185/189 Day A Mastery Training Program

Front 1

1-mortality rate of 50% in ICU?
2classic CXRF?

Back 1

1-ARDS
2-bilateral pulmonary infiltrates, normal sized heart

Front 2

1-MC associated injury with acetabular fx?
2-acetabulum is supported by_____ bone
form an ____?
3-posterior column & anterior column
comprised of (4)?4
4-M @ risk with lateral dissection over superior pubic ramus & Classic soft tissue injury?
5 obturator oblique & iliac oblique show?mn
6-6 radiographic landmarks of the acetabulum
7- why get CT (4)

Back 2

1-50% injury to another organ system, MC 36% LE inj
2-acetabulum is supported by 2 columns of bone
form = "inverted Y"
(4: 1:liopectineal lnie. 2:Ilioischial line. 3:teardrop. 4:Sourcil (roof). 5: Ant rim. 6: Post rim.)
3-Post ant
post wall & dome ant wall & dome
ischial tuberosity lat sup pubic ramus
grtr/lesser sciatic notches ant ilium (gluts meds tub
quadrilateral surface iliopectineal eminence
4-corona mortis=anastamosis of ext iliac (epigastric) & internal iliac (obturator) A
-Morel-Lavalle lesion: skin degloving inj assoc w/ acetabular fx = extensive debridement. may suggest hip dislctn
5- OOP-WAC Obturator Obliq Post Wall & Ant Column (profile of obturator) r/o jt penetration iliac obiq-opposite
6- iliopectineal line (ant column) & ilioischial line (post column),
ant rim & pos rim
teardrop & wt bearing roof
7(1) frag size & orient(2) marginl impac(3) loose b(4)articl step off/gap

Front 3

1-Dx/xrayF/ pathomneumic F & CTF (counterclockwise)
1.1 best method to test stability
2-Tx/surgical approach/indications
3-MCC
(5 elementary fx & accociated fx?)

Back 3

1-AP =posterior rim shadow, subluxation of the femoral head and the posterior wall fragment.
OOP-WAC::OOP-articular surface involved as well as confirming the subluxation of the femoral head and the intraarticular fragment
IO- intact posterior border as well as the subluxation of the femoral head
1.1 exam under anesthesia using fluoroscopy
2-minimally displaced fx (< 2mm) & < 20% posterior wall fx protected WB x 6-8 weeks
S-indications=marginal impaction, intra-articular loose bodies, >2mm displacment > 40-50% of posterior wall-->percutaneous fixation with column screws
A-Posterior Approach, Kocher-Langenbach) topic
3-increased HO risk compared with anterior approach
• sciatic nerve injury (2-10%)
• damage to blood supply of femoral head (medial femoral circumflex)

Front 4

1-Dx/xrayF/ pathomneumic F & CTF (counterclockwise)
1.1 best method to test stability
2-Tx/surgical approach/indications
3-MCC, CI
(5 elementary fx & accociated fx?)

Back 4

1-Post column
xrayf-AP view, the displacement of the ilioischial line is apparent while the iliopectineal line is seen to be intact
NOT OOP-OO=anterior column to be intact and demonstrates the fracture of the ischial ramus
IO-iliac oblique view demonstrates the disruption of the greater sciatic notch and the displacement of the posterior column
2-Posterior Approach (Kocher-Langenbach)
displacement of roof (>2mm), marginal impaction
intra-articular loose bodies, irreducible fracture-dislocation
3-relative contraindications to surgery
morbid obesity
open contaminated wound
presence of DVT
-• increased HO risk compared with anterior approach • sciatic nerve injury (2-10%)
• damage to blood supply of femoral head (medial femoral circumflex)

Front 5

1-Dx/xrayF/ pathomneumic F & CTF (counterclockwise)
1.1 best method to test stability
2-Tx/surgical approach/indications
3-MCC, CI
(5 elementary fx & accociated fx?)

Back 5

1-Anterior column fx
NO-OOP WAC
AP view demonstrates the fracture from the iliac crest to the hip joint with disruption of the sourcil.
OO= single break in the iliopectineal line where the anterior column fracture crosses the pelvic brim
IO view confirms the posterior border of the bone to be intact
2-Anterior Approach (Ilioinguinal)
3- femoral nerve injury
• LFCN injury
• thrombosis of femoral vessels
• laceration of corona mortis in 10-15%

Front 6

1-Dx/xrayF/ pathomneumic F & CTF (counterclockwise)
1.1 best method to test stability
2-Tx/surgical approach/indications
3-MCC, CI
(5 elementary fx & accociated fx?)

Back 6

1-Anterior wall fx
femoral nerve injury
• LFCN injury
• thrombosis of femoral vessels
• laceration of corona mortis in 10-15%

Front 7

A 35-year-old male undergoes closed reduction under sedation in the emergency department for a posterior hip dislocation with an associated posterior wall fracture. The post-reduction CT is seen in Figure A. What is the appropriate next step in management of this injury?

