection with delayed closure

Answer 171

A

asthetic

less HO

10% improved strength with double

more often LCFN traction injury with single

Answer 172

A

always double glove

waterproof barriers

instrument tie or staples

pass sharp instruments in a bowl

JAAOS 1996

Answer 173

A

posterior tibialis tendon
flexor hallucis longus
flexor digitorum longus

Answer 174

A

Considerations
- transperitoneal has a higher risk of retrograde ejaculation (superior hypogastric plexus)
- if you go from left it’s easier, because easier to mobilize arteries rather than frail vessels
- Common Iliac branch at L4
Incise the rectus and transversalis
Find the arcuate line (fasica of the rectus); incise it and use it to retract the peritoneum
Iliolumbar vessles branch off the internal iliac and need to be ligated for exposure to L4/5
For exposure to L5/S1 the median sacral artery needs to be identified and ligated

Answer 175

A

I - minimal

II - hypoplasia of musculature

IIIA - tendon abnormal, hypoplastic MC, stable CMC

IIIB - tendon abonormal, hypoplastic MC, unstable CMC

IV - floating thumb

V - absent thumb

Answer 176

A

Purely ligamentous - Mayfeild

Stage 1 - SL ligament

Stage 2 - space of poirer (lunocapitate lig)

Stage 3 - UTCC/UL

Stage 4 - lunate dislocation (dorsal radiolunate ligament)

Answer 177

A

Usually operative, requires operative fixation as it requires anatomic fixation of the DRUJ
- volar approach to the radius
  - restoration of the radial bow is key
- dorsal approach to the DRUJ
  - make sure to examine TFCC if does not reduce with the radius
  - typically avulsed off the ulna
Treatment of the ulna
- immobilization in supination (6 weeks)
  - indicated if DRUJ stable following ORIF of radius
- percutaneous pin fixation
  - indicated if DRUJ reducible but unstable following ORIF of radius
  - cross-pin ulna to radius in supination
  - examine the TFCC
  - leave pins in place for 4-6 weeks
- open surgical reduction
  - indicated if reduction is blocked
  - suspect interposition of ECU Tendon
  - Examine and repair TFCC if still unstable
- open reduction internal fixation
  - indicated if a large ulnar styloid fragment exists
  - fix styloid and immobilize in supination

Answer 178

A

Lat dorsi/deltoid/biceps to triceps

PT to ECRB (Or ECRL to ECRB side to side if PIN)

FDS/FCR/FCU to EDC

PL/FDS to EPL

Answer 179

A

used to measure the intrinsic electrical activity of muscles
- activity at rest
- voluntary contraction
- following stimulation
can characterize myopathy versus denervation
- complex repetative DC = myopathy
- fasiculations and fibrillations = denervation
Early following denervation will not see fibrillations
- can assess chronicity
Affected by needle position, age, temp

Answer 180

A

Used primarily in older patients:

Ulnar drift

painful ECU subluxation

radio-ulnar impingement

instability of the ulnar shaft

Answer 181

A

wide resection
chemo

(treated like a bone tumor)

Answer 182

A

Lesion
- fraying of posterior rotator cuff
- posterior and superior labral lesions
- hypertrophy and scarring of posterior capsule glenoid (Bennet lesion)
- cartilage damage at posterior glenoid
Associated with GIRD

Answer 183

A

Genetics - autosomal dominant (AD) and recessive (AR) inheritance patterns
- AD linked to a mutation of the gene encoding filamin B
- AR linked to carbohydrate sulfotransferase 3deficiency
Normal intellegence
Multiple dislocations (hyperlaxity)
clubfoot
cervical kyphosis (60%)
- clinical important because often requires fusion for instability
- can present as myelopathy or with UE weakness
scoliosis
spatulate thumbs

Answer 184

A

contraindications to functional bracing
- severe soft tissue injury or bone loss
- unreliable patient
- polytrauma
- brachial plexus injury
- proximal one-third humeral fracture
- inability to maintain reduction (segmental fracture)
- radial nerve palsy is NOT a contraindication to functional bracing

Answer 185

A

Coxa magna

Coxa plana

short femoral neck

Answer 186

A

***imbalance of the musculature

FDS tear - overpull of FDP

mallet finger - ext at PIP

intrinsic contracture

MCP volar subluxation

Answer 187

A

< 10° of coronal plane
< 20° of sagittal plane deformity
no more than 2cm of shortening
< 10° of rotational malalignment

Answer 188

A

Intrinsic minus hand (or tight extrinsics)
causes
- ulnar nerve palsy
  - cubital tunnel syndrome
  - ulnar tunnel syndrome
- median nerve palsy
  - Volkmann’s ischemic contracture
  - leprosy (Hansen’s disease)
- failure to splint the hand in an intrinsic-plus posture following a crush injury
- Charcot-Marie-Tooth disease (hereditary motor-sensory neuropathy)
- compartment syndrome of the hand
Pathoanatomy
- loss of intrinsics
  - leads to loss of baseline MCP flexion and loss of IP extension
- strong extrinsic EDC
  - leads to unopposed extension of the MCP joint
  - remember the EDC is not a significant extensor of the PIP joint
  - most of the MCP extension forces on the terminal insertion of the central slip come from the interosseous muscles
- strong FDP and FDS
  - leads to unopposed flexion of the PIP and DIP
Tests
- ulnar nerve worse in 4/5
- median nerve worse in 2/3
- if the MCP is flexed, the IP joints will extend
  - opposite of bunnels test

Answer 189

A

Touniquette; aggressive debridement of all affected tissues including questionable tissues; meticulous hemostasis
Zone 1
- diagnosis (histology); grey, dead fascia with dishwater pus, foul smelling, hemorhhagic bullae with necrotic skin; send culture from here
Zone 2
- diagnosis (cultures); woody erythema with small bullae (potentially salvagable); can estabilish border with blunt finger disection
Zone 3
- healthy tissue, need to resect to this level with a margin of 5-10mm
Post-excision
- no VAC; silver dry dressing; inspect wound with-in 24 hours

Answer 190

A

1) mets (distant mets the most important factor for any staging system)
2) tumour grade (represents a tumours ability to metastasize)
3) size
4) compartmentalization
5) tumour depth- controversial as a prognosticator

Answer 191

A

IMA <15, HVA <30 = distal

IMA > 15, HVA > 30 = proximal

hypermobile first ray = lapidus

arthritis or progressive = fusion

congruent with high DMMA (>20) = consider double osteotomy

Answer 192

A

plantar release

Tendon transfer

dorsiflexion first ray

+/- jones

Answer 193

A

Affect synovial joints (there are 22)

C1-C2 can lead to both basilar invag and atlantoaxial instability

Lateral masses can be affected and contribute to AA instability

Answer 194

A

Same healing time, weaker bone

Answer 195

A

First - hand packed, no plug

Second - cement plug, gun, canal preparation with brush and adrenaline

Third - vacum, retrograde filling, pressurization, centralizer

Answer 196

A

pressure goes up with both flexion and extension

Answer 197

A

aseptic osteonecrosis of the medial clavicle

red joint

ESR/CRP/WBC/Rheum work-up are normal

MRI - necrotic bone islands

Answer 198

A

Cougling and Shurnas

Changes the arch of use due to dorsal osteophytes, >10 deg of motion is not needed for a normal gait, and in fact push-off improves following fusion in these patients
Pathology due to increased strain across the MTP joint
Grade 0
- Stiffness with normal XR
Grade 1
- mild pain at extremes of motion
- mild dorsal osteophyte, normal joint space
Grade 2
- moderate pain with range of motion increasingly more constant
- moderate dorsal osteophyte,
Grade 3
- significant stiffness, pain at extreme ROM, no pain at mid-range
- severe dorsal osteophyte, >50% joint space narrowing
Grade 4
- significant stiffness, pain at extreme ROM, pain at mid-range of motion
- same as grade III

Answer 199

A

Bennet fracture

Abductor pollicis longus

extensor pollicis longus

adductor pollicis

Answer 200

A

>10-15 deg varus/valgus
- compared to contralateral side
grade 3 tear (will open in extesion and flexion)
- >35 deg of opening
  - extension - accessory
  - 30 deg flexion - proper
- no end point
stener lesion
- may be able to palpate a lesion

US and MRI can help aid the diagnosis, but usually the diagnosis is made on physical exam

Answer 201

A

Increased DMMA

Answer 202

A

ABC

osteoblastoma

osteoid osteoma

ostosarcoma

Answer 203

A

Acrosyndactyly (ring syndrome)

Poland syndrome

Apert syndrome

Carpenter syndrome (acrocephalopolysyndactyly)

Answer 204

A

Inverted Brachioradialis
- tap on BR
- flexion of thumb and index finger
Hoffmann’s reflex
- forced flexion of MF DIPJ
- reflex finger and thumb flexion is elicited
Scapulohumeral Reflex
- tapping tip of spine of scapula
- brisk elevation of scapula & abduction of the humerus
- positive in > 95% of myelopaths
Jaw Jerk
- a cerebellar sign
- distinguishes myelopathy from cerebellum

Answer 205

A

flexion/distraction injury, with rotation

4/5 or 5/6

25% anterior translation (50% is bilateral)

SP don’t line up on AP

bow-tie sign

Answer 206

A

Increased wound complication rates with delayed closure (not necessarily infection)

Answer 207

A

Endocrinopathy (hypothyroid)

renal osteodystrophy

growth hormone

Answer 208

A

Common overuse syndrome
Less common than trigger (2-8/1000)
Can be a significant cause of loss of work in labourers
Best treatment is rest, NSAIDS and splinting
May require release of the first compartment

Answer 209

A

L thoracic curve

rapid progression (>1deg/month)

acute angle

neuro sx (abdominal reflex - tethered cord, sringomyelia, tumor, dysraphysm)

absence of rotation (syrinx = tumour, myelomeningocele)

pain

Answer 210

A

synoviocytes

Answer 211

A

defined as lack of union after 6 months
- 2 to 10% in nonoperative managment
- 15% with primary ORIF
risk factors
- axial distraction on injury films represents high level of soft tissue injury and increase chance of nonunion
- open fx
- unstable or segmental fx
- infection
- initial treatment with hanging cast
- shoulder or elbow stiffness (motion directed to fracture site)
- patient factors (smoking, obesity, alcoholism, malnutrition, noncompliance)
treatment
- compression plating with bone grafting
  - shown to be superior to both IM nailing with bone grafting and compression plating alone
  - use anterolateral approach (allows exploration of radial nerve)
- vascularized fibula bone graft and compression plating
  - indicated if > 6 cm bone defect
  - technique
    - use bone graft as an intramedullary dowel (1-2 cm inside each end)
    - stabilize with 4.5 dynamic compression plate
  - peroneal artery (fibula) is anastomosed to brachial artery
  - peroaneal vein anastomosed with basilic or cephalic vein

