Orthopedic Hyperguide: Advanced MCQs on Joint Infection Diagnosis & Aspiration

The patient has patellofemoral stress and a tight lateral retinaculum that has failed to respond to nonsurgical management; therefore, the most appropriate treatment includes an arthroscopic lateral retinacular release. A patellar restraining brace may aggravate the peripatellar pain by increasing pressure on the lateral facet. There is no evidence of patellar instability or significant malalignment; therefore, medial retinacular repair or a tibial tubercle transfer is not indicated. A modified Maquet tibial tubercle elevation would be considered only for significant patellofemoral arthrosis.
REFERENCES: Gambardella RA: Techical pitfalls of patellofemoral surgery. Clin Sports Med 1999;18:897-903.
Post WR: Clinical evaluation of patients with patellofemoral disorders. Arthroscopy 1999;15:841-851.

The patient had a valgus knee preoperatively and in these patients, care must be taken to avoid internal rotation of the femoral component that can lead to patellar instability. At the present time she has a completely dislocated patella, evidence of coronal instability on her AP radiograph, and internally rotated femoral and tibial components; therefore, management should consist of revision of both of her components to place them in appropriate external rotation.
REFERENCES: Malo M, Vince KG: The unstable patella after total knee arthroplasty: Etiology, prevention, and management. J Am Acad Orthop Surg 2003; 11:364-371.
Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3.
Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 123-145. Question 40
The term “paradoxical motion,” used to describe knee kinematics, is best described by which of the following definitions?
1. The patella does not roll forward into the trochlear groove during knee extension.
2. The tibia rolls back on the femur during knee extension.
3. The tibiofemoral contact point moves anteriorly during knee flexion.
4. The posterior cruciate ligament rolls posteriorly with respect to the anterior cruciate ligament during knee extension.
5. The femur rolls back on the tibia during knee flexion.
PREFERRED RESPONSE: 3
DISCUSSION: The term “rollback” describes the posterior movement of the tibiofemoral contact point with knee motion from extension to flexion. Therefore, with “paradoxical rollback” this contact point moves anteriorly. “Paradoxical rollback” is a term used to connote the inability of the anterior cruciate- deficient, posterior cruciate-retaining total knee prosthesis to create normal posterior femoral rollback with knee flexion.
REFERENCES: Dennis DA, Komistek RD, Mahfouz MR: In vivo fluoroscopic analysis of fixed-bearing total knee replacements. Clin Orthop Relat Res 2003;410:114-130.
Incavo SJ, Mullins ER, Coughlin KM, et al: Tibiofemoral kinematic analysis after total knee arthroplasty.
J Arthroplasty 2004;19:906-910.

C alcaneovalgus foot has all of these findings and resolves spontaneously.
Fibular hemimelia typically has less calcaneus attitude and more valgus and shortening. Vertical talus entails loss of an arch and loss of cohesive movement of the foot as a whole. There is no evidence of muscle weakness.
There is no evidence of a neuropathic component.

Based on these findings, the most likely diagnosis is a rotator cuff injury and probable tear; therefore, MRI is the study of choice. CT is preferred for articular fractures. A bone scan is nonspecific and can identify inflammation or occult fracture. Joint aspiration is not likely to identify an effusion. Physical therapy and a functional capacity examination are used to identify weakness during recovery prior to a return to work or sports.
REFERENCES: Hawkins RJ, Bell RH, Hawkins RH, Koppert GJ: Anterior dislocation of the shoulder in the older patient. Clin Orthop 1986;206:192-195.
Matsen FA III, Thomas SC, Rockwood CA: Anterior glenohumeral instability, in Rockwood CA, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1990, pp 526-622.

The patient has radiographic findings compatible with diffuse idiopathic skeletal hyperostosis (DISH) of the cervical spine. Characteristics of DISH include flowing, non-marginal osteophytes at four or more levels. Patients with DISH develop a significant loss of flexibility of the spine. The spine acts more as a long bone with minimal force needed to create unstable fractures. Any minor trauma in patients with DISH should be
worked up aggressively to rule out occult fracture. In this patient, radiographs fail to clearly rule out a fracture; therefore, CT of the cervical spine is indicated.Without a suspicion of history of a head injury, admission specifically for a possible intracranial hematoma is not warranted. The more concerning injury in a patient with DISH is occult neck fracture. Treatment with a soft or hard collar is not advised until a fracture is ruled out. Repeat radiographs are unlikely to show any occult fractures, and flexion and extension views would not be advised in a patient with a suspected vertebral fracture.

This pathology is most consistent with giant-cell tumor. Note the presence of multinucleated cells and stroma of spindlelike cells with pale staining cytoplasm and nuclei. Giant-cell tumors typically occur in patients ages 20 to 40. Common sites include the epiphysis of the distal femur or proximal tibia (50% of the time). Although it is a benign lesion, giant-cell tumors have a tendency for bone destruction, recurrence, and, rarely, metastasis. The initial treatment of choice is curettage with grafting or cementation. For recurrent or stage III tumors, wide excision may be necessary. Chemotherapy or radiation therapy are not indicated as initial treatment, especially if this is an isolated primary lesion.
RECOMMENDED READINGS
106. [Turcotte RE. Giant cell tumor of bone. Orthop Clin North Am. 2006 Jan;37(1):35-51. Review. PubMed PMID: 16311110.](http://www.ncbi.nlm.nih.gov/pubmed/16311110)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/16311110)
107. [Eckardt JJ, Grogan TJ. Giant cell tumor of bone. Clin Orthop Relat Res. 1986 Mar;(204):45-58. Review. PubMed PMID: 3514036.](http://www.ncbi.nlm.nih.gov/pubmed/3514036)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/3514036)

The first branch of the lateral plantar nerve (occasionally referred to as the nerve to the abductor digiti quinti) is occasionally involved in pathologic painful heel syndrome and plantar fasciitis.

The radiographic and clinical findings suggest a scapulothoracic dissociation with a widely displaced clavicular fracture and a laterally displaced scapula. These injuries have a high association with neurovascular injuries to the brachial plexus and subclavian artery. Emergent vascular evaluation with arteriography and possible vascular repair are indicated. This repair can be combined with open reduction and internal fixation of the clavicle to improve stability. Delay in treatment of these vascular injuries can be devastating.
REFERENCES: Iannotti JP, Williams GR (eds): Disorders of the Shoulder. Philadelphia, PA, Lippincott, 1999, pp 632-635.
Ebraheim NA, An HS, Jackson WT, et al: Scapulothoracic dissociation. J Bone Joint Surg Am 1988;70:428-432.

The patient has historical and clinical evidence of significant anterior shoulder instability. The imaging demonstrates significant anteroinferior glenoid bone loss, with a very shallow Hill-Sachs deformity. Patient factors that contribute to recurrent instability
risk include type of sport/activity, age at the time of first dislocation, hyperlaxity, and glenoid bone loss (and/or bipolar bone loss), and these can be utilized to determine if an arthroscopic or open solution is most appropriate. In this patient, restoring glenoid bone stock appears to be the most important variable in stabilizing the shoulder. “Critical” glenoid bone loss has frequently been reported to be >20-25%. In this case, significant bone loss can be suspected from the patient's history, including the number of dislocations, ease of dislocation and reduction, and instability in mid-range of motion.

- Anatomic total shoulder arthroplasty (TSA)_

This situation represents a definitively and chronically infected knee replacement. Antibiotic therapy alone might suppress the infection but would not eradicate it. Debridement and polyethylene exchange would be appropriate treatment for an early postoperative infection. The treatment of choice is to perform a two-stage debridement and reconstruction. Although not among the listed choices, an aspiration or culture could be done presurgically and might help clinicians identify the best antibiotics to treat the condition. Antibiotic selection would not affect the need for the two-stage reconstruction, however.

