Ortho Flashcards

Question

A 26-year-old football offensive lineman presents with shoulder pain which is affecting his ability to block effectively. On exam, he has a positive jerk test and a positive Kim test. What is his most likely diagnosis? ``` SLAP tear ALPSA lesion Hill-Sachs lesion Posterior labral tear PASTA tear ```

Answer 1

The posterior jerk test is a sensitive exam for ascertaining the presence of posterior glenoid labral tears in the mid-range of the glenoid. The Kim test is more sensitive for posterior-inferior labral tears. This is performed by having the patient seated, arm at 90° abduction, followed by flexing the shoulder to 45 forward flexion while simultaneously applying axial load on the elbow & posterior-inferior force on the upper humerus. The test is positive when pain is present. When the jerk test and Kim test are combined, there is 97% sensitivity in detecting a posterior labral tear. Escobedo et al performed a retrospective study of 166 shoulder MRI arthrograms from patients who had presented with shoulder pain and/or instability. They selected out 20 competitive football players and 20 age-matched controls. 55% of the football players had at least one posterior labral tear, while only 10% of the matched non-football players had a posterior labral tear, which was statistically significant. Acronyms are commonly used to describe injuries in sports medicine and may be tested with either the short or long name: SLAP=superior labrum anterior-posterior; ALPSA=anterior labral periosteal sleeve avulsion; PASTA=partial articular-sided supraspinatus tendon avulsion. Acute posterior shoulder dislocations are less common than anterior dislocations, but more commonly missed 50% of traumatic posterior dislocations seen in the emergency department are undiagnosed 2% to 5% of all unstable shoulders risk factors: bony abnormality, glenoid retroversion or hypoplasia is a less common cause of instability, ligamentous laxity Pathophysiology mechanism: trauma (posterior dislocation) - 50% of cases that present for evaluation - usually dramatic presentation microtrauma (posterior instability) - may lead to a labral tear, incomplete labral avulsion, or erosion of the posterior labrum. May lead to gradual stretching of capsule and patulous posterior capsule. Common in lineman, weight lifters, overhead athletes - usually insidious onset and presentation seizures and electric shock: tetanic muscle contraction pulls the humeral head out - anterior instability and dislocations are still more common with seizures. However, posterior dislocations are unlikely to occur without significant trauma (ie. seizures) biomechanical forces: flexed, adducted, and internally rotated arm is a high-risk position Lesions Associated with Posterior Instability Avulsion of posterior band of IGHL: Associated with acute subluxations Posterior Bankart lesions: Characterized by detachment of posterior inferior capsulolabral complex Reverse Hill-Sachs lesions :Associated with locked and difficult to reduce dislocations Posterior labral cyst: Associated with chronic reverse Bankart lesion Posterior glenoid rim fracture: Associated with chronic reverse Bankart lesion Lesser tuberosity fracture: Associated with acute posterior dislocation Large capsular pouch: Can see with MRI with contrast, often with chronic posterior instabiltiy Glenohumeral anatomy Primary stabilizers of the posterior shoulder Posterior band of IGHL: primary restraint in internal rotation subscapularis: primary dynamic restraint in external rotation, primary dynamic restraint against posterior subluxation superior glenohumeral ligament and coracohumeral ligament : primary restraint to inferior translation of the adducted arm and to external rotation, primary static stabilizer to posterior subluxation with shoulder in flexion, adduction, and internal rotation Static restraint: labrum deepens the glenoid by 50% Classification Acute versus chronic Acute = trauma, seizure, electric shock with dramatic presentation Chronic = microtrauma from repetition such as offense football lineman with insidious onset and presentation Voluntary versus involuntary Presentation History: trauma or microtrauma with the arm in a flexed, adducted, and internally rotated position chronic instability often presents with insidious onset, and vague symptoms (usually pain and not instability as opposed to anterior instability) often in sporting or occupational activities that require repetitive pushing with the arm in forward flexed position foot ball lineman, weight lifters, etc Symptoms pain with flexion, adduction, and internal rotation of the arm Physical exam prominent posterior shoulder and coracoid for acute posterior dislocation may be normal from chronic posterior instability from microtrauma motion limited external rotation for acute posterior dislocation shoulder locked in an internally rotated position common in undiagnosed posterior dislocations pain on flexion, adduction and internal rotation for posterior instability provocative tests - performed in the setting of chronic posterior instability posterior load & shift test: place patient supine with arm in neutral rotation with 40 to 60° abduction and forward flexion, load humeral head and apply anterior and posterior translating forces noting subluxation Jerk test: place arm in 90° abduction, internal rotation, elbow bent, apply an axial force along axis of humerus and adduct the arm to a forward-flexed position, a ‘clunk’ is positive for posterior subluxation. 97% sensitive for posterior labral tear when combined with a Kim test Kim test : performed by having the patient seated, arm at 90° abduction, followed by flexing the shoulder to 45 forward flexion while simultaneously applying axial load on the elbow & posterior-inferior force on the upper humerus. test is positive when pain is present posterior stress test: stabilize scapula and look for posterior translation with a posterior direct force pain is elicited often, but this is not a specific finding

Answer 2

Cast immobilization with close clinical followup The clinical presentation, physical exam, and radiographs are consistent with a Salter-Harris Type I fracture of the distal femoral physis. The radiographs show subtle physeal widening, but no displacement. If there is no displacement following the injury, as in this case, then cast immobilization is acceptable treatment. However, these fractures are associated with a high incidence of deformity so close clinical followup is mandatory. If there is evidence of displacement with a SHI or SHII, then closed reduction percutaneous pinning would be indicated. Open reduction is reserved for SHIII and SHIV fractures, or fractures that can not be reduced. Pediatric distal femoral physeal fractures are most commonly Salter-Harris II fractures that result from direct trauma in children with open physes. Treatment is usually closed reduction and percutaneous fixation followed by casting. Occur in patients with open growth plates must be considered in patients with open physes to avoid misdiagnosis with collateral ligament injury Pathophysiology Mechanism: often the result of direct trauma with some degree of rotation - most commonly a valgus-type force or a hyperextension force, most commonly Salter-Harris II fracture. The physis fails on the tension side and metaphysis fails on the compression side, creating a Thurston-Holland fragment Prognosis Physeal arrest 30-50% rate of physeal arrest that often leads to growth disturbance and deformity - counsel parents of poor prognosis associated with this fracture pattern an increased incidence of complications have been associated with: Salter-Harris classification type, fracture displacement, surgical hardware invading the physis Anatomy Osteology : formed from a single ossific nucleus that is present at birth and is the first epiphysis in the body to ossify Muscles: both heads of the gastrocnemius and plantaris muscles originate just proximal to the physis, this leads to flexion of the distal fracture fragment when fracture line is distal to muscle insertion Ligament : collateral ligaments attach distal to the physis at the level of the epiphysis - stress places tension on the collaterals which transfer force to the physis. ACL and PCL attach to epiphysis at the intercondylar notch and may be injured. Blood Supply : femoral artery travels through the adductor canal medially above the metaphysis and courses in the popliteal space. The popliteal artery is directly posterior to distal femur and trifurcates at this level. Due to poor collateral circulation, popliteal artery injury may result in loss of lower limb viability Physeal considerations of the knee leg growth continues until: 16 yrs in boys, 14 yrs in girls growth contribution: leg grows 23 mm/year, with most of that coming from the knee (in contrast to upper extremity where most of growth is away from the elbow) proximal femur - 3 mm / yr (1/8 in) distal femur - 9 mm / yr (3/8 in) proximal tibia - 6 mm / yr (1/4 in) distal tibia - 5 mm / yr (3/16 in) Presentation History of significant trauma Symptoms: pain with inability to bend knee, unable to bear weight Physical exam: pain and swelling, often in flexed position due to hamstring muscle spasm, tenderness along the physis in the presence of a knee effusion may see varus or valgus knee instability on exam swelling in the popliteal space may be a sign of vascular injury or disruption Imaging Radiographs - AP, lateral, oblique. Stress radiographs to look for physis opening if there was suspicion of physeal injury have fallen out of favor due to risk of physeal damage, patient discomfort, and possible need for sedation. MRI or ultrasound have replaced stress radiographs in this setting Close follow up with repeat x-rays if inital radiographs not definitive and treating as a possible Salter I fracture findings. Physeal widening: normal 3-5mm Direction of displacement suggestive of mechanism of injury - Anterior displacement due to hyperextension - Posterior displacement due to hyperflexion - Medial displacement due to valgus - Lateral displacement due to varus MRI : indications - diagnostic modality of choice to confirm physeal fracture Ultrasound : indications: can help confirm physeal fracture CT : may be necessary for evaluation of intra-articular extension and to define fracture fragments to plan fixation Angiography: occasionally necessary to evaluate for a vascular injury, (uncommon) - may be necessary in fractures with wide displacement and posterior spiked fragments Treatment Nonoperative - long leg casting : nondisplaced fractures treated for 4-6 weeks. Close clinical follow up is mandatory Operative Closed reduction and percutaneous fixation followed by casting (majority of cases) - displaced Salter-Harris I or II fractures - displaced fractures successfully reduced with closed methods typically should still be secured with fixation as fracture pattern is unstable - some Salter-Harris III or IV injuries if anatomic reduction is achieved postoperatively follow closely to monitor for deformity ORIF indications: Salter-Harris III and IV with weight-bearing articular involvement, Irreducible SHI and SHII fractures (irreducible type II fractures are most often due to interposed periosteum on the tension side of fracture) Techniques Closed reduction and percutaneous fixation - reduction: avoid multiple attempts at reduction, maneuver consists of 90% traction and 10% manipulation - fixation : if physis must be crossed (SH I and SH II with small Thurston-Holland fragments), use smooth K-wires and remove 3-6 weeks after surgery. SH II fracture with large enough metaphyseal fragment should be fixed with lag screws across the metaphyseal segment Open Reduction Internal Fixation approach: incision over the displaced physis to remove interposed periosteum is necessary. Fixation should avoid the physis if possible Complications Limb length discrepancy or angular deformity (most common) - results from physeal disturbance limb length inequality of >2 cm in one third of cases ``` Correlates with fracture pattern : 36% of SH 1 fractures 58% in SH 2 fractures 49% in SH 3 fractures 64% in SH 4 fractures ``` Minimize with: Anatomic physeal alignment (critical) and close follow up following nonoperative or operative No treatment necessary when predicted final leg length discrepancy <2 cm and no significant angulation Epiphysiodesis of the contralateral distal femur +/- proximal tibia: indicated for discrepancy between 2-6 cm Physeal bridge excision: if physeal bar of <50% and ≥ 2 years or 2.5 cm of growth remaining Septic arthritis Intra-articular pins have a risk of septic arthritis Popliteal artery injury and compartment syndrome rare, most common with anterior displacement of epiphysis or a posterior spike at the fracture site

Answer 3

Full-length steel shank and rocker sole shoe modifications would most likely improve this patient's gait. The steel shank replaces the lever arm length lost by toe amputation while the rocker bottom allows heel-toe weight transfer in the setting of decreased motion of the foot. Rigid foot orthoses limit joint motion and stabilize flexible deformities. Semirigid orthoses allow dorsiflexion and/or plantar flexion of the ankle. Soft orthoses have the best shock-absorbing ability and are used to accommodate fixed deformities of the feet. Rocker soles help to transfer the body weight forward while walking, but they may destabilize the knee by transferring body weight forward too rapidly. Mueller and Strube performed a cohort study of 30 patients that underwent a transmetatarsal amputation. They found that patients wearing full-length custom-made or a short shoe with a rigid rocker-bottom sole had significantly higher scores in the physical performance test (PPT) and faster walking speed than those wearing regular shoes with a toe filler. Janisse and Janisse authored a Level 5 review discuss the importance of adding a rocker soles to rock the foot from heel strike to toe-off when a rigid extended shank is utilized in order to reduce bending stresses across the midfoot. Figure A demonstrates a healed transmetatarsal amputation.

Answer 4

This patient has fracture separation of the lateral mass. This is best treated with posterior two-level fusion involving both the level above and the level below. Posterior instrumented fusion of C4-6 Lateral mass-facet fractures are a result of hyperextension, lateral compression and rotation. Fracture separations of the lateral mass are not well seen on plain radiographs. On axial cut CT scans typically one fracture line is seen through the lamina, and the second through the pedicle. This compromises the stability of the inferior facet (of the vertebra above) and the superior facet (of the vertebra below), leaving the entire lateral mass free from the adjacent vertebral segment, yielding 2 levels of instability. Surgical fixation is indicated in the presence of neurologic injury or segmental instability and should involve instrumented fusion across both levels. Lee et al. felt that it was unclear whether the management of these injuries should involve anterior, posterior or combined surgical approaches. In their series of 39 patients with 29 lateral mass fractures and 14 facet fractures, they found that nonsurgical treatment was usually unsuccessful, and single-level anterior fusion was adequate. However, for separation type fractures, they report two-level fusion is necessary. Levine et al. examined 24 patients with this injury. They found that deformity (mean translation 5 mm and angulation 7 deg) occurred more commonly at the level below (80%) than the level above (20%). They opined that because fracture separations were a posterior injury, the preferred surgical approach would be posterior and advocated posterior lateral mass instrumentation. Kotani et al. classified lateral mass fractures into 4 subtypes. Separation type fractures have 2 fracture lines involving the lamina and pedicle, leading to separation of the articular mass from the vertebral body. Comminution type fractures have multiple fracture lines, including lateral wedging and coronal plane deformity. Split type fractures have a vertical fracture line in the coronal plane, with separation of the lateral mass in the AP plane and upward migration of the superior articular process of the vertebra below. Traumatic spondylolysis fractures have bilateral horizontal fracture lines through the pars interarticularis. Figure A shows lateralization of the left C5 lateral mass. Figure B shows floating left lateral mass (fracture lines through lamina and pedicle). Illustration A shows the Kotani classification of lateral mass fractures (A, separation; B, comminution; C, split; D, traumatic spondylolysis). Incorrect Answers Answer 1: Anterior stabilization is an option, but must involve both the levels above and below (C4-6) for this separation type fracture. Answers 2,3: The vertebral body is not involved in this injury and corpectomy is unnecessary. Answer 5: Posterior fusion of C5-6 alone is insufficient as this injury pattern results in 2 level instability (C4-5 and C5-6). Cervical Lateral Mass Fracture Separation: Fracture separations of the lateral mass-facet are uncommon Injuries characterized by: - high degree of instability - neurological deficit - affect 2 levels (2 adjacent motion segments) because of involvement of the superior facet and inferior facet on either side of the fractured articular mass Mean age 35 yrs (20-70yrs) location : C6 > C5 > C7 > C4 > C3 Pathophysiology Mechanism of injury : traffic accident, falls, heavy object landing on head. Hyperextension, lateral compression and rotation of the cervical spine Associated conditions - anterior translation (listhesis): fractured vertebrae (77%), superior adjacent vertebrae (24%), inferior adjacent vertebrae (10%): coronal translation (33%) - vertebral body collapse (33%): lower in Type A Kotani Classification - Separation fracture subtypes Type A - Separation fracture 2 fracture lines of unilateral lamina and pedicle Type B - Comminution type Multiple fracture lines with lateral wedging in coronal plane Type C - Split type Vertical fracture line in the coronal plane, with invagination of the superior articular process of the caudal vertebra Type D - Traumatic spondylolysis Bilateral horizontal fracture lines of the pars interarticularis, leading to separation of the anterior-posterior spinal elements

Answer 5

The clinical presentation, MRI, and histology are consistent with clear cell chondrosarcoma. The histology demonstrates chondrocytes with a clear, vacuolated cytoplasm in a chondroid matrix, which is characteristic of clear cell chondrosarcoma. In addition, the lesion is in the epiphysis which is also typical of clear cell chondrosarcoma. Radiographs of clear cell chondrosarcoma usually demonstrate mixed lucent and sclerotic lesions with a paucity of matrix densities or calcifications. "Popcorn calcifications" typically seen in classic chondrosarcoma are not prevalent on radiographs of clear cell chondrosarcoma. Chondroblastoma and giant cell tumors are two other epiphyseal lesions that must be differentiated from clear cell chondrosarcoma. Chondroblastomas are predominantly found in teenagers and young adults. Giant cell tumors will demonstrate classic giant cells on pathology. Malignant primary bone tumor composed of chondrocytes with variable degrees of malignancy Primary chondrosarcoma which includes low-grade, high-grade, dedifferentiated chondrosarcoma clear cell chondrosarcoma, mesenchymal chondrosarcoma Secondary chondrosarcoma: arises from benign cartilage lesions including: - osteochondroma (<1% risk of malignant transfomation) - multiple hereditary exostosis (1-10% risk of malignant transformation) - enchondromas (1% risk of malignant transformation) - Ollier's disease (25-40% risk of malignant transformation) - Maffucci's (100% risk of malignant transformation) Chondrosarcomas are found in older patients (40-75 yrs) there is a slight male predominance. Most common locations include the pelvis, proximal femur, distal femur, scapula - tumor location is important for diagnosis as the same histology may be diagnosed as benign in the hand but malignant if located in the long bones Prognosis: histologic grade correlates with survival Grade I : 90% 5-year survival - grade 1 chondrosarcomas are generally slow growing Grade II : 60-70% 5-year survival Grade III : 30-50% 5-year survival De-differentiated chondrosarcoma <10% 5-year survival Poor prognostic variables - Axial and proximal extremity lesions have a more aggressive course - Pelvic location - Advanced patient age, inadequate surgical margins Increased telomerase activity - in chondrosarcoma, as determined by reverse transcriptase-polymerase chain reaction (RT-PCR), has been shown to directly correlate with the rate of recurrence

Answer 6

The Nurick Classification system is a classification system for cervical myelopathy that focuses on the ambulatory status of the patient. The different Grades of the Nurick classification system include: (GRADE 0) Signs or symptoms of root involvement but without evidence of spinal cord disease. (GRADE 1) Signs of spinal cord disease but no difficulty in walking. (GRADE 2) Slight difficulty in walking that did not prevent full-time employment. (GRADE 3) Difficulty in walking that prevented full-time employment or the ability to perform all housework but that was not severe enough to require someone else’s help to walk. (GRADE 4) Able to walk with someone else’s help or the aid of a frame. (GRADE 5) Chair bound or bedridden. Hirabayashi et al present a Level 4 study of 53 cases who underwent surgical decompression for patients with OPLL and concomitant myelopathy or radiculopathy. They reported a recovery rate of approximately 70%. Edwards et al present a Level 5 review of cervical myelopathy. They report that anterior decompression and fusion procedures including 1 or 2 levels have predictable results, but ACDFs involving 3 or more levels are associated with increased morbidity. Incorrect Answers: Answer 2: The Japanese Orthopaedic Association Classification system includes chopstick function. Answer 3: The Modified Japanese Orthopaedic Association Classification system includes upper extremity dexterity tasks such as buttoning of a shirt. Answer 4: The Ranawat Classiciation takes into account upper extremity, and well as lower extremity, symptoms. Answer 5: The Oswestry Disability Index is a classification for back pain, not cervical myelopathy. Cervical myelopathy is a common degenerative condition caused by compression on the spinal cord that is characterized by clumsiness in hands and gait imbalance. treatment is typically operative as the condition is progressive. Pathophysiology Etiology: - Degenerative cervical spondylosis (CSM) - most common cause of cervical myelopathy. Compression usually caused by anterior degenerative changes (osteophytes, discosteophyte complex). Degenerative spondylolisthesis and hypertrophy of ligamentum flavum may contribute - Congenital stenosis: symptoms usually begin when congenital narrowing combined with spondylotic degenerative changes in older patients - OPLL (Ossification Posterior Longitudinal Ligament) - tumor - epidural abscess - trauma - cervical kyphosis Neurologic injury - mechanism can be direct cord compression and/or ischemic injury secondary to compression of anterior spinal artery Associated conditions lumbar spinal stenosis: tandem stenosis occurs in lumbar and cervical spine in ~20% of patients Prognosis Tends to be slowly progressive and rarely improves with nonoperative modalities - progression characterized by steplike deterioration with periods of stable symptoms prognosis. Early recognition and treatment prior to spinal cord damage is critical for good clinical outcomes Classification of Myelopathy Nurick Classification Grade 0 Root symptoms only or normal Grade 1 Signs of cord compression; normal gait Grade 2 Gait difficulties but fully employed Grade 3 Gait difficulties prevent employment, walks unassisted Grade 4 Unable to walk without assistance Grade 5 Wheelchair or bedbound Based on gait and ambulatory function Ranawat Classification Class I Pain, no neurologic deficit Class II Subjective weakness, hyperreflexia, dyssthesias Class IIIA Objective weakness, long tract signs, ambulatory Class IIIB Objective weakness, long tract signs, non-ambulatory Japanese Orthopaedic Association Classification A point scoring system (17 total) based on function in the following categories upper extremity motor function lower extremity motor function sensory function bladder function Symptoms - neck pain and stiffness: axial neck pain (often times absent), occipital headache common - extremity paresthesias: diffuse nondermatomal numbness and tingling - weakness and clumsiness: weakness and decreased manual dexterity (dropping object, difficulty manipulating fine objects) - gait instability : patient feels "unstable" on feet, weakness walking up and down stairs, gait changes are most important clinical predictor - urinary retention: rare and only appear late in disease progression (not very useful in diagnosis due to high prevalence of urinary conditions in this patient population) Physical exam Motor - weakness: usually difficult to detect on physical exam - lower extremity weakness is a more concerning finding - finger escape sign: when patient holds fingers extended and adducted, the small finger spontaneously abducts due to weakness of intrinsic muscle - grip and release test: normally a patient can make a fist and release 20 times in 10 seconds. myelopathic patients may struggle to do this Sensory - proprioception dysfunction: due to dorsal column involvement - occurs in advanced disease & associated with a poor prognosis - decreased pain sensation: pinprick testing should be done to look for global decrease in sensation or dermatomal changes. Due to involvement of lateral spinothalamic tract (vibratory changes are usually only found in severe case of long-standing myelopathy) Upper motor neuron signs (spasticity) - hyperreflexia: may be absent when there is concomitant peripheral nerve disease (cervical or lumbar nerve root compression, spinal stenosis, diabetes) - inverted radial reflex: tapping distal brachioradialis tendon produces ipsilateral finger flexion - Hoffmann's sign : snapping patients distal phalanx of middle finger leads to spontaneous flexion of other fingers - Sustained clonus post > three beats defined as sustained clonus. Sustained clonus has poor sensitivity (~13%) but high specificity (~100%) for cervical myelopathy - Babinski test post: considered positive with extension of great toe Gait and balance - toe-to-heel walk: patient has difficulty performing - Romberg test : patient stands with arms held forward and eyes closed - loss of balance consistent with posterior column dysfunction Provocative tests - Lhermitte Sign: test is positive when extreme cervical flexion leads to electric shock-like sensations that radiate down the spine and into the extremities

Answer 7

Epiphysiodesis when the finger reaches adult length of the father Clinical photograph and radiographs demonstrate macrodactyly of the middle finger, a rare congenital malformation enlarging all structures of the digit. Ishida et al reviews 23 cases of surgically treated macrodactyly finding favorable results with epiphysiodesis/epiphysiodectomy while resection of hypertrophic nerves was unsuccessful in preventing overgrowth. The epiphysiodesis is performed once the finger reaches the length of the same sex parent, using their digit as a template for final growth. Nonhereditary congenital digit enlargement: very rare 90% are unilateral 70% involves more than one digit index involved most frequently - in order of decreasing frequency, the long finger, thumb, ring, and small are also involved Can involve digits of the hand or foot Risk factors and aetiology unknown, no genetic correlations known to date Affected digits correspond with neurologic innervation- the median nerve being the most common ``` Associated conditions - Lipfibromatous hamartoma of the median nerve is the adult homolog Has been associated with: Proteus syndrome Banayan-Riley-Ruvalcabe's disease Maffucci syndrome Ollier’s disease Milroy’s disease ``` Prognosis if static, asymmetry does not worsen if progressive, asymmetry worsens with time Classification Functional Classification Static: Present at birth and growth is linear with other digits Progressive: Not as noticable at birth but shows disproportionate growth over time Symptoms: pain, inability to use digits, complaints of cosmetic issues Physical exam inspection & palpation: thick, fibrofatty tissue involving enlarged digits ROM & instability: often limited ROM due to soft tissue constraints Imaging Biplanar hand radiographs: enlarged phalanges to involved digits - may see malalignment of joints or angled phalanges CT, MRI: not typically needed Angiography: only needed if used for surgical planning Treatment Nonoperative: observation in mild cases Operative Epiphysiodesis - indications: single digit perform once digit reaches adult length of same sex parent most common approach Postoperative care: soft tissue care, early ROM Osteotomies and shortening procedures - indications: thumb involvement, multiple digit involvement, severe deformity Postoperative care: local soft tissue care, early ROM Amputations if severe involvement of digit/ non-reconstructable digit Complications Digital stiffness Chronic digital pain or edema

Answer 8

The most common complaint associated with lateral closing wedge high tibial osteotomy is anterior knee pain. Lateral closing wedge high tibial osteotomies are commonly associated with anterior knee pain due to the high incidence of patella baja post-operatively. Patella baja is characterized by the lowering of the patella relative to its normal position, which is typically measured using the Insall-Salvati ratio of < 0.8 (Normal ratio = 0.8 - 1.2). The most common symptoms associated with patella baja include anterior impingement, knee pain, and knee stiffness. Scuderi at al. evaluated the effect of proximal tibial osteotomy on patellar height in 66 patients. They found that patellar height decreased by 89%, as measured by the Insall-Salvati index, and 76.3%, as measured by the Blackburne-Peel index, post-operatively. Wright et al. reviewed the complications associated lateral closing wedge and medial opening wedge high tibial osteotomy. They reported a 64% incidence of patella baja following these high tibial osteotomy techniques, with associated complaints of anterior knee pain. Illustration A shows an X-Ray of patella baja after closed wedge high tibial osteotomy. The Insall-Salvati ratio is determined by measuring the ratio of patella tendon length (TL) to the length of the patella bone (PL) with the knee flexed at 30 deg. Incorrect Answers: Answer 1: Knee stiffness, not laxity, is more common after high tibial osteotomy. Answer 2: The incidence of deep infection is roughly 0 - 4%. Answer 4: Quadriceps weakness typically exists prior to high tibial osteotomy. Answer 5: Leg shortening is more likely associated with lateral closing wedge high tibial osteotomy. Patella baja is characterized by lowering of the patella relative to its normal position- may be congenital or acquired Common causes include - proximal tibial osteotomy - patella baja is the most common complication seen following proximal tibial opening-wedge osteotomy. May be caused by shortening of the patellar tendon during tibial osteotomy or from scarring of the patellar tendon post-operatively - tibial tubercle slide or transfer - trauma to the proximal tibia - technical error during primary total knee replacement (joint line elevation) - ACL reconstruction Associated conditions total knee arthroplasty: patella infera is an important consideration when performing total knee arthroplasty improper technique may cause patella baja special techniques must be utilized when performing TKA in patients with patella baja from congenital or acquired (tibial osteotomy, prior TKA) causes

Answer 9

The history and MRI findings are consistent with a tension-side femoral neck stress fracture for which the most conservative treatment is percutaneous screw placement. Groin pain in an athlete is a nonspecific complaint with a large differential diagnosis, including adductor strain, iliopsoas tendinitis, FAI, labral tears, and stress fractures. Treatment of non-displaced tension-side fractures is still somewhat controversial as there are no prospective studies comparing nonoperative and operative treatment. Most authors, mindful of the potential for serious complications should this fracture displace, view tension-side fractures with a great deal of respect and recommend either extremely cautious conservative treatment or internal fixation. In the review by Shin & Gillingham, they recommend treating tension-side injuries aggressively with cannulated screws as soon as the diagnosis is clear to avoid the potentially catastrophic sequelae of displacement, prevent the harmful effects of bedrest, and allow early weight bearing with crutches. The article by Hajek & Noble from 1982 was one of the early case series describing femoral neck stress fractures in distance runners. Illustration A shows a fluid sensitive MRI hip coronal view with linear marrow edema extending from the lateral head-neck junction across most of the femoral neck. This is consistent with a non-displaced stress fracture. Incorrect Answers: Answers 2,3: These are procedures for femoral-acetabular impingement, not for stress fractures. The measurements described in the stem are within the normal range. Answers 4,5: Non-operative treatment is not usually recommended, but successful reports in the literature have used strict non-weight-bearing with 3+ weeks of bedrest, followed by prolonged crutch use. Fracture of the femoral neck secondary to repetitive loading of bone - common in runners. Repetitive loading causes microscopic fractures in the femoral neck - crack "initiation." Then continued repetitive loading does not allow for healing response and stress fracture occurs - crack "propagation" two types - compression side (inferior-medial neck) - tension side (superior-lateral neck) Associated conditions "female athlete triad" amenorrhea, eating disorder, and osteoporosis must be considered in any female athlete with stress fracture Prognosis: dependent upon patient compliance ``` Muscle insertions around femoral neck iliopsoas quadratus femoris gluteus medius piriformis ``` Blood supply to femoral neck provided by two branches of the femoral artery including medial femoral circumflex artery lateral femoral circumflex artery Biomechanics of femoral neck compression side : inferior medial neck with weight bearing tension side: superior lateral neck with weight bearing Treatment Nonoperative: non-weight bearing, crutches and activity restriction indications: compression side stress fractures with fatigue line <50% femoral neck width Operative ORIF with percutaneous screw fixation indications: - tension side stress fractures - compression side stress fractures with fatigue line >50% femoral neck width - progression of compression side stress fractures Technique: Use three 6.5mm or 7.0mm cannulated screws Postoperative weightbearing as tolerated Complications Fracture progression/completion if fracture is unrecognized and the athlete continues to train fracture completion is associated with severe, disabling complications precludes return to prior activity level (elite athletes will not be able to return to prior level following displaced fracture) Varus settling AVN Nonunion Refracture

Answer 10

Medial closing wedge femoral osteotomy Genu valgum in the skeletally mature individual is most appropriately treated with a varus-producing distal femoral osteotomy. If the deformity were to be addressed with a medial closing wedge tibial osteotomy an oblique joint line would be maintained. Varus and valgus can be determined by measuring the lateral distal femoral angle (normal=88 deg), medial proximal tibial angle (normal=87 deg), or the tibiofemoral angle (normal=5-10 degrees). Figure B shows that the the lateral distal femoral angle is less than 87 degrees and thus the femur should be addressed with the deformity correction. Tetsworth and Paley present a Level 4 review of 28 limbs that underwent external fixation for deformity correction. They measured mechanical axis deviation (MAD) and mechanical tibiofemoral angle (mTFA) pre and postoperatively in these patients and found external fixation to be a reliable method of deformity correction. Paley presents a Level 5 review discussing the spectrum of lower extremity angular and rotational deformities and their treatments. He cites that the work of Gavril Abramovich Ilizarov in the field of external fixation has been instrumental in advancing the field of deformity correction and the magnitude of the deformity is no longer an obstacle with gradual correction of bone or joint deformities. Genu valgum is a normal physiologic process in children therefore it is critical to differentiate between a physiologic and pathologic process Distal femur is the most common location of primary pathologic genu valgum but can arise from tibia Etiologies - Bilateral genu valgum: physiologic, renal osteodystrophy (renal rickets), skeletal dysplasia (Morquio syndrome, spondyloepiphyseal dysplasia, chondroctodermal dysplasia) - Unilateral genu valgum: physeal injury (from trauma, infection, or vascular insult), proximal metaphyseal tibia fracture, benign tumors (fibrous dysplasia, osteochondromas, Ollier's disease) Prognosis The threshold of deformity that leads to future degenerative changes is unknown Deformity after a proximal metaphyseal tibia fracture (Cozen) should be observed, as it almost always remodels Anatomy Normal physiologic process of genu valgum - between 3-4 years of age children have up to 20 degrees of genu valgum - genu valgum rarely worsens after age 7 - after age 7 valgus should not be worse than 12 degrees of genu valgum - after age 7 the intermalleolar distance should be <8 cm Treatment Nonoperative: observation is first line of treatment - genu valgum <15 degrees in a child <6 years of age bracing is rarely used - ineffective in pathologic genu valgum and unnecessary in physiologic genu valgum Operative: Hemiepiphysiodesis or physeal tethering (staples, screws, or plate/screws) of medial side indications: > 15-20° of valgus in a patient <10 years of age if line drawn from center of femoral head to center of ankle falls in lateral quadrant of tibial plateau in patient > 10 yrs of age technique - to avoid physeal injury place them extraperiosteally - to avoid overcorrection follow patients often - growth begins within 24 months after removal of the tether Distal femoral varus osteotomy indications insufficient remaining growth for hemiepiphysiodesis Complications peroneal nerve injury - perform a peroneal nerve release prior to surgery Gradually correct the deformity- utilize a closing wedge technique

Answer 11

The diagnosis of ALS requires a period of clinical observation to document the progressive loss of upper and lower motor function. Electrodiagnositic studies are required to make a definitive diagnosis. Amyotrophic lateral sclerosis (ALS) is the most common degenerative disease of the motor neuron system. Also referred to as Lou Gehrig's disease. A progressive motor neuron disorder characterized by involvement of anterior horn cells of spinal cord. Nerve conduction studies and needle electromyography (EMG) are useful for confirming the diagnosis of ALS and for excluding peripheral conditions that resemble ALS. Hallmark findings in the electrodiagnosis of ALS are abnormal motor nerve conduction studies, with normal sensory nerve conduction studies. EMG / NCS - shows denervation + reinnervation widespread decreased amplitude of CMAP and slowed motor conduction velocity - denervation (fibrillations and positive waves) + decreased recruitment in ≥ 3 extremities - reinnervation - abnormal spontaneous fibrillation & fasciculation potentials - normal sensory studies (SNAP, sensory nerve action potentials) UMN signs are mild weakness, spasticity, and abnormally brisk reflexes; LMN signs are progressive weakness, wasting, and loss of reflexes and muscle tone. Brooks et al. developed a diagnostic algorithm for the diagnosis of ALS. The algorithm is based on the degree of certainty of diagnosis, which is increased by the number of body segments that demonstrate upper motor neuron (UMN) and lower motor neuron (LMN) abnormalities. Clinical and electrophysiologic findings in 3 or more body segments is definitive of the diagnosis. Incorrect Answers: Answer 1: Genetic testing may be performed to identify genetic defects in some familial types of ALS. However to date, there is no single test that is definitive for diagnosing ALS. Answer 2: MRI brain and spinal card are used to rule out structural lesions and neurologic conditions that have a slimilar clinical presentation as ALS. Answer 3: Muscle biopsy is not required in the diagnosis of ALS Answer 4: Serum protein electrophoresis and immunoelectrophoresis will not provide a definitive diagnosis for ALS. They are used to rule out the differential diagnoses of ALS. Differentials Peripheral compressive neuropathy: hyperreflexia and other UMN signs (Babinski, Hoffman) are present in ALS (which can present in a single extremity mimicking cubital/carpal tunnel syndrome), but absent in peripheral neuropathy ALS has normal sensory studies on EMG/NCS Treatment Nonoperative - currently no cure or effective treatment Goals of treatment: provide supportive care, prevent progression, maintain independent patient function and comfort riluzole Modest benefits only, prolongs life by 2-3 months Blocks tetrodotoxin-sensitive sodium channels associated with damaged neurons - delays onset of ventilator-dependence and may prolong survival

Answer 12

The patient has a clinical presentation consistent with anterolateral ankle soft tissue impingement. Ankle arthroscopy with synovial debridement is indicated in cases recalcitrant to conservative management. Ferkel et al. present a Level 4 study evaluating 24 patients who had an arthroscopic diagnosis of anterolateral soft tissue impingement. They then reviewed the MR images of the patients and found a 78.9% accuracy in diagnosing anterolateral soft tissue impingement. Ferkel et al. also conducted a Level 4 study of 31 patients that underwent a partial synovectomy with debridement of scar tissue from the lateral gutter. They found that most patients had a good to excellent result at 2 year follow-up. Figure A demonstrates anterolateral soft tissue as shown by the arrow. The common region for anterolateral ankle soft tissue impingement between the ATFL and anterior inferior tibiofibular ligaments. Incorrect Answers: Answer 2: A Brostrom repair and Gould modification is an anatomic shortening and reinsertion of the ATFL and CFL reinforced with the inferior extensor retinaculum and distal fibular periosteum Answer 3: Chrisman-Snook procedure is a nonanatomic reconstruction using a split peroneus brevis tendon to reinforce the anterior talofibular and calcaneofibular ligaments. Answer 4: Syndesmosis reduction and screw fixation is indicated in syndesmosis diastasis. Answer 5: There is no loose body evident in this patient's presentation. Tibiotalar Impingement Most often caused by osteophyte impingement in anterior tibiotalar joint Can also be caused by excessive anterolateral soft tissues or posterior soft tissue or osseous abnormalities Common in athletes who play on turf or on grass including rugby, football, dancers, soccer Mechanism: repetitive overuse injuries, trauma, degenerative sequelae Presentation Symptoms: pain in anterior ankle Physical exam: pain with forced dorsiflexion, limited dorsiflexion, soft tissue swelling and effusion may be evident, subtalar joint is pain free Imaging Radiographs: AP, lateral, and oblique - spurs seen in anterior distal tibia or dorsal aspect of the talus oblique views are beneficial in revealing anteromedial talar spurs CT: delineates extent of bony osteophytes MRI: shows spurring and fluid in joint Treatment Nonoperative: therapy, lifestyle modifications, NSAIDS - first line of treatment corticosteroid injections - help with soft tissue impingement and synovitis-related pain Operative arthroscopic excision indications: nonoperative modalities fail Techniques Arthroscopic excision - supine position with external traction device and leg over a padded bump. Use knife to only cut the skin and use hemostat to spread to avoid neurovascular injury while making portals. Ensure adequate field of view prior to burring or shaving anterior distal tibia to avoid iatrogenic dorsal NV bundle injury Complications Superficial peroneal nerve injury during anterolateral portal creation Saphenous vein injury during anteromedial portal creation Dorsal neurovascular bundle injury during tibiotalar spur removal

Answer 13

A 30-year-old laborer with a paralysis of the deltoid and rotator cuff muscles A glenohumeral arthrodesis would be most beneficial to a patient with a flail shoulder but intact elbow and hand function. This is especially important for a laborer. It will allow the patient to have a stable base upon which to be able to use the hand. The position of arthrodesis is described in the review topic, and the goal is to position the shoulder so that the hand can reach the patient's mouth for feeding and groin for hygiene. The goal of shoulder arthrodesis is to provide a stable base for the upper extremity optimizing hand and elbow function it remains an important treatment option in appropriately selected patients According to Clare et al. the indications include posttraumatic paralysis of the deltoid muscle and rotator cuff, brachial plexus injuries, chronic infection, failed revision arthroplasty, severe refractory instability, and bone deficiency following tumor resection. The review by Safran & Iannotti noted marked improvements in pain and function in appropriately selected patients. Complications include nonunion, malposition, pain associated with prominent hardware, and periarticular fractures. Incorrect Responses: 1. Hemiarthoplasty may be better for a younger patient with AVN. 2. Continued therapy and revision arthroscopic or open stabilization would be better choices. 4. Once the infection is treated, a second-stage re-implantation of a TSA, hemiarthroplasty or reverse TSA would be a better option. 5. Patients with cleidocranial dysostosis may benefit from scapulo-thoracic arthrodesis, not glenohumeral. Indications - stabilization of paralytic disorders brachial plexus palsy - irreparable deltoid and rotator cuff deficiency with arthropathy - salvage of a failed total shoulder arthroplasty - reconstruction after tumor resection - painful ankylosis after chronic infection - recurrent shoulder instability which has failed previous repair attempts - paralytic disorders in infancy Contraindications - ipsilateral elbow arthrodesis - contralateral shoulder arthrodesis - lack of functional scapulothoracic motion - trapezius, levator scapulae, or serratus anterior paralysis - Charcot arthropathy during acute inflammatory stage (Eichenholtz 0-2) - elderly patients - progressive neurologic disease Anatomy Glenohumeral articulation: a relatively small amount of surface area exists allowing for predictable fusion. To increase the available fusion area, decortication of both the glenohumeral articular surface and the articulation between the humeral head and the undersurface of the acromion is performed. Only the glenoid fossa and base of the coracoid provide sufficient strength for fixation Symptoms: specific to the underlying condition necessitating arthrodesis, symptomatic dysfunction of the glenohumeral joint

Answer 14

Rotationplasty While intra-articular extension of osteosarcoma is a rare presentation, understanding of the various treatment options available is crucial for the treating surgeon. Often joint contamination occurs secondary to a previous surgical procedure when a malignant neoplasm isn't considered in the differential diagnosis. While limb salvage may be possible with joint contamination, optimization of function and limitation of the number of future surgical procedures needs to be considered. Rotationplasty offers the treating surgeon the ability to perform a safe and negative margin resection while at the same time maximizing patient function and limiting the number of future re-operations. Damron et al review the various joint-related tumors which mimic sports-related injuries in their instructional course lecture. They suggest that appropriate preoperative imaging and consideration of malignant conditions in the differential diagnosis of any suspicious condition will increase the chances that the treating surgeon correctly identifies the neoplasm and avoids a procedure which compromises limb-salvage. Quan et al retrospectively reviewed 27 cases of peri-articular osteosarcoma, specifically looking for intra-articular involvement. They suggest that intra-articular involvement of osteosarcoma is very rare as articular cartilage serves as a good boundary to tumor expansion. Joint contamination from an incorrect surgical procedure is a much more likely cause of intra-articular extension. Incorrect answers 1) Through knee amputation - with joint contamination, a through knee amputation would not provide an appropriate negative margin resection and therefore contaminate the distal resection margin with tumor 2) Above knee amputation - while this would provide a safe resection level, the level of function would not be as great as with a rotationplasty 4 & 5) Both of these options would be available for limb salvage, however they would not result in as high a level of function as a rotationplasty. In addition these procedures would likely require many subsequent operations given the higher rates of complication and the need for future prosthetic lengthening/exchange. Intramedullary osteosarcoma is the most common primary sarcoma of bone - the most common malignancy of bone is metastatic disease - the most common primary malignancy of bone is myeloma Bimodal distribution of occurrence - majority occur in the second decade of life - second peak in occurrence is in elderly patients with Paget's disease most common site is the distal femur and proximal tibia other common sites include proximal humerus, proximal femur, and pelvis Malignancy: most commonly diagnosed as Stage IIB (high grade, extra-compartmental, no metastases) 10-20% of patients present with pulmonary metastases (obtain CT of chest) - lung is most common site of metastasis bone is second most common site Genetics patients who carry the Retinoblastoma tumor suppressor gene (Rb) are predisposed to osteosarcoma risk increased in Rothmund Thomson syndrome - AR inheritance, mutations in RECQL4 gene, chr 8q24.3 sun-sensitive facial poikiloderma rash (pigmentation, thinned skin, prominent blood vessels), absent eyelashes, eyebrows, hair, juvenile cataracts, teeth abnormalities, osteosarcoma, fibrosarcoma, gastric adenocarcinoma, cutaneous BCC and SCC Prognosis 76% long-term survival with modern treatment poor prognostic factors include: advanced stage of disease (most predictive of survival), response to chemotherapy (as judged by percent tumor necrosis of resected specimen), tumor site and size, expression of P-glycoprotein, high serum alkaline phosphatase, high lactic dehydrogenase, vascular involvement, surgical margins, type of chemotherapy regimen Symptoms: rapidly progressive pain, fever, and swelling Physical exam: may feel mass on examination Imaging Radiographs: characteristic blastic and destructive lesion - sun-burst or hair on end pattern of matrix mineralization, periosteal reaction (Codman's triangle), large soft tissue mass with maintenance of bone cortices MRI: must include entire involved bone to determine soft tissue involvement, neurovascular involvement, presence skip metastases - if skip metastases are found, this is equivalent to metastatic (stage III) disease Bone scan: very hot in osteosarcoma. Useful to evaluate extent of local disease and presence of bone metastases CT: chest CT is required at presentation to evaluate for pulmonary metastases Labs Elevated alkaline phosphatase - may be 2-3 times normal value Histology: tumor cells show significant atypia, and produce "lacey" osteoid. Stroma cells show malignant characteristics with atypia, high nuclear to cytoplasmic ratio, and abnormal mitotic figures. May have mixed histology with different combinations of chondroblastic,osteoblastic, or fibroblastic looking cells depends on the subtype of osteosarcoma. Giant cells may be present in giant cell rich osteosarcoma - often confused with giant cell tumor of bone Diagnosis: biopsy is required to obtain tissue diagnosis and institute therapy - improper biopsy techniques are associated with increased rates of complications Biopsy should be performed by the surgeon responsible for definitive treatment of the sarcoma, or after discussion with this surgeon Treatment Operative: multi-agent chemotherapy and limb salvage resection indications high grade osteosarcoma chemotherapy : preoperative chemotherapy given for 8-12 weeks followed by maintenance chemotherapy for 6-12 months after surgical resection - 98% necrosis after neo-adjuvant chemotherapy is good prognostic sign. Expression of multi-drug resistance (MDR) gene tends to have a poor prognosis as tumor cells can pump chemotherapy out of cell with MDR expression (present in 25% of primary lesions and 50% of metastatic lesions) surgical technique - trend towards limb salvage whenever possible overall survival in osteosarcoma is equal after limb salvage vs. amputation to deal with local extent of disease rotationplasty is a great surgical option which optimizes the patient's function, and most commonly done in a pediatric population wide surgical resection - indicated in low grade osteosarcoma such as parosteal osteosarcoma amputation indications: pathologic fracture, encasing neurovascular bundle, enlarging during preop chemo AND adjacent to neurovascular bundle

Answer 15

The clinical presentation is consistent for a residual radial nerve palsy 4 months after a humeral shaft fracture. An EMG is indicated at this time to evaluate the status of the nerve recovery. A radial nerve injury which occurs during a humeral shaft fracture or after bracing is not an indication for immediate exploration. Most often, the nerve function returns without surgical intervention. An EMG should be performed at 3-5 months to evaluate the status of the nerve recovery. If fasciculations are present, then this represents recovery, and observation should be continued. If fibrillations are present, this represents denervation, and surgical exploration should be considered. Pollock et al followed 24 humeral-shaft fractures with associated radial-nerve injuries, 2 of which required open exploration and all recovered. They recommend careful observation for return of nerve function and exploration at 3.5-4 months after injury if there is still no clinical or EMG evidence of recovery. Bostman et al reviewed 59 immediate and 16 secondary radial nerve palsies and no support emerged for routine early exploration in either group. Figures A and B show an oblique fracture at the junction of the middle and distal 1/3 of the humeral shaft. Illustration A shows the relative close position of the radial nerve to the humerus at the midlevel of humerus, and why it is at risk with a humerus shaft fracture. Complications Humeral shaft fx nonunion : no callous on radiograph and gross motion at the fracture site at 6 weeks from injury has a 100% PPV of going on to nonounion in closed humeral shaft fractures Malunion: varus angulation is common but rarely has functional or cosmetic sequelae risk factors: transverse fracture patterns Radial nerve palsy incidence: seen in 8-15% of closed fractures increased incidence distal one-third fractures neuropraxia most common injury in closed fractures and neurotomesis in open fractures 85-90% of improve with observation over 3 months spontaneous recovery found at an average of 7 weeks, with full recovery at an average of 6 months treatment observation indicated as initial treatment in closed humerus fractures - obtain EMG at 3-4 months. Wrist extension in radial deviation is expected to be regained first - brachioradialis first to recover, extensor indicis is the last surgical exploration indications: - open fracture with radial nerve palsy (likely neurotomesis injury to the radial nerve) - closed fracture that fails to improve over ~ 3-6 months fibrillations (denervation) seen at 3-4 months on EMG

