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63 Cards in this Set
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A 35-year-old female office worker reports 6 months of deep aching on her lateral dominant elbow which worsens with repetitive movements. On physical exam, the patient has tenderness located 4cm distal to the lateral epicondyle. She also complains of night pain. What is the most likely diagnosis? |
As discussed by Dang et al in their review article on compression neuropathies of the upper extremity, the clinical diagnosis of radial tunnel syndrome (RTS) must be distinguished from that of lateral epicondylitis by the location of tenderness on physical exam. In lateral epicondylitis, the focal point of tenderness is on the lateral epicondyle at the insertion of the ECRB. In contrast, the characteristic pain of RTS is located 3-4 cm distal to the lateral epicondyle in the area of the mobile wad and radial tunnel. Ans2
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An otherwise healthy 30-year-old male sustains a left forearm injury as a result of a fall from a ladder. Initial examination in the emergency room reveals a clean 2 centimeter laceration over the volar forearm associated with the radiographs shown in Figures A and B. Treatment should consist of irrigation and debridement of the wound followed by which of the following? |
The clinical scenario is consistent with an open fractures of the distal radial and ulnar shafts. Literature shows that definitive plating of an open forearm fracture followed by primary closure of the wound is acceptable treatment at the time of injury. |
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A 10-year-old boy sustains an injury to his dominant elbow and presents with the injury shown in Figures A and B. What is the next best step in management?
1. Immobilization in full pronation 2. Open reduction 3. Closed reduction 4. Closed reduction and percutaneous pinning 5. Open reduction and internal fixation |
The scenario and image depict a patient with an isolated radial neck fracture. The next best step is an attempted closed reduction as the images demonstrate angulation >30. Techniques of closed reduction include applying extension, varus stress, and manual pressure; elbow flexion with forearm pronation and manual pressure(Israeli method), and the Esmarch method. Once reduced, the fractures are commonly stable and do not require fixation.
Incorrect Answers Answer 1: The presenting alignment is not acceptable. Answer 2: Open reduction may cause iatrogenic stiffness and should be avoided if possible. Answer 4: Percutaneous pinning is not required if the reduction is stable. Answer 5: Open reduction may cause iatrogenic stiffness and should be avoided if possible. Ans3 |
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A child is seen in the pediatric orthopedic hand clinic for evaluation of a congenital deformity. A clinical photograph and radiograph are seen in Figures A and B. What is the next best step in this child's evaluation to rule out an associated autosomal-recessive lethal condition? Topic Review Topic
FIGURES: A B QID: 3566 1. Cardiac ultrasound and renal ultrasound 2. Cardiac ultrasound, barium swallow and MRI 3. LFTs, CBC and cardiac ultrasound 4. Cardiac ultrasound, peripheral blood smear and MRI 5. CBC, peripheral blood smear and chromosomal breakage analysis |
The clinical and radiographic images depict a patient with radial club hand. This is associated with a number of congenital anomalies including Fanconi’s Anemia (FA), thrombocytopenia absent radius (TAR), Holt-Oram syndrome, VACTERL syndrome, and VATER syndrome. Although all these congenital anomalies are important to recognize and treat, none is more life-threatening than FA. FA is an autosomal-recessive condition resulting in aplastic anemia and eventual death. The typical presentation is between 6-9 years of age. It is the most common inherited form of aplastic anemia. Genetic testing will reveal increased chromosomal breakage. A CBC will show decreased leukocytes, red blood cells and platelets. Of the choices above, it is the only one which requires bone marrow transplantation for survival.Ans5
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A 51-year-old right-hand-dominant male fell onto his left arm and sustained the isolated injury shown in Figures A and B approximately 6 months prior to presentation. Examination of the wrist is notable for a stable DRUJ and no tenderness. The elbow shows no ligamentous laxity, and the patient reports isolated elbow pain during attempted pronation/supination Current radiographs reveal a malunited radial head fracture. Treatment should now consist of?