The EC RB transfer gives the greatest return of power pinch due to the strength of this wrist motor. This transfer should be coupled with a thumb MP arthrodesis to provide the best results. The ideal pinch transfer is an extensor pollicis brevis to first dorsal interosseous with a metaphalangeal (MP) arthrodesis at the thumb. The FDP and EDC tendons are not good choices because they are not independent tendons. The EIP provides power, but the vector of the transfer is not ideal. Transfer of the EC RL would unbalance the wrist.

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.

■
Cervical disk replacement is indicated for 1-2 levels depending on the chosen implant. Studies have examined its use in patients <60 years for symptomatic cervical radiculopathy and/or myelopathy.

There are different snake bite protocols depending on the species of snake. However, common steps in all snake bite protocols include keeping the patient emotionally and physically still, calling for help immediately, applying a moderately tight tourniquet proximally to prevent further spread of venom, and capture or identification of the snake. Local injection of the antivenin in the fingers or toes is contraindicated.

6,000,000

DISCUSSION: The calculated risk of a musculoskeletal allograft containing HIV despite adequate screening has been estimated to be approximately 1 in 1.6 million. This estimate is based on the risk of HIV in the population, projected population estimates, and current methods of donor screening.

REFERENCES: McAllister D, Joyce M, Mann B, et al: Allograft update: The current status of tissue regulation, procurement, processing, and sterilization. Am J Sports Med 2007;2148-2158.
Buck B, Malinin T: Human bone and tissue allografts: Preparation and safety. Clin Orthop Relat Res 1994;303:8 -
17.
Buck B, Malinin T, Brown M: Bone transplantation and human immunodeficiency virus: An estimate of risk of acquired immunodeficiency syndrome (AIDS). Clin Orthop Relat Res 1989;240:129-136.

_A i;___
Figure 92

Galvanic corrosion is caused by an electrochemical potential that is created between two metals that are located in a conductive environment, such as body fluids.
Examples of galvanic corrosion include: Screw heads and a plate
Femoral head screw and barrel of a dynamic hip screw
Interlocking screws and an intramedullary nail
Galvanic corrosion can also occur within a metal if there are impurities (intergranular corrosion).
The other responses refer to:
Fretting corrosion: Between the femoral head and tapered neck
C revice corrosion: Screw head and countersunk region of the acetabular component
Oxidative degradation: Delamination of high-density polyethylene
Oxidative degradation: Irradiation of high-density polytheylene in an ambient environment
C orrect Answer: At the interface between a plate and the screw heads

The description and radiograph reveal a case of proximal humeral epiphysiolysis, also called Little Leaguer’s shoulder (LLS). This is an overuse condition resulting from chronic repetitive microtraumatic forces imposed on the unossified cartilage of the proximal humeral
physis. Classic radiographic findings include widening of the proximal humeral physis with increased sclerosis and/or mineralization/lucency. Many factors have been studied as possible contributors to the development of LSS, including all options presented. However, no clear relationship between body weight/height or throwing mechanics exist with LSS. It has also been claimed that the use of breaking pitches (e.g. curve balls, sliders) at an early age are a contributing factor, but this has been refuted by a number of recent studies. By far, the most important factors are the numbers of pitches thrown and the frequency of pitching. This is reflected in a number of indicators, including numbers of innings pitched, number of throwing days, numbers of pitches or pitched innings per week, month and year, and playing for multiple teams.

The cystic lesion is shown in an area adjacent to the spinoglenoid notch. A space-occupying lesion in this area has the potential to compress the suprascapular nerve as it passes through the spinoglenoid notch to innervate the infraspinatus. Compression of the nerve can cause denervation and atrophy of the infraspinatus muscle. The supraspinatus is innervated by the suprascapular nerve proximal to the compressive lesions and will not undergo atrophy. The subscapularis and the teres major are innervated by the subscapular nerve.
RECOMMENDED READINGS
1. Getz CL, Ramsey ML, Williams GR. Paralabral cysts of the shoulder. In: Galatz LM, ed. Orthopaedic Knowledge Update: Shoulder and Elbow 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:339-344.
2. [Takagishi K, Saitoh A, Tonegawa M, Ikeda T, Itoman M. Isolated paralysis of the infraspinatus muscle. J Bone Joint Surg Br. 1994 Jul;76(4):584-7. PubMed PMID: 8027145.](http://www.ncbi.nlm.nih.gov/pubmed/8027145)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/8027145)

The images illustrate a large unstable osteochondral lesion of the medial femoral condyle. Radiographs and MR images clearly show deep subchondral bone involvement. The appropriate choice of surgery is OCA transplantation, which is indicated for primary treatment of large cartilage lesions, osteochondral lesions, and salvage procedure from failed prior cartilage surgery. Correction of mechanical axis malalignment, ligamentous insufficiency, and meniscal deficiency should also be addressed. ACI alone or an arthroscopic microfracture procedure would not address the bone defect, leaving an uneven articular surface. Although an osteotomy may be a viable choice, a distal femoral varus osteotomy would increase the contact pressure in the medial compartment and worsen the situation. The histologic anatomy of articular cartilage is well described. The superficial layer or lamina splendens contains a small amount of proteoglycan with collagen fibrils arranged parallel to the articular surface. In contrast, the deep zone contains the largest-diameter collagen fibrils, oriented perpendicular to the joint surface, and the highest _concentration of proteoglycans._

Staphylococcus aureus is the most common pathogen that causes septic arthritis in the hand. The second most common pathogen is streptococcus species infections, which are often the result of trauma. Treatment includes incision and drainage with copius irrigation.

The images reveal a medium-sized tear of the rotator cuff. As more clinical studies are published comparing double-row with single-row rotator cuff repair, it has become clear that the retear rate is lower with a double-row construct for small and medium-sized tears. This may be attributable to the stronger time-zero repair construct that double-row repair provides. No study to date has demonstrated a significant difference in clinical outcomes (functional and pain scores at any time) or time to healing between the two techniques.

