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OITE ORTHOPEDIC PRINCIPLES > Principles > Flashcards

Principles Flashcards

1
Q

What is the most common type of intimate partner violence?

What is the most common type of physical abuse?

A

Emotional abuse most common: 30.5%

Physical abuse 2nd most common: 8.5%

Sexual abuse: 3.3%

Of physical abuse:

Head/neck trauma most common

Orthopaedic injuries second most comon (sprains, fractures, dislocations, foot injuries)

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2
Q

Grafting of burns should take place within what time frame?

A

Within 5 days

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3
Q

In the aging population, what should the training regimen involve?

A

resistance

endurance

balance

flexibility

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4
Q

What addidtional specieis do you have to cover for in fresh and saltwater contaminated open fractures?

A

Fresh

Aeromonas hydrophilia (G-)

Vibrio

Salt

Clostridia (tetanus)

Vibrio

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5
Q

Virchow’s triad

A

Venous stasis

Hypercoaguable state

Endothelial injury

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6
Q

What is the major arterial supply to gastrocs flap

A

Sural artery (for both medial and lateral)

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7
Q

What is the term to define a loss of function resulting from an anatomic or physiologic derangement

A

Impairment

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8
Q

What is the best route and dosing for postop analgesics in a morbidly obese individual?

A

IV patient controlled analgesia (PCA) based on ideal body weight (not actual)

Avoid subcutaneous/submuscular (poor blood supply –> increased infectiion risk)

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9
Q

What anesthetics have an effect on neuromonitoring?

A

inhalational - affects both SSEP and MEP

neuromuscular blockage: MEPs only

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10
Q

What is the immune response when transplanting fresh articular cartilage allograft?

A

There is none, even when unmatched

There is once you start adding in cells, like BM aspirate

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11
Q

Mechanism of Tocilizuab

A

IL-6 antagonist

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12
Q

Do acidic or alkaline burns penetrate deeper?

A

Alkali

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13
Q

List 4 ways to optimize intra-operative cultures

A

No pre-op antibiotics

Bone and Soft Tissue Samples

>= 5 samples

Hold cultures for 10-14 days

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14
Q

toughness

A

amount of energy per unit volume a material can absorb before failure

= area under the stress/strain curve

units: joules/m3

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15
Q

When does braking time return to normal after:

knee arthroscopy

Surgical management of ankle fracture

After initiation of weight bearing following major lower extremity fracture?

A

knee arthroscopy: 4 weeks

Surgical management of ankle fracture: 9 weeks

After initiation of weight bearing following major lower extremity fracture: 6 weeks

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16
Q

Stress Strain curve: Yeild strength

A

amount of stress necessary to produce a specific amount of permanent deformation

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17
Q

Can a person drive with a simple forearm cast?

A

Yes (JAAOS 2013)

But not if the elbow is immobilized

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18
Q

What percentage of patietns in fracture clinic have been victims of intimate partner violence:

Overall:

this year:

Specifically for this visit:?

A

Overall: 33% (1 in 3)

this year: 15% (1 in 6)

Specifically for this visit: 2% (1 in 50)

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19
Q

Consequences of paralytic ileus (6)

A

abdominal pain

malnutrition

prolonged hospital stay

hospital readmission

bowel perforation

death

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20
Q

Define neuropraxia

A

Disruption of myelin sheath only, causing focal conduction block

No wallerian degeneration

full recovery expected

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21
Q

Higher Young’s modulus means what?

A

Young’s modulus of elasticity

Higher Young’s modulus = A stiffer material = more ability to resist deformation

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22
Q

What percentage of women presenting to ER with injuries are a result of domestic violence?

A

Up to 35%

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23
Q

What immunoglobulin does rheumatoid factor target?

A

IgG

It is an IgM that targets the Fc portion of IgG

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24
Q

Criteria for Bisphosphonate Related Fractures

A

Major

  • None or minimal trauma (fall from standin or less)
  • Originates from lateral cortex & is transverse or short oblique in nature
  • If complete, fracture extends through both cortices and may be associated with a medial spike (incomplete fractures only involve lateral cortex)
  • Fracture is noncomminuted or minimally comminuted
  • Localized periosteal or endosteal thickening of the latearl cortex is present at the fracture site (beaking or flaring)

Minor

  • Generalized increase in cortical thickness of the femoral diphaysis
  • Unilateral or bilateral prodromal sx (thigh pain)
  • Bilateral incomplete or complete femoral diphyseal fractures
  • Delayed fracture healing

Need 4/5 major. NO minor (they are just associations)

2013 American Society for Bone Mineral Task Force, as per JAAOS 2015

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25
Q

Ideal candidate for fresh osteochondral allograft?

A

Young (<25)

Symptoms < 1 year

They have better results and higher return to sport

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26
Q

2 muscles innervated by axillary nerve

A

Deltoid

teres minor

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27
Q

Ways to optimize for bone healing?

A

Provide mechanical stability and a favorable biologic environment

Tobacco cessation

glycemic control

nutritional optimization

  • Vit D deficiency

management of metabolic and endocrine abnormalities

  • thyroid
  • parathyroid
  • central hypogonadism
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28
Q

What is the only anticoagulation prophylaxis recommended by AAOS in all risks groups undergoing THA or TKA?

A

Pneumatic compression devices

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29
Q

Mixing what 2 metals has the highest risk of galvanic corrosion?

A

316L stainles steel and cobalt chromium (Co-Cr)

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30
Q

Nerve repair of what nerve has the best and the worst outcomes

A

Best: radial

Worst: peroneal

The following nerves had excellent recovery potential:

  • the radial, musculocutaneous, and femoral nerves.

The following nerves had moderate recovery potential:

  • the median, ulnar, and tibial nerves.

The following nerve had poor recovery potential:

  • the peroneal nerve.
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31
Q

Name the 3 main triggers of bone erosion in RA:

A

Synovitis

Anti-citrullinated protein antibodies (Anti-CCP)

RANKL

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32
Q

What do you have to do post-op medication-wise in patient with CRF

Specifially analgesia, abx, DVT prophylaxis

A

Narcotics:

decrease dose

Hydromorphone: reduce to 25% and titrate

Morphine: none (max short term only)

Anticoagulatns:

Unfractionated heparin, warfarin, ASA, clopidogrel, argatroban OK - no dose adjustment

No: LMWH, fondaparinux, dabigatran

Antibiotics

Ancef:1-2g IV q24

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33
Q

Describe updated CANMEDS

A

Medical Expert

Professional

Communicator

Collborator

Leader

Health advocate

Scholar

(no more Manager)

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34
Q

Hysteresis

A

Energy dissipation

characteristic of viscoelastic materials

the loading curve does not follow the unloading curve

the difference between the two curve is the energy that is disspitated

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35
Q

In relation to TB arthropathy.

