1
Q
techniques to prevent malalignment in tibial nail
A
- lateral blocking screw, posterior blocking screw
- in distal fragment
- blocking screws increase construct stiffness
- lateral start point to prevent valgus
- insertion technique critically important must be parallel to both lateral and anterior cortex
- semi-extended knee position prevents apex anterior or procurvatum deformity
- application of a provisional anterior unicortical plate
- useful to prevent procurvatum and anterior translation of the proximal fragment
2
Q
*Endocrine problems associated with SCFE
A
Hypothyroid
GH deficiency
Panhypopituity
Renal osteodystrophy
3
Q
Stabilizers of the DRUJ
A
- dorsal RU ligament
- volar RU ligament
- IOM
- radial syloid
- ulnar head
- ECU sheath
- pronator quadratus
4
Q
4 risk factors of DVT associated with MRSA ostoemyelitis
A
From yellow article:
CRP > 6 at admission
Surgery
Age > 8
MRSA
from journal of infectious disease 2012
male
5
Q
Release of a Varus knee
A
- osteophytes
- deep MCL
- SemiM, capsule
- superficial MCL
- PCL
- pes anserinus
- pop oblique ligamnet
6
Q
What are the components of the lenke classification
A
Curve Type
Lumbar modifier
Sagittal thoracic modifier
7
Q
3 predictors of successful treatment of UBC with methylprednisone
A
- Large size
- Multi-loculated
- Active lesion
8
Q
Anatomical anomalies in other organ systems that are associated with congential scoliosis
A
- VACTERL
- Vertebral anomalies
- Anorectal Atresia
- Cardiac abnormalities
- TracheoEsophageal fistula
- Renal Abnormalities
- Limb Deformities
- Absent kidney, obstructive uropathy
- Atrial septal defect, patent ductus arteriosus, tetraology of fallot
- Clubfoot, DDH, Spregnels
9
Q
Structures of the shoulder suspensory complex
A
glenoid
acromion
acromioclavicular ligaments
coracoclavicular ligaments
coracoid
10
Q
Motion preserving procedures for SLAC
A
4 corner fusion
Proximal row carpectomy
11
Q
+Changes associated with strength training
A
- results in increased cross-sectional area of muscle due to muscle hypertrophy
- results in increased motor unit recruitment +/- improved synchronization of muscule activity
- maximal force production is proportional to muscle physiologic cross-sectional area
12
Q
What are features suggestive of a structural curve
A
- rotational component
- corrects to >25 deg on lateral bend
- >20 deg kyphosis (T10-L2)
- if no other curve fits this definition the curve with the largest cobb angle is considered structural
13
Q
3 ways to prevent AVN in pediatric nail
A
Trochanteric start point
Lots of fluoro to prevent slipping to fossa
Sharp reamers to prevent reaming out into fossa
14
Q
Important factors for placing trans-articular screws
A
- is the most stable form of fixation and obviates need for postoperative halo immobilization
- Contraindicaitons
- large/medial VA (CT angio)
- nonanatomic reduction C1/C2
- hypoplastic C2 pars
- substatial thoracic kyphosis
- Optimal screw length is 34mm
15
Q
3 Way to fuse C1/2
A
- C1 lateral mass screws / C2 pedicle screw construct - Harms
- C1 lateral mass screws
- C2 pedicle screws - still VA s at risk
- C1-2 transarticular screw placement - Magerl
- is the most stable form of fixation and obviates need for postoperative halo immobilization
- Need to get a CT to check for high riding vertebral artery
- C1-2 wiring techniques
- also used but are considered less stable and are usually treated with postoperative halo immobilization. Wiring techniques include
- Brooke’s technique
- Gallie’s technique
16
Q
Considerations for DDH THA
A
- Acetabulum
- smaller cup
- smaller cup means smaller head
- superior migration, false acetabulum
- loss of anterior/superior and lateral coverage
- Augment with screw fixation
- Augment with implant augments
- Offset-bore components are available that change the position of the head in the poly to reduce risk of instability
- smaller cup
- Femur
- Previous surgeries
- Loss of canal
- Anteversion of neck
- May need to shorten
- Soft tissue changes associated with superior migration
- Abductors become transverse
- Psoas and capsule hypertrophy
- Adductor, rectus and hamstring shortening
17
Q
3 anatomical landmarks for the femoral component of TKA
A
- Whitesides (90 to)
- Epicondylar axis
- Posterior condylar axias (ER 3 degrees)
18
Q
How does a pediatric patient differ regarding trauma ressuciation
A
- large head - spine board cutout
- higher cervical injury with neuro damage
- higher C1-3 injury
- spleen and liver outside rib cage
- lower blood volume - high HR, low BP
- higher porportional surface area - hypothermia
- elastic rib cage - more thoracic trauma
- strong ligaments; weak bones - low chance of pelvic ring injury
- anterior trachea - no need for cuff in ETT
19
Q
Three biomechanical effects of the Latarjet (3)
A
- Sling concept from conjoint tendon
- De-function pec minor
- Bony block increases articular arc
- Capsular reinforcement
- Bony autograft for defect
20
Q
4 components of the syndesmosis
A
Anterior-inferior tib-fib ligament
Posterior-inferior tib-fib ligament
Intraosseous membrane
Intraosseous ligament
Inferior Transverse ligament (with PITFL)
21
Q
Differential diagnosis for lytic lesion in the proximal phalanx
A
- enchondroma
- ABC
- GCT
- UBC
- brown’s tumor
- EG
- infection
- NOF
22
Q
3 ways to avoid varus in a subtroch femur fracture
A
Medial start point: Nail will not reduce your fracture
- Piriformis entry nail
- Lateral nailing
- Abduct the body
Clamp or k-wire the reduction
Fixed angle plate (95 blade or PFLP)
23
Q
Long term complications of radiation for sarcoma treatment
A
Sarcoma
Pathological fracture
Joint contracture
Muscle atrophy
Limb length discrepancy
24
Q
Prognosis of poor predictors of Type II Odontoid
A
> 5 mm displacement (>50% nonunion rate)
fx comminution
angulations > 10 degrees
age > 50 years
delay in treatment
25
Risk factors for neurological deterioration of vertebral OM
* elderly
* diabetes
* MRSA (aggressive pathogen)
* associated abcess
* cervical level
* late diagnosis
26
Changes that muscles undergo during endurance training
* **contractile muscle adapts by increasing energy efficiency**
* increases in _mitochondrial size, number, and density_
* _increases in enzymes involved in Krebs cycle_, fatty acid processing, and respiratory chain
* over time, _increased use of fatty acids \> glycogen_
* over time, _oxidative capacity of Type I, IIA, and IIB fibers increase_
* _percentage of more highly oxygenated IIA fibers increases_
* Aerobic Threshold: level of effort at which anaerobic energy pathways become significant energy producer
* Anaerobic (lactate) Threshold: level of effort at which lactate production \> lactate removal
27
\*False positive for Thesaly test
Multiple knee injuries
Hx of knee surgery
OA
Articular cartilage injuries
Neurodegenerative disorders
28
\*Stages of perilunate dislocation
SL disruption (ligament vs. transscaphoid)
Lunocapitate disruption
Lunotriquetrial disruption
Lunate dislocation
29
What are you blocks to reduction in DDH (7)
psoas
**adductor tendon**
**labrum**
**capsule**
**hypertrophied teres**
**pulvinar**
**transverse acetabular ligament**
30
What are the 4 types of neural tube defects
* **spinal bifida oculta**
* defect in vertebral arch with confined cord and meninges
* **meningocele**
* protruding sac without neural elements
* **myelomeningocele**
* protruding sac with neural elements
* **rachischisis**
* neural elements exposed with no covering
31
Describe requirements of informed consent?