1. Radial head resection 2. Radial head replacement 3. ORIF of the malunited fracture 4. Arthroscopic debridement 5. Total elbow replacement |
The injury films represent a highly comminuted radial head fracture, which when treated with ORIF, is likely to have a poor outcome especially in the delayed setting. In the absence of DRUJ and elbow instability, and no wrist tenderness, radial head resection is the best treatment option. While a radial head prosthesis may theoretically prevent proximal radial head migration that can occur with radial head excision, this is unlikely in an isolated radial head fracture without other ligamentous injury (elbow ligaments, interosseous membrane or DRUJ). Ans1
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A 20 year-old Division 1 football player is injured in practice. His treatment regimen includes immobilization of the knee in 120 degrees of flexion. What injury has this patient most likely sustained?
1. Iliac crest contusion 2. Avulsion fracture of the lesser trochanter 3. Quadriceps contusion 4. Hamstring rupture 5. Sports Hernia |
This patient has a quadriceps contusion. Acute management includes cold compression and immobilization in flexion. Surveillance for compartment syndrome is needed acutely and chronic manifestations include myositis ossificans. Iliac crest contusions or “hip pointers” occur after direct trauma and benefit from placing the affected leg in extension. Athletic pubalgia or “sports hernia” is an injury to the muscles of the abdominal wall or adductor longus that produces anterior pelvis and groin pain in the absence of a true inguinal hernia. The references by Ryan et al and Aronen et al are Level 4 studies of soldiers sustaining quadriceps contusions treated with hyperflexion of the knee and cold compresses. The average time of disability was 3-13 days between the 2 studies. There was a 5% and 9% rate of myositis ossificans, respectively. Illustration A depicts the position of immobilization for quadriceps contusion treatment.Ans3
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A 24-year-old patient complains of vague right shoulder pain. On physical exam the patient is noted to have weakness with external rotation. EMG findings are consistent with quadrilateral space syndrome. Along with the deltoid, what other muscle is affected?
1. Teres major 2. Teres minor 3. Pectoralis major 4. Supraspinatus 5. Subscapularis |
The axillary nerve passes through the quadrilateral space on its path to innervate the teres minor and deltoid and provide sensation to the lateral arm. This syndrome is caused by compression of the posterior humeral circumflex artery and axillary nerve or one of its major branches in the quadrilateral space. Forward flexion and/or abduction and external rotation of the humerus aggravate the symptoms. In some individuals, especially, throwers, the nerve can become irritated from the repetitive motion leading to nerve dysfunction. The condition is usually self-limited. Ans2
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An MRI of the shoulder in a patient with chronic quadrilateral space syndrome is most likely to show which of the following?
1. Increased intra-capsular volume 2. Loss of intra-capsular volume 3. Fatty atrophy of the infraspinatus 4. Fatty atrophy of the teres minor 5. Fatty atrophy of the latissimus dorsi |
Quadrilateral space syndrome involves dysfunction of the axillary nerve, perhaps by entrapment or compression, resulting in the functional denervation of the teres minor.
The quadrilateral space is a potential space formed by the long head of the triceps medially, the humerus laterally, the teres minor above, and the teres major below. The axillary nerve and posterior circumflex humeral artery travel through this space. Ans4 |
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A 35-year-old butcher inadvertently lacerates his ring finger FDP tendon at the level of the DIP joint which is subsequently repaired. Following the operation he notes the inability to fully flex his long and small fingers at the DIP joints with attempted fist clenching as well as a weak grip. Which of the following intraoperative maneuvers was likely responsible for this?
1. FDP reconstruction with a long tendon graft 2. FDS to FDP transfer at level of the A2 pulley 3. Inadequate repair of the C3, A4 and A5 pulleys 4. Distal advancement of lumbricals 5. Overtensioning of the FDP tendon |
The clinical presentation is most consistent with the quadrigia effect which is caused by overtensioning of the FDP tendon during surgical repair. The FDP tendons share a common muscle belly and have many interconnections. Overtensioning one tendon has a reciprocal effect on the length-tension curve of the remaining three muscle-tendon units, weakening grip strength in these digits.
Malerich et al performed a cadaveric study looking at FDP advancement on hand function. They determined advancement >1cm can lead to an imbalance of muscle function in the profundus system. Ans5 |
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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?
1. Tensor fascia lata 2. Gluteus medius 3. Gluteus minimus 4. Rectus femoris 5. Biceps femoris |
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.
