2019 (All) Flashcards
(228 cards)
1
Q
In electrical burns, when is emergent surgical exploration required? (JAN2019)
A
- Compartment syndrome,
- progressive neuro dysfunction,
- vascular compromise,
- systemic unwell due to ongoing myonecrosis
Otherwise, wait 24-48 hrs for tissue demarcation before I&D (cutaneous burns grossly underestimate damage since most goes through muscle - low intrinsic resistance and larger mass)
2
Q
What type of burn has the highest rate of amputation? (JAN19)
A
Electrical
(35-40% amputation)
- Severity of injury (Not time of I&D) biggest factor determining need for amputation
3
Q
Mortality of electric current passing hand to hand VS leg to leg (JAN19)
A
- Hand to hand = 60% mortality
- Leg to Leg = 20% mortality
DURATION of current main factor predicting cardiac-resp arrest
4
Q
What determines the amount of heat produced by electricity in the body? (JAN19)
A
Amount of JOULES (current squared x resistance)
- more damage or heat where current goes from low resistance (forearm) to HIGH resistance (wrist and AC fossa)
5
Q
99% of current resistance in the body comes from what structure? (JAN19)
A
EPIDERMIS (mean 40,000 ohms….sometimes 1,000,000 - calloused palm)
6
Q
Name tissue’s resistance to electrical current from highest to lowest (JAN19)
A
Cortical bone > cancellous bone > fat > tendon > skin > muscle > vessels > nerves
7
Q
True or False?
Success rate of free flaps lower in electrical injuries (JAN19)
A
True
(Ofer et al. 15% flap failure occurred
within 5-21d)
8
Q
Definition of hip microinstability (JAN19)
A
Extraphysiological hip motion that causes pain
9
Q
Force needed to distract hip with labral tear (% difference) (JAN19)
A
60% less force to distract hip with labral tear
10
Q
Intraop findings of hip instability?
A
11
Q
Which capsuloligamentous structure does NOT insert directly on the acetabulum? (JAN19)
- Iliofemoral (ILFL)
- Pubofemoral (PFL)
- Ischiofemoral (ISFL)
A
Pubofemoral (PFL)
12
Q
What is the strongest ligament in the body (also in hip)? (JAN19)
A
ILFL (Iliofemoral ligament)
13
Q
What are causes of hip microinstability? (JAN19)
A
- (1) notable bony abnormalities or developmental dysplasia of the hip,
- (2) connective tissue disorders,
- (3) post- traumatic,
- (4) microtraumatic (ie, usu- ally associated with athletics such as ballet/ golfers, FAI may cause hip microtraumatic instability),
- (5) iatrogenic, and
- (6) idiopathic
14
Q
What three PE tests (together 95% likelihood) can dx hip microinstability? (JAN19)
A
- HEER or Anterior Apprehension (HyperExt + ER)
- Ext-Abd-ER
- Prone ER
15
Q
What are 3 general properties of stem cells? (JAN19)
A
- Capable of dividing and renewing themselves for a long period of time
- Unspecialized
- Capable of producing specialized cell types
16
Q
Leukocyte rich or poor PRP for tx of knee OA? Lateral elbow tendinopathy?
A
- RCT showed that PRP more effective if:
- Leukocyte RICH in lateral elbow tendinopathy
- Leukocyte POOR in knee OA
Trick: Only RICH people play tennis
17
Q
How many medial epicondyle # go to non-union? How many are symptomatic? (JAN19)
A
50-90% non union and 11% out of those become symptomatic
18
Q
Name the 3 components of the UCL of the elbow? (JAN19)
A
- Anterior oblique
- Strongest, 30-90 flex, most commonly injured
- Posterior oblique
- 90-120 flex
- Transverse
19
Q
What is the most common ankle fracture pattern? (JAN19)
A
Isolated lateral malleolus (56-65%)
20
Q
What are the primary and secondary ankle stabilizers? (JAN19)
A
21
Q
What does research say about locking vs non locking plates of the lateral malleolus ankle #? (JAN19)
A
Lyle et al.: No difference in complication rate or revision surgery rate at 2 yrs
between locking and non-locking plates (locking 6X more expensive)
22
Q
Post op shoulder arthroplasty for fracture with pain and pseudoparalysis, what is the cause? (JAN19)
A
- Pain that never improved after index procedure = indolent low-grade infection
- Pain with mechanical symptoms = anterior instability
- Pain with FF and Add = posterior instability
- Pain with pseudoparalysis = RTC dysfunction
23
Q
When is Subacromial decompression an option for post shoulder arthroplasty GT malunion?
A
Arthoscopic SA decompression successful for GT superior
displacement up to 15 mm
24
Q
What is the classification for PP # around shoulder arthroplasty?
A
25
Risk factors for intraop # for revision shoulder arthroplasty? (JAN19)
* Female
* revision Of hemiarthroplasty
* Pt with instability
26
How many days do you hold the cultures for P. Acnes? (JAN19)
21 days (knowing that increased chance of culturing contaminants after 11 days)
27
What % of patients decided to live with shoulder abx spacer permanently after stage 1 revision TSA? (JAN19)
43%
28
How many ACL ruptures will have chondral or meniscal pathology? (FEB19)
* 50% primary ACL ruptures and
* 90% of failed reconstructions = co-existing cartilage and/or meniscal pathology.
29
True or False?
Lateral meniscal tear (in ACL tear) more prone to secondary injury with surgical delay
FALSE
MEDIAL MENISCAL tears most prone to secondary injury due to surgical delay
* Increase rates of chondral/meniscal injury by 1%/ month with surgical delay.
* Lateral meniscus more associated with ACL tear; However, medial meniscal tear rates
increase with time without surgery and lateral meniscal tear remain constant.
30
Higher rates of chondral defects after previous meniscal repair OR partial meniscectomy?
* Higher rates of chondral injury with previous partial meniscectomy (vs repair or no tear)
o Lateral meniscal repairs were more protective of chondral injury then medial.
31
True or false? The sacral articular cartilage is TWICE as thick as iliac cartilage in SIJ (Feb2019)
TRUE
by 60s, marked fibrosis of SIJ with almost no motion
32
What is the Fortin Finger test? (Feb 2019)
Palpation, max point tenderness 2 cm inferomedial to PSIS = SIJ pathology
33
What % of ankle sprain and # have osteochondral lesions of the talus? (Feb2019)
Ankle sprain = 50% OC lesion
ANkle # = 73% OC lesion
34
In PRP (Platelet rich plasma), which type has anabolic cytokines and which type has catabolic cytokines? (Feb 2019)
Leukocyte RICH PRP = Catabolic
Leukocyte POOR PRP = anabolic
TRICK: The Rich spend (catabolic) money, and the poor need to make it
35
What is the incidence of adjacent segment disease after ACDF? (Feb2019)
2.9%/ year after cervical fusion
36
Difference in progression between cervical radic vs myelopathy?
Radiculopathy = MOST cases resolve non op
Myelopathy = progressive disorder, will need sx eventually
37
Name the contraindications for Cervical disc arthroplasty (Feb2019)
* 3 or more levels
* cervical instability
* allergy to implants
* Active local or systemic infx
* osteoporosis or penia
* previous sx at level
* post-traumatic vertebral deformity
* FACET arthropathy
* segmental kyphotic deformity
38
What is the most common complication specific to CDA (cervical disc arthroplasty)? (Feb 2019)
Heterotopic Ossification (HO)
39
What is the leading cause of EARLY pTHA failure?
