Orthopedics Hyperguide Review | Dr Hutaif General Ortho -...

This patient has an external rotation deformity of 40° of the distal fragment of the right femur. Correction would entail rotating the distal fragment internally by 40°.
The right femoral neck (RFN) is internally rotated (IR) by 13° to the horizontal (IR13). The left femoral neck (LFN) is externally rotated (ER) by 13° to the horizontal (ER13). The right distal fragment (RDF) is ER17. The left distal fragment (LDF) is ER3. Bringing both femoral necks to ER0/IR0 gives the absolute amount of rotation of the distal fragment to the horizontal. To do this, the RFN has to EXTERNALLY rotate 13° and the LFN has to INTERNALLY rotate 13°. Thus, RDF has a total of ER(13+17)=ER30, and LDF has IR(13-3)=IR10 to the horizontal. To correct the RDF from ER30 to IR10, internal rotation of 40° must occur.
Malrotation is the most common cause of limb deformity after nailing. To avoid this, patients should be examined for rotation and limb length after insertion of static interlocks, before leaving the operating room. Correction is easier to perform prior to fracture union. Drill-hole cutout is possible if correction<20° if the previous distal locking site is to be used because of the proximity of the new interlock to the previous interlock. To avoid this, (1) use alternative locking holes or the dynamic locking slot, or (2) advance or retract the nail to avoid previous locking sites.
Lindsey et al. reviewed rotational malalignment after femoral nailing. The incidence of rotational malalignment was 27.6%. Normal femoral neck anteversion (angle of the femoral neck relative to the transverse axis through the femoral condyles) is 11-13°. Some patients have up to 15° difference in version between limbs.
Jaarsma et al. reviewed rotational malalignment after nailing of 76 femoral fractures. The incidence of rotational malalignment >=15° was 28%. Patients with an ER malalignment (n = 12) had more functional problems than patients with a IR malalignment (n = 9).
Incorrect Answers:
Answer 1: This answer would be correct if LFN was IR13, and LDF was IR3, giving absolute LDF rotation of ER10. Then to correct ER30 (right) to ER10 (left), internal rotation of 20° would be needed.
Answers 2, 4: The RDF is more externally rotated. Correction must involve internal rotation.
Answer 3: This answer would be correct if LFN was IR13, giving absolute LDF rotation of ER16. Then to correct ER30 (right) to ER16 (left), internal rotation of 14° must occur.

- tarsal bones.

- interdigital neuroma.

The internal carotid artery can run in close proximity to the anterior surface of C1 in many patients; consequently, a drill bit or screw tip poses risk. This anatomy always must be considered when placing bicortical C1 screws.
RECOMMENDED READINGS
1. [Currier BL, Maus TP, Eck JC, Larson DR, Yaszemski MJ. Relationship of the internal carotid artery to the anterior aspect of the C1 vertebra: implications for C1-C2 transarticular and C1 lateral mass fixation. Spine (Phila Pa 1976). 2008 Mar 15;33(6):635-9. PubMed PMID: 18344857. ](http://www.ncbi.nlm.nih.gov/pubmed/18344857)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/18344857)
2. [Hoh DJ, Maya M, Jung A, Ponrartana S, Lauryssen CL. Anatomical relationship of the internal carotid artery to C-1: clinical implications for screw fixation of the atlas. J Neurosurg Spine. 2008 Apr;8(4):335-40. PubMed PMID: 18377318. ](http://www.ncbi.nlm.nih.gov/pubmed/18377318)[View Abstract at](http://www.ncbi.nlm.nih.gov/pubmed/18377318)[ ](http://www.ncbi.nlm.nih.gov/pubmed/18377318)[PubMed](http://www.ncbi.nlm.nih.gov/pubmed/18377318)

Match the description with the corresponding response.

A recent randomized trial of surgical versus nonsurgical management of calcaneal fractures showed that patients who were on workers’ compensation did poorly with surgical care. These patients had less favorable outcomes regardless of their initial management. Factors such as age, smoking, and vasculopathies compromise skin healing, leading to greater surgical risks. The best results were obtained in patients who are younger than age 40 years, have unilateral injuries and are injured during noncompensable activities. Women tend to do better with surgery than men.
REFERENCES: Howard JL, Buckley R, McCormack R, et al: Complications following management of displaced intra-articular calcaneal fractures: A prospective randomized trial comparing open reduction internal fixation with nonoperative management. J Orthop Trauma 2003;17:241-249.
Buckley R, Tough S, McCormack R, et al: Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: A prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2002;84:1733-1744.

- Subacromial injection with lidocaine
PREFERRED RESPONSE: 1- Disorganized collagen fibers with mucoid degeneration
CLINICAL SITUATION FOR QUESTIONS 7 THROUGH 9
A 26-year-old man has the chief complaint of right shoulder instability. He underwent an uncomplicated arthroscopic Bankart repair following an injury sustained while playing high school football. His condition was stable for 7 years, but he redislocated his shoulder in a fall 6 months ago. He describes weekly anterior instability events that he can reduce on his own. Radiographs reveal a located glenohumeral joint, but a Hill-Sachs lesion is noted. A CT scan reveals a 20% anteroinferior glenoid deficiency and a Hill-Sachs lesion involving 20% of the humeral head.