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A 63-year-old female sustains a subtrochanteric femoral fracture after a fall in her home. Five years ago she underwent resection of a left thigh leiomyosarcoma with adjuvant radiotherapy. All the following are known risk factors for development of pathologic fracture post radiotherapy EXCEPT:
1. Female 2. Age 3. Dose of radiotherapy 4. Periosteal stripping during sarcoma removal 5. Adjuvant chemotherapy |
The Level 4 study by Holt et al found a 26% incidence of postradiation fracture in 374 patients following combined surgical resection and external beam irradiation of soft tissue sarcomas. They also found that fracture risk was increased in females, patients older than 50 years of age, and those with higher doses of irradiation (>60 Gy). The Level 4 study by Lin et al of 205 patients found a 29% incidence of fracture at 5 years followup. They found that periosteal resection was a risk factor for fracture occurrence. The use of chemotherapy as an adjuvant treatment has not been shown to increase the risk of post-radiation fracture. The approximate calculated risk of a femoral fracture for this patient is 25%. Ans5
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An 18-year-old female has 9 months of anterior knee pain recalcitrant to physical therapy that includes VMO strengthening, NSAIDS, and lifestyle modification. On physical examination she has no effusion in the knee and her Q angle is measured at 15 degrees. She has less than one quadrant of medial patella translation and less than two quadrants of lateral patella translation. The lateral edge of the patella is unable to be everted. A merchant view radiograph is shown in Figure A. The tibia tubercle-trochlear groove distance is measured as 14mm on a CT scan. Which of the following procedures is MOST appropriate?
1. Lateral retinacular release 2. Anterolateral tibial tubercle osteotomy 3. Anterior tibial tubercle osteotomy (Maquet) 4. Medial tibial tubercle osteotomy (Elmslie-Trillat) 5. Medial plica resection |
The patient's radiograph and clinical presentation are consistent with lateral patellar tilt and lateral facet compression syndrome, respectively. Of the options available, lateral retinacular release is the most appropriate treatment. The surgical treatment for this condition is rare and used only in cases that are recalcitrant to conservative measures. Illustration A demonstrates how the tibia tubercle-trochlear groove (TT-TG) distance is measured by (A) first drawing a line from the trough of the trochlea perpendicular to the line connecting the posterior condyles. These lines are superimposed onto an image through the tibial tubercle (B), and the TT-TG distance is measured as that between the above-described line and the tibial tubercle (distance AB). A TT-TG distance greater than 20mm is an indicator that a medializing tibia tubercle osteotomy is needed.Ans1
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1-mn radius & ulna
2-most important w/radius fx to have a good functional outcome/ 3-when evalu xray of radius KIF 4- indications BG radius fx, best choice of BG? 5-when doing ORIF of radius what fixation of choice? 6-MCC with single incision? 7-MC nerve injury w/prox ulna fx? aka |
1-GRIMUS
G - Galeazzi R - radius I - inferior M - Monteggia U - Ulna S - Superior 2-restore radial bow bc/-> sup/pron 3-KIV=radial head must be aligned with the capitellum on all views 4-bone loss that is segmental or associated with open injury, comminution >1/3 length of shaft, nonunions of the forearm -best BG=autograft 5-3.5 mmDCP with AO technique 6-synostois 7-PIN w/ Henry volar approach to middle upper 1/3 |
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1-adult male is protecting his head from attack injures his forearm, c/o gross deformity, pain, swelling, loss of forearm and hand function, PE=NO pain w/ passive stretch of digits or open fx; xray=radial head is aligned with the capitellum on all views?