What is Phemister’s Triad?

A

Juxta-articular osteopenia/osteoporosis

Peripheral osseous erosions

Gradual narrowing of joint space

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36
Q

What medication combined with MTX makes it more effective against RA?

A

Doxycycline

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37
Q

Components of WHO pre op sign in

A

Before induction of anesthesia

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38
Q

Plastic deformation

A

irreversible changes in shape to a material due to a load

material DOES NOT return to original shape when load is removed

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39
Q

Salt water open fracture. Treatment?

A

doxycycline and ceftazidime, or a fluoroquinolone

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40
Q

Mechanism of Etanercept:

A

TNF-alpha inhibitor

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41
Q

2 dDx for erosive arthritis

A

Inflammatory arthritis

TB - always think TB & ask about foreign travel

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42
Q

Kid steps on a nail at a cottage.

what is your initial magagement?

A

Tetanus

I&D in ER

No need for abx - tell them to return if any signs/symptoms

FYI: remember NEVER to give cipro to a kid - risk of tendon rupture

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43
Q

After contaminated needle stick, risk of:

HIV

Hep B

Hep C

A

HIV: 0.3%

Hep B: 37-62% (good thing we got our shots)

Hep C: 0.5-1.8%

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44
Q

2 factors/cytkines that promote differentiation into osteoclasts:

A

RANKL (releaesd by osteoblasts), M-CSF

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45
Q

Peroneus brevis flaps are good for:

A

distal 1/3 coverage leg

small defects only

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46
Q

Characteristics of an abused patient

A

Change in affect

Constantly seeking partner approval

Finding excuses to stay in treatment facility for prolonged period of time

Repeated visits to the emergency department

Significant time missed at work or decreased productivity at work

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47
Q

Define ICER

A

Incremental cost effectiveness ratio

Determines which intervention is more cost effective in a patient population

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48
Q

Define health utility

A

Reflects a patient’s preference for a particular health state or health-related outcome in a single index number between 0 (death) & 1(perfect health)

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49
Q

When can a patient drive after THA?

A

4-6 weeks

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50
Q

Who should be screened for intimate partner violence?

Who should screen?

A

All women in a fracture clinic

Screening should be done by an IPV coordinator

(Sprague & Bhandari 2013)

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51
Q

Define axonotmesis

A

Disruption of myelin sheath and axon

Endoneurium is intact

leads to conduction block with wallerian degeneration

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52
Q

Managment of Anti-TNFa inhibitors perioperatively

A

Etanercept: discontinue 1-2 weeks prior, restart when wound is healed (2 weeks)

Rituximab: discontinue 2 months prior

All other: discontinue 1 month prior

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53
Q

Complications of transfusion (especially massive transfusion)

A

thrombocytopenia

coagulation factor depletion

stored blood contains all coag factors except V and VIII

DIC consequence of delayed or inadequate resus

oxygenic affinity changes

Hypocalcemia

side effects of hypocalcemia ® tetany, hypotension, arrhythmias

hyperkalemia

not a problem unless very large amounts of blood given quickly

acid / base disturbances

hypothermia (frozed PRBCs – warmed to room temp)

leads to ­ tendency to cardiac dysrhymthmias

ARDS/TRALI

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54
Q

What antihypertensives should you hold preop?

A

ACE-I

ARB

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55
Q

Components of WHO Sign out

A

Before patient leaves OR

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56
Q

Best test for RA

A

Anti-CCP

Most sensitive and specific

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57
Q

Stress

A

intensity of an internal force

= force/area

units: Pascal’s (Pa) or N/m2

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58
Q

What test is diagnostic for hypophosphatasia?

A

Increased urine phosphoethanolamine

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59
Q

What material is the most susceptible to crevice corrision?

A

316L stainless steel

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60
Q

Best way to size fresh osteochondral allograft for the knee?

A

AP x-ray

(MRI are worse)

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61
Q

ARDS criteria

A
  • acute, meaning onset over 1 week or less
  • bilateral opacities consistent with pulmonary edema must be present and may be detected on CT or chest radiograph
  • PF ratio
  • “must not be fully explained by cardiac failure or fluid overload,” in the physician’s best estimation using available information — an “objective assessment“ (e.g. echocardiogram) should be performed in most cases if there is no clear cause such as trauma or sepsis.

(Berlin criteria)

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62
Q

Name a common location of fretting corrision

A

Head neck junction in THA

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63
Q

Important aspects of consent

A

Capacity

Disclosure (of material risks and benefits)

Demonstrate Understanding (synthesize, ask good questions)

Voluntary

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64
Q

Indications for thoracotomy in ATLS

A

Hemothorax >1500mL initially

Hemothorax >200-300mL/hr

Penetrating injury with PEA

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65
Q

Formula for absolute risk reduction

A

ARR = control event rate - treatment event rate

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66
Q

Sleep apnea has what effect post-op?

A

Increased complications, including

in hospital mortality

PE

wound hematoma/seroma

Can be diagnosed with STOP BANG (see pic)

JAAOS 2014

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67
Q

How does TXA work?

A

inhibits fibrinolysis via inhibition of activation of plasminogen

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68
Q

What is a thixotropic fluid?

A

It’s viscosity decreases with increase rate of movement (ie with increasing shear)

Sorry..it was on an exam

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69
Q

List 4 occupational hazards to the pregnant or lactating woman in the orthopaedic OR:

A

Radiation exposure

Physical stress

Blood borne pathogens (HIV, HCV, HBV)

Harmful chemical (PMMA, inhalational anesthestics)

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70
Q

Treatment of CRPS

A

1st line:

Gentle PT, stretching

Medications: NSAIDs, anti-depressants, alpha blockers, CCBS, antidepressants, anticonvulsants, GABA agonists

Nerve stimulation: type II only

Operative

Surgical sympathectomy

Indicated in failed nonoperative management

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71
Q

The bending rigidity of the implant shown in Figure A is proportional to what power of the measured radius of the implant

A

The bending rigidity of a solid cylindrical pin is related to the fourth power of the pin’s radius. The bending rigidity of the implant shown in Figure A is proportional to what power of the measured radius of the implant

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72
Q

Bleeding risk in patients with Chronic renal fialure?

