Advanced Sports Orthopedics MCQs: Comprehensive Online Study & Exam Bank

Coronal shear fractures of the distal end of the humerus are rare. Failure to recognize the fracture pattern can lead to poor patient outcomes secondary to poor surgical decision making. The double arc sign is considered a pathognomonic finding on the lateral elbow radiograph seen in Figure 2. This is created by the subchondral bone of the capitellum and lateral trochlear ridge. Excessive internal rotation of the fracture fragment or a subpar lateral radiograph can make recognition of this sign difficult.
Ideal visualization of the fragment during surgery is provided through a laterally based elbow approach (Kaplan or Kocher) with the patient in the supine position. Extension of the approach can be accomplished by releasing the lateral collateral
ligament origin, which must be repaired to prevent post-operative instability. Posterior comminution and lateral column impaction are occasionally seen. When present, a posterior approach with an olecranon osteotomy is considered an alternative, but still does not allow ideal visualization of the anterior articular cartilage or safe angles for anterior to posterior screw placement. Therefore, the posterior approach not the preferred approach.
Headless screws are useful because this is typically a partial articular injury and screw orientation is ideally from anterior to posterior. The anterior entry of the screw should be buried beneath the articular cartilage margin.

Although the fracture is aligned in anatomic position, prominence of a least one of the distal screws is evident on the lateral radiographic view. The prominent screw is the most likely cause of the EPL tendon rupture. If the patient chooses surgical treatment, the best option would be removal of the offending hardware combined with extensor indicis proprius to EPL tendon transfer. Intercalary grafting would also be an acceptable option. If the tendon transfer were to be performed alone, the prominent screw(s) could rupture the transferred tendon as well. Also, it is rarely possible to repair the EPL tendon primarily in such cases, because this rupture is an attrition type. Casting would obviously not provide any benefit in this situation, and IP arthrodesis would not be the first surgical treatment option. This problem can be avoided by using shorter screws or not placing screws in plate holes that direct screws into the third dorsal extensor compartment. Intraoperative fluoroscopy and special views, such as the carpal shoot-through _view, are useful for avoiding this complication._

Fractures of the proximal humerus are now the third-most-common fracture in patients older than 60 years of age. This patient sustained a displaced, commonly described 3-part/4-part proximal humerus fracture. The number of fracture fragments and angulation, as initially described by Codman and then Neer, does not necessarily help to predict risk for subsequent AVN. Although the main blood supply to the humeral head historically was believed to be a branch from the anterior circumflex, adequate perfusion can remain through the posteromedial calcar following trauma. Hertel and associates reported that the most accurate predictor of ischemia was whether the length of the metaphyseal head extension for the calcar segment was shorter than 8 mm.
Locking plates have provided surgical alternatives to many unstable fracture patterns previously considered ominous. Although much enthusiasm remains for this use, a relatively high level of
complications has been reported with their use. A multicenter study reported a 14% incidence of intra-articular screw perforation as the most common complication.
When patients are deemed poor candidates for head preservation treatment, both hemiarthroplasty and rTSA can provide successful results when applied and performed appropriately. An increasing body of evidence appears to support consideration of a reverse prosthesis for older patients. A crucial aspect of hemiarthroplasty success is anatomic healing of the tuberosities around the implant. If the greater tuberosity displaces or reabsorbs, patients experience significant loss of active motion. The level of pain, however, is unpredictable. Although beneficial in a reverse prosthesis, anatomic tuberosity position does not appear to be as crucial. Depending on the definition of “complication,” some researchers have reported a higher complication rate for the reverse prosthesis.
If posttraumatic necrosis develops following head preservation treatment, conversion to an anatomic shoulder arthroplasty can provide good success in motion and function, particularly when the tuberosities heal in a relatively anatomic position. However, several researchers, most recently Moineau and associates, report suboptimal results when the greater tuberosity is positioned in a substantial amount of varus that necessitates osteotomy. In this scenario, rTSA should be considered.
RECOMMENDED READINGS
8. [Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004 Jul-Aug;13(4):427-33. PubMed PMID: 15220884. ](http://www.ncbi.nlm.nih.gov/pubmed/15220884)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/15220884)
9. [Südkamp N, Bayer J, Hepp P, Voigt C, Oestern H, Kääb M, Luo C, Plecko M, Wendt K, Köstler W, Konrad G. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J Bone Joint Surg Am. 2009 Jun;91(6):1320-8. PubMed PMID: 19487508. ](http://www.ncbi.nlm.nih.gov/pubmed/19487508)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/19487508)
10. [Anakwenze OA, Zoller S, Ahmad CS, Levine WN. Reverse shoulder arthroplasty for acute proximal humerus fractures: a systematic review. J Shoulder Elbow Surg. 2014 Apr;23(4):e73-80. doi: 10.1016/j.jse.2013.09.012. Epub 2014 Jan 7. Review. ](http://www.ncbi.nlm.nih.gov/pubmed/24406120)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/24406120)
11. [Jarrett CD, Brown BT, Schmidt CC. Reverse shoulder arthroplasty. Orthop Clin North Am. 2013 Jul;44(3):389-408, Epub 2013 Apr 29. Review. PubMed PMID: 23827841. ](http://www.ncbi.nlm.nih.gov/pubmed/23827841)[View Abstract ](http://www.ncbi.nlm.nih.gov/pubmed/23827841)[at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23827841)
12. Moineau G, McClelland WB Jr, Trojani C, Rumian A, Walch G, Boileau P. Prognostic factors and limitations of anatomic shoulder arthroplasty for the treatment of posttraumatic cephalic collapse or necrosis (type-1 proximal humeral fracture sequelae). J Bone Joint Surg Am. 2012 Dec 5;94(23):2186-
[94/. doi: 10.2106/JBJS.J.00412. PubMed PMID: 23224389. ](http://www.ncbi.nlm.nih.gov/pubmed/23224389)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23224389)
13. [Namdari S, Horneff JG, Baldwin K. Comparison of hemiarthroplasty and reverse arthroplasty for treatment of proximal humeral fractures: a systematic review. J Bone Joint Surg Am. 2013 Sep 18;95(18):1701-8.. PubMed PMID: 24048558. ](http://www.ncbi.nlm.nih.gov/pubmed/24048558)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/24048558)

