Which method of flexor tendon repair that necessitates excursion through the A2 pulley allows for the most thorough assessment of tendon gliding?

strand repair with 6-0 epitendinous suture under local anesthesia only

A 52-year-old woman with a 2-year history of a flexible (stage II) adult-acquired flatfoot deformity has failed to respond to nonsurgical management consisting of immobilization, custom orthotics, nonsteroidal anti-inflammatory drugs, and physical th

Tendon transfer, lateral column lengthening, medial column arthrodesis, and heel cord lengthening

Creatine is currently being used by athletes as a dietary supplement in an attempt to enhance performance. What is the physiologic basis for its use?

Converts to phosphocreatine (PCr), which acts as an energy reservoir for adenosine triphosphate (ATP) in muscle tissue

Figure 10 is an anteroposterior pelvis radiograph of an 82-year-old man who had right hip pain that began 2 weeks ago but has since resolved with use of over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs). Currently he has no pain. Examina

Observation and NSAID use as needed

A 14-year-old boy has medial ankle pain, progressive unilateral flatfoot deformity, and pain with most activities of daily living. He denies any recent injury. His parents recall that at age 7 years he sustained an injury that was treated as a sprain

closing wedge distal tibial osteotomy.

A 63-year-old woman has a femoral neck fracture. A biopsy specimen obtained from the fracture site at the time of her hemiarthroplasty reveals metastatic carcinoma. Seven days after surgery, she becomes confused and lethargic. Which of the following

Calcium level of 15 mg/dL (normal value 8.5-10.5 mg/dL)

Orthopedic Review | Dr Hutaif General Orthopedics Revie -... | 100 Random Orthopedic MCQs

Question 1High Yield

Based on his radiograph findings, what is the best next step?

Explanation

- Axillary radiograph_

Question 2High Yield

A unilateral "piano key" sign, indicates

Explanation

The piano key sign is a demonstration of instability at the DRUJ, typically seen after healing from a distal radius fracture with an associated ulnar styloid fracture (as in this case) or other wrist injury. The hand is pushed down against a table top, and the distal radius translates dorsally (with the distal ulna apparently moving volarly). In fact, the distal radius is the mobile segment, while the distal ulna is fixed in space. Treatment involves repair or reconstruction of the foveal insertion of the triangular fibrocartilage complex (TFCC) and distal radioulnar ligaments. This type of instability is also common in malunions of the distal radius or distal one-third of the radial shaft (Galeazzi-type fractures). In malunions, DRUJ instability can be treated with a corrective osteotomy of the distal radius to restore the anatomic relationship between the distal ulna and the distal radius at the DRUJ. Radiocarpal and midcarpal instability do not involve the DRUJ. Disruption of the interosseous membrane (in isolation, with intact distal radioulnar ligaments and an intact TFCC) does not lead to translational instability of the DRUJ. Although hypermobility syndrome may lead to ligamentous laxity, it does not lead to unilateral DRUJ instability.

Question 3High Yield

Slide 1
A 23-year-old carpenter fell off a roof 4 weeks ago. He has pain in the ankle and a deformity. The lateral radiograph is presented (Slide). Which of the following treatments is most likely to return this patient to work with a functioning foot and ankle:

Explanation

The calcaneus fracture is associated with subluxation of the subtalar joint, giving the appearance of injury to the talus and calcaneus. The true extent of the injury cannot be determined without a computed tomography scan; however, the question is not as to the outcome of treatment, but the ability to return this patient to his occupation. At 4 weeks following injury, while open reduction internal fixation of the fracture is possible, anatomic reduction may be difficult. The most likely means of returning this patient to work is with early arthrodesis, which should be combined with an open reduction internal fixation of the calcaneus.

Question 4High Yield

Long strut allografts are not indicated in the initial treatment of reverse obliquity subtrochanteric fractures.
5-Addition of a de-rotation screw would not change the stability of the fixation construct.

A 34-year-old female sustains a proximal third tibia fracture as an isolated injury and elects to undergo operative treatment with intramedullary nailing. Which of the following operative techniques would help to best avoid a procurvatum deformity of the tibia?

Explanation

The semiextended position for intramedullay nailing of proximal tibia shaft fractures has shown to cause less complications of flexion deformity and malunion. Proximal third tibia fractures are often times difficult to reduce anatomically due to the tendency for both valgus and flexion deformity at the fracture site. The semiextended position helps to eliminate the tendency for
the fracture to flex, due to the avoidance of excessive knee flexion during the reduction. Illustration A is an example of semiextended positioning for tibial nailing. Illustration B shows radiograph utilizing posterior blocking screws to prevent procurvatum deformity.
Tornetta et al looked at the semiextended intramedullary nailing of proximal tibia fractures. Of the 24 patients nailed using this technique, 19 had no anterior angulation, while only 5 had less than 5 degrees of flexion deformity.
In their study, Kubiak et al also advocate the semiextended position for tibial nailing. They note better control of fracture alignment and stabilization especially in the sagittal plane, and better ability to obtain imaging and maintenance of reduction during nail insertion and locking.
Incorrect answers:

would help to avoid valgus deformity. Answer 3 would worsen the flexion deformity.
Answer 4 would worsen the flexion deformity and drive the nail posterior in distal segment.
Answer 5 would not affect flexion deformity.

Which of the following cannulated screw configurations used in the treatment of subcapital femoral neck fractures is optimal?

1) Inverted triangle pattern with the inferior screw posterior to midline and adjacent to the calcar

2) Inverted triangle pattern with the inferior screw anterior to midline and adjacent to the calcar

3) Triangle pattern with the superior screw posterior to midline and adjacent to the calcar

4) Inverted triangle pattern with the inferior screw posterior to midline and central in the femoral neck

5) Inverted triangle pattern with the inferior screw anterior to midline and central in the femoral neck

The strongest portion of the femoral neck is the posterior inferior neck in the region of the femoral calcar. The optimal biomechanical configuration includes an inverted triangle pattern with the single screw in the inferior aspect of the femoral neck adjacent to the calcar.
Booth et al performed a cadaveric study comparing central versus calcar (cortical-adjacent) fixation. The results demonstrated significant improved stability, load, stiffness, and displacement in all tested parameters for the group with calcar-adjacent screw fixation.
Lindequist and Törnkvist performed a Level 4 study of 72 femoral neck fractures. They found that all 5 of their nonunions had screws placed greater than 3mm from the femoral calcar. Additionally, 16 of 18 fractures healed in the group of displaced fractures where both the fixating screws were placed within 3 mm from the femoral neck cortex.
Gurusamy et al performed a Level 4 study of 395 patients undergoing femoral neck fixation. They found a reduced spread of the screws on the lateral view was associated with an increased risk of nonunion of the fracture.
Illustration A depicts the optimal configuration of an inverted triangle with the single screw being inferior and all of the screws being cortical adjacent.

A 63-year-old female sustained a distal radius and associated ulnar styloid fracture 3 months ago after being involved in a motor vehicle collision. Radiographs obtained at the time of injury are shown in Figure A. She underwent open reduction and fixation of the distal radius fracture, and current radiographs are shown in Figure B. At the time of the index operation, there was no distal radioulnar joint instability after plating of the radius. Which of the following is true post-operatively regarding this patient's ulnar styloid fracture?
1) Worse outcomes on the Mayo wrist score are expected without fixation

2) Chronic distal radioulnar joint instability can be expected to occur without fixation

3) Wrist function depends on the level of ulnar styloid fracture and initial displacement

4) Grip strength and wrist range of motion are improved with fixation

5) There is no adverse effect on wrist function or stability without fixation

An accompanying ulnar styloid fracture in patients with stable fixation of a distal radial fracture has no apparent adverse effect on wrist function or stability of the distal radioulnar joint.
Kim et al evaluated 138 patients who underwent surgical treatment of an unstable distal radial fracture, without fixation of an associated ulnar styloid fracture if present. Postoperative evaluation included measurement of grip strength and wrist range of motion; calculation of the modified Mayo wrist score; as well as testing for instability of the distal radioulnar joint at a mean of 19 postoperatively. They did not find a significant relationship between wrist functional outcomes and ulnar styloid fracture level or the amount of displacement.
af Ekenstam et al performed prospective and randomized study of two different treatments of extraarticular Colles' fracture with a fractured ulnar styloid. In one group, the ulnar styloid was left alone, and in the other group it was transfixed and/or the triangular ligament was repaired after closed reduction of the fractured radius. They concluded that repair of the ulnar styloid complex in extraarticular fractures of the distal radius is not better than conventional treatment.

Each of the following are guidelines for management of a domestic violence victim EXCEPT:

1) Socioeconomic status should not preclude evaluation for domestic violence

2) Interview the patient outside the presence of other non-medical personnel

3) Federal law mandates photographs be taken of injuries

4) Document your opinion if the patient’s injuries are not consistent with the offered explanation

5) Physicians should check requirements to see if there is mandatory reporting statute in their state

It is important to fully document the abuse as it has been described to you, however there is no federal law mandating photographic documentation of domestic violence injuries. Photographs may be taken but only with the patient's permission. Disclosure of a diagnosis of abuse to any third party and reporting it to the authorities should be done only with the abused patient’s knowledge and consent, unless there is a mandatory reporting statue in the particular state of practice. Being a female, age 19-29, pregnant, or of a low
socioeconomic status (
An otherwise healthy 34-year-old female undergoes an elective L5-S1 microdiscectomy. At her 4 week followup, she is noted to have drainage from her wound. Labs reveal a CRP of 30 mg/L (normal
1) CRP 20 mg/L, ESR 40 mm/hr

2) CRP 15 mg/L, ESR 20 mm/hr

3) CRP 6 mg/L, ESR 10 mm/hr

4) CRP 1 mg/L, ESR 25 mm/hr

5) CRP 8 mg/L, ESR 5 mm/hr

A normalized C-reactive protein (CRP) value (60 years, smoking, diabetes, previous surgical infection, increased body mass index, and alcohol abuse were all statistically significant preoperative risk factors for developing a post-op wound infection.. The most likely procedure to be complicated by an infection was a combined anterior/posterior spinal fusion performed in a staged manner under separate anesthesia. Infections were primarily monomicrobial and the most common organism cultured from the wounds was Staphylococcus aureus.
Illustration A shows the CRP trends in the study by Khan et al. with postoperative wound infections after spinal surgery treated with IV antibiotics. ER refers to early responder while LR refers to late responder. At the 4-week time point, 16 patients have shown clinical improvement with no fevers, wound drainage, erythema, or need for wound packing. The other 5 patients, referred to as late responders, have shown one or more clinical signs of infection in addition to having an elevated CRP. At 20 weeks, both early and late responders both have shown normalized CRP levels and no clinical evidence of infection. Illustration B shows the ESR trends in the those which demonstrated incomplete normalization of ESR values despite resolution of infection.
Incorrect Answers:
Answer 1, 2, 3, 5: CRP levels > 3 mg/L are elevated and indicate incomplete response to infection

A 25-year-old man is struck by car while crossing the street. His injuries include the closed left tibial shaft fracture shown in Figure A. He is a smoker, but is otherwise healthy. Intramedullary nailing is performed without initial complications. Which of the following puts this patient at greatest risk for tibial nonunion?
1) Use of anti-inflammatories post-operatively

2) Post-operative gapping at the fracture site

3) Presence of an associated fibular fracture

4) History of smoking

5) Mechanism of injury

Post-operative gapping at the fracture site significantly increased the risk of reoperation due to nonunion or malunion.
Bhandari et al performed a retrospective study to identify which prognostic factors were associated with an increased risk of reoperation for nonunion in surgically treated tibial shaft fractures. They examined over 200 fractures, and found the presence of an open fracture wound (RR 4.32), lack of cortical continuity between the fracture ends following fixation (RR 8.33), and the presence of a transverse fracture (RR 20.0) were the three variables most predicitive of reoperation.
Audige et al analyzed 416 patients with operatively treated tibial shaft fractures who were followed for at least 6 months. They found that the greatest risk for delayed healing or nonunion was the presence of an open injury, fractures of the distal 1/3 of the tibia, and postoperative gapping at the
fracture site (The risk of healing problems was doubled for fractures of the distal shaft and for fractures showing a postoperative diastasis).

Figure A is a radiograph of a healthy, independent 51-year-old male. He is treated with immediate open reduction internal fixation to prevent which of the following complications?
1) Fracture non-union

2) Avascular necrosis

3) Skin necrosis

4) Plantar flexion weakness

5) Ankle stiffness

Figure A shows an avulsion fracture of the calcaneal tuberosity. Immediate open reduction and internal fixation is required to prevent wound complications.
Displaced avulsion fractures of the calcaneal tuberosity should be managed urgently to prevent necrosis of the soft tissues overlying the heel. In these injuries, the Achilles tendon is securely attached to the fractured tuberosity. Urgent closed reduction and casting is usually not possible due to the power and proximal pull of the triceps surae. Surgical fixation is required. The best treatment modality is open reduction and bone-to-bone fixation with screws. Closed reduction and percutaneous pinning fixation is not strong enough to provide a stable fixation of the tuberosity.
Lui reported on avulsion fractures of the bony insertion of the Achilles tendon at the calcaneus. He stated that screw fixation alone is not sufficient for repair of these injuries. His technique involved two suture anchors used capture the small bone fragment to the calcaneus. This allowed for the pull of the triceps surae to be neutralized and early physical therapy.
Hess et al. looked at a case series of calcaneal tuberosity avulsion fractures that were treated in a delayed fashion. All three patients with posterior tuberosity calcaneal avulsion fractures developed skin necrosis because of a delay in treatment.
Figure A shows a displaced posterior tuberosity calcaneal avulsion fracture. Illustration A shows skin breakdown overlying the posterior tuberosity calcaneal avulsion fracture.
Incorrect Answers:
Answer 1: The amount of displacement is an indication for fixation, however urgent treatment does not improve union rates with these fractures.
Answer 2: Tuberosity calcaneal avulsion fractures rarely disrupt the blood supply to the avulsion fragment and are not associated with avascular necrosis.
Answer 3: Plantar flexion weakness is a known complication of these injuries despite many treatment options.
Answer 4: Ankle stiffness is most commonly related to surgical fixation methods and post-operative immobilization and delayed rehabilitation.

