Short Answer 2011 Flashcards
List 4 clinical findings in a trauma patient with Class IV hemorrhagic shock (blood loss >2000ml)
1) Marked tachycardia (>140)
2) Decreased BP
3) Increased resp rate (>35/min)
4) Negligible urine output
5) Narrow pulse pressure
6) Marked depression of mental status (confused, lethargic)
List 8 radiographic findings on CXR consistent with traumatic aortic rupture from blunt force trauma.
- Widened mediastinum (>8cm at the level of the aortic knob is abnormal)
- Obliteration of aortic knob
- Deviation of trachea to right
- Deviation of the esophagus (NG tube) to the right
- Depression of the left mainstem bronchus
- Elevation of right mainstem bronchus
- Obscuration of aortopulmonary window
(obliteration of the space between the pulmonary artery and the aorta) - Widened paratracheal stripe
- Widened paraspinal interfaces
- Pleural or apical cap
- Left hemothorax
- Fractures of the first or second rib or scapula
List the 4 stages of perilunate instability (Mayfield)
Stage I – disruption of scapholunate ligamentous complex
Stage II – force propagates through the space of Poirier and interrupts the lunocapitate connection
Stage III – lunotriquetral connection is violated, and entire carpus separates from lunate
Stage IV – lunate dislocates from its fossa into the carpal tunnel, and capitate becomes aligned with the radius
List 3 reasons to cone down during radiography
1) Improved image quality
2) Decreased scatter - protects surgeon
3) Decreased radiation dose - protects patient
4) Avoid radiating normal nearby tissues
List 3 (or 4) potential reasons for unsuccessful treatment of UBC in proximal humerus with percutaneous injection of methylprednisolone
1) Larger cyst
2) Age <10y
3) Single injection site (multiple perforations increase healing, even without injection)
4) Multiloculation
5) Active cyst (close to growth plate) /patient age
6) Poor technique (ie, failure to inject lesion)
7) Wrong diagnosis
In Canada, the #1 cause of charcot neuropathy in the foot is due to diabetes. List 3 additional potential causes.
1) Syphilis/Tabes Dorsalis
2) EtOH
3) Leprosy
4) Syringomyelia
5) CMT
6) MS
7) Chronic demyelinating polyradiculopathy
8) Congential insensitivity to pain
List 6 causes of acquired coxa vara.
1) Traumatic
2) Infection
3) Rickets
4) Fibrous Dysplasia
5) Osteopetrosis
6) Paget
7) Osteogenesis imperfecta
8) Skeletal dysplasias SED, SMD, Cleidocranial dysplasia
List 4 potential long term sequelae after radial head fracture.
1) loss of motion
List 8 diagnostic criteria to help determine whether to institute Damage Control Orthopedics (8)
- Class IV shock
- PLT 6-8mmol/L
- Lactate >2.5
- Temperature /=3
- Crush injury
- > 30% burns
- Labile closed head injury
In a patient with hypotensive shock and decreased ATP, cellular metabolism is switched to anaerobic.
List how each of the following INTRAcellular components will change (increase/decrease/no change)
1) Sodium:
2) Potassium:
3) Calcium:
4) Water:
1)
List 3 issues that occur with greater frequency when performing open repair of Achilles rupture vs. closed management.
1) Infection
2) Wound problems
i. Dehiscence
ii. Hypertrophic scar and keloid formation
iii. Tethering of Achilles to skin
3) Sural nerve injury
35F, 2 years after sustaining the injury in the radiograph shown below. (Pt had R basicervical hip fx, now with coxa vara).
Pt was treated conservatively but ambulates with a limp. The pt has no pain.
Other than potential range of motion issues, list 3 clinical signs you expect to find on physical exam?
1) LLD
2) Trendellenburg gait (abductor lurch)
3) Trendellenburg sign (abductor muscle insufficiency)
4) Prominent GT
- In an adolescent with a femoral shaft fracture, list 3 (or 4) techniques to prevent the patient from developing AVN of the femoral head when treating with an antegrade femoral nail (3-4).
1) Lateral trochanteric entry point
2) Avoid dissection medial to tip of the greater trochanter
3) Removing nail only after Physis closure
4) Smaller nail diameter (rigid interlocking nail)
5) Proper patient positioning
6) Ensure good fluoroscopy images
7) Avoid at risk patients – overweight
List 2 potential advantages of using a piriformis entry point vs. a trochanteric entry point for antegrade femoral nail fixation(2)
1) The piriformis fossa starting point main advantage colinear trajectory with long axis
2) Less incidence of iatrogenic trochanteric fractures
3) Less incidence varus malalignment
Disadvantages of Piriformis entry IM nails (2-3)
- technical difficulty obtaining starting point (esp obese patient)
- piriformis starting point is also sensitive to anteroposterior translation
a. anterior positioning being associated with extreme hoop stresses and increased risk of iatrogenic bursting of the proximal segment - trochanteric-more cancellous, more forgiving less hoop stress
a. relatively anterior starting point in the trochanteric region is acceptable.
