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Flashcards in SAQ Deck (508):
1

What are 7 neurological causes of pes cavus aside from?

CMT
CP
Diastematomyelia
Stroke or closed head injury
Freidreich's ataxia
Huntington's chorea
Arthrogryposis

2

What are the 3 most common procedures performed after a terrible triad?

Column procedure
Radial head arthroplasty for failed ORIF
TEA

3

6 design features to reduce IM pressure during reaming?

Deeper flutes
Larger diameter bulb tip
Slower speed of rotation
Sharp reamer
455 stainless steel
Titanium nitride coating

4

8 risk factors for Pavlik harness failure?

Bilateral
Teratologic
Ortolani negative
Initiation of treatment after 7 weeks
Male
Inappropriate application
Femoral nerve palsy
Patient noncompliance

5

5 infantile disorders with thickened cortices/periosteal calcifications?

Caffey's disease
Scurvy
Rickets
Hypervitaminoses (A and D)
Congenital syphilis

6

8 risk factors for Dupuytren's disease?

Male
Advanced age
Manual laborer
Smoker
Alcohol
HIV
Diabetes
Anti-epileptics

7

6 indications for surgery in a Rheumatoid C-spine?

Progressive myelopathy
ADI >10mm static
ADI >4mm dynamic (ie: 4mm more on flex vs. ex view)
SAC <14mm
Tip of the dens past McRae's line
Tip of the dens >5mm above McGregor's line
>20% C3-C7 subluxation with neuro symptoms/severe pain

8

7 principles of tendon transfers?

Expendable donor tendon
Donor tendon has similar strength and excursion
Straight line of pull
Supple joint
One tendon performs one function
Synergistic function
Lose 1 point on power grade after transfer

9

Name 3 local complications related to metal toxicity

Pseudotumour
Metallosis (aseptic local necrosis secondary to metallic corrosion)
ALVAL (aseptic lymphocitic vasculitis associated lesion - T-cell mediated type IV hypersensitivity reaction to Co and Cr ions)

10

Name 4 principles for maintaining reduction in a length-stable pediatric femur fracture managed with Nancy nails

>80% canal fill
More nails to increase rigidity
Pre-contour nails to achieve adequate spread at fracture site
Use end caps to improve axial stability

11

What's an indication to do a metabolic work-up in SCFE?

Patient <10 yo or <50%ile for body weight

12

List 4 endocrine abnormalities associated with SCFE

Hypothyroidism
Panhypopitutiarism
Growth hormone deficiency
Renal osteodystrophy

13

Name 5 methods to reconstruct a zone 2 (periacetabular) pelvic lesion

Curettage and cementplasty
Conventional THA
THA with reinforcement ring/reconstruction cage
Harrington procedure (primary THA reinforced by 3 steel pins/screws from the iliac crest down and cement)
Megaprosthesis

14

List 6 complications of an HTO

Intra-articular fracture propagation
Recurrence of deformity (60% at 3 years)
Patella baja
Decreased posterior slope
Compartment syndrome (recurrent anterior tibial)
Malunion/non-union

15

3 advantages of a distal femoral locking plate over a DCS

Better fixation in osteoporotic bone
Better control of coronal-plane fractures
More bone preserving (screw removes a lot of bone)

16

6 radiographic features of FAI

Alpha angle >55
LCEA >39
Tonnis angle <0
Head-neck offset ratio <0.17
Crossover sign
Ischial spine sign

17

List 8 risk factors for infection in THA

Active infection
IVDU
Revision surgery
Diabetes
Obesity
Rheumatoid arthritis
Immunosuppression (HIV)
Smoker

18

List 8 radiographic features of aortic dissection on CXR

Widened mediastinum
Widened paraspinal stripe
Widened paratracheal stripe
Indistinct aortic contour
Right trachial deviation
Left depressed mainstem bronchus
Left apical pleural cap
Left large haemothorax

19

List 4 major and 4 minor criteria for fat embolism

1 major and 4 minor criteria required to make Dx.

Major: hypoxia, pulmonary edema, petechiae, CNS depression
Minor: fat in urine or sputum, tachycardia, fever, sudden indexplicable drop in platelets

20

List 6 orthopaedic features in the diagnostic criteria of Marfan's

Pectus excavatum requiring surgery
Reduced elbow extension
Positive wrist and thumb signs
Scoliosis or spondylolisthesis
Protrusio
Medial displacement of medial malleolus (pes planus)

21

List 5 non-orthopaedic features of Marfan's

Lens dislocation
Aortic dilatation
Aortic dissection
Mitral valve prolapse
Spontaneous pneumothorax

22

List 5 indications for immediate amputation in trauma

Medically unfit for surgery
Crush injury with warm ischemia time >6h
Crush injury with cool ischemia time >12h
Irreparable vascular injury
Complete laceration of sciatic or tibial nerve

23

List 3 methods of determining if a femoral neck fracture is anatomically-reduced in a young patient

Direct inspection through Smith-Peterson approach
Lowell alignment theory (head-neck should form an "S" on both the AP and lateral views)
Garden compression trabecular index (160 deg on AP and 180 deg on lateral)

24

List 8 surgical considerations in the management of severe hallux valgus

1st MTP OA?
1st TMT instability/OA?
Sesamoid OA?
Medial eminence prominence?
HVIA <9
DMAA <9
HVA <15
IMA <9

25

What are 10 risk factors for vision loss in spine surgery?

Male
Diabetes
PVD
Obesity
Preoperative anemia
Long procedure
Perioperative blood loss >1L
Hypotension
Prone positioning
No colloid used during resuscitation

26

What are the 4 principles of causality?

Strength of the association
Specificity of the association
Temporality
Reversibility

27

Explain the difference between blinding and concealment of allocation

Blinding: patient, their family, treating team and anyone involved in outcomes assessment is unaware to the intervention performed.

Concealment of allocation: individual who is enrolling participants does not know in advance which study arm each successive patient will be enrolled to.

28

List 4 indications for hemiresection and interpositional arthroplasty of the DRUJ

Painful arthritis (OA, RA, PTA)
Ulnocarpal impaction with radio-ulnar incongruity
Absence of longitudinal forearm instability
Absence of post-traumatic ulnar subluxation of the carpus

29

List 6 indications for MRI in juvenile scoliosis

Any child <10 with >20 degree curve
Short, sharp curve
Rapidly progressing curve
Asymmetric abdominal reflex
Upper motor-neuron signs
Associated cavus foot

30

List 3 risk factors for the development of metastasis in an isolated soft tissue sarcoma

High-grade tumour
Resection with positive margins
Local recurrence

31

Which 2 muscles are commonly transferred after a proximal humerus resection and endoprosthetic reconstruction?

Pectoralis major
Latissimus dorsi

32

Which 3 muscles require transfer after a proximal femoral resection and endoprosthetic reconstruction?

Iliopsoas
Short external rotators
Abductors

33

What % of resected and reconstructed (a) distal femoral and (b) proximal tibial tumours require a medial gastrocs flap for coverage?

(a) 25%
(b) 100%

34

What's the overall survival of an endoprosthetic reconstruction at 10 years? Which location has the worst?

85% (worst for proximal tibia, best for proximal humerus)

35

Which 4 factors facilitate local high-grade sarcoma spread in the shoulder as compared to other joints?

Direct capsular extension
Spread along the LHBT
Fracture hematoma from pathologic fracture
Inappropriately-planned biopsy

36

If a proximal humerus tumour involves the axillary/brachial artery, what's the implication?

Brachial plexus is also involved due to proximity to the artery (axillary vein, artery and brachial plexus are all within the axillary sheath), and so this is a contraindication to limb salvage

37

What are the 2 contraindications to a forequarter amputation?

Chest wall extension
Extension into the posterior triangle of the neck

38

Optimal position for wrist fusion? What about if bilateral?

10-15 deg extension, slight ulnar deviation.
If bilateral, other side in neutral.

39

What are the only 2 proven benefits to repair vs. accelerated rehab for achilles ruptures?

Better plantarflexion strength
Earlier return to work

40

What are the 3 risk factors for wound complications after achilles repair?

Female
Smoker
Steroid use

41

Rank CRPP, ORIF, RSA, HA for proximal humerus fractures in terms of highest (a) complications, and (b) revision rate

(a) CRPP, RSA, ORIF, HA
(b) ORIF, RSA/HA, CRPP

42

What are the 3 indications for ankle distraction arthroplasty?

Young patients with post-traumatic arthritis
Congruent joint
>20 degree arc of motion

43

How much distraction is needed in an ankle distraction arthroplasty?

5mm

44

What are the 2 predictors of failure in ankle distraction arthroplasty?

Female
<20 degree arc of motion

45

What's the diagnosis if you see an athlete with pubic pain and widening/lysis of the symphysis on XR?

Chronic osteitis pubis (due to repetitive pull of the adductors and rectus abdominis on the pubic symphysis)

46

What's the diagnosis if a patient presents with abdominal pain that radiates to the groin which is exacerbated by sport and relieved by rest?

Athletic pubalgia ("sports hernia" -- tear in abdominal wall)

47

Which nerve should be neurolysed when doing a repair for athletic pubalgia?

Genital branch of genitofemoral nerve

48

What is the hip labrum innervated by?

Branches of obturator nerve and nerve to quadratus femoris

49

By how much (%) does the labrum increase intra-articular contact surface and volume? Without it, how much do femoroacetabular contact pressures increase by?

Surface: 22%
Volume: 33%
Contact pressures: 92%

50

Has there been any level I/II evidence of better outcomes for labral repair vs. debridement?

Yes, repair is better in females with FAI. However, a recent Philippon JBJS study showed no difference at 10 year follow-up

51

When are C. diff infections considered community-acquired vs. hospital-acquired?

Community: <48h after admission or >12 weeks after discharge
Hospital: >48h-4 weeks after admission

52

List 6 risk factors for acquiring C. diff

Age >65
Diabetes
Prolonged hospital admission
Revision surgery
Multiple antibiotic exposure (especially Clinda)
Bowel surgery

53

What's the treatment for C. diff collitis (mild, moderate, severe, severe with elevated lactate, recurrence)?

Mild: PO Flagyl
Mod: PO Vanco
Severe: PO Vanco + IV Flagyl
Severe with lactate >5 or WBC >50: subtotal colectomy
Recurrence: Vanco, not Flagyl

54

What constitutes an acceptable reduction after ORIF of a distal radius?

Radial inclination >15
Volar tilt >15
Radial shortening <2mm
Articular incongruity <2mm
Sigmoid notch incongruity <2mm

55

Which ACL test has the best sensitivity and specificity?

Sensitivity: Lachman
Specificity: Pivot-shift under EUA

56

What's the first pelvic apophysis to appear and when does it ossify?
What's the last pelvic apophysis to appear and when does it ossify?

First: AIIS (4, 17)
Last: ASIS (17, 25)

57

What are 3 symptoms of lead toxicity after a retained bullet?

Cramping
Constipation
Seizures

58

When should you treat lead toxicity with chelation therapy?

Blood levels >0.45 μmol/L

59

List 6 general risk factors for HO

Male
Previous HO
Multiple surgeries
Closed head injury
Prolonged mechanical ventilation
DISH

60

In what situation is static progressive splinting used these days?

In patients with severe head injuries to prevent elbow and ankle equinus contractures (ICU)

61

What's the average wear rate of HXL-UHMWPE?
At what annual wear rate do you get concerned for osteolysis?

Average: 0.02mm/y
Concern: 0.2mm/y

62

1. What are the cutoffs for ESR, CRP, cell count and %PMNs for chronic hip and knee infection?
2. What are the cutoffs for an acute PJI?
3. What are the cutoffs for a native joint?
4. What are the cutoffs for gout/pseudogout?