The radiograph reveals a rotator cuff dysfunction secondary to malpositioning of the humeral stem and a nonanatomic humeral head. Glenohumeral kinematics have been altered, resulting in damage to the rotator cuff, which in turn has led to impingement with the coracoacromial arch. This single radiograph reveals excessive humeral head height, “overstuffing” of the joint, and severe narrowing of the acromiohumeral interval. Osteolysis and implant loosening are not radiographically apparent. An orthogonal view (axillary lateral) would be necessary to evaluate for shoulder instability. A CT arthrogram is the most appropriate advanced imaging test in the setting of a retained shoulder arthroplasty to evaluate the integrity of the rotator cuff. An MRI evaluation would be obfuscated by artifact. Three-phase and indium-tagged white blood cell scans may be appropriate in the setting of an occult infection evaluation, but not as a test to evaluate rotator cuff injury.
In the absence of infection with rotator cuff compromise, the most appropriate procedure(s) during revision would involve humeral component explantation and conversion to rTSA Revision anatomic hemiarthroplasty may provide pain relief, but function may not appreciably change because of the unbalanced forced couples of the rotator cuff complex. Placement of a glenoid component in the setting of an irreparable rotator cuff tear is contraindicated because rapid glenoid loosening will occur due to eccentric loading during active shoulder motion. Resection arthroplasty should be reserved for recalcitrant cases of infection because this procedure does not provide functional improvement.
In the event that frozen section analysis and positive gram stain results indicate an infection, the treating surgeon should remove all components, perform a thorough debridement and irrigation of suspect tissue, implant an antibiotic spacer, and perform a second-stage reconstruction when deemed appropriate (in light of laboratory studies, repeat shoulder aspiration, frozen section analysis, and arthroscopic soft-tissue biopsy findings). Irrigation and debridement with primary exchange/conversion of components remains inferior to 2-stage reconstruction for infection eradication. Resection arthroplasty remains a salvage procedure for resistant cases that preclude reimplantation and generally is performed for symptom control and sepsis prevention.
RECOMMENDED READINGS
1. [Bohsali KI, Wirth MA, Rockwood CA Jr. Complications of total shoulder arthroplasty. J Bone Joint Surg Am. 2006 Oct;88(10):2279-92. Review. PubMed PMID: 17015609. ](http://www.ncbi.nlm.nih.gov/pubmed/17015609)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/17015609)
2. [Florschütz AV, Lane PD, Crosby LA. Infection after primary anatomic versus primary reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2015 Aug;24(8):1296-301. doi: 10.1016/j.jse.2014.12.036. Epub 2015 Feb 19. PubMed PMID: 25704211. ](http://www.ncbi.nlm.nih.gov/pubmed/25704211)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/25704211)
3. [Padegimas EM, Maltenfort M, Ramsey ML, Williams GR, Parvizi J, Namdari S. Periprosthetic shoulder infection in the United States: incidence and economic burden. J Shoulder Elbow Surg. 2015 May;24(5):741-6. doi: 10.1016/j.jse.2014.11.044. Epub 2015 Jan 13. ](http://www.ncbi.nlm.nih.gov/pubmed/25595360)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/25595360)
4. [Leung B, Horodyski M, Struk AM, Wright TW. Functional outcome of hemiarthroplasty compared with reverse total shoulder arthroplasty in the treatment of rotator cuff tear arthropathy. J Shoulder Elbow Surg. 2012 Mar;21(3):319-23. doi: 10.1016/j.jse.2011.05.023. Epub 2011 Aug 26. PubMed PMID: 21872496. ](http://www.ncbi.nlm.nih.gov/pubmed/21872496)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/21872496)
5. [Iannotti JP, Spencer EE, Winter U, Deffenbaugh D, Williams G. Prosthetic positioning in total shoulder arthroplasty. J Shoulder Elbow Surg. 2005 Jan-Feb;14(1 Suppl S):111S-121S. PubMed PMID: 15726070. ](http://www.ncbi.nlm.nih.gov/pubmed/15726070)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/15726070)
6. [Iannotti JP, Gabriel JP, Schneck SL, Evans BG, Misra S. The normal glenohumeral relationships. An anatomical study of one hundred and forty shoulders. J Bone Joint Surg Am. 1992 Apr;74(4):491-500. PubMed PMID: 1583043.](http://www.ncbi.nlm.nih.gov/pubmed/1583043)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/1583043)
7. [Grosso MJ, Frangiamore SJ, Ricchetti ET, Bauer TW, Iannotti JP. Sensitivity of frozen section histology for identifying Propionibacterium acnes infections in revision shoulder arthroplasty. J Bone Joint Surg Am. 2014 Mar 19;96(6):442-7. doi: 10.2106/JBJS.M.00258. ](http://www.ncbi.nlm.nih.gov/pubmed/24647499)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/24647499)

The incidence of patella component loosening is less than 2%. Factors predisposing to loosening include cementation into deficient bone, component malposition, patellar subluxation or fracture, patellar avascular necrosis, asymmetriCpatellar bone resection, and loosening of other components. Treatment options include observation, component revision, patellectomy or component removal, and patellar arthroplasty if bone stock is sufficient

This patient's history and physical findings are concerning for deep infection. Inflammatory markers, including ESR and CRP, should be obtained first. If the levels are elevated, knee aspiration should be performed for the synovial cell count and culture. A bone scan is not indicated in an initial investigation for deep infection; it is rarely helpful and is not cost effective. CT to assess implant rotation is an appropriate investigation for knee pain when the clinical scenario is not suspicious for a deep infection
and when infection has been excluded.

The anterior cruciate ligament is attached to a portion of the lateral femoral condyle. The posterior cruciate ligament attaches to the medial femoral condyle. The lateral collateral and oblique popliteal ligaments attach proximal to this fragment. The intermeniscal ligament attaches the anterior horns of the menisci.
REFERENCES: Jobe CM, Wright M: Anatomy of the knee, in Fu FH, Harner CD, Vince KG (eds): Knee Surgery. Baltimore, MD, Williams & Wilkins, 1994, pp 1-54.
Moore KL, Dalley AF: Lower limb, in Moore KL, Dalley AF (eds): Clinically Oriented Anatomy, ed 4. Philadelphia, PA, Lippincott, Williams & Wilkins, 1999, pp 503-664.

The MRI scan shows advanced multilevel degenerative changes and moderate to severe stenosis at C3-C4 and C4-C5 with associated cord signal change. The patient has greater weakness in the upper extremities than in the lower extremities. This pattern is most compatible with central cord syndrome. Patients with brachial plexus injury will have unilateral weakness. Patients with anterior cord syndrome will have greater weakness in the legs than in the arms, and those with Brown-Séquard syndrome will have ipsilateral motor deficits and contralateral pain and temperature deficits.

A thoracolumbosacral orthosis is most effective for bracing of curves when the apex is at T7 or below. Bracing is used for patients who are skeletally immature (Risser stage 0, 1, or 2), and it is recommended that the brace be worn 16 to 23 hours per day and continued until skeletal maturity or until the curve progresses to beyond 45 degrees, at which point bracing is no longer considered effective.
RECOMMENDED READINGS
Luhmann SJ, Skaggs DL: Pediatric spine conditions, in Lieberman JR (ed): AAOS Comprehensive Orthopaedic Review. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2009, pp 245-265.
[Shaughnessy WJ. Advances in scoliosis brace treatment for adolescent idiopathic scoliosis. Orthop Clin North Am. 2007 Oct;38(4):469-75, v. Review. PubMed PMID: 17945126. ](http://www.ncbi.nlm.nih.gov/pubmed/17945126)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/17945126)

A retrospective comparison study has shown no increase of risks in delayed treatment of supracondylar fractures.

Osteofibrous dysplasia occurs exclusively in the tibia. This non-neoplastiCcondition may be related to adamantinoma. The lesion is usually located in the anterior cortex and there is often bowing of the tibia.

Posterior partial articular tibial plateau fractures are rare. Failure to recognize this pattern can lead to poor patient outcomes secondary to poor surgical decision making. Pathognomonic findings on the lateral radiograph include maintenance of continuity between the anterior articular surface and tibial shaft along with subluxation of the knee joint with excessively anterior tibial station (the femoral condyles remain with the fractured posterior articular pieces while the remainder of the tibia subluxes anteriorly).
Initial management of axially unstable tibial plateau fractures with soft tissue swelling should consist of spanning external fixation and closed manipulative realignment. This allows for soft tissue recovery with the knee joint provisionally stabilized in reduced station. It also provides time for pre-operative planning, which is typically empowered via a CT scan with reconstructions. If the pattern was initially misdiagnosed as a more typically bicondylar tibial plateau fracture, the CT scan will clarify the misconception and allow for better surgical decision making.
Attempting to visualize, reduce, and stabilize a posterior partial articular pattern in the supine position from an anterior approach is fraught with difficulties. Prone positioning is preferred for definitive fixation. Surgical approaches vary, but
typically incorporate a posteromedial interval deep to the popliteus and soleus to provide buttress plating to the posterior column of the tibia.

The number one cause of sudden death in the young athlete is myocardial pathology, with hypertrophic cardiomyopathy being most common. Because of cardiac muscle hypertrophy, the ventricular capacity is diminished and can result in decreased cardiac output. During exertional activities, the increased demand may not be able to be met and leads to sudden death. While the other choices can be the cause of sudden death in an otherwise healthy young athlete, their incidence is even more rare.
REFERENCES: Van Camp SP, Bloor CM, Mueller FO, et al: Nontraumatic sports death in high school and college athletes. Med Sci Sports Exerc 1995;27:641-647.
Maron BJ, Shirani J, Pollac LC, et al: Sudden death in young competitive athletes: Clinical, demographic, and pathological profiles. JAMA 1996;276:199-204.
Mills JD, Moore GE, Thompson PD: The athlete’s heart. Clin Sports Med 1997;16:725-737.

