Baby got back
Hand weenie stuff and the rest of the arm I guess.
My leg...
So you think you know bones?
Toddlers vs. Tumors
100
Figures 23a and 23b show the MRI scans of a 50-year-old woman who has increasing gait disturbance. She reports three falls in the past week. Examination reveals hyperreflexia, motor weakness in the biceps and triceps, and a positive Hoffman’s sign. What is the most appropriate treatment plan?
1 Observation
2 Physical therapy
3 Epidural steroid injection
4 Cervical laminectomy
5 Anterior cervical diskectomy and fusion
Figures 23a and 23b show the MRI scans of a 50-year-old woman who has increasing gait disturbance. She reports three falls in the past week. Examination reveals hyperreflexia, motor weakness in the biceps and triceps, and a positive Hoffman’s sign. What is the most appropriate treatment plan?
1 Observation
2 Physical therapy
3 Epidural steroid injection
4 Cervical laminectomy
5 Anterior cervical diskectomy and fusionThe patient has obvious signs of progressive myelopathy. Based on her significant physical examination findings, nonsurgical management will not significantly impact her outcome. Cervical decompression alone is contraindicated in patients with cervical kyphosis such as seen here. Anterior cervical fusion is the best option
100
Which of the following is helpful on physical examination to diagnose a fixed posterior shoulder dislocation?
1 Apprehension sign
2 Jobe relocation test
3 Sulcus sign
4 Jerk test
5 Lack of external rotation
Which of the following is helpful on physical examination to diagnose a fixed posterior shoulder dislocation?
1 Apprehension sign
2 Jobe relocation test
3 Sulcus sign
4 Jerk test
5 Lack of external rotation
The apprehension sign and Jobe relocation test are helpful for the diagnosis of anterior shoulder instability. The sulcus sign provides information on the status of the rotator interval. The jerk test is helpful for the diagnosis of posterior instability, but a fixed posterior shoulder dislocation is associated with loss of external rotation. Since an AP radiograph may miss this diagnosis, an axillary view should be obtained on patients with a shoulder injury.
100
1 A
2 B
3 A + B
4 C
5 C + D
1 A
2 B
3 A + B
4 C
5 C + D
The posterolateral bundle of the anterior cruciate ligament (ACL), labelled B, is primarily responsible for rotational stability of the knee.
The ACL is organized into two primary components: the anteromedial bundle (AMB) and the posterolateral bundle (PLB), named for their tibial insertions. The AMB is the main restraint to anterior tibial translation, particularly at knee flexion when the PLB is slack. The PLB provides rotational stability, particularly at knee extension when it is most taut, and is examined by the pivot shift test. A positive pivot shift test post-operatively indicates persistent rotatory instability and has been associated with functional instability with cutting activities.
100
Which of the following accurately describes the function of osteoprotegerin?
1 Binds to RANK receptor and stimulates osteoclastic bone resorption
2 Inhibits activation of adenylyl cyclase leading to inhibition of osteoclast differentiation
3 Binds to and sequesters RANKL preventing osteoclastic differentiation
4 Binds directly to osteoclasts and prevents osteoclast differentiation
5 Binds directly to osteoblasts to stimulate production of RANKL
Which of the following accurately describes the function of osteoprotegerin?
1 Binds to RANK receptor and stimulates osteoclastic bone resorption
2 Inhibits activation of adenylyl cyclase leading to inhibition of osteoclast differentiation
3 Binds to and sequesters RANKL preventing osteoclastic differentiation
4 Binds directly to osteoclasts and prevents osteoclast differentiation
5 Binds directly to osteoblasts to stimulate production of RANKL
Osteoprotegerin (OPG) binds to and sequesters RANK ligand (RANKL) preventing its attachment to the RANK receptor on osteoclasts and blocking osteoclastic differentiation.
