156 A 3/21 Day (A & B 3/22 ) Daily Mastery Plan

Front 1

The fusion gene resulting from the chromosomal translocation t(X;18)(p11;q11) is chararcteristically found in which malignancy?
1. Synovial sarcoma
2. Chronic myelogenous leukemia (CML)
3. Ewings sarcoma
4. Alveolar rhabdomyosarcoma
5. Clear cell sarcoma

Back 1

The SYT-SSX1 & SYT-SSX2 fusion genes resulting from the chromosomal translocation t(X;18)(p11;q11) are chararcteristically found in synovial sarcoma. Synovial sarcoma occurs MC in pts 15 to 40 yrs of age & affects M > F. It is a slow growing tumor that has a propensity for the juxta-articular regions around the knee, shoulder, arm, elbow, and foot. tx for synovial sarcoma is wide resection and radiation +/- chemotherapy with a 10 year survival of approximately 25%.
Incorrect Answers:
2-BCR-ABL is an oncogene assoc w/ chronic myelogenous leukemia (CML), the result of a reciprocal translocation between chrom 9 & 22.
3-The EWS (EWSR1) gene is involved in translocations in Ewing's sarcoma, clear cell sarcoma, desmoplastic small round cell tumor & myxoid liposarcoma. The Ewing sarcoma family of tumors is characterized by recurrent translocations that fuse EWS to one of the following genes FLI1 (>90% of cases), ERG, ETV1, E1AF and FEV.
4-4-PAX3-FKHR is a gene fusion in Alveolar RhAns1

Front 2

Which of the following statements regarding rhabdomyosarcoma is true?
1. Most common soft tissue sarcoma in the foot
2. Most common soft tissue sarcoma in a child
3. Commonly shows calcification on plain radiographs
4. Soft tissue sarcoma associated with Maffucci's syndrome
5. Dedifferentiates from benign myxomatous tumors

Back 2

Rhabdomyosarcoma is the most common soft tissue sarcoma in a child. The most common soft tissue sarcoma in the foot, and a sarcoma which commonly shows calcification on plain radiographs is a synovial cell sarcoma. Hemangiomas are commonly associated with Maffucci's syndrome (multiple enchondromas and hemangiomas). Finally, rhabdomyosarcoma does not dedifferentiate from benign myxomatous tumors. Pappo et al. retrospectively evaluated their cohort of children with rhabdomyosarcoma and tried to evaluate prognostic factors associated with poor prognosis after recurrence. They determined that histologic subtype, stage, and timing of diagnosis were directly related to survival after recurrence. Wexler and Helman review diagnosis and treatment of pediatric soft tissue sarcomas. Ans1

Front 3

1. what is the mortality rate for closed pelvic ring fracture
2. What is the mortality rate for a open pelvic ring fracture
3.  

Back 3

1. 25%
2. 50%

Front 4

1. What is the most common cause of death for pelvic ring fracture, ie highest rate transfusion which type
2. was the most common cause of head injury with which pelvic ring fracture, which type
3. which fracture pattern as the most common cause of death from visceral injury

Back 4

1. hemorrhage-AP3
2. Lateral compression 3
3. Anterior compression

Front 5

what is the most common and the  common associated injury pattern on there with pelvic ring fractures

Back 5

• most common = chest injury
• Long bone fracture, abdominal injury, spine fractures, urogenital injuries

Front 6

regarding prognosis there is a problem to poor functional outcome in chronic pain with injuries associated with what findings – 7

Back 6

1. SI joint incongruity >1 cm
2. I initially degree displacement
3. Malunion or residual displacement
4. Leg length discrepancy greater than 2 cm
5. Nonunion
6. Neurologic injury
7. Urethral injury

Front 7

what injury pattern do pediatric pelvic ring fractures have

 

 

Back 7

children open triradiate cartilages the iliac wing is weaker than an elastic pelvic ligaments therefore the bone fails reported pelvic ring disruption in these fractures really require surgical treatment

