2017 (All) Flashcards

Question

What are Philipon's (big name hip arthroscopist) poor prognostic factors in labral reconstruction (with autograft ITB) in irrepairable tears?

Answer 1

a) Age \>30 b) \<2-mm joint space

Answer 2

Anterosuperior labrum has lower collagen content and is parallel to the chondrolabral junction, as opposed to the posteroinferior labrum which has the highest collage content and is perpendicular note: Labrum increases the articular surface by 22% and volume by 33%; without it, femoroacetabular contact stresses increase up to 92%

Answer 3

Arthroscopic vs open = equivalent hip survival rates and patient-reported outcome measures

Answer 4

C. difficile infection classification: o Community-acquired: \<48h from admission o Hospital-acquired: 48h-4 weeks o \>12 weeks following discharge: community-acquired Note: NAP1 strain (25%) is hypervirulent -- resistant to fluoroquinolones

Answer 5

Risk factors: -Age \>65, diabetes, cancer, GI surgery, multiple antibiotic exposure (Clindamycin \> Vancomycin), hospital exposure, feeding tube, revision surgery Note: * Fecal-oral transmission (possible too) * Up to 50% rate of asymptomatic carriers in admitted patients

Answer 6

Extra-GI complications: reactive arthritis, cellulitis, osteomyelitis, PJI

Answer 7

Up to 40% of patients with an initial episode will have a recurrence

Answer 8

stool enzyme immunoassay looking for toxin A/B (sens 80%, spec 86%) --- if positive, obtain stool culture

Answer 9

Treatment: treat until symptom resolution o Mild: PO Metronidazole 500mg TID x 10-14 days o Mod: PO Vancomycin 125mg QID x 10-14 days o Severe: PO Vancomycin 500mg QID + IV Metronidazole 500mg TID o Severe with lactate \>5 and WBC \>50: subtotal colectomy o Recurrence: don’t use Metronidazole (potential for cumulative neurotoxicity)

Answer 10

YES Hip fracture patients that develop C. diff post-op have a 35% 6-month mortality (vs. 9% otherwise)

Answer 11

Volar plating is associated with the following vs. dorsal plating: o Improved function, grip strength and pain scores (first 6 months) and less risk of extensor irritation (dorsal plating = 30%)

Answer 12

Most common surgical complication: infection

Answer 13

Most common NON SURGICAL complication: median neuropathy

Answer 14

Recent RCT comparing volar locked plating vs. non-op favored surgery for the first 6 months, but no difference after.

Answer 15

Increased risk of fracture displacement, malunion and late carpal malalignment in osteoporotic patients with distal radius fractures

Answer 16

Pain, grip strength and ROM may improve up to 4 years post-fracture

Answer 17

Refer any patient with a distal radius fracture for BMD testing (FYI general guidelines are to perform BMD scan on women \>65 and men \>70)

Answer 18

What attaches to the radial column? o Brachioradialis o Long radiolunate ligament o Radioscaphocapitate ligament

Answer 19

What attaches to the volar rim fragment? o Short radiolunate ligament o Volar DRU ligament

Answer 20

What attaches to the dorsal ulnar corner fragment? o Dorsal DRU ligament

Answer 21

What attaches to the dorsal wall fragment? o Dorsal radiocarpal ligament

Answer 22

Volar rim fragment is seen on a standard lateral by measuring the teardrop angle (normal is 70deg) Note: On a true lateral, a line along the volar cortex of the radial shaft passes through the center of the capitate

Answer 23

DUC fragment is seen on the PA or oblique view

Answer 24

Goals of ORIF: o Radial shortening \<5mm o Inclination \>15deg o Step-off/gap \<2mm o Sigmoid notch incongruity \<2mm o Volar tilt 15-20deg Note: Fragment-specific fixation is useful when fragments are too small or too distal to be effectively captures with a volar locking plate

Answer 25

Excessive distraction through an ex-fix or dorsal bridge plate is a risk factor for CRPS

Answer 26

**1) Reduce intermediate column** (start with volar rim, DUC, FIA, then dorsal wall fragment) **2) Fix radial column (styloid)** **3) Fix ulnar column (if DRUJ instability persists)** (DUC = dorsal ulnar corner, FIA = free intra-articular fragment)

Answer 27

Reduce intermediate column to the pedestal (ulnar to radial) 1)Volar rim fragment (see first algorithm below) Keep screws 75% of AP width of the distal radius – if you go too long, can prevent your reduction of 2)-4) 2) Dorsal ulnar corner (see second algorithm below) 3) Free intra-articular fragment 4) Dorsal wall fragment

Answer 28

Radial column (styloid) -- algorithm is simple: if a VLP was used, insert the radial-most screws to capture the styloid fragment. If this isn’t enough, supplement with either a fragment-specific plate or K-wires. If F-S fixation was used, then do one of the latter two options. (VLP = volar locking plate, F-S = fragment specific)

Answer 29

Ulnar column (if DRUJ instability persists) - options are ORIF ulnar styloid fragment, TFCC repair or pin and cast in supination x 6 weeks (quadricortical); dealer’s choice

Answer 30

Impairment: derangement of anatomic structure or physiologic function

Answer 31

DISABILITY: impairment PLUS considerations of job requirement

Answer 32

Aggravation: worsening of a preexisting condition from a NEW incident

Answer 33

Exacerbation: temporary worsening of a pre-existing condition; eventually receds to former symptom level

Answer 34

Maximum medical improvement: No potential for further functional improvement with continued treatment

Answer 35

Causation: determination of whether occupational injury or exposure led to impairment

Answer 36

Temporary total disability: inability to return to work in any form of gainful employment on a limited time basis

Answer 37

Apportionment: Determination of the degree to which a disorder resulted from occupational or non-occupational conditions

Answer 38

Return to work on a temporary basis with or without certain work restrictions

Answer 39

Permanent total disability: permanent inability to pursue gainful employment in any capacity

Answer 40

Reduced capacity to perform work on a permanent basis

Answer 41

**Work restrictions:** physician judges what the patient _should/shouldn’t do_ **Work limitations:** worker’s physical capabilities to perform a task (what they _can/can’tdo_)

Answer 42

Order a _functional capacity evaluation_ (objective evaluation of the worker’s strength, endurance, function, etc.)

Answer 43

1-Acute effusion doesn’t allow for flexion to 90deg 2-Protective hamstrings spasm blocks anterior tibial translation 3-Posterior horn of the MM acts as a doorstop to anterior translation

Answer 44

Pivot-shift facts: Is subluxated in extension and reduces at around 40deg of flexion from the line of pull of the ITB as it passes posterior to the axis of the knee

Answer 45

The ACL is disrupted 78% of the time

Answer 46

MCL injury is most commonly at its femoral origin, whereas LCL is usually at its fibular head insertion (palpate it with the leg in figure-of-4 position)

Answer 47

Best sensitivity = Lachman Best specificity: - Awake = all equivalent - EUA = Pivot-shift

Answer 48

MCL grading: - Stable at 0 and 30deg - Laxity at 30deg = only sMCL - Laxity at 0 and 30deg = sMCL, POL, dMCL

Answer 49

25% PLC injuries are associated with common peroneal nerve injuries

Answer 50

Two best tests for the PLC: 1) Posterolateral rotary test: like the posterior drawer, but the foot is ER 15deg -- in this position, the PCL is relaxed, so an increase in the posterior drawer in this position vs. with the foot at neutral suggests PLC injury 2) Dial test (requires a 10-15deg side-to-side difference to be positive)

Answer 51

1) **Posterior drawer:** up to 90% sensitive and 99% specific (better in chronic cases) Grade I = increased posterior translation vs. contralateral side but tibia still anterior to MFC Grade II = tibia and MFC equal Grade III = tibia posterior to MFC 2) **Posterior sag:** knee positioned like for a posterior drawer and you check the position of the anterior tibia (should be 1cm anterior to the MFC normally) – 79% sensitive, 100% specific 3) **Quadriceps active test:** knee positioned like for a posterior drawer and patient is asked to contract his quads = this will bring the tibia forward from a subluxated (sagged) position – 54% sensitive, 97% specific

Answer 52

If suspecting a POL injury, do the anteromedial drawer test (like the anterior drawer, but foot is ER 15deg, which isolates the POL) \*\* Article had said 15 degrees IR but Laprade/Pickell all confirm ER for anterior drawer test to asses PMC. ER for posterior drawer test testing PLC IR for posterior drawer test tesing PMC

Answer 53

1. RA 2. Posttraumatic OA (SLAC/SNAC) 3. CP/spasticity disorders 4. Complete brachial plexus injuries 5. Salvage after failed arthroplasty (higher rate non-union, requires corticocancellous bone graft) 6. Postinfection degeneration 7. End stage Kienbock 8. Non-union or malunion DR # 9. Preiser osteonecrosis

Answer 54

-higher rate non-union -requires corticocancellous bone graft

Answer 55

1-Infection, non-union (~5%), radiographic loosening 2- ulnocarpal impaction (decreased with triquetral excision) 3-carpal tunnel syndrome 4-extensor tenosynovitis 5-implant failure/prominence

Answer 56

decreased with triquetral excision)

Answer 57

1- Denude and prepare joints 2-Combine with PRC and use as morcelized bone graft (PRC is one option, you don't have to) 3-Compression plating from distal radius to 2nd or 3rd MC (locking options) vs 2 smooth Stiemann pins into 2nd and 3rd MC’s (use if need MCP arthroplasty or if cannot perform forearm dissection)

Answer 58

Arthrodesis: - More reliable pain relief - Lower rates of complications - Decreased rates of revision - Both cost-effective (arthrodesis slightly better) - No definitive difference in clinical outcomes

Answer 59

Arthrodesis best option when: - Younger than 50 - Manual laborers - History of infection - Use of a walker - Lack active wrist motion

Answer 60

Contraindications: - Active wrist infection - Lack of adequate soft-tissue envelope note: Lack of bone stock no longer CI with locking plates Bilateral arthrodeses do well – single study – not CI

Answer 61

Position: --\>10-15 deg extension with slight ulnar dev àbetter grip strength If bilateral, consider one in neutral for more pro/sup

Answer 62

- Earlier return to work - Surgery may have better PF strength note: no difference in ankle ROM, strength, calf circumference, functional outcome scores

Answer 63

JBJS 2012 Meta-analysis of RCTs: functional bracing and early motion protocol = similar functional outcomes and rerupture rates(3-5%) decreased complications (approx. 12% for surgery) surgery= earlier return to work

Answer 64

Functional bracing = faster return to mobility and work, decreased re-rupture rates

Answer 65

72 HOURS (after which hematoma interposion) - A JBJS 2011 article talked about decreased rate of rerupture if present within 72 hrs of injury to prevent hematoma formation blocking apposition before immobilizing in PF. - BUT previous studies have not shown re-rupture rates to correlation with time to presentation

Answer 66

Achilles tendon avulsions (i.e. distal tears at calcaneus with our without bone fragment)

Answer 67

It's good to weight bear: -Weightbearing in CAM walker **decreased ankle stiffness, better quality of life** **-No difference** on re-rupture rate, functional outcomes or biomechanical tendon properties

Answer 68

-Sural nerve injury (especially in proximal-lateral stab incisions and suture passing) However, decreased wound infection rates!