Fractures of the proximal humerus are now the third-most-common fracture in patients older than 60 years of age. This patient sustained a displaced, commonly described 3-part/4-part proximal humerus fracture. The number of fracture fragments and angulation, as initially described by Codman and then Neer, does not necessarily help to predict risk for subsequent AVN. Although the main blood supply to the humeral head historically was believed to be a branch from the anterior circumflex, adequate perfusion can remain through the posteromedial calcar following trauma. Hertel and associates reported that the most accurate predictor of ischemia was whether the length of the metaphyseal head extension for the calcar segment was shorter than 8 mm.
Locking plates have provided surgical alternatives to many unstable fracture patterns previously considered ominous. Although much enthusiasm remains for this use, a relatively high level of
complications has been reported with their use. A multicenter study reported a 14% incidence of intra-articular screw perforation as the most common complication.
When patients are deemed poor candidates for head preservation treatment, both hemiarthroplasty and rTSA can provide successful results when applied and performed appropriately. An increasing body of evidence appears to support consideration of a reverse prosthesis for older patients. A crucial aspect of hemiarthroplasty success is anatomic healing of the tuberosities around the implant. If the greater tuberosity displaces or reabsorbs, patients experience significant loss of active motion. The level of pain, however, is unpredictable. Although beneficial in a reverse prosthesis, anatomic tuberosity position does not appear to be as crucial. Depending on the definition of “complication,” some researchers have reported a higher complication rate for the reverse prosthesis.
If posttraumatic necrosis develops following head preservation treatment, conversion to an anatomic shoulder arthroplasty can provide good success in motion and function, particularly when the tuberosities heal in a relatively anatomic position. However, several researchers, most recently Moineau and associates, report suboptimal results when the greater tuberosity is positioned in a substantial amount of varus that necessitates osteotomy. In this scenario, rTSA should be considered.
RECOMMENDED READINGS
8. [Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004 Jul-Aug;13(4):427-33. PubMed PMID: 15220884. ](http://www.ncbi.nlm.nih.gov/pubmed/15220884)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/15220884)
9. [Südkamp N, Bayer J, Hepp P, Voigt C, Oestern H, Kääb M, Luo C, Plecko M, Wendt K, Köstler W, Konrad G. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J Bone Joint Surg Am. 2009 Jun;91(6):1320-8. PubMed PMID: 19487508. ](http://www.ncbi.nlm.nih.gov/pubmed/19487508)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/19487508)
10. [Anakwenze OA, Zoller S, Ahmad CS, Levine WN. Reverse shoulder arthroplasty for acute proximal humerus fractures: a systematic review. J Shoulder Elbow Surg. 2014 Apr;23(4):e73-80. doi: 10.1016/j.jse.2013.09.012. Epub 2014 Jan 7. Review. ](http://www.ncbi.nlm.nih.gov/pubmed/24406120)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/24406120)
11. [Jarrett CD, Brown BT, Schmidt CC. Reverse shoulder arthroplasty. Orthop Clin North Am. 2013 Jul;44(3):389-408, Epub 2013 Apr 29. Review. PubMed PMID: 23827841. ](http://www.ncbi.nlm.nih.gov/pubmed/23827841)[View Abstract ](http://www.ncbi.nlm.nih.gov/pubmed/23827841)[at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23827841)
12. Moineau G, McClelland WB Jr, Trojani C, Rumian A, Walch G, Boileau P. Prognostic factors and limitations of anatomic shoulder arthroplasty for the treatment of posttraumatic cephalic collapse or necrosis (type-1 proximal humeral fracture sequelae). J Bone Joint Surg Am. 2012 Dec 5;94(23):2186-
[94/. doi: 10.2106/JBJS.J.00412. PubMed PMID: 23224389. ](http://www.ncbi.nlm.nih.gov/pubmed/23224389)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23224389)
13. [Namdari S, Horneff JG, Baldwin K. Comparison of hemiarthroplasty and reverse arthroplasty for treatment of proximal humeral fractures: a systematic review. J Bone Joint Surg Am. 2013 Sep 18;95(18):1701-8.. PubMed PMID: 24048558. ](http://www.ncbi.nlm.nih.gov/pubmed/24048558)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/24048558)

The most common reason for revision surgery is loosening of an implant. In most studies that distinguish glenoid from humeral loosening, it appears the glenoid is the problem. Infections, periprosthetic fractures, and rotator cuff tears are uncommon. In the population-based study by Matsen and associates, 10% of the revisions were performed for loosening vs 7% for infection and 7% for rotator cuff tearing.
RECOMMENDED READINGS
61. [Matsen FA 3rd, Li N, Gao H, Yuan S, Russ SM, Sampson PD. Factors Affecting Length of Stay, Readmission, and Revision After Shoulder Arthroplasty: A Population-Based Study. J Bone Joint Surg Am. 2015 Aug 5;97(15):1255-63. doi: 10.2106/JBJS.N.01107. Erratum in: J Bone Joint Surg Am. 2015 Sep 2;97(17):e60. PubMed PMID: 26246260.](http://www.ncbi.nlm.nih.gov/pubmed/26246260)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/26246260)
62. [Dillon MT, Ake CF, Burke MF, Singh A, Yian EH, Paxton EW, Navarro RA. The Kaiser Permanente shoulder arthroplasty registry: results from 6,336 primary shoulder arthroplasties. Acta Orthop. 2015 Jun;86(3):286-92. Epub 2015 Mar 2. PubMed PMID: 25727949. ](http://www.ncbi.nlm.nih.gov/pubmed/25727949)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/25727949)

The clinical scenario and radiographs are consistent with a Gustilo and Anderson type 3A open tibia fracture.
Melvin et al review the evidenced-based literature and make recommendations for the initial evaluation and management of open tibial shaft fractures. The time elapsed before antibiotic administration and adequate surgical debridement of all contamination are the only factors definitively shown to reduce infection and improve outcome. Traditional recommendations have suggested surgical debridement of open fractures occur within 6 hours of injury. However, there is no literature to support this time window. Certainly, open fractures should be addressed with urgency, but there is no evidence reporting a definitive time window. There is insufficient data to recommend gram negative coverage with gentamicin for all open fractures although this is a common practice. The addition of antibiotics to the irrigation solution has been shown to decrease bacterial load, but it has also demonstrated host tissue necrosis and delayed wound healing. There is not sufficient data to support its use over a castile soap solution or normal saline. Similarly, high pressure pulsatile lavage decreases bacterial load, but also seeds bacteria deeper within the soft tissues and harms host tissues. There is no evidence to support pulsatile lavage over gravity flow.
15. A 34-year-old female is involved in a motorcycle crash. She sustains a talus fracture with associated dislocation of the subtalar joint and maintained congruence of the tibiotalar and talonavicular joints as shown in Figure A. The fracture has healed and she now has symptomatic impingement of the dorsal surface of the talus on the distal tibia and restriction of ankle dorsiflexion. What is the most likely deformity causing these symptoms?

1. Combined varus and plantar malunion
2. Isolated varus malunion
3. Isolated valgus malunion
4. Isolated dorsal malunion
5. Isolated plantar malunion CORRECT ANSWER: 4
Figure A displays a Hawkins Type 2 talar neck fracture. (Hawkins classification shown in Illustration A). Malunion after inaccurate reduction of talar neck fractures has a reported incidence as high as 32%, with varus malunion occurring most frequently. Dorsal malunion can occur when the body is not properly derotated during reduction and the head fragment remains dorsal to the body. Dorsal malunion can lead to symptomatic impingement of the dorsal surface of the talus on the distal tibia and restriction of ankle dorsiflexion.
Canale found that 3 of the 4 patients with dorsal malunion improved following dorsal beak resection of the talar neck. Patients with varus malunion have decreased subtalar range of motion(especially eversion), walk with the foot internally rotated, and often complain of excessive weight bearing on the lateral border of the foot.
Level 4 evidence from Canale and Kelly found that varus malunion occurred most frequently in Hawkins type 2 fractures that had been treated in a closed manner.

16. What is the Injury Severity Score (ISS) for a patient with an open chest wound (Abbreviated Injury Scale, AIS=4), colon transection (AIS=4), femoral fracture (AIS=3), shoulder dislocation (AIS=2), and a thyroid gland contusion (AIS=1)
1/. 11
2/. 13
3/. 41
4/. 45
5/. 46
CORRECT ANSWER: 3
Injury Severity Score (ISS) scores are used to define injury severity for research purposes. The score is based on anatomic and severity indicies. Injury severity is based upon the AIS (abbreviated injury scale). AIS scores range from 1-6 where 1 is a minor laceration or contusion and 6 is a unsurvivable severe injury. An example of a 6 is a crushed head or brain whereas a 5 is a crushed larynx. Open pelvic fracture and femoral shaft fracture come in at 3 and large joint dislocations are a level 2 injury. ISS is the sum of the squares for the highest AIS grades in the three most severely injured ISS body regions. An ISS greater than 18 reflects multiply injured patients and that a transfer to a trauma center is indicated. So in this case, it would be (4x4)+(4x4)+(3x3)= 16+16+9=41. The AIS table can be found in Miller Review on page 699.
Recently, the New Injury Severity Score (NISS) has been developed and found by some authors (Lavoie et al & Balogh et al) to be more reliable indicator of
length of stay and ICU stay. The NISS differs from the ISS in that the NISS sums the squares of the 3 most significant injuries (even if they occur in the same anatomic area). The ISS sums the 3 most significant injuries in 3 separate anatomic areas.
17. A 42-year-old male sustains a closed, isolated ulna shaft fracture with 2mm displacement and 3 degrees valgus angulation. He is treated conservatively with early range of motion but presents at one year with a painful atrophic nonunion. What treatment is indicated at this time?
1. Dynamic splinting
2. Open autogenous cancellous bone grafting
3. Open reduction internal fixation with autogenous bone grafting
4. Closed reduction and percutaneous pinning
5. Use of an implantable ultrasound device
6. CORRECT ANSWER: 3
Appropriate treatment of an atrophic nonunion of the ulna includes open reduction and internal fixation with autogenous bone grafting. The atrophic nature of the nonunion reveals that biology, and not necessarily stability, is the major issue of the nonunion. The referenced article by Ring et al reviews a case series of these patients and found that even in the face of significant preoperative bone resorption, good clinical outcomes and union rate is possible with open plating and grafting. The article by Street reviews intramedullary nailing/pinning of the forearm, and found a 7% nonunion rate with this technique.
18. A 62-year-old man falls on his porch and sustains an elbow injury. A radiograph is provided in Figure A. Which of the following is the best treatment?