Answer 16

Adductor myodesis is a critical part of a transfemoral amputation. If it is not performed, then the abductors and hip flexors can cause the femur to abduct, leading to severe problems with gait. The gait disturbance persists despite proper prosthetic fitting. A transfemoral amputation is usually performed with equal anterior and posterior flaps. Pinzur et al highlight the fact that amputations are reconstructive procedures and should leave the patient with a functional residual limb. Transfemoral Amputation: - Maintain as much length as possible, however, ideal cut is 12 cm (10-15cm) above knee joint to allow for prosthetic fitting Technique - 5-10 degrees of adduction is ideal for improved prosthesis function - adductor myodesis: improves clinical outcomes creates dynamic muscle balance (otherwise have unopposed abductors). Provides soft tissue envelope that enhances prosthetic fitting Gritti-Stokes amputation: amputation through the femur near level of adductor tubercle. Synovium is excised to prevent postoperative effusion. Patella is arthrodesed to the end of femur for improved end bearing prepatellar soft tissue is maintained without iatrogenic injury - improved outcomes as compared to transfemoral amputation ``` Wound Healing Dependent on - vascular supply - nutritional status - immune status ``` Improved with - albumin > 3.0 g/dL - ischemic index > .5 measurement of doppler pressure at level being tested compared to brachial systolic pressure - transcutaneous oxygen tension > 30 mm Hg (ideally 45 mm Hg) - toe pressure > 40 mm Hg (will not heal if < 20 mm Hg) ankle-brachial index (ABI) > 0.45 total lymphocyte count (TLC) > 1500/mm3 - Hyperbaric oxygen therapy contraindications include: chemo or radiation therapy pressure-sensitive implanted medical device (automatic implantable cardiac defibrillator, pacemaker, dorsal column stimulator, insulin pump) , undrained pneumothorax Complications - Wound healing - Contractures: adjacent joint contractures are common prevent with early aggressive mobilization and position changes - Heterotopic ossification: more common in trauma-related setting - Infection: trauma-related amputation have an infection rate of around 34% - Postamputation Neuroma : occurs in 20-30% of amputees prevent with proper nerve handling at the time of procedure. Treatment: targeted muscle rein nervation - a method of guiding neuronal regeneration to prevent or treat post-amputation neuroma pain and improve patient use of myoelectric prostheses - Phantom limb pain occurs in 53-100% of traumatic amputations mirror therapy is a noninvasive treatment modality - Bone overgrowth: most common complication with pediatric amputations. Treatment: prevent by performing disarticulation or using epihphyseal cap to cover medullary canal

Answer 17

Figure A show a classic SAD (supination adduction) fracture according to the Lauge-Hansen Classfication. This is evident by the vertical medial malleolar fracture and supinated position of the foot. The vertical medial malleolar fracture is best treated by screw fixation parallel to the joint (perpendicular to the fracture line). Careful attention must be paid to the presence of any medial plafond impaction from the talar displacement; if this is present, disimpaction and stabilization must be performed in order to optimize outcomes. The referenced review article by Michelson covers rotational ankle fractures, with a review of the diagnosis, treatment options, and patient outcomes. He notes that unstable fractures (bimalleolar, bimalleolar equivalent, etc.) usually are managed with open reduction and internal fixation for optimal outcomes. Incorrect answers: Figure B shows a Weber C (high fibular) ankle fracture, PER, without any evidence of a medial malleolar fracture. Figures C (SER IV), D (PER IV), and E (isloated medial malleolar fracture) all show fractures not suitable for screw fixation of the medial malleolus parallel to the joint since their fracture lines are not vertical. Supination - Adduction (SA): Talofibular sprain or distal fibular avulsion Vertical medial malleolus and impaction of anteromedial distal tibia Supination - External Rotation (SER): Anterior tibiofibular ligament sprain Lateral short oblique fibula fracture (anteroinferior to posterosuperior) Posterior tibiofibular ligament rupture or avulsion of posterior malleolus Medial malleolus transverse fracture or disruption of deltoid ligament Pronation - Abduction (PA): Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament sprain Transverse comminuted fracture of the fibula above the level of the syndesmosis Pronation - External Rotation (PER): Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament disruption Lateral short oblique or spiral fracture of fibula (anterosuperior to posteroinferior) above the level of the joint Posterior tibiofibular ligament rupture or avulsion of posterior malleolus

Answer 18

Previous calcaneus fracture The referenced study by Buckley et al is a prospective study of intra-articular calcaneus fractures at several trauma centers. They found that overall, the outcomes after nonoperative treatment were not different from those after operative treatment. However, when stratifying groups, women who were managed operatively scored significantly higher on the SF-36 than did women who were managed nonoperatively. Also, patients who were less than twenty-nine years old, had a Böhler angle of 0 degrees to 14 degrees, a comminuted fracture, or a light workload did better after surgery compared with those who were treated non operatively. incidence: most frequent tarsal fracture 17% open fractures Pathophysiology mechanism: traumatic axial loading is the primary mechanism of injury - fall from height, motor-vehicle accidents pathoanatomy - intra-articular fractures: primary fracture line results from oblique shear and leads to the following two primary fragments 1. superomedial fragment (constant fragment): includes the sustentaculum tali and is stabilized by strong ligamentous and capsular attachments 2. superolateral fragment: includes an intra-articular aspect through the posterior facet secondary fracture lines dictate whether there is joint depression or tongue-type fracture - extra-articular fractures: strong contraction of gastrocnemius-soleus with concomitant avulsion at its insertion site on calcaneus. More common in osteopenic bone - anterior process fractures: inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament Associated injuries: extension into the calcaneocuboid joint occurs in 63%, vertebral injuries in 10%, contralateral calcaneus in 10% Prognosis: poor with 40% complication rate - increased due to mechanism (fall from height), smoking, and early surgery - lateral soft tissue trauma increases the rate of complication Osteology articular facets - superolateral fragment contains the articular facets - superior articular surface contains three facets that articulate with the talus - posterior facet is the largest and is the major weight bearing surface - the flexor hallucis longus tendon runs just inferior to it and can be injured with errant drills/screws that are too long - middle facet is anteromedial on sustentaculum tali - anterior facet is often confluent with middle facet sinus tarsi: between the middle and posterior facets lies the interosseous sulcus (calcaneal groove) that together with the talar sulcus makes up the sinus tarsi sustentaculum tali: projects medially and supports the neck of talus. FHL passes beneath it. Deltoid and talocalcaneal ligament connect it to the talus. Contained in the anteromedial fragment, which remains "constant" due to medial talocalcaneal and interosseous ligaments bifurcate ligament: connects the dorsal aspect of the anterior process to the cuboid and navicular Classification Extra-articular (25%) - avulsion injury of anterior process by bifurcate ligament, sustentaculum tali, calcaneal tuberosity (Achilles tendon avulsion) Intra-articular (75%): Essex-Lopresti classification - the primary fracture line runs obliquely through the posterior facet forming two fragments. The secondary fracture line runs in one of two planes - the axial plane beneath the facet exiting posteriorly in tongue-type fractures when the superolateral fragment and posterior facet remain attached to the tuberosity posteriorly - behind the posterior facet in joint depression fractures Sanders classification Based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet Type I • Nondisplaced posterior facet (regardless of number of fracture lines) Type II • One fracture line in the posterior facet (two fragments) Type III • Two fracture lines in the posterior facet (three fragments) Type IV • Comminuted with more than three fracture lines in the posterior facet (four or more fragments) Physical exam: diffuse tenderness to palpation, ecchymosis and swelling, shortened, widened, heel with a varus deformity Imaging Radiographs: AP, lateral, oblique Optional views: Broden: allows visualization of posterior facet - useful for evaluation of intraoperative reduction of posterior facet with ankle in neutral dorsiflexion and ~45 degrees internal rotation, take x-rays at 40, 30, 20, and 10 degrees cephalad from neutral Harris : visualizes tuberosity fragment widening, shortening, and varus positioning. Place the foot in maximal dorsiflexion and angle the x-ray beam 45 degrees AP ankle: demonstrates lateral wall extrusion causing fibular impingement Findings - double-density sign: represents subtalar incongruity - indicates partial separation of facet from sustentaculum - calcaneal shortening - varus tuberosity deformity - decreased Bohler angle : angle between line from highest point of anterior process to highest point of posterior facet + line tangential to superior edge of tuberosity measured on lateral view (normal 20-40° ) represents collapse of the posterior facet - increased angle of Gissane : angle between line along lateral margin of posterior facet + line anterior to beak of calcaneus - measured on lateral view (normal 120-145°) represents collapse of the posterior facet CT: gold standard - demonstrates posterior and middle facet displacement, calcaneocuboid joint involvement and tuberosity displacement MRI: used only to diagnose calcaneal stress fractures in the presence of normal radiographs and/or uncertain diagnosis Treatment Nonoperative: - Cast immobilization with nonweightbearing for 6 weeks. Indications: calcaneal stress fractures - Cast immobilization with nonweightbearing for 10 to 12 weeks. Indications: small extra-articular fracture (<1 cm) with intact Achilles tendon and <2 mm displacement, Sanders Type I (non displaced), anterior process fracture involving <25% of calcaneocuboid joint, comorbidities that preclude good surgical outcome (smoker, diabetes, PVD) techniques: begin early range of motion exercises once swelling allows Operative Closed reduction with percutaneous pinning indications - minimally displaced tongue-type fxs or those with mild shortening - large extra-articular fractures (>1 cm) Early reduction prevents skin sloughing and need for subsequent flap coverage techniques: lag screws from posterior superior tuberosity directed inferior and distal ORIF indications - displaced tongue-type fractures - large extra-articular fractures (>1 cm) with detachment of Achilles tendon and/or > 2 mm displacement (urgent if skin is compromised) - Sanders Type II and III (posterior facet displacement >2 to 3 mm, flattening of Bohler angle, or varus malalignment of the tuberosity) - anterior process fracture with >25% involvement of calcaneocuboid joint - displaced sustentaculum fractures timing: wait 10-14 days until swelling and blisters resolve and wrinkle sign present 10-14 days. No benefit to early surgery due to significant soft tissue swelling outcomes surgical outcome correlates with the number of intra-articular fragments and the quality of articular reduction factors associated with a poor outcome: age > 50, obesity, manual labor, workers comp, smokers, bilateral calcaneal fractures, multiple trauma, vasculopathies, men do worse with surgery than women Factors associated with most likely need for a secondary subtalar fusion: male worker's compensation patient who participates in heavy labor work with an initial Böhler angle less than 0 degrees Primary subtalar arthrodesis indications: Sanders Type IV techniques: combined with ORIF to restore height

Answer 19

The images demonstrate a posterior column acetabular fracture. These are best surgically treated with a Kocher-Langenbeck approach, which allows access to the posterior column and posterior wall. Figure A shows disruption of the ilioischial line with an intact iliopectineal line which is diagnostic of this fracture pattern. The CT image in Figure D shows the characteristic horizontal (coronal) orientation of the column fracture when viewed on an axial CT. Illustration A shows the radiographic landmarks used in diagnosing acetabular fractures. Illustrations B and C show the orientation of column and wall fractures respectively. Ilioinguinal and Stoppa approaches allow access for anterior column fixation and symphysis fixation respectively. The extended iliofemoral approach can be used to treat both column injuries, but has high rates of post-operative heterotopic ossification. Acetabulum fractures can involve one or more of the two columns, two walls or roof within the pelvis Osteology acetabular inclination & ante version: mean lateral inclination of 40 to 48 degrees, anteversion of 18 to 21 degrees Column theory : acetabulum is supported by two columns of bone - form an "inverted Y". Connected to sacrum through sciatic buttress - Posterior column: comprised of quadrilateral surface, posterior wall and dome, ischial tuberosity, greater/lesser sciatic notches - anterior column: comprised of anterior ilium (gluteus medius tubercle), anterior wall and dome, iliopectineal eminence, lateral superior pubic ramus Vascular corona mortis : anastomosis of external iliac (epigastric) and internal iliac (obturator) vessels - at risk with lateral dissection over superior pubic ramus Letournel Classification Judet and Letournel: most common referenced classification system - classifed as 5 elementary and 5 associated fracture patterns Most common fracture patterns Younger : posterior wall or transverse fracture "family" (transverse, T-type, transverse + posterior wall) Elderly : anterior column (e.g., quadrilateral plate fractures), anterior column, posterior hemitransverse, assoicated both column fractures Posterior wall • Most common • "gull sign" on obturator oblique view Posterior column • check for injury to superior gluteal NV bundle Anterior wall • Very rare Anterior column • More common in elderly patients with fall from standing (most common in elderly is "anterior column + medial wall") Transverse • Axial CT shows anterior to posterior fx line • Only elementary fx to involve both columns Associated Both Column • Characterized by dissociation of the articular surface from the inonimate bone • "spur sign" on obturator oblique Transverse + Post. Wall • Most common associated fx T Shaped • May need combined approach Anterior column or wall + Post. hemitransverse • Common in elderly patients Post. column + Post. wall • Only associated fracture that does not involve both columns Treatment Nonoperative: protected weight bearing for 6-8 weeks indications: patient factors - high operative risk (e.g., elderly patients, presence of DVT), morbid obesity, open contaminated wound, late presenting > 3 weeks fracture characteristics: minimally displaced fracture (< 2 mm), < 20% posterior wall fractures (treatment based on size of posterior wall is controversial - recommend an exam under anesthesia (EUA) using fluoroscopy best method to test stability), Femoral head congruency with weight bearing roof (out of traction) - both column fracture pattern with secondary congruence (out of traction), displaced fracture with roof arcs > 45° in AP and Judet views or >10 mm on axial CT cuts technique - Skeletal traction NOT required if stable fracture pattern, outside the weight-bearing dome - activity as tolerated with crutches/walker Weight-bearing: lowest joint reactive forces seen with toe-touch weight bearing and passive hip abduction, greatest joint contact force seen when rising from a chair on the affected extremity DVT prophylaxis if slow to mobilize Close radiographic follow-up Operative treatment open reduction and internal fixation indications - Patient factors: < 3 weeks from date of injury, physiologically stable, adequate soft-tissue envelope, no local infection, pregnancy is not contraindication to surgical fixation - Fracture factors: displacement of roof (> 2 mm), unstable fracture pattern (e.g. posterior wall fracture involving > 40-50%), marginal impaction, intra-articular loose bodies, irreducible fracture-dislocation Approaches - Anterior : ilioinguinal, iliofemoral, modified stoppa - Posterior: Kocher-Langenbach - Combined: extended ilifemoral Fixation modalities: - Column fixation strategies: reconstruction bridging plate and screws, percutaneous column screws, cable fixation - Wall fixation strategies: bridge plate and screws, lag screw and neutralization plate, spring (butress) plate outcomes timing: associated hip dislocations should be reduced within 12 hours for improved outcomes worse outcomes with fixation of fracture > 3 weeks from time of injury - earlier operative treatment associated with increased chance of anatomic reduction Peri-operative : clinical outcome correlates with quality of articular reduction Postoperative CT scan is most accurate way to determine posterior wall accuracy of reduction which has greatest correlation with clinical outcome - ideally articular reduction <2mm Post-operative greatest stress on acetabular repair occurs when rising from a seated position using the affected leg, and occurs in the posterior superior portion of the acetabulum Functional outcomes most strongly correlate with hip muscle strength and restoration of gait postoperatively Total hip arthroplasty indications usually elderly patients with significant osteopenia and/or significant comminution, pre-existing arthritis, post-traumatic arthritis in all ages techniques timing: immediate vs. delayed THA immediate THA (with, or without, fracture fixation) wall fractures : butress plate with multi-hole cup column fracture: cage and cup constructs delayed THA outcomes: patients older than 60 years have approx. a 30% late conversion rate to THA after acetabular fractures 10-year implant survival noted to be around 75-80%

Answer 20

The "corona mortis" (translated as “crown of death”) artery is a vascular variant that joins the external illiac and the obturator artery as it crosses the superior pubic ramus. Tornetta et al did a study where "fifty cadaver halves were dissected to determine the occurrence and location of the corona mortis. Anastomoses between the obturator and external iliac systems occurred in 84% of the specimens. Thirty-four percent had an arterial connection, 70% had a venous connection, and 20% had both. The distance from the symphysis to the anastomotic vessels averaged 6.2 cm (range, 3-9 cm)." The corona mortis can be injured in superior ramus fractures and iatrogenically while plating pelvic ring injuries using the ilioinguinal approach. Acetabulum fractures can involve one or more of the two columns, two walls or roof within the pelvis Osteology acetabular inclination & ante version: mean lateral inclination of 40 to 48 degrees, anteversion of 18 to 21 degrees Column theory : acetabulum is supported by two columns of bone - form an "inverted Y". Connected to sacrum through sciatic buttress - Posterior column: comprised of quadrilateral surface, posterior wall and dome, ischial tuberosity, greater/lesser sciatic notches - anterior column: comprised of anterior ilium (gluteus medius tubercle), anterior wall and dome, iliopectineal eminence, lateral superior pubic ramus Vascular corona mortis : anastomosis of external iliac (epigastric) and internal iliac (obturator) vessels - at risk with lateral dissection over superior pubic ramus Letournel Classification Judet and Letournel: most common referenced classification system - classifed as 5 elementary and 5 associated fracture patterns Most common fracture patterns Younger : posterior wall or transverse fracture "family" (transverse, T-type, transverse + posterior wall) Elderly : anterior column (e.g., quadrilateral plate fractures), anterior column, posterior hemitransverse, assoicated both column fractures Posterior wall • Most common • "gull sign" on obturator oblique view Posterior column • check for injury to superior gluteal NV bundle Anterior wall • Very rare Anterior column • More common in elderly patients with fall from standing (most common in elderly is "anterior column + medial wall") Transverse • Axial CT shows anterior to posterior fx line • Only elementary fx to involve both columns Associated Both Column • Characterized by dissociation of the articular surface from the inonimate bone • "spur sign" on obturator oblique Transverse + Post. Wall • Most common associated fx T Shaped • May need combined approach Anterior column or wall + Post. hemitransverse • Common in elderly patients Post. column + Post. wall • Only associated fracture that does not involve both columns Treatment Nonoperative: protected weight bearing for 6-8 weeks indications: patient factors - high operative risk (e.g., elderly patients, presence of DVT), morbid obesity, open contaminated wound, late presenting > 3 weeks fracture characteristics: minimally displaced fracture (< 2 mm), < 20% posterior wall fractures (treatment based on size of posterior wall is controversial - recommend an exam under anesthesia (EUA) using fluoroscopy best method to test stability), Femoral head congruency with weight bearing roof (out of traction) - both column fracture pattern with secondary congruence (out of traction), displaced fracture with roof arcs > 45° in AP and Judet views or >10 mm on axial CT cuts technique - Skeletal traction NOT required if stable fracture pattern, outside the weight-bearing dome - activity as tolerated with crutches/walker Weight-bearing: lowest joint reactive forces seen with toe-touch weight bearing and passive hip abduction, greatest joint contact force seen when rising from a chair on the affected extremity DVT prophylaxis if slow to mobilize Close radiographic follow-up Operative treatment open reduction and internal fixation indications - Patient factors: < 3 weeks from date of injury, physiologically stable, adequate soft-tissue envelope, no local infection, pregnancy is not contraindication to surgical fixation - Fracture factors: displacement of roof (> 2 mm), unstable fracture pattern (e.g. posterior wall fracture involving > 40-50%), marginal impaction, intra-articular loose bodies, irreducible fracture-dislocation Approaches - Anterior : ilioinguinal, iliofemoral, modified stoppa - Posterior: Kocher-Langenbach - Combined: extended ilifemoral Fixation modalities: - Column fixation strategies: reconstruction bridging plate and screws, percutaneous column screws, cable fixation - Wall fixation strategies: bridge plate and screws, lag screw and neutralization plate, spring (butress) plate outcomes timing: associated hip dislocations should be reduced within 12 hours for improved outcomes worse outcomes with fixation of fracture > 3 weeks from time of injury - earlier operative treatment associated with increased chance of anatomic reduction Peri-operative : clinical outcome correlates with quality of articular reduction Postoperative CT scan is most accurate way to determine posterior wall accuracy of reduction which has greatest correlation with clinical outcome - ideally articular reduction <2mm Post-operative greatest stress on acetabular repair occurs when rising from a seated position using the affected leg, and occurs in the posterior superior portion of the acetabulum Functional outcomes most strongly correlate with hip muscle strength and restoration of gait postoperatively Total hip arthroplasty indications usually elderly patients with significant osteopenia and/or significant comminution, pre-existing arthritis, post-traumatic arthritis in all ages techniques timing: immediate vs. delayed THA immediate THA (with, or without, fracture fixation) wall fractures : butress plate with multi-hole cup column fracture: cage and cup constructs delayed THA outcomes: patients older than 60 years have approx. a 30% late conversion rate to THA after acetabular fractures 10-year implant survival noted to be around 75-80%

Answer 21

The athlete has symptoms referable to the axillary, musculocutaneous, and suprascapular nerves resulting from an injury to the upper trunk of the brachial plexus. This portion of the plexus is formed by contributions of the fourth through sixth cervical nerve roots. This area is often contused or stretched following a tackling maneuver that results in either depression of the shoulder from contact at Erb’s point or traction of the upper plexus from forced stretching of the neck to the contralateral side. Supraclavicular injuries: - complete involvement of all roots is most common: 75%-80% of traumatic BPIs - C5 and C6 upper trunk (Erb palsy): 20%-25% of traumatic BPIs - C8, T1 or lower (Klumpke palsy): 0.6%-3.0% of traumatic BPIs Mechanism - high speed vehicular accidents (mostly motorcycle): 83% of traumatic BPIs - caudally forced shoulder: predominantly affect upper brachial plexus - with high enough energy all roots can be affected - forced arm abduction (as in grabbing onto something while falling) predominantly affects lower roots Prognosis Recovery of reconstructed plexus can take up to 3 years nerve regeneration occurs at speed of 1mm/day ``` infraclavicular plexus injuries have better prognosis than supraclavicular injuries Upper plexus injuries have improved prognosis - preservation of hand function root avulsion (preganglionic injuries) have worst prognosis (not repairable) other surgeries such as arthrodesis and tendon transfers may be needed ``` Anatomy brachial plexus motor and sensory innervation Classification Preganglionic vs. postganglionic - preganglionic: avulsion proximal to dorsal root ganglion involves CNS which does not regenerate – little potential recovery of motor function (poor prognosis) Lesions suggesting preganglionic injury: Horner’s syndrome (disruption of sympathetic chain), winged scapula medially, loss of serratus anterior (long thoracic nerve) rhomboids (dorsal scapular nerve) leads to medial winging (inferior border goes medial). Presents with motor deficits (flail arm), sensory intact, absence of a Tinel sign or tenderness to percussion in the neck, normal histamine test (C8-T1 sympathetic ganglion), intact triple response (redness, wheal, flare), elevated hemidiaphragm (phrenic nerve rhomboid paralysis (dorsal scapular nerve), supraspinatus/infraspinatus (suprascapular nerve), latissimus dorsi (thoracodorsal) Evaluation: EMG may show loss of innervation to cervical paraspinals Postganglionic: involve PNS, capable of regeneration (better prognosis) Presents with motor deficit (flail arm), sensory deficits Evaluation: EMG shows maintained innervation to cervical paraspinals abnormal histamine test only redness and wheal, but NO flare Classification based on location Upper Lesion: Erb's Palsy (C5,6) Most common obstetric brachial plexopathy Results from excessive displacement of head to opposite side and depression of shoulder on same side producing traction on plexus. Occurs during difficult delivery in infants or fall onto shoulder in adults Best prognosis Clinically, arm will be adducted, internally rotated, at shoulder; pronated, extended at elbow (“waiter’s tip”) C5 deficiency: axillary nerve deficiency (weakness in deltoid, teres minor), suprascapular nerve deficiency (weakness in supraspinatus, infraspinatus), musculocutaneous nerve deficiency (weakness to biceps) C6 deficiency: radial nerve deficiency (weakness in brachioradialis, supinator) Lower Lesion: Klumpke Palsy (C8,T1) Rare in obstetric palsy. Usually avulsion injuries caused by excessive abduction (person falling from height clutching on object to save himself) Other causes may include cervical rib, or lung mets in lower deep cervical lymph nodes Frequently associated with a preganglion injury and Horner's Syndrome Poor prognosis Deficit of all of the small muscles of the hand (ulnar and median nerves) - Clinically, presents as “claw hand” with wrist held in extreme extension because of the unopposed wrist extensors. Hyperextension of MCP due to loss of hand intrinsics, flexion of IP joints due to loss of hand intrinsics Total Palsy (C5-T1): A form of brachial plexopathy Worst prognosis - Leads to a flaccid arm Involves both motor and sensory

Answer 22

The Lisfranc level amputation removes the attachment of the peroneus brevis (base of the fifth metatarsal) and the peroneus longus (base of the first metatarsal), creating a varus deformity due to unopposed overpull by the tibialis anterior and posterior muscles. An anterior tibialis tendon transfer may be necessary. Other possible tissue balancing choices include posterior tibialis transfer and lengthening of the gastrocsoleus complex. Another option is to leave the base of the fifth metatarsal attached to preserve the eversion pull of the peroneus brevis. All the other amputations do not require soft-tissue balancing procedures to prevent deformities. However, adherence to the prescribed surgical techniques for reattachment of major muscle groups is important for optimizing limb strength and function. Ankle/Foot Amputation: Syme amputation (ankle disarticulation) - patent tibialis posterior artery is required. More energy efficient than midfoot even though it is more proximal Stable heel pad is most important factor Used successfully to treat forefoot gangrene in diabetics Technique: medial and lateral malleoli are removed flush with distal tibia articular surface. The medial and lateral flares of the tibia and fibula are beveled to enhance heel pad adherence. Heel pad is secured to anterior tibia Pirogoff amputation (hindfoot amputation): removal of the forefoot and talus followed by calcaneotibial arthrodesis calcaneus is osteotomized and rotated 50-90 degrees to keep posterior aspect of calcaneus distal Allows patient to mobilize independently without use of prosthetic Chopart or Boyd amputation (hindfoot amputation) a partial foot amputation through the talonavicular and calcaneocuboid joints. Primary complication is equinus deformity - avoid by lengthening of the Achilles tendon and transfer of the tibialis anterior to the talar neck leads to apropulsive gait pattern because the amputation is unable to support modern dynamic elastic response prosthetic feet Lisfranc amputation (midfoot amputation) - equinovarus deformity is common caused by unopposed pull of tibialis posterior and gastroc/soleus. Prevent by maintaining insertion of peroneus brevis and performing achilles lengthening. A walking cast is generally used for 4 week to prevent late equinus contracture. Energy cost of walking similar to that of BKA Transmetatarsal amputation: more appealing to patients who refuse transtibial amputations Almost all require achilles lengthening to prevent equinus Great toe amputations: preserve 1cm at base of proximal phalanx - preserves insertion of plantar fascia, sesamoids, and flexor hallucis brevis - reduces amount of weight transfer to remaining toes so lessens risk of ulceration Metabolic cost of walking - increases with more proximal amputations perform amputations at lowest possible level to preserve function - exception: Syme amputation is more efficient than midfoot amputation - inversely proportional to length of remaining limb Ranking of metabolic demand (% represents amount of increase compared to baseline) Syme - 15% transtibial: traumatic - 25% average, short BKA - 40%, long BKA - 10%, vascular - 40% transfemoral: traumatic - 68%, vascular - 100% thru-knee amputation: varies based on patient habitus but is somewhere between transtibial and transfemoral Most proximal amputation level available in children to maintain walking speeds without increased energy expenditure compared to normal children Transfemoral Amputation: - Maintain as much length as possible, however, ideal cut is 12 cm (10-15cm) above knee joint to allow for prosthetic fitting Technique - 5-10 degrees of adduction is ideal for improved prosthesis function - adductor myodesis: improves clinical outcomes creates dynamic muscle balance (otherwise have unopposed abductors). Provides soft tissue envelope that enhances prosthetic fitting Gritti-Stokes amputation: amputation through the femur near level of adductor tubercle. Synovium is excised to prevent postoperative effusion. Patella is arthrodesed to the end of femur for improved end bearing prepatellar soft tissue is maintained without iatrogenic injury - improved outcomes as compared to transfemoral amputation ``` Wound Healing Dependent on - vascular supply - nutritional status - immune status ``` Improved with - albumin > 3.0 g/dL - ischemic index > .5 measurement of doppler pressure at level being tested compared to brachial systolic pressure - transcutaneous oxygen tension > 30 mm Hg (ideally 45 mm Hg) - toe pressure > 40 mm Hg (will not heal if < 20 mm Hg) ankle-brachial index (ABI) > 0.45 total lymphocyte count (TLC) > 1500/mm3 - Hyperbaric oxygen therapy contraindications include: chemo or radiation therapy pressure-sensitive implanted medical device (automatic implantable cardiac defibrillator, pacemaker, dorsal column stimulator, insulin pump) , undrained pneumothorax Complications - Wound healing - Contractures: adjacent joint contractures are common prevent with early aggressive mobilization and position changes - Heterotopic ossification: more common in trauma-related setting - Infection: trauma-related amputation have an infection rate of around 34% - Postamputation Neuroma : occurs in 20-30% of amputees prevent with proper nerve handling at the time of procedure. Treatment: targeted muscle rein nervation - a method of guiding neuronal regeneration to prevent or treat post-amputation neuroma pain and improve patient use of myoelectric prostheses - Phantom limb pain occurs in 53-100% of traumatic amputations mirror therapy is a noninvasive treatment modality - Bone overgrowth: most common complication with pediatric amputations. Treatment: prevent by performing disarticulation or using epihphyseal cap to cover medullary canal

Answer 23

A Syme amputation is effectively a tibiotalar disarticulation, which provides an end-bearing stump that could potentially allow ambulation without a prosthesis over short distances. It works better for tumor and trauma, but the heel pad must be viable. The two most common problems are 1) skin sloughing from compromised vascular supply and 2) migration of the heel pad due to instability. A hypermobile heel pad can cause difficulty with prosthesis wear and damage to the soft tissues which can eventually lead to failure. Both malleoli are usually removed in the procedure, except in children or during the first stage procedure of a diabetic or infection case. The tibialis anterior is usually tenodesed to the anterior heel pad along with the EDL tendon to avoid posterior migration of the heel pad. Ankle/Foot Amputation: Syme amputation (ankle disarticulation) - patent tibialis posterior artery is required. More energy efficient than midfoot even though it is more proximal Stable heel pad is most important factor Used successfully to treat forefoot gangrene in diabetics Technique: medial and lateral malleoli are removed flush with distal tibia articular surface. The medial and lateral flares of the tibia and fibula are beveled to enhance heel pad adherence. Heel pad is secured to anterior tibia Pirogoff amputation (hindfoot amputation): removal of the forefoot and talus followed by calcaneotibial arthrodesis calcaneus is osteotomized and rotated 50-90 degrees to keep posterior aspect of calcaneus distal Allows patient to mobilize independently without use of prosthetic Chopart or Boyd amputation (hindfoot amputation) a partial foot amputation through the talonavicular and calcaneocuboid joints. Primary complication is equinus deformity - avoid by lengthening of the Achilles tendon and transfer of the tibialis anterior to the talar neck leads to apropulsive gait pattern because the amputation is unable to support modern dynamic elastic response prosthetic feet Lisfranc amputation (midfoot amputation) - equinovarus deformity is common caused by unopposed pull of tibialis posterior and gastroc/soleus. Prevent by maintaining insertion of peroneus brevis and performing achilles lengthening. A walking cast is generally used for 4 week to prevent late equinus contracture. Energy cost of walking similar to that of BKA Transmetatarsal amputation: more appealing to patients who refuse transtibial amputations Almost all require achilles lengthening to prevent equinus Great toe amputations: preserve 1cm at base of proximal phalanx - preserves insertion of plantar fascia, sesamoids, and flexor hallucis brevis - reduces amount of weight transfer to remaining toes so lessens risk of ulceration Metabolic cost of walking - increases with more proximal amputations perform amputations at lowest possible level to preserve function - exception: Syme amputation is more efficient than midfoot amputation - inversely proportional to length of remaining limb Ranking of metabolic demand (% represents amount of increase compared to baseline) Syme - 15% transtibial: traumatic - 25% average, short BKA - 40%, long BKA - 10%, vascular - 40% transfemoral: traumatic - 68%, vascular - 100% thru-knee amputation: varies based on patient habitus but is somewhere between transtibial and transfemoral Most proximal amputation level available in children to maintain walking speeds without increased energy expenditure compared to normal children Transfemoral Amputation: - Maintain as much length as possible, however, ideal cut is 12 cm (10-15cm) above knee joint to allow for prosthetic fitting Technique - 5-10 degrees of adduction is ideal for improved prosthesis function - adductor myodesis: improves clinical outcomes creates dynamic muscle balance (otherwise have unopposed abductors). Provides soft tissue envelope that enhances prosthetic fitting Gritti-Stokes amputation: amputation through the femur near level of adductor tubercle. Synovium is excised to prevent postoperative effusion. Patella is arthrodesed to the end of femur for improved end bearing prepatellar soft tissue is maintained without iatrogenic injury - improved outcomes as compared to transfemoral amputation ``` Wound Healing Dependent on - vascular supply - nutritional status - immune status ``` Improved with - albumin > 3.0 g/dL - ischemic index > .5 measurement of doppler pressure at level being tested compared to brachial systolic pressure - transcutaneous oxygen tension > 30 mm Hg (ideally 45 mm Hg) - toe pressure > 40 mm Hg (will not heal if < 20 mm Hg) ankle-brachial index (ABI) > 0.45 total lymphocyte count (TLC) > 1500/mm3 - Hyperbaric oxygen therapy contraindications include: chemo or radiation therapy pressure-sensitive implanted medical device (automatic implantable cardiac defibrillator, pacemaker, dorsal column stimulator, insulin pump) , undrained pneumothorax Complications - Wound healing - Contractures: adjacent joint contractures are common prevent with early aggressive mobilization and position changes - Heterotopic ossification: more common in trauma-related setting - Infection: trauma-related amputation have an infection rate of around 34% - Postamputation Neuroma : occurs in 20-30% of amputees prevent with proper nerve handling at the time of procedure. Treatment: targeted muscle rein nervation - a method of guiding neuronal regeneration to prevent or treat post-amputation neuroma pain and improve patient use of myoelectric prostheses - Phantom limb pain occurs in 53-100% of traumatic amputations mirror therapy is a noninvasive treatment modality - Bone overgrowth: most common complication with pediatric amputations. Treatment: prevent by performing disarticulation or using epihphyseal cap to cover medullary canal

Answer 24

Corrective osteotomy of fibular malunions, with appropriate lengthening, even in the presence of early arthritis, has been shown to decrease ankle pain and increase stability. Reduction and bone grafting of the medial malleolar nonunion is also needed. There is no evidence supporting the use of intra-articular steroids or hyaluronic acid in the ankle joint. Lateral talar displacement of even 1 mm has been reproducibly shown to decrease tibiotalar contact by 40% to 42%, causing a predisposition to arthritis. Supination - Adduction (SA): Talofibular sprain or distal fibular avulsion Vertical medial malleolus and impaction of anteromedial distal tibia Supination - External Rotation (SER): Anterior tibiofibular ligament sprain Lateral short oblique fibula fracture (anteroinferior to posterosuperior) Posterior tibiofibular ligament rupture or avulsion of posterior malleolus Medial malleolus transverse fracture or disruption of deltoid ligament Pronation - Abduction (PA): Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament sprain Transverse comminuted fracture of the fibula above the level of the syndesmosis Pronation - External Rotation (PER): Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament disruption Lateral short oblique or spiral fracture of fibula (anterosuperior to posteroinferior) above the level of the joint Posterior tibiofibular ligament rupture or avulsion of posterior malleolus

Answer 25

Extent of soft tissue injury has been shown in Level 2 evidence as having the highest impact on the decision to undergo limb salvage or amputation. The referenced study by MacKenzie et al looked at 527 of the 601 patients initially enrolled in the Lower Extremity Assessment Project (LEAP) and looked at several variables which are thought to be predictors of amputation. Severe muscle injury had the highest impact on the decision to amputate the limb, likely related to the surgeon’s assessment that the salvaged limb would function poorly because of the risk of infection, nonunion, and poor function. The absence of plantar sensation had the next most significant impact on surgical decision making. Factors that would influence proceeding with an amputation include an nonviable limb, irreparable vascular injury, warm ischemia time of more than 8 hours, or a severe crush injury with minimal remaining viable tissue. Amputation should also be considered when attempts at limb salvage leave the limb so severely damaged that function will be less satisfactory than that afforded by a prosthetic replacement, are a threat to the patient’s life, or would demand multiple surgical procedures and prolonged reconstruction time that is incompatible with the personal, sociologic, and economic consequences the patient is willing to undergo. amputation vs. reconstruction LEAP study ◾impact on decision to amputate limb: severe soft tissue injury - highest impact on decision-making process ◾absence of plantar sensation - 2nd highest impact on surgeon's decision making process. Not an absolute contraindication to reconstruction. Plantar sensation can recover by long-term follow-up Outcome measure ◾SIP (sickness impact profile) and return to work not significantly different between amputation and reconstruction at 2 years in limb-threatening injuries ◾25% infection rate ◾Mangled foot and ankle injuries requiring free tissue transfer have a worse SIP than BKA ◾most important factor to determine patient-reported outcome is the ability to return to work (About 50% of patients are able to return to work ) METALS study ◾study focused on military population in response to LEAP study ◾slightly better results in regard to patient-reported outcomes for the amputation group with a lower risk of PTSD - more severe limbs were going into salvage pathway, military population with better access to prostheses

Answer 26

Early fixation of acetabular fractures is associated with lesser organ dysfunction, so therefore answer three is not true. Plaisier et al showed the timing of acetabular and pelvic ring fracture fixation greatly impacted patient outcome. Patients who had fixation within 24 hours of injury showed shorter length of stay in the hospital and ICU (decreased number of ventilator days), improved functional outcomes including a highly likelihood of being discharged to home as opposed to a rehabilitation facility, and lesser organ dysfunction. The reference by Matta et al is a classic article that shows that patients fixed within 3 weeks of injury showed both a higher rate of anatomical reduction and lower overall complication rate than patients with similar fracture patterns treated after 3 weeks. Acetabulum fractures can involve one or more of the two columns, two walls or roof within the pelvis Osteology acetabular inclination & ante version: mean lateral inclination of 40 to 48 degrees, anteversion of 18 to 21 degrees Column theory : acetabulum is supported by two columns of bone - form an "inverted Y". Connected to sacrum through sciatic buttress - Posterior column: comprised of quadrilateral surface, posterior wall and dome, ischial tuberosity, greater/lesser sciatic notches - anterior column: comprised of anterior ilium (gluteus medius tubercle), anterior wall and dome, iliopectineal eminence, lateral superior pubic ramus Vascular corona mortis : anastomosis of external iliac (epigastric) and internal iliac (obturator) vessels - at risk with lateral dissection over superior pubic ramus Letournel Classification Judet and Letournel: most common referenced classification system - classifed as 5 elementary and 5 associated fracture patterns Most common fracture patterns Younger : posterior wall or transverse fracture "family" (transverse, T-type, transverse + posterior wall) Elderly : anterior column (e.g., quadrilateral plate fractures), anterior column, posterior hemitransverse, assoicated both column fractures Posterior wall • Most common • "gull sign" on obturator oblique view Posterior column • check for injury to superior gluteal NV bundle Anterior wall • Very rare Anterior column • More common in elderly patients with fall from standing (most common in elderly is "anterior column + medial wall") Transverse • Axial CT shows anterior to posterior fx line • Only elementary fx to involve both columns Associated Both Column • Characterized by dissociation of the articular surface from the inonimate bone • "spur sign" on obturator oblique Transverse + Post. Wall • Most common associated fx T Shaped • May need combined approach Anterior column or wall + Post. hemitransverse • Common in elderly patients Post. column + Post. wall • Only associated fracture that does not involve both columns Treatment Nonoperative: protected weight bearing for 6-8 weeks indications: patient factors - high operative risk (e.g., elderly patients, presence of DVT), morbid obesity, open contaminated wound, late presenting > 3 weeks fracture characteristics: minimally displaced fracture (< 2 mm), < 20% posterior wall fractures (treatment based on size of posterior wall is controversial - recommend an exam under anesthesia (EUA) using fluoroscopy best method to test stability), Femoral head congruency with weight bearing roof (out of traction) - both column fracture pattern with secondary congruence (out of traction), displaced fracture with roof arcs > 45° in AP and Judet views or >10 mm on axial CT cuts technique - Skeletal traction NOT required if stable fracture pattern, outside the weight-bearing dome - activity as tolerated with crutches/walker Weight-bearing: lowest joint reactive forces seen with toe-touch weight bearing and passive hip abduction, greatest joint contact force seen when rising from a chair on the affected extremity DVT prophylaxis if slow to mobilize Close radiographic follow-up Operative treatment open reduction and internal fixation indications - Patient factors: < 3 weeks from date of injury, physiologically stable, adequate soft-tissue envelope, no local infection, pregnancy is not contraindication to surgical fixation - Fracture factors: displacement of roof (> 2 mm), unstable fracture pattern (e.g. posterior wall fracture involving > 40-50%), marginal impaction, intra-articular loose bodies, irreducible fracture-dislocation Approaches - Anterior : ilioinguinal, iliofemoral, modified stoppa - Posterior: Kocher-Langenbach - Combined: extended ilifemoral Fixation modalities: - Column fixation strategies: reconstruction bridging plate and screws, percutaneous column screws, cable fixation - Wall fixation strategies: bridge plate and screws, lag screw and neutralization plate, spring (butress) plate outcomes timing: associated hip dislocations should be reduced within 12 hours for improved outcomes worse outcomes with fixation of fracture > 3 weeks from time of injury - earlier operative treatment associated with increased chance of anatomic reduction Peri-operative : clinical outcome correlates with quality of articular reduction Postoperative CT scan is most accurate way to determine posterior wall accuracy of reduction which has greatest correlation with clinical outcome - ideally articular reduction <2mm Post-operative greatest stress on acetabular repair occurs when rising from a seated position using the affected leg, and occurs in the posterior superior portion of the acetabulum Functional outcomes most strongly correlate with hip muscle strength and restoration of gait postoperatively Total hip arthroplasty indications usually elderly patients with significant osteopenia and/or significant comminution, pre-existing arthritis, post-traumatic arthritis in all ages techniques timing: immediate vs. delayed THA immediate THA (with, or without, fracture fixation) wall fractures : butress plate with multi-hole cup column fracture: cage and cup constructs delayed THA outcomes: patients older than 60 years have approx. a 30% late conversion rate to THA after acetabular fractures 10-year implant survival noted to be around 75-80%

Answer 27

.A transfemoral level amputation requires the greatest increase in energy expenditure of the amputation levels given, and a Syme amputation the least. Biologic joints are energy couples. When performing amputation surgery, more proximal amputations, accompanied by the removal of more joints, decreases the ability of patients to walk and live independently. Therefore a Syme amputation would require only a small increase in energy needed for ambulation. Bilateral transtibial amputee patients have an energy expenditure that is 40% above baseline levels. According to Miller's Review text, unilateral transfemoral amputee's require a 65% increase in energy expenditure. Pinzur et al. retrospectively studied 97 adult patients with diabetes mellitus who underwent Syme ankle disarticulation because of a neuropathic foot with an infection or gangrene, or both, during an 11 year period. They found that overall 84.5% of the patients achieved wound healing. Their data support the value of Syme ankle disarticulation in diabetic patients with infection or gangrene. Laughlin et al. retrospectively reviewed the surgical results and functional outcome of 52 patients treated with Syme amputations for forefoot gangrene. Wound healing was correlated with the preoperative status of the posterior tibial artery and follow-up averaged 27 months. The authors found that that posterior tibial artery Doppler examination is predictive of healing in the Syme amputation performed on diabetics, and that furthermore, diabetics can attain a functional level of ambulation with a Syme amputation. Illustration A shows a clinical photo of a standard Syme amputation with a healthy heel pad which can allow for limited weight bearing in the absence of a prosthesis. Incorrect Answers: 1,2,4,5: All of these amputation levels have lower energy expenditure increases than a transfemoral amputation. A Syme amputation is effectively a tibiotalar disarticulation, which provides an end-bearing stump that could potentially allow ambulation without a prosthesis over short distances. It works better for tumor and trauma, but the heel pad must be viable. The two most common problems are 1) skin sloughing from compromised vascular supply and 2) migration of the heel pad due to instability. A hypermobile heel pad can cause difficulty with prosthesis wear and damage to the soft tissues which can eventually lead to failure. Both malleoli are usually removed in the procedure, except in children or during the first stage procedure of a diabetic or infection case. The tibialis anterior is usually tenodesed to the anterior heel pad along with the EDL tendon to avoid posterior migration of the heel pad. Ankle/Foot Amputation: Syme amputation (ankle disarticulation) - patent tibialis posterior artery is required. More energy efficient than midfoot even though it is more proximal Stable heel pad is most important factor Used successfully to treat forefoot gangrene in diabetics Technique: medial and lateral malleoli are removed flush with distal tibia articular surface. The medial and lateral flares of the tibia and fibula are beveled to enhance heel pad adherence. Heel pad is secured to anterior tibia Pirogoff amputation (hindfoot amputation): removal of the forefoot and talus followed by calcaneotibial arthrodesis calcaneus is osteotomized and rotated 50-90 degrees to keep posterior aspect of calcaneus distal Allows patient to mobilize independently without use of prosthetic Chopart or Boyd amputation (hindfoot amputation) a partial foot amputation through the talonavicular and calcaneocuboid joints. Primary complication is equinus deformity - avoid by lengthening of the Achilles tendon and transfer of the tibialis anterior to the talar neck leads to apropulsive gait pattern because the amputation is unable to support modern dynamic elastic response prosthetic feet Lisfranc amputation (midfoot amputation) - equinovarus deformity is common caused by unopposed pull of tibialis posterior and gastroc/soleus. Prevent by maintaining insertion of peroneus brevis and performing achilles lengthening. A walking cast is generally used for 4 week to prevent late equinus contracture. Energy cost of walking similar to that of BKA Transmetatarsal amputation: more appealing to patients who refuse transtibial amputations Almost all require achilles lengthening to prevent equinus Great toe amputations: preserve 1cm at base of proximal phalanx - preserves insertion of plantar fascia, sesamoids, and flexor hallucis brevis - reduces amount of weight transfer to remaining toes so lessens risk of ulceration Metabolic cost of walking - increases with more proximal amputations perform amputations at lowest possible level to preserve function - exception: Syme amputation is more efficient than midfoot amputation - inversely proportional to length of remaining limb Ranking of metabolic demand (% represents amount of increase compared to baseline) Syme - 15% transtibial: traumatic - 25% average, short BKA - 40%, long BKA - 10%, vascular - 40% transfemoral: traumatic - 68%, vascular - 100% thru-knee amputation: varies based on patient habitus but is somewhere between transtibial and transfemoral Most proximal amputation level available in children to maintain walking speeds without increased energy expenditure compared to normal children Transfemoral Amputation: - Maintain as much length as possible, however, ideal cut is 12 cm (10-15cm) above knee joint to allow for prosthetic fitting Technique - 5-10 degrees of adduction is ideal for improved prosthesis function - adductor myodesis: improves clinical outcomes creates dynamic muscle balance (otherwise have unopposed abductors). Provides soft tissue envelope that enhances prosthetic fitting Gritti-Stokes amputation: amputation through the femur near level of adductor tubercle. Synovium is excised to prevent postoperative effusion. Patella is arthrodesed to the end of femur for improved end bearing prepatellar soft tissue is maintained without iatrogenic injury - improved outcomes as compared to transfemoral amputation ``` Wound Healing Dependent on - vascular supply - nutritional status - immune status ``` Improved with - albumin > 3.0 g/dL - ischemic index > .5 measurement of doppler pressure at level being tested compared to brachial systolic pressure - transcutaneous oxygen tension > 30 mm Hg (ideally 45 mm Hg) - toe pressure > 40 mm Hg (will not heal if < 20 mm Hg) ankle-brachial index (ABI) > 0.45 total lymphocyte count (TLC) > 1500/mm3 - Hyperbaric oxygen therapy contraindications include: chemo or radiation therapy pressure-sensitive implanted medical device (automatic implantable cardiac defibrillator, pacemaker, dorsal column stimulator, insulin pump) , undrained pneumothorax Complications - Wound healing - Contractures: adjacent joint contractures are common prevent with early aggressive mobilization and position changes - Heterotopic ossification: more common in trauma-related setting - Infection: trauma-related amputation have an infection rate of around 34% - Postamputation Neuroma : occurs in 20-30% of amputees prevent with proper nerve handling at the time of procedure. Treatment: targeted muscle rein nervation - a method of guiding neuronal regeneration to prevent or treat post-amputation neuroma pain and improve patient use of myoelectric prostheses - Phantom limb pain occurs in 53-100% of traumatic amputations mirror therapy is a noninvasive treatment modality - Bone overgrowth: most common complication with pediatric amputations. Treatment: prevent by performing disarticulation or using epihphyseal cap to cover medullary canal