The most significant side effect of biphosphonates is esophagitis and dyspepsia. Biphosphonates must be taken on an empty stomach with no oral intake for 30 minutes. In addition, patients should remain upright

Varus posteromedial rotatory instability is a complex injury pattern that starts with varus stress resulting in a fracture of the anteromedial coronoid. The anterior MCL attaches to the sublime tubercle, which is part of the anteromedial coronoid facet. The posterior MCL attaches to the posterior medial aspect of the ulna. The radial collateral and lateral ulnar collateral attach to the ulna at the crista supinatoris. The bony landmark is the sublime tubercle; as noted above, the crista supinatoris is lateral on the ulna. The radial notch is also lateral and is the articulation between the proximal ulna and proximal radius. The anteromedial coronoid facet is part of the coronoid, which extends more lateral and anterior than the anteromedial facet. The anteromedial facet represents the critical weight-bearing portion of the ulnohumeral joint. Damage to this structure causes posteromedial subluxation that often results in severe progressive arthritis. The coronoid is the larger structure of which the anteromedial coronoid facet is a portion. The posteromedial coronoid facet does not appear to be critical in weight bearing. The radial notch is not associated with increased stress with weight bearing. The treatment of displaced fractures of this structure is open reduction and internal fixation utilizing buttress plating. Closed treatment is acceptable only for nondisplaced fractures with appropriate radiographic follow-up. Suture fixation is not advocated because of inadequate strength.
RECOMMENDED READINGS
1. Pollock JW, Brownhill J, Ferreira L, McDonald CP, Johnson J, King G. The effect of anteromedial facet fractures of the coronoid and lateral collateral ligament injury on elbow stability and kinematics. J Bone Joint Surg Am. 2009 Jun;91(6):1448-58. doi: 10.2106/JBJS.H.00222.
2. Sanchez-Sotelo J, O'Driscoll SW, Morrey BF. Anteromedial fracture of the coronoid process of the ulna. J Shoulder Elbow Surg. 2006 Sep-Oct;15(5):e5-8. Epub 2006 Jul 26. Erratum in: J Shoulder Elbow Surg. 2007 Jan-Feb;16(1):127. PubMed PMID: 16979044.

**
The patient has a severe rheumatoid forefoot deformity involving all metatarsophalangeal joints. Coughlin and Mann have found that 90% of patients have excellent and good results with combined first metatarsophalangeal fusion and lesser metatarsal head resection. Keller arthroplasty does not provide a stable platform for walking and is associated with recurrent deformity and pain. The first metatarsophalangeal joint replacement has not been shown to provide reliable long- term results. Osteotomies may be indicated in patients without erosive joint changes. The Lapidus procedure is an arthrodesis of the first tarsometatarsal joint, which would not address the patient's arthritic first metatarsophalangeal joint.

■
In patients identified and treated for a SCFE, the most devastating complication is AVN. The most likely indication for a total joint replacement in patients with SCFE is the presence of AVN or chondrolysis. The severity of slip, presence of FAI, and/or degenerative changes may increase the possibility of requiring a THA, but typically at an older age than patients with AVN. The age of onset of SCFE has not been found to be directly related to complications or outcomes, such as the development of AVN.

The radiographs show tarsometatarsal joint subluxation without fragmentation. The clinical history and delay in presentation with the radiographic findings suggest a neuropathic or Charcot arthropathy involving the midfoot area. Intact sensory examination to light touch is not diagnostic for an intact peripheral neurologic system; monofilament testing is a more accurate office baseline examination for the presence of sensory peripheral neuropathy. With an acute traumatic Lisfranc fracture-dislocation, a history of a traumatic event is necessary, and radiographic abnormalities are expected, although nonstanding radiographs still may be misleading. Acquired pes planus due to posterior tibial tendon rupture may have negative nonstanding radiographs. Standing radiographs may reveal pes planus. However, intermetatarsal disruption is not expected as seen in a Lisfranc abnormality. Localized osteomyelitis of the foot without a penetrating injury or cutaneous ulceration is extremely unlikely and does not fit with the clinical picture described. An isolated metatarsal stress fracture would show osseous irregularity without the instability pattern pictured.
REFERENCES: Brodsky JW: The diabetic foot, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 895-969.
Myerson MS: Diabetic neuroarthropathy, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 439-465.

The most common age is the second decade; the mean age is 13 years old.

Plain film radiographs can successfully detect cam and pincer impingement and cartilage space narrowing, as well as allow quantified measurement of femoral head coverage. A magnetiCresonance arthrogram is necessary, however, to successfully visualize labral pathology.

Following anterior dislocation of the shoulder, the affected arm is typically placed in a sling with the shoulder in adduction and internal rotation. A recent study has shown that placement in this position actually results in laxity of the anterior supporting structures of the shoulder, allowing the postinjury hemarthrosis to push the labrum and capsular ligaments away from the anterior glenoid rim. Thus, immobilization in this position may actually impede healing of these structures. Alternatively, resting the arm in a position of adduction and external rotation allows the anterior supporting structures to abut against the anterior glenoid rim by forcing the hemarthrosis posteriorly. Placing the arm in this position following anterior dislocation is believed to allow for better healing of the anterior labrum and ligaments.
REFERENCE: Itoi E, Sashi R, Minagawa H, et al: Position of immobilization after dislocation of the glenohumeral joint: A study with use of magnetic resonance imaging. J Bone Joint Surg Am 2002;84:873-874.

This patient’s volar locking plate (VLP) is distal to the "watershed line", extending volarly beyond the most volar aspect of the distal radius. He is at greatest risk for an attritional rupture of the FPL.
A VLP placed this distal and volar is more likely to cause flexor tendon injury.
Up to 12% of all patients undergoing volar plate fixation will experience flexor tendon injury, and the FPL is the most common tendon associated with the VLP (57% of total flexor tendon ruptures). The average time from fixation to flexor tendon rupture has been cited at 9 months. To judge if a plate is volar to the watershed line, a plum line can be made in the proximal direction from the most volar edge of the distal radius. If a plate is volar to this (Soong) line, the patient is thought to be at a higher risk for flexor tendon injury. As a result, this patient should be followed closely and if pain with thumb flexion is present after 3 months, the surgeon should consider plate removal so long as the fracture is healed to reduce the chance of FPL rupture. Ruptured tendons require repair, grafting, or transfer with hardware removal.
Griffin and Chhabra comprehensively reviewed the risk factors and adverse events following VLP fixation of distal radius fractures, including flexor tendonitis and rupture. They found that risk factors for flexor tendon rupture following VLP fixation included plate placement distal to the watershed line and that PQ repair does not seem to affect flexor tendonitis.
Agnew et al. analyzed wrist MRIs to determine the relationship between the flexor tendons and the watershed line. They found that at 3mm proximal to the watershed line, the FPL and FDP to the index finger were 2.6 and 2.2mm anterior to the volar rim of the distal radius. The authors suggested that distally placed plates are incredibly close to the flexor tendons.
Chilelli et al. described 24 of 48 wrists which had VLP following distal radius fracture and went on to experiences loss of FPL flexion post-operatively. They found that FPL ROM generally returned after 52 days, however with an associated average loss of 11° in thumb IPJ ROM. The authors attribute this to stripping of FPL from the bone during the volar approach.
Soong et al. divided patients who underwent VLP fixation for distal radius fractures into three groups according to position of plate relative to a plum line extending proximally from the most volar and distal aspect of the distal radius: those with a VLP dorsal to the Soong line (grade 0), those with the VLP volar to the Soong line but proximal to the rim (grade 1), and those with a VLP volar to the Soong line and at or distal to rim (grade 2). Of the 73 cases reviewed, the authors reported three flexor tendon ruptures, two of which were grade 2 position. The authors concluded that both position of plate and type of plate were contributors to flexor tendon injury following VLP fixation.
Figure A is a lateral radiograph of the wrist demonstrating appropriate reduction and fixation but with the VLP volar to the "watershed" or Soong line.
Illustration A is a lateral radiograph with Soong's line drawn to show that this plate is too volar.
Incorrect Answers:
Answer 2: The FCR is very superficial and is not commonly injured following VLP fixation of distal radius fractures.
Answer 3: While the FDP to the index finger is the second most common flexor tendon injury following VLP, injury to the FDS to the index finger is unlikely.
Answer 4: The patient is only two weeks from fixation and has no symptoms. The reduction appears appropriate on the imaging seen. Therefore there is no need for urgent revision fixation.
Answer 5: The VLP shown is volar to the watershed line is therefore not in an appropriate position.

Little League shoulder is a physeal injury increasingly seen in young throwers. The primary treatment is refraining from throwing with rehabilitation, followed by a throwing program. The risk of recurrence is approximately 7%. The risk of recurrence is three times higher in athletes with glenohumeral internal rotation deficit. Hyperlaxity,
rotator cuff weakness, and increased height have not been shown to correlate with recurrent symptoms.