1. Closed reduction and long arm casting
2. Early motion with a hinged elbow brace
3. Open reduction internal fixation with a tension band construct
4. Open reduction internal fixation with a plate
5. Fragment excision and advancement of the triceps tendon CORRECT ANSWER: 4
The radiograph shows an olecranon fracture with articular comminution and depression of a large intra-articular fragment. This pattern is best treated with plate fixation to support the articular reduction.
Bailey et al reviewed 25 cases of olecranon fractures (simple and comminuted fracture patterns) treated with plate fixation. All 25 went on to union. There were no major complications reported. Twenty percent of patients underwent hardware removal at a later date for prominence.
Hak et al review the treatment options available for olecranon fractures. Simple intra-articular fractures without comminution are suitable for tension band fixation. Comminution of the articular surface is an indication for plate fixation and may benefit from bone graft to support depressed articular segments. Osteoporotic patients or fractures with severe comminution may do better with fragment excision and advancement of the triceps.
19. When viewing pelvic injury radiographs, which of the following describes the findings diagnostic of an isolated transverse acetabular fracture?
1. Fracture line crossing the acetabulum with disruption of the iliopectineal and ilioischial lines
2. Disruption of the iliopectineal and ilioischial lines, with extension into the iliac wing and obturator ring
3. Disruption of the iliopectineal and ilioischial lines, with extension into the obturator ring
4. Isolated disruption of the iliopectineal line, with an intact ilioischial ine
5. Isolated disruption of the ilioischial line, with an intact iliopectineal ine CORRECT ANSWER: 1
Transverse acetabular fractures separate the innominate bone into two fragments, the superior iliac and the inferior ischiopubic, by a single fracture line that crosses the acetabulum horizontally. The iliopectineal and ilioischial lines are disrupted on the AP pelvis radiograph. Axial CT scan of this fracture pattern at the level of the dome will show a vertical anterior to posterior fracture line. Illustrations A-C show AP and Judet pelvic radiographs of a transverse fracture. Illustration D demonstrates the axial CT appearance of this fracture type. Answer choice 2 is describing a both column injury or anterior column posterior hemitransverse, and answer choice 3 describes a T-type fracture pattern. Answer choices 4 and 5 describe an anterior column and posterior column injury respectively. Judet et al provide one of the first comprehensive reviews on acetabular surgical approaches, fracture types, and radiographic anatomy. Illustration E demonstrates the acetabular classification scheme developed by Judet.

20. A patient undergoes the treatment seen in Figure A for a displaced intertrochanteric femoral fracture. With use of this construct, a starting point 3 mm anterior to the center of the piriformis fossa has which of the following benefits?

1. Improved placement of screws through the nail into the femoral head
2. Decreased risk of varus alignment
3. Decreased risk of joint penetration
4. Decreased risk of avascular necrosis of femoral head
5. Decreased risk of iatrogenic proximal femur fracture CORRECT ANSWER: 1
Figure A shows an intertrochanteric fracture treated with a cephalomedullary device. A starting point slightly anterior to the piriformis fossa (starting point for standard antegrade femoral nail) has the benefit of improved placement of screws through the nail and into the femoral head. This is due to the fact that the hip is anteverted and the femoral neck arises from the anterior portion of the proximal femur. Therefore, by moving the nail anterior, that will increase the distance between the head screw and the posterior cortex of the neck and lead to a “straight” shot into the center of the femoral head.
Johnson et al investigated the effect of starting hole position, fracture component length, reamed diameter, and nail type on the potential for femoral bursting and fracture instability. They found the most significant factor in the proximal femoral component was found to be the position of the starting hole.
They found excessive anterior displacement greater than 6 mm from the neutral axis of the medullary canal consistently caused high hoop stresses at the level of the fracture, which can increase the possibility of iatrogenic fracture. Posterior starting points increase the risk of possible distal femur anterior cortex impingement/fracture.
Ostrum et al showed that lateral starting points should be avoided in order to avoid varus reduction when using a trochanteric antegrade nail in subtrochanteric fractures. They recommended a slightly medial starting point.
21. An 11-year-old child has a tibia-fibula fracture following a fall from a swing. The fracture is reduced and placed in a long leg splint in the emergency room. What is considered the earliest sign or symptom of a developing compartment syndrome of the leg?
1. pain out of proportion to injury
2. pale appearance of the foot
3. loss of the ability to move the toes
4. decreased sensation in the foot
5. decreased pulses in the foot CORRECT ANSWER: 1
The Willis reference states “the single most important symptom of impending compartment syndrome is pain out of proportion to the injury." This symptom requires a conscious patient. Most children requiring a reduction for a displaced upper or lower extremity fracture will become comfortable soon after the reduction has been completed. Children requiring frequent analgesia or complaining loudly about pain should be examined very carefully for possible compartment syndrome.” The key wording in this question is “earliest indicator”. Pulselessness, paralysis, pallor, and parasthesias are all late indicators.
The Willis article also lists the most reliable signs of a developing compartment syndrome as severe pain with passive stretching of the involved compartment, pain with palpation of the involved compartment, sensory disturbances
22. When discussing treatment options with a 35-year-old healthy male with an isolated, closed tibial shaft fracture, the surgeon should inform him that in comparison to closed treatment, the advantages of intramedullary nail fixation include all of the following EXCEPT?
1. Quicker time to union
2. Decreased risk of malunion
3. Decreased risk of compartment syndrome
4. Decreased risk of shortening
5. Quicker return to work CORRECT ANSWER: 3
All of the answer choices are correct except #3. Intramedullary nailing can increase the risk of compartment syndrome.
In a study of 94 tibial fractures, Finkemeier reported 10 (11%) had compartment syndromes. Three of the 10 patients developed the compartment syndrome postoperatively.
In comparing IM nailing to non-op, Bone et al showed that IM nailing had a shorter time to union (mean, 18 vs 26 weeks; p = 0.02), lower non-union rate (2% vs 10%), decreased incidence of shortening (2% vs 27%), and quicker return to work (mean, 4 vs 6.5 months), but no difference in compartment syndrome (0% in both groups).
The classic article cited by Sarmiento el al. reported that closed treatment with use of a prefabricated functional below-the-knee brace was effective in a study of 1000 closed diaphyseal fractures of the tibia with an incidence of nonunion of only 1.1%. However, those authors had very strict criteria for use of the fracture-brace (exclusion criteria included intact fibula and tibial shortening
>2cm).
23. A 58-year-old man underwent distal radius ORIF with a volar locking plate yesterday. Preoperatively, he reported some mild sensory disturbances in the volar thumb and index finger, but had 2-point discrimination of 6mm in each finger. Now, he complains of worsening hand pain and sensory disturbances in his volar thumb and index finger. Two-point discrimination is now >10mm in these fingers. Radiographs show a well-fixed fracture in good alignment. What is the most appropriate treatment at this time?
1. Strict elevation
2. Removal of hardware
3. Immediate carpal tunnel release
4. Carpal tunnel release if no resolution at 6-12 weeks
5. Trial of night splinting CORRECT ANSWER: 3
This patient had mild median parasthesias preoperatively that have significantly worsened postoperatively. Immediate carpal tunnel release is the most appropriate next step in treatment.
Mack et al reported on ten cases of acute carpal tunnel syndrome (ACTS) and six cases of nerve contusion in patients with acute median neuropathy associated with blunt wrist trauma. The patients with ACTS initially had normal sensation and subsequently developed objective sensory loss (2-point discrimination greater than 15 mm) in the median nerve distribution associated with severe wrist pain. In contrast, patients with nerve contusion injuries had immediate sensory loss and symptoms were nonprogressive. Four of five patients with ACTS who underwent carpal tunnel release within 40 hours of the onset of numbness had normal 2-point discrimination within 96 hours.
Neuropathy, secondary to nerve contusion without coexisting ACTS, may be treated initially by observation.
Ford et al reported of five cases of ACTS. Four with delayed treatment had poor outcomes while the one patient with early CTR had full recovery. All patients with ACTS had increasing and severe pain in the wrist with parasthesia and impaired sensation in the median distribuation. These symptoms initially weren’t present after wrist trauma, but developed rapidly in the next few hours.
24. A 20-year-old man falls from his bicycle. He is going to be scheduled for open reduction internal fixation. What best describes the injury shown in Figure A and B?

