Boards 2018 Flashcards
(201 cards)
1
Q
This soft tissue sarcoma does not respond to radiation treatment and is treated with wide resection only:
A
atypical lipoma AKA well differentiated liposarcoma
2
Q
Most accurate way to determine tibial tunnel placement in ACL recon?
A
10mm anterior to the PCL insertion
3
Q
Is there correlation between timing of ORIF bicondylar tibial plateau and fasciotomy closure after compartment syndrome to minimize risk of infection?
A
No
ORIF can be done before, at time of, or after closure of fasciotomy without altering infection risk
4
Q
Medications implicated in osteoporosis:
A
- phenytoin
- overdoseages of levothyroxine
- furosemide
- antiretrovirals
- high dose methotrexate
- glucocorticoids
- LMWH and unfractionated heparins
- cytotoxic/antineoplastic drugs
5
Q
Indication for surgery in Dupuytren’s contracture?
A
- MP flexion contracture >30 deg
- PIP flexion contracture >15 deg
6
Q
Dorsal Thompson Approach Interval
A
ECRB and EDC
7
Q
Cervical spine changes of Rheumatoid Arthritis
A
multi-level subaxial subluxations
mid-cervical kyphosis
8
Q
Treatment of a hemorrhagic frostbite blister
A
Drainage of the blister with overlying skin left intact
9
Q
Dominant arterial supply to patella enters:
A
inferomedially
- distal pole has greatest contribution to the peripatellar ring and polar vessel system
10
Q
These metastatic tumors are highly radiosensitive
A
- prostate
- breast
- lymphoma
- myeloma
RENAL IS NOT
THYROID IS NOT
11
Q
Most common cause of non-anesthetic related reversible sustained changes on intraoperative neurominotiring during spinal surgery:
A
patient positioning
12
Q
What finding is common to cartilage in both aging and OA:
A
decreased proteoglycan content
- increased water content in OA not aging
- decreased collagen/modulus/keratin sulfate in aging but not OA
13
Q
Treatment of an ankle sprain is:
A
Early functonal rehab
- this is regardless of initial physical exam findings of instability
14
Q
ACVR1 Gene mutation causes:
A
“Stone Man Disease”
- fibrodysplasia ossificans progressiva
- progressive HO and congenital malforamtion of the great toe in hallux valgus/monphalangism
- will see loss of spinal motion and kyphosis
15
Q
Major indications for reverse TSA on the boards:
A
will be indicated for OLD patients with severe rotator cuff deficiency
- don’t pick this answer in young patients regardless of the pathology. pick anatomic.
16
Q
Symptomatic PE rate in TKA patients without DVT ppx:
A
8%
17
Q
A2 Retinacular cysts: description and treatment
A
firm non-mobile mass at the base of the P1
do not move with tendon motion
Aspiration is highly effective
18
Q
Risk factors for child abuse:
A
- parent losing job
- premature birth
- child with birth defect/disability
- step child
- unplanned birth
19
Q
Avoid these exercises during early ACL rehab:
A
Isokinetic exercises
20
Q
Chondromyxoid Fibroma
A
google image it
Curettage and bone grafting
21
Q
Medial Approach to the Hip
A
- adductor longus and gracilis superficial
- adductor magnus and adductor brevis deep
- medial femoral circumflex runs posterior to iliopsoas and is at risk during release of this muscle
22
Q
Anterolateral bowing of tibia
A
on spectrum with congenital pseudoarthrosis of tibia
- pseudoartrhosis occurs due to fracture nonunion at the site of bowing
- associated with neurofibromatosis
- treat bowing with bracing/PTB cast
- treat fracture with surgical fixation vs amputation after multiple failed attempts
23
Q
Hooknail deformity
A
result of incompletely removed nailbed following distal phalanx amputation
24
Q
Treatment of failed A1 pulley release for trigger finger?
A
Extensile incision, release of 1 slip of FDS
If still triggering, release A3 pulley
25
Classification modality for Kienbock's disease?