Answer 28

In an ankle syndesmosis injury, the fibula is most unstable in an anterior and posterior direction. This is whether or not there is an accompanying ankle fracture. Most commonly, the fibula will subluxate in an anterior-posterior direction in an ankle fracture model. The first referenced article by Xenos et al found that stress lateral radiographs have more interobserver reliability than stress AP/mortise radiographs and that two syndesmotic screws are stronger than one. The referenced article by Candal-Couto et al is a biomechanical study that found more anterior-posterior instability in a syndesmosis injury model, and more ankle instability is noted with syndesmosis injury and a concomitant deltoid injury. The referenced article by Zalavras et al is an excellent review article on ankle syndesmosis injuries. Associated Syndesmotic Injury •Overview ◦suspect injury in all ankle fractures - most common in Weber C fracture patterns ◾fixation usually not required when fibula fracture within 4.5 cm of plafond ◾up to 25% of tibial shaft fractures will have ankle injury Evaluation ◦measure clear space 1 cm above joint: it has also been reported that there is no actual correlation between syndesmotic injury and tibiofibular clear space or overlap measurements. Lateral stress radiograph has more interobserver reliability than an AP/mortise stress film ◦best option is to assess stability intraoperatively with abduction/external rotation stress of dorsiflexed foot ◦instability of the syndesmosis is greatest in the anterior-posterior direction Treatment ◦operative ◾syndesmotic screw fixation ◾indications: widening of medial clear space, tibiofibular clear space (AP) greater than 5 mm, tibiofibular overlap (mortise) narrowed, any postoperative malalignment or widening should be treated with open debridement, reduction, and fixation ◾technique: length and rotation of fibula must be accurately restored - Outcomes are strongly correlated with anatomic reduction. Placing reduction clamp on midmedial ridge and the fibular ridge at the level of the syndesmosis will achieve most reliable anatomic reduction ◾"Dime sign"/Shentons line to determine length of fibula ◾open reduction required if closed reduction unsuccessful or questionable ◾one or two cortical screw(s) 2-4 cm above joint, angled posterior to anterior 20-30 degrees - lag technique not desired ◾maximum dorsiflexion of ankle not required during screw placement (can't overtighten a properly reduced syndesmosis) Postoperative ◾screws should be maintained in place for at least 8-12 weeks ◾must remain non-weight bearing, as screws are not biomechanically strong enough to withstand forces of ambulation Controversies ◾number of screws ◾1 or 2 most commonly reported ◾number of cortices ◾3 or 4 most commonly reported ◾size of screws ◾3.5 mm or 4.5 mm screws ◾implant material (stainless steel screws, titanium screws, suture, bioabsorbable materials) ◾need for hardware removal: no difference in outcomes seen with hardware maintenance (breakage or loosening) or removal at 1 year ◾outcome may be worse with maintenance of intact screws

Answer 29

The supraspinatus is innervated by the suprascapular nerve off the upper trunk and therefore would not be affected by an injury to the posterior cord. The posterior cord of the brachial plexus gives rise to the 1) upper subscapular nerve : subscapularis 2) lower subscapular nerve : teres major, subscapularis 3) thoracodorsal nerve : latissimus dorsi 4) axillary nerves : deltoid, ,teres minor 5) radial nerve. : triceps, brachioradialis, wrist extensors, finger extensors Preganglionic vs. postganglionic Preganglionic: avulsion proximal to dorsal root ganglion involves CNS which does not regenerate – little potential recovery of motor function (poor prognosis) lesions suggesting preganglionic injury: - Horner’s syndrome: disruption of sympathetic chain -> - winged scapula medially (loss of serratus anterior (long thoracic nerve), rhomboids (dorsal scapular nerve) leads to medial winging (inferior border goes medial)) - Presents with motor deficits (flail arm), sensory intact, absence of a Tinel sign or tenderness to percussion in the neck. Normal histamine test (C8-T1 sympathetic ganglion) - intact triple response (redness, wheal, flare) - Elevated hemidiaphragm (phrenic nerve - rhomboid paralysis (dorsal scapular nerve) - supraspinatus/infraspinatus (suprascapular nerve) - latissimus dorsi (thoracodorsal) - Evaluation: EMG may show loss of innervation to cervical paraspinals Postganglionic - involve PNS, capable of regeneration (better prognosis) presentation. Presents with motor deficit (flail arm) & sensory deficits - Evaluation: EMG shows maintained innervation to cervical paraspinals. Abnormal histamine test - only redness and wheal, but NO flare Classification based on location Upper Lesion: Erb's Palsy (C5,6) Most common obstetric brachial plexopathy Results from excessive displacement of head to opposite side and depression of shoulder on same side producing traction on plexus Occurs during difficult delivery in infants or fall onto shoulder in adults Best prognosis Clinically, arm will be adducted, internally rotated, at shoulder; pronated, extended at elbow (“waiter’s tip”) C5 deficiency: axillary nerve deficiency (weakness in deltoid, teres minor), suprascapular nerve deficiency (weakness in supraspinatus, infraspinatus), musculocutaneous nerve deficiency (weakness to biceps) C6 deficiency: radial nerve deficiency (weakness in brachioradialis, supinator) Lower Lesion: Klumpke Palsy (C8,T1) Rare in obstetric palsy Usually avulsion injuries caused by excessive abduction (person falling from height clutching on object to save himself) Other causes may include cervical rib, or lung mets in lower deep cervical lymph nodes Frequently associated with a preganglion injury and Horner's Syndrome Poor prognosis Deficit of all of the small muscles of the hand (ulnar and median nerves)- Clinically, presents as “claw hand” wrist held in extreme extension because of the unopposed wrist extensors hyperextension of MCP due to loss of hand intrinsics flexion of IP joints due to loss of hand intrinsics Total Palsy (C5-T1): A form of brachial plexopathy Worst prognosis Leads to a flaccid arm Involves both motor and sensory Presentation History: high energy injury Physical exam - Horner's syndrome features include drooping of the left eyelid, pupillary constriction, anhidrosis. Usually show up three days after injury. Represents disruption of sympathetic chain via C8 and/or T1 root avulsions - severe pain in anesthetized limb - correlates with root avulsion important muscles to test: serratus anterior (long thoracic nerve) and rhomboids (dorsal scapular nerve) - if they are functioning then it is more likely the C5 injury is postganglionic pulses check radial, ulnar and brachial pulses arterial injuries common with complete BPIs

Answer 30

Restricted weight bearing and magnetic resonance imaging of the foot is indicated in this military recruit with a positive heel compression test and suspicion for calcaneal stress fracture. Calcaneal stress fractures occur as a result of repetitive loading and are more common in females with the female athlete triad (anorexia athletica) of disordered eating, amenorrhea, and osteoporosis. On exam tenderness is obtained with medial and lateral compression of the calcaneus. Sormaala et al. performed a Level 4 review over 8 years of the Finnish military. They found 34 calcaneal stress fractures with 19 occurring in the posterior part of the calcaneus. Only 15% of the patients had the stress fracture visualized on plain radiography. They conclude that MRI is warranted if plain radiography does not show abnormalities in a physically active patient with exercise-induced pain in the ankle or heel. A nuclear medicine bone scan is also appropriate for diagnosis but MRI may give greater detail. Gehrmann et al. present a Level 5 review of foot stress fractures. They report that with calcaneal stress fractures the fracture lines are oriented vertically or obliquely in the tuberosity of the calcaneus. Figures A and B show some sclerosis in the central calcaneus with no evidence of overt fracture and an enthesophyte at the Achilles tendon insertion. Illustration A and B are T2 sagittal and coronal images demonstrating a stress fracture in the superior calcaneal tuberosity with surrounding edema. Incorrect Answers: Answer 1: Heel pad cortisone injections are typically avoided due to risk of fat pad atrophy and are not indicated in calcaneal stress fractures. Answer 2: Platelet rich plasma is not indicated in calcaneal stress fractures. Answer 4: The patient presents with a negative Tinel's at the tibial nerve and presentation is not consistent with first branch of the lateral plantar nerve entrapment. Answer 5: ASTYM and Graston physical therapies are not indicated for calcaneal stress fractures. Most frequent tarsal fracture 17% open fractures Pathophysiology mechanism: traumatic axial loading is the primary mechanism of injury, fall from height, motor-vehicle accidents pathoanatomy - intra-articular fractures: PRIMARY FRACTURE line results from oblique shear and leads to the following two primary fragments: 1. superomedial fragment (constant fragment): includes the sustentaculum tali and is stabilized by strong ligamentous and capsular attachments 2. superolateral fragment: includes an intra-articular aspect through the posterior facet SECONDARY FRACTURE lines dictate whether there is joint depression or tongue-type fracture - Extra-articular fractures: strong contraction of gastrocnemius-soleus with concomitant avulsion at its insertion site on calcaneus. More common in osteopenic bone - Anterior process fractures: inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament Associated injuries - extension into the calcaneocuboid joint occurs in 63% - vertebral injuries in 10% - contralateral calcaneus in 10% Prognosis poor with 40% complication rate - increased due to mechanism (fall from height), smoking, and early surgery lateral soft tissue trauma increases the rate of complication Osteology Articular facets : superolateral fragment contains the articular facets - superior articular surface contains three facets that articulate with the talus: - posterior facet is the largest and is the major weight bearing surface - the flexor hallucis longus tendon runs just inferior to it and can be injured with errant drills/screws that are too long - middle facet is anteromedial on sustentaculum tali - anterior facet is often confluent with middle facet sinus tarsi - between the middle and posterior facets lies the interosseous sulcus (calcaneal groove) that together with the talar sulcus makes up the sinus tarsi sustentaculum tali: Projects medially and supports the neck of talus - FHL passes beneath it. Deltoid and talocalcaneal ligament connect it to the talus - contained in the anteromedial fragment, which remains "constant" due to medial talocalcaneal and interosseous ligaments bifurcate ligament: connects the dorsal aspect of the anterior process to the cuboid and navicular Classification Extra-articular (25%) : avulsion injury of: anterior process (by bifurcate ligament), sustentaculum tali, calcaneal tuberosity (Achilles tendon avulsion) Intra-articular (75%) Essex-Lopresti classification: the primary fracture line runs obliquely through the posterior facet forming two fragments The secondary fracture line runs in one of two planes - the axial plane beneath the facet exiting posteriorly in tongue-type fractures - when the superolateral fragment and posterior facet remain attached to the tuberosity posteriorly - behind the posterior facet in joint depression fractures Sanders classification: based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet Sanders Classification Type I • Nondisplaced posterior facet (regardless of number of fracture lines) Type II • One fracture line in the posterior facet (two fragments) Type III • Two fracture lines in the posterior facet (three fragments) Type IV • Comminuted with more than three fracture lines in the posterior facet (four or more fragments)

Answer 31

Equinus deformity The Chopart amputation is an amputation of the foot at the level of the calcaneocuboid and talonavicular level. Historically, its use has been criticized because an amputation at this level results in a muscular imbalance with flexor predominance and equinus deformity that eventually leads to stump breakdown. To prevent this complication it should be coupled with Achilles tenotomy (vs. lengthening) as well as transfer of the tibialis anterior insertion to the talar neck. Advantages of the Chopart amputation include increased limb length and maintenance of heel proprioception that cannot be preserved with more proximal amputations. Lieberman et al argue in patients with peripheral vascular disease, it is important to preserve as much tissue as possible to preserve maximum function. They recommend that with appropriate care, an amputation at the Chopart (calcaneocuboid-talonavicular) level can give a good functional result. Ankle/Foot Amputation Syme amputation (ankle disarticulation) : patent tibialis posterior artery is required more energy efficient than midfoot even though it is more proximal. Stable heel pad is most important factor. Used successfully to treat forefoot gangrene in diabetics technique: medial and lateral malleoli are removed flush with distal tibia articular surface the medial and lateral flares of the tibia and fibula are beveled to enhance heel pad adherence heel pad is secured to anterior tibia Pirogoff amputation (hindfoot amputation): removal of the forefoot and talus followed by calcaneotibial arthrodesis calcaneus is osteotomized and rotated 50-90 degrees to keep posterior aspect of calcaneus distal allows patient to mobilize independently without use of prosthetic Chopart or Boyd amputation (hindfoot amputation) : a partial foot amputation through the talonavicular and calcaneocuboid joints primary complication is equinus deformity : avoid by lengthening of the Achilles tendon and transfer of the tibialis anterior to the talar neck Leads to apropulsive gait pattern because the amputation is unable to support modern dynamic elastic response prosthetic feet ``` Lisfranc amputation (midfoot amputation) : equinovarus deformity is common - caused by unopposed pull of tibialis posterior and gastroc/soleus. Prevent by maintaining insertion of peroneus brevis and performing achilles lengthening. A walking cast is generally used for 4 week to prevent late equinus contracture Energy cost of walking similar to that of BKA ``` Transmetatarsal amputation more appealing to patients who refuse transtibial amputations: almost all require achilles lengthening to prevent equinus Great toe amputations preserve 1cm at base of proximal phalanx - preserves insertion of plantar fascia, sesamoids, and flexor hallucis brevis Reduces amount of weight transfer to remaining toes lessens risk of ulceration Complications Wound healing Contracture: adjacent joint contractures are common - prevent with early aggressive mobilization and position changes Heterotopic ossification: more common in trauma-related setting Infection: trauma-related amputation have an infection rate of around 34% Postamputation Neuroma : occurs in 20-30% of amputees prevent with proper nerve handling at the time of procedure treatment: targeted muscle rein nervation - a method of guiding neuronal regeneration to prevent or treat post-amputation neuroma pain and improve patient use of myoelectric prostheses Phantom limb pain: occurs in 53-100% of traumatic amputations - mirror therapy is a noninvasive treatment modality Bone overgrowth: most common complication with pediatric amputations treatment: prevent by performing disarticulation or using epihphyseal cap to cover medullary canal

Answer 32

The external iliac and obturator artery anastomose to form the corona mortis. During the Stoppa or ilioinguinal approach to the pelvis, you need to be careful of the corona mortis because the vessels can cause significant bleeding especially if they retract into the pelvis. In the Tornetta et al article, fifty cadaver halves were dissected to determine the occurrence and location of the corona mortis. Anastomoses between the obturator and external iliac systems occurred in 84% of the specimens. Thirty-four percent had an arterial connection, 70% had a venous connection, and 20% had both. The distance from the symphysis laterally to the anastomotic vessels averaged 6.2 cm. The Okcu et al article showed similar results in 150 cadavers: they found vascular anastomoses between the obturator and external iliac systems in 61% of the sides, and anastomotic veins in 52% of the exposures. The mean distance between the anastomotic arteries and the symphysis pubis was 6.4 cm, and 5.6 cm for the communicating veins. There seemed to be no significant difference between genders in the incidence of corona mortis and the distance between communicating vessels and the symphysis pubis.

Answer 33

A through-knee disarticulation has been shown to have decreased energy expenditure with ambulation, improved limb proprioception, improved sitting capabilities, decreased hip joint flexion contracture incidence, and improved lever arm for mobilization. Knee disarticulation is also recommended in children to prevent overgrowth of the distal femur which may be seen in transfemoral amputations (if the physis remains open). No difference in prosthesis fitting has been shown between transfemoral amputation and through-knee disarticulation. The referenced paper by Pinzur et al is a excellent review of knee disarticulation, from technique to outcomes. Ranking of metabolic demand (% represents amount of increase compared to baseline) Syme - 15% transtibial: traumatic - 25% average, short BKA - 40%, long BKA - 10%, vascular - 40% transfemoral: traumatic - 68%, vascular - 100% thru-knee amputation: varies based on patient habitus but is somewhere between transtibial and transfemoral Most proximal amputation level available in children to maintain walking speeds without increased energy expenditure compared to normal children Transfemoral Amputation: - Maintain as much length as possible, however, ideal cut is 12 cm (10-15cm) above knee joint to allow for prosthetic fitting Technique - 5-10 degrees of adduction is ideal for improved prosthesis function - adductor myodesis: improves clinical outcomes creates dynamic muscle balance (otherwise have unopposed abductors). Provides soft tissue envelope that enhances prosthetic fitting Gritti-Stokes amputation: amputation through the femur near level of adductor tubercle. Synovium is excised to prevent postoperative effusion. Patella is arthrodesed to the end of femur for improved end bearing prepatellar soft tissue is maintained without iatrogenic injury - improved outcomes as compared to transfemoral amputation ``` Wound Healing Dependent on - vascular supply - nutritional status - immune status ``` Improved with - albumin > 3.0 g/dL - ischemic index > .5 measurement of doppler pressure at level being tested compared to brachial systolic pressure - transcutaneous oxygen tension > 30 mm Hg (ideally 45 mm Hg) - toe pressure > 40 mm Hg (will not heal if < 20 mm Hg) ankle-brachial index (ABI) > 0.45 total lymphocyte count (TLC) > 1500/mm3 - Hyperbaric oxygen therapy contraindications include: chemo or radiation therapy pressure-sensitive implanted medical device (automatic implantable cardiac defibrillator, pacemaker, dorsal column stimulator, insulin pump) , undrained pneumothorax Complications - Wound healing - Contractures: adjacent joint contractures are common prevent with early aggressive mobilization and position changes - Heterotopic ossification: more common in trauma-related setting - Infection: trauma-related amputation have an infection rate of around 34% - Postamputation Neuroma : occurs in 20-30% of amputees prevent with proper nerve handling at the time of procedure. Treatment: targeted muscle rein nervation - a method of guiding neuronal regeneration to prevent or treat post-amputation neuroma pain and improve patient use of myoelectric prostheses - Phantom limb pain occurs in 53-100% of traumatic amputations mirror therapy is a noninvasive treatment modality - Bone overgrowth: most common complication with pediatric amputations. Treatment: prevent by performing disarticulation or using epihphyseal cap to cover medullary canal

Answer 34

The posterior wall is best visualized on the obturator oblique pelvic view. The obturator oblique and iliac oblique views make up the Judet views that are used to evaluate acetabular fractures, along with a standard AP pelvis radiograph. The obturator oblique pelvic view is best to view the anterior column and posterior wall in detail. The iliac oblique shows the profile of involved iliac wing, the posterior column, and the anterior wall. Letournel reviewed his classification and treatment protocols, based on his 22 years of experience at that time. He noted that perfect anatomical reduction of the acetabulum led to the best outcomes. Patel et al reviewed of the Letournel classification, and they found moderate to high inter- and intra-observer reliability with this classification system. The presence of articular displacement, marginal impaction, incongruity, intra-articular fragments and osteochondral injuries to the femoral head were found to have less reliability (intra- and interobserver). Incorrect Answers: Answers 1: Inlet pelvic imaging is best for assessing pelvic ring injuries (rotation and anterior-posterior or medial-lateral translation). Answers 2: Outlet pelvic imaging is best for assessing pelvic ring injuries (proximal-distal translation, rotation). Answers 3: AP pelvis is a good screening tool for pelvic and acetabular fractures. Answers 5: Iliac oblique pelvis is best for assessing the posterior column and anterior wall of the acetabulum. Acetabulum fractures can involve one or more of the two columns, two walls or roof within the pelvis Osteology acetabular inclination & ante version: mean lateral inclination of 40 to 48 degrees, anteversion of 18 to 21 degrees Column theory : acetabulum is supported by two columns of bone - form an "inverted Y". Connected to sacrum through sciatic buttress - Posterior column: comprised of quadrilateral surface, posterior wall and dome, ischial tuberosity, greater/lesser sciatic notches - anterior column: comprised of anterior ilium (gluteus medius tubercle), anterior wall and dome, iliopectineal eminence, lateral superior pubic ramus Vascular corona mortis : anastomosis of external iliac (epigastric) and internal iliac (obturator) vessels - at risk with lateral dissection over superior pubic ramus Letournel Classification Judet and Letournel: most common referenced classification system - classifed as 5 elementary and 5 associated fracture patterns Most common fracture patterns Younger : posterior wall or transverse fracture "family" (transverse, T-type, transverse + posterior wall) Elderly : anterior column (e.g., quadrilateral plate fractures), anterior column, posterior hemitransverse, assoicated both column fractures Posterior wall • Most common • "gull sign" on obturator oblique view Posterior column • check for injury to superior gluteal NV bundle Anterior wall • Very rare Anterior column • More common in elderly patients with fall from standing (most common in elderly is "anterior column + medial wall") Transverse • Axial CT shows anterior to posterior fx line • Only elementary fx to involve both columns Associated Both Column • Characterized by dissociation of the articular surface from the inonimate bone • "spur sign" on obturator oblique Transverse + Post. Wall • Most common associated fx T Shaped • May need combined approach Anterior column or wall + Post. hemitransverse • Common in elderly patients Post. column + Post. wall • Only associated fracture that does not involve both columns Treatment Nonoperative: protected weight bearing for 6-8 weeks indications: patient factors - high operative risk (e.g., elderly patients, presence of DVT), morbid obesity, open contaminated wound, late presenting > 3 weeks fracture characteristics: minimally displaced fracture (< 2 mm), < 20% posterior wall fractures (treatment based on size of posterior wall is controversial - recommend an exam under anesthesia (EUA) using fluoroscopy best method to test stability), Femoral head congruency with weight bearing roof (out of traction) - both column fracture pattern with secondary congruence (out of traction), displaced fracture with roof arcs > 45° in AP and Judet views or >10 mm on axial CT cuts technique - Skeletal traction NOT required if stable fracture pattern, outside the weight-bearing dome - activity as tolerated with crutches/walker Weight-bearing: lowest joint reactive forces seen with toe-touch weight bearing and passive hip abduction, greatest joint contact force seen when rising from a chair on the affected extremity DVT prophylaxis if slow to mobilize Close radiographic follow-up Operative treatment open reduction and internal fixation indications - Patient factors: < 3 weeks from date of injury, physiologically stable, adequate soft-tissue envelope, no local infection, pregnancy is not contraindication to surgical fixation - Fracture factors: displacement of roof (> 2 mm), unstable fracture pattern (e.g. posterior wall fracture involving > 40-50%), marginal impaction, intra-articular loose bodies, irreducible fracture-dislocation Approaches - Anterior : ilioinguinal, iliofemoral, modified stoppa - Posterior: Kocher-Langenbach - Combined: extended ilifemoral Fixation modalities: - Column fixation strategies: reconstruction bridging plate and screws, percutaneous column screws, cable fixation - Wall fixation strategies: bridge plate and screws, lag screw and neutralization plate, spring (butress) plate outcomes timing: associated hip dislocations should be reduced within 12 hours for improved outcomes worse outcomes with fixation of fracture > 3 weeks from time of injury - earlier operative treatment associated with increased chance of anatomic reduction Peri-operative : clinical outcome correlates with quality of articular reduction Postoperative CT scan is most accurate way to determine posterior wall accuracy of reduction which has greatest correlation with clinical outcome - ideally articular reduction <2mm Post-operative greatest stress on acetabular repair occurs when rising from a seated position using the affected leg, and occurs in the posterior superior portion of the acetabulum Functional outcomes most strongly correlate with hip muscle strength and restoration of gait postoperatively Total hip arthroplasty indications usually elderly patients with significant osteopenia and/or significant comminution, pre-existing arthritis, post-traumatic arthritis in all ages techniques timing: immediate vs. delayed THA immediate THA (with, or without, fracture fixation) wall fractures : butress plate with multi-hole cup column fracture: cage and cup constructs delayed THA outcomes: patients older than 60 years have approx. a 30% late conversion rate to THA after acetabular fractures 10-year implant survival noted to be around 75-80%

Answer 35

The general trend is increasing energy requirement for more proximal amputations. Amputation should be performed at the lowest possible level in order to preserve the most function. Pinzur compared 5 patients with amputations at midfoot, Syme’s, BKA, through knee, and AKA with five controls. Walking speed and cadence decreased while oxygen consumption per meter walked increased with each more proximal amputation. The only exception is the Syme which was the most energy efficient even though it is more proximal to the midfoot amputation. Ankle/Foot Amputation: Syme amputation (ankle disarticulation) - patent tibialis posterior artery is required. More energy efficient than midfoot even though it is more proximal Stable heel pad is most important factor Used successfully to treat forefoot gangrene in diabetics Technique: medial and lateral malleoli are removed flush with distal tibia articular surface. The medial and lateral flares of the tibia and fibula are beveled to enhance heel pad adherence. Heel pad is secured to anterior tibia Pirogoff amputation (hindfoot amputation): removal of the forefoot and talus followed by calcaneotibial arthrodesis calcaneus is osteotomized and rotated 50-90 degrees to keep posterior aspect of calcaneus distal Allows patient to mobilize independently without use of prosthetic Chopart or Boyd amputation (hindfoot amputation) a partial foot amputation through the talonavicular and calcaneocuboid joints. Primary complication is equinus deformity - avoid by lengthening of the Achilles tendon and transfer of the tibialis anterior to the talar neck leads to apropulsive gait pattern because the amputation is unable to support modern dynamic elastic response prosthetic feet Lisfranc amputation (midfoot amputation) - equinovarus deformity is common caused by unopposed pull of tibialis posterior and gastroc/soleus. Prevent by maintaining insertion of peroneus brevis and performing achilles lengthening. A walking cast is generally used for 4 week to prevent late equinus contracture. Energy cost of walking similar to that of BKA Transmetatarsal amputation: more appealing to patients who refuse transtibial amputations Almost all require achilles lengthening to prevent equinus Great toe amputations: preserve 1cm at base of proximal phalanx - preserves insertion of plantar fascia, sesamoids, and flexor hallucis brevis - reduces amount of weight transfer to remaining toes so lessens risk of ulceration Metabolic cost of walking - increases with more proximal amputations perform amputations at lowest possible level to preserve function - exception: Syme amputation is more efficient than midfoot amputation - inversely proportional to length of remaining limb Ranking of metabolic demand (% represents amount of increase compared to baseline) Syme - 15% transtibial: traumatic - 25% average, short BKA - 40%, long BKA - 10%, vascular - 40% transfemoral: traumatic - 68%, vascular - 100% thru-knee amputation: varies based on patient habitus but is somewhere between transtibial and transfemoral Most proximal amputation level available in children to maintain walking speeds without increased energy expenditure compared to normal children Transfemoral Amputation: - Maintain as much length as possible, however, ideal cut is 12 cm (10-15cm) above knee joint to allow for prosthetic fitting Technique - 5-10 degrees of adduction is ideal for improved prosthesis function - adductor myodesis: improves clinical outcomes creates dynamic muscle balance (otherwise have unopposed abductors). Provides soft tissue envelope that enhances prosthetic fitting Gritti-Stokes amputation: amputation through the femur near level of adductor tubercle. Synovium is excised to prevent postoperative effusion. Patella is arthrodesed to the end of femur for improved end bearing prepatellar soft tissue is maintained without iatrogenic injury - improved outcomes as compared to transfemoral amputation ``` Wound Healing Dependent on - vascular supply - nutritional status - immune status ``` Improved with - albumin > 3.0 g/dL - ischemic index > .5 measurement of doppler pressure at level being tested compared to brachial systolic pressure - transcutaneous oxygen tension > 30 mm Hg (ideally 45 mm Hg) - toe pressure > 40 mm Hg (will not heal if < 20 mm Hg) ankle-brachial index (ABI) > 0.45 total lymphocyte count (TLC) > 1500/mm3 - Hyperbaric oxygen therapy contraindications include: chemo or radiation therapy pressure-sensitive implanted medical device (automatic implantable cardiac defibrillator, pacemaker, dorsal column stimulator, insulin pump) , undrained pneumothorax Complications - Wound healing - Contractures: adjacent joint contractures are common prevent with early aggressive mobilization and position changes - Heterotopic ossification: more common in trauma-related setting - Infection: trauma-related amputation have an infection rate of around 34% - Postamputation Neuroma : occurs in 20-30% of amputees prevent with proper nerve handling at the time of procedure. Treatment: targeted muscle rein nervation - a method of guiding neuronal regeneration to prevent or treat post-amputation neuroma pain and improve patient use of myoelectric prostheses - Phantom limb pain occurs in 53-100% of traumatic amputations mirror therapy is a noninvasive treatment modality - Bone overgrowth: most common complication with pediatric amputations. Treatment: prevent by performing disarticulation or using epihphyseal cap to cover medullary canal

Answer 36

The partial foot amputation through the talonavicular and calcaneocuboid joints is also known as the Chopart amputation. The Chopart amputation may result in significant equinovarus deformity with anterior weight bearing through the scar line, predisposing to skin breakdown over time. Therefore, lengthening of the Achilles tendon and transfer of the tibialis anterior to the talar neck should also be performed in conjunction with this disarticulation. The tibialis anterior transfer results in dorsiflexion and distributes the weight-bearing portion more centrally and the lengthening of the Achilles tendon is necessary to accommodate this posteriorly. Transfer of the tibialis anterior or posterior tibialis to the calcaneus would exacerbate the equinovarus deformity. Shortening of the Achilles tendon would also exacerbate the anterior loading of the scar. Ankle/Foot Amputation: Syme amputation (ankle disarticulation) - patent tibialis posterior artery is required. More energy efficient than midfoot even though it is more proximal Stable heel pad is most important factor Used successfully to treat forefoot gangrene in diabetics Technique: medial and lateral malleoli are removed flush with distal tibia articular surface. The medial and lateral flares of the tibia and fibula are beveled to enhance heel pad adherence. Heel pad is secured to anterior tibia Pirogoff amputation (hindfoot amputation): removal of the forefoot and talus followed by calcaneotibial arthrodesis calcaneus is osteotomized and rotated 50-90 degrees to keep posterior aspect of calcaneus distal Allows patient to mobilize independently without use of prosthetic Chopart or Boyd amputation (hindfoot amputation) a partial foot amputation through the talonavicular and calcaneocuboid joints. Primary complication is equinus deformity - avoid by lengthening of the Achilles tendon and transfer of the tibialis anterior to the talar neck leads to apropulsive gait pattern because the amputation is unable to support modern dynamic elastic response prosthetic feet Lisfranc amputation (midfoot amputation) - equinovarus deformity is common caused by unopposed pull of tibialis posterior and gastroc/soleus. Prevent by maintaining insertion of peroneus brevis and performing achilles lengthening. A walking cast is generally used for 4 week to prevent late equinus contracture. Energy cost of walking similar to that of BKA Transmetatarsal amputation: more appealing to patients who refuse transtibial amputations Almost all require achilles lengthening to prevent equinus Great toe amputations: preserve 1cm at base of proximal phalanx - preserves insertion of plantar fascia, sesamoids, and flexor hallucis brevis - reduces amount of weight transfer to remaining toes so lessens risk of ulceration Metabolic cost of walking - increases with more proximal amputations perform amputations at lowest possible level to preserve function - exception: Syme amputation is more efficient than midfoot amputation - inversely proportional to length of remaining limb Ranking of metabolic demand (% represents amount of increase compared to baseline) Syme - 15% transtibial: traumatic - 25% average, short BKA - 40%, long BKA - 10%, vascular - 40% transfemoral: traumatic - 68%, vascular - 100% thru-knee amputation: varies based on patient habitus but is somewhere between transtibial and transfemoral Most proximal amputation level available in children to maintain walking speeds without increased energy expenditure compared to normal children Transfemoral Amputation: - Maintain as much length as possible, however, ideal cut is 12 cm (10-15cm) above knee joint to allow for prosthetic fitting Technique - 5-10 degrees of adduction is ideal for improved prosthesis function - adductor myodesis: improves clinical outcomes creates dynamic muscle balance (otherwise have unopposed abductors). Provides soft tissue envelope that enhances prosthetic fitting Gritti-Stokes amputation: amputation through the femur near level of adductor tubercle. Synovium is excised to prevent postoperative effusion. Patella is arthrodesed to the end of femur for improved end bearing prepatellar soft tissue is maintained without iatrogenic injury - improved outcomes as compared to transfemoral amputation ``` Wound Healing Dependent on - vascular supply - nutritional status - immune status ``` Improved with - albumin > 3.0 g/dL - ischemic index > .5 measurement of doppler pressure at level being tested compared to brachial systolic pressure - transcutaneous oxygen tension > 30 mm Hg (ideally 45 mm Hg) - toe pressure > 40 mm Hg (will not heal if < 20 mm Hg) ankle-brachial index (ABI) > 0.45 total lymphocyte count (TLC) > 1500/mm3 - Hyperbaric oxygen therapy contraindications include: chemo or radiation therapy pressure-sensitive implanted medical device (automatic implantable cardiac defibrillator, pacemaker, dorsal column stimulator, insulin pump) , undrained pneumothorax Complications - Wound healing - Contractures: adjacent joint contractures are common prevent with early aggressive mobilization and position changes - Heterotopic ossification: more common in trauma-related setting - Infection: trauma-related amputation have an infection rate of around 34% - Postamputation Neuroma : occurs in 20-30% of amputees prevent with proper nerve handling at the time of procedure. Treatment: targeted muscle rein nervation - a method of guiding neuronal regeneration to prevent or treat post-amputation neuroma pain and improve patient use of myoelectric prostheses - Phantom limb pain occurs in 53-100% of traumatic amputations mirror therapy is a noninvasive treatment modality - Bone overgrowth: most common complication with pediatric amputations. Treatment: prevent by performing disarticulation or using epihphyseal cap to cover medullary canal

Answer 37

Subscapularis is innervated by the upper and lower subscapular nerves derived from the posterior cord of the brachial plexus. While the subscapularis is innervated by the upper and lower subscapular nerves, it may also be innervated by a middle subscapular nerve. The upper subscapular nerve consistently originates from the posterior cord (C5-C6) and usually innervates the bulk of the muscle, but the lower subscapular nerve often shows variation. The most common variation of the lower subscapular nerve is as a branch of the axillary nerve, yet this has not been shown to place the nerve at greater risk during surgery. Lyons et al. review subscapularis tears, including diagnosis and management. While they recommend repair of acute tears, they state that repair of chronic tears is often impossible and may require tendon or muscle transfers. Kasper et al. dissected 20 cadavers to detail the innervation of the subscapularis muscle. They found a highly variable pattern of innervation, with 25% of cadavers having a lower subscapular nerve arising from the axillary nerve. Incorrect Answers: Answer 1: the biceps brachii, innervated by the musculocutaneous nerve derived from the lateral cord. Answer 2: the pectoralis major, innervated by the medial and lateral pectoral nerves derived from the medial and lateral cords, respectively. Answer 3: the rhomboid major, innervated by the dorsal scapular nerve derived from the C5 nerve root. Answer 5: the supraspinatus, innervated by the suprascapular nerve derived from the upper trunk. The posterior cord of the brachial plexus gives rise to the 1) upper subscapular nerve : subscapularis 2) lower subscapular nerve : teres major, subscapularis 3) thoracodorsal nerve : latissimus dorsi 4) axillary nerves : deltoid, ,teres minor 5) radial nerve. : triceps, brachioradialis, wrist extensors, finger extensors Preganglionic vs. postganglionic Preganglionic: avulsion proximal to dorsal root ganglion involves CNS which does not regenerate – little potential recovery of motor function (poor prognosis) lesions suggesting preganglionic injury: - Horner’s syndrome: disruption of sympathetic chain -> - winged scapula medially (loss of serratus anterior (long thoracic nerve), rhomboids (dorsal scapular nerve) leads to medial winging (inferior border goes medial)) - Presents with motor deficits (flail arm), sensory intact, absence of a Tinel sign or tenderness to percussion in the neck. Normal histamine test (C8-T1 sympathetic ganglion) - intact triple response (redness, wheal, flare) - Elevated hemidiaphragm (phrenic nerve - rhomboid paralysis (dorsal scapular nerve) - supraspinatus/infraspinatus (suprascapular nerve) - latissimus dorsi (thoracodorsal) - Evaluation: EMG may show loss of innervation to cervical paraspinals Postganglionic - involve PNS, capable of regeneration (better prognosis) presentation. Presents with motor deficit (flail arm) & sensory deficits - Evaluation: EMG shows maintained innervation to cervical paraspinals. Abnormal histamine test - only redness and wheal, but NO flare Classification based on location Upper Lesion: Erb's Palsy (C5,6) Most common obstetric brachial plexopathy Results from excessive displacement of head to opposite side and depression of shoulder on same side producing traction on plexus Occurs during difficult delivery in infants or fall onto shoulder in adults Best prognosis Clinically, arm will be adducted, internally rotated, at shoulder; pronated, extended at elbow (“waiter’s tip”) C5 deficiency: axillary nerve deficiency (weakness in deltoid, teres minor), suprascapular nerve deficiency (weakness in supraspinatus, infraspinatus), musculocutaneous nerve deficiency (weakness to biceps) C6 deficiency: radial nerve deficiency (weakness in brachioradialis, supinator) Lower Lesion: Klumpke Palsy (C8,T1) Rare in obstetric palsy Usually avulsion injuries caused by excessive abduction (person falling from height clutching on object to save himself) Other causes may include cervical rib, or lung mets in lower deep cervical lymph nodes Frequently associated with a preganglion injury and Horner's Syndrome Poor prognosis Deficit of all of the small muscles of the hand (ulnar and median nerves)- Clinically, presents as “claw hand” wrist held in extreme extension because of the unopposed wrist extensors hyperextension of MCP due to loss of hand intrinsics flexion of IP joints due to loss of hand intrinsics Total Palsy (C5-T1): A form of brachial plexopathy Worst prognosis Leads to a flaccid arm Involves both motor and sensory Presentation History: high energy injury Physical exam - Horner's syndrome features include drooping of the left eyelid, pupillary constriction, anhidrosis. Usually show up three days after injury. Represents disruption of sympathetic chain via C8 and/or T1 root avulsions - severe pain in anesthetized limb - correlates with root avulsion important muscles to test: serratus anterior (long thoracic nerve) and rhomboids (dorsal scapular nerve) - if they are functioning then it is more likely the C5 injury is postganglionic pulses check radial, ulnar and brachial pulses arterial injuries common with complete BPIs

Answer 38

Based on the choices above, the most important predictor of wound healing is the serum albumin level. Wound healing is based on several factors, which include the vascular status, the immune status, and the nutritional status of the patient. Some important clinical findings include an ankle brachial index (ABI) > 0.45, a total lymphocyte count > 1500/mm3 and a serum albumin > 3.0 g/dL. Kay et al. discuss the importance of the nutritional status in wound healing after lower extremity amputation procedures. They found eleven of 25 patients who were malnourished sustained either local or systemic complications postoperatively. They recommend that patients should undergo nutritional screening prior to elective lower extremity amputations, to help optimize their wound healing. Incorrect Answers Answer 2: While total protein is a marker of nutritional status, it is not as sensitive as the serum albumin for wound healing potential. Answers 3, 4, 5: Calcium levels, C-reactive protein and ESR are not markers of wound healing ``` Wound Healing Dependent on - vascular supply - nutritional status - immune status ``` Improved with - albumin > 3.0 g/dL - ischemic index > .5 measurement of doppler pressure at level being tested compared to brachial systolic pressure - transcutaneous oxygen tension > 30 mm Hg (ideally 45 mm Hg) - toe pressure > 40 mm Hg (will not heal if < 20 mm Hg) ankle-brachial index (ABI) > 0.45 total lymphocyte count (TLC) > 1500/mm3 - Hyperbaric oxygen therapy contraindications include: chemo or radiation therapy pressure-sensitive implanted medical device (automatic implantable cardiac defibrillator, pacemaker, dorsal column stimulator, insulin pump) , undrained pneumothorax Complications - Wound healing - Contractures: adjacent joint contractures are common prevent with early aggressive mobilization and position changes - Heterotopic ossification: more common in trauma-related setting - Infection: trauma-related amputation have an infection rate of around 34% - Postamputation Neuroma : occurs in 20-30% of amputees prevent with proper nerve handling at the time of procedure. Treatment: targeted muscle rein nervation - a method of guiding neuronal regeneration to prevent or treat post-amputation neuroma pain and improve patient use of myoelectric prostheses - Phantom limb pain occurs in 53-100% of traumatic amputations mirror therapy is a noninvasive treatment modality - Bone overgrowth: most common complication with pediatric amputations. Treatment: prevent by performing disarticulation or using epihphyseal cap to cover medullary canal

Answer 39

Figure A shows an unstable, ankle fracture-dislocation in a otherwise healthy 48-year-old diabetic patient. The most appropriate management would be open reduction and internal fixation with an extended period of restricted weight-bearing. Surgical treatment of unstable ankle fractures in diabetic patients is associated with a high complication rates. Diabetic patients are inherently poor healers due to the alterations in their microvascular system. Over-fixation of the fracture and extended immobilization has been shown to reduce wound and bone healing complications associated with diabetes. Surgical techniques typically call for multiple syndesmotic screws, stronger plates (vs 1/3 tubular plates) and prolonged periods of immobilization. Jani et al. retrospectively examined a cohort of 15 patients with diabetes mellitus who sustained unstable ankle fractures. The combination of transarticular fixation (Retrograde transcalcaneal-talar-tibial fixation using large Steinmann pins or screws) and prolonged (>12 weeks), protected weightbearing provided 13 of 15 patients with a stable ankle for weight bearing. Wukich et al. compared the complication rates of ankle fracture fixation in 46 patients with complicated diabetes and 59 patients with uncomplicated diabetes. They found that patients with complicated diabetes had 3.4 times increased risk of a non-infectious complications (eg. malunion, nonunion or Charcot arthropathy) and 5 times higher likelihood of needing revision surgery/arthrodesis. Figure A shows AP and lat radiographs of SER4 ankle fracture-dislocation. Incorrect Answers: Answer 1,2: Non-operative treatment would be appropriate in stable ankle fractures. Again, these need to be treated with an extended period of immobilization. Answer 3,4: Internal fixation would be warranted in this patient, however the duration of immobilization should more than double the typical period of immobilization. Diabetic Ankle Fractures (with or without Neuropathy) Risks: prolonged healing, high risk of hardware failure, high risk of infection Enhanced fixation - multiple quadricortical syndesmotic screws (even in the absence of syndesmotic injury) - tibiotalar Steinmann pins or hindfoot nailing - ankle spanning external fixation - augment with intramedullary fibula K-wires - stiffer, more rigid fibular plates (instead of 1/3 tubular plates): compression plates, small fragment locking plates Delay weight bearing: maintain non-weightbearing postop for 8-12 weeks (instead of 4-8 weeks in normal patients Nonoperative treatment: Stable unimalleolar ankle fractures Increased risk for: Charcot arthropathy, Loss of reduction (greatest risk) , Infection Complications - Wound problems (4-5%). Deep infections (1-2%) : up to 20% in diabetic patients, largest risk factor for diabetic patients is presence of peripheral neuropathy - Malunion: high suspicion for articular impaction of the tibial plafond in supination-adduction injuries, which should be addressed at the time of surgery - Post-traumatic arthritis : rare with anatomic reduction and fixation, corrective osteotomy requires anatomic fibular and mortise correction for optimal outcomes

Answer 40

The radiograph shows a tongue-type calcaneus fracture, with major displacement of the posterior calcaneal body/tuberosity. The Achilles tendon insertion here causes characteristic proximal and posterior displacement, and with increasing displacement, posterior skin necrosis can be caused in a short period. Per the references, this should be treated urgently to prevent this sequelae. Lag screw fixation is appropriate for this fracture pattern, placed perpendicular to the fracture. Most frequent tarsal fracture 17% open fractures Pathophysiology mechanism: traumatic axial loading is the primary mechanism of injury, fall from height, motor-vehicle accidents pathoanatomy - intra-articular fractures: PRIMARY FRACTURE line results from oblique shear and leads to the following two primary fragments: 1. superomedial fragment (constant fragment): includes the sustentaculum tali and is stabilized by strong ligamentous and capsular attachments 2. superolateral fragment: includes an intra-articular aspect through the posterior facet SECONDARY FRACTURE lines dictate whether there is joint depression or tongue-type fracture - Extra-articular fractures: strong contraction of gastrocnemius-soleus with concomitant avulsion at its insertion site on calcaneus. More common in osteopenic bone - Anterior process fractures: inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament Associated injuries - extension into the calcaneocuboid joint occurs in 63% - vertebral injuries in 10% - contralateral calcaneus in 10% Prognosis poor with 40% complication rate - increased due to mechanism (fall from height), smoking, and early surgery lateral soft tissue trauma increases the rate of complication Osteology Articular facets : superolateral fragment contains the articular facets - superior articular surface contains three facets that articulate with the talus: - posterior facet is the largest and is the major weight bearing surface - the flexor hallucis longus tendon runs just inferior to it and can be injured with errant drills/screws that are too long - middle facet is anteromedial on sustentaculum tali - anterior facet is often confluent with middle facet sinus tarsi - between the middle and posterior facets lies the interosseous sulcus (calcaneal groove) that together with the talar sulcus makes up the sinus tarsi sustentaculum tali: Projects medially and supports the neck of talus - FHL passes beneath it. Deltoid and talocalcaneal ligament connect it to the talus - contained in the anteromedial fragment, which remains "constant" due to medial talocalcaneal and interosseous ligaments bifurcate ligament: connects the dorsal aspect of the anterior process to the cuboid and navicular Classification Extra-articular (25%) : avulsion injury of: anterior process (by bifurcate ligament), sustentaculum tali, calcaneal tuberosity (Achilles tendon avulsion) Intra-articular (75%) Essex-Lopresti classification: the primary fracture line runs obliquely through the posterior facet forming two fragments The secondary fracture line runs in one of two planes - the axial plane beneath the facet exiting posteriorly in tongue-type fractures - when the superolateral fragment and posterior facet remain attached to the tuberosity posteriorly - behind the posterior facet in joint depression fractures Sanders classification: based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet Sanders Classification Type I • Nondisplaced posterior facet (regardless of number of fracture lines) Type II • One fracture line in the posterior facet (two fragments) Type III • Two fracture lines in the posterior facet (three fragments) Type IV • Comminuted with more than three fracture lines in the posterior facet (four or more fragments)

Answer 41

Male worker's compensation patient who participates in heavy labor work with an initial Böhler angle less than 0 degrees The Level 2 study by Czisy et al is a review of a randomized trial database that analyzed the prospective clinical outcome of 45 patients who failed closed or open treatment of a displaced intra-articular calcaneal fractures. The cohort underwent a subtalar fusion by distraction bone-block arthrodesis for subtalar arthritis. They found that male worker's compensation patients who participate in heavy labor work with a fracture pattern with Böhler angle less than 0 degrees were the most likely to undergo a subtalar fusion. The meta-analysis by Randle et al reviewed 6 clinical studies comparing the results of operative vs. conservative management of calcaneal fracture studies. They found a trend for nonoperatively treated patients to have a higher risk of experiencing severe foot pain than did operatively treated patients, however they could not draw any definitive conclusions guiding treatment. Calcaneus: Most frequent tarsal fracture 17% open fractures Pathophysiology mechanism: traumatic axial loading is the primary mechanism of injury, fall from height, motor-vehicle accidents pathoanatomy - intra-articular fractures: PRIMARY FRACTURE line results from oblique shear and leads to the following two primary fragments: 1. superomedial fragment (constant fragment): includes the sustentaculum tali and is stabilized by strong ligamentous and capsular attachments 2. superolateral fragment: includes an intra-articular aspect through the posterior facet SECONDARY FRACTURE lines dictate whether there is joint depression or tongue-type fracture - Extra-articular fractures: strong contraction of gastrocnemius-soleus with concomitant avulsion at its insertion site on calcaneus. More common in osteopenic bone - Anterior process fractures: inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament Associated injuries - extension into the calcaneocuboid joint occurs in 63% - vertebral injuries in 10% - contralateral calcaneus in 10% Prognosis poor with 40% complication rate - increased due to mechanism (fall from height), smoking, and early surgery lateral soft tissue trauma increases the rate of complication Osteology Articular facets : superolateral fragment contains the articular facets - superior articular surface contains three facets that articulate with the talus: - posterior facet is the largest and is the major weight bearing surface - the flexor hallucis longus tendon runs just inferior to it and can be injured with errant drills/screws that are too long - middle facet is anteromedial on sustentaculum tali - anterior facet is often confluent with middle facet sinus tarsi - between the middle and posterior facets lies the interosseous sulcus (calcaneal groove) that together with the talar sulcus makes up the sinus tarsi sustentaculum tali: Projects medially and supports the neck of talus - FHL passes beneath it. Deltoid and talocalcaneal ligament connect it to the talus - contained in the anteromedial fragment, which remains "constant" due to medial talocalcaneal and interosseous ligaments bifurcate ligament: connects the dorsal aspect of the anterior process to the cuboid and navicular Classification Extra-articular (25%) : avulsion injury of: anterior process (by bifurcate ligament), sustentaculum tali, calcaneal tuberosity (Achilles tendon avulsion) Intra-articular (75%) Essex-Lopresti classification: the primary fracture line runs obliquely through the posterior facet forming two fragments The secondary fracture line runs in one of two planes - the axial plane beneath the facet exiting posteriorly in tongue-type fractures - when the superolateral fragment and posterior facet remain attached to the tuberosity posteriorly - behind the posterior facet in joint depression fractures Sanders classification: based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet Sanders Classification Type I • Nondisplaced posterior facet (regardless of number of fracture lines) Type II • One fracture line in the posterior facet (two fragments) Type III • Two fracture lines in the posterior facet (three fragments) Type IV • Comminuted with more than three fracture lines in the posterior facet (four or more fragments)

Answer 42

The patients hip radiograph demonstrates an os acetabuli marginalis superior which is a benign accessory ossification center found in the superior aspect of the acetabulum. This can be commonly confused with an acute fracture or avascular necrosis. Although the os acetabuli marginalis superior occasionally persists into adult life, it usually fuses to the acetabulum by the time an individual reaches age 20. Caudle et al provide a case report of a a patient with a painful os acetabuli marginalis superior. This was successfully treated with resection of the fragment, and bone grafting. This was noted to be a very unusual source of hip pain in adolescents. Incorrect Answers: 2-The fovea capitis is the depression on the head of the femur where the ligamentum teres inserts. This can appear as a small ossicle on the surface of femoral heads in skeletally immature patients. 3-Myositis ossificans is soft tissue calcification which develops after trauma, or more rarely, surgery. 4-Avascular necrosis of the femoral head classically occurs in patient with a history of alcoholism, steroid use, or sickle cell disease. Radiographs can demonstrate femoral head sclerosis, and eventually collapse of the articular surface. 5-Acetabular fractures occur in the setting of trauma, and are relatively rare in the pediatric population.