A

INcreased ris of BOTH bleeding and thrombosis

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73
Q

5 poor prognostic indicators in nerve injuries

A

Old >54

Proximal nerve injury

  • At level of wrist, 50% good recovery

Graft >7cm

War injuryBlast:

  • Large zone of injury or heavily contaminated

Surgery delayed >18 months

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74
Q

Fasiculations: a sign of upper or lower motor neuron lesion?

A

Lower

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75
Q

List 4 principles of treating fractures through burned skin

A

If fracture needs OR:

Definitive treatment ideal

Through alternate skin incision if possible

If incision must be through burn, must do this within 48hrs

If >48hrs (tissue will be colonized):

  • Ex-fix (until wounds healed)
  • Splint (until wounds healed)
  • ORIF at the same time of wound debridement and skin grafting
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76
Q

How long is the consolidation phase of distraction osteogenesis technique?

A

2x transport

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77
Q

5 ways to decrease risk of injury with a tourniquet:

A

Time:

< 2 hours generally safe

Deflation time: The more the better (at least 30 mins)

Pressure

<200 mmHg in UE (or 50 above sBP)

<250mmHg in LE (or 100 above sBP)

Best is to measure Limb Occlusion Pressure using commercially available devices

Shape

Wide

Conical

Other

Not using a tourniquet

Having 2 cuffs and alternating between them

Well padded

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78
Q

Post-op, what adjustment to post-op pain control will redheads need ?

A

Higher dosing

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79
Q

What levels of MAP and PaO2 are protective in spinal surgery/post spinal trauma?

A

MAP > 85mmHg

PaO2 > 60mmHg

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80
Q

3 main cytokines in RA

A

TNF-alpha, IL-1, IL-6

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81
Q

After frostbite, administration of what drug has been shown to decrease rates of amputation?

A

Tissue plasminogen activator

Thought that thrombosis after re-warming leads to necrosis/amputation

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82
Q

What is the most common cause of OM?

A

Staph aureus in all age groups and demographics (including IVDU)

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83
Q

What percentage of women have been abused in the last 12 months?

A

2013 PRAISE - Lancet/Multinational Study: 1/6

2011 PRAISE - JBJS Ontario Only, smaller study = 1/3

So I would say 1/6, bigger study.

** Should say IPV rather than abuse. IPV includes physical, emotional and sexual.

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84
Q

What does the OTA & American College of Chest Physicians recommend as anticoagulation prophylaxis?

A

LMWH

(JAAOS is wishy washy)

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85
Q

General principles of delivering bad news/news of complication:

A

Sit down 1 on 1 with patient

Find a quiet, non-rushed environment

Turn off pager and cell phone

Tell them what happened

Tell them what we will do:

  • a. to correct the patient’s problem
  • b. to ensure that this will not happen again (patient’s want to hear this)

Ask if they have any questions

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86
Q

T/F:

Most people lose weight after THA/TKA

A

False

Most people DO NOT lose weight after TKA

So the idea that we give people a TJA to help them lose weight is bullshit

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87
Q

Classificaiton of CRPS

A

Type I: CRPS without demostrable neve lesion

most common

Type II: CRPS with evidence of obvious nerve damage

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88
Q

For optimal wound healing, albumin should be:

A

>3.0g/dL

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89
Q

Nerve repair spiel

A

I will aim for a tension free repair in a clean wound bed

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90
Q

Name 5 local and 5 systemic manifestations of using a tourniquet

A

Local

Post-operative swelling and stiffness

Delay in recovery of muscle power

compression neurapraxia

wound hematoma

Wound infection

Direct vascular injury

Bone and soft-tissue necrosis

Compartment syndrome

Systemic:

increased VP

arterial hypertension

cardiorespiratory decompensation

Cerebral infarction (CVA)

Alterations in acid-base balance

Rhabdomyolysis

DVT (controversial)

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91
Q

Contraindications to hyperbaric oxygen therapy

A

Chemo or radiation therapy

  • pressure-sensitive implanted medical device:
  • defibrillator, pacemaker, dorsal column stimulator, insulin pump
  • Undrained pneumothorax
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92
Q

Define neurontmesis

A

Complete disruption of the nerve, including disruption of endoneurium

No recovery unless surgial repair performed

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93
Q

After burns, what level of urine output should be maintained?

A

at least 2mL/kg/hr

(for 70kg man: 140mL/hr)

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94
Q

What medication has been shown to increase skeletal muscle regeneration and decrease fibrosis (in animal models)

A

Angiotension II Receptor blockers (Losartan)

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95
Q

What do you do after identifying a medical error?

A

Offer an apology to family/patient

Provide full disclosure (explain what happened)

Accept responsibility

Offer corrective steps to prevent recurrence

Document fully

Call CMPA

(an apology is NOT the same as accepting blame. You are sorry for what happened, not for doing something bad)

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96
Q

Define a neurologic level in SCI

A

Lowest level with normal sensation and 3/5 power

So the lowest normal level

If there is a lesion at L3, it would be an L2 level

In other words, an L2 level means everything below L3 is messed

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97
Q

What is the additional energy expediture for the following:

Transtibial amputation

Long transtibial amputation

Transfemoral amputation

A

Transtibial amputation: 25%

Long transtibial amputation: 10%

Transfemoral amputation: 65%

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98
Q

Name the CanMeds Components

A

Professional

Health advocate

Medical expert

Manager

Scholar

Communicator

Collaborate

“Please Help Me Memorize Stupid Canmeds Crap”

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99
Q

Who should be listed as an author on a research paper?

A

Each author should have participated sufficiently in the work, including:

Conception or design, or analysis and interpretation of data, or both

Drafting the article or revising it for critically important intellectual content

Final approval of the version to be published

*participation solely in the collection of data does not justify authorship (ie can’t be in it if you let your patient’s take part)

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100
Q

Mortality rate of fat emboli syndrome?