Bone marrow transplantation is effective in minimizing the deposition of mucopolysaccharides in solid organs. Transplantation should be done early to prevent organ damage. Because the lysosomal enzyme does not cross the cell membrane of osteocartilaginous cells, it does not affect the orthopedic aspects. The risk of graft-versus-host disease is high but may be treated in most cases. Survival rate is 61% at 2 years for Hurler disease, which is otherwise fatal before maturity.

Ghiselli and associates described a rate of symptomatic degeneration at an adjacent segment warranting either decompression or arthrodesis to be 16.5% at 5 years and 36.1% at 10 years based on a Kaplan-Meier analysis.
Question 49 Halo treatment for preadolescent children typically requires the use of which of the following?
1. # 4 to 6 pins with an insertional torque of 1 to 5 in-lb
2. # 4 to 6 pins with an insertional torque of 4 to 6 in-lb
3. # 4 to 6 pins with an insertional torque of 6 to 8 in-lb
4. # 8 to 12 pins with an insertional torque of 1 to 5 in-lb
5. # 8 to 12 pins with an insertional torque of 4 to 6 in-lb
DISCUSSION: The complication rate with halo vest treatment in children is reported to be as high as 68% in contrast to a 36% complication rate in adults. These complications include not only pin tract infections,but also skull penetration. Multiple pins allow for the early removal of pins without fixation consequences should pin site infections begin to develop. Moreover, there is significant variability in the insertional torque applied by a variety halo pin torque wrenches, including those from the same manufacturer.
Consequently, the use of a large number of pins (8 to 12) placed a very low insertional torque (1 to 5 in-lb) in children is recommended. A CT scan of the head should also be considered to assess for the thickest areas of the skull suitable for pin application. PR: 4

DISCUSSION: A supracondylar femoral periprosthetic fracture that is a reducible or an irreducible fracture with poor distal bone stock and in the vicinity of loose or malpositioned components (type III) is very difficult to treat. One of the treatment options for patients with a loose femoral component and poor bone stock is the use of distal femoral replacement. The distal femoral replacement can be performed with relative ease, expediency, and is best suited for elderly or sedentary patients.

REFERENCES: Kassab M, Zalzal P, Azores GM, et al: Management of periprosthetic femoral fractures after total knee arthroplasty using a distal femoral allograft. J Arthroplasty 2004;19:361-368.
Kim KI, Egol KA, Hozack WJ, et al: Periprosthetic fractures after total knee arthroplasties. Clin Orthop Relat Res
2006;446:167-175.

■
The genitofemoral nerve is at risk at almost any level in the lateral transpsoas approach. The nerve provides sensory innervation to the anterior thigh and scrotum/labia. The ilioinguinal nerve provides sensory innervation to the mons pubis or labia in women and the upper scrotum in men. The femoral nerve is responsible for sensation to the anterior and medial aspects of the thigh, leg, and medial foot. It also provides innervation to knee extensor muscles. Prolonged decubitus positioning, especially with jackknife hyperextension, can cause stretching of the femoral nerve and transient weakness of the ipsilateral quadriceps.

■
The patient has classic symptoms of myelopathy with upper motor neuron signs on examination. His symptoms have been present for years, and are getting worse. The cervical spine MRI scan shows spinal stenosis with multilevel spondylosis causing spinal cord compression at multiple levels. With the longstanding duration of the patient's signs and symptoms, combined with involvement of multiple levels in the cervical spine, posterior multilevel laminectomy and fusion is the best treatment option. Two-level anterior diskectomy and fusion would address the two areas of most severe narrowing, but it would fail to decompress the other stenotic areas which also require decompression. Posterior cervical foraminotomies would only address radicular symptoms, which are not present in this patient, and would not succeed in decompression of the spinal cord. Cervical epidural injections are not indicated for myelopathy symptoms, and may in fact place this patient at risk for neurologic deterioration.

DISCUSSION: The patient has a periprosthetic fracture of the patella but is able to actively extend his knee. Despite the wide displacement of the fracture fragments, nonsurgical management is recommended given the high risk of complications and problems when open treatment of these fractures is undertaken.

REFERENCES: Ortiguera CJ, Berry DJ: Patellar fracture after total knee arthroplasty. J Bone Joint Surg Am 2002;84:532-540.
Parvizi J, Kim KI, Oliashirazi A, et al: Periprosthetic patella fractures. Clin Orthop Relat Res
2006;446:161-166.

Figure 43a Figure 43b

Eighty percent of giant cell tumors occur in patients older than age 20 years, with the peak incidence in the third decade of life. Most of these tumors are eccentrically located and epiphyseal in location. They are lytic in nature as in this patient. Although named for the hallmarked multinucleated giant cells seen in the lesion, the basic cell type is the spindle-shaped stromal cell. Chondroblastoma is highly cellular and contains large multinucleated giant cells with intercellular chondroid material, some of which is calcified. Chondromyxoid fibroma has chondroid tissue separated by strands of more cellular tissue with occasional multinucleated giant cells. Desmoplastic fibroma is characterized by poorly cellular fibrous tissue, and lymphoma is highly cellular with characteristic round cells.
REFERENCES: Campanacci M, Baldini N, Boriani S, et al: Giant cell tumor of bone. J Bone Joint Surg Am 1987;69:106-114.
Goldenberg RR, Campbell CJ, Bonfiglio M: Giant cell tumor of bone: An analysis of two hundred and eighteen cases. J Bone Joint Surg Am 1970;52:619-664.

The most common cause of recurrent injury to the fifth metatarsal is unrecognized varus heel deformity. Surgeons must also check for ankle instability, which may be present in this patient. A varus heel, ankle instability, and injury to the fifth metatarsal are associated with recurrent deformity.

The radiographs reveal a trimalleolar ankle fracture dislocation with an
associated distal tibiofibular syndesmotic disruption. Medial and lateral malleolar stabilization are consistently agreed upon. The decision to stabilize the posterior malleolus is more controversial. Posterior malleolar stabilization accomplishes the following:
21. Restores incisura competence thereby reducing the incidence of syndesmotic malreduction by creating containment
22. Assists in stabilizing the syndesmosis via the posterior inferior tibiofibular ligament, potentially limiting the need for additional syndesmotic stabilization
23. Maximizes the surface area for ankle joint loading
24. Enhances posterior translational stability of the talus
The traditional indication for stabilization of the posterior malleolus is based on fragment size. However, fracture orientation varies and makes evaluation of the fragment size challenging with a lateral radiograph alone. The three primary types include the posterolateral oblique, medial extension, and shell. Because of the additive syndesmotic stability which is gained through the deep deltoid ligament and medial malleolar fixation, the anterior talofibular ligament and lateral malleolar fixation, and the posterior inferior tibiofibular ligament and posterior malleolar fixation, syndesmotic stability should only be assessed after all other points of instability that are planned for fixation are fixed.
Syndesmotic instability should be assessed with direct manipulation on both the anteroposterior and lateral views with special attention to the lateral view. Syndesmotic reduction should be assessed either through open visualization or by comparing closed reduction parameters (clear space, overlap, and fibular position on the lateral view) with the patient’s contralateral side (assuming no injury). This is more effective than using population norms secondary to the two types of syndesmotic morphologies which create different absolute values for these parameters.

Figure B demonstrates an isolated medial femoral condyle fracture. Lateral locked plating is not an appropriate technique for this fracture.
The fracture shown in Figure B is an AO B type (partial articular fracture). This fracture is best treated with open reduction internal fixation through a medial approach, with lag screw and buttress plate fixation.
Figures A, C, D and E show supracondylar distal femur fractures that can be treated with ORIF with a fixed-angle device such as lateral locked plating.
Incorrect Answers:

. Fixed angle fixation is appropriate for comminuted extra-articular distal femur fractures.
Answers 3, 4, 5. ixed angle fixation is appropriate for comminuted intraarticular distal femur fractures. Non-locked plating for type C (complete articular) distal femur fractures has been associated with varus malalignment.

A 70-year-old female with a history of poorly controlled diabetes mellitus presents with purulent ulcers along the plantar aspect of her right forefoot and exposed metatarsal bone. She elects to undergo an amputation. She is insensate to the midfoot bilaterally. Her ankle-brachial index (ABI) for her right posterior tibial artery is 0.4. Further preoperative evaluation demonstrates a transcutaneous oxygen pressure of 45 and an albumin of 3.4. Which of the following would be a contraindication to performing a Syme amputation (ankle disarticulation) in this patient?

