Free Orthopedics Review | Dr Hutaif General Orthopedics -...

Imaging studies in the evaluation of plantar fasciitis should always include weight-bearing foot radiographs to reveal alignment and exclude calcaneal stress fracture, tumor, subtalar arthritis, and insertional posterior spurs. MRI is occasionally indicated in problematic cases. Ultrasound can be helpful to evaluate thickening and disease in the proximal plantar fascia. Ultrasound is quick and much more cost effective than MRI. Laboratory screenings to evaluate inflammatory arthritis are indicated only for patients with bilateral heel pain who may be more likely to have systemic disease.
In the nonsurgical treatment of plantar fasciitis, high-impact loading exercises may make the condition worse. Corticosteroid injections may provide short-term relief only and can occasionally cause plantar fascia rupture. They should be used with caution. PRP injections are expensive and currently not covered by insurance. Studies have not demonstrated long-term pain relief with PRP. Plantar fascia-specific stretching has been shown more effective than Achilles tendon stretching alone.
Surgical treatment is indicated for fewer than 5% of patients. It is not necessary to resect the heel spur because the spur is not attached to the plantar fascia and rarely contributes to a patient's pain. The open extensile approach is associated with a much longer recovery than the open or endoscopic approaches and is no longer justified. Multiple studies have demonstrated the efficacy of endoscopic and open plantar fasciotomy techniques.
RECOMMENDED READINGS
Bader L, Park K, Gu Y, O'Malley MJ. Functional outcome of endoscopic plantar fasciotomy. Foot Ankle Int. 2012 Jan;33(1):37-43. doi: 10.3113/FAI.2012.0037. PubMed PMID:
[22381234.](http://www.ncbi.nlm.nih.gov/pubmed/22381234)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/22381234)
Lareau CR, Sawyer GA, Wang JH, DiGiovanni CW. Plantar and medial heel pain: diagnosis and management. J Am Acad Orthop Surg. 2014 Jun;22(6):372-80. doi: 10.5435/JAAOS-22-06-
[372/. PubMed PMID: 24860133.](http://www.ncbi.nlm.nih.gov/pubmed/24860133)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/24860133)

After HTO, particularly in patients who have been immobilized after a closing-wedge osteotomy, patella baja is a common finding. This can precipitate anterior knee pain or patellofemoral pain syndrome. Recurrence of medial joint overload is incorrect because the patient has no medial joint complaints. Nonunion is less likely with a closing-wedge osteotomy and likely will not result in anterior knee pain.

During a lateral transpsoas approach, retractors and instruments are passed through the psoas muscle. The lumbar plexus is within the psoas muscle. The neural structures are found in the dorsal half of the vertebral body. Moro and associates found all the nerve roots in the dorsal 25% of the vertebral body at L2-3 and above. As a person moves more distally, the location of the neural structures moves more ventrally. As a result, L4-5 is at highest risk.
RECOMMENDED READINGS
16. [Moro T, Kikuchi S, Konno S, Yaginuma H. An anatomic study of the lumbar plexus with respect to retroperitoneal endoscopic surgery. Spine (Phila Pa 1976). 2003 Mar 1;28(5):423-8; discussion 427-8. PubMed PMID: 12616150.](http://www.ncbi.nlm.nih.gov/pubmed/12616150)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/12616150)
17. Park DK, Lee MJ, Lin EL, Singh K, An HS, Phillips FM. The relationship of intrapsoas nerves during a transpsoas approach to the lumbar spine: anatomic study. J Spinal Disord Tech. 2010 Jun;23(4):223-
[8/. doi: 10.1097/BSD.0b013e3181a9d540. PubMed PMID: 20084033. ](http://www.ncbi.nlm.nih.gov/pubmed/20084033)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/20084033)
18. Benglis DM, Vanni S, Levi AD. An anatomical study of the lumbosacral plexus as related to the minimally invasive transpsoas approach to the lumbar spine. J Neurosurg Spine. 2009 Feb;10(2):139-
[44/. doi: 10.3171/2008.10.SPI08479. PubMed PMID: 19278328. ](http://www.ncbi.nlm.nih.gov/pubmed/19278328)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/19278328)

The image demonstrates a rotational fluoroscopic view of the lateral distal radius while attempting to recreate the inclination of the distal radius. This view is most useful to ensure against intra-articular screw penetration. The overall alignment of the joint surface is best viewed with a posteroanterior tilt of 11 degrees. The alignment of the sigmoid notch is not seen well on lateral images. Carpal alignment is seen
well on lateral images. Dorsal screw penetration is best viewed dynamically with a flexed wrist tangential _view._

Patients recover the ability to safely operate the brakes of an automobile 9 weeks following operative repair of an ankle fracture. Because this patient is currently 8 weeks out from surgery, his braking time will be expected to return to normal one week from now.
Egol et al studied the time braking ability returns to normal in patients with operatively treated ankle fractures. Patients were studied at 6, 9, and 12 weeks postoperatively and compared to healthy controls. It was determined that total braking time returned to normal by 9 weeks.