A

15%

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101
Q

Contraindications to primary closure in open fracture

A
  • Inadequate debridement
  • Gross contamination
  • Farm related or freshwater immersion injuries
  • Delay in treatment >12 hours
  • Delay in antibiotic administration
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102
Q

Describe Brooker Classification

A

Classification for HO

class I: represents islands of bone w/in soft tissues about hip

class II: inclues bone spurs in pelvis or proximal end of femur leaving at least 1 cm between the opposing bone surfaces;

class III: represents bone spurs that extend from pelvis or the proximal end of femur, which reduce the space between the opposing bone surfaces to less than 1 cm;

class IV: indicates radiographic ankylosis of the hip;

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103
Q

Classic radiographic findings with TB arthorpathy?

A

Phemister’s triad

juxta-articular osteopaenia/osteoporosis

peripheral osseous erosions

gradual narrowing of joint space

*Major dDx of inflammatory arthritis - always ask

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104
Q

What gives the greatest risk for multiple joint sepsis?

105
Q

Risks of Intimate Partner Violence

A

Younger age

Shorter duration of
relationship

coexistence of emotional, psychological or
sexual abuse

drug or EtOH dependency

106
Q

CRF in orthopaedic surgery:

A

Its bad - they have 2x increase in risk of complications including mortality

107
Q

Stress Strain curve: elastic zone

A

zone where a material will return to its origina shape for a given amount of stress

108
Q

4 principles of antibiotic stewardship

A
  1. determining appropriate indications ofr antibiotic administration
  2. choosing correct Abx based on known or expected pathogen
  3. determining the correct dosage
  4. determining the appropriate duration of treatment
109
Q

Gram positive cocci in chains

What do you think of?

A

Nec fasc

Is strep pyogenes

vs. gram + in clusters: staph

110
Q

3 phases of distraction osteogenesis

A

(1) Latency phase (5-7 days) (after corticotomy)

(2) Distraction phase (1 mm per day [approximately 1 inch per month])

(3) Consolidation phase (typically twice as long as the distraction phase)

111
Q

What fluid should you resuscitate with in SIADH?

A

Normal saline

It keeps intravascular sodium high (counteracting dilutional effect of SIADH)

112
Q

Classifications of Non-union: Name 2

A

Type:

  • atrophic
  • oligotrophic
  • hypertrophic

Location

  • intraarticular
  • metaphyseal
  • diaphyseal
113
Q

What is the only calcium disease with decreased ALP?

A

Hypophosphatasia

b/c it’s a disease of ALP with a mutation in Tissue nonspecific isoenzyme of ALP (TNSALP)

114
Q

nerve grafts should be _______ (longer/shorter) than the defect

A

10-20% longer

as it will shorten with fibrosis

115
Q

Define the value of an intervention

A

the quality of the intervention divided by the cost of the intervention, measured over an adequate time horizon

JAAOS 2013

116
Q

The Frostbite complication of vasospastic disease: what can you use to treat it (2)

A

Calcium channel blockers

surgical sympathetectomy

117
Q

What populations are considered vulnerable and require consent from IRBs prior to enlisting in clinical trials?

A

Fetuses

Children

Pregnant women

prisoners

118
Q

4 ways to reduce risk of fat emboli syndrome

A

Early fixation of long bone fracture

Overreaming the femoral canal during TKA

Use of reamers with decreased shaft width reduces the risk during femoral reaming for IM fixation

Use of Ex-Fix as definitive long bone fractures in the medially unstable patients

119
Q

What antibiotic never to give to a kid?

A

FLuoroquinolone

120
Q

What is the max acute shortening of a bone you can do?

A

3-5cm (almost same as lengthening)

due to kinking of NV bundles

121
Q

Define the Endurance limit

A

maximal stress under which an object is immune to fatigue failure regardless of the number of cycles

122
Q

Cardinal signs of CRPS

A

Exaggerated pain

swelling

stiffness

Skin discoloration

Also:

vasomotor disturbances

trophic skin changes

hyperhidrosis

flamingo gait (if knee involved)

123
Q

FHB or FDB flaps can be used to cover:

A

Small heel defects

124
Q

Ortho cases that have increased risk of PE

A

Hip fracture

Elective hip arthroplasty

  • Intra-operative PE occurs more frequently with cement pressurization of the femoral canal

Elective knee arthroplasty

Spine fracture with paralysis

*EARLY DETECTION & TREATMENT MOST IMPORTANT FOR SURVIVAL

125
Q

Name the values of medical ethics

A

Autonomy: patient has right to refuse or choose treatment

Non-maleficence: primum non nocere

Beneficence: maximize benefit and minimize risk (for individual & society)

Justice: distribution of health resources (fairness & equality)

Dignity & respect: the patient (and person treating patient) has right to dignity

Truthfulness & honesty: informed consent (Tuskegee Syphilis study)

126
Q

Stress Strain curve: yield point

A

transition point between elastic and plastic deformation

127
Q

Name values that commonly apply to medical ethics (not just the pillars)

A

Autonomy

Non-maleficence

Justice

Beneficence

Dignity: the patient has the right to dignity

Truthfulness & honesty: concept of informed consent. Relates back to Tuskegee syphylis strudy

128
Q

What do you use to compare 3 or more continuous variables?

129
Q

Name 4 ways to prevent transmission of HIV (PPE etc)

A
  • Double gloving
  • Instrumented suture tying
  • Waterproof gowns
  • Passing instruments between surgeon and nerve through an intermediate tray
130
Q

Crevice corrosion

A

occurs in fatigue cracks due to differences in oxygen tension

131
Q

Ortho procedures/injuries with high rates of DVT: (5)

A

Spine fractures with paralysis

Elective TKA

  • 2-3x greater rate of DVT than THA

Elective THA

Hip fracture

Polytrauma

*RATES OF DVT DO NOT CORRELATE WITH PE OR DEATH AFTER THA/TKA

132
Q

Outcomes of orthopaedic surgery in a patient who uses opoioids pre-op

A

Poorer overall

More complications

More painful recoveries

133
Q

Most common source of infection in freshwater?

A

Skin flora:

Staph

Strep

134
Q

Describe 4 elements of medical negligene

A

Duty:

duty of the physician is to provide care equal to the same standard of care ordinarily executed by surgeons in the same medical specialty

Breach of Duty:

The actions, or failure to act, deviates from standard of care

Causation

Breach of duty was the direct cause of the patient’s injuries

Damages

Monies awarded as compensation for injuries sustained as the result of medical negligence

135
Q

Only RA drug shown to increase risk of infection post op?

