Short Answer 2013 Flashcards
Indications for scaphoid fixation (4)
- proximal pole fractures
- fracture gap >1mm on any view
- Humpback - intrascaphoid angle >35 degrees
- Associated with perilunate dislocation
- radiolunate angle >15 degrees
- patient who wants faster return to work/sport
List minimally invasive techniques for treating CVT (3)
congenital vertical talus
- Percutaneous Achilles tenotomy
- selective capsulotomies of talonavicular joint and anterior aspect of subtalar joint
- TaloNavicular pin fixation through small medial incision
*Achilles plus one of the other 2 options
All 3 proceedures are preceeded by serial casting
Thessaly test. What are 3 factors (exclusion criteria) that will give you false positives (3)
1) Symptomatic OA
2) Combined ACL injury
3) Loose bodies
4) OCD
Mayfield stages of perilunate dislocation. (4)
1) scapholunate dissociation
2) + lunocapitate disruption
3) + lunotriquetral disruption, “perilunate”
4) lunate dislocated from lunate fossa (usually volar)
Endocrinopathies associated with SCFE (5)
- hypothyroidism (labs show elevated TSH)
- osteodystrophy of chronic renal failure (abnormal BUN and creatinine)
- panhypopituitarism
- low growth hormone level
- hypogonadism
- adiposogenital syndrome
- pseudohypopituitarism
Benefits of conning down x-ray (3)
- reduce patient radiation dose
- . improves the quality of the radiograph by decreasing the amount of scatter radiation produced
- . decreases the potential exposure to the hands surgeon/radiographer
Perthes head at risk signs (5)
1.Gage’s sign,
a radiolucent defect between the lateral epiphysis and metaphysis
2) calcification lateral to the epiphysis
3) metaphyseal cysts
4) lateral subluxation
5) horizontal growth plate
Rheumatoid arthitis. Unable to extend Ring Finger and Little Finger. List 3 most LIKELY causes.
(3)
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) MCP dislocation
4) Partial PIN palsy (compression neuropathies seen in RA; compression of PIN at elbow)
Differentiation between transient synovitis vs septic hip excluding hip aspiration.
List 3 clinical criteria. (3)
- Fever oral temperature >38.5 degrees C
2) elevated C-reactive protein >2.0 mg/dL (>20 mg/L)
3) Unable to weight-bear
4) Elevated WBC (>12000)
5) Elevated ESR (>40)
6) Pseudo-paralysis
Ulnar sided wrist pain in a middle age lady tennis player. O/E she is tender over distal ulna, ulnar carpal and triquetrum. List 3 possible dx: (3)
- ECU subluxation
- Triangular fibrocartilage complex (TFCC) traumatic lesions
- Distal radioulnar joint (DRUJ) arthritis
- Ulnar impaction
List landmarks of dorsal ulnar and radial portals (2)
- 3-4 Located just distal to Lister tubercle, between EPL and EDC; Established
first, primary viewing portal - 6U Located just ulnar to ECU tendon; Primary adjuct for visualization and
instrumentation, ulnar-sided TFCC repairs
Principles of tendon transfers (6)
- donor tendon must be expendable
- donor muscles with > or = 4/5 strength should be used for tendon transfers
- tendon excursion of the donor unit must be sufficient to restore the lost function of the recipient unit
- vector of recipient tendon should be in line with donor muscle & ideally, transfer should cross only one joint
- single transferred tendon should perform one function
6.Transfers must not be placed through heavily scarred
soft-tissue planes, which limit excursion
- Preop joints must have nearly full passive ROM
- Tendons with in-phase functions should be used preferentially
Reasons to be cautious in performing surgical repair of achilles tendon (4)
- Wound healing problems
2) Infection
3) Sural nerve injury
4) Rupture of Achilles tendon
5) Deep vein thrombosis
Contra-indications for periacetabular osteotomy (3).
- Moderate to advanced secondary osteoarthritis—grade 2or 3
2) Older age
3) Major hip joint incongruity
4) Obesity
5) Major restriction of hip motion (hip flexion of less than100 degrees or
abduction of less than 30 degrees, unless a proximal femoral procedure is
planned to address femoroacetabular impingement)
6) For rotational osteotomy
a. CE angle lower than 40 degrees
b. Acetabular roof inclination greater than 60 degrees
c. Femoral head deformity inaccessible for correction
7) Major medical comorbidities
8) Patient noncompliance
2.
