The List Challenge Flashcards

Question 1

Q

LIST THE THREE MOST COMMON PEDIATRIC AVULSION FRACTURES IN THE PELVIS/FEMUR

Answer

A

Sartorius from ASIS
Iliopsoas from LT
Hamstrings from ischium (only one that may cause symptoms after healing)

Skaggs - Staying out of trouble

Question 2

Q

METHODS TO MEASURE PATELLA HEIGHT

Answer

A

 Insall-Salvati 0.8-1.2
 Blackbourne-Peel Ratio 0.5-1.0
 Canton-Deschamps 0.6-1.3
 Plateau-Patella angle 20-30 degrees is normal
 Blumensaats line should intersect inferior pole of patella at 30 degrees of flexion

Question 3

Q

BONY BANKART - HOW ARE YOU GOING TO TREAT THE FOLLOWING LESIONS IN A 25 YR OLD (FOLLOWING THE BOORMAN DOGMA OF SOFT TISSUE FOR SOFT TISSUE AND BONE FOR BONE)?

Answer

A

Attempt at ORIF
then I would do a Latarjet

Question 4

Q

DESCRIBE ANATOMICALLY HOW YOU WILL PLACE YOU TUNNELS FOR ACL RECONSTRUCTION

Answer

A

• For a single bundle ACL recon, going from center of origin to center of insertion (anatomic)
• Femoral:
- center of femoral ACL origin is 1.7mm proximal (posterior on scope) to bifurcate ridge and 6.1mm posterior to intercondylar ridge (inferior on scope)
- to confirm this position, also ensure its ~8.5mm anterior to the posterior cartilage and between 11-8 o’ clock

• Tibia:

center of tibial insertion is 7.5mm medial to anterior horn of lateral meniscus, 7.9mm lateral to medial plateau cartilage, and 13mm anterior to the retroeminence ridge
radiographically tunnel centered in AP direction at 41% from anterior and 47% from medial

Question 5

Q

What are 7 ways to optimize conditions in distraction Osteogenensis?

Answer

A

Low energy osteotomy
Minimal soft tissue stripping at corticotomy
Stable external fixation
Latency period 5-7 days
Distraction at 1 mm/day divided into 4
Neutral fixation interval - consolidation
Normal physiologic use of the extremity during the process

Miller’s page 17

Question 6

Q

List 4 Risk Factors for Mortality after Hip Fracture

Answer

A

Advanced age
Male
Poor cognitive function
> 3 medical comorbidities (when not actively medically optimizing)
> 48 hrs until treatment

Miller’s

Question 7

Q

WHAT ARE THE 17 MUSCLES ATTACHED TO THE SCAPULA?

Answer

A

Serratus Anterior

Supraspinatus

Subscapularis

Trapezius

Teres Major

Teres Minor

Triceps Brachii long head

Biceps Brachii

Rhomboid Major

Rhomboid Minor

Coracobrachialis

Omohyoid inferior belly

Lattisimus Dorsi

Deltoid

Levator Scapula

Infraspinatus

Pectoralis Minor

Question 8

Q

What is the. Safe zone for acetabular screw placement and what structures are at risk in each zone?

Answer

A

Postero superior (safe)

Sciatic nerve

superior gluteal vessels

posteroinferior

sciatic nerve

inferior gluteal artery and nerve

internal pudendal nerve and vessel

use screw <20mm, then safe

antero-inferior (Unsafe - danger zone)

obturator nerve, artery and vein (artery most at risk)

anteo-superior (Unsafe - death zone)

external iliac vessels ( vein most at risk)

Question 9

Q

WHAT ARE 3 CRITERIA TO DIAGNOSE POST RADIATION SARCOMA?

Answer

A

The histological features of the original lesion and PRS are completely different.
PRS is located within the field of irradiation.
Patients with cancer syndromes such as Li-Fraumeni and Rothmund-Thomson are excluded.
The latent period (period between initiation of radiotherapy and histologic diagnosis of second neoplasm) is more than 5 years.

Manny’s notes

Question 10

Q

Regarding Patellar Clunk Syndrome

What type of TKR’S are affected?
What causes it?
In what degree of flexion does it occur?
What is the treatment?

Answer

A

PS
Fibrous tissue posterior to the quads above the superior pole of the patella catches in the box when the knee flexes/extends.
30-45 degrees
arthroscopic or open debridement

Question 11

Q

LIST 6 SARCOMAS THAT METASTASIZE TO LYMPH NODES

Answer

A

SCREAM
• Synovial cell
• Clear Cell Sarcoma
• Rhabdomyosarcoma
• Epitheloid
• Angiosarcoma
• Myxoid liposacoma

From Mike’s notes

Question 12

Q

MDI - HOW ARE YOU GOING TO TREAT THE FOLLOWING LESIONS IN A 25 YR OLD (FOLLOWING THE BOORMAN DOGMA OF SOFT TISSUE FOR SOFT TISSUE AND BONE FOR BONE)?

Answer

A

Non-op x 1
then arthroscopic bankart repair using suture anchor construct

Question 13

Q

What 5 Factors can Contribute to Catastrophic Wear in TKA?

Answer

A

PE thickness (>=8mm is better)
Articular geometry (flatter = worse)
PE sterilization (oxygen environment = worse)
PE machining (compression molding = better)
Sagittal plane kinematics (sliding = worse)

Question 14

Q

COMPLICATIONS OF MENISCAL REPAIR

Answer

A

 Saphenous neuropathy (7%)
 Arthrofibrosis (6%)
 Effusion (2%)
 Peroneal neuropathy (1%)
 Infection (1%)

Question 15

Q

WHAT IS THE BEST LABORATORY TEST TO “RULE IN” INFECTION AND WHAT IS THE BEST TEST TO “RULE OUT” INFECTION?

Answer

A

Neutropenia (WBC < 5000) in a newborn is best to rule infection
CRP is best to rule out infection

Question 16

Q

LIST SIX SIGNS/SYMPTOMS OF HYPERCALCEMIA

Answer

A

Polyuria
Polydypsia
Renal stones/flank pain
Osteitis fibrous cystica
Altered CNS function (marty does not like points)
Anorexia
Nausea
Vomitting
Constipation
Weakness

Question 17

Q

LIST THREE BLOCKS TO REDUCTION OF A PEDIATRIC PROXIMAL HUMERUS FRACTURE

Answer

A

Periosteum
joint capsule
Long head of biceps tendon

Rockwood and Wilkins 7th ed p650

Question 18

Q

LIST 6 MINIMALLY INVASIVE TECHNIQUES TO REDUCE A PEDIATRIC RADIAL NECK FRACTURE

Answer

A

Closed reduction Techniques
o Patterson’s Technique: traction with forearm in supination and apply a varus force and manipulate the fragment with a thumb.
o Israeli technique: Flex the arm to 90 degrees in supination and put a thumb on the radial head. Pronate the arm and push the RH back in. If the patient can achieve 60 pro and 60 sup, it is a success.
o Esmarch Bandage (Chambers technique): wrap the extremity tightly from distal to proximal.
Percutaneous Reductions
o Perc pin: Single perc Steinmann pin as close to the lateral border of the olecranon as possible.
o Wallace Method: Periosteal elevator plated perc down the lateral border of the olecranon. Lever the distal fragment laterally and the proximal fragment medially with a thumb. Can hold the reduction if unstable with a perc K wire.
o Metaizeau: Percutaneous bent intramedullary rod from radial styloid proximally. Hook the displaced radial head and rotate it into position.

Question 19

Q

List 10 Radiographic Findings with Achondroplasia

Answer

A

Foramen magnum stenosis
TI kyphosis
Lumbar stenosis
Short pedicles
Decreased intra-pedicular distance
Genu varum
Coxa vara
Champagne pelvis
Trident hands
Frontal bossing
Button nose
Normal intelligence
Hypotonia

Question 20

Q

HOW LONG DO YOU BRACE POST PONSETTI TREATMENT?
WHAT IS THE SUCCESS RATE WITH VIGILANT FOLLOW-UP AND BRACING?
WHAT IS THE RECURRENCE RATE IF NOT VIGILANT?
PIRANI SCORE?

Answer

A

• continuous for 3 mos, • Then 14-16 hours per day until 3-4 yrs
> 90 %
80%
- Midfoot
  o Curved lateral border
  o Lateral head of talus
  o Medial crease
  - Hindfoot

o Empty heel
o Posterior heel crease
o Rigid equinus

Question 21

Q

LIST 5 PREDICTORS OF HUMERAL HEAD ISCHEMIA FOLLOWING FRACTURE

Answer

A

• Less than 8 mm metaphyseal extension attached to humeral head
• Anatomic neck fracture
• Medial hinge disruption > 2mm
• 4 pt fracture
• More than 45 deg angular displacment of humeral head
 10 mm displacement of a tuberosity
• Glenohumeral fracture dislocation
• 3 pt fracture
• Head splitting fracture

Mo’s book p361

Question 22

Q

List 4 Techniques to Dislocate the Hip in a THA Patient with Protrusio

Answer

A

Liberal capsular release
In-situ neck cut
Extended trochanteric osteotomy/gt osteotomy
Resect a small portion of the medial wall

ref: I think I got if from Campbell’s

Question 23

Q

FACTORS ASSOCIATED WITH POSITIVE OUTCOMES WITH PHYSEAL BAR RESECTION

Answer

A

Younger presentation
Smaller the bridge
Smaller the deformity
Central bridge
Shorter the time interval between injury and surgery

Meningococcal septicemia do worse

Question 24

Q

WHAT ARE THE HONEY BADGERS 4 SOFT TISSUE MASSES THAT REQUIRE CHEMOTHERAPY

Answer

A

RSSD

Rhabdomyosarcoma
Synovial Cell Sarcoma
Soft tissue Osteosarcoma (MFH), Soft tissue Ewings
De-differentiated or Mesenchymal Chondrosarcoma

Question 25

Q

LIST 5 SIGNS OF IATROGENIC AVN IN DDH TREATMENT

Answer

A

Salter classification of AVN (5 signs)

• Failure of appearance of ossific nucleus of femoral head during one yr or longer after reduction
• Failure of growth of an existing ossific nucleus during one year or longer after reduction
• Broadening of the femoral neck within one year after reduction
• Increased radiographic bone density followed by fragmentation of the femoral head
• Residual deformity of the femoral head and neck when reossification (resolution) is complete
o These deformities include coxa plana, coxa magna, coxa vara, short broad femoral neck

• Chief notes

Question 26

Q

WHAT ARE THE DIAGNOSTIC CRITERIA FOR FAT EMBOLISM SYNDROME?