One should remember the genetic findings in patients with osteoarthritis: Siblings have a 27% risk compared to spouses
Twice as common in monozygotic twins compared to dizygotic twins Precocious osteoarthritis is associated with type V collagen mutation Does not occur universally in aging hip joints
Distal interphalangeal joint arthritis linked to a region of chromosome 2q
C orrect Answer: Siblings have a 27% risk compared to spouses

Various cytokines and cytokine antagonists hold promise as new therapeutiCagents for osteoporosis. Baltzer and colleagues showed that intramedullary injection of Ad-IL-1Ra gene in a murine ovariectomy model strongly reduced the loss of bone mass. Using a similar model, Bolon and associates studied the effect of adenovirus-mediated transfer of osteoprotegerin, which showed more bone volume with reduced osteoclast numbers in axial and appendicular bones after 4 weeks compared with sham-operated mice

In a patient with a drop foot and with 5/5 muscle strength of the posterior tibial tendon, a split posterior tibial tendon transfer would be the most appropriate treatment option based on the options presented. The deep peroneal nerve innervates the anterior tibial tendon. This muscle has been affected by the injury; therefore, the anterior tibial tendon cannot be transferred. A subtalar fusion would help correct inversion and eversion deformities, but is not effective for plantar flexion deformities.
The foot drop is caused by a neurologic condition in this patient, not a contracture of the gastrocsoleus complex.Therefore, a recession would not be beneficial. A flexor hallucis longus tendon transfer would not take the deforming force and make it a corrective force.

This clinical scenario describes a patient with FAI attributable to pincer (acetabular) deformity. This form of FAI, which involves prominence of the anterosuperior acetabular lip, may be more common among women. Decreased range of motion and pain occur secondary to the abutment of the femoral head against the acetabular labrum and rim. Hip flexion, combined with adduction and internal rotation, recreates this contact and causes pain, but CAM or pincer etiology remains unknown. The differential diagnosis of hip pain in a young athlete includes femoral neck stress reaction/fracture, sacroiliac arthritis, intra-articular loose body, trochanteric bursitis, osteitis pubis, and hernia. No information presented in this scenario suggests any of these causes. Diagnosis of FAI is best performed via MR imaging, with an arthrogram increasing the sensitivity and specificity for labral pathology. Ultrasonography may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping hip, but ultrasonography is not commonly used to diagnose labral pathology. Although concomitant chondral lesions of the femoral head are uncommon, the forced leverage of the anterosuperior femoral neck upon the anterior acetabulum may result in a “contra-coup” chondral injury on the posteroinferior acetabulum. This is the most common location of chondral lesions in this scenario. Without bony resection to prevent further impingement, this patient will continue to experience symptoms. Because there is no evidence of femoral neck prominence (CAM lesion), there is no indication for osteoplasty of the femoral neck; resection of the pincer lesion is necessary. This will often require take-down of the labrum in this location. If possible, iatrogenic or traumatic labral tears should subsequently be repaired after pincer debridement because the labrum has _important functions for hip stability and maintenance of the suction seal of the joint._

Figure D shows lag screw fixation neutralized with a locking plate. Plates that allow locking screw fixation create a fixed-angle construct with inherently high stiffness.
Fixation options for fibular fractures vary widely with many possible implant types and many different ways to utilize each of those implants. Fibula fixation with locking plates can be advantageous in the setting of poor bone quality or extremely distal fracture fragments with small amounts of available bone.
Locking plates are generally stiffer implants however techniques of widely spacing screws can decrease the construct stiffness. The disadvantages of locking plates for the fibula are hardware prominence and excessive stiffness leading to nonunion.
Siegel et al. reviewed 31 patients with pronation-abduction ankle injuries who were treated strictly with extraperiosteal plating of the fibula. They found a 100% healing rate with no deep infections and average AOFAS of 82. They concluded extraperiosteal plating of the fibula in pronation-abduction ankle fractures leads to predictable fibular union.
Bottlang et al. reviewed how locked plate stiffness can affect bone healing and if that stiffness can be decreased by various techniques. They found that interfragmentary motion is attenuated at the near cortex and that far cortical locking screws allow for more motion across the fracture site and greater amounts of callus formation. They concluded their research supports locked plates can be too stiff and that far cortical locking screws reduce construct stiffness and improves bone healing.
Figure A shows a fibular nail without syndesmotic fixation. Figure B shows a 1/3 tubular plate acting as an anti-glide plate. Figure C shows a 1/3 tubular plate with non-locking screws acting as a bridging construct. Figure D shows an example of an a lag screw with a locking plate used as a neutralization plate. Figure E is an example of an isolated lag screw fixation of a distal fibula fracture without a neutralization plate.
Incorrect Answers:
Answer 1: A fibular nail which is an intramedullary device and not as stiff as a
locking plate.
Answer 2: An anti-glide plate is not as stiff a construct compared to a locking plate.
Answer 3: A bridge plate using non-locking screws is not as stiff of a construct as a bridge plate with using locking screws.
Answer 5: Isolated lag screws without a neutralization plate would be less rotationally stable.