1. Competent patient
2. Disclosure of all relevant risks and alternative
3. Free or coercion/voluntary
32
Abnormalities associated with the spinal anatomy in dysplastic spondylolisthesis
hypoplastic facets
maloriented facets
sacral beaking
abnormal pars development (leads to elongation and slippage)
33
Name five modifiable risk factors (non-medication) for osteoporosis
1. Smoking
2. Impact exercise
3. Diet high in calcium 1-1.2g/day and vitamin d/sunlight exposure
4. EtOH - \> 2 units/day
5. Low BMI
6. Estrogen deficiency
34
Etiology of groin pain after THA
* infection
* psoas impingement
* aseptic loosening
* stress fracture
* pseudotumor
* GT impingement
35
\*Risk factors for femoral neck fracture in hip resurfacing?
notching of the femoral neck
osteoporotic bone
large areas of pre-existing osteonecrosis
femoral neck impingement (from malaligned acetabular component)
female sex
varus positioning of femoral component
36
\*Complications associated with tibial tuberosity fixation?
* **Recurvatum deformity**
* more common than leg length discrecancy
* growth arrest anteriorly as posterior growth continues leading to decrease in tibial slope
* **Compartment syndrome**
* related to injury of anterior tibial recurrent artery
* **Loss of range of motion**
* **Bursitis**
* due to prominence of screws and hardware about the knee
* **Skin Necrosis**
37
Radiologic assessment of femoral shaft fracture reduction (3)
1. LT contour compared to uninjured side
2. Cortical width/diameter
3. Cortical thickness
4. C- arm true lateral of femoral neck and other with posterior condyles aligned (differences in inclination of the position of the C-Arm reflects angle of anteversion of femoral neck)
5. Post op CT scan - femoral malrotation using limited cuts through proximal and distal femurs (femoral neck and posterior condyles)
6. Compare lines tangential to these to assess rotation
38
Risk factors for SMA syndrome following scoliosis
* Smaller (shorter, weight less)
* Rigid curve on lateral bend
* Lenke lumbar modifier B, C
* Staged procedure
* Low BMI
39
\*Classes of Shock (Usually specifically about class IV)
* **I
* * BP normal
* \> 30 mL/hr
* HR normal
* Anxious**
* **II 15% to 30%**
* (750-1500ml)
* \> 100 bpm
* BP normal
* 20-30 mL/hr
* pH normal
* confused, irritable, combative
* **III 30% to 40%**
* (1500-2000ml)
* \> 120 bpm
* decreased BP
* 5-15 mL/hr urine
* acidoditc
* lethargic
* **IV \> 40% (life threatening)**
* (\>2000ml)
* \> 140 bpm
* decreased
* negligible uring
* acidotic
* coma
40
Conditions associated with dural ectasia
* Marfans
* Neurofibromatosis
* Ehuler Danlos
* Osteogenesis Imperfecta
* Ankylosing Spondylitis
41
Relative contraindications to total joint arthroplasty?
Neurologic disorder
Previous infection (osteo)
Neuropathic
Poor medical status
Dementia
42
Complications of OM in a pediatric patient
* **DVT**
* is an infrequent complication
* _risk factors_
* CRP \> 6
* surgical treatment
* age \> 8-years-old
* MRSA
* Meningitis
* **Chronic osteomyelitis**
* **Septic arthritis**
* **Growth disturbances**
* **Limb-length discrepancies**
* may result in gait abnormalities
* **Pathologic fractures**
43
\*Determinants of skeletal growth remaining
* * **Tanner stage (**
* **Risser Stage (0-1)**
* Risser 0 covers the first 2/3rd of the pubertal growth spurt
* correlates with the greatest velocity of skeletal linear growth
* **open triradiate cartilage**
* **open olecranon physis**
* **timing of menarche**
* **hand XR**
44
Varus malunion in femoral neck fracture, clinical findings?
* Decreased ROM
* LLD
* Abductor lurch
* Trendelenburg sign
* Prominent GT
45
What are radiological risk factors for development of SCFE
* Posterior slope angle \>14
* vertical physis
* retroverted head
* protrusio
46
\*4 things that lead to bad prognosis in pediatric radial head fracture
* Open management
* Internal fixation
* AVN
* Synostosis
* \> 3 mm translation
* \>45 angulation
* Malunion
*
47
Risk factors for radioulnar synostosis
Comminution
Proximal third of both bones
Same level fractures
IOM injury
Severe soft tissue disruption
Head injury
Boyd approach
Delayed management
Bone in IO space
Onlay graft
Hardware in IO space
48
\*Measures of adequate resusitation
* MAP \> 60
* HR
* urine output 0.5-1.0 ml/kg/hr (30 cc/hr)
* **serum lactate levels**
* most sensitive indicator as to whether some circulatory beds remain inadequately perfused (normal
* gastric mucosal ph
* base deficit
* normal -2 to +2
* pH
49
What are the components of the DRUJ?