Answer 212

A

Clinical
- neck pain
- midline tenderness
- pain with rotation/flexion
- neurological findings
Subtle changes on XR
- soft-tissue swelling
- hypolordosis
- disk-space narrowing or widening
- widening of the interspinous distances
- Angulation >11 deg between vertebrae
- Saggital translation >3.5mm

Answer 213

A

TFL-sartorius

Rectus - glut med

Answer 214

A

Pillar Pain (25%) most common cause of pain post-op)
- pain between triquetrum and hamate
Palmar cutaneous branch
Recurrent CTR due to inadequate release (7-20%)
- most common complication of endoscopic procedure
- Inadequate proximal transverse ligament release with scarring of the nerve
- inadquate distal release
Other
- recurrent motor branch
- hypertrophic scar
- laceration of superficial arch

Answer 215

A

A - complete

B - sensation but not motor

C - < grade 3 > 50% levels

D - > grade 3 > 50% levels

E - sensory only

Answer 216

A

Type 1
- null hypothesis is rejected even though it is true
- by definition, alpha-error rate is set to .05, meaning there is a 1/20 chanc a type-I error has occured
- Bonferroni correction
  - post-hoc statistical correction made to P values when several dependent or independent statistical tests are being performed simultaneously on a single data set
Type 2
- a false negative difference that can occur by detecting no difference when there is a difference or accepting a null hypothesis when it is false and should be rejected
- power = 1 - (type-II error)
- Clinical significance
  - a study that fails to find a difference may be because
    - there actually is no difference or
    - the study is not adequately powered

Answer 217

A

recruitment of more motor units

Answer 218

A

Indications
- comminuted radial head fracture
- nonunion/maluion
- instabilty (essex-lopraseti)
- rheumatoid or osteoarthritis
- tumour
Contraindications
- repariable fracture
- capitellar arthrosis

Answer 219

A

2006 study showed that replacement is as good as ALIF with 50% success rate. Single level fusion for isolated back pain is controversial at best, and disc replacement has been shown to have inferior results when provocative discography is positive…some think that single level with disease free adjacent levels is the indication

Answer 220

A

BADO
I - anterior
- Pronation injury
- Reduced with flexion and supination
II - posterior
- Supnation injury
- Reduced with extension and pronation
III - lateral
- Direct lateral injury
- Reduced with flexion and supination
IV - # rad/ulna

Answer 221

A

2.5mm shortening
malrotation
comminution
angulation 10/20/30/40
multiple MC fractured (leads to instability)

Answer 222

A

Usually golfers or raquet with ulnar wrist pain

+/- nerve sx

carpal tunnel view

CT IS BEST TO MAKE DIAGNOSIS

Answer 223

A

get an increase FPL thickening (normal sheath) with triggering at A1
- 25% are bilateral
- presents with a fixed deformity
- > 2yo = resolution unlikley
- Usually not painful
- Notta’s nodule = flexor tendon prominence
passive extension exercises and observation
- indications
  - usually considered first line of treatment
  - not recommended for fixed deformities in older children
- technique
  - passive thumb extension exercises
  - duration based on clinical response
- outcomes
  - 30-60% will resolve spontaneously before the age of 2 years old
  - - extension splinting
- indications
  - consider alongside stretching regime
  - not recommended with fixed deformities in older children
- technique
  - splints maintain IP joint hyperextension and prevent MCP joint hyperextension
  - duration for 6-12 weeks
- outcomes
  - 50-60% resolution in all age groups
  - high drop out rate from therapy
A1 pulley release
- indications
  - fixed deformity beyond age of 12 months of age
  - failed conservative treatment
- outcomes
  - 65-95% resolution in all age groups

Answer 224

A

Characteristics
- 2-3% of the general population
- ring finger most commonly affected
- usually idipathic but more common in
  - dibetics
  - RA
  - amyloidosis
night splinting, activity modification, NSAIDS
- first line of treatment
steroid injections
- best initial treatment for fingers, not for thumb
- technique
  - give 1 to 3 injections in flexor tendon sheath
  - diabetics do not respond as well as non-diabetics
surgical debridement and release of the A-1 pulley
- in cases that fail nonoperative treatment
release of A1 pulley and 1 slip of FDS (usually ulnar slip)
- pediatric trigger finger
- presents with Notta’s nodule (proximal to A1 pulley), flexion contracture and triggering
- may need to release remaining FDS slip and A2 or A3 pulley as well

Answer 225

A

simple decompression (in situ, neurolysis) is the best
If you need to transpose, subcuteanous is better
- failed in situ
- throwing athlete
- poor nerve bed - tumor, HO
- After stiff elbow
  - <90 bend
  - >30 deg motion release

Answer 226

A

L5-S1 (L5 nerve root is most affected)

Answer 227

A

I - no treatment

II/IIIA - tendon correction, oppenoneplasty with UCL recon

IIIB - ablation with pollicization OR 2nd toe/toe joint transfer

IV - ablation with pollicization OR 2nd toe transfer

V - pollicization or 2nd toe transfer

Answer 228

A

circumferntial

Answer 229

A

posterior anti-glide plate with lag screw

especially superior in weak bone

Answer 230

A

A benign proliferative disorder characterized by fascial nodules and contractures of the hand
- starts as nodules in the hand, pregresses to fibrous bands and then contractures of MCP, moving distally
Epidemiology & genetics
- autosomal dominant with variable penetrance
- 5-7th decade of life with 2:1 male to female ratio
- highest incidence in Caucasian males of northern European descent
Pathophysiology
- myofibroblast is the dominant cell type
- cytokines have been implicated
- ectopic manifestations
  - Ledderhose disease (plantar fascia)
  - Peyronie’s disease (dartos fascia of penis)
  - **Garrod disease (knuckle pads) **
Associated conditions
- HIV, alcoholism, diabetes, antiseizure medications
Prognosis
- long-term recurrence rate after operative management up to 50%

Answer 231

A

Continuous data
- __potentially infinite possible values (ie. Height, HEAD SIZE)
Categorical data
- __variables are a given number of categories (ie. Gender, fracture classification)
T-test
- used to compare TWO independent CONTINUOUS variables
Chi square
- used to compare two or more CATEGORICAL variables
ANOVA
- used to compare three or more CONTINUOUS Variables
Linear Regression
- used to investigate whether a variable can be predicted by another single variable (simple linear regression) or by a combination of other variables (multiple linear regression)

Answer 232

A

Open fracture
Associated articular fracture Neurovascular injury
Floating elbow
Impending pathologic fracture Polytrauma
Failure of closed management

Answer 233

A

Block vertebrae
incarcerated hemivertebrae
nonsegmental hemivertebrae
some partially segmented hemivertebrae

Answer 234

A

high risk of penetration

higher risk of AVN

Better torsional control

Answer 235

A

MCP joint subluxation

Mallet finger

FDS tear

tight intrinsics

Answer 236

A

insufficient subscap repair

Answer 237

A

wire passed superficial to triceps

Nonuion, failure and necessary hardware removal are common complications

Technique - 1.2mm wire, 3-4 cm distal to # drill 2.0mm hole in olecranon, k-wires parallel into anterior cortex, wire must pass under triceps on periosteum proximally (use an angiocath)

Answer 238

A

deformity
- 5mm rotation = 1.5cm rotation at finger
- 2mm short = 7 deg ext lag
neck fractures
- multiple MC
- 10/20/40/60
- comminution
- open fracture
transverse/short oblique
- if short oblique is non-displaced can treat with cast immobilization
- apex dorsal due to long flexors and interosseous
- easy to reduce with flexion to of MCP 90 deg; difficult to maintain
- transverse usually need to be reduced, if you can reduce it then ok to cast, otherwise need to fix
- easy to control with “Ex-fix” - pinning to other MC
  - DC at 3-4 weeks
long spiral
- difficult to maintain closed due to shortening and rotation
  - if not displaced; can treat in cast
  - if it’s displaced, you can’t reduce it without ORIF
- fix wtih lag screws
  - one perpendicular to fracture, one perpendicular to bone
  - if fracture < 2X cortical diameter then neutralize with plate
- wear intrinsic plus splint during high risk situations; but can start moving right away
- ORIF
  - 2-5mm shortening (5mm in JAAOS 2000)
  - malrotation
  - comminution
  - multiple
  - 10/20/30/40

Answer 239

A

when they have a flexible compensatory curve

Answer 240

A

Level 1
- Randomized controlled trial (RCT)
- Meta-analysis of randomized trials with homogeneous results
Level 2
- Prospective comparative study (therapeutic)
- Meta-analysis of Level 2 studies or Level 1 studies with inconsistent results
Level 3
- Retrospective cohort study
- Case-control study
- Meta-analysis of Level 3 studies
Level 4
- Case series
Level 5
- Case report (a report of a single case)
- Expert opinion
- Personal observation

Answer 241

A

a generic, multi-purpose, short-form health survey consisting of 36 questions
useful for
- surveys of general and specific populations
- comparing the relative burden of diseases
- differentiating the health benefits produced by a wide range of different treatment
Self-rated preinjury pain-related disability is a predictor of moderate to severe pain 6 months after musculoskeletal injury as measured by SF-12
consists of 8 scaled scores, which are the weighted sums of the questions in their section
transformed into a 0-100 scale on the assumption that each question carries equal weight
- vitality
- physical functioning
- bodily pain
- general health perceptions
- physical role functioning
- emotional role functioning
- social role functioning
- mental health

Answer 242

A

chondral lesion (strongest)

obesity

medial meniscectomy

Answer 243

A

Adduction deformity of the great toe characterized by
- deformity at metatarsophalangeal joint
- short thick 1st metatarsal
- firm band-like abductor hallucis muscle
Associated conditions
- often associated with polydactyly – duplication of the great toe
Must be differentiated from metatarsus adductus
- Lateral border of the foot is normal
- More rigid than MA
Early casting is used, associated with hallux valgus
Severe deformity is indication for osteotomy

Answer 244

A

improved outcomes with reaming
- may even be better than plates
no difference with weight bearing early
avoid eccentric reaming
stabilize posterior malleolus first
blocking screws
bone reduction forceps
distal locking screw first with appropriate technique
femoral distractor
unicortical plates
multiple screws
multiple planes
use of a VAC can decrese edema

Answer 245

A

**Eosinophilic granuloma (EG) **
- usually a single self-limited lesion found in younger patients
**Hand-Schuller-Christian disease (HSC) **
- chronic, disseminated form with bone and visceral lesions
- also known as Langerhans cell histiocytosis with visceral involvement
**Letterer-Siwe disease (LSD) **
- fatal form that occurs in young children

