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Question

- cancers that mets to spine - SINS score - NOMS - modified tokuhashi - radiosensitve tumours - radioresistant tumours

Answer 1

- breast, thyroid, prostate, renal, lung - SINS: - 6 categories: Location, Pain relief unloading of spine, type of lesion, radiographic spinal alignment, vertebral body collapse, posterolateral involvement of spine (facet/pedicle/CV joint) - <6 stable, 7-12 impending, >12 unstable - NOMS - neurologic - degree of spinal cord compromise - oncologic - radiosensitive vs radioresistance tumours - mechanical - instability/pain/SINS score - systemic - ability of patient to tolerate intervention - determine if need: radiation vs sterotactic radiosurgery, decompress/separation surgery and stabilization - modified tokuhashi - predicts prgnosis, guide tx decision; categories functional score, extraspinal mets, mets to VB, mets internal organs, primary site of CA - radiosensitive(NOMS LBP) - neuroendocirne, ovarian, MM, seminoma, lymphoma, breast, prostate - radioresistant (SMRT CA) - sarcoma, melanoma, RCC, thyroid, colorectal, adenocarcinoma

Answer 2

Anterior - mets, MM, plasmocytoma, lymphoma, chordoma, hemangioma, EG, GCT Posterior - osteoid osteoma, osteoblastoma, osteochondroma, ABC, chondrosarc, osteosarc, ewing osteoid osteoma - NSAIDs, radiofreq therma ablation, en block resection ABC - marginal resection vs en bloc, consider emboliz

Answer 3

4 red flags on hx when assessing back pain: Constitutional sx. Constant unrelenting pain Bowel bladder dysfunction Night pain Leg weakness What are 4 things that enhance with gadolinium? Scar tissue Infection (discitis, abscess rim enhance) Tumors Vascular lesion ***Recurrent disc is dark*** RF for bacterial spine infection? - advanced age, immunocompromised, DM, IVDU, HIV, malignancy, chronic steroid use, renal failure, septicemia, spinal sx, intravasc devices, presence of foreign bodies other non spine related test you should get - TEE Name 4 indications for surgical management? Failed nonop/medical manageemnt Progressive neuro Deformity correction Need for stabilization/decompression What are 3 RF for failure of medical management: Incomplete or complete SC deficit Age >65 DM MRSA Management - medical: abx after blood and tissue culture - if fusion, used autograft instead of cages/allograft

Answer 4

patterns - peridiscal, central, anterior RF - immunocompromised, travel, homeless, known exposure workup and findings - CBC, ESR/CRP, Tb skin test, interferon gamma release assay, PCR, CXR with isilateral hilar mediastinal lymphadenopathy, osteolysis/kyphosis on TL spine xray MRI shows T2 heterogenous high signal with sublig spread, CT guided bx - acid fast bacilli smear, PCR path for caseating granuloma spine at risk signs of dev kyphosis: separation of facet jts, retropulsion, lateral translation, toppling tx - RIPE - rifampin, isoniazid, ethambutol, pyrazinamide: 6-18months, serial clinical and radiographic evals - sx if failed medical tx, neuro def, instability

Answer 5

3 patterns of cspine disease * C1-2 instability * Basilar invagination – atlantoaxial impaction * Subaxial subluxation - RF for progression: male, RF +, higher CRP, SQ nodules, adv peripheral jt diesase methods of assessing basilar invagination: * Clark station - N C1 at 1/3 of dense * Ranawat index * Macreas, McGregors, Chamberlains * cervicomedullar angle abn <135 - Ranawat classification: 1: no neuro; 2: subjective weakness with hyper-reflexia, 3 – objective weakness, UMN, normal gati, 4: weakness, UMN, gait change What are the surgical indications for patient with RA * Progressive neuro deficit * Mechanical neck pain not responding to meds * XR RF for impending neuro innjury * PADI <14/SAC <14 * Cervicomedullary angle <135 * AAI (ADI >10mm * Odontoid migration past 1st clark station What are methods of C1-2 fixation * C1-2 intraarticular screw (MAGERL) * C1 lateral mass, C2 pedicle screws (HARMS) * Sublaminar wirining (Gallie) extra-articular manifestations of RA? - Rheumatoid nodules, Small vessel vasculitis, Episcleritis, Pleural effusion (exudative), Pericarditis (exudative), Anemia periop considerations: * A- Anesthesia/Airway: Obtain anesthesia consult * B- Bone - Osteoporosis * C- C-spine – Flex-ex views * D- Drugs – Consult Rheum – drug cessation 2 weeks preop/postop, steroid stress dose * S – Skin/soft tissue management: Thin skin, altered soft tissue XR: subaxial subluxation of vertebral body >4mm or 20% listhesis Cervical body height/width ratio: abnormal <2.0 consider preop HALO with subaxial subluaxation or basilar invagination

Answer 6

**Principles**: Visualize the tear, protect neural elements, repair the tear, Watertight closure **Intra-op tear ** * Exposure – visualize whole tear – get lighting/scope * Head of bed down – decrease fluid pressure * Reduce neural elements if exposed * water tight primary closure with 6-0 prolene (Non-absorbable, monofilament) starting at the apex * Adjuncts if needed: Dural patch, fibrin sealant, fat grafts, fascia lata, lumbodorsal fascia * Test repair with valsalva (40 mmHg x15-20s) * Tight fascial and wound closures in layers * Keep supine bedrest for 48 hrs (no evidence) if lumbral; If cervical (sitting) * discuss with patient complication in OR **RF:** OPLL (14x more likely), revision surgery, ossified ligamentum flavum, synovial cysts, age, experience of spine surgeon **Post-op tear** Sx of persistent CSF leaks post-op - Positional headache nausea, photophobia, Back pain and fullness, Abducens nerve palsy, Fistula formation and pseudomeningocoele, CSF leak from wound or subfascial drain Management: - Symptomatic early: Image with MRI, r/o infection, monitor and discuss may need surgery - Ongoing symptomatic: Primary dural repair 6-0 prolene, fibrin glue augment, possible dural patch - IR consult for subdural drain to decrease subarachnoid pressure Complications of persistent dural tears - Spinocutaneous fistula, Pseudocyst, Meningitis, Nerve root entrapment, Cranial nerve palsy, Mass effect, Wound healing complications and infections - B-2 transferrin assay can detect CSF

Answer 7

genetic mutation: HLA b27, seronegative peri-op considerations: * Resp function: Restrictive lung disease * Meds: Consult medicine/Rheum: consider holding biologics * Anaesthesia consult: Intubation with rigid spine - glide scope * Hb level – bleeding risk, iron supplement * Bone quality – calcium/vitamin d * Modifiable: stop smoking, optimize nutrition * Operative: Positioning, Transfers, instrumentation, hemostasis Dx criteria - New York Criteria: Need 1 clinical and 1 XR finding: Clinical: LBP for >3 months (better with exercise), restricted lumbar ROM, restricted chest expansion; XR: SI arthritis systemic features - Uveitis, Iritis, Pulmonary fibrosis, Renal amyloidosis, Cardiac conduction abnormality, Ascending aortic – aortitis/stensosi/regurg, autoimmune disease ((UC), psoriasis differences between AS and DISH - see table P/E special tests - kyphosis - chin to chest deformity, chin brow to vertical angle, occiput to wall distance, schober test, chest wall expansion, FABER investigations: ESR/CRP, HLA b27, RF, creatinine, echo/ekg, eye exam, CXR/CT chest, PFTs surgical principles: long construct, OP bone, high risk of epidural hematoma, do not correct deformity

Answer 8

Neurological status is monitored by 3 recordings 1 SSEP: Somatosensory evoked potentials, continually monitored Looks at dorsal columns mostly Real time insults to cord are recorded but sensitivity is low because most insults are anterior cord 2 MEP: transcranial motor evoked potential stimulated every few minutes by electrophysiologists, looks at anterior cord. a Will show delay in recognizing spinal cord injury b More sensitive than SSEP 3 EMG: Electromyelography; surgeon touches pedicle screw with monopolar probe. a Impedance is high if pedicle screw is in bone b Impedance is low if pedicle screw is on a nerve **Management** - Intra-op pause - alert anesthesia, neurphysiologist, call for fluoro and senior colleague **R/o systemic causes** * MAP elevated to >80 mm Hg * Optimize Hgb, Hct, pH, PCO2 and transfuse if low * Check body temp - elevate to >36.5°C (97.7°F) **R/o technical problem** * Check status of anesthetic agents * Check extent of neuromuscular blockade * Electrode connections * Check neck and limb positioning **Surgical** * Remove traction * Decrease or remove corrective forces * Remove rods * Remove recent screws * Evaluate for cord compression with U/S **Wake up test** * Flood surgical field with NW, cover with sponges, decrease sedation until patient awake, ask patient to move their feet, avoid touching the patient, no sensory testing is done, re-sedate patient * Close and CT if abnormal wake up test

Answer 9

* Symptoms: Swallowing difficulty, Fullness, Neck mass, Stridor, agitation (hypercarbia) * Causes: Hematoma - Risk factors * Surgical: >3 VB, C2-4, Blood loss >300, OR time 5 hours * Patient: Obesity, OSA, Pulmonary disease, Myelopathy, Revision * Anesthetic: Multiple attempts, Need for fiberoptic Management - Assess patient immediately - need for airway - Have bronchoscope and surgical airway available - Vitals, ABCs - look for clinical signs of airway obstruction (speech, resp rate), examine wound and neck for hematoma - Notify airway specialist (anesthesia or ENT) - remove dressing, remove sutures

Answer 10

cervical spine **- lateral mass** * Starting point center of lateral mass * Drill angled 15 degrees superiorly and 30 degrees laterally from starting point * Unicortical or bicortical purchase thoracic pedicle screws - entry point is intersection of lateral border of superior articular process and orizontal line across base of TP - 5-25 degrees medially, mostly straight lumbar pedicle screws - entry point is junction of lateral aspect of superior articular facet and based of TP - 5-25 medially, parallel to superior endplate

Answer 11

>10 with >10 degrees of vertebral rotation RF for curve progression - curve magnitude > 25 degrees before skeletal maturity - skeletal maturity: <12yo, open triradiate, peak growth velocty - best predictor - curve type: thoracic>lumbar, double>single Lenke classification * Morphology of curve – 1-6 * Lumbar modifier – A/B/C * Thoracic sagittal profile – normal is 10-40 (hypo <10, hyper >40) exam: shoulder eight, truncal shift, rib prominence, adams forward bend test, abdo reflees (syrinx), foot deformity (cavovarus -tethered cord), cafe au lait (NF), hyperlaxity, LLD cobb angle * Obtain a frontal spinal X-ray (AP/PA view). * Identify the upper and lower end vertebrae of the curve (most tilted). * Draw a line along the top endplate of the upper vertebra. * Draw a line along the bottom endplate of the lower vertebra. * Draw perpendicular lines from both of those lines. * Measure the angle where the perpendiculars intersect — this is the Cobb angle. MRI indications - age < 10, male, L thoracic curve, apical kyphosis >30, short curve, rapid progression, excessive kyphosis, neuro symptoms or pain, foot deformity, asymmetric abdo reflex determine skeletal maturity * Risser * Age of menarche * Tri-radiates * Olecranon (Sauvergrain method - elbow XR) * Atlas of Greulich + Pyle - AP left hand * Tanner treatment - cobb angle 25-45 and risser 0-2 = brace 16-23h/day until skeletal maturity - cobb angle >45 in young patient or 45-60 in mature patients do a PSIF