1-PE-r/o:::KIFs (key image finding)-> Dx-(mn) classification 2-Tx indications both bone forearm fx : 2.1-functional fx brace with good interosseous mold 2.2-primary ORIF w/OUT bone grafting (5) 2.3-ORIF with bone grafting (3) 2.4-external fixation 2.5-IM nailing 3-MC Complication (7) what increases risk & how TX |
1-PE-r/o= DRUJ & elbow ->Galeazzi fx & Monteggia fx
KIF=ap/lat forearm & ipsilateral wrist & elbow-> Dx=both bone fx r/o G - Galeazzi;R - radius;I - inferior;M - Monteggia;U - Ulna;S - Superior 2.1-isolated nondisplaced or distl 2/3 ulna fx (nightstick fx) w/< 50% displacement & < 10° of ang 2.2-displaced distal 2/3 isolated ulna fxs, prox 1/3 isolated ulna fxs, all radial shaft fxs (even if ND) both bone fxs, Gustillo I, II, and IIIa OPEN fx 2.3-bone loss =segmental or assoc w/ open injry; comminution >1/3 length of shaft, nonunions forearm 2.4-Gustillo IIIb & IIIc open fx 2.5-poor ST integrity, NOTpreferred bc/lack of rotatnl & axial stab & diff maintaining radial bow (highest nonunion) 3-Synostosis->risk=ORIF w/ 1 incision tx= excision @ 4-6 mth post-inj when prophy XRT and/or indomethacin post-op -Infec-vascul fib grafts >BG -Comp syndr=MC w/crush -Nonunion tx= 3.5 mm plates & autogs BG -PIN inj-Montg -re-fx=4.5 mm remove plates <15 mth & NO protected activity<3 mth |
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1-what is miserable triad?
2-what is theatre sign, dx of? 3-(4) surgeries to dx lateral patellar compression syndrome, indication? |
1-anatomic characteristics that lead to an increased Q angle and an exacerbation of patellofemoral dysplasia. include: femoral anteversion; genu valgum; external tibial torsion / pronated feet
2-pain with sitting for long periods of time, dx lateral patellar compression syndrome 3-arthroscopic lateral release I=objective evidence of lateral tilting (neutral or negative tilt), ideal candidate has no symptoms of instability, medial patellar glide of< 1 quadrant, lateral patellar glide of < 3 quadrants Maquet,I- only for distal pole lesions (tubercle anteriorization) Elmslie-Trillat (medialization); I=indicated only for instability with lateral translation (not isolated lateral tilt) Fulkerson alignment surgery; I=lateral and distal pole lesions tubercle anteriorization and medialization |
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16-adult F c/o pain w/stair climbing, pain w/ sitting for long periods of time, PE=pain with compression of patella & inability to evert the lateral edge of the patella.
1- KIF(key image finding)->Dx/def 2-Tx indications: 2.1-NSAIDS, activity modification, and therapy, PT goals? 2.2 -arthroscopic lateral release 2.3-patellar realignment surgery, Maquet (tubercle anteriorization) 2.4-Elmslie-Trillat 2,5-Fulkerson alignment surgery, CI 3-Complication |
1-KIV->merchant see excessive lateral tilt w/out excessive patellar mobility ->Lateral Patellar Compression Syndrome/Improper tracking of patella in trochlear groove
2.1-done for extensive period of time PT=emphasize vastus medialis strengthening and closed chain short arc quadriceps exercises arthroscopic lateral release:I-objective evidence of lateral tilting (neutral or negative tilt)(2)pain refractory to extensive rehabilitation(3)inability to evert the lateral edge of the patella(4)ideal candidate has no symptoms of instability 2.3Maquet:I-only for distal pole lesions, only elevate 1 cm or else risk of skin necrosis Elmslie-Trillat:I-only for instability w/ lateral translation (not isolated lateral tilt), avoid if medial patellar facet arthrosis Fulkerson:I-lateral and distal pole lesions, increased Q ang:::CI=superior medial arthrosis (scope before you perform the surgery), skeletal immaturity 3-persistent or worsened pain, patellar instability with medial translation |
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1-classif of ped radial neck fx