Understanding the molecular pathogenesis of bone signaling is central in understanding disorders of bone metabolism. The RANKL/RANK pathway plays a critical role in this process. Bone resorption is stimulated by RANKL binding to the RANK receptor on osteoclasts leading to osteoclast differentiation/activation. There are many molecules that lead to the activation of this pathway (and thus stimulate bone resorption) through a variety of different mechanisms and they include PTH, IL-1, Vitamin D, IL-6, and in some models, prostaglandins. In contrast, there are many molecules that inhibit the activation of this pathway (and thus prevent bone resorption) and these include OPG, calcitonin, estrogen, IL-10, and TGF-B.
100
Figures 59a and 59b are the radiographs of a 7-year-old boy who was seen 1 week after he underwent a closed reduction and casting in the emergency department after a fall on an outstretched arm. What is the most appropriate next step for this patient?
1 Observation
2 Repeat closed reduction and casting
3 Open reduction and plate fixation
4 Closed reduction and intramedullary nail fixation
Figures 59a and 59b are the radiographs of a 7-year-old boy who was seen 1 week after he underwent a closed reduction and casting in the emergency department after a fall on an outstretched arm. What is the most appropriate next step for this patient?
1 Observation
2 Repeat closed reduction and casting
3 Open reduction and plate fixation
4 Closed reduction and intramedullary nail fixation
This child's radiograph shows an acceptably reduced fracture of both the radius and ulna. Generally accepted limits of shaft angulation for cast treatment for girls 8 years of age or younger and boys age 10 or younger are 20 degrees for distal-third, 15 degrees for middle-third, and 10 degrees for proximal-third fractures. Remodeling decreases as one goes from distal to proximal in the forearm. Unless the child's fracture deviates from these criteria, surgical treatment is not necessary. Because of the risk of displacement, however, close follow-up is recommended.
200
A 36-year-old woman is brought to the emergency department intubated and sedated following a motor vehicle accident. She is moving her upper and lower extremities spontaneously. She cannot follow commands. CT scans are shown in Figures 7a through 7c. The initial survey does not reveal any other injuries. Initial management of the cervical injury should consist of immediate
1 immobilization with a halo ring and vest with reduction when medically stable.
2 closed traction reduction using Gardner-Wells tongs.
3 posterior open reduction, stabilization, and fusion.
4 cervical MRI followed by reduction.
5 anterior open reduction, stabilization, and fusion.
A 36-year-old woman is brought to the emergency department intubated and sedated following a motor vehicle accident. She is moving her upper and lower extremities spontaneously. She cannot follow commands. CT scans are shown in Figures 7a through 7c. The initial survey does not reveal any other injuries. Initial management of the cervical injury should consist of immediate
1 immobilization with a halo ring and vest with reduction when medically stable.
2 closed traction reduction using Gardner-Wells tongs.
3 posterior open reduction, stabilization, and fusion.
4 cervical MRI followed by reduction.
5 anterior open reduction, stabilization, and fusion.
The patient has a bilateral facet dislocation of C6-C7 with preservation of at least some neurologic function. Urgent reduction is necessary. However, because she is sedated and unable to follow commands, an MRI scan is necessary before any closed or open posterior reduction to look for an associated disk herniation. If a disk herniation is present, it must be removed prior to any reduction maneuver to prevent iatrogenic neurologic injury. It is very unlikely that this injury can be reduced with an open anterior procedure alone.
200
During an open carpal tunnel release, the recurrent motor branch of the median nerve is iatrogenically transected. What postoperative disability would be expected, and what is the most likely way this disability arose?
1 Inability to adduct the thumb; cut the transverse carpal ligament radially
2 Inability to oppose the thumb; cut the transverse carpal ligament ulnarly
3 Inability to oppose the thumb; cut the transverse carpal ligament radially
4 Inability to abduct the thumb palmarly; cut the transverse carpal ligament ulnarly
5 Inability to extend the thumb; cut the transverse carpal ligament ulnarly
During an open carpal tunnel release, the recurrent motor branch of the median nerve is iatrogenically transected. What postoperative disability would be expected, and what is the most likely way this disability arose?
