FRCS Questions

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Xrays findings of telangiectatic osteosarcoma (6)

Risk factors for malignant transformation of enchondromas (5)

LArge|Lytic with bone expansion|Cortical thinning|Painful|Soft tissue mass Pathology; Nick's list

Small round blue cell tumors (5)

Poor prognostic factors for Ewing's sarcoma (6)

Principles of Biopsy (8)

Glomus triad

Pain|Cold intolerance|Purple|Xrays with dorsal shelled out lesion Pathology; Nick's list

Indications for resection and Megaprosthesis replacement for subtrochanteric mets (5)

Periarticular destruction precluding internal fixation|Displaced pathological fracture|Radio-resistant lesion|Solitary lesion|Salvage of failed internal fixation Pathology; Nick's list

List 6 etiologies associated with sclerosing periosteal reaction and cortical thickening in infancy and young children

4 pathognomonic factors for recurrent shoulder dislocations:

Post lateral detachment of labrum |Deffect in post head|Reverse hillsachs |Post glenoid deficiency Upper Extremity

Bone tumor presenting complaints?

Soft tissue mass|Incidental finding|Painless bony mass|Painful bone lesion|Pathologic fracture Pathology; Nick's list

2. List 6 factors associated with early mortality after hip fracture

Source: J Bone Joint Surg [Br], 2008;90-B:1357-63. Holt et al., Early mortality after surgical fixation of hip fracture in the elderly||- Age|- ASA score|- Gender|- Fracture type|- Pre-fracture residence|- Pre-fracture Mobility|- Surgery after 24 hours from time of fracture Trauma

Malignant lesions in Pediatric foot and ankle (JAAOS 2017)

Synovial sarcoma: ttx: wide resection and radiotherapy|Fibrosarcoma: ttx: wide resection and irradiation|Liposarcoma https://fcdblob.blob.core.windows.net/media/ab5NwXiDFfuYab2kOWQwCw.jpg?/_0390_2p.jpg

3 radiographic or clinical signs of thoracolumbar instability?

TLICS score components:|• Unstable fracture morphology|• Involvment of the posterior ligamentous complex|• Neurological deficit 2015 Spine

Open fracture describe the tetanus prophylaxis

Tetanus immune:|- Clean wound: tetanus toxoid only if last booster > 10y ago|- Dirty wound: tetanus toxoid (0.5cc) only if last booster > 5y ago||Tetanus immune status unknown or bad|- clean: tetanus toxoid (0.5cc IM)|- dirty: tetanus toxoid + Ig (250 U IM adult)||Open fracture Type 1: 1st gen cephalosporin: ancef (Clinda or vanco if allergy)|Type2: add aminoglucoside (genta 1mg/kg)|Type 3: add PNC (1million U) 2017 Trauma

what stabilizes the ulnar side of the carpus ( TFCC topic)||Intrinsic and extrinsic

Ulnar side of carpus:|Intrinsic stabilizers:|- capitatehamate lig|- lunotriquetram ligm||Extrinsic lig:|- ulnotriquetral lig|- ulnolunate lig

Hemophilia patient: a. at what level does his factor has to be during surgery? b. for how long does his factor has to be at surgery levels? c. Is the long term outcome the same in haemophiliacs compared to non-haemophiliac patients?

a) 100% b) 2 days Yes, absent infection, the durability of knee implants in young population remarkably good and equivalent to other arthritic groups • 80-100% 30min pre-op to 2 days • 60-80% to day 4th • 40-60% to day 6th • The highest risk of bleeding - 7-10 days post-op regardless of factor level| • Higher risk of arthrofibrosis, not laxity| • 10x increased risk of infection s/p arthroplasty| • 95% good to excellent at 9.2yrs

Flat bone tumors (5)

Benign lesions in Pediatric foot and ankle (JAAOS Jan 2017)

https://fcdblob.blob.core.windows.net/media/LLpyG6WuQq9Z0vE3wbqVpQ.jpg?/_0389_2p.jpg

What is the treatment algorithm for Rotator cuff arthropathy?

https://fcdblob.blob.core.windows.net/media/Nv1lem4Gupzul4EJtMQiAg.jpg?/_0349_2p.jpg

Describe in general how to examine the rotator cuff muscles

https://fcdblob.blob.core.windows.net/media/SNb1gz4c0NqUH6MPaHKL9A.jpg?/_0394_2p.jpg

Write the tetanus protocol fill the boxes

https://fcdblob.blob.core.windows.net/media/cbSJQa9qYE7dypWCAwfW4Q.jpg?/_0373_2p.jpg 2017 Trauma

What are the options for Femur bone defect < 6cm and >6cm diaphyseal and metaphyseal|For Tibia? And for upper extremity?

https://fcdblob.blob.core.windows.net/media/gKOcbGyXWmm9jPyf66E1aA.jpg?/_0357_2p.jpg https://fcdblob.blob.core.windows.net/media/0S054DbvgZDddSNS0sQwJA.jpg?/_0357_3p.jpg https://fcdblob.blob.core.windows.net/media/B0bzxX0bJBZyUBJbP67oOw.jpg?/_0357_4p.jpg 2017 Trauma

Pt with wrist pain. Radiologist confirm that the wrist changes are compatible with Kienbock's disease. ||What are the 4 radiologic changes of avascular necrosis of the lunate?

https://fcdblob.blob.core.windows.net/media/gdvUN0aFAy09ym2Y8NK4QA.jpg?/_0329_2p.jpg Upper Extremity

Ddx of Ulnar side wrist pain

https://fcdblob.blob.core.windows.net/media/grm3ZWbDDCb7NcKkZzQ0kQ.jpg?/_0377_2p.jpg Upper Extremity

Risk factors for HIV transmission from a needle stick|||JAAOS 2017

https://fcdblob.blob.core.windows.net/media/q4IzteeuKH2teIP8v1u49A.jpg?/_0356_2p.jpg 2017 Trauma

Name the elbow arthroscopy portals (+) and nerves at risk

https://fcdblob.blob.core.windows.net/media/xMz3FUcBQnrBjOvkcFsyKA.jpg?/_0395_2p.jpg https://fcdblob.blob.core.windows.net/media/cZUoAZSrmGbwe8zf6UwH2Q.jpg?/_0395_3p.jpg https://fcdblob.blob.core.windows.net/media/DRfv8Z4vuqbup51V3DRTmA.jpg?/_0395_4p.jpg

Describe the foot position and the beam position when doing a Canale view of the talus.

optimal view of talar neck||technique is =|maximum equinus, |15 degrees pronated, |Xray 75 degrees cephalad from horizontal https://fcdblob.blob.core.windows.net/media/tMimlBkRoitcztliUvqhvQ.jpg?/_0104_2p.jpg 2016 Foot & Ankle

Describe Phemister Triad (TB)

tubercular arthropathy. A triad ofradiologic abnormalities (Phemister's triad) include:| |1. Juxta-articular osteoporosis |2. peripherally osseous erosion |3. gradual narrowing of the joint space Trauma

3 options for 45M patient with a large reverse Hill-Sachs lesion?

|| A patient undergoes open reduction of a locked posterior shoulder dislocation. Has persistent instability due to a large revers Hill-Sachs lesion. Describe 4 methods to address this lesion. (Lesion 30-40%) • McLaughlin procedure: Lesser tuberosity + subscap tendon transfer into defect|• Fresh osteochondral (osteoarticular) allograft|• Disimpaction + bone graft|• Hemiarthroplasty (lesions >40%) 2015; 2016 Sports

List 3 at risk signs for Perthes (Prognostic )

• Calcification lateral to the epiphysis|• Horizontal growth plate|• Femoral head lateral subluxation|• Gage sign - V-shaped radiolucency at lateral epiphysis|• Metaphyseal cysts Catterall head at risk signs 2010; 2013 Pediatrics

List 2 components of the push-up test for assessing posterolateral rotatory instability (PLRI)

• Can be done prone push-up or seated in chair push-up|• Try to get up with maximally fully pronated, then repeated maximally supinated|• Test is positive if symptoms (apprehension/radial head dislocation) manifest in supination, but not in pronation Lateral pivot shift - other clinical special test|• Supine, arm extended & supinated|• Axial load with valgus stress and brought into flexion|• Radial head reduces ~ 40o 2014 Trauma

Order of ossification of the pediatric elbow (didn't ask for age)

• Capitellum (1 female, 1 male)|• Radial head (3 female, 4 male)|• Medial epicondyle (5 female, 6 male)|• Trochlea (7 F, 8 M)|• Olecranon (9 F, 10 M)|• Lateral epicondyle (11 F, 12 M)||2x2 rule CRITOE: mnemonics Come Rub My Tree Of Love|Capitellum|Radial head|Int epicondyle= medial epicondyle|Trochela|Olecranon|Ext epicondyle= lateral epicondyle https://fcdblob.blob.core.windows.net/media/Wm8yc90vKacNG4lqbOAvEA.jpg?/_0139_3p.jpg 2012 Pediatrics

List 8 organ systems associated with congenital scoliosis

• Cardiovascular: atrial septal defect, ventricular septal defect, patent ductus arteriosus, tetralogy of Fallot|• Genitourinary|• Renal|• Neurologic |• MSK (Limb defects)|• Respiratory (Thoracic insufficiency syndrome)|• Gastroenteric (Tracheoesophageal fistula, Anal atresia)|• Craniofacial abnormalities|• Auditory problems|- intraspinal pathology • Spine, MSK, cardiovascular, GU all develop at the same time in embryonic phase|• Cardiac - ASD, VSD (most common), PDA, Tetralogy|• Dysraphism, Chiari, tethered cord (most common), syringomyelia, diastatomyelia, intradural lipoma) 2012 Spine

Define these terms regarding syndactyly: complex, complete, synonychia

• Complex: Side-to-side fusion of adjacent phalanges|• Complete: Skin fused up to the fingertips|• Synonychia: Fusion of 2 adjacent nails 2015 Upper Extremity

What are two important considerations to take into account for placing C1-C2 trans-artricular screws.

• Coratid artery in front of C1 (CT angio to see the position of the artery)|• C2 nerve root|• Hypoplastic C2 pars|• Thoracic kyphosis (because entry is at T1)|• Anatomic reduction (you cannot hit the canal)| | Vertebral artery, nerve root, death, hypoglassal, coratid artery 2011 Spine

List 4 long term complications of osteomyelitis in pediatric patient.

In soft tissue sarcoma, other than metastatic disease, what are the 3 most important determinants of a worse prognosis?

• Histological Grade - high grade/dedifferentiated|• Tumour - size (>5 cm)|• Depth (below fascia)|• Age|• Regional lymph node positive|• Distant metastases||AJCC staging of soft tissue sarcoma||Local recurrence: important factor for survival 2012; 2015 Pathology

List 3 anatomic features associated with C2-3 pseudosubluxation

• Horizontal facet joints|• Ligamentous laxity|• Wedged vertebrae|• Shallow facet joints 2012 Spine

List 4 dysplastic features seen in developmental spondylolisthesis that would indicate a risk for progression. (Increase the risk of further slippage)

List 3 endocrinopathies that are seen in SCFE

Name 3 non-femoroacetabular hip impingement syndromes (? Types of snapping hip)

• IT Band|• Iliopsoas tendon|• Rectus femoris|• Labrum|• Intra-articular loose bodies 2015 Sports

List 3 components of the Lenke classification.

• Identify primary curve type (measure regional curve, ID major curve, determine if minor curve is structural or not)|• Assign lumbar modifier (dependant on where apical lumbar vertebrae is in relation to central sacral vertical line)|• Assign sagittal thoracic modifier (kyphosis angle) 2013 Spine

List 4 findings on clinical exam that you would see in a 6-month old kid to diagnose a posterior shoulder dislocation resulting from a brachial plexus injury

• Impaired passive ER|- Locked in IR, excessive adduction|• Asymmetry of shoulder (prominent coracoid) with palpable humeral head posteriorly|• Shortening of length of the upper arm/humeral segment|• Asymmetry of skin fold due to telescoping of humerus and axillary asymmetry|• Palpable click during shoulder manipulation|- prominent acromion anteriorly|- asymmetry of skin fold due to telescoping of humerus and axillary asymmetry 2014 Pediatrics

List 3 complications of doing an ankle ORIF in a patient with DM.

Patient with THA 15 years ago and sustains a periprosthetic fracture. List 3 things that may affect your treatment plan.

• Implant stability • Location of fracture • Bone quality/ stock • Infection Vancouver Classification: - location (A, B, C) - implant stability (B1 vs B2); bone quality (B3) |Infection needs to be ruled out - 1 vs 2 stage revision 2010-2014 Arthroplasty

Name two radiographic risk factors for SCFE development

• Increased physeal obliquity|• Increased femoral retroversion|- coxa profunda 2012 Pediatrics

List 4 complications with a traction table and hemi-lithotomy position

Give 4 factors that are prognostic of neurologic deficit in patients with vertebral osteomyelitis

List 3 spinal conditions that will light up on a gadolinium enhanced MRI.

• Infection/inflammation, epidural abscess|• Post-op fibrosis - to differentiate from recurrent herniated disc|• Tumor - hypervascular tissue, malignancy 2013; 2012 Spine

List 4 reasons to do ORIF of a scaphoid fracture acutely

• Initial displacement (>1mm)|• Humpback (flexion) deformity (intraschaphoid angle > 35 deg)|• Associated perilunate fracture-dislocation (ie, greater arc)|• Bone loss/ Comminution|• DISI deformity (>60 deg scapholunate angle, >15 deg radiolunate)|• Unstable vertical or oblique fractures|-Proximal pole fractures 2013; 2012; 2015 Trauma

List 4 reasons to CRPP a distal radius fracture in a child

List the 4 knee ligaments (ie, ACL, MCL, LCL, and PCL) in order from the weakest to the strongest.

• LCL - 750 N|• ACL - 2200 N|• PCL - 2500 N|• MCL - 4000 N||Most Powerful of All Ligaments 2013 Sports

What are 3 ways to decrease the rate of AVN when performing an antegrade femoral nailing in an adolescent patient. (Peds pt )

• Lateral trochanteric entry nail|• Smaller nail|• Solid nail - not reaming Rigid nailing --> > 11yrs, > 49kg|Elastic nailing - each nail should be 40% canal width --> 80% fill 2011; 2013 Pediatrics

How do you determine the risk of pathologic fracture in matastasis? ||What components make up Mirel's criteria?

• Lesion size (<1/3, 1/3-2/3, and >2/3 the cortical diameter)|• Pain (mild, moderate, severe)|• Location (Upper Extremity, Lower extremity, Peritrochanteric region)|• Lesion characteristics (Blastic, Mixed, Lytic) • Score > 8 suggests prophylactic fixation|• Harrington criteria: >50% destruction diaphyseal cortices, >50-75% of metaphyses (>2.5cm), permeative destruction of subtroch femur, persistent pain after radiation 2012; 2015 Pathology

List 3 advantages of locking plates vs DCS for the treatment of distal femur fractures.

• Less angulation in comminuted metaphyseal fractures |• Improved fixation in osteoporotic bone|• Increased construct rigidity |• Allow for preservation of periosteal blood supply|• Able to control coronal plane fractures 2013 Trauma

5 Radiographic features of atypical femur fractures?

• Located between LT and supracondylar region |• Transverse or slight oblique (<30 deg)|• No comminution|• Complete fracture crossing from one cortex to the other with or without a medial cortical beak, or incomplete fracture on the outer cortex|• Periosteal fracture along the lateral cortex|• Increased cortical thickness|• Delayed healing|• Bilateral https://fcdblob.blob.core.windows.net/media/W3y7Ueuj2UyVAjmlpZaaKg.jpg?/_0223_3p.jpg 2015 Trauma

What are 3 poor prognostic factors in chondrosarcoma?

• Location: axial or proximal |• High histologic grade|• Increased telomerase activity 2015 Pathology

List 4 risk factors for developing SMA syndrome when doing peds scoliosis surgery

• Low BMI (<25)|• Stiff thoracic curve (<60 deg correction on bending films)|• Laterally displaced curve (Lenke B or C)|• Staged operation|• Dual approach 2012 Spine

List 5 non-medication related modifiable risk factors for osteoporosis

• Low body weight|• Low protein intake|• Smoking|• Heavy EtOH consumption|• Sedentary lifestyle 2014 Misc

List 5 features associated with increased risk of peri-operative mortality in hip fractures

• Male|• Ambulatory status pre-op (ie, not household ambulators) |• Delay in O.R. greater than 48 hours (>4days)|• Medical co-morbidities/ASA III-IV (>2 chronic diseases)|• Poor mental status (ie, demented or institutionalized) decreased mental/cognitive function prefracture|• Age (>85y)|• Pre-fracture residence|- pt in lower half for hand-grip strength|- IT # > than FN# 2014; 2012 Trauma

What are clinical features of Class IV hemorrhagic shock?

