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1
Q

How to predict risk of growth disturbance?

A

Bone age by radiograph (Greuloch and Pyle Atlas)

Knee radiographs

Menarchal status in females

Tanner staging
–> Tanner 3 and above have less chance of sig issues due to their reduced growth potential

Skeletal growth is usually complete by 14 in gis and 16 in boys

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2
Q

Corona mortis and in which approach to be ligated?

A

Vascular connection between the obturator and external iliac vessels

Located behind the superior pubic ramus at variable distance from the symphysis pubis

To gain visualisation laterally and into the true pelvis during the Stoppa (anterior intra pelvic) approach

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3
Q

Indications for Stoppa approach

anterior intra pelvic approach

A
  1. Acetabular fractures

2. Pelvic ring fractures

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4
Q

Protrusio acetabuli when seen

A

Medial migration of the femoral head past the radiographic teardrop

Seen in:

  1. RA
  2. Marfan’s syndrome
  3. Paget’s disease
  4. Otto’s pelvis
  5. Other metabolic diseases
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5
Q

Rituximab

Rituxan

A

Monoclonal AB to CD20 antigen (inhibits B cells)

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6
Q

Rituximab

Rituxan

A

Monoclonal AB to CD20 antigen (inhibits B cells)

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7
Q

Anakinra

Kineret

A

Recombinant IL1-receptor antagonist

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8
Q

Most frequently injured tarsal bone?

A

Calcaneus

Accounts for 60% of all tarsal fractures and 1-2% of all fractures

Approximately 75% of these have a displaced Intra-articular component

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9
Q

Radiographs for calcaneal fractures

–> 2 important radiographic measurements for measuring the degree of posterior facet collapse

A
  1. AP ankle view
  2. Lateral ankle view
  3. Calcaneal Harris view

–>

  1. Bohler’s angle (normal 20-40°)
  2. Giassane’s angle (normal 120-145°)
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10
Q

Classic appearance of stress fractures in MRI

A

Low signal on T1

Increased signal on T2

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11
Q

Inferior gluteal artery

A

Leaves pelvis beneath piriformis

If it is cut and retracts into the pelvis, then treat by flipping patient, open abdomen, and tie off internal iliac artery

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12
Q

Kocher-Langenbeck approach

A

Posterior approach to the acetabulum

Uses same interval as Southern /Moore approach (no internervous plane (gluteus max innervated by inf gluteal nerve) (vascular plane (upper 1/3 of muscle supplied by superior gluteal artery, lower 2/3 of muscles supplied by inferior gluteal artery))

Provides access to

  1. Posterior wall of acetabulum
  2. Lateral aspect of the posterior column of acetabulum
  3. Indirect access to true pelvis and anterior aspect of posterior column through palpitation
  4. Proximal femur
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13
Q

Functional knee instability

A

Symptom that refers to the sensation of buckling, slippage or giving way of the knee during functional activities

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14
Q

Passive knee laxity

A

Clinical sign that indicates either lack of tension in the capsuloligamentous structures of the knee, or the degree of ‘joint looseness’ on passive motion testing

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15
Q

Which type of nerve is most commonly injured with extension type pediatric supracondylar fractures?

A

Anterior interosseous nerve, a branch of the median nerve, is a principally motor nerve and innervates the flexor digitorum profundus index, the flexor digitorum profundus middle, flexor pollicis longus and pronator quadratus

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16
Q

Henry approach

A

Volar approach to radius shaft

Internervous plane
Proximally between brachioradialis (Radial nerve)
Pronator tere (median nerve)

Distally between
Brachioradialis (radial nerve)
FCR (median nerve)

Supinate arm to minimise injury to posterior interosseous nerve (branch of the radial nerve)

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17
Q

Wartenberg syndrome

A

Superficial radial nerve compression syndrome

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18
Q

Test nerves hand

A

Thumbs up - posterior interosseous nerve (radial nerve)

OK sign - anterior interosseous branch (median nerve)

Cross fingers - (ulnar nerve)

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19
Q

Hip anterior approach

Smith-Petersen

A

Superficial internervous plane
Satorius (femoral nerve)
Tensor fascia lata (superior gluteal nerve)

Deep internervous plane
Rectus femoris (femoral nerve) 
Gluteus medius (superior gluteal nerve)

Dangers
1. Lateral femoral cutaneous nerve, most commonly between sartorius and tensor fascia lata

  1. Femoral nerve
  2. Ascending branch of lateral circumflex artery, Proximally in superficial internervous plane, be sure to ligate to prevent excessive bleeding
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20
Q

What needs to be reduced in Intra-articular radius fractures?