1.  Nonoperative management based on the size of the posterior wall fragment

2.  Operative management based on the size of the posterior wall fragment

3.  Operative management based on the history of hip dislocation

4.  Dynamic fluorscopic stress exam under anesthesia in the obturator oblique view

5.  Dynamic fluorscopic stress exam under anesthesia in the iliac oblique view

Back 7

Joint stability is critical for successful nonoperative management of posterior wall acetabular fractures. Recent evidence has established that dynamic fluoroscopic stress examination is the best method to determine joint stability in the setting of a posterior wall fracture. The obturator oblique view allows for the best evaluation of hip joint stability during examination for posterior wall fractures.ans4

Front 8

A 35-year-old male suffers an anterior column acetabular fracture during a motor vehicle collision, and subsequently undergoes percutaneous acetabular fixation. Intraoperatively, fluoroscopy is positioned to obtain an obturator oblique-inlet view while placing a supraacetabular screw. Which of the following screw relationships is best evaluated with this view?

1.  Intraarticular penetration of the screw

2.  Position of the screw cephalad to the sciatic notch

3.  Screw starting point at the anterior inferior iliac spine

4.  Screw starting point at the gluteal pillar

5.  Screw position between the inner and outer tables of the ilium

Back 8

The obturator oblique-inlet view, as seen in Illustration A, best demonstrates the position of a supra-acetabular screw or pin relative to the tables of the ilium. ans5

Front 9

A 74-year-old man falls, sustaining the injury shown in Figures A through C. In surgical planning, what is the best surgical approach to treat this injury?

1.  Kocher-Langenbeck

2.  Watson-Jones

3.  Extended iliofemoral

4.  Ilioinguinal

5.  Hardinge

Back 9

T-type fracture of the right acetabulum. The ilioinguinal approach provides access to the anterior wall and anterior column for fracture fixation, in addition to allowing fixation of the nondisplaced posterior transverse fracture line. The lateral femoral cutaneous nerve (LFCN) is at risk in the superficial part of the dissection. Another option for the approach would be the modified Stoppa, which would also allow excellent access to the anterior column as well as the internal aspect of the iliac wing and quadrilateral plate.ans4

Front 10

A 32-year-old male sustains a posterior wall acetabulum fracture as the result of a high-speed motor vehicle collision. Improved patient-reported outcomes after surgical treatment are associated with which of the following variables?

1.  Increased age

2.  Increased hip flexion-extension arc

3.  Immediate weight-bearing

4.  Increased hip muscle strength

5.  Decreased stride length

Back 10

Patient functional outcomes after acetabular fractures have been shown to be related to postoperative hip strength, regardless of surgical approach. 

The reference by Borrelli et al evaluated muscle strength and outcomes after acetabular surgery via an anterior approach. They report that hip extension strength was affected least (6%), whereas abduction, adduction, and flexion strength was affected to a greater degree. They note that hip muscle strength after operative treatment of a displaced acetabular fracture directly influences patient outcome.
ans4

Front 11

When placing a percutaneous retrograde pubic rami screw for fixation of an acetabular fracture, which of the following radiographic views can best ensure that the screw does not exit the posterior aspect of the superior pubic ramus?

1.  AP pelvis

2.  Outlet obturator oblique view

3.  Inlet iliac oblique view

4.  Iliac oblique view

5.  Obturator oblique view

 

Back 11

As reviewed in the referenced article by Starr et al, when placing a retrograde pubic rami screw, the pelvic inlet iliac oblique view will best determine the anteroposterior placement of the screw in the pubic ramus. To ensure placement outside of the joint, the outlet obturator oblique is best, but all other views should be incorporated into determination of the position of fixation, as the corridor for this screw placement is quite narrow. 

Illustration A shows a left sided inlet iliac view on a pelvic bone model.

ans3

Front 12

 A 33-year-old male sustains the injury seen in Figure A as a result of a high-speed motor vehicle collision. Based on this image, what is the most likely acetabular fracture pattern?  1.  Both column

2.  Anterior column

3.  Anterior column posterior hemitransverse

4.  Transverse

5.  T-type

Back 12

The radiograph in Figure A shows a transverse acetabulum fracture. The iliopectineal (anterior column) and ilioischial lines (posterior column) are interrupted, revealing bicolumnar involvement; however, this is different than the both column fracture, as a transverse pattern has articular surface still in continuity with the axial skeleton via the sacroiliac joint. ans4
 

Front 13

A 22-year-old female is involved in a motor vehicle collision and sustains the injury shown in Figures A through D. According to these images, what is the acetabular fracture classification? 

1.  Anterior column posterior hemitransverse

2.  Both column

3.  Transverse

4.  Transverse with posterior wall

5.  Anterior column

Back 13

Figures A through D show a comminuted both column acetabular fracture. In this injury, both columns are involved, with the acetabulum losing all connection to the axial skeleton (sacrum). This differentiates it from all other patterns, where at least part of the acetabular cartilage maintains connection to the sacrum. Figure C shows the ischial spur, which is classically known as the spur sign and most easily seen on the obturator oblique radiograph.  Incorrect Answers:
Answer 1: This injury has axial skeleton attachment to the acetabular cartilage through the posterior column.
Answer 3: This injury has axial skeleton attachment to the acetabular cartilage through the anterior and posterior columns.
Answer 4: This injury has axial skeleton attachment to the acetabular cartilage through the anterior column as well as the posterior column, depending on fracture pattern.
Answer 5: This injury has no posterior column involvement, and therefore the posterior column maintains the axial skeleton attachment to the acetabulum. ans2

Front 14

 A 42-year-old female sustains the injury seen in the computed tomography images seen in Figures A and B. According to the Letournel classification, what is the injury pattern shown?