Answer

A

Gurd and Wilson Criteria: Needs at least one major and 4 minor criteria
• Major
o Petechiae in a vest distribution
o Hypoxemia with PaO2<60 mmhg and FiO2<0.4
o CNS depression disproportionate to hypoxemia
o Pulmonary edema
• Minor
o Tachycardia (>110 bpm)
o Pyrexia (>38.5)
o Fat emboli visible in retina
o Fat in urine
o Fat in sputum
o Unexplained drop in HCT or PLT count
o Increasing ESR
Ref: Gurd and Wilson

Question 27

Q

POSTERIOR TIBIAL TENDON DYSFUNCTION CLASSIFICATION

Answer

A

Stage 1:
o able to perform straight toe raise
o tenosynovitis without deformity
o No x-ray changes
Stage 2:
o A:
 unable to perform single leg heel rise.
 Flexible Hindfoot
 <30% TN uncoverage on X-ray
o B:
 unable to perform single leg heel rise.
 Flexible Hindfoot
 Too many toes sign clinically
 >30% TN uncoverage
Stage 3:
o unable to perform single leg heel rise
o Rigid hind and forefoot deformity
o Degenerative changes subtalar joint
Stage 4:
o 3 + deltoid compromise (lateral tilt ankle)

Question 28

Q

LIST 5 INDICATIONS TO OPERATE ON A SCAPULA FRACTURE

Answer

A

Open fracture
25% glenoid involvement with humeral instability
5 mm glenoid articular surface step-off or major gap
Extensive medialization of glenoid
Displaced scapular neck fracture > 40 deg of angulation or 1 cm translation
Glenopolar angle <20
Coracoid displace > 1cm7

(Chart here I could not copy)

GPA = Angle measured between a line connecting the most cranial with the most caudal point of the glenoid cavity (white line)and a line connecting the most cranial point of the glenoid cavity with the most caudal point of the scapular body (black line).
The GPA measures the obliquity of the glenoid articular surface in relation to the scapular body.
Normal is 30° to 45°

Question 29

Q

Name 3 Indications for Revision for Metal on Metal Hips (COA 2011)

Answer

A

Painful hips with MRI showing a soft tissue mass and high blood cobalt (>7ppb)
Painful hips with +MRI and normal Cobalt levels
Soft tissue mass increasing in size with or without high blood levels

Rising levels on their own are an indication for follow-up, not revision.

Jer’s notes …(and COA update)

Question 30

Q

REVERSE BANKART IN POSTERIOR INSTABILITY - HOW ARE YOU GOING TO TREAT THE FOLLOWING LESIONS IN A 25 YR OLD (FOLLOWING THE BOORMAN DOGMA OF SOFT TISSUE FOR SOFT TISSUE AND BONE FOR BONE)?

Answer

A

• reverse Bankart repair

Question 31

Q

SIX FEATURES OF CRPS

Answer

A

o Hyperaesthesia, hyperalgesia, allodynia
o Temperature difference compared to contralateral
o Skin colour change
o Edema
o Sweating change
o Stiff joints, weakness, tremor, dystonia, trophic changes (nail, hair skin)
o Osteopenia

Manny’s Lists

Question 32

Q

SPINE
NAME A PHYSICAL EXAM METHOD TO DISTINGISH C8 RADICULOPATHY FROM ULNAR NERVE PALSY?

Answer

A

• FDS to 2nd digit - C8 provides power grip and will so FDS to index will be weak but this is not affected because it is innervated by the medial nerve.

Question 33

Q

CAVUS (CMT - WEAK PB AND STRONG PL AND WEAK TA AND STRONG PL)
WHAT ARE NON-OP STRATEGIES?

Answer

A

• Extra-depth shoes (gets forces spread across whole foot vs over heel and MT heads), lateral posting orthotic, achilles stretching

Question 34

Q

List 12 Biological or Mechanical Factors Influencing Fracture Healing

Answer

A

Patient age
Comorbid medical conditions
Functional level
Nutritional status
Nerve function
Vascular injury
Hormones
Growth factors
Health of soft tissue envelope
Sterility (open fractures)
Cigarette smoking
Local pathologic condition
Level of energy imparted
Type of bone loss
Extent of bone loss
Soft tissue attachments to bone
Stability of immobilization
Anatomic location
Blood supply

Table 1-6 p 15 Miller’s

Question 35

Q

HOW CAN YOU DIFFERENTIATE CLINICALLY PSEUDOPARALYSIS (FRACTURE AND INFECTION) FROM PARALYSIS (BRACHIAL PLEXUS)?

Answer

A

• Palpation or Moro reflex
o stimulating the limb in some way should lead to some movement if pseudoparalysis

Question 36

Q

WHY ARE KIDS PRONE TO TIBIA VALGUS IN PROX TIB METAPHYSEAL # ? (IE WHAT ARE THE PROPOSED THEORIES)

Answer

A

Physeal arrest of the lateral prox tib physis/ assymmetric activity of the physis
Early weight bearing
Tethering effect of the fibula
Inadequate reduction/ interposed soft tissue
Loss of tethering effect of the pes anserinus
? increased vascularity (no mention in LW or chief notes…)

Chief review notes

Question 37

Q

NAME 8 POSITIVE PREDICTORS FOR GOOD SURGICAL OUTCOME OF CALCANEUS FRACTURES

Answer

A

(Buckley – 2002)
- Women (higher SF-36)
- Non worker’s compensation patient
- Men Age <30
- Bohler’s angle > 0-15
- Light work labourers
- Single fracture line
(Buckley – 1992)
- Non Smokers
- Anatomic reduction or <2mm step

Comminuted fractureOperative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial JBJS 2002
Poor Outcomes (10-20% Wound Complications)
o Age > 50
o Obese
o Manual Labor
o Workers Comp
o Smoking
o Bilateral
o Polytrauma
o DM, PVD
o Men

Question 38

Q

WHEN WOULD YOU USE TRANSILIAC TRANS SACRAL SCREWS

Answer

A

• Transiliac-transsacral screws may be particularly useful in the presence of

Osteoporosis
Significant posterior pelvic instability including spinopelvic dissociation
Patient obesity
Anticipated noncompliant behavior
Bilateral posterior pelvic injuries
Nonunion procedures.

• Transiliac-transsacral screws for posterior pelvic stabilization; J Orthop Trauma. 2011 Jun;25(6):378-84.

Question 39

Q

WHAT SARCOMA’S NEED WIDE EXCISION ONLY (NO RAD/CHEMO) (3)

Answer

A

Chondrosarcoma
Adamantinoma
Parosteal Osteosarcoma
Low grade intrameduallary osteosarcoma

AAOS 2010

Question 40

Q

LIST 5 “MALIGNANT” TUMORS THAT CAN BE TREATED WITH SURGERY ALONE

Answer

A

Chondrosarc
Parosteal osteosarc
Chordoma
adamantinoma
squamous cell (if no mets)
LOW GRADE intramedullary osteosarc

Question 41

Q

HOW MANY PATIENTS WITH ACL RECONSTRUCTION GO ON TO DEVELOP OA

Answer

A

 16-70%

Question 42

Q

WHAT ARE 5 COMPLICATIONS OF A HALO?

Answer

A

Complications:
o pin loosening is the most common.
• A loose pin with no infection can be tightened 1-2 turns.
o Pin site infection is in 20%.
 Deep infection=pin removal and new site, big scars at anterior pins (10%),
o Supraorbital nerve injury (V1 branch of trigeminal)
o skin breakdown
 scapulae and sternum are most common
o intracranial penetration (1%),

o dysphagia is from too much extension.
o Respiratory distress
o Six pins do NOT have more complications than 4 (Nemeth et al., 2001 JBJS)

intracranial penetration (1%),

Question 43

Q

LIST THE AGE APPROPRIATE MANAGEMENT OF A FEMUR FRACTURE IN A: 4 MOS OLD, 4 YR OLD, 8 YR OLD, 13 YR OLD (IMMATURE), 17 YR OLD (MATURE)

Answer

A

4 mos old proximal femur #__________________
4 yr old midshaft spiral____________________
8 yr old midshaft comminuted____________________
13 yr old distal diaphyseal comminuted___________________
17 yr old midshaft horizontal___________________

My thoughts…obviously other options
• Pavlik
• Hip spica
• Flexible nails
• Lateral submuscular plate
• Antegrade nail (piriformis or GT start)

Question 44

Q

WHAT POTENTIALLY LETHAL ABNORMALITY MUST YOU BE LOOKING FOR IN A PATIENT WITH LARSEN SYNDROME?

Answer

A

• Cervical Kyphosis

Question 45

Q

LIST 3 FEATURES OF POEMs (Osteosclerotic myeloma)

Answer

A

Polyneuropathy
Organomegaly
Endocrinopathy
M proteins
Skin changes

Question 46

Q

LIST 3 OPERATIVE INTERVENTIONS FOR DEVELOPMENTAL COXA VARA

Answer

A

Proximal femoral valgus osteotomy
Greater trochanter epiphyseodesis (Age 5 is when apophysis is visible)
Greater trochanter transfer (When 9 yrs or older)

Chief review notes

Question 47

Q

LIST 5 CONDITIONS ON DIFFERENTIAL DIAGNOSIS IN A < 4 YR OLD, 4-10 YR OLD AND > 10 YR OLD WITH A LIMP

< 4 yrs (not in order of frequency)

Answer

A

Toddlers fracture (tibia or foot)
Osteomyelitis, septic arthritis or discitis
Arthritis (JRA or Lyme disease)
Discoid meniscus
Foreign body in foot
Benign or malignant tumor

Question 48

Q

LIST 4 CONDITIONS ASSOCIATED WITH ATLANTOAXIAL INSTABILITY

Answer

A

Down syndrome (odontoid hypoplasia)
JRA
Os odontoideum
o (Ossiculum terminale – NOT ASSOCIATED WITH INSTABILITY)
Pseudochondroplasia
Diastrophic dysplasia
SED congenita (odontoid hypoplasia)
Metaphyseal dysplasia: McKusick’s
Morquio’s (odontoid hypoplasia)

Question 49

Q

INDICATIONS FOR MENISCAL TRANSPLANT

Answer

A

 Young patients with near total meniscectomy
 Lateral > Medial
 Proper mechanical alignment
 < Grade 4 chondrosis
 Intact ACL

Question 50

Q

WHAT THREE SOFT TISSUE FLAPS WILL I KNOW FOR MY EXAM TO DEAL WITH SOFT TISSUE COVERAGE IN THE PROXIMAL / MIDDLE / DISTAL LEG?

Answer

A

Proximal - medial gastrocnemius flap
Middle - soleus flap
Distal - reverse sural artery flap

Question 51

Q

WHAT ARE 2 RADIOGRAPHIC SIGNS OF A POSTERIOR SHOULDER DISLOCATION?

Answer

A

Lightbulb sign
Anterior rim sign
Trough sign

Question 52

Q

LIST 3 FEATURES OF Maffucci’s syndrome

o Multiple exostoses
o Tissue angiomas
o 100% malignant transformation

Answer

A

Multiple enchondromas
Hemangiomas
100% chance of malignant transformation of enchondroma

Question 53

Q

LIST THREE WAYS TO DETERMINE SKELETAL AGE

Answer

A

Gruelich and Pyle
Sauvegrain method
Risser

ref: LW

Question 54

Q

OSCE - WHAT IS YOUR MANAGEMENT OF A POSTEROLATERAL SIMPLE ELBOW DISLOCATION (1)

IN A 25 YR OLD WRESTLER, POST REDUCTION CONGRUENT, STABLE ARC FROM 5-145 DEG

Answer

A

• Splint backslab for < 7 days to let soft tissue settle
• X-ray out of splint to verify reduction
• Clinically assess stability
• No brace so begin gentle active rom
• see back in 2 weeks
• When would he return to sport?
o Full pain free ROM
o Equal strength to opposite side

Question 55

Q

List 5 Indications for a Medial Approach to the Hip

Answer

A

Open reduction of congenital dislocation (good access to psoas)
Obturator neurectomy
Psoas release
Biopsy

Hoppenfeld p455

Question 56

Q

NAME 3 CONDITIONS ASSOCIATED WITH TARSAL COALITION?

Answer

A

Fibular deficiency
PFFD
Aperts syndrome

AAOS

Question 57

Q

WHAT ARE 2 MOST RELIABLE SIGN OF HAND COMPARTMENT SYNDROME?

Answer

A

Swollen
Intrinsic minus position

Question 58

Q

NAME 5 WAYS TO REDUCE IO PRESSURE WHILE REAMING LONG BONES

Answer

A

(Continuously) high revolution speeds
Low insertion (driving) speed
Thinner diameter shaft
Sharp reamers
Deeper flutes
Hollow reamer head
Increased increments by 0.5mm
Venting?

