The List Challenge

Question 1

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

Answer 1

• Sartorius from ASIS• Iliopsoas from LT• Hamstrings from ischium (only one that may cause symptoms after healing) Skaggs - Staying out of trouble

Question 2

METHODS TO MEASURE PATELLA HEIGHT

Answer 2

 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

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 3

• Attempt at ORIF • then I would do a Latarjet

Question 4

DESCRIBE ANATOMICALLY HOW YOU WILL PLACE YOU TUNNELS FOR ACL RECONSTRUCTION

Answer 4

For a single bundle ACL recon, going from center of origin to center of insertion (anatomic)

Femoral

• center of femoral ACL origin: 1.7mm proximal (posterior on scope) to bifurcate (resident’s) 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
• About 40% from the back, 60% from the front when viewing from scope

Tibia

• center of tibial insertion is 7.5mm medial to anterior horn of lateral meniscus, 7.9mm lateral to medial plateau cartilage, and 8mm anterior to PCL
• Posterior aspect of the anterior horn of medial meniscus (Liew)

Radiographically

• tunnel centered in AP direction at 41% from anterior and 47% from medial

Question 5

What are 7 ways to optimize conditions in distraction Osteogenensis?

Answer 5

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

List 4 Risk Factors for Mortality after Hip Fracture

Answer 6

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

Question 7

WHAT ARE THE 17 MUSCLES ATTACHED TO THE SCAPULA?

Answer 7

Serratus AnteriorSupraspinatusSubscapularisTrapeziusTeres MajorTeres MinorTriceps Brachii long headBiceps BrachiiRhomboid MajorRhomboid MinorCoracobrachialisOmohyoid inferior bellyLattisimus DorsiDeltoidLevator ScapulaInfraspinatusPectoralis Minor

Question 8

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

Answer 8

Postero superior (safe)Sciatic nervesuperior gluteal vessels posteroinferiorsciatic nerveinferior gluteal artery and nerveinternal pudendal nerve and vesseluse screw 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

WHAT ARE 3 CRITERIA TO DIAGNOSE POST RADIATION SARCOMA?

Answer 9

• 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

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 10

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

LIST 6 SARCOMAS THAT METASTASIZE TO LYMPH NODES

Answer 11

SCREAM• Synovial cell• Clear Cell Sarcoma• Rhabdomyosarcoma• Epitheloid• Angiosarcoma• Myxoid liposacomaFrom Mike’s notes

Question 12

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 12

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

Question 13

What 5 Factors can Contribute to Catastrophic Wear in TKA?

Answer 13

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

COMPLICATIONS OF MENISCAL REPAIR

Answer 14

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

Question 15

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

Answer 15

• Neutropenia (WBC • CRP is best to rule out infection

Question 16

LIST SIX SIGNS/SYMPTOMS OF HYPERCALCEMIA

Answer 16

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

Question 17

LIST THREE BLOCKS TO REDUCTION OF A PEDIATRIC PROXIMAL HUMERUS FRACTURE

Answer 17

• Periosteum• joint capsule• Long head of biceps tendon Rockwood and Wilkins 7th ed p650

Question 18

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

Answer 18

Closed reduction Techniqueso 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 Reductionso 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

List 10 Radiographic Findings with Achondroplasia

Answer 19

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

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 20

* • 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

LIST 5 PREDICTORS OF HUMERAL HEAD ISCHEMIA FOLLOWING FRACTURE

Answer 21

• 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 fractureMo’s book p361

Question 22

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

Answer 22

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

FACTORS ASSOCIATED WITH POSITIVE OUTCOMES WITH PHYSEAL BAR RESECTION

Answer 23

• Younger presentation- Smaller the bridge- Smaller the deformity- Central bridge- Shorter the time interval between injury and surgery Meningococcal septicemia do worse

Question 24

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

Answer 24

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

Question 25

LIST 5 SIGNS OF IATROGENIC AVN IN DDH TREATMENT

Answer 25

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 completeo These deformities include coxa plana, coxa magna, coxa vara, short broad femoral neck• Chief notes

Question 26

WHAT ARE THE DIAGNOSTIC CRITERIA FOR FAT EMBOLISM SYNDROME?

Answer 26

Gurd and Wilson Criteria: Needs at least one major and 4 minor criteria• Major o Petechiae in a vest distribution o Hypoxemia with PaO2 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 ESRRef: Gurd and Wilson

Question 27

POSTERIOR TIBIAL TENDON DYSFUNCTION CLASSIFICATION

Answer 27

• Stage 1: o able to perform straight toe raise o tenosynovitis without deformityo No x-ray changes- Stage 2:o A:  unable to perform single leg heel rise.  Flexible Hindfoot 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 riseo Rigid hind and forefoot deformityo Degenerative changes subtalar joint- Stage 4:o 3 + deltoid compromise (lateral tilt ankle)

Question 28

LIST 5 INDICATIONS TO OPERATE ON A SCAPULA FRACTURE

Answer 28

• 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 • 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

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

Answer 29

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

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 30

• reverse Bankart repair

Question 31

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

Answer 31

• 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 32

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

Answer 32

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

Question 33

List 12 Biological or Mechanical Factors Influencing Fracture Healing

Answer 33

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 34

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

Answer 34

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

Question 35

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

Answer 35

• 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 36

WHEN WOULD YOU USE TRANSILIAC TRANS SACRAL SCREWS

Answer 36

• 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 37

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

Answer 37

• Chondrosarcoma- Adamantinoma- Parosteal Osteosarcoma- Low grade intrameduallary osteosarcoma AAOS 2010

Question 38

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

Answer 38

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

Question 39

HOW MANY PATIENTS WITH ACL RECONSTRUCTION GO ON TO DEVELOP OA

Answer 39

 16-70%

Question 40

WHAT ARE 5 COMPLICATIONS OF A HALO?

Answer 40

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 commono intracranial penetration (1%), o dysphagia is from too much extension. o Respiratory distresso Six pins do NOT have more complications than 4 (Nemeth et al., 2001 JBJS) intracranial penetration (1%),

Question 41

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 41

• 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 42

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

Answer 42

• Cervical Kyphosis

Question 43

LIST 3 FEATURES OF POEMs (Osteosclerotic myeloma)

Answer 43

• Polyneuropathy- Organomegaly- Endocrinopathy- M proteins- Skin changes

Question 44

LIST 3 OPERATIVE INTERVENTIONS FOR DEVELOPMENTAL COXA VARA

Answer 44

• 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 45

LIST 5 CONDITIONS ON DIFFERENTIAL DIAGNOSIS IN A 10 YR OLD WITH A LIMP

Answer 45

• 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 46

LIST 4 CONDITIONS ASSOCIATED WITH ATLANTOAXIAL INSTABILITY

Answer 46

• 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 47

INDICATIONS FOR MENISCAL TRANSPLANT

Answer 47

 Young patients with near total meniscectomy Lateral > Medial Proper mechanical alignment  Intact ACL

Question 48

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

Answer 48

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

Question 49

WHAT ARE 2 RADIOGRAPHIC SIGNS OF A POSTERIOR SHOULDER DISLOCATION?

