UK*TE Dec 21 Flashcards
“Gagey’s sign” is elicited by stabilising the scapula with one hand, and abducting the arm with the other. Achieving abduction beyond 105 degrees is regarded as abnormal, and is a sign of:
a. Inferior laxity
b. Posterior laxity
c. Superior laxity
d. Anterior laxity
e. A large bony lesion
Answer: A
Gagey sign - hyperabduction test for assessment of the IGHL - range passive abduction >105 deg with 90 in the contralateral shoulder in 85% of patients with instability. An RPA of more than 105° is associated with lengthening and laxity of the inferior glenohumeral ligament.
Passive abduction occurs within the glenohumeral joint only, is controlled by the inferior glenohumeral ligament
Traumatic Anterior Shoulder Instability, also referred to as TUBS (Traumatic Unilateral dislocations with a Bankart lesion requiring Surgery), are traumatic shoulder injuries that generally occur as a result of an anterior force to the shoulder while its abducted and externally rotated and may lead to recurrent anterior shoulder instability.
Diagnosis is made clinically with the presence of positive anterior instability provocative tests and confirmed with MRI studies that may reveal labral and/or bony injuries of the glenoid and proximal humerus (Hill-Sachs lesion).
Treatment may be nonoperative or operative depending on the chronicity of symptoms, the presence of risk factors for recurrence, and the severity of labral and/or glenoid defects. In high-risk populations, surgery is often offered after a single dislocation event.
bankart lesion
is an avulsion of the anterior labrum and anterior band of the IGHL from the anterior inferior glenoid.
is present in 80-90% of patients with TUBS
bony bankart lesion
is a fracture of the anterior inferior glenoid
present in up to 49% of patients with recurrent dislocations
higher risk of failure of arthroscopic treatment if not addressed
defect >20-25% is considered “critical bone loss” and is biomechanically highly unstable
stability cannot be restored with soft tissue stabilization alone (unacceptable >2/3 failure rate)
requires bony procedure to restore bone loss (Latarjet-Bristow, other sources of autograft or allograft)
Humeral avulsion of the glenohumeral ligament (HAGL) occurs in patients slightly older than those with Bankart lesions
associated with a higher recurrence rate if not recognized and repaired
an indication for possible open surgical repair
glenoid labral articular defect (GLAD) is a sheared off portion of articular cartilage along with the labrum
presence is a risk factor for failure following arthroscopic stabilization procedures
anterior labral periosteal sleeve avulsion (ALPSA)
can cause torn labrum to heal medially along the medial glenoid neck
associated with higher failure rates following arthroscopic repair
common finding in patients with recurrent instability managed nonoperatively
97% of patients with recurrent instability have either a Bankart or ALPSA lesion
Hill-Sachs defect
is a chondral impaction injury in the posterosuperior humeral head secondary to contact with the glenoid rim.
is present in 80%-100% of traumatic dislocations and 25% of traumatic subluxations
Static restraints: bony anatomy, capsule, glenohumeral ligaments, labrum (labrum contributes 50% of additional glenoid depth)
Dynamic restraints: rotator cuff muscles & long head of biceps tendon
Anterior static shoulder stability is provided by:
1. Anterior band of IGHL (main restraint)
provides static restraint with arm in 90° of abduction and external rotation
2. MGHL - provides static restraint with arm in 45° of abduction and external rotation
3. SGHL - provides static restraint with arm at the side
- Which of the following tests is positive in thoracic outlet syndrome?
a. O’Brien’s test
b. Speed’s test
c. Hawkin’s sing
d. Hornblower’s sign
e. Adson’s test
Answer: E
Thoracic outlet syndrome is a neurovascular disorder resulting from compression of the brachial plexus and/or subclavian vessels in the interval between the neck and axilla.
Diagnosis can be suspected clinically with specific provocative tests and supplemented with radiographs or vascular studies. showing anatomic causes of compression.
Treatment may be nonoperative or include surgical decompression or a vascular procedure depending on the specific etiology.
neurogenic is most common (95%)
vascular may be venous (4%) or arterial (< 1%)
- hypertrophy of anterior scalene
- scalenus minimus: accessory muscle found in 30-50% of patients with TOS. Originates from cervical transverse process and inserts onto 1st rib between the subclavian artery and T1 root
-fibromuscular bands: increase stiffness and decrease compliance of the thoracic outlet
- costoclavicular ligament: abnormal insertion implicated in Paget-Schroetter syndrome (intermittent obstruction of subclavian vein in costoclavicular space –> upper extremity DVT)
- soft tissue tumors: Pancoast tumor, neuroblastoma, schwannoma brachial plexus
- abnormal pec minor
Osseous:
- cervical rib (arises from C7 vertebra)
- prominent C7 transverse process
- abnormal clavicle or 1st rib
- ACJ or SCJ injury or dislocation
- Osseous tumours - bone mets, osteoid osteoma
- Chronic overuse - repetitive lifting - weight lifters, rowers, swimmers
Thoracic outlet is composed of 3 distinct spaces:
- interscalene triangle: brachial plexus trunks, subclavian artery
- costoclavicular space: brachial plexus divisions, subclavian artery and vein
- retropectoralis minor space: brachial plexus cords, axillary artery and vein
Adson Test - evaluates for compression at the interscalene triangle - patient seated, shoulder slightly abducted, externally rotated, elbow extended, forearm supinated - palpate radial pulse, then get patient to maximally extend and laterally rotate the neck towards side being tested, then inhales and holds breath + result is reduction amplitude /loss of radial pulse or reproduction pain/paraesthesia.
a. O’Brien’s test = active compression test +for SLAP is pain deep in GHJ while forearm is pronated, but not when supinated. Forward flex arm to 90deg, keep elbow fully extended, adduct arm to 10-15deg across body, pronate forearm (thumb pointing down) then examiner applies downward force and patient resists. Patient then supinates forearm and examiner applies pressure while patient resists.
b. Speed’s test - biceps injury - +is pain elicited in bicipital groove - forward elevate shoulder against resistance with elbow extended and forearm supinated.
c. Hawkin’s sign - impingement - flex shoulder and elbow to 90 and forcibly IR driving the greater tuberosity farther under the CA ligament.
d. Hornblower’s sign - terms minor - bring shoulder to 90deg abduction and ER, ask patient to hold this position, +if falls into IR
- In a patient with vascular concerns, which of the following is NOT a reason for performing a trans-radial amputation at the junction of the middle and distal third, rather than a more distal site?
