Short Answer 2012

Question 1

Complications of pediatric radial head fracture (list 4)

Answer 1

1. Loss of motion (expected) pron»sup(flex/ext less)
2. Radial head overgrowth (2nd 20%to 40%)
3. Notching of the radial neck secondary to scar tissue
4. Premature physeal closure (usually 5mm short)
5. Angular deformities (increased cubitus valgus +10)
6. Nonunion (radial neck is rare)
7. Osteonecrosis 10-20% all, 25% for open reductions
8. Radioulnar synostosis »_space;open reduction >5 days
9. Nerve injuries
   partial ulnar & PIN may occurb/c fracture
   PIN usually sx expl/percutaneous reduction.
10. Compartment Syndrome
11. Myositis ossificans supinator most common
12. Osteomyelitis(Rare)

Question 2

Principles of plafond fixation other than soft tissue issues (list 4)

Answer 2

1. restoration of length
2. reconstruction of the metaphyseal shell
3. bone grafting
4. reattachment of the metaphysis to the diaphysis

Question 3

Indications foracute scaphoid ORIF (4)

Answer 3

1. proximal pole fractures
2. vertical oblique fracture
3. displaced
   a. fracture gap >1mm on any view
   b. SL angle >60 degrees
   c. radiolunate angle >15 degrees
   d. intrascaphoid angle >35 degrees
4. comminution
5. scaphoid fracture with perilunate dislocation
6. delayed presentation (>4 weeks)
7. patient who wants faster return to work/sport

Question 4

Complications for hemilithotomy positioning in fixing femur diaphyseal fracture (list 4)

Answer 4

1. Well leg compartment syndrome (best answer)
2. Pudendal nerve palsy
   a. range from 1.9% to 27.6% due to excessive and/or prolonged traction against the perineal post
   b. Erectile dysfunction (ED) assoc pudendal nerve palsy
3. Sciatic or common peroneal nerve palsy of well leg
4. Perineal Soft Tissue injury
   a. traction table–induced genitoperineal skin necrosis
5. Malrotation and mal-alignment

Question 5

What are the three components of terrible triad (list 3)

Answer 5

1. Radial Head #
2. Coronoid #
3. Elbow Dislocation (usually posterolateral)

Question 6

Complications in tibial tubercle fracture (list 4)

Answer 6

1. Compartment Syndrome
2. Recurvatum
3. Screw Prominence
4. Stiffness

Question 7

List ossification order for distal humerus

Answer 7

CRMTOL

1. Capitellum
2. Radial Head
3. Medial Epicondyle
4. Trochlea
5. Olecranon
6. Lateral Epicondyle

Question 8

List factors contributing to progression of tibia vara (Blount’s) (list 3)

Answer 8

1. Increased metaphyseal-diaphyseal angle
2. Epiphyseal-metaphyseal angle
3. Osseous physeal bar
   Clinical
4. Overweight
5. Lateral thrust with ambulation
6. Increased instability to varus stress with the knee flexed 20°, as compared with the instability at full extension, and this is related to secondary laxity of the medial collateral ligament.

Question 9

List operative options for chronic posterior shoulder dislocation to address reverse hill-sachs (list 4)

Answer 9

1. Lesser Tuberosity transfer into bone defect (Modified McLaughlin procedure)
2. Hemiarthroplasty/resurfacing/TSA >40%
3. Osteochondral allograft
4. Humeral Rotational osteotomy

Question 10

What is needed in order to establish causative factor in a study (list 3?4?)

Answer 10

1.
2.
3.
4.

Question 11

List causes for cavovarus foot in adults (list 6?8?)

Answer 11

Neurologic
1. Hereditary motor and sensory neuropathies (CMT)
2. Cerebral palsy
3. After effects of cerebral injury (stroke)
4. Anterior horn cell disease (spinal root injury)
5. Spinal cord lesions
Traumatic
6. Compartment syndrome
7. Talar neck malunion
8. Peroneal nerve injury
9. Knee dislocation (neurovascular injury)
10. Residual clubfoot
11. Idiopathic
12. Polio
13. Spinal Motor Atrophy

Question 12

List clinical and radiological indications for cervical spine instability (list 6?8?)