1. Hip: CRP >10, ESR > 30, Cell count >3,000, PMNs >80%
Knee: CRP >10, ESR >30, Cell count >1,100, PMNs > 65%
2. >10,000 cells, PMNs >90%
3. >50,000 cells
4. >25,000 cells

63

List 4 ways to measure wear in a THA

Linear wear
Volumetric wear
Dual circle technique
Radiostereometric analysis

64

How do you determine if a THA is "stable" intraoperatively?

Flexion >90
IR >45 with hip flexed to 90
ER >15 with hip extended

65

List 3 ways to test for malnourishment and their cutoffs

Albumin <35
WBC < 1.5
Transferrin <20

66

List 3 intraoperative considerations for obese patients undergoing a TKA

Reverse Trendelenburg is best for ventilation
Computer navigation
Stemmed tibial baseplate

67

Where is type I collagen found?

Bone, ligaments, sclerae, dentin

68

What are the spinal manifestations of patients with OI?

Basilar invagination
Scoliosis
Kyphosis
Spondylolisthesis

69

What are the 4 types of OI, their features and inheritance pattern?

I: mild (blue sclerae, fractures after walking age, mild scoliosis) -- AD
II: deadly intra-uterine -- AR/spontaneous
III: severe (fractures before walking age, spinal manifestations, dentinogenesis imperfecta, joint instability) -- AR/spontaneous
IV: intermediate (less severe form of type III) -- AD

70

What non-operative modality has been shown to reduce fracture rate and prevent scoliosis progression in OI?

Bisphosphonates (if started before age 6)

71

How do you treat scoliosis in OI?

Bracing doesn't work; fuse when >45 degrees and consider cement augmentation through fenestrated screws at the most proximal and distal levels

72

How do you treat basilar invagination that doesn't reduce with intraoperative traction?

Staged approach (trans-oral decompression followed by occiput-C2 posterior fusion usually 1 week later)

73

List 5 intraoperative considerations when managing any patient with OI

Difficult airway (large head, short neck)
Gentle transfer to table (fracture risk)
Avoid tourniquet use (fracture risk)
Avoid succinylcholine (can cause fasciculations = fracture risk)
Increased bleeding risk

74

What are 4 complications of a vascularized fibular transfer in pediatric patients with open physes?

Peroneal nerve injury
Claw toes (FHL)
Syndesmotic instability (consider doing a synostosis for distal harvests)
Ankle valgus deformity (from distal tibial growth arrest)

75

List 6 complications of halo gravity traction

Pin infection
Skull penetration (don't use in patients <18 mo)
Cranial nerve VI palsy (lateral gaze)
Brachial plexus palsy
Odontoid AVN
SMA syndrome

76

Where is the humeral head center of rotation relative to the intramedullary canal?

5mm medial and posterior

77

What are the 4 red flags for back pain?

Night pain
Constant pain
B symptoms
Back pain in patients <10

78

What's the Sorensen criteria for Scheueremann's kyphosis?

>5 degree anterior wedging at 3 adjacent levels
>45 degree local kyphosis

79

What's the typical fusion level in Scheuermann's kyphosis? When is surgery indicated (4)?

T2-include first lordotic disc

Surgery when:
1. >75 degree kyphosis
2. Pain not managed adequately without surgery
3. Neurologic symptoms
4. Failed conservative treatment

80

What proportion of vertebral osteomyelitis shows (a) leukocytosis, (b) positive blood cultures, (c) organism identified on biopsy?

(a) half
(b) one third
(c) most

81

What are the surgical indications for FDP reconstruction?

1. failed zone II repair
2. supple joint
3. no neurovascular injury
4. disrupted FDS (can still do it if FDS is intact by releasing FDS insertion on the middle phalanx and repairing it end-to-end to the distal FDP stump, but some people recommend against it since an intact FDS still provides reasonable function).

82

Describe the general principles of a 2-stage Hunter procedure for a flexor tendon reconstruction

First stage: insert silicon rod in the flexor tendon sheath and reconstruct the pulleys as needed (A2 and A4 most importantly).

Second stage: 3 months later, remove silicon rod and insert tendon graft (palmaris, plantaris)

83

Describe the Seddon and Sunderland classification of nerve injuries and expected prognosis for each

I: Neurapraxia (full recovery, up to 2 months)
II: Axonotmesis with intact endoneurium (mostly full recovery, 2-4 months)
III: Axonotmesis with disrupted endoneurium (partial recovery, 12 months)
IV: Axonotmesis with disrupted endo- and perineurium and only epineurium intact (poor recovery)
V: Neurotmesis (no recovery)

84

What tendon transfer is used for a foot drop (peroneal palsy)?

PTT through IOM to the lateral cuneiform (4 incision technique)

85

List 5 risk factors for failure of bracing in AIS

Male
Suboptimal correction in-brace
Non-compliance
Obesity
Hypokyphotic thoracic curve

86

List 5 ways to determine appropriateness of humeral implant height

5.6 cm above upper border of pectoralis major
0.8 cm above GT
1 cm below lateral acromial edge
Anatomic reduction of the tuberosities
Measure resected head

87

Which 3 structures can block reduction of a medial subtalar dislocation? What about lateral?

Medial: EDB, deep peroneal bundle, TN capsule
Lateral: Tib post, but also FHL, FDL, posterior tibial bundle

88

Where are pediatric trigger fingers most commonly located? What % spontaneously resolve? What's the treatment if conservative management fails?

Thumb.
50%.
A1 pulley release (if digit other than thumb is involved, A1 pulley release is not adequate since disease involved A3 pulley as well and has multiple nodules in the tendon).

89

What 5 endocrine abnormalities is polyostotic fibrous dysplasia associated with?

Hyperthyroidism
Hyperprolactinemia
Cushing's
Hypophosphatemia
Acromegaly

90

List 5 extra-osseous manifestations of fibrous dysplasia (McCune-Albright and Mazabraud syndrome)

Hyperthyroidism, hyperparathyroidism, precocious puberty, cafe-au-lait spots (M-A syndrome) and intramuscular myxomas (Mazabraud)

91

What's the difference between the cafe-au-lait sports in neurofibromatosis vs. McCune-Albright syndrome?

NF1: "coast of California" smooth appearance
M-AS: "cost of Maine" roughened appearance

92

What is the histological hallmark of fibrous dysplasia?

Inability to produce mature lamellar bone from immature woven bone with "alphabet soup" appearance

93

What can exacerbate fibrous dysplasia?

Pregnancy (increased number of hormones, and osteoblasts in FD have more hormone receptors)

94

When are bisphosphonates used in fibrous dysplasia

Polyostotic form

95

Which bone graft should you use in fibrous dysplasia?

Cortical or cancellous allograft (never autograft)

96

What are the zones of the physis?

1. Trabecular bone zone
2. Zone of provisional calcification
3. Zone of hypertrophy (weakest)
4. Zone of proliferation (entire growth depends on this)
5. Resting zone

97

List 6 factors that can lead to reduced knee extension after ACLR

Cyclops lesion
Arthrofibrosis
Anterior tibial tunnel placement (notch impingement)
Graft tensioning in 30 degrees of flexion
Failed bucket handle meniscal repair
Delayed physiotherapy

98

List 4 structures that can contribute to a swan-neck deformity in patients with RA

1. FDS rupture
2. PIP volar plate rupture with dorsal subluxation of lateral bands
3. Collateral extensor band rupture (mallet finger)
4. Volar subluxation of MCP joint

99

List 4 malignant transformations of fibrous dysplasia

Osteosarcoma
Chondrosarcoma
MFH
Fibrosarcoma

100

What are 5 methods to diminish blood loss during spine surgery?

Permissive hypotension (aim for MAP 80)
Acute normovolemic hemodilution
Epidural blockade (vasoconstricts proximally)
TEXA
Electrocautery use

101

List 6 risk factors for non-therapeutic opioid use

Age <45
History of drug abuse
Family history of drug abuse
Smoker
Pre-operative opioid use
Mental illness

102

List 4 features of infantile scoliosis that suggests the deformity will progress

Mehta predictors of progression:
1. Cobb angle >20
2. RVAD >20
3. Phase 2 rib
4. Progression >6 degrees/year

103

What's the feared complication in an infant with granulomatous vertebral osteomyelitis? What are 6 risk factors?

Buckling collapse (>120 degree kyphosis)

Risk factors:
1. Pre-treatment kyphosis >30 degrees
2. Junctional level
3. Gapping of facet joints
4. Retropulsion of infected vertebra
5. Lateral listhesis
6. Toppling

104

List 4 radiographic risk factors for progression of infantile Blount's

Drennan angle >16
Epiphyseal distortion
Langenskiold IV-VI
Progressive varus

105

List 5 radiographic findings of femoral head AVN in DDH

Delayed development of ossific nucleus
Fragmentation of ossific nucleus
Lateral physeal irregularity
Metaphyseal widening
Varus neck with GT overgrowth

106

List 5 radiographic findings in pediatric rheumatoid spine

Apophyseal fusion (C2-3 usually)
Dens waist erosion (apple core deformity)
Atlantoaxial instability
Hypoplastic vertebral bodies
Loss of cervical lordosis

107

List 6 risk factors for non-union in type II odontoid fractures

Age >40
Gapping >1mm
Posterior displacement >5mm
Posterior re-displacement >2mm after start of treatment
Angulation >11 degrees
Comminution

108

List 4 seronegative spondyloarthropathies

Ankylosing spondylitis
Psoriatic arthritis
Reiter's sydnrome
Inflammatory bowel disease-associated arthropathy

109

List 3 reasons to prophylactically pin the contralateral hip in SCFE

SCFE associated with endocrinopathy
Age <10
Obesity (>90%ile)

110

List 5 pediatric manifestations of Peyronie's disease

Bent penile erections
Painful erections
Penile plaques
Penile numbness
Decreased penile rigidity

111

List 5 causes of lower extremity Charcot arthropathy other than diabetes

ETOH
Myelomeningocoele
Syrinx
Syphilis
Spinal cord injury

112

List 4 compliciations associated with BMP-2 use in spine surgery

Ectopic bone formation
Seroma
Post-operative radiculitis
Carcinogenic

113

List 3 strategies for safe tourniquet usage for surgeries that are expected to take longer than 2.5 hours

1. Use wider cuff
2. Let tourniquet down at 2h for 10 minutes, then 10 minute down-times at hourly intervals
3. Inflate 75 mmHg >limb occlusion pressure

114

Does GA or spinal anesthetic have a higher complication rate in TKA, and list 4 complications?

GA (infection, pneumonia, AKI, mortality)

115

What nerves are blocked by an adductor canal block?

Saphenous
Obturator nerve branches
Medial retinacular branches
Nerve to vastus medialis (motor)

116

List 4 indications for debridement in isolation for shoulder OA?

Young laborer
Concentric joint
Small osteophytes
<2cm OCDs

117

List 3 predictors for requiring a THA following a hip arthroscopy?

Older age
<2mm joint space
Microfracture required

118

What's a normal talocrural angle?

8-15 degrees (angle between a line perpendicular to the tibial plafond articular surface and a line connecting the malleoli)

119

What is PDGF approved for in Canada?

Hindfoot fusions

120

What is the risk of PGDF use?

Carcinogenic with topical form (not with rhPDGF that is used in foot and ankle fusions)

121

What is BMP approved for in Canada?

Lumbar fusions
Open tibia fractures

122

What do NSQIP databases measure? Is IRB required to analyse the data?

Pre-operative events
Post-operative events
Comborbidities
30-day morbidity and mortality

IRB is not required since patients are de-identified

123

What's the initial non-operative treatment of a UCL injury?

