WHat are the cutoffs for PCL and PCL + PLC on posterior stress xrays?
10 - 12 mm = PCL
> 12 mm = PCL and PLC
What two ligaments form a complex that marks the superolateral margin of the subscapularis tendon?
SGHL and CH
2 indications for surgical intervention in hamstring ruptures
1) Athletes when all of the hamstring tendons have avulsed off their origin or
2) Two tendons have avulsed and retracted more than 2 cm.
3 contraindications to hamstrings graft in ACL reconstruction
ligamentous laxity (pathologic graft)
previous hamstrings injury (pathologic graft)
Sprinter (they need it)
In the UE, which artery is dominant?
Ulnar in 88% of population
Median in the rest
What abnormal motion of the humerus on the glenoid will there be in a patient with an internal rotation deficit of his shoulder?
What degree of flexion is best for rehab of ACL when doing:
a) Hamstring isometric
b) Isometric quads
c) Active ROM
a) Any angle
b) greater 60
c) between 35 and 90
Most common sites for osteochondral injury in lateral patellar dislocation
Medial patellar facet
Lateral trochlear ridge
Muscles most commonly affected by Parsonage-Turner syndrome?
Shoulder Motor: muscles (RTC)
Sensory: lateral antebrachial cutaneous nerve
4 elbow problems in the overhead throwing athlete
Valgus extension overload
Ulnar neuropathy (cubital tunnel)
No mention of ulnohumeral arthritis
2 Options for treating medial winging
Operative: Pec major transfer: sternal head transferred to scapula
What's an Eden Lange Transfer?
Transfer of rhomboids from medial to lateral border of scapula for treating lateral scapular winging
What type of muscles are more at risk for muscle strains?
Ones that cross 2 joints
Management algorithm for a chronic anterior shoulder dislocation with boney bankart.
When the glenoid defect is greater than 20-30% then bony augmentation is indicated.
The humeral head defect should be addressed if engaging or 20-40% head loss
Hemiarthroplasty should be considered if >40% of the head is involved.
Most common location for hip labral tear.
What nerve is at risk with a posterior capsular releas ein shoulder?
Inferior suprascapular nerve
Physical findings of shoulder instability?
+ Load and shift
What is the arthroscopic landmark to the iliopsoas?
Can use as a guide for arthorscopic release
Describe provocative test for posterior labral tear.
Pain if hip is brought from a flexed, adducted, and internally rotated position to one of abduction, external rotation, and extension.
Three reasons to consider open Bankart repair
1. large boney bankart
2. engaging hills sachs
3. HAGL lesion
What is the exam finding of someone with scapulothoracic dyskinesis and what is the main treatment?
1. low, protracted scapula
2. Physio with emphasis on coordination of scapular motion with trunk and hip movements
Normal TT-TG ratio?
Normal: Less than 15mm (ie 14mm or less)
Abnormal not until greater than 20mm
In between is a grey zone
What is the most common variant of attachment site of Biceps to glenoid?
Posterior attachment (70%)
6 contraindications to TSA?
insufficient glenoid bone stock
rotator cuff arthropathy
irreparable rotator cuff :
- hemiarthroplasty or reverse total shoulder are preferable
- risk of loosening of the glenoid prosthesis is high ("rocking horse" phenomenon)
brachial plexus palsy
What is the Thessaly test?
Patient stands at 20 degrees of flexed knee and twists.
Positive test is discomfort or clicking and suggests a meniscal injury.
What sort of osteotomy is helpful in a chronic PCL injury?
Medial opening wedge with an increase of tibial slope
Usually have a varus deformity
3 things that cause decreased knee flexion
- (Yes. Or excessive tightening of the extensor mechanism).
Adhesions in medial/lateral gutters/Arthrofibrosis
- (Yes. Arthrofibrosis anywhere in the joint can lead to stiffness).
- (Yes. Patella baja usually secondary joint line elevation. > 10 mm joint line elevation found to result in significantly less flexion).
Cyclops lesion will NOT. It will cause decreased EXTENSION
What causes Os Acromiale?
Failure of fusion between the meso-acromion and meta-acromion.
What is a STIR sequence on MRI?
T1 with fat suppression
What are cruciate cysts associated with?
a) name the borders
b) contents (4)
a) Anterior Surpaspinatus tendon to superior Subscapularis tendon
b) SGHL, CHL, capsule LH biceps
Management of Heat-stroke
Caused by core temp >40C
Whole body cooling (ice bath)
can be fatal
Indications for transport to hospital after sports head injury: (8)
Concussion with spinal-cord like symptoms
LOC > 1minute
Seizure in patient with no history of seizure
Deep scalp laceration with substantial blood loss
Worsening HA, especially when accompnied by vomiting
Severe neck pain
Difficulty moving the arms or legs
Any lateralizng neurologic sign such as motor asymmtery, pupil asymmetry, hemisensory loss
MPFL femoral insertion during reconstruction
Schottle et al have described the radiographic landmark to be:
- 1 mm anterior to the posterior cortex extension line
- 2.5 mm distal to the posterior origin of the medial femoral condyle
- Proximal to the level of the posterior point of the Blumensaat line.
Meniscal cyst is indicative of what?
Patient with mononucleosis - can they play non-contact sports?
Why or why not?
If they sit out - for how long?
No - 50% of splenic ruptures are atraumatic due to increased Valsalva (rowing)
Off for 3-5 weeks at least
What is the maximal amount of glenoid retroversion that can be dealt with by eccentrically reaming the anterior glenoid?
List 6 things to evaluate on MRI for RTC tears?
- Partial vs. Full thickness
- Shape of tear
- Tendons involved
- Degree of retraction
- Subluxation of biceps
What is Miserable Malalignment Syndrome?