3.
List 3 non-skeletal manifestations of Marfans syndrome. (3)
1) Cardiac abnormalities
a. Aortic root dilation
b. Aortic dissection
c. Mitral valve prolapse
2) Ocular – superior lens dislocation (60%)
3) Spontaneous pneumothoraces (and/or apical blebs)
4) Dural ectasia (60%)
5) Meningocele
Knee ligaments: Rank from weakest to strongest (MCL, LCL, PCL, ACL). (4)
1) LCL – tensile strength 750N (weakest)
2) ACL – 2200-2500N
3) PCL – 2500-3000N
4) MCL – 4000N (strongest)
List 6 risk factors for development of radioulnar synostosis after surgery (ORIF of radius & ulna fractures). (6)
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 factors for poor prognosis in pediatric radial neck fracture (4)
1) Age > 10 years
2) Angulation > 30 degrees
3) Displacement > 3mm
4) Delayed treatment
5) Associated injuries
6) Open reduction
List 3 predictors of bad outcome in pediatric radial neck fractures (3)
The later the surgical intervention, the poorer the result (5 days).
- Open reduction compared to closed reduction
- Severely displaced - initial angulation > 30 degrees or displacement >3 mm (or 4mm).
- Associated with other injuries:
a. elbowdislocation
b. fracture of the olecranon
c. avulsion of the medial epicondylar apophysis - Magnitude of force to the elbow is a major factor in determining the quality of the result.
List the two muscles that surround the radial nerve after passing through the intermuscular septum. (2)
1) Brachialis
2) Brachioradialis
What are 3 conditions in the spine that enhance with gadolinium on MRI. (3)
1) Epidural fibrosis/scar (after previous discectomy/laminectomy)
2) Infection (osteomyelitis and/or discitis, sinus tract, abscess)
a. Abscesses peripherally enhance
3) Tumors
a. Helpful to determine area to biopsy; do not biopsy necrotic area (which does not enhance)
b. Post-op to assess for tumor recurrence
4) Atlantodental joint in rheumatoid arthritis
a. Joint effusion will enhance, pannus will not
Developmental spondylolisthesis - what are four dysplastic anatomic features that
predict/contribute to progression. (4)
1) Laminar dysplasia
2) Facet dysplasia
3) Size of L5 transverse process
4) Lumbar index
5) L5-S1 disc height
6) Sacral doming
What are benefits of increased offset in THA. (4)
1) Decreased joint reaction force
2) Restores tension of abductor muscles
3) Greater hip abduction motion and strength
4) Decreases risk for dislocation
5) Reduction in polyethylene wear
6) Reduced bony impingement
Indications for percutaneous pinning in pediatric distal radius fracture (4)
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?
List (poor) prognostic factors for osteosarcoma. (5)
1) Metastases on presentation
2) Discontinuous involvement of bone (skip lesions)
3) Primary tumor located in axial skeleton
4) Large tumor size (>8cm)
5) Increased ALP or LDH levels
6) Poor response to pre-op chemo (<90% necrosis)
7) Adult presentation
8) Pathologic #
9) Local recurrence
10) Lymph node involvement
Risk factors for DVT in association with MRSA osteomyelitis (4)
Risk factors for DVT in children with osteomyelitis include
Holmig et al. JBJS-Am 2007;89:1517-1523.
1) CRP > 6
2) Age > 8 years
3) Surgical Tx of osteomyelitis
4) MRSA osteomyelitis
Altobelli & Quinonez. Hospital Pediatrics 2012;2:167-172.