Throwing cessation for 3 months
Elbow strengthening
Mechanics re-structuring
Graduated painless return-to-throwing program

124

List 5 risk factors for a pediatric VTE

Infection surgery
Hyponatremia
Hematologic disorder
Abnormal PTT
Elevated AST

125

List 4 downsides of minimalist running vs. shod running (heel-strike)

1. Increased gastrosoleus injuries (eccentric contraction as forefoot or midfoot strike the ground)
2. Increased base of metatarsal stress fractures
3. Higher risk of puncture wounds
4. Higher risk of plantar fasciitis

126

List 2 benefits of minimalist running vs. shod running

1. Less patellofemoral pain
2. Less joint reactive forces on the hip (center of gravity shifts more centrally)

127

List 6 negative prognostic factors in TTC nailing

Diabetes
PVD
Previous foot ulcerations
Smoker
Rheumatoid arthritis
Chronic steroid use

128

The _____ an extra-articular knee deformity is to the knee, the _____ the impact is on alignment

closer, greater

129

When can you manage an extra articular (a) femoral and (b) tibial deformity simply with soft-tissue balancing and not an extra-articular osteotomy?

Far from the joint line
<20 degree deformity in the femur
<30 degree deformity in the tibia

130

List 6 clinical features of ankylosing spondylitis

Bilateral sacroiliitis
Inflammatory back pain (>3 months)
Progressive kyphosis (chin-to-chest)
Anterior uveitis
Peripheral joint arthritis
Enthesopathy

131

How many levels above and below a fracture in ankylosing spondylitis should be included in the fusion?

3

132

List 2 complications specific to spine surgery in ankylosing spondylitis

Epidural hematoma
Aortic dissection

133

Which PCL bundle is largest and strongest?

Anterolateral

134

What's the position of fusion for D2-5 MCPs and PIPs?

MCPs: start at 25 degrees for D2, then increase by 5
PIPs: start at 40 degrees for D2, then increase by 5

135

Describe the (a) incision and (b) fixation choice for MCP/PIP fusion

(a) curved incision (allows both MCPs and DIPs to be addressed if needed)
(b) crossed K-wires have a proven track-record

136

List 4 special considerations when nailing a femur fracture in a patient with OI

1. Increased fracture risk
2. Non-linear canal due to previous fracture healing
3. Atypical femoral bowing (may need to do multiple osteotomies to pass the nail)
4. Short limb (may need to use pediatric implants)

137

List 2 special considerations when performing a THA in a patient with OI

1. Acetabular protrusio (may need to either bone graft and use screws vs. cup-cage)
2. Cement the femur always

138

What's the risk of femoral head AVN in hip dislocation if it was reduced within 6 hours and >6 hours?

<6h: 5%
>6h: 50%

139

What's the definition of proximal junctional kyphosis?

>10 degree Cobb angle and >10 degree change from pre-operative films at the top level of the fusion

140

List 6 risk factors for PJK

Combined approached
Fusion to sacrum (more rigidity but also worse curve)
Pedicle screws at all levels (increased rigidity)
>5 degree kyphosis at UIV preoperatively
High preoperative pelvic incidence (saggital imbalance)
Osteopenia

141

List 5 strategies to diminish the risk of PJK

Single approach without disruption of PLC at UIV
Hooks at UIV rather than screws (soft landing)
Strategic use of pedicle screws if all-screw construct
Instrument one level above UIV if >5 degree kyphosis
Osteotomies to correct saggital imbalance

142

List 5 factors associated with trunnion wear

Larger head
Increased offset
Varus neck
Dissimilar metals
Smaller, more flexible necks

143

What's the optimal fixation for C1-C7?

C1: lateral mass screws
C2: pars or intra-laminar screws
C1-2: trans-articular screws (if C1-2 is reduced)
C3-6: lateral mass screws
C7: lateral mass/pedicle screws

144

List 3 risk factors for navicular stress fractures

Long 2nd metatarsal
Metatarsus adductus
Equinus contracture

145

What % of patients with chronic (>2 weeks) elbow dislocations will have HO?

75%

146

List 4 structures that are pathologic in a chronic elbow dislocation

Triceps contracture
Collateral contracture
Capsular contracture
Arthrofibrosis

147

What's the best approach for dealing with a chronic elbow dislocation and why?

Medial and lateral paratricipital (Kocher interval extension laterally) since you can transpose the ulnar nerve which is often needed as well as release the collaterals to achieve reduction then repair them

148

List 3 indications for triceps lengthening in a chronic elbow dislocation

>3 months
<100 degrees of flexion after other releases performed
>5cm overlap between humerus and olecranon on AP

149

List 3 ways to achieve lengthening of the triceps

Triceps mobilization from distal humerus
Anconeus slide
Triceps V-Y lengthening

150

What are the 2 indications to perform a supramalleolar osteotomy?

1. Asymmetric varus/vaglus deformity with >50% tibiotalar articular surface preserved
2. To correct alignment for planned ankle arthrodesis/arthroplasty

151

List 5 contraindications to a SMO

Hindfoot instability
Age >70
Inflammatory arthritis
Charcot foot
Severe PVD

152

How can you determine if an ankle asymmetric varus/valgus deformity is originating from within the joint or outside?

If the difference between the *distal tibial plafond angle and **talar articular angle is >4 degrees, it means there's an intra-articular deformity. If the total amount of varus/valgus deformity on the Saltzman hindfoot alignment view exceeds that value, then there's also an extra-articular deformity.

*Distal tibial plafond angle is the angle between the anatomic axis of the tibia and the tibial plafond.
**Talar articular angle is the angle between the anatomic axis of the tibia and the talar dome.

153

Describe the principles behind a SMO for an extra-articular varus deformity (1. where it's done; 2. what correction you aim for; 3. how you deal with the fibula)

1. Medial opening wedge at the CORA for <15 degree correction; medial opening dome osteotomy at the CORA for >15 degree correction.
2. Aim for 4 degrees of valgus at the level of the ankle joint (anatomical axis of the tibia to pass just lateral to the center of the ankle joint)
3. Fibular osteotomy required if >10 degree correction.

154

What may need to be done if you're doing an opening dome SMO for an extra-articular varus deformity?

Lengthening of posteromedial structures
Tarsal tunnel release

155

Describe the principles behind a SMO for an extra-articular valgus deformity (1. where it's done; 2. what correction you aim for; 3. how you deal with the fibula)

1. Medial closing wedge at the CORA for <15 degree correction; medial closing dome osteotomy at the CORA for >15 degree correction.
2. Aim for 4 degrees of varus at the level of the ankle joint.
3. Almost always requires a fibular osteotomy.

156

Which approach is used for a medial wedge vs. dome (opening or closing) osteotomy?

Wedge: medial approach
Dome: anterior approach

157

List 3 treatment strategies for prevention of PJK

Teriparatide (better than bisphosphonates)
Use hooks at UIV (soft landing)
Cement augmentation at UIV

158

List 8 risk factors for development of a pseudarthrosis after an attempted spine fusion

Uninstrumented fusion
Multilevel fusion
L5/S1 level
Smoker
Diabetes
Steroid use
NSAIDs
Bisphosphonates

159

Where's the location of the anatomic femoral ACL tunnel?

8mm anterior to posterior articular margin
1.7mm proximal to the bifurcate ridge (ridge that divides the AM and PL bundles)

160

Describe the ossification of the clavicle

Lateral: intramembranous
Medial: endochondral

161

Is diaphyseal endosteal blood flow centripetal or centrifugal?

Centrifugal in adults (starts of centripetal in paeds)

162

Describe the course of the MFCx artery

Branch of profunda femoris (75%) or femoral artery proper (25%), runs between psoas and pectineus, then between obturator externus and adductor brevis, then it gives off ascending branch (femoral head), acetabular branch, transverse branch and posteroinferior branch.

163

What's a donor artery option for vascularized fibular grafts?

Ascending branch of the LFCx

164

What two arteries are at risk in a Kocher-Langenbeck approach?

MFCx
Inferior gluteal (supplies GMax; emerges from GSN between piriformis and superior gemellus)

165

What's the blood supply to the acetabulum?

Acetabular artery (branch of obturator -- supplies the triradiate cartilage)
SGA
IGA
Ischial artery (branch of internal pudendal)

166

How much bone superior to the acetabulum should be left intact during a PAO to preserve the blood supply?

2-2.5cm

167

List 1 high-profile medical device failure

DePuy ASR metal-on-metal hip (4 x std revision rate)

168

List the 4 pertinent findings of the BRAIST trial (bracing vs. observation in AIS patients with 20-40 degree curves between Risser 0-2)

78% of braced didn't progress past 50 degrees vs. 48%
NNT was 3 to avoid 1 surgery
>13 hrs/d was the threshold for a >90% success
No difference in QOL scores for bracing vs. observation

169

When is the Providence brace indicated?

TLSO used mostly for lumbar curves (per Dr. Smit)

170

When is the Rigo brace effective?

Most AIS curves (thee-dimensional curve correction) -- can be worn during the day and night

171

What's the goal of curve correction when the brace is applied?

About 50%

172

List 8 contra-indications to participation in strenuous physical activity after a C-spine fracture

Occipital-cervical fusion
C1 ring non-union
C1-2 residual instability
Subaxial instability
Loss of cervical lordosis
Pavlov ratio <0.8 (narrow canal from retropulsed frag.)
3 or more level arthrodesis
Neurological symptoms

173

What's the most common site of metastasis in the hand?

Distal phalanges (thumb most commonly)

174

Where are hand enchondromas usually found?

Proximal phalanges

175

List 4 local treatment adjuncts after intralesional curettage in GCTs and enchondromas

Phenol
Dehydrated alcohol
PMMA
Liquid nitrogen (can cause skin burns, neuropraxia)

176

How does MSSA become MRSA?

It gains resistance to b-lactams via 4 types of staphylococcal cassette chromosomes, which allow for transfer of the mecA gene to S. aureus (types I-III cassette chromosomes are associated with hospital-acquired MRSA, while type IV is associated with community-acquired). The mecA gene encodes for a penicillin-binding protein that has a low affinity for b-lactams, hence resulting in resistance.

177

What are the most common bacteria in septic arthritis in patients <1, 1-5 and >5?

<1: Staph species, GBS
1-5: S. aureus, S. pneumo, Kingella Kingae, H. flu
>5: S aureus, N. ghonorrhea

178

What's the Kocher criteria (including CRP)?

Fever
WBC >12
CRP >20
ESR >40
Refusal to weightbear

179

What's the diagnostic criteria for juvenile idiopathic arthritis?

Fever >2 weeks
Effusion >6 weeks
25,000-100,000 cells on aspirate
<75% PMNs on aspirate

180

List 5 factors associated with successful closed reduction in DDH

Appropriate timing (<6 months)
Pre-reduction traction
Medial die pool <5mm
Adductor tenotomy
Maintenance of reduction on post-operative CT

181

What's the safe zone for spica casting in DDH?

100 degrees flexion
<55 degrees abduction

182

How can you growth modulate a coxa valga?

Single screw inserted just below the GT aiming for the inferior 1/3 of the femoral head epiphysis

183

Define toughness

Area under the stress-strain curve

184

What's the optimal % screw density for a bridge plate?

50%

185

Compared to patients <80 yo undergoing THA/TKA, what risks are patients >80 subject to?

3 x higher risk of MI, pneumonia and death. However, no correlation between ASA score and postoperative complications in this age group.

186

What's the pedicle for a medial gastrocnemius flap?

Medial sural artery

187

Describe the posterior approach to the knee

1. S-shaped incision over popliteal fossa (extend along LHBT proximally, and along semiT distally)
2. Find medial sural cutaneous nerve, then incise deep fascia and follow it to the tibial nerve
3. In the fossa, the tibial nerve is most superficial and the popliteal artery is the deepest
4. Retract the bundle laterally off the capsule (may need to ligate superior medial and middle geniculates)
5. Retract medial head of gastrocs medially (may need to release off the femur)

188

What's the best flap?
1. small tibial tubercle/patellar tendon defect (anterior distal knee)
2. moderate patellar/suprapatellar defect (anterior proximal knee)
3. large suprapatellar defect
4. large, complex defect

1. Medial gastrocs flap (medial sural artery)
2. Vastus lateralis flap (descending branch of LFCx, lateral superior geniculate)
3. ALT (anterolateral thigh) fasciocutaneous flap, which can be combined with a cuff of vastus lateralis (descending branch of LFCx, lateral superior geniculate)
4. Latissimus dorsi free flap (donor = thoracodorsal; recipient = descending geniculate)

189

What's the % risk of vascular compromise in a free flap?

