Abos- Day 29 1/3 A

Front 1

A teenage boy injured his hip while competing in a track meet. His radiograph is shown in Figure A. Which of the following muscles is most likely injured?
tx?

Back 1

Adolescent athletes may sustain an avulsion of the anterior inferior iliac spine (AIIS) which is due to the pull of the rectus femoris. Figure A shows a radio-density overlying the right acetabulum which is consistent with a mildly displaced AIIS avulsion in a skeletally immature patient.
tx-NSAIDS, rest, ice, stretching/strengthening,usually resolves within 4-6 weeks

Front 2

Rectus femoris strain
Epidemiology-
MoI-

Back 2

Epidemiology- seen MC in soccer and football players
MoI- sudden, forceful eccentric contraction of the muscle sprinting from standing position
kicking soccer ball with great force

Front 3

PEI/P
provocative maneuvers
x-ray findings
Origin
Insertion
Action
Arterial Supply

Back 3

PE-I/P; tenderness to palpation in the injured area, proximally at origin of rectus femoris muscle belly midthigh region distally at knee; feel for defect in muscle indicating a full tear (unusual finding)
provocative maneuvers- pain elicited with resisted hip flexion or extension
x-ray- avulsion at insertion site on anterior inferior iliac spine in adolescent athletes ,normal in most cases
Origin-Straight head from anterior inferior iliac spine; reflected head from groove just above acetabulum
Insertion-Base of patella to form the more central portion of the quadriceps femoris tendon
Action-Extends the knee
Innervation-Muscular branches of femoral nerve (L2, L3, L4)
Arterial Supply Lateral circumflex femoral artery

Front 4

A 60-year-old man has chronic shoulder pain and weakness. Radiographs show moderate glenohumeral arthritis and narrowing of the acromio-humeral distance. He is scheduled to undergo either hemiarthroplasty or total shoulder arthroplasty. His postoperative function will be most affected by which of the following factors?

Back 4

The integrity of the rotator cuff
If there is an irrepairable rotator cuff tear, TSA is CONTRA-INDICATED.
irrepairable rotator cuff tear-Tx options hemiarthroplasty (with limited functional outcomes) or rev TSA

Front 5

A 78-year old female sustained a 4-part proximal humerus fracture on her dominant side 2 days ago and undergoes a shoulder hemiarthroplasty. Intraoperatively, the lesser tuberosity reduction was difficult and placed too close to the greater tuberosity, which was anatomic. What post-operative problem is likely to result due to the position of the lesser tuberosity?

Back 5

external rotation deficit
Placing the lesser tuberosity in a more lateral position will increase tension on the subscapularis and likely lead to a deficit in external rotation.

Front 6

CONTRA-INDICATED hemiarthroplasty (horse big one)
most common causes of failure?

Back 6

Contraindications-1 infection;2 neuropathic joint;3 unmotivated patient; 4 coracoacromial ligament deficiency provides a barrier to humeral head proximal migration in the case of a rotator cuff tear; subcutanous escape will occur if coracoacromial ligament and rotator cuff are deficient
tuberosity migration is one of the most common causes of failure with hemiarthroplasty

Front 7

SI for hemi artho of shoulder (pins)

Back 7

SI-1 primary arthritis 2 if rotator cuff is deficient 3 glenoid bone stock is inadequate 4risk of glenoid loosening is high-young patients & active laborers
5 rotator cuff arthropathy
6osteonecrosis without glenoid involvement 7 proximal humerus fractures --3-part fractures with poor bone quality; 84-part fractures; 9 head-splitting fractures; 10 fracture with significant destruction of the articular surface

Front 8

which images?
B2.12 (RXrV &PPFs?)
B2.14 RmriP/PS & MRI-fs?)MRI

Back 8

(Grashey view) true AP of shoulder- extent of DJD
delineation of fracture pattern
axillary view:look for posterior wear of glenoid & helps quantify displacement in cases of fracture
CT scan:determine glenoid version and glenoid bone stock,
if fracture pattern is poorly understood after radiographic evaluation
MRI; evaluation of rotator cuff

Front 9

A 20 year-old distance runner developed proximal tibial pain 6 weeks ago. Initially it was only painful while running, but she now has pain with walking. There is no knee effusion. The radiographs are normal. The MRI is shown. Which of the following is the most appropriate initial management?