Answer 49

• Lightbulb sign• Anterior rim sign• Trough sign

Question 50

LIST 3 FEATURES OF Maffucci’s syndrome o Multiple exostoseso Tissue angiomaso 100% malignant transformation

Answer 50

• Multiple enchondromas- Hemangiomas- 100% chance of malignant transformation of enchondroma

Question 51

LIST THREE WAYS TO DETERMINE SKELETAL AGE

Answer 51

• Gruelich and Pyle• Sauvegrain method• Risser ref: LW

Question 52

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 52

• Splint backslab for • 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 53

List 5 Indications for a Medial Approach to the Hip

Answer 53

Open reduction of congenital dislocation (good access to psoas) Obturator neurectomy Psoas release Biopsy Hoppenfeld p455

Question 54

NAME 3 CONDITIONS ASSOCIATED WITH TARSAL COALITION?

Answer 54

• Fibular deficiency• PFFD• Aperts syndrome AAOS

Question 55

WHAT ARE 2 MOST RELIABLE SIGN OF HAND COMPARTMENT SYNDROME?

Answer 55

• Swollen• Intrinsic minus position

Question 56

NAME 5 WAYS TO REDUCE IO PRESSURE WHILE REAMING LONG BONES

Answer 56

• (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 57

Knee Osteotomy Outcomes

Answer 57

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

Question 58

NAME 6 INDICATIONS FOR BISPHOSHONATES?

Answer 58

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

Question 59

LIST THE ACCEPTABLE CRITERIA FOR FLEXIBLE NAILING IN PEDIATRICS TRAUMA

Answer 59

• Age: 5-11• Weight: = 50 kg• Fracture in the mid 80% of the diaphysis RW 7th ed. p811

Question 60

Name 3 Advantages of Lateral Parapatellar Approach (Valgus Knee)

Answer 60

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 61

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

Answer 61

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 62

LIST 5 INDICATIONS FOR ARTHRODESIS IN A HALLUX VALGUS

Answer 62

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

Question 63

LIST VARIABLES THAT DETERMINE PLATE STIFFNESS

Answer 63

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

Question 64

LIST 5 COMPLICATIONS ASSOCIATED WITH ACDF

Answer 64

• 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 decompressionOrthobullets and chief notes

Question 65

WHICH MENISCAL REPAIR MODALITY HAS SHOWN BETTER RESULTS, INSIDE-OUT, OUTSIDE-IN OR ALL-INSIDE?

Answer 65

 They are all equivocal in the literature

Question 66

WHICH GRAFT OPTION HAS BEEN SHOWN TO HAVE BETTER RESULTS - HAMSTRING AUTO, ALLO OR BTB?

Answer 66

 All equivocal, each with their own pros and cons

Question 67

List 5 Risk Factors for Patella Malalignment

Answer 67

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

Question 68

WHAT ARE THE EFFECTS OF WEIGHT TRAINING ON MUSCLE

Answer 68

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

Question 69

LIST 4 COMPONENTS OF MEDICAL NEGLIGENCE

Answer 69

• Dutyo 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.- Causationo 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 dutyo Breach of duty occurs when action or failure to act deviates from the standard of care.- Damageso Damages are monies awarded as compensation for injuries sustained as the result of medical negligenceOrthobulletsDCB’D

Question 70

FACTORS PREDISPOSING GIRLS TO ACL TEAR

Answer 70

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

Question 71

CLASSIFY DISCOID MENISCUS

Answer 71

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

Question 72

INDICATIONS OF ADEQUATE RESUSITATION

Answer 72

• 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

Question 73

NAME THE 3 TOP REASONS FOR IN-TOEING

Answer 73

• increased femoral anteversion• tibial tosion• metatarsus adductus

Question 74

Describe 4 MSK and 4 Non MSK Features Down’s

Answer 74

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)

Question 75

OSCE SHOULDER INSTABILITY - OTHER THAN WITH INSTABILITY, HOW DO THESE PATIENT OFTEN PRESENT?

Answer 75

• highly variable• May have RC tendinitis and impingement in

Question 76

RISKS FOR PATELLA AND QUADS RUPTURE

Answer 76

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

Question 77

LIST 4 NORMAL PEDIATRIC CERVICAL SPINE FINDINGS THAT MAY BE MISINTERPRETED AS TRAUMATIC PATHOLOGY

Answer 77

• 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.

Question 78

Risk Factors for Patellar Fracture Following TKA

Answer 78

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)

Question 79

WHAT ARE 4 COMPLICATIONS OF HIP SPICA CASTS

Answer 79

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

Question 80

WHAT IS THE MORTALITY OF HALOS IN PATIENTS 79 YEARS AND OLDER?

Answer 80

• 21%

Question 81

Name 5 Risk Factors Supported by Evidence for Total Joint Infections (Hip or Knee or Both)

Answer 81

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

Question 82

POSITIVE PROGNOSIS IN NERVE REPAIR

Answer 82

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

Question 83

LIST 6 FACTORS WHICH PREDISPOSE TO TENDON ADHESIONS POST FLEXOR TENDON REPAIR

Answer 83

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

Question 84

ACL TUNNEL MALALIGNMENT

Answer 84

• 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

Question 85

LIST 5 THINGS THAT ALLOGRAFT BONE IS TESTED FOR

Answer 85

• HIV• HCV• HBV• CMV• HTLV-1• Syphilis

Question 86

PROPERTIES OF AN IDEAL FRACTURE CLASSIFICATION SYSTEM - NAME 6

Answer 86

• 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

Question 87

WHAT IS INDICATION FOR C-CLAMP

Answer 87

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

Question 88

LIST 3 FEATURES OF McCune Albright o Café-au-laito Fibrous dysplasiao Precocious puberty

Answer 88

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

Question 89

INDICATIONS FOR MENISCAL REPAIR

Answer 89

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

Question 90

WHAT IS THE MOST COMMON FORM OF OSTEOARTHRITS OF THE FOOT/ANKLE?

Answer 90

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

Question 91

LIST 5 RISK FACTORS FOR A FRAGILITY FRACTURE:

Answer 91

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

Question 92

LIST THREE RADIOGRAPHIC CHARACTERISTICS OF A STRUCTURAL CURVE

Answer 92

According to JR Cobb 1960 JBJS (attached):• Abnormal vertebral angulation• Abnormal vertebral rotation• Abnormal vertebral position• Abnormal vertebral wedgingAccording 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 25o Kyphosis between T2 and T5 of at least 20.• Main Thoracic curve pattern must haveo Main residual coronal curve of at least 25o Kyphosis between T10 and L2 of at least 20.• Thoracolumbar/Lumbar curve pattern must haveO Minimum residual curve of at least 25O Kyphosis between T10 and L2 of at least 20

Question 93

TREATMENT OPTIONS FOR CONVERGENCE IN A FAILED DARRACH OR SAUVE-KAPANDJI

Answer 93

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

Question 94

What are 4 Design Features of a High Flexion Knee Compared to a Standard TKA

Answer 94

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.

