OITE: Orthobullets Key Concepts
Initial treatment of elbow MCL injury in the juvenile thrower.
6 weeks activity restriction. Begin therapy for flexor pronantor mass strengthening after period of activity restriction.
Brake time guidelines
6 weeks post weight-bearing (long bone) 9 weeks post-op (ankle fx) Based on some studies by Egol
Normal alpha angle
60 degrees
Energy expenditure with unilateral transfemoral amputation?
65%
2 mm of shortening associated with a metacarpal frx is associated with what degree of extensor lag?
7 degrees for every 2 mm of extensor lag
After applying Pavlik harness, how long do you wait before obtaining an ultrasound?
7-10 days
Gunshot wound through abdomen and into vertebral body - treatment?
7-14 days IV abx broad spectrum
Low velocity gunshot through abdomen and into ilium - treatment?
7-14 days abx, observation
Thinnest PE you should use
8 mm
What measurement indicates a C1 fracture or transverse ligmament rupture
8.1 mm of total lateral mass displacement
After a digit replantation what pulse ox reading is worrisome for vascular compromise?
94%
Linear wear rates of polyethylene greater than ______ are associated with implant failure in total hip arthroplasty
< 0.1 mm / year
Arterial Thrombosis occurs in what time range following finger replantation procedure?
< 12 hours. After twelve hours consider venous congestion.
Normal HVA
< 15
Normal IMA
< 9
At what ABI is healing significantly impaired and amputation contraindicated?
<0.5
Steroid treatment of acute spinal injury
<3 hours = 5.4 mg/kg x 23 hours 3-8 hours = 5.4 mg/kg x 48 hours
Normal ADI (Adult and Child)
<3 mm (Adults) <5 mm (Children) ADI > 7 = Rupture of transverse, alar, apical, and tectorial membrane
How do you decide that a posterior wall acetabular fx is non-operative?
<40% fragment Stable on dynamic fluoroscopic examination
Below what age could you consider spica casting for a femur fracture with less than 2 cm of shortening?
<5
How much tibial widening after ORIF of plateau fracture is acceptable without adversely affecting outcomes?
<5 mm
Signs of vascular compromise in replanted digit
> 2 degree drop in an hour, temp < 30
When do you fix ASIS avulsion fracture?
> 3 cm displacement
Scheurmann Kyphosis - Name 3 diagnostic criteria
> 45 degrees, wedging of 5 degrees on 3 subsequent vertebrae, does not correct with extension
Risk Factors for Odontoid Non-union
> age 50, > 6 mm, posterior displacement, comminuted, angulated > 10 degrees, delay in treatment
Abnormal TT-TG Distance
>20 operative. Do not correct to less than 10.
Initiate DCO for what ISS scores?
>20 with thoracic injury >40 without thoracic injury
What percentage of glenoid must bankart consist of to warrant bone replacing procedure (Bristow/Latarjet)?
>20%
Radiographic indication to proceed with extraarticular scapular fracture involving the glenoid
>40 degrees angulation or > 1 cm displacement
What percentage of the physes need to be damaged before epiphysiodesis is indicated?
>50%
Unacceptable alignment of proximal humerus fractures in children
>60 degrees angulation (10-13 yo) >45 degrees or 2/3 displaced (<13)
Serendipity Views
Clavicle views at 40 degrees cephalad and caudad....visualizes anterior versus posterior translation. Useful for SC dislocations and medial clavicle physeal separations.
Hunter Syndrome Mnemonic
Clear-eyed hunters tend to be males (X-linked recessive)
What are the relationship of Cleland and Grayson's ligaments to the volar digital nerve?
Cleland is above (dorsal), Grayson is below (volar). Clelands ligaments are not involved in Depuytrens contracture (ABOVE it all)
Child floating elbow (distal radius + supercondylar humerus fracture) - how do you treat?
Closed reduction and pinning on both injuries. Elevated risk of compartment syndrome with just casting of the distal radius. (Ring et al)
Chondroblastoma (Histology)
Cobblestone pattern, Chickenwire Calcifications, coffee bean nuclei
For PCL deficient knee...increase or decrease tibial slope?
Increase the slope. Think about it in weight bearing...the femur slides down the slope and pushes the tibia forward
Hip dyplasia is associated with what anatomic variation in the proximal femur?
Increased femoral anteversion
What changes are seen on EMG/NCV in carpal tunnel
Increased insertional activity Fibrillation Sharp waves Increased motor latency (>4.5) Increased distal sensory latency (>3.5)
What happens within cartilage cells when they are affected by osteoarthritis?
Water content: Increased Collagen: Decreased / Disorganized Proteoglycan: Decreased Synthesis: Increased Modulus: Decreased
At what week is pecutaneous heel cord tenotomy undertaken in treatment of clubfoot?
Week 8
How long after THA must you wait before excising HO?
6 months minimum
Most common concommitant injury with hip dislocation?
Ipsilateral knee meniscus tear
Lateral wall collapse in calcaneus fractures causes what condition?
Peroneal tendonitis
Fracture through ABC
Wait for it to heal. If still growing then resect afterwards.
Optimum pore size for bone ingrowth
50-150 uM
Treat the following soft tissue deficiencies: Volar Thumb < 2 cm Volar Thumb > 2 cm Dorsal Thumb
- Moberg - FDMA Flap or Island Advancemet Flap (up to 4 cm) - FDMA Flap
Benefits of posterior (antiglide) plating for fibular fx
- Stronger biomechanical - Less hardware prominence - Decreased rates of intraarticular screw penetration
Treat the following soft tissue deficiencies: Finger Tip Dorsal Finger Volar Finger Large dorsal hand defect
- VY Advancement - Reverse Cross Finger - Cross Finger - Groin flap
MPFL is primary restraint to lateral translation of the patella at what knee position?
0-20 degrees. Just remember that you are testing the MPFL when you are measuring patellar glide
Timeline of DDH Treatment
0-6 months: Pavlik (d/c after 3 weeks if failed --> Abduction splint) 6-18 months: CR + Spica Cast 2-4 years: Open reduction + Femoral Osteotomy > 4 years: Open reduction + Pelvic osteotomy
Maximal wear rate before osteolysis
0.1 mm / year
Which lumbrical muscles are unipennate?
1 & 2 (controlled by the median nerve).
Describe the safe zone for halo pin placement
1 cm above the superior orbital rim and at the lateral 1/3 of the rim.
Indications for surgical treatment of Thoracolumbar burst fracture
1) Neuro Compromise 2) Instability (Posterior ligamentous complex damage, progressive kyphosis) 3) (Relative) Multiple fractures...encouraging early ambulation
Name three assocations with valgus extension overload at the elbow
1) Pain at Deceleration Phase 2) Posteromedial olecranon fossa osteophytes 3) Overresection of olecranon causes MCL stress and valgus instability
Radiographic indicator of lateral meniscus tear in the setting of tibial plateau.
6 mm joint widening
Inflection age - Both bone forearm fractures
10
Describe the Stryker Notch view
10 degrees off of AP with the arm above the head. Forms a notch between the humeral head and the lateral aspect of the scapula (see picture)
Ideal suture purchase in flexor tendon repair is located how far from the tendon edge?
10 mm
Where should the greater tuberosity be fixed relative to the articular surface of the humeral head?
10 mm below the surface
What weight is associated with higher failure rate of flexible nails?
100 lbs or 48 kg
Temperature that defines heat exhaustion versus stroke
102 or 40.5 degrees
What is the inflection point for an abnormal Drennan angle (Blount's dz)?
11 degrees - likely not just physiologic 16 degrees - definitive Blounts
Width of the superspinatus tendon
12 mm. >50% tear should be repaired
How long do you immobilize a diabetic with neuropathy after fixation of an ankle fracture
12 weeks
At what degree of glenoid retroversion is allograft reconstruction of the posterior glenoid a better option than eccentric anterior reaming?
15 degrees
Chromosome and gene involved in CMT
17 - PMP
What is maximum size nerve gap that can be bridged using an artificial conduit?
2 cm. Quality drops off below that of autologous grafting with defects > 5 mm
At what angle is it appropriate to fuse a Duchenne's spine?
20-30 degrees. Always order cardiology evaluation prior to surgery.
HO can be excised from the forearm after what time period and expect low recurrence rates?
6 months
How long until recovery of elbow motion after a supercondylar humerus fracture?
6 months (94% restoration of elbow motion)
How long should you continue abx in open fx treatment.
24 hours after definitive closure
Time period for stabilization of midshaft femur fracture to avoid complications?
24 hours. Optimal - but only if resuscitated and no head or pulmonary injury
At what cobb angle do you treat a skeletally immature child with TLSO bracing?
25-40 degrees
How long of a delay in abx admin after open fx is associated with increased complications?
3 hours
Jump Gait
3 levels of contracture: Hip and knee flexion, ankle equinus
How many cruciate pulleys are there and where are they lcoated?
3 total. Located over the shaft of the proximal and middle phalanx. Order of pulley ligaments: A1, A2, C1, A3, C2, A4, C3, A5
What is the ideal timeframe in which to fix flexor tendon injuries?