A. The distal subcutaneous tissue is scant and less ideal for fashioning a stump
B. The forearm skin is thinner distally
C. Underlying soft tissue structures are relatively more avascular distally
D. Prosthesis fitting is easier
E. High incidence of complications with distal site
Answer: D
Easier prosthesis fitting is not a reason for a more proximal amputation
- Shoulder provocation test where pain is elicited when the patients shoulder is flexed to 90deg, adducted 15deg, internally rotated and a downward force applied is most suggestive of:
a. Superior labral anterior to posterior (SLAP) tear
b. Inferior glenohumeral ligament tear
c. Middle glenohumeral ligament tear
d. Supraspinatus tear
e. Glenohumeral arthritis
Answer: A
• Active Compression test (“O’Brien’s Test”) - positive for SLAP tear when there is pain is “deep” in the glenohumeral joint while the forearm is pronated but not when the forearm is supinated. Technique.
o patient forward flexes the affected arm to 90 degrees while keeping the elbow fully extended. The arm is then adducted 10-15 degrees across the body. The patient then pronates the forearm so the thumb is pointing down. The examiner applies downward force to the wrist while the arm is in this position while the patient resists. The patient then supinates the forearm so the palm is up and the examiner once again applies force to the wrist while the patient resists.
Answer: Superior labral anterior to posterior (SLAP) tear – O’Brien’s test.
Impingement:
- Neer Impingement: indicative of impingement of rotator cuff tendon/bursa against the coracoacromial arch. Use one hand to prevent motion of the scapula; raise the arm of the patient with the other hand in forced elevation (somewhere between flexion and abduction) - pain is elicited (positive test) as the greater tuberosity impinges against the acromion (between 70-110°)
- Hawkins Test: flex shoulder to 90°, flex elbow to 90°, and forcibly internally rotate driving the greater tuberosity farther under the CA ligament.
Subscapularis Tests:
- Internal rotation lag sign = most sensitive and specific test for subscap pathology. stand behind patient, flex elbow to 90°, hold shoulder at 20° elevation and 20° extension. Internally rotate shoulder to near maximum holding the wrist by passively lifting the dorsum of the hand away from the lumbar spine – then supporting the elbow, tell patient to maintain position and release the wrist while looking for a lag.
- Lift off test, Belly press, Increased passive ER
Supraspinatus Tests:
• Jobe’s Test: weakness and/or impingement. Abduct arm to 90°, angle forward 30° (bringing it into the scapular plane), and internally rotate (thumb pointing to floor). Then press down on arm while patient attempts to maintain position testing for weakness or pain.
• Drop Sign: for function/integrity of supraspinatus. Passively elevate arm in scapular plan to 90°. Then ask the patient to slowly lower the arm. The test is positive when weakness or pain causes them to drop the arm to their side.
o most specific test for full thickness rotator cuff tear (specificity 98%)
infraspinatus Tests:
- External rotation lag sign
Teres Minor:
- Hornblower’s sign: bring the shoulder to 90 degrees of abduction, 90 degrees of external rotation and ask the patient to hold this position. Positive if the arm falls into internal rotation
- Which of the following is not a contraindication to total shoulder arthroplasty?
a. Non functioning deltoid
b. Complete tear of subscapularis and supraspinatus
c. Charcot arthropathy
d. Active infection
e. B2 glenoid
Answer: E
Replacement of humeral head and glenoid resurfacing
cemented all-polyethylene glenoid resurfacing is standard of care
Total shoulder arthroplasty unique from THA and TKA in that:
- greater range of motion in the shoulder
- success depends on proper functioning of the soft tissues
- glenoid is less constrained
- leads to greater sheer stresses and is more susceptible to mechanical loosening
Factors required for success of TSA
- Rotator cuff intact and functional: if rotator cuff is deficient and proximal migration of humerus is seen on x-rays (rotator cuff arthropathy) then glenoid resurfacing is contraindicated. If there is an irreparable rotator cuff deficiency then proceed with hemiarthroplasty or a reverse ball prosthesis
an isolated supraspinatus tear without retraction can proceed with TSA (incidence of full thickness rotator cuff tears in patients getting a TSA is 5% to 10%). If positive impingement signs on exam, order a pre-operative MRI
- Glenoid bone stock and version: if glenoid is eroded down to coracoid process then glenoid resurfacing is contraindicated
Outcomes
pain relief most predictive benefit (more predictable than hemiarthroplasty)
reliable range of motion
good survival at 10 years (93%)
good longevity with cemented and press-fit humeral components
worse results for post-capsulorrhaphy arthropathy
- You are called to see a 76 year old diabetic male patient admitted yesterday with sepsis and a 4 week history of low back pain. He denies bladder or bowel symptoms and is ambulating with mild discomfort around the ward. Blood cultures have grown gram positive cocci and he has been started on empirical antibiotics. The medical team arrange whole spine MRI which shows discitis at the L4/5 level and an associated epidural abscess compressing the thecal sac including the cauda equina. On examination he is pyrexial, has absent sensation to the tips of his toes but normal perianal sensation. The most appropriate management is?
a. Biopsy of disc material with samples to microbiology
b. Percutaneous stabilisation
c. Debridement of epidural abscess via a posterior approach
d. Continued IV antibiotics with observations
e. Debridement of infection disc via anterior approach and stabilisation
Answer: D
- Which of the following changes are not seen in adult Hallux Valgus?
a. Plantar migration of abductor hallucis
b. Lateral migration of extensor hallucis longus
c. Attenuation of medial capsule
d. Supination of great toe
e. Increased 1st-2nd toe intermetatarsal angle
Answer: D
Hallux Valgus, commonly referred to as a bunion, is a complex valgus deformity of the first ray that can cause medial big toe pain and difficulty with shoe wear.