Answer 12

RF: maternal DM, EtOH, valproic acid, hyperthermia assoc conditions: cardiac defect, GU defect, spinal cord malformation, VACTERL classification: - failure of formation, failure of segmentation or mixed - unilateral unsegmented bar - fully segmented hemivertebra - unicarcerated hemivertebra - incarverated hemivertebra - unsegmented hemivertebra - block vertebrae treatment: - observe if no documented progression - operative if progresion or when high risk of progression when is hemi epiphysiodesis indicated - <5yrs, no bar, small correction, no truncal imbalance, curve <40 hemivertebrectomy: wedge/hemivert resection work up: XR, CT and MRI, ECHO and renal U/S

Answer 13

**RFs:** 1 Distorted anatomy (infection, tumor) 2 Multilevel corpectomy 3 Oblique troughs 4 Dissection lateral to uncinate **Consequences of dominant vertebral artery injury:** * Vertebrobasilar Insufficiency * Dizziness, Vertigo, Nausea, Diplopia, blindness, Ataxia (cerebellar), Bilateral weakness, Oropharyngeal dysfunction * 1 Wallenberg syndrome * 2 Cerebellar infarction * 3 Cranial nerve palsies * 4 Quadriparesis * 5 Mortality 12% **Goals of Management** 1 Control local hemorrhage 2 Prevent immediate vertebrobasilar ischemia 3 Prevent cerebrovascular complications **Management** * Notify anesthesia, anticipate 3-5L blood loss * Page vascular surgery, interventional Radiology, and call for senior colleague if available * Control local hemorrhage - a Two sucker tips up, Tamponade with local pressure, Avoid bone wax for theoretical risk of Embolization, Head of bed to neutral - if tamponade does not work, get proximal control - place screw in if posterior and occurs after screw tap - post-op angiography and possible embolization to prevent pseudo-aneurism

Answer 14

short - Activate trauma team, place pt on O2, continuous monitors and 2 large bore IV, initiate fluid resuscitation, c-spine immobilization and proceed through primary and secondary survey long - Activate the trauma team, 2 large bore IVs and starting bolus, oxygen, c-spine collar in place and monitors and BW sent off and proceed with primary and secondary survey - Starting with airway, seeing if patient is able to speak and airway is clear from obstruction - Breathing making sure trachea is midline, bilateral air entry, checking for signs of flail chest and SC emphysema - Circulation I would check BP and HR, look and attempt to reduce hemorrhage - Tourniquet, pressure, pelvic binder, splint, traction - Disability - check GSC, pupil size - Environment - I would expose patient and identify any long bone deformity, treat hypothermia with warming blankets - Log roll/DRE - I would log roll patient, check for tenderness and step deformity and perform a DRE - I would request adjuncts including CXR, c-spine and pelvis XR and FAST and reexamine vitals - Proceed to secondary survey including AMPLE history and complete head to toe from orthopedic perspective checking fo limb deformities and pelvic stability

Answer 15

- Unstable Patients: Hypotensive, not improving, hypothermia, coagulopathy, acidosis - ISS > 40 without thoracic trauma - IS5 > 20 w/ Thoracic trauma (Pulmonary contusion on CXR) - GCS of 8 or below - multiple injuries with severe pelvic/abdominal trauma and hemorrhagic shock - bilateral femoral fractures - pulmonary contusion noted on radiograph - hypothermia <35 degrees C - head injury with AIS of 3 or greater Early appropriate care (femur, pelvis, acetabulum, spine <36h) - pH < 7.25 [N 7.35-7.45] - Base Excess < - 5.5 [N -2 - +2] - Lactate > 4.0 [N,2.5] - **components: **resuscitative surgery, physiologic resuscitation in ICU, definitnive surgical management - **Rationale = **prevent second hit, reduce ARDS, SIRS, MODS

Answer 16

5th intercostal space, anterior to mid axillary line - go over top of the rib into pleural space with kelly - anterior and superior for pneumo - posterio and inferior for hemothorax needle decompression 2nd intercostal space midclavicular line (tension pneumothorax) 5th ICS, anterior to mid axillary line - safer and more effective - newer standard 14-16 gauge large bore angiocatheter

Answer 17

ATLS and resuscitation Tetanus status/prophylaxis -Tetanus prophylaxis (based on vaccination history and ° of contamination - Toxoid 0.5ml IM if vaccinates, immune globulin 250U if unvaccinated Early antibiotics (ideally within 66min) - Ancef +/- gram neg coverage if type 3/femur/farm - Gram + coverage in open fracture (ancef) - Add gram negative coverage for type III open fracture (Gent/tobra/piptazo) - options if allergic to penicillin for GP coverage: Clindamycin, vancomycin - Add high dose penicillin for barnyard injuries (i.e. those likely to be contaminated with soil/ feces – risk of clostridium) – 5 million units/24h - Aquatic: most common is staph/strep fresh water (aeromans hydraphila): Cipro/Levo (fluoroquinolone) Salt water (vibrio): Doxy/Ceftazidime Neurovascular, compartment, soft tissue examination Bedside I&D (ideally within 24h) - remove gross debris, cover with sterile permeable sterile dressing Fracture reduction and splinting Repeat neurovascular exam and imaging - I will extend the wound proximally and distally. - I will perform a meticulous debridement layer by layer removing debris and devitalized tissue and bone. -I will irrigate with 3-9L of NS based on Gustillo grading, under low flow. - If the wound is then clean then re-prep and drape and proceed to stabilize the fracture - a If the wound can be closed primarily then proceed to early definitive fixation and closure - b If you cannot close then ex-fix outside area of definitive fixation, intra-operative plastic surgery consultation, pack or vac dressing, with plans to definitively stabilize the bone at the time of flap coverage (ideally within 5-7 days) - If high degree of initial gross contamination then pack the wound with proviodine soaked gauze and perform serial debridements every 24-48 hours until the wound bed is clean.

Answer 18

My goal is to restore length alignment rotation of the limb with a stable construct using pins outside the zone of injury and planned definitive fixation. **Femur:** anterolateral/lateral 6mm **Tibia:** anteromedial / 5mm **Calcaneus:** 4mm transcalcaneal pin placed from medial to lateral in the safe zone of the calcaneal tuberosity **Foot :** talar neck/cuboid / 3 mm **Humerus:** anterolateral / 5 mm **Elbow:** Spanning frame A 2 x 5mm anterolateral humerus B 2 x 4mm proximal ulna pins placed posterior subcutaneous boarder (FCU, ECU split) **Forearm:** Ulnar/radial border / 4 mm **Hand:** 2nd metacarpal dorsal / 3 mm **Wrist Spanning** 2 x 3mm pins 2nd MC base 2 x 4 mm pins radial shaft (junction 1/3 2/3 avoiding superficial radial nerve and artery) between BR ECRL Avoid heat (sharp bits, fluted, pause, irrigate) Protect soft tissue (sleeves, incise) Avoid joints, NV structures Increase Pin Diameter (most important way to increase stability) Increase Number of Pins Increase pin spread Decrease Pin-Fracture Distance Decrease Rod-Bone Distance Double stack Rods Stiffer Rods Multiplanar Fixation

Answer 19

**1. Iliac crest/wing external fixation pins (for DCO)** a. Start point – 3-4cm posterior to the ASIS centred between the inner and outer tables b. Fluoro image used – obturator outlet view (60° cranial tilt) c. Pin direction – superior to inferior directed towards the supraacetabular bone **2. Supraacetabular external fixation pins (not in DCO)** a. Start point – centre of the teardrop visualized on obturator outlet view and at least 2cm above superior acetabulum b. Fluoro image used – obturator outlet view for start point, iliac oblique view for depth and to ensure ~1-2cm above sciatic notch, obturator inlet view for visualization of pin along its entire length between inner and outer tables c. Pin direction – AIIS to PIIS Advantages - Pins are out of the way of abdominal procedures - Two pins are sufficient (one on either side) - Fixation is excellent - Allows for direction of closure of open book injury in the same plane - Biomechanically superior in resisting rotational forces and equal control of flexion/extension forces compared to iliac crest pins Disadvantages - More dependent on fluoro

Answer 20

I will perform an open release of all compartments, debridement of any necrotic tissue (unless pediatric), intra-operative plastic surgery consultation for coverage followed by sterile dressing +/- vac. Post-operatively I will continue antibiotics while wound is open and return to the OR in 24-48 hours for repeat assessment. **1 Forearm:** a Dual incision fasciotomy; - Volar (radial to FCU, or other) and dorsal approach releasing from carpal tunnel to lacertus fibrosus including superficial and deep flexor, extensor compartments and mobile wad b Separate incision for carpel tunnel if using henry approach (e.g. post op ORIF) **2 Arm:** a Dual anterior posterior incisions releasing anterior and posterior compartments. **3 Thigh:** a Lateral single incision fasciotomy releasing anterior and posterior compartments. b Usually medial compartment does not need to be released but if concerned can do from lateral incision or separate medial. **4 Leg:** a Two incision fasciotomy, anterolateral (gerdy’s tubercle to lateral malleolus) and posteromedial (posteromedial boarder of tibia) b anterolaterally identify protect SPN, incise above and below the lateral septum for anterior and lateral compartment. c Posteromedially, protect saphenous nerve and vein follow the tibia to release superficial, deep flexor compartments and soleus bridge.

Answer 21

I will perform an open release of all compartments, debridement of any necrotic tissue (unless pediatric), intra-operative plastic surgery consultation for coverage followed by sterile dressing +/- vac. Post-operatively I will continue antibiotics while wound is open and return to the OR in 24-48 hours for repeat assessment. **5 Foot:** a Three incision fasciotomy, dorsal 2, 4 and medial, releasing all 9 compartments (4 interossei, 3 central, medial and lateral) b Dorsal 2nd MT incision for adductor hallucis and second/third interosseous c Dorsal 4th for remaining central compartments, lateral compartment d Medial incision for medial compartment **3 Hand:** a Four incision fasciotomy with separate incision for carpel (or extend hypothenar incision) b Thenar, hypothenar and dual dorsal (over 2nd and 4th metacarpals) incisions c Release all 10 compartments d Compartments released: 4 dorsal interosseous, 3 volar interosseous, adductor policis, thenar and hypothenar.