Figure 39c
Figure 39d

This irritable patient refuses to move his hand during a difficult examination. The hand is in an
intrinsic minus position with the extension of the metacarpophalangeal joints and flexion of the proximal interphalangeal joints. Patients who are difficult to examine may require compartment pressure measurements. Observation with elevation and possible PO steroids to decrease swelling are not indicated. This scenario has been ongoing for 4 days, and a carpal tunnel release with a release of the interosseous, thenar, hypothenar, and adductor compartments (Figures 39c and 39d) is now necessary. Finger fasciotomies are probably not needed.
If this scenario involved the forearm and a prolonged ischemic process, it may not have been prudent to perform a fasciotomy; with dead muscle, risk for infection is high. In small pediatric hands with compartment syndrome, it is often easier to find the median nerve in the forearm rather than the hand because significant edema in the hand distorts the anatomy.
RECOMMENDED READINGS
27. [Ouellette EA, Kelly R. Compartment syndromes of the hand. J Bone Joint Surg Am. 1996 Oct;78(10):1515-22. PubMed PMID: 8876579. ](http://www.ncbi.nlm.nih.gov/pubmed/%208876579)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/%208876579)
28. [DiFelice A Jr, Seiler JG 3rd, Whitesides TE Jr. The compartments of the hand: an anatomic study. J Hand Surg Am. 1998 Jul;23(4):682-6. PubMed PMID: 9708383. ](http://www.ncbi.nlm.nih.gov/pubmed/9708383)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/9708383)
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The patient has sustained a complex proximal humerus fracture with head split component and multiple articular fragments. When the articular surface is significantly compromised, arthroplasty procedures are favored. The only procedure listed that addresses the damaged humeral head is hemiarthroplasty, making it the correct response. Although a possible option, ORIF would be difficult due to the fragmented humeral head, and there would be a high risk for fracture collapse or avascular necrosis. IM nailing will not provide enough control of the fracture pieces, nor will it replace the damaged articular surface. Closed reduction is not an option given the complex nature of the fracture.

The Timed Up and Go test can be used as a quantitative assessment of a patients functional status. A score of < 12 seconds is normal in a population of adults of all ages.
The timed up and go test requires a patient to rise from a chair, walk around a cone 10 feet away, and return to the seated position in the same chair (see video below). It is a commonly used assessment of functional status across clinical settings (pulmonary, cardiac, musculoskeletal, etc.). It has been used in the hip fracture literature and found to be most predictive of use of ambulatory aids.
Laflamme et al. found that the timed up and go test at 3 wks following
hemiarthroplasty for hip fractures is predictive of ambulatory aid use two years after the fracture. Specifically, a test score of greater than 26 seconds predicted a 90x higher chance of using an ambulatory device.
Kristensen et al. established high interrater reliability with an ICC of 0.95 in a group of fifty hip fracture patients evaluated with the timed up and go test.
The video link below shows a patient performing the test without an ambulatory aid. It can be performed with one as well.
Incorrect Answers:
Answers 1, 5: The patient has a normal timed up and go test within normal limits. The FRAX score calculation would be a better tool for future fragility fracture risk. Abnormal scores are indicative of cardiac and pulmonary system compromises, but this question is not referring to these clinical settings.
Answer 3: While gait speed is predictive of overall longevity, this has not been evaluated beyond 20 years in the geriatric hip fracture population.
Answer 4: Persistent use of ambulatory aids would be predicted if his score had been > 26 seconds.

The most specific laboratory finding is an elevated antibody titer to Borrelia burgdorferi. This test is commonly referred to as a
Lyme titer.
All of the mentioned tests are generally seen in Lyme disease, however, elevated erythrocyte sedimentation rate, elevated C - reactive protein, negative antinuclear antibody, and negative rheumatoid factor are all nonspecific.

The clinical findings indicate venous obstruction without arterial compression, and the venogram reveals occlusion of the subclavian vein, which is most likely the result of thoracic outlet compression. In the developed athlete, scalene muscle hypertrophy (Paget-Schroetter syndrome) causes compression of the subclavian vein. Treatment should consist of thrombolysis followed by decompressive surgery.
REFERENCES: Angle N, Gelabert HA, Farooq MM, et al: Safety and efficacy of early surgical decompression of the thoracic outlet for Paget-Schroetter syndrome. Ann Vasc Surg 2001;15:37-42.
Azakie A, McElhinney DB, Thompson RW, et al: Surgical management of subclavian-vein effort thrombosis as a result of thoracic outlet compression. J Vasc Surg 1998;28:777-786.

- Nonsurgical treatment with early passive range of motion

The majority of mallet fractures can be treated nonsurgically with a distal interphalangeal joint extension splint. Excellent results can be obtained in most patients with splinting alone. The fragment size, amount of displacement, and degree of articular incongruity usually do not affect final outcome, as long as the joint is reduced. Surgical fixation takes on several forms but is fraught with complications including skin/wound problems, loss of fixation, nonunion, and stiffness of the distal interphalangeal joint. Volar subluxation of the distal phalanx remains the primary indication for surgical treatment.
REFERENCES: Green DP, Butler TE Jr: Fractures and dislocations in the hand, in Rockwood CA, Green DP, Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, pp 621-623.
Light TR (ed): Hand Surgery Update 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 19-28.