3 weeks
What length of time separates acute and chronic SCFE
3 weeks
Time before allowed to bill for new patient
3 years
When to obtain EMG when observing a radial nerve palsy
3-5 months
Maximum angulation of radial neck fracture for closed reduction
30 degrees
What is the post-exercise value for compartment pressure that indicates exertional compartment syndrome?
30 mm Hg within 1 minute 20 mm Hg within 5 minutes
Mortality rate after femoral neck fx at 2 years? w/ Kidney failure?
30%. 45% w/ CKD.
Mantra for shoulder arthrodesis
30-30-30 (30 Abduction, 30 Flexion, 30 Internal rotation)
When do you pursue spinal fusion in severe OI patients (at what angle)?
35 degrees
According to the Paprosky classficiation what is the minimum amount of diaphyseal bone required to support and long fully coated stem as opposed to a revision modular stem?
4 cm
What number is important to remember regarding the treatment of traumatic articular cartilage defects.
4 cm2 Femoral: < 4 cm = Microfracture / Autograft > 4 cm = Allograft / ACI Patella: < 4cm = Microfracture / Autograft > 4 cm = ACI
What time interval can pass before significant increase in 1 year mortality after femoral neck fx?
4 days
Initial Management Tibial Stress Fx
4-6 weeks NWB
Operative indications for extraarticular scapula fx
40 degrees angulation or 1 cm displacement
Energy expenditure with bilateral transtibial amputation?
40% increase
How long after surgery does it take before CRP starts to go down?
48 hours
What is the maximum duration to surgery to allow for good outcomes in cauda equina syndrome?
48 hours
Femoral neck fractures should be fixed in what time window?
48 hours. Higher rate of non-union outside of this but okay to delay if not medically optimized. Increased mortality rates if not treated within 4 days.
How far below prosthesis head should the greater tuberosity be located in hemiarthroplasty?
5-8 mm
How far above the pec tendon is the top of a hemiarthroplasty supposed to be?
5.6 cm
How far from the pec insertion should the head of the prosthesis sit when assessing a shoulder hemiarthroplasty or total shoulder arthroplasty?
5.6 cm. "Fifty six is where it sits!"
Denis Classfication
Classification of sacral fractures. Zone 3 (medial to the foramina) injuries are most likely to lead to neurologic dysfunction.
Which annular ligament are located over the finger joints?
A1 = MCP A3 = PIP A5 = DIP
What structure is typically involved in the development of trigger finger?
A1 Pulley
What annular pully is most commonly involved with trigger finger?
A1 pully
At what angle do you tension an ACL graft? A PCL graft.
ACL = 30 degrees PCL = 90 degrees Makes sense...want to tension at its most lax angle
What ligament is deficient in PFFD?
ACL absent
Cervical instability requiring C1-C2 fusion in a Down's patient is defined by.....
ADI > 10 mm or SAC < 14
What are the absolute measurement indication for a C1/C2 fusion in rheumatoid atlantoaxial instability?
ADI>10, SAC<14
What nerve is at risk during placement of pins during tension band fixation of an olecranon fx
AIN
What complication are patient's with AS at high risk for after THA?
ANTERIOR Hip Dislocation (Even after a posterior approach)
What are the deforming forces on a base of thumb fracture?
APL and Adductor Pollicis
Deforming Forces of Bennett and Rolando Fractures
APL, Adductor pollicis
Preiser's Disease
AVN of the Scaphoid
What non-orthopedic injury should you be concerned about with a chance fx?
Abdominal injury
What monitoring test should be performed on a patient with hemihypertrophy?
Abdominal ultrasound (rule out Wilm's tumor)
SNAC Wrist
Abnormal articulation of the scaphoid caused by untreated non-union. Results in pancarpal arthritis that will spare the radiolunate articulation until last.
Clinodactyly
Abnormal curvature of a digit.
Ligament of Struthers
Abnormal ligamentous structure which connects a residual anterior supercondylar tubercle to the medial epicondyle. This structure can cause compression of the median nerve.
Delta Phalanx
Abnormal physis orientation - results in abnormal curvature of a digit (toe or finger)
In phase of the throwing cycle is valgus load the greatest?
Acceleration phase
What type of calcaneus fracture do you treat with percutaneous reduction and screw fixation?
Achilles tendon avulsion fractures. Notice that there is no extension of the fracture to the posterior facet.
What are the disorders affecting the proliferative zone?
Achondroplasia, Gigantism, MHE
Foramen magnum stenosis is associated with what condition?
Achondroplasia. Stenosis causes central sleep apnea. Patients should be appropriately screened.
Treatment of hook of hamate fracture? Acute = Chronic =
Acute = Casting Chronic = Excision
Treatment of SL ligament injury. Acute versus Chronic.
Acute = Ligament repair + Pinning Chronic = Scaphoid fusion of some sort
Metal on metal hips produce what type of rxn
Acute lymphocytic - delayed hypersensitivity
Formula for calculation of ISS score
Add the square of the 3 highest AIS scores
What muscle is typically involved / tender in athletic pubalgia?
Adductor Longus
Where do hamstring tears occur? Adults? Kids?
Adults: Myotendinous junction Kids: Ischium bony avulsion
Main blood supply to the talus
Artery of the tarsal canal
Guidelines for return to sport after Mono
After 3 weeks, if splenomegaly completely resolved
What is the inflection age for Legg-Calves-Perthes Disease
Age 6
What is the inflection age for performing an HTO on a patient for unicompartmental arthritis?
Age < 60. Thin, active patient. TKA has a
Lumbar Disc Herniation (SPORT Trial) - Positive Outcome Factors
Age > 41, Married, No workers compensation, absence of other joint problems.
Major risk factor for development of complications after posterior spinal fusion for alignment correction?
Age > 60
#1 Risk Factor For Failure to heal RC tears?
Age > 65
When do you operate on internal tibial torsion?
Age>8 + >30 degrees of internal rotation - plan for supramalleolar ostoeotomy
Identify appropriate location of Stryker needle in the compartments of the leg.
All spots should be within 5 cm of the fracture site. Anterior Compartment: 1 cm lateral to the anterior border of the tibia Lateral Compartment: Just anterior to the posterior border of the fibula Deep Posterior: Bouncing off the medial border of the tibia Superficial Posterior: Mid Calf
Lab Findings in Hypophosphatemic Rickets
All you need to know is Low phosphate, normal calcium - but it makes sense that labs also show normal PTH and normal vitamin D.
What medication can be used to decrease reperfusion injury?
Allopurinol
Most common reason for incongruent radial capitellar joint after reduction of a Bado Type III
Annular Ligament interposition
What tendon is transferred to prevent equinovarus after a chopart amputation?
Anterior Tibialis is transferred to the neck of the talus
Treatment of persistent stiffness following non-op treatment of a radial head fx?
Anterior and posterior capsular release
Most sensitive test for combined ACL/MCL tear
Anterior drawer in external rotation
Grade III MCL + ACL Tear: What physical exam to diagnose?
Anterior drawer with knee in ER. Tests for posteromedial instability.
What vessel is at risk with tibial tubercle avulsion fractures?
Anterior recurrent tibial artery ---> This can result in compartment syndrome
Left unstable intertroch complication with SHS
Anterior spike displacement of the proximal fragment
Left sided femoral neck fx fixed with DHS...associate!
Anterior spike displacement.
What artery supplies the majority of perfusion to the spinal cord?
Anterior spinal artery - fed by the artery of Ademkawicz
Approaches to Humerus Fractures
Anterolateral (proximal 2/3 fx) Posterior (Distal 1/3 fx) Lateral (radial nerve expoloration necessary)
Supination adduction ankle fx - what should you look for intraoperatively?
Anteromedial plafond impaction
FGFR2
Apert Syndrome
Osteoid Osteomas occur on what side of their associated scoliotic deformity.
Apex of the concavity. Most often in the posterior elements.
Treatment of small stable OCD lesion in kid at skeletal maturity.
Arthroscopic subchondral drilling
Rollback Phenomenon
As the knee comes from extension into flexion the femur pivots about the medial joint line (smaller radiius of curvature on lateral side) and rolls back
AMBRI
Atraumatic Multidirectional Bilateral - (treated with) Rehabilitation and Inferior capsular imbication (if failed conservative tx)
Cleidocranial Dysplasia...Associate!
Autosomal Dominant Absence of clavicles Proportionate dwarfism CBFA1 / RUNX2 Gene - limits osteoblast activity
Indications for fixation of medial epicondyle fracture?
Avulsion into joint, >5 mm displacement (relative), ulnar nerve dysfunction (relative), throwing athlete with displacement - always look for displaced fragment in the joint with a medial epicondylar avulsion.
Jersey Finger
Avulsion of the FDP from the distal phalanx
What nerve is at risk with suture repair of the posteroinferior shoulder labrum?
Axillary nerve
Treatment of septic bursitis - per AAOS guidelines...apparently
Bursectomy and IV abx. Also encourages aspiration to distinguish aseptic.
Which knee implant design has the best flexion associated with its use?
Posterior stabilized
Fibrodysplasia ossificans progressiva (Stone Man Syndrome) - Physiologic defect
BMP 4 Abnormality
DCO should be applied to patient's considered "in extremis" - defined as....
