OITE: Orthobullets Key Concepts

Initial treatment of elbow MCL injury in the juvenile thrower.

6 weeks activity restriction. Begin therapy for flexor pronantor mass strengthening after period of activity restriction.

Brake time guidelines

6 weeks post weight-bearing (long bone) 9 weeks post-op (ankle fx) Based on some studies by Egol

Normal alpha angle

60 degrees

Energy expenditure with unilateral transfemoral amputation?

65%

2 mm of shortening associated with a metacarpal frx is associated with what degree of extensor lag?

7 degrees for every 2 mm of extensor lag

After applying Pavlik harness, how long do you wait before obtaining an ultrasound?

7-10 days

Gunshot wound through abdomen and into vertebral body - treatment?

7-14 days IV abx broad spectrum

Low velocity gunshot through abdomen and into ilium - treatment?

7-14 days abx, observation

Thinnest PE you should use

8 mm

What measurement indicates a C1 fracture or transverse ligmament rupture

8.1 mm of total lateral mass displacement

After a digit replantation what pulse ox reading is worrisome for vascular compromise?

94%

Linear wear rates of polyethylene greater than ______ are associated with implant failure in total hip arthroplasty

< 0.1 mm / year

Arterial Thrombosis occurs in what time range following finger replantation procedure?

< 12 hours. After twelve hours consider venous congestion.

Normal HVA

< 15

Normal IMA

< 9

At what ABI is healing significantly impaired and amputation contraindicated?

<0.5

Steroid treatment of acute spinal injury

<3 hours = 5.4 mg/kg x 23 hours 3-8 hours = 5.4 mg/kg x 48 hours

Normal ADI (Adult and Child)

<3 mm (Adults) <5 mm (Children) ADI > 7 = Rupture of transverse, alar, apical, and tectorial membrane

How do you decide that a posterior wall acetabular fx is non-operative?

<40% fragment Stable on dynamic fluoroscopic examination

Below what age could you consider spica casting for a femur fracture with less than 2 cm of shortening?

<5

How much tibial widening after ORIF of plateau fracture is acceptable without adversely affecting outcomes?

<5 mm

Signs of vascular compromise in replanted digit

> 2 degree drop in an hour, temp < 30

When do you fix ASIS avulsion fracture?

> 3 cm displacement

Scheurmann Kyphosis - Name 3 diagnostic criteria

> 45 degrees, wedging of 5 degrees on 3 subsequent vertebrae, does not correct with extension

Risk Factors for Odontoid Non-union

> age 50, > 6 mm, posterior displacement, comminuted, angulated > 10 degrees, delay in treatment

Abnormal TT-TG Distance

>20 operative. Do not correct to less than 10.

Initiate DCO for what ISS scores?

>20 with thoracic injury >40 without thoracic injury

What percentage of glenoid must bankart consist of to warrant bone replacing procedure (Bristow/Latarjet)?

>20%

Radiographic indication to proceed with extraarticular scapular fracture involving the glenoid

>40 degrees angulation or > 1 cm displacement

What percentage of the physes need to be damaged before epiphysiodesis is indicated?

>50%

Unacceptable alignment of proximal humerus fractures in children

>60 degrees angulation (10-13 yo) >45 degrees or 2/3 displaced (<13)

Serendipity Views

Clavicle views at 40 degrees cephalad and caudad....visualizes anterior versus posterior translation. Useful for SC dislocations and medial clavicle physeal separations.

Hunter Syndrome Mnemonic

Clear-eyed hunters tend to be males (X-linked recessive)

What are the relationship of Cleland and Grayson's ligaments to the volar digital nerve?

Cleland is above (dorsal), Grayson is below (volar). Clelands ligaments are not involved in Depuytrens contracture (ABOVE it all)

Child floating elbow (distal radius + supercondylar humerus fracture) - how do you treat?

Closed reduction and pinning on both injuries. Elevated risk of compartment syndrome with just casting of the distal radius. (Ring et al)

Chondroblastoma (Histology)

Cobblestone pattern, Chickenwire Calcifications, coffee bean nuclei

For PCL deficient knee...increase or decrease tibial slope?

Increase the slope. Think about it in weight bearing...the femur slides down the slope and pushes the tibia forward

Hip dyplasia is associated with what anatomic variation in the proximal femur?

Increased femoral anteversion

What changes are seen on EMG/NCV in carpal tunnel

Increased insertional activity Fibrillation Sharp waves Increased motor latency (>4.5) Increased distal sensory latency (>3.5)

What happens within cartilage cells when they are affected by osteoarthritis?

Water content: Increased Collagen: Decreased / Disorganized Proteoglycan: Decreased Synthesis: Increased Modulus: Decreased

At what week is pecutaneous heel cord tenotomy undertaken in treatment of clubfoot?

Week 8

How long after THA must you wait before excising HO?

6 months minimum

Most common concommitant injury with hip dislocation?

Ipsilateral knee meniscus tear

Lateral wall collapse in calcaneus fractures causes what condition?

Peroneal tendonitis

Fracture through ABC

Wait for it to heal. If still growing then resect afterwards.

Optimum pore size for bone ingrowth

50-150 uM

Treat the following soft tissue deficiencies: Volar Thumb < 2 cm Volar Thumb > 2 cm Dorsal Thumb

- Moberg - FDMA Flap or Island Advancemet Flap (up to 4 cm) - FDMA Flap

Benefits of posterior (antiglide) plating for fibular fx

- Stronger biomechanical - Less hardware prominence - Decreased rates of intraarticular screw penetration

Treat the following soft tissue deficiencies: Finger Tip Dorsal Finger Volar Finger Large dorsal hand defect

- VY Advancement - Reverse Cross Finger - Cross Finger - Groin flap

MPFL is primary restraint to lateral translation of the patella at what knee position?

0-20 degrees. Just remember that you are testing the MPFL when you are measuring patellar glide

Timeline of DDH Treatment

0-6 months: Pavlik (d/c after 3 weeks if failed --> Abduction splint) 6-18 months: CR + Spica Cast 2-4 years: Open reduction + Femoral Osteotomy > 4 years: Open reduction + Pelvic osteotomy

Maximal wear rate before osteolysis

0.1 mm / year

Which lumbrical muscles are unipennate?

1 & 2 (controlled by the median nerve).

Describe the safe zone for halo pin placement

1 cm above the superior orbital rim and at the lateral 1/3 of the rim.

Indications for surgical treatment of Thoracolumbar burst fracture

1) Neuro Compromise 2) Instability (Posterior ligamentous complex damage, progressive kyphosis) 3) (Relative) Multiple fractures...encouraging early ambulation

Name three assocations with valgus extension overload at the elbow

1) Pain at Deceleration Phase 2) Posteromedial olecranon fossa osteophytes 3) Overresection of olecranon causes MCL stress and valgus instability

Radiographic indicator of lateral meniscus tear in the setting of tibial plateau.

6 mm joint widening

Inflection age - Both bone forearm fractures

10

Describe the Stryker Notch view

10 degrees off of AP with the arm above the head. Forms a notch between the humeral head and the lateral aspect of the scapula (see picture)

Ideal suture purchase in flexor tendon repair is located how far from the tendon edge?

10 mm

Where should the greater tuberosity be fixed relative to the articular surface of the humeral head?

10 mm below the surface

What weight is associated with higher failure rate of flexible nails?

100 lbs or 48 kg

Temperature that defines heat exhaustion versus stroke

102 or 40.5 degrees

What is the inflection point for an abnormal Drennan angle (Blount's dz)?

11 degrees - likely not just physiologic 16 degrees - definitive Blounts

Width of the superspinatus tendon

12 mm. >50% tear should be repaired

How long do you immobilize a diabetic with neuropathy after fixation of an ankle fracture

12 weeks

At what degree of glenoid retroversion is allograft reconstruction of the posterior glenoid a better option than eccentric anterior reaming?

15 degrees

Chromosome and gene involved in CMT

17 - PMP

What is maximum size nerve gap that can be bridged using an artificial conduit?

2 cm. Quality drops off below that of autologous grafting with defects > 5 mm

At what angle is it appropriate to fuse a Duchenne's spine?

20-30 degrees. Always order cardiology evaluation prior to surgery.

HO can be excised from the forearm after what time period and expect low recurrence rates?

6 months

How long until recovery of elbow motion after a supercondylar humerus fracture?

6 months (94% restoration of elbow motion)

How long should you continue abx in open fx treatment.

24 hours after definitive closure

Time period for stabilization of midshaft femur fracture to avoid complications?

24 hours. Optimal - but only if resuscitated and no head or pulmonary injury

At what cobb angle do you treat a skeletally immature child with TLSO bracing?

25-40 degrees

How long of a delay in abx admin after open fx is associated with increased complications?

3 hours

Jump Gait

3 levels of contracture: Hip and knee flexion, ankle equinus

How many cruciate pulleys are there and where are they lcoated?

3 total. Located over the shaft of the proximal and middle phalanx. Order of pulley ligaments: A1, A2, C1, A3, C2, A4, C3, A5

What is the ideal timeframe in which to fix flexor tendon injuries?

