OITE Flashcards
(322 cards)
1
Q
The highest risk of viral transmission with blood transfusion is…
A
Hepatitis B.
2
Q
Donor blood is screened for…
A
HIV-1 HIV-2 HBV HCV West Nile virus Syphilis
3
Q
Normal lactate
A
Less than 2.5
4
Q
Normal gastric mucosal PH
A
Greater than 7.3
5
Q
Normal base deficit
A
-2 to +2
6
Q
Injury severity score equal to
A
A squared plus B squared plus B squared
A, B and C refer to top three most severely injured regions
7
Q
Risk factors for under triage in trauma bay
A
Female, age greater than 65, 2+ comorbid conditions, non-white, GCS 15
8
Q
Risk factors for mortality after poly trauma in elderly individuals
A
ISS, Initial GCS less than or equal to 10, admission PH, admission lactate, need for ventilation
9
Q
After major trauma, compared to men, women have…
A
Poorer quality of life outcomes ( higherPTSD, more sickleave time)
10
Q
Compared to adults, with regards to physiologic inflammatory response, children have…
A
A dampened systemic response but a robust local inflammatory response. In children, multi organ failure occurs early after the admission, during resuscitation.
In adults, multi organ failure begins 48 hours after the injury due to the robust systemic response.
11
Q
Neurogenic shock
A
Disruption of sympathetic activity leading to hypotension and bradycardia
12
Q
Spinal shock
A
Temporary loss of spinal cord function below the level of the injury; in addition to loss of sympathetic tone (neurogenic shock), There is complete loss of sensory motor function and reflexes
13
Q
Class 2 hemorrhagic shock Is differentiated from class three by…
A
Blood pressure.
Class 2:15 to 30% blood volume loss. Tachycardic and normotensive
Class 3:30 to 40% blood volume loss. Tachycardic and hypotensive
14
Q
Antibiotics for type one and two open fracture
A
First generation cephalosporin, gram-positive coverage. Example is ancef.
15
Q
Antibiotics for type three open fracture
A
First generation cephalosporin and aminoglycoside. Example gentamicin for Graham negative coverage
16
Q
Antibiotics for farm injury or bowel contamination of a fracture
A
Add penicillin for anaerobic coverage. Example clostridium.
17
Q
Best method of irrigation for open fracture
A
Saline at low flow or pressure
18
Q
In the masquelet technique, the membrane around the spacer harbors…
A
BMP-2 which peaks at four weeks and returned to baseline at six months
19
Q
PMMA antibiotic spacer has the highest antibiotic concentration At…
A
24 hours. Levels remain bactericidal for up to four months.
20
Q
Vancomycin is released in a…
A
Time dependent manner.
21
Q
Tobramycin is released in a…
A
Concentration dependent matter
22
Q
Maximum recommended concentration of vancomycin
A
10.5 g/ 40 mg of PMMA
23
Q
Maximum recommended concentration of Tobramycin
A
12.5 g per 40 mg of PMMA
24
Q
Treatment of intra-articular gunshot wound
A
I&D And retrieval of bullet fragments to prevent plumbism
25
Gunshot wound to the hip is most Commonly associated with…
Bowel perforation. Needs laparotomy.
26
Gun shot wound to the spine treatment
Antibiotics for 24 to 48 hours or longer if there is intestinal injury. Needs decompression and fusion only if there is neurologic deficit or instability.
27
During initial exploration of a gun shot wound, if there is nerve transaction…
It should be treated 1 to 3 weeks post injury.
28
What nerve has the worst functional recovery after repair due to a gunshot wound?
Ulnar nerve
29
When comparing amputation to limb reconstruction, there is no difference between…
Return to work, functional outcomes, cost
30
After severe lower extremity injury, psycho social function…
Does not improve with time.
31
After severe injury to soft tissue, hyperbaric oxygen therapy can be utilized. Contraindications include…
Insulin pump, pacemaker and ICD.
32
The most energy efficient amputation is…
Syme amputation
33
Energy expenditure for traumatic versus vascular BKA
25% versus 40%
34
Does a bilateral BKA or unilateral AKA result in higher energy expenditure?
Unilateral AKA. This is 65% versus 40% for bilateral BKA
35
Factors for improved wound healing
```
Albumin greater than three
ABI greater than .45
Lymphocyte count greater than 1500
Toe pressure greater than 40
Transcutaneous oxygen tension greater than 30
```
36
Compared to a regular BKA, and Ertl bridging synostosis…
Provides equivalent functional outcomes but higher complications
37
What should you do with the dog ears on a BKA?