BP< 90, temp<32, or platelets < 70,000
Little League Elbow
Basically the valgus extension overload of children. Actually a continuum of MCL sprain, medial epicondyle apophysitis, and osteophytosis of the posteromedial olecranon
Cervical myelopathy occurs in OI patients because of what condition?
Basilar invagination
What is the advantage of a locking plate versus blade for fixation of distal femur fracture?
Better control of coronal plane fracture
What finding is associated with the best outcomes after obstetric brachial plexus palsy?
Biceps motor function at 3 months
What ligament is involved in fractures of the anterior process of the calcaneus?
Bifurcate ligament
Jefferson Fracture
Bilateral anterior and posterior ring injuries to C1 vertebrae (Mnemonic: Jefferson was our 1st president...of the Confederacy)
Describe Hangman's Fracture?
Bilateral fracture of the pars in the cervical spine (C2/C3)
Hurler Syndrome mnemonic
Blind Gargoyles Hurl with Double Strength (DS = Dermatan Sulfate)
When does the secondary ossfication center of the dens (the tip part) fuse?
Body fuses to the shaft of the dens at 3. Tip fuses at 10-12. Mnemonic: "3-10 not the dens"
Scenario: Impingement of patella on femoral component during flexion (joint line elevation) w/ large poly in place during a revision knee. What do you do?
Bone loss from the component removal causes large flexion and extension gaps that are trying to be compensated for by a large poly. This results in joint line elevation. To fix this problem you need to decrease the size of the flexion and extension gaps (using augments or changing the component size) and then using a smaller poly.
What test can be used to distinguish sickle cell crisis from infection?
Bone scan. Normal marrow uptake in osteo and decreased uptake with crisis
Contracture of the oblique retinacular ligament results in what deformity?
Boutonierre deformity
Contracture of the transverse bands results in what condition of the finger?
Boutonierre deformity. Essentially just pulls on the oblique retinacular ligament causing flexion at the PIP and extension and DIP
What happens if the oblique pulley of the thumb is cut?
Bowstringing of the FPL and decreased excursion of the thumb. Actually you need to rupture both the oblique pulley and more proximal A1 pulley.
What nerve can be used to trace back to the radial nerve during a posterior approach to the humurus?
Brachial Cutaneous Nerve or Posterior Antebrachial Cutaneous Nerve
First line of treatment for Blounts disease if age < 3
Bracing
Double PCL sign
Bucket-handle meniscus
What physical exam finding is associated with CIND?
CIND = Carpal INstability Non-Dissociative - Basically the carpal bones stay together but are dissociated from the radius articulation due to disruption of the extrinsic ligaments. Clunk with neutral to ulnar deviation while pushing palmarly.
Treatment for Z-deformity secondary to CMC arthritis
CMC joint resection, fusion of MCP joint
PMP22
CMT
Pseudoachondroplasia....associate!
COMP (COMPared to achondroplasia) Autosomal Dominant Cervical instability Normal face
What is the strongest predictive factor for pediatric septic arthritis?
CRP>20
Best method to determine spine fusion non-union
CT
Most sensitive exam for determining amount of lunate collapse.
CT
What imaging do you need before doing a C1/C2 Transarticular screw?
CT angiogram to look for aberrant interosseous vertebral artery
11 yo girl with growth arrest following fracture - what do you do first?
CT scan to evaluate if the physeal bar is resectable
Most likely ligament to be compromised with PTT dysfunction?
Calcaneonavicular (Spring) Ligament
BMP - 7 Use
Can be used with as good effect as autologous bone graft in the treatment of closed tibial shaft fx. BMP-2 has shown good results in OPEN tibial shaft fx
How do you treat symptomatic os odontoideum?
C1/C2 Fusion
Treatment for Basilar Invagination > 5 mm
C2-Occiput Fusion
Klippel Feil....associate cervical level of importance.
C3 Above C3 = Sports okay. Normal life expectancy Below C3 = No contact sports. Shorter life-expectancy
Most common nerve root injured after laminoplasty of the c-spine for cervical myelopathy
C5
Arthritis in what carpal facet is a contraindication to proceeding with a proximal row carpectomy?
Capitolunate
Treatment for anterior shoulder instability?
Capsular Shift (Retensions the IGHL) +/- Bankart repair
Bartonella Henslae
Cat scratch fever, differential for cat bites, causes grossly swollen lymph node.
Elderly person with minor neck extension injury....Associate!
Central Cord Syndrome
Which way is the neurovascular bundle displaced by the spiral cord of Depuytrens contracture?
Central and superficial
What structure is at risk with volar dislocation of the PIP joint and what deformity results?
Central slip is often disrupted. Boutonierre deformity i s common. Initial treatment is splinting in extension for 6 weeks to allow the central slip to heel. Open repair of central slip can be undertaken if no resolution
Head-on motor vehicle collision with seat belt contusion and back pain...Associate!
Chance Fx. Think concomitant abdominal viscera injury
How do you differentiate a clasped thumb from a pediatric trigger thumb?
Clasped thumb has restriction in abduction because of first web spaced contracture and absence of EPB
What factor determines whether you use submuscular bridge plating versus flexible nail for treatment femur fracture in a 5-10 yo child?
Comminution = Plate Transverse = Flexible nail
After TEA what restrictions are placed in the immediate post-operative period?
Complete splint immobilization x 4 weeks following TEA (some sources say only 10 days the gentle ROM)
Wartenberg's Syndrome
Compression of SBRN at interval between BR and ECRL
Dorsal Bunion is associated with what foot deformity?
Congenital club foot.
Parona's Space
Connection between the fascia of pronator quadratus and FDP. Important because it serves as a channel of communication for flexor tenosynovitis to the proximal wrist.
Congenital curly toe treatment....associate?
Conservative until persistent symptoms + age > 3. Complete tenotomy of the FDL and FDB.
AIIS Avulsion Fx Treatment?
Conservative. Hip flexed x 2 weeks
Treatment of Kohler's Disease
Conservative. Short leg walking cast shortens duration of symptoms.
After failure of conservative treatment of sports hernia what do you do?
Consult general surgery for pelvic floor reconstruction. Might also consider an adductor longus recession.
Deficiency of what ligament in combination with a deficient rotator cuff is a contraindication to shoulder hemiarthroplasty?
Coracoacromial ligament
Iridocyclitis is associated with what condition?
JRA. Uveitis is associated with ankylosing spondylitis and Reiters syndrome.
Post axial polydactyly in CaucasianElii
Genetic workup (Ellis Crevald Dz)
Describe the "Miserable Malalignment" Syndrome
Genu Valgum External Tibial Torsion Increased femoral anteversion (internal rotation of the femur)
SIRS Criteria
HR>90, Temp outside range of 36-38, RR > 20 or hypoxic, WBC outside Range 4-12. - 1 point for each, >2 = SIRS dx
Panner Disease
Juvenile elbow OCD (children less than 10)...imaging show fragmentation of the capitellar epiphyseal nucleus. Self-limited - treat conservatively - no sequelae
Ulnar negative variance is associated with what?
Kienbock's Disease
What is the most important predictor of failing a back rehabilitation program for low back pain?
High VAS scores (i.e. severe pain)
How do you decide how may levels to fuse in the setting of spondylolisthesis?
High grade (>50%) = 2 levels (+/- anterior support) Low Grade = 1 level
What is the advantage of the blade plate versus locked plates in treatment of distal femur fracture?
Higher strength in torsional strength
Treat the following: Volar finger tip Volar defect of finger < 2 cm Dorsal defect of finger
Cross Finger Flap-
Primary complication of physeal separation
Cubitus varus - up to 70%
What is the last elbow apophyses to FUSE during growth?
Medial epicondyle (closes at 17). Radial head and olecranon close at 15 - everything else closes at 12
Where is the blood supply in the proximal humerus?
If the posteromedial segment is intact on x-rays then the rate of AVN is signicantly lower. Main blood supply is the posterior cirumflex humeral artery.
Factors associated with peroneal palsy after total hip
DDH, lengthening, surgeon opinion, post-traumatic arthritis
What deformity causes SLAC wrist?
DISI deformity caused by SL ligament disruption
What happens when you section the scapholunate ligament.
DISI deformity. The lunate extends as the scaphoid flexes.
8 yo male with CRP>6 who undergoes surgical debridement of MRSA tibial osteomyelitis...what are you worried about?
DVT
What is the correct treatment of an isolated expanding osteolytic defect (surrounding a screw) in a THA.
Debridement and bone grafting of defect with revision of PE liner
Treatment of lumbar stenosis without instability or spondylolisthesis
Decompression with laminectomy and medial facetectomies
Increased femoral offset will cause what change in joint reaction forces?
Decrease joint reaction forces
Comminuted olecranon fx in low demand elderly. Tx?
Immobilize at 90 degrees For non-displaced fragments you should splint in less flexion 45-90.
pH of the nucleus pulposus changes in what way with aging?
Decreases.
Spiral tibia fx - what exam should be ordered?
Dedicated ankle films or CT ankle.
The deep palmar arch is the distal extension of what vessel primarily?
Deep branch of the radial artery
Spondyloepiphyseal Dysplasia....associate!
