MCQ Flashcards

Question

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

Answer 1

triple arthrodesis

Answer 2

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

Answer 3

* **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

Answer 4

* 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

Answer 5

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

Answer 6

* increased load * limit mobility

Answer 7

* **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

Answer 8

* **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

Answer 9

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

Answer 10

\> 9 back pain 3-9 abdo pain\*\* \< 3 limp, posivite log roll

Answer 11

cortical metaphyseal/diaphyseal 1-3cm bubbly - not loculated Eccentric

Answer 12

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

Answer 13

* **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

Answer 14

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

Answer 15

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)

Answer 16

* **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

Answer 17

* **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

Answer 18

BEST decreased need secondary intervention or subsequant bone grafting increased healing rate decreased infection in grade III only

Answer 19

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

Answer 20

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

Answer 21

basilar invagination

Answer 22

\< 60 - observe 60-80 and risser \< 3 - milwakee brace \>75 in skeletally mature - PSF

Answer 23

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

Answer 24

* 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)

Answer 25

Latex allergy

Answer 26

* 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

Answer 27

* **\> 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

Answer 28

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

Answer 29

* 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

Answer 30

* 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

Answer 31

* 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)*

Answer 32

1. **Hilgenreiner's physeal angle \> 60** * ****\<45 unlikely to progress * \>60 will likely progress 2. **Neck-shaft angle \< 110** 3. **trendelenberg** 4. **pain** 5. **evidence of progression with serial exams** Important considerations - may need to transfer aductor tubercle to increase tension, monitor for LLD

Answer 33

* **chronic SL ligament injury** creates a **DISI deformity** * **scaphoid is flexed** and l**unate 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

Answer 34

* 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_

Answer 35

* **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.

Answer 36

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

Answer 37

\*Arcade of struthers \*Aponeurosis of FCU \*MCL and osborne's ligament medial head of triceps intermuscular septum medial epicondyle anconeus epitrochleris

Answer 38

* **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 39

CT - better than MRI to look for the nidus

Answer 40

* **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 41

**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 42

* lateral Bending * then torsion

Answer 43

* **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 44

* 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 45

* **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 46

myelomeningocele tethered cord arthrogryposis

Answer 47

number failed divided by the number still being followed

Answer 48

* 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 49

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

Answer 50

Rib Phase 1 (\>2 will progress) RVAD/Mheta \< 20 (90% will resolve spont) Cobb \< 25 Double major curves progress

Answer 51

posterior radial collateral artery

Answer 52

neutral dorsiflexion 5 valgus 10 ER

Answer 53

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 54

blocks ACTH from release at the pre-synapic vesicles

Answer 55

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

Answer 56

Partial ruptures Proximal tears ( in the muscle or musculotendonous junction) Sedentary patient

Answer 57

\<1mm = cast \> 1mm and large = screw \> 1mm and small = k-wire (wagner pinning) (one=oblique ligament, one=counter tendons)

Answer 58

PIN 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 59

* 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 60

* 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 61

unstable CMC joint

Answer 62

Patient Selection Timing of surgery Prioritization of restoration

Answer 63

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

Answer 64

* **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 65

* **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 66

* **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 67

* **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 68

* **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 69

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 70

* **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 71

* 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 72

antiprotrusio cage with screws liner secured PMMA 3 rods to reconstruct posterior column of the acetabulum

Answer 73

* **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 74

better forefoot aduction

Answer 75

* **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 76

* 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 77

**_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 78

MRI to rule out hematoma/edema/cord transection or missed ligamentous injury Immoblization (c-collar) 2-3 weeks monitor

Answer 79

* EPL control IP flexion

Answer 80

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 81

chronic MCL deficiency leads to calcification next to medial femoral epicondyle

Answer 82

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 83

A - Observe, casting B, B/C - containment in fragmentation phase Later can do abduction/ext or chiari as salvage procedures

Answer 84

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

Answer 85

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 86

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

Answer 87

Medial - peroneals, EDB, TN capsule Lateral - FHL, FDL, Tib post

Answer 88

Patients change their outcome based on the treatment they receive

Answer 89

When they have a new physician

Answer 90

pre-op ROM

Answer 91

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

Answer 92

* 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 93

* **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 94

\<5 yo no kyphosis \<5 segments hemivertebrae (NOT unsegmented bars) absence of neurological deficiet

Answer 95

LCP - lateral pillar A - no involvement B - \> 50% lateral pillar height B/C - lateral pillar at 50% C - \< 50% lateral pillar height

