The List Challenge Flashcards

Question

LIST 5 SIGNS OF IATROGENIC AVN IN DDH TREATMENT

Answer 1

Salter classification of AVN (5 signs) • Failure of appearance of ossific nucleus of femoral head during one yr or longer after reduction • Failure of growth of an existing ossific nucleus during one year or longer after reduction • Broadening of the femoral neck within one year after reduction • Increased radiographic bone density followed by fragmentation of the femoral head • Residual deformity of the femoral head and neck when reossification (resolution) is complete o These deformities include coxa plana, coxa magna, coxa vara, short broad femoral neck • Chief notes

Answer 2

Gurd and Wilson Criteria: Needs at least one major and 4 minor criteria • Major o Petechiae in a vest distribution o Hypoxemia with PaO2 o CNS depression disproportionate to hypoxemia o Pulmonary edema • Minor o Tachycardia (\>110 bpm) o Pyrexia (\>38.5) o Fat emboli visible in retina o Fat in urine o Fat in sputum o Unexplained drop in HCT or PLT count o Increasing ESR Ref: Gurd and Wilson

Answer 3

- Stage 1: o able to perform straight toe raise o tenosynovitis without deformity o No x-ray changes - Stage 2: o A:  unable to perform single leg heel rise.  Flexible Hindfoot  o B:  unable to perform single leg heel rise.  Flexible Hindfoot  Too many toes sign clinically  \>30% TN uncoverage - Stage 3: o unable to perform single leg heel rise o Rigid hind and forefoot deformity o Degenerative changes subtalar joint - Stage 4: o 3 + deltoid compromise (lateral tilt ankle)

Answer 4

* Open fracture * 25% glenoid involvement with humeral instability * 5 mm glenoid articular surface step-off or major gap * Extensive medialization of glenoid * Displaced scapular neck fracture \> 40 deg of angulation or 1 cm translation * Glenopolar angle • Coracoid displace \> 1cm7 (Chart here I could not copy) GPA = Angle measured between a line connecting the most cranial with the most caudal point of the glenoid cavity (white line)and a line connecting the most cranial point of the glenoid cavity with the most caudal point of the scapular body (black line). The GPA measures the obliquity of the glenoid articular surface in relation to the scapular body. Normal is 30° to 45°

Answer 5

* Painful hips with MRI showing a soft tissue mass and high blood cobalt (\>7ppb) * Painful hips with +MRI and normal Cobalt levels * Soft tissue mass increasing in size with or without high blood levels Rising levels on their own are an indication for follow-up, not revision. Jer's notes ...(and COA update)

Answer 6

• reverse Bankart repair

Answer 7

o Hyperaesthesia, hyperalgesia, allodynia o Temperature difference compared to contralateral o Skin colour change o Edema o Sweating change o Stiff joints, weakness, tremor, dystonia, trophic changes (nail, hair skin) o Osteopenia Manny's Lists

Answer 8

• FDS to 2nd digit - C8 provides power grip and will so FDS to index will be weak but this is not affected because it is innervated by the medial nerve.

Answer 9

• Extra-depth shoes (gets forces spread across whole foot vs over heel and MT heads), lateral posting orthotic, achilles stretching

Answer 10

* Patient age * Comorbid medical conditions * Functional level * Nutritional status * Nerve function * Vascular injury * Hormones * Growth factors * Health of soft tissue envelope * Sterility (open fractures) * Cigarette smoking * Local pathologic condition * Level of energy imparted * Type of bone loss * Extent of bone loss * Soft tissue attachments to bone * Stability of immobilization * Anatomic location * Blood supply Table 1-6 p 15 Miller's

Answer 11

• Palpation or Moro reflex o stimulating the limb in some way should lead to some movement if pseudoparalysis

Answer 12

* Physeal arrest of the lateral prox tib physis/ assymmetric activity of the physis * Early weight bearing * Tethering effect of the fibula * Inadequate reduction/ interposed soft tissue * Loss of tethering effect of the pes anserinus * ? increased vascularity (no mention in LW or chief notes…) Chief review notes

Answer 13

(Buckley – 2002) - Women (higher SF-36) - Non worker’s compensation patient - Men Age - Bohler’s angle \> 0-15 - Light work labourers - Single fracture line (Buckley – 1992) - Non Smokers - Anatomic reduction or - Comminuted fractureOperative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial JBJS 2002 - Poor Outcomes (10-20% Wound Complications) o Age \> 50 o Obese o Manual Labor o Workers Comp o Smoking o Bilateral o Polytrauma o DM, PVD o Men

Answer 14

• Transiliac-transsacral screws may be particularly useful in the presence of - Osteoporosis - Significant posterior pelvic instability including spinopelvic dissociation - Patient obesity - Anticipated noncompliant behavior - Bilateral posterior pelvic injuries - Nonunion procedures. • Transiliac-transsacral screws for posterior pelvic stabilization; J Orthop Trauma. 2011 Jun;25(6):378-84.

Answer 15

- Chondrosarcoma - Adamantinoma - Parosteal Osteosarcoma - Low grade intrameduallary osteosarcoma AAOS 2010

Answer 16

* Chondrosarc * Parosteal osteosarc * Chordoma * adamantinoma * squamous cell (if no mets) * LOW GRADE intramedullary osteosarc

Answer 17

 16-70%

Answer 18

Complications: o pin loosening is the most common. • A loose pin with no infection can be tightened 1-2 turns. o Pin site infection is in 20%.  Deep infection=pin removal and new site, big scars at anterior pins (10%), o Supraorbital nerve injury (V1 branch of trigeminal) o skin breakdown  scapulae and sternum are most common o intracranial penetration (1%), o dysphagia is from too much extension. o Respiratory distress o Six pins do NOT have more complications than 4 (Nemeth et al., 2001 JBJS) intracranial penetration (1%),

Answer 19

* 4 mos old proximal femur #\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ * 4 yr old midshaft spiral\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ * 8 yr old midshaft comminuted\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ * 13 yr old distal diaphyseal comminuted\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ * 17 yr old midshaft horizontal\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ My thoughts...obviously other options • Pavlik • Hip spica • Flexible nails • Lateral submuscular plate • Antegrade nail (piriformis or GT start)

Answer 20

• Cervical Kyphosis

Answer 21

- Polyneuropathy - Organomegaly - Endocrinopathy - M proteins - Skin changes

Answer 22

* Proximal femoral valgus osteotomy * Greater trochanter epiphyseodesis (Age 5 is when apophysis is visible) * Greater trochanter transfer (When 9 yrs or older) Chief review notes

Answer 23

- Toddlers fracture (tibia or foot) - Osteomyelitis, septic arthritis or discitis - Arthritis (JRA or Lyme disease) - Discoid meniscus - Foreign body in foot - Benign or malignant tumor

Answer 24

- Down syndrome (odontoid hypoplasia) - JRA - Os odontoideum o (Ossiculum terminale – NOT ASSOCIATED WITH INSTABILITY) - Pseudochondroplasia - Diastrophic dysplasia - SED congenita (odontoid hypoplasia) - Metaphyseal dysplasia: McKusick’s - Morquio’s (odontoid hypoplasia)

Answer 25

 Young patients with near total meniscectomy  Lateral \> Medial  Proper mechanical alignment   Intact ACL

Answer 26

- Proximal - medial gastrocnemius flap - Middle - soleus flap - Distal - reverse sural artery flap

Answer 27

* Lightbulb sign * Anterior rim sign * Trough sign

Answer 28

- Multiple enchondromas - Hemangiomas - 100% chance of malignant transformation of enchondroma

Answer 29

* Gruelich and Pyle * Sauvegrain method * Risser ref: LW

Answer 30

• Splint backslab for • X-ray out of splint to verify reduction • Clinically assess stability • No brace so begin gentle active rom • see back in 2 weeks • When would he return to sport? o Full pain free ROM o Equal strength to opposite side

Answer 31

* Open reduction of congenital dislocation (good access to psoas) * Obturator neurectomy * Psoas release * Biopsy Hoppenfeld p455

Answer 32

* Fibular deficiency * PFFD * Aperts syndrome AAOS

Answer 33

* Swollen * Intrinsic minus position

Answer 34

* (Continuously) high revolution speeds * Low insertion (driving) speed * Thinner diameter shaft * Sharp reamers * Deeper flutes * Hollow reamer head * Increased increments by 0.5mm * Venting? A Comparison Of Pressures Created By Various Commonly Used Intramedullary Reamers

Answer 35

* HTO - 85% 10 years * DFO - 50% 10 years

Answer 36

* Pagets * Osteoporosis * Metastatic bone disease * Polyostotic fibrous dysplasia * OI * AVN * HO * MM * Hypercalcemia

Answer 37

* Age: 5-11 * Weight: = 50 kg * Fracture in the mid 80% of the diaphysis RW 7th ed. p811

Answer 38

* Less violation of medial based blood supply * Easier access to posterolateral corner for release * Better patellar tracking * Lateral releases performed during exposure * Better exposure to affected condyle/plateau

Answer 39

* Joint line is 1-1.5 cm above the fibular head * Joint line is at meniscal scar/remnant * Joint line is 1 cm distal to the inferior pole of the patella * Joint line is 2.5 cm distal to the medial epicondyle

Answer 40

• DJD • RA • Gout • Down's • CP • Connective tissue disorder (Ehler's, Marfans) Manny's notes and OKU FNA

Answer 41

 Plate material  Offset from bone  Working length  Plate length  Number of screws  Locked or non-locked screws