A 22-year-old male presents 4 weeks following open reduction and internal fixation of his unstable ankle fracture. He has had three days of increasing pain, swelling and the new onset of purulent drainage from the mid-portion of the lateral incision. Laboratory values, including white blood cell count, sedimentation rate, and C-reactive protein are elevated. Current radiographs are seen in Figures A and B. On examination the wound probes deep and likely involves the lateral plate. What is the best step in management at this time?
1) Suppression with broad spectrum oral antibiotics until fracture healing

2) Suppression with broad spectrum intravenous antibiotics until fracture healing

3) Surgical debridement, removal of internal fixation, culture specific antibiotics, casting until fracture healing

4) Surgical debridement, maintenance of internal fixation, culture specific antibiotics until fracture healing

5) Wound culture in the office and suppression with culture specific antibiotics until fracture healing

The patient is presenting with an acute deep infection following open reduction and internal fixation of an unstable ankle fracture. Recent studies have shown that a protocol of early aggressive surgical debridement, maintenance of internal fixation and culture specific antibiotics can be effective at achieving fracture healing.
Management of early postoperative infection following open reduction and internal fixation can be challenging. Effective treatment typically involves a combination of surgical debridement and culture specific antibiotics. Removing internal fixation prior to fracture healing can lead to additional insult to the soft tissue and ongoing inflammation secondary to fracture instability. Recently published protocols have shown effective treatment with maintenance of implants and culture specific antibiotics following early, aggressive surgical debridement.
Berkes et al. performed a multi-center retrospective study of 121 patients with acute postoperative infection (defined as less than 6 weeks from surgery) following internal fracture fixation. The authors demonstrated a 71% rate of success (defined by maintenance of implants until fracture healing) with a protocol of debridement and suppression with culture specific antibiotics. Risk factors for failure of this technique include open fractures and the use of an intramedullary nail for fracture fixation.
Figures A and B show an ankle status post open reduction and internal fixation of a lateral malleolus fracture. There are no signs of loosening of fixation or cortical erosions concerning for osteomyelitis.
Illustrations A and B are weight bearing X-rays that demonstrate the same fracture, now healed, after debridement and culture specific antibiotics.
Illustrations C and D demonstrate the same fracture after elective removal of implants at 10 months following the index procedure. Intraoperative cultures at the time of hardware removal were negative for recurrent infection.
Incorrect answers:
Answers 1 and 2: Broad spectrum antibiotics without surgical debridement would not be effective in dealing with the infection in this clinical scenario with purulence tracking to the level of the plate
Answer 3: Surgical debridement and antibiotics would control the infection adequately, however removal of fracture fixation in an unstable fracture would lead to instability, soft tissue inflammation and likely malunion or nonunion that would require complex revision
Answer 5: Although culture specific antibiotics are an improvement over broad spectrum, again surgical debridement in conjunction with antibiotics is the most appropriate choice in this scenario. Intraoperative deep cultures in a sterile environment are preferred over cultures obtained in the office.

A 28-year-old male sustained an ankle injury 3 months ago, and was treated with closed management and splinting; a current x-ray is shown in Figure A. Which of the following is the most important factor in deciding between a joint sacrificing and a joint preserving operation for this patient at this time?
1) Workers' Compensation involvement

2) Gender

3) Date of injury

4) Degree of tibiotalar arthritis

5) Degree of deformity

This patient presents with malunion after sustaining a bimalleolar ankle fracture. Surgical treatment options consist of osteotomy for deformity correction with internal fixation (joint preserving) versus fusion (joint sacrificing) with the primary determinant being the amount of ankle arthritis present.
When treating ankle malunions, the decision to perform deformity correction and preserve the joint versus fusing the joint is dependent on signs of progressive, advanced tibiotalar arthritis on radiographs.
Yablon and Leach followed 26 patients following corrective fibular osteotomy following malunion and noted excellent results at a mean follow-up of 7 years. All but 3 returned to preinjury level of activity and had desired outcomes following deformity correction.
Reidsma et al. prospectively followed 57 patients with a minimum follow-up of 10 years following corrective osteotomy and fixation for ankle fracture malunions. Good to excellent results were obtained for 85% of the cohort. The authors concluded that those ankle fracture malunions with none to minimal arthritic changes should still receive corrective osteotomy to prevent further progression of arthritis.
Yablon et al. following 53 patients for 6-9 months, reported on the importance of anatomic restoration of the lateral malleolus when fixing bimalleolar ankle fractures. With anatomic reduction and fixation, no progression of arthritis was noted with return to function.
Figure A is an AP radiograph of a right ankle fracture malunion. Incorrect answers:
Answers 1-3, 5: Factors such as age, gender, and degree of deformity are not
as important as the presence of advanced arthritis that may suggest requiring a joint sacrificing fusion procedure. The date of injury may portend a poor outcome (the longer from the date of injury/subsequent malunion), but is not the most important factor in deciding between corrective osteotomy versus fusion.

A 45-year-old male presents after falling off of a ladder. Radiograph is shown in Figure A. Which of the following is the appropriate sequence in management?
1) Closed reduction, splint application, computed tomography (CT) scan, delayed open reduction and internal fixation

2) Closed reduction, cast application, close observation

3) Splint application, CT scan, application external fixator, delayed open reduction and internal fixation

4) Splint application, application external fixator, CT scan, delayed open reduction and internal fixation

5) Splint application, acute open reduction and internal fixation

This patient has sustained a pilon fracture, with severe comminution and impaction at the articular surface.
The correct sequence of management includes (1) immediate splinting, (2) application of an external fixator, (3) restoration of length alignment and rotation with temporizing external fixation, (4) computed tomography, followed by (5) definitive fixation once soft tissues are amenable.
Tornetta and Gorup analyzed the use of preoperative CT scans in comparison to radiographs in preparation for fixing pilon fractures. The authors noted increased recognition of intra-articular fragments, comminution and noted a high percentage of operative planning changes following CT analysis.
Furthermore, the authors recommended CT scans AFTER external fixation, for even better fragment characterization.
Marsh et al. in their instructional course lecture provide tips and tricks in successful management of pilon fractures. One of the highlighted points include staged, delayed treatment of pilon fractures via spanning external fixator as well as highlighting the importance of obtaining the CT after restoring length and alignment.
Figure A exhibits a radiograph of a comminuted, impacted, shortened pilon fracture.
Incorrect answers:
Answer 1: With such a short, impacted fracture, external fixation as a temporizing measure is recommended to help calm the soft tissue envelope. Answer 2: Closed treatment is not accepted in this type of fracture, due to the high incidence of arthritis and malunion.
Answer 3: CT scan should be obtained AFTER external fixation, not before. Answer 5: This high-energy injury likely has severe soft tissue injury, which is not amenable to acute fixation.

A 45-year-old male with long-standing diabetes sustains the injury shown in Figure A. He has a BMI of 38, established peripheral neuropathy, and his most recent HbA1c is 8.8. What is the most appropriate definitive management option of Figures B through F?
1) Figure B

2) Figure C

3) Figure D

4) Figure E

5) Figure F

Open reduction and internal fixation (ORIF) remains the mainstay of treatment for ankle fractures in patients with diabetes.
ORIF for ankle fractures in diabetics can be augmented with increased density of fixation to account for notable, pathologic bone. Specifically, multiple quadricortical syndesmotic screws, bicortical medial malleolar screws, and stiffer plates are all viable options. Furthermore, due to delayed healing properties, prolonged immobilization may also be required to avoid fixation failure.
Guo et al. performed a cohort controlled comparison between diabetics and non-diabetic patients with operative ankle fractures. Although they hypothesized that there would be more complications in the diabetic group, there was no statistical differences in fixation failure or complications when adhering to treatment principles for diabetics (including prolonged non-weight bearing for 10-12 weeks and increased density of fixation).
Chaudhary et al. review the notable complications following ankle fracture treatment in patients with diabetes. In reviewing the literature, the authors recommend ORIF with meticulous soft tissue handling, increased density of fixation, and prolonged immobilization as the mainstay of diabetic ankle fracture treatment. External fixation and frames, while treatment options, should be reserved for salvage or infectious clinical scenarios.
Figure A depicts a bimalleolar ankle fracture. Figure B depicts a cam walker.
Figure C depicts a cast. Figure D standard fixation for ankle fracture for a patient without diabetes. Figure E exhibits definitive fixation with additional screws to increase construct stability. Figure F depicts a ring fixator.
Incorrect Answers:
Answers 1,2: Non-operative treatment is not appropriate for this fracture pattern
Answer 3: Figure D, typically used for those without diabetes is less appropriate for this patient/clinical scenario.
Answer 5: While external fixation and a ring fixator may be utilized, ORIF should be attempted first, however, as it provides stiffer fixation.

Distraction bone block arthrodesis alone would most likely help a patient suffering from a painful calcaneus fracture malunion with all of the following except:

1) Low talar declination angle

2) Hindfoot varus alignment

3) Subtalar arthritis

4) Talonavicular subluxation

5) Peroneal impingement

Distraction bone block arthrodesis in isolation would be unlikely to improve pain related to peroneal impingement. Lateral wall exostectomy would likely be needed for this, and should be concomitantly performed in most cases.
Calcaneal fracture malunions demonstrate several common patterns. Patients may manifest pain from anterior tibiotalar impingement (a result of a low talar declination angle), difficulty with shoe wear due to shortening and widening of the hindfoot, painful talonavicular subluxation, subfibular impingement, and post-traumatic subtalar osteoarthritis. The distraction bone block arthrodesis procedure was developed to eliminate the pain of subtalar arthritis while simultaneously normalizing hindfoot height by inserting a contoured structural bone graft into the subtalar joint. The procedure can correct pathologic hindfoot varus/valgus and restore a normal talocalcaneal angle, thereby improving symptomatic post-traumatic pes planus. The procedure alone does not address lateral wall blowout causing subfibular or peroneal impingement, which requires lateral wall exostectomy. Lateral wall exostectomy therefore should be done in addition to address this issue.
Carr et al. first reported the use of subtalar distraction bone block arthrodesis for salvage of post-traumatic subtalar arthritis following calcaneus fractures. In their 16 patient series, distraction of the subtalar joint with insertion of the bone block allowed for correction of talocalcaneal angle, restoration of hindfoot height, and improvement in symptoms related to tibiotalar impingement.
Clare et al. evaluated a treatment protocol for calcaneal malunions based upon the classification of Stephens and Sanders. Type II and III malunions were treated with subtalar bone-block arthrodesis and other concomitant procedures. They found that their treatment protocol was effective for pain relief, re-establishing a plantigrade foot, and improving function. The most difficult component of the case was restoration of calcaneal height.
Braley et al. evaluated isolated lateral decompression in the treatment of symptomatic calcaneal malunions without concomitant subtalar arthrodesis. These 11 patients had persistent lateral sided pain and their malunions did demonstrate subtalar involvement. The authors reported 9 of the 11 patients had a satisfactory outcome with lateral decompression alone. They concluded that a lateral decompression in management of symptomatic malunions with lateral-sided symptoms is an essential consideration.
Incorrect Answers:
Answer 1: Talar declination angle describes the relative plantar- or dorsiflexion of the talus relative to the ground.
Answer 2: Hindfoot alignment can be improved with distraction arthrodesis. Answer 3: Arthrodesis addresses painful subtalar arthritis.
Answer 4: Restoration of the normal talocalcaneal angle can be achieved, which can also normalize the talonavicular relationship.

A 31-year-old patient has had activity related lateral ankle pain for 4 months. She underwent the procedure shown in Figure A approximately 8 months ago. What surgical technique has most likely resulted in this patients pain?
1) Failure to recognize the most distal screw penetrating the joint surface

2) Low posterior plating with prominent distal screw

3) Failure to recognize an associated syndesmosis disruption

4) Fracture malreduction causing shortening of the fibula

5) Failure to use a longer plate with the lag screw positioned outside the plate

Figure A shows a low posterior plate with a prominent screw head in the most distal hole of the plate. This fixation technique is correlated with peroneal pathology, which usually presents months after fixation when the patient increases their activity level.
The two most common fixation techniques of lateral malleolus fractures are (1) lag screw plus lateral neutralizing plating and (2) posterolateral antiglide plating. The disadvantages of the lateral plating includes the risk of intraarticular screws distally, prominent lateral hardware, and poor distal screw fixation. To overcome these complications, posterolateral antiglide plating allows for bicortical distal fixation with no articular perforation. However, low placement of the plate with a prominent screw head in the most distal hole is associated with symptomatic peroneal pathology. If the most distal screw is not prominent, or absent, this is less likely to cause peroneal complications.
Weber et al. examined the effect of antiglide plate and screw positioning on peroneal tendon pathology. They showed that low posterior plating and large screw heads caused significant retromalleolar pain in most patients. To decrease peroneal pathology, they state that the distal end of the plate should stay proximal to the osteosynovial peroneal groove. Radiologically this level
corresponds to the junction of the proximal and middle thirds of the lateral malleolus.
Figure A shows a posterior positioned 5 hole 1/3 tubular plate. There is no articular screw penetration and the fracture is healed in an anatomical position. The distal aspect of the plate is is the distal third of the lateral malleolus.
Incorrect Answers:
Answer 1: The most distal screws rarely penetrates the joint with the use of fibular antiglide plates. In addition, there is no evidence of screw penetration in this patient.
Answer 3: A missed syndesmosis disruption would usually show some radiographic findings. The tibiofibular clear space is usually most sensitive, which is measured radiographically by the distance from the lateral border of the posterior malleolus in the distal tibia to the medial border of the fibula. As a general rule, it is considered normal if the measurement is less than approximately 6 mm on both AP and mortise views.
Answer 4: The fracture reduction looks anatomic. The talocrural angle, 'dime' sign and “Shenton's line” of the ankle all normal.
Answer 5: The construct used to fix this isolated lateral trans-syndesmotic fracture is acceptable. The one-third tubular plate, which is placed posterolaterally on the fibula as an antiglide plate, indirectly reduces the fracture and acts as a buttress to resist the posterior and proximal displacement of the distal fragment. Insertion of a lag screw through the plate is a described technique.