1.  Posterior wall

2.  Transverse

3.  Anterior wall

4.  Posterior column

5.  Both column

Back 14

The axial CT cut and Judet radiographic view shown reveals a transverse fracture pattern according to the Letournel classification system. This can be determined by the fact that the articular surface of the acetabulum is attached to the intact portion of the ilium, which is connected to the axial skeleton posteriorly through the sacroiliac joint. This differs from a both-column fracture, in which the articular surface of the acetabulum has no attachments to the axial skeleton due to fracture line(s). The axial CT scan also shows a vertical fracture line which is typical of a transverse fracture pattern. ans2

Front 15

 An 84-year-old community-ambulating female sustains a comminuted left acetabular fracture as a result of a fall from standing height. A radiograph is shown in Figure A. What is the most appropriate definitive treatment for this patient?

1.  Skeletal traction

2.  Conservative treatment with delayed physical therapy and shoe lifts

3.  Open reduction and internal fixation

4.  Open reduction and internal fixation with acute total hip arthroplasty

5.  Closed reduction and percutaneous fixation

Back 15

The patient described in this question has sustained an insufficiency fracture, with the radiograph showing significant osteopenia with comminution of both columns, the dome and the medial wall. Treatment of this problem should include reduction and fixation of the column(s) and placement of a total hip arthroplasty (THA), with use of flanged and/or custom acetabular components as needed. 
ans4

Front 16

mnemonic to remember 7 bisphophonates-- 2 categories nitrogen containing NO nitrogen containing, name the drugs that are in each category and the mechanism of action

Back 16

nitrogen containing think nitrous oxide and 4 fast cars

A- Audi A1-Alendronate

P- PORCHE --Pamidronate tx OI

Z -- 300 ZX-Zoledronate

R -- CLA AMG is RIGHT for me!!!-Risedronate--inhibits cholesterol pathway & inhibits to GTP Ace

 

No O2 =death no nitrogen= apoptosis, death-RIP -- TEC -- Tiludronate, Etidronate, Clodronate--toxic ATP Ace

Front 17

Longterm bisphosphonate usage has been shown to cause an increased risk of stress reaction leading to fracture at which of the following areas?

1.  Jaw

2.  Lumbar spine

3.  Femoral neck

4.  Subtrochanteric femur

5.  Anterior cortex of tibia

Back 17

Subtrochanteric stress reaction and fracture is a known complication of longterm bisphosphonate use. Imaging typically shows lateral cortical thickening in the subtrochanteric femur (Illustration A). Without discontinuation of bisphosphonate use and prophylactic fixation, this stress reaction can go on to a transverse fracture (Illustration B.) ans4

Front 18

An 85-year-old patient diagnosed with osteoporosis is begun on a bisphosphonate. What can you tell her about her risk of vertebral fracture after 3 years of treatment?

1.  remain the same

2.  decrease by 20%

3.  decrease by 40%

4.  decrease by 60%

5.  increase by 10%

Back 18

reduced by 65% following one year of treatment and by 41% following 3 years of treatement. In addition to these findings, the authors noted a 39% decrease in incidence of non-vertebral fractures and a significant increase in bone mineral density. ans3

Front 19

Which of the following molecules binds to the surface of hydroxyapatite crystals and prevents protein prenylation?

1.  Calcitonin

2.  Parathyroid Hormone

3.  Raloxifene

4.  Calcium

5.  Alendronate

Back 19

Bisphophonates accumulate in high concentration in bones due to their binding affinity to hydroxyapatite crystals. 

There are two types of bisphosphonates with different mechanisms, although both classes ultimately inhibit osteoclast resorption of bone. Nitrogen containing bisphosphonates (alendronate/Fosamax, pamidronate/Aredia, risedronate/Actonel) prevent protein prenylation by inhibiting farnesyl diphosphate synthase, an enzyme in the mevalonate (cholesterol) pathway. ans5

Front 20

there are 5 bacteriostatic antibioticand 8 bactericidal: antibiotics

Back 20

there are 8 KILLER antibiotics

2 cell wall symphysis inhibitors--

Front 21

A 62-year-old man undergoes an uncomplicated total shoulder replacement 9 months ago. What is an appropriate choice of prophylactic antibiotics to be taken prior to dental work if he has no allergies?