Answer 246

A

Normal alignment
- 140 deg Neck shaft angle
- 30 deg retroversion
humeral head is 5.6cm above pec major
- >10mm proud = increased tuberosity failure
- 15mm shortening tolerated
Use bicipetal groove or long head biceps to access version compared to fin
- 20-30 deg retroversion
Tuberosity placement 1-1.5cm distal to superior margin
- wire or sutures can augment fixation

Answer 247

A

GAS - gram + in chains
- think nec fasc
Clostridium - gram + rods
- think nec fasc
Staph - gram + clusters

Answer 248

A

findings suggestive of Blounts disease
- varus focused at proximal tibia
- severe deformity
- asymmetric bowing
- progressing deformity
- sharp angular deformity
- lateral thrust during gait
- metaphyseal beaking
- different than physiologic bowing which shows a symmetric flaring of the tibia and femur
measurements
- metaphyseal-diaphyseal angle (Drennan)
  - >16 ° = blounts
  - 10-16 is controversial and should be observed
  - <10 ° = normal
- tibiofemoral angle
  - angle between the longitudinal axis of the femur and tibia

Answer 249

A

pretendinous band
spiral band
natatory band/ligament
- causes contracture of the web space lateral and reduces abduction
lateral digital sheet
Grayson’s ligament

pulls the NV strucutre central and superficial

Answer 250

A

indications
- older patients with limited demands
- in a delayed setting for continued pain of an isolated radial head fracture
contraindications
- forearm ligament injury (identify with radius pull test)
- coronoid fracture
- MCL deficiency
complications
- muscle weakness
- wrist pain
  - proximal migration of radius leads to ulanr positive variance and ulnocarpal abutment
- valgus elbow instability
- heterotopic ossification
- arthritis

Answer 251

A

50% are caused by trauma
More common to have recurrent subuluxation that wears the posteior gleniod
May present with recurrence of pain more than instability, but can be quite limited
Some are traumatic, some are habitual
- habitual will not do well with surgery
Physical
- sulcus, jerk, posterior stress, load and shift
Most will benefit from strengthening dynamic stabilizers
Can benefit from surgery when nonsurgical fails (ideally recurrent, post-traumatic, unilateral)
- Posterior Bankart lesion
  - Arthroscopic or open posterior Bankart repair
- Excessive capsulolabral laxity
  - Arthroscopic or open posterior capsular shift ± rotator interval closure
- Glenoid erosion
  - Posterior glenoid bone grafting
- Increased glenoid retroversion >20
  - Posterior opening wedge glenoid osteotomy
Complications
- recurrence
- subscapular nerve injury
  - if you split the IS more than 1.5cm medially
- stiffness from overtightening
- may be associated with future OA

Answer 252

A

Rupture of FPL in RA with-in the carpal tunnel due to scaphoid ostophyte, volar synovitis

Treated with FDS transfer or pullthrough, resect spicule, or PIP fusion

Important to rule out AIN palsy

Answer 253

A

lack of terminal extension

Answer 254

A

Allow to heal

then curettage and bone graft

increase complications associated with acute treatment

Answer 255

A

collateral ligaments

The volar plate resists joint hyperextension, while the collateral ligaments are the primary restraints to motion in the coronal plane
At terminal extension, the volar plate and the accessory collateral ligaments assume a larger role.
In flexion, the proper collateral ligament is tightened over the flare of the condyle and becomes the primary stabilizer against lateral displacement.
Both the volar plate and at least one collateral ligament must be injured for dislocation of the PIP joint to occur

Answer 256

A

increased PE, cardiac complications, need for transfusions and mortality

lower infection, lower DVT

Answer 257

A

HASTINGS

Type I-Stable
- <30%-treat with dorsally based extension block splint
Type II-Tenuous
- 30-50%-if reducible in flexion, dorsally based extension block splint
Type III-Unstable
- >50%-ORIF if possible, hamat autograft/dynamic ex-fix, or volar plate arthroplasty
Comminuted type C
- Dynamic distraction external fixation
Chronic
- fusion

Answer 258

A

age of 80
metaphyseal comminution
5mm shortening
dorsal angulation IS NOT
- according to Mcqueen study

Answer 259

A

becomes strongest at 24 hours
provides adhesion to bone (not to the prosthesis)
weak in shear and tension, strongest in compression
decreasing porosity increases strength by 15%

Answer 260

A

Sharp Injury
- repair immediately
Blunt injury
- tag the nerve ends acutely and repair or graft at 3-4 weeks (this is after they have demarcated)
If concern of root avulsion
- 3-6 weeks (nerve graft or transfer)
- graft targeted for specific function (sural)
  - C5 - shoulder abduction (axially or suprasca)
  - C6 - elblow flexion (MC)
  - C7 - elbow and wrist extension (rad)
- neurotization (transfer)
  - spinal accessory
  - intercostal
  - medial pectoral
  - phrenic
  - ulnar (oberlin)
Neuropraxia - 3-4 months if no re-innervation (>12 months has poor outcomes)
- PT and splinting to maintain ROM of the joints
- EMG at 3-4 weeks (when wallarian degeneration will occur)
- then repeat to see if improving or follow clinically
  - decreased fibrillations and increased AP (but may not correlate so still need to check clinically)
>12 months - secondary procedures
- tendon transfers
- osteotomy
- arthrodesis

Answer 261

A

AVN of the medial clavicle

atraumatic dislocation

often occurs in females

medial bowing of the clavicle

Answer 262

A

Annulus Type 1 collagen
Nucleus is Type 2 collagen
30% proteoglycans
Aging disc
- decrease in
  - nutritional transport
  - water content
  - absolute number of viable cells
  - proteoglycans
  - pH
- increase in
  - an increase keratin sulfate to chondroitin sulfate ratio
  - lactate
  - degradative enzyme activity
- no change in
  - absolute quantity of collagen

Answer 263

A

sensory changes - shows prolonged sensory latency

Answer 264

A

UCL rupture
ulnar neuritis
golfers elbow
medial epicondyle epophysitis
valgus extension overload
OCD capitellum
olecranon stress fracture
****elbow OA is NOT a cause of medial elbow OA

Answer 265

A

posterior decompression

Answer 266

A

Chance of fracture increases with size of cyst

(<10%) rarely heal with fracture

steroid injection equivalent to bone aspirate

no malignant transformation

curettage with bone graft when failed or with lower extremity

Answer 267

A

triceps to biceps
steindler flexorplasty
lat dorsi to biceps
posterior release with triceps lengthening pec major to biceps

Answer 268

A

unilateral bar, contralateral hemivertebrae (5-10deg)
double hemivertebrae
- although depends on whether on opposite sides or not
unilateral bar (5-6 deg)
segemented hemivertebrae (2-5deg)
unsegmented hemivertebra
incarcerated hemivertebra
unincarcerated hemivertebra
block vertebrae

Answer 269

A

partial tear

proximal tears (sternoclavicular origin)

Older/sedentary individuals

Answer 270

A

Ligament of struthers

biceps aponeurosis (lacertus fibrosis) - AIN

heads of pronator - AIN

FDS arcade - AIN

accessory FPL - AIN

thrombosed artery - AIN

Answer 271

A

thin cortex
decreased cancellous bone
increased fibrous tissue
Radiographs:
- thin cortex
- osteopenia
- sabre shins
- wormian bones
Histology:
- increased diameter haversion canals,
- increased osteoblasts, osteoclasts
- replicated cement lines
- less trabeculae
- thin cortices

Answer 272

A

Simple - soft tissue only

Complex - fusion of adjacent phalanges

Complicated - abnormal bone

Complete vs incomplete - complete extends to fingertips

Answer 273

A

Descending Tracts (motor)
- lateral corticospinal tract (LCT)
  - UMN are in the lateral portion of the white matter
  - They synapse with anterior horn cells (ventral) in the grey matter, and more central portion of the spinal cord
- ventral corticospinal tract
  - Rubriospinal
    - smaller, less axons
    - voluntary muscle control
    - primarily flexion (decorticate)
    - extra-pyramidal
  - vestibulospinal
    - extension
    - extrapyramidal
    - postural
Ascending tracts (sensory)
- Synapse with the doral root ganglion and enter via the posterior horn of the grey matter (doral)
- dorsal columns
  - deep touch
  - vibration
  - proprioception
- lateral spinothalamic tract (LST)
  - pain
  - temperature
- ventral spinothalamic tract (VST)
  - light touch

Answer 274

A

Double ring splint
- can try this first always
volar plate advancement and PIP balancing with central slip tenotomy
- indications
  - progressive deformity
- technique
  - address volar plate laxity with volar plate advancement
  - correct PIP joint muscles imbalances with either
    - FDS tenodesis indicated with FDS rupture
    - spiral oblique retinacular ligament reconstruction
    - central slip tenotomy (Fowler)
DIP Arthrodesis
- Dorsal approach
- Extensor tenodesis with capsulotomy

Answer 275

A

conduction velocity <50 m/sec across elbow

Answer 276

A

Group 1 - middle, most common

Group 2 - distal (Neer)

1 - lateral (non-op)

2a - medial (sux)

2b - medial with conoid (sx)

3 - intra-articular

4- physeal

5 - comminuted

Group 3 - proximal (anterior, posterior)

Answer 277

A

Cross sectional

Answer 278

A

lunotriquetral

dorsal radiocarpal

long and short radiolunate

Answer 279

A

Delays (10 days), even severe, do not re-reduce. Mould the cast and hope to remodel. Already starting to heal so can do osteotomy later if you need to

Answer 280

A

malignant hyperthermia is common intraoperatively
- pretreat with dantrolene
intraoperative cardiac events

Answer 281

A

FDS/ECRB to Adductor

APL/ECRL/EIP to 1st interosseous

FDS/ECRL to lateral band of ulnar digits (must pass volar to the transferverse intermetatarsal ligament)

Answer 282

A

Pros
- best wear characteristics
- particles are non-oncogenics
Cons
- risk of fracture
  - 1/5000-1/12000
  - 70% with-in 12 months
  - higher with small, neutral offset heads
- Chipping 1.2%
- Squeak 0.45%
- Stripe wear with edge loading
- Fewer prosthetic options
- More technically demanding

Answer 283

A

LACN most commonly
PIN and superficial radial nerve
- two incision technique was supposed to reduce this, but now with smaller anterior incision it is low with both
synosteosis
HO

Answer 284

A

medial clavicle

Answer 285

A

supintation (and extension)

get a tear in the sheath of the 6th compartment
supnation it subluxes out of the sheath and reduces with pronation
US can assess dynamic stability, MRI can show tendonisits
Usually treated with a splint, if fails can repair the sheath

Answer 286

A

GAGs accumulate in lysosomes of chondrocytes, synovium → disorganized physeal architecture → 2° inflammatory response → irregularly shaped metaphyses → skel dysplasia