Answer 22

**BKA** * * 1 Hand breadth below tibial tubercle, create a long posterior flap * 2 Identify and tie off ant and post tib artery; identify and cut SPN and DPN nerves sharply under tension * 3 Perform osteotomy of tibia cutting the fibula 1cm short, beveling bony edges * 4 Myodesis of the gastrocnnemius to anterior periosteum * trim dog ears and tension free closure **AKA** * Position: supine, tourniquet. * Mark Desired bone length, Fishmouth shaped incision * Deepen the incisions through the subcutaneous tissue and deep fascia. * Isolate the femoral artery/vein in the femoral canal on the medial side of the thigh and tie off * Cut femur bone using saw and bevel edges * Cut sciatic nerve and saphenous nerve sharply under tension * Muscle attachments: * Attach adductor and hamstring muscle groups to the bone with suture * Bring the quadriceps muscle (“quadriceps apron”) posteriorly and attach to the posterior thigh fascia. * trim dog ears and tension free closure

Answer 23

- Formation of ectopic lamellar bone in soft tissues RF - male, traumatic brain injury, spinal cord injury, burns, delay in teratment, revision surgery, injury/surgery to acetabulum/THA/elbow fracture/distal humerus, ank spon/DISH, blast injury Brooker - see table workup - H&P, radiographs, CT, MRI if by NV structures, bone scan (detect HO earlier), ALP prophylaxis - NSAIDs indomethacin 25mg PO TID for 6 wks - radiation single fraction doe 24 hrs preop to 72h post op (700-800 Gy) surgery - persistent symptomatic HO despite nonop management, - delay surgical intervention until ALP levels normalize and HO mature on xray/look stable

Answer 24

**1 Symptoms:** Chest pain, interscapular pain, confusion, parasthesias/weakness in the legs **2 Clinical Signs: **hypertension, hypotension, interarm pressure > 20mmHg, signs of regurg (bounding pulses, wide PP, diastolic murmur), findings suggestive of tamponade (muffled heart sounds, hypotension, pulsus paradoxus, JVD, kussmaul) **3 Radiographic signs** a Mediastinal enlargement > 8 cm and/or 25% of the width of the thorax b Deviation of the trachea to the right c Deviation of the NG tube to the right d Obliteration of the contours of the aortic knob e Lowering of the left main stem bronchus f Opacification of the space between the aorta and pulmonary artery g Left sided hemothorax/pleural effusion h Apical capping i Calcium sign > 5mm j Loss of aortic knob

Answer 25

Management Principles * Splint to prevent contractures * PT/OT referral to maintain ROM * EMG 6 weeks and 3 months * Early plastic surgery referral for possible nerve surgeries (decompression, or nerve/tendon transfer) * Anticipate prolonged recovery requiring 6-9 months, notify the patient of this * Surgical intervention - Axillary nerve palsy decompressed at 3 months, neurotization between 3-6 months - Radial and other nerve tendon transfers considered at 1 year, potentially earlier decompression

Answer 26

**Axillary nerve** Neurotization (medial triceps branch to axillary nerve transfer) Tendon transfers: Pec major transfer, trapezius transfer **MSC nerve** innervates: biceps, brachialis, coracobrachialis options: 1. sternocostal head of pec major to biceps tendon 2. lat dorsi to biceps/radial tuberosity 3. steindler flexorplasty - proximal advancement of flexor pronator mass origin

Answer 27

Biceps to triceps, PT to ECRB, FCR to EDC, PL to EPL (FDS4 if no PL)

Answer 28

**low median nerve palsy** loss: thumb opposition - Opponensplasty (FDS 4 to APB), **high median nerve palsy also have** loss of thumb IP flexion (FPL) - BR to FPL loss of finger flexion 4-5 - FDP 4 & 5 side to side with FDP 2 & 3 if high median nerve palsy FDS4 does not function, therefore use EIP to APB

Answer 29

**High lesion** – lose function of FDP 4-5 + power pinch Effects FCU, FDP 4-5, intrinsics Deformity – no clawing, loss of FDP 4-5 **Tendon transfer:** -Finger flexion: FDP 4-5 side-side transfer of FDP 2-3 (as long as median nerve intact) - If median nerve not intact – use ECRL - power pinch/thumb adduction: ECRB to adductor pollicis with interposed graft (smith) **Low lesion** – develop clawing, decreased pinch Effects intrinsics – interossei, lumbricals, adductor pollicis, hypothenar Deformity: hand clawing, Froments sign, Jeanne sign, Wartenberg sign, grip strength <50%, decreased pinch strength **Tendon transfer: ** - Clawing = FDS -> lateral bands of prox phalanx Or ECRB to intrinsics -Power pinch/thumb adduction: ECRB to adductor pollicis -Finger flexion: FDP 4-5 side-side transfer of FDP 2-3 (as long as median nerve intact)

Answer 30

Tib post 4 incision technique transfer from navicular to lateral cuneiform/cuboid **Incision 1:** Medial and distal for PTT harvest: medial malleolus and 5cm distal. Harvest subperiosteally from distal to proximal at naviculocuneiform joint. **Incision 2:** 15cm Medial and Proximal to pass the tendon: The soleus and FDL are retracted posteriorly to expose the PTT, the PTT is then pulled through the proximal incision and tagged with suture **Incision 3:** Lateral and proximal to pass tendon through IOM: EDL is retracted medially and a ~4cm of interosseous membrane is dissected off the fibula and excised, the PTT is then passed through the window created **Incision 4:** Distal lateral for fixation to lateral midfoot: Incision over the lateral cuneiform. PTT is tunneled subcutaneously to this incision and anchored to the lateral cuneiform with an interference screw

Answer 31

1 Obtain a CT to assess union, and confirm the hardware based on previous operative note 2 Follow old skin incisions 3 Send multiple intraoperative cultures 4 Perform meticulous layer by layer debridement of any devitalized tissue or bone a If there is solid union: Removal of hardware, curetting screw holes, debriding bony edges, thorough irrigation including the joint with primary closure b If there is not a solid union and construct is stable: Irrigate 9L NS under low flow, debride any contaminated tissue, curette around the plate, and retain hardware. c If there is not a solid union and the construct is unstable: Removal of hardware and revise ORIF with new locking plate after thorough irrigation with 9L of NS under low flow

Answer 32

**Definition: **failed to head in expected time frame and is not likely to heal without new intervention; no interval healing on 2 consecutive xrays 6 wks apart **types:** septic, aseptic (hypertrophic, oligotrophic, atrophic) **Fracture Factors:** * High-energy trauma * Open fractures * Comminuted fractures * Segmental bone loss * Fractures with poor vascularity (e.g., scaphoid, femoral neck) * Fracture displacement * Interposed soft tissue at fracture site * Infection at the fracture site * Pathological fractures **Host (Patient) Factors:** * Smoking * Diabetes mellitus * Malnutrition * Chronic steroid use * NSAID use * Alcohol abuse * Immunosuppression * Radiation * PVD * Poor compliance with treatment * Age (older patients may heal more slowly) * Osteoporosis or other metabolic bone diseases **Surgeon (Iatrogenic) Factors:** * Inadequate reduction or fixation * Inappropriate implant selection * Excessive soft tissue stripping * Failure to achieve mechanical stability * Inadequate post-op immobilization * Failure to recognize and treat infection * Premature weight-bearing or mobilization **Management** - obtain previous OR report, rule out infection and do a nutrition and metabolic workup - Xray/CT scans - BW: WBC, CRP/ESR, ext lytes, Vit D, Hgb A1C, ALP albumin, thyroid, renal function test - smoking cessation, nutrition optimization, discontinue meds if possible, optimize medical conditions

Answer 33

* 1 AMPLE history * 2 Examination * a Neurovascular examination * b Examine the limb for any injuries that would preclude manual traction * i including ligamentous knee injury, midshaft femur, floating knee,etc * 3 Prior to reduction have skeletal traction setup available * 4 Perform closed reduction * a **Allis maneuver** in flexion adduction internal rotation with an assistant * b For anterior hip dislocations In line traction, abduction, external rotation followed by IR and adduction when hip in joint * 5 Check stability * a Place patient in knee immobilizer in slight abduction to prevent recurrence * b For anterior dislocations tape the legs in adduction IR for anterior hip dislocation * 6 Post-reduction neurovascular examination, plain films and CT

Answer 34

Diagnosis = at least 1 major and 4 minor Major criteria * Petechial rash, * PaO2 < 60mmHg, * CNS depression, * pulmonary edema Minor criteria * tachycardia, pyrexia 38.5, emboli in retina, fat in urine or sputum, increased ESR, drop hematocrit/platelet 1 Use sharp and fluted reamers 2 Narrow shaft 3 High RPM, slow advancement 4 Over ream compared to size of nail 5 Distal vent Management - supportive care: maintenace of adequate oxygenation, stable hemodymanics, blood products as indicated, hydration, ppx for dvt, nutrition

Answer 35

Boyd – subanconeus Kocher – ECU/anconeus EDC split Dorsal Thompson/Kaplan – EDC/ECRB ECRL/ECRB interval only developed for lateral column procedure

Answer 36

Hotchkiss over the top Flexor pronator split Bryan Morrey floor cubital tunnel Taylor-scham approach (medial equivalent of boyd, submuscular interval)

Answer 37

PMRI 1 Anteromedial facet coronoid 2 LCL avulsion 3 Posterior band MCL (remember anterior band is connected to the AM facet) 4 Radial head intact PLRI 1 Coronoid tip 2 LCL avulsion 3 Anterior band MCL 4 Radial head fracture

Answer 38

Strong predictors: posteromedial calcar extension < 8mm, disruption medial hinge > 2mm, anatomic neck Moderate: 3 part, 4 part, > 45 degrees displacement head, tuberosity displacement > 1cm, associated dislocation, head split 1 Anatomic reduction of the medial cortices 2 Inferomedial calcar screw 3 Head-on-shaft impaction (valgus impaction) 4 Fibular strut allograft

Answer 39

< 30° varus/valgus angulation < 20° AP angulation <30 ° rotation < 3cm of shortening Proximal 1/3 fractures, oblique proximal 1/3, increasing fracture gap size, smoking, female

Answer 40

1 Restoration of Shenton’s line 2 Garden alignment index 160 on AP, 180 on lateral 3 Lowell’s alignment S and reverse S on lateral 4 Restoration neck shaft angle (125-130) 1 Varus angulation 2 Inferior offset 3 Retroversion

Answer 41

1 Posteromedial comminution 2 Reverse obliquity 3 Subtrochanteric extension 4 Lateral wall comminution 5 Reverse oblique variant (fracture orientation when viewed on AP looks typical, however on the lateral the fracture extends from proximal-anterior to distal-posterior)

Answer 42

1 Medialize start point 2 Joysticks 3 Femoral distractor 4 Reduction spoon 5 Blocking screws (medial and posterior on proximal fragment) 6 Schantz pins 7 Clamps 8 Lateral decubitus position neutralizes deforming forces 9 Unicortical plating

Answer 43

1 LT profile 2 Cortical keys 3 Cortical thickness 4 Cortical diameter 5 Use built in version of the nail (Many ways to do this but if centre centre in the neck and head, you can go to a perfect circle of the nail distally, and rotate the knee for a perfect lateral. In this way the rotation of the femurwill match the rotation of the nail.) 6 Clinical comparison contralateral leg (IR ER) CT rotational profile – looks at the axial cut in line of the femoral neck superimposed over the intercondylar axis distally May be compared to contralateral side Prior to union: Remove distal locking screws, correct deformity, re-place locking screws If less than 20 degrees screw holes will likely touch (and cut out) so consider lengthening the nail After union: remove the nail, transverse osteotomy at the CORA and replace the nail 1 Length 2 Alignment 3 Rotation 4 Neurovascular status 5 Femoral neck 6 Knee ligaments

Answer 44

Diagnostic Criteria: Fracture is in the subtrochanteric region Major (need 4/5): Associated with minimal/no trauma (fall from standing or less) LATERAL aspect of fracture is TRANSVERSE in orientation Medial cortical spike (if complete fracture) Thickened lateral cortex/beaking Minimal/no comminution. Minor (do not need for diagnosis): Generalized increased cortical thickness in diaphysis, Unilateral/bilateral prodromal pain (ache in groin/thigh) - Bilateral presentation in 53%, Bilateral incomplete/complete femoral diaphysis fracture, Delayed fracture healing. other signs: dreaded black line

Answer 45

1 Percutaneous pointed reduction forceps 2 Bend ball tipped guide wire 3 Blocking screws (on concavity proximal fragment) 4 Universal distractor 5 Unicortical plating 6 Consider fixing fibula

Answer 46

want to fall into procurvatum (quads) and valgus (pes) To avoid procurvatum: insert screw just posterior to midline To avoid valgus: Insert screw just lateral to midline (insert posterolateral) Coronal 1 Lateralize start point 2 Blocking screw on the concavity of the deformity (lateral to midline in proximal segment) 3 Unicortical plating 4 Universal distractor Sagittal 1 Suprapatellar start point 2 Semi-extended position (neutralizes extensor mechanism force) 3 Blocking screw (posterior in proximal segment) 4 More proximal Herzog bend (stays within proximal fragment)