Question 95

LIST 5 PRE-CLAVICULAR NERVES

Answer 95

• Phrenic• Dorsal scapular• Suprascapular• Nerve to subclavius• Long thoracic

Question 96

Name 5 Non-inflammatory Arthropathies

Answer 96

OA Charcot Ochronosis (alkaptonuria) Acute rheumatic fever Secondary pulmonary hypertrophic osteoarthropathy (secondary to factors secreted by a large tumor) Miller’s - page 45

Question 97

5 SIGNS OF VERTIBROBASILAR INSUFFICIENCY?

Answer 97

• Cant see, cant speak, cant walk the talk!• VERTEBROBASILAR INSUFFICIENCYo Nystagmuso Diplopliao Loss of vision in one or both eyeso Vertigoo Dizzynesso Dysarthria/Dysphagiao Sudden drop attack

Question 98

DDX OF A DIAPHYSEAL LESION

Answer 98

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

Question 99

COMPARED TO LATERAL FEMORAL PINS, ANTERIOR FEMUR EX FIX PINS ARE WORSE BECAUSE

Answer 99

• 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

Question 100

ASIA CLASSIFICATION

Answer 100

• 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

Question 101

INDICATIONS FOR MRI IN ADOLECENT SCOLIOSIS

Answer 101

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

Question 102

FOOT AND ANKLECAVUS (CMT - WEAK PB AND STRONG PL AND WEAK TA AND STRONG PL) HOW DO YOU DECIDE WHEN TO STOP IMMOBILIZING A CHARCOT FOOT?

Answer 102

• 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

Question 103

HAD DO YOU MANAGE A RECURRENT LARYNGEAL NERVE INJURY?

Answer 103

• Observation 6 mos- Refer to ENT for scope

Question 104

OSCE SHOULDER INSTABILITY - REGARDLESS OF AGE AND ACTIVITY OF PATIENT, WHEN PLANNING YOUR TREATMENT, WHAT ARE THE THREE MOST IMPORTANT VARIABLES TO CONSIDER?

Answer 104

• Diagnosis: MDI vs. unidirectional• Soft tissue lesions present• Bone lesions present

Question 105

WHAT ARE 3 CAUSES FOR FAILURE OF SLIDING HIP SCREW FOR REVERSE OBLIQUE FRACTURE

Answer 105

• 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 segmentReverse Obliquity Fractures of the Intertrochanteric Region of the Femur - JBJS 2001

Question 106

LIST 6 FACTORS THAT INCREASE THE CONSTRUCT OF YOUR EXTERNAL FIXATOR

Answer 106

• 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)

Question 107

LIST 5 CAUSES OF HALLUX VARUS

Answer 107

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

Question 108

KNEE OCD

Answer 108

  > 2cm, OATS > 2cm Osteochondral allograft, ACI

Question 109

LIST ASSOCIATED INJURIES ASSOCIATED WITH SCAPULA FRACTURE

Answer 109

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

Question 110

ACCESSORY IMAGING OF THE SHOULDER

Answer 110

• 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

Question 111

LIST THREE TREATMENT OPTIONS FOR AVN OF HUMERAL HEAD

Answer 111

• Non-op• Core decompression (Cruess I,II,III)• Hemiarthroplasty (Cruess IV)• TSA (Cruess V)ref Mo’s book p351 onward

Question 112

Name Features of 3rd Generation Cementing

Answer 112

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

Question 113

List 6 causes of FAI

Answer 113

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

Question 114

LIST 5 FACTORS FOR OSTEOSARCOMA THAT YIELD A POOR PROGNOSIS

Answer 114

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

Question 115

LIST 3 COMMON REASONS FOR SUCCESSFUL PROSECUTION OF PHYSICIANS - …MMM (MO VOICE)

Answer 115

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

Question 116

PATIENT HAS EARLY POST-OP INFECTION, TREATED WITH I&D (TO YOUR SATISFACTION) AND HARDWARE RETENTION. WHAT ARE 2 PREDICTORS TO FAILURE?

Answer 116

• 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

Question 117

HOW DO YOU PUT ON A HALO?

Answer 117

• 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)

Question 118

LIST THE THREE CONDITIONS IN THE FEMALE ATHLETE TRIAD

Answer 118

• Amenorrhea• Eating disorder• Stress fracture / osteopeniaMillers p294

Question 119

WHAT IS THE INDICATION FOR AN ACHILLES TENOTOMY? HOW COMMONLY IS THIS REQUIRED?

Answer 119

• DF • 85-90%

Question 120

BANKART LESION - 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 120

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

Question 121

LIST 4 STRUCTURES PASSING THROUGH THE LESSER SCIATIC FORAMEN

Answer 121

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

Question 122

DESCRIBE THE SEQUENCE OF CORRECTIONS FOR CLUBFOOT

Answer 122

• 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

Question 123

WHAT ARE 4 RADIOGRAPHIC SIGNS AT 3 MONTHS THAT PREDICT THE NEED FOR FEMORAL NECK NONUNION/REVISION?

Answer 123

• 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 headActa 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

Question 124

WHO AM I? Dx? What screening test must be done regularly until age 5-6?

Answer 124

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 syndrome3 - Renal U/S to r/o Wilm’s tumour

Question 125

5 Contraindications to Immediate Wound Closure for Traumatic Open Wounds

Answer 125

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

Question 126

LIST 3 OPERATIVE INDICATIONS TO REPAIR A ROTATOR CUFF

Answer 126

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

Question 127

Name 3 Side Effects from Radiation for Hip HO

Answer 127

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) 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.)

Question 128

WHAT ARE THE 4 VECTORS TO REDUCE A BENNETT’S FRACTURE?

Answer 128

• Traction- Extension- Pronation- Abduction

Question 129

OSCE - WHAT IS YOUR MANAGEMENT OF A POSTEROLATERAL SIMPLE ELBOW DISLOCATION (2) IN A 25 YR OLD WRESTLER, POST REDUCTION CONGRUENT, STABLE ARC FROM 40-145 DEG

Answer 129

• Splint in backslab for • 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

Question 130

4 WAYS TO DEAL WITH INFECTED BONE LOSS

Answer 130

• 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

Question 131

OSCE SHOULDER INSTABILITY - DEFINE INSTABILITY VS. LAXITY

Answer 131

• 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

Question 132

LIST THE FOUR MOST IMPORTANT POOR PROGNOSTIC SIGNS FOR PEDIATRIC SEPTIC ARTHRITIS

Answer 132

• Delay > 4 days• Age • Joint effusion with underlying osteomyelitis• Hip involvement

Question 133

LIST 5 CONTRAINDICATIONS TO A GH FUSION

Answer 133

• 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

Question 134

OSCE - BisphophonatesYour colleague sends her away for MRI and 3 months later, she comes back. Pain still present and there is bony edema on the MRI. What now? Your colleague thinks her canal is too tight - he wants to use the new-fangle locking plate he’s been hearing about because he figures it will be easy to use for the first time in a non-broken bone. He wants your opinion - What do you tell him?

Answer 134

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

Question 135

NAME 7 CAUSES OF CHARCOT ARTHROPATHY

Answer 135

• 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- AmyloidosisMiller’s pp45-6

Question 136

NAME 7 PEDIATRIC CONDITIONS ASSOCIATED WITH ATLANTOAXIAL INSTABILITY

Answer 136

• 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- Marfans1) Miller’s pp198-2072) Manny’s lists

Question 137

AFTER NAILING A FEMUR, WHAT THINGS DO YOU CHECK FOR PRIOR TO WAKING UP THE PATIENT?

