The List Challenge Flashcards
LIST THE THREE MOST COMMON PEDIATRIC AVULSION FRACTURES IN THE PELVIS/FEMUR
- Sartorius from ASIS
- Iliopsoas from LT
- Hamstrings from ischium (only one that may cause symptoms after healing)
Skaggs - Staying out of trouble
METHODS TO MEASURE PATELLA HEIGHT
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
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)?
- Attempt at ORIF
- then I would do a Latarjet
DESCRIBE ANATOMICALLY HOW YOU WILL PLACE YOU TUNNELS FOR ACL RECONSTRUCTION
• 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
What are 7 ways to optimize conditions in distraction Osteogenensis?
- 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
List 4 Risk Factors for Mortality after Hip Fracture
- Advanced age
- Male
- Poor cognitive function
- > 3 medical comorbidities (when not actively medically optimizing)
- > 48 hrs until treatment
Miller’s
WHAT ARE THE 17 MUSCLES ATTACHED TO THE SCAPULA?
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
What is the. Safe zone for acetabular screw placement and what structures are at risk in each zone?
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)
WHAT ARE 3 CRITERIA TO DIAGNOSE POST RADIATION SARCOMA?
- 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
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?
- 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
LIST 6 SARCOMAS THAT METASTASIZE TO LYMPH NODES
SCREAM
• Synovial cell
• Clear Cell Sarcoma
• Rhabdomyosarcoma
• Epitheloid
• Angiosarcoma
• Myxoid liposacoma
From Mike’s notes
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)?
- Non-op x 1
- then arthroscopic bankart repair using suture anchor construct
What 5 Factors can Contribute to Catastrophic Wear in TKA?
- PE thickness (>=8mm is better)
- Articular geometry (flatter = worse)
- PE sterilization (oxygen environment = worse)
- PE machining (compression molding = better)
- Sagittal plane kinematics (sliding = worse)
COMPLICATIONS OF MENISCAL REPAIR
Saphenous neuropathy (7%)
Arthrofibrosis (6%)
Effusion (2%)
Peroneal neuropathy (1%)
Infection (1%)
WHAT IS THE BEST LABORATORY TEST TO “RULE IN” INFECTION AND WHAT IS THE BEST TEST TO “RULE OUT” INFECTION?
- Neutropenia (WBC < 5000) in a newborn is best to rule infection
- CRP is best to rule out infection
LIST SIX SIGNS/SYMPTOMS OF HYPERCALCEMIA
- Polyuria
- Polydypsia
- Renal stones/flank pain
- Osteitis fibrous cystica
- Altered CNS function (marty does not like points)
- Anorexia
- Nausea
- Vomitting
- Constipation
- Weakness
LIST THREE BLOCKS TO REDUCTION OF A PEDIATRIC PROXIMAL HUMERUS FRACTURE
- Periosteum
- joint capsule
- Long head of biceps tendon
Rockwood and Wilkins 7th ed p650
LIST 6 MINIMALLY INVASIVE TECHNIQUES TO REDUCE A PEDIATRIC RADIAL NECK FRACTURE
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.
List 10 Radiographic Findings with Achondroplasia
- 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
- 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?
- • 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
- Midfoot
o Empty heel
o Posterior heel crease
o Rigid equinus
LIST 5 PREDICTORS OF HUMERAL HEAD ISCHEMIA FOLLOWING FRACTURE
• 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
List 4 Techniques to Dislocate the Hip in a THA Patient with Protrusio
- 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
FACTORS ASSOCIATED WITH POSITIVE OUTCOMES WITH PHYSEAL BAR RESECTION
- Younger presentation
- Smaller the bridge
- Smaller the deformity
- Central bridge
- Shorter the time interval between injury and surgery
Meningococcal septicemia do worse
WHAT ARE THE HONEY BADGERS 4 SOFT TISSUE MASSES THAT REQUIRE CHEMOTHERAPY
RSSD
- Rhabdomyosarcoma
- Synovial Cell Sarcoma
- Soft tissue Osteosarcoma (MFH), Soft tissue Ewings
- De-differentiated or Mesenchymal Chondrosarcoma
LIST 5 SIGNS OF IATROGENIC AVN IN DDH TREATMENT
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
WHAT ARE THE DIAGNOSTIC CRITERIA FOR FAT EMBOLISM SYNDROME?
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
POSTERIOR TIBIAL TENDON DYSFUNCTION CLASSIFICATION
- 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)
LIST 5 INDICATIONS TO OPERATE ON A SCAPULA FRACTURE
- 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°
Name 3 Indications for Revision for Metal on Metal Hips (COA 2011)
- 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)
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)?
• reverse Bankart repair
SIX FEATURES OF CRPS
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
SPINE
NAME A PHYSICAL EXAM METHOD TO DISTINGISH C8 RADICULOPATHY FROM ULNAR NERVE PALSY?