2-mn; what are the age of ossification of 6 centers in elbow, age, which is the last age of fusion? 3-mn-best xray view to see Radial Head and Neck Fractures - Pediatric, def, if NO fx what else KIF*** 4-(2) associated conditions w/Radial Head and Neck Fractures - Pediatric 5-MC loc of referred elbow pain? 6-chambers class for? describe, MC SH? 7-name 6 reduction techniques open(1) CR (5) describe, MCComplic w/ which type reduction causing AVN/ON |
1-SH2
2-(C-R-I-T-O-E) Capitellum (1 yr.); Radius (3 yr.); Intrnl /med epicondyle (5 yr.); Trochlea (7 yr.);Olecranon (9 yr.); Extrnl/lat epicondyle (11 yr.) last-med epicondyle 3-RH/Neck Fx-Ped=Greenspan view radiocapitellar =oblique lat w/forearm neutral rotn & beam directed 45 deg prox KIF=****a portion R neck is extra-articular & therefore effusion & fat pads signs maybe ABSENT. 4-elbow dislctn, med epicondyle fx 5-wrist 6-R H/Neck FX- Ped: 3 types 1 displcd RH, MoI-valgus SH 1/2/4 2 R neck, Monteggia variant 3 Stress injury OCD 7-CR=Patterson maneuver=elbow extend & apply distal traction w/ forearm supintd & pull the forearm into varus applyg direct pres ->RH CR2=Israeli technique=pronate the supinated forearm while elbow is flex 90° & direct pres stabilizes RH CR3=elastic bandage, tight application of elastic bandage begin @ wrist conting->forearm 4CRPP=K-wire joystick 5Metaizeau tech=retrograde inser pin/nail 6kocher-DO NOT transcapitellar pins MCCompl-OR 70% |
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9 yo child c/o elbow pain, refusal to move elbow, MoI=valgus loading injury of the elbow PE=pain in wrist***lateral swelling and pain exacerbated by motion, especially supination and pronation in elbow.
1-KIF(key image finding) ->Dx/def & 3 classification 2-Tx indications: 2.1-immobilization NO CR, how long immobilize 2.2-immobilization +CR 2.3 operative percutaneous reduction (3) 2.4-open reduction, MCCompl 3-Complication (4) direction of loss which is greatest? |
1-KIV->AP/lat of the elbow; radiocapitellar (Greenspan) view-no fat pad sign, ND fx may be difficult to visualize->
Dx=Radial Head and Neck Fractures - Pediatric class=typ1 displaced radial head, MoI-valgus I SH 1/2/4 typ2 Primary displacement of radial neck, Monteggia variant, typ3 Stress injury OCD 2.1-NO CR:I=< 30° ang NO immobilize w/out CR Tx-early ROM at 3-7 days to prevent stiffness 2.2-CR:I=>30° ang CR & immobilize if angulation reduced to < 30° 2.3percut R:I-> 30° of residual ang, 3-4 mm of translation, < 45° of pron/supintn 2.4-OR:I=fx that cannot be adequately CR or CRPP 3-MCCompl-> loss of ROM- pron>sup, Radial head overgrowth-NO affect function ON-GREATEST w/OPEN REDUC Synostosis-occurs in cases of OR w/extensive dissection or delayed tx |
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1-MCC of longitudinal deficiency of the radius/genetic?
2-Radial Clubhand (radial deficiency) associations (5)? 3-what does VACTERL syndrome mn? 4-what is the class for Radial Clubhand (radial deficiency) name 4 types & describe MC tpe 5-(3) lab test MUST order w/thumb is absent? 6-age of surgery for hand centralization procedure? |
1-sonic hedgehog gene
2-TAR, Fanconi anemia-AR tx BM transplant, holt oram syndrome-AD cardiac defects, VACTERL syndrome, VATER syndrome 3-VACTERL=Vertebral anomalies, Anal atresia, Cardiac abnormalities, TracheoEsophageal fistula, Renal agenesis, Limb defects 4-Bayne and Klug Class:(1)Deficient distal radial epiphysis(2)Deficient distal and proximal radial epiphyses(3) Present proximally (partial aplasia)(4)Completely absent MC typ=total aplasia typ4 5-CBC r/o-TAR & Fanconi's anemia renal US r/o-VACTERL Syndrm & VATER Syndrm echocardiogram r/o-Holt-Oram syndrm 6-@6-12 mth of age |
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1-child w/ b/l absent thumb PE=good elbow motion and biceps function intact initial work-up is negative CBC, renal ultrasound, and echocardiogram .
