Orthopedics Hyperguide Review | Dr Hutaif General Ortho -...

This patient has postradiation osteosarcoma of the sacrum after undergoing treatment for pelvic cancer. Examinees should discern that this is a postradiation sarcoma by the imaging findings of an osteoblastic tumor with extraosseous extension arising in the expected radiation field for a patient who was treated with radiation for colorectal cancer 5 years earlier. The histology demonstrates a high-grade sarcoma.
Postradiation sarcomas are treated with chemotherapy and margin-negative surgical resection, but they are associated with a relatively poor prognosis likely attributable to the advanced age of most affected patients and the frequent axial location of these tumors, which can delay diagnosis and make it difficult to obtain an appropriate margin of resection. The imaging reveals a tumor, not an insufficiency fracture or postradiation changes, and the histology shows a sarcoma, not colorectal cancer.
RECOMMENDED READINGS
15. [Mavrogenis AF, Pala E, Guerra G, Ruggieri P. Post-radiation sarcomas. Clinical outcome of 52 Patients. J Surg Oncol. 2012 May;105(6):570-6. doi: 10.1002/jso.22122. Epub 2011 Oct 19. PubMed PMID: 22012601.](http://www.ncbi.nlm.nih.gov/pubmed/22012601)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/22012601)
16. [Patel SR. Radiation-induced sarcoma. Curr Treat Options Oncol. 2000 Aug;1(3):258-61. Review. PubMed PMID: 12057168.](http://www.ncbi.nlm.nih.gov/pubmed/12057168)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/12057168)

Chronic Vitamin D deficiency leads to problems with bone health and has been shown to increase the risk of falls in the elderly. Appropriate supplementation of Vitamin D has been shown to decrease this risk. Conversion in the skin decreases with age and may be nearly nonexistent in darkly pigmented individuals. Vitamin D3 is the preferred form for supplementation, but D2 is the form most available by prescription in the US. Hypervitaminosis D is rare and very high doses can be tolerated without significant concern for toxicity. Because the patient has sustained one insufficiency fracture, she is at risk for insufficiency fractures in other skeletal locations, rendering expectant observation insufficient. Her serum calcium is normal, and with a low Vitamin
D level, calcium utilization in her system would be inadequate. Bisphosphonate therapy in addition to calcium and vitamin D supplementation may provide a good long-term solution, but should not be instituted until the bone mineral imbalance has been adequately corrected. Surgical fixation of this fracture is not indicated, particularly in lieu of improving symptoms.

The primary nerves of the region are the sciatic, femoral, inferior and superior gluteal, and obturator. The most common nerve injury during THA is to the peroneal division of the sciatiCnerve, followed by superior gluteal, obturator, and femoral nerves. Injury to these structures can lead to loss of function and poor outcomes

Heat exhaustion and heat stroke reflect varying degrees of heat illness, with both marked by increased heat production with impaired heat dissipation. Heat exhaustion typically involves a core body temperature between 37°C (98.6°F) and 40°C (104°F) and usually presents with heavy sweating, as well as nausea; vomiting; headache; fainting; weakness; and cold or clammy skin. Fatigue, malaise, and dizziness may occur, but necessary to the diagnosis is normal mentation and stable neurologic status. Heat stroke is defined by a core body temperature >40°C (>104°F) and disturbances of the central nervous system, such as confusion, irritability, ataxia, and even coma. Heat exhaustion is a less urgent scenario and can usually be treated with rest, elevation, and rehydration. Heat stroke, confirmed here by the presence of mental status changes, is a more critical situation. The most important immediate step is rapid body cooling through whatever means are available, as this has been clearly shown to improve outcomes. Ideally, a whole body ice bath would be used, with ice towels, ice packs, cold water, and air fans all utilized if needed. Emergency department transportation and rehydration may be considered as well but are not as important as immediate lowering of body temperature. Anti-pyretics have no role in this process.

When contemplating the causes of subtalar joint degeneration in young patients, an unstable tarsal coalition should be considered in the absence of antecedent trauma. Initial treatment with casting is appropriate because this intervention can relieve symptoms for many patients. There are 2 surgical options for a symptomatic tarsal coalition: bar resection or completion fusion. Risk factors for a poor outcome after bar resection are adult age and a bar that encompasses more than 50% of the middle facet of the subtalar joint. Because this patient has both risk factors, the appropriate procedure is a subtalar fusion.
RECOMMENDED READINGS
[Comfort TK, Johnson LO. Resection for symptomatic talocalcaneal coalition. J PediatrOrthop. 1998 May-Jun;18(3):283-8. PubMed PMID: 9600549. ](http://www.ncbi.nlm.nih.gov/pubmed/9600549)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/9600549)
[Thorpe SW, Wukich DK. Tarsal coalitions in the adult population: does treatment differ from the adolescent? Foot Ankle Clin. 2012 Jun;17(2):195-204. doi: 10.1016/j.fcl.2012.03.004. Epub 2012 Apr 6. Review. PubMed PMID: 22541520. ](http://www.ncbi.nlm.nih.gov/pubmed/22541520)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/22541520)

Figure 2 depicts a typical unicameral bone cyst with a pathologic fracture. The decision to treat this lesion should be based on the amount of cortical thinning. If these lesions involve a pathologic fracture, many surgeons will treat them nonsurgically to see if the fracture stimulates healing of the cyst. If the cyst wall remains thin or the patient is symptomatic, then treatment is directed at decreasing cyst volume, increasing cortical thickness, and eliminating symptoms. This can be accomplished by curettage and grafting, injection with autogenous bone marrow, or grafting with 1 of the many available bone void fillers. In some cases, internal fixation may be required. This typically is accomplished with flexible intramedullary nails.
Figure 3 shows a typical nonossifying fibroma. These benign lesions are usually incidental findings on a radiograph and often resolve in adulthood. Treatment usually is not required, and these lesions typically do not produce symptoms.
Figure 4 shows an osteoid osteoma of the femoral neck. This is characterized by a central radiolucent nidus surrounded by reactive bone with increased radiodensity. These lesions are painful because of the large amount of prostaglandin they secrete. They temporarily respond to oral anti-inflammatory drugs. Treatment is directed at eliminating the nidus and can be done through curettage, but radiofrequency ablation, which allows for a minimally invasive approach, is often used today.
Figure 5 shows diskitis with vertebral osteomyelitis. The disease is characterized by fever and back pain. Movement is extremely uncomfortable for these children, and they may adopt unusual postures to alleviate pain. The MRI shows involvement of 1 vertebrae and an adjacent disk. Left untreated, this condition often spreads to involve multiple vertebrae and also can cause an epidural abscess. Treatment during the early stages is IV antibiotics. Many orthopaedic surgeons also use bracing to prevent late vertebral collapse.
Figures 6a through 6c show septic arthritis of the ankle with metaphyseal osteomyelitis. The recommended treatment is incision and drainage followed by IV antibiotics. MRI may be considered before surgery to assess for an associated osteomyelitis or abscess that may also necessitate surgical debridement. Increasingly, these scenarios are managed with a rapid transition to oral antibiotics.

- Nonsurgical treatment with early passive range of motion

Calcaneal apophysitis (Sever's disease) is a common cause of heel pain in adolescent athletes who participate in running or jumping sports. The condition occurs primarily before or during peak growth and is characterized by a tight Achilles tendon, a positive squeeze test, and tenderness over the calcaneal apophysis. Pain is localized to the heel and exacerbated by running. Os trigonum syndrome involves posterior ankle impingement and is commonly associated with ballet dancers. Gastrocnemius strain typically causes pain more proximally at the myotendinous junction. The Thompson test is performed with the patient lying prone on the examination table. Absence of ankle plantar flexion when the examiner squeezes the calf constitutes a positive test and is indicative of Achilles rupture.

