Must know Flashcards

Question

What are the borders and the contents of the Triangular Space?

Answer 1

3 word artery with 's' Inferior - teres major Lateral - long head of triceps Superior - inferior border of teres minor * CONTENTS - circumflex scapular artery

Answer 2

anterior bundle of medial collateral ligament central band origin: median epicondyle insertion: sublime tubercle primary statis stabilizer to valgus stress from 20-120 degrees of elbow flexion

Answer 3

PT, FCR, PL, FDS, FCU all inervated by median n. except for FCU, supplied by the ulnar n. all originate from common flexor origin on medial epicondyle FDS also originates on anterior radius

Answer 4

FDP, FPL, PQ all innervated by AIN FDP has dual innervation (ulnar haf by ulnar n., radial half by AIN)

Answer 5

brachioradialis, ECRL, ECRB * The lateral supracondylar ridge of the humerus serves as an attachment point for the brachioradialis and ECRL, which also has attachments onto the superior aspect of the lateral epicondyle * ECRB originates on the lateral epicondyle * AllinnervatedbytheRadialn.

Answer 6

anconeus, EDC, EDM, ECU all innervated by PIN except for anconeus, supplied by radial n. ECU not innervated by ulnar n.

Answer 7

* Supinator * Abductor Pollicis Longus * Extensor Pollicis Brevis * Extensor Pollicis Longus * Extensor indicis proprius all innervated by PIN

Answer 8

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

Answer 9

LUCL origin lateral humeral epicondyle insertion tubercle of supinator crest of ulnar

Answer 10

* VPMRI * No radial head fracture * > 15% (anteromedial facet) * Posterior band of MCL ruptured, anterior band intact (attached to anteromedial facet) * LCL complex (includes LUCL) avulsion * Valgus stress, moving valgus, milking maneuver * VPLRI * Radial head fracture * < 15% (coronoid tip) * Anterior band of MCL ruptured * LCL complex (includes LUCL) avulsion * Varus stress, chair rise, lateral pivot shift

Answer 11

kocher approach

Answer 12

likely LUCL injury if any lig (most common) cast in pronation 'thumb away from injured side'

Answer 13

FOOSH with axial compression, in supination and valgus

Answer 14

- lateral pivot-shift test - patient lies supine with affected arm overhead; forearm is supinated and valgus stress is applied while bringing the elbow from full extension to 40 degrees of flexion - with increased flexion, triceps tension reduces the radial head - often more reliable on anesthetized patient - posterior drawer test - patient lies supine with affected arm overhead; forearm is supinated and the examiner's index finger is placed under the radial head and the thumb over it. - application of a posterior force will cause posterior subluxation of the radial head - prone push up - chair push up - table top relocation test

Answer 15

interval between the anconeus and extensor carpi ulnaris indications: radial head #, excision, prosthesis, LUCL recon advantages: low risk of PIN injury disadvantage: distal extension may endager PIN relatively more posterior and thus risks injuring the lateral collateral ligament complex.

Answer 16

interval between the extensor carpi radialis brevis and extensor digitorum communis Indications Radial head fractures – fixation, excision and prosthesis. Advantages Good view of the anterior half of the radial head which is a common site of fracture. No disruption of the LUCL. Drawbacks Inadvertent injury to the PIN if the incision is too anterior. Distal extension can endanger the PIN. Remember: If there is a supinator crest of ulna fracture or LUCL avulsion as in 5% of terrible triad injuries, this approach should not be used.

Answer 17

EDC tendon is dissected directly longitudinally starting at its origin at the lateral epicondyle The approach offers a slightly more anterior access than the Kocher's approach.

Answer 18

Interval: splits the flexor-pronator mass and elevates the anterior part (pronator teres (PT), flexor carpi radialis (FCR), and palmaris longus (PL)) along with brachialis from the anterior elbow capsule Indications The Hotchkiss or ‘over-the-top approach’ is the most anterior of the medial approaches and provides good access to the tip of the coronoid process and the anterior elbow joint. Advantages Good view of the coronoid tip fracture site. Drawbacks Ulnar nerve exploration and visualisation is required. Possible injury to medial antebrachial cutaneous nerve.

Answer 19

interval: between the heads of the flexor carpi ulnaris Indications Coronoid fractures. Advantages Good view of the fracture site especially the anteromedial facet. Drawbacks Ulnar nerve exploration is required. Possible injury to medial antebrachial cutaneous nerve.

Answer 20

Interval - For access to the base consider elevating the entire flexor-pronator mass from posterior to anterior Indications This is a good approach for a medial plate fixation for a large basilar fracture of the coronoid. Advantages Good view of the fracture site. Drawbacks Ulnar nerve exploration is required. Possible injury to medial antebrachial cutaneous nerve.

Answer 21

anconeus Lateral epidondylitis is classically thought to be caused by histopathologic angiofibroblastic hyperplasia at the origin of the extensor carpi radialis brevis. ECRB originates from the common extensor wad, that also includes ECRL, ED, ECU. The anconeus shares the same attachment site at the lateral epicondyle as the ECRB

Answer 22

- tendinosis (degenerative condition) rather than tendinitis (inflammation) - angiofibroblastic hyperplasia - characterized by dense populations of fibroblasts, vacular hyperplasia and disorganized collagen

Answer 23

do not extend beyond equator of radial head may lead to PLRI

Answer 24

- describes collection of injuries in the medial, lateral and posterior aspects of the overhead thrower’s elbow - occurs as a consequence of the large valgus loads and rapid elbow extension during the throwing motion

Answer 25

1. decreased performance (velocity, control, fatigue) 2. posteromedial elbow pain with full extension of elbow 3. locking/catching (loose bodies), loss of terminal elbow extension 4. ulnar nerve symptoms (neuritis, subluxation) 5. pain in deceleration of throwing phase

Answer 26

valgus instability - over-resection of posteromedial ostephy past its native margin or >3mm may lead to increased stress on the MCL and valgus instability

Answer 27

1. lateral ulnar collateral ligament * inserts on the supinator crest 2. radial collateral liagement * inserts on the annular ligament 3. annular ligament * inserts on the supinator crest 4. accessory lateral collateral ligament * inserts on the supinator crest

Answer 28

- **anterior bundle** - **strongest and most significant stabilizer to valgus stress** - insert - **sublime tubercle** - provides stability between 30-120° flexion - subdivides into anterior and posterior bands - **anterior band - 1° restraint to valgus stress**, exhibiting nearly **isometric strain during elbow ROM** - **posterior bundle** - **greatest change in tension from flexion to extension** - tighter in flexion - **transverse bundle**

Answer 29

moving valgus test (100% sensitive, 75% specific)

Answer 30

1. Limit pitching to 100 innings in a calendar year 2. Do not pitch for multiple teams 3. Do not pitch all year (3 month rest period advised) 4. No pitching on consecutive days 5. No pitching in a game or practice after being removed from a game 6. No breaking pitches (curveballs/sliders) until puberty 7. Proper pitching mechanics and year round conditioning should be stressed 8. Avoid pitching while fatigued

Answer 31

on radial side of tubersosity footprint

Answer 32

high BMI, smoking, anabolic steroids

Answer 33

medial) median nerve, brachial a., biceps tendon, radial n. (lateral)

Answer 34

during surgical disseciton btw biceps and brachialis

Answer 35

1. The tendon externally rotates 90° - Brings the medial short head fibres anterior and the lateral long head fibres posterior 2. The tendon inserts with: - Short head fibres distal on the radial tuberosity - Stronger flexor - Long head fibres proximal - Stronger supinator

Answer 36

Supination - 79% endurance [50% loss] - 21-55% strength [40% loss] Flexion - 10-40% strength [30% loss] - 30% endurance

Answer 37

proxial - BR and brachialis distal - BR and PT

Answer 38

Forearm held in supination to protect the PIN and bring the radial tuberosity into view

Answer 39

affects traversing/descending/lower nerve root at L4/5 - affects L5 nerve root most common PLL is weakest here

Answer 40

less common (5-10%) affects exiting/upper nerve root at L4/5 affects L4 nerve root

Answer 41

Pronator syndrome (SLAPS) * **Struther’s ligament **Resisted Flexion at 120 * **Lacertus fibrosis **resisted flexion with supinated forearm * **Arch of FDS **(sublimus arch) resisted FDS middle finger * **Pronator Teres (**2 heads) resisted supination with elbow flexed

Answer 42

1. Motor Order: - Forearm - Pronator teres - FCR - Palmaris longus - FDS - Radial FDP [AIN] - Index and middle finger - FPL [AIN] - Pronator quadratus [AIN] - Hand - APB - FDB (superficial head) - OP - Lumbricals 1 & 2

Answer 43

2. Sensory 1. volar wrist capsule, radial palm and palmar aspect of thumb, index, long and radial half of ring 1. terminal AIN 2. palmar cutaneous branch of median nerve 3. terminal digital cutaneus branch

Answer 44

* Lies medial to brachial a. at the elbow * Passes between the two heads of the pronator teres and then runs between FDS and FDP

Answer 45

- Carpal tunnel borders - scaphoid tubercle and trapezium radially - hook of hamate and pisiform ulnarly - transverse carpal ligament palmarly (roof) - proximal carpal row dorsally (floor) - Carpal tunnel contents - four flexor digitorum superficialis (FDS) tendons - four flexor digitorum profundus (FDP) tendons - flexor pollicis longus (FPL) - most radial structure - median nerve

Answer 46

- bilateral AIN signs caused by viral brachial neuritis - be suspicious if motor loss is preceded by intense shoulder pain and viral prodrome

