orthopedi Flashcards
- Following preoperative chemotherapy, the percent of tumor necrosis has been shown to be of prognostic value for which of the following tumors ?
a. Rhabdomyosarcoma
b. Chondrosarcoma
c. Metastatic adenocarcinoma
d. Osteosarcoma
e. Giant cell tumor of bone
Answer: d. Osteosarcoma
Huvos grade 1,2,3,4: grading for histological response to preoperative chemotherapy
- grade-I : little or no necrosis (involving 50 per cent of the tumor or less);
- grade-II : necrosis of more than 50 per cent but less than 90 per cent of the tumor;
- grade-Ill : only scattered foci of viable tumor cells (necrosis of 90 to 99 per cent of the tumor); grade-IV response, by no viable tumor (100 per cent necrosis).
The histological response to preoperative chemotherapy was determined retrospectively by the same pathologist in a blinded fashion.
Huvos grade 3,4 : kemo efektif.
What factor is most likely to be associated with non union of the type II odontoid fracture?
- Fracture displacement greater than 4 mm
- Advanced age of patient
- Posterior versus anterior displacement
- Blood supply to dens fragment
- Presence of neurologic injury
Answer: 4. Blood supply to dens fragment
Classification of Odontoid fracture: (Anderson and Alonzo)
- Type I: Oblique avulsion fracture of the apex (5%)
- Type II: Fracture at the junction of the body and the neck; high nonunion rate, which can lead to myelopathy (60%)
- Type IIA: Highly unstable comminuted injury extending from the waist of the odontoid into the body of the axis
- Type III: Fracture extending into the cancellous body of C2 and possibly involving the lateral facets (30%)
Treatment
- Type I: If it is an isolated injury, stability of the fracture pattern allows for immobilization in a cervical orthosis.
- Type II: This is controversial, because the lack of periosteum and cancellous bone and the presence in watershed area result in a high incidence of nonunion (36%). Risk factors include age >50 years, >5 mm displacement, and posterior displacement. It may require screw fixation of the odontoid or C1-C2 posterior fusion for adequate treatment. Nonoperative treatment is halo immobilization.
- Type III: There is a high likelihood of union with halo immobilization owing to the cancellous bed of the fracture site.
A patient has a burst fracture at L 1 with 70% canal compromise from a single retropulsed bone fragment and complete surgical decompression and stabilization is performed. One month later the bulbocavernosus reflex is still absent, but function of the lower extremity is normal. What is the most likely diagnosis ?
- Residual cord or conus compression
- Conus medullaris injury
- Persistent spinal shock
- Spinal cord infarction
- Cauda equina syndrome
Answer: 1. Residual cord or conus compression
Bulbocavernosus Reflex:
- The bulbocavernosus reflex refers to contraction of the anal sphincter in response to stimulation of the trigone of the bladder with either a squeeze on the glans penis, a tap on the mons pubis, or a pull on a urethral catheter.
- The absence of this reflex indicates spinal shock.
- The return of the bulbocavernosus reflex, generally within 24 hours of the initial injury, hallmarks the end of spinal shock.
- The presence of a complete lesion after spinal shock has resolved portends a virtually nonexistent chance of neurologic recovery.
- The bulbocavernosus reflex is not prognostic for lesions involving the conus medullaris or the cauda equina.
Conus Medullaris Syndrome:
- This is seen in T12-L1 injuries and involves a loss of voluntary bowel and bladder control (S2-4 parasympathetic control) with preserved lumbar root function.
- It may be complete or incomplete; the bulbocavernosus reflex may be permanently lost.
- It is uncommon as a pure lesion and more common with an associated lumbar root lesion (mixed conus-cauda lesion).
- Titanium, an extremely reactive metal, is one of the most biocompatible implant material because :
a. Nothing in the biologic environment reacts with titanium
b. Physiologic condition inhibit titanium reaction
c. Protein coat the titanium and “insulate” it from the body
d. Titanium spontaneously forms a stable oxide coating
e. Titanium alloy are less reactive than metal
Answer : d. Titanium spontaneously forms a stable oxide coating
Reference : Miller 5th edition . Chapter 1 Basic science: biomaterial.
Titanium is extremely biocompatible material; it rapidly forms an adherent oxide coating (self-passivation), TiO2, that covers its surface (a nonreactive ceramic coating), thus makes these material extremely biocompatible. Another advantage of titanium is its relatively low E (most closely emulates the axial and torsional stiffness of bone) and high yield strength.
Orthopaedic implants are typically made of 316L (L = low carbon) stainless steel (iron, chromium, and nickel), “supermetal” alloys (e.g., Co-Cr-molybdenum (Mo) [65% Co, 35% Cr, 5% Mo] made with a special forging process), and titanium alloy (Ti-6Al-4V). Each possesses a different stiffness (E) (Fig. 1–97). Problems associated with certain metals include wear, stress shielding (increased in metals with a higher E), and ion release (Co-Cr causes macrophage proliferation and synovial degeneration)
- Which of the following cell membrane proteins convey chemotherapeutic resistance to tumor cells:
a. CD 44 glycoprotein
b. P-glycoproteins
c. Paracrine peptides
d. Matrix metalloproteinases (MMPs)
e. Stromelysins
Answer: b. p-glycoprotein.
Reference : Ling V (1997). “Multidrug resistance: molecular mechanisms and clinical relevance”. Cancer Chemother. Pharmacol. 40 Suppl (7): S3–8. doi:10.1007/s002800051053. PMID 9272126.
P-glycoprotein also known as multidrug resistance protein
One of the mechanism resistance of cancer cells is through expression of the multidrug resistance gene 1 (MDR1). MDR 1 codes for a membrane phosphoglicoprotein (p-glycoprotein).
At least four basic mechanisms of drug resistance are now recognized under the category of the MDR phenotype.
- changes in glutathione metabolism
- alterations in topoisomerase II
- non-P-glycoprotein (P-gp)-mediated mechanisms
- P-gp-mediated mechanisms (1,2).
- Recent evidence has suggested that P-gp may be of particular relevance to osteosarcoma.
P-gp is a glycoprotein encoded by the MDR-1 gene on the long arm of chromosome 7 in humans .
Lovell & Winter’s Pediatric Orthopedic. 6th ed. Ch 14. 2006. Lippincott Williams & Wilkins.
- Which of the following antibiotic is bacteriostatic at therapeutic serum concentration ?
a. Penicillin
b. Cefoxitin
c. Clindamycin
d. Vancomysin
e. Bacitracin
Answer : c. Clindamycin
Mechanism of action ß lactam antibiotic including penicillin and cephalosporin and so does vancomycin: inhibit peptidoglycan synthesis in bacterial wall result in autolysis bacteries. Thus they are bactericid.
Cefoxitin is 2nd generation of cephalosporin.
Bacitracin also has mechanism of action inhibitin synthesis of bacterial wall. Bacitracin interferes with the dephosphorylation of the C55-isoprenyl pyrophosphate, a molecule that carries the building-blocks of the peptidoglycan bacterial cell wall outside of the inner membrane
Reference Goodman and Gilman’s. The Pharmacological Basic of Therapeutic. 12th ed.
Clindamycin has a bacteriostatic effect. It is a bacterial protein synthesis inhibitor by inhibiting ribosomal translocation, in a similar way to macrolides. It does so by binding to the 50S rRNA of the large bacterial ribosome subunit.
Reference : Lincosamides, Oxazolidinones, and Streptogramins”. Merck Manual of Diagnosis and Therapy. Merck & Co.. November 2005. Retrieved 2007-12-01
- What antibiotic works by inhibiting peptidoglycan synthesis ?
a. Penicillin
b. Gentamycin
c. Rifampicin
d. Tetracycline
e. Clindamycin
Answer : a. penicillin
Penicillin and cephalosporins such as cefoxitin, vancomycin, and bacitracin are all bactericidal by causing loss of bacterial cell viability, either by activating enzymes that disrupt cell membrane or by inhibiting synthesis of cell wall. Clindamycin is bacteriostatic and acts by inhibiting sintesis protein.
- Which of the following organism is (are) most likely to cause hematogenous osteomyelitis in hemodialysis patients ?
a. Escherichia coli and Klebsiella pneumonia
b. Staphylococci
c. Candida species
d. Anaerobic oral organism
e. Anaerobic enteral organism
Answer : b. Staphylococci
Hemodialysis patients and intravenous drug abusers—S. aureus, S. epidermidis, and Pseudomonas aeruginosa are common organisms. The treatment of choice is one of the penicillinase-resistant synthetic penicillins (PRSPs) plus ciprofloxacin; an alternative treatment is vancomycin with ciprofloxacin.
Reference : Miller’s Review of Orthopedics. 5th ed. Chapter 5 :Orthopedic infection and Microbiology. 2008. Elsevier inc.
- The pharmacologic effect of warfarin is caused by what mechanism ?
a. Inhibition of platelet aggregation
b. Inhibition of hepatic enzymes that activates vitamin K
c. Bonding to vitamin K dependent cloting factors II, VII, IX,X
d. Bonding to antithrombin III which increase its affinity for activated factor X and thrombin
e. Direct binding to vitamin K
Answer: b. inhibition of hepatic enzymes that activates vitamin K
Warfarin inhibits the vitamin K-dependent synthesis of biologically active forms of the calcium-dependent clotting factors II, VII, IX and X, as well as the regulatory factors protein C, protein S, and protein Z.
Jawaban buku AAOS comprehensive review ; b. warfarin inhibit hepatic enzymes that activates vitamin K, vitamin K epoxide. This inhibition leads to reduced carboxylation of vitamin K dependent protein (protrombin, and factor VII, IX, X). Warfarin does not act by binding directly to vitamin K or clotting factor.
References :
• Ansell J, Hirsh J, Poller L, Bussey H, Jacobson A, Hylek E (2004). “The pharmacology and management of the vitamin K antagonists: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy”. Chest 126 (3 Suppl): 204S–233S. Doi :10.1378/chest.126.3_suppl.204S. PMID 15383473.
• Freedman MD (March 1992). “Oral anticoagulants: pharmacodynamics, clinical indications and adverse effects”. J Clin Pharmacol 32 (3): 196–209. PMID 1564123
- The risk of human immunodeficiency virus (HIV) transmission via a processed musculoskeletal allograft obtained from an American Association of Tissue Bank (AATB) certified bone bank is estimated to be :
a. 1 in 50,000
b. 1 in 100,000
c. 1 in 500,000
d. 1 in 1,5 million
e. 1 in 5 million
Answer: d. 1 in 1,5 million.
Reference : AAOS Comprehensive Orthopedic Review: Study Questions. 2009.
- Warfarin limit the risk of deep venous thrombosis (DVT) by which of the following action ?
a. Competitive inhibition of vitamin K dependent clotting factors
b. Inhibition of the post translational modification of vitamin K dependent clotting factors
c. Reversible inhibition of platelet function
d. Potentiation of antithrombin III
Answer : b. Inhibition of the post translational modification of vitamin K dependent clotting factors
- Most natural biologic material are anisotropic, meaning that their stress strain curve exhibits:
a. Different moduli for compressive and tensile stress
b. A high degree of nonlinearity
c. A high sensitivity to the size of the test specimen
d. Dependence on the rate loading
e. Dependence of the direction of load application
Answer ; e. Dependence of the direction of load application
Reference Miller’s Review of Orthopedic. 5th ed. Chapter 1 Basic Science. Section 8, subsection 2. 2008. Elsevier inc.
Isotropic materials—Possess the same mechanical properties in all directions (e.g., a golf ball)
Anisotropic materials—Have mechanical properties that vary with the direction of the applied load (e.g., bone is stronger axially than radially)
- Which of the following factors is most commonly associated with late aseptic loosening of cemented acetabular components ?
a. Increased frictional torque
b. Recurrent neck socket impingement
c. Fatique failure of cement
d. Poor initial component fixation
e. Polyethylene wear
Answer : e. Polyethylene wear
Polyethylene wear are foreign body material which elicit hystiocytic (osteoclast) response to begin an osteolytic process.
Osteolytic process—As a result of particle ingestion by the macrophages, the activated macrophage (osteoclast) liberates osteolytic factors, including tumor necrosis factor (TNF)-α, interleukin-1β, interleukin-6, prostaglandins, oxide radicals, hydrogen peroxide, and acid phosphatase. Interleukin-1β, interleukin-6, prostaglandins works paracrine stimulating end nerve fiber, causing PAIN. These factors activate the osteoclast system and together assist in the dissolution of bone. Osteoclastic resorption of bone around the prosthesis allows prosthetic micromotion to occur. This leads to further generation of wear debris. Additional lysis of bone allows for prosthetic macromotion, loosening, and pain. Symptoms pain after hemiarthroplasty even without periprosthetic radioluscent area, is a symptoms that osteolytic process has begin. Give your patient BIPHOSPHONATE to repress osteoclast activity.
Cara kerja biphosphonate :
Bisphosphonates inhibit osteoclast resorption of bone (by preventing the osteoclast from forming the ruffled border necessary for expression of acid hydrolases)
- Methicillin resistant Staphylococcus aureus can be effectively with an oral quinolone and which of the following antibiotics to achieve synergy?
a. Penicillin
b. Probenecid
c. Rifampin
d. Cefoxitin
e. Amoxillin
Answer : c. Rifampicin
Rifampin has been shown to have synergy with quinolones in the treatment of MRSA. Together they lessen development of resistant mutant.
- A fully differentiated osteoclast has receptors for which of the following proteins ?
a. Parathyroid hormone (PTH)
b. Calcitonin
c. Cholecalciferol
d. Bone morphogenetic protein (BMP)
e. Interleukin -2 (IL-2)
Answer : b. Calcitonin
Calcitonin—A 32–amino acid peptide hormone produced by the clear cells in the parafollicles of the thyroid gland; has a limited role in calcium regulation (see Table 1–13). Increased extracellular calcium levels cause secretion of calcitonin, which is controlled by a β2 receptor. Calcitonin inhibits osteoclastic bone resorption (osteoclasts have calcitonin receptors; decreases osteoclast number and activity) and decreases serum calcium
- Cephalosporin are effective antibiotic agents because of their action on what aspect of bacterial metabolism ?
a. DNA gene
b. Cell wall
c. mRNA
d. cell membrane
e. protein
Answer : b. Cell wall
- The structure of cartilage proteoglycan can be described as
a. Multiple hyaluronate molecules bound to core protein, which is subsequently bound to a glycosaminoglycan chain
b. Multiple glycosaminoglycan chains bound to hyaluronate, which is subsequently bound to core protein
c. Multiple glycosaminoglycan bound to core protein, which is subsequently bound to hyaluronate via a link protein
d. Multiple link protein bound to core protein, which is subsequently bound to glycosaminoglycan
e. Multiple hyaluronate chains bound to link protein, which is subsequently bound to glycosaminoglycan
Answer: c. Glycosaminoglycan molecules bound to core protein forming proteoglycan aggrecan, subsequently proteoglycan aggrecan bound to hyaluronate via a link protein, forming proteoglycan aggregate.
Reference Miller’s Review of Orthopedic. 5th ed. Chapter 1 Basic Science. 2008. Elsevier inc.
- Virtually all biological material are viscoelastic, which means their mechanical behavior is dependent on what factor ?
a. Load applied
b. Cross sectional area
c. Rate of loading
d. Mode of loading
e. Direction of loading
Answer : c. rate of loading
Material—Related to a substance or element. Defined by mechanical properties (force, stress, strain) and rheologic properties (elasticity [ability to regain original shape], plasticity [permanent deformation], viscosity [resistance to flow or shear stress], and strength).
a. Brittle materials (e.g., PMMA)—Exhibit a linear stress–strain curve up to the point of failure. Brittle materials undergo only fully recoverable (elastic) deformation prior to failure and have little or no capacity to undergo permanent (plastic) deformation prior to failure.
b. Ductile materials (e.g., metal)—Undergo a large amount of plastic deformation prior to failure. Ductility is a measure of postyield deformation.
c. Viscoelastic materials (e.g., bone and ligaments)—Exhibit stress–strain behavior that is time-rate dependent (varies with the material); the material’s deformation and properties depend on the load and the rate at which the load is applied. Viscoelastic materials exhibit properties of both a fluid (viscosity; resistance to flow) and a solid (elasticity). The modulus of viscoelastic material increases as the strain rate increases. Viscoelastic behavior is a function of the internal friction of the material. Viscoelastic materials also exhibit hysteresis: Loading and unloading curves differ because energy is dissipated during loading. Most biologic tissues (bone, ligament, muscle, etc.) exhibit viscoelasticity.
d. Isotropic materials—Possess the same mechanical properties in all directions (e.g., a golf ball)
e. Anisotropic materials—Have mechanical properties that vary with the direction of the applied load (e.g., bone is stronger axially than radially)
f. Homogeneous materials—Have a uniform structure or composition throughout.
- What is the dominant component of articular cartilage extracellular matrix by weight ?
a. Wear
b. Collagen
c. Keratan sulfate
d. Chondroitin sulfate
e. Nerve and lymphatic tissue
Answer ; a. wear ??. Pasti maksudnya WATER !!
Reference Miller’s Review of Orthopedics. 5th ed. Chapter 1 section 2.
Articular cartilage composition
a. Water (65-80% of wet weight)—Shifts in and out of cartilage to allow deformation of cartilage surface in response to stress. Water is not distributed homogeneously (65% in deep zone, 80% at surface). Water content increases (90%) in osteoarthritis (Table 1–18). Water is also responsible for nutrition and lubrication. Increased water content leads to increased permeability, decreased strength, and decreased Young’s modulus (E).
b. Collagen (10-20% of wet weight; >50% of dry weight) (Fig 1–36)—Type II collagen accounts for approximately 95% of the total collagen content of articular cartilage and provides a cartilaginous framework and tensile strength. Type II collagen is very stable, with a half-life of approximately 25 years. Increased amounts of glycine, proline, hydroxyproline, and hydrogen bonding are responsible for its unique characteristics. Hydroxyproline is unique to collagen and can be measured in the urine to assess bone turnover. Small amounts of types V, VI, IX, X, and XI collagen are present in the matrix of articular cartilage. An overview of all collagen types is shown in Table 1–19. Collagen type VI is a minor component of normal articular cartilage, but its content increases significantly in early osteoarthritis. Collagen type X is produced only by hypertrophic chondrocytes during enchondral ossification (growth plate, fracture callus, HO formation, calcifying cartilaginous tumors) and is associated with calcification of cartilage; a genetic defect in type X collagen is responsible for Schmid’s metaphyseal chondrodysplasia (affects the hypertrophic physeal zone). Collagen type XI is an adhesive holding the collagen lattice together.
c. Proteoglycans (10-15% of wet weight)—Protein polysaccharides provide compressive strength. Proteoglycans are produced by chondrocytes, are secreted into the extracellular matrix, and are composed of subunits known as glycosaminoglycans (GAGs, disaccharide polymers). These GAGs include two subtypes of chondroitin sulfate (the most prevalent GAG in cartilage) and keratin sulfate. The concentration of chondroitin-4-sulfate decreases with age, that of chondroitin-6-sulfate remains essentially constant, and that of keratin sulfate increases with age. GAGs are bound to a protein core by sugar bonds to form a proteoglycan aggrecan molecule. Link proteins stabilize these aggrecan molecules to hyaluronic acid to form a proteoglycan aggregate. Proteoglycans have a half-life of 3 months, provide structural properties for the articular cartilage, provide elastic strength, produce cartilage’s porous structure, and trap and hold water (regulate and retain fluid in the matrix). Figure 1–37 illustrates a proteoglycan aggregate and an aggrecan molecule.
d. Chondrocytes (5% of wet weight)—Active in protein synthesis, possess a double effusion barrier; produce collagen, proteoglycans, and some enzymes for cartilage metabolism, including the metalloproteinases (breakdown cartilage matrix) and tissue inhibitor of metalloproteinases (TIMPs; inhibit the metalloproteinases); least active in the calcified zone. Deeper cartilage zones have chondrocytes with a decreased rough endoplasmic reticulum (RER) and increased intraplasmic filaments (degenerative products). Chondroblasts, derived from undifferentiated mesenchymal cells (stimulated by motion), are later trapped in lacunae to become chondrocytes.
e. Other matrix components
(1) Adhesives (noncollagenous proteins, such as fibronectin, chondronectin, and anchorin CII)—Involved in interactions between chondrocytes and fibrils. Fibronectin may be associated with osteoarthritis.
(2) Lipids—Unknown function
- A 2 week old infant has been referred for evaluation of nonmovement of the hip. History reveals that the patient was delivered 6 weeks premature by cesarean section. Examination reveals no fever, and there is mild swelling of the thigh. Passive movement of the hip appears to elicit tenderness and very limited hip motion. A radiograph of the pelvis shows mild subluxation of the left hip. The next step in evaluation should consist of :
a. Aspiration of the left hip
b. Application of Pavlik harness
c. A gallium scan
d. An MRI scan of the spine
e. Modified Bryan traction
Answer : a. Aspiration of the left hip
Early diagnosis is important : Rule out these differential diagnosis:
Septic arthritis
Transient synovitis
Early coxitis TB
Hip subluxation.
If clinical findings suggest bone or joint sepsis, aspiration is mandatory (for Gram staining and culture). Radiograph may reveal subluxation (due to joint effusion, due to infection). DDH is not painful and not accompany by localized swelling. If no purulent material obtained from aspiration, an arthrogram should be obtained to rule out femoral epiphysiolysis.
- A 12 year old girl has had lower back pain for the past 6 months that interferes with her ability to participate in sports. She denies any history of radicular symptoms, sensory changes, or bowel and bladder dysfunction. Examination reveals a shuffling gait, restriction of forward bending, and tight hamstrings. Radiographs show a grade III spondylolisthesis of L5 on S1, with a slip angle 20°. Management should consist of :
a. Brace treatment
b. Laminectomy, nerve root decompression, and in situ fusion of L4 to the sacrum
c. In situ fusion of L4 to the sacrum
d. Excision of the L5 lamina
e. Physical therapy
Answer : c. In situ fusion of L4 to the sacrum
Indication for surgical treatment of spondilolisthesis:
• pain and/or progressive deformity
• persisten pain or neurologic deficit that not respond to nonsurgical therapy
Choice of surgical treatment :
• insitu posterolateral L5-S1 fusion is adequate for mild spondilolisthesis
• extension of fusion to L4 offers better mechanical advantage for more severe slips (Meyerding gr II)
DO NOT perform laminectomy alone in children It is contraindicated. Nerve root decompression is indicated if radiculopathy present clinically.
Ref. AAOS Comprehensive Orthopedic Review.
Marfan Syndrome is associated with defects in which of the following structural proteins ?
a. Elastin
b. Fibrillin
c. Fibronectin
d. Type II collagen
e. Type III collagen
Answer : b. Fibrillin
Reference Miller’s Review of Orthopedics. 5th ed. Chapter 1 section 4 subsection 3.
COMPREHENSIVE COMPILATION OF INHERITANCE PATTERN, DEFECT, AND ASSOCIATED GENE OF MUSCULOSKELETAL-RELATED DISORDERS
Disorder Inheritance Pattern Defect Associated Gene
Dysplasias
Achondroplasia Autosomal dominant Defect in the fibroblast growth factor (FGF) receptor 3 FGF receptor 3 gene
Diastrophic dysplasia Autosomal recessive Mutation of a gene coding for a sulfate transport protein Sulfate-transporter gene (chromosome 5)
Kniest’s dysplasia Autosomal dominant Defect in type II collagen COL 2A1
Laron’s dysplasia (pituitary dwarfism) Autosomal recessive Defect in the growth hormone receptor
McCune-Albright syndrome (polyostotic fibrous dysplasia, café-au-lait spots, precocious puberty) Sporadic mutation Germ line defect in the Gsα protein Mutation of Gsα subunit of the receptor/adenylyl cyclase–coupling G proteins
Metaphyseal chondrodysplasia (Jansen form) Autosomal dominant
Metaphyseal chondrodysplasia (McKusick form) Autosomal recessive
Metaphyseal chondrodysplasia (Schmid-tarda form) Autosomal dominant Defect in type X collagen COL 10A1
Multiple epiphyseal dysplasia Autosomal dominant (most commonly) Cartilage oligomeric matrix protein
Spondyloepiphyseal dysplasia Autosomal dominant (congenita form)
X-linked recessive (tarda form)
Defect in type II collagen Linked to X p22.12-p22.31 and COL 2A1
Achondrogenesis Autosomal recessive Fetal cartilage fails to mature
Apert syndrome Sporadic mutation/autosomal dominant
Chondrodysplasia punctata (Conradi–Hünerman) Autosomal dominant
Chondrodysplasia punctata (rhizomelic form) Autosomal recessive Defect in subcellular organelles (peroxisomes)
Cleidocranial dysplasia (dysostosis) Autosomal dominant Mutation of a gene coding for a protein related to osteoblast function cbfal
Dysplasia epiphysealis hemimelica (Trevor’s disease) ??
Ellis-van Creveld syndrome (chondroectodermal dysplasia) Autosomal recessive
Fibrodysplasia ossifican progressiva Sporadic mutation/autosomal dominant
Geroderma osteodysplastica (Walt Disney dwarfism) Autosomal recessive
Grebe chondrodysplasia Autosomal recessive
Hypochondroplasia Sporadic mutation/autosomal dominant
Kabuki make-up syndrome Sporadic mutation
Mesomelic dysplasia (Langer type) Autosomal recessive
Mesomelic dysplasia (Nievergelt type) Autosomal dominant
Mesomelic dysplasia (Reinhardt-Pfeiffer type) Autosomal dominant
Mesomelic dysplasia (Werner type) Autosomal dominant
Metatrophic dysplasia Autosomal recessive
Progressive diaphyseal dysplasia (Camurati-Engelmann disease) Autosomal dominant
Pseudoachondroplastic dysplasia Autosomal dominant
Pyknodysostosis Autosomal recessive
Spondylometaphyseal chondrodysplasia Autosomal dominant
Spondylothoracic dysplasia (Jarcho-Levin syndrome) Autosomal recessive
Thanatophoric dwarfism Autosomal dominant
Tooth-and-nail syndrome Autosomal dominant
Treacher Collins syndrome (mandibulofacial dysostosis) Autosomal dominant
Metabolic Bone Diseases
Hereditary vitamin D–dependent rickets Autosomal recessive See Table 1–15
Hypophosphatasia Autosomal recessive See Table 1–15
Hypophosphatemic rickets (vitamin D–resistant rickets) X-linked dominant See Table 1–15
Osteogenesis imperfecta Autosomal dominant (types I and IV) Defect in type I collagen (abnormal cross-linking) COL 1A1, COL 1A2
Autosomal recessive (types II and III)
Albright hereditary osteodystrophy (pseudohypoparathyroidism) Uncertain Parathyroid hormone has no effect at the target cells (in the kidney, bone, and intestine)
Infantile cortical hyperostosis (Caffey’s disease) ???
Ochronosis (alkaptonuria) Autosomal recessive Defect in the homogentisic acid oxidase system
Osteopetrosis Autosomal dominant (mild, tarda form)
Autosomal recessive (infantile, malignant form)
Connective Tissue Disorders
Marfan’s syndrome Autosomal dominant Fibrillin abnormalities (some patients also have type I collagen abnormalities) Fibrillin gene (chromosome 15)
Ehlers-Danlos syndrome (there are at least 13 varieties) Autosomal dominant (most common) Defects in types I and III collagen have been described for some varieties; lysyl oxidase abnormalities COL 1A2 (for Ehlers-Danlos type VII)
Homocystinuria Autosomal recessive Deficiency of the enzyme cystathionine β-synthase
Mucopolysaccharidosis
Hunter’s syndrome (“gargoylism”) X-linked recessive
Hurler’s syndrome Autosomal recessive Deficiency of the enzyme α-L-iduronidase
Maroteaux-Lamy syndrome Autosomal recessive
Morquio’s syndrome Autosomal recessive
Sanfilippo’s syndrome Autosomal recessive
Scheie’s syndrome Autosomal recessive Deficiency of the enzyme α-L-iduronidase
Muscular Dystrophies
Duchenne’s muscular dystrophy X-linked recessive Defect on the short arm of the X chromosome Dystrophin gene
Becker’s dystrophy X-linked recessive
Fascioscapulohumeral dystrophy Autosomal dominant
Limb-girdle dystrophy Autosomal recessive
Steinert’s disease (myotonic dystrophy) Autosomal dominant
Hematologic Disorders
Hemophilia (A and B) X-linked recessive Hemophilia A–factor VIII deficiency
Hemophilia B–factor IX deficiency
Sickle cell anemia Autosomal recessive Hemoglobin abnormality (hemoglobin S)
Gaucher’s disease Autosomal recessive Deficient activity of the enzyme β-glucosidase (glucocerebrosidase)
Hemochromatosis Autosomal recessive
Niemann-Pick disease Autosomal recessive Accumulation of sphingomyelin in cellular lysosomes
Smith-Lemli-Opitz syndrome Uncertain
Thalassemia Autosomal recessive Abnormal production of hemoglobin A
von Willebrand’s disease Autosomal dominant
Chromosomal Disorders with Musculoskeletal Abnormalities
Down syndrome Trisomy of chromosome 21
Angelman’s syndrome Chromosome 15 abnormality
Clinodactyly Associated with many genetic anomalies, including trisomy of chromosomes 8 and 21
Edward’s syndrome Trisomy of chromosome 18
Fragile X syndrome X-linked trait (does not follow the typical pattern of an X-linked trait) Xq27-Xq28
Klinefelter’s syndrome (XXY) Male has an extra X chromosome
Langer-Giedion syndrome Sporadic mutation Chromosome 8 abnormality
Nail-patella syndrome Autosomal dominant Chromosome 9 abnormality
Patau’s syndrome Trisomy of chromosome 13
Turner’s syndrome (XO) Female missing one of the two X chromosomes
Neurologic Disorders
Charcot-Marie-Tooth disease Autosomal dominant (most common)
Congenital insensitivity to pain Autosomal recessive
Dejerine-Sottas disease Autosomal recessive
Friedreich’s ataxia Autosomal recessive
Huntington’s disease Autosomal dominant
Menkes’ syndrome X-linked recessive Inability to absorb and use copper
Pelizaeus-Merzbacher disease X-linked recessive Defect in the gene for proteolipid (a component of myelin)
Riley-Day syndrome Autosomal recessive
Spinal muscular atrophy (Werdnig-Hoffman disease and Kugelberg-Welander disease) Autosomal recessive
Sturge-Weber syndrome Sporadic mutation
Tay-Sachs disease Autosomal recessive Deficiency in the enzyme hexosaminidase A
Diseases Associated with Neoplasias
Ewing’s sarcoma 11;22 chromosomal translocation (EWS/FL11 fusion gene)
Multiple endocrine neoplasia I (MEN I) Autosomal dominant RET
MEN II Autosomal dominant
MEN III Autosomal dominant Chromosome 10 abnormality
Neurofibromatosis (von Recklinghausen’s disease) Autosomal dominant NF1, NF2
Synovial sarcoma X;18 chromosomal translocation (STT/SSX fusion gene)
Miscellaneous Disorders
Malignant hyperthermia Autosomal dominant
Osteochondromatosis Autosomal dominant
Polydactyly Autosomal dominant (a small number of cases of sporadic gene mutations have been reported)
Captodactyly Autosomal dominant
Cerebro-oculofacioskeletal syndrome Autosomal recessive
Congenital contractural arachnodactyly Fibrillin gene (chromosome 5)
Distal arthrogryposis syndrome Autosomal dominant
Dupuytren’s contracture Autosomal dominant (with partial sex limitation)
Fabry’s disease X-linked recessive Deficiency of α-galactosidase A
Fanconi’s pancytopenia Autosomal recessive
Freeman-Sheldon syndrome Autosomal dominant
(craniocarpotarsal dysplasia; whistling face syndrome) Autosomal recessive
GM1 gangliosidosis Autosomal recessive
Hereditary anonychia Autosomal dominant
Autosomal recessive
Holt-Oram syndrome Autosomal dominant
Humeroradial synostosis Autosomal dominant
Autosomal recessive
Klippel-Feil syndrome Faulty development of spinal segments along the embryonic neural tube
Klippel-Trénaunay-Weber syndrome Sporadic mutation
Krabbe’s disease Autosomal recessive Deficiency of galactocerebroside β-galactosidase
Larsen’s syndrome Autosomal dominant
Autosomal recessive
Lesch-Nyhan disease X-linked trait Absence of the enzyme hypoxanthine guanine phosphoribosyl transferase
Madelung’s deformity Autosomal dominant
Mannosidosis Autosomal recessive Deficiency of the enzyme α-monosidase
Maple syrup urine disease Autosomal recessive Defective metabolism of the amino acids leucine, isoleucine, and valine
Meckel’s syndrome (Gruber’s syndrome) Autosomal recessive
Mobius’ syndrome Autosomal dominant
Mucolipidosis (oligosaccharidosis) Autosomal recessive A family of enzyme deficiency diseases
Multiple exostoses Autosomal dominant
Multiple pterygium syndrome Autosomal recessive
Noonan’s syndrome Sporadic mutation
Oral-facial-digital (OFD) syndrome OFD I—X-linked dominant
OFD II (Mohr’s syndrome)— autosomal recessive
Osler-Weber-Rendu syndrome (hereditary hemorrhagic telangiectasia) Autosomal dominant
Pfeiffer’s syndrome (acrocephalosyndactyly) Sporadic mutation/autosomal dominant
Phenylketonuria Autosomal recessive Enzyme deficiency characterized by the inability to convert phenylalanine to tyrosine due to a chromosome 12 abnormality
Phytanic acid storage disease Autosomal recessive
Progeria (Hutchinson-Gilford progeria syndrome) Autosomal dominant
Proteus syndrome Autosomal dominant
Prune-belly syndrome Uncertain Localized mesodermal defect
Radioulnar synostosis Autosomal dominant
Rett’s syndrome Sporadic mutation/X-linked dominant
Roberts’ syndrome (pseudothalidomide syndrome) Sporadic mutation/autosomal recessive
Russell-Silver syndrome Sporadic mutation (possibly X-linked)
Saethre-Chotzen syndrome Autosomal dominant
Sandhoff’s disease Autosomal recessive Enzyme deficiency of hexosaminidase A and B
Schwartz-Jampel syndrome Autosomal recessive
Seckel’s syndrome (bird-headed dwarfism) Autosomal recessive
Stickler’s syndrome (hereditary progressive arthro-ophthalmopathy) Autosomal dominant Collagen abnormality
TAR syndrome (thrombocytopenia–aplasia of radius syndrome) Autosomal recessive
Tarsal coalition Autosomal dominant
Trichorhinophalangeal syndrome Autosomal dominant
Urea cycle defects Argininemia—autosomal recessive
Argininosuccinic aciduria—autosomal recessive
Carbamyl phosphate synthetase deficiency—autosomal recessive
Citrullinemia—autosomal recessive
Ornathine transcarbamylase deficiency—X-linked
A group of enzyme disorders characterized by high levels of ammonia in the blood and tissues
VATER association Sporadic mutation
Werner’s syndrome Autosomal recessive
Zygodactyly Autosomal dominant
- A 7-year old boy with a closed supracondylar fracture of distal humerus is unable to flex the distal interphalangeal (DIP) joint of his index finger and the interphalangeal (IP) joint of his thumb. These findings are most likely due to a deficit involving fibers of which following nerves ?
a. Ulnar
b. Radial
c. Musculocutaneous
d. Anterior interosseous
e. Posterior interosseous
Answer : d. Anterior interosseous
Median(C(5)6-T1): runs between 2 heads of PT[*], through ligament of Struthers[*] and lacertus fibrosus[*], under FDS[*] into carpal tunnel[*] (Martin Gruber formation: ulnar motor branches run with median nerve then branch to ulnar nerve distally). In wrist, median divides to Motor branch and palmar cutaneous (runs between FCR/PL): at risk in CTS release
Sensory: NONE (in forearm)
Motor: ANTERIOR COMPARTMENT OF FOREARM
Superficial Flexors Pronator Teres [PT]
Flexor Carpi Radialis [FCR]
Palmaris longus [PL]
Flexor digitorum superficialis[FDS][sometimes considered a “middle” flexor]
Deep Flexors Anterior Interosseous N. (AIN) AIN compressed by PT in forearm, injured in supracondylar fractures
Flexor digitorum profundus [digits 2, 3]
Flexor pollicis longus [FPL]
Pronator Quadratus [PQ]
* Potential nerve compression site
- Examination of 7 year old boy reveals 20° of valgus following a lawn mover to lateral femoral epiphysis. Treatment consists of total distal femoral epiphysiodesis and varus osteotomy. Following surgery he has a limb length discrepancy of 3 cm and 5° genu valgum. Assumsing that he undergoes no further treatment, the patient’s predicted limb-length discrepancy at maturity would be how many centimeter ?
a. Less than 7
b. 7 to 10
c. 11 to 13
d. 14 to 17
e. Greater than 17
Answer : c. 11 to 13
The distal femoral epiphysis growa approximately 1 cm per year, in boys growth ceases at approximately age 16 years old. Therefore the patient’s limb length discrepancy at maturity would be 12 cm ( 9 cm plus 3 cm discrepancy he suffered from the previous surgery)
Ref: AAOS Orthopedic Comprehensive Review. Page 82. 2009.
- A 4 year old child sustains a spiral fracture to the tibia in an unwitnessed fall. History reveals three other fractures to long bones, and the parents are vague about the etiology of each. There is no family history of bone disease. The parents ask if the child has osteogenesis imperfect (OI); however, there are no clinical or radiographic indication of this diagnosis. In addition to fracture care, management should include:
a. Notification of child protective services and hospital admission
b. A punch biopsy of skin for collagen analysis
c. DNA testing for OI
d. Calcium, phosphate, and alkaline phosphatase studies
e. Placement of intramedullary rods to prevent further fracture
Answer : c. Notification of child protective services and hospital admission
OI : Mutation on genes encoding type I collagen : COL1A1 and COL1A2.
DD multiple fractures in children : OI and child abuse.
DNA testing not commercially available for OI. In this patient, physician suspect nonaccidental trauma and is legally obliged to notify child protective service. Work up for both OI and abuse can be done during hospitalization
- A 6 year old boy with spastic diplegic cerebral palsy has a crouched gait. Examination reveals hip flexion contracture of 15º and popliteal angle of 70º. Equinus contractures measure 10º with the knee extended. Which of the following surgical procedure performed alone, will worsen the crouching ?
a. Iliopsoas release from the lesser trochanter
b. Iliopsoas release at the pelvic brim
c. Hamstring lengthening
d. Heel cord lengthening
e. Splint posterior tibial tendon transfer
Answer : d. Heel cord lengthening
Children with bspastic diplegic cerebral palsy often have multiple joints contractures. Because the gait abnormalities can be complex, isolated surgery is rarely indicated. To avoid compensatory at other joints, it is preferable to correct all deformities in a single operation. Isolated heel cord lengthening in the presence of thight hamstring and tight hip flexor, will lead to progressive flexion at the knees and hips, thus worsening the crouched gait
Split posterior tibial tendon is indicated for heel varus.
- Which of the following pathogens are most commonly associated with neonatal septic arthritis and osteomyelitis ?
a. Staphylococcus aureus and Escherichia coli
b. Staphylococcus aureus and group A streptococci
c. Staphylococcus aureus and group B streptococci
d. Haemophilus influenza and Escherichia coli
e. Haemophilus influenza and group A streptococci
Answer c. Staphylococcus aureus and group B streptococci
Reference : Miller’s Review of Orthopedics. 5th ed. Chapter 1. Section 5.
Reference : AAOS Orthopedic Comprehensive Review. 2009.
Newborn (up to 4 months of age)—The most common organisms include Staphylococcus aureus, gram-negative bacilli, and group B streptococcus. Primary empirical therapy includes nafcillin or oxacillin plus a third-generation cephalosporin. Alternative antibiotic therapy includes vancomycin plus a third-generation cephalosporin. Newborns with hematogenous osteomyelitis may be afebrile, and the best predictors of the osteomyelitis are local signs in the extremity, including warmth. Almost 70% of newborn patients with hematogenous osteomyelitis have positive blood cultures.
Children 4 years of age or older—The most common organisms are S. aureus, group A streptococcus, and coliforms (uncommon). The empirical treatment of choice is nafcillin or oxacillin; alternative regimens include vancomycin or clindamycin. When the Gram stain shows gram-negative organisms, a third-generation cephalosporin should be added. With recent immunization programs, Haemophilus influenzae bone infections causing hematogenous osteomyelitis have been almost completely eliminated.
Adults 21 years of age or older—The most common organism is S. aureus, but a wide variety of other organisms have been isolated. Initial empirical therapy includes nafcillin, oxacillin, or cefazolin; vancomycin can be used as an alternative initial therapy.
Sickle cell anemia—Salmonella is a characteristic organism. The primary treatment is with one of the fluoroquinolones (only in adults); alternative treatment is with a third-generation cephalosporin.
Hemodialysis patients and intravenous drug abusers—S. aureus, S. epidermidis, and Pseudomonas aeruginosa are common organisms. The treatment of choice is one of the penicillinase-resistant synthetic penicillins (PRSPs) plus ciprofloxacin; an alternative treatment is vancomycin with ciprofloxacin.
- During soft tissue release for an idiopathic clubfoot, it is noted than the peroneus longus tendon has been transected in the midfoot. Failure into repair this structure may be lead to
a. Cavus
b. Claw toes
c. A dorsal bunion
d. Hindfoot valgus
e. Forefoot pronation
Answer: c. A dorsal bunion
A statistically significant varus displacement of the first metatarsal was observed only after transection of the peroneus longus tendon. It was concluded that the peroneus longus tendon is a strong retaining mechanism of the first metatarsal to opposes the tibialis anterior dorsal pull on 1st ray . When tendon peroneus longus injured, flexor hallucis longus try to compensate by flex the MTP. Thus forming deformity dorsal bunion.
Dorsal bunion can be result from sequel of poliomyelitis or direct injury to tendon peroneus longus.
Ref : Bohne WH, Lee KT, Peterson MG. Action of the peroneus longus tendon on the first metatarsal against metatarsus primus varus force. Foot Ankle Int. 1997 Aug;18(8):510-2.
- The use of multiagent adjuvant chemotherapy is associated with a clear survival benefit in which of the following diseases?
a. Renal carcinoma
b. Osteosarcoma
c. Differentiated chondrosarcoma
d. Adult soft tissue sarcoma
e. Melanoma
Answer: b. Osteosarcoma
Osteosarcoma is the most common bone tumor in children and adolescents. The most common sites are the distal femur and proximal tibia, and some 15–20% of patients have clinically detectable metastases at the time of diagnosis. Most studies in osteosarcoma include only patients with “classical osteosarcoma”, a good prognostic group of patients without metastases at presentation, extremity localized tumors and age < 40 years.
However, nonclassical osteosarcoma represents more than 40% of the entire high-grade osteosarcoma population, emphasizing the need for focus also on this group of patients in clinical research (Huvos 1991, Saeter and Bruland 1998).
The modern multidisciplinary approach to the osteosarcoma patients has significantly improved outcome, especially for the patients with classical disease. Before the introduction of intensive polyagent chemotherapy, 2-year overall survival around 15–20% was reported (Harvei and Solheim 1981, Friedman and Carter 1972). With todayʼs combination of chemotherapy and surgery long-term survival rates of more than 70% have been reported in several studies (Saeter et al. 1991, Bacci et al. 1993, Fuchs et al. 1998, Smeland et al. 2003).
Neoadjuvant chemotherapy with high-dose ifosfamide added to methotrexate, cisplatin, and doxorubicin for patients with localized osteosarcoma of the extremity.
- A 12 year old girl has progressive development of cavus feet. Examination reveals slightly diminished vibratory sensation on the bottom of the foot. Reflexes are 1+ at the knees and ankles. Motor examination shows that all muscles are 5/5 in the foot, except the peroneal and anterior tibial muscles are rated as 4+/5. Which of the following studies is considered most diagnostic ?
a. Nerve conduction velocity studies
b. Biopsy of the quadriceps femoris muscle
c. Biopsy of the sural nerve
d. DNA testing
e. Chromosomal analysis
Answer ; d. DNA testing
This patient most likely has a form of Charcot –Marie-Tooth disease, or hereditary motor-sensory-neuropathy. The most common varieties can now diagnosed with DNA testing. Mutation could be in peripheral myelin protein-22 (PMP 22)gene in HMSN type IA and in the connexin gene in the x linked HMSN.
Reference: AAOS Comprehensive Orthopedic Review. 2009.
- A newborn has a flail upper extremity after a difficult right occiput anterior vaginal delivery. Examination shows an obvious fracture of the right clavicle. Following stimulation, there is no movement of the arm or hand and there appears to be no sensation in the hand. Management should include :
a. A CT scan arteriogram
b. An MRI scan of the brachial plexus
c. Nerve conduction velocity studies and an electromyogram
d. Surgical exploration and repair of the brachial plexus
e. Observation for 60 days before obtaining further test
Answer: e. Observation for 60 days before obtaining further test
BIRTH BRACHIAL PLEXUS PALSY
Type Roots Deficit Prognosis
Erb-Duchenne palsy C5, 6 Deltoid, cuff, elbow flexors, wrist and hand dorsiflexors; “waiter’s tip” deformity. Best prognosis.
Total plexus C5, T1 Sensory and motor; flaccid arm. Worst prognosis.
Klumpke C8, T1 Wrist flexors, intrinsics; Horner’s Poor prognosis.
Brachial plexus palsy—Decreasing in severity as a result of better obstetric management, yet 2 per 1000 births still have an injury associated with stretching or contusion of the brachial plexus. Occurs most often with large babies, shoulder dystocia, forceps delivery, breech position, and prolonged labor. Three types are commonly recognized, as mentioned in table above.
- The most severe and rapidly progressive form of congenital scoliosis is :
a. Block vertebra
b. Semisegmented hemivertebra
c. Fully segemented hemivertebra
d. Unilateral unsegmented bar
e. Unilateral unsegmented bar with contralateral hemivertebra
Answer: e. Unilateral unsegmented bar with contralateral hemivertebra
PROGRESSION OF CONGENITAL SCOLIOSIS PATTERNS AND TREATMENT OPTIONS
Risk of Progression (Highest to Lowest) Character of Curve Progression Treatment Options
Unilateral unsegmented bar with contralateral hemivertebra Rapid and relentless Posterior spinal fusion (add anterior fusion for girls age < 10 yr, boys < 12 yr)
Unilateral unsegmented bar Rapid Same
Fully segmented hemivertebra Steady Anterior spinal fusion
Hemivertebra excision
Partially segmented hemivertebra Less rapid; curve usually < 40 degrees at maturity Observation, hemivertebra excision
Incarcerated hemivertebra May slowly progress Observation
Nonsegmented hemivertebra Little progression Observation
- Posterior spinal fusion for scoliosis should be performed on a patient with Duchenne muscular dystrophy when
a. The patient is still ambulatory
b. Lordotic posture is present
c. The forced vital capacity (FVC) is less than 30% of the predicted value
d. Curve magnitude measures 25% or greater
e. Orthotic management fails
Answer : d. Curve magnitude measures 25% or greater
Surgery is indicated in patients with Duchenne’s muscular dystrophy for curves greater than 30 degrees and usually involves fusion from T2 to the pelvis. Preoperative assessment of pulmonary function (should be over 40% predicted) and cardiac function is necessary
Reference: AAOS Comprehensive Orthopedic Review. 2009.
- Which of the following deformities is most likely associated with slight valgus of femur, dimpling over the tibia, mild leg length discrepancy, increased heel valgus, and tarsal coalition?
a. Type 1 fibular hemimelia
b. Type 2 tibial hemimelia
c. Type 4 proximal focal femoral deficiency (PFFD)
d. Posterior medial bowing of the tibia
e. Congenital pseudoarthrosis of the tibia
Answer: a. Type 1 fibular hemimelia. (Ref: AAOS).
Seharusnya type II menurut klasifikasi Conventry Johnson (b) ?
Tibial bowing—Three types based on the apex of the curve.
1. Posteromedial-physiologic bowing—Usually of the middle and distal thirds of the tibia and may be the result of abnormal intrauterine positioning (Fig. 3–36). It is commonly associated with calcaneovalgus feet and tight anterior structures. Spontaneous correction is the rule, but follow the patient to evaluate LLD. The most common sequela of posteromedial bowing is an average LLD of 3-4 cm, which may require an age-appropriate epiphysiodesis of the long limb. Tibial osteotomies are not indicated.