A 35-year-old painter falls from a ladder sustaining an isolated fracture of his left calcaneus. Months later at follow-up, he is noted to have pain and a catching sensation in his medial foot with active flexion of the great toe. What is the most likely initial injury leading to this complication?

1) Displaced calcaneal beak fracture

2) Displaced fracture of the calcaneal tuberosity

3) Comminuted posterior facet fracture

4) Fracture of the sustentaculum tali

5) Lateral wall blowout fracture

A known complication of fractures of the sustentaculum tali is stenosis (delayed) or injury (acute) of the flexor hallucis longus (FHL) tendon. Stenosis
can cause pain and popping with great toe flexion.
Fractures of the calcaneus often occur after falls from height, and in addition, may be associated with vertebral fractures due to the high-impact mechanism. The FHL tendon runs directly underneath the sustentaculum tali on the medial calcaneus and can be injured causing frank tears or delayed stenosis. These fractures may be missed on ankle or foot plain films alone, and advanced imaging should be ordered if clinical suspicion for calcaneus fractures exists given mechanism and location of pain/swelling.
Komiya et al. present a case report of direct impalement of the FHL tendon in the tunnel under the sustentaculum tali. Though this particular complication is quite rare, such a report highlights the relevant anatomy and structures at risk as well as demonstrates the need for a good clinical exam as the injury was not noted on imaging but the concern was raised on physical exam of FHL involvement.
Della Rocca et al. report their 19-patient series on operatively managed isolated sustentaculum tali fractures. They report a high rate of associated ipsilateral foot injuries (14 patients) and describe fixation using a medial approach and retracting the flexor tendons and neurovascular bundle.
Illustration A is an axial CT image from Della Rocca (2009) et al. showing a representative sustentaculum tali fracture
Incorrect Answers:
Answer 1 - beak fractures are posterior, anatomically related to the Achilles tendon insertion, not the FHL tendon.
Answer 2 - FHL tendon is not associated with the tuberosity.
Answer 3 - FHL tendon runs anterior to the posterior facet and would unlikely be involved in that injury.
Answer 5 - FHL tendon runs medially, not laterally.

A 30-year-old male patient involved in a hang-gliding accident sustains a knee dislocation with multiligamentous knee injury and transection of his peroneal nerve. He undergoes multiple reconstructive surgeries. Two years later, he continues to have a foot drop and dynamic tendon transfer is recommended. This treatment most commonly involves transferring a tendon from which native insertion point to which new insertion point?

1) Plantar distal phalanges to medial navicular

2) Medial navicular to dorsal lateral cuneiform

3) Plantar 1st metatarsal to dorsal lateral cuneiform

4) 5th metatarsal base to dorsal medial cuneiform

5) Plantar distal phalanx of the hallux to dorsal distal phalanx of hallux

Dynamic tendon transfer to restore active dorsiflexion of the foot involves transferring the posterior tibial tendon (PTT) insertion on the medial navicular to the dorsal lateral cuneiform.
Common peroneal nerve (CPN) injuries following traumatic knee dislocation are common, with an incidence of 25-40%. CPN palsy is characterized by foot drop
due to loss of ankle dorsiflexors with a steppage gait and eventual development of a supinated equinovarus foot secondary to the unopposed pull of the PTT. Nonsurgical management involves use of an ankle-foot orthosis and physical therapy. Surgical options include acute primary repair, nerve grafting with either autologous sural nerve or nerve conduits and dynamic tendon transfer. The PTT is harvested from its insertion at the navicular, passed through the interosseous membrane (IOM) and anchored to the lateral cuneiform (see Illustration A). The classic bridle procedure involves concomitant anastamosis of the PTT to the tibialis anterior (TA) and peroneus longus (PL) tendons.
Garozzo et al reported a case series of 62 patients with post-traumatic CPN palsy who underwent a one-stage procedure consisting of nerve repair and PTT transfer. Nerve repair combined with PTT transfer improved postoperative outcomes compared to nerve repair alone. At 2-year follow up, neural regeneration was demonstrated in 90% of patients. The authors hypothesized that poor outcomes following nerve repair alone are due to force imbalance between the functioning flexors and paralyzed extensors, which is somewhat equalized by performing a PTT transfer at time of repair.
Niall et al reviewed 55 patients with traumatic knee dislocation and reported a 41% incidence of CPN injury, exclusively associated with dislocations involving disruption of the posterior cruciate ligament (PCL) and posterolateral corner (PLC). Complete neurologic recovery was found in only 21% of patients. The best prognosis was found with lesions in continuity, less than 7cm of nerve involvement, and short conduction block and muscle activity on nerve conduction and EMG studies.
Vigasio et al described a dynamic tendon transfer technique for traumatic complete CPN injury, involving transfer of the PTT to the TA rerouted to a new origin at the lateral cuneiform to restore ankle dorsiflexion and flexor digitorum longus (FDL) to the extensor digitorum longus (EDL) and extensor hallucis longus (EHL) to restore digit dorsiflexion. Rerouting the TA towards the transferred PTT ensures the PTT harvest length is sufficient. This avoids excessive tensioning of the PTT, which may limit tendon excursion and result in a static tenodesis rather than dynamic function, as well as the need for PTT lengthening which may decrease strength of the transfer
Illustration A is a series of intraoperative photographs demonstrating PTT transfer from Garg et al. An incision is made distal to the medial malleolus and the PTT is harvested subperiosteally (A). The PTT is delivered through a second incision ~15cm proximal to the medial malleolus (B-C). The PTT is then passed through the interosseous membrane and out a third incision over the anterior
fibula (D). Lastly, the PTT is passed through a fourth incision over the dorsal midfoot and anchored to the lateral cuneiform (E).
Incorrect Responses:
Answer 1: Transferring the FDL (insertion = plantar distal phalanges) to the medial navicular is used for correction of flexible flatfoot deformity arising from PTT insufficiency. Some surgeons transfer the FDL to the medial navicular at the time of PTT transfer to the dorsum of the foot, to compensate for loss of PTT function and minimize risk of flatfoot development.
Answers 3: Transferring the PL (insertion = plantar 1st metatarsal) is not recommended, as this muscle is innervated by the CPN via the superficial peroneal nerve and therefore would not be functional.
Answer 4: Transferring the peroneus brevis (PB; insertion = 5th metatarsal base) is not recommended, this muscle is innervated by the CPN via the superficial peroneal nerve and therefore would not be functional.
Answer 5: Transferring the flexor hallucis longus (FHL; insertion = plantar distal phalanx of the hallux) to the insertion of the EHL (dorsal distal phalanx of hallux) is recommended for correction of claw toe deformity and would not help restore foot dorsiflexion in this patient.

Which of the following represents the most common complication following operative treatment of the injury shown in Figure A?
1) Figure B

2) Figure C

3) Figure D

4) Figure E

5) Figure F

This patient has a displaced talar neck fracture. The most common complication is post-traumatic arthritis.
Complications after treatment of displaced talar neck fractures are common. Both tibiotalar and subtalar arthritis occur, with subtalar arthritis being the most common. Osteonecrosis is also common, but post-traumatic arthritis is the most common.
Lindvall et al. reviewed 26 displaced talar fractures treated with internal fixation and found that post-traumatic arthritis was the most common complication, occurring in 100% of patients. Osteonecrosis was found in 13 of 26 patients (50%).
Vallier et al. reviewed patients presenting with talar neck fractures and found post-traumatic arthritis in 21 of 39 patients (54%). Osteonecrosis was found in 19 of 39 patients (49%).
Figure A shows a displaced talar neck fracture. Figure B shows talar neck nonunion (arrow) and osteonecrosis of the talar body. Figure C is an AP of the same patient shown in Figure B and again shows osteonecrosis of the talar body. Figure D shows subtalar arthritis after internal fixation of a talar neck fracture via medial malleolar osteotomy. Figure E shows a clinical photo of a patient with a varus malunion after talar neck fracture. Figure F shows a wound dehiscence.
Incorrect answers:
Answers 1, 2, 4, 5. These are all known complications of surgical treatment of displaced talar neck fractures but occur less frequently than post-traumatic arthritis.

A 25-year-old woman began training for a marathon and she reports a 2-week history of heel pain. She has pain throughout the day that worsens with prolonged weight-bearing. On exam, the location of
maximal tenderness is indicated by the white arrow in Figure A. The patient denies point tenderness at the location of the yellow arrow in Figure A. Which of the following MRI images (Figures B to F) would you expect to find in this patient?
1) Figure B

2) Figure C

3) Figure D

4) Figure E

5) Figure F

The clinical presentation is consistent with a stress fracture of the calcaneus. The T1 MRI shows a fracture line within the calcaneus which is consistent with
a calcaneal stress fracture.
Calcaneal stress fractures most commonly occur in long-distance runners and military recruits. Usually, they are caused by overload and inability of bone formation to match resorption. Patients usually begin a rapid increase of activity level from a prior sedentary lifestyle. Patients complain of heel pain that persists throughout the day. The pain is located along the medial and lateral walls of the calcaneus. Diagnosis can be made with radiographs 2-3 weeks after symptom onset by the appearance of a sclerotic line. If the diagnosis is uncertain, MRI may be obtained.
Gehrmann et al. performed a review of stress fractures in the foot. They report that most studies of calcaneal stress fractures are from military recruits.
Primary treatment includes rest, avoidance of weight-bearing, and physical therapy. Patients usually return to full duty between 8 and 10 weeks. Recruits with inadequate treatment had a recurrence of symptoms. They conclude that most studies are from the 1940’s and 1950’s and lack any significant detail into specific treatment protocols.
Sormaala et al. performed a retrospective study in which they reviewed MRIs in all military recruits who had exercise-induced heel pain, over an eight-year period. They report that only 15% of injuries were visible on radiographs and a portion of patients had stress fractures of another tarsal bone. They conclude that a majority of calcaneal stress fractures occur in the posterior part of the bone, but some fractures may be found in the middle and anterior parts. They recommend obtaining an MRI if a radiograph is negative in a patient with exercise-induced foot or heel pain.
Figure A demonstrates the most common area of tenderness and pain of a calcaneal stress fracture, indicated by the white arrow, while the yellow arrow points to the area of tenderness consistent with plantar fasciitis. Figure B is a sagittal T2-weighted MRI demonstrating plantar fasciitis. Figure C is a sagittal T1-weighted MRI demonstrating a calcaneal stress fracture. Figure D is an axial T1-weighted MRI demonstrating a mass on the medial aspect of the calcaneus consistent with a ganglion cyst. Figure E is a sagittal T1-weighted MRI of the foot demonstrating an intraosseous lipoma within the calcaneus. Figure F is a sagittal T2-weighted MRI demonstrating insertional Achilles tendinopathy.
Illustration A demonstrates the most common etiologies of plantar foot pain.
Incorrect Answers:
Answer 1: Figure B, a sagittal T2-weighted MRI, demonstrates plantar fasciitis. Symptoms of plantar fasciitis are sharp heel pain, usually worse in the morning. Tenderness is usually found on the plantar aspect of the foot.
Answer 3: Figure D, an axial T1-weighted MRI, demonstrates a ganglion cyst in the tarsal tunnel. Symptoms of tarsal tunnel syndrome include sharp burning pains in the foot and parasthesias and numbness in the plantar foot.
Answer 4: Figure E, a sagittal T1-weighted MRI, demonstrates an intraosseous lipoma. Intraosseous lipomas are usually incidental findings.
Answer 5: Figure F, a sagittal T2-weighted MRI, demonstrates insertional Achilles tendinitis. This usually presents with pain over the insertion of the Achilles. It may have a relapsing and remitting course, which worsens with activity.