Answer 47

- FDP (index and middle finger) - FPL - pronator quadratus

Answer 48

AIN Syndrome * Forearm pain * Weakness of grip and pinch - FPL, FDP 1&2, PQ * * unable to make OK sign *** No sensory disturbance** Pronator Syndrome * Pain in proximal, volar forearm *** Paresthesias in thumb, index, long fingers** *** AIN Syndrome PLUS weakness of all digits & wrist flexion** * Exacerbated by resisted pronation * Tinel’s at anterior elbow

Answer 49

- potential sites of entrapment of AIN - tendinous edge of deep head of** pronator teres** - most common cause ** - fibrous arch of the FDS** ** - aberrant vessels** ** - accessory head of FPL (Gantzer's muscle)** - accessory muscle from FDS to FDP - abberant muscles (FCRB, palmaris profundus)

Answer 50

- should have characteristics differentiating from carpal tunnel syndrome (CTS) - aching pain over proximal volar forearm - sensory disturbances over the distribution of palmar cutaneous branch of the median nerve (palm of hand) - arises 4 to 5 cm proximal to carpal tunnel - lack of night symptoms

Answer 51

- less clawing - sensory deficit to dorsum of the hand - motor deficit to ulnar-innervated extrinsic muscles - Tinel sign at the elbow - positive elbow flexion test

Answer 52

floor:Transverse carpal ligament, hypothenar muscles roof: Volar carpal ligament ulnar border: Pisiform and pisohamate ligament, abductor digiti minimi muscle radial border: Hook of hamate ulnar nerve, a/v

Answer 53

- zone I - proximal to bifurcation (motor and sensory) - zone II - deep motor branch (motor only) - zone III - superifical sensory branch (sensory only)

Answer 54

1. Motor - FCU - Ulnar half of FDP - All intrinsics except lateral 2 lumbricals and thenar muscles - Except deep head of FPB 2. Sensory - Elbow joint - Ulnar palm and dorsum of hand including small finger and ulnar half of ring finger - Branches: - Articular branch of the elbow - Dorsal cutaneous branch - Palmar cutaneous branch - Only present in 58% of people - Terminal superficial branch

Answer 55

1. Medial intermuscular septum 2. Arcade of Struthers 3. Triceps fascia 4. Osborne ligament** (most common site)** - Roof of cubital tunnel 5. Medial epicondyle 6. FCU - Deep fascia - Between two heads 7. FDS/FDP fascia 8. Anconeus epitrochlearis - Anomalous muscle which arises from medial border of olecranon & adjacent triceps & inserts into the medial epicondyle 9. Canal of Guyon

Answer 56

- numbness/paresthesia of the small and ulnar half of ring finger (ulnar palm and dorsum are spared) - intrinsic muscle weakness (thenar spared)

Answer 57

FREAS (radial nerve) * Fascia superficial to radiocapitallar joint * Radial Recurrent Vessels (Leash of Henry) * ECRB tendinous proximal margin at origin * Arcade of Frohse (prox aponeurotic/tendinous edge of sup, most common site of PIN entrapment) * Supinator (distal edge of)

Answer 58

- Borders: - Proximal border – begins at radiocapitellar joint - Distal border – arcade of Froshe - Roof – BR - Medial border – brachialis and biceps tendon - Lateral border – ECRB, ECRL, BR

Answer 59

- Pain at lateral forearm distal to lateral epicondyle - Lack motor and sensory changes

Answer 60

motor common extensors * ECRB (often from radial nerve proper, but can be from PIN) * Extensor digitorum communis (EDC) * Extensor digiti minimi (EDM) * Extensor carpi ulnaris (ECU) deep extensors * Supinator * Abductor pollicis longus (APL) * Extensor pollicus brevis (EPB) * Extensor pollicus longus (EPL) * Extensor indicis proprius (EIP) sensory * sensory fibers to dorsal wrist capsule - provided by terminal branch which is located on the floor of the 4th extensor compartment * no cutaneous innervation

Answer 61

triceps brachii, anconeus, brachioradialis, extensor carpi radialis longus, *brachialis*

Answer 62

- Provocative maneouvers - Pressure over supinator muscle in supinated position - Pain with resisted wrist or long finger extension

Answer 63

- fibrous tissue anterior to the radiocapitellar joint - between the brachialis and brachioradialis - “leash of Henry” - are recurrent radial vessels that fan out across the PIN at the level of the radial neck - extensor carpi radialis brevis edge - medio-proximal edge of the extensor carpi radialis brevis - "arcade of Fröhse" - which is the proximal edge of the superficial portion of the supinator - supinator muscle edge - distal edge of the supinator muscle

Answer 64

- Weakness of PIN innervated muscles - Sparing of BR, ECRL - Pain in dorsal radial forearm - no sensory changes - Wrist extension demonstrates radial deviation - Intact ECRL - resisted supination - will increase pain symptoms

Answer 65

1. Compression of the superficial radial nerve ~9cm proximal to radial styloid where the nerve passes between BR and ECRL 2. Characterized by: - Dorsal radial forearm pain radiating to dorsoradial hand - more common in women - SRN compressed by scissoring action of brachioradialis and ECRL tendons during forearm pronation - provocative test: wrist flexion, ulnar deviation and pronation for one minute - De Quervain's tenosynovitis: pain is not aggravated by wrist pronation,

Answer 66

cleland's ligament (c for feiling - dorsal to digital nerve

Answer 67

1. EPB + APL = De Quervain’s tenosynovitis 2. ECRB + ECRL = intersection syndrome 3. EPL = drummer’s wrist, traumatic rupture with DR # 4. EDC + extensor indicis = extensor tenosynovitis 5. EDM = Vaughn-Jackson syndrome 6. ECU = snapping ECU

Answer 68

- **DISI (dorsal intercalated segmental instability)** - Division of the dorsal component of the SLIL results in gradual collapse of the scaphoid into flexion, while the lunate is pulled into extension to form the dorsal intercalated segment instability pattern - Diagnosis of DISI deformity can be made with lateral wrist radiographs showing - a scapholunate angle > 70 degrees. (N 30-60) - DISI defined by radiolunate angle >15°

Answer 69

1. Widened SL distance 1. gap >3mm with clenched fist view (terry thomas sign) 2. Cortical ring sign 1. caused by schaphoid malalignment 3. Shortening of the scaphoid 4. Scapholunate angle >70° (normal = 30-60) 5. Lunate extension 6. DISI defined by radiolunate angle >15°

Answer 70

- scapholunate advanced collapse - describes a pattern of wrist arthritis that occurs following a scapholunate ligament injury Watson Classification Stage I - radial styloid Stage II - radioscaphoid joint Stage III - capitolunate joint [Stage IV - pancarpal involvment (controversial)]

Answer 71

- Stage I - scaphoid and radial styloid arthritis - radial styloidectomy - PIN and AIN denervation - Stage II - scaphoid/scaphoid facet of radius arthritis - proximal row carpectomy - contraindicated with caputolunate arthritis because capitate articulates with lunate fossa of the distal radius - contraindicated if there is an incompetent radioscaphocapitate ligament - advantages - greater postop ROM (flexion, extension, total flexion/extension arc), lower complication rate - others - earlier ROM no hardware - scaphoid excision and 4 corner fusion - advantages - greater radial deviation ROM, greater grip strength - Stage III - pan carpal arthritis - scaphoid excision and 4 corner fusion - wrist fusion - wrist fusion gives best pain relief and good grip strength at the cost of wrist motion

Answer 72

synovitis and significant edema

Answer 73

- **major blood supply is dorsal carpal branch (branch of the radial artery)** - enters scaphoid in a nonarticular ridge on the dorsal surface and supplies proximal 80% of scaphoid via retrograde blood flow - supplies proximal 80% of scaphoid via retrograde blood flow - minor blood supply from superficial palmar arch (branch of volar radial artery) - enters distal tubercle and supplies distal 20% of scaphoid

Answer 74

1. In the normal wrist: - Scaphoid links the proximal and distal carpal rows - Proximal row moves with the scaphoid - Scaphoid has a tendency to assume a flexed posture - Capitate longitudinal load on the lunate is eccentric causing the lunate and triquetrum to extend - These forces are balanced as long as the link between the scaphoid and lunate are intact 2. With scaphoid nonunion - The distal scaphoid flexes - The proximal scaphoid extends with the lunate and triquetrum

Answer 75

- Stage I - radial styloid - Stage II - proximal scaphocapitate joint - Stage III - capitolunate joint - Initially, degeneration occurs between the radial styloid and radial side of the distal scaphoid fragment - Degeneration does not progress proximally in the radioscaphoid joint because the proximal scaphoid relationship with the lunate is maintained - Degeneration progresses to the midcarpal joint starting with the proximal scaphocapitate joint then the capitolunate joint

Answer 76

3rd metacarpal shaft

Answer 77

10-15° of extension, slight ulnar deviation

Answer 78

1. Hemiresection-interposition 2. Ulnar shortening osteotomy 3. ‘Wafer’ resection 4. Sauve-Kapandji - DRUJ fusion with proximal pseudoarthrosis 5. Darrach - Complete distal ulna resection 6. Arthroplasty

Answer 79

humpback deformity (distal pole flexes over the volar radioscaphocapitate ligament) results from volar angulation of the proximal and distal poles of the scaphoid in the setting of scaphoid fracture through the waist The dorsal component forms a 'humpback' which can be palpated

Answer 80

1. Delayed union (<6 months) - ORIF with headless compression screw 2. Established nonunion without humpback - ORIF with headless compression screw + bone graft (cancellous ICBG or distal radius) 3. Nonunion with humpback deformity; no AVN - ORIF via volar approach + corticocancellous bone graft 4. AVN without humpback deformity - Vascularized bone graft via volar or dorsal approach 5. AVN with humpback deformity - Vascularized medial femoral condyle bone graft via volar approach