1) Critically ill patients
2) Patients who had central venous catheters placed
3) Patients with pulmonary findings
4) Patients with positive blood cultures, particularly those with MRSA bacteremia
Proximal tibiofibular dislocation – this question was on twice
Mechanism (2) – leg position and knee position
- Sudden internal rotation & plantarflexion of foot
- External rotation of leg & flexion of knee
b. Clinical findings (2) - Visible bony prominence in region of fibular head
- Lateral knee pain with tenderness over fibular head
- Locking & popping of knee when mobilized
- Peroneal nerve symptoms
c. How to reduce (2) - Pressure applied to fibular head
- Knee flexed to 100 degrees, ankle externally rotated & dorsiflexed
Muscular dystrophy. Use of corticosteroids
Benefits (3)
- Acutely improves strength
- Slows weakening
- Prevents scoliosis formation
- Delays deterioration of pulmonary function
- Prolongs ambulation
b. Complications (3)
- ON
- weight gain
- cushingoid appear
4 techniques of pediatric ACL reconstruction
Types
- Physeal sparing
- Partial transphyseal
- Full transphyseal
- wait until skeletal maturity
- Tunnels smaller more vertical tunnel
- Tendon graft only
- Irrigate tunnels profusely
< 5% cross sectional area will not cause growth arrest
List the Long term radial head fracture complications (4)
- Elbow stiffness (missed osteochondral fracture)
- Radiocapitallar osteoarthritis
- Chronic wrist pain (missed Essex-Lopresti lesion)
- RSD
- Instability/Late elbow dislocation
- AVN (rare)
List 8 criteria to determine DCO vs early total care (Only 4 f’ing marks!)
- Chicago review
- ISS > 40 (without thoracic trauma)
- ISS >20 (multiple injuries) plus thoracic trauma (AIS >2) à eg. Multiple rib #’s
- Multiple injuries with severe pelvic/abdominal trauma and hemorrhagic shock
- Bilateral femur fractures
- Pulmonary contusions noted on x-ray
- Hypothermia < 35 degrees C
- Head injury with AIS of 3 or greater
- Previous exam
- pH<7.2
- Fibrinogen <1
- DIC
- Platelets <70
- sBP <70-90
- lactate >2.5
- base deficit >6-8mmol/L?? (JAAOS)
List 8 x-ray findings of aortic rupture. (8) – ATLS
- Widened mediastinum (>8cm at level of aortic arch is abnormal)
- Fracture of 1st or 2nd ribs or scapula
- Displacement of esophagus (NG tube) to right
- Displacement of trachea to right
- Depression of left mainstem bronchus
- Elevation of right mainstem bronchus
- Left hemothorax
- Cardiac enlargement
- Pericardial effusion
- Obliteration of aortic knob
- Diffuse enlargement of aorta with poor definition or irregularity of aortic contour
- Inward displacement of aortic wall calcification >10 mm
- Pleural effusion (left)
- Apical pleural hematoma
- Loss of aortopulmonary window
- Widened paratracheal stripe
- Apical cap
List extra-osseous findings of fibrous dysplasia (4)
Mazabraud
- intramuscular myxoma
McCune-Albright
- Café-au-lait
- Endocrine hyperfunction
- precocious puberty
- hyperthyroid,
- hyperphosphatemia
- hyperprolactinemia
- hypercortisolism (cushing)
- growth hormone excess(acromegaly)
List three Benefits of locking plate vs DCS plate (3)
- Less bone is removed
- Better fixation in osteoporotic bone
- 55% RRR of deep infection in open fractures
To note : locking plates have higher risk of fixation failure and revision sx
c/w DCS plate JAAOS Distal Femur Fractures: current concepts
- Less soft tissue stripping
- Do not need locking plate to be placed along bone
Ways to avoid AVN in adolescent femoral nail (3)
- Avoid at risk patients – overweight
- IM nailing of femoral fractures in adolescents CORR 1998
- Avoid piriformis start point
- Avoid extensive dissection when removing the nail
3 radiologic criteria confirming reduction of young adult femoral neck fracture (3)
AP
- Align trabeculae(proximal and distal segments)
- Ensure neck/shaft angle is restored
Developmental spondylolisthesis - what are four dysplastic anatomic features that predict/contribute to progression. (4)
- Laminar dysplasia
- Facet dysplasia
- Size of L5 transverse process
- Lumbar index
- L5-S1 disc height
- Sacral doming
Muscular dystrophy. Use of corticosteroids list 3 benifits and 3 complications.