3 weeks

What length of time separates acute and chronic SCFE

3 weeks

Time before allowed to bill for new patient

3 years

When to obtain EMG when observing a radial nerve palsy

3-5 months

Maximum angulation of radial neck fracture for closed reduction

30 degrees

What is the post-exercise value for compartment pressure that indicates exertional compartment syndrome?

30 mm Hg within 1 minute 20 mm Hg within 5 minutes

Mortality rate after femoral neck fx at 2 years? w/ Kidney failure?

30%. 45% w/ CKD.

Mantra for shoulder arthrodesis

30-30-30 (30 Abduction, 30 Flexion, 30 Internal rotation)

When do you pursue spinal fusion in severe OI patients (at what angle)?

35 degrees

According to the Paprosky classficiation what is the minimum amount of diaphyseal bone required to support and long fully coated stem as opposed to a revision modular stem?

4 cm

What number is important to remember regarding the treatment of traumatic articular cartilage defects.

4 cm2 Femoral: < 4 cm = Microfracture / Autograft > 4 cm = Allograft / ACI Patella: < 4cm = Microfracture / Autograft > 4 cm = ACI

What time interval can pass before significant increase in 1 year mortality after femoral neck fx?

4 days

Initial Management Tibial Stress Fx

4-6 weeks NWB

Operative indications for extraarticular scapula fx

40 degrees angulation or 1 cm displacement

Energy expenditure with bilateral transtibial amputation?

40% increase

How long after surgery does it take before CRP starts to go down?

48 hours

What is the maximum duration to surgery to allow for good outcomes in cauda equina syndrome?

48 hours

Femoral neck fractures should be fixed in what time window?

48 hours. Higher rate of non-union outside of this but okay to delay if not medically optimized. Increased mortality rates if not treated within 4 days.

How far below prosthesis head should the greater tuberosity be located in hemiarthroplasty?

5-8 mm

How far above the pec tendon is the top of a hemiarthroplasty supposed to be?

5.6 cm

How far from the pec insertion should the head of the prosthesis sit when assessing a shoulder hemiarthroplasty or total shoulder arthroplasty?

5.6 cm. "Fifty six is where it sits!"

Denis Classfication

Classification of sacral fractures. Zone 3 (medial to the foramina) injuries are most likely to lead to neurologic dysfunction.

Which annular ligament are located over the finger joints?

A1 = MCP A3 = PIP A5 = DIP

What structure is typically involved in the development of trigger finger?

A1 Pulley

What annular pully is most commonly involved with trigger finger?

A1 pully

At what angle do you tension an ACL graft? A PCL graft.

ACL = 30 degrees PCL = 90 degrees Makes sense...want to tension at its most lax angle

What ligament is deficient in PFFD?

ACL absent

Cervical instability requiring C1-C2 fusion in a Down's patient is defined by.....

ADI > 10 mm or SAC < 14

What are the absolute measurement indication for a C1/C2 fusion in rheumatoid atlantoaxial instability?

ADI>10, SAC<14

What nerve is at risk during placement of pins during tension band fixation of an olecranon fx

AIN

What complication are patient's with AS at high risk for after THA?

ANTERIOR Hip Dislocation (Even after a posterior approach)

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

APL and Adductor Pollicis

Deforming Forces of Bennett and Rolando Fractures

APL, Adductor pollicis

Preiser's Disease

AVN of the Scaphoid

What non-orthopedic injury should you be concerned about with a chance fx?

Abdominal injury

What monitoring test should be performed on a patient with hemihypertrophy?

Abdominal ultrasound (rule out Wilm's tumor)

SNAC Wrist

Abnormal articulation of the scaphoid caused by untreated non-union. Results in pancarpal arthritis that will spare the radiolunate articulation until last.

Clinodactyly

Abnormal curvature of a digit.

Ligament of Struthers

Abnormal ligamentous structure which connects a residual anterior supercondylar tubercle to the medial epicondyle. This structure can cause compression of the median nerve.

Delta Phalanx

Abnormal physis orientation - results in abnormal curvature of a digit (toe or finger)

In phase of the throwing cycle is valgus load the greatest?

Acceleration phase

What type of calcaneus fracture do you treat with percutaneous reduction and screw fixation?

Achilles tendon avulsion fractures. Notice that there is no extension of the fracture to the posterior facet.

What are the disorders affecting the proliferative zone?

Achondroplasia, Gigantism, MHE

Foramen magnum stenosis is associated with what condition?

Achondroplasia. Stenosis causes central sleep apnea. Patients should be appropriately screened.

Treatment of hook of hamate fracture? Acute = Chronic =

Acute = Casting Chronic = Excision

Treatment of SL ligament injury. Acute versus Chronic.

Acute = Ligament repair + Pinning Chronic = Scaphoid fusion of some sort

Metal on metal hips produce what type of rxn

Acute lymphocytic - delayed hypersensitivity

Formula for calculation of ISS score

Add the square of the 3 highest AIS scores

What muscle is typically involved / tender in athletic pubalgia?

Adductor Longus

Where do hamstring tears occur? Adults? Kids?

Adults: Myotendinous junction Kids: Ischium bony avulsion

Main blood supply to the talus

Artery of the tarsal canal

Guidelines for return to sport after Mono

After 3 weeks, if splenomegaly completely resolved

What is the inflection age for Legg-Calves-Perthes Disease

Age 6

What is the inflection age for performing an HTO on a patient for unicompartmental arthritis?

Age < 60. Thin, active patient. TKA has a

Lumbar Disc Herniation (SPORT Trial) - Positive Outcome Factors

Age > 41, Married, No workers compensation, absence of other joint problems.

Major risk factor for development of complications after posterior spinal fusion for alignment correction?

Age > 60

#1 Risk Factor For Failure to heal RC tears?

Age > 65

When do you operate on internal tibial torsion?

Age>8 + >30 degrees of internal rotation - plan for supramalleolar ostoeotomy

Identify appropriate location of Stryker needle in the compartments of the leg.

All spots should be within 5 cm of the fracture site. Anterior Compartment: 1 cm lateral to the anterior border of the tibia Lateral Compartment: Just anterior to the posterior border of the fibula Deep Posterior: Bouncing off the medial border of the tibia Superficial Posterior: Mid Calf

Lab Findings in Hypophosphatemic Rickets

All you need to know is Low phosphate, normal calcium - but it makes sense that labs also show normal PTH and normal vitamin D.

What medication can be used to decrease reperfusion injury?

Allopurinol

Most common reason for incongruent radial capitellar joint after reduction of a Bado Type III

Annular Ligament interposition

What tendon is transferred to prevent equinovarus after a chopart amputation?

Anterior Tibialis is transferred to the neck of the talus

Treatment of persistent stiffness following non-op treatment of a radial head fx?

Anterior and posterior capsular release

Most sensitive test for combined ACL/MCL tear

Anterior drawer in external rotation

Grade III MCL + ACL Tear: What physical exam to diagnose?

Anterior drawer with knee in ER. Tests for posteromedial instability.

What vessel is at risk with tibial tubercle avulsion fractures?

Anterior recurrent tibial artery ---> This can result in compartment syndrome

Left unstable intertroch complication with SHS

Anterior spike displacement of the proximal fragment

Left sided femoral neck fx fixed with DHS...associate!

Anterior spike displacement.

What artery supplies the majority of perfusion to the spinal cord?

Anterior spinal artery - fed by the artery of Ademkawicz

Approaches to Humerus Fractures

Anterolateral (proximal 2/3 fx) Posterior (Distal 1/3 fx) Lateral (radial nerve expoloration necessary)

Supination adduction ankle fx - what should you look for intraoperatively?

Anteromedial plafond impaction

FGFR2

Apert Syndrome

Osteoid Osteomas occur on what side of their associated scoliotic deformity.

Apex of the concavity. Most often in the posterior elements.

Treatment of small stable OCD lesion in kid at skeletal maturity.

Arthroscopic subchondral drilling

Rollback Phenomenon

As the knee comes from extension into flexion the femur pivots about the medial joint line (smaller radiius of curvature on lateral side) and rolls back

AMBRI

Atraumatic Multidirectional Bilateral - (treated with) Rehabilitation and Inferior capsular imbication (if failed conservative tx)

Cleidocranial Dysplasia...Associate!

Autosomal Dominant Absence of clavicles Proportionate dwarfism CBFA1 / RUNX2 Gene - limits osteoblast activity

Indications for fixation of medial epicondyle fracture?

Avulsion into joint, >5 mm displacement (relative), ulnar nerve dysfunction (relative), throwing athlete with displacement - always look for displaced fragment in the joint with a medial epicondylar avulsion.

Jersey Finger

Avulsion of the FDP from the distal phalanx

What nerve is at risk with suture repair of the posteroinferior shoulder labrum?

Axillary nerve

Treatment of septic bursitis - per AAOS guidelines...apparently

Bursectomy and IV abx. Also encourages aspiration to distinguish aseptic.

Which knee implant design has the best flexion associated with its use?

Posterior stabilized

Fibrodysplasia ossificans progressiva (Stone Man Syndrome) - Physiologic defect

BMP 4 Abnormality

DCO should be applied to patient's considered "in extremis" - defined as....