Answer 43

Posterolateral ridge of the tibia As described by Hoblitzell et al, the so-called "Bosworth fracture-dislocation" is a rare fracture-dislocation of the ankle where the fibula becomes entrapped behind the tibia and becomes irreducible. It can cause compartment syndrome, as reported by Beekman and Watson. Hoblitzell et al stress the importance and difficulty of recognizing these injuries. Standard radiographs are difficult to interpret due to the often severe external rotation of the foot. Prompt treatment, though can lead to good results in patients. The posterolateral ridge of the distal tibia hinders reduction and reduction often requires an open technique Mayer and Evarts stated AP and mortise radiographs can be hard to interpret due to the external rotation posture of the foot. In their series a closed reduction consisting of traction and medial rotation applied to the foot while the fibular shaft is pushed laterally was successful in 3/4 patients. Bosworth Fracture-Dislocation Rare fracture-dislocation of the ankle where the fibula becomes entrapped behind the tibia and becomes irreducible posterolateral ridge of the distal tibia hinders reduction of the fibula Operative open reduction and fixation of the fibula in the incisura fibularis indicated in most cases Ankle fracture Injury patterns: - isolated medial malleolus fracture - isolated lateral malleolus fracture - bimalleolar and bimalleolar-equivalent fractures - posterior malleolus fractures - Bosworth fracture-dislocations - open ankle fractures - associated syndesmotic injuries - isolated syndesmosis injury Anatomy Biomechanics - deltoid ligament (deep portion): primary restraint to anterolateral talar displacement - fibula: acts as buttress to prevent lateral displacement of talus Syndesmotic injury - decreased tibiofibular overlap: measure at point of maximum overlap - normal >6 mm on AP view & >1 mm on mortise view. NB it has also been reported that there is no actual correlation between syndesmotic injury and tibiofibular clear space or overlap measurements - increased medial clear space : normal ≤ 4 mm on mortise or stress view. Medial clear space of >5mm with external rotation stress applied to a dorsiflexed ankle is predictive of deep deltoid disruption - increased tibiofibular clear space : measure clear space 1 cm above joint - normal <6 mm on both AP and mortise views Lateral malleolus fractures - talocrural angle : measured by bisection of line through tibial anatomical axis and another line through the tips of the malleoli. Shortening of lateral malleoli fractures can lead to increased talocrural angle. Talocrural angle is not 100% reliable for estimating restoration of fibular length can also utilize the realignment of the medial fibular prominence with the tibiotalar joint Posterior malleolus fractures - double contour sign - misty mountains sign Lauge-Hansen based on foot position and force of applied stress/force has been shown to predict the observed (via MRI) ligamentous injury in less than 50% of operatively treated fractures: Supination - Adduction (SA): Talofibular sprain or distal fibular avulsion Vertical medial malleolus and impaction of anteromedial distal tibia Supination - External Rotation (SER): Anterior tibiofibular ligament sprain Lateral short oblique fibula fracture (anteroinferior to posterosuperior) Posterior tibiofibular ligament rupture or avulsion of posterior malleolus Medial malleolus transverse fracture or disruption of deltoid ligament Pronation - Abduction (PA): Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament sprain Transverse comminuted fracture of the fibula above the level of the syndesmosis Pronation - External Rotation (PER): Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament disruption Lateral short oblique or spiral fracture of fibula (anterosuperior to posteroinferior) above the level of the joint Posterior tibiofibular ligament rupture or avulsion of posterior malleolus Anatomic / Descriptive - isolated medial malleolar - isolated lateral malleolar - bimalleolar - trimalleolar - Bosworth fracture-dislocation (posterior dislocation of the fibula behind incisura fibularis) Danis-Weber (location of fibular fracture) A - infrasyndesmotic (generally not associated with ankle instability) B - transsyndesmotic C - suprasyndesmotic AO / ATA 44A - infrasyndesmotic 44B - transsyndesmotic 44C - suprasyndesmotic General Treatment Nonoperative - short-leg walking cast/boot indications: - isolated nondisplaced medial malleolus fracture or tip avulsions - isolated lateral malleolus fracture with < 3mm displacement and no talar shift - bimalleolar fracture if elderly or unable to undergo surgical intervention - posterior malleolar fracture with < 25% joint involvement or < 2mm step-off Operative - open reduction internal fixation indications: - any talar displacement - displaced isolated medial malleolar fracture - displaced isolated lateral malleolar fracture - bimalleolar fracture and bimalleolar-equivalent fracture - posterior malleolar fracture with > 25% or > 2mm step-off - Bosworth fracture-dislocations - open fractures - malleolar nonunions Technique: goal of treatment is stable anatomic reduction of talus in the ankle mortise - 1 mm shift of talus leads to 42% decrease in tibiotalar contact area - Overall success rate of 90% - prolonged recovery expected (2 years to obtain final functional result) significant functional impairment often noted Anatomic reduction is considered the most important factor for a satisfactory outcome Worse outcomes with: smoking, decreased education, alcohol use, presence of medial malleolar fracture ORIF superior to closed treatment of bimalleolar fractures in Lauge-Hansen supination-adduction fractures, restoration of marginal impaction of the anteromedial tibial plafond leads to optimal functional results after surgery Postoperative rehabilitation - time for proper braking response time (driving) returns to baseline at nine weeks for operatively treated ankle fractures - braking travel time is significantly increased until 6 weeks after initiation of weight bearing in both long bone and periarticular fractures of the lower extremity

Answer 44

There are 5 simple and 5 associated fracture types according to the classification system created by Judet and Letournel. The key feature which distinguishes both column fractures from other associated types is that all articular segments are detached from the intact portion of the ilium, which remains attached to the sacrum through the SI joint. Although the transverse plus posterior wall, T-shaped, and anterior plus posterior hemi-transverse fractures all show involvement of the anterior and posterior columns, they are not “both columns” because a portion of the articular surface remains in its normal position, attached to intact ilium. The intact ilium is responsible for the "spur sign" noted most prominently on the obturator oblique radiograph. Acetabulum fractures can involve one or more of the two columns, two walls or roof within the pelvis Osteology acetabular inclination & ante version: mean lateral inclination of 40 to 48 degrees, anteversion of 18 to 21 degrees Column theory : acetabulum is supported by two columns of bone - form an "inverted Y". Connected to sacrum through sciatic buttress - Posterior column: comprised of quadrilateral surface, posterior wall and dome, ischial tuberosity, greater/lesser sciatic notches - anterior column: comprised of anterior ilium (gluteus medius tubercle), anterior wall and dome, iliopectineal eminence, lateral superior pubic ramus Vascular corona mortis : anastomosis of external iliac (epigastric) and internal iliac (obturator) vessels - at risk with lateral dissection over superior pubic ramus Letournel Classification Judet and Letournel: most common referenced classification system - classifed as 5 elementary and 5 associated fracture patterns Most common fracture patterns Younger : posterior wall or transverse fracture "family" (transverse, T-type, transverse + posterior wall) Elderly : anterior column (e.g., quadrilateral plate fractures), anterior column, posterior hemitransverse, assoicated both column fractures Posterior wall • Most common • "gull sign" on obturator oblique view Posterior column • check for injury to superior gluteal NV bundle Anterior wall • Very rare Anterior column • More common in elderly patients with fall from standing (most common in elderly is "anterior column + medial wall") Transverse • Axial CT shows anterior to posterior fx line • Only elementary fx to involve both columns Associated Both Column • Characterized by dissociation of the articular surface from the inonimate bone • "spur sign" on obturator oblique Transverse + Post. Wall • Most common associated fx T Shaped • May need combined approach Anterior column or wall + Post. hemitransverse • Common in elderly patients Post. column + Post. wall • Only associated fracture that does not involve both columns Treatment Nonoperative: protected weight bearing for 6-8 weeks indications: patient factors - high operative risk (e.g., elderly patients, presence of DVT), morbid obesity, open contaminated wound, late presenting > 3 weeks fracture characteristics: minimally displaced fracture (< 2 mm), < 20% posterior wall fractures (treatment based on size of posterior wall is controversial - recommend an exam under anesthesia (EUA) using fluoroscopy best method to test stability), Femoral head congruency with weight bearing roof (out of traction) - both column fracture pattern with secondary congruence (out of traction), displaced fracture with roof arcs > 45° in AP and Judet views or >10 mm on axial CT cuts technique - Skeletal traction NOT required if stable fracture pattern, outside the weight-bearing dome - activity as tolerated with crutches/walker Weight-bearing: lowest joint reactive forces seen with toe-touch weight bearing and passive hip abduction, greatest joint contact force seen when rising from a chair on the affected extremity DVT prophylaxis if slow to mobilize Close radiographic follow-up Operative treatment open reduction and internal fixation indications - Patient factors: < 3 weeks from date of injury, physiologically stable, adequate soft-tissue envelope, no local infection, pregnancy is not contraindication to surgical fixation - Fracture factors: displacement of roof (> 2 mm), unstable fracture pattern (e.g. posterior wall fracture involving > 40-50%), marginal impaction, intra-articular loose bodies, irreducible fracture-dislocation Approaches - Anterior : ilioinguinal, iliofemoral, modified stoppa - Posterior: Kocher-Langenbach - Combined: extended ilifemoral Fixation modalities: - Column fixation strategies: reconstruction bridging plate and screws, percutaneous column screws, cable fixation - Wall fixation strategies: bridge plate and screws, lag screw and neutralization plate, spring (butress) plate outcomes timing: associated hip dislocations should be reduced within 12 hours for improved outcomes worse outcomes with fixation of fracture > 3 weeks from time of injury - earlier operative treatment associated with increased chance of anatomic reduction Peri-operative : clinical outcome correlates with quality of articular reduction Postoperative CT scan is most accurate way to determine posterior wall accuracy of reduction which has greatest correlation with clinical outcome - ideally articular reduction <2mm Post-operative greatest stress on acetabular repair occurs when rising from a seated position using the affected leg, and occurs in the posterior superior portion of the acetabulum Functional outcomes most strongly correlate with hip muscle strength and restoration of gait postoperatively Total hip arthroplasty indications usually elderly patients with significant osteopenia and/or significant comminution, pre-existing arthritis, post-traumatic arthritis in all ages techniques timing: immediate vs. delayed THA immediate THA (with, or without, fracture fixation) wall fractures : butress plate with multi-hole cup column fracture: cage and cup constructs delayed THA outcomes: patients older than 60 years have approx. a 30% late conversion rate to THA after acetabular fractures 10-year implant survival noted to be around 75-80%

Answer 45

Revision ORIF of fibula and syndesmosis The above clinical scenario shows acute postoperative fibular malrotation and tibiofibular syndesmotic malreduction. Restoration of the proper syndesmotic relationship involves regaining fibular length as well as reestablishing correct rotation and position of the fibula relative to the tibia. In addition, removal of interposed tissue (deltoid ligament) in the medial joint space may be necessary. However, deltoid reconstruction is not routinely required. Syndesmosis screw fixation in ankle fractures with syndesmotic disruption is indicated if there is residual or dynamic instability with stress testing of the tibiofibular joint after fixation of the fibula. Syndesmotic screws are commonly maintained in place for at least 12 weeks before removal, if necessary or desired. Controversy exists over use of 1 or 2 screws, screw size, and purchase of 3 or 4 cortices. Gardner et al. compared radiographic measurements vs CT scans to assess reduction of the tibiofibular syndesmosis in ankle fractures. They found CT was better able to detect syndesmotic malreduction. Although they did not seek to correlate this with functional outcomes, they recommended heightened vigilance for assessing accurate syndesmosis reduction. Zalavras et al. performed a review on ankle syndesmotic injuries. In their review, they highlight that syndesmotic injuries may occur in isolation or may be associated with ankle fractures. In the absence of fracture, physical examination findings suggestive of injury include ankle tenderness over the anterior aspect of the syndesmosis and a positive squeeze or external rotation test. They recommend stress testing for detecting syndesmotic instability with fixation of the syndesmosis when evidence of a diastasis is present. Incorrect Answers: Answer 1&5: Would not address the current syndesmotic malreduction which should be addressed. Answer 2: Would not address the syndesmotic malreduction. Answer 3: Fibular length appears appropriate on AP and lateral radiographs. Ankle fracture Injury patterns: - isolated medial malleolus fracture - isolated lateral malleolus fracture - bimalleolar and bimalleolar-equivalent fractures - posterior malleolus fractures - Bosworth fracture-dislocations - open ankle fractures - associated syndesmotic injuries - isolated syndesmosis injury Anatomy Biomechanics - deltoid ligament (deep portion): primary restraint to anterolateral talar displacement - fibula: acts as buttress to prevent lateral displacement of talus Syndesmotic injury - decreased tibiofibular overlap: measure at point of maximum overlap - normal >6 mm on AP view & >1 mm on mortise view. NB it has also been reported that there is no actual correlation between syndesmotic injury and tibiofibular clear space or overlap measurements - increased medial clear space : normal ≤ 4 mm on mortise or stress view. Medial clear space of >5mm with external rotation stress applied to a dorsiflexed ankle is predictive of deep deltoid disruption - increased tibiofibular clear space : measure clear space 1 cm above joint - normal <6 mm on both AP and mortise views Lateral malleolus fractures - talocrural angle : measured by bisection of line through tibial anatomical axis and another line through the tips of the malleoli. Shortening of lateral malleoli fractures can lead to increased talocrural angle. Talocrural angle is not 100% reliable for estimating restoration of fibular length can also utilize the realignment of the medial fibular prominence with the tibiotalar joint Posterior malleolus fractures - double contour sign - misty mountains sign Lauge-Hansen based on foot position and force of applied stress/force has been shown to predict the observed (via MRI) ligamentous injury in less than 50% of operatively treated fractures: Supination - Adduction (SA): Talofibular sprain or distal fibular avulsion Vertical medial malleolus and impaction of anteromedial distal tibia Supination - External Rotation (SER): Anterior tibiofibular ligament sprain Lateral short oblique fibula fracture (anteroinferior to posterosuperior) Posterior tibiofibular ligament rupture or avulsion of posterior malleolus Medial malleolus transverse fracture or disruption of deltoid ligament Pronation - Abduction (PA): Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament sprain Transverse comminuted fracture of the fibula above the level of the syndesmosis Pronation - External Rotation (PER): Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament disruption Lateral short oblique or spiral fracture of fibula (anterosuperior to posteroinferior) above the level of the joint Posterior tibiofibular ligament rupture or avulsion of posterior malleolus Anatomic / Descriptive - isolated medial malleolar - isolated lateral malleolar - bimalleolar - trimalleolar - Bosworth fracture-dislocation (posterior dislocation of the fibula behind incisura fibularis) Danis-Weber (location of fibular fracture) A - infrasyndesmotic (generally not associated with ankle instability) B - transsyndesmotic C - suprasyndesmotic AO / ATA 44A - infrasyndesmotic 44B - transsyndesmotic 44C - suprasyndesmotic General Treatment Nonoperative - short-leg walking cast/boot indications: - isolated nondisplaced medial malleolus fracture or tip avulsions - isolated lateral malleolus fracture with < 3mm displacement and no talar shift - bimalleolar fracture if elderly or unable to undergo surgical intervention - posterior malleolar fracture with < 25% joint involvement or < 2mm step-off Operative - open reduction internal fixation indications: - any talar displacement - displaced isolated medial malleolar fracture - displaced isolated lateral malleolar fracture - bimalleolar fracture and bimalleolar-equivalent fracture - posterior malleolar fracture with > 25% or > 2mm step-off - Bosworth fracture-dislocations - open fractures - malleolar nonunions Technique: goal of treatment is stable anatomic reduction of talus in the ankle mortise - 1 mm shift of talus leads to 42% decrease in tibiotalar contact area - Overall success rate of 90% - prolonged recovery expected (2 years to obtain final functional result) significant functional impairment often noted Anatomic reduction is considered the most important factor for a satisfactory outcome Worse outcomes with: smoking, decreased education, alcohol use, presence of medial malleolar fracture ORIF superior to closed treatment of bimalleolar fractures in Lauge-Hansen supination-adduction fractures, restoration of marginal impaction of the anteromedial tibial plafond leads to optimal functional results after surgery Postoperative rehabilitation - time for proper braking response time (driving) returns to baseline at nine weeks for operatively treated ankle fractures - braking travel time is significantly increased until 6 weeks after initiation of weight bearing in both long bone and periarticular fractures of the lower extremity

Answer 46

Figures A through C depict and AP pelvis and Judet views of a T-type fracture of the right acetabulum. The ilioinguinal approach provides access to the anterior wall and anterior column for fracture fixation, in addition to allowing fixation of the nondisplaced posterior transverse fracture line. The lateral femoral cutaneous nerve (LFCN) is at risk in the superficial part of the dissection. Another option for the approach would be the modified Stoppa, which would also allow excellent access to the anterior column as well as the internal aspect of the iliac wing and quadrilateral plate. Illustration A shows the five basic and 5 associated acetabular fractures. Incorrect Answers: Answer 1. Kocher-Langenbeck: access for posterior wall and column fractures Answer 2. Watson-Jones: anterolateral approach best for the hip, not the anterior column of the acetabulum. Answer 3. Extended iliofemoral: visualization for both column fractures Answer 5. Hardinge approach: lateral approach for THA Acetabulum fractures can involve one or more of the two columns, two walls or roof within the pelvis Osteology acetabular inclination & ante version: mean lateral inclination of 40 to 48 degrees, anteversion of 18 to 21 degrees Column theory : acetabulum is supported by two columns of bone - form an "inverted Y". Connected to sacrum through sciatic buttress - Posterior column: comprised of quadrilateral surface, posterior wall and dome, ischial tuberosity, greater/lesser sciatic notches - anterior column: comprised of anterior ilium (gluteus medius tubercle), anterior wall and dome, iliopectineal eminence, lateral superior pubic ramus Vascular corona mortis : anastomosis of external iliac (epigastric) and internal iliac (obturator) vessels - at risk with lateral dissection over superior pubic ramus Letournel Classification Judet and Letournel: most common referenced classification system - classifed as 5 elementary and 5 associated fracture patterns Most common fracture patterns Younger : posterior wall or transverse fracture "family" (transverse, T-type, transverse + posterior wall) Elderly : anterior column (e.g., quadrilateral plate fractures), anterior column, posterior hemitransverse, assoicated both column fractures Posterior wall • Most common • "gull sign" on obturator oblique view Posterior column • check for injury to superior gluteal NV bundle Anterior wall • Very rare Anterior column • More common in elderly patients with fall from standing (most common in elderly is "anterior column + medial wall") Transverse • Axial CT shows anterior to posterior fx line • Only elementary fx to involve both columns Associated Both Column • Characterized by dissociation of the articular surface from the inonimate bone • "spur sign" on obturator oblique Transverse + Post. Wall • Most common associated fx T Shaped • May need combined approach Anterior column or wall + Post. hemitransverse • Common in elderly patients Post. column + Post. wall • Only associated fracture that does not involve both columns Treatment Nonoperative: protected weight bearing for 6-8 weeks indications: patient factors - high operative risk (e.g., elderly patients, presence of DVT), morbid obesity, open contaminated wound, late presenting > 3 weeks fracture characteristics: minimally displaced fracture (< 2 mm), < 20% posterior wall fractures (treatment based on size of posterior wall is controversial - recommend an exam under anesthesia (EUA) using fluoroscopy best method to test stability), Femoral head congruency with weight bearing roof (out of traction) - both column fracture pattern with secondary congruence (out of traction), displaced fracture with roof arcs > 45° in AP and Judet views or >10 mm on axial CT cuts technique - Skeletal traction NOT required if stable fracture pattern, outside the weight-bearing dome - activity as tolerated with crutches/walker Weight-bearing: lowest joint reactive forces seen with toe-touch weight bearing and passive hip abduction, greatest joint contact force seen when rising from a chair on the affected extremity DVT prophylaxis if slow to mobilize Close radiographic follow-up Operative treatment open reduction and internal fixation indications - Patient factors: < 3 weeks from date of injury, physiologically stable, adequate soft-tissue envelope, no local infection, pregnancy is not contraindication to surgical fixation - Fracture factors: displacement of roof (> 2 mm), unstable fracture pattern (e.g. posterior wall fracture involving > 40-50%), marginal impaction, intra-articular loose bodies, irreducible fracture-dislocation Approaches - Anterior : ilioinguinal, iliofemoral, modified stoppa - Posterior: Kocher-Langenbach - Combined: extended ilifemoral Fixation modalities: - Column fixation strategies: reconstruction bridging plate and screws, percutaneous column screws, cable fixation - Wall fixation strategies: bridge plate and screws, lag screw and neutralization plate, spring (butress) plate outcomes timing: associated hip dislocations should be reduced within 12 hours for improved outcomes worse outcomes with fixation of fracture > 3 weeks from time of injury - earlier operative treatment associated with increased chance of anatomic reduction Peri-operative : clinical outcome correlates with quality of articular reduction Postoperative CT scan is most accurate way to determine posterior wall accuracy of reduction which has greatest correlation with clinical outcome - ideally articular reduction <2mm Post-operative greatest stress on acetabular repair occurs when rising from a seated position using the affected leg, and occurs in the posterior superior portion of the acetabulum Functional outcomes most strongly correlate with hip muscle strength and restoration of gait postoperatively Total hip arthroplasty indications usually elderly patients with significant osteopenia and/or significant comminution, pre-existing arthritis, post-traumatic arthritis in all ages techniques timing: immediate vs. delayed THA immediate THA (with, or without, fracture fixation) wall fractures : butress plate with multi-hole cup column fracture: cage and cup constructs delayed THA outcomes: patients older than 60 years have approx. a 30% late conversion rate to THA after acetabular fractures 10-year implant survival noted to be around 75-80%

Answer 47

A Syme amputation (ankle disarticulation) is a function-preserving amputation option that allows for terminal weight bearing, however strict criteria must be met for a patient to undergo successful Syme amputation. An ankle-brachial index (ABI) less than 0.5 for the posterior tibial artery in a patient with diabetes would be a contraindication for this procedure as success is dependent on the vascular supply of posterior tibial artery to the plantar flap and heel pad. Pinzur et al retrospectively reviewed their results when performing a single-stage Syme ankle disarticulation in patients with diabetes either for peripheral neuropathy or infection. Patients with ABIs less than 0.5 for the posterior tibial artery had significantly decreased healing rates and smokers had a three-fold increased risk of postoperative infection. Incorrect Answers: Answer 1: Albumin of 3.4 indicates adequate preoperative nutrition. Albumin of 2.0 or less would be concerning for increased wound healing risk. Answer 2: Osteomyelitis was the indication for amputation in a number of diabetic patients in the referenced study, and should not preclude Syme amputation unless the hindfoot and/or distal tibia is involved Answer 4: Transcutaneous 02 pressure of 45 signifies adequate oxygenation and vascularity. Less than 30 is generally considered a cutoff for adequate vascularity. Answer 5: Peripheral neuropathy with recurrent ulceration was an indication for amputation in the referenced study. Ankle/Foot Amputation: Syme amputation (ankle disarticulation) - patent tibialis posterior artery is required. More energy efficient than midfoot even though it is more proximal Stable heel pad is most important factor Used successfully to treat forefoot gangrene in diabetics Technique: medial and lateral malleoli are removed flush with distal tibia articular surface. The medial and lateral flares of the tibia and fibula are beveled to enhance heel pad adherence. Heel pad is secured to anterior tibia Pirogoff amputation (hindfoot amputation): removal of the forefoot and talus followed by calcaneotibial arthrodesis calcaneus is osteotomized and rotated 50-90 degrees to keep posterior aspect of calcaneus distal Allows patient to mobilize independently without use of prosthetic Chopart or Boyd amputation (hindfoot amputation) a partial foot amputation through the talonavicular and calcaneocuboid joints. Primary complication is equinus deformity - avoid by lengthening of the Achilles tendon and transfer of the tibialis anterior to the talar neck leads to apropulsive gait pattern because the amputation is unable to support modern dynamic elastic response prosthetic feet Lisfranc amputation (midfoot amputation) - equinovarus deformity is common caused by unopposed pull of tibialis posterior and gastroc/soleus. Prevent by maintaining insertion of peroneus brevis and performing achilles lengthening. A walking cast is generally used for 4 week to prevent late equinus contracture. Energy cost of walking similar to that of BKA Transmetatarsal amputation: more appealing to patients who refuse transtibial amputations Almost all require achilles lengthening to prevent equinus Great toe amputations: preserve 1cm at base of proximal phalanx - preserves insertion of plantar fascia, sesamoids, and flexor hallucis brevis - reduces amount of weight transfer to remaining toes so lessens risk of ulceration Metabolic cost of walking - increases with more proximal amputations perform amputations at lowest possible level to preserve function - exception: Syme amputation is more efficient than midfoot amputation - inversely proportional to length of remaining limb Ranking of metabolic demand (% represents amount of increase compared to baseline) Syme - 15% transtibial: traumatic - 25% average, short BKA - 40%, long BKA - 10%, vascular - 40% transfemoral: traumatic - 68%, vascular - 100% thru-knee amputation: varies based on patient habitus but is somewhere between transtibial and transfemoral Most proximal amputation level available in children to maintain walking speeds without increased energy expenditure compared to normal children Transfemoral Amputation: - Maintain as much length as possible, however, ideal cut is 12 cm (10-15cm) above knee joint to allow for prosthetic fitting Technique - 5-10 degrees of adduction is ideal for improved prosthesis function - adductor myodesis: improves clinical outcomes creates dynamic muscle balance (otherwise have unopposed abductors). Provides soft tissue envelope that enhances prosthetic fitting Gritti-Stokes amputation: amputation through the femur near level of adductor tubercle. Synovium is excised to prevent postoperative effusion. Patella is arthrodesed to the end of femur for improved end bearing prepatellar soft tissue is maintained without iatrogenic injury - improved outcomes as compared to transfemoral amputation ``` Wound Healing Dependent on - vascular supply - nutritional status - immune status ``` Improved with - albumin > 3.0 g/dL - ischemic index > .5 measurement of doppler pressure at level being tested compared to brachial systolic pressure - transcutaneous oxygen tension > 30 mm Hg (ideally 45 mm Hg) - toe pressure > 40 mm Hg (will not heal if < 20 mm Hg) ankle-brachial index (ABI) > 0.45 total lymphocyte count (TLC) > 1500/mm3 - Hyperbaric oxygen therapy contraindications include: chemo or radiation therapy pressure-sensitive implanted medical device (automatic implantable cardiac defibrillator, pacemaker, dorsal column stimulator, insulin pump) , undrained pneumothorax Complications - Wound healing - Contractures: adjacent joint contractures are common prevent with early aggressive mobilization and position changes - Heterotopic ossification: more common in trauma-related setting - Infection: trauma-related amputation have an infection rate of around 34% - Postamputation Neuroma : occurs in 20-30% of amputees prevent with proper nerve handling at the time of procedure. Treatment: targeted muscle rein nervation - a method of guiding neuronal regeneration to prevent or treat post-amputation neuroma pain and improve patient use of myoelectric prostheses - Phantom limb pain occurs in 53-100% of traumatic amputations mirror therapy is a noninvasive treatment modality - Bone overgrowth: most common complication with pediatric amputations. Treatment: prevent by performing disarticulation or using epihphyseal cap to cover medullary canal

Answer 48

decreased chance of anatomic fracture reduction Madhu et al showed time to surgery was a significant predictor of radiological and functional outcome for both elementary and associated displaced fractures of the acetabulum. Both anatomic reduction and functional outcome significantly worsened as time to surgery increased. It was found anatomic reduction was more likely when surgery was within 15 days for elementary fracture and 5 days for associated. Incorrect answers: 2: No data exists showing a decrease in heterotopic ossification as time to surgery increases. 3: Neurologic injury is more associated with the initial injury. 4,5: Multi-organ failure was not commented on, but infection showed a trend towards being more likely with longer time to surgery. Acetabulum fractures can involve one or more of the two columns, two walls or roof within the pelvis Osteology acetabular inclination & ante version: mean lateral inclination of 40 to 48 degrees, anteversion of 18 to 21 degrees Column theory : acetabulum is supported by two columns of bone - form an "inverted Y". Connected to sacrum through sciatic buttress - Posterior column: comprised of quadrilateral surface, posterior wall and dome, ischial tuberosity, greater/lesser sciatic notches - anterior column: comprised of anterior ilium (gluteus medius tubercle), anterior wall and dome, iliopectineal eminence, lateral superior pubic ramus Vascular corona mortis : anastomosis of external iliac (epigastric) and internal iliac (obturator) vessels - at risk with lateral dissection over superior pubic ramus Letournel Classification Judet and Letournel: most common referenced classification system - classifed as 5 elementary and 5 associated fracture patterns Most common fracture patterns Younger : posterior wall or transverse fracture "family" (transverse, T-type, transverse + posterior wall) Elderly : anterior column (e.g., quadrilateral plate fractures), anterior column, posterior hemitransverse, assoicated both column fractures Posterior wall • Most common • "gull sign" on obturator oblique view Posterior column • check for injury to superior gluteal NV bundle Anterior wall • Very rare Anterior column • More common in elderly patients with fall from standing (most common in elderly is "anterior column + medial wall") Transverse • Axial CT shows anterior to posterior fx line • Only elementary fx to involve both columns Associated Both Column • Characterized by dissociation of the articular surface from the inonimate bone • "spur sign" on obturator oblique Transverse + Post. Wall • Most common associated fx T Shaped • May need combined approach Anterior column or wall + Post. hemitransverse • Common in elderly patients Post. column + Post. wall • Only associated fracture that does not involve both columns Treatment Nonoperative: protected weight bearing for 6-8 weeks indications: patient factors - high operative risk (e.g., elderly patients, presence of DVT), morbid obesity, open contaminated wound, late presenting > 3 weeks fracture characteristics: minimally displaced fracture (< 2 mm), < 20% posterior wall fractures (treatment based on size of posterior wall is controversial - recommend an exam under anesthesia (EUA) using fluoroscopy best method to test stability), Femoral head congruency with weight bearing roof (out of traction) - both column fracture pattern with secondary congruence (out of traction), displaced fracture with roof arcs > 45° in AP and Judet views or >10 mm on axial CT cuts technique - Skeletal traction NOT required if stable fracture pattern, outside the weight-bearing dome - activity as tolerated with crutches/walker Weight-bearing: lowest joint reactive forces seen with toe-touch weight bearing and passive hip abduction, greatest joint contact force seen when rising from a chair on the affected extremity DVT prophylaxis if slow to mobilize Close radiographic follow-up Operative treatment open reduction and internal fixation indications - Patient factors: < 3 weeks from date of injury, physiologically stable, adequate soft-tissue envelope, no local infection, pregnancy is not contraindication to surgical fixation - Fracture factors: displacement of roof (> 2 mm), unstable fracture pattern (e.g. posterior wall fracture involving > 40-50%), marginal impaction, intra-articular loose bodies, irreducible fracture-dislocation Approaches - Anterior : ilioinguinal, iliofemoral, modified stoppa - Posterior: Kocher-Langenbach - Combined: extended ilifemoral Fixation modalities: - Column fixation strategies: reconstruction bridging plate and screws, percutaneous column screws, cable fixation - Wall fixation strategies: bridge plate and screws, lag screw and neutralization plate, spring (butress) plate outcomes timing: associated hip dislocations should be reduced within 12 hours for improved outcomes worse outcomes with fixation of fracture > 3 weeks from time of injury - earlier operative treatment associated with increased chance of anatomic reduction Peri-operative : clinical outcome correlates with quality of articular reduction Postoperative CT scan is most accurate way to determine posterior wall accuracy of reduction which has greatest correlation with clinical outcome - ideally articular reduction <2mm Post-operative greatest stress on acetabular repair occurs when rising from a seated position using the affected leg, and occurs in the posterior superior portion of the acetabulum Functional outcomes most strongly correlate with hip muscle strength and restoration of gait postoperatively Total hip arthroplasty indications usually elderly patients with significant osteopenia and/or significant comminution, pre-existing arthritis, post-traumatic arthritis in all ages techniques timing: immediate vs. delayed THA immediate THA (with, or without, fracture fixation) wall fractures : butress plate with multi-hole cup column fracture: cage and cup constructs delayed THA outcomes: patients older than 60 years have approx. a 30% late conversion rate to THA after acetabular fractures 10-year implant survival noted to be around 75-80%

Answer 49

Adductor myodesis is critical for optimal outcome after transfemoral amputation. Pinzur et al. emphasize that when the adductors are not anchored to bone, the hip abductors are able to act unopposed, producing a dynamic flexion-abduction deformity. This deformity prepositions the femur in an orientation that is not conducive to efficient walking. The retracted adductor muscles lead to a poorly cushioning soft-tissue envelope, further complicating prosthetic fitting. Preservation of a functional adductor magnus helps to maintain the muscle balance between the adductors and abductors by allowing the adductor magnus to maintain its power and retain the mechanical advantage for positioning the femur. Preservation is best accomplished with a myodesis. Ankle/Foot Amputation: Syme amputation (ankle disarticulation) - patent tibialis posterior artery is required. More energy efficient than midfoot even though it is more proximal Stable heel pad is most important factor Used successfully to treat forefoot gangrene in diabetics Technique: medial and lateral malleoli are removed flush with distal tibia articular surface. The medial and lateral flares of the tibia and fibula are beveled to enhance heel pad adherence. Heel pad is secured to anterior tibia Pirogoff amputation (hindfoot amputation): removal of the forefoot and talus followed by calcaneotibial arthrodesis calcaneus is osteotomized and rotated 50-90 degrees to keep posterior aspect of calcaneus distal Allows patient to mobilize independently without use of prosthetic Chopart or Boyd amputation (hindfoot amputation) a partial foot amputation through the talonavicular and calcaneocuboid joints. Primary complication is equinus deformity - avoid by lengthening of the Achilles tendon and transfer of the tibialis anterior to the talar neck leads to apropulsive gait pattern because the amputation is unable to support modern dynamic elastic response prosthetic feet Lisfranc amputation (midfoot amputation) - equinovarus deformity is common caused by unopposed pull of tibialis posterior and gastroc/soleus. Prevent by maintaining insertion of peroneus brevis and performing achilles lengthening. A walking cast is generally used for 4 week to prevent late equinus contracture. Energy cost of walking similar to that of BKA Transmetatarsal amputation: more appealing to patients who refuse transtibial amputations Almost all require achilles lengthening to prevent equinus Great toe amputations: preserve 1cm at base of proximal phalanx - preserves insertion of plantar fascia, sesamoids, and flexor hallucis brevis - reduces amount of weight transfer to remaining toes so lessens risk of ulceration Metabolic cost of walking - increases with more proximal amputations perform amputations at lowest possible level to preserve function - exception: Syme amputation is more efficient than midfoot amputation - inversely proportional to length of remaining limb Ranking of metabolic demand (% represents amount of increase compared to baseline) Syme - 15% transtibial: traumatic - 25% average, short BKA - 40%, long BKA - 10%, vascular - 40% transfemoral: traumatic - 68%, vascular - 100% thru-knee amputation: varies based on patient habitus but is somewhere between transtibial and transfemoral Most proximal amputation level available in children to maintain walking speeds without increased energy expenditure compared to normal children Transfemoral Amputation: - Maintain as much length as possible, however, ideal cut is 12 cm (10-15cm) above knee joint to allow for prosthetic fitting Technique - 5-10 degrees of adduction is ideal for improved prosthesis function - adductor myodesis: improves clinical outcomes creates dynamic muscle balance (otherwise have unopposed abductors). Provides soft tissue envelope that enhances prosthetic fitting Gritti-Stokes amputation: amputation through the femur near level of adductor tubercle. Synovium is excised to prevent postoperative effusion. Patella is arthrodesed to the end of femur for improved end bearing prepatellar soft tissue is maintained without iatrogenic injury - improved outcomes as compared to transfemoral amputation ``` Wound Healing Dependent on - vascular supply - nutritional status - immune status ``` Improved with - albumin > 3.0 g/dL - ischemic index > .5 measurement of doppler pressure at level being tested compared to brachial systolic pressure - transcutaneous oxygen tension > 30 mm Hg (ideally 45 mm Hg) - toe pressure > 40 mm Hg (will not heal if < 20 mm Hg) ankle-brachial index (ABI) > 0.45 total lymphocyte count (TLC) > 1500/mm3 - Hyperbaric oxygen therapy contraindications include: chemo or radiation therapy pressure-sensitive implanted medical device (automatic implantable cardiac defibrillator, pacemaker, dorsal column stimulator, insulin pump) , undrained pneumothorax Complications - Wound healing - Contractures: adjacent joint contractures are common prevent with early aggressive mobilization and position changes - Heterotopic ossification: more common in trauma-related setting - Infection: trauma-related amputation have an infection rate of around 34% - Postamputation Neuroma : occurs in 20-30% of amputees prevent with proper nerve handling at the time of procedure. Treatment: targeted muscle rein nervation - a method of guiding neuronal regeneration to prevent or treat post-amputation neuroma pain and improve patient use of myoelectric prostheses - Phantom limb pain occurs in 53-100% of traumatic amputations mirror therapy is a noninvasive treatment modality - Bone overgrowth: most common complication with pediatric amputations. Treatment: prevent by performing disarticulation or using epihphyseal cap to cover medullary canal

Answer 50

Ankle syndesmosis The inferior tibiofibular syndesmosis is a fibrous articulation consisting of four ligaments; the elasticity of these ligaments permits axial, vertical, anterior, posterior, and mediolateral motion at the ankle syndesmosis during weight bearing. Of note, the Cotton test was originally described around 1910 by Frederic J. Cotton as the "talar glide test" evaluating the medial/lateral translation of the talus in the mortise. A positive result indicates disruption of the ankle syndesmosis in the face of an ankle injury. Nielson et al reported that the level of the fibular fracture does not correlate reliably with the integrity or extent of the interosseous membrane (IOM) tears identified on MRI in operative ankle fractures. Therefore, one cannot consistently estimate the integrity of the IOM and subsequent need for transsyndesmotic fixation based solely on the level of the fibular fracture. This supports the need for intraoperative stress testing (ie, external rotation stress or Cotton test) of the ankle syndesmosis in all operative ankle fractures. The study by Leeds et al noted a correlation between syndesmosis reduction (initial and final) and outcomes (radiographic and clinical). Ankle fracture Injury patterns: - isolated medial malleolus fracture - isolated lateral malleolus fracture - bimalleolar and bimalleolar-equivalent fractures - posterior malleolus fractures - Bosworth fracture-dislocations - open ankle fractures - associated syndesmotic injuries - isolated syndesmosis injury Anatomy Biomechanics - deltoid ligament (deep portion): primary restraint to anterolateral talar displacement - fibula: acts as buttress to prevent lateral displacement of talus Syndesmotic injury - decreased tibiofibular overlap: measure at point of maximum overlap - normal >6 mm on AP view & >1 mm on mortise view. NB it has also been reported that there is no actual correlation between syndesmotic injury and tibiofibular clear space or overlap measurements - increased medial clear space : normal ≤ 4 mm on mortise or stress view. Medial clear space of >5mm with external rotation stress applied to a dorsiflexed ankle is predictive of deep deltoid disruption - increased tibiofibular clear space : measure clear space 1 cm above joint - normal <6 mm on both AP and mortise views Lateral malleolus fractures - talocrural angle : measured by bisection of line through tibial anatomical axis and another line through the tips of the malleoli. Shortening of lateral malleoli fractures can lead to increased talocrural angle. Talocrural angle is not 100% reliable for estimating restoration of fibular length can also utilize the realignment of the medial fibular prominence with the tibiotalar joint Posterior malleolus fractures - double contour sign - misty mountains sign Lauge-Hansen based on foot position and force of applied stress/force has been shown to predict the observed (via MRI) ligamentous injury in less than 50% of operatively treated fractures: Supination - Adduction (SA): Talofibular sprain or distal fibular avulsion Vertical medial malleolus and impaction of anteromedial distal tibia Supination - External Rotation (SER): Anterior tibiofibular ligament sprain Lateral short oblique fibula fracture (anteroinferior to posterosuperior) Posterior tibiofibular ligament rupture or avulsion of posterior malleolus Medial malleolus transverse fracture or disruption of deltoid ligament Pronation - Abduction (PA): Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament sprain Transverse comminuted fracture of the fibula above the level of the syndesmosis Pronation - External Rotation (PER): Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament disruption Lateral short oblique or spiral fracture of fibula (anterosuperior to posteroinferior) above the level of the joint Posterior tibiofibular ligament rupture or avulsion of posterior malleolus Anatomic / Descriptive - isolated medial malleolar - isolated lateral malleolar - bimalleolar - trimalleolar - Bosworth fracture-dislocation (posterior dislocation of the fibula behind incisura fibularis) Danis-Weber (location of fibular fracture) A - infrasyndesmotic (generally not associated with ankle instability) B - transsyndesmotic C - suprasyndesmotic AO / ATA 44A - infrasyndesmotic 44B - transsyndesmotic 44C - suprasyndesmotic General Treatment Nonoperative - short-leg walking cast/boot indications: - isolated nondisplaced medial malleolus fracture or tip avulsions - isolated lateral malleolus fracture with < 3mm displacement and no talar shift - bimalleolar fracture if elderly or unable to undergo surgical intervention - posterior malleolar fracture with < 25% joint involvement or < 2mm step-off Operative - open reduction internal fixation indications: - any talar displacement - displaced isolated medial malleolar fracture - displaced isolated lateral malleolar fracture - bimalleolar fracture and bimalleolar-equivalent fracture - posterior malleolar fracture with > 25% or > 2mm step-off - Bosworth fracture-dislocations - open fractures - malleolar nonunions Technique: goal of treatment is stable anatomic reduction of talus in the ankle mortise - 1 mm shift of talus leads to 42% decrease in tibiotalar contact area - Overall success rate of 90% - prolonged recovery expected (2 years to obtain final functional result) significant functional impairment often noted Anatomic reduction is considered the most important factor for a satisfactory outcome Worse outcomes with: smoking, decreased education, alcohol use, presence of medial malleolar fracture ORIF superior to closed treatment of bimalleolar fractures in Lauge-Hansen supination-adduction fractures, restoration of marginal impaction of the anteromedial tibial plafond leads to optimal functional results after surgery Postoperative rehabilitation - time for proper braking response time (driving) returns to baseline at nine weeks for operatively treated ankle fractures - braking travel time is significantly increased until 6 weeks after initiation of weight bearing in both long bone and periarticular fractures of the lower extremity

Answer 51

The pelvic spur sign is indicative of a both column acetabular fracture. It is best seen on an AP or obturator oblique x-ray. The spur is the intact portion of the ilium, still attached to the axial skeleton and seen posterosuperior to the displaced acetabulum (typically medially displaced). Acetabulum fractures can involve one or more of the two columns, two walls or roof within the pelvis Osteology acetabular inclination & ante version: mean lateral inclination of 40 to 48 degrees, anteversion of 18 to 21 degrees Column theory : acetabulum is supported by two columns of bone - form an "inverted Y". Connected to sacrum through sciatic buttress - Posterior column: comprised of quadrilateral surface, posterior wall and dome, ischial tuberosity, greater/lesser sciatic notches - anterior column: comprised of anterior ilium (gluteus medius tubercle), anterior wall and dome, iliopectineal eminence, lateral superior pubic ramus Vascular corona mortis : anastomosis of external iliac (epigastric) and internal iliac (obturator) vessels - at risk with lateral dissection over superior pubic ramus Letournel Classification Judet and Letournel: most common referenced classification system - classifed as 5 elementary and 5 associated fracture patterns Most common fracture patterns Younger : posterior wall or transverse fracture "family" (transverse, T-type, transverse + posterior wall) Elderly : anterior column (e.g., quadrilateral plate fractures), anterior column, posterior hemitransverse, assoicated both column fractures Posterior wall • Most common • "gull sign" on obturator oblique view Posterior column • check for injury to superior gluteal NV bundle Anterior wall • Very rare Anterior column • More common in elderly patients with fall from standing (most common in elderly is "anterior column + medial wall") Transverse • Axial CT shows anterior to posterior fx line • Only elementary fx to involve both columns Associated Both Column • Characterized by dissociation of the articular surface from the inonimate bone • "spur sign" on obturator oblique Transverse + Post. Wall • Most common associated fx T Shaped • May need combined approach Anterior column or wall + Post. hemitransverse • Common in elderly patients Post. column + Post. wall • Only associated fracture that does not involve both columns Treatment Nonoperative: protected weight bearing for 6-8 weeks indications: patient factors - high operative risk (e.g., elderly patients, presence of DVT), morbid obesity, open contaminated wound, late presenting > 3 weeks fracture characteristics: minimally displaced fracture (< 2 mm), < 20% posterior wall fractures (treatment based on size of posterior wall is controversial - recommend an exam under anesthesia (EUA) using fluoroscopy best method to test stability), Femoral head congruency with weight bearing roof (out of traction) - both column fracture pattern with secondary congruence (out of traction), displaced fracture with roof arcs > 45° in AP and Judet views or >10 mm on axial CT cuts technique - Skeletal traction NOT required if stable fracture pattern, outside the weight-bearing dome - activity as tolerated with crutches/walker Weight-bearing: lowest joint reactive forces seen with toe-touch weight bearing and passive hip abduction, greatest joint contact force seen when rising from a chair on the affected extremity DVT prophylaxis if slow to mobilize Close radiographic follow-up Operative treatment open reduction and internal fixation indications - Patient factors: < 3 weeks from date of injury, physiologically stable, adequate soft-tissue envelope, no local infection, pregnancy is not contraindication to surgical fixation - Fracture factors: displacement of roof (> 2 mm), unstable fracture pattern (e.g. posterior wall fracture involving > 40-50%), marginal impaction, intra-articular loose bodies, irreducible fracture-dislocation Approaches - Anterior : ilioinguinal, iliofemoral, modified stoppa - Posterior: Kocher-Langenbach - Combined: extended ilifemoral Fixation modalities: - Column fixation strategies: reconstruction bridging plate and screws, percutaneous column screws, cable fixation - Wall fixation strategies: bridge plate and screws, lag screw and neutralization plate, spring (butress) plate outcomes timing: associated hip dislocations should be reduced within 12 hours for improved outcomes worse outcomes with fixation of fracture > 3 weeks from time of injury - earlier operative treatment associated with increased chance of anatomic reduction Peri-operative : clinical outcome correlates with quality of articular reduction Postoperative CT scan is most accurate way to determine posterior wall accuracy of reduction which has greatest correlation with clinical outcome - ideally articular reduction <2mm Post-operative greatest stress on acetabular repair occurs when rising from a seated position using the affected leg, and occurs in the posterior superior portion of the acetabulum Functional outcomes most strongly correlate with hip muscle strength and restoration of gait postoperatively Total hip arthroplasty indications usually elderly patients with significant osteopenia and/or significant comminution, pre-existing arthritis, post-traumatic arthritis in all ages techniques timing: immediate vs. delayed THA immediate THA (with, or without, fracture fixation) wall fractures : butress plate with multi-hole cup column fracture: cage and cup constructs delayed THA outcomes: patients older than 60 years have approx. a 30% late conversion rate to THA after acetabular fractures 10-year implant survival noted to be around 75-80%

Answer 52

Distraction bone block subtalar arthrodesis The complex pathology in this scenario includes: incongruous subtalar joint, loss of calcaneal body height, and likely decreased lateral talocalcaneal angle. Complications of this injury include pain, shoe wear difficulties, and foot deformity. Foot deformity (collapse of the talus into the posterior facet) can result in tibiotalar neck impingement. Carr et al described a subtalar fusion technique for late complications of calcaneus fractures that were treated conservatively. The subtalar fusion technique involves distraction of the subtalar joint, insertion of a bone block, and rigid screw fixation. The distraction allows correction of the talocalcaneal relationship and regains lost hindfoot height. (A subtalar fusion would address the pain issue but not the other factors). Chandler et al states that distraction arthrodesis should be considered only if findings of anterior ankle impingement are present, as is true in this case. Calcaneus: Most frequent tarsal fracture 17% open fractures Pathophysiology mechanism: traumatic axial loading is the primary mechanism of injury, fall from height, motor-vehicle accidents pathoanatomy - intra-articular fractures: PRIMARY FRACTURE line results from oblique shear and leads to the following two primary fragments: 1. superomedial fragment (constant fragment): includes the sustentaculum tali and is stabilized by strong ligamentous and capsular attachments 2. superolateral fragment: includes an intra-articular aspect through the posterior facet SECONDARY FRACTURE lines dictate whether there is joint depression or tongue-type fracture - Extra-articular fractures: strong contraction of gastrocnemius-soleus with concomitant avulsion at its insertion site on calcaneus. More common in osteopenic bone - Anterior process fractures: inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament Associated injuries - extension into the calcaneocuboid joint occurs in 63% - vertebral injuries in 10% - contralateral calcaneus in 10% Prognosis poor with 40% complication rate - increased due to mechanism (fall from height), smoking, and early surgery lateral soft tissue trauma increases the rate of complication Osteology Articular facets : superolateral fragment contains the articular facets - superior articular surface contains three facets that articulate with the talus: - posterior facet is the largest and is the major weight bearing surface - the flexor hallucis longus tendon runs just inferior to it and can be injured with errant drills/screws that are too long - middle facet is anteromedial on sustentaculum tali - anterior facet is often confluent with middle facet sinus tarsi - between the middle and posterior facets lies the interosseous sulcus (calcaneal groove) that together with the talar sulcus makes up the sinus tarsi sustentaculum tali: Projects medially and supports the neck of talus - FHL passes beneath it. Deltoid and talocalcaneal ligament connect it to the talus - contained in the anteromedial fragment, which remains "constant" due to medial talocalcaneal and interosseous ligaments bifurcate ligament: connects the dorsal aspect of the anterior process to the cuboid and navicular Classification Extra-articular (25%) : avulsion injury of: anterior process (by bifurcate ligament), sustentaculum tali, calcaneal tuberosity (Achilles tendon avulsion) Intra-articular (75%) Essex-Lopresti classification: the primary fracture line runs obliquely through the posterior facet forming two fragments The secondary fracture line runs in one of two planes - the axial plane beneath the facet exiting posteriorly in tongue-type fractures - when the superolateral fragment and posterior facet remain attached to the tuberosity posteriorly - behind the posterior facet in joint depression fractures Sanders classification: based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet Sanders Classification Type I • Nondisplaced posterior facet (regardless of number of fracture lines) Type II • One fracture line in the posterior facet (two fragments) Type III • Two fracture lines in the posterior facet (three fragments) Type IV • Comminuted with more than three fracture lines in the posterior facet (four or more fragments) Complications Wound complications (10-25%) : increased risk in smokers, diabetics, and open injuries Subtalar arthritis : increased with nonoperative management Lateral impingement with peroneal irritation Damaged FHL: at risk with placement of lateral to medial screws, especially at level of sustentaculum tali (constant fragment) Compartment syndrome (10%): results in claw toes Malunion: loss of height, widening, and lateral impingement. Causes limited ankle dorsiflexion due to dorsiflexed talus with talar declination angle <20. Treatment: distraction bone block subtalar arthrodesis - indications: chronic pain from subtalar joint, incongruous subtalar joint/post-traumatic DJD, loss of calcaneal height, mechanical block to ankle dorsiflexion (results from posterior talar collapse into the posterior calcaneus). Goal is to correct : hindfoot height, ankle impingement, subfibular impingement, subtalar arthritis

Answer 53

This patient has undergone ORIF of the lateral malleolus with shortening of the lateral malleolus and lateral tibiotalar tilt. Revision surgery would entail bone grafting and re-plating of the fibula. Malunion of the fibula component of ankle fractures lead to tibiotalar instability and post-traumatic ankle arthritis. The distal fragment is usually shortened and externally rotated. The osteotomy can restore length and correct rotation. Markers for potential instability include: (1) asymmetry of the medial-lateral clear spaces, (2) talar tilt >2mm, (3) talar subluxation, (4) abnormal talocrural angle (normal, 75-86deg). Chu et al. opined that reconstruction for distal fibula malunions should include: (1) osteotomy, (2) +/- syndesmotic fixation and (3) autologous bone graft. They recommend: (1) low oblique osteotomy for fractures below the syndesmosis, (2) transverse osteotomy above the syndesmosis for high fractures (PER4) and low fractures with tibiofibular instability, (3) inspection of the tibiofibular joint through an anterolateral window to ensure anatomic reduction. Weber et al. described a method of corrective lengthening osteotomy of the fibula in 23 cases. They described 3 criteria for assessing normal fibular length. Seventeen patients had good-excellent results, and 6 had fair-poor results (1 of these 6 needed ankle fusion). Incorrect Answers: Answer 1, 2, 5: There is no syndesmotic disruption. Answer 4: There is no evidence of a loose osteochondral fragment.