Leave them alone to prevent injury to the blood supply to the flap
38
In children, What is the most proximal level at which walking speed can be maintained without significantly increase in energy expenditure?
Knee disarticulation
39
What artery hasto be patent for any amputation distal to a BKA?
Posterior tibial artery. Requires a viable heel pad.
40
ChoPart amputation
Through the transverse tarsal joints. Can lead to Equinus deformity so need to perform Achilles tendon lengthening and transfer the tibialis anterior to the talar neck
41
Lisfranc amputation
Through the TMT joints. Need to maintain insertion of peroneus brevis or will lead to equinovarus deformity
42
Treatment of post amputation neuroma pain
TMR
43
High rates of SLAP repair failures have been associated with...
age > 36. Consider tenotomy for this age group.
44
Treatment for clavicle
sling (NOT figure of 8)
45
Predictors of clavicle nonunion
female, displacement, comminution, advanced age
46
Nonoperative treatment of clavicle fractures has higher risk of...
symptomatic nonunion and malunion, lower functional outcomes
47
What provides the AP stability fo the AC joint?
superior and posterior AC ligaments
48
What provides the superoinferior stability of the AC joint?
CC ligaments (conoid is medial to trapezoid)
49
Congenital pseudarthrosis of the clavicle is usually located at...
the middle third of the right clavicle.
50
Treatment of sternoclavicular dislocation is generally...
non-op except for posterior SC dislocation with compression of the trachea and esophagus (closed vs open reduction with thoracic surgery avaialble)
51
What is predictive of intact vascular supply for proximal humerus fx?
posteromedial calcar spike > 8 mm
52
Predominant blood supply to the humeral head?
posterior humeral circumflex artery
53
Most common complication of ORIF of porximal humerus fractures
screw cut out and intraarticular penetration
54
What is key to preventing varus collapse of proximal humerus fx?
adding an inferomedial screw to purchase the calcar
55
What guides the humeral prosthesis height for rTSA?
superior edge of of the pec major insertion.
The PMI is 5.6 cm distal to the superior aspect of the humeral head.
56
Normal retroversion and neck shaft angle of the humerus?
30 degrees of retroversion
| 130-140 degrees neck shaft angle
57
rTSA dislocation is associated with...
subscapularis rupture/insufficiency postoperative. Dislocation usually occurs with arm in extension, ADD and ER - anterior dislocation)
58
Treatment of isolated greater tuberosity fracture
Surgery for > 5 mm displacement. The cuff pulls the GT superior (which blocks abduction) and posterior (which blocks ER).
59
When and what is considered humeral shaft nonunion?
Fracture site mobility at 6 weeks.
60
Indications for plating of humeral shaft fracture
open fracture, vascular injury requiring repair, brachial plexus injury (higher nonunion rate with nonop), floating elbow, b/l humeral shaft fx, polytrauma
61
When to use anterior vs posterior approach to the humerus
Anterior: proximal and middle third humeral shaft
Posterior: middle and distal third
62
In relation to the heads of the triceps, where does the radial nerve lie?
Medial to long and lateral heads and proximal to the deep head. You can follow the posterior antebrachial cutaneous nerve proximally to find the radial nerve
63
When cabling the humerus, what reduces risk of iatrogenic radial nerve injury?
fixation proximal to the inferior edge of the lat dorsi
64
When compared to plating humerus, IMN is associated with...
higher total complications (shoulder stiffness and impingement).
65
IMN humeral nail distal interlock dangers
A to P: musculocutaneous nerve
| L to M: radial nerve
66
Radial nerve palsy in closed vs open humeral shaft fracture
Closed: likely neuropraxia --> observe
Open: likely neurotmesis --> explore and repair
67
First and last muscles to recover with radial nerve palsy
Brachioradialis is first (wrist extension in radial deviation) and EIP is last to recover (index finger MCP hyperextension)
68
When operating on a distal humerus and deciding between TEA or ORIF, what should be avoided?
Avoid olecranon osteotomy during exposure as this may affect TEA.
69
Chevron osteotomy for olecranon osteotomy
Perform 2 cm distal to triceps insertion in bare area of ulna. AIN is at risk.
70
Postoperative ulnar neuropathy is associated with...
intra-op ulnar nerve transposition.
71
What does a double arc sign represent?
coronal shear fracture of the capitellum with extension into the trochlea. This requires exposure of the entire lateral column, elevating off the common extensors and capsule.