Periprosthetic #
(Severeal national joint registries show lower risk of revision surgery if use CEMENTED pTHA when pt \>75 yo)
40
What are risk factors for PP# in THA? (Feb2019)
* \> 65 yo
* female
* cementless stem
* metabolic conditions
41
What is the Number needed to treat with cemented THA to prevent one intraop femoral #? (Feb 2019)
NNT = 18 patients
42
What are the practical phases of PMMA cement? (feb2019)
* Mixing
* Waiting
* Working
* Setting
43
What is the working time for medium viscocity cement at 20 degrees celsius? (Feb2019)
4-7 minutes
44
Indication to use CEMENTED stem in THA (age)? (FEb2019)
Over 70 yo
Note less then 55 yo do better (longevity) with cementless.
45
Nerve and blood supply to lat dorsi? (Feb2019)
* Thoracodorsal artery
* Thoracodorsal nerve
* C5-C7
* Branch of posterior cord of brachial plexus
46
Lats are one of highest power generators inwhat phase of throwing? (Feb2019)
* Acceleration phase
47
Deadliest TBI in sports? (Feb2019)
Epidural hematomas = notorious for so-called lucid intervals, mental clarity followed
by extreme neurologic decompensation
§ Subdural hematomas = DEADLIEST in highschool/college football, 79% of brain
injury –related deaths
48
Evaluation of concussion at side line, what is more reliable? (Feb2019)
Full neuro exam and evaluation with assessment tool: Sports Concussion Assessment Tool
version 5 (SCAT5)
§ Most athletes have pre-season baseline used as a reference
o Memory assessment is MORE RELIABLE than standard orientation questions.
49
Most common ocular injury in what sport? (Feb2019)
From 2010-2013 – basketball accounted for most eye injuries. (22.6%), followed by baseball
and air-gun shooting.
o From abrasion to globe ruptures.
50
Dental trauma, what to do with tooth?
If tooth cannot be re-implanted within 5 minutes of avulsion
§ PUT IN Hank’s balanced salt solution (celle and tissue culture solution = best
solution)
§ WHOLE MILK is another option (similar pH and osmolality as the mouth).
§ If water or saliva used – tooth needs to be implanted within 20 minutes.
§ If \> 60 min, small chance of saving tooth since death of periodontal ligament cells.
§ Some advocate to put back in mouth (chocking hazard)
51
Most common cardiac cause of death in \<35 yo? (Feb2019)
Most COMMON causes of cardiac death in athletes \< 35 yo is hypertrophic cardiomyopathy
(26%), commotion cordis “blow to heart” (20%) and anomalous coronary arteries (14%)
o Most COMMON causes of cardiac death in athletes \> 35 yo, is acquired atherosclerotic
coronary artery disease.
52
Asymptomatic RTC tears in 60 yo? 80yo? % (March2019)
DEGENERATIVE ROTATOR CUFF TEARS: REFINING SURGICAL
INDICATIONS BASED ON NATURAL HISTORY DATA (MARCH 1,
2019)
Asymptomatic RTC tears present in
20% of 60yo and 80% of 80yo.
53
Most important risk factor of supraspinatus degeneration? (March2019)
Most important predictor of SUPRA degen = disruption of
anterior supra insertion
(anterior cable)
§ Most important predictor of INFRA degen = larger tear size
Supraspinatus insertion = 12.6 mm
o Infraspinatus insertion = 32.7 mm
54
RTC healing in relation to location of musculotendinous junction? (March2019)
Tashjian et al., tendon healing was 92% when musculutendinous junction was LATERAL to
glenoid compared to 56% if medial to glenoid.
55
Risk of tear enlargement in RTC tear and management?
56
Advantages of UKA? (March 2019)
Adv of UKA: less-invasive surgical
exposure, preservation of native bone
stock, retention of cruciate ligs, lower
perioperative morbidity, enhanced
postop recovery, improved pt
satisfaction.
o Biomechanics more closely
resembles native knee function,
improved dynamic
proprioception and postural
control.
o Cost effective
57
Difference in outcome of Mobile bearing vs fixed bearing UKA? (March 2019)
In vivo meta-analysis = lower revision rates ATTRIBUTABLE to wear in MB at 5 and 10 yrs f/u
(12% revision in FB vs zero in MB), higher rates of aseptic loosening in MB, higher rates of OA
progression in FB, dislocation accounted for 11% of failures in MB…BUT no difference in
clinical outcomes, PROM, overall revision rates.
58
What is the most common cause of UKA revision?
Australian registry (46,094 UKAs)
§ 14.6% UKA revision at 10 years and 21% at 15 years
§ Aseptic loosening MOST COMMON indication for revision (43.5%)
§ Progression of OA (29%) and unexplained pain (9.5%)
59
Most prevalent risk factor in necrotizing infections? (March2019)
Epidemiology and Risk Factors:
o Diabetes mellitus is the MOST prevalent
risk factor and present in 71% of
infections.
o IVDU another predisposing factor in
43% of patients.
o Others: smoking, trauma, prior MRSA,
chronic hepatitis C, HIV/AIDS, chronic
illness, increasing age, NSAID use,
exposure to persons infected with Group A Strep.
60
What does MRS produce that results in muscle necrosis? (March2019)
MRSA = produce PANTON-VALENTINE LEUKOCIDIN
which causes muscle necrosis
61
Abx for nec fasc? (March2019)
Antibiotics:
o Broad-spectrum empiric abx should be administered at presentation (pip tazo)
o + Clindamycin or carbapenem
o + Vanco or linezolid (MRSA coverage)
o Antiribosomal agents recommended: (ie CLINDAMYCIN)
§ Limit toxin production
§ Enhance effectiveness of cell wall antimicrobial agents
62
Most important modifiable factor for outcome in nec fasc? (March 2019)
Surgical delay is the single most important modifiable factor contributing to mortality. (don’t
transfer, operate)
63
Abx for aquatic open wounds/injuries? (march 2019)
Fresh water:
§ Aeromonas hydrophila (can
cause necrotizing infections)
§ Ceftazidime 2g IV q8h (3
rd
gen cephalosporin) or
fluoroquinolone
o Salt water:
§ Vibrio violaceum (Gulf of mexico)
• Can be very aggressive, cause necrotizing infections
§ Chromobacterium violaceum (Western Pacific)
Shewanella species (Mediterranean)
§ Ceftazidime + Doxycycline 100 mg IV/PO q12h (to cover Vibrio)
o Broad spectrum abx empirically
64
Tx for envenomization by aquatic animal? (March 2019)
Puncture wounds = raise suspicion for envenomization
§ Hot water immersion with 45 degrees Celsius water for all envenomization wounds x 30-90
minutes or until pain subside.
§ Venom from stingrays, scorpionfish, stonefish, lionfisk, sea urchins, catfisk, and weever fish
are all HEAT LABILE.
65
Classification of scapular notching in rTSA? (March2019)
66
Alcoholism dx questionnaire? Which is more sensitive? (March 2019)
CAGE questionnaire: cutting down,
anooyance by criticism, guilty feeling,
eye-openers
o AUDIT (Alcohol Use Disorders
Identification Test): superior
sensitivity and specificity and PPV
compared to CAGE. \*\* especially in
elderly pt.