Risk factors
intrinsic:
genetic predisposition (70% of pts with hallux valgus have family history)
increased distal metaphyseal articular angle (DMAA)
ligamentous laxity (1st tarso-metatarsal joint instability)
convex metatarsal head
2nd toe deformity/amputation
pes planus
rheumatoid arthritis
cerebral palsy
extrinsic: shoes with high heel and narrow toe box
Pathoanatamy
- Valgus deviation of phalanx promotes varus position of metatarsal
- the metatarsal head displaces medially, leaving the sesamoid complex laterally translated relative to the metatarsal head
- Sesamoids remain within the respective head of the flexor hallucis brevis tendon and are attached to the base of the proximal phalanx via the sesamoido-phalangeal ligament
- this lateral displacement can lead to transfer metatarsalgia due to shift in weight bearing
- medial MTP joint capsule becomes stretched and attenuated while the lateral capsule becomes contracted
- adductor tendon becomes deforming force (inserts on fibular sesamoid and lateral aspect of proximal phalanx)
- lateral deviation of EHL further contributes to deformity
- plantar and lateral migration of the abductor hallucis causes muscle to plantar flex and pronate phalanx
- windlass mechanism becomes less effective - leads to transfer metatarsalgia
Normal IMA <9 deg
Operative Mx:
distal osteotomy: indicated in mild disease (IMA < 13)
proximal or combined osteotomy: indicated in more moderate disease (IMA > 13)
1st TMT arthrodesis: arthritis at TMT joint or instability
fusion procedures: indicated in severe deformity/spasticity/arthritis
MTP resection arthroplasty: only indicated in elderly patients with low functional demands
- During the approach for an anterior L5/S1 interbody fusion, you are mobilising the vessels and encounter significant bleeding. Which vessel has most likely been injured?
a. Ilio-lumbar vein
b. Left common iliac artery
c. Median sacral vessels
d. Right common iliac artery
e. Right common iliac vein
Answer: C
There are multiple techniques for performing LIF. However, the L5/S1 level is particularly suitable for the ALIF approach due to the efficient vascular access below with bifurcation of the aorta and inferior vena cava. Hence, the L5/S1 discectomy with an anterior approach is suggested as the choice of treatment.
Supine position. For the L5/S1 exposure, a transverse incision (mini-Pfannenstiel) is performed between the umbilicus and the symphysis pubis. Dissection of skin and soft tissue is done with the diathermy with an inferior and superior flap raised to give the vertical exposure. The exposed linea alba is divided using monopolar diathermy. Tissue forceps are used to elevate and retract the left sided rectus muscles so that the retroperitoneal plane can be entered.
The retroperitoneum is approached with blunt dissection, the inferior epigastric vessels are visualized, preserved and retracted anteriorly. The psoas muscle and the genitofemoral nerve are visualized. As the vessels are identified (left common iliac artery and vein), a low profile narrow ring-based retractor blade system is positioned. The iliac arteries and veins are then exposed and retracted laterally to reveal the L5/S1 disc space, with the median sacral vessels double clipped and divided.
- A 16 year old boy presents to your clinic with a background of spastic cerebral palsy affecting all 4- limbs. He is level V on GMFCS and has a left thoracolumbar scoliosis of approximately 55degrees on XR. These also demonstrate pelvic obliquity, He has problems with sitting and recurrent lower respiratory tract infections. There is some curve flexibility on elevation.
What is the best course of action in this scenario?
a. Anterior release and posterior correction with instrumented fusion T3-pelvis
b. Moulded brace and wheelchair modifications
c. Observation and further review in 6 months
d. Posterior correction with instrumented fusion T3-pelvis
e. Selective dorsal rhizotomy
Answer: D
Cerebral palsy is a common congenital condition that occurs due to insult to the immature brain presenting with cognitive and musculoskeletal abnormalities of varying severity. Non-progressive UMN disease (static encephalopathy) due to insult to immature brain.
Diagnosis is made clinically with evaluation of developmental milestones, cognitive function, and musculoskeletal abnormalities including spasticity, loss of motor control, and impaired balance.
Treatment involves a multidisciplinary approach to address spasticity, orthopedic manifestations, and cognitive function.
Orthopaedic manifestations:
- Contractures, fractures, upper extremity deformities, hip subluxation and dislocation, spinal deformity, foot deformity and gait disorders.
Pathoanatomy: mix of weakness and spasticity. Encephalopathy is static while the affected portion of the MSK changes with growth.
Primary: Abnormal tone, loss of motor control, impaired balance, spasticity.
Secondary: Contractures - start as dynamic, and become static with time (continuous muscle contraction results in shortening) and growth (growth of bones occurs at a faster longitudinal rate than muscles in spastic cerebral palsy).
Hip subluxations and dislocations, spinal deformity, foot deformity, gait deformities, fractures (low BMD)
Physiologic Classification:
- Spastic: commonest - velocity dependent increased muscle tone and hyperreflexia with slow, restricted movement due to simultaneous contraction of agonist and antagonist muscles - most amenable to operative treatments.
Athetoid: characterised by a constant succession of slow, writhing, involuntary movements.
Ataxic: characterised by inability to coordinate muscle movements -> unbalanced, wide based gait.