20%

190

What's an optimal cast index for distal radius fractures and how is it calculated?

<0.84 (internal width of the cast on the lateral XR/internal width of the cast on the AP at the level of the fracture)

191

List 5 indications for surgery in radius fractures in kids

Failure to achieve acceptable closed reduction
Loss of reduction at follow-up
Open fracture
Associated vascular injury or compartment syndrome
Floating elbow

192

Where is the entry point for a radius TEN?

Between 1st and 2nd extensor compartments proximal to the physis

193

What's the difference in time to union, blood loss, time in hospital and early ROM in TENs vs. ORIF for BBFFs?

No difference in time to union, blood loss or admission time; ORIF however allows early ROM, no immobilization (TENs require 3-4 weeks in cast) and anatomic reduction.

194

What's the most common site of facet joint cysts and what's the pathophysiology?

L4-5 (DDD results in loss of disc height, which increases the stresses on the facet joints and add on to that L4-5 degenerative spondylolisthesis due to facet joint orientation at this level results in a stretched out facet joint capsule and cyst formation)

195

What's the recurrence rate after surgery for a lumbar facet cyst?

<2% for decompression alone and 0% for decompression with fusion

196

What are the 3 patterns of congenital spinal stenosis?

1. Short pedicles (decreased AP space)
2. Flat laminae (decreases transverse spacpe)
3. Global (combined)

197

What's the best clinical outcome measure for lumbar spinal stenosis?

Oswestry Disability Index

198

What are the transfers for a wrist drop?

PL to EPL
FCR to EDC
Pronator teres to ECRB

199

Describe where the thumb UCL originates and inserts

Proximal-dorsal metacarpal to distal-volar proximal phalanx

200

What indicates a grade 3 UCL thumb tear?

Absolute laxity of >35 degrees or >15 degree laxity compared to the other side

201

List 2 indications for surgery in a Stener lesion

1. Soft tissue Stener >3mm displaced
2. Bony avulsion Stener

202

List 5 risk factors for patellar tendinosis

Fat
Flat foot
Frail quads
inFlexible quads
LLD

203

When doing the distraction method for pelvic discontinuity, when do you know you've reamed enough?
How much bigger should the acetabular component be than what you reamed?

Reamed enough when you have AS and PI contact.
6-8mm bigger.

204

List 2 radiographic measurements for scapulothoracic dissociation

1. Scapular distance >1cm (medial border to spinous processes)
2. Scapular distance ratio >1.29 (injured:uninjured)

205

What's the rate of limb-threatening ischemia in scapulothoracic dissociation? How about mortality?

10%
10%

206

What are the principles behind the Zelle classification for scapulothoracic dissociation?

Injury progresses from pure MSK injury, to MSK and vascular injury, to those plus post-ganglionic nerve injury to those plus plexus avulsion and Horner's syndrome.

207

What's the best imaging modality for a pre- and post-ganglionic injury?

Pre-ganglionic: CT myelogram
Post-ganglionic: MRI

208

List 5 ways to determine appropriate joint height in a revision TKA

15mm above fibular head
25mm below lateral epicondyle
30mm below medial epicondyle
40mm below adductor tubercle
at the level of the inferior patellar pole with knee at 90

209

What are the 8 main dorsal wrist arthroscopy portals? List 1 danger for each.

3,4 - EPL
4,5 - EDC
Radial midcarpal (just distal to 3,4) - EDC
Ulnar midcarpal (just distal to 4,5) - EDC
6R (radial side of 6th compartment) - DSBUN
6U (ulnar side of 6th compartment) - DSBUN
1,2 - Radial artery
STT - Radial artery

210

List 5 negative prognostic factors in a patient with DDH undergoing a PAO

Tonnis grade 3
LCEA <0
<10 degrees of acetabular anteversion
Asymmetric femoral head
Os acetabuli

211

Which is worse, CA-MRSA or HA-MRSA? How can they be differentiated?

CA-MRSA is much worse.

CA-MRSA can be differentiated by:
1. Genetic elements (type IV cassette chromosome)
2. Presence of virulent exotoxins (PVL)
3. Absence of multi-drug resistance

212

List the 4 Boston criteria for predicting chance of MRSA infection in pediatrics

Fever
WBC >12
CRP >13
Hct <34%

213

How is conventional radiation therapy given?

3 Gy x 10 fractions

214

What are the 3 terminal branches of the tibial nerve?

Medial plantar
Lateral plantar
Calcaneal

215

Where does the medial plantar nerve run and what does it innervate?

Between abductor hallucis and FDB.
Motor supply to abductor hallucis, FDB, FHB, and 1st lumbrical.

216

Where does the lateral plantar nerve run and what does it innervate?

Between FDB and quadratus plantae.
Motor to quadratus plantae, flexor digiti minimi, abductor digiti minimi, lateral 3 lumbricals, interossei and adductor hallucis

217

What is Jogger's foot and what's the surgical treatment if non-surgical management fails?

Medial plantar nerve compression.
Treatment is release of abductor hallucis fascia from its origin to the Knot of Henry.

218

Describe 3 differences between Baxter neuropathy vs. plantar fasciitis

Radiation to medial ankle and across lateral foot
Exacerbation with activity and improvement with rest
Exacerbated with foot eversion and abduction

219

What's the surgical treatment of Baxter neuropathy if non-surgical management fails?

Release of abductor hallucis fascia, then follow nerve distally and release FDB fascia if it's tethering it

220

What's soleal sling syndrome?

Compression of tibial nerve proximally in the calf deep to the fascial sling of the soleus

221

List 3 indications for delaying surgery in patients with ESRD on dialysis?

K >5.5
pH <7.25
Hypervolemia

222

List the attachments of tibialis posterior

navicular, medial, middle, lateral cuneiforms, cuboid, metatarsals 2-4, sustentaculum

223

List the (7) attachments of semimembranosus

posteromedial tibia, OPL, POL, popliteus fascia, medial head of gastrocs, posteromedial capsule, sMCL

224

List 4 transfers to restore elbow flexion in a musculocutaneous nerve palsy

Clark's pec major to biceps tendon transfer
Lat dorsi to biceps tendon transfer
Triceps to biceps transfer
Steindler flexorplasty

225

List two transfers to restore elbow extension in a high radial nerve palsy

Deltoid or lat dorsi to triceps

226

List the transfer indicated in a low median nerve palsy

Abductor pollicis brevis is affected (thumb opposition), so the transfer is D4 FDS to APB tendon

227

List the two transfers indicated in a high median nerve palsy

BR to FPL
D4/5 FDP side-to-side transfer to D2/3 FDP

228

List the three transfers in an ulnar nerve palsy

D4 FDS to adductor pollicis (thumb adduction)
APL to 1st dorsal interosseous (index abduction)
D3 FDS to lateral bands of D4/5 (reverses clawing)

229

What's the usual critical segmental bone defect?

>50% cortex width or >2cm loss

230

What's the management of a bone defect of size:
a) <2 cm
b) 2-5 cm
c) 5-10 cm
d) >10 cm

a) Acute shortening with secondary lengthening if needed
b) ICBG (20 cc/side)
c) Masquelet with RIA (40cc/femur) and allograft vs. distraction osteogenesis (1 cm/month defect)
d) Masquelet, vascularized fibula, amputation

231

What's the optimal ratio of allograft:autograft for a Masquelet?

<3:1

232

How proximal and how distal can you harvest a vascularized fibula?

4cm from fibular head to 6cm from ankle joint

233

What (2) factors differentiate SED from MED?

Basically the same presentation, except:
1. scoliosis and vertebral body abnormalities
2. COL2A gene

234

List 3 considerations when planning a THA in a patient with MED

1. Small, shallow acetabulum
2. Modular implants needed (meta-dia mismatch)
3. HO prophylaxis (larger exposure needed)

235

What's the only spasmolytic agent used in conscious sedation? What's its mechanism?

Benzodiazepines (midazolam)
GABA agonist

236

What's ketamine's mechanism? When is ketamine contraindicated?

Mechanism: NMDA antagonist (threshold-dependent, not dose-dependent)
Contraindicated in uncontrolled HTN or CAD

237

What's propofol's mechanism?

GABA agonist

238

Why is fractionation important in radiation therapy?

4 "R's":
1. Repair
2. Reoxygenation (radiation damage relies on free radical formation)
3. Redistribution (to G2 cell cycle when cells are most vulnerable)
4. Repopulation of tumor cells (with rapidly-dividing cells that are vulnerable)

239

List 4 pros and 3 cons of neoadjuvant radiation vs. adjuvant

Pros: shrinks tumor (can make it operable), less risk of positive margins, less risk of tumor seeding during surgery, lower dose than adjuvant (50 Gy divided over 5 weeks vs. 60 Gy).

Cons: delays wound healing, risk of wound complications, more difficult for pathologist to examine margins

240

What's the usual radiation protocol following surgical stabilization in a metastasis?

Single 8 Gy dose

241

List 5 indications for replantation

Thumb
Single digit distal to FDS
Multiple digits
Proximal to mid-palm
Any pediatric amputation

242

List the order of soft tissue repair in a replant

1. extensor tendon
2. flexor tendon
3. arteries
4. veins
5. nerves

243

What are the 3 intraoperative options for poor venous outflow in a replant?

Remove nailbed and perform heparin swabs hourly
Leave lateral incisions to close by secondary intention
Leeches (need to cover with TMP-SMX)

244

List 5 important postoperative management principles following a replant

Keep limb elevated
Keep limb warm for 24h (heat lamps, room temp)
Keep patient NPO in case you need to return to OR
Adequate analgesia to prevent vasoconstriction
Maintain high rate of IV fluids

245

Describe the rehabilitation protocol following a replant

5 days: ROM of adjacent digits, tenodesis effect
2 weeks: intrinsic plus (wrist extended, MCPs flexed, IPs extended) and minus (wrist neutral, MCPs extended, IPs flexed) exercises
4 weeks: ROM with wrist at neutral
6 weeks: gentle functional ROM
8 weeks: resistance exercises
12 weeks: job simulation exercises

246

List 8 negative prognostic factors in ORIF of calcaneus fractures

Male
>50 yo
Manual laborer
Worker's compensation
Smoker
Bilateral
Obesity
Sanders IV

247

List 5 indications for surgery in calcaneus fractures

Large, displaced extra-articular fractures
Tongue-type
Calcaneal tuberosity avulsion
Intra-articular displacement >2mm
Sanders II-III with flat Bohler's angle (normally 20-40)

248

List cobal-chrome, cancellous bone, cortical bone, PMMA, titanium, steel, cermaic and polyethylene in terms of Young's modulus (high to low)

Cermic, Co-Cr, steel, titanium, cortical bone, PMMA, poly, cancellous bone

249

List the 7 poor prognostic signs for hip survival following acetabular fracture surgery

Age >40
Associated hip dislocation
Initial displacement >2cm
Posterior wall fracture
Femoral head injury
Marginal impaction
Non-anatomic reduction

250

When do the following bones ossify/fuse and where does the growth of that bone occur?
a) clavicle
b) proximal humerus

a) central clavicle ossifies at 5 weeks gestation, medial and lateral ossify at 18 and fuse at 25; 80% growth from medial epiphysis
b) epiphysis ossifies at 6 mo, GT at 2 and LT at 4 yrs and fuse at skeletal maturity; 80% of growth of the humerus is from the proximal epiphysis

251

What's the closed reduction maneuver for pediatric proximal humerus fractures?

Longitudinal traction
Abduction to 90 deg
ER

252

What are the (5) static stabilizers of the SC joint?

Posterior SC ligament (strongest)
Anterior SC ligament
Costoclavicular ligament
Interclavicular ligament
Intra-articular disk ligament

253

Which muscles attach to the clavicle (6)?