67
```
Serologic alteration with chronic
alcohol use (\> 8/day)? (March2019)
```
Serologic alteration with chronic
alcohol use (\> 8/day)
§ Elevated carbohydrate-deficient
transferrin
§ Macrocytosis
§ Elevated GGT
§ Elevated liver enzymes
68
Symptoms of alcohol withdrawal? What is PAWS?
69
Risk of osteolysis with HXLPE? (March2019)
Highly-cross-linked polyethylene (HXLPE)
reduced incidence of osteolysis by 92%.
§ Conventional poly (0.22 mm/ yr wear
rate) vs 0.04 mm/yr in HXLPE.
§ Incidence of clinically important
osteolysis (\>1.5 cm
2
) was zero in
HXLPE.
70
What has the greatest effect on biologic response to wear debris? (March 2019)
SIZE HAS GREATEST EFFECT on biologic response
Particle \< 7 micrometers ingested by macrophages and lead to release of cytokines included tumor
necrosis factor ALPHA and interleukin 1 and 6.
71
Most notable risk factor involved in osteolysis? (March 2019)
Most notable transcription factor implicated in osteolyssis activation is nuclear factor kbeta.
o Activation of macrophage/ osteoblasts = release of receptor activator of nuclear factor kB ligand =
binds to osteoclast receptor = stimulating bone resorption and granuloma formation.
72
Classification of THA osteolysis? (March 2019)
Saleh and Gross Classification:
§ Type 1: no notable loss of bone stock
§ Type 2: Contained defect
§ Type 3: Uncontained defect with \<50% of acetabulum involved (one column involved)
§ Type 4: Uncontained defect with ?50% loss of both columns
§ Type 5: pelvic discontinuity
73
Limb bud orientation influences (3)? (March 2019)
Limb bud orientation under 3 influences:
1. Apical ectodermal ridge
• Prox to distal development
2. Zone of polarizing activity (ZPA)
• Produces sonic hedgehog (Shh) protein -
directs anterior vs posterior orientation (ie
radioulnar or tibfib)
3. Wnt signaling pathway
• Secreted by dorsal limb bud –
dorsoventral development
74
Most common classification for congenital tibial deficiency? Most common type?
* Jones classification
* Type 1A (complete absence with hypoplastic med fem condyle) MOST COMMON (46%)
Type 2 (distal absence) 2nd most common 21%
75
Gene involved in congenital tibial deficiency? (March2019)
NO specific gene
• Suggested autosomal-dominant
inheritance with incomplete
penetrance
• Possible 5kb deletion within DNA of
Shh repressor Gli3 protein
§ Shh pathway in syndromic forms
76
Associated conditions with congenital tibial deficiency? (March2019)
Associated Pathology:
o Congenital hip dislocation – MOST COMMON
o Coxa valga – 2nd
o PFFD – 3
rd
o Vertebral malformation
77
Concentration of lead for plumbism? (April 2019)
Plumbism (lead poisoning)
o Neurotoxicity in adults \>18 ugdL, in children \>5 ugdL
78
Most common nerve injury in UE GSW? (April2019)
Peripheral Nerve Injury
• Median nerve most commonly injury (32.3%)
• Spontaneous nerve recovery of 69%
o 4-8 mths for injuries above elbow
o 3-7 mths for injuries below elbow
• Author recommends: surgical exploration when associated with a vascular injury or another
indication for surgery
o Otherwise observe nerve for signs of return of function for at least 3 months
o Baseline EMG/NCS at 6 weeks, repeat at 3-4 mths
o Irreversible muscle reinnervation by 12-18 mths – need to consider
79
Most common benign tumor of the shoulder? (april2019)
Osteochondroma
80
Charcot shoulder most common caused by... (April2019)
```
Neuropathic Shoulder (Charcot Arthropathy)
• Most commonly due to cervical synringomyelia
```
81
• Most common primary malignancy of bone? (April2019)
Multiple Myeloma
• Most common primary malignancy of bone (2x osteosarcoma), age \>55 yrs
82
Most common coracoid primary malignancy? (April2019)
Chondrosarcoma
83
4 clinical finding that raises suspicion for ST sarcoma? (April2019)
4 key clinical findings – raise suspicion for soft-tissue sarcoma
o Firm, deep to fascia, \>5 cm, non-tender
84
When should you consider a glenoid augmentation in rTSA? (March 2019)
Decreased scapular neck length (SNL) leads to increased
rates of notching.
§ SNL measured from lateral column to articular
glenoid surface on TRUE AP (Grashey AP) approx..
10 mm.
§ Larger in Caucasian males
o \*\*\*When performing rTSA on SNL \< 9mm should
have glenoid augmentation (bone graft or augment)
85
Describe ways to decrease scapular notching (March 2019)
Glenosphere placement:
§ Glenosphere extension (hang) below the inferior glenoid = greatest impingement-free
adduction angle.
§ No notching bserved with an overhang of \> 3.5 mm regardless of concentric vs eccentric
design.
o Glenosphere Design:
§ Lateralized believed to more closely replicate a physiologic centre of rotation and decrease
notching
§ Augment or autograft (hemoral head) or allograf (femoral neck most closely resembles shape
of glenoid pear-shape)
§ Larger diameter glenosphere = more stable, improve impingement free ROM and decreases
notching. (ie 42 mm better then 36 mm)
Humeral Implant design:
§ Decrease neck shaft angle (more varus) = more offset laterally.
86
Minimum f/u to determine presence of notching (scapula)? (April2019)
24 months
87
Incidence of Fat emboli? (April2019)
FE syndrome itself lower incidence – largest
clinical study shoes 0.9% incidence
o More common in LE fracture, closed
fracture – femur most common
o Most common in males, and in ages
10-40 yrs
• Paediatrics – much lower incidence of FES
o However Duchenne muscular
dystrophy – high rate of FES 1-20%
88
Fat emboli triad (April 2019)
FE syndrome triad = respiratory distress, neurologic symptoms, petechial rash
89
Diagnostic criteria for fat emboli (Gurd)? (April 2019)
90
Complications post THA for postraumatic OA
Complication rate compared to THA for primary OA?
