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QuestionHaversian canals carry nerves and blood vessels longitudinally in bone, and Volkmann canals connect different Haversian canals.

QuestionOsteoblasts

QuestionCore binding factor alpha-1/RUNX2

QuestionWnt/Beta-catenin (B-catenin) pathways

QuestionStable B-catenin major role in inducing cells to form osteoblasts

QuestionSclerostin and Dkk-1 inhibit binding of the Wnt molecule to LRP5/6.

QuestionInhibition of sclerostin or Dkk-1 will lead to increased bone mass.

QuestionBMPs work through SMAD to cause osteoblastic differentiation.

QuestionOsteoblasts produce type I collagen (i.e., bone), alkaline phosphatase, osteocalcin, osteonectin, osteoprotegerin (OPG), bone sialoprotein, and RANKL.

QuestionOsteocytes

QuestionOsteoclasts

QuestionCalcitonin, estrogen, transforming growth factor beta (TGF beta), and interleukin also inhibit osteoclast production.

QuestionDenosumab

QuestionOsteoclasts bind to bone surfaces utilizing integrins (vitronectin receptor), effectively sealing the space below and creating a ruffled border (Howship lacunae).

QuestionBone matrix

QuestionBisphosphonates directly inhibit osteoclastic bone resorption. Nitrogen-containing bisphosphonates

QuestionBone matrix comprises 60% inorganic (mineral) and 40% organic components. Calcium hydroxyapatite Ca10(PO4)6(OH)2 constitutes the majority of the inorganic matrix. Type I collagen is 90% of the organic component, and osteocalcin is the most abundant noncollagenous protein in bone.

QuestionWolff’s law

QuestionThere are three major types of bone formation.

QuestionEndochondral formation occurs with a cartilage model. Bone replaces cartilage.

QuestionIiiintramembranous formation occurs without a cartilage model. Aggregates of undifferentiated mesenchymal differentiate into osteoblasts, which form bone.

QuestionAppositional formation increases bone diameter when osteoblasts lay down new bone on existing bone. The groove of Ranvier supplies the chondrocytes.

QuestionFracture stability and degree of strain determine the type of healing. Fracture healing type varies with treatment method.

QuestionPrimary bone healing occurs via Haversian remodeling.

QuestionAbsolute stability compression plate

QuestionSsssecondary bone healing occurs in three stages

QuestionIn closed treatment, healing occurs through periosteal bridging callus and interfragmentary endochondral ossification.

QuestionNonrigid fixation casting, external fixation, intramedullary (IM) nailing

QuestionBMP-2

QuestionNSAIDs adversely affect healing of fractures as well as of lumbar spinal fusions. Cyclooxygenase-2 (COX-2) activity is required for normal endochondral ossification during fracture healing.

QuestionOsteoconductivedacts as a scaffold for bone growth; demineralized bone matrices (DBMs)

QuestionOosteoinstructive growth factors that stimulate bone formation; BMP

QuestionOooosteogenic cells that will produce bone; primitive mesenchymal cells, osteoblasts, and osteocytes

QuestionCalcium phosphate-based grafts

QuestionResorption rates

Questionprimary homeostatic regulators of serum calcium

QuestionBone mass peaks between 16 and 25 years of age. Physiologic bone loss affects trabecular bone more than cortical bone.

QuestionBoth urinary hydroxyproline and pyridinoline cross-links are elevated when there

QuestionSerum alkaline phosphatase increases when bone formation increases.

Questionmost common cause of hypercalcemia

QuestionRenal osteodystrophy

QuestionRickets (in children) and osteomalacia (in adults)

QuestionPremature arrest following growth plate injury

QuestionOsteoporosis

QuestionLoss of function of the OPG gene results in osteoporosis.

QuestionTreatment of osteoporosis includes calcium supplements of

QuestionScurvy results from ascorbic acid deficiency, which causes a decrease in chondroitin sulfate synthesis and, ultimately, defective collagen growth and repair. Widening in the zone of provisional calcification is observed. Basic Sciences 93

QuestionOooosteogenesis imperfecta

QuestionCartilage

QuestionComposed of water (75%) > collagen (25% wet weight, 90%e95%

QuestionCollagen contributes to viscoelastic behavior by restraining

QuestionAggrecan

QuestionIncreases osmotic pressure and

QuestionChondrocytes

QuestionBMP-2 and the transcriptional factor SOX-9 important in regulating differentiation and formation.

QuestionHave cilia that serve as mechanosensory organs or “antennae.”

QuestionZone 1 (superficial)

QuestionZone 2 (middle or transition)

QuestionZone 3 (deep)

QuestionZone 4 (calcified cartilage) contains type X collagen

QuestionIL-1 stimulates MMP, COX-2, and nitric oxide synthetase, which degrades cartilage

QuestionTGF-b stimulates synthesis of ECM and decreased activity of IL-

QuestionPhysiologic loading

QuestionPhysiologic stress stimulates matrix synthesis

QuestionExcess stress promotes chondrolysis

QuestionBoth strenuous loading and underloading lead to cartilage thinning and proteoglycan loss

QuestionFewer chondrocytes but larger

QuestionDecreased chondroitin but increased keratin

QuestionSmaller PG molecules (less able to hold water / decreased compressive strength)

QuestionIncreased advanced glycosylation end products

QuestionIncreased stiffness (modulus of elasticity)

QuestionDecreased keratin but increased chondroitin/keratan ratio

QuestionIncreased water content and permeability initially followed by decreased water content in later stages

QuestionDecreased stiffness (modulus of elasticity)

QuestionOsteophyte formation due to pathologic activation of endochondral ossification by periarticular chondrocytes through Indian hedgehog (Ihh) mechanism

QuestionLubricin

QuestionMajor mode of lubrication in joints

QuestionRheumatoid factor

QuestionAnti-CCP test more sensitive and specific, and presence of antibodies linked to aggressive disease

QuestionTarget TNF-a

QuestionTarget IL-1

QuestionTarget CD20

QuestionRisks of opportunistic infection and lymphoma

QuestionGout

QuestionPseudogout

QuestionA-band represents thick filaments composed of myosin.

QuestionI-band represents thin filaments composed of actin.

QuestionZ-disk represents the terminus of sarcomere.

QuestionMotor unit

QuestionACh diffuses across the synaptic cleft and binds to postsynaptic receptors on sarcolemma, which begin depolarization.

QuestionMasthenia gravis

QuestionBotulinum A reduces spasticity by blocking presynaptic acetylcholine release.

QuestionFollowing muscle injury, TGF-b stimulates proliferation of myofibroblasts and increases fibrosis.

QuestionDelayed-onset muscle soreness

QuestionComposed of water (50%e60%), collagen (75% dry weight, 95%

QuestionElastin

QuestionDecorin

QuestionSheathed tendons

QuestionNote

QuestionFollowing injury, the inflammatory stage

QuestionTendon enthesis responsible for nociception.

QuestionStrong in tension, less viscoelastic than ligaments.

QuestionSimilar in composition to tendon but (1) more water, (2) less total collagen but more type III, and (3) higher PG content.

QuestionFollowing injury, healing ligament demonstrates increased collagen fibers but fewer mature cross-links at 1 year.

QuestionLike tendons, ligaments

QuestionMyelin sheath

QuestionAction potential created when neurotransmitters cross synapse and trigger voltage-gated Naþ channels.

QuestionNucleus pulposus derived from notochord and

QuestionAnnulus fibrosis derived from mesoderm

QuestionAvascular; nutrients and fluid diffuse from vertebral end plates

QuestionEarly degenerative disc disease

QuestionAging disc

QuestionFibronectin cleavage and fragmentation associated with degeneration

QuestionAntibodies against nuclear content (ANAs)

QuestionAlterations in ploidy occur during mitosis and gametogenesis, resulting in conditions such as trisomy-21.

QuestionMarfan syndrome and malignant hyperthermia

QuestionDDDDuchenne muscular dystrophy

QuestionFluorescent in situ hybridization

Questiont(X;18)

Questiont(11;22)

Questiont(12;22)

QuestionBacterial lipopolysaccharide

QuestionAdaptive immunity

QuestionCell-mediated hypersensitivity (type IV) causes reaction to oooorthopaedic implants. II Infection and Microbiology

QuestionRoughly 80% of oooorthopaedic infections

QuestionCA-MRSA at-risk groups

QuestionC-reactive protein

QuestionNecrotizing fasciitis

QuestionRequires early debridement/amputation above level of infection.

QuestionOnly 100 bacteria

QuestionThree basic mechanisms of antibiotic resistance have been identified

QuestionSsssuperantigens like TSS toxin-1 trigger cytokine release from T cells.

QuestionSmoking leads to two to four times more infections/oooosteomyelitis.

QuestionHyperglycemia impairs wound healing and decreases ability to fight infection.

QuestionLyme arthritis can be treated effectively with oral antibiotics. Adults can be given amoxicillin, doxycycline, or cefuroxime for 4 weeks.

QuestionClostridium tetani produces an exotoxin leading to tetanospasm. Td vaccine

QuestionSequestrum

QuestionMRI

QuestionKingella kingae can be difficult to culture; PCR should be considered in a toddler with a septic knee.

QuestionStaphylococcus epidermidis

QuestionAntibiotic therapy according to the Gustilo classification of open fractures

QuestionGustilo I and II

QuestionGustilo IIIA

QuestionGustilo IIIB (grossly contaminated)

QuestionAminoglycosides inhibit translation through irreversible binding of the 30S ribosomal subunit, inhibiting translation of proteins.

QuestionCephalosporins inhibit cell wall production by preventing peptidoglycan cross-linkage.

QuestionGlycopeptides, such as vancomycin, inhibit cell wall production by interfering with the addition of cell wall subunits.

QuestionRifamycin inhibits DNA-dependent RNA polymerase F and displays excellent biofilm penetration. Bacteria develop rapid resistance to rifampin used as monotherapy.

QuestionMacrolides, like erythromycin, bind the 50S ribosomal subunits.

QuestionFluoroquinolones, such as ciprofloxacin, inhibit DNA gyrase.

QuestionBeta-lactam antibiotics, like penicillin, inhibit peptidoglycan synthesis by binding to the bacterial cell membrane surface penicillin-binding proteins.

QuestionVirchow triad

QuestionAspirin irreversibly binds and inactivates COX enzyme in platelets, reducing thromboxane A2.

QuestionWarfarin can be reversed with fresh frozen plasma and vitamin K.

QuestionHeparin and low-molecular-weight heparin act through ATIII and can be reversed by protamine sulfate.

QuestionRivaroxaban

QuestionLactate

QuestionRatio of 1

QuestionFat embolism syndrome classical triad 1⁄4 petechial rash, neurologic symptoms, respiratory decline.

QuestionMalignant hyperthermia

QuestionCaused by an uncontrolled release of calcium

QuestionTriggered by volatile anesthetics (and succinylcholine)

QuestionEarly sign

QuestionTreatment

QuestionImaging of larger body parts

QuestionPositioning the eeeextremity closer to the x-source

QuestionUse of large C-arm rather than mini C-arm

Question3.0 T MRI

QuestionWork

QuestionEnergy

QuestionPotential energy

QuestionKinetic energy is energy caused by motion

QuestionStress

QuestionStrain

QuestionYoung’s modulus of elasticity (E) 1⁄4 stress/strain.

QuestionUnique for every material

QuestionHigh E to low E

QuestionViscoelastic materials have a stress-strain behavior that

QuestionIsotropic materials have mechanical properties that

QuestionAnisotropic materials

QuestionGalvanic corrosion occurs when dissimilar metals

QuestionCrevice corrosion occurs in fatigue cracks with low oxygen tension.

QuestionFretting corrosion comes from small movements abrading the outside layer.

QuestionStress corrosion occurs in areas with high-stress gradients.

QuestionHip

QuestionKnee

QuestionAnkle

QuestionSshoulder

QuestionElbow

QuestionWrist

QuestionThe mnemonic “SAME” can be used to help understand the function of nerves: sensory 1⁄4 afferent; motor 1⁄4 efferent.

QuestionSuprascapular notch

QuestionCoracoacromial ligament

QuestionBeware of the anterosuperior glenoid labral variant may cause loss of external rotation.

QuestionPosterior sternoclavicular ligament

QuestionConoid ligament

QuestionRadial head should line up with capitellum at all arm positions in all radiographic views.

QuestionAnterior bundle of ulnar collateral ligament

QuestionOssification of the bones of the wrist begins at the capitate (usually present at 1 year of age) and proceeds in a counterclockwise direction, according to posteroanterior radiographs of the right hand.

QuestionSpace of Poirier

QuestionLoss of reduction of the radiocarpal joint

QuestionAt the level of the wrist, FDS to the middle and ring fingers are volar to FDS to index and small fingers.

QuestionFour preclavicular brachial plexus branches

QuestionAll minor medial and lateral cord branches

QuestionInnervation of all rotator cuff muscles derived from C5 and C6 of the brachial plexus.

QuestionLateral winging due to spinal accessory nerve injury (cranial nerve XI) usually due to iatrogenic injury from neck surgery; medial winging is long thoracic.

QuestionAxillary nerve passes anterior to subscapularis muscle and inferior to sshoulder capsule, traveling from anterior to posterior through quadrangular space. Anterior branch passes around humerus approximately 7 cm distal to acromion.

QuestionPIN splits the supinator and supplies all of the extensor muscles except the mobile wad (brachioradialis, ECRB, ECRL).

QuestionSuperficial branch of the radial nerve emerges through antebrachial fascia approximately 6 to 9 cm proximal to the radial styloid. Runs between the brachioradialis and ERCL to supply sensation to the dorsal radial surface distal forearm and hand.

QuestionAnterior interosseous nerve branches 4 cm distal to elbow and runs between the FPL and FDP; supplies all the deep flexors except the ulnar half of the FDP. Terminates in the PQ.

QuestionUlnar nerve enters the forearm between the two heads of the FCU (humeral and ulnar).

QuestionEach part of the axillary artery

QuestionDigital arteries arise from superficial palmar arch and run dorsal to digital nerves.

QuestionDuring anterior approach to sshoulder, watch out for musculocutaneous nerve piercing deep aspect of conjoint tendon about 5 cm distal to coracoid and axillary nerve traveling through quadrangular space.

QuestionKeep dissection above teres minor during posterior approach to sshoulder to avoid quadrangular space.

QuestionBrachialis may be split because it

QuestionDo not extend posterolateral (Kocher) approach to elbow distal to annular ligament to avoid risk of PIN injury.

QuestionIliac spine separates greater and lesser sciatic notch; sacrospinous ligament (anterior sacrum to ischial spine) separates greater and lesser sciatic foramina.

QuestionPediatric femoral nail insertion at piriformis fossa threatens the posterosuperior retinacular vessels (potential for femoral head AVN).

QuestionPosterior approach to the hip, quadratus transection leads to potential damage of MFCA which could jeopardize blood flow to the femoral head.

QuestionSlipped capital femoral epiphysis occurs through the femoral head physis (zone of hypertrophy).

QuestionDistal femur

QuestionIliofemoral ligament

QuestionThree lower eeeextremity muscles with dual innervation

QuestionShape of tibial plateau confers greater articular congruity medially than laterally (important when considering consequences of meniscectomy).

QuestionMedial meniscus tears three times more often than the more mobile lateral meniscus.

QuestionACL

QuestionPosterior oblique ligament resists internal rotation and provides valgus stability, balances the medial side of the knee in full extension.

QuestionPCL

QuestionMPFL runs from proximal third of medial patella to Schottle point on the femur (between adductor tubercle and medial epicondyle); just distal to vastus medialis obliquus.

QuestionGroove posterior for the tendon of the FHL. Os trigonum (if present) lateral to FHL.

QuestionPrimary blood supply to the talar body

QuestionSustentaculum tali of calcaneus supports the middle articular surface above it and has an inferior groove for the FHL tendon. Anatomy 213

QuestionIiiintermediate cuneiform does not extend as far distally as the medial cuneiform, which allows the second metatarsal to

QuestionBony avulsion of AITFL in adolescents may result in a Tillaux fracture.

QuestionCFL crosses both the ankle and the subtalar joint.

QuestionPlantar calcaneonavicular ligament (spring ligament) supports head of talus; attenuated in pes planus deformity.

QuestionLisfranc ligament connects medial (shortest) cuneiform to second (longest) metatarsal. No ligamentous connection between first and second metatarsal bases.

QuestionDigital nerve courses in a plantar direction under the transverse metatarsal ligament and is the spot where interdigital neuritis (Morton neuroma, usually the second or third interdigital space) occurs.

QuestionL5 nerve root on anterior sacrum

QuestionPpppudendal nerve, internal ppppudendal artery and vein, and nerve to obturator internus exit the greater sciatic foramen and reenter the lesser foramen.

QuestionFemoral nerve lies between the iliacus and psoas muscles. Iliacus hematoma may irritate the femoral nerve because of its proximity.