BP< 90, temp<32, or platelets < 70,000

Little League Elbow

Basically the valgus extension overload of children. Actually a continuum of MCL sprain, medial epicondyle apophysitis, and osteophytosis of the posteromedial olecranon

Cervical myelopathy occurs in OI patients because of what condition?

Basilar invagination

What is the advantage of a locking plate versus blade for fixation of distal femur fracture?

Better control of coronal plane fracture

What finding is associated with the best outcomes after obstetric brachial plexus palsy?

Biceps motor function at 3 months

What ligament is involved in fractures of the anterior process of the calcaneus?

Bifurcate ligament

Jefferson Fracture

Bilateral anterior and posterior ring injuries to C1 vertebrae (Mnemonic: Jefferson was our 1st president...of the Confederacy)

Describe Hangman's Fracture?

Bilateral fracture of the pars in the cervical spine (C2/C3)

Hurler Syndrome mnemonic

Blind Gargoyles Hurl with Double Strength (DS = Dermatan Sulfate)

When does the secondary ossfication center of the dens (the tip part) fuse?

Body fuses to the shaft of the dens at 3. Tip fuses at 10-12. Mnemonic: "3-10 not the dens"

Scenario: Impingement of patella on femoral component during flexion (joint line elevation) w/ large poly in place during a revision knee. What do you do?

Bone loss from the component removal causes large flexion and extension gaps that are trying to be compensated for by a large poly. This results in joint line elevation. To fix this problem you need to decrease the size of the flexion and extension gaps (using augments or changing the component size) and then using a smaller poly.

What test can be used to distinguish sickle cell crisis from infection?

Bone scan. Normal marrow uptake in osteo and decreased uptake with crisis

Contracture of the oblique retinacular ligament results in what deformity?

Boutonierre deformity

Contracture of the transverse bands results in what condition of the finger?

Boutonierre deformity. Essentially just pulls on the oblique retinacular ligament causing flexion at the PIP and extension and DIP

What happens if the oblique pulley of the thumb is cut?

Bowstringing of the FPL and decreased excursion of the thumb. Actually you need to rupture both the oblique pulley and more proximal A1 pulley.

What nerve can be used to trace back to the radial nerve during a posterior approach to the humurus?

Brachial Cutaneous Nerve or Posterior Antebrachial Cutaneous Nerve

First line of treatment for Blounts disease if age < 3

Bracing

Double PCL sign

Bucket-handle meniscus

What physical exam finding is associated with CIND?

CIND = Carpal INstability Non-Dissociative - Basically the carpal bones stay together but are dissociated from the radius articulation due to disruption of the extrinsic ligaments. Clunk with neutral to ulnar deviation while pushing palmarly.

Treatment for Z-deformity secondary to CMC arthritis

CMC joint resection, fusion of MCP joint

PMP22

CMT

Pseudoachondroplasia....associate!

COMP (COMPared to achondroplasia) Autosomal Dominant Cervical instability Normal face

What is the strongest predictive factor for pediatric septic arthritis?

CRP>20

Best method to determine spine fusion non-union

CT

Most sensitive exam for determining amount of lunate collapse.

CT

What imaging do you need before doing a C1/C2 Transarticular screw?

CT angiogram to look for aberrant interosseous vertebral artery

11 yo girl with growth arrest following fracture - what do you do first?

CT scan to evaluate if the physeal bar is resectable

Most likely ligament to be compromised with PTT dysfunction?

Calcaneonavicular (Spring) Ligament

BMP - 7 Use

Can be used with as good effect as autologous bone graft in the treatment of closed tibial shaft fx. BMP-2 has shown good results in OPEN tibial shaft fx

How do you treat symptomatic os odontoideum?

C1/C2 Fusion

Treatment for Basilar Invagination > 5 mm

C2-Occiput Fusion

Klippel Feil....associate cervical level of importance.

C3 Above C3 = Sports okay. Normal life expectancy Below C3 = No contact sports. Shorter life-expectancy

Most common nerve root injured after laminoplasty of the c-spine for cervical myelopathy

C5

Arthritis in what carpal facet is a contraindication to proceeding with a proximal row carpectomy?

Capitolunate

Treatment for anterior shoulder instability?

Capsular Shift (Retensions the IGHL) +/- Bankart repair

Bartonella Henslae

Cat scratch fever, differential for cat bites, causes grossly swollen lymph node.

Elderly person with minor neck extension injury....Associate!

Central Cord Syndrome

Which way is the neurovascular bundle displaced by the spiral cord of Depuytrens contracture?

Central and superficial

What structure is at risk with volar dislocation of the PIP joint and what deformity results?

Central slip is often disrupted. Boutonierre deformity i s common. Initial treatment is splinting in extension for 6 weeks to allow the central slip to heel. Open repair of central slip can be undertaken if no resolution

Head-on motor vehicle collision with seat belt contusion and back pain...Associate!

Chance Fx. Think concomitant abdominal viscera injury

How do you differentiate a clasped thumb from a pediatric trigger thumb?

Clasped thumb has restriction in abduction because of first web spaced contracture and absence of EPB

What factor determines whether you use submuscular bridge plating versus flexible nail for treatment femur fracture in a 5-10 yo child?

Comminution = Plate Transverse = Flexible nail

After TEA what restrictions are placed in the immediate post-operative period?

Complete splint immobilization x 4 weeks following TEA (some sources say only 10 days the gentle ROM)

Wartenberg's Syndrome

Compression of SBRN at interval between BR and ECRL

Dorsal Bunion is associated with what foot deformity?

Congenital club foot.

Parona's Space

Connection between the fascia of pronator quadratus and FDP. Important because it serves as a channel of communication for flexor tenosynovitis to the proximal wrist.

Congenital curly toe treatment....associate?

Conservative until persistent symptoms + age > 3. Complete tenotomy of the FDL and FDB.

AIIS Avulsion Fx Treatment?

Conservative. Hip flexed x 2 weeks

Treatment of Kohler's Disease

Conservative. Short leg walking cast shortens duration of symptoms.

After failure of conservative treatment of sports hernia what do you do?

Consult general surgery for pelvic floor reconstruction. Might also consider an adductor longus recession.

Deficiency of what ligament in combination with a deficient rotator cuff is a contraindication to shoulder hemiarthroplasty?

Coracoacromial ligament

Iridocyclitis is associated with what condition?

JRA. Uveitis is associated with ankylosing spondylitis and Reiters syndrome.

Post axial polydactyly in CaucasianElii

Genetic workup (Ellis Crevald Dz)

Describe the "Miserable Malalignment" Syndrome

Genu Valgum External Tibial Torsion Increased femoral anteversion (internal rotation of the femur)

SIRS Criteria

HR>90, Temp outside range of 36-38, RR > 20 or hypoxic, WBC outside Range 4-12. - 1 point for each, >2 = SIRS dx

Panner Disease

Juvenile elbow OCD (children less than 10)...imaging show fragmentation of the capitellar epiphyseal nucleus. Self-limited - treat conservatively - no sequelae

Ulnar negative variance is associated with what?

Kienbock's Disease

What is the most important predictor of failing a back rehabilitation program for low back pain?

High VAS scores (i.e. severe pain)

How do you decide how may levels to fuse in the setting of spondylolisthesis?

High grade (>50%) = 2 levels (+/- anterior support) Low Grade = 1 level

What is the advantage of the blade plate versus locked plates in treatment of distal femur fracture?

Higher strength in torsional strength

Treat the following: Volar finger tip Volar defect of finger < 2 cm Dorsal defect of finger

Cross Finger Flap-

Primary complication of physeal separation

Cubitus varus - up to 70%

What is the last elbow apophyses to FUSE during growth?

Medial epicondyle (closes at 17). Radial head and olecranon close at 15 - everything else closes at 12

Where is the blood supply in the proximal humerus?

If the posteromedial segment is intact on x-rays then the rate of AVN is signicantly lower. Main blood supply is the posterior cirumflex humeral artery.

Factors associated with peroneal palsy after total hip

DDH, lengthening, surgeon opinion, post-traumatic arthritis

What deformity causes SLAC wrist?

DISI deformity caused by SL ligament disruption

What happens when you section the scapholunate ligament.

DISI deformity. The lunate extends as the scaphoid flexes.

8 yo male with CRP>6 who undergoes surgical debridement of MRSA tibial osteomyelitis...what are you worried about?

DVT

What is the correct treatment of an isolated expanding osteolytic defect (surrounding a screw) in a THA.

Debridement and bone grafting of defect with revision of PE liner

Treatment of lumbar stenosis without instability or spondylolisthesis

Decompression with laminectomy and medial facetectomies

Increased femoral offset will cause what change in joint reaction forces?

Decrease joint reaction forces

Comminuted olecranon fx in low demand elderly. Tx?

Immobilize at 90 degrees For non-displaced fragments you should splint in less flexion 45-90.

pH of the nucleus pulposus changes in what way with aging?

Decreases.

Spiral tibia fx - what exam should be ordered?

Dedicated ankle films or CT ankle.

The deep palmar arch is the distal extension of what vessel primarily?

Deep branch of the radial artery

Spondyloepiphyseal Dysplasia....associate!