72
When operating on the lateral aspect of the elbow, disruption of the posterior perforating vessels leads to...
AVN of the capitellum.
73
When operating on the lateral aspect of the elbow, disruption of the LUCL leads to...
valgus posterolateral rotatory instability.
74
Mechanism of elbow dislocation
fall onto outstretched arm (axial compression, forearm supination, and valgus load
75
After closed reduction of an elbow dislocation, it should be splinted in...
elbow flexion and pronation.
76
Direction of elbow dislocation is usually...
posterolateral and structures fail from lateral to medial. LCL fails via ligament avulsion off the lateral epicondyle.
77
Most common complication of elbow dislocation is...
loss of terminal extension
78
Most common associated injury with pediatric elbow dislocation is...
medial epicondyle fracture. Treat surgically if > 5 mm displacement or incarcerated fragment.
Ulnar nerve is at risk of entraptment.
79
For a simple pediatric elbow dislocation, treat with...
splint for 10 days followed by protected ROM.
80
Mechanism of a terrible triad
fall onto outstretched hand with the forearm in supination and valgus thrust
81
Order of fixation of terrible triad
radial head, then coronoid, then LCL and finally MCL
82
When to fix vs repair radial head
fix radial head if < 3 fragments and replace if greater than or equal to 3 fragments. Never perform acute resection.
83
When to repair coronoid fracture
if less than 50%, may not have to repair (?). Less than 10% does NOT need repair.
84
If only LCL is ruptured in terrible triad, then splint in...
flexion and pronation.
85
If LCL and MCL are ruptured in terrible triad, then splint in...
neutral and flexed position.
86
Terrible triad post op ROM should start at...
48 hours.
87
The anterior bundle of the MUCL inserts on...
the sublime tubercle (the anteromedial facet of the coronoid).
88
Fracture of the sublime tubercle or injury to the anterior bundle of the MUCL leads to...
varus instability/varus posteromedial rotatory instability.
89
When treating olecranon fractures, penetration of the anterior cortex of the ulna leads to...
AIN injury and mechanical block to prono-supination.
90
Treatment of comminuted olecranon fracture in elderly, osteoporotic patient
excision with triceps advancement if fracture involves < 30-50% of the articular surface.
91
HO prophylaxis
- Indomethacin
| - single radiation (700 cGY dose) either 4 hours before or within 72 hours after surgery
92
With regards to a monteggia fracture, the apex of the ulnar fracture is...
generally in the same direction as the radial head dislocation.
93
What nerve is at greatest risk after a Monteggia fracture?
PIN which leads to radial deviation of the hand with wrist extension (from pull of the mobile wad)
94
What may block anatomic reduction of the monteggia fracture?
annular ligament interposition in the radiocapitellar joint
95
Treatment of radial head fracture with no or minimal displacement
early ROM
96
Treatment of radial head fracture with > 2 mm displacement
< 3 fragments: ORIF
| comminuted: radial head replacement
97
Safe zone for HW placement of radial head
90 degree arc from radial styloid to Lister's tubercle
98
Acute radial head resection can lead to...
proximal radial migration resulting in distal ulnar impaction syndrome
99
Esesx-Lopresti injury
radial head fracture with DRUJ dislocation and disruption of the interosseous membrane
100
How position forearm with lateral approaches to the elbow...
pronate the forearm to pull the PIN anteriorly away from the field
101
What is the most important ligament of the interosseous membrane in the forearm?
central band
102
Best plate to use for BBFF
3. 5 mm LC-DCP
| 4. 5 plate has higher risk of refracture
103
for BBFF, do not remove hardware before...
15 months. after plate removal, consider bracing to prevent refracture.
104
Single incision for BBFF has higher risk of...
synostosis.
105
On x-ray, mature HO is characterized by....
sharp cortical margins.
106
When to use bone graft on BBFF
if there is segmental bone loss of the radius.
107
Formal PT after DRF (surgery or injury) does...
not change outcomes
108
CRPS prevention
vitamin C 500 qd for 50 days
109
CRPS type 1 vs 2
type 1: no identifiable nerve lesion
| type 2: identifiable nerve lesion
110
Treatment of EPL rupture
EIP to EPL transfer.
111
EPL rupture of volar plate fixation is related to...
screw penetration through the dorsal cortex.
112
FPL rupture of volar plate fixation is related to...
plate placement distal to the watershed line and protrusion of the plate beyond volar lip of the radius.
113
Dorsal plate fixation of the DR is reserved for...
intra-articular DRF with significant comminution.