* **TFCC made up of**
* dorsal and volar radioulnar ligaments
* deep ligaments known as ligamentum subcruatum
* central articular disc
* meniscus homolog
* ulnar collateral ligament
* ECU subsheath
* origin of ulnolunate and ulnotriquetral ligaments
* **DRUJ Stability - TFCC has elements that converge to this, so you need to repair it first when you have instability**
* Primary - moves in the direction of the palm
* One will act as a buttress, one will act as a check rein, so we don't really know which one is more important
* _volar radioulnar ligaments_
* volar translation
* supination
* _dorsal radioulnar ligaments_
* dorsal translation
* pronation
* _trigangular fibrocartilage_
* Secondary
* ulnar head
* sigmoid notch
* interosseous membrane
* pronator quadratus
50
Radiographic evidence of syndesmotic injury
medial clear space \> 4mm
tib-fib clear space \> 6mm
tib-fib overlap
51
Spinal findings in achondroplasia
* **lumbar spinal stenosis**
* caused by short pedicles
* most likely to cause disability
* **thoracolumbar kyphosis**
* may cause neurologic symptoms
* **foramen magnum and upper cervical stenosis**
* may cause periods of apnea
52
Three ways to avoid patellar maltracking
* Avoid internal rotation of the femoral prosthesis
* use the transepicondylar axis
* use the posterior condyles with 3 deg ER
* lateralization of the femoral component
* internal rotation of the tibial prosthesis
* medial 1/3 of the tibial tubercule is your landmark
* placing the patellar prosthesis lateral on the patella
53
anatomic reasons for pseudosubluxation
* horizontal facets
* hyperlaxity
* poor motor control
54
4 non-skeletal features of fibrous dysplasia
* **Commonwith polyostotic**
* _Hyperthyroidism_
* _Hypophosphatemia_
* _Acromegaly_
* _hyperprolactinemia_
* Café au lait spots (McCune Albright - coast of maine)
* Precocious puberty (McCune Albright)
* Eye deviation and blindness (Chereubism)
* Cranial abnormalities (Chereubism)
55
4 types of SLAP tears
* I - Labral and biceps fraying, anchor intact
* II - Labral fraying with detached biceps tendon anchor
* III - Bucket handle tear, intact biceps tendon anchor (biceps separates from bucket handle tear)
* IV- Bucket handle tear with detached biceps tendon anchor (remains attached to bucket handle tear)
* V - SLAP lesion and anterior labral tear (Bankart lesion)
* VI- Superior flap tear
* VII- SLAP lesion with capsular injury
56
\*3 causes for RA patient not to extend 4/5th digits
* Caput Ulnae Syndrome
* Vaughn- Jackson Syndrome (attritional rupture of EDQ only)
* MCP dislocation
* Sagital band attenuation
* PIN palsy
57
Describe the leadbetter maneauver
* Flex the hip to 90, pull axial traction
* relaxes hip musculature
* IR to 45 degrees
* relaxes Y ligament
* Extend and slightly abduct the hip maintaining IR and traction
58
Principles of medical ethics
* **Respect for autonomy** - the patient has the right to refuse or choose their treatment
* **Beneficence** - a practitioner should act in the best interest of the patient
* **Non-maleficence** - "first, do no harm"
* **Justice** - concerns the distribution of scarce health resources, and the decision of who gets what treatment (fairness and equality)
* **Respect for persons** - the patient (and the person treating the patient) have the right to be treated with **dignity.**
* **Truthfulness and honesty** - the concept of informed consent has increased in importance since the historical events of the Doctors' Trial of the Nuremberg trials and Tuskegee syphilis experiment.
59
\*4 long term complications of radial head fracture in adults
* Elbow stiffness
* Heterotopic Ossification
* Concurrent injury
* Recurrent surgery
* Delay to surgery
* Prolonged immobilization
* PIN Palsy
* Ulnar nerve injury
* Infection
* Instability
* Elbow OA
* Fracture displacement
60
Borders of the triangular space
long head triceps
teres major
teres minor
61
This healthy patient had a fall from height onto a plantar-flexed foot. What are the key things you need to look for on XR?
**five critical radiographic signs that indicate presence of midfoot instability**
1. disruption of the continuity of a line drawn from the medial base of the second metatarsal to the medial side of the middle cuneiform (diagnostic of lisfranc)
2. widening of the interval between the first and second ray (may see a _fleck sign_ diagnosic of lisfranc)
3. medial side of the base of the fourth metatarsal does not line up with medial side of cuboid on oblique view
4. metatarsal base dorsal subluxation on lateral view
5. disruption of the medial column line (line tangential to the medial aspect of the navicular and the medial cuneiform)
*Don't forget WB or stress veiws if you have concerns and there is nothing obvious on XR*
62
Structures of the PLC
* **Static structure** - is what you will reconstruct during injury
* LCL
* Attaches 8mm behind the most anterior fibula
* Politeus tendon with popliteofigular ligament
* Inserts 18.5mm distal, anterior and underneath LCL on the tibia
* Popliteofibular ligament
* Lateral capsule
* Arcuate ligament
* Fabellofibular ligament
* **Dynamic**
* Biceps femoris (inserts posterior to LCL on fibula)
* Popliteus
* Iliotibial tract
63
3 ways to assess adequate femoral neck reduction
* Restoration of Shenton’s line
* S- curve on all views (head-neck jxn) – never a c-curve (Rockwood and Green’s)
* Garden Alignment Index (Rockwood and Green’s)
* AP: medial trabeculae:medial femoral cortex 155-180 degrees
* Lateral: central trabeculae in head:neck 155-180 degrees
64
+Deformities associated with CAM (radiographic)
decreased head-to-neck ratio
aspherical femoral head
decreased femoral offset
femoral neck retroversion
65
Indications for scaphoid ORIF
* Proximal pole fracture
* Displaced scaphoid fractures
* 1 mm displacement
* SL angle \> 60
* RL angle \> 15
* Intrascaphoid angle \> 35
* Associated perilunate
* Multipy injured patient
* Comminution
* DISI \> 15 degrees
66
Describe mechanism of proximal tib-fib dislocation. Features on exam, reduction mechanism and treatment?