1) Albumin of 3.4

2) Active osteomyelitis

3) ABI of 0.4 for the posterior tibial artery

4) Transcutaneous oxygen pressure of 45

5) Peripheral neuropathy

A Syme amputation (ankle disarticulation) is a function-preserving amputation option that allows for terminal weight bearing, however strict criteria must be met for a patient to undergo successful Syme amputation. An ankle-brachial index (ABI) less than 0.5 for the posterior tibial artery in a patient with diabetes would be a contraindication for this procedure as success is dependent on the vascular supply of posterior tibial artery to the plantar flap and heel pad.
Pinzur et al retrospectively reviewed their results when performing a single-stage Syme ankle disarticulation in patients with diabetes either for peripheral neuropathy or infection. Patients with ABIs less than 0.5 for the posterior tibial artery had significantly decreased healing rates and smokers had a three-fold increased risk of postoperative infection.
Incorrect Answers:
Answer 1: Albumin of 3.4 indicates adequate preoperative nutrition. Albumin of
2.0 or less would be concerning for increased wound healing risk.
Answer 2: Osteomyelitis was the indication for amputation in a number of diabetic patients in the referenced study, and should not preclude Syme amputation unless the hindfoot and/or distal tibia is involved
Answer 4: Transcutaneous 02 pressure of 45 signifies adequate oxygenation and vascularity. Less than 30 is generally considered a cutoff for adequate vascularity.
Answer 5: Peripheral neuropathy with recurrent ulceration was an indication for amputation in the referenced study.

A 35-year-old-male sustains the fracture seen in Figure A. Which of the following reduction forces must be applied to the proximal fragment to correct the deformity commonly seen in these fractures?
1) Adduction and extension

2) Abduction and extension

3) Adduction and flexion

4) Abduction and flexion

5) External rotation

Figure A demonstrates a displaced subtrochanteric femur fracture with an intact lesser trochanter. The pull of iliopsoas on the lesser trochanter as well as the intact external rotators and gluteal musculature results in the the proximal fragment being in a flexed and externally rotated or abducted position (the most common post operative deformity). Reduction manuevers must be biologically friendly but also counteract the flexion/abduction moment. Lundy's review article discusses evaluation and treatment of subtrochanteric fractures. The review article details the various implants often used which include 95 degrees plates, femoral reconstruction nails, or trochanteric femoral nails with interlocking options. Lundy's article discourages the use of the 135 degree screw and side plate combo due to high failure rates in these fracture patterns. Bedi et al also review treatment of these fractures and discuss common
problems of malunion, nonunion, and implant failure. The article reviews reduction techniques that are soft tissue friendly, as well as the use of appropriate implants in these fracture types.

A 12-year-old male sustains an ulnar fracture with an associated posterior-lateral radial head dislocation. After undergoing closed reduction, the radiocapitellar joint is noted to remain non-concentric. What is the most likely finding?

1) Lateral ulnar collateral ligament disruption

2) Anterior band of the medial collateral disruption

3) Posterior band of the medial collateral ligament disruption

4) Annular ligament interposition

5) Anconeus muscle interposition

In pediatric Monteggia fractures the annular ligament is commonly interposed in the radiocapitellar joint.
Bado initially described and classified Monteggia fractures. The most common injury pattern is an extension type 1 with anterior radial head dislocation and apex anterior ulnar shaft fracture. The apex of the ulna fracture determines the direction of the radial head subluxation or dislocation. Adults typically require ORIF of the ulna. These fractures in children are often treated non-operatively with closed reduction if the ulna fracture is transverse and stable. Type III is the one most commonly associated with irreducibility of the radial head because of interposition of the annular ligament. The incidence of posterior interosseous nerve injury is high with this lesion. The nerve deficit usually completely resolves rapidly and spontaneously.
Tan et al reviewed their treatment of 35 children with Type I and Type III Monteggia fractures. All radial heads were explored and the interposed annular ligament was stretched out of the joint space. They noted that none of the patients had any recurrent dislocation or subluxation.
Ring et al in their review stress the importance of an anatomic reduction of the ulna to restore the reduction of the radial head.

All of the following are factors associated with transfer of patients to Level 1 trauma centers EXCEPT:

1) Male

2) Medicaid insurance

3) Injury severity score of 36

4) Caucasian race

5) One or more comorbidity

Caucasian race has not been found to be a predictor for transfer to a Level 1 trauma center.
The retrospective case-control study by Koval et al found that African-American race, presence of medical comorbidity, medicaid insurance, and male gender are predictors for transfer of patients to a trauma center that have ISS scores less than 9.
The article by Nathens et al found that lack of insurance was an independent predictor for transfer to a trauma center after adjusting for differences in injury severity. An injury severity score of 36 represents a patient that has sustained life-threatening polytrauma and should be transferred to a Level 1 trauma center.

A 34-year-old male falls from a roof and sustains a right elbow dislocation that is closed reduced in the emergency room. An AP radiograph is shown in Figure A. This injury pattern is at highest risk for which of the following?
1) Anterior interosseous nerve palsy

2) Varus posteromedial rotatory instability

3) Posterior interosseous nerve palsy

4) Valgus posterolateral rotatory instability

5) Elbow instability when pushing oneself up from a seated position in a chair

Anteromedial coronoid facet fracture and LCL injury following an elbow dislocation is commonly associated with varus posteromedial rotatory instability. Varus and posteromedial rotation force on the forearm results in rupture of the LCL from its humeral origin. As the LCL ruptures, the medial coronoid process is fractured as it impacts against and under the medial trochlea. Fracture involvement of the sublime tubercle, where the MCL attaches, can lead to more instability. Ulnar neuropathy can be seen following this injury pattern but AIN and PIN nerve palsy do not commonly characterize this injury pattern.
The review article by O'Driscoll highlights key points in diagnosis and management of capitellum, distal humerus, coronoid, and terrible triad injuries.
The article by Doornberg and Ring is a Level 4 study of 18 patients that sustained varus posteromedial rotational injuries resulting in anteromedial facet coronoid fractures. They found that lack of fixation at injury or malunion of the anteromedial facet were significant predictors of suboptimal functional outcome and development of arthrosis.
The anteromedial facet is highlighted in yellow as displayed in Illustration A. Illustration B depicts the lateral collateral ligament injury also evident during
varus stress fluroscopic examination, due to tension failure of the LCL off its humeral origin during the various mechanism.

Which of the following factors is most associated with malrotation during antegrade or retrograde femoral nailing?

1) Surgeon experience

2) Level of primary fracture line

3) Use of a piriformis starting portal

4) Fracture comminution

5) Closed reduction technique

Femoral malrotation after intramedullary nailing is unfortunately a possibility with either antegrade or retrograde nailing techniques. Malrotation and iatrogenic length changes are most common when comminution is present, as cortical reads are inherently limited.
Hufner et al report that malrotation (internal or external >15 degrees) was seen in 22% of their patients via CT scan after intramedullary nailing. There was a significant difference depending on the time of surgery, with significantly more malrotation during the night shift. Increased fracture comminution also significantly increased malrotation rates.
Incorrect Answers:
1,2,3,5: No significant increases were seen with the other answers listed above.

What is the most common type of malalignment after intramedullary nailing of distal 1/3 extra-articular tibia fractures using a infrapatellar approach when compared with plating?

1) Varus

2) Valgus

3) Translational

4) Shortening

5) Apex anterior

The most common type of malalignment after intramedullary nailing of distal 1/3 extra-articular tibia fractures using an infrapatellar approach when compared with plating is valgus malalignment.
Fixation of distal one-third tibial shaft fractures can be successfully treated with either intramedullary nailing or plating. The literature describes advantages and disadvantages to both approaches, however intramedullary nailing has been shown to lead to increased rates of valgus malunion. Recent studies have shown that using a suprapatellar approach may decrease the incidence of valgus malalignement.
Vallier et al performed a randomized prospective study to compare plate and nail stabilization for distal tibia shaft fractures by assessing complications and secondary procedures. One-hundred and four patients were randomized to either reamed intramedullary nailing, or medial distal tibia plate fixation.
Primary angular malalignment was identified in 17 patients (16.3%). This included four patients treated with tibial plating (8.3%) and 13 patients treated with nails (23%, P = 0.02). Eight of these (7.7% of all patients) had malalignment between 6° and 10° of angulation. Valgus was the most common
angular deformity, accounting for 70% of angular deformity cases.
Avilucea et al. looked at the immediate postoperative alignment of distal tibia fractures (within 5 cm of the tibial plafond) treated with suprapatellar intramedullary nail (IMN) insertion compared with the infrapatellar technique. They found primary angular malalignment of ≥5 degrees occurred in 35 (26.1%) patients with infrapatellar IMN insertion and in 5 (3.8%) patients who underwent suprapatellar IMN insertion. They conclude suprapatellar IMN technique results in a significantly lower rate of malalignment compared with the infrapatellar IMN technique.
Incorrect Answers:
Answer 1, 3,4, and 5: Vallier et al. found that valgus was the most common angular deformity.