A

Etanercept

no evidence for any of the others

136
Q

Role of Satellite Cells?

A

Muscle injury repair

137
Q

Characteristics of an intimate partner violence abuser

A

Refuses to leave patient alone

Overly attentive

Aggressive or hostile

Refuses to let patient answer their own questions

138
Q

What do you use to compare 2 or more categorical variables?

A

Chi square test

139
Q

Risks for paralytic ileus in ortho

A

Type of surgery

spine surgery

lower extremity reconstruction

trauma ± abdom injuries

140
Q

Finite element analysis

A

breaking up a complex shape into triangular or quadrilateral forms and balancing forces and moments of each for to match it with its neighbour

141
Q

Signs of sacral dysmorphism

A

Assessed on outlet view

Mamillary bodies

Lumbarization of S1

Sacraliation of L5

Oblong foramen

Preservation of sacral disc spaces

Tongue in groove sign

142
Q

For optimal wound healing, ABI should be:

A

>0.45

vs. ischaemic index >0.5

143
Q

Classification & Treatment of Ex-Fix infections

144
Q

Conditions that promote bone formation in distraction osteogenesis

A

a. Low-energy corticotomy/osteotomy

b. Minimal soft tissue stripping at the corticotomy site (preserves blood supply)

c. Stable external fixation to eliminate torsion, shear, and bending moments

d. Latency period (no lengthening) of 5-7 days

e. Distraction at 0.25 mm 3-4 times per day (0.75-1.0 mm per day)

f. Neutral fixation interval (no distraction) during consolidation

g. Normal physiologic use of the extremity, including weight bearing.

145
Q

Hooke’s law

A

when a material is loaded in the elastic zone, the stress is proportional to the strain

146
Q

What is a viscoelastic material?

A

one that exhibits a stress-strain relationship that is dependnet on the load AND the rate at which the load is applied

ie:

ligaments, bone

147
Q

Definition of osteoporosis?

A

T-score more than 2.5 standard deviations below that of a 25 year old individual

(T score

148
Q

Load relaxation

A

Load relaxation is characterized by decreased peak loads over time with the same amount of elongation

Gets stretched out and gets weaker

Occurs after releasing the mobile wad (just kidding)

149
Q

Creep

A

Chris dowding

Increased load deformation with time under a constant load

150
Q

What are the criteria for causality in research?

A

Bradford Hill Criteria

  • Strength (effect size)
  • consistency (reproducibility)
  • Specificity
  • Temporality
  • Biological gradient
  • Plausibility
  • Coherence
  • Experiment
  • Analogy
  • ?Reversibility?

Sex Causes Size To Be a Plausibly Crafted Excuse, Always

151
Q

What are new 4th generation composite sawbones made out of?

How do they compare to the real things?

A

fibreglass resin and epoxy

They replicate physiologic or near physiologic values for torsional, axial compressive, and lateral bending stiffness, as well as cancellous screw pullout strength

They are also cheaper than cadavers

One downdie is that they don’t have soft tissue overlying it

152
Q

Define anisotropic material

A

one that possesses different mechanical properties depending on which way it is loaded

ie: bone, ligaments

153
Q

True or false:

You are mandated to report intimate partner violence to police/authorities

A

False

Only report with the patient’s permission

154
Q

Most common electrolyte abnormality after ortho surgery in patient with CRF

A

hyperkalemia

155
Q

What imaging to order for HO?

A

Regular x-rays ± CT

Bone scan has NO ROLE

156
Q

Stress Strain curve: breaking point

A

point where an object fails and breaks

157
Q

6 good prognostic indicators in nerve injury

A

Young

Early repair

Single function nerve

Distal location (level)

Sharp transection

Short nerve graft

158
Q

For optimal wound healing, transcutaneous oxygen tension should be:

A

at least 30mmHg

Preferably 45mmHg

159
Q

Open fracture with fresh water contamination. Treatment?

A

fluoroquinolone (cipro, levofloxacin) or a third- or fourth-generation cephalosporin (eg, ceftazidime).

160
Q

CRPS around knee - most common xray finding?

A

Patellar osteopenia

161
Q

Difference between dwarf & midget

A

Dwarf: disproportionate short stature

Midget: proportionate short stature

162
Q

What is PTH’s effect on calcium and phosphate?

A

Calcium: increases it (increase blood levels)

Phosphate: decrease blood levels

PTH = phosphate trashing hormone

163
Q

When does peak blood flow occur in fracture healing?

A

at 2 weeks

normal by 3-5 months

most important determinant of fracture healing

164
Q

Signs of Tension pneumothorax

How do you treat

A

Deviated trachea (away from side)

hypotension

JVP

Hyper-resonant

Treatment:

Needle decompression

2nd intercostal space, midclavicular line

Followed by chest tube

4th/5th intercostal space, anterior axillary line

165
Q

Fretting corrosion

A

Occurs at contact sites between 2 materials that are subject to micromotion

166
Q

In RA Foot, what is the main risk factor for developing post-op infection?

A

Previous infection

(NOT the continuation of DMARDs)

167
Q

Strain

A

relative measure of deformation of an object

=change in length / original length

168
Q

Abnormal findings in NCV

A

Increased latencies

Decreased conduction velocity

Decreased amplitude

Prolonged/absent evoked response

169
Q

Define Disability

A

Limitation of an individual’s capacity to meet certain personal, social, or occupational demands.

This is not an objective medical designation, but a legal definition.

vs. Impairment: loss of function from a physical or anatomical derangement

170
Q

Define fatigue failure

A

failure at a point below the ultimate tensile strength secondary to repetitive loading

it depends on the magnitude of stress and the number of cycles

171
Q

Stress Strain curve: plastic zone

A

zone where a material will not return to its origina shape for a given amount of stress

172
Q

Why isn’t free fibular graft used anymore?

A

High rate of complications and donor side morbidity

Higher risk of fracture

BUT it gets 95% union rate

JAAOS

173
Q

For optimal wound healing, total lymphocyte count should be:

A

>1500/mm^3

174
Q

What is the toe region of Stress Strain curve?