Gerritsen and associates, Hui and associates, and Jarvik and associates compared the effectiveness of surgical versus nonsurgical treatment for the relief of carpal tunnel symptoms. All three studies showed that surgery was superior for the relief of paresthesias and the improvement of grip strength. According to the American Academy of Orthopaedic Surgeons Clinical Guidelines on the Treatment of Carpal Tunnel Syndrome, strong evidence supports the assertion that surgical treatment of carpal tunnel syndrome should have a greater treatment benefit at 6 and 12 months than splinting, NSAIDs, physical therapy, and a single steroid injection. The other choices, including no change in grip strength and
paresthesias, decrease in grip strength and increase in paresthesias, and increase in grip strength and _paresthesias, are not supported by the evidence._

Increased tibial slope (>12°) may be a risk factor for noncontact ACL injury and subsequent failure of repair, and corrective proximal tibial osteotomy may be indicated combined with primary or revision ACL reconstruction. The indications for proximal tibial valgus osteotomy are generally isolated medial compartment degeneration in a knee with varus malalignment in a young, active individual. Factors associated with early failure include increased age (>55 years), increased BMI (10% greater than normal), preoperative flexion
<120° and under- or overcorrection. Inflammatory arthritis, including gout, would be a relative contraindication.

chronic exertional compartment syndrome is commonly seen in running athletes and causes a constellation of lower leg pain, weakness and/or
numbness/paresthesias. It is an exercise-induced condition that is thought to result from muscle swelling during activity and
resultant hypoperfusion to the muscles and nerves within the compartment. The description of this patient, with symptoms in the anterior and lateral areas of her lower legs and the foot slap that she describes, indicates symptoms localized to the anterior and lateral compartments as opposed to posterior compartment symptoms. The anterior and lateral compartments would have been released in this patient. The structure seen lays between two released muscular compartments over the intermuscular septum and is the superficial peroneal nerve, which pierces the fascia 10 to 12 cm proximal to the tip of the lateral malleolus.
The structure that would cause medial leg numbness would be injury to the saphenous nerve. Her symptom description is not consistent with posterior compartment syndrome, and these compartments would not have been released at the time of surgery. The structure is not a blood vessel.

A superior labrum, when intact, stabilizes the shoulder by increasing its ability to withstand excessive external rotational forces by an additional 32%. The presence of a SLAP lesion decreases this restraint and increases the strain in the superior band of the inferior glenohumeral ligament by over 100%.
REFERENCES: Rodosky MW, Harner CD, Fu FH: The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder. Am J Sports Med 1994;22:121-130.
Itoi E, Kuelchle DK, Newman SR, Morrey BF, An KN: Stabilizing function of the biceps in stable and unstable shoulders. J Bone Joint Surg Br 1993;75:546-550.

Cadet and colleagues studied the formation of cortical bone in the metaphyses of rabbits. They found that the metaphyseal cortical bone is formed by coalescence of enchondral trabecular bone.
Important points from this study include:
Metaphyseal cortical bone is formed by coalescence of enchondral trabecular bone. The coalescence is formed by an increased osteoblast surface.
The increased osteoblast surface is likely caused by factors from the periosteum.
The bone that is produced by the cells in the groove of Ranvier probably does not contribute to the metaphyseal cortical bone.

The anterior drawer test is performed with the ankle in 10° of plantar flexion, which results in the greatest amount of translation. The test investigates the integrity of the anterior talofibular ligament with a key distance of translation being 8 to 10 mm. While the patient is sitting and has her knees flexed over the edge of a table or bench, the physician uses one hand to stabilize the distal leg and with the other hand applies an anterior force to the heel in an attempt to gap the talus anteriorly from under the tibia. The
anterior talofibular ligament and calcaneofibular ligament are both compromised based on the examination findings. The anterior drawer test result reflects injury to the anterior talofibular ligament and a possible injury to the calcaneofibular ligament. A lateral talar tilt test angle measurement >15° degrees reflects a rupture of both anterior talofibular ligament and calcaneofibular ligaments. The diagnosis is a severe lateral ligament complex sprain. This is optimally managed with early mobilization _and a guided rehabilitation program that emphasizes proprioceptive stability._

A Morton’s extension limits excursion of the first metatarsophalangeal joint. It also functions as a ground reaction stabilizer during the toe-off phase of gait and thus reduces torque and joint reaction force at the first metatarsophalangeal joint. The metatarsal arch pad and full-length semi-rigid longitudinal arch support may help by dorsiflexing the first metatarsal relative to the phalanx and thus decompress the first metatarsophalangeal joint. However, they are not as biomechanically effective as the Morton’s extension. Both medial hindfoot and lateral forefoot posting are contraindicated because they increase ground reaction at the first metatarsophalangeal joint.
REFERENCES: Coughlin MJ: Arthritides, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, p 611.
Watson AD, Wapner KL: Foot and ankle reconstruction, in Baratz ME, Watson AD, Imbriglia JE (eds): Orthopaedic Surgery: The Essentials. New York, NY, Thieme, 1999, p 635.

In patients who have radial nerve dysfunction associated with a closed humeral fracture, nerve function usually will return to normal without surgical exploration. If clinical findings or electromyographic studies show no improvement at 3 months, surgical exploration and repair can be performed. Tendon transfers are performed if nerve repair is deemed unsuccessful.
REFERENCES: Pollock FH, Drake D, Bovill EG, et al: Treatment of radial neuropathy associated with fractures of the humerus. J Bone Joint Surg Am 1981;63:239-243.
Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 237-247.

