SAQ Flashcards
What are 7 neurological causes of pes cavus aside from?
CMT
CP
Diastematomyelia
Stroke or closed head injury
Freidreich’s ataxia
Huntington’s chorea
Arthrogryposis
What are the 3 most common procedures performed after a terrible triad?
Column procedure
Radial head arthroplasty for failed ORIF
TEA
6 design features to reduce IM pressure during reaming?
Deeper flutes
Larger diameter bulb tip
Slower speed of rotation
Sharp reamer
455 stainless steel
Titanium nitride coating
8 risk factors for Pavlik harness failure?
Bilateral
Teratologic
Ortolani negative
Initiation of treatment after 7 weeks
Male
Inappropriate application
Femoral nerve palsy
Patient noncompliance
5 infantile disorders with thickened cortices/periosteal calcifications?
Caffey’s disease
Scurvy
Rickets
Hypervitaminoses (A and D)
Congenital syphilis
8 risk factors for Dupuytren’s disease?
Male
Advanced age
Manual laborer
Smoker
Alcohol
HIV
Diabetes
Anti-epileptics
6 indications for surgery in a Rheumatoid C-spine?
Progressive myelopathy
ADI >10mm static
ADI >4mm dynamic (ie: 4mm more on flex vs. ex view)
SAC <14mm
Tip of the dens past McRae’s line
Tip of the dens >5mm above McGregor’s line
>20% C3-C7 subluxation with neuro symptoms/severe pain
7 principles of tendon transfers?
Expendable donor tendon
Donor tendon has similar strength and excursion
Straight line of pull
Supple joint
One tendon performs one function
Synergistic function
Lose 1 point on power grade after transfer
Name 3 local complications related to metal toxicity
Pseudotumour
Metallosis (aseptic local necrosis secondary to metallic corrosion)
ALVAL (aseptic lymphocitic vasculitis associated lesion - T-cell mediated type IV hypersensitivity reaction to Co and Cr ions)
Name 4 principles for maintaining reduction in a length-stable pediatric femur fracture managed with Nancy nails
> 80% canal fill
More nails to increase rigidity
Pre-contour nails to achieve adequate spread at fracture site
Use end caps to improve axial stability
What’s an indication to do a metabolic work-up in SCFE?
Patient <10 yo or <50%ile for body weight
List 4 endocrine abnormalities associated with SCFE
Hypothyroidism
Panhypopitutiarism
Growth hormone deficiency
Renal osteodystrophy
Name 5 methods to reconstruct a zone 2 (periacetabular) pelvic lesion
Curettage and cementplasty
Conventional THA
THA with reinforcement ring/reconstruction cage
Harrington procedure (primary THA reinforced by 3 steel pins/screws from the iliac crest down and cement)
Megaprosthesis
List 6 complications of an HTO
Intra-articular fracture propagation
Recurrence of deformity (60% at 3 years)
Patella baja
Decreased posterior slope
Compartment syndrome (recurrent anterior tibial)
Malunion/non-union
3 advantages of a distal femoral locking plate over a DCS
Better fixation in osteoporotic bone
Better control of coronal-plane fractures
More bone preserving (screw removes a lot of bone)
6 radiographic features of FAI
Alpha angle >55
LCEA >39
Tonnis angle <0
Head-neck offset ratio <0.17
Crossover sign
Ischial spine sign
List 8 risk factors for infection in THA
Active infection
IVDU
Revision surgery
Diabetes
Obesity
Rheumatoid arthritis
Immunosuppression (HIV)
Smoker
List 8 radiographic features of aortic dissection on CXR
Widened mediastinum
Widened paraspinal stripe
Widened paratracheal stripe
Indistinct aortic contour
Right trachial deviation
Left depressed mainstem bronchus
Left apical pleural cap
Left large haemothorax
List 4 major and 4 minor criteria for fat embolism
1 major and 4 minor criteria required to make Dx.
Major: hypoxia, pulmonary edema, petechiae, CNS depression
Minor: fat in urine or sputum, tachycardia, fever, sudden indexplicable drop in platelets
List 6 orthopaedic features in the diagnostic criteria of Marfan’s
Pectus excavatum requiring surgery
Reduced elbow extension
Positive wrist and thumb signs
Scoliosis or spondylolisthesis
Protrusio
Medial displacement of medial malleolus (pes planus)
List 5 non-orthopaedic features of Marfan’s
Lens dislocation
Aortic dilatation
Aortic dissection
Mitral valve prolapse
Spontaneous pneumothorax
List 5 indications for immediate amputation in trauma
Medically unfit for surgery
Crush injury with warm ischemia time >6h
Crush injury with cool ischemia time >12h
Irreparable vascular injury
Complete laceration of sciatic or tibial nerve
List 3 methods of determining if a femoral neck fracture is anatomically-reduced in a young patient
Direct inspection through Smith-Peterson approach
Lowell alignment theory (head-neck should form an “S” on both the AP and lateral views)
Garden compression trabecular index (160 deg on AP and 180 deg on lateral)
List 8 surgical considerations in the management of severe hallux valgus
1st MTP OA?
1st TMT instability/OA?
Sesamoid OA?
Medial eminence prominence?
HVIA <9
DMAA <9
HVA <15
IMA <9
What are 10 risk factors for vision loss in spine surgery?
Male
Diabetes
PVD
Obesity
Preoperative anemia
Long procedure
Perioperative blood loss >1L
Hypotension
Prone positioning
No colloid used during resuscitation
What are the 4 principles of causality?
Strength of the association
Specificity of the association
Temporality
Reversibility
Explain the difference between blinding and concealment of allocation
Blinding: patient, their family, treating team and anyone involved in outcomes assessment is unaware to the intervention performed.
Concealment of allocation: individual who is enrolling participants does not know in advance which study arm each successive patient will be enrolled to.
List 4 indications for hemiresection and interpositional arthroplasty of the DRUJ
Painful arthritis (OA, RA, PTA)
Ulnocarpal impaction with radio-ulnar incongruity
Absence of longitudinal forearm instability
Absence of post-traumatic ulnar subluxation of the carpus
List 6 indications for MRI in juvenile scoliosis
Any child <10 with >20 degree curve
Short, sharp curve
Rapidly progressing curve
Asymmetric abdominal reflex
Upper motor-neuron signs
Associated cavus foot
List 3 risk factors for the development of metastasis in an isolated soft tissue sarcoma
High-grade tumour
Resection with positive margins
Local recurrence
Which 2 muscles are commonly transferred after a proximal humerus resection and endoprosthetic reconstruction?
Pectoralis major
Latissimus dorsi
Which 3 muscles require transfer after a proximal femoral resection and endoprosthetic reconstruction?
Iliopsoas
Short external rotators
Abductors
What % of resected and reconstructed (a) distal femoral and (b) proximal tibial tumours require a medial gastrocs flap for coverage?
(a) 25%
(b) 100%
What’s the overall survival of an endoprosthetic reconstruction at 10 years? Which location has the worst?
85% (worst for proximal tibia, best for proximal humerus)
Which 4 factors facilitate local high-grade sarcoma spread in the shoulder as compared to other joints?
Direct capsular extension
Spread along the LHBT
Fracture hematoma from pathologic fracture
Inappropriately-planned biopsy
If a proximal humerus tumour involves the axillary/brachial artery, what’s the implication?
Brachial plexus is also involved due to proximity to the artery (axillary vein, artery and brachial plexus are all within the axillary sheath), and so this is a contraindication to limb salvage
What are the 2 contraindications to a forequarter amputation?
Chest wall extension
Extension into the posterior triangle of the neck
Optimal position for wrist fusion? What about if bilateral?
10-15 deg extension, slight ulnar deviation.
If bilateral, other side in neutral.
What are the only 2 proven benefits to repair vs. accelerated rehab for achilles ruptures?
Better plantarflexion strength
Earlier return to work
What are the 3 risk factors for wound complications after achilles repair?
Female
Smoker
Steroid use
Rank CRPP, ORIF, RSA, HA for proximal humerus fractures in terms of highest (a) complications, and (b) revision rate
(a) CRPP, RSA, ORIF, HA
(b) ORIF, RSA/HA, CRPP
What are the 3 indications for ankle distraction arthroplasty?
Young patients with post-traumatic arthritis
Congruent joint
>20 degree arc of motion
How much distraction is needed in an ankle distraction arthroplasty?
5mm
What are the 2 predictors of failure in ankle distraction arthroplasty?
Female
<20 degree arc of motion
What’s the diagnosis if you see an athlete with pubic pain and widening/lysis of the symphysis on XR?
Chronic osteitis pubis (due to repetitive pull of the adductors and rectus abdominis on the pubic symphysis)
What’s the diagnosis if a patient presents with abdominal pain that radiates to the groin which is exacerbated by sport and relieved by rest?
Athletic pubalgia (“sports hernia” – tear in abdominal wall)
Which nerve should be neurolysed when doing a repair for athletic pubalgia?
Genital branch of genitofemoral nerve
What is the hip labrum innervated by?
Branches of obturator nerve and nerve to quadratus femoris
By how much (%) does the labrum increase intra-articular contact surface and volume? Without it, how much do femoroacetabular contact pressures increase by?
Surface: 22%
Volume: 33%
Contact pressures: 92%
Has there been any level I/II evidence of better outcomes for labral repair vs. debridement?
Yes, repair is better in females with FAI. However, a recent Philippon JBJS study showed no difference at 10 year follow-up
When are C. diff infections considered community-acquired vs. hospital-acquired?
Community: <48h after admission or >12 weeks after discharge
Hospital: >48h-4 weeks after admission
List 6 risk factors for acquiring C. diff
Age >65
Diabetes
Prolonged hospital admission
Revision surgery
Multiple antibiotic exposure (especially Clinda)
Bowel surgery
What’s the treatment for C. diff collitis (mild, moderate, severe, severe with elevated lactate, recurrence)?
Mild: PO Flagyl
Mod: PO Vanco
Severe: PO Vanco + IV Flagyl
Severe with lactate >5 or WBC >50: subtotal colectomy
Recurrence: Vanco, not Flagyl
What constitutes an acceptable reduction after ORIF of a distal radius?
Radial inclination >15
Volar tilt >15
Radial shortening <2mm
Articular incongruity <2mm
Sigmoid notch incongruity <2mm
Which ACL test has the best sensitivity and specificity?
Sensitivity: Lachman
Specificity: Pivot-shift under EUA
What’s the first pelvic apophysis to appear and when does it ossify?
What’s the last pelvic apophysis to appear and when does it ossify?
First: AIIS (4, 17)
Last: ASIS (17, 25)
What are 3 symptoms of lead toxicity after a retained bullet?
Cramping
Constipation
Seizures
When should you treat lead toxicity with chelation therapy?
Blood levels >0.45 μmol/L
List 6 general risk factors for HO
Male
Previous HO
Multiple surgeries
Closed head injury
Prolonged mechanical ventilation
DISH
In what situation is static progressive splinting used these days?
In patients with severe head injuries to prevent elbow and ankle equinus contractures (ICU)
What’s the average wear rate of HXL-UHMWPE?
At what annual wear rate do you get concerned for osteolysis?
Average: 0.02mm/y
Concern: 0.2mm/y
List 4 ways to measure wear in a THA
Linear wear
Volumetric wear
Dual circle technique
Radiostereometric analysis
How do you determine if a THA is “stable” intraoperatively?