• Marked tachycardia > 140|• Marked decreased blood pressure sBP < 90|• Negligible urine output: nil|• Severely decreased mental status - obtunded, lethargic|• Cold, pale skin https://fcdblob.blob.core.windows.net/media/n5febcz1M7eSIaeBnkKxOQ.jpg?/_0197_3p.jpg 2011; 2014 Trauma

Define the 4 borders of the quadrangular (quadrilateral) space and its content

• Medial - long head of the triceps|• Upper - teres minor|• Lower - teres major|• Lateral - medial aspect of humeral shaft||Contents: |• Axillary nerve |•Posterior circumflex humeral artery 2011; 2016 Upper Extremity

Please list the dermatomes for the following: medial knee, groin, medial calf, clavicle

• Medial knee - L3. (Anterior knee)|• Groin - L1|• Medial calf - L4|• Clavicle - C4 C1: top of head|C2: temporal and occipital region of head|C3: neck and posterior cheek|C4: superior shoulder and clavicle|C5: deltoid patch and lateral arm|C6: lateral forearm, thumb and index finger|C7: posterior lateral forearm and middle finger|C8: medial forearm, ulnar border and ring/little fingers|T1: medial side of the forearm and upper arm||L1: back, hip, groin |L2: anterior superior thigh, medial thigh above knee|L3: back anterior thigh and medial knee|L4: lateral thigh, knee, anterior medial lower leg to medial aspect of big toe|L5: lateral knee and lateral lower leg and Top of foot|S1: buttocks, posterior lateral thigh and lateral plantar surface of foot|S2: buttocks, posterior medial thigh and medial plantar surface of foot 2011 Spine

A surgeon is called by the ER for a 40 y.o male with olecranon # who needs surgery. The surgeon is conducting a research trial that is comparing tension band wiring with pre-contoured locking plate fixation. The surgeon is currently busy performing another surgery in the OR but the OR would be ready to do the olecranon case right after the surgeon finishes with his first case. Since the surgeon is currently operating he sends his medical student, who is new on the service, to get verbal consent from the patient for the surgery and for participation in the research trial.|| List 3 problems with obtaining consent for the surgery and the research participation in this scenario.

• Medical Expert - student not qualified or aware of details around research project or surgery|• Professionalism - surgeon not meeting with patient him/herself|• Communicator - surgeon needs to explain study and obtain proper consent; verbal consent inappropriate and not accepted|• Manager - surgeon is not managing his/her time appropriately||(CANMEDs Scenario) 2012 Misc

List the 7 CANMEDs domains

• Medical expert • Professional • Collaborator • Health advocate • Scholar • Communicator • Leader (previously Manager)

A patient sustains a posterior shoulder dislocation. Shown an x-ray of a reduced shoulder with a large reverse hill-sachs lesion. List 3 reasonable surgical treatment options

• Modified McLaughlin procedure:open transfer of subscap tendon and lesser tuberosity to fill humeral head defect|• Elevation & bone grafting |• Fresh osteoarticular humeral head allograft|• Hemiarthroplasty|• Total shoulder arthroplasty|• Proximal humerus rotational osteotomy|• Partial articular replacement|- Prosthetic reconstruction: large lesions >40% 2010; 2014; 2012 Upper Extremity

DM is a common cause of Charcot arthropathy of the foot and ankle. List 3 other causes.

• Myelomeningocele • Leprosy • Syphilis - tabes dorsalis| • Congenital insensitivity to pain| • Alcoholism

List 3 radiographic criteria for determining a good reduction of a displaced femoral neck fracture

• Neck-shaft angle 130-150 degrees| • S-shape contour and reverse S shaped of head-neck junction (described by Lowell)| • Garden alignment index - Primary compressive trabeculae 160-180 degrees on AP and lateral|- WIF: western infirmary Glasgow angle (acceptable AP: 145-155 deg)|- GT is aprox at the same level of center of femoral head|| Lowell's Alignment Theory:| - radiographic outline of femoral head & neck junction will have convex outline of femoral head meeting concave outline of femoral neck regardless on all radiographic views;| - this outline produces image of S or reversed S curve;| - hence, if outline reveals an unbroken C curve frx is not reduced • < 10 degrees of AP angulation|• < 5mm translation on AP and Lat - Leadbetter Technique: (preferred technique)| - flex the hip to 90 deg, w/ slight adduction, and apply traction in line with the femur;| - next, while maintaining traction, apply internal rotation to 45 deg;| - idea is that when the hip is flexed to 90 deg (quadriped position) all muscles about the hip are maximally relaxed;| - further internal rotation also relaxes the Y ligament;| - by having these structures relaxed, reduction is possible;| - finally, full flexion and adduction "books open" the frx site which then allows the reduction to procede;| - the leg is slowly brought into slight abduction and full extension, while maintaining traction and internal rotation;||| - heel palm test:| - the surgeon holds both heels in his palms with both legs in abduction and internal rotation;| - internal rotation is then released, and the surgeon notes the amount of external rotation of both feet;| - if the fractured site has significantly more external rotation than the non injured side, then reduction is probably not satisfactory;| - if the injured side, stays in internal rotation, then the reduction is complete;| - if this maneuver, does not reduce hip satisfactorily, then proceed w/ open reduction rather than repeated attempts with greater force, which may damage blood supply to femoral head;| - references: https://fcdblob.blob.core.windows.net/media/g5Qg72pEpJoUninQpGtZXA.jpg?/_0061_4p.jpg https://fcdblob.blob.core.windows.net/media/TZQ9H5iRYC7vxKHKYhHnlA.jpg?/_0061_5p.jpg 2010; 2013; 2015 Trauma

3 complications of vertebroplasty?

• Neurological compromise from cement extravasation into spinal canal|• Cement leak into paravertebral veins leading to pulmonary emboli, cardiac perforation, cerebral emboli, death|• Infection|• Increased fracture risk in adjacent levels 2015 Spine

Name the following Dermatomes: Nipple line, Umbilicus, Groin, medial calf

• Nipple line - T4|• Umbilicus - T10|• Groin - L1|• Medial calf - L4 2012 Spine

List three radiographic criteria suggesting syndesmotic injury

• No overlap of the fibula and tibia on ANY view. Normally should be > 1mm (at 1cm above joint line)in mortise|• Widened Tibia-fibular clear space on AP or mortise > 6mm (at 1cm above joint line)|• Tibia and fibula overlap is < 6mm or < 42% width of fibular on the AP (at 1cm above joint line)|• >4mm of medial space widening. Normal values for sydnesmosis|• Mortise - clear space < 6mm, overlap > 1mm, talocrural 83+/- 4 degrees, medial jt space < 4mm|• AP - clear space < 6mm, overlap > 6mm or 42% of fibular width 2012 Trauma

List 5 indications for ORIF of a mid shaft humerus fracture

A patient is having surgery for Hallux valgus.|| List 4 causes that could result in hallux varus deformity post-op

• Overzealous plication of medial capsule| • Medial displacement of tibial sesamoid, removal of fibular sesamoid| • Overpull of abductor hallucis muscle against incompetent lateral ligamentous complex| • Overcorrection with a post-op dressing, holding MTP in varus= over correction IMA| • Excessive resection of medial eminence| • Overzealous lateral release (excessive)

What is the formula for pelvic incidence

• PI= Sacral slope (SS) + Pelvic Tilt (PT)||• PI = point middle of sup end plate of S1, draw perpendicular line to sup end plate & line from middle of sup end plate of S1 to centre of femoral head|• SS = line from sup end plate of S1 to the horizontal|• PT = point middle of sup end plate to centre of femoral head & vertical line from centre of femoral head|• Normal PT < 25o|• Normal PI L lordosis +/- 9o https://fcdblob.blob.core.windows.net/media/n2EdtmIEsAGrqcQMuH0kdA.jpg?/_0166_3p.jpg 2012 Spine

Name the Four components of the WOMAC

• Pain • Stiffness • Physical function / social function / emotional function • WOMAC is for knee and hip arthritis only • SF-36: functional health and well-being: 8 scales: 4 physical: Physical Functioning, Role-Physical, Bodily Pain, General Health. 4 Mental: Vitality, Social functioning, Role-Emotional, Mental Health 2012 Misc

List 3 physical findings of sacral sparing in a spinal cord injury.

• Perianal sensation intact (S2-4)|• Rectal motor function intact: reflex anal sphincter (S2-4)|• Great toe flexor activity intact (S1) 2013 Spine

Name 4 radiographic reasons for progression of infantile Blount's

• Physeal bar formation|• Increased metaphyseal-diaphyseal angle (>16)(Drennan's), varus angulation|• Increased varus deformity|• Increased internal tibial torsion|• Prominent beaking of the medial metaphysis|• Lateral subluxation of the proximal tibia|- Widening and irregularity of the medial aspect of the physis|- medial sloping and irregular ossification of the epiphysis 2012; 2016 Pediatrics

Lesions of posterior elements of vertebra (3)

AOOO|ABC|Osteoid osteoma|Osteoblastoma Pathology; Nick's list

X-ray of AP pelvis that showed DDH left hip in an adult. The patient is ready to undergo a THA. || List 4 things that you have to consider from a technical aspect with regards to the procedure

- Acetabular Hip centre - high vs medialized Poor bone stock - ream in reverse to prevent med wall blowout| Typically smaller socket - Femur -Metaphyseal-diaphyseal mismatch need smaller, modular implant (S-ROM)|• Possible need for femoral shortening (10% vs 4cm), limited by soft tissue (hamstrings & rectus femoris) → LLD|• Anterior bowing|• Smaller canal|• Valgus neck, excessive anteversion -Soft tissue|:Tension on sciatic nerve - lengthening 3-4cm max; usually 2cm|• Difficult exposure 2010 Arthroplasty

List 4 benefits of using a high offset THA.

- Improved wear rate - Improved gait (less Trendelenburg) - Improved abductor strength - Improved ROM - decreased impingement - Improved hip stability - Decreased joint reaction forces

Patient presents 8 months after TKA. His preoperative flexion was 120 degrees, but he now only has 75 degrees. In the absence of infection, mention 4 causes of decreased flexion. (4)

- Oversized femoral component/ - component - malrotation|• - Arthrofibrosis - Patella baja| - Poor physio compliance - HO - Not enough bone removed posteriorly|• - Insufficient tibial slope|• - Aggressive anticoagulation -hematoma|• - Poor pain management regimen-CRPS|• - Post-op complications: DVT, wound dehiscence

What are the 3 phases of muscle repair?

- Degeneration, - Inflammation - Reparative phase, (Muscle regeneration) - Remodelling phase: (development of fibrosis) (Same as Fracture healing)

List 6 RISK FACTORS for pediatric Acute hematogenous Osteomyelitis

List 4 contraindications to an HTO for a varus knee with OA

- Inflammatory arthritis (RA) - Decreased ROM : lack of flexion > 90 degrees knee flexion contracture > 10 degrees - More than 20 degrees of correction needed - Ligamentous instability - varus thrust gait - Lateral tibial subluxation > 1cm - Medial compartment bone loss - Arthritis in lateral/PF compartments - Lateral compartment narrowing/loss of a large amount of lat meniscus - valgus stress radiograph - Inability to accept the cosmetic appearance of leg - Non-concordant pain - Obese (BMI > 35) 2012 Arthroplasty - Vascular disease

List 8 things that will make you decide on DCO versus primary treatment.

- Labs • Base excess > 5 • Lactate > 2.5 • Platelets < 90 000|| - Trauma • Assoc brain injury • Persistent hypotension sBP<90 • Hypothermia <35C • Pulmonary contusions bilat seen on Xrays • ISS > 40 without thoracic injury • ISS > 20 with thoracic injury • Long bone fractures - femur fractures Surgery > 6hrs Head trauma ASI score 3, GCS < 8 Polytrauma pelvic and abdominal injury

List 6 causes for groin pain and decreased function in a total hip.

- Referred pain: Spinal stenosis Degenerative/inflammatory disorders of L-spine/SI joints Paget's Primary bone tumours and mets in pelvis, L-spine, or femur - Implant related pain Aseptic loosening Joint instability Insufficient anteversion - prominent anterior lip cause iliopsoas impingement Deep sepsis - Soft tissue related pain Trochanteric bursitis|• Tendinitis - abductor, adductor, iliopsoas|• Nerve injury - sciatic, femoral, obturator, LCFN (meralgia parasthetica) Herniation of vastus lateralis thru defect in fascia lata closure|• Poor abductor tensioning||Bone pain|• Intra-op fractures of GT or shaft|• Femoral stress fractures - mantle defect|• Non-union of GT osteotomy/ETO||o Infection|o Aseptic loosening of the acetabular component (osteolysis)|o iliopsoas tendon impingement|o Arthrofibrosis|o Heterotropic ossification|o Periprosthetic fracture|o Pseudotumor|o Component impingement

List 3 contraindications for pelvic realignment in an adult.

- Severe arthritic changes - Non-ambulator - Medical co-morbidities precluding operation - Active infection - Advanced age

List 4 relative contraindications to total joint arthroplasty.

- Skin conditions (psoriasis) - Morbidly obese -Neurologic conditions (Parkinson or seizure disorder predisposing to dislocation) - Neuropathic joint - Massive abductor soft tissue loss - Recurrent UTIs

What are 2 physical exam findings in a patient who has a Trendelenburg gait

- Trunk lurches toward the affected side during gait - Contralateral pelvic tilt in stance phase due to weakened abductors

List 3 anatomic landmarks for placing the femoral component in a TKA.

- Whiteside's line| - Epicondylar axis| - Posterior condylar axis

What is the order of releases for the correction of a valgus knee? Name 4 possible soft tissue releases to help balance during a total knee arthroplasty in a valgus knee

1. Osteophytes 2. Posterolateral capsule 3. IT band: off tibia (if tight in extension)| 4. Popliteus: off femur just ant and distal to LCL origin (if tight in flexion)| 5. LCL (if tight in both flex-ext): off femur| Consider constrained prosthesis is LCL and popliteus released (loss of flexion gap stability) 2016 Arthroplasty

Shown an AP hip x-ray of a 6 month-old with DDH. |Name 4 radiographic findings suggestive of DDH in this picture.

-Hilgenreiner's line: horizontal line through right and left triradiate cartilage|femoral head ossification should be inferior to this line|- Perkin's line: line perpendicular line to Hilgenreiner's through a point at lateral margin of acetabulum, femoral head ossification should be medial to this line||- Broken Shenton's line: arc along inferior border of femoral neck and superior margin of obturator foramen, arc line should be continuous|- delayed ossification of the femoral head is seen in cases of dislocation|- Acetabular index: should be <25 deg in older than 6 months old. |-CEA: center edge angle of Wiberg: less than 20 deg abnormal (reliable in pt over 5y)|- Acetabular teardrop no typically present prior to hip reduction https://fcdblob.blob.core.windows.net/media/uF03KrlJ2UkNIFMCzDnKbg.jpg?/_0228_2p.jpg https://fcdblob.blob.core.windows.net/media/n6GIvvU3ALPmscjdd5fJ3g.jpg?/_0228_3p.jpg 2016 Pediatrics

List 4 systemic conditions associated with basilar invagination in peds

1. Achondroplasia|2. Morquio (despite de odontoid hypoplasia)|3. SED|4. Osteogenesis Imperfecta Pediatrics; Spine

List 3 conditions that have Uveitis

1. Ankylosing spondylitis|2. Juvenile RA|3. Reactive arthritis: Reiter's Syndrome: conjunctivitis Pediatrics

List nine (9) features of Diastrophic Dysplasia ||(Autosomal Recessive, Sulfate transporter)

List 6 essential components of obtaining an informed consent.

1. Competence|2. Voluntariness|3. Disclosure|4. Recommendation|5. Understanding|6. Decision|7. Authorization|||JAAOS • Patient must know/understand the diagnosis|• Proposed treatment|• Possible risks and benefits of treatment|• Possible alternatives|• Possible risks of NOT receiving treatment ||Patient must have adequate reasoning, capacity to understand Must be voluntary with no coercion, manipulation and or influence ||( Think Shriner's consent) 2013; 2015; 2016 Misc

List Syndromes associated with Congenital Radial head Dislocation (7)

List 6 anatomical releases for balancing a varus knee.