Treatment
- IV enzyme replacement
- bone marrow transplant
Improved cardiac/resp, improved hearing and resolution of hydrocephalus
no effect on orthopedic manifestations

Answer 287

A

Insensate foot with repetative microtrauma
Autonaumic dysfuction causes hyperemia, resorption and osteopenia
Inflammatory cytokines and TNF-alpha

Answer 288

A

**Occurs in distal arthrogryposis

Flexion, adduction of thumb (thumb in palm)
narrowing first web space
flexion/ulnar deviation of fingers

Answer 289

A

obtain serendipity views ( beam at 40 cephalic tilt)

anterior dislocation - affected clavicle above contralateral clavicle
posterior dislocation - affected clavicle below contralateral clavicle

Answer 290

A

Biceps inserts on radial tuberosity
- 21 mm total
- long head more for supnation
  - Proximal and radial
- Short head more for flexion
  - Distal and ulnar
  - Lacertus originates from the short head
Complete vs Partial
- Parital usually occurs on the radial side
Intersubstance transection
Mechanism of tear
- eccentric contraction at 90 deg flexion

Answer 291

A

central band is key portion of IOM to be reconstructed
accessory band
distal oblique bundle
proximal oblique cord
dorsal oblique accessory cord

Answer 292

A

A - intra-articular coronoid
B - extra-articular coronoid
C - extra-articular shaft
D - intra-articular comminuted

Answer 293

A

Morquio syndrome
- Accumulation of keratin sulfate
- Type A - (galactosamine-6-sulfate-sulphatase deficiency)
- Type B - (beta-galactosidase deficiency)
Hurler syndrome - worst
- dermatin sulfate
- alpha-L iduronidase deficiency
- bone marrow transplant in first year of life reduces mortality but not orthopedic manifestations
Sanfilippo syndrome - most common
- heparan sulphate
Hunter syndrome
- dermatin/heparin sulfate
- sulpho-iduronate-sulphatase deficiency

Answer 294

A

indicated in patients after femoral neck nonunion
- verticle fracture (Pawel C)
- can be done even in presence of AVN, as long as not severely collapsed, but may want to consider MRI preop
Plan your osteotomy for the fracture to be 30 deg from horizontal
- choose appropriate blade plate
First K-wire for blade goes into the head at your planned site
second K-wire at the osteotomy should be 2 cm distal to this
Try not to medialize the canal
- decreases offset, reduces abductor strength
- increase joint reaction force

Answer 295

A

Swan Neck Deformity

Characterized by
- hyperextension of PIP
- flexion of DIP
Caused by
- lax volar plate
- imbalance of muscles forces on PIP (extension force > flexion force)
Injuries include
- MCP joint volar subluxation (rheumatoid arthritis)
- mallet finger
- FDS laceration
- intrinsic contracture
Primary lesion is lax volar plate that allows hyperextension of PIP
- trauma
- RA
- Hyperlaxity
Secondary lesion is imbalance of forces on the PIP joint (PIP extension forces that is greater than the PIP flexion force)
- mallet injury
  - leads to transfer of DIP extension force into PIP extension forces
- FDS rupture
  - leads to unopposed PIP extension with an intact FDP
- intrinsic contracture
  - tethering of the lateral (collateral) bands by the transverse retinacular ligament as a result of PIP hyperextension.
  - if the lateral (collateral) bands are tethered, excursion is restricted and the extension force is not transmitted to the terminal tendon, and is instead transmitted to the PIP joint
- MCP joint volar subluxation
  - caused by rhuematoid arthritis

Answer 296

A

Lateral ankle instability (can occur with or without syndesmosis injury)

Answer 297

A

** proper placement **

    1-2 mm rim of bone between tunnel and posterior cortex of femur

** anterior misplacement**

    leads to a knee that is tight in flexion and loose in extension

    occurs from failure to clear "residents ridge"

**posterior misplacement** (over-the-top)

    leads to a knee that is lax in flexion and tight in extension

Answer 298

A

If fracture can be treated no-op …. splint ensuring wound access possible
If fracture needs OR
- Definitive treatment ideal
- Through alternate skin incision if possible
- If incision must be through burn, must do this < 48hrs from injury
- If >48hrs (tissue will be colonized):
  - Ex-fix (until wounds healed)
  - Splint (until wounds healed)
  - ORIF at the same time of wound debridement and skin grafting

Answer 299

A

debridement with tendon re-attachement to the extra-articular surface
don’t take more than 40% of the patella
+/- circlage wire re-inforcement

Answer 300

A

Saggital band

Answer 301

A

Cortical allograft (cortical is slower to incorperate)

Answer 302

A

Flares
- can help with partial foot amputation
- fixed deformity
- ankle instability
Shank - rigid lever that comes into toes
- amputation
- hallux rigidis
Mild rocker
- mild metatarsalgia
In most of the questions around a lisfranc amputation the only appropropritate awnswer is an AFO
Heel-Toe Rocker
- hammer toe
- ankle fusion
- midfoot amputation
Toe -only
- proprioception
Severe angle
- ulcerations
Double rocker
- charcot foot

Answer 303

A

Elbow flexion
shoulder abduction/stability
hand sensibility
wrist extension
finger flexion
wrist flexion
finger extension
intrinsic hand function

Answer 304

A

Abx, tetanus
Abx as soon as possible
IM Nailing
- has been shown to be safe initially for treatment gustilo I-IIIb
- no consensus reamed vs unreamed
Ex-fix
- If ex-fix required change to IM nail as soon as possible
Plates not recommended
Indications for Ex-fix
- gross conatmination
- delay to treatment

Answer 305

A

hypercholermic metabolic acidoisis

Answer 306

A

Basion to Posterior C1 / Opisthion to Anterior C1

(CD/BA)

Answer 307

A

Children < 8yo

Column can stretch without injury (>2 inches), but causes damage to the cord (<1cm)

most common in c-spine

50% are delayed presentation

(some thought that better emerg care and more immobilization has decreased delayed injury to cord)

Answer 308

A

Dorsal
- 30-50%,
- >50% OR >30 flexion to maintain = unstable
__Volar
- >50% OR unable to maintain with extension
Pilon
- either stable or grossly unstable

Answer 309

A

blue sclera
hearing loss
brownish opalescent teeth (dentinogenesis imperfecta)
wormian skull bones (puzzle piece intrasutural skull bones)
Thin skin, prone to bruising
Cardiac manifestations
increased risk of malignant hyperthermia

Answer 310

A

Plates have lower malunion rate
- better for a very distal fracture
  - use anterolateral and MIPO
- cause hardware irritation
Nails better for elderly patients with thin skin and poor soft tissues
- fracture blisters, diabetes, open
- cause knee pain
How to increase nail stability
- locked screws
- more screws
- multi-planar screws

Answer 311

A

** osteophytes**

deep MCL

Semi- M - moslty extension, should be released last

SMCL - anterior or posterior based on whether you need release

PCL - flexion

Answer 312

A

anterior to quads, posterior to the patellar tendon

form a ring around the patellar and penetrate anteriorly

avoid anterior soft tissue stripping

25% necrosis rate with fracture

Answer 313

A

change in ulnar varience (ie radial height)

Answer 314

A

Navicular

Answer 315

A

>4mm distraction
>2mm stepoff
intra-articular fragments
osteochondral fragment
lose of extensor mechanism

no data exist on post-op rehab protocols

Answer 316

A

5 deg valgus

neutral dorsiflexion

5 deg ER

Answer 317

A

Spinal fusion
- indications
  - In young patients anterior fusion needed to prevent progression or crankshaft
  - young patients with significant progression, neurologic deficits, or declining respiratory function
    - girls < 10 yrs
    - boys < 12 yrs
  - patients with failure of formation with contralateral failure of segmentation at any age
- technique
  - nutritional status of patient must be optimized prior to surgery
- in situ arthrodesis, anterior/posterior or posterior alone
  - unlateral unsegmented bars with minimal deformity
- hemiepiphysiodesis
  - intact growth plates on the concave side of the deformity
  - patients less than 5 yrs. with < 40-50 degree curve
  - mixed results
- osteotomy
  - osteotomy of bar
- hemivertebrectomy
  - hemivertebrae with progressive curve causing truncal imbalance and oblique takeoff
  - often caused by a lumbosacral hemivertebrae
  - patients < 6 yrs. and flexible curve < 40 degrees best candidates
- spinal column shortening resection
  - deformities that present late and have severe decompensation
  - rigid, severe deformities
  - pelvic obliquity, fixed

growing rod construct
- indications
  - may be used in an attempt to control deformity during spinal growth and delay arthrodesis
- outcomes
  - need to be lengthened approximately every 6 months for best results
VEPTR (vertical expanding prosthetic titanium rib)
- indications
  - thoracic insufficiency syndrome
- outcomes
  - long-term follow up is needed to determine efficacy

Answer 318

A

in situ decompression
- just as good results with fewer complications compared to transposition
decompression with transposition
- subcutaneous is better than submuscular with fewer complications
medial epiconylectomy
- visibly subluxing ulnar nerve

Answer 319

A

ULNAR CLAW HAND

Associated conditions
- cubitus varus or valgus deformities
- medial epicondylitis
- burns
- elbow contracture release
most common
- between the two heads of FCU/aponeurosis (most common site)
- within arcade of Struthers (hiatus in medial intermuscular septum)
- between Osborne’s ligament and MCL
less common
- medial head of triceps
- medial intermuscular septum
- medial epicondyle
- fascial bands within FCU
- anconeus epitrochlearis (anomalous muscle from the medial olecranon to the medial epicondyle)
- aponeurosis of FDS proximal edge

Answer 320

A

The most common infections are still staph aureus and strep pyogenes
- but need extra coverage for the strange bugs
A hydrophilia - fresh
pseudomonas
mycobacterium marinum - swimming pool
- chronic or occult
Vibrio - salt water

Answer 321

A

Anti-diuretic hormone

Promotes water resorption in kidneys

restores intravascular volume

low osmolailty = ADH off
- increase urine output
- increase osmolality
High osmolaltiy = AHD on
- decrease urine output
- decrease osmolaity
SIADH
- dilution of plasma from water retention and therefore low NA
- hyponatremia = headache, N/V, confusion
- treated with water restriction