A 33-year-old secretary presents three months after a motor vehicle collision with a mild asymmetry to her sternal area and difficulty swallowing. She denies any complaints of respiratory distress or upper extremity paresthesias. Her upper extremity neurovascular exam shows no deficits. A 3-D computed tomography image is shown in Figure A. What is the most appropriate treatment for this patient?
1) Nonoperative treatment with a sling and unrestricted activity in 3 months

2) Open reduction in the operating room with thoracic surgery back-up

3) Closed reduction in the office with local anesthetic

4) Closed reduction in the operating room with thoracic surgery back-up

5) Nonoperative treatment with immediate unrestricted active range of motion of the shoulder

The clinical presentation is consistent with a chronic sternoclavicular dislocation, which is defined as being greater than 3 weeks old. The 3D CT image shows posterior displacement of the medial clavicle relative to the sternum. Chronic anterior dislocations are recommended to be treated conservatively, especially if not symptomatic, but as this is a posterior dislocations, current recommendations are to treat them with reduction in order to avoid delayed issues with the medial clavicle interacting with the mediastinal structures.
The review article by Wirth and Rockwood notes the following complications with posterior dislocation: respiratory distress, venous congestion or arterial insufficiency, brachial plexus compression, and myocardial conduction abnormalities. They recommend reconstruction of the costoclavicular ligaments with resection of the medial claviclar head as needed for unstable or symptomatic injuries.

A 35 year-old female presents after prolonged extrication from a motor vehicle collision complaining of severe pelvic pain. Physical examination reveals diminished perianal sensation. She is otherwise neurologically intact. Figures A through D are radiographs and representative CT cuts of her injury. Which of the following nerve roots has likely been injured by the acute trauma?
1) L3

2) L4

3) L5

4) S1

5) S2

The clinical scenario is consistent with a high-energy sacral fracture. The radiographs in figures A and B demonstrate a sacral fracture with posterior displacement of the right hemipelvis seen on the inlet view. Figures C and D are axial and sagittal CT images which show a displaced fracture of the right
hemisacrum along with a transvere fracture component through the S3 body . Diminished perianal sensation is concerning for an S2 nerve root injury.
Mehta et al reviewed the current management of sacral fractures. They note that the S1 and S2 nerve roots are more likely to be injured with sacral fractures as they occupy 1/3 to 1/4 of the neural foramina, as opposed to S3 and S4, which only occupy 1/6 of the neural foramina.
Robles reviewed the current literature to ascertain principles of evaluation and treatment for transverse sacral fractures. The author notes that injury to nerve roots S2 to S5 is manifested by impairment of urinary and anal continence and sexual function.
The first illustration demonstrates the sacral nerve root dermatomal distribution. The second shows a pelvic cadaver dissection demonstrating the sacral nerve roots as they exit the foramina.

A 44-year-old male is struck by a vehicle while riding his bike. In the trauma bay, he complains of right shoulder pain . Upper extremity physical exam reveals no neurologic deficits, and an initial radiograph of the shoulder is shown in Figure A. A CT scan of the shoulder shows 1cm of posterior displacement of the tuberosity fragment. Which of the following is true regarding this injury?
1) It is usually associated with a posterior shoulder dislocation

2) The subscapularis muscle is the main deforming force

3) Non-operative treatment of this displaced injury results in good long term shoulder function

4) Open reduction and internal fixation is the treatment of choice

5) Associated rotator cuff tears are uncommon

The radiograph in Figure A demonstrates a posteriorly displaced greater tuberosity fracture. These injuries are often associated with anterior shoulder dislocations, and concomitant rotator cuff tears. The subscapularis attaches to the lesser tuberosity, and is not a deforming force. Open reduction and internal fixation (ORIF) is usually the treatment of choice, and it is well accepted that more than 5mm of displacement is an indication for surgery in patients that require overhead function of the arm.
Flatow et al evaluated 12 patients who were an average of five years status post ORIF of displaced greater tuberosity fractures. All fractures healed without postoperative displacement. Six patients had an excellent result and six had a good result.
Platzer et al retrospectively analyzed functional and radiographic results of 52 patients with operative treatment of displaced greater tuberosity fractures at an average time of 5.5 years from surgery compared to 9 patients with equivalent injuries treated non-operatively. Evaluation of the results of the surgical study group and the nonoperative control group, patients with reduction and fixat ion of greater tuberosity fractures had significantly better
results on shoulder function than did those with conservative treatment.

Which of the following is a recognized predictor of mortality after hip fracture?

1) American Society of Anesthesiologist (ASA) classification

2) Post-operative weight bearing status

3) Fracture comminution

4) Fixation device used

5) Type of anesthetic used

American Society of Anesthesiologist (ASA) classification is predictive of post-surgical mortality in hip fracture patients.
The ASA classification (detailed in Illustration A) was initially developed in 1963 and has been shown to be predictive of post-surgical mortality in hip fracture patients. Basic categories are as follows: 1= normal, healthy; 2= mild systemic disease; 3= severe systemic disease, not incapacitating; 4= severe incapacitating systemic condition, constant threat to life; 5= moribund patient; 6 = brain dead, organs being donated.
Richmond et al. looked at 836 patients treated for a hip fracture and found that this injury is not associated with significant excess mortality among patients older than age 85. However, in younger patients, those with ASA classifications of 3 or 4 have significant excess mortality following hip fracture that persists up to 2 years after injury.
Holt et al. investigated the relationship between a number of patient and management variables and mortality after surgery for fracture of the hip. Data relating to 18,817 patients were obtained from the Scottish Hip Fracture Audit database. They found that type of anesthetic did not adversely affect the 30 or 120 day mortality rate.

A 25-year-old male sustains an ankle fracture dislocation and undergoes open reduction and internal fixation. He returns to clinic five months following surgery complaining of continued ankle pain and instability with weight bearing. His immediate post-operative AP radiograph is seen in Figure A. Which of the following could have prevented this patient from developing persistent pain?
1) Deep deltoid ligament repair

2) Quadricortical syndesmotic screw fixation

3) Restoration of fibular length and rotation

4) Lateral collateral ligament complex repair

5) Use of two syndesmotic screws

The patient presents with continued ankle pain and instability following open reduction and internal fixation. The radiograph in figure A demonstrates inadequate restoration of fibular length, likely leading to continued tibiotalar instability.
Illustration A demonstrates fibular malreduction with dislocation of the fibula anterior to the tibial incisura. Illustration B shows a comminuted fibula fracture along with a measurement of length from an intact fibula. The arc from the lateral process of the talus to the peroneal groove of the distal fibula is known as the "dime" sign and should remain unbroken if fibular length has been restored. Illustration C demonstrates the use of a push-pull screw and lamina spreader to regain length intraoperatively for a comminuted fibula fracture.
Chu and Weiner review management of malunions of the distal fibula. The authors state that restoration of fibular length, alignment and rotation leads to reduction of the talus, provides a buttress to talar motion in the setting of an incompetent deltoid, and allows the syndesmotic ligaments to heal at the appropriate tension.
Wikeroy et al conducted a study of patients from a prior prospective, randomized control trial comparing different methods of syndesmotic fixation. There was no significant difference in outcomes between tricortical or quadricortical 3.5mm screw fixation, however worse outcomes were seen with associated posterior malleolar fractures, obesity, a difference in sydesmotic width of 1.5mm or greater, and a CT confirmed tibio-fibular synostosis.
Sinha et al present a simple technique for fibular lengthening in the setting of distal fibula malunion. They found high union rates and improved AOFAS scores at short-term follow up with their technique.