Answer 81

- Lichtman Classification - Stage I - Normal xray - **MRI decreased signal T1** - Bone scan positive - Stage II - **Lunate sclerosis** - Stage IIIa - **Lunate collapse (no scaphoid rotation)** - Carpal height maintained - Stage IIIb - Lunate collapse - Carpal collapse - Scaphoid rotation (hyperflexed, RS angle >60°) - Cortical ring sign - Capitate migrates proximal - Decreased carpal height - Stage IV - Pancarpal arthritis (Kienbock’s disease advanced collapse)

Answer 82

- Stage I (normal xray, mri decreased signal t1) - Nonoperative (3 months immobilization) - Stage II (lunate sclerosis) - Radial shortening osteotomy - If ulnar negative or neutral - Capitate shortening - If ulnar positive - (vascularized bone graft) - Stage IIIa (lunate collapse) - Same as Stage II - Vascularized bone graft (dorsal pedicle) - 4,5 ECA graft - Vascularized pisiform - Free vascularized medial femoral condyle - Stage IIIb (lunate/capitate collapse and scaphoid rotation) - Scaphocapitate fusion - STT fusion - PRC - Stage IV (pancarpal arthritis) - PRC - Total wrist arthrodesis

Answer 83

dorsal 4 + 5 extensor compartment artery (ECA) pedicled VBG

Answer 84

- what are surgical management options for DRUJ arthritis - darrach procedure - indications - preferred for low demand and nonreconstructable joint - technique - subperiosteal distal ulna exposure - distal ulna resection just proximal to sigmoid notch - preserve soft tissue - TFCC, ECU sheath, periosteum - hemiresection - indications -required intact TFCC - technique - classic -resection of articular distal ulna with remainder left insitu including TFCC attachment - hemi-resection interposition technique (HIT) - resection as classic - soft tissue interposition into void to prevent radioulnar convergence (capsular flap or free tendon) - sauve-kapandji procedure - indications - preferred for young, active patient with nonreconstructable joint - technique - dorsal or ulnar approach preserving soft tissue - identify and protect the dorsal cutaneous branch of the ulnar nerve - ulnar neck resection just proximal to sigmoid (~10-15mm) - sigmoid notch and ulnar head prepared for fusion (Cancellous bone) - DRUJ fusion with 2 k-wires or 3.5mm screw (neutral ulnar variance) - pronator quadratus interposed in osteotomy site (prevents re-ossificaiton) - FCU slip can be tenodesed through drill hole in ulnar stump to prevent instability - partial ulnar head arthroplasty - indication - isolated DRUJ arthritis without instability - failed HIT - total ulnar head arthroplasty - indications - painful instability after failed resection, isolated instability - requires stability from native soft tissues - total DRUJ arthroplasty - indications - incompetent native soft tissues, salvage option after failed distal ulnar resection

Answer 85

1. bone contour (sigmoid notch of radius and ulnar head) 2. TFCC 3. ulnocarpal ligament complex 4. ECU 5. ECU tendon sheath 6. pronator quadratus 7. interosseous membrane 8. DRUJ joint capsule

Answer 86

- nonop - acute dislocation - closed reduction and splinting in stable position for 6 weeks - dorsal radioulnar ligament injury - splint midsupination - volar radioulnar dislocaiton - splint midpronation - operative - acute DRUJ instability indications - irreducible - open reduction +/- DRUJ pinning +/- TFCC repair +/- ulnar styloid fracture fixation - associated fractures - ORIF of associated fractures often resolves the instability - if remains unstable pin in reduced position - TFCC tear - open or arthroscopic repair - open - dorsal interval between 5 & 5 compartment, TFCC repaired to distal ulnar with anchor or suture tunnels - reconstruction if repair fails - chronic DRUJ instability - in absence of arthritis - distal radius malunion - indications for correction = >20° of dorsal angulation (controversial) - correct distal radius malunion then assess DRUJ stability - if still unstable reconstruct the DRUJ - reconstruction - indications - TFCC or radioulnar ligament repair failure, unrepairable - Adams procedure +/- notchplasty (if flat lesser sigmoid) - dorsal approach between 5-6 compartments and PL graft radius and ulna - bain procedure - indication - chronic DRUJ instability with a TFCC foveal tear and stable radial attachment - positive arthroscopic hook and trampoline test - technique - dorsal approach via 5th extensor compartment, PL graft in TFCC and ulna - in presence of arthritis - darrach with ulnar stump stabilization - sauve-kapandji

Answer 87

- recommended views - AP radiograph with wrist in neutral supination/pronation and zero rotation - required to evaluate ulnar variance - pronated grip view - increases radiographic impaction - findings - ulna positive variance - sclerosis of lunate and ulnar head

Answer 88

- Ulnar shortening osteotomy - Technique - Subcutaneous approach to the ulna - Osteotomy at junction of distal and middle 1/3 - Compression plate - Volar surface preferred - Goal of 0 to -1mm ulnar variance - Advantages - Addresses ulnar styloid carpal impaction concomitantly - Decreases dorsal subluxation of distal ulna - Larger shortening can be achieved compared to wafer - Stabilizes ulnar ligament complex - Preferred if associated LT ligament injury - Disadvantages - Nonunion - Hardware irritation - Wafer procedure - Technique - Open or arthroscopic - Resection of thin wafer of dome of ulnar head - Advantage - Less revision compared to shortening osteotomy (hardware removal) - No nonunion - Disadvantage - Limit resection to 2-3mm - Does not address associated ulnar styloid carpal impaction - Does not improve dorsal ulnar subluxation - Does not tighten ulnar ligament complex

Answer 89

1. Articular disc * Extends between the volar and dorsal radioulnar ligaments (hammock) 2. Meniscus homologue 3. Volar and dorsal radioulnar ligaments * Superficial and deep (ligamentum subcruentum) * Major stabilizers of the DRUJ 4. Sheath of ECU 5. Ulnar capsule (ulnar collateral ligament) * Arises from the ulnar styloid and extends between the ulnotriquetral ligament and the ECU sheath 6. Ulnolunate and ulnotriquetral ligaments (volar)

Answer 90

1. Prominent ulna 2. Fovea sign - Palpation of the depression volar between ulnar styloid, FCU and pisiform - Tenderness suggests: - Tear of ulnotriquetral ligament - Foveal disruption of TFCC - Chondromalacia of ulnar aspect lunate - Suggestive of ulnocarpal impaction 3. Ulnocarpal stress test - Ulnar deviation with axial loading in alternating supination and pronation 4. Positive grind test - Clicking, crepitus or pain with passive supination and pronation 5. Lunotriquetral shuck test - Pain and laxity when examiner grasps the pisiform/triquetrum and lunate with opposite hands and translates volar and dorsal

Answer 91

extended wrist with forearm pronation

Answer 92

1. Nonoperative - Most tears are initially treated nonoperative 2. Operative - Contraindications: - Severe OA - Previous infection - Severe osteoporosis of ulnar head - Open - Indicated when fixing distal radius fracture or surgeon not familiar with arthroscopy - Arthroscopic - Palmar 1A – debridement - Palmer 1B, C, D – repair - Transosseous or suture anchor fixation - Ulnar positive wrists - Perform ulnar shortening osteotomy or wafer procedure at time of TFCC repair - Better outcomes

Answer 93

1. Proper collateral ligament * Taut in flexion 2. Accessory collateral ligament and volar plate * Taut in extension

Answer 94

1. UCL * Proximal phalanx avulsion (90%) * Midsubstance and metacarpal avulsion less common 2. RCL * Variable, more common proximal at metacarpal

Answer 95

1. Distal edge of the avulsed UCL is displaced proximal to the adductor aponeurosis * Blocked from reapproximation to its insertion on the proximal phalanx 2. Surgical management is recommended

Answer 96

Grade 1 * Sprain with no joint instability Grade 2 * Incomplete tear with asymmetric joint laxity * Instability does not meet the criteria for a complete tear * Characterized by increased laxity with a firm end point, or an incomplete tear Grade 3 * Complete tear with joint instability * Laxity of \>35° in 0° and 30° of flexion * Or 15° greater than that of the contralateral side

Answer 97

1. RCL * Adductor pollicis inserts on the proximal phalanx and ulnar sesamoid creating an ulnar and volar deforming force 2. Assess with anterior drawer test * \>3mm displacement volar is more common with RCL injury

Answer 98

Grade 1 and 2 * Nonoperative * Cast or splint x 4 weeks * Grip and pinch strengthening after 6 weeks Grade 3 * Surgical * Acute collateral ligament injury = repair * Avulsion from proximal or distal insertion * Suture anchor repair * Midsubstance tear * Direct repair * Chronic collateral ligament injury (\>3 weeks) * No arthritis * Ligament reconstruction with free graft (palmaris longus) * Arthritis = arthrodesis

Answer 99

DIP arthritis > CMC arthritis

Answer 100

Eaton and Littler Classification of Basilar Thumb Arthritis - Stage I - Normal joint with widening - Synovitis, effusion, ligamentous laxity - Stage II - Mild joint narrowing - Mild subchondral sclerosis - Subchondral cysts and/or periarticular debris - Stage III - Severe joint space narrowing - Subchondral sclerosis/cysts - Larger periarticular debris - Stage IV - Involves scaphotrapezial joint

Answer 101

1. Nonoperative - Exercise therapy, heat, education, magnetotherapy, adaptive equipment, orthoses, NSAIDs, corticosteroid injections 2. Operative - **Joint preserving options described (Stage I/II)** - 1st metacarpal extension osteotomy - Arthroscopy and debridement - Imbrication of the dorsoradial capsule - Volar beak ligament reconstruction - **Joint sacrificing options described (Stage III/IV)** - Trapeziectomy - **Trapeziectomy and ligament reconstruction and tendon interposition (LRTI)** - Distraction hematoma arthroplasty - **Suture suspension arthroplasty** - Prosthesis - CMC arthrodesis