Answer 42

- Psuedoarthrosis (5-10% single level, 30% multiple levels) - Laryngeal nerve injury ( 1% theoretically higher on right side) - Hypoglossal nerve injury - Vertebral artery injury - Dysphagia - Horner's syndrome - Adjacent segment disease - Hematoma - Airway compromise - Spina cord injury - Dural tear - Esophageal injury - Nerve root injury (C5 most susceptible) - infection - Graft dislodgement - Incomplete decompression Orthobullets and chief notes

Answer 43

 They are all equivocal in the literature

Answer 44

 All equivocal, each with their own pros and cons

Answer 45

* Genu valgum * Femoral anteversion * Pronated feet * Female * Ehlers Danlos * Marfans * Trochlea dysplasia * Patella Alta * Lateral femoral condyle dysplasia * Lateral patella tilt

Answer 46

 Increased surface area  Increased mitochondria  Increased capillary density  Increased strength  Thicker connective tissue

Answer 47

- Duty o The duty of the physician is to provide care equal to the same standard of care ordinarily executed by surgeons in the same medical specialty. - Causation o Causation is present when it is demonstrated that failure to meet the standard of care was the direct cause of the patient’s injuries. - Breach of duty o Breach of duty occurs when action or failure to act deviates from the standard of care. - Damages o Damages are monies awarded as compensation for injuries sustained as the result of medical negligence Orthobullets DCB’D

Answer 48

 Quads dominant (NM control)  Landing biomechanics (valgus moment)  Smaller notch  Genetics (? Collagen production)  Smaller ligament  Estrogen  Valgus alignment

Answer 49

* Rigid fixation * Normal bone metabolism * Optimal porosity (40-50%) * Minimal gaps ( * Optimal pore depth (deeper the better) * Optimal pore size (50-150um) * Minimal micromotion ( * Good cortical contact \*\*\*rule of 50's for everything\*\*\* (Millers)

Answer 50

- Watanabe classification o Type 1 Complete o Type 2 Incomplete o Type 3 Wrisberg variant (lack of posterior attachment)

Answer 51

- Normal serum lactate - Normal base deficit - Normal gastric pH (7.4) - Note: can have normal BP, U/O and HR and still be in ‘compenstated’ shock. Thus, look for the biochemical markers of peripheral blood flow

Answer 52

* increased femoral anteversion * tibial tosion * metatarsus adductus

Answer 53

Orthopaedic * Generalized ligamentous laxity and hypotonia * C1-2 instability (22%) * Hip subluxation and dislocation (late) * Patellofemoral instability and dislocation * Scoliosis (50%) and spondylolisthesis (6%) * Pes planovalgus * Metatarsus primus varus * SCFE * Short stature (walk at 2-3) * Clinodactyly, polyarticular arthropathy (10%) Medical * Mental retardation * Heart disease (50%) * Endocrine disorders (hypothyroidism) * Premature aging Orthobullets - Also * HEENT: - Flat occiput, microcephaly, upslanting palpebral fissure, epicanthal folds, speckled iris (Brushfield spost), hearing loss * CNS: hypotonia, mental retardation * CVS: congenital cardiac defects (50%) ie: AVSD, endocardial cushion * GI: duodenal/esophageal/anal atresia, TE fistula * GU: cryptorchidism * Derm: single palmar crease (Simian crease) * Endo: hypothryoid, DM (later in life) * Other: leukemia/lymphoma (later in life), Alzheimer's (later in life)

Answer 54

* highly variable * May have RC tendinitis and impingement in

Answer 55

 Intrarticular steroids  Hyperparathyroidism  Renal failure  Diabetes  Chronic tendonosis  RA  Systemic steroids  Connective tissue disease

Answer 56

* Soft tissue swelling anterior to C1-2 (crying makes this soft tissue shadow larger) * C2-3 pseudosubluxation * cervical body wedging * lack of cervical lordosis ref: Rang's.

Answer 57

* Not needed for * Not needed for * Do need if stopped long term within 3 months

Answer 58

* Devascularized patella following lateral retinacular release * Use of a patellar component with a single central peg * Use of bone cement (thermal necrosis) * High patellar strain due to component malalignment * Increased thickness of PF articulation (thick patella, oversized femur, anterior translation of femur) * O'Neill did the knee * To much resection * To little resection (stuffing) * Femoral component to large (stuffing) * Flexion of femoral component (stuffing) * Asymmetric resection (common from lateral aspect) * Central drill hole in contrast to peripheral holes * Operative disruption of patellar blood flow (lateral release disruption lateral superior geniculate artery)

Answer 59

* Skin erosions * Compartment syndrome * Ileus (SMA) * Malunion * Shortening \>2cm * Nerve pressure injury

Answer 60

* Superficial sugical site infection (hip + knee) * Extended operative time \> 2.5 hrs (hip + knee) * Prior infection of joint (knee) * Immunosuppression (knee) * Obesity (hip) AAOS Consensus Guidelines 2010

Answer 61

- Early repair - More distal (lower) - Shorter length of repair - Pre and post op rehab

Answer 62

* 6 weeks in extension (early mobility is not good) * patient has 20 % recurrence risk 1st time dislocater * 2nd time 50% recurrence risk

Answer 63

• Repair within zone II • crush injuries • Surgical manipulation • associated fractures • infection • revision • older age AAOS COR

Answer 64

- Femoral tunnel o Too anterior  Tight in flexion  Loose in extension o Too posterior  Loose in flexion  Tight in extension o Vertical tunnel  Residual pivot (rotational instability) - Tibial tunnel o Too anterior  Tight in flexion  Impinge in extension o Too posterior  Impinges on PCL

Answer 65

* Tight lateral retinaculum * Weakness or dehis of VMO * Increased Q angle * Excessive tibial or femoral valgus or medialization * Excessive IR of the femoral or tibial component * leads to relative ER of the actual tibia/femur * Anterior component placement * Lateralization of patella component (when resurfaced)

Answer 66

* HIV * HCV * HBV * CMV * HTLV-1 * Syphilis

Answer 67

- Descriptive - Easy to interpret and easy to remember - Good intra- and inter- observer reliability - Dictate injury severity - Dictate treatment strategies - Predict prognosis or potential complications

Answer 68

- APC 3 and vertically unstable PELVIS that: - Binder placed and skeletal traction in, and still unstable.

Answer 69

- roast beef sandwich

Answer 70

- Precocious puberty - cafe au lait - Polyostotic fibrous dysplasia - Short stature - Female \> Male

Answer 71

 Peripheral tear o SIZE OF RIM IS BEST PREDICTOR OF HEALING  Vertical/Longitudinal  1-4 cm in length  Combined with ACL reconstruction o Best results!

Answer 72

• Hallux Rigidus; 1/40 adults have this. Ref: OKU

Answer 73

* Previous fragility fracture * Female * Caucasian or asian * Smoker * Etoh abuse * RA * Dementia * Anticonvulsant use * Menaupause • Sedentary (no physical activity) * Low bone mineral density * Low calcium intake * Oral glucocorticoids * recurrent falling

Answer 74

According to JR Cobb 1960 JBJS (attached): • Abnormal vertebral angulation • Abnormal vertebral rotation • Abnormal vertebral position • Abnormal vertebral wedging According to Lenke • Curve segment with the largest cobb angle (The major curve is always structural) Minor curves that meet the following criteria • Proximal Thoracic curve pattern must have: o Minimal residual coronal curve on bending film of at least 25 o Kyphosis between T2 and T5 of at least 20. • Main Thoracic curve pattern must have o Main residual coronal curve of at least 25 o Kyphosis between T10 and L2 of at least 20. • Thoracolumbar/Lumbar curve pattern must have O Minimum residual curve of at least 25 O Kyphosis between T10 and L2 of at least 20

Answer 75

- ECU longitudinal tenodesis - PQ transfer - Radial ulnar resection - Creation of one bone forearm - Spherical ulnar head prosthesis (only if SK)

Answer 76

* The posterior lip of the posterior femoral condyle is more rounded (requires more host bone resection) * Decreased congruence of the posterior portion of the poly tibial tray * Recession of the poly anteriorly (allows for the patellar tendon with deep flexion) * Increased post height (may minimize jumping the post with deep flexion) Ref: Bhandari's 2012 book; nice pictures there.