A Comparison Of Pressures Created By Various Commonly Used Intramedullary Reamers

Question 59

Q

Knee Osteotomy Outcomes

Answer

A

HTO - 85% 10 years
DFO - 50% 10 years

Question 60

Q

NAME 6 INDICATIONS FOR BISPHOSHONATES?

Answer

A

Pagets
Osteoporosis
Metastatic bone disease
Polyostotic fibrous dysplasia
OI
AVN
HO
MM
Hypercalcemia

Question 61

Q

LIST THE ACCEPTABLE CRITERIA FOR FLEXIBLE NAILING IN PEDIATRICS TRAUMA

Answer

A

Age: 5-11
Weight: = 50 kg
Fracture in the mid 80% of the diaphysis

RW 7th ed. p811

Question 62

Q

Name 3 Advantages of Lateral Parapatellar Approach (Valgus Knee)

Answer

A

Less violation of medial based blood supply
Easier access to posterolateral corner for release
Better patellar tracking
Lateral releases performed during exposure
Better exposure to affected condyle/plateau

Question 63

Q

List 4 Ways to Judge the TF Joint Line in a Revision Knee

Answer

A

Joint line is 1-1.5 cm above the fibular head
Joint line is at meniscal scar/remnant
Joint line is 1 cm distal to the inferior pole of the patella
Joint line is 2.5 cm distal to the medial epicondyle

Question 64

Q

LIST 5 INDICATIONS FOR ARTHRODESIS IN A HALLUX VALGUS

Answer

A

• DJD
• RA
• Gout
• Down’s
• CP
• Connective tissue disorder (Ehler’s, Marfans)
Manny’s notes and OKU FNA

Answer 65

A

 Plate material
 Offset from bone
 Working length
 Plate length
 Number of screws
 Locked or non-locked screws

Answer 66

A

Psuedoarthrosis (5-10% single level, 30% multiple levels)
Laryngeal nerve injury ( 1% theoretically higher on right side)
Hypoglossal nerve injury
Vertebral artery injury
Dysphagia
Horner’s syndrome
Adjacent segment disease
Hematoma
Airway compromise
Spina cord injury
Dural tear
Esophageal injury
Nerve root injury (C5 most susceptible)
infection
Graft dislodgement
Incomplete decompression
Orthobullets and chief notes

Answer 67

A

 They are all equivocal in the literature

Answer 68

A

 All equivocal, each with their own pros and cons

Answer 69

A

Genu valgum
Femoral anteversion
Pronated feet
Female
Ehlers Danlos
Marfans
Trochlea dysplasia
Patella Alta
Lateral femoral condyle dysplasia
Lateral patella tilt

Answer 70

A

 Increased surface area
 Increased mitochondria
 Increased capillary density
 Increased strength
 Thicker connective tissue

Answer 71

A

Duty
o The duty of the physician is to provide care equal to the same standard of care ordinarily executed by surgeons in the same medical specialty.
Causation
o Causation is present when it is demonstrated that failure to meet the standard of care was the direct cause of the patient’s injuries.
Breach of duty
o Breach of duty occurs when action or failure to act deviates from the standard of care.
Damages
o Damages are monies awarded as compensation for injuries sustained as the result of medical negligence
Orthobullets
DCB’D

Answer 72

A

 Quads dominant (NM control)
 Landing biomechanics (valgus moment)
 Smaller notch
 Genetics (? Collagen production)
 Smaller ligament
 Estrogen
 Valgus alignment

Answer 73

A

Rigid fixation
Normal bone metabolism
Optimal porosity (40-50%)
Minimal gaps (<50um)
Optimal pore depth (deeper the better)
Optimal pore size (50-150um)
Minimal micromotion (<50um)
Good cortical contact

***rule of 50’s for everything*** (Millers)

Answer 74

A

Watanabe classification
o Type 1 Complete
o Type 2 Incomplete
o Type 3 Wrisberg variant (lack of posterior attachment)

Answer 75

A

Normal serum lactate
Normal base deficit
Normal gastric pH (7.4)
Note: can have normal BP, U/O and HR and still be in ‘compenstated’ shock. Thus, look for the biochemical markers of peripheral blood flow

Answer 76

A

increased femoral anteversion
tibial tosion
metatarsus adductus

Answer 77

A

Orthopaedic

Generalized ligamentous laxity and hypotonia
C1-2 instability (22%)
Hip subluxation and dislocation (late)
Patellofemoral instability and dislocation
Scoliosis (50%) and spondylolisthesis (6%)
Pes planovalgus
Metatarsus primus varus
SCFE
Short stature (walk at 2-3)
Clinodactyly, polyarticular arthropathy (10%)

Medical

Mental retardation
Heart disease (50%)
Endocrine disorders (hypothyroidism)
Premature aging

Orthobullets - Also

HEENT: - Flat occiput, microcephaly, upslanting palpebral fissure, epicanthal folds, speckled iris (Brushfield spost), hearing loss
CNS: hypotonia, mental retardation
CVS: congenital cardiac defects (50%) ie: AVSD, endocardial cushion
GI: duodenal/esophageal/anal atresia, TE fistula
GU: cryptorchidism
Derm: single palmar crease (Simian crease)
Endo: hypothryoid, DM (later in life)
Other: leukemia/lymphoma (later in life), Alzheimer’s (later in life)

Answer 78

A

highly variable
May have RC tendinitis and impingement in < 20 yr old

Answer 79

A

 Intrarticular steroids
 Hyperparathyroidism
 Renal failure
 Diabetes
 Chronic tendonosis
 RA
 Systemic steroids
 Connective tissue disease

Answer 80

A

Soft tissue swelling anterior to C1-2 (crying makes this soft tissue shadow larger)
C2-3 pseudosubluxation
cervical body wedging
lack of cervical lordosis

ref: Rang’s.

Answer 81

A

Not needed for < 5mg/d
Not needed for < 3 wks duration
Do need if stopped long term within 3 months

Answer 82

A

Devascularized patella following lateral retinacular release
Use of a patellar component with a single central peg
Use of bone cement (thermal necrosis)
High patellar strain due to component malalignment
Increased thickness of PF articulation (thick patella, oversized femur, anterior translation of femur)
O’Neill did the knee
To much resection
To little resection (stuffing)
Femoral component to large (stuffing)
Flexion of femoral component (stuffing)
Asymmetric resection (common from lateral aspect)
Central drill hole in contrast to peripheral holes
Operative disruption of patellar blood flow (lateral release disruption lateral superior geniculate artery)

Answer 83

A

Skin erosions
Compartment syndrome
Ileus (SMA)
Malunion
Shortening >2cm
Nerve pressure injury

Answer 84

A

Superficial sugical site infection (hip + knee)
Extended operative time > 2.5 hrs (hip + knee)
Prior infection of joint (knee)
Immunosuppression (knee)
Obesity (hip)

AAOS Consensus Guidelines 2010

Answer 85

A

Early repair
More distal (lower)
Shorter length of repair
Pre and post op rehab

Answer 86

A

6 weeks in extension (early mobility is not good)
patient has 20 % recurrence risk 1st time dislocater
2nd time 50% recurrence risk

Answer 87

A

• Repair within zone II
• crush injuries
• Surgical manipulation
• associated fractures
• infection
• revision
• older age
AAOS COR

Answer 88

A

Femoral tunnel
o Too anterior
 Tight in flexion

 Loose in extension

o Too posterior
 Loose in flexion
 Tight in extension
o Vertical tunnel
 Residual pivot (rotational instability)

Tibial tunnel
o Too anterior
 Tight in flexion
 Impinge in extension
o Too posterior
 Impinges on PCL

Answer 89

A

Tight lateral retinaculum
Weakness or dehis of VMO
Increased Q angle
Excessive tibial or femoral valgus or medialization
Excessive IR of the femoral or tibial component
- leads to relative ER of the actual tibia/femur
Anterior component placement
Lateralization of patella component (when resurfaced)

Answer 90

A

HIV
HCV
HBV
CMV
HTLV-1
Syphilis

Answer 91

A

Descriptive
Easy to interpret and easy to remember
Good intra- and inter- observer reliability
Dictate injury severity
Dictate treatment strategies
Predict prognosis or potential complications

Answer 92

A

APC 3 and vertically unstable PELVIS that:
Binder placed and skeletal traction in, and still unstable.

Answer 93

A

roast beef sandwich

Answer 94

A

Precocious puberty
cafe au lait
Polyostotic fibrous dysplasia
Short stature
Female > Male

Answer 95

A

 Peripheral tear
o SIZE OF RIM IS BEST PREDICTOR OF HEALING
 Vertical/Longitudinal
 1-4 cm in length
 Combined with ACL reconstruction
o Best results!

Answer 96

A

• Hallux Rigidus; 1/40 adults have this.
Ref: OKU

Answer 97

A

Previous fragility fracture
Female
Caucasian or asian
Smoker
Etoh abuse
RA
Dementia
Anticonvulsant use
Menaupause < 45 yrs
Sedentary (no physical activity)
Low bone mineral density
Low calcium intake
Oral glucocorticoids
recurrent falling

Answer 98

A

According to JR Cobb 1960 JBJS (attached):
• Abnormal vertebral angulation
• Abnormal vertebral rotation
• Abnormal vertebral position
• Abnormal vertebral wedging

According to Lenke
• Curve segment with the largest cobb angle (The major curve is always structural)
Minor curves that meet the following criteria
• Proximal Thoracic curve pattern must have:
o Minimal residual coronal curve on bending film of at least 25
o Kyphosis between T2 and T5 of at least 20.
• Main Thoracic curve pattern must have
o Main residual coronal curve of at least 25
o Kyphosis between T10 and L2 of at least 20.
• Thoracolumbar/Lumbar curve pattern must have
O Minimum residual curve of at least 25
O Kyphosis between T10 and L2 of at least 20

Answer 99

A

ECU longitudinal tenodesis
PQ transfer
Radial ulnar resection
Creation of one bone forearm
Spherical ulnar head prosthesis (only if SK)

Answer 100

A

The posterior lip of the posterior femoral condyle is more rounded (requires more host bone resection)
Decreased congruence of the posterior portion of the poly tibial tray
Recession of the poly anteriorly (allows for the patellar tendon with deep flexion)
Increased post height (may minimize jumping the post with deep flexion)

Ref: Bhandari’s 2012 book; nice pictures there.