2. Anteromedial tibial bowing—Typically caused by fibular hemimelia; a congenital longitudinal deficiency of the fibula is the most common long-bone deficiency. It is usually associated with anteromedial bowing, ankle instability, equinovarus foot (with or without lateral rays), tarsal coalition, and femoral shortening. Classically, skin dimpling is seen over the tibia. Significant LLD often results from this disorder. The fibular deficiency can be intercalary, which involves the whole bone (absent fibula) or terminal. Fibular hemimelia is frequently associated with femoral abnormalities such as coxa vara and PFFD. Radiographic findings include complete or partial absence of the fibula, a ball-and-socket ankle (secondary to tarsal coalitions), and deficient lateral rays in the foot. Treatment varies from a simple shoe lift or bracing to Syme’s amputation. Treatment decisions are based on the degree of foot deformity, the number of rays, and the degree of shortening of the limb. Amputation is usually done to treat limbs with severe shortening and/or a stiff, nonfunctional foot at about 10 months of age. For less severe cases, reconstructive procedures, including lengthening, may be an alternative. This procedure should include resection of the fibular anlage to avoid future foot problems.
3. Anterolateral tibial bowing—Congenital pseudarthrosis of the tibia is the most common cause of anterolateral bowing. It is often accompanied by neurofibromatosis (50%, but only 10% of patients with neurofibromatosis have this disorder). Classification (Boyd’s) is based on bowing and the presence of cystic changes, sclerosis, or dysplasia; dysplasia and cystic changes are the most common. Initial treatment includes a total-contact brace to protect the patient from fractures. Intramedullary fixation with excision of hamartomatous tissue and autogenous bone grafting are options for nonhealing fractures. A vascularized fibular graft or Ilizarov’s method should also be considered if bracing fails. Osteotomies to correct the anterolateral bowing are contraindicated. Amputation (Syme’s) and prosthetic fitting are indicated after two or three failed surgical attempts. Syme’s amputation is preferred to below-knee amputation in these patients because the soft tissue available at the heel pad is superior to that in the calf as a weight-bearing stump. The soft tissue in the calf in these patients is often scarred and atrophic.
4. Other lower limb deficiencies—Include tibial hemimelia, an AD disorder that is a congenital longitudinal deficiency of the tibia. Tibial hemimelia is the only long-bone deficiency with a known inheritance pattern (AD). It is much less common than fibular hemimelia and is often associated with other bony abnormalities (especially a lobster-claw hand). Clinically, the extremity is shortened and bowed anterolaterally with a prominent fibular head and an equinovarus foot, with the sole of the foot facing the perineum. The treatment for severe deformities with an entirely absent tibia is a knee disarticulation. Fibular transposition (Brown’s) has been unsuccessful, especially with absent quadriceps function and an absent proximal tibia. When the proximal tibia and quadriceps functions are present, the fibula can be transposed to the residual tibia and create a functional below-knee amputation.
Classification of congenital absence of fibula (Conventry Johnson 1952)
Type I Partial unilateral absence of fibula
Shortening of the extremity
Minimal or no bowing of the tibia
Little or no deformity of the foot
No other congenital anomalies
Type II Fibula completely or almost completely absent
Unilateral deformity
Anterior bowing of the tibia with skin dimple
Equinovalgus of the foot
Foot deformity may include absence of tarsal bone, rays, or tarsal coalition
Type III Bilateral type I atau II with deformities elsewhere in the body
- Which of the following types of iliac osteotomy provides the greatest potential for increased coverage ?
a. Ganz periacetabular
b. Pamberton innominate
c. Salter innominate
d. Sutherland double innominate
e. Steels tripe innominate
Answer : a. Ganz periacetabular
Surgical choice based on the degree of acetabular dysplasia and the age of the children.
Procedures
(a) The Salter osteotomy—May lengthen the affected leg up to 1 cm.
(b) The Pemberton acetabuloplasty—A good choice for residual dysplasia because it reduces acetabular volume (bends on triradiate cartilage).
(c) Acetabular reorientation procedures in older patients—Include the triple innominate osteotomy (Steel or Tönnis).
(d) Dega-type osteotomies—Often favored for paralytic dislocations and in patients with posterior acetabular deficiency.
(e) The Ganz periacetabular osteotomy—Provides improved three-dimensional correction because the cuts are close to the acetabulum, allow immediate weight bearing, spare stripping of the abductor muscles, allow for a capsulotomy to inspect the joint, and are performed through a single incision. However, the triradiate cartilage must be closed.
(f) The Chiari osteotomy—A salvage procedure when a concentric reduction of the femoral head within the acetabulum cannot be achieved. This osteotomy shortens the affected leg and requires periarticular soft tissue metaplasia for success. It depends on metaplastic tissue (fibrocartilage) for a successful result.
(g) The lateral shelf acetabular augmentation procedure—Done in patients over 8 years old with inadequate lateral coverage or trochanteric advancement and increased trochanteric overgrowth (improves hip abductor biomechanics). It depends on metaplastic tissue (fibrocartilage) for a successful result.
COMMON PELVIC OSTEOTOMIES
Osteotomy Procedure Requirement
Femoral Intertrochanteric osteotomy (VDRO) Concentric reduction < 8 years of age
Salter’s Open wedge osteotomy through ileum Concentric reduction < 8 years of age
Pemberton’s Through acetabular roof to triradiate cartilage Concentric reduction < 8 years of age
Sutherland’s (double) Salter’s + pubic osteotomy Concentric reduction
Open triradiate cartilage
Steel’s (triple) Salter’s + osteotomy of both rami Concentric reduction
Open triradiate cartilage
Ganz Periacetabular osteotomy Surgeon’s experience
Closed triradiate cartilage
Chiari’s Through ilium above acetabulum (makes new roof) Salvage procedure for asymmetrical incongruity
Shelf ’s Slotted lateral acetabular augmentation Salvage procedure for asymmetrical incongruity
VDRO, varus derotation osteotomy.
Reference : Miller’s Review of Orthopaedic. 5th ed. 2008. Elsevier inc.
- A 4 year old child sustains a spiral fracture to the tibia in an unwitnessed fall. History reveals three other fractures to long bones, and the parents are vague about the etiology of each. There is no family history of bone disease. The parents ask if the child has osteogenesis imperfect (OI); however, there are no clinical or radiographic indication of this diagnosis. In addition to fracture care, management should include:
a. Notification of child protective services and hospital admission
b. A punch biopsy of skin for collagen analysis
c. DNA testing for OI
d. Calcium, phosphate, and alkaline phosphatase studies
e. Placement of intramedullary rods to prevent further fracture
Answer : c. Notification of child protective services and hospital admission
OI : Mutation on genes encoding type I collagen : COL1A1 and COL1A2.
DD multiple fractures in children : OI and child abuse.
DNA testing not commercially available for OI. In this patient, physician suspect nonaccidental trauma and is legally obliged to notify child protective service. Work up for both OI and abuse can be done during hospitalization.
TABLE SPECIFICITY OF RADIOLOGIC FINDINGS
High Specificity
Classic metaphyseal lesions
Rib fractures, especially posterior
Scapular fractures
Spinous process fractures
Sternal fractures
Moderate Specificity
Multiple fractures, especially bilateral
Fractures of different ages
Epiphyseal separations
Vertebral body fractures and subluxations
Digital fractures
Complex skull fractures
Common, but low specificity
Subperiosteal new bone formation
Clavicular fractures
Long bone shaft fractures
Linear skull fractures
Highest specificity applies to infants.
From Kleinman PK. Diagnostic imaging of child abuse, 2nd ed. St. Louis, MO: Mosby, 1998:9.
Osteogenesis Imperfecta
Differentiating child abuse from OI is one of the most classic differential diagnostic challenges that the orthopaedist and radiologist can face. Claiming that their child has OI can be a common defense used by an abusive family in legal defenses. The classification of Sillence is well known. OI is a rare disorder of type I collagen (incidence of approximately 1 in 25,000 live births). OI type I is mild and is typically distinguished by distinctly blue sclerae (however, some children with OI type I do not have blue sclerae). OI type II is lethal in the perinatal period. OI type III is severe and causes progressive deformity. OI type IV is typically a milder form, with normal sclerae. Of the two subtypes, type IVA has no dentinogenesis imperfecta. OI is either dominantly inherited or occurs sporadically as a consequence of a new mutation. However, mosaicism has been reported and could explain the occurrence of more than one affected child to apparently “unaffected†parents. The only types that represent a practical differential challenge of abuse are the unusual type I OI without blue sclerae and type IVA OI.
Certainly biochemical analysis of type I collagen can be instrumental in confirming cases of OI when abuse is otherwise considered to be the cause (60). If testing is indicated, a skin biopsy for cultured dermal fibroblasts can detect approximately 85% of OI cases.
If there is a reliable reporter and a history of multiple fractures with minimal trauma, OI is likely. Smith offered these guidelines (62):
• In suspicious circumstances, suspect child abuse.
• Consider collagen testing if
o bruises or burns are not seen
o the reported injury seems too minor to have caused a fracture
o fractures occur in different environments
When the diagnosis is uncertain, children are typically placed in protective custody. In such an environment, a child with OI type IVA will still fracture. The fractures will likely cease to occur in the abused child. Children with OI can also be victims of abuse (63). Collagen synthesis testing is rarely required to rule out OI, as the diagnosis would have already been strongly suspected in most cases (64).
The reliability of bone mineral density (BMD) measurements to differentiate between abuse and OI is unknown, as values for BMD are not available for either typically developing children younger than 2 years or for children with OI
Reference: Lovell & Winter’s Pediatric Orthopedic. 6th ed. Ch 34.
- Which of the following pathogens are most commonly associated with neonatal septic arthritis and osteomyelitis ?
a. Staphylococcus aureus and Escherichia coli
b. Staphylococcus aureus and group A streptococci
c. Staphylococcus aureus and group B streptococci
d. Haemophilus influenza and Escherichia coli
e. Haemophilus influenza and group A streptococci
Answer c. Staphylococcus aureus and group B streptococci
Reference : Miller’s Review of Orthopedics. 5th ed. Chapter 1. Section 5.
Reference : AAOS Orthopedic Comprehensive Review. 2009.
Newborn (up to 4 months of age)—The most common organisms include Staphylococcus aureus, gram-negative bacilli, and group B streptococcus. Primary empirical therapy includes nafcillin or oxacillin plus a third-generation cephalosporin. Alternative antibiotic therapy includes vancomycin plus a third-generation cephalosporin. Newborns with hematogenous osteomyelitis may be afebrile, and the best predictors of the osteomyelitis are local signs in the extremity, including warmth. Almost 70% of newborn patients with hematogenous osteomyelitis have positive blood cultures.
Children 4 years of age or older—The most common organisms are S. aureus, group A streptococcus, and coliforms (uncommon). The empirical treatment of choice is nafcillin or oxacillin; alternative regimens include vancomycin or clindamycin. When the Gram stain shows gram-negative organisms, a third-generation cephalosporin should be added. With recent immunization programs, Haemophilus influenzae bone infections causing hematogenous osteomyelitis have been almost completely eliminated.
Adults 21 years of age or older—The most common organism is S. aureus, but a wide variety of other organisms have been isolated. Initial empirical therapy includes nafcillin, oxacillin, or cefazolin; vancomycin can be used as an alternative initial therapy.
Sickle cell anemia—Salmonella is a characteristic organism. The primary treatment is with one of the fluoroquinolones (only in adults); alternative treatment is with a third-generation cephalosporin.
Hemodialysis patients and intravenous drug abusers—S. aureus, S. epidermidis, and Pseudomonas aeruginosa are common organisms. The treatment of choice is one of the penicillinase-resistant synthetic penicillins (PRSPs) plus ciprofloxacin; an alternative treatment is vancomycin with ciprofloxacin.
- During soft tissue release for an idiopathic clubfoot, it is noted than the peroneus longus tendon has been transected in the midfoot. Failure into repair this structure may be lead to
a. Cavus
b. Claw toes
c. A dorsal bunion
d. Hindfoot valgus
e. Forefoot pronation
Answer: c. A dorsal bunion
A statistically significant varus displacement of the first metatarsal was observed only after transection of the peroneus longus tendon. It was concluded that the peroneus longus tendon is a strong retaining mechanism of the first metatarsal to opposes the tibialis anterior dorsal pull on 1st ray . When tendon peroneus longus injured, flexor hallucis longus try to compensate by flex the MTP. Thus forming deformity dorsal bunion.
Dorsal bunion can be result from sequel of poliomyelitis or direct injury to tendon peroneus longus.
Ref : Bohne WH, Lee KT, Peterson MG. Action of the peroneus longus tendon on the first metatarsal against metatarsus primus varus force. Foot Ankle Int. 1997 Aug;18(8):510-2.
Answer : e. Presence of metastases
Eventhough size greater than 15 cm, extra-compartment involvement, number of mitotic figures per high power filed (grade), large size in a proximal location are given bad prognosis but presence of metastases is the worst
- What is the most common presentation of a benign bone tumor in childhood ?
a. Pain
b. Deformity
c. Pathologic fracture
d. Presence af a mass
e. Incidental finding
Answer : e. Incidental finding
Benign bone tumor can be classified as : laten, active, aggressive. Only aggressive benign bone tumors are associated with soft tissue mass, and they are far less common than indolent bone tumors, especially in children.
Ref : AAOS comprehensive review.
- Soft tissue sarcomas most commonly metastasize to the
a. Liver
b. Lung
c. Bone
d. Regional nodes
e. Distant nodes
Answer: b. Lung
- Following preoperative chemotherapy, the percent of tumor necrosis has been shown to be of prognostic value for which of the following tumors ?
a. Rhabdomyosarcoma
b. Chondrosarcoma
c. Metastatic adenocarcinoma
d. Osteosarcoma
e. Giant cell tumor of bone
Answer: d. Osteosarcoma
Huvos grade 1,2,3,4: grading for histological response to preoperative chemotherapy
• grade-I : little or no necrosis (involving 50 per cent of the tumor or less);
• grade-II : necrosis of more than 50 per cent but less than 90 per cent of the tumor;
• grade-III : only scattered foci of viable tumor cells (necrosis of 90 to 99 per cent of the tumor)
• grade-IV response, by no viable tumor (100 per cent necrosis).
The histological response to preoperative chemotherapy was determined retrospectively by the same pathologist in a blinded fashion. Huvos grade 3,4 : kemo efektif.
- What is the most common clinical presentation of a patient with a malignant bone tumor ?
a. Incidental finding
b. Pain
c. Pathologic fracture
d. Deformity
e. Presence of a mass
Answer: b. pain
Ref. AAOS comprehensive orthopedic review. Pg 2.
What is the current 5 year survival rate for patients with classic nonmetastatic, high grade osteosarcoma of the extremity ?
a. 10%
b. 20%
c. 40%
d. 70%
e. 90%
Answer: d. 70%
Ref. AAOS comprehensive orthopedic review. Pg 124.
- The scoring system for impending pathologic fractures devised by Mirels involves assessment of which of the following factors?
- Lesion location, amount of pain, lesion type (lucent/blastic), lesion size
- Patient’s functional status, lesion location, amount of pain, lesion size
- Lesion type (lucent/blastic), patient’s functional status, lesion location, amount
- of pain
- Lesion size, lesion type (lucent/blastic), lesion location, patient’s functional status
- 5- Amount of pain, patient’s functional status, lesion type (lucent/blastic), lesion size
Answer: 1. Lesion location, amount of pain, lesion type (lucent/blastic), lesion size
Tabel Mirels Scoring System
Variable 1 point 2 points 3 points
Site Upper limb Lower limb Peritrochanteric
Pain Mild Moderate Functional
Lesion Blastic Mixed Lytic
Extent < 1/3 1/3 - 2/3 > 2/3
A mean score of 7 or below, indicates a low risk of fracture; radiation therapy should be considered. A score of 8 or above suggest a substantial risk, and surgical intervention is recommended
Reference : Operative Techniques in Orthopaedic Surgery. Vol 1. Pg 800. Lippicott William & Wilkins.
- What is the most common malignancy involving the hand?
1- Epithelioid sarcoma
2- Synovial sarcoma
3- Metastatic lung carcinoma
4- Chondrosarcoma
5- Squamous cell carcinoma
Answer 5. Squamous cell carcinoma
Squamous cell carcinoma (SCC)—The most common malignancy of the hand is squamous cell carcinoma. It is usually seen in elderly men with premalignant conditions such as actinokeratosis or chronic osteomyelitis. The primary risk factor is excessive exposure to ultraviolet radiation. SCC is also the most common subungual malignancy. It has a higher metastatic potential than basal cell carcinoma. Treatment is with wide excision or Mohs micrographic surgery. Lymph node biopsy may be necessary.
Reference : Miller’s Review of Orthopedic. 5th ed. Ch 7, Subch 15. Elsevier inc. 2008
Summary ;
The most common benign soft tissue tumor in hand and wrist is ganglion
The most common benign bone tumor in hand is enchondroma
The most common sarcomas are epithelioid and synovial. Other common sarcomas of the upper extremity include liposarcoma and malignant fibrous histiocytoma
The most common hand malignancy (metastases bone disease) is metastatic lung carcinoma, which is usually seen in the distal phalanx. The next most common primary sites of disease metastasizing to the hand are from the breast or kidney
The most common malignant primary bone tumor of hand and wrist are chondrosarcoma, osteosarcoma, and Ewing sarcoma
- What is the most common bone tumor in the hand?
1- Periosteal chondroma
2- Subungual exostosis
3- Chondrosarcoma
4- Osteoid osteoma
5- Enchondroma
Answer ; 5. Enchondroma
Enchondroma—The most common benign bone tumor of the upper extremity. It typically occurs in the second to fourth decades, and most cases are asymptomatic and discovered incidentally. The tumor arises from the metaphyseal medullary canal and spreads to the diaphysis. It is usually seen in the proximal phalanx and metacarpal (Fig. 7–58). Enchondroma causes symmetrical fusiform expansion of bone, with endosteal scalloping and intramedullary calcifications. It may present as a pathologic fracture. Histologically, enchondroma of the hand is characterized by benign cartilage of high cellularity. If mitotic figures are present, low-grade chondrosarcoma should be suspected. The recommended treatment is with curettage and bone grafting. Excision, intramedullary internal fixation, and bone cementing have also been successful in a small series.
Reference : Miller’s Review of Orthopedic. 5th ed. Ch 7, Subch 15. Elsevier inc. 2008
Summary ;
The most common benign soft tissue tumor in hand and wrist is ganglion
The most common benign bone tumor in hand is enchondroma
The most common sarcomas are epithelioid and synovial. Other common sarcomas of the upper extremity include liposarcoma and malignant fibrous histiocytoma
The most common hand malignancy (metastases bone disease) is metastatic lung carcinoma, which is usually seen in the distal phalanx. The next most common primary sites of disease metastasizing to the hand are from the breast or kidney
The most common malignant primary bone tumor of hand and wrist are chondrosarcoma, osteosarcoma, and Ewing sarcoma
A 15-year old boy has haemophilic arthropathy of his knee. Radiographs showed widening of the intercondylar notch of femur and squaring off of patella. The next step in his management is
A. Joint aspiration
B. Synovectomy
C. Replacement of factor VIII
D. Traction in bed to correct flexion deformity.
E. Total knee replacement.
Answer: c. replacement of factor VIII
Joint aspiration : not mentioned whether there is any acute joint hemorrhage
Traction in bed to correct flexion deformity : not recommended since it may worsen osteopenia
Total knee replacement: not recommended for 15 years old
Hemophilia—X-linked recessive disorder with decreased factor VIII (hemophilia A), abnormal factor VIII with platelet dysfunction (von Willebrand’s disease), or factor IX (hemophilia B-Christmas disease); associated with bleeding episodes and skeletal/joint sequelae. Can be mild (5-25% of factor present), moderate (1-5% available), or severe (< 1% of factor present).
- Presentation and diagnosis—Hemarthrosis presents with painful swelling and decreased range of motion (ROM) of affected joints. The knee is the most commonly affected joint. Deep intramuscular bleeding is also common and can lead to the formation of a pseudotumor (blood cyst), which can occur in soft tissue or bone. Intramuscular hematomas can lead to compression of adjacent nerves (e.g., an iliacus hematoma may cause femoral nerve paralysis and may mimic bleeding into the hip joint). Radiographic findings in hemophilia include squaring of the patellas and condyles, epiphyseal overgrowth with leg-length discrepancy, and generalized osteopenia with resulting fractures. Fractures heal in normal time with proper clotting. Cartilage atrophy due to enzymatic matrix degeneration and chondrocyte death is frequent.
- Treatment—Home transfusion therapy has reduced the severity of the arthropathy with the advantage of treatment when bleeding occurs. Treatment of the sequelae includes contracture release, osteotomies, open synovectomy, arthroscopic synovectomy (better motion, shorter hospitalization), radiation synovectomy (useful in patients with antibody inhibitors and poor medical management), and total joint arthroplasty. Mild to moderate hemophilia A can be treated with desmopressin. Factor VIII levels should be increased for prophylaxis in the following situations: vigorous physical therapy (20%), treatment of hematoma (30%), acute hemarthrosis or soft tissue surgery (> 50%), and skeletal surgery (approach 100% preoperatively and maintain over 50% for 10 days postoperatively).
Tourniquets, ligated vessels rather than cauterized vessels, and rigid fixation of fractures decrease postoperative bleeding. Immunoglobulin G (IgG) antibody inhibitors are present in 4-20% of hemophiliacs and are a relative contraindication to surgery. Because of the amount of blood component therapy required to treat this disorder, a large percentage of older hemophiliacs are positive for human immunodeficiency virus (HIV).
- Eosinophillic granuloma frequently occurs as a solitary lesion in the tubular long bones. After biopsy, what is the best course of action ?
a. Neoadjuvant chemotherapy
b. En bloc resection
c. Observation
d. Amputation
e. Chemotherapy followed by radiation therapy
Answer : c. observation
Most lesions of eosinophilic granuloma are simply observed, but larger, aggressive lesions may require curettage and bone grafting. Frequently, biopsy is required to rule out malignant diagnosis. The differential diagnosis of eosinophilic granuloma is osteomyelitis, Ewing sarcoma of bone, or osteogenic sarcoma. The biopsy alone can be followed by spontaneous resolution. In some patients, low dose radiation therapy is used. Chemotherapy or amputation is not indicated for these benign lesions.
Reference ; Simon M, Springfield D, et al: Common Benign Bone Tumors: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p200.
- Which fiber of the anterior cruciate ligament are thight in flexion ?
a. Anteromedial
b. Anterolateral
c. Posteromedial
d. Posterolateral
e. Middle
Answer : a. anteromedial
There are 2 bundles of anterior cruciate ligaments (ACL). The anteromedial bundle and posterolateral. The anteromedial tight in flexion, while in extension both bundle are tensioned.
Reference : AAOS Comprehensive Orthopedic System Review. 2009. P 143
- Following harvesting of patellar tendon autograft, paresthesia most commonly occurs in which of the following location ?
a. Medial to incision
b. Lateral to incision
c. First web space of the foot
d. Medial foot
e. Dorsal foot
Answer : b. lateral to incision
The infrapatellar branch of the saphenous nerve often crosses over the anterior aspect of the knee and innervates the skin lateral to the anterior midline of the knee. An anterior midline incision, often result in incision of the terminal branches, resulting in lateral numbness. The superficial peroneal, deep peroneal, and saphenous nerve provide sensation to the foot are not at risk.
- According to the Third National Acute Spinal Cord Injury Study (NASCIS 3), what is the recommended protocol for a patient who sustained a spinal cord injury 7 hours ago ?
- Methylprednisolone 30 mg/kg initial bolus, followed by 5.4 mg/kg/h for 23 hours
- Methylprednisolone 30 mg/kg initial bolus, followed by 5.4 mg/kg/h for 48 hours
- Dexamethasone 10 mg bolus, followed by 6 mg every 6 hour for 24 hours
- Dexamethasone 10 mg bolus, followed by 6 mg every 6 hour for48 hours
- No treatment
Answer: 2. Methylprednisolone 30 mg/kg initial bolus, followed by 5.4 mg/kg/h for 48 hours.
Based on National Acute Spinal Cord Injury Study (NASCIS) 1 & 2:
Methylprednisolone 30 mg/kg initial bolus, followed by 5.4 mg/kg/h for 23 hours.
NASCIS 2 established the recommended doses of methylprednisolone for spinal cord injury : an initial bolus of 30 mg/kg over 1 hour, followed by an infusion of 5.4 mg/kg/hour for an additional 23 hours. If injury was more than 8 hours old, the methylprednisolone was not recommended.
Based on National Acute Spinal Cord Injury Study (NASCIS) 3;
The objectives of the third and final NASCIS were to investigate the interplay between timing of steroid administration and duration of therapy and to evaluate the efficacy of the 21-aminosteroid tirilazad mesylate, which purportedly had a better safety profile than methylprednisolone. Four-hundred ninety-nine patients were randomized into three treatment groups within 6 hours of injury: the first group received methylprednisolone according to the NASCIS II dosing for 24 hours, the second group received this dosing for 48 hours, and the third group received a methylprednisolone bolus of 5.4 mg/kg/hr followed by a maintenance infusion of tirilazad at 2.5 mg/kg IV every 6 hours for 48 hours.
With outcome measures including motor function, sensory function, and functional independence; the NASCIS III revealed that increased duration of steroid administration (48 hours) resulted in statistically significant benefit only if treatment was initiated between 3 and 8 hours of injury.
Infectious complications were more common in the 48-hour corticosteroid group but were statistically insignificant. There were no differences between the tirilazad group and the 24-hour methylprednisolone group.
So, NASCIS 3 recommended changed the dosing schedule based on the time from injury. If the time from injury to treatment was less than 3 hours, the standard protocol was followed ( 30 mg/kg bolus followed by 5.4 mg/kg/hour for 23 hours).
If the time from injury to treatment was between 3 – 8 hours, the infusion was continued at 5.4 mg/kg/hour for an additional 23 hours (48 hours total).
Reference : Rothman-Simeone’ s The Spine. 6th ed. Ch : Basic Science of Spinal cord injury. Pg 1302.
- Injury to which of the following structures has been reported following iliac crest bone graft harvest?
a. Superior gluteal artery from anterior crest harvest
b. Superior cluteal artery from anterior crest harvest
c. Inferior gluteal artery from posterior crest harvest
d. Ilioinguinal nerve from a posterior crest harvest
e. Lateral femoral cutaneous nerve from an anterior crest harvest
Answer : e. Lateral femoral cutaneous nerve from an anterior crest harvest
Injury to the lateral femoral cutaneous nerve (Bernhardt’s syndrome) or MERALGIA PARESTHETICA occurs after harvest of the bone from the anterior iliac crest. The lateral femoral cutaneous nerve is a terminal sensory nerve that originates from L2-L3 and innervates the skin of the thigh laterally.
- Injury to the lateral femoral cutaneous nerve and the ilioinguinal nerve have both been described with an anterior iliac crest bone graft harvest.
- The lateral femoral cutaneous nerve may be injured from retraction after elevating the iliacus muscle or from direct injury when the nerve actually cross over the crest.
- Injury to ilioiguinal nerve has been reported from vigorous retraction of iliaus muscle after exposing inner table of anterior ilium.
- A posterior crest harvest can injury the superior gluteal injury if a surgical instrument violates the sciatic notch.
- Cluneal nerve injury may occur with posterior crest harvest, particularly if the skin incision is horizontal or extends more than 8 cm superolateral from the posterior superior iliac spine.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 226.
- A patient who sustained injuries in motocycle accident 30 minutes ago, has significant motor and sensory deficit corresponding to a C6 level of injury. A lateral radiograph obtained during the initial on scene evaluation reveals bilateral jumped facets as C5-C6, this appear to be an isolated injury. The patients is awake and alert. The next step in management of the dislocation should consist of :
a. Immediate posterior surgical reduction and stabilization
b. Immediate anterior discectomy and fusion
c. MRI
d. Reduction in Gardner-Wells tongs with serial traction
e. Rigid collar immobilization until spinal shock resolves
Answer : d. Reduction in Gardner-Wells tongs with serial traction
Surgical open reduction may increase the neurologic deficit if a disk herniation occur. Evidence from animal studies suggest, that rapid decompression of the spinal cord may improve recovery. Serially increasing traction weight to reduce dislocation has been shown to be safe when used in patient who are awake. Indication for MRI include patient who are unable to cooperate with serial examinations, the need for open reduction, and progression of deficit during awake reduction.
Reference AAOS Comprehensive Orthopedic Review. 2009. Pg 226.
- A 64 year old man who underwent an L4-L6decompression approximately 1 year ago reported relief on his claudicatory leg pain initially, but he now has increasing low back pain and recurrent neurogenic claudication despite nonsurgical management. Radiograph shows show ney asymmetric collapse and spondylolisthesis at the decompressed segment, and MRI scans show lateral recess stenosis. The next most appropriate step in management should consist of
- L4-5 discectomy
- L4-5 discectomy and lateral recess decompression
- Revision posterior decompression
- Revision posterior decompression and posterolateral fusion
- Anterior lumbar interbody fusion with cages
Answer: 4. Revision posterior decompression and posterolateral fusion
When radiographic findings reveal postlaminectomy instability, procedures that do not include some type of fusion will fail to solve the problem. In fact, wider decompression or discectomy alone will only further destabilize the segment. Because there is radiographic, evidence of recurrent lateral recess stenosis and symptomatic neurogenic claudication, a revision decompression should be included. Since acces to the canal involves a posterior approach, the stabilization should be performed through the same approach.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 227.
- The longus colli muscle are directly anterior to which of the following structures ?
a. Prevertebral fascia
b. Pretracheal fascia
c. Esophagus
d. Vertebral arteries
e. Cervical nerve root
Answer :d. vertebral arteries
The longus colli muscle are posterior to the prevertebral fascia, pretracheal fascia, and esophagus. They are anterior to both the vertebral arteries and cervical nerve roots, but the later are posterior to the vertebral arteries.
So the sequence structure from anterior to posterior are :
• Longus colli muscle
• Vertebral arteries
• Cervical nerve roots
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pgg 224.
- What is the prognosis for ambulation, from best to worst, for patient with an incomplete spinal cord injury ?
a. Central cord syndrome, anterior cord syndrome, brown sequard syndrome
b. Central cord syndrome, brown sequard syndrome, anterior cord syndrome
c. Brown sequard syndrome, anterior cord syndrome, central cord syndrome
d. Brown sequard syndrome, central cord syndrome, anterior cord syndrome
e. Anterior cord syndrome, central cord syndrome, brown sequard syndrome
Answer : d. Brown sequard syndrome, central cord syndrome, anterior cord syndrome
Of the incomplete spinal cord injury, Brown Sequard syndrome has the best prognosis for ambulation. Central cord syndrome has a variable recovery. Anterior cord syndrome has the worst prognosis, with motor recovery rare below the level of injury.
Reference ; AAOS Comprehensive Orthopedic Review. 2009. Pg 229.
- In the upright standing position, approximately what percent of the vertical load is borne by the lumbar facet joint?
a. 0%
b. 20%
c. 40%
d. 50%
e. 80%
Answer: b. 20%
Direct measurement and finite element modeling results show that approximately 20% of the vertical load is borne by the posterior structures of the lumbar spine in the upright position.
Reference : AAOS Comprehensive Orthopedic review. 2009. Pg 229.
Facet joint can carry up to 33% of dynamic axial loading. But when stand upright, 90% vertical load is borned by nucleus pulposus
- An elderly patient falls and sustain an extension injury to the neck that result in upper extremity weakness, spared perianal sensation, and lower extremity spasticity. These findings best describe what syndrome?
a. Brown sequard
b. Cauda equina
c. Anterior cord
d. Posterior cord
e. Central cord
Answer: e. central cord
- These findings indicate central cord syndrome, an injury that is more common in the older population who have some degrees of spondylosis. The physiologic insult can be a central spinal hematoma with result hematomyelia. Bowel and bladder function return, has agood prognosis, unlike the upper extremity motor loss.
- Cauda equina syndrome generally involves injury at the lumbar level. With some degrre of lower extremity motor loss.
- Posterior cord syndrome is characterized by preservation of motor function below the level of injury and position/vibration sensory loss.
- Brown-Sequard syndrome, which is often produced by a penetrating injury, result in hypalgesia and ipsilateral weakness.
- Anterior cord syndrome has a poor prognosis for functional return; lower extremity findings include loss of light touch, sharp/dull, and temperature sensation below the level of injury, as well as motor function.
- A type 2A Hangman’s fracture, which has the potential to overdistract with traction has which of the following hallmark findings ?
a. Anterior translation of greater than 3 mm
b. Severe angulation with minimal translation
c. Extension at the fracture site
d. Associated C 1 ring fracture
e. Associated C2-3 facet dislocation
Answer: b. Severe angulation with minimal translation
Classification (Levine and Edwards; Effendi)
- Type I: Nondisplaced, no angulation; translation <3 mm; C2-C3 disc intact (29%); relatively stable
- Type Ia: Atypical unstable lateral bending fractures that are obliquely displaced and usually involve only one pars interarticularis, extending anterior to the pars and into the body on the contralateral side
- Type II: Significant angulation at C2-C3; translation >3 mm; most common injury pattern; unstable; C2-C3 disc disrupted (56%); subclassified into flexion, extension, and listhetic types
- Type IIA: Avulsion of entire C2-C3 intervertebral disc in flexion with injury to posterior longitudinal ligament, leaving the anterior longitudinal ligament intact; results in severe angulation; no translation; unstable; probably caused by flexion-distraction injury (6%); traction contraindicated
- Type III: Rare; results from initial anterior facet dislocation of C2 on C3 followed by extension injury fracturing the neural arch; results in severe angulation and translation with unilateral or bilateral facet dislocation of C2-C3; unstable (9%); type III injuries most commonly associated with spinal cord injury
- A 44 year old farmer involved in a rollover accident on his tractor sustained on a L1 burst fracture with a 20% loss of anterior vertebral body height, 30% canal compromise, and 15% kyphosis. He remains neurologically intact. The preferred course of action should consist of:
a. Posterior spinal fusion with instrumentation
b. thoracolumbalsacral orthosis (TLSO) extension brace and early mobilization
c. Bed rest for 6 weeks followed by mobilization in a cast
d. Anterior L1 corpectomy and fusion with instrumentation
e. Anterior corpectomy followed by posterior fusion with instrumentation
Answer : b. thoracolumbosacral orthosis (TLSO) extension brace and early mobilization
Surgical decompression is unnecessary in a patient with no neurologic deficit and canal compromise of less than 50%. A compression deformity of less than 50% and kyphotic of less than 30° may be successfully treated with a TLSO extension brace. Deformity in this range will reliably heal with minimal risk for late deformity or residual pain. Although some studies suggest 6 weeks of bed rest as treatment, early mobilization and bracing is preferred.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 232.
- A 19 year old man who sustained a spinal cord injury in a motor vehicle accident 3 days ago has 5/5 full strength in the deltoid and biceps bilaterally, 4/5 strength in wrist extension bilaterally, 1/5 triceps function on the right side, and 2/5 triceps function on the left side. The patient has no detectable lower extremity motor function. Based on the American Spinal Injury Association’ classification, what is the patient’s functional level ?
a. C4
b. C5
c. C6
d. C7
e. C8
Answer: c. C6
By convention, when determining the motor level, the key muscle must be at least 3/5. The next most rostral level must be 4/5. Therefore, this patient’s function level is C6.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 232.
- The longus colli muscle are directly anterior to which of the following structures ?
a. Prevertebral fascia
b. Pretracheal fascia
c. Esophagus
d. Vertebral arteries
e. Cervical nerve root
Answer :d. vertebral arteries
The longus colli muscle are posterior to the prevertebral fascia, pretracheal fascia, and esophagus. They are anterior to both the vertebral arteries and cervical nerve roots, but the later are posterior to the vertebral arteries.
So the sequence structure from anterior to posterior are :
• Longus colli muscle
• Vertebral arteries
• Cervical nerve roots
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pgg 224.
- According to the Third National Acute Spinal Cord Injury Study (NASCIS 3), what is the recommended protocol for a patient who sustained a spinal cord injury 7 hours ago ?
a. Methylprednisolone 30 mg/kg initial bolus, followed by 5.4 mg/kg/h for 23 hours
b. Methylprednisolone 30 mg/kg initial bolus, followed by 5.4 mg/kg/h for 48 hours
c. Dexamethasone 10 mg bolus, followed by 6 mg every 6 hour for 24 hours
d. Dexamethasone 10 mg bolus, followed by 6 mg every 6 hour for48 hours
e. No treatment
Answer: b. Methylprednisolone 30 mg/kg initial bolus, followed by 5.4 mg/kg/h for 48 hours.
Based on National Acute Spinal Cord Injury Study (NASCIS) 1 & 2:
Methylprednisolone 30 mg/kg initial bolus, followed by 5.4 mg/kg/h for 23 hours.
NASCIS 2 established the recommended doses of methylprednisolone for spinal cord injury : an initial bolus of 30 mg/kg over 1 hour, followed by an infusion of 5.4 mg/kg/hour for an additional 23 hours. If injury was more than 8 hours old, the methylprednisolone was not recommended.
Based on National Acute Spinal Cord Injury Study (NASCIS) 3;
The objectives of the third and final NASCIS were to investigate the interplay between timing of steroid administration and duration of therapy and to evaluate the efficacy of the 21-aminosteroid tirilazad mesylate, which purportedly had a better safety profile than methylprednisolone. Four-hundred ninety-nine patients were randomized into three treatment groups within 6 hours of injury: the first group received methylprednisolone according to the NASCIS II dosing for 24 hours, the second group received this dosing for 48 hours, and the third group received a methylprednisolone bolus of 5.4 mg/kg/hr followed by a maintenance infusion of tirilazad at 2.5 mg/kg IV every 6 hours for 48 hours.
With outcome measures including motor function, sensory function, and functional independence; the NASCIS III revealed that increased duration of steroid administration (48 hours) resulted in statistically significant benefit only if treatment was initiated between 3 and 8 hours of injury.
Infectious complications were more common in the 48-hour corticosteroid group but were statistically insignificant. There were no differences between the tirilazad group and the 24-hour methylprednisolone group.
So, NASCIS 3 recommended changed the dosing schedule based on the time from injury. If the time from injury to treatment was less than 3 hours, the standard protocol was followed ( 30 mg/kg bolus followed by 5.4 mg/kg/hour for 23 hours).
If the time from injury to treatment was between 3 – 8 hours, the infusion was continued at 5.4 mg/kg/hour for an additional 23 hours (48 hours total).
Reference : Rothman-Simeone’ s The Spine. 6th ed. Ch : Basic Science of Spinal cord injury. Pg 1302.
- Which of the following is considered the most reliable early clinical finding for hemorrhagic shock ?
a. Decreased systolic blood pressure
b. Decreased diastolic blood pressure
c. Decreased hemoglobin level
d. Low urine output
e. Tachycardia
Answer : e. Tachycardia
Because there are no laboratory tests to diagnose shock, the initial treatment of hemorrhagic shock is recognizing the problem. In most patients with hemorrhagic shock, tachycardia is the earliest measurable sign. Cutaneous vasoconstriction is also an early clinical finding. A drop in systolic blood pressure is often a late finding in hemorrhagic shock. As much as 30% of circulatory blood volume can be lost prior to any change in the systolic blood pressure. In an early state of shock, diastolic blood pressure is increased because of arterial vasoconstriction, which lead to narrow pulse pressure. A decreased hemoglobin level is uncommon finding in early state of hemorrhagic shock. If present, it may relatively preserved in the early state of shock.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 184.
- After undergoing a closed undreamed tibial nailing, a patient is diagnosed with an isolated anterior leg compartment syndrome. However, no treatment is initiated because the patient is thought to have a nerve palsy. Which of the following findings should be present at 2 weeks when the cast is removed ?
a. Drop foot and numbness in the first web space of the foot
b. Calcaneal deformity of the ankle
c. Rigid equines deformity
d. Plantar foot numbness
e. Supple claw toes
Answer: a. Drop foot and numbness in the first web space of the foot
Anterior compartment of cruris contain deep peroneal nerve which innervates tibialis anterior muscle, function in dorsiflexing the ankle, while its sensoric area is over the 1 st web space of the foot.
In the acute phase, anterior leg compartment syndrome may look identical to a peroneal nerve palsy; however, with removal of the cast, the patient will most likely have a drop foot and numbness in the first web space of the foot. Calcaneal deformity of the ankle is unlikely to develop following anterior leg compartment syndrome. Deep posterior compartment syndrome most often result in a rigid equines deformity or claw toes.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 185.
- A patient with an acromioclavicular dislocation has a very prominent distal clavicle. Examination reveals that the deformity increases rather than reduces with an isometric shoulder shrug. Which of the following structures is most likely intact ?
a. Trapezoid ligament
b. Conoid ligament
c. Acromioclavicular ligament
d. Deltoid muscle origin
e. Trapezius muscle insertion
Answer: e. Trapezius muscle insertion
Severely displaced acrmioclavicular injuries disrupt the deltopectoral fascia and muscular origin in addition to the ligaments (acromioclavicular and coracoclavicular or trapezoid and conoid). When the deltoid is still attached to the clavicle, an isometric shoulder shrug will tend to reduce the displacement. When the deltoid is detached, but the trapezius is attached, this maneuver will increase the deformity, and surgery may indicated.
Reference ; AAOS Comprehensive Orthopedic Review. 2009. Pg 86.
Classification—Classified by extent of involvement of the ligamentous support and direction and magnitude of displacement
- Type I—Sprain of AC joint
- Type II—Rupture of AC ligaments and sprain of CC ligaments
- Type III—Rupture of both AC and CC ligaments
- Type IV—The clavicle is buttonholed through the trapezius posteriorly
- Type V—The trapezius and deltoid are detached
- Type VI—The clavicle is translocated beneath the coracoid
- Posterior sternoclavicular dislocation are most commonly associated with which of the following complication ?
a. Chronic instability
b. Brachial plexus palsy
c. Pneumothorax
d. Esophageal compression
e. Tracheal compression
Answer: e. Tracheal compression
Many complications have been reported secondary to the retrosternal dislocation:
- right pulmonary artery laceration
- transected internal mammary artery and lacerated brachiophalic vein
- pneumothorax and laceration of the superior vena cava
- respiratory distress
- venous congestion in the neck
- rupture of the esophagus with abscess and osteomyelitis of the clavicle
- pressure on the subclavian artery in an untreated patient
- occlusion of the subclavian artery late in a patient who was not treated
Worman and Leagus, in their excellent review of the complications associated with posterior dislocations of the sternoclavicular joint, reported that 16 of 60 patients reviewed from the literature had suffered c_omplications of the trachea,_ esophagus, or great vessels
Worman LW, Leagus C. Intrathoracic injury following retrosternal dislocation of the clavicle. Trauma 1967;7:416-423.
Rereference : Rockwood & Green’s Fractures in Adult. 6th ed. Ch 36.
- During an anterior approach to the shoulder, excessive traction on the conjoined tendon is most likely to result in loss of
a. Elbow flexion
b. Shoulder flexion
c. Shoulder internal rotation
d. Shoulder abduction
e. Forearm pronation
Answer : a. elbow flexion
Conjoined tendon consist of biceps, coracobrachialis. The musculocutaneous nerve travels through the conjoined tendon approximately 8 cm distal to tip of acromion. The musculocutaneous nerve innervates the biceps muscle and the brachialis muscle, both of which responsible for elbow flexion. Shoulder flexion is facilitated by the anterior fibers of the deltoid muscle (axillary nerve), and the supraspinatus muscle (suprascapular nerve). The subsacpular muscle fascilitates internal rotation of the shoulder (upper and lower subscapularis nerve). Shoulder abduction is performed by the deltoid muscle (axillary nerve), and forearm pronation is fascilitated by the pronator teres (median nerve)
Reference: AAOS Comprehensive Orthopedic System reviw. 2009. pg 187
- Which of the following ligaments is most commonly involved in posterolateral rotator instability of the elbow?
a. Annular
b. Lateral ulnar collateral
c. Anterior band of medial collateral
d. Radial part of the lateral collateral
e. Posterior capsul
Answer: b. Lateral ulnar collateral
Recurrent posterolateral rotator instability of the elbow is difficult to diagnose. Such instability can be demonstrated only by lateral pivot shift test. The cause for this condition is laxity for the ulnar part of lateral collateral ligament, which allow transient rotator subluxation of the ulnohumeral joint and a secondary dislocation of the radiohumeral joint. The annular ligament remain intact, so the radioulnar joint does not dislocate. Treatment consist of surgical reconstruction of the lax ulnar part of the lateral collateral ligament. The anterior band is the most important p[art of the medial collateral ligament which is lax in valgus instability of the elbow.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 189.
- Which of the following factors is considered most important when assessing an ankle fracture for surgical treatment?
a. Level of fibular fracture
b. Displacement of fibular fracture
c. Size of posterior malleolus
d. Position of the talus in the mortise view
e. Rupture of the deltoid ligament
Answer:d. Position of the talus in the mortise view
Although all of these factors may influence the decision to perform surgery, the most important is the position of the talus in the mortise. The goal of treatment of ankle fractures is to maintain the talus centered in the mortise. If it is in this position, the other factor do not enter into the decision intervene surgically.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 192.
- After stabilizing a bimalleolar fracture with a plate and lag screws foot the fibula and two interfragmental compression screws for the medial malleolus, a syndesmosis screw is indicated of the following situation
a. In all suprasyndesmosis fibular fractures
b. In all trans syndesmosis fibular fracture
c. When there is increased medial clear space with external rotation stress
d. If the deltoid ligament is ruptured
e. If the posterior malleolus is fracture
Answer : c. When there is increased medial clear space with external rotation stress
It is imperative to recognize the need for a position screw (syndesmosis screw) to hold the syndesmosis in proper alignment when surgically stabilizing an ankle fracture. Although many different fracture patterns are suspicious for a disrupted syndesmosis, the only way to asses the syndesmosis is to stress it with abduction and external rotation of the talus and attempt to displace the fibula from the incisura fibularis. Under fluoroscopy, the talus will move laterally and displace the fibula, show a valgus talar tilt, or show an increase medial clear space. If any of all of these signs occur, a syndesmosis screw is inserted after making sure that fibula is reduced into the incisura fibularis. This screw may transverse 3 or 4 cortices but must not act as a lag screw. It usually is inserted with the ankle in maximal dorsiflexion.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 193.
- A 32 year old man sustain an iliac wing fracture and a contralateral femur fracture. Twelve hours later he has shortness of breath with tachypnea, hypoxia, and confusion. A chest radiograph is normal. What is the most likely diagnosis ?
a. Fat emboli syndrome
b. Adult respiratory distress syndrome
c. Pulmonary embolus
d. Tension penumothorax
e. Sepsis
Answer: a. Fat emboli syndrome
Sevitt mayor criteria of fat emboli syndrome:
• Hipoxia
• Loss of consciousness
• Ptechiea
Sevitt minor criteria of fat emboli syndrome:
• Tachypnea
• Anemia
• Trombositopenia
• Fat macroglobulinuria
- The nerve that transverse the triangular internal (bounded by the teres major superiorly, the long head of triceps medially, and the humeral shaft laterally) supplies which of the following muscle ?
a. Brachioradialis
b. Flexor pollicis longus
c. Deltoid
d. Teres major
e. Pronator teres
Answer : a. Brachioradialis
The radial nerve and profunda brachii artery gain acces to the posterior aspect of the arm through the triangular interval. The radial nerve supplies the brachioradialis.
Reference : Netter
- A 24 year old woman has a spleen laceration and hypotension. Radiographs reveal a pulmonary contusion and a displaced mid diaphyseal fracture of the femur. The trauma surgeon clears the patient for stabilization of the femoral fracture. What technique will offer the least potential complication?
a. External fixation
b. Plate fixation
c. Unreamed unlocked intramedullary nailing
d. Reamed statically locked intramedullary nailing
e. Reamed unlocked nailing
Answer: a. External fixation
A concern in the multiply injured patient who has a pulmonary contusion is the potential for further pulmonary compromise because of embolization of marrow, blood clot, or fat during manipulation of the medullary canal. Recent evidence has shown that the presence of a lung injury is the most important determining factor in future deterioration. However despite the lung injury and its potential consequences, this patient’s femur fracture needs stabilization.
Damage control in the multiply injured patient requires a technique that can performed rapidly and consistently, the treatment of choice is application of an external fixator. This allow the patient to be resuscitated and treated at a later date when definitive management of the fracture can be carried out. There is little difference between plate fixation and IM nailing with reaming in mortality or ARDS following thoracic injury.
Reference ; AAOS Comprehensive Orthopedic Review. 2009. Pg 195.
- The synonym for Paget’s disease is:
a. Osteitis fibrosa.
b. Osteitis proliferans.
c. Osteitis deformans.
d. None of the above.