Answer 96

* 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 97

* 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 98

IR view stryker notch

Answer 99

attach heel pad to anterior tibia

Answer 100

* 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 101

scaphoid flexion triquetrum extesion volar flexion lunate No LT widening SL angle \<30 break in gilula's arc with superior migration of triquetrum

Answer 102

Stage 2 SNAC Stage 2 SLAC Stage IIIb, IV Keinbochs failed implant severe trauma to lunate

Answer 103

* **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 104

* **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 105

**thumb hypoplasia/radial clubhand** VACTERL Holt-Oram thrombocytopenia-absent radius (TAR) Fanconi anemia

Answer 106

Regain elbow flexion Stindler's flexorplasty latissiumus dorsi/pec major to biceps

Answer 107

* Low ALP * High Ca * Normal PTH

Answer 108

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 109

* 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 110

figure of 8 wires with cannulated screws ## Footnote *interfrag screws for comminution*

Answer 111

vastus medius, adductor magnus, sartorius femoral artery, femoral vien, saphenous nerve, nerve to vastus medialis

Answer 112

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

Answer 113

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

Answer 114

5 deg valgus

Answer 115

Penecillin

Answer 116

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

Answer 117

* 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 118

* **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 119

medial sural cutaneous nerve

Answer 120

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 121

Fibrous Bands Recurrent radial artery - lesh of henry Tendonous ECRB Arcade of Frosch (proximal supinator) (MOST) Distal supinator (least)

Answer 122

* 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 123

*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 124

* **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 125

* **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 126

* 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 127

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 128

the number to prevent one bad outcome

Answer 129

**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 130

* 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 131

* **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 132

* 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 133

90% resolve by 2 years Recovery of biceps by 2 months is good prognosis

Answer 134

* 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 135

palmar cutaneous branch of the median nerve

Answer 136

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 137

**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 138

Glut med split with hardinge

Answer 139

* 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 140

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

Answer 141

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

Answer 142

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

Answer 143

posterior malleolus fracture

Answer 144

lower need for future bone graft lower rate subsequent soft tissue lower infection rate (only in Gustilo 3 pattern)

Answer 145

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

Answer 146

* 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 147

* 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 148

asthetic less HO 10% improved strength with double more often LCFN traction injury with single

Answer 149

always double glove waterproof barriers instrument tie or staples pass sharp instruments in a bowl JAAOS 1996

Answer 150

posterior tibialis tendon flexor hallucis longus flexor digitorum longus

Answer 151

* 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 152

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 153

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 154

* 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 155

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 156

* 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 157

Used primarily in older patients: Ulnar drift painful ECU subluxation radio-ulnar impingement instability of the ulnar shaft

Answer 158

* wide resection * chemo (treated like a bone tumor)

Answer 159

* **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 160

* 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 161

* **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 162

Coxa magna Coxa plana short femoral neck

Answer 163

\*\*\*imbalance of the musculature FDS tear - overpull of FDP mallet finger - ext at PIP intrinsic contracture MCP volar subluxation

Answer 164

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

Answer 165

* **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 166

* 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 167

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 168

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 169

plantar release Tendon transfer dorsiflexion first ray +/- jones

Answer 170

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 171

Same healing time, weaker bone

Answer 172

First - hand packed, no plug Second - cement plug, gun, canal preparation with brush and adrenaline Third - vacum, retrograde filling, pressurization, centralizer

Answer 173

pressure goes up with both flexion and extension

Answer 174

aseptic osteonecrosis of the medial clavicle red joint ESR/CRP/WBC/Rheum work-up are normal MRI - necrotic bone islands

Answer 175

**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 176

**Bennet fracture** Abductor pollicis longus extensor pollicis longus adductor pollicis

Answer 177

* **\>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 ## Footnote *US and MRI can help aid the diagnosis, but usually the diagnosis is made on physical exam*

Answer 178

Increased DMMA

Answer 179

ABC osteoblastoma osteoid osteoma ostosarcoma

Answer 180

Acrosyndactyly (ring syndrome) Poland syndrome Apert syndrome Carpenter syndrome (acrocephalopolysyndactyly)

Answer 181

* **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 182

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 183

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

Answer 184

Endocrinopathy (hypothyroid) renal osteodystrophy growth hormone

Answer 185

* 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 186

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 187

synoviocytes

Answer 188

* **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 189

* **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 190

TFL-sartorius Rectus - glut med

Answer 191

* 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 192

A - complete B - sensation but not motor C - \< grade 3 \> 50% levels D - \> grade 3 \> 50% levels E - sensory only

Answer 193

* **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 194

recruitment of more motor units

Answer 195

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

Answer 196

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 197

* 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 198

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

Answer 199

Usually golfers or raquet with ulnar wrist pain +/- nerve sx carpal tunnel view CT IS BEST TO MAKE DIAGNOSIS