Time to definitive fixation is not a modifiable risk factor concerning open fractures. The other factors are risk factors that have been studied in regards to infection, and all are more important than definitive fixation. Definitive fixation can wait until complete closure and/or coverage.
When concerning management of open fractures, the most important factor is a thorough debridement. However, the quality of debridement is often not able to be quantified and thus, often not mentioned in studies. While early clinical and animal studies have shown that initial debridement should occur within 6 hours of injury, more recent clinical trials have not found a significant correlation within that urgent time frame, but rather recommend initial debridement as soon as possible within 24 hours. Time to antibiotic administration has been found to have a significant impact in lowering infection risk. Immediate administration in the emergency room is recommended. The ability to cover and/or close an open wound also has a significant impact on infection. Recent studies have recommended placing hardware after fasciotomy closure and have also demonstrated lower infection rates when flaps are placed
within 72 hours of injury.
Pape and Webb concisely review the evolution of open fractures and wound management. The authors describe the early days where amputation was favored, to wet-to-dry dressings, to the advent of negative pressure wound therapy. Throughout, however, the authors emphasize the importance of soft tissue coverage. They also stress the importance of a technically thorough debridement, the most important factor of any wound management.
Scheneker et al. performed a systematic review and meta-analysis of 16 studies to determine if time to the operating room for debridement was an independent, modifiable risk factor in regards to subsequent infection following open tibia fracture. At the time of the study, the gold standard (based on a previous rat model), had recommended initial debridement within 6 hours of injury. The results of this meta-analysis, however, could not find conclusive evidence to suggest that late debridement alone placed the patient at a significantly higher risk for infection. The authors provided a moderate recommendation that initial debridement should occur as soon as possible within 24 hours, although more data is required in order to find a definitive time.
The SPRINT investigators report a landmark study that randomized over 1200 patients to either reamed or unreamed tibial IMN with the primary outcome analyzed as return to the operating room for either non-union treatment or deep infection. A notable difference between the two cohorts was a significantly higher primary event rate in the unreamed group.
Figure A exhibits a distal third open tibia fracture. Incorrect answers:
Answer 1: Antibiotic administration as soon as an open fracture has been
diagnosed is a significant risk factor in minimizing infection risk.
Answer 2: Although a non-quantifiable measure, a thorough debridement is the most important component of treating an open fracture.
Answer 3: Initial animal models cite a 6 hour window to initial debridement, however, clinical trials have not found a significant window that can affect increased or lowered infection risk.
Answer 4: Coverage and/or closure of any open wounds or soft tissue defects is a significant factor in lowering infection risk; when flap coverage is needed, coverage within 72 hours is optimal.

A great toe fusion is the most appropriate treatment. It is an excellent procedure for pain relief and it gives a predictable result for return to activity and lack of recurrence. A soft-tissue correction is not indicated due to patient age and reducibility. An amputation is not indicated in this case in terms of activity level and is an unreasonable choice for an otherwise healthy 72-year-old patient. The Keller resection arthroplasty and the MTP joint replacement allow motion, but they offer unpredictable results for pain relief, activity, and recurrence.

The clinical presentation and imaging studies are consistent with Hawkins II talar neck fracture, which by definition is a displaced talar neck fracture with subtalar dislocation/subluxation. Despite achieving an adequate reduction initially (shown in Figure C), there is no role for closed treatment of these unstable injuries, and the treatment of choice is open reduction and internal fixation.
The referenced article by Bibbo et al describes these injuries: 32% of subtalar joints are irreducible to closed means (half with soft tissue block, half with bony block to reduction), 88% have co-existing injuries of the ipsilateral foot, 89% have radiographic subtalar arthrosis at 5 years (62% symptomatic).

Patients with painful progressive hallux valgus are surgical candidates. Presurgical evaluation includes radiographic examination. The IMA between the first and second metatarsals as well as the HVA must be measured. If the IMA is smaller than 15 degrees and the HVA is smaller than 35 degrees, a distal osteotomy is preferred. Distal soft-tissue reconstruction is only useful for IMAs smaller than 11 degrees and HVAs smaller than 25 degrees. Proximal osteotomies and the Lapidus bunionectomy are reserved for larger hallux valgus deformities with IMAs exceeding 15 degrees and HVAs exceeding 35 degrees.
RECOMMENDED READINGS
Pentikainen I, Ojala R, Ohtonen P, Piippo J, Leppilahti J. Distal Chevron Osteotomy: Preoperative Radiological Factors Contributing to Long-Term Radiological Recurrence of Hallux
[Valgus. Foot Ankle Int. 2014 Sep 5. pii: 1071100714548703. [Epub ahead of print] PubMed PMID: 25192724. ](http://www.ncbi.nlm.nih.gov/pubmed/25192724)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/25192724)
Fakoor M, Sarafan N, Mohammadhoseini P, Khorami M, Arti H, Mosavi S, Aghaeeaghdam A. Comparison of Clinical Outcomes of Scarf and Chevron Osteotomies and the McBride Procedure in the Treatment of Hallux Valgus Deformity. Arch Bone Jt Surg. 2014 Mar;2(1):31-
[6/. Epub 2014 Mar 15. PubMed PMID: 25207310. ](http://www.ncbi.nlm.nih.gov/pubmed/25207310)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/25207310)
[Park YB, Lee KB, Kim SK, Seon JK, Lee JY. Comparison of distal soft-tissue procedures combined with a distal chevron osteotomy for moderate to severe hallux valgus: first web-space versus transarticular approach. J Bone Joint Surg Am. 2013 Nov 6;95(21):e158. doi: 10.2106/JBJS.L.01017. PubMed PMID: 24196470. ](http://www.ncbi.nlm.nih.gov/pubmed/24196470)[View ](http://www.ncbi.nlm.nih.gov/pubmed/24196470)[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/24196470)
RESPONSES FOR QUESTION 47 THROUGH 50
1. Observation
2. Arizona brace
3. Medial arch support
4. Casting
5. Hindfoot fusion
Select the most appropriate initial treatment from the list above to address each of the conditions described below.