Answer 69

Increased wound complications with: 1)smoking, 2) steroids, 3) female (NOT high BMI, age, DM)

Answer 70

1) PRP – no benefit 2) BM stem cells or mesenchymal stem cells – increased ultimate strength to failure in animal models, no human studies So neither currently have a proven role as adjuncts to surgical management of acilles ruptures.

Answer 71

EASY to remember (essentially 2 week intervals): Week 0 to 2: NWB + crutches Week 2 to 4: ROM PF to neutral DF _only_ Week 4: WBAT in boot with heel lift Week 6: Remove heel lift, still WBAT Week 8-12: Wean out of boot

Answer 72

Low impact: 6 months High impact: 9 months (i.e. soccer, rugby, football)

Answer 73

Rapid growth Presdisposition related to syndromes and family hx Size \>5cm Involvement of deep fascial layers Heterogenous appearance on MRI Poorly defined margins Increased vascularity

Answer 74

- Benign soft tissue lesion - Benign vascular lesion - PVNS/GCT of tendon sheath - Neurogenic lesions - Benign bone lesions - Malignant soft tissue lesion

Answer 75

1-Ganglion and synovial cyst 2-Synovial sarcom (tender, fixed firm -- get MRI, then biopsy/excise)

Answer 76

Most common – infantile **myofibroma and myofibromatosis** - \<2cm, firm, skin colored or pale red, nonop recommended because high recurrence

Answer 77

1-Superficial fibromatoses – small, firm, pea-sized, painful with WBing; Ledderhose disease when in plantar fascia, no imaging required 2-Deep fibromatoses – deep, rapid, infiltrative growth, not known to metastasize, younger age 3- infantile myofibroma and myofibromatosis (most common) 4- Adipocytic – 2/3 lipomas, 1/3 lipoblastomas

Answer 78

Yes for lipoma - Looks like fat on all MRI sequences NO for lipoblasdtoma - So get a biopsy if locally aggressive, and the treatment is wide resection if symptomatic.

Answer 79

A Benign vascular lesions

Answer 80

**Hemangioma** - appear within first 3 mos of life, strawberry like appearance, grow quickly until 9-10 mos, involute by age 7-10yrs **Vascular malformation -** if arise after 3 mos or do not involute = vascular malformation; AV or venous malformation imaging – Doppler US; if asymptomatc (no hemorrhage, thrombosis or sepsis) àfitted pressure stockigns and ASA or other anticoag; if fails àinterventional for sclerotherapy vs vascular for sx

Answer 81

**PVNS vs GCCT** Similar appearance on MRI – hypointense T1 and T2 due to hemosiderin GCTTS = almost always extra-art; PVNS = diffuse and intra-art PVNS – high rate recurrence, can use adjuvant rads (DDx: synovitis, tenosynovitis, ganglion cyst, lipoma, fibromatosis, **synovial sarcoma**)

Answer 82

(benign bone foot lesion) Exostoses at epiphyses of long bones may indicate Trevor disease (dysplasia epiphysealis heimelica)

Answer 83

**Neurogenic Lesions** _Neurofibroma_ – most common, mostly Schwann cells, **excision requires excision of the nerve**, 3 types: localized, diffuse, plexiform (pathognomonic for NF 1); MRI – target sign _Schwannoma_ – can be **excised without the nerve**

Answer 84

adjuvant phenol

Answer 85

1) Synovial sarcoma - most common soft-tissue sarcoma in F and A, most juxta-articular, painless, slow-growing, US – well-defined solid lesion, t(X;18); Tx – wide resection and rads 2) Fibrosarcoma – 2ndmost common, good prognosis of infantile vs adult type 3) Liposarcoma – 3rdmost common

Answer 86

Posterior humeral circumflex artery – 64% blood supply to humeral head

Answer 87

AO (A – unifocal extra-art, B – bifocal extra-art, C – articular (fracture dislocations/head splits))

Answer 88

Humeral head ischemia RF’s (BUT initial ischemia does NOT predict development of necrosis) - Metaphyseal head extension (head-neck junction to inferior extent of medial cortex) \<8mm - Medial hinge disruption \>2mm

Answer 89

Complication rate: CRPP\>RSA\>ORIF\>HA

Answer 90

Revision rate: ORIF\>RSA=HA\>CRPP

Answer 91

Consider OR: 2 – part: * GT \>5mm displacement (decrease risk of subacromial impingement) * LT fracture with IR impingement 3/4 part: **article pushes ORIF if active and \<65yo** non-op if poor baseline, inability to tolerate surgery, or valgus-impacted with \<1cm displacement of the tuberosities

Answer 92

**RSA:** 3/4 part, \>65 yo, comminuted tuberosities Grammont principles (medializing glenohumeral center of rotation lowering humerus) **HA** The authors from this study recommended HA for patients who are active aged 40 to 65 years with complex four-part fractures or head split patterns that ar likely to have complications with plate osteosynthesis. **Comparing the two techniques:** 1. The authors of this article said that the evidence for one of the other is unclear. However one of the main downfalls of RSA was the decreased ER compared to HA. However, as we have learned to better fix the tuberosities (especially by adding bone graft), the ER hs improved in RTSA. 2. Furthermore, the Meta-Analysis presented in the CORR document showed that RSA was better than HA for patients\>65yo 3. Another CORR study showed no benefit of HA over non op for PHF aged \>65, with better constant murray scores in non op. 4. For patients \<65yo who are active, we should be attempting osteosynthesis.

Answer 93

HA: Humeral head height: 5.6cm from upper border pec major, can assess reduction of tuberosities \>10mm lengthening = excessive tension on supra

Answer 94

IMN with fixed angle blade (vs IMN locking screw, fixed angle small and large frag plates)

Answer 95

Medial calcar fixation at least 2cm distal to articular surface to minimize injury to axillary n and posterior humeral circumflex a

Answer 96

initial varus displacement

Answer 97

ORIF better Constant scores vs HA osteonecrosis 8 -15%

Answer 98

RFs - Short 2ndMT - Decreased depth of 2ndTMT mortise

Answer 99

Mechanism 1) Direct – high-energy crush to dorsal foot 2) Indirect (most) – Axial and/or rotational force applied to a PF and stationary foot

Answer 100

**Ligaments** - No InterMT Lig between 1 and 2 - Instead, dorsal, IO and plantar Ligs secure 2ndMT to medial cuneiform **Strength** IO (aka “Lisfranc Ligament”) \> Plantar \> Dorsal

Answer 101

Tib ant and peroneus longus note: can also become entrapped and preclude reduction

Answer 102

Midfoot stability -3 cuneiforms with their MT bases have trapezoidal configuration Middle cuneiform and 2ndMT base acting as the “keystone”

Answer 103

Lateral – 4th and 5th TMT jts =Mobile, shock absorber Arthrodesis substantially increases plantar forefoot and CC jt pressure

Answer 104

**PEx** - Plantar arch ecchymosis – highly suggestive - Palpate and stress midfoot for pain - Watch for ++swelling and # blisters – stage if needed

Answer 105

20% Untreated, result in painful post-traumatic DJD and arch collapse

Answer 106

**Classification (doesn’t predict outcome)** A – total joint incongruity B – Partial joint incongruity B1 – Medial column B2 – Lateral column C – Divergent patterns C1 – Partial C2 – Total incongruity

Answer 107

**Instability** * \>2mm widening of 1st MT to medial cuneiform vs contralateral * \>2mm jt subluxation of TMT * Any dorsal displacement of MT on Lat view * Fleck sign = Lisfranc ligament avulsion

Answer 108

CT – delineate articular comminution, but not dynamic MRI – valuable to assess subtle lig injuries

Answer 109

Nonsurgical Indications: - Stable pattern - Unable to tolerate surgery Duration: NWB in SLC vs A/C x4-6wks

Answer 110

Initial Surgical Mgmt - CR for dislocations - Splint until STs appropriate for OR

Answer 111

Goal – restore functional anatomy of the foot

Answer 112

**Order** – prox to distal, medial to lateral Intercuneiform jt --to-- 1st TMT jt --to-- 2nd MT base in mortise

Answer 113

2 incisions * Medial - between 1stand 2ndray (interval between EHL and EHB) * Lateral – centered over 4thray (mobilize EDC medially and split EDB)

Answer 114

* Medial and middle columns -- Rigid fixation * Lateral column -- Flexible fixation * Assess for cuboid impaction – need to restore lateral column length * Strayer if equinus contracture present – can lead to increased midfoot loading Removal of spanning fixation at 8-12wks

Answer 115

This is controversial **Joint sparing** * Dorsal plate fixation is biomechanically equivalent to transarticular screw fixation, but avoids drilling through articular surface

Answer 116

**ORIF vs Arthrodesis** * Post traumatic DJD 25%, despite good reduction * Arthritis and AOFAS score correlate with quality of reduction * Increased arthritis in pts with purely ligamentous injury (40%) Trend towards better results with arthrodesis for purely Lig injury but not definitive.