Overall higher rate of complications compared to THA for primary OA
• Higher risk of infection, blood loss, need for transfusion
• Higher rate of dislocation à deficient GT/abductor mechanism, implant positioning
o Consider using larger diameter femoral head, dual mobility
• HO prophylaxis indicated if prior HO present (indomethacin, radiation therapy)
• Sciatic nerve injury more common after post-traumatic conversion THA
91
Indications for bracing in Scheuerman kyphosis (April 2019)
Bracing – for small, flexible curves
(\<55-80 deg, 40% passive correction)
o Brace wear recommended for 16-23 hours/day
o Reports of up to 50% reduction in kyphosis – however some loss of
correction after termination of brace treatment
92
Define sagittal deformity angular ratio in scheuerman kyphosis (May 2019)
Sagittal deformity angular ratio (DAR)
o Maximum kyphotic angle divided by the # of levels involved
o Can be used to differentiate sharp angular SK from smooth multilevel SK
o Correlates with risk of intra-op spinal cord monitoring alerts
§ 75% incidence of motor-evoked potential alert for DAR \> 22 deg
93
Level selection for fusion in Scheuerman kyphosis (May 2019)
Level Selection and Junctional Kyphosis
o Up to 40% rate of junctional loss of correction between fused & unfused segments, proximal
JK \> distal JK (5.1%)
o Defined as Cobb \> 10 deg difference between fused & unfused segments
o PJK correlated with magnitude of pelvic incidence
o Recommend including proximal end vertebrae in the construct (+/- 1 above)
§ Consider hooks/wires at top of construct to gradually transition force
o Lowest instrumented vertebra – below the 1st lordotic disk (\>5 deg ant opening)
94
Normal cervical lordosis? (2019)
Lordosis/Kyphosis
o 64% of axial load goes through posterior C-spine (facet joints)
o Cervical Cobb angle C2-C7, newer measurement with Ishihara index
§ Normal cervical lordosis 10-20 deg (avg 14.4 deg)
o Sagittal vertical axis (C7 plumb line) – compare C2 and C7 SVA
§ Normal range 16.8 +/- 11.2 mm
o High T1 slope requires greater cervical lordosis – can lead to kyphosis
o Thoracic inlet alignment – correlates with T1 slope and cervical lordosis
o Chin brow vertebral axis (CBVA) – used to assess horizontal gaze
95
Formula for a good screening test, June 2019
good screening test = high sensitivity, low LR–
96
Most common cause of early revision for rTSA? (June 2019)
Instability
o Most common cause of early
revision after RTSA
o Inadequate soft tissue tensioning
97
% axial strength difference between parallel cannulated screws in femoral neck vs Biplane double supported screw? (June 2019)
Parallel cannulated screws – 46% associated
with poor outcomes
• Biplane double-supported screw fixation
(BDSF) – 44% higher axial fixation strength
than parallel screw fixation + 96.6% union
rate
• BDSF = 3 medially diverging cannulated
screws in steeper angles to diaphyseal axis
98
Microbiology of C. (Cutibacterium) acnes.
Micro bio: anerobic, nonspore producing gram positive rod
Superficial skin, hair follicles, sebaceous glands, concentrated
in back and neck. M\> F
99
What is the stork maneuver and what does it diagnose? (July2019)
* Dx of spondylolysis/ spondylolisthesis
* Paper about injuries in gymnasts
100
Where does the deltoid ligament typical rupture
Off the medial malleolus side
101
1mm of lateral deviation of the talus = what decrease in contact
42% reduction in tibiotalar contact
102
What are the two things you look for on plain XRs for deltoid rupture?
\>4mm of medial clear space widening \>1mm more than superior tibiotalar space
103
If reduced on WB views of ankle do you still need a stress?
Yes - doesn't maximally stress syndesmosis
104
Does MRI help with deltoid ruptures
No - not useful to make surgical decision
105
When should you repair deltoid?
Controversial Right now algorithm: Fix fibular +/- syndesmosis PRN If persistent widening on ER stress and talar tilt on EVERSION stress consider it
106
What are you looking for on Eversion stress test of ankle
Valgus tilt of talus greater than 7 degrees
107
What's the literature on deltoid repair vs. no?
Literature to support either side - One RTC shows no difference but lacked power, short FU and lacked ability to test medial instability - Perhaps better for preventing medial widening and better pain IF the syndemosis was also fixed
108
Name five diagnostic tests for ACJ pathology
1. TTP over ACJ 2. O'Brien test 3. Paxino test 4. Cross-body adduction 5. AC resisted extension ACJ TTP – best screening test to r/o ACJ pathology O’Brien/cross-body adduction/AC resisted extension useful in confirming ACJ pathology if positive
109
Describe the Paxino test
Pt sitting with arm resting @ side Create shearing force over ACJ by applying thumb pressure over PL acromial corner and counterpressure with index and middfle fingers over distal clavicle Positive if pain occurs @ ACJ
110
Describe the O'Brien test as it applies to ACJ pathology
FF of arm to 90 deg with elbow extended and arm adducted 10 deg Examiner applies downward force and patient resists first with forearm IR/pronated (thumb points down) and then with arm ER/supinated ACJ pain exacerbated by pronated position but alleviated with supinated position
111
Name five diagnostic tests for LHBT pathology
1. Palpation of LHBT 2. Speed's test 3. Yergason test 4. Upper Cut test TTP at biceps – not reliable test for detecting or r/o biceps pathology Speed’s/Yergason/Upper Cut tests – good confirmatory test Upper cut test – highest clinical utility as screening and confirmatory test Combining Speed and upper cut test significantly improves predictability of detecting biceps pathology
112
Describe the Upper Cut test
Pt makes fist while flexing elbow to 90 deg, and supinating forearm Examines places hand over first and resists pt bringing their hand up and toward examiner’s chin (boxing uppercut motion) Pain/painful pop @ anterior shoulder indicates positive test
113
Name nine diagnostic tests for SLAP tears
1. O'Brien tetst 2. Crank test 3. Anterior slide test 4. Biceps Load I test 5. Biceps Load II test 6. Modified Dynamic Labral Shear 7. Labral tension 8. Resisted Supination External Rotation 9. Forced Shoulder Abduction and Elbow Flexion • Only test to show consistency as screening test was modified dynamic labral shear test • Combining anterior slide and crank tests improves ability to rule in SLAP tear
114
Describe the O'Brian test as it applies to SLAP tears
FF arm 90 deg with elbow extended and arm adducted 10 deg Examiner applies downward force and patient resists first with forearm IR/pronated (thumb points down) and then with forearm ER/supinated GHJ pain with pronated position that decreases with supinated position is positive test
115
Describe the Crank test for SLAP tears
Pt seated and examiner positions arm @ 160 deg FF in scapular plane GHJ axially loaded with passive IR/ER of humerus Positive if pain with/out a click develops
116
Describe the Anterior Slide test for SLAP tears
Pt places hands on hips with thumbs pointed posteriorly Examiner places one hand across top of shoulder (index finger extends over anterior acromion) Examiner’s other hand placed behind elbow, and applies antero-superior force to elbow while pt resists this force Pain and/or click @ anterior shoulder is positive test
117
Describe the Biceps Load I test
Designed for patients with anterior instability and a SLAP tear Pt supine, and examiner grasps pt’s wrist and elbow, and abducts arm to 90 deg Examiner ER arm until apprehension felt and resists pt’s attempted elbow flexion Positive test if apprehension does not change or if increased pain with resisted elbow flexion
118
Describe the Biceps Load II test
Designed to assess potential isolated SLAP pathology Patient supine, and examiner places shoulder in 120 deg abduction, elbow in 90 deg flexion, forearm in supination, and then ER shoulder Pt flexes elbow against resistance Positive if pain with resisted elbow flexion
119
Describe the Modified Dynamic Labral Shear test for SLAP tears