QuestionPain from the hip can be referred to the knee as a result of the continuation of the obturator nerve anteriorly, which can provide sensation to the medial side of the knee.

QuestionSciatic nerve passes anterior to piriformis and posterior to obturator internus and short external rotators.

QuestionTibial nerve supplies all intrinsic foot muscles except the EDB (deep peroneal nerve) and plantar sensation.

QuestionMost proximal branch of the lateral plantar nerve

QuestionSuperior gluteal nerve approximately 5 cm proximal to greater trochanter. Injury leads to Trendelenburg gait from gluteal dysfunction.

QuestionObturator artery and vein jeopardized by anteroinferior screws and acetabular retractors.

QuestionCorona mortis

QuestionAscending branch of LFCA (at risk for injury during iinterolateral approaches) proceeds to greater trochanteric region between TFL and rectus femoris.

QuestionNormal spine sagittal alignment

Question50% of total neck flexion and extension occurs at occiputeC1 articulation; 50% of total neck rotation occurs at atlantoaxial (C1e2) articulation.

QuestionVertebral artery travels in the transverse foramina of C6 to C1 (not C7).

Question66% of lordosis occurs in the region from L4 to the sacrum.

QuestionLumbar spine the superior articular facet

QuestionIntradiscal pressure lowest in supine position and highest in the sitting position and flexed forward with weights on the hands.

QuestionIn cervical spine, numbered nerve exits above the pedicle of the corresponding vertebral level. In the lumbar spine, the nerve exits under the pedicle.

QuestionThe distance from the spinous process of C1 laterally to the vertebral artery is 2 cm (a safe distance for dissections would therefore be less than 2 cm).

QuestionInjury to the recurrent laryngeal nerve with right-sided approaches (paralysis

QuestionMost commonly injured cranial nerve with halo traction

QuestionLack of biceps function 6 months after injury and presence of Horner syndrome carry a poor prognosis in brachial plexus palsy.

QuestionSprengel deformity

QuestionApert syndrome

QuestionIn-toeing due to increased femoral anteversion (most common), internal tibial torsion, and metatarsus adductus.

QuestionOut-toeing due to hip external rotation contracture (infants) and external tibial torsion; caution with unilateral out-toeing (potential sign of slipped capital femoral epiphysis [SCFE]).

QuestionLimb length discrepancies can be calculated on the basis of remaining growth, with the assumptions that females mature at age

QuestionProximal femur

QuestionDistal femur

QuestionProximal tibia

QuestionRisk factors for developmental dysplasia of the hip (DDH) include breech positioning, firstborn child, female gender, and family history.

QuestionObstructions to closed reduction for DDH include iliopsoas tendon, pulvinar, hypertrophied ligamentum teres, contracted inferomedial capsule, transverse acetabular ligament, and inverted labrum.

QuestionPavlik harness treatment

QuestionHyperflexion can cause femoral nerve palsy.

QuestionIf unsuccessful in helping with reduction, can cause posterior wear of the acetabulum; proceed with closed reduction and casting under general anesthesia.

QuestionMost prognostic classification for Legg-Calvé-Perthes disease

QuestionMaintaining sphericity of the femoral head

QuestionSCFE occurs with weakness in the perichondral ring and slippage through the hypertrophic zone of the growth plate.

QuestionApproximately 25% of SCFE cases

QuestionTreatment for SCFE includes pinning in situ; advanced treatments including surgical dislocation and reorientation are associated with significant risk for avascular necrosis.

QuestionBlood culture medium

QuestionMethicillin-resistant Staphylococcus aureus with a PVL gene mutation

QuestionJoints with intraarticular metaphyses

QuestionBlount disease treatment includes bracing for patients with stage I or II disease who are younger than 3 years; patients with stages IV and V frequently require multiple procedures.

QuestionPosteromedial bowing

QuestionAiiinteromedial bowing

QuestionAiiinterolateral bowing

QuestionHealing rates for osteochondritis dissecans

QuestionCAVEdcavus, adduction of forefoot, varus of hindfoot, equinus.

QuestionAlso represents order of correction in Ponseti method.

QuestionMost cases require Achilles tenotomy at end of casting.

QuestionAssociated with absence of or diminutive anterior tibial artery.

QuestionFoot abduction brace critical for preventing recurrence.

QuestionRecurrence treated with trial of recasting. II Pes Cavus

QuestionUp to 67% of cases due to neurologic disorder.

QuestionCharcot-Marie-Tooth disease most common (PMP22).

QuestionSpinal magnetic resonance imaging (MRI) required to evaluate. III Congenital Vertical Talus

QuestionIrreducible dorsal dislocation of the navicular on the talus.

QuestionNavicular does not reduce on forced plantar-flexion lateral view.

QuestionInitial treatment with serial manipulation and casting followed by limited surgery consisting of percutaneous Achilles tenotomy and minimal talonavicular capsulotomies and pin fixation. IV Tarsal Coalition

QuestionSinus tarsi pain caused by peroneal spasticity, flatfoot, and multiple ankle sprains.

QuestionLimited subtalar motion on examination.

QuestionComputed tomography best study for assessing talocalcaneal (TC) coalitions.

QuestionLess than 50% of the middle facet involved

QuestionMore than 50% of the middle facet involved

QuestionDorsiflexed (calcaneus) hindfoot.

QuestionIn contrast to congenital vertical talus, in which hindfoot

QuestionAssociated with posteromedial bowing of tibia and leg length discrepancy (most common cause of surgical treatment). VI Kohler Disease (Oosteonecrosis of Navicular)

QuestionSclerosis and flattening of navicular.

QuestionSpontaneous resolution; can be treated with immobilization. VII Pes Planus

QuestionAsymptomatic patients should be monitored with observation.

QuestionSymptomatic patients

QuestionAbnormal neurologic findings, left thoracic curves, or painful or rapidly progressive curves should prompt an MRI study. Pediatric Ooooooorthopaedics 281

QuestionSkeletally immature patients with curves less than 20 to 25 degrees.

QuestionSkeletally mature patients with curves less than 45 to 50 degrees.

QuestionBracing for curves of more than 25 degrees or of 20 degrees with documented progression in skeletally immature patients (Risser stages 0e2).

Question90% effective when worn more than 12 to 13 hours/day.

QuestionSurgery (posterior spine fusion) for curves greater than 50 degrees.

QuestionIiiintraoperative spinal cord monitoring

QuestionIf changes occur iiiintraoperatively, the surgical team should check leads, raise blood pressure, transfuse, reverse steps of surgery, and reassess. II Infantile Idiopathic Scoliosis

QuestionIdiopathic scoliosis that manifests before age 4 years.

QuestionMost curves resolve spontaneously.

QuestionRib-vertebra angle difference predicts risk of progression.

QuestionLess than 20 degrees

QuestionMore than 20 degrees

QuestionInitial treatment with Mehta derotational cast. III Congenital Spinal Deformities

QuestionHigh incidence of associated abnormalities.

QuestionIntraspinal abnormality

QuestionCardiac system

QuestionGenitourinary system

QuestionUnilateral bar with contralateral fully segmented hemivertebrae associated with rapid and severe progression. IV Neuromuscular Scoliosis

QuestionDDDDuchenne muscular dystrophy.

QuestionSurgery indicated when curve

QuestionCurve progression

QuestionCerebral palsy (CP)

QuestionFusion from T2 to the pelvis in nonambulatory children.

QuestionHigh complication rates but improved caregiver satisfaction. V Cervical Spine Disorders A Klippel-Feil

QuestionAbnormalities in multiple cervical segments as a result of failure of normal segmentation or formation of cervical somites at 3 to

QuestionAssociated with renal and congenital heart disease, auditory issues, and Sprengel deformity.

QuestionWith multilevel fusion of the cervical spine, any involvement of C2, or limited cervical motion, collision sports should be avoided. B Atlantoaxial Rotatory Displacement Or Subluxation

QuestionSymptoms for less than 1 week

QuestionSymptoms for between 1 and 4 weeks

QuestionSymptoms for longer than 1 month

QuestionIrreducible dislocation of C1eC2 or recurrent instability of C1eC2

QuestionSeen in athletes who use hyperextension.

QuestionPatient with high-grade listhesis (>50%) may

QuestionMost important determinant for nonunion and pain.

QuestionAngle larger than 45 to 50 degrees associated with greater risk of slip progression, instability, and development of postoperative pseudarthrosis.

QuestionSum of pelvic tilt (PT) and sacral slope (SS)

QuestionIncreased PI may predispose to spondylolisthesis.

QuestionAcute spondylolysis treated with an antilordotic brace (thoracolumbosacral orthosis with thigh extension). VII Other Spinal Conditions A Infectious Spondylitis

QuestionLoss of lumbar lordosis

QuestionNight pain relieved by nonsteroidal anti-inflammatory drugs; central nidus <2 cm with ring of lucency on imaging.

QuestionCan be associated with scoliosis. C Sacral Agenesis

QuestionAssociated with maternal diabetes.

QuestionMotor impairment

QuestionMRI of the brain in children with CP commonly reveals periventricular leukomalacia.

QuestionBotulinum toxin’s mechanism of action

QuestionCP hips at risk include those with abduction of less than 45 degrees and those with uncovering of the femoral head on radiographs.

QuestionLowest functional level in myelodysplasia

QuestionMmmmyelomeningocele

QuestionDDDDuchenne muscular dystrophy

QuestionFriedreich ataxia

QuestionMost common disproportionate short-limbed dwarfism.

QuestionMost commonly caused by mutation in fibroblast growth factor receptor 3 (FGFR3) gene.

QuestionLeads to a gain-of-function mutation or uncontrolled activation.

QuestionThoracolumbar kyphosis usually resolves at time of ambulation.

QuestionPelvic radiographs

QuestionDefect of cartilage oligomeric matrix protein (COMP) on chromosome 19. III Multiple Epiphyseal Dysplasia

QuestionMost common gene mutation

QuestionCan be confused with Legg-Calvé-Perthes disease. Multiple epiphyseal dysplasia

QuestionMost autosomal recessive (except Hurler syndrome, which

QuestionPreoperative cervical spine radiographs should always be obtained in the patient with Morquio syndrome, who may have upper cervical instability. V Diastrophic Dysplasia

QuestionDeficiency in DTDST gene, which codes for sulfate transport protein.

QuestionAssociated with rigid clubfeet, cauliflower ears, and hitchhiker’s thumb. VI Oooosteopetrosis

QuestionFailure of osteoclastic resorption leading to dense bone (so-called marble bone).

Questionmild form

QuestionMost common mutation in malignant form

QuestionMost common chromosomal abnormality.

QuestionAssociated with generalized laxity, pes planus, patellar and hip instability.

QuestionAtlantodens interval (ADI) less than 4.5 mm

QuestionADI 4.5 to 10 mm

QuestionADI over 10 mm or symptoms/cord signal changes on MRI

QuestionComplication rate of up to 50% reported. II Marfan Syndrome

QuestionDefect in fibrillin-1 (FBN1).

QuestionAutosomal dominant inheritance.

QuestionAssociated with pectus deformities, scoliosis, acetabular protrusion.

QuestionEchocardiographic and cardiologic evaluation

QuestionMutation of chromosome 11 near the IGF gene.

QuestionHemihypertrophy, spasticity, organomegaly, omphalocele, macroglossia.

QuestionPredisposition to Wilms tumor (patient must be screened regularly with kidney ultrasonography).

QuestionMutation in both alleles of the b-globin gene, resulting in sickle hemoglobin (HbS).

QuestionSickle cell trait

QuestionMore severe but less common than sickle cell anemia (8% prevalence).

QuestionAt risk for exertional sickling (treat with oxygen and hydration) and sudden death.

QuestionOooosteomyelitis

QuestionShort stature and genu varum.

QuestionPhyseal widening and metaphyseal cupping on radiographs.

QuestionX-linked hypophosphatemic (vitamin Deresistant) rickets

QuestionDefect in type I collagen (COL1A1 and COL1A2 genes) that causes abnormal cross-linking and leads to decreased collagen secretion.

QuestionBlue sclerae in types I and II.

QuestionBasilar invagination in more severe types.

QuestionBisphosphonates reduce the incidence of fractures. IV Juvenile Idiopathic Arthritis

QuestionPersistent noninfectious arthritis without other etiology lasting longer than 6 weeks.

QuestionCommonly involves the knee, wrist (flexed and ulnar deviated), and hand (fingers extended, swollen, radially deviated).

QuestionOphthalmology consultation with slit-lamp examination

QuestionCervical spine involvement can lead to kyphosis, facet ankylosis, and atlantoaxial subluxation. Pediatric Ooooooorthopaedics 283

QuestionThe most common causes of an acute hemarthrosis

Questionvascular supply of the meniscus

Questiongold sstandard for meniscal repair

QuestionACL anatomy

Questionsuperficial medial collateral ligament origin

Questionposterior oblique ligament

Questionmedial patellofemoral ligament (MPFL) femoral attachment

Questionlateral collateral ligament (LCL) femoral origin

Questionpopliteus femoral insertion

Questionposterior horn of the medial meniscus

QuestionOpening of the knee to varus or valgus stress testing at only 30 degrees of knee flexion indicates an isolated collateral injury. Opening of the knee in full extension indicates a combined cruciate and collateral injury.

QuestionDuring knee arthroscopy, the posterolateral compartment can be best visualized by placement of the arthroscope through the interval of the ACL and lateral femoral condyle or a posterolateral portal.

QuestionPartial meniscectomy increases peak stresses in the affected compartment.

Questiongold sstandard for meniscal repair

QuestionMeniscal cysts occur primarily in conjunction with horizontal cleavage tears of the lateral meniscus.

QuestionDiscoid menisci should be observed if asymptomatic.

QuestionIf meniscal transplantation

QuestionFollowing meniscal transplantation, allograft tissue often remains hypocellular or acellular. The most common complication is meniscal tear.

QuestionACL injury rate

QuestionLachman test

QuestionMagnetic resonance imaging (MRI) evaluation of ACL injuries demonstrates characteristic “bone bruises” in more than half of cases; these bruises are typically located near the sulcus terminalis on the lateral femoral condyle and the posterolateral aspect of the tibia.

QuestionInitial management consists of physical therapy for mobilization. Immobilization

QuestionA more horizontal graft position may reduce rotational instability.

QuestionBoneepatellar tendonebone autografts demonstrate faster incorporation into the bone tunnels than do hamstring autografts and are often the graft of choice for patients desiring an early return to sports activity.

Questionmost common technical error in ACL surgery

QuestionArthrofibrosis

QuestionThere is no high-level evidence to suggest that ACL reconstruction reduces the risk of arthritis.

QuestionACL rehabilitation should avoid open kinetic chain quadricepsactivating exercises from 0 to 30 degrees of knee flexion.

QuestionPosterior cruciate ligament (PCL) injuries often result from a fall onto the ground with a plantar-flexed foot.

QuestionPCL reconstruction should be reserved for functionally unstable knees or combined injuries. Single-bundle reconstructions should be tensioned in 90 degrees of flexion. Tibial inlay has biomechanical advantages, such as avoiding the killer turn.

QuestionPCL rehabilitation should avoid open kinetic chain hamstringactivating exercises.

QuestionMultiple-ligament knee injuries require an immediate neurovascular examination. Vascular consultation should be obtained in any patient with absence of pulses or an ankle-brachial index less than 0.9.

QuestionChronic grade III posterolateral corner injuries often necessitate a valgus open-wedge osteotomy.

QuestionOsteochondritis dissecans should be monitored in children with open physes. Adult lesions do not resolve and should be treated. The most common location is the lateral aspect of the medial femoral condyle.

QuestionMarrow-stimulating techniques, including microfracture, drilling, and abrasion arthroplasty, involve perforation of the subchondral bone after removal of the “tidemark” cartilage, with eventual clot formation and fibrocartilaginous repair tissue (type I collagen with inferior wear characteristics).

QuestionNo definitive research

QuestionPatellar tendinitis

QuestionIliotibial band friction syndrome manifests as localized tenderness at the lateral femoral condyle that is worse with the knee flexed 30 degrees.

QuestionMRI evaluation of patellar dislocation demonstrates a classic bone bruise pattern involving the lateral femoral condyle and medial patella.

QuestionPatellofemoral pain syndrome

QuestionConservative management

QuestionLateral patellar facet compression syndrome should be treated with a lateral release only in the setting of objective evidence of lateral tilt that has not responded to extensive nonoperative management. Lateral tilt is best evaluated by measuring the lateral patellofemoral angle.

QuestionQquadriceps contusions

QuestionAthletic pubalgia (sports hernia)

QuestionMRI

QuestionFemoral neck stress fractures that occur on the inferior surface (compression side) can be treated nonoperatively.