Answer 117

**RFs for transfusion:** 1. Longer surgical time 2. \>6 levels fused 3. Osteotomies 4. Cobb \>50deg 5. NM etiology 6. Low body weight

Answer 118

Erythropoeitindecreases transfusion rate by 50%

Answer 119

* Preop anemia is predictive of postop transfusion * target a preop Hgb level 5g/dL higher than the surgeon’s preferred transfusion trigger * Erythropoeitindecreases transfusion rate by 50%

Answer 120

Other medications – associated with increased blood loss * Valproid Acid – platelet-mediated adverse effects * Antidepressants (SSRI, SNRI, and others) Discuss stopping preop or anticipating increased blood loss

Answer 121

TXA is an **_anti-fibrinolytic_** Decrease bleeding by inhibiting the degradation of fibrin. (basically tries to stop plasminogen transformation to PLASMIN, the main fibrinolytic)

Answer 122

Autologous blood transfusion Approx 30% more expensive than allogenic units

Answer 123

1. Controlled Hypotension * Lowered BP to decrease blood loss * Use during exposure, then reverse before deformity correction 2. Epidural blockade * Induce vasodilation distal and vasoconstriction proximal to the blocked levels =Decreased arterial flow to the surgical field (proximal to blockade) 3.Acute normovolemic hemodilution * Removal of venous blood before incision to decrease hematocrit * Replace with crystalloid to dilute blood * Return autologous blood postoperatively

Answer 124

There have been different studies performed but the RCT that was done showed: * Decrease blood loss and Hemovac output * But no difference in transfusion rate. Other studies have shown decrease in transfusion but they were retrospective. Note: TXA Loading dose – 10mg/kg up to 1g Maintenance 1-100mg/kg/hr

Answer 125

Cell salvage * Does not affect blood loss * Reduces the need for transfusion * Cost is greatest drawback

Answer 126

17.8% in PSIF for AIS

Answer 127

Physiologic transfusion triggers * Tacchycardia * Hypotension * U/O \<0.5mL/kg/hr * Acidosis Historical threshold - \<30% Hct

Answer 128

30% (Disk herniation, DDD, spondylolysis)

Answer 129

95% occur at L4/5 and L5/S1 Note: * Most common age 20-35 * R/O Cauda equina and Conus medullaris * Saddle anesthesia, autonomic dysfunction (overflow incontinence and impotence), leg pain

Answer 130

**Nonsurgical** \>80% improve within 6wks (\>90% in gen pop) * Give symptomatic relief while LDH resolves naturally * NSAIDs, PT (core strengthening), Epidural steroids

Answer 131

**Surgical** * If nonsurgical Tx fails \>6wks * Laminotomy with discectomy * 75-100% return to play within 2.8-8.7mos later

Answer 132

Good prognosis, 82% return to play

Answer 133

Lumbar disc herniation Lumbar DDD Spondylolysis

Answer 134

Most important RF – Genetic predisposition Also – aging, occupational hazards, smoking

Answer 135

MRI – loss of signal intensity on T2, annular tears, bone marrow/endplate changes

Answer 136

**Nonsurgical (Standard of care)** * PT + NSAIDs * No evidence to support epidural or facet injections

Answer 137

**Indications:** * Mechanical LBP with evidence of single-level degenerative disk * Failure of \>6mos nonsurgical Tx * Localized midline spinal tenderness at the affected level **Relative C/I:** * Narcotic abuse, smoking, unrealistic expectations

Answer 138

Surgical – unpredictable success Only consider if nonsurgical has failed, and cannot return to sports

Answer 139

(not recommended) Can lead to considerably faster progression of degeneration

Answer 140

**Surgical** Persistent Neuro Sx or progressive spondylolisthesis despite \>6mos nonsurgical Tx

Answer 141

**Surgical Options:** * Direct pars repair - only for L4 and above and with minmal slippage. Cannot repair L5 * L5-S1 fusion * +/- Decompression if Neuro Sx * Usually of exiting L5 nerve

Answer 142

Surgery = Diskectomy, fusion vs arthroplasty Adjacent disk Dz in 36% at 10yrs But, no improvement with Arthroplasty at midterm f/u Note: Fusion does not c/i return to play

Answer 143

up to 50% incidence Spondylolysis = Defect within the pars intraarticularis due to repetitive microtrauma

Answer 144

**_Nonsurgical_** Acute ==\> Activ mod, bracing, rest, PT * Avoid Lumbar extension * Sport cessation x3-6mos * Healing rate \>90%

Answer 145

Replaces bony resection with metal and plastic of the same thickness to replicate anatomy based on anatomic landmarks.

Answer 146

Best if: * Clearly identified anatomic landmarks * Large posterior osteophytes * Fixed coronal deformity (contracted or attenuated ligaments) - this is because you need intact ligaments in gap balancing to know what cuts to make. **N.B.** In severe PF disease, should consider using Gap balancing because whitesides is often not reliable.

Answer 147

**Gap Balancing** Use ligament tension relative to a perpendicular tibial cut to judge implant rotation for equal rectangular flexion and extension gaps

Answer 148

Mechanical Alignment (Fig 1) **Femur** * 9deg vs vertical * 6deg vs mechanical axis **Tibia** * 3deg vs vertical

Answer 149

Condylar liftoff during gait (difference between medial and lateral condylar heights relative to the tibial baseplate) **causes increased load transfer and inc PE wear**

Answer 150

Symmetric/Balanced Gaps Flexion/Extension Accurate Femoral Rotation

Answer 151

Measured resection vs Gap Balancing (or hybrid of both)

Answer 152

**Best if:** Advanced PF DJD or trochlear dysplasia (difficult to identify Whiteside’s) Minimal osteophytes Normal collateral ligaments

Answer 153

ASymmetric and unEqual Ligament Balance: ST imbalance and instability is the most common cause for early failure and 2nd most common cause of late failure.

Answer 154

Most important technical factors are femoral and tibial rotation, and restoration of the Q angle to 13-19deg. **How to decrease Q angle** * Lateralize femoral component * ER femoral component * ER tibial component * Medialize patellar component

Answer 155

Femoral sizing: **1)Posterior referencing** * Constant posterior condylar resection, adjust anterior resection for size * Use larger size to avoid notching **2)Anterior referencing** * Constant anterior resection, adjust posterior condylar resection for size * Use smaller size to avoid overstuffing the PJ jt – can cause flexion instability

Answer 156

**Femoral position** * Measured resection – use TEA (most accurate) * Gap balancing **Tibial position** * Middle of implant is set to medial 1/3 of the Tib Tubercle

Answer 157

**Measured Resection** **2 goals:** * Replace bony resections with prosthesis * Determine femoral rotation using anatomic landmarks **3 possible References** * _TEA_ – prominence of lateral epicondyle to sulcus of medial epicondyle * AP axis (Whiteside’s line) – Trochlear sulcus to midpoint of intercondylar notch * Posterior condylar axis * 3deg ER should be parallel to TEA **2 Pitfalls** * Landmark reliability– TEA \> Whiteside \> Post condylar axis * _Gap balancing has least variability and lowest percentage of surgical outliers of rotation_ (\>5deg) – 20% vs 56% for TEA * Increased coronal instability – more condylar liftoff through ROM

Answer 158

_Gap balancing_ has least variability and lowest percentage of surgical outliers of rotation (\>5deg) – 20% vs 56% for TEA (measured resection)

Answer 159

**Gap Balancing Goal:** * Optimize flexion and extension gap symmetry **Pitfalls (5)** 1. Joint line elevation * Mismatched gaps are often corrected with femoral resection and increased poly thickness * Causes midflexion instability and alters PF biomechanics 2. Midflexion instability * Femoral implant 5mm anterior and proximal will be balanced at 0 and 90deg, but unstable through arc of motion. 3. Patellar biomechanics * Contact force increases by 60% for every 1cm of joint elevation 4. Nonanatomic femoral rotation 5. Excessive flexion gap with PCL resection

Answer 160

**ORIF** * Plate fixation: * Precontoured plate \> recon * More holes \> 2 holes per side * Locking = non-locking * Most important factors are plate-bone contactand compression at symphysis **Arthrodesis** * Plate fixation + Autograft posterior to symphysis * +/- Perc SI screw augmentation * If posterior pelvic pain also: * SI jt DJD? * Yes =\> SI jt fusion (Lateral window II approach) * No =\> leave alone, will improve with anterior fixation

Answer 161

**Hybrid** Combine the strengths of both * Measured resection – appropriate implant positioning and alignment * Gap balancing – Joint conformity Minimize the weakness of each * Gap balancing – joint line elevation * Measured resection – suboptimal flexion balance _In short_ – start with measured resection technique - once jig set based on TEA, tension the knee at 90deg to confirm good rotation based on gap balance

Answer 162

Anterior Pelvic Ring Instability – pathologic motion under physiologic loads at the symphysis **Causes:** - Trauma - Pregnancy/parturition - Osteitis pubis (inflammation of pubic symphysis) - Rheumatologic and Uro/Gyne procedures

Answer 163

Pubic Symphysis - Thin layer of hyaline cartilage - Interposed fibrocartilage disk - Superior ligament - Arcuate ligament – inferiorly, ++ strong

Answer 164

**Posterior pelvis ring contributes most of the pelvic ring resistance to deformation.** **Generally Motion is limited at Symphysis:** * \<2mm translation * \<3deg rotation **Stability at Pubic symphysis** * Sectioning causes 21% decrease in pelvic load tolerance * Sectioning causes increased rotational stress but does not make SI jt unstable * Sacrospinous and sacrotuberous ligs don’t provide any substantial stability

Answer 165

**Pregnancy** 1. Pelvic girdle relaxation * physiologic change that begins during pregnancy * most resolve within weeks of delivery 2. Puerperal symphyseal rupture * Acute pain and “pop” during delivery * most don’t get better non-surgically

Answer 166

**Imaging**: AP, inlet, outlet, Judet views * AP – normal symphyseal clear space is 4.4mm **Flamingo views** * =Single leg stance bilaterally * \>5mm cranial difference = _unstable_ **CT** to assess posterior pelvis for ?nonunion/malunion

Answer 167

**Surgical Indications:** * Symphyseal instability(\>5mm cranial displacement difference on flamingo views) * Persistent nonunionon XR/CT * Puerpal symphyseal rupture (ORIF if \<2wks; Arthrodesis if \>2wks) * Failure of nonsurgical Tx x3mos (do Arthrodesis)

Answer 168

**Pregnancy-related pelvic ring relaxation:** * Nonsurgical Tx – 99% resolve by 3mos post-partum * Lateral recumbancy * Bracing * PT

Answer 169

**Puerperal symphyseal rupture** _Surgical Tx at presentation_ * poor results with non-op (press sores, gait issues, post ring pain) * \<2wks – ORIF * \>2wks – Arthrodesis

Answer 170

**Osteitis pubis** * Most resolve without Surgery * PT, NSAIDs, Steroids, RTx, Activ restrictions, Orthoses * If refractory – do flamingo XRs to assess for instability * Tx with Arthrodesis

Answer 171

1. Diabetes 2. Rheumatoid arthritis: review preoperative medication and hold DMARDS 1-2 weeks preop, until 2 weeks postop 3. Obesity 4. Malnutrition 5. Anemia

Answer 172

* 72 hours. * \>48 hours drainage is a risk factor for deep infection in TKA * Drainage \>5-7 days warrents operative intervention

Answer 173

1. Inflammation (0- 4 days) * activation of clotting cascade * formation of fibrin clot * neutrophil dominant 2. Proliferation (48 hours - 14 days) * macrophage dominant * angiogenesis, fibroplasia & ephithelialization 3. Maturation (day 8 - 1 year) -remodelling -collagen synthesis and remodelling 3. maturation

Answer 174

1. Consult microvascular surgeon if previous flap 2. Consult vascular for patient with circulation issues 3. Planned medial gastrocs flap 4. Tissue expanders preop for adherent skin

Answer 175

All from the patellar anastomoses which has contributions from: 1. Supreme geniculate artery 2. Medial and lateral superior geniculate arteries 3. Recurrent anterior tibial artery 4. Branch of profunda femoris

Answer 176

1. Most lateral vertical incision even if it nessecitates a lateral arthrotomy * More medial incisions interrupt blood supply closer to the source, thus are are at risk for wound healing complications. 2. Cross transverse incisions at 90 degrees 3. Incorporate short oblique incisions into a new vertical incision if near midline 4. Ideal spacing of 7cm between multiple verticle incisions. (AVOID 2.5-5cm skin bridges, unless considerable time since incision was made previously and sufficient revascularization of area)

Answer 177

1. Apex of incisions should form a V. If flattens out to a U- means too much tension and incision should be extended 2. Avoid excessive retraction 3. Full thickness skin flaps to avoid underminining skin 4. Avoid lateral retinacular release to preserve lateral skin oxygenation

Answer 178

1. Dry dressings with frequent changes 2. Limit physio for 24-48 hours (flexion of knee \>40 degrees after TKA has shown to reduced transcutaneous oxygen saturation around the incision) 3. Consider temporarily stopping LMWH 4. VAC dressings (shown significant reduction in deep infection vs dry dressings) * indicated for patients draining serous fluid after 48 hours * 50mmHg pressure, to avoid skin irritation No evidence to support use of antibiotics to improve outcome of draining wound.