Answer 137

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

Question 138

LIST 5 WAYS TO MINIMIZE FEMORAL MALROTATION WHEN PLACING AN IM NAIL FOR FEMUR FRACTURES

Answer 138

• 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

Question 139

MEDIAL PIN, ULNAR NERVE OUT, WHAT ARE YOU GOING TO DO BUSTA?

Answer 139

• Iatrogenic ulnar nerve injuries 1-15%• 60% children • 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

Question 140

SCREW DENSITY

Answer 140

 Number of holes/number of screws

Question 141

WHEN TO USE BISPHOSPHONATES

Answer 141

• Metastatic disease- GCT- Pagets- Fibrous Dysplasia- Myeloma

Question 142

LIST 3 FEATURES OF Ollier’s syndrome o Sporadic inheritenceo Multiple exostoseso 30% malignant transformation

Answer 142

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

Question 143

LIST 5 CONDITIONS ON DIFFERENTIAL DIAGNOSIS IN A 10 YR OLD WITH A LIMP 10 yrs of age

Answer 143

• 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 tumorSkaggs - Staying out of trouble…I think the original reference is JAAOS 2001 FlynnDuchenne’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)

Question 144

NAME THE NORMAL VALUES FOR THE ROTATIONAL PROFILE ASSESSMENT IN KIDS?

Answer 144

Table 3–14 – EVALUATION OF ROTATIONAL PROBLEMS OF THE LOWER EXTREMITIESMeasurement Technique Normal Values (degrees) SignificanceFoot-progression angle Foot vs. straight line −5 to +20 Nonspecific rotationMedial rotation Prone hip ROM 20-60 > 70 degrees; femoral anteversionLateral rotation Prone hip ROM 30-60 Thigh–foot angle Knee bent; foot up 0-20 Foot lateral border Convex; medial crease Straight; flexible Metatarsus adductus

Question 145

LIST 3 WAYS TO CONFIRM SCREW POSITION DURING SCFE PINNING

Answer 145

• near-far fluoro technique• inject dye through screw• 3D imaging (CT) Manny’s notes

Question 146

List 5 Conditions that are Associated with Increased Risk of Osteopenia

Answer 146

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

Question 147

WHAT ARE THE CLASSIC THREE RISK FACTORS FOR NONUNION OF A TIBIA FRACTURE

Answer 147

• 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

Question 148

OSCE – HALOWHAT ARE 5 CONTRAINDICATIONS TO A HALO?

Answer 148

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

Question 149

How to Avoid Varus

Answer 149

“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 2. 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.1. 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;91:1913-1918.1. Medial Blocking Screw - AP direction2. 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 nail1. 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 fragment1. 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 varusUse ronger, awl to remove bone MEDIALLY at entry point.

Question 150

List 4 Intraoperative Risk Factors for Acetabular Fractures During Total Hip Arthroplasty

Answer 150

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

Question 151

NAME 4 RISK FACTORS FOR MYELOMENINGOCELE

Answer 151

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

Question 152

List 5 AP Pelvis Radiographic Features of Pincer FAI

Answer 152

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

Question 153

OSCE SHOULDER INSTABILITY - CLASSIFY INSTABILITY

Answer 153

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

Question 154

WHAT IS THE RISK OF AVN (%) IN EACH OF THE FOLLOWING HUMERAL HEAD # PATTERNS? - 4 part fracture dislocation- displaced 4 part #- 3 part #- valgus impacted 4 part #

Answer 154

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

Question 155

WHAT ARE 5 FEATURES OF A MALIGNANT CELL (A LA SCHACHAR)

Answer 155

• 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)

Question 156

LIST 5 WAYS TO JUDGE THE HEIGHT OF A HUMERAL PROSTHESIS

Answer 156

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

Question 157

LIST 5 COMPLICATIONS OF PNEUMATIC TOURNIQUET

Answer 157

• Localo Post op swelling / stiffnesso Delay in muscle power recoveryo Compression neuropraxiao Wound hematomao Wound infectiono Direct vascular injuryo Bone and soft tissue necrosiso Compartment syndrome- Systemico CVPo Arterial hypertensiono Cardiorespiratory decompensationo Cerebral infarctiono Alterations in acid-base balanceo Rhabdomolysiso DVTPneumatic Tourniquets in Extremity Surgery JAAOS 2001

Question 158

LIST 5 CAUSES OF CHONDROCALCINOSIS

Answer 158

• CPPD crystal deposition• Ochronosis• Hemochromatosis• Hyperparathyroidism• Hypothyroidism• Calcium hydroxyapatite crystal deposition (“Milwaukee shoulder”)Miller’s p53

Question 159

GIVE TWO EXAMPLES OF TUMORS FOR EACH RADIOSENSITIVITY High radiosensitivity:Moderate radiosensitivity:Low radiosensitivity:

Answer 159

• High radiosensitivity:o MMo Small cell lungo Testicularo Leukemiao Lymphomao Germ cell tumors- Moderate radiosensitivity:o Non small cell lungo Thyroido Breasto Prostate o (epithelial)- Low radiosensitivity:o Renal cello Melanomao ColonFrom Manny notes (and wikipedia)

Question 160

List 5 Places Where Metal Particles Can Be Found in Body with Mom Hips

Answer 160

Capsule Bone Marrow Blood Urine Lymph nodes (para-aortic) Liver Spleen Dumbleton J Arthroplasty 2005JBJS Br Case et al 1994 Sep;76(5):701-12

Question 161

OSCE SHOULDER INSTABILITY - WHAT ARE THE CLINICAL EXAM REQUISITES TO GIVE SOMEONE A DIAGNOSIS OF MDI

Answer 161

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

Question 162

Knee Fusions What is the Position for Knee Fusion? What position would you fuse a PFFD Knee?

Answer 162

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.

Question 163

NAME 3 CAUSES OF CROUCH GAIT IN CP?

Answer 163

• Hip flexion contracture• Hamstring contracture• Excessively loose heel cords AAOS

Question 164

What do Patients with Paget’s Present With? (list 5)

Answer 164

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)

Question 165

Dx Osteosclerosis associated with secondary hyperparathyroidism of renal failureAlso described for Osteopetrosis

Answer 165

“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

Question 166

WHAT 3 CLINICAL SIGNS INDICATE YOU HAVE ADEQUATE ABDUCTION AND CAN PROCEED WITH CORRECTION OF EQUINUS / TENOTOMY?

Answer 166

• 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

Question 167

RISK FACTORS FOR SPINAL PSEUDARTHROSIS IN DEFORMIT CORRECTION

Answer 167

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

Question 168

ASYMPTOMATIC CUFF TEARS BY AGE

Answer 168

50 – 60 yrs 13%- 60 – 70 yrs 20%- 70 – 80 yrs 30%- > 80 yrs 50%- U/S Study of PARTIAL or FULL thickness tears

Question 169

What are the 6 Major Determinants of Gait?

