188/189

Front 1

 A 65-year-old diabetic male with forefoot gangrene is evaluated for possible amputation. When discussing the amputation levels with the patient, which of the following should be noted to require the greatest increase in energy expenditure for ambulation?

1.  Syme amputation

2.  Unilateral transtibial amputation

3.  Transfemoral amputation

4.  Bilateral transtibial amputations

5.  Through the knee amputation

Back 1

A transfemoral level amputation requires the greatest increase in energy expenditure of the amputation levels given, and a Syme amputation the least.  The authors found that that posterior tibial artery Doppler examination is predictive of healing in the Syme amputation performed on diabetics, and that furthermore, diabetics can attain a functional level of ambulation with a Syme amputation.ANS3

Front 2

Figure A shows a below the knee amputation performed in a diabetic patient with significant vascular disease. Removal of the "dog ears", indicated by the red arrows, could cause direct damage to what vasculature leading to flap necrosis?

1.  Anterior tibial artery

2.  Saphenous and sural arteries

3.  Posterior tibial artery

4.  Peroneal artery

5.  Lower popliteal artery

Back 2

"Dog ears" at the edge of a long posterior flap BKA incision are typically left intact because removal risks posterior flap blood supply. 

Gray et al conducted an anatomic study to examine the BKA vascular anatomy and specifically the blood supply contribution of the soleus muscle. In their article, they describe the saphenous and sural arteries as being the main blood supply to the proximal posterior aspect of the calf. These arteries lie on the medial and lateral border of a long posterior flap, and can be at risk for transection when excising "dog ears". These arteries are particularly important in patients with severe vascular disease, as the popliteal artery and its immediate branches may be occluded, while the collateral smaller vessels (ie. saphenous and sural arteries) remain patent. Of note, the authors did conclude that the soleus muscle does not contribute blood supply to a long posterior flap, and it should be entirely excised. ANS 2

Front 3

most common complication with chopart amputation most common technique to prevent it from recurring?

Back 3

equinus deformity to prevent do Achilles lengthening and transferred tibialis anterior tendon

Front 4

most common complication with Lisfranc amputation most common technique to prevent it from occurring?

Back 4

equina varus deformity prevented by keeping peroneus brevis tendon attached and it occurs because of unopposed pull posterior tibialis tendon and gastric soleus complex

Front 5

most important for success with a symes amputation and most important  laboratory tests to ensure healing of the amputation?

Back 5

must have a stable heel pad and must have a patent posterior tibialis artery

albumin level greater than 3.0

Front 6

most common complication with an amputation pediatric patient and most common technique to prevent?

Back 6

overgrowth, knee disarticulation or cartilaginous cap to prevent overgrowth

Front 7

 best predictor of wound healing after amputation?

Back 7

albumin level greater than 3.0

Front 8

what are the minimal values necessary for wound parenting healing when comparing albumin, transient transcutaneous oxygen tension, total lymphocyte count, ABIs and toe pressures

Back 8

3.0/30//15/0.45 /40

Front 9

what are the energy expenditure is when comparing amputations at different levels for example bilateral transfemoral amputations, transfemoral amputation, bilateral knee amputations, transtibial amputation, bilateral transtibial amputations, symes amputation

Back 9

bilateral transfemoral amputationequals 200

Bilateral knee disarticulation equals 120

Transfemoral amputation equals 70/100

Bilateral transtibial amputation equals 40

transtibial amputation 25/40

SYMES amputation equals 15

 

Front 10

 

In addition to lengthening the Achilles, transfer of which tendon is most important for functional ambulation after performing a Chopart amputation of the foot? 

1.  peroneus brevis

2.  peroneus longus

3.  tibialis anterior

4.  tibialis posterior

5.  flexor hallucis longus

Back 10

The partial foot amputation through the talonavicular and calcaneocuboid joints is also known as the Chopart amputation. The Chopart amputation may result in significant equinovarus deformity with anterior weight bearing through the scar line, predisposing to skin breakdown over time. Therefore, lengthening of the Achilles tendon and transfer of the tibialis anterior to the talar neck should also be performed in conjunction with this disarticulation.ans3

Front 11

1. on x-ray what is seen that is different from physiologic bowing compared to BLOUNT's disease?
2. the metaphyseal diaphyseal angle of DRENNAN is considered abnormal and BLOUNTS disease at what amount?  
3. What amount most likely will resolve and is considered physiologic we normal?