Answer : c. Osteitis deformans
Paget’s disease—Elevated serum alkaline phosphatase and urinary hydroxyproline; virus-like inclusion bodies observed in osteoclasts. Can display both decreased and increased osteodensity (depending on the phase of the disease). Discussed in Chapter 9, Orthopaedic Pathology.
a. Active phase
(1) Lytic phase—Intense osteoclastic bone resorption
(2) Mixed phase
(3) Sclerotic phase—Osteoblastic bone formation predominates
b. Inactive phase
PA : Section from pagetic bone, showing the mosaic pattern due to overactive bone resorption and bone formation. The trabeculae are thick and patterned by cement lines. Some surfaces are excavated by osteoclastic activity whilst others are lined by rows of osteoblasts. The marrow spaces contain fibrovascular tissue.
Marble or mosaic appearance
Reference picture : Apley 9th ed. Ch 7. Pg 144
- Multiple myeloma tumor cells resemble:
a. Granulocytes.
b. Plasma cells.
c. Lymphocytes.
d. Chondrocytes.
Answer :b. plasma cells
HistoPA: Eccentric round or oval cells nuclei membentuk roda pedati (tentiran dr Sjahjenny Sp.PA)
- The enzyme found in osteoclasts but not in osteoblasts is:
a. Alkaline phosphatase.
b. Acid phosphatase.
c. Elastase.
d. Cytochrome oxidase.
Answer : b. Acid phosphatase
Osteoclast : Multinucleated, irregularly shaped giant cells originate from hematopoietic cells in the macrophage lineage (monocyte progenitors form giant cells by fusion). Possess a ruffled (“brush”) border (plasma membrane enfoldings that increase surface area. Osteoclasts synthesize tartrate-resistant acid phosphate. Bisphosphonates inhibit osteoclast resorption of bone (by preventing the osteoclast from forming the ruffled border necessary for expression of acid hydrolases)
Reference : Miller’s Review of Orthopedic. 5th ed. Ch 1. Section 1.
- Healing of tuberculous arthritis can lead to:
a. Calcification.
b. Fibrous ankylosis.
c. Bony ankylosis.
d. None of the above.
Answer: b. Fibrous ankylosis.
Tanda healing TB musculoskeletal : aspek klinis
Dan radiologis.
Klinis: keluhan nyeri(-), BB naik, KU baik
Radiologis : spinal fusion
Release from treatment setelah OAT 1 tahun,klinis,
dan radiologis
INH rifampicin, PZA : 3 bulan fase intensif
INH, rifampicin : 9 bulan fase lanjutan
- What is not True of Brodie’s abscess:
a. A form of chronic osteomyelitis
b. Intermittent pain and swelling.
c. Common to diaphysis
d. Excision is very often required.
Answer : c. Common to diaphysis.(common to metaphysis)
The typical radiographic lesion is a circumscribed, round or oval radiolucent ‘cavity’ 1–2 cm in diameter. Most often it is seen in the tibial or femoral metaphysis, but it may occur in the epiphysis or in one of the cuboidal bones (e.g. the calcaneum). Sometimes the ‘cavity’ is surrounded by a halo of sclerosis (the classic Brodie’s abscess); occasionally it is less well defined, extending into the diaphysis. Metaphyseal lesions cause little or no periosteal reaction; diaphyseal lesions may be associated with periosteal new bone formation and marked cortical thickening. If the cortex is eroded the lesion may be mistaken for a malignant tumour. The radioisotope scan shows markedly increased activity. Curettage is also indicated if the x-ray shows that there is no healing after conservative treatment; this is always followed by a further course of antibiotics.
- A 54 year old man undergoes uneventful anterior cervical discectomy and interbody fusion at C4 -5 for focal disc herniation and C5 radiculopathy. At the 3 week follow up examination, the patient reports a persistent cough. Pulmonary evaluation reveals a mild but persistent aspiration. Laryngoscop reveals partial paralysis of the left vocal cord, most likely caused by:
a. Entrapment of the superior laryngeal nerve during ligation of the superior thyroid artery
b. Stretch of the recurrent laryngeal as it enters the esophageal tracheal groove
c. Injury to the vocal cord during endotracheal intubation
d. Displacement of the lanrynx against the endotracheal tube by retraction
e. Retraction pressure on the laryngeal nerve in the esophageal groove
Answer : e. Displacement of the lanrynx against the endotracheal tube by retraction
The exact anatomic event responsible for vocal cord paralysis associated with anterior cervical surgery remains a question Apfelbaum et al, in an excellent review of 900 anterior cervical surgeries, identified 30% with vocal cord paralysis, 3 of which were permanent. They showed that retractor placed under the longus colli for anterior cervical exposures can compress the laryngeal-tracheal branches within the larynx against the tented endotracheal tube rather than the recurrent laryngeal nerve which is extrinsic to the larynx. By releasing the endotrachela cuff and allowing the tube to recenter itself after placement of retractors, they were able to decrease vocal cord injury from 6.4% to 1.7%. Jewett et al suggested that a left sided approach may result in lower incidence of injury. Endotracheal intubation is the 2nd most common cause of vocal cord injury, with an incidence approximately 2%.
Reference : AAOS Comprehensive Orthopedic review. 2009. Pg 236.
- A type 2A Hangman’s fracture, which has the potential to overdistract with traction has which of the following hallmark findings ?
a. Anterior translation of greater than 3 mm
b. Severe angulation with minimal translation
c. Extension at the fracture site
d. Associated C 1 ring fracture
e. Associated C2-3 facet dislocation
Answer: b. Severe angulation with minimal translation
Classification (Levine and Edwards; Effendi):
- Type I: Nondisplaced, no angulation; translation <3 mm; C2-C3 disc intact (29%); relatively stable
- Type Ia: Atypical unstable lateral bending fractures that are obliquely displaced and usually involve only one pars interarticularis, extending anterior to the pars and into the body on the contralateral side
- Type II: Significant angulation at C2-C3; translation >3 mm; most common injury pattern; unstable; C2-C3 disc disrupted (56%); subclassified into flexion, extension, and listhetic types
- Type IIA: Avulsion of entire C2-C3 intervertebral disc in flexion with injury to posterior longitudinal ligament, leaving the anterior longitudinal ligament intact; results in severe angulation; no translation; unstable; probably caused by flexion-distraction injury (6%); traction contraindicated
- Type III: Rare; results from initial anterior facet dislocation of C2 on C3 followed by extension injury fracturing the neural arch; results in severe angulation and translation with unilateral or bilateral facet dislocation of C2-C3; unstable (9%); type III injuries most commonly associated with spinal cord injury
- A 44 year old farmer involved in a rollover accident on his tractor sustained on a L1 burst fracture with a 20% loss of anterior vertebral body height, 30% canal compromise, and 15% kyphosis. He remains neurologically intact. The preferred course of action should consist of:
a. Posterior spinal fusion with instrumentation
b. thoracolumbalsacral orthosis (TLSO) extension brace and early mobilization
c. Bed rest for 6 weeks followed by mobilization in a cast
d. Anterior L1 corpectomy and fusion with instrumentation
e. Anterior corpectomy followed by posterior fusion with instrumentation
Answer : b. thoracolumbosacral orthosis (TLSO) extension brace and early mobilization
Surgical decompression is unnecessary in a patient with no neurologic deficit and canal compromise of less than 50%. A compression deformity of less than 50% and kyphotic of less than 30° may be successfully treated with a TLSO extension brace. Deformity in this range will reliably heal with minimal risk for late deformity or residual pain. Although some studies suggest 6 weeks of bed rest as treatment, early mobilization and bracing is preferred.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 232.
- A 19 year old man who sustained a spinal cord injury in a motor vehicle accident 3 days ago has 5/5 full strength in the deltoid and biceps bilaterally, 4/5 strength in wrist extension bilaterally, 1/5 triceps function on the right side, and 2/5 triceps function on the left side. The patient has no detectable lower extremity motor function. Based on the American Spinal Injury Association’ classification, what is the patient’s functional level ?
a. C4
b. C5
c. C6
d. C7
e. C8
Answer: c. C6
By convention, when determining the motor level, the key muscle must be at least 3/5. The next most rostral level must be 4/5. Therefore, this patient’s function level is C6.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 232.
- What spinal nerve in the cauda equine are primarily responsible for innervations of the bladder?
a. L1,L2, and L3
b. L4 and L5
c. L5 and S1
d. S2, S3, and S4
e. Filum terminale
Answer : d. S2, S3, and S4
The spinal nerves primarily responsible for bladder function are the S2, S3, S4 nerve roots. With significant compression of the cauda equine by either disk herniation, tumor, or degenerative stenosis, bladder dysfunction may result.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 234.
- Which of the following is a long complication of ankle arthrodesis for post traumatic arthritis ?
a. Progressive limb length discrepancy
b. Contralateral ankle arthritis
c. Ipsilateral hindfoot and midfoot arthritis
d. Ipsilateral knee arthritis
e. Talar osteonecrosis
Answer : c. Ipsilateral hindfoot and midfoot arthritis
Ankle arthrodesis for posttraumatic ankle arthrosis provide reliable pain relief. However, the long term sequel of joint arthrodesis is the development of arthrosis in the surrounding joints. Over time, following ankle arthrodesis, the ipsilateral hindfoot and midfoot jints show sign of join space wear, and this may be symptomatic. With a stable ankle arthrodesis, progressive limb-length discrepancy or talar osteonecrosis is not expected. Ankle arthrodesis has not been definitely linked to ipsilateral knee arthritis or contralateral ankle arthritis.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 199.
- A 24 year old woman has a spleen laceration and hypotension. Radiographs reveal a pulmonary contusion and a displaced mid diaphyseal fracture of the femur. The trauma surgeon clears the patient for stabilization of the femoral fracture. What technique will offer the least potential complication?
a. External fixation
b. Plate fixation
c. Unreamed unlocked intramedullary nailing
d. Reamed statically locked intramedullary nailing
e. Reamed unlocked nailing
Answer: a. External fixation
A concern in the multiply injured patient who has a pulmonary contusion is the potential for further pulmonary compromise because of embolization of marrow, blood clot, or fat during manipulation of the medullary canal. Recent evidence has shown that the presence of a lung injury is the most important determining factor in future deterioration. However despite the lung injury and its potential consequences, this patient’s femur fracture needs stabilization.
Damage control in the multiply injured patient requires a technique that can performed rapidly and consistently, the treatment of choice is application of an external fixator. This allow the patient to be resuscitated and treated at a later date when definitive management of the fracture can be carried out. There is little difference between plate fixation and IM nailing with reaming in mortality or ARDS following thoracic injury.
Reference ; AAOS Comprehensive Orthopedic Review. 2009. Pg 195.
- A 21 year old man sustained a displaced pelvic fracture after falling 40 feet from examination reveals the presence of blood in the urethral meatus. Which of the following measures is most likely to complicate urologic management ?
a. Intravenous pyelography
b. Placement of a Foley catheter
c. Placement of suprapubic catheter
d. Rectal examination
e. Retrograde cystogram
Answer: b. Placement of a Foley catheter
- A 18 year old man has a simple oblique fracture of the humeral shaft that require surgical stabilization to maintain reduction and facilitate mobilization. Which of the following methods will provide the best outcome ?
a. Unreamed intramedullary nail
b. Reamed statically locked intramedullary nail
c. External fixation
d. Plate fixation and interfragmentary compression
e. Bridge plate stabilization
Answer: d. Plate fixation and interfragmentary compression
The patient has a simple fracture pattern that can be reduce anatomically and stabilized with absolute stability by interfragmental compression and protection plating. This will guarantee a 95% - 98% union rate eith no radial nerve palsy. Intramedullary nailing does not equal these result in simple fracture pattern in humerus. Bridge palting is indicated for multifragmented fracture pattern when anatomic reductionand absolute stability cannot be achieved. External fixation is reserved for severe open fractures.
Reference : AAOS Comprehensive Orthopedic Review. 2009. 202.
- Origin of bone is from:
a. Ectoderm
b. Mesoderm
c. Endoderm
d. All of the above
Answer: b. Mesoderm
Fourth week of embryogenesis
During this week, the limb buds become recognizable. Somites (mesoderm) differentiate into three dermatome, mtome, and sclerotome. The dermatome becomes skin, the myotome becomes muscle, and the sclerotome becomes cartilage and bone.
Reference : Staheli. Practice of Pediatric Orthopedic. 2nd. 2006. Lippincott William & Wilkins. Ch 1
- Acute osteomyelitis usually begins at :
a. Epiphysis
b. Metaphysis
c. Diaphysis
d. Any of above
Answer: b. Metaphysis
Reference: Apley 9th ed
Predilection for this site has traditionally been attributed to the peculiar arrangement of the blood vessels in that area (Trueta, 1959):
- the non-anastomosing terminal branches of the nutrient artery
- twist back in hairpin loops before entering the large network of sinusoidal veins
- the relative vascular stasis
- consequent lowered oxygen tension
- What is not true of acute pyogenic osteomyelitis
a. Trauma is a predisposing factor
b. Common infecting agent is Staphylococcus aureus
c. Infection is usually blood borne
d. All are true
Answer: c. Infection is usually blood borne
In adults, haematogenous infection accounts for only about 20% of cases of osteomyelitis, mostly affecting the vertebrae. Staphylococcus aureus is the commonest organism but Pseudomonas aeruginosa often appears in patients using intravenous drugs.
Reference : Apley’s System of Orthopedic and Fractures. 9th ed, Ch 2: Pg 31.
- What is not true of Brodi’s abscess
a. Form of chronic osteomyelitis
b. Intermittent pain and swelling
c. Common to diaphysis
d. Excision is very often required
Answer: d. Common to diaphysis
Brodie’s abscess, characteristic in subacute hematogenous osteomyelitis. The typical radiographic lesion is a circumscribed, round or oval radiolucent ‘cavity’ 1–2 cm in diameter. Most often it is seen in the tibial or femoral metaphysis, but it may occur in the epiphysis or in one of the cuboidal bones (e.g. the calcaneum). Sometimes the ‘cavity’ is surrounded by a halo of sclerosis (the classic Brodie’s abscess); occasionally it is less well defined, extending into the diaphysis.
Reference : Apley’s System of Orthopedic and Fractures. 9th ed, Ch 2: Pg 31.
- The earliest sign of TB hip in X-ray is:
a. Narrow joint space.
b. Irregular moth eaten femoral head.
c. Periarticular osteoporosis.(Apley Ch2)
d. Dislocation.
Answer : c. Periarticular osteoporosis
Tuberculosis – clinical and x-ray features (a) Generalized wasting used to be a common feature of all forms of tuberculosis. Nowadays, skeletal tuberculosis occurs in deceptively healthy-looking individuals. An early feature is peri-articular osteoporosis due to synovitis – the left knee in (b). This often resolves with treatment, but if cartilage and bone are destroyed (c), healing occurs by fibrosis and the joint retains a ‘jog’ of painful movement. Reference : Apley 9th ed. Ch 2.
- Which of the following is the most appropriate treatment for an acute comminuted radial head fracture, is associated with an Essex Lopresty injury (radioulnar dissociation)
- Radial head preservation
- Radial head excision
- Suave-Kapandji procedure
- Darrach procedure
- Radioulnar synostosis
Answer: 1. Radial head preservation
An Essex lopresti injury consist of a fracture of the radial head, disruption of the radioulnar interosseous membrane, and dislocation of the distal radioulnar joint. The diagnosis is frequently made late, ie after excision of comminuted radial head fracture, after pain develops at the distal radioulnar joint, and radiographs show progressive positive ulnar variance and/or dislocation due to proximal migration of radial shaft. Patient who have undergone reduction and internal fixation of the radial head or replacement have done better than those who had excision. Concurrent treatment should include reduction of the distal radioulnar joint and temporary stabilization.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 179.
- A posterior approach to the knee with an incision of the superficial fascia medial to the small saphenous vein avoids injury to what structure that line just lateral and adjacent to the small saphenous vein ?
a. Popliteal vein
b. Popliteal artery
c. Tibial nerve
d. Common peroneal nerve
e. Medial sural cutaneous nerve
Answer : e. Medial sural cutaneous nerve
Posterior approach by Burks and Schaffer
Burks and Schaffer
- With the patient prone, make a gently curved incision, with a horizontal limb near the flexion crease of the knee and a vertical limb overlying the medial aspect of the gastrocnemius muscle.
- Carry the dissection to the deep fascial layer and incise it vertically over the medial head of the gastrocnemius.
- Protect the medial sural cutaneous nerve (posterior cutaneous nerve of the calf), which usually perforates the deep fascia distal to the horizontal limb of the incision.
- Identify the medial border of the medial gastrocnemius and bluntly develop the interval between it and the semimembranosus tendon, exposing the posterior joint capsule. The middle geniculate artery may be encountered near the midposterior capsule and can be ligated if necessary. By lateral retraction on the medial head of the gastrocnemius, no tension is directly applied to the motor branch to the medial head of the gastrocnemius, the only motor branch from the tibial nerve in the popliteal fossa that traverses medially. The thick muscle belly protects the neurovascular structures as the capsule is exposed. Dissection on this protected medial side of the popliteal fossa is therefore relatively safe.
- Expose the posterior aspect of the proximal tibia and posterior margins of the femoral condyle.
- If further lateral exposure is necessary, release a portion of the tendinous origin of the medial head of the gastrocnemius from the distal femur and joint capsule. Slight knee flexion will aid exposure, and complete sectioning of the medial head of the gastrocnemius rarely is needed.
- Make a vertical incision through the posterior capsule to expose the contents of the posterior intercondylar notch and the tibial attachment of the posterior cruciate ligament.
- Proceed as described by Berg
- Suture the capsular incision, allow the gastrocnemius to settle into position, approximate the subcutaneous layers, and close the skin in a routine fashion.
- Patient with hip disease may report knee pain, which is primarily caused by irritation of which of the following branches of the obturator nerve ?
a. Cutaneous continuation of the brach on the gracilis muscle
b. Continuation of the branch to the adductor magnus
c. Accessory obturator nerve branch
d. Branch within the sartorius muscle
e. Branch within the linea aspera
Answer: b. Continuation of the branch to the adductor magnus
The branch of the obturator nerve to the knee is the continuation of the motor branch to the adductor magnus.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 144
- Following harvesting of patellar tendon autograft, paresthesia most commonly occurs in which of the following location ?
a. Medial to incision
b. Lateral to incision
c. First web space of the foot
d. Medial foot
e. Dorsal foot
Answer : b. lateral to incision
The infrapatellar branch of the saphenous nerve often crosses over the anterior aspect of the knee and innervates the skin lateral to the anterior midline of the knee. An anterior midline incision, often result in incision of the terminal branches, resulting in lateral numbness. The superficial peroneal, deep peroneal, and saphenous nerve provide sensation to the foot are not at risk.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 144.
- Which fiber of the anterior cruciate ligament are thight in flexion ?
a. Anteromedial
b. Anterolateral
c. Posteromedial
d. Posterolateral
e. Middle
Answer : a. anteromedial
There are 2 bundles of anterior cruciate ligaments (ACL). The anteromedial bundle and posterolateral. The anteromedial tight in flexion, while in extension both bundle are tensioned.
Reference : AAOS Comprehensive Orthopedic System Review. 2009. P 143
- Which of the following tendons are topically harvested when performing anterior cruciate ligament reconstruction with double loop hamstring autograft?
a. Semitendinosus and semimembranosus
b. Sartorius and semitendinosus
c. Gracilis and semimembranosus
d. Gracilis and semitendinosus
e. Biceps and semimembranosus
Answer : d. Gracilis and semitendinosus
Because of the availability of long tendons and the minimal donor morbidity associated with the gracilis and semitendinosus tendons, they are currently considered the structures of choice for hamstring tendon autograft ACL reconstruction by most authors. The gracilis and semitendinosus are beneath and behind the sartorius (not a hamstring) at the tibial insertion of pes anserinus.
They have long tendon and relatively small muscle bellies of vestigial muscles (in contrasts to the biceps and semimembranosus). With approximately 20 cm of tendon typically available, this allows the double loop technique to provide graft of sufficient strength.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 145.
- What tendon has an intra articular (intrasynovial) location in the knee joint ?
a. Patellar
b. Popliteal
c. Semitendinosus
d. Semimembranosus
e. Biceps femoris
Answer : b. Popliteal
The popliteal tendon arises from the posterior aspect of the tibia and courses through the knee joint through the popliteus hiatus of the lateral meniscus before attaching on the lateral femur, anterior to the lateral collateral ligament. It is the only tendon in knee joint that can be viewed directly on arthroscopy.
Reference: AAOS Comprehensive Orthopedic Review. 2009. Pg 146.
- What is the most anatomic location for placement of the femoral tunnel anterior cruciate ligament reconstruction ?
a. As far superior in the notch as possible
b. As far posterior as possible on the lateral femoral condyle
c. As far posterior as possible on the medial femoral condyle
d. Directly across from the posterior cruciate femoral insertion
e. At resident’s ridge
Answer: b. As far posterior as possible on the lateral femoral condyle
It is critical for graft isometry and knee stability that the femoral tunnel be placed as far as posterior as possible on the lateral femoral condyle. Superiorly, the graft should be at the 1 o’clock position at the left knee. Resident’s ridge is a false posterior shelf that often seems like the extreme posterior cortex. Abnormal tunnel placement result in variety of complication, including an unstable knee, early graft failure, and joint stiffness.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 146.
- What neurovascular structure is most at risk when performing an inside out repair of the posterior horn of the medial meniscus ?
a. Popliteal artery
b. Peroneal nerve
c. Saphenous nerve
d. Tibial nerve
e. Sciatic nerve
Answer: c. Saphenous nerve
The saphenous nerve is located on the postero medial aspect of the knee, and must be protected when performing an inside out repair of the medial meniscus. The peroneal nerve is most at risk with lateral meniscus repairs. The other structures are usually are not at rick during meniscal repairs.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 147.
- A patient with no history of patellar instability sustains a traumatic lateral patellar dislocation. What structure most likely has been torn ?
a. Vastus medialis obliquus
b. Medial patellofemoral ligament
c. Medial patellotibial ligament
d. Medial retinaculum
e. Quadriceps tendon
Answer: b. Medial patellofemoral ligament
Any of the above structures may be involve in a lateral patellar dislocation. However, biomechanic studies have found that the medial patellofemoral ligament is the major soft tissue static restraint of lateral patellar displacement, providing at leqast 50% of this function
Reference: AAOS Comprehensive Orthopedic Review. 2009. Pg 148.
- A 17 year old high scholl long distance runner is seeking advice before running a amarathon for the first time. What advice should be given regarding his fluid, carbohydrate, and electrolyte intake around the time of the race
a. Restrict fluid intake 2 hours before the start of the race to avoid abdominal cramping
b. Drink low osmolality (less than 10% solutions before, during, and after race)
c. Drink fruit juice, such as orange juice, instead of water to replenish essential carbohydrates
d. Drink high osmolality (greater than 10%) solutions before and during the race and low osmolality solutions after the race
e. Avoid the use of glucose polymers because they slow down gastric emptying and may lead to abdominal cramping
Answer: b. Drink low osmolality (less than 10% solutions before, during, and after race)
The goal of fluid replacement should be replace the sweat that has been lost. Sweat is mostly water, with a small concentration of salts and other electrolytes. Absorption is enhanced by solution of low osmolality. Scientific research has also shown that adding carbohydrates to the drink improves athletic performances. Carbohydrates such as glucose and maltodextrins (glucose polymers) stimulate fluid absorption by the intestines. Fructose slow intestinal absorption of fluids. Drinks that are high in fructose, such as orange juice, can lead to gastrointestinal distress and osmotic diarrhea.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 149.
- What artery is the primary blood supply to the humeral head ?
a. Thoracoacromial
b. Posterior humeral circumflex
c. Anterior humeral circumflex
d. Suprascapular
e. Suprahumeral
Answer : c. Anterior humeral circumflex
- The major blood supply is from the anterior and posterior humeral circumflex arteries.
- The arcuate artery is a continuation of the ascending branch of the anterior humeral circumflex. It enters the bicipital groove and supplies most of the humeral head. Small contributions to the humeral head blood supply arise from the posterior humeral circumflex, reaching the humeral head via tendo-osseous anastomoses through the rotator cuff. Fractures of the anatomic neck are uncommon, but they have a poor prognosis because of the precarious vascular supply to the humeral head.
- A 25 year old man has a midshaft femoral fracture with 25% comminution and is undergoing closed intramedullary nailing. Proximal locking is performed uneventfully; however, during distal locking screw insertion, only one of the screws is noted to have bone purchase. Which of the following proceure is the best solution to this problem?
a. Leave only one distal screw; this will provide adequate fixation
b. Exchange the nail for one either longer or shorter, and relock at a new level
c. Insert a screw through the hole either anterior or posterior to the intramedullary nail locking hole
d. Insert a small diameter threaded pin at a different angle through the locking hole
Answer: a. Leave only one distal screw; this will provide adequate fixation
For the majority of femoral diaphyseal fractures above the distal third, one distal locking screw is sufficient. Fractures located in the distal third, will often require the additional of a second locking screw.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 174.
- Which of the following organism is most commonly isolated in acute necrotizing fasciitis?
a. Group A streptoccus
b. Group D streptococcus
c. Pseudomonas aeruginosa
d. Staphylococcus aureus
e. Clostridium difficile
Answer: a. Group A streptoccus
Many cases of acute necrotizing fasciitis involve a synergy of several organisms. The most commonly isolated organism, singly or in combination, is group A streptococcus.
Reference : AAOS Comprehensive Orthoepdic review. 2009. Pg 175.
- What is the main disadvantage of using antibiotic impregnated polymethylmethacrylate beads to threat infected or contaminated wounds ?
a. Local toxicity
b. Systemic toxicity
c. Inadequate antibiotic solution
d. Foreign body reaction
e. Allergic reaction
Answer: d. Foreign body reaction.
Reference :Miller’s Review of Orthopedics. 5th ed. 2008. Elsevier inc.
Antibiotic beads or spacers—PMMA impregnated with antibiotics (usually an aminoglycoside); useful when treating infected TJA or osteomyelitis with bony defects. Antibiotic powder is mixed with cement powder; the antibiotic used is guided by the microorganism, and dosage depends on the selected antibiotic and type of PMMA. Antibiotics that have been used with PMMA for infection are tobramycin, gentamicin, cefazolin and other cephalosporins, oxacillin, cloxacillin, methicillin, lincomycin, clindamycin, colistin, fucidin, neomycin, kanamycin, and ampicillin. Chloramphenicol and tetracycline appear to be inactivated during polymerization. Antibiotics elute from PMMA beads, with an exponential decline over a 2-week period, and cease to be present locally in significant levels by 6-8 weeks. Much higher local tissue concentrations of antibiotic can be achieved than those obtained by systemic administration but do not seem to cause problems in the doses typically used. (Extremely high local concentrations of antibiotics can decrease cellular replication or even result in cell death.) Increased surface area of PMMA (e.g., with oval beads) enhances antibiotic elution. Beads are inserted only after thorough débridement.Because PMMA may cause a foreign body reaction, the beads should always be removed. Antibiotic powder in doses of 2 g/40 g of powdered PMMA (simplex P) does not appreciably affect the compressive strength of PMMA. Much higher concentrations (4-5 g antibiotic powder/40 g PMMA) significantly reduce the compressive strength (important in cemented joint arthroplasties). Antibiotic-impregnated cement spacers help prevent soft tissue contracture after removing an infected TKA.
- Which of the following preoperative findings correlates best with results after operative fixation of the calcaneus ?
a. Displacement of the sustentaculum tali
b. Displacement of the lateral wall
c. Number of major fragments of the posterior facet
d. Diminution of Bohler’s angle
e. Amount of heel varus
Answer: c. Number of major fragments of the posterior facet
Satisfactory result correlate with fewer fragments of posterior facet. Two part fractures has a good outcome, whereas four-part fractures tend to do poorly. Varus and lateral wall displacement that occur postoperatively predict a poor result, but the presence of these findings preoperatively is common and indicate a need for surgery.
Reference: AAOS Comprehensive Orthopedic Review. 2009. Pg 177.
- Ivory osteomata occur most often in the:
a. Skull
b. Spine
c. Humerus
d. Femur
e. Tibia
Answer: a. skull
Introduction and Definition:
Osteoma is a benign bony outgrowth of membranous bones. They are found mostly on skull and facial bones.
Incidence and Demographics:
Large osteomas may develop on the clavicle, pelvis, and tubular bones (parosteal osteomas). Soft tissue osteomas may occur in the head, eye,and tongue,or in the extremities. The highest incidence is in the sixth decade. Some authors report that osteomas occur more often in women than men (3:1). Multiple osteomas are associated with Gardner’s syndrome. The etiology of osteomas is unclear. They may be related to osteoblastomas or may simply be a developmental anomaly. The fact they are often found in the auditory canals of swimmers and divers who frequent cold water suggests that in some cases they are some type of inflammatory reaction.
Symptoms and Presentation:
Osteomas are slow growing lesions that are normally completely asymptomatic. They only present if their location within the head and neck region is causing problems with breathing, vision, or hearing.
X-Ray Appearance and Advanced Imaging Findings:
The radiological appearance of osteomas depends on their location. Central osteomas are well delineated sclerotic lesions with smooth borders, without surface irregularities or satellite lesions. Dr. Enneking describes the lesion as having the appearance of “one-half of a billiard ball” attached to the underlying bone. The adjacent cortex is not involved or weakened. Peripheral osteomas are radiopaque lesions with expansive borders that may be sessile or pedunculated. Osteomas need to be differentiated from enostosis which also appear as densely sclerotic well-defined lesions on x-ray. Bone scan will show increased uptake during the active phase of growth, which will diminish to background levels as the lesion becomes progressively less active.
Histopathology findings:
There are two types of osteomas microscopically. Compact or “ivory” osteomas are made of mature lamellar bone. They have no Haversian canals and no fibrous component. Trabecular osteomas are composed of cancellous trabecular bone with marrow surrounded by a cortical bone margin. Trabecular osteomas can be found centrally (endosteal) or peripherally (subperiosteal).
Treatment options for this tumor:
Treatment of osteomas is only necessary if they are symptomatic. Large osteomas should be evaluated to rule out other diagnoses.
Suggested Reading and Reference:
Bulloughs, Peter, Orthopaedic Pathologv (third edition), Times Mirror International Publishers Limited, London, 1997. Huvos, Andrew, Bone Tumors: Diagnosis, Treatment and Prognosis, W.B.Saunders, Co., 1991. Some text adapted from Dr. Enneking’s site.
- Which one of the following statements is untrue concerning chondrosarcoma:
a. Occurs most often between the ages 20 and 60 yrs
b. Is always a primary malignant tumor of bone
c. Most commonly affects scapula, pelvis, ribs & sternum
d. Causes bone expansion and destruction with irregular opacities in the X-ray
e. Is radioresistant
Answer: b. Is always a primary malignant tumor of bone
CHONDROSARCOMA
• Primary malignant tumour whose cells produce cartilage matrix
• May arise de novo or secondarily to existing benign cartilaginous tumour (majority)
Incidence
• 17% of primary malignant bone tumours
• Peak incidence 30-60 yrs
• M:F 2:1
• Sites
• Pelvis 30%
• Femur 20%
• Femoral head 10%
• Ribs 10%
Clinical
• Most common malignant tumour of hands & face in middle aged patients
• Usually occurs in metaphysis or diaphysis
• Presents with constant ache or increased size of pre-existing lump
• Metastatic deposits infrequent & usually go to lung
X-rays
• Variable appearance with 60-70% have calcification & 50% have subperiosteal new bone
• May be a large cystic lesion with cortical destruction & central calcification, endosteal scalloping & cortical expansion. Popcorn lesions (rings, arcs, stipples)
Chondrosarcoma can also be classified as
Intramedullary, which generally arise from enchondroma
• Patients with Ollier’s disease (multiple enchondromatosis) or Maffucci’s syndrome (multiple enchondromas & hemangiomas) are at much higher risk of chondrosarcoma than normal population
Surface, which arise from osteochondroma
• Malignant change in osteochondroma: increased size, fuzzy outline, cartilage cap >1 cm thick, base >6 cm diameter
Pathology
Cellular pleomorphism & increased cellularity with focally calcified matrix X-ray & CT of a chondrosarcoma involving the right hemipelvis & sacrum.
Treatment
- These tumours tend to metastasise late therefore attempt wide local excision initially
- However, relatively resistant to chemotherapy & radiotherapy
- Chemotherapy for occasional grade 3 dedifferentiated tumors
- Radiotherapy useful for Rx of surgically inaccessible sites
Prognosis
Dependant on grade
- >90% grade 1 or 2
- Low grade - 65-85% 5-yr survival
- High grade - 15-25% 5-yr survival
- The following statements about bone sarcoma are true except that it:
a. Arises from osteoblasts of the periosteum or bone cortex
b. Forms a fusiform mass ensheathing the bone
c. Often invades the epiphyseal cartilage and neighbouring joint
d. Produces characteristic new bone formation in the X-ray
e. Disseminates rapidly by the blood stream
Answer: a. Arises from osteoblasts of the periosteum or bone cortex
Sarcomas—These are malignant neoplasms of connective tissue (mesenchymal) origin. Sarcomas generally exhibit rapid growth in a centripetal fashion and invade adjacent normal tissues. Each year in the United States there are about 2800 new bone sarcomas. High-grade, malignant bone tumors tend to destroy the overlying cortex and spread into the soft tissues. Low-grade tumors are generally contained within the cortex or the surrounding periosteal rim. Bone sarcomas metastasize primarily via the hematogenous route, with the lungs being the most common site.
Refrerence : Miller’e Review of Orthopedics. 5th ed. 2008 Ch 9.
- Which of the following is most common in the small bones of the hands and feet:
a. Osteochondroma
b. Enchondroma
c. Osteoid osteoma
d. Osteochondritis juvinelis
e. Tuberculous osteitis
Answer: b. Enchondroma
Enchondroma—The most common benign bone tumor of the upper extremity. It typically occurs in the second to fourth decades, and most cases are asymptomatic and discovered incidentally. The tumor arises from the metaphyseal medullary canal and spreads to the diaphysis. It is usually seen in the proximal phalanx and metacarpal. Enchondroma causes symmetrical fusiform expansion of bone, with endosteal scalloping and intramedullary calcifications. It may present as a pathologic fracture. Histologically, enchondroma of the hand is characterized by benign cartilage of high cellularity. If mitotic figures are present, low-grade chondrosarcoma should be suspected. The recommended treatment is with curettage and bone grafting. Excision, intramedullary internal fixation, and bone cementing have also been successful in a small series.
Reference : Miller’s Review of Orthopedic. 5th ed. 2008. Ch 7.
First treatment priority in patient with multiple injuries is:
a. Airway maintenance
b. Bleeding control
c. Circulatory volume restoration
d. Splinting of fractures
e. Reduction of dislocation.
Answer: a. Airway maintenance
A.B.C. (Airway, bleeding and circulation) are the priorities in management of seriously injured patient in that order
A patient who has sustained open wound on leg is bleeding profusely. Before patient arrives in hospital the safest method to stop bleeding is:
a. Elevation of leg
b. Local pressure on wound and elevation of leg
c. Ligation of bleeding vessel
d. Use of tourniquet
e. Pressure over femoral artery in groin.
Answer: b. Local pressure on wound and elevation of leg
Local pressure on wound and elevation of leg is the safest and most effective method to stop bleeding. Tourniquet can be dangerous if not properly used. Elevation alone and local pressure on femoral artery is ineffective.
Commonest cause of deformity in a long bone is:
a. Osteoporosis
b. Rickets
c. Paget’s disease
d. Malunited fracture
e. Fibrous dysplasia.
Answer: d. Malunited fracture
Malunited fractures are the commonest cause of deformity in long bones since the incidence of fracture is much higher than congenital, developmental, metabolic, infective and neoplastic conditions.
What is the second most important aspect in the treatment of fractures of long bones:
a. Adequate nutrition of patient
b. Accurate anatomical reduction
c. Immobilization
d. Restoration of bone alignment
e. Antibiotics.
Answer: c. Immobilization
First and foremost requisite to ensure healing of long bone fractures to restore function is the reduction of bone fragments into good alignment so that malunion does not occur. Accurate anatomical reduction is not necessary. Second important aspect is immobilization of the fracture.
Which of the following is an absolute contraindicatiou of open reduction:
a. Active infection
b. Small sized fragment
c. Very soft bone
d. General medical complications
e. Severe scarring of adjacent soft tissues.
Answer: a. Active infection
Active infection is a contraindication for open reduction as this may lead to further complications and even more difficulty in salvage. In other conditions mentioned open reduction can produce problem and should not be lightly undertaken.
Commonest cause of failure of internal fixation is:
a. Infection
b. Corrosion
c. Metal reaction
d. Immune deficient patient
e. Stress fracture of implant.
Answer: a. Infection
Most common and serious disadvantage of open reduction and internal fixation is infection which will ultimately lead to implant becoming loose and non union. Immune deficient patient does not behave differently as regards fracture healing. Corrosion, metal reaction and stress fracture of implant are rare.
Which of the following fracture does not usually need open reduction and internal fixation:
a. Mid shaft fracture of femur
b. Pathological fractures
c. Trochanteric fracture in elderly
d. Displaced intra articular fractures
e. Displaced fracture of both bones of forearm in adults.
Answer: a. Mid shaft fracture of femur
Out of the fractures mentioned, femoral shaft fracture is least likely to need operative treatment. In this fracture operation is done to get patient out of traction early. All other fractures mentioned will almost always need open reduction and internal fixation
8 Which of the following is the best way to preserve amputated part for replantation:
a. Immersion in cold saline
b. Immersion in cold ringer lactate
c. Immersion in cold antibiotic solution
d. Dry cooling with ice
e. Deep freezing.
Answer: d. Dry cooling with ice
Dry cooling with ice is the best way to preserve amputated part as this causes least alteration of tissue structures
Death 3 days after pelvic fracture is most likely to he due to:
a. Haemorrhage
b. Pulmonary embolism
c. Fat embolism
d. Respiratory distress
e. Infection.
Answer: c. Fat embolism
Within first few hours after severe injuries death may occur due to hypovolaemia from haemorrhage and within 3 days from fat embolism. Pulmonary embolism usually occurs at about 3 weeks from injury. Respiratory distress is a part of fat embolism syndrome.
Myositis ossificans is most commonly seen at:
a. Hip
b. Knee
c. Shoulder
d. Elbow
e. Ankle
Answer: d. elbow
Myositis ossificans can occur at any place following injury, vigorous massage or operative intervention, but is most common around the elbow joint
Hyperbaric Oxygen is not used for which of following conditions in usual clinical practice:
a. Gas gangrene
b. Carbon monoxide poisoning
c. Arterial gas embolism
d. Decompression sickness
e. Chronic osteomyelitis
Answer: e. Chronic osteomyelitis
Hyperbaric Oxygen is not generally used in chronic osteomyelitis, although in experimental situations it has been shown to be effective by enhancing action of phagocytes, potentiating immune response and promoting both bone and soft tissue healing. HBO therapy allows patients to breathe 100% oxygen in a chamber under conditions of increased barometric pressure. It was first used in the late 1800s to treat caisson workers injured with decompression sickness (the “bends”) during construction of the Hudson River tunnel in NewYork. Subsequently the military used it to treat the bends and air gas emboli. Beginning in the 1960s, animal experimentation and clinical case reports indicated applications for HBO therapy in the management of both severe anemia and gas gangrene. Most clinical hyperbaric medicine is practiced at 2 to 3 ATA—that is, 1 or 2 atmospheres greater than ambient pressure. Each atmosphere is considered to be 760mmHg; thus, a patient receiving 100% oxygen at 3 ATA is exposed to a pO2 of 2,280mmHg (ie, 3 × 760mmHg).
Indication :
Air or gas embolism
Carbon monoxide poisoning
Clostridial myositis and myonecrosis (gas gangrene)
Crush injury, compartment syndrome, or acute traumatic peripheral ischemia
Decompression sickness
Enhancement of healing in select problem wounds
Exceptional blood loss anemia
Intracranial abscess
Necrotizing soft-tissue infections
Osteomyelitis (refractory)
Delayed radiation injury (soft-tissue and bony necrosis)
Skin flaps and grafts (compromised)
Thermal burns
Reference : Greensmith JE. Perspectives in Modern Orthopedic: Hyperbaric Oxygen Therapy in Extremity Trauma. J Am Acad Orthop Surg 2004;12:376-384
Which of the following fracture is slowest to heal and often develops non union:
a. Intracapsular femoral neck fracture
b. Scaphoid
c. Lower third of tibia
d. Proximal humerus
e. Distal femur.
Answer: a. Intracapsular femoral neck fracture
Intracapsular femoral neck fractures are slowest to heal and develop non union in higher percentage of cases compared to scaphoid and distal tibial fractures, both of which also tend to heal slowly due to deficient blood supply of one fragment. Proximal humerus and distal femoral fractures do not usually go to delayed union.
Which of the following is commonest cause of deformity in long bones:
a. Bone dysplasias
b. Metabolic disorders
c. Bone tumours
d. Infections
e. Malunited fracture.
Answer: e. malunited fracture
While all the conditions produce deformity of bone malunited fracture is statistically most important cause of bony deformity.
15 Which of the following is most common cause of Volkmann’s ischaemic contracture:
a. Fracture of humeral shaft
b. Dislocation of elbow
c. Supracondylar fracture of humerus
d. Brachial artery injury
e. Tight bandage and plaster
Answer: e. Tight bandage and plaster
Commonest cause of Volkmann’s contracture is injudiciously applied tight plaster and bandages following injury, which result in compromise of circulation. This is followed in frequency by supracondylar fracture of humerus, dislocation of elbow and brachial artery injury. Fracture of humeral shaft does not usually produce this complication
16 Development of gas gangrene can be prevented by:
a. Prophylactic immunization
b. Administration of intravenous antibiotics
c. Proper debridement of wound
d. Administration of hyperbaric oxygen
e. Amputation.
Answer: c. Proper debridement of wound
The only prophylaxis against development of gas gangrene is early and thorough debridment of open wounds, and wound should be left open. A wound left open after adequate debridment rarely develops gas gangrene. Immunization is of no value and all other methods of treatment are used when gas gangrene is developing or has developed.
17 Commonest cause of failure of internal fixation of fracture is:
a. Infection
b. Fatigue fracture of implant
c. Corrosion in implant
d. Loosening of implant
e. Metal reaction.
Answer: a. infection
Infection following an open operation is the commonest cause of failure following internal fixation. All other factors can also lead to complications but. statistically they are not as important
Most serious disadvantage of open reduction of fracture is:
a. Delayed union
b. Non union
c. Infection
d. Joint stiffness
e. Cosmetic deformity.
Answer: c. Infection
Introduction of infection in a closed fracture is most serious disadvantage of open reduction. Badly placed incisions produce cosmetic deformity. Excessive and injudicious stripping of soft tissues during operation can impair vascularity of bone and lead to delayed or non union. Scarring of muscles can lead to joint stiffness
19 Which is commonest occasion in orthopaedic practice for use of bone grafts:
a. Fresh fractures
b. Non union
c. For arthrodesis
d. To bridge bone gap
e. To fill cavities after curettage of tumours.
Answer: b. Non union
Statistically non union is the commonest indication for use of bone grafts.
20 Chemically Plaster of Paris is:
a. Calcium carbonate
b. Calcium phosphate
c. Calcium sulphate
d. Anhydrous calcium sulphate
e. Hemihydrated calcium sulphate.
Answer: e. Hemihydrated calcium sulphate.
Powder of plaster of Paris chemically is hemihydrated calcium sulphate : CaSO4. ½ H2O
21 Most often open reduction of fracture is required in:
a. Closed fracture with nerve injury
b. Compound fracture
c. Fracture in children
d. Unsatisfactory closed reduction
e. Non union.
Answer: d. Unsatisfactory closed reduction
Unsatisfactory closed reduction is the commonest reason for performing open reduction. Next commonest reason for this is non union. Fractures in children rarely require open reduction. Compound fractures and fractures associated with nerve injury are also uncommon reasons
22 In internal fixation of fracture, compression plating gives following advantages:
a. Easier reduction as the exposure is longer
b. It is simpler to use
c. Provides more rigid fixation
d. Induces osteogensis
e. Increases vascular proliferation.
Answer: c. Provides more rigid fixation
Only advantage of a compression plate fixation is more rigid fixation of fracture. Compression plating is neither simpler nor easier. Plate fixation has no influence on vascular proliferation or rate of osteogensis
23 What is fracture disease:
a. Non union
b. Infection
c. Joint stiffness
d. Vascular damage
e. Neurological damage.
Answer: c. Joint stiffness
Joint stiffness and contractures along with poor muscle tone leading to functional impairment even after the fracture has united is termed fracture disease. This can be avoided by continuing physiotherapy while fracture is uniting.
Concerning intra articular fractures at knee which of the following statement is true:
a. Early knee mobilization is inadvisable
b. Intercondylar fracture of femur quite often leads to avascular necrosis
c. Non union of tibial condyle fracture is common
d. Extraarticular adhesions play no role in producing joint stiffness
e. Displaced intra articular fractures usually need open reduction
Answer: e. Displaced intra articular fractures usually need open reduction
Joint congruity should be restored by accurate reduction of displaced intraarticular fractures, and early movements thereafter is the best course to regain joint mobility. Tibial and femoral condyle fractures occur in area of abundant cancellous bone where non union is extremely rare, and so is the incidence of avascular necrosis.
25 Which of the following is not an absolute indication of open reduction:
a. Non union
b. Displaced intra articular fractures
c. Fractures irreducible by manipulation
d. Fractures associated with vascular injury
e. Early mobilization.
Answer: e. Early mobilization
Absolute indication :
- Non union
- Displaced intraarticular fractures
- Fractures inreducible by manipulation
- Fractures associated with vascular injury
Relative indication :
- Early mobilization
- Improve nursing care in multiple injury patient
- Tto reduce morbidity from prolonged immobilization
- Delayed union
26 A bone graft from same species and of identical histocompatibility of antigens is called
a. Homograft
b. Heterograft
c. Allograft
d. Isograft
e. Autograft
Answer: d. Isograft
When donor and receipient are same individual, graft is called autograft. When donor and receipient are of same species but not having compatible antigens, graft is called homograft. In same species between donor and receipient but not have identical histocompatibility of antigens, graft is called allograft. In same species when donor and receipient have histocompatibility of antigens graft is called isograft.
27 What is the commonest cause of non union:
a. Pathological fracture
b. Inadequate immobilization
c. Soft tissue interposition
d. Infection
e. Distraction at fracture site.
Answer: b. Inadequate immobilization
Commonest cause of non union is inadequate, immobilization as repeated movements retard or even stop the process of fracture healing. All other factors mentioned also lead to non union but statistically their incidence is not so much.
28 A prototype of external fixator was first devised by:
a. Charnley
b. Anderson
c. Hoffman
d. Muller
e. Malgaigne
Answer: e. Malgaigne
In 1853 Malgaigne devised a claw like device to compress fragments of fractured patella. Charnley and Anderson used the fixator for limited indications and laid down scientific principles. Hoffman and Muller are credited with making it versatile and popularizing this method
29 In few days old fracture which of the following does not occur:
a. Capillary proliferation
b. Proliferation of osteogenic cells over endosteum and bone ends
c. Local pH is acid
d. Local pH is alkaline
e. There is very little rise in level of alkaline phosphatase at fracture site.
Answer: d. Local pH is alkaline
Upto a week after fracture local pH remains acidic and only after this period pH becomes alkaline and level of alkaline phosphatase markedly rises. All other statements are true.
30 Modified Phemister bone grafting technique is:
a. Extraperiosteal placement of bone grafts
b. Subperiosteal placement of bone grafts
c. Intramedullary placement of bone grafts
d. Placing the grafts under osteo periosteal flap
e. Patelling and placement of cancellous bone grafts under osteo¬periosteal flap.
Answer: e. Patelling and placement of cancellous bone grafts under osteo¬periosteal flap.
Modified Phemister bone grafting includes both patelling of bone ends and placement of cancellous grafts under osteoperiosteal flap. Periosteum is not elevated separtely and neither is the central area of non union disturbed. Original Phemister technique was to place the grafts under periosteal flap only
31 Last stage in fracture healing is
a. Organisation of blood clot
b. Vascular proliferation
c. Osteoblastic proliferation
d. Provisional calcification
e. Remodelling of Haversian system.
Answer: e. Remodelling of Haversian system
Remodelling of Haversian system is the last stage in fracture healing and it orientates bone formation along lines of normal stress. The process takes many months for completion.
32 Fracture disease can he prevented by:
a. Plaster immobilization of fracture
b. Cast brace treatment of fracture
c. Internal fixation of fracture
d. External fixation of fracture
e. Physiotherapy
Answer: e. Physiotherapy
Fracture disease in some measure always occurs and none of the methods of treatment of fracture can prevent it. It can only be minimised by regular physiotherapy to reduce oedema, improve muscle tone and maintain functional movements in joints which have not been immobilized.
33 In a healing fracture amount of cartilage formation is increased by:
a. Rigid immobilization
b. Movement at fracture site
c. Necrosis of bone ends
d. Compression plating
e. Infection.