Many of these kyphoses will correct spontaneously if the curve does not exceed 50°. In this patient, the inability to walk is most likely due to other skeletal factors.
There is no evidence that orthosis will change the natural history of the disorder.
There is no need for traction given the high chance of spontaneous resolution and the dangers of traction.
Posterior fusion is only indicated if the kyphosis is continually progressive, or if neurologic signs or symptoms develop. Anterior and posterior surgery is only indicated in cases with severe pre-existing neurologic deficit.

- Proximal junctional failure

The MR images show a lesion consistent with a ganglion cyst located near the hook of the hamate. The ulnar nerve divides into motor and sensory branches just proximal to this lesion. In this case, the ganglion cyst compresses the ulnar nerve motor branch but not the sensory branch, resulting in motor dysfunction but no sensory disturbance. Excision of the ganglion cyst should alleviate his symptoms. Compression of the ulnar nerve proximal to the motor branch take-off (in either the cubital tunnel or proximal Guyon’s canal) would cause both sensory and motor dysfunction. Although chronic nonunion of the hook of the hamate can cause ulnar nerve symptoms, the hook of the hamate appears intact on the MR image. The MR image shows a lesion that is well circumscribed with high intensity on T1 and T2 images, consistent with a benign ganglion cyst, and ganglion cysts are relatively common lesions in this area.

Patients develop lateral ankle pain with progression of adult-acquired flatfoot deformity. This is associated with increased hindfoot valgus deformity. Calcaneal fibular impingement has been considered the primary cause of this pain. Studies demonstrate that arthrosis of the posterior facet of the subtalar joint strongly correlates with lateral pain in adult-acquired flatfoot deformity. Both conditions are related to hindfoot valgus deformity. Although lateral column lengthening is a powerful tool for correction of flatfoot deformity, its effect on hindfoot deformity is less defined. Lateral column lengthening provides better correction of the longitudinal arch of the midfoot and realignment of the medial column than other osteotomies. A medializing calcaneal osteotomy has a significant linear effect on hindfoot valgus alignment. Spring ligament reconstruction and medial cuneiform opening-wedge osteotomies have less effect on hindfoot alignment than the medial calcaneal slide.
RECOMMENDED READINGS
Ellis SJ, Deyer T, Williams BR, Yu JC, Lehto S, Maderazo A, Pavlov H, Deland JT. Assessment of lateral hindfoot pain in acquired flatfoot deformity using weightbearing multiplanar imaging. Foot Ankle Int. 2010 May;31(5):361-71. doi: 10.3113/FAI.2010.0361. PubMed PMID:
[20460061/. ](http://www.ncbi.nlm.nih.gov/pubmed/20460061)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/20460061)
[Chan JY, Williams BR, Nair P, Young E, Sofka C, Deland JT, Ellis SJ. The contribution of medializing calcaneal osteotomy on hindfoot alignment in the reconstruction of the stage II adult acquired flatfoot deformity. Foot Ankle Int.2013 Feb;34(2):159-66.doi: 10.1177/ 1071100712460225. Epub 2013 Jan 10. PubMed PMID: 23413053. ](http://www.ncbi.nlm.nih.gov/pubmed/23413053)[View ](http://www.ncbi.nlm.nih.gov/pubmed/23413053)[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23413053)

An unplanned excision of a soft-tissue sarcoma occurs when a surgeon removes a soft-tissue mass while believing it is benign, and, upon pathologic examination, learns that it is malignant. These procedures often are performed without presurgical staging studies or appropriate oncologic surgical technique. Following an unplanned excision, patients usually are referred to a sarcoma center for definitive care. Definitive treatment is hindered by the lack of presurgical imaging, sophisticated pathologic examination findings, and a contaminated tumor bed larger than the original tumor. Further, as many as 50% of cases are associated with residual disease within the tumor bed, even when no tumor can be identified with imaging or an examination and the initial
surgical report indicates all gross disease has been removed. Most patients for whom an inadequate excision of an unsuspected sarcoma is performed are treated with reexcision of the tumor bed, and, very often, adjuvant radiotherapy.
RECOMMENDED READINGS
99. [Gutierrez JC, Perez EA, Moffat FL, Livingstone AS, Franceschi D, Koniaris LG. Should soft tissue sarcomas be treated at high-volume centers? An analysis of 4205 patients. Ann Surg. 2007 Jun;245(6):952-8. PubMed PMID: 17522521.](http://www.ncbi.nlm.nih.gov/pubmed/17522521)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/17522521)
100. [Johnson GD, Smith G, Dramis A, Grimer RJ. Delays in referral of soft tissue sarcomas. Sarcoma. 2008;2008:378574. doi: 10.1155/2008/378574. PubMed PMID: 18317511. ](http://www.ncbi.nlm.nih.gov/pubmed/18317511)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/18317511)