1. Deep MCL (to the mid-coronal plane of the tibia) 2. Medial osteophytes (Marginal osteophytes) 3. Release posteromedial corner (POL, posterior oblique ligament)| 4. Medial tibial reduction osteoplasty: downsize tibial component, lateralize it, resect uncovered bone| 5. Consider PCL release/ substitution if imbalance(PS knee)| 6. Release semimembranosus (if flexion contracture is present) 7. Pie crust superficial MCL (18G needle) 8. Complete superficial MCL and pes Anserinus (differential release: post deep MCL if tight in extension, anterior deep MCL if deep in flexion) Capsule posteromedial Medial femoral condyle osteotomy

Describe 4 ways to deal with posterior glenoid bone loss when doing a shoulder arthroplasty for osteoarthritis.

1. Eccentric reaming: most common|2. Posterior bone grafting|3.Posterior implant augments|4.Reverse total shoulder arthroplasty Current options that should be considered for managing glenoid bone loss that results in >15° of retroversion include bone-grafting, augmented glenoid components, lateralized implant and reverse total shoulder replacement. ||Asymmetric reaming is commonly used to improve version but should be limited to correction of 10° to 15° of retroversion in order to preserve subchondral bone. ||Implantation of an augmented polyethylene glenoid component offers the potential to improve version while preserving subchondral bone. ||Reverse total shoulder arthroplasty offers improved fixation and stability compared with an anatomic prosthesis for elderly patients with severe glenoid bone loss but is associated with a high complication rate. Glenoid dysplasia is defined as a deformity that results in >25° of glenoid retroversion 2016 Arthroplasty

List the embryological classification of congenital hand anomalies

Name 19 structures on a slide axial cut ,(cut a few cm disal to tibial plateau)

1. Fibula |2. Tibia |3. Tibial tuberosity |4. Patellar tendon |5. Tibialis anterior |6. EDL 7. Common peroneal nerve 8. Laeral head of gastrocnemious 9. Soleus |10. Tibialis posterior 11. Popliteal vessels 12. Tibial nerve 13. Medial head of gastrocnemious 14. Lesser saphenous vein, and medial sural cutaneous nerve 15. Gracilis |16. Long saphenous Vein |17. MCL |18. Semitendinosus |19. sartorius https://fcdblob.blob.core.windows.net/media/kdjEuYo1Aflx34JcdebR4Q.jpg?/_0106_1p.jpg 2016 Misc

List features of Downs Syndrome, trisomy 21|(18)

List 3 spine manifestations of Achondroplasia

1. Foramen magnum stenosis, upper C spine stenosis|2. Lumbar spine stenosis: short pedicles|3. Thoracolumbar khyphosis Pediatrics

TB spine risk of progression

1. Gapping of the facet joint|2. Posterior retropulsion of an infected vertebrae in relation to the adjacent normal levels|3. Lateral listhesis|4. Toppling: a line draw tangential to the caudal "normal" anterior vertebral body intersects the cranial (normal ) vertebra higher than the midpoint of that vertebra body's anterior surface Spine

List 4 reasons to percutaneous pin a displaced distal radius fracture In a child

1. Grade 3 Open fracture (gross contamination)|2. Neurovascular compromise|3. Irreducible fracture (failed closed reduction)|4. Floating elbow|5. Massive swelling Pediatrics

List 5 syndromes associated with radial longitudinal deficiency

1. Holt-Oram|2. TAR: thrombocytopenia absent radius|3. Fanconi's anemia: life's threatening need bone marrow transplant|4. VACTER|5. VACTERL Pediatrics

List three neurologic features of a Brown Sequard syndrome. (3)

1. Ipsilateral paralysis: loss of motor function|2. Ipsilateral loss of vibration and proprioception|3. Contralateral loss of pain and temperature sensation: 1-2 levels below the lesion 2010; 2012 Spine

20M with postero-lateral dislocation of the elbow. It is reduced but there is still instability despite normal xrays.||What structures provide stability to prevent Posterolateral dislocations?

1. LUCL/ LCL (most commonly injured)|2. Anterior capsule/ Coronoid + posterior capsule|3. Medial ulnar collateral ligament||Reconstruct Ulnar collateral ligament (medial epicondyle): with open repair, reconstruction with lateral docking procedure, with Y-shaped tunnels using palmaris longus autograft Sports

Enneking Classification of Benign Bone tumors (3)

1. Latent|2. Active|3. Aggressive Pathology; Nick's list

List 3 obstacles to reduction of proximal humerus fractures in peds

1. Long head of biceps|2. periosteum|3. Glenohumeral joint Capsule Pediatrics

Which 2 muscles are innervated by the lower subscapular nerve?

1. Lower part of subscapularis muscle 2. Teres major muscle (some times supplied by separate branch) || Lower subscapular nerve: from C5-C6 spinal nerves | Branch from posterior cord of brachial plexus Upper subscapular nerve: innervates the upper portion of subscapular muscle ||Middle subscapular nerve same thoracodorsal nerve: innervates Latissumus dorsi 2016 Misc

Given 2 x-rays and a 3D CT scan of an elbow. ||Describe 4 surgical principles in managing a coronoid anteromedial facet fracture. |(Posteromedial Varus rotatory instability= PMRI)

1. Posterior approach : medial and lateral intervals|2.Buttress plate fixation for the anteromedial coronoid|3. Reconstruct LCL|4. Assess and reconstruct MCL|||ORIF with buttress plate fixation or pins and lateral ligament repair for posteromedial rotatory instability |solid fixation of the anteromedial facet is critical for functional outcome and prevention of arthrosis Coronoid fracture fixation with plates, screws, or sutures and radial collateral ligament repair. Anteromedial facet fractures (O'Driscoll type II) : The small fractures are best repaired with suture reattachment of the capsule through a medial exposure. Larger fractures, often associated with varus posteromedial subluxation, are best fixed with an anteromedial plate Prinicples of treatment= -Restore contour and dimensions of trochlear notch| -Contoured dorsal plate| -Fixation of coronoid| -Bridge fragmentation Coronoid anteromedial facet: important for varus stability |- It is the insertion for MCL (medial ulna collateral lig) |Anteromedial varus instability= injury to the LCL and fracture of the anteromedial facet of the coronoid 2016 Trauma

List seven (7) NON- SPINE features of achondroplasia||(Autosomal dominant: FGFR-3 Receptor)

List 6 fractures common in child abuse

1. Posterior rib fractures|2. Metaphyseal fractures (Corner fractures/ bucket fractures), humerus, tibia, femur|3. Femur fracture in preambulatory pt < 1y diaphyseal fractures|4. Transphyseal fractures|5. Fractures at different healing stages|6. Skull fractures|7. Metaphyseal lesions|8. Scapula fractures|9. Transverse process fractures|10. Sternum fractures||Moderate specificity:|- epiphyseal separations|- digital fractures|- clavicle fractures|- https://fcdblob.blob.core.windows.net/media/2cwJfvyycXPeDl7kifRYNQ.jpg?/_0268_3p.jpg Pediatrics

List risk factors for Brachial plexus birth palsy

List 6 Syndromes with overgrowth : think elephant man

1. Proteus Syndrome: (bizarre facial disfigurement with scoliosis, genu valgum, hemangiomas, lipomas, nevi- need to differentiate from McCune Albright and NF1)|2. NF1|3. Klippel-trenaunay- Weber Syndrome: overgrowth caused by AV malformations|4. Beckwith-Widemann Syndrome (overgrowth associated with spastic CP- Wilm's Tumor)|5. Idiopathic hemihypertrophy: needs serial Abd US until age 5 to r/o Wilm's tumor)|6. Juvenile idiopathic arthritis Pediatrics

List five (5) syndromes with atlantoaxial instability

1. Pseudoachondroplasia|2. SED, MED|3. MPS|4. Trisomy 21|5. Mckusick type metaphyseal dysplasia||(Not Marphan and not achon) Pediatrics; Spine

List 3 ways of monitoring neurologic status intraop while performing spine surgery

1. SSEPs: somatosensory evoked potential|2. Motor evoked potentials|3. Stagnara wakeup test|4. Pedicle screw stimulation|5. Continuous EMG: stimulated and spontaneous EMG Spine

List 4 risk factors for SMA syndrome in idiopathic scoliosis correction of spine surgery.

1. Staged procedure, anterior approach|2. Lumbar modifier: laterally displaced lumbar curve: B, C.|3. Low body mass index|4. Thoracic stiffness <60 percent bending

Name 6 other causes of lateral pain in a 12 year-old girl with recurrent ankle sprains?

List 9 anatomical abnormalities in the Upper Extremity associated with radial longitudinal deficiency

You are doing a case, which will likely require more than 2.5h of tourniquet time. Give 3 possible management methods to prevent tourniquet related complications

1. Use only minimal effective pressure required to reliably maintain arterial occlusion throughout the procedure |2.Use a cuff that properly fits the extremity and has the maximum bladder width possible|3. Use a limb protection sleeve that matches the selected cuff|4. Apply the cuff at the proper location of the limb|5.Release the tourniquet mid case https://fcdblob.blob.core.windows.net/media/x14zvMtrMrwmzygPDfUbrw.jpg?/_0347_2p.jpg Misc; Trauma

List 2 issues to address intraoperatively when placing C1-C2 transarticular screws

1. Vertebral artery|2. C2 nerve roots Spine

List 4 potential complications of using BMP-2 in spine surgery.

1. Verterbral osteolysis (44-55%)| 2.Massive soft tissue swelling (27%)| 3. Postop radiculitis at 6 mo (26%)| 4.Retrograde ejaculation (7%)| 5. Malignancy at 5y (5%)|- Ectopic bone formation| 6. Seroma -graft subsidence (27%) | -graft migration (31%) | -formation of neutralizing antibodies against BMP-2 (26%)| -ectopic/heterotopic bone formation (7%)| -hematoma formation (3%)||retrograde ejaculation, |antibodies formation. |postoperative radiculitis, postoperative nerve root injury, |ectopic bone formation, |vertebral osteolysis/edema, dysphagia and neck swelling, hematoma formation, interbody graft lucency, and wound healing complications

List 4 xrays signs of distal radius Epiphysiolysis

1. Widened physis|2. Blurred physis|3. Metaphyseal changes: sclerosis|4. volar, radial fragmentation of the growth plate Pediatrics

List 3 findings associated with dural ectasia

1. Widened spinal canal|2. Instability|3. Erosions|4. Scalloping of vertebral body|5. Widened neuroforamina Pediatrics

Patient with grade 2 open tibia fracture. Allergy to penicillin (gets anaphylactic reaction) and does not know his tetanus status ||A - List the antibiotic treatment |B - List the tetanus treatment - State the surgical treatment

A - Antibiotic treatment|• Clindamycin 600 mg IV x4 / day Tetanus treatment: Tetanus booster 0.5 mL & IVIG B-Surgical treatment | Urgent layer-by-layer irrigation and debridement Necrotic tissue/debris Deliver both bone ends If happy with wound, close and nail the tibia (reamed statically locked) If unhappy, ex-fix and return to OR for reassessment of tissue viability with external fixation and delayed definitive management of the fracture

45 y.o. male with left hip pain. Shown an AP pelvis. A - List 3 common causes of his left hip pain. B - You had to determine that he had AVN of the left hip. Give 3 common causes

A - Differential for hip pain - intra-articular bony changes| - AVN - arthritis - FAI - infection B - Differential for AVN: Pancreatitis, lupus, alcohol, steroids, trauma (femoral neck#), idiopathic/infection, Caissons, RA/radiation, amyloidosis, Gaucher's, sickle cell|| PLASTIC RAGS - the acronym for AVN 2010-2014 Arthroplasty

Proximal tibiofibular dislocation|| A - Mechanism (2) - leg position and knee position| B - Clinical findings (5)| C - How to reduce (2)

A - Mechanism - anterolateral - most common (85%)|• Knee flexion, ankle inversion, plantarflexion||B - Clinical findings|• Lateral knee pain aggravated by pressure over the fibular head|• Limited knee extension|• Crepitus|• Visual deformity|• Popping & locking|• Ankle movement may exacerbate pain|• Transient peroneal nerve palsy||C - Reduction maneuvre|• Knee flexion, ankle dorsiflexion & ER • MOI: mechanism of injury - fall on flex adducted knee|• Fibular head resection - surgical management 2013 Trauma

An adolescent with a major right-sided thoracic curve with also a left-sided thoracolumbar curve.|| A - List 3 radiographic signs that would suggest that the TL curve is not compensatory but is a primary curve as well|| B - List 5 things that can predict skeletal age of the patient (? What are 5 ways to assess her skeletal maturity?)

Patient sustained an elbow dislocation that was reduced but remained unstable at 45 degrees with posterolateral instability||A - List 3 stabilizers to posterolateral instability |B - What is most likely injured?|C - What is the treatment?

A - Stabilizers|• Lateral collateral ligament complex|• Joint capsule|• Common extensor origin||B - Most likey injured|• Lateral ulnar collateral ligament||C - Treatment|• Splint immobilization in 75 degrees of flexion and pronation |• Reassess stability on a weekly basis 2010 Trauma

The Lisfranc joint in the foot is stabilized by both ligaments and bones.||A - List 4 important bony and ligamentous features that stabilize the Lisfranc joint||B - What is the location of the strongest Lisfranc ligament (dorsal vs plantar)?

A - Stabilizers|• Trapezoidal shape of middle 3 MT bases - transverse Roman arch|• Keystone of arch - recessed middle cuneiform - allows 5 stabilizing structures to articulate with 2nd MT|• Transverse ligaments - 2nd to 5th MT bases (none between 1st & 2nd)|• Oblique interosseous ligament aka Lisfranc ligament||B - Lisfranc ligament|• Originates inferolateral aspect of medial cuneiform and inserts onto 2nd MT|• Composed of 3 ligaments, strength: interosseous > plantar > dorsal 2014; 2016 Foot & Ankle

AJCC staging of bone sarcomas (4)

AJCC Staging of bone sarcomas |Stage I: Low grade| A: <8cm| B: >8cm||Stage II: High grade| A: <8cm| B: > 8cm||Stage III: SKIP mets|Stage IV: Distant mets| A: Pulmonary| B: non pulmonary including other bones T|1. <= 5cm|2. > 5cm| A: Superficial| B: Deep||N: nodal involvement|M: distant mets Pathology; Nick's list

List 3 key radiographic relationships seen in a Lisfranc fracture

AP: Medial border of navicular and medial cuneiform - medial column line Medial border of 2nd MT and middle cuneiform Fleck sign Widening between 1st and 2nd ray Oblique: Medial border of 4th MT and cuboid Lateral| :Dorsal subluxation of MT base

Diaphyseal lesions (6)||A.E.I.O.U and sometimes Y

A.E.I.O.U and sometimes Y||Adamantinoma|EG|Infection|Osteoid Osteoma/ Osteoblastoma|Ewings|MYeloma/ Lymphoma, fibrous Dysplasia Pathology; Nick's list

Campanacci Staging for ABC (5)

ABC:|Type I: central cyst with intact bone profile|Type II: central cyst with enlarged bone|Type III: eccentric cyst with minimal bone expansion|Type IV: subperiosteal cyst with superficial cortical erosion|Type V: cortical destruction with cyst expansion into the soft tissues Pathology; Nick's list

AC joint anatomy Ligaments

AC ligament: give ant and post stability (most important for stability post and sup AC lig|CC lig: coracoclavicular lig: provide superior-inferior stability (conoid, trapezoid) 2017 Upper Extremity

Sites of compression of AIN syndrome

Risk factors for Achilles' tendon rupture/tear

Achilles' tendon rupture|Hyperpronation and cavus foot |- Increasing age |- Flouroquinolone use (Cipro etc) |- Ochronosis |- Steroid use |- Inflammatory arthritis. |-Acute ruptures occur most commonly in men in the third and fourth decades of life who participate in sports intermittently |- The left side is ruptured more commonly than is the right - In a prospective study of serious runners, approximately 10% had Achilles tendon problems within the 1-year observation period |- Sudden increases in training intensity

Describe the protocol for Achilles' tendon tear: functional bracing aggressive rehabilitation program

Achilles' tendon|0-2 wks: posterior slab, NWB crutches (immediate postop or nonop)|2-4wks: air cast walking boot 2cm heel lift (protected WB crutches active plantiflex and dorsiflex to neutral|- inversion.eversion below neutral, modalities, knee/hip ROM |4-6wks: WBAT, continue as above|6-8wks: remove heel lift from boot, WBAT (dorsiflex stretching, open and closed kinetic chain ROM, proprioception, modalities, cardio excercises with WB|8-12wks: wean off boot, return to crutches/cane prn. Gradual wean off, progress ROM, strength, proprioception|>12 wks: progress ROM, strength proprioception, power endurance, sport specific training

Give 5 principles of managing a medical error

Acknowledge error Explain it to the patient (Why? How?) Take responsibility Offer emotional support (apology, compassion, honesty) Find the underlying cause Prevent its recurrence

Cortical based lesions (3)

Adamantinoma|Chodromyxoid Fibroma (CMF)|NOF|Osteofibrous Dysplasia Pathology; Nick's list

Bubbly lesions on Peds tibia (3)

Adamantinoma|FD|Osteofibrous dysplasia Pathology; Nick's list

List 6 prognostic factors when treating osteosarcoma

All factors stated worsen prognosis:||Tumour factors|• Location - axial skeleton|• Size - large tumour volume >8cm|• Response to neo-adjuvant chemo - tumour necrosis < 90%||Blood work|• Elevated LDH/Alk phos||Spread|• Presence of mets on initial diagnosis|• Skip lesions/discontinous|• Lymph node involvement 2013 Pathology

What is the difference between blinding and allocation concealment

Allocation concealment: different than blinding|-The person randomising the pt does not know what the next treatment allocation will be.|- important as it prevents selection bias affecting which patient are given which treatment|It is possible even with unblinded trials, it is universally recommended.|- Done with the use of centralized system.||Blinding:|Single blind: pt blinded to the ttx given but not the administering clinician.|Double blind: neither pt nor clinician know which treatment the pt is randomized to. 2017 Misc

Name the layers of cartilage (see picture) (6)

Articular surface Tangential zone Transitional zone Radial zone Calcified cartilage Subchondral bone

Most common metastatic tumors (5)

16 y/o F Jehovah witness trauma patient who has lost enough blood to require a blood transfusion. | You explain to her that she needs blood. She gets agitated when you say this and refuses. |Although she is in shock, she seems competent. What ethical principles are in conflict with each other when dealing with this situation?