1 Inability to adduct the thumb; cut the transverse carpal ligament radially
2 Inability to oppose the thumb; cut the transverse carpal ligament ulnarly
3 Inability to oppose the thumb; cut the transverse carpal ligament radially
4 Inability to abduct the thumb palmarly; cut the transverse carpal ligament ulnarly
5 Inability to extend the thumb; cut the transverse carpal ligament ulnarly
The recurrent motor branch of the median nerve innervates the opponens pollicis, which is responsible for thumb opposition; cutting the transverse carpal ligament radially increases the risk of transection in cases of a transligamentous recurrent motor branch variation (Answer 3).
The recurrent motor branch of the median nerve innervates the majority of the thenar musculature, including opponens pollicis, abductor pollicis brevis, and most of flexor pollicis brevis. There are several described variations in the path of the recurrent branch of the median nerve, of which the three most common are the extraligamentous, subligamentous and transligamentous variations. While reports vary regarding the exact incidence of each variant, the variation that poses the most risk for transection occurs when this nerve branch passes through the actual fibers of the transverse carpal ligament (transligamentous variation).The recurrent branch originates from the central and radial aspect of the median nerve, and thus the transverse carpal ligament should be cut ulnarly to minimize the risk of transection.
200
1 Increases medial extension space
2 Increases lateral extension space
3 Increases medial flexion space
4 Increases lateral flexion space
5 No impact on coronal plane balancing
1 Increases medial extension space
2 Increases lateral extension space
3 Increases medial flexion space
4 Increases lateral flexion space
5 No impact on coronal plane balancing
This patient has a valgus knee and is undergoing a total knee arthroplasty (TKA). An isolated release of the popliteus may be utilized to preferentially increase the lateral flexion space.
The valgus knee poses unique challenges to the treating surgeon. The goals of a TKA in the valgus knee are to create precise bone cuts, release the tight lateral ligaments, tighten the lax medial ligaments, and balance the flexion and extension gaps. When the knee is found to be tight in flexion, release of the popliteus tendon may be performed to increase the lateral flexion gap. Due to the fact that the tibia maximally internally rotates with knee flexion, the popliteus is tightest in this position despite the relaxing effect in the sagittal plane.
200
1 Bryan-Morrey approach and parallel plating
2 Triceps reflecting anconeus pedicle approach and parallel plating
3 Triceps reflecting anconeus pedicle approach and orthogonal plating on the posteromedial and lateral surfaces
4 Olecranon osteotomy and parallel plating
5 Olecranon osteotomy and orthogonal plating on the posteromedial and lateral surfaces
1 Bryan-Morrey approach and parallel plating
2 Triceps reflecting anconeus pedicle approach and parallel plating
3 Triceps reflecting anconeus pedicle approach and orthogonal plating on the posteromedial and lateral surfaces
4 Olecranon osteotomy and parallel plating
5 Olecranon osteotomy and orthogonal plating on the posteromedial and lateral surfaces
Access to complex intra-articular fractures is best achieved by an olecranon osteotomy (OO). Fixation can be with parallel plating or orthogonal plating.
Bicolumnar fixation of distal humerus fractures should follow the principles outlined by O'Driscoll: Distal fragments should be held by as many screws as possible; every screw in the distal fragments should pass through a plate; each screw should engage as many articular fragments as possible.
Incorrect Answers:
Answer 1: The Bryan-Morrey approach provides excellent medial exposure, but inadequate lateral exposure. The triceps is lifted subperiosteally, and the anconeus is released subperiosteally. Triceps repair depends on tendon-bone healing.
Answer 2: The O'Driscoll TRAP approach detaches triceps and anconeus from their distal insertions in a V-shaped flap that is reflected proximally. Repair to bone is via drill holes in the ulna. Early mobilization is not recommended.