CT scan
4 stages
Stage 4 is arthrosis of the joint seen on xray/ct
26
most common complication of distal biceps avulsion repair is:
LABC irritation
27
Airbags in frontal collisions do NOT protect against:
pelvic ring injuries
28
Bone scan findings for shin splints
diffuse longitudinal involvement of the posterior tibial cortex
- as opposed to stress fractures with focal uptake
29
Ilioinguinal nerve: function and anatomical course
sensation to the inner thigh, groin, perineum
- pierces obliquus internus
- accompanies spermatic cord/round ligament through the superficial inguinal ring
30
Anatomy of the sartorial branch of the saphenous nerve
- may be extrafascial in only 43% of cases (can commonly be seen during deep dissection)
- posterior to sartorius
- anterior to the semitendinosus in knee extension
31
Alveolar Rhabdomyosarcoma
2;13 translocation
32
Clear cell carcinoma
12;22 translocation
33
Synovial sarcoma
X;18 translocation
34
Myxoid Liposarcoma
12;16 translocation
35
Chondrosarcoma
9;22 translocation
36
Return to work rates for acute low back pain:
60-70% return by 6 weeks
| 80-90% return by 12 weeks
37
Important option for balancing an unstable MTP joint?
metatarsal shortening osteotomy
| - can relax soft tissue structures allowing for joint rebalancing
38
Traditionally what total hip approach yielded lowest dislocation rate
Direct lateral (Hardinge) - 0.55%
39
Treatment for chondrosarcoma
wide resection and reconstruction
| - NO chemo or radiation sensitivity
40
When performing a lateral release during TKA via a medial parapatellar approach, presrve this vessel:
superior lateral geniculate
41
can you detect hGH supplements via a blood test?
yes
| there is no Urine test for this
42
What is the effect of forearm pronation on the MCL complex
TIGHTENS it
- improves elbow stability
- good after terrible traid fixation, splint in elbow flexion and pronation
43
Equation defining specificity:
true negatives divided by true negatives + false positives
44
Anatomic action of the anterior bundle of the medial ulnar collateral ligament
primary restraint to valgus at 30, 60, and 90 degrees of flexion
- primary anatomic structure involved in valgus overload in throwers
posterior bundle is tight beyond 120 deg flexion and is typically not involved in valgus overload
45
The anteromedial bundle of the ACL controls:
translation
46
The posteromedial bundle of the ACL controls:
rotation
47
Infection rate comparison between Grade I and II open calcs compared with closed calcs:
no difference in infection rate when treated with an extensile lateral approach
48
Cellularly, Paget's disease is characterized by:
increased disorganized bone remodeling
- don't be fooled by "increased osteoclastic resorption"
49
Borders of the Rotator Interval
```
Superior = Supraspinatus
Inferior = Anterior edge of subscap
Medial = Coracoid
Lateral = Transverse humeral ligament
```
50
Contents of the rotator interval:
- LHBT
- SGHL
- CHL
51
Best shoe modification for end stage tibiotalar OA:
single rocker modification
52
Max tension on the SGHL occurs when arm is:
max adduction
| inferiorly translated
53
Splinting in intrinsic minus position (MP joints extended) will cause:
- PIP and DIP flexion contracture
54
Herring showed these patients with LCP benefit from surgery:
- Age >8 years
| - Lateral Pillar B or B/C border subgroup
55
Best prognostic indicator for good outcome from LCP:
Presentation at age < 6 years
56
Lateral Pillar B
Lateral head maintains >50% height
57
Lateral Pillar B/C Border
narrowed, poorly ossified, maintains ~50% height
58
Lateral Pillar Group C
<50% height maintained
| - poor outcomes in all patients
59
Paralytic scoliosis
high cervical AIS A in children <10 years will have 100% rate of paralytic scoliosis
60
Aorta bifurcates in front of this vertebral body
L4
61
Posterior articular sided supraspinatus tears in concert with posterosuperior labral tears and biceps anchor injury are consistent wiht:
internal impingement
62
At what age should internal tibial torsion resolve
age 3-4 years
63
Maximal size of defect coverable by Moberg advancement flap:
3cm, but best for defects <1.5cm
| - if trying to go larger than 3cm, will risk IP Flexion contractures
64
How common are full thickness supraspinatus tears in primary shoulder OA?