Using press-fit tibial stems during a hybrid revision total knee arthroplasty is associated with a 3% to 5% incidence of intraoperative tibial shaft fracture. Diaphyseal fixation of press-fit stems has the advantage of setting component alignment, dispersing forces on the proximal tibia, and offers excellent clinical results. The disadvantages include proximal and distal tibia anatomic mismatch and tibial shaft fracture. Cipriano and associates reported a tibial shaft fracture incidence of 4.9% in a series of 420 consecutive
knee revisions. All fractures healed with nonsurgical management, and none led to implant loosening. In this patient, it is important to recognize on the radiograph that this technique is a hybrid method of revision total knee arthroplasty, with cementation along the tibial tray and metaphysis and with press-fit fixation of the diaphyseal engaging stem. Then, it is important to know the risk and management of intraoperative diaphyseal tibial fractures. Cemented tibial stems are associated with a low rate of intraoperative fracture, because the implant is typically undersized to allow for an appropriate cement mantle. Option C is incorrect, because this revision is not cemented. Option A underestimates the incidence of fracture,
whereas D overestimates the rate of fracture.

Type 1 osteoporosis is the most common form of osteoporosis and is found in women during postmenopausal years. Type 1 osteoporosis is related to estrogen deficiency rather than a problem in calcium intake or absorption.
Features of type 1 osteoporosis include:
Female to male ratio is 6:1
High turnover osteoporosis
Bone loss rate of 2% to 3% per year for 6 to 10 years following menopause
Trabecular bone is most affected
Related to estrogen deficiency rather than calcium intake
Type 2 osteoporosis, also called senile or involutional osteoporosis, is a low turnover osteoporosis and principally occurs in patients older than 75 years of age.
Features of type 2 osteoporosis include: Female to male ratio is 2:1
Patients older than 75 years of age
Low turnover osteoporosis
Trabecular and cortical bone affected
Associated with hip fractures
Related to a lifelong deficiency of calcium

Illustration A, a coronal CT image, shows a vertical sacral fracture, which creates a vertically unstable pelvic ring. Percutaneous iliosacral screw fixation is a useful technique in the management of vertically unstable pelvic fractures, but a vertical sacral fracture should make the surgeon more wary of fixation failure and loss of reduction.
According to the referenced study by Griffin et al, fixation failure of iliosacral screws was significantly associated with vertical sacral fractures and not with any of the other answers listed above. All cases of hardware failure occured within the first 3 weeks; a lesser relationship between hardware failure and sacroiliac joint injury was noted.

RSA has been shown to result in better clinical outcomes with a similar complication rate compared with hemiarthroplasty for the treatment of comminuted proximal humeral fractures in elderly patients. If an RSA is necessary in a delayed fashion to salvage failed nonoperative management, a systematic review and meta-analysis have shown no significant difference in outcomes between acute versus delayed RSA in this patient population.
35

The patient has the classic signs of Little Leaguer’s shoulder, with findings that include pain localized to the proximal humerus during the act of throwing and radiographic evidence of widening of the proximal humeral physis. Examination usually reveals tenderness to palpation over the proximal humerus, but the presence of any swelling, weakness, atrophy, or loss of motion is unlikely. The treatment of choice is rest from throwing for at least 3 months, followed by a gradual return to pitching once the shoulder is asymptomatic.
REFERENCES: Carson WG Jr, Gasser SI: Little Leaguer’s shoulder: A report of 23 cases. Am J Sports Med 1998;26:575-580.
Barnett LS: Little League shoulder syndrome: Proximal humeral epiphyseolysis in adolescent baseball pitchers. A case report. J Bone Joint Surg Am 1985;67:495-496.

The axillary nerve originates from the posterior cord of the brachial plexus. It passes down the anteroinferior aspect of the subscapularis, courses posteriorly beneath the glenoid and inferior capsule, then wraps around the humerus from posterior to anterior on the deep surface of the deltoid. In the setting of glenoid and humeral head deformity, the inferior border of the subscapularis can be a useful landmark to ensure the nerve is appropriately protected intraoperatively.

- Figure 51d_

Figures A & B demonstrate a right, unstable intertrochanteric femur fracture. Surgical stabilization within 48 hours improves short-term and 30-day mortality.
Hip fractures are common and mortality rates vary. In the elderly, mortality rates may reach 10% at 1-month, 20% at 4-months, and 30% at 1-year. Time to surgery has found to be a decisive factor. A pre-operative delay may lead to an increase in mortality and adversely influence other clinical outcomes.
Clinical guidelines recommend immediate operative stabilization, given the patient is medically fit for surgery.
Nyholm et al. performed a retrospective study of the Danish Fracture Database to investigate whether a surgical delay increases 30-day and 90-day mortality rates for patients with proximal femoral fractures. The 30-day and 90-day mortalities were 10.8% and 17.4%, respectively. The risk of 30-day mortality increased with increasing time intervals of more than 12 hours, 24 hours, and more than 48 hours. 90-day mortality increased with a surgical delay of more than 24 hours. They conclude that rapid surgical treatment should be performed by attending orthopaedic surgeons.
Moja et al. performed a meta-analysis and meta-regression to assess the relationship between surgical delay and mortality in elderly patients with a hip fracture. They analyzed 35 independent studies with 191,873 patients and 34,448 deaths. The majority of studies had a cut-off of 48 hours. They report that early hip surgery was associated with a lower risk of death and pressure sores. They conclude that early hip fracture surgery appears to provide a survival benefit compared to later intervention.
Rodriguez-Fernandez et al. performed a study examining 2 groups with hip fractures. The first group was studied retrospectively and had an average delay of surgical treatment of more than 1-week while the second group was studied prospectively, and had surgical treatment within 48 hours. They found a larger number of complications in the group with a delay in surgical treatment. They conclude that elderly patients with hip fractures should be treated as soon as their medical condition permits.
Figures A and B are the AP and lateral radiographs demonstrating a right, unstable intertrochanteric femur fracture. Illustration A is an intertrochanteric femur fracture, stabilized with a cephalomedullary nail.
Incorrect Answers:
Answer 1: A surgical delay of greater than 48 hours has not been found to increase intraoperative time when patients get to surgery.
Answer 3: A surgical delay of greater than 48 hours has been shown to increase the rate of postoperative pneumonia.
Answer 4: A surgical delay of greater than 48 hours has not been associated with higher rates of blood transfusion.
Answer 5: A surgical delay of greater than 48 hours has not been associated with an increased risk of post-operative infection.