This radiograph presents a Brooker class IV heterotopiCossification in a 79-year-old woman after revision of a monopolar hemiarthroplasty to a press-fit, porous-coated acetabular component and a cemented femoral stem. The patient sustained a cerebrovascular accident 12 weeks before surgery. She had no other risk factors for heterotopiCossification formation after total hip arthroplasty. Other risk factors for heterotopiCossification include previous surgery, men with hypertrophiCosteoarthritis, traumatiCbrain injury, spinal hyperostosis, and posttraumatiCarthritis

Base excess (or deficit) is the most important value in determining overall resuscitation status of a polytrauma patient and will dictate initial fracture management when deciding between definitive fixation and damage control orthopaedics (DCO).
Base deficit is synonymous with systemic lactate present which directly reflects the overall resuscitation status following trauma. Normal reference values are
-2 to +2 mEq/L and 0.6 to 1.7 mmol/L, respectively. Excessive deficit or lactate should prompt DCO and temporary stabilization.
Abramson et al. prospectively followed 76 ICU polytrauma patients and found that survival was 100% if lactate was corrected within the first 24 hours and 75% if corrected within the first 48 hours. They found that the time needed to normalize serum lactate levels also is an important prognostic factor for survival in severely injured patients.
Manikis et al. prospectively followed 100 ICU patients, following serum lactate levels until normalization. Lactate levels were the most significant prognostic indicator of morbidity and mortality, and not only the absolute lactate level, but the duration of hyperlactatemia can be correlated with the development of organ failure.
Illustration A shows a damage control orthopaedic treatment algorithm. Incorrect Answers:
Answer 1: End tidal carbon dioxide does not predict mortality or morbidity and
should not be the marker for resuscitation status.
Answer 2: Hematocrit does not predict mortality or morbidity and should not be the marker for resuscitation status.
Answer 3: Heart rate does not predict mortality or morbidity and should not be the marker for resuscitation status.
Answer 5: Blood pressure does not predict mortality or morbidity and should not be the marker for resuscitation status.

DISCUSSION
Greater tuberosity fractures and rotator cuff tears associated with a traumatic dislocation are more commonly seen in women >60 years. Greater tuberosity fractures that are displaced <5 mm in the general population and
<3 mm in laborers and professional athletes can be treated successfully without surgery. Early passive range
of motion is important to avoid stiffness.

This patient has a substantial nascent malunion of his distal radius. Although a distal ulna excision would likely improve his ulnar-sided wrist pain, the Darrach procedure is more appropriate for older, somewhat less active individuals. In addition, the distal radius malunion is substantial, and it would be preferable to address the malunion given the major loss of radial length, inclination, and increased palmar tilt. The joint surface of the distal radius is uninvolved, and there is no evidence of arthrosis. It is preferable to osteotomize the distal radius sooner rather than later. Delayed osteotomy is often more difficult with more severe soft-tissue contractures, and improved results have been demonstrated following surgical treatment of nascent rather than mature distal radius malunions. Advantages include easier correction, no need for structural bone grafts, less overall total disability, and earlier return to work.
RECOMMENDED READINGS
30. Bilgin SS, Armangil M. Correction of nascent malunion of distal radius fractures. Acta Orthop Traumatol Turc. 2012;46(1):30-4. PubMed PMID: 22441449.
31. Jupiter JB, Ring D. A comparison of early and late reconstruction of malunited fractures of the distal end of the radius. J Bone Joint Surg Am. 1996 May;78(5):739-48. PubMed PMID: 8642031.

This is a common problem. Selection of a smaller polyethylene spacer results in a correction of the flexion contracture but also results in flexion instability as the flexion gap will be larger than the extension gap. First, surgeons should remove any posterior osteophytes from the distal femur. Second, the posterior capsule should be incised. If both of these maneuvers fail to correct the contracture, the surgeon should remove additional bone from the distal femur. The joint line may be raised up to 8 mm when performing posterior stabilized arthroplasties without compromising the result

The axial MRI scan reveals a subluxated biceps tendon. In the study by Koh and associates, 85% of patients with a biceps subluxation on MRI were found to have a subscapularis tear at the time of arthroscopy. These are not always obvious on the MRI, and close inspection of the leading edge/upper border of the subscapularis tendon at the time of arthroscopy is necessary. Although supraspinatus tears, SLAP tears, and Bankart tears can all occur in conjunction with a biceps subluxation, none have been shown to be strongly correlated with this pathology, nor as specific to this pathology.
57

This patient has bilateral jumped facet joints at C6-7. Although MR imaging is useful for revealing disk herniations, cord injuries, and bony fragments, early closed reduction to restore anatomic alignment may be attempted prior to MR imaging because reduction will decrease pressure on the cord. There have been reports of catastrophic outcomes with closed reduction in patients who are intubated when disk fragments are pushed into the spinal cord. Consequently, closed reduction should be attempted only in awake and cooperative patients for whom neurologic status monitoring is possible. MR imaging is generally performed after reduction is attempted (successful or not).
RECOMMENDED READINGS
[Initial closed reduction of cervical spine fracture-dislocation injuries. Neurosurgery. 2002 Mar;50(3 Suppl):S44-50. Review. PubMed PMID: 12431286. ](http://www.ncbi.nlm.nih.gov/pubmed/12431286)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/12431286) Radcliff K, Sonagli MA, Delasotta L, Singh N, Morrison E, Levine AM, Vaccaro AR. Cervical facet fractures and dislocations. In: Zigler JE, Eismont FJ, Garfin SR, Vaccaro AR, eds. Spine Trauma. 2nd ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2011:441-464.
[Vaccaro AR, Falatyn SP, Flanders AE, Balderston RA, Northrup BE, Cotler JM. Magnetic resonance evaluation of the intervertebral disc, spinal ligaments, and spinal cord before and after closed traction reduction of cervical spine dislocations. Spine (Phila Pa 1976). 1999 Jun 15;24(12):1210-7. PubMed PMID: 10382247. ](http://www.ncbi.nlm.nih.gov/pubmed/10382247)[View ](http://www.ncbi.nlm.nih.gov/pubmed/10382247)[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/10382247)
[Wimberley DW, Vaccaro AR, Goyal N, Harrop JS, Anderson DG, Albert TJ, Hilibrand AS. Acute quadriplegia following closed traction reduction of a cervical facet dislocation in the setting of ossification of the posterior longitudinal ligament: case report. Spine (Phila Pa 1976). 2005 Aug 1;30(15):E433-8. PubMed PMID: 16094262. ](http://www.ncbi.nlm.nih.gov/pubmed/16094262)[View ](http://www.ncbi.nlm.nih.gov/pubmed/16094262)[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/16094262)

The radiographs demonstrate a reverse obliquity intertrochanteric femur fracture. Compared to the more stable intertrochanteric femur fracture, a reverse oblique intertrochanteric hip fracture is not optimally treated with a sliding hip screw. Compression along a sliding hip screw is designed to create compression along the plane of the fracture, however in a reverse obliquity fracture pattern as seen here, shear force is created causing medial displacement of the femoral shaft and screw cutout.
Haidukewych et al showed in their retrospective review of 55 consecutively treated reverse obliquity intertrochanteric fractures, that patients treated with a sliding hip screw had nearly a 56% failure rate (9/16). The failure rate of patients treated with a blade plate was only 13%.
Sadowski et al showed in their prospective randomized trial in patients with a reverse obliquity or transverse intertrochanteric fracture who were randomized to either a 95 degree screw-plate or cephalomedullary nail a much higher failure rate for the plate-screw implant. Implant failure was seen in 7/19 patients treated with the 95 degree screw plate and only 1/30 in the intramedullary nail group. Both articles support the use of a blade plate or cephalomedullary nail for reverse obliquity fractures.
An example of screw cutout and medial displacement is seen in Illustration A.

Necrotizing fasciitis is an aggressive and rapidly spreading soft-tissue infection, usually caused by group A beta-hemolytic Streptococcus pyogenes. Presentation is typical of a rapidly ascending cellulitis, recalcitrant to antibiotic treatment. Differentiation between cellulitis and impetigo is difficult, and success depends on a high level of suspicion. The skin and subcutaneous tissues are affected, with sparing of the muscles. Septic shock and multi-organ system failure can be fatal. Treatment is aggressive surgical debridement with broad-spectrum antibiotics. Repeat irrigation and debridement may be necessary. Hyperbaric oxygen studies have shown inconsistent results.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp 199-205.
Fontes RA Jr, Ogilvie CM, Miclau T: Necrotizing soft-tissue infections. J Am Acad Orthop Surg 2000;8:151-158.

The clinical scenario and radiographs are consistent with a Gustilo and Anderson type 3A open tibia fracture.
Melvin et al review the evidenced-based literature and make recommendations for the initial evaluation and management of open tibial shaft fractures. The time elapsed before antibiotic administration and adequate surgical debridement of all contamination are the only factors definitively shown to reduce infection and improve outcome. Traditional recommendations have suggested surgical debridement of open fractures occur within 6 hours of injury. However, there is no literature to support this time window. Certainly, open fractures should be addressed with urgency, but there is no evidence reporting a definitive time window. There is insufficient data to recommend gram negative coverage with gentamicin for all open fractures although this is a common practice. The addition of antibiotics to the irrigation solution has been shown to decrease bacterial load, but it has also demonstrated host tissue necrosis and delayed wound healing. There is not sufficient data to support its use over a castile soap solution or normal saline. Similarly, high pressure pulsatile lavage decreases bacterial load, but also seeds bacteria deeper within the soft tissues and harms host tissues. There is no evidence to support pulsatile lavage over gravity flow.
15. A 34-year-old female is involved in a motorcycle crash. She sustains a talus fracture with associated dislocation of the subtalar joint and maintained congruence of the tibiotalar and talonavicular joints as shown in Figure A. The fracture has healed and she now has symptomatic impingement of the dorsal surface of the talus on the distal tibia and restriction of ankle dorsiflexion. What is the most likely deformity causing these symptoms?