Answer 200

* **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 201

* 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 202

* 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 203

L5-S1 (L5 nerve root is most affected)

Answer 204

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 205

circumferntial

Answer 206

posterior anti-glide plate with lag screw especially superior in weak bone

Answer 207

* 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 208

* _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 209

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

Answer 210

Block vertebrae incarcerated hemivertebrae nonsegmental hemivertebrae some partially segmented hemivertebrae

Answer 211

high risk of penetration higher risk of AVN Better torsional control

Answer 212

MCP joint subluxation Mallet finger FDS tear tight intrinsics

Answer 213

insufficient subscap repair

Answer 214

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 215

* 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 216

when they have a flexible compensatory curve

Answer 217

* **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 218

* 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 219

chondral lesion (strongest) obesity medial meniscectomy

Answer 220

* **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 221

* *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 222

* **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 223

* 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 224

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

Answer 225

* **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 226

* 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 227

* **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 228

* **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 229

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 230

lack of terminal extension

Answer 231

**Allow to heal** **then curettage and bone graft** **increase complications associated with acute treatment**

Answer 232

**collateral ligaments** ## Footnote 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 233

increased PE, **cardiac complications,** need for transfusions and mortality lower infection, lower DVT

Answer 234

**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 235

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

Answer 236

* 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 237

* **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 238

AVN of the medial clavicle atraumatic dislocation often occurs in females medial bowing of the clavicle

Answer 239

* **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 240

sensory changes - shows prolonged sensory latency

Answer 241

* 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 242

posterior decompression

Answer 243

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 244

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

Answer 245

* 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 246

partial tear proximal tears (sternoclavicular origin) Older/sedentary individuals

Answer 247

Ligament of struthers biceps aponeurosis (lacertus fibrosis) - AIN heads of pronator - AIN FDS arcade - AIN accessory FPL - AIN thrombosed artery - AIN

Answer 248

* 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 249

Simple - soft tissue only Complex - fusion of adjacent phalanges Complicated - abnormal bone Complete vs incomplete - complete extends to fingertips

Answer 250

* **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 251

* **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 252

conduction velocity \<50 m/sec across elbow

Answer 253

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 254

Cross sectional

Answer 255

lunotriquetral dorsal radiocarpal long and short radiolunate

Answer 256

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 257

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

Answer 258

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 259

* 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 260

* 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 261

medial clavicle

Answer 262

**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 263

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 264

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

Answer 265

\*\*Occurs in distal arthrogryposis * Flexion, adduction of thumb (thumb in palm) * narrowing first web space * flexion/ulnar deviation of fingers

Answer 266

obtain serendipity views ( beam at 40 cephalic tilt) anterior dislocation - affected clavicle above contralateral clavicle posterior dislocation - affected clavicle below contralateral clavicle

Answer 267

* 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 268

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

Answer 269

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

Answer 270

* **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 271

* 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 272

**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 273

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

Answer 274

**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 275

* 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 276

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

Answer 277

Saggital band

Answer 278

Cortical allograft (cortical is slower to incorperate)

Answer 279

* 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 280

1. Elbow flexion 2. shoulder abduction/stability 3. hand sensibility 4. wrist extension 5. finger flexion 6. wrist flexion 7. finger extension 8. intrinsic hand function

Answer 281

* 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 282

hypercholermic metabolic acidoisis

Answer 283

Basion to Posterior C1 / Opisthion to Anterior C1 (CD/BA)

Answer 284

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 285

* **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 286

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 287

* **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 288

**osteophytes** **deep MCL** **Semi- M - moslty extension, should be released last** **SMCL - anterior or posterior based on whether you need release** **PCL - flexion**

Answer 289

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 290

change in ulnar varience (ie radial height)

Answer 291

* \>4mm distraction * \>2mm stepoff * intra-articular fragments * osteochondral fragment * lose of extensor mechanism ## Footnote *no data exist on post-op rehab protocols*

Answer 292

5 deg valgus neutral dorsiflexion 5 deg ER

Answer 293

* **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 294

* **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 295

**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 * l**ess 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 296

* 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 297

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 298

**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 299

**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 300

ABI \> 0.5 02 \>30mmHg albumin \> 2.5 WBC \> 1500

Answer 301

* **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 302

* diabetes incipidous * EG * exopthalamos

Answer 303

acute - CRPP with dorsal ligament repair Chronic - LT fusion If due to ulnocarpal abutment - ulnar shortening with arthroscopic debridement of LT and TFCC

