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Flashcards in The List Challenge Deck (306):
1

LIST THE THREE MOST COMMON PEDIATRIC AVULSION FRACTURES IN THE PELVIS/FEMUR

•    Sartorius from ASIS
•    Iliopsoas from LT
•    Hamstrings from ischium (only one that may cause symptoms after healing)

 

 

 

Skaggs - Staying out of trouble

2

METHODS TO MEASURE PATELLA HEIGHT

    Insall-Salvati         0.8-1.2
    Blackbourne-Peel Ratio     0.5-1.0
    Canton-Deschamps    0.6-1.3
    Plateau-Patella angle    20-30 degrees is normal
    Blumensaats line should intersect inferior pole of patella at      30 degrees of flexion

 

3

BONY BANKART - HOW ARE YOU GOING TO TREAT THE FOLLOWING LESIONS IN A 25 YR OLD (FOLLOWING THE BOORMAN DOGMA OF SOFT TISSUE FOR SOFT TISSUE AND BONE FOR BONE)?

•    Attempt at ORIF 
•    then I would do a Latarjet

 

4

DESCRIBE ANATOMICALLY HOW YOU WILL PLACE YOU TUNNELS FOR ACL RECONSTRUCTION

•    For a single bundle ACL recon, going from center of origin to center of insertion (anatomic)
•    Femoral: 
-    center of femoral ACL origin is 1.7mm proximal (posterior on scope) to bifurcate ridge and 6.1mm posterior to intercondylar ridge (inferior on scope)
-    to confirm this position, also ensure its ~8.5mm anterior to the posterior cartilage and between 11-8 o' clock 

•    Tibia:
-    center of tibial insertion is 7.5mm medial to anterior horn of lateral meniscus, 7.9mm lateral to medial plateau cartilage, and 13mm anterior to the retroeminence ridge
-    radiographically tunnel centered in AP direction at 41% from anterior and 47% from medial

5

What are 7 ways to optimize conditions in distraction Osteogenensis?

  • Low energy osteotomy
  • Minimal soft tissue stripping at corticotomy
  • Stable external fixation
  • Latency period 5-7 days
  • Distraction at 1 mm/day divided into 4
  • Neutral fixation interval - consolidation
  • Normal physiologic use of the extremity during the process

Miller's page 17

6

List 4 Risk Factors for Mortality after Hip Fracture

  • Advanced age
  • Male
  • Poor cognitive function
  • > 3 medical comorbidities (when not actively medically optimizing)
  • > 48 hrs until treatment

Miller's

7

WHAT ARE THE 17 MUSCLES ATTACHED TO THE SCAPULA?

Serratus Anterior

Supraspinatus

Subscapularis

Trapezius

Teres Major

Teres Minor

Triceps Brachii long head

Biceps Brachii

Rhomboid Major

Rhomboid Minor

Coracobrachialis

Omohyoid inferior belly

Lattisimus Dorsi

Deltoid

Levator Scapula

Infraspinatus

Pectoralis Minor

 

8

What is the. Safe zone for acetabular screw placement and what structures are at risk in each zone?

Postero superior (safe)

Sciatic nerve

superior gluteal vessels

 

posteroinferior

sciatic nerve

inferior gluteal  artery and nerve

internal pudendal nerve and vessel

use screw <20mm, then safe

 

antero-inferior (Unsafe - danger zone)

obturator nerve, artery and vein (artery most at risk)

 

anteo-superior (Unsafe - death zone)

external iliac vessels ( vein most at risk)

 

9

WHAT ARE 3 CRITERIA TO DIAGNOSE POST RADIATION SARCOMA?

-    The histological features of the original lesion and PRS are completely different.
-    PRS is located within the field of irradiation.

-    Patients with cancer syndromes such as Li-Fraumeni and Rothmund-Thomson are excluded.
-    The latent period (period between initiation of radiotherapy and histologic diagnosis of second neoplasm) is more than 5 years. 


Manny's notes

 

 

10

Regarding Patellar Clunk Syndrome

  • What type of TKR'S are affected?
  • What causes it?
  • In what degree of flexion does it occur?
  • What is the treatment?

  • PS
  • Fibrous tissue posterior to the quads above the superior pole of the patella catches in the box when the knee flexes/extends.
  • 30-45 degrees
  • arthroscopic or open debridement

11

LIST 6 SARCOMAS THAT METASTASIZE TO LYMPH NODES

SCREAM
•    Synovial cell
•    Clear Cell Sarcoma
•    Rhabdomyosarcoma
•    Epitheloid
•    Angiosarcoma
•    Myxoid liposacoma


From Mike's notes

12

MDI - HOW ARE YOU GOING TO TREAT THE FOLLOWING LESIONS IN A 25 YR OLD (FOLLOWING THE BOORMAN DOGMA OF SOFT TISSUE FOR SOFT TISSUE AND BONE FOR BONE)?

•    Non-op x 1 
•    then arthroscopic bankart repair using suture anchor construct

 

13

What 5 Factors can Contribute to Catastrophic Wear in TKA?

  • PE thickness (>=8mm is better)
  • Articular geometry (flatter = worse)
  • PE sterilization (oxygen environment = worse)
  • PE machining (compression molding = better)
  • Sagittal plane kinematics (sliding = worse)

14

COMPLICATIONS OF MENISCAL REPAIR

    Saphenous neuropathy (7%)
    Arthrofibrosis (6%)
    Effusion (2%)
    Peroneal neuropathy (1%)
    Infection (1%)

 

15

WHAT IS THE BEST LABORATORY TEST TO "RULE IN" INFECTION AND WHAT IS THE BEST TEST TO "RULE OUT" INFECTION?

•    Neutropenia (WBC < 5000) in a newborn is best to rule infection
•    CRP is best to rule out infection

 

16

LIST SIX SIGNS/SYMPTOMS OF HYPERCALCEMIA


•    Polyuria
•    Polydypsia
•    Renal stones/flank pain
•    Osteitis fibrous cystica
•    Altered CNS function (marty does not like points)
•    Anorexia
•    Nausea
•    Vomitting
•    Constipation
•    Weakness

 

17

LIST THREE BLOCKS TO REDUCTION OF A PEDIATRIC PROXIMAL HUMERUS FRACTURE


•    Periosteum
•    joint capsule
•    Long head of biceps tendon

 


Rockwood and Wilkins 7th ed p650

 

18

LIST 6 MINIMALLY INVASIVE TECHNIQUES TO REDUCE A PEDIATRIC RADIAL NECK FRACTURE

Closed reduction Techniques
o    Patterson’s Technique: traction with forearm in supination and apply a varus force and manipulate the fragment with a thumb.
o    Israeli technique:  Flex the arm to 90 degrees in supination and put a thumb on the radial head. Pronate the arm and push the RH back in. If the patient can achieve 60 pro and 60 sup, it is a success.
o    Esmarch Bandage (Chambers technique):  wrap the extremity tightly from distal to proximal.
Percutaneous Reductions
o    Perc pin:  Single perc Steinmann pin as close to the lateral border of the olecranon as possible.
o    Wallace Method: Periosteal elevator plated perc down the lateral border of the olecranon. Lever the distal fragment laterally and the proximal fragment medially with a thumb. Can hold the reduction if unstable with a perc K wire.
o    Metaizeau: Percutaneous bent intramedullary rod from radial styloid proximally. Hook the displaced radial head and rotate it into position.

 

19

List 10 Radiographic Findings with Achondroplasia

  • Foramen magnum stenosis
  • TI kyphosis
  • Lumbar stenosis
  • Short pedicles
  • Decreased intra-pedicular distance
  • Genu varum
  • Coxa vara
  • Champagne pelvis
  • Trident hands
  • Frontal bossing
  • Button nose
  • Normal intelligence
  • Hypotonia

20

  1. HOW LONG DO YOU BRACE POST PONSETTI TREATMENT?
  2. WHAT IS THE SUCCESS RATE WITH VIGILANT FOLLOW-UP AND BRACING?
  3. WHAT IS THE RECURRENCE RATE IF NOT VIGILANT?
  4. PIRANI SCORE?

  1. •    continuous for 3 mos, •    Then 14-16 hours per day until 3-4 yrs
  2. >    90 %
  3. 80%

  4. -    Midfoot
    o    Curved lateral border
    o    Lateral head of talus
    o    Medial crease
    -    Hindfoot

    o    Empty heel
    o    Posterior heel crease
    o    Rigid equinus

 

21

LIST 5 PREDICTORS OF HUMERAL HEAD ISCHEMIA FOLLOWING FRACTURE

•    Less than 8 mm metaphyseal extension attached to humeral head
•    Anatomic neck fracture
•    Medial hinge disruption > 2mm
•    4 pt fracture
•    More than 45 deg angular displacment of humeral head
    10 mm displacement of a tuberosity
•    Glenohumeral fracture dislocation
•    3 pt fracture
•    Head splitting fracture


Mo's book p361

 

22

List 4 Techniques to Dislocate the Hip in a THA Patient with Protrusio

  • Liberal capsular release
  • In-situ neck cut
  • Extended trochanteric osteotomy/gt osteotomy
  • Resect a small portion of the medial wall

 

 

ref: I think I got if from Campbell's

23

FACTORS ASSOCIATED WITH POSITIVE OUTCOMES WITH PHYSEAL BAR RESECTION

-    Younger presentation
-    Smaller the bridge
-    Smaller the deformity
-    Central bridge
-    Shorter the time interval between injury and surgery

 

Meningococcal septicemia do worse

 

24

WHAT ARE THE HONEY BADGERS 4 SOFT TISSUE MASSES THAT REQUIRE CHEMOTHERAPY

 

RSSD
-    Rhabdomyosarcoma
-    Synovial Cell Sarcoma
-    Soft tissue Osteosarcoma (MFH), Soft tissue Ewings
-    De-differentiated or Mesenchymal Chondrosarcoma

 

25

LIST 5 SIGNS OF IATROGENIC AVN IN DDH TREATMENT

Salter classification of AVN (5 signs)

•    Failure of appearance of ossific nucleus of femoral head during one yr or longer after reduction
•    Failure of growth of an existing ossific nucleus during one year or longer after reduction
•    Broadening of the femoral neck within one year after reduction
•    Increased radiographic bone density followed by fragmentation of the femoral head
•    Residual deformity of the femoral head and neck when reossification (resolution) is complete
o    These deformities include coxa plana, coxa magna, coxa vara, short broad femoral neck


•    Chief notes

26

WHAT ARE THE DIAGNOSTIC CRITERIA FOR FAT EMBOLISM SYNDROME?

Gurd and Wilson Criteria: Needs at least one major and 4 minor criteria
•    Major
  o    Petechiae in a vest distribution
  o    Hypoxemia with PaO2<60 mmhg and FiO2<0.4
  o    CNS depression disproportionate to hypoxemia
  o    Pulmonary edema
•    Minor
  o    Tachycardia (>110 bpm)
  o    Pyrexia (>38.5)
  o    Fat emboli visible in retina
  o    Fat in urine
  o    Fat in sputum
  o    Unexplained drop in HCT or PLT count
  o    Increasing ESR
Ref: Gurd and Wilson

27

POSTERIOR TIBIAL TENDON DYSFUNCTION CLASSIFICATION


-    Stage 1: 
o    able to perform straight toe raise 
o    tenosynovitis without deformity
o    No x-ray changes
-    Stage 2:
o    A: 
    unable to perform single leg heel rise. 
    Flexible Hindfoot
    <30% TN uncoverage on X-ray
o    B:
    unable to perform single leg heel rise. 
    Flexible Hindfoot
    Too many toes sign clinically
    >30% TN uncoverage 
-    Stage 3:
o    unable to perform single leg heel rise
o    Rigid hind and forefoot deformity
o    Degenerative changes subtalar joint
-    Stage 4:
o    3 + deltoid compromise (lateral tilt ankle)

 

28

LIST 5 INDICATIONS TO OPERATE ON A SCAPULA FRACTURE

•    Open fracture
•    25% glenoid involvement with humeral instability
•    5 mm glenoid articular surface step-off or major gap
•    Extensive medialization of glenoid
•    Displaced scapular neck fracture > 40 deg of angulation or 1 cm translation
•    Glenopolar angle <20
•    Coracoid displace > 1cm7

(Chart here I could not copy)

GPA = Angle measured between a line connecting the most cranial with the most caudal point of the glenoid cavity (white line)and a line connecting the most cranial point of the glenoid cavity with the most caudal point of the scapular body (black line).
The GPA measures the obliquity of the glenoid articular surface in relation to the scapular body.
Normal is 30° to 45°

 

 

 

29

Name 3 Indications for Revision for Metal on Metal Hips (COA 2011)

  • Painful hips with MRI showing a soft tissue mass and high blood cobalt (>7ppb)
  • Painful hips with +MRI and normal Cobalt levels
  • Soft tissue mass increasing in size with or without high blood levels

 

Rising levels on their own are an indication for follow-up, not revision.

Jer's notes ...(and COA update)

 

30

REVERSE BANKART IN POSTERIOR INSTABILITY - HOW ARE YOU GOING TO TREAT THE FOLLOWING LESIONS IN A 25 YR OLD (FOLLOWING THE BOORMAN DOGMA OF SOFT TISSUE FOR SOFT TISSUE AND BONE FOR BONE)?

•    reverse Bankart repair

31

SIX FEATURES OF CRPS


o    Hyperaesthesia, hyperalgesia, allodynia
o    Temperature difference compared to contralateral
o    Skin colour change
o    Edema
o    Sweating change
o    Stiff joints, weakness, tremor, dystonia, trophic changes (nail, hair skin)
o    Osteopenia

Manny's Lists

32

SPINE 
NAME A PHYSICAL EXAM METHOD TO DISTINGISH C8 RADICULOPATHY FROM ULNAR NERVE PALSY?

 

•    FDS to 2nd digit - C8 provides power grip and will so FDS to index will be weak but this is not affected because it is innervated by the medial nerve.

33

CAVUS (CMT - WEAK PB AND STRONG PL AND WEAK TA AND STRONG PL)
WHAT ARE NON-OP STRATEGIES?

 

•    Extra-depth shoes (gets forces spread across whole foot vs over heel and MT heads), lateral posting orthotic, achilles stretching

34

List 12 Biological or Mechanical Factors Influencing Fracture Healing

  • Patient age
  • Comorbid medical conditions
  • Functional level
  • Nutritional status
  • Nerve function
  • Vascular injury
  • Hormones
  • Growth factors
  • Health of soft tissue envelope
  • Sterility (open fractures)
  • Cigarette smoking
  • Local pathologic condition
  • Level of energy imparted
  • Type of bone loss
  • Extent of bone loss
  • Soft tissue attachments to bone
  • Stability of immobilization
  • Anatomic location
  • Blood supply

Table 1-6 p 15 Miller's

35

HOW CAN YOU DIFFERENTIATE CLINICALLY PSEUDOPARALYSIS (FRACTURE AND INFECTION) FROM PARALYSIS (BRACHIAL PLEXUS)?