Answer: b. Movement at fracture site
More the movement at fracture site, more will be cartilage formation and non union can occur. Compression plating helps in conversion of cartilage into bone and thereby fracture healing can occur in a delayed or non union. Infection retards all the stages of fracture repair.
34 Cast syndrome is commonest after:
a. Scoliosis surgery
b. Hip surgery
c. Spinal jacket application
d. Hip spica application
e. Halo traction
Answer: a. scoliosis surgery
More than 50% cases of cast syndrome occur in scoliosis and spinal deformity correction, and majority of others occur in patients being treated for trauma to spine and hip. It is also seen after application of body jacket, shoulder and hip spica, the common denominator being extensive coverage of abdomen and chest.
35 In cases of leg fractures, above knee plaster is applied, with knee slightly flexed for which of the following reason:
a. To avoid stretching posterior capsule of knee joint
b. To keep the cruciate ligaments relaxed
c. To allow easier ambulation
d. To prevent rotational movements being transmitted to the fracture site
e. Plaster application is easier with knee slightly flexed.
Answer: d. To prevent rotational movements being transmitted to the fracture site
In Complete extension knee locks and femur and tibia rotate as one, transmitting rotational stress to fracture site which will delay union. Therefore, knee is kept slightly flexed so that femoral rotation at hip can occur without movement being transmitted to proximal fragment of leg fracture.
36 Which deformity in malunited fracture is most likely to correct with remodelling:
a. Angular deformity in the middle of diaphysis in the plane of motion of nearby joint
b. Angular deformity in plane of motion of nearby joint when deformity is in metaphyseal area
c. Rotational malalignment
d. Angular deformity near end of bone when angulation is in a plane 900 to the plane of motion of nearby joint.
e. Shortening of bone length.
Answer: b. Angular deformity in plane of motion of nearby joint when deformity is in metaphyseal area
Angular deformity in the plane of motion of nearby joint has maximum potential for remodelling. Remodelling is still better if deformity is near the end of bone. The process is rapid in growing children and slows down as the adulthood is reached. Rotational malalignment never corrects. Shortening of bone length, will to some extent correct in a growing child since the fracture induces little overgrowth in a long bone.
37 In interfragmentary fixation screw works by producing:
a. Compression
b. Distraction
c. Antiglide mechanism
d. Increased shear
e. None of above.
Answer: a. Compression
Screw works by converting torsional stress (used during its insertion) into compressive force and this keeps fracture surfaces in close apposition. This is the basic mechanism on which screw works
39 What is most important aspect of the treatment of crush syndrome involving an extremity:
a. Amputation
b. Fluid and electrolyte balance
c. Dialysis
d. Antibiotics
e. Hyberbaric oxygen
Answer: b. amputation
Amputation proximal to the level of injury is the most important aspect of treatment. At the same time maintenance of fluid balance is also important. Dialysis may be required. Antibiotics really are of prophylactic value. Hyperbaric oxygen has no role.
40 Claw hand deformity of hand in Volkmann’s ischaemic contracture is due to involvement of.
a. Skin
b. Fascia
c. Nerves
d. Muscles
e. Tendons
Answer: d. Muscles
Volkmann’s ischaemia affects muscles and it is their fibrosis area contracture which produces the deformity of fingers.
41 Which of the following is the earliest laboratory finding in a case of fat embolism:
a. Increased serum cholestrol
b. Increased serum lipase
c. Increased serum fatty acids
d. Lipouria
e. Increased alkaline phosphatase.
Answer: d. Lipouria
Presence of fat droplet in urine is the earliest laboratory finding in fat embolism. But it must be remembered that the diagnosis is mainly clinical and one should not wait for any investigations before instituting treatment
42 Basic treatment of most non unions is:
a. Compression plating
b. Continuation of external splintage
c. Electrical stimulation
d. Bone grafting
e. Phemister grafting.
Answer: d. Bone grafting
In an established non union freshening of bone ends and bone grafting is the usual treatment. Electrical stimulation and compression plating is indicated in certain limited cases only. Phernister grafting is one method of bone grafting in cases where bone fragments are in good alignment
43 External fixator is not indicated in:
a. Comminuted fracture
b. Fracture associated with severe soft tissue damage
c. Infected fractures
d. Simple closed fracture of humeral shaft
e. Fracture associated with bums.
Answer: d. Simple closed fracture of humeral shaft
Use of external fixator is contraindicated in an uncomplicated fracture. It is an indispensable method of treatment of fracture in association with infection, burn and severe soft tissue damage requiring repeated dressing and skin grafting. External fixator is also used extensively for purpose of limb lengthening.
44 What is pathogenesis of cast syndrome:
a. Recumbancy
b. Psychological
c. Constriction of stomach
d. Intestinal obstruction
e. Obstruction of duodenum
Answer: e. Obstruction of duodenum
Cast syndrome, clinically known as superior mesenteric artery syndrome (SMAS), is gastric dilatation with partial or complete obstruction of the duodenum. Although rare, it is most frequently seen in orthopaedic patients who have had spinal surgery or who are in hip spica or body casts. Obstruction occurs when there is compression of the duodenum between the superior mesenteric artery anteriorly and the aorta and spinal column posteriorly. Obstruction can occur within days of surgery or casting or may not develop for several weeks. Treatment for SMAS varies from conservative nonoperative to operative procedures. Complications can be severe if symptoms are not quickly recognized and treatment instituted in a timely manner
Reference : Sprague J. Cast Syndrome: Superior Mesenteric Artery Syndrome. Orthop Nurs. 1998 Jul-Aug;17(4):12-5; quiz 16-7.
45 Which of the following is not seen in a case of fat embolism:
a. Fat globules in urine
b. Left heart strain on ECG
c. Snow storm appearance on chest X Ray
d. Normal carbon dioxide tension in arterial blood
e. Low oxygen tension in arterial blood.
Answer: b. Left heart strain on ECG
ECG will show right heart strain and not the left heart strain.
46 What can happen if drill hole has been made too small while inserting Sherman bone screw:
a. Non rigid fixation
b. Very rigid fixation
c. Fragmentation of bone while inserting the screw
d. Screw will pull out easily later on
e. Screw can never be removed.
Answer: c. Fragmentation of bone while inserting the screw
If drill hole is too small either it will be impossible to insert the screw or bone can fragment while it is being inserted. If the drill hole is too large screw threads will have insecure purchase in bone
47 Closed reduction with percutaneous K wire fixation is best suitable for:
a. Bennett fracture
b. Lateral malleolus fracture
c. Media] malleolus fracture
d. Lateral tibial condyle fracture
e. Clavicle fracture
Answer: a. Bennet fracture
Closed reduction followed by percutaneous K wire fixation is useful in unstable fractures like Bennett’s, comminuted Colles and unstable supracondylar humeral fracture in child. All these are situations where internal fixation is required for a relatively short time
48 Who first defined and applied tension band principle in fixation of fractures and non unions:
a. Pauwels
b. Muller
c. Allgower
d. Watson Jones
e. Girdlestone
Answer: a. Pauwels
This engineering principle of converting tensile force into compressive force in an eccentrically loaded bone was first defined and used by Pauwels. It has been popularized by the work of A.0. group notably Muller and Allgower
49 Dual plate applied for fixation of diaphyseal fracture will have strongest fixation when:
a. Both plates are superimposed on each other and applied on one side only.
b. Each plate is applied on opposite side on bone
c. Plates are applied at 900 to each other
d. Plates are applied at 300 to each other
e. Combination of two plates is always weaker than a single plate.
Answer: c. Plates are applied at 90 degrees to each other
When plates are applied at 901 to each other fixation is strongest. It is less rigid when plates are on opposite sides of bone. Double plating is more rigid than single plate but to apply two plates soft tissue and periosteal stripping has to be much more extensive
51 Which of the following is not the treatment of cast syndrome:
a. Nasogastric suction
b. Intravenous fluid
c. Removal of plaster
d. Laparotomy
e. Antiemetic drugs
Answer: e. Antiemetic drugs
Antiemetic drugs have no role. Most of the time conservative treatment by nasogastric suction and IN. drip succeeds after plaster has been removed. In rare cases not responding to conservative measures surgery is required to relieve or by pass the obstraction in duodenum.
52 Which of the following is not seen in fat embolism:
a. Altered mental state
b. Petechial haemorrhages
c. Bradycardia
d. Hypotension
e. Tachypnea.
Answer: c. Bradycardia
Tachycardia occurs in fat embolism along with other clinical features mentioned.
53 Which of the following is commonest material used to make orthopaedic implant:
a. Titanium
b. Stainless steel
c. Polyethylene (UHMWPE)
d. Methyl methacrylate
e. Carbon.
Answer: b. stainless steel
Most implants are made of stainless steel as it is comparatively cheap and can be easily cast into desired shape. Titanium is expensive and difficult to fashion into desired shape. Carbon and polyethylene implants are used only for some specific uses and methylmethacrylate is not made up into an implant as such.
Orthopaedic implants are typically made of 316L (L = low carbon) stainless steel (iron, chromium, and nickel), “supermetal” alloys (e.g., Co-Cr-molybdenum (Mo) [65% Co, 35% Cr, 5% Mo] made with a special forging process), and titanium alloy (Ti-6Al-4V)
54 Bone graft works by providing following mechanism: Which of these is most important.
a. Bone induction factor
b. Osteogenic cells
c. Living osteoblasts
d. Mineral scaffold for vascular proliferation
e. Bridging the bone gap.
Answer: d. Mineral scaffold for vascular proliferation
Provision of mineral scaffold into which newly forming vascular channels can grow is the most useful function of bone graft and that is why bank bone, heterogenous bone and homografts succeed. Bone inducing factor, osteogenic cells and living osteoblasts are supplied only by fresh autogenous grafts.
56 What is chief disadvantage of pulsed electromagnetic induction of bone union:
a. Difficult coil placement
b. Danger of infection
c. Can not be used in the presence of infection
d. Equipment is not portable
e. High cost.
Answer: d. Equipment is not portable
Main disadvantage is that equipment is not portable. This method can be used even in the presence of active infection since it is totally non invasive
57 What has been the maximum reported overall success rate when non union is treated by electrical stimulation:
a. 5%
b. 25%
c. 50%
d. 80%
e. 100%.
Answer: d. 80%
Maximum overall success rate in treatment of non union with electrical stimulation has been 80 85%
58 The use of axial compression in promoting union of cancellous bone fractures was originally described by:
a. Key
b. Charnley
c. Eggers
d. Danis
e. Muller.
Answer: a. Key
This was originally described by Key and later popularized and put to practical use by Charnley. Eggers, Danis and Muller have late also worked on this principle to devise internal fixation appliances
59 Commonest cause of refracture after removal of external fixator is:
a. Pin tract infection
b. Fracture through pin tract
c. Absence of periosteal callus
d. Destressing producing cancellization of cortex
e. Avascular necrosis of bone fragments.
Answer: d. Destressing producing cancellization of cortex
Removal of stress from bone by a rigid fixator produce osteoporosis and this is commonest cause of refracture. This car be prevented by staged removal of pin and fixator or giving additional external support after removal of fixator. Pin tract infection and fracture through pin tract will create a new additiona fracture and not refracture.
61 Which is commonest complication when femoral shaft fracture is treated in cast brace:
a. Varus angulation of fracture
b. Valgus angulation of fracture
c. Shortening
d. Delayed union
e. Neuro vascular impairment.
Answer: a. Varus angulation of fracture
Varus angulation is the commonest complication, even when a preliminary period of traction has been used. When brace has been put on without a sufficiently long period in traction rotational deformity and shortening can also occur.
60 Idea of dynamic compression plate was first used by:
a. Muller
b. Danis
c. Hicks
d. Egger
e. Sherman
Answer: b. Danis
Danis of Belgium was first to make use of a plate that actively compressed the fracture. In this a bolt was used to apply pressure against the end screw in plate. Modern dynamic compression plate utilizing the principle of gliding of screw head was made by Muller and co workers in A.0. group.
61 Which is commonest complication when femoral shaft fracture is treated in cast brace:
a. Varus angulation of fracture
b. Valgus angulation of fracture
c. Shortening
d. Delayed union
e. Neuro vascular impairment.
Answer: a. Varus angulation of fracture
Varus angulation is the commonest complication, even when a preliminary period of traction has been used. When brace has been put on without a sufficiently long period in traction rotational deformity and shortening can also occur.
62 Universal A.0. air drill used in orthopaedics normally consumes air at the rate of.
a. 50 litres per minute
b. 100 litres per minute
c. 200 litres per minute
d. 300 litres per minute
e. 400 litres per minute.
Answer: d. 300 litres per minute
For every minute of running time the universal A.O. air drill requires about 300 litres of air at pressure of 6 bar (90 psi). Oscilating bone saw uses same amount of air and pressure.
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63 Cobalt‑Chromium alloy used to make orthopaedic implants has iron content of.
a. Less than 5%
b. 5‑10%
c. 11‑20%
d. 21‑30%
e. 31‑40%.
Answer: a. Less than 5%
Maximum permissible iron content of cobalt chromium alloys is 3%. In most commercial preparations it is kept as low as 0.75%.
64 In an oblique fracture, screw fixation is most effective when screw is placed with:
a. Axis of screw at 900 to long axis of bone
b. Axis of screw at 900 to fracture surface
c. Axis of screw at equal angle to long axis of bone and fracture plane
d. Screw placed in any axis
e. Axis of screw at 450 to the fracture plane.
Answer: b. Axis of screw at 900 to fracture surface
As far as possible screw should be inserted at right angles to fracture line, but sometimes the direction may be dictated by local circumstances at fracture site. It is also preferable to use at least two screws with their long axes at an angle to one another.
- A patient with no history of patellar instability sustains a traumatic lateral patellar dislocation. What structure most likely has been torn ?
a. Vastus medialis obliquus
b. Medial patellofemoral ligament
c. Medial patellotibial ligament
d. Medial retinaculum
e. Quadriceps tendon
Answer: b. Medial patellofemoral ligament
Any of the above structures may be involve in a lateral patellar dislocation. However, biomechanic studies have found that the medial patellofemoral ligament is the major soft tissue static restraint of lateral patellar displacement, providing at least 50% of this function
Reference: AAOS Comprehensive Orthopedic Review. 2009. Pg 148.
- What neurovascular structure is most at risk when performing an inside out repair of the posterior horn of the medial meniscus ?
a. Popliteal artery
b. Peroneal nerve
c. Saphenous nerve
d. Tibial nerve
e. Sciatic nerve
Answer: c. Saphenous nerve
The saphenous nerve is located on the postero medial aspect of the knee, and must be protected when performing an inside out repair of the medial meniscus. The peroneal nerve is most at risk with lateral meniscus repairs. The other structures are usually are not at rick during meniscal repairs.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 147.
- What is the most anatomic location for placement of the femoral tunnel anterior cruciate ligament reconstruction ?
a. As far superior in the notch as possible
b. As far posterior as possible on the lateral femoral condyle
c. As far posterior as possible on the medial femoral condyle
d. Directly across from the posterior cruciate femoral insertion
e. At resident’s ridge
Answer: b. As far posterior as possible on the lateral femoral condyle
It is critical for graft isometry and knee stability that the femoral tunnel be placed as far as posterior as possible on the lateral femoral condyle. Superiorly, the graft should be at the 1 o’clock position at the left knee. Resident’s ridge is a false posterior shelf that often seems like the extreme posterior cortex. Abnormal tunnel placement result in variety of complication, including an unstable knee, early graft failure, and joint stiffness.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 146.
- What tendon has an intra articular (intrasynovial) location in the knee joint ?
a. Patellar
b. Popliteal
c. Semitendinosus
d. Semimembranosus
e. Biceps femoris
Answer : b. Popliteal
The popliteal tendon arises from the posterior aspect of the tibia and courses through the knee joint through the popliteus hiatus of the lateral meniscus before attaching on the lateral femur, anterior to the lateral collateral ligament. It is the only tendon in knee joint that can be viewed directly on arthroscopy.
Reference: AAOS Comprehensive Orthopedic Review. 2009. Pg 146.
- Which of the following tendons are topically harvested when performing anterior cruciate ligament reconstruction with double loop hamstring autograft?
a. Semitendinosus and semimembranosus
b. Sartorius and semitendinosus
c. Gracilis and semimembranosus
d. Gracilis and semitendinosus
e. Biceps and semimembranosus
Answer : d. Gracilis and semitendinosus
Because of the availability of long tendons and the minimal donor morbidity associated with the gracilis and semitendinosus tendons, they are currently considered the structures of choice for hamstring tendon autograft ACL reconstruction by most authors. The gracilis and semitendinosus are beneath and behind the sartorius (not a hamstring) at the tibial insertion of pes anserinus.
They have long tendon and relatively small muscle bellies of vestigial muscles (in contrasts to the biceps and semimembranosus). With approximately 20 cm of tendon typically available, this allows the double loop technique to provide graft of sufficient strength.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 145.
- A 17 year old high scholl long distance runner is seeking advice before running a amarathon for the first time. What advice should be given regarding his fluid, carbohydrate, and electrolyte intake around the time of the race?
a. Restrict fluid intake 2 hours before the start of the race to avoid abdominal cramping
b. Drink low osmolality (less than 10% solutions before, during, and after race)
c. Drink fruit juice, such as orange juice, instead of water to replenish essential carbohydrates
d. Drink high osmolality (greater than 10%) solutions before and during the race and low osmolality solutions after the race
e. Avoid the use of glucose polymers because they slow down gastric emptying and may lead to abdominal cramping
Answer: b. Drink low osmolality (less than 10% solutions before, during, and after race)
The goal of fluid replacement should be replace the sweat that has been lost. Sweat is mostly water, with a small concentration of salts and other electrolytes. Absorption is enhanced by solution of low osmolality. Scientific research has also shown that adding carbohydrates to the drink improves athletic performances. Carbohydrates such as glucose and maltodextrins (glucose polymers) stimulate fluid absorption by the intestines. Fructose slow intestinal absorption of fluids. Drinks that are high in fructose, such as orange juice, can lead to gastrointestinal distress and osmotic diarrhea.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 149.
- What artery is the primary blood supply to the humeral head ?
a. Thoracoacromial
b. Posterior humeral circumflex
c. Anterior humeral circumflex
d. Suprascapular
e. Suprahumeral
Answer : c. Anterior humeral circumflex
o The major blood supply is from the anterior and posterior humeral circumflex arteries.
o The arcuate artery is a continuation of the ascending branch of the anterior humeral circumflex. It enters the bicipital groove and supplies most of the humeral head. Small contributions to the humeral head blood supply arise from the posterior humeral circumflex, reaching the humeral head via tendo-osseous anastomoses through the rotator cuff. Fractures of the anatomic neck are uncommon, but they have a poor prognosis because of the precarious vascular supply to the humeral head.
- Which of the following preoperative findings correlates best with results after operative fixation of the calcaneus ?
a. Displacement of the sustentaculum tali
b. Displacement of the lateral wall
c. Number of major fragments of the posterior facet
d. Diminution of Bohler’s angle
e. Amount of heel varus
Answer: c. Number of major fragments of the posterior facet
Satisfactory result correlate with fewer fragments of posterior facet. Two part fractures has a good outcome, whereas four-part fractures tend to do poorly. Varus and lateral wall displacement that occur postoperatively predict a poor result, but the presence of these findings preoperatively is common and indicate a need for surgery.
Reference: AAOS Comprehensive Orthopedic Review. 2009. Pg 177.
- A 30 year old man underwent an intramedullary nailing for a close midthird tibial fracture 2 months age. He has had pain and erythema in the area of the fracture for the past 3 days, and radiograps show a midthird tibia fracture with an interlocking nail in place. Which of the following tests would be most appropriate to obtain a diagnosis ?
a. Erythrocyte sedimentation rate
b. MRI scan
c. CT scan
d. Aspiration of the fracture site
e. Indium labeled white blood cell scan
Answer : d. Aspiration of the fracture site
Aspiration of the fracture site and testing the aspiration fluid by Gram stain, culture, and sensitivities is the best way to confirm the diagnosis. The other test are either nondiagnostic or do not make a specific diagnosis.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 177.
- A 25 year old man has a midshaft femoral fracture with 25% comminution and is undergoing closed intramedullary nailing. Proximal locking is performed uneventfully; however, during distal locking screw insertion, only one of the screws is noted to have bone purchase. Which of the following proceure is the best solution to this problem?
a. Leave only one distal screw; this will provide adequate fixation
b. Exchange the nail for one either longer or shorter, and relock at a new level
c. Insert a screw through the hole either anterior or posterior to the intramedullary nail locking hole
d. Insert a small diameter threaded pin at a different angle through the locking hole
Answer: a. Leave only one distal screw; this will provide adequate fixation
For the majority of femoral diaphyseal fractures above the distal third, one distal locking screw is sufficient. Fractures located in the distal third, will often require the additional of a second locking screw.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 174.
- Which of the following organism is most commonly isolated in acute necrotizing fasciitis?
a. Group A streptoccus
b. Group D streptococcus
c. Pseudomonas aeruginosa
d. Staphylococcus aureus
e. Clostridium difficile
Answer: a. Group A streptoccus
Many cases of acute necrotizing fasciitis involve a synergy of several organisms. The most commonly isolated organism, singly or in combination, is group A streptococcus.
Reference : AAOS Comprehensive Orthoepdic review. 2009. Pg 175.
- What is the main disadvantage of using antibiotic impregnated polymethylmethacrylate beads to threat infected or contaminated wounds ?
a. Local toxicity
b. Systemic toxicity
c. Inadequate antibiotic solution
d. Foreign body reaction
e. Allergic reaction
Answer: d. Foreign body reaction.
Reference :Miller’s Review of Orthopedics. 5th ed. 2008. Elsevier inc.
Antibiotic beads or spacers—PMMA impregnated with antibiotics (usually an aminoglycoside); useful when treating infected TJA or osteomyelitis with bony defects. Antibiotic powder is mixed with cement powder; the antibiotic used is guided by the microorganism, and dosage depends on the selected antibiotic and type of PMMA. Antibiotics that have been used with PMMA for infection are tobramycin, gentamicin, cefazolin and other cephalosporins, oxacillin, cloxacillin, methicillin, lincomycin, clindamycin, colistin, fucidin, neomycin, kanamycin, and ampicillin. Chloramphenicol and tetracycline appear to be inactivated during polymerization. Antibiotics elute from PMMA beads, with an exponential decline over a 2-week period, and cease to be present locally in significant levels by 6-8 weeks. Much higher local tissue concentrations of antibiotic can be achieved than those obtained by systemic administration but do not seem to cause problems in the doses typically used. (Extremely high local concentrations of antibiotics can decrease cellular replication or even result in cell death.) Increased surface area of PMMA (e.g., with oval beads) enhances antibiotic elution. Beads are inserted only after thorough débridement.Because PMMA may cause a foreign body reaction, the beads should always be removed. Antibiotic powder in doses of 2 g/40 g of powdered PMMA (simplex P) does not appreciably affect the compressive strength of PMMA. Much higher concentrations (4-5 g antibiotic powder/40 g PMMA) significantly reduce the compressive strength (important in cemented joint arthroplasties). Antibiotic-impregnated cement spacers help prevent soft tissue contracture after removing an infected TKA.
- A 23 year old man is experiencing impotence and penile numbness following intramedullary nailing for a femoral shaft fracture. Which of the following condition is a likely cause of these symptoms ?
a. Unrecognized urologic trauma
b. Injury to S2- S3
c. Injury to the penis from the traction
d. Pudendal nerve palsy
e. Post traumatic stress
Answer: d. Pudendal nerve palsy
The magnitude of pudendal nerve palsy correlated with intraoperative traction. One prospective study of 106 patients, revealed 10 patients (9%) has pudendal nervel palsy from static intramedullary nailing which using average magnitude of force (kg/hour) : 73.3 kg/hour compared to the control group which using total traction force 34.9 kg/hour.
Reference: RJ Brumback, TS Ellison, H Molligan, DJ Molligan, S Mahaffey and C Schmidhauser. J Bone Joint Surg Am. 1992;74:1450-1455.
- An iliosacral screw that exits just anterior to the S1 body is most likely to injure which of the following structures ?
a. L4 nerve root
b. L5 nerve root
c. S1 nerve root
d. S2 nerve root
e. External iliac artery
Answer ; b. L5 nerve root
For sacral fractures and sacroiliac joint disruptions, Matta and Saucedo, Routt, Meier, and Kregor, and others have described image intensifier–directed screw fixation from the ilium posteriorly into the sacral body. This technique risks damage to the L5 nerve root and iliac vessels anterior to the body of the sacrum and to the sacral nerve roots within its bony confines, and it requires excellent radiographic technique and a thorough understanding of the three-dimensional anatomy of the pelvis.
Reference : Campbell’s Operative Orthopedics. 11th ed. Ch 53.
- Which of the following is a long complication of ankle arthrodesis for post traumatic arthritis ?
a. Progressive limb length discrepancy
b. Contralateral ankle arthritis
c. Ipsilateral hindfoot and midfoot arthritis
d. Ipsilateral knee arthritis
e. Talar osteonecrosis
Answer : c. Ipsilateral hindfoot and midfoot arthritis
Ankle arthrodesis for posttraumatic ankle arthrosis provide reliable pain relief. However, the long term sequel of joint arthrodesis is the development of arthrosis in the surrounding joints. Over time, following ankle arthrodesis, the ipsilateral hindfoot and midfoot jints show sign of join space wear, and this may be symptomatic. With a stable ankle arthrodesis, progressive limb-length discrepancy or talar osteonecrosis is not expected. Ankle arthrodesis has not been definitely linked to ipsilateral knee arthritis or contralateral ankle arthritis.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 199.
- A 18 year old man has a simple oblique fracture of the humeral shaft that require surgical stabilization to maintain reduction and facilitate mobilization. Which of the following methods will provide the best outcome ?
a. Unreamed intramedullary nail
b. Reamed statically locked intramedullary nail
c. External fixation
d. Plate fixation and interfragmentary compression
e. Bridge plate stabilization
Answer: d. Plate fixation and interfragmentary compression
The patient has a simple fracture pattern that can be reduce anatomically and stabilized with absolute stability by interfragmental compression and protection plating. This will guarantee a 95% - 98% union rate eith no radial nerve palsy. Intramedullary nailing does not equal these result in simple fracture pattern in humerus. Bridge palting is indicated for multifragmented fracture pattern when anatomic reduction and absolute stability cannot be achieved. External fixation is reserved for severe open fractures.
Reference : AAOS Comprehensive Orthopedic Review. 2009. 202.
- Injury to which of the following structures has been reported following iliac graft harvest ?
a. Superior gluteal artery from anterior crest harvest
b. Superior gluteal artery from anterior crest harvest
c. Inferior gluteal artery from posterior crest harvest
d. Ilioinguinal nerve from a posterior crest harvest
e. Lateral femoral cutaneous nerve from an anterior crest harvest
Answer: e. Lateral femoral cutaneous nerve from an anterior crest harvest
Injury to the lateral femoral cutaneous nerve (Bernhardt’s syndrome) or MERALGIA PARESTHETICA occurs after harvest of the bone from the anterior iliac crest. The lateral femoral cutaneous nerve is a terminal sensory nerve that originates from L2-L3 and innervates the skin of the thigh laterally.
- A 13 year old hockey player reports a 1 week history of left medial clavicle pain and dysphagia. A chest radiograph obtained at the emergency department on the day of injury was negative. Examination reveals swelling and tenderness along the medial edge of the left clavicle. The upper extremity neurologic examination is normal. What is the next most appropriate test to best define the patient’s injury ?
a. CT of the sternoclavicular joint
b. Barium swallowing study
c. Electromyography of the upper extremity
d. MRI of the glenohumeral joint
e. Bone scan
Answer: a. CT of the sternoclavicular joint
It might be a posterior dislocation of sternoclavicular joint
Computed Tomography Scans
Without question, the computed tomography (CT) scan is the best technique to study problems of the sternoclavicular joint. It clearly distinguishes injuries of the joint from fractures of the medial clavicle and defines minor subluxations of the joint. One must remember to request CT scans of both sternoclavicular joints and the medial half of both clavicles so the injured side can be compared with the normal side
Reference : Rockwood & Green’s Fractures in Adult. 6th ed. Ch 36.
- According to the Third National Acute Spinal Cord Injury Study (NASCIS 3), what is the recommended protocol for a patient who sustained a spinal cord injury 7 hours ago ?
a. Methylprednisolone 30 mg/kg initial bolus, followed by 5.4 mg/kg/h for 23 hours
b. Methylprednisolone 30 mg/kg initial bolus, followed by 5.4 mg/kg/h for 48 hours
c. Dexamethasone 10 mg bolus, followed by 6 mg every 6 hour for 24 hours
d. Dexamethasone 10 mg bolus, followed by 6 mg every 6 hour for48 hours
e. No treatment
Answer: b. Methylprednisolone 30 mg/kg initial bolus, followed by 5.4 mg/kg/h for 48 hours.
Based on National Acute Spinal Cord Injury Study (NASCIS) 1 & 2:
Methylprednisolone 30 mg/kg initial bolus, followed by 5.4 mg/kg/h for 23 hours.
NASCIS 2 established the recommended doses of methylprednisolone for spinal cord injury : an initial bolus of 30 mg/kg over 1 hour, followed by an infusion of 5.4 mg/kg/hour for an additional 23 hours. If injury was more than 8 hours old, the methylprednisolone was not recommended.
Based on National Acute Spinal Cord Injury Study (NASCIS) 3;
The objectives of the third and final NASCIS were to investigate the interplay between timing of steroid administration and duration of therapy and to evaluate the efficacy of the 21-aminosteroid tirilazad mesylate, which purportedly had a better safety profile than methylprednisolone. Four-hundred ninety-nine patients were randomized into three treatment groups within 6 hours of injury: the first group received methylprednisolone according to the NASCIS II dosing for 24 hours, the second group received this dosing for 48 hours, and the third group received a methylprednisolone bolus of 5.4 mg/kg/hr followed by a maintenance infusion of tirilazad at 2.5 mg/kg IV every 6 hours for 48 hours.
With outcome measures including motor function, sensory function, and functional independence; the NASCIS III revealed that increased duration of steroid administration (48 hours) resulted in statistically significant benefit only if treatment was initiated between 3 and 8 hours of injury.
Infectious complications were more common in the 48-hour corticosteroid group but were statistically insignificant. There were no differences between the tirilazad group and the 24-hour methylprednisolone group.
So, NASCIS 3 recommended changed the dosing schedule based on the time from injury. If the time from injury to treatment was less than 3 hours, the standard protocol was followed ( 30 mg/kg bolus followed by 5.4 mg/kg/hour for 23 hours).
If the time from injury to treatment was between 3 – 8 hours, the infusion was continued at 5.4 mg/kg/hour for an additional 23 hours (48 hours total).
Reference : Rothman-Simeone’ s The Spine. 6th ed. Ch : Basic Science of Spinal cord injury. Pg 1302.
- Injury to which of the following structures has been reported following iliac crest bone graft harvest?
a. Superior gluteal artery from anterior crest harvest
b. Superior cluteal artery from anterior crest harvest
c. Inferior gluteal artery from posterior crest harvest
d. Ilioinguinal nerve from a posterior crest harvest
e. Lateral femoral cutaneous nerve from an anterior crest harvest
Answer : e. Lateral femoral cutaneous nerve from an anterior crest harvest
Injury to the lateral femoral cutaneous nerve (Bernhardt’s syndrome) or MERALGIA PARESTHETICA occurs after harvest of the bone from the anterior iliac crest. The lateral femoral cutaneous nerve is a terminal sensory nerve that originates from L2-L3 and innervates the skin of the thigh laterally.
- Injury to the lateral femoral cutaneous nerve and the ilioinguinal nerve have both been described with an anterior iliac crest bone graft harvest.
- The lateral femoral cutaneous nerve may be injured from retraction after elevating the iliacus muscle or from direct injury when the nerve actually cross over the crest.
- Injury to ilioiguinal nerve has been reported from vigorous retraction of iliacus muscle after exposing inner table of anterior ilium.
- A posterior crest harvest can injury the superior gluteal injury if a surgical instrument violates the sciatic notch.
- Cluneal nerve injury may occur with posterior crest harvest, particularly if the skin incision is horizontal or extends more than 8 cm superolateral from the posterior superior iliac spine.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 226.
- A 54 year old man undergoes uneventful anterior cervical discectomy and interbody fusion at C4 -5 for focal disc herniation and C5 radiculopathy. At the 3 week follow up examination, the patient reports a persistent cough. Pulmonary evaluation reveals a mild but persistent aspiration. Laryngoscop reveals partial paralysis of the left vocal cord, most likely caused by:
a. Entrapment of the superior laryngeal nerve during ligation of the superior thyroid artery
b. Stretch of the recurrent laryngeal as it enters the esophageal tracheal groove
c. Injury to the vocal cord during endotracheal intubation
d. Displacement of the lanrynx against the endotracheal tube by retraction
e. Retraction pressure on the laryngeal nerve in the esophageal groove
Answer : e. Displacement of the lanrynx against the endotracheal tube by retraction
The exact anatomic event responsible for vocal cord paralysis associated with anterior cervical surgery remains a question Apfelbaum et al, in an excellent review of 900 anterior cervical surgeries, identified 30% with vocal cord paralysis, 3 of which were permanent. They showed that retractor placed under the longus colli for anterior cervical exposures can compress the laryngeal-tracheal branches within the larynx against the tented endotracheal tube rather than the recurrent laryngeal nerve which is extrinsic to the larynx. By releasing the endotrachela cuff and allowing the tube to recenter itself after placement of retractors, they were able to decrease vocal cord injury from 6.4% to 1.7%. Jewett et al suggested that a left sided approach may result in lower incidence of injury. Endotracheal intubation is the 2nd most common cause of vocal cord injury, with an incidence approximately 2%.
Reference : AAOS Comprehensive Orthopedic Review. 2009. Pg 236.
Describe PA below
Matrix osteoid Ganas bentuk lace like
- Tdp sel2 osteoblast ganas terjebak di dlm matrix osteoid
- Osteoblast ganas dlm renda2 osteoid matrix
- Nuclear pleumorfism
- Hypercromasi
Describe histoPA below
Osteochondroma :
Cartilage cap: jaringan tulang rawan diatas jar tulang keras.
Chondrosit berploriferasi selnya besar, tapi orientasi tumbuhnya keatas.
• Overlies cancellous bone of the stalk
describe histoPA below
Proliferasi anaplastia:
hiperseluler, nuclear pleumorfism,big nucleus,
BINUCLEATION
Describe histoPA below
GCT : Beberapa multinuclear giant cells:
• Jumlah inti >20
• Inti tipikal bulat sampai oval dan sama dengan stroma diluar
Describe histoPA below
Sel2 GCT less nuclei:
- Among fibrous stroma and oval nuclei surround
- Lipid laden histiocytes background: area putih dipinggir ada nuclei yg gelap dan ceper
Describe histoPA below
- Neurofibroma:
- Elongated spindle
- Bentuknya ada yang wavy (keriting)
- Terdapat pada bahan collagen
- Absen of mitotic figur
Describe histoPA below
Fibrosarcoma:
- hiperseluler
- Herring bone appearance
Describe histoPA below
Chondrosarcoma:
- lobulated tumor mass
- hypercellular chondrocyte with plum and enlarge nuclei
Describe histoPA below
GCT with secondary ABC
ABC component : blood filled/ containing cyst or space with fiborus wall without endothelial lining
Describe histoPA below
- Multinucleated giant cell (> 50 nuclei)
- the nuclei of the giant cells are similar to those in the mononucleus stromal cells
Describe histoPA below
Ewing sarcoma
Small round cell tumor with fibrous septa and necrotic cells (ghost cells)
A female 31 years old presented with chief complain of pain, getting worse at the hip region since 2 years ago. History of trauma (+). Fever (-). Loss of body weight (-).
Laboratory Findings :
Hb: 12.8 g.dl Leucocytes : 7,700/ml Thrombocytes : 483,000 /ml
ESR : 50 (N:0-20) LDH : 328 (N : 240-480)
SAP : 68 (N: 42 – 98 )
Describe what you see from plain X-ray, please!
Describe what you find from Histopathological examination!
What is your complete diagnosis?
How do you manage this patient?
X ray :
Periarticular osteoporosis
Irregularity of joint surface
narrowing joint space
femoral neck fracture subcapital
Histopathologic finding :
Granuloma with epitheloid (macrophage) cells. Langhans giant cells, and necrotic caseosa
Complete diagnosis
Osteomyelitis tuberculosis of proximal femur with pathological fracture of the neck of the femur
Management
Anti-TB drug therapy
Debridement
Temporary hip arthrodesis, then hip arthroplasty after 2 years release from Tb treatment
- During soft tissue release for an idiopathic clubfoot, it is noted than the peroneus longus tendon has been transected in the midfoot. Failure into repair this structure may be lead to:
a. Cavus
b. Claw toes
c. A dorsal bunion
d. Hindfoot valgus
e. Forefoot pronation
Answer: c. A dorsal bunion
A statistically significant varus displacement of the first metatarsal was observed only after transection of the peroneus longus tendon. It was concluded that the peroneus longus tendon is a strong retaining mechanism of the first metatarsal to opposes the tibialis anterior dorsal pull on 1st ray . When tendon peroneus longus injured, flexor hallucis longus try to compensate by flex the MTP. Thus forming deformity dorsal bunion.
Dorsal bunion can be result from sequel of poliomyelitis or direct injury to tendon peroneus longus.
Ref : Bohne WH, Lee KT, Peterson MG. Action of the peroneus longus tendon on the first metatarsal against metatarsus primus varus force. Foot Ankle Int. 1997 Aug;18(8):510-2.
- The earliest sign of TB hip in X-ray is:
a. Narrow joint space.
b. Irregular moth eaten femoral head.
c. Periarticular osteoporosis.(Apley Ch2)
d. Dislocation.
Answer : c. Periarticular osteoporosis
Tuberculosis – clinical and x-ray features (a) Generalized wasting used to be a common feature of all forms of tuberculosis. Nowadays, skeletal tuberculosis occurs in deceptively healthy-looking individuals. An early feature is peri-articular osteoporosis due to synovitis – the left knee in (b). This often resolves with treatment, but if cartilage and bone are destroyed (c), healing occurs by fibrosis and the joint retains a ‘jog’ of painful movement. Reference : Apley 9th ed. Ch 2.
Plain Ro spine:
• Adjacent end plate irregularity
• Subchondral bony erosion
• Narrowing of joint space
• Anterior vertebral body collapse
• Abses paravertebra
The triad of Phemister refers to three features seen classically with joint involvement from tuberculosis
They comprise of
• juxtarticular osteopaenia / osteoporosis
• peripheral osseous erosions
• gradual narrowing of joint space
- The synonym for Paget’s disease is:
a. Osteitis fibrosa.
b. Osteitis proliferans.
c. Osteitis deformans.
d. None of the above.
Answer : c. Osteitis deformans
Paget’s disease—Elevated serum alkaline phosphatase and urinary hydroxyproline; virus-like inclusion bodies observed in osteoclasts. Can display both decreased and increased osteodensity (depending on the phase of the disease). Discussed in Chapter 9, Orthopaedic Pathology.
a. Active phase
(1) Lytic phase—Intense osteoclastic bone resorption
(2) Mixed phase
(3) Sclerotic phase—Osteoblastic bone formation predominates
b. Inactive phase
Section from pagetic bone, showing the mosaic pattern due to overactive bone resorption and bone formation. The trabeculae are thick and patterned by cement lines. Some surfaces are excavated by osteoclastic activity whilst others are lined by rows of osteoblasts. The marrow spaces contain fibrovascular tissue.
Marble or mosaic appearance
Reference picture : Apley 9th ed. Ch 7. Pg 144
- Multiple myeloma tumor cells resemble:
a. Granulocytes.
b. Plasma cells.
c. Lymphocytes.
d. Chondrocytes.
Answer :b. plasma cells.
Eccentric round or oval cells nuclei membentuk roda pedati
- An adamantinoma historically contains:
a. Squamous cell rests.
b. Pallisading cells.
c. Cells resembling basilar cells.
d. All of the above.
Answer: d. all of the above
Adamantinoma—This rare tumor of long bones contains epithelium-like islands of cells. The tibia is the most common site, although other long bones are infrequently involved (fibula, femur, ulna, radius). Most patients are young adults and present with pain over months to years. The typical radiographic appearance is that of multiple sharply circumscribed, lucent defects of different sizes, with sclerotic bone interspersed between the zones and extending above and below the lucent zones. Typically, one of the lesions in the midshaft is the largest and is associated with cortical bone destruction. Histologically, the cells have an epithelial quality and are arranged in a palisading or glandular pattern; the epithelial cells occur in a fibrous stroma. The treatment of this low-grade, malignant lesion is by wide-margin surgical resection. The lesion may metastasize either early or after multiple failed attempts at local control.
Reference ; Miller’s Review of Orthopedic. 5th ed. 2008. Ch 9.
- Perthes’ disease is common to age group of:
a. 1-5.
b. 6-10.
c. 11-15.
d. 16-20.
b. 6 - 10 yo
Legg-Calve-Perthes Disease
(L.C.P.D)
I P. Sukarna
Isi
LEGG-CALVE-PERTHES DISEASE
• Definisi
• Pendahuluan
• Sejarah
• Vaskularisassi caput femoris
• Patogenesis
• Insidensi
• Etiologi
• Klasifikasi kronologi radiologi (Waldenström)
• Gambaran klinis
• Gambaran radiologis
• Klasifikasi radiologi LCPD menurut : Catteral, Thomson, Salter, Herring
o scintigraphy : Conway-Dias
• Hubungan caput-acetabulum
• Perjalanan LCPD (natural history)
• Penilaian LCPD pada akhir pertumbuhan : Mose, Stulberg
• Prognose
• Penanganan LCPD
o Observasi, simptomatik,
o Containtment : non surgical, surgical
• Tindakan operasi setelah terjadi deformasi
• Kepustakaan
Legg-Calve-Perthes Disease
(L.C.P.D)
I P. Sukarna
Definisi : Legg-Calve-Perthes disease adalah suatu penyakit nekrosis avaskular
juvenile yang idiopatik daripada caput femoris.
Kadang disebut Perthes disease, Waldenström disease, coxa plana.
PENDAHULUAN
Legg-Calve-Perthes disease (LCPD) masih merupakan suatu enigma, masih kontroversi bagi pediatric orthopaedist dalam hal etiologi, progonosis dan terapi
Legg-Calve-Perthes disease tergolong suatu chondromatosis :
a. dasarnya nekrosis avaskuler,
b. gangguan osifikasi endokondral sekunder
c. bisa mempengaruhi epiphyseal growth plate
d. kelainan (deformitas) daripada epiphysis bisa merubah permukaan sendi yang kelak mengakibatkan osteoarthrosis
Adapun 2 kelompok osteochondromatosis antara lain :
1. Yang mengenai pusat osifikasi primer (primary center of ossification)
tarsal naviculare : Köhler disease
carpal naviculare : Kienbock’s disease
corpus vertebrae : Calve’s disease
2. Yang mengenai pusat osifikasi sekunder (secondary center of ossification)
epiphysis caput femoris : LCP disease
caput humeri : Panner’s disease
caput metatarsal II : Freiberg’s disease
tuberositas tibia : Osgood –Schlatter’s disease
apophysis calacaneus “ Sever’s disease
SEJARAH :
1909 : Waldenström mengatakan bahwa bentuk kelainan avascular necrosis pada caput
femoris ini adalah karena proses tuberculosis
1910 : Publikasi yang secara terpisah oleh Arthur Legg dari Boston, Calve dari Perancis
dan Perthes dari Jerman mengatakan bahwa kelainan radiologis yang dikatakan oleh Waldenström itu bukan tuberkulose tetapi karena avascular necrosis
1921 : Phemister menguraikan kelainan patologi daripada LCP-disease
1948 : Salter dan Thomson melakukan percobaan-percobaan pada binatang sehingga
terjadi LCP
1997 : Tsao et al memprediksi prognosis daripada LCP-D dengan cara scintigrafi tulang
berseri : awal terbentuknya kolom lateral
Ada beberapa penyakit hampir sama dengan LCP, sebagai differential diagnosis :
- Irritable hip (keluhan serupa) : karena transient synovitis, trauma, gejala awal daripada tb-hip, low grade infection.
- Gambaran radiologis LCP (avascular necrosis) Penyakit Gaucher, penyakit Morquio, cretinism, Sickle cell, Caison disease, multiple epiphyseal dysplasia (MED), spinal epiphyseal dysplasia (SEP)
- Meyer’s disease (dysplasia caput femoral)
VASKULARISASI daripada CAPUT FEMORIS
Sampai dengan umur 4 bulan, caput femoris disuplai oleh :
• metaphyseal vessels yang menembus growth plate
• lateral epiphyseal vessels melalui retinacula
• sedikit pembuluh darah dari ligamen teres.
Setelah umur 4 tahun pembuluh darah metaphysis menghilang. Pada umur 7 tahun pembuluh darah ligament teres tumbuh.
Menurut Lin dan Ho (1991), pada umur (4-7) tahun a.v. retinacularis cabang dari a.v. epiphysealis lateralis mudah mengalami “stretching” dan tekanan dari efusi cairan. Tamporade kapsular ini bisa disebabkan oleh trauma, synovitis yang non spesifik sehingga menimbulkan ischemia daripada epiphysis caput femoris (ECP)
• Arteria femoralis berjalan diantara muskulus iliopsoas dan pectineus memberi dua cabang :
- medial circumflex artery
- lateral circumflex artery
• Medial circumflex artery ke medial capsule (extra capsuler) memberikan cabang-cabang yang menembus kapsul membentuk arteri-arteri retinacularis yang menuju ke epiphysis :
- Inferior medial ascending retinacular artery
- small retinacular artery
- superior ascending retinacular artery
• Lateral circumflex artery kelateral capsule memberikan beberapa cabang yang menembus kapsul menjadi arterior retinacular artery.
Medial dan lateral circumflex arteri bertemu satu dengan lainnya membentuk extracapsular ring.
Menurut Chung, superior ascending retinacular arteri adalah merupakan pembuluh darah utama mensuplai caput femoris. Pada laki-laki anastomosis vaskuler dan anterior circumflex sering tumbuh tidak sempurna.
Trueta & Chung : anak-anak umur 3 tahun kapsul bagian posterior trochanter tidak elastis merupakan daerah rawan cedera.
Aliran darah ke caput femoris disuplai oleh jaringan anastomosis anterior dan posterior. Jaringan anterior (panah kuning) bisa tidak lengkap terutama pada laki-laki (Chung, 1976)
PATOGENESIS
Menurut Thomson dan Salter,
ischaemia oleh penyebab yang tak diketahui mempengaruhi :
A. epiphysis caput femoris
B. growth plate
C. metaphysis (intracapsuler)
A1. Ischaemia epiphysis caput femoris (episode I)
Osifikasi endokondral didalam preosseous epiphyseal cartilage dan growth plate berhenti sementara, sedangkan articular cartilage yang memperoleh nutrisi dari cairan sinovial terus tumbuh (tidak terganggu). Pada x-ray akan tampak melebarnya celah sendi dibagian medial dan ossific-nucleus lebih kecil.
Gambaran radiologis yang pertama adalah perubahan densitas daripada epiphysis, dan marrow space daripada epiphysis mengalami nekrosis.
Revaskularisasi terjadi dari jaringan yang masih intak dari caput femoris yang avaskuler, mulai dari tepi pembuluh kapiler baru rekanalisasi pada kanal-kanal vaskuler yang lama. Osifikasi endochondral dalam epiphysis mulai dari perifer menuju kesentral.
Dengan pertumbuhan kapiler dan diikuti dengan osteoclast dan osteoblast mengisi permukaan subchondral cortical bone yang avascular dan central trabecular cancellous bone.
Terjadilah deposisi woven bone yang baru diikuti oleh resorpsi tulang yang mati bersamaan.
Suatu “critical point” terjadi saat terjadinya resorpsi dimana daerah subchondral menjadi lemah secara biomekanik dan mudah terjadi fraktur patologis. Sampai sebelum terjadinya fraktur, klinis penderita tidak ada keluhan. Bila potential form LCPD ini berlanjut, terjadilah “true form” LCPD karena terjadi subchondral fracture.
a) Potential form LCPD
Pada potential LCPD oleh karena gaya-gaya stress dan merobek (shear) pada revascularized epiphysis tidak melebihi kekuatan daerah subchondral yang melemah, tidak akan terjadi fraktur subchondral. Pertumbuhan dan perkembangan epiphysis berjalan normal karena proses reossification tidak mengalami gangguan. Jadi tak terjadi resorpsi epiphysis, tidak terjadi subluksasi dan caput femur tetap bulat. Anak tidak mempunyai keluhan, ROM baik. Daerah subchondral kembali stabil dan mempunyai kekuatan normal dan pada x-ray tampak “head-within-head” appearance. Gambaran ini menunjukkan adanya “growth arrest line” yang membatasi ossic nucleus pada saat permulaan infarction. Gambaran ini tampak secara kebetulan.
b) True form LCPD
Pada true form, terjadi fraktur subchondral patologis. Klinis diawali dengan rasa nyeri dan gambaran LCPD pada radiologi.