A 35-year-old male fell and sustained an open talar neck fracture. He underwent operative fixation of his fracture. He presents at 2 months after surgery. He denies any constitutional symptoms and his pain is well controlled. On exam, his wounds are well healed with no erythema. Imaging is shown in Figure A. What can the patient be told about his condition?
1) Hawkins sign is positive. The likelihood of developing osteonecrosis is high

2) Hawkins sign is positive. The likelihood of developing osteonecrosis is low

3) Hawkins sign is negative. The likelihood of developing osteonecrosis is high

4) Hawkins sign is negative. The likelihood of developing osteonecrosis is low

5) He has developed chondrolysis

This patient has a positive Hawkins sign, which signifies that he is unlikely to develop osteonecrosis.
A subchondral radiolucency of the talar dome after a talar neck fracture is known as the Hawkins sign. It is an indication that the talar body is viable. It usually appears by 6-8 weeks after injury and is best seen on the mortise view. If the Hawkins sign is present, it is unlikely that the patient will develop osteonecrosis.
Early writes a review on talus fracture management. He reports that talar neck fractures occur through the extra-articular portion of the talus and represent nearly half of talus fractures. The mechanism of injury is a combined ankle dorsiflexion followed by axial compression of the tibiotalar joint. He concludes that anatomic reduction gives the patient the best chance of a good outcome.
Leduc et al. wrote a review on posttraumatic avascular necrosis of the talus. They note that AVN is diagnosed on plain radiography by the absence of the Hawkins sign. They report that CT can also reveal characteristic talar AVN patterns and can be used to confirm radiographic findings. CT helps to assess subtle depression, collapse, fragmentation, and arthritic changes. MRI remains the most sensitive technique for detecting osteonecrosis of the talus, especially in the early stages. They conclude that although there are many published treatments of AVN of the talus, outcome studies are still lacking.
Tezval et al. performed a retrospective review to determine the prognostic reliability, sensitivity, and specificity of the Hawkins sign. They found that in all patients who developed osteonecrosis, none had the Hawkins sign present. In all patients that exhibited a Hawkins sign, none developed osteonecrosis. They determined the sensitivity of the Hawkins sign to be 100% while the specificity was 57.5%. They conclude that if a full or partial positive Hawkins sign is detected, it is unlikely that AVN will develop.
Figure A demonstrates the Hawkins sign with subchondral radiolucency which is noted by arrows in Illustration A.
Incorrect Answers:
Answers 1, 3, 4: The patient has a positive Hawkins sign, therefore the chance of developing osteonecrosis is low.
Answer 5: Chondrolysis is characterized by rapid destruction of articular cartilage on both sides of the joint which leads to loss of joint space

A 25-year-old male presents to the emergency department after a lawnmower accident with traumatic loss of his great toe. On examination, his wound is grossly contaminated with soil. In addition to a cephalosporin and an aminoglycoside, penicillin is given. Which of the following is true with regards to the organism that penicillin is targeting in this injury?

1) It is an Aerobic, Gram-positive rod

2) It is an Anaerobic, Gram-positive coccus

3) It is an Anaerobic, Gram-negative rod

4) It is Catalase positive

5) It may cause botulism

The organism being covered with penicillin is Clostridia spp. Clostridium botulinum is a Gram Positive Bacilli that is the cause of botulism.
Clostridia spp, is a Gram-positive, obligate anaerobic spore-forming rod that is found in soil and gut flora. It produces gas by the fermentation of glucose and
may cause gas gangrene. Common bacteria of this genus are C. perfringens (most common), C. tetani (causes tetanus), C. difficile, and C. botulinum (causes botulism). If wounds are grossly contaminated with soil, penicillin is given to cover against Clostridia.
Decoster et al. performed a review of traumatic foot wounds. They report that lawnmower injuries to the foot are relatively common. IV antibiotic therapy should be initiated with a broad-spectrum cephalosporin and an aminoglycoside to provide coverage against Gram-negative organisms.
Penicillin should be given to protect against Clostridial infection. They conclude that irrigation and debridement is indicated initially followed by packing of open wounds. Repeat debridements are necessary as nonviable tissue demarcates. If major reconstructive procedures are necessary, they should be delayed as they have a high rate of failure if performed too soon.
Cross et al. wrote a review on treatment principles in the management of open fractures and they note that in open fractures with soil contamination, additional coverage should be added for anaerobic bacteria, typically Clostridia. Another member of the genus Clostridia is C. tetani, the causative agent of tetanus. Vaccine status for tetanus must also be assessed in these situations as well.
Illustration A is a radiograph demonstrating soft tissue swelling and subcutaneous emphysema, consistent with gas gangrene. Illustration B is a clinical photograph of gas gangrene evidenced by edema, discoloration, ecchymosis, and hemorrhagic bullae. Illustration C is a pathology slide of C. perfringens, a Gram-positive rod.
Incorrect Answers:
Answers 1, 2, 3: Clostridia are Gram-positive, obligate anaerobes. Answer 4: Clostridia are catalase negative.

All of the following are ways that a negative pressure dressing is beneficial to wound healing EXCEPT:

1) Accelerated granulation tissue formation

2) Removes excess proteins and electrolytes from wound

3) Reducing anaerobic colonization

4) Causes cells to release vascular endothelial growth factor by mechanical force

5) Causes an increase in capillary afterload

Negative pressure dressings or vacuum-assisted wound closures (VAC) apply a negative pressure to the wound bed which allows a decrease in capillary afterload which produces a better inflow of blood.
VAC dressings exert their positive effects on wound healing in multiple ways. Firstly, they remove interstitial fluids, which have been found to contain inhibitory factors that suppress the formation of fibroblasts, vascular endothelial cells, and keratinocytes. This also eliminates the formation of any superficial purulence or slime which also reduces the potential for anaerobic colonization. Removal of excess fluid also pulls out excess proteins and electrolytes to help maintain and osmotic and oncotic gradient. VACs allow arterioles to dilate which produces a proliferation of granular tissue. Also, there is a decrease in capillary afterload, (the pressure against which the heart must overcome to eject blood), which promotes better inflow of blood. Lastly, applying a mechanical force to the surrounding soft tissues allows the edges of the wound to be drawn towards the center, uniformly. This decreases the size of the wound over time. The micromechanical forces exerted on individual cells causes a release in local growth factors, such as vascular endothelial growth factor (VEGF), which stimulate wound healing.
Herscovici et al. applied VAC dressings to 21 consecutive patients with open, high-energy soft tissue injuries. They found that wounds averaged 4.1 sponge changes and the device was used for an average of 19.3 days. 12 wounds avoided the need for further treatment. Only 9 patients required free tissue transfer. They concluded that the VAC is a viable treatment adjunct for the treatment of open, high-energy injuries.
Clare et al. reported their experience with the VAC dressing in the treatment of non-healing, diabetic and dysvascular wounds. They retrospectively reviewed 17 patients with non-healing wounds of the lower extremity. 9 had diabetes and 8 had severe peripheral vascular disease. The average length of treatment
was 8.2 weeks and 14/17 wounds successfully healed, and only 3 failed VAC treatment. They concluded that the VAC dressing is an acceptable option for wound care of the lower extremity.
Illustration A is a photo of an open wound being treated with a VAC dressing. Incorrect Answers:
Answers 1, 2, 3, and 4 are all ways that VAC dressings are beneficial to wound
healing.

Which of the following is true regarding anterior sternoclavicular joint dislocations?

1) Reduction may result in tracheal injury

2) They are usually stable following closed reduction

3) They require fusion to hold the reduction

4) They are rarely symptomatic when left unreduced

5) They should be treated acutely with medial clavicle excision

From the Bicos article, “Anterior SC joint instability should primarily be treated conservatively. The patients should be informed that there is a high risk of persistent instability with nonoperative or operative care, but that the persistent instability will be well tolerated and have little functional impact in the vast majority. Therefore, operative intervention for anterior SC joint instability is mainly cosmetic in nature."

An otherwise healthy 45-year-old female slips and falls with immediate right ankle pain. Stress examination of the right ankle is shown in Figure A. Which of the following is the most important for achieving a satisfactory outcome following open reduction internal fixation for this injury?
1) Weight-bearing before 3 weeks.

2) Medial clear space >5mm

3) Talocrural angle of 83 degrees

4) Tibiofibular clear space of >6mm

5) Talar tilt of >5 degrees

Anatomic reduction of a rotational ankle fracture is considered the most important factor in achieving a satisfactory outcome. A talocrural angle of 83 degrees suggests an anatomic reduction has been achieved.
Unstable rotational ankle fractures should be treated surgically in order to achieve anatomic reduction (if the fracture is not overly comminuted) as well as restore length, rotation, and alignment. Satisfactory outcomes can be best achieved when these surgical goals are achieved. Postoperative protocols
regarding immobilization and weight bearing may be somewhat variable depending on surgeon preference, fracture pattern, modifiable patient factors, and non-modifiable patient factors.
Lin et al. performed a systematic review of randomized studies looking at postoperative immobilization and rehabilitation following ankle fractures. They found that after surgical fixation, starting exercise in a removable brace improved pain, ankle range of motion, and improved activity limitations but led to a higher rate of adverse events. Early weight-bearing improved ankle range of motion as well. They concluded that there is limited evidence to support removable braces, early weight-bearing, and no immobilization following surgical fixation of ankle fractures.
Reidsma et al. retrospectively reviewed 57 malunited ankle fractures treated with revision osteotomy with a minimum of 10 years of follow-up. They found that 85% of patients had good or excellent outcomes and that prolonged time to reconstructive surgery led to a worse outcome. They concluded that reconstructive surgery should be performed early in the setting of a malunited ankle fracture even with early arthritic changes.
Figure A shows a displaced Weber B fibula fracture with medial joint space widening on stress examination. Illustration A shows intraoperative imaging following open reduction internal fixation of the same patient. Illustration B demonstrates the talocrural angle and medial clear space parameters in an anatomically reduced ankle.
Incorrect Answers:
Answer 1: Nonweightbearing for at least 6 weeks is common; however, some studies have shown improved outcomes in range of motion if weight-bearing is started early in the immobilization period.
Answer 2, 4, and 5: Postoperatively the parameters of the medial clear space

Which of the following arteries supplies the surgical flap in the extensile open treatment of the injury shown in Figure A?
1) Lateral calcaneal branch of the anterior tibial artery

2) Lateral calcaneal branch of the peroneal artery

3) Lateral malleolar branch of the peroneal artery

4) Lateral malleolar branch of the dorsalis pedis artery

5) Lateral malleolar branch of the anterior tibial artery

This patient has a displaced calcaneal fracture that is commonly treated through a lateral extensile approach. The flap of the lateral extensile approach is supplied by the lateral calcaneal branch of the peroneal artery.
Intraarticular fractures of the calcaneus represent approximately 2% of all fractures and are commonly the result of high-energy trauma such as motor vehicle accidents and falls. Successful operative treatment of these injuries depends on the anatomic reduction of the articular surface; restoration of the alignment, height, and length of the calcaneus; and avoidance of complications. These fractures are usually treated with a lateral extensile approach. The artery which provides blood supply to this flap is the lateral calcaneal branch of the peroneal artery. It is critical to maintain the integrity of this vessel in order to avoid complications.
Borrelli et al. performed a study to describe the arterial blood supply of the subcutaneous tissues of the lateral hindfoot and to define the relationships between these arteries and the lateral extensile incision. The lateral calcaneal artery appeared to be responsible for the blood supply to the corner of the flap.
Figure A demonstrates a displaced fracture of the calcaneus. Illustration A depicts the arteries on the lateral foot (PA: peroneal artery, LCA: lateral calcaneal artery, LMA: lateral malleolar artery, LTA: lateral tarsal artery). Illustration B (Borrelli et al.) is a lateral radiograph of the hindfoot and ankle that demonstrates skin staples placed along the surgical incision and vascular clips placed along the path of each artery. Illustration C is a clinical photograph of the lateral extensile approach.
Incorrect Answers:
Answer 1: The lateral calcaneal artery is a branch of the peroneal artery, not the anterior tibial artery.
Answers 3-5: The lateral malleolar artery is a branch of the anterior tibial artery. It does not supply the flap of the lateral extensile approach.

A 25-year-old male presents following a motor vehicle collision with a Glasgow Coma Scale of 7. Subsequent imaging in the trauma bay demonstrates a bifrontal cerebral contusion, an L4 burst fracture, multiple rib fractures, an LC-1 type pelvic ring injury, a femoral shaft fracture, and an open ipsilateral tibial shaft fracture. He is intubated and an intracranial pressure monitor is placed which consistently measures 30mm Hg. He is normotensive with a lactate of 1.5 after 2 liters of crystalloid and 1 unit of packed red blood cells. Which of his injuries would most dictate a temporizing approach with external
fixation of his femoral shaft fracture instead of reamed intramedullary nailing?

