SAQ 2010 Flashcards
1) List the 4 Stages of Perilunate Instability
- Scapholunate dissociation
- Capitolunate dissociation
- Lunotriquetrial dissociation
- Lunate dislocation
2) List the 7 CanMeds Components
“Please Help Me Memorize Stupid Canmeds Crap”
- Professional
- Health advocate
- Medical expert
- Manager
- Scholar
- Communicator
- Collaborator
3) List the 4 Types of Neural Tube Defects
- spina bifida occulta - defect in vertebral arch with confined cord and meninges
- meningeocele - sac without neural elements protruding through the defect
- myelomeningeocele - protrusion of the sac containing neural elements
- myeloschisis - neural elements exposed with no covering
4) List stages of Kienbock’s
Stage I No visible changes on xray, changes seen on MRI
Stage II Sclerosis of lunate
Stage IIIA Lunate collapse, no scaphoid rotation
Stage IIIB Lunate collapse, fixed scaphoid rotation
Stage IV Degenerated adjacent intercarpal joints
5) Unilateral DDH in 8 month old:
a) list the most important clinical sign AND
b) list 5 possible blocks to reduction
A: decreased (asymmetric) hip abduction
B: inverted labrum inverted limbus transverse acetabular ligament iliopsoas tendon pulvinar hypertrophied ligamentum teres
7) 70 yr old male with CR TKA now with NO pain, Flexion of 75 (pre-op 120) degrees and full extension. Infection ruled out. List 4 causes for this.
- Poor compliance with postoperative rehabilitation
- Postoperative complication (wound dehiscence, DVT, CRPS)
- Overstuffing of the patello-femoral joint
- Oversized components (femur)
- Failure to restore native tibial slope (insufficient tibial posterior slope)
- Incomplete osteophyte resection
- Mismatch of flexion and extension gaps (inappropriate balancing (PCL too tight)
- Component Malposition
- Elevation of the joint line
8) 45 y.o. male with left hip pain. Shown an AP pelvis. List 3 common causes of his left hip pain. You had to determine that he had AVN of the left hip.
• direct causes - trauma - irradiation - hematologic d/c (leukemia, lymphoma) - cytotoxins - dysbaric ON (Caisson disease) - Gaucher disease - Sickle cell disease / trait • indirect causes - EtOH abuse - “immune deficiency” conditions - corticosteroids - organ transplant - systemic conditions - renal failure - systemic lupus erythematosus - blood conditions - hemophilia - thrombophilia
9) 70 yr old with cemented 15 yr THA, 1 yr history of thigh pain and periprosthetic fracture. List 3 factors important in the surgical management.
- work up for infection
- Vancouver classification!
- location of fracture
- implant stability
- remaining bone stock - pre-op medical mngt
10) List 4 Indications for percutaneous pinning (CRPP) of distal radius in a child.
- Ipsilateral distal humerus fracture
- Excessive soft tissue swelling
- Inability to obtain a reduction
- SH III/IV fracture displaced
- Inability to maintain an adequate reduction (i.e. loss of reduction)
- < 50% of apposition (of physis or canal width if metaphyseal)
- After 2nd attempt at closed reduction
11) 50 yr old female with 2 week history of inability to extend 4th and 5th fingers. List 3 common causes in a Rheumatoid patient.
- Extensor tendon rupture (Vaughn Jackson syndrome)
- Subluxation of extensor tendon at MCP joint
- PIN palsy
- MCP dislocation
12) Describe the Leadbetter manoeuvre.
- flex the hip to 90 deg, w/ slight adduction, and apply traction in line with the femur;
- next, while maintaining traction, apply internal rotation to 45 deg;
- the leg is slowly brought into slight abduction and full extension, while maintaining traction and internal rotation;
- idea is that when the hip is flexed to 90 deg (quadriped position) all muscles about the hip are maximally relaxed;
- further internal rotation also relaxes the Y ligament;
- by having these structures relaxed, reduction is possible;
- finally, full flexion and adduction “books open” the frx site which then allows the reduction to procede;
Leadbetter JBJS 1938.
13) 3 sites of compression in radial tunnel syndrom
“FREAS
- fibrous bands from radiocapitellar joint
- recurrent radial artery (leash of henry)
- leading edge of ECRB
- Arcade of Frosch (#1)
- exiting Supinator
14) Patient sustained an elbow dislocation that was reduced but remained unstable at 45 degrees with posterolateral instability. List 3 stabilizers to posterolateral stability.