A

applies to a ligament’s stress/strain curve

represents straightening of the crimped ligament fibrils

175
Q

Steroid management perioperatively

A

If <5mg/d of prednisone or equivalent, NO perioperative dosing required

If >5mg/d prednisone:

Mild surgery: give Hydrocortisone 25mg (5mg predinisone)

  • ie knee arthroscopy, carpal tunnel

Moderate surgery: Give 50-75mg hydrocortisone (10-15mg prednisone)

  • joint arthroplasty

Major surgery: 100-150mg hydrocortisone (20-30mg prednisone)

  • polytrauma
176
Q

Who may you need to consult in the management of segmental bone defects?

A

microvascular

plastic surgery

internal medicine

psychiatry

infectious disease

(as needed)

177
Q

Definte T-score & Z-score as it pertains to osteoporosis

A

T-score:

BMD reliatve to a normal, young matched control (25yo F)

Used as a definition of osteopenia/porosis

osteopenia: T-score 1 - 2.5 STD below normal
osteoporosis: T-score >2.5 STD below normal

Z-score:

BMD relative to similar aged patients

178
Q

Initial management of frostbite

A

Rapid rewarming in 40-42C water for 30 minutes

avoid repetitive thaw-freeze cycles

179
Q

Stress Strain curve: Young’s Modulus

A

measure of stiffness (ability to resist deformation) of a material in the elastic zone

calculated by measuring the slope of the stress/strain curve in the elastic zone

higher modulus of elasticity = a stiffer material

180
Q

What happens to muscles as you age?

A

Diameter AND number of fibers decrease

vs

disuse atrophy: diameter decreases but number of fibers stays the same

181
Q

What is the most imporant factor in reducing fat emboli syndrome?

A

Early stabilization (within 24h) of long bone fracture

182
Q

Presence of 6 variables below correspond to short life expectancy in orthopaedic oncology

A

Multiple spinal mets

Multiple extra-spinal mets

Unresectable lesions in major organs

SCI (complete or incomplete)

Aggressive CA: lung, osteosarcoma, pancreas

Critically ill

183
Q

Salt water wound. You’ve given cipro. what else do you have to add in? Why?

A

Tetanus

Clostridium is in salt water

184
Q

When should chronic renal failure patients have dialysis before elective surgery?

A

on the day of or the day before surgery

185
Q

For optimal wound healing, toe pressure should be:

A

>40mmHg

Will not heal if <20mmHg

186
Q

Chronic renal failure

Overall complication risk ?

Risk of fracture?

A

Complication risk 2x that of normal

almost 2x more likely to have fracture

187
Q

Fat Emboli syndrome criteria

A

1.1. Major: x 1

  • 1.1.1. Hypoxemia (PaO2 less than 60)
  • 1.1.2. CNS depression
  • 1.1.3. Petechial rash
  • 1.1.4. Pulmonary infiltrates

1.2. Minor: x 4

  • 1.2.1. Tachycardia
  • 1.2.2. Pyrexia
  • 1.2.3. Retinal emboli
  • 1.2.4. Fat in urine
  • 1.2.5. Fat in sputum
  • 1.2.6. Thrombocytopenia
  • 1.2.7. Decreased HCT

1.3. Other

  • 1.3.1. PCO2>55
  • 1.3.2. pH
  • 1.3.3. RR>35
  • 1.3.4. Dyspnea
  • anxiety
188
Q

What is the evidence for the regular prescription of abx for dental procedures in a patient with a TKA/THA?

A

Limited

Spiel - read if you want

They know that dental work (including regular brushing) increases bacteremia, and that antibiotics decreases that bacteremia. However, there has been no link of bacteremia to increased rates of PJI in post-op hip/knee patients

189
Q

Preferred utility score for measuring quality in spine care?

A

QALY

quality adjusted life year

patient driven and can be used in economic evaluation, is easily communicable and can be compared across disease states

190
Q

Outcomes of grouped/matched fascicular repair vs. epineurial repair

3 indications for grouped fascicular repair

A

indications:

median nerve in distal 1/3 forearm

ulnar nerve in distal 1/3 forearm

sciatic nerve

However, results are no better so maybe don’t say this

191
Q

Barriers to reporting intimate partner violence? (4)

A

Fear of retaliation

Shame

Difficulty reporting to male doctors

Fear of custody conflicts

Fear of loss of finances

192
Q

Most important prognostic indicator in nerve injury

A

Age

Younger = better

193
Q

AC current burns/electrocutions are associated with what non-ortho, life-threatening condition?

A

Ventricular arrythmias

194
Q

3 factors associated with increased severeity of frostbite:

A

Alcohol consumption/intoxication

Contact of skin with metal or ice

Elevated wind chill factor

195
Q

Although they understand that the evidence supporting it is limited, who do the AAOS and ADA suggest giving prophylatic antibiotics to for dental procedures?

What antibiotics are suggested?

A

TJA patients at increased risk of hematogenous seeding should be given prophylactic antibiotics prior to dental procedures, including:

  • all patients for the first two years after TJA
  • immunocompromised patients
  • drug induced immunosuppression
  • radiation induced immunosuppression
  • inflammatory arthropathies including SLE and RA

comorbidities including

  • previous prosthetic joint infection
  • Type I (insulin-dependent) diabetes
  • malnourishment
  • hemophilia
  • HIV
  • malignancy

Suggest Cephalexin or clinda if allergic

196
Q

When should a CRF on dialysis patient have a nephro consult preop?

A

Within a day before surgery

197
Q

List 2 proinflammatory mediators

A

IL1

TNFa

These play a role in post traumatic OA after articular fracture

198
Q

Risks of septic arthritis

A

Age >80 years

Medial conditions (imunocompromised)

Diabetes

RA

Cirrhosis

HIV

History of crystal arthropathy

Endocarditis or recent bacteremia

IVDU

Recent joint surgery

199
Q

5 contraindications to primary closure of an open fracture

A
  • Inadequate debridement
  • Gross contamination
  • Farm related or freshwater immersion injuries
  • Delay in treatment >12 hours
  • Delay in antibiotic administration
  • Compromised host or tissue viability
200
Q

7 ways to decrease radiation exposure

A

Reduced exposure time

increasing distance from beam

increased shielding (gown, thryoid collar, gloves, glasses)

Beam collimation

Using the low-dose option

Inverting the c-arm

Surgeon control of the c-arm

201
Q

Mangled extremity severity score (MESS) takes into account what factors and predicts what?