Back 11

1. with physiologic bowing there is symmetric flaring of the tibia and femur compared to BLOUNT's disease which shows metaphyseal beaking
2. greater than 16 is considered abnormal and has a 95% chance of progressing
3. Less than 10° as a 95% chance of resolving

Front 12

if pediatric patient  3 years of age presents to the office with  metaphyseal diaphyseal angle of 16° what is the treatment and what is the classification

Back 12

a child less than 3 with stage I and 2 is treated with a brace K AFO

Front 13

pediatric patient who is 4 years old presents to the office with an metaphyseal diaphyseal angle of 16° what is the treatment and what is the classification?

Back 13

a child greater than 3 years of age with a stage II or 1 is treated with proximal tibia fibula valgus osteotomy and overcorrection of 10-15° of valgus

Front 14

if a pediatric patient 3 years of age presents to the office withmetaphyseal diaphyseal angle of 20° was a treatment was a classification?

Back 14

the child is greater than 3 years of age with stage III or 5 the treatment is proximal tibia and fibula valgus osteotomy with correction 10-15° of valgus

Front 15

if a child 2 years of age presents with a congenital bar across the physis what is the treatment?

Back 15

excision of the bar and epiphysial lysis

If the physeal bar is greater than 50% consider hemiepiphyseal lysis

Front 16

A valgus producing proximal tibial osteotomy with 10 degrees of overcorrection is the most appropriate treatment for which of the following patients with tibia vara? 

1.  A 4-year-old obese child with Blount's disease, Langenskiöld stage IV

2.  An 18-month-old child with a proximal tibia metaphyseal-diaphyseal angle of 11 degrees

3.  A 2-year-old obese child with Blount's disease, Langenskiöld stage II disease

4.  A 5-year-old child with untreated renal osteodystrophy and a proximal tibia metaphyseal-diaphyseal angle of 16 degrees

5.  A 8-year-old child with distal femoral varus a lateral distal femoral angle of 95 degrees

Back 16

children who are too old for bracing, morbidly obese, and have advanced Blount's disease (Langenskiöld stages IV, V, or VI) are candidates for proximal tibial osteotomy. Furthermore, it has been shown that overcorrection of the deformity can lead to decreased recurrence rates. Incorrect Answers:
2-Children with metaphyseal-diaphyseal angles between 9 and 16 degrees are generally treated with bracing if there has been no tendency toward correction after 24 months of age.
3-Bracing is often recommended as the initial treatment of children with Langenskiöld stage I or II tibia vara. 
4-Orthopaedic treatment of angular lower-limb deformities resulting from renal disease is wisely postponed until the renal status has stabilized in response to medical treatment or renal transplantation. Correction of genu varum or valgum with osteotomy will be short-lived unless the abnormal bone metabolism resulting from the renal disease has been reversed.
5-This child is presenting with late-onset tibia vara, and distal femoral varus. This is typically treated initially with a distal femoral osteotomy or guided growth if the lateral distal femoral angle is greater than 92 degrees. The tibia is only corrected if deformity within the tibia is present.

ans1

Front 17

A 32-month-old male with severe infantile Blounts disease has been treated with full time bracing for the past year. At most recent follow-up, the varus deformity of his bilateral legs has worsened despite compliance with bracing. What treatment is now recommended?