* **Mechanism:** Twisting of flexed knee (athletic injury)
* **Physical Exam:**
* Prominent lateral mass
* Pain worse with ankle DF (proximal fibular migration)
* Pain worse with knee extension
* Examine stability at 90 degrees (relaxes LCL)
* Translation of prox fibula
* Peroneal nerve
* Ankle exam
* LCL and PLC instability to rule out other injuries
* **Closed Reduction:**
* Flex btw 80-110 to relax LCL
* Reduce opposite direction of dislocation
* immobilize for 3 weeks (controversial)
* **Open Reduction**:
* Screw with repair of joint capsule
* immobilize for 6 weeks
* remove in 12 weeks
* **Chronic Dislocation**
* usually non-op with activity modificaiton and strap
* arthrodesis with mid-fibular resection is an option in older patients
* attempts have been made to use the IT or biceps to create a sling for the head of the fibula
* Results are improved with LCL/PLC pathology and repair
## Footnote
*Note that actue and chronic entities are two seperate issues and should be treated differented. The IT band can be use*
67
Anatomy of the DRUJ with scope
* Fibrocartilage
* can debride 80% without causing instability
* Radial and ulnar insertions of the radioulnar ligaments
* can stress them and assess for instability
* ECU sheath?
* sometimes used to teather a TFCC repair to
68
Deformities associated with Pincer - descriptive, not measurements
anterosuperior acetabular rim overhang
acetabular retroversion
acetabular protrusio
coxa profunda (deep socket)
69
Reasons for lack of extension post-op ACL
* lack of extension pre-op
* post-op arthrofibrosis
* cyclops lesion
* anterior tibial tunnel placement
* tighten in flexion
70
Measurements indicating normal c-spine alignment
* **Lateral view**
* Basion Dens Interval (BDI)
* Anterior spinolaminar line
* Drawn from opisthion to C1 arch, should pass C1/C2
* ADI
* Posterior cortex of atlas should be parallel to anterior cortex of axis
* SAC \> 13mm
* **Open mouth**
* Joint articulations should be
* Combine overhang
71
What are 4 major and 4 minor criteria for fat emboli syndrome
* **Major (1)**
* hypoxemia (PaO2
* CNS depression (changes in mental status)
* petechial rash
* pulmonary edema
* **Minor (4)**
* tachycardia
* pyrexia
* retinal emboli
* fat in urine or sputum
* thrombocytopenia
* decreased HCT
* **Additional**
* PCO2 \> 55
* pH
* RR \> 35
* dyspnea
* anxiety
72
\*4 ways to tell the difference bettween transient synovitis and septic OA
Temp \> 38.5
WBC \> 12
CRP \> 20
ESR \> 40
Refusal to WB
5 predictors à 98% septic
4 predictors à 93% septic
3 predictors à83% septic
73
Indications for fixation of the proxiaml humerus
* **Acceptable Alignment**
* * *
* **absolute indications**
* _floating elbow_
* _open fx_
* _vascular injury_
* _intraarticular fractures_
* **relative indications**
* bilateral humerus fx and other polytrauma (allows full weight bearing on humerus)
* failure of closed treatment
* segmental fractures
* polytrauma
* brachial plexus injury (allows earlier rehabilitation)
* post-reduction new-onset radial nerve palsy
* pathologic fractures
* neuromuscular conditions
74
Indications for hemiepiphyseodesis in congential scoliosis
* intact growth plates on the concave side
* patients less than 5 yrs
*
75
Important factors regarding periprothetic # of the hip
* fracture location
* stability of prosthesis
* bone loss
* rule out infection
76
4 risk factors of progression of degenerative spondylolisthesis
## Footnote
african americans
Diabetics
woman over 40 years of age
transitional L5 with saggital facets
77
4 stabilizers of the AC joint
1. AC ligament
2. CC ligament
3. Capsule
4. Deltoid and Trapezius
78
Complications of doing an ankle ORIF in diabetic
* Loss of fixation
* Wound infection
* Non-union
* Amputation
* delay to union
79
Non-operative treatment of carpal tunnel syndrome
NSAIDs
Nighttime bracing
activity modification
Cortisone injections
U/S
80
\*\*Name 8 steps in the WHO pre-operative checklist
5 most important
* procedure
* limb
* allergies
* antibiotics
* critical events
81
\*What are the ASIA dermatomes and myotomes
82
Classificaiton of congential kyphosis?
I - Failure of formation
II - Failure of segmentation
III - Mixed
*types I and III are at higher risk of neurological invovlement and progression*
83
\*What is important for staging Ewings?
* plain radiographs and MRI of the primary site
* CT chest - pulmonary mets
* Bone Scan - skip lesions, boney mets
* Bone marrow biopsy
* ESR, CRP, LDH/ALP
84
4 components of the WOMAC
Pain
Function
Stiffness
Global Scale
85
What are complications assoicated with hemophilia
* infection
* post-op hemarthrosis
86
knee ligaments, weakest to strongest
LCL (700 N)
ACL (2200 N)
PCL (2500 N)
MCL (4000 N)
87
Four benefits of high offset of THA
* Tensions abductors (decrease trendelenburg)
* Increased stability
* Decreased impingement
* decreased joint reaction force
* moves abductor moment away from center of rotation
* increase abductor moment arm
* reduces abductor force required for normal gait
88
Causes for lack of flexion post-op TKA
* number one predictor of post-op motion is pre-op motion
* **no tibial slope to tibial component**
* **oversized femoral component**
* **patella baja/raised joint line**
* **tight flexion gap**
* **arthrofibrosis**
* **lack of compliance with PT**
* **post-op complication (DVT, infection)**
89
\*4 techniques to fix and ACL in 11yo female
* IT Band Reconstuction (extra-articular)
* over the top
* Complete transphyseal
* small tunnels, verticle tunnels
* sharp drills, don't burn the bone
* one pass
* Transphyseal (Tanner 1-4)
* Partial
* All Epiphyseal (Tanner 1-3)
* Anderson
* All-inside
90
\*List complications of malpositioning of the acetabular cup
Instability
Poly wear
Cup spin out (loosening)
Osteolysis
Impingement
Pain
91
Formula for pelvic incidence
PI = PT + SS
92
6 biological capabilites for a tumor to metastasize
1. Evading apoptosis
2. Self-sufficiency in growth signals
3. Insensitivity to anti-growth signals
4. Tissue invasion and metastasis inactivation
5. Limitless replicative potential
6. Sustained angiogenesis
93
sites of radial nerve compression after is passes threw the septum
fibrous bands
leash of henry
ECRB
arcade of froshe
distal supnator
94
\*C-Spine Pathology in downs
Higher than sex match, healthy children
* **C1-2 Pathology** (assessed with observed flex-ex and ADI measurement)
* Atlantoaxial instability
* Os odontoideum
* persistent dentocentral synchondrosis of C2
* spina bifida occulta of C1
* ossiculum terminale
* **Atlano-occipitial instability** (assessed with powers ratio)
95
What are normal findings in pediatric C-spine imaging?