1. Combined varus and plantar malunion
2. Isolated varus malunion
3. Isolated valgus malunion
4. Isolated dorsal malunion
5. Isolated plantar malunion CORRECT ANSWER: 4
Figure A displays a Hawkins Type 2 talar neck fracture. (Hawkins classification shown in Illustration A). Malunion after inaccurate reduction of talar neck fractures has a reported incidence as high as 32%, with varus malunion occurring most frequently. Dorsal malunion can occur when the body is not properly derotated during reduction and the head fragment remains dorsal to the body. Dorsal malunion can lead to symptomatic impingement of the dorsal surface of the talus on the distal tibia and restriction of ankle dorsiflexion.
Canale found that 3 of the 4 patients with dorsal malunion improved following dorsal beak resection of the talar neck. Patients with varus malunion have decreased subtalar range of motion(especially eversion), walk with the foot internally rotated, and often complain of excessive weight bearing on the lateral border of the foot.
Level 4 evidence from Canale and Kelly found that varus malunion occurred most frequently in Hawkins type 2 fractures that had been treated in a closed manner.

16. What is the Injury Severity Score (ISS) for a patient with an open chest wound (Abbreviated Injury Scale, AIS=4), colon transection (AIS=4), femoral fracture (AIS=3), shoulder dislocation (AIS=2), and a thyroid gland contusion (AIS=1)
1/. 11
2/. 13
3/. 41
4/. 45
5/. 46
CORRECT ANSWER: 3
Injury Severity Score (ISS) scores are used to define injury severity for research purposes. The score is based on anatomic and severity indicies. Injury severity is based upon the AIS (abbreviated injury scale). AIS scores range from 1-6 where 1 is a minor laceration or contusion and 6 is a unsurvivable severe injury. An example of a 6 is a crushed head or brain whereas a 5 is a crushed larynx. Open pelvic fracture and femoral shaft fracture come in at 3 and large joint dislocations are a level 2 injury. ISS is the sum of the squares for the highest AIS grades in the three most severely injured ISS body regions. An ISS greater than 18 reflects multiply injured patients and that a transfer to a trauma center is indicated. So in this case, it would be (4x4)+(4x4)+(3x3)= 16+16+9=41. The AIS table can be found in Miller Review on page 699.
Recently, the New Injury Severity Score (NISS) has been developed and found by some authors (Lavoie et al & Balogh et al) to be more reliable indicator of
length of stay and ICU stay. The NISS differs from the ISS in that the NISS sums the squares of the 3 most significant injuries (even if they occur in the same anatomic area). The ISS sums the 3 most significant injuries in 3 separate anatomic areas.
17. A 42-year-old male sustains a closed, isolated ulna shaft fracture with 2mm displacement and 3 degrees valgus angulation. He is treated conservatively with early range of motion but presents at one year with a painful atrophic nonunion. What treatment is indicated at this time?
1. Dynamic splinting
2. Open autogenous cancellous bone grafting
3. Open reduction internal fixation with autogenous bone grafting
4. Closed reduction and percutaneous pinning
5. Use of an implantable ultrasound device
6. CORRECT ANSWER: 3
Appropriate treatment of an atrophic nonunion of the ulna includes open reduction and internal fixation with autogenous bone grafting. The atrophic nature of the nonunion reveals that biology, and not necessarily stability, is the major issue of the nonunion. The referenced article by Ring et al reviews a case series of these patients and found that even in the face of significant preoperative bone resorption, good clinical outcomes and union rate is possible with open plating and grafting. The article by Street reviews intramedullary nailing/pinning of the forearm, and found a 7% nonunion rate with this technique.
18. A 62-year-old man falls on his porch and sustains an elbow injury. A radiograph is provided in Figure A. Which of the following is the best treatment?

1. Closed reduction and long arm casting
2. Early motion with a hinged elbow brace
3. Open reduction internal fixation with a tension band construct
4. Open reduction internal fixation with a plate
5. Fragment excision and advancement of the triceps tendon CORRECT ANSWER: 4
The radiograph shows an olecranon fracture with articular comminution and depression of a large intra-articular fragment. This pattern is best treated with plate fixation to support the articular reduction.
Bailey et al reviewed 25 cases of olecranon fractures (simple and comminuted fracture patterns) treated with plate fixation. All 25 went on to union. There were no major complications reported. Twenty percent of patients underwent hardware removal at a later date for prominence.
Hak et al review the treatment options available for olecranon fractures. Simple intra-articular fractures without comminution are suitable for tension band fixation. Comminution of the articular surface is an indication for plate fixation and may benefit from bone graft to support depressed articular segments. Osteoporotic patients or fractures with severe comminution may do better with fragment excision and advancement of the triceps.
19. When viewing pelvic injury radiographs, which of the following describes the findings diagnostic of an isolated transverse acetabular fracture?
1. Fracture line crossing the acetabulum with disruption of the iliopectineal and ilioischial lines
2. Disruption of the iliopectineal and ilioischial lines, with extension into the iliac wing and obturator ring
3. Disruption of the iliopectineal and ilioischial lines, with extension into the obturator ring
4. Isolated disruption of the iliopectineal line, with an intact ilioischial ine
5. Isolated disruption of the ilioischial line, with an intact iliopectineal ine CORRECT ANSWER: 1
Transverse acetabular fractures separate the innominate bone into two fragments, the superior iliac and the inferior ischiopubic, by a single fracture line that crosses the acetabulum horizontally. The iliopectineal and ilioischial lines are disrupted on the AP pelvis radiograph. Axial CT scan of this fracture pattern at the level of the dome will show a vertical anterior to posterior fracture line. Illustrations A-C show AP and Judet pelvic radiographs of a transverse fracture. Illustration D demonstrates the axial CT appearance of this fracture type. Answer choice 2 is describing a both column injury or anterior column posterior hemitransverse, and answer choice 3 describes a T-type fracture pattern. Answer choices 4 and 5 describe an anterior column and posterior column injury respectively. Judet et al provide one of the first comprehensive reviews on acetabular surgical approaches, fracture types, and radiographic anatomy. Illustration E demonstrates the acetabular classification scheme developed by Judet.

20. A patient undergoes the treatment seen in Figure A for a displaced intertrochanteric femoral fracture. With use of this construct, a starting point 3 mm anterior to the center of the piriformis fossa has which of the following benefits?