Defect in COL2A1 - type II collagen deficiency ATLANTOAXIAL INSTABILITY Dwarfism Affects the proliferative zone of growth plate X-linked and AD forms
In the setting of vascular compromise of a replanted digit what is the algorithm for treatment?
Determine if venous or arterial. If arterial - place dependent, heparinize, stellate ganglion block, remove compressive bandages.
Treatment of quadriceps contusion?
Immobilize in 120 degrees of flexion for 24 hours
What method of PE manufacture is associated with the best wear characteristics?
Direct compression molding. Ram bar extrusion and sheet compression both require post mold machining which causes oxidation of the implant surface.
Eccentric poly wear presents the greatest risk of what complication?`
Dislocation
Most common complication after triflange?
Dislocation
What complication is common after isolated poly exchange for concentric wear and osteolysis?
Dislocation
Holstein-Lewis Fracture
Distal 1/3 humerus fracture. High risk of radial nerve palsy. Observe for 4 months then pursue treatment with EMG, nerve conduction and possible exploration if no improvement
Which has greater healing potential, distal or proximal MCL lesions?
Distal has less than proximal (Distal in on the medial face of the tibia...there is basically nothing there to help out with healing)
What is the source of vascularity to the lateral condyle and how does this affect the surgical approach?
Do not dissect posterior to the condyle because this is wear the bloody supply comes from
What toe deformity can be the result of Ponseti casting of clubfoot deformity.
Dorsal 1st toe bunion
Proximal 1/3 scaphoid fractures are best treated through what approach?
Dorsal approach
DISI
Dorsal intercalated segment (lunate) instability. Disruption of the scapholunate ligament causes the lunate to dorsiflex. This causes progression to SLAC wrist.
Hx of osteoporosis now with insidious femur pain...associate!
Impending fx associated with bisphosphonate. Look for lateral wall thickening. Treat with IM nail
What symptoms are specific to compression of the ulnar nerve in Guyon's canal (ulnar tunnel syndrome) as opposed to cubital tunnel compression?
Dorsal sensation intact More clawing No deficit of ulnar FDP Negative elbow flexion test
Structure at risk with creation of the 6-U / 6-R wrist portal
Dorsal sensory branch of the ulnar nerve
Residual cavus after after surgical clubfoot correction is caused by?
Dorsally subluxated navicular
Treatment of hemorrhagic blisters
Drainage but no debridement. Removal of blister can result in dessication of the underlying dermis.
What is the primary reason to get a spinal MRI on a patient with neurofibromatosis?
Dural ectasia
What structure is most commonly interposed in the fracture site of a tibial eminence avulsion?
Medial meniscus
What must be preserved in transmet amputation to prevent supination deformity?
Peroneus brevis attachments to the base of the 5th MT
Galleazi fx, unable to reduce, what structure is in the way?
ECU
Tendon interposed in DRUJ with Galeazzi fx
ECU
What tendon prevents DRUJ reduction in Galleazi fx?
ECU (Just remember that the ECU is part of the TFCC and intimately associated with the DRUJ)
Low velocity gunshot w/o fracture to extremity
ED irrigation, 3 days oral abx, and NO PRIMARY CLOSURE
Suprascapular compressive symptoms in setting of negative MRI...what next?
EMG/NCS
Where are the two most common locations that AIN compression can occur?
Edge of pronator teres Arch of FDS
COL5A1...associate!
Ehler's Danlos Syndrome
Child gymnast with lateral elbow pain and loss of extension...associate!
Elbow OCD
Coxa Magna
Enlargement of the femoral head associated with osteonecrosis - early finding
What layer of the nerve is the primary protecting agent against compression forces?
Epineurium
Chondroblastoma (XR)
Epiphyseal lesion, circumscribed with sclerotic borders
Revision microdiskectomy for repeat herniation results in...worse, better or equivalent outcomes to primary surgery?
Equivalent
What is a way to tell on X-ray that there is too much glenoid erosion to support an glenoid component?
Erosion past the level of the coracoid process
Bennett Lesion
Impingement of the supraspinatus on the top of the glenoid/labrum (type of internal impingement) causes hypertrophy and scarring of the posterior glenoid capsule. Associated with GIRD
Risk Factors for Dislocation after THA
Female, Inflammatory Arthropathy, Age>70, Osteonecrosis (Post traumatic arthritis is the same)
For severe intractable pes planus what operation can be done to correct talar head uncoverage and forefoot abduction?
Evan's Calcaneal Lengthening Procedure
What motion unlocks the subtalar joint?
Eversion (just remember that the PTT performs inversion and is necessary to do a heel rise i.e. lock the subtalar joint)
Thomas Test
Evidence of flexion contracture with the contralateral leg flat on table while patient is supine. Used for determining appropriateness of psoas release in CP patients with hip subluxation.
EWS:FL1 (11:22)
Ewing's Tumor
Optimal position for hip arthrodesis
External Rotation: 5-10 Adduction: 0-5 Flexion: 20-30
Lesions after shoulder dislocation (alphabet soup)
GLAD (Glenoid Articular Defect) ALPSA (Anterior Labral Periosteal Sleeve Avulsion) HAGL (Humeral Avulsion of Inferior Glenohumeral ligament) Hill-Sachs Bankart
Extraabdominal Desmoid Tumor Associated Condition
FAP
What tendon is the pisform contained in?
FCU
Tendon that ruptures with volar plating?
FPL
Which tendon most commonly ruptures after volar plating of the radiius?
FPL
Cause of Madelung Deformity
Failure of volar ulnar aspect of distal radial physis. May be related to constraint by Vicker's ligament (extra thick ligment between the radius and the lunate).
Most common reason for failure of compartment release for DeQuervain's
Failure to release EPB sub compartment
Type II muscle fibers are involved in what type of activities?
Fast twitch. IIA = Mixed / IIB = Anaerobic only
Benefit of percutaneous scaphoid fx fixation
Faster time to union
Most common complication after hip resurfacing?
Femoral neck fracture
FBN-1
Fibrillin. Associated with Marfans Syndrome
Describe a PAB ankle fx
Fibula: Comminuted fx at or above the level of the syndesmosis Tibia: Medial mal transverse fracture (pulled off)
Anteromedial Bowing is associated with what condition?
Fibular Hemimelia
What is the main determinant of whether a bony procedure is needed in the foot?
Flexible deformity: Soft-tissue procedure Fixed Deformity: Bone an soft tissue procedure
Stage II PTTD (Description + Treatment)
Flexible flatfoot, unable to perform toe raise. Can be treated with medial calcaneal osteotomy and FDL transfer.
In what position do you immobilize monteggia fx?
Flexion and supination
In why position do you immobilize a Galeazzi fracture?
Flexion and supination
Camptodactyly
Flexion deformity of the PIP joint. Usually only affects the small finger.
Describe the biomechanics of a Chance Fracture
Flexion-distraction injury. The anterior column fails in compression and the posterior and middle column fail in tension.
Proper collateral ligament of the thumb prevents radial deviation of the phalanx in what position?
Flexion.
What radiographs should you get in a patient with JRA?
Flexion/Extension Radiographs looking for instability
Describe Guyon's canal
Floor = the TCL Roof = Pisohamate ligament Contains the ulnar artery and deep and superficial branches of the ulnar nerve
Galleazi Fx
Fracture of distal 1/3 of radius with associated DRUJ injury. Volar radioulnar ligamentous structures are damaged.
Septic nec fasc, next step?
Frozen biopsy in the OR for diagnosis
What position do you splint the forearm in when you have an LCL disruption in an elbow dislocation?
Full pronation - tightens the lateral dynamic stabilizers
Post-axial polydactyly in caucasian...what do you do?
Further work up, maybe Ellis Van Creveld Syndrome?
What measure is predictive of ambulatory status after conversion of a hip fusion to an arthroplasty?
Gluteal muscle function
ACL Graft screw divergence > 30...Associate!
Greater risk of graft failure
Only good reason to ever use a soft collar
Grisel's disease with atlantoaxial rotatory displacement lasting less than 1 week. After 1 week you would do halter traction. After 3 weeks halo traction. After 3 months fusion.
Most common complication of distal femur physeal fracture?
Growth arrest - 60% incidence
What is the indication for a biplanar chevron osteotomy?
Hallux valgus requiring surgical treatment + DMAA > 10 degrees
During what phase of the gait cycle is the TA contracting eccentrically?
Heel Strike
Name the phases of gait
Heel Strike, Foot flat (loading response), Midstance, Terminal Stance, Pre-swing, Initial Swing, Mid swing, Terminal Swing, Heel Strike
Obturator Oblique Outlet
Help identify starting point of the supracetabular pin at the ASIS and prevents hip joint penetration.
Describe Brown Sequard Sydrome
Hemicord. Ipsilateral motor, contralateral sensory. Best prognosis
Arcade of Struthers
Hiatus in the intermuscular septum through which the ulnar nerve passes to get from the anterior to the posterior compartment
Hypertrophic Zone....Associations!
High O2 Physeal fractures, SCFE, Mucopoly, Rickets Type X collagen to lay down cartilage for calcification
Bullet embedded in bone after passing through abdomen - what do you do?
IV antibiotics 7-10 days broad spectrum
Describe internal impingement.