List 4 prognostic issues associated with a child who has Legg-Calve-Perthes Disease (4)
1) Degree of deformity (non-spherical heads have poorer prognosis)
2) Age of onset (earlier onset [ie, s sign, a radiolucent defect between the lateral epiphysis and metaphysis
2) calcification lateral to the epiphysis 3) metaphyseal cysts 4) lateral subluxation and 5) horizontal growth plate
Radiation therapy is used for the treatment of soft tissue sarcoma. List 4 potential adverse effects associated with the use of radiation therapy (4)
1) Fractures
2) Wound healing complications
3) Post-radiation sarcomas
4) Fibrosis
5) Joint stiffness and contractures
List 4 relative contraindications for offering total joint arthroplasty to a patient (4)
1) Neuropathic arthropathy (=Charcot joint)
2) Insufficient bone stock
3) Noncompliant patient (unable to rehab)
4) Morbid obesity
5) Poor soft tissue coverage (ex. active psoriasis)
6) Severe Peripheral vascular disease
7) Unmotivated patient
8) Unrealistic expectations
9) Poor health unfit for surgery
Absolute contraindications:
1) active infection
2) unstable medical condition
- A 65 y.o. female with longstanding rheumatoid arthritis comes to see you after losing the ability to extend the 4th and 5th digits on her right hand 2 weeks previous. List 3 potential causes for this finding.
1) Rupture of digital extensor tendons (commonly to EDM, EDC to 4th and 5th)
2) Rupture of sagittal bands; extensor tendons lose mechanical advantage
3) Volar subluxation of MCP’s
4) Partial PIN palsy (compression neuropathies seen in RA; compression of PIN at elbow)
List 3 anatomic relationships as seen on radiography to assess the integrity of the tarsometarsal (Lisfranc) joint.
1) width of interval between 1st and 2nd ray (*normal < 3mm)
2) medial base of 2nd MT aligns with medial side of middle
cuneiform
3) medial side of 4th MT lines up with medial side of cuboid (on oblique x-ray)
List 4 reasons to offer a patient hemi-resection interpositional arthroplasty of the distal radio-ulnar joint. (4)
1) Trauma: unreconstructible fractures of the ulna
2) Ulnocarpal impingement syndrome with potentially inadequate surfaces of the DRUJ
3) Rheumatoid arthritis (early stages)
4) Post-traumatic arthritis
5) osteoarthritis of the DRUJ
6) Chronic painful triangular fibrocartilage tears.
7) Ulnar head chondromalacia
List 3 (or 4) radiographic findings in a patient with Madelung’s deformity (doesn’t say Madelung’s—just x-ray).
1) Characteristic pyramidal configuration of the carpus
2) Radial physis narrowed ulnarly
3) Prominent ulnar head dorsally
4) bowing of the radial diaphysis
Diagnostic criteria using X-rays
1) Ulnar tilt ≥33°
2) lunate subsidence > 4mm
3) lunate fossa angle ≥40°
4) Palmar carpal displacement 20 mm or more
List three clinical findings you may expect in a patient with central cord syndrome (3).
1) Upper limb weakness > lower limbs
2) Distal muscles affected > proximal
3) Sacral sparing
4) Motor function more severely impaired than sensory function.
List four potential long term consequences in a child with chronic osteomyelitis (4).
1) LLD over or under growth
2) Angular deformity (if GP involved)
3) Septic arthritis to adjacent joints
4) Recurrent acute osteomylitis
5) Secondary osteosarcoma
6) Pathological fracture
List 4 negative prognostic criteria associated with a septic joint (4).
- Age < 6 months (some say less than 1 year definitely neonates worst)
- Delayed diagnosis > 4 days
- Staph aureus infection
- Associated osteomyelitis (Proximal femur)
- Hip involvement
List 3 relative indications to prophylactically pin the unaffected hip in a child with SCFE.
1) Endocrine or metabolic disorder (ex. Hypothyroidism, growth hormone deficiency, hypogonadism)
2) Inability to obtain regular follow-up
3) Open triradiate cartilage
4) Girl <12.5 yrs
6) Severe obesity
- List the 4 types of SLAP tears as described in the original anatomic classification.
(Snyder’s anatomic classification)
1) Type I: Superior labral fraying with localized degeneration; biceps anchor intact
2) Type II: Detachment of superior labrum/biceps anchor from glenoid
3) Type III: Bucket-handle tear of superior labrum, biceps anchor intact
4) Type IV: Bucket-handle tear of superior labrum with extension of tear into biceps tendon
List 3 ways of monitoring neurologic status intra-operatively while performing spine surgery.