Flexion >90
IR >45 with hip flexed to 90
ER >15 with hip extended
List 3 ways to test for malnourishment and their cutoffs
Albumin <35
WBC < 1.5
Transferrin <20
List 3 intraoperative considerations for obese patients undergoing a TKA
Reverse Trendelenburg is best for ventilation
Computer navigation
Stemmed tibial baseplate
Where is type I collagen found?
Bone, ligaments, sclerae, dentin
What are the spinal manifestations of patients with OI?
Basilar invagination
Scoliosis
Kyphosis
Spondylolisthesis
What are the 4 types of OI, their features and inheritance pattern?
I: mild (blue sclerae, fractures after walking age, mild scoliosis) – AD
II: deadly intra-uterine – AR/spontaneous
III: severe (fractures before walking age, spinal manifestations, dentinogenesis imperfecta, joint instability) – AR/spontaneous
IV: intermediate (less severe form of type III) – AD
What non-operative modality has been shown to reduce fracture rate and prevent scoliosis progression in OI?
Bisphosphonates (if started before age 6)
How do you treat scoliosis in OI?
Bracing doesn’t work; fuse when >45 degrees and consider cement augmentation through fenestrated screws at the most proximal and distal levels
How do you treat basilar invagination that doesn’t reduce with intraoperative traction?
Staged approach (trans-oral decompression followed by occiput-C2 posterior fusion usually 1 week later)
List 5 intraoperative considerations when managing any patient with OI
Difficult airway (large head, short neck)
Gentle transfer to table (fracture risk)
Avoid tourniquet use (fracture risk)
Avoid succinylcholine (can cause fasciculations = fracture risk)
Increased bleeding risk
What are 4 complications of a vascularized fibular transfer in pediatric patients with open physes?
Peroneal nerve injury
Claw toes (FHL)
Syndesmotic instability (consider doing a synostosis for distal harvests)
Ankle valgus deformity (from distal tibial growth arrest)
List 6 complications of halo gravity traction
Pin infection
Skull penetration (don’t use in patients <18 mo)
Cranial nerve VI palsy (lateral gaze)
Brachial plexus palsy
Odontoid AVN
SMA syndrome
Where is the humeral head center of rotation relative to the intramedullary canal?
5mm medial and posterior
What are the 4 red flags for back pain?
Night pain
Constant pain
B symptoms
Back pain in patients <10
What’s the Sorensen criteria for Scheueremann’s kyphosis?
> 5 degree anterior wedging at 3 adjacent levels
45 degree local kyphosis
What’s the typical fusion level in Scheuermann’s kyphosis? When is surgery indicated (4)?
T2-include first lordotic disc
Surgery when:
1. >75 degree kyphosis
2. Pain not managed adequately without surgery
3. Neurologic symptoms
4. Failed conservative treatment
What proportion of vertebral osteomyelitis shows (a) leukocytosis, (b) positive blood cultures, (c) organism identified on biopsy?
(a) half
(b) one third
(c) most
What are the surgical indications for FDP reconstruction?
- failed zone II repair
- supple joint
- no neurovascular injury
- disrupted FDS (can still do it if FDS is intact by releasing FDS insertion on the middle phalanx and repairing it end-to-end to the distal FDP stump, but some people recommend against it since an intact FDS still provides reasonable function).
Describe the general principles of a 2-stage Hunter procedure for a flexor tendon reconstruction
First stage: insert silicon rod in the flexor tendon sheath and reconstruct the pulleys as needed (A2 and A4 most importantly).
Second stage: 3 months later, remove silicon rod and insert tendon graft (palmaris, plantaris)
Describe the Seddon and Sunderland classification of nerve injuries and expected prognosis for each
I: Neurapraxia (full recovery, up to 2 months)
II: Axonotmesis with intact endoneurium (mostly full recovery, 2-4 months)
III: Axonotmesis with disrupted endoneurium (partial recovery, 12 months)
IV: Axonotmesis with disrupted endo- and perineurium and only epineurium intact (poor recovery)
V: Neurotmesis (no recovery)
What tendon transfer is used for a foot drop (peroneal palsy)?
PTT through IOM to the lateral cuneiform (4 incision technique)
List 5 risk factors for failure of bracing in AIS
Male
Suboptimal correction in-brace
Non-compliance
Obesity
Hypokyphotic thoracic curve
List 5 ways to determine appropriateness of humeral implant height
5.6 cm above upper border of pectoralis major
0.8 cm above GT
1 cm below lateral acromial edge
Anatomic reduction of the tuberosities
Measure resected head
Which 3 structures can block reduction of a medial subtalar dislocation? What about lateral?
Medial: EDB, deep peroneal bundle, TN capsule
Lateral: Tib post, but also FHL, FDL, posterior tibial bundle
Where are pediatric trigger fingers most commonly located? What % spontaneously resolve? What’s the treatment if conservative management fails?
Thumb.
50%.
A1 pulley release (if digit other than thumb is involved, A1 pulley release is not adequate since disease involved A3 pulley as well and has multiple nodules in the tendon).
What 5 endocrine abnormalities is polyostotic fibrous dysplasia associated with?
Hyperthyroidism
Hyperprolactinemia
Cushing’s
Hypophosphatemia
Acromegaly
List 5 extra-osseous manifestations of fibrous dysplasia (McCune-Albright and Mazabraud syndrome)
Hyperthyroidism, hyperparathyroidism, precocious puberty, cafe-au-lait spots (M-A syndrome) and intramuscular myxomas (Mazabraud)
What’s the difference between the cafe-au-lait sports in neurofibromatosis vs. McCune-Albright syndrome?
NF1: “coast of California” smooth appearance
M-AS: “cost of Maine” roughened appearance
What is the histological hallmark of fibrous dysplasia?
Inability to produce mature lamellar bone from immature woven bone with “alphabet soup” appearance
What can exacerbate fibrous dysplasia?
Pregnancy (increased number of hormones, and osteoblasts in FD have more hormone receptors)
When are bisphosphonates used in fibrous dysplasia
Polyostotic form
Which bone graft should you use in fibrous dysplasia?
Cortical or cancellous allograft (never autograft)
What are the zones of the physis?
- Trabecular bone zone
- Zone of provisional calcification
- Zone of hypertrophy (weakest)
- Zone of proliferation (entire growth depends on this)
- Resting zone
List 6 factors that can lead to reduced knee extension after ACLR
Cyclops lesion
Arthrofibrosis
Anterior tibial tunnel placement (notch impingement)
Graft tensioning in 30 degrees of flexion
Failed bucket handle meniscal repair
Delayed physiotherapy
List 4 structures that can contribute to a swan-neck deformity in patients with RA
- FDS rupture
- PIP volar plate rupture with dorsal subluxation of lateral bands
- Collateral extensor band rupture (mallet finger)
- Volar subluxation of MCP joint
List 4 malignant transformations of fibrous dysplasia
Osteosarcoma
Chondrosarcoma
MFH
Fibrosarcoma
What are 5 methods to diminish blood loss during spine surgery?
Permissive hypotension (aim for MAP 80)
Acute normovolemic hemodilution
Epidural blockade (vasoconstricts proximally)
TEXA
Electrocautery use
List 6 risk factors for non-therapeutic opioid use
Age <45
History of drug abuse
Family history of drug abuse
Smoker
Pre-operative opioid use
Mental illness
List 4 features of infantile scoliosis that suggests the deformity will progress
Mehta predictors of progression:
1. Cobb angle >20
2. RVAD >20
3. Phase 2 rib
4. Progression >6 degrees/year
What’s the feared complication in an infant with granulomatous vertebral osteomyelitis? What are 6 risk factors?
Buckling collapse (>120 degree kyphosis)
Risk factors:
1. Pre-treatment kyphosis >30 degrees
2. Junctional level
3. Gapping of facet joints
4. Retropulsion of infected vertebra
5. Lateral listhesis
6. Toppling
List 4 radiographic risk factors for progression of infantile Blount’s
Drennan angle >16
Epiphyseal distortion
Langenskiold IV-VI
Progressive varus
List 5 radiographic findings of femoral head AVN in DDH
Delayed development of ossific nucleus
Fragmentation of ossific nucleus
Lateral physeal irregularity
Metaphyseal widening
Varus neck with GT overgrowth
List 5 radiographic findings in pediatric rheumatoid spine
Apophyseal fusion (C2-3 usually)
Dens waist erosion (apple core deformity)
Atlantoaxial instability
Hypoplastic vertebral bodies
Loss of cervical lordosis
List 6 risk factors for non-union in type II odontoid fractures
Age >40
Gapping >1mm
Posterior displacement >5mm
Posterior re-displacement >2mm after start of treatment
Angulation >11 degrees
Comminution
List 4 seronegative spondyloarthropathies
Ankylosing spondylitis
Psoriatic arthritis
Reiter’s sydnrome
Inflammatory bowel disease-associated arthropathy
List 3 reasons to prophylactically pin the contralateral hip in SCFE
SCFE associated with endocrinopathy
Age <10
Obesity (>90%ile)
List 5 pediatric manifestations of Peyronie’s disease
Bent penile erections
Painful erections
Penile plaques
Penile numbness
Decreased penile rigidity
List 5 causes of lower extremity Charcot arthropathy other than diabetes
ETOH
Myelomeningocoele
Syrinx
Syphilis
Spinal cord injury
List 4 compliciations associated with BMP-2 use in spine surgery
Ectopic bone formation
Seroma
Post-operative radiculitis
Carcinogenic
List 3 strategies for safe tourniquet usage for surgeries that are expected to take longer than 2.5 hours
- Use wider cuff
- Let tourniquet down at 2h for 10 minutes, then 10 minute down-times at hourly intervals
- Inflate 75 mmHg >limb occlusion pressure
Does GA or spinal anesthetic have a higher complication rate in TKA, and list 4 complications?
GA (infection, pneumonia, AKI, mortality)
What nerves are blocked by an adductor canal block?
Saphenous
Obturator nerve branches
Medial retinacular branches
Nerve to vastus medialis (motor)
List 4 indications for debridement in isolation for shoulder OA?
Young laborer
Concentric joint
Small osteophytes
<2cm OCDs
List 3 predictors for requiring a THA following a hip arthroscopy?
Older age
<2mm joint space
Microfracture required
What’s a normal talocrural angle?
8-15 degrees (angle between a line perpendicular to the tibial plafond articular surface and a line connecting the malleoli)
What is PDGF approved for in Canada?
Hindfoot fusions
What is the risk of PGDF use?
Carcinogenic with topical form (not with rhPDGF that is used in foot and ankle fusions)
What is BMP approved for in Canada?
Lumbar fusions
Open tibia fractures
What do NSQIP databases measure? Is IRB required to analyse the data?
Pre-operative events
Post-operative events
Comborbidities
30-day morbidity and mortality
IRB is not required since patients are de-identified
What’s the initial non-operative treatment of a UCL injury?
Throwing cessation for 3 months
Elbow strengthening
Mechanics re-structuring
Graduated painless return-to-throwing program
List 5 risk factors for a pediatric VTE
Infection surgery
Hyponatremia
Hematologic disorder
Abnormal PTT
Elevated AST
List 4 downsides of minimalist running vs. shod running (heel-strike)
- Increased gastrosoleus injuries (eccentric contraction as forefoot or midfoot strike the ground)
- Increased base of metatarsal stress fractures
- Higher risk of puncture wounds
- Higher risk of plantar fasciitis
List 2 benefits of minimalist running vs. shod running
- Less patellofemoral pain
- Less joint reactive forces on the hip (center of gravity shifts more centrally)
List 6 negative prognostic factors in TTC nailing
Diabetes
PVD
Previous foot ulcerations
Smoker
Rheumatoid arthritis
Chronic steroid use
The _____ an extra-articular knee deformity is to the knee, the _____ the impact is on alignment
closer, greater
When can you manage an extra articular (a) femoral and (b) tibial deformity simply with soft-tissue balancing and not an extra-articular osteotomy?