Answer 77

* Phrenic * Dorsal scapular * Suprascapular * Nerve to subclavius * Long thoracic

Answer 78

* OA * Charcot * Ochronosis (alkaptonuria) * Acute rheumatic fever * Secondary pulmonary hypertrophic osteoarthropathy (secondary to factors secreted by a large tumor) Miller's - page 45

Answer 79

• Cant see, cant speak, cant walk the talk! • VERTEBROBASILAR INSUFFICIENCY o Nystagmus o Diploplia o Loss of vision in one or both eyes o Vertigo o Dizzyness o Dysarthria/Dysphagia o Sudden drop attack

Answer 80

A E I O U and sometimes Y - A - Adamantinoma - E - EG - I – Infection - O - Osteoid osteoma / Osteoblastoma - U - UUUUUEwings - Y - ...and some times Y: LYmphoma

Answer 81

- Endangers femoral nerve branches - Endangers femoral artery branches - More risk of inadvertent knee joint penetration - More risk of quads HO - Frame is bio-mechanically weaker when hooked up to anteromedial tibial pins

Answer 82

- ASIA A: Complete. No motor or sensory - ASIA B: Incomplete. No motor function but some remaining sensory - ASIA C: Incomplete. 50% or more of muscles below injury are less than Grade 3. - ASIA D: Incomplete. 50% or more of muscles below injury are greater than or equal to than Grade 3. - ASIA E: Normal

Answer 83

o With nerve root compression, the sensory NCSs are normal. This occurs because the sensory cell body, the dorsal root ganglion, is distal to the site of nerve compression Carpal Tunnel Syndrome: o there is no conclusive evidence that one single electrical conduction study has the highest sensitivity or specificity. However, median sensory latencies across the wrist compared to ulnar or radial latencies or proximal median conduction improved sensitivity as opposed to absolute median sensory or motor distal latencies Latency is a measure of the time required for conduction of the nerve impulse from the point of stimulation to the point of recording Rugger Jersey Spine: Sclerotic bands along superior and inferior thoracic and lumbar vertebral body endplates give a striped appearance to vertebral bodies - alternating parallel sclerotic and lucent bands are analogous to stripes on an English rugby sweater

Answer 84

- Left Thoracic Curve - Abnormal Reflexes - Rapid Curve Progression - Neurologic findings - Excessive kyphosis - Foot findings

Answer 85

• In addition to the standard non-progression on X-ray stuff, this is kind of cool; o as soon as there is no difference in skin temperature side to side

Answer 86

- Observation 6 mos - Refer to ENT for scope

Answer 87

• Diagnosis: MDI vs. unidirectional * Soft tissue lesions present * Bone lesions present

Answer 88

- Lag/sliding screw not perpendicular to fracture (forces parallel to screw) - Lack of medial buttress - Acts as load bearing device leading to lateralization of proximal and medialization of distal segment Reverse Obliquity Fractures of the Intertrochanteric Region of the Femur - JBJS 2001

Answer 89

- Fracture site apposition (most important) - Large diameter pins (second most important) - Additional pins - Rods in different planes - Pins in different planes - Decrease bone rod interface distance - Increased mass (size) or double stack rods - Increased spacing between pins (near far)

Answer 90

• This is a result iatrogenic complication of Hallux Valgus surgery: o Too much medial eminence resection o Excision of fibular sesamoid during distal soft tissue procedure o Over aggressive medial capsularplication o Overcorrection with post-op bunion dressing o Malalignment at osteotomy site

Answer 91

  \> 2cm, OATS  \> 2cm Osteochondral allograft, ACI

Answer 92

 Rib Fractures (50%)  Pulmonary injuries (40%)  Spine Fracture (30%)  Ipsilateral clavicle (25%)  Vascular Injury  Plexus injury

Answer 93

- Zanca View 40 degrees cephalad AC pathology - Strkyer Notch View Hill Sachs - AP IR View Hill Sachs - West Point View Bony Bankart - Axillary View Posterior glenoid

Answer 94

* Non-op * Core decompression (Cruess I,II,III) * Hemiarthroplasty (Cruess IV) * TSA (Cruess V) ref Mo's book p351 onward

Answer 95

_3rd generation_ * vacuum-mixing to reduce cement porosity * cement pressurization * femoral canal preparation * pulsatile lavage _1st generation_ * hand-mixed cement * finger packed cement * no canal preparation or cement restrictor _2nd generation_ * cement restrictor placement * cement gun * femoral canal preparation * brush and dry P's * Porosity reduction (vacuum - don't use in masquelet) * Pressurization cement * Pre-coat stem * Rough finish stem * Stem centralizer 2nd * Cement gun * Pulsatile lavage * Canal prep * Cement restrictor Millers

Answer 96

* Retroverted acetabulum * Sequelae of SCFE * Acetabular protrusio * Decreased native femoral head to neck ratio * Decreased native femoral neck offset * Overhang of anterosuperior acetabulum * Post-traumatic retroversion of femoral neck (post ORIF) * Non-spherical native femoral head Miller's p267

Answer 97

- Older age at presentation - Large tumor volume - Elevated ALP - Poor histological response to chemo o Good responders = \>90% necrosis (80% survival) o Poor responders = - Presence of metastasis on presentation o 10% of the time - Skip lesions - Local recurrence Manny's notes

Answer 98

- Miscommunication / Poor communication - Improper treatment - Failure to diagnose (missed diagnosed) - Failure to treat - Delay in response to patient / family The Monument files pg 222 MIFF’D

Answer 99

* Open Fracture * IM nail present THE JOURNAL OF BONE AND JOINT SURGERY (AMERICAN). 2010;92:823-828. Maintenance of Hardware After Early Postoperative Infection Following Fracture Internal Fixation

Answer 100

* position the patient flat in the supine position. Stabilize the head and neck. Trial fit the halo ring (it should not be \> 1cm away from the skin and not contact the ears at any point. Pins should engage the bone at 90 degrees. Put pins in (close eyes) and tighten in a diagonal fashion. Tighten to 8 in-lb in adults (2 in kids). Secure the lock nut and recheck in 24 hours and 1 wk. Can place vest before or after the ring application. The inferior border of the vest is at the xiphoid. Connect the vest to the ring with the vertical bars. Adjust the bars to get the desired position. * Pin position. 1 cm proximal to the brow in the lateral 1/3 of the brow. The posterior pins are above the pinna (make sure they are below the equator which comes up fast. A good number is 5-10 mm above the pinna). Prep sites and freeze the area. The patient should close their eyes (avoids entrapment of the orbicularis oculi)

Answer 101

* Amenorrhea * Eating disorder * Stress fracture / osteopenia Millers p294

Answer 102

* DF * 85-90%

Answer 103

* Non-op x 1 * then arthroscopic bankart repair using suture anchor construct

Answer 104

* Tendon to obturator internus * Nerve to obturator internus * Pudendal nerve * Internal pudendal artery

Answer 105

• Cavus  1st cast you DF the first ray (which is in PF) to align it with the talus and then increase supination to bring the first metatarsal in line the other tarsals (i.e. align the forefoot with the hindfoot) • Abduction  then abduct the forefoot by maintaining counter-pressure on the talus • Varus  No distinct step this will correct with steps 1 and 2 • Equinus  After 1,2,3 are complete DF of the hind foot is performed

Answer 106

* Change in fracture position by 10 mm * Change in screw position by 5% * Backing out of the screws by 20 mm * Perforation of the femoral head Acta Orthop Scand. 1999 Apr;70(2):141-4: Internally fixed femoral neck fractures. Early prediction of failure in 203 elderly patients with displaced fractures. Alho A, Benterud JG, Solovieva S

Answer 107

1 - My child is 18 mos old and I took him to a peds orthopod because he has a LLD with one leg larger than the other (hemihypertrophy). - He had surgery shortly after he was born for an omphalocele, but was otherwise healthy except for quite a large tongue. - His pediatrician says he has hypertrophic pancreatic islet cells (organomegaly), and he now has increasing spasticity and tone. 2 - Beckwith-Wiedeman syndrome 3 - Renal U/S to r/o Wilm's tumour

Answer 108

* Gross contamination with feces, dirt, or stagnant water * Farm related injuries * Freshwater boating injuries * Delay in initial abx \> 12 hours * Questionable viability of soft tissue * Doubt of the adequacy of initial debridement * Concern for myonecrosis Ref: Chief review notes

Answer 109

* Failure of non-surgical management of full-thickness and partial thickness tears * Acute tear in young patient ( • Acute loss of strength or motion at any age (due to cuff tear)

Answer 110

* Carcinogenesis (Theoretical, no case reports for HO prophylaxis) * Trochanteric non-union (Old literature with poor surgical techniques?) * Testicular tolerance (8Gy may cause reversible azospermia, but testicular shielding reduced does 50%) * NB: Dose 7-8Gy (700cGy) * Meta-analysis 2004 showed Radiation more effective than NSAIDS, but ARR only 2% Radiation vs nonsteroidal anti-inflammatory drugs for the prevention of heterotopic ossification after major hip procedures: a meta-analysis of randomized trials. (Pakos EE, Int J Radiat Oncol Biol Phys. 2004 Nov 1;60(3):888-95.)

Answer 111

- Traction - Extension - Pronation - Abduction

Answer 112

* Splint in backslab for • X-ray out of splint * Assess stability * Hinged elbow brace with extension block at 30-40 degrees for 1-2 weeks * block 10-20 degrees 1-2 weeks * No block for 2 weeks

Answer 113

* Masquelet (Induced Membrane) * Intercalary bone transport (with ring fixator) * Papineau (open bone grafting, modern done with Vac) * Vascularized Fibula • Induced Membrane Technique for Reconstruction To Manage Bone Loss - 2012 JAAOS • Modern Papineau technique with vacuum-assisted closure 2006 JOT • Vascularized fibular graft in infected tibial bone loss - 2011 IJO  F/u avg 46.5 months  10 stress #'s in 7 pts...  Graft union in 3.3 months  No post-op infections

Answer 114

• Instability: o Is a pathologic condition representing excessive translation of humeral head on the glenoid during ROM representing a spectrum of injury to shoulder stabilizers • Laxity: o Is a physiologic condition representing excessive translation of humeral head on glenoid during ROM with no pathologic or functional consequence to patient (Jeremy Lamothe) • Remember: Patients can be lax and stable or lax and unstable or lax and stiff

Answer 115

* Delay \> 4 days * Age • Joint effusion with underlying osteomyelitis * Hip involvement

Answer 116

• Osteonecrosis (arthropasty is better) • Charcot (high nonunion rate) • Ipsilateral elbow fusion • Contralateral shoulder fusion • Injury of the scapular stabilizer muscles (traps, levator scapulae, serratus anterior, lats dorsi, rhomboids) Ref: Richards et al., 1997