Perubahan epiphysis caput femoris.
Terjadi fraktur patologis pada tempat yang menerima stress yang terberat saat weight bearing yaitu bagian antero lateral daripada epiphysis. Garis patah ini tidak bertambah luas, mungkin setelah terasa nyeri, penderita mengurangi beban dengan mengurangi aktivitas.
A.2. Ischameia caput femoris (episode II)
Ischaemia terjadi setelah terjadi revaskularisasi tulang cancellous dibawah subchondral fracture, yaitu trabecular collapse dan oklusi pembuluh darah kapiler yang baru tumbuh. Berbeda dengan episode pertama penyebab ischaemia tak diketahui dengan pasti, episode ke dua ini karena mekanis yang bisa mengenai sebagian atau seluruh epiphysis, tergantung dari luasnya subchondral fracture.
Struktur stabilitas caput femoral epiphysis terganggu.
Pembuluh darah kapiler yang sedang tumbuh terganggu oleh karena obliterasi saluran-saluran pembuluh darah, oleh fraktur cortical dan trabecular dan marrow debris.
Kesembuhan avascular epiphysis ini akhirnya berlangsung secara “creeping substitution” yaitu dengan pelan-pelan terjadi revaskularisasi dan resorpsi daripada jaringan fibro osseous.
Pada saat proses “creeping substitution”, caput femoris bisa berbentuk bulat atau datar tergantung besarnya gaya yang duterima, kecepatan pertumbuhan didalam caput femur dimana daerah yang tidak terjadi resorpsi tumbuh lebih cepat dibanding pada daerah yang mengalami resorpsi, sifat remodeling ini disebut “ biologic plasticity” yang berakhir sampai mulai terjadinya reosifikasi subchondral.
Kombinasi faktor-faktor pressure dan pertumbuhan yang tidak simetris in penyebab dari terjadinya extrusion dan subluksasi.
Perubahan yang terjadi pada growth plate dan metaphysis diterangkan pada gambaran radiologi diluar caput femoris.
B. Ischaemia growth plate
Ischaemic episode yang juga terjadi dalam growth plate dimana blood supply berasal dari sisi epiphysis. Terjadi gangguan osifikasi yang normal. Terjadi distorsi kolom-kolom kondrosit.
Terjadi pengapuran yang berlebihan didalam tulang concellous primer kolom kartilago meluas tanpa terjadi kalsifikasi sampai metafisis (berbentuk seperti kista).
Terjadi gangguan pertumbuhan collum femur tampak pendek.
C. Metaphysis
Menurut Inoue cs, ada 4 macam kelainan :
• kelainan adanya jaringan adipose (lemak)
• terjadi fibrocartilage
• osifikasi yang tidak teratur
• terjadi ekstrusi dari growth plate (GP)
Growth plate dan metafisis menjadi pendek dan collum pendek (coxa vara), caput femur lebih besar (coxa magna).
Greater trochanter tidak terpengaruh, pertumbuhan normal, relatif membesar.
Kelainan pada sendi panggul ini memberikan test Trendelenburg yang positif. Perichondral ring tidak terganggu menyebabkan collum melebar.
INSIDENSI
Insidensi 1 : 1.500
Umur (3-13) tahun, rata-rata umur (5-9) tahun
Sex : laki>perempuan
10% bilateral
Insidence of Legg-Calve-Perthes Disease
Author Geographic location Overall Male Female
Malloy and Mc Mahon Masschusets, USA 1: 1.200 1: 740 1: 3.700
Helbo Denmark 1: 2.300
Cray et al British Columbia 1: 1.400 1: 820 1: 4.500
Harper et al South Wales, Wales 1: 4.750 1: 3.000 1: 11.800
Catterall Scotland 1: 5.590 1: 4.060 1: 14.830
Banker et al England 1: 12.500 1: 8.064 1: 30.300
ETIOLOGI
Belum diketahui penyebab yang pasti.
Faktor-faktor predisposisi diperkirakan factor genetic, tumbuh kembang dan lingkungan.
Semua teori dan hipotesis diarahkan kepada penyebab terjadinya avascular necrosis. Blood supply kecaput femoris terputus, terjadi bone infarction terutama subchondral cortical bone sedangkan articular cartilage tidak terganggu karena nutrisinya berasal dari cairan sendi.
1. Teori vaskuler
Venous congestion, arterial occlusion, embolism, meningkatnya tekanan intraartikuler
2. Teori viskositas oleh Bleck
3. Growth arrest theory
Delayed bone age : tebalnya pre ossification cartilage daripada caput femur yang mengakibatkan kurangnya proteksi pembuluh darah yang menembus cartilage guna osifikasi epiphysis. Penekanan daripada cartilage menyebabkan berkurangnya pengaliran darah sehingga terjadi ischaemia dan akhirnya terjadi infark.
4. Glueck et al (1996) : gangguan koagulasi (venous thrombolytic mechanism)
Dari 44 kasus dengan LCPD : 75% dengan gangguan koagulasi yaitu thrombophylia dari hypofibrinolysis.
Thrombophylia : cenderung terjadi peningkatan thrombosis.
Hypofibrinolysis : berkurangnya kesanggupan lysis daripada thrombi.
Gangguan koagulasi menurut Glueck ini menimbulkan oklusi venus thrombosis dalam caput femur mengakibatkan hipertensi vena intrameduler, terjadilah anoxia, ischaemia, akhirnya osteonecrosis.
Thrombophylia disebabkan oleh inactivated activation daripada protein C, protein C deficiency dan protein S deficiency. Mekanisme kelainan pembekuan ini belum diketahui. Kejadian yang serupa collaps dan fragmentasi caput femoris pada sickle cell disease, leukemia, lymphoma dan idiopathic thrombocytopenia.
Protein C, protein S dan antithrombin III adalah merupakan anticoagulans fisiologis.
- Faktor rokok
Penelitian Glueck et al (1998) mengenai korelasi 2nd hand smoking (passive smoker) terhadap LCPD.
Dari 39 anak-anak dengan LCPD :
• 15 (38%) bukan passive smoker
• 24 (62%) merupakan passive smoker
o 17 (71%) in uterus passive smoker
o 7 (29%) household passive smokers
Merokok sigaret mengganggu aktivitas fibrinolysis
• low tissue plasminogen activator activity
• high tissue plasminogen antigen
• Meningkatnya plasminogen activator inhibitor activity.
Terjadilah fibrinolysis yang mengakibatkan venous thrombosis, venous hypertension, intramedullary hypertension dengan akibat osteonecrosis.
Menurut Mata et al (2000) LCPD terjadi 5x lebih tinggi pada second hand passive smoker. - Mutasi faktor V Leiden dan anticardiolipin antibodies diduga penyebab daripada LCPD
KLASIFIKASI KRONOLOGIS RADIOLOGI (Waldenstöm)
1. Stage early avascular
• Epiphysis caput femur (ECF) sedikit mengecil, densitas bertambah
• Cartilage space melebar (joint space melebar)
• Bila ragu-ragu, gambaran ini lebih jelas dengan bone-scan
2. Stage revaskularisasi
6 bulan setelah penyumbatan vaskuler caput femur menjadi lebih padat (denser), endochondral ossification cepat terjadinya dan pada saat ini bisa terjadi fraktur subchondral (True LCP disease) dimana klinis anak menunjukkan jalan pincang, dan nyeri sendi panggul. Pada saat ini biasanya anak diperiksakan ke dokter.
Ukuran besarnya fraktur subchondral menentukan nilai prognosis LCPD terjadi bila terjadi fraktur subchondral (Waldenstöm’s sign)
3. Stage of collaps dan fragmentasi ( 2 bulan sampai 2 tahun, rata-rata 8 bulan)
Trabeculae dibawah fraktur subchondral mengalami collaps, gambaran radiologis caput menjadi gepeng (“flattening”). Keadaan ini menyebabkan obstruksi daripada pembuluh-pembuluh darah kapiler yang baru tumbuh (second ischaemic episode) dengan akibat nekrosis tulang. Kemudian diikuti dengan revaskularisasi dan osifikasi dengan cara “creeping substitution”.
Pada x-ray : awalnya bisa tampak “flattening” dan kemudian diikuti oleh fragmentasi daripada caput femoris (resorpsi dan formasi)
Pada stadium ini caput femoris sangat mudah mengalami deformasi maka terapi yang terbaik saat ini adalah koaptasi-biologic plasticity.
Containment treatment : ice cream cone theory (Wenger)
4. Stage of repair
Epiphysis telah mengalami pengerasan.
Pada perjalanan penyakit LCPD, caput femoris bisa berbentuk bundar, oval, bentuk sadel, coxa brevis, coxa magna, osteochondrosis.
- Stage gangguan pertumbuhan
Akibat ischaemia daripada growth plate maka gangguan pertumbuhan memanjang terganggu collum femoris pendek (coxa brevis).
Perichondral ring tidak terganggu, collum menjadi melebar (coxa magna).
Trochanter mayor tidak mengalami gangguan, maka terjadi functional coxa vara.
Secara singkat kronologis gambaran radiologis pada LCPD :
• Fuzziness : growth plate kabur, pelebaran joint space, epiphysis mengecil dan densitas bertambah.
• Fracture subchondral (jarang terlihat)
• Flattening
• Fragmentation
• Final fusion
GAMBARAN KLINIS
Terjadi pada umur (3-13) tahun, rata-rata (4-8) tahun laki-laki lebih banyak dibandingkan perempuan (4-5) x.
Kebanyakan unilateral; bila terjadi bilateral, sendi yang lainnya baru terjadi sekitar setahun kemudian.
Bila keluhan teradi pada umur lebih dari 13 tahun, ini tidak terolong LCPD, tapi adolescent avascular necrosis dengan prognosis yang jelek.
Anamnese
Keluhan biasanya rasa nyeri yang ringan, intermitten pada sendi panggul, depan lutut (“referred pain”) atau pincang atau kedua-duanya
Rasa nyeri bisa akut atau insidious jarang diawali dengan trauma. Trauma yang ringan bisa memberikan rasa nyeri karena terjadi fraktur patologis subkondral.
Gambaran klasik adalah “painless limp” maka dari itu sering menegakkan diagnose terlambat.
Pemeriksaan fisik
antalgic gait
atrophy otot (quadriceps)
spasme otot-otot
gerakan terbatas (ROM) terutama endorotasi dan abduksi
test Trendelenburg positif
leg length inequality karena terjadi collaps
short stature karena anak dengan LCPD punya delayed bone age
roll test (lihat gambar)
Differential Diagnosis
Paediatric limping
Inflamasi : transient synovitis, rheumatoid arthritis
Trauma sendi panggul :
o femoral neck fracture
o hip dislocation
o slipped epiphysis
Metabolic : hypothyroidie, myxedema coma (cretinism, Goucher disease, Morquio disease)
Infeksi : awal tb-hip; low grade infection (banal)
Toxic synovitis
Kelainan hematologis
o sickle cell
o hemophylia
o lupus erythematosis
Multiple epiphyseal dysplasia (MED)
Spinal epiphyseal dysplasia (SED)
Meyer’s disease
Tumor : lymphoma
LABORATORIUM
normal
RADIOLOGI
Pemeriksaan radiologi polos (plain) adalah sangat berguna
1. Frog lateral view : AP view pada posisi hip flexion 450, abduksi dan eksorotasi. Pada fase awal yaitu saat densitas caput femoris bertambah, pada 30% penderita LCPD memperlihatkan subchondral fracture (linear fracture). Fraktur subchondral ini disebut Waldenström sign.
2. AP position : kelainan yang diperoleh tergantung dari stadium daripada LCPD, mulai dari tampak seperti normal pelebaran celah sendi, meningkatnya densitas caput femoris dan lusensi metafisis sampai fragmentasi caput femoris, partial atau complete collaps daripada caput sampai healing proses. Stadium ini diutarakan oleh Waldenström (lihat gambar)
Dengan gambaran radiologi ini bisa ditentukan :
1. chronologic stage (Waldenström)
2. bisa menentukan klasifikasi — menentukan berat ringannya LCPD menurut Catterall, Thomson-Salter atau Herring (lateral pillar)
3. adanya subluxation, “head at risk”
4. epiphyseal extrusion index (Salter atau Klisic)
Beberapa penelitian LCPD difokuskan pada pemeriksaan MRI untuk diagnose dini dan menentukan prognosis.
Staheli membagi perjalanan penyakit LCPD (kronologis) menjadi 4 stage
• Stage 1 : synovitis
• Stage 2 : necrosis atau collaps
• Stage 3 : fragmentasi
• Stage 4 : reconstitution
4 stages (tingkatan) daripada LCPD, kronologis menurut Staheli :
Stage 1 : synovitis
stadium ini hanya sebentar (mingguan) karena efek daripada ischaemia
terjadi synovitis yang memberi keluhan : kaku dan nyeri
gambaran :
o radiologis : celah sendi melebar
o bone scan : reduced up take
o MRI : reduced signal
Stage 2 : necrosis atau collaps
bagian caput yang nekrosis mengalami collaps
gambaran radiologis : epiphysis mengecil, densitas bertambah
belangsung (6-12) bulan
Stage 3 : fragmentasi
merupakan fase kesembuhan (healing stage)
tulang yang nekrosis diresorpsi, tampak sebagai “patchy deossification” (radiologis)
deformation caput femoris sering terjadi pada stadium ini
berlangsung (1-2) tahun
Stage 4 : reconstitution
fase dimana pembentukan tulang baru
sering terjadi overgrowth : coxa magna, coxa brevi, coxa plana
Gambaran radiologis diluar caput femoris pada LCPD :
Pada metafisis tampak lucencis pada awalnya menunjukkan kista metaphysis yang sebenarnya. Mungkin pula suatu kista dari physis (growth plate).
Sagging rope sign pada metaphysis adalah garis tebal yang melengkung yang berasal dari proyeksi posterior rim (pillar) daripada caput.
Premature physeal arrest bisa terjadi walaupun gangguan pertumbuhan ini bukan karena bridging daripada plate.
Trochanteric overgrowth, caput dan collum, mengalami arah yang baru (redirection).
“Bicompartmentalization” daripada acetabulum menunjukkan sering mengalami “transient adaptive change” yang terjadi pada acetabulum yang mengakomodasi bentuk caput yang mengalami deformasi.
Gambaran final radiologis daripada LCPD
Bisa normal, caput yang bulat dan collum memanjang dengan sedikit flattening daripada caput dengan acetabulum yang congruent sampai caput sangat datar (coxa plana). Bisa dengan gangguan pertumbuhan dan premature arrest daripada physis dengan relative over growth daripada trochanter mayor. Spectrum deformitas ini diklasifikasi menurut Stulberg.
Keadaan lain yang memberikan gambaran x-ray serupa LCPD :
Epiphyseal dysplasia : SED, MED [dwarfism] hemoglobinapathies, endocrine disorders (hypothyroidism) dan lain-lain
KLASIFIKASI LCPD pada GAMBARAN X-RAY
1. Catterall
2. Thomson-Salter
3. Herring (lateral pillar)
Dengan scintigraphy
4. Conway-Dias
Klasifikasi menurut Catteral (1971)
Catteral membagi Perthes disease menjadi 4 group : sesuai dengan luasnya kerusakan caput femur (extent of involvement)
Group I dan II mempunyai prognose baik (90%) tak perlu intervensi
Group III dan IV mempunyai prognose jelek (90%) perlu suatu tindakan.
Klasifikasi ini berdasarkan foto frog-lateral dan AP, yaitu pada fase fragmentasi (saat terjadinya lucencies yang sebelumnya dense head)
Kerugian cara klasifikasi Catterall yaitu pembagian grup ini bisa berubah selama proses penyakit berjalan.
Catterall Group I
terkena hanya bagian anterior epiphysis (hanya tampak pada foto frog-lateral). Caput mengalami collapse <25%
Catteral Group II
fragmentasi segmen sentral dan collapse. Sedangkan lateral rim (pilar) masih intak sehingga memproteksi daerah sentral yang terkena. Caput mengalami collapse <50%
Catterall Group III
lateral head juga terkena atau fragmented, hanya bagian medial yang masih bebas (baik). Hilangnya lateral support memperburuk prognosis. Caput collaps <75%
Catterall Group IV
seluruh caput terkena (100%)
Cristienson et al (1986) kurang setuju dengan klasifikasi Catterall karena terjadi kesalahan yang signifikan inter dan intraobserver, dan tidak bisa dipakai untuk LCPD stadium awal.
Catterall menambahkan “risk factor” atau “head at risk collaps”
1. Gage sign : V shaped lucency pada lateral epiphysis.
2. Lateral calcification : pada lateral epiphysis, menunjukkan lateral support hilang
3. Lateral subluxation daripada caput, menunjukkan lateral support hilang
4. Horizontal growth plate, menunjukkan fenomena growth arrest dan deformitas
5. Metaphyseal cyst
Klasifikasi menurut Salter dan Thomson (1984)
Salter dan Thomson menyederhanakan klasifikasi Catterall menjadi 2 group klasifikasi : sesuai dengan besarnya fraktur subchondral.
1. Salter dan Thomson Group A : kurang dari 50% caput terkena (Catterall Group I dan II)
2. Salter dan Thomson Group B : lebih dari 50% caput terkena (Catterall Group II dan IV)
Sama halnya dengan Catterall, klasifikasi ini berdasarkan perbedaan integritas pilar bagian lateral.
Klasifikasi menurut Herring (Lateral Pillar) 1992
Klasifikasi ini berdasarkan atas tingginya pilar lateral daripada epiphysis dibandingkan yang normal pada AP-x-ray sendi panggul pada stadium awal fragmentasi. Apabila lateral rim (pilar) daripada caput masih intak, ini merupakan weight bearing portion dan akan memproteksi central portion dari kejadian collaps. Apabila lateral pillar terganggu integritasnya, kemudian seluruh caput (head) akan terjadi collaps (flatten)
Interobserver reliability lebih besar
Better predictor of long term outcome
Herring Lateral Pillar classification terdiri dari 3 group :
1. Lateral pillar Group A
Normal, tidak ada collaps dari pillar 1/3 lateral head. Fragmentasi terjadi pada segmen sentral daripada head
2. Lateral pillar Group B
Lateral pillar collaps <50% mungkin ada sedikit extrusion dari pada head
3. Lateral pillar Group C
Lateral pillar collaps >50%. Pillar lateral lebih rendah dari awal segmen sentral
Conway – Dias Classification (1997)
Klasifikasi ini dibuat menentukan prognose dengan cara bone scintigraphy
A pathway terdiri dari 4 stages
B pathway terdiri dari 4 stages
HUBUNGAN CAPUT dan ACETABULUM
Caput tergantung dari acetabulum yang bisa mencetak bentuk seperti es cream dibentuk sebagai wadahnya (scoop).
Hasil yang jelek LCPD karena bagian yang lunak daripada head keluar dari acetabulum
Salter dan Klisic membuat index acetabulum – head (epiphysis) :
• kurang dari 10% : tidak ada extrusion
• (10-20%) : sedikit extrusion
• >20% : severe extrusion
Pada gambar Klisic dan Salter membuat (menguraikan) epiphyseal extrusion
Menurut Klisic : bila extrusion >20% perlu dilakukan terapi “coaptation”.
PERJALANAN LCPD (NATURAL HISTORY)
1. Caput femoris spheris (bentuk normal)
2. Caput femoris spheris : coxa magna, coxa brevis, steep acetabulum
3. Caput femoris tidak spheris :
• cylinder
• bentuk sadel
PENILAIAN FINAL OUTCOME LCPD pada AKHIR PERTUMBUHAN
1. Cara Mose
2. Cara Stulberg
a. Klasifikasi Mose dengan mempergunakan Mose template : x-ray pada posisi AP dan lateral
a. head contour dalam batas 1 mm lingkaran baik
b. head contour dalam batas 2 mm lingkaran sedang
c. head contour dalam batas > 2 mm lingkaran jelek
b. Klasifikasi Stulberg
• Stulberg I : head normal spheris, congruens dengan acetabulum
• Stulberg II : head spheris,congruens, coxa magna, coxa brevis, steep acetabulum
• Stulberg III : head oval tetapi tidak flat (mendatar), congruens dalam steep acetabulum (aspherical congruency)
• Stulberg IV : head flat yang signifikan, congruens deformed acetabulum (aspherical congruency)
• Stulberg V : head flat tidak terakomodasi dalam acetabulum (aspherical incongruens) : prognose jelek
PROGNOSE
Menurut Thomson dan Salter
Ada 2 aspek utama mengenai prognosis LCPD
1. Prognose jangka pendek, deformitas caput femoris sampai fase kesembuhan.
2. Prognose jangka panjang, deformitas akhir setelah dewasa karena osteoarthritis sekunder
3. Ada tambahan. Baca revisi di kertas kecil.
Prognose jangka pendek : deformitas caput femoris
Ada 5 faktor yang signifikan :
a. Faktor sex : wanita mempunyai prognose lebih jelek dibanding pria, tak jelas penyebabnya. Kerusakan caput femoral epiphysis (CFE) pada wanita lebih luas.
b. Faktor umur : bila gejala klinis mulai pada umur (2-6) tahun, prognose baik, sedangkan bila mulai pada umur > 6 tahun prognose kurang baik, sebab kerusakan CFE lebih luas.
c. Faktor luasnya kerusakan CFE sesuai dengan klasifikasi
d. Faktor gerakan (ROM) sendi panggul. Berkurangnya range of motion (ROM) yang persisten karena spasme otot-otot ekstrusi kelateral atau subluksasi caput femur atau kombinasi.
e. Faktor premature physeal closure
Kerusakan yang luas daripada CFE (Catterall IV, Salter Thomson B atau Herring group C, physis ikut mengalami kerusakan, terjadi penutupan yang prematur daripada physis dengan akibat :
pertumbuhan yang tidak simetris, remodelling yang tidak adekwat sehingga terjadi deformitas caput femur.
trochanter mayor overgrowth/coxa vara fungsional
terjadi leg discrepancy
Faktor “head at risk” yang diungkapkan oleh Catterall bukan merupakan faktor prognostik yang signifikan. Hanya lateral extrusion merupakan prognostic yang signifikan (Stulberg dan Salter).
PENANGANAN LCPD
Tujuan dari pada terapi :
Mempertahankan ROM sendi panggul dan containment merupakan dasar terapi LCPD
1. menghilangkan rasa nyeri (hip irritability)
2. memperbaiki dan mempertahankan ruang gerak sendi
3. menghidari terjadinya head extrusion, subluksasi.
4. memperoleh caput femur yang spheris pada saat sembuh.
Sebelum melakukan terapi harus diperhatikan :
• stage dari LCPD
• beratnya
• status psychologis
Dasar-dasar penanganan LCPD
1. obervasi
2. simtomatik
3. definitive early treatment untuk menghindari terjadinya deformation dengan cara containment non surgery atau surgery
4. surgery pada LCPD yang telah mengalami deformation.
Terapi secara umum :
1. umur < 6 tahun prognose umumnya baik. Observasi dan simtomatik bila ada rasa nyeri dan stiffness : bedrest, traksi kulit, NSAID
2. a. Umur antara (6-8) tahun dengan bone age < 6 tahun
Herring A dan B (lateral pillar masih intak), terapi,
prognose sama dengan diatas (1)
b. Umur antara (6-8) tahun dengan bone age > 6 tahun
Herring B : containment treatment : non surgical atau surgical
3. Umur (6-8) tahun : Herring C : Surgical containment.
umur > 9 tahun : Herring B dan C surgical containment, prognose jelek.
Containment treatment
Containment treatment adalah menempatkan caput femoris dalam acetabulum untuk mempertahankan sphericitas caput dalam posisi abduksi.
Wenger mengatakan secara biomekanik, containtment treatment LCPD seperti “ Ice cream cone theory”
Salter mengatakan pada LCPD terjadi “biologic plasticity” maka containment caput femoris didalam acetabulum agar terjadi spherical remodeling saat reossifikasi dan pada fase-fase berikutnya. Tetapi pada kasus LCPD dengan total head involvement (Herring C) dimana lateral pillar mengalami collaps, efek containment kurang memuaskan.
Containment hamper efektif pada keadaan caput masih dalam “plastic phase” yaitu pada fragmentation stage
Ada 2 macam terapi containment :
1. Non surgical
2. Surgical
1. Non surgical containment
dengan abduction cast : Petrie cast, kalau perlu tenotomi adductor.
dengan abduction biasa : macam-macam design (special frames atau brace), selain harga mahal, compliance tidak konsisten. Lama pemakaian brace (12-16) bulan.
2. Surgical containment
Tindakan operasi biasanya dilakukan pada LCPD dengan Catterall grup 3 atau 4 atau pada anak LCPD yang tidak memuaskan pemakaian brace.
a. subtrochanter varus osteotomy : neck-shaft angle tidak boleh <1150
b. Salter innominate osteotomy
Ada beberapa keuntungan dengan surgical containment
lebih cepat mobilisasi penderita
containment yang permanen
permanen improvement, remodeling sampai sembuh.
Dibeberapa negara, ada usaha mengurangi pressure acetabulum-head dan meletakkan agak abduksi dengan cara distraction (orthrodiastasis)
o Hip distraction dan hinge system dengan external fixation (arthrodiastasis) untuk menghindari collapse, menghindari extrusion epiphysis; indikasi pada LCPD grup C, umur lebih dari 9 tahun
Dror Paley, dpaley@lengthening.us
o Trans-Neck – Head Tunnelling (TNHT)
Dr. Nuno Lopes dengan 5 mm hole with a drill (trephine) new vacularization melalui lubang ke epiphysis; baca lebih lanjut : http://clientes.netvisao.pt/nfrancac/
TINDAKAN OPERASI setelah terjadi DEFORMASI
1) Soft tissue release : tenotomi aduktor, iliopsoas, imobilisasi dengan Petrie cast (3-4) bulan. Bila ada extrusion caput, epiphysis dalam osifikasi
2) Cheilectomy : eksisi partial caput femoris
o Caput tidak bisa masuk kedalam acetabulum, setelah dilakukan soft tissue release seperti diatas (1), perlu dilakukan eksisi cartilage bersama tulang bagian yang ekstrusi. Prosedur ini boleh dilakukan bila physis telah menutup, imobilisasi dengan plaster posisi abduksi selama (3-4) bulan.
3) Proximal femoral valgus osteotomy
o Caput femoris sudah sembuh tetapi mengalami deformasi, tidak bisa abduksi. Pada x-ray AP : sendi panggul congruen pada posisi ekstensi dan aduksi. Operasi memperbaiki biomekanik.
4) Greater trochanter advancement
o Premature closure growth plate, collum femoris memendek (coxa brevis), sedangkan trochanter mayor tumbuh memanjang yang progresif. Dilakukan osteotomi trochanter mayor dimobilisasi ke distal dan lateral akan mengurangi rasa nyeri otot, mengurangi atau menghilangkan gait Trendelenburg. Juga bisa mengurangi pressure intraartikuler dan mengurangi resiko denegerative osteoarthrosis.
Legg-Calve-Perthes Disease Classification System
Classification System Group or Class
Herring Salter Catterall Phase/Stage Treatment Options
A 1 I Avascular/synovitis Range-of motion exercises
Casting (Patrie)
II Fragmentation/resorption Abduction orthosis
Crutches
B
2 III Reossification/regeneration Varus osteotomy
Salter osteotomy
C IV Remodelling/residual Distraction arthroplasty
Contralateral epiphysiodesis
Valgus osteotomy/Cheilectomy
Shelf procedure
OKU : Pediatrics 3
KEPUSTAKAAN
- Balasa VV, Gruppo RA, Glueck CJ, et al : Legg-Calve-Perthes disease and thrombophilia. J. Bone Joint Surg Am 86A (12) : 2642-2647, 2004
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- Catterall,A : The Natural history of Perthes disease. J.Bone Joint Surg. Br. 53 (37-53), 1971
- De Luca PA : Legg-Calve-Perthes Disease in Orthopaedic Knowledge Update-Pediatrics 2. American Academy of Orthopaedic Surgeons, Rosemount, Illinois pp (153-160), 2002
- Glueck CJ, Crawford A, Roy D, Freiberg R, Glueck H, Stroop D : Association of Antithrombic Factor deficiencies and hypofibrinolysin with Legg-Perthes-Disease, J.Bone Joint Surg.Am. 70 : (3-13), 1996
- Glueck CJ, Freiberg R, Tracy T, Stroop D, Wang P. Thrombophylia and hypofibrinolysis. Pathophysiology of osteonecrosis. Clin. Orth. Rel. Res. 334 : (43-56), 1997
- Glueck CJ, Glueck H, Greenfield D, Freiberg R, Hamer T, Stroop D, Troly T : Protein C and S deficiency, thrombophylia and hypofibrinolysis. Pathophysiologic causes of Legg-Perthes-Disease. Paediat.Res 35 : (383-388), 1994
- Glueck CJ, Freiberg R, Crawford A, Roy D, Tracy T, Sieve D and Wang. Second Hand Smoke, hypofibrinolysis and childhood osteonecrosis of the hip. Legg-Perthes-Disease (abstract). J. Invest.Med 44 : 37A, 1996
- Grueb Lee DM. Disorders of the hip. JB. Lipincott Co.Philadelphia, 1983
- Herring JA, Neustadt JB, Wiilliam JJ, Early JS, Browne PH. The Lateral Pillar Classification of Legg-Calve-Perthes-Disease. J.Ped.Orth. 12 : (143-150), 1992
- Katz JF, Siffert PS. Management of Hip Disorders in Children JB. Lipincott Co.Philadelphia, 1983
- Klisic : Personal Communication
- Mata SG,Aicua EA, Ovejero AH, Grande MM. Legg-Calve-Perthes disease and Passive smoking. J. Paed. Orthop 10 : (326-330). 2000
- Maxwell SL, Lappin KJ, Kealey WD, Mc Dowell BC, Cosgrove AP : Arthrodiastasis in Perthes disease. J Bone Joint Surg. Br 86 (2) : 244-250, 2004
- Salter RB, Thomson GH : Legg-Calve-Perthes disease. The Prognostic Significance of Subchondral Fracture and a two group Classification of the Femoral Head Involvement. J.Bone Joint Surg.Am. 66 : (479-489), 1984
- Smith GS, Pierz KA, Zahradnic JL, Legg-Calve-Perthes disease in Orthopaeic Knowledge Update. Pediatrics 3, American Academy of Orthopaedic Surgeons. p. 165-178, 2006
- Staheli LT. Fundamentals of Pediatric Orthopaedics. Raven Press, New York, 1992
- Stulberg SD, Cooperman DR, Wallenstein R. The Natural History of Legg-Calve-Perthes Disease. J. Bone Joint Surg. Am. 63 : (1095-1108), 1981
- Tachjian MO. Pediatric Orthopaedic. 2nd Ed W.B. Saunders Co. Philadelphia, 1990
- Thomson GH, Salter RB. Legg-Calve-Perthes Disease. Clinical Symposia-Ciba Vol. 38 No.1, 1986
- Thomson GH, Salter RB. Legg-Calve-Perthes Disease. Current Concepts and Controversies. Orth. Clin. N. Am. 18 : (617-635), 1987
- Tsao AK, Dias LS, Sonway JJ, Shake P : The Prognostic Value and Significance of Serial Bone Scintigraphy in Legg-Calve-Perthes disease. J. Pediatr. Orthop. 17 : (320-239), 1997
- Wall EJ. Legg-Calve-Perthes Disease. Current opinition in Orthopaedics 11: (137-140), 2000
- Wenger DR, Rang M : The Art and Practice of Children’s Orthopaedic Raven Press, New York, 1993
- The average duration of Perthes’ disease is:
a. 1-2 years.
b. 3- 4 years.
c. 1 month - 6 months.
d. 6 months - 1 year.
b. 3 -4 years
- Which one of the followings is the most important component of a stainless steel 316 L as the material of orthopaedic implants to prevent corrosion in the human body
- Ni
- MO
- Cr
- C
- P
. answer : 3. Cr
Stainless steel (316L) is the most susceptible metal to both crevice corrosion and galvanic corrosion
Corrosion can be decreased by using similar metals (e.g., with plates and screws of similar metals), with proper design of implants, and with passivation by an adherent oxide layer (a thin layer that effectively separates the metal from the solution [e.g., stainless steel coated with chromium oxide]).
Reference : Miller’s Orthopedic Review. 5th ed. Ch 1
- Repair of the peripheral one third of the meniscus is sometimes possible because it has which of the following characteristic?
a. increasing blood supply √
b. appropriate viscoelasticity
c. high glycoprotein concentration
d. high type II collagen concentration
e. large size
Answer : a increasing blood supply
Meniscus
- Anatomy (knee meniscus)—Triangular semilunar structure. Peripheral border is attached to the joint capsule. The medial meniscus is semicircular; the lateral meniscus is circular.
- Histology—The meniscus is composed of fibroelastic cartilage (Fig. 1–45), with an interlacing network of collagen fibers (90% type I), proteoglycans, glycoproteins, and cellular elements (Box 1–2).
- Innervation and blood supply (knee meniscus)—The peripheral two thirds is innervated by types I and II nerve endings (concentrated in the anterior and posterior horns; few fibers are found in the meniscal body); the greatest concentration of mechanoreceptors is in the posterior horns. Blood supply is from the geniculate arteries. Vessels branch circumferentially to form a plexus supplying the peripheral 25% of the meniscus; the remaining meniscus receives nutrition via diffusion. Peripheral meniscal tears in the vascularized region (“red zone”) can heal via fibrovascular scar formation, making surgical repair necessary; more central tears in the avascular region (“white zone”) cannot. The cell responsible for meniscal healing is the fibrochondrocyte. Peripheral acute meniscal tears with a rim width <4 mm have the best healing characteristics.
- What is the correct order (ranking lowest to highest) for the tensile modulus of elasticity of the following materials?
a. trabecular bone, polymethylmethacrylate (PMMA), cortical bone, titanium alloy, stainless steel √
b. trabecular bone, cortical bone, PMMA, titanium alloy, stainless steel
c. trabecular bone, PMMA, cortical bone, stainless steel, titanium alloy
d. trabecular bone, cortical bone, PMMA, stainless steel, titanium alloy
e. PMMA, trabecular bone, cortical bone, titanium alloy, stainless steel
Answer : a. trabecular bone, polymethylmethacrylate (PMMA), cortical bone, titanium alloy, stainless steel √
- What portion of the knee meniscus has the greatest concentration of mechanoreceptors?
a. peripheral one third
b. central one third
c. inner two third
d. anterior horn
e. posterior horn
Answer : e. posterior horn
Innervation and blood supply (knee meniscus)—The peripheral two thirds is innervated by types I and II nerve endings (concentrated in the anterior and posterior horns; few fibers are found in the meniscal body); the greatest concentration of mechanoreceptors is in the posterior horns
Reference : Miller’s Orthopedic Review. 5th ed.
- What is the most common reason for reoperation in total knee arthroplasty
a. polyethylene insert failure
b. malalignment of the knee
c. ligamentous instability
d. perioperative infection √
e. patellar related complication
Answer : d. perioperative infection
- What force is the most responsible for the initiation of loosening of a cemented femoral stem
a. frictional torque from the femoral-acetabular articulation
b. rotational torque in retroversion
c. repetitive axial loading in gait √
d. high impact loading
e. lateral loading
c. repetitive axial loading in gait
- Which of the following factor is most common associated with mechanical failure of a cemented total hip arthroplasty
a. increased stem offset
b. varus position of the stem √
c. osteoporotic bone
d. patient weight of greater than 154 lb
e. gender
Answer : b. varus position of the stem
- In revision total hip arthroplasty, an acetabular reconstruction cage is best indicated for which of the following patterns of bone loss
a. enlarged acetabular rim
b. cavitary central defect √
c. superior migration of 2 cm
d. deficient anterior wall
e. pelvic discontinuity
Answer: b. cavitary central defect
- The major blood supply to the cruciate ligaments arises from which of the following structure
a. superior genicular artery
b. middle genicular artery √
c. inferior genicular artery
d. infrapatellar fat pad
e. intramedullary vessels
Answer: b. middle genicular artery
- In the ACL deficient knee, which of the following variable has the highest correlation with the development of arthritis
a. duration of time since the injury
b. patient age
c. additional ligament injury
d. degree of laxity
e. meniscal integrity
Answer : e. meniscal integrity
- ACL injury reconstruction in athlete
a. does not reduce meniscal injury
b. with hamstring tendon gives poor result
c. does not allow for reinnervation with mechanoreceptors √
d. affect recovery of function if it is delayed till full extension is achieved
e. allows early return to athletics by 6 wks without risk of failure
Answer : c. does not allow for reinnervation with mechanoreceptors √
- Unicompartment knee joint replacement
a. is indicated in pt with medial compartment osteoarthritis
b. is contraindicated in rheumatoid arthritis
c. is contraindicated when there is a flexion contracture of 30 degrees √
d. requires a polyethylene tibial tray of less than 5 mm thickness
e. with ligament imbalance cause failure
Answer: c. is contraindicated when there is a flexion contracture of 30 degrees
(1) Chronic inflammatory arthritis such as rheumatoid arthritis and gout. Chondrocalcinosis due to calcium pyrophosphate deposition disease and evident radiologically or at arthroscopy is also a contraindication because of the aggressive inflammatory synovitis involving the whole joint.
(2) The anterior cruciate ligament should be intact.
(3) If there is lateral subluxation of the tibia on the weight-bearing X-ray with or without an obvious ‘lateral thrust’ on walking, unicompartmental knee replacement is unwise.
(4) The deformity of the knee should only be mild and therefore a flexion contracture of greater than 15 degrees, a varus deformity greater than 10 degrees or a valgus deformity greater than 20 degrees is a contraindication.
(5) The pathological changes in the opposite compartment or in the patello-femoral joint should only be mild. If there is significant loss of articular cartilage down to subchondral bone in the opposite compartment or in the patello-femoral joint unicompartmental replacement should not be undertaken.
Reference : Rush J. Unicompartmental knee joint replacement. Current Orthopaedics (2001) 15, 143-147
- The ACL ligament
a. passes from the medial femoral condyle to the tibia in front of the tibial spine
b. prevents posterior translation of tibia on the hyper extended knee
c. healing depends on intact synovial lining √
d. Lachman test for ACL integrity is done with the knee in extension
e. In chronically ACL deficient knee there is no risk of medial meniscus tears
Answer : c. healing depends on intact synovial lining √
- Successful arthrodesis using external fixation following debridement of an infected total knee replacement is most dependent on what factor
a. type on infecting organism
b. degree of bone loss √
c. external fixator frame configuration
d. an immunocompromised patient
e. underlying diagnosis of rheumatoid arthritis
Answer: b. degree of bone loss
Knee arthrodesis
Position— For primary arthrodesis, the desired position is 5-8 degrees of valgus, 0-10 degrees of external rotation (to match the other foot), and 0-15 degrees of flexion.
3. Technique—Intramedullary nailing is the preferred technique for arthrodesis when extensive bone loss (seen after failed total knee or tumor resection) does not allow compression to be exerted across broad areas of cancellous bone. Union rates in this scenario are much higher (up to 100%) with medullary rod fixation than with external fixation (38%). Bone graft can be used to augment arthrodesis when bone loss is encountered
Reference ; Miller’s Orthopaedic review. 5th ed.
- In lateral exposure of the hip joint
a. the lateral cutaneus nerve of thigh is at risk from injury
b. gluteal muscles are stripped from the ilium
c. medial circumflex artery is ligated
d. vastus lateralis is split
e. the interval between gluteus medius & tensor fascia lata is used to enter the hip
Answer: e. the interval between gluteus medius & tensor fascia lata is used to enter the hip
Hardinge
- Place the patient supine with the greater trochanter at the edge of the table and the muscles of the buttocks freed from the edge.
* Make a posteriorly directed lazy-J incision centered over the greater trochanter (Fig. 1-69 A).
* Divide the fascia lata in line with the skin incision and centered over the greater trochanter.
* Retract the tensor fasciae latae anteriorly and the gluteus maximus posteriorly, exposing the origin of the vastus lateralis and the insertion of the gluteus medius
* Incise the tendon of the gluteus medius obliquely across the greater trochanter, leaving the posterior half still attached to the trochanter. Carry the incision proximally in line with the fibers of the gluteus medius at the junction of the middle and posterior thirds of the muscle. Distally, carry the incision anteriorly in line with the fibers of the vastus lateralis down to bone along the anterolateral surface of the femur - Elevate the tendinous insertions of the anterior portions of the gluteus minimus and vastus lateralis muscles. Abduction of the thigh exposes the anterior capsule of the hip joint .
* Incise the capsule as desired.
* During closure, repair the tendon of the gluteus medius with nonabsorbable braided sutures
Reference : Campbell’s Operative Orthopaedic. 11th ed.. Ch 1.
- During an anterolateral (Watson-Jones) approach to the hip, bleeding when the reflected head of the rectus femoris is detached from the joint capsule most likely indicates injury to which of the following arteri?
a. profunda femoris
b. medial femoral circumflex
c. ascending branch of the lateral femoral circumflex √
d. transverse branch of the lateral femoral circumflex
e. common femoral
Answer : c. ascending branch of the lateral femoral circumflex
Watson-Jones
* Begin an incision 2.5 cm distal and lateral to the anterior superior iliac spine and curve it distally and posteriorly over the lateral aspect of the greater trochanter and lateral surface of the femoral shaft to 5 cm distal to the base of the trochanter (Fig. 1-66). * Locate the interval between the gluteus medius and tensor fasciae latae. The delineation of this interval often is difficult. Brackett pointed out that it can be done more easily by beginning the separation midway between the anterior superior spine and the greater trochanter, before the tensor fasciae latae blends with its fascial insertion. The coarse grain and the direction of the fibers of the gluteus medius help to distinguish them from the finer structure of the tensor fasciae latae muscle. * Carry the dissection proximally to expose the inferior branch of the superior gluteal nerve, which innervates the tensor fasciae latae muscle. * Incise the capsule of the joint longitudinally along the anterosuperior surface of the femoral neck. In the distal part of the incision, the origin of the vastus lateralis may be reflected distally or split longitudinally to expose the base of the trochanter and proximal part of the femoral shaft. * If a wider field is desired, detach the anterior fibers of the gluteus medius tendon from the trochanter or reflect the anterosuperior part of the greater trochanter proximally with an osteotome, together with the insertion of the gluteus medius muscle. This preserves the insertion of the gluteus medius in such a way that it can be easily reattached later
Reference : Campbell’s Operative Orthopaedics. 11th ed. Ch 1
- In a posterolateral approach to the femur for fixation of an intertrochanteric fracture, bleeding in encountered as the vastus lateralis muscle is dissected from the linea aspera. The bleeding vessels are most likely branches of which of the following arteries:
a. medial femoral circumflex
b. transverse branch of the lateral femoral circumflex
c. deep femoral √
d. superficial femur
e. descending branch of the lateral femoral circumflex
Answer : c. deep femoral
- In the anterior approach to the proximal third of the radius, the deep muscle incised to gain access to the bone is innervated by which nerve:
a. radial
b. median
c. posterior interosseus √
d. ulnar
e. musculocutaneous
Answer : c. posterior interosseous nerve
Henry approach
With the forearm supinated, begin a serpentine longitudinal incision at a point just lateral and proximal to the biceps tendon, and extend it distally in the forearm along the medial border of the brachioradialis and, if necessary, as far as the radial styloid
* Expose the biceps tendon by incising the deep fascia on its lateral side; divide the deep fascia of the forearm in line with the skin incision, taking care to protect the radial vessels * Isolate and ligate the recurrent radial artery and vein immediately; otherwise, the cut ends may retract, resulting in a hematoma that may cause ischemic (Volkmann) contracture of the forearm flexor muscles. Flex the elbow to a right angle to allow more complete retraction of the brachioradialis and the radial carpal extensor muscles to expose the supinator. * Incise the bicipital bursa, which lies in the angle between the lateral margin of the biceps tendon and the radius, and from this point distally, **strip the supinator subperiosteally from the radius and reflect it laterally; it carries with it and protects the deep branch of the radial nerve** * Pronate the forearm and expose the radius by subperiosteal dissection
reference : Campbell’s Operative Orthopaedics. 11th ed. Ch 1
- In posterior approaches to the shoulder, the radial nerve is relatively well-protected from injury by the
a. teres major √
b. teres minor
c. latissimus dorsi
d. trapezius
e. subscapularis
Answer : a. teres major
- In the posterior surgical approach to the humeral shaft, which of the following portions of the triceps muscle would be split
a. long head
b. medial head √
c. lateral head
d. long & medial heads
e. medial & lateral heads
Answer: b. medial head
Posterior approach of humerus
There is no true internervous plane; dissection involves separating the heads of the triceps brachii muscle, all of which are supplied by the radial nerve. Because the nerve branches enter the muscle heads relatively near their origin and run down the arm in the muscle’s substance, splitting the muscle longitudinally does not denervate any part of it. In addition, the medial head (which is the deepest head) has a dual nerve supply consisting of the radial and ulnar nerves; splitting the medial head longitudinally does not denervate either half
reference : Surgical Exposures in Orthopaedics: The Anatomic Approach. Hoppenfeld. 3rd ed. 2003
- In anterior surgical approach to the shoulder
a. the exploration is between the deltoid & pectoralis major muscles √
b. cephalic vein is retracted medially
c. musculocutaneous nerve is protected by avoiding dissection lateral to pectoralis minor
d. the subscapularis tendon is found posterior to the shoulder capsule
e. the axillary nerve is just inferior to shoulder capsule
Answer : a. the exploration is between the deltoid & pectoralis major muscles
Henry approach
Begin the incision over the anterior aspect of the acromioclavicular joint, passing it medially along the anterior margin of the lateral one third of the clavicle and distally along the anterior margin of the deltoid muscle to a point two thirds the distance between its origin and insertion (Fig. 1-88).
• Expose the anterior margin of the deltoid. The cephalic vein and the deltoid branches of the thoracoacromial artery lie in the interval between the deltoid and pectoralis major muscles (the deltopectoral groove), and although the cephalic vein may be retracted medially along with a few fibers of the deltoid muscle, it may be damaged during the operation. Ligating this vein proximally and distally as soon as it is reached may be indicated.
• Define the origin of the deltoid muscle on the clavicle; detach it by dividing it near the bone or at the bone together with the adjacent periosteum or by removing part of the bone intact with it. We prefer the first method, leaving enough soft tissue attached to the clavicle to allow suturing the deltoid to its origin later.
• Laterally reflect the anterior part of the deltoid muscle to expose the structures around the coracoid process and the anterior part of the joint capsule.
• To expose the deep aspects of the shoulder joint more easily, including the anterior margin of the glenoid, osteotomize the tip of the coracoid process. First, incise the periosteum of the superior aspect of the coracoid; next, cut through the bone and reflect medially and distally the tip of the bone along with the attached origins of the coracobrachialis, the pectoralis minor, and the short head of the biceps.
• For wider exposure, divide the subscapularis at its musculotendinous junction about 2.5 cm medial to its insertion into the lesser humeral tuberosity; separate the tendon medially from the underlying capsule and expose the glenoid labrum.
• When closing the wound, some surgeons replace the tip of the coracoid; if this is done with a screw, it is helpful to drill a hole in the process before osteotomy. We prefer to excise the tip subperiosteally and to suture the origins of the coracobrachialis, the pectoralis minor, and the short head of the biceps to the coracoid.
• Suture the deltoid in place, and close the wound in the usual way.
• If an extensile exposure is unnecessary, the skin incisions and deeper dissection may be limited to the deltopectoral portion of the approach. The anterior deltoid muscle need not be detached from the clavicle. Approach the joint anteriorly without an osteotomy of the coracoid process by retracting the short head of the biceps muscle in a medial direction. Take care to avoid a traction injury to the musculocutaneous nerve lying beneath the short head of the biceps in the distal part of this wound.
• Instead of this curved anteromedial approach, Henry later used an incision that arches like a shoulder strap over the shoulder from anterior to posterior (Fig. 1-89). The anterior part of this incision is similar to the deltopectoral part of his original approach, but at its superior end it proceeds directly over the superior aspect of the shoulder and distally toward the spine of the scapula. Mobilize a lateral flap by dissecting between the subcutaneous tissues and the deep fascia, and expose the lateral and posterior margins of the acromion and adjacent spine of the scapula. Detach as much of the deltoid as needed to reach the deeper structures sought
Reference : Campbell’s Operative Orthopaedics. 11th ed. Ch 1.