Far from the joint line
<20 degree deformity in the femur
<30 degree deformity in the tibia
List 6 clinical features of ankylosing spondylitis
Bilateral sacroiliitis
Inflammatory back pain (>3 months)
Progressive kyphosis (chin-to-chest)
Anterior uveitis
Peripheral joint arthritis
Enthesopathy
How many levels above and below a fracture in ankylosing spondylitis should be included in the fusion?
3
List 2 complications specific to spine surgery in ankylosing spondylitis
Epidural hematoma
Aortic dissection
Which PCL bundle is largest and strongest?
Anterolateral
What’s the position of fusion for D2-5 MCPs and PIPs?
MCPs: start at 25 degrees for D2, then increase by 5
PIPs: start at 40 degrees for D2, then increase by 5
Describe the (a) incision and (b) fixation choice for MCP/PIP fusion
(a) curved incision (allows both MCPs and DIPs to be addressed if needed)
(b) crossed K-wires have a proven track-record
List 4 special considerations when nailing a femur fracture in a patient with OI
- Increased fracture risk
- Non-linear canal due to previous fracture healing
- Atypical femoral bowing (may need to do multiple osteotomies to pass the nail)
- Short limb (may need to use pediatric implants)
List 2 special considerations when performing a THA in a patient with OI
- Acetabular protrusio (may need to either bone graft and use screws vs. cup-cage)
- Cement the femur always
What’s the risk of femoral head AVN in hip dislocation if it was reduced within 6 hours and >6 hours?
<6h: 5%
>6h: 50%
What’s the definition of proximal junctional kyphosis?
> 10 degree Cobb angle and >10 degree change from pre-operative films at the top level of the fusion
List 6 risk factors for PJK
Combined approached
Fusion to sacrum (more rigidity but also worse curve)
Pedicle screws at all levels (increased rigidity)
>5 degree kyphosis at UIV preoperatively
High preoperative pelvic incidence (saggital imbalance)
Osteopenia
List 5 strategies to diminish the risk of PJK
Single approach without disruption of PLC at UIV
Hooks at UIV rather than screws (soft landing)
Strategic use of pedicle screws if all-screw construct
Instrument one level above UIV if >5 degree kyphosis
Osteotomies to correct saggital imbalance
List 5 factors associated with trunnion wear
Larger head
Increased offset
Varus neck
Dissimilar metals
Smaller, more flexible necks
What’s the optimal fixation for C1-C7?
C1: lateral mass screws
C2: pars or intra-laminar screws
C1-2: trans-articular screws (if C1-2 is reduced)
C3-6: lateral mass screws
C7: lateral mass/pedicle screws
List 3 risk factors for navicular stress fractures
Long 2nd metatarsal
Metatarsus adductus
Equinus contracture
What % of patients with chronic (>2 weeks) elbow dislocations will have HO?
75%
List 4 structures that are pathologic in a chronic elbow dislocation
Triceps contracture
Collateral contracture
Capsular contracture
Arthrofibrosis
What’s the best approach for dealing with a chronic elbow dislocation and why?
Medial and lateral paratricipital (Kocher interval extension laterally) since you can transpose the ulnar nerve which is often needed as well as release the collaterals to achieve reduction then repair them
List 3 indications for triceps lengthening in a chronic elbow dislocation
> 3 months
<100 degrees of flexion after other releases performed
5cm overlap between humerus and olecranon on AP
List 3 ways to achieve lengthening of the triceps
Triceps mobilization from distal humerus
Anconeus slide
Triceps V-Y lengthening
What are the 2 indications to perform a supramalleolar osteotomy?
- Asymmetric varus/vaglus deformity with >50% tibiotalar articular surface preserved
- To correct alignment for planned ankle arthrodesis/arthroplasty
List 5 contraindications to a SMO
Hindfoot instability
Age >70
Inflammatory arthritis
Charcot foot
Severe PVD
How can you determine if an ankle asymmetric varus/valgus deformity is originating from within the joint or outside?
If the difference between the *distal tibial plafond angle and **talar articular angle is >4 degrees, it means there’s an intra-articular deformity. If the total amount of varus/valgus deformity on the Saltzman hindfoot alignment view exceeds that value, then there’s also an extra-articular deformity.
*Distal tibial plafond angle is the angle between the anatomic axis of the tibia and the tibial plafond.
**Talar articular angle is the angle between the anatomic axis of the tibia and the talar dome.
Describe the principles behind a SMO for an extra-articular varus deformity (1. where it’s done; 2. what correction you aim for; 3. how you deal with the fibula)
- Medial opening wedge at the CORA for <15 degree correction; medial opening dome osteotomy at the CORA for >15 degree correction.
- Aim for 4 degrees of valgus at the level of the ankle joint (anatomical axis of the tibia to pass just lateral to the center of the ankle joint)
- Fibular osteotomy required if >10 degree correction.
What may need to be done if you’re doing an opening dome SMO for an extra-articular varus deformity?
Lengthening of posteromedial structures
Tarsal tunnel release
Describe the principles behind a SMO for an extra-articular valgus deformity (1. where it’s done; 2. what correction you aim for; 3. how you deal with the fibula)
- Medial closing wedge at the CORA for <15 degree correction; medial closing dome osteotomy at the CORA for >15 degree correction.
- Aim for 4 degrees of varus at the level of the ankle joint.
- Almost always requires a fibular osteotomy.
Which approach is used for a medial wedge vs. dome (opening or closing) osteotomy?
Wedge: medial approach
Dome: anterior approach
List 3 treatment strategies for prevention of PJK
Teriparatide (better than bisphosphonates)
Use hooks at UIV (soft landing)
Cement augmentation at UIV
List 8 risk factors for development of a pseudarthrosis after an attempted spine fusion
Uninstrumented fusion
Multilevel fusion
L5/S1 level
Smoker
Diabetes
Steroid use
NSAIDs
Bisphosphonates
Where’s the location of the anatomic femoral ACL tunnel?
8mm anterior to posterior articular margin
1.7mm proximal to the bifurcate ridge (ridge that divides the AM and PL bundles)
Describe the ossification of the clavicle
Lateral: intramembranous
Medial: endochondral
Is diaphyseal endosteal blood flow centripetal or centrifugal?
Centrifugal in adults (starts of centripetal in paeds)
Describe the course of the MFCx artery
Branch of profunda femoris (75%) or femoral artery proper (25%), runs between psoas and pectineus, then between obturator externus and adductor brevis, then it gives off ascending branch (femoral head), acetabular branch, transverse branch and posteroinferior branch.
What’s a donor artery option for vascularized fibular grafts?
Ascending branch of the LFCx
What two arteries are at risk in a Kocher-Langenbeck approach?
MFCx
Inferior gluteal (supplies GMax; emerges from GSN between piriformis and superior gemellus)
What’s the blood supply to the acetabulum?
Acetabular artery (branch of obturator – supplies the triradiate cartilage)
SGA
IGA
Ischial artery (branch of internal pudendal)
How much bone superior to the acetabulum should be left intact during a PAO to preserve the blood supply?
2-2.5cm
List 1 high-profile medical device failure
DePuy ASR metal-on-metal hip (4 x std revision rate)
List the 4 pertinent findings of the BRAIST trial (bracing vs. observation in AIS patients with 20-40 degree curves between Risser 0-2)
78% of braced didn’t progress past 50 degrees vs. 48%
NNT was 3 to avoid 1 surgery
>13 hrs/d was the threshold for a >90% success
No difference in QOL scores for bracing vs. observation
When is the Providence brace indicated?
TLSO used mostly for lumbar curves (per Dr. Smit)
When is the Rigo brace effective?
Most AIS curves (thee-dimensional curve correction) – can be worn during the day and night
What’s the goal of curve correction when the brace is applied?
About 50%
List 8 contra-indications to participation in strenuous physical activity after a C-spine fracture
Occipital-cervical fusion
C1 ring non-union
C1-2 residual instability
Subaxial instability
Loss of cervical lordosis
Pavlov ratio <0.8 (narrow canal from retropulsed frag.)
3 or more level arthrodesis
Neurological symptoms
What’s the most common site of metastasis in the hand?
Distal phalanges (thumb most commonly)
Where are hand enchondromas usually found?
Proximal phalanges
List 4 local treatment adjuncts after intralesional curettage in GCTs and enchondromas
Phenol
Dehydrated alcohol
PMMA
Liquid nitrogen (can cause skin burns, neuropraxia)
How does MSSA become MRSA?
It gains resistance to b-lactams via 4 types of staphylococcal cassette chromosomes, which allow for transfer of the mecA gene to S. aureus (types I-III cassette chromosomes are associated with hospital-acquired MRSA, while type IV is associated with community-acquired). The mecA gene encodes for a penicillin-binding protein that has a low affinity for b-lactams, hence resulting in resistance.
What are the most common bacteria in septic arthritis in patients <1, 1-5 and >5?
<1: Staph species, GBS
1-5: S. aureus, S. pneumo, Kingella Kingae, H. flu
>5: S aureus, N. ghonorrhea
What’s the Kocher criteria (including CRP)?
Fever
WBC >12
CRP >20
ESR >40
Refusal to weightbear
What’s the diagnostic criteria for juvenile idiopathic arthritis?
Fever >2 weeks
Effusion >6 weeks
25,000-100,000 cells on aspirate
<75% PMNs on aspirate
List 5 factors associated with successful closed reduction in DDH
Appropriate timing (<6 months)
Pre-reduction traction
Medial die pool <5mm
Adductor tenotomy
Maintenance of reduction on post-operative CT
What’s the safe zone for spica casting in DDH?
100 degrees flexion
<55 degrees abduction
How can you growth modulate a coxa valga?
Single screw inserted just below the GT aiming for the inferior 1/3 of the femoral head epiphysis
Define toughness
Area under the stress-strain curve
What’s the optimal % screw density for a bridge plate?
50%
Compared to patients <80 yo undergoing THA/TKA, what risks are patients >80 subject to?
3 x higher risk of MI, pneumonia and death. However, no correlation between ASA score and postoperative complications in this age group.
What’s the pedicle for a medial gastrocnemius flap?
Medial sural artery
Describe the posterior approach to the knee
- S-shaped incision over popliteal fossa (extend along LHBT proximally, and along semiT distally)
- Find medial sural cutaneous nerve, then incise deep fascia and follow it to the tibial nerve
- In the fossa, the tibial nerve is most superficial and the popliteal artery is the deepest
- Retract the bundle laterally off the capsule (may need to ligate superior medial and middle geniculates)
- Retract medial head of gastrocs medially (may need to release off the femur)
What’s the best flap?
1. small tibial tubercle/patellar tendon defect (anterior distal knee)
2. moderate patellar/suprapatellar defect (anterior proximal knee)
3. large suprapatellar defect
4. large, complex defect
- Medial gastrocs flap (medial sural artery)
- Vastus lateralis flap (descending branch of LFCx, lateral superior geniculate)
- ALT (anterolateral thigh) fasciocutaneous flap, which can be combined with a cuff of vastus lateralis (descending branch of LFCx, lateral superior geniculate)
- Latissimus dorsi free flap (donor = thoracodorsal; recipient = descending geniculate)
What’s the % risk of vascular compromise in a free flap?
20%
What’s an optimal cast index for distal radius fractures and how is it calculated?