1) L4 burst fracture

2) Bifrontal cerebral contusion

3) Open ipsilateral tibia fracture

4) LC1 pelvic ring injury

5) Rib fractures

In the setting of a severe closed head injury such as a bifrontal cerebral contusion with elevated intracranial pressures, external fixation of a femoral shaft fracture is indicated to limit the risk of intraoperative hypotension and decreased cerebral perfusion pressure.
Immediate reamed nailing remains the standard treatment for the vast majority of femoral shaft fractures, however patients with multiple injuries with incomplete resuscitation and patients with severe intracranial trauma may benefit from a damage control approach with external fixation.
Anglen et al retrospectively reviewed the intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in patients undergoing femoral nailing. The authors found a significant decrease in intraoperative CPP, especially in those patient undergoing femoral nailing in the first 24 hours, however they were unable to demonstrate a link between the decreased CPP and poor patient outcomes.
Pietropaoli et al examined the effects of intraoperative hypotension on patients with blunt head trauma. The authors found that 32% of patients experienced intraoperative hypotension (systolic blood pressure less than 90mm Hg) and those patients with a hypotensive episode had an 82% mortality and significantly worse outcomes on the Glasgow Outcomes Scale.
McKee et al conducted a retrospective cohort study comparing matched groups of patients with femoral shaft fractures with and without a closed head injury. In contrast to previous studies, the authors found no significant difference in outcome between the groups including mortality, hospital length of stay or neuropsychologic testing.
Illustration A shows a femoral shaft fracture treated with external fixation. Incorrect Answers:
Answer 1, 3-5: Immediate reamed nailing would not change the outcome of any of these injuries

A 22-year-old left hand dominant laborer sustains the injury shown in Figures A and B as the result of a fall from a ladder. Which of the following has been shown to be true regarding operative versus nonoperative treatment of this injury?
1) Decreased chance of nonunion with nonoperative treatment

2) Improved Constant and DASH scores with operative treatment at all time points

3) Increased symptomatic malunion rate with operative treatment

4) No change in shoulder abduction strength

5) Increased time to union with operative treatment

Surgical management of displaced, shortened clavicle fractures is associated with a decreased rate of nonunion and malunion. General recommendations for surgical treatment include shortening of greater than 2 centimeters.
Kim et al. review clavicle fracture treatment history and current indications. They report that although previous thought was that nearly all clavicle fractures should be treated nonoperatively, outcomes can be improved with fixation of certain clavicle fracture patterns.
COTS et al. performed a multicenter, randomized controlled trial of 132 patients with a displaced midshaft fracture of the clavicle. They found that Constant and DASH scores were improved in the operative fixation group at all points in time, with union time being 28 weeks in the nonoperative group and
16 weeks in the operative group. Malunion was higher in the nonoperative group as well.
McKee et al. reviewed 30 patients who underwent closed treatment of a displaced midshaft clavicle fracture. They found that range of motion of the shoulder was maintained but the strength of the shoulder was decreased to 81% for flexion, 82% for maximum abduction, 81% for maximum external rotation, and 85% for maximum internal rotation. Endurance for these movements was also significantly decreased as compared to the contralateral side.
Figure A shows a clinical photo of a patient with a clavicle fracture. Figure B shows a displaced, comminuted clavicle fracture.
Incorrect Answers:
Answer 1: Operative treatment increases the union rate.
Answer 3: Operative treatment decreases the rate of symptomatic malunion. Answer 4: Operative treatment increases shoulder abduction strength.
Answer 5: Time to union is decreased with operative treatment.

A 45-year-old female presents to the office wearing a right upper arm splint with radiographs shown in Figure A and B. She sustained an isolated closed injury to the right arm 9 days ago. Her soft-tissues and neurological examination are normal. What would be the most appropriate treatment for this injury?
1) Continue current splint for 6 weeks

2) Continue current splint for 3 weeks and transition to hanging arm sling for additional 3 weeks

3) Transition to functional brace for additional 6-8 weeks

4) Open reduction internal fixation with compression plating

5) Staged procedure with humeral external fixator, then open reduction internal fixation with compression plating

Figures A and B show radiographs on a minimally displaced humeral shaft fracture. The most appropriate treatment for this injury would be functional bracing (Sarmiento) for an additional 6-8 weeks or until healed.
Commonly accepted parameters for closed treatment include less than 30 degrees of varus angulation, 20 degrees of anterior/posterior angulation, and 3 cm of shortening. Functional bracing has become the gold standard for humeral shaft fractures as it consistently shows excellent healing results as well as preventing the complication of shoulder +/- elbow stiffness associated with joint spanning splints or slings.
Sarmiento et al. treated 922 patients with humeral diaphysis fractures with a prefabricated brace. They found a 97% rate of union with the use of the brace. In addition, only 2% of the patients had lost more than 25 degrees of shoulder motion at the time of brace removal.
Koch et al. reviewed 67 humeral shaft fractures that were treated by Sarmiento bracing in a 15-year period. Fifty-eight cases (87%) had healed clinically at a mean of 10 weeks. Among 9 patients with delayed or nonunion leading to operative intervention, there were 6 cases with transverse fractures
Figures A and B show a moderately displaced right humeral shaft fracture with 13 degrees of AP angulation, 10 degrees of varus/valgus angulation and no shortening, treated in a coaptation splint. A nondisplaced proximal humeral fracture is also seen. Illustration A shows an image taken of a patient wearing the sarmiento brace.
Incorrect Answers:
Answer 1,2: Joint spanning splints or slings have not shown to be superior to functional bracing. They are associated with joint stiffness post removal.
Answer 4: Operative indications are: associated vascular injuries, bilateral humeral shaft fractures, polytrauma patient (including paraplegia), injury to the brachial plexus, pathological fractures, floating elbow, and floating shoulder.
Answer 5: Staged operative procedure would be indicated in open fractures or significant deformity with soft-tissue swelling.

Which of the following is an appropriate initial step in the management of a multiply injured patient with an unstable pelvic ring fracture and hemodynamic instability?

1) Application of an external fixator

2) Pelvic angiography

3) Pelvic packing

4) Application of a pelvic binder

5) Percutaneous Iliosacral screws

Patients with multiple injuries including a pelvic ring fracture who present with hemodynamic instability should have a pelvic binder or circumferential pelvic sheet placed as part of their initial resuscitation.
A systematic approach to search for sources of bleeding and control ongoing hemorrhage is necessary for patients who present with hemodynamic changes in the setting of a pelvic ring fracture. Management of continued hypotension after pelvic binder placement is controversial and varies among trauma centers.
Krieg et al. prospectively evaluated 16 patients with unstable pelvic ring injuries initially managed with a novel circumferential compression device. The authors found substantial reduction in pelvic width with the use of this
compressive device in patients with volume expanding pelvic ring fractures.
Croce et al. retrospectively compared patients with unstable pelvic ring injuries who were treated with either emergent pelvic fixation (EPF) or a pelvic orthotic device (POD). The authors found that those patients treated with POD had decreased transfusion requirements and shorter length of hospital stay.
Routt et al describe their technique for circumferential pelvic antishock sheeting (CPAS). The authors provide an illustrative case and discuss the potential advantages of sheet application versus other techniques of pelvic stabilization.
Illustration A is the initial AP radiograph of a patient with a pelvic fracture and hemodynamic instability. The pelvic binder was placed in the field prior to arrival. Illustration B demonstrates the same patient in the angiography suite after removal of the pelvic binder. Note the increased widening of bilateral SI joints, greater on the left than the right.
Incorrect Answers:
Answer 1: External fixation of pelvic ring fractures can be used to assist with resuscitation but pelvic binder application should be attempted first
Answer 2: The use of pelvic angiography is controversial and institution specific however some centers utilize pelvic angiography as part of the algorithm for management of ongoing hemorrhage.
Answer 3: Pelvic packing is utilized in some centers to control ongoing pelvic hemorrhage however it is not used as initial management of patients with hemodynamic instability
Answer 5: Percutaneous iliosacral screws can also be utilized as a form of resuscitation however they should not be used as as first line of management

A 19-year-old female sustains the injury shown in Figures A thru C as the result of a motor vehicle collision. Which of the following is the most common cause of death with this type of pelvic injury pattern?
1) Hypovolemic shock

2) Spinal injury

3) Solid organ rupture

4) Acute respiratory distress syndrome

5) Closed head injury

The injury pattern described in the question and images is a lateral compression pelvic ring injury. Of the choices provided, the most common associated cause of death is a closed head injury.
Pelvic ring disruptions are the result of high energy blunt trauma and are associated with other significant injuries in greater than 50% of the cases. These injuries may involve neurovascular structures and other organ systems.
Burgess et al. retrospectively reviewed their pelvic ring injuries and reported their classification system based upon the vector of force involved and the quantification of disruption from that force, i.e., lateral compression, anteroposterior compression, vertical shear, and combined mechanical injury. Overall blood replacement was highest in anterior-posterior patterns. Mortality was also highest in anteroposterior patterns. The most common identifiable cause of death in patients with lateral compression fractures is closed head injury. In contrast, the identifiable cause of death in patients with anteroposterior compression injuries is combined pelvic and visceral injury.
Watnik et al. reviewed lower urinary tract injuries and noted that they occur in as much as 25% of patients with pelvic ring disruptions. They also report that early repair of bladder injury can facilitate the placement anterior pelvic fixation, in efforts to minimize infection.
Smith et al. reviewed hemodynamically unstable pelvic ring fracture patients and found that there is a positive association of blood replacement requirements and mortality. They also reported that death within the first 24 hours after admission was most often a result of acute blood loss while death after the first day was most often caused by multi-organ failure.
Figure A shows an AP pelvic radiograph with evident anterior pelvic ring fractures. Figure B and C are axial CT cuts showing the posterior and anterior ring fractures, respectively. This fracture pattern is consistent with a lateracl compression mechanism.
Incorrect Answers:
Answer 1-4: These options are less commonly reported as causes of death than closed head injury in a lateral pelvic ring injury mechanism.

A 67-year-old male is involved in a motor vehicle accident and presents with the closed orthopedic injuries shown in Figures A and B. He is also noted to have a grade 1 splenic laceration and lung contusion. He is cleared by the trauma team, and undergoes early total care with reamed femoral and tibial nailing. A tourniquet is used for the tibial nailing portion of the case, and the tibial isthmus is over reamed to accept a larger nail. The use of a tourniquet in this case has been most clearly shown to be associated with which of the following?
1) Tibia shaft necrosis post-operatively

2) Increased pulmonary morbidity post-operatively

3) Increased cortical bone temperature during reaming

4) Increased nonunion rates

5) Decreased pain post-operatively

In patients with multitrauma, combining reamed femoral nailing with fracture fixation (ie. tibial shaft) under tourniquet control has been shown to increase pulmonary morbidity.
Limb reperfusion after tourniquet ischemia causes pulmonary microvascular injury. Similarly, microembolization, like that associated with reamed femoral nailing, can induce pulmonary microvascular injury. Both processes result in increased pulmonary capillary membrane permeability and edema, and ultimately increased pulmonary morbidity.
Karunakar et al showed in a canine model that there is no significant difference in the heat generated during reaming with and without a tourniquet. The factor that made the most difference was related to the size of the reamer used compared with the diameter of the isthmus. They concluded that the risk of
thermal necrosis appears to be related more to the process of intramedullary reaming than to the tourniquet.
Giannoudis and associates performed a prospective randomized trial on 34 patients to measure the rise of temperature during reaming of the tibia before intramedullary nailing with and without the use of a tourniquet. The factor that generated the most heat was using large reamers (11 mm to 12 mm) in a patient with a small isthmus (8 mm to 9 mm). Use of a tourniquet, steroid use, and knee flexion during reaming were not shown to be associated with diaphyseal necrosis after reamed tibial nailing.
Pollak et al evaluated the association between femoral nailing followed by tourniquet ischemia and clinical lung injury. They reviewed 72 patients with femoral shaft fractures and tibial or ankle fractures requiring internal fixation over a six year period. All femoral shaft fractures were treated with reamed intramedullary nails, and the patients were divided into groups, based on whether the tibial or ankle injury was managed surgically with or without a tourniquet. They noted increased pulmonary morbidity in the group where a tourniquet was used.
Figure A shows a femoral shaft fracture at the junction of the middle and proximal one-third of the femoral shaft. Figure B shows a contralateral tibial shaft fracture.
Incorrect Answers:
1-Tourniquet use has not been shown to lead to thermal necrosis of the bone during reaming of the tibial shaft.

Question 5High Yield

**ONLINE ORTHOPEDIC MCQS SPINE0 9**
**1**. Which is the best initial study for the diagnostic evaluation of diskogenic low back pain?

Explanation

Radiography is the best initial study for the evaluation of diskogenic low back pain. The normal degenerative process can be evaluated. Vacuum phenomenon may be found within the disk space. Other possible sources for back pain should also be evaluated. The other tests may be beneficial but represent later imaging options.**
**REFERENCE: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 319-329.**
**2****. A patient who is an observant Jehovah’s Witness requires major surgery for scoliosis that will likely result in significant blood loss. Which of the following might the patient consider allowing the surgical team to use?
1- Transfusion of whole blood
2- Transfusion of packed red blood cells
3- A cell saver with continuity maintained in a “closed circuit”
4- Transfusion of plasma
5- Transfusion of platelets
PREFERRED RESPONSE: 3**
**DISCUSSION: Jehovah’s Witnesses will not accept the transfusion of blood or blood products such as packed red or white cells, platelets, or plasma. However, many Jehovah’s Witnesses will accept the use of a cell saver in a “closed circuit.”**
**

Scientific References

Question 6High Yield

What is the most common complication following surgical treatment of a displaced talar neck fracture?

Explanation

The most frequent complication is posttraumatic arthritis. With talar neck fractures,osteonecrosis is relatively common, occurring in up to 50% of patients. Fracture nonunion occurs in 10%to 12% of patients. Varus malunion can occur with medial comminution. Wound dehiscence and deep infection are much less frequently encountered.

Question 7High Yield

..A 42-year-old woman has a posterior elbow dislocation. Closed reduction is performed, and the elbow appears stable under fluoroscopic examination. Further treatment should consist of

Explanation

- early mobilization only.
RESPONSES FOR QUESTIONS 12 THROUGH 16

Question 8High Yield

After normal menses has begun and in the absence of pregnancy, secondary amenorrhea is defined as which of the following?

Explanation

DISCUSSION: Secondary amenorrhea is defined as the absence of menstrual bleeding for 6 months or the absence of three to six consecutive menstrual cycles after normal menses has begun. The prevalence of amenorrhea among female athletes is estimated at 10% to 20% in women who exercise vigorously and as high as 40% to 66% in elite runners and professional ballet dancers.
REFERENCES: Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 345-346.
Feingold D, Hame SL: Female athlete triad and stress fractures. Orthop Clin North Am 2006;37:575-583.