Beneficence and autonomy

Duchenne Muscular dystrophy. |Use of corticosteroids: (Deflazacort for DMD)|• Benefits (3)|• Complications (3)

Benefits |• Delays and decreases Scoliosis progression |• Improved strength - mean isometric muscle strength in legs|• Delayed pulmonary deterioration: Preservation lung vital capacity|• Prolongs ambulation|• Slows weakening|• Improved performance||Complications|• Increased BMI/weight gain|• Osteoporosis|• AVN|• Short stature|• Cataracts|• Cushinoid appearance|- HTN, DM|- Hirsutism|- Growth suppression https://fcdblob.blob.core.windows.net/media/ch8gnI7Df2aQCaDKU3Ethw.jpg?/_0131_3p.jpg 2013 Pediatrics

36 year-old male comes to the office with 3-week history of acute onset shoulder pain in non-dominant arm. No history of trauma. Complains of night pain and 1 week of decreased shoulder abduction and external rotation as seen in the physical exam. |Has an MRI, which is normal except for increased signal in the supraspinatus and infraspinatus. ||Diagnosis and investigation?

Brachial Neuritis (Parsonage-Turner) -> EMG 2015 Sports

List 4 syndromes with Syndactyly

C-A-P-S|1. Carpenter Syndrome (craniofacial, syndactyly, obesity)|2. Apert Syndrome (affects the skull, face, hands and feet)|3. Poland Syndrome (rt sided syndactyly and pec major absence)|4. Streeter's Dysplasia (amniotic bands) Pediatrics

List 5 radiographic signs suggestive of juvenile idiopathic arthritis of the cervical spine.

C-spine involvement: ||1.-kyphosis. 2.- facet ankylosis, of the posterior elements of the cervical spine: of the apophyseal joints. The ankylosis usually involves C2-3, although it often involves multiple levels. 3.- atlantoaxial subluxation= ADI >3.5mm, PADI/SAC <14mm 4.-The small, narrow vertebral bodies and disk space narrowing seen at the levels affected by ankylosis are characteristic findings in JIA, as is antegonial notching of the mandible |5.-The vertebral bodies are commonly hypoplastic in both anteroposterior and transverse dimensions ("juvenile cervical vertebrae") with concomitant narrowing of the intervertebral disk space, typically seen at the same level as the apophyseal joint ankylosis|- Basilar invagination: Ranawat, McGregors, Chamberlains, McRae's, cervicomedullary angle < 135deg on MRI|- Subaxial subluxation: of vertebral body: (body height/ width)< 2.0 is almost 100% sensitive and specific for predicting neurologic compromise ||-Clinical symptoms of cervical spine involvement include neck stiffness and limited range of motion, especially upon extension and lateral flexion. https://fcdblob.blob.core.windows.net/media/9GuY9F0FxJSbpc0yNpN4rA.jpg?/_0229_2p.jpg 2016 Pediatrics

List sites of compression in CUBITAL TUNNEL SYNDROME

CUBITAL TUNNEL SYNDROME:|Mnemonic: SITEAOU||1. Struthers ligament|2. Intermuscular septum|3. Medial Triceps|4. Anconeous Epictrochlearis|5. Osburn ligament|7. FCU aponeurosis Upper Extremity

Ewing sarcoma chemotherapy (4)

C.A.Ve.D|Cysclophosphamide|Adriamycin|Vincristine|Dactinomycin Pathology; Nick's list

List 2 cervical spine issues associated with Down's Syndrome

C1-C2 instability|Atlanto-occipital instability

Name 3 operative techniques for management of odontoid fractures through a posterior approach.|3 ways to do a fusion for odontoid non-union:

C1-C2 transarticular screws|C1-C2: sublaminar wiring technique: Gallie or Brooks|C1 posterior lateral mass screw and C2 pedicle screw construct|||Anterior: Screw Osteosynthesis|||A. C1-C2 fusion with Brooks wiring|B. C1-C2 fusion with Gallie-wiring|C. C1-C2 fusion with Magerl transarticular scews|D. C1-C2 fusion with harms technique : C1 lateral mass screw and C2 pedicle screws) Spine

What are the characteristics of CAM in FAI

CAM impingement: bump or offset of femoral neck: aspherical femoral head-neck: wear of the the postero-superior acetabulum, causes thinning and delamination of the cartilage.|it is a Femoral Based disorder in young athletic males includes:|| Decrease Head to neck ratio| Aspherical femoral head| decrease femoral offset| femoral neck retroversion: can be due to previous SCFE deformity. Pediatrics

Indications for Biopsy of an enchondroma (4)

Change in size|Pain |Permeative lysis|Endosteal erosion Pathology; Nick's list

Lesions associated with secondary ABC (6)

Chodroblastoma 30%|Osteoblastoma 25%|NOF|FD|GCT|CMF Pathology; Nick's list

Epiphyseal lesions (5)

Chondroblastoma|clear cell chondrosarcoma|GCT|Telangiectatic osteosarcoma|Infection: Brodie's Pathology; Nick's list

1. List 5 Complications of treatment of displaced intra articular tibial tuberosity fracture in an adolescent patient

What are the criteria for Fat Embolism Syndrome ?

Criteria for Fat Embolism:|Major criteria:|- Hypoxemia (PaO2<60mmHg)|- CNS depression|- Petechial rash|- Pulmonary edema||Minor Criteria:|- Tachycardia > 110pbm|- Pyrexia > 38 C|- Retinal Emboli on fundoscopy|- fat in Urine|- Fat in sputum|- Thrombocytopenia|- Decreased Hematocrit Trauma

Name 5 sites of compression of the ulnar nerve.

Cubital tunnel Syndrome: Compression proximal to distal) 1. Medial intermuscular septum: 8cm prox to medial epicondyle 2. Arcade of Struthers 3. Medial epicondyle: osteophytes 4. Osburne's Ligament (cubital tunnel retinaculum): anconeus epitrochelaris muscle replaces Osburne's lig 11% casuing compression |5. Arcuate ligament (aponeurosis of 2 heads of FCU) 6. Deep flexor pronator apponeurosis: 4cm distal to medial epicondyle ||Ulnar tunnel Syndrome:Compression in Guyon's canal. Compression sites Zone 1: prox to bifurcation caused by hook of hamate # and ganglia (motor and sensory symptoms) Zone 2: hook of hamate # and ganglia (motor symptoms only) Zone 3: caused by ulnar artery thrombosis or aneurism (sensory symptoms only) Ulnar nerve: form Medial cord : C8-T1 |Cubital tunnel: roof: Osbourne's lig (FCU fascia) |-Floor: Posterior and transverse bands of MCL and elbos joint capsule ||Guyon's Canal: roof: volar carpal lig |- floor: transverse carpal lig |- Ulnar border: pisiform and pisohamate lig |- Radial border: hook of hamate |Guyon's canal compression: no involvement of dorsal nerves, no involvement of FDP of 4th, 5th and FCU 2016 Misc

Duchenne muscular dystrophy DMD what are they at risk with anesthesia

DMD|At risk of Anesthetic induced rhabdomyolisis (previously thought Malignant Hyperhermia)||Avoid inhaled agents|Use TIVA: Total I.V. Anesthesia

How to decrease the pressure in the canal in femoral fractures with IM nail reaming?

What is the classification for trochelar dysplasia |On Xrays/ CT (Dejour)

Dejour classification: trochelar dysplasia||Type A: crossing sign: trochlear shallow >145 deg|Type B: Supratrochlear spur : flat trochlea|Type C: Double contour : lateral convexity, medial hypoplasia|Type D: Double contour, supratrochlear spur: cliff https://fcdblob.blob.core.windows.net/media/9aSYFDlToTfGuVPhVwfakA.jpg?/_0358_3p.jpg Sports

Name 3 findings in Down's hips (3)

Down's hips:|1. Acetabular dysplasia|2. SCFE|3. Hip instability Pediatrics

Associated conditions with Dupuytren's Disease (5)

Dupuytren's Disease associated with|1. HIV|2. Alcoholism|3. DM|4. Anti-seizure medications 2017 Upper Extremity

Fibromatosis (benign aggressive) what is associated with Dupuytren's (1)

Dupuytren's contracture: fibromatosis in the hand|- Lederhosen disease: in the foot|- Peyronie Disease: in the penis||Lesions are <5cm diameters slow growing, rarely require imaging,|Small firm pea size mass, painful with WB

Radiographic finding of dystrophic scoli in NF

List 4 extraosseous findings in fibrous dysplasia.

Endocrine |- Hyperthyroidism|• Hypophosphatemia|• Acromegaly|• Hyperprolactinemia|• Cushing's||Non-endocrine:|- Mazabraud: intramuscular myxoma|- cafe au lait spots • McCune Albright - polyostotic fibrous dysplasia, endocrine dysfunction (precocious puberty), cafe au lait spots|• Mazabraud's syndrome - polyostotic fibrous dysplasia & soft tissue myxomas 2011; 2013 Pathology

Tumor reconstruction options (4)

Endoprosthesis|Osteoarticular/ intercallary allograft|APC: allograft- Prosthetic composites |Vascularized fibular autograft Pathology; Nick's list

Signs of hypercalcemia (10)

Early (5)|- Polyuria|-Polydipsia|-Anorexia|-Weakness|-Fatigue||Late (5)|- N/V|-Pych prob|- vision alt|-cardiac alt|- coma Pathology; Nick's list

What are the primary and secondary constraints of the elbow: static and Dynamic

Elbow:|Static Constraints:|PRIMARY: |- Ulnohumeral articulation|- MCL (ant band)|- LCL (LUCL)|SECONDARY:|- Radial head|- Common flexor origin and extensor origin|- capsule||Dynamic constraints:|- Anconeous|- triceps|- Brachialis|- Biceps

Being latent bone lesions (6)

Which inherited oncology syndrome give patients risk for extra-abdominal Desmond tumors?

Familial adenomatous polyposis Pathology; Nick's list

Tumor suppressor Syndromes (6)

Familial melanoma: (p161NKa= melanoma, osteosarcoma, chondrosarcoma)|Familial adenomatous polyposis (APC, colonic adenomas, desmoid tumor)|Hereditary Retinoblastoma: (RB= retinoblastoma, osteosarcoma)|Li- Fraumeni Sydnrome (P53= sarcomas and breast ca)|Multiple hereditary exostosis (EXT1/2- osteochondromatosis, chondrosarcoma)|Neurofibromatosis (neurofibromin- neurofibromas, sarcomas) Pathology; Nick's list

Describe forearm fasciotomy

Fasciotomy of forearm|Volar incision:|Curvilinear: radial to FCU, extends prox to medial condyle|Release:|Lacertus fibrosis|Fascia over FCU, retract FCU ulnarly|Retract FDS radially|Open fascia over deep muscles of the forearm||Dorsal incision:|Longitudinal incision 2cm distal to lat epicondyle towards midline of wrist|Dissect interval b/w EDC-ECRB (Kaplan approach)|Decompress mobile wad and dorsal compartment

Describe the Leadbetter manoeuvre to reduce a displaced femoral neck fracture (4)

Flexion with mild adduction Traction in-line with femur Internal rotation Circumduction (to abduction and extension while maintaining IR)

Campanacci staging for GCT (3)

GCT: |Stage I: benign latent lesion with normal bone morphology |Stage II: benign active lesion, with cortical expansion|Stage III: benign aggressive lesion with cortical disruption Pathology; Nick's list

What is Gardner's Syndrome |Name 4 manifestations

Gardner's Syndrome:|It is FAP (familial adenomatous Polpyposis) manifestations outside of the colon||Manifestations:|1. Desmoid tumors|2. Skin cysts|3. Osteomas|4. Congenital hypertrophy of the retinal pigmented epithelium Pathology; Nick's list

List 4 anatomic features of a pincer type femoral acetabular impingement

Global|• Anterosuperior acetabular rim overhang - CEA >39 → over coverage; >35 in symptomatic pt (normal CEA 25-39)|• Acetabular protrusio - femoral head touches/med to ilioischial line|• Coxa profunda - med acetabular line touches/med to ilioischial line|Acetabular retroversion||Focal|• Anterior over coverage - cross-over sign, post wall sign, ischial spine sign|• Posterior over coverage - post wall cross lat to centre of femoral head (normal w/in 2mm) 1. Asphericity and contour of the femoral head and neck: pistol grip deformity: indicates CAM impingement| 2. Examine for acetabular protrusio, retroversion, and coxa profunda: crossover sign= indicated acetabular retroversion PINCER| 3. Alpha angle > 42deg suggestive of head neck offset deformity| 4. Head neck offset ratio: the ratio is > 0.17 a cam deformity is likely present. https://fcdblob.blob.core.windows.net/media/8qcX4xGcPJCK9Cauc7NwvQ.jpg?/_0047_4p.jpg https://fcdblob.blob.core.windows.net/media/nUnTWiaDyWpwR2QG5nQ56g.jpg?/_0047_5p.jpg 2013; 2014 Arthroplasty

What are the realignment goals in ankylosing spondylitis Spine sx?

Goals for realignment in Ankylosing spondylitis|1. LL= PI +/- 10 deg. (Lumbar lordosis: normal: 30-60deg, Pelvic incidence Normal: 50 deg, sacral slope normal: 35 deg, Pelvic tilt: normal <25 deg)|2. SVA < 5cm ( C7 plum line < 5cm from post superior S1 endplate)|3. PT <20 (pelvic tilt)|4. Correction with long rigid construct Spine

Name 5 ways to limit bias in a randomized controlled trial?

Good randomization (centralized)|• Blinding (assessor, patient, surgeon)|• Intention-to-treat analysis Minimize loss to follow-up Large enough sample size Stratification|• Use validated outcome tools| Use reliable outcome tools| Ensure groups have similar baseline characteristics to ensure randomization was effective

Complications of Radiotherapy (7)

A patient of yours is being worked up for Fat Embolus Syndrome. ||List 4 Major criteria|List 4 Minor criteria

Gurd criteria for Fat Embolus (Need 1 Major criteria or 4 minor criteria to be present)||Major:|- Axillary or subconjunctival petechiae|- Hypoxemia PaO2 less than 60mmHg; FiO2=40%|- CNS depression disproportionate to hypoxaemia|- Pulmonary oedema||Minor:|- Tachycardia > 110 bpm|- Pyrexia > 38.5oC|- Emboli in the retina on fundoscopy|- Fat in urine|- Sudden inexplicable drop in hematocrit or platelets values|- Increasing ESR|- Fat globules in the sputum||• Positive diagnosis requires 1 Major and 4 Minor Other criterias:|- PCO2 less than 55|- pH less than 7.3|- Respiratory rate above 35|- Dyspnea|- Anxiety 2014 Trauma

Lesions on both sides of a joint (8)

Poor prognostic factors for soft tissue sarcomas (6)

Poor prognostic factor for osteosarcoma (6)

Name 6 risk factors for opioid analgesic abuse

Identifying the at risk patient:|Risk factors for nontherepeutic opioid use:|- Personal or family history of substance abuse|- Nicotine dependency|- age < 45y|-History of depression or other psychiatric dx (schizo, bipolar)|- lower level of education|- history of preinjury/preop opioid use||Aberrant behavior monitoring|- early refill requests|- ttx noncompliance|-reports of "lost or stolen" prescriptions"||JAAOS May 2015. The Opioid Endemic: impact on Orthopaedic Surgery https://fcdblob.blob.core.windows.net/media/96B1ACNq4uOeMvNIZbnGKA.jpg?/_0108_3p.jpg 2016 Misc

Give 4 changes in and around muscle with endurance training

Increase resistance to fatigue Increased capillary density, mitochondria and oxidative capacity|• Hypertrophy of slow-twitch fibres.(type 1 fibres) Improved lipid profile

Lesions with circumferential bone involvement (3)

Infection|Lymphoma|Ewings Pathology; Nick's list

List 6 risk factors of radioulnar synostosis that occurs after surgery.