<0.84 (internal width of the cast on the lateral XR/internal width of the cast on the AP at the level of the fracture)
List 5 indications for surgery in radius fractures in kids
Failure to achieve acceptable closed reduction
Loss of reduction at follow-up
Open fracture
Associated vascular injury or compartment syndrome
Floating elbow
Where is the entry point for a radius TEN?
Between 1st and 2nd extensor compartments proximal to the physis
What’s the difference in time to union, blood loss, time in hospital and early ROM in TENs vs. ORIF for BBFFs?
No difference in time to union, blood loss or admission time; ORIF however allows early ROM, no immobilization (TENs require 3-4 weeks in cast) and anatomic reduction.
What’s the most common site of facet joint cysts and what’s the pathophysiology?
L4-5 (DDD results in loss of disc height, which increases the stresses on the facet joints and add on to that L4-5 degenerative spondylolisthesis due to facet joint orientation at this level results in a stretched out facet joint capsule and cyst formation)
What’s the recurrence rate after surgery for a lumbar facet cyst?
<2% for decompression alone and 0% for decompression with fusion
What are the 3 patterns of congenital spinal stenosis?
- Short pedicles (decreased AP space)
- Flat laminae (decreases transverse spacpe)
- Global (combined)
What’s the best clinical outcome measure for lumbar spinal stenosis?
Oswestry Disability Index
What are the transfers for a wrist drop?
PL to EPL
FCR to EDC
Pronator teres to ECRB
Describe where the thumb UCL originates and inserts
Proximal-dorsal metacarpal to distal-volar proximal phalanx
What indicates a grade 3 UCL thumb tear?
Absolute laxity of >35 degrees or >15 degree laxity compared to the other side
List 2 indications for surgery in a Stener lesion
- Soft tissue Stener >3mm displaced
- Bony avulsion Stener
List 5 risk factors for patellar tendinosis
Fat
Flat foot
Frail quads
inFlexible quads
LLD
When doing the distraction method for pelvic discontinuity, when do you know you’ve reamed enough?
How much bigger should the acetabular component be than what you reamed?
Reamed enough when you have AS and PI contact.
6-8mm bigger.
List 2 radiographic measurements for scapulothoracic dissociation
- Scapular distance >1cm (medial border to spinous processes)
- Scapular distance ratio >1.29 (injured:uninjured)
What’s the rate of limb-threatening ischemia in scapulothoracic dissociation? How about mortality?
10%
10%
What are the principles behind the Zelle classification for scapulothoracic dissociation?
Injury progresses from pure MSK injury, to MSK and vascular injury, to those plus post-ganglionic nerve injury to those plus plexus avulsion and Horner’s syndrome.
What’s the best imaging modality for a pre- and post-ganglionic injury?
Pre-ganglionic: CT myelogram
Post-ganglionic: MRI
List 5 ways to determine appropriate joint height in a revision TKA
15mm above fibular head
25mm below lateral epicondyle
30mm below medial epicondyle
40mm below adductor tubercle
at the level of the inferior patellar pole with knee at 90
What are the 8 main dorsal wrist arthroscopy portals? List 1 danger for each.
3,4 - EPL
4,5 - EDC
Radial midcarpal (just distal to 3,4) - EDC
Ulnar midcarpal (just distal to 4,5) - EDC
6R (radial side of 6th compartment) - DSBUN
6U (ulnar side of 6th compartment) - DSBUN
1,2 - Radial artery
STT - Radial artery
List 5 negative prognostic factors in a patient with DDH undergoing a PAO
Tonnis grade 3
LCEA <0
<10 degrees of acetabular anteversion
Asymmetric femoral head
Os acetabuli
Which is worse, CA-MRSA or HA-MRSA? How can they be differentiated?
CA-MRSA is much worse.
CA-MRSA can be differentiated by:
1. Genetic elements (type IV cassette chromosome)
2. Presence of virulent exotoxins (PVL)
3. Absence of multi-drug resistance
List the 4 Boston criteria for predicting chance of MRSA infection in pediatrics
Fever
WBC >12
CRP >13
Hct <34%
How is conventional radiation therapy given?
3 Gy x 10 fractions
What are the 3 terminal branches of the tibial nerve?
Medial plantar
Lateral plantar
Calcaneal
Where does the medial plantar nerve run and what does it innervate?
Between abductor hallucis and FDB.
Motor supply to abductor hallucis, FDB, FHB, and 1st lumbrical.
Where does the lateral plantar nerve run and what does it innervate?
Between FDB and quadratus plantae.
Motor to quadratus plantae, flexor digiti minimi, abductor digiti minimi, lateral 3 lumbricals, interossei and adductor hallucis
What is Jogger’s foot and what’s the surgical treatment if non-surgical management fails?
Medial plantar nerve compression.
Treatment is release of abductor hallucis fascia from its origin to the Knot of Henry.
Describe 3 differences between Baxter neuropathy vs. plantar fasciitis
Radiation to medial ankle and across lateral foot
Exacerbation with activity and improvement with rest
Exacerbated with foot eversion and abduction
What’s the surgical treatment of Baxter neuropathy if non-surgical management fails?
Release of abductor hallucis fascia, then follow nerve distally and release FDB fascia if it’s tethering it
What’s soleal sling syndrome?
Compression of tibial nerve proximally in the calf deep to the fascial sling of the soleus
List 3 indications for delaying surgery in patients with ESRD on dialysis?
K >5.5
pH <7.25
Hypervolemia
List the attachments of tibialis posterior
navicular, medial, middle, lateral cuneiforms, cuboid, metatarsals 2-4, sustentaculum
List the (7) attachments of semimembranosus
posteromedial tibia, OPL, POL, popliteus fascia, medial head of gastrocs, posteromedial capsule, sMCL
List 4 transfers to restore elbow flexion in a musculocutaneous nerve palsy
Clark’s pec major to biceps tendon transfer
Lat dorsi to biceps tendon transfer
Triceps to biceps transfer
Steindler flexorplasty
List two transfers to restore elbow extension in a high radial nerve palsy
Deltoid or lat dorsi to triceps
List the transfer indicated in a low median nerve palsy
Abductor pollicis brevis is affected (thumb opposition), so the transfer is D4 FDS to APB tendon
List the two transfers indicated in a high median nerve palsy
BR to FPL
D4/5 FDP side-to-side transfer to D2/3 FDP
List the three transfers in an ulnar nerve palsy
D4 FDS to adductor pollicis (thumb adduction)
APL to 1st dorsal interosseous (index abduction)
D3 FDS to lateral bands of D4/5 (reverses clawing)
What’s the usual critical segmental bone defect?
> 50% cortex width or >2cm loss
What’s the management of a bone defect of size:
a) <2 cm
b) 2-5 cm
c) 5-10 cm
d) >10 cm
a) Acute shortening with secondary lengthening if needed
b) ICBG (20 cc/side)
c) Masquelet with RIA (40cc/femur) and allograft vs. distraction osteogenesis (1 cm/month defect)
d) Masquelet, vascularized fibula, amputation
What’s the optimal ratio of allograft:autograft for a Masquelet?
<3:1
How proximal and how distal can you harvest a vascularized fibula?
4cm from fibular head to 6cm from ankle joint
What (2) factors differentiate SED from MED?
Basically the same presentation, except:
1. scoliosis and vertebral body abnormalities
2. COL2A gene
List 3 considerations when planning a THA in a patient with MED
- Small, shallow acetabulum
- Modular implants needed (meta-dia mismatch)
- HO prophylaxis (larger exposure needed)
What’s the only spasmolytic agent used in conscious sedation? What’s its mechanism?
Benzodiazepines (midazolam)
GABA agonist
What’s ketamine’s mechanism? When is ketamine contraindicated?
Mechanism: NMDA antagonist (threshold-dependent, not dose-dependent)
Contraindicated in uncontrolled HTN or CAD
What’s propofol’s mechanism?
GABA agonist
Why is fractionation important in radiation therapy?
4 “R’s”:
1. Repair
2. Reoxygenation (radiation damage relies on free radical formation)
3. Redistribution (to G2 cell cycle when cells are most vulnerable)
4. Repopulation of tumor cells (with rapidly-dividing cells that are vulnerable)
List 4 pros and 3 cons of neoadjuvant radiation vs. adjuvant
Pros: shrinks tumor (can make it operable), less risk of positive margins, less risk of tumor seeding during surgery, lower dose than adjuvant (50 Gy divided over 5 weeks vs. 60 Gy).
Cons: delays wound healing, risk of wound complications, more difficult for pathologist to examine margins
What’s the usual radiation protocol following surgical stabilization in a metastasis?
Single 8 Gy dose
List 5 indications for replantation
Thumb
Single digit distal to FDS
Multiple digits
Proximal to mid-palm
Any pediatric amputation
List the order of soft tissue repair in a replant
- extensor tendon
- flexor tendon
- arteries
- veins
- nerves
What are the 3 intraoperative options for poor venous outflow in a replant?
Remove nailbed and perform heparin swabs hourly
Leave lateral incisions to close by secondary intention
Leeches (need to cover with TMP-SMX)
List 5 important postoperative management principles following a replant
Keep limb elevated
Keep limb warm for 24h (heat lamps, room temp)
Keep patient NPO in case you need to return to OR
Adequate analgesia to prevent vasoconstriction
Maintain high rate of IV fluids
Describe the rehabilitation protocol following a replant
5 days: ROM of adjacent digits, tenodesis effect
2 weeks: intrinsic plus (wrist extended, MCPs flexed, IPs extended) and minus (wrist neutral, MCPs extended, IPs flexed) exercises
4 weeks: ROM with wrist at neutral
6 weeks: gentle functional ROM
8 weeks: resistance exercises
12 weeks: job simulation exercises
List 8 negative prognostic factors in ORIF of calcaneus fractures
Male
>50 yo
Manual laborer
Worker’s compensation
Smoker
Bilateral
Obesity
Sanders IV
List 5 indications for surgery in calcaneus fractures
Large, displaced extra-articular fractures
Tongue-type
Calcaneal tuberosity avulsion
Intra-articular displacement >2mm
Sanders II-III with flat Bohler’s angle (normally 20-40)
List cobal-chrome, cancellous bone, cortical bone, PMMA, titanium, steel, cermaic and polyethylene in terms of Young’s modulus (high to low)
Cermic, Co-Cr, steel, titanium, cortical bone, PMMA, poly, cancellous bone
List the 7 poor prognostic signs for hip survival following acetabular fracture surgery
Age >40
Associated hip dislocation
Initial displacement >2cm
Posterior wall fracture
Femoral head injury
Marginal impaction
Non-anatomic reduction
When do the following bones ossify/fuse and where does the growth of that bone occur?
a) clavicle
b) proximal humerus
a) central clavicle ossifies at 5 weeks gestation, medial and lateral ossify at 18 and fuse at 25; 80% growth from medial epiphysis
b) epiphysis ossifies at 6 mo, GT at 2 and LT at 4 yrs and fuse at skeletal maturity; 80% of growth of the humerus is from the proximal epiphysis
What’s the closed reduction maneuver for pediatric proximal humerus fractures?
Longitudinal traction
Abduction to 90 deg
ER
What are the (5) static stabilizers of the SC joint?
Posterior SC ligament (strongest)
Anterior SC ligament
Costoclavicular ligament
Interclavicular ligament
Intra-articular disk ligament
Which muscles attach to the clavicle (6)?
Sternocleidomastoid
Sternohyoid
Subclavius
Pectoralis major
Deltoid
Trapezius
Which muscles attach to the scapula (17)?