Aneurysmal bone cysts frequently occur in the first two to three decades of life. Patients report pain and a slow-growing lesion. Radiographs show an expansile lesion with septae or striations.Treatment is usually curettage and grafting of the lesion. In the foot, unicameral bone cysts are seen most frequently in the calcaneus, and are usually incidental findings rarely requiring treatment. Infection or acute osteomyelitis typically shows lucency of bone, periosteal reaction, and a permeative pattern on radiographs.
Patients often have systemic complaints as well. Giant cell tumor is usually seen in the epiphysis of long bone with radiographs revealing a radiolucent lesion with a small rim of reactive bone.

---

The C1 lateral mass can safely accommodate screw fixation. Trajectory of 10 degrees medial and 22 degrees cephalad was safely applied in a series of 50 patients.
Postoperative CT scans confirmed the safe trajectory. The benefit of lateral mass screws is that they can be safely placed despite the existence of an anomalous vertebral artery that could preclude the safe placement of transarticular screws.

The clinical scenario describes an athlete with chronic exertional leg pain. The differential is large, and there is much overlap in clinical symptoms between different potential diagnoses. The most common overall cause would be medial tibial stress syndrome (MTSS), but in this situation, MTSS is unlikely given the location of her pain and the absence of bony tenderness,
76
which is typically along the posteromedial tibia in MTSS. Persistent MTSS is usually evaluated with bone scan or MRI to confirm the diagnosis and to assess for occult stress fracture. Angiography is useful primarily in cases of suspected popliteal artery entrapment, which is a dynamic exercise-related vascular phenomenon. Here, the description of pain in the anterior and/or lateral compartments, the multi-year history, and the predictable time-course for onset and relief of symptoms all strongly suggest a diagnosis of exercise- induced compartment syndrome, also called exertional compartment syndrome. MRI and bone scan are likely to be negative; definitive diagnosis can only be made through direct measurement of compartment pressures before, during and after exercise.

The use of halogenated inhaled anesthetic agents has been shown to abrogate the signals detected during neurophysiologic monitoring. Intravenous agents such as propofol should be used in favor of inhaled agents such as isoflurane and nitrous oxide. Neurophysiologic signals also can be dampened when hypotension and hypothermia are issues. In this case, the patient's mean arterial pressure and body temperature are within the range at which spinal cord blood flow and neurophysiologic monitoring may be optimized. A Stagnara wake-up test may be useful, but it poses risk. If there is another explanation for the patient's lack of signal, this test is not necessary.
RECOMMENDED READINGS
[Devlin VJ, Schwartz DM. Intraoperative neurophysiologic monitoring during spinal surgery. J Am Acad Orthop Surg. 2007 Sep;15(9):549-60. Review. PubMed PMID: 17761611. ](http://www.ncbi.nlm.nih.gov/pubmed/17761611)[View](http://www.ncbi.nlm.nih.gov/pubmed/17761611)[ ](http://www.ncbi.nlm.nih.gov/pubmed/17761611)[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/17761611)
[Chen Z. The effects of isoflurane and propofol on intraoperative neurophysiological monitoring during spinal surgery. J Clin Monit Comput. 2004 Aug;18(4):303-8. PubMed PMID: 15779842. ](http://www.ncbi.nlm.nih.gov/pubmed/15779842)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/15779842)

TEA is a popular option for treatment of end-stage elbow arthritis for elderly, lower-demand patients with rheumatoid arthritis. Good success rates have been published by several authors. The clear benefit of the current nonconstrained prosthesis has yet to be proven. Plaschke and associates investigated the Danish National Patient Registry to compare the longevity of the 2 types of implants. These authors found similar survival rates associated with both linked and unlinked implants at 10 years (88% and 77%, respectively). However, studies have documented an approximate 20% incidence of postsurgical instability with nonconstrained implants.
RECOMMENDED READINGS
63. [Kudo H, Iwano K. Total elbow arthroplasty with a non-constrained surface-replacement prosthesis in patients who have rheumatoid arthritis. A long-term follow-up study. J Bone Joint Surg Am. 1990 Mar;72(3):355-62. PubMed PMID: 2312530.](http://www.ncbi.nlm.nih.gov/pubmed/2312530)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/2312530)
64. [Plaschke HC, Thillemann TM, Brorson S, Olsen BS. Implant survival after total elbow arthroplasty: a retrospective study of 324 procedures performed from 1980 to 2008. J Shoulder Elbow Surg. 2014 Jun;23(6):829-36. doi: 10.1016/j.jse.2014.02.001. Epub 2014 Apr 22. ](http://www.ncbi.nlm.nih.gov/pubmed/24766794)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/24766794)
65. [Dos Remedios C, Chantelot C, Giraud F, Migaud H, Fontaine C. Results with Kudo elbow prostheses in non-traumatic indications : a study of 36 cases. Acta Orthop Belg. 2005 Jun;71(3):273-88. PubMed PMID: 16035700. ](http://www.ncbi.nlm.nih.gov/pubmed/16035700)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/16035700)