Answer 179

1. Articular Disk 2. Dorsal and volar radioulnar ligaments 3. Ulnocarpal ligaments (ulnotriquetral, ulnolunate) 4. ECU sheath 5. Meniscus Homolog

Answer 180

Ligamentous 1. TFCC injury 2. DRUJ Instability 3. LT ligament tear 4. UT ligament tear Osseus 1. Hook of hamate fracture 2. Ulnar styloid fracture 3. Base of 5th metacarpal fracture 4. Trequetral avulsion fracture 5. Ulnocarpal impaction 6. Keinbocks 7. Pisotriquetral arthritis 8. DRUJ arthritis Vascular - Ulnar artery thrombosis Neurology - Ulnar neuropathy at guyots canal Tendinous 1. ECU tendon subluxation 2. ECU tendinitis 3. EDM tendinitis 4. FCU tendinitis

Answer 181

* Ulnocarpal stress test (Nakamura) * Wrist in maximum ulnar deviation, forearm neutral rotation and elbow at 90 degrees flexion, axial load is applied while wrist is pronated * Assessess ulnar sided pathology ( TFCC, LT tear, arthritis, loose body) * Linsheid Test * Positive when creiptus occurs while wrist moves from ulnar to radia and gentle pressure applied to triquetrum * LT or Trequetro-hamate joint pathology * LT joint pathology * Keinman shuck test - examiner places their thumb or index finger on trequetruma nd pisiform, holding the radial side of the carpus and the lunate with the other, and then moves in opposite directions. * Regan Shear test - placing thumb on volar aspect of pisiforma nd other four fingers dorsal on the ulnar side of the wrist. Lunatean the radial side of the wrist are stabilized by the other hand and force is applied through he pisiform from dorsal to volar direction while keeping the other hand stable * Derby Relocation test - asking the patient if the wrist or hand feels unstable or loose, and performing three specific tests. One described below: * Begin in with hand in dorsiflexion and radial deviation with hand in full pronation * With other hand, examiner applies a dorsally directed force onto the pisiform with thumb, while other fingers apply a volarly directed counterforce to the the ulna. * While maintaining pressure on the pisiform, wrist is brought from radial deviation to neutral which reduces triquetrum. * Patient should report sense of instability has disappeared. * Pisiform Grind test * Dorsally directed pressure over the pisiform elicits pain. * Pisiform-hamate joint arthritis * Ulnar fovea test * Direct palpating of the fovea * Detect pathology of the UT ligament or fovea disruption of the distal radioulnar ligaments. * Piano Key Test * Patients forearm in pronation and hand stabilized by examiner, volar directed pressure on the ulna is applied. If it translates with minimal resistance - positive test * DRUJ instability * Repeat test in neutral and supination * Compare to other side * ECU Synergy test * Resisted finger abduction between thumb and index finger causes pain along ECU * ECU tendinitis * ECU instabilty test * Hold wrist in maximum flexion and ulnar deviation then supinate the wrist against resistance. Look for visible subulxation of ECU tendon * ECU tendon instability

Answer 182

a) higher risk of osteoporotic/fragility fractures * HIV and HAART results in reduced bone mineral density * the other options above have no definitive research behind them. multitude of studies for and against each.

Answer 183

1. HIV viral load 2. Preoperative chest radiographs 3. CD4 count 4. Comprehenisve metabolic panel with albumin 5. CBC 6. Protein C & S deficiency

Answer 184

Dynamic CT

Answer 185

1. Non-nucleoside reverse transcriptase inhibitors 2. Chemokine coreceoptor 5 antagonitsi 3. Nucleotide/nucleoside reverse transcriptase inhibitors 4. Protease inhibitors 5. Fusion inhibitors 6. Integrase transfer inhibitors

Answer 186

* Deep injury * Blood visible on the sharp * Large hollow-bore needle * High viral load * Terminal patient from disease * Procedure involving needle in arteries or veins * Emergency procedure

Answer 187

*Pneumocystis Carnii* pneumonia

Answer 188

This card was left blank but in skimming the article, I think it should be albumin. CD 4 and Viral count have both been shown to have increased risks but they say that overal nutrition and albumin are stronger predictors

Answer 189

A) Preoperative halting of HAART therapy * HIV patients 2-10 fold increase of postop VTE vs general population

Answer 190

1. Low energy mechanism 2. More frequently involve the anterior column 3. More comminuted 4. If posterior wall involved, more likely to involve a posterior hip dislocation 5. More marginal impaction at medial dome 6. Increased association with femoral head fracture

Answer 191

f) all of the above.

Answer 192

1. Elderly patients with secondary congruency 2. Patients who’s comorbidities preclude surgical managment * Important regardless of operative or nonoperative to mobilize the patients reletively quickly to avoid increases in morbidity and mortality associated with bed rest * In those where pain precludes ambulation, surgery should be performed to allow more rapid mobilization.

Answer 193

1. Percutaneous fixation - if adequate bony corridor and minimal comminution. Cannot be used for wall fractures 2. ORIF 3. Delayed total hip 4. Acute total hip

Answer 194

Hoehn and Yahr Grading * predictive of * rehabilitation potential * risk for implant failure after spine fusion

Answer 195

1. **Camptocormia**- “bent spine syndrome” sagital plane deformity with truncated kyphosis but resolves when patient is supine 1. Resolves when supine 2. **Pisa Syndrome**: coronal plane Spinal deformity with lateral bending deformity at trunk. Absence of vertebral body rotation and flexible compared to idiopathic scoliosis 1. Resolves when supine 3. **Antecollis**: “dropped head syndrome” - extreme kyphotic deformity fo cervical spine resulting on chin-on-chest deformity 1. resolves when supine 4. **Scoliosis**

Answer 196

1. Age \>40 2. Hip dislocation 3. Initial displacement \>2cm 4. Posterior wall fracture 5. Femoral head fracture/cartilage injury 6. Marginal impaction 7. Non-anatomic reduction

Answer 197

1. Full thickness cartilage loss 2. Femoral head impaction 3. \>40% impaction of acetabular fracture

Answer 198

c) Decreased blood loss in ORIF and THA vs ORIF alone * Cochrane Review * Combined ORIF & THA * Slightly Shorter surgery * increased blood loss * Similar mortality as ORIF alone * Bettern SF-36 outcomes * ORIF alone : better Harris hip scores

Answer 199

1. Infection 2. Aseptic Loosening 3. Fracture 4. Component Failure 5. Instability Other complications: * Requring additional surgery * Nerve entrapment (usually ulnar) * Triceps insufficiency * Increasing morbidity * Wound infections * Paresthesias * Fracture

Answer 200

1. Resting Tremour 2. Cogwheel rigidity 3. Bradykinesia 4. Shuffling gait 5. Increased forward posture 6. Loss of fascial expression

Answer 201

**Mayo Classification (pretty much a ripoff of the Vancouver Classification for Hips)** 1. Type I - Involve Humeral Condyle or Olecranon * Can Managed nonsurgically with immobilization * May require fragment excision and advancement of muscle mass * Periarticular fractures around olecranon with loss of extensor function should be managed surgially with ORIF (tension band) * Can't do a normal tension band with the ulnar compoenent there so try to engage the wires into the cement mantle * May need to remove the hardware eventually 2. Type II * 1- Fracture around the stem in a well-fixed implant * ORIF the fracture * Use paratricipital approach, protect radial n. * Bicortical fixation above the prosthesis , unicortical at the implant, supplement with circlage * 2- Fracture around the stem, loose implant, good bonestock * Revision of the component with plate and screw augmentation * 3- Fracture around the stem, loose implant, poor bonestock * Revision of the component with strut graft, circlage 3. Type III - Proximal to the implant * Nonop management with functional bracing * ORIF the fracture if you cant get good alignment nonop

Answer 202

1. Anticholinergics (alteration in PD medication can cause acute change in spinal alignment, sometimes using an anticholinergic to counteract the dopamine agonists helps) 2. Physical therapy 3. Deep Brain Stimulation 4. Bracing - often poorly tolerated due to ulceration in this population, but good at correcting deformity.

Answer 203

* **Avoid _traditional_ inhalational agents (halothane)** since they interact with levodopa and generate arrhythmias (use newer agents like iso/sevofluorane) * **Hypotension & bleeding** (due to poor oral intake and dopaminergic drug use) * Avoid meperidine (serotonin syndrome when combined with MAO inhibitors) * **Delirium** (can last up to 1 week) * **Urinary retention** (early foley removal)

Answer 204

1. Opoiod Interaction (those with seretonin inhibitory activity like merperidine) * Can cause seretonin syndrome 2. Postop aspiration 3. Respiratory failure associated with PD associated upper airway dysfunction 4. Prolonged post-op sommnolence, delirium and psychosis 5. Postop urinary retention

Answer 205

1. Myelopathic 2. Neurologic compromise * Essetially high risk for complications and infection

Answer 206

* 3-8% infection (higher than other arthroplasties. Thought to be due to the procedure being done in a large proportion of rheumatoid) * Staph Epidermidus * Also high amount of S. Aureus. * More difficultly eradicating infection if S. Epidermidus is the causative agent

Answer 207

a) Icepacks/Ice Compression - found to be effective for pain management edema control and delayed onset muscle soreness. * Ultrasound has little evidence in the realm of rehabilitation when not combined with other modalities. * There is a role for heat therapy in regards to tissue extensability * Limited role for iontophoresis in tennis elbow * TENS have shown little clinical utilty on their own.