Supraspinatus
Infraspinatus
Subscapularis
Teres minor
Teres major
Rhomboid major
Rhomboid minor
Triceps (long head)
Deltoid
Biceps
Coracobrachialis
Pectoralis minor
Trapezius
Levator scapulae
Omohyoid
Serratus anterior
Serratus posterior
What’s the closest neurovascular structure to the SC joint?
Brachiocephalic vein
How do you do a Rockwood (serendipity) view?
40 degrees angled up with both clavicles in view
What’s the expected grip strength compared to normal in a single ray resection of the hand?
80%
When is radiation risk from routine diagnostic procedures no longer a concern during pregnancy?
After 17 weeks
What imaging studies are absolutely contraindicated in pregnancy before 17 weeks?
Gadolinium studies (iodine is safe)
CT pelvis
*N.B. CXR, CT head and of the extremities is safe
List (5) ways that fetal radiation can be decreased during CT use?
Uterine shielding
Limit scanned areas
Lower voltage
Reduce magnification
Wider beam collimation
What is the sole predictor of pain at 24h postop from an ACLR?
Anxiety
What are the 2 most important factors influencing adherence to rehabilitation following ACLR in a) kids, and b) adults?
a) strong athletic identity, desire to return to sport
b) social support, self-motivation
What’s the most sensitive and specific test for syndesmotic injury?
Sensitive: ATFL tenderness
Specific: squeeze test
List 3 radiographic findings of syndesmotic injury
Tib-fib clear space >6mm at 1cm above the joint on AP/Lat
Tib-fib overlap <6mm at 1cm above the joint on AP
Medial clear space >5mm
What perpetuates the DIP flexion deformity in a non-operatively managed Seymour fracture?
- Differential insertion of extensors (epiphysis) and flexors (metaphysis)
- Interposition of tissue at the fracture site (nail germinal matrix usually)
What’s a Kaplan lesion?
Irreducible dorsal MCP dislocation where the metacarpal head button-holes volarly and the volar plate is interposed between the proximal phalanx and the metacarpal head
Which approach do you use for an irreducible MCP dislocation?
Dorsal dislocation: volar approach (release A1 pulley to expose volar plate)
Volar dislocation: dorsal approach (split extensor tendon to expose joint, push/split volar plate to remove it from the joint
What’s the reduction maneuver for an MCP dislocation?
- Flex wrist to de-tension flexors
- Direct pressure to proximal phalanx base
- Avoid longitudinal traction/extension (may displace volar plate into the joint and turn a simple dislocation into a complex one that need surgery)
What’s the interposed structure in an irreducible open vs. closed dorsal PIP dislocation? What approach do you use to get it reduced?
Closed: volar plate
Open: dislocated FDP tendon
Approach: dorsal, between central slip and lateral band
What are the deforming forces acting on a base of thumb fracture?
APL
EPL
Adductor pollicis
What’s the reduction maneuver in a Bennett fracture?
Traction
Extension
Pronation
Abduction
Which 7 ligaments stabilize the 1st CMC joint?
superficial volar oblique
deep volar oblique
posterior oblique
dorsoradial (primary restraint to dorsal subluxation; treatment of an unstable 1st CMC dislocation requires reconstruction of this ligament and pinning)
ulnar collateral
intermetacarpal
dorsal intermetacarpal
List the 3 indications required for limb lengthening with/without contralateral epiphysiodesis in PFFD
Aitken A/B
>50% femur remaining
<20cm predicted LLD at maturity
When is a knee arthrodesis and foot ablation indicated in PFFD vs. Van Ness rotationplasty?
Van Ness:
1. ipsilateral foot at the level of contralateral knee
2. Aitken C/D
3. >60 degrees ankle ROM
Knee fusion and foot ablation when ipsilateral foot is proximal to contralateral knee.
What’s the order of closure of the distal tibial physis?
Central, posterior, medial, anterior
List 5 challenges when trying to brace a child for early onset scoliosis
Larger abdomen
cylindrical body habitus
more pliable ribs
difficulty remaining still during molding
non-compliance with brace wear
List 3 factors associated with resolution of early-onset scoliosis following serial casting
- Initiation of treatment <20 months
- Curve <60 degrees
- Treatment for >1 year
What are 2 radiographic differences between granulomatous and pyogenic osteomyelitis?
- Granulomatous spares the disks
- Granulomatous can form thin-walled abscesses
What’s the order of surgical intervention in the lower extremity if the patient has multiple arthritic joints?
Forefoot
Hip
Knee
Hindfoot
Ankle
*Deal with most symptomatic first in reality
What are the only 3 medication/classes of medications that you need to hold for surgery in RA?
Sulfasalazine
Leflunomide
TNF-a inhibitors (Remicaide, Enbrel)
*Hold for 4 half-lives pre-op and resume 3 weeks post-op
List 5 factors associated with bisphosphonate-associated femur fractures
transverse fracture line laterally
no comminution
long medial spike
lateral beaking
increased femoral cortical thickness
Where does the artery of Adamkiewicz run?
Left side between T9 and T12
What’s the cutoff for metal ion levels?
> 7 ppb is abnormal
What’s TEXA’s mechanism of action?
Reversibly binds plasminogen’s binding site on fibrin, thereby inhibiting clot degradation by plasmin
How much hotter is an early Charcot joint compared to the other uninvovled side?
3.3 degrees
What do you need to do after reducing an inferior shoulder dislocation?
Brachial-brachial index (<0.95 is abnormal)
List 8 risk factors for synostosis after ORIF of a radius/ulna fracture
head injury
blast injury
proximal fracture (close to PRUJ)
both bones fractured at the same level
fracture fragments in the IOM
single incision
failure to restore radial bow
long screws that breach into IOM
What’s the normal radial bow and how do you measure it?
- Draw a line from the radial tuberosity to the ulnar articular margin of the distal radius
- Maximal radial bow is 60% of the distance of this line from proximal
- Bow is 10% the length of this line as measured from this line (radial bow)
List 4 blocks to radial head reduction in a Monteggia fracture
Annular ligament
Biceps
Capsule
PIN
How do you pin the radius/ulna if you need to, such as in an acute DRUJ instability or Essex-Lopresti injury?
neutral forearm rotation
pin radial to ulnar (protect superficial radial nerve)
What’s the rate of associated femoral neck fracture in a femoral shaft fracture?
10%
What’s the rate of associated Hoffa fragment in a distal femur fracture?
40% (usually lateral condyle)
What’s the blood supply to the talus?
- Posterior tibial artery
-Tarsal canal branch = main supply to talar body
-Deltoid branch = supplies medial talar body - Anterior tibial = talar head/neck
- Artery of tarsal sinus = talar head/neck
What 3 steps do you need to take when faced with a bisphosphonate fracture?
Endocrinology consult
Image contralateral leg
Consider starting Teraparatide
When is retroperitoneal pelvic packing indicated?
How is it done?
What if the patient is still unstable after?
Indicated in a hemodynamically unstable pelvic fracture that remains unstable after a binder is applied as an alternative to angiography since most bleeding is from the presacral venous plexus anyway.
Pfannenstiel incision, incise rectus longitudinally at the linea alba, bluntly dissect the plane between the peritoneum and the bony pelvis and insert 3 sponges/side towards the SI joints. Close. Remove sponges in 24-48h when patient stabilizes.
If patient remains unstable after packing and external fixation, send for angiography.
List 3 contraindications to inserting a foley in pelvic trauma
blood at the meatus
perineal bruising
high-riding prostate
If present, do a retrograde cystourethrogram
How do you do a retrograde cystourethrogram?
Insert a small foley into the meatus, inflate and inject 25 cc of dye. Then, take an AP pelvis and if no contrast extravasation, deflate the baloon and advance all the way. Final step is to obtain a cystogram with 400 cc of dye and shoot another AP to rule out a bladder rupture, then evacuate the bladder and take a final AP to rule out an occult extraperitoneal rupture.
List 5 ways to differentiate a congenital radial head dislocation from a traumatic one?
bilateral
convex radial head
hypoplastic capitellum
irreducible
atraumatic history
List 3 angles you look at in flat foot and what’s normal for each?
Meary’s angle (0-10 degrees)
Calcaneal pitch (15-20 degrees)
Talonavicular uncoverage (<40%)
How much of the humerus can be plated through a lateral triceps slide approach (a) with, and (b) without mobilization of the radial nerve and reflecting the triceps medially?
(a) 55%
(b) 94%
What’s a normal:
a) SL angle
b) Radiolunate angle
c) Capitolunate angle
a) 40-60 (<40 = VISI; >60 = DISI)
b) 0-15
c) 0-15
Where is the PUDA located? What’s the normal value? What’s the effect of changing the PUDA on elbow ROM?
PUDA is 5.7 degrees, located 47mm distal to the olecranon tip.
Increasing the PUDA results in decreased elbow extension. The PUDA however doesn’t affect elbow flexion.
List 5 factors associated with an unstable patient requiring a DCO approach
Lactate >2.5
SBP <90
Temp <33
Platelets <90
PaO2/FiO2 <300
List 5 features in the paediatric C-spine that are different than in the adult
Pseudosubluxation (C2-3 usually)
C1 can override C2
Hypolordosis
Anterior angulation of odontoid
Wedge-shaped vertebral bodies
What is Swischuk’s line?
Line drawn along the anterior border of the posterior arches from C1 to C3. The anterior border of the posterior arch of C2 should be within 1.5 mm of this for it to be pseudosubluxation.
What’s the procedure indicated for a flexible equinovarus foot in CP?
If driven by tibialis posterior, transfer plantar half of tendon around the fibula to peroneus brevis and lengthen Achilles (hoke vs. Strayer).
If driven by tibialis anterior, treatment is Rancho procedure (tib post lengthening above MM, split tibialis anterior transfer to cuboid) and Achilles lengthening.
What’s the procedure indicated for a flexible equinovalgus foot in CP?
Evans, Achilles lengthening +/- plantar closing wedge osteotomy of medial cuneiform for residual forefoot supination.
What special test is helpful to determine if the equinovarus is driven by tib ant in CP?
Confusion test (co-contraction of tib ant with resisted hip flexion)
How do you lengthen the hamstrings if needed in CP?
Medial tendon Z-lengthening (ST, gracilis)
Lateral intra-muscular fascial release, like a Strayer (biceps femoris long head, SM)
List 5 anatomical causes of thoracic outlet syndrome
Cervical rib
Scapular ptosis (from trapezius palsy)
Obesity
Large breasts
Clavicle/first rib malunion
Which bug do you need to cover against in fresh water open injuries and what do you use? Which antibiotic do you use for salt water?
Fresh: aeromonas hydrophilus; cover with cipro (fluoroquinolones)
Salt: doxycyline and ceftazidime (or cipro)
List 8 signs of denervation (ulnar neuropathy, CTS, etc.) on a NCS
Distal sensory c >3 ms
Distal motor latency >4 ms
Nerve conduction velocity <50 m/s
Sharp waves
Fibrillations (spontaneous discharge from single muscle fiber)
Fasciculations (spontaneous discharge from multiple fibers)
Complex repetitive discharges
Myokimic disharges
List 7 factors associated with early mortality after a hip fracture
Male
Age >85
Dementia
Reduced mobility prior to fracture
ASA status
2 or more comorbidities (especially renal failure)
Delay >48h
List 5 factors associated with femoral neck fracture following a resurfacing arthroplasty
Female (small neck)
Metaphyseal cysts
Notching
Varus positioning (<130 degrees)
Improper prosthesis seating
List 5 criteria for selective thoracic fusion in AIS
Lenke 1C, 2C curves
Thoracic prominence > lumbar on Adams FBT
Lifestyle factors (dancer, athlete requiring lumbar ROM)
Skeletally mature
Absence of hyperlaxity (if you selectively fuse in this case, can make the T/L-L curve worse due to the “adding on” effect)
What infections are patients with ankylosing spondylitis more susceptible to?