Examiner flexes elbow to 90 deg and abducts arm to 120 deg while maximally ER arm Examiner lowers arm to 60 deg abduction Positive test with pain/painful click along posterior joint line bw 120-90 deg abduction
120
Name the Beighton criteria for joint hyper mobility
1. Passive DF for fifth finger \> 90 deg 2. Passive flexion of thumb to forearm 3. Hyperflexion of elbows \> 10 deg 4. Hyperflexion of knees \> 10 deg 5. Forward flexion of trunk with knees fully extended and palms resting on floor Score greater than or equal to 5 indicates joint hyper mobility
121
Name four tests for anterior instability of the GHJ
1. Anterior apprehension 2. Jobe relocation and surprise 3. Anterior drawer test 4. Anterior load and shift
122
Name four tests for posterior instability of GHJ
1. Jerk test 2. Kim test 3. Posterior drawer 4. Posterior load and shift
123
Describe the Jerk test for posterior instability of GHJ
Pt sitting, examiner holds scapula with one hand while pt’s arm abducted to 90 deg and IR to 90 deg Pts arm is axially loaded at elbow while applying horizontal adduction force Positive if pain with/out clunk
124
Describe the Kim test for posterior instability of GHJ
Pt sitting with arm in 90 deg abduction, examiner holds elbow and applies axial force/45 deg of upward diagonal elevation while pushing postero-inferiorly on upper arm Positive if pain with/out clunk
125
Name two tests for inferior instability of GHJ
1. Sulcus sign 2. Gagey test
126
Describe the Gagey test
Examiner’s forearm pushing down on shoulder girdle, examiner lifts pt’s relaxed upper limb into abduction with other hand Abduction \> 105 deg or apprehension limiting passive abduction positive for interior laxity
127
Sulcus sign grading scheme
Sulcus Grading I -- Acromiohumeral interval \< 1cm II -- Acromiohumeral interval 1-2 cm III -- Acromiohumeral interval \> 2cm
128
Hawkin's Scale for GHJ translation
0 -- Little or no translation (\<25% of humeral head diameter) 1 -- Humeral head moves onto glenoid rim 2 -- Humeral head can be dislocated by spontaneously reduces 3 -- Humeral head does not relocate when pressure removed
129
Pathology of internal impingement in overhead throwing athletes
o Late cocking phase of throwing can translate GT/articular RC surface to impinge against posterosuperior glenoid Partial-/full-thickness RC tears, posterosuperior labral tears oSecondary to subtle anterior shoulder instability and posterior capsule/posterior band IGHL contracture Increased ER at expense of decreased IR
130
Name six diagnostic tests for the cervical spine
1. Spurling test 2. Axial Manual Traction Test 3. Shoulder Abduction Test 4. Valsalva Test 5. Upper Limb Tension Test Upper limb tension test • Only useful screening test Spurlilng/axial manual traction/shoulder abduction/Valsalva tests • Useful in confirming cervical spine pathology
131
Describe the Upper Limb Tension Test
Pt supine Examiner sequentially depresses scapula, abducts shoulder, supinates forearm, extends wrist and fingers, ER shoulder, extend elbow, and laterally flex neck away and then over to affected side Positive if • Radicular sxs reproduced • Side-to-side difference \>10 deg observed in elbow extension upon test completion • Sxs increased with CL lateral flexion of neck or decreased with ipsilateral lateral flexion
132
Name four diagnostic tests for scapular dyskinesia
1. Kibler Assessment 2. Scrapula Retraction Test 3. Lateral Scapular Slide Test 4. Scapular Assistance Test Interpret these tests with caution secondary to • Challenges with assessing scapulothoracic motion beneath overlying muscles and SC tissues, • Three rotational movements and two translations of scapula • Their weak association with clinically relevant shoulder pathology
133
Describe the Kibler Assessment Scapular Dyskinesis
Visual assessment by inspecting bilateral scapular motion during shoulder elevation and lowering in scapular and sagittal planes for any asymmetry in position or motion I -- Prominent inferior medial scapular border II -- Prominent entire medial scapular border III -- Excessive superior migration of superior medial scapular border IV -- Normal and symmetric scapular motion (posterior tilting, ER, upward motion of scapula during arm elevation)
134
Name three tests for subacromial impingement
1. Neer test 2. Neer sign 3. Hawkin's test • When evaluating for subacromial bursitis or RC tears, all three tests are useful screening tests for r/o these pathologies if negative • If positive, possibility of other shoulder pathologies still exists • Neer test only test to reliably predict subacromial bursitis alone or partial thickness rotator cuff tear (RCT)
135
Describe the Neer sign and test
Neer Sign Performed by preventing scapular motion with one hand while other hand of examiner passively forward flexes arm Positive if pain at anterior edge of acromion Neer Test Diagnosis confirmed when pain relieved with injection of 1% Xylocaine beneath anterior acromion
136
Name four tests for supraspinatus assessment
1. Jobe test 2. Full can test 3. Drop arm test 4. Painful arc • Jobe test useful as both screening and confirmatory test but only for massive/large RCT • Full can test has similar utility when finding is weakness • Drop-arm test is specific for detecting partial- and full-thickness RCT • Painful arc test is a valuable screening test
137
Name three tests for infraspinatus/teres minor assessment
1. Resisted ER 2. Hornblower test 3. ER Lag sign (dropping sign) Infraspinatus • Weakness in ER is good screening test for infraspinatus tears • ER lag sign is good confirmatory test for full-thickness infraspinatus tears Teres Minor • Pattie/Hornblower useful as both screening and confirmatory test for teres minor tear • ER lag sign \> 40 deg highly specific and sensitive for teres minor tear
138
Name six tests for subscapularis assessment
1. Belly press 2. Belly-off 3. Lift-off 4. Bear hug 5. IR lag sign 6. IR resistance at abduction and ER • Belly-off test is excellent screening and confirmatory test • Belly press, liftoff, and bear hug tests all useful confirmatory tests • Bear hug more sensitive than belly press for partial SSC tears • Lift-off test difficult to complete in setting of pain or restricted ROM
139
When does rotator cuff rehears normally occur post op
Retears occur early. ( often by 3 months, rates drop off after 6 mo ) Tendon healing is prolonged ( 6 mo to a year) therefore repairs need to be strong enough to last this long.
140
Where do rotator cuff tenders typically retear?
weak link = suture tendon interface caused by poor tissue quality of the tendon
141
Which of the following factors of mechanical augmentation creates the biggest increase in load to failure in rotator cuff tendon repair? A) stitch configuration B) size of instrument throwing suture C) shape of instrument throwing suture D ) size of tissue bite
A) stitch configuration Ponce et al – compared stitch configuration, size and shape of instrument, size of tissue bite and stich configuration had the biggest increase in load to failure But still have weakness in tendon suture interface – therefore strategies to improve RCR integrity with mechanical or biological means
142
Do dermal autografts (Acellular Dermal Matrices) improve outcomes after RCR?
Consensus RCR augmented with ADM appear to have higher rate of structural integrity on post op imaging
143
Effect of Marrow Venting Procedures (Microfracture) on RCR ?
Consensus Beneficial in improving healing rates on large and massive tears but may not make a different for small-medium size tears
144
Effect of PRP on RCR?
No true consensus Mixed results – some show benefit some don’t ? cause for inconsistency as not all PRP is the same. Large table in paper with no overt consensus.
145
Effect of Bone Marrow Aspirate on RCR?
2 studies available – poor scientific rigor ( no control ) There was some positive effects in the studies but consensus was not strong enough evidence for a conclusion supporting.
146
Effect of Adipose – Derived Stem Cells on RCR ?