1. Coronoid fracture
2. Capitellum fracture with extension into the trochlea
3. Radial head and capitellum fracture
4. Isolated capitellum fracture
5. Trochlea fracture CORRECT ANSWER: 2
The radiographs shows a coronal shear fracture of the capitellum with extension into the trochlea, which would be classified as a Type IV fracture under the Bryan and Morrey classification system which was modified by McKee to include this specific injury. The lateral radiograph in Figure B and Illustration A is an example of the "double arc" sign representing an injury to both the trochlea and capitellum. The treatment of choice for a displaced Type IV fracture is open reduction internal fixation.
Dushuttle et al demonstrated that absence of the capitellum did not lead to valgus instability unless the medial collateral ligament was injured, suggesting that excision of highly comminuted fractures could be performed.
The reference by Grantham et al looked at a series of capitellum fractures and recommended the choice of treatment should be selective and individualized
depending on age, character of the bone, and type of fracture.
McKee et al in their case review described this coronal injury pattern and their results for ORIF of these fractures.

25. An 85-year-old woman falls and injures her elbow in her non- dominant arm. Radiographs are shown in Figure A and B. She also suffers from severe osteoporosis, lives independently, and is a low- level community ambulator. Which of the following is the most appropriate treatment?

1. Hinged elbow brace
2. Olecranon osteotomy, articular ORIF, locked lateral plating
3. Triceps-splitting approach with double plate fixation
4. Total elbow arthroplasty
5. Casting for 4 weeks then ROM CORRECT ANSWER: 4
Total elbow arthroplasty (TEA) is ideal for treating comminuted osteoporotic fractures of the distal humerus in low demand elderly patients. Outcomes are good to excellent with quick return of stability and functional motion but with carrying weight restriction of 5 lbs. ORIF would be the best choice for younger individuals with better bone quality.
Cobb described the outcomes of 21 total elbow arthroplasties in elderly patients all of which had good or excellent results without evidence of component loosening. The mean motion was 25 to 130 degrees. Complications included fracture of the ulnar component in one patient after another fall, ulnar neurapraxia in three, and reflex sympathetic dystrophy in one.
McKee et al. performed a randomized controlled study of TEA versus fixation and found that TEA for the treatment of comminuted intra-articular distal humeral fractures resulted in more predictable and improved 2-year functional outcomes compared with ORIF. They also found that although elderly patients with this injury have an increased baseline DASH score, they appear to accommodate to objective limitations in function with time.
Frankle et al. retrospectively compared TEA to plate fixation for distal humerus fractures in the elderly and found a significant improvement in outcomes and revision rates with TEA as compared to plate fixation. The differences were seen most in women with associated comorbidities, such as rheumatoid arthritis, osteoporosis, and conditions requiring the use of systemic steroids.
26. Coupled with reduction of the syndesmosis, which of the following interventions is most important when surgically addressing the ankle malunion shown in Figure A?

1. Placement of an osteochondral allograft
2. Fibular lengthening osteotomy
3. Calcaneofibular ligament release
4. Medial malleolar shortening osteotomy
5. Deltoid ligament imbrication CORRECT ANSWER: 2
Late correction with a corrective osteotomy of a fibular malunion associated with diastasis of the ankle mortise (Illustrations A and B) is an effective means of salvaging function in a joint otherwise destined to be stiff and painful.
The referenced study by Offierski et al reports that the factors that determined the success of the revision were the duration of the malunion, the quality of the reduction achieved, and the condition of the articular cartilage at the time of revision.
The referenced study by Chao et al reported that the fibular lengthening osteotomy was crucial in regaining the anatomy and stability of the ankle mortise.
The referenced study by Weber et al is a review of the technique of such an osteotomy, with commentary regarding its clinical success even if mild degenerative changes are seen. They also note that no differences are seen in outcomes between oblique and step-cut osteotomies.
The referenced study by Weber and Simpson is a case series of corrective
lengthening osteotomies after malunited ankle fractures. They report that a lengthening and/or rotational osteotomy of a malunited fibula is successful in preventing further ankle arthrosis if no more than minimal degenerative radiographic changes are seen.

27. All of the following implants offer adequate fracture fixation of the injury shown in Figure A EXCEPT:

1. Trochanteric entry point cephalomedullary nail
2. Piriformis fossa entry point cephalomedullary nail
3. Dynamic hip screw
4. Fixed angle blade plate
5. 95 degree dynamic condylar screw CORRECT ANSWER: 3
Currently, cephalomedullary nails are used widely for reverse obliquity fractures because they limit medialization of the shaft fragment unlike sliding hip screws.
The Haidukewych et al study quoted demonstrated the superiority of fixed angle devices such as blade-plates or dynamic condylar screws over the sliding (or dynamic) hip screws. Reverse obliquity intertrochanteric fractures of the femur are recognized as biomechanically different from standard intertrochanteric fractures. The rate of failure of internal fixation for this fracture pattern was higher than the rates in most reports of internal fixation of intertrochanteric fractures devices.
28. A 27-year-old woman gives birth by normal spontaneous vaginal delivery. Two weeks after delivery she reports anterior pelvic pain and a radiograph is obtained (Figure A). What is the next step in management?

1. Pelvic external fixator
2. Open reduction and reconstruction plating of the symphysis
3. Protected weightbearing and binder as needed and observation
4. Open reduction and wiring of the symphysis
5. Symphysiotomy CORRECT ANSWER: 3
The clinical presentation and radiograph is consistent with an open-book type parturition-induced pelvic dislocation.
The case series by Kharrazi et al reports four patients treated with open-book type parturition-induced pelvic dislocations. The authors advocate nonoperative treatment with bedrest and a properly positioned pelvic binder in the acute setting for patients with a postpartum symphyseal diastasis less than 4.0 cm.
All four patients had significant symptoms and radiographic widening (anterior splaying) of the sacroiliac joints. The three patients who had presented acutely were treated with closed reduction and application of a pelvic binder, while two had closed reduction of their pelvic dislocation while anesthetized with a general anesthetic. At latest follow-up the diastasis at the pubic symphysis reduced to an average of 1.7 cm (range: 1.5-2.0) The authors advocate nonoperative treatment with bedrest and a properly positioned pelvic binder in the acute setting for patients with a symphyseal diastasis of 4.0 cm of less and operative treatment for diastasis greater than 4cm.
29. A 30-year-old patient sustains a comminuted tibia fracture and is treated with minimally invasive plating, shown in Figure A. The patient returns to the office 2 weeks after the surgery and reports persistent numbness over most of the dorsum of the foot, but motor exam is normal. What is the most likely explanation?