Benefits (3)
- Acutely improves strength
- Slows weakening
- Prevents scoliosis formation
- Delays deterioration of pulmonary function
- Prolongs ambulation
Complications (3)
- ON
- weight gain
- cushingoid appearance
- GI symptoms
- mood lability
- HA
- short stature
- cataracts
Techniques to avoid varus in adult subtrochanteric # using a nail (3)
- Medial entry point (and use a rongeur to remove more bone medially if the initial start point is too lateral)
- Partial (to LT or less) insertion of guidewire (deep guidewire placement constrains reamer into a varus fracture malreduction position)
- Avoid eccentric reaming of the proximal medial cortex of the distal fragment
- Reduce with picador/spiked pusher
- Schanz pins
- Clamp prior to reaming
- Place a unicortical plate
- Cerclage wire
List 4 ankle syndesmosis structures (4)
- anterior inferior tibiofibular ligament
- posterior inferior tibiofibular ligament
- interosseous ligament
- inferior transverse ligament
List 3 radiographic clues for Lisfranc injury. (3)
- widening of interval between 1st and 2nd ray (*normal is up to 3mm)
- medial base of 2nd MT does not align with medial side of middle cuneiform
- medial base of 1st MT does not align with medial side of medial cuneiform
- fleck sign – bony fragment in 1st intermetatarsal space
- medial side of 4th MT does not line up with medial side of cuboid
- medial side of 3rd MT does not align with medial border of lateral cuneiform
- dorsal displacement of base of 1st or 2nd MT
lateral weightbearing view
- disruption of Meary’s line
manual stress view
- AP with foot held in abduction, pivoting around the anterior aspect of the calcaneus. If the medial column line (along medial border of navicular and medial cuneiform) is >2mm away from intersecting the 1st MT, consider operative intervention
List 3 components of Lenke classification (3).
- Curve type
- Lumbar spine modifier
- Thoracic sagittal modifier
List four anatomic features of pincer FAI. (4)
- anterosuperior acetabular rim overhang
- acetabular retroversion
- acetabular protrusion
- coxa profunda
ASIA list 11 myotomes and their muscle groups. (11)
- C5 – elbow flexors - Biceps Brachii, Brachialis
- C6 – wrist extensors - ECRL, ECRB
- C7 – elbow extensors - Triceps
- C8 – finger flexors - FDP
- T1 – finger abductors - Abductor Digiti Minimi
- L2 – hip flexors - Iliopsoas
- L3 – knee extensors - Quadriceps
- L4 – ankle dorsiflexors - Tibialis Anterior
- L5 – great toe extensor - EHL
- S1 – ankle plantar flexors - Gastrocnemius, Soleus
- S4,5 – voluntary anal contraction
List three findings of sacral sparing in acute SCI. (3)
- voluntary anal contraction
- sensation of deep anal pressure
- S4-5 sensation (perianal)
Post tourniquet syndrome findings. (4)
- edema
- stiffness
- pallor
- weakness (but no paralysis)
- subjective numbness (without objective anesthesia)
- Edema
- Stiffness
- Palor
- weakness (but no paralysis)
- subjective numbness (without objective anesthesia)
Rotator cuff tear: 4 factors of poor healing of repair.
Not medical comorbidities & Not tear characteristics (4)
- increased patient age
- fatty infiltration
- muscle atrophy
- inability to elevate >100 degrees
- weak elevation and ER
- Smoking
- multiple corticosteroid injections
- use of immunosuppressive drugs, catabolites, or prednisone
seems as if 2,3 and 3,4 are similar or the same.
List 6 complications associated with acetabular malposition. (6)
- dislocation
- impingement
- increased linear wear (vertical cup)
- altered hip biomechanics
- leg length discrepancy
- pelvic osteolysis
- need for revision
-Lewinneck safe zone – 15 degrees anteversion (+/- 10 degrees), 40 degrees lateral
opening (+/- 10 degrees)
- Dislocation
- Impingement
- Bearing surface wear (increased with verticle cup)
- pelvic osteolysis
- altered hip biomechanics
- need for revision
- Leg length discrepency
Lewinneck safe zone – 15 degrees anteversion (+/- 10 degrees), 40 degrees lateral opening (+/- 10 degrees)
Components of WHO surgical safety checklist (6)
- patient confirms-ID,proceedure,site,conscent
- correct site (marked)
- allergies
- airway/aspiration risk
- antibiotics
- anesthetic equipment & medication check complete
- anticipation of blood loss
- Anticipated critical events
- Essential imaging displayed
List components of informed consent (4)
- nature of treatment
- anticipated outcome of treatment
- significant risks involved
- available alternatives (including expected outcome if patient does not undergo treatment)
other important elements of consent
- voluntary
- patient capable of giving consent
- patient comprehends
- documentation