Humerus impinges on postero-superior labrum during abduction/external rotation. There is a postero-superior shift in the humerus relative to the glenoid. Note that it is the posteroinferior capsule that becomes hypertrophic however
Dermatan Sulfate....associate
Hurler Syndrome
Treatment of acute saggital band rupture
Hyperextension splinting x 4-6 weeks. Open fixation in high level athletes.
SCFE occurs through what growth plate zone?
Hypertrophic
II/VI systolic murmer that increases with vasalva or standing...associate!
Hypertrophic cardiomyopathy
Open forearm injury - what do you do?
I&D + Immediate ORIF and skin closure Supported by Levin Article in injury 2007
Low velocity gunshot through abdomen and into hip joint - treatment?
I&D joint + 14 days IV antibiotics
Which Interleukin paracrine signaler is associated with MSK injury
IL-6
Complications of treatment of bisphosphonate fx. IM nail? Plating?
IM Nail: Iatrogenic fx Plating: Hardware failure Bisphosphonates inhibit intramembranous bone healing
How do you decide between using a semi-constrained TEA versus unconstrained?
If ligaments stable and no previous radial head resection then you can use unconstrained. Basically you don't ever use a completely constrained TEA because of the high rate of loosening. Note: Unconstrained prosthesis is contraindicated in late stage RA because there are bony and ligamentous changes that render the elbow unstable.
What are the disorders affecting the reserve zone?
Kniest, Gaucher, Hitchhiker (Diastrophic Dysplasia) - just remember the eponyms are in the reserve zone. Like the reserve zone in a club.
Smallest Pedicle
L1
Smallest lumbar pedicle diameter
L1 (Smaller than T12)
Using a jumbo cup might increase the rate of what complication after THA?
Increased rate of dislocation. Large cups often have soft tissue overgrowth over the rim that results in early impingement and dislocation.
What is the effect of increasing tibial slope?
Increases flexion gap - joint widens as the femur rolls back on the tibia
Advantage of a wound vac
Increases local vascularity and promotes accelerated granulation tissue formation
Greatest risk factor for post-operative complications after posterior decompression and fusion?
Increasing age
Center of rotation in a reverse total shoulder arthroplasty is moved in what direction relative to a native shoulder?
Inferior and medialized. Gives the deltoid a better lever arm.
How do you minimize scapular notching in RTSA?
Inferior position of baseplate with inferior inclination
Degree measurement indicating femoral anteversion
Internal rotation 70 degrees
What is the complication associated with use of a fracture table when putting down a nail?
Internal rotation deformity
Causes of increased Q-angle, lateral patellar mal-tracking
Internal rotation of tibial component, internal rotation of femoral component, medial translation of the femoral component, lateralization of the patellar component
Young laborer with end-stage post-traumatic or osteoarthritis of the elbow...best treatment?
Interpositional arthroplasty. Basically this is the treatment when the patient would otherwise be a candidate for prosthetic replacement but it too young to tolerate the restrictions. If there is bone loss (destructive JRA or osteonecrosis) then you have to do TEA
What is the most important structure that determines stability in the thoracolumbar spine?
The Posterior Ligamentous Complex (PLC)
What clinical scenario is artificial disk replacement appropriate?
Isolated discogenic pain without instability. As diagnosed by provocative discography.
Treatment for symptomatic synovial cyst of the spine?
Isolated laminectomy and decompression - high incidence of recurrence Facetectomy and instrumented fusion - best results
4 year old with limp and pain for > 6 weeks secondary ot pain and swelling in one or more joints...consider what diagnoses?
JIA versus Lyme's disease
What neurologic level in myelodysplastic patients puts them at highest risk for hip dislocation?
L3 level. Results in unopposed hip flexion and hip adduction. In these patients the hip is left dislocated as they never become functional ambulators.
What is the key determining factor whether a person with myelodysplasia is able to walk?
L4 intact (quadriceps function) - generally the patients are able to walk
Most common level affected by degenerative spondylolisthesis?
L4/L5
Trendelenburg gait is caused by deficiency in which lumbar nerve distribution?
L5 - innervates the gluteus medius
What nerve root is at risk with complete reduction of an L5/S1 Isthmic spondylolisthesis?
L5 nerve root
Most common level affected by isthmic spondylolisthesis
L5/S1
Describe anterior cord syndrome
LE>UE weakness, worst prognosis
Lowering the joint line results in what complications?
Lack of full extension Flexion instability
Osteosarcoma (Histology)
Lacy Osteoid
Treatment of choice for isolated paracentral disc herniation
Laminotomy and Diskectomy Study: Weinstein et al (SPORT 4 year results) showed in the as-treated analysis that patients treated surgically for intervertebral disc herniation showed significantly greater improvement in pain, function, satisfaction, and self-rated progress over 4 years compared to patients treated non-operatively. They found at four years there was no signifiBenecant difference in work status between the surgical and nonsurgical group.
What cell is involved in mediating response to metal ions in THA?
Lymphocytes
Best predictor of success of partial menisectomy
Outerbridge classification. Less arthritis = better result
When in the throwing cycle does internal impingement happen?
Late cocking, early acceleration (Maximal abduction and external rotation)
Inability to evert the patella is indicative of....
Lateral patella compression syndrome. Lateral patella retinaculum release indicated for persistent cases.
Scapulothoracic dissociation can be recognized on radiographs by what characteristics?
Lateral translation of the scapula
What radiographic characteristic indicates a meniscal injury on tibial plateau fracture films?
Lateral widening of the joint line >6 mm
What position should a pregnant lady be put in on the operating table to avoid intraoperative hypoperfusion?
Left lateral decubitus position
What position should be used in pregnant patients?
Left lateral decubitus.
Most common fracture during TKA
Medial Femoral Condyle Fracture
Mnemonic for remembering GMFCS classification for CP
Level I = Stands on one leg -near normal Level II = Two legs = independent walking Level III = Walks with 3 legs - needs assistive device You can take it from there
Open humerus fx - radial nerve palsy - associate!
Likely complete disruption of the nerve. Suggests exploring the nerve - performing neurolysis / repair
What should be the weight bearing status after an extended troch osteotomy?
Limited weight bearing. Reduces torque failure to 50% of intact femur.
Describe role of the posterolateral bundle of the ACL
Limits translation and rotation at 30 degrees (Just think Lachman's and pivot shift)
What should you look at to determine whether you are looking at a DISI or a VISI deformity on lateral wrist films?
Look at the lunate! If the moon is facing dorsal = DISI If the moon is facing volar = VISI
What medication adjunct can be used for treatment of quad contusion?
Losartan. Increases muscles regeneration.
Most common complication after distal humerus ORIF
Loss of ROM
Renal Osteodystrophy Lab Profile
Low calcium (kidneys can't hang on to it) High Phosphate (kidneys can't get rid of it) PTH is high because calcium is low Alkaline phosphatase is normal or elevated because the PTH is causing bone turnover
Proliferative Zone...Associations!
Low oxygen tension --> inhibits calcification High rate of ECM production Achondroplasia, Gigantism, MHE
VISI deformity is caused by damage to what structure?
Lunotriquetral ligament.
Chronic PCL deficiency causes arthritis in what distribution?
Medial Femoral Condyle and Patello-femoral Joint
Indicators of adequate resuscitation (6 markers)
MAP>60, HR<100, Base Deficit +2 to -2, UOP>30, Lactate < 2.5, Gastric pH ( normal, >7.3)
Through what ROM is the MPFL active in restraining lateral subluxation of the patella?
MPFL is the primary restraint to lateral patellar translation in the first 20 degrees of knee flexion
Kid < 10 with curve > 20 degrees...ASSOCIATE!
MRI
Left thoracic curve....associate!
MRI
Cervical facet dislocation....what test do you need?
MRI - to look for disk herniation
What are the characteristics of Larsen's Syndrome.
MULTIPLE JOINT DISLOCATIONS Flattened facies Cervical Kyphosis
What anatomic landmarks do you look out for when placing a proximal humeral locking plate?
Make sure to place the plate lateral to the bicipital groove and pec major insertion. More medial and you endanger the blood supply - anterior humeral circumflex.
Obturator Oblique Inlet View
Makes sure that the screw is between the two tables of the ilium
FBN1....Associate
Marfans. Chromosome 15. Fibrillin
How do you decide to operate on genu valgum?
Mechanical axis falls on the lateral joint line. If remaining growth - medial hemiepiphysiodesis If mature - distal femoral osteotomy
Describe the "Windlass Mechanism"
Mechanism by which the plantar fascia bears load while in stance phase. Basically acts like a tether between the hindfoot and forefoot.
What nerve can form a painful neuroma after ulnar nerve decompression?
Medial Antebrachial Cutaneous nerve
Windows of the ilioinguinal approach
Medial: Medial to the external iliac vessels Middle: Between iliac vessels / corona mortist and the iliopsoas tendon (or iliopectineal fascia) Lateral: Between the iliopectineal fascia and the lateral femoral cutaneous nerve.
To reduce glenoid component loosening on reverse prostheses it was necessary to do what?
Medialize the center of rotation
Asymptomatic patient seen in the office with MOM hip - what do you order?