Klebsiella pneumoniae synovitis
List 5 factors during hallux valgus surgery that can result in hallux varus
excessive lateral release
resection of the fibular sesamoid
medial plication
excessive medial eminence resection
overcorrection of the IMA
List 6 causes of acquired coxa vara
Fracture
Malunion
Infection
Perthes
SCFE
Fibrous dysplasia or Paget’s
List 6 negative prognostic signs for septic arthritis
Paediatric (age <6 months)
Delay in presentation >4 days
Polyarticular
Hip involvement
Associated osteomyelitis
High-virulence organism
List 5 medications associated with osteoporosis
corticosteroids
phenytoin
SSRIs
lasix
antiretrovirals
Where do you do a biopsy for the following locations?
1. wrist
2. distal humerus
3. proximal humerus
4. iliac crest
5. supraacetabular region
6. femoral neck/head
7. distal femur
8. tibia
9. internal pelvis
- 2nd dorsal compartment
- brachialis
- anterior deltoid
- superior abductors
- TFL and rectus femoris
- trans-trochanteric
- posteromedial vastus medialis or posterolateral vastus lateralis
- subcutaneous border
- pfannensteil incision, work along the pubic brim either medial or lateral to external iliac vessels
What approach has the highest risk of early aseptic femoral component loosening in THA?
DAA
What were the findings of the Kreder RCT on early vs. delayed WB for unstable ankle fractures (no syndesmotic injury, <25% posterior malleolus)?
- better early (<3 months) ROM and functional outcome scores, but this did not correlate to earlier RTW time
2 increased rate of hardware removal in delayed WB (perhaps early WB decreases scarring and sensitivity around the plate)
Which 5 factors are associated with failure of initial I&D in a septic native knee?
Male
Advanced age
Multiple comorbidities
Joint aspirate culture-positive
Open I&D (instead of arthroscopic)
In THA and TKA, is there a difference between IV and PO TEXA?
No, equivalent outcomes for 2g PO given 2 hrs prior to incision vs. 1g IV given immediately before incision.
After what age does THA become more cost-effective than ORIF for femoral neck fractures?
54 for no comorbidities
47 with mild comorbidties
44 for severe comorbidities
What percentage of fluid, soft-tissue and explant specimen cultures are positive in a revision TSA for an infection?
Soft-tissue: 66%
Explant: 55%
Fluid: 32%
Men have higher p. acnes load.
Which 5 factors are predictive of having a pseudotumor?
female
vertical cup
femoral osteolysis
acetabular osteolysis
acetabular loosening
Which 2 factors are predictive of not having a pseudotumor?
acetabular anteversion >5 degrees
heterotopic ossification
How do you culture p. acnes?
Hold cultures for 3 weeks in blood/Brucella/chocolate agar and brain-heart infusion broth
What did the 2017 RCT comparing TBW and plate ORIF for simple, displaced olecranon fractures show?
- no difference in outcomes
- equal cost despite higher initial cost in plate group
- more complications overall in the TBW group, but if hardware removal was excluded, plates had more complications (from infection)
What are 5 risk factors for malignant transformation of an osteochondroma?
pain
surface irregularity
continued growth after skeletal maturity
cartilage cap thickness >2 cm
osteochondroma size >5 cm
When are UBCs considered active vs latent?
Active when within 1 cm of the physis, latent when they progress to a diaphyseal location
Which 3 tumors often have secondary ABCs?
GCT
chondroblastoma
UBC
Which 2 benign tumors can metastasize to the lungs?
GCT
chondroblastoma
List 5 poor prognostic factors applicable to both osteosarcoma and Ewing’s
Metastases
Large lesion
Tumor necrosis <90% after neoadjuvant chemotherapy
Elevated LDH
Inadequate margins following resection
What are 5 important findings in the recent JBJS study comparing bilateral THAs under a single anesthetic vs a staged approach?
- shorter total length of stay and more cost-effective
- shorter total surgical time
- no difference in transfusion rate (intra-op recovery excluded)
- no difference in the rate of DVT/PE or complications
- ASA 1-3 not predictive of complications
What has been shown to improve fusion rates in osteoporotic patients undergoing PSIF?
Weekly Teriparatide infusions for 6 months post-operatively
What’s the best imaging modality for pseudotumor?
MARS MRI (or ultrasound if contraindications)
What serum values of vitamin D define insufficiency?
<20 ng/mL
What’s lab tests should you order for vitamin D deficiency?
25-hydroxyvitamin D (decreased)
PTH (increased)
Calcium
Which 3 muscles deform a Bennett fracture?
EPL (extension)
APL (abduction)
Adductor pollicis longus (supination)
List 3 strategies for preventing CRPS prior to surgery
Local anesthetic infiltration prior to incision
Vitamin C 500mg daily for 50 days
Gabapentin
List 3 medications with good evidence in the treatment of CRPS
Bisphosphonates
Gabapentin
TCAs
List 4 indications for ligament reconstruction instead of Brostrom repair
Attenuated ligaments
Failed initial repair
Obesity
Generalized ligamentous laxity
What did the HULC RCT on single- vs dual-incision DBTR show?
10% better flexion strength in dual-incision
More early LABCN palsy in single-incision
What are the 3 most common neuropraxias after an extension-type SCH #?
AIN
Median
Radial
Does MED or SED have atlantoaxial instability? List 3 other syndromes with AA instability
SED
Morquio’s
Pseudoachondroplasia
Down’s
List 3 factors associated with favorable wound healing in diabetic foot
TcO2 >30
Toe pressure >40
Triphasic flow
After how much of a platelet drop do you start a work-up for HIT?
> 50%
Where can you best appreciate atrophy from ulnar neuropathy?
1st dorsal interosseous
List 3 special signs for ulnar neuropathy
Wartenberg sign: D5 abducts when patient is asked to keep fingers adducted due to unnoposed abduction of abductor digiti quinti (weak parlmar interossei).
Froment’s sign: thumb IP joint flexes on attempted key pinch due to FPL compensating for weak adductor pollicis.
Jeanne sign: MCP hyperextends during attempted key pinch from EPL pull.
List 6 negative prognosticators following calcaneus fractures
Male
Smoker
WSIB
Heavy manual labourer
Sanders IV
Negative Bohler’s angle
What were the 2 pertinent findings of the RCT comparing ORIF to circular fixator for bicondylar tibial plateau fractures?
Shorter hospital stay in the fixator group
Less complications in the fixator group
What were the 2 pertinent findings of the interTAN vs DHS study in geriatric hip fractures?
No difference in outcomes
Less femoral shortening in interTAN group
What are 3 important findings of the RCT comparing wrist fusion to arthroplasty?
No difference in outcomes
Less complications in fusion
Fewer revisions in fusion
Describe the general principles behind the accelerated rehab protocol for Achilles ruptures
0-2 weeks: NWB in plantarflexion slab
2-4 weeks: PWB with 2 cm heel lift in Aircast
4-6 weeks: WBAT with 2 cm heel lift in Aircast
6-8 weeks: WBAT without heel lift in Aircast, start PT
8-12 weeks: wean Aircast, progress PT
>12 weeks: strengthening and endurance training
What’s the difference between a neurofibroma and schwannoma when it comes to surgical excision?
Neurofibroma requires excision of the nerve
Which nerve fibers transmit proprioception?
Pacini corpuscles (“P” for proprioception)
What is the hypervirulent strain of C. diff and what does it cause?
NAP1 (resistant to fluoroquinolones)
What’s the 6-month rate of mortality in patients who develop C. diff after a hip fracture vs those who do not?
35% (vs 9%)
What’s the most common complication following non-surgical management of a distal radius fracture in the elderly?
Median neuropathy
List 3 risk factors for pelvic discontinuity after THA
female
rheumatoid
previous radiation
List 6 risk factors for transfusion in spine surgery
longer surgery
>6 levels
Cobb >50
osteotomies
lower body weight (smaller reserve)
neuromuscular
List 5 downsides of the gap balancing method in TKA
- jointline elevation
- excessive flexion gap with PCL recession
- midflexion instability
- altered center of rotation
- altered patellar biomechanics (contact force increased by 60% for every 1 mm of jointline elevation)
What’s the best view to identify a post-partum symphyseal rupture?
Flamingo single-leg stance view (>5 mm vertical translation = instability)
List 3 initial options for peristent wound drainage >72 hours following TKA
limit physiotherapy for 24 h
NPWT for 24 h (good RCT evidence in trauma literature)
hold anticoagulation for 24 h
What does the gull sign predict?
inadequate reduction after ORIF
early loss of reduction after ORIF
progression to THA
What are 5 special considerations when planning for surgery in a patient with Parkinson’s disease?
- avoid traditional inhalational anesthetics (interact with levodopa)
- risk of hypotension (due to levodopa)
- risk of delirium
- risk of aspiration
- risk of urinary retention
What’s the primary source of failure in TEAs?
Bushing wear (from the link)
List 4 radiographic signs of crankshaft phenomenon
RVAD >20
Cobb angle change >10 degrees
>5 degrees apical rotation
Vertebral body penetration into the chest on axial CT
What does the recurrent motor branch of the median nerve supply?
APB
Opponens pollicis
FPB
What forms the superficial palmar arch?
Ulnar artery
Superficial palmar branch of radial artery
List 3 risk factors for displacement after a distal radius fracture
Age
Metaphyseal comminution
Radial shortening (ulnar variance)
List 5 sugical risk factors for periprosthetic fracture in a TKA
anterior notching
inadvertent perforation with the canal finder
eccentric box cut
malpositioned im plants
aggressive impaction of trial components
What’s the most important predictor for interprosthetic fracture (between THA and TKA)?
decreased femoral cortical thickness
When is open rotator interval plication beneficial over arthroscopic?
Arthroscopic: better for anterior instability
Open: better for posterior and inferior instability
List the 4 components of the WOMAC
pain
stiffness
function
global score
List 4 risk factors for SMA syndrome
2-stage procedure
Lumbar modifier B or C
Low BMI
Stiff thoracic curve
List 3 radiographic risk factors for SCFE
Coxa vara
Posteror sloped physis >12 degrees (on FLL)
Retroverted femoral head
List 4 things that change in muscles undergoing endurance training
increased capillaries
increased number of mitochondria
increased mitochondrial size
increased muscle glycogen content
List 5 factors associated with a poor prognosis in pediatric radial neck fractures
angulation >30 degrees
complete displacement
older age
delayed presentation
ORIF
List 7 ways to prevent overstuffing in a radial head arthroplasty
- template off resected head
- template off contralateral radial head
- proximal aspect of implant is 1 mm proximal to lateral ulnohumeral articular margin
- proximal aspect of implant is in line with the medial ulnohumeral articular margin
- proximal aspect of implant is 2 mm distal to coronoid tip
- intra-operative XR looking for ulnohumeral gapping
- check ROM
List 3 ways to more safely apply a Halo in a child
CT scan to identify suture lines and avoid them
Use more pins (8)
Use less torque (4 inch/lb vs. 8 inch/lb in adult)
What 3 radiographic findings are associated with Scheuermann’s kyphosis?