- When posterolateral bone grafting is performed for non-union of the tibia, the structure at most risk for injury is the
a. posterior tibial nerve
b. sural nerve
c. superficial peroneal nerve
d. lesser saphenous vein
e. peroneal artery √
Answer: e. peroneal artery
A. What the diagnosis
B. What the classification of this condition according Wassel’s classification
C. Please mention 1 syndrome that associate with this condition
D. How you treat this condition
A. Bifide thumb manus
B. Wassel classification IV
Wassel’s classification
Tipe I: Bifurkasi pada level falang distal
Tipe II: Bifurkasi pada level interphalang joint. Dapat dilihat bahwa falang proksimal tidak selalu simetris
Tipe III: Bifurkasi pada level falang proksimal. Pada level ini falang proksimal seperti terbelah, dan pada umumnya satu jari tidak fungsional
Tipe IV: Bifurkasi pada level joint. Pada level bifurkasi ini tampak bahwa penderita mempunyai jari tambahan yang sudah utuh.
Tipe V: Bifurkasi pada level metacarpal. Dapat dilihat os metacarpal yang terbelah
Tipe VI: Bifurkasi pada level carpometacarpal joint
Tipe VII: Triphalangeal thumb pada level metacarpophalangeal joint (varian tipe IV)
C. C. Acrocephalopolydactyly/Bloom/Holt-Oram/Fancony syndrome
D. Ablation of duplicated radial accessory by modified Bilhaut-Cloquet procedure
What is the diagnosis of this painful lesion in a 35-year-old female?
A. What is the pathognomonic feature of this lesion?
B. List the complications
C. Discuss the treatment
A. Giant cell tumor of the upper tibia (osteoblastoma). A secondary malignant deposit is the main differential diagnosis
B. An expansive lytic lesion at the end of a long bone extending to the joint surface is characteristic of giant cell tumours. Frequently there are trabeculae and a ‘soap-bubble” appearance. About one-third of such tumours are benign, one-third are usually invasive and one-third metastatic. Patients are usually age 20-40 years and female, and present with pain (sometimes a pathological fracture), swelling or inflammation of the adjacent joint
C. Recurrence (50%) after curretages alone, metastases and malignant transformation (10%)
D. Small lesions require curretage, cryotherapy and bone grafting. Large lesions such as this may require complete excision and bone or prosthetic replacement or, alternatively, radiotherapy and/or amputation if surgical reconstruction is impossible
- Which of the palpable anterior structure in the midline aids in identification of the C6 level during an anterior approach to the cervical spine ?
a. Lower border of the mandible
b. Hyoid bone
c. Thyroid cartilage
d. Cricoid cartilage
e. Carotid cartilage
Answer:d. Cricoid cartilage
- An incidental dural tear was primarily repaired with a watertight closure during an otherwise uncomplicated laminectomy. After surgery, the patient should be informed that
a. The chance of resolution of the preoperative symptoms will be decreased
b. There is a greater risk of a wound infection
c. The clinical outcome will be unaffected
d. Strict bed rest for 2 weeks is recommended
e. A compression dressing must be maintained for 7 days
Answer : c. The clinical outcome wii be unaffected
- A 55 year-old man is referred for orthopaedic consultation of a meniscal tear that is evident on MRI. What radiographic view is most likely to reveal concomitant arthritic changes ?
a. Merchant
b. 45 degrees posteroanterior flexion weight-bearing
c. 45 degrees posteroanterior flexion non-weight-bearing
d. Anteroposterior weight-bearing
e. Anteroposterior non-weight-bearing
Answer : 45 degrees posteroanterior flexion weight-bearing
- A sedentary 65 year old woman has pain and swelling localized to the first metatarsophalangeal joint for the past 12 months. She underwent a Silastic implant arthroplasty for hallux rigidus 12 years ago. Examination reveals that the first metatarsophalangeal joint is swollen and warm and has less than 20° of total motion. The lesions. Most of her arythema resolves with elevation. She is afebrile, and her C-reactive protein level and erythrocyte sedimentation rate are within normal limits. What is the most appropriate surgical treatment for this patient ?
a. Implant removal and joint debridement
b. Dorsiflexion phalangeal osteotomy
c. First metatarsal shortening osteotomy
d. First metatarsophalangeal joint fusion with bone block autograft
e. Revision Silastic arthroplasty
Answer : a. Implant removal and joint debridement
- Which of the following findings is considered a contraindications to a mobile – bearing unicompartmental knee arthroplasty ?
a. A range of flexion of 110°
b. A flexion of deformity of 10°
c. A correctable varus deformity of 5°
d. Absence of the anterior cruciate ligament
e. Osteophytes in the patellofemoral compartment
Answer: d. Absence of the anterior cruciate ligament
- What complication is frequently associated with a Weil Lesser metatarsal osteotomy (distal, oblique) in treating a lesser toe deformity ?
a. Excessive shortening
b. Dorsal displacement of the metatarsal head
c. Osteonecrosis of the metatarsal head
d. Nonunion
e. Extended or “ floating toe”
Answer : e. Extended or “ floating toe”
Which of the following is the most significant rehabilitation limitation after total shoulder arthroplasty ?
a. Deltoid insertion release required for exposure
b. Detachment of the subscapularis
c. Capsular repair
d. Porous ingrowth material on the surface of the device
e. Pectoralis major reattachment
Answer : b. Detachment of the subscapularis
- Compared to the use of a monoblock metal-backed tibial component in knee arthroplasty, use of a mosular tibial component results in :
a. Increased articular surface wear
b. Increased backside wear
c. Increased stress shielding of the tibia
d. Decreased articular surface wear
e. Decreased backside wear
Answer : b. Increased backside wear
- Which of the following condition is a relative contraindication to resurfacing hip
a. Coxa vara
b. Coxa valga
c. Rheumatoid arthritis
d. Subchondral acetabular cysts
e. Female gender
Answer: a. Coxa vara
- A 50 year-old has type II diabetes mellitus with neuropathy and palpable foot pulses. Examination reveals a 3- x 3- cm heel ulcer with osteomyelitis isolated to the calcaneal tuberosity. Treatment should consist of
a. Syme amputation
b. Below knee amputation
c. Above knee amputation
d. Partial calcanectomy
e. Coverage of the ulcer with a free flap
Answer : d. Partial calcanectomy
- A displaced midshaft clavicle fracture heals with 2 cm of shortening. What is the patient’s most likely clinical complaint ?
a. Decreased shoulder muscle strength and endurance
b. Decreased shoulder external rotation
c. Decreased shoulder abduction
d. Shoulder instability
e. Paresthesia and weakness in the arm below the shoulder
Answer: a. Decreased shoulder muscle strength and endurance
- Locked plate/screw constructs compared to non – locked plate / screw constructs results in :
a. Greater plate-bone friction for stability
b. Less angulation in comminuted metaphyseal fractures
c. Sequential rather than simultaneous screw failure
d. Better compression of the fracture
e. Easier reduction of the bone to the contoured plate.
Answer: b. Less angulation in comminuted metaphyseal fractures
- Which of the following studies is commonly used to radiographically classify / grade slipped capital femoral epiphysis ? :
a. CT of the hip
b. AP pelvis radiograph
c. Lateral hip radiograph
d. MRI of the hip
e. Hip sonography
Answer: c. . Lateral hip radiograph
- What is the most common complication after a transtibial amputation in children ?
a. Bone overgrowth
b. Phantom pain
c. Shortness of the residual limb
d. Varus knee deformity
e. Wound healing problems
Answer: a. bone overgrowth
- Which of the following terms best describes a child with spastic cerebral palsy involving both the upper and lower extremities with greater involvement present in the lower extremities ?
a. Total body
b. Quadriplegia
c. Diplegia
d. Paraplegia
e. Hemiplegia
Answer : c. diplegia
The term spastic diplegia is now universally preferred over paraplegia. Osler called it “bilateral spastic hemiplegia”. Spastic diplegia referred to one who has obvious spasticity in the lower limb, and none in the upper limbs except for fine motor coordination defect. Most were born preterm with a birth weight less than 2500 gr, and their prognosis for life function is generally good.
Paraplegia
Bleck referred to paraplegia as one who has spasticity in the lower limb with absolutely no involvement of upper limbs, and no associated defects.
Reference : Bleck EL. Orthopaedic Management in Cerebral Palsy. 2 nd ed. Pg 5.
- A 32- tear old-boy has been treated in the past with the Ponseti method for an isolated right clubfoot. He currently supinates and inverts his foot while walking. Examinations reveals full subtalar joint motion and dorsiflexion to 30°. Treatment should consist of :
a. Tibialis anterior tendon transfer to the lateral cuneiform
b. Split anterior tibialis tendon transfer
c. Split posterior tibialis tendon transfer
d. Tibialis anterior lengthening and cuboid closing wedge osteotomy
e. Posteromedial release
Answer : a. Tibialis anterior tendon transfer to the lateral cuneiform
- A 2-year old boy will not bear weight after tripping over a curb. He is afebrile. Laboratory studies show a WBC count of 6,000/mm3 (normal 3.500 to 10.500/ mm3 ) and an erythrocyte sedimentation rate of 10mm/h (normal up to 20 mm/h). Examination reveals reproducible tenderness over the midshaft of the right tibia. AP and lateral radiographs of the right femur and tibia are negative. What is the next most appropriate step in management ?
a. MRI of the femur
b. Ca++, alkaline phosphatase, and vitamin D levels
c. CT to rule out occult fracture
d. Long Leg Cast
e. Skeletal survey
Answer : d. Long Leg Cast
- A 2 year old boy has not been using his left arm since his mother pulled it while crossing the street. Examination reveals that the child doesn’t spontaneously move the left arm. The left elbow is held in flextion and pronation. The child is apprehensive with attempts to further flex or rotate the forearm. Radiographs of the elbow show no fracture. What is the next most appropriate step in management ?
a. MRI of the elbow
b. Initiation of formal child abuse work-up
c. Open reduction and / or ligament reconstruction
d. Long arm cast for three weeks
e. Reduction maneuver of the elbow with forced supination and hyper flexion
Answer : e. Reduction maneuver of the elbow with forced supination and hyper flexion
- In abused children, what is the most common fracture
a. Clavicle
b. Distal radius
c. Hip
d. Humerus
e. Pelvis
Answer : d. humerus
- Which of the following bone tumors contains epithelial cells in addition to mesenchymal cells ?
a. Osteosarcoma
b. Adamantinoma
c. Conventional chondrosarcoma
d. Osteoma
e. Giant cell tumor
Answer: b. Adamantinoma
- Increased telomerase activity in chondrosarcoma, as determined by immunohistochemistry, has been shown to directly correlate with :
a. Decreased tumor grade
b. The rate of recurrence
c. Technetium activity on a bone scan
d. Gadolinium uptake on MRI
e. Tumor senescence
Answer: b. The rate of recurrence
- Synovial sarcoma is closely associated with a translocation involving what genes ?
a. BCR-ABL
b. EWS-FLI1
c. PDGF-COL1A1
d. SYT-SSX
e. PAX3-FKHR
Answer : d. SYT-SSX
- The dorsal branch radial artery passes through what two structures to continue as the deep palmar arch ?
a. Abductor digiti minimi and flexor digiti minimi brevis
b. Two heads of the forst dorsal interosseous muscle
c. Extensor pollicis longus and extensor carpi radialis longus
d. Adductor pollicis and opponens pollicis
e. Adductor pollicis and first lumbrical
Answer : b. Two heads of the forst dorsal interosseous muscle
- During repair of an avulsed flexor digitorum profundus tendon to the ring finger, excessive advancement must be avoided to prevent of the occurrence of :
a. Lumbrical plus syndrome
b. Lumbrical minus syndrome
c. Quadrigia syndrome
d. Boutonniere deformity
e. Swan neck deformity
Answer : c. Quadrigia syndrome
quadrigia effect
- results from advancement of FDP beyond 1 cm (shortened tendon)
- flexion deformity inhibits full flexion of adjacent finger
- A 42 year old woman has had weakness in her right hand for the past 3 weeks. There is no history of trauma and she denies tingling in her fingers. Examinations reveal no weakness of thumb opposition, normal two point discrimination in all fingers, absent thumb interphalangeal joint flexion of the index finger. The initial treatment should include
a. Cervical fusion
b. observation
c. Carpel tunnel release
d. Ulnar nerve transposition
e. First rib resection
Answer ; b. observation
- A 42 year-old man who underwent repair of a lacerated posterior interosseous nerve 9 months ago has no return of finger or thumb metacarpophalangeal (MCP) joint extension. Tendon transfers are performed . The initial postoperative therapy protocol should consist of:
- a. Immediate active and passive motion exercises of the fingers and thumb
- b. 4 weeks of splinting with the MCP joints in slight flexion and the interphalangeal joints free
- c. 4 weeks of splinting with the MCP joints in 900 of flexion and the interphalangeal joints free
- d. Dynamic extension splinting and active finger flexion
- e. Dynamic flexion splinting and active finger flexion
Answer: b. 4 weeks of splinting with the MCP joints in slight flexion and the interphalangeal joints free
- Successful surgical management of symptomatic carpometacarpal arthritis of the thumb should always include
a. Excision of the trapezium
b. Interposition arthroplasty of the carpometacarpal joint
c. Suspensionplasty of the first metacarpal
d. Resection of the base of the first metacarpal
e. Stabilization of the metacarpophalangeal joint
Answer : a. Excision of the trapezium
- A 65 year old man has low back pain and leg pain with standing. Walking endurance is limited to two blocks due to leg cramping. He has a wide – based, unsteady gait and hyperreflexia. Lumbar radiographs reveal a degenerative spondylolisthesis at L4-5 and an MRI scan shows moderate spinal stenosis at this level. The next step in his care should include :
a. Lumbar epidural steroid injections
b. Lumbar decompression with fussion
c. A lumbar epidurogram
d. Interspinous distraction
e. Cervical MRI
Answer: e. Cervical MRI
- An increased rate of atlantoaxial instability is associated with what diagnosis ?
a. Multiple epiphyseal dysplasia
b. Morquio’s syndrome
c. Streeter’s dysplasia
d. Archondroplasia
e. Cleidocrainal dysplasia
Answer : b. Morquio’s syndrome
Which of the following examination findings suggests intrinsic tightness?
1 The patient is unable to fully extend the metacarpophalangeal (MCP), proximal
interphalangeal (PIP), and distal interphalangeal (DIP) joints of the fingers.
2 The PIP joints flex fully with the MCP joints flexed but not when the MCP joints
are extended.
3 The patient is unable to fully flex the MCP, PIP, and DIP joints into a fist.
4 The PIP joints flex fully with the MCP joints extended but not when the MCP joints
are flexed.
5 Active motion of the PIP joints is limited, but passive motion of the PIP joints is full.
Answer : 2. The PIP joints flex fully with the MCP joints flexed but not when the MCP joints
are extended.
A 25 year old professional boxer reports pain and persistent swelling over the metacarpophalangeal (MCP) joint of his middle finger. Radiographs, including Brewerton views, are normal. Nonsurgical management, consisting of a 3-month course of activity modification, extension splinting, and anti-inflammatory drugs, has failed to provide relief. Management should now consist of:
- reassurance and continued nonsurgical care
- debridement of the MCP joint
- cortisone injection into the flexor sheath
- curettage and bone grafting of the third metacarpal head
- repair of the extensor hood
Answer : 5. repair of the extensor hood
Reference :
Hame SL, Melone CP Jr: Boxer’s knuckle: Traumatic disruption of the extensor hood.Hand Clin 2000; 16: 375-380.
Araki S, Ohtani T, Tanaka T: Acute dislocation of the extensor digitorum communis
tendon at the metacarpophalangeal joint. JBJS Am 1987; 69: 616-619.
A 40-year-old woman has a chronic boutonniere deformity of the proximal interphalangeal (PIP) joint of her middle finger with a preserved joint space. She lacks 45 degrees of active extension but has full passive extension of the PIP joint. Treatment
should consist of:
1- central slip tenotomy
2- volar plate release
3- lateral band relocation
4- arthrodesis of the PIP joint
5- arthroplasty of the PIP joint
Answer : 3- lateral band relocation
Reference: Light TR (ed): Hand Surgery Update 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, p 313-323.
- A 12 year old competitive gymnast has had a 2 week history of acute low back pain. Examination reveals significant hamstring tightness (popliteal angles 80 degrees), pain exacerbated by hyperextention of the lumbar spine, symmetric reflexes, and intact motor and sensory examination. AP and lateral radiographs of the lumbar spine are negative. What additional diagnostic test will best confirm the diagnosis?
a. Standing AP and lateral radiographs of the thoracic spine
b. Oblique radiographs of the lumbosacral spine
c. Indium-labeled bone scan
d. Bone scan with SPECT images of the lumbar spine
e. CT with fine cuts from L1 to L3
Answer: d. Bone scan with SPECT images of the lumbar spine
- When performing a single – bundle posterior cruciate ligament reconstruction, the graft should be tensioned when the knee is in what position :
a. Full extension
b. Full flexion
c. 30 ° of flexion
d. 45° of flexion
e. 90°of flexion
Answer ; c. 30 ° of flexion
- Physical therapy in patients with isolated posterior cruciate ligaments tears should most focus on strengthening what muscle group ?
a. Knee extensors
b. Knee flexors
c. Hip flexors
d. Hip abductors
e. Hip extensors
Answer : a. Knee extensors
- The rehabilitation technique, closed kinetic chain, refers to :
a. Follow – through back to the starting position
b. Muscle contraction during muscle lengthening
c. Stretch augmentation of muscle contraction
d. Isolated strengthening of a specific muscle group
e. Axial loading to stimulate muscle co-contraction to increase joint stability
Answer : e. Axial loading to stimulate muscle co-contraction to increase joint stability
- What area of articular cartilage is most likely injured with a patellar dislocation ?
a. Medial trochlea
b. Odd facet of the patella
c. Medial facet of the patella
d. Lateral facet of the patella
e. Keel of the patella
Answer : c. Medial facet of the patella
- Which of the following pathophysiologic mechanisms is responsible for renal osteodystrophy ?
a. insufficient synthesis of 25(OH) vitamin D
b. Phospate retention secondary to uremia
c. Hypercalcemia
d. Metabolic alkalosis
e. Decreased parathyroid hormone in serum
Answer : b. Phospate retention secondary to uremia
- Which of the following pathophysiologic mechanisms is responsible for renal osteodystrophy ?
a. insufficient synthesis of 25(OH) vitamin D
b. Phospate retention secondary to uremia
c. Hypercalcemia
d. Metabolic alkalosis
e. Decreased parathyroid hormone in serum
Answer: b. Phospate retention secondary to uremia
- Point mutations that occur during embryogenesis in the Gs-α transcript of GNAS resulting in mutations in osteogenic cells that result in an inhibition of diferentation, are associated with which of the following conditions ?
a. Familial polyposis with desmoids
b. Enchondromatosis
c. Langerhan’s cell histiocytosis
d. Polyostotic fibrous dysplasia
e. Multiple hereditary exostosis
Answer: d. Polyostotic fibrous dysplasia
- During the normal gait cycle at the push-off phase of stance, the hindfoot :
a. Inverts and transverse tarsal joints lock
b. Inverts and transverse tarsal joints unlock
c. everts and transverse tarsal joints unlock
d. everts and transverse tarsal joints lock
e. Remains neutral and the transverse tarsal joints lock
Answer :a. Inverts and transverse tarsal joints lock
- During a posterior exposure of the hip, partial section of more than 2 cm of the gluteus maximus tendon attachment on the femur is associated with risk to what arterial structure ?
a. Deep femoral
b. Superficial femoral
c. First perforating
d. Obturator
e. Inferior gluteal
Answer: c. First perforating
- In performing an anterior approach to the sacroiliac joint for plating, what structure must be elevated off of the ala of the sacrum ?
a. Sciatic nerve
b. L5 nerve root
c. S1 nerve root
d. Femoral artery
e. Internal iliac artery
Answer : b. L5 nerve root
- The inferior gluteal nerve derives its name by exiting inferior to what structure :
a. Gluteus maximus tendon
b. Piriformis
c. Obturator internus
d. Sacral spinous ligament
e. Sacral tuberous ligament
Answer ; b. piriformis
- For patients with metastatic carcinoma to bone, which of the following primary cancers is associated with the shortest life expectancy following pathologic fracture?
a. Thyroid
b. Breast
c. Prostate
d. Lung
e. Renal
Answer : d. Lung
- Primary neurologic medial scapular winging is associated with weakness of what muscle group?
a. Rhomboids
b. Trapezius
c. Latissimus dosi
d. Serratus anterior
e. Subscapularis
Answer : d. Serratus anterior
- A 42-year old man has a chronic anterior cruciate ligament-deficient knee. What variable has the greatest correlation with the feature development of arthritis
a. Patient age
b. Medial collateral ligament injury
c. Meniscal integrity
d. Quadriceps atrophy of more than 25% compared with the opposite extremity
e. Isokinetic muscle deficit of more than 15% compared with the opposite extremity
Answer : c. Meniscal integrity
- What is the mechanism of antimicrobial action of aminoglycoside antibiotics ?
a. Alteration of bacterial cell membrane permeability
b. Inhibition of bacterial cell wall synthesis
c. Inhibition of bacterial metabolism
d. Inhibition of bacterial protein synthesis
e. Interference with bacterial nucleic acid synthesis or activity
Answer :d. Inhibition of bacterial protein synthesis
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- What type of bone healing occurs with a humeral shaft fracture that is treated with functional bracing?
a. Haversian remodeling
b. Osteonal remodeling
c. Primary bone healing
d. Direct ossification
e. Endochondral ossification
Answer: e. Endochondral ossification
- Which of the following factors improves the performance of cemented femoral stems in total hip arthroplasty
a. Stiffer materials
b. Precoated stems with polymethylmethacrylate
c. Calcar collar contact
d. Sharper corners
e. Decreased thickness of the cement mantle
Answer : a. Stiffer materials
- A 50 yo man has osteoarthritis of the knee, which is functionally limiting & is now unresponsive to non surgical treatment. Favorable result arthroscopic debridement can be expected based on what factor
a. duration of symptoms for 5 years or more
b. varus malalignment
c. advanced radiographic degenerative changes
d. localized medial joint line pain with degenerative meniscal tear √
e. history of chronic synovitis
Answer d. localized medial joint line pain with degenerative meniscal tear √
- A 59 yo man is in the recovery room after undergoing TKA for predominantly lateral compartment arthritis with genu valgum. Examination reveals decreased sensation on the first web space & he is unable to dorsiflexed or evert the foot. What is the best course of action?
a. return to the operating room for exploration of the wound
b. remove the dressing & flex the knee √
c. consult to a neurologist
d. obtain an electromyelogram
e. elevated the limb & apply ice
Answer : b. remove the dressing & flex the knee √
- The mechanism of osteolysis around total joint component is caused by
a. macrophage activation secondary to particulate debris √
b. stress shielding secondary to stiff component
c. direct osteoclast activation secondary to particulate debris
d. T cell mediated inflammatory response to metal ions
e. Polymorphonuclear leukocyte activation secondary to the complement cascade
Answer : a. macrophage activation secondary to particulate debris √
- The use of mini incision total hip arthroplasty versus conventional total hip arthroplasty can be expected to result in
a. reduced operating room time
b. equivalent hip function 1 year after surgery √
c. an increased length of hospital stay
d. reduced rate of post operative complication
e. increased surgical blood loss
Answer : b. equivalent hip function 1 year after surgery √
- External rotation of the femoral component in TKA has which of the following effect
a. medialization of the trochanter groove
b. less frequent need for lateral release √
c. higher patellofemoral contact pressure
d. increased lateral instability in flexion
e. decreased flexion
Answer : b. less frequent need for lateral release √
- What pattern of arthritis develops following nonsurgical treatment of an isolated posterior cruciate ligament injury
a. patellofemoral
b. patellofemoral & medial √
c. patellofemoral & lateral
d. medial
e. lateral
Answer : b. patellofemoral & medial √
Figure below shows the radiograph of a 7-year-old patient who has a rightTrendelenburg limp and limited range of hip motion but no pain. His work-up should include
- a skeletal survey.
- genetic evaluation.
- cardiac evaluation.
- coagulation studies.
- an MRI scan of the hips.
PREFERRED RESPONSE: 1. a skeletal survey.
DISCUSSION: The radiograph shows bilateral flattening of the femoral heads with mottling and “fragmentation” suggestive of Legg-Calve-Perthes disease. However, when these changes occur bilaterally and are symmetric, multiple epiphyseal dysplasia or spondyloepiphyseal dysplasia should be suspected. Skeletal survey will show irregularity of the secondary ossification centers. With these conditions, there is no true osteonecrosis and no evidence that orthotic or surgical “containment” will alter the outcome of progressive degenerative arthritis. Cardiac anomalies and coagulopathies are not associated with the epiphyseal dysplasias.
REFERENCES
Crossan JF, Wynne-Davies R, Fulford GE: Bilateral failure of the capital femoral epiphysis: Bilateral Perthes disease, multiple epiphyseal dysplasia, pseudoachondroplasia, and spondyloepiphyseal dysplasia congenita and tarda. J Pediatr Orthop 1983;3:297-301.
Sponseller PD: The skeletal dysplasias, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 269-270.
A 9-year-old boy who is small for his age has a painful limp and limited hip motion. Radiographs of the pelvis are shown in Figures 2. In addition to managing the problem with the hip, what laboratory studies should be obtained?
- Serum protein electrophoresis
- Serum glucose and hemoglobin A1C
- WBC and differential blood cell count
- Thyroxin and thyroid-stimulating hormone
- Transferrin and total iron-binding capacity
PREFERRED RESPONSE: 4. Thyroxin and thyroid-stimulating hormone
DISCUSSION: The child has bilateral slipped capital femoral epiphyses (SCFE). SCFE usually develops in early adolescence, but can occur in younger children with endocrine disorders such as panhypopituitarism and hypothyroidism. Any child younger than age 10 years or older than age 16 years who has SCFE should be carefully evaluated for an underlying endocrine problem. Unrecognized endocrine disorders can increase the risks of anesthesia.
REFERENCES
Loder RT, Wittenberg B, DeSilva G: Slipped capital femoral epiphysis associated with endocrine disorders. J Pediatr Orthop 1995;15:349-356.
Wells D, King JD, Roe TF, et al: Review of slipped capital femoral epiphysis associated with endocrine disease. J Pediatr Orthop 1993;13:610-614.
Figure below shows the current radiographs of a 13-year-old boy who was treated for an elbow fracture 1 year ago. He is neurovascularly intact. What is the most important component of treatment if reconstruction is being considered?
- Construction of the annular ligament
- Restoration of the radioulnar articulation
- Restoration and maintenance of ulnar length and alignment
- Adequate immobilization postoperatively in 120° of flexion
- Placement of a Kirschner wire from the radial head to the capitellum
PREFERRED RESPONSE: 3. Restoration and maintenance of ulnar length and alignment
DISCUSSION: Restoration of ulnar length and alignment is usually sufficient to allow complete reduction of the radial head. Reconstruction of the annular ligament may be unnecessary, and while immobilization in 100° to 110° of flexion is helpful in maintaining reduction, 120° is excessive and risks vascular compromise. Pins across the radiocapitellar joint frequently break and should be avoided. Pinning from the proximal radius to the ulna is safer and can stabilize the radiocapitellar joint just as well.
REFERENCES
Beaty JH, Kasser JR: Fractures about the elbow. Instr Course Lect 1995;44:199-215.
Mehta SD: Flexion osteotomy of ulna for untreated Monteggia fracture in children. Indian J Surg 1985;47:15-19.
The inheritance of the deformity shown in Figure below is most commonly
- autosomal recessive.
- autosomal dominant.
- X-linked dominant.
- mitochondrial.
- sporadic.
PREFERRED RESPONSE: 2. autosomal dominant.
DISCUSSION: Cleft hand and cleft foot malformations are commonly inherited as autosomal-dominant traits and are associated with a number of syndromes. An autosomal-recessive and an X-linked inheritance pattern have also been described, but these are much less common and are usually atypical. In the common autosomal-dominant condition, nearly one third of the known carriers of the gene show no hand or foot abnormalities. This is known as reduced penetrance. The disorder may be variably expressed; affected family members often exhibit a range from mild abnormalities in one limb only to severe anomalies in four limbs. Variable expressivity and reduced penetrance can cause difficulty in counseling families regarding future offspring in an affected family. Many patients have a cleft hand that may be caused by the split-hand, split-foot gene (SHFM1) localized on chromosome 7q21.
REFERENCE
Kay SPJ: Cleft hand, in Green DP (ed): Green’s Operative Hand Surgery. Philadelphia, PA, Churchill Livingstone, 1999, pp 402-414.
A 14-year-old girl with polyarticular juvenile rheumatoid arthritis (JRA) has severe neck pain and reports the onset of urinary incontinence. A lateral radiograph and lateral tomogram of the cervical spine are shown in Figures 5A and 5B. An MRI scan of the upper cervical spine is shown in Figure 5C. Management should consist of
- a rigid cervical orthosis.
- a soft cervical collar.
- posterior C1-2 fusion with halo immobilization.
- administration of methotrexate.
- activity restrictions.
PREFERRED RESPONSE: 3. posterior C1-2 fusion with halo immobilization.
DISCUSSION: The plain radiograph and tomogram show an abnormality of the upper cervical spine, with erosion of the dens. The MRI scan shows evidence of cord impingement. The cervical spine is frequently involved in polyarticular JRA. Stiffness and autofusion are commonly seen, but C1-2 instability can also occur secondary to synovitis and bony erosion. Basilar invagination is rare in JRA. There is no consensus regarding fusion in the asymptomatic patient. In patients with symptoms and neurologic signs, posterior C1-2 fusion is indicated.
REFERENCES
Fried JA, Athreya B, Gregg JR, Das M, Doughty R: The cervical spine in juvenile rheumatoid arthritis. Clin Orthop Relat Res 1983;179:102-106.
Hensinger RN, DeVito PD, Ragsdale CG: Changes in the cervical spine in juvenile rheumatoid arthritis. J Bone Joint Surg Am 1986;68:189-198.
Figure 6 shows the radiograph of a 13-year-old boy who has low back pain and tight hamstrings. There are no sensory or motor deficits. What is the recommended treatment for this condition?
- Gill procedure
- Thoracolumbosacral orthosis
- Direct repair of the pars defect
- Posterolateral fusion from L4 to the sacrum
- Combined anteroposterior fusion from L5 to the sacrum
PREFERRED RESPONSE: 4. Posterolateral fusion from L4 to the sacrum
DISCUSSION: The standard treatment of spondylolisthesis in skeletally immature patients with greater than 50% slippage is a posterolateral fusion from L4 to the sacrum. An orthosis will not prevent progression of the slip. Isolated decompression (Gill procedure) is contraindicated in adolescents as it increases the likelihood of progressive slippage. Direct repair of pars defects is appropriate for L3 or L4 spondylolysis without spondylolisthesis. Anterior procedures are not generally indicated in adolescents with grade III spondylolistheses.
REFERENCES
Bradford DS, Iza J: Repair of the defect in spondylolysis or minimal degrees of spondylolisthesis by segmental wire fixation and bone grafting. Spine 1985;10:673-679.
Harris IE, Weinstein SL: Long-term follow-up of patients with grade-III and IV spondylolisthesis: Treatment with and without posterior fusion. J Bone Joint Surg Am 1987;69:960-969.
Pizzutillo PD, Mirenda W, MacEwen GD: Posterolateral fusion for spondylolisthesis in adolescence. J Pediatr Orthop 1986;6:311-316.
Figure 7 shows the lateral cervical radiograph of a 2-year-old girl who was an unrestrained passenger in a motor vehicle accident. She is able to move her neck freely without pain, and her neurologic examination is normal. Management should include
- observation.
- anterior decompression.
- upper cervical arthrodesis.
- application of a soft collar.
- immobilization in a halo vest.
PREFERRED RESPONSE: 1. observation.
DISCUSSION: In children, injuries to the upper cervical spine are more common than injuries to the lower cervical spine. Radiographic findings that would indicate significant trauma in adults, such as anterior soft-tissue widening, may be normal variants in the cervical spine of a child. This child has pseudosubluxation of C2 on C3. Pseudosubluxation occurs because children have less slope to their articular facet joints and increased ligamentous laxity. It is possible to differentiate pseudosubluxation from more serious spinal problems by drawing a line along the front of the posterior elements of C1, C2, and C3, as described by Swischuk. Pseudosubluxation of C2 on C3 is a normal finding, so treatment is not indicated.
REFERENCES
Ehara S, el-Khoury GY, Sato Y: Cervical spine injury in children: Radiologic manifestations. Am J Roentgenol 1988;151:1175-1178.
Swischuk LE: Anterior displacement of C2 in children: Physiologic or pathologic. Radiology 1977;122:759-763.
Discussion:
- pediatric pseudosubluxation refers to normal mobility of C-2 on C-3 in flexion which may be so pronounced as to be mistaken
for pathologic motion; (is normal in children < 8 years old);
- prevalence:
- pseudosubluxation may be seen in 40% of children at C2-C3 level and in 14% of children at the C3-C4 level
- etiology:
- pediatric C-spine (up to 8 yrs of age) has greatly increased physiologic mobility as compared to the adult;
- occurs because of increased ligamentous laxity, more horizontal nature of facet joint (30 deg vs. 60-70 deg in adult);
- in children, fulcurm of motion that is relatively greatest at C2-C3 level (compared w/ C5-C6 in the adult);
- 70% of C-spine frx in infants and children occur from C1 to C3;
- hence increase frequency of atlantoaxial rotatory subluxation as compared to the adult;
- in normal circumstances, this anterior displacement only occurs in flexion, and should not occur in extension;
- Radiographs:
- look for anterior displacement of C2 on C3 of up to 4 mm or 40% displacement;
- often the pediatric cross table lateral will be taken with the child’s neck slightly flexed, (because the child’s relatively larger head size lies
flexed on the trauma board), which accentuates the deformity; - absence of significant soft tissue swelling;
- Distinguish between Normal and Abnormal Radiographs:
- lack of anterior swelling cont alignment of posterior interspinous distances & posterior cervical line (Schwisk) on radiographs
- note that a crying child may have increase soft tissue density;
- extension:
- in normal circumstances, this anterior displacement only occurs in flexion, and should not occur in extension;
- reduction of subluxation with neck extension help to differentiate this from more serious disorders;
- Swischuk’ Line:
- line is drawn from the anterior aspect of C1-C3 spinous processes;
- this line should be within 2 mm of the anterior C2 spinous process;
- spinal-laminar line:
- normally should remain intact;
- straight-line relationship of spinal-laminar line of C-1, C-2, & C-3 in flexion is helpful in differentiating physiologic from pathologic
anterior displacement of C-2 and C-3. - flexion:
- in flexion, posterior arch of C-2 will lie on or behind straight line connecting posterior arches of C-1 & C-3 in nl immature spine;
- Exam:
- rapid resolution of pain, relatively minor trauma
Figures 9A and 9B show the radiographs of an 11-year-old boy who felt a pop and immediate pain in his right knee as he was driving off his right leg to jam a basketball. Examination reveals that the knee is flexed, and the patient is unable to actively extend it or bear weight on that side. There is also a large effusion. Management should include
- ice and elevation, followed by graduated range-of-motion exercises.
- a long leg cast.
- excision of the fragment.
- open reduction and internal fixation.
- observation until maturity, followed by anterior cruciate ligament repair.
PREFERRED RESPONSE: 4.open reduction and internal fixation.
DISCUSSION: Fractures through the cartilage on the inferior pole of the patella, the so-called sleeve fracture, are often difficult to diagnose because of the paucity of ossified bone visible on the radiographs. If the fracture is missed and the fragments are widely displaced, the patella may heal in an elongated configuration that may result in compromise of the extensor mechanism function. The treatment of choice is open reduction and internal fixation using a tension band wire technique to achieve close approximation of the fragments and restore full active knee extension.
REFERENCES
Heckman JD, Alkire CC: Distal patellar pole fractures: A proposed common mechanism of injury. Am J Sports Med 1984;12:424-428.
Tolo VT: Fractures and dislocations around the knee, in Green NE, Swiontkowski MF (eds): Skeletal Trauma in Children. Philadelphia, Pa, WB Saunders, 1994, vol 3, pp 380-382.
A 4-year-old boy is seen in the emergency department with a 2-day history of left groin pain and a limp. His parents deny any history of injury. Examination of the hip shows a 5° hip flexion position, 20° of abduction, internal rotation to 15°, and external rotation to 30°. His temperature is 100.9°F (38.3°C). Blood studies show a normal WBC count, and the erythrocyte sedimentation rate is 18 mm/h. The C-reactive protein is pending. A radiograph is shown in Figure 10. What is the most likely diagnosis?
- Perthes disease
- Transient synovitis
- Slipped capital femoral epiphysis (SCFE)
- Septic arthritis
- Juvenile arthritis
PREFERRED RESPONSE: 2. Transient synovitis
DISCUSSION: Transient synovitis is the most common cause of hip pain in children. Males are affected more often than females, and this a typical age for this problem. Normal radiographs rule out SCFE and Perthes disease. The normal WBC count, temperature, ability to walk, and normal ESR make septic arthritis unlikely. Both juvenile arthritis and transient synovitis are diagnoses of exclusion and the subsequent clinical course would differentiate. Transient synovitis usually lasts less than 4 or 5 days. With juvenile arthritis, the ESR usually is elevated.
REFERENCES
Kocher MS, Mandiga R, Zurakowski D, Barnewolt C, Kasser J: Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am 2004;86:1629-1635.
Kocher MS, Zurakowski D, Kasser J: Differentiating between septic arthritis and transient synovitis of the hip in children: An evidence-based clinical prediction algorithm. J Bone Joint Surg Am 1999;81:1662-1670.
A 7-year-old patient has had a painless limp for several months. Examination reveals pain and spasm with internal rotation, and abduction is limited to 10° on the involved side. Management consists of 1 week of bed rest and traction, followed by an arthrogram. A maximum abduction/internal rotation view is shown in Figure 11A, and abduction and adduction views are shown in Figures 11B and 11C. The studies are most consistent with
- Catterall II involvement.
- tubercular synovitis.
- Herring type A involvement.
- hinge abduction.
- osteochondritis dissecans
PREFERRED RESPONSE: 4. hinge abduction.
DISCUSSION: The radiographs show classic hinge abduction. The diagnostic feature is the failure of the lateral epiphysis to slide under the acetabular edge with abduction, and the abduction view shows medial dye pooling because of distraction of the hip joint. Persistent hinge abduction has been shown to prevent femoral head remodeling by the acetabulum. Radiographic changes are characteristic of severe involvement with Legg-Calve-Perthes disease. The Catterall classification cannot be well applied without a lateral radiograph, but this degree of involvement would likely be considered a grade III or IV. Because the lateral pillar is involved, this condition would be classified as type C using the Herring lateral pillar classification scheme.
REFERENCE
Reinker KA: Early diagnosis and treatment of hinge abduction in Legg-Perthes disease. J Pediatr Orthop 1996;16:3-9.
Figure 12 shows the radiograph of a 3-year-old child with progressive bowlegs. Laboratory studies show a calcium level of 9.5 mg/dL (normal 9.0 to 11.0 mg/dL), a phosphorus level of 4.2 mg/dL (normal 3 to 5.7 mg/dL), and an alkaline phosphatase level of 305 IU/L (normal 104 to 345 IU/L). What is the most likely diagnosis?
- Blount disease
- Hypophosphatemic rickets
- Nutritional rickets
- Schmid metaphyseal dysostosis
- Jansen metaphyseal dysostosis
PREFERRED RESPONSE: 4. Schmid metaphyseal dysostosis
DISCUSSION: The patient has bowlegs associated with very wide physes, particularly noted at the hips. The widening of the growth plates is a classic sign of rickets; however, the normal levels of calcium, phosphorus, and alkaline phosphatase rule out both nutritional and hypophosphatemic rickets. Patients with nutritional rickets or hypophosphatemic rickets have hypophosphatemia and increased alkaline phosphatase levels. Jansen metaphyseal dysostosis has very severe radiographic findings that are not found in this patient; however, these radiographic findings are classic for Schmid metaphyseal dysostosis. This disorder is caused by a mutation in the gene for type X collagen, which is found only in the growth plates of growing children.
REFERENCES
Lachman RS, Rimoin DL, Spranger J: Metaphyseal chondrodysplasia, Schmid type: Clinical and radiographic delineation with a review of the literature. Pediatr Radiol 1988;18:93-102.
Warman ML, Abbot M, Apte SS, et al: A type X collagen mutation causes Schmid metaphyseal chondrodysplasia. Nat Genet 1993;5:79-82.
Figure 13 shows the radiograph of an 18-year-old patient who has severe knee pain. Treatment consisting of osteotomy should be performed
- above the tibial tubercle.
- at or just below the tibial tubercle.
- in the tibial diaphysis.
- on both the femur and tibia.
- on the femur alone
PREFERRED RESPONSE: 2. at or just below the tibial tubercle.
DISCUSSION: Very large corrections of tibial deformity can be achieved at or just below the tibial tubercle. This level of osteotomy maintains the relationship between the tubercle and the rest of the joint, does not alter patellofemoral mechanics, and avoids complicating possible future conversion to total knee arthroplasty. High tibial osteotomy is contraindicated for large corrections because of excessive elevation of the tibial tubercle and overhang of the lateral plateau. Correction in the tibial diaphysis creates a zigzag pattern in the tibia by correcting below the deformity and risks nonunion in cortical bone. There is no evidence that the femur is deformed; therefore, femoral osteotomy is not indicated.
REFERENCE
Murphy SB: Tibial osteotomy for genu varum: Indications, preoperative planning, and technique. Orthop Clin North Am 1994;25:477-482.
Figure 14 shows the radiograph of a 13-year-old girl who has scoliosis. She has long, slender fingers, and when she grasps her left wrist with her right hand, the index finger and thumb overlap by 3 cm. She wears glasses for myopia. A preoperative work-up should include
- an echocardiogram.
- neurofibromin testing.
- a serum fibrillin level.
- an MRI scan of the spine.
- a urine mucopolysaccharide screen.
PREFERRED RESPONSE: 1. an echocardiogram.
DISCUSSION: The patient has Marfan syndrome. In these patients, aortic dilation can be life-threatening and aortic rupture has been reported as a complication of spinal surgery. An ultrasound measurement of the diameter of the aorta should be done preoperatively and on a yearly basis thereafter, and treatment with beta blockers and avoidance of stressful activities should be prescribed prophylactically if dilation is present. An MRI scan of the spine is not indicated in the work-up of this disease. Urine mucopolysaccharide screening is used to rule out mucopolysaccharidoses, but this patient has no sign of these diseases. While fibrillin levels are abnormal in patients with Marfan syndrome, this is a structural protein and abnormality cannot be determined by serum measurement. Abnormalities of neurofibromin are associated with neurofibromatosis, not Marfan syndrome.
REFERENCES
Birch JG, Herring JA: Spinal deformity in Marfan syndrome. J Pediatr Orthop 1987;7:546-552.
Shores J, Berger KR, Murphy EA, et al: Progression of aortic dilation and the benefit of long-term beta-adrenergic blockade in Marfan’s syndrome. N Engl J Med 1994;330:1335-1341.
Tsipouras P, Del Mastro R, Sarfarazi M, et al: Genetic linkage of the Marfan syndrome, ectopia lentis, and congenital contractural arachnodactyly to the fibrillin genes on chromosomes 15 and 5: The International Marfan Syndrome Collaborative Study. New Engl J Med 1992;326:905-909.
A 2-day-old infant has the hyperextended knee deformity shown in Figure 16. No other deformities are found on examination. A radiograph shows that the ossified portion of the proximal tibia is slightly anterior to that of the distal femur. Management should consist of
- gentle stretching and serial casting.
- Bryant traction for 1 to 2 weeks, followed by closed reduction.
- percutaneous quadriceps recession, followed by serial casting.
- delayed open reduction at age 6 months to avoid iatrogenic damage to either the distal femoral or proximal tibial physes.
- a renal ultrasound.
PREFERRED RESPONSE: 1. gentle stretching and serial casting.
DISCUSSION: Congenital dislocation of the knee is an uncommon deformity that varies in presentation from simple hyperextension to complete anterior dislocation of the tibia on the femur. Treatment varies with the age at presentation and the severity of the deformity. Most authors recommend early nonsurgical management. A recent study of 24 congenital knee dislocations in 17 patients found that satisfactory results were obtained in most instances using closed treatment. Based on their findings, the authors concluded that immediate reduction or serial casting should be performed when the patient is seen early after birth. If the patient is seen late and correction cannot be achieved by serial casting, traction followed by closed or open reduction may be necessary. Early percutaneous quadriceps recession has been described for complex congenital knee dislocations associated with underlying disorders, such as arthrogryposis and Ehlers-Danlos syndrome. Ultrasound of the hip is required in all patients with congenital dislocation of the knee because 50% of these patients will have associated developmental dysplasia of the hip.
REFERENCES
Ko JY, Shih CH, Wenger DR: Congenital dislocation of the knee. J Pediatr Orthop 1999;19:252-259.
Johnson E, Audell R, Oppenheim WL: Congenital dislocation of the knee. J Pediatr Orthop 1987;7:194-200.
Roy DR, Crawford AH: Percutaneous quadriceps recession: A technique for management of congenital hyperextension deformities of the knee in the neonate. J Pediatr Orthop 1989;9:717-719.
A 10-year-old boy has activity-related knee pain that is poorly localized. He denies locking, swelling, or giving way. Examination shows mild tenderness at the medial femoral condyle and painless full range of motion without ligamentous instability. Radiographs are shown in Figures 17A through 17C. What is the best course of action?
- Knee arthroscopy with drilling of the lesion
- Limited activity for 6 to 12 weeks
- Removal of the loose body
- Biopsy of the lesion
- Open reduction and internal fixation
PREFERRED RESPONSE: 2.. Limited activity for 6 to 12 weeks
DISCUSSION: The radiographs show an osteochondritis dissecans (OCD) lesion in the medial femoral condyle of a skeletally immature patient. The lesion is not displaced from its bed. Nonsurgical management of a stable OCD lesion in a patient with open physes consists of a period of activity limitation and occasional immobilization. Unstable lesions, loose bodies, and patients with closed physes require more aggressive treatment. Most of the surgical procedures can be done arthroscopically. Because the radiographic appearance is typical, biopsy is unnecessary. The radiographs do not show an osteocartilaginous loose body, and the patient reports no catching or locking; therefore, removal of the loose body is not indicated.
REFERENCES
Linden B: Osteochondritis dissecans of the femoral condyles: A long term follow-up study. J Bone Joint Surg Am 1977;59:769-776.
Cahill BR: Osteochondritis dissecans of the knee: Treatment of juvenile and adult forms. J Am Acad Orthop Surg 1995;3:237-247.
Cahill BR, Phillips MR, Navarro R: The results of conservative management of juvenile osteochondritis dissecans using joint scintigraphy: A prospective study. Am J Sports Med 1989;17:601-606.
Figure 18 shows the hand deformities of a 3-year-old girl who has short stature. The most likely diagnosis is
- achondroplasia.
- pseudoachondroplasia.
- diastrophic dysplasia.
- metaphyseal chondrodysplasia.
- multiple epiphyseal dysplasia.
PREFERRED RESPONSE: 3. diastrophic dysplasia.
DISCUSSION: The thumb deformity shown in Figure 18 is termed a “hitchhiker’s thumb” and is a distinctive feature of diastrophic dysplasia. Although achondroplasia, pseudoachondroplasia, multiple epiphyseal dysplasia, and metaphyseal chondrodysplasia are all associated with dwarfism, none of these disorders is associated with this distinctive abducted and hypermobile deformity of the thumb. Diastrophic dysplasia was described by Lamy and Maroteaux in 1960 and is inherited as an autosomal-recessive trait. Diastrophic dysplasia is caused by a mutation of a gene coding for a sulfate transport protein located on chromosome 5. The patient is severely dwarfed with the limbs being very short (micromelia) and will reach an eventual adult height of 80 cm to 140 cm. The shortening of the limbs is more severe in the proximal segment than the distal segment and is termed rhizomelic. Diastrophic dysplasia is associated with multiple anomalies including scoliosis, cervical kyphosis, thoracolumbar kyphosis, lumbar lordosis, and flexion contractures of the hips, knees, and elbows. The distinctive feature of diastrophic dysplasia is shortening of the first metacarpal and metatarsal, resulting in the “hitchhiker’s thumb” and bilateral clubfoot deformities. Another distinctive feature is a deformity of the external ears termed “cauliflower ears.” The ears become thickened and twisted with furrowed lobes and narrowing of the external auditory canal. The patient with diastrophic dysplasia usually has normal intelligence and no abnormalities of the heart or kidney.