Metal ions
Describe the Paprosky Classification?
Metaphyseal bone loss, diaphyseal bone loss > 4 cm, complete loss of fixation. So basically if you have
Elevating the joint line results in what complication?
Mid flexion instability Patellar Maltracking
Quad atrophy most affects what phase of the gait?
Midstance phase - the patient will lean forward to get the knee into hyperextension to prevent buckling of the knee with weak quadriceps
Basilar Invagination
Migration of the odontoid above the foramen magnum
Define mild, moderate, and severe classifications of hallux valgus (HVA / IMA). Assign appropriate treatment.
Mild: <40 / <13 --> Distal osteotomy Moderate: >40 / >13 --> Proximal Osteotomy Severe: >40 / >16 --> Combined osteotomy
Treatment Algorithm for [Hangman's] Fracture [Mnemonic hint]
Mnemonic: 3-5 stay alive < 3 mm = Rigid Orthosis > 3 mm = Reduction / Halo vest > 5 mm = ORIF (C2/C3 fusion)
What is the mnemonic for normal EMG/NCV values.
Mnemonic: 32, 42, 52 Sensory Latency: 3.2 ms Motor Latency: 4.2 ms Conduction velocity: 52 m/s
Bado Classification
Monteggia Fx Based on direction of radial head dislocation Anterior is the most common
What mucopolysacharidoses is associated with the highest rate of odontoid hypoplasia and atlantoaxial instability?
Morquio Syndrome
Pasteurella Multocida
Most common species of bacteria isolated in cat bites
Relative safe zone for retrograde femoral nail interlocks
Much lower chance of hitting the femoral nerve or superficial artery ABOVE the level of the lesser trochanter
Mazabraud's Syndrome
Multiple Myxomas + Polyostotic Fibrous Dysplasia
What two nerve innervate the brachialis muscle?
Musculocutaneous - medial Radial - lateral
Primary complication of Latarjet procedure?
Musculocutaneous nerve injury
What nerve is at risk with AP interlock in a humeral nail?
Musculotaneous nerve
Volar lunate facet...associate!
Must be restored with fragment specific fixation during volar plating of a distal radius because this is the insertion of the radiocarpal (radiolunate) ligaments and if it displaces than the whole carpus falls off.
Proximal 1/3 oblique humerus fracture. Tx.
Must plate because high risk on non-union
What sub-type of NF is associated with dystrophic scoliosis?
NF-1. Dystrophic scoliosis is severe angle scoliosis occurring over a short segment - usually with dysplastic features. Scoliosis is not typically seen in NF-1
Stable thoracolumbar burst fracture with no neurologic deficits....ASSOCIATE
NO SURGERY. Increased complication rate, no improvement over non-op. Look for posterior ligamentous complex instability that could shift the balance towards operative treatment.
What is the relative orientation of the digital nerve and artery in the finger?
Nerve is volar to the artery (remember that you feel with the pad or your finger and test cap refill at the nail (dorsal))
Operative indications for a chance fracture
Neuro injury, injury to soft-tissue posterior structures (unstable)
Does formal therapy for a distal radius fx improve outcomes relative to a home program?
No
ADI = 5 in Down's Patient....what recommendation?
No contact sports
Pediatric anterior pelvic fx, less than 2 cm displacement. Treatment.
Non-op. WBAT.
Best treatment for pediatric type II tibial eminence avulsion
Non-surgical if reducible Suture fixation if unreducible Screw fixation can result in physeal arrest.
Morquio syndrome....associate!
Normal intelligence Genu valgum Keratan sulfate
Initial treatment of congenital curly toe
Observation
What structure is at risk with placement of a retractor inferior to the transverse acetabular ligament?
Obturator artery and nerve
Retrograde nail through CR knee...associate!
Often causes extension deformity due to more posterior starting point required by the anterior flange
Pitcher with posterior elbow pain, small crack in olecranon on CT....Condition and Treatment?
Olecranon stress fracture. Treat with discontinuation activity +/- splinting and then if failed proceed with compression screw.
Where is the volar plate located?
On the volar aspect of the MCP joint
Buckley Calcaneus Study
Op better than non-op for woman, less than 29, Bohler angle 0-14, and sedentary job
Treatment of hip dislocation in arthrogryposis?
Open reduction through a medial approach
Perilunate dislocation....treatment?
Open reduction through combined dorsal / volar approach and extend carpal tunnel release. Closed reduction is appropriate initial management but all those treated non-operatively do extremely poorly.
What indications for bilateral pinning of SCFE?
Open triradiate cartilage (younger than 10) Endocrine disorder Severe initial slip Super obese
Releasing the popliteus will have what effect on the coronal balancing in TKA?
Open up lateral FLEXION GAP
Release the IT band will have what effection on the coronal balancing in a TKA?
Open up the lateral EXTENSION GAP
Treatment of proximal hamstring avulsion?
Operative intervention. Most injuries occur at the myotendinous junction and can be treated non-operatively but avulsions off the ischium will not heal.
Delayed presentation of femoral neck fracture....associate!
Order DVT Scan. High incidence of DVT in elderly patients with delayed presentation (Hefley et al)
Olecranon apophyseal fracture....associate!
Osteogenesis imperfecta
Imhauser Osteotomy
Osteotomy for delayed treatment of SCFE deformity. Valgus, flexion, and internal rotation osteotomy.
Contraindication of PCL retaining knee
PCL rupture, inflammatory arthritis, patellectomy, and over-release of the PCL during surgery
Nerve palsy with Monteggia fx
PIN Palsy
Wrist extension weakness with radial deviation suggests the diagnosis of what?
PIN compression / neurapraxia. Intact ECRL but ECU dysfunctional
Intracellular Signaling: PTH, IGF, BMP
PTH --> G-protein --> Adenyl Cyclase BMP --> Serine/Threonine --> SMAD IGF --> Serine/Threonine
Elevated N-telopeptide is associated with what?
Paget's disease, osteolysis
What is lumbrical plus finger?
Paradoxical extension of the PIP during attempted flexion. Caused by rupture of the FDP tendon. When flexion attempted this activates the lumbrical (which attaches to the proximal flexor tendon) which would usually function to extend the PIP joint with flexion of the MCP. Results in paradoxical extension.
Radiographic sign of club foot
Parallelism of calcaneus and talus
What is the function of the transverse bands of the extensor mechanism?
Passes from volar to dorsal to insert onto the oblique retinacular ligament. Keeps the ligament volar to the axis of rotation at the PIP level - basically allows the oblique ligament to function in linking DIP and PIP motion.
Function of the oblique retinacular ligament
Passes volar PIP and dorsal to DIP. Acts to allow for DIP flexion when PIP flexes
Post-slap repair rehab?
Passive and active assisted flexion of the shoulder in the scapular plane
Most common complication after proximal tibia wedge osteotomy
Patella Baja
Most common complication of TKA?
Patella Maltracking
Exacerbation of pain at inferior pole of the patella when actively going from flexion to extension (Basset Sign)
Patellar Tendonitis
Contraindications to cruciate retaining knee?
Patellectomy, Cruciate Rupture, Inflammatory arthritis, >15 valgus or 10 varus
Where does OA occur in a PCL deficient knee
Patellofemoral and Medial Compartments
Describe West Point view
Patient in prone. Angle projector at 25 degrees off the table. Best view for seeing Bankart lesions. "Bank on a West Point grad"
Tx of Subscap Tear and Atrophy
Pectoralis transfer
Most common complication in THA performed for AVN of the femoral head (any etiology)
Perforation of the femoral canal
Tx of Galeazzi Fx
Perform open reduction and internal fixation of the radius, then assess the distal radioulnar joint for instability, and percutaneously fix the distal radioulnar joint if instability persists.
Main blood supply to the physis
Perichondrial Artery
What layer of the nerve is the primary restraint to tensile forces across the axon?
Perineurium
Schatzker type II is associated with what other injury
Peripheral lateral meniscal tear
Humeral shaft fx with non-union around a nail -- associate!
Plate fixation. No evidence for dynamization or exchange nailing
Treatment of humeral non-union following nailing
Plating with autogenous bone graft
Diseased caused by dysfunction of Gs subunit
Polyostotic Fibrous Dysplasia
Diminished pulses with active plantarflexion or passive dorsiflexion...associate!
Popliteal artery entrapment syndrome
What structure is at risk with proximal tibia physis displaced fracture?
Popliteal artery. The trifurcation of the vessels occurs at the level of the proximal tibial physis making it relatively constrained and thus prone to injury at this location.
Dominant blood supply to the humeral head?
Posterior Circumflex Humeral Artery. Reasoning: Anterior shoulder dislocations are very common - anterior artery is out - and yet low rate of osteonecrosis - so posterior must be dominant
Typical direction of acetabular deficiency (Cerebral Palsy)
Posterior Superior (versus anterior in typical DDH baby)
Most common location for biceps long head insertion?
Posterior aspect of superior labrum
Treatment of degenerative spondylolisthesis refractory to conservative treatment.
Posterior decompression with instrumented fusion
Lesser tuberosity avulsion -- associate!
Posterior dislocation
What ankle injury is associated with distal spiral tibia fx?