Answer 47

Split, split depression, depression, medial, bicondylar, metaphyseal 1 Restore of mechanical axis 2 Condylar width 3 Articular reduction 4 Knee stability

Answer 48

PCL → ACL → PLC → PMC 1 Arthroscopic ACL/PCL with open corner reconstruction 2 Arthroscopic ACL with open inlay PCL and open corner reconstruction **Achilles allograft for all ligaments** Timing controversial, pros and cons to early vs delayed recon

Answer 49

Static - LCL, popliteus tendon, popliteofibular ligament, posterolateral capsule Dynamic - Biceps femoris, popliteus muscle, ITB, lateral head of the gastrocnemius 1 Nonoperative – Isolated PLC grade 1-2 2 Acute repair within 2 weeks 3 Reconstruction for grade 3 and PLC with multilig a Fibular based (Larsen) reconstruction: Allograft passed through bone tunnel in fibular head, and docked lateral epicondyle b Transtibial double bundle reconstruction (laproad): Allograft is fixed to posterolateral tibia, one branch through fibular head P to A (PFL reconstruction), then into lateral epicondyle (LCL reconstruction), and one branch anterior inferior to lateral epicondyle (popliteus reconstruction)

Answer 50

ligaments * Distal tib fib joint - AITFL, PITFL, TTFL, IOL * Lateral ligaments – ATFL, PTFL, CFL * Medial * a Superficial - Tibionavicular, tibiocalcaneal, tibiospring, superficial posterior tibiotalar * b Deep - Deep anterior tibiotalar, deep posterior tibiotalar 3 angiosomes * supplied by anterior tibial artery, posterior tibial artery, peroneal artery, and multiple skin incisions can be made as long as they are parallel with these angiosomes * 1 Decreased tibiofibular overlap (<6mm on AP and mortise <1mm on mortise) * a Measured 1cm proximal to the plafond * b Overlap between lateral malleolus and anterior tibial tubercle * 2 Increased tibiofibular clear space (≥6mm on AP and mortise) * a Measured 1cm proximal to the plafond * b Distance between medial fibula and lateral incisura * 3 Increased medial clear space (≥4mm on mortise) * a Should be equal to superior clear space on mortise * 1 Radiographic lateral joint line congruity (lateral talus and medial fibula) * 2 Restoration shenton’s line (articular lateral distal tibia aligns with articular medial distal fibula) * 3 Restoration dime sign (unbroken curve connecting distal fibula with lateral process talus) * 4 Talocrural angle restored (83 +/- 4 degrees) * 5 Comparable to contralateral side

Answer 51

Standard 1 Medial (Deltoid ligament) 2 Posterolateral Volkman (PITFL) 3 Anterolateral Chaput (AITFL) 1 Malnutrition 2 Alcoholism 3 Diabetes 4 Neuropathy 5 Peripheral vascular disease 6 Tobacco use Begin with posterolateral constant fragment 2 Fix posteromedial to posterolateral fragment 3 Reduce central impaction 4 Reduce anterolateral fragment 5 Provisional wire fixation 6 Lag screw fixation 7 Fix articular block to diaphysis with periarticular plate 8 Back fill any body defects with bone graft or substitute a If closed then acute bone graft (ICBG) or allograft or bone substitute (calcium phosphate) b If open then abx cement spacer in defect, delayed bone grafting. Valgus pilon = lateral comminution = anterolateral plating Varus pilon = medial comminution = medial plating

Answer 52

Canale * 1 Max plantarflexion of ankle * 2 15° pronation * 3 Beam 75° from horizontal hawkin classification * TYPE I: Undisplaced AVN < 10% * TYPE II: Subtalar dislocation (most common) AVN up to 50% * TYPE III: Subtalar and tibiotalar (body usually dislocates posteromedially) AVN close to 100% * TYPE IV: ST TT TN dislocation AVN ~ 100% * 1 Dual incision approach anteromedial (medial tib ant) anterolateral (tertius and peroneals) * 2 Anatomic reduction under direct visualization and canale/Kelly views, avoiding varus * 3 Lateral partially threaded compression screw (antegrade or retrograde) or plate * 4 Medial fully threaded buttress screw * 5 Bone graft any defects necessary to prevent varus collapse * a ICBG, allograft

Answer 53

**Broden’s view: posterior facet calcaneus** 1 Neutral dorsiflexion 2 Leg is internally rotated 30-40° 3 Four radiographs are made at 40° (anterior aspect facet), 30°, 20° and 10° (posterior aspect facet) of cephalad tilt **Harris axial view/Saltzman –** demonstrates the body of the calcaneus and subtalar joint; 1 Stand on cassette 2 Beam is directed 45° caudal from behind indications for ORIF * 1 Displaced intra-articular fractures * 2 Fracture >25% involvement of CC joint * 3 Displaced tuberosity * 4 Fracture-dislocation of the calcaneous * 5 Open * 6 Pending open tuberosity * 7 Compartment syndrome

Answer 54

Radiographic signs * 1 Medial border of 2nd MT aligns with the medial middle cuneiform (AP view) * 2 Medial border of 4th MT aligns with the medial cuboid (oblique view) * 3 Dorsal subluxation TMT (lateral) * 4 Widening >2mm between 1st MT/medial cuneiform and 2nd MT * 5 Diastasis first and second ray * 6 Fleck sign – avulsion fracture off the base base of the 2nd MT or medial cuneiform

Answer 55

**Young Burgess** - 1 Lateral compression (LC); LC-I: horizontal ramus + sacral ala buckle LC-II: horizontal ramus + crescent LC-III: windswept pelvis (LC1 with contralateral SI opening) - 2 Anterior-Posterior compression (APC) APC-I <2.5cm symphasis diastasis APC-II Symphasis diastasis > 2.5cm + anterior SI opening APC-III > 2.5cm symphasis diastasis, anterior/posterior SI opening - 3 Vertical shear (VS) – inlet/outlet views show malrotation of hemipelvis, different heights of hemipelvis **Indications for ORIF anterior pelvic ring** 1 >2.5cm of symphysis diastasis on either static or dynamic (EUA) imaging 2 Augment posterior fixation in vertical shear fractures 3 Augmentation of posterior fixation in completely unstable pelvic fractures 4 Augmentation of posterior fixation in osteopenic bone 5 Significantly displaced rami fractures 6 Locked symphysis 7 Straddle fractures **Relative indications for ORIF posterior ring** 1 Complete disruption of the SI joint (anterior and posterior SI ligaments) 2 Vertical displacement 3 Displaced crescent fractures (iliac wing fractures that enter and exit both crest and greater sciatic notch or SI joint) 4 Displaced sacral fracture 5 Complete sacral fractures with potential for displacement 6 Lumbopelvic disassociation **Reduction technique** 1 Closed - a Traction - b Pelvic sheets - c IRTOTLE technique – internal rotation and taping of the lower extremities 2 Percutaneous - a Anterior frames - b Oblique frames - c Ball spiked pusher - d Supra-acetabular pins for joystick - e Clamps 3 Open - a Anterior/posterior/lateral window **Approach to packing** 1 Anterior incision stoppa approach over pelvic brim splitting the linea vertically 2 Protect the bladder and place 3 packs of sponges on each side following the quadrilateral plate and pelvic brim, packing from posterior to anterior 3 The patient must have these removed within 48 hrs

Answer 56

**Features of sacral dysmorphism** 1 Upper sacrum collinear with the iliac crest (normally below) 2 Alar mammillary process a Normal mamillary process in lumbar spine, with lumbarization of S1 will have mamillary process 3 Large irregular upper sacral foramina 4 Residual S1-2 disc space 5 Alar slope is more acute on lateral sacral view (not collinear with iliac cortical density) 6 Interdigitated/tongue-in-groove SI articulation (CT) 7 Anterior cortical indentation **Denis Classification ** Type I- vertical fracture lateral to the sacral foramina Type II - vertical fracture through the sacral formina Type III - vertical fracture medial to the sacral formina (neurological injury >50%)

Answer 57

Letournell * Elementary fracture patterns - Posterior wall, posterior column, anterior wall, anterior column, transverse * Associated fracture patterns - Posterior column and posterior wall, transverse and posterior wall, anterior column (or wall) and posterior hemitransverse, T-shaped, both column * Most common to least common: posterior wall > ABC > TPW > T type > Transverse > PC+W > ACPHT > AC > Anterior wall **Negative predictors after ORIF** 1 Age >40 2 Nonanatomic reduction 3 Hip dislocation 4 Weight bearing dome or posterior wall involvement 5 Femoral head involvement 6 Initial displacement ≥20mm

Answer 58

Type I – Infrafoveal Type II – Suprafoveal Type III – Associated neck Type IV – Associated acetabulum **Pipkin I & 2** Supine position Anterior smith pete with T capsulotomy Identify fracture fragment (can rotate the hip to fully expose the donor site) Secure with 1-2 countersunk headless screws **Pipkin 3** Supine position Combined anterior & lateral approaches Sliding hip screw for the femoral neck fracture 1-2 coutnersunk headless screws for the head **Pipkin 4** Lateral decubitus position Kocher langenbeck approach preserving short external rotators Surgical hip dislocation (digastric slide, z capsulotomy, anterior dislocation) 1-2 countersunk headless screws in the femoral head Close the posterior wall, lag screw buttress plate fixation

Answer 59

**1 Anterior wall: Anterior approach with brim plating **2 Anterior column: Anterior approach with lag screw and brim plating** **3 Posterior wall: Posteiror approach with lag screw buttress plate** a contoured parallel to the rim spanning ischium & ilium b small fractures spring plate/suture anchor **4 Posterior column: Posterior approach with lag screw (ischium to ilium) neutralization recon plate** a Alternative is dual plating **5 Transverse** a Infratectal transverse: Posterior approach, anterior column screw posterior dual plating b Juxtatectal or transtectal transverse: Anterior approach with lag screw brim plating **1 T type** a Infratectal T type: Posterior approach, same as transverse b Juxta/transtectal T type: Anterior approach, same as transverse c If performing front and back fix the anterior column first **2 Transverse posterior wall:** a First posterior approach fix transverse component (anterior column screw posterior dual plating) b Then posterior wall (lag screw buttress plate) **3 Posterior column and wall:** a Posterior approach, first fix the column (posterior dual plating) b Then wall (lag screw buttress plate) **4 ACPHT:** a Anterior approach first fix the anterior column (pelvic brim plate, lag screws) b Then posterior column (interfrag screws through brim plate) **5 ABC:** a Anterior approach first fix anterior column (pelvic brim plate) b Then posterior column (interfrag screws through plate) c Alternative is front and back procedure fixing front, then back

Answer 60

Triangular osteosynthesis a Lumbopelvic fixation via L5 pedicle screws and iliac screws linked with a bar and SI screws Isolated spinopelvic fixation a L4 and L5 pedicle screws and iliac screws linked with bars b Indicated if SI screws not possible (eg. comminuted S1 and S2 bodies)

Answer 61

1 Increased blood volume: Causes attenuated initial response to hemorrhage 2 Increased red cell size/white count: Predisposes DIC 3 Increased HR: Masks early shock 4 Enlarged uterus: Causes aortocaval compression and secondary supine hypotension 5 Decreased functional residual lung volume: Causes hypoxemia 6 Increased minute ventilation: Causes respiratory alkalosis

Answer 62

At inguinal region = saphenous bypass external iliac to femoral Mid femur = saphenous bypass graft femoral to femoral Distal femur = fem-pop bypass