Sternocleidomastoid
Sternohyoid
Subclavius
Pectoralis major
Deltoid
Trapezius

254

Which muscles attach to the scapula (17)?

Supraspinatus
Infraspinatus
Subscapularis
Teres minor
Teres major
Rhomboid major
Rhomboid minor
Triceps (long head)
Deltoid
Biceps
Coracobrachialis
Pectoralis minor
Trapezius
Levator scapulae
Omohyoid
Serratus anterior
Serratus posterior

255

What's the closest neurovascular structure to the SC joint?

Brachiocephalic vein

256

How do you do a Rockwood (serendipity) view?

40 degrees angled up with both clavicles in view

257

What's the expected grip strength compared to normal in a single ray resection of the hand?

80%

258

When is radiation risk from routine diagnostic procedures no longer a concern during pregnancy?

After 17 weeks

259

What imaging studies are absolutely contraindicated in pregnancy before 17 weeks?

Gadolinium studies (iodine is safe)
CT pelvis

*N.B. CXR, CT head and of the extremities is safe

260

List (5) ways that fetal radiation can be decreased during CT use?

Uterine shielding
Limit scanned areas
Lower voltage
Reduce magnification
Wider beam collimation

261

What is the sole predictor of pain at 24h postop from an ACLR?

Anxiety

262

What are the 2 most important factors influencing adherence to rehabilitation following ACLR in a) kids, and b) adults?

a) strong athletic identity, desire to return to sport
b) social support, self-motivation

263

What's the most sensitive and specific test for syndesmotic injury?

Sensitive: ATFL tenderness
Specific: squeeze test

264

List 3 radiographic findings of syndesmotic injury

Tib-fib clear space >6mm at 1cm above the joint on AP/Lat
Tib-fib overlap <6mm at 1cm above the joint on AP
Medial clear space >5mm

265

What perpetuates the DIP flexion deformity in a non-operatively managed Seymour fracture?

1. Differential insertion of extensors (epiphysis) and flexors (metaphysis)
2. Interposition of tissue at the fracture site (nail germinal matrix usually)

266

What's a Kaplan lesion?

Irreducible dorsal MCP dislocation where the metacarpal head button-holes volarly and the volar plate is interposed between the proximal phalanx and the metacarpal head

267

Which approach do you use for an irreducible MCP dislocation?

Dorsal dislocation: volar approach (release A1 pulley to expose volar plate)

Volar dislocation: dorsal approach (split extensor tendon to expose joint, push/split volar plate to remove it from the joint

268

What's the reduction maneuver for an MCP dislocation?

1. Flex wrist to de-tension flexors
2. Direct pressure to proximal phalanx base
3. Avoid longitudinal traction/extension (may displace volar plate into the joint and turn a simple dislocation into a complex one that need surgery)

269

What's the interposed structure in an irreducible open vs. closed dorsal PIP dislocation? What approach do you use to get it reduced?

Closed: volar plate
Open: dislocated FDP tendon
Approach: dorsal, between central slip and lateral band

270

What are the deforming forces acting on a base of thumb fracture?

APL
EPL
Adductor pollicis

271

What's the reduction maneuver in a Bennett fracture?

Traction
Extension
Pronation
Abduction

272

Which 7 ligaments stabilize the 1st CMC joint?

superficial volar oblique
deep volar oblique
posterior oblique
dorsoradial (primary restraint to dorsal subluxation; treatment of an unstable 1st CMC dislocation requires reconstruction of this ligament and pinning)
ulnar collateral
intermetacarpal
dorsal intermetacarpal

273

List the 3 indications required for limb lengthening with/without contralateral epiphysiodesis in PFFD

Aitken A/B
>50% femur remaining
<20cm predicted LLD at maturity

274

When is a knee arthrodesis and foot ablation indicated in PFFD vs. Van Ness rotationplasty?

Van Ness:
1. ipsilateral foot at the level of contralateral knee
2. Aitken C/D
3. >60 degrees ankle ROM

Knee fusion and foot ablation when ipsilateral foot is proximal to contralateral knee.

275

What's the order of closure of the distal tibial physis?

Central, posterior, medial, anterior

276

List 5 challenges when trying to brace a child for early onset scoliosis

Larger abdomen
cylindrical body habitus
more pliable ribs
difficulty remaining still during molding
non-compliance with brace wear

277

List 3 factors associated with resolution of early-onset scoliosis following serial casting

1. Initiation of treatment <20 months
2. Curve <60 degrees
3. Treatment for >1 year

278

What are 2 radiographic differences between granulomatous and pyogenic osteomyelitis?

1. Granulomatous spares the disks
2. Granulomatous can form thin-walled abscesses

279

What's the order of surgical intervention in the lower extremity if the patient has multiple arthritic joints?

Forefoot
Hip
Knee
Hindfoot
Ankle

*Deal with most symptomatic first in reality

280

What are the only 3 medication/classes of medications that you need to hold for surgery in RA?

Sulfasalazine
Leflunomide
TNF-a inhibitors (Remicaide, Enbrel)

*Hold for 4 half-lives pre-op and resume 3 weeks post-op

281

List 5 factors associated with bisphosphonate-associated femur fractures

transverse fracture line laterally
no comminution
long medial spike
lateral beaking
increased femoral cortical thickness

282

Where does the artery of Adamkiewicz run?

Left side between T9 and T12

283

What's the cutoff for metal ion levels?

>7 ppb is abnormal

284

What's TEXA's mechanism of action?

Reversibly binds plasminogen's binding site on fibrin, thereby inhibiting clot degradation by plasmin

285

How much hotter is an early Charcot joint compared to the other uninvovled side?

3.3 degrees

286

What do you need to do after reducing an inferior shoulder dislocation?

Brachial-brachial index (<0.95 is abnormal)

287

List 8 risk factors for synostosis after ORIF of a radius/ulna fracture

head injury
blast injury
proximal fracture (close to PRUJ)
both bones fractured at the same level
fracture fragments in the IOM
single incision
failure to restore radial bow
long screws that breach into IOM

288

What's the normal radial bow and how do you measure it?

1. Draw a line from the radial tuberosity to the ulnar articular margin of the distal radius
2. Maximal radial bow is 60% of the distance of this line from proximal
3. Bow is 10% the length of this line as measured from this line (radial bow)

289

List 4 blocks to radial head reduction in a Monteggia fracture

Annular ligament
Biceps
Capsule
PIN

290

How do you pin the radius/ulna if you need to, such as in an acute DRUJ instability or Essex-Lopresti injury?

neutral forearm rotation
pin radial to ulnar (protect superficial radial nerve)

291

What's the rate of associated femoral neck fracture in a femoral shaft fracture?

10%

292

What's the rate of associated Hoffa fragment in a distal femur fracture?

40% (usually lateral condyle)

293

What's the blood supply to the talus?

1. Posterior tibial artery
-Tarsal canal branch = main supply to talar body
-Deltoid branch = supplies medial talar body
2. Anterior tibial = talar head/neck
3. Artery of tarsal sinus = talar head/neck

294

What 3 steps do you need to take when faced with a bisphosphonate fracture?

Endocrinology consult
Image contralateral leg
Consider starting Teraparatide

295

When is retroperitoneal pelvic packing indicated?
How is it done?
What if the patient is still unstable after?

Indicated in a hemodynamically unstable pelvic fracture that remains unstable after a binder is applied as an alternative to angiography since most bleeding is from the presacral venous plexus anyway.

Pfannenstiel incision, incise rectus longitudinally at the linea alba, bluntly dissect the plane between the peritoneum and the bony pelvis and insert 3 sponges/side towards the SI joints. Close. Remove sponges in 24-48h when patient stabilizes.

If patient remains unstable after packing and external fixation, send for angiography.

296

List 3 contraindications to inserting a foley in pelvic trauma

blood at the meatus
perineal bruising
high-riding prostate

If present, do a retrograde cystourethrogram

297

How do you do a retrograde cystourethrogram?

Insert a small foley into the meatus, inflate and inject 25 cc of dye. Then, take an AP pelvis and if no contrast extravasation, deflate the baloon and advance all the way. Final step is to obtain a cystogram with 400 cc of dye and shoot another AP to rule out a bladder rupture, then evacuate the bladder and take a final AP to rule out an occult extraperitoneal rupture.

298

List 5 ways to differentiate a congenital radial head dislocation from a traumatic one?

bilateral
convex radial head
hypoplastic capitellum
irreducible
atraumatic history

299

List 3 angles you look at in flat foot and what's normal for each?

Meary's angle (0-10 degrees)
Calcaneal pitch (15-20 degrees)
Talonavicular uncoverage (<40%)

300

How much of the humerus can be plated through a lateral triceps slide approach (a) with, and (b) without mobilization of the radial nerve and reflecting the triceps medially?

(a) 55%
(b) 94%

301

What's a normal:
a) SL angle
b) Radiolunate angle
c) Capitolunate angle

a) 40-60 (<40 = VISI; >60 = DISI)
b) 0-15
c) 0-15

302

Where is the PUDA located? What's the normal value? What's the effect of changing the PUDA on elbow ROM?

PUDA is 5.7 degrees, located 47mm distal to the olecranon tip.

Increasing the PUDA results in decreased elbow extension. The PUDA however doesn't affect elbow flexion.

303

List 5 factors associated with an unstable patient requiring a DCO approach

Lactate >2.5
SBP <90
Temp <33
Platelets <90
PaO2/FiO2 <300

304

List 5 features in the paediatric C-spine that are different than in the adult

Pseudosubluxation (C2-3 usually)
C1 can override C2
Hypolordosis
Anterior angulation of odontoid
Wedge-shaped vertebral bodies

305

What is Swischuk's line?

Line drawn along the anterior border of the posterior arches from C1 to C3. The anterior border of the posterior arch of C2 should be within 1.5 mm of this for it to be pseudosubluxation.

306

What's the procedure indicated for a flexible equinovarus foot in CP?

If driven by tibialis posterior, transfer plantar half of tendon around the fibula to peroneus brevis and lengthen Achilles (hoke vs. Strayer).

If driven by tibialis anterior, treatment is Rancho procedure (tib post lengthening above MM, split tibialis anterior transfer to cuboid) and Achilles lengthening.

307

What's the procedure indicated for a flexible equinovalgus foot in CP?

Evans, Achilles lengthening +/- plantar closing wedge osteotomy of medial cuneiform for residual forefoot supination.

308

What special test is helpful to determine if the equinovarus is driven by tib ant in CP?

Confusion test (co-contraction of tib ant with resisted hip flexion)

309

How do you lengthen the hamstrings if needed in CP?

Medial tendon Z-lengthening (ST, gracilis)
Lateral intra-muscular fascial release, like a Strayer (biceps femoris long head, SM)

310

List 5 anatomical causes of thoracic outlet syndrome

Cervical rib
Scapular ptosis (from trapezius palsy)
Obesity
Large breasts
Clavicle/first rib malunion

311

Which bug do you need to cover against in fresh water open injuries and what do you use? Which antibiotic do you use for salt water?

Fresh: aeromonas hydrophilus; cover with cipro (fluoroquinolones)

Salt: doxycyline and ceftazidime (or cipro)

312

List 8 signs of denervation (ulnar neuropathy, CTS, etc.) on a NCS

Distal sensory c >3 ms
Distal motor latency >4 ms
Nerve conduction velocity <50 m/s
Sharp waves
Fibrillations (spontaneous discharge from single muscle fiber)
Fasciculations (spontaneous discharge from multiple fibers)
Complex repetitive discharges
Myokimic disharges

313

List 7 factors associated with early mortality after a hip fracture

Male
Age >85
Dementia
Reduced mobility prior to fracture
ASA status
2 or more comorbidities (especially renal failure)
Delay >48h

314

List 5 factors associated with femoral neck fracture following a resurfacing arthroplasty

Female (small neck)
Metaphyseal cysts
Notching
Varus positioning (<130 degrees)
Improper prosthesis seating

315

List 5 criteria for selective thoracic fusion in AIS

Lenke 1C, 2C curves
Thoracic prominence > lumbar on Adams FBT
Lifestyle factors (dancer, athlete requiring lumbar ROM)
Skeletally mature
Absence of hyperlaxity (if you selectively fuse in this case, can make the T/L-L curve worse due to the "adding on" effect)

316

What infections are patients with ankylosing spondylitis more susceptible to?