Injury|• Location - proximal third, fracture at same level|• Severity - comminution, severe local soft-tissue injury, IOM injury, high energy, open fracture| Traumatic brain injury|• Patient factors - concomittant head injury||Surgical technique|• Single incision (Boyd)|• Delayed surgical management <2wks|• Violation of IOM|• Retained bone fragments in IO space|• HW protruding into IO space|• Primary onlay bone grafting 2010; 2011; 2013 Trauma

List 6 complications of a mal-positioned acetabular component.

Instability Increased wear Impingement / high risk of dislocation Decreased ROM Decreased life expectancy of the implant Leg length problems/ discrepancy Trendelenburg gait/offset/decreased abductor tension

Type II tibial spine fracture: Block to reduction? ||Consequence of non-anatomic reduction

Intermeniscal ligament|Instability due to ACL laxity|Extension block 2015 Trauma

Types of Oncological surgical margins

Intralesional|Margina|Wide|radical Pathology; Nick's list

Characteristics of tumors that should prompt further investigations to rule out malignancy (JAAOS Jan 2017)

You have the clinical suspicion of flexor tenosynovitis. What are the KANAVEL Sings? (4)

Kanavel Sign|1. Pain on palpation of the flexor tendon sheath|2.Pain on passive extension of the digit|3. Digit rests in flexed position |4. Fusiform swelling of the affected digit Upper Extremity

What tumors give Lytic Mets?|And Blastic?

Lytic mets from:|- Thyroid|- Lungs|- Breast|- kidney||Blastic mets:|- prostate Pathology

Osteosarcoma Chemotherapy (4)

M.A.C.I|Methotrexate|Adriamycin|Cis-platinum|Ifosfamide Pathology; Nick's list

What is the chemotherapy regimen for Osteosarcoma? MACI

MACI: ttx chemo for osteosarcoma|M: MTX|A: Adriamycin(doxorubicin)|C: Cysplatin|I: Ifosfamide Pathology

Describe 4 standard physiologic maneuvers used in spine surgery that are neuroprotective to spinal perfusion.

MAP >85 until decompression is done or the correction of a deformity has been completed|Maintain Hb > 10g/dl|Decreasing CSF (goal 10-12mmHg)|Maintain oxygenation 1. adequate oxygenation, 2.blood pressure support through volume replacement (and, if necessary, cardiovascular support): MAP to 85-90 mmHg and avoiding SBP less than 90 mmHg (Class 3 evidence) for over 5-7 days. 3. immobilization. Intrathecal pressure monitoring may be beneficial to improve SCPPs in critical care areas. 4. minimize intraoperative blood loss.: Antifibrinolytic agents have been shown to decrease intraoperative and total perioperative blood loss. Hypotension is associated with neurologic deterioration in patients with SCI and must be circumvented by judicious administration of anesthetic agents, fluid resuscitation, and vasopressor and/or inotropic support when needed. 5.Homeostasis assays with rapid turnaround time should be used to evaluate the ongoing blood loss during surgery. 6.Multimodality neuromonitoring is sensitive and specific enough for detecting intraoperative neurologic injury during spine surgery and choice of anesthetic has an impact on its quality. 7.Corticosteroids may be used only after careful consideration of associated risk and benefits. . ||Somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) may assist in the detection of intraoperative spinal cord dysfunction, prompting corrective interventions before irreversible neural damage has occurred. |Placement of a central venous catheter and an arterial line may assist with intravascular volume and blood pressure management. Pulmonary artery catheterization or transesophageal echocardiography should be considered in the presence of severe hemodynamic compromise. . Use of the Jackson table, where the abdomen hangs free from compression, reduces the vena cava pressure which in turn lessens epidural venous bleeding when compared to positioning prone on the Wilson frame. There are currently no comparative studies existing to evaluate the effectiveness of normovolemic hemodilution or hypotensive anesthesia. Succinylcholine is contraindicated because of the potential for lethal hyperkalemic responses related to potassium efflux from extrajunctional acetylcholine receptors. |-No clinical evidence exists to definitively recommend the use of any neuroprotective pharmacologic agent, including steroids, in the treatment of acute spinal cord injury to improve functional recovery. -Vasopressors should be chosen so as to minimize exacerbation of bradycardia. An ideal agent should have both alpha- and beta-adrenergic actions, such as dopamine, norepinephrine, or epinephrine, to counter the loss of sympathetic tone and provide chronotropic support to the heart. If it has been started, stop administration of methylprednisolone as soon as possible in neurologically normal patients and in those whose prior neurologic symptoms have resolved to reduce deleterious side effects. 2016 Spine

What are 3 conditions that have dural ectasia?

MEAN|• Marfan's|• Ehlers Danlos|• Ank spond|• NF-1 2011 Spine

Soft tissue sarcomas that respond to chemotherapy (5)

Indications for MRI in scoliosis

MRI in scoliosis|- atypical curve pattern: left thoracic curve, short angular , absence of apical thoracic lordosis, absence of rotation, congenital scoliosis|- pt <10y with curve >20 deg|- abnormal neurological findings on exam, abnormal pain, rapid progressive curve: >1deg/ month

List 3 advantages of a valgus-producing medial opening wedge high tibial osteotomy, compared to a lateral closing wedge

Maintains posterior slope Avoids proximal tibiofibular joint Avoids peroneal nerve in the anterior compartment Lateral closing wedge: valgus-producing tibial osteotomy: advantages: - more inherent stability allows faster rehab and weight-bearing - No required bone grafting

Metaphyseal lesions (8)

Malignant (4)|- MFH of bone|- osteosarcoma|-Chodrosarcoma|-Mets||Benign: (4)|- Osteochondroma|- NOF|- ABC|-UBC Pathology; Nick's list

A worker comes with a high pressure injection injury||A. In which digit and which hand it occurs more often?||B. List 5 poor prognosticators for management of high pressure injection injuries in the hand?

More fc= Index in the non-dominant hand||5 Poor Px:|1. Increased time from injury to treatment|2. Higher force of injection (especially >7000 PSI)|3. Higher volume injected|4. Composition of material (solvents, paint vs water-based)|5. More distal site-> worse px Upper Extremity

List the 4 progressions for perilunar instability

Mayfield classification= perilunate dislocation||• Scapholunate ligament disruption|• Capitolunate ligament: through space of Poirier)|• Lunotriquetral ligament|• Lunate dislocation - dorsal radiocarpal ligament failure (aka: short radiolunate lig)= allows | - Lunate dislocation| -radio-lunate and carpus-lunate dislocation https://fcdblob.blob.core.windows.net/media/PymqoXUuJ4C1ZscyZdIcpw.jpg?/_0238_3p.jpg https://fcdblob.blob.core.windows.net/media/2DuE8MaBC6x1aoqyzgmUfQ.jpg?/_0238_4p.jpg 2010; 2011; 2013 Upper Extremity

A 14 year-old girl is diagnosed with adolescent idiopathic scoliosis and a right main thoracic curve. |Name 3 radiologic factors that would suggest that the lumbar curve is also structural.

Measure regional curves|-proximal thoracic (PT)|-main thoracic (MT)|-thoracolumbar/lumbar (TL/L)|Identify major curve (biggest curve)|-always either MT (Type 1-4) or .MT/L (Type 4*,5,6)||Determine if minor curve is structural or not:|-Bending films determine if curve bends-out to less correction 25 deg cobb on AP standing |- > 20° in sagittal plane|-Axial plane deformity: Adam's fwd bending test|- Curve magnitude equal or grater than adjacent curve|- Kyphosis > 20 deg 2016 Spine

Risk factors for malignant transformation of osteochondroma (6)

Steps involved in metastatic cascade (7)

Radiation sensitive tumors

Dx Criteria for NF-1 ( Von Recklinghausen's disease)= NIH

NF-1:|Dx: 2/7 criteria||> 6 cafe au lait spots: >5mm peds, > 15mm adults|>= 2 Lish nodules|Axillary/ inguinal freckling (Crowe's Sign)|>=2 neurofibromas or 1 plexiform neurofibroma|Optic glioma|Bone involvement: penciling of ribs, shaft vertebral endplates, tibial pseudoarthrosis, NOF, scoliosis|1deg relative with NF-1 as per criteria above Pathology; Nick's list

What are we looking for in MRI in NF? (3)

NF: MRI spine|1. Intraspinal tumor|2. Soft tissue mass|3. Dural ectasia Pediatrics

Diseases with multiple soft tissue masses (5)

NF|Hemangioma (mafucci's)|Myxomas: Mazabraud's|Lymphoma|Liposarcoma Pathology; Nick's list

In hypovolemic shock, the body relies on anaerobic metabolism. (Decreased ATP metabolism) List what happens intracellularly to the following (decreased/increased / no change) a) Na b) K c) Ca d) water

Na- up (increase intracell)|• K - down (decrease intra cell)|• Ca- up (increase intra cell)|• water - up (increase intra cell with H20)

Indications for amputation in MSK oncology (5)

Negative margins can not be achieved with limb salvage|Morbidity of limb salvage too high|Limb salvage will not give adequate function|Tumor unresponsive to neoadjuvant chemo/radio|Involvement of major neurovascular bundle Pathology; Nick's list

List 5 causes of a cavovarus foot in an adult

Neurologica| • HSMN - CMT| - Friedrich's ataxia - CP - Stroke • Anterior horn disease - Polio, ALS| • Spinal cord lesions: myelodysplasia, syringomyelia, polio, tumors, tethered cord|- Arthrogryposis|- Residual clubfoot||| - post-Traumatic: • Compartment syndrome, burns, crush syndrome, fracture malunion| • Talar neck malunion • Peroneal nerve injury

List common features of mucopolysaccharidosis (13)

Benign aggressive lesions (5)

Osteoblastoma|Chondroblastoma|ABC|GCT|CMF: chodromyxoid fibroma Pathology; Nick's list

Define PJK: proximal junctional khyphosis

PJK: proximal junctional khyphosis:|- > 10 deg pre and post difference|- presents at 6 months Spine

List 5 radiographic or clinical features suggesting an unstable C-spine injury

Surface bone lesions (5)

Parosteal osteosarcoma|Periosteal osteosarcoma|Periosteal chondrosarcoma|Myosotis ossificans|Sessile osteochodroma Pathology; Nick's list

4 reasons for loss of extensor mechanism in TKA?

Patellar fracture Quadriceps tendon rupture| Patellar tendon rupture Tibial tubercle avulsion

List 6 risks during spine or other orthopaedic procedures that can lead to postop vision loss

Patient Preparation-Avoid direct pressure to the eye and periorbital area-Keep the patient's neck in a neutral to forward position-Keep the patient's head higher than the heart|When the patient is in a prone position:-Ensure frequent evaluation of face position by anesthesia personnel Consider use of a mirror or real-time monitoring systemWhen the patient is in a lateral decubitus position:-On the dependent side: avoid pressure on the brachial plexus; use roll under the chest and another roll or pads under the axilla-On the nondependent side: adjust pillow height to avoid excessive lateral bend at the neckIntraoperative Monitoring-Frequently check head position and periorbital area because the head can shift intraoperatively; beware of excessive pressure from face pillow, horseshoe headrest, or eye protection goggles-Optimize hemodynamics with adequate monitoring of blood pressure, hemoglobin level, and hematocrit level -Consider using colloid along with crystalloid for fluid replacementImmediate Postoperative Management-Check vision immediately after the patient becomes alert; if POVL is suspected, urgently consult ophthalmologist If POVL is diagnosed, maximize hemodynamics to allow the patient to maintain sufficient orbital perfusion|||JAAOS 2016 https://fcdblob.blob.core.windows.net/media/bw0iJkaFHmkhihMdvG5Ncw.jpg?/_0353_2p.jpg 2017 Spine

Given a picture of an AP pelvis with bilateral hip resurfacing. Right femoral neck # / osteolysis. List 4 risk factors why this would happen.

Patient factors: -Obesity -Decreased BMD - Inflammatory arthritis - Small femoral head (female) - Femoral neck cysts - AVN Surgical factors: -Notching of femoral neck - Varus implantation (<130 neck shaft angle)| - Improper prosthetic seating 2011; 2014 Arthroplasty

Predictors for ischemia of proximal humeral fracture? (2)

Predictors of ischemia of prox humeral fracture (JAAOS Jan 2017)|- metaphyseal head extension <8mm|- medial hinge disruption >2mm||Strongly correlate with humeral head ischemia|However, post# humeral head ischemia does not predict the development of necrosis|Meaning should attempt ORIF with preservation of humeral head

Three (3) critical projections (xrays) for placing SI screws.

Projections for placing SI screws.|1. Lateral xrays: to center guidewire on sacrum anterior to the canal and ensure that is below the cortical density and sacral alar slope; to prevent injury to L5 Nerve root.||2. Outlet view: ensure that guidewire passes above S1 sacral foramen||3. Inlet view: ensure the guidewire is at the proper trajectory and coming to rest in the anterior aspect of the sacral body-promontory for maximal purchase. Spine; Trauma

List sites of compression in Pronator Syndrome

Name the 4 major seronegative spondylarthropathies

Psoriatic Arthritis Reiter's (reactive arthritis) Anklosing Spondylitis Anterior Uveitis Juvenile Idiopathic arthritis (subtype: late onset oligoartcular JIA) Enteropathic arthropathy (Crohn's Ulcerative cholitis) 2016 Misc

What is the difference between Radial Tunnel syndrome and PIN compression?||Are the locations of compression different?

Radial tunnel Syndrome:|Pain, but usually NO MOTOR deficit||PIN syndrome: Motor deficit (usually not painful)||The 5 locations are identical: FREAS Upper Extremity

Realignment objectives in spine with spondy

Realignment objectives:|restore lumbar lordosis: 30-60 deg|LL=PI +/- 10 degrees|LL= 0.8 x PI|Restore SVA to < 5cm (from C7 to post sup S1 endplate), Sacral vertebral axis: plumb line|Restore pelvic tilt to < 20 degrees||Normal:|Sacral slope: 35 deg|Pelvic tilt: 35 deg|Pelvic incidence: 50|PI= SS+PT

What are 2 mechanisms of action of BMP?

Recruitment Differentiation of mesenchymal progenitors into chondrocytes and osteoblasts|• Proliferation of mesenchymal stem cell

You see a pt with Raynaud's disease.|What systemic Syndrome do you have to monitor for pt for?||What are the 5 components of this disease? CREST

What are the risk factors for PJK: proximal junctional khyphosis

What are the risk factors for HO: Heterotopic Ossification in THA and TKA

Risk of HO in THA:|- male|- female > 65y/o|-Ank spon, DISH, Paget's|- Hypertrophic OA|- postraumatic OA|- Prior hip fusion|- Prior HO or contralateral hip HO: highest risk factor|- lateral approach|Cementless: controversial||Risk of HO in TKA:|- Hypertrophic OA: lots of osteophytes|- Women|- increased lumbar BMD|- notching of femur|- quads mechanism trauma|- postop hemarthrosis|- postop decrease ROM

What is SAPHO syndrome and what is it associated with?

SAPHO:|1. Synovitis|2. Acne|3. Pustulosis|4. Hyperostosis|5. Osteitis||Associated with: CRMO: chronic recurrent multifocal osteomyelitis Pediatrics

Soft Tissue sarcomas that metastasize to lymph nodes (5)||SCARE'M/ CREAMS

List the stages of Scapho-Lunate advanced collapse : SLAC

SLAC:|Stage 1: Arthritis b/w scaphoid and radial styloid|Stage 2: arthritis b/w scaphoid & entire scaphoid facet of radius|Stage 3: Capitellum proximal migration. See Capito-lunate arthritis Upper Extremity

A pt with Superior mesenteric Artery syndrome |What is it?