A 34-year-old male presents with the right posterior wall acetabular fracture shown in Figure A. What is the most accurate method to test for hip stability in this patient?
1) The Keith method

2) The Moed method

3) The Calkins method

4) Dynamic fluoroscopic examination of the hip under anesthesia

5) A history of associated hip dislocation

Dynamic fluoroscopic examination of the affected hip under anesthesia is considered the best method of predicting hip stability. Fragment size, which can be calculated using the Keith, Moed, or Calkins method, can be used to predict hip stability radiographically, however they are not as accurate. In general it is thought that posterior wall fractures involving less than 20% of the posterior wall are stable, whereas those involving greater than 40%-50% are unstable. Unfortunately, this leaves an indeterminent zone (20-40%) which does not provide guidance in treatment.
Moed et al retrospectively reviewed 33 patients with posterior wall fractures who underwent dynamic fluoroscopic stress testing and compared the results of this testing to the Moed, Calkins, and Keith method of hip stability prediction. They found that the Moed method is the only reliable technique that is predictive of hip stability for small fracture fragments while also being predictive of instability for large fracture fragments. However, they also stated that there remain a substantial number of fractures involving 20% or more of the posterior wall that are both stable and unstable by examination under anesthesia. Therefore, they recommend dynamic fluoroscopic examination for assessment of hip stability in the presence of a posterior wall fracture.
Moed et al in their second paper reviewed all patients with less than a ≤50% of the acetabular wall fracture, adequate imaging, and documented EUA results.
The group looked at multiple variables including fracture fragment size,
superior exit point of the fracture, center-edge angle, acetabular index, Tönnis angle, lateralized head sign, crossover sign, posterior wall sign, ischial spine sign, and hip version. Their conclusion was that no one variable was able to predict stability or instability and they continue to recommend EUA.
Tornetta et al conducted a study in which dynamic fluoroscopic stress views were taken of 41 acetabular fractures that met the criteria for non-operative management to determine subtle signs of instability. Of the 41 fractures, 38 were found to be stable and 91% of these had good or excellent outcomes at
2.7 years. They concluded that dynamic stress views can identify subtle instability in patients who would normally be considered for non-operative treatment.
incorrect answers:
1. > Keith Method - Depth of the fracture segment in injured hip is compared to the contralateral intact posterior wall depth at the level of the fovea
2. > Moed - Depth of the fracture segment in the injured hip is compared to contralateral posterior wall depth at the level of the greatest amount of fracture involvement
3. > Calkins - Length of posterior acetabular arc from each hip is compared at the level of the greatest amount of fracture involvement.

A 23-year-old male is an unrestrained driver in a motor vehicle accident and sustains an unstable pelvic ring fracture. During fluoroscopic-aided fixation, a lateral sacral view is used for proper placement of which of the following fixation methods?

1) Anterior column percutaneous screw placement

2) Posterior column percutaneous screw placement

3) Posterior iliosacral plating

4) Supra-acetabular pin placement

5) Percutaneous iliosacral screw placement

The lateral sacral view is used to place percutaneous iliosacral screws. Sacral alar morphology has been shown to be variable from patient to patient.
Therefore, intraoperative fluoroscopy is recommended. During placement of the screws, the L5 nerve root is at risk.
Routt et al (1997) examined the sacral slope and sacral alar anatomy in cadavers and a series of patients. They determined that the pelvic outlet and lateral sacral plain films provide the best plain radiographic view of the sacral ala. They recommended routine usage of these views intraoperatively to guide screw placement.
Routt et al (2000) reported on the early complications of percutaneous placement of iliosacral screws for treatment of posterior pelvic ring disruptions. While technically challenging, this technique leads to less blood loss and lower rates of infection compared to traditional open techniques.
Barei et al described methods of anterior and posterior pelvic ring disruptions. They determined that successful placement depends on accurate closed reduction, excellent intraoperative fluoroscopic imaging, and detailed preoperative planning. Early treatment decreased hemorrhage, provides patient comfort, and allows early mobilization.

A 23-year-old female is an unrestrained driver in a motor vehicle collision, sustaining the injury shown in Figure A. She subsequently undergoes reduction and percutaneous bilateral iliosacral screw placement. Which of the following is the most likely neurologic complication associated with percutaneous iliosacral screw insertion?
1) Weakness in knee extension

2) Decreased patellar reflex

3) Weakness in great toe extension

4) Weakness in ankle plantar flexion

5) Decreased Achilles reflex

Figure A shows an unstable bilateral pelvic ring injury. Percutaneous posterior iliosacral screw fixation places the L5 nerve root at risk as it courses across the sacral ala. Injury to the L5 nerve root would typically result in weakness in great toe extension and sensory changes on the dorsum of the foot. It is important to notice that L5 often partially innervates tibialis anterior along with L4, so weakness to ankle dorsiflexion may be present as well. Illustration A shows the post-operative films with bilateral iliosacral screws.
Routt et al examined the sacral slope and sacral alar anatomy in cadavers and a series of consecutive patients. They determined that the pelvic outlet and lateral sacral plain films provide the best plain radiographic views of the sacral ala. They recommended routine usage of these views intraoperatively to guide screw placement.
In another study, Routt et al reported on the early complications of percutaneous placement of iliosacral screws for treatment of posterior pelvic ring disruptions. While technically challenging, this technique leads to less blood loss and lower rates of infection compared to traditional open techniques.
Illustration B displays the root diagrams for sensation, reflex, and motor of the L4-S1 nerves.
Incorrect answers:
1: Weakness to knee extension would be caused primarily by an injury to the L4 nerve root.
2: Decreased patellar reflex would be caused primarily by an injury to the L4 nerve root.
4: Weakness in ankle plantar flexion would be caused primarily by an injury to the S1 nerve root.
5: Decreased Achilles reflex would be caused primarily by an injury to the S1 nerve root.

A 20-year-old patient presents after jumping from the window of a burning building with a sacral fracture. Which of the following fracture patterns seen in Figures A through E would give this patient the highest risk of associated nerve injury?
1) Figure A

2) Figure B

3) Figure C

4) Figure D

5) Figure E

Answering this question relies on knowledge of the Denis classification of sacral fractures and their associated risks of nerve injury. Figure A represents a Denis Zone 3 (medial to the foramina) sacral fracture, which has the highest associated risk of nerve injury.
Denis et al outlined a novel classification system of sacral fractures based on the position of the fracture line relative to the sacral foramina. The authors found a 56.7% incidence of nerve injury in fractures that extended medial to the sacral foramina (zone 3), compared with 28.4% for fractures through the
foramina (zone 2), and 5.9% for fractures lateral to the foramina (zone 1).
Mehta et al reviewed the current principles for management of sacral fractures. They note that bowel, bladder and sexual dysfunction occur in 76% of patients with zone 3 sacral fractures.
Illustration A below demonstrates the Denis classification of sacral fractures. Incorrect Answers:

Rheumatoid arthritis is a chronic inflammatory synovitis. The neck is a common site of involvement, after hands and feet. Fortunately, radiographic evidence of instability does not equal neurological deficits. The 3 most common cervical presentations are atlantoaxial subluxation, basilar invagination, and subaxial subluxation. Atlantoaxial subluxation is attributable to an incompetent transverse ligament or erosion of the dens. It is demonstrated by a widened anterior atlantodental interval. Basilar invagination is attributable to cranial settling with the tip of the dens pressing on the spinal cord or midbrain. Subaxial subluxation is attributable to the destabilization of the facet joints.
Basilar invagination symptoms can include posterior headaches, cervical myelopathy, dizziness, and sudden death from compression of the medulla oblongata. In this scenario, there is no subaxial or atlantoaxial subluxation or rheumatoid plaque.
RECOMMENDED READINGS
17. [Fujiwara K, Owaki H, Fujimoto M, Yonenobu K, Ochi T. A long-term follow-up study of cervical lesions in rheumatoid arthritis. J Spinal Disord. 2000 Dec;13(6):519-26. PubMed PMID: 11132984. ](http://www.ncbi.nlm.nih.gov/pubmed/11132984)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/11132984)
18. Boden SD, Dodge LD, Bohlman HH, Rechtine GR. Rheumatoid arthritis of the cervical spine. A longterm analysis with predictors of paralysis and recovery. J Bone Joint Surg Am. 1993 Sep;75(9):1282-
[97/. PubMed PMID: 8408150. ](http://www.ncbi.nlm.nih.gov/pubmed/8408150)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/8408150)
19. [Riew KD, Hilibrand AS, Palumbo MA, Sethi N, Bohlman HH. Diagnosing basilar invagination in the rheumatoid patient. The reliability of radiographic criteria. J Bone Joint Surg Am. 2001 Feb;83-A(2):194-200. PubMed PMID: 11216680. ](http://www.ncbi.nlm.nih.gov/pubmed/11216680)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/11216680)

The primary action of the posterior tibialis tendon is inversion of the foot; secondarily, it plantar flexes the ankle. The anterior tibialis tendon also inverts the foot and only partially antagonizes the posterior tibialis tendon. The primary action of the peroneus longus is plantar flexion of the first ray. It secondarily everts the posterior tibialis tendon. The action of the flexor digitorum longus tendon is synergistic with the posterior tibialis tendon. The primary action of the peroneus brevis tendon is eversion; therefore, it is the primary antagonist of the posterior tibialis tendon.
REFERENCES: Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993, pp 550-551.
Mann RA: Biomechanics of the foot and ankle, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 2-36.