* **prevertebral swelling of adjacent vertabral width**
* **smooth contour lines** of
* anterior vertebral bodies
* posterior vertebral bodies
* spinolaminar line (inside lamina)
* tips of spinous process
* **parallel facet joints**
* **normal retropharyngeal space**
* * * retrotracheal space
* **atlanto-dens interval**
* **absent vertebral body wedging**
* 7% of normal children have a wedge shaped C3 vertebral body
* **absence of of cervical lordosis**
* loss of cervical lordosis may be found in 14% of normal children
* **C2-3 or C3-4 pseudosubluxation
* considered normal as long as the posterior laminar line is contiguous**
96
Risk factors for progression of congential kyphosis
*Lovell and WInter - Congenital Kyphosis*
* Rapid growth periods
* 0-3 yo
* adolesence
* Type 1 - Failure of formation
* Type 2 - Mixed
**Treatment**
* No role for bracing
* * posterior fusion alone
* allows some correction with growth
* \>60 deg
* anterior and posterior fusion
* be careful with pre-op halo or attempts at correction because there is a high risk of neurological complication
97
Describe push up test for PLRI (2)?
Patient prone on floor in push up position, elbow flexed to 90 degree, forearms supinated and shoulder abducted slightly wider than push up position Patient attempts to push up using arms, patient will experience apprehension with terminal extension, guarding or dislocation are considered positive Similar idea to lateral pivot shift test --\> Supine with affected arm overhead - forearm supination and the arm is taken from extension to flexion - radial head reduces with flexion
98
List evidence for pseudosubluxation
* C2 with-in 1.5mm of Swischuk's line
* corrects with extension
* no anterior swelling
* no initiating trauma
99
3 ways to identify spinal cord injury in deformity correction
- MEPS
- SSEP
- Wake up test
- Clonus
100
Clinical and radiographic features that suggest C-spine instability?
* **Clinical**
* ****neck pain
* midline tenderness
* pain with rotation/flexion
* neurological findings
* **Subtle changes on XR******
* soft-tissue swelling
* hypolordosis
* disk-space narrowing or widening
* widening of the interspinous distances
101
Aspects of informed consent
* Nature of the procedure
* Reasonable alternatives to the proposed intervention
* Relevant risk/benefits, uncertainties related to each alternative
* Assessment of patient understanding
* Acceptance of the intervention by the patient
102
\*3 things that enhance in the spine with gad
Scar tissue
Infection
Tumors (most)
103
\*Pathology of cavus foot in adults
* **Neurologic**
* Hereditary motor and sensory (CMT)
* Cerebral palsy
* After effects of cerebral injury (stroke)
* Anterior horn cell disease (spinal root injury)
* Spinal cord lesions
* **Traumatic**
* Compartment syndrome
* Talar neck malunion
* Peroneal nerve injury
* Knee dislocation (neurovascular injury)
* **Residual clubfoot**
* **Idiopathic**
104
What is the criteria for causation
* **ACCESS PTB**
* **Analogy:** The effect of similar factors may be considered.
* **Consistency:** Consistent findings observed by different persons in different places with different samples strengthens the likelihood of an effect.
* **Coherence:** Coherence between epidemiological and laboratory findings increases the likelihood of an effect. However, Hill noted that "... lack of such [laboratory] evidence cannot nullify the epidemiological effect on associations"
* **Experiment:**"Occasionally it is possible to appeal to experimental evidence"
* **Strength:** A small association does not mean that there is not a causal effect, though the larger the association, the more likely that it is causal
* **Specificity:** Causation is likely if a very specific population at a specific site and disease with no other likely explanation. The more specific an association between a factor and an effect is, the bigger the probability of a causal relationship
* **Plausibility:** A plausible mechanism between cause and effect is helpful (but Hill noted that knowledge of the mechanism is limited by current knowledge)
* **Temporality:** The effect has to occur after the cause (and if there is an expected delay between the cause and expected effect, then the effect must occur after that delay).
* **Biological gradient:** Greater exposure should generally lead to greater incidence of the effect. However, in some cases, the mere presence of the factor can trigger the effect. In other cases, an inverse proportion is observed: greater exposure leads to lower incidence
105
Negative prognostic factors in osteosarcoma
High LDH
High ALP
Mets at presentation
Axial skeleton location
Lymph node involvement
Vascular involvement
Positive margins
106
Imaging required for FAI and associated radiological signs
* **Imaging**
* **AP pelvis**
* ****centered between pubis and ASIS, hips in 15 IR
* make sure to rule out OA
* Adequate
* equal obturator, iliac wing
* coccyx 2cm above symphisis
* **45deg Dunn lateral**
* best to look at alpha angle
* **Cross table lateral, frog-leg**
* assess anterior head-neck junction
* **Cam deformity (pistol grip)**
* _Alpha angle \>55_ on dunn
* _Head-neck offset \> 8mm_ on Dunn
* **Pincer deformity**
* _Protrusio_ - femoral head projects medial to ischioilial line
* ****Retroversion
* _cross over sign_
* _posterior wall sign_
* _ischial spine sign_
* ****Overcoverage
* _tonnis angle_
* _CEA \> 40_
107
Indications and Contraindications to HTO
* **Indications**
* medial compartment arthrosis
* knee instability
* medial compartment overload following meniscectomy
* osteochondral lesions requiring resurfacing procedures.
* **General contraindications**
* inflammatory arthritis
* obese patient BMI\>35
* flexion contracture \>15 degrees
* knee flexion
* procedure will need \>20 degrees of correction
* patellofemoral arthritis
* ligament instability
* varus thrust during gait
108
Three clinical findings in diagnosis of ankylosing spondylitis.