Answers 3 and 5: Orthogonal plating is performed on the POSTEROLATERAL and MEDIAL surfaces.
200
1 Observation
2 Wide excision
3 Wide excision plus chemotherapy
4 Radiation therapy
5 Cyrotherapy
1 Observation
2 Wide excision
3 Wide excision plus chemotherapy
4 Radiation therapy
5 Cyrotherapy
The pathological lesion seen in Figure A is that of chondrosarcoma. Unfortunately chondrosarcomas, the second most common primary malignant bone tumor (osteosarcoma being number one) are not chemosensitive or radiosensitive. Patients with this type of tumor who wish to have a chance of cure need to have wide excision of the lesion if possible. No increase in survival rates has been shown with any additional treatment beyond wide local excision.
300
A 17-year-old girl with a history of Scheuermann's kyphosis has a fixed thoracic deformity of 80 degrees. There was no correction of her deformity on supine hyperextension radiographs. What is the most appropriate treatment?
1 Posterior arthrodesis
2 Anterior interbody arthrodesis
3 Smith-Petersen osteotomies with posterior arthrodesis
4 Vertebral column resection with posterior arthrodesis
5 Pedicle subtraction osteotomy with posterior arthrodesis
A 17-year-old girl with a history of Scheuermann's kyphosis has a fixed thoracic deformity of 80 degrees. There was no correction of her deformity on supine hyperextension radiographs. What is the most appropriate treatment?
1 Posterior arthrodesis
2 Anterior interbody arthrodesis
3 Smith-Petersen osteotomies with posterior arthrodesis
4 Vertebral column resection with posterior arthrodesis
5 Pedicle subtraction osteotomy with posterior arthrodesis
The Smith-Petersen osteotomy is most appropriate for long, sweeping, global kyphosis, such as Scheuermann's kyphosis. It can achieve approximately 10 degrees of correction in the sagittal plane at each spinal level at which it is performed. The pedicle subtraction osteotomy is the preferred osteotomy for patients with ankylosing spondylitis, who have a sagittal plane imbalance. It can achieve approximately 30 degrees to 40 degrees of correction in the sagittal plane at each spinal level at which it is performed. Vertebral column resections are extensive procedures, thus they are most appropriately applied to pathologies with sharp angular kyphosis, anterior fusions, and when maximal visualization and decompression of the spinal cord is required. Sagittal curves were reduced an average of 50 degrees, with a lumbosacral deformity treated via vertebral column resection. Anterior arthrodesis alone will not provide sufficient correction and stabilization of the deformity. Posterior arthrodesis alone, while providing stabilization, will not correct the fixed deformity.
300
1 Numbness in the small finger and ulnar side of the ring finger
2 No elbow instability
3 Varus posteromedial rotatory instability
4 Valgus posterolateral rotatory instability
5 Anteromedial rotatory instability
6 Anterolateral rotatory instability
1 Numbness in the small finger and ulnar side of the ring finger
2 No elbow instability
3 Varus posteromedial rotatory instability
4 Valgus posterolateral rotatory instability
5 Anteromedial rotatory instability
6 Anterolateral rotatory instability
The x-ray shows a fracture of the anteromedial facet of the coronoid with an intact radial head. Large anteromedial facet fractures are associated with varus posteromedial rotatory instability.
The anteromedial facet of the coronoid provides support to the medial elbow against varus stress. Varus and posteromedial force applied to the elbow results in disruption of the lateral collateral ligament (LCL) from its proximal origin. The coronoid is fractured as it is forced against the medial trochlea. Coronoid fractures of significant size involving the sublime tubercle (insertion of medial collateral ligament) result in varus instability.
300
DAILY DOUBLE
What is the diagnosis?
What levels of the spinal cord?
What deforming forces are present at the shoulder, elbow, and wrist?