The patient has left hip pain and clinical and radiographic evidence of a left slipped capital femoral epiphysis. He also has open triradiate cartilage and a grade 1 slip on the right side that, at the present time, is silent. The best treatment is pinning of bilateral slipped capital femoral epiphysis. Reduction is not indicated because of the mild nature of both slips. Although prophylactic pinning of the uninvolved contralateral hip is controversial, this patient shows a clinically silent grade 1 slip on the right side.
REFERENCES: Puylaert D, Dimeglio A, Bentahar T: Staging puberty in slipped capital femoral epiphysis: Importance of the triradiate cartilage. J Pediatr Orthop 2004;24:144-147.
Dewnany G, Radford P: Prophylactic contralateral fixation in slipped upper femoral epiphysis: Is it safe? J Pediatr Orthop B 2005;14:429-433.

Uneven resection of bone, typically leaving a retained posterolateral corner of the distal clavicle, can lead to failure of arthroscopic distal clavicle excision. The amount of bone resected, the gender of the patient, or the diagnosis (osteoarthritis versus osteolysis) does not appear to affect the results.
REFERENCE: Flatow EL, Duralde XA, Nicholson GP, Pollock RG, Bigliani LU: Arthroscopic resection of the distal clavicle with a superior approach. J Shoulder Elbow Surg 1995;4:41-50.

The radiograph shows a complete acromioclavicular separation. Because the patient is a professional athlete who is unable to participate, surgery is indicated. Chronic separations, especially those with previous trauma from joint pinning, should be treated with resection of the distal clavicle and stabilization to the coracoid. Some type of biologic reconstruction of the coracoclavicular ligaments is generally recommended. Open repair of the ligaments is generally not possible in such a delayed fashion. Screw fixation alone will not provide a lasting solution as the screws usually need to be removed, leaving no fixation in place. Reconstruction using the coracoacromial ligament is generally recommended with coracoclavicular fixation to protect the repair while it heals.
REFERENCES: Nuber GW, Bowen MK: Disorders of the acromioclavicular joint: Pathophysiology, diagnosis and management, in Iannotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA, Lippincott Williams and Wilkins, 1999.
Weinstein DM, McCann PD, McIlveen SJ, Flatow EL, Bigliani LU: Surgical treatment of complete acromioclavicular dislocations. Am J Sports Med 1995;23:324-331.

The arrow is pointing to a structure of medium signal intensity that is equivalent to the nucleus pulposus on T2-weighted sequencing. This represents a foraminal disk herniation. A lumbar synovial cyst would display high-signal intensity on T2-weighted sequencing. Lumbar synovial cysts arise from the facet joints as a result of facet joint degeneration and may be a source of nerve root compression. The dorsal root ganglion is a collection of sensory nerve cell bodies and can be seen just dorsal and lateral to the disk herniation in Figure 32. The ligamentum flavum is located on the ventral
surface of the laminae and attaches between the laminae of adjacent vertebrae.
RECOMMENDED READINGS
Patel NM, Jenis LG. Inflammatory arthritis of the spine. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:339-349.
Carrino JA, Morrison WB. Musculoskeletal imaging. In: Vaccaro AR, ed. Orthopaedic Knowledge Update 8. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2005:119-136.

The gluteus medius attaches to the greater trochanter, leading to abduction, while the iliopsoas attaches to the lesser trochanter, leading to flexion. French et al evaluated forty-five Russell-Taylor Type 1B subtrochanteric femoral fractures which were stabilized using an interlocked cephalomedullary nail. The intraoperative complication rate was 13.5%; and the most frequent complication was a varus malreduction. The primary reason for this was failure to counteract the muscle forces acting on the proximal fragment combined with the adducted position of the distal femur during portal creation. This problem can be avoided if the position of the proximal fragment is evaluated carefully and reduced before guidewire insertion.

Because of the safety concerns, immunogenicity issues, and production complications associated with viral vectors, nonviral delivery systems were developed by complexing of genes (DNA) to various chemical formulations. Nonviral delivery systems stabilize DNA and increase its uptake and include plasmids, peptides, cationiCliposomes, DNA-ligand complexes (recognize
specifiCcell-surface receptors, leading to receptor-mediated uptake), and gene gun (particles of gold coated with DNA, forced into the cells with high velocity bombardment). However, nonviral vector efficiency is lower than viral vectors

Flexor digitorum profundus ruptures are classified into three types. In type I, the tendon retracts into the palm. In type II, the tendon retracts to the level of the proximal phalanx, the vinculum remains intact, and the blood supply is preserved to the tendon. A small fleck of bony fragment observed at the A2 pulley is pathognomonic for a type II rupture. Successful primary repair of the type II rupture has been reported as late as 2 months after the injury. Type III injuries have large fragments of the distal phalanx attached and are caught distally by the A1 pulley. Type III ruptures can be repaired up to several months after the injury.
REFERENCES: Leddy JP: Avulsions of the flexor digitorum profundus. Hand Clin
1985;1:77-83.
Kiefhaber TR: Closed tendon injuries in the hand. Oper Tech Sports Med 1996;4:227-241.