1) Decreased chest expansion less than 1 cm
**2) Sacroiliitis (FABER test)**
**3) Uveitis (Anterior iritis/Uveitis)**
4) Progressive kyphotic deformity (Chin brow vertical angle 30 degrees)
5) Decreased spine motion (Schober test)
6) Large joint OA
7) Enthesitis
8) Renal amyloidoss
**9) HLA B27 (Diagnostic criteria with SI inflammation/Uveitis**
109
Orthopedic and non-orthopedic association with marfans
* **orthopaedic conditions**
* Arachnodactyly
* scoliosis (50%)
* protrusio acetabuli (15-25%)
* ligamentous laxity
* recurrent dislocations (patella, shoulder, fingers)
* pes planovalgus
* **nonorthopaedic conditions**
* cardiac abnormalities
* aortic root dilatation
* possible aortic dissection in future
* _Most lethal consequence_
* May require prophylatic surgery to repair if \> 5cm
* mitral valve prolapse
* requires pre-op echo
* superior lens dislocations (60%) (ectopia lensitis)
* diagnose with slit lamp
* Mypoia
* Glaucoma
* cataracts
* pectus excavatum
* spontaneous pneumonthoraces
* dural ectasia (\>60%)
* Meningocele
110
\*Indications for CRPP of a pediatric distal radius fracture
* SH3 and 4
* BBFF \> 10 yrs
* Failure to maintain reduction closed
* 30deg
* \>9yo and \>20deg
* floating elbow
* compartment syndrome or excessive soft tissue damage
*
111
Differential Diagnosis for DRUJ pain
DRUJ instability or arthritis
TFCC tear
LT ligament tear
pisotriquetral arthritis
ECU tendonitis or instability
112
Indications for a hemiresection arthroplasty of the DRUJ
- DRUJ OA
- DR Malunion
- unconstructable ulnar head fracture
- RA DRUJ
113
Mirel's criteria
114
4 symptoms of post-tourniquette syndrome
Pain
Stiffness
Numbess
Pallor
Paresis
115
Advantages of uses locking plate over DCS compression plate in a distal femur fracture
* Locks to plate - better varus control
* Better control of comminution with multiple points of fixation
* Lock or compress as needed
* Less invasive insertion, less tissue disruption
* Has the versatility to use around TKA
Aside: 38% coronal plane fractures in all supracondylar femur fractures (L\>M)
116
\*Risk factors associated with short term mortality after hip fracture?
* male gender
* partially dependent functional status
* totally dependent
* dyspnea
* congestive heart failure
* serum sodium \>145
* WBC \>11
* INR \>1.3
* resident involvement
* dirty wound
* ASA class 3
* ASA class 4
117
5 concerning conditions for fixing achilles
Smoking
Steroids
Female
Diabtes
Obesity
118
Deformity associated with madelung's
* Pathology
* volar-ulnar tethering of radio-lunate ligament = vicker's ligament
* **Clinical**
* bilateral
* volar hand
* ulnar hand
* dorsal prominence ulnar wrist
* **Radiological**
* pyramidalizaiton of carpus
* narrowing of ulnar distal radius physis
* anterior bowing of the radial shaft
* dorsal subluxation of ulnar head
* **Radiological diagnosis**
* volar tilt
* lunate subsidence
* lunate fossa angle
* palmar carpal displacement
119
In a patient with trendelenberg gait what will you find on physical exam?
1. Non affected (contralateral) pelvis will sag inferiorly on single leg stance of affected limb
2. Weak abduction of hip to resistence
Possible weak dorsiflexion/ehl due to L4/L5 nerve injury Body may leave to weak side to help COG
120
List the 7 components of canmeds
“Please Help Me Memorize Stupid Canmeds Crap”
Professional
Health advocate
Medical expert
Manager
Scholar
Communicator
Collaborator
121
Swan neck deformity in RA patient
* Volar plate rupture
* MCP joint volar subluxation (rheumatoid arthritis)
* mallet finger
* FDS laceration
* intrinsic contracture
122
Mechanisms of action of BMP
* **Induce mesenchymal differenction to osteoblasts**
* **Active osteoblasts to lay down bone**
* _Mechanism_
* leads to bone formation
* activates mesenchymal cells to transform into osteoblasts and produce bone
* _Signaling Pathways and Cellular Targets_
* BMP targets undifferentiated perivascular mesenchymal cells
* activates a transmembrane serine/threonine kinase receptor that leads to the activation of intracellular signaling molecules called SMADs.
* SMADS are primary intracellular signaling mediators
* currently eight known SMADs, and the activation of different SMADs within a cell leads to different cellular responses.
123
What are complications of IM nail in hemi-lithotomy position?
* Well leg compartment syndrome
* Nerve injury (Pudendal 2-27% - this is a problem - ED)
* Fracture malalignment (3.5x risk of being IR)
* Skin and soft tissue injury (peroneal area)
* Crush syndrome (lateral position with thigh crushed against bed by the post)
124
Landmarks for wrist scope portals
* **Radiocarpar Portals**
* _3-4_
* Located just distal to Lister tubercle, between _EPL and EDC_
* Established first, primary viewing portal
* _4-5_
* Located in line with ring finger metacarpal, between _EDC and EDM_;
* Portal for instrumentation, visualization of TFCC
* _6R_
* Located just _radial to ECU tendon_;
* Primary adjunct for visualization and instrumentation, ulnar-sided TFCC repairs
* **Dorsal sensory branch of ulnar nerve**
* 6U
* Located just _ulnar to ECU tendon_;
* Primary adjuct for visualization and instrumentation, ulnar-sided TFCC repairs
* **Dorsal sensory branch of ulnar nerve**
* _1-2_
* Located between _APL and ECRB_, along dorsal aspect of snuffbox;
* Not often utilized, provides access to radial styloid and radial aspect of joint, sometimes used for inflow
* **Superficial branch of radial nerve; Radial artery**
* **Midcarpal Portals**
* MCR
* Located _1 cm distal to 3-4_ portal along axis of radial border of middle finger metacarpal, between _ECRB and EDC_.
* Allows visualization of scapholunate, scaphocapitate, and scaphotrapezoid joints.
* MCU
* Located _1 cm distal to 4-5_ portal along axis of ring finger metacarpal, between
* Allows visualization of lunocapitate, lunotriquetral, and triquetrohamate joints.
* STT
* Located along axis of index finger metacarpal just _ulnar to EPL_ at level of STT joint
* Allows visualization of scaphotrapezial and scaphotrapezoid joints.
* **First CMC Joint**
* _1U_
* Located on _ulnar aspect of EPL_ at level of first CMC joint (basal joint)
* Allows diagnosis of DJD of first CMC joint and arthroscopic debridement.
* **Superficial sensory branch of radial nerve**
* _1R_
* Located on _radial aspect of EPL_ at level of thumb CMC joint, just volar to APL tendon
* Allows diagnosis of DJD of first CMC joint and arthroscopic debridement.