Answer 54

Kocher-Langenbeck approach Operative treatment is indicated for most displaced acetabular fractures to allow early ambulatory function and to decrease the chance of post-traumatic arthritis. Among the various surgical approaches, the Kocher-Langenbeck allows direct exposure of both the posterior column and posterior wall. Indications for using this exposure include posterior wall fractures, posterior column fractures, combined posterior wall/posterior column fractures, and simple transverse fractures. Acetabulum fractures can involve one or more of the two columns, two walls or roof within the pelvis Osteology acetabular inclination & ante version: mean lateral inclination of 40 to 48 degrees, anteversion of 18 to 21 degrees Column theory : acetabulum is supported by two columns of bone - form an "inverted Y". Connected to sacrum through sciatic buttress - Posterior column: comprised of quadrilateral surface, posterior wall and dome, ischial tuberosity, greater/lesser sciatic notches - anterior column: comprised of anterior ilium (gluteus medius tubercle), anterior wall and dome, iliopectineal eminence, lateral superior pubic ramus Vascular corona mortis : anastomosis of external iliac (epigastric) and internal iliac (obturator) vessels - at risk with lateral dissection over superior pubic ramus Letournel Classification Judet and Letournel: most common referenced classification system - classifed as 5 elementary and 5 associated fracture patterns Most common fracture patterns Younger : posterior wall or transverse fracture "family" (transverse, T-type, transverse + posterior wall) Elderly : anterior column (e.g., quadrilateral plate fractures), anterior column, posterior hemitransverse, assoicated both column fractures Posterior wall • Most common • "gull sign" on obturator oblique view Posterior column • check for injury to superior gluteal NV bundle Anterior wall • Very rare Anterior column • More common in elderly patients with fall from standing (most common in elderly is "anterior column + medial wall") Transverse • Axial CT shows anterior to posterior fx line • Only elementary fx to involve both columns Associated Both Column • Characterized by dissociation of the articular surface from the inonimate bone • "spur sign" on obturator oblique Transverse + Post. Wall • Most common associated fx T Shaped • May need combined approach Anterior column or wall + Post. hemitransverse • Common in elderly patients Post. column + Post. wall • Only associated fracture that does not involve both columns Treatment Nonoperative: protected weight bearing for 6-8 weeks indications: patient factors - high operative risk (e.g., elderly patients, presence of DVT), morbid obesity, open contaminated wound, late presenting > 3 weeks fracture characteristics: minimally displaced fracture (< 2 mm), < 20% posterior wall fractures (treatment based on size of posterior wall is controversial - recommend an exam under anesthesia (EUA) using fluoroscopy best method to test stability), Femoral head congruency with weight bearing roof (out of traction) - both column fracture pattern with secondary congruence (out of traction), displaced fracture with roof arcs > 45° in AP and Judet views or >10 mm on axial CT cuts technique - Skeletal traction NOT required if stable fracture pattern, outside the weight-bearing dome - activity as tolerated with crutches/walker Weight-bearing: lowest joint reactive forces seen with toe-touch weight bearing and passive hip abduction, greatest joint contact force seen when rising from a chair on the affected extremity DVT prophylaxis if slow to mobilize Close radiographic follow-up Operative treatment open reduction and internal fixation indications - Patient factors: < 3 weeks from date of injury, physiologically stable, adequate soft-tissue envelope, no local infection, pregnancy is not contraindication to surgical fixation - Fracture factors: displacement of roof (> 2 mm), unstable fracture pattern (e.g. posterior wall fracture involving > 40-50%), marginal impaction, intra-articular loose bodies, irreducible fracture-dislocation Approaches - Anterior : ilioinguinal, iliofemoral, modified stoppa - Posterior: Kocher-Langenbach - Combined: extended ilifemoral Fixation modalities: - Column fixation strategies: reconstruction bridging plate and screws, percutaneous column screws, cable fixation - Wall fixation strategies: bridge plate and screws, lag screw and neutralization plate, spring (butress) plate outcomes timing: associated hip dislocations should be reduced within 12 hours for improved outcomes worse outcomes with fixation of fracture > 3 weeks from time of injury - earlier operative treatment associated with increased chance of anatomic reduction Peri-operative : clinical outcome correlates with quality of articular reduction Postoperative CT scan is most accurate way to determine posterior wall accuracy of reduction which has greatest correlation with clinical outcome - ideally articular reduction <2mm Post-operative greatest stress on acetabular repair occurs when rising from a seated position using the affected leg, and occurs in the posterior superior portion of the acetabulum Functional outcomes most strongly correlate with hip muscle strength and restoration of gait postoperatively Total hip arthroplasty indications usually elderly patients with significant osteopenia and/or significant comminution, pre-existing arthritis, post-traumatic arthritis in all ages techniques timing: immediate vs. delayed THA immediate THA (with, or without, fracture fixation) wall fractures : butress plate with multi-hole cup column fracture: cage and cup constructs delayed THA outcomes: patients older than 60 years have approx. a 30% late conversion rate to THA after acetabular fractures 10-year implant survival noted to be around 75-80%

Answer 55

Based on the clinical findings and imaging shown, one should be suspicious for a calcaneal stress fracture. This can be confirmed by obtaining an MRI. Calcaneal stress fractures are often associated with increases in training intensity. They may be seen in patients with the female athletic triad. An MRI is used to help delineate the diagnosis when it is not clear from the history and physical exam. Neufeld et al. review the diagnosis and management of plantar fasciitis. They note that there are many causes of inferior heel pain, including nerve compression, FHL tendinitis and calcaneal stress fractures. The latter commonly presents with diffuse swelling and pain with medial to lateral compression of the heel. Figure A shows a lateral radiograph of the foot with no obvious osseous abnormality of the calcaneus. Illustration A shows a T1 weighted sagittal reconstruction of an MRI that is demonstrative of a dark line; this is consistent with a stress fracture. Incorrect Answers Answer 1: EMG would be indicated in evaluation for tarsal tunnel syndrome Answer 2: Heel pad injections are not indicated in the treatment of calcaneal stress fractures Answer 3: Observation alone is not indicated Answer 5: A cast can be used for immobilization initially based on history and exam and discussion with patient or after the diagnosis is confirmed with a MRI. However, in this scenario 4-6 months of nonweightbearing is likely excessive. Calcaneus: Most frequent tarsal fracture 17% open fractures Pathophysiology mechanism: traumatic axial loading is the primary mechanism of injury, fall from height, motor-vehicle accidents pathoanatomy - intra-articular fractures: PRIMARY FRACTURE line results from oblique shear and leads to the following two primary fragments: 1. superomedial fragment (constant fragment): includes the sustentaculum tali and is stabilized by strong ligamentous and capsular attachments 2. superolateral fragment: includes an intra-articular aspect through the posterior facet SECONDARY FRACTURE lines dictate whether there is joint depression or tongue-type fracture - Extra-articular fractures: strong contraction of gastrocnemius-soleus with concomitant avulsion at its insertion site on calcaneus. More common in osteopenic bone - Anterior process fractures: inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament Associated injuries - extension into the calcaneocuboid joint occurs in 63% - vertebral injuries in 10% - contralateral calcaneus in 10% Prognosis poor with 40% complication rate - increased due to mechanism (fall from height), smoking, and early surgery lateral soft tissue trauma increases the rate of complication Osteology Articular facets : superolateral fragment contains the articular facets - superior articular surface contains three facets that articulate with the talus: - posterior facet is the largest and is the major weight bearing surface - the flexor hallucis longus tendon runs just inferior to it and can be injured with errant drills/screws that are too long - middle facet is anteromedial on sustentaculum tali - anterior facet is often confluent with middle facet sinus tarsi - between the middle and posterior facets lies the interosseous sulcus (calcaneal groove) that together with the talar sulcus makes up the sinus tarsi sustentaculum tali: Projects medially and supports the neck of talus - FHL passes beneath it. Deltoid and talocalcaneal ligament connect it to the talus - contained in the anteromedial fragment, which remains "constant" due to medial talocalcaneal and interosseous ligaments bifurcate ligament: connects the dorsal aspect of the anterior process to the cuboid and navicular Classification Extra-articular (25%) : avulsion injury of: anterior process (by bifurcate ligament), sustentaculum tali, calcaneal tuberosity (Achilles tendon avulsion) Intra-articular (75%) Essex-Lopresti classification: the primary fracture line runs obliquely through the posterior facet forming two fragments The secondary fracture line runs in one of two planes - the axial plane beneath the facet exiting posteriorly in tongue-type fractures - when the superolateral fragment and posterior facet remain attached to the tuberosity posteriorly - behind the posterior facet in joint depression fractures Sanders classification: based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet Sanders Classification Type I • Nondisplaced posterior facet (regardless of number of fracture lines) Type II • One fracture line in the posterior facet (two fragments) Type III • Two fracture lines in the posterior facet (three fragments) Type IV • Comminuted with more than three fracture lines in the posterior facet (four or more fragments) Complications Wound complications (10-25%) : increased risk in smokers, diabetics, and open injuries Subtalar arthritis : increased with nonoperative management Lateral impingement with peroneal irritation Damaged FHL: at risk with placement of lateral to medial screws, especially at level of sustentaculum tali (constant fragment) Compartment syndrome (10%): results in claw toes Malunion: loss of height, widening, and lateral impingement. Causes limited ankle dorsiflexion due to dorsiflexed talus with talar declination angle <20. Treatment: distraction bone block subtalar arthrodesis - indications: chronic pain from subtalar joint, incongruous subtalar joint/post-traumatic DJD, loss of calcaneal height, mechanical block to ankle dorsiflexion (results from posterior talar collapse into the posterior calcaneus). Goal is to correct : hindfoot height, ankle impingement, subfibular impingement, subtalar arthritis

Answer 56

Myodesis of the adductors Prior to the late 80’s, techniques for transfemoral amputation sacrificed the hip adductor muscles resulting in unopposed abductor forces. Amputation with an abducted femur leads to an increase in side lurch and higher energy consumption. Gottschalk in ’99 showed that myodesis of the adductor magnus through drill holes in the lateral femur preserved maximum muscle force and provided a mechanical advantage for the adductors of the thigh. This resulted in maintenance of the normal anatomic alignment of the femur and a balance between the abductor and adductor mechanisms of the hip, thus providing patients with improved control and easier prosthesis fit. Ankle/Foot Amputation: Syme amputation (ankle disarticulation) - patent tibialis posterior artery is required. More energy efficient than midfoot even though it is more proximal Stable heel pad is most important factor Used successfully to treat forefoot gangrene in diabetics Technique: medial and lateral malleoli are removed flush with distal tibia articular surface. The medial and lateral flares of the tibia and fibula are beveled to enhance heel pad adherence. Heel pad is secured to anterior tibia Pirogoff amputation (hindfoot amputation): removal of the forefoot and talus followed by calcaneotibial arthrodesis calcaneus is osteotomized and rotated 50-90 degrees to keep posterior aspect of calcaneus distal Allows patient to mobilize independently without use of prosthetic Chopart or Boyd amputation (hindfoot amputation) a partial foot amputation through the talonavicular and calcaneocuboid joints. Primary complication is equinus deformity - avoid by lengthening of the Achilles tendon and transfer of the tibialis anterior to the talar neck leads to apropulsive gait pattern because the amputation is unable to support modern dynamic elastic response prosthetic feet Lisfranc amputation (midfoot amputation) - equinovarus deformity is common caused by unopposed pull of tibialis posterior and gastroc/soleus. Prevent by maintaining insertion of peroneus brevis and performing achilles lengthening. A walking cast is generally used for 4 week to prevent late equinus contracture. Energy cost of walking similar to that of BKA Transmetatarsal amputation: more appealing to patients who refuse transtibial amputations Almost all require achilles lengthening to prevent equinus Great toe amputations: preserve 1cm at base of proximal phalanx - preserves insertion of plantar fascia, sesamoids, and flexor hallucis brevis - reduces amount of weight transfer to remaining toes so lessens risk of ulceration Metabolic cost of walking - increases with more proximal amputations perform amputations at lowest possible level to preserve function - exception: Syme amputation is more efficient than midfoot amputation - inversely proportional to length of remaining limb Ranking of metabolic demand (% represents amount of increase compared to baseline) Syme - 15% transtibial: traumatic - 25% average, short BKA - 40%, long BKA - 10%, vascular - 40% transfemoral: traumatic - 68%, vascular - 100% thru-knee amputation: varies based on patient habitus but is somewhere between transtibial and transfemoral Most proximal amputation level available in children to maintain walking speeds without increased energy expenditure compared to normal children Transfemoral Amputation: - Maintain as much length as possible, however, ideal cut is 12 cm (10-15cm) above knee joint to allow for prosthetic fitting Technique - 5-10 degrees of adduction is ideal for improved prosthesis function - adductor myodesis: improves clinical outcomes creates dynamic muscle balance (otherwise have unopposed abductors). Provides soft tissue envelope that enhances prosthetic fitting Gritti-Stokes amputation: amputation through the femur near level of adductor tubercle. Synovium is excised to prevent postoperative effusion. Patella is arthrodesed to the end of femur for improved end bearing prepatellar soft tissue is maintained without iatrogenic injury - improved outcomes as compared to transfemoral amputation ``` Wound Healing Dependent on - vascular supply - nutritional status - immune status ``` Improved with - albumin > 3.0 g/dL - ischemic index > .5 measurement of doppler pressure at level being tested compared to brachial systolic pressure - transcutaneous oxygen tension > 30 mm Hg (ideally 45 mm Hg) - toe pressure > 40 mm Hg (will not heal if < 20 mm Hg) ankle-brachial index (ABI) > 0.45 total lymphocyte count (TLC) > 1500/mm3 - Hyperbaric oxygen therapy contraindications include: chemo or radiation therapy pressure-sensitive implanted medical device (automatic implantable cardiac defibrillator, pacemaker, dorsal column stimulator, insulin pump) , undrained pneumothorax Complications - Wound healing - Contractures: adjacent joint contractures are common prevent with early aggressive mobilization and position changes - Heterotopic ossification: more common in trauma-related setting - Infection: trauma-related amputation have an infection rate of around 34% - Postamputation Neuroma : occurs in 20-30% of amputees prevent with proper nerve handling at the time of procedure. Treatment: targeted muscle rein nervation - a method of guiding neuronal regeneration to prevent or treat post-amputation neuroma pain and improve patient use of myoelectric prostheses - Phantom limb pain occurs in 53-100% of traumatic amputations mirror therapy is a noninvasive treatment modality - Bone overgrowth: most common complication with pediatric amputations. Treatment: prevent by performing disarticulation or using epihphyseal cap to cover medullary canal

Answer 57

Knee disarticulation level is associated with the worst functional result 2 years after injury (compared to transmetatarsal, Symes, AKA, or BKA). The prosthetic use is decreased with a knee disarticulation as compared to a transtibial amputation. The cohort study by MacKenzie et al prospectively followed 161 patients that were part of the Lower Extremity Assessment Project (LEAP). These patients underwent an above-the-ankle amputation at a trauma center within 3 months following the injury and followed for 2 years. This study revealed that through-the-knee amputations had significantly worse scores for the objective performance measures of self-selected walking speed, independence in transfers, walking, and stair-climbing. Through-the-knee amputees also had worse SIP scores than AKA and BKA patients. Physicians were also less satisfied with both the clinical and the cosmetic recovery of the patients with a through-the-knee amputation. It should be noted that patients with a BKA had a faster walking speed than those with an AKA. Despite the worse SIP scores for through-the-knee amputations, patients actually reported less pain than those with an AKA or BKA, though this wasn't statistically significant. Ankle/Foot Amputation: Syme amputation (ankle disarticulation) - patent tibialis posterior artery is required. More energy efficient than midfoot even though it is more proximal Stable heel pad is most important factor Used successfully to treat forefoot gangrene in diabetics Technique: medial and lateral malleoli are removed flush with distal tibia articular surface. The medial and lateral flares of the tibia and fibula are beveled to enhance heel pad adherence. Heel pad is secured to anterior tibia Pirogoff amputation (hindfoot amputation): removal of the forefoot and talus followed by calcaneotibial arthrodesis calcaneus is osteotomized and rotated 50-90 degrees to keep posterior aspect of calcaneus distal Allows patient to mobilize independently without use of prosthetic Chopart or Boyd amputation (hindfoot amputation) a partial foot amputation through the talonavicular and calcaneocuboid joints. Primary complication is equinus deformity - avoid by lengthening of the Achilles tendon and transfer of the tibialis anterior to the talar neck leads to apropulsive gait pattern because the amputation is unable to support modern dynamic elastic response prosthetic feet Lisfranc amputation (midfoot amputation) - equinovarus deformity is common caused by unopposed pull of tibialis posterior and gastroc/soleus. Prevent by maintaining insertion of peroneus brevis and performing achilles lengthening. A walking cast is generally used for 4 week to prevent late equinus contracture. Energy cost of walking similar to that of BKA Transmetatarsal amputation: more appealing to patients who refuse transtibial amputations Almost all require achilles lengthening to prevent equinus Great toe amputations: preserve 1cm at base of proximal phalanx - preserves insertion of plantar fascia, sesamoids, and flexor hallucis brevis - reduces amount of weight transfer to remaining toes so lessens risk of ulceration Metabolic cost of walking - increases with more proximal amputations perform amputations at lowest possible level to preserve function - exception: Syme amputation is more efficient than midfoot amputation - inversely proportional to length of remaining limb Ranking of metabolic demand (% represents amount of increase compared to baseline) Syme - 15% transtibial: traumatic - 25% average, short BKA - 40%, long BKA - 10%, vascular - 40% transfemoral: traumatic - 68%, vascular - 100% thru-knee amputation: varies based on patient habitus but is somewhere between transtibial and transfemoral Most proximal amputation level available in children to maintain walking speeds without increased energy expenditure compared to normal children Transfemoral Amputation: - Maintain as much length as possible, however, ideal cut is 12 cm (10-15cm) above knee joint to allow for prosthetic fitting Technique - 5-10 degrees of adduction is ideal for improved prosthesis function - adductor myodesis: improves clinical outcomes creates dynamic muscle balance (otherwise have unopposed abductors). Provides soft tissue envelope that enhances prosthetic fitting Gritti-Stokes amputation: amputation through the femur near level of adductor tubercle. Synovium is excised to prevent postoperative effusion. Patella is arthrodesed to the end of femur for improved end bearing prepatellar soft tissue is maintained without iatrogenic injury - improved outcomes as compared to transfemoral amputation ``` Wound Healing Dependent on - vascular supply - nutritional status - immune status ``` Improved with - albumin > 3.0 g/dL - ischemic index > .5 measurement of doppler pressure at level being tested compared to brachial systolic pressure - transcutaneous oxygen tension > 30 mm Hg (ideally 45 mm Hg) - toe pressure > 40 mm Hg (will not heal if < 20 mm Hg) ankle-brachial index (ABI) > 0.45 total lymphocyte count (TLC) > 1500/mm3 - Hyperbaric oxygen therapy contraindications include: chemo or radiation therapy pressure-sensitive implanted medical device (automatic implantable cardiac defibrillator, pacemaker, dorsal column stimulator, insulin pump) , undrained pneumothorax Complications - Wound healing - Contractures: adjacent joint contractures are common prevent with early aggressive mobilization and position changes - Heterotopic ossification: more common in trauma-related setting - Infection: trauma-related amputation have an infection rate of around 34% - Postamputation Neuroma : occurs in 20-30% of amputees prevent with proper nerve handling at the time of procedure. Treatment: targeted muscle rein nervation - a method of guiding neuronal regeneration to prevent or treat post-amputation neuroma pain and improve patient use of myoelectric prostheses - Phantom limb pain occurs in 53-100% of traumatic amputations mirror therapy is a noninvasive treatment modality - Bone overgrowth: most common complication with pediatric amputations. Treatment: prevent by performing disarticulation or using epihphyseal cap to cover medullary canal

Answer 58

The patient most likely to require late subtalar fusion for post-traumatic arthritis is a male patient with a Sanders Type III fracture treated with ORIF. The Sanders classification system seems to remain prognostic for injury severity. It has been shown that greater articular injury is associated with greater risk of arthritis, irrespective of patient gender and occupation. In current reviews, type III fractures are 6.5 times more likely to develop PTA and 4 times more likely to require an ST fusion than Sanders type II fractures. Post-traumatic arthritis of the subtalar joint is a common complication. Successful salvage can be achieved with a subtalar arthrodesis. Howard et al reported on complications following management of displaced intra-articular calcaneal fractures. 469 patients were randomized into ORIF and non-operative groups. ORIF patients were more likely to develop complications (overall 25% vs 18% of non-op) with fractures of increasing severity (Sanders IV) developing more complications regardless of management strategy. Sanders et al. reviewed the operative treatment of displaced intra-articular calcaneal fractures. Based on the results of this comparative analysis, the Sanders classification remains prognostic; after a minimum of 10 years, type III fractures were 4 times more likely to need a fusion than type II fractures. Incorrect Answers: Answers 1,3-5: Functional outcomes and arthritis will be determined by the amount of cartilage damage. This is directly correlated with initial injury, fracture pattern (Sanders) and reduction techniques. Worker compensation are associated with worse functional outcome scores, not post-traumatic arthritis. Calcaneus: Most frequent tarsal fracture 17% open fractures Pathophysiology mechanism: traumatic axial loading is the primary mechanism of injury, fall from height, motor-vehicle accidents pathoanatomy - intra-articular fractures: PRIMARY FRACTURE line results from oblique shear and leads to the following two primary fragments: 1. superomedial fragment (constant fragment): includes the sustentaculum tali and is stabilized by strong ligamentous and capsular attachments 2. superolateral fragment: includes an intra-articular aspect through the posterior facet SECONDARY FRACTURE lines dictate whether there is joint depression or tongue-type fracture - Extra-articular fractures: strong contraction of gastrocnemius-soleus with concomitant avulsion at its insertion site on calcaneus. More common in osteopenic bone - Anterior process fractures: inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament Associated injuries - extension into the calcaneocuboid joint occurs in 63% - vertebral injuries in 10% - contralateral calcaneus in 10% Prognosis poor with 40% complication rate - increased due to mechanism (fall from height), smoking, and early surgery lateral soft tissue trauma increases the rate of complication Osteology Articular facets : superolateral fragment contains the articular facets - superior articular surface contains three facets that articulate with the talus: - posterior facet is the largest and is the major weight bearing surface - the flexor hallucis longus tendon runs just inferior to it and can be injured with errant drills/screws that are too long - middle facet is anteromedial on sustentaculum tali - anterior facet is often confluent with middle facet sinus tarsi - between the middle and posterior facets lies the interosseous sulcus (calcaneal groove) that together with the talar sulcus makes up the sinus tarsi sustentaculum tali: Projects medially and supports the neck of talus - FHL passes beneath it. Deltoid and talocalcaneal ligament connect it to the talus - contained in the anteromedial fragment, which remains "constant" due to medial talocalcaneal and interosseous ligaments bifurcate ligament: connects the dorsal aspect of the anterior process to the cuboid and navicular Classification Extra-articular (25%) : avulsion injury of: anterior process (by bifurcate ligament), sustentaculum tali, calcaneal tuberosity (Achilles tendon avulsion) Intra-articular (75%) Essex-Lopresti classification: the primary fracture line runs obliquely through the posterior facet forming two fragments The secondary fracture line runs in one of two planes - the axial plane beneath the facet exiting posteriorly in tongue-type fractures - when the superolateral fragment and posterior facet remain attached to the tuberosity posteriorly - behind the posterior facet in joint depression fractures Sanders classification: based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet Sanders Classification Type I • Nondisplaced posterior facet (regardless of number of fracture lines) Type II • One fracture line in the posterior facet (two fragments) Type III • Two fracture lines in the posterior facet (three fragments) Type IV • Comminuted with more than three fracture lines in the posterior facet (four or more fragments) Complications Wound complications (10-25%) : increased risk in smokers, diabetics, and open injuries Subtalar arthritis : increased with nonoperative management Lateral impingement with peroneal irritation Damaged FHL: at risk with placement of lateral to medial screws, especially at level of sustentaculum tali (constant fragment) Compartment syndrome (10%): results in claw toes Malunion: loss of height, widening, and lateral impingement. Causes limited ankle dorsiflexion due to dorsiflexed talus with talar declination angle <20. Treatment: distraction bone block subtalar arthrodesis - indications: chronic pain from subtalar joint, incongruous subtalar joint/post-traumatic DJD, loss of calcaneal height, mechanical block to ankle dorsiflexion (results from posterior talar collapse into the posterior calcaneus). Goal is to correct : hindfoot height, ankle impingement, subfibular impingement, subtalar arthritis

Answer 59

The flexor hallucis longus runs along the medial aspect of the hindfoot, medial to the posterior facet and inferior to middle facet just under sustentaculum tali(constant fragment) This tendon can be injured with poor drilling technique or use of screws that are too long during reduction and fixation of a calcaneus fracture using a lateral plate. If present, the great toe will be in a fixed, flexed position from the tendon being tethered over a screw. Calcaneus: Most frequent tarsal fracture 17% open fractures Pathophysiology mechanism: traumatic axial loading is the primary mechanism of injury, fall from height, motor-vehicle accidents pathoanatomy - intra-articular fractures: PRIMARY FRACTURE line results from oblique shear and leads to the following two primary fragments: 1. superomedial fragment (constant fragment): includes the sustentaculum tali and is stabilized by strong ligamentous and capsular attachments 2. superolateral fragment: includes an intra-articular aspect through the posterior facet SECONDARY FRACTURE lines dictate whether there is joint depression or tongue-type fracture - Extra-articular fractures: strong contraction of gastrocnemius-soleus with concomitant avulsion at its insertion site on calcaneus. More common in osteopenic bone - Anterior process fractures: inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament Associated injuries - extension into the calcaneocuboid joint occurs in 63% - vertebral injuries in 10% - contralateral calcaneus in 10% Prognosis poor with 40% complication rate - increased due to mechanism (fall from height), smoking, and early surgery lateral soft tissue trauma increases the rate of complication Osteology Articular facets : superolateral fragment contains the articular facets - superior articular surface contains three facets that articulate with the talus: - posterior facet is the largest and is the major weight bearing surface - the flexor hallucis longus tendon runs just inferior to it and can be injured with errant drills/screws that are too long - middle facet is anteromedial on sustentaculum tali - anterior facet is often confluent with middle facet sinus tarsi - between the middle and posterior facets lies the interosseous sulcus (calcaneal groove) that together with the talar sulcus makes up the sinus tarsi sustentaculum tali: Projects medially and supports the neck of talus - FHL passes beneath it. Deltoid and talocalcaneal ligament connect it to the talus - contained in the anteromedial fragment, which remains "constant" due to medial talocalcaneal and interosseous ligaments bifurcate ligament: connects the dorsal aspect of the anterior process to the cuboid and navicular Classification Extra-articular (25%) : avulsion injury of: anterior process (by bifurcate ligament), sustentaculum tali, calcaneal tuberosity (Achilles tendon avulsion) Intra-articular (75%) Essex-Lopresti classification: the primary fracture line runs obliquely through the posterior facet forming two fragments The secondary fracture line runs in one of two planes - the axial plane beneath the facet exiting posteriorly in tongue-type fractures - when the superolateral fragment and posterior facet remain attached to the tuberosity posteriorly - behind the posterior facet in joint depression fractures Sanders classification: based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet Sanders Classification Type I • Nondisplaced posterior facet (regardless of number of fracture lines) Type II • One fracture line in the posterior facet (two fragments) Type III • Two fracture lines in the posterior facet (three fragments) Type IV • Comminuted with more than three fracture lines in the posterior facet (four or more fragments) Complications Wound complications (10-25%) : increased risk in smokers, diabetics, and open injuries Subtalar arthritis : increased with nonoperative management Lateral impingement with peroneal irritation Damaged FHL: at risk with placement of lateral to medial screws, especially at level of sustentaculum tali (constant fragment) Compartment syndrome (10%): results in claw toes Malunion: loss of height, widening, and lateral impingement. Causes limited ankle dorsiflexion due to dorsiflexed talus with talar declination angle <20. Treatment: distraction bone block subtalar arthrodesis - indications: chronic pain from subtalar joint, incongruous subtalar joint/post-traumatic DJD, loss of calcaneal height, mechanical block to ankle dorsiflexion (results from posterior talar collapse into the posterior calcaneus). Goal is to correct : hindfoot height, ankle impingement, subfibular impingement, subtalar arthritis

Answer 60

Preserving the soft-tissue envelope (peroneus brevis, tertius and plantar fascia) around the fifth metatarsal base A Lisfranc amputation is through the tarsometatarsal joints, except the 2nd metatarsal, which is osteotomized to preserve the stability of the medial cuneiform. To prevent the patient from supinating the foot following this amputation, the evertors on the foot must be maintained. The principal evertors are the peroneus brevis and longus. Therefore, the function of the peroneus brevis must be preserved. Technically this is done preserving the soft-tissue envelope (peroneus brevis, tertius and plantar fascia) around the fifth metatarsal base. Incorrect Answers: 1-The posterior tibialis is the primary supinator of the foot, and releasing it would lead to an eversion deformity. The tibialis posterior tendon attachment to the bases of the second and third metatarsals will actually be released with this amputation, but the main attachment to the navicular preserved. 3-The anterior tibialis dorsiflexes and inverts the foot, but transferring it to the medial and middle cuneiforms would mimick its native function to dorsiflex and invert the foot. 4-A lengthened Achilles would lead to increased dorsiflexion, not supination. 5-Osteotomy of 2nd MT is crucial to preserve the medial cuneiform and midfoot stable. Ankle/Foot Amputation: Syme amputation (ankle disarticulation) - patent tibialis posterior artery is required. More energy efficient than midfoot even though it is more proximal Stable heel pad is most important factor Used successfully to treat forefoot gangrene in diabetics Technique: medial and lateral malleoli are removed flush with distal tibia articular surface. The medial and lateral flares of the tibia and fibula are beveled to enhance heel pad adherence. Heel pad is secured to anterior tibia Pirogoff amputation (hindfoot amputation): removal of the forefoot and talus followed by calcaneotibial arthrodesis calcaneus is osteotomized and rotated 50-90 degrees to keep posterior aspect of calcaneus distal Allows patient to mobilize independently without use of prosthetic Chopart or Boyd amputation (hindfoot amputation) a partial foot amputation through the talonavicular and calcaneocuboid joints. Primary complication is equinus deformity - avoid by lengthening of the Achilles tendon and transfer of the tibialis anterior to the talar neck leads to apropulsive gait pattern because the amputation is unable to support modern dynamic elastic response prosthetic feet Lisfranc amputation (midfoot amputation) - equinovarus deformity is common caused by unopposed pull of tibialis posterior and gastroc/soleus. Prevent by maintaining insertion of peroneus brevis and performing achilles lengthening. A walking cast is generally used for 4 week to prevent late equinus contracture. Energy cost of walking similar to that of BKA Transmetatarsal amputation: more appealing to patients who refuse transtibial amputations Almost all require achilles lengthening to prevent equinus Great toe amputations: preserve 1cm at base of proximal phalanx - preserves insertion of plantar fascia, sesamoids, and flexor hallucis brevis - reduces amount of weight transfer to remaining toes so lessens risk of ulceration Metabolic cost of walking - increases with more proximal amputations perform amputations at lowest possible level to preserve function - exception: Syme amputation is more efficient than midfoot amputation - inversely proportional to length of remaining limb Ranking of metabolic demand (% represents amount of increase compared to baseline) Syme - 15% transtibial: traumatic - 25% average, short BKA - 40%, long BKA - 10%, vascular - 40% transfemoral: traumatic - 68%, vascular - 100% thru-knee amputation: varies based on patient habitus but is somewhere between transtibial and transfemoral Most proximal amputation level available in children to maintain walking speeds without increased energy expenditure compared to normal children Transfemoral Amputation: - Maintain as much length as possible, however, ideal cut is 12 cm (10-15cm) above knee joint to allow for prosthetic fitting Technique - 5-10 degrees of adduction is ideal for improved prosthesis function - adductor myodesis: improves clinical outcomes creates dynamic muscle balance (otherwise have unopposed abductors). Provides soft tissue envelope that enhances prosthetic fitting Gritti-Stokes amputation: amputation through the femur near level of adductor tubercle. Synovium is excised to prevent postoperative effusion. Patella is arthrodesed to the end of femur for improved end bearing prepatellar soft tissue is maintained without iatrogenic injury - improved outcomes as compared to transfemoral amputation ``` Wound Healing Dependent on - vascular supply - nutritional status - immune status ``` Improved with - albumin > 3.0 g/dL - ischemic index > .5 measurement of doppler pressure at level being tested compared to brachial systolic pressure - transcutaneous oxygen tension > 30 mm Hg (ideally 45 mm Hg) - toe pressure > 40 mm Hg (will not heal if < 20 mm Hg) ankle-brachial index (ABI) > 0.45 total lymphocyte count (TLC) > 1500/mm3 - Hyperbaric oxygen therapy contraindications include: chemo or radiation therapy pressure-sensitive implanted medical device (automatic implantable cardiac defibrillator, pacemaker, dorsal column stimulator, insulin pump) , undrained pneumothorax Complications - Wound healing - Contractures: adjacent joint contractures are common prevent with early aggressive mobilization and position changes - Heterotopic ossification: more common in trauma-related setting - Infection: trauma-related amputation have an infection rate of around 34% - Postamputation Neuroma : occurs in 20-30% of amputees prevent with proper nerve handling at the time of procedure. Treatment: targeted muscle rein nervation - a method of guiding neuronal regeneration to prevent or treat post-amputation neuroma pain and improve patient use of myoelectric prostheses - Phantom limb pain occurs in 53-100% of traumatic amputations mirror therapy is a noninvasive treatment modality - Bone overgrowth: most common complication with pediatric amputations. Treatment: prevent by performing disarticulation or using epihphyseal cap to cover medullary canal

Answer 61

Dynamic fluoroscopic examination of the affected hip under anesthesia is considered the best method of predicting hip stability. Fragment size, which can be calculated using the Keith, Moed, or Calkins method, can be used to predict hip stability radiographically, however they are not as accurate. In general it is thought that posterior wall fractures involving less than 20% of the posterior wall are stable, whereas those involving greater than 40%-50% are unstable. Unfortunately, this leaves an indeterminent zone (20-40%) which does not provide guidance in treatment. Moed et al retrospectively reviewed 33 patients with posterior wall fractures who underwent dynamic fluoroscopic stress testing and compared the results of this testing to the Moed, Calkins, and Keith method of hip stability prediction. They found that the Moed method is the only reliable technique that is predictive of hip stability for small fracture fragments while also being predictive of instability for large fracture fragments. However, they also stated that there remain a substantial number of fractures involving 20% or more of the posterior wall that are both stable and unstable by examination under anesthesia. Therefore, they recommend dynamic fluoroscopic examination for assessment of hip stability in the presence of a posterior wall fracture. Moed et al in their second paper reviewed all patients with less than a ≤50% of the acetabular wall fracture, adequate imaging, and documented EUA results. The group looked at multiple variables including fracture fragment size, superior exit point of the fracture, center-edge angle, acetabular index, Tönnis angle, lateralized head sign, crossover sign, posterior wall sign, ischial spine sign, and hip version. Their conclusion was that no one variable was able to predict stability or instability and they continue to recommend EUA. Tornetta et al conducted a study in which dynamic fluoroscopic stress views were taken of 41 acetabular fractures that met the criteria for non-operative management to determine subtle signs of instability. Of the 41 fractures, 38 were found to be stable and 91% of these had good or excellent outcomes at 2.7 years. They concluded that dynamic stress views can identify subtle instability in patients who would normally be considered for non-operative treatment. incorrect answers: 1-> Keith Method - Depth of the fracture segment in injured hip is compared to the contralateral intact posterior wall depth at the level of the fovea 2-> Moed - Depth of the fracture segment in the injured hip is compared to contralateral posterior wall depth at the level of the greatest amount of fracture involvement 3-> Calkins - Length of posterior acetabular arc from each hip is compared at the level of the greatest amount of fracture involvement. Acetabulum fractures can involve one or more of the two columns, two walls or roof within the pelvis Osteology acetabular inclination & ante version: mean lateral inclination of 40 to 48 degrees, anteversion of 18 to 21 degrees Column theory : acetabulum is supported by two columns of bone - form an "inverted Y". Connected to sacrum through sciatic buttress - Posterior column: comprised of quadrilateral surface, posterior wall and dome, ischial tuberosity, greater/lesser sciatic notches - anterior column: comprised of anterior ilium (gluteus medius tubercle), anterior wall and dome, iliopectineal eminence, lateral superior pubic ramus Vascular corona mortis : anastomosis of external iliac (epigastric) and internal iliac (obturator) vessels - at risk with lateral dissection over superior pubic ramus Letournel Classification Judet and Letournel: most common referenced classification system - classifed as 5 elementary and 5 associated fracture patterns Most common fracture patterns Younger : posterior wall or transverse fracture "family" (transverse, T-type, transverse + posterior wall) Elderly : anterior column (e.g., quadrilateral plate fractures), anterior column, posterior hemitransverse, assoicated both column fractures Posterior wall • Most common • "gull sign" on obturator oblique view Posterior column • check for injury to superior gluteal NV bundle Anterior wall • Very rare Anterior column • More common in elderly patients with fall from standing (most common in elderly is "anterior column + medial wall") Transverse • Axial CT shows anterior to posterior fx line • Only elementary fx to involve both columns Associated Both Column • Characterized by dissociation of the articular surface from the inonimate bone • "spur sign" on obturator oblique Transverse + Post. Wall • Most common associated fx T Shaped • May need combined approach Anterior column or wall + Post. hemitransverse • Common in elderly patients Post. column + Post. wall • Only associated fracture that does not involve both columns Treatment Nonoperative: protected weight bearing for 6-8 weeks indications: patient factors - high operative risk (e.g., elderly patients, presence of DVT), morbid obesity, open contaminated wound, late presenting > 3 weeks fracture characteristics: minimally displaced fracture (< 2 mm), < 20% posterior wall fractures (treatment based on size of posterior wall is controversial - recommend an exam under anesthesia (EUA) using fluoroscopy best method to test stability), Femoral head congruency with weight bearing roof (out of traction) - both column fracture pattern with secondary congruence (out of traction), displaced fracture with roof arcs > 45° in AP and Judet views or >10 mm on axial CT cuts technique - Skeletal traction NOT required if stable fracture pattern, outside the weight-bearing dome - activity as tolerated with crutches/walker Weight-bearing: lowest joint reactive forces seen with toe-touch weight bearing and passive hip abduction, greatest joint contact force seen when rising from a chair on the affected extremity DVT prophylaxis if slow to mobilize Close radiographic follow-up Operative treatment open reduction and internal fixation indications - Patient factors: < 3 weeks from date of injury, physiologically stable, adequate soft-tissue envelope, no local infection, pregnancy is not contraindication to surgical fixation - Fracture factors: displacement of roof (> 2 mm), unstable fracture pattern (e.g. posterior wall fracture involving > 40-50%), marginal impaction, intra-articular loose bodies, irreducible fracture-dislocation Approaches - Anterior : ilioinguinal, iliofemoral, modified stoppa - Posterior: Kocher-Langenbach - Combined: extended ilifemoral Fixation modalities: - Column fixation strategies: reconstruction bridging plate and screws, percutaneous column screws, cable fixation - Wall fixation strategies: bridge plate and screws, lag screw and neutralization plate, spring (butress) plate outcomes timing: associated hip dislocations should be reduced within 12 hours for improved outcomes worse outcomes with fixation of fracture > 3 weeks from time of injury - earlier operative treatment associated with increased chance of anatomic reduction Peri-operative : clinical outcome correlates with quality of articular reduction Postoperative CT scan is most accurate way to determine posterior wall accuracy of reduction which has greatest correlation with clinical outcome - ideally articular reduction <2mm Post-operative greatest stress on acetabular repair occurs when rising from a seated position using the affected leg, and occurs in the posterior superior portion of the acetabulum Functional outcomes most strongly correlate with hip muscle strength and restoration of gait postoperatively Total hip arthroplasty indications usually elderly patients with significant osteopenia and/or significant comminution, pre-existing arthritis, post-traumatic arthritis in all ages techniques timing: immediate vs. delayed THA immediate THA (with, or without, fracture fixation) wall fractures : butress plate with multi-hole cup column fracture: cage and cup constructs delayed THA outcomes: patients older than 60 years have approx. a 30% late conversion rate to THA after acetabular fractures 10-year implant survival noted to be around 75-80%