Answer 63

Boundaries of thoracic outlet: Supraclavicular fossa to axilla between first rib and clavicle Contents of thoracic outlet: a Subclavian artery b Subclavian vein c Brachial plexus Sites of compression for thoracic outlet 1 Interscalene triangle a Between anterior scalene, middle scalene and first rib 2 Costoclavicular space a Clavicle, subclavius, costoccoracoid ligament, first rib (posteriorly) and scalenes (anteriorly) 3 Retropectoralis minor space a Subcoracoid, posterior to rib 2-4 and pec minor b Contains axillary artery and vein Symptoms: Vary, nonspecific findings from multiple neurologic issues during day and sleep, arm fullness, pain anyway from occiput to chest Work-up 1 XR for cervical ribs or prominent C7TP 2 CT/MR for space occupying lesion 3 EMG for nerve involvement 4 Anterior scalene block by IR: botox in scalenes can decrease compression surgical tx Transaxillary ADV a Most commonly used approach, allows for complete exposure of first rib b Cosmetic scar c No retraction of neurovascular structures necessary for first rib removal DISADV a Risk of brachial plexus injury

Answer 64

- tourniquet control - small longitudinal incision, to be incorporated into resection specimen - through intramuscular compartment - meticulous hemostasis - do not udermine/raise flaps - avoid n/v structures and joints - biopsy soft tissue if present - watertight closure - drain if necessary in line with incision, place distal, avoid if possible - send frozen section for lesional tissue to make sure it is consistent with differential and adequate amount - send for C&S

Answer 65

goals - allow surgeon to work closer to important N/V structure, therefore allowing limb salvage and improved funciton - decrease risk of local recurrence - treat microscopic disease that is in surrounding edema radiosensitive: lumg breast, prostate, lymphoma, MM redioresistant: RCC, thyroid carcinoma, melanoma, GI adenocarcinoma complications - early: delayed wound healing, infection, skin desquamation/blistering - late: fibrosis, joint stiffness, secondary osteosarc, fracture RF for radiation induced fractures: radiation dose >59Gy, WB bone, female, volume of bone receiving radiation, ant comp resection of femur, age, periosteal stripping, OP

Answer 66

benign aggresive - ABC, GCT, chondromyxoid fibroma, osteoblastoma, osteochondroma, telangiectatic osteosarcoma malignant adult - mets, mm, primary bone tumour (chondrosarc, ewing, malignant fibrous histocytomy, chordoma, osteosarcoma), brown tumour, OM, lymphoma epiphyseal - OM, GCT, clear cell chondrosarcoma, chondroblastoma

Answer 67

- comprehensive H&P - CBC, extended lytes, creatinine, ureal, ALP, LDH, PTH, TSH, LFTs - CRP/ESR - PSA - UPEP, SPEP - Imaging - full length radiograph, CT/MRI of lesion, CT CAP, bone scan - skeletal survey if concern for MM - PET - biopsy

Answer 68

Stage IA = low grade, intracompartmental Stage IB = low grade, extracompartmental Stage IIA = high grade, intracompartmental Stage IIB = high grade, extracompartmental Stage III = metastatic disease

Answer 69

1 Site of lesion (UE, LE, trochanteric region) 2 Nature of lesion (blastic, mixed, lytic) 3 Size of lesion (<1/3, 1/3-2/3, >2/3 of cortex) 4 Pain (mild, moderate, functional) Graded 1, 2 or 3 Score >8: prophylactic fixation is indicated Score = 8: Surgeon discretion Score < 8: Medical management (bisphosphonates, analgesia, etc)

Answer 70

- symptoms: confusion, malaise, fatigue, abdo pain, N/V, bone pain, kidney stones, polyuria - EKG, consult medicine - hydration - IV NS to achieve urine output of 200cc/hr - diuretic once intravascular volume restored - bisphosphonate for long term treatment - calcitonin - dialysis

Answer 71

- SCARE - synovial sarcoma, clear cell sarcoma, angiosarcoma, rhabdomyosarcoma, epitheloid sarcoma - LEARN - lymphoma, ewings, acute leukemia, rhabdomyosarcoma, neuroblastoma

Answer 72

Follow up at 2 weeks, 6 weeks and then every 3 months for 2 years, then every 6 months up until year 5 then annually until year 10 to rule out local recurrence and mets

Answer 73

RF: previous chemo, bone disorders (pagets, FD, bone infarct, chronic OM, OI), genetic condition (rothmund-thomson sx, li-fraumeni), radiation overall management: chemo - restaging - limb sparing wide margin resection and recon - adj chemo S/E of chemo: neutropenia, thrombocytopenia, anemia, heart failure, cariomyopathy Management: - review with multiD oncologic team - BW: LDP, ALP, CBC, LFTs, Cr, Urea - Echo/MUGA scan, audiogram - chemo: doxirubicin (adriamycin), high dose methotrexate, cisplatin (MAC ATTACK) (-.0 ifofamide) - RESTAGE - xrays, full length mri, bone scan, CT CAP - surgery: wide margin resection + reconstruction - amp vs tumour prosthesis vs intercalary allo/autografts vs rotationplasty - adjuvant chemo - F/U surveillance Factors for worse prongnosis: - primary tumour in axial skeleton, mets on presentation, >14yo, increase ALP/LDH, large turmour, inadquate surgical margins, poor responders to neoadj chemo (<90%), pulm nodule >5mm, lymph node involv, relapse <2yrs parosteal - low grade, posterior distal femur, no chemo periosteal - int grade, no medullary canal involv, tx same as IM osteosarc

Answer 74

Indications * 1 Proximal pole fractures * 2 Displacement >1mm * 3 Associated carpal instability * 4 Humpback deformity * - a Dorsal cortical angle (DCA > 160) * - b Lateral intrascaphoid angle (LISA > 30) * - c Height to length ratio (HLR > 0.6) * 5 Radiolunate angle >15 degrees * 6 Scapholunate angle > 70 degrees * 7 Associated perilunate dislocation * 8 Comminuted fracture * 9 Unstable vertical or oblique fractures Volar: distal pole, humpback or if preferred for mid-waist - a Russe approach = Wagner incision, through FCR subsheath, retract FCR ulnarly, ligate superficial palmar artery, vertical capsulotomy, ranguer small piece of trapezium for appropriate trajectory, obtain reduction, retrograde variable threaded cannulated screw Dorsal: proximal pole or if preferred for mid-waist (contraindicated for humpback) - b Dorsal midline incision over listers tubercle, incise retinaculum, split third and fourth extensor compartment, T capsulotomy, dorsal antegrade variable threaded cannulated screw

Answer 75

1Decreased grip strength 2 Tender LT 3 LT shuck = grasp lunate and triquetrum and alternate volar dorsal loads 4 Kleinman’s shear test = same hand position as shuck but lunate is loaded dorsally 5 Compression test = grasp triquetrum and deviate radially and ulnarly * 1 Nonoperative – splint, injections, and activity modification * 2 LT repair: Open volar & dorsal approach for acute injuries, suture anchors fixation augmented with k wires and dorsal capsular plication * 3 LT reconstruction: Distally based slip ECU through bone tunnels triquetrum and lunate from ulnar to radial * 4 LT Arthrodesis Adjunctive procedures +/- Ulnar shortening osteotomy +/- Midcarpal arthrodesis +/- PRC

Answer 76

PA radiograph * 1 Intercarpal gapping * 2 Disruption of Gilulas lines (proximal proximal row, distal proximal row, proximal distal row) * 3 Loss carpal height (carpal height/third metacarpal ~ 0.5) * 4 Signet ring sign (from scaphoid flexion) * 5 Piece of pie sign Lateral view * 6 Loss collinearity between radius to capitate * 7 Spilled teacup sign Perilunate: Extension traction → flexion → finger pushing on lunate Lunate: Flexion → traction → extension → finger pushing on lunate

Answer 77

I will perform a comprehensive HPI, PMHx, meds, allergies, developmental, peripartum, vaccination, social history I would perform a comprehensive history of presenting complaint, as well as Pmhx including previous admissions and surgical history, medications, allergies and vaccinations. I would ask about any challenges around pregnancy, birth and peripartum history, developmental history and difficulties with milestones. I would obtain a social history and inquire about home setting, hx of abuse in the home, available supports, parental occupation and exposure to cigarette smoke

Answer 78

I would perform a thorough head to toe general examination looking for features of dysmorphism or congenital abnormalities, signs of spinal dysraphism, and neonatal reflexes (Moro, grasp, etc). From an orthopedic perspective I will check the cervical spine, upper and lower extremities for any congenital abnormalities, ranging each joint, ensuring the hips are reduced and stable, checking leg lengths. Details: General: height, weight, general nutritional status, nevi, hemangiomas, rashes, petechiae, jaundice, obvious areas of bruising, or deformity Head: head size and shape, fontanelles (should be present and soft) Eyes: hyper/hypotelorism, slant of palpebral fissures, EOM, sclera, corea, red reflex Ears: position of ears, tympanic membranes Nose: discharge, nasal septum Mouth and throat: lips for fissures, buccal mucosa, tongue teeth and gums Neck: trachea midline, thyroid Chest: heart sounds, breath sounds, pectus deformities Abdomen: inspection, shape, distension, hernias MSK: UE: number of fingers, mobile supple joints, deformity, edema, symmetry, ROM shoulder elbow wrist LE: Hips in joint /barlow ortolani Galeazzi, knee ROM, supple joint, ankles and foot deformities, IR/ER hips Sacral dimpling Pediatric reflexes (moro, grasping, etc)

Answer 79

- understand that this is a very difficult situation for the patient and family. - I will arrange for private area to sit and discuss the matter more fully. - Following the SPIKES framework, using non-judgemental, simple intelligible speech - I will empathetically respond to the patient’s concerns and answer any questions they have - while I was not at the original sx, cannot speak for my colleagues - my goal is to provide the best care moving forward at this point which involves X ## Footnote spikes : setting, perception, invitation, knowledge, empathy, summarize or strategize

Answer 80

General algorithm **Continue (MTX and hydroxychloroquine)** 1 day (leflunomide) 1 week (SANE -sulfasalazine, azathioprine, NSAID, etanercept) 1 month (the rest) **2 months (rituximab)** Post op NSAIDS re-start POD1-2 and rest are 2 weeks Specifics from JAAOS 1 NSAIDS – discontinue within 1 week before surgery. Aspirin at least 72 hr 2 MTX -continue 3 Sulfasalazine – 1 week preop 4 Azathioprine – 1 week preop 5 Leflunomide – 1-2 days preop, with cholestyramine to remove active metabolite, start 1-2 week postop 6 Hydroxychloroquine – continue 7 Etanercept – 1 week preop and restart 1-2 week postop 8 Infliximab – hold 1 month preop, reinstated 1-2 weeks postop 9 Golimumab – hold 1month preop restart 1-2 week post op 10 Toclizumab – hold 1 month preop 11 Abatacept – hold 1 month preop 12 Adalimumab – hold 1 month preop 13 Certolizumab – hold for 1 month preop 14 Rituximab – hold for 2 months preop

Answer 81

Surgical safety checklist prior to induction 1 Confirmed patient, site, procedure and consent obtained 2 Site is marked 3 Anesthetic concerns 4 Allergies 5 Anticipated blood loss greater than 500cc Checklist/Timout prior to skin incision 1 Confirm all team members know each other 2 Confirm patient name, procedure, side 3 Antibiotics 4 Anticipated critical events 5 Anesthetic concerns 6 Nursing concerns 7 Imaging available Prior to leaving OR 1 Name of procedure (nursing) 2 Confirm counts are correct (nursing) 3 Specimens labelled (nursing) 4 Surgeon/anesthetic concerns in post operative management

Answer 82

Neurapraxia = Axon intact, myelin damage, endoneurium intact (compression, nerve dysfunction because myelin is disrupted, but all components intact, will re-gain function) Axonotemesis = Axon and myelin damage, anything except the epineurium may be disrupted Neurotemesis = Axon and myelin and everything up to and including the epineurium is disrupted

Answer 83

I will disclose the error to the patient including the impact of that error on their medical treatment and disclose our plan to prevent future errors from occurring. I will apologize to the patient and using non-judgemental speech listen to their concerns and answer any questions they may have. I will provide appropriate practical and emotional support and document the disclosure.