Klebsiella pneumoniae synovitis

317

List 5 factors during hallux valgus surgery that can result in hallux varus

excessive lateral release
resection of the fibular sesamoid
medial plication
excessive medial eminence resection
overcorrection of the IMA

318

List 6 causes of acquired coxa vara

Fracture
Malunion
Infection
Perthes
SCFE
Fibrous dysplasia or Paget's

319

List 6 negative prognostic signs for septic arthritis

Paediatric (age <6 months)
Delay in presentation >4 days
Polyarticular
Hip involvement
Associated osteomyelitis
High-virulence organism

320

List 5 medications associated with osteoporosis

corticosteroids
phenytoin
SSRIs
lasix
antiretrovirals

321

Where do you do a biopsy for the following locations?
1. wrist
2. distal humerus
3. proximal humerus
4. iliac crest
5. supraacetabular region
6. femoral neck/head
7. distal femur
8. tibia
9. internal pelvis

1. 2nd dorsal compartment
2. brachialis
3. anterior deltoid
4. superior abductors
5. TFL and rectus femoris
6. trans-trochanteric
7. posteromedial vastus medialis or posterolateral vastus lateralis
8. subcutaneous border
9. pfannensteil incision, work along the pubic brim either medial or lateral to external iliac vessels

322

What approach has the highest risk of early aseptic femoral component loosening in THA?

DAA

323

What were the findings of the Kreder RCT on early vs. delayed WB for unstable ankle fractures (no syndesmotic injury, <25% posterior malleolus)?

1. better early (<3 months) ROM and functional outcome scores, but this did not correlate to earlier RTW time
2 increased rate of hardware removal in delayed WB (perhaps early WB decreases scarring and sensitivity around the plate)

324

Which 5 factors are associated with failure of initial I&D in a septic native knee?

Male
Advanced age
Multiple comorbidities
Joint aspirate culture-positive
Open I&D (instead of arthroscopic)

325

In THA and TKA, is there a difference between IV and PO TEXA?

No, equivalent outcomes for 2g PO given 2 hrs prior to incision vs. 1g IV given immediately before incision.

326

After what age does THA become more cost-effective than ORIF for femoral neck fractures?

54 for no comorbidities
47 with mild comorbidties
44 for severe comorbidities

327

What percentage of fluid, soft-tissue and explant specimen cultures are positive in a revision TSA for an infection?

Soft-tissue: 66%
Explant: 55%
Fluid: 32%

Men have higher p. acnes load.

328

Which 5 factors are predictive of having a pseudotumor?

female
vertical cup
femoral osteolysis
acetabular osteolysis
acetabular loosening

329

Which 2 factors are predictive of not having a pseudotumor?

acetabular anteversion >5 degrees
heterotopic ossification

330

How do you culture p. acnes?

Hold cultures for 3 weeks in blood/Brucella/chocolate agar and brain-heart infusion broth

331

What did the 2017 RCT comparing TBW and plate ORIF for simple, displaced olecranon fractures show?

1. no difference in outcomes
2. equal cost despite higher initial cost in plate group
3. more complications overall in the TBW group, but if hardware removal was excluded, plates had more complications (from infection)

332

What are 5 risk factors for malignant transformation of an osteochondroma?

pain
surface irregularity
continued growth after skeletal maturity
cartilage cap thickness >2 cm
osteochondroma size >5 cm

333

When are UBCs considered active vs latent?

Active when within 1 cm of the physis, latent when they progress to a diaphyseal location

334

Which 3 tumors often have secondary ABCs?

GCT
chondroblastoma
UBC

335

Which 2 benign tumors can metastasize to the lungs?

GCT
chondroblastoma

336

List 5 poor prognostic factors applicable to both osteosarcoma and Ewing's

Metastases
Large lesion
Tumor necrosis <90% after neoadjuvant chemotherapy
Elevated LDH
Inadequate margins following resection

337

What are 5 important findings in the recent JBJS study comparing bilateral THAs under a single anesthetic vs a staged approach?

1. shorter total length of stay and more cost-effective
2. shorter total surgical time
3. no difference in transfusion rate (intra-op recovery excluded)
4. no difference in the rate of DVT/PE or complications
5. ASA 1-3 not predictive of complications

338

What has been shown to improve fusion rates in osteoporotic patients undergoing PSIF?

Weekly Teriparatide infusions for 6 months post-operatively

339

What's the best imaging modality for pseudotumor?

MARS MRI (or ultrasound if contraindications)

340

What serum values of vitamin D define insufficiency?

<20 ng/mL

341

What's lab tests should you order for vitamin D deficiency?

25-hydroxyvitamin D (decreased)
PTH (increased)
Calcium

342

Which 3 muscles deform a Bennett fracture?

EPL (extension)
APL (abduction)
Adductor pollicis longus (supination)

343

List 3 strategies for preventing CRPS prior to surgery

Local anesthetic infiltration prior to incision
Vitamin C 500mg daily for 50 days
Gabapentin

344

List 3 medications with good evidence in the treatment of CRPS

Bisphosphonates
Gabapentin
TCAs

345

List 4 indications for ligament reconstruction instead of Brostrom repair

Attenuated ligaments
Failed initial repair
Obesity
Generalized ligamentous laxity

346

What did the HULC RCT on single- vs dual-incision DBTR show?

10% better flexion strength in dual-incision
More early LABCN palsy in single-incision

347

What are the 3 most common neuropraxias after an extension-type SCH #?

AIN
Median
Radial

348

Does MED or SED have atlantoaxial instability? List 3 other syndromes with AA instability

SED
Morquio's
Pseudoachondroplasia
Down's

349

List 3 factors associated with favorable wound healing in diabetic foot

TcO2 >30
Toe pressure >40
Triphasic flow

350

After how much of a platelet drop do you start a work-up for HIT?

>50%

351

Where can you best appreciate atrophy from ulnar neuropathy?

1st dorsal interosseous

352

List 3 special signs for ulnar neuropathy

Wartenberg sign: D5 abducts when patient is asked to keep fingers adducted due to unnoposed abduction of abductor digiti quinti (weak parlmar interossei).

Froment's sign: thumb IP joint flexes on attempted key pinch due to FPL compensating for weak adductor pollicis.

Jeanne sign: MCP hyperextends during attempted key pinch from EPL pull.

353

List 6 negative prognosticators following calcaneus fractures

Male
Smoker
WSIB
Heavy manual labourer
Sanders IV
Negative Bohler's angle

354

What were the 2 pertinent findings of the RCT comparing ORIF to circular fixator for bicondylar tibial plateau fractures?

Shorter hospital stay in the fixator group
Less complications in the fixator group

355

What were the 2 pertinent findings of the interTAN vs DHS study in geriatric hip fractures?

No difference in outcomes
Less femoral shortening in interTAN group

356

What are 3 important findings of the RCT comparing wrist fusion to arthroplasty?

No difference in outcomes
Less complications in fusion
Fewer revisions in fusion

357

Describe the general principles behind the accelerated rehab protocol for Achilles ruptures

0-2 weeks: NWB in plantarflexion slab
2-4 weeks: PWB with 2 cm heel lift in Aircast
4-6 weeks: WBAT with 2 cm heel lift in Aircast
6-8 weeks: WBAT without heel lift in Aircast, start PT
8-12 weeks: wean Aircast, progress PT
>12 weeks: strengthening and endurance training

358

What's the difference between a neurofibroma and schwannoma when it comes to surgical excision?

Neurofibroma requires excision of the nerve

359

Which nerve fibers transmit proprioception?

Pacini corpuscles ("P" for proprioception)

360

What is the hypervirulent strain of C. diff and what does it cause?

NAP1 (resistant to fluoroquinolones)

361

What's the 6-month rate of mortality in patients who develop C. diff after a hip fracture vs those who do not?

35% (vs 9%)

362

What's the most common complication following non-surgical management of a distal radius fracture in the elderly?

Median neuropathy

363

List 3 risk factors for pelvic discontinuity after THA

female
rheumatoid
previous radiation

364

List 6 risk factors for transfusion in spine surgery

longer surgery
>6 levels
Cobb >50
osteotomies
lower body weight (smaller reserve)
neuromuscular

365

List 5 downsides of the gap balancing method in TKA

1. jointline elevation
2. excessive flexion gap with PCL recession
3. midflexion instability
4. altered center of rotation
5. altered patellar biomechanics (contact force increased by 60% for every 1 mm of jointline elevation)

366

What's the best view to identify a post-partum symphyseal rupture?

Flamingo single-leg stance view (>5 mm vertical translation = instability)

367

List 3 initial options for peristent wound drainage >72 hours following TKA

limit physiotherapy for 24 h
NPWT for 24 h (good RCT evidence in trauma literature)
hold anticoagulation for 24 h

368

What does the gull sign predict?

inadequate reduction after ORIF
early loss of reduction after ORIF
progression to THA

369

What are 5 special considerations when planning for surgery in a patient with Parkinson's disease?

1. avoid traditional inhalational anesthetics (interact with levodopa)
2. risk of hypotension (due to levodopa)
3. risk of delirium
4. risk of aspiration
5. risk of urinary retention

370

What's the primary source of failure in TEAs?

Bushing wear (from the link)

371

List 4 radiographic signs of crankshaft phenomenon

RVAD >20
Cobb angle change >10 degrees
>5 degrees apical rotation
Vertebral body penetration into the chest on axial CT

372

What does the recurrent motor branch of the median nerve supply?

APB
Opponens pollicis
FPB

373

What forms the superficial palmar arch?

Ulnar artery
Superficial palmar branch of radial artery

374

List 3 risk factors for displacement after a distal radius fracture

Age
Metaphyseal comminution
Radial shortening (ulnar variance)

375

List 5 sugical risk factors for periprosthetic fracture in a TKA

anterior notching
inadvertent perforation with the canal finder
eccentric box cut
malpositioned im plants
aggressive impaction of trial components

376

What's the most important predictor for interprosthetic fracture (between THA and TKA)?

decreased femoral cortical thickness

377

When is open rotator interval plication beneficial over arthroscopic?

Arthroscopic: better for anterior instability
Open: better for posterior and inferior instability

378

List the 4 components of the WOMAC

pain
stiffness
function
global score

379

List 4 risk factors for SMA syndrome

2-stage procedure
Lumbar modifier B or C
Low BMI
Stiff thoracic curve

380

List 3 radiographic risk factors for SCFE

Coxa vara
Posteror sloped physis >12 degrees (on FLL)
Retroverted femoral head

381

List 4 things that change in muscles undergoing endurance training

increased capillaries
increased number of mitochondria
increased mitochondrial size
increased muscle glycogen content

382

List 5 factors associated with a poor prognosis in pediatric radial neck fractures

angulation >30 degrees
complete displacement
older age
delayed presentation
ORIF

383

List 7 ways to prevent overstuffing in a radial head arthroplasty

1. template off resected head
2. template off contralateral radial head
3. proximal aspect of implant is 1 mm proximal to lateral ulnohumeral articular margin
4. proximal aspect of implant is in line with the medial ulnohumeral articular margin
5. proximal aspect of implant is 2 mm distal to coronoid tip
6. intra-operative XR looking for ulnohumeral gapping
7. check ROM

384

List 3 ways to more safely apply a Halo in a child

CT scan to identify suture lines and avoid them
Use more pins (8)
Use less torque (4 inch/lb vs. 8 inch/lb in adult)

385

What 3 radiographic findings are associated with Scheuermann's kyphosis?