Back 9

Protected weight-bearing with crutches and possible use of a bone stimulator is useful early.minimum of 4-6 weeks but surgical intervention may be necessary if symptoms are not responsive to initial nonoperative treatment.
The typical posteromedial stress fracture is considered lower risk, whereas the anterior or “dreaded black line” stress fractures are considered higher risk. Ishibashi showed that MRI was better than bone scan for evaluating these injuries.

Front 10

A college football player has progressive leg pain for over 6 months, is no longer able to run and has failed non-operative treatment. His radiograph shows a linear lucency over the anterior tibia. What is the next most appropriate step to quickly return him to play?

Back 10

Once the radiographs show the fracture especially in the anterior cortex of the tibia, surgical treatment is often recommended. This location is uncommon, but at increased risk for nonunion and propagation to complete fracture.

Front 11

Which of the following stress fracture locations has the greatest likelihood of delayed healing or developing a non-union?

Back 11

The anterior tibial cortex is a tension side stress fracture and reportedly in the article below it is a problematic area to heal. Conversely, compression side tibial stress fractures usually heal without a problem. This is true on the femoral neck as well.

Front 12

def stress tibial fx
Epidemiology
Mechanism
Pathophysiology

Back 12

An overuse injury where normal or abnormal bone is subjected to repetitive stress, resulting in microfractures
- commonly seen in runners and military recruits
seen after change in training routine
-linear microfracures in trabecular bone from repetitive loading
- callus formation
woven bone
endochondral bone formation

Front 13

History
Symptoms
Physical exam
Tx

Back 13

A- 'normal response to abnormal stress' described as a biomechanical failure of bone under repetitive, nonviolent stress. A microfracture occurs which progresses to a stress fracture with continued stress.
Hx- recent increase in running speed, shoe or track error is common.
Eating disorders and menstrual irregularities have been associated with stress fractures.
sx- onset of symptoms often insidious
symptoms initially worse with running, then may develop symptoms with daily activities, usually describe localized pain which is relieved by rest. Pain continues to occur earlier in the training course with continued exercise.
PE- point tenderness on the bone, aggravated by percussion.
Surgery = reamed unlocked IM nail.

Front 14

Radiographs, recommended views & findings
other 2 test

Back 14

- AP and lateral
lateral xray may show "dreaded black line" anteriorly indicating tension fracture from posterior muscle force
endosteal thickening periosteal reaction with cortical thickening
Technetium Tc 99m bone scan- focal uptake in cortical and/or trabecular region
MRI-replacing bone scan for diagnosis and is most sensitive findings;
marrow edema
earliest findings on T2-weighted images
periosteal high signal
T1-weighted images show linear zone of low signal

Front 15

Back 15

1. Fibula
11. PoplitealVessels
2. Tibia
12.Tibial Nerve
3. Tibia Tuberosity
13. Medial Head of Gastrocnemius
4. Patellar Tendon
14. Lesser Saphenous Vein
5. Tibialis Anterior
15. Gracillis
6. Extensor Digitorum Longus
16. Long Saphenous Vein
7. Common Peroneal Nerve 17. Medial Collateral Ligament
8. Lateral Head of Gastrocnemius
18. Semitendinosus
9. Soleus
19. Sartorius
10. Tibialis Posterior

Front 16

Back 16

Intermediate Dorsal Cutaneous branch of Superficial peroneal nerve
10. Tibialis Posterior
2. Peroneus tertius
11. Flexor Digitorum Longus(FDL)
3. Medial Dorsal Cutaneous branch of Superficial peroneal nerve
12. Tibial Nerve and Posterior Tibial Vessels
4. Extensor Digitorum Longus
13. Flexor Hallucis Longus
5. Deep Peroneal Nerve and Anterior Tibial Vessels
14. Achilles tendon
6. Extensor Hallucis Longus
15. Sural Nerve and Lesser Saphenous Vein
7. Tibialis Anterior 16. Peroneus longus
8. Great saphenous vein and saphenous nerve
17. Peroneus brevis
9. Medial Malleolus of Tibia
18. Lateral Malleolus of Fibula
19. Talus