 

•    Palpation or Moro reflex
o    stimulating the limb in some way should lead to some movement if pseudoparalysis

 

36

WHY ARE KIDS PRONE TO TIBIA VALGUS IN PROX TIB METAPHYSEAL # ? (IE WHAT ARE THE PROPOSED THEORIES)


•    Physeal arrest of the lateral prox tib physis/ assymmetric activity of the physis
•    Early weight bearing
•    Tethering effect of the fibula
•    Inadequate reduction/ interposed soft tissue
•    Loss of tethering effect of the pes anserinus
•    ? increased vascularity (no mention in LW or chief notes…)

Chief review notes

 

 

 

 

37

NAME 8 POSITIVE PREDICTORS FOR GOOD SURGICAL OUTCOME OF CALCANEUS FRACTURES

(Buckley – 2002)
-    Women (higher SF-36)
-    Non worker’s compensation patient
-    Men Age <30
-    Bohler’s angle > 0-15
-    Light work labourers
-    Single fracture line
(Buckley – 1992)
-    Non Smokers
-    Anatomic reduction or <2mm step

-    Comminuted fractureOperative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial JBJS 2002

-    Poor Outcomes (10-20% Wound Complications)
     o    Age > 50
     o    Obese
     o    Manual Labor
     o    Workers Comp
     o    Smoking
     o    Bilateral
     o    Polytrauma
     o    DM, PVD
     o    Men

 

38

WHEN WOULD YOU USE TRANSILIAC TRANS SACRAL SCREWS

•    Transiliac-transsacral screws may be particularly useful         in the presence of 
-    Osteoporosis
-    Significant posterior pelvic instability including                        spinopelvic dissociation
-    Patient obesity
-    Anticipated noncompliant behavior
-    Bilateral posterior pelvic injuries
-    Nonunion procedures.

•    Transiliac-transsacral screws for posterior pelvic stabilization; J Orthop Trauma. 2011 Jun;25(6):378-84.

39

WHAT SARCOMA’S NEED WIDE EXCISION ONLY (NO RAD/CHEMO) (3)

-    Chondrosarcoma
-    Adamantinoma
-    Parosteal Osteosarcoma
-    Low grade intrameduallary osteosarcoma

 

AAOS 2010

 

40

LIST 5 "MALIGNANT" TUMORS THAT CAN BE TREATED WITH SURGERY ALONE

•    Chondrosarc
•    Parosteal osteosarc
•    Chordoma
•    adamantinoma
•    squamous cell (if no mets)
•    LOW GRADE intramedullary osteosarc

 

41

HOW MANY PATIENTS WITH ACL RECONSTRUCTION GO ON TO DEVELOP OA

    16-70%

42

WHAT ARE 5 COMPLICATIONS OF A HALO?

Complications: 
o    pin loosening is the most common. 
•    A loose pin with no infection can be tightened 1-2 turns. 
o    Pin site infection is in 20%. 
    Deep infection=pin removal and new site, big scars at anterior pins (10%), 
o    Supraorbital nerve injury (V1 branch of trigeminal)
o    skin breakdown
    scapulae and sternum are most common
o   intracranial penetration (1%), 

o    dysphagia is from too much extension. 
o    Respiratory distress
o    Six pins do NOT have more complications than 4 (Nemeth et al., 2001 JBJS)

    intracranial penetration (1%), 

 

 

43

LIST THE AGE APPROPRIATE MANAGEMENT OF A FEMUR FRACTURE IN A: 4 MOS OLD, 4 YR OLD, 8 YR OLD, 13 YR OLD (IMMATURE), 17 YR OLD (MATURE)

•    4 mos old proximal femur #__________________
•    4 yr old midshaft spiral____________________
•    8 yr old midshaft comminuted____________________
•    13 yr old distal diaphyseal comminuted___________________
•    17 yr old midshaft horizontal___________________

 

My thoughts...obviously other options
•    Pavlik
•    Hip spica
•    Flexible nails 
•    Lateral submuscular plate
•    Antegrade nail (piriformis or GT start)

 

 

44

WHAT POTENTIALLY LETHAL ABNORMALITY MUST YOU BE LOOKING FOR IN A PATIENT WITH LARSEN SYNDROME?

•    Cervical Kyphosis

45

LIST 3 FEATURES OF POEMs (Osteosclerotic myeloma)

 

-    Polyneuropathy
-    Organomegaly
-    Endocrinopathy
-    M proteins
-    Skin changes

 

46

LIST 3 OPERATIVE INTERVENTIONS FOR DEVELOPMENTAL COXA VARA


•    Proximal femoral valgus osteotomy
•    Greater trochanter epiphyseodesis (Age 5 is when apophysis is visible)
•    Greater trochanter transfer (When 9 yrs or older)

 


Chief review notes

 

47

LIST 5 CONDITIONS ON DIFFERENTIAL DIAGNOSIS IN A < 4 YR OLD, 4-10 YR OLD AND > 10 YR OLD WITH A LIMP

 

< 4 yrs (not in order of frequency)


-    Toddlers fracture (tibia or foot)
-    Osteomyelitis, septic arthritis or discitis
-    Arthritis (JRA or Lyme disease)
-    Discoid meniscus
-    Foreign body in foot
-    Benign or malignant tumor

 

48

LIST 4 CONDITIONS ASSOCIATED WITH ATLANTOAXIAL INSTABILITY


-    Down syndrome (odontoid hypoplasia)
-    JRA
-    Os odontoideum 
o    (Ossiculum terminale – NOT ASSOCIATED WITH INSTABILITY)
-    Pseudochondroplasia
-    Diastrophic dysplasia
-    SED congenita (odontoid hypoplasia)
-    Metaphyseal dysplasia: McKusick’s
-    Morquio’s (odontoid hypoplasia)

 

49

INDICATIONS FOR MENISCAL TRANSPLANT

    Young patients with near total meniscectomy
    Lateral > Medial
    Proper mechanical alignment
    < Grade 4 chondrosis
    Intact ACL

 

50

 WHAT THREE SOFT TISSUE FLAPS WILL I KNOW FOR MY EXAM TO DEAL WITH SOFT TISSUE COVERAGE IN THE PROXIMAL / MIDDLE / DISTAL LEG?

-    Proximal - medial gastrocnemius flap
-    Middle - soleus flap
-    Distal - reverse sural artery flap

 

51

WHAT ARE 2 RADIOGRAPHIC SIGNS OF A POSTERIOR SHOULDER DISLOCATION?

•    Lightbulb sign
•    Anterior rim sign
•    Trough sign

 

52

LIST 3 FEATURES OF Maffucci's syndrome  

 

o    Multiple exostoses
o    Tissue angiomas
o    100% malignant transformation

 

-    Multiple enchondromas
-    Hemangiomas
-    100% chance of malignant transformation of enchondroma

 

53

LIST THREE WAYS TO DETERMINE SKELETAL AGE

•    Gruelich and Pyle
•    Sauvegrain method
•    Risser

 


ref: LW

 

54

OSCE - WHAT IS YOUR MANAGEMENT OF A POSTEROLATERAL SIMPLE ELBOW DISLOCATION (1)

 

IN A 25 YR OLD WRESTLER, POST REDUCTION CONGRUENT, STABLE ARC FROM 5-145 DEG

•    Splint backslab for < 7 days to let soft tissue settle
•    X-ray out of splint to verify reduction
•    Clinically assess stability
•    No brace so begin gentle active rom
•    see back in 2 weeks
•    When would he return to sport?
   o    Full pain free ROM
   o    Equal strength to opposite side

 

55

List 5 Indications for a Medial Approach to the Hip

  • Open reduction of congenital dislocation (good access to psoas)
  • Obturator neurectomy
  • Psoas release
  • Biopsy

 

Hoppenfeld p455

56

NAME 3 CONDITIONS ASSOCIATED WITH TARSAL COALITION?


•    Fibular deficiency
•    PFFD
•    Aperts syndrome

 


AAOS

 

57

WHAT ARE 2 MOST RELIABLE SIGN OF HAND COMPARTMENT SYNDROME?

•    Swollen
•    Intrinsic minus position

 

58

NAME 5 WAYS TO REDUCE IO PRESSURE WHILE REAMING LONG BONES

•    (Continuously) high revolution speeds
•    Low insertion (driving) speed
•    Thinner diameter shaft
•    Sharp reamers
•    Deeper flutes
•    Hollow reamer head
•    Increased increments by 0.5mm
•    Venting?

A Comparison Of Pressures Created By Various Commonly Used Intramedullary Reamers

59

Knee Osteotomy Outcomes

  • HTO - 85% 10 years
  • DFO - 50% 10 years

60

NAME 6 INDICATIONS FOR BISPHOSHONATES?

•    Pagets
•    Osteoporosis
•    Metastatic bone disease
•    Polyostotic fibrous dysplasia
•    OI
•    AVN
•    HO
•    MM
•    Hypercalcemia

61

LIST THE ACCEPTABLE CRITERIA FOR FLEXIBLE NAILING IN PEDIATRICS TRAUMA

•    Age: 5-11
•    Weight: = 50 kg
•    Fracture in the mid 80% of the diaphysis 

 


RW 7th ed. p811

 

62

Name 3 Advantages of Lateral Parapatellar Approach (Valgus Knee)

 

  • Less violation of medial based blood supply
  • Easier access to posterolateral corner for release
  • Better patellar tracking
  • Lateral releases performed during exposure
  • Better exposure to affected condyle/plateau

63

List 4 Ways to Judge the TF Joint Line in a Revision Knee

  • Joint line is 1-1.5 cm above the fibular head
  • Joint line is at meniscal scar/remnant
  • Joint line is 1 cm distal to the inferior pole of the patella
  • Joint line is 2.5 cm distal to the medial epicondyle

64

LIST 5 INDICATIONS FOR ARTHRODESIS IN A HALLUX VALGUS


•    DJD
•    RA
•    Gout
•    Down's
•    CP
•    Connective tissue disorder (Ehler's, Marfans)
Manny's notes and OKU FNA

 

65

LIST VARIABLES THAT DETERMINE PLATE STIFFNESS

    Plate material
    Offset from bone
    Working length
    Plate length
    Number of screws
    Locked or non-locked screws

 

66

LIST 5 COMPLICATIONS ASSOCIATED WITH ACDF

-    Psuedoarthrosis (5-10% single level, 30% multiple levels)
-    Laryngeal nerve injury ( 1% theoretically higher on right side)  
-    Hypoglossal nerve injury
-    Vertebral artery injury
-    Dysphagia
-    Horner's syndrome
-    Adjacent segment disease
-    Hematoma

-    Airway compromise
-    Spina cord injury
-    Dural tear
-    Esophageal injury
-    Nerve root injury (C5 most susceptible)
-    infection
-    Graft dislodgement
-    Incomplete decompression
Orthobullets and chief notes

 

 

67

WHICH MENISCAL REPAIR MODALITY HAS SHOWN BETTER RESULTS, INSIDE-OUT, OUTSIDE-IN OR ALL-INSIDE?

    They are all equivocal in the literature

68

WHICH GRAFT OPTION HAS BEEN SHOWN TO HAVE BETTER RESULTS - HAMSTRING AUTO, ALLO OR BTB?

    All equivocal, each with their own pros and cons

69

List 5 Risk Factors for Patella Malalignment

  • Genu valgum
  • Femoral anteversion
  • Pronated feet
  • Female
  • Ehlers Danlos
  • Marfans
  • Trochlea dysplasia
  • Patella Alta
  • Lateral femoral condyle dysplasia
  • Lateral patella tilt

70

WHAT ARE THE EFFECTS OF WEIGHT TRAINING ON MUSCLE

    Increased surface area
    Increased mitochondria
    Increased capillary density
    Increased strength
    Thicker connective tissue

 

71

LIST 4 COMPONENTS OF MEDICAL NEGLIGENCE

-    Duty
o    The duty of the physician is to provide care equal to the same standard of care ordinarily executed by surgeons in the same medical specialty.
-    Causation
o    Causation is present when it is demonstrated that failure to meet the standard of care was the direct cause of the patient’s injuries.
-    Breach of duty
o    Breach of duty occurs when action or failure to act deviates from the standard of care.
-    Damages
o    Damages are monies awarded as compensation for injuries sustained as the result of medical negligence
Orthobullets
DCB’D

 

72

FACTORS PREDISPOSING GIRLS TO ACL TEAR

    Quads dominant (NM control)
    Landing biomechanics (valgus moment)
    Smaller notch
    Genetics (? Collagen production)
    Smaller ligament
    Estrogen
    Valgus alignment

 

73

What are the Requirements for Optimal Bone Ingrowth of an Uncemented Prosthesis?  Name 8

  • Rigid fixation
  • Normal bone metabolism
  • Optimal porosity (40-50%)
  • Minimal gaps (<50um)
  • Optimal pore depth (deeper the better)
  • Optimal pore size (50-150um)
  • Minimal micromotion (<50um)
  • Good cortical contact

 

***rule of 50's for everything*** (Millers)

74

CLASSIFY DISCOID MENISCUS

-    Watanabe classification
        o    Type 1        Complete
        o    Type 2        Incomplete
        o    Type 3        Wrisberg variant (lack of posterior                                                  attachment)

 

75

INDICATIONS OF ADEQUATE RESUSITATION

-    Normal serum lactate
-    Normal base deficit
-    Normal gastric pH (7.4)

-    Note: can have normal BP, U/O and HR and still be in ‘compenstated’ shock. Thus, look for the biochemical markers of peripheral blood flow

76

NAME THE 3 TOP REASONS FOR IN-TOEING

•    increased femoral anteversion
•    tibial tosion
•    metatarsus adductus

 

77

Describe 4 MSK and 4 Non MSK Features Down's

Orthopaedic

  • Generalized ligamentous laxity and hypotonia
  • C1-2 instability (22%)
  • Hip subluxation and dislocation (late)
  • Patellofemoral instability and dislocation
  • Scoliosis (50%) and spondylolisthesis (6%)
  • Pes planovalgus
  • Metatarsus primus varus
  • SCFE
  • Short stature (walk at 2-3)
  • Clinodactyly, polyarticular arthropathy (10%)

Medical

  • Mental retardation
  • Heart disease (50%)
  • Endocrine disorders (hypothyroidism)
  • Premature aging

Orthobullets - Also

  • HEENT:    - Flat occiput, microcephaly, upslanting palpebral fissure, epicanthal folds, speckled iris (Brushfield spost), hearing loss
  • CNS: hypotonia, mental retardation
  • CVS: congenital cardiac defects (50%) ie: AVSD, endocardial cushion
  • GI: duodenal/esophageal/anal atresia, TE fistula
  • GU: cryptorchidism
  • Derm: single palmar crease (Simian crease)
  • Endo: hypothryoid, DM (later in life)
  • Other: leukemia/lymphoma (later in life), Alzheimer's (later in life)

78

OSCE SHOULDER INSTABILITY - OTHER THAN WITH INSTABILITY, HOW DO THESE PATIENT OFTEN PRESENT?

•    highly variable
•    May have RC tendinitis and impingement in < 20 yr old

 

79

RISKS FOR PATELLA AND QUADS RUPTURE

    Intrarticular steroids
    Hyperparathyroidism
    Renal failure
    Diabetes
    Chronic tendonosis
    RA
    Systemic steroids
    Connective tissue disease

 

80

LIST 4 NORMAL PEDIATRIC CERVICAL SPINE FINDINGS THAT MAY BE MISINTERPRETED AS TRAUMATIC PATHOLOGY

•    Soft tissue swelling anterior to C1-2 (crying makes this soft tissue shadow larger)
•    C2-3 pseudosubluxation
•    cervical body wedging
•    lack of cervical lordosis

 

ref: Rang's. 