Mixed: Usually mixed spastic and athetoid features, involves the entire body.
Hypotonic: usually precedes spastic or ataxic for 2-3 years.
Anatomic Classification:
Quadriplegic: total body involvement and non-ambulatory
Diplegic: legs»arms but still ambulatory. IQ may be normal (injury in brain is midline)
Hemiplegic: arms and legs on one side of the body, usually with spasticity. Will be able to walk, regardless of treatment.
GMFCS:
I: Near normal gross motor function, independent ambulator
II: Walks independently, but difficulty with uneven surfaces, minimal ability to jump
III: Walks with assistive device
IV: Severely limited walking ability, primary mobility is wheelchair
V: Non-ambulator with global involvement, dependent in all aspects of care.
Spinal Disorders in Cerebral Palsy are thought to be caused by muscle weakness and truncal imbalance and most commonly present with progressive scoliosis - 20% incidence in CP. Most severe CP, higher the likelihood of scoliosis - spastic quadriplegia at highest risk, approaches 100% for bedridden children, rare in those that ambulate.
Pelvic obliquity causes deforming forces on spine and scoliosis.
CP curves are more likely to progress, begins at an earlier age, tends to be a long, stiff C-shaped curve (left sided curves are not uncommon), curve tends to have a greater sagittal plane deformity (kyphotic or lordotic), associated with pelvic obliquity, skeletal maturity is delayed in CP, bracing is less effective, longer fusions to the pelvis are often necessary, patients are more medically fragile and MDT approach is often necessary.
Goals of Surgery:
- obtain painless solid fusion with well corrected, well balanced spine with level pelvis
- decision to proceed with surgery must include careful assessment of family’s goals and careful risk-benefit analysis
Much higher complication rate in anterior surgery in CP than idiopathic scoliosis.
- A 33 year old woman is injured in an RTA and brought to ED resus. ATLS protocol is followed. No active haemorrhage is identified, but she is bradycardic and hypotensive, therefore an IV fluid challenge is administered and she is catheterised. She is unable to move either lower limb and has loss of torso sensation at and below the level of the 5th intercostal space. Sensory and motor function are intact in the upper limbs. There is no anal tone when tugging on the catheter.
What ASIA classification does this scenario describe?
a. A
b. B
c. Can’t determine at present
d. D
e. E
Answer: C
- A 54 year old woman with a history of early menopause presents with kyphosis resulting from a combination of osteoporosis and degenerative disc disease. Conservative management of her back pain has failed. She is therefore offered a sagittal correction spinal procedure. Which of the following is true of subtraction osteotomy?
a. Anterior column is opened, middle column is somewhat closed and posterior column is closed.
b. Correction occurs at the level of the vertebral body, not the disc
c. Classically done at T11/12 vertebrae
d. Allows a greater degree of correction than vertebral column resection or Smith Peterson osteotomy
e. Associated with fewer complications than vertebral column resection or Smith-Peterson osteotomy
Answer: B
Sagittal plane imbalance is defined as radiographic sagittal imbalance of >5cm.
Degenerative scoliosis results from the asymmetric degeneration of disc space and/or facet joints in the spine - may occur in the coronal plane (scoliosis) or sagittal plane (kyphosis/lordosis)
Factors contributing to sagittal plane imbalance:
- Osteoporosis
- Pre-existing scoliosis
- Iatrogenic instability
- Degenerative disc disease
Goals of surgery:
- Restore balance: sagittal plane balance is most reliable predictor of clinical symptoms post-operatively - can be measured by C7 plumb line. Correction of sagittal plane deformity requires intense preoperative planning. Correct lumbar lordosis to normal anatomic range:
PI = LL+/- 9°
LL ≤ 45° - TK - PI
- Most predictive of sagittal plane correction maintenance.
- Relieve pain
- Obtain solid fusion
Worse outcomes associated with baseline depression and obesity.
Osteotomies - used to regain sagittal balance in severe angulation deformities.
30 deg or more correction can be obtained through Smith-Peterson or pedicle subtraction osteotomies.
Smith-Peterson Osteotomy
- Indicated in mild-moderate sagittal imbalance requiring correction of up to 10 deg per level of osteotomy.
Pre-requisites:
- No anterior fusion at the level of the osteotomy
- Adequate correction requires adequate disc height and mobility - CORRECTION IS AT THE LEVEL OF THE DISC, therefore more correction can be obtained in the lumbar spine, where discs have more height and mobility, than the thoracic spine (less disc height and mobility).
Pedicle Subtraction Osteotomy:
Indicated in severe sagittal imbalance >12cm, requiring correction of 30-35 deg in the lumbar spine, and 25 deg in the thoracic spine.
Where anterior fusion is present - AS CORRECTION IS AT THE LEVEL OF THE VERTEBRAL BODY, NOT THE DISC.
Complication rate is significantly higher when osteotomies, revision procedures and combined anterior/posterior approaches are used.
Pseudoarthrosis, dural tear, infection, implant complication, neurologic deficits, epidural haematoma, PE, DVT, Death.
- A 42 year old male develops pain and a popping sensation in his upper right arm when catching a heavy box. Other than the likely structure injured, which of the following resides in the interval shown in the image?
a. Axillary nerve
b. Coracohumeral ligament
c. Supraspinatus tendon
d. Middle glenohumeral ligament
e. Short head of biceps
Answer: B
- A 56 year old lady has presented to your clinic with planovalgus deformity of her foot. What would you do to test the function of her tibialis anterior?
a. Place the patient’s ankle in plantar flexion and ask her to invert her foot against resistance
b. Place the patient’s ankle in maximal dorsiflexion and ask her to invert her foot against resistance
c. Place the patient’s ankle in maximum dorsiflexion and ask her to resist your attempt to plantarflex
d. Place the patient’s ankle in a neutral position and resisted eversion performed
e. Place the patient’s ankle in plantar flexion and eversion to maintain this position
Answer: A
- Which of the following is true regarding ankle arthroscopy?
a. The anteromedial port is located lateral to the tibialis anterior tendon
b. The anterolateral port is located just lateral to peroneus tertius tendon
c. The superficial peroneal is at risk on placing the anteromedial portal
d. The saphenous nerve and vein are at risk on placing the anterolateral portal
e. An external traction device is rarely used to distract the tibiotalar joint
Answer: B
Portals:
- Anteromedial: primary viewing portal (typically established first) and gives access to anteromedial joint.