Medial plateau fracture dislocations are rare. Failure to recognize this pattern can lead to poor patient outcomes secondary to poor surgical decision making. Pathognomonic findings on the anteroposterior radiograph include an intact lateral column (lateral articular surface still in continuity with tibial shaft), centrolateral articular impaction, shortening, and condylar widening. The medial femoral condyle stays with the fractured medial tibial plateau segment.
Initial management of axially unstable tibial plateau fractures with soft tissue swelling should consist of spanning external fixation and closed manipulative realignment. This allows for soft tissue recovery with the knee joint provisionally stabilized in reduced station. It also provides time for pre-operative planning, which is typically empowered via a CT scan with reconstructions. If the pattern was initially misdiagnosed as a more typically bicondylar tibial plateau fracture, the CT scan will clarify the misconception and allow for better surgical decision making.
Supine positioning is preferred for definitive fixation, but surgical approaches vary. Attempting to stabilize a medial partial articular pattern in the supine position from a lateral utility approach is fraught with difficulties. Lateral locked plating is not designed for this indication. The lateral utility approach allows for visualization of the centrolateral impaction and lateral meniscal peripheral capsular avulsion repair, but when used alone leads to biomechanically unsound implant placement. The primary plate should be on the medial side of the tibia rather than the intact lateral column.

- Walking boot and weight bearing as tolerated until pain subsides_

DISCUSSION: Labral and chondral lesions are observed within the anterosuperior quadrant of the acetabulum. Tearing of the labrum markedly reduces resistance to joint motion, leading to instability.
The most common associated lesions are chondral injuries. They can occur with or without abnormal bone morphology. The etiology for labral tears can be from traumatic and degenerative causes, structural abnormalities from femoroacetabular impingement, developmental abnormalities, and hip instability.
REFERENCES: Beck M, Kalhor M, Leunig M, et al: Hip morphology influences the pattern of damage to the acetabular cartilage: Femoroacetabular impingement as a cause of early osteoarthritis of the hip. J Bone Joint Surg Br 2005;87:1012-1018.
Ito K, Leunig M, Ganz R: Histopathologic features of the acetabular labrum in femoroacetabular impingement. Clin Orthop Relat Res 2004;429:262-271.
Crawford MJ, Dy CJ, Alexander JW, et al: The 2007 Frank Stinchfield Award. The biomechanics of the hip labrum and the stability of the hip. Clin Orthop Relat Res 2007;465:16-22.

The MRI scans reveal a posterior horn root tear of the medial meniscus. LaPrade and associates found that outcomes after posterior meniscal root 18
repair significantly improved postoperatively and patient satisfaction was high, regardless of age or meniscal laterality. Patients aged <50 years had outcomes similar to those of patients ≥50 years, as did patients who underwent medial versus lateral root repair. In patients undergoing pullout fixation for posterior medial meniscus root tear, Chung and associates (in “Pullout Fixation of Posterior Medial Meniscus Root Tears”) found that patients with decreased meniscus extrusion at postoperative 1 year have more favorable clinical scores and radiographic findings at midterm follow-up than those with increased extrusion at 1 year. Krych and associates found that nonoperative treatment of medial meniscus posterior horn root tears is associated with poor clinical outcome, worsening arthritis, and a relatively high rate of arthroplasty at 5-year follow-up. Reconstruction would have no role in the setting of a reparable meniscal root tear.

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)

DISCUSSION: Recurrence of a ganglion cyst of the tibiofibular joint is most successfully treated by proximal tibiofibular joint fusion. A repeat excision will most likely result in recurrence of the cyst. Total or partial excision may lead to instability of the posterolateral structures of the knee. Interpositional arthroplasty has not been proven to be effective for the treatment of recurrent ganglion cysts of the proximal tibiofibular joint.
REFERENCES: Miskovsky S, Kaeding C, Weis L: Proximal tibiofibular joint ganglion cysts: Excision, recurrence, and joint arthrodesis. Am J Sports Med 2004;32:1022-1028.
Vatansever A, Bal E, Okcu G: Ganglion cysts of the proximal tibiofibular joint review of literature with three case reports. Arch Orthop Trauma Surg 2006;126:637-640.

The clinical photograph reveals a child with amniotic band syndrome or constriction band syndrome. If a band causes an autofusion of the digits without amputation, acrosyndactyly can occur, as demonstrated in the clinical photograph. Typically, a proximal sinus tract with a distal syndactyly is present. Radial deviation of the thumb can be seen most frequently in Apert syndrome. Cardiac anomalies are associated with many congenital upper extremity differences but are not characteristic of amniotic band syndrome. _Ulnar longitudinal deficiency is characterized by hypoplasia or complete absence of the ulna._

Degenerative articular cartilage is characterized by degradation of hydrophilic proteoglycan chains and loss of permeable membrane, leading to increased permeability and lower modulus of elasticity. Although water concentration increases, the flow-dependent fluid support mechanisms become less effective. While overall proteoglycan content decreases, the relative concentration of chondroitin sulfate increases.

Of the possible
hoices, only adult-acquired flatfoot is associated with tarsal tunnel syndrome. The so-called "heel pain triad" includes adult-acquired flatfoot, plantar fasciitis, and tarsal tunnel syndrome, in which failure of the dynamic and static supports of the medial longitudinal arch increase traction on the tibial nerve.
PREFERRED RESPONSE: 1

The history is consistent with a stress fracture. Findings on the plain radiograph are marginal, but the MRI scan shows evidence of stress reaction in the medial neck of the femur (compression side). A lesion on the compression side is not normally at risk for displacement and usually can be managed nonsurgically. A bone scan would further identify the lesion but is not necessary. A skeletal survey and chest radiograph are used in staging a tumor. Radioisotope injection and guided biopsy are sometimes used for osteoid osteomas.
REFERENCES: Boden BP, Osbahr DC: High-risk stress fractures: Evaluation and treatment. J Am Acad Orthop Surg 2000;8:344-353.
Lynch SA, Renstrom PA: Groin injuries in sport: Treatment strategies. Sports Med 1999;28:137-144.

Shaken baby syndrome is associated with chest ecchymosis and head trauma. Retinal
hemorrhages are often found, but are not pathognomonic. Contracoup injury was originally implicated, but more recent evidence shows that the head is actually struck against a hard object that causes a subdural hematoma.
REFERENCES: LeFanu J, Edwards-Brown R: Patterns of presentation of shaken baby syndrome: Subdural and retinal haemorrhages are not necessarily signs of abuse. BMJ 2004;328:767.
Richards PG, Bertocci GE, Bonshek RE, et al: Shaken baby syndrome. Arch Dis Child 2006;91:205-206.

Gerritsen and associates, Hui and associates, and Jarvik and associates compared the effectiveness of surgical versus nonsurgical treatment for the relief of carpal tunnel symptoms. All three studies showed that surgery was superior for the relief of paresthesias and the improvement of grip strength. According to the American Academy of Orthopaedic Surgeons Clinical Guidelines on the Treatment of Carpal Tunnel Syndrome, strong evidence supports the assertion that surgical treatment of carpal tunnel syndrome should have a greater treatment benefit at 6 and 12 months than splinting, NSAIDs, physical therapy, and a single steroid injection. The other choices, including no change in grip strength and
paresthesias, decrease in grip strength and increase in paresthesias, and increase in grip strength and _paresthesias, are not supported by the evidence._

- gravity.