Answer 102

1. Advanced age - 36% >80y vs. 6.6% 40-49y 2. Female 3. Ligamentous laxity/ higher Beighton score 4. Occupations - Repetitive finger use or heavy manual labour 5. Post-traumatic - Intra-articular fracture - Traumatic ligamentous instability

Answer 103

Dorsoradial dorsoradial ligament

Answer 104

1. Traction 2. Abduction 3. Pronation 4. Dorsal pressure on the base of the metacarpal (anatomical snuffbox)

Answer 105

1. Anteromedial (volar-ulnar) fragment * Smaller (less articular surface area) * Nondisplaced, attached to volar oblique ligament 2. Metacarpal fragment * Larger (greater articular surface area) * Displaced * Proximal, dorsal and radial

Answer 106

1. APL = proximal, dorsal, radial 2. Adductor pollicis = narrowing of 1st web space

Answer 107

1. Traction 2. Abduction 3. Pronation 4. Pressure to the metacarpal base (dorsal to palmer) *TrAPP/TAPP

Answer 108

Wagner approach - Junction of the glabrous and nonglaborus skin - Elevate thenar muscles and perform capsulotomy

Answer 109

1. Large anteromedial fragment - Open reduction and direct screw fixation 2. Small anteromedial fragment - CRPP – transarticular or intermetacarpal 3. Irreducible or intra-articular gap >2mm [J Hand Surg 2009;34A:945–952.] - Open reduction

Answer 110

‘T’ or ‘Y’ pattern - Extra-articular fracture separating metadiaphysis from epiphysis and a vertical fracture separating the epiphysis into two fragments - Central joint depression may be present

Answer 111

Open or arthroscopic reduction - Followed by provisional K-wire fixation and miniplate fixation or definitive k-wire fixation

Answer 112

1. <30° of angulation 1. **>30 results in unacceptable narrowing of the 1st web space**

Answer 113

1. Extension (most common) 2. Axial load of a flexed PIP joint

Answer 114

1. Volar plate rupture or avulsion of volar base off middle phalanx 2. Volar avulsion of variable size (loss of buttress effect)

Answer 115

1. Stable * Articular surface \<30% involvement * Clinical stability = stable throughout ROM 2. Tenuous * Articular surface = 30-50% involvement * Clinical stability = Requires ≤30° of PIP flexion to maintain reduction 3. Unstable * Articular surface \>50% involvment * Clinical stability = Requires \>30° of PIP flexion to maintain reduction

Answer 116

1. Stable * Buddy taping 2. Tenuous * Extension block splinting (if no hinging) * Prevents extension of the PIPJ into the range where it is unstable while permitting motion within the stable range 3. Unstable * Operative options * Extension block pinning or transarticular pinning +/- percutaneous pinning of large fracture fragment * Indicated when concern for closed reduction failure or digit will not accommodate extension block splint (swollen, short, small digit) * Dynamic distraction and external fixation (Suzuki splint) * ORIF * Large fragments * Volar plate arthroplasty * Comminuted and impacted volar fragment * \<50% articular surface involvement * Hemi-hamate resurfacing arthroplasty * Comminuted and impacted volar fragment * \>50% articular surface involvement

Answer 117

1. Hyperflexion 2. Axial load of an extended PIP joint

Answer 118

1. Central slip rupture or avulsion of dorsal base of middle phalanx 2. Dorsal avulsion of variable size

Answer 119

1. Stable and small minimally displaced fracture * \<50% articular surface and \<2mm displacement * PIP joint splinting 2. Stable and large or displaced fracture * \>50% articular surface and \>2mm displacement * CRPP or ORIF 3. Unstable with minimally displaced fracture * Dynamic distraction and external fixation

Answer 120

dorsal dislocation

Answer 121

avulsion of volar lip/FDP

Answer 122

associated with avulsion of dorsal lip/terminal tendon

Answer 123

1. volar plate 2. FDP

Answer 124

terminal tendon interposition

Answer 125

Apex volar * Proximal fragment flexes due to interosseous attachments * Distal fragment extends due to extensor central slip

Answer 126

1. Apex dorsal if fracture proximal to FDS insertion 2. Apex volar if fracture distal to FDS insertion

Answer 127

1. No rotation 2. \<10-15° angulation 3. \<2mm shortening

Answer 128

- displaced distal phalangeal physeal fractures with an associated nailbed injury. - resuls from hyperflexion - presents as mallet deformity (i.e. apex dorsal) due to - terminal tendon attaches to proximal epiphyseal fragment - FDP attaches to distal fragment

Answer 129

the digital nerve is palmar/volar to the artery in the finger sensation is performed with the pads (nerve is palmar) of your fingers and you test for cap refill at the fingernail (artery is dorsal)

Answer 130

- injury of the terminal extensor mechanism resulting in loss of active extension at the level of the DIPJ - injury is characterized by extensor tendon disruption, either isolated or in combination with a distal phalanx avulsion fracture

Answer 131

- - D.I.P. joint osteoarthritis - Swan Neck Deformity - Hyperextension at the level of the PIP joint as a result of proximal retraction of the central slip

Answer 132

- nonop - no associated fracture - no volar subluxation of the distal phalanx - fracture involving <30% of the articular surface - operative - open - fracture involving >30% of the articular surface - palmar subluxation of the distal phalanx

Answer 133

A1 - MCP volar plate A2 - proximal phalanx C1 - between A2-A3 A3 - PIP volar plate C2 - between A3-A4 A4 - middle phalanx C3 - between A4-A5 A5 - DIP volar plate

Answer 134

A1 - MCP volar plate Oblique pulley - proximal half of proximal phalanx A2 - IP volar plate

Answer 135

Oblique pulley

Answer 136

Zone 1 - distal to FDS insertion Zone 2 - FDS insertion to proximal A1 pulley Zone 3 - proximal A1 pulley to distal transverse carpal ligament Zone 4 - carpal tunnel Zone 5 - proximal transverse carpal ligament to musculotendinous junction

Answer 137

1. Easy placement of sutures in the tendon 2. Secure knots 3. Smooth juncture of the tendon ends 4. Minimal gapping 5. Minimal interference with tendon vascularity 6. Sufficient strength

Answer 138

1. Minimal tendon handling to minimize adhesion 2. Strength of repair is proportional to the number of core sutures and caliber of suture 3. Core sutures should be 7-10mm from tendon edge 4. Dorsal placement is biomechanically advantaged 5. Epitendinous (peripheral) suture improves: * Strength * Minimizes gapping * Reduces CSA * Decreases gliding friction 6. Locking loops increase tensile repair 7. Internal knots have decreased strength

Answer 139

Pathways * Intrinsic = tenocytes within the tendon * Extrinsic = inflammatory cells outside the tendon * Implicated in adhesions/scarring Phases * Inflammatory (0-72h) * Strength of repair is equivalent to strength of suture repair * Proliferative (72h-4 weeks) * Type III collagen laid down * Strength increases * Remodeling phase (\>4 weeks - 112 days) * Type I collagen laid down * Strength increases * Does not reach preinjury

Answer 140

1. Tendon sheath * Fibrocartilaginous metaplasia * Cartilage degradation * Vascular ingrowth 2. Tendon * Chronic degenerative tears * Absence of inflammatory cells

Answer 141

Ring finger and thumb

Answer 142

1. Female 2. Diabetes 3. RA 4. Crystalline arthropathy 5. Thyroid disease 6. Renal insufficiency 7. Overuse

Answer 143

Carpal tunnel syndrome * \>60% of patients with trigger digits demonstrate clinical or electrodiagnostic evidence of median nerve compression at the wrist

Answer 144

1. Puncture wound (most common) 2. Staph aureus (most common)

Answer 145

1. Symmetric swelling of entire digit 2. Tenderness along course of tendon sheath 3. Semiflexed posture 4. Pain with passive extension of digit

Answer 146

1. Northern European 2. Caucasian 3. Male 4. Family history * Autosomal dominant 5. Advanced age 6. Smoking 7. Alcohol 8. Local trauma 9. Local infection 10. Diabetes (type I \> type II) 11. Epileptic medication 12. Manual labour

Answer 147

Myofibroblasts

Answer 148

Pretendinous cord [Normal fascial bands become pathologic cords]

Answer 149

1. Transverse ligament of the palmar aponeurosis 2. Cleland ligament

Answer 150

1. Pretendinous cord = MCP contracture 2. Central cord = PIP contracture 3. Lateral cord = PIP or DIP contracture 4. Natatory cord = web space contracture 5. Spiral cord = displaces NV bundle superficial and to midline * MCP and PIP contracture

Answer 151

Ring finger * Followed by: * Small * Long * Index * Thumb

Answer 152

MCP before PIP

Answer 153

Palmer to digital

Answer 154

1. Peyronie disease (penile fibromatosis) 2. Ledderhose disease (plantar fibromatosis)

Answer 155

1. Indications * ≥30° MCP joint contracture * \>15° PIP joint contracture 2. Techniques * Fasciotomy * Limited fasciectomy * Dermofasciectomy * Radical fasciectomy (healthy and diseased fascia)

Answer 156

1. Rheumatoid nodules 2. Caput ulnae syndrome * Dorsal subluxation of the distal ulna * Prominent ulnar head 3. Carpal deformity * Classically, palmar translation, ulnar translation, supination, radial deviation 4. DISI or VISI 5. Arthritis * Usually progression from DRUJ, radiolunate/radioscaphoid, pancarpal arthritis 6. Extensor tendon * Tenosynovitis * EDQ rupture * EDC rupture 7. Flexor tendon * Tenosynovitis * Carpal tunnel syndrome * FPL rupture over prominent distal scaphoid and trapezium (Mannerfelt syndrome) * FDS and FDP rupture 8. Ulnar drift 9. Volar subluxation of proximal phalanx to MCP joint 10. Swan neck deformity 11. Boutonniere deformity