 

81

Stress Dose Steroids

  • Not needed for < 5mg/d
  • Not needed for < 3 wks duration
  • Do need if stopped long term within 3 months

82

Risk Factors for Patellar Fracture Following TKA

  • Devascularized patella following lateral retinacular release
  • Use of a patellar component with a single central peg
  • Use of bone cement (thermal necrosis)
  • High patellar strain due to component malalignment
  • Increased thickness of PF articulation (thick patella, oversized femur, anterior translation of femur)
  • O'Neill did the knee
  • To much resection
  • To little resection (stuffing)
  • Femoral component to large (stuffing)
  • Flexion of femoral component (stuffing)
  • Asymmetric resection (common from lateral aspect)
  • Central drill hole in contrast to peripheral holes
  • Operative disruption of patellar blood flow (lateral release disruption lateral superior geniculate artery)

83

WHAT ARE 4 COMPLICATIONS OF HIP SPICA CASTS

•    Skin erosions
•    Compartment syndrome
•    Ileus (SMA)
•    Malunion
•    Shortening >2cm
•    Nerve pressure injury

 

84

WHAT IS THE MORTALITY OF HALOS IN PATIENTS 79 YEARS AND OLDER?

•    21%

85

Name 5 Risk Factors Supported by Evidence for Total Joint Infections (Hip or Knee or Both)

  • Superficial sugical site infection (hip + knee)
  • Extended operative time > 2.5 hrs (hip + knee)
  • Prior infection of joint (knee)
  • Immunosuppression (knee)
  • Obesity (hip)

 

AAOS Consensus Guidelines 2010

86

POSITIVE PROGNOSIS IN NERVE REPAIR 

-    Early repair
-    More distal (lower)
-    Shorter length of repair
-    Pre and post op rehab

 

87

HOW LONG SHOULD YOU IMMOBILIZE A PATELLA DISLOCATION PATIENT IN EXTENSION


•    6 weeks in extension (early mobility is not good)
•    patient has 20 % recurrence risk 1st time dislocater
•    2nd time 50% recurrence risk

 

88

LIST 6 FACTORS WHICH PREDISPOSE TO TENDON ADHESIONS POST FLEXOR TENDON REPAIR

 

•    Repair within zone II
•    crush injuries
•    Surgical manipulation
•    associated fractures
•    infection
•    revision
•    older age
AAOS COR

 

89

ACL TUNNEL MALALIGNMENT

-    Femoral tunnel
          o    Too anterior
                           Tight in flexion

                           Loose in extension

           o    Too posterior
                           Loose in flexion
                           Tight in extension
           o    Vertical tunnel
                           Residual pivot (rotational instability)

-    Tibial tunnel
           o    Too anterior
                          Tight in flexion
                          Impinge in extension
           o    Too posterior
                          Impinges on PCL

 

 

 

90

List 5 Causes for Patellar Dysfunction Post Total Knee Arthroplasty

Think peds causes of instability

  • Tight lateral retinaculum
  • Weakness or dehis of VMO
  • Increased Q angle
  • Excessive tibial or femoral valgus or medialization
  • Excessive IR of the femoral or tibial component
    • leads to relative ER of the actual tibia/femur
  • Anterior component placement
  • Lateralization of patella component (when resurfaced)

91

LIST 5 THINGS THAT ALLOGRAFT BONE IS TESTED FOR


•    HIV
•    HCV
•    HBV
•    CMV
•    HTLV-1
•    Syphilis

 

92

PROPERTIES OF AN IDEAL FRACTURE CLASSIFICATION SYSTEM - NAME 6

-    Descriptive
-    Easy to interpret and easy to remember
-    Good intra- and inter- observer reliability
-    Dictate injury severity
-    Dictate treatment strategies
-    Predict prognosis or potential complications

 

93

WHAT IS INDICATION FOR C-CLAMP

-    APC 3 and vertically unstable PELVIS that:
-    Binder placed and skeletal traction in, and still unstable.

 

94

HOW DO YOU MANAGE DYSPHAGIA?

-    roast beef sandwich

95

LIST 3 FEATURES OF McCune Albright

 

o    Café-au-lait
o    Fibrous dysplasia
o    Precocious puberty

 

-    Precocious puberty
-    cafe au lait
-    Polyostotic fibrous dysplasia
-    Short stature
-    Female > Male

 

96

INDICATIONS FOR MENISCAL REPAIR

    Peripheral tear
o    SIZE OF RIM IS BEST PREDICTOR OF HEALING
    Vertical/Longitudinal
    1-4 cm in length
    Combined with ACL reconstruction
o    Best results!

 

97

WHAT IS THE MOST COMMON FORM OF OSTEOARTHRITS OF THE FOOT/ANKLE?


•    Hallux Rigidus; 1/40 adults have this. 
Ref: OKU

 

98

LIST 5 RISK FACTORS FOR A FRAGILITY FRACTURE:

•    Previous fragility fracture
•    Female
•    Caucasian or asian
•    Smoker
•    Etoh abuse
•    RA
•    Dementia
•    Anticonvulsant use
•    Menaupause < 45 yrs
•    Sedentary (no physical activity)
•    Low bone mineral density
•    Low calcium intake
•    Oral glucocorticoids
•    recurrent falling

 

99

LIST THREE RADIOGRAPHIC CHARACTERISTICS OF A STRUCTURAL CURVE

According to JR Cobb 1960 JBJS (attached):
•    Abnormal vertebral angulation
•    Abnormal vertebral rotation
•    Abnormal vertebral position
•    Abnormal vertebral wedging

According to Lenke
•    Curve segment with the largest cobb angle (The major curve is always structural)
Minor curves that meet the following criteria
•    Proximal Thoracic curve pattern must have:
o    Minimal residual coronal curve on bending film of at least 25
o    Kyphosis between T2 and T5 of at least 20.
•    Main Thoracic curve pattern must have
o    Main residual coronal curve of at least 25
o    Kyphosis between T10 and L2 of at least 20.
•    Thoracolumbar/Lumbar curve pattern must have
O    Minimum residual curve of at least 25
O    Kyphosis between T10 and L2 of at least 20

100

TREATMENT OPTIONS FOR CONVERGENCE IN A FAILED DARRACH OR SAUVE-KAPANDJI

-    ECU longitudinal tenodesis
-    PQ transfer
-    Radial ulnar resection
-    Creation of one bone forearm
-    Spherical ulnar head prosthesis (only if SK)

 

101

What are 4 Design Features of a High Flexion Knee Compared to a Standard TKA

  • The posterior lip of the posterior femoral condyle is more rounded (requires more host bone resection)
  • Decreased congruence of the posterior portion of the poly tibial tray
  • Recession of the poly anteriorly (allows for the patellar tendon with deep flexion)
  • Increased post height (may minimize jumping the post with deep flexion)

 

Ref: Bhandari's 2012 book; nice pictures there.

102

LIST 5 PRE-CLAVICULAR NERVES

•    Phrenic
•    Dorsal scapular
•    Suprascapular
•    Nerve to subclavius
•    Long thoracic

 

103

Name 5 Non-inflammatory Arthropathies

  • OA
  • Charcot
  • Ochronosis (alkaptonuria)
  • Acute rheumatic fever
  • Secondary pulmonary hypertrophic osteoarthropathy  (secondary to factors secreted by a large tumor)

Miller's - page 45

104

5 SIGNS OF VERTIBROBASILAR INSUFFICIENCY?

•    Cant see, cant speak, cant walk the talk!
•    VERTEBROBASILAR INSUFFICIENCY
o    Nystagmus
o    Diploplia
o    Loss of vision in one or both eyes
o    Vertigo
o    Dizzyness
o    Dysarthria/Dysphagia
o    Sudden drop attack

 

105

DDX OF A DIAPHYSEAL LESION

A E I O U and sometimes Y
-    A - Adamantinoma
-    E - EG
-    I – Infection
-    O - Osteoid osteoma / Osteoblastoma
-    U - UUUUUEwings
-    Y - ...and some times Y:  LYmphoma
 

 

106

COMPARED TO LATERAL FEMORAL PINS, ANTERIOR FEMUR EX FIX PINS ARE WORSE BECAUSE

-    Endangers femoral nerve branches
-    Endangers femoral artery branches
-    More risk of inadvertent knee joint penetration
-    More risk of quads HO
-    Frame is bio-mechanically weaker when hooked up to anteromedial tibial pins

 

107

ASIA CLASSIFICATION

-    ASIA A: Complete. No motor or sensory
-    ASIA B: Incomplete. No motor function but some remaining sensory
-    ASIA C: Incomplete. 50% or more of muscles below injury are less than Grade 3.
-    ASIA D: Incomplete. 50% or more of muscles below injury are greater than or equal to than Grade 3.
-    ASIA E: Normal

 

108

Differentiating radiculopathy vs peripheral nerve compression:

o    With nerve root compression, the sensory NCSs are normal. This occurs because the sensory cell body, the dorsal root ganglion, is distal to the site of nerve compression

 

 

Carpal Tunnel Syndrome:

 

o    there is no conclusive evidence that one single electrical conduction study has the highest sensitivity or specificity. However, median sensory latencies across the wrist compared to ulnar or radial latencies or proximal median conduction improved sensitivity as opposed to absolute median sensory or motor distal latencies

Latency is a measure of the time required for conduction of the nerve impulse from the point of stimulation to the point of recording

Rugger Jersey Spine: 

Sclerotic bands along superior and inferior thoracic and lumbar vertebral body endplates give a striped appearance to vertebral bodies - alternating parallel sclerotic and lucent bands are analogous to stripes on an English rugby sweater

109

INDICATIONS FOR MRI IN ADOLECENT SCOLIOSIS

-    Left Thoracic Curve
-    Abnormal Reflexes
-    Rapid Curve Progression
-    Neurologic findings
-    Excessive kyphosis
-    Foot findings

 

110

FOOT AND ANKLE
CAVUS (CMT - WEAK PB AND STRONG PL AND WEAK TA AND STRONG PL)

 

HOW DO YOU DECIDE WHEN TO STOP IMMOBILIZING A CHARCOT FOOT?


•    In addition to the standard non-progression on X-ray stuff, this is kind of cool; 
o    as soon as there is no difference in skin temperature side to side

 

111

HAD DO YOU MANAGE A RECURRENT LARYNGEAL NERVE INJURY?

-    Observation 6 mos
-    Refer to ENT for scope 

 

112

OSCE SHOULDER INSTABILITY - REGARDLESS OF AGE AND ACTIVITY OF PATIENT, WHEN PLANNING YOUR TREATMENT, WHAT ARE THE THREE MOST IMPORTANT VARIABLES TO CONSIDER?

•    Diagnosis: MDI vs. unidirectional

•    Soft tissue lesions present
•    Bone lesions present

 

113

WHAT ARE 3 CAUSES FOR FAILURE OF SLIDING HIP SCREW FOR REVERSE OBLIQUE FRACTURE

 

-    Lag/sliding screw not perpendicular to fracture (forces parallel to screw)

-    Lack of medial buttress
-    Acts as load bearing device leading to lateralization of proximal and medialization of distal segment

Reverse Obliquity Fractures of the Intertrochanteric Region of the Femur - JBJS 2001

114

LIST 6 FACTORS THAT INCREASE THE CONSTRUCT OF YOUR EXTERNAL FIXATOR

-    Fracture site apposition (most important)
-    Large diameter pins (second most important)
-    Additional pins
-    Rods in different planes
-    Pins in different planes 
-    Decrease bone rod interface distance 

-    Increased mass (size) or double stack rods
-    Increased spacing between pins (near far)

 

 

115

LIST 5 CAUSES OF HALLUX VARUS

•    This is a result iatrogenic complication of Hallux Valgus surgery:
o    Too much medial eminence resection
o    Excision of fibular sesamoid during distal soft tissue procedure
o    Over aggressive medial capsularplication
o    Overcorrection with post-op bunion dressing
o    Malalignment at osteotomy site

 

116

KNEE OCD

    < 2cm, contained     Microfracture 
    > 2cm,             OATS
    > 2cm            Osteochondral allograft, ACI

 

117

LIST ASSOCIATED INJURIES ASSOCIATED WITH SCAPULA FRACTURE

    Rib Fractures (50%)
    Pulmonary injuries (40%)
    Spine Fracture (30%)
    Ipsilateral clavicle (25%)
    Vascular Injury

    Plexus injury

 

118

ACCESSORY IMAGING OF THE SHOULDER

-    Zanca View        40 degrees cephalad        AC pathology
-    Strkyer Notch View                    Hill Sachs
-    AP IR View                        Hill Sachs
-    West Point View                    Bony Bankart
-    Axillary View                        Posterior glenoid

 

119

LIST THREE TREATMENT OPTIONS FOR AVN OF HUMERAL HEAD

•    Non-op
•    Core decompression (Cruess I,II,III)
•    Hemiarthroplasty (Cruess IV)
•    TSA (Cruess V)


ref Mo's book p351 onward

120

Name Features of 3rd Generation Cementing

3rd generation

  • vacuum-mixing to reduce cement porosity
  • cement pressurization
  • femoral canal preparation
  • pulsatile lavage

 

1st generation

  • hand-mixed cement
  • finger packed cement
  • no canal preparation or cement restrictor

2nd generation

  • cement restrictor placement
  • cement gun
  • femoral canal preparation
  • brush and dry

 

 

 

P's

  • Porosity reduction (vacuum - don't use in masquelet)
  • Pressurization cement
  • Pre-coat stem
  • Rough finish stem
  • Stem centralizer

2nd

  • Cement gun
  • Pulsatile lavage
  • Canal prep
  • Cement restrictor

Millers

 

121

List 6 causes of FAI

  • Retroverted acetabulum
  • Sequelae of SCFE
  • Acetabular protrusio
  • Decreased native femoral head to neck ratio
  • Decreased native femoral neck offset
  • Overhang of anterosuperior acetabulum
  • Post-traumatic retroversion of femoral neck (post ORIF)
  • Non-spherical native femoral head

 

Miller's p267

122

LIST 5 FACTORS FOR OSTEOSARCOMA THAT YIELD A POOR PROGNOSIS

-    Older age at presentation
-    Large tumor volume
-    Elevated ALP
-    Poor histological response to chemo
   o    Good responders = >90% necrosis (80% survival)
   o    Poor responders = <90% necrosis (40-50% survival)
-    Presence of metastasis on presentation
   o    10% of the time
-    Skip lesions
-    Local recurrence


Manny's notes

 

123

LIST 3 COMMON REASONS FOR SUCCESSFUL PROSECUTION OF PHYSICIANS - …MMM (MO VOICE)

-    Miscommunication / Poor communication
-    Improper treatment
-    Failure to diagnose (missed diagnosed)
-    Failure to treat
-    Delay in response to patient / family
The Monument files pg 222
MIFF’D

 

124

PATIENT HAS EARLY POST-OP INFECTION, TREATED WITH I&D (TO YOUR SATISFACTION) AND HARDWARE RETENTION.                              

WHAT ARE 2 PREDICTORS TO FAILURE?

 

•    Open Fracture
•    IM nail present

 


THE JOURNAL OF BONE AND JOINT SURGERY (AMERICAN). 2010;92:823-828. Maintenance of Hardware After Early Postoperative Infection Following Fracture Internal Fixation

 

125

HOW DO YOU PUT ON A HALO?

•    position the patient flat in the supine position. Stabilize the head and neck. Trial fit the halo ring (it should not be > 1cm away from the skin and not contact the ears at any point. Pins should engage the bone at 90 degrees. Put pins in (close eyes) and tighten in a diagonal fashion. Tighten to 8 in-lb in adults (2 in kids). Secure the lock nut and recheck in 24 hours and 1 wk. Can place vest before or after the ring application. The inferior border of the vest is at the xiphoid. Connect the vest to the ring with the vertical bars. Adjust the bars to get the desired position. 