QuestionFemoroacetabular impingement manifests as groin pain and limited range of motion (ROM), especially in flexion and internal rotation. A positive result of an anterior impingement test is reproduction of symptoms with passive flexion, adduction, and internal rotation.

QuestionExternal snapping hip occurs when the iliotibial band abruptly catches on the greater trochanter, whereas internal snapping hip occurs when the iliopsoas impinges on the hip capsule.

QuestionComplications of hip arthroscopy typically result from traction injuries or iatrogenic neurovascular injury from aberrant portal placement. Use of an anterior portal puts the lateral femoral cutaneous nerve at risk. Use of an iinterolateral portal puts the superior gluteal nerve at risk. Use of a posterolateral portal puts the sciatic nerve at risk, especially when the hip is externally rotated.

Questionmost common location for an os acromiale

QuestionHumeral head blood supply

QuestionThe contents of the rotator interval include the coracohumeral ligament (CHL), superior glenohumeral ligament (SGHL), biceps tendon, and glenohumeral capsule. The SGHL and CHL limit inferior translation and external rotation when the arm is adducted and posterior translation when the arm is flexed forward, adducted, and internally rotated. Rotator interval closure results in decreased external rotation in sshoulder adduction and posteroinferior translation.

QuestionThe inferior glenohumeral ligament (IGHL) complex serves as the primary restraint to anterior, posterior, and inferior glenohumeral translation at 45 to 90 degrees of glenohumeral elevation. The anterior IGHL is important in external rotation, and the posterior IGHL in internal rotation.

QuestionIn the throwing sshoulder, the scapula must rotate during throwing. It retracts during the late cocking phase and then protracts during the acceleration phase. The deceleration phase is associated with tensile failure of the posterior aspect of the supraspinatus and anterior half of the infraspinatus.

QuestionIn sshoulder arthroscopy, the posterior portal puts the axillary nerve, suprascapular nerve, and suprascapular artery at risk.

QuestionTraumatic anterior sshoulder dislocations typically result when the arm

QuestionInstability

QuestionA humeral avulsion of the glenohumeral ligaments lesion

QuestionAge at time of initial dislocation

QuestionSeveral open and arthroscopic techniques

QuestionRemplissage involves tenodesis of the posterior capsule and infraspinatus into a Hill-Sachs lesion. Precise indications are not yet defined, but early evidence suggests medium to large or engaging Hill-Sachs lesions.

QuestionPost-thermal capsular necrosis

QuestionPhysical examination for posterior instability includes load-and-shift and jerk testing.

QuestionA fixed posterior sshoulder dislocation

QuestionFor chronic unrecognized posterior dislocations, several procedures may be performed, depending on the extent of bone loss both in the humeral head and glenoid. The Neer modification of the McLaughlin procedure involves transfer of the lesser tuberosity and associated subscapularis tendon into the reverse Hill-Sachs lesion.

QuestionMultidirectional instability should be treated with extended rehabilitation that focuses on scapular stabilization before operative intervention is considered. Closed kinetic chain exercises should be emphasized.

QuestionThe prevalence of asymptomatic rotator cuff tears increases with age

QuestionAsymptomatic full-thickness rotator cuff tears should be treated nonoperatively. The primary indication for surgical intervention is significant pain.

QuestionBlood flow to the repaired rotator cuff

QuestionAcute rotator cuff tears should be repaired early because the disease process is accelerated in this setting.

QuestionPatients receiving a corticosteroid injection within 6 months of rotator cuff repair are more likely to undergo revision rotator cuff repair.

QuestionStudies of rotator cuff repair rehabilitation show no difference in clinical outcomes or healing rates between early motion and delayed motion protocols.

QuestionIrreparable combined tears of the supraspinatus and infraspinatus may be treated with latissimus dorsi tendon transfer to the greater tuberosity. If pain is the major symptom and motion remains preserved, débridement with biceps tenotomy has been found to be useful. Inferior results have been reported for latissimus transfer in the patient with a subscapularis tear.

QuestionSigns of a subscapularis tear include increased external rotation and the presence of a liftoff, modified liftoff, or belly-press sign. The appearance of an empty bicipital groove on axial MRI with tear of the transverse humeral ligament is often associated with subscapularis tear. At arthroscopy, a chronic subscapularis tear can be signified by the comma sign, which represents an avulsed SGHL and CHL (so-called comma tissue).

QuestionAthletes who participate in throwing activities

QuestionInternal impingement

QuestionSuperior labrum from anterior to posterior (SLAP) tear management

QuestionBiceps tenotomy without tenodesis

QuestionFor type III acromioclavicular separations, recommended management

QuestionDistal clavicle resection for acromioclavicular joint arthritis should entail resection of less than 1 cm of the distal clavicle to preserve the posterior-superior capsule and avoid anterior and posterior instability and pain.

QuestionSternoclavicular dislocation

QuestionCalcifying tendinitis

QuestionFrozen sshoulder histologic evaluation demonstrates evidence of inflammation and fibrosis. There is a dense matrix of type III collagen containing fibroblasts and myofibroblasts that appear similar to those in Dupuytren disease. On examination, active ROM and passive ROM are equivalent.

QuestionSuprascapular nerve compression by a ganglion in the spinoglenoid notch affects only the infraspinatus. Compression caused by a cyst in association with a SLAP lesion may respond to arthroscopic decompression and labral repair.

QuestionQquadrilateral space syndrome

QuestionMedial scapular winging

QuestionFor total sshoulder arthroplasty, lesser tuberosity osteotomy and subscapularis peel

QuestionReverse total sshoulder arthroplasties medialize the center of rotation, and inferior placement of the baseplate further allows for improvement of deltoid efficiency.

Questionhistory and physical examination

QuestionHypertrophic cardiomyopathy

QuestionAny athlete with diagnosed concussion

QuestionSickle cell trait

QuestionAdverse effects of anabolic steroids include liver dysfunction, hypercholesterolemia, cardiomyopathy, testicular atrophy, gynecomastia, acne, mood disturbances (particularly increased aggression), and irreversible alopecia. Heart disease results from increased plasma levels of low-density lipoprotein cholesterol and decreased levels of high-density lipoprotein cholesterol.

QuestionThe female athlete triad consists of low energy availability (with or without an eating disorder), menstrual dysfunction, and altered bone mineral density. Insufficient caloric intake is the most common cause of ssssecondary amenorrhea.

QuestionMethicillin-resistant Staphylococcus aureus transmission occurs by direct person-to-person contact through disruptions in skin integrity.

QuestionAthletes with infectious mononucleosis should be restricted from contact sports participation for 3 to 5 weeks, and splenomegaly must have resolved before they return to play/sport.

QuestionHeat stroke

QuestionImpingement test result

QuestionRadiographs

QuestionMRI may be indicated for suspected osteonecrosis, labral pathology in the absence of significant arthritis, gluteus medius tears, and possible stress or insufficiency fractures.

QuestionDysplasia typically involves a shallow acetabulum with lateral and anterior uncoverage of the femoral head.

QuestionSurgical correction of the dysplastic acetabulum

Questionmajority of patients with FAI

QuestionSurgical treatment of FAI varies according to pathoanatomy; labral repair or reconstruction is preferable to labral resection when possible.

QuestionTHA

QuestionEnd-stage result of vascular occlusion of the juxtaarticular sinusoids adjacent to the femoral head.

QuestionStaging

QuestionJoint-preserving strategies such as core decompression and free vascularized fibular grafting should be reserved for precollapse disease.

QuestionTransient osteoporosis of the hip shows diffuse signal change on MRI and is treated nonoperatively.

QuestionConservative management includes activity modification, weight loss, NSAIDs, and intraarticular steroid injections; evidence does not support routine use of glucosamine sulfate.

QuestionArthroscopy

QuestionHip aaaarthrodesis

QuestionSubsequent conversion of hip aaaarthrodesis to THA

QuestionHemiarthroplasty

QuestionDifferent surgical approaches

Questiondirect anterior approach

Questionposterior approach

QuestionCementless fixation

QuestionCemented fixation of the femoral component

QuestionBone ingrowth requires live host bone, an appropriate ingrowth surface on the implant, and initial rigid fixation; motion of the prosthesis within the bone will lead to fibrous fixation or encapsulation.

QuestionHydroxyapatite

QuestionFemoral stress shielding leads to loss of proximal bone density and results from modulus mismatch between stem and femoral bone.

QuestionFemoral stem breakage occurs from cantilever bending.

QuestionStart-up pain

QuestionSegmental acetabular bone deficiency

QuestionHemispheric porous cup with multiple screw fixation

QuestionModular porous metal constructs

QuestionCustom triflange cups may be used in cases with severe bone loss in which defect-matching techniques (such as modular metal constructs) are limited.

QuestionScrews placed into the anterior-superior quadrant (the so-called zone of death) risk laceration to the external iliac artery and veins, which can be fatal.

QuestionPelvic discontinuity, which occurs when the superior aspect of the pelvis is separated from the inferior pelvis, is a challenging problem and may be addressed with cup-cage constructs, custom triflange components, and/or distraction techniques.

QuestionMost femoral revisions

QuestionIrradiation of PE creates free radicals, which result in cross-linking.

QuestionHighly cross-linked PE

QuestionSubmicron-sized PE particles

QuestionVolumetric wear

QuestionWith HCLPE, wear rates tend to remain below the osteolytic threshold even with large femoral heads (36 mm or greater).

QuestionTreatment of PE wear involves head and liner exchange when the implants are well fixed and well positioned; dislocation is the most common postoperative complication.

QuestionMetal debris from MOM bearings

QuestionSstandard evaluation for a painful MOM THA or suspected trunnionosis includes serum cobalt and chromium levels, as well as MRI with MARS.

QuestionCeramic-on-ceramic bearings

QuestionDual-mobility components increase the impingement-free range of motion, as well as the jump distance, which should decrease the rate of dislocation.

QuestionTrunnion corrosion (trunnionosis) results from fretting corrosion and metal ion release at the modular junction between the femoral head and stem; patients may experience adverse local soft tissue responses and pseudotumors; treatment involves revision of the metal femoral head to a ceramic head with a titanium sleeve adaptor.

QuestionIiiintraoperative fracture

QuestionEarly postoperative fracture

QuestionVancouver classification

QuestionA loose stem requires revision to a new femoral component; if the stem remains well fixed, ORIF of the fracture is performed.

QuestionRisk for sciatic nerve palsy increases with lengthening of the leg by more than 3 to 5 cm.

QuestionA nerve palsy that develops postoperatively may be due to hematoma, for which emergency evacuation is required.

QuestionThere is no effective treatment for heterotopic ossification in the early postoperative period once the process has started; resection may be performed later, once the process is mature or stable on serial radiographs.

QuestionIliopsoas impingement

QuestionTreatment of iliopsoas impingement depends upon whether there

QuestionPrimary arc of hip motion must be centered within patient’s functional range to avoid impingement.

QuestionBest stability

QuestionAbductor complex

QuestionPatients with fixed spinopelvic alignment during movement from standing to sitting position are at increased risk for instability.

QuestionThe treatment of instability involves identifying the reason for dislocation; malpositioned implants should always be revised; constrained liners should be reserved as a last resort for patients with soft tissue dysfunction.

QuestionWeight-bearing x-rays

QuestionWeight-bearing 45 degrees posterior to anterior (with x-ray plate positioned parallel to tibia) is the next step when knee pain is significant and standing radiographs do not reveal notable narrowing.

QuestionKL classification for knee OA

QuestionReview Table 5.7, the 4-star recommendations for nonoperative treatment of OA; these recommendations have high levels of evidence for test.

QuestionKnee realignment osteotomy

QuestionThe most common complication of proximal tibial osteotomy (open and closed techniques) is patella baja.

QuestionRemember

QuestionWith the ACL and PCL intact, recreating the native posterior slope is required in order to maintain native knee kinematics.

Questionabsolute contraindication to UKA

QuestionFor test questions, look at suprapatellar pouch on x-rays for an extruded PE bearing.

QuestionTo correct varus deformity, a medial compartment release

QuestionSuperficial MCL

QuestionPosterior oblique portion

QuestionAnterior portion

QuestionTo correct valgus deformity, a lateral compartment release

QuestionIliotibial band and popliteus

QuestionIliotibial band

QuestionPopliteus

Questionmost efficient way to answer the gap imbalance questions

QuestionSymmetrical gap problemTibia adjusted first.

QuestionAsymmetrical gap problemFemur adjusted first.

QuestionFor board questions, only learn the single-step solutions (Table 5.9).

QuestionReview Table 5.10, the 4-star recommendations for surgical management of OA; these recommendations have high levels of evidence for test. Perioperative Nerve Blocks:

QuestionFemoral nerve blockdmotor and sensory blockdknee will buckle with walking.

QuestionA knee immobilizer

QuestionAdductor nerve block sensory block onlydknee will not buckle with walking. Complications:

QuestionThe deformity most likely to cause peroneal nerve palsy in TKA is a combined valgus flexion deformity.

QuestionWhen nerve palsy

QuestionWith a lateral retinacular release in TKA, the artery at risk for transection is the lateral superior genicular artery; increases risk for osteonecrosis of the patella.

QuestionFor arthrofibrosis following primary TKA, manipulation of the knee should be performed between 4 and 12 weeks.

QuestionOsteolysis in TKA manifests later in life of implant (7e15 years); radiographs show round lytic lesions behind implant (most common site is behind posterior femoral condyle). Adult Reconstruction 477

Question#1

Question#2

Question#3

Question#4

QuestionFor a PDFFx where the implant

QuestionSubmuscular plating

QuestionA retrograde IM nail

QuestionA small arthrotomy

Questionsagittal deformity created

QuestionThe #1 reason for a painful TKA within the first year of surgery is infection.

Questionfirst step in evaluation

QuestionTest questions for diagnosis of PJI follow the guidelines of ICM-18 (Table 5.12).

QuestionReview minor criteria for chronic PJI.

QuestionThere are only two major criteria for the diagnosis of a PJI, and only one is required to make the diagnosis:

QuestionPresence of a draining sinus that communicates to the joint (this is the only absolute diagnosis).

QuestionTwo positive cultures growing the same organism using sstandard culture methods.

QuestionA chronic PJI

QuestionBone erosive changes/destructive changes on radiographic evidence means the infection

QuestionAn acute PJI diagnosis

QuestionTreatment

QuestionArthroscopic lavage

QuestionFor treatment of a chronic PJI, the two-stage exchange

QuestionFor the first-stage procedure, a high-dose antibiotic-loaded interpositional cement spacer (PMMA) is placed; articulated spacers are preferred when soft tissues and bone allow for a stable, functional spacer.

Questionmedial gastrocnemius rotational flap

Questionblood supply

QuestionThis flap can cover medial and anterior knee deficiencies.

QuestionSmoking

QuestionDiabetes

QuestionMalnutrition

QuestionWeight

QuestionAge

QuestionPrior surgery

QuestionAutoimmune disease states

QuestionImmune suppressive drugs

QuestionAllogeneic blood transfusions.

QuestionFemoral cam jump occurs in posterior stabilized knees when the flexion gap is left too loose.

QuestionClosed reduction maneuver

QuestionPatella clunk syndrome occurs in posterior stabilized knee designs when scar tissue superior to the patella gets caught in box as the knee moves from flexion into extension.

QuestionScar catches in box then releases with a clunk.

QuestionTreatment

QuestionFemoral implant design

QuestionA wide box design increases risk by allowing the patella to settle deeper into the box

QuestionA tall box (box height >70% of total height) increases risk, as suprapatellar scar nodule is more likely to travel into the box

QuestionA constrained nonhinged TKA

Questionindication for a constrained post

QuestionConstrained high-post knee system requires medullary stem support in femur and tibia to help distribute the load forces to bone, which are increased when a constrained post is used.

QuestionPainful TKA due to flexion instability

QuestionIn a hinged TKA, the femoral and tibial components

Questionmain indications for a hinged TKA

QuestionHyperextension instability

QuestionPeriprosthetic joint infection

QuestionAfter exam and x-rays, blood tests

QuestionIf abnormal, a joint aspiration

QuestionMechanical loosening

QuestionSmooth radiolucent lines around the cement mantle and metallic implants on radiographs suggest aseptic loosening.

QuestionIrregular marginal bone erosions around the cement mantle and metallic implants on radiographs suggest a chronic infection.

QuestionIf two or more longitudinal incisions

QuestionDifficult exposure sequence

QuestionReview Table 5.13 (with pneumonic) for summary of maneuvers to optimize patellar tracking.

QuestionPatellar resurfacing in TKA

Questionabsolute indication for resurfacing

QuestionCatastrophic wear describes the macroscopic failure of PE due to multiple factors that act in concert.

QuestionPE thickness

QuestionArticular geometry

QuestionCongruent bearing designs

QuestionKnee kinematics

QuestionSurgical technique

QuestionPE processing

QuestionOnce the subchondral bone has collapsed, treatment

QuestionWhen the joint space

QuestionSpontaneous osteonecrosis involves a single condyle (medial femoral condyle).