1.  daptomycin 600 milligrams intravenous 2 hours prior to procedure

2.  amoxicillin 4 grams oral 1 week prior to procedure

3.  levaquin 500 milligrams oral 1 hour prior to procedure

4.  trimethoprim-sulfamethoxazole 2 tablets double-strength oral 1 hour prior to procedure

5.  cephalexin 2 grams oral 1 hour prior to procedure

Back 21

Patients not allergic to penicillin should take 2 grams of Amoxicillin, Cephalexin, or Cephadrine, by mouth one hour prior to the dental procedure. IV antibiotics are very rarely used in dental offices. If allergic to penicillin, clindamycin would be the next best alternative. 
ans5

Front 22

All of the following antibiotics function by interfering with cell wall synthesis EXCEPT

1.  Cefazolin

2.  Penicillin G

3.  Vancomycin

4.  Imipenem

5.  Gentamicin

Back 22

Cephalosporins (cefazolin), penicillins, vancomycin, and imipenem function by interfering with cell wall synthesis. Gentamicin, an aminoglycoside, functions by inhibiting ribosomes and protein synthesis and does not affect cell wall synthesis. ans5

Front 23

 

A splenectomy is performed in a 7-year-old boy following a motor vehicle accident. All of the following are recommended for long-term management EXCEPT:

1.  Pneumococcal vaccination

2.  Haemophilus influenza type B vaccination

3.  Meningococcal group C vaccination

4.  Lifelong prophylactic antibiotics

5.  Hepatitis A vaccination

Back 23

All of the responses are correct except the need for Hepatitis A vaccine. Hepatitis A is a virus with tropism for hepatocytes which causes infection from fecal-oral contaminated food/water, and shows no increased rate of either infectivity or morbidity in patients with hyposplenism.Basic recommendations for splenectomized patients include: 
1. All splenectomized patients and those with functional hyposplenism should receive pneumococcal immunization. 
2. Patients not previously immunized should receive haemophilus influenza type B vaccine. 
3. Patients not previously immunized should receive meningococcal group C conjugate vaccine. 
4. Influenza immunization should be given. 
5. Lifelong prophylactic antibiotics are still recommended (oral phenoxymethylpenicillin or erythromycin). This is seemingly despite lack of good data demonstrating a role for lifelong chemoprophylaxis and the acknowledgement that long-term compliance may be problematic. ans5

Front 24

Which of the following antibiotic families inhibit bacterial DNA gyrase?

1.  Quinolones

2.  Penicillins

3.  Aminoglycosides

4.  Macrolides

5.  Sulfonamides

Back 24

Quinolones are a class of antibiotics which act by inhibition of bacterial DNA gyrase. Penicillins interfere with bacterial cell wall synthesis. Aminoglycosides and macrolides interfere with bacterial protein synthesis by acting on the 30S and 50S ribosome subunits respectively. Sulfonamides interfere with bacterial folic acid metabolism. 
ans1

Front 25

as it relates to anticoagulation which factors involved in the

1. extrinsic pathway
2. The intrinsic pathway
3. The common pathway

Back 25

1. extrinsic pathwayinclude factor VII
2. The intrinsic pathway include factor XII factor XI factor IX and the common factor VIII
3. The common pathway includes factor X prothrombin factor V, fibrinogen

Front 26

Virchow's triad describes what risk factors for DVT?

Back 26

1. D-Damage endothelial
2. V-Venous stasis
3. T-teeming coagulation state

Front 27

which medication inhibits the production of prostaglandin and thromboxanes?

Back 27

aspirin

Front 28

which medication enhances inability of antithrombin III?

Back 28

  Heparin unfractionated heparinand low molecular weight heparin Lovenox

Front 29

which medication inhibits factor X?(2)

Back 29

fundaparinux & Rivaroxaban

Front 30

which medication of action is irreversible activation of cyclooxygenase enzyme

Back 30

aspirin

Front 31

which medication is reversed by protamine?

Back 31

enoxaparin or Lovenox

Front 32

which medication has a highest bleeding complications and is not to be used with epidurals

Back 32

Fondaparinux

• trade name: Arixtra

Front 33

what is the mechanism of action of Coumadin

Back 33

it inhibits vitamin K 2, 3 peroxide reductase which prevents active vitamin K formation vitamin K is needed for the gamma caroxylation of glutamic  acid for factors to factor VII factor IX factor X protein C and protein S

Front 34

what 4 comorbid risk factors would have an adverse reaction with the patient taking Coumadin, what are the names of the medications?

Back 34

1. infection with TB being treated with rifampin
2. Seizures and being treated with phenobarbital
3. Hypertensive being treated with diuretics
4. diarrhea resulting from bile acid malabsorption for Crohn's disease patient's after ileal resection cholecystotomy

Front 35

1. which medication promotes and stabilizes clot formation
2. what is the mechanism of action of this medication
3. what is the indication for using this topical medication

Back 35

1. Tranexamic acid (TXA)
2. competitively inhibits the activation of plasminogen by binding to the life seen binding site
3. sprayed into the wound at the completion of the procedure as in a total knee replacement

Front 36

1. ginkgo, ginseng, and garlic have what effect in the  body?
2. mechanism of action

Back 36

they increase the rate of bleedingby acting on platelets

Front 37

how does the omega-3 fish oil effect the body

Back 37

increases the INR and platelet aggregation and vitamin K dependent coagulation factors

Front 38

what is the effective coenzme Q10, green tea, St. John's wort?

Back 38

reduces the INR agonist to warfarin and St. John's wort increases the catabolism of warfarin

Front 39

Which of the following supplements affects blood clotting through its effect on platelets? 