- Femoral anteversion
- Genu Valgum
- External tibial torsion/pronated feet
- increased risk of patellar instability (due to increased Q-angle)
- Exacerbation of patellofemoral dysplasia
What is the name of the condition caused by vascular insufficiency and repetitive microtrauma to the capitellum in someone
Similar to OCD, but younger population and more benign course
Differentiate GLAD and APSLA lesions.
Glenoid labral articular defect (GLAD) is a sheared off portion of articular cartilage along with the labrum.
Anterior labral periosteal sleeve avulsion (ALPSA) can cause torn labrum to heal medially along the medial glenoid neck.
List 5 intrinsic causes of elbow stiffness:
- joint incongruity
- loose bodies
- intra-articular fractures
- osteochondritis dissecans
- post-traumatic arthritis
What type of meniscal tear is more common in ACL tears?
Lateral meniscal tear
Three complications associated with biceps repair?
- LCNFA injury
What is a FAIR test and what does it test for?
Flexion, adduction and IR test
Tests for piriformis syndrome
What is the expected clinical finding with an anterior placed tibial tunnel with ACL?
Tightness in flexion
Impingement with extension
Causes of Thoracic Outlet Syndrome
1st rib malunion
scalene muscle insertion abnormalities
Causes in Athletes:
abnormal pec minor
repetitive shoulder use
extreme arm position
weightlifting, rowing, swimming
4 radiographic findings of pincer deformity.
- anterosuperior acetabular rim overhang
- acetabular retroversion
- acetabular protrusio
- coxa profunda
- Crossver sign
- Ischial spine sign
- Posterior wall sign
Can you change slope with tibial osteotomy?
opening wedge is easier
by changing position of Puudu plate
Blood supply of ACL
middle geniculate artery
Which bundle of the ACL is shorter?
Biceps pathology is associated most with pathology of what rotator cuff muscle?
What is the expected finding with a too-vertical femoral ACL tunnel?
+ pivot shift
Indications for meniscal root repair (as opposed to menisectomy)
no significant arthritis
No joint space narrowing
If LCL injury suspected what position do you splint in?
Components of PLC?
- LCL (295N)
- popliteus muscle and tendon (680N)
- popliteofibular ligament (229N)
- lateral capsule
- arcuate ligament
- iliotibial track
- fabellofibular ligament
What is Sinding-Larsen-Johansson Syndrome?
Traction apophysitis at base of patella.
Similar to OGS.
What is Remplissage and when do you do it?
Transfer of posterior capsule and Infraspinatus into a large, enagaging Hills Sachs
What causes subcoracoid impingement and what is the physical test?
Impingement of the LT/Subscap on the coracoid.
Pain over coracoid with flexion, IR and Adduction
List 4 causes of cardiovascular caused sudden death in athletes
HOCM: hypertrophic cardiomyopathy (most common)
Coronary artery abnormality: 2nd most common
Long QT syndrome
Commotio cordis: blow to anterior chest wall causes v.fib
What two nerves supply branches to the hip labrum?
- branch of nerve to the quadratus femoris
- obturator nerve
Physical exam maneouver to test for politeal entrapment syndrome?
Loss of pulses or diminished pulses with active plantarflexion or passive dorsiflexion.
Nerve most commonly injured during pec major transfer?
Extrusion of meniscus >3mm on imaging is worrisome for what?
Why does it matter?
Meniscal root tear
>3mm extrusion associated with increased articular cartilage loss and osteophyte formation
4 static GH stabilizers?
articular congruity and version
negative intraarticular pressure
Indications for diagnostic arthorscopy in OCD of Knee
Skeletally mature/impending physeal closure
Signs of instability (of fragment, ie mechanical symptoms)
Expanding lesion on plain films
Failure of non-operative management
Late complaint after PCL insufficient knee?
Medial compartment OA
Risk factors for Parsonage-Turner Syndrome
Viral infections (most common - question stem has this feature in it)
Mechanism for sports hernia
Hip hyperextension and abduction
causes eccentric contraction of the hip adductors
What is the most common Baker's cyst?
the gastrocnemius-semimembranosus bursa
Located under the medial head of gastrocs and semimembranosus
What is TUBS?
Traumatic Unilateral Dislocation with a Bankart Lesion
What is the advantage of tenodesis vs. tenotomy?
Thought to reduce crampoing and improve cosmesis. But not proven with quality studies.
If a patient has decreased ER with arm at side following surgery for instability what procedure was most likely done?
Closure of rotator interval
4 xray findings of cam deformity.
- decreased head-to-neck ratio
- aspherical femoral head
- decreased femoral offset
- femoral neck retroversion
Three stages of calcific tendinosis?
2 surgical treatment options for sports hernia
pelvic floor repair vs. adductor/rectus recession
Decompression of genitofemoral nerve
Three differences between Panner disease and OCD?
1. Panner disease exhibits an irregular epiphysis, OCD a well-defined subchondral lesion
2. Panner is younger,
3. Panner shows a more benign course
Posterior labral tear and weakness with external rotation of shoulder only. What is the cause?
Cyst at spinoglenoid notch compressing suprascapular nerve branch supplying infraspinatus
Posterior labral tears are associated with cysts at either the spinoglenoid notch or suprascapular notch
What is Parsonage-Turner syndrome?
What positional adjustment do you have to make to the leg before placing a posterior hip portal?
Make sure it is internally rotated to bring portal entry site away from sicatic nerve.
Risk factors for quad tendon rupture (8)
Connective tissue disorders
4 complications of Laterjet?
Post ACL reconstruction, how many people returned to play at the same level:
Best predictor of successful non-operative management in OCD of knee?
Open distal femoral growth plate.
What does a west point view look for?
Glenoid bone loss
Most common compartment affected by exertional compartment syndrome?
(worse prognosis if posterior involved)
What arthroscopic finding is a contraindication to a Faulkerson?
Which meniscus carries more of the load of the knee?