•    Pin position.  1 cm proximal to the brow in the lateral 1/3 of the brow. The posterior pins are above the pinna (make sure they are below the equator which comes up fast. A good number is 5-10 mm above the pinna). Prep sites and freeze the area. The patient should close their eyes (avoids entrapment of the orbicularis oculi)

126

LIST THE THREE CONDITIONS IN THE FEMALE ATHLETE TRIAD

•    Amenorrhea
•    Eating disorder
•    Stress fracture / osteopenia


Millers p294

127

WHAT IS THE INDICATION FOR AN ACHILLES TENOTOMY?

 

HOW COMMONLY IS THIS REQUIRED? 

•    DF < 10 after casting

 

 

•    85-90%

128

BANKART LESION  - HOW ARE YOU GOING TO TREAT THE FOLLOWING LESIONS IN A 25 YR OLD (FOLLOWING THE BOORMAN DOGMA OF SOFT TISSUE FOR SOFT TISSUE AND BONE FOR BONE)?

•    Non-op x 1 
•    then arthroscopic bankart repair using suture anchor construct

 

129

LIST 4 STRUCTURES PASSING THROUGH THE LESSER SCIATIC FORAMEN

 

•    Tendon to obturator internus
•    Nerve to obturator internus
•    Pudendal nerve
•    Internal pudendal artery

 

130

DESCRIBE THE SEQUENCE OF CORRECTIONS FOR CLUBFOOT


•    Cavus
    1st cast you DF the first ray (which is in PF) to align it with the talus and then increase supination to bring the first metatarsal in line the other tarsals (i.e. align the forefoot with the hindfoot)
•    Abduction
    then abduct the forefoot by maintaining counter-pressure on the talus
•    Varus
    No distinct step this will correct with steps 1 and 2
•    Equinus
     After 1,2,3 are complete DF of the hind foot is performed

 

131

WHAT ARE 4 RADIOGRAPHIC SIGNS AT 3 MONTHS THAT PREDICT THE NEED FOR FEMORAL NECK NONUNION/REVISION?

•    Change in fracture position by 10 mm
•    Change in screw position by 5%
•    Backing out of the screws by 20 mm
•    Perforation of the femoral head


Acta Orthop Scand. 1999 Apr;70(2):141-4: Internally fixed femoral neck fractures. Early prediction of failure in 203 elderly patients with displaced fractures.  Alho A, Benterud JG, Solovieva S

 

132

WHO AM I?

 

    Dx?

 

What screening test must be done regularly until age 5-6?

1 -    My child is 18 mos old and I took him to a peds orthopod because he has a LLD with one leg larger than the other (hemihypertrophy).
-    He had surgery shortly after he was born for an omphalocele, but was otherwise healthy except for quite a large tongue.
-    His pediatrician says he has hypertrophic pancreatic islet cells (organomegaly), and he now has increasing spasticity and tone.

2 -   Beckwith-Wiedeman syndrome

3 -    Renal U/S to r/o Wilm's tumour

 


 

133

5 Contraindications to Immediate Wound Closure for Traumatic Open Wounds

  • Gross contamination with feces, dirt, or stagnant water
  • Farm related injuries
  • Freshwater boating injuries
  • Delay in initial abx > 12 hours
  • Questionable viability of soft tissue
  • Doubt of the adequacy of initial debridement
  • Concern for myonecrosis

Ref: Chief review notes

134

LIST 3 OPERATIVE INDICATIONS TO REPAIR A ROTATOR CUFF

•    Failure of non-surgical management of full-thickness and partial thickness tears
•    Acute tear in young patient (< 60)
•    Acute loss of strength or motion at any age (due to cuff tear)

 

135

Name 3 Side Effects from Radiation for Hip HO

  • Carcinogenesis (Theoretical, no case reports for HO prophylaxis)
  • Trochanteric non-union (Old literature with poor surgical techniques?)
  • Testicular tolerance (8Gy may cause reversible azospermia, but testicular shielding reduced does 50%)

 

  • NB: Dose 7-8Gy (700cGy) <4hrs pre op, <72hrs post-op
  • Meta-analysis 2004 showed Radiation more effective than NSAIDS, but ARR only 2%

 

Radiation vs nonsteroidal anti-inflammatory drugs for the prevention of heterotopic ossification after major hip procedures:  a meta-analysis of randomized trials.  (Pakos EE, Int J Radiat Oncol Biol Phys. 2004 Nov 1;60(3):888-95.)

136

WHAT ARE THE 4 VECTORS TO REDUCE A BENNETT'S FRACTURE?


-    Traction
-    Extension
-    Pronation
-    Abduction

 

137

OSCE - WHAT IS YOUR MANAGEMENT OF A POSTEROLATERAL SIMPLE ELBOW DISLOCATION (2)

 

IN A 25 YR OLD WRESTLER, POST REDUCTION CONGRUENT, STABLE ARC FROM 40-145 DEG

•    Splint in backslab for < 7 days
•    X-ray out of splint
•    Assess stability
•    Hinged elbow brace with extension block at 30-40 degrees for 1-2 weeks
•    block 10-20 degrees 1-2 weeks
•    No block for 2 weeks

 

138

4 WAYS TO DEAL WITH INFECTED BONE LOSS

•    Masquelet (Induced Membrane)
•    Intercalary bone transport (with ring fixator)
•    Papineau (open bone grafting, modern done with Vac)
•    Vascularized Fibula

•    Induced Membrane Technique for Reconstruction To            Manage Bone Loss - 2012 JAAOS
•    Modern Papineau technique with vacuum-assisted                 closure 2006 JOT
•    Vascularized fibular graft in infected tibial bone loss -             2011 IJO
             F/u avg 46.5 months
             10 stress #'s in 7 pts...
             Graft union in 3.3 months
             No post-op infections

 

 

139

OSCE SHOULDER INSTABILITY - DEFINE INSTABILITY VS. LAXITY

•    Instability: 

    o    Is a pathologic condition representing excessive translation of humeral head on the glenoid during ROM representing a spectrum of injury to shoulder stabilizers

•    Laxity: 

    o    Is a physiologic condition representing excessive translation of humeral head on glenoid during ROM with no pathologic or functional consequence to patient (Jeremy Lamothe)

•    Remember: Patients can be lax and stable or lax and unstable or lax and stiff

140

LIST THE FOUR MOST IMPORTANT POOR PROGNOSTIC SIGNS FOR PEDIATRIC SEPTIC ARTHRITIS

•    Delay > 4 days
•    Age < 6 months
•    Joint effusion with underlying osteomyelitis
•    Hip involvement

 

141

LIST 5 CONTRAINDICATIONS TO A GH FUSION

•    Osteonecrosis (arthropasty is better)
•    Charcot (high nonunion rate)
•    Ipsilateral elbow fusion
•    Contralateral shoulder fusion
•    Injury of the scapular stabilizer muscles (traps, levator scapulae, serratus anterior, lats dorsi, rhomboids)
Ref: Richards et al., 1997

 

142

OSCE - Bisphophonates

Your colleague sends her away for MRI and 3 months later, she comes back.  Pain still present and there is bony edema on the MRI.  What now?

 

Your colleague thinks her canal is too tight - he wants to use the new-fangle locking plate he's been hearing about because he figures it will be easy to use for the first time in a non-broken bone.  He wants your opinion - What do you tell him?

  • IM nail

 

 

  • Locking plates have a higher failure rate - they preclude endosteal healing.
  • Should IM nail with enough reaming to fit the nail

143

NAME 7 CAUSES OF CHARCOT ARTHROPATHY

-    DM (most common in Foot)
-    Syringomyelia (most common cause in the UE)
-    Leprosy - Hansen's disease (second most common cause in the UE)
-    Myelomeningocele (foot and ankle)
-    Spinal cord injury
-    Neurosyphilis/tabes dorsalis
-    Congenital insensitivity to pain

-    Amyloidosis

Miller's pp45-6

 

144

NAME 7 PEDIATRIC CONDITIONS ASSOCIATED WITH ATLANTOAXIAL INSTABILITY


-    Down syndrome (odontoid hypoplasia)
-    JRA/JIA
-    Os odontoideum (ossiculum terminale – not associated with instability)
-    Pseudochondroplasia
-    Diastrophic dysplasia
-    SED congenita (odontoid hypoplasia)
-    Metaphyseal dysplasia: mckusick’s
-    Morquio’s (odontoid hypoplasia)
-    Osteogenesis Imperfecta
-    Marfans


1) Miller’s pp198-207
2) Manny's lists

145

AFTER NAILING A FEMUR, WHAT THINGS DO YOU CHECK FOR PRIOR TO WAKING UP THE PATIENT?

•    Length correct
•    Rotation correct
•    Knee ligaments stable
•    No associated fem neck #
•    Compartments soft
 

 

146

LIST 5 WAYS TO MINIMIZE FEMORAL MALROTATION WHEN PLACING AN IM NAIL FOR FEMUR FRACTURES

•    Clinically assess legs*
•    Fluoroscopically assess anteversion by moving the c arm and measuring this*
•    Perform lateral only imaging of the femur and compare the neck horizontal line*
•    Compare the LT profiles*

•    Ultrasound*
•    Computer assisted navigation*
•    All of these are relative to the contralateral side. 


Lindsey 2011 JAAOS paper

 

 

147

MEDIAL PIN, ULNAR NERVE OUT, WHAT ARE YOU GOING TO DO BUSTA?


•    Iatrogenic ulnar nerve injuries 1-15%
•    60% children < 5 yrs will have ulnar nerve that subluxes over medial epicondyle when elbow flexed
•    You are up to 2 mm off with palpation as a means for correctly identifying the nerve.
•    Ulnar nerve injury is most often due to the pin constricting the nerve in the cubital tunnel by increasing tension vs. piercing the nerve (although this can happen)
•    The ulnar nerve can recover with expectant management (no exploration, no pin removal)...but sometimes it doesn't

•    " there is insufficient information in the literature to offer an evidenced-based approach to iatrogenic ulnar nerve injury that occurs following medial pin placement"

•    I am pulling that sucker in recovery room (not exploring) and replacing it with another lateral pin (1st choice) or a better positioned medial pin. I will then follow the ulnar nerve expectantly...my approach (B)
R&W 7th ed p515

 

 

148

SCREW DENSITY

    Number of holes/number of screws

149

WHEN TO USE BISPHOSPHONATES

-    Metastatic disease
-    GCT
-    Pagets
-    Fibrous Dysplasia
-    Myeloma

 

150

LIST 3 FEATURES OF   Ollier's syndrome

 

o    Sporadic inheritence
o    Multiple exostoses
o    30% malignant transformation

 

-    Multiple enchondromas
-    30% chance of malignant transformation
-    involved bones are dysplastic
-    High risk of other malignancy

 

151

LIST 5 CONDITIONS ON DIFFERENTIAL DIAGNOSIS IN A < 4 YR OLD, 4-10 YR OLD AND > 10 YR OLD WITH A LIMP

 

10 yrs of age

-    Stress fracture
-    OM, septic arthritis, discitis
-    SCFE
-    Osgood Schlatter
-    Sindig-Larsen-Johanssen

-    Osteochondritis Dissecans
-    Chondromalacia Patellae
-    Arthritis (Lyme disease)
-    Accessory Navicular
-    Tarsal colaition
-    Benign or malignant tumor

Skaggs - Staying out of trouble...I think the original reference is JAAOS 2001 Flynn
Duchenne's will probably present between 2-5 yrs of age (Don't forget to do gowers sign in all boys - do gowers in girls too - they can have other myopathies/neuropathies too)

152

NAME THE NORMAL VALUES FOR THE ROTATIONAL PROFILE ASSESSMENT IN KIDS?


Table 3–14   -- EVALUATION OF ROTATIONAL PROBLEMS OF THE LOWER EXTREMITIES
Measurement    Technique    Normal Values (degrees)    Significance
Foot-progression angle    Foot vs. straight line    −5 to +20    Nonspecific rotation
Medial rotation    Prone hip ROM    20-60    > 70 degrees; femoral anteversion
Lateral rotation    Prone hip ROM    30-60    < 20 degrees; femoral anteversion
Thigh–foot angle    Knee bent; foot up    0-20    < −10 degrees; tibial torsion
Foot lateral border    Convex; medial crease    Straight; flexible    Metatarsus adductus

 

153

LIST 3 WAYS TO CONFIRM SCREW POSITION DURING SCFE PINNING


•    near-far fluoro technique
•    inject dye through screw
•    3D imaging (CT)

 


Manny's notes

 

154

List 5 Conditions that are Associated with Increased Risk of Osteopenia

  • MS
  • Estrogen deficiency (menopause)
  • OI
  • Ankylosing spondylitis
  • Diabetes
  • Renal disease
  • Nutritional deficiency (rickets)

155

WHAT ARE THE CLASSIC THREE RISK FACTORS FOR NONUNION OF A TIBIA FRACTURE

•    Transverse pattern (RR20)
•    Open (RR 4.3)
•    Gap (RR 8.3)


J Orthop Trauma. 2003 May;17(5):353-61.: Predictors of reoperation following operative management of fractures of the tibial shaft. - Bhandari M, Tornetta P 3rd, Sprague S, Najibi S, Petrisor B, Griffith L Guyatt GH

156

OSCE – HALO
WHAT ARE 5 CONTRAINDICATIONS TO A HALO?

 

•    cranial fracture
•    intracranial bleed that may require a craniotomy
•    infection

•    soft tissue injury at proposed site
•    chest trauma
•    obesity 
•    advanced age
•    barrel chest

 

 

157

How to Avoid Varus

"Get Reduced, Ream Reduced and Nail Reduced"
•    Less Attractive Option - Ream proximal fragment, then you finger or nail as joystick to get reduction - SHOULD RARELY BE USED
 
2.    Starting point at tip of GT or slightly medial, at the junction of the anterior one-third and posterior two-third on GT
◦    Guidewire needs to be parallel to lateral cortex of proximal fragment
◦    NEVER LATERAL TO TIP
    If you do, guide wire, opening ream and nail head medial - to get nail into shaft @ fracture site, you push your hand in towards the body and create varus at the fracture site
◦    Reference - J Orthop Trauma. 2005 Nov-Dec;19(10):681-6. A critical analysis of the eccentric starting point for trochanteric intramedullary femoral nailing. Ostrum RF, Marcantonio A, Marburger R.
1.    Clamp Assisted Open Reduction - Good for High, Transverse Subtochs - within 2 cortical diameters of lesser, How to do:
◦    Muscle Relaxants
◦    Attempt Closed Reduction  - if possible use closed reamed antegrade femoral nailing
•    If behaving like a Subtroch (flex, ER, Abduct) - Open
◦    3-5 cm lateral incision, split Lateralis directly through muscle belly, DO NOT VISUALIZE FRACTURE (do not evacuate hemtoma, strip soft tissue etc), insert large reduction clamp, cephallomedulary locking screws, remove clamp...if still mobile, add a cerclage wire, WBAT
◦    Union - 98%
◦    Other Option if very transverse - Lane Bone Holding forceps on proximal fragment - Reverse deformity (Extend,IR, Adduct) and Hyper Adduct
    Clamp-Assisted Reduction of High Subtrochanteric Fractures of the Femur. Alan Afsari, Frank Liporace, Eric Lindvall, Anthony Infante, Jr., Henry C. Sagi and George J. Haidukewych.  J Bone Joint Surg Am. 2009;91:1913-1918.
1.    Medial Blocking Screw - AP direction
2.    Shantz Pin  (see Harborview Book)
◦    AP - use to control flexion mainly
•    Stay above lesser, snap down to bone, be mindful of femoral nerve.
◦    Lateral to medial - posterior to the path of the nail

1.    Bone hook on shaft (lateralize fragment), ball spike pusher proximal fragment(push it into valgus)
◦    Helpful if purely coronal plane and not much flexion of proximal fragment
1.    Avoid Eccentric Lateral Reaming
◦    Tips
•    Medialize Entry Reamer, Medialize guidewire with thumb hole of snap, insert a curved LCDP plate to protect lateral cortex
◦    Bailouts if you Ream Laterally  and your nail reduces you into varus
Use ronger, awl to remove bone MEDIALLY at entry point.