• 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.
CAVUS (CMT - WEAK PB AND STRONG PL AND WEAK TA AND STRONG PL)
WHAT ARE NON-OP STRATEGIES?
• Extra-depth shoes (gets forces spread across whole foot vs over heel and MT heads), lateral posting orthotic, achilles stretching
List 12 Biological or Mechanical Factors Influencing Fracture Healing
- 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
HOW CAN YOU DIFFERENTIATE CLINICALLY PSEUDOPARALYSIS (FRACTURE AND INFECTION) FROM PARALYSIS (BRACHIAL PLEXUS)?
• Palpation or Moro reflex
o stimulating the limb in some way should lead to some movement if pseudoparalysis
WHY ARE KIDS PRONE TO TIBIA VALGUS IN PROX TIB METAPHYSEAL # ? (IE WHAT ARE THE PROPOSED THEORIES)
- 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
NAME 8 POSITIVE PREDICTORS FOR GOOD SURGICAL OUTCOME OF CALCANEUS FRACTURES
(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
WHEN WOULD YOU USE TRANSILIAC TRANS SACRAL SCREWS
• 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.
WHAT SARCOMA’S NEED WIDE EXCISION ONLY (NO RAD/CHEMO) (3)
- Chondrosarcoma
- Adamantinoma
- Parosteal Osteosarcoma
- Low grade intrameduallary osteosarcoma
AAOS 2010
LIST 5 “MALIGNANT” TUMORS THAT CAN BE TREATED WITH SURGERY ALONE
- Chondrosarc
- Parosteal osteosarc
- Chordoma
- adamantinoma
- squamous cell (if no mets)
- LOW GRADE intramedullary osteosarc
HOW MANY PATIENTS WITH ACL RECONSTRUCTION GO ON TO DEVELOP OA
16-70%
WHAT ARE 5 COMPLICATIONS OF A HALO?
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%),
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)
- 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)
WHAT POTENTIALLY LETHAL ABNORMALITY MUST YOU BE LOOKING FOR IN A PATIENT WITH LARSEN SYNDROME?
• Cervical Kyphosis
LIST 3 FEATURES OF POEMs (Osteosclerotic myeloma)
- Polyneuropathy
- Organomegaly
- Endocrinopathy
- M proteins
- Skin changes
LIST 3 OPERATIVE INTERVENTIONS FOR DEVELOPMENTAL COXA VARA
- 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
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)
- 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
LIST 4 CONDITIONS ASSOCIATED WITH ATLANTOAXIAL INSTABILITY
- 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)
INDICATIONS FOR MENISCAL TRANSPLANT
Young patients with near total meniscectomy
Lateral > Medial
Proper mechanical alignment
< Grade 4 chondrosis
Intact ACL
WHAT THREE SOFT TISSUE FLAPS WILL I KNOW FOR MY EXAM TO DEAL WITH SOFT TISSUE COVERAGE IN THE PROXIMAL / MIDDLE / DISTAL LEG?
- Proximal - medial gastrocnemius flap
- Middle - soleus flap
- Distal - reverse sural artery flap
WHAT ARE 2 RADIOGRAPHIC SIGNS OF A POSTERIOR SHOULDER DISLOCATION?
- Lightbulb sign
- Anterior rim sign
- Trough sign
LIST 3 FEATURES OF Maffucci’s syndrome
o Multiple exostoses
o Tissue angiomas
o 100% malignant transformation
- Multiple enchondromas
- Hemangiomas
- 100% chance of malignant transformation of enchondroma
LIST THREE WAYS TO DETERMINE SKELETAL AGE
- Gruelich and Pyle
- Sauvegrain method
- Risser
ref: LW
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
• 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
List 5 Indications for a Medial Approach to the Hip
- Open reduction of congenital dislocation (good access to psoas)
- Obturator neurectomy
- Psoas release
- Biopsy
Hoppenfeld p455
NAME 3 CONDITIONS ASSOCIATED WITH TARSAL COALITION?
- Fibular deficiency
- PFFD
- Aperts syndrome
AAOS
WHAT ARE 2 MOST RELIABLE SIGN OF HAND COMPARTMENT SYNDROME?
- Swollen
- Intrinsic minus position
NAME 5 WAYS TO REDUCE IO PRESSURE WHILE REAMING LONG BONES
- (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
Knee Osteotomy Outcomes
- HTO - 85% 10 years
- DFO - 50% 10 years
NAME 6 INDICATIONS FOR BISPHOSHONATES?