1-KIF(key image finding) 1.2 KEY PE finding->Dx/def & classification 1.3 key w/u ? 2- Tx INDICATIONS 2.1passive stretching & observation 2.2 hand centralization, what age is surgery done, step 2 in TX? CI (3)? |
1-AP/lat=entire radius and often thumb is absent
1.1- KEY PE= IF elbow motion and biceps function intact THEN hand centralization 1.3-CBC r/o-TAR & Fanconi's anemia renal US r/o-VACTERL Syndrm & VATER Syndrm echocardiogram r/o-Holt-Oram syndrm 2.1-if absent elbow motion or biceps deficiency 2.2-good elbow motion and biceps function intact, at 6-12 months of age stp2-tendon transfers CI-older patient with good function, patients w/elbow extension contracture who rely on radial deviation, proximate terminal condition |
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1- MC elbow fx in adults?
2-assoc inj w/ RH fx(8)-4 skeletal injuries & 4 ST 3-what is Essex-Lopresti lesion, terrible triad 4-what structure in elbow acts as secondary restraint to valgus force at the elbow/ 5-what is name class of RH fx, descr 4 tps 6- how long is short period of immobilization followed by early ROM, where is safe zone for ORIF RH plate placement? 7-MC nerve injury Kocher posterolateral approach? how to protect |
1-RH fx
2-4 ST= DRUJ) injuries, interosseous membrane disruption, MCL/LCL injuries, Essex-Lopresti lesion (DRUJ) inj +RH fx 4 skeletal injuries=coronoid fx, carpal fx, elbow dislocation, terrible triad 3-Essex-Lopresti lesion=(DRUJ) inj +RH fx terrible triad=elbow dislocation-LCL injury, radial head fx-unstable >3 pieces, coronoid fx-transverse fracture pattern>50% 4-RH 5-Mason class:: 1=Minimally displaced fx, no mech block to ROM, intra-articular displacement <2mm 2-Displaced fx >2mm or angulated, poss mech block to forearm ROM 3->3 piece=Comminuted & displaced fx, mechanical block to motion 4-RH fx w/ elbow dislocation 6- 3 to 5 days; safe zone=posterolateral (safe zone consists of 90-110 arc from radial styloid to Lister's tubercle) with arm in neutral rotation to avoid impingement of ulna with forearm rotation 7-PIN, protect-> pronation |
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adult s/p S &F onto outstretched hand c/o pain & tenderness along lateral aspect of elbow |
1-KIV=AP/lat of the elbow, r/o fat pad sign
1-1 add xray=radiocapitellar view (oblique lateral) CT-r/o comm & see fx pattern 2-typ1=short period of immobilization followed by early ROM typ2=ORIF w/ < 3 fragments via Kocher posterolateral, place plate posterolateral (safe zone &Herbert screws if placed in articular surface typ3=metal prostheses vs radial head resection CI=presence of destabilizing injuries =forearm interosseous lig inj (identify with radius pull test), coronoid fx, MCL deficiency elbow fracture-dislocations or Essex Lopresti lesions=radial head replacement, radial head excision will exacerbate elbow/wrist instability and may result in proximal radial migration and ulnocarpal impingement 3-comp=3 ST=PIN injury, stiffness, loss or rotation 4 skeletal=Displacement of fx, Loss of fixation, Radiocapitellar joint DJD, Infection |
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1-MCCompln w/quad contusion |
1-quad=Myositits ossificans
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"Both-bone" forearm fractures best functional results depends on? |
restoration of radial bow |
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central band |
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Excision of heterotopic bone about the forearm or elbow can be done with limited recurrence rates as early as which of the following after initial injury 1. Once ankylosis of the forearm or elbow occurs 2. 6 weeks 3. 6 months 4. 12 months 5. 18 months
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Excision of heterotopic bone about the elbow and forearm was classically treated once the bone was mature and no further bone development was occuring (bone scan became negative). However, several studies have shown that earlier removal before this point in time is safe, when done in conjunction with radiation therapy (XRT). ans3 |
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A 25-year-old man sustains an open forearm fracture from an auger depicted in Figures A and B. After debridement of non-viable bone a 7cm bone defect is left. In planning future, definitive treatment of the bone void, the use of an interposed strut allograft instead of transfer of a vascularized fibula graft would most likely result in the following complication: 1. Higher incidence of infection 2. Lower nonunion rate 3. Decreased forearm arc of rotation 4. Complex regional pain syndrome 5. Synostosis |
open fracture with a large amount of bone loss. A higher incidence of infection would be expected with the interposed strut graft treatment option. Calkins et al conducted a Level 4 study of segmental bone defects and found a 60% rate of infection and 43% rate of union with use of corticocancellous strut grafts. Falder et al and Wood also have Level 4 evidence showing a 74% and 72% rate of union, respectively and a much lower infection rate with vascularized fibular graft transfers. Forearm motion, complex regional pain syndrome, and synostosis were not discussed in these articles. ans1 |