- Lateral ulnar collateral ligament complex
- Radial Head
- Coronoid (30% loss)
Most important structure to posterolateral elbow stability
LUCL
16) 45 yr old male with pure ligamentous instability after elbow dislocation on lateral side. What is the management of this elbow?
- Acute dislocation:
- Reduce and examine for stability under anesthesia
- If unstable, document degree of flexion needed to maintain reduction.
- Splint at 90 then get xray to ensure concentric reduction.
- If stable under anesthesia (most are), can begin early mobilization at 1 week follow up visit.
- If unstable at extension only, can fit with extension-block hinged brace and increase extension weekly until full ROM achieved.
- If elbow requires flexion more than 50-60 degrees to be stable, this is an indication for surgery (repair of avulsed MCL (+/- LUCL) to humeral origins, +/-repair of avulsed musculature.
17) 55 year-old patient has ulnar head, triquetral pain. Normal ROM and stable wrist. Active woman and cannot play tennis anymore. List 3 possible Dx.
- Hook Hamate # (if volar)
- TFCC tear
- Ulnocarpal impaction
- ECU tendonitis (If dorsal)
- Ulnar styloid impaction (on the triquetrum)
- Ulnar nerve compression
List the dorsoradial and dorsoulnar wrist scope portals
- dorsoradial (3-4): 1 cm above lister’s tubercle, btwn 3rd and 4th compartments
- dorsoulnar: 6R → just radial to ECU tendon; 4-5 btwn 4th/5th compartments just radial to 6R
• remember:
- radial midcarpal → 1 cm distal to 3-4 portal, radial border of 3rd MC - ulnar midcarpal → 1 cm distal to 4-5 portal, in line w/ 4th MC
List 5 stabilizers of the DRUJ.
- sigmoid notch
- DRUJ capsule
- pronator quadratus
- IOM
- volar and dorsal radio-ulnar ligaments
- ECU tendon sub-sheath
- TFCC
List components of TFCC
- dorsal and volar radioulnar ligaments
- central articular disc
- meniscus homolog
- ulnar collateral ligament
- ECU subsheath
- origin of ulnolunate and ulnotriquetral ligaments
18) 10 year old child with pain at a prominence of foot medially. Firm and tender to palpation, non-mobile. Symptoms for 3 months. (Xray of accessory navicular). What is treatment?
Analgesics
Short period of cast immobilization
Excision if nonop mgmt failure
19) Child with multiple ankle sprains treated non-operatively. Pain in anterolateral aspect of ankle and symptoms for 3 months. No pain with ADLs. Unable to run more than 20 minutes. You are told that he has a tarsal coalition. List 2 treatment options at this time.
Initial - analgesics with immobilization.
Operative- excision of coalition bar with interposition of fat graft or EDB muscle.
20) 14 yr old female with Right Thoracic curve and Left lumbar curve.
List 3 radiographic features that are suggestive that this is a structural curve.
- Cobb angle > 25° on bending films
- kyphosis > 20° T10-L2
- There is more pedicle rotation
- curve with greatest magnitude (largest Cobb angle)
21) 12 yr old female with a 30 degree thoracic curve. List 6 ways to determine her skeletal maturity.
- Tanner stage
- Risser grade
- age of menarche
- presence of open tri-radiate cartilage
- presence of open physis in other bones → e.g. olecranon apophyseal closure right before peak growth velocity
- growth velocity
- radiographic bone age - greulich and pyle
- AP hand xray
22) 3 Causes of a superior labral tear
- forceful traction loads to arm
- direct compressive loads (trauma, FOOS arm/Fall onto shoulder)
- repetitive overhead throwing (peel back mechanism)
23) A patient sustains a posterior shoulder dislocation. Shown an x-ray of a reduced shoulder with a large reverse hill-sachs lesion. List 3 reasonable surgical treatment options.
- disimpact and bone graft (if acute)
- modified McLaughlin (LT + subscap transfer into defect)
- allograft
- hemiarthroplasty
- resurfacing
- total shoulder arthroplasty
24) 45 yr old male going for a TKA. What level should their factor level (hemophilia) be pre-op ?
24b) How long should these levels be maintained post-op ?
How would this patient’s outcome compare with an unaffected person with Hemophilia
A: - 100% for factor VIII (hemophilia A), factor XI (hemophilia B)
B: - 2 weeks post op for bony procedures
• remember: 3-5 days for soft tissue procedures
C: - higher rate of infection (long term) and higher post op hemarthrosis (stiffness) otherwise equivalent outcomes
List 3 factors to consider when thinking about doing a hemi-epiphyseodesis
o Angular correction, skeletal age, metabolic activity of physis
o good rule of thumb, 7 degrees per year distal femur, 5 degrees prox tibia
A child with a hemivertebra. What are 3 indications for being able to perform a hemi-epiphysiodesis?