Medial to tibialis anterior
Lateral to medial malleolus
Make portal between tibialis anterior and saphenous vein
• Anterolateral: gives access to anterolateral joint
Just lateral to peroneus tertius and superficial peroneal nerve
Medial to lateral malleolus
can trace out superficial peroneal nerve prior to incision
Answer: The anterolateral port is located just lateral to peroneus tertius tendon
- With regards to the diagnostic performance of a clinical investigation
Which of the following definitions is correct?
A. Accuracy is calculated by dividing all the positive test results by all the negative test results
B. Negative predictive value is determined by dividing the true negatives by all the negative test results
C. Positive predictive value is the ability of a test to detect all cases of a disease
D. Sensitivity is the ability to identify true negatives
E. Specificity is the calculated by dividing all the true positives by all the true positives plus the false negatives.
Answer: B
- Calcium hydroxyapatite is the most abundant inorganic component of bone.
What is the chemical composition of calcium hydroxyapatite?
a. Ca2(PO4)6(OH)2
b. Ca10(PO4)6(OH)5
c. Ca10(PO4)6(OH)2
d. CaPO4OH2
e. Ca2(PO4)10(OH
Answer: C
Ca10(PO4)6(OH)2
- During the posterior approach to the shoulder, excessive retraction of medial muscles results in injury to an artery. There is concern that an associated nerve injury has been sustained.
What is the defect following injury to this nerve?
a. Abduction of the shoulder
b. Abduction and external rotation of the shoulder
c. Adduction and internal rotation of the shoulder
d. Extension of the shoulder
e. Internal rotation of the shoulder
Answer: B
Dangers:
Suprascapular nerve
passes around the base of the scapular spine (do not retract infraspinatus too vigorously)
Axillary nerve
runs through the quadrangular space beneath the teres minor (stay superior to the teres minor)
this is accompanied by the posterior circumflex humeral artery
This approach is infrequently used
this approach offers access to the posterior and inferior aspects of the shoulder
Indications
proximal humerus fracture-dislocations
glenoid fractures/osteotomy
removal loose bodies
irrigation and debridement of septic joint
scapular neck fractures
Internervous plane
teres minor (axillary n.)
infraspinatus (suprascapular n.)
- Which of the following changes occurs within articular cartilage during ageing?
a. Decreased permeability
b. Decrease in chondrocyte size
c. Increased keratan sulfate concentration
d. Increased proteoglycan synthesis
e. Increased water content
Answer: C
- In patients with high risk of failure of ACL reconstruction, which of the following can reduce the graft rupture of hamstring tendon autograft reconstruction?
a. Using screws for tibial and femoral fixation
b. Using double bundle ACL reconstruction technique
c. Using a knee brace for 6 weeks post-op
d. Doing a lateral extra-articular tenodesis in combination with ACL reconstruction
e. Using all inside ACL reconstruction technique
Answer: D
ACL: femoral attachment – lateral intercondylar ridge demarcates the anterior edge of the ACL, with the bifurcate ridge separating the anteromedial and posterolateral bundle attachment. Tibial attachment – anterior tibia, between intercondylar eminences.
90% type I collagen, 10% type III collagen.
Blood supply: middle geniculate artery, Innervation: posterior articular nerve (branch of tibial nerve). 2200N strength (anterior).
Provides 85% of stability to prevent anterior translation of the tibia relative to the femur, and a secondary restraint to tibial rotation and varus/valgus rotation.
Lachman’s test = most sensitive examination test for ACL – predominantly assesses the anteromedial bundle of ACL fibres.
- Grading: A= firm endpoint, grade B= no endpoint
o Grade 1: <5mm translation
o Grade 2 A/B: 5-10mm translation
o Grade 3 A/B: >10mm translation
PCL tear can give false Lachman due to posterior subluxation.
Pivot Shift: extension to flexion – reduces at 20-30 degrees of flexion (patient must be completely relaxed). Predominantly assesses the posterolateral bundle of ACL fibres.
Quadriceps autograft shown to have equivalent outcomes to hamstring and patella tendons.
Allograft lacks donor site morbidity but have increased cost and increased failure rates in the young population.
Single vs Double Bundle:
- Single is most common, double may restore native knee kinematics with less laxity – no PROMs between the two.
Revision ACL reconstruction:
• approach considerations
o cause for prior ACL failure – graft failure for any cause is approximately 5%, tunnel malposition is the commonest cause (70% failures)
o concomitant pathology
o prior graft selection
o careful assessment of the underlying cause of re-rupture
• technique
o high strength grafts (quad tendon, hamstring, allograft)
o dual or back-up fixation (suspension + interference screws)
o bone grafting and reconstruction in cases of previous tunnel dilation (15mm) or if interfering with anatomic tunnel creation
o addition of anterolateral ligament/ALL reconstruction (lateral extra-articular tenodesis) controversial
o re-harvesting BPTB (bone-patella-tendon-bone) is contraindicated
Lateral extra-articular tenodesis (LET) to augment ACL reconstruction: The anterolateral structures (anterolateral ligament and iliotibial band) of the knee joint are important for providing rotational stability to the knee. In patients who have ACL tears with disruption to the anterolateral corner of the knee, ACLR alone may leave residual rotational instability and increase the risk of ACL re-rupture.