- Pagets
- Osteoporosis
- Metastatic bone disease
- Polyostotic fibrous dysplasia
- OI
- AVN
- HO
- MM
- Hypercalcemia
LIST THE ACCEPTABLE CRITERIA FOR FLEXIBLE NAILING IN PEDIATRICS TRAUMA
- Age: 5-11
- Weight: = 50 kg
- Fracture in the mid 80% of the diaphysis
RW 7th ed. p811
Name 3 Advantages of Lateral Parapatellar Approach (Valgus Knee)
- 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
List 4 Ways to Judge the TF Joint Line in a Revision Knee
- 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
LIST 5 INDICATIONS FOR ARTHRODESIS IN A HALLUX VALGUS
• DJD
• RA
• Gout
• Down’s
• CP
• Connective tissue disorder (Ehler’s, Marfans)
Manny’s notes and OKU FNA
LIST VARIABLES THAT DETERMINE PLATE STIFFNESS
Plate material
Offset from bone
Working length
Plate length
Number of screws
Locked or non-locked screws
LIST 5 COMPLICATIONS ASSOCIATED WITH ACDF
- 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
WHICH MENISCAL REPAIR MODALITY HAS SHOWN BETTER RESULTS, INSIDE-OUT, OUTSIDE-IN OR ALL-INSIDE?
They are all equivocal in the literature
WHICH GRAFT OPTION HAS BEEN SHOWN TO HAVE BETTER RESULTS - HAMSTRING AUTO, ALLO OR BTB?
All equivocal, each with their own pros and cons
List 5 Risk Factors for Patella Malalignment
- Genu valgum
- Femoral anteversion
- Pronated feet
- Female
- Ehlers Danlos
- Marfans
- Trochlea dysplasia
- Patella Alta
- Lateral femoral condyle dysplasia
- Lateral patella tilt
WHAT ARE THE EFFECTS OF WEIGHT TRAINING ON MUSCLE
Increased surface area
Increased mitochondria
Increased capillary density
Increased strength
Thicker connective tissue
LIST 4 COMPONENTS OF MEDICAL NEGLIGENCE
- 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
FACTORS PREDISPOSING GIRLS TO ACL TEAR
Quads dominant (NM control)
Landing biomechanics (valgus moment)
Smaller notch
Genetics (? Collagen production)
Smaller ligament
Estrogen
Valgus alignment
What are the Requirements for Optimal Bone Ingrowth of an Uncemented Prosthesis? Name 8
- 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)
CLASSIFY DISCOID MENISCUS
- Watanabe classification
o Type 1 Complete
o Type 2 Incomplete
o Type 3 Wrisberg variant (lack of posterior attachment)
INDICATIONS OF ADEQUATE RESUSITATION
- 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
NAME THE 3 TOP REASONS FOR IN-TOEING
- increased femoral anteversion
- tibial tosion
- metatarsus adductus
Describe 4 MSK and 4 Non MSK Features Down’s
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)
OSCE SHOULDER INSTABILITY - OTHER THAN WITH INSTABILITY, HOW DO THESE PATIENT OFTEN PRESENT?
- highly variable
- May have RC tendinitis and impingement in < 20 yr old
RISKS FOR PATELLA AND QUADS RUPTURE
Intrarticular steroids
Hyperparathyroidism
Renal failure
Diabetes
Chronic tendonosis
RA
Systemic steroids
Connective tissue disease
LIST 4 NORMAL PEDIATRIC CERVICAL SPINE FINDINGS THAT MAY BE MISINTERPRETED AS TRAUMATIC PATHOLOGY
- 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.
Stress Dose Steroids
- Not needed for < 5mg/d
- Not needed for < 3 wks duration
- Do need if stopped long term within 3 months
Risk Factors for Patellar Fracture Following TKA
- 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)
WHAT ARE 4 COMPLICATIONS OF HIP SPICA CASTS
- Skin erosions
- Compartment syndrome
- Ileus (SMA)
- Malunion
- Shortening >2cm
- Nerve pressure injury
WHAT IS THE MORTALITY OF HALOS IN PATIENTS 79 YEARS AND OLDER?
• 21%
Name 5 Risk Factors Supported by Evidence for Total Joint Infections (Hip or Knee or Both)
- 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
POSITIVE PROGNOSIS IN NERVE REPAIR
- Early repair
- More distal (lower)
- Shorter length of repair
- Pre and post op rehab
HOW LONG SHOULD YOU IMMOBILIZE A PATELLA DISLOCATION PATIENT IN EXTENSION
- 6 weeks in extension (early mobility is not good)
- patient has 20 % recurrence risk 1st time dislocater
- 2nd time 50% recurrence risk
LIST 6 FACTORS WHICH PREDISPOSE TO TENDON ADHESIONS POST FLEXOR TENDON REPAIR
• Repair within zone II
• crush injuries
• Surgical manipulation
• associated fractures
• infection
• revision
• older age
AAOS COR
ACL TUNNEL MALALIGNMENT
- 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
List 5 Causes for Patellar Dysfunction Post Total Knee Arthroplasty
Think peds causes of instability
- 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)
LIST 5 THINGS THAT ALLOGRAFT BONE IS TESTED FOR
- HIV
- HCV
- HBV
- CMV
- HTLV-1
- Syphilis
PROPERTIES OF AN IDEAL FRACTURE CLASSIFICATION SYSTEM - NAME 6
- 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
WHAT IS INDICATION FOR C-CLAMP
- APC 3 and vertically unstable PELVIS that:
- Binder placed and skeletal traction in, and still unstable.