* **Superficial sensory branch of radial nerve**
125
6 Reasons for revision of TKA
* Infection
* Instability
* Patellofemoral malalignment
* Stiffness
* Extensor mechanism failure
* Poly Wear/Osteolysis/Aspetic loosening
* Fracture
* PCL Failure
126
Poor prognostic factors associated with septic OA
* age
* associated osteomyelitis
* hip joint (versus knee)
* delay \>4 days until presentation
* MRSA
127
\*Features of central cord syndrome
Most common incomplete cord injury, usually in elderly with hyperextension injury and pre-existing pathology
## Footnote
**Painful dysthesias**
**UE\>LE**
**distal \> proxiaml**
**Sacral sparing**
128
Complications of performing an open repair of achilles tendon rupture
* Wound dehisence
* Deep Infection (smoking)
* Sural nerve
129
4 patient factors associated with cuff re-tear
\> 65
Diabetes
Smoking
Non-compliance with PT
130
\*3 advantages of coning down an XR
* **Coning**
* ****'Cone' that removes the periphery from the feild
* helps to reduce the scatter and the effective penumbra
* **Advantages**
* Decreased rads to patient
* reduces volume of tissue irradiated
* Decreased rads to staff
* Improved focus
131
Stages of muscle repair
* Hematoma
* Regeneration
* Fibrosis/tissue remodelling
132
\*3 ways to treat CVT minimally invasive
Serial casting
Perc pin fixation
Perc Achilles tenotomy
133
Prognosis of sarcoma other than metastasis
1) mets (distant mets the most important factor for any staging system)
2) tumour grade (represents a tumours ability to metastasize)
3) size
4) compartmentalization
5) tumour depth- controversial as a prognosticator
134
\*5 concerning signs of head at risk in LCP (Caterall criteria)
Gage sign
Lateral subluxation
Lateral Ossification
Horizontal growth plate
Metaphyseal cyts
135
What are risk factors for patellar instability?
* **ligamentous laxity (Ehlers-Danlos syndrome)**
* **dysplastic vastus medialis oblique (VMO) muscle**
* **lateral displacement of patella**
* **patella alta**
* causes patella to not articulate with sulcus, losing its constraint effects
* **trochlear dysplasia**
* **excessive lateral patellar tilt** (measured in extension)
* **lateral femoral condyle hypoplasia**
* **increased quadriceps angle (Q angle)**
* average for women 15 degrees
* average for men 10 degrees
* **previous patellar instability event**
* **"miserable malalignment syndrome"**
* femoral anteversion
* genu valgum
* external tibial torsion / pronated feet
136
Radiographic indicators for progression of blounts
MDA \>16
MEA \>20
medial physeal bar
metaphyseal beaking
137
\*What are the considerations for a pediatric halo?
* More pins (6-8)
* Less torque (4 lbs/finger tight)
* * \>2 use a custom vest
* Thin cortices - need a pre-op CT
* Avoid pins in sutures
* Avoid temporalis muscle
138
Pros and Cons to steroids in Duschennes
* Benefits
* Walk for longer
* Improved pulmonary function
* Decreased progression of scoliosis
* Downsides
* Weight gain
* Short stature
* Osteopenia
* Cataracts
139
\*3 ways to size the radial head
* _Size the contralateral joint_
* _Size to original radial head_ - thickness and cup
* _Trial reduction_
* Proximally should line up with lesser sigmoid notch
* Lateral UH joint are opposed
* _Flouro_
* Medial and lateral UH joint lines (can't see this until \>6mm)
* Look for congruency of the medial UH joint
140
\*Parameters that suggest the patient is unstable
* BP
* Lactate \> 2.5
* Blood transfusion \> 5 units
* Base deficiet \> 8
* Platlets
* Fibrinogen
* Tempature
* ISS \> 40
* ISS \> 20 with thoracic trauma; AIS \>2
* Clinical parameters
* bilateral femur fractures
* pulmonary contusions
* severe head injury
141
Three causes of a SLAP lesion
repetitive overhead activities (often seen in throwing athletes)
fall on outstretched arm with tensed biceps
traction on the arm
142
5 Ways to use a plate
* antiglide/buttress
* tension band
* bridge
* compression
* neutrilization
143
2 advantages of a piriformis start site
* Piriformis
* less risk of varus
* colinear with shaft
* less risk of eccentric reaming
* disadvantage
* medial can cause neck fracture
* lateral will increase varus
* risk of AVN
* Lateral entry
* easier to perform
* less risk AVN
* disadvantage
* risk of lateral GT #
* risk of femoral neck fracture
* eccentric reaming
* increased risk of varus
144
\*8 features of aortic arch rupture on CXR
Widened mediastinum (\>8cm)
Indistinct aortic arch contour
Deviated trachea
Depressed left bronchus
NG tube deviation to right
Apical pleural hematoma (left apical cap)
Fracture of rib 1 or 2
Disruption of of calcium ring of aortic knob (broken halo sign)
Enlarged aortic contour
145
+Contraindications for function bracing in humeral shaft fracture
* severe soft tissue injury or bone loss
* unreliable patient
* polytrauma
* brachial plexus injury
* proximal one-third humeral fracture
* inability to maintain reduction (segmental fracture)
* radial nerve palsy is NOT a contraindication to functional bracing
146
Sites of compression of the AIN
* Ligament of struthers
* heads of pronator
* biceps aponeurosis
* FDS (subliminis)
147
Three features of sacral sparing
Voluntary anal contraction
Intact perianal sensation
Great toe flexion (FHL is S2)
148
What are the stabilizers to posterolateral elbow instability
* **LCL**
* coronoid
* radial head
149
Causes of charcot joint
* Diabetes
* Alcoholism
* Leprosy
* Syphillis
* Syrinx/syringomyelia
* Spinal cord tumor
150
\*Requirements to perform a PAO?