A computed tomography scan provides important information in regard to the version of the glenoid, wear pattern, amount of wear, glenohumeral subluxation, as well as desired entry point

Radial head fractures are thought to occur as a result of valgus posterolateral rotary load across the elbow, although the mechanism can certainly vary. Minimally or nondisplaced fractures without any clinical instability or block to motion can often be successfully managed non-surgically. Fractures with >2 mm of displacement or fragments that block motion require surgical repair. A critical aspect during surgery is identifying concomitant injury to the lateral collateral ligament complex (LCL). When encountered, the LCL is most often avulsed from its origin at the lateral epicondyle, resulting in a bare area. After the radial head is either repaired or replaced (Figures 4 and 5), the LCL should
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be repaired back to its anatomic origin. Postoperatively, the surgeon must communicate to the therapist that elbow extension exercises should be performed with the forearm in pronation as a result of the compromised LCL, as this position places the least stress on the ligamentous repair. Elbow extension exercises in supination or neutral are recommended for compromise of the medial collateral ligament, or combined medial and lateral ligament injury, respectively. Without any medial elbow bruising, swelling, or tenderness, it is unlikely that the patient has an injury to the medial collateral ligament.

Immediate spica casting is ideal for younger children with uncomplicated femoral fractures that are the result of relatively low-energy injury. Surgical stabilization of pediatric femoral fractures is most commonly performed in children who are older than age 6 years or in children with other factors associated with their femoral fracture, such as concomitant head injury, open fracture, floating knee, severe comminution, or vascular injury.
REFERENCES: Flynn JM, Skaggs DL, Sponseller PD, et al: The surgical management of pediatric fractures of the lower extremity. Instr Course Lect 2003;52:647-659.
Sponseller PD: Surgical management of pediatric femoral fractures. Instr Course Lect 2002;51:361-365.
Wright JG: The treatment of femoral shaft fractures in children: A systematic overview and critical appraisal of the literature. Can J Surg 2000;43:180-189.
Levy J, Ward WT: Pediatric femur fractures: An overview of treatment. Orthopedics 1993;16:183-190.

Neurofibromas are benign tumors of neural origin that are transmitted as an autosomal dominant trait with variable penetrance. Neurofibromas are associated with cutaneous manifestations like cafe-au-lait spots and axillary freckles. They may be dumbbell shaped and can be identified with magnetic resonance imaging, which is especially helpful for deeper multiple lesions. They are infiltrative, making excision with preservation of peripheral nerve function difficult thus requiring bridge grafting for significant motor or sensory funtional requirements.

Storage temperature, ambient temperature, handling and kneading of bone cement, and introducing cement in a warm environment are factors of the setting time of cement. Use of a cement gun is not a factor

In most cases of radial club hand, excluding a hypoplastic radius, full correction cannot be achieved.

The majority of stress fractures are treated with rest and protected weight-bearing. When the patient rests, strain on the affected bone is reduced and formation exceeds resorption, leading to bone healing.
Electrical stimulation and ultrasound have not been shown to increase the rate of healing. For most stress fractures, surgery is not necessary.
C orrect Answer: Rest and protected weight-bearing

I. Important facts concerning FGFR3 physiology and disorders
A. Gain in function mutation results in achondroplasia
1/. Point mutation
2/. Homogenous (single, constant amino acid change)
3/. Receptor is active even without ligand binding
4/. Autosomal dominant
B. Regulates cell growth, proliferation, and differentiation
C . Ligand binding results in phosphorylation of the tyrosine kinase domain
D. Activation of the receptor limits enchondral ossification
E. Deficiency of the receptor results in elongation of the vertebral column and long bones (knockout mice) Correct Answe Gain of function mutation

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The observed subsidence in the first 6 weeks indicates lack of initial stability and is likely related to undersizing of the implant at the time of surgery. High BMI has been associated with higher rates of loosening. Based on the other hip, it is unlikely there is mismatch between the metaphysis and diaphysis. The modular neck design has not been associated with higher rates of aseptic loosening.

- Osteonecrosis_
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The standard treatment for a bicondylar tibial plateau fractures is a period of post-operative non-weight bearing.
Tingstad et al found favorable results of immediate weightbearing on humeral shaft fractures treated with plating and full weightbearing did not have any effect on the union or malunion rates.
Brumback et al evaluated the feasibility, safety and efficacy of immediate
weightbearing after treatment of femoral shaft fractures with statically locked IM nail. All the patients went on to union and no loss of fixation occurred.