Only one study – authors found no real difference clinically however struc integ higher on post op MRI Need more evidence before any recommendations can be made
147
Patient factor indications to augment rotator cuff repair (predictors of failure to heal)
age \> 65 multiple tendon involvement \> 1 large tear \> 2 cm retraction \> 2 cm high grade fatty infiltration (Goutallier \> 2)
148
What is the primary restraint to talus ER and lateral displacement
Deltoid ligament
149
Who is at highest risk for false positive for measuring medial clear space evaluation on standard XR
Tall males (on ave 1mm more)
150
What is cutoff for medial clear space (MCS)
\>5mm
151
Three ways to judge instability in lateral malleolus fractures
Manual stress XR Gravity stress XR Weight bearing XR
152
What did Sanders et al. study show on unstable weber B fractures?
81 patients with unstable weber B, randomized to op vs non op Good: No functional differences @ 1 years Bad: 20% nonop group showed signs of mal alignment at 1 year and had delayed union
153
1 advantage and 1 disadvantage of PL plating of fibula for weber B fractures
Pro: biomechanically most stable Con: Peroneal irritation - usually from distal oblique screw in plate - Suggest placing plate 1cm from tip of mal +/- using 2.0 or 2.4mm screw below plate
154
IM fixation for Weber B indications
Poor soft tissue High risk for wound complications
155
Advantage of IM fixation of Weber B fixation
- Soft tissue friendly - Greater torque resistance than 1/3 tubular + lag
156
What does TEG, thromboelastography measure? How fast is it? (July2019)
* TEG has been used to assess traumatic coagulopathy. The coagulation parameters measured by the TEG are reaction time (R- time), time to reach a certain clot strength (K-value), speed of fibrin build up (a-angle), maximum clot amplitude, and percentage decrease of clot in 30 minutes (LY30
* Only takes 15-20 min (faster then conventional coag test)
157
is the R time (Thromboelastography) prolonged or short in a hyPOcoagulable state? (July2019)
* Prolonged
* Kane et al: R time \> 6 associated with 52% mortality.
158
When can patients safely drive after upper extremity sugery? (July 2019)
* No consensus
* Jones et al: post op distal radius ORIF – conclusion that pts were safe to start driving within 2-3 weeks of
surgery and continued pain is the impediment to returning to drive.
* Short arm better then lon arm cast
* Cannot drive if using narcotics for pain
159
What are modic changes? (july2019)
* Modic Changes: represent vertebral bone
marrow lesions that have high specificity
for disk degeneration and discogenic LBP
a. type one: low signal on T1 weighted
MRI and high on T2 – fissuring and
disruption of the end plate
b. Type two: high signal T1 and T2 - fat
has replaced hematopoietic elements of
end plate
c. Type three: low T1 and T2 – bony
sclerosis
Studies show very high statistically sig correlation with positive cultures and MC.
Not ALL studies have been able to correlate low grade infection with MC.
160
Superficial vs deep deltoid? What movement do they restrict? (July2019)
* Superficial deltoid: hindfoot eversion
- Deep deltoid: Talar ER
\*to get valgus tilting both need to be ruptured
161
Anatomic nerve variations in the forearm and hand (ie martin-gruber,etc) (August 2019)
Anatomic variations
o Martin-Gruber – nerve fibres from median nerve crossover in forearm and travel
with ulnar nerve to hand
o Marinacci – ulnar nerve fibres crossover in the forearm and travel with median nerve
to hand
o Riche-Cannieu – thenar motor branch crosses over to the ulnar nerve
o Berrettini – ulnar nerve sensory fibres provide sensation to radial aspect of ring
finger and ulnar aspect of long finger
162
Position of DIP, PIP, MCP for fusion? (August 2019)
* DIP:
o Index and long in extension
o Ring and small in 10-20 flexion
- PIP
o Index: 30 degrees
o Long: 35 degrees
o Ring: 40 degrees
o Small: 45 degrees
- MCP
o Index: 25 degrees
o Long: 30 degrees
o Ring: 35 degrees
o Small: 40 degrees
163
What is the Bunnell test? (August 2019)
Intrinsic tightness tested with Bunnell intrinsic tightness test
• Positive
o PIP joint flexion diminished with MCP joint held in extension
compared to MCP joint held in flexion
o Tightness of PIP joint flexion with MCP joint ulnar deviation
compared with radial deviation signifies more notable
contribution of lumbricals over interossei because lumbricals
lie more radially
164
How effective is non-operative therapy in stiff hand (finger contractures)? (August 2019)
Nonsurgical treatment effective in most patients
o 87% PIP and MCP joint contractures managed successfully with hand therapy and
dynamic splinting
165
Name a foot and ankle injury common to ballet dancers (August 2019)
* Os trigonum syndrome
* FHL tendinitis
* Flexor (most common FHL) injury
166
What is the % return to competitive dance in ballet dancers postop os trigonum/FHL debridement for posterior ankle impingement? (August2019)
Average time return to dance 8 weeks, 94% returned to presurgical level of dance
167
What muscle belly is most distal between Peroneus Brevis and Longus? (August 2019)
Peroneus longus (PL) becomes tendinous 3-4 cm proximal to distal fibular tib, peroneus
brevis (PB) belly extends 0.6-2 cm more distally
o Sometimes muscle belly transitions beyond fibular tip (low-lying muscle belly) - ?
involvement in pathology?
- PB tendon anteromedial to PL tendon at fibular tip, common fibro-osseous tunnel
formed by superior peroneal retinaculum, posterolateral fibrocartilaginous ridge,
investing deep posterior compartment fascia, retromalleolar groove within fibula
o Groove concave shaped in 82% of cadavers, 11% flat, 7% convex
- Superior peroneal retinaculum most important factor for preventing tendons from
subluxating/dislocating
168
What is this and in which tendon is it located?
Os peroneum located in the peroneus LONGUS
169
3 types of pathology related to peroneal tendons
| (AUgust 2019)
3 types of pathology related to peroneal tendons
o Tendinopathy (tendinitis, tendinosis, stenosis)
o Tears and ruptures
o In situ subluxation or over dislocation
170
What peroneal tendon is more prone to tear? (August 2019)
Peroneus BREVIS
171
Which peroneal tendon is most likely to dislocate? (August 2019)
peroneal LONGUS
172
Different types of peroneal dislocation. Which one is more common? (August 2019)
Different types of dislocation
o SPR subperiosteally elevated from fibula while ridge remain in place.
§ Most common (51%)
§ Weak connection of fibrocartilaginous ridge to anterior part of the
periosteum of the fibula
o Elevation of SPR with avulsion of fibrocartilaginous ridge (33%)
o SPR ripped off fibular together with cortical fragment (13%)
o SPR ruptures in posterior part (rare)
173
Postoperative outcomes after peroneal dislocation surgery. August 2019
Repair of SPR/groove deepening
§ Good/excellent outcomes and favourable rates of return to sports (83-
100%)
§ Better return to sports if both procedures done rather than just SPR repair
174
Sign on lateral radiograph indicating peroneus longus tear. August 2019
Separation of OP fragment =/\> 6 mm or OP displacement =/\>10 mm relative to
calcaneocuboid joint is associated with full thickness PL tears
175
Strong Evidence of Factors Associated with Increased Risk of SSI - strong
o Anemia
o Duration of hospital stay
o Immunosuppressive medications
o History of alcohol abuse
o Obesity
o Depression
o History of CHF
o Dementia
o HIV/AIDS
176
Outcome of just increasing poly thickness in TKA flexion instability? (August 2019)
Upsize Polyethylene
- Overall outcomes of isolated poly exchange in revision TKA are moderate at best with a 50%
failure rate at 3 years
- Discouraged for isolated flexion instability
177
Management of recurrent hemarthrosis postop TKA? (September 2019)
Treatment-Proposed Algorithm
- Within 6 months from TKA
o Higher likelihood of iatrogenic vascular
injury
o Proceed to conventional angiography with
selective embolization
- Greater than 6 months (especially \>20 months)
o Inflammatory markers
§ If elevated, aspirate
§ It not, conservative measures
• If fail, then aspirate
o If aspiration negative, then it’s recurrent
hemarthrosis
§ Go through radiographs/physical
exam
• MRA/MR with selective
embolization if there is a
dominant bleeder
• If more diffuse blush on MR, then synovectomy (also if embolization
fails)
• If impingement, extensive osteolysis, aseptic loosening, or
malpositioning – revise
178
What is the most common MOI for an AC separation? (Sept2019)
Direct or indirect trauma
o Most common: fall directly onto superolateral aspect of shoulder with arm in
adducted position
o Indirect: fall on outstretched hand
179
Px in Ac separation? Test with highest sensitivity?