Answer 62

A trimalleolar ankle fracture can be associated with syndesmosis injuries. The syndesmosis acts to maintain the relationship of the fibula in the incisura fibularis of the distal tibia as well as the congruity of the ankle joint. Failure to detect these injuries can lead to lateral talar shift and negative outcomes. So, if there was an isolated fibula fracture, the stress examination would test the deep fibers of the deltoid ligament complex. However, in this case, with fixation of the fibula, widening of the ankle joint would require an injury to the syndesmosis, as this structure would prevent it after restoration of the lateral column of the ankle (fibula). Beumer et al describe that stress radiographs may be performed by external rotation stress on the hindfoot or by providing a lateral "pull" on the distal fibula after fixation (Cotton test). Park et al showed that "ankle stress radiographs taken in dorsiflexion-external rotation were most predictive of deep deltoid ligament disruption after distal fibular fracture. Under this stress condition, a medial clear space of > or =5 mm was the most reliable predictor of deep deltoid ligament status." Ankle fracture Injury patterns: - isolated medial malleolus fracture - isolated lateral malleolus fracture - bimalleolar and bimalleolar-equivalent fractures - posterior malleolus fractures - Bosworth fracture-dislocations - open ankle fractures - associated syndesmotic injuries - isolated syndesmosis injury Anatomy Biomechanics - deltoid ligament (deep portion): primary restraint to anterolateral talar displacement - fibula: acts as buttress to prevent lateral displacement of talus Syndesmotic injury - decreased tibiofibular overlap: measure at point of maximum overlap - normal >6 mm on AP view & >1 mm on mortise view. NB it has also been reported that there is no actual correlation between syndesmotic injury and tibiofibular clear space or overlap measurements - increased medial clear space : normal ≤ 4 mm on mortise or stress view. Medial clear space of >5mm with external rotation stress applied to a dorsiflexed ankle is predictive of deep deltoid disruption - increased tibiofibular clear space : measure clear space 1 cm above joint - normal <6 mm on both AP and mortise views Lateral malleolus fractures - talocrural angle : measured by bisection of line through tibial anatomical axis and another line through the tips of the malleoli. Shortening of lateral malleoli fractures can lead to increased talocrural angle. Talocrural angle is not 100% reliable for estimating restoration of fibular length can also utilize the realignment of the medial fibular prominence with the tibiotalar joint Posterior malleolus fractures - double contour sign - misty mountains sign Lauge-Hansen based on foot position and force of applied stress/force has been shown to predict the observed (via MRI) ligamentous injury in less than 50% of operatively treated fractures: Supination - Adduction (SA): Talofibular sprain or distal fibular avulsion Vertical medial malleolus and impaction of anteromedial distal tibia Supination - External Rotation (SER): Anterior tibiofibular ligament sprain Lateral short oblique fibula fracture (anteroinferior to posterosuperior) Posterior tibiofibular ligament rupture or avulsion of posterior malleolus Medial malleolus transverse fracture or disruption of deltoid ligament Pronation - Abduction (PA): Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament sprain Transverse comminuted fracture of the fibula above the level of the syndesmosis Pronation - External Rotation (PER): Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament disruption Lateral short oblique or spiral fracture of fibula (anterosuperior to posteroinferior) above the level of the joint Posterior tibiofibular ligament rupture or avulsion of posterior malleolus Anatomic / Descriptive - isolated medial malleolar - isolated lateral malleolar - bimalleolar - trimalleolar - Bosworth fracture-dislocation (posterior dislocation of the fibula behind incisura fibularis) Danis-Weber (location of fibular fracture) A - infrasyndesmotic (generally not associated with ankle instability) B - transsyndesmotic C - suprasyndesmotic AO / ATA 44A - infrasyndesmotic 44B - transsyndesmotic 44C - suprasyndesmotic General Treatment Nonoperative - short-leg walking cast/boot indications: - isolated nondisplaced medial malleolus fracture or tip avulsions - isolated lateral malleolus fracture with < 3mm displacement and no talar shift - bimalleolar fracture if elderly or unable to undergo surgical intervention - posterior malleolar fracture with < 25% joint involvement or < 2mm step-off Operative - open reduction internal fixation indications: - any talar displacement - displaced isolated medial malleolar fracture - displaced isolated lateral malleolar fracture - bimalleolar fracture and bimalleolar-equivalent fracture - posterior malleolar fracture with > 25% or > 2mm step-off - Bosworth fracture-dislocations - open fractures - malleolar nonunions Technique: goal of treatment is stable anatomic reduction of talus in the ankle mortise - 1 mm shift of talus leads to 42% decrease in tibiotalar contact area - Overall success rate of 90% - prolonged recovery expected (2 years to obtain final functional result) significant functional impairment often noted Anatomic reduction is considered the most important factor for a satisfactory outcome Worse outcomes with: smoking, decreased education, alcohol use, presence of medial malleolar fracture ORIF superior to closed treatment of bimalleolar fractures in Lauge-Hansen supination-adduction fractures, restoration of marginal impaction of the anteromedial tibial plafond leads to optimal functional results after surgery Postoperative rehabilitation - time for proper braking response time (driving) returns to baseline at nine weeks for operatively treated ankle fractures - braking travel time is significantly increased until 6 weeks after initiation of weight bearing in both long bone and periarticular fractures of the lower extremity

Answer 63

Involvement of both columns Negative outcome factors have been shown to include: increasing patient age, time from injury to surgery (>3 weeks), intraoperative complications, femoral head bone or cartilage injury, and fracture reduction > 1-2mm from anatomic. Choice of surgical approach has not been shown to affect patient outcomes. The referenced study by Matta evaluated outcomes of displaced acetabular fractures. The overall clinical result was excellent for 104 hips (40 per cent), good for ninety-five (36 per cent), fair for twenty-one (8 per cent), and poor for forty-two (16 per cent). The clinical result was related closely to the radiographic result. These findings indicate that in many patients who have a complex acetabular fracture the hip joint can be preserved and post-traumatic osteoarthrosis can be avoided if an anatomical reduction is achieved. Acetabulum fractures can involve one or more of the two columns, two walls or roof within the pelvis Osteology acetabular inclination & ante version: mean lateral inclination of 40 to 48 degrees, anteversion of 18 to 21 degrees Column theory : acetabulum is supported by two columns of bone - form an "inverted Y". Connected to sacrum through sciatic buttress - Posterior column: comprised of quadrilateral surface, posterior wall and dome, ischial tuberosity, greater/lesser sciatic notches - anterior column: comprised of anterior ilium (gluteus medius tubercle), anterior wall and dome, iliopectineal eminence, lateral superior pubic ramus Vascular corona mortis : anastomosis of external iliac (epigastric) and internal iliac (obturator) vessels - at risk with lateral dissection over superior pubic ramus Letournel Classification Judet and Letournel: most common referenced classification system - classifed as 5 elementary and 5 associated fracture patterns Most common fracture patterns Younger : posterior wall or transverse fracture "family" (transverse, T-type, transverse + posterior wall) Elderly : anterior column (e.g., quadrilateral plate fractures), anterior column, posterior hemitransverse, assoicated both column fractures Posterior wall • Most common • "gull sign" on obturator oblique view Posterior column • check for injury to superior gluteal NV bundle Anterior wall • Very rare Anterior column • More common in elderly patients with fall from standing (most common in elderly is "anterior column + medial wall") Transverse • Axial CT shows anterior to posterior fx line • Only elementary fx to involve both columns Associated Both Column • Characterized by dissociation of the articular surface from the inonimate bone • "spur sign" on obturator oblique Transverse + Post. Wall • Most common associated fx T Shaped • May need combined approach Anterior column or wall + Post. hemitransverse • Common in elderly patients Post. column + Post. wall • Only associated fracture that does not involve both columns Treatment Nonoperative: protected weight bearing for 6-8 weeks indications: patient factors - high operative risk (e.g., elderly patients, presence of DVT), morbid obesity, open contaminated wound, late presenting > 3 weeks fracture characteristics: minimally displaced fracture (< 2 mm), < 20% posterior wall fractures (treatment based on size of posterior wall is controversial - recommend an exam under anesthesia (EUA) using fluoroscopy best method to test stability), Femoral head congruency with weight bearing roof (out of traction) - both column fracture pattern with secondary congruence (out of traction), displaced fracture with roof arcs > 45° in AP and Judet views or >10 mm on axial CT cuts technique - Skeletal traction NOT required if stable fracture pattern, outside the weight-bearing dome - activity as tolerated with crutches/walker Weight-bearing: lowest joint reactive forces seen with toe-touch weight bearing and passive hip abduction, greatest joint contact force seen when rising from a chair on the affected extremity DVT prophylaxis if slow to mobilize Close radiographic follow-up Operative treatment open reduction and internal fixation indications - Patient factors: < 3 weeks from date of injury, physiologically stable, adequate soft-tissue envelope, no local infection, pregnancy is not contraindication to surgical fixation - Fracture factors: displacement of roof (> 2 mm), unstable fracture pattern (e.g. posterior wall fracture involving > 40-50%), marginal impaction, intra-articular loose bodies, irreducible fracture-dislocation Approaches - Anterior : ilioinguinal, iliofemoral, modified stoppa - Posterior: Kocher-Langenbach - Combined: extended ilifemoral Fixation modalities: - Column fixation strategies: reconstruction bridging plate and screws, percutaneous column screws, cable fixation - Wall fixation strategies: bridge plate and screws, lag screw and neutralization plate, spring (butress) plate outcomes timing: associated hip dislocations should be reduced within 12 hours for improved outcomes worse outcomes with fixation of fracture > 3 weeks from time of injury - earlier operative treatment associated with increased chance of anatomic reduction Peri-operative : clinical outcome correlates with quality of articular reduction Postoperative CT scan is most accurate way to determine posterior wall accuracy of reduction which has greatest correlation with clinical outcome - ideally articular reduction <2mm Post-operative greatest stress on acetabular repair occurs when rising from a seated position using the affected leg, and occurs in the posterior superior portion of the acetabulum Functional outcomes most strongly correlate with hip muscle strength and restoration of gait postoperatively Total hip arthroplasty indications usually elderly patients with significant osteopenia and/or significant comminution, pre-existing arthritis, post-traumatic arthritis in all ages techniques timing: immediate vs. delayed THA immediate THA (with, or without, fracture fixation) wall fractures : butress plate with multi-hole cup column fracture: cage and cup constructs delayed THA outcomes: patients older than 60 years have approx. a 30% late conversion rate to THA after acetabular fractures

Answer 64

The superomedial fragment of an intra-articular calcaneus fracture is also referred to as the sustentacular fragment. Additionally, the flexor hallucis longus (FHL) tendon wraps inferiorly around this piece within an osseus groove. In their CT analysis of acute calcaneal fractures, Gilmer et al describe that the superomedial piece typically does not move in these fractures due to its strong ligamentous attachments to the talus. For this reason, it is commonly referred to as the "constant fragment." The superomedial fragment is important during ORIF of calcaneal fractures, because fixation from the lateral side is typically based off this "constant" fragment as a guide to provide anatomic fixation. The reference by Berberian et al also reviews the CT findings of 100 consecutive calcaneus fractures, and reports that the sustentacular fragment was displaced in forty-two of the 100 fractures. This brings into question the nature of the "constant fragment" possibly being less of a constant finding as we previously thought. Incorrect Answers: Answer 1: This fragment does not typically move due to the Achilles tendon pull. Answer 3: The fragment does not typically stay in place due to navicular attachments. Answer 4: This fragment does not typically displace in these directions. Answer 5: The posterior tibial tendon does not wrap directly inferiorly to this piece of bone. Calcaneus: Most frequent tarsal fracture 17% open fractures Pathophysiology mechanism: traumatic axial loading is the primary mechanism of injury, fall from height, motor-vehicle accidents pathoanatomy - intra-articular fractures: PRIMARY FRACTURE line results from oblique shear and leads to the following two primary fragments: 1. superomedial fragment (constant fragment): includes the sustentaculum tali and is stabilized by strong ligamentous and capsular attachments 2. superolateral fragment: includes an intra-articular aspect through the posterior facet SECONDARY FRACTURE lines dictate whether there is joint depression or tongue-type fracture - Extra-articular fractures: strong contraction of gastrocnemius-soleus with concomitant avulsion at its insertion site on calcaneus. More common in osteopenic bone - Anterior process fractures: inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament Associated injuries - extension into the calcaneocuboid joint occurs in 63% - vertebral injuries in 10% - contralateral calcaneus in 10% Prognosis poor with 40% complication rate - increased due to mechanism (fall from height), smoking, and early surgery lateral soft tissue trauma increases the rate of complication Osteology Articular facets : superolateral fragment contains the articular facets - superior articular surface contains three facets that articulate with the talus: - posterior facet is the largest and is the major weight bearing surface - the flexor hallucis longus tendon runs just inferior to it and can be injured with errant drills/screws that are too long - middle facet is anteromedial on sustentaculum tali - anterior facet is often confluent with middle facet sinus tarsi - between the middle and posterior facets lies the interosseous sulcus (calcaneal groove) that together with the talar sulcus makes up the sinus tarsi sustentaculum tali: Projects medially and supports the neck of talus - FHL passes beneath it. Deltoid and talocalcaneal ligament connect it to the talus - contained in the anteromedial fragment, which remains "constant" due to medial talocalcaneal and interosseous ligaments bifurcate ligament: connects the dorsal aspect of the anterior process to the cuboid and navicular Classification Extra-articular (25%) : avulsion injury of: anterior process (by bifurcate ligament), sustentaculum tali, calcaneal tuberosity (Achilles tendon avulsion) Intra-articular (75%) Essex-Lopresti classification: the primary fracture line runs obliquely through the posterior facet forming two fragments The secondary fracture line runs in one of two planes - the axial plane beneath the facet exiting posteriorly in tongue-type fractures - when the superolateral fragment and posterior facet remain attached to the tuberosity posteriorly - behind the posterior facet in joint depression fractures Sanders classification: based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet Sanders Classification Type I • Nondisplaced posterior facet (regardless of number of fracture lines) Type II • One fracture line in the posterior facet (two fragments) Type III • Two fracture lines in the posterior facet (three fragments) Type IV • Comminuted with more than three fracture lines in the posterior facet (four or more fragments) Complications Wound complications (10-25%) : increased risk in smokers, diabetics, and open injuries Subtalar arthritis : increased with nonoperative management Lateral impingement with peroneal irritation Damaged FHL: at risk with placement of lateral to medial screws, especially at level of sustentaculum tali (constant fragment) Compartment syndrome (10%): results in claw toes Malunion: loss of height, widening, and lateral impingement. Causes limited ankle dorsiflexion due to dorsiflexed talus with talar declination angle <20. Treatment: distraction bone block subtalar arthrodesis - indications: chronic pain from subtalar joint, incongruous subtalar joint/post-traumatic DJD, loss of calcaneal height, mechanical block to ankle dorsiflexion (results from posterior talar collapse into the posterior calcaneus). Goal is to correct : hindfoot height, ankle impingement, subfibular impingement, subtalar arthritis

Answer 65

Joint stability is critical for successful nonoperative management of posterior wall acetabular fractures. Recent evidence has established that dynamic fluoroscopic stress examination is the best method to determine joint stability in the setting of a posterior wall fracture. The obturator oblique view allows for the best evaluation of hip joint stability during examination for posterior wall fractures. Grimshaw and Moed retrospectively reviewed the results of patients with posterior wall acetabular fractures managed nonoperatively after evaluation with dynamic fluoroscopic stress tests. At two year follow up, all had good to excellent Merle d’Aubigne clinical scores for hip function and no evidence of post-traumatic hip arthritis on AP pelvis radiographs. Tornetta retrospectively reviewed his results managing patients with dynamic fluoroscopic stress examination for acetabular fractures which met radiographic nonoperative criteria. Good-to-excellent clinical results were seen in 91% of patients managed nonoperatively. Tornetta reviewed management of acetabular fractures and Tornetta and Mostafavi separately reviewed management of hip dislocations. In both articles, emphasis is placed on dynamic examination of posterior wall fractures as instability has been seen with fractures comprising as little as 15% of the posterior wall. Instability will be seen on the obturator oblique view - demonstrates that the femoral head loses congruency with the acetabular dome. Incorrect Answers: Answers 1 & 2: Posterior wall fragment size less than 40% was historically used as an indirect measure of stability, however measurements of fragment size may be unreliable and instability has been seen with fractures much smaller than 40% Answer 3: A history of hip dislocation was thought to indicate a more unstable fracture. In the level IV study by Grimshaw and Moed, patients with an associated hip dislocation who were stable under stress exam had no significant difference in outcome with nonoperative management. Answer 5: The iliac oblique view is used to evaluate the anterior wall and posterior column. Displacement or instability of the posterior wall would not be seen with this view Acetabulum fractures can involve one or more of the two columns, two walls or roof within the pelvis Osteology acetabular inclination & ante version: mean lateral inclination of 40 to 48 degrees, anteversion of 18 to 21 degrees Column theory : acetabulum is supported by two columns of bone - form an "inverted Y". Connected to sacrum through sciatic buttress - Posterior column: comprised of quadrilateral surface, posterior wall and dome, ischial tuberosity, greater/lesser sciatic notches - anterior column: comprised of anterior ilium (gluteus medius tubercle), anterior wall and dome, iliopectineal eminence, lateral superior pubic ramus Vascular corona mortis : anastomosis of external iliac (epigastric) and internal iliac (obturator) vessels - at risk with lateral dissection over superior pubic ramus Letournel Classification Judet and Letournel: most common referenced classification system - classifed as 5 elementary and 5 associated fracture patterns Most common fracture patterns Younger : posterior wall or transverse fracture "family" (transverse, T-type, transverse + posterior wall) Elderly : anterior column (e.g., quadrilateral plate fractures), anterior column, posterior hemitransverse, assoicated both column fractures Posterior wall • Most common • "gull sign" on obturator oblique view Posterior column • check for injury to superior gluteal NV bundle Anterior wall • Very rare Anterior column • More common in elderly patients with fall from standing (most common in elderly is "anterior column + medial wall") Transverse • Axial CT shows anterior to posterior fx line • Only elementary fx to involve both columns Associated Both Column • Characterized by dissociation of the articular surface from the inonimate bone • "spur sign" on obturator oblique Transverse + Post. Wall • Most common associated fx T Shaped • May need combined approach Anterior column or wall + Post. hemitransverse • Common in elderly patients Post. column + Post. wall • Only associated fracture that does not involve both columns Treatment Nonoperative: protected weight bearing for 6-8 weeks indications: patient factors - high operative risk (e.g., elderly patients, presence of DVT), morbid obesity, open contaminated wound, late presenting > 3 weeks fracture characteristics: minimally displaced fracture (< 2 mm), < 20% posterior wall fractures (treatment based on size of posterior wall is controversial - recommend an exam under anesthesia (EUA) using fluoroscopy best method to test stability), Femoral head congruency with weight bearing roof (out of traction) - both column fracture pattern with secondary congruence (out of traction), displaced fracture with roof arcs > 45° in AP and Judet views or >10 mm on axial CT cuts technique - Skeletal traction NOT required if stable fracture pattern, outside the weight-bearing dome - activity as tolerated with crutches/walker Weight-bearing: lowest joint reactive forces seen with toe-touch weight bearing and passive hip abduction, greatest joint contact force seen when rising from a chair on the affected extremity DVT prophylaxis if slow to mobilize Close radiographic follow-up Operative treatment open reduction and internal fixation indications - Patient factors: < 3 weeks from date of injury, physiologically stable, adequate soft-tissue envelope, no local infection, pregnancy is not contraindication to surgical fixation - Fracture factors: displacement of roof (> 2 mm), unstable fracture pattern (e.g. posterior wall fracture involving > 40-50%), marginal impaction, intra-articular loose bodies, irreducible fracture-dislocation Approaches - Anterior : ilioinguinal, iliofemoral, modified stoppa - Posterior: Kocher-Langenbach - Combined: extended ilifemoral Fixation modalities: - Column fixation strategies: reconstruction bridging plate and screws, percutaneous column screws, cable fixation - Wall fixation strategies: bridge plate and screws, lag screw and neutralization plate, spring (butress) plate outcomes timing: associated hip dislocations should be reduced within 12 hours for improved outcomes worse outcomes with fixation of fracture > 3 weeks from time of injury - earlier operative treatment associated with increased chance of anatomic reduction Peri-operative : clinical outcome correlates with quality of articular reduction Postoperative CT scan is most accurate way to determine posterior wall accuracy of reduction which has greatest correlation with clinical outcome - ideally articular reduction <2mm Post-operative greatest stress on acetabular repair occurs when rising from a seated position using the affected leg, and occurs in the posterior superior portion of the acetabulum Functional outcomes most strongly correlate with hip muscle strength and restoration of gait postoperatively Total hip arthroplasty indications usually elderly patients with significant osteopenia and/or significant comminution, pre-existing arthritis, post-traumatic arthritis in all ages techniques timing: immediate vs. delayed THA immediate THA (with, or without, fracture fixation) wall fractures : butress plate with multi-hole cup column fracture: cage and cup constructs delayed THA outcomes: patients older than 60 years have approx. a 30% late conversion rate to THA after acetabular fractures

Answer 66

Examination of finger abduction would be normal in a patient with an isolated superior trunk brachial plexus injury. Finger abduction is performed by the ulnar nerve, which is supplied by the inferior trunk of the brachial plexus. Superior trunk brachial plexus injuries are thought to occur secondary to traction when an athlete sustains a lateral flexion injury of the neck. Transient injuries are often referred to as "stingers" or a "burner." Symptoms of these injuries are referable to the motor and sensory functions of the axillary, musculocutaneous, and supra-scapular nerves. Hershman reviewed the etiology of brachial plexus injuries. They showed that superior trunk brachial plexus injuries are usually transient, with 95% of people regaining full neurological recovery with conservative management. Schenck showed that injuries to the superior trunk will mainly affect muscles supplied by C5 and C6, such as the deltoid, biceps brachii, brachialis, and brachioradialis muscles. Decreased sensation will occur over the lateral shoulder, lateral aspect of the upper limb, as well as the radial half of the volar forearm with these injuries. Illustration A demonstrates a lateral traction injury that can precipitate this type of superior brachial plexus injury. Illustration B shows a schematic of the brachial plexus. The nerves supplied by the superior trunk of the brachial plexus include the axillary, musculocutaneous, and supra-scapular nerves. Incorrect Answers: Answer A: Decreased sensation over the lateral aspect of shoulder = axillary nerve. Answer B: Decreased biceps reflex = C5 +/- C6 reflex arc. Answer C: Weakness to shoulder abduction = axillary nerve. Answer D: Decreased sensation over the radial aspect of the forearm = lateral antebrachial cutaneous nerve of the forearm (branch of musculocutaneous nerve). The posterior cord of the brachial plexus gives rise to the 1) upper subscapular nerve : subscapularis 2) lower subscapular nerve : teres major, subscapularis 3) thoracodorsal nerve : latissimus dorsi 4) axillary nerves : deltoid, ,teres minor 5) radial nerve. : triceps, brachioradialis, wrist extensors, finger extensors Preganglionic vs. postganglionic Preganglionic: avulsion proximal to dorsal root ganglion involves CNS which does not regenerate – little potential recovery of motor function (poor prognosis) lesions suggesting preganglionic injury: - Horner’s syndrome: disruption of sympathetic chain -> - winged scapula medially (loss of serratus anterior (long thoracic nerve), rhomboids (dorsal scapular nerve) leads to medial winging (inferior border goes medial)) - Presents with motor deficits (flail arm), sensory intact, absence of a Tinel sign or tenderness to percussion in the neck. Normal histamine test (C8-T1 sympathetic ganglion) - intact triple response (redness, wheal, flare) - Elevated hemidiaphragm (phrenic nerve - rhomboid paralysis (dorsal scapular nerve) - supraspinatus/infraspinatus (suprascapular nerve) - latissimus dorsi (thoracodorsal) - Evaluation: EMG may show loss of innervation to cervical paraspinals Postganglionic - involve PNS, capable of regeneration (better prognosis) presentation. Presents with motor deficit (flail arm) & sensory deficits - Evaluation: EMG shows maintained innervation to cervical paraspinals. Abnormal histamine test - only redness and wheal, but NO flare Classification based on location Upper Lesion: Erb's Palsy (C5,6) Most common obstetric brachial plexopathy Results from excessive displacement of head to opposite side and depression of shoulder on same side producing traction on plexus Occurs during difficult delivery in infants or fall onto shoulder in adults Best prognosis Clinically, arm will be adducted, internally rotated, at shoulder; pronated, extended at elbow (“waiter’s tip”) C5 deficiency: axillary nerve deficiency (weakness in deltoid, teres minor), suprascapular nerve deficiency (weakness in supraspinatus, infraspinatus), musculocutaneous nerve deficiency (weakness to biceps) C6 deficiency: radial nerve deficiency (weakness in brachioradialis, supinator) Lower Lesion: Klumpke Palsy (C8,T1) Rare in obstetric palsy Usually avulsion injuries caused by excessive abduction (person falling from height clutching on object to save himself) Other causes may include cervical rib, or lung mets in lower deep cervical lymph nodes Frequently associated with a preganglion injury and Horner's Syndrome Poor prognosis Deficit of all of the small muscles of the hand (ulnar and median nerves)- Clinically, presents as “claw hand” wrist held in extreme extension because of the unopposed wrist extensors hyperextension of MCP due to loss of hand intrinsics flexion of IP joints due to loss of hand intrinsics Total Palsy (C5-T1): A form of brachial plexopathy Worst prognosis Leads to a flaccid arm Involves both motor and sensory Presentation History: high energy injury Physical exam - Horner's syndrome features include drooping of the left eyelid, pupillary constriction, anhidrosis. Usually show up three days after injury. Represents disruption of sympathetic chain via C8 and/or T1 root avulsions - severe pain in anesthetized limb - correlates with root avulsion important muscles to test: serratus anterior (long thoracic nerve) and rhomboids (dorsal scapular nerve) - if they are functioning then it is more likely the C5 injury is postganglionic pulses check radial, ulnar and brachial pulses arterial injuries common with complete BPIs

Answer 67

A through-knee amputation, or knee disarticulation, is the most proximal level of amputation a child can undergo and still maintain a self-selected walking speed without significantly increasing their energy expenditure. Jeans et al. conducted a study of 73 children. They found that children with Above-knee amputations (AKA) and hip disarticulation amputations had significantly reduced walking speed and increased oxygen consumption. They also determined that children with a Syme's amputation, transtibial amputation, or knee disarticulation ambulated with approximately the same speed and oxygen consumption as did normal children in the same age group. Herbert et al. performed a study of 10 children with below knee amputations (BKA's)compared to 14 children without amputations. They found that that children with BKAs did not choose speeds different from their peers without amputations, regardless of residual limb length of the BKA. Incorrect Answers: Answer 1: Girdlestone hip resection removes the entire proximal femur and commonly is done through a lateral approach. Answer 2: Above-knee amputation is performed through the femur and attention is needed for adductor myodesis to prevent abduction deformity. Answer 4: Below-knee amputation is performed commonly 12-15cm inferior to the knee joint line. Answer 5: Chopart amputation is performed through the transverse tarsal joints and leaves the talus and calcaneus intact. Ankle/Foot Amputation: Syme amputation (ankle disarticulation) - patent tibialis posterior artery is required. More energy efficient than midfoot even though it is more proximal Stable heel pad is most important factor Used successfully to treat forefoot gangrene in diabetics Technique: medial and lateral malleoli are removed flush with distal tibia articular surface. The medial and lateral flares of the tibia and fibula are beveled to enhance heel pad adherence. Heel pad is secured to anterior tibia Pirogoff amputation (hindfoot amputation): removal of the forefoot and talus followed by calcaneotibial arthrodesis calcaneus is osteotomized and rotated 50-90 degrees to keep posterior aspect of calcaneus distal Allows patient to mobilize independently without use of prosthetic Chopart or Boyd amputation (hindfoot amputation) a partial foot amputation through the talonavicular and calcaneocuboid joints. Primary complication is equinus deformity - avoid by lengthening of the Achilles tendon and transfer of the tibialis anterior to the talar neck leads to apropulsive gait pattern because the amputation is unable to support modern dynamic elastic response prosthetic feet Lisfranc amputation (midfoot amputation) - equinovarus deformity is common caused by unopposed pull of tibialis posterior and gastroc/soleus. Prevent by maintaining insertion of peroneus brevis and performing achilles lengthening. A walking cast is generally used for 4 week to prevent late equinus contracture. Energy cost of walking similar to that of BKA Transmetatarsal amputation: more appealing to patients who refuse transtibial amputations Almost all require achilles lengthening to prevent equinus Great toe amputations: preserve 1cm at base of proximal phalanx - preserves insertion of plantar fascia, sesamoids, and flexor hallucis brevis - reduces amount of weight transfer to remaining toes so lessens risk of ulceration Metabolic cost of walking - increases with more proximal amputations perform amputations at lowest possible level to preserve function - exception: Syme amputation is more efficient than midfoot amputation - inversely proportional to length of remaining limb Ranking of metabolic demand (% represents amount of increase compared to baseline) Syme - 15% transtibial: traumatic - 25% average, short BKA - 40%, long BKA - 10%, vascular - 40% transfemoral: traumatic - 68%, vascular - 100% thru-knee amputation: varies based on patient habitus but is somewhere between transtibial and transfemoral Most proximal amputation level available in children to maintain walking speeds without increased energy expenditure compared to normal children Transfemoral Amputation: - Maintain as much length as possible, however, ideal cut is 12 cm (10-15cm) above knee joint to allow for prosthetic fitting Technique - 5-10 degrees of adduction is ideal for improved prosthesis function - adductor myodesis: improves clinical outcomes creates dynamic muscle balance (otherwise have unopposed abductors). Provides soft tissue envelope that enhances prosthetic fitting Gritti-Stokes amputation: amputation through the femur near level of adductor tubercle. Synovium is excised to prevent postoperative effusion. Patella is arthrodesed to the end of femur for improved end bearing prepatellar soft tissue is maintained without iatrogenic injury - improved outcomes as compared to transfemoral amputation ``` Wound Healing Dependent on - vascular supply - nutritional status - immune status ``` Improved with - albumin > 3.0 g/dL - ischemic index > .5 measurement of doppler pressure at level being tested compared to brachial systolic pressure - transcutaneous oxygen tension > 30 mm Hg (ideally 45 mm Hg) - toe pressure > 40 mm Hg (will not heal if < 20 mm Hg) ankle-brachial index (ABI) > 0.45 total lymphocyte count (TLC) > 1500/mm3 - Hyperbaric oxygen therapy contraindications include: chemo or radiation therapy pressure-sensitive implanted medical device (automatic implantable cardiac defibrillator, pacemaker, dorsal column stimulator, insulin pump) , undrained pneumothorax Complications - Wound healing - Contractures: adjacent joint contractures are common prevent with early aggressive mobilization and position changes - Heterotopic ossification: more common in trauma-related setting - Infection: trauma-related amputation have an infection rate of around 34% - Postamputation Neuroma : occurs in 20-30% of amputees prevent with proper nerve handling at the time of procedure. Treatment: targeted muscle rein nervation - a method of guiding neuronal regeneration to prevent or treat post-amputation neuroma pain and improve patient use of myoelectric prostheses - Phantom limb pain occurs in 53-100% of traumatic amputations mirror therapy is a noninvasive treatment modality - Bone overgrowth: most common complication with pediatric amputations. Treatment: prevent by performing disarticulation or using epihphyseal cap to cover medullary canal

Answer 68

Late correction with a corrective osteotomy of a fibular malunion associated with diastasis of the ankle mortise is an effective means of salvaging function in a joint otherwise destined to be stiff and painful. The referenced study by Offierski et al reports that the factors that determined the success of the revision were the duration of the malunion, the quality of the reduction achieved, and the condition of the articular cartilage at the time of revision. The referenced study by Chao et al reported that the fibular lengthening osteotomy was crucial in regaining the anatomy and stability of the ankle mortise. The referenced study by Weber et al is a review of the technique of such an osteotomy, with commentary regarding its clinical success even if mild degenerative changes are seen. They also note that no differences are seen in outcomes between oblique and step-cut osteotomies. The referenced study by Weber and Simpson is a case series of corrective lengthening osteotomies after malunited ankle fractures. They report that a lengthening and/or rotational osteotomy of a malunited fibula is successful in preventing further ankle arthrosis if no more than minimal degenerative radiographic changes are seen. Ankle fracture Injury patterns: - isolated medial malleolus fracture - isolated lateral malleolus fracture - bimalleolar and bimalleolar-equivalent fractures - posterior malleolus fractures - Bosworth fracture-dislocations - open ankle fractures - associated syndesmotic injuries - isolated syndesmosis injury Anatomy Biomechanics - deltoid ligament (deep portion): primary restraint to anterolateral talar displacement - fibula: acts as buttress to prevent lateral displacement of talus Syndesmotic injury - decreased tibiofibular overlap: measure at point of maximum overlap - normal >6 mm on AP view & >1 mm on mortise view. NB it has also been reported that there is no actual correlation between syndesmotic injury and tibiofibular clear space or overlap measurements - increased medial clear space : normal ≤ 4 mm on mortise or stress view. Medial clear space of >5mm with external rotation stress applied to a dorsiflexed ankle is predictive of deep deltoid disruption - increased tibiofibular clear space : measure clear space 1 cm above joint - normal <6 mm on both AP and mortise views Lateral malleolus fractures - talocrural angle : measured by bisection of line through tibial anatomical axis and another line through the tips of the malleoli. Shortening of lateral malleoli fractures can lead to increased talocrural angle. Talocrural angle is not 100% reliable for estimating restoration of fibular length can also utilize the realignment of the medial fibular prominence with the tibiotalar joint Posterior malleolus fractures - double contour sign - misty mountains sign Lauge-Hansen based on foot position and force of applied stress/force has been shown to predict the observed (via MRI) ligamentous injury in less than 50% of operatively treated fractures: Supination - Adduction (SA): Talofibular sprain or distal fibular avulsion Vertical medial malleolus and impaction of anteromedial distal tibia Supination - External Rotation (SER): Anterior tibiofibular ligament sprain Lateral short oblique fibula fracture (anteroinferior to posterosuperior) Posterior tibiofibular ligament rupture or avulsion of posterior malleolus Medial malleolus transverse fracture or disruption of deltoid ligament Pronation - Abduction (PA): Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament sprain Transverse comminuted fracture of the fibula above the level of the syndesmosis Pronation - External Rotation (PER): Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament disruption Lateral short oblique or spiral fracture of fibula (anterosuperior to posteroinferior) above the level of the joint Posterior tibiofibular ligament rupture or avulsion of posterior malleolus Anatomic / Descriptive - isolated medial malleolar - isolated lateral malleolar - bimalleolar - trimalleolar - Bosworth fracture-dislocation (posterior dislocation of the fibula behind incisura fibularis) Danis-Weber (location of fibular fracture) A - infrasyndesmotic (generally not associated with ankle instability) B - transsyndesmotic C - suprasyndesmotic AO / ATA 44A - infrasyndesmotic 44B - transsyndesmotic 44C - suprasyndesmotic General Treatment Nonoperative - short-leg walking cast/boot indications: - isolated nondisplaced medial malleolus fracture or tip avulsions - isolated lateral malleolus fracture with < 3mm displacement and no talar shift - bimalleolar fracture if elderly or unable to undergo surgical intervention - posterior malleolar fracture with < 25% joint involvement or < 2mm step-off Operative - open reduction internal fixation indications: - any talar displacement - displaced isolated medial malleolar fracture - displaced isolated lateral malleolar fracture - bimalleolar fracture and bimalleolar-equivalent fracture - posterior malleolar fracture with > 25% or > 2mm step-off - Bosworth fracture-dislocations - open fractures - malleolar nonunions Technique: goal of treatment is stable anatomic reduction of talus in the ankle mortise - 1 mm shift of talus leads to 42% decrease in tibiotalar contact area - Overall success rate of 90% - prolonged recovery expected (2 years to obtain final functional result) significant functional impairment often noted Anatomic reduction is considered the most important factor for a satisfactory outcome Worse outcomes with: smoking, decreased education, alcohol use, presence of medial malleolar fracture ORIF superior to closed treatment of bimalleolar fractures in Lauge-Hansen supination-adduction fractures, restoration of marginal impaction of the anteromedial tibial plafond leads to optimal functional results after surgery Postoperative rehabilitation - time for proper braking response time (driving) returns to baseline at nine weeks for operatively treated ankle fractures - braking travel time is significantly increased until 6 weeks after initiation of weight bearing in both long bone and periarticular fractures of the lower extremity

Answer 69

The patient described in this question has sustained an insufficiency fracture of the right acetabulum that has been neglected. Total hip arthroplasty (THA), with use of flanged and/or custom acetabular components as needed, is necessary to reconstruct the acetabulum and address the significant femoral head damage. Total hip arthroplasty as the primary treatment for acetabular fracture remains controversial. Osteopenia, pre-fracture hip arthritis and significant chondral impaction injuries make osteosynthesis difficult and more prone to failure. In the elderly patient with these injury characteristics or delayed presentation, THA may be a preferred first procedure as it can definitively address these issues. Weber et al reviewed delayed THA in acetabular fractures that had previously undergone open reduction internal fixation, and reported a 78% 10-year survival rate, with worse outcomes in patients < 50 years old, males, weight >80kg, and patients with large residual segmental acetabular defects. Jiminez et al review the the use of THA after acetabular fractures, either in a delayed or acute fashion. They note that THA as an acute treatment of acetabular fractures is rarely indicated: "Circumstances in which this may be a consideration include certain pathologic fractures, patients with pre-existing symptomatic hip arthritis who are already candidates for hip arthroplasty prior to injury, and rare instances of associated femoral side injuries, including head-splitting fractures that preclude a satisfactory operative result or significantly displaced ipsilateral femoral neck fractures." Mears reviews acute THA in osteopenic acetabular fractures, with presentation of treatment algorithms and techniques, including conservative treatment, minimally invasive fixation, conventional fixation, acute and delayed THA. Incorrect answers: Answer 1: Traction would be acceptable if the patient had an unacceptable medical risk for surgery Answer 2: Conservative treatment inappropriate unless patient not a surgical candidate for medical reasons Answer 3: Several injury factors make this choice more prone to failure (1) delayed presentation, (2) osteopenia, (3) femoral head injury, (4) medial roof impaction Answer 5: Close reduction may improve the protrusio if the fracture is still mobile but cannot address the significant chondral injury. Acetabulum fractures can involve one or more of the two columns, two walls or roof within the pelvis Osteology acetabular inclination & ante version: mean lateral inclination of 40 to 48 degrees, anteversion of 18 to 21 degrees Column theory : acetabulum is supported by two columns of bone - form an "inverted Y". Connected to sacrum through sciatic buttress - Posterior column: comprised of quadrilateral surface, posterior wall and dome, ischial tuberosity, greater/lesser sciatic notches - anterior column: comprised of anterior ilium (gluteus medius tubercle), anterior wall and dome, iliopectineal eminence, lateral superior pubic ramus Vascular corona mortis : anastomosis of external iliac (epigastric) and internal iliac (obturator) vessels - at risk with lateral dissection over superior pubic ramus Letournel Classification Judet and Letournel: most common referenced classification system - classifed as 5 elementary and 5 associated fracture patterns Most common fracture patterns Younger : posterior wall or transverse fracture "family" (transverse, T-type, transverse + posterior wall) Elderly : anterior column (e.g., quadrilateral plate fractures), anterior column, posterior hemitransverse, assoicated both column fractures Posterior wall • Most common • "gull sign" on obturator oblique view Posterior column • check for injury to superior gluteal NV bundle Anterior wall • Very rare Anterior column • More common in elderly patients with fall from standing (most common in elderly is "anterior column + medial wall") Transverse • Axial CT shows anterior to posterior fx line • Only elementary fx to involve both columns Associated Both Column • Characterized by dissociation of the articular surface from the inonimate bone • "spur sign" on obturator oblique Transverse + Post. Wall • Most common associated fx T Shaped • May need combined approach Anterior column or wall + Post. hemitransverse • Common in elderly patients Post. column + Post. wall • Only associated fracture that does not involve both columns Treatment Nonoperative: protected weight bearing for 6-8 weeks indications: patient factors - high operative risk (e.g., elderly patients, presence of DVT), morbid obesity, open contaminated wound, late presenting > 3 weeks fracture characteristics: minimally displaced fracture (< 2 mm), < 20% posterior wall fractures (treatment based on size of posterior wall is controversial - recommend an exam under anesthesia (EUA) using fluoroscopy best method to test stability), Femoral head congruency with weight bearing roof (out of traction) - both column fracture pattern with secondary congruence (out of traction), displaced fracture with roof arcs > 45° in AP and Judet views or >10 mm on axial CT cuts technique - Skeletal traction NOT required if stable fracture pattern, outside the weight-bearing dome - activity as tolerated with crutches/walker Weight-bearing: lowest joint reactive forces seen with toe-touch weight bearing and passive hip abduction, greatest joint contact force seen when rising from a chair on the affected extremity DVT prophylaxis if slow to mobilize Close radiographic follow-up Operative treatment open reduction and internal fixation indications - Patient factors: < 3 weeks from date of injury, physiologically stable, adequate soft-tissue envelope, no local infection, pregnancy is not contraindication to surgical fixation - Fracture factors: displacement of roof (> 2 mm), unstable fracture pattern (e.g. posterior wall fracture involving > 40-50%), marginal impaction, intra-articular loose bodies, irreducible fracture-dislocation Approaches - Anterior : ilioinguinal, iliofemoral, modified stoppa - Posterior: Kocher-Langenbach - Combined: extended ilifemoral Fixation modalities: - Column fixation strategies: reconstruction bridging plate and screws, percutaneous column screws, cable fixation - Wall fixation strategies: bridge plate and screws, lag screw and neutralization plate, spring (butress) plate outcomes timing: associated hip dislocations should be reduced within 12 hours for improved outcomes worse outcomes with fixation of fracture > 3 weeks from time of injury - earlier operative treatment associated with increased chance of anatomic reduction Peri-operative : clinical outcome correlates with quality of articular reduction Postoperative CT scan is most accurate way to determine posterior wall accuracy of reduction which has greatest correlation with clinical outcome - ideally articular reduction <2mm Post-operative greatest stress on acetabular repair occurs when rising from a seated position using the affected leg, and occurs in the posterior superior portion of the acetabulum Functional outcomes most strongly correlate with hip muscle strength and restoration of gait postoperatively Total hip arthroplasty indications usually elderly patients with significant osteopenia and/or significant comminution, pre-existing arthritis, post-traumatic arthritis in all ages techniques timing: immediate vs. delayed THA immediate THA (with, or without, fracture fixation) wall fractures : butress plate with multi-hole cup column fracture: cage and cup constructs delayed THA outcomes: patients older than 60 years have approx. a 30% late conversion rate to THA after acetabular fractures

Answer 70

CT scanning is indicated in acetabular fractures for determination of surgical approach and techniques, evaluation of marginal impaction and presence of intra-articular loose bodies (especially after hip dislocation), and evaluation of fracture piece sizes and relative positions. Kellam et al reviewed their initial experience with CT scanning and acetabular fractures, and noted a 25% change in surgical planning when CT was utilized versus plain radiographs; they also noted the ability to detect marginal impaction and fracture size/position was improved with CT. Acetabulum fractures can involve one or more of the two columns, two walls or roof within the pelvis Osteology acetabular inclination & ante version: mean lateral inclination of 40 to 48 degrees, anteversion of 18 to 21 degrees Column theory : acetabulum is supported by two columns of bone - form an "inverted Y". Connected to sacrum through sciatic buttress - Posterior column: comprised of quadrilateral surface, posterior wall and dome, ischial tuberosity, greater/lesser sciatic notches - anterior column: comprised of anterior ilium (gluteus medius tubercle), anterior wall and dome, iliopectineal eminence, lateral superior pubic ramus Vascular corona mortis : anastomosis of external iliac (epigastric) and internal iliac (obturator) vessels - at risk with lateral dissection over superior pubic ramus Letournel Classification Judet and Letournel: most common referenced classification system - classifed as 5 elementary and 5 associated fracture patterns Most common fracture patterns Younger : posterior wall or transverse fracture "family" (transverse, T-type, transverse + posterior wall) Elderly : anterior column (e.g., quadrilateral plate fractures), anterior column, posterior hemitransverse, assoicated both column fractures Posterior wall • Most common • "gull sign" on obturator oblique view Posterior column • check for injury to superior gluteal NV bundle Anterior wall • Very rare Anterior column • More common in elderly patients with fall from standing (most common in elderly is "anterior column + medial wall") Transverse • Axial CT shows anterior to posterior fx line • Only elementary fx to involve both columns Associated Both Column • Characterized by dissociation of the articular surface from the inonimate bone • "spur sign" on obturator oblique Transverse + Post. Wall • Most common associated fx T Shaped • May need combined approach Anterior column or wall + Post. hemitransverse • Common in elderly patients Post. column + Post. wall • Only associated fracture that does not involve both columns Treatment Nonoperative: protected weight bearing for 6-8 weeks indications: patient factors - high operative risk (e.g., elderly patients, presence of DVT), morbid obesity, open contaminated wound, late presenting > 3 weeks fracture characteristics: minimally displaced fracture (< 2 mm), < 20% posterior wall fractures (treatment based on size of posterior wall is controversial - recommend an exam under anesthesia (EUA) using fluoroscopy best method to test stability), Femoral head congruency with weight bearing roof (out of traction) - both column fracture pattern with secondary congruence (out of traction), displaced fracture with roof arcs > 45° in AP and Judet views or >10 mm on axial CT cuts technique - Skeletal traction NOT required if stable fracture pattern, outside the weight-bearing dome - activity as tolerated with crutches/walker Weight-bearing: lowest joint reactive forces seen with toe-touch weight bearing and passive hip abduction, greatest joint contact force seen when rising from a chair on the affected extremity DVT prophylaxis if slow to mobilize Close radiographic follow-up Operative treatment open reduction and internal fixation indications - Patient factors: < 3 weeks from date of injury, physiologically stable, adequate soft-tissue envelope, no local infection, pregnancy is not contraindication to surgical fixation - Fracture factors: displacement of roof (> 2 mm), unstable fracture pattern (e.g. posterior wall fracture involving > 40-50%), marginal impaction, intra-articular loose bodies, irreducible fracture-dislocation Approaches - Anterior : ilioinguinal, iliofemoral, modified stoppa - Posterior: Kocher-Langenbach - Combined: extended ilifemoral Fixation modalities: - Column fixation strategies: reconstruction bridging plate and screws, percutaneous column screws, cable fixation - Wall fixation strategies: bridge plate and screws, lag screw and neutralization plate, spring (butress) plate outcomes timing: associated hip dislocations should be reduced within 12 hours for improved outcomes worse outcomes with fixation of fracture > 3 weeks from time of injury - earlier operative treatment associated with increased chance of anatomic reduction Peri-operative : clinical outcome correlates with quality of articular reduction Postoperative CT scan is most accurate way to determine posterior wall accuracy of reduction which has greatest correlation with clinical outcome - ideally articular reduction <2mm Post-operative greatest stress on acetabular repair occurs when rising from a seated position using the affected leg, and occurs in the posterior superior portion of the acetabulum Functional outcomes most strongly correlate with hip muscle strength and restoration of gait postoperatively Total hip arthroplasty indications usually elderly patients with significant osteopenia and/or significant comminution, pre-existing arthritis, post-traumatic arthritis in all ages techniques timing: immediate vs. delayed THA immediate THA (with, or without, fracture fixation) wall fractures : butress plate with multi-hole cup column fracture: cage and cup constructs delayed THA outcomes: patients older than 60 years have approx. a 30% late conversion rate to THA after acetabular fractures