uncommon
| <10%
65
Risk factors for type II odontoid nonunion:
- posterior displacement
- posterior angulation
- fracture displacement
66
Quadrigia occurs if FDP is advanced more than:
1.5cm
67
MACI Summit Trial
FDA approval based on this
| MACI superior to microfracture for every cartilage lesion of the knee
68
MACI
medium to large sized lesions in patients <50 years
| - NEVER after failed microfracture because the subchondral bone plate is destroyed
69
Treatment of talar OCD lesion with intact cartilage cap
retrograde drilling
| - leave the cap in place
70
Load transfer after AMZ case:
from inferolateral to proximal medial
| - should not do AMZ with a proximal medial cartilage lesion
71
physiologic bowing of the knee corrects by age:
2
72
Differential for "hip popping"
coxa saltans interna
coxa saltans externa
intra-articular loose bodies
labral tears
73
Prophylaxis of HO
- must give radiation within 24-72 hours of OR
- must give indocin within 72 hours of OR
- treatment at 6 weeks is not effective
if HO develops, monitor until symptomatic, and HO is stable on bone scan (cold)
74
Clinical manifestations of Cat Scratch Disease
regional lymphadenopathy including axillary, epitrochlear, and inguinal
Bartonella henselae
Cutaneous reaction 1-2 weeks prior to lymphadenopathy
75
criteria for significant change in spinal neuromintoring signals?
50% amplitude drop
| 10% latency increase
76
Posterior restraint of the AC joint is mediated by:
Superior and posterior AC ligaments
77
Normal coracoclavicular distance:
11-13mm
| compare to contralateral
78
Conoid and Trapezoid ligament anatomy
Conoid is 4.5cm medial to distal clavicle
| Trapezoid is 3cm medial to distal clavicle
79
Define: Tibiofibular clear space
horizontal distance between the lateral border of the incisura and the medial border of the fibula at the point where the malleolus is wides on an AP radiograph
Normal <5mm
80
Normal measure of the medial clear space of ankle:
<4mm
81
What platelet count in a trauma patient requires damage control orthopedic implementation?
<70,000 mer mcL
82
Complication of metal backed patellar resurfacing prostheses:
polyethylene wear, ultimately leading to metal on metal abrasion and wear, with soft tissue metallosis
83
DISI is caused by:
disruption of the DORSAL SL ligament
84
VISI is caused by
disruption of the VOLAR LT ligament
85
Basal joint OA is caused by
attenuation of the volar beak ligament
86
The ulnar artery in the hand is cominant in:
90% of people
| - majority of superficial arch contribution
87
Common digital arteries originate at the :
superficial palmar arch
88
Vascular supply to scaphoid:
volar carpal branch enters distally
dorsal branch enters the waist
proximal pole of scaphoid gets retrograde flow from here
89
Major forearm nerves and the muscles the enter through
```
median = pronator teres
ulnar = FCU
radial = supinator
```
90
arcade of frohse
entrapment of the radial nerve
most common site
it is the proximal edge of the supinator muscle
91
Ligament of struthers:
anomalous structure in 1% of people about the distal humerus on the medial side, can compress medial nerve
92
what sensory nerve travels on the floor of the 4th dorsal compartment?