Tenderness to palpation directly over AC joint is most common examination finding
- Cross-arm adduction test – highest sensitivity
- Active compression test – highest specificity
180
What are stingers? (Hint: Neuro injury)
Brachial plexus injury in athletes
Most common upper extremity neuro injury among athletes
- Symptoms
o Immediate, sharp burning pain radiating down arm
o Associated weakness/numbness/paresthesias
o Pain resolves in seconds to minutes
o Strength normalizes within 24 hours
o Variable strength may last up to 6 weeks in more severe cases
Epidemiology:
- 49-65% in American football players over career – up to 87% recurrence rate
181
Acute Stingers classification (September 2019)
Acute stinger classification: Seddon and Sunderland
o Grade 1: neurapraxia; transient motor or sensory loss
o Grade 2: axonotmesis; axons and myelin sheath damaged, but Schwann cells,
endoneurium, perineurium, and epineurium remain intact; more significant motor
deficits and possible sensory loss – symptoms last at least 2 weeks post-injury
o Grade 3: neurotmesis; complete transection of nerve; motor or sensory deficits that
last 1 year and are permanent
182
Management of brachial plexus injury (stinger) in football? (Sept2019)
Nonsurgical Management
- Initial
o Rest
o Pain control
o Physio (C-spine and upper extremity)
- Grade 1
o Return to play once symptoms resolve
- Grade 2
o Withdrawal from play, serial exam, workup with imaging and EMG
- Grade 3
o Withdrawal from play, frequent serial exams, advanced diagnostic workup, possible
surgical consultation for nerve exploration/transfer/reconstruction
- Preganglionic – central nervous system – no potential for regeneration
- Postganglionic – peripheral nervous system – potential for regeneration
183
Most common complication of stinger? (Sept 2019)
Most common complication: recurrence – 37.5%
o Leads to chronic symptoms
- Permanent injury uncommon
o Surgery should be within 4 months of injury for better outcomes
184
How to culture fungi in PJI? (Sept 2019)
Culture
- Up to 46% culture negative because organism difficult to isolate
- Fungal cultures held minimum 5-14 days – ideally up to 4 weeks!
- Blood culture bottles useful for organism isolation
- Multiple aspirations of joints/selective fungal culture useful
o Sabouraud dextrose agar – Candida/Aspergillus/Rhodotorula minuta/Aureobasidium
185
Should a DAIR be used to treat fungus PHI? (Sept 2019)
NOOOOOO
Fungus – tenacious biofilm and suppressive abx don’t work – do not use DAIR to treat
fungus infections
186
Composition of anti-fungal cement spacer? (Sept2019)
Antifungal Spacers
- 4g abx/40 g cement usual for bacteria
- Don’t know ideal antifungal or dose
- Amphotericin B crosslinks with PMMA (doesn’t elute) – liposomal better, poragens may help
- 100-200 mg amphotericin B/40 g cement the way to go, though Mayo goes up 3g/40 g
- Fluconazole/voriconazole useful for Candida albicans 200-800 mg/40 g
187
What nerves are most commonly affected in stingers? (Sept2019)
C5-6
188
How much extra-articular angular deformity can you correct intra-articularly with TKA? (Sept 2019)
Intra-articular compensatory correction achieved with TKA alone if extra-articular deformity
is \<20 degrees in coronal plane on femoral side or \<30 degrees on tibial side if CORA is
outside metaphyseal region
189
Does an angular deformity closer or farther away from the knee cause a greater angular deformity (and bigger cuts to correct it)? TKA (Sept 2019)
CORA closer to knee = greater deformity = need greater TKA bony cuts to correct
190
What is the max correctable sagittal deformity in TKA? (Sept 2019)
Preoperative Planning for Total Knee Arthroplasty: Sagittal Plane
- Sagittal plane deformity better tolerated than coronal
- Literature limited
- Intra-articular correction with TKA feasible if procurvatum deformity \<10 degrees or
recurvatum \<20 degrees
191
What nerve can be damaged with submuscular biceps tenodesis? (Sept 2019)
192
Which approach to the humerus causes the highest incidence of radial nerve palsy? (Sept2019)
Radial Nerve Injuries
- 7% in surgically treated diaphyseal humeral fractures
o Highest incidence in lateral exposure
o Higher in nonunion repair
193
Management of iatrogenic nerve injury? (Sept 2019)
- Would EMG at 4-6 weeks too, on top of U/S (Charles) See pic
194
Low amplitude vs high amplitude MUPs (motor unit potentials) - indicative of.... (Sept 2019)
Low amplitude, short-duration MUPs are indicative of early reinnervation due to regrowth
- Collateral sprouting from undamaged surrounding axons demonstrated by high-amplitude
short-duration MUPs
195
\_\_\_\_\_\_\_\_\_\_most common allegation against orthopaedic surgeons (Sept 2019)
Nerve injury most common allegation against orthopaedic surgeons
196
Presence of SSEP/MEP....pre-or postganglionic nerve injury? (Sept 2019)
SSEPs and MEPs – test spinal rootlets
o If present – post-ganglionic injury
o If not present – pre-ganglionic injury
- NAPs predict reinnervation months before conventional EMG
o If present – recovery will occur after neurolysis
o If not present – no regeneration occurred – additional treatment
197
What is the timing of surgery for nerve injuries? (Sept 2019)
Timing of Surgery
- Time-dependent motor degeneration occurs at level of motor endplate after division of
motor nerve
o Too much time – endplate dies – doesn’t matter if reinnervated
- Timing dependent on type and mechanism of injury
o Immediate repair in sharp injuries with acute deficits
§ End-to-end repair
o 3-4 weeks out
§ Blunt open injuries with rupture of the nerve
§ Tag ends at initial injury
o Low-velocity gunshots
§ Observed – most neurapraxic
o High-velocity gunshots
§ Surgical exploration
Too early: doesn’t allow reinnervation
o Too late (\>6 months) failure of motor end plate
o 3-6 weeks
§ Root avulsion – waiting for reinnervation futile
o 3-6 months after injury
§ Sufficient time to allow spontaneous recovery and save endplates
o \>6 months (delayed), \>12 months (late)
§ Crappy results
§ FFMT and tendon transfers
198
Oberlin transfer? (Sept 2019)
```
Oberlin transfer (ulnar nerve fascicle transfer to biceps motor branch)
for elbow flexion
```
199
If you transfer ICN (intercoastal nerves)....what are the restrictions to shoulder movement to prevent transfer nerve rupture? (Sept 2019)
If ICNs used – lifetime abduction/external rotation restrictions to prevent rupture
200
Nerve recon "DOES or DOES NOT?" reliably relieve neuropathic pain in patients with preganglionic injury –
helpful in postganglionic
Nerve recon does NOT reliably relieve neuropathic pain in patients with preganglionic injury –
helpful in postganglionic
201
Electrodiagnostic criteria for Cubital tunnel syndrome? (Sept 2019)
Électrodiagnostics
o Diagnostic criteria for cubital tunnel syndrome
§ Absolute conduction velocity \<50 m/s or relative drop in conduction of 10 m/s