THiNK: normal is valgus
Diagnostic criteria for exertional compartment syndrome (3)
- resting (pre-exercise) pressure > 15 mmHg
- immediate (1 minute) post-exercise is > 30 mmHg and/or
- continuous post-exercise failed to return to normal or remains > 15 mmHg at 15 minutes after cessation of exercise
Closure of the rotator interval has what effects?
Decreased AP glenohumeral translation
So it decreases risk of instability
Deficiency of what bundle causes a pivot shift?
PL bundle of ACL
Clinical features of thoracic outlet syndrome? (3)
Main blood supply of the patella?
Come from inferior
Can't find exactly what artery tho
What should be assumed in any unconscious athlete?
Management of a femoral stress fracture at inferomedial neck
If >50% across neck: operative with percutaneous fixation
Inferomedial neck is compression side and may be treated non-op
Superolateral neck is tension side and needs an operation
ACL: what bundle is tight in flexion? Extension?
Anteromedial bundle: tight in flexion
Posterolateral bundle: tight in extension
When do you do an outside in meniscal repair?
anterior horn tear
3 surgical options for Internal Impingement
- Posterior release vs. anterior stabilization if unstable
- Posterior labral repair
- Debridement of Bennet lesion
- Repair of PASTA if present
Ideal position for glenosphere baseplate?
inferior on glenoid with an inferior tilt
to avoid notching
How does weight training increase strength in adults vs. kids?
Adults: muscle hypertrophy
Kids: increased muscle firing efficiency and coordination
Two xray findings associated with little leaguers elbow.
Fragmentation or avulsion of the medial epicondyle
In ACL reconstruction with hamstring graft, what characteristic of the interference screw improves fixation?
What is Beighton's Score?
passive hyperextension of each small finger >90° (1 point each)
passive abduction of each thumb to the surface of forearm (1 point each)
hyperextension of each knee >10° (1 point each)
hyperextension of each elbow >10° (1 point each)
forward flexion of trunk with palms on floor and knees fully extended (1 point)
a score of 5 or more on 9-point Beighton-Horan scale defines joint hypermobility
What has the highest correlation with TUBS (traumatic anterior shoulder dislocation)?
Most happen young: 80-90% in teenagers
What is the thick bundle of fibers found at the avascular zone of the coracohumeral ligament running perpendicular to the supraspinatous fibers and spanning the insertions of the supra- and infraspinatus tendons?
The rotator cable.
Sounds like horseshit.
What is the blood supply to the ACL?
Middle geniculate artery
Three ways that Laterjet improves stability.
1. Increases excursion prior to subluxation
2. By passing the conjoint through a slit in the subscapularis, this prvides a supportive sling
3. You can sugment capsular repair with remanant of CA ligament
What phase of throwing does internal impingement occur?
When the arm is most abducted and ER'ed
Specific first line treatment for Internal Impingement?
posterior capsule stretching with sleeper stretches for at least 6 months
What is better for meniscal repairs, horizontal or vertical mattress stitches?
Why do vertical femoral tunnels cause ACLs to fail?
Placement of the ACL graft vertically at the apex of the notch causes the graft to wrap around the PCL
This causes high tension in the graft when the knee is flexed.
Will also stretch out the graft, preventing full extension
What is the interval for a lateral approach to capsule for a lateral inside out meniscal repair?
Between ITB and Biceps
Retract lateral head of gastrocs posteriorly
At what range should the MPFL ligament be isometric?
0-30 degrees of flexion
This reflects the native anisometry of the ligament and the range where it is isometric (0-30 degrees flexion)
Therefore tension at 30 degrees
What does AMBRI stand for and what is it referring to?
Rehabilitation (responds to)
Inferior Capsular shift (best surgial management)
Refers to MDI - good b/c tells you everything you need to know about it!
What is the Pellegrini Stieda Sign?
Medial femoral condyle avulsion fx (Chronic MCL injury)
Name two treatment modalities unique to quadriceps contusions (moderate - severe)
1. Use of Losartan - angiotensin 2 inhibitor - which decreases muscle death and fibrosis
2. Immobilization in 120 degrees of felxion for 24 hours
Meniscal cysts are more common on what side?
Post-SLAP repair, what amount of patients return to pre-activity level of sports?
5 pitching rules of paediatric pitchers
Radiographic signs of discoid meniscus
lateral joint space widening
squaring of the lateral condyle
cupping of lateral tibial plateau
hypoplasia of the lateral tibial spine.
What structure is at risk during posteiror shoulder labral repair?
Posterior branch of axillary nerve
Rusn 1mm from inferior border of shoulder capsule
Most common direction of proximal Tib-FIb dislocations?
Management of meniscal cyst
partial menisectomy + cystectomy
What two patient populations would cause you to think twice about doing an acromioplasty?
1 - WOrkmans Comp - do poorly
2 - Massive rotator cuff tear - plasty can compromise the superior arch and allow for excape in these cases
2 indications to operate on tibial stress fracture
Presence of dreaded black line
failure of non-operative
What condition is characterized by excessive lateral patellar tilt, a lack of excessive mobility and an inability to passivey evert the patella?
Lateral faet compression syndrome
What is the female athlete triad?
(JAAOS CORE 2)
Causes of shoulder AVN? (give 6)
Remember ASEPTIC mneumonic:
Steroids (most common), Sickle, SLE
Erlenmeyer flask (Gaucher’s)
Caisson’s (the bends)
What bacteria is especially known for causing biofilms in TEA and may need revision even if early infection?
What has been associated with the use of intra-articular shoulder local anesthetic infusions?
Contraindications to return to play after head injury (6)
Prior Grade 1 concussion in same season
Symptoms >15 mins (grade II)
Positive exertional stress test
What is the consequence of overdebridement during surgery for valgus extension overload?
Osteophyte is at posteromedial corner. Debridement into normal olcerenion can cause increased tensiuon on MCL and lead to symptoms or failure.
What is a Kim lesion?