posterior interosseous nerve
| - to dorsal capsule of the wrist
93
AIN innervates:
PQ, FPL, FDP to index and middle
94
Anatomic variability of the recurrent motor branch:
- 90% distal to transvserse carpal ligament
| - the remainder come proximal and trans-ligamentously
95
Dorsal ulnar sensory branch of ulnar nerve
releases 7cm before the wrist crease
96
Lumbricals insert on:
lateral bands to the lateral extensor hood
97
what thenar muscles are innervated by ulnar nerve
deep head of FPB and the adductor pollicis
98
nutritional supply of tendon in zone two comes from:
synovial sheath and fluid
| 90% of tendon nutrition comes from diffusion
99
Vincula facts:
2 per tendon
- branches of the digital arteries
- the secondary nutritional source for the flexor tendons
100
most important pulleys are:
A2 (P1) and A4 (P2)
| prevent bowstringing
101
Sagittal bands:
arise from volar plate
centralize the extensor tendon over the MP joint
responsible for transmitting force from the EDC for P1 extension
102
triangular ligament
holds the lateral bands dorsal as they terminate distally on P1
103
Hand deep spaces
- thenar space
| - mid palmar space
104
thumb pulleys
A1, A2, oblique
105
Treatment of a 50% tendon laceration with triggering:
trim the frayed edges
>60% partial laceration should be repaired with epitendinous sutures
106
FDP avulsion injuries Leddy classification
```
I = retracts to palm - fix within 9 days, dysvascular tendon
II = retracts to A2 pulley, can be fixed within 3 months
III = retracts to A4 pulley
```
107
strongest repair of flexor tendon achieved with
core and epitendinous suture
108
repair strength fo flexor tendon is proportional to:
number of core sutures and the caliber of the suture
109
rehab after flexor tendon injuries:
active mobilization with wrist in extension and MP joints in flexion
IP joints should be held in extension
Children cast for 4 weeks after repair
110
Zone II repair complications:
- joint contracture
| - adhesions - do tenolysis after 3-6 months of therapy
111
surgical manageent of bony mallet finger:
>1/3 of articular surface, do surgical pinning/ORIF
112
Boutonniere deformity is:
caused by central slip avulsion injury
- off the dorsal aspect of the P2
- PIP flexes, DIP hyperextends
113
Most common organism in Fight Bite:
Staph aureus
| Eikenella
114
in closed sagittal band disruptions, which band is most commonly involved?
radial sagittal band of the long finger
- will see ulnar subluxation of the extensor tendon
- digit deviates ulnarly
- will be an extensor lag
115
if you sew the FDP to the extensor tendon during a digital amputation, you can cause:
quadrigia effect
116
lumbrical plus finger
with laceration of the profundus tendon, it retracts, and activates the lumbrical due to its tension.
- causes paradoxical extension of the PIP joint during finger flexion.
- Treatment is tenotomy of the radial lateral band
117
Risk factors for trigger finger:
NIDDM, Gout, Renal disease
118
pediatric trigger finger (non-thumb) is best treated with:
excision of a slip of the FDS
119
Which tendon of the 1st dorsal compartment has a subsheath?
EPB
120
Treatment of EPL rupture
EIP transfer
121
Mannerfelt syndrome
FPL ruptures in RA patients
122
Radial Nerve Palsy Transfers
need to reconstitute wrist/thumb/digital extension in order to achieve grasp
123
Tendon Transfer for Wrist Extension (radial n palsy)
Pronator teres to ECRB
- why not ECRL? because this will give you radial deviation
124
Tendon transfer for digital extension (radial n palsy)
FCU to EDC 2-5
125
Tendon transfer for thumb extension (radial n palsy)
PL to EPL
126
Patient presents with radial clubhand, check for:
Fanconi anemia
TAR
Holt-Oram syndrome (cardiac)
do chromosomal breakage studies
127
Goal of treatment of radial clubhand
reconstruct the thumb and centralize the hand over the ulna
128
Post-axial polydactyly risk factor is:
family history
- this is a genetic problem with heritability
- Autosomal Dominant
129
Most common Wassel type of thumb duplication:
Type IV
- duplicate proximal phalanx
- must remove the digit and preserve the lateral structures, specifically the radial collateral ligament and the intrinsic tendon
130
Blauth Type III Thumb Hypoplasia - Management
If CMC joint stable, do reconstruction
| If CMC joint unstable, delete and pollicize
131
How do you treat camptodactyly and clinodactyly:
do nothing/treat conservatively (stretching/splinting)
132
Constriction band syndrome Rx
- release bands and do Z plasty
133
Where is the physeal defect in Madelung's?