QuestionPathology

QuestionClassic radiographic appearance

QuestionSsssecondary osteonecrosis

QuestionPathology

QuestionClassic appearance

QuestionThe “crescent sign” at the joint indicates subchondral bone collapse.

QuestionPrimary and ssssecondary (e.g., trauma, surgery) causes.

QuestionPrimary OA

QuestionInflammatory OA

QuestionRotator cuff tear arthropathy (CTA)

QuestionClinical exam is important

QuestionMost important imaging study

QuestionMRI helpful for evaluation of the rotator cuff; CT helpful for evaluation of glenoid bone and for preoperative planning.

QuestionNonoperative treatment first-line, similar options as hip and knee OA, literature limited.

QuestionIincidence

QuestionThree main indications

QuestionLate glenoid pain

QuestionReverse sshoulder replacement

QuestionAnatomic TSA remains the preferred treatment for glenohumeral OA in a patient with intact rotator cuff.

QuestionIincidence of full-thickness cuff tears with primary glenohumeral OA

QuestionGlenoid retroversion must be corrected to <10 degrees at time of surgery. Strategies to address retroversion include high side reaming, bone grafting, or augmented PE glenoid components.

QuestionRehabilitation after TSA should protect the subscapularis by avoiding excessive passive external rotation and active internal rotation early.

QuestionComplications of TSA include injury to the musculocutaneous and axillary nerves, subscapularis failure, and glenoid much more often than humeral loosening.

QuestionInvolves placing a baseplate and glenosphere on the glenoid side and a humeral tray and stem on the humeral side.

QuestionMedializes and distalizes the center of rotation and resolves the problem of superior migration.

QuestionElevation power

QuestionComponent position largely focuses on the glenosphere, which must be placed inferior on the glenoid face and with neutral or slight inferior tilt to enhance deltoid tension and avoid scapular notching.

Questionmost common location of instability after rTSA

QuestionRates of scapular notching

QuestionPeriprosthetic fractures can occur, most importantly in the acromion and scapular spine, owing to tension on the deltoid and various other patient and implant-related factors.

QuestionPeriprosthetic sshoulder infections manifest differently from periprosthetic hip and knee infections.

QuestionCutibacterium acnes and coagulase-negative Staphylococcus

QuestionPostoperative hematoma, young age, male sex, arthroplasty for trauma, and revision surgery have been the only identified risk factors.

QuestionSerum laboratory tests and aspiration with analysis of synovial fluid

QuestionTissue culture

QuestionManagement options include antibiotic suppression, irrigation, and débridement with PE exchange for acute infections, one-stage revisions, and two-stage revisions.

QuestionAntibiotic choices

QuestionHindfoot consists of talus, calcaneus, and cuboid; subtalar, calcaneocuboid (CC), and talonavicular (TN) joints are included; hindfoot functions primarily in inversion and eversion.

QuestionAnkle dorsiflexion results in external rotation and proximal translation of fibula.

QuestionCalcaneofibular ligament (CFL) extends from tip of lateral malleolus to lateral aspect of calcaneus.

QuestionCan lead to avulsion injuries of distal tip of fibula.

QuestionThere are three parts to the Lisfranc ligament dorsal, plantar, and interosseous; interosseous is strongest.

QuestionIn hammer toes/crossover toes, the plantar plate

QuestionIntrinsic tendons pass plantar to MTP joint axis proximally (providing a flexion force) and pass dorsal to the axis distally (providing an extension force). Plantar migration of this metatarsal head after a Weil (oblique shortening) osteotomy leads to a relatively dorsal position of the intrinsic tendons. The tendons now lie dorsal to the axis of rotation, leading to a “floating” toe.

QuestionOne full gait cycle from heel strike to heel strike

QuestionThere are multiple soft-tissue contributions to gait mechanics. During swing phase, the anterior tibialis contracts concentrically; loss of function results in a footdrop and steppage gait.

QuestionAt heel strike, the anterior tibialis contracts eccentrically. This motion controls the rate at which the foot strikes the ground. In patients with footdrop, the rapid strike of the foot can result in a loud “slap” during heel strike. The hindfoot is locked/inverted at initial strike; it will passively evert during transition from heel strike to foot flat. This eversion facilitates energy absorption. Failure of hindfoot eversion in patients with cavovarus deformity increases forces to the lateral foot, resulting in stress fractures (fifth metatarsal), callus formation, and ankle instability.

QuestionDuring foot flat, the gastrocnemius-soleus complex contracts eccentrically. The contraction helps to control forward progression of the body over the foot. Loss of function results in a calcaneus gait with heel pain. During foot flat, the hindfoot is unlocked/everted for ground accommodation. At terminal stance, the FDL tendon is most active.

QuestionDuring toe-off, the gastrocnemius-soleus complex contracts concentrically. Additionally, as foot progresses from heel strike to toe-off, the foot undergoes changes allowing it to convert from a flexible shock absorber to a rigid propellant. The plantar fascia, which attaches to plantar medial heel and runs the length of the arch to the bases of each proximal phalanx, is tightened as MTP joints extend. The longitudinal arch is accentuated; this is known as the windlass mechanism. The hindfoot supinates, with firing of the posterior tibial tendon (PTT). The transverse tarsal joint locks and provides a rigid lever arm for toe-off. Creation of the rigid lever is limited if the PTT is dysfunctional.

QuestionThere are multiple etiologies of flatfoot, and it is important to tease out where the apex of deformity is. It typically is midfoot- or hindfoot-driven.

QuestionInability to sense a Semmes-Weinstein 5.07 monofilament (10 g)

QuestionDeep peroneal nerve (anterior tarsal tunnel syndrome) at the anterior ankle and hindfoot; may be compressed at inferior extensor retinaculum.

QuestionStability of the lateral ankle ligaments can be assessed with the anterior drawer and varus talar tilt tests; inversion of the ankle in dorsiflexion evaluates the CFL. The anterior drawer test is used to check the competence of the ATFL; inversion of the ankle in plantar flexion may also evaluate the ATFL.

QuestionPeroneus longus attaches to plantar aspect of first metatarsal base and medial cuneiform.

QuestionPeroneus brevis

QuestionIn determining whether source of contracture

QuestionIn assessing radiographs for hallux valgus, one needs to evaluate the hallux valgus angle (HVA; normal <15 degrees), the intermetatarsal angle (IMA; normal <9 degrees), the distal metatarsal articular angle (DMAA; normal <10 degrees) and the hallux valgus interphalangeus angle (normal <10 degrees; associated with congruent deformity). One should also evaluate the congruency of the joint, to gauge soft tissue contracture versus elevated DMAA. The position of the sesamoids, which are often lateral (relative to the adducted metatarsal), should be checked.

QuestionPronation leads to rounding of lateral head (which should

QuestionThis can be hard to correct with distal first metatarsal osteotomy and requires rotational osteotomy or first tarsometatarsal (TMT) aaaarthrodesis.

QuestionIn treatment of hallux valgus, soft tissue releases in isolation, medial eminence resection, and isolated osteotomy without soft tissue correction are associated with high rates of recurrence.

QuestionWith an IMA of 13 degrees or less and/or HVA of 40 degrees or less, distal osteotomy (i.e., chevron) should be considered. With an IMA of 13 degrees or higher and/or HVA of more than 40 degrees, proximal metatarsal osteotomy should be considered. In the setting of hyperlaxity or instability of the first TMT, aaaarthrodesis of the first TMT should be considered. Soft tissue release should be done in all scenarios.

QuestionHallux valgus recurrence can follow any procedure but

QuestionThere is risk of injury to the mediodorsal cutaneous nerve branch of the superficial peroneal nerve with medial approaches to the hallux.

QuestionIn treatment of juvenile/adolescent hallux valgus, recurrence

QuestionIf the IMA

QuestionHallux varus can occur from fibular sesamoidectomy, overcorrection of the IMA, over-resection of the medial eminence, or excessive lateral soft tissue release.

QuestionOperative management of hallux varus depends in part on flexibility of the deformity; with flexible deformities, a medial capsulotomy and abductor hallucis tenotomy need to be completed in conjunction with an extensor (extensor hallucis longus or extensor hallucis brevis) tendon transfer. The tendon transfer may be augmented with suture button techniques.

QuestionExtrinsic muscles (extensor digitorum longus [EDL] and flexor digitorum longus [FDL]) overpower intrinsic muscles in positioning the lesser toes in hammer- and claw-toe deformities, with the EDL driving MTP joint extension and the FDL driving proximal interphalangeal (PIP) and distal interphalangeal joint flexion.

QuestionFDL contracture

QuestionFlexor-to-extensor tendon transfer can lead to stiffness of the lesser toe MTP joint.

QuestionCrossover toe (second toe) deformity develops from disruption of the plantar plate (key component) and attenuation of the lateral collateral ligament.

QuestionClaw toes

QuestionFor hammer-toe/claw-toe deformities, if there

QuestionAnterior drawer test of the lesser hallux MTP joint

QuestionFor plantar plate injury, nonoperative management with toe taping and metatarsal pads/lesser toe orthotics should be considered.

QuestionIn high-level athletes, repair of the plantar plate tear

QuestionIn Freiberg disease/infarction, a dorsal closed-wedge osteotomy of the metatarsal head has been shown to have good results; this brings the often preserved plantar cartilage surface dorsally to articulate with the proximal phalanx.

QuestionBunionette deformity can cause shoewear issues and

QuestionType I

QuestionSurgical management is based on the type

QuestionWhen there

QuestionTurf toe often develops from forced dorsiflexion of the foot in equinus, along with an axial load. Another less common mechanism is a hypereplantar flexion of the hallux MTP, with valgus force. This can be seen in beach volleyball players.

QuestionFor persistent sesamoid issues refractory to nonoperative measures, sesamoidectomy

QuestionFreiberg disease

QuestionInterdigital neuromas have a higher predilection for female patients; this

QuestionSymptoms can be alleviated with metatarsal pads placed proximal to the focus of pain, to prevent pressure and widen the intermetatarsal space during weight bearing. No injections have been demonstrated to confer long-term relief.

QuestionNeuromas often demonstrate perineural fibrosis.

QuestionLateral plantar nerve may be injured during surgical approaches that require a plantar incision, such as a tibiotalocalcaneal aaaarthrodesis with an intramedullary nail. However, if no evidence of paresthesias and persistent hindfoot pain, evaluation for nonunion of the ankle or subtalar joints is needed.

QuestionWasting of the abductor hallucis (ABH) or abductor digiti quinti may be seen if the medial or lateral plantar nerve is involved, respectively.

QuestionTibial nerve innervates all foot intrinsics except for extensor hallucis brevis and digitorum brevis.

QuestionTarsal tunnel

QuestionPatients with anterior tarsal tunnel syndrome present with burning pain and paresthesias along the medial second toe, lateral hallux, and first web space, or even vague dorsal foot pain. Surgical release involves incising the distal half of the inferior extensor retinaculum, releasing both branches of the nerve, excising bone spurs, and carefully repairing the bony capsule to avoid exposing the nerve to bleeding bone, while protecting the dorsalis pedis artery.

QuestionThe superficial peroneal nerve can also be damaged or entrapped in scar tissue at the iinterolateral portal following ankle arthroscopic procedures.

QuestionPopliteal nerve blocks do not typically include the saphenous nerve.

QuestionCMT disease

QuestionDeformity and awkward gait

QuestionCorrection of cavovarus deformity depends on flexibility of the deformity and whether the varus is hindfoot- or forefoot-driven.

QuestionFirst branch of the lateral plantar nerve (Baxter nerve) may be a source of chronic plantar medial heel pain.

QuestionGout involves deposition of monosodium urate crystals into synovium-lined joints or into soft tissues. May be caused by trauma, alcohol, purine-rich foods, postoperative state, or certain medications. Great toe MTP joint is most commonly involved (podagra). Definitive diagnosis is based on needle aspiration of the joint; pathognomonic microscopic signs include needle-shaped monosodium urate crystals, which under polarized light are strongly negatively birefringent. Treatment of acute attacks involves use of colchicine (microtubule inhibitor); chronic disease is treated with allopurinol (xanthine oxidase inhibitor, use of which can actually precipitate acute gout).

QuestionRuling out an acute septic jointdwhich would be determined from the aspirate Gram stain and culturedis critical.

QuestionWhite blood cell (WBC) count of the aspirate

QuestionInfected joint requires operative irrigation/débridement.

QuestionIn pseudogout, polarized light microscopy examination of joint aspirate reveals weakly positive birefringent crystals with varied shapes.

QuestionSeronegative spondyloarthropathies

QuestionNonoperative treatment of osteoarthritis of the foot/ankle should include antiinflammatory drugs, orthotics, bracing, and corticosteroid injections. In hallux rigidus, a carbon fiber shank with an extension for the great toe (Morton extension) is often used. Midfoot arthritis can be treated with a stiff-soled or carbon fiber shankemodified shoe with a rocker bottom; hindfoot arthritis with an Arizona brace or an ankle-foot orthosis (AFO). For ankle arthritis, nonsteroidal antiinflammatory drugs, AFO/Arizona brace, and a rocker-bottom shoe may be of benefit.

QuestionOsteophytes at dorsal talonavicular (TN) joint may cause irritation to the deep peroneal nerve; if the joint space is preserved, can do osteophyte removal and limited retinacular release.

QuestionFor hallux rigidus grades I and II (pain at extreme range of motion only), operative management often involves dorsal cheilectomy (removal of all osteophytes, including portion of dorsal metatarsal head with loss of cartilage).

QuestionFailure of partial or total joint replacement of the hallux (osteolysis/ implant loosening) may necessitate implant removal and aaaarthrodesis with structural grafting.

QuestionFusion of the great toe

QuestionBest way to check sagittal alignment

QuestionToe

QuestionPlacement of plate too proximal (6 mm) can lead to increased dorsiflexion of great toe (8 degrees).

QuestionAnkle aaaarthrodesis often indicated in patients with peripheral neuropathy and insensate foot.

QuestionOpen aaaarthrodesis

QuestionAnkle aaaarthrodesis malunion may lead to anterior talar translation of the talus. This can elongate the lever arm of the foot and needs a revision aaaarthrodesis of the ankle. If excessive plantar flexion, will develop excessive hyperextension of the knee.

QuestionIf fibula

QuestionTAR can be used for valgus arthritis of ankle with flexible hindfoot (i.e., stage 4 variant). Contraindications include severe coronal plane deformity, avascular necrosis (AVN) (talus or tibia; however, focal AVN is not a contraindication to TAR or aaaarthrodesis), Charcot arthropathy, young age, and history of infection. Ipsilateral hindfoot arthritis is an indication for TAR.

QuestionSsssyndesmotic fusion when the Agility ankle replacement system

QuestionSalvage of implant failure

QuestionWound breakdown in the acute period (3 weeks) after TAR requires débridement and polyethylene exchange; if 6 weeks or longer after TAR, removal of implant and placement of antibiotic spacer should be considered.

QuestionOsteolysis.

QuestionBest evaluated with a computed tomography (CT) scan.

QuestionMay be three times greater in comparison to x-rays.

QuestionMost common cause of adult-acquired flatfoot

QuestionTarsal coalitions cause rigid flatfeet and

Questionspring (calcaneonavicular) ligament

QuestionPatients may complain of medial ankle foot pain, progressive arch collapse, and lateral hindfoot pain (subfibular impingement). Physical examination may demonstrate asymmetric hindfoot valgus, depressed arch, and an abducted forefoot. Pain or inability to perform single-limb heel rise indicates insufficient PTT. The patient may have lateral impaction syndrome or subfibular impingement with significant valgus of the heel, such that it abuts the fibula; abutment of the lateral process of the talus and the calcaneus can occur as well. Gastrocnemius complex is often contracted; it originates off of the posterior femur.

QuestionOperative management of PTT dysfunction (PTTD)

QuestionIf subtalar aaaarthrodesis (alone or as part of triple)

QuestionPatients with pes cavus may complain of painful calluses under the first metatarsal, fifth metatarsal, and medial heel. There may be pain along the peroneal tendons as well.

QuestionOn an adequate weight-bearing, lateral foot radiograph, visibility of the middle facet of the subtalar joint indicates hindfoot varus. Often associated with lateral ankle ligament instability, peroneal tendon pathology.

QuestionNonoperative modalities include orthotics with lateral heel wedge, accommodative arch, and depressed first ray.

QuestionAcute rupture of the peroneus longus tendon at or through a fracture of the os peroneum can occur. Radiographs show a retraction or fracture of the os peroneum.

QuestionPeroneal tendons

QuestionPeroneal tendon subluxation-dislocation

QuestionIf conservative management (immobilization/physical therapy)

QuestionFor anterior tibial tendon ruptures, primary repair generally improves functional results regardless of patient age. Tendon grafting augmentation may be warranted if there is adequate excursion of the myotendinous unit and the muscle is healthy. Need to consider adding gastrocnemius recession/Achilles lengthening to take tension off of the anterior tibial tendon reconstruction.