To decrease failure rates following ACLR, patients with ligamentous laxity, hyperextension, strongly positive pivot shift test, and those in elite competitive pivoting sports, particularly at a younger age, may undergo ACLR with extra-articular tenodesis. The most commonly performed extra-articular augmentation procedures with ACLR include lateral extra-articular tenodesis (LET) and anterolateral ligament reconstruction (ALLR).
LET is reported to offload ACL graft by an average of 43%, reducing the risk of graft stretching or re-rupture during the rehabilitation phase.
In young patients engaging in pivoting sports, ACL reconstruction with ALLR is reported to have a 2.5 times reduction in graft failure rate than BPTB autograft alone and 3.1 times reduction in graft failure rate compared to HT autograft alone, at a mean of 38 months follow-up. Patients with ligamentous hyperlaxity undergoing ACL reconstruction with HT autograft and ALLR were found to have a lower graft failure rate and improved knee stability, compared to isolated HT autograft ACLR, 3.3% vs. 21.7%, at mean follow-up of 28.1 vs. 29.6 months respectively.
Therefore answer:
Doing a lateral extra-articular tenodesis in combination with ACL reconstruction
- Which of these structures does not cause compression of the ulnar nerve around the elbow?
a. Medial epicondyle
b. Osbourne’s ligament
c. Arcade of Struthers
d. Arcade of Frohse
e. FCU aponeurosis
Answer: D
- A 60 year old man presents with symptoms of worsening lower back, buttock and right lower limb pain. This has persisted several months despite physiotherapy and activity modifications. On examination she has normal sensation in the right lower limb, but 4/5 power in the right EHL and tibialis anterior. MRI shown. Which treatment option is most likely to give the best long-term results?
a. CT guided cyst aspiration
b. L4/5 laminectomy, cyst excision and complete facetectomy
c. L4/5 laminectomy and cyst excision
d. L4/5 posterior instrumented fusion, laminectomy and cyst excision
e. L4/5 posterior un-instrumented fusion, laminectomy and cyst excision
Answer: D
- An isthmic spondylolisthesis is the result of a defect in which part of the vertebra?
a. Lamina
b. Facet
c. Pars interarticularis
d. Transverse process
e. Mammillary process
Answer: C
- In congenital scoliosis, which anatomic pattern carries the worst prognosis?
A. Block vertebra
B. Unilateral unsegmented bar with contralateral hemivertebra
C. Segmented hemivertebra
D. Unsegmented hemivertebra
E. Unilateral unsegmented bar
Answer: B
- In spina bifida, a protruding sac without neural elements is classified as:
a. A gibbus
b. Spina bifida occulta
c. Rachischisis
d. Meningiocele
e. Myelomeningocele
Answer: D
- A 54 year old man with rheumatoid arthritis undergoes flexion-extension cervical radiographs that show evidence of atlanto-axial subluxation. This is usually related to destruction of which spinal ligament?
a. Alar ligament
b. Anterior longitudinal ligament
c. Apical ligament
d. Posterior longitudinal ligament
e. Transverse ligament
Answer: E
Transverse ligament – due to pannus formation
- All the following are true regarding Coleman block test during foot and ankle examination, except:
a. It is used to differentiate a flexible from rigid pes cavovalgus deformity
b. It is performed by placing the heel and lateral border of the foot on a block, with the 1st ray unsupported.
c. In a flexible deformity, the heel will correct to a neutral or valgus position.
d. In a rigid deformity, the heel will remain in varus position
e. A flexible deformity indicates that the deformity is forefoot driven and the subtalar joint is not stiff
Answer: A
Cavovarus foot is a common condition, seen in both paediatric and adult population, caused by either neurologic (67%( or traumatic disorder, and presents with a cavus arch and hindfoot varus.
Deformity is characterised by:
- Cavus (elevated longitudinal arch)
- Plantarflexion of 1st ray and pronated forefoot
- Hindfoot varus
- Forefoot adduction
Bilateral is most commonly due to Charcot Marie Tooth Disease.
Muscle imbalances generate the deformity:
- Weak tibialis anterior and peroneus brevis overpowered by strong peroneus longus and posterior tibialis. This results in a plantarflexed 1st ray and forefoot pronation with compensatory hindfoot varus.
- With the 1st metatarsal plantarflexed and forefoot pronated, the medial forefoot strikes the ground first.
- The subtalar joint supinates to bring the lateral forefoot to the ground and maintain 3-point contact, resulting in hindfoot varus.
- While initially flexible, hindfoot varus can become rigid with time.
Other conditions that present with a cavovarus foot: Charcot marie Tooth disease, Cerebral Palsy, Friedrich’s ataxia, spinal cord lesions, polio, amniotic band syndrome.
History:
- Recurrent ankle sprains and lateral ankle pain (peroneal tendon pathology)
- Lateral foot pain: excessive weight bearing by the lateral foot due to deformity (can result in 5th MT stress fractures.
- Painful plantar calluses under 1st MT head and 5th MT head or base.
- Plantar fasciitis (elevated medial arch, forefoot pronation and tight gastrocnemius lead to contracture of plantar fascia
Coleman Block Test: Evaluates flexibility of hindfoot deformity.
- Place 1inch block under the lateral foot (eliminates contribution of the plantarflexed 1st ray and forefoot pronation to the hindfoot deformity)
- A flexible hindfoot will correct to neutral or valgus when block placed under lateral aspect of foot. Rigid hindfoot will not correct to normal.
Answer: used to differentiate a flexible from rigid pes cavovalgus deformity – VARUS!!!