300
An 8-year-old girl presents to the emergency room with a 4-day history of limp and temperature 100.7 F. Lab results show a white blood cell count of 13,000 cells/µL (reference range, 4500-11000 cells/µL), hematocrit 33% (reference range, 41%-50%), and C-reactive protein of 14 mg/L (reference range, 0.08-3.1 mg/L). MR imaging demonstrates osteomyelitis of the proximal tibia without an abscess. During the work-up in the ER, the patient became hypotensive. What is the mechanism of action of the empiric antibiotic appropriate for this patient?
1 Binding to penicillin-specific binding proteins in the bacterial cell wall
2 Binding to the D-Ala-D-Ala residues in the bacterial cell wall
3 Inhibition of bacterial topoisomerase and DNA gyrase
4 Inhibition of nucleic acid synthesis
5 Binding to 30S ribosomal proteins
An 8-year-old girl presents to the emergency room with a 4-day history of limp and temperature 100.7 F. Lab results show a white blood cell count of 13,000 cells/µL (reference range, 4500-11000 cells/µL), hematocrit 33% (reference range, 41%-50%), and C-reactive protein of 14 mg/L (reference range, 0.08-3.1 mg/L). MR imaging demonstrates osteomyelitis of the proximal tibia without an abscess. During the work-up in the ER, the patient became hypotensive. What is the mechanism of action of the empiric antibiotic appropriate for this patient?
1 Binding to penicillin-specific binding proteins in the bacterial cell wall
2 Binding to the D-Ala-D-Ala residues in the bacterial cell wall
3 Inhibition of bacterial topoisomerase and DNA gyrase
4 Inhibition of nucleic acid synthesis
5 Binding to 30S ribosomal proteins
The patient described presents with osteomyelitis most likely due to methicillin-resistant staph aureus (MRSA). Empiric antibiotics for suspected MRSA infections include clindamycin and vancomycin, and vancomycin is recommended for severe infections, particularly with signs of sepsis. The mechanism of action of vancomycin is binding to D-Ala-D-Ala moieties to inhibit bacterial cell wall synthesis.
MRSA infections have become increasingly common causes of osteomyelitis and require appropriate antibiotic coverage for proper treatment. MRSA infections can often be more aggressive and progress more rapidly than MSSA infections.
300
A 14-year-old boy has complete growth arrest of his left proximal tibia after a skateboarding injury. He currently has a 3mm leg-length discrepancy with left shorter than the right. A radiograph of the patients left hand, wrist, and fingers demonstrate a bone-age of 14 years. What is the most appropriate management of this patient?
1 Observation
2 Left tibial lengthening
3 Right tibia epiphysiodesis
4 Right femur epiphysiodesis
5 Amputation
A 14-year-old boy has complete growth arrest of his left proximal tibia after a skateboarding injury. He currently has a 3mm leg-length discrepancy with left shorter than the right. A radiograph of the patients left hand, wrist, and fingers demonstrate a bone-age of 14 years. What is the most appropriate management of this patient?
1 Observation
2 Left tibial lengthening
3 Right tibia epiphysiodesis
4 Right femur epiphysiodesis
5 Amputation
Based on the arithmetic method for prediction of limb length discrepancy, the patient in question has about 2 years of growth remaining, and it can be calculated that his left tibia will be short by about 15 mm at maturity (6mm/yr for proximal tibia x 2 yrs + existing 3mm). Typically, LLD at maturity of <2cm is treated nonoperatively with observation and shoe lift if needed.
Treatment is dictated by the length discrepancy at maturity (not at the original presentation): <2cm is treated nonoperatively, 2-5cm is treated with epiphysiodesis or ostectomy, and greater than 5-6cm is treated with limb lengthening, and possible contralateral epiphysiodesis.
400
A 21-year-old male sustained a T12 burst fracture after a motor vehicle accident. His neurological examination reveals an incomplete spinal cord injury. Magnetic resonance imaging shows the posterior ligament complex is intact. What would be the Thoracolumbar Injury Classification System (TLICS) score and recommended treatment?