Answer 117

* IM nail * Locking plates have a higher failure rate - they preclude endosteal healing. * Should IM nail with enough reaming to fit the nail

Answer 118

- DM (most common in Foot) - Syringomyelia (most common cause in the UE) - Leprosy - Hansen's disease (second most common cause in the UE) - Myelomeningocele (foot and ankle) - Spinal cord injury - Neurosyphilis/tabes dorsalis - Congenital insensitivity to pain - Amyloidosis Miller's pp45-6

Answer 119

- Down syndrome (odontoid hypoplasia) - JRA/JIA - Os odontoideum (ossiculum terminale – not associated with instability) - Pseudochondroplasia - Diastrophic dysplasia - SED congenita (odontoid hypoplasia) - Metaphyseal dysplasia: mckusick’s - Morquio’s (odontoid hypoplasia) - Osteogenesis Imperfecta - Marfans 1) Miller’s pp198-207 2) Manny's lists

Answer 120

* Length correct * Rotation correct * Knee ligaments stable * No associated fem neck # * Compartments soft

Answer 121

* Clinically assess legs\* * Fluoroscopically assess anteversion by moving the c arm and measuring this\* * Perform lateral only imaging of the femur and compare the neck horizontal line\* * Compare the LT profiles\* * Ultrasound\* * Computer assisted navigation\* * All of these are relative to the contralateral side. Lindsey 2011 JAAOS paper

Answer 122

* Iatrogenic ulnar nerve injuries 1-15% * 60% children • You are up to 2 mm off with palpation as a means for correctly identifying the nerve. * Ulnar nerve injury is most often due to the pin constricting the nerve in the cubital tunnel by increasing tension vs. piercing the nerve (although this can happen) * The ulnar nerve can recover with expectant management (no exploration, no pin removal)...but sometimes it doesn't • " there is insufficient information in the literature to offer an evidenced-based approach to iatrogenic ulnar nerve injury that occurs following medial pin placement" • I **am pulling that sucker in recovery room (not exploring) and replacing it with another lateral pin (1st choice) or a better positioned medial pin. I will then follow the ulnar nerve expectantly...my approach (B) R&W 7th ed p515**

Answer 123

 Number of holes/number of screws

Answer 124

- Metastatic disease - GCT - Pagets - Fibrous Dysplasia - Myeloma

Answer 125

- Multiple enchondromas - 30% chance of malignant transformation - involved bones are dysplastic - High risk of other malignancy

Answer 126

- Stress fracture - OM, septic arthritis, discitis - SCFE - Osgood Schlatter - Sindig-Larsen-Johanssen - Osteochondritis Dissecans - Chondromalacia Patellae - Arthritis (Lyme disease) - Accessory Navicular - Tarsal colaition - Benign or malignant tumor Skaggs - Staying out of trouble...I think the original reference is JAAOS 2001 Flynn Duchenne's will probably present between 2-5 yrs of age (Don't forget to do gowers sign in all boys - do gowers in girls too - they can have other myopathies/neuropathies too)

Answer 127

Table 3–14 -- EVALUATION OF ROTATIONAL PROBLEMS OF THE LOWER EXTREMITIES Measurement Technique Normal Values (degrees) Significance Foot-progression angle Foot vs. straight line −5 to +20 Nonspecific rotation Medial rotation Prone hip ROM 20-60 \> 70 degrees; femoral anteversion Lateral rotation Prone hip ROM 30-60 Thigh–foot angle Knee bent; foot up 0-20 Foot lateral border Convex; medial crease Straight; flexible Metatarsus adductus

Answer 128

* near-far fluoro technique * inject dye through screw * 3D imaging (CT) Manny's notes

Answer 129

* MS * Estrogen deficiency (menopause) * OI * Ankylosing spondylitis * Diabetes * Renal disease * Nutritional deficiency (rickets)

Answer 130

* Transverse pattern (RR20) * Open (RR 4.3) * Gap (RR 8.3) J Orthop Trauma. 2003 May;17(5):353-61.: Predictors of reoperation following operative management of fractures of the tibial shaft. - Bhandari M, Tornetta P 3rd, Sprague S, Najibi S, Petrisor B, Griffith L Guyatt GH

Answer 131

* cranial fracture * intracranial bleed that may require a craniotomy * infection * soft tissue injury at proposed site * chest trauma * obesity * advanced age * barrel chest

Answer 132

"Get Reduced, Ream Reduced and Nail Reduced" • Less Attractive Option - Ream proximal fragment, then you finger or nail as joystick to get reduction - SHOULD RARELY BE USED 2. Starting point at tip of GT or slightly medial, at the junction of the anterior one-third and posterior two-third on GT ◦ Guidewire needs to be parallel to lateral cortex of proximal fragment ◦ NEVER LATERAL TO TIP If you do, guide wire, opening ream and nail head medial - to get nail into shaft @ fracture site, you push your hand in towards the body and create varus at the fracture site ◦ Reference - J Orthop Trauma. 2005 Nov-Dec;19(10):681-6. A critical analysis of the eccentric starting point for trochanteric intramedullary femoral nailing. Ostrum RF, Marcantonio A, Marburger R. 1. Clamp Assisted Open Reduction - Good for High, Transverse Subtochs - within 2 cortical diameters of lesser, How to do: ◦ Muscle Relaxants ◦ Attempt Closed Reduction - if possible use closed reamed antegrade femoral nailing • If behaving like a Subtroch (flex, ER, Abduct) - Open ◦ 3-5 cm lateral incision, split Lateralis directly through muscle belly, DO NOT VISUALIZE FRACTURE (do not evacuate hemtoma, strip soft tissue etc), insert large reduction clamp, cephallomedulary locking screws, remove clamp...if still mobile, add a cerclage wire, WBAT ◦ Union - 98% ◦ Other Option if very transverse - Lane Bone Holding forceps on proximal fragment - Reverse deformity (Extend,IR, Adduct) and Hyper Adduct Clamp-Assisted Reduction of High Subtrochanteric Fractures of the Femur. Alan Afsari, Frank Liporace, Eric Lindvall, Anthony Infante, Jr., Henry C. Sagi and George J. Haidukewych. J Bone Joint Surg Am. 2009;91:1913-1918. 1. Medial Blocking Screw - AP direction 2. Shantz Pin (see Harborview Book) ◦ AP - use to control flexion mainly • Stay above lesser, snap down to bone, be mindful of femoral nerve. ◦ Lateral to medial - posterior to the path of the nail 1. Bone hook on shaft (lateralize fragment), ball spike pusher proximal fragment(push it into valgus) ◦ Helpful if purely coronal plane and not much flexion of proximal fragment 1. Avoid Eccentric Lateral Reaming ◦ Tips • Medialize Entry Reamer, Medialize guidewire with thumb hole of snap, insert a curved LCDP plate to protect lateral cortex ◦ Bailouts if you Ream Laterally and your nail reduces you into varus Use ronger, awl to remove bone MEDIALLY at entry point.

Answer 133

* Cementless acetabular shell * Under-reaming by \>2mm * Use of an elliptical monoblock shell * Paget's * Hands of a honey badger * During removal of acetabular shell in revision * Osteoporosis AAOS

Answer 134

• Maternal pre-gestational DM • In utero exposure to carbamazipine/valproic acid • Previous affected pregnancy • Folic acid deficiency Manny's notes

Answer 135

* Cross-over sign * Os acetabuli * CEA \> 39 * Posterior wall lateral to the center of rotation of the femoral head * Profunda * Protrusio Manny's lists

Answer 136

• Chronological: o Acute, chronic, recurrent • Direction: o unidirectional vs. multidrectional • Control: o Voluntary vs. involuntary o If voluntary:  Positional, habitual, muscular

Answer 137

- 4 part fracture dislocation 100% - displaced 4 part fracture 45% - 3 part fracture 14% - valgus impacted 4 part fracture 11%

Answer 138

* Mitosis (cell division) * Pyknosis (irreversible condensation of chromatin in nucleus) * Anisocytosis (Cells of unequal size) * Necrosis (messy cell death) * Abnormal Nuclear/cytoplasmic ratio * Hyperkaryotosis (Hypercellular) * Pleiomorphism (variety of shapes/sizes)

Answer 139

* 8 mm above anatomically reduced GT * 5.7 cm above superior border of pec major * Appropriate tension reestablished in long head of biceps * Appropriate relationship to glenoid * Template off of pre-op x-rays of non-affected side ref: Multiple: 1 and 2 are in publications, 3, 4 5 are from courses and chatting with Duffy

Answer 140

- Local o Post op swelling / stiffness o Delay in muscle power recovery o Compression neuropraxia o Wound hematoma o Wound infection o Direct vascular injury o Bone and soft tissue necrosis o Compartment syndrome - Systemic o CVP o Arterial hypertension o Cardiorespiratory decompensation o Cerebral infarction o Alterations in acid-base balance o Rhabdomolysis o DVT Pneumatic Tourniquets in Extremity Surgery JAAOS 2001

Answer 141

• CPPD crystal deposition * Ochronosis * Hemochromatosis * Hyperparathyroidism * Hypothyroidism * Calcium hydroxyapatite crystal deposition ("Milwaukee shoulder") Miller's p53

Answer 142

- High radiosensitivity: o MM o Small cell lung o Testicular o Leukemia o Lymphoma o Germ cell tumors - Moderate radiosensitivity: o Non small cell lung o Thyroid o Breast o Prostate o (epithelial) - Low radiosensitivity: o Renal cell o Melanoma o Colon From Manny notes (and wikipedia)

Answer 143

* Capsule * Bone Marrow * Blood * Urine * Lymph nodes (para-aortic) * Liver * Spleen Dumbleton J Arthroplasty 2005 JBJS Br Case et al 1994 Sep;76(5):701-12

Answer 144

• Reproducible signs of inferior instability + instability in one other direction

Answer 145

* 20 deg flexion, 10-15 ER, 5 valgus * 0 deg flexion, 10-15 ER, 5 valgus * Because the tibia and the femur will both be "above knee" so don't want any flexion at the native knee joint.