- A patient has femoracetabular impingement with a labral tear, in order to perform a minimally invasive CAM resection, the surgeon approached the hip through an anterior and anterolateral portal. Which of the following structures is compromised following an extensive inter-portal capsulotomy during hip arthroscopy?
a. Ischiofemoral ligament
b. Pubofemoral ligament
c. Iliofemoral ligament
d. Ligamentum teres
e. Zona orbicularis
Answer: C
- In 2017 the Medicines and Healthcare Products Regulatory Agency published a Medical Device Alert to standardise follow-up for patients who had a total hip replacement with a metal on metal bearing surface.
Which of the following patients would be suitable for follow-up at 1 year, 7 years then every three years.
A. ASR resurfacing, male patient, 50 head size, asymptomatic.
B. BHR resurfacing, female patient, 50 head size, asymptomatic.
C. THR, male patient, 32 head size, asymptomatic.
D. BHR resurfacing, male patient, 50 head size, asymptomatic.
E. BHR resurfacing, male patient, 50 head size, symptomatic.
Answer: D
- What is the most lateral tendon within the anterior compartment of the leg?
a. Peroneus tertius
b. Peroneus brevis
c. Tibialis anterior
d. Extensor hallucis longus
e. Extensor digitorum longus
Answer: A
- When operating upon a distal tibia non-union, current guidance suggests 2 specimens be sent to pathology looking for evidence of infection. How many should be sent for microbiology?
a. 3
b. 5
c. 7
d. 6
e. 4
Answer: B
- For which of the below indications is ankle distraction arthroplasty most appropriate?
a. Inflammatory arthritis
b. Post traumatic OA
c. AVN talus
d. Talar OCL
e. Syndesmotic degeneration
Answer: B
- A plantar flexion malunion through a TMT joint fusion manifests clinically with plantar forefoot pain. Which is the most appropriate initial treatment
A. Orthotic insole
B. Revision fusion to correct malunion
C. Achilles lengthening
D. Supramalleolar osteotomy
E. Excision of metatarsal heads
Answer: A
- Within rough endoplasmic reticulum during the early stages of collagen synthesis, post translational modification occurs, where the single alpha chain forms a triple helix (pro-collagen). One of the enzyme dependent processes requires the cofactor vitamin C.
What is this process called?
a. Hydroxylation
b. Glycosylation
c. Exocytosis
d. Trimming terminal ends
e. Cross linking (covalent bond forming)
Answer: A
- All of the following are true regarding operative fixation for diabetic patients with ankle fractures, EXCEPT:
a. Is associated with higher rate of complications such as infections, wound complications and delayed union.
b. Adoption of a ‘super construct’ approach that includes extending fixation beyond the immediate zone of injury is considered beneficial
c. Patients may also require a prolonged period of immobilisation
d. Adoption of minimally invasive approaches and minimal metalwork is considered beneficial
e. Close follow up helps to early diagnosis of Charcot arthropathy development
Answer: D
- A six year old boy who loves to play cricket complains of elbow pain, XR shows no loose bodies. Clinical suspicion is this may be due to repetitive throwing action and requests an MRI, what is the most likely diagnosis?
a. Osteochondritis dissecans
b. Kienbock’s disease
c. Kohler’s disease
d. Severs’ disease
e. Panner Disease
Answer: E
- All are true regarding Hawkins sign, Except
A. presence of the sign means that the patient is unlikely to develop avascular necrosis (AVN) of the talus.
B. identified as a radiolucent line of the talar dome.
C. absence of the sign means that the patient will develop AVN.
D. is a good prognostic sign for this injury.
E. appears on the x-ray 6–8 weeks following the injury.
Answer: C
- A middle-aged female patient presents with medial hindfoot pain and a swollen ankle. Which of the following is true?
A. Inability to perform heel raise is confirmatory of tibialis posterior tendon dysfunction.
B. An ability to perform single heel raise confirms an intact tibialis posterior tendon.
C. While performing a single heel raise a false-positive result can be elicited by the patient leaning forward.
D. Tibialis posterior tendon strength can be assessed by asking the patient to forcefully invert the plantigrade ankle.
E. Initial management may require a short period of cast immobilisation.
Answer: E
- A young patient presents with recurrent ankle instability and non-healing 5th metatarsal fracture. Which of the following is true?
A. A positive peek-a-boo sign will help to guide further management options.
B. A CT scan should be performed to assess the state of healing of the 5th metatarsal fracture.
C. The patient should be offered surgical fixation of the non-healing fracture.
D. Surgery has no role in the management of recurrent ankle instability.
E. It is unnecessary to enquire of a positive family history.
Answer: A
A 67 year old woman reports a 3 month history of worsening back pain. Over the last 36 hours she has developed progressive weakness in both lower limbs which has increasingly impacted on her walking. She is now not able to ambulate, though prior to this she mobilised unaided. She complains of not being able to void urine. On neurological examination, she has 3/5 power throughout both lower limbs, and a sensory level corresponding to the pathology seen in the MRI image of her spine. She has a staging CT which shows likely breast cancer with metastases to the spine, left proximal femur, as well as lesions in the lungs and liver.
Which of the following is the most appropriate step in management of the patient?
a. Bone biopsy
b. Decompression and stabilisation
c. Decompressive laminectomy
d. En bloc excision and reconstruction
e. Palliative radiotherapy based on prognosis
Answer: B
. An 82 year old woman presents 10 days after a fall from standing height, due to progressively worsening neck pack. She describes no weakness or pain in her arms, nor any changes from her usual dexterity. CT image shown (Type II odontoid peg fracture) . Which of the following would you explain that she is at increased risk of with conservative as opposed to surgical management?
a. Cervical radiculopathy
b. Deterioration in dexterity
c. Dysphagia
d. Fracture non-union
e. Myelopathy
Answer: D
- An elderly patient presents with forefoot pain. Examination reveals asymptomatic hallux valgus deformity, plantar callosity and painful 2nd and 3rd metatarsophalangeal joints.