A 21-year-old male sustained a T12 burst fracture after a motor vehicle accident. His neurological examination reveals an incomplete spinal cord injury. Magnetic resonance imaging shows the posterior ligament complex is intact. What would be the Thoracolumbar Injury Classification System (TLICS) score and recommended treatment?
TLICS = 5; posterior decompression and arthrodesis
400
The muscle responsible for internal rotation of the humerus and inserting on the medial lip of the intertubercular sulcus is innervated by what peripheral nerve labeled in Figure A?
NAME the muscle, the nerve and correctly identify it in the diagram.
The muscle responsible for internal rotation of the humerus and inserting on the medial lip of the intertubercular sulcus is innervated by what peripheral nerve labeled in Figure A?
Letter D corresponds to the lower subscapular nerve of the posterior cord of the brachial plexus. The lower subscapular nerve innervates the teres major muscle.
The lower subscapular nerve arises from the posterior cord of the brachial plexus, along with the upper subscapular nerve and the thoracodorsal nerve. The lower subscapular nerve receives contributions from C5 and C6 and also innervates the lower part of the subscapularis muscle. Teres major receives innervation from the thoracodorsal nerve in 20% of cases. An understanding of the neurovascular anatomy of this muscle is critical for performing safe tendon transfers, sometimes utilized in the treatment of massive rotator cuff tears.
400
A 56 year-old male with chronic foot pain presents to your clinic for initial evaluation. He has been treated nonoperatively by a podiatrist with custom orthotics and physical therapy. However his symptoms have progressed to the point it is limiting his ability to perform his job as a postal worker. On examination you note complete loss of his medial arch of the foot. He is unable to perform a single-leg heel rise, but his hindfoot is flexible and passively correctible. He has full strength with inversion, eversion, plantar flexion, and dorsiflexion. You obtained an Xray in your clinic demonstrated in figure A and B. What surgical intervention should you offer this patient?
A 56 year-old male with chronic foot pain presents to your clinic for initial evaluation. He has been treated nonoperatively by a podiatrist with custom orthotics and physical therapy. However his symptoms have progressed to the point it is limiting his ability to perform his job as a postal worker. On examination you note complete loss of his medial arch of the foot. He is unable to perform a single-leg heel rise, but his hindfoot is flexible and passively correctible. He has full strength with inversion, eversion, plantar flexion, and dorsiflexion. You obtained an Xray in your clinic demonstrated in figure A and B. What surgical intervention should you offer this patient?
Navicular-cuneiform arthrodesis
This patient has pes planus secondary to deformity at the navicular-cuneiform joint. Treatment should be deformity correction with a fusion of the involved joint.
Pes planus, adult-acquired flatfoot deformity (AAFD), is most often caused by posterior tibial tendon insufficiency (PTTI). It manifests by the collapse of the medial longitudinal arch of the foot and often has an associated valgus hindfoot deformity. Radiographically it is determined by the lateral talometatarsal angle greater than 4 degrees (Meary's Angle). Within the differential for AAFD however is a midfoot deformity. Classically on radiographs with PTTI driven AAFD there is dorsal subluxation of the navicular on the talus. This is differentiated from midfoot driven AAFD by cuneiform subluxation dorsally on the talus with the maintenance of alignment between the navicular and the talus. Treatment for midfoot AAFD is with realignment and fusion of the midfoot. Initial treatment for all types of AAFD is nonoperative with orthotics and physical therapy.
400
SOX-9 is a key transcription factor involved in the differentiation of which of the following cell lineages?
SOX-9 is a key transcription factor involved in the differentiation of which of the following cell lineages?
SOX-9 is considered a “master switch” for the differentiation of cells of chondrocytic lineage.