Answer 101

A

Phrenic
Dorsal scapular
Suprascapular
Nerve to subclavius
Long thoracic

Answer 102

A

OA
Charcot
Ochronosis (alkaptonuria)
Acute rheumatic fever
Secondary pulmonary hypertrophic osteoarthropathy (secondary to factors secreted by a large tumor)

Miller’s - page 45

Answer 103

A

• Cant see, cant speak, cant walk the talk!
• VERTEBROBASILAR INSUFFICIENCY
o Nystagmus
o Diploplia
o Loss of vision in one or both eyes
o Vertigo
o Dizzyness
o Dysarthria/Dysphagia
o Sudden drop attack

Answer 104

A

A E I O U and sometimes Y

A - Adamantinoma
E - EG
I – Infection
O - Osteoid osteoma / Osteoblastoma
U - UUUUUEwings
Y - …and some times Y: LYmphoma

Answer 105

A

Endangers femoral nerve branches
Endangers femoral artery branches
More risk of inadvertent knee joint penetration
More risk of quads HO
Frame is bio-mechanically weaker when hooked up to anteromedial tibial pins

Answer 106

A

ASIA A: Complete. No motor or sensory
ASIA B: Incomplete. No motor function but some remaining sensory
ASIA C: Incomplete. 50% or more of muscles below injury are less than Grade 3.
ASIA D: Incomplete. 50% or more of muscles below injury are greater than or equal to than Grade 3.
ASIA E: Normal

Answer 107

A

o With nerve root compression, the sensory NCSs are normal. This occurs because the sensory cell body, the dorsal root ganglion, is distal to the site of nerve compression

Carpal Tunnel Syndrome:

o there is no conclusive evidence that one single electrical conduction study has the highest sensitivity or specificity. However, median sensory latencies across the wrist compared to ulnar or radial latencies or proximal median conduction improved sensitivity as opposed to absolute median sensory or motor distal latencies

Latency is a measure of the time required for conduction of the nerve impulse from the point of stimulation to the point of recording

Rugger Jersey Spine:

Sclerotic bands along superior and inferior thoracic and lumbar vertebral body endplates give a striped appearance to vertebral bodies - alternating parallel sclerotic and lucent bands are analogous to stripes on an English rugby sweater

Answer 108

A

Left Thoracic Curve
Abnormal Reflexes
Rapid Curve Progression
Neurologic findings
Excessive kyphosis
Foot findings

Answer 109

A

• In addition to the standard non-progression on X-ray stuff, this is kind of cool;
o as soon as there is no difference in skin temperature side to side

Answer 110

A

Observation 6 mos
Refer to ENT for scope

Answer 111

A

• Diagnosis: MDI vs. unidirectional

Soft tissue lesions present
Bone lesions present

Answer 112

A

Lag/sliding screw not perpendicular to fracture (forces parallel to screw)
Lack of medial buttress
Acts as load bearing device leading to lateralization of proximal and medialization of distal segment

Reverse Obliquity Fractures of the Intertrochanteric Region of the Femur - JBJS 2001

Answer 113

A

Fracture site apposition (most important)
Large diameter pins (second most important)
Additional pins
Rods in different planes
Pins in different planes
Decrease bone rod interface distance
Increased mass (size) or double stack rods
Increased spacing between pins (near far)

Answer 114

A

• This is a result iatrogenic complication of Hallux Valgus surgery:
o Too much medial eminence resection
o Excision of fibular sesamoid during distal soft tissue procedure
o Over aggressive medial capsularplication
o Overcorrection with post-op bunion dressing
o Malalignment at osteotomy site

Answer 115

A

 < 2cm, contained Microfracture
 > 2cm, OATS
 > 2cm Osteochondral allograft, ACI

Answer 116

A

 Rib Fractures (50%)
 Pulmonary injuries (40%)
 Spine Fracture (30%)
 Ipsilateral clavicle (25%)
 Vascular Injury

 Plexus injury

Answer 117

A

Zanca View 40 degrees cephalad AC pathology
Strkyer Notch View Hill Sachs
AP IR View Hill Sachs
West Point View Bony Bankart
Axillary View Posterior glenoid

Answer 118

A

Non-op
Core decompression (Cruess I,II,III)
Hemiarthroplasty (Cruess IV)
TSA (Cruess V)

ref Mo’s book p351 onward

Answer 119

A

3rd generation

vacuum-mixing to reduce cement porosity
cement pressurization
femoral canal preparation
pulsatile lavage

1st generation

hand-mixed cement
finger packed cement
no canal preparation or cement restrictor

2nd generation

cement restrictor placement
cement gun
femoral canal preparation
brush and dry

P’s

Porosity reduction (vacuum - don’t use in masquelet)
Pressurization cement
Pre-coat stem
Rough finish stem
Stem centralizer

2nd

Cement gun
Pulsatile lavage
Canal prep
Cement restrictor

Millers

Answer 120

A

Retroverted acetabulum
Sequelae of SCFE
Acetabular protrusio
Decreased native femoral head to neck ratio
Decreased native femoral neck offset
Overhang of anterosuperior acetabulum
Post-traumatic retroversion of femoral neck (post ORIF)
Non-spherical native femoral head

Miller’s p267

Answer 121

A

Older age at presentation
Large tumor volume
Elevated ALP
Poor histological response to chemo
o Good responders = >90% necrosis (80% survival)
o Poor responders = <90% necrosis (40-50% survival)
Presence of metastasis on presentation
o 10% of the time
Skip lesions
Local recurrence

Manny’s notes

Answer 122

A

Miscommunication / Poor communication
Improper treatment
Failure to diagnose (missed diagnosed)
Failure to treat
Delay in response to patient / family
The Monument files pg 222
MIFF’D

Answer 123

A

Open Fracture
IM nail present

THE JOURNAL OF BONE AND JOINT SURGERY (AMERICAN). 2010;92:823-828. Maintenance of Hardware After Early Postoperative Infection Following Fracture Internal Fixation

Answer 124

A

position the patient flat in the supine position. Stabilize the head and neck. Trial fit the halo ring (it should not be > 1cm away from the skin and not contact the ears at any point. Pins should engage the bone at 90 degrees. Put pins in (close eyes) and tighten in a diagonal fashion. Tighten to 8 in-lb in adults (2 in kids). Secure the lock nut and recheck in 24 hours and 1 wk. Can place vest before or after the ring application. The inferior border of the vest is at the xiphoid. Connect the vest to the ring with the vertical bars. Adjust the bars to get the desired position.
Pin position. 1 cm proximal to the brow in the lateral 1/3 of the brow. The posterior pins are above the pinna (make sure they are below the equator which comes up fast. A good number is 5-10 mm above the pinna). Prep sites and freeze the area. The patient should close their eyes (avoids entrapment of the orbicularis oculi)

Answer 125

A

Amenorrhea
Eating disorder
Stress fracture / osteopenia

Millers p294

Answer 126

A

DF < 10 after casting
85-90%

Answer 127

A

Non-op x 1
then arthroscopic bankart repair using suture anchor construct

Answer 128

A

Tendon to obturator internus
Nerve to obturator internus
Pudendal nerve
Internal pudendal artery

Answer 129

A

• Cavus
 1st cast you DF the first ray (which is in PF) to align it with the talus and then increase supination to bring the first metatarsal in line the other tarsals (i.e. align the forefoot with the hindfoot)
• Abduction
 then abduct the forefoot by maintaining counter-pressure on the talus
• Varus
 No distinct step this will correct with steps 1 and 2
• Equinus
 After 1,2,3 are complete DF of the hind foot is performed

Answer 130

A

Change in fracture position by 10 mm
Change in screw position by 5%
Backing out of the screws by 20 mm
Perforation of the femoral head

Acta Orthop Scand. 1999 Apr;70(2):141-4: Internally fixed femoral neck fractures. Early prediction of failure in 203 elderly patients with displaced fractures. Alho A, Benterud JG, Solovieva S

Answer 131

A

1 - My child is 18 mos old and I took him to a peds orthopod because he has a LLD with one leg larger than the other (hemihypertrophy).

He had surgery shortly after he was born for an omphalocele, but was otherwise healthy except for quite a large tongue.
His pediatrician says he has hypertrophic pancreatic islet cells (organomegaly), and he now has increasing spasticity and tone.

2 - Beckwith-Wiedeman syndrome

3 - Renal U/S to r/o Wilm’s tumour

Answer 132

A

Gross contamination with feces, dirt, or stagnant water
Farm related injuries
Freshwater boating injuries
Delay in initial abx > 12 hours
Questionable viability of soft tissue
Doubt of the adequacy of initial debridement
Concern for myonecrosis

Ref: Chief review notes

Answer 133

A

Failure of non-surgical management of full-thickness and partial thickness tears
Acute tear in young patient (< 60)
Acute loss of strength or motion at any age (due to cuff tear)

Answer 134

A

Carcinogenesis (Theoretical, no case reports for HO prophylaxis)
Trochanteric non-union (Old literature with poor surgical techniques?)
Testicular tolerance (8Gy may cause reversible azospermia, but testicular shielding reduced does 50%)
NB: Dose 7-8Gy (700cGy) <4hrs pre op, <72hrs post-op
Meta-analysis 2004 showed Radiation more effective than NSAIDS, but ARR only 2%

Radiation vs nonsteroidal anti-inflammatory drugs for the prevention of heterotopic ossification after major hip procedures: a meta-analysis of randomized trials. (Pakos EE, Int J Radiat Oncol Biol Phys. 2004 Nov 1;60(3):888-95.)

Answer 135

A

Traction
Extension
Pronation
Abduction

Answer 136

A

Splint in backslab for < 7 days
X-ray out of splint
Assess stability
Hinged elbow brace with extension block at 30-40 degrees for 1-2 weeks
block 10-20 degrees 1-2 weeks
No block for 2 weeks

Answer 137

A

Masquelet (Induced Membrane)
Intercalary bone transport (with ring fixator)
Papineau (open bone grafting, modern done with Vac)
Vascularized Fibula

• Induced Membrane Technique for Reconstruction To Manage Bone Loss - 2012 JAAOS
• Modern Papineau technique with vacuum-assisted closure 2006 JOT
• Vascularized fibular graft in infected tibial bone loss - 2011 IJO
 F/u avg 46.5 months
 10 stress #’s in 7 pts…
 Graft union in 3.3 months
 No post-op infections

Answer 138

A

• Instability:

o Is a pathologic condition representing excessive translation of humeral head on the glenoid during ROM representing a spectrum of injury to shoulder stabilizers

• Laxity:

o Is a physiologic condition representing excessive translation of humeral head on glenoid during ROM with no pathologic or functional consequence to patient (Jeremy Lamothe)

• Remember: Patients can be lax and stable or lax and unstable or lax and stiff

Answer 139

A

Delay > 4 days
Age < 6 months
Joint effusion with underlying osteomyelitis
Hip involvement

Answer 140

A

• Osteonecrosis (arthropasty is better)
• Charcot (high nonunion rate)
• Ipsilateral elbow fusion
• Contralateral shoulder fusion
• Injury of the scapular stabilizer muscles (traps, levator scapulae, serratus anterior, lats dorsi, rhomboids)
Ref: Richards et al., 1997

Answer 141

A

IM nail
Locking plates have a higher failure rate - they preclude endosteal healing.
Should IM nail with enough reaming to fit the nail

Answer 142

A

DM (most common in Foot)
Syringomyelia (most common cause in the UE)
Leprosy - Hansen’s disease (second most common cause in the UE)
Myelomeningocele (foot and ankle)
Spinal cord injury
Neurosyphilis/tabes dorsalis
Congenital insensitivity to pain
Amyloidosis

Miller’s pp45-6

Answer 143

A

Down syndrome (odontoid hypoplasia)
JRA/JIA
Os odontoideum (ossiculum terminale – not associated with instability)
Pseudochondroplasia
Diastrophic dysplasia
SED congenita (odontoid hypoplasia)
Metaphyseal dysplasia: mckusick’s
Morquio’s (odontoid hypoplasia)
Osteogenesis Imperfecta
Marfans

1) Miller’s pp198-207
2) Manny’s lists

Answer 144

A

Length correct
Rotation correct
Knee ligaments stable
No associated fem neck #
Compartments soft

Answer 145

A

Clinically assess legs*
Fluoroscopically assess anteversion by moving the c arm and measuring this*
Perform lateral only imaging of the femur and compare the neck horizontal line*
Compare the LT profiles*
Ultrasound*
Computer assisted navigation*
All of these are relative to the contralateral side.