Answer 146

* Hip flexion contracture * Hamstring contracture * Excessively loose heel cords AAOS

Answer 147

* Incidental x-ray findings * Incidental lab findings (elevated alk phos) * Bone pain * Bone deformity * Fracture * Arthropathy * Skin temperature changes * 8 neurologic complications (deafness, cranial nerve palsies)

Answer 148

"Prolonged renal failure causes phosphate retention and subsequent hyperplasia of parathyroid gland chief cells, which results in a decrease in serum calcium and an increase in serum parathyroid hormone. Increased serum phosphate causes a decrease in 1,25(OH)2D synthesis, which decreases calcium absorption. The increased parathyroid hormone acts on the kidneys and on bone to normalize serum calcium. The direct results are (a) stimulation of vitamin D metabolism, which increases intestinal resorption of calcium, thereby antagonizing the effects of phosphate on 1,25(OH)2D synthesis; (b) increased resorption of calcium from the kidneys, with increased excretion of phosphate in the kidneys; and (c) increased osteoclast activity, which causes the release of calcium from bone (6). Osteoblasts form an increased amount of osteoid in response to bone resorption and a subsequent loss of bone mass. This excess osteoid does not contain hydroxyapatite but appears opaque on radiographs, thus producing the rugger jersey spine appearance" Oteopetrosis

Answer 149

* Anterior process of calcaneous is palpable as it corrects from under the talus (best sign) * You've achieved at least 60 deg of abduction in reference to the tibia * Neutral or slight valgus of os clacis is present

Answer 150

 Smoking  Long segment fusion  Kyphosis  Positive sagittal balance \> 5 cm  Hip OA  Thoracolumbar approach  Age 55  Incomplete lumbopelvic fixation  Anterior fixation alone

Answer 151

50 – 60 yrs 13% - 60 – 70 yrs 20% - 70 – 80 yrs 30% - \> 80 yrs 50% - U/S Study of PARTIAL or FULL thickness tears

Answer 152

* Pelvic rotation * Pelvic tilt * Pelvic lateral rotation * Knee flexion in stance phase * Knee mechanics * Foot mechanics Saunders et al., jbjs 1953

Answer 153

- P53 tumor suppressor gene mutation - predisposes to second hit - Increased risk of sarcoma and other cancer in young patients Reference: Tim's Bone tumor handout, the Monument files and orthobullets

Answer 154

* Gross contamination with feces, dirt, or stagnant water * Farm related injuries * Freshwater boating injuries * Delay in initial abx \> 12 hours * Questionable viability of soft tissue * Doubt of the adequacy of initial debridement * Concern for myonecrosis Ref: Chief review notes

Answer 155

- Acetabularization of the acromion (AP view) o comment on thickness of acromion; at risk for peri-op fracture - Femoralization of the humeral head (AP view) - Eccentric superior gleniod wear (AP view) - Loss of CA arch (anterior superior escape) - Lack of typical peripheral osteophytes - Osteopenia - Subarticular sclerosis (snowcap sign)

Answer 156

- Tarsal coalition - Tumor (osteoid osteoma) - Infection - Inflammatory arthritis - Vertical talus - Oblique talus chief notes

Answer 157

* Continuous administration may delay remodeling of hard callus but will not affect the strength of the hard callus. * One single dose administration can delay hard callus remodelling but improve hard callus strength.

Answer 158

* Proximal pole fracture * Initial displacement \> 2 mm * Vertical fracture pattern * Delay to treatment 4 wk * Smokers * Female * K-wire fixation * Carpal collapse * Prior surgery Wright's book or Bhandari's book

Answer 159

* Latarjet * Think of remplissage depending on size

Answer 160

* Intra-articular release of rotator cuff from glenoid labrum * Cuff mobilization with traction sutures * Anterior slide (release rotator interval from base of coracoid (may increase tendon excursion by 1.5 cm) * Posterior slide (release between infraspinatus and supraspinatus) * Supraspinatus dissection - from the supraspinatus fascia and scapular spine to allow mobilization from the supraspinatus fossa

Answer 161

* Elbow stiffness (most common) * Radial head overgrowth (second most common) * Notching of the radial neck * Premature physeal closure * Nonunion of the neck * Head osteonecrosis * Cubitus valgus * Vascular injury * Nerve injury (PIN) * Compartment syndrome * Radioulnar synostosis * Myositis ossificans * Osteomyelitits * Malunion Ref for both Rockwood and Wilkins

Answer 162

- Associations o Arthrogryposis o Ellis-van Creveld syndrome o Holt-Oram syndrome o Turner's syndrome - Familial - Most frequently in black males - Bilateral - Lunotriquetrial is most common - Mostly incomplete - Usually asymptomatic

Answer 163

 Weak VMO  High Q angle  Genu Valgum  Excessive femoral anteversion Miserable Malalignment  External tibial torsion Miserable Malalignment  Pronated feel Miserable Malalignment  Trochlear dysplasia  Ligamentous laxity  Patella alta  Lateral condyle hypoplasia

Answer 164

* Large tongue * Large mandible * Foramen magnum stenosis * Limited neck extension * May have decreased chest wall compliance and FRC * Frequent URTI * Difficult spinal/epidural anaesthesia Manual of Anaesthesia practice: Chapter on Achon's

Answer 165

Stage \> 3 (50%) correlates with poor outcome - Stage 0 Normal Muscle - Stage 1 Fatty Streaks - Stage 2 - Stage 3 50% fatty muscle - Stage 4 \> 50% fatty muscle

Answer 166

• AARI o Grissel • neurogenic o SC tumors, posterior possa tumors, syrinogmyelia, Arnold-Chiari • neoplasms o osteoid osteoma, ABC • infection o cervical adenitis, retropharyngeal bascess, Grisel’s syndrome • inflammatory o interverberal disc calcification, JIA • iatrogrenic o H&N surgery

Answer 167

* Antibiotic administration prior to incision (or tourniquet inflation) * Perioperative antibiotic course should not exceed 24 hours * Antibiotics should be re-dosed when the duration of the procedure exceeds one to two times the half life of the antibiotic OR with significant intra-operative blood loss (two Swamys). The half life of Ancef is 1.8 hours with administered IV * Verification of prophylactic antibiotic administration by a "time out" protocol Bhandari

Answer 168

- New pain in a longstanding Paget’s patient - Pathologic fracture - Elevation of ALP ...above normally elevated levels - Biopsy - actually necessary to tell you what sarcoma it has become - Soft tissue mass - Cortical destruction Orthobullets

Answer 169

* Flexion * IR * ...rarely need valgus but can be done in setting of AVN Webinar vumedi

Answer 170

- Non-ossifying fibromas - Cafe au lait - May be associated / subtype of NF ?

Answer 171

* Rocker bottom foot * Pressure sores * Crowded toes * Flat heel pad

Answer 172

* Gonarthrosis in patients with a varus limb alignment * Gonarthrosis in patients with a valgus limb alignment (unloads the knee in flex and ex compared to a DFVO that is only in ex) * OCD of MFC * SPONK of MFC * Posterolateral instability * Chondral resurfacing * Non Obese * Unilateral CONTRAINDICATIONS * Inflammatory arthritis * Flexion * Contracture \>15 * BMI \> 35 * \> 20 degrees of correction required * PF OA * Varus thrust * Instability

Answer 173

* SCFE * Rickets (provisional calcification zone) * SH 1 fractures (provisional calcification) * Mucopolysacharide disease * SED * MED * Acromegaly Proliferative o Achon's o Gigantism o MHE Reserve o Gaucher's o Disatrophic Dysplasia o Pseudoachon's 1) “Rich Pretty Girls Do Koke” R = Reserve Zone P = Pseudoachondroplasia = COMP G = Gaucher’s Disease D = Diastrophic Dysplasia = Sulfate Transport K = Kniest Syndrome = Type 2 collagen defect 2) “Big and Small” - Proliferative Zone G = Gigantism A = Achondroplasia (FGFR-3) 3) “MORE Sex Please” - Hypertrophic Zone M = Mucopolysaccharidoses O = Osteomalacia R = Rickets E = Enchondroma S = SCFE P = Physeal Fracture 4) Metaphysis - SCFE with Endocrine Problem - OSTEOPETROSIS - OI (Type 1 Collagen) - Scurvy (Vitamin C)

Answer 174

* Operate * Although this is a simple dislocation I would go through the King algorithm in my head to make sure I am not missing and bony injuries and to help with me sequence of repair/reconstruction

Answer 175

- Failure - Infection - Arthrofibrosis o Minimal 12 wks before considering MUA - Cyclops - Loss of motion - Patella fracture/rupture - Tunnel osteolysis - Late arthritis

Answer 176

 Plate length / Fracture length

Answer 177

* Diminishes joint contact forces compared to high hip center * Improved abductor function * Fascilitates limb lengthening * Best bone stock Ref: Campbell's