1.  Ginkgo

2.  Vitamin D

3.  Ephedra

4.  St. John's Wort

5.  Selenium

Back 39

Ginkgo and ginseng are two common supplements used in the general population that have inhibitory effects of platelet function. Adverse peri-operative complications consisting of increased bleeding and hematoma formation have been reported with the use of these two herbal supplements. The most commonly used supplements that could have an effect in the peri-operative period include echinacea, ephedra, garlic, ginkgo, ginseng, kava, St John's wort, and valerian. Bleeding has been shown to be effected by garlic, ginkgo, and ginseng; cardiovascular instability from ephedra; and hypoglycemia from ginseng. Kava and valerian have pharmacodynamic herb-drug interactions that can increase the sedative effect of anesthetics. St John's wort has been shown to alter the metabolism of certain drugs used in the perioperative period. ans1

Front 40

as as it relates to adult spinal deformity how many_____  degrees effect pulmonary function and ______degrees increase the mortality

Back 40

60° effect pulmonary function

90° increase mortality

Front 41

adult spinal deformity what is indication for an anterior procedure?

Back 41

large curves  greater than 70°  and rigid curve's

Front 42

what is incidence of complication with adult spinal deformity surgery?

 

Back 42

10--20%

Front 43

A 53-year-old woman is seen in the adult spine clinic for long-standing back pain. History reveals she had untreated scoliosis as a child. Her current radiographs are shown in Figures A and B. Due to discomfort with ADLs and progressive pain, surgical intervention is planned. Which of the following factors would increase her risk of nonunion?

1.  An anterior thoracoabdominal approach

2.  Preoperative Cobb angle of 60 degrees

3.  Age greater than 35 years

4.  A posterior midline approach

5.  Positive sagittal balance < 5 cm

 

Back 43

n the surgical treatment of adult idiopathic scoliosis, a thoracoabdominal approach has been shown to have higher rates of pseudoarthrosis compared to posterior procedures.ans1

Front 44

 In patients with adult scoliosis requiring long thoracolumbar fusions, which of the following is the major advantage of extending the fusion to the sacrum as opposed to ending at L5.

1.  Improved function outcomes

2.  Decreased pseudoarthosis rates

3.  Decreased major medical complications

4.  Improved correction and maintenance of sagittal balance

5.  Improved curve correction in the coronal plane

Back 44

In adult patients with spinal deformity, extension of a long fusion to the sacrum is associated with improved correction and maintenance of sagittal balance. 
ans4

Front 45

In adult patients with scoliosis, severity of symptoms correlates with which of the following variables?

1.  Coronal imbalance

2.  Sagittal imbalance

3.  Magnitude of coronal Cobb angle

4.  Number of spine levels involved in the deformity

5.  Level of the apex of the curve

 

Back 45

Sagittal balance is the most reliable radiographic predictor of clinical health status in adults with spinal deformity.
ans2

Front 46

A 66-year-old female presents to your clinic complaining of back pain, difficulty standing-up straight, weakness in her legs, and neurogenic claudication. On upright thoracolumbar radiographs, there is a 75 degree thoracolumbar curve with the apex at L2, and the C7 plumb line falls 12 cm anterior to the posterosuperior corner of S1. Aside from a decompression of the stenotic levels, which of the following choices will lead to the most reliable decrease in overall disability?

1.  Decreasing the cobb angle to less than 50 degrees

2.  Decreasing the cobb angle to less than 30 degrees

3.  Correcting the sagittal vertical axis to within 5 cm of neutral

4.  Correcting the sagittal vertical axis to neutral

5.  Stopping the fusion at L5

 

Back 46

The clinical scenario presents a 66-year-old female with a spinal deformity in both the coronal and sagittal plane. Correction of the sagittal plane to within 5cm of neutral is the most reliable predictor of clinical symptoms. ans3

Front 47

atlas fracture AKA ×2

Back 47

JEFFERSON fracture AKA C1 fracture

Front 48

  if looking at an open mouth odontoid view, much displacement is considered significant? (2)

Back 48

1. some of the lateral mass displacement greater than 7 is significant greater than 7 = transverse ligament rupture therefore unstable
2. ADI greater than 5 mm equals injury transverse ligament alar ligaments and tectorial membrane
3.  ADI normal less than 3 mmAnd adult

Front 49

the patient has a C1 fracture after trauma what is the next most appropriate step in the management of this fracture pattern?

Back 49

1. CT scan to delineate fracture pattern or and to identify associated injury of the cervical spine which is a 50% association of spine injury.
2. if suspect ligament injury then get an MRI to detect transverse ligament injury

Front 50

what is the treatment of a C1 cervical fracture with an intact transverse ligament type 1,2,3

Back 50

the stable injuries and the treatment is halo immobilization ×6-12 weeks or hard cervical orthoses

Front 51

what is the treatment of an unstable type II unstable type III that is transverse ligament rupture

Back 51

posterior C1/C2 fusion oroccipital cervical fusion

Front 52

 A Gallie C1-2 fusion with sublaminar wiring of C1 to the spinous process of C2 is a valid treatment option for which of the following injury patterns? 