As described in the review by Hoffman et al, SOX-9 binds to a critical consensus sequence in the collagen 2 (Col2) promoter to activate its transcription. Formation of the cartilage template involves a multi-step process in which prechondrogenic mesenchymal cells form condensations prior to differentiating into matrix-producing chondroblasts. Retinoids, particularly retinoic acid, are among the numerous signaling molecules that have been implicated in this process. Efforts aimed at understanding the mechanisms by which expression of retinoic acid receptor attenuates chondroblast differentiation led to the discovery of the transcriptional activity of SOX-9.
400
A 71-year-old male presents with a large mass on his right thigh. An MRI and biopsy are performed and are shown in Figures A-C. What is the genetic basis of the condition, and what is the next best step in treatment?
A 71-year-old male presents with a large mass on his right thigh. An MRI and biopsy are performed and are shown in Figures A-C. What is the genetic basis of the condition, and what is the next best step in treatment?
MDM2 amplification; marginal resection without radiation
The patient has a well-differentiated liposarcoma (WDLPS), also known as an atypical lipomatous tumors (ALT), which results from MDM2 amplification. The best step in treatment is marginal resection without radiation.
Liposarcomas are a heterogeneous class of sarcomas with differentiation towards adipose tissue. Well-differentiated liposarcomas are a low-grade subtype of liposarcomas that result from MDM2 amplification. Due to the low risk of local recurrence, they are amenable to marginal resection without radiation. Intermediate-grade and high-grade liposarcomas (such as round cell liposarcomas, pleomorphic liposarcomas, and dedifferentiated liposarcomas), on the other hand, should be treated with wide resection and adjuvant radiation.
500
During an anterior retroperitoneal approach to the lumbar spine, what nerve is encountered lying on the anteromedial surface of the psoas muscle?
During an anterior retroperitoneal approach to the lumbar spine, what nerve is encountered lying on the anteromedial surface of the psoas muscle?
The genitofemoral nerve arises from the L1 and L2 roots and then emerges through the psoas between the third and fourth lumbar vertebrae from where it runs along the surface of the psoas. The ilioinguinal, lateral femoral cutaneous, and the iliohypogastric nerves all arise from upper lumbar roots but remain posterior to the psoas and then run along the inner surface of the quadratus lumborum and iliacus muscles. The femoral nerve runs posterior to the psoas muscle in the retroperitoneum before wrapping around laterally to ultimately lie on the anterior surface of the iliopsoas muscles distally as it exits the pelvis.
500
Figure A is a radiograph of a 35-year-old women who sustained an isolated left wrist injury after a fall onto an outstretched hand. She has been complaining of left dorsal wrist pain since the fall. Examination reveals a positive Watson's scaphoid shift test. What ligamentous structure is an important secondary stabilizer to prevent dorsal intercalated segment instability (DISI) deformity in this patient?
Figure A is a radiograph of a 35-year-old women who sustained an isolated left wrist injury after a fall onto an outstretched hand. She has been complaining of left dorsal wrist pain since the fall. Examination reveals a positive Watson's scaphoid shift test. What ligamentous structure is an important secondary stabilizer to prevent dorsal intercalated segment instability (DISI) deformity in this patient?
The integrity of the dorsal intercarpal ligaments is important in preventing dorsal intercalated segment instability (DISI) deformity and persistent scapholunate instability.
Scapholunate instability is the most common carpal instability. The primary stabilizing structure of the scaphoid and lunate bones is the scapholunate ligament, which is commonly injured with a fall on an outstretched hand. Secondary stabilizers of the scaphoid and lunate include the dorsal intercarpal ligaments and the dorsal radiocarpal ligaments. Failure to recognize injury of these structures can cause persistent dorsal intercalated segment instability (DISI). This can predispose patients to a SLAC wrist and early wrist osteoarthritis.