Answer 208

b) Tissue extensability - heat therapy has shown to be effective here, but not cold.

Answer 209

1. Tissue (skin, fat, fascia) 2. Muscle 3. Nerve

Answer 210

d) Quads Strengthening Post ACL

Answer 211

1) Hormonal - decreased sex hormones 2) Unloading - Wolff's law 3) Denervation - Effective sympathectomy due to the SCI causes disorganized vasoregulation leading to poor bone formation

Answer 212

Yes - which confirms that osteoporosis is not just secondary to off loading (also hormonal and denervation)

Answer 213

Skull is spared and Knee is most vulnerable

Answer 214

1) Acute - \< 4 months 2) Subacute 4-16 months 3) Chronic \>16 months - Peak bone loss occurs at 16 months in the LE

Answer 215

With exuberant callus but quality is questionable

Answer 216

Non op with well padded casts and regular skin checks. ONly 7% get surgery Do NOT use Ex fix but frames are ok. ORIF has been associated with SHORTED LOS When patient presents with what looks to be a fracture, dont; forgot to RO infection

Answer 217

1) Bisphosphonates - may be helpful in first 6 months 2) Thiazides - can decrease fracture risk by 25% 3) Physical Therapy - unclear if it's for sure helpful, but thought to contribute Anticonvulsants (Phenytoin) INCREASES risk of fracture

Answer 218

Autonomic dysreflexia - Hypertension, shivering, anxiety, and headache, nausea, diaphoresis and flushing.

Answer 219

FBN1 and Chromosome 15

Answer 220

Superior lens dislocation and aortic root aneurysm

Answer 221

Scoliosis, tall stature, pes planovalgus, pectus excavatum, long fingers (look for wrist and thumb sign), dural ectasia, acetabular protrusion

Answer 222

No quick bursts of energy or strength and no contact sports

Answer 223

Subscapularis

Answer 224

Posterior IGHL Shoulder in ABduction: MGHL Shoulder in ADDuction: SGHL

Answer 225

The RI contribution to stability is controversial. It helps to prevent INFERIOR and POSTERIOR translation when the arm is in adduction.

Answer 226

SGHL, MGHL, Capsule, Biceps, CHL

Answer 227

Deep pain in the posterior aspect of the shoulder

Answer 228

If no symptoms of posterior shoulder instablity OR MDI is diagnosed, then do rehab for \>3 months. If this fails, then you can proceed to the usual posterior shoulder instability algorithm. If there is posterior shoulder instability symptoms or recurrent dislocations, then you need to evaluate for glenoid bone loss. a) If \<10% glenoid bone loss - do posteiror inferior capsular plication and labral repair b) if 10-20%, Same but CONSIDER Bony augmentation c) If \>20% then open vs arthroscopic posterior inferior glenoid bony augmentation with iliac crest bone graft, or allograft (distal tibia is authors preference)

Answer 229

Both are acceptable but arthroscopic has lower recurrence with higher return to play

Answer 230

Recurrent micro trauma (Repetitive bench press, overhead weight lifting, rowing, swimming)

Answer 231

1) Acute trauma 2) Repetitive Microtrauma (most common) 3) Insidious onset (Think MDI and high Beighton score\>4/9) 4) Voluntary - Either voluntary positional - i.e. subluxation in a provocative position (FF+IR). These patients SHOULD be considered for surgery OR Voluntary Muscular instability - arm is Adducted (non positional dependent). These patients should NOT be considered for surgery

Answer 232

1) Jerk test - Shoulder at 90 degrees of FF, IR and the elbow is pushed posteriorly 2) Kim test - Shoulder is 90 abducted. Apply an inferior force while moving the arm 45 degrees of FF 3) Sulcus test 4) Load and shift test 5) Posterior stress test - FF of 90, IR and adduction and then load the shoulder, pushing posteriorly

Answer 233

Osteoporosis, age, prolonged steroids, neurologic disorder, inflammatory arthritis, obesity

Answer 234

Cortical bone thickness

Answer 235

1) ORIF (Nail or plate) 2) Revision instrumentation (constraied and unconstrained) 3) Allograft prosthetic composites (However these have grossly gone out of failure due to poor outcomes even in young patients)

Answer 236

If ligaments stable - unconstrained TKA If ligaments unstable - Constrained TKA

Answer 237

If Unconstrained defect, then need to consider allograft composite TKA for young patient and femoral/tibial endoprosthesis for elderly patients. If it's a constrained defect then you can use metal augments

Answer 238

Transepicondylar is msot often still present, whereas whitesides and posterior condyles are absent

Answer 239

Appropriate soft tissue coverage and maintenance of the extensor mechanism

Answer 240

Knee alignment rotation, stability and early mobilization

Answer 241

Abductor pollicis, opponens policis and superficial part of the flexor pollicis brevis

Answer 242

volar radial side of the foream, between 4-10cm proximal to the wrist crease. usually runs B/w PL and FCR

Answer 243

1-19% of patients have it and need to be aware that there is a higher incidence of CTS in these patients.

Answer 244

1) Subligamentous (31%) 2) Ulnar take off 3) Extraligamentous (46%) 4) Transligamentous (23%)

Answer 245

No true safe zone but make an incision along the long axis of the 4th digit. This seems to pose the least risk

Answer 246

Skeletal immaturity at the time of PSF and Risser 0. Others: RVAD\>20, Actual age\<11, skeletal age\<10 and open triradiate

Answer 247

Axial plane growth

Answer 248

There are 3 Transverse gorwth plates 1. Spinous process, 2. base of each pedicle, 3. and the endplates. Longitudinal growth occurs from the endplates

Answer 249

1) Cobb progression \>10 2)RVAD \>20 Apical vertebral rotation \>5

Answer 250

Shilla Growth Guidance System (I can't find this on the Medtronic website, but essentially it sounds like you put non polyaxial screws at the apex and polyaxial screws elsewhere. You can then grow the construct with the rods because the rods are not firmly attached to the pedicle screws....

Answer 251

Elderly, independent patients \>80yo

Answer 252

The trochlea

Answer 253

Low Type A and Type C

Answer 254

The same (but young patients still have better outcome scores)

Answer 255

○ Painless elbow with 30-130 ROM ○ And if you have to choose, get it anatomically aligned and fix stiffness later ○ FYI - can accept shortening in the metaphysis, but MUST get the trochlea width correct. If you shorten the metaphysis, then you need to burr out the olecranon fossa

Answer 256

30% **Includes:** * stiffness, * infection, * SSI, * ulnar nerve injury, * malunion, * non-union

Answer 257

Surgical fixation within 48-72 hours (has been shown multiple times)

Answer 258

No, not in the young patient with good bone but in osteoporotic bone then you should use locked plates.

Answer 259

Parallel plating had greater axial (p\<0.005) and external rotation (p\<006) stability

Answer 260

Nonunion secodnary to loosening of the posterior lateral plate

Answer 261

Age \>50, Osteopenia and open fracture

Answer 262

TEA has better DASH and MEPS scores and shorter surgical durtation (McKee) - All Statistically significant There was also a trend (although did not reach statisticaly significance) for greater ROM and less re-operation for TEA

Answer 263

Osbornes ligament at cubital tunnel

Answer 264

Ligament of struthers Osbornes ligament (cubital tunnel) Two heads of FCU Deep Fascia of FCU FDS Fascia Anconeus Epitrochlearis Guyons Canal

Answer 265

C8-T1 radiculopathy Thoracic outlet symdrome Ulnar nerve compresison at Guyon's canal

Answer 266

Pisotriquetral OA Hook of hamate fracture (think about this in golfers!) Hypothenar hammer syndrome (when there is decreased blood flow to the digits due to using the hypothenar emminence as a "hammer" - it can damage the ulnar artery. FCU tendinitis

Answer 267

muscular atrophy in 1st webspace Wartenberg sign (little finger cannot adduct), Froment (thumb IP hyperflexion due to inability to adduct the thumb) Jeanne sign (thumb hyper extension due to overpull of EPL) Claw hand - advanced

Answer 268

Nerve percussion - Tinnels at elbow Elbow flexion test - Flex elbow and extend the wrist Flexion-compression Test - compress Ulnar nerve while flexing the elbow Scratch collapse test (unclear if this actually is reliable)

Answer 269

\<50m/s velocity drop or \>10m/s difference across different areas of the elbow

Answer 270

If there is atrophy or impaired 2 point discrimination In moderate disease, 33% will require surgery In Severe disease, 66% will need surgery.

Answer 271

Those with vascular concerns because you need to dissect anteriorly and may compromise vascularity to the flap - increased risk in someone who already has impaired vascular status

Answer 272

\>19% (O'Driscoll) When doing the osteotomy, need to be careful to preserve the MCL

Answer 273

Unclear which is better, but might want to consider transposition when the nerve is hypermobile and in the post-traumatic cubital tunnel situation (i.e. patient has had elbow dislocation, DHF etc) Should also consider for revision surgery where all areas of compression had previously been decompressed

Answer 274

increase pseudoarthrosis, increased pain scores, higher revision rates

Answer 275

Transforaminal lumbar interbody fusion. Discectomy ACDF, and anterior lumbar IB fusion all showed worse results in workers comp patients

Answer 276

1) Narcotic use within 7 days of injury 2) Chronic opioid use (\>1yr) 3) litigation status - 9.5x more likely to have long term functional limitations 4) Mental health issues - get psychology involved!

Answer 277

metal on metal and resurfacing

Answer 278

Nickel (#1) Cobalt Chromium

Answer 279

female, piercings, history of hand eczema, metal allergy in first degree relative, Hx of smoking, following well functioning arthroplasty and following failed arthroplasty

Answer 280

Type IV - T cell mediated (not antibody) Examples: contact dermatitis, chronic transplant rejection, MS

Answer 281

xrays to look for loosening and malposition, along with metal reduction MRI to look for pseudotumor and aseptic lymphocytic vasculitis-associated lesions (ALVALS) \*\*\* MRI and US have the same ability to detect AVALS

Answer 282

elevated white count and high % of monocytes. (These findings are NOT specific for allergy, just suggestive) NO DOT test for metal ion concentration (no benefit in diagnosis)

Answer 283

PMMA, Bioabsorbable implants, suture materials

Answer 284

1) Low Risk - well fixed with no symptoms - MOonitor yearly 2) Moderate Risk (well fixed, well positioned who exibit some symptoms - follow Q3-6months 3) High Risk - Severely Symptomatic with high ion levels (\>10ppb) and malposition - revision is generally considered

Answer 285

Convert Co-Cr to Zirconium femoral implants, and titanium tibial trays with poly, or ALL poly.