158

List 4 Intraoperative Risk Factors for Acetabular Fractures During Total Hip Arthroplasty

  • Cementless acetabular shell
  • Under-reaming by >2mm
  • Use of an elliptical monoblock shell
  • Paget's
  • Hands of a honey badger
  • During removal of acetabular shell in revision
  • Osteoporosis

 

AAOS

159

NAME 4 RISK FACTORS FOR MYELOMENINGOCELE


•    Maternal pre-gestational DM
•    In utero exposure to carbamazipine/valproic acid
•    Previous affected pregnancy
•    Folic acid deficiency
Manny's notes

 

160

List 5 AP Pelvis Radiographic Features of Pincer FAI

  • Cross-over sign
  • Os acetabuli
  • CEA > 39
  • Posterior wall lateral to the center of rotation of the femoral head
  • Profunda
  • Protrusio

 

Manny's lists

161

OSCE SHOULDER INSTABILITY - CLASSIFY INSTABILITY

•    Chronological: 
  o    Acute, chronic, recurrent
•    Direction: 
  o    unidirectional vs. multidrectional
•    Control: 
  o    Voluntary vs. involuntary
  o    If voluntary: 
            Positional, habitual, muscular

 

162

WHAT IS THE RISK OF AVN (%) IN EACH OF THE FOLLOWING HUMERAL HEAD # PATTERNS?

 

-    4 part fracture dislocation
-    displaced 4 part #
-    3 part #
-    valgus impacted 4 part #

 

-  4 part fracture dislocation                   100%


-   displaced 4 part fracture                       45%


-    3 part fracture                                       14%


-    valgus impacted 4 part fracture           11%

 

163

WHAT ARE 5 FEATURES OF A MALIGNANT CELL (A LA SCHACHAR)

•    Mitosis (cell division)
•    Pyknosis (irreversible condensation of chromatin in nucleus)
•    Anisocytosis  (Cells of unequal size)
•    Necrosis (messy cell death)

•    Abnormal Nuclear/cytoplasmic ratio
•    Hyperkaryotosis (Hypercellular)
•    Pleiomorphism (variety of shapes/sizes)

 

 

164

LIST 5 WAYS TO JUDGE THE HEIGHT OF A HUMERAL PROSTHESIS

•    8 mm above anatomically reduced GT
•    5.7 cm above superior border of pec major
•    Appropriate tension reestablished in long head of biceps
•    Appropriate relationship to glenoid
•    Template off of pre-op x-rays of non-affected side


ref: Multiple: 1 and 2 are in publications, 3, 4 5 are from courses and chatting with Duffy

 

165

LIST 5 COMPLICATIONS OF PNEUMATIC TOURNIQUET


-    Local
o    Post op swelling / stiffness
o    Delay in muscle power recovery
o    Compression neuropraxia
o    Wound hematoma
o    Wound infection
o    Direct vascular injury
o    Bone and soft tissue necrosis
o    Compartment syndrome

-    Systemic
o    CVP
o    Arterial hypertension
o    Cardiorespiratory decompensation
o    Cerebral infarction
o    Alterations in acid-base balance
o    Rhabdomolysis
o    DVT

Pneumatic Tourniquets in Extremity Surgery JAAOS 2001

 

166

LIST 5 CAUSES OF CHONDROCALCINOSIS

 

•    CPPD crystal deposition

•    Ochronosis
•    Hemochromatosis
•    Hyperparathyroidism
•    Hypothyroidism
•    Calcium hydroxyapatite crystal deposition  ("Milwaukee shoulder")


Miller's p53

 

167

GIVE TWO EXAMPLES OF TUMORS FOR EACH RADIOSENSITIVITY

 

High radiosensitivity:
Moderate radiosensitivity:
Low radiosensitivity:

 

-    High radiosensitivity:
o    MM
o    Small cell lung
o    Testicular
o    Leukemia
o    Lymphoma
o    Germ cell tumors

-    Moderate radiosensitivity:
o    Non small cell lung
o    Thyroid
o    Breast
o    Prostate 

o    (epithelial)

-    Low radiosensitivity:
o    Renal cell
o    Melanoma
o    Colon

From Manny notes (and wikipedia)

168

List 5 Places Where Metal Particles Can Be Found in Body with Mom Hips

  • Capsule
  • Bone Marrow
  • Blood
  • Urine
  • Lymph nodes (para-aortic)
  • Liver
  • Spleen

 

Dumbleton J Arthroplasty 2005

JBJS Br Case et al 1994 Sep;76(5):701-12

169

OSCE SHOULDER INSTABILITY - WHAT ARE THE CLINICAL EXAM REQUISITES TO GIVE SOMEONE A DIAGNOSIS OF MDI

•    Reproducible signs of inferior instability + instability in one other direction

170

Knee Fusions

  • What is the Position for Knee Fusion?

 

  • What position would you fuse a PFFD Knee?

  • 20 deg flexion, 10-15 ER, 5 valgus

 

 

  • 0 deg flexion, 10-15 ER, 5 valgus
  • Because the tibia and the femur will both be "above knee" so don't want any flexion at the native knee joint.

171

NAME 3 CAUSES OF CROUCH GAIT IN CP?

•    Hip flexion contracture
•    Hamstring contracture
•    Excessively loose heel cords

 

AAOS

172

What do Patients with Paget's Present With? (list 5)

  • Incidental x-ray findings
  • Incidental lab findings (elevated alk phos)
  • Bone pain
  • Bone deformity
  • Fracture
  • Arthropathy
  • Skin temperature changes
  • 8 neurologic complications (deafness, cranial nerve palsies)

173


Dx Osteosclerosis associated with secondary hyperparathyroidism of renal failure
Also described for Osteopetrosis

 

"Prolonged renal failure causes phosphate retention and subsequent hyperplasia of parathyroid gland chief cells, which results in a decrease in serum calcium and an increase in serum parathyroid hormone. Increased serum phosphate causes a decrease in 1,25(OH)2D synthesis, which decreases calcium absorption. The increased parathyroid hormone acts on the kidneys and on bone to normalize serum calcium. The direct results are (a) stimulation of vitamin D metabolism, which increases intestinal resorption of calcium, thereby antagonizing the effects of phosphate on 1,25(OH)2D synthesis; (b) increased resorption of calcium from the kidneys, with increased excretion of phosphate in the kidneys; and (c) increased osteoclast activity, which causes the release of calcium from bone (6). Osteoblasts form an increased amount of osteoid in response to bone resorption and a subsequent loss of bone mass. This excess osteoid does not contain hydroxyapatite but appears opaque on radiographs, thus producing the rugger jersey spine appearance"

Oteopetrosis

174

WHAT 3 CLINICAL SIGNS INDICATE YOU HAVE ADEQUATE ABDUCTION AND CAN PROCEED WITH CORRECTION OF EQUINUS / TENOTOMY?

 

•    Anterior process of calcaneous is palpable as it corrects from under the talus (best sign)
•    You've achieved at least 60 deg of abduction in reference to the tibia
•    Neutral or slight valgus of os clacis is present

 

175

RISK FACTORS FOR SPINAL PSEUDARTHROSIS IN DEFORMIT CORRECTION

    Smoking
    Long segment fusion 
    Kyphosis
    Positive sagittal balance > 5 cm
    Hip OA
    Thoracolumbar approach
    Age  55
    Incomplete lumbopelvic fixation
    Anterior fixation alone

 

176

ASYMPTOMATIC CUFF TEARS BY AGE

50 – 60 yrs        13%
- 60 – 70 yrs        20%
- 70 – 80 yrs        30%
- > 80 yrs        50%

- U/S Study of PARTIAL or FULL thickness tears

177

What are the 6 Major Determinants of Gait?

  • Pelvic rotation
  • Pelvic tilt
  • Pelvic lateral rotation
  • Knee flexion in stance phase
  • Knee mechanics
  • Foot mechanics

 

Saunders et al., jbjs 1953

178

LIST 3 FEATURES OF Li Fraumeni Syndrome

-    P53 tumor suppressor gene mutation
-    predisposes to second hit
-    Increased risk of sarcoma and other cancer in young patients


Reference: Tim's Bone tumor handout, the Monument files and orthobullets

 

179

5 CONTRAINDICATIONS TO IMMEDIATE WOUND CLOSURE FOR TRAUMATIC OPEN WOUNDS

•    Gross contamination with feces, dirt, or stagnant water
•    Farm related injuries
•    Freshwater boating injuries
•    Delay in initial abx > 12 hours
•    Questionable viability of soft tissue
•    Doubt of the adequacy of initial debridement
•    Concern for myonecrosis


Ref: Chief review notes

 

180

LIST 4 RADIOGRAPHIC FINDINGS IN CUFF TEAR ARTHROPATHY

-    Acetabularization of the acromion (AP view)
      o     comment on thickness of acromion; at risk for peri-op       fracture
-    Femoralization of the humeral head (AP view)
-    Eccentric superior gleniod wear (AP view)
-    Loss of CA arch (anterior superior escape)
-    Lack of typical peripheral osteophytes
-    Osteopenia
-    Subarticular sclerosis (snowcap sign)

 

181

LIST 5 POSSIBLE CAUSES OF A RIGID FLAT FOOT


-    Tarsal coalition
-    Tumor (osteoid osteoma)
-    Infection
-    Inflammatory arthritis
-    Vertical talus
-    Oblique talus
chief notes

 

182

OSCE - Bisphosphonates

What is the Effect of Biophosphonates on Acute Fractures?

  • Continuous administration may delay remodeling of hard callus but will not affect the strength of the hard callus.
  • One single dose administration can delay hard callus remodelling but improve hard callus strength.

183

RISK FACTORS FOR DEVELOPING A SCAPHOID NONUNION - LIST AT LEAST 5

•    Proximal pole fracture
•    Initial displacement > 2 mm
•    Vertical fracture pattern
•    Delay to treatment 4 wk
•    Smokers
•    Female
•    K-wire fixation
•    Carpal collapse
•    Prior surgery


Wright's book or Bhandari's book

 

184

HILL SACHS (IN SETTING OF RECURRENT INSTABILITY) - HOW ARE YOU GOING TO TREAT THE FOLLOWING LESIONS IN A 25 YR OLD (FOLLOWING THE BOORMAN DOGMA OF SOFT TISSUE FOR SOFT TISSUE AND BONE FOR BONE)?

•    Latarjet
•    Think of remplissage depending on size

 

185

LIST 5 SURGICAL TECHNIQUES TO MOBILIZE ROTATOR CUFF

 

(RISKS FOR CUFF REPAIR NOT HEALING)

•    Intra-articular release of rotator cuff from glenoid labrum
•    Cuff mobilization with traction sutures
•    Anterior slide (release rotator interval from base of coracoid (may increase tendon excursion by 1.5 cm)
•    Posterior slide (release between infraspinatus and supraspinatus)
•    Supraspinatus dissection - from the supraspinatus fascia and scapular spine to allow mobilization from the supraspinatus fossa

 

186

IN THE NATURAL HISTORY OF ACL TEARS, HOW MANY PATIENTS, WITH NO RECONSTRUCTION GO ON TO DEVELOP OA?

    0-16%

187

LIST 10 COMPLICATIONS AFTER SUSTAINING A RADIAL NECK/HEAD FRACTURE

•    Elbow stiffness (most common)
•    Radial head overgrowth (second most common) 
•    Notching of the radial neck
•    Premature physeal closure

•    Nonunion of the neck
•    Head osteonecrosis 
•    Cubitus valgus
•    Vascular injury
•    Nerve injury (PIN)
•    Compartment syndrome
•    Radioulnar synostosis
•    Myositis ossificans
•    Osteomyelitits
•    Malunion

Ref for both Rockwood and Wilkins
 

 

188

FACTS ON CARPAL SYNOSTOSIS

-    Associations
o    Arthrogryposis
o    Ellis-van Creveld syndrome
o    Holt-Oram syndrome
o    Turner's syndrome
-    Familial

-    Most frequently in black males
-    Bilateral
-    Lunotriquetrial is most common
-    Mostly incomplete
-    Usually asymptomatic
 

 

 

189

RISK FACTORS FOR PATELLAR INSTABILITY

    Weak VMO
    High Q angle
    Genu Valgum
    Excessive femoral anteversion          

            Miserable Malalignment
    External tibial torsion          

           Miserable Malalignment
    Pronated feel                   

            Miserable Malalignment
    Trochlear dysplasia
    Ligamentous laxity
    Patella alta

    Lateral condyle hypoplasia

 

190

List Pre-op Consideration for Achons

  • Large tongue
  • Large mandible
  • Foramen magnum stenosis
  • Limited neck extension
  • May have decreased chest wall compliance and FRC
  • Frequent URTI
  • Difficult spinal/epidural anaesthesia

Manual of Anaesthesia practice:  Chapter on Achon's

191

GOUTALLIER CLASSIFICATION

Stage > 3 (50%) correlates with poor outcome

-    Stage 0        Normal Muscle
-    Stage 1        Fatty Streaks
-    Stage 2        < 50% fatty muscle
-    Stage 3        50% fatty muscle
-    Stage 4        > 50% fatty muscle

192

LIST 4 CAUSES OF ACQUIRED TORTICOLLIS


•    AARI 
o    Grissel

•    neurogenic                                    
o    SC tumors, posterior possa tumors, syrinogmyelia, Arnold-Chiari
•    neoplasms                                    
o    osteoid osteoma, ABC
•    infection                                    
o    cervical adenitis, retropharyngeal bascess, Grisel’s syndrome
•    inflammatory                  
o    interverberal disc calcification, JIA
•    iatrogrenic                                    
o    H&N surgery

 

 

193

List 3 Modalities to Maximize the Beneficial Effects of Prophylactic Antibiotics while Minimizing Adverse Events

  • Antibiotic administration prior to incision (or tourniquet inflation)
  • Perioperative antibiotic course should not exceed 24 hours
  • Antibiotics should be re-dosed when the duration of the procedure exceeds one to two times the half life of the antibiotic OR with significant intra-operative blood loss (two Swamys).  The half life of Ancef is 1.8 hours with administered IV
  • Verification of prophylactic antibiotic administration by a "time out" protocol

Bhandari

194

195

LIST 5 FINDINGS SUGGESTIVE OF PAGETOID SARCOMATOUS DEGENERATION


-    New pain in a longstanding Paget’s patient
-    Pathologic fracture
-    Elevation of ALP ...above normally elevated levels
-    Biopsy - actually necessary to tell you what sarcoma it has become
-    Soft tissue mass
-    Cortical destruction


Orthobullets

 

196

LIST THE TWO CORRECTIONS PERFORMED WHEN DOING A PROXIMAL FEMORAL OSTEOTOMY TO TREAT THE SEQUELAE OF A HIGH GRADE SCFE

 

•    Flexion
•    IR
•    ...rarely need valgus but can be done in setting of AVN

 


Webinar vumedi

 

197

LIST 3 FEATURES OF Jaffe-Campanacci (many NOF)

 

o    Café-au-lait
o    Mental retardation
o    Hypogonadism
o    Disseminated NOF

 

-    Non-ossifying fibromas
-    Cafe au lait 
-    May be associated / subtype of NF ?