1. Improved placement of screws through the nail into the femoral head
2. Decreased risk of varus alignment
3. Decreased risk of joint penetration
4. Decreased risk of avascular necrosis of femoral head
5. Decreased risk of iatrogenic proximal femur fracture CORRECT ANSWER: 1
Figure A shows an intertrochanteric fracture treated with a cephalomedullary device. A starting point slightly anterior to the piriformis fossa (starting point for standard antegrade femoral nail) has the benefit of improved placement of screws through the nail and into the femoral head. This is due to the fact that the hip is anteverted and the femoral neck arises from the anterior portion of the proximal femur. Therefore, by moving the nail anterior, that will increase the distance between the head screw and the posterior cortex of the neck and lead to a “straight” shot into the center of the femoral head.
Johnson et al investigated the effect of starting hole position, fracture component length, reamed diameter, and nail type on the potential for femoral bursting and fracture instability. They found the most significant factor in the proximal femoral component was found to be the position of the starting hole.
They found excessive anterior displacement greater than 6 mm from the neutral axis of the medullary canal consistently caused high hoop stresses at the level of the fracture, which can increase the possibility of iatrogenic fracture. Posterior starting points increase the risk of possible distal femur anterior cortex impingement/fracture.
Ostrum et al showed that lateral starting points should be avoided in order to avoid varus reduction when using a trochanteric antegrade nail in subtrochanteric fractures. They recommended a slightly medial starting point.
21. An 11-year-old child has a tibia-fibula fracture following a fall from a swing. The fracture is reduced and placed in a long leg splint in the emergency room. What is considered the earliest sign or symptom of a developing compartment syndrome of the leg?
1. pain out of proportion to injury
2. pale appearance of the foot
3. loss of the ability to move the toes
4. decreased sensation in the foot
5. decreased pulses in the foot CORRECT ANSWER: 1
The Willis reference states “the single most important symptom of impending compartment syndrome is pain out of proportion to the injury." This symptom requires a conscious patient. Most children requiring a reduction for a displaced upper or lower extremity fracture will become comfortable soon after the reduction has been completed. Children requiring frequent analgesia or complaining loudly about pain should be examined very carefully for possible compartment syndrome.” The key wording in this question is “earliest indicator”. Pulselessness, paralysis, pallor, and parasthesias are all late indicators.
The Willis article also lists the most reliable signs of a developing compartment syndrome as severe pain with passive stretching of the involved compartment, pain with palpation of the involved compartment, sensory disturbances
22. When discussing treatment options with a 35-year-old healthy male with an isolated, closed tibial shaft fracture, the surgeon should inform him that in comparison to closed treatment, the advantages of intramedullary nail fixation include all of the following EXCEPT?
1. Quicker time to union
2. Decreased risk of malunion
3. Decreased risk of compartment syndrome
4. Decreased risk of shortening
5. Quicker return to work CORRECT ANSWER: 3
All of the answer choices are correct except #3. Intramedullary nailing can increase the risk of compartment syndrome.
In a study of 94 tibial fractures, Finkemeier reported 10 (11%) had compartment syndromes. Three of the 10 patients developed the compartment syndrome postoperatively.
In comparing IM nailing to non-op, Bone et al showed that IM nailing had a shorter time to union (mean, 18 vs 26 weeks; p = 0.02), lower non-union rate (2% vs 10%), decreased incidence of shortening (2% vs 27%), and quicker return to work (mean, 4 vs 6.5 months), but no difference in compartment syndrome (0% in both groups).
The classic article cited by Sarmiento el al. reported that closed treatment with use of a prefabricated functional below-the-knee brace was effective in a study of 1000 closed diaphyseal fractures of the tibia with an incidence of nonunion of only 1.1%. However, those authors had very strict criteria for use of the fracture-brace (exclusion criteria included intact fibula and tibial shortening
>2cm).
23. A 58-year-old man underwent distal radius ORIF with a volar locking plate yesterday. Preoperatively, he reported some mild sensory disturbances in the volar thumb and index finger, but had 2-point discrimination of 6mm in each finger. Now, he complains of worsening hand pain and sensory disturbances in his volar thumb and index finger. Two-point discrimination is now >10mm in these fingers. Radiographs show a well-fixed fracture in good alignment. What is the most appropriate treatment at this time?
1. Strict elevation
2. Removal of hardware
3. Immediate carpal tunnel release
4. Carpal tunnel release if no resolution at 6-12 weeks
5. Trial of night splinting CORRECT ANSWER: 3
This patient had mild median parasthesias preoperatively that have significantly worsened postoperatively. Immediate carpal tunnel release is the most appropriate next step in treatment.
Mack et al reported on ten cases of acute carpal tunnel syndrome (ACTS) and six cases of nerve contusion in patients with acute median neuropathy associated with blunt wrist trauma. The patients with ACTS initially had normal sensation and subsequently developed objective sensory loss (2-point discrimination greater than 15 mm) in the median nerve distribution associated with severe wrist pain. In contrast, patients with nerve contusion injuries had immediate sensory loss and symptoms were nonprogressive. Four of five patients with ACTS who underwent carpal tunnel release within 40 hours of the onset of numbness had normal 2-point discrimination within 96 hours.
Neuropathy, secondary to nerve contusion without coexisting ACTS, may be treated initially by observation.
Ford et al reported of five cases of ACTS. Four with delayed treatment had poor outcomes while the one patient with early CTR had full recovery. All patients with ACTS had increasing and severe pain in the wrist with parasthesia and impaired sensation in the median distribuation. These symptoms initially weren’t present after wrist trauma, but developed rapidly in the next few hours.
24. A 20-year-old man falls from his bicycle. He is going to be scheduled for open reduction internal fixation. What best describes the injury shown in Figure A and B?

1. Coronoid fracture
2. Capitellum fracture with extension into the trochlea
3. Radial head and capitellum fracture
4. Isolated capitellum fracture
5. Trochlea fracture CORRECT ANSWER: 2
The radiographs shows a coronal shear fracture of the capitellum with extension into the trochlea, which would be classified as a Type IV fracture under the Bryan and Morrey classification system which was modified by McKee to include this specific injury. The lateral radiograph in Figure B and Illustration A is an example of the "double arc" sign representing an injury to both the trochlea and capitellum. The treatment of choice for a displaced Type IV fracture is open reduction internal fixation.
Dushuttle et al demonstrated that absence of the capitellum did not lead to valgus instability unless the medial collateral ligament was injured, suggesting that excision of highly comminuted fractures could be performed.
The reference by Grantham et al looked at a series of capitellum fractures and recommended the choice of treatment should be selective and individualized
depending on age, character of the bone, and type of fracture.
McKee et al in their case review described this coronal injury pattern and their results for ORIF of these fractures.

25. An 85-year-old woman falls and injures her elbow in her non- dominant arm. Radiographs are shown in Figure A and B. She also suffers from severe osteoporosis, lives independently, and is a low- level community ambulator. Which of the following is the most appropriate treatment?

1. Hinged elbow brace
2. Olecranon osteotomy, articular ORIF, locked lateral plating
3. Triceps-splitting approach with double plate fixation
4. Total elbow arthroplasty
5. Casting for 4 weeks then ROM CORRECT ANSWER: 4
Total elbow arthroplasty (TEA) is ideal for treating comminuted osteoporotic fractures of the distal humerus in low demand elderly patients. Outcomes are good to excellent with quick return of stability and functional motion but with carrying weight restriction of 5 lbs. ORIF would be the best choice for younger individuals with better bone quality.
Cobb described the outcomes of 21 total elbow arthroplasties in elderly patients all of which had good or excellent results without evidence of component loosening. The mean motion was 25 to 130 degrees. Complications included fracture of the ulnar component in one patient after another fall, ulnar neurapraxia in three, and reflex sympathetic dystrophy in one.
McKee et al. performed a randomized controlled study of TEA versus fixation and found that TEA for the treatment of comminuted intra-articular distal humeral fractures resulted in more predictable and improved 2-year functional outcomes compared with ORIF. They also found that although elderly patients with this injury have an increased baseline DASH score, they appear to accommodate to objective limitations in function with time.
Frankle et al. retrospectively compared TEA to plate fixation for distal humerus fractures in the elderly and found a significant improvement in outcomes and revision rates with TEA as compared to plate fixation. The differences were seen most in women with associated comorbidities, such as rheumatoid arthritis, osteoporosis, and conditions requiring the use of systemic steroids.
26. Coupled with reduction of the syndesmosis, which of the following interventions is most important when surgically addressing the ankle malunion shown in Figure A?

1. Placement of an osteochondral allograft
2. Fibular lengthening osteotomy
3. Calcaneofibular ligament release
4. Medial malleolar shortening osteotomy
5. Deltoid ligament imbrication CORRECT ANSWER: 2
Late correction with a corrective osteotomy of a fibular malunion associated with diastasis of the ankle mortise (Illustrations A and B) is an effective means of salvaging function in a joint otherwise destined to be stiff and painful.
The referenced study by Offierski et al reports that the factors that determined the success of the revision were the duration of the malunion, the quality of the reduction achieved, and the condition of the articular cartilage at the time of revision.
The referenced study by Chao et al reported that the fibular lengthening osteotomy was crucial in regaining the anatomy and stability of the ankle mortise.
The referenced study by Weber et al is a review of the technique of such an osteotomy, with commentary regarding its clinical success even if mild degenerative changes are seen. They also note that no differences are seen in outcomes between oblique and step-cut osteotomies.
The referenced study by Weber and Simpson is a case series of corrective
lengthening osteotomies after malunited ankle fractures. They report that a lengthening and/or rotational osteotomy of a malunited fibula is successful in preventing further ankle arthrosis if no more than minimal degenerative radiographic changes are seen.

27. All of the following implants offer adequate fracture fixation of the injury shown in Figure A EXCEPT:

1. Trochanteric entry point cephalomedullary nail
2. Piriformis fossa entry point cephalomedullary nail
3. Dynamic hip screw
4. Fixed angle blade plate
5. 95 degree dynamic condylar screw CORRECT ANSWER: 3
Currently, cephalomedullary nails are used widely for reverse obliquity fractures because they limit medialization of the shaft fragment unlike sliding hip screws.
The Haidukewych et al study quoted demonstrated the superiority of fixed angle devices such as blade-plates or dynamic condylar screws over the sliding (or dynamic) hip screws. Reverse obliquity intertrochanteric fractures of the femur are recognized as biomechanically different from standard intertrochanteric fractures. The rate of failure of internal fixation for this fracture pattern was higher than the rates in most reports of internal fixation of intertrochanteric fractures devices.
28. A 27-year-old woman gives birth by normal spontaneous vaginal delivery. Two weeks after delivery she reports anterior pelvic pain and a radiograph is obtained (Figure A). What is the next step in management?