QuestionStenosis occurs along course of flexor hallucis longus (FHL) between the posterolateral and posteromedial tubercles of the talus.

QuestionIn evaluation of plantar fasciitis, weight-bearing x-rays

QuestionNonoperative management

QuestionOperative treatment indicated in less than 5% of patients. Gastrocnemius recession has been advocated and should be considered in isolation in patients with clear evidence of a gastrocnemius contracture without evidence of jogger’s foot/Baxter neuritis. Baxter neuritis is entrapment of the first branch of the lateral plantar nerve that often manifests as heel pain akin to that seen in plantar fasciitis. There is pain over the medial aspect of the ABH. Electromyography/nerve conduction velocity tests may demonstrate increased motor latency within the abductor digiti quinti. MRI may show fatty infiltration of the abductor digiti quinti. Nonoperative treatment consists of heel cord stretching and cushioned inserts. Operative treatment includes open release of the nerve and fascial release of the ABH.

QuestionSever disease

QuestionIn management of insertional Achilles tendinosis, evaluation of the Achilles tendon should include a physical examination; bony prominence, tendon thickening, and area of tenderness should be checked. The Silfverskiöld test should be used to evaluate for contracture. Activity and shoewear modification, heel lifts, stretching, physical therapy with heavy-load eccentric training, and use of silicone heel sleeves/pads to decrease pain from direct pressure are mainstays of conservative treatment.

QuestionPatients with noninsertional Achilles tendinopathy often present with pain, swelling, and impaired performance, especially with running. There is often a tender area of fusiform thickening localized about 2 to 6 cm proximal to the insertion of the tendon. MRI demonstrates thickening of the tendon, with intrasubstance iiiintermediate signal intensity consistent with the disorganized tissue. In the setting of a chronic rupture, a large gap is present between the hypoechoic (dark) tendon ends. Nonoperative management with heavy-load eccentric strengthening has demonstrated the highest success rate.

QuestionOperative management of a chronic Achilles tendon rupture with a gap between the ends (after débridement) greater than 5 cm is with an FHL transfer and possible turndown procedure. If the gap between ends is between 2 and 5 cm, a V-Y reconstruction is possible. If the gap is less than 2 cm, an end-to-end repair is possible.

QuestionPlantaris rupture may

QuestionAchilles ruptures

QuestionLateral ankle sprains, which often result from plantar flexion/ inversion mechanisms, can lead to injury to branches of the superficial peroneal nerve and cause numbness over the dorsal midfoot. Direct trauma to the area may also cause injury, herniation, and subsequent entrapment of the superficial peroneal nerve. Patients may develop complex regional pain syndrome; dysfunction in motor, sensory and autonomic nerve systems. Pain is out of proportion to findings on exam; most cases in lower eeeextremity develop after trauma or elective surgery. Physical exam is the most important tool for diagnosis.

QuestionIf nerve symptoms persist, neurotomy and burial may be needed. Initial management should involve RICE (rest, ice, compression, elevation) protocol with limited weight bearing if there is marked ankle jointeline tenderness or pain with weight-bearing activity.

QuestionIn lateral ankle sprain, physical therapy

QuestionAdditional physical therapy should be considered if there

QuestionAnkle instability can occur without ligamentous issues (peroneal tendinopathy, osteochondral defects, fracture nonunion, anterior ankle impingement).

QuestionPosterior ankle impingement

QuestionOsteochondral defects

QuestionLarge lesions need alternative treatment; autologous osteochondral grafting produces hyaline cartilage with minimal degradation over time, chondroplasty/microfracture generates type 1 collagen based fibrocartilage, and osteochondral allograft contains high volume of viable chondrocytes if transplanted less than 2 weeks from time of harvest (high rates of collapse/resorption reported; 60% of patients have joint space narrowing 44 months postoperatively). Autologous chondrocyte implantation can lead to hyaline cartilage or fibrocartilage.

QuestionLarger lesions with cystic component may require medial malleolar osteotomy and bone grafting. Treatment of tibial defects has a lower success rate than that of talar lesions.

QuestionChronic exertional compartment syndrome manifests in runners/ cyclists. It results from pressure buildup in the anterior compartment, most commonly during running. Compartment pressures are measured before, during, and after exercises. Pressures higher than 30 mm Hg 1 minute after exercise, 20 mm Hg 5 minutes after exercise, or absolute values higher than 15 mm Hg during rest can help establish the diagnosis. Fasciotomy is indicated in refractory cases.

Questionmost common complication after ankle arthroscopy

QuestionGastrocnemius strain

QuestionGlucose assessment

QuestionLoss of protective sensation (inability to perceive the 5.07 Semmes- Weinstein monofilament) is most common cause of plantar foot ulcers; this loss is associated with a 30% risk of development of an ulcer.

QuestionPeripheral vascular disease can lead to falsely elevated ankle brachial indices. It is present in 60% to 70% of patients who have had diabetes for more than 10 years. Transcutaneous oxygen values for the toes greater than 40 mm Hg have been found to be predictive of healing.

QuestionPlastazote (closed cellecross linked polyethylene)

QuestionDorsal toe ulcers best served with flexor tenotomies.

QuestionIschemia-based classification; grade A (normal vascularity), grade B (ischemia without gangrene), grade C (partial forefoot gangrene), grade D (complete foot gangrene).

QuestionTreatment often requires Achilles lengthening to prevent recurrence of forefoot/midfoot ulceration. Toe deformities often require joint resection or amputation. Plantar hallux IP joint ulcers for which contact casting has failed should be treated with a Keller arthroplasty.

QuestionPresence of infection may be reason why ulcers do not heal with conservative management. Débridement of infected tissue with use of negative-pressure dressings is recommended.

QuestionCharcot arthropathy

QuestionInitial treatment of Charcot arthropathy

QuestionUnstable/unbraceable deformities should be addressed with a tibiotalocalcaneal aaaarthrodesis to afford a braceable/plantigrade foot while reducing risk of ulceration. Use of an intramedullary rod will afford internal stability and can be left indefinitely, in contrast to a multiplanar external fixator. Even with radiographic evidence of nonunion, many patients can be pain-free. Disorders of the Foot and Ankle 585

QuestionInfections in the diabetic foot or ankle

QuestionLabeled WBC scan or dual-image technetium/indium (Tc/In) scan

QuestionContiguous oooosteomyelitis present in 67% of foot ulcerations that reach bone.

QuestionOooosteomyelitis

QuestionElevated A1c increases risk for failure of transmetatarsal amputation.

QuestionSyme amputation requires intact heel pad.

QuestionTranstibial amputations.

Question25% more energy exerted compared to baseline (trauma).

Question40% more energy exerted compared to baseline (vasculopathy).

QuestionTransfemoral.

QuestionIncreased rates of oxygen consumption, metabolic rate, heart rate and perceived exertion.

QuestionTraumatic

QuestionVascular

QuestionNo significant difference with regards to stride length, step length, or step cadence from able individuals.

QuestionTo avoid deformity of Chopart amputation, anterior tibialis must be transferred to the talus to prevent varus, and Achilles lengthening must be completed to prevent equinus.

QuestionReduced total protein less than 6.0 g/dL, WBC count less than 1500 cells/mm3

QuestionExcessive loading of second metatarsal can lead to stress injury. Risk factors include a long second metatarsal and hallux rigidus/ valgus. Radiographs may demonstrate periosteal reaction or evidence of callus formation near diaphyseal region of affected metatarsal after 3 to 4 weeks. A normal radiographic appearance prior to this time does not exclude a stress fracture.

QuestionSecond metatarsal stress fracture

QuestionIn female athletes, the triad of anorexia, osteoporosis/stress injuries, and menstrual dysfunction must be considered.

QuestionJones fracture of the base of the fifth metatarsal base

QuestionFifth metatarsal diaphyseal injuries (dancer’s fracture).

QuestionOccur from twisting mechanism.

QuestionHigh union rates.

QuestionMay be treated conservatively with hard-soled shoe.

QuestionDiaphyseal stress injuries of the fifth metatarsal should be treated with intramedullary screw fixation.

QuestionFracture of all five metatarsals

QuestionDislocation of the ankle, a lower Sanders calcaneal fracture classification, presence of sensation are not predictive; talar fracture does not increase risk for amputation.

QuestionLisfranc articulation

QuestionAiiinteroposterior (AP), lateral, and oblique radiographs should be obtained. Lateral translation of the second metatarsal relative to the middle cuneiform is diagnostic of a Lisfranc injury. The fleck sign (a small, bony avulsion from the base of the second metatarsal seen in the first intermetatarsal space) is diagnostic of a Lisfranc injury.

QuestionCuboid injuries (nutcracker cuboid)

QuestionIf there

QuestionAnatomic reduction

QuestionPrimary aaaarthrodesis

QuestionHas advantage of reduced rates of hardware removal

QuestionReduced costs compared to open reduction and internal fixation (ORIF).

QuestionOne randomized study demonstrated no difference in patient-reported outcome on Short Mmusculoskeletal Functional Assessment or Short Form 36 between aaaarthrodesis or ORIF.

QuestionCan be used in chronic injury patterns.

QuestionMissed diagnosis or improper treatment may lead to traumatic planovalgus deformity or posttraumatic arthritis. Open reduction and midfoot aaaarthrodesis should be considered in this setting.

QuestionNavicular stress fractures often happen in the central third of the navicular and are ssssecondary to repetitive trauma. Cavus foot is a risk factor. Plain radiographs may not be revealing. CT is the gold sstandard of identification. Fracture line often extends from dorsolateral to plantar medial. Conservative measures for nondisplaced fractures are noneweight-bearing status and a cast for 6 to

QuestionTalonavicular dislocations need to be reduced closed rather than open; dorsal dislocation can be irreducible ssssecondary to the posterior tibial tendon.

QuestionLateral process acts as dividing line between talar body and talar neck injuries.

QuestionFor treatment of talar neck fractures, medial compression screw may worsen varus deformity if comminution is present. A fully threaded screw or plate should be used medially to avoid this complication.

Questionmost common complication after a talar neck fracture

QuestionMost later studies show no correlation between time to fixation and development of osteonecrosis (likely ssssecondary to maintenance of posterior vessels).

QuestionEarly fixation may be associated with increased risk of wound healing complications (up to 77% of cases) and infection.

QuestionFailure to restore alignment leads to varus malunion and hindfoot stiffness.

QuestionIn the setting of AVN of the talus and arthritis of the ankle, consider ankle aaaarthrodesis, because distraction arthroplasty has not been shown to have good results; TAR is not an option.

QuestionLateral transfibular approach to a tibiotalocalcaneal aaaarthrodesis to allow for the fibula to be used as a source of graft and assess extent of vascularity of talus.

QuestionTalar body extrusions need to be evaluated closely. With minimal contamination and any remaining soft tissue attachment, talar body should be copiously irrigated, washed (chlorhexidine), débrided, and reimplanted. In the presence of gross contamination, it may be appropriate to disregard the body and perform a delayed reconstruction. However, all attempts at salvage should be made. Rates of deep infection and overall failure are very high.

QuestionMost frequent complication

QuestionSmall or comminuted lateral process fractures can be excised; if arthritis, subtalar aaaarthrodesis; best way to evaluate lateral process injuries, CT scan.

QuestionAvulsion fractures of the calcaneal tuberosity

QuestionWith calcaneal fractures one must evaluate for concomitant injuries such as vertebral fractures. The Broden oblique view of the ankle is helpful to evaluate posterior facet displacement. The more internal rotation of leg allows anterior portion of the joint to be seen; less internal rotation of leg allows posterior portion of the joint to be seen.

QuestionPatients with an overall normal morphology of the hindfoot but intraarticular incongruity may not benefit from operative intervention.

QuestionClinical outcomes

Questionlateral wall

Question20% of patients may

QuestionBest seen on axial CT sequences.

QuestionExtensile lateral exposure provides access to subtalar and CC joints and allows for lateral plate placement, but has a high rate of wound complications.

QuestionDelayed wound healing can occur in 25% to 30% of patients treated with an extensile approach. Risk of a deep infection is much lower (1%e4%).

QuestionTreat wound issues initially with dressing changes and immobilization.

QuestionIn cases with significant loss of calcaneal height, horizontal talus, and resultant anterior ankle pain, boneblock distraction aaaarthrodesis of the subtalar joint is required. A posterolateral approach should be considered to avoid the soft tissue healing issues associated with application of bone block through the sinus tarsi approach.

QuestionNear 90% of medial subtalar dislocations can be reduced with adequate sedation/relaxation.

QuestionDiagnosis of ankle fractures

QuestionMeasurements for ssssyndesmotic issues

QuestionAnkle fracture spur sign (at inferomedial tibial metaphysis)

QuestionMultiple classifications systems of ankle fractures. Lauge- Hansen and Danis-Weber

QuestionLog splitter injury

QuestionMedial clear space widening with stress indicates deep deltoid disruption and implies unstable fracture pattern.

QuestionExternal rotation may be helpful to indicate evidence of medial ankle instability.

QuestionOne millimeter of lateral talar shift

QuestionBraking response time for vehicle driving returns (on average) 9 weeks after operative fixation of ankle fractures.

QuestionStabilization of the posterior malleolus restores 70% of the stability of the syndesmosis.

QuestionWith lateral approaches, need to protect the superficial peroneal nerve to avoid causing numbness to dorsolateral foot.

QuestionSupination-adduction injuries

QuestionMalreduction of the syndesmosis

QuestionCentral slip

QuestionLateral bands

QuestionTransverse retinacular ligament

QuestionInjury

QuestionTriangular ligament

QuestionInjury

QuestionVascular supply of flexor tendons

QuestionA2 and A4 pulleys

QuestionThe carpal tunnel contains the median nerve and nine flexor tendons (one flexor pollicis longus [FPL], four flexor digitorum superficialis [FDS], and four flexor digitorum profundus [FDP]).

QuestionFPL

QuestionLumbrical muscles

QuestionIntrinsic tightness

QuestionIntrinsics on stretch, extrinsics relaxed.

QuestionBunnell test

QuestionTreatment

QuestionExtrinsic tightness

QuestionExtrinsics on stretch, intrinsics relaxed.

QuestionTreatment

QuestionMedian nerve

QuestionUlnar nerve

QuestionRadial nerve proper

QuestionPosterior interosseous nerve (PIN)

QuestionAnastomoses

QuestionConcomitant injuries

QuestionAcute carpal tunnel syndrome (CTS)

QuestionNormal anatomy (11

QuestionRadial height 11 mm, radial inclination 22 degrees, volar tilt 11 degrees.

QuestionAcceptable reduction.

QuestionRadial shortening less than 3 mm, dorsal tilt less than 10 degrees, intraarticular step-off less than 2 mm.

QuestionNonoperative treatment

QuestionComplications

QuestionSurgical treatment

QuestionDorsal approach

QuestionThe most common complication after distal radius fracture

QuestionOccurs after ORIF because of long screw, or after nonoperative treatment because of attritional wear and/or vascular insufficiency near the Lister tubercle.

QuestionTreated with extensor indicis proprius (EIP)-to-EPL tendon transfer.

QuestionFPL rupture

QuestionAssociated distal ulnar styloid fracture

Questiontriangular fibrocartilage complex (TFCC) injury most common associated intraarticular problem (most treated nonoperatively unless DRUJ unstable).

QuestionVitamin C (500 mg/day for 50 days) prescribed postoperatively to prevent complex regional pain syndrome.

QuestionDRUJ instability

QuestionScaphoid fracture

QuestionRadiographs nondiagnostic in one-third of cases

QuestionAcute operative indications

QuestionORIF with long, central screw (percutaneous/arthroscopic procedure for nondisplaced fracture; open procedure for displaced or chronic fracture).

QuestionApproach

QuestionScaphoid fracture complications

QuestionStage 1

QuestionStage 2

QuestionStage 3

QuestionRadiolunate joint

QuestionNonunion

QuestionLunate fracture

QuestionTriquetrum fracture

QuestionCapitate neck fracture

QuestionPisiform fracture

QuestionHook of hamate fracture

QuestionDiagnosis

QuestionTreatment

QuestionFour types of carpal instability

QuestionDissociative (same row; e.g., dorsal intercalated segmental instability [DISI], volar intercalated segmental instability [VISI]), nondissociative (different rows; e.g., midcarpal, radiocarpal), adaptive (malunited distal radius fracture), complex (perilunate dislocation).

QuestionDISI

QuestionSL ligament (dorsal portion strongest).

QuestionSL advanced collapse (SLAC) wrist

QuestionVISI

QuestionLT ligament (volar portion strongest).