500
A 52-year-old woman presents with a painful bunion deformity of her left foot shown in Figure A. A radiograph of her foot shows the following: (1) hallux valgus angle (HVA) = 35°, (2) intermetatarsal angle (IMA) = 12°, (3) hallux valgus angle distal metatarsal articulation angle (DMAA) = 9°, (4) hallux valgus interphalangeus angle is 12°, (5) the 1st metatarsal joint is congruent. What procedure OR combination of procedures will most effectively achieve correction?
Distal metatarsal osteotomy, displacing the metatarsal head laterally.
Distal metatarsal osteotomy, displacing the metatarsal head medially
Medial closing wedge proximal phalanx osteotomy.
Lateral opening wedge proximal phalanx osteotomy.
Distal soft-tissue release.
A 52-year-old woman presents with a painful bunion deformity of her left foot shown in Figure A. A radiograph of her foot shows the following: (1) hallux valgus angle (HVA) = 35°, (2) intermetatarsal angle (IMA) = 12°, (3) hallux valgus angle distal metatarsal articulation angle (DMAA) = 9°, (4) hallux valgus interphalangeus angle is 12°, (5) the 1st metatarsal joint is congruent. What procedure OR combination of procedures will most effectively achieve correction?
Distal metatarsal osteotomy, displacing the metatarsal head laterally.
Distal metatarsal osteotomy, displacing the metatarsal head medially
Medial closing wedge proximal phalanx osteotomy.
Lateral opening wedge proximal phalanx osteotomy.
Distal soft-tissue release.
Distal metatarsal osteotomy, displacing the metatarsal head laterally AND Medial closing wedge proximal phalanx osteotomy.
Considering that the DMAA <10°, the HVA is moderate (<40°), the IMA is not large (<15°) the joint is congruent, and hallux valgus interphalangeus angle is >10°, a distal metatarsal osteotomy with lateral displacement of the MT head, and Akin medial closing wedge proximal phalanx osteotomy is indicated.
Indications for an Akin osteotomy include: (1) hallux valgus interphalangeus, (2) a congruent joint with DMAA < 10°, and use as a secondary procedure if a primary procedure (e.g., chevron or distal soft-tissue procedure) did not provide sufficient correction due to a large DMA angle or hallux valgus interphalangeus. It also repositions the FHL towards the midline, contributing both to biomechanical and cosmetic correction for residual hallux valgus deformity. It is contraindicated with an incongruent joint and where DMAA> 15°. For joint incongruence, perform distal soft tissue correction. For large DMAA, perform biplanar distal Chevron osteotomy.
Incorrect Answers:
Answers 1, 2, 4,: Distal soft tissue procedures are indicated where there is joint incongruence. In hallux valgus distal osteotomies, the metatarsal head is displaced laterally.
Answer 5: With the Akin osteotomy, a medial closing wedge is employed, rather than lateral opening wedge, because of faster bone healing (better bony contact), earlier removal of hardware, and no need for bone graft.
500
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?
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?
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.
500
A 3 1/2-year-old boy has bowlegs that have become more noticeable over the past year. A radiograph is shown in Figure 28. Based on these findings, treatment should now consist of?
A 3 1/2-year-old boy has bowlegs that have become more noticeable over the past year. A radiograph is shown in Figure 28. Based on these findings, treatment should now consist of?
tibia and fibula osteotomy.
The child has infantile tibia vara, also called Blount's disease. The radiograph shows sloping of the medial metaphysis and irregularity of the epiphysis. The most appropriate treatment in a child who is younger than age 4 years, with progressive varus, and who has the radiographic findings described above is tibia and fibula osteotomy. Although the natural history of Blount's disease is not known with certainty, some studies predict that patients who have more advanced radiographic changes will develop progressive genu varum. Observation may be useful in young infants when the differentiation between infantile tibia vara and physiologic genu varum is uncertain. Although controversial, bracing may have a role in early, mild Blount's disease. Epiphysiodesis is not indicated in a 3+-year-old child. Hemi-plateau elevation may be considered in children with severe uncorrected or relapsed infantile tibia vara.