Answer 169

Pelvic rotation Pelvic tilt Pelvic lateral rotation Knee flexion in stance phase Knee mechanics Foot mechanics Saunders et al., jbjs 1953

Question 170

LIST 3 FEATURES OF Li Fraumeni Syndrome

Answer 170

• P53 tumor suppressor gene mutation- predisposes to second hit- Increased risk of sarcoma and other cancer in young patientsReference: Tim’s Bone tumor handout, the Monument files and orthobullets

Question 171

5 CONTRAINDICATIONS TO IMMEDIATE WOUND CLOSURE FOR TRAUMATIC OPEN WOUNDS

Answer 171

• 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 myonecrosisRef: Chief review notes

Question 172

LIST 4 RADIOGRAPHIC FINDINGS IN CUFF TEAR ARTHROPATHY

Answer 172

• 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)

Question 173

LIST 5 POSSIBLE CAUSES OF A RIGID FLAT FOOT

Answer 173

• Tarsal coalition- Tumor (osteoid osteoma)- Infection- Inflammatory arthritis- Vertical talus- Oblique taluschief notes

Question 174

OSCE - BisphosphonatesWhat is the Effect of Biophosphonates on Acute Fractures?

Answer 174

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.

Question 175

RISK FACTORS FOR DEVELOPING A SCAPHOID NONUNION - LIST AT LEAST 5

Answer 175

• Proximal pole fracture• Initial displacement > 2 mm• Vertical fracture pattern• Delay to treatment 4 wk• Smokers• Female• K-wire fixation• Carpal collapse• Prior surgeryWright’s book or Bhandari’s book

Question 176

HILL SACHS (IN SETTING OF RECURRENT 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 176

• Latarjet• Think of remplissage depending on size

Question 177

LIST 5 SURGICAL TECHNIQUES TO MOBILIZE ROTATOR CUFF (RISKS FOR CUFF REPAIR NOT HEALING)

Answer 177

• 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

Question 178

IN THE NATURAL HISTORY OF ACL TEARS, HOW MANY PATIENTS, WITH NO RECONSTRUCTION GO ON TO DEVELOP OA?

Answer 178

 0-16%

Question 179

LIST 10 COMPLICATIONS AFTER SUSTAINING A RADIAL NECK/HEAD FRACTURE

Answer 179

• 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• MalunionRef for both Rockwood and Wilkins

Question 180

FACTS ON CARPAL SYNOSTOSIS

Answer 180

• Associationso Arthrogryposiso Ellis-van Creveld syndromeo Holt-Oram syndromeo Turner’s syndrome- Familial- Most frequently in black males- Bilateral- Lunotriquetrial is most common- Mostly incomplete- Usually asymptomatic

Question 181

RISK FACTORS FOR PATELLAR INSTABILITY

Answer 181

 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

Question 182

List Pre-op Consideration for Achons

Answer 182

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

Question 183

GOUTALLIER CLASSIFICATION

Answer 183

Stage > 3 (50%) correlates with poor outcome- Stage 0 Normal Muscle- Stage 1 Fatty Streaks- Stage 2 - Stage 3 50% fatty muscle- Stage 4 > 50% fatty muscle

Question 184

LIST 4 CAUSES OF ACQUIRED TORTICOLLIS

Answer 184

• 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

Question 185

List 3 Modalities to Maximize the Beneficial Effects of Prophylactic Antibiotics while Minimizing Adverse Events

Answer 185

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

Question 186

LIST 5 FINDINGS SUGGESTIVE OF PAGETOID SARCOMATOUS DEGENERATION

Answer 186

• 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 destructionOrthobullets

Question 187

LIST THE TWO CORRECTIONS PERFORMED WHEN DOING A PROXIMAL FEMORAL OSTEOTOMY TO TREAT THE SEQUELAE OF A HIGH GRADE SCFE

Answer 187

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

Question 188

LIST 3 FEATURES OF Jaffe-Campanacci (many NOF) o Café-au-laito Mental retardationo Hypogonadismo Disseminated NOF

Answer 188

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

Question 189

LIST 4 COMPLICATIONS OF PONSETTI CASTING

Answer 189

• Rocker bottom foot• Pressure sores• Crowded toes• Flat heel pad

Question 190

List 5 Indications for an HTO

Answer 190

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 Contracture >15 BMI > 35 > 20 degrees of correction required PF OA Varus thrust Instability

Question 191

LIST 4 CONDITIONS AFFECTING HYPERTROPHIC ZONE OF PHYSIS

Answer 191

• SCFE• Rickets (provisional calcification zone)• SH 1 fractures (provisional calcification)• Mucopolysacharide disease• SED• MED• AcromegalyProliferativeo Achon’so Gigantismo MHEReserveo Gaucher’so Disatrophic Dysplasiao Pseudoachon’s 1) “Rich Pretty Girls Do Koke”R = Reserve ZoneP = Pseudoachondroplasia = COMPG = Gaucher’s DiseaseD = Diastrophic Dysplasia = Sulfate TransportK = Kniest Syndrome = Type 2 collagen defect 2) “Big and Small”- Proliferative ZoneG = GigantismA = Achondroplasia (FGFR-3) 3) “MORE Sex Please”- Hypertrophic ZoneM = Mucopolysaccharidoses O = OsteomalaciaR = RicketsE = EnchondromaS = SCFEP = Physeal Fracture 4) Metaphysis- SCFE with Endocrine Problem- OSTEOPETROSIS- OI (Type 1 Collagen)- Scurvy (Vitamin C)

Question 192

OSCE - WHAT IS YOUR MANAGEMENT OF A POSTEROLATERAL SIMPLE ELBOW DISLOCATION (3) IN A 25 YR OLD WRESTLER, POST REDUCTION CONGRUENT, STABLE ARC FROM 65-145 DEG

Answer 192

• 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

Question 193

ACL RECONSTRUCTION COMPLICATIONS

Answer 193

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

Question 194

PLATE SPAN WIDTH

Answer 194

 Plate length / Fracture length

Question 195

Benefits for Placing the Acetabular Component at the Native Hip Centre in DDH (4)

Answer 195

Diminishes joint contact forces compared to high hip center Improved abductor function Fascilitates limb lengthening Best bone stock Ref: Campbell’s

Question 196

LIST 10 RISK FACTORS FOR DUPUYTRENS

Answer 196

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

Question 197

WHAT ARE 5 TECHNICAL TRICKS FOR TREATING FRACTURES WITH OSTEOPETROSIS?

Answer 197

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.

Question 198

LIST 5 TECHNICAL CONSIDERATIONS WHEN PLACING LATERAL PINS IN A PEDIATRIC SUPRACONDYLAR FRACTURE

Answer 198

• 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 fractureRockwood and wilkins 7th ed. p498

Question 199

Name 5 Conditions Associated with Acetabular Protrusio?