Answer 84

1 I will validate their feelings (not her fault), unfortunately this is very common a Ensure this is conversation is confidential 2 Thoroughly document the complaints a Clinical photographs where applicable 3 Find out if other’s are at risk a Children b Elderly 4 Offer support through hospital a Social services b Shelter c Exit plan d Toll free numbers e Counselling f Support groups g Legal services 4 Work together to document a plan with regards to the orthopedic injury and the social issues, and obtain a follow-up.

Answer 85

Medical expert, communicator, professional, collaborator, leader, health advocate, scholar

Answer 86

- activate ATLS protocol - assemble trauma team - primary survey and team members start monitors, oxigen, vitals, IV lins, trauma blood and cross match and c spine immobilized - airway - breathing - circulaton - IV access intra osseus in prox tibia under 6 yo - fluid resus - 20ml/kg RL x 3 boluses **Key Differences in Peds:** * Higher incidence of multi-organ injury * High BSA to volume ratio - Increased Risk of hypothermia * Transport : Large head - Boost trunk/occiput cutout spine board  want to avoid passive c-spine flexion * appropriate sized equipment * ETT = (age/4) + 4, Chest tube = ETT X 4 * Systolic BP = 80 + 2 X age; Diastolic BP = 2/3 systolic * Hypotension = 45% loss of blood and occurs precipitously * R/O child abuse: subdural, retinal hemorrhage, genital trauma, injuries of different ages, burns, posterior rib fracture, bucket handle/corner fractures * Ask about helmet for bike trauma * Airway: smaller midface, larger tongue, anterior larynx, short trachea

Answer 87

reserve proliferative hypertrophic zone zone of provision calcification **Reserve zone** - Pathology: Gauchers, Diastrophic dysplasia, Kniest dysplasia, pseudochondroplasia **Proliferative zone** - Pathology: Achondroplasia, SED, Gigantism, MHE **Hypertrophic zone:** Path: SCFE, Rickets, Enchondroma, Mucopolysaccharide, SED, MED, Schmids, Kneist **Fractures through zone of provisional calcification (SH1)** Path: Metaphyseal corner injuries, Scurvy **Secondary spongiosa = metaphysis** Path: Renal SCFE

Answer 88

Common organisms: - Neonates: GBS, s. aureus, gram –ve, Kingella * < 4: S. aureus, s. pneumo, H. influenza, Kingella (hold cultures longer) * > 4: aureus * Septic shock – MRSA, MSSA * Shoe puncture – pseudomonas, s.aureus * Sickle cell – s aureus/salmonella * Neisseria – Sexually active/abused (culture mucous membranes), neonate with affected mother, grown on chocolate agar, multiple joints * Treated with non-op – Ceftriaxone (only I+D if hip joint involved) RF = premature, c-section, intra-articular metaphysis (Hip, shoulder, elbow, ankle) Poor prognosis: Age < 6 months, associated OM, hip joint, delay >4 days ddx hip pain * Transient synovitis * Septic arthritis * OM * Dysplasia * SCFE * Perthes * MED * Psoas abscess (can spread to joint via psoas bursa in 15%) * Discitis * Malignancy Kocher Criteria (for septic arthritis of the hip): * Non–weight-bearing on the affected limb * Fever > 38.5°C (101.3°F) * ESR ≥ 40 mm/hr * WBC ≥ 12,000 /μL Cx = Early arthritis, AVN, coxa magna, dysplasia, LLD, contracture

Answer 89

**club hand/radial longtidunal deficiency;** - What: Failure of formation of radial forearm, wrist, hand Thumb + index hypoplasia/absence (80%) - Bilateral in 50% - Associated: TAR (thrombocytopenia + absent radius – thumb usually present + have severe genu varum), Fanconi anemia, Holt-Oram (CHD), VACTERL, VATER - test: CBC, renal U/S, echo - most importants **congenital deficiency of ulna + ulnar sided structures** - What: congenital deficiency of ulna + ulnar sided structures - Associated: Syndactyly, PFFD, fibular hemimelia, radial head dislocation, elbow instability, synostosis, scoliosis, thumb duplication/hypoplasia **congenital radial head D/L** - usually posterior with bowing and shortening of radius - assoc: Silvers/Steel, Marfans, achondroplasia, MHE, Ehlers Danlos, Larsen, Ulnar longitudinal deficiency, Downs, Klippel-Feil, arthrogryposis **constrictive ring syndrome** What: Loose fibrous bands of ruptured amnion adhere to and entangle structures of fetus – 90% distal to wrist Not hereditary – central digits more commonly affected – bands perpendicular to long axis of limb Associated with: club foot, syndactyly, cleft palate, cardiac defect, encephalocele, craniofacial defect

Answer 90

- assoc with :Associated: VACTERL, Holt-Oram (CHD), TAR, Fanconi – most important - Classification – Blauth: depends on CMC joint stability Type 1 – Minor hypoplasia Type 2 – all osseous structures present, MCP UCL instability, thenar hypoplasia Type 3A – musculotendinous and osseous deficient, CMC intact Type 3B - musculotendinous and osseous deficient, deficient CMC Type 4 – Floating thumb – only attached via skin and NV Type 5 – complete absence - echo, kidney u/s abdo u/s O/E: Hypoplasia of thenar, Pollex abductus (FPL inserts onto extensor tendon), absence of skin creases, 1st web space tightness, UCL laxity = excessive MCP abduction, absent MCP/IP joint Tx: - Observe: Type1 – does not require augmentation of thenar musculature for thumb abduction - Oppenensplasty – for type 1 with deficient thumb abduction (opposition tendon transfer) - Use FDS or abductor digit minmi - Release of 1st web space (Z-plasty), opposition transfer, stabilize MCP (fusion, reconstruct UCL with FDS) = Type 2 + 3A - Pollicization = Type 3B, 4, 5 (turn index finger into thumb) * Local skin flaps to reconstitute webspace * Isolate index finger on NV bundle -> reduce new digit and stabilize * Tendon transfers (EDC -> APL, EIP -> EPL

Answer 91

**RF** - - Multiparous, Macrosomia >4-5kg (14x), vertex/breech, shoulder dystocia (100x), difficult labor/forceps (9x), DM, wt gain >20kg (most have no RF) **assoc: ** - Glenohumeral dysplasia (70%) - due to internal rotation contracture - features glenoid retroversion, humeral head flattening, posterior subluxation - Good prognosis: Erbs palsy, Biceps + deltoid anti-gravity power by 2-3 months, early twitch biceps recovery (if > 5 months then likely incomplete recovery - Poor prognosis: Lack of biceps by 3 months, preganglionic injury (avulsion off cord – loss of rhomboid function – dorsal scapular nerve + elevated hemidiaphragm –phrenic nerve, Horners, C7 involved, Klumpke palsy **Classification:** - Group 1: Duchenne-Erbs palsy – C5-6 (45-60%) – upper lesion – best prognosis + Most common Lateral flexion of head toward contrateral side and ipsilateral depression of shoulder C5-C6 deficient – Axillary nerve, suprascapular, musculocutaneous, radial nerve Paralysis of deltoid + biceps – intact wrist/finger extension and flexion = Adducted/IR shoulder, pronated forearm, extended elbow, slight wrist flexion -> deceased shoulder ER -> shoulder subluxes posterior – hand is normal - Group 2: Intermediate paralysis (30%) – C5-7 – Paralysis of deltoid, biceps, wrist extension, digit extension – intact wrist/digit flexion - Group 3: Total brachial plexus palsy (20%) – C5-T1 – Flail extremity (No Horners) – no motor or sensory - Group 4: Total brachial plexus palsy + Horners – Roots C5-T1 – Flail extremity - Klumpke = < 2% = lower lesion = poor prognosis – C8-T1 (ulnar/median) Treatment - Neurotization (neuroma resection) + sural nerve cable graft = postganglionic vs. Nerve transfer = pre-ganglionic injury or root avulsion injury (donate intercostals, spinal accessory nerves) – done at 3-12 months - Contractures – often multi-level – work proximal to distal IR contracture = 40% = due to large muscles for IR overpower ER  PT > night splint > botox initially Done at age 4 = soft tissue = Subscap release + lat dorsi transfer Bony procedure = done > age 5 = ER osteotomy of humerus +/- glenoid osteotomy - Elbow Flexion contracture = Serial casting and nighttime splinting OR surfical release of anterior capsule + biceps lengthening + night time splinting Transfer pec, triceps, steindlers flexorplasty - Forearm rotation = supination is worse deformity – rotational osteotomy or re-route biceps around radial head to make it function as pronator - Wrist drop = Pronator teres to ECRB, loss of finger extension = FCR to EDC

Answer 92

**RF** - female, first born, breech, Fhx, oligohydramnios, swaddling, caucasian **P/E** - general inspection face for absnormal facies, neck for torticollis, back/spine for spinal dysraphism/soliosis, knees for congenital knee D/L, hips - galeazzi, ortalani, barlow, hip ROM, feet for metatarsus adducturs, clubfoot, calcaneovalgus ft and N/V exam **Assoc packing disorders** - torticollis, metatarsus adducturs, congenital knee dislotaion, club foot, calcaneovalgus foot, PM tibial bowing **Imaging** - U/S < 6 mo: alpha angle >60 is normal, beta angle < 55 is normal, morin index N>50% - xray > 6mo: hilgenreiner, perkin line shenton line, AI N <25 at >6 mol comment on fem ossific nucleus, is it in inft quad and AI; other xray signs: widened teardrop, rounded acetab corners, mild sclerosis head, fem anteversion and coxa valga - centre edge angle of wilberg for >5yo, < 20 is abnormal - tonnis angle - similar to AI but WB roof of acetabulum, should be 0-10 **Treatment** **0-6** - pavlik harness, exam/u/s weekly, make sure family is coping, fit is ok, kicking, readjust straps, D/C if harness fails at 3 wks - chest strap at nipple level, able to put hand under strap - anterior strap in line with anterior ax line, prevent hip extension beyond 90 - posterior strap level of scapula prevent adduction beyong neutral - complications: femoral n palsy with excessive flexon, femoral head aVN with excession abduction, brachial plexus neuropathy from shoulder strap compression, skin breakdown, inf D/l and paclik harness disease - wear pavlik until abduction similar to N side or U/S normal, 6wk to 3 months - contraindicated to pavlik: major muscle imabalnce, major stiffness, lig laxity **6-12 months** - closed reduction, adductor tenotomy, arthrogram and spica cast and CT/MRI - EUA, closed reduction and test ROM, arthrogram confirm < 5mm of medial dye pool - adductor tenotomy if abductio nrequired for stability within 20 degrees of max abduction - release adductor longus protect anterior branch of obturator n. - spica cast in human position - flex 90 Abd in safe zone <50, IR slight, and GT mould - post reduction Ct/MRI - @ 6 wks EUA, arthrogram and change spica - @ 12 wks D/C spica - blocks to reduction: lig teres, labrum, limbus, pulvinar, psoas tendon, capsule, tranverse aetab lig, adductor tendon, shape of fem head **12-18 months** - open reduction, adductor tenotomy, capsulorrhaphy, spica cast, CT/MRI - spica cast for 6 wks, 30 abd, 30 flex, 30 IR **>2 yo** - open reduction +/- femur/pelvis osteotomy - adductor tentomy/psoas recession, open reduction, pelvic osteotomy, femoral shortening and derotation oseotomyy, capsulorrhaphy, spica casting, Ct/MRI - NO VARUS CORRECTION FOR FEMUR, only shortened and derotate - pelvis osteotomy to imrpove stability and coverage of femoral head, increase anterolateral coverage, salter or pemberton - pemberton decrease acetab volune and hinge via open triradiate - femur osteotomy - transvere subtroch osteotomy, derotate by ER femur and fix with 4 hole plate