1.  Observation, discontinuation of bracing

2.  Observation, continuation of full-time bracing

3.  Bilateral proximal tibial osteotomies

4.  Bilateral distal femur osteotomies

5.  Bilateral proximal tibial medial hemiepiphysiodesis

 

Back 17

The clinical scenario is consistent for a child with Infantile Blount’s disease who is < 3 year of age BUT has failed the first line of treatment which is bracing. At this time bilateral proximal tibial osteotomies is the most appropriate treatment. ncorrect Answers:
Answer 4: Incorrect because the pathology is in the tibia and not the femur in infantile blount’s.
Answer 5: Incorrect because closing down the medial side will cause further varus. ans3

Front 18

A 30-month-old boy has worsening bilateral bowleg deformities, and radiographs are shown in Figure A. The most appropriate initial management should consist of which of the following?

1.  Observation

2.  Full-time bracing with knee-ankle-foot orthoses

3.  Night-time bracing with knee-ankle-foot orthoses

4.  Proximal tibia/fibula valgus osteotomy with bar resection

5.  Proximal tibia/fibula valgus osteotomy with hemiepiphysiodesis

Back 18

initial management of infantile Blount's disease in children less than 3 years old consists of full time bracing with a knee-ankle-foot orthosis. 

Front 19

what kind of anesthesia leads to increased difficulty with fluoroscopic identification during pelvic and spinal procedures?

Back 19

 nitrous oxide with increase gases abdominal distention

Front 20

what is the most common complication with interscalene regional block?

Back 20

sensorimotor neuropathy

Front 21

when an interscalene regional block is performed where is the brachial plexus found for injection?

Back 21

the groove between the anterior and middle scalene muscles at the level of the cricoid cartilage

Front 22

was difference between epidural anesthesia and spinal anesthesia?

Back 22

spinal anesthesia as a single injection and epidural anesthesia isan indwelling catheter

Front 23

• what kind of anesthesia would be given for severe hip pain from osteoarthritis or abductor muscle spasm?
• which areas targeted for the hip and which areas targeted for the knee?

Back 23

• obturator nerve block
• one targets the anterior branch of the obturator nerve which decreases sensation to the hip and inner thigh compared to the
• posterior branch which decreases sensation to the knee

Front 24

what kind of anesthesia would be given for procedures around the medial aspect of the knee leg and ankle/

Back 24

saphenous nerve block

Front 25

A surgeon recommends an interscalene regional block to a patient undergoing shoulder arthroscopy. When asked about potential complications, which of the following is most likely to occur?

1.  Persistent motor neuropathy

2.  Sensory neuropathy

3.  Complex regional pain syndrome

4.  Pneumothorax

5.  Cardiac arrythmia and arrest

Back 25

Sensory neuropathy is the most common complication seen with interscalene regional block.
sensory neuropathy in eleven patients and a complex regional pain syndrome that resolved at three months in one patient. For ten of the eleven patients, the neuropathy had resolved by six months. ans2

Front 26

regarding the  SF 36 what is this outcome measurement tool used to compare and what is the differentiate?

Back 26

the SF 36 is used to compare the relative burden of disease and differentiate health benefits produced from different treatments

Front 27

in the SF 36 the burden of disease fracture 8 categories what are they?

1. what is a scale of the SF 36
2. What is the SF 12

Back 27

1. vitality
2. Mental health
3. Emotional role functioning
4. Social role functioning

•  

1. bodily pain
2. General health perceptions
3. Physical functioning
4. Physical roll functioning

• .

1. the scale is 0-100 and each question carries the same weight
2. Self rated free injury pain related disability as a predictor of moderate to severe pain 6 months after musculoskeletal injury

Front 28

the harris hip score is based on what 4 categories?

Back 28

1. pain
2. Function
3. Functional activities
4. Physical exam
5. Does not allow for individual differences based on age health, other personal issues that may affect a total score

Front 29

one of the 5 categories for the following ankle outcome score and what clinical conditions are commonly used in patient's?

 

Back 29

1. pain
2. Other symptoms
3. Activities of daily living
4. Functions and sport and recreation
5. Foot and ankle related quality-of-life
6. Lateral ankle instability, Achilles tendinosis, plantar fasciitis

Front 30

what is the constant shoulder outcomes score includes 4 variables ?

Back 30

1. pain score 
2. Functional assessment
3. Range of motion
4. Strength measures
5.  