Serratus anterior palsy or long thoracic nerve palsy is usually caused by traction injury to the nerve, blunt injury, or iatrogenic injury. The palsy results in winging of the scapula and medial rotation of the inferior pole of the scapula. A patient with this injury will usually recover in 12 to 18 months. Initial treatment should include observation and shoulder strengthening exercises. Nerve exploration with repair has not proven beneficial in changing the outcome. Many orthopaedic surgeons favor using a split pectoralis major transfer for symptomatic patients. Electrodiagnostic studies are helpful in confirming the diagnosis.
REFERENCES: Post M: Pectoralis major transfer for winging of the scapula. J Shoulder Elbow Surg 1995;4:1-9.
Kuhn JE, Plancher KD, Hawkins RJ: Scapular winging. J Am Acad Orthop Surg 1995;3:319-325.

consistency.
Viscosity is the measure of resistance of a fluid to deform under force or the resistance to flow (ie, thickness of a fluid). The lower the viscosity, the more water-like the bone cement will be; the higher the viscosity, the more doughy the bone cement will be after mixing. Additionally, as the cement polymerizes, the process is broken down into four phases: mixing, waiting, working and hardening. Ideally, we would like a cement to have a short mixing, waiting and hardening time and a long working time. The working time is the period of time during which the cement is manageable to use for cementing implants into place. The cement must penetrate into the cancellous bone for it to function like a “grout” as it is supposed to do. There has been a recent push to use high-viscosity cement in total knee arthroplasty, despite concerns that the doughier cement may not penetrate the bone as well. Based on the properties of cement, high-viscosity cement is doughier with a shorter waiting and mixing time and a longer working time versus low-viscosity cement, which is runnier and has a shorter working time.

One should remember the important mutations that occur in musculoskeletal conditions: FGFR3 mutation: Achondroplasia
Type IX collagen mutation: Multiple epiphyseal dysplasia (MED)
WISP3 mutation: Spondyloepiphyseal dysplasia with progressive osteoarthropathy
Type II collagen mutation: Stickler syndrome
Sulfate transporter gene mutation: Diastrophic dysplasia
Fibrillin gene mutation: Marfanâs syndrome
Type V collagen mutation: Ehlers-Danlos syndrome
Type I collagen mutation: Osteogenesis imperfecta
C orrect Answer: WISP3 mutation

Cr is concentrated in the epithelial cells of the proximal renal tubules and can impair renal function, induce tubular necrosis, and cause marked interstitial changes in experimental animals and humans. Indicators of tubular dysfunction have been identified in human objects exposed to Cr (VI) through occupation. Al, Ni, and Co are all rapidly excreted by the kidney, hence renal toxicity tends to require significantly larger doses

The lower thoracic-upper lumbar spine is most commonly affected by tuberculosis. Multiple vertebrae are often involved in tuberculosis spondylitis.

Gerdy’s tubercle is a bony prominence on the anterolateral aspect of the proximal tibia and is the distal insertion point for the iliotibial band. The iliotibial band contributes to lateral knee stability and also functions to assist in extension, abduction and external rotation of the hip. Proximally, it becomes confluent with the tensor fascia lata, which inserts onto the iliac crest. The biceps femoris tendon inserts onto the fibular head. The popliteus muscle originates from the lateral femoral epicondyle. The LCL inserts onto the lateral femoral condyle and fibular head. The pes anserinus is the confluence of the sartorius, gracilis and semitendinosus muscles and inserts on the medial proximal tibia.
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MCL repair or reconstruction may be considered in younger, more active patients, but this intervention is technically demanding and produces variable results. Rotating-hinge TKA is associated with good results in a number of small series that include cases performed with MCL insufficiency or absence. A rotating hinge is preferable over a fixed hinge because of decreased stresses on implants imposed by fixed-hinge devices.

Lunate or perilunate dislocations are usually treated with open reduction and internal fixation through a dorsal or combined dorsal and volar approach. A high index of suspicion is necessary when treating patients who sustain multiple trauma because as many as 25% of lunate or perilunate dislocations are missed initially. The radio dense appearance of the lunate seen in Figure 1 is an example of transient ischemia of the lunate that can occur following treatment of lunate and perilunate dislocations. It has been reported in up to 12.5% of cases. This usually is seen between 1 and 4 months post injury with a relative radio density of the lunate. This appearance of the lunate should not be over treated and usually is a benign self-limiting event. Surgery is not indicated at this time; the incorrect responses are treatment options for Kienbock disease. Treatment of the lunate or perilunate dislocation involves initial gentle closed reduction followed by open reduction, ligamentous and bone repair, and internal fixation. Median nerve dysfunction is common, and a simultaneous carpal tunnel release is often performed. Early treatment seems to produce better results, but good results have been reported when treatment is delayed for up to 6 months. The many questions regarding treatment of this problem involve the use of capsulodesis to supplement intercarpal ligament repair, repair/stabilization of the lunotriquetral interval vs no treatment of that articulation, and intercarpal fixation techniques. In delayed cases, proximal row carpectomy when the head of the capitate is intact and total wrist fusion if there are degenerative changes have been used. Chondral injuries are common, may not be recognized on radiographs, and may negatively affect longterm outcomes. Even when treatment is optimal, this injury is associated with a guarded prognosis and possible permanent partial loss of wrist motion and grip strength. At 10-year follow-up, radiographs will often demonstrate degenerative changes, but these changes do not always substantially negatively affect _hand function._

This patient demonstrates scapholunate dissociation with an associated dorsal intercalated segment instability deformity. Chronic scapholunate ligament tears lead to scapholunate advanced collapse (SLAC) wrist. Watson and Ballet describe SLAC wrist as having a predictable progression of arthritic changes, starting at the radial styloid, progressing to the radioscaphoid joint, and advancing to the lunocapitate joint. Some authors have described the radiolunate joint as being affected in very late-stage _SLAC wrist._