Schmorl’s nodes
AP elongation of vertebral bodies
narrowing of intervertebral spaces
List 8 risk factors for vertebral osteomyelitis in adults
immunocompromised
malignancy
IVDU
HIV
intravascular hardware
spine surgery
bacterial endocarditis
speticemia
List 4 medications that require renal dosing
morphine
enoxaparin
ancef
vancomycin
What are the ASA recommendations for initiating anticoagulation in the setting of an epidural catheter?
wait 2 hours after catheter removal
Biomechanically, how does UCL reconstruction do relative to the native UCL wrt restoring valgus stability?
At flexion angles >90 degrees, both the modified Jobe and docking techniques are equivalent to the native UCL, but at <90 degrees the native UCL wins
What are the anatomic sites of compression of the PIN and indicate which is most common?
“FREAS”:
fibrous bands of the radiocapitellar joint
radial recurrent vessels (Leash of Henry)
ECRB fascia
Arcade of Frohse (proximal supinator - most common)
Supinator distal edge
Describe when the midfoot and hindfoot bones ossify
6 mo fetal: calcaneus
7 mo fetal: talus
9 mo fetal: cuboid
1 yo: lateral cuneiform
3 yo: medial cuneiform
4 yo: middle cuneiform, navicular
Where do you plate the occiput in occipital plating in kids?
external occipital prominence (unicortical)
Where’s the start point for a C1 lateral mass screw? How do you angle it?
Just inferior to where the posterior C1 ring enters the lateral mass (need to retract C2 nerve root inferiorly and may even need to resect it to expose the start point).
Screw is angled medial to the vertebral artery foramen without breaching into the spinal canal (need to dissect and see the medial edge of the lateral mass). Fluoroscopy is used for cranial-caudal angulation.
List 6 differentials for shoulder pain in a swimmer
- subacromial impingement
- GIRD
- scapular dyskinesis (from over-developed lat dorsi and pec major)
- hyperlaxity
- labral tear
- suprascapular neuropathy (associated with scapular dyskinesia)
List the components of a scoliosis brace
“BRACe MaP”
Build (custom vs. pre-fabricated)
Rigidity (soft, elastic, rigid)
Anatomic level (C, T, L, S)
Construction of the Envelope (symmetric vs. asymmetric)
Mechanism of Action (3-point, elongation, etc.)
Plane of action (2D vs 3D)
List 4 complications of MRSA infection in kids
persistent bacteremia
DVT
septic emboli
pathologic fracture
What’s the precursor to scoliosis in patients with Parkinson’s disease?
Pisa syndrome (lateral thoracic bend >10 degrees)
What are 4 spine abnormalities in Parkinson’s disease?
- Pisa syndrome
- Anterocollis (>45 degree cervical flexion; passively correctable)
- Camptocormia (>45 degree T-L flexion; passively correctable)
- Scoliosis
List 4 non-surgical options for spine issues in patients with Parkinson’s disease
Bracing with anterior distraction
Botox injection of iliopsoas (improves camptocormia)
Lidocaine injection of external obliques (improves pisa)
Deep brain stimulation (improves camptocormia)
Which vessels make up the anastomotic ring around the knee?
medial superior geniculate (dominant)
medial inferior geniculate (dominant)
lateral superior geniculate
lateral inferior geniculate
descending geniculate
anterior tibial recurrent
When repairing a jersey finger (FDP avulsion), what’s the best fixation method biomechanically?
suture-anchor
Which type of jersey finger should be repaired acutely (within 10 days) and why?
type I (soft-tissue FDP avulsion, no bony component) since these retract all the way into the palm and disrupt the vinculae (brevis and longus profundus)
List 2 indications for flexor pulley reconstruction
multiple pulley rupture (A2 and A4)
bowstringing
What’s the best type of muscle strengthening for patellar tendinosis?
eccentric
How can you distinguish a weak tib ant from a common peroneal nerve palsy or L4/5 radiculopathy?
Test resisted hip abduction (also L5) and if this is weak as well, then it’s due to radiculopathy
List 5 advantages for the lateral decubitus position over the beach chair
better cerebral perfusion
less risk of hypotensive bradycardia
lateral force distracting and opening up the GHJ
better access to posterior/postero-inferior labrum
bubbles move up/out of the way when using cautery
What are 5 disadvantages of the lateral decubitus position
disorienting anatomy
have to reach around arm to establish anterior portal
risk of traction injury to brachial plexus
increased DVT risk vs. beach chair
difficulty accessing the airway
What are 3 risk factors for development of DVT in paediatric MRSA infections?
MRSA osteomyelitis
Age >8
CRP >6
*Should provide DVT prophylaxis in all kids with MRSA
Where does calcific tendinitis most commonly occur in the hand and wrist and what’s the most common site of recurrence?
FCU insertion (most common site of recurrence)
MCPs
IPs
What 3 conditions are associated with calcific tendinitis?
Scleroderma
Dialysis
Hypophosphatemia
What’s the best way to screen for structure allograft bone quality?
cortical thickness (age and BMD don’t correlate well)
What are 4 surgical steps to do when operating on a patient with ESRD?
cement femur in arthroplasty
use locking plates
fill any metaphyseal bone voids
delayed weight-bearing
List 5 ways of increasing the stiffness of a circular frame
smallest rings possible
largest wires possible
inter-wire angle >60 degrees
use a drop wire
use 2-level frames
List 5 risk factors for extensor mechanism disruption following TKA
previous surgery
diabetes
ESRD
rheumatoid arthritis
obesity
What are the 3 diagnostic criteria for chronic exertional compartment syndrome?
Pre-exercise pressure >15 mm Hg
Pressure >30 mm Hg 1 min after exercise
Pressure >20 mm Hg 5 min after exercise
List 5 sequelae of untreated foot compartment syndrome
claw toes
cavus foot
chronic pain
neuropathy
neuropathic ulcerations
How do you surgically treat a flexible claw toe deformity following missed foot compartment syndrome?
flexor tenotomy
extensor tendon lengthening
How do you surgically treat a rigid claw toe deformity following missed foot compartment syndrome?
IP fusion
MCP capsulotomy
flexor tenotomy
extensor tendon lengthening
List the 6 risk factors for LCP
male
hyperactivity
Low body weight
family history
history of Perthes in the other hip
Inuit population
List 8 anatomic/physiologic differences in paeds that can affect how you manage them in a polytrauma setting
- large head to body ratio
- higher incidence of C-spine injury due to the above
- SCIWORA
- pseudosubluxation
- anterior airway
- large tongue
- require 30% blood volume loss to show tachycardia (vs. 15% in adults)
- rapid hemodynamic crash after critical threshold
What are the components of the Pirani severity score in clubfoot?
Hindfoot contracture score:
1. posterior crease
2. empty heel
3. rigid equinus
Midfoot contracture score:
1. medial crease
2. curvature of lateral border of the foot
3. position of the head of the talus
How much correction can you obtain with a Pemberton or innominate (Salter) osteotomy?
10-20 degrees (more with Pemberton)
Describe the steps for a repair of a dural tear
Trendelenberg position
Microscope
Use paddys instead of suction to not injure roots
6-0 non-absorbable suture repair
Watertight closure
Valsalva to check repair
+/- paraspinal fascial patch and fibrin sealant if needed
What’s the major type of radiation used for metastatic bone lesions (of the spine, pelvis, etc.)?
focused external beam radiation
When applying sequential traction during a closed reduction of a jumped facet, how do you know radiographically that you’re over-distracted and should abandon?
if the involved disc space is >1.5 times the width of adjanced disc spaces
What’s the algorithm for surgical management of a chronic Achilles tendon rupture?
<2 cm: primary repair
2-5 cm: V-Y lengthening +/- FHL transfer
>5 cm: FHL transfer and pulvertaft weave of either auto/allograft (semiT)
What are patients with Achilles ruptures at higher risk for (aside from wound complications)?
DVT
What is rheumatoid factor?
IgM against native IgG
List 5 conditions associated with rheumatoid arthritis
- vasculitis
- pericarditis
- pulmonary fibrosis
- Still’s disease (acute onset of RA with fever, rash and splenomegaly)
- Sjogren’s disease (autoimmune exocrine gland disease)
What are the 7 diagnostic criteria for rheumatoid arthritis?
Must have 4 or more:
morning stiffness
swelling in 3 joints
rheumatoid nodules
symmetric arthritis
arthritis of the hand and wrist
bony erosions
positive rheumatoid factor
What’s the general surgical treatment of a cavovarus foot?
LCO, dorsiflexion medial cuneiform osteotomy, tibialis posterior to anterior transfer, peroneus longus to brevis transfer
What’s the total safe traction time for hip arthroscopy?
2 hours
How do you decrease the risk of femoral and sciatic nerve injury during portal placement for hip arthroscopy?
Femoral: stay lateral to a vertical line down from the ASIS.
Sciatic: internally rotate the leg.
List 3 flap options for a full-thickness defect over the heel
Free flap
Reverse sural flap
Propeller flap
What’s the metal ion ratio suggestive of trunnionosis?
Co:Cr ratio >2:1
List 4 indications for a static spacer vs. an articulating one
wound concerns
stability concerns
extensor mechanism disruption
massive bone loss
List 8 risk factors for scaphoid non-union
smoker
delayed presentation
proximal pole fracture
displaced >1 mm
intrascaphoid angle >35
scapholunate angle >60
radiolunate angle >15
previous surgery
List the congenital scoliosis causes in order of likelihood to progress
unilateral hemivertebra with contralateral bar
unilateral bar
fully-segmented hemivertebra
unincarcerated hemivertebra
incarcerated hemivertebra
unsegmented hemivertebra
block vertebra
What two types of steroid injections are used in lumbar spinal stenosis?
Epidural
Transforaminal
For a medical practice to be considered “ethical”, it must respect all four of these principles
Justice
Beneficence (patient’s well-being is the goal)
Non-maleficence
Autonomy
What are McQueen’s modifications of LaFontaine’s criteria of displacement in non-operatively managed distal radius fractures?
Age >60
Metaphyseal dorsal comminution
Radial shortening
(LaFontaine’s initial criteria also had dorsal angulation >20 degrees, but this was disproved in McQueen’s paper)
List 4 causes of dural ectasia
“MEAN”
Marfan’s
Ehlers-Danlos
Ankylosing spndylitis
Neurofibromatosis
What’s the return to play, return to previous level and return to competitive level sport following ACLR?
Return to play: 80%
Previous level: 60%
Competitive: 40%
List 5 factors affecting RTP following ACLR
Age (younger is better)
Pre-operative ROM
Knee extension
Proprioception
Fear of reinjury (#1 reason)
What’s the risk of re-rupture after ACLR and of contralateral ACL tear?
5-10% re-rupture
10% contralateral ACL tear
List 5 risk factors for SCC of the hand
UV exposure
Chronic inflammation/nonhealing wound
HPV
Arsenic exposure
Polyaromatic hydrocarbon exposure
List 5 negative prognostic signs in SCC of the hand
> 2 cm
Deep to reticular dermis
Perineural invasion
Poorly-differentiated
Arising in areas of chronic inflammation
What are the 5 signs of a cutaneous melanoma?
ABCDE
Asymmetry
Border irregularity
Color variation
Diameter >5 cm
Evolution
- What’s the most important prognostic factor for a skin melanoma?
- What’s the treatment for a subungal melanoma?
- Breslow thickness
- Amputation through IP joint and sentinel node biopsy (node biopsy is true for any melanoma)
List 5 contraindications to surgery for elbow contractures
Continued gains with static progressive splinting
Mid-arc ROM pain (suggests OA)
Head injury
Non-compliance
Poor soft-tissue envelope
What’s the algorithm for pediatric chronic (>2 weeks) torticollis secondary to AARI?