Front 31

UCLA shoulder score which consist of 5 pain, function, active forward flexion, strength of forward flexion, satisfaction of the patient what is a maximal score?

Back 31

maximal score 35" excellent results is score greater than 27

Front 32

what is the Oswestry disability index used for?

Back 32

the patient's permanent functional disability and this considering the gold standard for lower back functional outcome tool

Front 33

 A 45-year-old male trauma patient presents with multiple extremity injuries including the foot injury shown in Figure A. The foot fracture is treated surgically, and heals without any initial complications. At a minimum of 12 months, this patient will be expected to have which of the following scores compared to a matched polytrauma patient without a foot injury? 

1.  Lower mean Short Form 36 (SF-36) score

2.  Higher mean score on the AAOS lower limb and foot and ankle outcomes questionnaire

3.  Equivalent score on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)

4.  Lower Constant score

5.  Higher score on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)

 

Back 33

Turchin et al assessed the outcome of two groups of matched polytrauma patients, with the only difference being the presence of a foot injury in Group 1. They used three outcome tools, SF-36, WOMAC, and Modified Boston Children's Hospital Grading System to evaluate the the two groups at a minimum of 2 years from injury. The foot injury group, including all types of foot fractures, had a poor outcome when using any of these measures. Turchin concludes that “Foot injuries cause significant disability to multiply injured patients. More attention should be given to these injuries, and more aggressive management should be considered to improve the outcome of this group of multiply injured patients.” ans1

Front 34

what compressive neuropathy result in motor deficits only with no sensory changes?

Back 34

A AIN compressive neuropathy

Front 35

where is the most common cause of AIN compressive neuropathy at the elbow?

Back 35

the tenderness as of the deep head of the pronator teres

Front 36

the patient presents with bilateral weakness of grip and pinch, unable to make the capital okay sign, weakness with resisted pronation at the elbow maximally flexed

1. what is the diagnosis?
2. what is you treatment?
3. what is the next best diagnostic study to confirm the diagnosis?

 

Back 36

1. the diagnosis is bilateral AIN neuropathy also known as Parsonage TURNER syndrome
2. the treatment is observation rest and splinting in 90° for 8-12 weeks because it is caused by virus
3. best test.  EMG and may reveal abnormalities in the FPL, FDP index and middle finger and pronator quadratus muscles

Front 37

patient presents to the office note pain but has weakness of grip and pinch, unable to make the okay sign and weakness with pronation what is the diagnosis?

Back 37

the diagnosis AIN nerve palsy

Front 38

A 34-year-old seamstress was diagnosed with Parsonage-Turner brachial neuritis in the right upper extremity 1 month ago. She has weak forearm pronation with the elbow in the flexed position. She denies any current sensory changes. A clinical image of her hands attempting to make a clenched fist are shown in Figure A. Which of the following most likely represents her diagnosis and treatment?

1.  Anterior interosseous nerve syndrome treated with observation

2.  Posterior interosseous nerve syndrome with release of the Arcade of Frohse

3.  Pronator syndrome with surgical release of the lacertus fibrosis

4.  Anterior interosseous nerve syndrome with surgical release of Gantzer's muscle

5.  Posterior interosseous nerve syndrome treated with observation

 

Back 38

This patient presents with anterior interosseous nerve (AIN) syndrome and is often seen in conjunction with brachial neuritis (Parsonage-Turner Syndrome). ans1

Front 39

what muscles are affected and found to be abnormal by EMG with AIN nerve palsy and how to test each of these muscles

Back 39

1.  (1)FDP and (2)FPL muscles are weak patient is unable to make the Okay sign
2. patient has a weak grip and pinch specifically affecting the thumb index and middle finger flexion
3. (3)Pronator quadratus weakness is physical exam weak resisted pronation with the elbow maximally flexed
4. The tenodesis effect is intact therefore does not  FPL rupture, the tenodesis effect is passive wrist flexion and extension which brings the thumb IP joint and index finger DIP joint into a relatively flexed position