SMA:|Compression of the third portion of the duodenum b/w the superior mesenteric artery (2nd branch of abdominal aorta) and the spine.||Causes: bloating, abdominal discomfort, vomiting. Spine

List the Stages of Scaphoid-Nonunion Advanced collapse. : SNAC?

SNAC:|Stage I: Arthritis localized to distal scaphoid and radial styloid|Stage II: Radioscaphoid + scaphocapitate arthritis|Stage III: Periscaphoid arthritis (radioscaphoid, scaphocapitate and lunocapitate) Upper Extremity

How to recognize sacral dysmorphism

Sacral dysmorphism:|1. The upper part of the sacrum and iliac crests are co-linear on outlet view|2. Residual disc b/w S1-2 on outlet view|3. Alar mammillary processs|4. Abnormal upper sacral ala|5. Iliac cortical density not co-planar with alar slope Spine; Trauma

SALTER Classification of of AVN hip (5)||(Post reduction hip)

Salter Classification of AVN|1. Failure of appearance of ossific nucleus of femoral head during 1y or longer after reduction|2. Failure of growth of an existing ossific nucleus during one year or longer after reduction|3. Broadening of the femoral neck within 1y after reduction |4. Increasing radiographic bone density followed by fragmentation of the femoral head|5. Residual deformity of the femoral head and neck when reossification (resolution) is complete.||These deformities include coxa plana, coxa magna, coxa vara, short broad femoral neck Pediatrics

List 8 components of the pre-op checklist approved by WHO that will decrease patient morbidity and mortality.

Sign in (before induction)| • Confirm patient ID, site, procedure and consent.| • Mark surgical site| • Anesthesia machine and medication check| • Pulse oximeter| • Confirm patient allergies, airway concerns (difficult airway/aspiration risk)||Pre-op checklist (before incision)| • Confirm all members have introduced themselves by name and role| • Confirm patient indentity, procedure and incision site| • Confirm prophylactic antibiotics in the last 60 min| • Anticipated critical events (>500cc blood loss)|• Confirm any essential imaging is displayed|| Sign out (before patient leaves room)| 1. Nurses verbally confirm:| • Procedure done| • Instrument, sponge, and needle count| • Specimen labeling| • Whether any equipment problems need to be addressed| 2. Communicate any key concerns for the recovery and management of the patient. 2011; 2013; 2014; 2012 Misc

Give the 4 types of SLAP tears.

Snyder Classification|• I - Degenerative - fraying of superior labrum & biceps anchor|• II - Complete detachment of biceps anchor from superior labrum|• III - Bucket handle tear with biceps anchor intact|• IV - Bucket handle tear including biceps tendon Management|• I - debride labrum|• II - re-attach labrum|• III - debride flaps|• IV - if tendon involvement < 1/3 - excise the bucket; | if tendon involvement > 1/3 - excise & tenotomy vs tenodesis 2011; 2013 Upper Extremity

What are the predictors to develop PJK (7)

Strong predictor to develop PJK|1. Age |2. LIV: L5-S1: lower instrumented vertebra more PJK the closer to the pelvis instrumentation|3. Preop SVA|4. UIV :T10-L3 (upper instrumented vertebrae)|5. UIV implant type: screw vs hooks (hooks could be better less PJK as has a soft landing smooth transition)|6. Preop PT|7. Preop PI-LL||Frailty independent predictor for complications postop Spine

List 3 non-skeletal findings in Marfan's syndrome

Reverse total shoulder arthroplasty= RTSA||Indications ?|Contraindications?

The general indications for implanting this device in the setting of CTA include |-patient age older than 70 years, |-pseudoparesis of the shoulder with an inability to abduct the arm above 90, |- functional impairment that has not improved with nonoperative methods. ||Contraindications include a :|-nonfunctional deltoid, |-inadequate glenoid bone stock, |-previous shoulder infections, and other significant medicalcomorbidities. |Unlike otherprostheses, anintact CA ligament is not a prerequisite for the procedure. Sports; Upper Extremity

Radiation resistant tumors

Thyroid |Renal|GI|Melanoma Pathology; Nick's list

What are the types of PJK?

Types of PJK:||1. ligamentous (evident in xrays)|2. Osseous( symptomatic)|3. Implant failure (symptomatic Spine

Name 3 upper extremity and 3 lower extremity findings of cervical myelopathy.

Upper Extremity.:|- Hoffman's, Finger escape sign, inverted radial reflex, scapulohumeral reflex, L'hermitte's sing| |1. neck pain and stiffness: axial neck pain (often times absent)|2. occipital headache common|3. extremity paresthesias:diffuse nondermatomal numbness and tingling|4. weakness and clumsiness|5. weakness and decreased manual dexterity (dropping object, difficulty manipulating fine objects) ||Lower extremity:|- Babinski, clonus, rhomberg, heel to toe gait| |1. gait instability: patient feels "unstable" on feet|2. weakness walking up and down stairs:gait changes are most important clinical predictor|3. urinary retention: rare and only appear late in disease progression|not very useful in diagnosis due to high prevalence of urinary conditions in this patient population 4.gait and balance|- toe-to-heel walk:patient has difficulty performing|- Romberg test: patient stands with arms held forward and eyes closed|loss of balance consistent with posterior column dysfunction|provocative tests|- Lhermitte Sign: test is positive when extreme cervical flexion leads to electric shock-like sensations that radiate down the spine and into the extremities upper motor neuron signs (spasticity) |-hyperreflexia: may be absent when there is concomitant peripheral nerve disease (cervical or lumbar nerve root compression, spinal stenosis, diabetes)|- inverted radial reflex: tapping distal brachioradialis tendon produces ipsilateral finger flexion|-Hoffmann's sign: snapping patients distal phalanx of middle finger leads to spontaneous flexion of other fingers|-sustained clonus post: > three beats defined as sustained clonus|sustained clonus has poor sensitivity (~13%) but high specificity (~100%) for cervical myelopathy|Babinski test post: considered positive with extension of great toe 2016 Spine

What is the shoulder pathology of weight lifters and Xrays findings?

List Portals for Wrist scope and landmarks

Wrist scope:|Dorsal:|- The 3-4 portal: located just distal to lister tubercle: B/w EPL and EDC (Danger: superficial sensory branch: radial N)||Radial:|-1-2 portal: b/w APL and ECRB, along the dorsal aspect of the snuffbox (Danger: same as above)||Ulnar:|-6R: located just radial to ECU tendon at the level of the wrist (Danger: dorsal sensory branch: ulnar nerve) https://fcdblob.blob.core.windows.net/media/cxpec3mexoQ2c8KgxsuH9A.jpg?/_0330_2p.jpg https://fcdblob.blob.core.windows.net/media/Pa5LMTV2tur5KiBgSnNRBA.jpg?/_0330_3p.jpg https://fcdblob.blob.core.windows.net/media/8571cTgfYb2sz8hNP7ulbA.jpg?/_0330_4p.jpg

List 3 x-ray findings of Madelung's deformity.

Xrays:|• can see proximal synostosis|characteristic undergrowth of the volar, ulnar corner of the radius|increased radial inclination|increased volar tilt||MRI|indications|concern for pathologic Vickers ligament|views|thickening ligament from the distal radius to the lunate Pyrimidal configuration of carpus|• Prox subsidence of lunate|• Absence/narrowing of ulnar aspect of distal radial physis|• Anterior bowing of radial shaft|• Dorsal subluxation of ulnar head 2011 Pediatrics

Risk factors for local recurrence of ABC after Sx resection (5)

Young age|Open physis|Stage : campanacci stage)|Type of sx removal|Resulting margin Pathology; Nick's list

Shown a histologic picture of a physis. Name the layers.

Zone of reserve= Quiescent chondrocytes are found at the epiphyseal end|Zone of proliferation= Chondrocytes undergo rapid mitosis under influence of growth hormone|Zone of maturation and hypertrophy= Chondrocytes stop mitosis, and begin to hypertrophy by accumulating glycogen, lipids, and alkaline phosphatase|Zone of calcification= Chondrocytes undergo apoptosis. Cartilagenous matrix begins to calcify.|Zone of ossification=Osteoclasts and osteoblasts from the diaphyseal side break down the calcified cartilage and replace with mineralized bone tissue. "Real People Have Career Options," standing for: Resting zone, Proliferative zone, Hypertrophic cartilage zone, Calcified cartilage zone, Ossification zone https://fcdblob.blob.core.windows.net/media/T4vaP7YBxOGbcaxmtJG9LQ.jpg?/_0120_2p.jpg https://fcdblob.blob.core.windows.net/media/g0wrMqIlvev8qMBamjGLDw.jpg?/_0120_3p.jpg 2016 Pediatrics

55 year-old patient has ulnar head, triquetral pain. Normal ROM and stable wrist. Active woman and cannot play tennis anymore.|| a. list 3 possible diagnoses| b. the patient has hyperintensity on an MRI and needs a wrist scope. List the dorsoradial and dorsoulnar portals. |c. list 6 stabilizers of the DRUJ.

a. Dx: |• Ulnocarpal impaction|• TFCC tear|• ECU tendonitis/ subluxation|• Ulnar styloid impaction|• lunotriquetral ligament tear|• ulnar nerve compression - Guyon's canal|- Hook of hamate fracture|-ulnar abutment syndrome|- Pisotriquetral entrapment|| b. Wrist Scope Portals| - Dorsoradial - dorsal 3,4 (between 3rd and 4th compartments)| - Dorsoulnar - 6R (radial side of ECU)|| c. DRUJ stabilizers=|• TFCC (palmar & dorsal radioulnar ligaments)|• ECU tendon sheath|• DRUJ capsule|• Interosseous membrane|• Pronator quadratus|• Bony anatomy - ulnar head & sigmoid notch DRUJ: primary stabilizers|volar and dorsal radioulnar ligaments |TFCC |TFCC attaches to the fovea at the base of the ulnar styloid|components include:|-central articular disc|-meniscal homologue|-volar and dorsal radioulnar ligaments|-ulnolunate and ulnotriquetral ligament origins|-floor of the ECU tendon sheath 2010; 2013; 2014; 2016 Upper Extremity

Describe 6 clinical/pathoanatomic findings in a flexible flat foot (pes planus).

foot is only flat with standing reconstitutes with toe walking, hallux dorsiflexion, or foot hanging|valgus hindfoot deformity|forefoot abduction||ROM normal and painless subtalar motion|hindfoot valgus corrects to a varus position with toe standing|evaluate for decreased dorsiflexion and tight heel cord. ||Pathoanatomy|generalized ligamentous laxity is common|25% are associated with gastrocnemius-soleus contracture STAGE I: tenosynovitis along PTT: no deformity|STAGE II| A: unable to perform single heel rise, flexible flatfoot, > 30% talonavicular uncoverage| B:severely flexible flatfoot but >30% talonavicular uncoverage|StageIII: rigid flatfoot, with subtalar OA|Stage IV: rigid flatfoot with subtalar and tibiotalar OA and lateral talar tilt: deltoid incompetence 2016 Foot & Ankle

Name 4 methods used to prevent the placement of the humeral stem too proud when performing a shoulder hemiarthroplasty for a humerus fracture.

greater tuberosity should be|-5 to 8 mm below the top of the prosthetic humeral head:functions to maintain cuff and biceps tension|recreate normal contour of medial calcar|technique to achieve|- cement prosthesis proud|- distance from top of prosthesis head to upper border of pectoralis major should be 56mm. Mobilize and tag the GT and LT|Inspect the glenoid|Inspect the rotator cuff||How to judge the height and inversion:|- pec major frog the height: 5.6cm from pec major to height to humeral head prosthesis|- GT 5-7mm below humeral head|- soft tissue tension of biceps and cuffs||Version:|- 30 deg retroversion|-posterior fracture dislocation would retrovert less to increase stability|Take an xray with trial in place to see where you are then implant final prosthesis 2016 Arthroplasty

List 4 prognosis factors for future instability in pediatric spine tuberculosis.

in children| kyphosis progresses in 40% of cases because of growth spurt|classification of progression (Rajasekaran)| Type-I, increase in deformity until cessation of growth should be treated with surgery| Type-II, decreasing progression with growth | Type-III, minimal change during either active / healed phases. ||Risk factors for buckling collapse ("spine at risk signs") |- retropulsion|- subluxation|- lateral translation|- toppling Indications for surgery. |spinal instability |kyphosis correction|> 60° in adult |progressive kyphosis in child |≥3 vertebrae involved with loss of ≥1.5 vertebral bodies in thoracic spine|children ≤ 7 years with ≥3 vertebral bodies affected in T/TL spine and ≥ 2 at risk signs are likely to have progression and should undergo correction|late onset paraplegia (from kyphosis)|cosmetic correction of kyphosis controversial. |Risk factors for buckling collapse= |- age of less than 7 years at the time of the disease, thoracolumbar involvement, loss of more than two vertebral bodies, and presence of radiographic spine-at-risk signs. Children at risk for buckling collapse must be carefully watched and the spine stabilized to avoid a massive increase in deformity. 1. Separation of the facet joints: the facet joint dislocates at the level of the apex of the curve causing instability and loss of alignment. In severe cases the separation can occur at two levels.|2. Posterior retropulsion: this is ID by drawing tow lines along the posterior surface of the first upper and lower normal vertebrae. The diseased segments are found to be posterior to the intersection of the lines.|3.lateral translation: this is confirmed when a vertical line drawn through the middle of the pedicle of the 1st lower normal verterbrae does not touch the pedicle of the first upper normal vertebrae.|4. Toppling sign: in the initial stages of collapse, a line drawn along the anterior surface of the first lowest normal vertebrae intersected the inferior surface of the first upper normal vertebrae, TILT or TOPPLING occurs when the line intersects higher than the middle of the anterior surface of the first normal upper vertebrae 2016 Spine

List 6 types of failure of a TKA requiring a revision

infection polyethene wear Osteolysis causing Bone loss and aseptic loosening Ligamentous injury-causing instability Periprosthetic fracture causing instability Patellofemoral mal-tracking (Most common!) Arthrofibrosis Abnormal joint line (patella Baja, flexion instability)

Name 4 radiographic risk factors for progression in infantile scoliosis

progression|-most resolve spontaneously|-if progressive by age 5 >50% of children will have a curve > 70 degrees|Mehta predictors of progression|-Cobb angle > 20 degrees (progression to >30deg)|-RVAD > 20 degrees|-phase 2 rib-vertebral relationship (when the rib head overlaps with vertebral body)= 100% indication of Sx no reason to calculate RVDA||prognosis|-progressive curves have poor outcomes and must be treated|can be fatal if not treated appropriately. ||Girls with right sided curves tend to have more progressive curves than other infants 2016 Spine

A patient has developed a lytic lesion into a known fibrous dysplasia (FD) of the proximal femur.

||Name 1 possible benign lytic lesion and 1 possible malignant lytic lesion. Malignant transformation 1% risk transform to: - Osteosarcoma |- Fibrosarcoma |- Malignant Fibrous histiocytoma||Benign: pathological fracture FD: associated with McCune Albright S. Mazabraud s. Osteofibrous displasia |FD: Xrays: Sheperd's Crook deformity, Punched out lesions, ground glass ||Histology "Alphabet soup", "Chinese letters"||Associated with: |McCune Albright Syndrome: café au lait spots, precocious puberty, oncogenic osteomalacia unilateral polyostotic FD|- Mazabraud Syndrome: polyostotic fibrous dysplasia , soft tissue intramuscular myxomas 2016 Pathology

List 3 ways to do a posterior C1-2 fusion

• 2 transarticular screws (between C1-C2)|• Posterior instrumentation with pedicle screws (only in C2) lateral mass screws (in C1) and rods|• Sublaminar wire fixation of C1-C2 (Gallie or Brooks) 2012 Spine

Using the ASIA classification, state the myotome associated with each of the following muscle groups:||A - 3rd digit DIP flexion|B - wrist extension|C - long toe extensors|D - Voluntary anal control

• 3rd digit DIP flexion - C8|• Wrist extension - C6|• Long toe extensors - L5|• Voluntary anal control - S4/5 2014 Spine

Patient with a type 3 bunionnette deformity with large intermetatarsal angle (between 4th and 5th). ||List 3 things you would do surgically

• 5th metatarsal oblique diaphyseal rotational osteotomy (IMA > 12)| • 5th metatarsal distal osteotomy (IMA < 12)| • Medial release of 5th MTP: distal soft tissue procedure|• Excision of lateral prominence: lateral 5th metatarsal condyle resection • Type I - lateral prominence of MT head|• Type II - lateral bowing of 5th MT|• Type III - widening of 4th & 5th IM angle (N - 8 degrees) - most common 2010; 20- most common

List 3 radiographic features associated with peds C2-3 pseudosubluxation

• <1.5mm of C2 spinous process displacement past the spinolaminar line (Swischuck's line)|• More horizontally oriented facet joint (compared to adult)|• Reduction of subluxation on extension views|• Absence of soft tissue swelling|• Disruption of the anterior spinal line of C2 on C3 <4mm (If >4mm then bad)||- Ligamentous laxity|- shallow facets|- wedged vertebrae|- weak musculature|- Horizontal facets 2012 Spine

List 4 stabilizers of the AC joint

• AC ligament - horizontal stability (post, sup)|• CC ligament - vertical stability - trapezoid 3cm, conoid (stronger) - 4.5cm from distal clavicle|• CA ligament|• AC joint capsule, deltoid & trapezius additional stabilizers 2014 Sports

List 3 conditions that would result in a false +ve result using the Thessaly test. (Used for dx: meniscal tears)

Child with multiple ankle sprains treated non-operatively. |Pain in anterolateral aspect of ankle and symptoms for 3 months. No pain with ADLs. Unable to run more than 20 minutes. |You are told that he has a tarsal coalition. ||List 2 treatment options at this time

• Activity modification|• NSAIDs|• Insoles|• Immobilization in below knee walking cast - 6wks|- Resection and interposition of muscle into the coalition||||• 30% remain pain free after cast application 2010 Foot & Ankle

10 year old child with pain at a prominence of foot medially. |Firm and tender to palpation, non-mobile. Symptoms for 3 months. |Shown an x-ray with an accessory navicular. ||List the treatment options at this time (2).