 

198

LIST 4 COMPLICATIONS OF PONSETTI CASTING

•    Rocker bottom foot
•    Pressure sores
•    Crowded toes
•    Flat heel pad

 

199

List 5 Indications for an HTO

  • Gonarthrosis in patients with a varus limb alignment
  • Gonarthrosis in patients with a valgus limb alignment (unloads the knee in flex and ex compared to a DFVO that is only in ex)
  • OCD of MFC
  • SPONK of MFC
  • Posterolateral instability
  • Chondral resurfacing
  • Non Obese
  • Unilateral

CONTRAINDICATIONS

  • Inflammatory arthritis
  • Flexion <90
  • Contracture >15
  • BMI > 35
  • > 20 degrees of correction required
  • PF OA
  • Varus thrust
  • Instability

200

LIST 4 CONDITIONS AFFECTING HYPERTROPHIC ZONE OF PHYSIS

•    SCFE
•    Rickets (provisional calcification zone)
•    SH 1 fractures (provisional calcification)
•    Mucopolysacharide disease
•    SED
•    MED
•    Acromegaly

Proliferative
o    Achon's

o    Gigantism
o    MHE

Reserve
o    Gaucher's
o    Disatrophic Dysplasia
o    Pseudoachon's


  1) “Rich Pretty Girls Do Koke”
R = Reserve Zone
P = Pseudoachondroplasia = COMP
G = Gaucher’s Disease
D = Diastrophic Dysplasia = Sulfate Transport
K = Kniest Syndrome = Type 2 collagen defect
    2) “Big and Small”
- Proliferative Zone
G = Gigantism
A = Achondroplasia (FGFR-3)    

  3) “MORE Sex Please”
- Hypertrophic Zone
M = Mucopolysaccharidoses 
O = Osteomalacia
R = Rickets
E = Enchondroma
S = SCFE
P = Physeal Fracture
    4) Metaphysis
- SCFE with Endocrine Problem
- OSTEOPETROSIS
- OI (Type 1 Collagen)
- Scurvy (Vitamin C)

 

 

 

 

 

 

201

OSCE - WHAT IS YOUR MANAGEMENT OF A POSTEROLATERAL SIMPLE ELBOW DISLOCATION (3)

 

IN A 25 YR OLD WRESTLER, POST REDUCTION CONGRUENT, STABLE ARC FROM 65-145 DEG

•    Operate
•    Although this is a simple dislocation I would go through the King algorithm in my head to make sure I am not missing and bony injuries and to help with me sequence of repair/reconstruction

 

202

ACL RECONSTRUCTION COMPLICATIONS

-    Failure
-    Infection

-    Arthrofibrosis
      o    Minimal 12 wks before considering MUA
-    Cyclops
-    Loss of motion
-    Patella fracture/rupture
-    Tunnel osteolysis
-    Late arthritis

 

 

203

PLATE SPAN WIDTH

    Plate length / Fracture length

204

Benefits for Placing the Acetabular Component at the Native Hip Centre in DDH (4)

  • Diminishes joint contact forces compared to high hip center
  • Improved abductor function
  • Fascilitates limb lengthening
  • Best bone stock

 

Ref: Campbell's

205

LIST 10 RISK FACTORS FOR DUPUYTRENS

 

-    Male
-    Family history
-    Northern European
-    Manual labor - with vibration exposure (5x increase)
-    Diabetes
-    Local trauma
-    Etoh/liver disease
-    Smoking (3x increase)
-    Hyperlipidemia
-    CRPS

-    RA protective
Controversial:
-    HIV
-    Epilepsy
-    Chronic pulmonary disease
-    Tb

206

WHAT ARE 5 TECHNICAL TRICKS FOR TREATING FRACTURES WITH OSTEOPETROSIS?

Problems/Solutions

  1. Hard, sclerotic bone - Sequential drilling with regular cooling saline, frequent change of drill bit
  2. Impaired vascularity and white celi function - Warn patient about increased risk of infection
  3. Brittle bones - Avoid undue force and use of mallet
  4. Dynamic hip screw fixation - Fractional decrease in drilling, tapping and screw length, regular clean out of tap and screw tract
  5. IM nailing-absent medullary canal - Drilling and cannulated reaming under fluoroscopic control
  6. Tension band wiring - Pre-drill k wire tract under fluoroscopic control
  7. Plate fixation- Fully tap all holes before screw insertion
  8. Total hip replacement - Uncemented arthroplasty, use of power drill, reamer, burr to create medullary canal
  9. Total knee replacement - Anticipate extra-medullary alignment and difficult sawing

De Palma et al.8 reported the histology of fracture callus in a patient with autosomal dominant osteopetrosis.  They found normal healing to be present at 10 days after a fracture.  At 20 days there was normal woven formation; however there were fewer than normal vessels and few osteoclasts.  At 1 year biopsy of the healed fracture showed unorganised woven bone with absence of osteoclasts.  Microfractures were frequently noted.  Thus osteopetrotic fractures do heal, but remodeling does not occur. 

207

LIST 5 TECHNICAL CONSIDERATIONS WHEN PLACING LATERAL PINS IN A PEDIATRIC SUPRACONDYLAR FRACTURE

•    Maximize pin separation at fracture site
•    Engage medial and lateral columns proximal to fracture site
•    Engage sufficient bone in both the proximal segment and distal fragment

•    Low threshold for a third lateral pin if fracture stability is a concern
•    Use three pins for a type III fracture
Rockwood and wilkins 7th ed. p498

 

 

208

Name 5 Conditions Associated with Acetabular Protrusio?

  • RA
  • AS
  • Marfan's
  • Paget's
  • Otto's pelvis (aka protrusion)

Miller's p48

Also

  • Neurofibromatosis
  • Radiation induced osteonecrosis
  • JIA/JRA
  • Psoriatic
  • Reactive arthritis
  • OI
  • Ochronosis
  • HPT
  • Ehler Danlos
  • Sickle Cell
  • Hemophilia

The German pathologist Otto first described Protrusio acetabuli, (also known as "arthrokatadysis",) in 1824.  Hence also known as Otto Pelvis

http://orthopaedicprinciples.blogspot.ca/2009/10/protrusio-acetabuli-otto-pelvis.html

Wheeless:

  • primary form, Otto pelvis (arthrokatadysis), involves both hips, occurs most often in females, & causes pain & limitation of motion at a relatively early age;

 

209

OCD IN KIDS

    Type 1        Depressed OC Fracture
    Type 2        Fragment attached by bridge
    Type 3        Detached, non-displaced
    Type 4        Displaced

 

210

LIST 5 RISK FACTORS FOR FAILURE OF A ROTATOR CUFF REPAIR

•    Higher rate of primary RCR failure:
  o    Age >65
  o    Massive tear (>5cm)
  o    Moderate to severe muscle atrophy (T1 MRI > 50%)
  o    Tear retracted >2.5cm at scope after mobilization
  o    Tear retracted medial to glenoid on MRI
  o    DM
  o    Active smoker
  o    Unwillingness/inability to participate in rehab or comply restrictions


JAAOS 2012

 

211

WHAT’S THE CLASSIC TRIAD FOR HAND-SCHULLER-CHRISTIAN DISEASE

 

-    Exophthalmos
-    Diabetes Insipidous
-    Lytic skull lesion (multifocal Langerhans cell histiocytosis)
(Apparently classic, but only seen in 25%)


Millers 544
 

 

212

LIST THE PRINCIPLES / STEPS IN A POSTEROMEDIAL RELEASE OF CLUBFOOT


-    Pre-op: Consent- standard stuff, + mention recurrence / stiffness
-    Position: prone / abx / tourniquet
-    Incision: Cincinatti  (from navicular/medial cuneiform to lateral sinus tarsi)
-    ID and protect: 
o    Medial vascular bundle 
    how many clubfoots have absent dorsalis pedis? - 45%
o    Medial and plantar nerves
o    Sural nerve
o    interosseous talocalaneal ligament
-    Releases:...Pretty much everything else

-    1) Medial
o    Plantar fascia
o    Abductor hallucis
o    lacinate ligament (flexor retinaculum)
o    TN capsule
o    Calcaneounavicular ligament (spring)
o    Knot of henry
o    superficial deltoid
o    Lengthen: tib post, FDL and FHL
-    2) Posterior (?usually first according to chief notes)
o    Z-lengthening of achilles
o    release posterior tibiofibular and talofibular ligaments
o    Subtalar joint capsule
-    3) Lateral
o    calcaneofibular
o    calcaneocuboid
o    peroneal sheaths
-    May need to pin the CC joint and TN joint if unstable

-    Recurrence:
o    ? etiology - consider MRI for spinal cord

-    Revision
o    SPLATT
o    Dwyer Osteotomy

 

 

213

LIST 5 TUMORS THAT CAN GO ON TO SECONDARY ABC FORMATION?

•    Chondroblastoma
•    osteoblastoma
•    GCT
•    CMF
•    NOF
•    Fibrous dysplasia

 

214

DEFINE THE MRI "BOW TIE" SIGN

-    3 or more 5mm sagittal images with meniscal continuity

215

WHAT ARE THE CRITERIA FOR DIAGNOSING NEUROFIBROMATOSIS 1?

NIH Diagnosis of Neurofibromatosis Type 1 (NF1)
•    Six or more café au lait macules over 5 mm in greatest diameter in prepubertal individuals and over 15 mm in greatest diameter in postpubertal individuals 
•    Two or more neurofibromas of any type or one plexiform neurofibroma 
•    Freckling in the axillary or inguinal regions (Crowe´s sign) 
•    Optic glioma 
•    Two or more Lisch nodules (iris harmartomas) 
•    A distinctive osseous lesion such as sphenoid dysplasia or thinning of long bone cortex with or without pseudoarthrosis 
•    A first-degree relative (parent, sibling, or offspring) with NF1 by the above criteria 
The criteria are met in an individual if two or more of the features listed are present.
Manny Notes
http://www.medicalcriteria.com/criteria/neuro_nf.htm

 

216

LIST 5 INDICATIONS FOR TEA IN TRAUMA

•    Patient mentally and physically fit for surgery

•    Low demand < 10 lbs lifting restriction

•    Males > 75 and female > 70

•    Fractures not "ORIFable"

•    Pre-existing arthritis

 

Ref: Graham King webinar

217

DIFFERENTIAL DIAGNOSIS FOR POSTERIOR VERTEBRAL SCALLOPING (NAME 4)

•    Neurofibromatosis
•    Achondroplasia
•    Marfan syndrome
•    Ehlers-Danlos syndrome
•    Ankylosing Spondylitis
•    Morquio syndrome
•    Hurler syndrome
•    Acromegaly
•    Intraspinal tumor
•    Communicating hydrocephalus
The Posterior Vertebral Scalloping Sign - Radiology 2006 

 

218

NAME 5 SMALL ROUND BLUE CELL TUMORS

LERN'M
-    L - Lymphoma
-    E – Ewings (most common kid >5)
-    R - Rhabdomyosarcoma
-    N – Neuroblastoma (most common kid <5yo)
-    M – Myeloma
Also - Small round cell carcinoma (r/o >40yrs)


Millers Page 549, and Board review Webinar 2012

 

219

DESCRIBE PATTERNS OF MENISCAL TEARS

    Vertical/Longitudinal         Assn with ACL
    Bucket Handle            Vertical with displacement
    Oblique/Flap/Parrot beak    May cause mechanical symptoms
    Radial
    Horizontal            Common in elderly, ass’n with cysts
    Complex

 

220

WHAT MRI FEATURES SUGGEST PRIMARY ABC VERSUS SECONDARY?  DON'T TREAT TELANGIECTATIC OS!!!!!!

•    Lack of soft tissue component 
•    GAD will light up septa in primary lesion but not secondary
•    Look for perilesional edema to decipher from OS


Sources AAOS and radiology journal

 

221

List 5 Medications/Drug Therapies Associated with Osteopenia

  • Anticonvulsants
  • Steroids
  • Heparin
  • Excess Thyroid medication
  • Aromatase inhibitors
  • Testosterone antagonists
  • Immunosuppressants

222

A quickie, but something I came across that I could imagine being asked as a short-answer or osce question.

What are the most common and concerning positioning-related complications related to the prone position (especially spine)?

UE - Peripheral/Plexus neuropathy - (Shoulders abducted no more than 90deg, elbows 90deg, forearms pronated)
Pelvis - LFCN or Fem n compression on bolsters/posts - (Check & re-check position/impingement)
Face, Breasts, Genitals - Compression - (Adjust posts/padding, check during long procedure)
POVL (Post-op Vision Loss) - Most secondary to ischemic optic neuropathy (mechanism unknown, but associated with prone position, Mayfield, >6hrs anesthetic time, blodd loss> 1L), some are central retinal artery occlusion due to direct pressure.

 

223

STATE WHETHER EACH OF THE FOLLOWING IS AD, AR, OR X-LINKED RECESSIVE

NF1
Becker Muscular Dystrophy
Friedrich’s ataxia
Gaucher’s
Hemophilia A
HMSN-1
Marfan
OI 1
OI 2
OI 3

OI 4

-    NF1                                               AD
-    Becker Muscular Dystrophy         X-linked recessive
-    Friedrich’s ataxia                            AR
-    Gaucher’s                                      AR
-    Hemophilia A                                  X-linked recessive
-    HMSN-1                                         AD
-    Marfan                 AD
-    OI 1                AD
-    OI 2                AR
-    OI 3                AR
-    OI 4                AD

remember in general:
•    AD gene → structural deformities
•    AR gene → enzymatic / biochemical defects
•    translocations / deletions → chromosomal abn

 

224

WRITE OUT YOUR STEPS FOR A TERRIBLE TRIAD

•    Lateral decubitus position, flouro, k-wires, plates, screws, etc
•    Universal posterior approach skin incision
•    Go lateral first (Aconeus/ECU interval)
•    ? Can I see across to coronoid and reduce it 
        o    Yes - fix coronoid with PA screws(or lasso) on Ulna                and then fix or replace radial head
        o    No - Fix or replace radial head
                         Go medial - ID and protect ulnar nerve 
                             •    Flexor pronator split vs. subcutaneous                                elevation of flexor pronator mass
                              o    Fix coronoid
•    Repair LCL
•    Assess stability    

         o    Yes stable - close up you're done
         o    No unstable - fix MCL
                        Check stability
                          -  Yes stable - close up you're done
                          -   No unstable - hinged external ixator...with                           a hope and a prayer
•    I think this follows King's alogorythm

•    Splint 1-2 weeks, wound check, 2-6 weeks hinged elbow brace ROM active + self assisted passive, 6 weeks D/C elbow brace ROM active and passive, 12 weeks reassess

 

225

LIST THREE RADIOGRAPHIC (PLAIN FILM) FEATURES OF A DISCOID MENISCUS

-    Lateral femoral condyle squaring
-    Increased joint space (up to 11 mm)
-    Cupping of the lateral tibial plateau
-    Hypoplastic lateral intercondylar spine

 

226

NAME 5 COMPLICATIONS SPECIFIC TO A PEDS LATERAL CONDYLE # 


•    Tardy ulnar nerve palsy
•    Non union

•    Cubitus valgus
•    Acute nerve injury (rare)
•    Lateral condylar overgrowth
•    AVN
•    Cubitus varus


Ref: Chief review notes

 

 

227

CAUSES FOR SUPRASCAPULAR NEUROPATHY

•    Suprascapular notch compression (most common)
•    Spinoglenoid notch cyst
•    Synovial mass
•    Traction neuropathy (overhead athletes)
•    Massive retracted cuff tear in the elderly
•    Humeral fracture dislocations


JAAOS

 

228

List 5 Indications for Hip Arthroscopy

  • Chondral injury
  • Labral tears
  • Loose bodies
  • Synovial disorders
  • Ligamentum Teres rupture
  • Impinging osteophytes
  • Mechanical symptoms NYD

 

Miller's p267

229

LIST 4 FRACTURE PATTERNS SUGGESTIVE OF CHILD ABUSE


-    Metaphyseal corner fractures
-    Posterior rib fractures
-    Multiple fractures at different stages of healing
-    Femur (long bone) fracture in non-ambulatory child
-    Scapular fracture
-    Vertebral compression and SP #’s
-    Epiphyseal separation

 

230

10 Techniques to Improve Fixation in Osteoporotic Bone

  • Large thread diameter screws
  • Place screws parallel across cancellous trabeculae
  • Get fixationin cortical bone
  • Use fixed angle constructs (locking plates)
  • Augment screw fixation with PMMA
  • Antiglide plating
  • IM nailing
  • Place IM nail locking screws in different planes
  • Double plating
  • Longer plates with widely spaced screws
  • Tension band constructs
  • Bone graft augmentation

231

INTRAARTICULAR SPREAD OF METAPHYSEAL OM TO WHICH JOINTS?