DISCUSSION: Schilders and associates reported their results of treating adductor-related groin pain in competitive athletes. They reported that a single corticosteroid injection into the pubic cleft can be expected to provide at least 1 year of relief of adductor-related groin pain in a competitive athlete with normal findings on MRI. In contrast, when there is evidence of enthesopathy on MRI in this competitive- athlete population, these injections are not therapeutic and are associated with a high likelihood of recurrence of symptoms. Hip arthroscopy is generally reserved for intra-articular problems. Percutaneous adductor tenotomy is not indicated for this condition. A bone scan is unlikely to provide any useful information for clinical decision-making. Rheumatology consultation is also not indicated in the absence of any evidence of inflammatory arthropathy.
REFERENCES: Schilders E, Bismil Q, Robinson P, et al: Adductor-related groin pain in competitive athletes: Role of adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections. J Bone Joint Surg Am 2007;89:2173-2178.
Robinson P, Barron DA, Parsons W, et al: Adductor-related groin pain in athletes: Correlation of MR imaging with clinical findings. Skelet Radiol 2004;33:451-457.

This patient has elbow stiffness caused by posteromedial heterotopic ossification after healing of his distal humerus fracture.
Stiffness and limited range of motion is common secondary to extrinsic causes. Studies have shown operative treatment via HO excision, capsular release, and/or release of the posterior band of the UCL can improve range of motion.
Park et al. studied 42 patients with extrinsic contracture of less than 100 degrees. They report posteromedial HO excision with capsular release and release of the posterior band of the UCL significantly improved ROM.
Williams et al. studied 164 patients who underwent release for extrinsic
tightness with ulnar nerve decompression for preoperative symptoms. Following decompression, low rates of postoperative ulnar nerve symptoms were noted. More post-operative symptoms were seen for more severe contractures.
Figure A is an AP and lateral radiograph of the elbow with posteromedial heterotopic ossification. Figure B is a 3D CT reconstruction confirming the posteromedial location.
Incorrect Answers:
Answer 1. There is a mechanical block to motion. Continued therapy will not improve the patient's range of motion.
Answer 2. Indomethacin is used for heterotopic ossification prophylaxis. Answer 3. Radiation therapy is used for heterotopic ossification prophylaxis. Answer 5. The anterior band of the ulnar collateral ligament should not be released because it will cause secondary valgus instability.

The inability to actively supinate affects many functions; this patient has a pronation deformity of the forearm that affects function. Transfer of the pronator teres by rerouting the insertion point allows this muscle to act primarily as a supinator of the forearm rather than as a pronator. This can markedly improve his ability to accomplish activities of daily living. Release of the pronator quadratus is not necessary because there is full passive supination and no presurgical contracture. A physical therapy program would not be helpful in this situation because of the total absence, rather than weakness, of active supination. A humeral derotational osteotomy is not necessary because this patient has normal radiograph findings and bony alignment.
RECOMMENDED READINGS
22. Cobeljic G, Rajkovic S, Bajin Z, Lešic A, Bumbaširevic M, Aleksic M, Atkinson HD. The results of surgical treatment for pronation deformities of the forearm in cerebral palsy after a mean follow-up of
17.5 years. J Orthop Surg Res. 2015 Jul 8;10:106. doi: 10.1186/s13018-015-0251-3. PubMed PMID: 26152666.
23. Van Heest AE, House JH, Cariello C. Upper extremity surgical treatment of cerebral palsy. J Hand Surg Am. 1999 Mar;24(2):323-30. PubMed PMID: 10194018.

Cubitus varus is a common complication of displaced supracondylar humeral fractures that are treated with closed reduction and cast immobilization. Treatment with closed reduction and percutaneous pinning decreases the incidence of this complication. Cubitus varus also can occur in minimally displaced fractures when unrecognized collapse of the medial column of the distal humerus is not corrected with manipulation. This can be detected on physical examination of the carrying angle or on radiographs measuring Baumann’s angle, both in comparison to the opposite side. Cubitus varus may result in unacceptable cosmesis and may predispose the patient to fractures of the lateral condyle. The lateral radiograph demonstrates the crescent sign from overlap of the distal humerus with the olecranon seen in patients with cubitus varus. Patients with growth arrest to the medial trochlear physis would have atrophy of the trochlea on radiographs.
REFERENCES: Flynn JM, Sarwark JF, Waters PM, et al: The surgical management of pediatric fractures of the upper extremity. Instr Course Lect 2003;52:635-45.
Papandrea R, Waters PM: Posttraumatic reconstruction of the elbow in the pediatric patient. Clin Orthop 2000;370:115-126.
Lins RE, Simovitch RW, Waters PM: Pediatric elbow trauma. Orthop Clin North Am 1999;30:119-132.