- Halter traction (NSAIDs, Benzos)
-if successful, C-collar x 3 months
-if fails after 2 weeks, progress to next step - Skull traction (NSAIDs, Benzos)
-if successful, Halo x 3 months
-if fails after 2 weeks, progress to C1/2 fusion
Which meds treat Tb?
RIPE
Rifampin
INH
Pyrazinamide
Ethambutol (can be DC’d if bug is sensitive to RIP)
What’s the union rate in an atypical femoral fracture?
50-70%
List 4 conditions associated with CVT
distal arthrogryposis
myelomeningocoele
Costello syndrome
Rasmussen syndrome
Quartet of nail-patella syndrome?
- Nail dysplasia
- Patellar hypoplasia (and often hypoplastic lateral femoral condyle)
- Capitellar hypoplasia (with associated radial head dislocation)
- Iliac horns (ram’s horn exostoses from the ilium)
What’s the most important non-orthopaedic manifestation of nail-patella syndrome?
Renal failure
Which 2 syndromes are associated with Madelung’s?
Nail-patella
Leri-Weill
List 7 non-orthopaedic manifestations of Down’s syndrome
- Developmental delay
- Cardiac disease (ASD, VSD)
- Duodenal atresia
- Risk of leukemia
- Hypothyroidism
- Risk of infections
- Premature aging
List 10 orthopaedic manifestations of Down’s syndrome
- Occiput-C1 instability
- C1/2 instability
- Odontoid hypoplasia
- Cervical spinal stenosis
- Scoliosis
- Spondylolisthesis
- General hyperlaxity
- Hip dysplasia
- Patellar dislocation
- Pes planovalgus
What are 6 indications for hemiepiphysiodesis in congenital scoliosis?
- Age <5
- Curve <70 deg
- <5 segments involved
- Lumbar curve
- No kyphosis
- Hemivertebrae instead of bars
Which 5 conditions affect the zone of hypertrophy of the physis?
- SCFE/fractures
- Rickets
- Mucopolysaccharidoses (Hunter’s, Hurler’s, Morquio’s)
- MED
- SED
Which 3 conditions affect the zone of resting cartilage (reserve zone) of the physis?
- Diastrophic dysplasia
- Pseudoachondroplasia
- Gaucher’s disease
Which 4 X-Rays are standard in assessing CVT?
AP, lateral in neutral/maximal dorsiflexion/plantarflexion
Which 2 angles are used to diagnose CVT and what’s abnormal for each? What’s the angle used for clubfoot?
CVT:
Talo-calcaneal angle (Kite) >40 (normal is 20-40)
Talar axis-1st metatarsal base angle (TAMBA) >35
Clubfoot:
Kite <20
TAMBA <35
Describe the principles for treatment of CVT
- Serial reverse-Ponsetti weekly casting (5 usually)
- Foreoot dorsiflexion and abduction are simultaneously corrected with the fulcrum being the head of the talus
- Foot is progressively brought into equinovarus to stretch out the posterolateral capsule (at the end of 5 weeks it looks like a clubfoot)
- Once most of the correction is achieved, patient undergoes TN open reduction and pinning and percutaneous Achilles tenotomy
- Pin removal at 6 weeks
- Boots-and-bars in neutral DF and 0 degrees of abduction full-time for 2 months then night-time use for 2 years
What’s the most important part of the S-L ligament?
Dorsal
List 8 steps when faced with neuromonitoring loss intra-operatively
Alert anesthesia
Anesthesia to check Hgb, temperature, MAP
Check patient positioning
Check leads
Reverse correction
Check screws and remove if concerned
Wake-up test
When doing an L5-S1 decompression and fusion for a spondylolisthesis, what do you decompress?
- L5 lamina (usually just comes off easily due to the listhesis)
- S1 upper half laminectomy and resect part of the posterior S1 body (this is where the S1 nerve roots drape over)
List 4 MRI and 4 X-Ray findings of dystrophic curves in neurofibromatosis
MRI:
Dural ectasia
Dumbbell lesions in neuroforamina
Dislocation of rib heads into the canal
Intraspinal neuroforamina
X-Ray:
Rib penciling
Vertebral scalloping
Vertebral body wedging
Foraminal widening
What’s the acronym for coxa vara etiologies?
“PORT IS SOFT”
Perthes
OI
Rickets
Trauma
Infection
SCFE
SED/MED
Osteopetrosis
Fibrous dysplasia
Tumour
List 8 indications for DCO
Lactate >2.5
Base deficit/excess outside -2 to +2 range
Platelets <90
ISS > 40
ISS > 20 with lung injury
Hypothermia
Hemodynamic instability
Severe head injury (relative, since can get neurosurg to do intra-cranial pressure monitoring)
List 5 contraindications for inserting an odontoid screw
Reverse-obliquity fracture pattern
Displaced fracture
Barrel chest
Obesity
Kyphotic deformity
What are the 2 mechanisms of action of BMP?
- promote MSC differentiation into osteoblasts
- upregulate growth factors involved in various functions such as angiogenesis
List 5 conditions associated with clubfoot
tibial hemimelia
arthrogryposis
Larsen syndrome
diastrophic dysplasia
myelodysplasia
List 2 indications for limited open fasciectomy in Dupuytren’s disease
MCP contracture >30
PIP contracture >15
List 3 contra-indications to teraparatide (Forteo)
Paget’s
Prior radiation
Open physes
List 5 conditions that present in the newborn with thickened cortices
“CCOMP”
Caffey’s disease
Camurati-Engelmann disease
Osteopetrosis
Melorheostosis
Pyknodysostosis
Describe the Leadbetter maneuver
FATI CAR
Flexion (to 90), Adduction, Traction, IR, Circumduction, Abduction and Reduction check in extension
List 6 indications for bisphosphonates other than osteoporosis
OI (ideally before age 6)
Polyostotic fibrous dysplasia
Paget’s disease
AVN (pre-collapse)
Hypercalcemia
Mets/myeloma
Where does the common iliac bifurcate?
What are the branches of the internal iliac artery?
Bifurcates at L4
“I Love Going Places In My Very Own Underwear”
Iliolumbar
Lateral sacral
superior/inferior Gluteal
internal Pudendal
Inferior vesicle
Middle rectal
Vaginal
Obturator
Umbilical
How much combined overhang of C1 on C2 following a Jefferson fracture is indicative of rupture of the transverse ligament?
6.9 mm
What are 3 potential spaces in the hand?
Midpalmar
Thenar
Hypothenar
Which nerves emerge lateral to psoas?
iLioinguinal
iLiohypogastric
LFCN
Which nerves emerge medial to psoas?
Obturator
Lumbosacral trunk
What are the indications for initiation of bisphosphonates in osteoporosis?
Age >50 with either:
1. T-score < -2.5
2. T-score -1 to -2.5 with >3% 10-year hip # risk or >20% risk of major osteoporosis-related fracture
List 5 side-effects of bisphosphonates in adults
Osteonecrosis of the jaw
Esophagitis
Dysphagia
Gastric ulcers
Atypical femoral fractures
List 5 side-effects of teriparatide
Transient hypercalcemia
Dizziness
Nausea
Headache
Malignancy (especially in Paget’s)
Which conditions cause ligamentous laxity?
Marfan’s
Ehlers-Danlos
OI
Achondroplasia
Pseudoachondroplasia
Mucopolysaccharidoses
Which conditions don’t have C1-2 instability?
Achondroplasia
Diastrophic dysplasia
What is congenital radioulnar synostosis associated with?
MACKA
Mandibulfacial dysostosis
Apert syndrome
Carpenter’s syndrome
Klinefelter’s syndrome
Arthrogryposis
What is syndactyly associated with?
PACA
Poland syndrome
Apert syndrome
Carpenter’s syndrome
Acrosyndactyly
What are the features of Poland syndrome?
- Unilateral chest wall hypoplasia (absent sternal head of pec major)
- Hand/forearm hypoplasia
- Symbrachydactyly
- Sprengel’s deformity
- Scoliosis
When do you transfuse postoperatively in a pediatric spine?
Tachycardia
Hypotension
Urine output <0.5 cc/kg/hr
Acidosis
List 4 risk factors for lumbar DDD
Age
Genetic predisposition
Occupation
Smoker
What are the indications for surgery in lumbar DDD?
Symptoms >6 months
Single level disease
Midline tenderness at that level
What’s the treatment for puerpal symphyseal rupture?
<2 weeks: ORIF
>2 weeks: arthrodesis
Which surgical factors are associated with successful ORIF of puerpal symphyseal ruptures?
Longer plate (>2 screws per side)
Precontoured plate (better contact)
Locking plate
What’s the main advantage of a press-fit humeral component vs. cemented in TSA?
Press-fit has better rotational stability (axial is the same)
List 5 ways of ensuring proper femoral and tibial tunnel placement in anatomic ACLR (not including fluoroscopy, which is an option)
Femoral:
1. 8-mm anterior to posterior margin, 1.7-mm proximal to bifurcate ridge
2. 45% of the proximal-to-distal length of the condyle along the posterior 1/3 of the condyle
Tibial:
3. In line with the posterior border of the anterior horn of the lateral meniscus
4. 9-mm behind the posterior border of the intermeniscal ligament
5. 5-mm anterior to the peak of the medial eminence
Where does the common iliac bifurcate?
What are the branches of the internal iliac artery?
Bifurcates at L4
“I Love Going Places In My Very Own Underwear”
Iliolumbar
Lateral sacral
superior/inferior Gluteal
internal Pudendal
Inferior vesicle
Middle rectal
Vaginal
Obturator
Umbilical
List 5 side-effects of bisphosphonates in adults
Osteonecrosis of the jaw
Esophagitis
Dysphagia
Gastric ulcers
Atypical femoral fractures
List 5 side-effects of teriparatide
Transient hypercalcemia
Dizziness
Nausea
Headache
Malignancy (especially in Paget’s)
List 4 risk factors associated with recurrence of clubfoot
- Drop toe sign
- Flexion contractures of wrists and fingers (distal arthrogryposis)
- Spinal dysraphism
- Noncompliance with FAOs
What are 4 risk factors for poor outcomes in growth modulation for adolescent Blount’s?
Age >14
BMI >45
Severe deformity
Titanium implants (high risk of hardware failure)
List 5 ways to gauge accuracy of femoral/tibial tunnel placement in an anatomic ACLR
Femoral:
1. 8-mm anterior to posterior margin, 1.7-mm proximal to bifurcate ridge
2. 45% of the proximal-to-distal length of the condyle along the posterior 1/3 of the condyle
Tibial:
3. In line with the posterior border of the anterior horn of the lateral meniscus
4. 9-mm behind the posterior border of the intermeniscal ligament
5. 5-mm anterior to the peak of the medial eminence
List 5 factors that predict success of single-stage revision arthroplasty
THA
Monomicrobial culture-positive organism
Gram +
Optimal host factors
Sensitivity-tailored antibiotic therapy for 3 months
List 5 methods of assessing for patella alta and indicate normal values for each
- Caton-Deschamps (0.6-1.3)
- Insall-Salvati (0.8-1.2)
- Blackburne-Peel (0.5-1)
- Plateau-patella angle (normal 20 degrees)
- Blumenstaat’s line should touch the inferior patellar pole at 30 degrees of knee flexion
List 5 poor prognostic factors in pilon fractures
Male
Multiple comorbidities
Lower SES
Lower education level
WSIB