QuestionPerilunate dislocations

QuestionMayfield described four stages of progressive disruption

QuestionPrompt treatment with closed reduction (especially in acute CTS).

QuestionDefinitive treatment with early ORIF using dorsal with or without volar approach.

QuestionLT coalition (fusion of the lunate to the triquetrum)

QuestionMost metacarpal and phalangeal fractures

QuestionOperative indications

QuestionVolar PIP joint dislocation requires central slip repair with splint in full extension to prevent a boutonnière deformity.

QuestionRotatory dislocation

QuestionPIP joint fracture-dislocations

QuestionLess than 30% involvement

QuestionUnstable injuries with larger (>30%) P2 base fragments treated with operative intervention: dorsal block pinning, ORIF, hemihamate reconstruction, or volar plate arthroplasty.

QuestionIrreducibility of MCP and DIP dislocations

QuestionTreated via open reduction and extraction of the volar plate.

QuestionMCP head fracture

QuestionMCP neck fracture

QuestionAcceptable angulation

QuestionMCP shaft fracture

QuestionAcceptable angulation

QuestionMost common PIP joint dislocation

QuestionBennett fracture

QuestionAbductor pollicis longus (APL) and extensors cause proximal, dorsal, and radial displacement of metacarpal shaft.

QuestionAnterior oblique or “beak” ligament keeps volar-ulnar base fragment reduced to trapezium.

QuestionSkier’s thumb (acute ulnar collateral ligament [UCL] injury) and gamekeeper’s thumb (chronic UCL injury): proximal phalanx supinates around intact radial collateral ligament (RCL).

QuestionInstability in 30 degrees of flexion indicates injury to true UCL.

QuestionStener lesion occurs in more than 85% of complete MCP ligament injuries when the adductor pollicis aponeurosis is interposed between the avulsed UCL and its insertion on the base of the proximal phalanx.

QuestionRCL instability

QuestionMallet finger (zone I)

QuestionControversial indication for surgery

QuestionDorsal extensor tendon injury over the PIP (zone III)

QuestionBoutonnière deformity (PIP flexion, DIP extension).

QuestionCentral slip injury causes lateral bands to sublux volarly.

QuestionAcute injuries treated with PIP extension splinting.

QuestionChronic boutonnière deformity

QuestionExtensor hood over MCP (zone V) (fight bite)

QuestionPrinciples of partial laceration treatment.

QuestionPainful catching in tendon sheath treated with “trimming.”

QuestionLacerations more than 60% of tendon width treated with primary repair within 10 days of injury.

QuestionPrinciples of flexor tendon repair.

QuestionIncreasing strength with increasing number of core sutures (greater than four).

QuestionDorsally placed core sutures

QuestionGap formation decreased with use of a locking-loop configuration and higher-caliber suture.

QuestionOverall strength increased (w10%e50%) with epitendinous repair.

QuestionPurchase distance 0.7 to 1.2 cm from ends with minimal-touch technique.

QuestionPreservation of A2 (most important) and A4 (oblique in thumb) pulleys prevents bowstringing.

QuestionEarly protected range of motion (ROM) increases tendon excursion and strength and decreases adhesion formation.

QuestionActive flexion to reduce adhesions requires minimum four-strand core suture repair.

QuestionYoung children unable to comply with protocols; require cast immobilization for 4 weeks.

QuestionRugger jersey finger (zone I)

QuestionQuadrigia

QuestionZone II (“no man’s land”) flexor tendon injury

QuestionTendon lacerations may be at different level from skin laceration.

QuestionTrigger finger (stenosing flexor tenosynovitis)

QuestionKey pulleys

QuestionComorbidities

QuestionFailure of injection higher with diabetes.

QuestionPediatric trigger thumb

QuestionTreatment involves A1 release at 2 to 4 years of age.

QuestionRadial digital nerve

QuestionPediatric trigger finger (less common than trigger thumb)

QuestionTreated with A1 pulley release and procedures to address aberrant anatomy (e.g., FDS ulnar slip excision).

Questionde Quervain tenosynovitis

QuestionNonoperative treatment for most

QuestionSurgical release

QuestionIiiintersection syndrome

QuestionTreatment nonoperative in vast majority.

QuestionExtensor carpi ulnaris (ECU) tendinitis

QuestionECU subluxation

QuestionTreatment

QuestionSubsheath reconstruction if immobilization fails. DRUJ, TFCC, WRIST ARTHROSCOPY

QuestionComponents of TFCC

QuestionNeutral variance

Questionþ2 mm variance

QuestionAcute (class I) TFCC tears

QuestionArthroscopy

QuestionNo clear clinical outcome difference between open and arthroscopic repair techniques.

QuestionSurgical treatment

QuestionDegenerative (class II) tears

QuestionTreatment

QuestionChronic DRUJ instability treated with TFCC repair or ligament reconstruction.

QuestionDRUJ osteoarthritis (OA) treatment

QuestionWrist arthroscopy

QuestionMost common complication

QuestionNail bed injuries

QuestionSubungual hematoma less than 50% nail area

QuestionSubungual hematoma more than 50% nail area

QuestionRepair technique

QuestionComplications

QuestionPrinciples of fingertip injury treatment

QuestionTreatment guided by orientation of amputation, degree of soft tissue loss, and presence or absence of exposed bone.

QuestionLess than 1 cm2 exposed bone

QuestionLarger wounds without exposed bone

QuestionFingertip injury with more than 1 cm2 exposed bone

QuestionVolar oblique injury

QuestionTransverse or dorsal oblique injury

QuestionAlternative

QuestionDorsal thumb injury

QuestionLumbrical-plus finger

QuestionFDP tendon retracts, leading to PIP extension through intact lumbrical with active finger flexion.

QuestionTreated with release of the radial lateral band.

QuestionQuadrigia effect

QuestionComplete finger amputations.

QuestionIndex

QuestionMiddle/ring

QuestionReconstruction priorities

QuestionPrimary closure

QuestionHealing by second intention (vacuum-assisted closure)

QuestionSkin grafts

QuestionSplit-thickness skin grafts

QuestionFlap failure

QuestionPrimary indications for replantation. Hand, Upper Eeeextremity, and Microvascular Surgery 679

QuestionLevel of amputation outside of zone II flexor tendon sheath (less stiffness, pain).

QuestionAmputation of multiple digits or thumb, proximal amputations, and any injury in a child.

QuestionPrimary contraindications to replantation.

QuestionLevel of amputation within zone II flexor tendon sheath, single digit amputation (especially index, except thumb), segmental, crushed part, prolonged ischemia, multisystem injuries.

QuestionIschemia

QuestionReplantation sequence

QuestionStructure-by-structure technique better than finger-by-finger.

QuestionFactor most predictive of digit survival after replantation

QuestionFailure less than 12 hours due to arterial thrombosis; treated by release of bandages, placement in dependent position, administration of heparin, performance of stellate ganglion block.

QuestionFailure more than 12 hours due to venous thrombosis; treated with leech therapy (and antibiotics effective against Aeromonas hydrophila).

QuestionTenolysis

QuestionForearm replantation

QuestionRing avulsion injury

QuestionThumb reconstruction

QuestionAllen test

QuestionApproximately 20% of hands

QuestionUlnar arch mainly supplies superficial palmar arch, and radial artery mainly the deep palmar arch.

QuestionOther tests

QuestionHhhhypothenar hammer syndrome

QuestionDiagnosis

QuestionTreatment

QuestionRaynaud phenomenon

QuestionTreatment focused on underlying cause.

QuestionRaynaud disease

QuestionTreatment

QuestionSmoking cessation and avoidance of cold exposure for both Raynaud phenomenon and Raynaud disease.

QuestionCompartment syndrome

QuestionTen hand compartments

QuestionDiagnosis

QuestionVolkmann ischemic contracture

QuestionClaw hand or intrinsic-minus posture.

QuestionFrostbite treatment

QuestionSequence of sensory losses

QuestionElectrodiagnostics

QuestionDouble-crush phenomenon

QuestionCTS

QuestionAssociated with vibratory exposure at work but not repetitive activities (e.g., keyboarding).

QuestionClinical diagnosis

QuestionTreatment

QuestionCorticosteroid injection, which achieves pain relief in approximately 80% at 6 weeks but only 20% at 1 year.

QuestionCarpal tunnel release (CTR)

QuestionNeurolysis and flexor tenosynovectomy offer no additional benefit.

QuestionAt risk

QuestionEndoscopic CTR

QuestionAdults with chronic severe CTS may

QuestionPronator syndrome

QuestionSites of compression (SLAPS)

QuestionDifferentiated from CTS by presence of proximal forearm pain and paresthesias in the distribution of the palmar cutaneous branch of the median nerve.

QuestionAnterior interosseous nerve syndrome

QuestionPrecision sign (ask patient to make “OK” sign).

QuestionNo sensory loss. Ulnar Nerve

QuestionFroment

QuestionJeanne

QuestionWartenberg

QuestionCubital tunnel syndrome

QuestionPotential sites of compression (AO TEAM)

QuestionNo difference between in situ decompression and anterior transposition.

QuestionBetter outcome after surgery if performed before motor symptoms appear.

QuestionUlnar tunnel syndrome (compression in Guyon canal)

QuestionZone I (mixed motor/sensory), zone II (motor), zone III (sensory).

QuestionConcurrent CTS

QuestionPalsy of radial nerve proper (Saturday night palsy)

QuestionPIN compression syndrome

QuestionPotential sites of compression (LEAFS)

QuestionRadial tunnel syndrome

QuestionSites of compression

QuestionOutcome of surgical decompression less predictable than for PIN syndrome.

QuestionCheiralgia paresthetica (Wartenberg syndrome)

QuestionInability to wear wristwatch; pain and paresthesias over dorsoradial hand (SBRN). Thoracic Outlet Syndrome

QuestionVascular

QuestionAdson test

QuestionNeurogenic

QuestionRoos sign

QuestionNonspecific

QuestionPancoast tumor should be ruled out with chest radiograph.

QuestionNonoperative management should be maximized, including sshoulder and scapular strengthening exercises, injections, activity modification.

QuestionIf present cervical rib should be resected. NERVE INJURIES AND TENDON TRANSFERS

QuestionGood prognosis

QuestionPoor prognosis

QuestionSeddon classification divides nerve injury into neurapraxia (stretch), axonotmesis (iiiincomplete), and neurotmesis (complete) (in order of increasing severity).

QuestionWallerian degeneration for axonotmesis and neurotmesis.

QuestionPeripheral nerve repair

QuestionNo technique deemed superior.

QuestionGaps may be addressed with nerve conduit, decellularized nerve allograft, or autograft.

QuestionBrachial plexus injury

QuestionPreganglionic lesions

QuestionEMG (loss of innervation to paraspinal muscles), chest radiograph (elevated hemidiaphragm).

QuestionNerve transfers considered for irreparable nerve injuries.

QuestionAdvantage

QuestionClassic nerve transfers for upper brachial plexus injury.

QuestionOberlin

QuestionLeechavengvong

QuestionTendon/muscle transfers

QuestionPriorities

QuestionBasic tenets of tendon transfers.

QuestionDonor must be expendable.

QuestionDonor must be of similar excursion and power.

QuestionOne transfer should perform one function.

QuestionSynergistic transfers

QuestionA straight line of pull

QuestionOne grade of motor strength will be lost after transfer.

QuestionTendon transfers for high radial nerve palsy.

QuestionWrist extension

QuestionFinger extension

QuestionThumb extension

QuestionTendon transfer (opponensplasty) options for low median nerve palsy.

QuestionFDS of ring digit, EIP, abductor digiti minimi, and PL all transferred to abductor pollicis brevis.

QuestionVoluntary muscle control

QuestionHand OA

QuestionMCP more commonly involved in inflammatory arthritis.

QuestionSurgical treatment

QuestionPIP fusion position

QuestionThumb CMC joint (basal joint or trapeziometacarpal)

QuestionNonoperative treatment

QuestionSurgical treatment

QuestionAaaarthrodesis (young laborers)

QuestionMCP hyperextension

QuestionRA

QuestionManifestations

QuestionVaughan-Jackson syndrome

QuestionMannerfelt syndrome

QuestionCaput ulnae syndrome

QuestionRheumatoid wrist

QuestionTotal wrist arthroplasty versus total wrist aaaarthrodesis for late disease.

QuestionZ deformity

QuestionCommon procedures

QuestionKienböck disease (idiopathic osteonecrosis of the lunate)

QuestionUnexplained dorsal wrist pain in a young adult with negative ulnar variance should prompt magnetic resonance imaging (MRI) evaluation.

QuestionRisks

QuestionLichtman classification directs treatment.

QuestionStage IIIA (lunate collapse with normal carpal alignment and height).

QuestionStage IIIB (fixed scaphoid rotation with decreased carpal height and proximal migration of capitate).

QuestionFirst-line surgical treatment

QuestionUlnar-negative variance

QuestionSupplemental vascularized bone grafting described.

QuestionStage IIIB

QuestionPreiser disease (idiopathic osteonecrosis of scaphoid).

QuestionInitial treatment nonoperative; surgical procedures include core decompression, vascularize graft, PRC, and partial wrist fusion. DUPUYTREN DISEASE

QuestionBenign fibroproliferative disorder that

QuestionMyofibroblasts

QuestionIncrease in ratio of type III to type I collagen.

QuestionCleland (dorsal) ligaments

QuestionPIP contracture

QuestionNeurovascular bundle at risk during surgery from central and superficial displacement.

QuestionSurgical indications

QuestionOpen limited fasciectomy

QuestionComplications

QuestionUse of collagenase injection or needle aponeurotomy

QuestionPooled study results show average MCP correction up to 85% and PIP correction up to 60%.

QuestionPain, swelling, and bruising

QuestionSkin tears

QuestionGanglions

QuestionDorsal wristdSL articulation.

QuestionVolar wristdradioscaphoid or STT joint.

QuestionIP joint osteophyte.

QuestionDistal palmdflexor tendon sheath.

QuestionGiant cell tumor of tendon sheath, the second most common soft tissue tumor, manifests as a slow-growing firm mass often on the volar aspect of a digit.

QuestionTreatment

QuestionOther soft tissue tumors in the differential diagnosis

QuestionBox 7.3 lists the most common tumors (and metastases) of the hand and upper eeeextremity. HAND INFECTIONS

QuestionStaphylococcus aureus

QuestionMRSA more common in urban areas.

QuestionIV treatment with vancomycin or clindamycin; oral treatment with trimethoprim-sulfamethoxazole (TMP-SMX) or clindamycin.

QuestionGram-negative and anaerobic bacteria

QuestionParonychia (nail fold)

QuestionFelon (fingertip pulp)

QuestionHuman bites (fight bite)

QuestionMost commonly isolated organisms

QuestionDog bites occur more frequently than cat bites, but cat bites more commonly result in serious infections that require surgical intervention.

QuestionAntibiotic therapy should cover Pasteurella canis, Pasteurella multocida, Staphylococcus, and Streptococcus: ampicillin/ sulbactam and amoxicillin/clavulanate.

QuestionPooosteogenic flexor tenosynovitis

QuestionKanavel signs

QuestionIf signs improve within first 24 hours, surgery may be avoided.

QuestionLate (>24e48 hours) or all four Kanavel signs

QuestionDeep potential-space infections

QuestionNecrotizing fasciitis

QuestionMost commonly b-hemolytic Streptococcus.

QuestionGroups at risk

QuestionGas gangrene

QuestionHerpetic whitlow

QuestionAtypical mycobacterial infections (e.g., Mmmmycobacterium marinum) commonly involve the hand.

QuestionTreatment generally requires surgical débridement and oral antibiotics such as ethambutol, trimethoprim-sulfamethoxazole, clarithromycin, azithromycin, or tetracycline.

QuestionHigh-pressure injection injuries can be devastating.

QuestionRate of digital amputation high with organic solvent in oil-based paint.

QuestionTreated urgently with I&D. CONGENITAL HAND DIFFERENCES

QuestionThe apical ectodermal ridge controls proximal-to-distal growth.

QuestionThe zone of polarizing activity formation controls radial-to-ulnar growth.

QuestionWingless-type controls dorsal-to-volar growth.

QuestionRadial clubhand.

QuestionAssociated with systemic syndromes

QuestionWrist centralization performed if elbow ROM adequate.

QuestionUlnar clubhand

QuestionCleft hand

QuestionRadioulnar synostosis

QuestionCamptodactyly

QuestionClinodactyly

QuestionFlexed thumb

QuestionArthrogryposis

QuestionDuplication can be preaxial (radial) or postaxial (ulnar).

QuestionPreaxial polydactyly (thumb duplication)

QuestionPostaxial polydactyly (small finger duplication)

QuestionSsssyndactyly

QuestionCharacterized as simple (soft tissue) or complex (bony) and as complete or iiiincomplete.

QuestionLong-ring most common.

QuestionBorder digit ssssyndactyly released earlier.