Lindsey 2011 JAAOS paper

Answer 146

A

Iatrogenic ulnar nerve injuries 1-15%
60% children < 5 yrs will have ulnar nerve that subluxes over medial epicondyle when elbow flexed
You are up to 2 mm off with palpation as a means for correctly identifying the nerve.
Ulnar nerve injury is most often due to the pin constricting the nerve in the cubital tunnel by increasing tension vs. piercing the nerve (although this can happen)
The ulnar nerve can recover with expectant management (no exploration, no pin removal)…but sometimes it doesn’t

• “ there is insufficient information in the literature to offer an evidenced-based approach to iatrogenic ulnar nerve injury that occurs following medial pin placement”

• I am pulling that sucker in recovery room (not exploring) and replacing it with another lateral pin (1st choice) or a better positioned medial pin. I will then follow the ulnar nerve expectantly…my approach (B)
R&W 7th ed p515

Answer 147

A

 Number of holes/number of screws

Answer 148

A

Metastatic disease
GCT
Pagets
Fibrous Dysplasia
Myeloma

Answer 149

A

Multiple enchondromas
30% chance of malignant transformation
involved bones are dysplastic
High risk of other malignancy

Answer 150

A

Stress fracture
OM, septic arthritis, discitis
SCFE
Osgood Schlatter
Sindig-Larsen-Johanssen
Osteochondritis Dissecans
Chondromalacia Patellae
Arthritis (Lyme disease)
Accessory Navicular
Tarsal colaition
Benign or malignant tumor

Skaggs - Staying out of trouble…I think the original reference is JAAOS 2001 Flynn
Duchenne’s will probably present between 2-5 yrs of age (Don’t forget to do gowers sign in all boys - do gowers in girls too - they can have other myopathies/neuropathies too)

Answer 151

A

Table 3–14 – EVALUATION OF ROTATIONAL PROBLEMS OF THE LOWER EXTREMITIES
Measurement Technique Normal Values (degrees) Significance
Foot-progression angle Foot vs. straight line −5 to +20 Nonspecific rotation
Medial rotation Prone hip ROM 20-60 > 70 degrees; femoral anteversion
Lateral rotation Prone hip ROM 30-60 < 20 degrees; femoral anteversion
Thigh–foot angle Knee bent; foot up 0-20 < −10 degrees; tibial torsion
Foot lateral border Convex; medial crease Straight; flexible Metatarsus adductus

Answer 152

A

near-far fluoro technique
inject dye through screw
3D imaging (CT)

Manny’s notes

Answer 153

A

MS
Estrogen deficiency (menopause)
OI
Ankylosing spondylitis
Diabetes
Renal disease
Nutritional deficiency (rickets)

Answer 154

A

Transverse pattern (RR20)
Open (RR 4.3)
Gap (RR 8.3)

J Orthop Trauma. 2003 May;17(5):353-61.: Predictors of reoperation following operative management of fractures of the tibial shaft. - Bhandari M, Tornetta P 3rd, Sprague S, Najibi S, Petrisor B, Griffith L Guyatt GH

Answer 155

A

cranial fracture
intracranial bleed that may require a craniotomy
infection
soft tissue injury at proposed site
chest trauma
obesity
advanced age
barrel chest

Answer 156

A

“Get Reduced, Ream Reduced and Nail Reduced”
• Less Attractive Option - Ream proximal fragment, then you finger or nail as joystick to get reduction - SHOULD RARELY BE USED

Starting point at tip of GT or slightly medial, at the junction of the anterior one-third and posterior two-third on GT
◦ Guidewire needs to be parallel to lateral cortex of proximal fragment
◦ NEVER LATERAL TO TIP
If you do, guide wire, opening ream and nail head medial - to get nail into shaft @ fracture site, you push your hand in towards the body and create varus at the fracture site
◦ Reference - J Orthop Trauma. 2005 Nov-Dec;19(10):681-6. A critical analysis of the eccentric starting point for trochanteric intramedullary femoral nailing. Ostrum RF, Marcantonio A, Marburger R.
Clamp Assisted Open Reduction - Good for High, Transverse Subtochs - within 2 cortical diameters of lesser, How to do:
◦ Muscle Relaxants
◦ Attempt Closed Reduction - if possible use closed reamed antegrade femoral nailing
• If behaving like a Subtroch (flex, ER, Abduct) - Open
◦ 3-5 cm lateral incision, split Lateralis directly through muscle belly, DO NOT VISUALIZE FRACTURE (do not evacuate hemtoma, strip soft tissue etc), insert large reduction clamp, cephallomedulary locking screws, remove clamp…if still mobile, add a cerclage wire, WBAT
◦ Union - 98%
◦ Other Option if very transverse - Lane Bone Holding forceps on proximal fragment - Reverse deformity (Extend,IR, Adduct) and Hyper Adduct
Clamp-Assisted Reduction of High Subtrochanteric Fractures of the Femur. Alan Afsari, Frank Liporace, Eric Lindvall, Anthony Infante, Jr., Henry C. Sagi and George J. Haidukewych. J Bone Joint Surg Am. 2009;91:1913-1918.
Medial Blocking Screw - AP direction
Shantz Pin (see Harborview Book)
◦ AP - use to control flexion mainly
• Stay above lesser, snap down to bone, be mindful of femoral nerve.
◦ Lateral to medial - posterior to the path of the nail
Bone hook on shaft (lateralize fragment), ball spike pusher proximal fragment(push it into valgus)
◦ Helpful if purely coronal plane and not much flexion of proximal fragment
Avoid Eccentric Lateral Reaming
◦ Tips
• Medialize Entry Reamer, Medialize guidewire with thumb hole of snap, insert a curved LCDP plate to protect lateral cortex
◦ Bailouts if you Ream Laterally and your nail reduces you into varus
Use ronger, awl to remove bone MEDIALLY at entry point.

Answer 157

A

Cementless acetabular shell
Under-reaming by >2mm
Use of an elliptical monoblock shell
Paget’s
Hands of a honey badger
During removal of acetabular shell in revision
Osteoporosis

AAOS

Answer 158

A

• Maternal pre-gestational DM
• In utero exposure to carbamazipine/valproic acid
• Previous affected pregnancy
• Folic acid deficiency
Manny’s notes

Answer 159

A

Cross-over sign
Os acetabuli
CEA > 39
Posterior wall lateral to the center of rotation of the femoral head
Profunda
Protrusio

Manny’s lists

Answer 160

A

• Chronological:
o Acute, chronic, recurrent
• Direction:
o unidirectional vs. multidrectional
• Control:
o Voluntary vs. involuntary
o If voluntary:
 Positional, habitual, muscular

Answer 161

A

4 part fracture dislocation 100%
displaced 4 part fracture 45%
3 part fracture 14%
valgus impacted 4 part fracture 11%

Answer 162

A

Mitosis (cell division)
Pyknosis (irreversible condensation of chromatin in nucleus)
Anisocytosis (Cells of unequal size)
Necrosis (messy cell death)
Abnormal Nuclear/cytoplasmic ratio
Hyperkaryotosis (Hypercellular)
Pleiomorphism (variety of shapes/sizes)

Answer 163

A

8 mm above anatomically reduced GT
5.7 cm above superior border of pec major
Appropriate tension reestablished in long head of biceps
Appropriate relationship to glenoid
Template off of pre-op x-rays of non-affected side

ref: Multiple: 1 and 2 are in publications, 3, 4 5 are from courses and chatting with Duffy

Answer 164

A

Local
o Post op swelling / stiffness
o Delay in muscle power recovery
o Compression neuropraxia
o Wound hematoma
o Wound infection
o Direct vascular injury
o Bone and soft tissue necrosis
o Compartment syndrome
Systemic
o CVP
o Arterial hypertension
o Cardiorespiratory decompensation
o Cerebral infarction
o Alterations in acid-base balance
o Rhabdomolysis
o DVT

Pneumatic Tourniquets in Extremity Surgery JAAOS 2001

Answer 165

A

• CPPD crystal deposition

Ochronosis
Hemochromatosis
Hyperparathyroidism
Hypothyroidism
Calcium hydroxyapatite crystal deposition (“Milwaukee shoulder”)

Miller’s p53

Answer 166

A

High radiosensitivity:
o MM
o Small cell lung
o Testicular
o Leukemia
o Lymphoma
o Germ cell tumors
Moderate radiosensitivity:
o Non small cell lung
o Thyroid
o Breast
o Prostate

o (epithelial)

Low radiosensitivity:
o Renal cell
o Melanoma
o Colon

From Manny notes (and wikipedia)

Answer 167

A

Capsule
Bone Marrow
Blood
Urine
Lymph nodes (para-aortic)
Liver
Spleen

Dumbleton J Arthroplasty 2005

JBJS Br Case et al 1994 Sep;76(5):701-12

Answer 168

A

• Reproducible signs of inferior instability + instability in one other direction

Answer 169

A

20 deg flexion, 10-15 ER, 5 valgus
0 deg flexion, 10-15 ER, 5 valgus
Because the tibia and the femur will both be “above knee” so don’t want any flexion at the native knee joint.

Answer 170

A

Hip flexion contracture
Hamstring contracture
Excessively loose heel cords

AAOS

Answer 171

A

Incidental x-ray findings
Incidental lab findings (elevated alk phos)
Bone pain
Bone deformity
Fracture
Arthropathy
Skin temperature changes
8 neurologic complications (deafness, cranial nerve palsies)

Answer 172

A

“Prolonged renal failure causes phosphate retention and subsequent hyperplasia of parathyroid gland chief cells, which results in a decrease in serum calcium and an increase in serum parathyroid hormone. Increased serum phosphate causes a decrease in 1,25(OH)2D synthesis, which decreases calcium absorption. The increased parathyroid hormone acts on the kidneys and on bone to normalize serum calcium. The direct results are (a) stimulation of vitamin D metabolism, which increases intestinal resorption of calcium, thereby antagonizing the effects of phosphate on 1,25(OH)2D synthesis; (b) increased resorption of calcium from the kidneys, with increased excretion of phosphate in the kidneys; and (c) increased osteoclast activity, which causes the release of calcium from bone (6). Osteoblasts form an increased amount of osteoid in response to bone resorption and a subsequent loss of bone mass. This excess osteoid does not contain hydroxyapatite but appears opaque on radiographs, thus producing the rugger jersey spine appearance”

Oteopetrosis

Answer 173

A

Anterior process of calcaneous is palpable as it corrects from under the talus (best sign)
You’ve achieved at least 60 deg of abduction in reference to the tibia
Neutral or slight valgus of os clacis is present

Answer 174

A

 Smoking
 Long segment fusion
 Kyphosis
 Positive sagittal balance > 5 cm
 Hip OA
 Thoracolumbar approach
 Age 55
 Incomplete lumbopelvic fixation
 Anterior fixation alone

Answer 175

A

50 – 60 yrs 13%

60 – 70 yrs 20%
70 – 80 yrs 30%
> 80 yrs 50%
U/S Study of PARTIAL or FULL thickness tears

Answer 176

A

Pelvic rotation
Pelvic tilt
Pelvic lateral rotation
Knee flexion in stance phase
Knee mechanics
Foot mechanics

Saunders et al., jbjs 1953

Answer 177

A

P53 tumor suppressor gene mutation
predisposes to second hit
Increased risk of sarcoma and other cancer in young patients

Reference: Tim’s Bone tumor handout, the Monument files and orthobullets

Answer 178

A

Gross contamination with feces, dirt, or stagnant water
Farm related injuries
Freshwater boating injuries
Delay in initial abx > 12 hours
Questionable viability of soft tissue
Doubt of the adequacy of initial debridement
Concern for myonecrosis

Ref: Chief review notes

Answer 179

A

Acetabularization of the acromion (AP view)
o comment on thickness of acromion; at risk for peri-op fracture
Femoralization of the humeral head (AP view)
Eccentric superior gleniod wear (AP view)
Loss of CA arch (anterior superior escape)
Lack of typical peripheral osteophytes
Osteopenia
Subarticular sclerosis (snowcap sign)

Answer 180

A

Tarsal coalition
Tumor (osteoid osteoma)
Infection
Inflammatory arthritis
Vertical talus
Oblique talus
chief notes

Answer 181

A

Continuous administration may delay remodeling of hard callus but will not affect the strength of the hard callus.
One single dose administration can delay hard callus remodelling but improve hard callus strength.