Answer 199

* RA * AS * Marfan’s * Paget’s * Otto’s pelvis (aka protrusion) Miller’s p48Also * 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 Pelvishttp://orthopaedicprinciples.blogspot.ca/2009/10/protrusio-acetabuli-otto-pelvis.htmlWheeless: * primary form, Otto pelvis (arthrokatadysis), involves both hips, occurs most often in females, & causes pain & limitation of motion at a relatively early age;

Question 200

OCD IN KIDS

Answer 200

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

Question 201

LIST 5 RISK FACTORS FOR FAILURE OF A ROTATOR CUFF REPAIR

Answer 201

• 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 restrictionsJAAOS 2012

Question 202

WHAT’S THE CLASSIC TRIAD FOR HAND-SCHULLER-CHRISTIAN DISEASE

Answer 202

• Exophthalmos- Diabetes Insipidous- Lytic skull lesion (multifocal Langerhans cell histiocytosis)(Apparently classic, but only seen in 25%)Millers 544

Question 203

LIST THE PRINCIPLES / STEPS IN A POSTEROMEDIAL RELEASE OF CLUBFOOT

Answer 203

• 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 nerveso Sural nerveo interosseous talocalaneal ligament- Releases:…Pretty much everything else- 1) Medialo Plantar fasciao Abductor halluciso lacinate ligament (flexor retinaculum)o TN capsuleo Calcaneounavicular ligament (spring)o Knot of henryo superficial deltoido Lengthen: tib post, FDL and FHL- 2) Posterior (?usually first according to chief notes)o Z-lengthening of achilleso release posterior tibiofibular and talofibular ligamentso Subtalar joint capsule- 3) Lateralo calcaneofibularo calcaneocuboido peroneal sheaths- May need to pin the CC joint and TN joint if unstable- Recurrence:o ? etiology - consider MRI for spinal cord- Revisiono SPLATTo Dwyer Osteotomy

Question 204

LIST 5 TUMORS THAT CAN GO ON TO SECONDARY ABC FORMATION?

Answer 204

• Chondroblastoma• osteoblastoma• GCT• CMF• NOF• Fibrous dysplasia

Question 205

DEFINE THE MRI “BOW TIE” SIGN

Answer 205

• 3 or more 5mm sagittal images with meniscal continuity

Question 206

WHAT ARE THE CRITERIA FOR DIAGNOSING NEUROFIBROMATOSIS 1?

Answer 206

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 Noteshttp://www.medicalcriteria.com/criteria/neuro_nf.htm

Question 207

LIST 5 INDICATIONS FOR TEA IN TRAUMA

Answer 207

• Patient mentally and physically fit for surgery• Low demand • Males > 75 and female > 70• Fractures not “ORIFable”• Pre-existing arthritis Ref: Graham King webinar

Question 208

DIFFERENTIAL DIAGNOSIS FOR POSTERIOR VERTEBRAL SCALLOPING (NAME 4)

Answer 208

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

Question 209

NAME 5 SMALL ROUND BLUE CELL TUMORS

Answer 209

LERN’M- L - Lymphoma- E – Ewings (most common kid >5)- R - Rhabdomyosarcoma- N – Neuroblastoma (most common kid - M – MyelomaAlso - Small round cell carcinoma (r/o >40yrs)Millers Page 549, and Board review Webinar 2012

Question 210

DESCRIBE PATTERNS OF MENISCAL TEARS

Answer 210

 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

Question 211

WHAT MRI FEATURES SUGGEST PRIMARY ABC VERSUS SECONDARY? DON’T TREAT TELANGIECTATIC OS!!!!!!

Answer 211

• Lack of soft tissue component • GAD will light up septa in primary lesion but not secondary• Look for perilesional edema to decipher from OSSources AAOS and radiology journal

Question 212

List 5 Medications/Drug Therapies Associated with Osteopenia

Answer 212

Anticonvulsants Steroids Heparin Excess Thyroid medication Aromatase inhibitors Testosterone antagonists Immunosuppressants

Question 213

A quickie, but something I came across that I could imagine being asked as a short-answer or osce question.What are the most common and concerning positioning-related complications related to the prone position (especially spine)?

Answer 213

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.

Question 214

STATE WHETHER EACH OF THE FOLLOWING IS AD, AR, OR X-LINKED RECESSIVENF1Becker Muscular DystrophyFriedrich’s ataxiaGaucher’sHemophilia AHMSN-1MarfanOI 1OI 2OI 3OI 4

Answer 214

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

Question 215

WRITE OUT YOUR STEPS FOR A TERRIBLE TRIAD

Answer 215

• 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

Question 216

LIST THREE RADIOGRAPHIC (PLAIN FILM) FEATURES OF A DISCOID MENISCUS

Answer 216

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

Question 217

NAME 5 COMPLICATIONS SPECIFIC TO A PEDS LATERAL CONDYLE #

Answer 217

• Tardy ulnar nerve palsy• Non union• Cubitus valgus• Acute nerve injury (rare)• Lateral condylar overgrowth• AVN• Cubitus varusRef: Chief review notes

Question 218

CAUSES FOR SUPRASCAPULAR NEUROPATHY

Answer 218

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

Question 219

List 5 Indications for Hip Arthroscopy

Answer 219

Chondral injury Labral tears Loose bodies Synovial disorders Ligamentum Teres rupture Impinging osteophytes Mechanical symptoms NYD Miller’s p267

Question 220

LIST 4 FRACTURE PATTERNS SUGGESTIVE OF CHILD ABUSE

Answer 220

• 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

Question 221

10 Techniques to Improve Fixation in Osteoporotic Bone

Answer 221

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

Question 222

INTRAARTICULAR SPREAD OF METAPHYSEAL OM TO WHICH JOINTS?

Answer 222

• SHEA Stadium- Shoulder- Hip- Elbow- Ankle NOT the knee

Question 223

WHAT ARE 6 SPINE CONSIDERATIONS IN ACHONDROPLASIA?

Answer 223

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

Question 224

LIST 5 ABSOLUTE INDICATIONS FOR REPLANT OF A TRAUMATIC UPPER EXTREMITY AMPUTATION

Answer 224

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

Question 225

RISK FACTORS FOR ADHESIVE CAPSULITIS

Answer 225

• Female• Cardiovascular Disease• Thyroid disease• Breast cancer treatment• Stroke• MI• DiabetesRef: JAAOS

Question 226

ENERGY EXPENDITURE IN AMPUTATION LEVELS

Answer 226

• From lowest consumption to highesto Symeo Midfooto BKAo Through Kneeo AKA

Question 227

LIST 3 OPTIONS TO MANAGE LAMOTHE’S AMBRI

Answer 227

• Physical therapy & rehabilitation• Inferior capsular shift / plication• Rotator interval closure• Psychiatric referral Miller’s p276.

Question 228

5 COMPLICATIONS OF DURAL TEARS

Answer 228

• positional headache• wound complications• meningitis• arachnoiditis• pseudomeningocoele (10%)

Question 229

ORDER OF APEARANCE AND CLOSURE IN PEDIATRIC ELBOW

Answer 229

• Appearance: CRITOEo Capitellum 1 o Radial head 5o Internal epicondyle 5o Trochlea 9o Olecranon 9o External Epicondyle 10- Closureo Lateral Epicondyle 10o Capitellum 12o Trochlea 14o Radial head 15o Olecranon 15o Medial Epicondyle 16

Question 230

List 3 Technical Advantages of Using an Inducible Membrane Instead of Just Slapping some Graft in the Defect

Answer 230

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

Question 231

LIST THREE PREDICTORS OF FAILURE OF ARTHROSCOPIC BANKART REPAIR

Answer 231

• Age 30 Yrs)• Overhead or contact athlete• Hill Sachs defect on AP in external rotationo Or loss of sclerotic inferior glenoid bordero lesions visualized in this view are high risk• Hyperlax individual (Jer)• Glenoid bone lossREFERENCE: BOILEAU, P - vumedi webinar Or Instability Severity Score JBJS (Br) Boileau 2007

Question 232

LIST 5 ABSOLUTE INDICATIONS FOR AN AMPUTATION

Answer 232

o B has the trauma roomo Life threatening infection with unsalvageable necrosiso Partial traumatic amputationo Irreparable vascular injuryo Warm ischemia time > 8 hours (not talking about a finger here)o Nonviable limb o Poor hosto No resources to facilitate salvage

Question 233

OSCE SHOULDER INSTABILITY - WHAT ARE THE CLASSIC LESIONS?