Answer 178

- Male - Family history - Northern European - Manual labor - with vibration exposure (5x increase) - Diabetes - Local trauma - Etoh/liver disease - Smoking (3x increase) - Hyperlipidemia - CRPS - RA protective Controversial: - HIV - Epilepsy - Chronic pulmonary disease - Tb

Answer 179

Problems/Solutions 1. Hard, sclerotic bone - Sequential drilling with regular cooling saline, frequent change of drill bit 2. Impaired vascularity and white celi function - Warn patient about increased risk of infection 3. Brittle bones - Avoid undue force and use of mallet 4. Dynamic hip screw fixation - Fractional decrease in drilling, tapping and screw length, regular clean out of tap and screw tract 5. IM nailing-absent medullary canal - Drilling and cannulated reaming under fluoroscopic control 6. Tension band wiring - Pre-drill k wire tract under fluoroscopic control 7. Plate fixation- Fully tap all holes before screw insertion 8. Total hip replacement - Uncemented arthroplasty, use of power drill, reamer, burr to create medullary canal 9. Total knee replacement - Anticipate extra-medullary alignment and difficult sawing De Palma et al.8 reported the histology of fracture callus in a patient with autosomal dominant osteopetrosis. They found normal healing to be present at 10 days after a fracture. At 20 days there was normal woven formation; however there were fewer than normal vessels and few osteoclasts. At 1 year biopsy of the healed fracture showed unorganised woven bone with absence of osteoclasts. Microfractures were frequently noted. Thus osteopetrotic fractures do heal, but remodeling does not occur.

Answer 180

* Maximize pin separation at fracture site * Engage medial and lateral columns proximal to fracture site * Engage sufficient bone in both the proximal segment and distal fragment • Low threshold for a third lateral pin if fracture stability is a concern • Use three pins for a type III fracture Rockwood and wilkins 7th ed. p498

Answer 181

* RA * AS * Marfan's * Paget's * Otto's pelvis (aka protrusion) Miller's p48 Also * Neurofibromatosis * Radiation induced osteonecrosis * JIA/JRA * Psoriatic * Reactive arthritis * OI * Ochronosis * HPT * Ehler Danlos * Sickle Cell * Hemophilia The German pathologist Otto first described Protrusio acetabuli, (also known as "arthrokatadysis",) in 1824. Hence also known as Otto Pelvis http://orthopaedicprinciples.blogspot.ca/2009/10/protrusio-acetabuli-otto-pelvis.html Wheeless: * primary form, Otto pelvis (arthrokatadysis), involves both hips, occurs most often in females, & causes pain & limitation of motion at a relatively early age;

Answer 182

 Type 1 Depressed OC Fracture  Type 2 Fragment attached by bridge  Type 3 Detached, non-displaced  Type 4 Displaced

Answer 183

• Higher rate of primary RCR failure: o Age \>65 o Massive tear (\>5cm) o Moderate to severe muscle atrophy (T1 MRI \> 50%) o Tear retracted \>2.5cm at scope after mobilization o Tear retracted medial to glenoid on MRI o DM o Active smoker o Unwillingness/inability to participate in rehab or comply restrictions JAAOS 2012

Answer 184

- Exophthalmos - Diabetes Insipidous - Lytic skull lesion (multifocal Langerhans cell histiocytosis) (Apparently classic, but only seen in 25%) Millers 544

Answer 185

- Pre-op: Consent- standard stuff, + mention recurrence / stiffness - Position: prone / abx / tourniquet - Incision: Cincinatti (from navicular/medial cuneiform to lateral sinus tarsi) - ID and protect: o Medial vascular bundle  how many clubfoots have absent dorsalis pedis? - 45% o Medial and plantar nerves o Sural nerve o interosseous talocalaneal ligament - Releases:...Pretty much everything else - 1) Medial o Plantar fascia o Abductor hallucis o lacinate ligament (flexor retinaculum) o TN capsule o Calcaneounavicular ligament (spring) o Knot of henry o superficial deltoid o Lengthen: tib post, FDL and FHL - 2) Posterior (?usually first according to chief notes) o Z-lengthening of achilles o release posterior tibiofibular and talofibular ligaments o Subtalar joint capsule - 3) Lateral o calcaneofibular o calcaneocuboid o peroneal sheaths - May need to pin the CC joint and TN joint if unstable - Recurrence: o ? etiology - consider MRI for spinal cord - Revision o SPLATT o Dwyer Osteotomy

Answer 186

* Chondroblastoma * osteoblastoma * GCT * CMF * NOF * Fibrous dysplasia

Answer 187

- 3 or more 5mm sagittal images with meniscal continuity

Answer 188

NIH Diagnosis of Neurofibromatosis Type 1 (NF1) • Six or more café au lait macules over 5 mm in greatest diameter in prepubertal individuals and over 15 mm in greatest diameter in postpubertal individuals • Two or more neurofibromas of any type or one plexiform neurofibroma • Freckling in the axillary or inguinal regions (Crowe´s sign) • Optic glioma • Two or more Lisch nodules (iris harmartomas) • A distinctive osseous lesion such as sphenoid dysplasia or thinning of long bone cortex with or without pseudoarthrosis • A first-degree relative (parent, sibling, or offspring) with NF1 by the above criteria The criteria are met in an individual if two or more of the features listed are present. Manny Notes http://www.medicalcriteria.com/criteria/neuro\_nf.htm

Answer 189

* Patient mentally and physically fit for surgery * Low demand * Males \> 75 and female \> 70 * Fractures not "ORIFable" * Pre-existing arthritis Ref: Graham King webinar

Answer 190

• Neurofibromatosis • Achondroplasia • Marfan syndrome • Ehlers-Danlos syndrome • Ankylosing Spondylitis • Morquio syndrome • Hurler syndrome • Acromegaly • Intraspinal tumor • Communicating hydrocephalus The Posterior Vertebral Scalloping Sign - Radiology 2006

Answer 191

LERN'M - L - Lymphoma - E – Ewings (most common kid \>5) - R - Rhabdomyosarcoma - N – Neuroblastoma (most common kid - M – Myeloma Also - Small round cell carcinoma (r/o \>40yrs) Millers Page 549, and Board review Webinar 2012

Answer 192

 Vertical/Longitudinal Assn with ACL  Bucket Handle Vertical with displacement  Oblique/Flap/Parrot beak May cause mechanical symptoms  Radial  Horizontal Common in elderly, ass’n with cysts  Complex

Answer 193

* Lack of soft tissue component * GAD will light up septa in primary lesion but not secondary * Look for perilesional edema to decipher from OS Sources AAOS and radiology journal

Answer 194

* Anticonvulsants * Steroids * Heparin * Excess Thyroid medication * Aromatase inhibitors * Testosterone antagonists * Immunosuppressants

Answer 195

UE - Peripheral/Plexus neuropathy - (Shoulders abducted no more than 90deg, elbows 90deg, forearms pronated) Pelvis - LFCN or Fem n compression on bolsters/posts - (Check & re-check position/impingement) Face, Breasts, Genitals - Compression - (Adjust posts/padding, check during long procedure) POVL (Post-op Vision Loss) - Most secondary to ischemic optic neuropathy (mechanism unknown, but associated with prone position, Mayfield, \>6hrs anesthetic time, blodd loss\> 1L), some are central retinal artery occlusion due to direct pressure.

Answer 196

- NF1 AD - Becker Muscular Dystrophy X-linked recessive - Friedrich’s ataxia AR - Gaucher’s AR - Hemophilia A X-linked recessive - HMSN-1 AD - Marfan AD - OI 1 AD - OI 2 AR - OI 3 AR - OI 4 AD remember in general: • AD gene → structural deformities • AR gene → enzymatic / biochemical defects • translocations / deletions → chromosomal abn

Answer 197

• Lateral decubitus position, flouro, k-wires, plates, screws, etc • Universal posterior approach skin incision • Go lateral first (Aconeus/ECU interval) • ? Can I see across to coronoid and reduce it o Yes - fix coronoid with PA screws(or lasso) on Ulna and then fix or replace radial head o No - Fix or replace radial head  Go medial - ID and protect ulnar nerve • Flexor pronator split vs. subcutaneous elevation of flexor pronator mass o Fix coronoid • Repair LCL • Assess stability o Yes stable - close up you're done o No unstable - fix MCL  Check stability - Yes stable - close up you're done - No unstable - hinged external ixator...with a hope and a prayer • I think this follows King's alogorythm • Splint 1-2 weeks, wound check, 2-6 weeks hinged elbow brace ROM active + self assisted passive, 6 weeks D/C elbow brace ROM active and passive, 12 weeks reassess

Answer 198

- Lateral femoral condyle squaring - Increased joint space (up to 11 mm) - Cupping of the lateral tibial plateau - Hypoplastic lateral intercondylar spine

Answer 199

* Tardy ulnar nerve palsy * Non union * Cubitus valgus * Acute nerve injury (rare) * Lateral condylar overgrowth * AVN * Cubitus varus Ref: Chief review notes

Answer 200

* Suprascapular notch compression (most common) * Spinoglenoid notch cyst * Synovial mass * Traction neuropathy (overhead athletes) * Massive retracted cuff tear in the elderly * Humeral fracture dislocations JAAOS

Answer 201

* Chondral injury * Labral tears * Loose bodies * Synovial disorders * Ligamentum Teres rupture * Impinging osteophytes * Mechanical symptoms NYD Miller's p267