1. unrecognized compartment syndrome
2. common peroneal nerve injury
3. superficial peroneal nerve injury
4. sural nerve injury
5. tibial nerve injury CORRECT ANSWER: 3
Superficial peroneal nerve (SPN) injury is a known complication of percutaneous plating of proximal tibial fractures with the LISS system as seen in Figure A.
The Less Invasive Stabilization System (LISS) is a minimally invasive implant that uses indirect fracture reduction techniques. When using the LISS system, percutaneous screw placement increases the risk of injury to nearby structures because they are not necessarily visualized. The superficial peroneal nerve exits the superficial fascia of the leg approximately 8 cm above the tip of the
lateral malleolus. The nerve then travels from posterior to anterior in the vicinity of the distal aspect of the 13-hole proximal tibia LISS plate (near holes 11-13). In a patient of shorter stature, the nerve could cross the distal portion of a 9-hole plate.
Deangelis et al. performed a cadaveric study using Less Invasive Stabilization System (LISS) plates and found that the average distance from the SPN to the center of holes 11, 12, and 13 was 10.0 mm, 6.8 mm, and 2.7 mm respectively. They recommended using a larger incision and careful dissection down to the plate in this region to minimize the risk of damage to the nerve.
Cole et al. retrospectively reviewed 77 tibia fractures treated with LISS and found that 91% healed without complication. In their cohort, there were no superficial peroneal nerve palsies and one deep peroneal nerve palsy.
Figure A demonstrates AP and lateral x-rays of a tibial shaft fracture treated with a LISS plate.
Incorrect Answers:
A: compartment syndrome would have demonstrated pain out of proportion which the patient never complains of
B, D, and E are all less likely to be injured with LISS plate application than the superficial peroneal nerve.
30. A 20-year-old male is involved in a motorcycle accident and presents with the injuries shown in Figures A-F. The left ankle injury is open medially, with a clean 3cm laceration, and the right femur and tibia are closed. He has no visceral or head injury, and is hemodynamically stable. He is cleared to go to the operating room. Without taking into account order of fixation, how should his injuries be treated?

1. Retrograde nailing of the femur, intramedullary nailing of the tibia, ankle debridement and casting
2. External fixation of the femur, intramedullary nailing of the tibia, ankle debridement and ORIF
3. Antegrade nailing of the femur, external fixation of the tibia and ankle after debridement
4. Retrograde nailing of the femur, intramedullary nailing of the tibia, ankle debridement and ORIF
5. External fixation of the tibia and femur, and ankle debridement and external fixation
CORRECT ANSWER: 4
The patient is hemodynamically stable, has no other injuries, and is medically cleared for the operating room. Therefore, there is no need for damage control fixation.
Ostrum et al conducted a review of 20 patients treated by percutaneous stabilization for ipsilateral fractures of the femur and tibial shafts. All patients were treated with a retrograde femoral intramedullary nail and a small diameter tibial intramedullary nail through a 4-cm medial parapatellar tendon incision. Six of the tibial shaft fractures required revision surgery, and no patients reported signs or symptoms of knee pain. Ostrum concluded that although this is an excellent treatment option for patients with ipsilateral femoral and tibial shaft fractures, the tibial fracture complication rates remain high.
Franklin et al reviewed 38 cases of open ankle fractures that had been treated with immediate splinting, antibiotics, debridement, and internal fixation. They found that all of the fractures united, but three patients required subsequent ankle fusion because of cartilage damage noted at the initial operation. Of the thirty-five ankles with complete follow-up, the functional result was excellent in twenty-six and fair or poor in nine.
31. A 33-year-old male is involved in a motor vehicle accident and suffers a right pilon fracture. Which of the bone fragments labeled on the distal tibia in the axial CT scan shown in Figure A is attached to the posterior inferior tibiofibular ligament?**

1. A
2. B
3. C and B
4. D
5. A and D **CORRECT ANSWER: 4
Figure A is an axial CT scan slice of an intra-articular distal tibia fracture. The bands of the posterior tibiofibular ligament pass obliquely from the fibula to the posterolateral aspect of the distal tibia. The ligaments of the ankle often remain intact after a pilon fracture producing the major fracture segments consisting of posterolateral or Volkmann's fragment (labeled D), the anterolateral or Chaput fragment (labeled B), and the medial fragment (labeled C). The fibula is labeled A. Any surgical approach taken to treat this injuries should respect these attachments.
Michelson reviews the important role of ankle ligamentous anatomy in his study on rotational ankle fractures.
Hermans et al review the anatomy of the ankle syndesmosis and state that stress on the posterior inferior tibiofibular ligament results more often in a posterior malleolus avulsion fracture than in a rupture of the ligament. They go on to state that with direct reduction of the posterior malleolus avulsion fracture, the syndesmosis can often be stabilized.
Illustration A shows the posterior inferior tibiofibular ligament highlighted in red on MRI imaging in a LEFT ankle (the CT image in the question is of a RIGHT ankle).

32. What structure has been described as having a risk of injury with retractor placement on the sacrum during combined acetabular-pelvic ring surgery using the Stoppa approach with a lateral window?
1. External iliac artery
2. Pudendal nerve
3. Corona mortis
4. L5 nerve root
5. Ilioinguinal nerve CORRECT ANSWER: 4
Care must be taken when placing a retractor on the anterior aspect of the sacrum, as the L4 and L5 nerve roots are both at risk.
Illustration A shows a diagram of the lumbosacral plexus, indicating the proximity of the L4 and L5 nerve roots to the anterior sacrum and SI joint.
The first referenced article by Atlihan et al reported on the anatomy of the anterior sacroiliac joint and reported that the L4 nerve root is within 1 cm of the joint at its inferior margin.
The second article by Ebraheim et al found that the L4 and L5 nerve roots are 10 mm medial to the sacroiliac joint at the pelvic brim.

33. A 24-year-old man who sustained a gunshot wound to the abdomen ten hours earlier was brought to the emergency department. On physical examination he was found to have 4 of 5 weakness in his bilateral lower extremities. Radiographs are shown in Figure A. Computed tomography of the lumbar spine showed retained missile in the vertebral body and paraspinal soft tissues, but not within the spinal canal. His FAST was positive and he underwent an emergent exploratory laparotomy where an injury to the cecum was identified and treated. Management should now include which of the following?

1. Bullet fragment removal from a transabdominal approach
2. Bullet fragment removal from a retroperitoneal approach
3. Broad-spectrum oral antibiotics for 3-5 days
4. Broad-spectrum intravenous antibiotics for 7-14 days
5. IV methylprednisolone at 5.4mg/kg/h for 48 hours CORRECT ANSWER: 4**
The patient in the scenario has a GSW to the lumbar spine with neurologic deficits but without a retained missile in the spinal canal. In patients with visceral injury, the treatment is broad-spectrum antibiotic coverage for 7 days.
Kumar et al reviewed 33 patients with GSW to the spine and associated visceral injuries. They concluded that 7 days of antibiotic treatment targeted at colonic flora is the treatment of choice.
Roffi et al reviewed 51 low-velocity GSW that perforated the viscus prior to the spine. They concluded that broad spectrum antibiotics combined with bedrest significantly reduced the risk of spinal or paraspinal infections. Furthermore, bullet removal had no effect on infection rates.
Velmahos et al followed 153 GSW to the spine for 28 months. While rates of sepsis were higher in the lumbar spine than cervical and thoracic spine, they concluded that retained bullets do not increase the likelihood of septic complications.
Incorrect Answers:
Answer 1 & 2: Indications for surgery with a GSW to the lumbar spine include

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Flexion-distraction injuries of the spine are frequently associated with concomitant intraabdominal injuries including hollow viscus injuries, mesenteric tears, and liver and spleen injuries. This is especially evident in seat-belt related motor vehicle collisions. Often patients with seat-belt injuries will have abdominal bruising or contusions that should be looked for on initial evaluation. General surgical or trauma team evaluation includes abdominal evaluation typically with CT evaluation of the abdomen or peritoneal lavage. Treatment of the spinal injury especially in a neurologically intact patient. should be delayed until proper evaluation for abdominal injuries with this fracture pattern.