Which of the following is true?
a. The hallux valgus deformity is an incidental finding
b. Plantar callosity confirms the need for surgical intervention
c. It is useful to flex the knee as part of the clinical examination
d. Improvement in ankle dorsi-flexion with passive flexion is an indication for surgery
e. Metatarsal shortening osteotomy would be essential in managing this patient
Answer: C
. Authors conducted a randomised trial to compare the effectiveness of physiotherapy vs arthroscopic decompression for rotator cuff tendinopathy. The results were analysed using intention to treat. Which of the following is true?
A. Intention to treat analysis was based on patients’ intention to be treated.
B. Patients were analysed only if they completed the allocated treatment.
C. Intention to treat would allow a pragmatic analysis of the effectiveness of the intervention.
D. Patients who crossed-over to the alternative intervention were excluded from analysis.
E. The results could be affected by confounding bias.
Answer: C
- A 63 year old man with single-level degenerative lumbar stenosis undergoes an ALIF (anterior lumbar interbody fusion) with a bone graft substitute to aide osteoinduction. Which rhBMP (recombinant human Bone Morphogenic Protein) is licensed for this?
a. 2
b. 3
c. 4
d. 6
e. 7
Answer: A
. Which of the following is not associated with osteonecrosis of the humeral head after a proximal humerus fracture?
a. Intact calcar length of 6mm
b. Surgical neck displacement 12mm
c. 4-part with head splitting fracture pattern
d. Medial hinge disruption
e. Greater tuberosity displacement of 6mm
Answer: E
- A 29 year-old-man has brachialgia with weak wrist extension. What MRI findings are consistent with this
A. C4/5 central disc
B. C5/6 foraminal disc
C. C6/7 central disc
D. C6/7 foraminal disc
E. C7/T1 central disc
Answer: B
Nerve root anatomy
key differences between cervical and lumbar spine are
pedicle/nerve root mismatch
cervical spine C6 nerve root travels above C6 pedicle (mismatch)
lumbar spine L5 nerve root travels under L5 pedicle (match)
extra C8 nerve root (no C8 pedicle) allows transition
horizontal (cervical) vs. vertical (lumbar) anatomy of nerve root
because of vertical anatomy of lumbar nerve root, a paracentral and foraminal disc will affect different nerve roots, whereas in the cervical spine both foraminifera and central discs will affect the same nerve root
C4 radiculopathy
scapular winging
numbness and pain at the base of the neck
C5 radiculopathy
deltoid and biceps weakness
diminished biceps reflex
pain and numbness in the superior shoulder and lateral upper arm
C6 radiculopathy
brachioradialis and wrist extension weakness
diminished brachioradialis reflex
paresthesias in the thumb and radial arm
C7 radiculopathy
triceps and wrist flexion weakness
diminished triceps reflex
paresthesia in the middle finger
most commonly affected nerve root in cervical radiculopathy in several studies
C8 radiculopathy
weakness to distal phalanx flexion of middle and index finger (difficulty with fine motor function)
paresthesias in ring and little finger
C8 radiculopathy is extremely rare and often manifests similarly as ulnar neuropathy
T1 radiculopathy
intrinsic hand muscle weakness
axillary numbness
ipsilateral Horner’s syndrome
because of horizontal anatomy of cervical nerve root, a central and foraminal disc will affect the same nerve root
- A 70 year old man with back and leg pain was weak resisted ankle dorsiflexion. What finding would be present on MRI?
a. L3/4 extraforaminal stenosis
b. L3/4 foraminal stenosis
c. L3/4 lateral recess stenosis
d. L4/5 central stenosis
e. L4/5 Lateral recess stenosis
Answer: C
- A 15 year old girl has a pain thoracolumbar scoliosis, worse at night and relieved by ibuprofen. What would you see on histology?
a. Anaplastic spindle cells in storiform pattern
b. Anastomosing trabeculae with osteoblastic rimming
c. Round blue cells in sheets
d. Hyperchromic epithelial cells
e. Irregular woven bone
Answer: B
Pathological scoliosis is a form of scoliosis resulting from a benign bone tumour, most commonly located in the posterior elements of the spine.
Causes:
- Osteoid osteomas: occur in the apex of the concavity of the curve, curves are typically rigid, can occur in the vertebral body or posterior elements
o XR cortical thickening radiolucent nidus (osteoid osteoma <2cm in diameter, osteoblastoma > 2cm)
- Osteoblastomas: larger lesion than osteoid osteoma, pain is usually less severe than osteoid osteoma (less relief with anti-inflammatories)
Scoliosis is thought to develop in response to painful paraspinal muscle spasms.
Surgical management only indicated in painful, progressive scoliosis.
Answer: Anastomosing trabeculae with osteoblastic rimming (osteoid osteoma)
- Anterior cervical approach is performed in a myelopathic patient. In a lower cervical approach, a muscle crosses the operative field and can be divided.
Which nerve supplies this muscle?
a. Ansa cervicalis
b. Cranial nerve VII
c. Cranial nerve X
d. Cranial nerve XI
e. Recurrent laryngeal nerve
Answer: A
- During the anterior approach to the cervical spine, a deep structure is reflected sub-periosteally and laterally each side of the midline to immediately expose the anterior vertebral body. What is this structure?
a. Longus capitis
b. Longus coli
c. Multifidus
d. Prevertebral fascia
e. Sternocleidomastoid
Answer: B
- A 16 year old boy presents with a painful heel of one month duration. Examination reveals soft tissue swelling and warmth to the plantar aspect of his heel. Radiographs show a sclerotic mass with periosteal reaction. MRI T1 imagin shows a heterogenous low signal mass which enhanced during contrast administration. What is the most likely diagnosis?
A. Chondrosarcoma
B. Ewings Sarcoma
C. Fibrosarcoma
D. Metastatic Lesion
E. Osteosarcoma
Answer: E