Volar Ulnar Closure
| causes volar and ulnar deviation of the distal radius
134
princeps pollicis
thumb arterial supply
comes from radial artery or deep arch
also supplied radial artery of index finger
135
occlusive embolic disease of the digits most commonly comes from:
subclavian arteries
136
Treatment of Hypothenar Hammer Syndrome
calcium channel blockers and smoking cessation
- if the radial artery can sustain the fingers, based on Digital BRachial Index (DBI) >0.7
- If DBI <0.7 then you need to do a reverse vein graft
- If there is an aneurysm, you have to reconstruct. If just thrombosed, then do thrombolysis
137
Associated conditions with Raynaud's syndrome:
CREST Syndrome
- calcinosis cutis
- esophageal strictures
- sclerodactyly
- telangectasia
Treat Raynaud's with Botox injections, calcium channel blockers, digital sympathectomy
138
Appearance of a glomus tumor on MRI:
low T1
bright T2
Rx = marginal excision
139
treatment of a melanoma of a distal phalanx of thumb:
amputation at the IP joint
140
Maffucci's
hemangiomas and enchodnromas with high rate of malignant transformation
141
Differentiation of ulnar impaction from Kienbock's radiographically:
ulnar impaction will demonstrate lunate changes just on its ulnar aspect
Kienbock's has global involvement of the lunate
142
Joint leveling procedures in Kienbock's:
if ulnar negative, do radial shortening osteotomy
if ulnar positive, do capitate shortening osteotomy
143
1st hand compartment affected by compartment syndrome:
deep volar
- fpl, fdp, pq
so check thumb flexion early
144
Giant cell tumor of tendon sheath
distal, volar, nodular, giant cells and hemosiderin on histo
- treatment is excision because it will continue to grow
- 50% recurrence
145
Epithelioid Sarcoma of Hand
most common soft tissue sarcoma of hand
- high grade
- high recurrence rate
- wide excision/amputation
146
Squamous Cell Carcinoma of Hand
most common cancer of the hand overall
- treat with wide excision
- 6mm margin if high risk >2cm and in hair bearing area
147
Enchondroma of hand
- most common primary bone tumor o fhand
- benign cartilage tumor
- observation if incidental
- if pathologic fracture, let bone heal, then curettage +/- bone grafting
148
Giant Cell Tumor of Hand
common in distal radius
- aggressive, expanile, lytic
- can metastasize so GET A CHEST CT
- curettage and local adjuvant
- high recurrence rate
149
Collagen type in Dupuytren's disease:
Type III Collagen
150
Genetics of Dupuytren's disease
AD with variable penetrance
151
Can you do a carpal tunnel release concomitantly with Dupuytren's release?
no
| can cause dupuytren's flare
152
Which component of palmar fascia is not involved in Dupuytren's disease?
Cleland's ligament
| - most dorsal fascia and remains uninvolved
153
Spiral band involvement in Dupuytren's
passes dorsal to the NV bundle
| when it becomes a cord, it brings the NV bundle volar making it higher risk of injury during surgery
154
similarities and differences between collagenase and needle aponeurotomy
big cost difference
- similar recurrence rate (20-25%)
- similar post procedure pain
155
define synechia
nail fold adhering to germinal matrix preventing growth of a new nail.. .causes a split nail
156
skin grafts on hand palm:
must be full thickness
on dorsum can be split thickness
157
Z plasty is:
up to a 60 deg angle Z to lengthen scar and reorient tissue
- all limbs must be of equal length
- with 60 deg angles you get 75% increase in length, at the expense of tightening the surrounding tissues
158
benefit of a VY advancement flap for a musician with distal or dorsal tip loss:
it is an innervated finger flap
159
how far can you advance a Moberg flap?