1.  occipital-cervical dissociation

2.  comminuted C1 burst fracture

3.  type I odontoid fracture

4.  type III odontoid fracture

5.  transverse ligament disruption

Back 52

A C1-2 fusion with sublaminar wiring or modern screw-rod constructs is indicated in transverse ligament injuries. ans5

Front 53

most common location for bipartite patella?

Back 53

superior lateral and a 50% bilateral

Front 54

 A 14-year-old high school running back strikes his left knee on an opposing players helmet during practice. He is able to continue playing for 10 more minutes before seeking medical attention. On examination, he has soft tissue swelling at the anterior knee and early ecchymosis formation. His range of motion was full and no palpable crepitus over the patella was noted. His knee is stable to varus and valgus at 30 degrees. He has a grade one Lachman examination and the medial tibial plateau is anterior to the medial femoral condyle upon a posteriorly directed force on the proximal tibia. There is less than one-quartile of medial and lateral patellar translation with a negative "J" sign. Radiographs are shown in Figures A-C. What is the most appropriate next step in management.

1.  Magnetic resonance imaging (MRI) for ligament reconstruction planning

2.  Immobilize in 120 degrees of knee flexion for 24 hours and return-to-play in 2 weeks

3.  Open reduction and internal fixation with interfragmentary screws with return-to-play in 5 months

4.  Symptomatic treatment with return-to-play as tolerated

5.  Long leg cast for 6 weeks with toe-touch weightbearing precautions with return-to-play in 2 months

Back 54

he patient has a benign exam and radiographs demonstrate a bipartite patella. No further evaluation is necessary and symptomatic treatment with RICE and return-to-play as tolerated is most appropriate.

A bipartite patella has rounded borders and is usually located superolaterally and occurs in approximately 1 in 20 people. They are 
bilateral in 50%. The vast majority are treated with symptomatic treatment. ans4
 

Front 55

the child develops a torticollis after respiratory infection 3 months ago and the CAT scan shows subluxation of C1 on C2 what is the next step in management?

Back 55

posterior Atlantaaxial fusion if greater than 3 months

Front 56

An 3-year-old girl developed torticollis after a severe respiratory tract infection 8 months ago. A dynamic computed tomographic (CT) is performed and shows fixed rotatory subluxation of C1 and C2 despite maximum rotation of the head. What is the most appropriate next step in management?

1.  Closed reduction under conscious sedation

2.  Neck immobilization in a soft cervical collar

3.  Traction with maximal tolerated weight followed by halo brace

4.  Occipitocervical fusion

5.  Posterior atlantoaxial fusion

Back 56

The clinical presentation is consistent with torticollis caused by rotatory atlantoaxial instability. Common causes of this condition include trauma and infection. Diagnosis is made with standard radiographs and a dynamic CT (CT with the head turned maximally to either side and at neutral). If the symptoms are chronic (> 3 months), nonoperative modalities have failed, or if there are any neurologic deficits, then a posterior atlantoaxial fusion is indicated. 

Front 57

atlantoaxial instability name 5 causes in an adult

Back 57

1. Down syndrome
2. Rheumatoid arthritis
3. Os odontoideum
4. atlas fracture
5. Transverse ligament injury

Front 58

atlantoaxial instability name 3 causes in the pediatric patients

Back 58

1. juvenile rheumatoid arthritis
2. MORQUIO syndrome
3. Rotatory atlantoaxial subluxation

Front 59

1. which cervical vertebrae are responsible for 50% of the rotation?
2. which cervical vertebrae is responsible for 50% of the flexion and extension?
3. which cervical vertebrae is responsible for 60% of the lateral bending?

Back 59

1. C1/C2 = atlas axis
2. occiput C1
3. C3-C7

Front 60

1. which cervical vertebrae is the only one with a transverse foramen but the vertebral artery does not travel within it?
2. which cervical vertebrae do not have a bifid spinous process?

Back 60

1. C7 the vertebral artery is not in its transverse foramina
2. C1 and C7 do not have bifid spinous processes

Front 61

1. what is the normal ADI atlantodens interval in adults and children
2. and adult in ADI of what values considered unstable
3. what is considered unstable requiring surgery and a rheumatoid arthritis patient

Back 61

1. less than 3 mm for dull and less than 2.5 mm for pediatrics
2. Greater than 3.5 mm in adult is considered unstable
3. greater than 10 mm and rheumatoid arthritis is considered unstable

Front 62

 A 11-year-old male complains of one year duration of neck pain. He denies any recent trauma. He has noticed intermittent episodes of gait imbalance and difficulty with buttoning his shirt over the past 3 months. Physical exam shows normal strength in all four extremities and hyper-reflexic patellar tendons. Neutral and flexion radiographs are shown in Figure A and B. A sagittal CT scan is shown in Figure C with a coronal reconstruction shown in Figure D. What is the most appropriate treatment? 

1.  PT to strengthen the dynamic stabilizers of the neck

2.  Soft collar wear during any athletic activities

3.  Cessation of all contact sports with no surgical intervention

4.  Posterior C1-C2 fusion

5.  Anterior C1-2 fusion

Back 62

The clinical presentation and imaging studies are consistent with Os odontoideum with neurologic deficits. A posterior C1-C2 fusion is the most appropriate treatment.ans4

Front 63

1. most common cause of adult pyogenic vertebral osteomyelitis?
2. most common cause an IV drug user?
3. Most common cause and patient with sickle cell disease?