Answer 182

A

Proximal pole fracture
Initial displacement > 2 mm
Vertical fracture pattern
Delay to treatment 4 wk
Smokers
Female
K-wire fixation
Carpal collapse
Prior surgery

Wright’s book or Bhandari’s book

Answer 183

A

Latarjet
Think of remplissage depending on size

Answer 184

A

Intra-articular release of rotator cuff from glenoid labrum
Cuff mobilization with traction sutures
Anterior slide (release rotator interval from base of coracoid (may increase tendon excursion by 1.5 cm)
Posterior slide (release between infraspinatus and supraspinatus)
Supraspinatus dissection - from the supraspinatus fascia and scapular spine to allow mobilization from the supraspinatus fossa

Answer 185

A

 0-16%

Answer 186

A

Elbow stiffness (most common)
Radial head overgrowth (second most common)
Notching of the radial neck
Premature physeal closure
Nonunion of the neck
Head osteonecrosis
Cubitus valgus
Vascular injury
Nerve injury (PIN)
Compartment syndrome
Radioulnar synostosis
Myositis ossificans
Osteomyelitits
Malunion

Ref for both Rockwood and Wilkins

Answer 187

A

Associations
o Arthrogryposis
o Ellis-van Creveld syndrome
o Holt-Oram syndrome
o Turner’s syndrome
Familial
Most frequently in black males
Bilateral
Lunotriquetrial is most common
Mostly incomplete
Usually asymptomatic

Answer 188

A

 Weak VMO
 High Q angle
 Genu Valgum
 Excessive femoral anteversion

Miserable Malalignment
 External tibial torsion

Miserable Malalignment
 Pronated feel

Miserable Malalignment
 Trochlear dysplasia
 Ligamentous laxity
 Patella alta

 Lateral condyle hypoplasia

Answer 189

A

Large tongue
Large mandible
Foramen magnum stenosis
Limited neck extension
May have decreased chest wall compliance and FRC
Frequent URTI
Difficult spinal/epidural anaesthesia

Manual of Anaesthesia practice: Chapter on Achon’s

Answer 190

A

Stage > 3 (50%) correlates with poor outcome

Stage 0 Normal Muscle
Stage 1 Fatty Streaks
Stage 2 < 50% fatty muscle
Stage 3 50% fatty muscle
Stage 4 > 50% fatty muscle

Answer 191

A

• AARI
o Grissel

• neurogenic
o SC tumors, posterior possa tumors, syrinogmyelia, Arnold-Chiari
• neoplasms
o osteoid osteoma, ABC
• infection
o cervical adenitis, retropharyngeal bascess, Grisel’s syndrome
• inflammatory
o interverberal disc calcification, JIA
• iatrogrenic
o H&N surgery

Answer 192

A

Antibiotic administration prior to incision (or tourniquet inflation)
Perioperative antibiotic course should not exceed 24 hours
Antibiotics should be re-dosed when the duration of the procedure exceeds one to two times the half life of the antibiotic OR with significant intra-operative blood loss (two Swamys). The half life of Ancef is 1.8 hours with administered IV
Verification of prophylactic antibiotic administration by a “time out” protocol

Bhandari

Answer 193

A

New pain in a longstanding Paget’s patient
Pathologic fracture
Elevation of ALP …above normally elevated levels
Biopsy - actually necessary to tell you what sarcoma it has become
Soft tissue mass
Cortical destruction

Orthobullets

Answer 194

A

Flexion
IR
…rarely need valgus but can be done in setting of AVN

Webinar vumedi

Answer 195

A

Non-ossifying fibromas
Cafe au lait
May be associated / subtype of NF ?

Answer 196

A

Rocker bottom foot
Pressure sores
Crowded toes
Flat heel pad

Answer 197

A

Gonarthrosis in patients with a varus limb alignment
Gonarthrosis in patients with a valgus limb alignment (unloads the knee in flex and ex compared to a DFVO that is only in ex)
OCD of MFC
SPONK of MFC
Posterolateral instability
Chondral resurfacing
Non Obese
Unilateral

CONTRAINDICATIONS

Inflammatory arthritis
Flexion <90
Contracture >15
BMI > 35
> 20 degrees of correction required
PF OA
Varus thrust
Instability

Answer 198

A

SCFE
Rickets (provisional calcification zone)
SH 1 fractures (provisional calcification)
Mucopolysacharide disease
SED
MED
Acromegaly

Proliferative
o Achon’s

o Gigantism
o MHE

Reserve
o Gaucher’s
o Disatrophic Dysplasia
o Pseudoachon’s

1) “Rich Pretty Girls Do Koke”
R = Reserve Zone
P = Pseudoachondroplasia = COMP
G = Gaucher’s Disease
D = Diastrophic Dysplasia = Sulfate Transport
K = Kniest Syndrome = Type 2 collagen defect
2) “Big and Small”
- Proliferative Zone
G = Gigantism
A = Achondroplasia (FGFR-3)

3) “MORE Sex Please”
- Hypertrophic Zone
M = Mucopolysaccharidoses
O = Osteomalacia
R = Rickets
E = Enchondroma
S = SCFE
P = Physeal Fracture
4) Metaphysis
- SCFE with Endocrine Problem
- OSTEOPETROSIS
- OI (Type 1 Collagen)
- Scurvy (Vitamin C)

Answer 199

A

Operate
Although this is a simple dislocation I would go through the King algorithm in my head to make sure I am not missing and bony injuries and to help with me sequence of repair/reconstruction

Answer 200

A

Failure
Infection
Arthrofibrosis
o Minimal 12 wks before considering MUA
Cyclops
Loss of motion
Patella fracture/rupture
Tunnel osteolysis
Late arthritis

Answer 201

A

 Plate length / Fracture length

Answer 202

A

Diminishes joint contact forces compared to high hip center
Improved abductor function
Fascilitates limb lengthening
Best bone stock

Ref: Campbell’s

Answer 203

A

Male
Family history
Northern European
Manual labor - with vibration exposure (5x increase)
Diabetes
Local trauma
Etoh/liver disease
Smoking (3x increase)
Hyperlipidemia
CRPS
RA protective
Controversial:
HIV
Epilepsy
Chronic pulmonary disease
Tb

Answer 204

A

Problems/Solutions

Hard, sclerotic bone - Sequential drilling with regular cooling saline, frequent change of drill bit
Impaired vascularity and white celi function - Warn patient about increased risk of infection
Brittle bones - Avoid undue force and use of mallet
Dynamic hip screw fixation - Fractional decrease in drilling, tapping and screw length, regular clean out of tap and screw tract
IM nailing-absent medullary canal - Drilling and cannulated reaming under fluoroscopic control
Tension band wiring - Pre-drill k wire tract under fluoroscopic control
Plate fixation- Fully tap all holes before screw insertion
Total hip replacement - Uncemented arthroplasty, use of power drill, reamer, burr to create medullary canal
Total knee replacement - Anticipate extra-medullary alignment and difficult sawing

De Palma et al.8 reported the histology of fracture callus in a patient with autosomal dominant osteopetrosis. They found normal healing to be present at 10 days after a fracture. At 20 days there was normal woven formation; however there were fewer than normal vessels and few osteoclasts. At 1 year biopsy of the healed fracture showed unorganised woven bone with absence of osteoclasts. Microfractures were frequently noted. Thus osteopetrotic fractures do heal, but remodeling does not occur.

Answer 205

A

Maximize pin separation at fracture site
Engage medial and lateral columns proximal to fracture site
Engage sufficient bone in both the proximal segment and distal fragment

• Low threshold for a third lateral pin if fracture stability is a concern
• Use three pins for a type III fracture
Rockwood and wilkins 7th ed. p498

Answer 206

A

RA
AS
Marfan’s
Paget’s
Otto’s pelvis (aka protrusion)

Miller’s p48

Also

Neurofibromatosis
Radiation induced osteonecrosis
JIA/JRA
Psoriatic
Reactive arthritis
OI
Ochronosis
HPT
Ehler Danlos
Sickle Cell
Hemophilia

The German pathologist Otto first described Protrusio acetabuli, (also known as “arthrokatadysis”,) in 1824. Hence also known as Otto Pelvis

http://orthopaedicprinciples.blogspot.ca/2009/10/protrusio-acetabuli-otto-pelvis.html

Wheeless:

primary form, Otto pelvis (arthrokatadysis), involves both hips, occurs most often in females, & causes pain & limitation of motion at a relatively early age;

Answer 207

A

 Type 1 Depressed OC Fracture
 Type 2 Fragment attached by bridge
 Type 3 Detached, non-displaced
 Type 4 Displaced

Answer 208

A

• Higher rate of primary RCR failure:
o Age >65
o Massive tear (>5cm)
o Moderate to severe muscle atrophy (T1 MRI > 50%)
o Tear retracted >2.5cm at scope after mobilization
o Tear retracted medial to glenoid on MRI
o DM
o Active smoker
o Unwillingness/inability to participate in rehab or comply restrictions

JAAOS 2012

Answer 209

A

Exophthalmos
Diabetes Insipidous
Lytic skull lesion (multifocal Langerhans cell histiocytosis)
(Apparently classic, but only seen in 25%)

Millers 544

Answer 210

A

Pre-op: Consent- standard stuff, + mention recurrence / stiffness
Position: prone / abx / tourniquet
Incision: Cincinatti (from navicular/medial cuneiform to lateral sinus tarsi)
ID and protect:
o Medial vascular bundle
 how many clubfoots have absent dorsalis pedis? - 45%
o Medial and plantar nerves
o Sural nerve
o interosseous talocalaneal ligament
Releases:…Pretty much everything else
1) Medial
o Plantar fascia
o Abductor hallucis
o lacinate ligament (flexor retinaculum)
o TN capsule
o Calcaneounavicular ligament (spring)
o Knot of henry
o superficial deltoid
o Lengthen: tib post, FDL and FHL
2) Posterior (?usually first according to chief notes)
o Z-lengthening of achilles
o release posterior tibiofibular and talofibular ligaments
o Subtalar joint capsule
3) Lateral
o calcaneofibular
o calcaneocuboid
o peroneal sheaths
May need to pin the CC joint and TN joint if unstable
Recurrence:
o ? etiology - consider MRI for spinal cord
Revision
o SPLATT
o Dwyer Osteotomy

Answer 211

A

Chondroblastoma
osteoblastoma
GCT
CMF
NOF
Fibrous dysplasia

Answer 212

A

3 or more 5mm sagittal images with meniscal continuity

Answer 213

A

NIH Diagnosis of Neurofibromatosis Type 1 (NF1)
• Six or more café au lait macules over 5 mm in greatest diameter in prepubertal individuals and over 15 mm in greatest diameter in postpubertal individuals
• Two or more neurofibromas of any type or one plexiform neurofibroma
• Freckling in the axillary or inguinal regions (Crowe´s sign)
• Optic glioma
• Two or more Lisch nodules (iris harmartomas)
• A distinctive osseous lesion such as sphenoid dysplasia or thinning of long bone cortex with or without pseudoarthrosis
• A first-degree relative (parent, sibling, or offspring) with NF1 by the above criteria
The criteria are met in an individual if two or more of the features listed are present.
Manny Notes
http://www.medicalcriteria.com/criteria/neuro_nf.htm

Answer 214

A

Patient mentally and physically fit for surgery
Low demand < 10 lbs lifting restriction
Males > 75 and female > 70
Fractures not “ORIFable”
Pre-existing arthritis

Ref: Graham King webinar

Answer 215

A

• Neurofibromatosis
• Achondroplasia
• Marfan syndrome
• Ehlers-Danlos syndrome
• Ankylosing Spondylitis
• Morquio syndrome
• Hurler syndrome
• Acromegaly
• Intraspinal tumor
• Communicating hydrocephalus
The Posterior Vertebral Scalloping Sign - Radiology 2006

Answer 216

A

LERN’M
- L - Lymphoma
- E – Ewings (most common kid >5)
- R - Rhabdomyosarcoma
- N – Neuroblastoma (most common kid <5yo)
- M – Myeloma
Also - Small round cell carcinoma (r/o >40yrs)

Millers Page 549, and Board review Webinar 2012

Answer 217

A

 Vertical/Longitudinal Assn with ACL
 Bucket Handle Vertical with displacement
 Oblique/Flap/Parrot beak May cause mechanical symptoms
 Radial
 Horizontal Common in elderly, ass’n with cysts
 Complex

Answer 218

A

Lack of soft tissue component
GAD will light up septa in primary lesion but not secondary
Look for perilesional edema to decipher from OS

Sources AAOS and radiology journal

Answer 219

A

Anticonvulsants
Steroids
Heparin
Excess Thyroid medication
Aromatase inhibitors
Testosterone antagonists
Immunosuppressants

Answer 220

A

UE - Peripheral/Plexus neuropathy - (Shoulders abducted no more than 90deg, elbows 90deg, forearms pronated)
Pelvis - LFCN or Fem n compression on bolsters/posts - (Check & re-check position/impingement)
Face, Breasts, Genitals - Compression - (Adjust posts/padding, check during long procedure)
POVL (Post-op Vision Loss) - Most secondary to ischemic optic neuropathy (mechanism unknown, but associated with prone position, Mayfield, >6hrs anesthetic time, blodd loss> 1L), some are central retinal artery occlusion due to direct pressure.