Hip disease can present with knee pain in up to 47% of cases. The knee may be the only location of pain. Hip disease should be suspected as a cause of knee pain in patients who have pain and disability disproportionate to disease severity, especially with use of walkers and wheelchairs, symptoms nonresponsive to injections, surgical management, and with limbs fixed in external rotation making it difficult to obtain anteroposterior imaging. This patient has all of these features. His hip radiograph is shown in Figure 4.
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The arrow in Figure 2 marks the dorsal sensory branch of the ulnar nerve. Injury to this nerve results in sensory loss of the dorsal ulnar palm and the dorsal small and ring finger digits. The dorsal sensory branch of the ulnar nerve exits the main ulnar nerve at an average distance of 8.3 cm from the proximal border of the pisiform. It becomes subcutaneous on the ulnar aspect of the forearm at an average distance of 5
cm from the proximal edge of the pisiform. It then travels dorsal to the extensor carpi ulnaris tendon to innervate the dorsal ulnar hand and the dorsal ring and small digits. Injuries to this nerve can occur from open and arthroscopic procedures (such as triangular fibrocartilage complex repair) as well as from procedures requiring percutaneous pinning. Care must be taken to identify and protect this nerve to avoid the complications of numbness and possible neuroma formation. The inability to extend the small finger would be caused by an injury to the extensor tendon(s) in this area, and the inability to abduct the small finger would require an injury to the abductor digiti minimi muscle/tendon unit or the ulnar nerve motor branch, which is located on the volar aspect of the proximal palm. Clawing of the small and ring fingers would be caused by absent intrinsic function due to an injury to the ulnar motor nerve branch located on _the volar proximal palm._

Threaded pins are frequently inserted into the femoral shaft and tibial shafts or proximal tibia to attach arrays for tracking devices. There have been case reports of fractures propagating through the pin tracks, which is a complication unique to computer navigation. Intercondylar fractures can occur following posterior stabilized TKA. Vascular injury, ligament disruption, and nerve palsy are rare complications following TKA performed with or without computer navigation.
Figures 1 through 5 are the radiographs and MR arthrograms of a 19-year-old woman who presents with right hip pain that has been present for 4 years that is insidious in onset. The pain is located in the groin and lateral hip and is worse with weight-bearing activity. Flexion, adduction and internal rotation reproduces her pain, and she has a positive external log roll for pain. She has tried NSAIDs, physical therapy and activity modification. What is the best next step?
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A. Dry needling therapy to the gluteus medius tendon insertion
B. Hip arthroscopy with acetabuloplasty and labral advancement
C. Open hip dislocation with osteochondroplasty and labral repair
D. Periacetabular osteotomy with arthrotomy and labral repair
The patient has hip dysplasia with acetabular index of 14.4 and a lateral center- edge (LCE) angle of 17. MRI scan reveals a labral tear with mild acetabular retroversion. Dry needling may be an effective treatment for chronic lateral hip pain, but would not treat intra-articular pathology. Although hip arthroscopy for labral pathology in the setting of borderline hip dysplasia (LCE 18-25°) may be successful, in higher degrees of dysplasia with potential for additional resection to address mild retroversion, arthroscopy may be associated with high rates of failure. Open hip surgery offers no advantage over arthroscopic treatment in the treatment of labral tears in dysplasia. Periacetabular osteotomy may be combined with open or arthroscopic treatment of intra-articular pathology with good results.
Correct answer : D
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When performing a cruciate-retaining total knee arthroplasty, trial components are inserted. The knee comes to full extension but is tight in flexion. The surgeon should consider
A. flexing the femoral component.
B. releasing the posterior cruciate ligament.
C. downsizing the tibial insert thickness.
D. resecting more distal femur.
In this scenario, the flexion gap needs to be increased. Increase in flexion gap can be accomplished by downsizing the femoral component and increasing posterior tibial slope. In posterior cruciate-retaining TKA procedures, recession or release of the posterior cruciate ligament can loosen the flexion gap, allowing for an increase in flexion. Flexing the femoral component tightens the flexion gap, and downsizing the tibial insert thickness decreases flexion and extension gaps, while resection of the distal femur only increases the extension gap.
Correct answer : B
Figures 1 through 3 are the radiographs of a 78-year-old woman with a severe valgus deformity and worsening pain in her right knee. She has failed all nonsurgical management and is interested in pursuing a total knee arthroplasty (TKA). When performing a TKA on this patient, attention should be directed toward avoiding what intraoperative femoral component positioning error?
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A. Oversize
B. External rotation
C. Flexion
D. Internal rotation
Patients who present with a severe valgus knee deformity often have a hypoplastic lateral femoral condyle, which must be assessed intraoperatively. If using a measured resection technique in the setting of a hypoplastic femoral condyle, the femoral component may end up internally rotated, which can lead to issues with patellofemoral tracking and overall extremity rotational alignment. Care must be taken to avoid internal rotation of the femoral component in patients with a hypoplastic lateral femoral condyle.
Correct answer : D