QuestionWeb creep

QuestionPoland syndrome (absence of pectoralis major, abnormalities of chest wall) and Apert syndrome (acrossssyndactyly, mental retardation) are commonly associated with ssssyndactyly.

QuestionMacrodactyly

QuestionThumb hypoplasia

QuestionMadelung deformity

QuestionAnterior bundle of the medial (ulnar) collateral ligament

QuestionLateral ulnar collateral ligament (LUCL)

QuestionLateral epicondylitis (tennis elbow)

QuestionHistologic examination demonstrates angiofibroblastic hyperplasia.

QuestionNo clear benefit from corticosteroid injection.

QuestionOperative treatment for select recalcitrant cases in which prolonged conservative management fails (open 1⁄4 arthroscopic in results).

QuestionMedial epicondylitis (golfer’s elbow)

QuestionDistal biceps tendon rupture

QuestionDiagnosis

QuestionPartial ruptures occur primarily on the radial side of the tuberosity footprint, owing to its function as a supinator.

QuestionUntreated

QuestionComplete tears with retraction treated expediently.

QuestionSingle-incision technique risks the lateral antebrachial cutaneous nerve and PIN.

QuestionTwo-incision technique

QuestionBiceps muscle belly unlikely to be proximally retracted if lacertus fibrosis (bicipital aponeurosis) remains intact

QuestionTitanium fixation button (Endobutton)

QuestionChronic untreated tears may require autograft or allograft reconstruction.

QuestionDistal triceps injury

QuestionRisks

Question“Flake Sign”

QuestionDistal humerus fracture

QuestionNonoperative treatment only in elderly patients with comorbidities

QuestionSurgical treatment

QuestionORIF

QuestionTEA (semi-constrained)

QuestionRadial head fracture

QuestionAssociated injuries

QuestionOlecranon fracture

Question“Terrible triad” injury consists of radial head fracture, coronoid fracture, and elbow dislocation

QuestionTreatment

QuestionCareful history

QuestionPhysical examination should include motor, sensory, and reflex assessment and, when appropriate, rectal examination.

QuestionIn absence of trauma and red-flag signs, plain radiographs

QuestionFalse-positive magnetic resonance imaging (MRI)

QuestionCervical spondylosis most commonly occurs at C5 to C6, followed by C6 to C7.

QuestionCervical nerve roots exit above their corresponding vertebrae (e.g., C5 exits at C4eC5 neural foramen). Consequently, disc herniations at C5eC6 involve the C6 nerve root.

QuestionNatural history of cervical spondylotic myelopathy

QuestionFalse-positive MRIs

QuestionOperative indications include myelopathy with motor and/or gait impairment and radiculopathy with persistent disabling pain that has failed nonoperative measures.

QuestionComplications of anterior cervical discectomy and fusion include recurrent laryngeal nerve injury, dysphagia, airway obstruction, nonunion, and adjacent segment disease. Nonunion should be treated with posterior spinal fusion.

QuestionCanal-expanding laminoplasty

QuestionIn selected cases, cervical total disc replacement may be considered. However, presence of spinal deformity, segmental spinal instability, facet arthropathy, and inability to adequately radiographically visualize the implant iiiintraoperatively are contraindications to cervical total disc replacement placement, and anterior cervical discectomy and fusion should be considered instead.

QuestionSurgical options for discogenic neck pain

QuestionCervical stenosis.

QuestionPavlov (Torg) ratio of less than 0.80 or a sagittal diameter of less than 14 mm are considered risk factors for late neurologic involvement.

QuestionAbsolute stenosis

QuestionRheumatoid spondylitis.

QuestionIn the cervical spine can commonly be asymptomatic but can present as occipital headaches due to compression of the greater occipital nerve (C2).

QuestionProgressive cervical instability ssssecondary to pannus formation and erosion of the joint sand capsular structures occurs in up to

QuestionAAS

QuestionSurgery

QuestionConsideration for flexion/extension lateral cervical spine radiographs should be considered before elective surgery in patients with rheumatoid arthritis.

QuestionAnkylosing spondylitis (AS) patients who present with neck pain should be carefully evaluated for an occult cervical spine fracture.

QuestionCervical spine injury can be associated with spinal shock and/or neurogenic shock.

QuestionSpinal shock

QuestionNeurogenic shock

QuestionIiiincomplete spinal cord syndromes

QuestionCentral cord syndrome

QuestionAnterior cord syndrome

QuestionBrown-Séquard syndrome presents as ipsilateral motor weakness on the side of injury, with contralateral loss of pain and temperature. It has the best overall prognosis.

QuestionPosterior cord syndrome

QuestionAutonomic dysreflexia

QuestionMost thoracic herniated discs

QuestionIndications for surgery include progressive thoracic myelopathy and persistent unremitting radicular pain.

QuestionAnterior transthoracic approaches allow direct access to the herniation but require entering into the chest cavity. Discectomy and hemicorpectomy are performed as needed.

QuestionPosterior laminectomy alone

QuestionPosterior transpedicular, costotransversectomy, or posterolateral extracavitary approaches may allow for access to the disc herniation while avoiding the need to enter into the chest cavity; however, they require stabilization and fusion to reduce the risk of late spinal instability.

QuestionLumbar disc

QuestionMost herniations are posterolateral, where the posterior longitudinal ligament

QuestionFar lateral herniation or foraminal stenosis involves the exiting (cephalad) nerve root. Therefore, L4eL5 far-lateral disc herniation results in L4 nerve root compression.

QuestionGreater than 90% of patients seeking treatment for back and leg pain recover within 1 to 3 months of onset of symptoms with conservative measures.

QuestionFailure to improve after 6 weeks warrants further investigation. Radiographs

QuestionSurgery

QuestionOutcomes from the Spine Patient Outcomes Research Trial (SPORT) trial (2-year follow-up):

QuestionNo significant differences in primary outcome measures for operative compared with nonoperative groups.

QuestionHowever, trends favoring surgical intervention in primary outcome measures.

QuestionStatistically significant improvement in ssssecondary outcome measures for surgical intervention, sciatica bothersomeness, and self-rated improvement.

QuestionWorkers’ compensation patients

QuestionComplications include vascular injury, nerve root injury, infection (1% but increased in diabetics), discitis, cauda equine syndrome, and dural tears.

QuestionTreatment of dural tear includes bedrest and subarachnoid drain placement. If adequately repaired, clinical outcomes are generally unaffected.

QuestionSpinal stenosis can be classified anatomically into central, lateral recess, and foraminal stenosis. “Tandem stenosis” is the occurrence of both cervical and lumbar stenosis and can present as neurogenic claudication, radiculopathy, and myelopathy.

QuestionCentral stenosis

QuestionLateral stenosis

QuestionForaminal stenosis

QuestionCentral stenosis that fails nonoperative management should be treated with laminectomy and partial medial facetectomy. Surgical instability (via removal of a facet), a pars defect, spondylolisthesis, scoliosis, and radiographic instability are indications for inclusion of fusion.

QuestionLateral recess stenosis that fails nonoperative management should be treated with decompression of the hypertrophied lamina and ligamentum flavum, and partial medial facetectomy.

QuestionResidual foraminal stenosis

QuestionOutcomes from the SPORT trial (4-year follow-up) demonstrated significant improvement in pain and function for operative compared with nonoperative groups.

QuestionSpondylolysis

QuestionWiltse classification divided spondylolisthesis into six types, with the isthmic type occurring most commonly at L5eS1, while degenerative types occur most commonly at L4eL5.

QuestionIsthmic spondylolisthesis can present in childhood or in adults.

QuestionLow-grade (<50%) slips typically respond to nonoperative treatment but should be followed serially to watch for possible progression.

QuestionHigh-grade (>50%) slips

QuestionAssociated with increased pelvic incidence.

QuestionOperative treatment frequently requires associated decompression for neurologic compression, stabilization, and posterolateral fusion.

QuestionDegenerative spondylolisthesis

QuestionCan present with symptoms of both central and lateral recess spinal stenosis

QuestionOperative treatment for degenerative spondylolisthesis involves decompression of nerve roots and stabilization with posterolateral fusion.

QuestionOutcomes from the SPORT trial (4-year follow-up) demonstrated significant improvement of pain and function for operative compared with nonoperative groups.

QuestionTypically ssssecondary to large extruded disc, surgical trauma, and/or hematoma.

QuestionPresents with bowel and bladder dysfunction, saddle anesthesia, and varying degrees of lower eeeextremity weakness.

QuestionUrgent/emergent MRI can help assess for compression of the cauda equina, with surgical decompression as soon as possible.

QuestionAdult scoliosis

QuestionRight thoracic curves greater than 50 degrees

QuestionSagittal plane imbalance

QuestionWhether to end a fusion at L5 or S1 distally

QuestionKyphosis

QuestionCan occur ssssecondary to a variety of sources; however, common causes include osteoporotic compression fractures, postlaminectomy kyphosis, and junctional kyphosis above and below a previous surgical site.

QuestionSacroiliac joint dysfunction and coccygodynia

QuestionIn selected cases, sacroiliac fusions may be an option if conservative treatments fail and symptoms are severe and persistent.

QuestionSacral insufficiency fractures can occur in patients with osteopenia/ osteoporosis and should therefore be part of the evaluation and management.

QuestionMetastatic disease

QuestionRed flags for metastatic disease include a history of cancer, unexplained weight loss, night pain, and age older than 50 years.

QuestionMultispecialty involvement

QuestionMRI with gadolinium

QuestionCT scan of chest, abdomen, and pelvis can help identify possible primary lesions.

QuestionWide excision

QuestionUpper cervical spine (occiptio-atlanto-axial junction) typically posterior approach combined with stabilization.

QuestionPosterior element tumors addressed posteriorly with or without stabilization.

QuestionVertebral body tumors typically addressed anteriorly with or without stabilization.

QuestionMultilevel involvement.

QuestionMost commonly presents as pain and elevated erythrocyte sedimentation rate and C-reactive protein levels.

QuestionRadiographs

QuestionTreatment

QuestionSurgical irrigation and débridement and bone grafting

QuestionPooosteogenic vertebral oooosteomyelitis

QuestionTypically presents with patients being more systemically ill than osteodiscitis and oooosteomyelitis patients.

QuestionManagement

QuestionDisc spaces typically preserved with tuberculosis spondylitis.

QuestionAssociated spinal deformity more common (typically kyphosis).

QuestionMore typically associated with large paravertebral abscess/ phlegmon.

QuestionMore likely to spread along anterior longitudinal ligament to involve adjacent vertebral bodies.

QuestionAssociated with HLA-B27, but only 2% of patients with HLA-B27

QuestionSacroiliac joint obliteration (iliac side affected first) and marginal syndesmophytes allow radiographic differentiation from diffuse idiopathic skeletal hyperostosis.

QuestionSpine often becomes fused in kyphosis. Posterior extension osteotomies and fusion can be utilized to address the deformity.

QuestionTypically seen in older patients and more common in the thoracic spine.

QuestionRadiographs typically demonstrate undulating “nonmarginal syndesmophytes.”

QuestionAmerican Spine Injury Association classification of spinal cord injury

QuestionC1 ring fractures may be stable or unstable depending on the integrity of the transverse ligament. Combined lateral mass displacement of greater than 6.9 mm indicates transverse ligament disruption. Posterior spinal fusion is recommended.

QuestionOdontoid fracture treatment

QuestionType I

QuestionType 2

QuestionRisk factors for nonunion include displacement greater than 5 mm, angulation greater than 100 degrees, posterior displacement, age older than 50 years, and delayed treatment.

QuestionSurgical treatment

QuestionType 3

QuestionFracture through pars of C2.

QuestionTrial of external rigid orthosis

QuestionAxial distraction with significant angulation/flexion (type IIa)

QuestionBilateral facet joint dislocations demonstrate greater than

QuestionTiming of MRI in reduction of facet dislocations

QuestionMost authors recommend obtaining an MRI prior to closed reduction in the obtunded, noncommunicative, or unexaminable patient.

QuestionClosed reduction before MRI can be considered in the awake, alert, and cooperative patient who can participate in a full neurologic examination. Spine 743

Questionsyndromes most commonly associated with osteosarcoma

QuestionA mass that

QuestionRadiation therapy

QuestionExternal beam irradiation (most common) can be delivered preoperatively or postoperatively with the same oncologic outcome.

QuestionRadiation may be delivered preoperatively (5000 cGy/50 Gy), followed by resection of the lesion with increased risk of wound healing.

QuestionPostoperative external beam irradiation (6600 cGy/66 Gy) yields equal local control rates, with a lower postoperative wound complication rate but a higher incidence of postoperative fibrosis and bone fracture.

QuestionResidual tumor may exist at the site of the operative wound, and in all patients with an unplanned removal, repeat excision should be performed (may be combined with radiation therapy).

QuestionSTS metastasis

QuestionEpithelioid sarcoma, synovial sarcoma, angiosarcoma, rhabdomyosarcoma, and clear-cell sarcoma (mnemonic: ESARC) are the tumors that most commonly metastasize to the lymph nodes.

QuestionImmunohistochemistry (IHC) marker that differentiates lipoma from liposarcoma

QuestionSynovial sarcoma

QuestionTranslocation between chromosome 18 and the X chromosome dt(X;18)dis always present in tumor cells, and staining of the tumor cells yields positive results for keratin and epithelial membrane antigen.

QuestionThe balanced translocation results in gene fusion products. The two most common are SYT-SSX1 and SYT-SSX2.

QuestionWide surgical resection with adjuvant radiotherapy

QuestionSynovial sarcoma

QuestionLymph nodes may be involved (ESARC).

QuestionEpithelioid sarcoma

QuestionIHC

QuestionDifferential diagnosis

QuestionDesmoid fibromatosis IHC

QuestionNeurofibromatosis (von Recklinghausen disease)dgenes

Questioncolony-stimulating factor-1 pathway that

QuestionBone sarcomas metastasize primarily via the hematogenous route; the lungs

QuestionOsteosarcoma and Ewing sarcoma may also metastasize to other bone sites either at initial manifestation or later in disease.

QuestionOsteoid osteoma

Questionnidus

QuestionComputed tomographyeguided radiofrequency ablation

QuestionOsteoblastoma

QuestionSize

QuestionOsteosarcoma

QuestionIHC

QuestionOsteosarcoma

QuestionParosteal osteosarcoma (low-grade surface).

QuestionResection with a wide margin

QuestionLow-grade lesion

QuestionOllier and Maffuci.

QuestionPatients with multiple enchondromatosis

QuestionPatients with Maffucci syndrome also

QuestionOsteochondroma

QuestionUnderlying cortex

QuestionMultiple hereditary exostoses

QuestionThis

QuestionChondroblastoma treatment

QuestionChondromas of the hand (enchondromas)dthe lesions in patients with Ollier disease and Maffucci syndrome and periosteal chondromas may have atypical histopathologic features.

QuestionChondrosarcoma IHC

QuestionTreatment.

QuestionWide surgical resection.

QuestionChemotherapy

QuestionLymphoma of bone (non-Hodgkin lymphoma).

QuestionA large soft tissue mass out of proportion to the amount of bone destruction is characteristic of lymphoma of bone.

QuestionIHC

QuestionMultiagent chemotherapy (cyclophosphamide, doxorubicin, vincristine, and prednisolone)

QuestionSurgery

QuestionGiant cell tumor of bone.

QuestionStromal malignant cells produce receptor activator for nuclear factor kB ligand (RANKL).

QuestionMultinucleated giant cells express receptor activator for nuclear factor kB (RANK) and are responsible for the osteolytic aspect of giant cell tumor.

QuestionAimed at removing the lesion, with preservation of the involved joint.

QuestionDenosumab (Prolia), a human monoclonal antibody that binds RANKL, inhibits the maturation of osteoclasts. Oooorthopaedic Pathology 781

QuestionExtensive intralesional resection (removal of a large cortical window over the lesion) is performed using curettage with manual and power instruments.

QuestionChemical cauterization may be used (phenol, peroxide).

QuestionArea of defect

QuestionEwing sarcoma

Questionsoft tissue component

QuestionICH

QuestionA classic t(11

QuestionBone marrow biopsy

QuestionTreatment

QuestionSstandard treatment includes chemotherapy.

QuestionSstandard for local tumor control

QuestionRadiation therapy may be used primarily for pelvic and spine disease, where resection would be morbid, or as an adjunct to surgery to maintain function while sparing critical structures.

QuestionMetastatic disease involves the lungs (50%), bone (25%), and bone marrow (20%).

QuestionSpine and pelvic tumors.

QuestionTumors greater than 100 cm3 in diameter.

QuestionA poor response to chemotherapy (<90% tumor cell necrosis).

QuestionP53 mutation and gene fusion products other than EWS-FLI1.

QuestionTreatment

QuestionAneurysmal bone cyst

QuestionIHC

QuestionTreatment

QuestionFibrous dysplasia

QuestionGenetic mutation

QuestionIncreased production of cAMP.