Reverse bankart lesion occuring in posterior shoulder dislocation
Avulsion of the deep posteroinferior labrum
May have intact superoinferior labrum
During which stage of throwing is valgus load the highest?
What is a Sleeper Stretch used for?
Posterior capsule stretching in internal impingement or internal rotation deficit (GIRD) of the shoulder
Specifically targets the posterior band of the IGHL
What's an ALPSA?
Anterior labral periosteal sleeve avulsion
Deficiency in what two structures with a shoulder hemi leads to increased instances of anterosuperior excape?
RTC and CA ligament
Which bundle of the ACL is shorter?
What a HAGL? What structure does it involve?
Humeral avuslion of the glenohumeral ligament
Specifically involves inferior GHL and occurs in conjunction with TUBS
Max correction with Valgus producing HTO?
List 5 extrinsic causes of elbow stiffness:
- formation of eschar following a burn
- heterotopic ossification
- adhesions/contraction of the capsule
- myositis ossificans
- ligament contractures
- scarring of posterior oblique portion of medial ulnar collateral
List 5 risk factors for triceps rupture:
systemic illness (renal osteodystrophy)
anabolic steroid use
local steroid injection
chronic olecranon bursitis
previous triceps surgery
Describe Foucher Sign
Change in size of popliteal cyst with different positioning
Indicative of popliteal cyst
What muscle shares an origin with ECRB?
Which stage of calcific tendinosis is most painful?
Resorptive (Stage 3)
What is Hoffa's test for?
Fat pad impingement - infrapatellar impingement
Name 5 risk factors associated with frozen shoulder
Previous shoulder surgery
Activity instructions after arthroscopic hip labral debridement.
- limited weight-bearing x4 weeks
- flexion and abduction are limited for 4 to 6 weeks
Three technical errors that will lead to failure of meniscal transpalnt?
- Not correcting axial alignment
- Not fixing ACL tear
- > 15% mismatch between donor and recipient condyle
Pre-existing arthritic change, obesity and inflammatory arthritis are also bad.
3 physical exam findings of FAI
- limited hip flexion (
- anterior impingement test (flexion, adduction, internal rotation) elicits pain
- externally rotated extremity
3 athletic injuries that women are more prone to
What has been shown to decrease ACL ruptures in female athletes?
Neuromuscular training, jump training and plyometrics
Because a major modifiable cause of increased ACL tears in women is lack/worse neuromuscular coordination and training
Prognostic indicators for OCD in Knee: (good and bad)
Young age (open physis)
fluid behind lesion on MRI
Location other than medial femoral condyle (lateral femoral condyle and patella have worst prognosis)
3 radiographic findings with spear tacklers spine?
- developmental narrowing (stenosis) of the cervical canal
- persistent straightening or reversal of the normal cervical lordotic curve
- concomitant posttraumatic roentgenographic abnormalities of the cervical spine
What are the 3 most important PLC structures that need to be reconstructed after injury?
Average retroversion and neck shaft angle of humeral head?
30 degrees retroversion
130 neck shaft angle
Closing wedge HTO does what to posterior slope? Opening wegge
Closing: decreases it
Opening wedge: opens it - but medial opening wedge says it preserves slope
If MCL injury suspected what position do you splint in?
What treatment regimen has the most reliable increase in DASH score with post traumatic elbow stiffness?
Supervised exercise therapy with static progressive elbow splinting.
4 indications for RSA
- Cuff tear arthropathy
- antero-superior escape of hemi
- pseudoparalysis - irreperable cuff tear and OA
- 3 or 4 part fractures in the elderly
What does SONK look like on MRI?
Crescent shaped lesion on medial femoral condyle
Steps to performing an olecrenon osteotomy?
- Part of the anconeus and the flexor carpi ulnaris are released off the olecranon to identify the position of the osteotomy
- Osteotomy performed at the apex of the semilunar notch
- Preserve at least 1 cm of intact olecranon proximal to the apex of the osteotomy.
- Osteotomy is made near to completion with an oscillating saw and completed with a sharp osteotome cracking through the articular cartilage.
- The osteotomized olecranon is then reflected superiorly with the triceps tendon.
Four surgical options for a large, engaging Hill Sachs?
- Rotational Osteotomy
- Allograft recon
What does a patulous inferior capsule on MRI suggest?
Name 2 tests for LHB pathology:
Speeds: resisted FF with elbow extended and arm supinated
Yeargason's: resisted supination
How do you do a lateral pivot shift of elbow?
The patient is placed in the supine postion with forearm overhead and elbow extended. The elbow is then supinated with force and flexed to >40° while a valgus load applied. A positive result is palpable / visible clunk as the ulna and radius reduce suddenly.
What muscles are affeted in quadrilateral space syndrome?
Teres minor & deltoid
both innervated by axillary nerve, which runs in quadrilateral space
What is little leaguers shoulder and three methods of prevention.
A Salter Harris Type I physeal injury to proximal humerus.
1. no breaking pitches
2. pitch counts
3. max 2 games per week
What is the most important medial restraint to LHB subluxation/dislocation?
What is an important LATE complication of inferior shoulder dislocation?
Axillary artery thrombus
What motions are weak after Pec Major tendon rupture?
Adduction & IR
When is Lat Dorsi transfer indicated in the treament of RTCR?
Irreparable posterosuperior tears with intact subscapularis
glenoid labral articular defect
Where do muscle strains occur?
Ideal position for elbow fusion?
in a unilateral arthrodesis
90° of flexion
0-7° of valgus
in a bilateral arthrodesis
one elbow in 110 ° of flexion for feeding
one elbow in 65 ° of flexion for perineal hygiene
Name and describe three provocative tests for MCL deficiency of the elbow.