Answer 322

A

Jersey Finger

Refers to an avulsion injury of FDP from insertion at base of distal phalanx
- a Zone I flexor tendon injury
- FDP muscle belly in maximal contraction during forceful DIP extension
Ring finger involved in 75% of cases
- during grip ring fingertip is 5 mm more prominent than other digits in ~90% of patients
- Weaker insertion point
- Least independent movement
__Proximal to A5 there is a dual vascualr supply, treatment will depend on whether one or both are disrupted
- Vinculum Longus Profundus (VLP)
- Vinculum Longus Superficialis (VSP)
Leddy Packer Classification
- Type I
  - FDP tendon retracted to palm
  - Leads to disruption of the vascular supply
  - Prompt surgical treatment within 7 to 10 days
- Type II
  - FDP retracts to level of PIP joint
  - VLP intact
  - Attempt to repair within several weeks for optimal outcome
- Type III
  - Large avulsion fracture limits retraction to the level of the DIP joint (A4)
  - All blood supply intact
  - Attempt to repair within several weeks for optimal outcome
- Type IV
  - Osseous fragment incarcerated in A4 and simultaneous avulsion of the tendon from the fracture fragment (“Double avulsion” with subsequent retraction of the tendon usually into palm)
  - If tendon separated from fracture fragment, first fix fracture via ORIF then reattach tendon as for Type I/II injuries
- Type V
  - boney avulsion with comminution

Answer 323

A

Definition

an estimate of the probability a study will be able to detect a true effect of the intervention

Equation

power = 1 - (probability of a type-II, or beta error)

Answer 324

A

ABI > 0.5

02 >30mmHg

albumin > 2.5

WBC > 1500

Answer 325

A

Absolute
- Associated Injury
- >50% rotator cuff tear
- Glenoid osseous defect >25%
- Humeral head articular surface osseous defect >25%
- Proximal humerus fracture requiring surgery
- Irreducible dislocation
- Interposed tissue or nonconcentric reduction
- Failed trial of rehabilitation
- Inability to tolerate shoulder restrictions
- Inability to perform sport-specific drills without instability
Relative
- >2 shoulder dislocations during the season
- Overhead or throwing athletes Contact sport athletes
- Injury near the end of the season Age <20 years

Answer 326

A

diabetes incipidous
EG
exopthalamos

Answer 327

A

acute - CRPP with dorsal ligament repair

Chronic - LT fusion

If due to ulnocarpal abutment - ulnar shortening with arthroscopic debridement of LT and TFCC

Answer 328

A

water
- makes up 65% to 80% of mass of the cartilage
- accounts for 80% of the weight near the surface
- 65% at the deep zone
- water content
  - decreases with normal aging
  - increases with osteoarthritis
  - increased water content leads to
    - increased permeability
    - decreased strength
    - decreased Young Modulus of elasticity
collagen
- makes up 10 to 20% of total cartilage mass
- type II collagen accounting for 90% to 95% of the total collagen content.
- functions to provide cartilagenous framework and tensile strenth
- small amounts of types V, VI, IX, X, and XI collagen are also present
proteoglycans
- makes up 10 to 15% of cartilage
- functions to provide compressive strength and attract water (hydrophilic)
- produced by chondrocytes
- composed of GAG subunits and bound to protein core
  - chondroitin sulfate
  - keratin sulfate
noncollagenous protein

Answer 329

A

6-8 weeks
- best seen on the mortise
The presence of hawkins sign is a reliable indicator that AVN is not presence
HOWEVER, the absence of hawkins sign does mean they have AVN
If you have concerns the best next step in an MRI

Answer 330

A

This should only be done after exhaustion of non-operative options
must address capsule +/- rotator interval
inferior capsular shift (capsule shifted superiorly)
- plication of redundant capsule in a balanced fashion
rotator interval closure (open or arthroscopic)
- produces the most significant decrease in range of motion in external rotation with the arm at the side
address any anterior or posterior labral pathology if present
thermal capsulorrhaphy (historical)

Answer 331

A

posteior stabilization with halo for 3 months; prevents neurological deficit

early recognition is the key

Answer 332

A

Superficial zone (tangential zone)
- Type II collagen orientation is parallel to joint
- Has flattened chondrocytes, condensed collagen fibers, and sparse proteoglycans
- only zone where articular cartilage progenitor cells have been found
Intermediate zone
- Type II collagen has an oblique or random organization
- Is the thickest layer with round chondrocytes, and abundant proteoglycan content
Deep layer (basal layer)
- Type II collagen is perpendicular to joint and crosses tidemark; has the highest concentration of proteoglycans
- Round chondrocytes arranged in columns
Tidemark
- Is deep to the basal layer and separates the true articular cartilage from the deeper cartilage that is a remnant of the cartilage anlage, which participated in endochondral ossification during longitudinal growth in childhood.
- The tidemark divides
  - the superficial uncalcified cartilage from the deeper calcified cartilage
  - division between nutritional sources for the chondrocytes
- The tidemark is found only in joints
- Most prominently in the adult and nongrowing joint
Subchondral Bone

Answer 333

A

Sites of compression
- ligament of struthers
- lacertus fibrosus (under biceps)
- head of pronator
- FDS - subliminus bridge
- accessory head of FPL (Gantzer)
Innervation
- Median nerve
  - FDS, PL, Pronator teres, FCR
  - Palmar branch of the median cutaneous
    - thenar palm
  - AIN
    - FPL, FDP, Pronator
Restoration of Thumb Opposition (Opponensplasty)
- EIP to APB (ie, Burkhalter)
- FDS of ring finger to APB (ie, Royle- Thompson)
- PL to APB (ie, Camitz)
Restoration of Thumb Interphalangeal Flexion
- BR to FPL
- ECRL to FPL
- ECU to FPL
Restoration of Index Distal Interphalangeal Flexion
- ECRL to FDP
- side to side FDP

Answer 334

A

sensory loss
hypothenary atrophy
1st web space atrophy
ulnar claw hand
tinel’s sign
weakened grasp
- from loss of MP joint flexion power
weak pinch
- from loss of thumb adduction (as much as 70% of pinch strength is lost)
**Froment sign **
- compensatory thumb IP flexion by FPL (AIN) during key pinch
- compensates for the loss of MCP flexion by adductor pollicis (ulna n.)
- adductor pollicis muscle normally acts as a MCP flexor, first metacarpal adductor, and IP extensor
**Jeanne sign **
- compensatory thumb MCP hyperextension and thumb adduction by EPL (radial n.) with key pinch
- compensates for loss of IP extension and thumb adduction by adductor pollicis (ulna n.)
Wartenberg sign
- persistent small finger abduction and extension during attempted adduction secondary to weak 3rd palmar interosseous and small finger lumbrical
Masse sign
- palmar arch flattening and loss of ulnar hand elevation secondary to weak opponens digiti quinti and decreased small finger MCP flexion

Answer 335

A

2 weeks Normal by 3-5 months

Answer 336

A

Leg-Length Discrepancy
- most common complication
- overgrowth
  - 0.7 - 2 cm is common in patients between the ages of 2 - 10 years at time of fracture
  - typically presents within 2 years of injury
- shortening
  - is acceptable if less than 2 - 3 cm because of anticipated overgrowth
  - can be symptomatic if greater than 2 - 3 cm
  - temporary traction or internal fixation used to prevent persistent shortening
**Osteonecrosis (ON) of femoral head **
- has been reported with piriformis and greater trochanter entry nails
- femoral nailing through the piriformis fossa is contraindicated in adolescents with open physes because of the risk of osteonecrosis of femoral head
Nonunion
- higher risk with load bearing devices
  - external fixator or submuscular plates
- can occur after flexible intramedullary nailing in patients
  - aged over 11 years old
  - who weigh >49 kg (>108 lb)
Malunion
- typical deformity is varus and flexion of the distal fragment
  - remodeling is greatest in sagittal plane (ie flexion/extension deformity)
  - remodeling does not occur with rotational malalignment and therefore must be corrected at the initial surgery
- rarely symptomatic
Refracture
- most commonly seen after external fixator removal
- highest risk in transverse and short oblique fractures
- less likelihood of secondary callus formation

Answer 337

A

Decrease in amplitude = axonal loss
- occurs with more severe compression
- will also be detected by EMG
Increase in latency = demyelination
- typically occurs with a compression injury (cubital tunnel)
Sensory is affected first
Late waves
- H - reflex is a measure of the achilles
  - absence is an indication of peripheral or S1 radiculopathy
- F - waves
  - more indicitive of proximal pathology
  - thoracic outlet
Factors that can affect NCS
- Temperature, age, height

Answer 338

A

fixed flexion/adduction deformity
associated with contracture of the first web space and thenar muscls
associated with arthrogryposis and other anomalies

Answer 339

A

Forces on fracture
- Volar oblique ligament
- Abductor pollicis longus (PIN) - base
- Extensor pollicis longus (PIN) - base
- Adductor pollicis (Ulnar) - shaft
Reduction maneuver
- Traction
- Abduction
- Extension
- Pronation

Answer 340

A

SGHL
- restraint to inferior translation at 0° degrees of abduction (neutral rotation)
MGHL
- resist anterior and posterior translation in the midrange of abduction (~45°) in ER
IGHL
- posterior band IGHL
  - most important restraint to posterior subluxation at 90° flexion, abduction and IR
  - tightness leads to internal impingement and increased shear forces on superior labrum (linked to SLAP lesions)
- anterior band IGHL
  - primary restraint to anterior/inferior translation 90° abduction and maximum ER (late cocking phase of throwing)
    - anchors into anterior labrum
    - forms weak link that predisposes to Bankart lesions
- superior band IGHL
  - most important static stabilizer about the joint
  - 100% increased strain on superior band of IGHL in presence of a SLAP lesion
Coracohumeral ligament (CHL)
- limits posterior translation with shoulder in flexion, adduction and internal rotation
- limits inferior translation and external rotation at adducted position

Answer 341

A

Pathology - usually sporatic
- abnormal lumbrical insertion/origin
- abnormal (adherent, hypoplastic) FDS insertion
- other less common causes include
  - abnormal central slip
  - abnormal extensor hood
  - abnormal volar plate
  - skin, subcutaneous tissue, or dermis contracture
Non-operative treatment is favoured
- most will respond to passive splinting
FDS tenotomy +/- FDS transfer
- reserved for cases of progressive deformity leading to functional impairment
- technique
  - must address all abnormal anatomy
  - passive (correctable) deformities
  - FDS tenotomy, or
  - FDS transfer to radial lateral band if full active PIP extension can be achieved with MCP flexion
osteotomy vs. arthrodesis
- severe fixed deformities

Answer 342

A

Assymetric joint space narrowing is not an indication to do ankle arthroscopy

osteochondral lesions of the talus
microfracture of OCD
debridement of post-traumatic synovitis
ATFL anterolateral impingement
AITFL anterolateral impingement
resection of anterior tibiotalar spurs
- such as anterior bony impingement
os trigonum excision
removal of loose bodies
cartilage debridement in conjunction with ankle fusions

Answer 343

A

Ceramic (Al2O3)
Alloy (Co-Cr-Mo)
Stainless steel
Titanium
Cortical bone
Matrix polymers
PMMA
Polyethylene
Cancellous bone
Tendon / ligament
Cartilage