- age < 5
- smaller curve (< 50°)
- type of hemivertebrae (fully segmented)
- progressive curve
- sagittal balance (no kyphosis)
- concave growth potential < 5 years
- Single hemivertebrae
- Short segment curve (< 5 levels)
Hedden JBJS 2007
26) List 5 factors that would lead to a poor outcome in a patient with a Type II Odontoid.
o Fracture gap >1-2mm o Posterior displacement >5mm o Angulation >10 deg o Delay in tx (4 days) o Smoker o Debate whether anterior displacement (5mm), sex and age (>40,60) risks… (JBJS 2004)
28) 4 Year old male with hip pain. List 4 clinical or laboratory finding to differentiate from Transient Synovitis.
- ESR > 40
- CRP > 20
- WBC > 12000 cells/mL
- Temperature > 38.5
- Inability to walk
29) 16 yr old with Gr II open tibia with zero tetanus vaccinations and an anaphylactic reaction to penicillin:
a) What antibiotic to use ?
b) What Immunization protocol to implement
c) What surgical treatment to implement?
- clindamycin 600mg IV
- tetanus toxoid + TIG
o Tetanus prone wound? • Stellate/irregular shape • > 6 hours old • Depth > 1 cm • Crush injury/projectile injury/burn/frostbite • Devitalized tissue • Gross contamination
- urgent layer-by-layer irrigation and debridement
o necrotic tissue/debris
o deliver both bone ends
o if happy with wound, close and nail the tibia
o If unhappy, ex-fix and return to OR for reassessment of tissue viability with external fixation and delayed definitive management of the fracture
30) A 23 y.o. male has 4 month history of increasing pain in proximal phalanx of middle finger. Not shown the x-ray, but told that there is a lytic lesion that the radiologist thinks is benign. List 7 possible diagnoses.
- enchondroma
- Browns tumor
- Infection
- GCT
- ABC
- UBC
- langerhans histiocytosis/EG
- NOF
- Glomus if distal…
31) 70 year old male with pathologic fracture of diaphyseal femur. Has 3 other skeletal lesions and thyroid lesion.
a) What would be the appropriate surgical treatment ?
b) What systemic skeletal intervention would be appropriate (medical)?
c) What local treatment would assist your surgery ?
A: locked cephallomedullary nail
B: - Bisphonates (after surgery!) Pamidronate over 2hr 90mg IV
- Radioactive iodine
C: - radiation (post-op)
o (1 dose 8Gy, or 30Gy 10 sessions)
- Arteriogram and embolization
32) List 4 risk factors for neurological deterioration in vertebral osteomyelitis
- aggressive bacteriology (e.g. MRSA)
- medical co-morbidities (e.g. immunocompromised patient, DM
- failure to initiate treatment / late diagnosis
- associated paraspinal abscess
- elderly age
- higher vertebral involvement (i.e. cervical)
33) List 6 principles of tendon transfers
“SEACOAST”
- synergistic transfer
- expendable donor
- adequate motor power of transfered tendon ((must be 4-5/5)
- contractures need releasing (supple joint)
- one tendon, one function
- adequate excursion (length)
• (3/5/7 rule)
• Wrist Flexors/extensors 3 cm
• Finger extensors 5 cm (and thumb flexor)
• Finger flexors 7 cm
- straight line of pull
- tissue equilibrium: scar free bed, stable joint, well healed wound
34) List 6 risk factors for Radio-ulnar synostosis after surgery?
- radius-ulna # at same level
- screws that penetrate IOM
- bone grafting into IOM
- history of HO
- closed head injury
- use of one incision to ORIF both radius and ulna
36) 25 yr old female with a severe bunionette and high 4-5 angle ? What are 3 surgical treatment components?
-5th MT diaphyseal osteotomy
(ie . Coughlin – proximal-dorsal to distal-plantar; dorsomedial translation of the MT head + screw fixation)
-Medial 5th MTP soft tissue release (lateral condylectomy w/ reefing of lateral MTP joint capsule)
-Distal osteotomy
-Excision of the lateral prominence
Recall: Coughlin classification:
- Type 1 – enlarged 5th MT head/lateral exostosis
- Type 2 – lateral bend of the 5th MT with normal 4,5-IM angle
- Type 3 – (most common) 4,5 IM angle > 8 deg
37) Ankle fracture in a diabetic that you treat surgically - what are three complications that diabetics that they are higher risk?