114
Reduction of a galeazzi fracture may be blocked by....
ecu interposition.
115
At what level do radial shaft fractures have a higher incidence of DRUJ instability?
< 7.5 cm from articular surface.
116
The DRUJ is most stable in...
supination.
117
After fixing a DRF, if the DRUJ is stable, then immobilize in...
supination if the DRUJ dislocates dorsally or pronation if DRUJ dislocates volarly.
118
The TFCC has 7 components:
1. volar and dorsal radioulnar ligaments (primary stabilizers of the DRUJ)
2. central articular disc
3. meniscal homologue
4. ulnolunate and ulnotriquetral ligaments
5. ulnar collateral ligament
6. ECU tendon sheath
119
A positive ulnar fovea sign indicates...
TFCC tear
120
Position of hip in dislocation
Posterior: hip will be flexed, ADD and IR
Anterior: hip will be flexed, ABD and ER
121
If open reduction of a hip is required, you should approach from...
the direction of dislocation since those soft tissues are already compromised.
122
Most common complication of a FNF...
osteonecrosis. Main blood supply is the MFCA.
123
Biggest risk factor for necrosis in FNF
pre-operative degree of displacement
124
CRPP treatment of FNF
inverted triangle with inferior screw in posteroinferior neck adjacent to calcar
125
Treating a FNF with DHS leads to...
higher AVN than cannulated screws but equivalent union
126
Treatment of femoral neck nonunion in young patient
valgus intertrochanteric osteotomy which converts vertical fracture line (shear force) to a horizontal fracture line (compressive force)
127
Treatment of femoral neck stress fracture
compression side: PWB (but consider CRPP if > 50% neck is involved)
tension side: CRPP
128
In peri-troch hip fracture, the proximal fragment is displaced...
flexed (iliopsoas), abducted (gluts) and ER (SERs)
129
2 hole vs 4 hole DHS
equivalent
130
There has been increased use of CMN over DHS for intertroch fractures due to...
higher medicare reimbursement.
131
Treatment of stable intertroch fx
DHS or short locked CMN
132
Performing CMN nail in lateral position advantages
- easier to identify starting point
| - facilitates fracture reduction
133
Most common deformity with CMN of peritroch fractures
varus and flexion (procurvatum)
134
No differences been shown between short and long CMN except...
cost (higher with longer nails)
135
what percentages of patients with femoral shaft fracture have ipsilateral FNF?
as high as 10%
136
Femoral shaft fracture blood loss
1250 cc
137
Sx of fat embolism syndrome
petechiae, hypoxemia and AMS
138
Weakest muscle groups after antegrade IMN femoral fx
quads and abductors
139
If you use a straight nail with a trochanteric starting point, this can lead to...
varus malalignment.
140
Most common complication after IMN femur is...
malrotation. CT is best to diagnose. Defined as > 15 degrees compared to contralateral side.
141
Using a fracture table to fix femoral shaft fracture increases risk of...
internal malrotation.
142
If the LE IR is increased after femur IMN, then either...
too much femoral anteversion of proximal fragment or too much IR of distal fragment.
143
After IMN of femur, if the LE ER is increased, then either...
too much femoral retroversion proximally or too much ER distally.
144
Treatment of femoral shaft nonunion
compression plating with bone graft
145
Shortening of the femur will deviate the mechanical axis...
medially whereas lengthening will deviate it laterally.
146
Hoffa fracture
coronal fracture of femoral condyle (lateral more common than medial)
147
For distal femur fractures, a golf club deformity will occur if the locking plate is placed...
too far posterior distally.
148
Blood supply to the patella
genicular arteries arising from the popliteal
149
How to minimize wire migration with patella fx
bend k-wires both proximally and distally
150
Predictors of fixation failure for patella fractures
increasing age, fixation with k-wires (compared to screws)
151
Bipartite patella is most commonly located...
superolateral. Has smooth cortical borders and fibrocartilage between the two fragments.
152
How to treat pediatric patellar sleeve fracture
ORIF, usually with suture fixation
153
What structures are at risk with knee dislocation
Common peroneal nerve and popliteal artery
154
SPN deficit
peroneal brevis and longus
| senation over dorsum of foot
155
DPN deficit
TA, EHL, EDL
| sensation over 1st dorsal webspace
156
If patient is pulseless after reduction of knee...
vascular consult with exploration (NOT imaging).
157
Buttonholing at the knee is caused by...
posterolateral dislocation with the medial femoral condyle coming through the capsule (dimple sign). This can prevent closed reduction.