REFERENCES
Bethem D, Winter RB, Lutter L: Disorders of the spine in diastrophic dwarfism. J Bone Joint Surg Am 1980;62:529-536.
Bassett GS, Scott CI Jr: The osteochondrodysplasias, in Morrissy RT (ed): Lovell and Winter’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, JB Lippincott, 1990, vol 1, pp 91-142.
Hollister DW, Lachman RS: Diastrophic dwarfism. Clin Orthop Relat Res 1976;114:61-69.
Figure 19 shows the clinical photograph of a 3-month-old infant with a foot deformity that has been nonprogressive since birth. Examination reveals that the deformity corrects actively and with passive manipulation. There is no associated equinus. Management should consist of
- serial casting.
- UCBL orthoses.
- abductor hallucis lengthening.
- observation and parental reassurance.
- corrective shoes.
PREFERRED RESPONSE: 4. observation and parental reassurance.
DISCUSSION: The patient has bilateral metatarsus adductus deformities. In a long-term follow-up study by Farsetti and associates, deformities that were passively correctable spontaneously resolved and no treatment was required. More rigid deformities were successfully treated with serial manipulation, with good results in 90%. There were no poor results. Therefore, observation is the management of choice for passively correctable deformities. In feet that are more rigid, serial manipulation and casting is the management of choice.
REFERENCE
Farsetti P, Weinstein SL, Ponseti IV: The long-term functional and radiographic outcomes of untreated and non-operatively treated metatarsus adductus. J Bone Joint Surg Am 1994;76:257-265.
A 2-year-old girl has had lethargy, fever, and abdominal pain for the past 6 months. In addition to multiple lytic lesions in the long bones and calvaria shown on the skeletal survey, the radiograph of the spine shown in Figure 21A reveals a vertebral lesion. A biopsy specimen is shown in Figure 21B. The most likely diagnosis is
- leukemia.
- tuberculosis.
- Langerhans cell histiocytosis.
- metastatic neuroblastoma.
- multifocal osteomyelitis.
PREFERRED RESPONSE: 3. Langerhans cell histiocytosis.
DISCUSSION: Leukemia, Langerhans cell histiocytosis, and metastatic neuroblastoma typically present with constitutional symptoms, bone pain, and multiple lytic lesions in young children. The radiographic appearance of the spinal lesion is a typical vertebra plana caused by eosinophilic granuloma (Langerhans cell histiocytosis). The biopsy specimen shows histiocytes with leukocytic infiltration, predominantly eosinophils. The clinical and other radiographic findings are also consistent with disseminated histiocytosis. Spinal tuberculosis is not usually associated with multiple osseous lesions, especially in the skull. The histology is not consistent with osteomyelitis.
REFERENCES
Campanacci M: Bone and Soft Tissue Tumours. Vienna, Austria, Springer-Verlag, 1990.
Springfield DS: Bone and soft tissue tumors, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 1, pp 423-467.
Figure 22 shows the radiograph of a girl who has had a 3-month history of activity-related foot pain. She has had two previous ankle sprains on this side. Examination reveals that subtalar motion is limited and there is mild heel valgus. Which of the following studies will best confirm your diagnosis?
- Comparison radiograph of the contralateral foot
- Calcaneal radiograph
- Electromyography (EMG) and a nerve conduction velocity study
- CT scan
- Rheumatoid factor
PREFERRED RESPONSE: 4. CT scan
DISCUSSION: The radiograph shows sclerosis in the midportion of the subtalar joint with no signs of degenerative joint disease present in any other joint. The diagnosis, based on the history and physical examination, is a tarsal coalition. Limited subtalar motion is the characteristic finding. A calcaneal view or an angled axial view parallel to the subtalar joint may show a talocalcaneal coalition. In younger children with fibrous or cartilaginous bars, radiographs may not reveal the problem. CT (or MRI) will best confirm that a coalition is present. EMG can rule out a neurologic problem causing foot deformity, but in a unilateral problem with limited subtalar motion and history of ankle sprains, a coalition is much more likely. A rheumatoid factor may be positive in isolated subtalar arthritis, but it is often negative even if arthritis is present and the history and physical examination are much more suggestive of a coalition.
REFERENCES
Westberry DE, Davids JR, Oros W: Surgical management of symptomatic talocalcaneal coalitions by resection of the sustentaculum tali. J Pediatr Orthop 2003;23:493-497.
Mosier KM, Asher M: Tarsal coalitions and peroneal spastic flat foot. J Bone Joint Surg Am 1984;66:976-984.
Figure 23 shows a newborn who has severe multiple symmetric joint contractures, including adduction/internal rotation of the shoulders, extended elbows, flexion-ulnar deviation of the wrists, thumbs in the palm of the hands, dislocated hips, knee flexion deformity, and clubfeet. The most likely diagnosis is
- amyoplasia multiplex congenital.
- Friedreich ataxia.
- distal arthrogryposis.
- spinal muscle atrophy.
- thoracic-level myelomeningocele.
PREFERRED RESPONSE: 1. amyoplasia multiplex congenital.
DISCUSSION: There are more than 150 different types of contracture syndromes included under the category of arthrogryposis, the most common of which some authors term amyoplasia multiplex congenital. Distal arthrogryposis is a much less severe form, affecting primarily the hands and feet. Spinal muscle atrophy is generally associated with hypotonia without contracture. Friedreich ataxia has a later onset and is usually not associated with significant contractures. While myelomeningocele can exhibit similar lower extremity deformities, the upper extremities rarely have fixed contractures.
REFERENCES
Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 195-202.
Sarwark JF, MacEwen GD, Scott CI Jr: Amyoplasia (A common form of arthrogryposis). J Bone Joint Surg Am 1990;72:465-469.
Figure 24A shows the clinical photograph of a 2-year-old boy who has a deformity of the left leg. Examination reveals eight cutaneous markings similar to those shown in Figure 24B. Radiographs are shown in Figure 24C. Management should consist of
- fragmentation, realignment, and intramedullary nailing of the tibia.
- resection of the dysplastic region of the tibia and insertion of a vascularized fibula.
- supplemental vitamin D and phosphate.
- a clamshell orthosis.
- observation for spontaneous remodeling.
PREFERRED RESPONSE: 4. a clamshell orthosis.
DISCUSSION: The diagnosis of neurofibromatosis may be based on the presence of at least six cafe-au-lait spots larger than 5 mm in diameter and the osseous lesion shown in Figure 24C. Neurofibromatosis occurs in 50% of patients who have an anterolateral bowing deformity of the tibia, and this bowing may be the first clinical manifestation of this disorder. The patient has anterolateral bowing of the tibia and fibula that warrants concern for a possible fracture and pseudarthrosis; therefore, the limb should be protected in a total contact orthosis to prevent fracture. In contradistinction to posteromedial bowing of the tibia and fibula, spontaneous remodeling of an anterolateral bowing deformity is not expected. Intramedullary nailing or the use of a vascularized fibula is reserved for the treatment of a congenital pseudarthrosis of the tibia.
REFERENCES
Crawford AH Jr, Bagamery N: Osseous manifestations of neurofibromatosis in childhood. J Pediatr Orthop 1986;6:72-88.
Schoenecker PL, Rich MM: The lower extremity, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, vol 2, pp 1059-1104.
Figure 26 shows the pedigree of a family with an unusual type of muscular dystrophy. This pedigree is most consistent with what type of inheritance pattern?
- Autosomal dominant
- Autosomal recessive
- X-linked dominant
- X-linked recessive
- Mitochondrial inheritance
PREFERRED RESPONSE: 4. X-linked recessive
DISCUSSION: The pedigree documents involvement of male offspring only, and it also shows transmission through an uninvolved female carrier. This inheritance pattern is most consistent with an X-linked recessive inheritance. It would be inconsistent with a dominant inheritance pattern unless there was incomplete penetrance. Autosomal-recessive inheritance would be possible only if the family member labeled II.F was also a carrier of the same gene; however, this is unlikely. Mitochondrial inheritance is possible, but as with autosomal patterns, mitochondrial inheritance normally affects both male and female offspring. It is transmitted only through the maternal line.
REFERENCE
Gelehrter TD, Collins FS: Principles of Medical Genetics. Baltimore, MD, Williams & Wilkins, 1990, pp 27-45.
A 13-year-old boy sustains a closed injury to his knee after a fall. A radiograph is shown in Figure 27. Treatment should consist of which of the following?
- Long leg cast in extension
- Long leg cast in 45° of flexion
- Percutaneous pinning with smooth wires and a cylinder cast
- Anterior cruciate ligament reconstruction and early motion
- Open reduction and internal fixation with lag screws and a cylinder cast
PREFERRED RESPONSE: 5. Open reduction and internal fixation with lag screws and a cylinder cast
DISCUSSION: The patient sustained a type III fracture of the tibial tubercle. This injury has been associated with Osgood-Schlatter disease. Treatment should consist of open reduction and internal fixation with lag screws, followed by casting for 6 weeks. Complications include meniscal tears, compartment syndrome, and leg length discrepancy.
REFERENCE
Wiss DA, Schilz JL, Zionts L: Type III fractures of the tibial tubercle in adolescents. J Orthop Trauma 1991;5:475-479.
Figure 28 shows the radiograph of a 10-year-old girl who reports chronic shoulder pain after her gymnastics classes. Examination reveals pain on internal and external rotation but no instability. What is the most likely diagnosis?
- Acromial fracture
- Humeral stress fracture
- Acromioclavicular joint separation
- Fracture of the surgical neck of the scapula
- Triceps avulsion fracture
PREFERRED RESPONSE: 2
DISCUSSION: The patient has a very wide humeral growth plate, indicating the presence of a proximal humeral stress fracture, an uncommon diagnosis in gymnasts. Gymnasts are prone to stress fractures of the scaphoid, distal radius, elbow, and clavicle. Proximal humeral stress fractures are more commonly seen in those participating in racket or throwing sports. Stress fractures can lead to growth arrest or inhibition, particularly in the distal radius. The radiograph shows normal findings for the acromion, acromioclavicular joint, scapula, and triceps origin.
REFERENCES
Fallon KE, Fricker PA: Stress fracture of the clavicle in a young female gymnast. Br J Sports Med 2001;35:448-449.
Sinha AK, Kaeding CC, Wadley GM: Upper extremity stress fractures in athletes: Clinical features of 44 cases. Clin J Sports Med 1999;9:199-202.
Caine D, Howe W, Ross W, Bergman G: Does repetitive physical loading inhibit radial growth in female gymnasts? Clin J Sports Med 1997;7:302-308.
Chan D, Aldridge MJ, Maffulli N, Davies AM: Chronic stress injuries of the elbow in young gymnasts. Br J Radiol 1991;64:1113-1118.
Incidence
Because rotational forces applied to the shoulder are especially prevalent in the pitching activity associated with baseball, the proximal humeral stress fractures involving the physis are most commonly seen in the immature baseball player. This injury has also been seen in gymnasts,[75] badminton players,[76] and cricketers.[77]
Biomechanically there are similarities between throwing and overhead racquet strokes, and indeed it has been suggested that overuse epiphyseal injuries at the shoulder may occur as the result of any repetitive sporting explosive actions-for instance, baseball and racquet sports-dynamic movements-for instance, swimming-and
upper limb weight-bearing activities-for instance,
gymnastics.7 Common to all these activities are shearing stresses applied to the epiphyseal plate as the limb moves repetitively from cocking to follow through phases.
The principal treatment modality in confirmed cases is rest and avoidance of exacerbating activities with rehabilitation of the shoulder girdle and rotator cuff musculature before return to sport. Ultimately, fusion of the epiphysis should normally offer a favourable outcome. The potential of long term complications
such as growth arrest and angular deformity in these young athletes is unknown.
Prevention is based on sound coaching practice,
shoulder conditioning, and the limitation
of excessive shoulder activity in these sports.9
Ref:
Hill JA. Epidemiologic perspective on shoulder injuries. Clin Sports Med 1983;2:241-6.
Gross ML, Flynn M, Sonzogni JJ. Overworked shoulders: managing the proximal humeral physis. Physician and Sportsmedicine 1 994;22:
A 16-year-old boy has had thigh pain for the past several months. He denies any history of trauma. Examination reveals a large, deeply fixed, soft-tissue mass in the thigh. Laboratory results show an elevated erythrocyte sedimentation rate (ESR) and leukocytosis. A plain radiograph and MRI scan are shown in Figures 1A and 1B. Biopsy specimens are shown in Figures 1C and 1D. What is the most likely diagnosis?
- Ewing sarcoma
- Osteomyelitis
- Osteosarcoma
- Chondrosarcoma
- Giant cell tumor of bone
PREFERRED RESPONSE: 1
DISCUSSION: Ewing sarcoma typically can occur in the diaphysis of the long bones (50% to 55%). It is often accompanied by a large soft-tissue mass. Abnormal findings are common, including a low-grade fever, an elevated ESR, and leukocytosis. The histology is consistent with a small round blue cell tumor. The unique pathology and other findings exclude osteosarcoma. Giant cell tumor and chondrosarcoma have a different histologic appearance and typically are more metaphyseal in location. Chondrosarcoma typically is found in older age groups, has a different histologic pattern, and rarely occurs in the midshaft of the femur.
REFERENCE
Simon MA, Springfield DS, et al: Ewing’s Sarcoma: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, pp 287-297.
The lesion seen in Figure 2 is most likely the result of metastases from what solid organ?
- Breast
- Lung
- Thyroid
- Prostate
- Liver
PREFERRED RESPONSE: 2
DISCUSSION: The primary carcinoma most likely to metastasize distal to the elbow and knees is lung carcinoma. Renal cell carcinoma can also metastasize to distal sites. Most metastatic bone disease occurs in the vertebral bodies, pelvis, and proximal long bones.
Bone metastasis in the hand is rare. The etiology is quite different from that of metastasis to other bones; bronchogenic carcinoma is by far the most frequent case. Distal phalanges are mainly involved with irregular osteolysis and cortical destruction. Differential diagnosis of phalangeal metastasis includes osteomyelitis, rheumatoid arthritis and gout. The prognosis is always that of metastatic bronchial cancer with an average survival of three months. Treatment may involve distal digital amputation or antalgic radiotherapy
REFERENCES
Simon MA, Bartucci EJ: The search for the primary tumor in patients with skeletal metastases of unknown origin. Cancer 1986;58:1088-1095.
Leeson MC, Makley JT, Carter JR: Metastatic skeletal disease distal to the elbow and knee. Clin Orthop Relat Res 1986;206:94-99.
A 10-year-old child has leg discomfort with activity. A radiograph, bone scan, and biopsy specimen are shown in Figures 3A through 3C. What is the most likely diagnosis?
- Parosteal osteosarcoma
- Unicameral bone cyst
- Aneurysmal bone cyst
- Eosinophilic granuloma
- Fibrous dysplasia
PREFERRED RESPONSE: 5
DISCUSSION: The ground glass appearance on the radiograph, the hot bone scan, and histologic findings of bony spicules without osteoblastic rimming in a background of bland fibrous tissue all suggest fibrous dysplasia. Stress-related pain is common with activity because of the dysplastic bone. Parosteal osteosarcomas are surface lesions. Simple cysts, aneurysmal bone cysts, and eosinophilic granuloma are all possible radiographically; however, the histology is most consistent with fibrous dysplasia.
REFERENCES
Harris WH, Dudley HR Jr, Barry RS: The natural history of fibrous dysplasia: An orthopaedic, pathological and roentgenographic study. J Bone Joint Surg Am 1962;44:207.
Campanacci M: Bone and Soft Tissue Tumors. Vienna, Austria, Springer-Verlag, 1990.
An athletic 55-year-old man reports a painless mass in the anterior aspect of the thigh that appeared 3 weeks ago and has not changed in size. The patient denies any history of trauma. Examination reveals a firm, well-defined nontender mass in the anterior thigh and no inguinal adenopathy or cutaneous changes. Plain radiographs are unremarkable. T1- and T2-weighted MRI scans are shown in Figures 5A and 5B. What is the most likely diagnosis?
- Hematoma
- Lipoma
- Soft-tissue sarcoma
- Pyomyositis
- Hemangioma
PREFERRED RESPONSE: 3
DISCUSSION: The presence of a painless soft-tissue mass that is greater than 5 cm and deep to the fascia should be considered a soft-tissue sarcoma until proven otherwise. The diagnosis of a hematoma should be made with great caution because the absence of a history of trauma, pain, or presence of ecchymosis makes it unlikely. A diagnosis of pyomyositis is unlikely because of the absence of warmth, erythema, or adenopathy. The MRI scans are not consistent with lipoma or hemangioma. The MRI signal characteristics of a lipoma should be the same as subcutaneous fat on all sequences. Soft-tissue hemangiomas are not well defined and have an infiltrative appearance on MRI scans, as does pyomyositis.
REFERENCES
Sim FH, Frassica FJ, Frassica DA: Soft-tissue tumors: Diagnosis, evaluation and management. J Am Acad Orthop Surg 1994;2:202-211.
Kransdorf MJ, Jelinek JS, Moser RP Jr, et al: Soft-tissue masses: Diagnosis using MR imaging. Am J Roentgenol 1989;153:541-547.
A 77-year-old man has had increasing right knee pain for the past 3 months. A radiograph and coronal T1-weighted MRI scan are shown in Figures 6A and 6B. A biopsy specimen is shown in Figure 6C. What is the most likely diagnosis?
- Metastatic prostate cancer
- Enchondroma
- Osteomyelitis
- Dedifferentiated chondrosarcoma
- Lymphoma
PREFERRED RESPONSE: 4
DISCUSSION: The radiograph shows a calcified lesion in the medullary canal of the distal femoral diaphysis. The AP radiograph reveals a lucent lesion extending down to the intercondylar notch. The lateral radiograph reveals an ominous periosteal reaction in the anterior cortex associated with a soft tissue mass. The blastic changes within the intramedullary canal on AP and lateral radiographs suggest osteoid or chondroid matrix.
The MRI scan shows extensive marrow change distal to the lesion, which is not consistent with an enchondroma. T1-weighted (left) and STIR (right) coronal images reveal the extent of the intramedullary lesion.
The histology shows a biphasic pattern with low-grade cartilage just apposed to high-grade spindle cell sarcoma.
the interface between malignant spindle cells (above) and the chondroid portion of the tumor (below) is seen, diagnostic of dedifferentiated chondrosarcoma.
The overall appearance is consistent with dedifferentiated chondrosarcoma. The radiographic appearance is not consistent with enchondroma, and the histologic appearance is not consistent with the other choices.
REFERENCES
Mitchell AD, Ayoub K, Mangham DC, et al: Experience in the treatment of dedifferentiated chondrosarcoma. J Bone Joint Surg Br 2000;82:55-61.
Frassica FJ, Unni KK, Beabout JW, Sim FH: Dedifferentiated chondrosarcoma: A report of the clinicopathological features and treatment of seventy-eight cases. J Bone Joint Surg Am 1986;68:1197-1205.
Dedifferentiated Chondrosarcoma
DEFINITION AND PATHOGENESIS
A conventional chondrosarcoma juxtaposed next to a high-grade (non-cartilaginous) sarcoma
Two groups of precursor lesions have been identified
Low-grade (to high-grade) malignant chondrosarcoma
Moderate- to high-grade malignant chondrosarcoma, osteosarcoma, MFH, fibrosarcoma, or unspecified and anaplastic spindle-cell sarcoma
IMPORTANCE
Very aggressive and high grade chondrosarcoma that must be aggressively txd
Transformation to a higher grade occurs in ~11% of chondrosarcomas
CLINICAL FEATURES
6th decade disease on the average (wide age range)
Mean age 59
M (53%) > F
Pain, swelling
10-29% present with pathologic fx (rare for conventional chondrosarcoma)
Most in femur or pelvis
Unusual location
Maxilla
Facial swelling, epistaxis and proptosis reported
Primary lung location reported in a pt with systemic sclerosis
Sxs from a large pleural effusion were present
RADIOLOGIC FEATURES
Second area with aggressive characteristics
Soft tissue mass with penetrated/destroyed cortex (72%) adjacent to a less aggressive area
Type 1: resembles conventional central chondrosarcoma with cortical penetration, soft tissue mass, pathological fx, angiographic contrast uptake, extraosseous ossification, rapid progression
Type 2: resembles conventional central chondrosarcoma with an aggressive component
Type 3: no resemblance radiographically to conventional central chondrosarcoma
Nearly 2/3 may be associated with a secondary chondrosarcoma
Enchondroma
Reported in a thumb PP fxd 15 yrs previously through an enchondroma
Ollier’s disease
Osteochondromatosis
Most often > 7cm
± pathological fx
Diaphyseal or metaphyseal
Typically in the pelvis, femur, humerus
Has been reported arising in a solitary osteochondroma
dedifferentiated component can be leiomyosarcoma, osteosarcoma, MFH, and fibrosarcoma
3 categories of plain radiographic appearance
Type I: cortex not deformed, no periosteal reaction, calcific matrix, and an indolent osteolytic reion with indistinct margins
Type II: cortical expansion and/or with osteolytic areas
Type III: cortex destroyed with osteolytic regions predominate
GROSS PATHOLOGY
Two areas may be distinctly visible on cross sectioning
HISTOLOGIC FEATURES
High-grade spindle cell sarcoma (not recognizable as cartilaginous in origin) next (an abrupt interface) to low-grade cartilage tissue
Osteosarcoma
Fibrosarcoma
Precursor lesion may be seen
Dedifferentiated tumor in LR of previously low-grade chondrosarcoma (review previous pathology)
DIFFERENTIAL CLINICOPATHOLOGIC DIAGNOSIS
Sarcomatous transformation of a bone infarct
Conventional chondrosarcoma
GCT due to lucency when in metaepiphyseal location
DISEASE COURSE AND TREATMENT
Dx with FNA reported in a pelvic location
(Presence of both low and high grade components documented)
Wide resection and chemotx
Wide range of chemotherapeutic regimens have been used without proven benefit or standardization
Doxorubicin and cisplatin
Doxorubicin and ifosfamide
XRT may be used preop in some of the larger lesions where margins may be close; the theory is that the tumor cells will not be able to seed the wound if a positive margin is obtained
Lack of response to chemotx may be related to high likelihood of P-glycoprotein expression
Pulmonary, skeletal, and visceral metastases occur with high risk
Skin metastasis has been reported dxd with FNA
21% with metastases at the time of dx
Median survival of 5 mos
10% 2-yr-survival
~7-24% 5-yr survivals have been reported (median survival < 9 months)
With no metastases at presentation, overall survival 28% at 10 yrs reported
Best prognosis in radiologic type 1 lesions
Grade of dedifferentiated sarcoma the most important predictor of biological behavior (rather than type of tumor differentiation–osteoblastic or fibroblastic)
A 47-year-old woman has an asymptomatic pelvic mass that was discovered on routine gynecologic examination. A radiograph, CT scan, MRI scan, and biopsy specimen are shown in Figures 7A through 7D. Metastatic work-up is negative. Treatment should consist of
- observation.
- primary wide resection.
- intralesional curettage.
- radiation therapy.
- preoperative chemotherapy.
PREFERRED RESPONSE: 2
DISCUSSION: The imaging studies show a chondrosarcoma; therefore, surgical treatment is indicated. There is no role for intralesional treatment of an exophytic lesion, particularly in the pelvis. Even obtaining a biopsy specimen risks intrapelvic contamination, although many surgeons would still perform a biopsy prior to a resection to confirm the diagnosis. Chondrosarcoma is considered resistant to both radiation therapy and chemotherapy; therefore, radiation therapy generally is not used except for unresectable lesions. Chemotherapy would be used only for metastatic disease or in patients with high-grade chondrosarcoma. The grade would not be known until after resection, and in this patient, the histology slide showed a grade I neoplasm. Chemotherapy would not be used preoperatively because a cartilage tumor is unlikely to shrink, and in this patient, the lesion is resectable.
REFERENCES
Springfield DS, Gebhardt MS, Mcguire MH: Chondrosarcoma: A review. J Bone Joint Surg Am 1996;78:141-149.
Marco RA, Gitelis S, Brebach GT, Healey JH: Cartilage tumors: Evaluation and treatment. J Am Acad Orthop Surg 2000;8:292-304.
A 20-year-old patient has foot pain. A radiograph and T1-weighted MRI scan are shown in Figures 8A and 8B. A biopsy specimen is shown in Figure 8C. Treatment should consist of
- extended curettage and cementation.
- amputation of the first ray.
- wide resection and chemotherapy.
- extended curettage, radiation therapy, and chemotherapy.
- Syme amputation.
PREFERRED RESPONSE: 1. extended curettage and cementation
DISCUSSION: Giant cell tumors occur near articular surfaces in young adults. The histology shows abundant giant cells with nuclei resembling the surrounding cells. Although the MRI scan shows soft-tissue involvement, curettage is still the preferred treatment. Chemotherapy is not necessary for benign lesions, and amputation is too aggressive. Cementation, phenol, and cryosurgery (liquid nitrogen) are all acceptable local adjuvants to curettage. Packing the cavity with bone graft rather than cement is also acceptable.
REFERENCES
Dahlin DC, Unni KK: Bone Tumors: General Aspects and Data on 8,542 Cases. Springfield, IL, Charles C. Thomas, 1986.
Gitelis S, Mallin BA, Piasecki P, Turner F: Intralesional excision compared with en bloc resection for giant cell tumor of bone. J Bone Joint Surg Am 1993;75:1648-1655.
A 69-year-old man has a painful slow-growing lesion of the distal phalanx of his thumb. History reveals that he has had chronic osteomyelitis of the thumb for the past 12 years. The radiograph and biopsy specimens are seen in Figures 9A through 9C. Treatment should consist of
- intralesional curettage.
- wrist disarticulation.
- amputation.
- chemotherapy.
- radiation therapy.
PREFERRED RESPONSE: 3. amputation.
DISCUSSION: The diagnosis is squamous cell carcinoma. The radiograph shows a destructive lesion, and the histologic slides demonstrate squamous cells invading bone. The preferred treatment for squamous cell carcinoma is wide resection; however, in this location a wide margin can be achieved only with amputation. Overall survival in patients with squamous cell carcinoma secondary to chronic osteomyelitis is not significantly worse than that expected for age-matched controls.
REFERENCES
Dell PC: Hand, in Simon MA, Springfield D (eds): Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott-Raven, 1998, pp 405-420.
McGrory JE, Pritchard DJ, Unni KK, Ilstrup D, Rowland CM: Malignant lesion arising in chronic osteomyelitis. Clin Orthop Relat Res 1998;362:181-189.
A 43-year-old woman has had pain in the left hip for the past 2 months. A radiograph, CT scan, MRI scan, and biopsy specimens are shown in Figures 10A through 10E. What is the most likely diagnosis?
- Osteosarcoma
- Osteochondroma
- Chondrosarcoma
- Chordoma
- Enchondroma
PREFERRED RESPONSE: 3
DISCUSSION: The imaging studies are consistent with a chondrosarcoma. The radiograph shows a radiolucent lesion in the pelvis, and there are stippled calcifications on the CT scan. The histology shows a low-grade cellular hyaline cartilage neoplasm with stellate, occasionally binucleated chondrocytes. Enchondroma has a more benign histologic appearance.
REFERENCE
Mirra JM, Gold R, Downs J, Eckardt JJ: A new histologic approach to the differentiation of enchondroma and chondrosarcoma of the bones: A clinicopathologic analysis of 51 cases. Clin Orthop Relat Res 1985;201:214-237.
A 10-year-old girl reports activity-related bilateral arm pain. Examination reveals no soft-tissue masses in either arm, and she has full painless range of motion in both shoulders and elbows. The radiograph and bone scan are shown in Figures 11A and 11B, and biopsy specimens are shown in Figures 11C and 11D. What is the most likely diagnosis?
- Enchondroma
- Fibrous dysplasia
- Osteogenic sarcoma
- Aneurysmal bone cyst
- Periosteal chondroma
PREFERRED RESPONSE: 2
DISCUSSION: Based on these findings, the most likely diagnosis is fibrous dysplasia. Twenty percent of patients with fibrous dysplasia have multifocal disease. The lesions show a typical ground glass appearance. Fibrous dysplasia frequently involves the diaphysis of the long bones. There is no associated soft-tissue mass and no periosteal reactions to these lesions, suggesting a benign lesion. The histology shows proliferating fibroblasts in a dense collagen matrix. Trabeculae are arranged in an irregular or “Chinese letter” appearance. Osteogenic sarcoma and Ewing sarcoma have a much different radiographic appearance of malignant osteoid and small round blue cells. Periosteal chondroma does occur in the proximal humerus but is not typically multifocal. It appears as a surface lesion with saucerization of the underlying bone and a bony buttress adjacent to the lesion. Some patients with multifocal lesions have associated endocrine abnormalities (McCune-Albright syndrome).
REFERENCES
Wold LA, et al: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990, pp 118-119.
Simon M, et al: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 197.
An 83-year-old man has a painful mass of the great toe. Radiographs and a biopsy specimen are seen in Figures 12A and 12B. What is the most likely diagnosis?
- Gout
- Pseudogout
- Infection
- Epidermal inclusion cyst
- Charcot joint
PREFERRED RESPONSE: 1.Gout
DISCUSSION: Gouty arthritis, pseudogout, and infection can all present with inflammatory arthritis and periarticular erosions. Strongly negative birefringent crystals are seen in gout. The histologic image shows elongated “needle-like” crystals of gout. Epidermal inclusion cysts are rarely painful and usually have a history of localized penetrating trauma.
REFERENCES
Hamilton W, Breedman KB, Haupt HM, Lackman R: Knee pain in a 40-year-old man. Clin Orthop Relat Res 2001;383:282-285,290-292.
Mizel M, Miller R, Scioli M (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 301-302.
A 10-year-old child reports acute leg pain after wrestling with his brother. AP and lateral radiographs are shown in Figures 13A and 13B. What is the best course of action?
- Biopsy, curettage, and plating
- Wide segmental resection
- Hip disarticulation
- Closed reduction and a long leg cast
- Tibial traction and MRI
PREFERRED RESPONSE: 4. Closed reduction and a long leg cast
DISCUSSION: The radiographs show an eccentric metaphyseal lesion with a well-defined reactive rim of bone that is consistent with a nonossifying fibroma. Pathologic fractures through benign lesions should be treated as appropriate for the fracture, allowing the fracture to heal. Biopsy is not needed when the radiographic diagnosis is benign. MRI, in the presence of a fracture, is not particularly helpful because of the hematoma. If radiographic findings reveal that the lesion appears aggressive, a biopsy should be performed, obtaining tissue away from the fracture site.
REFERENCES
Marks KE, Bauer TW: Fibrous tumors of bone. Orthop Clin North Am 1989;20:377. Ponseti IV, Friedman B: Evaluation of metaphyseal fibrous defects. J Bone Joint Surg Am 1949;31:582.
A 16-year-old girl has had pain in the left groin for the past 4 months. She notes that the pain is worse at night; however, she denies any history of trauma and has no constitutional symptoms. There is no history of steroid or alcohol use. Examination reveals pain in the left groin with rotation of the hip. There is no associated soft-tissue mass. A radiograph and MRI scan are shown in Figures 16A and 16B, and biopsy specimens are shown in Figures 16C and 16D. What is the most likely diagnosis?
- Clear cell chondrosarcoma
- Chondroblastoma
- Giant cell tumor
- Aneurysmal bone cyst
- Osteonecrosis of the femoral head
PREFERRED RESPONSE: 2
DISCUSSION: Based on the epiphyseal location and sharp, well-defined borders, the radiograph suggests chondroblastoma. Histologically, multinucleated giant cells are scattered among mononuclear cells. The nuclei are homogeneous and contain a characteristic longitudinal groove.
Although not seen here, “chicken-wire calcification” with a bland giant cell-rich matrix is also typical for chondroblastoma. Clear cell chondrosarcoma occurs in epiphyseal locations but has a more aggressive histologic pattern and occurs in an older age group. Giant cell tumors occur in the epiphysis but have a more uniform giant cell population histologically. Aneurysmal bone cyst often results in bone remodeling and has a different pathologic appearance. Osteonecrosis has a typical histologic pattern of empty lacunae and necrotic bone.
REFERENCES
Springfield DS, Capanna R, Gherlinzoni F, et al: Chondroblastoma: A review of seventy cases. J Bone Joint Surg Am 1985;67:748-755.
Simon M, Springfield D, et al: Chrondroblastoma: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 190.
Wold LA, et al: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990, pp 62-67.
Male, 28 y.o. He got crushed in both of lower leg and dark urine after several hours
- Describe pathophysiology of this condition?
- What are/is complications?
- How is your early management for this case ?
- What is your plan in relation to patients mobility ?
Answer:
- The pathophysiology of muscular cytolysis in the crush syndrome:
- based on cellular Ca changes. Excess Ca enter intracellular trigger contraction result in energy depletion
- Excess Ca activates phospholipase A2, vasoactive molecules, and protease, result in fre radical release
- all these event finally result in progressive muscle destruction
Patophysiology of acute renal failure (ARF) ec crush injury
- intraluminal myoglobin cast formation
- renal vasoconstriction
- direct heme-protein induced cytotoxicity
- Complication are:
early:
- neurovascular damage
- compartment syndrome
- acute renal failure
intermediate
- infection
late
- heterotrophic ossification due to excess Ca accumulation intramuscular
Plan tx:
- fluid rehydration
- hemodyalisis if uremia, acidosis, or hyperkalemi present
Boy, 11 y.o with limb length inequality
- What is the probable diagnosis ?
- What is the most accepted classification for that anomalies? Please describe!
- What is suitable candidate for limb lengthening ?
- How to predict discrepancy at maturity ?
Answer:
- Proximal Focal Femoral Deficiency
- Aitken’s classification: type A
- Type (A):
The femur is short with coxa vara and lateral bowing
Adequate acetabulum that contains the femoral head.
Pseudoarthrosis develops At the Subtrochanteric region.
At the skeletal maturity, ossification of the pseudoarthrosis will take place in moat cases, but the varus angulation may be very severe. - Type (B):
The ossification of the capital femoral epiphysis is delayed and the acetabulum is mildly dysplastic.
The upper end of the femoral shaft lies above the femoral head.
The junction between the femoral head and shaft is by defective cartilage that fail to ossify at skeletal maturity. - . Type (C):
-The acetabulum is markedly dysplastic and the femoral head never ossify.
-The femoral shaft is very short and its upper end tapers sharply to a point.
-The hip is very unstable. - . Type (D ):
Both acetabulum and femoral head are absent.
The femur is represented by the femoral condyles.
- The most suitable candidate for limb lengthening is Aitken type A with > 5 cm discrepancies
- Predicted femoral length at maturity :
The percentage of growth inhibition in the involved femur compared to the contralateral side was found to be constant in unilateral cases.
Calculation:
- The percentage of growth inhibition is calculated by the difference between the normal and abnormal lengths divided by the normal length and multiplied by 100.
- The anticipated normal limb segment length is determined by using serial scanograms and plotting the limb length on the Green-Anderson graph according to skeletal age.
- The anticipated normal limb length is multiplied by the percentage of growth inhibition, and the length of the involved limb segment at skeletal maturity can be determined.
This figure shows the MRI scan of a 43-year old man who has had worsening low back pain for the past 4 months.
- What is MRI finding ?
- What is the most likely diagnosis ?
- What is differential diagnosis ?
- What is other investigation to rule out the diagnosis ?
- MRI sagital of T2 weight lumbosacral of a man 43 yo shows:
- Alignment: kiphotic deformity on L 1 and 2
- Hyperintense image on L 1 and 2 suggesting destruction of corpus, space filled with fluid which might be pus
- destruction also on intervertebral disc of L1-L2
- the fluid/pus extend to spinal canal, pushing the spinal cord, continue to posterior until paravertebral muscle
- Spondilitis Tb V L 1 - 2
- Pyogenic spondilitis
- Lab : diff count, LED, Ro : lumbosacral AP/lat, culture of destroyed tissue/pus
This is a radiograph of the shoulder of a patient who was diagnosed a week ago as a sprained shoulder in the A&E after a road traffic accident.
A. List the abnormal features you see in this x-ray
B. What is your radiological diagnosis?
C. How will you treat him now?
D. List any special diagnostic investigation you may have done during the first visit to the A&E
ANSWER :
A. Internal rotate of humeral, Abnormal shape : electrical bulb appearance, Empty glenoid sign
B. Posterior dislocation of shoulder
C. Closed reduction under anesthesia
D. Axillary view, lateral view
- Boy 7 yo
• What the pathology he has ?
• What kind of gait she has?
• How do corret of deformity?
Answer:
- genu recurvatum D might be cause by neuromuscular disorder
- Dx: genu recurvatum D ec residual paralysis post poliomyelitis
- Extensor is stronger than hamstring muscles ??? Extensor is weaker than hamstring
- Gait : circumduction gait
- Correction by knee brace, pasient will walk by tilting of the hip
• I have read some paper mentioned about bilateral genu recurvatum after poliomyelitis
- • Patients with weak quadriceps will attempt to create stance stability by placing their body weight anterior to the knee joint, (i.e., hyperextension) to lock their knee. This places the soft tissues posterior to the knee in tension and may produce progressive recurvatum. (Clark DR, Perry J, Lunsford TR. Cases studies-The Orthotic Management of the Adult Post Poliomyelitis Patient. Orthotics and Prosthetics. Vol 40; No 1: pp 43-50. 1986. The American Orthotics and Prosthetics Association. )
- • The common orthotic answer is to provide a locked knee-ankle-foot orthosis (KAFO). This requires the patient to accommodate the locked knee joint by hiking the pelvis or utilizing other substitutions for the stiff-legged gait
- Boy 12 yo, never able to walk since 3 yo after suffering fever.
a. What is the most likely diagnosis ?
b. What is the treatment?
Answer:
a. This is also residual paralysis post poliomyelitis with hamstring contracture and iliotibial band contracture
b. For hip flexion contracture: Yount procedure, extend to 15 degree hip extension. Haldstead procedure, multiple incision at septum
c. For knee flexion contracture : release hamstring, bone procedure: supracondylar osteotomy if needed
The iliotibial band is a thickening of the fascia lata of the thigh. Its upper end splits to enclose tensor fascia lata and distally it is attached to a smooth triangular anterolateral facet on the lateral condyle of the tibia.
Spasm of the tensor fascia lata leading to contracture of the iliotibial band is common in patients with residual paralysis after polio. This produces a flexion, abduction and external rotation contracture at the hip. Ober’s test2 is used to demonstrate the contracture.
In the classical Ober’s test the patient is in a lateral position with the normal thigh next to the table and flexed sufficiently to obliterate any lumbar lordosis. The upper leg is then flexed to a right angle at the knee and the examiner
holds the ankle lightly with one hand and steadies the patient’s hip with the other. The upper leg is abducted widely and extended so that the thigh is in line with the body. If the limb is now released, it will stay suspended in abduction before showing a delayed drop depending on the degree of contracture. It is very difficult to determine the delayed drop of the limb because flexion at the hip relaxes the iliotibial band and renders the test ineffective
- Lady 18 yo, tilting of the head, no pain, dolicocephal.
a. What is the diagnosis ?
b. What is treatment ?
Answer:
a. Torticollis, which might be caused by :
a. Infection: Tb, soft tissue contracture at the neck
b. Tumor
c. Congenital , anomaly of the cervical spine: hemivertebra, sprangel
d. Trauma
b. Baby with torticollis has always breech delivery (60%, Prof SKN experiences), it will occur couple of weeks or months later.
c. What usually happen during the torticollis : lump of m. sternocleidomastoideus, kosistensi kenyal, in the middle of m. strenocleidomastoideus
d. Send the patient for rehabilitation for passive stretching, 5-6 x / day, in the beginning of its appearance, subsequently only 5% of patients will have torticollis
e. Measure the angle-shoulder angle. Correct the deformity by bipolar release of origo and insersi of m. sternocleidomastoideus. Total release do not left any thread of muscle., check wether there is contracture in the fascia. After surgery, put in cotrell traction, 1 week post op put in soft collar brace with higher height in pathologic site, do passive stretching.
f. What is the most complication of upper pole release : palsy of n. assesorius.
describe the histoPA below
Proliferasi anaplastia:
hiperseluler, nuclear pleumorfism,big nucleus,
BINUCLEATION
diagnosat: chondrosarcoma
Describe the histoPa below
- Elongated spindle
- Bentuknya ada yang wavy (keriting)
- Terdapat pada bahan collagen
- Absen of mitotic figur
- Dx: neurofibroma
A 12-year-old boy reports knee discomfort after prolonged strenuous activities. He denies knee swelling or catching and has no pain with activities of daily living. A radiograph is shown in Figure 1. Prognosis for the pathology shown is most influenced by
- weight.
- gender.
- the knee compartment involved.
- open or closed growth plates.
- limb alignment.
PREFERRED RESPONSE: 4. open or closed growth plates
DISCUSSION: While many factors play a role in the outcome of osteochondritis dissecans, ample evidence has shown that the prognosis is most influenced by the growth status of the plates. If the growth plates are open, the chance of a successful outcome is significantly greater than if they are closed.
REFERENCES
Federico DJ, Lynch JK, Jokl P: Osteochondritis dissecans of the knee: A historical review of etiology and treatment. Arthroscopy 1990;6:190-197.
Linden B: Osteochondritis dissecans of the femoral condyles: A long-term follow-up study. J Bone Joint Surg Am 1977;59:769-776.
Figures 1A and 1B show the radiographs of a 51-year-old woman who injured her left leg after falling off a stepladder. Surgical reconstruction was performed with a compression screw and side plate; the postoperative radiograph is shown in Figure 1C. Following gradual progression of weight bearing, she reports that she slipped again and placed full weight on the extremity. She now notes a new onset of increased pain in her left thigh and hip region. Follow-up radiographs are shown in Figures 1D and 1E. Reconstruction should consist of
- conversion to a longer side plate with the same compression screw and tube angle.
- in situ bone grafting.
- hardware removal and reconstruction with an intramedullary device that provides fixation into the femoral head and neck.
- hardware removal and retrograde femoral nailing.
- revision reconstruction with cerclage wiring.
PREFERRED RESPONSE: 3. hardware removal and reconstruction with an intramedullary device that provides fixation into the femoral head and neck.
DISCUSSION: The initial fracture was an unstable reverse oblique intertrochanteric fracture with subtrochanteric extension. Initial fixation with a high-angled screw and side plate construct may not provide stability as well as a 95° fixed-angle device or a intramedullary hip screw device. The follow-up radiographs show loss of fixation and further propagation of the fracture distally. Reconstruction would best be accomplished with hardware removal and conversion to a long intramedullary nail with femoral head fixation or a 95° angled plate and screw device. Conversion to a longer plate does not improve the biomechanical situation at the primary fracture site. In situ bone grafting would not provide any additional stability and would not correct the deformity. The proximal femoral fracture is not amenable to retrograde nailing. Cerclage wiring will not sufficiently enhance stability and is not indicated.
Data from research:
Thirty-two (68%) of forty-seven hips treated with internal fixation healed without an additional operation.
Fifteen (32%) of the forty-seven failed to heal or had a failure of fixation.
The failure rate was nine of sixteen for the sliding hip screws, two of fifteen for the blade-plates, three of ten for the dynamic condylar screws, one of three for the cephalomedullary nails, and zero of three for the intramedullary hip screws.
Use of the fixed-angle devices (the blade-plate and the dynamic condylar screw) resulted in fewer failures than did use of the sliding hip screw (p = 0.023)
REFERENCES
Bridle SH, Patel AD, Bircher M, Calvert PT: Fixation of intertrochanteric fractures of the femur: A randomized prospective comparison of a gamma nail and dynamic hip screw. J Bone Joint Surg Br 1991;73:330-334.
DeLee JC: Fractures and dislocations of the hip, in Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, pp 1659-1825.
Haidukewych GJ, Israel TA, Berry DJ: Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643-650.
Sanders RW, Regazzoni P: Treatment of subtrochanteric femur fractures using the dynamic condylar screw. J Orthop Trauma 1989;3:206-213.
Seven hours ago, a 32-year-old man who was not wearing a seat belt was injured when his car struck a power pole. He needed to be extricated from the vehicle. Examination reveals absent pulses in the left foot, the thigh is swollen and tender, and a closed fracture is noted. Radiographs are shown in Figures 2A and 2B. Doppler examination reveals no significant flow distal to the fracture site. Treatment should include which of the following?
- Immediate angiography
- Insertion of a distal femoral traction pin in the emergency department and angiography
- Surgical exploration of the femoral and popliteal artery through a medial approach
- Manipulative reduction in the emergency department and angiography
- Urgent reduction of the fracture, followed by an on-table angiogram or arterial exploration
PREFERRED RESPONSE: 5. Urgent reduction of the fracture, followed by an on-table angiogram or arterial exploration
DISCUSSION: This patient has a probable vascular injury based on absent pulses and a Doppler examination. Since 7 hours have elapsed since the injury, immediate restoration of blood flow is imperative. Angiography with the fracture in a displaced position will be misleading. The patient should undergo urgent reduction of the fracture and an on-table angiogram or arterial exploration, followed by fracture and vascular repair.
REFERENCES
Johnson KD: Femur: Trauma, in Frymoyer JW (ed): Orthopaedic Knowledge Update 4: Home Study Syllabus. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1993, pp 559-567.
Johnson KD: Femoral shaft fractures, in Browner BD, Jupiter JB, Levine AM, et al (eds): Skeletal Trauma. Philadelphia, PA, WB Saunders, 1992, vol 2, pp 1575-1576.
A 36-year-old man sustains the injury seen in Figure 3A and 3B. Examination reveals a 3-cm wound overlying the site of the ulnar fracture. The neurovascular status of the limb is normal. In addition to tetanus prophylaxis, IV antibiotics, and urgent debridement, treatment should include which of the following?
- Splint immobilization without an attempt at fracture reduction
- Closed reduction and splint immobilization
- Open reduction and internal fixation of both bones of the forearm
- External fixation of the ulna with splint supplementation
- External fixation of the ulna, and open reduction and plate fixation of the radius
PREFERRED RESPONSE: 3. Open reduction and internal fixation of both bones of the forearm
DISCUSSION: The patient has a type II open fracture of the forearm, and assuming treatment takes place less than 24 hours after the injury, open reduction and plate fixation is the preferred method for stabilization of types I, II, and IIIA open forearm fractures.
REFERENCES
Moed BR, Kellam JF, Foster RJ, et al: Immediate internal fixation of open fractures of the diaphysis of the forearm. J Bone Joint Surg Am 1986;68:1008-1017.
Duncan R, Geissler W, Freeland AE, et al: Immediate internal fixation of open fractures of the diaphysis of the forearm. J Orthop Trauma 1992;6:25-31.
A 23-year-old man sustains the injury shown in Figures 4A and 4B. In association with this injury, which of the following nerves is most commonly injured?
- Axillary
- Median
- Musculocutaneous
- Radial
- Ulnar
PREFERRED RESPONSE: 1. Axillary
DISCUSSION: An anterior dislocation of the shoulder is shown in Figures 4A and 4B. The axillary nerve is the most commonly involved nerve, having an incidence ranging from 5% to 33% for first-time anterior glenohumeral dislocations. The likelihood of injury to the axillary nerve increases with age and the duration of the dislocation. It is usually a traction neurapraxia but the prognosis for recovery is good.
REFERENCES
Blom S, Dahlback LO: Nerve injuries in dislocations of the shoulder joint and fractures of the neck of the humerus: A clinical and electromyographical study. Acta Chir Scand 1970;136:461-466.
Rockwood CA Jr, Thomas SC, Matsen FA III: Subluxation and dislocations about the glenohumeral joint, in Rockwood CA Jr, Green DP, Bucholz RW (eds): Rockwood & Green’s Fractures in Adults, ed 3. Philadelphia, PA, JB Lippincott, 1991, pp 1021-1179.
A 37-year-old man sustains an isolated injury to his right arm as the result of being struck by a car. Examination reveals that the radial and ulnar pulses are normal, and the neurologic examination reveals that he is unable to extend the wrist, fingers, or thumb. A radiograph of the right humerus is shown in Figure 5. Management should consist of
- plate osteosynthesis via an anterolateral approach.
- external fixation.
- closed reduction and application of a splint.
- exploration of the radial nerve and a locked intramedullary nail.
- electrodiagnostic studies of the radial nerve.
PREFERRED RESPONSE: 3. closed reduction and application of a splint.
DISCUSSION: The patient has a high-energy closed humeral shaft fracture with an immediate complete radial nerve palsy. Closed reduction and application of a splint yield excellent results in closed humeral shaft fractures. With observation, the prognosis of the nerve injury is favorable for return of extension. Indications for surgical treatment, such as open an fracture, vascular injury, a floating elbow, or associated intra-articular fractures, are not present. Exploration of radial nerve injuries has not been shown to improve the neurologic outcome.