Answer 12

1. Neurological deficits
2. AADI > 5mm = instability > 7mm (alar ligament rupture) >9 gross instability N=3mm
3. Flex/Ext views with >3.5mm movement in AADI
4. Subaxial subluxation >4mm or >20% of vertebral body
5. Kyphosis >11 degrees
6. Bilateral Jumped facets (PLL ruptured unstable even after reduced)
7. Large teardrop fragment lateral X-ray
8. Facet #
9. Disrupted discoligamentous complex integrity – widened disc space
10. Fracture in the presence of AS or DISH

Question 13

List radiological findings in pseudosubluxation of cervical spine (list 3?4?)

Answer 13

1. Anterolisthesis of C2 on C3 (most common) or C3 on C4
   a. Up to 4mm or 40% translation
   2) Swischuk’s line intact and smooth
   a. Draw spinolaminar line from C1-C3
   b. Spinolaminar point on C2 falls within 1.5mm of Swischuk’s line
   Lovell & Winter’s says 1mm normal, 2mm pathologic
   3) Absence of soft tissue swelling
   4) Reduction of subluxation with extension

Question 14

Other than “buttress plate techniques” list other plating techniques (list 4)

Answer 14

1. Tension band plating
2. Compression plating
3. Neutralizing plate
4. Bridge plating

Question 15

List findings in Brown-Sequard spinal injury (3 neurological)

Answer 15

1. Ipsilateral loss of motor function
2. Ipsilateral loss of deep touch, proprioception, & vibration sense
3. Contralateral loss of pain & temperature (~2 levels below injury)
4. May have loss of ipsilateral autonomic function (Horner syndrome)

Question 16

List types of posterior surgical management for fusion of C1-C2 (list 3)

Answer 16

1. Wiring techniques (Gallie, Brooks techniques)
2. Trans-articular screws (Magerl technique)
3. C1 lateral mass & C2 pedicle screws (Harms technique)
4. C1 lateral mass & C2 translaminar screws

Question 17

List ways to decrease complications of halo in pediatric population (list 3)

Answer 17

1. Increase number of pins (6-8 pins vs. 4 pins in adult)
2. Decrease torque of Halo pins (2-4 inch-lbs or finger-tight vs. 8inch-lbs in adult)
3. CT skull 1st to aid in pin placement
   Helps avoid cranial sutures
   Helps avoid thin regions of skull

Question 18

List conditions that cause bright signal change for gadolinium MRI (list 3)

Answer 18

1) Epidural fibrosis/scar (discectomy/laminectomy)
2) Infection (osteomyelitis+/-discitis, sinus tract, abscess)
a. Abscesses peripherally enhance
3) Tumors
a. area to biopsy;not necrotic area (doesn’t enhance)
b. Post-op to assess for tumor recurrence
4) Atlantodental joint in rheumatoid arthritis
a. Joint effusion will enhance, pannus will not

Question 19

List factors contributing to congenital kyphosis progression (list 3)

Answer 19

1. Rapid growth of spine
   a. Birth to 3 years
   b. Adolescent growth spurt
2. Mixed (failure of formation & segmentation) or failure of formation defect
3. Multiple adjacent vertebrae (vs. single level anomaly)
4. Lots of growth remaining

Question 20

List factors preventing full extension post ACL reconstruction (list 3)

Answer 20

1. ACL reconstruction performed before full ROM regained
2. Arthrofibrosis (too early inflammation still present)
3. Cyclops lesion
4. Improper tunnel placement
   Tibial tunnel too anterior -Impinges on femoral notch.

Question 21

List structures of PLC of knee (list 4)

Answer 21

1. LCL
2. Popliteus tendon
3. Popliteofibular ligament
4. Posterolateral joint capsule

Other supporting structures (secondary components)

5) IT Band
6) Biceps femoris
7) Fabellofibular ligament
8) Lateral gastrocs
9) Lateral capsular ligament

Question 22

List factors of Mirels classification for assessment of prophylactic fixation of tumor (4)

Answer 22

1. Location of lesion (UE/LE/Peritrochanteric)
2. Pain (Min, Mod, Functional)
3. Type of lesion (Blastic/Mixed/Lytic)
4. Size of lesion (2/3)

Question 23

List minimally invasive procedures for CVT (list 3?4?)