• Activity restriction & shoe modification (custom-moulded insoles w/ medial padding)| • NSAIDs, immobilization in BKC| • Stretching • If conservative fails - excision of ossicle w/o advancement of tendon (split tib post)

List 5 risk factors for poor healing in a type 2 odontoid fracture (negative px factors)

• Age > 50 y|• Posterior displacement > 5mm - (most important - highest risk of non-union)|• Angulation > 11 degrees|• Delayed presentation|• Smoker|• Comminution|- concomitant neurologic deficit||Age - Millers/OKU say 40, |AAOS review course says 60-65 2010; 2011; 2016 Spine

Other than medical comorbidities or tear characteristics, list 4 patient factors that are predictive of poor healing of the rotator cuff tear following surgery

• Age > 65|• Female|• Poor tendon quality|• Detachment at deltoid insertion|• Stage 4 muscle fatty degeneration, of SS, IS, Subscap|• Assoc delamination of subscap or infraspinatus|• Size of tear: large|• Presence of tear of long head of biceps|• Degree of pre-op shoulder weakness|• Osteoporosis|- short acromio humeral distance|-multiple tendons involved|- concomitant AC/ biceps procedures at time of repair||• Workman's comp|• Tear size|• Fatty degeneration|• Age at time of intervention Prognostic factors for better recovery|• Demographic - young age, male gender|• Clinical factors - higher BMD, absence of DM, higher level of sports activity, greater pre-operative ROM, absence of obesity|• Cuff integrity - smaller lesion, less retraction of cuff, less fatty infiltration, no multiple tendon involvement|• Surgical factors - no concomittant biceps or AC procedures 2013; 2016 Upper Extremity

List 3 predictors that contribute to POOR prognosis for Perthes disease on INITIAL PRESENTATION.

• Age > 6|• Extent of subchondral fracture (Salter-Thompson classificaction)|• Extent of head involvement at fragmentation stage (Catterall classification)|• 2 or more Catterall head-at-risk signs|• Lateral pillar height at fragmentation stage (B/C, C)|• Premature physeal closure|- Presence of subluxation or hinged abduction 2011 Pediatrics

Three reasons for the progression of congenital kyphosis

• Amount of normal growth remaining in affected vertebrae|• Number of vertebrae involved|• Type of congenital kyphosis (types 1 (worse) vs type 2, 3)|• Magnitude of Cobb angle||• Type 1 - failure of formation|• Type 2 - failure of segmentation|• Type 3 - mixed 2012 Spine

List 3 ways that a coracoid transfer (Latarjet) provides stability to the GH joint

• Anterior Bony block - increases glenoid bony support and excursion distance prior to dislocation|• Conjoined tendon passes through subscapularis becoming a supportive sling esp in ABER (prevents subscap to move superior to humeral head with abduction)|• CA ligament support - uses remnant CA to aid in capsular repair|- short head of biceps acts as anterior buttress (esp in abduction)|||Cons:|- does not corrects pathology|-produces IR contracture|- musculocutaneous nerve injury|- subscap weakness 2014; 2015 Sports

List the 4 structures of the ankle syndesmosis

• Anterior inferior tibio-fibular ligament - AITFL| • Posterior inferior tibio-fibular ligament - PITFL| • Inferior transverse ligament - ITL| • Interosseous ligament - IOL| • Interosseous membrane - IOM

List 4 features of pediatric radial neck/head fractures that would lead to a poor outcome.

• Assoc injury - elbow dislocation, olecranon fracture, med epicondyle fracture|• Magnitude of force - high energy mechanism|• Initial & post-reduction angulation & displacement: > 30 deg and >3mm displacement|• Late surgical intervention (> 5 days/ 3wks)|• Age - younger have better remodeling potential|- Older age: poor px|- Decrease ROM 2014; 2012 Pediatrics

List 4 criteria for selective throracic fusion in AIS : Adolescent Idiopathic scoliosis

• At least 20% more apical vertebral translation and apical vertebral rotation than compensatory curve|• L curve < 40|• L apical translation < 3cm|• L curve should bend to < 25 degrees|• Cobb of T > L; ratio 1.25|• Tri-radiate cartilage closed|-T10-L2 Kyphosis: < 20 deg|- Lenke type 5 curve and Selective T-L/L fusion is possible|- Lenke 1C,2C,3C,4C|- Lifestyle and activity level: Thoracic rotational prominence> lumbar prominence (soft tissue flexibility:thumb abduction test)|- Coronal plane ratio criteria > 1.2|- TL/L curve < 60 deg 2014 Spine

What are 3 cervical spine findings in Down syndrome?

• Atlantoaxial instability - ligamentous laxity of transverse ligament & C1-C2 joint capsules= hypermobility/ frank instability|• Atlanto-occipital instability - laxity of atlanto-occipital joint capsule, tectorial membrane & ant & post atlanto-occipital membranes|• Osseous anomalies (os odontoideum, persistent dentocentral synchondrosis of C1, ossiculum terminale)|- spina bifida occulta of C1|- scoliosis, spondy. 2011; 2014 Spine

List 3 anatomic causes of swan neck deformity in a RA patient as a result of synovitis.

• Attenuation of collateral ligaments|• Lateral Band subluxation dorsal to the axis of rotation of the PIP joint|• Attenuation of volar plate|• Rupture of FDS insertion||- PIP synovitis (most common)|• MCP volar dislocation|• Intrinsic muscle tightness|• Mallet finger https://fcdblob.blob.core.windows.net/media/3PioA4v33oYyWjec4M04Fg.jpg?/_0245_3p.jpg 2011 Upper Extremity

List 3 principles to avoid patellar maltracking when performing a TKA

• Avoid IR of the femoral component - increased tension laterally, lateral patellar tilt and increased loading stresses| • Avoid medialization of femoral component - effect similar to IR of femoral component| • Avoid IR of tibial component - forces tibia into ER during knee flexion - increasing Q angle - lateral patellar tracking and subluxation| • Do not overstuff the PF joint - tightens lateral retinaculum and increases risk of lateral patellar tracking| • Medialization of patellar component on the cut surface of patellar bone allows button to be centralized in trochlear groove and improves tracking by decreasing lateral patellar subluxation forces| • Resection of more bone from medial facet necessary to obtain symmetric cut b/c medial facet thicker

3 ways to prevent patellar maltracking in TKA?

• Avoid residual valgus alignment| • Avoid internal rotation of femur & tibia| • Avoid medialization of femur/tibia| • Avoid lateralization of the patella •Avoid PF joint overstuffing

List 4 principles of ethics

• Beneficence • Non-maleficence • Autonomy • Justice

List 3 advantages for coning an X-ray. (Collimate)

• Better quality picture • Less scatter exposure to surgeon, protects surgeon| • Less radiation to the patient|- avoiding radiating normal nearby tissues

You see a 9 year-old boy with an expanding mass in his thigh. Radiographs show destruction of the femur diaphyseal cortex and onion-skinning. Biopsy shows small round blue cells. ||What are the 5 most important actions to systemically stage this tumor? (Suspect Ewing)

• Bone marrow biopsy|• CT chest|• Bone scan|• MRI whole bone (soft tissue involvement, skip lesions)|• Bloodwork (CBC+Dif, lytes (Na, K, Cl, CO3), secondary lytes (Ca, Mg, PO4), ESR, CRP, LDH, ALP) 2014; 2012 Pathology

List the 2 muscles that surround the radial nerve after it pierces the intramuscular septum.

• Brachialis|• Brachioradialis 2013 Upper Extremity

List 4 ways a plate can function other than a buttress

• Bridge plate|• Neutralization plate (in combination with a lag screw)|• Compression plate|• Locking plate (internal ex-fix)|• Tension band 2012 Trauma

List 11 muscle groups that are important to test for the ASIA classification and give their respective myotome level.

List 4 risk factors for developing a DVT in a pediatric patient with MRSA osteomyelitis.

When performing an IM nailing of the femur on a fracture table, name 3 radiologic criteria you can use to prevent malrotation of the femur

• Cortical step sign - assess cortical width of prox & distal fracture fragments|• Align contralateral knee with patella upright, fluoro the contralateral proximal femur, assess the LT and make the affected side's LT match, place the affected side's patella facing upright and lock |• Line up anteversion with inherent anteversion of femoral nail. Align femoral head with guide arm and place prox locking screws, rotate distal fragment thru table to obtain a perfect lateral, manipulate only C-arm to obtain perfect circles||1- Cortical step sign|2- Lateral only imaging technique|3- Lesser trochanteric profile Tornetta, Riz and Cantor described a true lateral of the femoral neck and true lateral of the distal femur with posterior condyles aligned. The difference I inclination of the C-Arm for tese two images is the anterversion of the neck. 2014; 2015 Trauma

A child with a hemivertebra. What are 3 indications for being able to perform a hemiepiphysiodesis

List 5 causes for decreased extension in an ACL reconstruction

• Cyclops lesion (anterior intercondylar notch scar tissue)|• Tibial tunnel too anterior (due to impingement)|• Femoral tunnel too posterior |• Arthrofibrosis|• Infection|• Insufficient notchplasty|• Extension mechanism disruption (BTB graft) patellar tendon rupture||Postop immobilization in flexion 2012; 2016 Sports

8 month old with unilateral DDH.|| a. List the most important clinical sign| b. List 5 possible blocks to reduction

• Decreased abduction - most sensitive tests when contractures have set in||Possible blocks:|• Inverted labrum|• Neolimbus|• Hypertrophied ligamentum teres|• Transverse acetabular ligament|• Psoas tendon|• Pulvinar|• Contracted joint capsule 2010 Pediatrics

Name 4 reasons not to do a re-directional pelvic osteotomy in a pt with complete dislocated head in adult DDH

List 5 conditions to be considered if you are thinking about treating an Achilles tendon rupture non-operatively

• Diabetes/neuropathy • Peripheral vascular disease • Immunocompromised state • Age > 65 • Obesity BMI > 30| • Smoker • Sedentary Lifestyle /Low demand- unable to tolerate sx • Local/systemic dermatologic disorder| • Location - musculotendinous junction tear

List the 5 structures of the shoulder superior suspensory complex (SSSC)

What are 4 MRI findings of a patient with scoliosis and neurofibromatosis?

6 types of spondylolisthesis by etiology (Wiltse classification)?

• Dysplastic (congenital predisposition)|• Isthmic (pars stress fracture, lysis, elongation)|• Degenerative|• Traumatic|• Pathological/neoplastic|• Post-surgical Wiltse- Newman classification: "Did Tim Pass"||I: Dysplastic facets: congenital: high risk of neurologic symptoms|IA: axially oriented facets|IB: sagitally oriented facets|Facets permit translation: higher chance for neural compression as intact posterior arch move fwd (like a cigar cutter)|II: Isthmic Pars: defect pars intrarticular: pain but not high risk of neuro symptoms: 95% at L5 most common in adolescents (pars intrarticularis is between the area between the two facets)|IIA spondylolytic: stress # pars|IIB, pars interarticularis: elongation of pars (pars healed lytic lesion)|IIC. acute traumatic fracture of pars|Most commonly affected L5-S1 nerve root L5 due to foraminal stenosis caused by fracture callus but not centra stenosis|III: Degenerative|IV: Post-Traumatic: acute # post elements not isthmic|V: Pathologic|VI: Iatrogenic 2015 Spine

Terrible triad; list the three injuries making this up

• Elbow dislocation|• Radial head fracture|• Coronoid fracture 2012 Trauma

A 23 y.o. male has 4 month history of increasing pain in proximal phalanx of middle finger. Not shown the x-ray, but told that there is a lytic lesion that the radiologist thinks is benign. ||List 7 possible diagnoses

List 3 relative indications to perform contralateral prophylactic pinning in a patient with SCFE.

Patients with Ankylosing Spondylitis are known to have sacroiliitis. ||List 3 other clinical findings that are used for the diagnosis of Ankylosing Spondylitis

• Enthesopathy - inflammation & bony destruction at site of tendon insertion (Achilles/plantar tendons)|• IBD: inflammatory bowel disease|• Uveitis/Iritis|• Psoriasis|• Aortitis (aortic & mitral regurgitation murmurs)|• Cardiac conduction disturbances - heart block|• Chest wall pain with deep inhalation - obligate diaphragmatic breather, pulmonary fibrosis: severe Tspine kyphosis, Limited chest wall expansion: fusion of costoverterbal joints|• Typically present 2-4th decade, LBP & stiffness, worse in AM, at night or after prolonged sitting|• Renal amyloidosis|- new bone formation in response to inflammation: Zygapophyseal joints: bamboo spine|- sacroiliitis: tender on palpation, worse on hyperextension of hips: can develop hip flexion contractures|- Decrease ROM and curvature of L spine: abnormal Schubert test|- C-Spine rigidity loss flex/ext: chin brow angle, occiput to wall distance, gaze angl https://fcdblob.blob.core.windows.net/media/Mc4lYhHycZsGU7dUCyUmeQ.jpg?/_0177_3p.jpg 2014 Spine

Give 2 advantages of doing a piriformis starting point vs. a trochanteric starting point for an antegrade femoral nail.

• Entry point is collinear with femur (decrease hoop stresses)|• Decrease risk of medial wall blow out|- Decrease abductor disruption 2011 Trauma

List 3 ways that will help you make sure you don't overstuff the joint when doing a radial head replacement

• Excised fragments of radial head re-assembled and sized to determine correct thickness|• Contralateral elbow radiographs : templating, |• Examination of the lateral ulnohumeral joint radiographically before and after trial implant (gapping 0.9mm = 2mm overstuff)|• most proximal part of implant should not be more than 1mm proximal to lateral coronoid or lesser sigmoid notch|• Align most proximal portion of lesser sigmoid notch with proximal surface of the implant|- congruency of implant with capitelum 2014; 2012 Trauma

List 6 principles of tendon transfers

RA patient with decreased extension of 4th and 5th digits. List 3 possible reasons for this

• Extensor tendon rupture - Vaughn Jackson syndrome|• Ulnar subluxation of extensor tendons (sagittal band rupture) at the MCP|• MCP dislocation and spasm of ulnar intrinsics|• MCP subluxation|- cubital tunnel syndrome (compression of ulnar nerve at elbow) 2010; 2011; 2012 Upper Extremity

Signs of AVN following closed reduction of DDH?|| Name 3 radiographic signs of osteonecrosis of the femoral epiphysis in a pediatric patient with developmental dysplasia of the hip.

• Failure to ossify the head within 1 year of the procedure: after reduction|• Widening of the femoral neck within 1 year|• Changes in the femoral head density: increased density and fragmentation|• Residual deformity of proximal femur after ossification= suggesting growth disturbance 2015; 2016 Pediatrics

List 4 long term complications of radiation therapy for sarcoma treatment.

A patient with PIN/radial tunnel syndrome. List 3 possible compression sites

• Fibrous bands of radio-capitellar joint|• Recurrent radial artery branches: Leash of Henry|• ECRB|• Arcade of Frohse (proximal edge of supinator) #1|• Distal edge of supinator|||FREAS 2010; 2011 Upper Extremity

Patient with history of thyroid cancer. Bone scan (not shown) is said to have multiple bony lesions. He has a pathologic femur fracture.|| a. What is your treatment/How would you manage this fracture surgically?| b. What radiographic intervention would you want to do pre-operatively?| c. What post-operative systemic adjunct would you want to give for the skeletal system?| d. What would you want to do post-operatively to reduce the chance of progression?