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All of the following have been shown to increase the risk of refracture following removal of forearm plates used for internal fixation EXCEPT: 1. initial fracture comminution 2. initial fracture displacement 3. use of 3.5 mm dynamic compression plate 4. plate removal before 12 months 5. immediate weight bearing as tolerated following removal
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Plates removed under 15 months showed an increased risk of refracture. There were no fractures in this series using the 3.5 DCP plate. Deluca et al concluded that, in retrospect, radiolucency at the site of the original fracture was seen in most patients (with refracture) when the plate was removed. |
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with the definition of the miserable triad |
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patella should passively tilt at least 80° |
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An 18-year-old female has 9 months of anterior knee pain recalcitrant to physical therapy that includes VMO strengthening, NSAIDS, and lifestyle modification. On physical examination she has no effusion in the knee and her Q angle is measured at 15 degrees. She has less than one quadrant of medial patella translation and less than two quadrants of lateral patella translation. The lateral edge of the patella is unable to be everted. A merchant view radiograph is shown in Figure A. The tibia tubercle-trochlear groove distance is measured as 14mm on a CT scan. Which of the following procedures is MOST appropriate? 1. Lateral retinacular release 2. Anterolateral tibial tubercle osteotomy 3. Anterior tibial tubercle osteotomy (Maquet) 4. Medial tibial tubercle osteotomy (Elmslie-Trillat) 5. Medial plica resection |
The patient's radiograph and clinical presentation are consistent with lateral patellar tilt and lateral facet compression syndrome, respectively. Of the options available, lateral retinacular release is the most appropriate treatment. The surgical treatment for this condition is rare and used only in cases that are recalcitrant to conservative measures.ans1 |
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mechanism of injuryradial head fracture |
valgus load |
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radial head radial neck fracture classification |
most cases are Salter-Harris type II fractures |
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For age of ossification 6 centers around the elbow joint |
CRITOE C – capitellum one year R – radius 3 years I – internal or medial epicondyle 5 years T – trochlea 7-year-old O – olecranon 90 E – external lateral epicondyle 11 |
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when assessing the forearm4 for radial head fracture what is the best view to get |
radiocapitellar review GREENSPAN equals oblique lateral |
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what is indication for open percutaneous reduction with a radial head fracture |
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with the disadvantage of open reduction radial head fracture |
increased rates of osteonecrosis and synostosis and greater loss of motion |
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A 10-year-old boy sustains an injury to his dominant elbow and presents with the injury shown in Figures A and B. What is the next best step in management? 1. Immobilization in full pronation 2. Open reduction 3. Closed reduction 4. Closed reduction and percutaneous pinning 5. Open reduction and internal fixation |
The scenario and image depict a patient with an isolated radial neck fracture. The next best step is an attempted closed reduction as the images demonstrate angulation >30.ans3 elastic stable intramedullary nailing |
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radial club hand genetics |
sonic hedgehog jean |
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if the patient presents with a radial club hand what is the next most important step in management what the 1st test to be ordered |
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how those one tell the difference between TAR syndrome and radial club hand |
TAR |
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patient presents with this x-ray
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patient presents to the emergency room after fall with the arm forearm in pronation and complains that there is a block to rotation of the forearm with reaching
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A 51-year-old right-hand-dominant male fell onto his left arm and sustained the isolated injury shown in Figures A and B approximately 6 months prior to presentation. Examination of the wrist is notable for a stable DRUJ and no tenderness. The elbow shows no ligamentous laxity, and the patient reports isolated elbow pain during attempted pronation/supination Current radiographs reveal a malunited radial head fracture. Treatment should now consist of? 1. Radial head resection 2. Radial head replacement 3. ORIF of the malunited fracture 4. Arthroscopic debridement 5. Total elbow replacement |