Posterior malleolus fx
Kim Lesion
Postero-inferior labral tear - "reverse bankart"
Direction of displacement with transphyeal separation at the distal humerus
Posteromedial. As opposed to posterolateral in elbow dislocation.
What is the most important consideration when determining whether to proceed with ulnar centralization for a hand with radial deficiency?
Presence of intact biceps strength
Most predictive factor for growth arrest after physeal fracture?
Presence or absence of displacement. Amount and direction do not influence incidence of growth arrest.
Characteristics of Duchenne Muscular Dystrophy
Presents at age 3 Hypertrophied calves Gower's sign X-linked recessive Increased CPK and aldolase Dystrophin abnormal Cardiomyopathy
What zone of the physis do corner fractures occur in?
Primary spongiosa
Bosworth Fracture Dislocation
Rare fracture pattern where the talus dislocates laterally and the fibula gets trapped behind the posterolateral ridge of tibia making it irreducible. Requires open reduction.
Contraindication to elbow arthroscopy
Prior ulnar nerve transposition
What is the thing to worry about in a patient with Larsen's Syndrome?
Progressive cervical kyphosis - can be lethal - should be fused before 18 months if significant
Indications for operative intervention with disc or vertebral body infection
Progressive neurologic deficits with evidence of spinal canal compromise, spinal instability, or failure to respond to medical management.
What is the common abnormality to all the mucopolysaccaridoses?
Proportionate dwarfism originating from dysfunction of the hypertrophic zone of the physis.
Arcade of Frohse
Proximal edge of supinator. Can cause PIN compression
Attachment site of MPFL
Proximal to blumensatt's line. 1 mm anterior to line of posterior aspect of the femur between the adductor tubercle and the medial femoral condyle
What are cutoffs to replant extremities? Distal/Proximal - Warm/Cold Ischemia?
Proximal: 6/12, Distal 12/24
What is the first joint affected in a SLAC wrist picture?
Radioscaphoid joint
Anatomic blocks to reduction of DDH hip
Pulvinar, Transverse Ligament, Inverted Labrum, Limbus, Capsule, Ligamentum Teres
Mason Classification
Radial Head Fractures Type I: non-displaced Type 2: Mild displacement Type 3: Comminuted
Pain 4 cm distal to the lateral epicondyle is consistent with what diagnosis?
Radial Tunnel Syndrome
SHH
Radial club hand
What nerve is at risk with ML interlocks in a humeral nail?
Radial nerve
Proximal Anterolateral elbow arthroscopy portal....associate
Radial nerve injury
What is ulnar impaction syndrome?
Radial shortening causes ulnar positive variance. Results in lunate chondromalacia and degen TFCC tears. Treat with ulnar shortening.
How to determine rotational alignment of the radius and ulna on radiographs.
Radial styloid and tuberosity should be 180 degrees from one another. (AP Radiograph) Ulnar styloid and coronoid should be 180 degrees from one another. (Lateral Radiograph)
What ligament must be preserved when performing a proximal row carpectomy?
Radioscaphocapitate ligament
Treatment of SNAC wrist
Radioscaphoid arthritis only: Radial styloidectomy + Fixation of scaphoid No luno-capitate arthrosis: Proximal carpectomy Midcarpal Arthritis: Scaphoid excision and Four-corner fusion
Medial Talar Dislocation Facts
Reduction blocked by EDB More common, lessly likely to have associated fx
Lateral Talar Dislocation Facts
Reduction blocked by PTT FDL or FHL Less common, more likely to have fracture, more likely to be open
Most frequent complication of syndactyly repair
Regrowth of web commisure
Most accurate way to identify and monitor hip instability.
Reimer's Index - ratio of uncovered over convered femoral head
Characteristics of Pott's Disease
Relative sparing of the disks Progressive kyphotic deformity, often severe
Anterior Slide (Rotator Cuff)
Release attachment of supraspinatous to rotator interval to allow for lateral mobilization of the tendon
Posterior slide (Rotator Cuff)
Release medial attachment of supraspinatous to the infraspinatous to allow for lateral mobilization of infraspinatous
What method of PE processing is used to most efficiently remove free radicals?
Remelting after cross-linking is the most efficient; however, this results in loss of structural integrity of the PE, therefore most commericially produced PE is annealed (heated below melting point) after cross-linking
>25% Hill-Sachs...treatment?
Remplissage (Suture the posterior capsule and infraspinatus into the defect)
Most important factor for survival of replant?
Repair of at least 2 veins. No affect of smoking apparently.
What is the double bubble of the elbow?
Represents a combined fracture of the capitellum and the trochlea
Hallux varus after surgery for Hallux Valgus is caused by what factors?
Resection of fibular sesamoid - attachment of the adductor hallucis
Strongest predictor of clinical outcomes for tibial plateau fx.
Restoration of joint stability
Post-Op Fusion Infection
Retain hardware until fusion obtained.
Matizeau Technique
Retrograde insertion of pin to reduce a radial neck fracture
Best shoe modification for people with ankle arthrodesis
Rocker bottom
Most common complication of flexible femoral nails?
Rod irritation distally - necessitating removal
Borders of the cubital tunnel
Roof = Osbornes ligament Walls = Medial epicondyle Floor = MCL / Coopers ligament (transverse bundle of ligament)
What is the typical deformity present with IM nail of distal 1/3 tibia fractures?
Rotational deformity (usually > 10 degrees)
Stener Lesion of the Thumb
Rupture of accessory and proper ulnar collateral ligament allowing the adductor aponeurosis to interpose itself between the ligament and the bone. This lesion necessitates operative intervention because the ligament will not heal.
Cause of boutonierre deformity
Rupture of the central slip --> Causes lack of PIP extension and thus unopposed pull of the intrinsics into flexion at the PIP and the DIP into extnesion Attenutation of the triangular ligmament allows the lateral bands to sublux volarly which
ADI > 7 mm...associate!
Rupture of transverse, apical, alar ligaments and the tectorial membrane
Tongue Fasciculation and absent DTRs in infant....associate!
SMA. If less then 6 months old patient has acute Werdnig-Hoffman disease and will likely not live past 2
60 yo woman with sudden onset knee pain and lesion in medial femoral condyle
SONK. Treat with arthroplasty after failure of conservative treatment.
Heparan Sulfate in the urine is associated with what disease process?
San Fillipo Syndrome
Heparan Sulfate...associate
San Fillippo Syndrome
Ganglion cysts derive most commonly from what articulation?
Scapholunate articulation for dorsal cysts. Volar cysts are from the radioscaphoid articulation.
SICK Scapula
Scapular malposition, Inferior medial border prominence, Coracoid pain and malposition, and dysKinesis of scapular movement
Describe treatment of congenital vertical talus
Serial casting and manipulation to stretch soft tissue prior to surgery then talonavicular pinning at 12 months
Parsonage Turner Syndrome
Severe shoulder pain followed by muscle paralysis. The most common associated risk factor is viral illness (25-55%). EMG can be useful to confirm the diagnosis and will show positive sharp waves and fibrillations consistent with acute denervation.
Tibia pain initiated by running but then alleviated with more running....associate!
Shin splints
Explain quadrigia
Shortening the FDP > 1cm results in inability to fully flex normal fingers because motion is limited by the common muscle belly.
Most reliable for predicting ability to walk in CP patient?
Sitting by age 2
When making posterior portal for hip arthroscopy in what position should the hip be in to reduce risk to the sciatic nerve?
Slight internal rotation. Moves the back of the trochanter away from the sciatic nerve.
Where should the lateral fin of a shoulder hemiarthroplasty be positioned to achieve 30 degrees of retroversion?
Slightly posterior to the bicipital groove
Metal on metal wear is associated with what factors?
Smaller implants Abduction angle > 55
Risk factors for pseudoarthrosis in adult spinal deformity
Smoking, kyphosis >20 degrees, positive sagittal balance greater than 5cm, preexisting hip arthritis, age greater than 55, and a throacoabdominal approach were determined to be significant risk factors.
Intrinsic plus hand position is caused by what pathophysiology? What disease is the most common etiology?
Spastic intrinsics and weak extrinsics. Most common cause is rheumatoid arthritis. Progress subluxation of the joints cause decreased mechanical advantage of EDC and creates spasticity of the intrinsics.
Characteristics of Freidrich's Ataxia
Spinocerebellar degeneration Wide-based gait GAA repeats Cavovarus foot
SLAP tear with cyst....location?
Spinoglenoid notch
Holstein Lewis Fx
Spiral distal 1/3 humerus fx - often accompanied by radial nerve injury
Pain with single leg standing extension
Spondlolysis
COL2A1 mutation causes what condition....
Spondyloepiphyseal Dysplasia
With hypoplastic thumb what is the most important factor in determining thumb reconstruction versus ablation and pollicization?
Stability of CMC joint
Treatment of intraoperative fracture of the acetabulum
Stable cup: Add screws Unstable cup: Fix fracture, upsize cup until stable, add screws
Most common underlying metabolic abnormality in non-union
Vitamin D deficiency
In what position is the hindfoot position during correction of a clubfoot deformity?
Supination. Actually appears to accentuate the deformity but is working to align the plantarflexed first ray which is pushing up the midfoot arch.