He has a kyphosis of 35°.
This degree of kyphosis increases the risk of pseudarthrosis with posterior fusion alone. The laminectomy increases the risk of pseudarthrosis.
Anterior fusion should be added when there is a history of pseudarthrosis.
A 9-year-old boy has a high risk of crankshift phenomenon with posterior fusion alone.

- Anterior translation and internal rotation

Wide-awake repair under only local anesthesia, regardless of the technique, allows direct inspection of the tendon repair and active excursion. Regional anesthesia and Bier block anesthesia do not allow active motion (Bier block necessitates continued use of a tourniquet, which limits muscle function). The A2
pulley should be preserved, especially the distal 50%, to maintain tendon function. All of the listed techniques for suture repair are acceptable options.

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In the management of pediatric acute osteomyelitis, early transition to oral antibiotic therapy has been demonstrated to have a similar risk of treatment failure as prolonged IV therapy via a peripherally inserted central catheter (PICC). Transition to oral antibiotic therapy can avoid the substantial risks of a PICC complication, which can result in a higher rate of rehospitalization or return visit to the emergency department.

Fundamental to understanding the pathogenesis of rotator cuff tears is an appreciation of the likely initiating site of the disease process. Although authors initially postulated that rotator cuff tears originated in the anterior margin of the supraspinatus tendon near the biceps tendon, recent research has challenged this notion. Kim and associates analyzed 360 full-thickness or partial-thickness rotator cuff tears using ultrasonograms. They separated stratified tears based on their anteroposterior size and whether they were partial- or full-thickness tears. The mean width and
length of tear size was 16.3 mm and 17 mm, respectively. Histograms showed that the most common tear location for all tears regardless of size was approximately 15 mm posterior to the biceps tendon. This corresponds to the center of the rotator crescent initially described by Burkhart and associates. This location is described as being more susceptible to degeneration secondary to its diminished vascular supply and mechanical properties. The rotator cable is an arch-shaped thick bundle of fibers that is thought to shield the crescent from stress.
RECOMMENDED READINGS
12. [Kim HM, Dahiya N, Teefey SA, Middleton WD, Stobbs G, Steger-May K, Yamaguchi K, Keener JD. Location and initiation of degenerative rotator cuff tears: an analysis of three hundred and sixty shoulders. J Bone Joint Surg Am. 2010 May;92(5):1088-96. doi: 10.2106/JBJS.I.00686. PubMed PMID: 20439653. ](http://www.ncbi.nlm.nih.gov/pubmed/20439653)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/20439653)
13. [Burkhart SS, Esch JC, Jolson RS. The rotator crescent and rotator cable: an anatomic description of the shoulder's "suspension bridge". Arthroscopy. 1993;9(6):611-6. Erratum in: Arthroscopy 1994 Apr;10(2):239. PubMed PMID: 8305096. ](http://www.ncbi.nlm.nih.gov/pubmed/8305096)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/8305096)
14. [Jarrett CD, Schmidt CC. Arthroscopic treatment of rotator cuff disease. J Hand Surg Am. 2011 Sep;36(9):1541-52; quiz 1552. doi: 10.1016/j.jhsa.2011.06.026. Epub 2011 Aug 6. Review. PubMed PMID: 21821368. ](http://www.ncbi.nlm.nih.gov/pubmed/21821368)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/21821368)
15. [Mall NA, Kim HM, Keener JD, Steger-May K, Teefey SA, Middleton WD, Stobbs G, Yamaguchi K. Symptomatic progression of asymptomatic rotator cuff tears: a prospective study of clinical and sonographic variables. J Bone Joint Surg Am. 2010 Nov 17;92(16):2623-33. doi: 10.2106/JBJS.I.00506. PubMed PMID: 21084574. ](http://www.ncbi.nlm.nih.gov/pubmed/21084574)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/21084574)
_This is the last question of the exam._
_GOOD LUCK_

The normal regulation of a cartilage surface is a delicate balance of degradation and synthesis. When this normal regulation of the cartilage is disturbed, a proinflammatory state tips the cellular pathway in the direction of degradation. The proinflammatory state upregulates the production of cytokines and proteolytic enzymes, specifically matrix metalloproteinases. These enzymes attack the proteoglycan content of the cartilage, leading to an overall reduction in the proteoglycan content. This reduction in content leads to increased permeability of the cartilage substrate. With increased permeability, water is able to move into the cartilage itself, thereby increasing the overall water content within the cartilage in an arthritic state. Finally, because of the increased permeability and increased water content, the overall load or pressure placed on the underlying solid matrix is increased. Increased water content, decreased proteoglycan content, and an increased load on the solid matrix are typical of an osteoarthritic process within normal cartilage. Therefore, the only correct option is that the cartilage has an increased amount
of permeability in osteoarthritis.