highly comminuted radial head fracture, which when treated with ORIF, is likely to have a poor outcome especially in the delayed setting. In the absence of DRUJ and elbow instability, and no wrist tenderness, radial head resection is the best treatment option. While a radial head prosthesis may theoretically prevent proximal radial head migration that can occur with radial head excision, this is unlikely in an isolated radial head fracture without other ligamentous injury (elbow ligaments, interosseous membrane or DRUJ). ans1 |
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Patient presents with pain and paresthesias with overhead activities no history of trauma other than being a baseball pitcher
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soccer player goes to kick the ball experiences pain in his hip
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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 1. Tensor fascia lata 2. Gluteus medius 3. Gluteus minimus 4. Rectus femoris 5. Biceps femoris |
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.ans4 |
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which primary malignant bone tumor is responding favorably to external beam irradiation |
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name 2 other conditions that respond favorably to radiation |
soft tissue sarcomas Metastatic bone disease |
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how much radiation can be given that will not interfere with tissue healing |
<45 gray |
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what is the most common complication with radiation |
fracture |
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was the most common complication to shorten five-year survival |
radiation-induced sarcoma |
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A 63-year-old female sustains a subtrochanteric femoral fracture after a fall in her home. Five years ago she underwent resection of a left thigh leiomyosarcoma with adjuvant radiotherapy. All the following are known risk factors for development of pathologic fracture post radiotherapy EXCEPT: 1. Female 2. Age 3. Dose of radiotherapy 4. Periosteal stripping during sarcoma removal 5. Adjuvant chemotherapy
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Level 4 study by Holt et al found a 26% incidence of postradiation fracture in 374 patients following combined surgical resection and external beam irradiation of soft tissue sarcomas. They also found that fracture risk was increased in females, patients older than 50 years of age, and those with higher doses of irradiation (>60 Gy). The Level 4 study by Lin et al of 205 patients found a 29% incidence of fracture at 5 years followup. They found that periosteal resection was a risk factor for fracture occurrence. The use of chemotherapy as an adjuvant treatment has not been shown to increase the risk of post-radiation fracture. The approximate calculated risk of a femoral fracture for this patient is 25%. ans5 |
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radial tunnel syndrome– compression of the PIP and nerve injection with CORTISONE or radial tunnel release |
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was most frequent site of entrapment of the PIN nerve |
proximal aponeurotic edge of the supinator AKA arcade of Frohse |
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when surgery is done to release the radial tunnel what is released |
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A 35-year-old female office worker reports 6 months of deep aching on her lateral dominant elbow which worsens with repetitive movements. On physical exam, the patient has tenderness located 4cm distal to the lateral epicondyle. She also complains of night pain. What is the most likely diagnosis? 1. Lateral epicondylitis 2. Radial tunnel syndrome 3. Carpal tunnel syndrome 4. Erb's palsy 5. Multiple sclerosis |
the characteristic pain of RTS is located 3-4 cm distal to the lateral epicondyle in the area of the mobile wad and radial tunnel. |
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pain and anterior thigh with limited flexion due to pain
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A 20 year-old Division 1 football player is injured in practice. His treatment regimen includes immobilization of the knee in 120 degrees of flexion. What injury has this patient most likely sustained? 1. Iliac crest contusion 2. Avulsion fracture of the lesser trochanter 3. Quadriceps contusion 4. Hamstring rupture 5. Sports Hernia |
quadriceps contusion. Acute management includes cold compression and immobilization in flexion. Surveillance for compartment syndrome is needed acutely and chronic manifestations include myositis ossificans. Iliac crest contusions or “hip pointers” occur after direct trauma and benefit from placing the affected leg in extension. Athletic pubalgia or “sports hernia” is an injury to the muscles of the abdominal wall or adductor longus that produces anterior pelvis and groin pain in the absence of a true inguinal hernia. The references by Ryan et al and Aronen et al are Level 4 studies of soldiers sustaining quadriceps contusions treated with hyperflexion of the knee and cold compresses. The average time of disability was 3-13 days between the 2 studies. There was a 5% and 9% rate of myositis ossificans, |