Figure 2 depicts a typical unicameral bone cyst with a pathologic fracture. The decision to treat this lesion should be based on the amount of cortical thinning. If these lesions involve a pathologic fracture, many surgeons will treat them nonsurgically to see if the fracture stimulates healing of the cyst. If the cyst wall remains thin or the patient is symptomatic, then treatment is directed at decreasing cyst volume, increasing cortical thickness, and eliminating symptoms. This can be accomplished by curettage and grafting, injection with autogenous bone marrow, or grafting with 1 of the many available bone void fillers. In some cases, internal fixation may be required. This typically is accomplished with flexible intramedullary nails.
Figure 3 shows a typical nonossifying fibroma. These benign lesions are usually incidental findings on a radiograph and often resolve in adulthood. Treatment usually is not required, and these lesions typically do not produce symptoms.
Figure 4 shows an osteoid osteoma of the femoral neck. This is characterized by a central radiolucent nidus surrounded by reactive bone with increased radiodensity. These lesions are painful because of the large amount of prostaglandin they secrete. They temporarily respond to oral anti-inflammatory drugs. Treatment is directed at eliminating the nidus and can be done through curettage, but radiofrequency ablation, which allows for a minimally invasive approach, is often used today.
Figure 5 shows diskitis with vertebral osteomyelitis. The disease is characterized by fever and back pain. Movement is extremely uncomfortable for these children, and they may adopt unusual postures to alleviate pain. The MRI shows involvement of 1 vertebrae and an adjacent disk. Left untreated, this condition often spreads to involve multiple vertebrae and also can cause an epidural abscess. Treatment during the early stages is IV antibiotics. Many orthopaedic surgeons also use bracing to prevent late vertebral collapse.
Figures 6a through 6c show septic arthritis of the ankle with metaphyseal osteomyelitis. The recommended treatment is incision and drainage followed by IV antibiotics. MRI may be considered before surgery to assess for an associated osteomyelitis or abscess that may also necessitate surgical debridement. Increasingly, these scenarios are managed with a rapid transition to oral antibiotics.

Following a CVA and with the resumption of upright posture, downward subluxation of the glenohumeral joint may occur. Although usually painless, some patients may report pain secondary to stretching of the brachial plexus. This is the result of flaccid paralysis of the deltoid muscle, and it will persist until some motor tone or spasticity returns to the shoulder girdle musculature. Early sling support and range-of-motion exercises to prevent contracture will provide the best relief. Surgical procedures are not indicated.
REFERENCES: Braun RM, Botte MJ: Treatment of shoulder deformity in acquired spasticity. Clin Orthop 1999;368:54-65.
McCollough NC III: Orthopaedic evaluation and treatment of the stroke patient. Instr Course Lect 1975;24:45-55.

Figure A demonstrates a tibial plafond fracture. Initial superficial zone cartilage cell death via necrosis at the fracture margins has been shown to contribute to post-traumatic arthritis.
Post-traumatic osteoarthritis typically occurs after an intra-articular fracture. Impacted chondrocytes die by either necrosis or apoptosis, which have both been implicated in post-traumatic osteoarthritis. Initial cell death in the superficial cartilage zones at the fracture margins occurs by necrosis. Apoptosis occurs in a delayed fashion and is mitigated by several bioactive agents.
Apoptosis also affects the superficial cartilage zones near the fracture margins. Deep cartilaginous zones and areas away from the fracture margins do not seem to be involved in these processes.
McKinley et al. performed a review of the basic science of intra-articular fractures and posttraumatic osteoarthritis. They report that initial damage to the cartilage in combination with the ensuing pathomechanical and pathobiologic response of the cartilage after a fracture contribute to posttraumatic arthritis. Chronic abnormal joint loading is also thought to contribute to this process as well. They conclude that the relative contribution of each is unknown.
Tochigi et al. performed a study to determine the distribution and progression of chondrocyte damage after intra-articular ankle fractures. They harvested 7 normal human ankles and subjected them to impaction. They found that immediate superficial zone chondrocyte death was greater in fracture-edge regions than on-fracture regions. Subsequent cell death over the next 48 hours was significantly higher in fracture-edge regions as well. They conclude that cartilage damage in intra-articular fractures was characterized by chondrocyte death at fracture margins.
Figure A is an ankle mortise radiograph demonstrating an intra-articular tibial plafond fracture.
Incorrect Answers:
Answer 1: Initial superficial zone chondrocyte cell death occurs by necrosis, not apoptosis.
Answer 2: Initial superficial zone chondrocyte cell death occurs by necrosis at the fracture margins.
Answer 3: Delayed superficial zone cartilage cell death occurs via apoptosis at the fracture margins.
Answer 5: Delayed superficial zone cartilage cell death occurs via apoptosis, not necrosis.

Intraoperative vascular injuries during THA can be a catastrophic complication, and knowledge of the practical vascular anatomy is critical to complication avoidance. The external iliac artery travels along the medial border of the psoas muscle and is at risk when placing screws in the anterosuperior quadrant, and further distal when placing retractors over the anterior column, before branching into the femoral vessels at the inguinal ligament. The superior gluteal artery is at risk when placing screws in the sciatic notch, and also during the direct lateral approach as it runs between the gluteus medius and minimus about 5 cm superior to the greater trochanter. The obturator artery is located along the quadrilateral surface of the acetabulum and can be injured when placing an inferior retractor under the transverse acetabular ligament. The ascending branches of the lateral femoral circumflex artery are routinely isolated and cauterized during the anterior approach as they run in the interval between the tensor fascia lata and sartorius.