Answer 221

A

NF1 AD
Becker Muscular Dystrophy X-linked recessive
Friedrich’s ataxia AR
Gaucher’s AR
Hemophilia A X-linked recessive
HMSN-1 AD
Marfan AD
OI 1 AD
OI 2 AR
OI 3 AR
OI 4 AD

remember in general:
• AD gene → structural deformities
• AR gene → enzymatic / biochemical defects
• translocations / deletions → chromosomal abn

Answer 222

A

• Lateral decubitus position, flouro, k-wires, plates, screws, etc
• Universal posterior approach skin incision
• Go lateral first (Aconeus/ECU interval)
• ? Can I see across to coronoid and reduce it
o Yes - fix coronoid with PA screws(or lasso) on Ulna and then fix or replace radial head
o No - Fix or replace radial head
 Go medial - ID and protect ulnar nerve
• Flexor pronator split vs. subcutaneous elevation of flexor pronator mass
o Fix coronoid
• Repair LCL
• Assess stability

o Yes stable - close up you’re done
o No unstable - fix MCL
 Check stability
- Yes stable - close up you’re done
- No unstable - hinged external ixator…with a hope and a prayer
• I think this follows King’s alogorythm

• Splint 1-2 weeks, wound check, 2-6 weeks hinged elbow brace ROM active + self assisted passive, 6 weeks D/C elbow brace ROM active and passive, 12 weeks reassess

Answer 223

A

Lateral femoral condyle squaring
Increased joint space (up to 11 mm)
Cupping of the lateral tibial plateau
Hypoplastic lateral intercondylar spine

Answer 224

A

Tardy ulnar nerve palsy
Non union
Cubitus valgus
Acute nerve injury (rare)
Lateral condylar overgrowth
AVN
Cubitus varus

Ref: Chief review notes

Answer 225

A

Suprascapular notch compression (most common)
Spinoglenoid notch cyst
Synovial mass
Traction neuropathy (overhead athletes)
Massive retracted cuff tear in the elderly
Humeral fracture dislocations

JAAOS

Answer 226

A

Chondral injury
Labral tears
Loose bodies
Synovial disorders
Ligamentum Teres rupture
Impinging osteophytes
Mechanical symptoms NYD

Miller’s p267

Answer 227

A

Metaphyseal corner fractures
Posterior rib fractures
Multiple fractures at different stages of healing
Femur (long bone) fracture in non-ambulatory child
Scapular fracture
Vertebral compression and SP #’s
Epiphyseal separation

Answer 228

A

Large thread diameter screws
Place screws parallel across cancellous trabeculae
Get fixationin cortical bone
Use fixed angle constructs (locking plates)
Augment screw fixation with PMMA
Antiglide plating
IM nailing
Place IM nail locking screws in different planes
Double plating
Longer plates with widely spaced screws
Tension band constructs
Bone graft augmentation

Answer 229

A

SHEA Stadium
Shoulder
Hip
Elbow
Ankle

NOT the knee

Answer 230

A

Foramen Magnum Stenosis
Thoracolumbar kyphosis
Short pedicles
Decreased intrapedicular distance
Lumbar Lordosis
Lumbar stenosis
Vertebral scalloping

Answer 231

A

• Any level thumb
• Amputation of multiple digits
• Amputation through palm
• Wrist / forearm / below elbow
• Any level in a child
Manny’s notes

Answer 232

A

Female
Cardiovascular Disease
Thyroid disease
Breast cancer treatment
Stroke
MI
Diabetes

Ref: JAAOS

Answer 233

A

From lowest consumption to highest
o Syme
o Midfoot
o BKA
o Through Knee
o AKA

Answer 234

A

Physical therapy & rehabilitation
Inferior capsular shift / plication
Rotator interval closure
Psychiatric referral

Miller’s p276.

Answer 235

A

positional headache
wound complications
meningitis
arachnoiditis
pseudomeningocoele (10%)

Answer 236

A

Appearance: CRITOE

o Capitellum 1

o Radial head 5

o Internal epicondyle 5

o Trochlea 9

o Olecranon 9

o External Epicondyle 10

Closure

o Lateral Epicondyle 10

o Capitellum 12

o Trochlea 14

o Radial head 15

o Olecranon 15

o Medial Epicondyle 16

Answer 237

A

Protection against autograft resorption
Relative maintenance of graft position
Prevention of soft tissue interposition

Answer 238

A

• Age < 20 (33% failure vs 4% if > 30 Yrs)
• Overhead or contact athlete
• Hill Sachs defect on AP in external rotation
o Or loss of sclerotic inferior glenoid border
o lesions visualized in this view are high risk
• Hyperlax individual (Jer)
• Glenoid bone loss

REFERENCE: BOILEAU, P - vumedi webinar
Or Instability Severity Score JBJS (Br) Boileau 2007

Answer 239

A

o B has the trauma room
o Life threatening infection with unsalvageable necrosis

o Partial traumatic amputation
o Irreparable vascular injury
o Warm ischemia time > 8 hours (not talking about a finger here)
o Nonviable limb
o Poor host
o No resources to facilitate salvage

Answer 240

A

Patulous inferior capsule (ant and post IGHL)
Functional deficient rotator interval

Answer 241

A

• Non-op and Refer

Answer 242

A

Infection (p. acnes)
Stiffness
Deltoid dehisence (open)
Severe edema (arthroscopic)
Suprascapular nerve injury
Missed pathology: biceps tendinitis

Answer 243

A

• A severe fracture (combined Plafond-talus, Hawkins 2/3)
• An open fracture
• Local infection
• Evidence osteonecrosis talus
• Coexisting major medical problems
• Smoking (16x increased risk)
AAOS

Answer 244

A

>2 weeks
Loose pin sites
Fever
Increased WBC
pus

Answer 245

A

• Kids: consider a CT before hand to determine pin placement and determine cranial thickness. Use 10-12 pins at lower torque (2 in-lb)

Answer 246

A

Life Style Factors

Anorexia nervosa
Excessive protein intake
Smoking
Excessive alcohol intake

Endocrinopathies

Hyperthyroidism
Hyperparathyroidism
Cushing’s syndrome
Type 1 diabetes melitus
Hypogonadism

Systemic Diseases

Gaucher’s disease
Mastocytosis
Rheumatoid arthritis
Ankylosing spondylitis
Psoriasis

Organ Dysfunction

Cystic fibrosis
Asthma
Chronic obstructive pulmonary disease
Renal failure
Primary Biliary cirrhosis
Inflammatory bowel disease
Celiac sprue
Organ transplantation

Medications

Glucocorticoids
Diuretics
Antiepileptics
Methotrexate
Cyclosporin A
Excess thryoid hormone replacement
Alkylating chemotherapeutic agents
Gonadotropin-releasing hormone agonist

Neoplastic conditions

Multiple myeloma

J Am Acad Orthop Surg 2005;13:475-486

Answer 247

A

Superior - Supraspinatus
Medial - Coracoid
Lateral - Transverse humeral ligament
Inferior- Subscapularis

Answer 248

A

Posterior plafond/medial mall and anterior/lateral of the talus (horisberger study)
The anterior talus was the worst

Answer 249

A

Cartilage cap > 1 cm in an adult (kids can be as thick as 2-3 cm at times)
Sudden increase in uptake on bone scan in an adult
Confirmation by CT or MRI of a soft tissue mass

Answer 250

A

Blue sclera
Dentinogenesis imperfecta
Hearing loss (can have either conductive, sensorial, or both)
This skin prone to hemorrhage
CV disease (MV prolapse, Aortic regurg)
Hypermetabolism (heat intolerance, hyperhidrosis, tachycardia, tachypnea)
Pulmonary – decreased excusion
Allopecia

JAAOS 2008

Answer 251

A

AP with IR hip x-ray pre-op
Dedicated femoral neck CT with fine cuts
Lateral fluoro intra-op
Post-reduction/pre-extubation do AP and lateral hip

Tournetta paper 2007, showed reduction in missed fractures from 58%  10%
Ipsilateral neck: shaft in 2.5  9% of high energy femoral shaft fractures
30% are missed initially according to 1993 paper by Bennett (CORR)

Answer 252

A

Age < 40
Dislocation due to a seizure
Large Reverse Hill Sachs as defined by > 1.5 cm3

I know there are more, but these came from a paper Duffy stressed us to know back in the fall (Robinson et al., 2011 JBJS)

Answer 253

A

• TRUE flexion contracures should be present:
o Knee 21 degrees
 decrease to 11 degrees at 3 mos and 3 degrees at 6 mos
o Hip
o Elbow

Answer 254

A

• Well, draw it chump!

Answer 255

A

o Vasculitis
o Pleurisy
o Pericarditis
o Fever
o Splenomegaly
o Leukopenia
o Decreased lacrimal and Salivary gland production (Sjogren’s)
o Lymphoid proliferation
o Rash
o Iridocyclitis (JRA)
o Miller’s p48

Answer 256

A

Neurological deficit (tx by decompression)
Failed structural stability
failed medical management
sepsis
persistent pain
drainage of abcess
failed percutaneous biopsy x 2 (for tissue dx)
chief notes

Answer 257

A

o small size, particularly in smaller women,
o morbidity associated with harvest,
o increased surgical time,
o decreased hamstring strength (particularly important in explosive athletes) in Terminal flexion
o Increased failure in young, active
o infection rate (theoretical however),
o the quality of the graft is dependent on the individual it comes from
o the handling and sterilization performed by the processor
o Bone:bone healing is good
o Anterior knee pain,
o Potential for patellar fracture,
o Will result in a really long graft if patient has patella alta

Answer 258

A

• Ideal for the obese patient
• Easier for the trochanteric entry hole;
• Better control of proximal 1/3 frx
 Tend to angulate in varus w/ supine position
• Lower risk of Pudendal nerve palsy (thanks to bigger posts? No reports of injury in lateral position)

Wheeless

http: //orthopaedicprinciples.com/2011/06/current-concepts-in-im-nailing-of-femoral-shaft-fractures/
- This web site has lots of good lists…

Answer 259

A

Malunion
Non-union (usually hypertrophic)
Insertion site irritation
Septic knee
leg length discrepancies (over or under)
Acute synovitis (non-infectious)
Re-fracture
Growth plate injury (…not in RW but I almost thought I did a transphyseal nail once…I didn’t)
Malrotation (not mentioned but reasonable)

RW p815

Answer 260

A

If the patient has pain and no findings of fracture on x-ray, can order a bone scan or MRI looking for increased uptake or peri-lesional edema (stress fracture)
If the patient has minimal pain, can have them go home NWB with follow-up once the investigations are completed.
Endo consult - D/C bisphosphonates, Vitamin D and calcium, consider teriparatide.