Answer 233

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

Question 234

R HAGL - 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 234

• Non-op and Refer

Question 235

LIST 5 COMPLICATIONS OF ROTATOR CUFF REPAIR

Answer 235

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

Question 236

LIST 4 RISK FACTORS FOR NON UNION OF ANKLE ARTHRODESIS

Answer 236

• 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

Question 237

WHAT 3 FEATURES WOULD LEAD YOU TO DO A 2 STAGE CONVERSION FROM EXTERNAL FIXATION TO NAIL?

Answer 237

• >2 weeks• Loose pin sites• Fever• Increased WBC• pus

Question 238

HOW ARE HALOS DIFFERENT IN KIDS?

Answer 238

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

Question 239

LIST 6 CAUSES OF SECONDARY OSTEOPOROSIS (IE NOT POST MENOPAUSAL/AGING)

Answer 239

Life Style Factors- Anorexia nervosa- Excessive protein intake- Smoking- Excessive alcohol intakeEndocrinopathies- Hyperthyroidism- Hyperparathyroidism- Cushing’s syndrome- Type 1 diabetes melitus- HypogonadismSystemic Diseases- Gaucher’s disease- Mastocytosis- Rheumatoid arthritis- Ankylosing spondylitis- PsoriasisOrgan Dysfunction- Cystic fibrosis- Asthma- Chronic obstructive pulmonary disease- Renal failure- Primary Biliary cirrhosis- Inflammatory bowel disease- Celiac sprue- Organ transplantationMedications- Glucocorticoids- Diuretics- Antiepileptics- Methotrexate- Cyclosporin A- Excess thryoid hormone replacement- Alkylating chemotherapeutic agents- Gonadotropin-releasing hormone agonistNeoplastic conditions- Multiple myelomaJ Am Acad Orthop Surg 2005;13:475-486

Question 240

LIST THE BORDERS OF THE ROTATOR INTERVAL

Answer 240

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

Question 241

WHAT LOCATION FOR ANKLE OSTEOCHONDRAL LESIONS HAVE THE WORST OUTCOMES?

Answer 241

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

Question 242

3 RADIOGRAPHIC FEATURES SUGGESTING MALIGNANT TRANSFORMATION OF AN OSTEOCHONDROMA

Answer 242

• 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

Question 243

LIST 5 EXTRASKELETAL MANIFESTATIONS OF OI

Answer 243

• 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• AllopeciaJAAOS 2008

Question 244

WHAT ARE 4 WAYS TO CHECK FOR NECK FRACTURE ASSOCIATED WITH HIGH ENERGY FEMORAL SHAFT FRACTURE?

Answer 244

• 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 fractures30% are missed initially according to 1993 paper by Bennett (CORR)

Question 245

LIST THREE RISK FACTORS FOR RECURRENCE OF POSTERIOR SHOULDER DISLOCATION

Answer 245

• Age • Dislocation due to a seizure• Large Reverse Hill Sachs as defined by > 1.5 cm3I know there are more, but these came from a paper Duffy stressed us to know back in the fall (Robinson et al., 2011 JBJS)

Question 246

TRUE OR FALSE: IT IS NORMAL FOR A NEW BORN TO HAVE FLEXION CONTRACTURES?

Answer 246

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

Question 247

BRACHIAL PLEXUS

Answer 247

• Well, draw it chump!

Question 248

LIST 5 NON-SKELETAL MANIFESTATIONS OF RA

Answer 248

o Vasculitiso Pleurisyo Pericarditiso Fevero Splenomegalyo Leukopeniao Decreased lacrimal and Salivary gland production (Sjogren’s)o Lymphoid proliferationo Rasho Iridocyclitis (JRA)o Miller’s p48

Question 249

NAME 5 REASONS TO OPERATE ON DISCITIS

Answer 249

• 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

Question 250

WHAT ARE THE PROS AND CONS OF EACH GRAFT OPTION?1. Hamstring: 2. Allograft: 3. BTB:

Answer 250

1. 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 flexion2. o Increased failure in young, activeo infection rate (theoretical however), o the quality of the graft is dependent on the individual it comes fromo the handling and sterilization performed by the processor3. o Bone:bone healing is goodo Anterior knee pain, o Potential for patellar fracture, o Will result in a really long graft if patient has patella alta

Question 251

LIST 4 ADVANTAGES OF LATERAL POSITIONING FOR ANTEGRADE FEMORAL IM NAIL

Answer 251

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

Question 252

LIST 5 COMPLICATIONS OF FLEXIBLE NAILING

Answer 252

• 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

Question 253

OSCE - BisphosphonatesHave a 70 yo woman with 10 years of Bisphophonate use. She is in your clinic - has one month history of mild thigh pain - seems mechanical in nature. Radiographs show good femoral cortices bilaterally, no stress fracture. What is your next course of management?

Answer 253

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.

Question 254

FOOT AND ANKLECAVUS (CMT - WEAK PB AND STRONG PL AND WEAK TA AND STRONG PL) WHAT ARE OPERATIVE STRATEGIES?

Answer 254

• 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 toeso PF release - Turco incision medially, ID and protect ML plantar nerves, seperate PF from tendons and subcu tissue and releaseo DF 1st ray opening wedge proximal MT osteotomyo Calcaneous: Lateral sliding or Dwyer closing wedge (lateral incision, oblique and slide, fix with 2 7.3 screws)o TAL

Question 255

WHAT ARE THE STEPS IN RESPONSE TO AN INTRAOPERATIVE SSEP/MEP CHANGE DURING SPINE SURGERY?

Answer 255

• 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)

Question 256

• You are a community orthopaedic surgeon and have just finished a R TKA on a patient. While dictating you realize you have may have put in a left femoral component. The patient is in the recovery room.

Answer 256

• 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?

Question 257

LIST 5 CONDITIONS ON DIFFERENTIAL DIAGNOSIS IN A 10 YR OLD WITH A LIMP 4-10 yrs of age

Answer 257

• 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

Question 258

OSCE: You are called to see a 4 day old child in the NICU who is not moving. What is the top 3 on your differential diagnosis?

Answer 258

trauma infection brachial plexus

Question 259

OUTERBRIDGE ARTHROSCOPIC CLASSIFICATION

Answer 259

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

Question 260

What are 4 Disadvantages of HCLPE?

Answer 260

Miller p. 307-8Disadvantages 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

Question 261

NAME THE AFFECTED GENEAchondroplasiaNF1Diastrophic dysplasiaPseudochondroplasiaCleidocranial dysplasiaMarfan’sHemophilia BJansen’sCMTDuchenne’s/BeckersMyotonic DystrophySMA

Answer 261

• 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

Question 262

LIST 5 WAYS TO DISTINGUISH A CONGENITAL RADIOCAPITELLAR DISLOCATION FROM AN ACUTE ONE

Answer 262

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

Question 263

LIST 5 CONTRAINDICATIONS TO ROTATOR CUFF REPAIR

Answer 263

• Infection• GH arthritis• Acromial humeral distance • Deltoid axillary nerve dysfunction• Atrophic cuff/chronicity/retraction

Question 264

LIST THREE METHODS OF DETERMINING PATELLA HEIGHT

Answer 264

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 ( 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, - Miller’s p252

Question 265

LIST THE STEPS IN AN ACHILLES TENOTOMY?