1. valgus stress test
place elbow at 20 to 30 degrees (unlocks the olecranon), externally rotate the humerus, and apply valgus stress
2. milking maneuver
create a valgus stress by pulling on the patient's thumb with the forearm supinated and elbow flexed at 90 degrees
positive test is a subjective apprehension, instability, or pain at the MCL origin
3. moving valgus stress test
place elbow in same position as the "milking maneuver" and apply a valgus stress while the elbow is ranged through the full arc of flexion and extension
positive test is a subjective apprehension, instability, or pain at the MCL origin between 70 and 120 degrees
100% sensitive and 75% specific
Minimally invasive treatment for calcific tendinosis by stage (3)
- Formative: Extracorporeal shock wave therapy
- Resting: Extracorporeal shock wave therapy
- Resorptive: U/S guided needle lavage
When can this guy go back to wrestling?
No new lesions within the preceeding 72 hours
at least 5 days of anti-viral medications
AND wouds have scabbed over
Consequence of not fixing distal biceps tear?
will lose 40-50% supination
will lose ~30% flexion
will lose 15% grip strength
What are the main surgical options for RTC arthropathy?
1) Hemiarthroplasty - consider if younger, deltoid deficient or not enough glenoid bone to do revers
2) RTSA - mainstay, better pain and functional outcomes
What important structure runs along the lateral aspect of the long head of the biceps?
Ascending branch of the anterior humeral circumflex artery
What is another, more commonly used term for AMBRI?
How does cardio improve CO?
Increased stroke volume
Entrapment at spinoglenoid notch. What nerve and muscles will it affect?
During arthroscopic rotator cuff repair in a 45 year old man, you find a SLAP tear incidentally. How do you manage?
NOT necessary to repair if it is incidental and patient was asymptomatic AND patient is older >40
Repair may actually cause shoulder stiffness
What is the "movie theatre sign"?
Patellar tendon pain with extended sitting (knee in flexion)
Coincides with Blazina Type 3 tendonitis
Contraindications to HTO
Obese with BMI >35
Knee flexion contracture >15 degrees
Procedure needing >20 degrees of correction
Varus thrust during gait
Benefits of medial opening wedgie high tibial osteotomy vs. lateral closing wedge
Maintenance of posterior slope
Avoids tib-fib joint
Avoids peroneal nerve and anterior compartment
Downside: patella baja
What is a normal acromial-humeral interval?
Femoral condyle articular cartilage lesion >4mm^2. Treatment options:
Autologous chondrocyte implantation (2-stage)
Allograft osteochondral transplantation
4 causes of internal impingement
fraying of posterior rotator cuff
posterior and superior labral lesions
hypertrophy and scarring of posterior capsule glenoid (Bennet lesion)
cartilage damage at posterior glenoid
MRI diagnosis of discoid meniscus
3 or more 5mm sagittal images with meniscal continuity ("bow-tie sign")
Pre-op ACL, what 3 factors are assocaited with increased knee pain?
higher body mass index (BMI)
concurrent lateral collateral ligament injury
What radiologic finding precludes use of ACI for patellofemoral joint?
Joint space narrowing on merchant view.
Where do most partial biceps tears occur?
Radial side of tuberosity
Causes of thoracic outlet syndrome? (7)
Anamalous insertion of scalenes
1st rib malunion
Repetitive shoulder use
How long until considering surgical management with a stiff knee post ACL recon?
12 weeks of physio
Then consider LOA/MUA
Poor prognositc indicators of osteochondritis dissecans
Location: Posterolateral aspect of lateral femoral condyle or patella
Fluid behind lesion on MRI
Risk factors for growth arrest in paediatric ACL reconstruction
Oblique tunnel position across physis
Interference screw across physis
High-speed burring across physis
Large diameter tunnels >8mm across physis
What ligaments are most imporant for AC stability?
Posterior & superior AC ligaments
Is there a major difference in growth arrest between trans-physeal and physeal sparing ACL reconstruction in paeds?
Name 1 legal supplement that actually improves performance
2-3mg/kg improves performance
Allowed by IOC up to 12 micrograms/mL of urine
Treatment of cruciate cysts
Arthroscopic excision ± percutaneous aspiration
When is the saphenous nerve most likely to be injured during ACL surgery?
Hamstring harvest with leg in extension
Does scapular elevation or depression lead to thoracic out let syndrome?
Tractions all the nerves/roots
List 3 effects and 13 side effects of anabolic steroids
increased muscle strength
increased aggressive behaviour
Increased body weight
Irreverisble deepending of the female voice
Reduction in gonadotropic and sex hormones (estrogens & testosterone)
- Results in Decreaed bone mineral density, Oligospermia or azoospermia
Insulin resistance (HGH specifically)
Incresed blood viscosity --> stroke/MI (EPO specifically)
INdications for RTC repair?
- Bursal sided tears > 3 mm
- PASTA tears > 50%
- Complete tears in a younger patient
Greatest risk factor in recurrence of shoulder instability?
Recurrence rates 60-90%
What percentage of asymptomaic patients over 60 have RCT tear?
What is the biggest risk factor for sciatic nerve traction injury duing hip scope?
Maximal traction weight (not traction time)
What are 4 surgical treatments for posterior shoulder instability?
1. Arthroscopic posterior labral repair/capsular shift
2. McLaughlin - Transfer of subscap/LT into reverse Hill Sachs (has to be less than 50%
3. Hemiarthroplasty - Hill Sachs > 50% or humerhead arthritis
4. TSA - GH artritis
Name 3 absolute contraindications to play (neck injuries)
Klippel-Feil anomalies: mass fusion of the cervical and thoracic vertebrae is an absolute contraindication to play
What is released with an a) anterior or b) posterior interval slide?
a) SS from rotator interval
b) SS from IS (needs to be repaired after)
Name the types of snapping hip syndrome:
External: ITB over GT
Internal: iliopsoas over:
- femoral head
- prominent iliopectineal ridge
- exostoses of LT
- iliopsoas bursa
Intra-articular: loose body or labral tears
Contents and borders or cubital fossa.
contents-- biceps tendon (lateral), brachial artery, median nerve (medial)
medial border--pronator teres
proximal border --distal humerus
Interval for lateral approach to knee (i.e. for LCL repair)?