-    SHEA Stadium

-    Shoulder
-    Hip
-    Elbow
-    Ankle

 

NOT the knee

232

WHAT ARE 6 SPINE CONSIDERATIONS IN ACHONDROPLASIA?

-    Foramen Magnum Stenosis
-    Thoracolumbar kyphosis
-    Short pedicles
-    Decreased intrapedicular distance
-    Lumbar Lordosis
-    Lumbar stenosis
-    Vertebral scalloping

 

233

LIST 5 ABSOLUTE INDICATIONS FOR REPLANT OF A TRAUMATIC UPPER EXTREMITY AMPUTATION


•    Any level thumb
•    Amputation of multiple digits
•    Amputation through palm
•    Wrist / forearm / below elbow
•    Any level in a child
Manny's notes

234

RISK FACTORS FOR ADHESIVE CAPSULITIS

•    Female
•    Cardiovascular Disease
•    Thyroid disease
•    Breast cancer treatment
•    Stroke
•    MI
•    Diabetes


Ref: JAAOS

 

235

ENERGY EXPENDITURE IN AMPUTATION LEVELS

-    From lowest consumption to highest
o    Syme
o    Midfoot
o    BKA
o    Through Knee
o    AKA

 

236

LIST 3 OPTIONS TO MANAGE LAMOTHE'S AMBRI


•    Physical therapy & rehabilitation
•    Inferior capsular shift / plication
•    Rotator interval closure
•    Psychiatric referral 


Miller's p276.

 

237

5 COMPLICATIONS OF DURAL TEARS


•    positional headache
•    wound complications
•    meningitis
•    arachnoiditis
•    pseudomeningocoele (10%)

 

238

ORDER OF APEARANCE AND CLOSURE IN PEDIATRIC ELBOW

-    Appearance: CRITOE

o    Capitellum            1    

o    Radial head            5

o    Internal epicondyle        5

o    Trochlea            9

o    Olecranon            9

o    External Epicondyle        10

-    Closure

o    Lateral Epicondyle        10

o    Capitellum            12

o    Trochlea            14

o    Radial head            15

o    Olecranon            15

o    Medial Epicondyle        16

 

239

List 3 Technical Advantages of Using an Inducible Membrane Instead of Just Slapping some Graft in the Defect

  • Protection against autograft resorption
  • Relative maintenance of graft position
  • Prevention of soft tissue interposition

240

LIST THREE PREDICTORS OF FAILURE OF ARTHROSCOPIC BANKART REPAIR

•    Age < 20 (33% failure vs 4% if > 30 Yrs)
•    Overhead or contact athlete
•    Hill Sachs defect on AP in external rotation
o    Or loss of sclerotic inferior glenoid border
o    lesions visualized in this view are high risk
•    Hyperlax individual (Jer)
•    Glenoid bone loss


REFERENCE: BOILEAU, P - vumedi webinar 
Or Instability Severity Score JBJS (Br) Boileau 2007

 

241

LIST 5 ABSOLUTE INDICATIONS FOR AN AMPUTATION

o    B has the trauma room
o    Life threatening infection with unsalvageable necrosis

o    Partial traumatic amputation
o    Irreparable vascular injury
o    Warm ischemia time > 8 hours (not talking about a finger here)
o    Nonviable limb 
o    Poor host
o    No resources to facilitate salvage

 

 

242

OSCE SHOULDER INSTABILITY - WHAT ARE THE CLASSIC LESIONS?

•    Patulous inferior capsule (ant and post IGHL)
•    Functional deficient rotator interval

 

243

R HAGL - HOW ARE YOU GOING TO TREAT THE FOLLOWING LESIONS IN A 25 YR OLD (FOLLOWING THE BOORMAN DOGMA OF SOFT TISSUE FOR SOFT TISSUE AND BONE FOR BONE)?

•    Non-op and Refer

244

LIST 5 COMPLICATIONS OF ROTATOR CUFF REPAIR

•    Infection (p. acnes)
•    Stiffness
•    Deltoid dehisence (open)
•    Severe edema (arthroscopic)
•    Suprascapular nerve injury
•    Missed pathology: biceps tendinitis

 

245

LIST 4 RISK FACTORS FOR NON UNION OF ANKLE ARTHRODESIS

 

•    A severe fracture (combined Plafond-talus, Hawkins 2/3)
•    An open fracture
•    Local infection
•    Evidence osteonecrosis talus
•    Coexisting major medical problems
•    Smoking (16x increased risk)
AAOS

 

246

WHAT 3 FEATURES WOULD LEAD YOU TO DO A 2 STAGE CONVERSION FROM EXTERNAL FIXATION TO NAIL?

•    >2 weeks
•    Loose pin sites
•    Fever

•    Increased WBC
•    pus

 

 

247

HOW ARE HALOS DIFFERENT IN KIDS?

•    Kids:  consider a CT before hand to determine pin placement and determine cranial thickness. Use 10-12 pins at lower torque (2 in-lb)

 

248

 LIST 6 CAUSES OF SECONDARY OSTEOPOROSIS (IE NOT POST MENOPAUSAL/AGING)

Life Style Factors

- Anorexia nervosa

- Excessive protein intake

- Smoking

- Excessive alcohol intake

Endocrinopathies

- Hyperthyroidism

- Hyperparathyroidism

- Cushing's syndrome

- Type 1 diabetes melitus

- Hypogonadism

Systemic Diseases

- Gaucher's disease

- Mastocytosis

- Rheumatoid arthritis

- Ankylosing spondylitis

- Psoriasis

Organ Dysfunction

- Cystic fibrosis

- Asthma

- Chronic obstructive pulmonary disease

- Renal failure

- Primary Biliary cirrhosis

- Inflammatory bowel disease

- Celiac sprue

- Organ transplantation

Medications

- Glucocorticoids

- Diuretics

- Antiepileptics

- Methotrexate

- Cyclosporin A

- Excess thryoid hormone replacement

- Alkylating chemotherapeutic agents

- Gonadotropin-releasing hormone agonist

Neoplastic conditions

- Multiple myeloma

J Am Acad Orthop Surg 2005;13:475-486

 

 

 

 

 

 

249

LIST THE BORDERS OF THE ROTATOR INTERVAL

•    Superior - Supraspinatus
•    Medial - Coracoid
•    Lateral - Transverse humeral ligament
•    Inferior- Subscapularis

 

250

WHAT LOCATION FOR ANKLE OSTEOCHONDRAL LESIONS HAVE THE WORST OUTCOMES?

 

•    Posterior plafond/medial mall and anterior/lateral of the talus (horisberger study)
•    The anterior talus was the worst

251

3 RADIOGRAPHIC FEATURES SUGGESTING MALIGNANT TRANSFORMATION OF AN OSTEOCHONDROMA

 

•    Cartilage cap > 1 cm in an adult (kids can be as thick as 2-3 cm at times)
•    Sudden increase in uptake on bone scan in an adult
•    Confirmation by CT or MRI of a soft tissue mass

 

252

LIST 5 EXTRASKELETAL MANIFESTATIONS OF OI

•    Blue sclera
•    Dentinogenesis imperfecta
•    Hearing loss (can have either conductive, sensorial, or  both)
•    This skin prone to hemorrhage
•    CV disease (MV prolapse, Aortic regurg)
•    Hypermetabolism (heat intolerance, hyperhidrosis, tachycardia, tachypnea)
•    Pulmonary – decreased excusion
•    Allopecia

JAAOS 2008

253

WHAT ARE 4 WAYS TO CHECK FOR NECK FRACTURE ASSOCIATED WITH HIGH ENERGY FEMORAL SHAFT FRACTURE?

•    AP with IR hip x-ray pre-op
•    Dedicated femoral neck CT with fine cuts 
•    Lateral fluoro intra-op
•    Post-reduction/pre-extubation do AP and lateral hip

 

Tournetta paper 2007, showed reduction in missed fractures from 58%  10%
Ipsilateral neck: shaft in 2.5  9% of high energy femoral shaft fractures
30% are missed initially according to 1993 paper by Bennett (CORR)

254

LIST THREE RISK FACTORS FOR RECURRENCE OF POSTERIOR SHOULDER DISLOCATION

•    Age < 40
•    Dislocation due to a seizure
•    Large Reverse Hill Sachs as defined by > 1.5 cm3


I know there are more, but these came from a paper Duffy stressed us to know back in the fall (Robinson et al., 2011 JBJS)

 

255

TRUE OR FALSE: IT IS NORMAL FOR A NEW BORN TO HAVE FLEXION CONTRACTURES?

•    TRUE flexion contracures should be present: 
o    Knee 21 degrees
    decrease to 11 degrees at 3 mos and 3 degrees at 6 mos
o    Hip
o    Elbow

 

256

BRACHIAL PLEXUS

•    Well, draw it chump!

257

LIST 5 NON-SKELETAL MANIFESTATIONS OF RA


o    Vasculitis
o    Pleurisy
o    Pericarditis
o    Fever
o    Splenomegaly
o    Leukopenia
o    Decreased lacrimal and Salivary gland production (Sjogren's)
o    Lymphoid proliferation
o    Rash
o    Iridocyclitis (JRA)
o    Miller's p48

258

NAME 5 REASONS TO OPERATE ON DISCITIS

-    Neurological deficit (tx by decompression)
-    Failed structural stability
-    failed medical management
-    sepsis
-    persistent pain
-    drainage of abcess
-    failed percutaneous biopsy x 2 (for tissue dx)
chief notes

 

259

WHAT ARE THE PROS AND CONS OF EACH GRAFT OPTION?

1.   Hamstring:  

 

2.  Allograft:  

 

3.  BTB:  

1. o    small size, particularly in smaller women, 
o    morbidity associated with harvest, 
o    increased surgical time, 
o    decreased hamstring strength (particularly important in explosive athletes) in Terminal flexion

2.  o    Increased failure in young, active
o    infection rate (theoretical however), 
o    the quality of the graft is dependent on the individual it comes from
o    the handling and sterilization performed by the processor

3.  o    Bone:bone healing is good
o    Anterior knee pain, 
o    Potential for patellar fracture, 
o    Will result in a really long graft if patient has patella alta

 

 

 

260

LIST 4 ADVANTAGES OF LATERAL POSITIONING FOR ANTEGRADE FEMORAL IM NAIL

•    Ideal for the obese patient
•    Easier for the trochanteric entry hole;
•    Better control of proximal 1/3 frx 
    Tend to angulate in varus w/ supine position
•    Lower risk of Pudendal nerve palsy (thanks to bigger posts? No reports of injury in lateral position)

 

Wheeless

http://orthopaedicprinciples.com/2011/06/current-concepts-in-im-nailing-of-femoral-shaft-fractures/
-    This web site has lots of good lists...

 

261

LIST 5 COMPLICATIONS OF FLEXIBLE NAILING

•    Malunion
•    Non-union (usually hypertrophic)
•    Insertion site irritation
•    Septic knee
•    leg length discrepancies (over or under)
•    Acute synovitis (non-infectious)
•    Re-fracture
•    Growth plate injury (...not in RW but I almost thought I did a transphyseal nail once...I didn't)
•    Malrotation (not mentioned but reasonable)

 


RW p815

 

262

OSCE - Bisphosphonates

Have a 70 yo woman with 10 years of Bisphophonate use.  She is in your clinic - has one month history of mild thigh pain - seems mechanical in nature.  Radiographs show good femoral cortices bilaterally, no stress fracture.  What is your next course of management?

  • If the patient has pain and no findings of fracture on x-ray, can order a bone scan or MRI looking for increased uptake or peri-lesional edema (stress fracture)
  • If the patient has minimal pain, can have them go home NWB with follow-up once the investigations are completed.
  • Endo consult - D/C bisphosphonates, Vitamin D and calcium, consider teriparatide.

263

FOOT AND ANKLE
CAVUS (CMT - WEAK PB AND STRONG PL AND WEAK TA AND STRONG PL)

 

WHAT ARE OPERATIVE STRATEGIES?

•    Hindfoot procedures only if no correction with coleman block
•    Triple for arthritis
•    Think forefoot, hindfoot, soft tissue and bone:
o    Address claw big toe (EHL transfer plantarly to 1st toe with IP fusion = 1st toes jones)

o    Address claw toes 2-5: MTP dorsal capuslotomy, EDB tenotomy and EDL lengthening or release and transfer EDL proximally +/- fusion of of IP's depending on flexible or fixed claw toes
o    PF release - Turco incision medially, ID and protect ML plantar nerves, seperate PF from tendons and subcu tissue and release
o    DF 1st ray opening wedge proximal MT osteotomy
o    Calcaneous: Lateral sliding  or Dwyer closing wedge (lateral incision, oblique and slide, fix with 2 7.3 screws)
o    TAL

 

 

264

WHAT ARE THE STEPS IN RESPONSE TO AN INTRAOPERATIVE SSEP/MEP CHANGE DURING SPINE SURGERY?

 


•    Discontinue spinal instrumentation, release distraction forces
•    Rule out technical factors (electrodes)
•    Rule out anesthesia related concerns (Inhalational anesthetic - stop)
•    Elevate MAP (>90)
•    Increase O2 concentration
•    Irrigate wound with warm saline
•    Assess ABG (metabolic abn or low Hgb)
•    if no return - remove last step of hardware, or wake up test
•    If still no change, remove spinal instrumentation or anterior strut/cage
•    Consider use of corticosteriod

 

JAAOS 2007:
•    This is for SSEP amplitude decrease >50% or MEP decrease  >75%
•    MEP amplitude loss in presence stable SSEP not uncommon, but opposite BAD (rare)

265

•    You are a community orthopaedic surgeon and have just finished a R TKA on a patient. While dictating you realize you have may have put in a left femoral component. The patient is in the recovery room.