Answer 157

1. Darrach procedure * Favoured in low demand, elderly patients * Main concern in RA is ulnar translation of carpus (weak ligamentous support) 2. Sauve-Kapandji * Favoured in active, younger patients * Main concern in RA is less predictable fusion

Answer 158

1. Thumb amputation 2. Multiple digit amputation 3. Amputations at or proximal to the palm 4. Pediatric finger amputation at any level 5. Single digit amputation in Zone I (relative)

Answer 159

1. Single digit amputation through Zone II 2. Severe crush, mangled or contaminated amputation 3. Segmental injuries 4. Prolonged warm ischemia time 5. Medically unfit

Answer 160

1. Red line sign * Red stripe along the mid lateral aspect of the avulsed digit * Represents hemorrhage along the vessel 2. Ribbon sign * Tortuous, spiraled blood vessels are seen * Indicates significant intimal injury

Answer 161

Elson test * The examiner holds the PIP joint in 90° of flexion and instructs the patient to actively extend the DIP joint * With an intact extensor mechanism, holding the PIP joint in 90° of flexion causes slack in the lateral bands as they are held distally by their attachments to the central slip * The patient is unable to generate any extension power at the DIP joint * With a boutonnière injury, flexion of the PIP joint does not advance the lateral bands distally secondary to disruption of the central slip * Tension is generated in the terminal tendon because of the disrupted central slip * Therefore, the patient is able to generate an abnormal amount of active extension at the DIP joint with the PIP joint held in flexion

Answer 162

Bunnell test * A patient with intrinsic muscle tightness will have a decrease in passive and active flexion of the PIP joint with the MP joint held in extension

Answer 163

1. Postaxial (ulnar) polydactyly (most common) 2. Preaxial (radial) polydactyly * Involves the thumb 3. Central polydactyly (rare)

Answer 164

Type A * Well-formed digit with osseous connection Type B * Incompletely-formed with soft tissue connection * Nonfunctional

Answer 165

Type I * Bifid distal phalanx Type II * Duplicated distal phalanx (2nd most common) Type III * Bifid proximal phalanx Type IV * Duplicated proximal phalanx (most common) Type V * Bifid metacarpal Type VI * Duplicated metacarpal Type VII * Any triphalangeal thumb

Answer 166

- Mannerfelt syndrome - rupture of FPL due to scaphoid spur - treatment - FDS4 to FPL tendon transfer + excision of scaphoid spurs (may also lead to rupture index FDP2) - tendon graft + spur excision - IPJ fusion (for advanced disease)

Answer 167

Vaughan-Jackson syndrome describes the rupture of the hand digital extensor tendons, which start on the ulnar side of the wrist first and then move radially. This is thought to occur from DRUJ instability, resulting in dorsal prominence of the ulnar head, leading to an attritional rupture of the extensor tendons. Extensor digiti minimi is the extensor tendon commmonly ruptured. (5th compartment)

Answer 168

Destruction of the DRUJ leads to caput ulnae syndrome: dorsal dislocation of the distal ulna, supination of the carpus on the radius, and volar subluxation of the extensor carpi ulnaris tendon. The “piano keyboard sign” is indicative of DRUJ instability and is elicited when the ulnar head is depressed volarly and rebounds as pressure is released. A “Z collapse pattern” is observed as the carpus translates ulnarly, the metacarpals deviate radially, followed by ulnar deviation of the fingers. - **Darrach distal ulna resection** - must also relocate ECU dorsally with a retinacular flap or perform ECU stabilization of ulna - **ulnar hemiresection** - **Sauvé-Kapandji** (ulnar pseudoarthrosis) - has advantage of preserving the TFCC - good option for younger patients

Answer 169

CN IX, X, XI * travel in jugular foramen adjacent to occipital condyle

Answer 170

1. Traumatic – often fatal 2. Acquired – often associated with Down’s syndrome

Answer 171

1. Harris lines (Harris rule of 12s) * Basion-dens interval * Normal = \<12mm * Distance from basion to tip of dens * Basion-axis interval * Normal = 4-12mm * Distance between line parallel to posterior cortex of C2 and basion 2. Powers ratio [Orthobullets] * Distance from basion to posterior arch C1/distance from opisthion to anterior arch C1 * Normal = 1 * \>1 = anterior dislocation * \<1 = posterior dislocation, dens fracture, ring of atlas fracture 3. Wackenheim line * Line parallel along the posterior portion of the clivus to the upper cervical spine * Normal = tip of dens is \<1-2mm from Wackenheim line

Answer 172

1. Atlanto-dens interval (ADI) * Distance between anterior dens and posterior aspect of anterior arch of C1 * Normal = \<3mm in adults * \>3mm indicates transverse ligament disruption and C1-C2 instability 2. Lateral atlanto-dens interval * Distance between the lateral surface of the dens and the medial surface of the lateral mass of C1 * Normal = \<2mm of asymmetry 3. Combined lateral mass overhang * Combined horizontal distance from lateral border of C1 to lateral border of C2 on open mouth radiographs or coronal CT * Normal = \<7mm * \>7mm indicates transverse ligament rupture and C1-C2 instability

Answer 173

Landells Classification * Type I - isolated anterior or posterior arch fracture * Type II - Jefferson burst fracture (bilateral anterior and posterior arch fractures) * Type III - unilateral lateral mass fracture

Answer 174

Dickman classification * Type I - intrasubstance tear * Type II - bony avulsion from tubercle at lateral mass of C1

Answer 175

1. Atlanto-dens interval * Normal <3mm in adults (<5mm in children) 2. Space available for the cord – SAC (posterior atlantodens interval – PADI) * Normal >13mm

Answer 176

1. Anderson and D’Alonzo Classification * Type I - odontoid tip fracture * Oblique fracture due to bony avulsion of the alar ligament * Type II - base of the dens fracture * Does not involve the C2 superior articular facet * High non-union rate due to watershed area * Type III – C2 body fracture * Does involve the C2 superior articular facet 2. Grauer modification * Type IIA - transverse fracture, \<1mm displacement * Type IIB- oblique fracture extending from anterosuperior to posteroinferior * Type IIC- oblique fracture extending from anteroinferior to posterosuperior * May be associated with significant anterior comminution

Answer 177

1. Type I * Stable fractures (at least one alar ligament and the transverse ligament is intact) * Cervical collar * Unstable fractures (associated craniocervical dissociation) * Posterior C0-C2 fusion 2. Type II * Young patient * No risk factors for nonunion = halo immobilization * Risk factors for nonunion = surgery * Elderly patient * Surgical candidate = surgical stabilization * Posterior C1-C2 fusion * Not surgical candidate = cervical orthosis * Results in fibrous union in most cases * Halo vest is associated with high rate of morbidity and mortality in elderly 3. Type III * Cervical orthosis

Answer 178

1. Age \>40 2. Posterior displacement \>5mm 3. Angulation \>11° 4. Comminution 5. Fracture gap \>1mm 6. Delay in treatment (4 day delay) 7. Concomitant neurological injury

Answer 179

Levine and Edwards Classification * Type I * Minimally displaced pars interarticularis fracture * Translation \<3mm of C2, no angulation * MOI = axial load and hyperextension * Type Ia * Oblique fracture through one pars interarticularis and anterior to the pars within the body of the contralateral side (unstable) * Type II * Translation \>3mm of C2 * MOI – axial load and hyperextension followed by flexion * Type IIa * Angulation (kyphosis) more than translation * MOI = flexion-distraction * Type III * Similar pars fracture as type I plus C2/C3 facet dislocation * MOI = flexion distraction followed by hyperextension * \*\*\*Note: hyperextension causes the pars fracture and flexion causes PLL and disc rupture

Answer 180

Type I - hard cervical orthosis (12 weeks) Type Ia - halo immobilization Type II - halo immobilization (12 weeks) Type IIa * C2-C3 ACDF or posterior fixation [JAAOS 2014;22:718-729] * Reduction with gentle axial load + hyperextension, then compression halo immobilization for 6-12 weeks [Orthobullets] Type III - posterior reduction and stabilization * C2-C3 or C1-C3 fusion

Answer 181

1. Allen and Ferguson * 6 classes based on mechanism of injury and static radiographs (used in research) * Flexion-compression, vertical compression, flexion-distraction, extension-compression, extension-distraction, lateral flexion 2. Subaxial Injury Classification System (SLIC) * Three components * Morphology * Integrity of the discoligamentous complex * Neurological status * Score dictates treatment * \<4 = conservative treatment * 4 = treatment at discretion of surgeon * \>4 = surgical treatment

Answer 182

1. Compression fracture * Characteristics = anterior vertebral height loss, posterior vertebrae not involved * Nonoperative * Indicated if stable and PLC intact * Facet joints are not subluxed or dislocated * No vertebral translation * Minimal gapping of interspinous spaces * Kyphosis \<11° * Rigid cervical collar for 3 months followed by flex-ex views * Operative * Indicated if unstable or neurological deficit * Facet joint subluxation or dislocation * Vertebral translation * Gapping of interspinous spaces * Kyphosis \>11° * MRI findings suggestive of PLC disruption * Anterior or posterior stabilization 2. Burst fracture * Characteristics = comminuted vertebral body fracture involves the posterior vertebral body often with retropulsed fragments * Nonoperative: * Indicated if no PLC disruption, no neurological deficit (rare) * Halo vest or rigid cervicothoracic orthosis * Operative: * Indicated if PLC disruption, neurological deficit * Anterior corpectomy * Plus posterior instrumentation and fusion if PLC is disrupted 3. Flexion teardrop fracture * Characteristics = oblique fracture line from anterior vertebral body to the inferior endplate (quadrangular fragment) * May have posterior translation of the posterior vertebral body * PLC disruption suggested by interspinous and facet gapping * Nonoperative * Minimally displaced, little kyphosis, intact PLC * Rigid cervical collar * Operative * Neurological deficit, PLC disruption * Posterior VB translation, kyphosis \>11° * ACDF 4. Extension teardrop fracture * Characteristics = small avulsion from anterior vertebral body * Nonoperative * Considered a stable injury * Rigid cervical collar