Answer 23

1. K-wiring of talonavicular joint through small medial incision
2. Selective capsulotomies of talonavicular joint and anterior aspect of subtalar joint
3. Percutaneus Achilles tenotomy
4. In the presence of pre-op casting (reverse Ponsetti technique)

Question 24

List procedures for carpal-radial ROM preserving (but not carpal bone motion
preserving) surgeries for SLAC stage II wrist (list 2)

Answer 24

1. Proximal row carpectomy

2. Scaphoidectomy & 4-corner fusion

Question 25

List radiological clues for ankle syndesmotic injury (list 4)

Answer 25

1. tibiofibular clear space 6mm on AP or > 42% fibular width 5. tibiofibular overlap >1mm on mortise Tibiofibular overlap measured 1 cm above plafond

Question 26

List factors to prevent “over-stuffing” of radial head replacement (list 3)

Answer 26

1. Radius - Rebuild #’d radial head on side table to determine native radial head size 2. Length - Height of prosthesis should be the same as the semilunar notch 3. Should be congruent and have smooth motion with the capitellum through full ROM 4. Look at ulnohumeral gapping medially a. (Lateral UH joint space widening is not diagnostic of radial head arthroplasty overstuffing JHS 2007) 5. X-ray - compare to contra-lateral side, should line up to semilunar notch

Question 27

List causes for persistent groin pain in patients who had THA (list 6)

Answer 27

1) Infection 2) Aseptic loosening (acetabular or femoral) 3) Mechanical subluxation 4) Impingement 5) Stress fracture (pubic ramis, Periprosthetic) 6) Avulsion apophysitis (ASIS, AIIS) 7) Osteitis pubis/pubic symphysis 8) Muscle strain (Adductor, Iliopsoas, Rectus femoris) 9) Tendonopathy (Adductor, Rectus abdominus) 10) Bursitis (iliopsoas, Iliopectineal) 11) Nerve entrapment (Ilioinguinal, genitofemoral, Obturator) 12) Arterial stenosis/ Aneurysm (iliac, gluteal, femoral) 13) Referred pain (lumbar spine, SI joint)

Question 28

What are structures to release in varus knee during TKA (list 5)

Answer 28

1) Osteophytes 2) Capsule and meniscus 3) Deep MCL 4) PMC (Semi-membranosus and capsule) 5) Superficial MCL (subperiosteal release not complete) 6) PCL 7) Medial Gastroc 8) Posterior oblique ligament

Question 29

List structures of superior shoulder suspensory complex (list 6)

Answer 29

1) Acromion 2) AC joint 3) Distal clavicle 4) Coracoclavicular ligaments 5) Coracoid 6) Glenoid 7) CA ligament (not in original description)

Question 30

List indications for humerus shaft fracture ORIF (list 5)