Answer 344

A

F>M
caused by compression of neurovascular bundle as it passes over the first rib or through the scalene muscle
causes include
- scalene muscle abnormalities
- scapular ptosis
- clavicle and first rib malunion
- cervical rib
- vertebral transverse process
causes in athletes
- fibromuscular bands
- abnormal pectoralis minor
- repetitive shoulder use
- extreme arm positions
- weightlifting, rowing, swimming

Answer 345

A

Primary
- volar radioulnar ligaments
  - volar translation
  - supination
- dorsal radioulnar ligaments
  - dorsal translation
  - pronation
- trigangular fibrocartilage
Secondary
- Boney = 20%
  - ulnar head
  - sigmoid notch
- interosseous membrane
  - constrains dorsal radius translation
Note - ECU subsheath and volar ulnocarpal ligaments do not play a role in stabilization

Answer 346

A

lumbar burst fracture

centripital disruption of the vertebral body
anterior wedging
laminar fractures abut the spinous process
increased interpedicular distance
retropulsion of the superior endplate

Answer 347

A

intrinsic plus
causes
- trauma
- rheumatoid arthritis (secondary to distal joint malalignment)
pathology
- spastic intrinsics
  - lead to flexion of the MCP and extension of the IP joints
- weak EDC
  - fails to provide balancing extension force of MCP
- weak FDS & FDP
  - fails to provide balancing flexion force on PIP and DIP
Bunnell test - for intrinsic
- diff between intrinsic and extrinsic
- test is positive when there is less PIP flexion with MCP extension than when the MCP is flexed

Answer 348

A

endocrinopathy

<10 with open triradiate

lack of ability to follow-up

Answer 349

A

SPRINT trial
- improved stability with use of a larger nail
- more biomechanically stable construct
- Improved outcomes with reamed nails for closed fractures
- No difference with open fractures

Answer 350

A

clavicle, first rib, subclavius muscle, costoclavicular ligament, and anterior scalene muscle
- junction of lower trunk and first rib
Brachial plexus and subclavian vessels travel between anterior and middle scalene
- more often neuro compression occurs
- rarely vascular compression occurs; this requires heparinizaiton and surgical treatment
Physical
- Wright
  - abduction and external rotation with the neck rotated away leads to loss of pulse and reproduction of symptoms
- Adson
  - extension of the arm with the neck extended and turned towards the affected side may result in loss of radial pulse or reproduction of symptoms with inhaling
- Roos
  - hands repeatedly opened and closed while holding them overhead for 1 minute can reproduce symptoms
CXR
- most common finding is a cervical rib
- assess for pancoast tumor

Answer 351

A

Erbs (C5/6); waiter’s tip; best prognosis

Answer 352

A

usually result from translocations that occur as a result of lack of tumor suppression
spontaneous mutation of p53 is much more common than inheritable
- Li-Fraumeni is an example of a heritable p53 disorder

Answer 353

A

Collaterals may also be disrupted
Dorsal
- Volar plate - loose the static restraint
Volar
- lateral bands/central slip

The third is refered to as a pilon fracture

Answer 354

A

CP - Thumb in palm/clasp thumb
- many babies hold thumb in palm
- most are not associated with a syndrome
contracture of first web and tight fascial bands in the first dorsal interosseous and adductor aponeuroses
Thumb-in-palm deformities are complex, and require careful assessment before the appropriate treatment can be recommended.
Principles of treatment:
- release of contractures of the skin, joints, and spastic muscles
- stabilization of the joints (MCP is usually unstable)
- augmentation of the weakened muscles

Answer 355

A

Increased sodium, decreased potassium, increased water

Cellular level – O2 demand > O2 supply – cellular hypoxia

Answer 356

A

plastic deformity of the ulna

peaks 4-10 yo

Answer 357

A

sclerosis and englargement of the medial clavicle
women, 30-40, unilateral
most respond to NSAIDS

Answer 358

A

< 5% percentile growth

<10yo

Answer 359

A

Note that these are not mutally exclusive and you should always screen for all of them; see baby below with thumb hypoplasia, fanconi’s anemia; also has several features of VACTERL
- CBC
- echo
- Renal U/S
- full head-toe exam
These patients should be treated with a team based approach - invovle genetics, pediatrics and all necessary specialties
TAR
- autosomal recessive condition with thrombocytopenia and absent radius
- thrombocytopenia fluctuants over time
  - exaccerbated by infection, stress
- presents in first week of life
  - purpura, petechiae
  - intracranial hemmorhage - fatigues, lethary, difficulty feeding
- low platlets, normal chormosomes
- Basic first aid, platelet transfusion
- different in that thumb is typically present
Fanconi’s anemia
- autosomal recessive condition with aplastic anemia
- can get hemmorhage, infection, neoplasia
- Work-up
  - CBC - pancytopenia or complete aplasia
  - Diagnosis - Fanconi screen and chromosomal breakage test to screen
- treatment is bone marrow transplant
Holt-Oram syndrome
- autosomal dominant condition characterized by cardiac defects
  - ASD most common
- diagnoses with blood test and genetics
VACTERL Syndrome
- vertebral anomalies
- anal atresia
- cardiac abnormalities
- tracheoesophageal fistula
- renal agenesis
- limb defects
VATER Syndrome
- vertebral anomalies, anal atresia, tracheoesophageal fistula, esophageal atresia, renal agenesis)

Answer 360

A

AD inheritance
linked to P53 inactivity
linked to rhabdomyosarcoma in kinds
also known as Sarcoma, breast, leukaemia and adrenal gland (SBLA) syndrome.

Answer 361

A

Blood work (anemia, thrombocytopenia)

Echo/asceulation

Renal U/S

Abdomenal U/S

Answer 362

A

Ollier’s disease (multipe enchondromatosis)
- no genetic predisposition has been identified
- multiple enchondromas in long bone diaphysis
- 10-30% chance of malignant transformation into chondrosarcoma
- however associated with high rate of both skeletal and non-skeletal malignancies
- involved bones are dysplastic
Maffucci’s syndrome
- no genetic predisposition has been identified
- multiple enchondromas and soft-tissue angiomas
- 100% chance of malignant transformation into chondrosarcoma
- increased risk of visceral malignancies (astrocytoma, GI malignancy)

Answer 363

A

proper placement

center of tunnel entrance into joint should be 10-11mm in front of anterior border of PCL insertion

tunnel trajectory of < 75° from horizontal

obtain by moving tibial starting point halfway between tibial tubercle and posterior medial edge of tibia.

anterior misplacement

leads to knee that is tight in flexion with impingement in extension

posterior misplacement

leads to ACL that will impinge on posterior condyle

Answer 364

A

male, 20-40

repetative injury

I pattern vascularity

ulnar negative variance

Answer 365

A

Atavastic great toe

short, thick, first MT

associated with polydactyly

Often need to syndactylize to second toe to control deformity

MT osteotomy +/- lengthening

release addutor hallucis

Answer 366

A

cost effectiveness

(content, methodology and clinical utility are all important)

Answer 367

A

wide resection
no role for chemo unless there is a high grade component
30-40 yo
surface of bones, usually the distal femur
less aggressive than periosteal osteosarcoma

Answer 368

A

Heel to toe rocker

Answer 369

A

> 50 yo (worse prog over 40)

pain, swelling, path #

distal femur, proximal tibia

XR - purely lytic wth moth eatten appearance, no evidence of codman’s triangle or osseous matrix

Treat as if osteosarc

Chest XR - rule out lung mets

Local staging with MRI

Chemo - doxyrubicin and cysplatinin

Re-stage

Limb salvage surgery

Chemo

Answer 370

A

ACCESS PTB
Analogy: The effect of similar factors may be considered.
Consistency: Consistent findings observed by different persons in different places with different samples strengthens the likelihood of an effect.
Coherence: Coherence between epidemiological and laboratory findings increases the likelihood of an effect. However, Hill noted that “… lack of such [laboratory] evidence cannot nullify the epidemiological effect on associations”
Experiment:“Occasionally it is possible to appeal to experimental evidence”
Strength: A small association does not mean that there is not a causal effect, though the larger the association, the more likely that it is causal
Specificity: Causation is likely if a very specific population at a specific site and disease with no other likely explanation. The more specific an association between a factor and an effect is, the bigger the probability of a causal relationship
Plausibility: A plausible mechanism between cause and effect is helpful (but Hill noted that knowledge of the mechanism is limited by current knowledge)
Temporality: The effect has to occur after the cause (and if there is an expected delay between the cause and expected effect, then the effect must occur after that delay).
Biological gradient: Greater exposure should generally lead to greater incidence of the effect. However, in some cases, the mere presence of the factor can trigger the effect. In other cases, an inverse proportion is observed: greater exposure leads to lower incidence

Answer 371

A

peroneal tendons
extensor digitorum brevis
talonavicular joint capsule

Answer 372

A

spinal bifida oculta

defect in vertebral arch with confined cord and meninges

meningocele

protruding sac without neural elements

myelomeningocele

protruding sac with neural elements

rachischisis

neural elements exposed with no covering

Answer 373

A

Angio for embolization

Answer 374

A

SAPHO

pustulitic arthro-arthritis

soft tissue ossification between the clavicles

palmoplantar pustolosis and severe acne

Males 40-50, severe pain and redness over SC joint

often bilateral

Answer 375

A

suprascapular notch apparently more common
- due to confinement and limited mobility
- nerves to supraspinatous are adhered to periosteium
- leads to more functional deficiet
Other site is spinoglenoid notch
- IS is more compenstated by deltoid
Etiology
- cysts
- transverse scapular ligament
- fracture callus
- Can be associated with
  - RC tear, AC OA, adhesive capsulitis, GH OA, parsonage turner syndrome
XR - stryker notch view
EMG/NCS will confirm pathology of location of the entrapment
Get MRI and treat pathology
- trace the nerve
- look for mass occupying lesions
- compare SS and IS atrophy

Answer 376

A

central, anteromedial, then circles laterally

Answer 377

A

oppositve to clubfoot except achilles

flat foot

abducted

valgus

equinus

talus is vertical and not articulating with navicular; need to get platarflexion views to R/O the more common calcaneovalgus

Achilles, peroneals are tight, tib ant and post are not functioning

Answer 378

A

Radial Head Fracture

Physical
- check ROM
  - 30-130 flex-ex
  - 45-45 sup-pro
- check the pin
Imaging
- can get a greenspan view to help assess
  - 45 deg oblique center over the RC joint
- CT
Classification - Mason Allen
- Type 1 - nondisplaced
- Type II - partial head fx
- Type III - complete head
- Type IV - radial head fx with elbow dislocatoin
short period of immobilization followed by early ROM
- Nondisplaced, stable (30-130)
- no mechanical block
- complications
  - nonunion
    - new studies have shown a higher rate of nonunion in nonoperative managmeent than previously expected
ORIF
- Indications
  - Simple fracture
  - - Mechanical block
- technique
  - plate in safe zone
  - countersink screws in articular surface
Fragment Excision (partial excision)
- indicated if fragment
- Cannot be a part of the PRUJ
- complications
  - even small fragment excision may lead to instability
radial head replacement
- indications
  - for comminuted fracture with 3 or more fragments
- complications
  - overstuffing of joint that leads to capitellar wear problems and malalignment instability
radial head resection
- indications
  - older patients with limited demands
  - in a delayed setting for continued pain of an isolated radial head fracture
- contraindications
  - forearm ligament injury (identify with radius pull test)
  - coronoid fracture
  - MCL deficiency
- complications
  - muscle weakness
  - wrist pain
  - valgus elbow instability
  - heterotopic ossification
  - arthritis