Split biceps and ITB
While outcomes are equivocal, name 2 areas in which proximal biceps tenodesis is better at than tenotomy
Less arm cramping
*NO difference in functional outcomes
Indications and contraindications for meniscal transplant
Young patients with near total menisectomy, especially lateral
Grade IV condrosis (if not concurrently addressed)
Malalignment (if not concurrently addressed)
6 structures visible in the peripheral compartment during hip scope.
- femoral head
- zona orbicularis
- medial synovial fold
- femoral neck
- peripheral capsular attachments
Main difference in treatment between acute and chronic AC separation?
For acute there are many options, including hook plate.
With chronic you have to reconstruct the CC ligaments in addition to ORIF.
Does early physio and ROM improve outcomes with RTCR at 1 year?
What is the main type of valgus producing tibial osteotomy?
Medial opening wedge osteotomy
4 causes of suprascapular ligament compression at the spinoglenoid notch
posterior labral tears causing a cyst
spinoglenoid notch ganglion
Dial Test: results and interpretation
+ is >10 degrees ER asymmetry
+ at 30: PLC injury
+ at 30/90: PLC & PCL injury
What is the most important muscle group in a) ACL and b) PCL rehab?
Name the high risk sites for stress fracture
- inferomedial: Lower risk than superolateral
Anterior tibial diaphysis
Politeal cysts are larger in flexion or extesion?
This decreases joint space, increases pressure and fluid into cyst, and closes off the communication between cyst and joint entrapping the fluid
What does EMG show with brachial neuritis?
Sharp waves and fibrillations.
Desscribe treatment for SLAP tears by type
Type I - debride labrum
Type II - reattach labrum
Type III - debridement of flaps
if tendon involvement
if tendon involvement >1/3, same and perform biceps tenodesis or tenotomy.
decompress any cysts
For what stages of shoulder AVN is core needle decompression most appropriate?
Creuss stage 1-2
What is the treatment for proximal tib/fib cysts?
don't want it causing pressure on the peroneal nerve
What is a HAGL lesion?
Humeral avulsion of the glenohumeral ligament, which happends with TUBS.
Older patients than Bankarts.
Important to repair.
May have to repair open.
Risk factors for knee OA after ACL tear
concomitant ligamentous pathology
*NO evidence that the ACL injury itself predisposes to arthritis*
When is it safe for return to play following a hamstring injury?
When it has 90% strength of other side.
How to do you protect the sciatic nerve during insertion of the posterior hip portal?
IR the hip
ER is bad
Name three radiographic signs of a discoid meniscus:
- Widened joint space (11 mm)
- Squaring of lateral femoral condyle
- Hypoplastic lateral spine
What is the cause of cruciate cysts?
Mucoid degeneration of the cruciate ligaments in areas subjected to constant stress
Name the hip scope portals
Distal anterolateral (3-5cm distal to anterolateral)
Classification of discoid meniscus
Type I: complete
Type II: Incomplete
Type III: Wrisberg - thickened posterior horn with no posterior attachmends, held on only by ligament or Wrisberg
Closure of the rotator interval has what effect?
Decreass ER with arm at 0 deg of abduction (arm at side)
Involves plication of SGHL & MGHL
THINK: closure of anterior capsular structures decreases ER, while closure of posterior capsule strucures decrease IR
Most common muscle injured in adductor strain?
Drugs that cause osteoporosis
NOT NSAIDs - they cause decreased bone healing (controversial)
indications for surgery in PLC injuries
within 2 weeks
Isolated Grade 1, 2 - can observe
Tension on the ACL increaes with____________
Hyperextenion places most strain on ACL
What concomitant injury do young (teenagers/20's) and older people (>40) get with traumatic shoulder dislocation?
Old: rotator cuff tear
Name 5 indications for meniscal repair
Tear between 1 and 4cm
Red-red zone tears
No mechanical axis malalignment
acute tears (
Concurrent ACL reconstruction
4 treatment options for lateral winging
Observation & trapezius strengthening
Nerve exploration (if iatrogenic)
Eden-Lange transfer: rhomboids transferred from medial border of scapula to lateral border
What is the direction of winging clinically defined by
Direction of the supermedial corner of the shoulder
Medial winging: superomedial border moves medially
Lateral winging: superomedial border moves laterally
What two structures are important to release when doing a release for extrinsic elbow stiffness?
- anterior capsule
- posterior band of MCL
Nerve deficit in lateral winging
CN XI (spinal accessory)
Trapezius is weak
Risk factors for females for ACL tear
Landing biomechanics and neuromuscular control differences
Cyclic hormone levels (greater risk during 1st half - preovulatory)
smaller ACL size
What position of the forearm is avoided for first 6 weeks after LUCL recon?
What type of exersizes cause co-contraction of the scapular and rotator cuff muscles during physio for MDI?
closed kinetic chain exercises
Good prognostic indicators for meniscal repair
Tear in peripheral red-red zone
- AKA decreased rim width: the distance from the tear to the peripheral meniscocapsular junction (blood supply)
- Rim width correlates with ability of a meniscal tear to heal
- Lower rim width has a better blood supply
- Basically if it's in the red-red zone
Vertical and longitudinal tear
1-4cm in length
Acute repair combined with ACL reconstruction
4 components of PMC?
- insertion of semimembranosus
- posterior oblique ligament
- resists tibial internal rotation in full extension
- oblique popliteal ligament
- posterior capsule
What is RTS after meniscal transplant?
At 10 years most have improved function and pain
Suprascapular notch impingement. What nerve and muscles will it affect?