Answer 202

- Metaphyseal corner fractures - Posterior rib fractures - Multiple fractures at different stages of healing - Femur (long bone) fracture in non-ambulatory child - Scapular fracture - Vertebral compression and SP #’s - Epiphyseal separation

Answer 203

* Large thread diameter screws * Place screws parallel across cancellous trabeculae * Get fixationin cortical bone * Use fixed angle constructs (locking plates) * Augment screw fixation with PMMA * Antiglide plating * IM nailing * Place IM nail locking screws in different planes * Double plating * Longer plates with widely spaced screws * Tension band constructs * Bone graft augmentation

Answer 204

- SHEA Stadium - Shoulder - Hip - Elbow - Ankle NOT the knee

Answer 205

- Foramen Magnum Stenosis - Thoracolumbar kyphosis - Short pedicles - Decreased intrapedicular distance - Lumbar Lordosis - Lumbar stenosis - Vertebral scalloping

Answer 206

• Any level thumb • Amputation of multiple digits • Amputation through palm • Wrist / forearm / below elbow • Any level in a child Manny's notes

Answer 207

* Female * Cardiovascular Disease * Thyroid disease * Breast cancer treatment * Stroke * MI * Diabetes Ref: JAAOS

Answer 208

- From lowest consumption to highest o Syme o Midfoot o BKA o Through Knee o AKA

Answer 209

* Physical therapy & rehabilitation * Inferior capsular shift / plication * Rotator interval closure * Psychiatric referral Miller's p276.

Answer 210

* positional headache * wound complications * meningitis * arachnoiditis * pseudomeningocoele (10%)

Answer 211

- Appearance: CRITOE o Capitellum 1 o Radial head 5 o Internal epicondyle 5 o Trochlea 9 o Olecranon 9 o External Epicondyle 10 - Closure o Lateral Epicondyle 10 o Capitellum 12 o Trochlea 14 o Radial head 15 o Olecranon 15 o Medial Epicondyle 16

Answer 212

* Protection against autograft resorption * Relative maintenance of graft position * Prevention of soft tissue interposition

Answer 213

• Age 30 Yrs) • Overhead or contact athlete • Hill Sachs defect on AP in external rotation o Or loss of sclerotic inferior glenoid border o lesions visualized in this view are high risk • Hyperlax individual (Jer) • Glenoid bone loss REFERENCE: BOILEAU, P - vumedi webinar Or Instability Severity Score JBJS (Br) Boileau 2007

Answer 214

o B has the trauma room o Life threatening infection with unsalvageable necrosis o Partial traumatic amputation o Irreparable vascular injury o Warm ischemia time \> 8 hours (not talking about a finger here) o Nonviable limb o Poor host o No resources to facilitate salvage

Answer 215

* Patulous inferior capsule (ant and post IGHL) * Functional deficient rotator interval

Answer 216

• Non-op and Refer

Answer 217

* Infection (p. acnes) * Stiffness * Deltoid dehisence (open) * Severe edema (arthroscopic) * Suprascapular nerve injury * Missed pathology: biceps tendinitis

Answer 218

• A severe fracture (combined Plafond-talus, Hawkins 2/3) • An open fracture • Local infection • Evidence osteonecrosis talus • Coexisting major medical problems • Smoking (16x increased risk) AAOS

Answer 219

* \>2 weeks * Loose pin sites * Fever * Increased WBC * pus

Answer 220

• Kids: consider a CT before hand to determine pin placement and determine cranial thickness. Use 10-12 pins at lower torque (2 in-lb)

Answer 221

Life Style Factors - Anorexia nervosa - Excessive protein intake - Smoking - Excessive alcohol intake Endocrinopathies - Hyperthyroidism - Hyperparathyroidism - Cushing's syndrome - Type 1 diabetes melitus - Hypogonadism Systemic Diseases - Gaucher's disease - Mastocytosis - Rheumatoid arthritis - Ankylosing spondylitis - Psoriasis Organ Dysfunction - Cystic fibrosis - Asthma - Chronic obstructive pulmonary disease - Renal failure - Primary Biliary cirrhosis - Inflammatory bowel disease - Celiac sprue - Organ transplantation Medications - Glucocorticoids - Diuretics - Antiepileptics - Methotrexate - Cyclosporin A - Excess thryoid hormone replacement - Alkylating chemotherapeutic agents - Gonadotropin-releasing hormone agonist Neoplastic conditions - Multiple myeloma J Am Acad Orthop Surg 2005;13:475-486

Answer 222

* Superior - Supraspinatus * Medial - Coracoid * Lateral - Transverse humeral ligament * Inferior- Subscapularis

Answer 223

* Posterior plafond/medial mall and anterior/lateral of the talus (horisberger study) * The anterior talus was the worst

Answer 224

* Cartilage cap \> 1 cm in an adult (kids can be as thick as 2-3 cm at times) * Sudden increase in uptake on bone scan in an adult * Confirmation by CT or MRI of a soft tissue mass

Answer 225

* Blue sclera * Dentinogenesis imperfecta * Hearing loss (can have either conductive, sensorial, or both) * This skin prone to hemorrhage * CV disease (MV prolapse, Aortic regurg) * Hypermetabolism (heat intolerance, hyperhidrosis, tachycardia, tachypnea) * Pulmonary – decreased excusion * Allopecia JAAOS 2008

Answer 226

* AP with IR hip x-ray pre-op * Dedicated femoral neck CT with fine cuts * Lateral fluoro intra-op * Post-reduction/pre-extubation do AP and lateral hip Tournetta paper 2007, showed reduction in missed fractures from 58%  10% Ipsilateral neck: shaft in 2.5  9% of high energy femoral shaft fractures 30% are missed initially according to 1993 paper by Bennett (CORR)

Answer 227

* Age • Dislocation due to a seizure * Large Reverse Hill Sachs as defined by \> 1.5 cm3 I know there are more, but these came from a paper Duffy stressed us to know back in the fall (Robinson et al., 2011 JBJS)

Answer 228

• TRUE flexion contracures should be present: o Knee 21 degrees  decrease to 11 degrees at 3 mos and 3 degrees at 6 mos o Hip o Elbow

Answer 229

• Well, draw it chump!

Answer 230

o Vasculitis o Pleurisy o Pericarditis o Fever o Splenomegaly o Leukopenia o Decreased lacrimal and Salivary gland production (Sjogren's) o Lymphoid proliferation o Rash o Iridocyclitis (JRA) o Miller's p48

Answer 231

- Neurological deficit (tx by decompression) - Failed structural stability - failed medical management - sepsis - persistent pain - drainage of abcess - failed percutaneous biopsy x 2 (for tissue dx) chief notes

Answer 232

1. o small size, particularly in smaller women, o morbidity associated with harvest, o increased surgical time, o decreased hamstring strength (particularly important in explosive athletes) in Terminal flexion 2. o Increased failure in young, active o infection rate (theoretical however), o the quality of the graft is dependent on the individual it comes from o the handling and sterilization performed by the processor 3. o Bone:bone healing is good o Anterior knee pain, o Potential for patellar fracture, o Will result in a really long graft if patient has patella alta

Answer 233

• Ideal for the obese patient • Easier for the trochanteric entry hole; • Better control of proximal 1/3 frx  Tend to angulate in varus w/ supine position • Lower risk of Pudendal nerve palsy (thanks to bigger posts? No reports of injury in lateral position) Wheeless http: //orthopaedicprinciples.com/2011/06/current-concepts-in-im-nailing-of-femoral-shaft-fractures/ - This web site has lots of good lists...

Answer 234

* Malunion * Non-union (usually hypertrophic) * Insertion site irritation * Septic knee * leg length discrepancies (over or under) * Acute synovitis (non-infectious) * Re-fracture * Growth plate injury (...not in RW but I almost thought I did a transphyseal nail once...I didn't) * Malrotation (not mentioned but reasonable) RW p815

Answer 235

* If the patient has pain and no findings of fracture on x-ray, can order a bone scan or MRI looking for increased uptake or peri-lesional edema (stress fracture) * If the patient has minimal pain, can have them go home NWB with follow-up once the investigations are completed. * Endo consult - D/C bisphosphonates, Vitamin D and calcium, consider teriparatide.

Answer 236

• Hindfoot procedures only if no correction with coleman block • Triple for arthritis • Think forefoot, hindfoot, soft tissue and bone: o Address claw big toe (EHL transfer plantarly to 1st toe with IP fusion = 1st toes jones) o Address claw toes 2-5: MTP dorsal capuslotomy, EDB tenotomy and EDL lengthening or release and transfer EDL proximally +/- fusion of of IP's depending on flexible or fixed claw toes o PF release - Turco incision medially, ID and protect ML plantar nerves, seperate PF from tendons and subcu tissue and release o DF 1st ray opening wedge proximal MT osteotomy o Calcaneous: Lateral sliding or Dwyer closing wedge (lateral incision, oblique and slide, fix with 2 7.3 screws) o TAL

Answer 237

* Discontinue spinal instrumentation, release distraction forces * Rule out technical factors (electrodes) * Rule out anesthesia related concerns (Inhalational anesthetic - stop) * Elevate MAP (\>90) * Increase O2 concentration * Irrigate wound with warm saline * Assess ABG (metabolic abn or low Hgb) * if no return - remove last step of hardware, or wake up test * If still no change, remove spinal instrumentation or anterior strut/cage * Consider use of corticosteriod JAAOS 2007: • This is for SSEP amplitude decrease \>50% or MEP decrease \>75% • MEP amplitude loss in presence stable SSEP not uncommon, but opposite BAD (rare)

Answer 238

* What do you do? * What is the consequence of placing a left femoral component in a right knee? * What do you tell the patient? * How could this mistake have been avoided?