A

Skeletal and soft tissue injury

Limb ischaemia

Shock

Age

Score > 7 is highly predictive of amputation

Not saying you should amputate, just saying that it is an eventuality, so why not do it now

202
Q

Management of Methotrexate perioperative

203
Q

What are 3 questions to screen for IPV?

(Sprague & Bhandari 2013)

A

Woman Abuse Screening Tool (WAST)

Have you been physically abused by an intimate partner?

Have you been emotionally abused by an intimate partner?

Have been sexually abused by an intimate partner?

204
Q

Define Isotropic material

A

one that possesses the same mechanical properties in all directions

ie a golf ball

205
Q

8 Ways to decrease blood loss

A

Tourniquet

Technique (cautery)

Cell saver

Controlled hypotension

Tranexamic acid

Gel foam

Surgicel

fibrin glue

local epinephrine

206
Q

What are 2 disadvantages of tendons?

1 advantage?

(biomechanically)

A

Disadvantages

Demonstrates Creep & stress relaxation

Advantage

Strong in tension (more then bone)

Other characteristics:

viscoelastic with nonlinear elasticity

displays histeresis

207
Q

How long do you hold cultures for TB? What are you culturing?

A

Hold at least 8-10 weeks

Culturing for mycobacteria

208
Q

Side effect of quinolones (cipro)?

A

Toxic effect of chondrocytes leading to:

  • ABnormal fracture healing
  • increased risk of tendon rupture (achilles)

Do not give to kids

209
Q

Therapies in treatment of paralytic ileus

A

minimization of opioids

early patient mobilization

pharmacologic intervention (prokinetics, anti-emetics)

multidiscipliary care

Chewing gum (intestinal motility via cephalic-vagal stimulation)

Use of regional anestheisa (prevention)

Surgery not indicated in absence of perforation or ischaemia

210
Q

EMG abnormalities with denervation

A

Abnormal insertional activity

  • Increased: denervation
  • Decreased: muscle fibrosing

Abnormal spontaneous activity

  • fibrillations
  • fasciculations (indicate healing if at 3-6 months)
  • Sharp waves
  • complex repetitive discharges
  • myokimic discharges
211
Q

What type of bone loses mechanical strength with aging?

A

Trabecular > cortical

212
Q

What is a critical bone defect?

A

Void that will not fill without intervention

Subjective, but generally:

>50% circumferential bone loss or length >2cm

(jaaos 2015)

213
Q

What factors will turn an open fracture into Gustillo 3 no matter the size of the wound?

A

Exposure to soil

Exposure to water (pools, lakes/streams)

Exposure to fecal material (barnyard)

Exposure to oral flora (bite)

Gross contamination on inspection

Delay in treatment >12 hours

214
Q

Kid steps on a nail

Initial management and abx?

Most common organism?

Abx for pseudomonas infection?

A

I&D in ER

No consensus on initial Abx - POSNA says you don’t have to give any

Most common organisms: staph aureus

Most distinctive organisms: pseudomonas

Treat pseudomonas with certazidime (3rd gen ceph that is active vs. pseudomonas)

215
Q

What happens clinically with an acute UMN lesion?

A

Initially:

  • flaccid* paralysis
  • decreased* tone
  • decreases* reflexes

Not until hours - weeks that the classic signs of increase tone,reflexes etc will present

216
Q

6 Risk factors for OM

A

Recent trauma or surgery

Immunocompromised

Illicit drug use

Poor vascular supply

Systemic conditions:

  • DM
  • Sickle cell

Peripheral neuropathy

217
Q

What metal has a Young’s Modulus most similar to cortical bone?

218
Q

Mechanism of Rituximab:

A

inhibits B-cells

it is a monoclonal antibody to CD20 antigen

219
Q

In induced membrane technqiue, in second stage, what do you fill void with?

A

Autograft

Can have allograft but not more than 3:1 allo : autograft

220
Q

Best candidate for a myoelectric prosthesis?

A

transradial amputation

221
Q

Name 9 factors to decrease radiation from C-arm

A

Imaging small body parts (non-modifiable, but large parts have more radiation)

Position extreity further from x-ray source (closer = more rads)

use of mini c-arm

Maximizing distance between surgeon and beam

minimizing exposure time

Collimation

Orienting the beam in an inverted position relative to the patient

Avoid being in the path of the x-ray beam

use of protective shielding

222
Q

List the components of informed consent

A

Nature of the problem

Proposed treatment to address the condition (if the surgeon has a specific recommendation)

Alternative treatments

Anticipated benefits of each treatment option

Risks and side effects of each treatment option

Consequences of no treatment

Assessment of the patient’s understanding of the proposed treatment

(AAOS online)

223
Q

3 independent predictors for foot ulceration:

A

absence of the Achilles’ tendon reflex

a foot insensate to the 5.07 Semmes-Weinstein monofilament

a transcutaneous oxygen tension (TcPO2) of less than 30 mm Hg

224
Q

Mechanism of Anakinra (Kineret)

A

recombinant IL-1 receptor antagonist

225
Q

Name 7 resistance mechanisms of antibiotics

A

Beta lactamase

mecA mutational bacterial gene encoding an altered penicillin-binding protein.

Altered cell wall permeability

Creation of biofilm barrier

Active efflux pumps

msrA in staph

Ribosome alteration

226
Q

What is a ductile material? Give an example

A

One that undergoes a large amount of plastic deformation

ie: metal

227
Q

Order of nerve function return

A

“Some People Tend To Piss Me Off”

  • Sympathetic
  • Pain
  • Temperature
  • Touch (light touch)
  • Proprioception
  • Motor

Off (nothing - just finishes the mnemonic)

The 2 T’s, TEmperature comes before TOuch

228
Q

What is the risk of pin site infection in distraction osteogenesis?

229
Q

What kind of viruses do the following transmit after bites:

Humans

Rats/mice

Monkeys

Dogs, bats, skunks

A

Humans: HIV, Hep C, Hep B

Rats/mice: Hantavirus

Monkeys: Simian B

Dogs, bats, skunks: rabies (rhabdoviridae)

230
Q

When can a worker’s comp patient settle a claim?