Answer 183

1. Facet subluxation 2. Unilateral facet dislocation (25% displacement on XR) 3. Bilateral facet dislocation (50% displacement on XR) 4. Complete dislocation (100% displacement on XR)

Answer 184

1. Presence of a disc herniation can lead to neurological injury upon reduction/realignment of the cervical spine 2. Herniations with disc material posterior to the displaced vertebral body are most concerning

Answer 185

1. Obtain MRI * Neurologically intact patient * No urgency to perform reduction, if disc is present you can convert a neurologically intact patient to one with deficits if reduction performed * Obtunded, nonexaminable patient * If neurologically intact, reduction in presence of disc may lead to neurological deficit * Planning posterior approach and reduction * Failed closed reduction or neurological deterioration during closed reduction [Orthobullets] 2. Omit MRI * Awake, alert, cooperative patient with incomplete cord injury or worsening neurological deficit * Patient would benefit from immediate reduction rather than delaying for MRI * Complete cord injury

Answer 186

1. Requires an awake, alert and cooperative patient 2. Gardner-Wells tongs are applied * Pins 1cm above the pinna of the ear in line with the external auditory meatus below the equator of the skull * Placement slightly posterior produces flexion moment (often desirable in cervical facet dislocation) * Skin is prepped and lidocaine injected subcutaneously and subperiosteally * Pins are tightened until indicator pin protrudes at least 1mm 3. 10lbs of weight is applied initially then 5-10lbs added incrementally * After each weight – lateral radiograph and neurological examination * Apply additional weight after 10-15mins 4. Once reduction is achieved the weight can be reduced to approximately 10-20lbs to maintain reduction

Answer 187

1. Presence of disc herniation 2. Absence of disc herniation (if surgeon prefers over posterior)

Answer 188

1. synchondroses between ossification centers 1. neurocentral synchondroses - between posterior elements and body 2. dentocentral synchondroses - between dens and body of C2 3. normal = smooth with subchondral sclerotic lines 2. increased elasticity of ligaments, capsule and enplates 3. wedge-shaped vertebral bodies 1. normal = ≤ 3mm of anterior wedging 4. horizontally oriented facet joints 5. virtually absent uncinate processes 6. pseudosubluxation of C2 and C3 1. normal = spinolaminar line (swichuk’s line) between C1-3 should pass within 1mm of C2 spinolaminar junction 2. abnormal = >1.5mm of displacement 7. loss of cervical lordosis in neutral position 8. increased ADI 1. normal = 3-5mm Note - pediatric spine adops a more adult configuration by age 8

Answer 189

- sciwora = spinal cord injury without radiographic abnormality - refers to ‘objective signs of myelopathy resulting from trauma with no evidence of ligamentous injury or fractures on plain radiographs or CT - occurs as a result of greater elasticity of spinal structures in pediatric population - more common in younger children but may occur at the age of 16 - traditionally treated by external immobilization for up to 3 months to allow tissues to heal - at 3 months a flexion-extension radiograph is performed to ensure no instability

Answer 190

1. Anterior column = anterior half/part of vertebral body/disc and ALL 2. Middle column = posterior half/part of vertebral body/disc and PLL 3. Posterior column = posterior elements including pedicles, facets, lamina, spinous process and ligaments \*\*\*NOTE – based on this system fractures extending into the middle column are largely considered unstable

Answer 191

1. AP view = widened interpedicular distance 2. Lateral view = loss of height of posterior cortex

Answer 192

1. Thoracolumbar Injury Classification and Severity Score (TLICS) * 3 injury characteristics * Injury morphology * Neurological status * Integrity of PLC * Score dictates treatment * \<4 = nonsurgical * 4 = nonsurgical or surgical * \>4 = surgical 2. AO Thoracolumbar Classification (Morphology) * TYPE A = Compression Injuries * A0 = Minor, nonstructural fractures * Fractures which do not compromise the structural integrity of the spinal column (eg. transverse process and spinous processes) * A1 = Wedge-compression * Fracture of a single endplate without involvement of the posterior wall of the vertebral body * A2 = Split * Fracture of both endplates without involvement of the posterior wall of the vertebral body * A3 = Incomplete burst * Fracture with any involvement of the posterior wall; only a single endplate fractured * Vertical fracture of the lamina is usually present and does not constitute a tension band failure * A4 = Complete burst * Fracture with any involvement of the posterior wall and both endplates * Vertical fracture of the lamina is usually present and does not constitute a tension band failure * TYPE B = Distraction Injuries * B1 = Transosseous tension band disruption (Chance fracture) * Monosegmental pure osseous failure of the posterior tension band * B2 = Posterior tension band disruption * Bony and/or ligamentary failure of the posterior tension band together with a Type A fracture * Type A fracture should be classified separately * B3 = Hyperextension * Injury through the disc or vertebral body leading to hyperextended position of the spinal column * Commonly seen in ankylotic disorders * Anterior structures, especially ALL are ruptured but there is a posterior hinge preventing further displacement * TYPE C = Translation Injuries * C = Displacement/dislocation * There are no subtypes because various configurations are possible due to dissociation/dislocation * Can be combined with subtypes of A or B

Answer 193

1. Neurologically intact 2. \<25° kyphosis 3. \<50% vertebral height loss 4. \<50% canal compromise 5. Intact PLC

Answer 194

Asia A: Complete * No motor or sensory function preserved in sacral elements Asia B: Incomplete * Sensory but not motor function preserved below neurological level Asia C: Incomplete * Greater than half the muscles below affected level are \< antigravity power (\<3/5) Asia D: Incomplete * Greater than half the muscles below affected level are \> antigravity (\>3/5) Asia E: Normal

Answer 195

1. temporary loss of motor (flaccid paralysis), sensation and reflexes as a result of an acute spinal cord injury 2. state of complete areflexia as demonstrated by loss of bulbocavernosus reflex secondary to an acute spinal cord injury 3. the significance is that thee extent of the neurologic injury cannot be determined until the spinal shock has resolved 4. spinal shock is resolved upon return of the bulbovacernosus reflex 1. usually resolves within 24h from time of injury 2. bulbocavernosus test = clinical test to assess the integrity of the intact S3-S4 arc, performed by squeezing the glans penis, placing pressure on the clitoris, or tugging on a foley catheter 3. an intact reflex will result in contraction of the anal sphincter

Answer 196

1. hypotension and bradycardia 2° to loss of sympathetic tone as a result of an acute spinal cord injury 2. typically occurs with an acute spinal cord injury above the level of T6

Answer 197

1. ipsilateral loss of all sensory modalities at the level of the lesion 2. ipsilateral flaccid paralysis at the lecel of the lesion 3. ipsilateral spastic paraparesis below the lesion 4. ipsilateral loss of vibration and position sense below the lesion 5. contralateral loss of pain and temperature below the lesion

Answer 198

1. loss of pain, temperature, crude touch sensations below the level of the lesion 2. loss of motor below the level of the lesion 3. orthostatic hypotension, bladder and/or bowel incontinence and sexual dysfunction 4. preservation of fine touch, proprioception and vibration

Answer 199

1. loss of fine-touch, proprioception and vibration below the level of the lesion 2. preservation of motor, pain, temperature, crude touch

Answer 200

1. lower extremity weakness (mixed UMN and LMN deficits) 2. main difference between cauda equina syndrome (only LMN deficits) 3. saddle anesthesia 4. bowel and bladder dysfunction 5. impotence

Answer 201

L1 vertebral body (T12-L2 vertebra)

Answer 202

1. Collection of peripheral nerves (L1-S5) in a common dural sac within the lumbar spinal canal 2. Therefore, lesions involving the cauda equina are lower motor neuron lesions

Answer 203

1. Cervical nerve roots exit above their numbered pedicles * Except C8 which exits above T1 2. Exiting nerve roots affected * Eg. C5-C6 disc herniation affects the C6 nerve root

Answer 204

1. Unilateral neck pain 2. Upper trapezial and interscapular pain 3. Radiculopathy patterns/Symptoms * C2 * Posterior occipital headaches, temporal pain * C3 * Occipital headache, retro-orbital or retroauricular pain * C4 * Base of neck, trapezial pain * C5 * Lateral arm pain * Motor loss - Deltoid * Reflex - Biceps * C6 * Radial forearm pain, pain in the thumb and index fingers * Motor loss - Biceps, wrist extension * Reflex - Brachioradialis * C7 * Middle finger pain * Motor loss - Triceps, wrist flexion * Reflex - Triceps * C8 * Pain in the ring and little fingers * Motor loss - Finger flexors * T1 * Ulnar forearm pain * Motor loss - Hand intrinsics

Answer 205

1. Inherited predisposition 2. Congenital stenosis

Answer 206

1. Degenerative disc (anterior) 2. Uncovertebral joint osteophyte (anterior) 3. Hypertrophied/infolded ligamentum flavum (posterior) 4. Facet joint degeneration (posterior)

Answer 207

1. \>10° rigid kyphosis * 1 or 2 levels of compression = anterior approach * ACDF/Corpectomy * 3+ levels of compression = combined anterior and posterior * Anterior corrects kyphosis and decompresses * Posterior decompresses 2. \<10° rigid kyphosis * 1 or 2 levels of compression = anterior approach * ACDF/Corpectomy * 3+ levels of compression = posterior approach * Laminectomy + fusion OR laminoplasty

Answer 208

C5 palsy (4.6% of patients) * Thought to be due to posterior migration of the spinal cord with tethering of the nerve root