Answer 286

Decreased vascularity, decreased number of collagen fibers with disorganized course, and there can be mucoid degenration

Answer 287

Watanabe I- Complete co verage of the tibial plateau and stable to probing II- 80% coverage of the tibial plateau and stable III- unstable to probing (There are no posterior meniscotibial attachments) - only posterior attachment is Ligament of Wrisberg

Answer 288

Squarring of the femoral condyle, cupping of the tibial condyle, increased lateral joint space, decreased size of the lateral tibial spine

Answer 289

Need to have 3 cuts of 5mm where there is continuity from anterior to posterior (Bowtie sign)

Answer 290

Physical exam. MRI has lower sensitivity

Answer 291

1- Asymptomatic - monitor. 2- Symptomatic - Saucerization and then assessment of meniscal stability. Stabilize meniscus with sutures

Answer 292

Discoid meniscus group had significantly decreased ROM

Answer 293

\>600IU for patients 19-70, and 800 for patients \>70

Answer 294

aids in bony integration, improves implant survival and can help prevent fractures. DO NOT stop them perioperatively

Answer 295

The elderly with poor bone quality due to the risk of fracture and subsidence

Answer 296

Female Age Non cemented implants reivision surgery

Answer 297

Fix the fracture first and then convert to THA once fracture is healed. This prevents the need for a long stemmed THA

Answer 298

Renal failure (or transplant) and Sickel cell

Answer 299

1) SCD patients have smaller Bones 2) Confirm small implants are available pre op 3) Can have deformities in the proximal femur, poor bone quality and sclerotic canals 4) Hip dislocations can be very difficult due to protrusio, large osteophytes and intra-articular adhesions

Answer 300

Good hydration, good O2 (to prevent sickling), and may require Transfusion

Answer 301

concentric and Medial joint space narrowing

Answer 302

They have increased risk of intra-op bleeding due to hypervascular abnormal bone. As a result, bisphosphonates should be considered as they decrease bone activity They are also at higher risk of HO and periprosthetic fracture

Answer 303

Fibrous dysplasia Deformity of the proximal femur (when the proximal femur is severe varus) but can also be Paget's or OI!

Answer 304

C-spine xrays to RO cervical instability

Answer 305

1) In situ neck cut 2) Remove the overhanging portion of the acetabular wall or ossified labrum

Answer 306

reinforcement of the medial wall Lateralization of acetabular implant rigid fixation with appropriate coverage of the defect

Answer 307

Canal diameter 10cm distal to the LT DIVIDED by the canal diameter at the LT Dorr A = \<0.5 Dorr B = 0.5-0.75 Dorr C \>0.75

Answer 308

15cm from the knee joint

Answer 309

The medial dural cutaneous nerve (branch of the tibial nerve)

Answer 310

Medial extends to 5cm above the distal tip of the medial malleolus, while the lateral extends to 10cm above the lateral malleolus ti[

Answer 311

Medial and lateral sural arteries, along with 1 or 2 veins. (branches of the popliteal artery)

Answer 312

1) Active purulent infection 2) Defect \>15cm from the knee joint 3) Patient with serious malnutrition reuslting in inability to heal surgical insult

Answer 313

No. Only if there is history of previous injury to leg vasculature

Answer 314

1) Can release gastroc from the femoral condyle (gives 5cm) 2) pie crust the gastroc fascia, or remove it all together

Answer 315

1) Decreased push off strength of ~7% 2) Contra lateral stride length is decreased to reduce the demand on the ipsilateral calf muscle

Answer 316

MCL and Posterior oblique

Answer 317

I - Sartorius fascia and retinaculum - Pes and saphenous nerve run between layers I and 2 II- Superficial MCL, POL, Semi-membranosus, MPFL III- Deep MCL and joint capsule, coronary ligament \*\*\* There is a newer description of the medial side of the knee which describes it in thirds - Patellar tendon to anterior edge of sMCL, width of sMCL, and PMC (i.e. posterior edge of sMCL to gastroc head)

Answer 318

1) POL 2) Oblique popliteal ligament 3) Semi membranosus 4) Posterior medial joint capsule 5) Posterior horn of the medial meniscus \*\*Superficial and Deep MCL are NOT typically considered part of the PMC)

Answer 319

1) POL 2) OPL 3) Posterior medial tibia 4) Par reflexa 5) popliteus poneurosis expansion

Answer 320

Avulsion Tendon rupture Tenidinitis

Answer 321

Bony avulsion of the meniscotibial ligament insertion and occurs in association to the PCL rupture.

Answer 322

**1) Anterior drawer** with the foot externally rotated to 10-15 degrees - will see anterior translation of the anterior medial tibial plateau **2) Valgus stress test with the knee at 30 degrees and externally rotated foot.** Look for rotatory component of medial tibial plateau in relation to femur **3) Valgus stress test at 0 and 30** - If the knee opens with Valgus stress in 30 then think MCL, but if opens at 0 and 30, then need to RO PMC **4) Posterior drawer test** with foot in internal rotation \*\***If you're having trouble remembering which way the foot points, it points in the same direction of your rotatory force - i.e. for anterior drawer, you are also applying a ER force, trying to get the medial tibia to move forward (foot is ER'd for anterior drawer). Meanwhile, for posterior drawer you are IR'ing the tibia to seee if the medial tibia goes back (Foot is IR in posterior drawer for PMC).** **Same for PLC - you do posterior drawer with foot ER'd and you apply and ER force to see if the lateral tibial plateau goes posteriorly**

Answer 323

1) Gr I and II MCL extending to the PMC can be treated non op 2) Otherwise, there are no clear cut indications for surgical maangement of PMC. But should be considered in multi lig knee injuries, those with gapping with valgus stress at 0 those with Stener type MCL injuries and PMC injuries that are avulsed.

Answer 324

MCL - 20 degrees of flexion and varus POL - Full extension and neutral rotation

Answer 325

Decreased from 52 to 16%

Answer 326

Can reduce variablity within orthopedic centers and improve order sets, use of drugs and post op mobilization. Essentially, it standardizes everything so that it is the most efficient (time and cost) process, while still being safe and effective. Requires Multidisciplinary input, including the patient (customer)

Answer 327

PMC and PLC. both of these add rotatory support and can be contributory to instability

Answer 328

sMCL: * Origin is posterior and proximal to medial epicondyle. * Insertion: Anterior Proximal Tibia POL: * origin: Is posterior and DISTAL to adductor tubercle (just inferior to Gastroc Tubercle) * Insertion: Has 3 "arms" but CENTRAL arm is most important and runs at an angle 25 degrees posteriorly and inserts on posterior tibia/capsule. * This is the part of the POL that is reconstructed in Laprade technique of PMC reconstruction

Answer 329

1) POL and capsular arm of semimembranosis (70%) 2) POL and complete peripheral meniscal detachment (30%) 3) POL and capsular arm, and peripheral meniscal detachment (19%) POL was injured in 99% of these knees

Answer 330

tibia ER and valgus stress Direct Valgus will more likely lead to isolated MCL

Answer 331

1. Weakness to manual muscle testing with resisted abduction or weakness to resisted external rotation with arm at side 2. Drop arm sign 3. External rotation lag sign 4. Painful arc

Answer 332

Full thickness supraspinatous tears found in 90% of patients in which distance between humeral head and undersurface of acromion \< 7 mm

Answer 333

1. **Anterior Approach** 1. most challenging because of CA ligament anteriorly and anterior acromial spurs in some patient 2. **Lateral approach** 1. Allows easy access to subacromial space 2. Provides flexibility for addressing both anterior and posterior abnormalities 3. Needle should be aimed just below lateral and inferior border 3. **Posterior approach** 1. When pain is primarily posterior, injection into posterior site can be used

Answer 334

No Aly et al - systematic review of 4 cadaver studies and 9 clinical studies, no difference in accuracy fo injections in to subacromial space when performed with or without ultrasounaography

Answer 335

1. Palpation of AC joint 2. Cross- body adduction stress test 3. Arm extension test - shoulder and elbow are flexed to 90, and then the patient abducts the shoulder while the examiner applies an adduction force 4. Active compression test - O'Brien' Test

Answer 336

1. Small joint with fibrous capule 2. Joint obliquely oriented 3. Small meniscus occupies joint space between distal clavicle and acromial articulation * Ultrasound assisted injections more accuracy than blind (94% vs 68%), Aly et al. * Care should be taken to avoid advancing the needle too deep to avoid injecting the subacromial space instead.

Answer 337

Many pathologies which makes GH injections a difficult diagnostic tool. 1. Frozen Shoulder 2. Glenohumeral Arthritis 3. Labral Tear 4. Massive Rotator Cuff Tear (leaks into the subacromial space) 5. Biceps Tendonitis 6. SLAP tear **Approaches:** Anterior or posterior * generally when blind injection technique used without imaging, **anterior approach provides more predictable result** than posterior approach (65% vs 46% accurate) * ALSO, US guided glenohumeral injections vs landmark-guided injections was 92.5% vs 72.5% respectively

Answer 338

* **Traction** on suprascapular nerve believed to cause symptoms in those who play **volleyball or overhead ball-throwing sports** such as baseball and team handball * \*\*N.B. **Compressive injuries** typically associated with synovial or ganglion cyst

Answer 339

This article states that the **spinoglenoid notch** is the most common location for surprascapular nerve injury, resulting in infraspinatus atrophy. \*\*The question we have debated is where the nerve is affected for Massive rotator cuff tears - The 2019 consensus is Suprascapular notch but this is a dumb question

Answer 340

1. Palpating of biceps in the groove with pain 2. Speeds test 3. OBrien’s Test (SLAP tear) None have good sensitivity/specificity

Answer 341

strong: don't do routine postop duplex u/s moderate: discontinue antiplatelet agents before moderate: pharmacologic and/or mechanical VTEp Moderate: neuraxial anesthesia to help limit blood loss even though it does not affect occurence of VTEp

Answer 342

12 hours postop, to limit postoperative bleeding. Recommended prophylaxis for 10-14 days for both hip and knee, can be extended to 35 days.

Answer 343

◦Previous VTE ◦Advanced age ◦Obesity ◦Immobilization ◦Estrogen therapy ◦Prolong immobilization ◦Cancer ◦Thrombophilias - antithrombin III deficiency, proteins C abnormalities, protein S abnormalities ◦Molecular risk factories - eg Factor V Leiden, prothrombin 20210A gene mutation, hyperhomocysteinemia

Answer 344

C) Warfarin - INR needs to be monitored to ensure therapeutic dose.