Answer 379

A

Type I Transphyseal (10%)
- IA - without dislocation of epiphysis from acetabulum
- IB, with dislocation of epiphysis
- Risk of ANV = 90-100%
Type II Transcervical (40-50%)
- AVN - 50%
- Nonunion - 15%
Type III Basicervical (30-35%)
- AVN - 25%
- Nonunion - 15-20%
Type IV Intertrochanteric (10-20%)
- AVN - 10%
- 5%

Answer 380

A

Some will recommend in combination ACL - rehab to get ROM, then reconstruct ACL and if still valgus instability reconstruct the MCL - highly controversial as to what you do
Nonoperative
- treat in hinged knee brace for 6-8 weeks
- only knee ligament injury the body can heal independently
- proximal ruptures have better healing potential than distal ruptures
- rehabilitation
  - early ROM and functional rehab (immediate quads) in athletes
  - return to play depends on discomfort and residual instability
    - Grade I: 2 weeks
    - Grade II: 3 weeks
    - Grade III: full extension for 2 weeks followed by 6 to 8 weeks of total rehab (must ensure it is isolated MCL)
- medications
  - ibuprofen shown to not be deleterious to MCL healing
  - new studies have shown that platelet-derived growth factor (PDGF) improves healing
Operative
- indicated only in Grade III injuries as part of multiple ligament knee injuries (with ACL and/or PCL/PLC)
  - tibial avulsion in athlete
  - grade III with valgus alignment
  - associated fractures (plateau or avulsion)
  - intra-articular intrapment
- treatment options include
  - treat MCL nonoperatively, wait for it to heal, then reconstruct ACL
  - primary repair of all torn structures
    - use sutures, suture anchors, or screws with washers for avulsions of the MCL origin or insertion
  - MCL reconstruction
    - can use allograft or semitendinosus autograft
    - attach to anatomic origin and insertion
  - tension in 30° knee of flexion after PCL, ACL, and lateral side have been tensioned
- timing of repair
  - address multiple ligament knee injuries as soon as safely possible
  - allow 2-3 weeks for capsule to heal to allow arthroscopy and still permit repair of posterolateral structures
- postoperative
  - block full knee extension to protect repair for 3 weeks, then full ROM and WBAT at 3 weeks
  - progressive activity starting at 6 weeks
complications
- stiffness
  - must counsel patient increased risk of loss of motion

Answer 381

A

GH arthrodesis

Answer 382

A

Lateral approach - kocher distally to see LCL, mobile wad and extensors proximally; the large the peice the more anterior you need to get (can use a homen under brachialis and capsule to get across the humerus)

On the rare occasion that you can’t see across you can do a concurrent flexor/pronator split medially, or use an olecranon osteotomy (although you don’t see much joint anteriorly this way)

Answer 383

A

Rockwood and Green Ch 27

They observed a significantly greater loss of ROM in forearms with middle-third deformities than with distal-third deformities, with more supination being lost than pronation. They also observed a significant decrease of ROM with 15° of angulation

Answer 384

A

toughness - engery absorbed until failure

Answer 385

A

Bankhart lesion

Answer 386

A

makes up 10 to 15% of cartilage
functions to provide compressive strength and attract water
produced by chondrocytes
composed of GAG subunits
- chondroitin sulfate
- keratin sulfate

Answer 387

A

Nerve injury same risk
Reports of higher rates of nonunion with IM nail
reports of better function with plate

Answer 388

A

olecranon

Answer 389

A

ABC

osteoblastoma

osteoid osteoma

osteochondroma

Answer 390

A

immediate mechanical stability
low cost
ease of use
no donor site morbidity
no disease transmission
easier detection of recurrence
exothermic reaction leaves a rim of necrotic bone

Answer 391

A

Boundaries of Guyon’s canal
- Floor
  - Transverse carpal ligament, hypothenar muscles
- Roof
  - Volar carpal ligament
- Ulnar border
  - Pisiform and pisohamate ligament, abductor digiti minimi muscle belly
- Radial border
  - Hook of hamate
Zones of Guyon’s canal
- Zone 1
  - Proximal to bifurcation of the nerve
  - Ganglia and hook of hamate fractures
  - Mixed motor and sensory
- Zone 2
  - Surrounds deep motor branch
  - Ganglia and hook of hamate fractures
  - Motor only
- Zone 3
  - Surrounds superficial sensory branch
  - Ulnar artery thrombosis or aneurysm
  - Sensory only

Answer 392

A

pulvertaf

Answer 393

A

I - capitellum

II - avulsion capitellum

III - comminuted capitellum

IV - trochlea (double arc sign)

Answer 394

A

Torticollis

Deformity in the SCM
- head tilts towards the affected side and rotates away
Pathophysiology
- some studies suggest association with intrauterine compartment syndrome of SCM
- non-SCM causes include
  - ophthalmologic
  - vestibular
  - congenital
  - traumatic
  - tumors
Associated conditions
- Packing disorders
  - DDH (5 - 20% association)
  - metatarsus adductus
- traumatic delivery
- plagiocephaly (head assymetry)
- congenital atlanto-occipital abnormalities
Differential
- Rotatory atlanto-axial instability / Grisel’s disease
- Klippel-Feil syndrome
Imaging
- XR/CT
  - if no palpable mass
  - to rule out AARD/klippel-fiel
- US can show lesion in SCM
Treatment
- passive stretching
  - condition present for less than 1 year
  - limitation less than 30°
  - should include lateral head tilt away from the affected side and chin rotation toward the affected side (opposite of the deformity)
  - 90% response with-in one year
- Z plasty lengthening or distal bipolar release of SCM
  - > 1 year
  - > 30°

Answer 395

A

vagus
loops around the aorta on the left and subclavian on the right
historically less risk on the left but new studies to show no difference
Treatment of injury
- monitor
- if no return in 6 weeks refer to ENT for assessment and teflon injection

Answer 396

A

chondrosarcoma

Answer 397

A

associated with increased OA

ACL recon does not decrease OA risk

chronic ACL tear = medial meniscus

Answer 398

A

normal subtalar motion

Answer 399

A

steroids
thyroid meds
antacids
anti-convulsants (Vit D metabolism)
PPI’s
Tetracycline
Loop diuretics
Lithium
Methotrexate

**Diclofenac does not

Answer 400

A

0.2-1.6%

Squamous cell carcinoma = Marjolin’s ulcer

Answer 401

A

acute fever

transient hypocalcemia, hypophosphatemia, hypomagnesemia

Oversuppression of bone remodelling

NO growth delay

NO fracture healing issues

Some difficulty healing osteotomy

Answer 402

A

FDS to APB (bunnell opponensplasty)

EIP to APB

Answer 403

A

Open segmental fracture, irrespective of the size of the wound
Gunshot wounds -high velocity and short-range shotgun injuries
Open fracture with neurovascular injury
Farm injuries, with soil contamination, irrespective of the size of the wound
Traumatic amputations
Open fractures over 8 hours old
Mass casualties; eg, war and tornado victims

Answer 404

A

ulnar (then radial)

proximal medial

Answer 405

A

>80 yo

>2mm ulnar variance

metaphyseal comminution

dependant patient

NOT dorsal angulation

Answer 406

A

Homocysteinuria has inferior lens dislocation
Marfan’s has superior lens dislocation
Neurofibromatosis has Lisch nodules in the iris.

Answer 407

A

overcorrection of 1st IMA
excessive lateral capsular release with overtightening of medial capsule
overresection of medial first metatarsal head
lateral sesamoidectomy

Answer 408

A

3 cannulated screws

inverted triangle

Answer 409

A

Overall - supnation is the most stable position for the DRUJ

dorsal - supnation

volar - pronation

LAC - 6 weeks

Answer 410

A

Type 1: similar to nonrheumatoid stenosing tenosynovitis, in which the tendons catch at the first annular pulley during flexion secondary to small, localized hyperproliferation of the synovium.
Type 2: the nodules form in the distal palm and cause the finger to lock in flexion. In
type 3: nodules on the flexor digitorum profundus (FDP) tendon near the second annular pulley (over the proximal phalanx) lock the finger in extension.
Type 4: trigger finger results from generalized tenosynovitis within the fibroosseous canal. Active motion is more restricted than passive motion, and contracture and stiffness result.

Answer 411

A

pain scores better in arthroplasty
revision rate lower in fixation
mortality the same
blood loss lower for internal fixation

Answer 412

A

Volar IP dislocation
- always has a central slip rupture
late deformity
- Boutinerre - from central slip rupture
Blocks to reduction
- one collateral
- central slip and lateral band
  - __button holes between the two
Treatment
- buddy tape for 6-8 weeks if reducible
  - if fracture < 40%
  - no associated fracture
- ORIF or CRPP
  - >40% articular surface

Answer 413

A

Comes underneath quads femoris, travels superiorly in front of the ERs, except obturator externus because it is a more antereiror structure

Answer 414

A

dysplasic (and more neuro)

>50% slip

>50 deg slip angle

Answer 415

A

Normally takes 20% loads
positive - pronation
negative - supnation

Answer 416

A

Timing
- syndactyly
  - perform at ~ 1 year of age
  - controversial
- acrosyndactyly
  - perform in neonatal period
- if multiple digits are involved perform procedure in two stages to avoid compromising vasculature
  - early surgery allows this
  - thumb and index at
- release digits with significant length differences first to avoid growth disturbances
technique
- zigzag flaps are created during release to avoid longitudinal scarring
- a nailbed can be re-created in complete syndactyly
complications
- Web creep
  - most common complication of surgical treatment
  - reconstruct web space with local skin flaps
- Nail deformities
- Scar
- Avascular digit
  - __never operate threw both sides of the digit

Answer 417

A

With IM nails
- improved stiffness
- improved alignment
- increased risk of nonunion
  - avoid if causes tibial fracture gapping
Absolute indications
- evidence of syndesmotic injury
- medial tibial plating
  - to avoid valgus