Front 8

1. what is the strongest ligament in the body
2. identify this ligament resist external rotation after failure of the pelvic floor and the anterior structures
3. identify this structure that resist anterior posterior translation of the pelvis
4. Identified this structure that resist cephalad caudad displacement of the pelvis
5. Identified this structure that resist rotation and augments posterior SI ligaments

Back 8

•  1=2: posterior iliac sacral ligaments;
• 2=8: interosseous sacroiliac ligaments-anterior
• 3=interosseous sacroiliac 
• 4=posterior sacroiliac 
• 5-1: iliolumbar ligament;
• 3: sacrospinous ligament; 4: sacrotuberous ligament; 5: obturator membrane; 6: lesser sciatic foramen; 7: greater sciatic foramen; 

Front 9

1. which ligament and the pelvic floor resist external rotation identify it
2. Which ligament of the pelvic floor resist sheer and flexion identified

Back 9

1=3: sacrospinous ligament;

2=4: sacrotuberous ligament; 

1: iliolumbar ligament; 2: posterior iliac sacral ligaments;  5: obturator membrane; 6: lesser sciatic foramen; 7: greater sciatic foramen; 8: interosseous sacroiliac ligaments

Front 10

patient presents to the emergency room after trauma high speed and there is a leg length discrepancy

1. what is the diagnosis
2. was the most common lumbosacral plexus indication injury

Back 10

1. pelvic ring
2. L5 and S1 are most common)

Front 11

1. what review of the pelvis is best
2. What E looking for

Back 11

1. AP pelvis
2. Symmetry, rotation and displacement of the hemipelvis

Front 12

1. what review his this to the pelvis
2. what is it used for visualizing

Back 12

1. inlet view

• Anterior posterior translation of the hemipelvis
• Internal and external rotation of hemipelvis
• Widening of the SI joint
• Sacral alar impaction

Front 13

1. what view of the pelvis as this
2. What is the used for visualizing

Back 13

1. outlet view

• Vertical translation of the hemipelvis
• Flexion-extension of the hemipelvis
• There was disruption of the sacral foramina
• location of sacral fractures

Front 14

what are the radiographic signs of instability

Back 14

1. >5 mm displacement posterior sacroiliac complex
2. Posterior sacral fracture gap
3. Avulsion fracture she'll spine, additional tuberosity, sacrum, transverse process of the 5th lumbar vertebrae

Front 15

1. what is the diagnosis
2. What is the most common cause of death with this fracture pattern
3. Treatment

Back 15

1. anterior posterior compression3
2. Hemorrhage injury to the superior gluteal artery
3. Anterior symphyseal multihole plate or ex-fix with posterior stability stabilization with SI screws and plate and screws

Front 16

1. what is the diagnosis
2. Was most common cause of death from this type injury
3. What is the treatment

Back 16

1. vertical shear
2. Hypovolemic shock 25% mortality
3. Posterior stabilization plate or SI screws as needed
4. Percutaneous or open injury) surgeon preference

Front 17

1. what is the diagnosis
2. What is the most common cause of death with this fracture pattern
3. what is most common source of arterial hemorrhage
4. what is the treatment

Back 17

1. lateral compression type III
2. closed head injury
3. Internal pudendal artery and obturator artery
4. Posterior stabilization with plate or SI screws as needed percutaneous or open

Front 18

1. what is the most common long-term complication with a pelvic ring fracture
2. was the most common nerve injury with posterior stabilization
3. What is a contraindication for external fixation of pelvis

Back 18

1. urethral stricture
2. L5 nerve root
3. fracture of the ilium

Front 19

was the indication for ORIF of pelvic ring fracture

Back 19

1. symphysis diastases >2.5 cm
2. SI joint displacement >1 cm
3. Sacral fracture with displacement >1 cm
4. Displacement and rotation hemipelvis
5. Open fracture