Back 63

1. staph aureus
2. pseudomonas
3. Salmonella

Front 64

1. classic x-ray finding seen in 7-10 days with adult pyogenic  osteomyelitis of the spine?
2. what is the next most appropriate step in the management of adult pyogenic osteomyelitis of the spine
3. what if the patient can't do this as with the next best test?

Back 64

1. classic disc space narrowing with disc destruction remember this destruction is atypical for neoplasm
2. MRI with gadolinium contrast
3. technetium 99 bone scan for patient's he cannot obtain an MRI

Front 65

1. if a thinking about osteomyelitis what is mandatory and a workup?
2. what is the indication for CT-guided biopsy of an adult pyogenic osteomyelitis?

Back 65

1. mandatory to get blood cultures to identify the organism is so specific treatment can be started best if done when the patient is febrile
2. patients who do not have any immediate need for open surgery and if blood cultures are negative

Front 66

what is the standard of care treatment for an adult pyogenic osteomyelitis of the spine?

Back 66

bracing and long-term antibiotics 6-8 weeks no surgery

Front 67

what is the treatment of adult pyogenic osteomyelitis of the spine with neurologic deficits or spinal instability?

Back 67

anterior debridement and strut grafting plus or minus posterior instrumentation with the patella below

Front 68

 A 33-year-old man with a history of IV drug abuse presents with low back pain of increasing intensity. His neurologic examination is intact. Laboratory studies reveal a WBC count of 11,000/mm3 and erythrocyte sedimentation rate of 82 mm/h. Blood cultures are negative. Plain radiographs are shown in Fig A. An MRI T1-weighted images and a post gadolinium fat-suppressed T1-weighted images are shown in Fig B. Initial management should consist of:

1.  Physical therapy with supportive therapy

2.  IV antibiotics

3.  Open surgical decompression and biopsy

4.  CT-guided closed biopsy

5.  Repeat MRI in 6 weeks

 

Back 68

The clinical presentation is consistent with pyogenic vertebral osteomyelitis. A CT guided biopsy is the most appropriate next step in management to identify an organism and direct antimicrobial therapy.ans4

Front 69

 A 69-year-old male presents to the emergency room with low back pain for 1 week duration. His past medical history is significant for diabetes and coronary artery disease that was treated with stenting 7 years prior. Recently he was hospitalized for a urinary tract infection which was treated with oral antibiotics. On physical exam he is afebrile and has no neurologic deficits in his lower extremity. Laboratory studies show a white blood cell count of 10,300/mm3, an erythrocyte sedimentation rate of 35 mm/h (reference range, 0-25 mm/h), and C-reactive protein of 13 mg/L (reference range, 0-5.0 mg/L). A radiograph and MRI are performed and shown in Figure A and B respectively. Repeat blood cultures x2 are performed and both show methicillin-sensitive Staphylococcus aureus. What is the most appropriate next step in treatment.

1.  CT guided biopsy

2.  Referral to an orthopaedic pathologist

3.  Organism specific intravenous antibiotics

4.  Posterior lumbar debridement

5.  Anterior lumbar debridement

 

Back 69

The clinical presentation is consistent with discitis and vertebral osteomyelitis in a patient without neurologic deficits and an identified organism. Organism specific intravenous antibiotics would be the most appropriate next step in treatment.ans3

Front 70

A 45-year-old female IV drug user presents to the emergency department with a chief complaint of severe focal low back pain that has progressed over the past 10 days. She now reports the pain is severe enough that it is difficult for her to walk. She reports night sweats, fluctuating fever, and a loss of appetite. Physical exam shows exquisite pain with flexion and extension of the lumbar spine. Routine urinalysis by the ER physician shows evidence of a urinary tract infection. Her blood leukocyte count is 12,600 per mm3, and erythrocyte sedimentation rate is 78 mm/h. A lateral radiograph is shown in Figure A. Which of the following is the best choice in management?

1.  Discharge from the ER with a course of oral antibiotics

2.  Admission to the hospital with empirical IV antibiotics

3.  Admission, antibiotics, and MRI of the lumbar spine with and without gadolinium

4.  Nuclear medicine bone scan

5.  Renal ultrasound

 

Back 70

The clinical presentation is consistent with spondylodiscitis. Although the patient has risk factors for spinal tuberculosis, a CT guided biopsy should be performed to establish a diagnosis.