Defect in COL2A1 - type II collagen deficiency ATLANTOAXIAL INSTABILITY Dwarfism Affects the proliferative zone of growth plate X-linked and AD forms

In the setting of vascular compromise of a replanted digit what is the algorithm for treatment?

Determine if venous or arterial. If arterial - place dependent, heparinize, stellate ganglion block, remove compressive bandages.

Treatment of quadriceps contusion?

Immobilize in 120 degrees of flexion for 24 hours

What method of PE manufacture is associated with the best wear characteristics?

Direct compression molding. Ram bar extrusion and sheet compression both require post mold machining which causes oxidation of the implant surface.

Eccentric poly wear presents the greatest risk of what complication?`

Dislocation

Most common complication after triflange?

Dislocation

What complication is common after isolated poly exchange for concentric wear and osteolysis?

Dislocation

Holstein-Lewis Fracture

Distal 1/3 humerus fracture. High risk of radial nerve palsy. Observe for 4 months then pursue treatment with EMG, nerve conduction and possible exploration if no improvement

Which has greater healing potential, distal or proximal MCL lesions?

Distal has less than proximal (Distal in on the medial face of the tibia...there is basically nothing there to help out with healing)

What is the source of vascularity to the lateral condyle and how does this affect the surgical approach?

Do not dissect posterior to the condyle because this is wear the bloody supply comes from

What toe deformity can be the result of Ponseti casting of clubfoot deformity.

Dorsal 1st toe bunion

Proximal 1/3 scaphoid fractures are best treated through what approach?

Dorsal approach

DISI

Dorsal intercalated segment (lunate) instability. Disruption of the scapholunate ligament causes the lunate to dorsiflex. This causes progression to SLAC wrist.

Hx of osteoporosis now with insidious femur pain...associate!

Impending fx associated with bisphosphonate. Look for lateral wall thickening. Treat with IM nail

What symptoms are specific to compression of the ulnar nerve in Guyon's canal (ulnar tunnel syndrome) as opposed to cubital tunnel compression?

Dorsal sensation intact More clawing No deficit of ulnar FDP Negative elbow flexion test

Structure at risk with creation of the 6-U / 6-R wrist portal

Dorsal sensory branch of the ulnar nerve

Residual cavus after after surgical clubfoot correction is caused by?

Dorsally subluxated navicular

Treatment of hemorrhagic blisters

Drainage but no debridement. Removal of blister can result in dessication of the underlying dermis.

What is the primary reason to get a spinal MRI on a patient with neurofibromatosis?

Dural ectasia

What structure is most commonly interposed in the fracture site of a tibial eminence avulsion?

Medial meniscus

What must be preserved in transmet amputation to prevent supination deformity?

Peroneus brevis attachments to the base of the 5th MT

Galleazi fx, unable to reduce, what structure is in the way?

ECU

Tendon interposed in DRUJ with Galeazzi fx

ECU

What tendon prevents DRUJ reduction in Galleazi fx?

ECU (Just remember that the ECU is part of the TFCC and intimately associated with the DRUJ)

Low velocity gunshot w/o fracture to extremity

ED irrigation, 3 days oral abx, and NO PRIMARY CLOSURE

Suprascapular compressive symptoms in setting of negative MRI...what next?

EMG/NCS

Where are the two most common locations that AIN compression can occur?

Edge of pronator teres Arch of FDS

COL5A1...associate!

Ehler's Danlos Syndrome

Child gymnast with lateral elbow pain and loss of extension...associate!

Elbow OCD

Coxa Magna

Enlargement of the femoral head associated with osteonecrosis - early finding

What layer of the nerve is the primary protecting agent against compression forces?

Epineurium

Chondroblastoma (XR)

Epiphyseal lesion, circumscribed with sclerotic borders

Revision microdiskectomy for repeat herniation results in...worse, better or equivalent outcomes to primary surgery?

Equivalent

What is a way to tell on X-ray that there is too much glenoid erosion to support an glenoid component?

Erosion past the level of the coracoid process

Bennett Lesion

Impingement of the supraspinatus on the top of the glenoid/labrum (type of internal impingement) causes hypertrophy and scarring of the posterior glenoid capsule. Associated with GIRD

Risk Factors for Dislocation after THA

Female, Inflammatory Arthropathy, Age>70, Osteonecrosis (Post traumatic arthritis is the same)

For severe intractable pes planus what operation can be done to correct talar head uncoverage and forefoot abduction?

Evan's Calcaneal Lengthening Procedure

What motion unlocks the subtalar joint?

Eversion (just remember that the PTT performs inversion and is necessary to do a heel rise i.e. lock the subtalar joint)

Thomas Test

Evidence of flexion contracture with the contralateral leg flat on table while patient is supine. Used for determining appropriateness of psoas release in CP patients with hip subluxation.

EWS:FL1 (11:22)

Ewing's Tumor

Optimal position for hip arthrodesis

External Rotation: 5-10 Adduction: 0-5 Flexion: 20-30

Lesions after shoulder dislocation (alphabet soup)

GLAD (Glenoid Articular Defect) ALPSA (Anterior Labral Periosteal Sleeve Avulsion) HAGL (Humeral Avulsion of Inferior Glenohumeral ligament) Hill-Sachs Bankart

Extraabdominal Desmoid Tumor Associated Condition

FAP

What tendon is the pisform contained in?

FCU

Tendon that ruptures with volar plating?

FPL

Which tendon most commonly ruptures after volar plating of the radiius?

FPL

Cause of Madelung Deformity

Failure of volar ulnar aspect of distal radial physis. May be related to constraint by Vicker's ligament (extra thick ligment between the radius and the lunate).

Most common reason for failure of compartment release for DeQuervain's

Failure to release EPB sub compartment

Type II muscle fibers are involved in what type of activities?

Fast twitch. IIA = Mixed / IIB = Anaerobic only

Benefit of percutaneous scaphoid fx fixation

Faster time to union

Most common complication after hip resurfacing?

Femoral neck fracture

FBN-1

Fibrillin. Associated with Marfans Syndrome

Describe a PAB ankle fx

Fibula: Comminuted fx at or above the level of the syndesmosis Tibia: Medial mal transverse fracture (pulled off)

Anteromedial Bowing is associated with what condition?

Fibular Hemimelia

What is the main determinant of whether a bony procedure is needed in the foot?

Flexible deformity: Soft-tissue procedure Fixed Deformity: Bone an soft tissue procedure

Stage II PTTD (Description + Treatment)

Flexible flatfoot, unable to perform toe raise. Can be treated with medial calcaneal osteotomy and FDL transfer.

In what position do you immobilize monteggia fx?

Flexion and supination

In why position do you immobilize a Galeazzi fracture?

Flexion and supination

Camptodactyly

Flexion deformity of the PIP joint. Usually only affects the small finger.

Describe the biomechanics of a Chance Fracture

Flexion-distraction injury. The anterior column fails in compression and the posterior and middle column fail in tension.

Proper collateral ligament of the thumb prevents radial deviation of the phalanx in what position?

Flexion.

What radiographs should you get in a patient with JRA?

Flexion/Extension Radiographs looking for instability

Describe Guyon's canal

Floor = the TCL Roof = Pisohamate ligament Contains the ulnar artery and deep and superficial branches of the ulnar nerve

Galleazi Fx

Fracture of distal 1/3 of radius with associated DRUJ injury. Volar radioulnar ligamentous structures are damaged.

Septic nec fasc, next step?

Frozen biopsy in the OR for diagnosis

What position do you splint the forearm in when you have an LCL disruption in an elbow dislocation?

Full pronation - tightens the lateral dynamic stabilizers

Post-axial polydactyly in caucasian...what do you do?

Further work up, maybe Ellis Van Creveld Syndrome?

What measure is predictive of ambulatory status after conversion of a hip fusion to an arthroplasty?

Gluteal muscle function

ACL Graft screw divergence > 30...Associate!

Greater risk of graft failure

Only good reason to ever use a soft collar

Grisel's disease with atlantoaxial rotatory displacement lasting less than 1 week. After 1 week you would do halter traction. After 3 weeks halo traction. After 3 months fusion.

Most common complication of distal femur physeal fracture?

Growth arrest - 60% incidence

What is the indication for a biplanar chevron osteotomy?

Hallux valgus requiring surgical treatment + DMAA > 10 degrees

During what phase of the gait cycle is the TA contracting eccentrically?

Heel Strike

Name the phases of gait

Heel Strike, Foot flat (loading response), Midstance, Terminal Stance, Pre-swing, Initial Swing, Mid swing, Terminal Swing, Heel Strike

Obturator Oblique Outlet

Help identify starting point of the supracetabular pin at the ASIS and prevents hip joint penetration.

Describe Brown Sequard Sydrome

Hemicord. Ipsilateral motor, contralateral sensory. Best prognosis

Arcade of Struthers

Hiatus in the intermuscular septum through which the ulnar nerve passes to get from the anterior to the posterior compartment

Hypertrophic Zone....Associations!

High O2 Physeal fractures, SCFE, Mucopoly, Rickets Type X collagen to lay down cartilage for calcification

Bullet embedded in bone after passing through abdomen - what do you do?

IV antibiotics 7-10 days broad spectrum

Describe internal impingement.