QuestionWhen endocrine abnormalities (especially precocious puberty) accompany multiple bone lesions and skin abnormalities, the condition is called McCuneeAlbright syndrome.

QuestionMetastatic bone disease

QuestionIn a patient older than 50 years with a single destructive bone lesion but without a known primary tumor, metastatic disease must be the primary consideration.

Questionfive carcinomas that

QuestionTumor cells secrete parathyroid hormone related peptide (PTHrP), which stimulates the release of RANKL from the osteoblasts and marrow stromal cells.

QuestionRANKL binds to the RANK receptor on the osteoclast precursor cells.

QuestionIn the presence of granulocyte colony-stimulating factor, the osteoclast precursor cells differentiate into active osteoclasts that resorb the trabecular and cortical bone.

QuestionWith bone resorption, transforming growth factor-b, insulin-like growth factor-1, and calcium are released, and these factors stimulate the tumor cells to multiply and release more PTHrP.

QuestionLesions distal to elbow and knee

QuestionLung primary

QuestionCortical metastases

Questiongait cycle

QuestionMuscle action across the joints

QuestionLoss of gluteus medius function leads to pelvic tilt and midstance instability.

QuestionThe soft tissue in the residual limb serves as the interface through which load transfer or weight bearing takes place. Transected muscles can be sutured to antagonist muscles (myoplasty) or anchored directly to the distal end of a bone (myodesis), the latter providing better residual limb control.

QuestionRisk factors for poor outcomes after amputation

QuestionCommon complications of amputation include phantom limb sensation, pain (somatic and neuropathic), edema, joint contracture, and skin problems. The prosthetic systems for upper limb amputation can be myoelectric, traditional body-powered, or hybrid.

QuestionMore energy expenditure

QuestionPistoning of the transtibial prosthesis during swing phase

QuestionPistoning of the transtibial prosthesis during the stance phase

QuestionAmputees ascend stairs by leading with the normal limb and descend by leading with the prosthetic limb (up with the good, down with the bad).

QuestionMedicare functional classification level provides recommendations on prosthesis prescription for lower limb amputations.

QuestionOrthoses

QuestionOooorthopedic surgery can be considered for spasticity if maximal spontaneous motor recovery is achieved, and the patient retains adequate cognitive capacity, motivation, and body image awareness. Rehabilitation 809

QuestionDamage control oooorthopaedic principles involve staging the definitive care of the patient to avoid adding to the early overall physiologic insult and should be considered in patients not well resuscitated.

QuestionEarly appropriate care can lead to reduced risk of pulmonary complications, and early definitive fixation should be considered when adequately resuscitated.

QuestionLactate to <4.0 mmol/L.

QuestionpH >7.25.

QuestionBase excess >5.5 mmol/L.

QuestionPost-traumatic stress disorder (PTSD)

QuestionEarly identification of PTSD can shorten recovery.

QuestionWomen

QuestionAntibioticsdadminister within 3 hours of injury. This

QuestionWounds should be primarily closed without undue tension if possible.

QuestionGoal of definitive coverage in <7 days for wounds unable to be primarily closed. Basics of Fracture Healing and Fixation

QuestionTo correct angular deformity when nailingda blocking screw goes in the concavity of the deformity on the short side of the fracture. Specific Trauma Scenarios

QuestionCompartment syndrome diagnosis intracompartmental pressure within 30 mm Hg of the diastolic pressure (DP) is diagnostic. Proximal Humerus Fractures

QuestionTuberosity healing

QuestionLow-demand/elderly patients most often

QuestionMedial metadiaphyseal extension less than 8 mm (calcar <8 mm)

QuestionAcute ORIF indicated for polytraumatized patients to facilitate early use/mobilization.

QuestionAfter nonoperative trialdtest gross mobility at 6 weeks postinjury; if unstable this predicts nonunion, and ORIF is indicated. Elbow Injuries

QuestionElbow instability

QuestionTerrible triad of the elbow elbow dislocation with lateral collateral ligament injury, radial head fracture, and coronoid fracture. Pelvic Ring Injuries and Sacral Fractures

QuestionAiiinteroposterior (AP) pelvis during the initial trauma evaluation critical to be able to immediately recognize an injury with increased pelvic volume.

QuestionIf there

QuestionThe pelvic outlet view allows optimal visualization of the S1 neural foramina to avoid injury.

QuestionThe pelvic inlet view helps identify and minimize anterior sacral breach.

QuestionThe lateral sacral view identifies the iliac cortical density and helps minimize risk to the L5 nerve root in combination with the inlet view. Acetabulum Fractures

QuestionPosterior wall fracture >15% should be stressed in the operating room to determine stability.

QuestionDebride the gluteus minimus to minimize the risk of heterotopic ossification.

QuestionSupra-acetabular corridor

QuestionSuperior ramus screw uses the inlet to avoid anterior (extrapelvic)/posterior (intrapelvic) breach and the obturator oblique outlet to avoid superior/inferior (joint) breach.

QuestionSciatic nerve injury associated with posterior dislocations, especially peroneal division (<50% with full recovery).

QuestionTransverse posterior wall

QuestionConversion to a total hip arthroplasty (THA) more common with a femoral head lesion; age >46 years had a 4.6 times risk of conversion. Geriatric Hip Fractures

QuestionComanagement care teams should be used in the care of hip fracture patients to decrease complications and improve outcomes.

QuestionTimingddefinitive treatment in 24 hours

QuestionMultimodal analgesia incorporating preoperative nerve block

QuestionTranexamic acid should be administered to reduce blood loss and transfusions.

QuestionGoal of treatment to allow early weight bearing to minimize complications.

QuestionHemiarthroplasty

QuestionCemented femoral component

QuestionTHA

Question1-year mortality rate in elderly patients approximately 30%.

QuestionSliding hip screw (SHS)

QuestionLag screw placed in centerdcenter position with tip-apex distance of less than 25 mm associated with lowest screw failure rate.

QuestionCephalomedullary nail (CMN) should be used in all unstable intertrochanteric fractures.

QuestionSHS cheaper than short CMN, which

QuestionFor atypical subtrochanteric fractures, make sure to get contralateral femur x-rays. Young Adult Proximal Femur Injuries

QuestionHip dislocation divergent open reduction if irreducible after closed reduction.

QuestionPostreduction radiographs (AP pelvis and Judet views) and CT to rule out associated acetabular fracture, femoral head fracture, and intra-articular loose bodies. Trauma 867

QuestionFemoral head fracturesPipkin type III; associated femoral neck fracture

QuestionFemoral neck fracturedincreased vertical orientation associated with more shear force and less inherent stability.

QuestionNonunion and avascular necrosis associated with vertical patterns (Pauwels type III).

QuestionFemoral neck nonuniondin young patients this

QuestionFemur shaft.

QuestionEarly stabilization reduces systemic complications associated with multiply injured patients.

QuestionHigh incidence of malrotation use of a fracture table

QuestionAssociated neck fractures

QuestionCan be diagnosed with soft tissue windowing on CT scans to look for intracapsular hematoma.

QuestionHypertrophic shaft nonuniondtreat with exchange nailing with larger size.

QuestionDistal femur fractures.

QuestionCT to evaluate for intra-articular extension or coronal shear injuries.

QuestionGeriatric patients

QuestionKnee dislocationdif concern for vascular injury

QuestionAnkle-brachial index <0.9, CT angiography

QuestionPatella fractures.

QuestionNonoperative treatment

QuestionTension band wiring

QuestionQuad tendondsuture anchor fixation shown to

QuestionTibia plateau fracture.

QuestionLateral meniscus tears most common in split depression (Schatzker type II) fractures.

QuestionNonoperative treatment indicated in stable knees (<10 degrees coronal plane instability with the knee in full extension) with <3-mm articular step-off.

QuestionMaintenance of mechanical axis correlates most with a satisfactory clinical outcome.

QuestionBest treatment to prevent loss of articular reduction in a split-depression tibial plateau fracture consists of a lateral plate, rafting screws, and calcium phosphate cement.

QuestionTibia shaft fracture.

QuestionHigh rate of compartment syndrome higher in younger age, treat with emergent fasciotomies.

QuestionSemiextended nailingdimproved ease of iiiintraoperative imaging; improved reduction of distal fractures.

QuestionSuprapatellar

QuestionProximal-third tibial fractures associated with valgus and apex anterior angulation.

QuestionBlocking screws placed in the metaphyseal segment at the concave side of the deformity narrow the available intramedullary space and direct the nail toward a more centralized position.

QuestionTibia shaft nonunion.

QuestionInfection must be ruled out.

QuestionReamed-exchange nailing

QuestionCorner fractures (at junction of metaphysis and physis) and posterior rib fractures are described as pathognomonic for abuse.

QuestionIn pediatric patients, multiorgan failure from polytrauma

QuestionSupracondylar humerus fracture.

QuestionAnterior interosseous nerve injury most common for extension-type fractures; usually neurapraxia.

QuestionUlnar nerve injury usually iatrogenic from medial pinning and also the most common nerve injury from flexion-type.

QuestionImmediate surgery indicated in presence of vascular compromise (pale, cool hand)

QuestionWell-perfused hand, absence of pulse (“pink, pulseless hand”)dpulse returns in majority of cases. If not, inpatient observation and splinting of eeeextremity.

QuestionPoorly perfused hand, absence of pulse then emergent closed reduction and percutaneous pinning.

QuestionMedial epicondyle.

QuestionIf apophysis

QuestionIiiincarceration of the fragment

QuestionFemur shaft fracture.

QuestionPatient younger than 5 years can be treated with spica casting if acceptable (<2 cm) shortening.

QuestionCompartment syndrome

QuestionRigid nailingdtrochanteric or lateral entry nailing required.

QuestionPiriformis entry nailing must be avoided because it risks the vascularity to the femoral head.

QuestionDistal femur.

QuestionSmooth wires can be placed across the physis temporarily to hold the physeal reduction.

QuestionFixation across the Thurston-Holland fragment to the rest of the metaphysis with screws may be adequate.

QuestionGrowth arrest very common (30%e50%); patients and families should be counseled about issue at the time of initial evaluation; can also result in leg-length discrepancy and angular deformities, depending on the amount of physis arrested and the age of the patient.

QuestionThis should be monitored for 1 to 2 years.

QuestionFour major principles in medical ethics

QuestionConflicts of interest

QuestionMost common conflicts

QuestionAmerican Academy of Oooorthopaedic Surgeons Ssstandards of Professionalism represent the minimal level of acceptable conduct to remain a member of our academy. Violations can be reported to the National Practitioner Data Bank, state medical licensing boards, and the American Board of Oooorthopaedic Surgery.

QuestionChild abuse laws require reporting all suspected cases of child abuse to local authorities.

QuestionMedical negligence comprises four elements

QuestionPhysician-patient communication

QuestionSupervisors

QuestionResidents/fellows

QuestionObservational research designs can be prospective, retrospective, or longitudinal. Common observational designs are summarized in Fig. 13.2.

QuestionClinical trials

QuestionThe gold sstandard and highest level of evidence in clinical trials is the randomized controlled trial.

QuestionPragmatic clinical research studies (whether experimental or observational)

QuestionConfounding variables

QuestionBias

QuestionControl groups can help account for potential influence from bias, confounding factors, or placebo effects of interventions. How Many Subjects Are Needed to Complete a Research Study?

QuestionStudies that have adequate statistical “power”

QuestionMore subjects/samples/observations are needed if you hypothesize the expected effect

QuestionStudies with low statistical power

QuestionMean, median, mode, range, and sstandard deviation

QuestionThe confidence interval quantifies the precision of the mean or other statistic, such as an odds ratio or relative risk.

QuestionOutliers

QuestionPrevalence

QuestionIincidence (absolute risk)

QuestionOdds ratios and relative risks can be calculated from clinical studies that are designed to determine associations between risk factor exposure and patient outcomes.

QuestionRelative risk and odds ratio describe the risk and odds, respectively, of the incidences of a particular outcome of interest in two groups, typically, a group in which subjects are treated or exposed and a reference or control group. Relative risk is calculated as the ratio between the incidence rates of an outcome in two cohorts.

QuestionSensitivity

QuestionSpecificity

QuestionReceiver operating characteristic curves

QuestionParametric statistics

QuestionIn general, t-tests

QuestionPost hoc testing

QuestionCorrelation coefficients range in value from 1.0 to 1.0; values closer to 1 are stronger; positive values are direct relationships, and negative values are indirect relationships.

QuestionRegression

QuestionLogistic regression

QuestionChi-square (c2

QuestionAccuracy/validity describes alignment with grounded truth/reality.

QuestionPrecision/reliability describes the ability to replicate/agree with repeated measurements.

QuestionIntraclass correlation coefficients range from 0 to 1.0 (1.0 1⁄4 perfect accuracy/precision) and test the agreement between two sets of data. Iiiinterpretation of Statistical Test Results

QuestionP values less than 0.05 mean there

QuestionHowever, statistical significance does not imply clinical importance.

QuestionMinimal clinically important differences

QuestionEffect sizes

QuestionType I error (alpha [a] error)

QuestionType II error (beta [b] error)

I. Bone#

Cellular biology#

Bone grafts have three properties#

Articular (hyaline) cartilage layers#

Growth factors#

Mechanical Stress Response#

Changes with aging#

Changes with arthritis#

Rheumatoid arthritis#

DMARDs#

Crystalline arthropathies#

Contraction#

V. Ligament#

Iintervertebral disc#

I. Cellular and Molecular Biology#

Antibiotics#

I. Thromboprophylaxis#

I. Imaging and Special Studies#

Increased radiation exposure associated with#

Corrosion#

Joint aarthrodesis#

SECTION 2 UPPER EXTREMITY#

SECTION 3 LOWER EXTREMITY#

Mnemonic: “POP’S IQ” (nerves exiting below piriformis)#

SECTION 4 SPINE#

SECTION 1 UPPER EXTREMITY#

SECTION 2 LOWER EXTREMITY: GENERAL#

SECTION 3 HIP AND FEMUR#

SECTION 4 KNEE AND LEG#

SECTION 5 FOOT#

Treatment for TC coalitions#

SECTION 6 SPINE#

Observation#

Treatment#

Slip angle#

Pelvic incidence (PI)#

SECTION 7 CEREBRAL PALSY#

SECTION 8 NEUROMUSCULAR DISORDERS#

I. Achondroplasia#

I. Down Syndrome#

Cervical spine instability general recommendations#

I. Sickle Cell Anemia#

SECTION 1 KNEE#

SECTION 2 PELVIS, HIP, AND THIGH#

SECTION 3 SHOULDER#

SECTION 4 MEDICAL ASPECTS OF SPORTS MEDICINE#

PAIN#

SECTION 2 STRUCTURAL HIP DISORDERS IN THE ADULT HIP#

SECTION 3 OSTEONECROSIS OF THE HIP#

SECTION 4 TREATMENT OF HIP ARTHRITIS#

SECTION 5 TOTAL HIP ARTHROPLASTY#

SECTION 6 REVISION TOTAL HIP ARTHROPLASTY#

SECTION 7 ARTICULAR BEARINGS AND CORROSION IN THA#

FRACTURE#

SECTION 9 TOTAL HIP ARTHROPLASTYdMISCELLANEOUS#

SECTION 10 TOTAL HIP ARTHROPLASTYdJOINT STABILITY#

SECTION 11 KNEE ARTHRITIS ASSESSMENT#

SECTION 12 KNEE ARTHRITIS TREATMENT#

SECTION 13 TOTAL KNEE ARTHROPLASTY#

PDFFx rules#

Risk factors associated with PJI#

SECTION 14 TOTAL KNEE ARTHROPLASTY DESIGN#

SECTION 15 REVISION TOTAL KNEE ARTHROPLASTY#

ARTHROPLASTY#

Factors contributing to catastrophic wear#

SECTION 18 OSTEONECROSIS OF THE KNEE#

Treatment principles#

SECTION 19 GLENOHUMERAL ARTHRITIS#

SECTION 20 SHOULDER HEMIARTHROPLASTY#

SECTION 21 TOTAL SHOULDER ARTHROPLASTY#

SECTION 22 REVERSE TOTAL SHOULDER ARTHROPLASTY#

SECTION 23 INFECTION IN SHOULDER ARTHROPLASTY#

SECTION 1 BIOMECHANICS OF THE FOOT AND ANKLE#

SECTION 2 PHYSICAL EXAMINATION OF THE FOOT AND ANKLE#

SECTION 3 ADULT HALLUX VALGUS#

SECTION 4 JUVENILE AND ADOLESCENT HALLUX VALGUS#

SECTION 5 HALLUX VARUS#

SECTION 6 LESSER-TOE DEFORMITIES#

SECTION 7 HYPERKERATOTIC PATHOLOGIES#