There is an increasing incidence of TB in United States due to increasing immunocompromised population from HIV. 15% of patients with TB will have extrapulmonary involvement. 5% of all TB patients have spine involvement. With any type of spondylodiscitis the infectious organism must be identified with blood cultures or a biopsy prior to initiating treatment.ans3
 

Front 71

1- pt c/o dyspnea, fever PE-cyanotic skin, intercostal retractions, tachypnea labs Pulmonary capillary wedge pressure < 12 (normal) PaO2 / FIO2 ratio < 200 mm Hg, Pulmonary artery wedge pressure < 18 mmHg
1.1 Dx & TX
1.2 Next best diagnostic study that confirms a diagnosis? (2)
1.3 what is nl ABG finding pH, HCO3, BE, PaCO2 anion gap, Sao2?
1.4 what is expected ABG finding w/ ARDS pH, HCO3, BE PaCO2 anion gap?
1.5 MC associated injury

Back 71

1.1 ARDS tx-mechanical ventilation in ICU w/ moderate-to-high levels of PEEP of 5 cmH2O; goal oxygen satur=88-95% or (PO2) of 55-80.
2-CXR=(1)diffuse b/l infiltrates sparing costophrenic angles (2) patchy pulmonary edema (air space disease) (3) nl sized heart
1.3 ph=nl (7.35 - 7.45); PaCO2=Nl: 35 - 45 mmHg (4.6 - 6 kPa); HCO3=Nl: 22 - 26 mEq/L BE=Nl: -2 to +2 mmol/L
-Look @ pH, PaCO2, and B.E./HCO3- to decide whether compensatory mechanisms are @ work.
In pure respiratory acidosis (high PaCO2, nl [HCO3-], low pH) we expect an eventual compensatory increase in plasma [HCO3-] that would work to restore the pH to nl. Similarly, we expect respiratory alkalosis to elicit an eventual compensatory decrease inplasma [HCO3-]. A pure metabolic acidosis (low [HCO3-], nl PaCO2, low pH) All compensatory responses work to restore pH to nl range (7.3- 7.45)
Sao2=95% to 100%
1.4 ABG=hypoxemia, initially show respiratory alkalosis. pH: 7.57
PaCO2: 23 mmHg
HCO3-: 21 mEq/L
1.5 b/l fem fx, ear

Front 72

patient presents to the emergency room after trauma and bilateral femur fractures with persistent hypoxemia intercostal retractions rales/crackles rhonchi tachypnea dyspnea fever and cyanotic skin with the

1. diagnosis
2. define
3. what is diagnostic study that confirms the diagnosis,
4. looking for?
5. treatment?
6. Most common complication with this treatment
7. what is normal PAo2/Fio2
8. what is normal Fio2
9. what is normal Pulmonary Capillary Wedge Pressure
10. what is NormalA--a gradient = PA O2--PaO2

•  

1.  

Back 72

1. ARDS, 
2. Hypoxemia is refractory to O2 
3. Chest x-ray
4. bilateral patchy pulmonary edema and bilateral pulmonary infiltrates, 
5. PEEP ventilation >5 cm H2O is required and steroids as well as early stabilization of long bone fractures, goal PaO2>55-80
6. pneumothorax secondary to  high PEEP
7. Normal PaO2/FiO2 =300--500
8. Normal FiO2 =21%
9. nl Pulmonary Capillary Wedge Pressure=6–12 mm Hg (Swan Ganz) 
10. Normal A--a gradient is PA O2--PaO2= 0--10 mm Hg age/4 +4 

•  

1.  

Front 73

• for the following conditions what are the values pH bicarb, PCO2

1. Met Acidosis: 
2. Met Alkalosis:
3. Resp Acidosis:
4. Resp Alkalosis:

Back 73

1. Met Acidosis: low pH and low 
   bicarb
2. Met Alkalosis: high pH and high 
   bicarb
3. RespAcidosis: low pH and high PCO2
4. RespAlkalosis: high pH and low PCO2

Front 74

1. what PAo2/Fio2 defines ARDS
2. what Pulmonary Capillary Wedge Pressure defines ARDS
3. What is acute hypercapnic respiratory failure?
4. What is acute hypoxemic respiratory failure?
5. What are the fundamental initial treatment priorities in any patient with respiratory distress?
6. Describe measures that allow differentiation of the various causes of hypoxemia in emergency patients with respiratory distress.
7. How will I recognize a patient with severe respiratory distress?

Back 74

1. PaO2 / FIO2 ratio < 200 mm Hg 
2. Pulmonary Capillary Wedge Pressure <18 mmHg
3. arterial partial pressure of carbon dioxide (PaCO2) greater than 45 mmHg
4. PaO2 of less than 60 mmHg, despite addition of supplemental oxygen of at least 60%. 
5. establishing a patent airway, instituting or assisting ventilation, and maintaining an adequate oxygen tension, by administration of supplemental oxygen, to maximize oxygen delivery.
6. pulse ox SpO2 of less than 90% or an arterial blood gas (ABG) analysis that reveals a PaO2 of less than 60 mmHg. ABG analysis is essential for proper interpretation of causes of hypoxemia. Alternatively, use of pulse oximetry and capnography can be useful in diagnosis. Hypoxemia with normocapnia implies diffusion impairment, ventilation/perfusion imbalance ("V/Q mismatch"),
7. Abnormal sounds (stridor, wheezes), abnormal posture (orthopnea, head and neck extended, elbows abducted, sternal recumbency), abnormal mucous membrane color (cyanosis or pale), tachypnea, weakness and exhaustion, altered respiratory effort (shallow and rapid, or labored and forceful, or absent), and vigorous resistance to restraint