Answer 30

``` Absolute indications: 1) Open # 2) Vascular injury 3) Brachial Plexus injury Relative indications; 4) Polytrauma (for early WB) 5) Bilateral humerus #s 6) Floating Elbow 7) Pathologic # 8) Burns or S.T. injury that precludes bracing 9) Fracture characteristics (long oblique proximal, intra-articular, distraction at fracture site) ```

Question 31

Formula for Pelvic inicidence?

Answer 31

Pelvic Incidence = sacral slope + pelvic tilt PI= SS + PT line from the center of the S1 endplate to the center of the femoral head a second line perpendicular to the S1 endplate, intersecting the point in the center of the S1 endplate the angle is the pelvic incidence

Question 32

4 causes Superior Mesenteric Artery Syndrome in AIS adolescent Idiopathic scoliosis surgery?

Answer 32

1. spinal elongation, which decreases the aortomesenteric angle 2. Postoperative weight loss 3. Anatomical variants: - high insertion of the duodenum at the ligament of Treitz - low origin of the superior mesenteric artery 4. compression of the duodenum due to peritoneal adhesions

Question 33

List 4 contraindications to HTO for varus knee? (4)

Answer 33

1) Severe medial compartment articular damage 2) Tri-compartmental or Patellofemoral OA 4) Decreased ROM (less than 5 – 120 flexion ) 5) Age > 65 6) Infection 7) Rheumatoid/inflammatory arthritis

Question 34

List 4 components of WOMAC scale? (4)

Answer 34

1. Pain 2. Stiffness 3. Physical function 4. Social function

Question 35

List 6 other organ systems that are affected in congenital scoliosis? (6)

Answer 35

1) Limb Anomalies (most common assoc (in cong scoli): spine, hips, feet, sprengel) 2) Renal Anomalies, GU anomalies (get screening U/S or MRI – 20%) 3) Cardiac anomalies (Get screening ECHO – 26%: VSD > ASD > PDA, TOF) 4) Gastrointestinal system (anal atresia, trachea/esophageal anomalies) 5) Neural Axis (spinal dysraphism 20-40%: tethered cord most common) 6) Auditory (esp Cervical scoli) 7) Respiratory System (Thoracic Insufficiency Syndrome) – not specifically mentioned as affected BUT will be a consequence of…

Question 36

Who are at higher risk for the development of superior mesenteric artery syndrome following correction of spinal deformity (3-4)

Answer 36

1. body mass index that is in less than the twenty-fifth percentile for their age 2. those with a stiffer thoracic curve (<60% correction on bending radiographs) 3. a laterally displaced lumbar curve (Lenke B or C) 4.

Question 37

List 3 stages of muscle injury recovery?

Answer 37

1) Inflammation - hematoma - myofibrils contract 2) Repair - macrophages remove injured tissue - new cells are generated from satellite cells - new vascular ingrowth - production of connective tissue scar 3) Remodeling - maturation of regenerated myofibers - reorganization of scar

Question 38

List 4 changes in muscle with endurance training? (4)

Answer 38

Early 1. fewer motor units required to maintain given force 2. increased activation of synergistic muscles Late 1. increased mitochondrial size and number 2. increased aerobic enzyme activity 3. increased muscular capillary density 4. increased type I fiber concentration Cardiovascular changes adapts to provide O2 to muscles at a higher rate 1. increased stroke volume 2. increased ventricle size

Question 39

List 5-6 key components of pre-op surgical checklist?

Answer 39

1) Patient confirms ID,Consent,Procedure,Site 2) Correct site and side (marked) 3) Anesthesia machine and medication check completed 4) Pulse oximeter on and functioning 5) Difficult airway or aspiration risk identified 6) Anticipation of blood loss 7) Anticipated critical events 8) Essential imaging displayed

Question 40

List Five things to do in systemic staging of Ewings sarcoma? (5)

Answer 40

1) Bone Scan 2) CT Chest (pulmonary mets) 3) Bone Marrow Biopsy (rule out marrow mets) 4) Blood work (CBC, ESR, CRP, ALP, Lactate Dehydrogenase) *ESR increased in up to 50% 5) MRI of complete bone involved (look for skip lesions, ST involvement) * this is technically local involvement

Question 41

Three things to do to prevent procurvatum in proximal tibial fracture fixation? (3)

Answer 41

1) use an appropriate nail – Herzog curve should be proximal to the fracture, to minimize the deforming forces (if the curve passes distal to the fracture, a wedge effect may translate the distal segment posteriorly as the nail is seated) 2) nail the knee in extension – (15 degrees flexion) – this neutralizes the force of the patellar ligament on the proximal fragment (which otherwise pulls it into procurvatum) 3) posterior blocking (Poller) screws 4) reduce the fracture before reaming & maintain reduction with unicortical plate Clamp with reduction clamps 5) ex-fix, femoral distractor 7) multiple proximal locking screws to prevent loss of reduction

Question 42

List 2 anatomic reasons why proximal femur is predisposed to SCFE?

Answer 42

1) decreased femoral anteversion (N=11,mean is 0 in obese adolescents) increases shear stress 2) vertical orientation of physis – 8-11 degrees more vertical compared to normal adolescents 3) hormonal changes = increased height of zone of hypertrophy

Question 43

Four principles/procedures to use in 11yo with open physis and ACL deficiency (4)

Answer 43

1) complete transphyseal soft-tissue reconstruction 2) all-intraepiphyseal 3) hamstring graft passed under the intermeniscal ligament and then over the top on the femur 4) partial transphyseal - vertical transphyseal tibial tunnel - over the top femur or transepiphyseal femur

Question 44

Name the following dermatomes: 1. Nipple Line 2. Umbilicus 3. Groin 4. Medial Calf

Answer 44

1. T4 2. T10 3. L1 4. L4

Question 45

List 4 successful things to non-operatively manage carpal tunnel (4)

Answer 45

1) local steroid injections 2) oral steroids 3) splinting 4) ultrasounds

Question 46

List Five features associated with increased risk of peri-operative mortality in hip fractures (5)

Answer 46

1. delayed surgery 2. advanced age 3. male gender nursing home or facility residence poor pre-op walking capacity poor ADLs higher ASA grading poor mental state multiple comorbidities dementia or cognitive impairment diabetes cancer cardiac disease