Answer 209

low signal on T1 clasically also have high signal on T2

Answer 210

Replacement of the PLL with lamellar bone

Answer 211

1. East Asians 2. Male 3. DISH 4. Hyperparathyroidism 5. Hypophosphatemic rickets 6. Hyperinsulinemia 7. Obesity

Answer 212

1. Line from center of the spinal canal at C2 to center of canal at C7 2. Assesses the affect of the size of OPLL and the cervical lordosis 3. Negative K-line = OPLL protrudes posterior to the K-line 4. Positive K-line = OPLL protrudes anterior to the K-line 5. Significance = negative K-line is a negative predictor of outcome for posterior surgery alone

Answer 213

1. OPLL occupies \>60% of the canal 2. Loss of cervical lordosis

Answer 214

1. OPLL (greatest risk factor for cervical spine surgery) 2. Revision surgery 3. Surgeon inexperience 4. Age * Due to: * Narrowing of the spinal canal * Thicker ligamentum flavum * Osteophyte formation * Redundant dura due to shortening of the spine

Answer 215

1. Ensure proper visualization * Dry field * Adequate hemostasis * Loupes or microscope 2. Primary repair when possible * Augment as necessary * Fat grafts, fibrin glue, collagen matrix, hydrogels * Dural grafts when primary closure not possible * Fascia lata, lumbodorsal fascia 3. Test the repair for watertight closure * Deflated dura should inflate in pulsatile fashion * Test repair with Valsalva * Duration of 15-20 sec, supine posture, and 40 mmHg intrathoracic pressure [Can J Anesth (2018) 65: 578.] 4. Tight fascial and wound closure in layers 5. Bedrest until symptoms of CSF leak resolve * Cervical durotomy – position patient upright * Lumbar durotomy – position patient supine * Symptoms managed with opiods, NSAIDs, antiemetics, caffeine

Answer 216

* Positional headache * Nausea * Photophobia * CSF leak from wound or subfascial drain

Answer 217

B-2 transferrin assay

Answer 218

Up to 95% at L4-L5 and L5-S1

Answer 219

1. Central * Causes back pain * Can cause cauda equina 2. Paracentral (posterolateral) * Affects the descending nerve root (L4/5 affects L5) 3. Foraminal (far lateral) * Affects the exiting nerve root (L4/5 affects L4)

Answer 220

1. Protrusion * Eccentric bulging through an intact anulus fibrosus 2. Extrusion * Disc material crosses the disrupted anulus fibrosus but is continuous with the disc space 3. Sequestered * Free fragment * Disc material is not continuous with the disc space

Answer 221

Achondroplasia * Congenitally short pedicles * Thick lamina * Interpedicular distance that decreases caudally

Answer 222

1. Central * Disc-osteophyte complex and ligamentum flavum hypetrophy 2. Lateral recess * Facet hypertrophy and osteophytes 3. Foraminal * Loss of disc height * Foraminal disc protrusion * Osteophyte * Scoliosis 4. Extraforaminal * Far lateral disc herniation

Answer 223

Facet arthrosis

Answer 224

1. Sagittally oriented facets (congenital) 2. Transitional lumbosacral L5 /sacralization of L5

Answer 225

1.Central and lateral recess stenosis * A. Caused by slippage, hypertrophied ligamentum flavum, facet arthrosis * B. Affects descending L5 nerve root 2.Foraminal stenosis * A. Caused by * i. Vertical stenosis – due to loss of disc height and posterolateral osteophytes from vertebral body compressing nerve root against inferior pedicle * ii. Anterosuperior stenosis – due to facet arthrosis and posterior vertebral body osteophytes * B. Affects exiting L4 nerve root

Answer 226

Pars interarticularis defect (spondylolysis)

Answer 227

L5 spondylolysis (L5 on S1)

Answer 228

1. Slip \<50% = low grade (Grade I-II) 2. Slip \>50% = high grade (Grade III-V)

Answer 229

1. Degenerative * Level = L4-5 * Central Stenosis = present * L5 nerve compression = at origin 2. Isthmic * Level = L5-S1 * Central Stenosis = absent * L5 nerve compression = foramen

Answer 230

1.Pelvic balance * Balanced = SS \> PT * Unbalanced = SS \< PT 2.Spinopelvic balance * Balanced = C7 plumb line falls over or behind the femoral heads * Unbalanced = C7 plumb line falls infront of the femoral heads

Answer 231

Staph aureus

Answer 232

Lumbar spine

Answer 233

Thoracic spine

Answer 234

Caseating granuloma

Answer 235

1. Peridiscal (most common) * Begins adjacent to a single vertebral end plate (metaphysis) * Spreads peripherally to the adjacent intervertebral disc * Less severely affected and relatively preserved * Tracks deep to the ALL to spread to an adjacent vertebra 2. Central * Abscess formation in the central vertebral body * Leads to vertebral collapse and spinal deformity 3. Anterior * Begins anterior to the vertebral body and posterior to the ALL * Spreads under ALL, scallops vertebral body and may extend multiple levels

Answer 236

1. Nonspecific – WBC, ESR, CRP 2. Tuberculin skin test * Positive = induration \>5-15mm after 48-72 hours 3. Interferon gamma release assay * Blood test equally sensitive but more specific 4. PCR 5. CXR * Segmental or lobar infiltrates with ipsilateral hilar or mediastinal lymphadenopathy 6. Thoracolumbar xray * Osteolysis of affected vertebra * Kyphotic deformity (late) 7. MRI * T1 - Homogenous low signal with subligamentous spread * T2 – Heterogenous high signal with subligamentous spread 8. CT guided biopsy * Diagnostic yield = 42-76% * If nondiagnostic consider open biopsy * Send biopsy for: * Aerobic, anaerobic and tuberculous-specific culture (broth cultures) * Acid-fast bacilli smear microscopy * PCR * Pathology (detects caseating granuloma)

Answer 237

Atlantoaxial instability → atlantoaxial impaction → subaxial instability

Answer 238

1. Atlantoaxial impaction * Collapse of the lateral masses due to involvement of the atlanto-occipital and atlantoaxial joints * Erosion of O-C1 and C1-2 joints such that odontoid appears to enter foramen magnum * Weakening and collapse of the lateral masses 2. Atlantoaxial instability * Due to weakening or rupture of the transverse, alar and apical ligaments * Synovitis and pannus weaken the transverse, alar and apical ligaments * Repetitive strain leads to stretching or rupture * Bony erosion of dens or atraumatic dens fractures possible 3. Subaxial instability * Due to destabilization of the facet joints with weakening of the facet capsule and interspinous ligaments * Destruction of facet joints and uncovertebral joints * Weakening of interspinous ligaments * Lack of osteophyte formation results in relative instability * Versus stability in OA due to osteophytes * Disc and annulus also degenerative but synovitis does not develop * Thus, anterior disease does not directly contribute to instability

Answer 239

1. Atlantoaxial impaction * McCrae’s line * Line between basion and opisthion * Normal = tip of dens should be below line * McGregor’s line * Line between hard palate and base of the occiput * Abnormal = tip of dens 4.5mm above line * Ranawat Index * Distance from midpoint of C2 pedicle along centre of odontoid to horizontal line through C1 * Abnormal = \<15mm in males, \<13mm in females * Cervicomedullary angle (MRI) * Angle between anterior aspect of cervical cord and anterior medulla * \<135° indicates impending neurological impairment * Clark’s station * C2 divided into thirds (1 is superior, 3 is inferior) * Abnormal = anterior ring of C1 is in the 2nd or 3rd station * Simplest method to use as the relationship does not change in flexion, extension or neutral * \*\*\*McRae and McGregors inaccurate with odontoid erosion 2. Atlantoaxial instability * ADI (atlantodental interval) * Distance between the anterior dens and the posterior anterior arch of C1 * Abnormal = \>3.5mm * \>5mm suggests instability * \>10mm suggests complete loss of ligamentous integrity * PADI/SAC * Posterior atlantodental interval/space available for the cord * Distance between the posterior dens and the posterior arch of C1 * Abnormal = ≤14mm is an indication for surgery * Need 14mm for canal (10 cord, 1 dura, 1 CSF) * \<10mm assoc with poor neuro outcomes * ≥14mm assoc with excellent neuro outcomes * Better predictor of neuro outcomes than ADI * \*\*\*ADI and PADI can not evaluate cord compression by soft tissues (i.e. pannus) 3. Subaxial instability * C2/3 and C4/5 most commonly involved * Kyphosis * “staircase” when multiple levels involved * Facet joint erosions and widening * Spindling of the spinous processes * Subluxation * Abnormal = \>4mm or 20% listhesis of vertebral body diameter

Answer 240

1. Intractable pain 2. Neurologic deficits 3. ADI \>10 [Orthobullets] 4. PADI ≤14mm 5. Dens migration ≥5mm rostral to McGregor’s line 6. Subaxial subluxation with canal diameter ≤14mm 7. Cervicomedullary angle \<135° \*\*\*Increased function and lifespan compared to non-op

Answer 241

1. Flowing ossification along the anterolateral aspect of at least 4 contiguous vertebra 2. Preservation of disc height and relative absence of degenerative changes 3. Absence of facet joint or SI joint ankylosis

Answer 242

Thoracic spine (right sided due to aorta)

Answer 243

Lower cervical spine followed by thoracolumbar junction

Answer 244

- 1. bilatearl symmetric sacroiliitis 1. initial widening, progressive sclerosis to eventual fusion 2. marginal syndesmophytes development 1. shiny corner sign (sclerosis of the annulus fibrosus insertion into the endplate) 2. romanus lesion (erosion of the annulus fibrosus insertion into the endplate) 3. squaring of the vertebral body 4. marginal syndesmophyte (ossification of the outer annulus fibrosus fibers) 3. bamboo spine 1. continuous marginal syndesmophytes giving a bamboo stalk appearance indicating ankylosis 4. ankylosis of the facet joints 5. trolley track sign on AP view 6. central line of ossification (supraspinous and interspinous ligaments ) with 2 lateral lines of ossificaiton (facet joints) 7. osteopenia 8. dural ectasia