HOW DO YOU MANAGE DYSPHAGIA?
- roast beef sandwich
LIST 3 FEATURES OF McCune Albright
o Café-au-lait
o Fibrous dysplasia
o Precocious puberty
- Precocious puberty
- cafe au lait
- Polyostotic fibrous dysplasia
- Short stature
- Female > Male
INDICATIONS FOR MENISCAL REPAIR
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!
WHAT IS THE MOST COMMON FORM OF OSTEOARTHRITS OF THE FOOT/ANKLE?
• Hallux Rigidus; 1/40 adults have this.
Ref: OKU
LIST 5 RISK FACTORS FOR A FRAGILITY FRACTURE:
- 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
LIST THREE RADIOGRAPHIC CHARACTERISTICS OF A STRUCTURAL CURVE
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
TREATMENT OPTIONS FOR CONVERGENCE IN A FAILED DARRACH OR SAUVE-KAPANDJI
- ECU longitudinal tenodesis
- PQ transfer
- Radial ulnar resection
- Creation of one bone forearm
- Spherical ulnar head prosthesis (only if SK)
What are 4 Design Features of a High Flexion Knee Compared to a Standard TKA
- 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.
LIST 5 PRE-CLAVICULAR NERVES
- Phrenic
- Dorsal scapular
- Suprascapular
- Nerve to subclavius
- Long thoracic
Name 5 Non-inflammatory Arthropathies
- OA
- Charcot
- Ochronosis (alkaptonuria)
- Acute rheumatic fever
- Secondary pulmonary hypertrophic osteoarthropathy (secondary to factors secreted by a large tumor)
Miller’s - page 45
5 SIGNS OF VERTIBROBASILAR INSUFFICIENCY?
• 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
DDX OF A DIAPHYSEAL LESION
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
COMPARED TO LATERAL FEMORAL PINS, ANTERIOR FEMUR EX FIX PINS ARE WORSE BECAUSE
- 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
ASIA CLASSIFICATION
- 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
Differentiating radiculopathy vs peripheral nerve compression:
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
INDICATIONS FOR MRI IN ADOLECENT SCOLIOSIS
- Left Thoracic Curve
- Abnormal Reflexes
- Rapid Curve Progression
- Neurologic findings
- Excessive kyphosis
- Foot findings
FOOT AND ANKLE
CAVUS (CMT - WEAK PB AND STRONG PL AND WEAK TA AND STRONG PL)
HOW DO YOU DECIDE WHEN TO STOP IMMOBILIZING A CHARCOT FOOT?
• 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
HAD DO YOU MANAGE A RECURRENT LARYNGEAL NERVE INJURY?
- Observation 6 mos
- Refer to ENT for scope
OSCE SHOULDER INSTABILITY - REGARDLESS OF AGE AND ACTIVITY OF PATIENT, WHEN PLANNING YOUR TREATMENT, WHAT ARE THE THREE MOST IMPORTANT VARIABLES TO CONSIDER?
• Diagnosis: MDI vs. unidirectional
- Soft tissue lesions present
- Bone lesions present
WHAT ARE 3 CAUSES FOR FAILURE OF SLIDING HIP SCREW FOR REVERSE OBLIQUE FRACTURE
- 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
LIST 6 FACTORS THAT INCREASE THE CONSTRUCT OF YOUR EXTERNAL FIXATOR
- 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)
LIST 5 CAUSES OF HALLUX VARUS
• 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
KNEE OCD
< 2cm, contained Microfracture
> 2cm, OATS
> 2cm Osteochondral allograft, ACI
LIST ASSOCIATED INJURIES ASSOCIATED WITH SCAPULA FRACTURE
Rib Fractures (50%)
Pulmonary injuries (40%)
Spine Fracture (30%)
Ipsilateral clavicle (25%)
Vascular Injury
Plexus injury
ACCESSORY IMAGING OF THE SHOULDER
- 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
LIST THREE TREATMENT OPTIONS FOR AVN OF HUMERAL HEAD
- Non-op
- Core decompression (Cruess I,II,III)
- Hemiarthroplasty (Cruess IV)
- TSA (Cruess V)
ref Mo’s book p351 onward
Name Features of 3rd Generation Cementing
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
List 6 causes of FAI
- 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
LIST 5 FACTORS FOR OSTEOSARCOMA THAT YIELD A POOR PROGNOSIS
- 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