•    What do you do?

•    What is the consequence of placing a left femoral component in a right knee?

•    What do you tell the patient?

•    How could this mistake have been avoided?

266

LIST 5 CONDITIONS ON DIFFERENTIAL DIAGNOSIS IN A < 4 YR OLD, 4-10 YR OLD AND > 10 YR OLD WITH A LIMP

 

4-10 yrs of age

-    Fracture
-    OM, septic joint, discitis
-    LCPD
-    Transient synovitis
-    Osteochondritis dissecans
-    Discoid meniscus
-    Sever's disease
-    Accessory navicular
-    Arthritis (JRA or Lyme disease)
-    Benign or malignant tumor

 

267

OSCE:  You are called to see a 4 day old child in the NICU who is not moving.  What is the top 3 on your differential diagnosis?

 

  • trauma
  • infection 
  • brachial plexus

268

OUTERBRIDGE ARTHROSCOPIC CLASSIFICATION

    Type 1        Softening and swelling only (can’t see must                                probe)
    Type 2        Fissuring, < 1.5 cm diameter
    Type 3        Crabmeat changes >1.5 cm, fissure to                                           subchondral bone
    Type 4        Exposed subchondral bone

 

269

What are 4 Disadvantages of HCLPE?

Miller p. 307-8

Disadvantages of HCLPE

  • Decreased tensile strength (pulling force to break)
  • Decreased fatigue strength (maximum cyclic stress)
  • Decreased fracture toughness (force to crack)
  • Decreased ductility (elongation without fracture)
  • Increased cost
  • No long term data
  •  

Advantages

  • Improves resistance to adhesive and abrasive wear
  • Improves bearing wear rate

 

270

NAME THE AFFECTED GENE

Achondroplasia
NF1
Diastrophic dysplasia
Pseudochondroplasia
Cleidocranial dysplasia

Marfan’s
Hemophilia B
Jansen’s
CMT
Duchenne’s/Beckers
Myotonic Dystrophy
SMA

 

 

-    Achondroplasia                            FGFR3
-    NF1                                                neurofibromin
-    Diastrophic dysplasia                  Sulfate transporter gene
-    Pseudochondroplasia                   COMP
-    Cleidocranial dysplasia                 CBFA1/osteocalcin
-    Marfan’s                                          fibrillin
-    Hemophilia B                               Factor IX
-    Jansen’s                                         PTHrP receptor
-    CMT                Peripheral Myelin Protein22
-    Duchenne’s/Beckers        Dystrophin
-    Myotonic Dystrophy        Myotonin
-    SMA                Survival Motor Neuro Protein

271

LIST 5 WAYS TO DISTINGUISH A CONGENITAL RADIOCAPITELLAR DISLOCATION FROM AN ACUTE ONE

 

Congenital ones are:
•    Often bilateral
•    Often have a misshapen radial head
•    The affected radius is longer than the ulna
•    The capitellum is hypoplastic 
•    The distal humerus is grooved 
•    The ossification is more advanced than on the opposite side.         Ref: Rang book


-    Convex radial head
-    Hypoplastic capitellum
-    Short ulna with long curved radius
-    Bilateral
-    Posterior dislocation      Reference millers 5th ed p461

 

 

272

LIST 5 CONTRAINDICATIONS TO ROTATOR CUFF REPAIR

•    Infection
•    GH arthritis
•    Acromial humeral distance < 7 mm
•    Deltoid axillary nerve dysfunction
•    Atrophic cuff/chronicity/retraction

 

273

LIST THREE METHODS OF DETERMINING PATELLA HEIGHT

Knee has to be at 30 deg flexion for all three of these methods to be valid

-    Inferior pole relationship to Blumensaat's line
-    Blackburn-Peel ratio: 

          o    Distance from tibial plateau to inferior border of               articular surface / length of articular surface = 0.8 (<1)
          o    An index of 1 is alta
-    Insall-Salvati ratio: 
          o    Length of patella tendon (LT) / Length of patella              (LP). LT/LP = 1, >1.2 = alta, < 0.8 = Baja
-    Miller's p252

 

 

274

LIST THE STEPS IN AN ACHILLES TENOTOMY?


•    Prepare the family
•    Position the patient - need an assistant to keep foot in maximum dorsiflexion
•    Local aneasthetic to site
•    Aseptic preparation from midfoot to mid leg
•    11 blade, longitudinal incision on the medial side of achilles 1.5 cm above os calcis
•    Perform complete tenotomy from anterior to posterior direction (must get "pop") and should see increase in DF by about 15-20 deg
•    Dress site and apply cast (15 to 20 DF and 60-70 deg of abduction), remain in place for 3 weeks

275

Name 4 causes of hemihypertrophy?

•    Idiopathic
•    Neurofibromatosis
•    Beckwith-Weidmann Syndrome
    Macroglossia, macrosomia, midline abdominal wall defects, ear creases/pits, neonatal hypoglycemia
    Can be one limb or a whle side of boy
    *Increased Risk of Childhood Cancers*  Wilm's Tumour, hepatoblastoma, adrenal cortical carcinoma, neuroblastoma, rhabdomyosarcoma
    Cancer screening - abdominal U/S q 3mos until age 8, AFP q 6 wks until age 4
1.    Wilm's Tumour (aka nephroblastoma)
◦    Painless abdominal mass
Dx  - Abdominal U/S

 

276

LIST 6 CLINICAL EXAM FEATURES YOU MAY FIND IN KIDS WITH FLEXIBLE PES PLANOVALGUS


-    Valgus knee
-    Increased ER of tibia
-    Decreased femoral anteversion
-    Tight heel cord (or gastroc)
-    Hypermobile first ray
-    Obesity
-    Generalized ligamentous laxity
-    Normal reconsitituion of the arch with the jack toe test

 

277

Risks for Peroneal Nerve Palsy Post TKA

  • Valgus > 12
  • Abberant retractor
  • Epidural anesthesia
  • Previous laminectomy
  • Peripheral neuropathy

These last two are due to "doublecrush" phenomenon

 

Basic Science

278

RISK FACTORS FOR DEVELOPING A SOFT TISSUE SARCOMA

•    Li-Fraumeni
•    Retinoblastoma
•    NF-1
•    HIV
•    Prior radiation
•    EBV (controversial)


A collection of JAAOS, Miller's, and AAOS COR

 

279

ETIOLOGY OF CHARCOT SHOULDER

•    Syrinx most common

•    DM2

•    Leprosy

•    Syphillis

•    Alcoholism

280

LIST TWO DIFFERENCES BETWEEN A POSTERIOR HIP DISLOCATION AND KOCHER-LANGENBACH FOR AN ACETABULAR WALL FRACTURE

 


-    Take less external rotators off with the acetabular approach
o    Save quadratis and OE
-    The classic KL incision aims more towards the PSIS rather than straight
-    Release the ER off the femur
o    Directly off bone in a THA and leaving a 1 cm cuff with KL

 

281

WHAT ARE THE STRENGTHS OF THE KNEE LIGAMENTS

    MCL 4000 N
    PCL 2500 N
    ACL 2200 N
    LCL 700 N

 

282

LIST 3 FEATURES OF MHE

-    EXT 1 or EXT 2 or even EXT 3 
-    AD
-    10% malignant risk
-    Knee > shoulder
-    Limb deformity
-    Ulna bow
-    Radial head dislocation
-    Sessile or pedunculated
-    Lesions grow away from the physis
-    Lesions are in continuity with IM canal (differentiates from parosteal osteosarcoma)

 

283

ASSOCIATED FINDINGS IN ACUTE ACL TEAR

-    Hemarthrosis
-    Bone bruise
o    mid-third lateral femoral condyle
o    post-third lateral tibial plateau
-    Lateral meniscus tear
-    Segond fracture
o    Lateral capsular avulsion of tibia

 

284

NAME 3 WAYS TO RADIOGRAPHICALLY DETERMINE THE CARRYING ANGLE OF A PEDIATRIC ELBOW


•    Bauman's angle (not that good in older children where start to get fusion of the ossification center)
•    Metaphyseal-diaphyseal angle (least accurate)
•    Humeral-ulnar angle (best)

Source:  Rockwood and Wilkins

 

285

LIST THE THREE KEY LIGAMENTOUS STABILIZERS OF THE LISFRANC ARTICULATION (SPECIFICALLY THE BAST OF THE 2ND MT BASE AND MEDIAL CUNEIFORM)

 

•    Interosseous ligament (largest; 8 mm thick)
•    Plantar (second largest)
•    Dorsal (small and whimpy)
See reference - Anatomy of the Lisfranc Ligament Anthony Johnson 2008

 

286

WHAT ARE THE STRENGTHS OF THE ACL LIGAMENT GRAFTS

-    Load-to-failure
o    Hamstrings 4000 N load-to-failure
o    Quadriceps in between
o    BTB 2600 N load

o    Native ACL: 2200N

287

WHAT IS A LIKELY DIAGNOSIS IN A CHILD WITH NO FLEXION CONTRACTURES OF HIPS OR KNEES?

•    Larsen syndrome

288

SMALL ROUND CELL TUMORS (7)

-    Ewings
-    Lymphonma
-    EG
-    Neuroblastoma
-    PNET
-    Rhabdomyosarc
-    Myeloma

 

289

77 yo woman with periprothetic greater trochanter fracture.  What would you do in each of the cases?

Stem and acetabular component stable, mecanical fall with no previous symptoms.

 

  • Displaced > 2cm, no osteolysis
  • Displaced > 2cm, osteolysis
  • Displaced < 2cm, osteolysis
  • Displaced < 2cm, no osteolysis

 

  • ORIF
  • ORIF and bone graft
  • Some controversy - can either leave to heal or if osteolysis significant, can ORIF with bone graft
  • Treat non-op

290

LIST 3 INDICATIONS TO OPERATE ON CERVICAL RADICULOPATHY

-    Failure of at least 6 weeks of non-op management
-    Progressive neurological deficit
-    Instability or deformity + radiculopathy
-    Significant motor deficit (deltoid or wrist extension deficit)

 


Chief notes

 

291

LIST 3 REQUIREMENT TO MAKE CAUSALITY

-    Association
-    Prediction
-    Excluding alternative
-    Dose response

 

292

WHAT ARE 3 OTHER RADIOGRAPHIC RISK FACTORS FOR OSTEONECROSIS IN PROX HUM # (HELFET CRITERIA)?

vascularity of articular segment more likely to be preserved if
•    > 8 mm of calcar attached to articular segment
•    integrity of medial hinge
•    fracture pattern (anatomic neck)

 

293

WAYS TO JUDGE HEIGHT OF RADIAL HEAD HEIGHT 

•    Piece it together on the back table and compare
•    Proximal implant should line up with the proximal lesser sigmoid notch
•    Inspection should show no lateral ulnohumeral gapping (medial side starts to gap at 6 mm)
•    DRUJ has appropriate ulnar variance compared to the contralateral side.
•    Template off the contralateral side
Ref: mostly Athwal JBJS 2010

 

294

NAME 3 PEDIATRIC CONDITIONS ASSOCIATED WITH BASILAR INVAGINATION?

-    AKON
-    Morquios
-    SED

 

295

HAGL - HOW ARE YOU GOING TO TREAT THE FOLLOWING LESIONS IN A 25 YR OLD (FOLLOWING THE BOORMAN DOGMA OF SOFT TISSUE FOR SOFT TISSUE AND BONE FOR BONE)?

•    Rehab
•    then open repair (I am referring this one)

 

296

LIST 3 INDICATIONS FOR NON-OPERATIVE MANAGEMENT OF A TERRIBLE TRIAD

•    Minimally or nondisplaced fractures of coronoid and radial head
•    Congruent reduction
•    Stable arc of motion, extension > 40 deg


Vumedi Webinar Graham king

 

297

3 CAUSES OF NON-IDIOPATHIC CLUB FOOT?

•    Arthrogrypotic
•    Myelomeningocele

•    Diastrophic dysplasia
•    Amniotic band syndrome

 


AAOS

 

 

298

LIST 5 PATIENT FACTORS YOU SHOULD CONSIDER WHEN DECIDING UPON TREATMENT OF TRAUMATIC SHOULDER INSTABILITY IN PERSON (OSCE)

•    Age
•    Sport
•    Level of sport participation
•    Laxity
•    Soft tissue lesions
•    Bone lesions on glenoid
•    Bone lesions on humerus

 

299

LIST 3 STRUCTURES CONTAINED WITHIN THE ROTATOR INTERVAL


•    Biceps tendon
•    SGHL
•    CHL
•    Glenohumeral capsule

Hunt, et. al. JAOSS 2007 15 p218-219

300

What 3 conditions give a classic Erlenmeyer Flask Deformity to the Metaphyses?

  • Gauchers
  • Osteopetrosis
  • Niemann-pick

301

NAME 3 CONDITIONS ASSOCIATED WITH CVT?

-    Myelomeningocele
-    Syrinx
-    Arthrogryposis

 

302

LIST 11 STRUCTURES PASSING THROUGH GREATER SCIATIC FORAMEN

-    Superior gluteal artery and nerve
-    Piriformis
-    Internal Pudendal artery and pudendal nerve
-    Nerve to Obturator internus
-    Posterior femoral cutaneous nerve
-    Sciatic nerve
-    Inferior gluteal artery and nerve
-    Nerve to Quadratus femoris


POPS-IQ below piriformis…

 

303

NAME 5 PREDICTORS OF POOR PROGNOSIS FOR ROTATOR CUFF REPAIR

-    Marked atrophy or fatty infiltration of spinate muscles on MRI ( >50% (grade IV) Sagittal T1)

-    Acromiohumeral distance less than 5 mm on AP (<3mm --> very poor)

-    Dynamic antero-superior subluxation of humeral head on resisted abduction

-    Irreparable tears of the subscapularis or teres minor

-    Poor tissue quality

-    Loss of GT from prior surgery

-    Poor patient compliance

-    Axillary nerve or suprascapular nerve deficit

-    Pseudoparalysis without pain

-    Chronic tears longer than 1 yr

-    History of deltoid injury or acromioplasty

-    Prior infection

-    Presence of Os Acromiale

Complex And Revision Problems In Shoulder Surgery - By Jon J. P. Warner, Joseph P. Iannotti, Evan L. Flatow & ICL 55-5

304

HOW DO YOU DEAL WITH IT IF YOU'VE CAUSED IT?


•    Mild , 7-10 degrees - usually asymptomatic
o    Can treat with dressing/splint opposite direction of bunion splint

•    Moderate severe – 
o    EHL tendon transfer, use medial capsular incision and release joint capsule. then release lateral 2/3's of EHL distally and pass plantar to transverse metatarsal ligament . drill hole through 1st metatarsal head and attach to medial periosteum holding toe in 10-15 degrees of valgus

305

LIST 3 FEATURES OF Gardner syndrome (Familial Colorectal Polyposis)

 

o    Osteoma
o    Desmoid tumors
o    Thyroid carcinoma
o    Fibromas

 

-    Multiple enostosis (bone islands)
-    Colorectal polyps
-    Fibromas
-    Sebaceous cyst

 

306

List the 3 Conditions of Miserable Malalignment

  • Femoral anteversion
  • Genu valgum
  • Pronated feet