or \> across cubital tunnel
202
Deformity/ malreduction in plate placement for distal femoral #? (Sept 2019)
(golf-club deformity with
distal segment translated medially if plate put too posterior)
203
204
Where is the ulnar nerve compressed in cubitus valgus/varus? (Sept 2019)
Medial head of triceps in cubitus varus after supracondylar fractures
- Arcuate ligament of Osborne/cubital tunnel in cubitus valgus/
205
Radial head anatomy...angulation relative to radial shaft? (Sept 2019)
Radial neck 15 degrees valgus and 10 degrees apex posterior relative to radial shaft
206
Worst prognosis in radial headd fractures in children? (Sept 2019)
Worse outcomes
o Greater initial angulation and displacement
o Associated injury
o Age \>10 years
o Articular involvement
o Need for open reduction
o Inadequate fixation
207
First and second most common ortho issue in CP kids? (Sept 2019)
Hip dysplasia second most common orthopaedic issue in children with CP (behind equinus)
208
Describe the HORIZON trial (Zoledronic acid) and FREEDOM trial (denosumab)? (Oct 2019)
HORIZON trial
§ Zoledronic acid did not increase nonunion rates if given within 2 weeks of
fracture, delayed healing rates similar between treatment and placebo
o Early vs late diphosphonate use also not shown to increase union time in hip/distal
radius fractures
- Antiresorptive could theoretically impair fracture healing
o FREEDOM trial
§ Denosumab did not increase delayed healing after nonvertebral fracture vs
placebo
o Clinically insignificant delay in fracture healing if already on diphosphonates before
fracture; one study had increase risk of nonunion in humerus fracturs, but rates were
very low in both groups
209
What type of osteoporotic fracture is calcitonin given to prevent? (Oct 2019)
vertebral OP #
210
WHAT is the strongest independent risk factor for survival in traumatic SCI
Age
...is the strongest independent risk factor for survival in traumatic SCI
211
What was found to be the strongest indicator of AIS conversion (Nov2019) -
IMLL was found to be the strongest indicator of AIS conversion, with 1- and 10-mm increases
in IMLL corresponding to 4% and 40% decreases in the odds of AIS grade conversion,
respectively
- Intramedullary lesion length (in spinal cord)
212
213
Treatment of orthostatic hypotension in SCI? (Nov2019)
Orthostatic Hypotension - are given a standing order for the short acting alpha-agonist vasopressor midodrine
5 to 10 mg every 4 to 6 hours as needed during waking hours to maintain SBP above 90 mm Hg.
214
Most common complication of living with SCI? (nov2019)
```
pressure injury (previously referred to as pressure ulcer) remains the most common complication with an
annual prevalence in the acute setting ranging from 10.2% to 38%.
```
215
What is the radial preload technique during ORIF of OP bone?
radial preload can aid surgeons when placing standard screws in cancellous bone. A
radial preload is effected when a pilot hole is underdrilled (eg, drilling with a 1.6-mm rather than 1.8-mm drill for insertion of a 2.4-mm screw), therefore allowing impaction and displacement of the
cancellous bone around the screw
216
Evidence for use of vascular bone graft for surgical fixation of scaphoid non union? (Nov 2019)
There is limited evidence to support the routine use of VBGs in the setting of scaphoid nonunion with
AVN. A recent systematic review of 48 studies including 1,602 patients found no significant
difference in union rates between VBG (92%) and non-VBG (88%).
217
Direction/evolution of tendon rupture in RA? Flexors? Extensors? (Nov2019)
* Flexors - radial to ulnar
* Extensors - ulnar to radial
The flexor pollicis longus is the most commonly affected at the wrist, while the index finger
FDP is themost commonly affected within the palm and digit. Flexor tendons tend to rupture
in a radial to ulnar direction.
o If less than 50% of the tendon width is involved, a débridement is sufficient. If greater than
50% is involved, repair versus reconstruction should be considered.
o Preferred tendon graft is palmaris longus, though half of the flexor carpi radialis can be used
218
Hamstring injury MOI = eccentric or concentric contraction?
ECCENTRIC HAMSTRING CONTRACTION
219
When to fix a hamstring rupture?
Recommend surgical repair if more than one tendon is involved in a soft-tissue injury or if a bony
avulsion is
displaced \>2 cm. There is good evidence that if tendon retraction is \>2 cm, surgical fixation leads to
improved outcomes.
220
Hamstring muscle belly injury? Which muscle is more commonly affected? (Dec 2019)
Biceps femoris (84%)
221
Skeletal anomalies of Turner syndrome (45X0)
222
Stages of RA thumb
223
Determining if you have an ideal inlet and outlet view of the pelvis (Dec2019)
The ideal outlet view is defined as superimposition of the top of the pubic symphysis with the S2
body and helps identify vertical translation of a hemipelvis. The ideal inlet view is a superimposition
of the anterior-most aspects of the S1 and S2 bodies and helps identify anteriorposterior hemipelvic
translation
224
Importance of CSA (Critical shoulder angle) in the setting of Shoulder OA? What is the CSA? (Dec2019)
The CSA is measured as the angle between a line from the superior and inferior bony margins of the
glenoid and an intersecting line from the inferior bony margin of the glenoid to the most inferolateral
acromion on a true AP radiograph of the shoulder.
o CSA measurements less than 30° have been shown to be markedly correlated with
glenohumeral OA.
o lower CSAs have been shown to increase glenohumeral joint reactive forces and glenoid
articular cartilage strain.
o CSA may also be an important risk factor for glenoid loosening.
o CSA may be predictive of full-thickness rotator cuff tears in patients with OA.
o A CSA greater than 35° was 90% specific and 52% sensitive for a full-thickness rotator cuff tear in the
setting of OA.
225
What type of glenoid wear is associated with muscle fatty infiltration of infra and teres minor? (Dec2019)
posterior cuff fatty infiltration was present in 8% of A1 glenoids versus 55% of B3 glenoids.
o Higher joint medialization correlated with higher fatty infiltration in all rotator cuff muscles
o Increasing glenoid retroversion correlated with increased fatty infiltration of the infraspinatus and
teres minor.
o B3 glenoids were more likely to have fatty infiltration of the supraspinatus and infraspinatus muscles
than B2 glenoids were.
226
What is preop anemia associated with in the setting ofTJA? (Dec2019)
Preoperative anemia is associated with longer
hospital stays, and increased rates of blood
transfusion, periprosthetic joint infection, surgical
site infection, genitourinary and cardiovascular
complications, and death.
227
What is the most common type of anemia? (Dec2019)
Iron Deficiency anemia is most common type of
anemia
228