Answer 245

thoracic kyphosis with anterior wedging of ≥ 5° of at least 3 consecutive vertebral bodies (rigid thoracic hyperkyphosis >45°, apex usually T6-8)

Answer 246

narrowed disc space, irregular endplates, schmorl nodes

Answer 247

Indications * Painful osteoporotic compression fracture that does not improve with 2 to 3 weeks of nonsurgical care * Patient hospitalized as a result of painful osteoporotic fracture * Painful pathologic fracture * Aggressive hemangioma of the spine * Kümmell disease * Post traumatic AVN of vertebral body Absolute Contraindications * Asymptomatic fractures * History of vertebral body osteomyelitis * Allergy to bone fillers or opacification agents * Irreversible coagulopathy Relative Contraindications * Presence of radiculopathy * Bone retropulsion against neural structures * Greater than 70% collapse of vertebral body height * Multiple pathologic fractures * Lack of surgical backup to manage potential complications

Answer 248

Rotation of the atlantoaxial complex that is held in a fixed position as a result of muscle spasm or a mechanical block to reduction

Answer 249

1. New, fixed torticollis 2. Head held in classic “cock robin” position * Head tilted to one side and chin rotated to the side opposite the facet subluxation 3. Pain in the neck or jaw 4. No preexisting history of congenital muscular torticollis, significant trauma or congenital abnormality

Answer 250

Spine * Thoracic \> lumbar \> cervical

Answer 251

Modified Tokuhashi scoring system * high score is good, low score is bad * 6 components * Karnofsky performance status * Number of extraspinal metastases foci * Number of metastases in the vertebral body * Metastases to the major internal organs * Primary site of cancer * Palsy (neurological status) * Score: * 0-8 = life expectancy ≤ 6 months * Conservative treatment versus palliative * 9-11 = life expectancy ≥ 6 months * Palliative surgery * 12-15 = life expectancy ≥1 year * Excisional surgery

Answer 252

SINS (Spinal Instability Neoplastic Score) * 6 components * Location * Pain * Bone lesion * Radiographic spinal alignment * Vertebral body collapse * Posterolateral involvement of spinal elements * Score: * 0-6 = stable * 7-12 = impending instability * 13-18 = unstable

Answer 253

1. A decision making framework for making treatment decisions in patients with spinal metastasis 2. Considers 4 factors: * Neurologic * Degree of spinal cord compromise * Radiographic assessment (degree of epidural spinal cord compression) * Oncologic * Radiosensitive vs. radioresistant tumors * Mechanical (instability) * Mechanical pain (movement related) * SINS score * Systemic * Ability of patient to tolerate intervention 3. Determines treatment options based on above factors including: * Conventional external beam radiation * Stereotactic radiosurgery * Decompression/separation surgery * Stabilization surgery

Answer 254

Radiosensitive = “NOMS LBP” * Neuroendocrine (carcinoid/pancreatic) * Ovarian * Myeloma * Seminoma * Lymphoma * Breast * Prostate Radioresistant = “SMRT Cancers” * Sarcoma * Melanoma * Renal * Thyroid * Colorectal * adenocarcinoma lung

Answer 255

1. Location = primarily posterior elements 2. Presentation * Back pain, often night pain, relieved with NSAIDs * Avg age is 19 * Most common cause of painful scoliosis in adolescents * Lesion typically on concavity of curve 3. Imaging * Radiographs – area of sclerosis * CT – better defines lesion * MRI – better for preop planning to assess proximity to neural structures 4. Treatment * Nonoperative – first line (NSAIDs) * Radiofrequency thermal ablation – failed nonop * En bloc resection – indicated for: * Fixed spinal deformity * Neurological compression * RFA unsafe

Answer 256

1. Location = posterior elements 2. Presentation * Dull back pain, possible neural compression * Differs from osteoid osteoma in that not worse at night, does not respond to NSAIDs, less frequently associated with scoliosis 3. Imaging * Radiographs * Compared to osteoid osteoma: * Multiple calcifications * Aggressive bony destruction * Infiltration into surrounding tissues * CT – better defines lesion and location * MRI – better assess neural and soft tissue involvement 4. Treatment * En bloc resection +/- fusion if instability created

Answer 257

Anterior lesions: 1. hemangioma 2. EG 3. GCT 4. osteosarc 5. ewing (ant +sacrum) Posterior lesions: 1. Osteoblastoma 2. Osteoid osteoma 3. Osteochondroma 4. ABC (start posterior) 5. Metastasis

Answer 258

1. Curve magnitude * Thoracic curve \>50° and lumbar curve \>40° progress 1° per year after skeletal maturity * Curve \>30° at peak growth velocity will likely require surgery 2. Skeletal maturity * Tanner stage * Females with Tanner \<3 have greatest risk of progression * Risser grade * Peak growth velocity is Grade 0 * Age of menarche * Peak growth velocity is just before onset of menses * Triradiate cartilage * Open triradiate have the greatest risk of progression

Answer 259

1. Age \<10 2. Males 3. Abnormal curve pattern * Left thoracic or right lumbar curve 4. Rapid curve progression 5. Abnormal neurological exam 6. Apical thoracic kyphosis 7. Persistent neck pain and headache 8. Preoperative planning to evaluate for dural ectasia in patients with neurofibromatosis, Ehlers-Danlos and Marfans

Answer 260

Lenke classification * Requires upright AP and lateral and supine left and right bending * 4 steps * STEP 1 – divide spine into 3 regions * Proximal thoracic – Apex at T3, T4 or T5 * Main thoracic – Apex between T6 and the T11-T12 disc * Thoracolumbar/Lumbar – T/L apex between T12 and L1, and lumbar apex between the L1-L2 disc and L4 * STEP 2 – determine the major and minor curves * Curve with largest Cobb angle is the major curve * Other curves are minor * STEP 3 – determine if minor curves are structural or nonstructural * Curve is structural if: * Residual curve \>25° in coronal plane on the bending film * Kyphosis \>20 in sagittal plane (regardless of coronal flexibility) * STEP 4 – based on above information determine the curve type * For LENKE 4 – Main Thoracic OR TL/L can be the Major Curve * STEP 5 – determine lumbar and sagittal modifiers * Lumbar modifier – draw the CSVL and compare to lumbar apical vertebra * A = line is between pedicles of apical vertebra * B = line touches pedicle * C = line does not touch vertebra or pedicle * Sagittal modifier – assess kyphosis from T5-T12 * ‘-‘ (hypo) = kyphosis \<10 * ‘N’ (Normal) = kyphosis 10-40 * ‘+’ (hyper) = kyphosis \>40

Answer 261

1. Cobb angle * Superior endplate of the upper end vertebra, to the inferior endplate of the lower end vertebra 2. End vertebra * Define the ends of a curve in a frontal or sagittal projection * Cephalad EV – first vertebra from apex whose superior surface is tilted maximally toward the concavity of the curve * Caudal EV – first vertebra from apex whose inferior surface is tilted maximally toward the concavity of the curve 3. Neutral vertebra * Vertebra without axial rotation 4. Stable vertebra * Thoracic or lumbar vertebra cephalad to a lumbar scoliosis that is most closely bisected by CSVL assuming the pelvis is level 5. Apical vertebra * Vertebra most deviated laterally from the CSVL

Answer 262

1. Curves 20-40° and Risser 0-1 2. Curves 30-45° and Risser 2-3 should also be considered for bracing 3. Curves \>25 during growth [SRS Guidelines]

Answer 263

1. Curve apex above T7 = Milwaukee CTLSO [Orthobullets] 2. Curve apex below T7 = Boston TLSO [Orthobullets]

Answer 264

1. Thoracic curve \>50° 2. Lumbar curve \>45°

Answer 265

1. Congenital/Structural/Thoracogenic 2. Neuromuscular 3. Syndromic 4. Idiopathic

Answer 266

1. Rib-Vertebra Angle Difference (RVAD) * AKA Mehta angle * **Most reliable indicator** * RVAD = angle formed between a line perpendicular to the end plate of the apical vertebra and a line from the midpoint of the rib head to the midpoint of the rib neck * Concave RVA – Convex RVA = RVAD * RVAD \>20° = high risk of curve progression * RVAD \<20° = curve more likely to resolve 2. Phase 2 relationship * Rib head overlaps the apical vertebra * Implies that progression is certain 3. Cobb angle \>20^o

Answer 267

1. Failure of vertebral body formation * Hemivertebra (unilateral formation failure) * Fully segmented, partially segmented, unsegmented * Segmented if normal disc present * Incarcerated or nonincarcerated * Incarcerated = within the curve * Pedicle of hemivertebra is inline with adjacent pedicles * Adjacent vertebral bodies conform in their shape * Less disruption of spinal curvature * Nonincarcerated = outside of the curve * Pedicle of hemivertebra is outside the line of adjacent pedicles * Typically fully segmented * More disruption of spinal curvature (adjacent vertebrae do not accommondate) * Wedge vertebra (unilateral partial formation failure) 2. Failure of vertebral body segmentation * Block vertebra * Unilateral bars * Unilateral bars with contralateral hemivertebra 3. Multiple congenital rib fusions (thoracogenic)

Answer 268

1. Echocardiogram 2. Renal US 3. MRI spine 4. C-spine radiographs

Answer 269

1. Long, C-shaped curve 2. Pelvic obliquity 3. Kyphosis

Answer 270

1. Down syndrome 2. Marfan and Ehlers-Danlos 3. Neurofibromatosis 4. OI 5. Klippel-Feil 6. VACTERL

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