* Indicated in young patients with pain or progressive limp
* No OA - tonnis grade
* Painless passive ROM
* Flexion \> 90 deg
* Abduction \> 30 deg
* congruent joint
151
List four signs of posterior should dislocation in BPP
1. Internal rotation contracture of shoulder
2. Decreased ROM
3. Asymmetry of skin folds of the axilla and proximal arm
4. Apparent shortening of humeral segment
5. Palpable asymmetric fullness in posterior shoulder
6. Progressive loss of ER between monthly exams
7. Glenohumeral deformation secondary to muscular imbalance/physeal trauma
8. Leads to glenoid dysplasia and posterior should subluxation occur as a result around 6/12 Investigate with US!
152
What should the factor levels be pre-op and how long do you maintain them
* 100%
* factor VIII (hemophilia A)
* factor XI (hemophilia B)
* 2 hrs preop - infuse to attain 100% activity of normal
* intra-op - continuous infusion of factor to maintain levels \>60%
* immediate post-op - continuous infusion to maintain \>60% level until d/c
* 2 weeks post op - infusion of bolus doses to maintain levels 30-60%
* vigorous physio - infused to a 30% level just before therapy
153
Criteria for selective thoracic fusion in AIS (4)
* Lumbar modifier
* saggital modifier
* flexibity
* lumbar curve is more flexible than thoracic
* thoracic \> 20% AVT
* more apical rotation
* magnitude/type
* include all structural curves
* no need to fuse non-structure
* only need to fuse one that crosses central line
* maturity
154
Principles of treating a pilon
1. Restore length
2. anatomic articular reduction
3. bridge metaphysis and diaphysis
4. address bone loss
155
MRI findings with neurofibromatosis and scoliosis
Paraspinal mass (helps to distinguish from AIS)
Dumbell lesions
Dural ectasia
Vertebral body scalloping
156
Component of brown-segard syndrome
* ipsilateral motor loss (corticospinal)
* ipsilateral vibration/touch (dorsal column)
* contralateral pain/temp (spinothalamic)
* good prognosis
* usually direct trauma (stabbing)
157
Sites of compression of the radial nerve
* fibrous bands
* recurrent radial nerve (leash of henry)
* ECRB
* proximal supnator (arcade of froshe)
* distal supnator
158
Clinical (not radiographic) findings in FAI
* groin pain with activity
* mechanical symptoms
* difficulty sitting
* trauma as child
* trendeleberg
* * anterior impingment
* ER extremity
* increased anteversion
* old SCFE
159
4 changes in and around muscles with endurance training
160
4 risks for SCFE (radiographic risks)
Posterior slope angle \>14
Vertical physis
Retroverted femoral head
Protrusion
161
X-ray findings of AVN of femoral head post DDH treatment
1) Failure of appearance or growth of ossific nucleus at 1 year after reduction
2) Broadening of femoral neck
3) Increased density and fragmentation of ossified femoral head
4) Residual deformity of proximal femur after reduction
5) Shortening of the femoral neck
6) Greater trochanter overgrowth
7) Premature physeal closure
162
Radiogrpahic Findings after persisent ankle pain after "ankle sprain"
1) Anterior process of calcaneus fracture
2) Lateral process of talus fracture
3) Base of 5th metatarsal fracture
4) OCD
5) Peroneal tendon injury
6) Tarsal coalition
7) Syndesmosis injury
163
Posterior shoulder dislocation with hill sachs
3 treatment options
1) McLaughlin Procedure (subscap transfer)
2) Modified McLaughlin Procedure (LT transfer)
3) Anterior approach, disimpaction and bone grafting (autograft or allograft)
4) hemiarthroplasty (\>40%)
164
Marfans: name orthopaedic associations
○ arachnodactyly
○ scoliosis (50%)
○ protrusio acetabuli (15-25%)
○ ligamentous laxity
○ recurrent dislocations (patella, shoulder, fingers)
○ pes planovalgus
○ dural ectasia (\>60%)
○ meningocele
○ pectus excavatum
165
5 factors associated with poor prognosis for patient undergoing PAO
1. Tonnis Grade 3 osteoarthrosis
2. aspheric femoral head
3. preop center edge angle
4. preop os acetabuli
5. acetabular anteversion
166
Describe the Leadbetter maneuver
- Flex hip to 90deg
- Adduct hip
- Apply traction
- Internally rotate 45deg
- Slowly extend and abduct while maintaining traction/IR
167
Tibial eminene fracture
Block to reduction
Consequences of failed reduction
_Blocks to reduction_
* entrapped meniscus
* intermeniscal ligament
_Consequences of failed reduction_
* ACL laxity
* Loss of full extension from impingement of the displaced fracture in the notch
168
Orthotic for a 16yo M with subtle cavovarus foot
custom full-length semi-rigid with “recessed first ray, a lateral wedge, and a lowered medial longitudinal arch,”
169
Types of spondy
Wiltse-Newman Classification
170
6 modifiable risk factors for fracture non-union
Smoking
NSAID use
Alcohol Abuse
Low Vitamin D levels
Poor nutrition
Poorly controlled diabetes
Hypothyroidism
Anemia
171
5 components of capacity to provide informed consent
Does the person understand the condition for which the specific treatment is being proposed?
Is the person able to explain the nature of the treatment and understand relevant information?
Is the person aware of the possible outcomes of treatment, alternatives or lack of treatment?
Are the person’s expectations realistic?
Is the person able to make a decision and communicate a choice?
Is the person able to manipulate the information rationally?
172
5 steps in management of a medical error
Disclosure
Notify agency (CMPA)
Empathy
Documentation
Follow-up
173
5 ways to elimate bias in RCT
Randomization
Allocation concealment
Blinding/Masking
Intention to treat analysis
Adequate washout period
174
List 4 ways in which radiographs of the cervical spine in children differ from those of skeletally mature patients?
1. C2/3 and C3/4 pseudosubluxation up to 4mm, age 1-7
2. absence of cervical lordosis - reduces with extension
3. anterior wedging of vertebral bodies
4. ADI up to 5mm (2.5 mm in adults)
5. facets are more horizontal in c-spine
175
List 4 indications for surgery in rheumatoid c-spine.
ADI \> 10 mm
- PADI
- Basilar invagination (cervicomedullary angle
- Subaxial subluxation \> 4mm (or body height/width ratio
- Brain stem compromise
- Progressive neuro deficit
176
INdications for bracing congenital scoliosis
* Age
* Site of anomaly in lumbar as opposed to thoracic spine
* A curve of five segments or less
* A progressive curve
* Anomalies consisting of
* Absence of excessive kyphosis
* Absence of neurological deficits, including syrinx, di
astomatomyelia and tethered spinal cord
177
4 traditional pillars of medical ethics
Autonomy
Non-Malfescience
Beneficience
Justice
178
Complications of Darrach procedure
* *instability of the distal ulnar shaft*
* *painful subluxation of the ECU over the transected end of the ulna*
* *palmar subluxation or ulnar translation of the carpi*
* *radio-ulnar impingement*
179
► Med Misc 53
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