Answer 93

**RF** - fhx, low BW, abn birth presentation, 2nd hand smoke, lower SES, later born child, disease in other hip, ADHD, delayed bone age, asian inuit, central european **ddx** - MED, SED, sickle cell ,gaucher, hypothyroid **prognostic RF:** - >6, sphericity of fem head and congruence at maturity, lateral pillar, female, obese, decrease ROM, gage sign horizontal physis **at risk signs:** 1 Lateral subluxation 2 Calcification lateral to the epiphysis 3 Horizontal growth plate 4 Gage sign (lateral V shaped epiphysis, pathogneumonic for LCP) metaphyseal cysts Classification **Waldenstrom:** Initial, Fragmentation, Re-ossification, Remodel **Lateral Pillar (Herring):** - based on height of lateral pillar of capital epiphysis: - Used at beginning of fragmentation stage – 6 months after onset of symptoms - Group A – lateral pillar maintains full height without density changes - Group B - >50% height maintained (poor outcome if bone age >6 yrs.) - Group B/C – Lateral pillar -narrowed 2-3mm or poorly ossified, height loss 50% - Group C - <50% height maintained – poorest outcome **Ideally the patient has the following characteristics** 1 Herring B or BC boarder 2 Children over 8 3 Full hip ROM 4 Congruent joint 5 Initial or fragmentation stages (ie no deformity) **get hand xray for bone age** Nonop: - PT, activity restriction – age < 6-8 in groups A+B – 60% don’t need operative intervention +/- Bisphosphonates - Restrict activity until reossification complete, crutches or period of NWB if painful - Group C – does not benefit from OR – observed as well (poor outcomes no matter what) Operative - Age 6-8 + lateral pillar B or B/C - nonshortening **VRDO** or Pelvic osteotomy to keep hip contained (improved outcomes if >8 yrs with surgery) - Perform a trochanteric apophysiodesis to reduce trochanteric prominence - Valgus and Shelf osteotomy if Hinge Abduction (secondary to extruded capital femoral epiphysis – present with fixed flexion and adduction) Children will need containment (regardless of age, phase of disease, ROM, etc) if 1 Hip is uncovered or subluxed 2 Hinged abduction present on arthrogram **Post perthes hip deformity** 1 Coxa magna a Osteotomies of the neck to reduce neck width 2 Prominent and proximal GT a Osteotomies of GT to distalize 3 Residual deformity in varus a Osteotomies to correct varus 4 LLD

Answer 94

- congenital defect assoc with ossification defect in inf neck - assoc with fem neck stress fracture, decreased limb length, early Oa, risk of SCFE - xray findings: neck shaft angle <120, short neck, vertical physis, decrase anteversion, increased hilgenreiners epiphyseal angle ( N < 25) - tx: - hilgenreiners-epiphyseal angle < 45 degree - not likely to progerss - hilgenreiner physeal angle >60 or symptomatic operate: valgus troch osteotomy with blade plate and adductor tenotomy, GT epiphysiodesis +/- transfer distal and lateral

Answer 95

**definition:** slippage of metaphysis anterosuperior while epiphysis remains in acetabulum **Deformity produced by SCFE and maneuver for corrective osteotomy** Deformity a Extension (anterior displacement neck) b Varus c ER Southwick osteotomy (intertroch) a Flexion b Valgus c IR - W/U if < 10 or < 50% wt: TSH, BUN/Cr, GH level - **xrays** - southwick angle: measurement of difference between both hips and epiphyseal shaft angle on AP and frog laeg lag, mild <30, mod 30-50, severe >50 1 Widening physis 2 Irregular physis 4 Metaphyseal blanch sign of Steel a Radiographic double density created by the anteriorly displaced metaphysis overlapping the epiphysis 5 Kleins line does not bisect epiphysis (epiphysis is flush or below) **RF** * Obesity * Pubertal Age: * M>F * Ethnicity ->African American (2.2x), Pacific Islanders (4.5x). * Susceptible Physis: * Femoral retroversion - Obesity is a known risk factor for decreased anteversion/increased retroversion. * Increased physeal obliquity (vertical physis)- Decreased neck shaft angle * Previous chemo or radiation to femoral head region. * Hormonal Factors – Endocrine, thyroid, Down Syndrome **In-situ pinning of proximal femur epiphysis (SCFE)** * patient placed supine on fracture table with involved extremity in traction * triangulate with fluoro to confirm skin start point * on AP and lateral use a wire placed on skin so that it projects over the center of the epiphysis and perpendicular to the physis; draw a line on the skin parallel to these lines, at the point where they intersect a stab incision is made * advance the guidewire free hand down to the start point on the anterior femoral neck * advance the wire with drill so that the wire is the center of the epiphysis and perpendicular to the physis on both the AP and lateral views * measure the screw length with depth gauge * ream over the wire * advance a 7.3mm cannulated screw over the wire such that 4-5 threads engage the epiphysis and the tip is no closer than 5mm within subchondral bone * confirm screw does not penetrate joint with the near-far technique by taking hip from max IR to ER **SCFE indications for contralateral pinning** 1 Contralateral symptoms 2 Radiographic evidence of contralateral slip 3 History of radiation 4 Endocrinopathy a hypothyroidism b GH treatment c Adiposogenital dystrophy ie decreased GnRH d panhypopituitarism 5 Young age a Controversial but < 8 b Open triradiates **Flexion intertrochanteric osteotomy technique** * Goal is to achieve flexion, valgus and IR and generally want to correct a high grade southwick angle (>50) to a low grade (<30). Preoperatively template correction with CT. * Involve a senior colleague. * 1 Supine approach * 2 Lateral subvastus approach to the proximal femur * 3 Mark a line in the femur with cautery as a guide to rotation * 4 Chisel impacted in proximal segment * 5 Blade plate is inserted proximally * a Stabilized with a screw in the proximal fragment * 6 Transverse osteotomy is made just proximal to the LT * 7 The distal fragment is flexed and internally rotated to desired correction * a Distal fragment is reduced to the plate and secured with screws * 8 Confirm reduction and position on final fluoro * 9 Tension free closure in layers with protected post-operative weight bearing

Answer 96

varus deformity of proximal tibia in age 2-5 - deceleration fo growth occurs at PM prox tibia with time leading to varus, flexion, IR deformity - RF: early walking, obese, vit D deficient, black - ddx: persistent physiologic varus, rickets, vit D deficient, OI, MED/SED, physeal injury - xr: proc tibia varus, epiphyseal/metaphysea irrgularity, medial metaphyseal beaking - metaphyseal-diaphyseal angle (drennan) > 16 is abnormal - RF for progression: drennan angle >16, bony bridge, langenskold stage 3 or greater, LLD, progressive radiographic deformity - TX: - KAGO if <3 - operative: correct varus/flexion/IR if > 4 **RAb osteotomy with fibular osteotomy and prophylactic partial fasciotomy.** <9 degrees represents physiological varus 9-16 degrees with varus thrust may progress >16 requires surgical treatment Nonsurgical a bracing controversial, can attempt up until age 3 Surgical 1 HTO with fibular osteotomy a medially based osteotomy b laterally based osteotomy c dome osteotomy 2 Growth modulation a lateral hemiepiphysiodesis 3 Physeal bar resection, fat interposition 4 Hemiplateau elevation (indicated for older children with severe plateau depression) 5 Angular deformity correction and lengthening (?)

Answer 97

age >10 - more likely to have femoral deformity and be unilateral - prognosis: never resolves spontaneously, increased risk of OA, deformity likely to progress during remainging growth Tx: * Lateral tibial hemiepiphysiodesis – mild to moderate deformity with growth remaining * RF for failure = >14, BMI >45, severe deformity * Operative: Prox tibial + fibula osteotomy with internal fixation or TSF = for more severe cases * Do not overcorrect – check for distal femoral varus * Distal femoral hemiepiphysiodesis - for varus deformity >8 degrees

Answer 98

* Autosomal dominant neural crest cell disorder * **Extremity deformity:** anterolateral bowing of tibia, hemihypertrophy, bowing of forearm * **Spine deformity:** scoliosis, kyphosis, atlantoaxial instability **Dx – need 2 of 7:** * 6+ café au lait spots – must be >5mm in pre-pubery or >15mm in post-puberty – has smooth borders – Coast of California * 2+ neurofibromas of any type OR 1+ plexiform neurofibroma (pathognomonic for NF1) * Axillary/inguinal freckling = Crowes sign * Optic glioma * 2+ Lisch nodules – iris hamartoma * Distinctive osseous lesions – sphenoid dysplasia, thinning of long bone cortex +/- pseudarthrosis (anterolateral tibia bowing, radial bow) * Family Hx: 1st degree relative (parent/sibling/child) with NF1 * Other signs: dystrophic kyphoscoli, rib peniciling, intraspinal neurofibromas (dumb-bell), dural ectasia, meningiomas **Non-ortho: **Aortic stenosis, Neoplasias (PHEO, astrocytoma, WILMS, NF, Schawannoma, neurofibrosarcoma, brain stem glioma), HTN, MPNST * NF1 = Most common; NF2 = bilateral vestibular schwannoma **O/E:** Café au lait spots, hemihypertrophy, axillary freckles, scoliosis, plexiform neurofibroma, Lisch nodules, bowed limbs **Spine:** - Atlantoaxial instability, dural ectasia, dumb-bell lesions, kyphosis, scoliosis – XR: vertebral scalloping, rib pencil, enlarged foramina - MRI: always obtain preoperative MRI to identify dural ectasia and dumbbell lesion (neurofibroma on nerve root) - paraspinal masses are useful to distinguish from idiopathic scoliosis **Anterolateral bowing:** * 50% of anterolateral bowing have NF1 (10% of NF1 have anterolateral bowing) * Can progress to pseudarthrosis **AL tibial bowingTX:** Tx: - Bracing in clamshell or PTB (ambulatory child + bowing with no pseud/fracture) - ORIF/IMN if pseud/fracture + Bone grafting or vascularized fibula * Amputation if 3+ failed surgical attempts (Symes) **Cx:** Recurrent fracture – 50% Valgus deformity LLD – close to 5cm on average

Answer 99

Linked to Sonic-hedge hog gene Associated with 1. Foot and ankle * a. Absent lateral rays * b. Tarsal coalition * c. Ball and socket ankle * d. Ankle instability * e. Equinovalgus (equinovarus less frequently) 2. Lower extremity * a. Fibular hemimelia/amelia * b. Anteromedial tibial bowing * c. Hypoplastic lateral femoral condyle * d. Genu valgum * e. ACL deficiency * f. PCL deficiency * g. Patella alta * h. Hypoplastic patella * i. PFFD * j. Varus and valgus femoral neck * k. Femoral retroversion * l. Acetabular dysplasia 3. Upper extremity * a. Ulnar hemimelia/amelia * b. Syndactyly * 4. Other * a. Renal anomalies * b. Cardiac anomalies **Classification:** 1A: Portion of fibula remains – prox fib epiphysis is distal to level of tibial physis + distal fib is proximal to talus  Tx: Heel lift, contralateral epiphysiodesis, limb lengthening 1B: Partial absence of fibula (30-50%), unable to support ankle Tx: Contralateral epiphysiodesis, limb lengthening, supramalleolar osteotomy, foot procedures 2: Complete absence of fibula – TSF O/E: Short limb, skin dimple over mid-anterior tibia, equinovalgus foot, missing toes, genu valgum **Tx: Determined by stability of foot and ankle and amount of limb shortening** Nonop: Shoe lift + bracing Operative: Contralateral epiphysiodesis if mild LLD + stable foot Limb lengthening if stable foot and LLD <10% +/- epiphysiodesis if moderate LLD 10-30% Syme amp: Nonfunctional, deformed, unstable foot + LLD >30% Do at 1 year of age to allow early prosthesis fitting 1 Lengthening treatment pathway a If no indications for amputation then stabilize ankle and knee, start lengthening 2 Amputation treatment pathway a Syme/Boyd and prosthetic fitting 3 Genu valgum a Timed medial distal femoral epiphysiodesis (<15) or tibial and femoral epiphysiodesis 4 Associated PFFD a Determine if patient needs a more proximal procedure to address the femur