A

When the patient is determined to reach maximum medical improvement when further restoration of function is no longer anticipated (as judged by the primary physician)

231
Q

SIRS criteria

A

WBC: low or high

Temp: <36 or >38C

HR: above 90bpm

Resp: rate >20 or PaCO2 <32mmHg

232
Q

Factors in decision to operate in HO?

A

Matured bone (corticated)

Bone scan has NO ROLE

233
Q

Elastic deformation

A

reversible changes in shape to a material due to a load

material returns to original shape when load is removed

234
Q

5 signs of LMN lesion

A

Weakness

atrophy

fasciculation

decreased reflexes decreased tone

235
Q

Which direction is bone strongest & weakest in?

A

Strongest in compression

Weakest in shear

236
Q

Stress Strain curve: ultimate (tensile) strength

A

defined as the load to failure

237
Q

8 ways to decrease radiation exposure

A
  • reduced exposure time
  • increased distance from the beam
  • increased shielding (gown, thyroid gland cover, gloves, and glasses)
  • beam collimation
  • using the low-dose option
  • inverting the C-arm - source is far way so can include more in 1 picture
  • surgeon control of the C-arm
238
Q

You dropped bone on the floor but want to use it. What is the best way to sterilize it?

A

I&D with poviodine and allow it to dry

239
Q

Antibiotic stewardship programs lead to a decrease in what type of infection?

A

C. diff

b/c C.diff comes from inappropriate abx killing gut flora

240
Q

Induced membrane technique: when is second stage?

A

6-8 weeks later

241
Q

Risk factors for abuse (11)

A

Pregnant: #1 risk factor:

  • 40-60% of abused women were abused while pregnant

Female

Young age (19-29 years old)

Low-income families

Low socioeconomic status

Emotional abuse is a risk of physical abuse

Psychological abuse is a risk of physical abuse

Sexual abuse is a risk for physical abuse

Drug dependency

Alcohol dependency

*History of Divorce is NOT a risk factor

242
Q

T/F

Increased glucose is an independent risk factor for post-op infection even in the absence of dianosed diabetes

A

True

Increased glucose is just bad

(JAAOS 2014)

243
Q

Name the WHO checklist steps and when they occur

A

Sign in: before induction

Time out: before skin incision

Sign out: before patient leaves OR

244
Q

Distraction osteogenesis: what are times for total, latent, distraction and consolidation

A

Latent: ~10 days recommended

Distraction: determined by length of defect

Consolidation: 2x distrction

Total: 3x distraction

245
Q

For optimal wound healing, Ischaemix index should be:

A

>0.5

This is a measurement of doppler pressure at level being tested compared to brachial artery pressure

Basically an ABI for any part of the body

246
Q

Eikenella Corrodens:

Gram staining & treatment

A

Gram negative

Treat with penicillin

247
Q

How do the distraction and docking sites heal with disraction ostegenesis?

A

Distraction: intramembranous

Docking: endochondral

248
Q

Components of WHO Time out

A

Before skin incision

249
Q

Galvanic corrosion

A

dissimilar metals lead to electrochemical destruction

250
Q

In a hospital with a high MRSA colonization rate, or in a patient with known MRSA colonization, what preoperative, prophylactic antibiotic do you use?

A

Vanco

“in a study performed at our institution, high-risk patients undergoing total hip or total knee arthroplasty or spine surgery were screened for MRSA and methicillin-sensitive S aureus (MSSA), and 3% were found to have nares colonized with MRSA. This pattern should alter local recommendations with regard to perioperative antibiotic prophylaxis in patients colonized with MRSA. Several studies have suggested that vancomycin be used for perioperative prophylaxis in patients at high risk of MRSA colonization and/or infection.”

Although later they say there is no consensus but they advocate for vanco

(JAAOS 2014 - antibiotic stewardship)

251
Q

What do you use to measure 2 independent continuous variables?

A

Student T-test

252
Q

Define brittle material & give an example

A

Material that exhibits linear stress strain relationship up until the point of failure

Undergoes plastic deformation only with little to no plastic deformation

examples:

  • Ceramic
  • PMMA
253
Q

PMMA:

What is the function of

  • Benzoyl peroxide
  • barium sulfate
  • DMPT
  • Hydroquinone
A

Found in powder

Benzoyl peroxide: initiator

barium sulfate: radio-opacifier

Found in liquid

DMPT: accelerator

Hydroquinone: stabilizer

The powder and liquid are mixed and a free radical polymerization occurs

254
Q

How large of a bone defect can you use with:

Autograft

induced membrane technique

Free fibular graft

Distraction osteogenesis

A

Autograft: 5cm

Induced membrane: 10cm (JAAOS - prob more now)

Free fibular graft (10cm)

Distraction osteogenesis (unlimited)

255
Q

When do you nerve graft?

What is the gold standard?

A

Defects > 2.5cm

Autologous nerve graft

256
Q

What man made material has a modulus of elasticity closest to cancellous bone?

A

Polyethylene

257
Q

X-ray findings of AVN of femoral head post DDH treatment

A

1) Failure of appearance or growth of ossific nucleus at 1 year after reduction
2) Broadening of femoral neck
3) Increased density and fragmentation of ossified femoral head
4) Residual deformity of proximal femur after reduction
5) Shortening of the femoral neck
6) Greater trochanter overgrowth
7) Premature physeal closure

258
Q

Features of CRPS

A

exaggerated pain (hyperesthesia, allodynia, hyperalgesia)

swelling

stiffness

skin discoloration

Physical exam

vasomotor disturbance

trophic skin changes

hyperhidrosis

“flamingo gait” if the knee is involved

X-ray

Osteopenia

259
Q

List 6 causes of secondary osteoporosis (not aging/menopause)

A

Lifestyle

anorexia nervosa

excessive protein intake

smoking

EtOH

Endorinopathies

Hyperthyroidism

Hyperparthyroidism

Cushing’s syndrome

DM

Systemic disease

Gaucher’s

RA

AS

Psoriasis

Oragn dysfunction

CF

Asthma

COPD

Renal failure

Primary biliary cirrhosis

IBD

Celiac sprue

Organ transplatation

Meds

Steroids

Diuretics

Antiepileptics

MTX

Cyclsporin A

Excess thyroid hormone replacement

Aklylating chemotherapeutic agents

GnRH agonist

Cancer

OITE ORTHOPEDIC PRINCIPLES (1 decks)

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