- infection
- amputation
- mal/non-union
- wound dehiscence
- cardiopulmonary complicaitons
38) Patient with a lisfranc injury - what are 3 radiographic features to look for ?
- widened space btwn 1st and 2nd MT
- bony avulsion of lis franc ligament (base of 2nd MT base)
- dorsal subluxation of 2nd MT base on lateral xray
- incongruity of metatarsals with cuneiforms
- lateral aspect of 1st MT does not line up with medial cuneiform on AP
- medial aspect of 2nd MT does not line up with middle cuneiform on AP
- medial aspect of 3rd MT does not line up with lateral cuneiform on oblique
- medial aspect of 4th MT does not line up with cuboid on oblique
39) X-ray with a Crowe 4 hip - The patient is ready to undergo a THA. List 4 things that you have to consider from a technical aspect with regards to the procedure.
GENERAL:
- restoring hip centre to true acetabulum
- (avoid overlengthening to avoid sciatic nerve injury→ subtroch shortening osteotomy)
- ↑ anteversion of femoral neck and small femoral diaphyseal shaft → modular femoral stem
APPROACH
-ABductors frequently poorly developed and oriented more transversely (fnc less efficiently)
-ADductors, psoas, hamstrings, rectus femoris shortened
(tenotomy may be needed to correct deformity)
-capsule elongated and redundant → may need extensive capsulotomy
-sciatic nerve assumed normal length → susceptible to stretch during correction
ACETABULUM
- acetabulum shallow / oblong / roof eroded
- deficient anteriorly, laterally, superiorly
- may need very small acetabular component (< 40 mm)
-false acetabulum
• usually not deep / wide for cup containment
• cup should be implanted in true acetabulum
• medial and inferior location ↓ joint contact forces
• thickest bone
• facilitates limb lengthening
• improves ABductor function
• ↓ risk of loosening
• cup should be confined within bone if possible (see below)
• medial wall should be left intact
FEMORAL SIDE
o proximal migration of femur
o femoral head small & deformed
o femoral neck short and narrow with varying but ↑ anteversion (may need osteotomy)
• anteversion of implanted acetabular component will influence how much anteversion can be accepted on femoral side
o valgus neck shaft angle
o GT small and posterior (may need to be moved to more anatomic position)
o femoral canal narrow (exacerbated by ↑ ant bowing of proximal 1/3 of femur)
40) List 3 ways to monitor for a spinal cord injury when performing spinal deformity correction ?
- somatosensory evoked potentials
- motor evoked potentials
- wake up test
- Ankle clonus test (positive test is absence of clonus in a patient emerging from anaesthesia – LMN returns prior to UMN so you should see clonus)
41) List 4 Principles of medical ethics
- beneficience
- automony
- non-malefience
- justice
42) List 3 Non-skeletal manifestions of Marfan’s?
- ocular: ectopia lentis (superior lens dislocation)
- cardiovascular: ascending aorta dilation / aortic regurgation, ascending aorta dissection, mitral valve prolapse / regurgitation
- pulmonary: spontaneous pneumothorax, apical blebs
- dura: lumbosacral dura ectasia
43) List 3 Radiographic ways to determine adequate alignment in a femoral neck # in a young person.
- Lowell’s Lines (lining up of anterior and posterior cortices on lateral = S-shaped contour of the head-neck junction
- Neck shaft angle matching contralateral side
- Femoral head center of rotation level with GT
- Shenton’s line not disrupted
- Lining up of tensile and compressive trabecular
- < 10 degrees of anterior/posterior angulation
- < 5 mm translation on AP and lateral
-Garden’s alignment index
o Primary compressive trabeculae 160-180 degrees on AP
o Primary compressive trabeculae 160-180 degrees on lateral
44) List three neurological features of Brown-Sequard?
- ipsilateral corticospinal (motor) lost
- ipsilateral dorsal column (proprioception, vibration) lost
- contra-lateral spinothalamic (pain and temperature) lost
- Variable loss of bowel and bladder function
45) What are 3 at risk signs for LCP?
Catterall’s Head at Risk signs:
- V shaped radiolucency in lateral epiphysis (Gage’s sign)
- calcification lateral to the epiphysis
- horizontal physis
- lateral extrusion of femoral head
- metaphyseal cysts
Factors to consider DCO (8)
MAP less than 60 HR over 100 U/O less than 0.5-1 ml/kg/hr Lactate >2.5 IL-6 >800 pg/mL INR >1.5 Temperature less than 35 Platelets less than 100 Base excess over 6
