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1

What is true about the sesamoids?

the tibial sesamoid is larger

Blood supply - medial plantar artery and plantar arch

Sesamoid complex transmits 50% of the body weight

2

What are the surgical options for a burst fracture?

Anterior decompression with stabilization

Retropulsion with need for decompression

corepectomy with strut grafting 

Posterior decompression with fusion

Instrumentation with distraction, get indirect decompression of the canal

Posterior fusion

Progressive kyphotic deformity

3

Compare two incision distal biceps

both can get PIN

same HO

better flexion with two incision

less LABCN with two incision

4

What are approapriate antibiotics for open wounds

  • Gustilo 1
    • cefazolin
    • clinda if allergy
  • Gustilo 2/3
    • cefazolin
    • gentamycin
    • Farm wounds - penicillin or flagyl
  • Freshwater (A hydrophilia)
    • cipro or ceftazidime
  • Salt water (vibrio)
    • Doxycycline
    • ceftaxidime or cipro

5

What is true about NF2?

  • less common
  • bilateral acoustic neuroma
  • no scoliosis

6

What are the indications for treatment of a pediatric  proxiaml humerus fracture?

  • Neer-Horowitz classification
    • type I is minimally displaced (< 5mm)
    • type II is displaced less than 1/3 of the shaft width
    • type III is displaced greater than 1/3 and less than 2/3 the shaft width
    • type IV is displaced greater than 2/3 the shaft width
  • > 6 with the following displacement
    • >50% displaced
    • > 45 deg angulated
    • open
    • dysvascular

7

Sites of compression of the ulnar nerve at the cubital tunnel

Arcade of struthers
Medial intermuscular septum
Medial epicondyle
Osborne's ligament
Between heads of FCU (fasica)
Aponeurosis of FDS

8

What structure causes retrograde ejaculation in the anterior approach to the lumbar spine?

Superior hypogastric plexus

9

What are the releases for a valgus knee?

osteophytes

Capsule

IT (extension)

popliteus (flexion)

LCL

10

What is your approach to factor replacement in a hemophiliac

  • 2 hours pre op infuse with clotting factor calculated to attain 100% activity of normal 
  • Then maintained on continuous infusion of factor to maintain levels at >60% throughout the procedure
    • Thereafter, levels are checked every 1 or 2 days.
    • A 60% level is maintained by continuous infusion until the patient is discharged.
  • Home infusion of bolus doses is used to maintain levels of 30% to 60% for at least 2 weeks postoperatively.
  • If vigorous physical therapy is needed the patient is infused to a 30% level just before therapy
  • Complications
    • hemarthorosis at 4-7 days if it occurs
    • infection slightly higher
    • risk of stiffness so no concern for instability

11

Complications of talar neck fractures

  • Subtalar OA
  • AVN
  • malunion
  • In that order, no matter the Hawkins classification, but the risk of each one will go up with subsequent grade
  • Nonunion is a very low risk 

12

What is the incidence of bilateral slip in a SCFE?

General population - 20%

Renal osteodystrophy - 80%

13

What injury pattern has the lowest rate of ligament injury in a tibial plateau fracture?

lateral split

14

Which dwarfism does not have an ustable c-spine?

achondroplasia

15

What is the most common cause of heel pain in the pediatric population?

Sever's

16

Acceptable alignment of a humeral shaft fracture

< 20° anterior angulation
< 30° varus/valgus angulation
< 3 cm shortening

17

What is true about the genetics and etiology of achondroplasia?

  • FGFR3 point mutation G380R
    • AD
    • 80% are spontaneous
      • associated with higher paternal age
  • Leads to abnormal chondroid production in the proliferative zone
    • short long bones
    • endosteal ossification
    • proximal > distal (?why)
  • Spine
    • narrow interpedicular distance (L1-5)
    • narrow foramen magnum
      • mortality, apnea, UMN
      • screen all with MRI who have positive sleep study
    • thoracolumbar kyphosis
      • brace when young
      • usually will resolve
    • lumbosarcral hyperlordosis
    • spinal stensosis
      • narrow pedicles
      • hyperplastic discs
  • MSK
    • genu varum
    • rhizomelic shortening
    • trident hand