Answer 71

Letournel and Judet developed a schematic representation of the acetabulum as being contained within asymmetric long anterior and short posterior arms of an inverted “Y”. On the bony pelvis, the ilioischial component becomes that posterior column and the iliopectineal line becomes the anterior column. The Judet-Letournel classification system is based on this scheme. By careful evaluation of landmarks on a standard AP pelvis radiograph, as well as on 45-degree oblique obturator and iliac views, the extent of injury can be determined accurately. The AP view usually demonstrates the six fundamental landmarks relatively well. The obturator oblique view reveals additional information about the anterior column and posterior wall. In an obturator oblique view the x-ray beam is centered on and almost perpendicular to the obturator foramen. The iliac oblique view visualizes the posterior column and anterior wall. This view also shows the best detail of the iliac wing as the radiographic beam is roughly perpendicular to the iliac wing. Inclusion of the opposite hip is essential for evaluation of symmetrical contours that may have slight individual variations and to evaluate the width of the normal articular cartilage in each view in a pelvic series (AP, Judet's) . Acetabulum fractures can involve one or more of the two columns, two walls or roof within the pelvis Osteology acetabular inclination & ante version: mean lateral inclination of 40 to 48 degrees, anteversion of 18 to 21 degrees Column theory : acetabulum is supported by two columns of bone - form an "inverted Y". Connected to sacrum through sciatic buttress - Posterior column: comprised of quadrilateral surface, posterior wall and dome, ischial tuberosity, greater/lesser sciatic notches - anterior column: comprised of anterior ilium (gluteus medius tubercle), anterior wall and dome, iliopectineal eminence, lateral superior pubic ramus Vascular corona mortis : anastomosis of external iliac (epigastric) and internal iliac (obturator) vessels - at risk with lateral dissection over superior pubic ramus Letournel Classification Judet and Letournel: most common referenced classification system - classifed as 5 elementary and 5 associated fracture patterns Most common fracture patterns Younger : posterior wall or transverse fracture "family" (transverse, T-type, transverse + posterior wall) Elderly : anterior column (e.g., quadrilateral plate fractures), anterior column, posterior hemitransverse, assoicated both column fractures Posterior wall • Most common • "gull sign" on obturator oblique view Posterior column • check for injury to superior gluteal NV bundle Anterior wall • Very rare Anterior column • More common in elderly patients with fall from standing (most common in elderly is "anterior column + medial wall") Transverse • Axial CT shows anterior to posterior fx line • Only elementary fx to involve both columns Associated Both Column • Characterized by dissociation of the articular surface from the inonimate bone • "spur sign" on obturator oblique Transverse + Post. Wall • Most common associated fx T Shaped • May need combined approach Anterior column or wall + Post. hemitransverse • Common in elderly patients Post. column + Post. wall • Only associated fracture that does not involve both columns Treatment Nonoperative: protected weight bearing for 6-8 weeks indications: patient factors - high operative risk (e.g., elderly patients, presence of DVT), morbid obesity, open contaminated wound, late presenting > 3 weeks fracture characteristics: minimally displaced fracture (< 2 mm), < 20% posterior wall fractures (treatment based on size of posterior wall is controversial - recommend an exam under anesthesia (EUA) using fluoroscopy best method to test stability), Femoral head congruency with weight bearing roof (out of traction) - both column fracture pattern with secondary congruence (out of traction), displaced fracture with roof arcs > 45° in AP and Judet views or >10 mm on axial CT cuts technique - Skeletal traction NOT required if stable fracture pattern, outside the weight-bearing dome - activity as tolerated with crutches/walker Weight-bearing: lowest joint reactive forces seen with toe-touch weight bearing and passive hip abduction, greatest joint contact force seen when rising from a chair on the affected extremity DVT prophylaxis if slow to mobilize Close radiographic follow-up Operative treatment open reduction and internal fixation indications - Patient factors: < 3 weeks from date of injury, physiologically stable, adequate soft-tissue envelope, no local infection, pregnancy is not contraindication to surgical fixation - Fracture factors: displacement of roof (> 2 mm), unstable fracture pattern (e.g. posterior wall fracture involving > 40-50%), marginal impaction, intra-articular loose bodies, irreducible fracture-dislocation Approaches - Anterior : ilioinguinal, iliofemoral, modified stoppa - Posterior: Kocher-Langenbach - Combined: extended ilifemoral Fixation modalities: - Column fixation strategies: reconstruction bridging plate and screws, percutaneous column screws, cable fixation - Wall fixation strategies: bridge plate and screws, lag screw and neutralization plate, spring (butress) plate outcomes timing: associated hip dislocations should be reduced within 12 hours for improved outcomes worse outcomes with fixation of fracture > 3 weeks from time of injury - earlier operative treatment associated with increased chance of anatomic reduction Peri-operative : clinical outcome correlates with quality of articular reduction Postoperative CT scan is most accurate way to determine posterior wall accuracy of reduction which has greatest correlation with clinical outcome - ideally articular reduction <2mm Post-operative greatest stress on acetabular repair occurs when rising from a seated position using the affected leg, and occurs in the posterior superior portion of the acetabulum Functional outcomes most strongly correlate with hip muscle strength and restoration of gait postoperatively Total hip arthroplasty indications usually elderly patients with significant osteopenia and/or significant comminution, pre-existing arthritis, post-traumatic arthritis in all ages techniques timing: immediate vs. delayed THA immediate THA (with, or without, fracture fixation) wall fractures : butress plate with multi-hole cup column fracture: cage and cup constructs delayed THA outcomes: patients older than 60 years have approx. a 30% late conversion rate to THA after acetabular fractures

Answer 72

The obturator oblique-inlet view best demonstrates the position of a supra-acetabular screw or pin relative to the tables of the ilium. Starr et al review their initial results and technique of closed or limited open reduction and percutaneous fixation of acetabular fractures. They defined two groups of patients who may benefit from this technique; elderly patients with multiple comorbidities to facilitate early mobilization and restore hip morphology, and young patients with elementary fracture patterns and multiple associated injuries. Starr et al describe their operative technique and outcomes for a case series of 3 patients using percutaneous acetabular fixation to augment open reduction of acetabular fractures. The authors state that, for placement of an anterior colum ramus screw, an iliac oblique-inlet (not obturator oblique-inlet) will ensure that the screw is within the medullary canal of the ramus and does not exit anterior or posterior. Gardner and Nork describe a technique for placement of a large femoral distractor in the supra-acetabular region to compress displaced posterior pelvic ring injuries. They note that the obturator oblique-inlet view is necessary to view the entire length of the pin as well as to ensure that pin remains in bone. Incorrect answers: Answer 1: Relationshiop of the screw to the acetabulum is best evaluated with the obturator oblique-outlet view as well as the iliac oblique view Answer 2: The iliac oblique view is used to ensure the trajectory of the screw is superior to the sciatic notch Answer 3: The Obturator oblique-outlet view, otherwise known as the "teepee" or "tear drop" view, is used to identify the start for supra-acetabular implant placement Answer 4: The gluteal pillar is not utilized as a start point when placing supraacetabular fixation, and the obturator oblique-inlet view would not be ideal to visualize this region of the pelvis Acetabulum fractures can involve one or more of the two columns, two walls or roof within the pelvis Osteology acetabular inclination & ante version: mean lateral inclination of 40 to 48 degrees, anteversion of 18 to 21 degrees Column theory : acetabulum is supported by two columns of bone - form an "inverted Y". Connected to sacrum through sciatic buttress - Posterior column: comprised of quadrilateral surface, posterior wall and dome, ischial tuberosity, greater/lesser sciatic notches - anterior column: comprised of anterior ilium (gluteus medius tubercle), anterior wall and dome, iliopectineal eminence, lateral superior pubic ramus Vascular corona mortis : anastomosis of external iliac (epigastric) and internal iliac (obturator) vessels - at risk with lateral dissection over superior pubic ramus Letournel Classification Judet and Letournel: most common referenced classification system - classifed as 5 elementary and 5 associated fracture patterns Most common fracture patterns Younger : posterior wall or transverse fracture "family" (transverse, T-type, transverse + posterior wall) Elderly : anterior column (e.g., quadrilateral plate fractures), anterior column, posterior hemitransverse, assoicated both column fractures Posterior wall • Most common • "gull sign" on obturator oblique view Posterior column • check for injury to superior gluteal NV bundle Anterior wall • Very rare Anterior column • More common in elderly patients with fall from standing (most common in elderly is "anterior column + medial wall") Transverse • Axial CT shows anterior to posterior fx line • Only elementary fx to involve both columns Associated Both Column • Characterized by dissociation of the articular surface from the inonimate bone • "spur sign" on obturator oblique Transverse + Post. Wall • Most common associated fx T Shaped • May need combined approach Anterior column or wall + Post. hemitransverse • Common in elderly patients Post. column + Post. wall • Only associated fracture that does not involve both columns Treatment Nonoperative: protected weight bearing for 6-8 weeks indications: patient factors - high operative risk (e.g., elderly patients, presence of DVT), morbid obesity, open contaminated wound, late presenting > 3 weeks fracture characteristics: minimally displaced fracture (< 2 mm), < 20% posterior wall fractures (treatment based on size of posterior wall is controversial - recommend an exam under anesthesia (EUA) using fluoroscopy best method to test stability), Femoral head congruency with weight bearing roof (out of traction) - both column fracture pattern with secondary congruence (out of traction), displaced fracture with roof arcs > 45° in AP and Judet views or >10 mm on axial CT cuts technique - Skeletal traction NOT required if stable fracture pattern, outside the weight-bearing dome - activity as tolerated with crutches/walker Weight-bearing: lowest joint reactive forces seen with toe-touch weight bearing and passive hip abduction, greatest joint contact force seen when rising from a chair on the affected extremity DVT prophylaxis if slow to mobilize Close radiographic follow-up Operative treatment open reduction and internal fixation indications - Patient factors: < 3 weeks from date of injury, physiologically stable, adequate soft-tissue envelope, no local infection, pregnancy is not contraindication to surgical fixation - Fracture factors: displacement of roof (> 2 mm), unstable fracture pattern (e.g. posterior wall fracture involving > 40-50%), marginal impaction, intra-articular loose bodies, irreducible fracture-dislocation Approaches - Anterior : ilioinguinal, iliofemoral, modified stoppa - Posterior: Kocher-Langenbach - Combined: extended ilifemoral Fixation modalities: - Column fixation strategies: reconstruction bridging plate and screws, percutaneous column screws, cable fixation - Wall fixation strategies: bridge plate and screws, lag screw and neutralization plate, spring (butress) plate outcomes timing: associated hip dislocations should be reduced within 12 hours for improved outcomes worse outcomes with fixation of fracture > 3 weeks from time of injury - earlier operative treatment associated with increased chance of anatomic reduction Peri-operative : clinical outcome correlates with quality of articular reduction Postoperative CT scan is most accurate way to determine posterior wall accuracy of reduction which has greatest correlation with clinical outcome - ideally articular reduction <2mm Post-operative greatest stress on acetabular repair occurs when rising from a seated position using the affected leg, and occurs in the posterior superior portion of the acetabulum Functional outcomes most strongly correlate with hip muscle strength and restoration of gait postoperatively Total hip arthroplasty indications usually elderly patients with significant osteopenia and/or significant comminution, pre-existing arthritis, post-traumatic arthritis in all ages techniques timing: immediate vs. delayed THA immediate THA (with, or without, fracture fixation) wall fractures : butress plate with multi-hole cup column fracture: cage and cup constructs delayed THA outcomes: patients older than 60 years have approx. a 30% late conversion rate to THA after acetabular fractures

Answer 73

This patient requires revision open reduction and internal fixation of her syndesmosis as post-operative radiographs demonstrate a severely malaligned ankle with obvious syndesmosis widening and fibular shortening. Malalignment following ankle fracture fixation can alter the anatomical axis of the joint, articular congruency, and normal load distribution. This predisposes the patient to the development of chronic pain, functional impairment, and finally early post-traumatic ankle arthritis. Marti et al. retrospectively reviewed the outcomes of 31 patients with malunited ankle fractures who underwent reconstructive osteotomies. The authors found that reconstruction resulted in good or excellent results in the majority of patients. They also note that minor post-traumatic arthritis was not a contraindication to reconstruction. Ramsey et al. evaluated 23 cadaveric ankles using a carbon black transference technique to determine the contact area in the dissected tibiotalar articulations, with the talus in neutral position and displaced one, two, four, and six millimeters laterally. They found that 1 mm of lateral talar displacement resulted in a 42% decrease in tibiotalar contact area. Figure A is a x-ray demonstrating severe malalignment of a bimalleolar ankle fracture following fixation of the fibula and medial malleolus. There is obvious shortening of the fibula and lateral shift and valgus tilt of the talus associated with a disrupted syndesmosis. Incorrect Answers: Answer 1 & 2: Physical therapy and short leg bracing are not indicated at this point as the anatomical malalignment needs to first be addressed via revision surgery. Answer 4: The addition of a syndesmosis screw will not successfully reduce the syndesmosis as it has been chronically malreduced and will require open reduction and debridement prior to syndesmosis screw fixation. Answer 5: Open medial ankle ligament reconstruction is insufficient in isolation to provide mechanical stability to the ankle fractures with syndesmosis disruption. Ankle fracture Injury patterns: - isolated medial malleolus fracture - isolated lateral malleolus fracture - bimalleolar and bimalleolar-equivalent fractures - posterior malleolus fractures - Bosworth fracture-dislocations - open ankle fractures - associated syndesmotic injuries - isolated syndesmosis injury Anatomy Biomechanics - deltoid ligament (deep portion): primary restraint to anterolateral talar displacement - fibula: acts as buttress to prevent lateral displacement of talus Syndesmotic injury - decreased tibiofibular overlap: measure at point of maximum overlap - normal >6 mm on AP view & >1 mm on mortise view. NB it has also been reported that there is no actual correlation between syndesmotic injury and tibiofibular clear space or overlap measurements - increased medial clear space : normal ≤ 4 mm on mortise or stress view. Medial clear space of >5mm with external rotation stress applied to a dorsiflexed ankle is predictive of deep deltoid disruption - increased tibiofibular clear space : measure clear space 1 cm above joint - normal <6 mm on both AP and mortise views Lateral malleolus fractures - talocrural angle : measured by bisection of line through tibial anatomical axis and another line through the tips of the malleoli. Shortening of lateral malleoli fractures can lead to increased talocrural angle. Talocrural angle is not 100% reliable for estimating restoration of fibular length can also utilize the realignment of the medial fibular prominence with the tibiotalar joint Posterior malleolus fractures - double contour sign - misty mountains sign Lauge-Hansen based on foot position and force of applied stress/force has been shown to predict the observed (via MRI) ligamentous injury in less than 50% of operatively treated fractures: Supination - Adduction (SA): Talofibular sprain or distal fibular avulsion Vertical medial malleolus and impaction of anteromedial distal tibia Supination - External Rotation (SER): Anterior tibiofibular ligament sprain Lateral short oblique fibula fracture (anteroinferior to posterosuperior) Posterior tibiofibular ligament rupture or avulsion of posterior malleolus Medial malleolus transverse fracture or disruption of deltoid ligament Pronation - Abduction (PA): Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament sprain Transverse comminuted fracture of the fibula above the level of the syndesmosis Pronation - External Rotation (PER): Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament disruption Lateral short oblique or spiral fracture of fibula (anterosuperior to posteroinferior) above the level of the joint Posterior tibiofibular ligament rupture or avulsion of posterior malleolus Anatomic / Descriptive - isolated medial malleolar - isolated lateral malleolar - bimalleolar - trimalleolar - Bosworth fracture-dislocation (posterior dislocation of the fibula behind incisura fibularis) Danis-Weber (location of fibular fracture) A - infrasyndesmotic (generally not associated with ankle instability) B - transsyndesmotic C - suprasyndesmotic AO / ATA 44A - infrasyndesmotic 44B - transsyndesmotic 44C - suprasyndesmotic General Treatment Nonoperative - short-leg walking cast/boot indications: - isolated nondisplaced medial malleolus fracture or tip avulsions - isolated lateral malleolus fracture with < 3mm displacement and no talar shift - bimalleolar fracture if elderly or unable to undergo surgical intervention - posterior malleolar fracture with < 25% joint involvement or < 2mm step-off Operative - open reduction internal fixation indications: - any talar displacement - displaced isolated medial malleolar fracture - displaced isolated lateral malleolar fracture - bimalleolar fracture and bimalleolar-equivalent fracture - posterior malleolar fracture with > 25% or > 2mm step-off - Bosworth fracture-dislocations - open fractures - malleolar nonunions Technique: goal of treatment is stable anatomic reduction of talus in the ankle mortise - 1 mm shift of talus leads to 42% decrease in tibiotalar contact area - Overall success rate of 90% - prolonged recovery expected (2 years to obtain final functional result) significant functional impairment often noted Anatomic reduction is considered the most important factor for a satisfactory outcome Worse outcomes with: smoking, decreased education, alcohol use, presence of medial malleolar fracture ORIF superior to closed treatment of bimalleolar fractures in Lauge-Hansen supination-adduction fractures, restoration of marginal impaction of the anteromedial tibial plafond leads to optimal functional results after surgery Postoperative rehabilitation - time for proper braking response time (driving) returns to baseline at nine weeks for operatively treated ankle fractures - braking travel time is significantly increased until 6 weeks after initiation of weight bearing in both long bone and periarticular fractures of the lower extremity

Answer 74

Contracture of the intrinsic flexor muscles of the foot can be the result of unrecognized foot compartment syndrome. Foot compartment syndrome is a known complication of calcaneus fractures. Myerson reported 3/43 patients in his series below had chronic foot compartment syndrome. There are 9 compartments in the foot: (1) medial, (2) superficial, (3) lateral, (4) adductor, (5-8) four interossei, and (9) calcaneal. The plantar fascia limits the space available for hematoma and swelling, causing damage to the intrinsic flexors of the foot (particularly the lumbricals and interossei), resulting in clawtoes. Calcaneus: Most frequent tarsal fracture 17% open fractures Pathophysiology mechanism: traumatic axial loading is the primary mechanism of injury, fall from height, motor-vehicle accidents pathoanatomy - intra-articular fractures: PRIMARY FRACTURE line results from oblique shear and leads to the following two primary fragments: 1. superomedial fragment (constant fragment): includes the sustentaculum tali and is stabilized by strong ligamentous and capsular attachments 2. superolateral fragment: includes an intra-articular aspect through the posterior facet SECONDARY FRACTURE lines dictate whether there is joint depression or tongue-type fracture - Extra-articular fractures: strong contraction of gastrocnemius-soleus with concomitant avulsion at its insertion site on calcaneus. More common in osteopenic bone - Anterior process fractures: inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament Associated injuries - extension into the calcaneocuboid joint occurs in 63% - vertebral injuries in 10% - contralateral calcaneus in 10% Prognosis poor with 40% complication rate - increased due to mechanism (fall from height), smoking, and early surgery lateral soft tissue trauma increases the rate of complication Osteology Articular facets : superolateral fragment contains the articular facets - superior articular surface contains three facets that articulate with the talus: - posterior facet is the largest and is the major weight bearing surface - the flexor hallucis longus tendon runs just inferior to it and can be injured with errant drills/screws that are too long - middle facet is anteromedial on sustentaculum tali - anterior facet is often confluent with middle facet sinus tarsi - between the middle and posterior facets lies the interosseous sulcus (calcaneal groove) that together with the talar sulcus makes up the sinus tarsi sustentaculum tali: Projects medially and supports the neck of talus - FHL passes beneath it. Deltoid and talocalcaneal ligament connect it to the talus - contained in the anteromedial fragment, which remains "constant" due to medial talocalcaneal and interosseous ligaments bifurcate ligament: connects the dorsal aspect of the anterior process to the cuboid and navicular Classification Extra-articular (25%) : avulsion injury of: anterior process (by bifurcate ligament), sustentaculum tali, calcaneal tuberosity (Achilles tendon avulsion) Intra-articular (75%) Essex-Lopresti classification: the primary fracture line runs obliquely through the posterior facet forming two fragments The secondary fracture line runs in one of two planes - the axial plane beneath the facet exiting posteriorly in tongue-type fractures - when the superolateral fragment and posterior facet remain attached to the tuberosity posteriorly - behind the posterior facet in joint depression fractures Sanders classification: based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet Sanders Classification Type I • Nondisplaced posterior facet (regardless of number of fracture lines) Type II • One fracture line in the posterior facet (two fragments) Type III • Two fracture lines in the posterior facet (three fragments) Type IV • Comminuted with more than three fracture lines in the posterior facet (four or more fragments) Complications Wound complications (10-25%) : increased risk in smokers, diabetics, and open injuries Subtalar arthritis : increased with nonoperative management Lateral impingement with peroneal irritation Damaged FHL: at risk with placement of lateral to medial screws, especially at level of sustentaculum tali (constant fragment) Compartment syndrome (10%): results in claw toes Malunion: loss of height, widening, and lateral impingement. Causes limited ankle dorsiflexion due to dorsiflexed talus with talar declination angle <20. Treatment: distraction bone block subtalar arthrodesis - indications: chronic pain from subtalar joint, incongruous subtalar joint/post-traumatic DJD, loss of calcaneal height, mechanical block to ankle dorsiflexion (results from posterior talar collapse into the posterior calcaneus). Goal is to correct : hindfoot height, ankle impingement, subfibular impingement, subtalar arthritis

Answer 75

During the Kocher-Langenbeck approach, the sciatic nerve is at the least amount of tension with the hip extended and the knee flexed to 90 degrees. The CT exhibits a posterior wall acetabular fracture, which is fixed via a Kocher-Langenbeck approach. The sciatic nerve, which comes out of the greater sciatic notch, is at the least amount of tension with the hip extended and knee flexed to 90 degrees. Borrelli et al examined the intraneural pressure of the sciatic nerve with the hip and knee in various different positions. The authors noted that the highest tension was placed on the sciatic nerve when the hip was flexed to 90 degrees and the knee was fully extended. As a result, the leg is typically position with the hip in extension (or minimal flexion) and the knee in about 90 degrees of flexion when performing acetabular surgery via a posterior approach. Figure A shows an axial pelvic CT cut with a posterior wall acetabular fracture. Incorrect answers: Answer 1,2,3,5: With any degree of hip flexion, it places tension on the sciatic nerve, answer 4 (hip flex to 90 and knee fully extended), specifically places the highest amount of intraneural pressure on the nerve. Acetabulum fractures can involve one or more of the two columns, two walls or roof within the pelvis Osteology acetabular inclination & ante version: mean lateral inclination of 40 to 48 degrees, anteversion of 18 to 21 degrees Column theory : acetabulum is supported by two columns of bone - form an "inverted Y". Connected to sacrum through sciatic buttress - Posterior column: comprised of quadrilateral surface, posterior wall and dome, ischial tuberosity, greater/lesser sciatic notches - anterior column: comprised of anterior ilium (gluteus medius tubercle), anterior wall and dome, iliopectineal eminence, lateral superior pubic ramus Vascular corona mortis : anastomosis of external iliac (epigastric) and internal iliac (obturator) vessels - at risk with lateral dissection over superior pubic ramus Letournel Classification Judet and Letournel: most common referenced classification system - classifed as 5 elementary and 5 associated fracture patterns Most common fracture patterns Younger : posterior wall or transverse fracture "family" (transverse, T-type, transverse + posterior wall) Elderly : anterior column (e.g., quadrilateral plate fractures), anterior column, posterior hemitransverse, assoicated both column fractures Posterior wall • Most common • "gull sign" on obturator oblique view Posterior column • check for injury to superior gluteal NV bundle Anterior wall • Very rare Anterior column • More common in elderly patients with fall from standing (most common in elderly is "anterior column + medial wall") Transverse • Axial CT shows anterior to posterior fx line • Only elementary fx to involve both columns Associated Both Column • Characterized by dissociation of the articular surface from the inonimate bone • "spur sign" on obturator oblique Transverse + Post. Wall • Most common associated fx T Shaped • May need combined approach Anterior column or wall + Post. hemitransverse • Common in elderly patients Post. column + Post. wall • Only associated fracture that does not involve both columns Treatment Nonoperative: protected weight bearing for 6-8 weeks indications: patient factors - high operative risk (e.g., elderly patients, presence of DVT), morbid obesity, open contaminated wound, late presenting > 3 weeks fracture characteristics: minimally displaced fracture (< 2 mm), < 20% posterior wall fractures (treatment based on size of posterior wall is controversial - recommend an exam under anesthesia (EUA) using fluoroscopy best method to test stability), Femoral head congruency with weight bearing roof (out of traction) - both column fracture pattern with secondary congruence (out of traction), displaced fracture with roof arcs > 45° in AP and Judet views or >10 mm on axial CT cuts technique - Skeletal traction NOT required if stable fracture pattern, outside the weight-bearing dome - activity as tolerated with crutches/walker Weight-bearing: lowest joint reactive forces seen with toe-touch weight bearing and passive hip abduction, greatest joint contact force seen when rising from a chair on the affected extremity DVT prophylaxis if slow to mobilize Close radiographic follow-up Operative treatment open reduction and internal fixation indications - Patient factors: < 3 weeks from date of injury, physiologically stable, adequate soft-tissue envelope, no local infection, pregnancy is not contraindication to surgical fixation - Fracture factors: displacement of roof (> 2 mm), unstable fracture pattern (e.g. posterior wall fracture involving > 40-50%), marginal impaction, intra-articular loose bodies, irreducible fracture-dislocation Approaches - Anterior : ilioinguinal, iliofemoral, modified stoppa - Posterior: Kocher-Langenbach - Combined: extended ilifemoral Fixation modalities: - Column fixation strategies: reconstruction bridging plate and screws, percutaneous column screws, cable fixation - Wall fixation strategies: bridge plate and screws, lag screw and neutralization plate, spring (butress) plate outcomes timing: associated hip dislocations should be reduced within 12 hours for improved outcomes worse outcomes with fixation of fracture > 3 weeks from time of injury - earlier operative treatment associated with increased chance of anatomic reduction Peri-operative : clinical outcome correlates with quality of articular reduction Postoperative CT scan is most accurate way to determine posterior wall accuracy of reduction which has greatest correlation with clinical outcome - ideally articular reduction <2mm Post-operative greatest stress on acetabular repair occurs when rising from a seated position using the affected leg, and occurs in the posterior superior portion of the acetabulum Functional outcomes most strongly correlate with hip muscle strength and restoration of gait postoperatively Total hip arthroplasty indications usually elderly patients with significant osteopenia and/or significant comminution, pre-existing arthritis, post-traumatic arthritis in all ages techniques timing: immediate vs. delayed THA immediate THA (with, or without, fracture fixation) wall fractures : butress plate with multi-hole cup column fracture: cage and cup constructs delayed THA outcomes: patients older than 60 years have approx. a 30% late conversion rate to THA after acetabular fractures

Answer 76

The presence of a crush injury to an extremity is an indication for hyperbaric oxygen (HBO) therapy. The remainder of the options listed are contraindications to hyperbaric oxygen treatment. Hyperbaric oxygen therapy potentially can provide enhanced oxygen delivery to peripheral tissues affected by vascular disruption, cytogenic and vasogenic edema, and cellular hypoxia caused by extremity trauma. The idea behind HBO is to provide enhanced oxygen delivery to peripheral tissues affected by vascular disruption, cytogenic and vasogenic edema, and cellular hypoxia caused by extremity trauma. Greensmith et al provide a review of HBO therapy and discuss the relative and absolute contraindications and indications for this treatment. They report in patients with crush injury or early compartment syndrome, hyperbaric oxygen therapy may reduce the penumbra of cells at risk for delayed necrosis and secondary ischemia. They report that both animal studies and prospective human clinical trials suggest the benefits of such therapy. Buettner et al found that based on clinical evidence and cost analysis, medical institutions that treat open fractures and crush injuries are justified in incorporating HBO theray as a standard of care. Incorrect Answers: Answer 2: COPD is a contraindication to hyperbaric oxygen treatment due to the possible presence of air trapping or bleb formation, which could place the patient at risk of pneumothorax. Answer 3: History of bleomycin treatment is a contraindication to hyperbaric oxygen treatment because supplemental oxygen may cause life threatening pneumonitis. Answer 4: Presence of a pneumothorax is a contraindication as hyperbaric oxygen treatment may cause a gas embolism, tension pneumothorax, or pneumomediastinum. Answer 5: Presence of an insulin pump is a contraindication to hyperbaric oxygen treatment because malfunction or deformation of the device may occur under pressure. Wound healing: - Dependent on: vascular supply, nutritional status, immune status - Improved with: albumin > 3.0 g/dL, ischemic index > .5 (measurement of doppler pressure at level being tested compared to brachial systolic pressure), transcutaneous oxygen tension > 30 mm Hg (ideally 45 mm Hg), toe pressure > 40 mm Hg (will not heal if < 20 mm Hg), ankle-brachial index (ABI) > 0.45, total lymphocyte count (TLC) > 1500/mm3 Hyperbaric oxygen therapy contraindications include - chemo or radiation therapy - pressure-sensitive implanted medical device (automatic implantable cardiac defibrillator, pacemaker, dorsal column stimulator, insulin pump) - undrained pneumothorax

Answer 77

A dynamic external rotation stress test with the ankle dorsiflexed to 90 degrees is the most accurate way to evaluate the integrity of the syndesmosis. Nielson et al evaluated 70 ankle fractures with radiographs and MRI. Neither measurements of the tibiofibular clear space nor the tibiofibular overlap correlated with syndesmotic injury on MRI. Medial clear space widening of more than 4 mm occurred with MRI evidence of disruption of the deltoid and the tibiofibular ligaments. Nielson et al used this same cohort of ankle fractures in a separate study to evaluate whether the level of the fibular fracture correlated with syndesmotic incompetence. They found no correlation. The level of fracture on the fibula cannot be used to accurately predict disruption of the syndesmosis. Ebraheim et al reviewed a series of Weber B fibula fractures with deltoid injury and syndesmotic disruption. Their findings concluded that the surgeon's dynamic assessment of syndesmotic stability was more predictive of syndesmotic stability than any imaging parameters including radiographs and CT scans. Ankle fracture Injury patterns: - isolated medial malleolus fracture - isolated lateral malleolus fracture - bimalleolar and bimalleolar-equivalent fractures - posterior malleolus fractures - Bosworth fracture-dislocations - open ankle fractures - associated syndesmotic injuries - isolated syndesmosis injury Anatomy Biomechanics - deltoid ligament (deep portion): primary restraint to anterolateral talar displacement - fibula: acts as buttress to prevent lateral displacement of talus Syndesmotic injury - decreased tibiofibular overlap: measure at point of maximum overlap - normal >6 mm on AP view & >1 mm on mortise view. NB it has also been reported that there is no actual correlation between syndesmotic injury and tibiofibular clear space or overlap measurements - increased medial clear space : normal ≤ 4 mm on mortise or stress view. Medial clear space of >5mm with external rotation stress applied to a dorsiflexed ankle is predictive of deep deltoid disruption - increased tibiofibular clear space : measure clear space 1 cm above joint - normal <6 mm on both AP and mortise views Lateral malleolus fractures - talocrural angle : measured by bisection of line through tibial anatomical axis and another line through the tips of the malleoli. Shortening of lateral malleoli fractures can lead to increased talocrural angle. Talocrural angle is not 100% reliable for estimating restoration of fibular length can also utilize the realignment of the medial fibular prominence with the tibiotalar joint Posterior malleolus fractures - double contour sign - misty mountains sign Lauge-Hansen based on foot position and force of applied stress/force has been shown to predict the observed (via MRI) ligamentous injury in less than 50% of operatively treated fractures: Supination - Adduction (SA): Talofibular sprain or distal fibular avulsion Vertical medial malleolus and impaction of anteromedial distal tibia Supination - External Rotation (SER): Anterior tibiofibular ligament sprain Lateral short oblique fibula fracture (anteroinferior to posterosuperior) Posterior tibiofibular ligament rupture or avulsion of posterior malleolus Medial malleolus transverse fracture or disruption of deltoid ligament Pronation - Abduction (PA): Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament sprain Transverse comminuted fracture of the fibula above the level of the syndesmosis Pronation - External Rotation (PER): Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament disruption Lateral short oblique or spiral fracture of fibula (anterosuperior to posteroinferior) above the level of the joint Posterior tibiofibular ligament rupture or avulsion of posterior malleolus Anatomic / Descriptive - isolated medial malleolar - isolated lateral malleolar - bimalleolar - trimalleolar - Bosworth fracture-dislocation (posterior dislocation of the fibula behind incisura fibularis) Danis-Weber (location of fibular fracture) A - infrasyndesmotic (generally not associated with ankle instability) B - transsyndesmotic C - suprasyndesmotic AO / ATA 44A - infrasyndesmotic 44B - transsyndesmotic 44C - suprasyndesmotic General Treatment Nonoperative - short-leg walking cast/boot indications: - isolated nondisplaced medial malleolus fracture or tip avulsions - isolated lateral malleolus fracture with < 3mm displacement and no talar shift - bimalleolar fracture if elderly or unable to undergo surgical intervention - posterior malleolar fracture with < 25% joint involvement or < 2mm step-off Operative - open reduction internal fixation indications: - any talar displacement - displaced isolated medial malleolar fracture - displaced isolated lateral malleolar fracture - bimalleolar fracture and bimalleolar-equivalent fracture - posterior malleolar fracture with > 25% or > 2mm step-off - Bosworth fracture-dislocations - open fractures - malleolar nonunions Technique: goal of treatment is stable anatomic reduction of talus in the ankle mortise - 1 mm shift of talus leads to 42% decrease in tibiotalar contact area - Overall success rate of 90% - prolonged recovery expected (2 years to obtain final functional result) significant functional impairment often noted Anatomic reduction is considered the most important factor for a satisfactory outcome Worse outcomes with: smoking, decreased education, alcohol use, presence of medial malleolar fracture ORIF superior to closed treatment of bimalleolar fractures in Lauge-Hansen supination-adduction fractures, restoration of marginal impaction of the anteromedial tibial plafond leads to optimal functional results after surgery Postoperative rehabilitation - time for proper braking response time (driving) returns to baseline at nine weeks for operatively treated ankle fractures - braking travel time is significantly increased until 6 weeks after initiation of weight bearing in both long bone and periarticular fractures of the lower extremity

Answer 78

Unopposed pull of gastrocnemius-soleus and posterior tibialis The loss of the peroneus longus, peroneus brevis, EHL, EDL, and peroneus tertius insertions result in an equinovarus deformity due to the pull of the gastroc-soleus complex, posterior tibialis, and anterior tibialis. Several surgical techniques have been described to address or prevent equinovarus deformities after Lisfranc amputation. Open or percutaneous achilles tendon lengthening, open gastrocnemius recession, or endoscopic gastrocnemius recession have shown to address the equinus deformity. Split tibialis anterior tendon transfer (STATT), 4th and 5th digit flexor-to-extensor tendons tenodesis, as well as peroneus brevis (PB) to peroneus longus (PL) tendon transfers have shown to address the varus deformity. Early et al. state the Lisfranc amputation should be considered when there is inadequate soft tissue coverage for transmetatarsal amputation or instability at the LisFranc joint. In addition, they comment that the deforming forces, the gastroc-soleus complex and posterior tibialis, are primarily innervated by the S1 nerve root. The classic Lisfranc amputation describes transaction of the first, third, fourth, and fifth tarsometatarsal joints. The second TMT is usually left in place, as it provides stability for the middle cuneiform. Incorrect Answers: Answers 1-4: The equinus deformity occurs after the elimination of extensor digitorum longus and extensor hallucis longus muscles, which cause an imbalance between the posterior compartment and the anterior compartment muscles that across the ankle. The varus deformity occurs when tibialis anterior and posterior compartment muscles overpower the eversion strength of the peroneus brevis muscle. Ankle/Foot Amputation: Syme amputation (ankle disarticulation) - patent tibialis posterior artery is required. More energy efficient than midfoot even though it is more proximal Stable heel pad is most important factor Used successfully to treat forefoot gangrene in diabetics Technique: medial and lateral malleoli are removed flush with distal tibia articular surface. The medial and lateral flares of the tibia and fibula are beveled to enhance heel pad adherence. Heel pad is secured to anterior tibia Pirogoff amputation (hindfoot amputation): removal of the forefoot and talus followed by calcaneotibial arthrodesis calcaneus is osteotomized and rotated 50-90 degrees to keep posterior aspect of calcaneus distal Allows patient to mobilize independently without use of prosthetic Chopart or Boyd amputation (hindfoot amputation) a partial foot amputation through the talonavicular and calcaneocuboid joints. Primary complication is equinus deformity - avoid by lengthening of the Achilles tendon and transfer of the tibialis anterior to the talar neck leads to apropulsive gait pattern because the amputation is unable to support modern dynamic elastic response prosthetic feet Lisfranc amputation (midfoot amputation) - equinovarus deformity is common caused by unopposed pull of tibialis posterior and gastroc/soleus. Prevent by maintaining insertion of peroneus brevis and performing achilles lengthening. A walking cast is generally used for 4 week to prevent late equinus contracture. Energy cost of walking similar to that of BKA Transmetatarsal amputation: more appealing to patients who refuse transtibial amputations Almost all require achilles lengthening to prevent equinus Great toe amputations: preserve 1cm at base of proximal phalanx - preserves insertion of plantar fascia, sesamoids, and flexor hallucis brevis - reduces amount of weight transfer to remaining toes so lessens risk of ulceration Metabolic cost of walking - increases with more proximal amputations perform amputations at lowest possible level to preserve function - exception: Syme amputation is more efficient than midfoot amputation - inversely proportional to length of remaining limb Ranking of metabolic demand (% represents amount of increase compared to baseline) Syme - 15% transtibial: traumatic - 25% average, short BKA - 40%, long BKA - 10%, vascular - 40% transfemoral: traumatic - 68%, vascular - 100% thru-knee amputation: varies based on patient habitus but is somewhere between transtibial and transfemoral Most proximal amputation level available in children to maintain walking speeds without increased energy expenditure compared to normal children Transfemoral Amputation: - Maintain as much length as possible, however, ideal cut is 12 cm (10-15cm) above knee joint to allow for prosthetic fitting Technique - 5-10 degrees of adduction is ideal for improved prosthesis function - adductor myodesis: improves clinical outcomes creates dynamic muscle balance (otherwise have unopposed abductors). Provides soft tissue envelope that enhances prosthetic fitting Gritti-Stokes amputation: amputation through the femur near level of adductor tubercle. Synovium is excised to prevent postoperative effusion. Patella is arthrodesed to the end of femur for improved end bearing prepatellar soft tissue is maintained without iatrogenic injury - improved outcomes as compared to transfemoral amputation ``` Wound Healing Dependent on - vascular supply - nutritional status - immune status ``` Improved with - albumin > 3.0 g/dL - ischemic index > .5 measurement of doppler pressure at level being tested compared to brachial systolic pressure - transcutaneous oxygen tension > 30 mm Hg (ideally 45 mm Hg) - toe pressure > 40 mm Hg (will not heal if < 20 mm Hg) ankle-brachial index (ABI) > 0.45 total lymphocyte count (TLC) > 1500/mm3 - Hyperbaric oxygen therapy contraindications include: chemo or radiation therapy pressure-sensitive implanted medical device (automatic implantable cardiac defibrillator, pacemaker, dorsal column stimulator, insulin pump) , undrained pneumothorax Complications - Wound healing - Contractures: adjacent joint contractures are common prevent with early aggressive mobilization and position changes - Heterotopic ossification: more common in trauma-related setting - Infection: trauma-related amputation have an infection rate of around 34% - Postamputation Neuroma : occurs in 20-30% of amputees prevent with proper nerve handling at the time of procedure. Treatment: targeted muscle rein nervation - a method of guiding neuronal regeneration to prevent or treat post-amputation neuroma pain and improve patient use of myoelectric prostheses - Phantom limb pain occurs in 53-100% of traumatic amputations mirror therapy is a noninvasive treatment modality - Bone overgrowth: most common complication with pediatric amputations. Treatment: prevent by performing disarticulation or using epihphyseal cap to cover medullary canal

Answer 79

hip extension, knee flexion In the cited study, researchers measured tissue fluid pressure within the sciatic nerve in cadaveric specimens using a pressure transducer. The hip and knee were taken through a combination of ranges and found that the clinically relevant increase in pressure happened with the hip flexed at 90 degrees and the knee fully extended. They concluded that increased intraneural pressure was related to excursion of the nerve as linear distance between the greater sciatic notch and the distal leg increase. Hence, according to the question stem, to avoid traction injury, the reverse position should be implemented (hip extension and knee flexion). Acetabulum fractures can involve one or more of the two columns, two walls or roof within the pelvis Osteology acetabular inclination & ante version: mean lateral inclination of 40 to 48 degrees, anteversion of 18 to 21 degrees Column theory : acetabulum is supported by two columns of bone - form an "inverted Y". Connected to sacrum through sciatic buttress - Posterior column: comprised of quadrilateral surface, posterior wall and dome, ischial tuberosity, greater/lesser sciatic notches - anterior column: comprised of anterior ilium (gluteus medius tubercle), anterior wall and dome, iliopectineal eminence, lateral superior pubic ramus Vascular corona mortis : anastomosis of external iliac (epigastric) and internal iliac (obturator) vessels - at risk with lateral dissection over superior pubic ramus Letournel Classification Judet and Letournel: most common referenced classification system - classifed as 5 elementary and 5 associated fracture patterns Most common fracture patterns Younger : posterior wall or transverse fracture "family" (transverse, T-type, transverse + posterior wall) Elderly : anterior column (e.g., quadrilateral plate fractures), anterior column, posterior hemitransverse, assoicated both column fractures Posterior wall • Most common • "gull sign" on obturator oblique view Posterior column • check for injury to superior gluteal NV bundle Anterior wall • Very rare Anterior column • More common in elderly patients with fall from standing (most common in elderly is "anterior column + medial wall") Transverse • Axial CT shows anterior to posterior fx line • Only elementary fx to involve both columns Associated Both Column • Characterized by dissociation of the articular surface from the inonimate bone • "spur sign" on obturator oblique Transverse + Post. Wall • Most common associated fx T Shaped • May need combined approach Anterior column or wall + Post. hemitransverse • Common in elderly patients Post. column + Post. wall • Only associated fracture that does not involve both columns Treatment Nonoperative: protected weight bearing for 6-8 weeks indications: patient factors - high operative risk (e.g., elderly patients, presence of DVT), morbid obesity, open contaminated wound, late presenting > 3 weeks fracture characteristics: minimally displaced fracture (< 2 mm), < 20% posterior wall fractures (treatment based on size of posterior wall is controversial - recommend an exam under anesthesia (EUA) using fluoroscopy best method to test stability), Femoral head congruency with weight bearing roof (out of traction) - both column fracture pattern with secondary congruence (out of traction), displaced fracture with roof arcs > 45° in AP and Judet views or >10 mm on axial CT cuts technique - Skeletal traction NOT required if stable fracture pattern, outside the weight-bearing dome - activity as tolerated with crutches/walker Weight-bearing: lowest joint reactive forces seen with toe-touch weight bearing and passive hip abduction, greatest joint contact force seen when rising from a chair on the affected extremity DVT prophylaxis if slow to mobilize Close radiographic follow-up Operative treatment open reduction and internal fixation indications - Patient factors: < 3 weeks from date of injury, physiologically stable, adequate soft-tissue envelope, no local infection, pregnancy is not contraindication to surgical fixation - Fracture factors: displacement of roof (> 2 mm), unstable fracture pattern (e.g. posterior wall fracture involving > 40-50%), marginal impaction, intra-articular loose bodies, irreducible fracture-dislocation Approaches - Anterior : ilioinguinal, iliofemoral, modified stoppa - Posterior: Kocher-Langenbach - Combined: extended ilifemoral Fixation modalities: - Column fixation strategies: reconstruction bridging plate and screws, percutaneous column screws, cable fixation - Wall fixation strategies: bridge plate and screws, lag screw and neutralization plate, spring (butress) plate outcomes timing: associated hip dislocations should be reduced within 12 hours for improved outcomes worse outcomes with fixation of fracture > 3 weeks from time of injury - earlier operative treatment associated with increased chance of anatomic reduction Peri-operative : clinical outcome correlates with quality of articular reduction Postoperative CT scan is most accurate way to determine posterior wall accuracy of reduction which has greatest correlation with clinical outcome - ideally articular reduction <2mm Post-operative greatest stress on acetabular repair occurs when rising from a seated position using the affected leg, and occurs in the posterior superior portion of the acetabulum Functional outcomes most strongly correlate with hip muscle strength and restoration of gait postoperatively Total hip arthroplasty indications usually elderly patients with significant osteopenia and/or significant comminution, pre-existing arthritis, post-traumatic arthritis in all ages techniques timing: immediate vs. delayed THA immediate THA (with, or without, fracture fixation) wall fractures : butress plate with multi-hole cup column fracture: cage and cup constructs delayed THA outcomes: patients older than 60 years have approx. a 30% late conversion rate to THA after acetabular fractures

Answer 80

Subtalar distraction arthrodesis using a bone graft is not indicated in a patient with full ankle dorsiflexion and no tibiotalar impingement. The radiograph demonstrates post-traumatic subtalar arthritis with deformity. Subtalar arthrodesis in situ would not correct the deformity. Substantial loss of heel height may lead to symptomatic anterior tibiotalar impingement and is considered the most appropriate indication for subtalar distraction arthrodesis. Measurement of the talocalcaneal angle is made using a line representing the long axis of the talus and its intersection with the longitudinal axis of the calcaneus. The talar declination angle is formed by the axis of the talus to the plane of support. The talocalcaneal height is measured from the dome of the talus to the base of the calcaneus. Each of these measurements along with longitudinal arch are often decreased in patients with post-traumatic subtalar arthritis and are discussed as deformities that can be corrected with bone block subtalar distraction arthrodesis. Chandler et al and Trnka et al each performed Level 4 studies that concluded that distraction arthrodesis was most appropriate in the setting anterior ankle impingement. Calcaneus: Most frequent tarsal fracture 17% open fractures Pathophysiology mechanism: traumatic axial loading is the primary mechanism of injury, fall from height, motor-vehicle accidents pathoanatomy - intra-articular fractures: PRIMARY FRACTURE line results from oblique shear and leads to the following two primary fragments: 1. superomedial fragment (constant fragment): includes the sustentaculum tali and is stabilized by strong ligamentous and capsular attachments 2. superolateral fragment: includes an intra-articular aspect through the posterior facet SECONDARY FRACTURE lines dictate whether there is joint depression or tongue-type fracture - Extra-articular fractures: strong contraction of gastrocnemius-soleus with concomitant avulsion at its insertion site on calcaneus. More common in osteopenic bone - Anterior process fractures: inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament Associated injuries - extension into the calcaneocuboid joint occurs in 63% - vertebral injuries in 10% - contralateral calcaneus in 10% Prognosis poor with 40% complication rate - increased due to mechanism (fall from height), smoking, and early surgery lateral soft tissue trauma increases the rate of complication Osteology Articular facets : superolateral fragment contains the articular facets - superior articular surface contains three facets that articulate with the talus: - posterior facet is the largest and is the major weight bearing surface - the flexor hallucis longus tendon runs just inferior to it and can be injured with errant drills/screws that are too long - middle facet is anteromedial on sustentaculum tali - anterior facet is often confluent with middle facet sinus tarsi - between the middle and posterior facets lies the interosseous sulcus (calcaneal groove) that together with the talar sulcus makes up the sinus tarsi sustentaculum tali: Projects medially and supports the neck of talus - FHL passes beneath it. Deltoid and talocalcaneal ligament connect it to the talus - contained in the anteromedial fragment, which remains "constant" due to medial talocalcaneal and interosseous ligaments bifurcate ligament: connects the dorsal aspect of the anterior process to the cuboid and navicular Classification Extra-articular (25%) : avulsion injury of: anterior process (by bifurcate ligament), sustentaculum tali, calcaneal tuberosity (Achilles tendon avulsion) Intra-articular (75%) Essex-Lopresti classification: the primary fracture line runs obliquely through the posterior facet forming two fragments The secondary fracture line runs in one of two planes - the axial plane beneath the facet exiting posteriorly in tongue-type fractures - when the superolateral fragment and posterior facet remain attached to the tuberosity posteriorly - behind the posterior facet in joint depression fractures Sanders classification: based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet Sanders Classification Type I • Nondisplaced posterior facet (regardless of number of fracture lines) Type II • One fracture line in the posterior facet (two fragments) Type III • Two fracture lines in the posterior facet (three fragments) Type IV • Comminuted with more than three fracture lines in the posterior facet (four or more fragments) Complications Wound complications (10-25%) : increased risk in smokers, diabetics, and open injuries Subtalar arthritis : increased with nonoperative management Lateral impingement with peroneal irritation Damaged FHL: at risk with placement of lateral to medial screws, especially at level of sustentaculum tali (constant fragment) Compartment syndrome (10%): results in claw toes Malunion: loss of height, widening, and lateral impingement. Causes limited ankle dorsiflexion due to dorsiflexed talus with talar declination angle <20. Treatment: distraction bone block subtalar arthrodesis - indications: chronic pain from subtalar joint, incongruous subtalar joint/post-traumatic DJD, loss of calcaneal height, mechanical block to ankle dorsiflexion (results from posterior talar collapse into the posterior calcaneus). Goal is to correct : hindfoot height, ankle impingement, subfibular impingement, subtalar arthritis