Schmorl's nodes
AP elongation of vertebral bodies
narrowing of intervertebral spaces

386

List 8 risk factors for vertebral osteomyelitis in adults

immunocompromised
malignancy
IVDU
HIV
intravascular hardware
spine surgery
bacterial endocarditis
speticemia

387

List 4 medications that require renal dosing

morphine
enoxaparin
ancef
vancomycin

388

What are the ASA recommendations for initiating anticoagulation in the setting of an epidural catheter?

wait 2 hours after catheter removal

389

Biomechanically, how does UCL reconstruction do relative to the native UCL wrt restoring valgus stability?

At flexion angles >90 degrees, both the modified Jobe and docking techniques are equivalent to the native UCL, but at <90 degrees the native UCL wins

390

What are the anatomic sites of compression of the PIN and indicate which is most common?

"FREAS":
fibrous bands of the radiocapitellar joint
radial recurrent vessels (Leash of Henry)
ECRB fascia
Arcade of Frohse (proximal supinator - most common)
Supinator distal edge

391

Describe when the midfoot and hindfoot bones ossify

6 mo fetal: calcaneus
7 mo fetal: talus
9 mo fetal: cuboid
1 yo: lateral cuneiform
3 yo: medial cuneiform
4 yo: middle cuneiform, navicular

392

Where do you plate the occiput in occipital plating in kids?

external occipital prominence (unicortical)

393

Where's the start point for a C1 lateral mass screw? How do you angle it?

Just inferior to where the posterior C1 ring enters the lateral mass (need to retract C2 nerve root inferiorly and may even need to resect it to expose the start point).

Screw is angled medial to the vertebral artery foramen without breaching into the spinal canal (need to dissect and see the medial edge of the lateral mass). Fluoroscopy is used for cranial-caudal angulation.

394

List 6 differentials for shoulder pain in a swimmer

1. subacromial impingement
2. GIRD
3. scapular dyskinesis (from over-developed lat dorsi and pec major)
4. hyperlaxity
5. labral tear
6. suprascapular neuropathy (associated with scapular dyskinesia)

395

List the components of a scoliosis brace

"BRACe MaP"
Build (custom vs. pre-fabricated)
Rigidity (soft, elastic, rigid)
Anatomic level (C, T, L, S)
Construction of the Envelope (symmetric vs. asymmetric)
Mechanism of Action (3-point, elongation, etc.)
Plane of action (2D vs 3D)

396

List 4 complications of MRSA infection in kids

persistent bacteremia
DVT
septic emboli
pathologic fracture

397

What's the precursor to scoliosis in patients with Parkinson's disease?

Pisa syndrome (lateral thoracic bend >10 degrees)

398

What are 4 spine abnormalities in Parkinson's disease?

1. Pisa syndrome
2. Anterocollis (>45 degree cervical flexion; passively correctable)
3. Camptocormia (>45 degree T-L flexion; passively correctable)
4. Scoliosis

399

List 4 non-surgical options for spine issues in patients with Parkinson's disease

Bracing with anterior distraction
Botox injection of iliopsoas (improves camptocormia)
Lidocaine injection of external obliques (improves pisa)
Deep brain stimulation (improves camptocormia)

400

Which vessels make up the anastomotic ring around the knee?

medial superior geniculate (dominant)
medial inferior geniculate (dominant)
lateral superior geniculate
lateral inferior geniculate
descending geniculate
anterior tibial recurrent

401

When repairing a jersey finger (FDP avulsion), what's the best fixation method biomechanically?

suture-anchor

402

Which type of jersey finger should be repaired acutely (within 10 days) and why?

type I (soft-tissue FDP avulsion, no bony component) since these retract all the way into the palm and disrupt the vinculae (brevis and longus profundus)

403

List 2 indications for flexor pulley reconstruction

multiple pulley rupture (A2 and A4)
bowstringing

404

What's the best type of muscle strengthening for patellar tendinosis?

eccentric

405

How can you distinguish a weak tib ant from a common peroneal nerve palsy or L4/5 radiculopathy?

Test resisted hip abduction (also L5) and if this is weak as well, then it's due to radiculopathy

406

List 5 advantages for the lateral decubitus position over the beach chair

better cerebral perfusion
less risk of hypotensive bradycardia
lateral force distracting and opening up the GHJ
better access to posterior/postero-inferior labrum
bubbles move up/out of the way when using cautery

407

What are 5 disadvantages of the lateral decubitus position

disorienting anatomy
have to reach around arm to establish anterior portal
risk of traction injury to brachial plexus
increased DVT risk vs. beach chair
difficulty accessing the airway

408

What are 3 risk factors for development of DVT in paediatric MRSA infections?

MRSA osteomyelitis
Age >8
CRP >6

*Should provide DVT prophylaxis in all kids with MRSA

409

Where does calcific tendinitis most commonly occur in the hand and wrist and what's the most common site of recurrence?

FCU insertion (most common site of recurrence)
MCPs
IPs

410

What 3 conditions are associated with calcific tendinitis?

Scleroderma
Dialysis
Hypophosphatemia

411

What's the best way to screen for structure allograft bone quality?

cortical thickness (age and BMD don't correlate well)

412

What are 4 surgical steps to do when operating on a patient with ESRD?

cement femur in arthroplasty
use locking plates
fill any metaphyseal bone voids
delayed weight-bearing

413

List 5 ways of increasing the stiffness of a circular frame

smallest rings possible
largest wires possible
inter-wire angle >60 degrees
use a drop wire
use 2-level frames

414

List 5 risk factors for extensor mechanism disruption following TKA

previous surgery
diabetes
ESRD
rheumatoid arthritis
obesity

415

What are the 3 diagnostic criteria for chronic exertional compartment syndrome?

Pre-exercise pressure >15 mm Hg
Pressure >30 mm Hg 1 min after exercise
Pressure >20 mm Hg 5 min after exercise

416

List 5 sequelae of untreated foot compartment syndrome

claw toes
cavus foot
chronic pain
neuropathy
neuropathic ulcerations

417

How do you surgically treat a flexible claw toe deformity following missed foot compartment syndrome?

flexor tenotomy
extensor tendon lengthening

418

How do you surgically treat a rigid claw toe deformity following missed foot compartment syndrome?

IP fusion
MCP capsulotomy
flexor tenotomy
extensor tendon lengthening

419

List the 6 risk factors for LCP

male
hyperactivity
Low body weight
family history
history of Perthes in the other hip
Inuit population

420

List 8 anatomic/physiologic differences in paeds that can affect how you manage them in a polytrauma setting

1. large head to body ratio
2. higher incidence of C-spine injury due to the above
3. SCIWORA
4. pseudosubluxation
5. anterior airway
6. large tongue
7. require 30% blood volume loss to show tachycardia (vs. 15% in adults)
8. rapid hemodynamic crash after critical threshold

421

What are the components of the Pirani severity score in clubfoot?

Hindfoot contracture score:
1. posterior crease
2. empty heel
3. rigid equinus

Midfoot contracture score:
1. medial crease
2. curvature of lateral border of the foot
3. position of the head of the talus

422

How much correction can you obtain with a Pemberton or innominate (Salter) osteotomy?

10-20 degrees (more with Pemberton)

423

Describe the steps for a repair of a dural tear

Trendelenberg position
Microscope
Use paddys instead of suction to not injure roots
6-0 non-absorbable suture repair
Watertight closure
Valsalva to check repair
+/- paraspinal fascial patch and fibrin sealant if needed

424

What's the major type of radiation used for metastatic bone lesions (of the spine, pelvis, etc.)?

focused external beam radiation

425

When applying sequential traction during a closed reduction of a jumped facet, how do you know radiographically that you're over-distracted and should abandon?

if the involved disc space is >1.5 times the width of adjanced disc spaces

426

What's the algorithm for surgical management of a chronic Achilles tendon rupture?

<2 cm: primary repair
2-5 cm: V-Y lengthening +/- FHL transfer
>5 cm: FHL transfer and pulvertaft weave of either auto/allograft (semiT)

427

What are patients with Achilles ruptures at higher risk for (aside from wound complications)?

DVT

428

What is rheumatoid factor?

IgM against native IgG

429

List 5 conditions associated with rheumatoid arthritis

1. vasculitis
2. pericarditis
3. pulmonary fibrosis
4. Still's disease (acute onset of RA with fever, rash and splenomegaly)
5. Sjogren's disease (autoimmune exocrine gland disease)

430

What are the 7 diagnostic criteria for rheumatoid arthritis?

Must have 4 or more:
morning stiffness
swelling in 3 joints
rheumatoid nodules
symmetric arthritis
arthritis of the hand and wrist
bony erosions
positive rheumatoid factor

431

What's the general surgical treatment of a cavovarus foot?

LCO, dorsiflexion medial cuneiform osteotomy, tibialis posterior to anterior transfer, peroneus longus to brevis transfer

432

What's the total safe traction time for hip arthroscopy?

2 hours

433

How do you decrease the risk of femoral and sciatic nerve injury during portal placement for hip arthroscopy?

Femoral: stay lateral to a vertical line down from the ASIS.

Sciatic: internally rotate the leg.

434

List 3 flap options for a full-thickness defect over the heel

Free flap
Reverse sural flap
Propeller flap

435

What's the metal ion ratio suggestive of trunnionosis?

Co:Cr ratio >2:1

436

List 4 indications for a static spacer vs. an articulating one

wound concerns
stability concerns
extensor mechanism disruption
massive bone loss

437

List 8 risk factors for scaphoid non-union

smoker
delayed presentation
proximal pole fracture
displaced >1 mm
intrascaphoid angle >35
scapholunate angle >60
radiolunate angle >15
previous surgery

438

List the congenital scoliosis causes in order of likelihood to progress

unilateral hemivertebra with contralateral bar
unilateral bar
fully-segmented hemivertebra
unincarcerated hemivertebra
incarcerated hemivertebra
unsegmented hemivertebra
block vertebra

439

What two types of steroid injections are used in lumbar spinal stenosis?

Epidural
Transforaminal

440

For a medical practice to be considered "ethical", it must respect all four of these principles

Justice
Beneficence (patient's well-being is the goal)
Non-maleficence
Autonomy

441

What are McQueen's modifications of LaFontaine's criteria of displacement in non-operatively managed distal radius fractures?

Age >60
Metaphyseal dorsal comminution
Radial shortening
(LaFontaine's initial criteria also had dorsal angulation >20 degrees, but this was disproved in McQueen's paper)

442

List 4 causes of dural ectasia

"MEAN"
Marfan's
Ehlers-Danlos
Ankylosing spndylitis
Neurofibromatosis

443

What's the return to play, return to previous level and return to competitive level sport following ACLR?

Return to play: 80%
Previous level: 60%
Competitive: 40%

444

List 5 factors affecting RTP following ACLR

Age (younger is better)
Pre-operative ROM
Knee extension
Proprioception
Fear of reinjury (#1 reason)

445

What's the risk of re-rupture after ACLR and of contralateral ACL tear?

5-10% re-rupture
10% contralateral ACL tear

446

List 5 risk factors for SCC of the hand

UV exposure
Chronic inflammation/nonhealing wound
HPV
Arsenic exposure
Polyaromatic hydrocarbon exposure

447

List 5 negative prognostic signs in SCC of the hand

>2 cm
Deep to reticular dermis
Perineural invasion
Poorly-differentiated
Arising in areas of chronic inflammation

448

What are the 5 signs of a cutaneous melanoma?

ABCDE
Asymmetry
Border irregularity
Color variation
Diameter >5 cm
Evolution

449

1. What's the most important prognostic factor for a skin melanoma?
2. What's the treatment for a subungal melanoma?

1. Breslow thickness
2. Amputation through IP joint and sentinel node biopsy (node biopsy is true for any melanoma)

450

List 5 contraindications to surgery for elbow contractures

Continued gains with static progressive splinting
Mid-arc ROM pain (suggests OA)
Head injury
Non-compliance
Poor soft-tissue envelope

451

What's the algorithm for pediatric chronic (>2 weeks) torticollis secondary to AARI?