158
Treatment of multilig knee injury with early arthroscopy leads to...
increased risk of compartment syndrome due to capsular defects.
159
What is a poor prognostic factor after multi-lig knee injury?
morbid obesity
160
Traumatic knee arthrotomy joint loading
175 cc - detects 99%
| 155 cc - detects 95%
161
Lateral tibial plateau is...
convex and proximal; medial plateau is concave and distal
162
Lateral plateau fracture and meniscus tear is associated with...
> 10 mm articular depression.
163
With plateau fractures and meniscus tears, treat radial tears with...
debridement and longitudinal tears with repair.
164
Primary goal of tx of plateau fx
restore joint stability and limb alignment (articular reduction is 2ndary goal)
165
Does timing to definitive ORIF for plateau fractures after fasciotomy influence infection risk?
no
166
calcium phosphate
less subsidence than even autograft
167
calcium sulfate
not preferred because of fast resorption and serous wound drainage
168
Risk factors for infection after tibial plateau ORIF
- male
- smoker
- high ASA
- pulmonary disease
- bicondylar pattern
169
Treatment of plateau fractures with hybrid external fixation leads to...
higher malunion rates comapred to ORIF.
170
TKA after tibial plateau fx is associated with...
higher complications, equivalent patient reported outcomes and satisfaction.
171
Starting point for tibial IMN
just medial to the lateral tibial spine and at the reflection point between the tibial plateau and anterior tibial metaphysis
172
Proximal third tibial shaft fracture deformity
valgus and procurvatum
173
where to place poller screws for proximal third tibia fractures
-posterior (to prevent procurvatum) and lateral (to prevent valgus)
174
Suprapatellar or semiextended position nailing for proximal third tibial shaft fractures leads to...
procurvatum
175
lateral entry point for proximal third tibial shaft fractures leads to...
valgus
176
Best way to prevent malalignment of distal third tibial shaft fractures
plating. Plating of the fibula can also help.
177
Deformity seen with isolated tibial shaft fracture with intact fibula
varus
178
Why can you see a dropped hallux after tibial IMN?
transient peroneal nerve neurapraxia --> EHL weakness/sensory deficit in 1st websapce
179
danger with proximal tibia LISS plating
SPN injury when placing perc screws at holes 11-13
180
Soft tissue coverage of the leg
proximal third: use gastroc flap
middle third: use soleus flap
distal third: use free flap
181
Gastroc flap is supplied by...
sural artery
182
compartment syndrome is a compromise of...
venous outflow relative to arterial inflow.
183
Diagnosis of exertional compartment syndrome
resting P > 15
1-min post exercise P > 30
5 minute post exercises P > 20
184
Most accurate measure of exertional compartment syndrome
continuous pressure measurement
185
Recurrence of exertional compartment syndrome is most often due to...
postsurgical fibrosis within the fascial defect.
186
3 main fragments of a pilon fracture
1. anterolateral/Chaput (AITFL)
2. posterolateral/Volkmann (PITFL)
3. medial malleolus (deltoid)
187
after pilon fracture (or any intra-articular fracture), chondrocyte apoptosis occurs...
in the superficial zone of cartilage at fracture margins.
188
Treating a pilon with acute fibular fixation and ex fix is associated with...
increased post-op complications.
189
Brake time after long bone diaphyseal/metaphyseal ORIF:
returns to normal 9 weeks after surgery or 6 weeks after initiation of weight bearing
190
How to evaluate the integrity of the deltoid ligament
manual or gravity ER stress test (check medial clear space)
191
Disadvantages of lateral vs posterior fibular plating
lateral: HW prominence, intra-articular screw penetration
posterior: peroneal tendonitis (but biomechanically stronger)
192
Treatment of supination adduction ankle fracture
buttress plating of medial mal and place screws parallel to plafond
193
Interval for posterior approach to ankle
between FHL and peroneus longus
194
Syndesmosis is most unstable in...