Answer 100

etiology: * Idiopathic * Vascular malformation * Syndromic: NF1, Beckwith-Wiedemann, Proteus, Klippel-Trenauney * Acquired - Infection, inflammation, radiation, injury, trauma * Tumor: Osteochondramtosis, Olliers, Osteoid osteoma associated with: scoliosis, nerve entrapment, wilms tumour, GU problems, organomegaly, omphalocele, large tongue investigations: serum AFP (alpha-fetoprotein), abdo u/s q3mo Tx: Observe, shoe lift – if <2cm projected at maturity Leg length correction – based on projection

Answer 101

- associated with sonic hedge hog gene - assoc conditions - Fibular hemimelia (50%), ACL deficient, Coxa vara, knee contractures - O/E: Severe shortening of 1 or both legs, % shortening remains constant with growth - Leg often flexed, abducted, ER Tx: Operative: Limb lengthening +/- Contralateral epiphysiodesis - Indications: Predicted LLD <20, stable and functional foot, femoral length >50% of opposite side, femoral head present (A+B) - Contraindication: Proximal femoral neck pseudarthrosis, acetabular dysplasia (can dislocate) Prosthesis: - Knee fusion and foot ablation (If ipsilateral foot proximal to level of contralateral knee) - Femoral pelvic fusion (Browns) – femoral head absent - Van Ness Rotationplasty (if ipsilateral foot at level of contralateral knee, ankle with >60% motion, absent femoral head (C+D) – 180 degree rotation through femur --> allows below knee prosthesis (better if >12 yrs - Amputation – Femoral length <50% of opposite side -> do through knee if possible (avoid overgrowth)

Answer 102

ddx: - Congenital: Hemihypertrophy Dysplasia DDH PFFD Fibular hemimelia Tibula hemimelia Unilateral club foot Paralytic: CP Polio Physis: infection, trauma tumor Methods: Mosley graph  estimation technique (Prox femur 3mm, distal femur 9mm, prox tib 6mm, distal tib 5mm) Green-Anderson table/Mosely graph  extremity length for given age Multiplier method: Multiple current discrepancy by sex and age (most accurate for congenital) – 50% final LL – Girls at 3, Boys at 4 - UE growth: prox 80% = 7mm/year, elbow (20%) = 2mm/year, prox radius 25% <2mm/year, distal radius 75% = 5mm/year 40% prox humeurs, 40% DR; 20% elbow - LE growth: prox femur 3mm, distal femur 9mm, prox tib 6mm, distal tibia 5mm Shoe lift for <2cm Shorten long side for 2-5cm LLD Lengthen short side for >5cm projected LLD Combine with shortening procedure Distration osteogenesis (1mm/day) Amp = >20cm projected LLD Physeal bar resection = >2 years growth left and bar <50% of physis

Answer 103

- nonprogressive static disease of UMN due to injury to immature brain - Classification: * Spastic – Most common – 75% - velocity dependent increased tone – hyper-reflexic * Dyskinetic: Dystonia (involuntary sustained twisting movement, athetoid (Slow, writhing movement) – more unpredictable results * Mixed (10%) * Ataxic (<5%): cant coordinate movement Anatomic classification: * Diplegia – Legs >arms * Hemiplegia – one side of body * Quadriplegia – all 4 limbs GMFCS 1 = Independent 2 = Uses aids for stairs and steps 3 = Assistive devices primarily 4 = Primarily wheelchair (may do transfer) 5 = Nonambulatory Exam - gait - LLD, rotational profile, hips, thig-foot, transmalleolar axis, foot progression angle - flexion contracture - thomas test, popliteal angle, adduction contracture, duncan ely, confusion test for foot/ankle, silverskold - spine for scoliosis and pelvic obliquity - imaging: brain mri for periventricular leukomalacia - consults: neurology, PT,OT, pediatricians **equinovarus foot** muscles involved in deformity - Tibialis posterior leads to inversion and supination of the foot Tibialis anterior leads to inversion and supination of the foot Gastrocnemius-soleus complex is also often contracted, further contributing to deformity surgical intervention would you suggest? If tib post is primary muscle involved: Tibialis posterior tendon transfer to peroneus brevis Achilles tendon vs. gastroc lengthening If tib ant is primary muscle involved: Rancho procedure: Tib post lengthening Split tibialis anterior tendon transfer to cuboid Achilles tendon lengthening

Answer 104

What: CTD with long narrow limbs, skeletal abnormalities, CV abnormalities, ocular abnormalities Genetics: Fibrillin-1 gene (elastin) – Cr. 15 - AD (possible sporadic mutation) **Orthopaedic condtions:** * Scoliosis (50%) – usually first thing to be Dx * Acetabular protrusion (15-25%) * Reduced extension at the elbows (<170 degrees) * Arachnodactyly – long slender digits * Hyperlaxity/recurrent dislocations * Lumbar dural ectasia (>60%) * Dolichostenomelia - Arm Span-to-Height Ratio > 1.05 (limb overgrowth) * Pes Planus (planovalgus – Hx of ankle sprains  give orthotics), Pes Excavatum, Pes Carinatum **Nonortho:** cardiac abnormalities - aortic root dilatation, aortic dissection, mitral valve prolapse superior lens dislocations (60%) spontaneous pneumonthorax Skin striae, recurrent hernias **XR/MRI: Scoliosis series + MRI to look for dural ectasia Get cardiology consult and ECHO** Tx: Nonop: BB to decrease risk of aortic dilatation; orthotics; can use bracing for scoli (not as efffective) Operative: PSF +/- ASF – No bracing Indications: Rapid progressing curve in skeletal immature, large curve in skeletal mature Use long consult; Fuse to pelvis if distal curve, poor bone quality, obliquity **Get MRI before OR** Acetab protrusio: If progressive or ++pain -> Valgus osteotomy if no arthritis -> otherwise THA only option Cx: All of below are more than AIS Fixation failure #1 – thin lamina, thin pedicles Infection Pseudarthrosis Dural tear and CSF leak (8%) Curve decompensation  use long construct

Answer 105

1. History * Acute onset of pain * Chronic pain since surgery * Wound healing problems, drainage, superficial or deep infection * Systemic symptoms (fever, chills, etc.) * Prior surgeries on affected joint 2. Physical exam * Swelling, Erythema, Drainage, Sinus tract 3. Obtain OR note for date and type of implants 4. ESR/CRP 5. Blood culture if fever or acute onset of symptoms 6. Radiographs 7. Joint arthrocentesis * Cell count, cell differential, gram stain, culture and sensitivity, crystals

Answer 106

Single Stage Revision 1. DAIR – debridement, antibiotics, irrigation and retention of implants * A. Utilize previous approach * B. Multiple tissue samples for culture (3-6) * C. Extensive debridement of all devitalized soft tissue and bone * D. Synovectomy * E. Exchange of modular components * i. Liner, modular head * F. Low pressure irrigation (6-9L) 2. Administration of 6 weeks of IV antibiotics * Possible 3-6 months of oral antibiotics following

Answer 107

2 Stage Revision: 1. First stage * A. Utilize previous approach * B. Remove all implants * C. Multiple tissue samples for culture (3-6) * D. Extensive debridement of all devitalized soft tissue and bone * E. Synovectomy * F. Reaming of intramedullary canals * G. Low pressure irrigation (6-9L) * H. Insert static or dynamic antibiotic spacer dependent on patient factors (soft tissue, bone loss, previous failed dynamic spacer) 2. Administration of 6-8 weeks of IV antibiotics based on sensitivities (consult ID) * Consider 3-4 months if immunocompromised, poor soft tissue coverage, sinus tract or virulent organism * 2 week antibiotic holiday prior to proceeding to second stage * i. ESR/CRP remain stable and no clinical signs of infection 3. Second stage * A. Remove antibiotic cement spacer * B. Send tissue for frozen section * i. If \<5 PMNs per high powered field for all specimens proceed with second stage * ii. If \>5 PMNs per high powered field for any specimen repeat first stage * C. Irrigation and debridement * D. Reconstruction with revision components 4. Administration of antibiotics until cultures negative

Answer 108

1.Preoperative * a.Malnutrition * b.Diabetes * c.Obesity * d.Male * e.Posttraumatic arthritis * f.Inflammatory arthritis * g.Colonization with MRSA * h.Prophylactic antibiotics 2.Intraoperative * a.Skin prep * b.Longer surgical time * c.Antibiotic impregnated cement * d.OR configuration and traffic * e.Wound closure * f.Frequent glove changes 3. Postoperative * a.Retention of foley catheter \>1 day * b.Blood transfusions * c.Prolonged wound drainage * d.Dental procedures

Answer 109

1.Major Criteria * Two positive cultures of the same organism * Sinus tract with evidence of communication to the joint or visualization of the prosthesis * DECISION * At least one of the following = infected 2.Minor Criteria * SERUM * Elevated CRP OR D-Dimer - Score 2 * Elevated ESR - Score 1 * SYNOVIAL * Elevated synovial WBC count or LE - Score 3 * Positive alpha-defensin - Score 3 * Elevated synovial PMN% (>80%)- Score 2 * Elevated synovial CRP (>6.9) - Score 1 * DECISION * ≥6 = infected * 2-5 = possibly infected * For patients with inconclusive minor criteria, operative criteria can also be used to fulfill definition for PJI. * 0-1 = not infected 3. Inconclusive preop score OR dry tap * Positive histology - Score 3 * Positive purulence - Score 3 * Single positive culture - Score 2 * DECISION * ≥6 = infected * 4-5 = inconclusive * Consider further molecular diagnostics such as next-generation sequencing * ≤3 = not infected ## Footnote MSIS criteria parameters ESR >30, CRP >10 synovial leukocyte count >1100 for knees, > 3000 for hips PMN% >64% for knees, >80% for hips

Answer 110

1. The donor tendon must be expendable (minimal loss of function) 2. The strength of the donor tendon decreases by one grade following transfer (donor muscles must have 5/5 or 4/5 strength) 3. The tendon excursion of the donor must be sufficient to restore lost function of the recipient tendon - a. Difficult for a muscle to replace one with greater excursion - b. Excursion of muscles available to transfer: - i. Wrist extensors and flexors = 30mm (ECRL, ECRB, ECU, FCR, FCU) - ii. Digital extensors = 50mm (EDC, EIP, EDQ, EPL) - iii. Digital flexors = 70mm (FDS) 4. The direction of pull of the recipient tendon should be in line with the donor 5. A single transferred tendon should perform a single function 6. Transferred tendon should cross only one joint 7. Tendon transfers should not be placed through heavily scarred soft-tissue planes (limits excursion) - a. Allow scars to mature or pass through healthy tissue 8. The joints controlled by the transferred tendon should have near full passive ROM 9. Tendons with in-phase functions should be used preferentially