Distal humeral shaft fracture spiral configuration with association with radial nerve palsy = Holstein Lewis fracture
Acceptability criteria of closed reduction management:
Twenty degrees of anterior angulation, 30 degrees of varus angulation, and up to 3 cm of bayonet apposition are acceptable and will not compromise function or appearance
Imobilization :
- Hanging cast: This utilizes dependency traction by the weight of the cast and arm to effect fracture reduction.
- Indications include displaced midshaft humeral fractures with shortening, particularly spiral or oblique patterns. Transverse or short oblique fractures represent relative contraindications because of the potential for distraction and healing complications.
- The patient must remain upright or semiupright at all times with the cast in a dependent position for effectiveness.
- It is frequently exchanged for functional bracing 1 to 2 weeks after injury.
- More than 95% union is reported.
- Coaptation splint: This utilizes dependency traction to effect fracture reduction, but with greater stabilization and less distraction than a hanging arm cast. The forearm is suspended in a collar and cuff.
- It is indicated for the acute treatment of humeral shaft fractures with minimal shortening and for short oblique or transverse fracture patterns that may displace with a hanging arm cast.
- Disadvantages include irritation of the patient’s axilla and the potential for splint slippage.
- It is frequently exchanged for functional bracing 1 to 2 weeks after injury.
- Thoracobrachial immobilization (Velpeau dressing): This is used in elderly patients or children who are unable to tolerate other methods of treatment and in whom comfort is the primary concern.
- It is indicated for minimally displaced or nondisplaced fractures that do not require reduction.
- Passive shoulder pendulum exercises may be performed within 1 to 2 weeks after injury.
- It may be exchanged for functional bracing 1 to 2 weeks after injury.
- Shoulder spica cast: This has limited application, because operative management is typically performed for the same indications.
- It is indicated when the fracture pattern necessitates significant abduction and external rotation of the upper extremity.
- Disadvantages include difficulty of cast application, cast weight and bulkiness, skin irritation, patient discomfort, and inconvenient upper extremity position.
- Functional bracing: This utilizes hydrostatic soft tissue compression to effect and maintain fracture alignment while allowing motion of adjacent joints.
* It is typically applied 1 to 2 weeks after injury, after the patient has been placed in a hanging arm cast or coaptation splint and swelling has subsided.
It consists of an anterior and posterior shell held together with Velcro straps.
Success depends on an upright patient and brace tightening daily.
Contraindications include massive soft tissue injury, an unreliable patient, and an inability to obtain or maintain acceptable fracture reduction.
A collar and cuff may be used to support the forearm, but sling application may result in varus angulation.
The functional brace is worn for a minimum of 8 weeks after fracture or until radiographic evidence of union.
REFERENCES
Levine AM (ed): Orthopaedic Knowledge Update: Trauma. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 25-34.
Zagorski JB, Latta LL, Zych GA, Finnieston AR: Diaphyseal fractures of the humerus: Treatment with prefabricated braces. J Bone Joint Surg Am 1988;70:607-610.
A 28-year-old man sustains the closed injury shown in Figures 6A through 6C after falling 8 feet while rock climbing. Management should consist of
- open reduction and internal fixation via an anteromedial arthrotomy.
- talectomy.
- primary tibiotalocalcaneal arthrodesis.
- open reduction and internal fixation via a medial malleolar osteotomy and limited anterior lateral arthrotomy.
- closed reduction and a non-weight-bearing cast.
PREFERRED RESPONSE: 4. open reduction and internal fixation via a medial malleolar osteotomy and limited anterior lateral arthrotomy
DISCUSSION: The radiographs show a comminuted talar body fracture. The goal of treatment is to minimize the risks of posttraumatic arthrosis of the ankle and subtalar joint and to maintain vascularity. Open reduction and internal fixation with an attempt at anatomic reduction will lead to improved outcomes. Attempting to repair this fracture via an arthrotomy only is extremely difficult, and the addition of a medial malleolar osteotomy is warranted. A limited anterior lateral arthrotomy with minimal soft-tissue stripping may assist with fixation of anterior-lateral and lateral fragments and allow better assessment of reduction of the major fracture line. Nonsurgical care would lead to inadequate reduction and increased risk of both ankle and hindfoot arthrosis. Talectomy and primary ankle and hindfoot arthrodesis should not be performed as primary surgical reconstructive options in this closed injury pattern.
REFERENCES
Sanders R: Fractures and fracture-dislocations of the talus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 1465-1518.
Grob D, Simpson LA, Weber BG, Bray T: Operative treatment of displaced talus fractures. Clin Orthop Relat Res 1985;199:88-96.
A 20-year-old man sustains the injury shown in Figures 7A and 7B in a motorcycle accident. In addition to a prompt closed reduction, his outcome might be optimized by
- a subtalar arthrodesis.
- screw fixation of the talar neck.
- repair of the medial subtalar capsule.
- temporary transarticular pin fixation.
- evaluation for and excision or fixation of osteochondral fractures.
PREFERRED RESPONSE: 5. evaluation for and excision or fixation of osteochondral fractures.
DISCUSSION: Lateral subtalar dislocations, which are less common than medial subtalar dislocations, are high-energy injuries that are frequently associated with small osteochondral fractures. It is generally recommended that large fragments be internally fixed, and small fragments entrapped within the joint be excised. Although arthrosis frequently occurs after this injury and is the most common long-term complication, primary subtalar arthrodesis is not indicated. A talar neck fracture is not evident on the radiographs, and lateral subtalar dislocation usually does not lead to instability.
REFERENCE
Saltzman C, Marsh JL: Hindfoot dislocations: When are they not benign? J Am Acad Orthop Surg 1997;5:192-198.
A 28-year-old woman who is training for the New York Marathon reports pain in the posteromedial aspect of her right ankle. Examination reveals tenderness just posterior to the medial malleolus. Radiographs are normal. An MRI scan is shown in Figure 8. What is the most likely diagnosis?
- Posterior tibial tendinitis
- Osteoid osteoma
- Posterior ankle impingement
- Tibial stress fracture
- Flexor hallucis longus tendinitis
PREFERRED RESPONSE: 4.Tibial stress fracture
DISCUSSION: Any of the above conditions is credible with a limited history. The MRI scan unequivocally shows the stress fracture in the distal tibia. Most tibial stress fractures can be managed with rest and immobilization.
REFERENCES
Boden BP, Osbahr DC: High risk stress fractures: Evaluation and treatment. J Am Acad Orthop Surg 2000;8:344-353.
Lee JK, Yao L: Stress fractures: MR imaging. Radiology 1988;169:217-220.
A 10-year-old boy has a painful, swollen knee after falling off his bicycle. Examination reveals that the knee is held in 45° of flexion, and any attempt to actively or passively extend the knee produces pain and muscle spasms. A lateral radiograph is shown in Figure 9. What is the most likely diagnosis?
- Patellar sleeve fracture
- Avulsion of the tibial tubercle
- Avulsion of the anterior tibial spine
- Osteochondral fracture of the femoral condyle
- Osteochondral fracture of the patella
PREFERRED RESPONSE: 1. Patellar sleeve fracture
DISCUSSION: This is a typical patellar sleeve fracture. The patellar tendon avulses a portion of the distal bony patella, along with the retinaculum and articular cartilage from the inferior pole of the patella. It is common in children between ages 8 and 10 years. Anatomic reduction and repair of the extensor mechanism are mandatory to reestablish full knee extension.
REFERENCES
Houghton GR, Ackroyd CE: Sleeve fractures of the patella in children: A report of three cases. J Bone Joint Surg Br 1979;61:165-168.
Wu CD, Huang SC, Liu TK: Sleeve fracture of the patella in children: A report of five cases. Am J Sports Med 1991;19:525-528.
A 35-year-old woman who underwent open reduction and internal fixation of a calcaneal fracture 14 months ago reports pain that has failed to respond to nonsurgical management. Examination reveals limited painful subtalar motion but no hindfoot deformity. A lateral radiograph is shown in Figure 10. Surgical reconstruction is best accomplished with
- calcaneal osteotomy.
- subtalar joint arthrodesis.
- triple arthrodesis.
- pantalar arthrodesis.
- distraction bone block arthrodesis.
PREFERRED RESPONSE: 2. subtalar joint arthrodesis.
DISCUSSION: The patient has posttraumatic subtalar joint arthrosis that developed following a calcaneal fracture. Because there is no hindfoot deformity, in situ subtalar joint arthrodesis is the treatment of choice. Calcaneal osteotomy or distraction bone block arthrodesis is beneficial in patients with severe talar dorsiflexion or malunion of the calcaneal body. Triple arthrodesis is not warranted without changes at the transverse tarsal joint, and typically even with injury into the calcaneocuboid joint, this joint is often asymptomatic. Pantalar arthrodesis is not indicated because the pathology is occurring at the subtalar joint and not in the ankle joint.
REFERENCES
Sanders R: Fractures and fracture-dislocations of the calcaneus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 1422-1464.
Juliano TJ, Myerson MS: Fractures of the hindfoot, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1297-1340.
Chandler JT, Bonar SK, Anderson RB, Davis WH: Results of in situ subtalar arthrodesis for late sequelae of calcaneus fractures. Foot Ankle Int 1999;20:18-24.
Figure 11 shows the radiograph of a 23-year-old man who has severe right shoulder pain after his motorcyle hit a bridge guardrail. He is neurologically intact. Nonsurgical management will most likely result in
- nonunion of the clavicle or glenoid.
- thoracic outlet syndrome.
- less than 50% range of motion compared with the contralateral shoulder.
- less than 50% strength compared with the contralateral shoulder.
- high patient satisfaction and good shoulder function.
PREFERRED RESPONSE: 5. high patient satisfaction and good shoulder function.
DISCUSSION: Internal fixation of the clavicle, glenoid, or both has been recommended for fractures of the clavicle and glenoid neck (floating shoulders).
Diverging opinions are reported in the literature
regarding the choice for the treatment of ipsilateral fracture of the scapula and clavicle, which is thought to be floating shoulder injury.
The initial trend was towards surgical treatment, which included fixation of either clavicle (9, 11, 14) or scapula (16) or of both (10). However some recent studies did favour conservative treatment (4, 13, 16). Understanding of the floating shoulder has also changed and not all ipsilateral clavicle and scapular fracture are floating shoulder injuries (17).
Recently, the inherent instability of these dual fractures has been questioned in a biomechanical model without further disruption of the coracoclavicular or acromioclavicular ligamentous structures.
Nonsurgical management of the majority of combined scapular/glenoid fractures in patients with less than 10 mm of displacement has resulted in excellent shoulder function and will most likely achieve an excellent result in this patient.
Goss in 1993 introduced the concept of the superior shoulder suspensory complex (SSSC) (7). He described it as a bony / soft tissue ring at the end of a superior and inferior bony strut. The ring is composed of the glenoid fossa, the coracoid process, the coracoclavicular ligaments, the distal clavicle, the acromioclavicular joint and the acromial process (fig 1).
The superior strut is the middle clavicle while the inferior strut is the lateral scapular body / spine. This complex maintains a normal stable relationship between the scapula and the axial skeleton. According to the author, double disruption of the ring, i.e. failure of the ring at two places creates an unstable anatomic situation
REFERENCES
Egol KA, Connor PM, Karunakar MA, Sims SH, Bosse MJ, Kellam JF: The floating shoulder: Clinical and functional results. J Bone Joint Surg Am 2001;83:1188-1194.
Williams GR Jr, Naranja J, Klimkiewicz J, et al: The floating shoulder: A biomechanical basis for classification and management. J Bone Joint Surg Am 2001;83:1182-1187.
Edwards SG, Whittle AP, Wood GW: Nonoperative treatment of ipsilateral fractures of the scapular and clavicle. J Bone Joint Surg Am 2000;82:774-779.
Vasapula C, Mandalia V. The floating shoulder. Acta Orthop. Belg., 2004, 70, 393-400
Goss PT. Double disruption of the superior shoulder
suspensory complex. J Orthop Trauma 1993 ; 7 : 99-106.
A left-handed 23-year-old man who fell 5 feet from a ladder onto his left elbow sustained the closed injury shown in Figure 12. Management should consist of
- percutaneous pin fixation.
- a percutaneous 6.5-mm screw.
- long arm casting in flexion.
- open reduction and internal fixation with a tension band plate.
- closed reduction and long arm casting in extension.
PREFERRED RESPONSE: 4. open reduction and internal fixation with a tension band plate.
DISCUSSION: The radiographs reveal a displaced olecranon fracture. To maximize joint congruity of this intra-articular injury, open reduction and internal fixation is the treatment of choice. A tension band plate will assist with maintenance of the reduction and may aid in early range of motion because injuries to the elbow are prone to stiffness. The oblique fracture line is particularly well suited to plate fixation. Percutaneous pin fixation is unlikely to achieve anatomic joint reduction that can be obtained with open means. External immobilization will not accomplish joint reduction and will most likely lead to a nonunion.
REFERENCES
Hotchkiss RN: Fractures and dislocations of the elbow, in Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, pp 929-1024.
Murphy DF, Greene WB, Gilbert JA, Dameron TB Jr: Displaced olecranon fractures in adults: Biomechanical analysis of fixation methods. Clin Orthop Relat Res 1987;224:210-214.
Hume MC, Wiss DA: Olecranon fractures: A clinical and radiographic comparison of tension band wiring and plate fixation. Clin Orthop Relat Res 1992;285:229-235.
Figure 13 shows the radiograph of an 8-year-old boy who has a swollen forearm after falling out of a tree. Examination reveals that all three nerves are functionally intact, and there is no evidence of circulatory embarrassment. Management should consist of
- open reduction of both the radius and ulna with plate and screw fixation.
- closed reduction and a long arm cast, with the elbow in 90° of flexion and the forearm in neutral rotation.
- closed reduction and a long arm cast, with the elbow in 120° of flexion and the forearm in full supination.
- closed reduction and a long arm cast, with the elbow extended and the forearm pronated.
- closed reduction and intramedullary pin fixation of both the radius and ulna.
PREFERRED RESPONSE: 5. closed reduction and intramedullary pin fixation of both the radius and ulna.
DISCUSSION: The patient has a Bado type IV Monteggia lesion. It involves dislocation of the radial head and fractures of both the radial and ulnar shafts. These fractures are very difficult to manage by closed reduction alone. The radial and ulnar shafts first have to be stabilized surgically to give a lever arm to reduce the radial head. In this age group, intramedullary pins are easy to insert percutaneously and cause less tissue trauma than plates and screws. In these types of injuries, the focus is often on the forearm fracture; the radial head dislocation may not be appreciated, as was the case with this patient.
REFERENCES
Gibson WK, Timperlake RW: Operative treatment of a type IV Monteggia fracture-dislocation in a child. J Bone Joint Surg Br 1992;74:780-781.
Stanley EA, DeLaGarza JF: Part IV: Monteggia fracture. Dislocations in children, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 576-577.
A 40-year-old woman has local back pain and intense burning pain in her perianal region after being shot twice in the back. Motor and sensory examination of her lower extremities reveals no apparent deficit. She has present but decreased sensation in her perianal region, an intact anal wink, good rectal tone, and an intact bulbocavernosus reflex. Radiographs and CT scans are shown in Figures 1A through 1D. What is the next most appropriate step in management?
- Initiation of spinal cord injury steroid protocol
- MRI of the lumbar spine
- Immobilization in a thoracolumbosacral orthosis
- Removal of the metallic fragments via laminectomy
- Removal of the metallic fragments and posterior fusion with instrumentation
PREFERRED RESPONSE: 4. Removal of the metallic fragments via laminectomy
DISCUSSION: Because the patient has an apparent compressive neuropathy secondary to the metallic fragments, removal of the fragments in this incomplete lesion at the cauda equina level can be expected to improve her sensory dysesthesias and pain. Steroids are not indicated in a root lesion secondary to a penetrating injury. MRI will have significant artifact effect and will not provide much additional information. The posterior bony elements are not significantly injured; therefore, stabilization is not indicated.
REFERENCES
Bracken MB, Shepard MJ, Holford TR, et al: Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury: Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study. JAMA 1997;277:1597-1604.
Waters RL, Adkins RH: The effects of removal of bullet fragments retained in the spinal canal: A collaborative study by the National Spinal Cord Injury Model Systems. Spine 1991;16:934-939.
Stauffer ES, Wood RW, Kelly EG: Gunshot wounds of the spine: The effects of laminectomy. J Bone Joint Surg Am 1979;61:389-392.
A 32-year-old woman with systemic lupus erythematosus treated with methotrexate and oral corticosteroids reports right groin pain with ambulation and night pain. Examination reveals pain with internal and external rotation and flexion that is limited to 105° because of discomfort. Laboratory studies show a serum WBC of 9.0/mm3 and an erythrocyte sedimentation rate of 35 mm/h. Figures 1A and 1B show AP and lateral radiographs of the right hip. Further evaluation should include
- examination under fluoroscopy.
- MRI.
- a bone scan.
- arthrography.
- aspiration and arthrography.
PREFERRED RESPONSE: 2. MRI.
DISCUSSION: The radiographs show Ficat and Arlet stage 2 osteonecrosis. The femoral head remains round, and there are sclerotic changes in the superolateral quadrant. Patients with systemic lupus erythematosus are at risk for osteonecrosis because of prednisone use and the underlying metabolic changes associated with the condition (hypofibrinolysis and thrombophilia). MRI is the best diagnostic method for detecting osteonecrosis, with a greater than 98% sensitivity and specificity. For this patient, an MRI can assess the contralateral hip for any involvement and can quantify the extent of the lesion.
Ficat & Arlet (1980) introduced the concept of radiographic staging for osteonecrosis of the hip:
- Stage 1: no x-ray change
- intraosseous pressure measurement increase
- bony biopsy : it showed the
presence of necrosis of haematopoietic marrow and
adipocytes - Stage II: femoral head contour was still normal, but they were early signs of reactive changes in the subchondral area
- Stage III: clearcut x ray signs of osteonecrosis and evidence of structural damage and distortion in bony outline
- Stage IV : collaps of articular surface and signs of secondary OA
Shimuzu classification for femoral head osteonecrosis based on MRI images. For predicting the progression and collapse of the head.
- Grade 1: are restricted to the medial part of femoral head. progress very slowly or no at all. Tx:observe
- Grade 2: lesion are occupying up to one half of femoral head. between one and two third of the weightbearing surface. Liable to progress. Tx: core decompression with 7 mm drilling. realignment osteotomy in youor THR in px older than 45 yo.
- Grade 3: lesion are occupying a large part of femoral head, more than two thirds of the weightbearing surface. poor prognosis. younger px: tx by realignment: Radical trantrochanteric rotational osteotomy by Sugioka (Sugioka osteotomy)
Sugioka Osteotomy:
is a transtrochanteric rotational osteotomy which allowed the femoral head to be rotated in its long axis, thus turning the femoral head through an arc of 90 degrees. The operation is mainly used for segemental necrosis of femoral head.
REFERENCES
Mont MA, Jones LC, Sotereanos DG, Amstutz HC, Hungerford DS: Understanding and treating osteonecrosis of the femoral head. Instr Course Lect 2000;49:169-185.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 417-451.
Figures 2A and 2B show the current radiographs of a 58-year-old man who underwent total knee arthroplasty with a cruciate ligament-sparing prosthesis 7 years ago. Examination reveals boggy synovitis and moderate pain, particularly anteriorly. Management should consist of
- follow-up radiographs.
- alendronate, with follow-up examinations every 6 months.
- revision to a posterior stabilized prosthesis.
- exchange of the tibial insert through a limited incision.
- surgical exploration with revision or exchange based on the findings.
PREFERRED RESPONSE: 5. surgical exploration with revision or exchange based on the findings.
DISCUSSION: The patient has symptoms of synovitis that are most likely the result of the release of particles from the tibial polyethylene. While observation may be warranted in a completely asymtomatic knee, some intervention is indicated for this patient as there is clear radiographic evidence of lysis in both the tibia and femur. The decision about the extent of the revision should be made at the time of surgery. A limited incision technique is not indicated. Grafting (or using graft substitute) the defect is the most appropriate approach for treating the osteolytic lesions. While a posterior stabilized prosthesis might be the solution, surgical findings might dictate otherwise.
REFERENCE
Brassard MF, Insall JN, Scuderi GR: Complications of total knee arthroplasty, in Insall JN, Scott WN (eds): Surgery of the Knee, ed 3. Philadelphia, PA, Churchill Livingstone, 2001, vol 2, pp 1801-1844.
Figure 3 shows the radiograph of a 75-year-old woman who reports the sudden onset of disabling medial knee pain. What is the most likely diagnosis?
- Osteoarthritis
- Osteonecrosis
- Meniscal tear
- Metastatic lesion
- Synovial osteochondromatosis
PREFERRED RESPONSE: 2. Osteonecrosis
DISCUSSION: Idiopathic osteonecrosis of the medial femoral condyle occurs predominantly in women older than age 60 years. It is characterized by pain centered in the medial anterior aspect of the knee, and onset is sudden. Flattening, sclerosis, and the radiolucent crescent sign are radiographic indicators of osteonecrosis. The radiographs show no narrowing of the joint space or osteophyte formation to indicate osteoarthritis, and there are no loose bodies to indicate synovial osteochondromatosis. A meniscal tear is not consistent with the radiographic findings shown here. Meniscal tears can coexist with osteonecrosis, but the pain is not eliminated merely by partial meniscectomy. Metastatic lesions to the distal femoral epiphysis are exceedingly rare.
REFERENCES
Urbaniak JR, Jones JP Jr (eds): Osteonecrosis: Etiology, Diagnosis, and Treatment. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 413-418.
Insall JN, Windsor RE, Scott WN, Kelly MA, Aglietti P (eds): Surgery of the Knee, ed 2. New York, NY, Churchill Livingstone, 1993, pp 609-634.
A 60-year-old woman reports anterior knee pain 2 years after undergoing primary total knee arthroplasty for rheumatoid arthritis. A Merchant view of the patella is shown in Figure 5. What is the most likely cause of her pain?
- Elevation of the joint line
- Lateral placement of the femoral component
- Medial placement of the patellar component
- Internal rotation of the femoral component
- External rotation of the tibial component
PREFERRED RESPONSE: 4. Internal rotation of the femoral component
DISCUSSION: Patellar complications commonly occur after primary total knee arthroplasty; therefore, proper component positioning is critical in obtaining a successful result. This patient has lateral tilting and subluxation of the patellar component. Internal rotation of the femoral component has the most deleterious effect on patellar tracking. Lateral placement of the femoral component, medial placement of the patellar component, and external rotation of the tibial component have beneficial effects on patellar tracking. Elevation of the joint line, if not excessive, should not impact patellar tracking.
REFERENCES
Rand JA: Patellar resurfacing in total knee arthroplasty. Clin Orthop Relat Res 1990;260:110-117.
Healy WL, Wasliewski SA, Takei R, Oberlander M: Patellofemoral complications following total knee arthroplasty: Correlation with implant design and patient risk factors. J Arthroplasty 1995;10:197-201.
A 32-year-old man has posttraumatic arthritis after undergoing open reduction and internal fixation of a left acetabular fracture. A total hip arthroplasty is performed, and the radiograph is shown in Figure 6. What is the most common mode of failure leading to revision in this group of patients?
- Infection
- Heterotopic ossification
- Dislocation
- Periprosthetic fracture
- Acetabular component loosening
PREFERRED RESPONSE: 5. Acetabular component loosening
DISCUSSION: Acetabular component loosening has been reported as the most common mode of failure following total hip arthroplasty in patients with a previous acetabular fracture. Following acetabular fracture and subsequent open reduction and internal fixation, the bone quality and vascularity are compromised, thus reducing the success rate of acetabular component cementless fixation.
REFERENCES
Jimenez ML, Tile M, Schenk RS: Total hip replacement after acetabular fracture. Orthop Clin 1997;28:435-446.
Romness DW, Lewallen DG: Total hip arthroplasty after fracture of the acetabulum: Long-term results. J Bone Joint Surg Br 1990;72:761-764.
A 42-year-old man sustained the periprosthetic fracture shown in Figures 7A and 7B. The femoral component is well fixed. What is the next most appropriate step in management?
- Closed reduction and bracing
- Retrograde femoral intramedullary nailing
- Open reduction and internal fixation of the fracture, leaving the femoral stem in place
- Open reduction and internal fixation of the fracture and insertion of a proximally porous-coated stem
- Open reduction and internal fixation of fracture fragments and insertion of a fully porous-coated femoral stem with diaphyseal fixation distal to the fracture
PREFERRED RESPONSE: 3.Open reduction and internal fixation of the fracture, leaving the femoral stem in place
DISCUSSION: The patient has a periprosthetic fracture below the femoral stem. The component is porous coated and well fixed. Open reduction and internal fixation, leaving the stem in place, can be performed when bone quality is good. Plating with or without allograft struts and supplemental cerclage fixation generally is acceptable. If the component is loose, revision to a longer device is recommended with appropriate stabilization of the fracture using the aforementioned methods. If bone loss has occurred, allograft supplementation or a tumor prosthesis may be indicated. Fractures located well below the stem tip can be treated without regard for the prosthesis. Closed reduction and bracing is not associated with good results for periprosthetic femoral fractures. Retrograde intramedullary nailing is not appropriate for this fracture.
REFERENCES
Duncan CP, Masri BA: Fractures of the femur after hip replacement. Instr Course Lect 1995;44:293-304.
Bono JV, McCarthy JC, Thornhill TS, Bierbaum BE, Turner RH (eds): Revision Total Hip Arthroplasty. New York, NY, Springer Verlag, 1999, pp 530-592.
A homebound 75-year-old woman with diabetes mellitus has had progressive left knee pain and swelling for the past 6 weeks. She is febrile with a temperature of 103°F (39.5°C). History reveals that she underwent arthroplasty 5 years ago. Examination shows passive range of motion of 0° to 100° with no active extension. Knee aspiration reveals purulent fluid with a Gram stain showing gram-negative rods. A radiograph is shown in Figure 8. In addition to IV antibiotics, which of the following management options offers the best chance of a successful outcome?
- Incision and drainage with repair of the extensor mechanism
- Removal of components and delayed revision knee arthroplasty with an allograft extensor mechanism
- Removal of components and immediate exchange revision total knee arthroplasty
- Removal of components and delayed knee arthrodesis
- Removal of components and delayed revision knee arthroplasty with extensor mechanism repair
PREFERRED RESPONSE: 4. Removal of components and delayed knee arthrodesis
DISCUSSION: The patient has an infected total knee arthroplasty and an interrupted extensor mechanism. A late infection of a total knee arthroplasty in a patient with diabetes mellitus and a virulent organism requires removal of the components, debridement, antibiotic spacers, and surveillance to ensure eradication of the infection. Reconstruction of an incompetent extensor mechanism in an infected knee is extremely unlikely to be successful. Arthrodesis is the procedure of choice if a revision total knee arthroplasty is not likely to succeed. Resection arthroplasty is recommended only as a long-term solution if the patient is medically unable to undergo further surgery.
REFERENCES
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgery, 2002, pp 513-536.
Hanssen AD, Rand JA: Evaluation and treatment of infection at the site of a total hip or knee arthroplasty. Instr Course Lect 1999;48:111-122.
A 58-year-old man has anterior knee pain after undergoing total knee arthroplasty for osteoarthritis 2 years ago. He denies any history of trauma. A Merchant view is shown in Figure 9. What is the most likely cause of his pain?
- External rotation of the femoral component
- Overstuffing of the patellofemoral joint
- Less than 12 mm of bony patella remaining after resection
- Lateral retinacular release
- Use of a cemented patellar component
PREFERRED RESPONSE: 3. . Less than 12 mm of bony patella remaining after resection
DISCUSSION: The patient has a patellar stress fracture after resurfacing in a total knee arthroplasty. Several studies have shown that over-resection of the patella to less than 12 to 15 mm increases anterior patellar surface strains to a point where the risk of fracture is increased. Increasing the patellar thickness, positioning of the femoral component, lateral releases, and component types have not been clearly associated with increased fracture risk.
REFERENCES
Reuben JD, McDonald CL, Woodard PL, Hennington LJ: Effect of patella thickness on patella strain following total knee arthroplasty. J Arthroplasty 1991;6:251-258.
Hsu HC, Luo ZP, Rand JA, An KN: Influence of patellar thickness on patellar tracking and patellofemoral contact characteristics after total knee arthroplasty. J Arthroplasty 1996;11:69-80.
Greenfield MA, Insall JN, Case GC, Kelly MA: Instrumentation of the patellar osteotomy in total knee arthroplasty: The relationship of patellar thickness and lateral retinacular release. Am J Knee Surg 1996;9:129-131.
A 68-year-old woman underwent a successful total right hip arthroplasty with a metal-on-metal articulation and cementless porous-coated components. Three months later, she underwent identical surgery on the left hip. Three months after surgery on the left hip, she reports groin pain on ambulation. Examination reveals significant groin discomfort with passive hip motion, particularly at the extremes of motion. Radiographs are shown in Figures 10A and 10B. Laboratory studies show an erythrocyte sedimentation rate of 35 mm/h and a C-reactive protein of 0.9. Aspiration yields scant growth of Staphylococcus epidermidis in the broth only, with no evidence of loosening on arthrography. A second aspiration yields scant growth of S epidermidis in the broth only. What is the most likely cause of the patient’s pain?
- Allergic metal synovitis
- Aseptic loosening of the acetabular component
- Septic loosening of the acetabulum
- Deconditioning following hip arthroplasty
- Iliopsoas tendinitis
PREFERRED RESPONSE: 3. Septic loosening of the acetabulum
DISCUSSION: The difference in the clinical results combined with the laboratory findings points to infection. While there is a significant risk of false-positive findings with aspiration, the fact that two successive aspirations grew the same organism strongly suggests infection. The radiograph shows that there is more radiolucency around the left acetabular component than the right component.
REFERENCES
White RE: Evaluation of the painful total hip arthroplasty, in Callaghan JJ, Rosenberg AG, Rubash HE (eds): The Adult Hip. Philadelphia, PA, Lippincott-Raven, 1998, vol 2, pp 1377-1385.
Barrack RL, Harris WH: The value of aspiration of the hip joint before revision total hip arthroplasty. J Bone Joint Surg Am 1993;75:66-76.
Figure 11 shows the radiographs of a 56-year-old woman who has pain and varus knee deformity after undergoing total knee arthroplasty 8 years ago. Aspiration and studies for infection are negative. During revision surgery, management of the tibial bone loss is best achieved by
- a custom tibial implant.
- a hinged prosthesis.
- reconstruction with structural allograft.
- reconstruction with iliac crest bone graft.
- filling the defect with cement.
PREFERRED RESPONSE: 3. reconstruction with structural allograft.
DISCUSSION: Massive bone loss encountered in revision total knee arthroplasty remains a significant challenge. Recent reports have shown high success rates using structural allograft to reconstruct massive bone defects. Custom and hinged prostheses in this setting are no longer favored. The defect shown is segmental and is too large to be filled with cement or iliac crest bone graft.
REFERENCES
Mow CS, Wiedel JD: Structural allografting in revision total knee arthroplasty. J Arthroplasty 1996;11:235-241.
Engh GA, Herzwurm PJ, Parks NL: Treatment of major defects of bone with bulk allografts and stemmed components during total knee arthroplasty. J Bone Joint Surg Am 1997;79:1030-1039.
Clatworthy MG, Ballance J, Brick GW, Chandler HP, Gross AE: The use of structural allograft for un-contained defects in revision total knee arthroplasty: A minimum five-year review. J Bone Joint Surg Am 2001;83:404-411.
A 62-year-old man who underwent total knee arthroplasty 6 months ago now reports pain after falling on the anterior portion of the knee. Examination reveals weakness of knee extension but no extensor lag. Flexion that had once measured 115° is now limited to 70° because of pain. A radiograph is shown in Figure 12. Management should now consist of
- immediate repair of the ruptured patellar tendon insertion.
- knee joint aspiration and injection of a local anesthetic to facilitate examination.
- joint aspiration for culture, broad-spectrum antibiotics, and immobilization.
- immobilization until comfortable, followed by protected range of motion and strengthening.
- immediate fracture repair.
PREFERRED RESPONSE: 4. immobilization until comfortable, followed by protected range of motion and strengthening.
DISCUSSION: The patient has a type IIIB patellar fracture (inferior pole fracture with an intact patellar tendon). Non-surgical management is the treatment of choice if there is little displacement and the extensor mechanism is intact.
REFERENCES
Brown TE, Diduch DR: Fractures of the patella, in Insall JN, Scott WN (eds): Surgery of the Knee, ed 3. Philadelphia, PA, Churchill Livingstone, 2001, vol 2, pp 1290-1312.
Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 323-337.
Figure 13 shows the radiograph of a 47-year-old woman who has severe right hip pain and a limp. Management should consist of
- acetabular osteotomy.
- femoral and acetabular osteotomy.
- total hip arthroplasty using standard trochanter osteotomy and cementless components.
- total hip arthroplasty using femoral shortening osteotomy and cementless components.
- total hip arthroplasty using femoral shortening osteotomy, a cemented socket, and a cementless femoral component.
PREFERRED RESPONSE: 4. total hip arthroplasty using femoral shortening osteotomy and cementless components.
DISCUSSION: Femoral shortening osteotomy for a Crowe type IV hip dislocation has been shown to provide superior results with minimal complications. Cementless fixation of the stem allows for modular implants that greatly simplify the reconstruction.
In 1979 Dr. John F. Crowe proposed a classification to define the degree of malformation and dislocation of DDH. Grouped from least severe Crowe I dysplasia to most severe Crowe IV
Crowe Classification:
CROWE I: Minimal abnormal development
CROWE II: Rim of the acetabulum is not horizontal. Femoral head is not dislocated.
CROWE III: The joint is fully or nearly dislocated. The socket lacks a roof. A false socket starts to form.
CROWE IV: The joint is dislocated. The femur is positioned high up on the pelvis. Significant underdevelopment of the acetabulum.
REFERENCE
Jaroszynski G, Woodgate IG, Saleh KJ, Gross AE: Total hip replacement for the dislocated hip. Instr Course Lect 2001;50:307-316.
A 72-year-old woman with rheumatoid arthritis who underwent primary total knee arthroplasty 2 years ago has had diffuse knee pain that developed shortly after the surgery. The patient has difficulty with stair descent and arising from chairs. Evaluation for infection is negative. AP and lateral radiographs are shown in Figure 14. Management should now consist of
- anti-inflammatory drugs.
- a knee brace.
- physical therapy for quadriceps strengthening.
- revision to a thicker polyethylene insert.
- revision to a posterior stabilized implant.
PREFERRED RESPONSE: 5. revision to a posterior stabilized implant.
DISCUSSION: The radiographs show posterior flexion instability that is the result of flexion-extension gap imbalance and/or posterior cruciate ligament incompetence after a posterior cruciate-retaining total knee arthroplasty. The radiographs also show anterior femoral displacement on the tibia. Pagnano and associates reported on a series of patients with painful total knee arthroplasties who had been previously diagnosed as having pain of unknown etiology, showing that the pain was secondary to flexion instability. Pain relief was achieved by revision to a posterior stabilized implant.
REFERENCES
Pagnano MW, Hanssen AD, Lewallen DG, Stuart MJ: Flexion instability after primary posterior cruciate retaining total knee arthroplasty. Clin Orthop Relat Res 1998;356:39-46.
Fehring TK, Valadie AL: Knee instability after total knee arthroplasty. Clin Orthop Relat Res 1994;299:157-162.
Fehring TK, Odum S, Griffin WL, Mason B, Nadaud M: Early failures of total knee arthroplasty. Clin Orthop Relat Res 2001;392:315-318.
Figure 15 shows the AP radiograph of an 18-year-old woman with progressive and severe right hip pain. Nonsteroidal anti-inflammatory drugs no longer control her pain. What is the next most appropriate step in management?
- Total hip arthroplasty
- Single innominate (Salter) osteotomy
- Chiari osteotomy
- Periacetabular osteotomy
- Varus intertrochanteric osteotomy
PREFERRED RESPONSE: 4. Periacetabular osteotomy
DISCUSSION: A concentric hip with acetabular dysplasia in a symptomatic patient is best treated by periacetabular osteotomy. The Salter osteotomy is less optimal because the method has limited correction, is uniaxial, cannot be tailored to the deformity, and lateralizes the entire hip joint, thereby increasing the joint reactive forces. Because the hyaline cartilage of the joint is histologically normal, rotating the hyaline cartilage into an optimal position is preferable to augmenting the acetabulum with a shelf or by Chiari osteotomy. Varus intertrochanteric osteotomy has no significant role in the treatment of acetabular dysplasia. Total hip arthroplasty may be required in the future but should not be the first choice.
Persistent acetabular dysplasia is a well-known cause of premature hip osteoarthritis. In the dysplastic hip, point loading occurs at the edge of the steep, shallow acetabulum. Pelvic osteotomies reduce this load by increasing the contact area, relaxing the capsule and muscles about the hip, improving the moment arm of the hip, and normalizing the forces of weight bearing.
The orthopaedic surgeon can choose from among a variety of pelvic osteotomies : REDIRECTIONAL, RESHAPING, and SALVAGE for the purpose of restoring normal anatomy and biomechanical forces across the hip joint.
Redirectional osteotomies change the orientation of the acetabulum. These include the Salter, Sutherland, Dega and periactebular
osteotomies (Steel, Tonnis and Ganz)
Reshaping osteotomies reduce the volume and
shape of the acetabulum. They include the Pemberton, PemberSal and San Diego
osteotomies
Salvage/augmentation osteotomies, such as the Chiari osteotomy and shelf
procedure, improve the coverage of deformed femoral heads.
Redirectional and reshaping osteotomies are physiologic procedures as they maintain normal contact between the hyaline cartilage at the femoral head and acetabulum.
The salvage/augmentation osteotomies are non-physiologic as they depend on fibrocartilagenous metaplasia of the interposed capsule to provide a stable weight bearing
surface.
Treatment of residual dysplasia is BASED ON PATIENT’S AGE and the presence or absence of congruent hip reduction.
A Salter or Pemberton procedure is generally appropriate for a child between the ages of 2 and 10.
A triple innominate osteotomy can be considered for the older child or adolescent in whom the triradiate cartilage remains open.
After triradiate closure, the Ganz periacetabular osteotomy can be considered in addition to the triple innominate osteotomy.
REFERENCE
Millis MB, Murphy SB, Poss R: Osteotomies about the hip for the prevention and treatment of osteoarthritis. Instr Course Lect 1996;45:209-226.
A-35: A 52-year-old man has had groin and deep buttock pain for the past 2 months. Examination reveals that hip range of motion is mildly restricted, and he has pain with both weight bearing and at rest. An MRI scan is shown in Figure 16. Management should consist of
- protected weight bearing and anti-inflammatory drugs.
- core decompression of the femoral head.
- vascularized free fibular grafting to the femoral head.
- bipolar hemiarthroplasty of the hip.
- total hip arthroplasty.
PREFERRED RESPONSE: 1. protected weight bearing and anti-inflammatory drugs.
DISCUSSION: The MRI findings show highly increased signal through the entire femoral head and neck that is diagnostic of transient osteoporosis of the femoral head. This recently described entity is often seen in middle-aged men and should be treated nonsurgically with protected weight bearing and anti-inflammatory drugs. The natural history is that of self-resolution.
REFERENCES
Guerra JJ, Steinberg ME: Distinguishing transient osteoporosis from avascular necrosis of the hip. J Bone Joint Surg Am 1995;77:616-624.
Urbanski SR, de Lange EE, Eschenroeder HC Jr: Magnetic resonance imaging of transient osteoporosis of the hip. A case report. J Bone Joint Surg Am 1991;73:451-455.
A-36: Figure 17 shows the radiograph of an 80-year-old woman who has right groin pain. She underwent a total hip arthroplasty 15 years ago and has no history of hip dislocation; however, she now reports that the pain results in functional impairment. Preoperative findings reveal that the component used has been discontinued, the locking mechanism is poor, and there is no replacement polyethylene available from the company. During surgery, the acetabular component is found to be well fixed, it is in satisfactory position, and adequate access can be obtained through the screw holes in the component to debride the osteolytic cavities. What is the best course of action for revision?
- Remove the component and replace it with a “jumbo” cup with bone graft or substitute.
- Remove the component and replace it with a bipolar component with bone graft or substitute.
- Remove the component and replace it with a support ring with graft or graft substitute and cement a cup into the support ring.
- Score the component for improved cement interdigitation and cement a cup into the retained socket with bone graft or substitute.
- Use a structural acetabular graft to reconstruct the acetabulum and cement a cup into the structural graft.
PREFERRED RESPONSE: 4. Score the component for improved cement interdigitation and cement a cup into the retained socket with bone graft or substitute.
DISCUSSION: The clinical result in this patient has been good, with no dislocations, suggesting that the components are in reasonably good position. The radiograph and examination at the time of surgery suggest that the acetabular component is well fixed. The surrounding bone of the acetabulum is osteopenic and there would most likely be considerable bone loss if the acetabular component is removed. Access to the osteolytic lesions is possible. Cementing an acetabular component into the retained socket will cause the least amount of bone loss, shorten the procedure, and most likely result in a functional hip.
REFERENCES
Maloney WJ: Socket retention: Staying in place. Orthopedics 2000;23:965-966.
Blaha JD: Well-fixed acetabular component retention or replacement: The whys and the wherefores. J Arthroplasty 2002;17:157-161.
A-37: Figures 18A and 18B show the AP and lateral radiographs of a 67-year-old woman who has severe left knee pain when ambulating. History reveals that she underwent primary total knee arthroplasty 7 years ago. The patient reports increasing deformity over the past several years and uses a knee brace and a cane. Examination reveals that she walks with a varus thrust and has an uncorrectable varus deformity with valgus force. What is the primary reason for implant failure?
- Osteolysis
- Polyethylene wear
- Tibial component fixation failure
- Modular tibial component failure
- Posterior cruciate ligament retention
PREFERRED RESPONSE: 3. Tibial component fixation failure
DISCUSSION: Both cemented and cementless total knee arthroplasties depend on adequate fixation of the tibial component to promote long-term survivorship. An effective stem and adequate peripheral fixation of the tibial component to the cancellous-cortical portion of the proximal tibia are necessary for cementless fixation. Peripheral screws and pegs can serve as adjunctive fixation to decrease micromotion and shear forces and allow bone ingrowth to occur. Careful preparation of the proximal tibial surface can minimize fixation failure. Cemented fixation of the tibial stem should be performed in addition to the plateau. Osteolysis, polyethylene wear, and failure at the insert/tray locking mechanism have not occurred. Posterior cruciate ligament retention has not caused the tibial component fixation failure.
REFERENCE
Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 275-279.
A-39: A 35-year-old male laborer with isolated posttraumatic degenerative arthritis of the right hip undergoes the procedure shown in Figure 19. What is the most appropriate position of the right lower extremity?
- 0° of flexion, 10° of abduction, 0° of rotation
- 15° of flexion, 20° of abduction, 15° of external rotation
- 20° of flexion, 10° of abduction, and 5° of external rotation
- 30° of flexion, 5° of adduction, and 5° of external rotation
- 45° of flexion, 10° of adduction, 0° of rotation
PREFERRED RESPONSE: 4. 30° of flexion, 5° of adduction, and 5° of external rotation
DISCUSSION: The primary indication for hip arthrodesis is isolated unilateral hip disease in a young, active patient. Avoiding abductor damage and preserving proximal femoral anatomy are imperative to allow conversion to a future total hip arthroplasty. Optimal positioning is 30° of flexion to allow swing-through. Neutral abduction and adduction and slight external rotation allow the most efficient gait while allowing sufficient support in stance. A small degree of adduction is acceptable for a successful hip arthrodesis.
REFERENCES
Callaghan JJ, Brand RA, Pedersen DR: Hip arthrodesis: A long term follow-up. J Bone Joint Surg Am 1985;67:1328-1335.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 417-451.
A-41: A 48-year-old woman has knee pain that is worse with weight bearing. She reports no night pain or pain at rest. History reveals that she underwent total knee arthroplasty with cementless components 2 years ago. Examination reveals tenderness along the medial joint line. Figures 20A through 20C show radiographs and a bone scan. What is the most likely cause of the patient’s pain?
- Deep infection
- Malalignment
- Fibrous ingrowth of the femoral component
- Fibrous ingrowth of the tibial component
- Patellar component loosening
PREFERRED RESPONSE: 4. Fibrous ingrowth of the tibial component
DISCUSSION: The radiographs show a halo-like sclerotic margin around the tibial stem and lucency under the baseplate. The bone scan shows markedly increased uptake under the tibial component, particularly on the medial side (not diffusely through the knee as seen with infection). These studies indicate lack of bone ingrowth fixation of the cementless porous-coated tibial component. The recent report of Fehring and associates has identified failure of ingrowth of a porous-coated implant as a dominant mode of early failure of total knee arthroplasties.
REFERENCES
Fehring TK, Odum S, Griffin WL, Mason B, Nadaud M: Early failures of total knee arthroplasty. Clin Orthop Relat Res 2001;392:315-318.
Fehring TK: Revision TJA corrects flexion extension gap imbalance. Orthop Today 2002;22:44.
A-42: A 65-year-old woman has nausea, vomiting, and abdominal distention after undergoing total knee arthroplasty 48 hours ago. An abdominal radiograph is shown in Figure 21. Associated risk factors for this disorder include
- hypokalemia.
- administration of warfarin.
- administration of antibiotics.
- general anesthesia.
- early mobilization and physical therapy.
PREFERRED RESPONSE: 1. hypokalemia.
DISCUSSION: The prevalence of postoperative ileus associated with total joint arthroplasty has been reported to be as high as 3%. Metabolic abnormalities such as hypokalemia are believed to contribute to the onset of ileus and Ogilvie syndrome (acute pseudo-obstruction of the colon). Prolonged bed rest also has been associated with the development of ileus and Ogilvie syndrome. Untreated Ogilvie syndrome can result in cecal perforation. Ileus usually is not accompanied by mechanical obstruction. Antibiotic administration and the type of anesthesia used have not been correlated with development of ileus. Administration of warfarin has been associated with elevated prothrombin time/partial thromboplastin time and international normalized ratio levels when ileus is managed with a nasogastric tube and suction. Metabolic imbalances must be corrected to reverse the ileus process.
REFERENCES
Iorio R, Healy WL, Appleby D: The association of excessive warfarin anticoagulation and postoperative ileus after total joint replacement surgery. J Arthroplasty 2000;15:220-223.
Clarke HD, Berry DJ, Larson DR: Acute pseudo-obstruction of the colon as a postoperative complication of hip arthroplasty. J Bone Joint Surg Am 1997;79:1642-1647.
A-1: What component (pulley) of the flexor tendon sheath is commonly involved in trigger finger?
- A1
- A2
- A4
- C1
- C2
PREFERRED RESPONSE: 1. A1
DISCUSSION: Although flexor tendons are occasionally seen to trigger anywhere within the fibroosseous tunnel, the most common location of mechanical mismatch is at the proximal opening, A1 pulley, of the tunnel. The pulleys are named by their configuration, either annular (A) or cruciate (C), and numbered by their location, beginning proximally.
REFERENCE
Froimson AL: Tenosynovitis and tennis elbow, in Green DP (ed): Operative Hand Surgery, ed 3. New York, NY, Churchill Livingstone, 1993, vol 2, pp 1992-1995.
A-17: A 28-year-old woman has had progressive pain and loss of motion in her nondominant wrist for the past 6 months. Plain radiographs are shown in Figures 1A and 1B. Treatment should consist of
- proximal row carpectomy.
- total wrist arthrodesis.
- lunate excision and silicone prosthesis replacement.
- radial shortening osteotomy.
- capitohamate fusion.
PREFERRED RESPONSE: 4. radial shortening osteotomy.
DISCUSSION: Based on the radiographic findings of lunate collapse without loss of carpal height nor a fixed carpal malalignment, the patient has stage IIIA Kienbock disease according to Lichtman’s classification. Although much controversy remains regarding optimal treatment for Kienbock disease, radial shortening osteotomy decreases the radiolunate load and has shown excellent clinical results in patients with stage III or IIIA disease who have a negative ulnar variance. Proximal row carpectomy and total wrist arthrodesis are both salvage procedures that are applicable in stage IIIB or IV disease. The use of a silicone lunate prosthesis is no longer advised because of a high rate of particulate synovitis. Capitohamate fusion alone has not been shown to unload the lunate, although it is sometimes combined with capitate shortening, which decreases the load across the radiolunate articulation.
REFERENCES
Quenzer DE, Dobyns JH, Linscheid RL, Trail IA, Vidal MA: Radial recession osteotomy for Kienbock’s disease. J Hand Surg [Am] 1997;22:386-395.
Trumble T, Glisson RR, Seaber AV, Urbaniak JR: A biomechanical comparison of the methods for treating Kienbock’s disease. J Hand Surg [Am] 1986;11:88-93.