1. Pelvic external fixator
2. Open reduction and reconstruction plating of the symphysis
3. Protected weightbearing and binder as needed and observation
4. Open reduction and wiring of the symphysis
5. Symphysiotomy CORRECT ANSWER: 3
The clinical presentation and radiograph is consistent with an open-book type parturition-induced pelvic dislocation.
The case series by Kharrazi et al reports four patients treated with open-book type parturition-induced pelvic dislocations. The authors advocate nonoperative treatment with bedrest and a properly positioned pelvic binder in the acute setting for patients with a postpartum symphyseal diastasis less than 4.0 cm.
All four patients had significant symptoms and radiographic widening (anterior splaying) of the sacroiliac joints. The three patients who had presented acutely were treated with closed reduction and application of a pelvic binder, while two had closed reduction of their pelvic dislocation while anesthetized with a general anesthetic. At latest follow-up the diastasis at the pubic symphysis reduced to an average of 1.7 cm (range: 1.5-2.0) The authors advocate nonoperative treatment with bedrest and a properly positioned pelvic binder in the acute setting for patients with a symphyseal diastasis of 4.0 cm of less and operative treatment for diastasis greater than 4cm.
29. A 30-year-old patient sustains a comminuted tibia fracture and is treated with minimally invasive plating, shown in Figure A. The patient returns to the office 2 weeks after the surgery and reports persistent numbness over most of the dorsum of the foot, but motor exam is normal. What is the most likely explanation?

1. unrecognized compartment syndrome
2. common peroneal nerve injury
3. superficial peroneal nerve injury
4. sural nerve injury
5. tibial nerve injury CORRECT ANSWER: 3
Superficial peroneal nerve (SPN) injury is a known complication of percutaneous plating of proximal tibial fractures with the LISS system as seen in Figure A.
The Less Invasive Stabilization System (LISS) is a minimally invasive implant that uses indirect fracture reduction techniques. When using the LISS system, percutaneous screw placement increases the risk of injury to nearby structures because they are not necessarily visualized. The superficial peroneal nerve exits the superficial fascia of the leg approximately 8 cm above the tip of the
lateral malleolus. The nerve then travels from posterior to anterior in the vicinity of the distal aspect of the 13-hole proximal tibia LISS plate (near holes 11-13). In a patient of shorter stature, the nerve could cross the distal portion of a 9-hole plate.
Deangelis et al. performed a cadaveric study using Less Invasive Stabilization System (LISS) plates and found that the average distance from the SPN to the center of holes 11, 12, and 13 was 10.0 mm, 6.8 mm, and 2.7 mm respectively. They recommended using a larger incision and careful dissection down to the plate in this region to minimize the risk of damage to the nerve.
Cole et al. retrospectively reviewed 77 tibia fractures treated with LISS and found that 91% healed without complication. In their cohort, there were no superficial peroneal nerve palsies and one deep peroneal nerve palsy.
Figure A demonstrates AP and lateral x-rays of a tibial shaft fracture treated with a LISS plate.
Incorrect Answers:
A: compartment syndrome would have demonstrated pain out of proportion which the patient never complains of
B, D, and E are all less likely to be injured with LISS plate application than the superficial peroneal nerve.
30. A 20-year-old male is involved in a motorcycle accident and presents with the injuries shown in Figures A-F. The left ankle injury is open medially, with a clean 3cm laceration, and the right femur and tibia are closed. He has no visceral or head injury, and is hemodynamically stable. He is cleared to go to the operating room. Without taking into account order of fixation, how should his injuries be treated?

1. Retrograde nailing of the femur, intramedullary nailing of the tibia, ankle debridement and casting
2. External fixation of the femur, intramedullary nailing of the tibia, ankle debridement and ORIF
3. Antegrade nailing of the femur, external fixation of the tibia and ankle after debridement
4. Retrograde nailing of the femur, intramedullary nailing of the tibia, ankle debridement and ORIF
5. External fixation of the tibia and femur, and ankle debridement and external fixation
CORRECT ANSWER: 4
The patient is hemodynamically stable, has no other injuries, and is medically cleared for the operating room. Therefore, there is no need for damage control fixation.
Ostrum et al conducted a review of 20 patients treated by percutaneous stabilization for ipsilateral fractures of the femur and tibial shafts. All patients were treated with a retrograde femoral intramedullary nail and a small diameter tibial intramedullary nail through a 4-cm medial parapatellar tendon incision. Six of the tibial shaft fractures required revision surgery, and no patients reported signs or symptoms of knee pain. Ostrum concluded that although this is an excellent treatment option for patients with ipsilateral femoral and tibial shaft fractures, the tibial fracture complication rates remain high.
Franklin et al reviewed 38 cases of open ankle fractures that had been treated with immediate splinting, antibiotics, debridement, and internal fixation. They found that all of the fractures united, but three patients required subsequent ankle fusion because of cartilage damage noted at the initial operation. Of the thirty-five ankles with complete follow-up, the functional result was excellent in twenty-six and fair or poor in nine.
31. A 33-year-old male is involved in a motor vehicle accident and suffers a right pilon fracture. Which of the bone fragments labeled on the distal tibia in the axial CT scan shown in Figure A is attached to the posterior inferior tibiofibular ligament?**

1. A
2. B
3. C and B
4. D
5. A and D **CORRECT ANSWER: 4
Figure A is an axial CT scan slice of an intra-articular distal tibia fracture. The bands of the posterior tibiofibular ligament pass obliquely from the fibula to the posterolateral aspect of the distal tibia. The ligaments of the ankle often remain intact after a pilon fracture producing the major fracture segments consisting of posterolateral or Volkmann's fragment (labeled D), the anterolateral or Chaput fragment (labeled B), and the medial fragment (labeled C). The fibula is labeled A. Any surgical approach taken to treat this injuries should respect these attachments.
Michelson reviews the important role of ankle ligamentous anatomy in his study on rotational ankle fractures.
Hermans et al review the anatomy of the ankle syndesmosis and state that stress on the posterior inferior tibiofibular ligament results more often in a posterior malleolus avulsion fracture than in a rupture of the ligament. They go on to state that with direct reduction of the posterior malleolus avulsion fracture, the syndesmosis can often be stabilized.
Illustration A shows the posterior inferior tibiofibular ligament highlighted in red on MRI imaging in a LEFT ankle (the CT image in the question is of a RIGHT ankle).

32. What structure has been described as having a risk of injury with retractor placement on the sacrum during combined acetabular-pelvic ring surgery using the Stoppa approach with a lateral window?
1. External iliac artery
2. Pudendal nerve
3. Corona mortis
4. L5 nerve root
5. Ilioinguinal nerve CORRECT ANSWER: 4
Care must be taken when placing a retractor on the anterior aspect of the sacrum, as the L4 and L5 nerve roots are both at risk.
Illustration A shows a diagram of the lumbosacral plexus, indicating the proximity of the L4 and L5 nerve roots to the anterior sacrum and SI joint.
The first referenced article by Atlihan et al reported on the anatomy of the anterior sacroiliac joint and reported that the L4 nerve root is within 1 cm of the joint at its inferior margin.
The second article by Ebraheim et al found that the L4 and L5 nerve roots are 10 mm medial to the sacroiliac joint at the pelvic brim.

33. A 24-year-old man who sustained a gunshot wound to the abdomen ten hours earlier was brought to the emergency department. On physical examination he was found to have 4 of 5 weakness in his bilateral lower extremities. Radiographs are shown in Figure A. Computed tomography of the lumbar spine showed retained missile in the vertebral body and paraspinal soft tissues, but not within the spinal canal. His FAST was positive and he underwent an emergent exploratory laparotomy where an injury to the cecum was identified and treated. Management should now include which of the following?