Answer 345

c) increased rates of bleeding * RECORD 1 * Rivaoxaban significantly more effective in preventing total VTE * Equivalent for rates of symptomatic VTE and major bleeding * RECORD 2 * Extended rivaoxaband therapy more effective in preventing total VTE and symptomatic VTE * Similar rates of bleeding * RECORD 3 * Rivaoxiban more effective in preventing total VTE and symptomatic VTE * RECORD 4 * Rivaoxaban superior to enox in preventing total VTE and deaths * Similar for symptomatic VTE and deaths

Answer 346

1. Anemia 2. Female Sex 3. BMI \> 25 (added risk if BMI \>30) 4. Age \>70 5. Total Knee Replacement 6. Atrial Fibrillation 7. Postop DVT

Answer 347

* GT, ASIS, AIIS, iliac crest, tibial tubercle, calcaneus * Appear between ages 4 (GT) and 17 (ASIS) and fuse by age 17 (aside from ASIS – 25)

Answer 348

1. AIIS 2. Ischial tuberosity 3. ASIS

Answer 349

* Consider surgery for ischial tuberosity avulsion fractures with \>2cm displacement * (Kocher-Langenbeck approach) * Post-op protocol is NWB x 6 weeks, then running at 4 months and return to play at 6

Answer 350

* Delayed ASIS avulsion fractures can present with meralgia paresthetica from compression of LFCN * * * Treatment of ASIS avulsion fractures is essentially non-op (can consider surgery for unremitting pain or displacement \>2cm, but very poor evidence)

Answer 351

LAbral tears

Answer 352

1. Male 2. African American 3. Teenager

Answer 353

1. **Temporary cavity** - the energy from the bullet makes temporary cavities 1. Tissues that are more elastic (lung, muscle) have smaller temporary cavity formation 2. **Permanent cavity** - The energy from the bullet entrance it self creates destruction

Answer 354

* Low-energy gunshot wounds (handgun) don’t cause extensive soft tissue injury, so if the bony injuries meet the parameters for closed management, then the treatment is a bedside I&D and casting * * High-energy gunshot wounds (rifle) cause extensive soft tissue injury and require aggressive I&D and ORIF if fractures are unstable or are associated with bone loss

Answer 355

* Any injury involving a joint should be treated operatively

Answer 356

* No clear evidence on antibiotic prophylaxis in the absence of grossly contaminated wounds, but most people would administer them

Answer 357

Yes - the energy from the bullet can cause physeal injury, especially in high energy gunshot wounds

Answer 358

* Digital nerves are often pushed out of the way of the projectile and not lacerated, resulting in **neuropraxia** * * In cases of nerve injury, if the patient is going to the OR anyway then should explore the nerve and **if it’s transected**, the ends should be approximated to prevent retraction and definitive treatment is performed 1-3 weeks later to better define the extent of injury. **If the nerve is in continuity**, then observe for 2 months and refer if no return of function at that point.

Answer 359

1. Retained fragments in the disk space (lead toxicity risk) or spinal cord 2. CSF fistulas 3. Epidural hematoma/abscess 4. Instability (rare)

Answer 360

* _Symptoms of lead toxicity:_ constipation, cramping, seizures, developmental delay, encephalopathy à if blood lead levels \>45 µg/dL, * * Treat with chelation therapy

Answer 361

* ALP is elevated early and plateaus at 4 weeks (non-specific in fracture patients). But between 2 nd 3 months it normalizes. * Bone Scan is hot early before any mineralization is seen and is cold at 2-3months. * CT is helpful for pre op planning * MRI is NOT helful * Pain resolves and swelling resolves around 2-3 months

Answer 362

Up to 100%

Answer 363

1. Surgical: approach (iliofemoral \> K-L \> ilioinguinal), dual approaches, trochanteric osteotomy 2. Soft-tissue injury: debride any necrotic muscle to reduce risk 3. Systemic: male, brain injury, thoracoabdominal trauma, ipsilateral femur fracture, associated sciatic nerve injury, prolonged mechanical ventilation

Answer 364

* Postop XRT within 72h (600-800 cGray) à 3% incidence of HO à post op radiation is more effective than NSAIDs. * **Pre op has not shown to be as effective** * * NSAIDs **not effective** after acetabular fracture surgery (3 RCTs), but it’s still used. **But it IS** associated with increased risk of non union

Answer 365

* When HO is causing nerve entrapment leading to neurological symptoms, you shouldn’t wait for maturation to intervene * * Symptomatic HO should be removed – can get pre op CT to assess location of neurovascular structures and asses the extent of HO. Work from area of known to unknown when removing \*\*Was previously thought that HO should be fully mature before removing but that is now debated. If at any point there is nerve injury, should interven at that time

Answer 366

1) Inhibitis upregulation of systemic factors 2) Inhibitis upregulation Local factors Radiation inhibits recruitment of osteoprognitor cells

Answer 367

* With reduced mobility, the number of sarcomeres decreases and cross-sectional area declines = loss of muscle mass and length, but this is reversible within 2 weeks; after 4 weeks, connective tissue also loses its elasticity as adhesions turn into fibrosis à end result is irreversible contracture

Answer 368

* Static progressive splinting/casting (best evidence is to prevent equinus contractures in patients with head injuries; also useful for patients who develop elbow contractures following brain injury)

Answer 369

1. ![]() Instability (22%) 2. Aseptic loosening (20%) 3. Infection (15%) 4. Implant failure (10%) 5. Other mechanical problems 6. Osteolysis (7%) 7. Periprosthetic fracture (6%)

Answer 370

* Average wear rate of HXLPE is 0.02mm/y * Increased risk of osteolysis when poly wear rate \> 0.2mm/y

Answer 371

* Evidence of infection: ESR \> 30, CRP \> 10, \> 3000 cells, PMNs \>80%

Answer 372

* Beaule defined well-fixed acetabular components as absence of RLL (radioluscent lucency) \> 1mm in any 2 zones on AP XR

Answer 373

1. Dual-circle technique 2. Linear wear 3. Volumetric wear (calculated from the magnitude of linear wear, size of the head and the direction of wear path relative to the face of the cup) 4. Radiostereometric analysis

Answer 374

1. \>90^O flexion 2. \>45^O IR with the hip flexed to 90^O 3. \>15^O ER with the hip extended

Answer 375

4mm IF it's HXLPE

Answer 376

* Consider stemmed tibial baseplate for class II and III obese patients (increased risk of loosening) * WHO classes: I (BMI 30-35), **II (BMI 35-40), III (BMI \> 40)**; class III = morbid obesity \*\*They have worse implant survival and is usually on the tibial side which is likley why they recommend stems

Answer 377

* In obese patients, **reverse Trendelenburg** is the best position from an oxygenation perspective * * **Increased risk of infection**, revision and failure of two-stage revision in obese patients * * **No evidence** of increased blood loss in obese patients *

Answer 378

The evidence says NO

Answer 379

* Level I evidence supports the routine perioperative use of **NSAIDs** to improve pain control and reduce opioid consumption for spine surgery, and the use of selective COX-2 inhibitors for short-term, low-dose nonselective NSAIDs **does not appear to affect spinal fusion rates,** although high-dose nonselective NSAIDs (Ketorolac \>120mg/d) may decrease fusion rates * Level I evidence supports the use of **single-dose intrathecal opioid analgesia** as an adjunct in pain management after spine surgery * Level I evidence supports the addition of **gabapentin/pregabalin** in perioperative pain management for spine surgery * Gabapentin and pregabalin reduce neuronal excitability by inhibiting presynaptic calcium-gated channels (alpha-2-delta subunit)

Answer 380

* * No evidence for acetaminophen use in spine surgery, but generally it’s used since it’s shown in so many other places that it helps diminish perioperative opioid requirements

Answer 381

scoliosis, kyphosis, basilar invagination, lumbar spondylolisthesis

Answer 382

* Type I collagen * It is found in **bone**, **ligaments**, **dentin** and **sclerae** - * Associated features are: * fragility fractures, short stature, joint hypermobility, dentinogenesis imperfecta, blue sclerae, early hearing loss

Answer 383

* Bisphosphonates (Pamidronate) have positive effects on vertebral morphology, bone density and fracture rate **without any major side-effects**, so they’re started in infancy for patients with type III or IV OI (and sometimes more severe forms of type I)

Answer 384

* Bisphosphonates given **before age 6** in **type III** OI slows scoliosis progression * No evidence for this but recommendation is to hold for 4 months post-PSIF to allow for osteoclast function to remodel fusion mass

Answer 385

* Scoliosis features in OI: * Usually present after age 6 * Rapidly-progressive (correlates with lower Z-score and 6 or more biconcave vertebrae) * Single thoracic curves most commonly (almost 100% for type I and 60% for type III) * * Etiology of scoliosis in OI: secondary to vertebral fractures

Answer 386

* Fuse when \>45^O * * Improved outcomes with pedicle screws with **cement augmentation at the proximal and distal screws** (48% curve correction with no loss of correction at follow-up) * * Difficult exposure of thoracic spine due to rib overgrowth and thoracic lordosis - Ponte and rib osteotomies may be required *

Answer 387

1. Headaches (hydrocephalus), 2. Cranial nerve palsy, 3. dysphagia, 4. myelopathy

Answer 388

* Dens tip above McRae’s line, * \>5mm above Chamberlain’s or * \>7mm above McGregor’s lines

Answer 389

1. 40% reduce with intra-operative traction and posterior decompression, 1. Tx: occipitocervical fusion usually to C7, T1 or T2 (+/- instrumentation with sublaminar wiring), Halo vest until union 2. 60% do not reduce with traction 1. Tx: Usually require a staged approach -- transoral decompression, then occiput-C2 fusion 1 week later, Halo vest until union

Answer 390

* Gentle transfer to operating table (fracture risk) * In type III and IV, avoid tourniquet (fracture risk) * Difficult airway (large head, short neck) * Avoid succinylcholine (fasciculations are a fracture risk) * Increased risk of bleeding (controlled hypotension, TEXA)

Answer 391

Within the first 5 years

Answer 392

1. Drop toe sign (no toe extension with plantar stimulation – indicative of absent function of anterior/lateral compartments) 2. Flexion contracture of wrist and fingers (sign of distal arthrogryposis) 3. Spinal dysraphism 4. Noncompliance with foot abduction orthosis (compliance decreases from 91% in the first month to 77% in third month)

Answer 393

* For bilateral deformity, the FAO positions the feet in 60-70^O abduction, 5-10^O dorsiflexion * For unilateral deformity, the uninvolved foot is positioned in 40^O abduction * Night-time brace until age 3-4

Answer 394

* Earliest sign of relapse is less dorsiflexion than the previous examination

Answer 395

* If unable to dorsiflex \>10^O but flexible deformity, start treatment of relapse