Question 9High Yield

Figure 1 is the clinical photograph of a 64-year-old man who crashed while riding his motorcycle. An examination reveals his long-finger metacarpophalangeal (MP) joint is stuck in extension. He cannot passively or actively flex at the MP joint. A hand radiograph is seen in Figure

Explanation

This patient has a dorsally dislocated MP joint. In these cases, the volar plate can be displaced dorsal to the metacarpal head, preventing reduction. Although early publications described a “noose effect” of the lumbrical and flexor tendons, the primary block to reduction is the volar plate. Simple MP dislocations can be reduced closed by flexing the wrist and then gently sliding the base of the proximal phalanx over the end of the metacarpal. Longitudinal traction on the finger will only incarcerate the volar plate further and should be avoided. Patients with complex dislocations that fail closed reduction require open
reduction.

Question 10High Yield

Figure 1 is the radiograph of a 21-year-old college lacrosse player who has a 2-year history of progressive left groin pain that is exacerbated by activity. Pain is preventing him from participating with his team. Examination reveals a fit man without tenderness to palpation around the hip. No clicking or popping occurs with hip range of motion. Strength of all muscles about the hip is normal, but there is some mild pain with resisted hip flexion and hip adduction. While lying supine, progressive hip flexion with internal rotation and adduction reproduces his groin pain. Further workup confirms an anterosuperior tear of the acetabular labrum and prominence of the acetabulum. What is the most likely location of a chondral injury associated with these findings?
---

Explanation

This clinical scenario describes a patient with FAI attributable to pincer (acetabular) deformity. This form of FAI, which involves prominence of the anterosuperior acetabular lip, may be more common among women. Decreased range of motion and pain occur secondary to the abutment of the femoral head against the acetabular labrum and rim. Hip flexion, combined with adduction and internal rotation, recreates this contact and causes pain, but CAM or pincer etiology remains unknown. The differential diagnosis of hip pain in a young athlete includes femoral neck stress reaction/fracture, sacroiliac arthritis, intra-articular loose body, trochanteric bursitis, osteitis pubis, and hernia. No information presented in this scenario suggests any of these causes. Diagnosis of FAI is best performed via MR imaging, with an arthrogram increasing the sensitivity and specificity for labral pathology. Ultrasonography may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping hip, but ultrasonography is not commonly used to diagnose labral pathology. Although concomitant chondral lesions of the femoral head are uncommon, the forced leverage of the anterosuperior femoral neck upon the anterior acetabulum may result in a “contra-coup” chondral injury on the posteroinferior acetabulum. This is the most common location of chondral lesions in this scenario. Without bony resection to prevent further impingement, this patient will continue to experience symptoms. Because there is no evidence of femoral neck prominence (CAM lesion), there is no indication for osteoplasty of the femoral neck; resection of the pincer lesion is necessary. This will often require take-down of the labrum in this location. If possible, iatrogenic or traumatic labral tears should subsequently be repaired after pincer debridement because the labrum has _important functions for hip stability and maintenance of the suction seal of the joint._

Question 11High Yield

A 65-year-old right–hand-dominant woman has been experiencing thenar and wrist pain for 18 months. She has no history of trauma. The pain worsens during the opening of jars, grasping, writing, and repetitive thumb use. Examination reveals tenderness to palpation over the volar thenar eminence, just distal to the scaphoid tubercle, and along the flexor carpi radialis sheath. A Watson scaphoid shift test produces pain but no instability or clunk. Radiographs reveal isolated scaphotrapeziotrapezoidal (STT) arthritis with mild dorsal intercalated segment instability (DISI) deformity. She has worn a splint on and off for the past year, has had multiple cortisone injections, and has modified her activity, all of which helped initially. She wants to move forward with surgical intervention. STT arthrodesis is chosen over distal pole scaphoid excision. What factor in her evaluation indicates that arthrodesis would be preferred over distal pole excision?

Explanation

Isolated STT arthritis is common and can cause substantial patient disability and pain. After nonsurgical treatment has failed, surgical intervention is warranted. Surgical options include distal pole scaphoid excision, STT arthrodesis, or carpometacarpal (CMC) arthroplasty, if concomitant thumb CMC degenerative changes are present. Distal pole scaphoid excision is less commonly employed for the treatment of STT arthritis, because of the potential development of intercalated segmental instability. However, distal pole scaphoid excision is less technically demanding, engenders fewer surgical complications, and promotes a faster return to previous activity levels. In any patient with preoperative carpal malalignment, removing the distal pole of the scaphoid would exacerbate that deformity and could lead to symptoms from the DISI deformity. Thus, in this patient with mild DISI deformity seen on _preoperative radiographs, STT arthrodesis is the most appropriate treatment option._

Question 12High Yield

A 19-year-old college cross-country runner is amenorrheic and has recurrent stress fractures. Long-term management should consist of

Explanation

The triad of menstrual dysfunction, disordered eating, and stress fracture is well recognized in women who participate in endurance sports. The best treatment remains to be determined, but at present, the combination of oral contraceptives to regulate menses, an increased intake of calcium and vitamin D, as well as nutritional counseling, is the recommended treatment for decreased bone mass related to exercise-induced amenorrhea.
REFERENCES: Nattiv A, Armsey TD Jr: Stress injury to bone in the female athlete. Clin Sports Med 1997;16:197-224.
Drinkwater BL: Exercise and bones: Lessons learned from female athletes. Am J Sports Med 1996;24:S33-S35.

Question 13High Yield

A 36-year-old woman presents with a grade 3 open midshaft femoral shaft fracture as the result of a high-speed motor vehicle collision. Concomitant injuries include a high-grade splenic laceration requiring splenectomy as well as a subdural hematoma that requires monitoring and maintenance of cerebral perfusion pressure. After irrigation and debridement of the open fracture, which of the following is the most appropriate management of the femoral shaft fracture at this time?

Explanation

The clinical scenario is consistent with a femoral shaft fracture in a patient that is not stable from a neurosurgical perspective. Therefore, the most appropriate treatment at this time is placement of an external fixator.
When evaluating polytrauma patients with long bone fractures, timing of surgery must be approached considering all clinical conditions. One factor most likely to adversely affect long term outcome in polytrauma patients with severe brain injury is intra-operative hypotension; therefore, whenever a patient has a subdural hematoma that requires close observation, definitive surgery of long bone fractures should be delayed.
Flierl et al. review the immunopathophysiology of traumatic brain injury and the role of the orthopaedic surgeon in avoiding a "second hit" injury to the brain by appropriately timing the fixation of femoral shaft fractures. They recommend a multidisciplinary approach, taking individual patient-specific factors into consideration and in general, DCO principles for severe head-injured patients (GCS 3-13) and "early total care" principles for patients with mild head injury (GCS 14-15).
Illustration A is a visual representation of the treatment algorithm recommended in the article.
Incorrect Answers:
Answer choice 1 is incorrect because it does not appropriately address the fracture and there is no indication for bead placement.
Answer choices 2 and 3 are incorrect as this patient is not stable for prolonged surgery.
Answer 4 is incorrect as this patient is already under general anesthesia and external fixation is a better option than traction for stabilization of the fracture.

Question 14High Yield

-Which of the following imaging studies must be obtained for this patient?

Explanation

No detailed explanation provided for this question.

Question 15High Yield

A 7-year-old boy presents with bilateral high arches. His parents report that they are having difficulty finding shoes that comfortably fit him. The patient denies any foot pain. The father had similar problems with his feet and was diagnosed with a âmildâ neurologic condition. On exam, the child has bilateral pes cavus with a supple hindfoot. Treatment of the feet at this time should consist of:

Explanation

The child has a supple deformity secondary to C harcot-Marie-Tooth disease that will progress if untreated. Soft tissue procedures, which may consist of claw toe correction, plantar release, and possibly tendon transfer, are recommended for children younger than 8 years old who have a supple hindfoot.
The calcaneal osteotomy is reserved for patients with a rigid hindfoot.
Triple arthrodesis is a salvage procedure reserved for a fixed, painful foot in older children.
Bracing and observation are not preferred options due to the progressive nature of the disease, and the lack of ability to apply corrective forces to the foot in cavus.

Question 16High Yield

The nerve most likely to be at risk during surgical exposure when performing a triple arthrodesis is the:

Explanation

The sural nerve has a variable path in the distal leg, but lies immediately adjacent to the peroneal tendons on the lateral side of the foot. The lateral incision used to expose the subtalar and calcaneocuboid joints is adjacent to this nerve.

Question 17High Yield

A healthy 2-year-old boy falls from a swing and sustains a displaced midshaft femoral fracture with 1 cm of shortening. What is the most appropriate treatment?

Explanation

**28 • American Academy of Orthopaedic Surgeons**

DISCUSSION: For children between the ages of 1 and 6 years, closed reduction and early spica casting is recommended. In some instances, associated injuries or body habitus may preclude cast treatment. Pavlik harness treatment of femoral fractures is for infants younger than 1 year of age. Rarely is there an indication for traction. Internal fixation is reserved in general for children older than age 6 years or with confounding factors.

REFERENCES: Abel MF (ed): Orthopaedic Knowledge Update: Pediatrics 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 271-280.
Flynn JM, Schwend RM: Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg 2004;12:347- 359.

Figure 29a Figure 29b

Question 18High Yield

A 34-year-old female is involved in a high-speed motor vehicle collision and sustains a traumatic proximal forearm amputation. She successfully undergoes debridement and closure, and six weeks later, is fitted with her temporary prosthesis. In order to optimize her
outcomes upon returning to work as a secretary, which of the following is recommended?

Explanation

Upper extremity trauma has serious, acute psychological effects that can linger long after the physical injury. These effects may negatively affect patient-reported outcomes, and may also be associated with worsening pain complaints. Coping and stress management techniques can be reviewed with formal psychological counseling, and should be offered to all patients who have underwent an amputation.
Richards et al surveyed 34 patients who had emergency upper extremity surgery and found high levels of psychological distress in patients, including 29% with high levels of both depression and post-traumatic stress disorder (PTSD). They also found that disability was strongly related to pain, depression, and PTSD symptoms.
Mallette et al assessed the attitudes of hand surgery patients and hand surgeons regarding psychologic influences on illness and compared their attitudes with those of the general population. They found that surgeons underestimated the openness of patients to discuss psychological issues and that patients believed in the strong effect of psychologic factors on healing and pain.
Illustration A shows a myoelectric prosthesis in a military veteran. Incorrect Answers:
Answer 1: Formal function capacity testing is not typically necessary unless
Workers' Compensation is involved or formal disability proceedings occur. Answer 2: Final prosthetic fitting is not necessary for full release.
Answer 3: Prosthetic use will vary according to needs and patient factors such as pain.
Answer 4: Return to work does not have to wait for full return of elbow range of motion.

Question 19High Yield

A 6-year-old girl is wearing a seatbelt but no shoulder harness when the car she is occupying strikes another car. She suffers an abdominal contusion as well as a spine injury. The facets of L1 and L2 are spread apart as is the disk between them. The angle between the two vertebrae is 35Â°. The neurologic exam is within normal limits. Recommended treatment includes:

Explanation

Open reduction and 2-level fusion is the simplest way of handling this injury.
Immobilization in a hyperextension cast is likely to exacerbate the abdominal injury. An orthosis is not likely to reduce the deformity.
Traction would not be a good mechanism to reduce the deformity. In situ fusion would be insufficient without instrumentation.

Question 20High Yield

An 83-year-old woman with a long history of her foot slowly and progressively “turning out” now reports significant ankle pain. History reveals that she has significant cardiac disease and exercise-induced angina. Examination reveals a deficiency in the posterior tibial tendon; however, the hindfoot remains moderately supple. Radiographs reveal a valgus tilt of the tibiotalar joint and early arthrosis. What is the most appropriate orthotic management?

Explanation

The patient will continue to have pain secondary to the ankle arthrosis with both the UCBL and the molded articulated ankle-foot orthosis. The total contact orthotic does not provide enough hindfoot control to support the progressive collapse of the ankle into valgus positioning. A molded leather gauntlet will not only control tibiotalar motion but also control hindfoot motion and allow support of the longitudinal arch.
REFERENCE: Augustin JF, Lin SS, Berberian WS, et al: Nonoperative treatment of adult acquired flat foot with the Arizona brace. Foot Ankle Clin 2003;8:491-502.

Question 21High Yield

A 42-year-old woman reports neck stiffness, upper extremity pain, clumsiness, weakness, and instability of gait. Examination reveals 4+ of 5 strength in the upper extremities and 3+ biceps, brachioradialis, and patellar reflexes with a positive Hoffman sign bilaterally. MRI and CT scans are shown in Figures 10a and 10b. Based on the history and imaging findings, what is the most likely diagnosis?

Explanation

The sagittal T2-weighted MRI scan shows moderate-severe multilevel cervical stenosis.The cord compression is noted to be not only
at the disk levels but also at the midvertebral body levels,and the posterior longitudinal ligament appears to be thickened. The CT scan confirms that the posterior longitudinal ligament is indeed thickened and ossified, compatible with a diagnosis of ossification of the posterior longitudinal ligament. This diagnosis is most common in individuals of
Japanese descent and has a genetic linkage. The anterior osteophytes are smaller than those seen in diffuse idiopathic skeletal hyperostosis and are not syndesmotic. Patients with ankylosing spondylitis typically have non-marginal syndesmophytes. Patients with rheumatoid arthritis may have evidence of instability at C1-C2 on flexionextension radiographs and subaxial subluxations.

Question 22High Yield

To avoid damage to the ascending branch of the anterior humeral circumflex artery during open reduction and internal fixation of a proximal humeral fracture, the blade plate should be placed in what position?