Humerus impinges on postero-superior labrum during abduction/external rotation. There is a postero-superior shift in the humerus relative to the glenoid. Note that it is the posteroinferior capsule that becomes hypertrophic however

Dermatan Sulfate....associate

Hurler Syndrome

Treatment of acute saggital band rupture

Hyperextension splinting x 4-6 weeks. Open fixation in high level athletes.

SCFE occurs through what growth plate zone?

Hypertrophic

II/VI systolic murmer that increases with vasalva or standing...associate!

Hypertrophic cardiomyopathy

Open forearm injury - what do you do?

I&D + Immediate ORIF and skin closure Supported by Levin Article in injury 2007

Low velocity gunshot through abdomen and into hip joint - treatment?

I&D joint + 14 days IV antibiotics

Which Interleukin paracrine signaler is associated with MSK injury

IL-6

Complications of treatment of bisphosphonate fx. IM nail? Plating?

IM Nail: Iatrogenic fx Plating: Hardware failure Bisphosphonates inhibit intramembranous bone healing

How do you decide between using a semi-constrained TEA versus unconstrained?

If ligaments stable and no previous radial head resection then you can use unconstrained. Basically you don't ever use a completely constrained TEA because of the high rate of loosening. Note: Unconstrained prosthesis is contraindicated in late stage RA because there are bony and ligamentous changes that render the elbow unstable.

What are the disorders affecting the reserve zone?

Kniest, Gaucher, Hitchhiker (Diastrophic Dysplasia) - just remember the eponyms are in the reserve zone. Like the reserve zone in a club.

Smallest Pedicle

L1

Smallest lumbar pedicle diameter

L1 (Smaller than T12)

Using a jumbo cup might increase the rate of what complication after THA?

Increased rate of dislocation. Large cups often have soft tissue overgrowth over the rim that results in early impingement and dislocation.

What is the effect of increasing tibial slope?

Increases flexion gap - joint widens as the femur rolls back on the tibia

Advantage of a wound vac

Increases local vascularity and promotes accelerated granulation tissue formation

Greatest risk factor for post-operative complications after posterior decompression and fusion?

Increasing age

Center of rotation in a reverse total shoulder arthroplasty is moved in what direction relative to a native shoulder?

Inferior and medialized. Gives the deltoid a better lever arm.

How do you minimize scapular notching in RTSA?

Inferior position of baseplate with inferior inclination

Degree measurement indicating femoral anteversion

Internal rotation 70 degrees

What is the complication associated with use of a fracture table when putting down a nail?

Internal rotation deformity

Causes of increased Q-angle, lateral patellar mal-tracking

Internal rotation of tibial component, internal rotation of femoral component, medial translation of the femoral component, lateralization of the patellar component

Young laborer with end-stage post-traumatic or osteoarthritis of the elbow...best treatment?

Interpositional arthroplasty. Basically this is the treatment when the patient would otherwise be a candidate for prosthetic replacement but it too young to tolerate the restrictions. If there is bone loss (destructive JRA or osteonecrosis) then you have to do TEA

What is the most important structure that determines stability in the thoracolumbar spine?

The Posterior Ligamentous Complex (PLC)

What clinical scenario is artificial disk replacement appropriate?

Isolated discogenic pain without instability. As diagnosed by provocative discography.

Treatment for symptomatic synovial cyst of the spine?

Isolated laminectomy and decompression - high incidence of recurrence Facetectomy and instrumented fusion - best results

4 year old with limp and pain for > 6 weeks secondary ot pain and swelling in one or more joints...consider what diagnoses?

JIA versus Lyme's disease

What neurologic level in myelodysplastic patients puts them at highest risk for hip dislocation?

L3 level. Results in unopposed hip flexion and hip adduction. In these patients the hip is left dislocated as they never become functional ambulators.

What is the key determining factor whether a person with myelodysplasia is able to walk?

L4 intact (quadriceps function) - generally the patients are able to walk

Most common level affected by degenerative spondylolisthesis?

L4/L5

Trendelenburg gait is caused by deficiency in which lumbar nerve distribution?

L5 - innervates the gluteus medius

What nerve root is at risk with complete reduction of an L5/S1 Isthmic spondylolisthesis?

L5 nerve root

Most common level affected by isthmic spondylolisthesis

L5/S1

Describe anterior cord syndrome

LE>UE weakness, worst prognosis

Lowering the joint line results in what complications?

Lack of full extension Flexion instability

Osteosarcoma (Histology)

Lacy Osteoid

Treatment of choice for isolated paracentral disc herniation

Laminotomy and Diskectomy Study: Weinstein et al (SPORT 4 year results) showed in the as-treated analysis that patients treated surgically for intervertebral disc herniation showed significantly greater improvement in pain, function, satisfaction, and self-rated progress over 4 years compared to patients treated non-operatively. They found at four years there was no signifiBenecant difference in work status between the surgical and nonsurgical group.

What cell is involved in mediating response to metal ions in THA?

Lymphocytes

Best predictor of success of partial menisectomy

Outerbridge classification. Less arthritis = better result

When in the throwing cycle does internal impingement happen?

Late cocking, early acceleration (Maximal abduction and external rotation)

Inability to evert the patella is indicative of....

Lateral patella compression syndrome. Lateral patella retinaculum release indicated for persistent cases.

Scapulothoracic dissociation can be recognized on radiographs by what characteristics?

Lateral translation of the scapula

What radiographic characteristic indicates a meniscal injury on tibial plateau fracture films?

Lateral widening of the joint line >6 mm

What position should a pregnant lady be put in on the operating table to avoid intraoperative hypoperfusion?

Left lateral decubitus position

What position should be used in pregnant patients?

Left lateral decubitus.

Most common fracture during TKA

Medial Femoral Condyle Fracture

Mnemonic for remembering GMFCS classification for CP

Level I = Stands on one leg -near normal Level II = Two legs = independent walking Level III = Walks with 3 legs - needs assistive device You can take it from there

Open humerus fx - radial nerve palsy - associate!

Likely complete disruption of the nerve. Suggests exploring the nerve - performing neurolysis / repair

What should be the weight bearing status after an extended troch osteotomy?

Limited weight bearing. Reduces torque failure to 50% of intact femur.

Describe role of the posterolateral bundle of the ACL

Limits translation and rotation at 30 degrees (Just think Lachman's and pivot shift)

What should you look at to determine whether you are looking at a DISI or a VISI deformity on lateral wrist films?

Look at the lunate! If the moon is facing dorsal = DISI If the moon is facing volar = VISI

What medication adjunct can be used for treatment of quad contusion?

Losartan. Increases muscles regeneration.

Most common complication after distal humerus ORIF

Loss of ROM

Renal Osteodystrophy Lab Profile

Low calcium (kidneys can't hang on to it) High Phosphate (kidneys can't get rid of it) PTH is high because calcium is low Alkaline phosphatase is normal or elevated because the PTH is causing bone turnover

Proliferative Zone...Associations!

Low oxygen tension --> inhibits calcification High rate of ECM production Achondroplasia, Gigantism, MHE

VISI deformity is caused by damage to what structure?

Lunotriquetral ligament.

Chronic PCL deficiency causes arthritis in what distribution?

Medial Femoral Condyle and Patello-femoral Joint

Indicators of adequate resuscitation (6 markers)

MAP>60, HR<100, Base Deficit +2 to -2, UOP>30, Lactate < 2.5, Gastric pH ( normal, >7.3)

Through what ROM is the MPFL active in restraining lateral subluxation of the patella?

MPFL is the primary restraint to lateral patellar translation in the first 20 degrees of knee flexion

Kid < 10 with curve > 20 degrees...ASSOCIATE!

MRI

Left thoracic curve....associate!

MRI

Cervical facet dislocation....what test do you need?

MRI - to look for disk herniation

What are the characteristics of Larsen's Syndrome.

MULTIPLE JOINT DISLOCATIONS Flattened facies Cervical Kyphosis

What anatomic landmarks do you look out for when placing a proximal humeral locking plate?

Make sure to place the plate lateral to the bicipital groove and pec major insertion. More medial and you endanger the blood supply - anterior humeral circumflex.

Obturator Oblique Inlet View

Makes sure that the screw is between the two tables of the ilium

FBN1....Associate

Marfans. Chromosome 15. Fibrillin

How do you decide to operate on genu valgum?

Mechanical axis falls on the lateral joint line. If remaining growth - medial hemiepiphysiodesis If mature - distal femoral osteotomy

Describe the "Windlass Mechanism"

Mechanism by which the plantar fascia bears load while in stance phase. Basically acts like a tether between the hindfoot and forefoot.

What nerve can form a painful neuroma after ulnar nerve decompression?

Medial Antebrachial Cutaneous nerve

Windows of the ilioinguinal approach

Medial: Medial to the external iliac vessels Middle: Between iliac vessels / corona mortist and the iliopsoas tendon (or iliopectineal fascia) Lateral: Between the iliopectineal fascia and the lateral femoral cutaneous nerve.

To reduce glenoid component loosening on reverse prostheses it was necessary to do what?

Medialize the center of rotation

Asymptomatic patient seen in the office with MOM hip - what do you order?

Metal ions

Describe the Paprosky Classification?