1. Halter traction (NSAIDs, Benzos)
-if successful, C-collar x 3 months
-if fails after 2 weeks, progress to next step

2. Skull traction (NSAIDs, Benzos)
-if successful, Halo x 3 months
-if fails after 2 weeks, progress to C1/2 fusion

452

Which meds treat Tb?

RIPE
Rifampin
INH
Pyrazinamide
Ethambutol (can be DC'd if bug is sensitive to RIP)

453

What's the union rate in an atypical femoral fracture?

50-70%

454

List 4 conditions associated with CVT

distal arthrogryposis
myelomeningocoele
Costello syndrome
Rasmussen syndrome

455

Quartet of nail-patella syndrome?

1. Nail dysplasia
2. Patellar hypoplasia (and often hypoplastic lateral femoral condyle)
3. Capitellar hypoplasia (with associated radial head dislocation)
4. Iliac horns (ram's horn exostoses from the ilium)

456

What's the most important non-orthopaedic manifestation of nail-patella syndrome?

Renal failure

457

Which 2 syndromes are associated with Madelung's?

Nail-patella
Leri-Weill

458

List 7 non-orthopaedic manifestations of Down's syndrome

1. Developmental delay
2. Cardiac disease (ASD, VSD)
3. Duodenal atresia
4. Risk of leukemia
5. Hypothyroidism
6. Risk of infections
7. Premature aging

459

List 10 orthopaedic manifestations of Down's syndrome

1. Occiput-C1 instability
2. C1/2 instability
3. Odontoid hypoplasia
4. Cervical spinal stenosis
5. Scoliosis
6. Spondylolisthesis
7. General hyperlaxity
8. Hip dysplasia
9. Patellar dislocation
10. Pes planovalgus

460

What are 6 indications for hemiepiphysiodesis in congenital scoliosis?

1. Age <5
2. Curve <70 deg
3. <5 segments involved
4. Lumbar curve
5. No kyphosis
6. Hemivertebrae instead of bars

461

Which 5 conditions affect the zone of hypertrophy of the physis?

1. SCFE/fractures
2. Rickets
3. Mucopolysaccharidoses (Hunter's, Hurler's, Morquio's)
4. MED
5. SED

462

Which 3 conditions affect the zone of resting cartilage (reserve zone) of the physis?

1. Diastrophic dysplasia
2. Pseudoachondroplasia
3. Gaucher's disease

463

Which 4 X-Rays are standard in assessing CVT?

AP, lateral in neutral/maximal dorsiflexion/plantarflexion

464

Which 2 angles are used to diagnose CVT and what's abnormal for each? What's the angle used for clubfoot?

CVT:
Talo-calcaneal angle (Kite) >40 (normal is 20-40)
Talar axis-1st metatarsal base angle (TAMBA) >35

Clubfoot:
Kite <20
TAMBA <35

465

Describe the principles for treatment of CVT

1. Serial reverse-Ponsetti weekly casting (5 usually)
2. Foreoot dorsiflexion and abduction are simultaneously corrected with the fulcrum being the head of the talus
3. Foot is progressively brought into equinovarus to stretch out the posterolateral capsule (at the end of 5 weeks it looks like a clubfoot)
4. Once most of the correction is achieved, patient undergoes TN open reduction and pinning and percutaneous Achilles tenotomy
5. Pin removal at 6 weeks
6. Boots-and-bars in neutral DF and 0 degrees of abduction full-time for 2 months then night-time use for 2 years

466

What's the most important part of the S-L ligament?

Dorsal

467

List 8 steps when faced with neuromonitoring loss intra-operatively

Alert anesthesia
Anesthesia to check Hgb, temperature, MAP
Check patient positioning
Check leads
Reverse correction
Check screws and remove if concerned
Wake-up test

468

When doing an L5-S1 decompression and fusion for a spondylolisthesis, what do you decompress?

1. L5 lamina (usually just comes off easily due to the listhesis)
2. S1 upper half laminectomy and resect part of the posterior S1 body (this is where the S1 nerve roots drape over)

469

List 4 MRI and 4 X-Ray findings of dystrophic curves in neurofibromatosis

MRI:
Dural ectasia
Dumbbell lesions in neuroforamina
Dislocation of rib heads into the canal
Intraspinal neuroforamina

X-Ray:
Rib penciling
Vertebral scalloping
Vertebral body wedging
Foraminal widening

470

What's the acronym for coxa vara etiologies?

"PORT IS SOFT"
Perthes
OI
Rickets
Trauma
Infection
SCFE
SED/MED
Osteopetrosis
Fibrous dysplasia
Tumour

471

List 8 indications for DCO

Lactate >2.5
Base deficit/excess outside -2 to +2 range
Platelets <90
ISS > 40
ISS > 20 with lung injury
Hypothermia
Hemodynamic instability
Severe head injury (relative, since can get neurosurg to do intra-cranial pressure monitoring)

472

List 5 contraindications for inserting an odontoid screw

Reverse-obliquity fracture pattern
Displaced fracture
Barrel chest
Obesity
Kyphotic deformity

473

What are the 2 mechanisms of action of BMP?

1. promote MSC differentiation into osteoblasts
2. upregulate growth factors involved in various functions such as angiogenesis

474

List 5 conditions associated with clubfoot

tibial hemimelia
arthrogryposis
Larsen syndrome
diastrophic dysplasia
myelodysplasia

475

List 2 indications for limited open fasciectomy in Dupuytren's disease

MCP contracture >30
PIP contracture >15

476

List 3 contra-indications to teraparatide (Forteo)

Paget's
Prior radiation
Open physes

477

List 5 conditions that present in the newborn with thickened cortices

"CCOMP"
Caffey's disease
Camurati-Engelmann disease
Osteopetrosis
Melorheostosis
Pyknodysostosis

478

Describe the Leadbetter maneuver

FATI CAR
Flexion (to 90), Adduction, Traction, IR, Circumduction, Abduction and Reduction check in extension

479

List 6 indications for bisphosphonates other than osteoporosis

OI (ideally before age 6)
Polyostotic fibrous dysplasia
Paget's disease
AVN (pre-collapse)
Hypercalcemia
Mets/myeloma

480

Where does the common iliac bifurcate?
What are the branches of the internal iliac artery?

Bifurcates at L4

"I Love Going Places In My Very Own Underwear"
Iliolumbar
Lateral sacral
superior/inferior Gluteal
internal Pudendal
Inferior vesicle
Middle rectal
Vaginal
Obturator
Umbilical

481

How much combined overhang of C1 on C2 following a Jefferson fracture is indicative of rupture of the transverse ligament?

6.9 mm

482

What are 3 potential spaces in the hand?

Midpalmar
Thenar
Hypothenar

483

Which nerves emerge lateral to psoas?

iLioinguinal
iLiohypogastric
LFCN

484

Which nerves emerge medial to psoas?

Obturator
Lumbosacral trunk

485

What are the indications for initiation of bisphosphonates in osteoporosis?

Age >50 with either:
1. T-score < -2.5
2. T-score -1 to -2.5 with >3% 10-year hip # risk or >20% risk of major osteoporosis-related fracture

486

List 5 side-effects of bisphosphonates in adults

Osteonecrosis of the jaw
Esophagitis
Dysphagia
Gastric ulcers
Atypical femoral fractures

487

List 5 side-effects of teriparatide

Transient hypercalcemia
Dizziness
Nausea
Headache
Malignancy (especially in Paget's)

488

Which conditions cause ligamentous laxity?

Marfan's
Ehlers-Danlos
OI
Achondroplasia
Pseudoachondroplasia
Mucopolysaccharidoses

489

Which conditions don't have C1-2 instability?

Achondroplasia
Diastrophic dysplasia

490

What is congenital radioulnar synostosis associated with?

MACKA
Mandibulfacial dysostosis
Apert syndrome
Carpenter's syndrome
Klinefelter's syndrome
Arthrogryposis

491

What is syndactyly associated with?

PACA
Poland syndrome
Apert syndrome
Carpenter's syndrome
Acrosyndactyly

492

What are the features of Poland syndrome?

1. Unilateral chest wall hypoplasia (absent sternal head of pec major)
2. Hand/forearm hypoplasia
3. Symbrachydactyly
4. Sprengel's deformity
5. Scoliosis

493

When do you transfuse postoperatively in a pediatric spine?

Tachycardia
Hypotension
Urine output <0.5 cc/kg/hr
Acidosis

494

List 4 risk factors for lumbar DDD

Age
Genetic predisposition
Occupation
Smoker

495

What are the indications for surgery in lumbar DDD?

Symptoms >6 months
Single level disease
Midline tenderness at that level

496

What's the treatment for puerpal symphyseal rupture?

<2 weeks: ORIF
>2 weeks: arthrodesis

497

Which surgical factors are associated with successful ORIF of puerpal symphyseal ruptures?

Longer plate (>2 screws per side)
Precontoured plate (better contact)
Locking plate

498

What's the main advantage of a press-fit humeral component vs. cemented in TSA?

Press-fit has better rotational stability (axial is the same)

499

List 5 ways of ensuring proper femoral and tibial tunnel placement in anatomic ACLR (not including fluoroscopy, which is an option)

Femoral:
1. 8-mm anterior to posterior margin, 1.7-mm proximal to bifurcate ridge
2. 45% of the proximal-to-distal length of the condyle along the posterior 1/3 of the condyle

Tibial:
3. In line with the posterior border of the anterior horn of the lateral meniscus
4. 9-mm behind the posterior border of the intermeniscal ligament
5. 5-mm anterior to the peak of the medial eminence

500

Where does the common iliac bifurcate?
What are the branches of the internal iliac artery?

Bifurcates at L4

"I Love Going Places In My Very Own Underwear"
Iliolumbar
Lateral sacral
superior/inferior Gluteal
internal Pudendal
Inferior vesicle
Middle rectal
Vaginal
Obturator
Umbilical

501

List 5 side-effects of bisphosphonates in adults

Osteonecrosis of the jaw
Esophagitis
Dysphagia
Gastric ulcers
Atypical femoral fractures

502

List 5 side-effects of teriparatide

Transient hypercalcemia
Dizziness
Nausea
Headache
Malignancy (especially in Paget's)

503

List 4 risk factors associated with recurrence of clubfoot

1. Drop toe sign
2. Flexion contractures of wrists and fingers (distal arthrogryposis)
3. Spinal dysraphism
4. Noncompliance with FAOs

504

What are 4 risk factors for poor outcomes in growth modulation for adolescent Blount's?

Age >14
BMI >45
Severe deformity
Titanium implants (high risk of hardware failure)

505

List 5 ways to gauge accuracy of femoral/tibial tunnel placement in an anatomic ACLR

Femoral:
1. 8-mm anterior to posterior margin, 1.7-mm proximal to bifurcate ridge
2. 45% of the proximal-to-distal length of the condyle along the posterior 1/3 of the condyle

Tibial:
3. In line with the posterior border of the anterior horn of the lateral meniscus
4. 9-mm behind the posterior border of the intermeniscal ligament
5. 5-mm anterior to the peak of the medial eminence

506

List 5 factors that predict success of single-stage revision arthroplasty

THA
Monomicrobial culture-positive organism
Gram +
Optimal host factors
Sensitivity-tailored antibiotic therapy for 3 months

507

List 5 methods of assessing for patella alta and indicate normal values for each

1. Caton-Deschamps (0.6-1.3)
2. Insall-Salvati (0.8-1.2)
3. Blackburne-Peel (0.5-1)
4. Plateau-patella angle (normal 20 degrees)
5. Blumenstaat's line should touch the inferior patellar pole at 30 degrees of knee flexion

508

List 5 poor prognostic factors in pilon fractures

Male
Multiple comorbidities
Lower SES
Lower education level
WSIB