Front 20

1. what is the indication for a diverting colostomy
2. what is the most common neurologic injury in the pelvic ring
3. what is the diagnosis of this image & what is does it mean?
4. what kind of CATHETER IS CONTRAINDICATED WITH ANTERIOR RING PLATING

Back 20

1. open pelvic fracture
2. posterior urethral tear
3. bladder rupture, mortality rate 33%
4. suprapubic catheter placement

Front 21

1. when placing iliosacral screw screws percutaneously into the safe zone of the S1 vertebral body what radiographic view is past for superior inferior screw placement
2. Which review is best for anterior posterior screw placement

Back 21

1. superior/inferior = outlet view
2. anterior posterior view = inlet

Front 22

1. what is the classification of an anterior posterior pelvic ring fracture
2. with the treatment

Back 22

1. 1 symphysis widening < 2.5 cm– nonoperative weightbearing
2.  type II=symphysis widening > 2.5 cm =pubic symphysis diastases, torn anterior sacroiliac ligaments torn sacral tuberous and sacrospinalis ligament ,intact posterior sacroiliac ligaments=>treatment =anterior symphyseal plate or external fixator plus or minus posterior fixation
3. type III =all the above plus posterior SI ligaments disrupted=>anterior surface symphyseal multihole plate or ex-fix and posterior stabilization with SI screws

Front 23

1. which fractures AKA windswept pelvis

Back 23

lateral compression type III

Front 24

which fracture is also known as crescent fracture located on the side of impact

Back 24

lateral compression type II

Front 25

which fracture pattern is most likely cause bladder rupture and urethral injury

Back 25

lateral compression type III

Front 26

A 23-year-old male is involved in a motor vehicle accident and sustains a left open femur fracture, right open humeral shaft fracture, and an LC-II pelvic ring injury. Which of the following best describes the radiographic findings associated with this pelvic injury pattern using the Young-Burgess Classification system?

1.  Crescent fracture located on the side of impact

2.  Widened anterior SI joint, disrupted sacrotuberous and sacrospinous ligaments with intact posterior SI ligaments

3.  Complete SI disruption with lateral displacement

4.  Sacral compression fracture on side of impact with transverse pubic rami fractures

5.  Open-book injury with contralateral sacral compression fracture

Back 26

Lateral compression type II fractures (as described by the Young-Burgess Classification System) are associated with a crescent fracture of the iliac wing located on the side of impact. A representative CT scan image and illustration of this injury are shown in Illustration A and B respectively. A table describing each pelvic injury and their associated complications is shown in Illustration C. Illustration D shows each Young-Burgess pelvic injury type. Incorrect Answers:
Answer 2: This describes an APC-II injury
Answer 3: This describes an APC-III injury
Answer 4: This describes and LC-I injury
Answer 5: This describes an LC-III injury (ie. "wind-swept pelvis")
ans1

Front 27

which classification does this description fits

2. Widened anterior SI joint, disrupted sacrotuberous and sacrospinous ligaments with intact posterior SI ligaments

3.  Complete SI disruption with lateral displacement

4.  Sacral compression fracture on side of impact with transverse pubic rami fractures

5.  Open-book injury with contralateral sacral compression fracture

Back 27

Answer 2: This describes an APC-II injury
Answer 3: This describes an APC-III injury
Answer 4: This describes and LC-I injury
Answer 5: This describes an LC-III injury (ie. "wind-swept pelvis")

Front 28

what nerve is most at risk when of applying up pelvic ex-fix with supra-acetabular pins through the AIIS

Back 28

lateral femoral cutaneous nerve

Front 29

 What nerve is most at risk when applying the external fixator shown in Figure A using a minimally invasive fluoroscopic technique of pin insertion?