Affects supra & infraspinatus b/c it occurs before the nerve branches
Treatment for the following causes of patellar instability:
Excessively lateral tibial tuberosity:
Severe trochlear dysplasia:
Excessive limb rotation:
Patella alta: distal tibial tuberosity transfer
Excessively lateral tibial tuberosity: medial tibial tuberosity transfer
Severe trochlear dysplasia: trochleoplasty
Excessive limb rotation: femoral/tibial derotation osteotomy
Medial patellar dislocation and medial PF arthritis are major complications of the overcorrection of lateral patellar dislocation.
Three most common placees for OCD?
What is the significance of having a concurrent peroneal nerve injury in a patient with hamstring rupture?
It means short head of biceps may not function and will significantly delay the rehabilitation process.
mechanical lateral proximal femoral angle (mLPFA)
anatomic medial proximal femoral angle (aMPFA)
mechanical lateral distal femoral angle (mLDFA)
anatomic lateral distal femoral angle (aLDFA)
mechanical medial proximal tibial angle (mMPTA)
mechanical lateral distal tibial angle (mLDTA)
mechanical lateral proximal femoral angle (mLPFA): 90
anatomic medial proximal femoral angle (aMPFA): 84
mechanical lateral distal femoral angle (mLDFA): 88
anatomic lateral distal femoral angle (aLDFA): 81
mechanical medial proximal tibial angle (mMPTA): 87
mechanical lateral distal tibial angle (mLDTA): 89
*Remember in tibia, anatomic = mechanical axis
How many patients at the highschool and college level returned to play post ACL reconstruction?
How many of these returned to the same level of play?
Highschool: 63% returned to play (45% at same level)
College: 69% returned to play (45% at the same level)
How much distal clavicle can you safely excise?
What is a fulkerson osteotomy? Name a contraindication
Antermedialization of tibial tubercle
CI if there is medial patellar facet arthrosis
Survivorship for TEA done for RA at 15 years?
When can you return to play after a stinger?
complete resolution of symptoms
normal strength and range of motion
Nerve injury in medial winging
Long thoracic nerve (C 5, 6, 7)
Serratus anterior weak
What is Paget-Schroetter Syndrome?
thoracic outlet syndrome with compression of subclavian vein in the developed athlete due to scalene muscle hypertrophy
What connects the dMCL to the medial meniscus?
Risk of injury with medial and lateral inside-out meniscal repair techniques?
Medial: saphenous nerve and vein injury
Lateral: peroneal nerve injury
Risk factors for patellar ligament ruptures
- Chronic Renal Disease
- Patellar degeneration (most common)
- Previous injury
- Patellar tendinopathy
- Corticosteroid injection
What is the Outerbridge-Kashiwagi procedure?
It is used for patients with hypertrophic osteoarthritis of the elbow and associated contracture.
Burr through the olecrenon fossa to get anterior osteophytes.
Need to decompress the ulnar nerve.
2 absolute contraindications to TEA
5 complications following open capsular shift of shoulder?
Axillary nerve injury
Loss of ROM
Late arthritis (posterior wear)
Recurrance of instability
Subscapularis deficiency (has to be tenotomized and repaired as part of procedure)
What approach and fixation for MCL recon of elbow has the best outcomes?
Splitting of flexor-pronator mass and docking graft fixation.
Risk Factors for patellar instability
- ligamentous Laxity (Ehlers-Danlos)
- Previous patellar instability event
Miserable Malaignment syndrome: (Increased Q angle)
- Femoral anteversion
- Genu vlagum
- External tibial torsion/pronated feet
- Patellar alta
- trochlear dysplasia
- excessive lateral patellar tilt
- Lateral femoral condyle dysplasia
- Increased TT-TG distance
- Dysplastic VMO
- Overpull of lateral structures (ITB, Vastus lateralis)
If you do HTO concurrently with ACL reconstruction, what else do you want to correct?
decrease it to tibia doesn't slide forwards on femur (prevents drawer) to protect graft
What is the expected clinical finding with an anterior placed femoral tunnel with ACL?
Tightness in flexion
2 hallmark findings of MDI
Patulous inferior capsule (IGHL & posterior bands)
Rotator interval deficiency
ACL graft choice with the highest rate of failure?
Highest risk population?
Highest risk population was age 10-19
Jaaos 2015 (MOON Group)
What is a Bennett Lesion in the shoulder?
Hypertrophy and scarring of posterior capsule glenoid
Warrants operative intervention
Best predictor of good outcome in osteochondritis dissecans of the knee:
Open distal femoral physis
Where is the origin of LCL relative to politeus and where does it insert on fibula?
a) Proximal and posterior
b) Anterior to ITB
In frozen shoulder, what is the main direction of ROM lost?
What percentage of OCD lesions in the knee treated non-operatively in a skeletally immature patient will heal?
Classification system for AVN of the shoulder?
I: normal x-ray but +MRI
II: Sclerosis & Osteopenia
III: Crescent sign (subchondral fracture)
IV: Flattening & collapse of the humeral head
V: Degenerative changes extend to the glenoid
Presentation of cruciate cysts
3 diagnostics tests for thoracic outlet syndrome
- Have them abduct their shoulder to >90 degrees with extension. Ask the patient to take a deep breath and hold. A positive test is a decrease in radial pulse vigor.
- Shoulders drawn downward and back causing + arm symptoms and loss of radial pulse
- the loss of the radial pulse in the arm by rotating head to the ipsilateral side with extended neck following deep inspiration. NOT USED as this happens to many people without TOS
Most common mechanism for PCL injury
Direct posteriorly directed blow to tibia
In athletes: most common is fall onto flexed knee with foot in plantarflexion
3 imporant factors with non-operative treatment of MCL tear of elbow.
1. 6 weeks rest from throwing
2. flexor-pronator strengthening
3. progressive return to throwing
3 steps for medial approach to knee capsule for an inside out meniscal repair?
Insice the sartorius fascia
Retracting the pes tendons and semimembranosus posteriorly
Develop the plane between the medial gastrocnemius and capsule
Nerve invovled and surgical treatment of medial scapular winging.