What is the critical thing to think about when evaluating a cervical facet dislocation?
Status of the disc. If the disc is intact then you can go posterior to fix if disc is disrupted then you have to go anterior. ALL FACET DISLOCATIONS NEED TO HAVE AN MRI BEFORE SURGERY
Reserve Zone...Associate!
Stores nutrients, low cellular activity Gaucher's, Kniest, Diastrophic Dysplasia
Supercondylar fracture, AIN palsy and vascular compromise (pulseless extremity) - what to do?
Straight to exploration of the antecubital fossa - high risk of attendant vascular injury
Most common bacteria causing neonatal septic arthritis
Streptococcus B
Most common complication of talus fx.
Subtalar Arthritis
Diastrophic Dysplasia....associate!
Sulfate transporter deficiency DTDST Gene Cauliflower ears, hitchhiker thumb Effects proliferative zone of growth plate Severe cervical kyphosis
Structure at risk with creation of the 1-2 wrist portal (between APB and APL)
Superficial Branch of the radial nerve
Lateral tibial plate complication
Superficial peroneal palsy secondary to distal screws
Most commonly injured arterial vessel with APC pelvic fracture?
Superior gluteal artery
Degenerative spondylolisthesis
Superior vertebrae moves anterior relative to the inferior vertebrae (spondylolisthesis) without evidence of a pars fracture. Results in symptoms similar to lumbar stenosis.
Stiff elbow treatment
Supervised PT ---> PT + Static (Turnbuckle) Splinting ---> MUA (Last resort)
Dorsal DRUJ instability is most stable in what position?
Supination. "Am I SUPposed to DRUJ back (dorsal) there!"
Insertion of the LUCL
Supinator Crest
Nerve at greatest risk with posterior capsular release around the shoulder?
Suprascapular Nerve
What artery provides blood flow to a gastrocnemius flap?
Sural artery
Attenuation of the transverse bands results in what condition of the finger?
Swann Neck Deformity. Without the transverse bands the oblique ligament migrates dorsal thereby extending the PIP and causing flexion of the DIP joint.
Smallest thoracic pedicle diameter?
T4-T6
If the thumb is present in what appears to be a radial club hand then what diagnosis are you thinking?
TAR (Thrombocytopenia Absent Radius) Syndrome
What molecular signaler increases fibrosis in muscle?
TGF Beta
Humpback deformity of the scaphoid is best treated through what approach?
Volar approach
Arthrodesis of what hindfoot joint results in the greatest loss of motion?
Talonavicular fusion
Indications for treatment of femoral neck stress fracture?
Tensile Side or >50% compression side. Treat with compression screws..
Elson test?
Test for central slip injury. The finger is held over the edge of a table with the PIP flexed and asked to extend PIP against resistance. If the central slip is injured than the DIP will extend because it transmits force through the lateral bands.
Injury of what ligament leads to a VISI deformity?
The Lunotriquetral ligament. May also be physiologic (unlike DISI deformity)
Varus collapse follow proximal humerus plating can be reduced by including what construct?
The addition of an inferomedial locking screw helps prevent varus collapse and cut out
What structure travels underneath the hook of the hamate?
The deep branch of the ulnar nerve
What nerve root is affected with degenerative spondylolisthesis - traversing or exiting nerve root?
The exiting nerve root is affected most typically due to foraminal recess stenosis
Most common head of the pec major to tear?
The sternocostal head. Maximum tension at 30 degrees of humeral extension (bottom of bench press)
Rotator Cable
Thickened portion of the coracohumeral ligament that runs perpendicular to the distal insertion of the supra and infraspinatus at its insertion
What physical exam result can define internal tibial torsion?
Thigh-Foot Progression Angle < -10 (10 degrees of internal rotation)
TUBS
Traumatic Unidirectional Bankart - (treated with) Surgery
How do you differential ulnar artery thrombosis (ulnar hammer syndrome) versus chronic hook of hamate fx?
Thrombosis results in only sensory symptoms
Posterior labral tear in the setting of non-labral exam findings...treatment
Throwing program / therapy. Apparently very common in throwing athletes but are asymptomatic.
The proper collateral ligament of the MCP joint is tightest at what degree of flexion?
Tightest at 30 degreees
Where does OPG Bind?
To RANKL from the osteoblasts - prevents it from binding to receptors on the osteoclast precursors.
When the hypoglossal nerve is injured during an anterior approach to the spine what is the presenting symptom?
Tongue deviation towards the side of the lesion Mnemonic: "Lick your wounds"
Young patient, hx of dislocation and operative treatment, now with arthritis and apparent loss of motion?....treatment?
Total shoulder arthroplasty. Reverse is for old people unless there is a documented irreparable RC tear.
Glenoid Osteoarthritis with reparable RC tear...treatment?
Total shoulder with concurrent repair
Severs Disease
Traction apophysitis of the calcaneal apophysis
Femoral neck fracture, rotated so difficult to ascertain pattern - what xrays do you order?
Traction internal rotation view. Removes antersion of neck to allow visualization.
McLaughlin Procedure
Transfer of the lesser tuberosity into an unstable reverse Hill-sachs lesion
Treatment of calcaneus deformity in L5 myelodysplastic paitnet
Transfer tibialis anterior posteriorly
ADI >3 (in adult)
Transverse ligament insufficiency
Algorithm for treatment of C1 fx
Transverse ligament intact = Halo immobilization vs. Hard orthosis (includes smashed Jefferson fx, anterior ring fx, etc) Transverse Ligament Disrupted (ADI > 5, Lateral mass displacement > 8.1) = C1/C2 Screw
Most common treatment for thumb CMC arthritis
Trapezium excision (CMC joint resection) + LRTI
AVN w/o significant collapse in the shoulder...treatment
Treat with core decompression and arthroscopy
What structure often prevents closed reduction in MCP dislocations?
Volar plate
Best treatment for elbow stiffness.
Turnbuckle bracing
Predominant collagen type in annulus
Type 1
Predominant collagen type in pulposus
Type 2
Determining treatment for odontoid fractures
Type I: Hard Orthosis Type II (Young): Halo vest Type II (Young + Risk Factor): Screw Type II (Old): Surgery unless contraindicated Type III: Hard Orthosis Non-Union: Posterior screw
Indications for ORIF with occipital condyle fracture
Type III (avulsion type) with disruption of the alar ligments, instability, associated atlanto-axial pathology
Describe central cord syndrome
UE>LE weakness
What nerve is at risk with open reduction of a medial condyle avulsion fracture.
Ulnar Nerve
Treatment of chronic monteggia fx
Ulnar osteotomy + annular ligament reconstruction
Name the components of the TFCC
Ulnotriquetral ligament Radioulnar ligament Ulnolunate ligament ECU sheath Meniscal homolog
If you damage the MCL intraoperatively and are unable to repair what level of constraint is necessary?
Unhinged, high post design. only need hinged when there is multi-directional instability
Supercondylar fracture, pulseless after reduction....associate!
Unreduce and then explore fossa (controversial if pulse resolves after undoing the reduction)
Paraspinal Approach of Wiltse
Used for approach to far lateral disc herniations in the lumbar spine
Varus femoral neck non-union. Tx?
Valgus intertroch osteotomy with blade plate fixation (or another fixed angle device)
Use of a piriformis nail through a troch entry leads to what deformity?
Varus
Most common complication of IM nailing subtroch fracture?
Varus malreduction - secondary to pull of abductors
Most common deformity after talus neck fracture
Varus malunion (correct with medial opening wedge osteotomy)
Typical deformity in talar neck malunion
Varus malunion most common. Dorsal malunion, causes ankle impingement
Maturation Zone (Primary Spongiosa)....Assocations!
Vascular Invasion Metaphyseal corner fractures Scurvy
Treatment of thoracic HNP
Very rare. Must have persistent and progressive neurologic symptoms. Hemicorporectomy + Diskectomy through a transthoracic (anterior) approach - with or without fusion. Treatment associated with interocostal neuralgia
Distinguishing characteristics of NF-1 from NF-2
Vestibular Schwanommas No spine involvement
When is acute bone grafting indicated with both bone forearm fractures?
When there is segmental bone loss and unable to obtain compression.
How do you treat dynamic supination following clubfoot correction?
Whole TA transfer to lateral cuneiform at age 2-4
In what position are the transverse tarsal joints (talonavicular and calcaneocuboid joints) parallel?
With eversion - subtalar joint is unlocked
External fixation for definitive treatment of open tibia fx is associated with....
Worse outcomes (See LEAP study)
Osteoid Osteoma
Woven bone surrounded by osteoblasts, without neoplastic cells or cellular atypia
Causes of hypophosphatemic rickets: genotype and phenotype
X-linked dominant. PHEX. Inability to resorb phosphate. AKA Vitamin D resistant rickets.
Treatment of first webspace soft tissues deficiency
Z-plasty with 60 degree flaps
Where is collagen X located in the physis? What is its function?
Zone of provisional calcification - allows for calcification
Abnormal values for electrodiagnostic studies
distal motor latency of >4.5 msec, a distal sensory latency of >3.5msec, or a conduction velocity of < 52 m/sec. CMV = Cutaneous, Motor, Velocity = 35, 45, 55