Answer 396

1. Repeat Ponsetti casting for 3 sessions, 1 week apart 2. Repeat Achilles tenotomy if \<15O dorsiflexion after casting 3. Full-time FAO use if \<2 ½ yo; 12-14 hours a day if \>2 ½ yo 4. Consider ATTT if \>2 ½ yo (by this stage, enough ossification has occurred in the lateral cuneiform to allow for bone-tendon healing) – still need to regain correction of foot via casting before transfer. But benefit is that ATTT prevents the nee for FAO 5. Transfer the whole AT tendon – do NOT split 6. If ATTT is done, no need to further brace due to everting force of pull of the tibialis anterior

Answer 397

* If deformity is rigid and patient is older, then osteotomies +/- releases are needed: 1. **Forefoot adduction** - lateral cuboid closing wedge, medial cuneiform opening wedge osteotomies 2. **Posteromedial release:** principles are release circumferentially tight capsules (posterior ankle, subtalar, TN) and ligaments (superficial deltoid) and lengthen tight tendons (tib post, FDL, FHL) 3. **Ilizarov** for crazy deformities that need to be staged (multiple osteotomies, releases)

Answer 398

* Estimated LLD at skeletal maturity: * \<2 cm, no need to do anything * 2-5 cm à contralateral epiphysiodesis at the appropriate time * \>5 cm à extendible prosthesis, secondary limb lengthening, rotationplasty

Answer 399

* **\<10 cm of bones loss:** intercalary allograft with either nail or _locked_ plate fixation, bone transport * Non-union with locked vs. non-locked plates (25% vs. 45%) * Often, the initial fixation crosses the physis, but the epiphyseal screws in the locking plate can be removed after bony union * **\>10 cm à vascularized fibula (90% union rate)** * Risks: 1. Peroneal nerve injury 2. Claw toes (FHL) 3. Syndesmotic instability (for very distal harvests, consider doing distal tibiofibular synostosis) 4. ![]() Late ankle valgus deformity (from distal tibial growth arrest due to supraphysiologic loads)

Answer 400

* Even if the physis needs to be resected, it’s still worth preserving the articular surface and reconstructing as per diaphyseal resections (\<10cm vs \>10cm ) * Should do these cuts either with patient-specific guides or intra-operative navigation due to low margin for error

Answer 401

1. **Osteoarticular allograft** (proximal tibia is a common one) * **Pros**: avoids stemmed implant across the knee, restores bone stock * **Cons:** low graft availability, graft remains necrotic, infection, fracture\*, instability \*Consider intra-medullary cement in the allograft to decrease risk of fracture * **72% rate of conversion to allograft-prosthetic composite** 1. **Endoprosthetic reconstruction (gold standard)** * Cemented (immediate weight-bearing) * Uncemented (delayed weight-bearing due to slow rate of bony ingrowth while patient undergoes adjuvant chemo)

Answer 402

* * Syme = 15% increased energy expenditure * AKA = 50% increased energy expenditure

Answer 403

Overgrowth following amputation occurs in up to 40% of kids * **Risk Factors:** * ****\<10 yo, * humeral diaphysis, * tibial diaphysis

Answer 404

* Only structure that needs to be left intact for success of a rotationplasty is Sciatic nerve and its branches (can resect/anastomose vessels if necessary to achieve margins) * Quality of life scores nearly _equivalent_ to the general population * Relational and emotional difficulties in high-school which are overcome by adulthood

Answer 405

* Options include: 1. Halo gravity traction 2. Halo-femoral traction 3. Temporary internal distraction 4. Anterior-posterior combined approaches

Answer 406

* Indications: \>70^O curves that correct \<20% with side-bend * Contraindications: 1. \<18 mo (pin penetration into skull) 2. Short, sharp, rigid curve 3. C-spine instability

Answer 407

* Start with 5lbs and add 2lbs each day until 50% body weight is reached, then maintain maximal traction for 2 weeks

Answer 408

* No difference in complications, surgical time, blood loss and ultimate Cobb angle after surgery between those treated with/without HGT prior to fusion * The HGT group had a lower incidence of required vertebral column resection

Answer 409

1. **Pin-site infection and loosening** * Proper pin placement: four anteriorly (1 cm superior to lateral eye brow) and four posteriorly (1 cm superior and posterior to the pinnae) with 2 cm of space between the halo ring and the head 2. **Nerve palsies (CN VI most commonly and due to traction – loss of lateral gaze)** * Treat by reducing traction until they resolve, then gradually increase again * All resolve 3. **Brachial plexus palsy** 4. **Skull penetration** 5. **SMA syndrome** 6. **Odontoid AVN**

Answer 410

* * Pre-initiation of treatment * At 50% body weight of traction * Immediately pre-operatively

Answer 411

1. **Halo-femoral traction:** * Requires bedrest until surgery (whereas HGT can be used with wheelchairs for mobility) – increased risk of complications * Otherwise, same principles and complications as HGT * May be helpful intraoperatively when there’s **_a significant pelvic obliquity_** 2. **Temporary internal distraction:** * _Consider when HGT is contraindicated_ * Sublaminar or subpedicle hooks proximally, supralaminar hooks or pedicle screws distally at the two most proximal and distal levels that will be used for the definitive fusion and intraoperative distraction * _Timing: 1 week (no benefit after that)_

Answer 412

* Apex is approached from the convex side and the ALL, discs and endplates are excised (250^O) arc of release * Can place bone graft in the disc spaces for fusion * **Complications:** 1. Increased surgical time/blood loss 2. Pneumonia 3. Prolonged intubation 4. Coagulopathy 5. Hypotension requiring vasopressors

Answer 413

* Multiple recent studies show no difference vs. posterior-only approach since pedicle screws are much stronger than previously-used fixation methods and can achieve huge amounts of correction

Answer 414

1. Increased SI/PS distance 2. Increased blood volume 3. Increased WBC and RBC mass 4. Increased minute ventilation 5. Decreased Functional residual lung volume 6. Decrease BP 7. ![]() Decreased GI motility 8. Decreased esoph sphincter competency

Answer 415

* Transient osteoporosis occurs during pregnancy, especially during **third trimester** when much of the calcification of the fetus is happening   * If not taking supplemental calcium, increased risk of fractures.   * osteoporosis resolves on its own a few months post partum  

Answer 416

* Always need to draw **bHCG** if female   * if concern for fetal-maternal hemorrhage need to test blood for **Rh antigen (+ or -** **Other considerations:** * spine board inclined 15degrees to left to reduce IVC compression * Fetal heart rate monitoring

Answer 417

1. high ISS 2. low GCS 3. Low hgb level 4. development of DIC 5. Length of hospital stay

Answer 418

Max cummulative dose to a fetus is 5rad (50 mGy)

Answer 419

1. **Teratogenesis** (fetal malformation resulting in CNS changes; mental ![]() retardation, microcephaly. Linear relationship with radiation dose.) 2. **Carcinogenesis** (Induced malignancy) 3. **Mutagenesis** (alteration of germline genes) \*\*\***Weeks 3-15 are greatest risk for teratogenesis\*\***

Answer 420

\*\*\*Weeks 3-15 are greatest risk for teratogenesis\*\*

Answer 421

**LMWH** has replaced UFH – does not cross the placenta, do not require monitoring, have better schedule, and less risk of osteoporosis **Other facts:** * Pregnant patients have 5X DVT risk due to hypercoagulable state. * Use ICDs

Answer 422

* Higher dose but **“CT should not be withheld if it is indicated clincially”** * Important for uterine rupture, placental separation, fractures Limit slice width and number of cuts as possible

Answer 423

* Shield fetus at all times (from all directions) * Use surgical technique to minimize femoral/pelvic xrays * Limit preop imaging * MRI * Careful preop planning

Answer 424

* Left lateral decubitus (or if on spine precautions, wedge under patient, tilt the bed) * MAP \> 65 for placental flow * For Bogdan: If it's a left calc, non op! They all do miserably anyways. * Plating often has less fluoro than nails/perc plating so keep those options in mind

Answer 425

1. Open pubic symphysis rupture secondary to severe vaginal tearing 2. Diastasis of the symphysis of \>3cm 3. Substantial malreduction of the pelvis 4. Diastasis with pelvic binder in place 5. Displacement of one or both of the SI joints

Answer 426

* Depends on if fractures have healed – 6-8weeks, then can still do vag * If concerned, displaced, c section should be considered.

Answer 427

Mean Retroversion 18-25deg, range 5 ante to 60 retro

Answer 428

The humeral head COR is Offset from the canal medially by 5-11mm, and posteriorly 1-5mm

Answer 429

* Important to reproduce for cuff * Excessive thickness can overtension the cuff, increase contact pressures, and lose ROM. * Insufficient thickness can result in undertensioning and weakness of the cuff, excess translation of the HH, prosthesis instability, glenoid failure. Overstuffing = decreased translation and decreased ROM à leads to increased glenoid stress, accelerated glenoid loosening, RC failure

Answer 430

* Same axial micromotion * Rotational micromotion - Press fit \> cement

Answer 431

1. **Benefits:** * Overcome mismatch of implant fit * Smaller implant so less stress shielding * Decreased intraop # * Don’t rely on in/on-growth if compromised bone 1. **Disadvantages:** 1. Longer OR time 2. Difficult revision

Answer 432

* Advantages: * Lower risk of PeriP # * Preserve PH bone stock

Answer 433

Moves it medially and inferiorly

Answer 434

* **Inc Retroversion** – inc ER, dec IR * **Inc Anteversion** – Dec ER, inc posterior notching * Retroversion of 20-40deg best restores functional ROM

Answer 435

* Skeletally mature (no upper age limit) * Chronic wrist pain (\>6mos) * Refractory to non-surgical management

Answer 436

* **Absolute:** * Active infection * Cognitive impairment * Poor compliance * Acute/chronic conditions that can be managed nonoperatively * **Relative:** * Diffuse arthritis * Unrealistic patient expectations * Severe instability * Posttraumatic incongruity * Patient desire for more definitive procedure (ie arthrodesis)

Answer 437

* Complete/Total * Up to 10 articular nerve branches * Partial denervation * AIN and PIN * AIN alone * PIN alone – deterioration over time

Answer 438

* between IOM and deep head of PQ * usually is ulnar to PIN and radial to anterior interosseous artery **Other facts** * 2-3x size of PIN * Final motor branch (to PQ) branches off approx 2cm prox of the ulnar head * Resect 1cm segment of the AIN distal to the last motor branch

Answer 439

* High negative predictive value if no pain relief with analgesic block, i.e. denervation may not be effective * Pain relief post injection carries a good prognosis

Answer 440

* Sensory disturbance due to retraction * Tinel sign (May persist up to 6 mos)

Answer 441

* Palpate the coracoid, soft spot is superior and lateral to this which is the rotator cuff interval - this is the ideal location for needle insertion. * when you insert the needle and hit bone, gently rotate the arm to see if there is movement. If no movement, then you are on glenoid so move laterally. If you feel movement, then move medially * when you are in the joint, stop rotating and inject