Metaphyseal bone loss, diaphyseal bone loss > 4 cm, complete loss of fixation. So basically if you have

Elevating the joint line results in what complication?

Mid flexion instability Patellar Maltracking

Quad atrophy most affects what phase of the gait?

Midstance phase - the patient will lean forward to get the knee into hyperextension to prevent buckling of the knee with weak quadriceps

Basilar Invagination

Migration of the odontoid above the foramen magnum

Define mild, moderate, and severe classifications of hallux valgus (HVA / IMA). Assign appropriate treatment.

Mild: <40 / <13 --> Distal osteotomy Moderate: >40 / >13 --> Proximal Osteotomy Severe: >40 / >16 --> Combined osteotomy

Treatment Algorithm for [Hangman's] Fracture [Mnemonic hint]

Mnemonic: 3-5 stay alive < 3 mm = Rigid Orthosis > 3 mm = Reduction / Halo vest > 5 mm = ORIF (C2/C3 fusion)

What is the mnemonic for normal EMG/NCV values.

Mnemonic: 32, 42, 52 Sensory Latency: 3.2 ms Motor Latency: 4.2 ms Conduction velocity: 52 m/s

Bado Classification

Monteggia Fx Based on direction of radial head dislocation Anterior is the most common

What mucopolysacharidoses is associated with the highest rate of odontoid hypoplasia and atlantoaxial instability?

Morquio Syndrome

Pasteurella Multocida

Most common species of bacteria isolated in cat bites

Relative safe zone for retrograde femoral nail interlocks

Much lower chance of hitting the femoral nerve or superficial artery ABOVE the level of the lesser trochanter

Mazabraud's Syndrome

Multiple Myxomas + Polyostotic Fibrous Dysplasia

What two nerve innervate the brachialis muscle?

Musculocutaneous - medial Radial - lateral

Primary complication of Latarjet procedure?

Musculocutaneous nerve injury

What nerve is at risk with AP interlock in a humeral nail?

Musculotaneous nerve

Volar lunate facet...associate!

Must be restored with fragment specific fixation during volar plating of a distal radius because this is the insertion of the radiocarpal (radiolunate) ligaments and if it displaces than the whole carpus falls off.

Proximal 1/3 oblique humerus fracture. Tx.

Must plate because high risk on non-union

What sub-type of NF is associated with dystrophic scoliosis?

NF-1. Dystrophic scoliosis is severe angle scoliosis occurring over a short segment - usually with dysplastic features. Scoliosis is not typically seen in NF-1

Stable thoracolumbar burst fracture with no neurologic deficits....ASSOCIATE

NO SURGERY. Increased complication rate, no improvement over non-op. Look for posterior ligamentous complex instability that could shift the balance towards operative treatment.

What is the relative orientation of the digital nerve and artery in the finger?

Nerve is volar to the artery (remember that you feel with the pad or your finger and test cap refill at the nail (dorsal))

Operative indications for a chance fracture

Neuro injury, injury to soft-tissue posterior structures (unstable)

Does formal therapy for a distal radius fx improve outcomes relative to a home program?

No

ADI = 5 in Down's Patient....what recommendation?

No contact sports

Pediatric anterior pelvic fx, less than 2 cm displacement. Treatment.

Non-op. WBAT.

Best treatment for pediatric type II tibial eminence avulsion

Non-surgical if reducible Suture fixation if unreducible Screw fixation can result in physeal arrest.

Morquio syndrome....associate!

Normal intelligence Genu valgum Keratan sulfate

Initial treatment of congenital curly toe

Observation

What structure is at risk with placement of a retractor inferior to the transverse acetabular ligament?

Obturator artery and nerve

Retrograde nail through CR knee...associate!

Often causes extension deformity due to more posterior starting point required by the anterior flange

Pitcher with posterior elbow pain, small crack in olecranon on CT....Condition and Treatment?

Olecranon stress fracture. Treat with discontinuation activity +/- splinting and then if failed proceed with compression screw.

Where is the volar plate located?

On the volar aspect of the MCP joint

Buckley Calcaneus Study

Op better than non-op for woman, less than 29, Bohler angle 0-14, and sedentary job

Treatment of hip dislocation in arthrogryposis?

Open reduction through a medial approach

Perilunate dislocation....treatment?

Open reduction through combined dorsal / volar approach and extend carpal tunnel release. Closed reduction is appropriate initial management but all those treated non-operatively do extremely poorly.

What indications for bilateral pinning of SCFE?

Open triradiate cartilage (younger than 10) Endocrine disorder Severe initial slip Super obese

Releasing the popliteus will have what effect on the coronal balancing in TKA?

Open up lateral FLEXION GAP

Release the IT band will have what effection on the coronal balancing in a TKA?

Open up the lateral EXTENSION GAP

Treatment of proximal hamstring avulsion?

Operative intervention. Most injuries occur at the myotendinous junction and can be treated non-operatively but avulsions off the ischium will not heal.

Delayed presentation of femoral neck fracture....associate!

Order DVT Scan. High incidence of DVT in elderly patients with delayed presentation (Hefley et al)

Olecranon apophyseal fracture....associate!

Osteogenesis imperfecta

Imhauser Osteotomy

Osteotomy for delayed treatment of SCFE deformity. Valgus, flexion, and internal rotation osteotomy.

Contraindication of PCL retaining knee

PCL rupture, inflammatory arthritis, patellectomy, and over-release of the PCL during surgery

Nerve palsy with Monteggia fx

PIN Palsy

Wrist extension weakness with radial deviation suggests the diagnosis of what?

PIN compression / neurapraxia. Intact ECRL but ECU dysfunctional

Intracellular Signaling: PTH, IGF, BMP

PTH --> G-protein --> Adenyl Cyclase BMP --> Serine/Threonine --> SMAD IGF --> Serine/Threonine

Elevated N-telopeptide is associated with what?

Paget's disease, osteolysis

What is lumbrical plus finger?

Paradoxical extension of the PIP during attempted flexion. Caused by rupture of the FDP tendon. When flexion attempted this activates the lumbrical (which attaches to the proximal flexor tendon) which would usually function to extend the PIP joint with flexion of the MCP. Results in paradoxical extension.

Radiographic sign of club foot

Parallelism of calcaneus and talus

What is the function of the transverse bands of the extensor mechanism?

Passes from volar to dorsal to insert onto the oblique retinacular ligament. Keeps the ligament volar to the axis of rotation at the PIP level - basically allows the oblique ligament to function in linking DIP and PIP motion.

Function of the oblique retinacular ligament

Passes volar PIP and dorsal to DIP. Acts to allow for DIP flexion when PIP flexes

Post-slap repair rehab?

Passive and active assisted flexion of the shoulder in the scapular plane

Most common complication after proximal tibia wedge osteotomy

Patella Baja

Most common complication of TKA?

Patella Maltracking

Exacerbation of pain at inferior pole of the patella when actively going from flexion to extension (Basset Sign)

Patellar Tendonitis

Contraindications to cruciate retaining knee?

Patellectomy, Cruciate Rupture, Inflammatory arthritis, >15 valgus or 10 varus

Where does OA occur in a PCL deficient knee

Patellofemoral and Medial Compartments

Describe West Point view

Patient in prone. Angle projector at 25 degrees off the table. Best view for seeing Bankart lesions. "Bank on a West Point grad"

Tx of Subscap Tear and Atrophy

Pectoralis transfer

Most common complication in THA performed for AVN of the femoral head (any etiology)

Perforation of the femoral canal

Tx of Galeazzi Fx

Perform open reduction and internal fixation of the radius, then assess the distal radioulnar joint for instability, and percutaneously fix the distal radioulnar joint if instability persists.

Main blood supply to the physis

Perichondrial Artery

What layer of the nerve is the primary restraint to tensile forces across the axon?

Perineurium

Schatzker type II is associated with what other injury

Peripheral lateral meniscal tear

Humeral shaft fx with non-union around a nail -- associate!

Plate fixation. No evidence for dynamization or exchange nailing

Treatment of humeral non-union following nailing

Plating with autogenous bone graft

Diseased caused by dysfunction of Gs subunit

Polyostotic Fibrous Dysplasia

Diminished pulses with active plantarflexion or passive dorsiflexion...associate!

Popliteal artery entrapment syndrome

What structure is at risk with proximal tibia physis displaced fracture?

Popliteal artery. The trifurcation of the vessels occurs at the level of the proximal tibial physis making it relatively constrained and thus prone to injury at this location.

Dominant blood supply to the humeral head?

Posterior Circumflex Humeral Artery. Reasoning: Anterior shoulder dislocations are very common - anterior artery is out - and yet low rate of osteonecrosis - so posterior must be dominant

Typical direction of acetabular deficiency (Cerebral Palsy)

Posterior Superior (versus anterior in typical DDH baby)

Most common location for biceps long head insertion?

Posterior aspect of superior labrum

Treatment of degenerative spondylolisthesis refractory to conservative treatment.

Posterior decompression with instrumented fusion

Lesser tuberosity avulsion -- associate!

Posterior dislocation

What ankle injury is associated with distal spiral tibia fx?