Answer 418

A

elastohydrodynamic
- main mechanism during dynamic joint function
- elastic deformation of articular surfaces
- thin films of lubricant separate the surfaces
boundary (slippery surfaces)
- bearing surface is non-deformable
- lubricant only partially separates surfaces
- superficial zone proteins have a role in this lubrication mechanism
boosted (fluid entrapment)
- concentration of lubricating fluid in pools
- trapped by regions of bearing surfaces that are making contact
hydrodynamic
- fluid separates surfaces when one surface is sliding on the other
weeping
- fluid shifts out of articular cartilage in response to load
- surfaces separated by hydrostatic pressure

Answer 419

A

65 and 110

Answer 420

A

NOT Sex

NOT medical status

Tip-apex > 25mm

increased age (controversial)

unstable fracture

poor reduction

Higher (150) deg plate

Answer 421

A

helps to maintain the stability of the joint
- strains the IGHL without it
Buford complex is a normal anatomical variant
Pathoanatomy
- forceful traction
- repetative throwing
- direct compression
Physical exam
- no specific exam is useful
- O’briens, yeargson and speed can be helpful
- assess the cuff
- Assess for associated spinoglenoid compression

Answer 422

A

Inability to hydroxylate 25-VitD
Accentuated by
- inactivity
- poor intake vit D
- reduced exposure to sunlight

Answer 423

A

Correct hypotension

correct anemia with transfusion

DON’T give O2

Answer 424

A

most common presentation is pain
en bloc resection with tumor free margins
no role for chemo or RT because is a slow growing tumour
rads can be used if there is any concern at all about recurrence or positive margins

Answer 425

A

No difference in reamed nails with regard to infection, nonunion or need for additional procedures
- not suggested in grossly contaminated wound, delay to treatment, gustilo IIIb
Gapping is the number one reason for nonunion
BMP-2 has been shown to have decreased time to union, decreased need for secondary procedures in all fractures and decrease infection in Gustilo III
With regards to plating an open tibia - the most common reason they progress to nonunion is periosteal stripping

Answer 426

A

90 deg abduction, 90 deg ER

LHB most common

capsule, periosteium

Answer 427

A

Epiphyseal, benign aggressive
- can get cortial thinning with neocortex and soft tissue invasion
- destruction caused by activation of osteoclasts
30-40 yo (ABC is 20)
Location
- 50% knee
- 10% sacrum
- distal radius
Medical treatment
- bisphosphanates
- denosemab
extensive curettage and reconstruction (with adjuvant treatment)
- challenge - remove lesion while preserving joint and providing support to subchondral joint
- extensive exterioration (removal of a large cortical window over the lesion) is required
- 10-30% recurrence with curettage alone verses 3% with adjuvant treatment (phenol, hydrogen peroxide, argon beam, etc)
- can fill lesion with bone cement or a_utograft/allograft bone_
hand lesion treatment is controversial
- if no cortical breakthrough treat with curettage and cementing
- if significant cortical breakthrough consider intercalary resection (with free fibular graft) vs. amputation

Answer 428

A

Blacks > whites
usually carpometacarpal fusion failure of cavitation 4-8 wks gestation
usually bilateral
90% between lunate-triquetrum

Answer 429

A

50% spontaneous
autosomal dominant (AD)
- mutation in NF1 gene on chromosome 17q21
- codes for neurofibromin protein
- negatively regulates Ras signaling pathway
- neurofibromin deficiency leads to increased Ras activity
- affects Ras-dependent MAPK activity which is essential for osteoclast function and survival
neurofibromatosis is the most common genetic disorder caused by a new mutation of a single gene

Answer 430

A

increases with flexion and contralateral rotation
decreases with extension and ipsilateral rotation (ie; spurling test)

Answer 431

A

indications
- curve > 20° in nonambulatory patient
  - (treat early, < 30° curve, before pulmonary function declines)
  - can wait slightly longer (Cobb ~ 40°) if patient is responding well to corticosteroids
- FVC drops below 35%
- rapidly progressive curve
techniques
- extension to pelvis is controversial
Complications
- malignant hyperthermia is common intraoperatively
  - pretreat with dantrolene
- intraoperative cardiac events

Answer 432

A

Goal is to have as many independant and functional digits as possible
- deep and wide web
- cover deficits with soft tissue
Indications
- skin bridge that hinders use
Contraindications
- super digit
- complex digit that functions in unison
- no active muscle control with functional digits

Answer 433

A

Local
- post-op swelling and stiffness
- delay in recovery of muscle power
- compression neuropraxia
- wound hematoma
- wound infection
- direct vascular injury
- bone and soft tissue necrosis
- compartment syndrome
Systemic
- increased CVP
- increased arterial HTN
- Cariorespiratory compensation
- cerebral infarct
- altered acid-base balance
- rhabdomyolysis

Answer 434

A

Compartment syndrome
- TIII, admit and monitor pre-op and post-op with Q2H compartment checks
- Increased risk with worse deformity and vascular injury (even after repair)
- Treatment - forearm fasciotomy
Pin migration
- most common complication (~2%)
Infection
- occurs in 1-2.4%
- typically superficial and treated with oral antibiotics
Cubitus varus (gunstock deformity)
- caused by fracture malunion
- can lead to tarda ulnar nerve palsy
- usually a cosmetic issue with little functional limitations - this is changing
- Can lead to attenuation of the LUCL and eventually PLRI
  - Changes the force of the triceps (assymetric)
  - Osteotomy has good results
- Corrective osteotomy is recommended if substantial deformity is present
  - Explain to parent risk of PLRI
  - Opening lateral wedge
- Timing
  - >1 year after no improvement in ROM
  - When old enough to comply with PT
Recurvatum
- common with non-operative treatement of Type II and Type III fractures
Nerve palsy
- usually resolve with no need for treatment or investigation
Vascular Injury
- Volkmann ischemic contracture
- rare, but dreaded complication associated with supracondylar humerus fractures
- more often as a result of brachial artery compression with treatment utilizing elbow hyperflexion and casting than true arterial injury
- increase in forearm compartment pressures and loss of radial pulse with elbow flexed greater than 90°
- rarely seen with CRPP and postoperative immobilization in less than 90°
Stiffness
- Rare after casting or pinning
- Will resolve by 6 months
- Literature does not support use of PT

Answer 435

A

LHB can help locate the asecnding branch and localize the tuberosity
ascending branch is just posterior and lateral to the LHB
ascending branch of the anterior circumflex is the primary blood supply to the femoral head
the second supply is the posterior circumflex which wraps around the medial calcar

Answer 436

A

VISI - volar intercalated segmental instability

LT ligament injury occurs with
- wrist hyperextension or
- extension and radial deviation
2 important ligaments tears
- lunotriquetral (intrinsic)
  - volar - strongest
  - dorsal - more important rotation
- Dorsal radiocarpal (extrinsic)
- volar long and short radioluntae ligaments - extrinsic that might also tear
scaphoid induces the lunate into further flexion while triquetrum extends

Answer 437

A

Adductor fascia (Stener lesion)

Answer 438

A

Type I
- noxious stimiulant
- crush, soft tissue, immobilization in cast
Type II
- defined nerve injury
Presentation
- hypermia, edema, skin changes
- temperature changes, sweating
Requires multi-modal and team approach with treatment started as soon as possible
Treatment
- Continue aggressive PT
- Medication
  - vitamin C
  - gabapentin
  - antidepressants, muscle relaxants
- Nerve block
  - local injection into the nerve
- Stellate ganglion blocks or spinal cord stimulator
  - should be reserved for refractory cases

Answer 439

A

Keinboch’s - Litchman Classification

Stage I
- No visible changes on xray, changes seen on MRI
  - Immobilization
  - NSAIDS
Stage II
- Sclerosis of lunate
  - Ulnar negative - ulnar shortening
  - Ulnar positive - Radial wedge, STT fusion
  - Distal radius core decompression
  - Revascularization procedures
Stage IIIA
- Lunate collapse, no scaphoid rotation
  - Same as Stage II above
Stage IIIB
- Lunate collapse, fixed scaphoid rotation
  - Proximal row carpectomy
  - STT fusion
Stage IV
- Degenerated adjacent intercarpal joints
  - Wrist fusion
  - proximal row carpectomy
  - limited intercarpal fusion

Answer 440

A

Simple
- Only soft tissue involvement, no bony connections
Complex
- Side to side fusion of adjacent phalanges
Complicated
- Accessory phalanges or abnormal bones involved in fusion
Complete vs. Incomplete
- Complete: syndactyly the skin extends to finger tips
- incomplete: skin does not extend to fingertips

Answer 441

A

Congruent joint surface OR only necessary if can’t do this with closed means

Answer 442

A

Closed reduction in LAC for 6 weeks
ORIF with immoblization
- loss of reduction at follow-up
- unable to get a reduction at time of injury
More stable due to
- thick periosteum
- superior fracture remodeling capacity
- the increased ligamentous strength and elasticity of the DRUJ

Answer 443

A

Wait for fracture to heal

Answer 444

A

Nonoperative
- shoe modification/ pads/ orthoses
- silastic spacer
  - orthoses more helpful in patients with pes planus or metatarsalgia
Soft Tissue Procedure - modified McBride
- never appropriate in isolation
- in conjunction with medial eminence resection osteotomy
- release medial capsule of 2nd MTP; can be sutured to lateral capsule of 1st
- adductor hallucis is released and interposed
  - Can be left to scar down
- Transverse intertarsal ligament is releases which attaches to the fibular sesamoid
- Don’t resect the fibular sesamoid as was done with the original McBride or you will get hallux varus
distal metatarsal osteotomy
- mild disease (HVA 20-40, IMA 10-13)
- distal metatarsal osteotomies include
  - Chevron
  - biplanar Chevron
  - Mitchell
- may be combined with proximal phalanx osteotomy
proximal metatarsal osteotomy
- moderate disease (HVA >40°, IMA >13°)
- proximal metatarsal osteotomies include
  - crescentric osteotomy
  - Broomstick osteotomy
  - Ludloff
  - Scarf
double (proximal and distal) osteotomy
- severe disease (HVA 41-50°, IMA 16-20°)
- DMAA > 15
- Scarf + chevron
- Lapidus + Akin
first cuneiform osteotomy
- severe deformity in young patient with open physis
Lapidus procedure (1st metatarsocuneiform arthrodesis)
- severe deformity
- Metatarsus primus varus
- hypermobile 1st tarsometatarsal joint
MTP Arthrodesis
- Gout
- Rheumatoid arthritis
- Down’s syndrome
- cerebral palsy
- Severe DJD
- Ehler-Danlos
- Resection arthroplasty
proximal phalanx (Keller) resection arthroplasty
- largely abandoned
- still indicated in some elderly patient with reduced function demands

Answer 445

A

posterior heel pad migration

others - skin sloughing, post tib comprimise

used to be an issue fitting a prosthesis due to limited space requiring lift of the contralateral limb - not an issue any more

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