Answer 304

* **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 305

* 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 306

* ***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 307

posteior stabilization with halo for 3 months; prevents neurological deficit early recognition is the key

Answer 308

* **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 309

* 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 310

* **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 311

2 weeks Normal by 3-5 months

Answer 312

* **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 313

* 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 314

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

Answer 315

* **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 316

* **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 317

* **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 318

**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 319

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

Answer 320

* 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 321

* **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 322

**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 323

* **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 324

endocrinopathy \<10 with open triradiate lack of ability to follow-up

Answer 325

* **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 326

* 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 327

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

Answer 328

* 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 329

* **Collaterals may also be disrupted** * **Dorsal** * ****Volar plate - loose the static restraint * **Volar** * ****lateral bands/central slip ## Footnote *The third is refered to as a pilon fracture*

Answer 330

* 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 331

Increased sodium, decreased potassium, increased water Cellular level – O2 demand \> O2 supply – cellular hypoxia

Answer 332

plastic deformity of the ulna peaks 4-10 yo

Answer 333

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

Answer 334

\< 5% percentile growth \<10yo

Answer 335

* ***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 336

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

Answer 337

Blood work (anemia, thrombocytopenia) Echo/asceulation Renal U/S Abdomenal U/S

Answer 338

* **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 339

**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 340

male, 20-40 repetative injury I pattern vascularity ulnar negative variance

Answer 341

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 342

cost effectiveness (content, methodology and clinical utility are all important)

Answer 343

* **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 344

Heel to toe rocker

Answer 345

**\> 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 346

* **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 347

peroneal tendons extensor digitorum brevis talonavicular joint capsule

Answer 348

**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 349

Angio for embolization

Answer 350

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 351

* 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 352

central, anteromedial, then circles laterally

Answer 353

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 354

**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 355

* **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 356

* 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 357

GH arthrodesis

Answer 358

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 359

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 360

toughness - engery absorbed until failure

Answer 361

Bankhart lesion

Answer 362

* 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 363

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

Answer 364

ABC osteoblastoma osteoid osteoma osteochondroma

Answer 365

1. **immediate mechanical stability** 2. **low cost** 3. **ease of use** 4. **no donor site morbidity** 5. **no disease transmission** 6. **easier detection of recurrence** 7. **exothermic reaction leaves a rim of necrotic bone**

Answer 366

* **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 367

I - capitellum II - avulsion capitellum III - comminuted capitellum IV - trochlea (double arc sign)

Answer 368

**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 369

* 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 370

chondrosarcoma

Answer 371

associated with increased OA ACL recon does not decrease OA risk chronic ACL tear = medial meniscus

Answer 372

normal subtalar motion

Answer 373

steroids thyroid meds antacids anti-convulsants (Vit D metabolism) PPI’s Tetracycline Loop diuretics Lithium Methotrexate \*\*Diclofenac does not

Answer 374

0.2-1.6% Squamous cell carcinoma = Marjolin's ulcer

Answer 375

acute fever transient hypocalcemia, hypophosphatemia, hypomagnesemia Oversuppression of bone remodelling NO growth delay NO fracture healing issues Some difficulty healing osteotomy

Answer 376

FDS to APB (bunnell opponensplasty) EIP to APB

Answer 377

* 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 378

ulnar (then radial) proximal medial

Answer 379

\>80 yo \>2mm ulnar variance metaphyseal comminution dependant patient NOT dorsal angulation

Answer 380

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

Answer 381

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

Answer 382

3 cannulated screws inverted triangle

Answer 383

Overall - supnation is the most stable position for the DRUJ dorsal - supnation volar - pronation LAC - 6 weeks

Answer 384

* **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 385

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

Answer 386

* **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 387

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

Answer 388

dysplasic (and more neuro) \>50% slip \>50 deg slip angle

Answer 389

* Normally takes 20% loads * positive - pronation * negative - supnation

Answer 390

* **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 391

* 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 392

* **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 393

65 and 110

Answer 394

NOT Sex NOT medical status Tip-apex \> 25mm increased age (controversial) unstable fracture poor reduction Higher (150) deg plate

Answer 395

* 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 396

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

Answer 397

Correct hypotension correct anemia with transfusion DON'T give O2

Answer 398

* 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 399

* 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 400

90 deg abduction, 90 deg ER LHB most common capsule, periosteium

Answer 401

* 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 402

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

Answer 403

* 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 404

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

Answer 405

* **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 406

* **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 407

* 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 408

* **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 409

* 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 410

**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 411

Adductor fascia (Stener lesion)

Answer 412

* 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 413

**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 414

* **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 415

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

Answer 416

* **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 417

Wait for fracture to heal

Answer 418

* **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 419

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