Answer 239

- Fracture - OM, septic joint, discitis - LCPD - Transient synovitis - Osteochondritis dissecans - Discoid meniscus - Sever's disease - Accessory navicular - Arthritis (JRA or Lyme disease) - Benign or malignant tumor

Answer 240

* trauma * infection * brachial plexus

Answer 241

 Type 1 Softening and swelling only (can’t see must probe)  Type 2 Fissuring,  Type 3 Crabmeat changes \>1.5 cm, fissure to subchondral bone  Type 4 Exposed subchondral bone

Answer 242

Miller p. 307-8 Disadvantages of HCLPE * Decreased tensile strength (pulling force to break) * Decreased fatigue strength (maximum cyclic stress) * Decreased fracture toughness (force to crack) * Decreased ductility (elongation without fracture) * Increased cost * No long term data * Advantages * Improves resistance to adhesive and abrasive wear * Improves bearing wear rate

Answer 243

- Achondroplasia FGFR3 - NF1 neurofibromin - Diastrophic dysplasia Sulfate transporter gene - Pseudochondroplasia COMP - Cleidocranial dysplasia CBFA1/osteocalcin - Marfan’s fibrillin - Hemophilia B Factor IX - Jansen’s PTHrP receptor - CMT Peripheral Myelin Protein22 - Duchenne’s/Beckers Dystrophin - Myotonic Dystrophy Myotonin - SMA Survival Motor Neuro Protein

Answer 244

Congenital ones are: • Often bilateral • Often have a misshapen radial head • The affected radius is longer than the ulna • The capitellum is hypoplastic • The distal humerus is grooved • The ossification is more advanced than on the opposite side. Ref: Rang book - Convex radial head - Hypoplastic capitellum - Short ulna with long curved radius - Bilateral - Posterior dislocation Reference millers 5th ed p461

Answer 245

* Infection * GH arthritis * Acromial humeral distance • Deltoid axillary nerve dysfunction * Atrophic cuff/chronicity/retraction

Answer 246

Knee has to be at 30 deg flexion for all three of these methods to be valid - Inferior pole relationship to Blumensaat's line - Blackburn-Peel ratio: o Distance from tibial plateau to inferior border of articular surface / length of articular surface = 0.8 ( o An index of 1 is alta - Insall-Salvati ratio: o Length of patella tendon (LT) / Length of patella (LP). LT/LP = 1, \>1.2 = alta, - Miller's p252

Answer 247

* Prepare the family * Position the patient - need an assistant to keep foot in maximum dorsiflexion * Local aneasthetic to site * Aseptic preparation from midfoot to mid leg * 11 blade, longitudinal incision on the medial side of achilles 1.5 cm above os calcis * Perform complete tenotomy from anterior to posterior direction (must get "pop") and should see increase in DF by about 15-20 deg * Dress site and apply cast (15 to 20 DF and 60-70 deg of abduction), remain in place for 3 weeks

Answer 248

• Idiopathic • Neurofibromatosis • Beckwith-Weidmann Syndrome Macroglossia, macrosomia, midline abdominal wall defects, ear creases/pits, neonatal hypoglycemia Can be one limb or a whle side of boy \*Increased Risk of Childhood Cancers\* Wilm's Tumour, hepatoblastoma, adrenal cortical carcinoma, neuroblastoma, rhabdomyosarcoma Cancer screening - abdominal U/S q 3mos until age 8, AFP q 6 wks until age 4 1. Wilm's Tumour (aka nephroblastoma) ◦ Painless abdominal mass Dx - Abdominal U/S

Answer 249

- Valgus knee - Increased ER of tibia - Decreased femoral anteversion - Tight heel cord (or gastroc) - Hypermobile first ray - Obesity - Generalized ligamentous laxity - Normal reconsitituion of the arch with the jack toe test

Answer 250

* Valgus \> 12 * Abberant retractor * Epidural anesthesia * Previous laminectomy * Peripheral neuropathy These last two are due to "doublecrush" phenomenon Basic Science

Answer 251

* Li-Fraumeni * Retinoblastoma * NF-1 * HIV * Prior radiation * EBV (controversial) A collection of JAAOS, Miller's, and AAOS COR

Answer 252

* Syrinx most common * DM2 * Leprosy * Syphillis * Alcoholism

Answer 253

- Take less external rotators off with the acetabular approach o Save quadratis and OE - The classic KL incision aims more towards the PSIS rather than straight - Release the ER off the femur o Directly off bone in a THA and leaving a 1 cm cuff with KL

Answer 254

 MCL 4000 N  PCL 2500 N  ACL 2200 N  LCL 700 N

Answer 255

- EXT 1 or EXT 2 or even EXT 3 - AD - 10% malignant risk - Knee \> shoulder - Limb deformity - Ulna bow - Radial head dislocation - Sessile or pedunculated - Lesions grow away from the physis - Lesions are in continuity with IM canal (differentiates from parosteal osteosarcoma)

Answer 256

- Hemarthrosis - Bone bruise o mid-third lateral femoral condyle o post-third lateral tibial plateau - Lateral meniscus tear - Segond fracture o Lateral capsular avulsion of tibia

Answer 257

* Bauman's angle (not that good in older children where start to get fusion of the ossification center) * Metaphyseal-diaphyseal angle (least accurate) * Humeral-ulnar angle (best) Source: Rockwood and Wilkins

Answer 258

• Interosseous ligament (largest; 8 mm thick) • Plantar (second largest) • Dorsal (small and whimpy) See reference - Anatomy of the Lisfranc Ligament Anthony Johnson 2008

Answer 259

- Load-to-failure o Hamstrings 4000 N load-to-failure o Quadriceps in between o BTB 2600 N load o Native ACL: 2200N

Answer 260

• Larsen syndrome

Answer 261

- Ewings - Lymphonma - EG - Neuroblastoma - PNET - Rhabdomyosarc - Myeloma

Answer 262

* ORIF * ORIF and bone graft * Some controversy - can either leave to heal or if osteolysis significant, can ORIF with bone graft * Treat non-op

Answer 263

- Failure of at least 6 weeks of non-op management - Progressive neurological deficit - Instability or deformity + radiculopathy - Significant motor deficit (deltoid or wrist extension deficit) Chief notes

Answer 264

- Association - Prediction - Excluding alternative - Dose response

Answer 265

vascularity of articular segment more likely to be preserved if • \> 8 mm of calcar attached to articular segment • integrity of medial hinge • fracture pattern (anatomic neck)

Answer 266

• Piece it together on the back table and compare • Proximal implant should line up with the proximal lesser sigmoid notch • Inspection should show no lateral ulnohumeral gapping (medial side starts to gap at 6 mm) • DRUJ has appropriate ulnar variance compared to the contralateral side. • Template off the contralateral side Ref: mostly Athwal JBJS 2010

Answer 267

- AKON - Morquios - SED

Answer 268

* Rehab * then open repair (I am referring this one)

Answer 269

* Minimally or nondisplaced fractures of coronoid and radial head * Congruent reduction * Stable arc of motion, extension \> 40 deg Vumedi Webinar Graham king

Answer 270

* Arthrogrypotic * Myelomeningocele * Diastrophic dysplasia * Amniotic band syndrome AAOS

Answer 271

* Age * Sport * Level of sport participation * Laxity * Soft tissue lesions * Bone lesions on glenoid * Bone lesions on humerus

Answer 272

* Biceps tendon * SGHL * CHL * Glenohumeral capsule Hunt, et. al. JAOSS 2007 15 p218-219

Answer 273

* Gauchers * Osteopetrosis * Niemann-pick

Answer 274

- Myelomeningocele - Syrinx - Arthrogryposis

Answer 275

- Superior gluteal artery and nerve - Piriformis - Internal Pudendal artery and pudendal nerve - Nerve to Obturator internus - Posterior femoral cutaneous nerve - Sciatic nerve - Inferior gluteal artery and nerve - Nerve to Quadratus femoris POPS-IQ below piriformis…

Answer 276

- Marked atrophy or fatty infiltration of spinate muscles on MRI ( \>50% (grade IV) Sagittal T1) - Acromiohumeral distance less than 5 mm on AP ( very poor) - Dynamic antero-superior subluxation of humeral head on resisted abduction - Irreparable tears of the subscapularis or teres minor - Poor tissue quality - Loss of GT from prior surgery - Poor patient compliance - Axillary nerve or suprascapular nerve deficit - Pseudoparalysis without pain - Chronic tears longer than 1 yr - History of deltoid injury or acromioplasty - Prior infection - Presence of Os Acromiale Complex And Revision Problems In Shoulder Surgery - By Jon J. P. Warner, Joseph P. Iannotti, Evan L. Flatow & ICL 55-5

Answer 277

• Mild , 7-10 degrees - usually asymptomatic o Can treat with dressing/splint opposite direction of bunion splint • Moderate severe – o EHL tendon transfer, use medial capsular incision and release joint capsule. then release lateral 2/3's of EHL distally and pass plantar to transverse metatarsal ligament . drill hole through 1st metatarsal head and attach to medial periosteum holding toe in 10-15 degrees of valgus

Answer 278

- Multiple enostosis (bone islands) - Colorectal polyps - Fibromas - Sebaceous cyst

Answer 279

* Femoral anteversion * Genu valgum * Pronated feet

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