1.  Ilioinguinal nerve

2.  Obturator nerve

3.  First branch of the femoral nerve

4.  Lateral femoral cutaneous nerve

5.  Superior gluteal nerve

Back 29

Pelvic external fixation with supraacetabular pins through the AIIS can be utilized to stabilize a pelvic fracture. While using this technique, care must be taken not to injure the lateral femoral cutaneous nerve (LFCN). Gardner et al describe the technique for placement of supraacetabular external fixation pins and state that pins in this location are more stable biomechanically compared to other locations in the iliac crest. Grothaus et al performed a cadaveric study to determine the anatomic detail and variation of the LFCN and the distances it traveled from various landmarks.The found the nerve to potentially be at risk as far as 7.3 cm medial to the anterior superior iliac spine along the inguinal ligament and as much as 11.3 cm distal on the sartorius muscle from the anterior superior iliac spine. Riina et al performed a cadaveric study to define the neurovascular structures at risk with the placement of anterior-posterior locking screws in the proximal femur. They found that risks to the neurovascular structures during anterior-posterior locking in the proximal femur are diminished if locking is performed above the level of the lesser trochanter. 
ans4

Front 30

What structure has been described as having a risk of injury with retractor placement on the sacrum during combined acetabular-pelvic ring surgery using the Stoppa approach with a lateral window?

1.  External iliac artery

2.  Pudendal nerve

3.  Corona mortis

4.  L5 nerve root

5.  Ilioinguinal nerve

Back 30

Care must be taken when placing a retractor on the anterior aspect of the sacrum, as the L4 and L5 nerve roots are both at risk. 

Illustration A shows a diagram of the lumbosacral plexus, indicating the proximity of the L4 and L5 nerve roots to the anterior sacrum and SI joint.ans4

Front 31

was most lower form of inflammatory arthritis

Back 31

heumatoid arthritisr

Front 32

1. rheumatoid arthritis is what type of immunologic response
2. what is rheumatoid factor
3. Order the primary cellular mediator of tissue destruction the rheumatoid arthritis

Back 32

1. cell mediated T-cell – MHC type II
2. rrheumatoid factor = IgM attacking IgG
3. Mononuclear cells

Front 33

what is the diagnosis rheumatoid arthritis splenomegaly and leukopenia

Back 33

Felty's syndrome

Front 34

 A 64-year-old female with rheumatoid arthritis has decreased functional use of the left hand for activities of daily living. On physical examination she has fixed deformities of the metacarpophalangeal (MCP) joints as demonstrated in Figure A. A radiograph is shown in Figure B. Which of the following management options for the finger MCP joints most likely lead to the least amount of extensor lag and improvement of the ulnar drift at 1-year followup?

1.  Tenosynovectomies with extensor indicis proprius (EIP) to EDQ transfer

2.  Tenosynovectomies with extensor reconstructions (central slip imbrication, Fowler distal tenotomy)

3.  Metacarpal joint resection arthroplasties with palmaris autograft interposition

4.  Extensor tendon relocation, extrinsic tendon release, and metacarpophalangeal joint collateral ligament reefing

5.  Metacarpophalangeal joint arthroplasties

Back 34

The history, clinical image, and radiograph demonstrate severe MCP joint involvement with fixed deformities. MCP arthroplasty is the procedure of choice for severe finger MCP joint arthritis involvement or fixed deformities. Thumb MCP involvement is treated with arthrodesis in most cases. ans5

Front 35

A 45-year-old woman with rheumatoid arthritis is being scheduled for a total knee athroplasty in 2 weeks. She is currently taking sulfasalazine, Penicillamine, and etanercept, a tumor necrosis factor inhibitor (aTNF-a). What changes should be made to her medication regimen prior to surgery?