1. Bullet fragment removal from a transabdominal approach
2. Bullet fragment removal from a retroperitoneal approach
3. Broad-spectrum oral antibiotics for 3-5 days
4. Broad-spectrum intravenous antibiotics for 7-14 days
5. IV methylprednisolone at 5.4mg/kg/h for 48 hours CORRECT ANSWER: 4**
The patient in the scenario has a GSW to the lumbar spine with neurologic deficits but without a retained missile in the spinal canal. In patients with visceral injury, the treatment is broad-spectrum antibiotic coverage for 7 days.
Kumar et al reviewed 33 patients with GSW to the spine and associated visceral injuries. They concluded that 7 days of antibiotic treatment targeted at colonic flora is the treatment of choice.
Roffi et al reviewed 51 low-velocity GSW that perforated the viscus prior to the spine. They concluded that broad spectrum antibiotics combined with bedrest significantly reduced the risk of spinal or paraspinal infections. Furthermore, bullet removal had no effect on infection rates.
Velmahos et al followed 153 GSW to the spine for 28 months. While rates of sepsis were higher in the lumbar spine than cervical and thoracic spine, they concluded that retained bullets do not increase the likelihood of septic complications.
Incorrect Answers:
Answer 1 & 2: Indications for surgery with a GSW to the lumbar spine include

This patient was treated with doxorubicin, an anthracycline chemotherapy agent that causes cardiomyopathy in a dose-dependent fashion. Patients with osteosarcoma frequently undergo noninvasive cardiac testing with an echocardiogram or radionuclide angiography prior to anthracycline treatment. Cardiac toxicity is the typical cumulative dose-limiting effect of these agents. Posttreatment cardiac surveillance testing with an echocardiogram or radionuclide angiography is recommended for childhood cancer survivors treated with anthracyclines. Renal toxicity is a common adverse effect of cisplatin but usually manifests acutely. Similarly, methotrexate may cause acute hepatic toxicity that manifests acutely. In contrast, congestive heart failure attributable to doxorubicin cardiotoxicity frequently manifests late, with patients typically experiencing no or minimal symptoms until substantial cardiac dysfunction has occurred. Areflexia and peripheral neuropathy are also common side effects associated with these chemotherapeutic agents.
RECOMMENDED READINGS
65. Armenian SH, Hudson MM, Mulder RL, Chen MH, Constine LS, Dwyer M, Nathan PC, Tissing WJ, Shankar S, Sieswerda E, Skinner R, Steinberger J, van Dalen EC, van der Pal H, Wallace WH, Levitt G, Kremer LC; International Late Effects of Childhood Cancer Guideline Harmonization Group. Recommendations for cardiomyopathy surveillance for survivors of childhood cancer: a report from the International Late Effects of Childhood Cancer Guideline Harmonization Group. Lancet Oncol. 2015 Mar;16(3):e123-36. doi: 10.1016/S1470-2045(14)70409-7. Review. PubMed PMID: 25752563.
[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/25752563)
66. [Longhi A, Ferrari S, Tamburini A, Luksch R, Fagioli F, Bacci G, Ferrari C. Late effects of chemotherapy and radiotherapy in osteosarcoma and Ewing sarcoma patients: the Italian Sarcoma Group Experience (1983-2006). Cancer. 2012 Oct 15;118(20):5050-9. doi: 10.1002/cncr.27493. Epub 2012 Mar 13. PubMed PMID: 22415578.](http://www.ncbi.nlm.nih.gov/pubmed/22415578)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/22415578)

Opioids must be used with caution in infants younger than 3 months of age because of decreased clearance and decreased protein binding. This results in greater bioavailability.

Surgical indications for scapular fractures are debatable in the literature. Historical indications for extra-articular fractures of the glenoid neck have ranged from 10-25 mm of medial displacement, 25-40⁰ of angular deformity of the glenoid, and a glenopolar angle cut-off of 20-30⁰. While the Judet approach can offer access to the entire scapular body, a modified Judet approach is a more limited approach that allows access to the glenoid neck in the interval
7
between the infraspinatus and teres minor. The infraspinatus is innervated by the suprascapular nerve, whereas the teres minor is innervated by the axillary nerve. The long thoracic nerve innervates the serratus anterior muscle. The spinal accessory nerve innervates the sternocleidomastoid and trapezius muscles.

The MRI scans show disruption of the fibers of the PCL. Patients sustaining an isolated acute PCL injury can present with only minimal discomfort and have full range of motion. When examination reveals a contusion over the tibial tubercle and discomfort with the posterior drawer examination, with or without instability, a possible injury to the PCL should be considered. In acute injuries, the reported accuracy of MRI imaging for diagnosing PCL tears ranges from 96% to 100%.
REFERENCES: Resnick D, Kang HS: Internal Derangement of Joints: Emphasis on MRI Imaging. Philadelphia, PA, WB Saunders, 1997, pp 699-700.
Harner CD, Hoher J: Evaluation and treatment of posterior cruciate ligament injuries. Am J Sports Med 1998;26:471-482.
Fischer SP, Fox JM, Del Pizzo W, Friedman MJ, Snyder SJ, Ferkel RD: Accuracy of diagnoses from magnetic imaging of the knee: A multi-center analysis of one thousand and fourteen patients. J Bone Joint Surg Am 1991;73:2-10.

Patients with brachial neuritis or Parsonage-Turner syndrome usually report the sudden onset of intense pain that subsides in 1 to 2 weeks, followed by weakness for a period of up to 1 year in the muscle that is supplied by the involved nerve. Calcific tendinitis usually can be diagnosed radiographically, with calcium deposits seen in the rotator cuff. Bursitis and rotator cuff tendinosis usually are seen after an increase in activity, and both decrease with rest and medication. Glenohumeral arthritis is a slow, progressive problem that results in a loss of range of motion.
REFERENCES: Misamore GW, Lehman DE: Parsonage-Turner syndrome (acute brachial neuritis). J Bone Joint Surg Am 1996;78:1405-1408.
Dillin L, Hoaglund FT, Scheck M: Brachial neuritis. J Bone Joint Surg Am 1985;67:878-880.

The diagnostic criteria for chronic exertional compartment syndrome is pressure >15 mm Hg at rest, or
>30 mm Hg at 1 minute post exercise, or >20 mm Hg at 5 minutes post-exercise. The anterior and lateral compartments are the only ones that meet strict diagnostic criteria for chronic exertional compartment syndrome. The superficial posterior compartment, although close to meeting criteria, is not responsible _for the patient's symptoms and falls below current thresholds for diagnosis._

**
Numerous drugs are associated with an increased risk of osteoporosis in
adults, including oral corticosteroids, androgen-deprivation therapy, aromatase inhibitors, protease inhibitors, selective serotonin reuptake inhibitors,
prolactin-raising antiepileptic agents and many cytotoxic agents.
Additionally, a number of disease states are associated with osteoporosis, including endocrinopathies such as hyperparathyroidism, thyrotoxicosis and type I diabetes, hypogonadism, chronic glucocorticoid therapy, malnutrition, malabsorption states, chronic immobilization, rheumatoid arthritis, alcoholism, vitamin D deficiency, and multiple myeloma.
NSAIDs have not been shown to increase risk of osteoporosis.

Throwers and in particular, pitchers, are prone to high valgus loads to the elbow. A constellation of medial elbow pathology can develop, including medial epicondylitis, ulnar nerve neuritis, medial ulnar collateral ligament injuries, and posteromedial osteophytes of the olecranon. The MRI scans show significant increases in signal intensing as well as fiber disruption of the medial collateral ligament, indicating a complete tear. The common flexor origin shows a homogeneous signal and normal morphology. Therefore, excision of posterior osteophytes and debridement of the common flexor origin are not indicated. Likewise, this patient’s symptoms do not indicate ulnar nerve pathology; therefore ulnar nerve transposition is not indicated. Primary repair of medial collateral ligament tears of the elbow lead to unpredictable results with an unacceptable rate of reoperation. The most predictable result in treating this high-demand athlete is reconstruction of the medial collateral ligament with autogenous tissue.
REFERENCES: Norris TR (ed): Athletic Injuries of the Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 311-323.
Hyman J, Breazeale NM, Altchek DW: Valgus instability of the elbow in athletes. Clin Sports Med 2001;20:11-24.

- Percutaneous lag screw fixation
This patient’s MR images are indicative of a nondisplaced navicular stress fracture, which is best treated with percutaneous lag screw fixation. She has persistent symptoms despite appropriate nonsurgical treatment. Although all of the above choices may allow successful healing of her navicular, surgery has been shown to result in a shorter recovery and a more predictable outcome, which is especially important to serious athletes. Use of bone morphogenic protein has not been established as a treatment for this injury.
RECOMMENDED READINGS
1. [Lee S, Anderson RB. Stress fractures of the tarsal navicular. Foot Ankle Clin. 2004 Mar;9(1):85-104. Review. PubMed PMID: 15062216. ](http://www.ncbi.nlm.nih.gov/pubmed/15062216)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/15062216)
2. Anderson RB, Cohen BE. Stress fractures of the foot and ankle. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. Vol 2. 8th ed. Philadelphia, PA: Mosby; 2007:1590-1597.

A retrospective Level IV study followed 84 patients with diabetes who underwent open reduction internal fixation of unstable ankle fractures. After analyzing multiple patient factors including sex, fracture pattern, open or closed injury, nephropathy, hypertension, vasculopathy, peripheral neuropathy, and diabetic control (insulin-dependent compared with non-insulin- dependent), the only factors that predicted a higher rate of complications were vasculopathy and peripheral neuropathy. There was a 12% rate of postoperative infection and an overall 14% rate of complications.