This patient has a classic presentation of postmeniscectomy medial compartment arthritis. The appropriate diagnostic study is weight-bearing radiographs to confirm the diagnosis. An MRI scan will reveal medial compartment arthritis but will not provide information about alignment. A CT scan would be appropriate to detect an occult fracture; however, this condition is not suspected in this clinical scenario. Ultrasonography can provide information about fluid collection around the knee or a deep vein thrombosis; however, these conditions also are not suspected in this clinical scenario. Because the patient has a correctable deformity (gaps 3 mm with valgus stress), and his symptoms are localized to the involved compartment, a trial of a medial unloader brace is appropriate both diagnostically and therapeutically. If unloading the medial compartment resolves the patient’s symptoms, he would be an excellent candidate for an osteotomy. An MRI scan may be obtained to evaluate ligamentous integrity or to evaluate degenerative involvement of the lateral and patellofemoral compartment for presurgical planning of an osteotomy; however, the integrity of the medial meniscus has no clinical importance in a patient with severe medial compartment arthritis. A repeat corticosteroid injection is not indicated within 1 month of his last injection, and referral to pain management is not appropriate with other options available to help this patient. A VPHTO is the appropriate intervention considering the patient’s young age, high-functional occupation, examination, radiographic findings, and response to medial unloader bracing. A revision knee arthroscopy would be appropriate for a recurrent medial meniscus tear, but not appropriate in a patient with severe medial compartment arthritis. The patient’s young age and high functional requirements are contraindications to TKA. The presence of severe arthritis is a contraindication to medial meniscus transplant. The patient is a candidate for a VPHTO. The technical options include a medial opening-wedge or a lateral closing-wedge osteotomy. Both techniques have advantages and disadvantages; however, a medial opening-wedge osteotomy is contraindicated in a smoker because of concern for nonunion. As a result, current smoking history is the only factor listed that would influence the technique used. The history of prior arthroscopy has no relevance in the decision about which type of osteotomy is appropriate. Normal BMI is between 18.5 and 24.9, so this patient’s BMI is considered normal and would not affect the surgical technique (if this patient were obese, a lateral closing-wedge osteotomy would be considered, but this is controversial). His age of 40 years is an indication for HTO but does not influence technique.

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The patient has an epidural abscess following a dental procedure. The epidural abscess spans from C2 to the upper thoracic spine. He has severe neck pain, neurologic changes, and elevated laboratory markers. Sang and associates have demonstrated that, in patients older than 65 years with a methicillin-resistant Staphylococcus aureus infection, a history of diabetes, and neurologic deficits, nonsurgical management has a 99% chance of failure. Prompt surgical decompression to evacuate the abscess followed by antibiotic treatment is the best method of treatment for this patient.

Individuals afflected by Polandâs anomaly exhibit unilateral symbrachydactyly (simple syndactyly with short or absent middle phalanges), absent sternocostal head of the pectoralis major, and hypoplasia of the ipsilateral breast and nipple. Apertâs syndrome, the other syndrome most commonly associated with syndactyly, is characterized by complex acrosyndactyly of the hands and feet associated with premature closure of the cranial sutures. The features of the VATER association include Verterbral anomalies and or Ventricular septal defect, Anal atresia, T-E fistula, and Renal anomalies and or Radial dysplasia (pre-axial syndactyly is a possible but inconsistent feature). Individuals with Marfan syndrome exhibit arachnodactyly in addition to retinal detachments, lens subluxations, aortic dilatations/aneurysms, and tall stature with long, thin limbs. Hand manifestations of Down syndrome include short metacarpals and phalanges, clinodactyly, and abnormal crease patterns, but not syndactyly. Hunter syndrome (mucopolysaccharidosis II) is marked by stiffened joints and the development of a clawhand, but not by syndactyly.

THA has proven durable and reliable for pain relief and improving function for patients with end-stage arthritis. Appropriate bearing selection is critical to minimize wear and hip complications. A metal-on- metal articulation is associated with excellent wear rates in vitro. With its capacity to offer a low wear rate with large femoral heads, it is an attractive bearing choice for THA. However, local soft-tissue reactions, pseudotumors, and potential systemic reactions including renal failure, cardiomyopathy, carcinogenesis, and potential teratogenesis with potential transfer of metal ions across the placental barrier make metal-on-metal bearings less desirable and relatively contraindicated for younger women of child- bearing age. The workup of a painful metal-on-metal hip arthroplasty necessitates a systematic approach. Several algorithms have been proposed. Routine laboratory studies including sedimentation rate, CRP, and serum cobalt and chromium ion levels should be obtained for all patients with pain. Advanced imaging including MARS MRI should be performed to evaluate for the presence of fluid collections, pseudotumors, and abductor mechanism destruction. Infection can coexist with metal-on-metal reactions, so, when indicated (if the CRP level is elevated), a hip arthrocentesis should be obtained. However, in this setting, a manual cell count and differential should be obtained because an automated cell counter may provide falsely elevated cellcounts. The results of revision surgery for a failed metal-on-metal hip prosthesis can be variable. The amount of local tissue destruction and the integrity of the hip abductor mechanism can greatly influence outcomes. Instability is the most common complication following revision of failed metal-on-metal hip replacements.

Osteochondritis dissecans of the capitellum is a painful condition that affects immature athletes who undergo repetitive compression of the radiocapitellar joint. Management is based primarily on the integrity of the articular cartilage surface and the stability of the lesion. Nonsurgical treatment is typically selected for patients
with early-grade, stable lesions, and it involves activity modification with cessation of sports participation. The duration of activity modification is dictated by symptoms, with 3 to 6 weeks of rest followed by return to sport in 3 to 6 months commonly used as a guideline. Strengthening and stretching exercises are commonly incorporated after the pain has subsided. Surgical intervention or corticosteroid injection would not be first-line treatment.

Usage of an anterior starting point that is too anterior leads to creation of significant hoop stresses in the proximal segment, potentially leading to iatrogenic fracture of the proximal segment. The referenced study by Johnson et al reviews the topic of femoral bursting and he notes that even shifting 6mm too far anteriorly can lead to proximal femoral fracture creation. He also reported that overreaming the canal by at least 0.5mm diameter is necessary to decrease hoop stresses throughout the femur, likely due to a mismatch in the radius of curvature of the femur and intramedullary nail.

66
Bone marrow aspirate has been shown to have higher concentrations of IL-1ra versus both leukocyte-rich and leukocyte-poor platelet-rich plasma. IL-1 is a potent proinflammatory cytokine. IL-1ra blocks binding of IL-1 to its receptor and therefore, serves an anti-inflammatory role.