18

What structures are released during plantar fascial release

  • divide supericial fascia of the abductor hallucis
  • fascia between abductor hallucis and plantar quadratus is released
    • releases the nerve between the two
  • a portion of the plantar fascia is incised
  • medial heel spur is resected if present

19

Treatment of unstable PIP fracture-dislocations

  • Extension block pinning (transarticular)
    • reducible joint with tenuous stability
    • flex the joint slightly and pin the proximal phalax
  • CRPP
    • reducible joint with tenous stability
    • larger fragment ammenable to pinning
    • not superior to extension pinning
  • Dynamic distraction and Ex-fix
    • unstable pilon or > 50% (B type fracture)
    • off-loads the joint and permits early ROM
  • Volar Plate arthroplasty
    • augmented with button
    • proected with k-wire
  • Hemihamate reconstruction arthroplasty (more for volar fractures)
    • section of hamate if measured and transplated
    • B type fractures can use hemiH or dynamic ex-fix; no studies to compare the two
    • 2 week extension splint then ROMAT
    • no long term studies
    • easier to do in a more chronic situation where you can't do a DynEx

20

What is the most common complication of a talar neck fracture?

subtalar OA

21

What are the indications for epiphyseodesis in congential scoliosis

  • Age <5 years
  • Site of anomaly in lumbar as opposed to thoracic spine
  • A curve of five segments or less
  • A progressive curve <40°
  • Anomalies consisting of hemivertebrae instead of unsegmented bars
  • Absence of excessive kyphosis
  • Absence of neurological deficits, including syrinx, diastomatomyelia and tethered spinal cord

22

What are the MRI characteristics and treatment of an ABC?

  • MRI - cystic, fluid-fluid levels showing blood and solid components
  • curettage and grafting with cryotherapy

23

Approach to adolescent bunions

  • best to wait until skeletal maturity to operate
  • can not perform metatarsal osteotomies if physis is open (cuneiform osteotomy OK)
  • surgery indicated in symptomatic patients with an IMA > 10° and HVA of > 20°
  • severe deformity with a DMAA > 20 perform a double MT osteotomy
  • technique
    • soft tissue procedure alone not successful
    • similar to adults if physis is closed (except in severe deformity)

24

What is the most sensitive test to detect OM?

MRI

25

What is the best treatment for a 20 yo female with JRA and trashed TN, CC and TC joints?

triple arthrodesis

26

What is the nonopertive treatment of spondylolisthesis?

Asx - non-op, full contact

Sx low grade - PT for pelvic tilt, core strength and hamstring stretches (know the risks and monitor)

Acute - TLSO, better than activity mod alone

27

What are the sensitivity/specificity/PPV/NPV

  • sensitivity = (true positive) / (true positive + false negative)
    • proportion of individuals who truly have a designated disorder who are so identified by test
  • specificity = (true negative) / (true negative + false positive)
    • proportion of individuals who are truly free of a designated disorder who are so identified by test
  • PPV = (True positive) / (True + False positives)
    • proportion of individuals with a positive test who have the disease
  • NPV = (true negative) / (true + false negatives)
    • proportion of individuals with a negative test who are free of the disease

28

What is the typical presentation of a glomus tumor

  • Small red-blud nodule on gross histoloy
  • typically in the nailbed
    • can occur in other places
    • riding or discoloration of the nailbed
  • 20-40 yo
  • F>M in subungual region only
  • Triad
    • paroxysmal pain
    • cold intolerance
    • localized tenderness
  • XR
    • may not be helpful
    • scalloped osteolystic defect with sclerotic border
  • MRI
    • diagnostic

29

What are indications for surgery of a clavicle fracture?

unstable Group II fxs (Type IIA, Type IIB, Type V) 

open fxs
displaced fracture with skin tenting 
subclavian artery or vein injury
floating shoulder (clavicle and scapula neck fx)
symptomatic nonunion
posteriorly displaced Group III fxs

displaced Group I (middle third) with >2cm shortening

30

What is the effect of overstuffing a radial head arthroplasty

  • increased load
  • limit mobility