Answer 265

• 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

Question 266

Name 4 causes of hemihypertrophy?

Answer 266

• 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 41. Wilm’s Tumour (aka nephroblastoma)◦ Painless abdominal massDx - Abdominal U/S

Question 267

LIST 6 CLINICAL EXAM FEATURES YOU MAY FIND IN KIDS WITH FLEXIBLE PES PLANOVALGUS

Answer 267

• 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

Question 268

Risks for Peroneal Nerve Palsy Post TKA

Answer 268

Valgus > 12 Abberant retractor Epidural anesthesia Previous laminectomy Peripheral neuropathy These last two are due to “doublecrush” phenomenon Basic Science

Question 269

RISK FACTORS FOR DEVELOPING A SOFT TISSUE SARCOMA

Answer 269

• Li-Fraumeni• Retinoblastoma• NF-1• HIV• Prior radiation• EBV (controversial)A collection of JAAOS, Miller’s, and AAOS COR

Question 270

ETIOLOGY OF CHARCOT SHOULDER

Answer 270

• Syrinx most common• DM2• Leprosy• Syphillis• Alcoholism

Question 271

LIST TWO DIFFERENCES BETWEEN A POSTERIOR HIP DISLOCATION AND KOCHER-LANGENBACH FOR AN ACETABULAR WALL FRACTURE

Answer 271

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

Question 272

WHAT ARE THE STRENGTHS OF THE KNEE LIGAMENTS

Answer 272

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

Question 273

LIST 3 FEATURES OF MHE

Answer 273

• 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)

Question 274

ASSOCIATED FINDINGS IN ACUTE ACL TEAR

Answer 274

• Hemarthrosis- Bone bruiseo mid-third lateral femoral condyleo post-third lateral tibial plateau- Lateral meniscus tear- Segond fractureo Lateral capsular avulsion of tibia

Question 275

NAME 3 WAYS TO RADIOGRAPHICALLY DETERMINE THE CARRYING ANGLE OF A PEDIATRIC ELBOW

Answer 275

• 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

Question 276

LIST THE THREE KEY LIGAMENTOUS STABILIZERS OF THE LISFRANC ARTICULATION (SPECIFICALLY THE BAST OF THE 2ND MT BASE AND MEDIAL CUNEIFORM)

Answer 276

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

Question 277

WHAT ARE THE STRENGTHS OF THE ACL LIGAMENT GRAFTS

Answer 277

• Load-to-failureo Hamstrings 4000 N load-to-failureo Quadriceps in betweeno BTB 2600 N loado Native ACL: 2200N

Question 278

WHAT IS A LIKELY DIAGNOSIS IN A CHILD WITH NO FLEXION CONTRACTURES OF HIPS OR KNEES?

Answer 278

• Larsen syndrome

Question 279

SMALL ROUND CELL TUMORS (7)

Answer 279

• Ewings- Lymphonma- EG- Neuroblastoma- PNET- Rhabdomyosarc- Myeloma

Question 280

77 yo woman with periprothetic greater trochanter fracture. What would you do in each of the cases?Stem and acetabular component stable, mecanical fall with no previous symptoms. Displaced > 2cm, no osteolysis Displaced > 2cm, osteolysis Displaced Displaced

Answer 280

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

Question 281

LIST 3 INDICATIONS TO OPERATE ON CERVICAL RADICULOPATHY

Answer 281

• 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

Question 282

LIST 3 REQUIREMENT TO MAKE CAUSALITY

Answer 282

• Association- Prediction- Excluding alternative- Dose response

Question 283

WHAT ARE 3 OTHER RADIOGRAPHIC RISK FACTORS FOR OSTEONECROSIS IN PROX HUM # (HELFET CRITERIA)?

Answer 283

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)

Question 284

WAYS TO JUDGE HEIGHT OF RADIAL HEAD HEIGHT

Answer 284

• 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 sideRef: mostly Athwal JBJS 2010

Question 285

NAME 3 PEDIATRIC CONDITIONS ASSOCIATED WITH BASILAR INVAGINATION?

Answer 285

• AKON- Morquios- SED

Question 286

HAGL - 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 286

• Rehab• then open repair (I am referring this one)

Question 287

LIST 3 INDICATIONS FOR NON-OPERATIVE MANAGEMENT OF A TERRIBLE TRIAD

Answer 287

• Minimally or nondisplaced fractures of coronoid and radial head• Congruent reduction• Stable arc of motion, extension > 40 degVumedi Webinar Graham king

Question 288

3 CAUSES OF NON-IDIOPATHIC CLUB FOOT?

Answer 288

• Arthrogrypotic• Myelomeningocele• Diastrophic dysplasia• Amniotic band syndrome AAOS

Question 289

LIST 5 PATIENT FACTORS YOU SHOULD CONSIDER WHEN DECIDING UPON TREATMENT OF TRAUMATIC SHOULDER INSTABILITY IN PERSON (OSCE)

Answer 289

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

Question 290

LIST 3 STRUCTURES CONTAINED WITHIN THE ROTATOR INTERVAL

Answer 290

• Biceps tendon• SGHL• CHL• Glenohumeral capsuleHunt, et. al. JAOSS 2007 15 p218-219

Question 291

What 3 conditions give a classic Erlenmeyer Flask Deformity to the Metaphyses?

Answer 291

Gauchers Osteopetrosis Niemann-pick

Question 292

NAME 3 CONDITIONS ASSOCIATED WITH CVT?

Answer 292

• Myelomeningocele- Syrinx- Arthrogryposis

Question 293

LIST 11 STRUCTURES PASSING THROUGH GREATER SCIATIC FORAMEN

Answer 293

• 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 femorisPOPS-IQ below piriformis…

Question 294

NAME 5 PREDICTORS OF POOR PROGNOSIS FOR ROTATOR CUFF REPAIR

Answer 294

• Marked atrophy or fatty infiltration of spinate muscles on MRI ( >50% (grade IV) Sagittal T1)- Acromiohumeral distance less than 5 mm on AP ( 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 AcromialeComplex And Revision Problems In Shoulder Surgery - By Jon J. P. Warner, Joseph P. Iannotti, Evan L. Flatow & ICL 55-5

Question 295

HOW DO YOU DEAL WITH IT IF YOU’VE CAUSED IT?

Answer 295

• Mild , 7-10 degrees - usually asymptomatico 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

Question 296

LIST 3 FEATURES OF Gardner syndrome (Familial Colorectal Polyposis) o Osteomao Desmoid tumorso Thyroid carcinomao Fibromas

Answer 296

• Multiple enostosis (bone islands)- Colorectal polyps- Fibromas- Sebaceous cyst

Question 297

List the 3 Conditions of Miserable Malalignment

Answer 297

Femoral anteversion Genu valgum Pronated feet