Posterior malleolus fx

Kim Lesion

Postero-inferior labral tear - "reverse bankart"

Direction of displacement with transphyeal separation at the distal humerus

Posteromedial. As opposed to posterolateral in elbow dislocation.

What is the most important consideration when determining whether to proceed with ulnar centralization for a hand with radial deficiency?

Presence of intact biceps strength

Most predictive factor for growth arrest after physeal fracture?

Presence or absence of displacement. Amount and direction do not influence incidence of growth arrest.

Characteristics of Duchenne Muscular Dystrophy

Presents at age 3 Hypertrophied calves Gower's sign X-linked recessive Increased CPK and aldolase Dystrophin abnormal Cardiomyopathy

What zone of the physis do corner fractures occur in?

Primary spongiosa

Bosworth Fracture Dislocation

Rare fracture pattern where the talus dislocates laterally and the fibula gets trapped behind the posterolateral ridge of tibia making it irreducible. Requires open reduction.

Contraindication to elbow arthroscopy

Prior ulnar nerve transposition

What is the thing to worry about in a patient with Larsen's Syndrome?

Progressive cervical kyphosis - can be lethal - should be fused before 18 months if significant

Indications for operative intervention with disc or vertebral body infection

Progressive neurologic deficits with evidence of spinal canal compromise, spinal instability, or failure to respond to medical management.

What is the common abnormality to all the mucopolysaccaridoses?

Proportionate dwarfism originating from dysfunction of the hypertrophic zone of the physis.

Arcade of Frohse

Proximal edge of supinator. Can cause PIN compression

Attachment site of MPFL

Proximal to blumensatt's line. 1 mm anterior to line of posterior aspect of the femur between the adductor tubercle and the medial femoral condyle

What are cutoffs to replant extremities? Distal/Proximal - Warm/Cold Ischemia?

Proximal: 6/12, Distal 12/24

What is the first joint affected in a SLAC wrist picture?

Radioscaphoid joint

Anatomic blocks to reduction of DDH hip

Pulvinar, Transverse Ligament, Inverted Labrum, Limbus, Capsule, Ligamentum Teres

Mason Classification

Radial Head Fractures Type I: non-displaced Type 2: Mild displacement Type 3: Comminuted

Pain 4 cm distal to the lateral epicondyle is consistent with what diagnosis?

Radial Tunnel Syndrome

SHH

Radial club hand

What nerve is at risk with ML interlocks in a humeral nail?

Radial nerve

Proximal Anterolateral elbow arthroscopy portal....associate

Radial nerve injury

What is ulnar impaction syndrome?

Radial shortening causes ulnar positive variance. Results in lunate chondromalacia and degen TFCC tears. Treat with ulnar shortening.

How to determine rotational alignment of the radius and ulna on radiographs.

Radial styloid and tuberosity should be 180 degrees from one another. (AP Radiograph) Ulnar styloid and coronoid should be 180 degrees from one another. (Lateral Radiograph)

What ligament must be preserved when performing a proximal row carpectomy?

Radioscaphocapitate ligament

Treatment of SNAC wrist

Radioscaphoid arthritis only: Radial styloidectomy + Fixation of scaphoid No luno-capitate arthrosis: Proximal carpectomy Midcarpal Arthritis: Scaphoid excision and Four-corner fusion

Medial Talar Dislocation Facts

Reduction blocked by EDB More common, lessly likely to have associated fx

Lateral Talar Dislocation Facts

Reduction blocked by PTT FDL or FHL Less common, more likely to have fracture, more likely to be open

Most frequent complication of syndactyly repair

Regrowth of web commisure

Most accurate way to identify and monitor hip instability.

Reimer's Index - ratio of uncovered over convered femoral head

Characteristics of Pott's Disease

Relative sparing of the disks Progressive kyphotic deformity, often severe

Anterior Slide (Rotator Cuff)

Release attachment of supraspinatous to rotator interval to allow for lateral mobilization of the tendon

Posterior slide (Rotator Cuff)

Release medial attachment of supraspinatous to the infraspinatous to allow for lateral mobilization of infraspinatous

What method of PE processing is used to most efficiently remove free radicals?

Remelting after cross-linking is the most efficient; however, this results in loss of structural integrity of the PE, therefore most commericially produced PE is annealed (heated below melting point) after cross-linking

>25% Hill-Sachs...treatment?

Remplissage (Suture the posterior capsule and infraspinatus into the defect)

Most important factor for survival of replant?

Repair of at least 2 veins. No affect of smoking apparently.

What is the double bubble of the elbow?

Represents a combined fracture of the capitellum and the trochlea

Hallux varus after surgery for Hallux Valgus is caused by what factors?

Resection of fibular sesamoid - attachment of the adductor hallucis

Strongest predictor of clinical outcomes for tibial plateau fx.

Restoration of joint stability

Post-Op Fusion Infection

Retain hardware until fusion obtained.

Matizeau Technique

Retrograde insertion of pin to reduce a radial neck fracture

Best shoe modification for people with ankle arthrodesis

Rocker bottom

Most common complication of flexible femoral nails?

Rod irritation distally - necessitating removal

Borders of the cubital tunnel

Roof = Osbornes ligament Walls = Medial epicondyle Floor = MCL / Coopers ligament (transverse bundle of ligament)

What is the typical deformity present with IM nail of distal 1/3 tibia fractures?

Rotational deformity (usually > 10 degrees)

Stener Lesion of the Thumb

Rupture of accessory and proper ulnar collateral ligament allowing the adductor aponeurosis to interpose itself between the ligament and the bone. This lesion necessitates operative intervention because the ligament will not heal.

Cause of boutonierre deformity

Rupture of the central slip --> Causes lack of PIP extension and thus unopposed pull of the intrinsics into flexion at the PIP and the DIP into extnesion Attenutation of the triangular ligmament allows the lateral bands to sublux volarly which

ADI > 7 mm...associate!

Rupture of transverse, apical, alar ligaments and the tectorial membrane

Tongue Fasciculation and absent DTRs in infant....associate!

SMA. If less then 6 months old patient has acute Werdnig-Hoffman disease and will likely not live past 2

60 yo woman with sudden onset knee pain and lesion in medial femoral condyle

SONK. Treat with arthroplasty after failure of conservative treatment.

Heparan Sulfate in the urine is associated with what disease process?

San Fillipo Syndrome

Heparan Sulfate...associate

San Fillippo Syndrome

Ganglion cysts derive most commonly from what articulation?

Scapholunate articulation for dorsal cysts. Volar cysts are from the radioscaphoid articulation.

SICK Scapula

Scapular malposition, Inferior medial border prominence, Coracoid pain and malposition, and dysKinesis of scapular movement

Describe treatment of congenital vertical talus

Serial casting and manipulation to stretch soft tissue prior to surgery then talonavicular pinning at 12 months

Parsonage Turner Syndrome

Severe shoulder pain followed by muscle paralysis. The most common associated risk factor is viral illness (25-55%). EMG can be useful to confirm the diagnosis and will show positive sharp waves and fibrillations consistent with acute denervation.

Tibia pain initiated by running but then alleviated with more running....associate!

Shin splints

Explain quadrigia

Shortening the FDP > 1cm results in inability to fully flex normal fingers because motion is limited by the common muscle belly.

Most reliable for predicting ability to walk in CP patient?

Sitting by age 2

When making posterior portal for hip arthroscopy in what position should the hip be in to reduce risk to the sciatic nerve?

Slight internal rotation. Moves the back of the trochanter away from the sciatic nerve.

Where should the lateral fin of a shoulder hemiarthroplasty be positioned to achieve 30 degrees of retroversion?

Slightly posterior to the bicipital groove

Metal on metal wear is associated with what factors?

Smaller implants Abduction angle > 55

Risk factors for pseudoarthrosis in adult spinal deformity

Smoking, kyphosis >20 degrees, positive sagittal balance greater than 5cm, preexisting hip arthritis, age greater than 55, and a throacoabdominal approach were determined to be significant risk factors.

Intrinsic plus hand position is caused by what pathophysiology? What disease is the most common etiology?

Spastic intrinsics and weak extrinsics. Most common cause is rheumatoid arthritis. Progress subluxation of the joints cause decreased mechanical advantage of EDC and creates spasticity of the intrinsics.

Characteristics of Freidrich's Ataxia

Spinocerebellar degeneration Wide-based gait GAA repeats Cavovarus foot

SLAP tear with cyst....location?

Spinoglenoid notch

Holstein Lewis Fx

Spiral distal 1/3 humerus fx - often accompanied by radial nerve injury

Pain with single leg standing extension

Spondlolysis

COL2A1 mutation causes what condition....

Spondyloepiphyseal Dysplasia

With hypoplastic thumb what is the most important factor in determining thumb reconstruction versus ablation and pollicization?

Stability of CMC joint

Treatment of intraoperative fracture of the acetabulum

Stable cup: Add screws Unstable cup: Fix fracture, upsize cup until stable, add screws

Most common underlying metabolic abnormality in non-union

Vitamin D deficiency

In what position is the hindfoot position during correction of a clubfoot deformity?

Supination. Actually appears to accentuate the deformity but is working to align the plantarflexed first ray which is pushing up the midfoot arch.