A
  1. Radius height
  2. Articular surfaces
  3. Volar tilt
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21
Q

Metastatic lesions distal to knee/elbow most likely due to

A

Primary lung or renal tumor

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22
Q

Outcome measures of Intra-articular fractures

A
  1. Correction of meta- and diaphyseal deformity
  2. Restoration of joint stability
  3. Restoration of ROM
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23
Q

Glasgow coma scale

A 
Eye opening response
4 spontaneously 
3 to speech 
2 to pain 
1 no response 
Verbal response
5 oriented to time, person and place 
4 confused 
3 inappropriate words 
2 incomprehensible sounds 
1 no response

Motor response
6 obeys commands 
5 moves to localized pain
4 flex to withdraw from pain 
3 abnormal flexion 
2 abnormal response
1 no response

Severe, GCS <8-9
Moderate, GCS 8 or 9-12
Minor, GCS above 13

Usually 3-8 means in coma

Document as GCS 9 = E2 V2 M3 at 07:35

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24
Q

Severe trauma

A

ISS > 16

Injury severity score assigns a score of 1-5 (minor to severe) to six organ systems. The three worst organ system scores are squared, and the ISS is the sum of those three squares.

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25
Revised trauma score
Respiratory rate Systolic blood pressure GCS
26
Principles of damage control
Limit the surgical burden (or 2nd hit phenomenon) on the immune response that occurs in poly-trauma patients with an already high risk of adverse outcome This is based on the finding that prolonged operation on poly-trauma patients can lead to coagulation disturbances and an abnormal immuno-inflammatory state causing remote organ injury
27
CPP Cerebral perfusion pressure
CCP = MAP - ICP (mean arterial pressure) (intracerebral pressure) Autoregulatory mechanisms of cerebral blood flow may be disrupted in severe head injury
28
Hip anterolateral approach
Watson-Jones Intermuscular plane Tensor fascia lata (superior gluteal nerve) Gluteus medius (superior gluteal nerve) Danger Compression neuropraxia of the femoral nerve caused by medial retraction
29
Anterior lumps of the knee
Housemaid's knee (pre-patellar bursa) Clergyman's knee (infra-patellar bursa)
30
3 Tests for knee effusion
1. Ballotment test --> for large effusion 2. Patella tap test --> moderate effusion Obliterate the supra-patellar pouch and press patella posteriorly 3. Wipe (or bulge) test --> small effusion Obliterate the supra-patella pouch and wipe fluid from one side of the patella tendon followed by the other side
31
Pivot shift test
A valgus force is applied to an internally rotated tibia, which, in the presence of a ruptured ACL, subluxes the joint and when the knee is then passively flexed the iliotibial band, in the presence of an intact MCL, reduces the knee joint with a palpable and sometimes audible clunk. Best performed under anaesthesia
32
Differentiate between isolated MCL/LCL tear and rupture of the collaterals + the secondary restraints (cruciates)
Isolated : opening of the joint at 30°flexion (which relaxes the cruciates and isolates the collaterals) Combined : opening of the joint at full extension
33
Clark's test
May indicate chondromalacia or arthritis of the patellofemoral joint Patient supine Patient is asked to contract the quadriceps whilst a hand is placed over the superior pole of the patella with a slight downward pressure --> discomfort
34
Normal T5-T15 kyphosis
20-50° Any degree of kyphosis at thoracolumbar area is considered abnormal
35
Hip direct lateral approach
Hardinge, transgluteal approach No true internervous plane Intermuscular plane Splits gluteus medius distal to innervation (sup gluteal nerve) Vastus lateralis is also split lateral to innervation (femoral nerve) For THA and prox femur fractures
36
Osteoconduction
Promotion of bone opposition to its surface, functioning in part as a receptive scaffold to facilitate enhanced bone formation
37
Osteoinduction
Provision of a biologic stimulus that induces local or transplanted cells to enter a pathway of differentiation leading to mature osteoblasts
38
Major complications following autologous chondrocyte implantation or cartilage grafting
Hypertrophy of the transplant Disturbed fusion of the regenerative cartilage and the healthy surrounding cartilage Insufficient regenerative cartilage Arthrofibrosis Osteonecrosis
39
Osteochondrosis dissecans
Acquired phenomenon localized to the subchondral bone, which can result in destabilisation of the overlying articular cartilage Classic : involves lateral aspect of the medial femoral condyle Males > females Cause multifactorial or microtrauma