Explanation

The pectoralis major tendon inserts lateral to the biceps tendon, which runs in the bicipital groove. The primary vascular supply of the articular surface of the humeral head is derived from the anterior circumflex humeral artery, which continues into the arcuate artery once it enters the bone. The entry point is on the anterolateral aspect of the humerus just medial to the greater tuberosity within the bicipital groove. To avoid compromising circulation, the blade plate should be placed lateral to the bicipital groove and pectoralis major tendon insertion.
REFERENCES: Loebenberg M, Plate AM, Zuckerman J: Osteonecrosis of the humeral head. Instr Course Lect 1999;48:349-357.
Gerber C, Schneeberger AG: The arterial vascularization of the humeral head: An anatomical study. J Bone Joint Surg Am 1990;72:1486-1494.

Question 23High Yield

Figures 1 and 2 are the radiographs of a 21-year-old man who has a long history of thoracic back pain. His lumbar spine is asymptomatic. He has failed prolonged nonsurgical treatment. Surgical correction should consist of

Explanation

■
When planning surgical intervention for Scheuermann kyphosis, it is imperative that the instrumentation and fusion extend across the entirety of the deformity. Distally, this means extending across the first lordotic disk space. In this scenario, this disk is the L1-L2 disk, which means the fusion needs to extend to L2. Shorter and longer fusions are not necessary or appropriate.

Question 24High Yield

A 19-year-old female field hockey player sustains a right ankle injury last night during a game. The patient
is on crutches and reports that she has not been able to put any weight on her right ankle since the injury. She was running alongside with another player when her right ankle “gave out” and she twisted it, falling to the ground. Physical examination reveals discoloration similar to a hematoma and significant swelling around the lateral ankle area. Pain is elicited during palpation of the anterior talofibular ligament. Radiographs of the player’s right ankle confirm there are no fractures. With a lateral talar tilt test result of 19°, which additional structure is most likely damaged?

Explanation

The anterior drawer test is performed with the ankle in 10° of plantar flexion, which results in the greatest amount of translation. The test investigates the integrity of the anterior talofibular ligament with a key distance of translation being 8 to 10 mm. While the patient is sitting and has her knees flexed over the edge of a table or bench, the physician uses one hand to stabilize the distal leg and with the other hand applies an anterior force to the heel in an attempt to gap the talus anteriorly from under the tibia. The
anterior talofibular ligament and calcaneofibular ligament are both compromised based on the examination findings. The anterior drawer test result reflects injury to the anterior talofibular ligament and a possible injury to the calcaneofibular ligament. A lateral talar tilt test angle measurement >15° degrees reflects a rupture of both anterior talofibular ligament and calcaneofibular ligaments. The diagnosis is a severe lateral ligament complex sprain. This is optimally managed with early mobilization _and a guided rehabilitation program that emphasizes proprioceptive stability._

Question 25High Yield

1222) Which of the following fluoroscopic views is used to assess
intra-articular screw penetration during volar fixation of a distal radius fracture?

Explanation

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.

Question 26High Yield

A 10-month-old infant has no flexion at the elbows, mild flexion contractures at the wrist, a rigid clubfoot deformity on the left foot, and a rigid rocker bottom deformity on the right foot. Examination of the patient’s hips reveals limited abduction with 80 degrees of hip flexion/extension and full range of motion of the knees. A radiograph of the pelvis is seen in Figure 35. What is the most appropriate treatment for the patient’s hip problem?

Explanation

DISCUSSION: The patient has arthrogryposis. Szoke and associates performed open reduction through a medial approach on 40 hip dislocations in 26 patients with this condition and reported good results in 80% and fair results in 12%. Due to the stiffness associated with this disorder, closed reduction with or without skin or skeletal traction is not feasible. Open reduction through an anterior approach is reserved for older children.

REFERENCES: Szoke G, Staheli LT, Jaffe K., et al: Medial-approach open reduction of hip dislocations in amyoplasia-type arthrogryposis. J Pediat Orthop 1996;16:127-130.
Staheli LT, Chew DE, Elliott JS, et al: Management of hip dislocations in children with arthrogryposis. J Pediatr
Orthop 1987;7:681-685.

**2010 Pediatric Orthopaedic Examination Answer Book • 33**

Figure 36a Figure 36b

Question 27High Yield

Figures 1 and 2 show CT images from a 24-year-old man who was the unrestrained driver in a single motor vehicle collision. By report, he was ejected from the vehicle and initially was found unresponsive. The patient was intubated in the field and then brought by ambulance to the emergency department, where he was resuscitated aggressively with crystalloid and blood transfusions. Radiographs were taken and showed an intracranial hemorrhage, which required emergent burr hole evacuation by Neurosurgery. In the intensive care unit, his blood pressure is 80/48, and his pulse is 48. He is breathing spontaneously on the ventilator at 16 breaths per minute. He can follow commands. Physical examination reveals absent motor function in the legs, no sensation below the nipple level, and a positive bulbocavernosus reflex. His skin is warm and dry. What best describes his condition?

Explanation

■
This patient has classic neurogenic shock, which usually occurs when a cervical or high thoracic cord injury disrupts the autonomic pathways and causes a loss of sympathetic tone. Characteristic hypotension and bradycardia are present due to an unopposed vagal tone. Low cardiac output also is present, along with venous and arterial dilatation. The treatment for neurogenic shock is administration of agents called pressors (phenylephrine, dopamine, dobutamine, and norepinephrine) to improve cardiac contractility and increase peripheral vascular resistance. Atropine is given to increase the heart rate. Pressors are titrated to keep the mean arterial pressure above 80 and maintain spinal cord perfusion.

Question 28High Yield

A
B
C
Figures 62a through 62c are the MR images and CT scan of a 65-year-old man with a history of diabetes mellitus, hypertension, and smoking. He has a 6-week history of increasing midback pain, lower extremity pain, and weakness. What is the most likely diagnosis, and how should this diagnosis be confirmed?

Explanation

The sagittal T2-weighted and axial T2-weighted images show a lesion within the T8 vertebral body that involves the posterior elements. There is an associated epidural component that results in compression of the spinal cord. The sagittal reconstructed CT image shows a lytic lesion within the T8 vertebral body. This pattern of vertebral body involvement with preservation
of the adjacent disks and endplates in a 65-year-old patient is most compatible with a diagnosis of a tumor. The most likely tumor is a metastatic lesion. A CT-guided biopsy will confirm this diagnosis. Although thoracic tuberculosis does not typically cross the disk space, the lack of an anterior soft-tissue component decreases the likelihood of this diagnosis.
RECOMMENDED READINGS
[Khanna AJ, Shindle MK, Wasserman BA, Gokaslan ZL, Gonzales RA, Buchowski JM, Riley LH 3rd. Use of magnetic resonance imaging in differentiating compartmental location of spinal tumors. Am J Orthop (Belle Mead NJ). 2005 Oct;34(10):472-6. Review. PubMed PMID: 16304794. ](http://www.ncbi.nlm.nih.gov/pubmed/16304794)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/16304794)
[White AP, Kwon BK, Lindskog DM, Friedlaender GE, Grauer JN. Metastatic disease of the spine. J Am Acad Orthop Surg. 2006 Oct;14(11):587-98. Review. PubMed PMID: 17030592. ](http://www.ncbi.nlm.nih.gov/pubmed/17030592)[View](http://www.ncbi.nlm.nih.gov/pubmed/17030592)[ ](http://www.ncbi.nlm.nih.gov/pubmed/17030592)[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/17030592)

Question 29High Yield

Figures 16a through 16c are the radiograph, MR image, and biopsy specimen of a 12-year-old boy who injured his leg during a soccer game. Assuming other staging study findings are negative, what is the Musculoskeletal Tumor Society (MSTS) stage of this lesion?

Explanation

The MSTS staging system assigns progressively higher degrees of risk to neoplasms based on their surgical grade, anatomic location, and presence or absence of metastases. Lesions that are low grade are assigned a score of I, while high-grade lesions are assigned a score of II. Lesions contained in the bone or those that are intracompartmental are designated as A, and extracompartmental lesions are designated as B. Metastases elevates the score to III. The radiograph and biopsy specimen reveal a high-grade bone sarcoma with a soft-tissue component with no evidence of metastatic disease. Therefore, this is a stage IIB lesion.
RECOMMENDED READINGS
28. [Wolf RE, Enneking WF. The staging and surgery of musculoskeletal neoplasms. Orthop Clin North Am. 1996 Jul;27(3):473-81. Review. PubMed PMID: 8649730.](http://www.ncbi.nlm.nih.gov/pubmed/8649730)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/8649730)
29. [Wafa H, Grimer RJ. Surgical options and outcomes in bone sarcoma. Expert Rev Anticancer Ther. 2006 Feb;6(2):239-48. Review. PubMed PMID: 16445376. ](http://www.ncbi.nlm.nih.gov/pubmed/16445376)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/16445376)

Question 30High Yield

Figures 1 and 2 are the radiographs after attempted reduction of an injury in a 9-year-old girl. Which anatomic structure is most likely to be interposed?

Explanation

■
The injury shown is a flexion-type supracondylar humerus fracture. The most commonly interposed anatomic structure is the ulnar nerve. The brachialis muscle is often interposed in extension-type fractures, as are the median nerve and radial artery. The radial nerve is at risk for entrapment in a humeral shaft fracture or distal third humeral fracture.

Question 31High Yield

Figure below depicts the radiograph obtained from a 52-year-old woman who has leg-length inequality
and chronic, activity-related buttock discomfort. This problem has been lifelong, but it is getting worse and increasingly causing back pain. What is the best current technique for total hip arthroplasty?

Explanation

A high hip center is not recommended for Crowe type IV hips because of the lack of acetabular bone and altered hip biomechanics. An anatomic center is a better option but necessitates a technique to address the tight soft-tissue envelope. A trochanteric osteotomy with progressive femoral shortening has been described but can be prone to trochanter nonunion. Iliofemoral lengthening prior to surgery has been described but may not be tolerated by all patients. A shortening subtrochanteric osteotomy avoids trochanter nonunion and allows adjustment of femoral anteversion. Fixation of the osteotomy can include a stem with distal rotational control, plate fixation, a step versus oblique cut, or strut grafts.

Question 32High Yield

Based on this patient's history and examination, what is the best next step?

Explanation

- Obtain blood cultures

Question 33High Yield

Figures 2a and 2b show the clinical photograph and radiograph of a 16-year-old cheerleader who fell on her left lower extremity while performing a pyramid. Following adequate sedation, closed reduction is performed, but an incomplete reduction is noted. What structure is most likely preventing a reduction?

Explanation

The stretched peroneus brevis muscle and tendon follow anterior to the fibula and are most likely incarcerated with reduction. The anterior talofibular ligament is too small to prevent reduction of the ankle joint itself. The extensor digitorum brevis originates from the talus; therefore, it is not involved in the tibiotalar joint. The posterior tibial tendon lies medially and would not be interposed into the ankle joint. Similarly, the anterior tibialis tendon also would not be involved.
REFERENCES: Pehlivan O, Akmaz I, Solakoglu C, et al: Medial peritalar dislocation. Arch Orthop Trauma Surg 2002;122:541-543.
Rivera F, Bertone C, De Martino M, et al: Pure dislocation of the ankle: Three case reports and literature review. Clin Orthop 2001;382:179-184.

Question 34High Yield

Injury to the structure noted with an arrow in the MRI in Figure 1 would lead to what clinical condition?

Explanation

The image depicts the medial ulnar collateral ligament of the elbow. This ligament is the primary restraint to valgus forces at the elbow. It is commonly injured in baseball pitchers. Pain with resisted wrist flexion would suggest medial epicondylitis. Pain with resisted wrist extension would suggest lateral epicondylitis. Lateral elbow pain and varus instability would suggest posterolateral rotatory instability.

Question 35High Yield

A 16-year-old football player reports the acute onset of pain in his left foot. An AP radiograph is shown in Figure
8/. What treatment is most likely to result in successful healing for this injury?

Explanation

Fractures in this region of the fifth metatarsal have been shown to be prone to delayed union and
nonunion and therefore are most reliably managed with internal fixation. Bone grafting is generally not required.
REFERENCES: Herrera-Soto JA, Scherb M, Duffy MF, et al: Fractures of the fifth metatarsal in children and adolescents. J Pediatr Orthop 2007;27:427-431.
Fetzer GB, Wright RW: Metatarsal shaft fractures and fractures of the proximal fifth metatarsal. Clin Sports Med 2006;25:139-150.

Question 36High Yield

A 12-year-old child with spina bifida paraplegia requires brace management for ankle stability. Which of the following principles applies to brace management in this individual?

Explanation

Bracing for spina bifida paraplegia provides both support and improved function of the movable limb. An orthosis has value in controlling unstable joints. The three-point pressure effect applies a force above and below the joint to prevent it from buckling. A four-point pressure effect is only required for a two-joint system (this patient has problems only at the ankle). A longer lever arm brace and a brace with a greater area of support provide better stability. Finally, a straighter limb, without contracture, applies less pressure to the brace and lessens overload to the skin.
REFERENCES: Gage JR: An overview of normal walking. Instr Course Lect 1990;39:291-303.
Bleck EE: Current concepts review: Management of the lower extremities in children who have cerebral palsy. J Bone Joint Surg Am 1990;72:140-144.
Harris MB, Banta JV: Cost of skin care in the myelomeningocele population. J Pediatr Orthop 1990;10:355:361.