AP plane
195
4 ligaments of the syndesmosis
1. AITFL
2. PITFL
3. transverse tibiofibular ligament
4. interosseous ligament
196
Most sensitive/specific test for syndesmotic injury
MRI (see lambda sign on coronal)
197
Bosworth fracture dislocation
fibula is entrapped behind the posterolateral ridge of the tibia at the incisura fibularis
198
Treatment of diabetic ankle fractures
ORIF with multiple syndesmotic screws, immobilize 12 weeks instead of 6
(non-op treatment poses risk for loss of reduction)
199
greatest risk factor for postop complications of diabetic ankle fracture is
peripheral neuropathy
200
The superior glenohumeral ligament resists…
Inferior translation at 0° of abduction
201
The middle glenohumeral ligament resist…
Anterior and posterior translation at 45° of abduction
202
The inferior glenohumeral ligament resists…
Anterior and if your translation at 90° of abduction and external rotation (Anterior band)
Posterior translation at 90° of flexion and internal rotation (posterior band)
203
Buford complex
A congenital variant with no anterior superior labrum and a cord like MGHL
204
Bankart lesion
Avulsion of anterior band of a IGHL and anterior labrum
205
Boundaries of the rotator interval
Supraspinatus tendon superior, subscapularis tendon inferior, transverse humeral ligament lateral
206
Content of the rotator interval
SGHL, coracohumeral ligament, long head of biceps tendon
207
What is the strongest predictor of redislocation of the shoulder?
Age less than 40 at time of dislocation
208
For an anterior shoulder dislocation, the shoulder is unstable in…
Abduction and external rotation
209
Glenoid bone loss is best assessed with…
3D CT reconstruction
210
Latarjet procedure
Performed for glenoid deficiency more than 20 to 25%. This is a coracoid transfer to the glenoid. Musculocutaneous nerve is most commonly injured. Axillary nerve also at risk.
211
Remplissage procedure
Transfer of posterior capsule and infraspinatus into hill sachs lesion of the posterosupererior humeral head
212
A large hill sachs lesion will engage with the glenoid when…
There is more than 25 to 40% of the bone missing. There will be catching sensation when the arm is 90° abducted and externally rotated.
213
After a remplissage procedure, avoid…
Adduction with shoulder forward flexed because this will stress the posterior myocapsulodesis
214
Blood supply to the talus is via...
PT artery branches - artery of the tarsal canal (main branch) and deltoid branch
215
Option to preserve the deltoid ligament for surgical approach to the talus
medial malleolar osteotomy
216
Where is the comminution typically located in a talus fracture?
dorsal (leads to dorsal malunion) and medial (leads to varus malunion)
217
Treatment of a displaced talar neck fracture
ORIF thru medial and lateral incisions
218
What do you do with an extruded talus fragment?
clean and reimplant during ORIF
219
Hawkins sign
subchondral lucency on xrays (indicating bone resorption) at 6 weeks is a good prognostic sign indicating intact vascularity
220
After a talus fracture, is posttraumatic tibiotalar or subtalar arthritis more common?
subtalar
221
What is the common skier/snowboarder fracture?>
fracture of lateral process of talus (lateral talocalcaneal ligament)
If chronic, comminuted and symptomatic: fragment excision
222
Superomedial (constant) fragment of calcaneus
FHL wraps inferior to the sustentaculum tali.
Thus, FHL is at risk when placing lateral to medial screw, esp when the screw is too long (leads to tethered FHL and a fixed, flexed hallus).
223
Treatment of subtalar arthritis with loss of calcaneal height after calc fx
distraction bone block subtalar arthrodesis
***will see limited dorsifelxion and anterior ankle impingement
224
Factors associated with better outcomes after calcaneus ORIF
- female
- non workers comp
- < 29 years old
- less comminution
- sedentary jobs
- Bohler's angle 0-14
225
Bohler's angle
The angle between two lines drawn tangent to the superior aspect of the anterior and posterior calcaneus (normal is 20-40 degrees)
226
Most common direction of subtalar dislocation
Medial is more common but lateral is more often open.
227
Block to reduction of medial subtalar dislocation
lateral structures (peroneal tendons, EBD)
228
Block to reduction of lateral subtalar dislocation
medial structures (PT, FHL/FDL)
229
Subtalar dislocation can also be associated with...
talonavicular dislocation.
230
Lisfranc ligament location
medial cuneiform to base of 2nd MT
231
Treatment of ligamentous or chronic lisfranc injury
open reduction and arthrodesis of TMTs 1-3
232
Treatment of bony lisfranc
ORIF of TMT 1-3 with screws (not K-wires)
233
APC pelvic ring injuries are associated with...
hemorrhage
234
LC pelvic ring injuries are associated with...
head injury
235
Difference between APC II vs III
II: posterior sacroiliac ligaments are intact
236
Complications associated with anterior subcutaneous pelvic fixator (INFIX)
HO is most common.
LFCN is most common nerve injury.
Femoral nerve injury leads to loss of knee extension.