What is the critical thing to think about when evaluating a cervical facet dislocation?

Status of the disc. If the disc is intact then you can go posterior to fix if disc is disrupted then you have to go anterior. ALL FACET DISLOCATIONS NEED TO HAVE AN MRI BEFORE SURGERY

Reserve Zone...Associate!

Stores nutrients, low cellular activity Gaucher's, Kniest, Diastrophic Dysplasia

Supercondylar fracture, AIN palsy and vascular compromise (pulseless extremity) - what to do?

Straight to exploration of the antecubital fossa - high risk of attendant vascular injury

Most common bacteria causing neonatal septic arthritis

Streptococcus B

Most common complication of talus fx.

Subtalar Arthritis

Diastrophic Dysplasia....associate!

Sulfate transporter deficiency DTDST Gene Cauliflower ears, hitchhiker thumb Effects proliferative zone of growth plate Severe cervical kyphosis

Structure at risk with creation of the 1-2 wrist portal (between APB and APL)

Superficial Branch of the radial nerve

Lateral tibial plate complication

Superficial peroneal palsy secondary to distal screws

Most commonly injured arterial vessel with APC pelvic fracture?

Superior gluteal artery

Degenerative spondylolisthesis

Superior vertebrae moves anterior relative to the inferior vertebrae (spondylolisthesis) without evidence of a pars fracture. Results in symptoms similar to lumbar stenosis.

Stiff elbow treatment

Supervised PT ---> PT + Static (Turnbuckle) Splinting ---> MUA (Last resort)

Dorsal DRUJ instability is most stable in what position?

Supination. "Am I SUPposed to DRUJ back (dorsal) there!"

Insertion of the LUCL

Supinator Crest

Nerve at greatest risk with posterior capsular release around the shoulder?

Suprascapular Nerve

What artery provides blood flow to a gastrocnemius flap?

Sural artery

Attenuation of the transverse bands results in what condition of the finger?

Swann Neck Deformity. Without the transverse bands the oblique ligament migrates dorsal thereby extending the PIP and causing flexion of the DIP joint.

Smallest thoracic pedicle diameter?

T4-T6

If the thumb is present in what appears to be a radial club hand then what diagnosis are you thinking?

TAR (Thrombocytopenia Absent Radius) Syndrome

What molecular signaler increases fibrosis in muscle?

TGF Beta

Humpback deformity of the scaphoid is best treated through what approach?

Volar approach

Arthrodesis of what hindfoot joint results in the greatest loss of motion?

Talonavicular fusion

Indications for treatment of femoral neck stress fracture?

Tensile Side or >50% compression side. Treat with compression screws..

Elson test?

Test for central slip injury. The finger is held over the edge of a table with the PIP flexed and asked to extend PIP against resistance. If the central slip is injured than the DIP will extend because it transmits force through the lateral bands.

Injury of what ligament leads to a VISI deformity?

The Lunotriquetral ligament. May also be physiologic (unlike DISI deformity)

Varus collapse follow proximal humerus plating can be reduced by including what construct?

The addition of an inferomedial locking screw helps prevent varus collapse and cut out

What structure travels underneath the hook of the hamate?

The deep branch of the ulnar nerve

What nerve root is affected with degenerative spondylolisthesis - traversing or exiting nerve root?

The exiting nerve root is affected most typically due to foraminal recess stenosis

Most common head of the pec major to tear?

The sternocostal head. Maximum tension at 30 degrees of humeral extension (bottom of bench press)

Rotator Cable

Thickened portion of the coracohumeral ligament that runs perpendicular to the distal insertion of the supra and infraspinatus at its insertion

What physical exam result can define internal tibial torsion?

Thigh-Foot Progression Angle < -10 (10 degrees of internal rotation)

TUBS

Traumatic Unidirectional Bankart - (treated with) Surgery

How do you differential ulnar artery thrombosis (ulnar hammer syndrome) versus chronic hook of hamate fx?

Thrombosis results in only sensory symptoms

Posterior labral tear in the setting of non-labral exam findings...treatment

Throwing program / therapy. Apparently very common in throwing athletes but are asymptomatic.

The proper collateral ligament of the MCP joint is tightest at what degree of flexion?

Tightest at 30 degreees

Where does OPG Bind?

To RANKL from the osteoblasts - prevents it from binding to receptors on the osteoclast precursors.

When the hypoglossal nerve is injured during an anterior approach to the spine what is the presenting symptom?

Tongue deviation towards the side of the lesion Mnemonic: "Lick your wounds"

Young patient, hx of dislocation and operative treatment, now with arthritis and apparent loss of motion?....treatment?

Total shoulder arthroplasty. Reverse is for old people unless there is a documented irreparable RC tear.

Glenoid Osteoarthritis with reparable RC tear...treatment?

Total shoulder with concurrent repair

Severs Disease

Traction apophysitis of the calcaneal apophysis

Femoral neck fracture, rotated so difficult to ascertain pattern - what xrays do you order?

Traction internal rotation view. Removes antersion of neck to allow visualization.

McLaughlin Procedure

Transfer of the lesser tuberosity into an unstable reverse Hill-sachs lesion

Treatment of calcaneus deformity in L5 myelodysplastic paitnet

Transfer tibialis anterior posteriorly

ADI >3 (in adult)

Transverse ligament insufficiency

Algorithm for treatment of C1 fx

Transverse ligament intact = Halo immobilization vs. Hard orthosis (includes smashed Jefferson fx, anterior ring fx, etc) Transverse Ligament Disrupted (ADI > 5, Lateral mass displacement > 8.1) = C1/C2 Screw

Most common treatment for thumb CMC arthritis

Trapezium excision (CMC joint resection) + LRTI

AVN w/o significant collapse in the shoulder...treatment

Treat with core decompression and arthroscopy

What structure often prevents closed reduction in MCP dislocations?

Volar plate

Best treatment for elbow stiffness.

Turnbuckle bracing

Predominant collagen type in annulus

Type 1

Predominant collagen type in pulposus

Type 2

Determining treatment for odontoid fractures

Type I: Hard Orthosis Type II (Young): Halo vest Type II (Young + Risk Factor): Screw Type II (Old): Surgery unless contraindicated Type III: Hard Orthosis Non-Union: Posterior screw

Indications for ORIF with occipital condyle fracture

Type III (avulsion type) with disruption of the alar ligments, instability, associated atlanto-axial pathology

Describe central cord syndrome

UE>LE weakness

What nerve is at risk with open reduction of a medial condyle avulsion fracture.

Ulnar Nerve

Treatment of chronic monteggia fx

Ulnar osteotomy + annular ligament reconstruction

Name the components of the TFCC

Ulnotriquetral ligament Radioulnar ligament Ulnolunate ligament ECU sheath Meniscal homolog

If you damage the MCL intraoperatively and are unable to repair what level of constraint is necessary?

Unhinged, high post design. only need hinged when there is multi-directional instability

Supercondylar fracture, pulseless after reduction....associate!

Unreduce and then explore fossa (controversial if pulse resolves after undoing the reduction)

Paraspinal Approach of Wiltse

Used for approach to far lateral disc herniations in the lumbar spine

Varus femoral neck non-union. Tx?

Valgus intertroch osteotomy with blade plate fixation (or another fixed angle device)

Use of a piriformis nail through a troch entry leads to what deformity?

Varus

Most common complication of IM nailing subtroch fracture?

Varus malreduction - secondary to pull of abductors

Most common deformity after talus neck fracture

Varus malunion (correct with medial opening wedge osteotomy)

Typical deformity in talar neck malunion

Varus malunion most common. Dorsal malunion, causes ankle impingement

Maturation Zone (Primary Spongiosa)....Assocations!

Vascular Invasion Metaphyseal corner fractures Scurvy

Treatment of thoracic HNP

Very rare. Must have persistent and progressive neurologic symptoms. Hemicorporectomy + Diskectomy through a transthoracic (anterior) approach - with or without fusion. Treatment associated with interocostal neuralgia

Distinguishing characteristics of NF-1 from NF-2

Vestibular Schwanommas No spine involvement

When is acute bone grafting indicated with both bone forearm fractures?

When there is segmental bone loss and unable to obtain compression.

How do you treat dynamic supination following clubfoot correction?

Whole TA transfer to lateral cuneiform at age 2-4

In what position are the transverse tarsal joints (talonavicular and calcaneocuboid joints) parallel?

With eversion - subtalar joint is unlocked

External fixation for definitive treatment of open tibia fx is associated with....

Worse outcomes (See LEAP study)

Osteoid Osteoma

Woven bone surrounded by osteoblasts, without neoplastic cells or cellular atypia

Causes of hypophosphatemic rickets: genotype and phenotype

X-linked dominant. PHEX. Inability to resorb phosphate. AKA Vitamin D resistant rickets.

Treatment of first webspace soft tissues deficiency

Z-plasty with 60 degree flaps

Where is collagen X located in the physis? What is its function?

Zone of provisional calcification - allows for calcification

Abnormal values for electrodiagnostic studies

distal motor latency of >4.5 msec, a distal sensory latency of >3.5msec, or a conduction velocity of < 52 m/sec. CMV = Cutaneous, Motor, Velocity = 35, 45, 55