• First obtain Dx|- Femoral lesions require Open Biopsy + Frozen section for soft tissues |-Pathological fracture: require fixation:|- Protect the entire length of the bone do not leave stress risers(risk of periprosthetic #)|If femoral : protect Head and neck= Antegrade, reamed, statically locked long cephalomedullary nail of femur (consider cement )|• Angio embolization |• Radioactive iodine, bisphosphonates (only if differentiated thyroid CA for uptake of iodine) Iodine 131 Ttx. (I-133 Dx)|-External Beam radiation therapy to entire femur= reduce recurrence postop.|• Radiation therapy|Radiology:|- Xrays, full limb, CXR|- CT chest abdo, pelvis-> staging|- Bone scan-> ID other lesions|+/_ MRI: for soft tissues 2010; 2014 Pathology

Four principles of managing with definitive ORIF for Pilon Fractures (excluding soft tissue)

• Fix fibula first in order to restore length|• Restore articular congruity (anatomic articular reduction) and place interfragmentary screws between all large articular fragments|• Use plate fixation to fix the metaphysis to the diaphysis (rigid fixation): recon metaphyseal shell|• Using bone graft if needed|• Regain original length, alignment & rotation 2012 Trauma

List 3 spine findings in Anchondroplasia.

• Foramen magnum stenosis|• Lumbar stenosis|• Thoracolumbar kyphosis|• Short pedicle with decreased interpedicular distance - lumbar lordosis 2011 Pediatrics

List 3 possible mechanisms for a SLAP lesion

• Forceful traction|• Repetitive overhead throwing - 'peel back'|• Direct compressive loads - axial force|• Recurrent anterior shoulder instability 2010 Upper Extremity

List 2 motion sparing techniques to manage a stage II SLAC wrist

• Four corner fusion (with scaphoid excision)|• Proximal row carpectomy (PRC)|||• 4 corner fusion - lunate, triquetrum, capitate & hamate 2012 Upper Extremity

6 risk factors for non-union

Describe the orthotics for a subtle cavus foot

• Full length semi-rigid insole • Recessed first ray • Lateral wedge/post • Lowered medial longitudinal arch • Heel cushion

List 5 anatomic abnormalities associated with patellar dislocation

List 4 reasons for placing an ex-fix on a both bone forearm fracture

• Grade IIIB or IIIC open fracture|• Major bone loss|• Adjacent joint instability|• Polytrauma patient - DCO|- Grade 3 Vascular Injury 2013 Trauma

List 5 complications with managing a displaced intra-articular tibial tubercle fracture in an adolescent

List 4 different ACL management/reconstruction techniques for an active 11 year old.

• Physio, strict activity restrictions, then repair ACL once skeletally mature in a few years.|• Physeal sparring combined extra/intra-articular reconstruction w/ autogenous IT band|• Physeal sparring all epiphyseal fixation|• Partial transphyseal with soft tissue graft thru tibia and over the top for femur|• Partial transphyseal with all epiphyseal femoral fixation with transphyseal tibia soft tissue graft • IT band - turn-down of the IT band, keeping its insertion on the tibia and passing it behind the lateral femoral condyle into the joint and securing it back to the tibia (best choice for Tanner Stage 1 or 2)|• If going transphyseal - more vertical tunnel, smaller (<8mm tunnels), ream slowly 2013; 2012 Sports

List 4 components of the postero-lateral corner

• Popliteus tendon|• Lateral collateral ligament: LCL|• Popliteofibular ligament|• Lateral capsule||• Iliotibial band|• Biceps femoris|• Lateral head of the gastrocnemius|• Arcuate ligament|• Fabellofibular ligament 2012 Sports

4 Poor radiographic prognostic factors when doing a periacetabular osteotomy in an adult?

• Pre-op: - Severe dysplasia - reduced acetabular anteversion on CT - presence of os acetabuli (calcified detached labrum), - severe arthritis, - joint incongruency |• Immediate post-op: - Small width of sclerotic acetabular zone, - excessive lateral/proximal dislocation

List 3 components of the minimally invasive treatment of congenital vertical talus

• Pre-operative serial casting (reverse Ponsetti) to reduce the deformity and stretch the dorsal soft-tissues. Cast the foot in plantarflexion and inversion. And gradually reduce talonavicular joint||• Closed reduction (vs open) and percutaneous pin the Talonavicular joint in a reduced position. Release the capsule surrounding the talus to obtain reduction if necessary (This is more maximally invasive, maybe don't do the large soft tissue release).||• Percutaneous achilles tendon lengthening. 2013; 2012 Pediatrics

List 4 findings in the cervical spine of a pediatric patient that can be confused with cervical spine trauma

• Prevertbral soft tissue thickening|• Increased ADI (normal <5mm in kids, <3mm in adults)Atlanto axial instability|• Over riding C1 anterior arch on the dens|• Pseudospread of the C1 lateral masses on C2 on open mouth view (C1 grows faster)Pseudo-Jefferson #: pseudospread of atlas on axis, up to 6mm displacement of lateral masses relative to dense is common in peds 4-7 y/o|• Pseudosubluxation of C2 on C3 and C3 on C4= 40%: 4mm seen in peds: normal physiologic (can be confused with traumatic subluxation) ITs considered normal <4mm as long as posterior laminar line is contiguous.|• Radiolucent synchondrosis|• Wedging of subaxial cervical vertebral bodies: 7% normal peds have C3 wedged vertebral body= similar to compression #: <3mm anterior vertebral wedging Normal|• Absence of cervical lordosis : normal variant on peds < 16y/o|- Os odontoideum can be confused with odontoid fracture|- 2014; 2015 Spine

4 surgical indications in rheumatoid spine?

List 4 prognostic factors associated with poor prognosis in a patient with septic arthritis.

List four indications for a hemi-resection interpositional arthroplasty of the distal radioulnar joint of the wrist?

• RA in early stages (requires intact TFCC) involving the DRUJ|• Unreconstructable fractures of the ulnar head|• Painful post-traumatic or osteoarthritis of DRUJ|• Ulnocarpal impaction syndrome w/ incongruity of DRUJ|• Instability of DRUJ|• Rotational contractures of the DRUJ 2011 Upper Extremity

Name the 5 terminal branches of the posterior cord

• Radial|• Axillary|• Upper subscapular|• Lower subscapular|• Thoracodorsal 2015 Misc

Name 3 mechanisms for SLAP tears

• Repetitive overhead throwing activities|• Forceful traction load on arm|• Direct compression load 2015 Sports

Syndactyly, definitions

• Simple: only soft tissue fusion|-Complex: fusion of adjacent phalanges|- complicated: adicional phalanx or abnormal|• Complete: Skin fused to the fingertips|Incomplete: skin fused but not distal to finger tips|• Synonychia: Fusion of the nails 2015 Pediatrics

List 3 reasons for unsuccessful treatment of UBC of the proximal humerus with methylprednisone (perc injection)

• Size (Cyst area) small do better|• Multiloculated appearance|• Active vs Late - proximity to physis|• Age < 10 (younger do worse - closer to physis) 2011 Pathology

List 4 signs of post-tourniquet syndrome.

• Skeletal muscle injury - worst at compression site than distal ischemic muscle|• Nerve injury - worst at compression site, EMG changes in 62%, lasted avg 52 days; incidence of peroneal & tibial nerve palsy increases >150min|• Metabolic dysfunction - lactic acid, pH, reactive oxygen metabolites|• Coagulopathy & DVT - increased fibrinolytic activity after tourniquet 2013 Trauma

4 ways to assess spinal injury intra-op

• Somatosensory evoked potentials (SSEP)|• Transcutaneous motor evoked potentials (MEP)|• Stagnara wake-up test|• Ankle clonus test (positive test is absence of clonus in a patient emerging from anaesthesia - LMN returns prior to UMN so you should see clonus) 2010; 2011 Spine

List the 4 different subtypes of neural tube defects

• Spina bifida occulta - defect in vertebral arch with confined cord and meniges|• Meningocele - sac without neural elements protruding through the defect|• Myelomeningocele - "spina bifida" - protrusion of the sac containing neural elements|• Rachischisis - neural elements exposed with no covering 2010 Spine

In the evaluation of a child's hip, mention 4 criteria that will help differentiate between septic arthritis and transient synovitis.

• WBC count >12|• ESR > 40mm/h|• Fever > 38.5|• Inability to WB||Septic Arthritis||Kocher criteria:|• CRP > 20: independent risk factor for septic arthritis (CRP and NWB: 74% probability septic joint)||Order of sensitivity of criteria: Fever>CRP>ESR>NWB>WBC|If all 4 present: 99.6% chance of septic arthritis |1 present: 3% chance|2 present: 40%|3 present : 93% 2010; 2011; 2013 Pediatrics

A patient has lunate AVN. ||List the 4 stages

• Stage I - Normal x-rays, MRI changes seen|• Stage II - X-rays show sclerosis|• Stage IIIa - Lunate collapse with normal carpal height|• Stage IIIb - Lunate collapse with decreased carpal height, proximal migration of capitate and scaphoid flexion|• Stage IV - Lunate collapse with peri-lunate arthritic changes IIIa vs IIIb - assessment of carpal height|• Ratio of carpus to 3rd MC - 0.54|Management|• I - NSAIDs, immobilization 3mths|• II - ulnar negative - joint leveling; ulnar positive or neutral - osteotomy to change inclination, radial wedge osteotomy, radial core decompression, vascularized graft from dorsal DR, ST-SC pinning to prevent collapse|• IIIA - similar to II|• IIIB - STT fusion, PRC|• IV - PRC, wrist fusion 2010; 2012 Upper Extremity

List 3 techniques to avoid varus deformity when nailing a subtrochanteric femur fracture.

• Starting point - at the tip or just medial on the GT at junction of ant 1/3 and post 2/3 - avoid lateral starting point|• Nail in lateral position|• Femoral distractor|• Schanz pins calcar to joystick|- Blocking screw - AP blocking screw placed medially to the desired path of the nail|• Picador & bone hook - ball spike on lateral cortex of distal fragment & hook around proximal fragment|• Open reduction and collinear clamp, prophylactic wire, unicortical plate|• Reduction aids (intramedullary finger, F-tool, blocking screw, crutch, mallet)|- Lateral starting points lead to varus reductions 2013 Trauma

List 4 complications of a radial head fracture.(long term sequelae)

List 3 complications of performing an open repair of an Achilles tendon rupture vs. closed treatment.

• Sural nerve injury • Infection • wound complications: Skin breakdown, wound dehiscence, Poor cosmesis - hypertrophic scar • Adhesions - Achilles tendon tethered to skin

List 4 nerves to block in an ankle block

• Sural nerve| • Saphenous nerve| • Posterior Tibial nerve| • Peroneal nerves (superficial and deep)

List 4 principles for establishing causality

• Temporal relationship|• Strength of association|• Dose-response relationship|• Consistency - findings by different people in different places with different samples|• Biologic plausibility|• Consideration of alternate explanations|• Experiment (eg. cessation of exposure)|• Specificity|• Coherence with previous knowledge||(Bradford Hill criteria) 2012 Misc

When performing a Chopart amputation, what two things can you do to prevent equinus?

• Tendo-Achilles lengthening • Transfer tibialis anterior tendon to talar neck

Muscles contributing to equinovarus foot? How to differentiate?

• Tibialis anterior, tibialis posterior, gastroc-soleus complex|• Confusion test: active hip flexion against resistance, if tib. Ant. Contracts, the foot supinates and in this case the TIb ant is overactive = then need to do tib ant transfer.(Rancho procedure)||If foot does not supinate then no need to do tib ant transfer but only tib post. 2015 Pediatrics

List 4 muscles that act as inverters of the sub-talar joint

• Tibialis posterior • Tibialis anterior • FHL • FDL • EHL

List 6 causes of acquired coxa vara.

Given an x-ray of a varus malunited femoral neck fracture. ||List 4 clinical findings found on physical exam other than decreased ROM.|||35y F post 2 years after Rt basicervical Fracture (xrays) no with coxa vara, pt with limp and no pain)

Describe the Vancouver classification

• Type A: Fracture is located in the trochanteric region (type AG fractures are located in the greater trochanter and type AL fractures are located in the lesser trochanter). • Type B1: Fracture is located around or just distal to the femoral stem, and the stem is well fixed. Type B2: Fracture is located around or just distal to the femoral stem, the stem is loose, and there is good bone stock in the proximal femur. • Type B3: Fracture is located around or just distal to the femoral stem, the stem is loose, and there is poor bone stock in the proximal femur. • Type C: Fracture is located well below the femoral stem

List 3 ways to prevent procurvatum in a proximal tibia fracture

• Use a blocking screw placed posterior to the nail to prevent procurvatum (or placed laterally to prevent valgus)|• Reaming with knee in semi-extension (using a suprapatellar or parapatellar skin incision if needed)|• Unicortical plate fixation |• Femoral distractor|• Travelling traction|• Ex-fix 2012; 2015 Trauma

List 3 considerations/ principles for applying a pediatric halo safely

• Use more pins (8-12)|• Finger tight screws only, lower torque (2-4 inches/ pound, vs. 8 in adults)|• CT of skull prior (looking for open sutures or thin corticies): to avoid cranial sutures|- Anterior pins placed lateral enough to avoid the frontal sinus, supraorbital and supratrochlear nerves|- place pins anterior enough to avoid temporalis muscle |- the posterior pins should be placed on the opposite side of the ring from the anterior pins||Brace/vest: custom fitted vest for children >2y|- if < 2y/o should use Minerva cast 2014; 2012 Spine

Talus malunion: most common types and 3 ways to prevent?

• Varus (with shortening and dorsiflexion)|• Use two approaches, anatomic reduction based on lateral neck due to medial comminution.|• Avoid compression screw medially, favour position screws or plates. Fix both sides.|• Use bone graft in cases of large bone defect. 2015 Trauma

3 findings of an incomplete spinal cord injury

• Voluntary anal contraction (sacral sparing)|• Perianal sensation present|• Palpable or visible muscle contraction below level 2015 Spine

What are 8 chest radiographic findings of aortic arch rupture?

• Widened mediastinum > 8cm|• Obliteration of aortic knob|• Deviation of trachea to right|• Deviation of esophagus (NG tube) to right|• Obliteration of space between pulmonary artery and aorta (obscuration of AP window)|• Depression of left main stem bronchus|• Elevation of the right main stem bronchus|• Widened paratracheal stripe|• Widended paraspinal interfaces|• Presense of pleural or apical cap|• Left hemothorax|• Fractures of 1st, 2nd rib or scapula, multiple rib fractures, posterior displaced clavicle fracture 2011; 2013; 2015 Trauma

List 4 successful things to non-operatively manage carpal tunnel syndrome

• Wrist Splints|• Steroid injections |• oral steroid|• ultrasound therapy |- Activity modification and NSAIDs (no recommendation for or against its use)|||From AAOS guidelines 2012 Upper Extremity

Prognostic factors in the management of juvenile knee OCD?

• Young age with open physis = better success with conservative tx|• Lateral condyle, patella = worse|• MRI: fluid behind the lesion = worse 2015 Pediatrics

Give 5 indications for early amputation in trauma?

• non reconstructible soft tissue injury|-Non-viable limb|• Irrepairable vascular injury, failed revascularization|• Warm ischemia > 6hrs|- significant wound contamination|- Severe comorbidities||• Severe crush with minimal remaining viable tissue|• Severe trauma in which the retained limb has excessive metabolic cost to patient and threatens survival|• Salvage will have worse function than prosthetics available 2016 Trauma

List 4 possible compression sites for the AIN from the elbow to the forearm

•FPL accessory muscle :Gantzer's muscle|- Lacertus fibrosus|- Artery ulnar artery thrombosis|- Pronator heads: between 2 heads of pronator teneres|-S FDS: apponeurotic arch|-S Between accessory muscle that is between FDS and FDP|||FLAPSS 2014 Upper Extremity

List 3 features of central cord syndrome.

•Symptoms |- Upper > lower body involvement= Hands worse than upper limb: hand dexterity most affected (UE>LE, distal>proximal)|- Hyperpathia - burning sensation in upper extremity||Physical exam:|- motor deficit worse UE vs LE, hands more deficit than arms|• Sacral sparing (preserved)||• Mecahnism: Caused by hyperextension in spondylotic spine, usually elderly|• Most common cause of incomplete cord injury|• Late presentation - UE have LMN signs (clumsy), LE have UMN signs (spastic)||GOOD PROGNOSIS: recover distal to proximal 2011; 2014 Spine

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