237
What can result in underestimation of pelvic ring injury severity?
application of pelvic compression device and CT
238
Risk with SI screws
L5 nerve root (EHL) as it runs over the sacral ala
239
What do you see on inlet view for SI screws?
anterior-posterior screw placement
240
What do you see on outlet view for SI screws?
superior-inferior screw placement
241
what do you see on lateral sacral view?
entry point for SI screws
242
What pelvic ring injury poses the greatest risk for loss of fixation of SI screws?
vertical shear fracture
243
Risk factors for deep infxn after pelvic/acetabular sx?
obesity
leukocytosis
embolization
injury severity
244
The most common urethral injury associated with pelvic fracture is...
posterior urethral tear
**diagnose with retrograde urethrocystogram
245
How to treat a sacral insufficiency fracture if chronic and symptomatic
perc screws
246
Chronic pelvic ring instability is best assessed with...
alternating single-leg-stance pelvic xrays
247
How to treat parturition induced pubic diastasis
non-op (bedrest, binder) if less than 4 cm
248
What does a judet view show you?
iliac oblique: posterior column, anterior wall
| obturator oblique: posterior wall, anterior column
249
What is a transverse acetabular fracture?
an elementary acetabular fracture pattern involving both columns
**axial CT demonstrates a vertical fracture line
250
Both column acetabular fracture
complete discontinuity between the articular surface and the posterior ilium
**see the spur sign on the obturator oblique view (which is the posterioinferior aspect of the intact ilium)
251
What protocol has lower joint reactive forces on the hip?
TTWB is lower than NWB.
252
What aspect of the acetabulum experiences the highest joint reactive forces?
posterosuperior
253
When treating acetabular fractures surgically, operate within...
5 days because it is easier to mobilize and reduce fracture fragments
254
What approach to the acetabulum has the highest risk of HO?
extended iliofemoral
255
What do you see on inlet iliac oblique view for perc screws?
AP screw placement in the pubic ramus
256
What do you see on the inlet obturator oblique view?
ensure screw placement within the inner and outer tables of the ilium
257
What do you see on the outlet obturator oblique view?
ensure placement outside of the joint (superior/inferior placement)
258
Corona mortis
anastomosis of the epigastric (branch of external iliac) and obturator (branch of internal iliac)
*needs to be ligated during Stoppa approach
259
The ulnar artery supplies which part of the palmar arch?
The ulnar artery supplies the superficial palmar arch while the radial artery supplies the deep palmar arch.
260
In the digit, the digital artery is located…
Dorsal to the digital nerve.
261
The rotator interval is an extension of...
the coracohumeral ligament.
262
What size Hill Sachs lesion requires bone grafting?
>40%
263
Shoulder is at risk for posterior dislocation in...
flexion, adduction and IR.
264
What structure is most important in preventing posterior subluxation/dislocation of the shoulder?
subscapularis
265
To protect a posterior labral tear, avoid...
adduction with shoulder flexed for 3 weeks.
266
Treatment for a reverse hill-sachs lesion > 25-40%
McLaughlin - subscapularis transfer
or lesser tuberosity transfer (modified McLaughlin)
267
Luxatio erecta
inferior shoulder dislocation; will be fixed in abduction
268
Multi-directional instability is...
instability in 2 or more planes.
269
If MDI fails 6 months of PT, then treat with...
capsular shift and plication, closure of rotator interval.
270
Closure of the rotator interval will...
limit shoulder ER with the arm adducted.
271
Avoid thermal capsulorrhaphy because of...
chondrolysis.
272
Parsonage-Turner syndrome
aka brachial neuritis or neuralgic amyotrophy
intense shoulder/UE pain, multifocal weakness, fatty atrophy on MRI, EMG with denervation and reinnervation potentials
treatment: observation
273
Thoracic outlet syndrome
compression of brachial plexus --> paresthesias and sensorimotor deficits
compression of subclavian artery --> cool, pallor UE
compression of subclavian vein --> swelling/discoloration of UE
274
Symptoms of thoracic outlet syndrome occur with...
overhead activities.
275
Common causes of thoracic outlet syndrome
hypertrophy of scalene muscles, pancoast tumor, cervical rib
276
Quadrilateral space boundaries
teres minor, teres major, long head of triceps, humerus
277
Quadrilateral space contents
axillary nerve, PCHA
278
Quadrilateral space syndrome
compression in thrower during late cocking/early acceleration
279
Glenohumeral OA pattern
eccentric glenoid wear (posterior wear with posterior humeral head subluxation)
280
Glenohumeral inflammatory arthritis wear pattern
concentric glenoid wear leading to medialization of GH joint
281
Does TSA or hemiarthroplasty have lower revision rate?