Pec major transfer (only in cases of extreme failure of non-op)
what percentage of proximal tib/fib joints communicate with the knee joint?
What is the success rate with treatment of Type 1 stable elbow OCD with activity modification and brief immoblization?
Must be for 3-6 weeks followed by 6-12 weeks gradual return to sport
Strenght of ACL
Native ACL: 2200N
Quadrupled hamstring: 4000N
So hamstring is 2x native ACL
Three strategies to avoid neural injury with elbow portal placement:
- Fully distend joint through lateral soft spot before placing portals
- capsule distension moves NV structures away from the joint when trocar is introduced
- Careful "nick and spread" technique using hemostat
- Selection of portals
- posterior medial portal usually avoided due to proximity to ulnar nerve
What type of xray is most sensitive for detecting knee joint degenerative changes
Weight bearing 45 degree flexion views.
Indications for HTO
Single compartment disease
Healthy patient with good vascular status
Pain interfering with daily life
What does biopsy of frozen shoulder capsule show?
Main indication for arthroscopic hip labral repair?
Full-thickness tears at the labral-chondral junction
If indicated, what is the timeframe that ACL reconstruction should be performed within?
AAOS CPG 2014
Treatment of Type 2 slap tear in patient 40 or older?
Tenotomy or tenodesis. Do not repair the slap tear - they do poorly
What has better long term functional outcomes, proximal biceps tenotomy or tenodesis?
2 indications for surgery in pec major tear?
Tendon avulsion from bone (will see ecchymosis on arm)
High level athletes
*May show improvement regardless of location of tear - so maybe do in all
3 ways to radiologically diagnose an mcl tear of the elbow.
1. gravity stress ragiograph - > 3mm medial joint opening
2. MRA - t-sign
3. dynamic ultrasound
Most common site of injury for hamstring rupture
What is the average medial-to-lateral distance of the supraspinatus tendon footprint on the greater tuberosity?
Name three exam tests for posterior labral tear.
Posterior load and shift
During what part of a bench press is the pec major most susceptible to rupture?
It is eccentrically contracting
For a valgus knee, why is distal varus producing femoral osteotomy preferred to a tibial procedure?
It prevents obliquity at the joint line
A distal varus osteotomy will maintain a congruent, non-oblique joint at the same time as it fixes alignment
Describe provocative test for anterior labral tear.
Pain if hip is brought from a fully flexed, externally rotated, and abducted position to a position of extension, internal rotation, and adduction
Classification of cruciate cysts?
Anterior to ACL
between ACL & PCL
Posterior to PCL
5 signs of generalized hypermobility
able to touch palms to floor while bending at waist
thumb abduction to the ipsilateral forearm
Femoral condyle articular defect
Osteochondral allograft transfer (OATS)
Outerbridge Arthroscopic Grading System
Grade 0: Normal
Grade 1: softening of cartilage
Grade 2: superficial fissure
Grade 3: Deep fissures, without exposed bone
Grade 4: Exposed subchondral bone
What is the most anterior structure inserting on the fibular head?
When I say Thermal capsulorraphy, you say:
High rate of recurrent instability
Contraindication to revision soft tissue labral repair
Physical exam maneuver to test for internal snapping hip.
Passively move hip from a flexed and externally rotated position to an extended and internally rotated position.
Will reproduce psoas snapping over pectineal eminence or femoral head.
What is internal impingement?
Impingement of posterior under-surface of supraspinatus tendon on greater tuberosity insertion on the posterosuperior glenoid rim
What does a Stryker view look for?
Hill Sachs Lesion
What is the female athlete triad?
Must workup all 3 if 1 is present (ie a stress fracture)
What do the ACL bundles do?
Anteromedial bundle: provides anterior-posterior stability
Posterolateral bundle: provides the rotational stability.
What are the four most important technical considerations for shoulder hemiarthroplasty?
- Retroversion: Should be 30 degrees, lateral fin should be just posterior to biceps groove
- Head Size: Don't overstuff, compare to other side and compare to removed head
- Implant height: 56 mm from top of prosthesis to pec tendon, 10 mm from top of prosthesis to GT
- Fixation of tuberosities: Can use autograft from head to aid in healing
What is Paget-Schretter Sydrome
Throacic Outlet syndrome with concurrent subclavian vessel compression
Occurs in athletes due to scalene muscle hypertrophy
What is pec major transfer for?
Irreperable subscapularis tears.
Transferred UNDER conjoitn tendon.
What hormone/cytokine promotes scar formation in lacerated muscle?
List the meniscal tear injury patterns
What structure provides the limit for acromioplasty?
Anterior fibers of deltoid.
Most common location for patellar tendon rupture?
Off inferior pole of patella ± bone (avulsion)
Name 5 benefits to aquatic training/rehab
decreases joint stress by lowering vertical component of the ground reaction force through buoyancy
unique advantages in cardiorespiratory fitness when compared to land training
less abrupt increases in heart rate
increased oxygen consumption
prevents secondary injuries to the lower limb
3 causes of suprascapular nerve impingement at the suprascapular notch
ganglion cyst (often associated with labral tears)
transverse scapular ligament entrapment
How many corticosteroid injections for tennis elbow is too many?
(up to 3 is the reccomendation)
What is the landmark that is the limit for ecrb release?
Equator of radial head, or else risks injury to LUCL
Risk factors for dislocation following RSA (4)?
- proximal humeral bone loss
- chronic fracture sequelae with malunited/ununited tuberosities
- failed previous arthroplasty
- fixed glenohumeral dislocation preoperatively
3 primary stabilizers of posterior shoulder?
Posterior badn of IGHL
What type of HTO has higher rates of:
a) loss of posterior slope
b) patella baja
c) peroneal nerve injury
a) lateral closing wedge
b) medial opening wedge
c) lateral closing wedge