1.5cm
| if need greater than that, need another option
160
Role of neurovascular island flap:
severe thumb pulp defects
sensate
donor site is usually ulnar side of middle or ring finger
- DO A DIGITAL ALLEN TEST
161
coverage for dorsum distal finger tissue losses:
reverse cross finger flap
162
dorsal aspects of the finger/thumb tissue loss treated with:
dorsal metacarpal artery flap or axial flag flap``
163
Treatment of Hydrofluoric Acid Burns (industrial cleaning agents)
treat with calcium gluconate
164
Treatment of elemental sodium exposures
use mineral oil to wash , not water, as it will explode
165
Treatment of white phosphorus exposure (fireworks)
use copper sulfate to identify particles
| - submerge the hand under water
166
Warm ischemia time for replants:
<6 hours for muscle
| <12 hours for distal (fingers)
167
Cold ischemia time for replants:
<12 hours for proximal (muscle)
| <24 hours for distal (finger)
168
Order of repair for finger replantation:
BEFANV
- Bone
- Extensor tendon
- Flexor tendon
- Artery anastomosis
- Nerve repair
- Vein anastomosis
But if multiple replants, do it structure by structure..., not digit by digit
169
Order of repair for proximal replantations:
arterial shunting first to get muscle perfusion ASAP
- fasciotomies
- bone shortening possible to take tension off NV repairs
170
Infection from leaching is:
Aeromonas hydrophilia
171
Functional protection of the perineurium is:
protects against stretch
172
Pacinian Corpuscles:
vibration
- tests nerve threshold
- vibration
- Semmes Weinstein monofilaments test this
173
Meissner's corpuscles
test moving 2 point discrimination
174
Merkel's bodies
slow adapting
- static 2 point discrimination
- tests innervation density
175
Wallerian degeneration
distal axon dies
- macrophages and distal schwann cells clear debris and create a scaffold
- growth rate is 1-2mm/day
- growth is ANTEGRADE AXONAL SPROUTING
176
GRade II Axonotmesis
axons damaged, endoneurum is intact
- Wallerian degeneration occurs
- EMG shows fibrillations
177
Do you see EMG changes after neurapraxia
No
178
Severe Grade IV Axonotmesis
only the epineurium is intact
- intraneurl scarring (neuroma) may prevent healing
- may require neuroma excision and repair/ grafting
179
Management of neurotmesis
complete nerve transection must be repaired
- epineurial vs group fascicular
- no difference in outcome
180
for nerve injury, is distal or proximal injury worse?
proximal injury is worse
| - you want end organ re-innervated ASAP
181
repair for nerve with <3cm gap
nerve conduit
182
repair for nerve with >3cm gap
nerve autograft
183
management options for CRPS:
- PT/OT
- sympathetic block
- edema glove
- steroids, gabapentin, bisphosophonates
- nerve decompression
- Vitamin C
184
Nerve conduction studies test:
LARGE MYELINATED FIBERS
- becuase compressive neuropathies affect myelinated nerves
- will see latencies
185
When will you see EMG findings after a nerve injury?
at least 3-5 weeks after injury
| - will see fibrillations and positive sharp waves indicating deneration
186
Nerve threshold testing is used for:
evaluation of compressive neuropathies
- light touch, vibration
- semmes-weinstein
187
Innervation Density testing is used for:
evaluating nerve disruption
| - two point discrim
188
medical risk factors for carpal tunnel syndrome
RA, hypothyroid, DM, dialysis, Pregnancy
189
Treatment of thumb abduction weakness following longstanding carpal tunnel syndrome:
opponensplasty
| - EIP transfer to opponens pollicis
190
distinguishing CTS from pronator syndrome
pronator syndrome will have pain in the forearm and also have NUMBNESS IN THE PALM
- CTS does not have numbness in the palm
191
Gantzer's muscle
accessory head of the FPL
| - can cause AIN compression
192
3 Zones of entrapment at Guyon's canal:
I: before bifurcation = motor + sensory
II: after bifurcation = motor
III afterbifurcation = sensory
most common cause is a GANGLION
193
Martin-Gruber anastomosis
Motor connection in the forearm
- median to ulnar to median
- can have a carpal tunnel syndrome at the wrist but still have all inneration to your hand intrinsics
194
Riche-Canniue anastomosis
deep motor branch of ulnar to motor of the median
| -
195
Areas of radial nerve entrapment (FREAS)
- fibrous bands at the radial head
- radial recurrent artery (Leash of Henry)
- ECRB fibrous edge
- Arcade of Frohse (leading edge of supinator)
- Supinator distal edge
196
Treatment of PIN syndrome:
observation for 6 months
| - followed by neurolysis
197
Wartenberg's syndrome
Cheiralgia paresthetica
- sensory deficit in the superficial radial nerve
- compression between BR and ECRL
198
Wartenberg's point
7-9cm proximal to radial styloid
199
Parsonage-Turner Syndrome
rapid onset shoulder pain and then weakness about the shoulder girlde
- followed by motor dysfunction anywhere in the arm
- EMG positive and Wallerian degeneration
- can take several years to improve
200
What is most likely to block reduction of a MCP dislocation?
Volar plate
201
Clinical manifestation of sagittal band rupture:
decentralization of the extensor tendon
inability to extend digit, but able to maintain extension once passively extended