40
Classic test for Osteochondrosis dissecans of the knee
Wilson's test Aims to impinge the tibial spine on the OD lesiin Performed by Internal rotation of the involved knee while extending the knee from 90° of flexion The pain is relieved when the same motion is performed with the knee externally rotated
41
Presentation of osteochondrosis dissecans of the knee
Initially : vague knee pain that is worse with activity If the OD is loose or unstable, mechanical symptoms with episodes of giving way and recurrent effusions are common The patient may ambulate with an externally rotated gait On examination : May have effusion, point tenderness over the condyle, and positive Wilson's test
42
Role of MRI in osteochondrosis dissecans
Imaging modality of choice Differentiating between OD and variations of normal ossification centres Can assess lesion size, location, and stability Instability criteria : High intensity signal rim on T2 imaging Articular breach Fluid filled cysts
43
Prognostic features in osteochondrosis dissecans
Skeletal maturity, juvenile better healing Lesion stability
44
Hip medial approach
``` Open reduction of congenital hip dislocation Psoas release (danger medial femoral circumflex artery) ``` Plane Superficial No superficial internervous plane as both adductor longus and gracilis are innervated by the anterior division of the obturator nerve Deep Internervous plane between adductor brevis and adductor magnus Adductor brevis supplied by the anterior division of the obturator nerve Adductor magnus has dual innervation Adductor portion is supplied by the posterior division of the obturator nerve Ischial portion by the tibial portion of the sciatic nerve
45
Which view best depicts acetabular fractures?
Judet view Easily reproducible in the OT for surgical planning
46
Retroperetoneal (anterolateral) approach to the lumbar spine
Can access L1-sacrum Bifurcation of great vessels anterior to L4 vertebral body
47
Only branch of the common iliac vessels
Iliolumbar vein Must be ligated to safely mobilise the common iliac vessels towards midline from laterally
48
Systemic, local and other risk factors for patella tendon rupture
``` Systemic SLE RA DM chronic renal disease ``` Local Patellar degeneration (most common) Previous injury Patellar tendinopathy Other Coricosteroid injection
49
Insall-Salvati ratio
Patella tendon length /patella bone length Patella tendon length Length of posterior surface of the patella tendon from the lower pole of the patella to its insertion on the tibia Patella bone length Patellar length :greatest pole-to-pole length On plain radiographs (30° flexed lateral knee) Patella baja: <0.8 Normal : 0.8-1.2 Patella alta : >1.2 Slightly different values for sagittal MRI
50
Clinical findings of patellar tendon rupture
Inability to extend the knee against gravity Large hematoma Palpable gap below the inferior pole
51
When and why primary repair of ruptured patella tendon
Within 2 weeks to prevent extensor mechanism contracture
52
Most common location of patella tendon rupture
At the junction of the tendon and the distal patella pole
53
Closed kinetic chain exercises
When terminal or distal segment of an appendage is fixed Squat, leg press, pull up
54
Open kinetic chain exercises
When terminal or distal segment is free to move Leg extension, hamstring curl Tend to produce greater shear stresses than closed chain
55
Screw home mechanism
Tibia externally rotates 5° in the final 15° of extension
56
Acute knee swelling may indicate
ACL tear Peripheral meniscal tear Osteochondral fracture Capsule tear
57
Most sensitive view for revealing early knee OA
Rosenberg view | Weight-bearing 45-degree knee flexion posteroanterior
58
Radiographs used in pediatric patients to evaluate injury to the femoral physis and to differentiate it from an MCL injury
Stress radiographs Used to characterise PCL, MCL, LCL, PLC injuries
59
Arcuate sign on knee radiographs
Avulsion of tip of fibular head
60
Block of knee ROM
Meniscus (bucket handle) injury Loose body Impingement of ACL tear
61
Kissing lesion
Chondral lesions adjacent to each other on the femur and tibia
62
Pellegrini-Stieda sign
Calcification at the medial femoral condyle insertion May be present in chronic MCL injuries Usually responds to a brief period of immobilisation followed by progressive motion
63
MCL injuries occur most commonly at Treatment
The femoral condyle Non-operative treatment (hinged knee brace) highly successful
64
What to check in LCL injury?
Rarely isolated, check for PCL and PLC injury 10% associated with peroneal nerve palsy

Orthopaedics HARIBO (12 decks)

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