TSA
282
After TSA, most common reason for revision is...
loosening (glenoid > humerus).
283
In rTSA, the center of rotation is moved....
medially and inferiorly which decreases deltoid abduction force and joint load.
284
Latissimus dorsi transfer can help with...
ER. If loss of ER, consider concomitant LD transfer with rTSA.
285
Risks with anterior vs posterior lat dorsi transfer
anterior: radial nerve
posterior: axillary nerve
286
For TSA, the thickness of the humeral head is about...
70% its radius of curvature.
287
The humeral head COR is...
4 mm posterior and 8 mm medial to the center of the humeral intramedullary canal.
288
Most common organism responsible for shoulder PJI
P. acnes (gram positive aerotolerant anaerobic bacillus)
289
Treatment of elbow flexion contracture > 30 or flexion < 130
static progressive elbow splinting
290
If elbow stiffness fails non-op tx, then...
perform capsular release with possible release of posterior oblique bundle of MCL (which is tight in flexion)
291
Arthroscopic contracture release of the elbow should be avoided in...
obese patients and those with prior elbow surgery.
292
Treatment of young laborer with advanced OA at the elbow with stiffness/pain
osteophyte resection and capsular release
293
Treatment of active patient with ulnohumeral arthritis and minimal radiocapitellar arthritis
arthroscopic ulnohumeral arthroplasty (fenestration of olecranon fossa, osteophyte debridement)
294
OCD of elbow is usually at...
the capitellum. Sx include painful catching, clicking, locking.
295
Total elbow arthroplasty is the best outcome for....
RA.
296
Best TEA systems are...
semi-constrained (linked).
297
The ulnar artery supplies which portion of the palmar arch?
The superficial palmar arch while the radial artery supplies the deep arch.
298
In the digit, the digital artery is located....
dorsal to the digital nerve.
299
What is the radial most extrinsic ligament of the wrist?
Radioscaphocapitate ligament
300
What can prevent reduction of a dorsal MCP dislocation?
volar plate
301
Location of wrist arthroscopy 3,4 portal
1 cm directly distal to Lister tubercle between EPL and EDC tendons
302
With the 6R or 6U wrist portal, what structure is at risk?
dorsal sensory branch of the radial nerve
303
With the 1,2 wrist portal, what structures are at risk?
superficial branch of radial nerve and radial artery
304
Function of free nerve ending
pain (nociception)
305
Function of meissner corpuscle
touch, pressure
306
function of pacinian corpuscle
deep pressure and vibration
307
function of merkel cell
sustained touch and pressure
308
function of ruffini ending
skin stretch
309
function of golgi tendon organ
muscle length and tension proprioception
310
1st dorsal compartment
EPB, APL
Pathology: deQuervain's tenosynovitis
311
2nd dorsal compartment
ECRL, ECRB
Pathology: Intersection syndrome (often seen in rowers, pain 5 cm proximal to wrist joint)
312
3rd dorsal compartment
EPL
313
4th dorsal compartment
EIP, EDC, PIN
314
5th dorsal compartment
EDM
Pathology: Vaughan-Jackson syndrome (rheumatoid wrist, DRUJ instability causes volar carpal subluxation which leads to attritional rupture of digital extensor tendons from ulnar to radial; EDM is first to rupture)
315
6th dorsal compartment
ECU
Pathology: snapping ECU due to attenuation of ECU subsheath. ECU subluxates with forearm supination.
316
Mechanism of scaphoid fracture
fall onto outstretched wrist in extension
| highest load transmission through the radioscaphoid articulation is when the wrist is extended
317
Most common location of scaphoid fractures in adults and children
adults: waist fracture
children: distal pole
318
What artery supplies the scaphoid?
the dorsal carpal branch of the radial artery (retrograde)
319
Treatment of scaphoid fracture
Nondisplaced or suspected: thumb spica cast
any displacement: ORIF
320
Approach to scaphoid ORIF
proximal pole fracture: dorsal approach
waist or distal pole or humpback deformity: volar approach
***use long screw down the central axis of the scaphoid
321
Best way to ensure proper screw seating below subchondral bone in scaphoid ORIF
direct visualization
322
Treatment of scaphoid nonunion in a young person
revision ORIF with vascularized medial femoral condyle graft
(obtain CT scan along axis of the scaphoid to assess union)