Answer 81

A both column acetabular fracture is defined as an acetabular fracture with no articular surface in continuity with the remaining posterior ilium (and therefore, axial skeleton). The spur sign is a radiological sign seen with these fractures, and is the posterio-inferior aspect of the intact posterior ilium. The spur sign and other radiographic findings consistent with a both column acetabular fracture Acetabulum fractures can involve one or more of the two columns, two walls or roof within the pelvis Osteology acetabular inclination & ante version: mean lateral inclination of 40 to 48 degrees, anteversion of 18 to 21 degrees Column theory : acetabulum is supported by two columns of bone - form an "inverted Y". Connected to sacrum through sciatic buttress - Posterior column: comprised of quadrilateral surface, posterior wall and dome, ischial tuberosity, greater/lesser sciatic notches - anterior column: comprised of anterior ilium (gluteus medius tubercle), anterior wall and dome, iliopectineal eminence, lateral superior pubic ramus Vascular corona mortis : anastomosis of external iliac (epigastric) and internal iliac (obturator) vessels - at risk with lateral dissection over superior pubic ramus Letournel Classification Judet and Letournel: most common referenced classification system - classifed as 5 elementary and 5 associated fracture patterns Most common fracture patterns Younger : posterior wall or transverse fracture "family" (transverse, T-type, transverse + posterior wall) Elderly : anterior column (e.g., quadrilateral plate fractures), anterior column, posterior hemitransverse, assoicated both column fractures Posterior wall • Most common • "gull sign" on obturator oblique view Posterior column • check for injury to superior gluteal NV bundle Anterior wall • Very rare Anterior column • More common in elderly patients with fall from standing (most common in elderly is "anterior column + medial wall") Transverse • Axial CT shows anterior to posterior fx line • Only elementary fx to involve both columns Associated Both Column • Characterized by dissociation of the articular surface from the inonimate bone • "spur sign" on obturator oblique Transverse + Post. Wall • Most common associated fx T Shaped • May need combined approach Anterior column or wall + Post. hemitransverse • Common in elderly patients Post. column + Post. wall • Only associated fracture that does not involve both columns Treatment Nonoperative: protected weight bearing for 6-8 weeks indications: patient factors - high operative risk (e.g., elderly patients, presence of DVT), morbid obesity, open contaminated wound, late presenting > 3 weeks fracture characteristics: minimally displaced fracture (< 2 mm), < 20% posterior wall fractures (treatment based on size of posterior wall is controversial - recommend an exam under anesthesia (EUA) using fluoroscopy best method to test stability), Femoral head congruency with weight bearing roof (out of traction) - both column fracture pattern with secondary congruence (out of traction), displaced fracture with roof arcs > 45° in AP and Judet views or >10 mm on axial CT cuts technique - Skeletal traction NOT required if stable fracture pattern, outside the weight-bearing dome - activity as tolerated with crutches/walker Weight-bearing: lowest joint reactive forces seen with toe-touch weight bearing and passive hip abduction, greatest joint contact force seen when rising from a chair on the affected extremity DVT prophylaxis if slow to mobilize Close radiographic follow-up Operative treatment open reduction and internal fixation indications - Patient factors: < 3 weeks from date of injury, physiologically stable, adequate soft-tissue envelope, no local infection, pregnancy is not contraindication to surgical fixation - Fracture factors: displacement of roof (> 2 mm), unstable fracture pattern (e.g. posterior wall fracture involving > 40-50%), marginal impaction, intra-articular loose bodies, irreducible fracture-dislocation Approaches - Anterior : ilioinguinal, iliofemoral, modified stoppa - Posterior: Kocher-Langenbach - Combined: extended ilifemoral Fixation modalities: - Column fixation strategies: reconstruction bridging plate and screws, percutaneous column screws, cable fixation - Wall fixation strategies: bridge plate and screws, lag screw and neutralization plate, spring (butress) plate outcomes timing: associated hip dislocations should be reduced within 12 hours for improved outcomes worse outcomes with fixation of fracture > 3 weeks from time of injury - earlier operative treatment associated with increased chance of anatomic reduction Peri-operative : clinical outcome correlates with quality of articular reduction Postoperative CT scan is most accurate way to determine posterior wall accuracy of reduction which has greatest correlation with clinical outcome - ideally articular reduction <2mm Post-operative greatest stress on acetabular repair occurs when rising from a seated position using the affected leg, and occurs in the posterior superior portion of the acetabulum Functional outcomes most strongly correlate with hip muscle strength and restoration of gait postoperatively Total hip arthroplasty indications usually elderly patients with significant osteopenia and/or significant comminution, pre-existing arthritis, post-traumatic arthritis in all ages techniques timing: immediate vs. delayed THA immediate THA (with, or without, fracture fixation) wall fractures : butress plate with multi-hole cup column fracture: cage and cup constructs delayed THA outcomes: patients older than 60 years have approx. a 30% late conversion rate to THA after acetabular fractures

Answer 82

Normal cervical paraspinal muscle activity on EMG is characteristic of a post-ganglionic injury. Determining whether a brachial plexus injury is pre- or post-ganglionic has important treatment and prognostic implications. Findings that suggest a pre-ganglionic lesion include Horner syndrome (ptosis, miosis, anhidrosis), a medially winged scapula, loss of paraspinal musculature activity on EMG, and a normal histamine test. These injuries tend to have a worse prognosis than post-ganglionic lesions, which show an abnormal histamine test and intact cervical paraspinal activity on EMG. Moran et al. review brachial plexus injuries. They recommend a baseline EMG for non-operative injuries at 3-4 weeks time after Wallerian degeneration has occurred. Shin et al. also review brachial plexus injuries. While an MRI can visualize much of the brachial plexus and may be able to demonstrate neuromas, a CT myelogram still remains the primary mode of radiographic evaluation for nerve root avulsion in the acute setting. Incorrect Answers: Answer 1: This is the definition of a pre-ganglionic lesion. Answer 2: Horner syndrome is typically found in patients with pre-ganglionic lesions. Answer 4: Neurotization is usually only considered for pre-ganglionic lesions. Answer 5: Post-ganglionic injuries show an abnormal histamine test. The posterior cord of the brachial plexus gives rise to the 1) upper subscapular nerve : subscapularis 2) lower subscapular nerve : teres major, subscapularis 3) thoracodorsal nerve : latissimus dorsi 4) axillary nerves : deltoid, ,teres minor 5) radial nerve. : triceps, brachioradialis, wrist extensors, finger extensors Preganglionic vs. postganglionic Preganglionic: avulsion proximal to dorsal root ganglion involves CNS which does not regenerate – little potential recovery of motor function (poor prognosis) lesions suggesting preganglionic injury: - Horner’s syndrome: disruption of sympathetic chain -> - winged scapula medially (loss of serratus anterior (long thoracic nerve), rhomboids (dorsal scapular nerve) leads to medial winging (inferior border goes medial)) - Presents with motor deficits (flail arm), sensory intact, absence of a Tinel sign or tenderness to percussion in the neck. Normal histamine test (C8-T1 sympathetic ganglion) - intact triple response (redness, wheal, flare) - Elevated hemidiaphragm (phrenic nerve - rhomboid paralysis (dorsal scapular nerve) - supraspinatus/infraspinatus (suprascapular nerve) - latissimus dorsi (thoracodorsal) - Evaluation: EMG may show loss of innervation to cervical paraspinals Postganglionic - involve PNS, capable of regeneration (better prognosis) presentation. Presents with motor deficit (flail arm) & sensory deficits - Evaluation: EMG shows maintained innervation to cervical paraspinals. Abnormal histamine test - only redness and wheal, but NO flare Classification based on location Upper Lesion: Erb's Palsy (C5,6) Most common obstetric brachial plexopathy Results from excessive displacement of head to opposite side and depression of shoulder on same side producing traction on plexus Occurs during difficult delivery in infants or fall onto shoulder in adults Best prognosis Clinically, arm will be adducted, internally rotated, at shoulder; pronated, extended at elbow (“waiter’s tip”) C5 deficiency: axillary nerve deficiency (weakness in deltoid, teres minor), suprascapular nerve deficiency (weakness in supraspinatus, infraspinatus), musculocutaneous nerve deficiency (weakness to biceps) C6 deficiency: radial nerve deficiency (weakness in brachioradialis, supinator) Lower Lesion: Klumpke Palsy (C8,T1) Rare in obstetric palsy Usually avulsion injuries caused by excessive abduction (person falling from height clutching on object to save himself) Other causes may include cervical rib, or lung mets in lower deep cervical lymph nodes Frequently associated with a preganglion injury and Horner's Syndrome Poor prognosis Deficit of all of the small muscles of the hand (ulnar and median nerves)- Clinically, presents as “claw hand” wrist held in extreme extension because of the unopposed wrist extensors hyperextension of MCP due to loss of hand intrinsics flexion of IP joints due to loss of hand intrinsics Total Palsy (C5-T1): A form of brachial plexopathy Worst prognosis Leads to a flaccid arm Involves both motor and sensory Presentation History: high energy injury Physical exam - Horner's syndrome features include drooping of the left eyelid, pupillary constriction, anhidrosis. Usually show up three days after injury. Represents disruption of sympathetic chain via C8 and/or T1 root avulsions - severe pain in anesthetized limb - correlates with root avulsion important muscles to test: serratus anterior (long thoracic nerve) and rhomboids (dorsal scapular nerve) - if they are functioning then it is more likely the C5 injury is postganglionic pulses check radial, ulnar and brachial pulses arterial injuries common with complete BPIs

Answer 83

Inlet iliac oblique view As reviewed in the referenced article by Starr et al, when placing a retrograde pubic rami screw, the pelvic inlet iliac oblique view will best determine the anteroposterior placement of the screw in the pubic ramus. To ensure placement outside of the joint, the outlet obturator oblique is best, but all other views should be incorporated into determination of the position of fixation, as the corridor for this screw placement is quite narrow. Acetabulum fractures can involve one or more of the two columns, two walls or roof within the pelvis Osteology acetabular inclination & ante version: mean lateral inclination of 40 to 48 degrees, anteversion of 18 to 21 degrees Column theory : acetabulum is supported by two columns of bone - form an "inverted Y". Connected to sacrum through sciatic buttress - Posterior column: comprised of quadrilateral surface, posterior wall and dome, ischial tuberosity, greater/lesser sciatic notches - anterior column: comprised of anterior ilium (gluteus medius tubercle), anterior wall and dome, iliopectineal eminence, lateral superior pubic ramus Vascular corona mortis : anastomosis of external iliac (epigastric) and internal iliac (obturator) vessels - at risk with lateral dissection over superior pubic ramus Letournel Classification Judet and Letournel: most common referenced classification system - classifed as 5 elementary and 5 associated fracture patterns Most common fracture patterns Younger : posterior wall or transverse fracture "family" (transverse, T-type, transverse + posterior wall) Elderly : anterior column (e.g., quadrilateral plate fractures), anterior column, posterior hemitransverse, assoicated both column fractures Posterior wall • Most common • "gull sign" on obturator oblique view Posterior column • check for injury to superior gluteal NV bundle Anterior wall • Very rare Anterior column • More common in elderly patients with fall from standing (most common in elderly is "anterior column + medial wall") Transverse • Axial CT shows anterior to posterior fx line • Only elementary fx to involve both columns Associated Both Column • Characterized by dissociation of the articular surface from the inonimate bone • "spur sign" on obturator oblique Transverse + Post. Wall • Most common associated fx T Shaped • May need combined approach Anterior column or wall + Post. hemitransverse • Common in elderly patients Post. column + Post. wall • Only associated fracture that does not involve both columns Treatment Nonoperative: protected weight bearing for 6-8 weeks indications: patient factors - high operative risk (e.g., elderly patients, presence of DVT), morbid obesity, open contaminated wound, late presenting > 3 weeks fracture characteristics: minimally displaced fracture (< 2 mm), < 20% posterior wall fractures (treatment based on size of posterior wall is controversial - recommend an exam under anesthesia (EUA) using fluoroscopy best method to test stability), Femoral head congruency with weight bearing roof (out of traction) - both column fracture pattern with secondary congruence (out of traction), displaced fracture with roof arcs > 45° in AP and Judet views or >10 mm on axial CT cuts technique - Skeletal traction NOT required if stable fracture pattern, outside the weight-bearing dome - activity as tolerated with crutches/walker Weight-bearing: lowest joint reactive forces seen with toe-touch weight bearing and passive hip abduction, greatest joint contact force seen when rising from a chair on the affected extremity DVT prophylaxis if slow to mobilize Close radiographic follow-up Operative treatment open reduction and internal fixation indications - Patient factors: < 3 weeks from date of injury, physiologically stable, adequate soft-tissue envelope, no local infection, pregnancy is not contraindication to surgical fixation - Fracture factors: displacement of roof (> 2 mm), unstable fracture pattern (e.g. posterior wall fracture involving > 40-50%), marginal impaction, intra-articular loose bodies, irreducible fracture-dislocation Approaches - Anterior : ilioinguinal, iliofemoral, modified stoppa - Posterior: Kocher-Langenbach - Combined: extended ilifemoral Fixation modalities: - Column fixation strategies: reconstruction bridging plate and screws, percutaneous column screws, cable fixation - Wall fixation strategies: bridge plate and screws, lag screw and neutralization plate, spring (butress) plate outcomes timing: associated hip dislocations should be reduced within 12 hours for improved outcomes worse outcomes with fixation of fracture > 3 weeks from time of injury - earlier operative treatment associated with increased chance of anatomic reduction Peri-operative : clinical outcome correlates with quality of articular reduction Postoperative CT scan is most accurate way to determine posterior wall accuracy of reduction which has greatest correlation with clinical outcome - ideally articular reduction <2mm Post-operative greatest stress on acetabular repair occurs when rising from a seated position using the affected leg, and occurs in the posterior superior portion of the acetabulum Functional outcomes most strongly correlate with hip muscle strength and restoration of gait postoperatively Total hip arthroplasty indications usually elderly patients with significant osteopenia and/or significant comminution, pre-existing arthritis, post-traumatic arthritis in all ages techniques timing: immediate vs. delayed THA immediate THA (with, or without, fracture fixation) wall fractures : butress plate with multi-hole cup column fracture: cage and cup constructs delayed THA outcomes: patients older than 60 years have approx. a 30% late conversion rate to THA after acetabular fractures

Answer 84

Intra-articular calcaneus fracture A drill bit or screw that penetrates the subchondral area of the posterior facet of the calcaneus can lead to direct injury of the flexor hallucis longus as it runs just inferior to the sustentaculum tali on its way to its insertion on the first phalanx of the great toe. A medial calcaneal groove is seen where this structure runs from superior to inferior. Injury to the flexor hallucis longus tendon can be acute or attritional. Bajammal et al investigated intra-articular calcaneus fractures and reported that patients who were NOT receiving Workers' Compensation, were younger (less than twenty-nine years old), had a moderately lower Böhler angle (0 degrees to 14 degrees ), a comminuted fracture, a light workload, or an anatomic reduction or a step-off of < or =2 mm after surgical reduction (p = 0.04) scored significantly higher on the scoring scales after surgery compared with those who were treated nonoperatively. Calcaneus: Most frequent tarsal fracture 17% open fractures Pathophysiology mechanism: traumatic axial loading is the primary mechanism of injury, fall from height, motor-vehicle accidents pathoanatomy - intra-articular fractures: PRIMARY FRACTURE line results from oblique shear and leads to the following two primary fragments: 1. superomedial fragment (constant fragment): includes the sustentaculum tali and is stabilized by strong ligamentous and capsular attachments 2. superolateral fragment: includes an intra-articular aspect through the posterior facet SECONDARY FRACTURE lines dictate whether there is joint depression or tongue-type fracture - Extra-articular fractures: strong contraction of gastrocnemius-soleus with concomitant avulsion at its insertion site on calcaneus. More common in osteopenic bone - Anterior process fractures: inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament Associated injuries - extension into the calcaneocuboid joint occurs in 63% - vertebral injuries in 10% - contralateral calcaneus in 10% Prognosis poor with 40% complication rate - increased due to mechanism (fall from height), smoking, and early surgery lateral soft tissue trauma increases the rate of complication Osteology Articular facets : superolateral fragment contains the articular facets - superior articular surface contains three facets that articulate with the talus: - posterior facet is the largest and is the major weight bearing surface - the flexor hallucis longus tendon runs just inferior to it and can be injured with errant drills/screws that are too long - middle facet is anteromedial on sustentaculum tali - anterior facet is often confluent with middle facet sinus tarsi - between the middle and posterior facets lies the interosseous sulcus (calcaneal groove) that together with the talar sulcus makes up the sinus tarsi sustentaculum tali: Projects medially and supports the neck of talus - FHL passes beneath it. Deltoid and talocalcaneal ligament connect it to the talus - contained in the anteromedial fragment, which remains "constant" due to medial talocalcaneal and interosseous ligaments bifurcate ligament: connects the dorsal aspect of the anterior process to the cuboid and navicular Classification Extra-articular (25%) : avulsion injury of: anterior process (by bifurcate ligament), sustentaculum tali, calcaneal tuberosity (Achilles tendon avulsion) Intra-articular (75%) Essex-Lopresti classification: the primary fracture line runs obliquely through the posterior facet forming two fragments The secondary fracture line runs in one of two planes - the axial plane beneath the facet exiting posteriorly in tongue-type fractures - when the superolateral fragment and posterior facet remain attached to the tuberosity posteriorly - behind the posterior facet in joint depression fractures Sanders classification: based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet Sanders Classification Type I • Nondisplaced posterior facet (regardless of number of fracture lines) Type II • One fracture line in the posterior facet (two fragments) Type III • Two fracture lines in the posterior facet (three fragments) Type IV • Comminuted with more than three fracture lines in the posterior facet (four or more fragments) Complications Wound complications (10-25%) : increased risk in smokers, diabetics, and open injuries Subtalar arthritis : increased with nonoperative management Lateral impingement with peroneal irritation Damaged FHL: at risk with placement of lateral to medial screws, especially at level of sustentaculum tali (constant fragment) Compartment syndrome (10%): results in claw toes Malunion: loss of height, widening, and lateral impingement. Causes limited ankle dorsiflexion due to dorsiflexed talus with talar declination angle <20. Treatment: distraction bone block subtalar arthrodesis - indications: chronic pain from subtalar joint, incongruous subtalar joint/post-traumatic DJD, loss of calcaneal height, mechanical block to ankle dorsiflexion (results from posterior talar collapse into the posterior calcaneus). Goal is to correct : hindfoot height, ankle impingement, subfibular impingement, subtalar arthritis

Answer 85

Patient functional outcomes after acetabular fractures have been shown to be related to postoperative hip strength, regardless of surgical approach. The reference by Borrelli et al evaluated muscle strength and outcomes after acetabular surgery via an anterior approach. They report that hip extension strength was affected least (6%), whereas abduction, adduction, and flexion strength was affected to a greater degree. They note that hip muscle strength after operative treatment of a displaced acetabular fracture directly influences patient outcome. The reference by Engsberg et al is a review of patients that underwent ORIF of acetabular fractures through anterior or posterior approaches. They report that maximizing hip muscle strength may improve gait, and improvement in hip muscle strength and gait is likely to improve functional outcome. Worsening functional outcomes were correlated with decreased gait kinematics and stride length. Acetabulum fractures can involve one or more of the two columns, two walls or roof within the pelvis Osteology acetabular inclination & ante version: mean lateral inclination of 40 to 48 degrees, anteversion of 18 to 21 degrees Column theory : acetabulum is supported by two columns of bone - form an "inverted Y". Connected to sacrum through sciatic buttress - Posterior column: comprised of quadrilateral surface, posterior wall and dome, ischial tuberosity, greater/lesser sciatic notches - anterior column: comprised of anterior ilium (gluteus medius tubercle), anterior wall and dome, iliopectineal eminence, lateral superior pubic ramus Vascular corona mortis : anastomosis of external iliac (epigastric) and internal iliac (obturator) vessels - at risk with lateral dissection over superior pubic ramus Letournel Classification Judet and Letournel: most common referenced classification system - classifed as 5 elementary and 5 associated fracture patterns Most common fracture patterns Younger : posterior wall or transverse fracture "family" (transverse, T-type, transverse + posterior wall) Elderly : anterior column (e.g., quadrilateral plate fractures), anterior column, posterior hemitransverse, assoicated both column fractures Posterior wall • Most common • "gull sign" on obturator oblique view Posterior column • check for injury to superior gluteal NV bundle Anterior wall • Very rare Anterior column • More common in elderly patients with fall from standing (most common in elderly is "anterior column + medial wall") Transverse • Axial CT shows anterior to posterior fx line • Only elementary fx to involve both columns Associated Both Column • Characterized by dissociation of the articular surface from the inonimate bone • "spur sign" on obturator oblique Transverse + Post. Wall • Most common associated fx T Shaped • May need combined approach Anterior column or wall + Post. hemitransverse • Common in elderly patients Post. column + Post. wall • Only associated fracture that does not involve both columns Treatment Nonoperative: protected weight bearing for 6-8 weeks indications: patient factors - high operative risk (e.g., elderly patients, presence of DVT), morbid obesity, open contaminated wound, late presenting > 3 weeks fracture characteristics: minimally displaced fracture (< 2 mm), < 20% posterior wall fractures (treatment based on size of posterior wall is controversial - recommend an exam under anesthesia (EUA) using fluoroscopy best method to test stability), Femoral head congruency with weight bearing roof (out of traction) - both column fracture pattern with secondary congruence (out of traction), displaced fracture with roof arcs > 45° in AP and Judet views or >10 mm on axial CT cuts technique - Skeletal traction NOT required if stable fracture pattern, outside the weight-bearing dome - activity as tolerated with crutches/walker Weight-bearing: lowest joint reactive forces seen with toe-touch weight bearing and passive hip abduction, greatest joint contact force seen when rising from a chair on the affected extremity DVT prophylaxis if slow to mobilize Close radiographic follow-up Operative treatment open reduction and internal fixation indications - Patient factors: < 3 weeks from date of injury, physiologically stable, adequate soft-tissue envelope, no local infection, pregnancy is not contraindication to surgical fixation - Fracture factors: displacement of roof (> 2 mm), unstable fracture pattern (e.g. posterior wall fracture involving > 40-50%), marginal impaction, intra-articular loose bodies, irreducible fracture-dislocation Approaches - Anterior : ilioinguinal, iliofemoral, modified stoppa - Posterior: Kocher-Langenbach - Combined: extended ilifemoral Fixation modalities: - Column fixation strategies: reconstruction bridging plate and screws, percutaneous column screws, cable fixation - Wall fixation strategies: bridge plate and screws, lag screw and neutralization plate, spring (butress) plate outcomes timing: associated hip dislocations should be reduced within 12 hours for improved outcomes worse outcomes with fixation of fracture > 3 weeks from time of injury - earlier operative treatment associated with increased chance of anatomic reduction Peri-operative : clinical outcome correlates with quality of articular reduction Postoperative CT scan is most accurate way to determine posterior wall accuracy of reduction which has greatest correlation with clinical outcome - ideally articular reduction <2mm Post-operative greatest stress on acetabular repair occurs when rising from a seated position using the affected leg, and occurs in the posterior superior portion of the acetabulum Functional outcomes most strongly correlate with hip muscle strength and restoration of gait postoperatively Total hip arthroplasty indications usually elderly patients with significant osteopenia and/or significant comminution, pre-existing arthritis, post-traumatic arthritis in all ages techniques timing: immediate vs. delayed THA immediate THA (with, or without, fracture fixation) wall fractures : butress plate with multi-hole cup column fracture: cage and cup constructs delayed THA outcomes: patients older than 60 years have approx. a 30% late conversion rate to THA after acetabular fractures

Answer 86

The subtalar fusion technique involves distraction of the subtalar joint, insertion of a bone block, fusion, and rigid screw fixation. The distraction allows correction of the talocalcaneal relationship. In Carr’s series, pre- and postoperative radiographic analysis for tibiotalar impingement, lateral talocalcaneal angle, and talonavicular alignment was performed, with improvement to a normal range seen in the cases analyzed. Bednarz did a radiographic analysis and showed an average increase of 8 mm in hindfoot height, 9 degrees in lateral talocalcaneal angle, and 11 degrees in lateral talar declination angle. Rammelt found that compared with the unaffected side, the talocalcaneal height was corrected by 61.8%, the talus-first metatarsal axis by 46.5%, the talar declination angle by 38.5% and the talocalcaneal angle by 35.4%. Based on these three references, this procedure ultimately addresses the lost hindfoot height, subtalar arthritis (joint is fused), ankle impingement (improvement of the talus 1st MT axis), and peroneal impingement. It does not address hindfoot valgus. However, the deformity after a calcaneus fracture is usually from lateral wall blowout and hindfoot varus. Calcaneus: Most frequent tarsal fracture 17% open fractures Pathophysiology mechanism: traumatic axial loading is the primary mechanism of injury, fall from height, motor-vehicle accidents pathoanatomy - intra-articular fractures: PRIMARY FRACTURE line results from oblique shear and leads to the following two primary fragments: 1. superomedial fragment (constant fragment): includes the sustentaculum tali and is stabilized by strong ligamentous and capsular attachments 2. superolateral fragment: includes an intra-articular aspect through the posterior facet SECONDARY FRACTURE lines dictate whether there is joint depression or tongue-type fracture - Extra-articular fractures: strong contraction of gastrocnemius-soleus with concomitant avulsion at its insertion site on calcaneus. More common in osteopenic bone - Anterior process fractures: inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament Associated injuries - extension into the calcaneocuboid joint occurs in 63% - vertebral injuries in 10% - contralateral calcaneus in 10% Prognosis poor with 40% complication rate - increased due to mechanism (fall from height), smoking, and early surgery lateral soft tissue trauma increases the rate of complication Osteology Articular facets : superolateral fragment contains the articular facets - superior articular surface contains three facets that articulate with the talus: - posterior facet is the largest and is the major weight bearing surface - the flexor hallucis longus tendon runs just inferior to it and can be injured with errant drills/screws that are too long - middle facet is anteromedial on sustentaculum tali - anterior facet is often confluent with middle facet sinus tarsi - between the middle and posterior facets lies the interosseous sulcus (calcaneal groove) that together with the talar sulcus makes up the sinus tarsi sustentaculum tali: Projects medially and supports the neck of talus - FHL passes beneath it. Deltoid and talocalcaneal ligament connect it to the talus - contained in the anteromedial fragment, which remains "constant" due to medial talocalcaneal and interosseous ligaments bifurcate ligament: connects the dorsal aspect of the anterior process to the cuboid and navicular Classification Extra-articular (25%) : avulsion injury of: anterior process (by bifurcate ligament), sustentaculum tali, calcaneal tuberosity (Achilles tendon avulsion) Intra-articular (75%) Essex-Lopresti classification: the primary fracture line runs obliquely through the posterior facet forming two fragments The secondary fracture line runs in one of two planes - the axial plane beneath the facet exiting posteriorly in tongue-type fractures - when the superolateral fragment and posterior facet remain attached to the tuberosity posteriorly - behind the posterior facet in joint depression fractures Sanders classification: based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet Sanders Classification Type I • Nondisplaced posterior facet (regardless of number of fracture lines) Type II • One fracture line in the posterior facet (two fragments) Type III • Two fracture lines in the posterior facet (three fragments) Type IV • Comminuted with more than three fracture lines in the posterior facet (four or more fragments) Complications Wound complications (10-25%) : increased risk in smokers, diabetics, and open injuries Subtalar arthritis : increased with nonoperative management Lateral impingement with peroneal irritation Damaged FHL: at risk with placement of lateral to medial screws, especially at level of sustentaculum tali (constant fragment) Compartment syndrome (10%): results in claw toes Malunion: loss of height, widening, and lateral impingement. Causes limited ankle dorsiflexion due to dorsiflexed talus with talar declination angle <20. Treatment: distraction bone block subtalar arthrodesis - indications: chronic pain from subtalar joint, incongruous subtalar joint/post-traumatic DJD, loss of calcaneal height, mechanical block to ankle dorsiflexion (results from posterior talar collapse into the posterior calcaneus). Goal is to correct : hindfoot height, ankle impingement, subfibular impingement, subtalar arthritis

Answer 87

Patients recover the ability to safely operate the brakes of an automobile 9 weeks following operative repair of an ankle fracture. Because this patient is currently 8 weeks out from surgery, his braking time will be expected to return to normal one week from now. Egol et al studied the time braking ability returns to normal in patients with operatively treated ankle fractures. Patients were studied at 6, 9, and 12 weeks postoperatively and compared to healthy controls. It was determined that total breaking time returned to normal by 9 weeks. Bosworth Fracture-Dislocation Rare fracture-dislocation of the ankle where the fibula becomes entrapped behind the tibia and becomes irreducible posterolateral ridge of the distal tibia hinders reduction of the fibula Operative open reduction and fixation of the fibula in the incisura fibularis indicated in most cases Ankle fracture Injury patterns: - isolated medial malleolus fracture - isolated lateral malleolus fracture - bimalleolar and bimalleolar-equivalent fractures - posterior malleolus fractures - Bosworth fracture-dislocations - open ankle fractures - associated syndesmotic injuries - isolated syndesmosis injury Anatomy Biomechanics - deltoid ligament (deep portion): primary restraint to anterolateral talar displacement - fibula: acts as buttress to prevent lateral displacement of talus Syndesmotic injury - decreased tibiofibular overlap: measure at point of maximum overlap - normal >6 mm on AP view & >1 mm on mortise view. NB it has also been reported that there is no actual correlation between syndesmotic injury and tibiofibular clear space or overlap measurements - increased medial clear space : normal ≤ 4 mm on mortise or stress view. Medial clear space of >5mm with external rotation stress applied to a dorsiflexed ankle is predictive of deep deltoid disruption - increased tibiofibular clear space : measure clear space 1 cm above joint - normal <6 mm on both AP and mortise views Lateral malleolus fractures - talocrural angle : measured by bisection of line through tibial anatomical axis and another line through the tips of the malleoli. Shortening of lateral malleoli fractures can lead to increased talocrural angle. Talocrural angle is not 100% reliable for estimating restoration of fibular length can also utilize the realignment of the medial fibular prominence with the tibiotalar joint Posterior malleolus fractures - double contour sign - misty mountains sign Lauge-Hansen based on foot position and force of applied stress/force has been shown to predict the observed (via MRI) ligamentous injury in less than 50% of operatively treated fractures: Supination - Adduction (SA): Talofibular sprain or distal fibular avulsion Vertical medial malleolus and impaction of anteromedial distal tibia Supination - External Rotation (SER): Anterior tibiofibular ligament sprain Lateral short oblique fibula fracture (anteroinferior to posterosuperior) Posterior tibiofibular ligament rupture or avulsion of posterior malleolus Medial malleolus transverse fracture or disruption of deltoid ligament Pronation - Abduction (PA): Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament sprain Transverse comminuted fracture of the fibula above the level of the syndesmosis Pronation - External Rotation (PER): Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament disruption Lateral short oblique or spiral fracture of fibula (anterosuperior to posteroinferior) above the level of the joint Posterior tibiofibular ligament rupture or avulsion of posterior malleolus Anatomic / Descriptive - isolated medial malleolar - isolated lateral malleolar - bimalleolar - trimalleolar - Bosworth fracture-dislocation (posterior dislocation of the fibula behind incisura fibularis) Danis-Weber (location of fibular fracture) A - infrasyndesmotic (generally not associated with ankle instability) B - transsyndesmotic C - suprasyndesmotic AO / ATA 44A - infrasyndesmotic 44B - transsyndesmotic 44C - suprasyndesmotic General Treatment Nonoperative - short-leg walking cast/boot indications: - isolated nondisplaced medial malleolus fracture or tip avulsions - isolated lateral malleolus fracture with < 3mm displacement and no talar shift - bimalleolar fracture if elderly or unable to undergo surgical intervention - posterior malleolar fracture with < 25% joint involvement or < 2mm step-off Operative - open reduction internal fixation indications: - any talar displacement - displaced isolated medial malleolar fracture - displaced isolated lateral malleolar fracture - bimalleolar fracture and bimalleolar-equivalent fracture - posterior malleolar fracture with > 25% or > 2mm step-off - Bosworth fracture-dislocations - open fractures - malleolar nonunions Technique: goal of treatment is stable anatomic reduction of talus in the ankle mortise - 1 mm shift of talus leads to 42% decrease in tibiotalar contact area - Overall success rate of 90% - prolonged recovery expected (2 years to obtain final functional result) significant functional impairment often noted Anatomic reduction is considered the most important factor for a satisfactory outcome Worse outcomes with: smoking, decreased education, alcohol use, presence of medial malleolar fracture ORIF superior to closed treatment of bimalleolar fractures in Lauge-Hansen supination-adduction fractures, restoration of marginal impaction of the anteromedial tibial plafond leads to optimal functional results after surgery Postoperative rehabilitation - time for proper braking response time (driving) returns to baseline at nine weeks for operatively treated ankle fractures - braking travel time is significantly increased until 6 weeks after initiation of weight bearing in both long bone and periarticular fractures of the lower extremity

Answer 88

Presence of peripheral neuropathy has important implications in treating ankle fractures in diabetic patients. Increased immobilization periods, attention to tight glucose control, and adjunct/alternative operative techniques may be necessary for an optimal outcome. The first referenced article by Chaudry et al is an excellent review of diabetic ankle fractures. The second reference by Costigan et al noted that peripheral neuropathy is the most significant risk factor for postoperative complications, followed closely by lack of pedal pulses preoperatively. The last referenced article by Jones et al noted a significantly higher complication rate in diabetics with operative ankle fractures, and reported that neuroarthropathy is a significant risk factor for postoperative complications.

Answer 89

Comminuted fracture at or above the level of the syndesmosis In the Lauge-Hansen classification, the characteristic fibular fracture pattern in a pronation-abduction injury is a comminuted fibular fracture above the level of the syndesmosis. In the first stage of this injury pattern, the deltoid fails in tension, or an avulsion fracture of the medial malleolus occurs. In the second stage, the anterior inferior tibiofibular ligament ruptures, or a small bony avulsion of this ligament's insertion/origin occurs. The final stage includes the creation of a comminuted fibular fracture above the level of the syndesmosis. The referenced article by Siegel et al noted that extraperiosteal bridge plating of these ankle injuries was safe and had excellent radiographic and clinical outcomes at final follow-up. Supination - Adduction (SA) Talofibular sprain or distal fibular avulsion Vertical medial malleolus and impaction of anteromedial distal tibia Supination - External Rotation (SER) Anterior tibiofibular ligament sprain Lateral short oblique fibula fracture (anteroinferior to posterosuperior) Posterior tibiofibular ligament rupture or avulsion of posterior malleolus Medial malleolus transverse fracture or disruption of deltoid ligament Pronation - Abduction (PA) Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament sprain Transverse comminuted fracture of the fibula above the level of the syndesmosis Pronation - External Rotation (PER) Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament disruption Lateral short oblique or spiral fracture of fibula (anterosuperior to posteroinferior) above the level of the joint Posterior tibiofibular ligament rupture or avulsion of posterior malleolus

Answer 90

Bone overgrowth is a poorly understood phenomenon in which the bone end undergoes disorganized appositional growth following amputation in a skeletally immature patient. Overgrowth is the most common complication following transosseous amputation in pediatric patients. Krajbich reviews the management of pediatric patients with lower-limb deficiences and amputations. He advocates disarticulation as opposed to transosseous amputation when possible as bone overgrowth has not been observed in bone ends covered by articular cartilage. O'neal et al retrospectively reviewed their rates of surgical revision for bone overgrowth in pediatric and adolescent amputees. The highest rates of revision were seen with metaphyseal-level amputations (50%) and with traumatic amputations (43%). Benevenia et al reviewed their rates of overgrowth in skeletally immature transosseous amputees using an autogenous epiphyseal transplant from the amputated limb to cap the medullary canal. They found that only 1 of 10 patients undergoing amputation with this technique had complications due to bone overgrowth, compared with 6 of 7 patients undergoing traditional transosseous amputation. Incorrect Answers: Answer 1. Neurogenic pain is a concern for adults, but rarely occurs in children. Answer 3. Flexion contracture is not a common complication following amputation in pediatric patients. Answer 4. Adduction contracture is not a common complication following amputation in this patient population. Answer 5. The proximal tibial physis, important for longitudinal growth of the limb, would be sacrificed with a knee disarticulation, meaning the residual limb will be shorter than if the patient had a transtibial amputation.

Answer 91

Marginal impaction of the anteromedial tibial plafond The radiograph demonstrates a Lauge-Hansen supination-adduction fracture-dislocation. There is a transverse fibula fracture and a vertical medial malleolus fracture. McConnell and Tornetta performed a Level 4 review and found that nearly 50% of these injuries have marginal impaction of the anteromedial tibial plafond and they found that anatomic reduction of that aspect of the injury led to good to excellent outcomes. Supination - Adduction (SA) Talofibular sprain or distal fibular avulsion Vertical medial malleolus and impaction of anteromedial distal tibia Supination - External Rotation (SER) Anterior tibiofibular ligament sprain Lateral short oblique fibula fracture (anteroinferior to posterosuperior) Posterior tibiofibular ligament rupture or avulsion of posterior malleolus Medial malleolus transverse fracture or disruption of deltoid ligament Pronation - Abduction (PA) Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament sprain Transverse comminuted fracture of the fibula above the level of the syndesmosis Pronation - External Rotation (PER) Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament disruption Lateral short oblique or spiral fracture of fibula (anterosuperior to posteroinferior) above the level of the joint Posterior tibiofibular ligament rupture or avulsion of posterior malleolus

Answer 92

Adductor myodesis enhances clinical function following an above knee amputation. Adductor myodesis balances the pull of the hip abductors and flexors that insert proximally This prevents an abducted and flexed deformity that encumbers ambulation. It also creates a soft tissue envelope that pads the distal bony amputation and enhances suction fitting of the prosthesis. Performing the myodesis does not preserve femoral length. A little extra distal femur is actually resected to facilitate the myodesis insertion. In an instructional course lecture, Pinzur et al review the goals and techniques of lower extremity amputations. To achieve a successful amputation, the surgeon must establish reasonable goals with the patient, manage the soft tissue envelope, create an osseous platform for weight-bearing, and facilitate physical rehabilitation.

Answer 93

The clinical presentation is consistent with a supination external rotation (SER) injury. An external rotation stress radiograph is the most appropriate method to assess the competency of the deltoid ligament. Plain static radiographs alone can not be relied on to detect deltoid injury, which is one variable used to assess ankle stability. Various preoperative methods have been suggested, including the presence of medial tenderness, allowing the patient to weight bear with follow up radiographs, manual ER stress radiographs, and gravity ER stress radiographs. Evidence shows both a manual or gravity external rotation stress radiograph can indicate deltoid competency, although this isn't absolute. Park et al. performed a cadaveric study of SER ankle injuries and found that a medial clear space of > or =5 mm on radiographs taken in dorsiflexion with an external rotational stress was most predictive of deep deltoid ligament transection after distal fibular fracture. All other stress conditions and increases in medial clear space of 2 or 3 mm were less predictive. DeAngelis et al. performed a study to identify whether medial tenderness is a predictor of deep deltoid ligament incompetence in supination-external rotation ankle fractures. They identified 55 Weber B type fractures, and sought to correlate medial tenderness with positive stress radiographs. They found no statistical significance between the presence of medial tenderness and deep deltoid ligament incompetence. A spiral fibula fracture at the level of the tibial plafond is consistent with a supination external rotation (SER) injury. An external rotation stress with medial clear space widening, indicates incompetent deltoid ligament. Ankle gravity stress test: the patient lies in the lateral position and the ankle is allowed to hang down freely over a support. The Cotton test is intra-operative, and involves direct lateral stress on the fibula with use of a clamp. Incorrect Answers: Answer 1: The anterior drawer assesses the anterior talofibular ligament and is a physical exam test that can be done pre/intra/postoperatively. Answer 4: The lateral stress (Cotton) test is used intraoperatively to assess for syndesmotic injury . This test involves manual/clamp distraction of the fibula away from the tibia under fluoroscopy after stabilization of the lateral and medial malleoli. Supination - Adduction (SA) Talofibular sprain or distal fibular avulsion Vertical medial malleolus and impaction of anteromedial distal tibia Supination - External Rotation (SER) Anterior tibiofibular ligament sprain Lateral short oblique fibula fracture (anteroinferior to posterosuperior) Posterior tibiofibular ligament rupture or avulsion of posterior malleolus Medial malleolus transverse fracture or disruption of deltoid ligament Pronation - Abduction (PA) Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament sprain Transverse comminuted fracture of the fibula above the level of the syndesmosis Pronation - External Rotation (PER) Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament disruption Lateral short oblique or spiral fracture of fibula (anterosuperior to posteroinferior) above the level of the joint Posterior tibiofibular ligament rupture or avulsion of posterior malleolus

Answer 94

Posterior antiglide plating is a technique that involves placement of a plate on the posterior aspect of the distal fibula, using the plate as a reduction tool and direct buttress against distal fracture fragment displacement. Schaffer et al showed from a biomechanical standpoint that posterior antiglide plating was superior to lateral neutralization plating for distal fibula fracture fixation. Weber et al reported a (30/70) 43% rate of plate removal secondary to peroneal discomfort. In addition, peroneal tendon lesions were found in 9 of the 30 patients. - Lateral: lag screw fixation with neutralization plating bridge plate technique - Posterior: antiglide technique, lag screw fixation with neutralization plating, most common disadvantage of using posterior antiglide plating is peroneal irritation if the plate is placed too distally Posterior antiglide plating is biomechanically superior to lateral plate placement

Answer 95

Open reduction internal fixation of the fibula and medial malleolus with syndesmosis reduction and suture-button repair The radiograph demonstrates an ankle fracture-dislocation. There is diastasis of the distal tibia and fibula, indicating a syndesmosis injury. Zalavras et al stated failure to recognize and treat the syndesomsis injury leads to inferior outcomes, and should be assessed after fibula and medial malleolar fixation. Treatment of choice is reduction of the syndesmosis and fixation.

Answer 96

The most common deformity after a midfoot amputation is an equinuovarus deformity due to the pull of the Achilles and plantarflexors in face of loss of the common extensors and distal insertion of the tibialis anterior. Ng et al. review foot and ankle amputations, and review the issues inherent with each amputation level, including prosthesis fitting and use. They also mention that careful repair of all released or transected tendons is needed to maintain a plantigrade foot. Early reviews the importance of soft tissue balancing with midfoot amputations. They note that the attachment of the resected tendons into the more proximal retained bones is critical for success in restoration of foot position and ambulation capabilities. Incorrect Answers: Answer 1, 2, 3, 5: Loss of the common extensor tendons of the toes would not lead to the listed deformities.

Answer 97

Fracture line crossing the acetabulum with disruption of the iliopectineal and ilioischial lines Transverse acetabular fractures separate the innominate bone into two fragments, the superior iliac and the inferior ischiopubic, by a single fracture line that crosses the acetabulum horizontally. The iliopectineal and ilioischial lines are disrupted on the AP pelvis radiograph. Axial CT scan of this fracture pattern at the level of the dome will show a vertical anterior to posterior fracture line. Answer choice 2 is describing a both column injury or anterior column posterior hemitransverse, and answer choice 3 describes a T-type fracture pattern. Answer choices 4 and 5 describe an anterior column and posterior column injury respectively. Judet et al provide one of the first comprehensive reviews on acetabular surgical approaches, fracture types, and radiographic anatomy.

Answer 98

Degree of displacement seen on postoperative pelvic CT scan Moed et al performed a study to determine the clinical outcome in patients in whom a displaced fracture of the posterior wall of the acetabulum had been treated by open reduction and internal fixation. They were able to show good to excellent clinical results for patients who underwent anatomic reduction and internal fixation of posterior wall acetabulum fractures as assessed using radiographs. Fractures in elderly patients and patients who sustained extensive comminution were more likely to have worse clinical result. In a separate study, Moed et al. evaluated the results of 67 patients who underwent ORIF of a posterior wall fractures by assessing the accuracy of postoperative AP pelvis, obturator oblique films, iliac oblique films, and CT scans. They found that postoperative pelvic CT scan was the most accurate way to judge final fracture reduction and was able to pick up residual fracture displacements that were not seen on postoperative plain radiographs. They concluded that the accuracy of reduction as assessed on postoperative CT scan was the most reliable indicator of clinical outcomes. Transverse acetabular fractures separate the innominate bone into two fragments, the superior iliac and the inferior ischiopubic, by a single fracture line that crosses the acetabulum horizontally. The iliopectineal and ilioischial lines are disrupted on the AP pelvis radiograph. Axial CT scan of this fracture pattern at the level of the dome will show a vertical anterior to posterior fracture line.

Answer 99

According to the first referenced study by Egol et al, appropriate braking time returns at a point 6 weeks after initiation of weightbearing after treatment of lower extremity long bone and periarticular fractures, as examined with a driving simulator. No differences were seen in return of braking time between periarticular fractures and long bone injuries. The second reference by Egol studied only operatively treated ankle fractures and found that time to appropriate braking returns at 9 weeks postoperatively. Interestingly, no significant association was found between the functional scores and normalization of total braking time. Supination - Adduction (SA) Talofibular sprain or distal fibular avulsion Vertical medial malleolus and impaction of anteromedial distal tibia Supination - External Rotation (SER) Anterior tibiofibular ligament sprain Lateral short oblique fibula fracture (anteroinferior to posterosuperior) Posterior tibiofibular ligament rupture or avulsion of posterior malleolus Medial malleolus transverse fracture or disruption of deltoid ligament Pronation - Abduction (PA) Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament sprain Transverse comminuted fracture of the fibula above the level of the syndesmosis Pronation - External Rotation (PER) Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament disruption Lateral short oblique or spiral fracture of fibula (anterosuperior to posteroinferior) above the level of the joint Posterior tibiofibular ligament rupture or avulsion of posterior malleolus

Answer 100

Contact pressures from an insturmented hip endoprosthesis can have important implications in both implant positioning and rehabilitation protocols. Hodge et al implanted a pressure-measuring Moore-type endoprosthesis in a patient who had sustained a displaced fracture of the femoral neck. They used this prosthesis to determine the measurement and telemetry of contact pressures in the hip for 36 months post-operatively. The highest pressure, eighteen megapascals, was recorded while the patient was getting up from a chair using the affected leg and was localized in the posterior superior portion of the acetabulum. This can be important in the post-operative care of acetabular fractures, as patients are at increased risk of loss of fixation with greater acetabular contact forces. Interestingly, peak pressures in vivo were found to be considerably higher than previously measured pressures in vitro. Incorrect Answers: 1,2,4,5,-These regions of the acetabulum have less contact pressure compared to the posterior superior portion.

Answer 101

The patient presents with continued ankle pain and instability following open reduction and internal fixation. The radiograph in figure A demonstrates inadequate restoration of fibular length, likely leading to continued tibiotalar instability. Illustration A demonstrates fibular malreduction with dislocation of the fibula anterior to the tibial incisura. Illustration B shows a comminuted fibula fracture along with a measurement of length from an intact fibula. The arc from the lateral process of the talus to the peroneal groove of the distal fibula is known as the "dime" sign and should remain unbroken if fibular length has been restored. Illustration C demonstrates the use of a push-pull screw and lamina spreader to regain length intraoperatively for a comminuted fibula fracture. Chu and Weiner review management of malunions of the distal fibula. The authors state that restoration of fibular length, alignment and rotation leads to reduction of the talus, provides a buttress to talar motion in the setting of an incompetent deltoid, and allows the syndesmotic ligaments to heal at the appropriate tension. Wikeroy et al conducted a study of patients from a prior prospective, randomized control trial comparing different methods of syndesmotic fixation. There was no significant difference in outcomes between tricortical or quadricortical 3.5mm screw fixation, however worse outcomes were seen with associated posterior malleolar fractures, obesity, a difference in sydesmotic width of 1.5mm or greater, and a CT confirmed tibio-fibular synostosis. Sinha et al present a simple technique for fibular lengthening in the setting of distal fibula malunion. They found high union rates and improved AOFAS scores at short-term follow up with their technique.

Answer 102

The talocrural angle is formed by the intersection of a line perpendicular to the plafond with a line drawn between the malleoli (average = 83+/-4deg). When the lateral malleolus is shortened secondary to fracture, this can lead to increased talocrural angle. This malunion leads to lateral tilt of the talus. Phillips et al looked at 138 patients with a closed grade-4 supination-external rotation or pronation-external rotation ankle fracture. Although the conclusions were limited due to poor follow up, they found the difference in the talocrural angle between the injured and normal sides was a statistically significant radiographic indicator of a good prognosis. Pettrone et al looked at a series of 146 displaced ankle fractures, and the effect of open or closed treatment, and internal fixation of one or both malleoli. They found open reduction proved superior to closed reduction, and in bimalleolar fractures open reduction of both malleoli was better than fixing only the medial side.

Answer 103

Figure A shows a lateral malleolar fracture from a rotational-type injury. Evaluation of the medial structures (deltoid ligament) is important for therapeutic reasons, as medial sided instability will portend a poor prognosis if treated nonoperatively. The referenced study by McConnell et al showed that physical exam is a poor indicator of medial ankle injury and that stress radiography is needed for proper medial ankle evaluation. All ankles found to be stable via stress examination healed with an intact mortise. The study by Gill et al showed that gravity stress radiographs are equivalent to manual stress radiographs of the ankle when evaluating rotational ankle fractures. This was true when both pronation-external rotation and supination-external rotation ankle fractures were examined.

Answer 104

A supination-adduction ankle fracture leads to a vertical fracture of the medial malleolus. Traditional fixation of the medial malleolus with oblique screws from the tip of the malleolus directed proximally will ineffectively protect against shear forces at the fracture site; these also are directed quite obliquely to the vertical fracture line, and therefore have poor biomechanical resistance to failure. An antiglide plate is used medially to prevent displacement of the fracture segment due to shear forces. According to the referenced article by Toolan et al, placement of two horizontal (perpendicular to the fracture line) lag screws from medial to lateral are biomechanically the most important aspect of the construct whether a plate is used or not.

Ortho Flashcards

(128 cards)