Due to radial inclination, a true lateral view of the wrist will not show whether screws from a volar plate are intra-articular; a 23° elevated lateral view is needed to adequately assess this.
The amount of elevation will depend on the degree to which the surgeon restores radial inclination; for example, if the surgeon only restores 15° of radial inclination, then the surgeon would only have to elevate the wrist 15° from a true lateral in order to have the radiographic beam point down the joint line. Failure to diagnose intra-articular screws intraoperatively can lead to degenerative changes.
Tweet et al. performed a survey of orthopedic surgeons regarding their preferred method of visualizing screw placement during wrist fixation. The majority of surgeons reported that they obtain multiple views, including AP/PA wrist views, a 23° lateral inclination view, and a true lateral view. They also performed a cadaveric study looking at different x-ray views and screw penetration. They reported that live rotational fluoroscopy provided the highest sensitivity (93%) and specificity (96%) for the detection of intra-articular screw penetration.
Patel et al. evaluated the ability of surgeons at different levels to critically assess distal radius fixation and screw placement. They found that supplementation with a 23° lateral view increased accuracy and confidence in all position, specialty, and experience groups. Confidence scores were significantly higher following the evaluation of three views versus two views. Residents exhibited the greatest improvements in accuracy and confidence. For first-phase (standard view) assessments, accuracy scores were significantly better for attendings with less than 10 years of post-fellowship experience than those with more.
Illustration A is a non-elevated lateral of the wrist, while illustration B is a 23° elevated lateral radiograph. Illustration C is an example of a skyline view, which assesses for screws penetrating the dorsal cortex.
Incorrect Answers:
Answer 1: The dorsal skyline view shows dorsal screw length and is useful to
check for long distal screws.
Answers 2 and 3: The AP and PA wrist views do not show intra-articular screw penetration due to the volar tilt and concavity of the joint.
Answer 5: A 45° oblique lateral view does not visualize the joint as this angle does not match the radial inclination.

DISCUSSION: The anterior approach to the hip joint involves identifying the plane between the tensor fascia lata and the sartorius muscles.

REFERENCES: Berger RA, Duwelius PJ: The two-incision minimally invasive total hip arthroplasty: Technique and results. Orthop Clin North Am 2004;35:163-172.
Matta JM, Shahrdar C, Ferguson T: Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clin Orthop Relat Res 2005;441:115-124.
**2**

Figure 3Id Figure 31e

Osteopetrosis is a rare disorder in which there is decreased osteoclastiCresorption of bone and cartilage with normal bone formation. There are a number of different forms of the condition.
The most common form of osteopetrosis is an autosomal dominant type with mild features (adult or tarda). Patients may have mild anemia, have one or more fractures, or be asymptomatic.
The juvenile form of osteopetrosis is a severe autosomal disorder. Children have multiple fractures, severe anemia, thrombocytopenia, and hepatosplenomegaly. Effected children are also immunocompromised

Painful MOM THA and taper corrosion can cause substantial damage to a patient's hip if left untreated. In this case, the workup for a painful MOM THA starts the same as a workup for a painful metal-on- polyethylene bearing couple. Infection must be ruled out in every case with a set of inflammatory markers. If these markers are remotely elevated, this is an indication for joint aspiration. In patients with metal debris, the pathology report often indicates too many cells to count or cellular debris. Metal ion levels do not seem to correlate with prognosis. There are well-functioning patients with high ion levels and poor- functioning patients with low ion levels. Advanced imaging with MARS MRI to evaluate for peritrochanteric fluid collection, a soft-tissue mass, or synovial/capsular hypertrophy will reveal signs of a metal reaction that indicate the need for a revision discussion. A CT scan can show more advanced bony destruction as an indicator of poor prognosis. These films can be used to determine the need for a structural graft or augments for reconstruction of bone loss attributable to metal debris.

This patient has a fracture dislocation through the body of C6. Because the spine is ankylosed, it is rigid and prone to injury even in the setting of low-energy incidents. This patient has ankylosing spondylitis because the anterior longitudinal ligament is ossified. Ankylosing spondylosis is a seronegative spondyloarthropathy with sacroiliac joint involvement most commonly. It has a male predilection of 3:1. In the spine, it is characterized by diffuse syndesmotic ankylosis resulting in a “bamboo spine.”
This patient also has degenerative changes found at C3-4, C4-5, but the ankylosing of the spine is the main reason for the higher fracture risk. DISH (Forestier disease) is a noninflammatory
spondyloarthropathy characterized by flowing ossifications and bone proliferations at sites of tendinous and ligamentous insertion.
RECOMMENDED READINGS
7. [El Tecle NE, Abode-Iyamah KO, Hitchon PW, Dahdaleh NS. Management of spinal fractures in patients with ankylosing spondylitis. Clin Neurol Neurosurg. 2015 Dec;139:177-82. doi: 10.1016/j.clineuro.2015.10.014. Epub 2015 Oct 23. Review. PubMed PMID: 26513429. ](http://www.ncbi.nlm.nih.gov/pubmed/26513429)[View Abstract](http://www.ncbi.nlm.nih.gov/pubmed/26513429)[ ](http://www.ncbi.nlm.nih.gov/pubmed/26513429)[at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/26513429)
8. [Lukasiewicz AM, Bohl DD, Varthi AG, Basques BA, Webb ML, Samuel AM, Grauer JN. Spinal Fracture in Patients With Ankylosing Spondylitis: Cohort Definition, Distribution of Injuries, and Hospital Outcomes. Spine (Phila Pa 1976). 2016 Feb;41(3):191-6. doi: 10.1097/BRS.0000000000001190. PubMed PMID: 26579959. ](http://www.ncbi.nlm.nih.gov/pubmed/26579959)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/26579959)

**
To establish negligence, certain criteria must be met. 1) A duty was owed by the surgeon (in this case, yes, a relationship was established). 2) The duty was breached, where the provider failed to meet the standard of care (there
was a technical error, but it was corrected). 3) The breach caused an injury. In this case, the patient had an outcome that was very acceptable, as
documented with outcome studies, for femur fractures. Also, the rotational error and locking distally would have had little impact on the hip, whereas antegrade nailing itself is expected to result in some objective impairment of the hip in some patients. 4) Damages were incurred as a result. In this case, the patient returned to work and could not rock climb which could be reasonably expected with a femur fracture in some patients, and cannot be causally linked to the corrective surgery. For all practical purposes, the patient had a very acceptable outcome. Thus, settling the case for an error would be rather permissive and the important issue is that the surgeon recognized the problem, addressed it, and fulfilled his or her postoperative responsibility. The case is very defendable, and thus it is unlikely to be lost. Defending the case and alleging no error is incorrect because there was an error. The surgeon should never function outside of his or her legal counsel once a suit is filed.

DISCUSSION: Cervical spinal stenosis is a contraindication to participation in collision and contact sports. Previously, the risks of permanent quadriparesis from cervical spinal stenosis were thought to be unclear and athletes with cervical spinal stenosis were often allowed to play contact sports. In 1996, Torg and associates reported that developmental narrowing of the cervical canal in a stable patient does not appear to predispose an individual to permanent catastrophic neurologic injury and therefore should not preclude an athlete from participation in contact sports. However, the current understanding is that the actual risks of permanent neurologic injury from cervical stenosis are significant. The Torg ratio was previously used for diagnosis but is more recently thought to be of low predictive value as reported by Cantu. Current methods for diagnosis of cervical spinal stenosis rely on MRI and CT. Current diagnosis is based on comparisons of measurements with normal values. A cervical canal of less than 13 mm is considered stenotic whereas a diameter of less than 10 mm is considered absolute stenosis as reported by Crowl and Kong. This patient has symptomatic stenosis and should not be cleared for contact sports. A neck roll will not prevent neurologic injury in the presence of cervical spinal stenosis. Electrodiagnostic studies are not likely to add any additional significant findings with central canal stenosis. Cervical traction is not of value in the long-term. Epidural steroid injections or a methylprednisolone dose pack are not of value in this situation.

REFERENCES: Torg JS, Naranja RJ Jr, Pavlov H, et al: The relationship of developmental narrowing of the cervical spinal canal to reversible and irreversible injury of the cervical spinal cord in football players. J Bone Joint Surg Am 1996;78:1308-1314.
Cantu RC: The cervical spinal stenosis controversy. Clin Sports Med 1998;17:121-126. Crowl AC, Kong JF: Cervical Spine, in Johnson DL, Mair SD (eds): Clinical Sports Medicine. Philadelphia, PA, Mosby Elsevier, 2006, pp 143-149.

Restoration of the anatomy of the radial bow directly correlates with the range of motion postoperatively (pronation-supination).
The referenced study by Schemitsch et al found that restoration of the normal radial bow was related to the functional outcome. A good functional result
(more than 80 percent of normal rotation of the forearm) was associated with restoration of the normal amount and location of the radial bow. Similarly, the recovery of grip strength was associated with restoration of the location of the radial bow toward normal.