Answer 261

A

• Hindfoot procedures only if no correction with coleman block
• Triple for arthritis
• Think forefoot, hindfoot, soft tissue and bone:
o Address claw big toe (EHL transfer plantarly to 1st toe with IP fusion = 1st toes jones)

o Address claw toes 2-5: MTP dorsal capuslotomy, EDB tenotomy and EDL lengthening or release and transfer EDL proximally +/- fusion of of IP’s depending on flexible or fixed claw toes
o PF release - Turco incision medially, ID and protect ML plantar nerves, seperate PF from tendons and subcu tissue and release
o DF 1st ray opening wedge proximal MT osteotomy
o Calcaneous: Lateral sliding or Dwyer closing wedge (lateral incision, oblique and slide, fix with 2 7.3 screws)
o TAL

Answer 262

A

Discontinue spinal instrumentation, release distraction forces
Rule out technical factors (electrodes)
Rule out anesthesia related concerns (Inhalational anesthetic - stop)
Elevate MAP (>90)
Increase O2 concentration
Irrigate wound with warm saline
Assess ABG (metabolic abn or low Hgb)
if no return - remove last step of hardware, or wake up test
If still no change, remove spinal instrumentation or anterior strut/cage
Consider use of corticosteriod

JAAOS 2007:
• This is for SSEP amplitude decrease >50% or MEP decrease >75%
• MEP amplitude loss in presence stable SSEP not uncommon, but opposite BAD (rare)

Answer 263

A

What do you do?
What is the consequence of placing a left femoral component in a right knee?
What do you tell the patient?
How could this mistake have been avoided?

Answer 264

A

Fracture
OM, septic joint, discitis
LCPD
Transient synovitis
Osteochondritis dissecans
Discoid meniscus
Sever’s disease
Accessory navicular
Arthritis (JRA or Lyme disease)
Benign or malignant tumor

Answer 265

A

trauma
infection
brachial plexus

Answer 266

A

 Type 1 Softening and swelling only (can’t see must probe)
 Type 2 Fissuring, < 1.5 cm diameter
 Type 3 Crabmeat changes >1.5 cm, fissure to subchondral bone
 Type 4 Exposed subchondral bone

Answer 267

A

Miller p. 307-8

Disadvantages of HCLPE

Decreased tensile strength (pulling force to break)
Decreased fatigue strength (maximum cyclic stress)
Decreased fracture toughness (force to crack)
Decreased ductility (elongation without fracture)
Increased cost
No long term data

Advantages

Improves resistance to adhesive and abrasive wear
Improves bearing wear rate

Answer 268

A

Achondroplasia FGFR3
NF1 neurofibromin
Diastrophic dysplasia Sulfate transporter gene
Pseudochondroplasia COMP
Cleidocranial dysplasia CBFA1/osteocalcin
Marfan’s fibrillin
Hemophilia B Factor IX
Jansen’s PTHrP receptor
CMT Peripheral Myelin Protein22
Duchenne’s/Beckers Dystrophin
Myotonic Dystrophy Myotonin
SMA Survival Motor Neuro Protein

Answer 269

A

Congenital ones are:
• Often bilateral
• Often have a misshapen radial head
• The affected radius is longer than the ulna
• The capitellum is hypoplastic
• The distal humerus is grooved
• The ossification is more advanced than on the opposite side. Ref: Rang book

Convex radial head
Hypoplastic capitellum
Short ulna with long curved radius
Bilateral
Posterior dislocation Reference millers 5th ed p461

Answer 270

A

Infection
GH arthritis
Acromial humeral distance < 7 mm
Deltoid axillary nerve dysfunction
Atrophic cuff/chronicity/retraction

Answer 271

A

Knee has to be at 30 deg flexion for all three of these methods to be valid

Inferior pole relationship to Blumensaat’s line
Blackburn-Peel ratio:

o Distance from tibial plateau to inferior border of articular surface / length of articular surface = 0.8 (<1)
o An index of 1 is alta
- Insall-Salvati ratio:
o Length of patella tendon (LT) / Length of patella (LP). LT/LP = 1, >1.2 = alta, < 0.8 = Baja
- Miller’s p252

Answer 272

A

Prepare the family
Position the patient - need an assistant to keep foot in maximum dorsiflexion
Local aneasthetic to site
Aseptic preparation from midfoot to mid leg
11 blade, longitudinal incision on the medial side of achilles 1.5 cm above os calcis
Perform complete tenotomy from anterior to posterior direction (must get “pop”) and should see increase in DF by about 15-20 deg
Dress site and apply cast (15 to 20 DF and 60-70 deg of abduction), remain in place for 3 weeks

Answer 273

A

• Idiopathic
• Neurofibromatosis
• Beckwith-Weidmann Syndrome
Macroglossia, macrosomia, midline abdominal wall defects, ear creases/pits, neonatal hypoglycemia
Can be one limb or a whle side of boy
*Increased Risk of Childhood Cancers* Wilm’s Tumour, hepatoblastoma, adrenal cortical carcinoma, neuroblastoma, rhabdomyosarcoma
Cancer screening - abdominal U/S q 3mos until age 8, AFP q 6 wks until age 4
1. Wilm’s Tumour (aka nephroblastoma)
◦ Painless abdominal mass
Dx - Abdominal U/S

Answer 274

A

Valgus knee
Increased ER of tibia
Decreased femoral anteversion
Tight heel cord (or gastroc)
Hypermobile first ray
Obesity
Generalized ligamentous laxity
Normal reconsitituion of the arch with the jack toe test

Answer 275

A

Valgus > 12
Abberant retractor
Epidural anesthesia
Previous laminectomy
Peripheral neuropathy

These last two are due to “doublecrush” phenomenon

Basic Science

Answer 276

A

Li-Fraumeni
Retinoblastoma
NF-1
HIV
Prior radiation
EBV (controversial)

A collection of JAAOS, Miller’s, and AAOS COR

Answer 277

A

Syrinx most common
DM2
Leprosy
Syphillis
Alcoholism

Answer 278

A

Take less external rotators off with the acetabular approach
o Save quadratis and OE
The classic KL incision aims more towards the PSIS rather than straight
Release the ER off the femur
o Directly off bone in a THA and leaving a 1 cm cuff with KL

Answer 279

A

 MCL 4000 N
 PCL 2500 N
 ACL 2200 N
 LCL 700 N

Answer 280

A

EXT 1 or EXT 2 or even EXT 3
AD
10% malignant risk
Knee > shoulder
Limb deformity
Ulna bow
Radial head dislocation
Sessile or pedunculated
Lesions grow away from the physis
Lesions are in continuity with IM canal (differentiates from parosteal osteosarcoma)

Answer 281

A

Hemarthrosis
Bone bruise
o mid-third lateral femoral condyle
o post-third lateral tibial plateau
Lateral meniscus tear
Segond fracture
o Lateral capsular avulsion of tibia

Answer 282

A

Bauman’s angle (not that good in older children where start to get fusion of the ossification center)
Metaphyseal-diaphyseal angle (least accurate)
Humeral-ulnar angle (best)

Source: Rockwood and Wilkins

Answer 283

A

• Interosseous ligament (largest; 8 mm thick)
• Plantar (second largest)
• Dorsal (small and whimpy)
See reference - Anatomy of the Lisfranc Ligament Anthony Johnson 2008

Answer 284

A

Load-to-failure
o Hamstrings 4000 N load-to-failure
o Quadriceps in between
o BTB 2600 N load

o Native ACL: 2200N

Answer 285

A

• Larsen syndrome

Answer 286

A

Ewings
Lymphonma
EG
Neuroblastoma
PNET
Rhabdomyosarc
Myeloma

Answer 287

A

ORIF
ORIF and bone graft
Some controversy - can either leave to heal or if osteolysis significant, can ORIF with bone graft
Treat non-op

Answer 288

A

Failure of at least 6 weeks of non-op management
Progressive neurological deficit
Instability or deformity + radiculopathy
Significant motor deficit (deltoid or wrist extension deficit)

Chief notes

Answer 289

A

Association
Prediction
Excluding alternative
Dose response

Answer 290

A

vascularity of articular segment more likely to be preserved if
• > 8 mm of calcar attached to articular segment
• integrity of medial hinge
• fracture pattern (anatomic neck)

Answer 291

A

• Piece it together on the back table and compare
• Proximal implant should line up with the proximal lesser sigmoid notch
• Inspection should show no lateral ulnohumeral gapping (medial side starts to gap at 6 mm)
• DRUJ has appropriate ulnar variance compared to the contralateral side.
• Template off the contralateral side
Ref: mostly Athwal JBJS 2010

Answer 292

A

AKON
Morquios
SED

Answer 293

A

Rehab
then open repair (I am referring this one)

Answer 294

A

Minimally or nondisplaced fractures of coronoid and radial head
Congruent reduction
Stable arc of motion, extension > 40 deg

Vumedi Webinar Graham king

Answer 295

A

Arthrogrypotic
Myelomeningocele
Diastrophic dysplasia
Amniotic band syndrome

AAOS

Answer 296

A

Age
Sport
Level of sport participation
Laxity
Soft tissue lesions
Bone lesions on glenoid
Bone lesions on humerus

Answer 297

A

Biceps tendon
SGHL
CHL
Glenohumeral capsule

Hunt, et. al. JAOSS 2007 15 p218-219

Answer 298

A

Gauchers
Osteopetrosis
Niemann-pick

Answer 299

A

Myelomeningocele
Syrinx
Arthrogryposis

Answer 300

A

Superior gluteal artery and nerve
Piriformis
Internal Pudendal artery and pudendal nerve
Nerve to Obturator internus
Posterior femoral cutaneous nerve
Sciatic nerve
Inferior gluteal artery and nerve
Nerve to Quadratus femoris

POPS-IQ below piriformis…

Answer 301

A

Marked atrophy or fatty infiltration of spinate muscles on MRI ( >50% (grade IV) Sagittal T1)
Acromiohumeral distance less than 5 mm on AP (<3mm –> very poor)
Dynamic antero-superior subluxation of humeral head on resisted abduction
Irreparable tears of the subscapularis or teres minor
Poor tissue quality
Loss of GT from prior surgery
Poor patient compliance
Axillary nerve or suprascapular nerve deficit
Pseudoparalysis without pain
Chronic tears longer than 1 yr
History of deltoid injury or acromioplasty
Prior infection
Presence of Os Acromiale

Complex And Revision Problems In Shoulder Surgery - By Jon J. P. Warner, Joseph P. Iannotti, Evan L. Flatow & ICL 55-5

Answer 302

A

• Mild , 7-10 degrees - usually asymptomatic
o Can treat with dressing/splint opposite direction of bunion splint

• Moderate severe –
o EHL tendon transfer, use medial capsular incision and release joint capsule. then release lateral 2/3’s of EHL distally and pass plantar to transverse metatarsal ligament . drill hole through 1st metatarsal head and attach to medial periosteum holding toe in 10-15 degrees of valgus

Answer 303

A

Multiple enostosis (bone islands)
Colorectal polyps
Fibromas
Sebaceous cyst

Answer 304

A

Femoral anteversion
Genu valgum
Pronated feet

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