Question 37High Yield

Figure 1 is the MR image of a 36-year-old athlete who is tackled from behind and falls forward onto his left knee. He has pain, swelling, and stiffness. Examination includes a moderate effusion, positive quadriceps active test, and normal Lachman test finding. The injured structure is composed of an
---

Explanation

The clinical description and MR image point to an injury to the posterior cruciate ligament (PCL). This ligament is thought to be primarily composed of anterolateral and posteromedial bundles, with the former tightening in flexion and the latter in extension. Because of alterations in knee kinematics and increased varus alignment in PCL insufficiency, contact stresses and cartilage loads increase in the patellofemoral and medial compartments. Although good outcomes may be obtained with transtibial, open inlay, and arthroscopic inlay techniques, one major difference is the creation of the “killer-turn” during the transtibial approach. This sharp turn in the graft as it emerges from the tibia appears to lead to more pronounced attenuation and thinning of the graft during cyclic loading. The scenario describes a patient with chronic PCL and posterolateral corner (PLC) injury, as evidenced by the varus thrust and abnormal Dial test finding. A valgus-producing osteotomy may be effective, and, in fact, may be the only treatment necessary to address chronic PLC injury. Accordingly, an opening lateral osteotomy would not be appropriate. Of the remaining responses, an osteotomy that increases tibial slope would also address the PCL deficiency by reducing posterior tibial sag. Vascular injury is an uncommon, but potentially devastating, complication associated with PCL surgery and may occur regardless of the technique used.
Numerous strategies have been described to reduce the risk, including use of a posteromedial accessory incision to allow finger retraction of the popliteal neurovascular bundle, oscillating drills to prevent excessive soft-tissue entanglement, and tapered (rather than square) drill bits that may minimize cut-out of sharp edges as drilling reaches the posterior tibial cortex. Knee extension lessens, rather than increases, the distance between the posterior tibia and the neurovascular bundle and increases, not lessens, risk for _vascular injury._

Question 38High Yield

Which of the following activities predisposes a patient to an anterior tibial cortex stress fracture:

Explanation

Repetitive stresses from jumping or leaping is a risk factor for anterior tibial cortex stress fractures. C orrect Answer: Repetitive jumping or leaping

Question 39High Yield

What is the main function of collagen found within articular cartilage?

Explanation

The main function of collagen in articular cartilage is to provide the tissue’s tensile strength. It also immobilizes proteoglycans within the extracellular matrix. Compressive properties are maintained by proteoglycans. Cartilage metabolism is maintained by the indwelling chondrocytes. The flow of water through the tissue promotes transport of nutrients and provides a source of lubricant for the joint.
REFERENCES: Simon SR (ed): Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 3-44.
Mow VC, Ratcliffe A: Structure and function of articular cartilage and meniscus, in Mow VC, Hayes WC (eds): Basic Orthopaedic Biomechanics, ed 2. Philadelphia, PA, Lippincott-Raven, 1997, pp 113-177.

Question 40High Yield

Figure 21 shows the AP radiograph of a 41-year-old patient who sustained a closed bicolumnar fracture of the distal humerus that resulted in a painful nonunion. What is the best initial construct for rigid stabilization of this fracture pattern?

Explanation

The dual plate fixation construct is significantly stronger than single plate or “Y” plate fixation. Two-plate constructs at right angles, the ulnar plate medially and the lateral plate posteriorly, would appear to be biomechanically optimal. This approach usually is feasible at the time of surgery. Clinically, dual 3.5-mm reconstruction or dynamic compression plates are superior to one third tubular plate fixation. Supplementary external fixation is not considered a better treatment option. Failure of fixation and nonunion are often the result of inadequate fixation and osteoporosis.
REFERENCES: Helfet DL, Hotchkiss RN: Internal fixation of the distal humerus: A biomechanical comparison of methods. J Orthop Trauma 1990;4:260-264.
Sodergard J, Sandelin J, Bostman O: Mechanical failures of internal fixation in T and Y fractures of the distal humerus. J Trauma 1992;33:687-690.

Question 41High Yield

The lateral arm flap is based on what arterial supply?

Explanation

The lateral arm flap is based on the posterior radial collateral artery, a branch of the profunda brachial artery.
REFERENCES: Katsaros J, Tan E, Zoltie N: The use of the lateral arm flap in upper limb surgery. J Hand Surg 1991;16:598-604.
Katsaros J, Schusterman M, Beppu M, et al: The lateral upper arm flap: Anatomy and clinical applications. Ann Plast Surg 1984;12:489-499.

Question 42High Yield

If the patient had an isolated spine injury without neurologic deficit, the most appropriate next step would be

Explanation

The treatment of thoracolumbar burst fractures has evolved over the years. In the absence of a neurologic deficit or a posterior ligamentous complex injury, nonsurgical treatment is as effective as surgery. The degree of spinal canal compromise is not a risk factor for neurologic symptoms. Similarly, although kyphosis may be a marker of more significant injury, the degree of kyphosis does not correlate with chronic pain. In the setting of a burst fracture, MRI can be used to evaluate the integrity of the posterior ligamentous complex. Polytrauma may be considered a relative indication for surgical intervention in the setting of a stable burst fracture.
RECOMMENDED READINGS
[Rechtine GR 2nd. Nonoperative management and treatment of spinal injuries. Spine (Phila Pa 1976). 2006 May 15;31(11 Suppl):S22-7; discussion S36. Review. PubMed PMID: 16685232. ](http://www.ncbi.nlm.nih.gov/pubmed/16685232)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/16685232)
[Shen WJ, Shen YS. Nonsurgical treatment of three-column thoracolumbar junction burst fractures without neurologic deficit. Spine (Phila Pa 1976). 1999 Feb 15;24(4):412-5. PubMed PMID: 10065527. ](http://www.ncbi.nlm.nih.gov/pubmed/10065527)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/10065527)
[Wood K, Buttermann G, Mehbod A, Garvey T, Jhanjee R, Sechriest V. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. A prospective, randomized study. J Bone Joint Surg Am. 2003 May;85-A(5):773-81. Erratum in: J Bone Joint Surg Am. 2004 Jun;86-A(6):1283. Butterman, G [corrected to Buttermann, G]. PubMed PMID: 12728024. ](http://www.ncbi.nlm.nih.gov/pubmed/12728024)[View Abstract at ](http://www.ncbi.nlm.nih.gov/pubmed/12728024)[PubMed](http://www.ncbi.nlm.nih.gov/pubmed/12728024)
[Wood KB, Li W, Lebl DS, Ploumis A. Management of thoracolumbar spine fractures. Spine J. 2014 Jan;14(1):145-64. doi: 10.1016/j.spinee.2012.10.041. Review. PubMed PMID: 24332321.](http://www.ncbi.nlm.nih.gov/pubmed/24332321)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/24332321)

Question 43High Yield

Slide 1
This patient presents for treatment of a painful hallux varus deformity following correction of hallux valgus deformity (Slide). All of the following procedures may be acceptable surgical alternatives for correction of deformity with the exception of:

Explanation

The extensor hallucis longus or the extensor hallucis brevis (rarely the abductor hallucis) may be used as a tendon transfer for correction. Arthrodesis of the hallux interphalangeal joint may be performed for correction of a fixed claw deformity of the interphalangeal joint, usually in conjunction with a tendon transfer. Arthrodesis of the metatarsophalangeal joint is a reasonable alternative provided there is no fixed deformity of the interphalangeal joint present and when arthritis or fixed deformity of the metatarsophalangeal joint is present.

Question 44High Yield

A 16-year-old female gymnast reports a 2-month history of back pain since falling off the parallel bars, and she has been unable to return to gymnastics. She has no numbness or tingling. Examination reveals lower back tenderness, some paravertebral muscle spasm, range of motion of the lumbosacral spine is 20 degrees of flexion and 20 degrees of extension, and an equivocal straight leg raise. Lumbosacral spine radiographs demonstrate Schomorl’s nodes but no evidence of spondylolisthesis. What is the next best step in management?

Explanation

DISCUSSION: Injuries to the anterior and middle column in gymnasts occur but are far less common than posterior column injuries such as spondylolysis and spondylolisthesis. The data on injuries to the anterior and middle columns are more limited. Long-term gymnastics exercise is associated with disk degeneration and other anterior and middle column abnormalities as reported by Katz and Scerpella. They identified a series of anterior and middle column abnormalities, including vertebral compression fractures, Schmorl’s nodes, disk degeneration, and disk herniation in young competitive female gymnasts with back pain. Therefore, the differential diagnosis of back pain in these athletes should include abnormalities of the anterior and middle column. Although diagnostic imaging should begin with radiographs, MRI is the best way to diagnosis these abnormalities. A bone scan is more useful for imaging bony abnormalities of the posterior elements. Flexion-extension radiographs are not indicated in this patient. Treatment such as physical therapy or a lumbosacral corset should not be initiated prior to a complete work-up.
REFERENCES: Katz DA, Scerpella TA: Anterior and middle column thoracolumbar spine injuries in young female gymnasts: Report of seven cases and review of the literature. Am J Sports Med 2003;31:611-616.
Tertti M, Paajanen H, Kujala UM, et al: Disc degeneration in young gymnasts: A magnetic resonance imaging study. Am J Sports Med 1990;18:206-208.

Question 45High Yield

-A 45-year-old man sustained bilateral femur fractures in a motorcycle accident. On admission to the emergency department, the patient is unconscious with a heart rate of 120 bpm and a systolic blood pressure of 80 mm Hg. A chest radiograph reveals bilateral pulmonary contusions. After resuscitation with 2 L of crystalloid, the patient’s heart rate is 115 bpm, the systolic blood pressure is 90 mm Hg, and the patient’s delta base is -10 mmol/L. What is the most appropriate treatment for the femoral fractures at this point?

Explanation

No detailed explanation provided for this question.

Question 46High Yield

A patient presents with hand weakness. On examination, she has no sensory deficient, decreased strength with pronation, and her elbow is at 90Âº of flexion and pulp-to-pulp contact on key pinch. The most likely diagnosis is:

Explanation

Anterior interosseous nerve syndrome is due to compression of the anterior interosseous nerve (AIN) in the forearm by lacterus fibrosis, flexor digitorum superficialis, or pronator teres. The AIN innervates the pronator quadratus, flexor digitorum profundus (FDP) to the index finger and the flexor pollicis longus (FPL). Anatomy variation exists where the AIN may innervate part of the flexor digitorum superficialis. In this patient, she has decreased pronation at 90Âº flexion, which relaxes the humeral attachment of the pronator from the pronator quadrus weakness. She also has pulp-to-pulp contract due to weakness of the FPL and FDP to the index finger.

Question 47High Yield

A 72-year-old female presents to the office 5 weeks after distal radius fracture surgery with the findings seen in Figure A. She performed daily cleansing with soap and water and dry dressings.
Which of the following has been shown to decrease the risk of developing this complication?

Explanation

There is no difference between daily showers with soap, water and dry dressings, and solutions comprising (1) saline and chlorhexidine, or (2) saline and hydrogen peroxide.
The risks of external fixation include cellulitis, pin-track drainage, osteomyelitis and pin loosening. The rate of complications is about 20%. Chlorhexidine gluconate has broad spectrum activity against gram-positive and negative bacteria by disrupting cell membranes. It is not affected by blood and has low skin irritancy. Studies show that simple pin-site care (showers, dry dressings) maintains a low infection rate.
Egol et al. performed a randomized trial examining external fixation pin tracts about the wrist. They compared (1) weekly dry dressings, (2) daily pin care with half normal saline (NS) and hydrogen peroxide (H2O2) and (3) chlorhexidine discs with weekly changes. They found pin-site complications in 19%, with no difference between the 3 groups. They do not recommend additional wound care beyond sterile dressings.
Stinner et al. performed a survey on the use of half-pins by the limb lengthening and reconstruction society. They found that most respondents preferred hydroxyapatite coating (81%) because of improved fixation and decreased loosening (less radiographic pin-tract rarefaction and greater extraction torque, which may lead to lower infection rates). Most encouraged
shower (60%) and washing solution (67%)(soap and water, peroxide or saline) for pin site care.
Figure A shows an external fixator around the wrist with cellulitis around the proximal half-pins.
Incorrect Answers
Answers 1-4: Hydrogen peroxide and chlorhexidine based solutions have not been conclusively shown to decrease the rate of pin site complications.

Question 48High Yield

Based on imaging alone, what does this bone lesion most closely resemble?

Explanation

- Enchondroma_

Question 49High Yield

Figure 35

Explanation

- Walking boot and weight bearing as tolerated until pain subsides_

Question 50High Yield

A right-handed 14-year-old pitcher has had a 3-month history of shoulder pain while pitching. Examination reveals full range of motion, a mildly positive impingement sign, pain with rotational movement, and no instability. Plain AP radiographs of both shoulders are shown in Figures 25a and 25b. Management should consist of

Explanation

The patient has the classic signs of Little Leaguer’s shoulder, with findings that include pain localized to the proximal humerus during the act of throwing and radiographic evidence of widening of the proximal humeral physis. Examination usually reveals tenderness to palpation over the proximal humerus, but the presence of any swelling, weakness, atrophy, or loss of motion is unlikely. The treatment of choice is rest from throwing for at least 3 months, followed by a gradual return to pitching once the shoulder is asymptomatic.
REFERENCES: Carson WG Jr, Gasser SI: Little Leaguer’s shoulder: A report of 23 cases. Am J Sports Med 1998;26:575-580.
Barnett LS: Little League shoulder syndrome: Proximal humeral epiphyseolysis in adolescent baseball pitchers. A case report. J Bone Joint Surg Am 1985;67:495-496.

Updated Orthopedic Review | Dr Hutaif General Orthopedi -...

Orthopedic Review | Dr Hutaif General Orthopedics Revie -...

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