Salvage of a total elbow arthroplasty is possible with early aggressive management of acute infection (symptoms for less than 30 days) with serial irrigation and debridement and antibiotic bead placement. This form of treatment is indicated when there are no radiographic or intraoperative signs of loosening. However, successful treatment is largely dependent on the organism. Staphylococcus epidermidis is associated with persistent infection because it is an encapsulating organism, and it is best treated with implant removal and
IV antibiotics.
REFERENCES: Yamaguchi K, Adams RA, Morrey BF: Infection after total elbow arthroplasty. J Bone Joint Surg Am 1998;80:481-491.
Schoifet SD, Morrey BF: Treatment of infection after total knee arthroplasty by debridement with retention of the components. J Bone Joint Surg Am 1990;72:1383-1390.

The phenotype of achondroplasia includes: Varus knee deformity
Spinal stenosis
Atlantoaxial instability
The other responses:
Neurofibromatosis: C afé au lait spots, pseudoarthrosis of tibia and scoliosis C harcot-Marie-Tooth disease: C avovarus feet, areflexia, and distal motor wasting Duchenne muscular dystrophy: Proximal muscle weakness and calf hypertrophy Marfanâs syndrome: Dolichostenomelia and scoliosis
C orrect Answer: Knee varus and spinal stenosis

The pathology is that of posterior ankle impingement, which is secondary to a symptomatic os trigonum. Endoscopic excision necessitates posteromedial and posterolateral ankle portals. Although plantar numbness has been described as a relatively common postsurgical complication, the neurovascular structure most commonly injured is the sural nerve.

All of the tissues noted above are stronger than native ACL. Although it is often thought that the bone-patellar tendon-bone graft is the strongest when selecting a graft source for ACL reconstruction, biomechanical studies show that the quadruple semitendinosus and gracilis tendons are the strongest of the tissues listed.
REFERENCES: Woo SL, Hollis JM, Adams DJ, et al: Tensile properties of the human femur-anterior cruciate ligament-tibia complex: The effects of specimen age and orientation. Am J Sports Med 1991;19:217-225.
Staubli HU, Schatzmann L, Brunner P, et al: Quadriceps tendon and patellar ligament cryosectional anatomy and structural properties in young adults. Knee Surg Sports Traumatol Arthrosc 1996;4:100-110.
Wilson TW, Zafuta MP, Zobitz M: A biomechanical analysis of matched bone-patellar tendon-bone and doubled looped semitendinosus and gracilis tendon grafts. Am J Sports Med 1999;27:202-207.

In a patient with a displaced and shortened middle third clavicle fracture, nonunion would be expected to occur more often than any of the other complications listed.
The risk of nonunion following mid-shaft clavicle fractures is increased with
advanced age, female gender, displacement, and comminution ("Z-deformity"). Nonoperative management of mid-shaft clavicle fractures has also been associated with decreased shoulder strength and endurance.
Furthermore, range of motion and shoulder strength have not been shown to be sufficiently different between operative and nonoperative management.
Hoogervorst et al. reviewed the treatment of mid-shaft clavicle fractures. They cite that the rate of nonunion for fractures treated nonoperatively is about 15%. The authors note that those with >2cm of shortening and displacement
>100% of the shaft width are at a greater risk for nonunion and that nearly 66% of those who go on to nonunion eventually undergo surgical repair.
Robinson et al. performed a prospective observational cohort study to evaluate the prevalence of and risk factors for nonunion of clavicle fractures treated nonoperatively. They found that the risk of nonunion was significantly increased by advancing age, female gender, displacement of the fracture, and the presence of comminution.
Figure A shows a radiograph demonstrating a middle third clavicle shaft fracture with >100% displacement and >2cm shortening.
Incorrect Answers:
Answer 1: The rate of skin necrosis following nonoperative treatment has not been shown to be higher than nonunion.
Answer 3: The rate of complex regional pain syndrome (CRPS) was shown to be around 2% in nonoperatively treated patients.
Answer 4 ad 5: Sternoclavicular arthritis and acromioclavicular arthritis or abnormalities have been shown to be somewhere between 4-6%

The radial and ulnar bursae are extensions of the tendon sheaths of the flexor pollicis longus and the flexor digitorum profundus of the small fingers. They can easily be involved in a case of pyogenic flexor tenosynovitis. Although not direct extensions of the flexor sheaths, the thenar space and Parona's space are adjacent to the flexor sheaths and can be involved in suppurative conditions. The snuffbox, however, does not have any contributions from the flexor system and is not usually involved in cases of pyogenic flexor tenosynovitis.

The best way to address varus malunion in talar neck fractures and maintain motion is by talar neck osteotomy. However, there is a further possible risk of talar avascular necrosis with this procedure. The other acceptable treatment is a triple arthrodesis, although this eliminates all hindfoot motion.

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_**DISCUSSION FOR QUESTIONS 107 AND 108:**_
The fracture at the insertion of the AITFL into the fibula represents a syndesmosis injury. In some cases, a direct repair of the fracture will stabilize the syndesmosis, but in most cases this injury should most likely be reinforced by placing a screw or suture tensioning device across the syndesmosis for additional support.A Brostrom or allograft reconstruction is indicated for an ankle sprain involving the ATFL or CFL.Simply excising the fragment will leave the patient with an incompetent syndesmosis. Repairing the SPR with or without a groove deepening procedure is indicated if there is evidence of subluxated or dislocated peroneal tendons, which is not demonstrated on the CT scans. The bone has been avulsed off the fibula by the portion of the AITFL that attaches to the fibula, therefore indicating that there is a syndesmosis injury. Allograft lateral ligament reconstruction and excision of loose body/fracture fragment are incorrect procedures based on location. The deltoid is a medial structure and this fracture is lateral. The ATFL and CFL attach at the inferior margin of the fibula near the lateral process of the talus and calcaneus. A SPR avulsion would present as an avulsion off the lateral wall of the fibula, not superior and not into the syndesmotic space as shown on the CT scans.

This patient has elbow stiffness caused by posteromedial heterotopic ossification after healing of his distal humerus fracture.
Stiffness and limited range of motion is common secondary to extrinsic causes. Studies have shown operative treatment via HO excision, capsular release, and/or release of the posterior band of the UCL can improve range of motion.
Park et al. studied 42 patients with extrinsic contracture of less than 100 degrees. They report posteromedial HO excision with capsular release and release of the posterior band of the UCL significantly improved ROM.
Williams et al. studied 164 patients who underwent release for extrinsic
tightness with ulnar nerve decompression for preoperative symptoms. Following decompression, low rates of postoperative ulnar nerve symptoms were noted. More post-operative symptoms were seen for more severe contractures.
Figure A is an AP and lateral radiograph of the elbow with posteromedial heterotopic ossification. Figure B is a 3D CT reconstruction confirming the posteromedial location.
Incorrect Answers:
Answer 1. There is a mechanical block to motion. Continued therapy will not improve the patient's range of motion.
Answer 2. Indomethacin is used for heterotopic ossification prophylaxis. Answer 3. Radiation therapy is used for heterotopic ossification prophylaxis. Answer 5. The anterior band of the ulnar collateral ligament should not be released because it will cause secondary valgus instability.

In a multivariate analysis, the strongest factor for the development of compartment syndrome is fracture of the proximal third of the forearm. However, compartment syndrome can still occur without a fracture. Therefore, these patients should be followed with a high level of suspicion for the development of compartment syndrome.
REFERENCES: Moed BR, Fakhouri AJ: Compartment syndrome after low-velocity gunshot wounds to the forearm. J Orthop Trauma 1991;5:134-137.
Hahn M, Strauss E, Yang EC: Gunshot wounds to the forearm. Orthop Clin North Am 1995;26:85-93.

The optimal position for hallux interphalangeal joint arthrodesis is 5° to 10° of plantarflexion, neutral varus-valgus, and neutral rotation. The plantarflexion helps the toe pad to contact the ground during gait.

The MRI scan and surgical video are showing an example of a posterior medial meniscal root tear/avulsion. Many studies have shown successful treatment of these tears with repair using various techniques and minimal progression to osteoarthritis (OA). Most studies exclude patients with high BMI. Brophy and associates demonstrated in their series that high BMI was associated with higher rates of clinical OA and need for subsequent surgery.
Multiple studies in the literature demonstrate good results with a variety of techniques. A valgus alignment in this setting would be considered protective, as opposed to a varus alignment >5°, which has also been associated with worse outcomes. The vascularity of the meniscus is consistently poor throughout most of its volume, including the root, and is not considered to be significantly different from person to person and should affect all root repairs equally.