1) Somatosensory Evoked Potentials (SSEPs)
2) Transcranial Motor-Evoked Potentials (MEPs)
3) EMG (spontaneous and triggered)
4) Wake-up Test
5) Clonus test
List 3 issues associated with the ORIF of an ankle fracture in a diabetic patient vs. a non-diabetic.
1) Impaired wound healing
2) Infection
3) Poor bone fixation
4) Malunion
5) Nonunion
6) Delayed healing
7) Charcot Arthropathy
Other than joint aspiration, list 4 diagnostic criteria that can be used to help distinguish septic arthritis from transient synovitis in a child.
1) Fever >38.5°C (* Best predictor)
2) CRP > 2 mg/dL (= 20 mg/L) ( Second best predictor*)
3) Unable to weight bear
4) ESR > 40 mm/hr
5) Serum WBC >12.0 x 109/L
List 6 issues which may predispose to radio-ulnar synostosis after treating a radial and ulnar fracture with ORIF.
Trauma-related
1) Monteggia #/associated elbow dislocation
2) Both bone # at same level
3) Open #
4) Significant soft tissue damage/crush
5) Comminuted #
6) High energy #
7) Associated head trauma/closed head injury
8) Bone fragments on interosseous membrane
9) Infection
Treatment-related
10) Use of one incision for both radius & ulna
11) Delay in surgery > 2 weeks
12) Screws that penetrate interosseous membrane
13) Bone grafting into interosseous membrane
14) Prolonged immobilization
List 4 reasons to percutaneously pin a displaced distal radius fracture in a child.
1) Fracture instability (high risk of loss of reduction/high likelihood of repeat manipulation)
2) Excessive local swelling (increases risk of neurovascular compromise)
3) Ipsilateral fractures of distal radius & elbow (ex. Supracondylar humerus fracture) = floating elbow
4) Unable to obtain acceptable reduction closed
5) Intra-articular fracture (SHIII or IV)
6) Open fracture
7) Neurovascular compromise with displaced physeal fracture
The World Health Organization has established guidelines to help decrease the likelihood of intraoperative errors. List 8 of these.
1) Patient confirms identity, site, procedure, & consent
2) Mark site
3) Anesthesia & medication check
4) Pulse oximeter on patient (& functioning)
5) Confirm allergies, difficult airway, risk blood loss >500cc
6) All team members introduced
7) Team members confirm pt’s name, procedure, and where incision to be made
8) Team members confirm any anticipated critical events
9) Necessary equipment available
10) Abx prophylaxis given
11) Essential imaging displayed
In a child with neurofibromatosis and scoliosis, list 4 findings you may see on MRI of the spine.
1) Dural ectasia (expansion of dural sac)
2) Dumbbell lesions (=neurofibromas within canal expanding outward thru neural foramina)
3) Paravertebral soft-tissue mass
4) Short curve with severe apical rotation
5) Vertebral scalloping
6) Vertebral wedging
7) Transverse process spindling
8) Intervertebral foraminal enlargement
9) Widened interpediculate distances
10) Dysplastic pedicles
11) Meningomyelocele
12) Rib penciling
In a child with neurofibromatosis and scoliosis, list 3 features that suggest curve progression.
- 3 pencilled ribs
- 3 dystrophic features
- or manifests before age 7
List 4 issues that may have led to the complication seen in the radiograph below (given AP pelvis of patient with bilateral hip resurfacing, Left side is OK, Right side has femoral neck fracture).
1) Obesity
2) Osteopenia
3) Inflammatory arthritis
4) Femoral neck cysts and exposed bone
5) Notching of femoral neck
6) Varus positioning of femoral component (
The axillary nerve runs in the quadrilateral space. List the 4 structures which make up this space.