1.  Discontinuation of all three medications 4 weeks prior to surgery

2.  Discontinuation of sulfasalazine 4 weeks prior to surgery, continuation of etanercept and penicillamine

3.  Continuation of sulfasalazine, penicillamine, and etanercept

4.  Continuation of sulfasalazine and penicillamine, discontinuation of etanercept 4 weeks prior to surgery

5.  Continuation of penicillamine, discontinuation of sulfasalazine and etanercept 4 weeks prior to surgery

Back 35

Anticytokine disease-modifying antirheumatic drugs (DMARD) have become increasingly popular in the treatment of RA. Immunosuppression and the risk of infection are potential complications for all anti-TNF-alpha medications. Current recommendations for cessation of immunosuppressive therapy are when the drug concentrations are at their lowest levels which include the following: 3 days after etanercept injection; 2 weeks prior to infliximab infusion; 10 days after adalimumab injection. Medications such as sulfasalazine and penicillamine may be continued during the pre and post-operative period. Recent evidence and guidelines such as those reviewed by Keith's paper, suggest that anti-TNF-alpha medications should be stopped 4 weeks prior to surgery. ans4

Front 36

In the treatment of patients with rheumatoid arthritis, TNF-alpha is blocked by which of the following agents?

1.  Tocilizumab

2.  Anakinra

3.  Etanercept

4.  Abatacept

5.  Rituximab

Back 36

Etanercept is a biochemically designed soluble p75 tumor necrosis factor receptor immunoglobulin G fusion protein, which blocks the downstream effects of TNF. ans3

Front 37

 Which of the following drugs is an IL-1 antagonist typically used as a second line agent in the treatment of rheumatoid arthritis?

1.  Anakinra

2.  Methotrexate

3.  Leflunomide

4.  Adalimumab

5.  Etanercept

Back 37

IL-1 receptor antagonist (IL-1Ra) is a naturally occurring molecule that blocks the biologic effects of the pro-inflammatory cytokine IL-1. A recombinant form of human IL-1Ra, anakinra, is used to manage rheumatoid arthritis patients who are refractory to more conventional forms of treatment. Methotrexate and leflunomide are DMARD's, and are typically prescribed if low dose corticosteroids are ineffective. Adalimumab and etanercept are both TNF-alpha blockers. 
ans1

Front 38

 Which immunoglobulin subtype does the rheumatoid factor target?

1.  IgA

2.  IgE

3.  IgM

4.  IgG

5.  Rheumatoid factor does not target an immunoglobulin

Back 38

Rheumatoid factor is an auto-antibody most commonly seen with rheumatoid arthritis. The presence of rheumatoid factor can also indicate generalized autoimmune activity unrelated to rheumatoid arthritis (e.g. tissue or organ rejection). Rheumatoid factor is itself an IgM antibody that is directed against the Fc portion of IgG antibody. Rheumatoid factor (IgM) attaches to IgG to form immune complexes which are deposited in tissues like the kidney and contribute to the overall disease process in rheumatoid arthritis. ans4

Front 39

 Infliximab is a chimeric monoclonal antibody used to treat rheumatoid arthritis. What cytokine does it target?

1.  TGF-beta

2.  TNF-alpha

3.  CD-20 antigen

4.  IL-6

5.  IL-1

Back 39

In rheumatoid arthritis, and other chronic inflammatory conditions, cytokines produced by activated T-cells/macrophages contribute to the pro-inflammatory state. TNF-alpha (tumor-necrosis factor-alpha) and IL-1b are thought to be the major cytokines involved in rheumatoid arthritis pathology. Most DMARDs (disease modifying anti-rheumatoid drugs) are directed towards blocking TNF-alpha or its receptors. ans2

Front 40

 A 43-year-old female with long-standing rheumatoid arthritis complains of right forefoot pain for several years. She has failed conservative treatment and radiographs are shown in Figure A. What is the most appropriate treatment?

1.  Bunionectomy

2.  Keller procedure with lesser metatarsal head resections

3.  1st MTP joint fusion and lesser metatarsal head resections

4.  Forefoot amputation

5.  1st MTP joint interposition arthroplasty and lesser MTP joint arthroplasties

 

Back 40

Surgical treatment of a rheumatoid forefoot involves fusion of the 1st MTP and lesser metatarsal head resections. The earliest manifestation of rheumatoid arthritis of the forefoot is synovitis of the MTP joints with eventual hyperextension deformity of the MTP joints including distal migration of the forefoot pad, painful plantar callosities and skin ulcerations over bony prominences. 
ans3