1) Teres Minor (Superior)
2) Teres Major (Inferior)
3) Long Head of Triceps (Medial)
4) Humerus (Lateral)
List the dermatome associated with each of the following:
a. Anterior aspect of the knee
b. Medial aspect of the calf
c. Skin in groin area
d. Skin over clavicle
1) Anterior aspect of the knee - L3
2) Medial aspect of the calf - L4
3) Skin in groin area - L1
4) Skin over clavicle - C4 (AC joint)
[note: in diagram below, C3 is in supraclavicular fossa, not medial clavicle]
List 6 non-osseus manifestations of fibrous dysplasia
a. Mazabraud
1. intramuscular myxoma
b. McCune-Albright
2. Café-au-lait
3. Endocrine hyperfunction
4. precocious puberty
5. hyperthyroid
6. hyperphosphatemia
7. hyperprolactinemia
8. hypercortisolism (cushing)
9. growth hormone excess(acromegaly))
List 6 Osseus manifestations of fibrous dysplasia
- Shepherd’s crook deformity (varus of femur)
- LLD
- Skull bossing
- Prominent jaw
- Tibial bowing
- Rib masses
- ‘Cherubism’ (=symmetric involvement of both mandible & maxilla)]
List 5 negative prognostic factors for healing of a type II odontoid fracture
a. Age >40 years
b. Posterior displacement >5mm
c. Angulation >11°
d. Significant comminution
e. Fracture gap >2mm
f. Concomitant neurologic deficits
g. >4-day delay to the start of treatment
h. Loss of position > 2mm
i. Patient factors smoking, malnutrition, DM, EtOH
List 2 cervical spine issues associated with Down’s syndrome
a. Atlanto-Occipital instability
b. Atlanto-Axial instability
c. Subaxial C spine instablilty
List non- cervical spine issues associated with Down’s syndrome (made up for fun)
i. Cardiac - Congenital heart disease 50%, AVSD 45%, VSD 35%, PDA 7%, TOF 4%
ii. Leukemia - ALL .3%, AML .3%
iii. ENT - Hearing loss 75%, Otitis media 50%, OSA 50%
iv. Optho - Near/far sighted 50%, Strabismus 40%, Congenital cataracts
v. GI - atresia 12%, celiac 7%, Hirschsprung 1%
vii. Neuro/psych - Mental impairment, seizures 8%, alzheimers 75%, ADD 6%, Depression 6%
viii. Endocrine - Hypothyroidism 15%, DM 1%
ix. MSK –
1. Hip/PF instability
2. scoliosis,
3. MCP/Hip/PF/Ankle arthropathy
4. SCFE
5. foot deformitie
List 2 issues to address intraoperatively when placing C1-2 screws
- Reduce C1/2 and confirm with fluoro
2. Posterior to see C2 lateral mass, debride C1/2 joint and bone graft prn
List 4 potential sites of compression for posterior interosseous nerve (PIN)
a. Fibrous bands - proximal to joint (BR and Brachialis)
b. RC joint - masses
c. Leash of Henry - recurrent radial vessels that fan out across PIN at level of radial neck
d. ECRB - fibrous edge
e. Arcade of Frohse - Proximal edge of supinator
f. Supinator muscle - usually distally
List 3 imaging findings/clinical findings/associated diseases (?) associated with dural ectasia.
i. Enlargement of neural canal (anywhere along spinal column)
ii. Cortical thinning of pedicles
iii. Cortical thinning of lamina
iv. Widening of neural foraminae
v. Anterior meningocele
Associated diseases:
i. Marfans ii. Ehlers-Danlos iii. NF-1 iv. Ankylosing Spondylosis v. Osteogenesis imperfect vi. Tumors vii. Post-traumatic and post-surgical
List 6 potential complications associated with a malpositioned acetabular component.
a) dislocation
b) impingement
c) bearing surface wear
d) leg length discrepancy
e) osteolysis
f) altered hip biomechanics
g) need for revision
Lewinneck safe zone
• 15 degrees anteversion (+/- 10 degrees)
• 40 degrees lateral opening (+/- 10 degrees)
List 3 distinct anatomic landmarks used to ensure proper alignment of the femoral component in TKA
a) Transepicondylar axis
b) Whitesides line
c) Posterior condylar axis
The Thessaly test is designed to identify knee meniscal tears. This test is performed by alternatively internally and externally rotating the tibia while the patient is weightbearing on a slightly flexed knee. (20 degrees flexion > sens/specific > 5 degrees). List 4 possible reasons that may lead to erroneous (false positive) findings
a) Symptomatic OA
b) Combined ACL injury
c) Loose bodies
d) OCD
List 3 possible anatomic causes secondary to synovitis which can cause to swan neck deformity.
Swan neck causes secondary to synovitis at the PIP (3)
a) PIP volar plate attenuation - PIP hyperextension
b) FDS attenuation/rupture - PIP hyperextension
c) Collateral band subluxation (attenuated transverse retinacular ligament) - constant PIP hyperextension
Accentuating factors
d) Extensor tendon rupture over DIP (DIP synovitis) - mallet finger
e) MCP flexion/volar subluxation - increases intrinsic muscle tightness
f) Intrinsic contractures - increases intrinsic muscle tightness
16 y.o. Jehovah’s witness involved in trauma leading to high volume blood loss. Patient coherent and psychologically stable but with impending shock. You tell patient she needs blood transfusion but she adamantly refuses. List two conflicting ethical principles in this dilemma. (2)
1) Autonomy
2) Beneficence
List 2 mechanisms of BMP
a. Recruitment
i. Of stem cells
b. Induction
i. Osteoblast and chondrocyte formation
ii. BMP-7 – blood vessel formation
iii. BMP2 – increases vascularity of tumors
List 3 spine findings in Achondroplasia?
- Foramen magnum stenosis
- Upper c spine stenosis
- Thoracolumbar junction kyphosis
- Lumbar spinal stenosis