Supervised exercise therapy with static or dynamic progressive elbow splinting over a 6 month period has shown to have the greatest improvement on DASH scores and functional range of motion (ROM) in patients with post-traumatic elbow stiffness.
The goal of treatment in post-traumatic stiffness is to restore a functional range of elbow motion (30° to 130°). Non-operative modalities are considered the first-line of treatment. Aggressive physical therapy has traditionally been advocated. However, the use of static or dynamic progressive elbow splinting with a turnbuckle has shown to provide better functional outcomes. Treatment is usually maintained over a period of 6-12 months. Surgery is considered when nonoperative therapy fails.
Gelinas et al. treated 22 patients with an elbow contracture using a static progressive turnbuckle splint for a mean of 4.5 +/- 1.8 months. The mean range of motion improved from 32 - 108, to 26 - 127 degrees (p = 0.0001). Their results suggest that static progressive splinting is an effective modality for postoperative elbow stiffness.
Lindenhovius et al. randomized sixty-six patients with post-traumatic elbow stiffness into static progressive elbow splint therapy or dynamic elbow splinting over a 12 month period. There was no significant difference in outcomes between treatment modalities. ROM increased by 40° vs. 39° at six months, respectively. DASH scores improved from 50 vs 45 at enrollment to 32 vs. 25 at six months, respectively.
Illustration A shows an image of a static progressive elbow splint.
Incorrect Answers:
Answer 1: Intra-articular and extra-capsular cortisone injection have not shown to improve ROM in this scenario.
Answer 2: Closed manipulation under anesthesia may worsen elbow stiffness and cause intra-articular damage. Manipulation causes significant swelling and inflammation with tearing of soft tissues, causing hemarthrosis and additional fibrosis in the joint.
Answer 3: Aggressive home exercise program are not effective when formal physiotherapy has failed.
Answer 4: Continuous passive motion machines have a limited role in treating established contractures. They do not seem to improve end-range mobility in these patients.

Fractures of the volar base of the middle phalanx are very common injuries. After a congruent reduction, stability of the PIP joint is the most important treatment consideration. If the joint is stable, simple immobilization for comfort followed by early protected motion is adequate treatment. Clinical and cadaveric studies have demonstrated that injuries involving 20% of the volar articular surface of the middle phalanx are uniformly stable, whereas compromise of 60% of the articular surface leads to uniform instability. The threshold at which dorsal subluxation becomes problematic appears to be fractures involving 40% or more of the articular surface. Injuries of this pattern need to be examined carefully for evidence of instability and treated accordingly.
Regarding acute treatment options, extension block splinting is not recommended because of the inherent instability associated with this injury. The case in question involves a young patient; therefore, the use of primary implant arthroplasty is not the treatment of choice. In the ring finger, motion is important for power grip, so arthrodesis should be avoided if a reasonable alternative exists. Volar plate arthroplasty, although an option, has generated disappointing results for longterm joint motion and stability. Hemi-hamate arthroplasty has been described as a useful and predictable method with which to reconstruct the volar base of the middle phalanx in cases in which comminution prevents direct internal fixation. When performing hemi-hamate arthroplasty, a free osteocartilaginous graft is harvested from the dorsal and distal surface of the hamate. Using the portion of the hamate that articulates with the concave contour of the fourth to fifth
carpometacarpal joints provides a midline ridge that approximates that of the native middle phalangeal base.
Reconstruction with hemi-hamate autograft can restore the concavity of the middle phalangeal base in the anteroposterior direction. This concavity provides a volar buttress-to-dorsal subluxation of the middle phalanx. Hemi-hamate grafting is performed to the middle phalanx, not the proximal phalanx. Collateral ligament integrity is generally sacrificed to achieve adequate exposure to perform this procedure. It is not generally necessary to perform formal collateral ligament repair or reconstruction once adequate bony reconstruction is achieved. Volar plate integrity is not the primary aim of hemi-hamate arthroplasty; however, the volar plate is repaired to the middle phalangeal insertion of the collateral ligaments at the conclusion of the procedure.
Arthrodesis of the small joints of the hand is a predictable and effective method with which to control pain and instability when preservation of functional motion is not possible. This procedure offers a lower complication rate than prosthetic arthroplasty and yields satisfactory functional results. The trend is to favor arthrodesis for the radial digits and arthroplasty for the ulnar digits because of the importance of PIP flexion in the ulnar digits for power grip. Another consideration is age; younger, more active patients are more prone to eventual prosthetic failure and recurrence of digital deformity. A variety of recommendations have been made by various authors regarding the optimal position for PIP arthrodesis. The consensus is that approximately 40 degrees of flexion is optimal for the ring finger PIP joint.
RECOMMENDED READINGS
1. [Tyser AR, Tsai MA, Parks BG, Means KR Jr. Stability of acute dorsal fracture dislocations of the proximal interphalangeal joint: a biomechanical study. J Hand Surg Am. 2014 Jan;39(1):13-8. doi: 10.1016/j.jhsa.2013.09.025. Epub 2013 Nov 6. PubMed PMID: 24211175.](http://www.ncbi.nlm.nih.gov/pubmed/24211175)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/24211175)
2. [Williams RM, Kiefhaber TR, Sommerkamp TG, Stern PJ. Treatment of unstable dorsal proximal interphalangeal fracture/dislocations using a hemi-hamate autograft. J Hand Surg Am. 2003 Sep;28(5):856-65. PubMed PMID: 14507519. ](http://www.ncbi.nlm.nih.gov/pubmed/14507519)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/14507519)
3. [Capo JT, Hastings H 2nd, Choung E, Kinchelow T, Rossy W, Steinberg B. Hemicondylar hamate replacement arthroplasty for proximal interphalangeal joint fracture dislocations: an assessment of graft suitability. J Hand Surg Am. 2008 May-Jun;33(5):733-9. doi: 10.1016/j.jhsa.2008.01.012. PubMed PMID: 18590857. ](http://www.ncbi.nlm.nih.gov/pubmed/18590857)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/18590857)
4. Woodworth JA, McCullough MB, Grosland NM, Adams BD. Impact of simulated proximal interphalangeal arthrodeses of all fingers on hand function. J Hand Surg Am. 2006 Jul-Aug;31(6):940-
[6/. PubMed PMID: 16843153. ](http://www.ncbi.nlm.nih.gov/pubmed/16843153)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/16843153)

In a cadaver ligament sectioning study, the posterior capsular ligament was considered the most important structure for anterior-posterior stability of the sternoclavicular joint. The anterior capsular ligament also helps prevent anterior displacement but not to the same degree as the posterior ligament. The interclavicular ligament provides little support for anteroposterior translation.
REFERENCES: Spencer EE, Kuhn JE, Huston LJ, et al: Ligamentous restraints to anterior and posterior translation of the sternoclavicular joint. J Shoulder Elbow Surg 2002;11:43-47.
Rockwood CA Jr, Matsen FA III, Jobe CM: Gross Anatomy of the Shoulder. Philadelphia, PA, WB Saunders, 1998.

ACL tears are several times more common among women than men. Women who land from jumps in increased valgus and external rotation are at particularly increased risk for ACL tears. Women have smaller notch widths and a smaller ACL cross-sectional area than men, but these factors have not been definitively proven to increase risk for ACL tears.

Morton neuroma is a compressive neuropathy of the interdigital nerves of the forefoot that most commonly is noted in the third web space. Perineural fibrosis is commonly noted on microscopic examination of resected tissue. This accounts for the relatively higher failure rate of neuroma decompression by transection of the intermetatarsal ligament as opposed to resection. Wallerian degeneration is seen following axonal transection in the distal part of the nerve. Distal axonopathy is degeneration of the axon and myelin and is associated with "stocking-glove" distribution neuropathy. Segmental demyelination is characterized by breakdown of myelin with an intact axon
and is associated with lead poisoning and hereditary sensory motor neuropathy.
RECOMMENDED READINGS
[Akermark C, Crone H, Saartok T, Zuber Z. Plantar versus dorsal incision in the treatment of primary intermetatarsal Morton's neuroma. Foot Ankle Int. 2008 Feb;29(2):136-41. doi: 10.3113/FAI.2008.0136. PubMed PMID: 18315967.](http://www.ncbi.nlm.nih.gov/pubmed/18315967)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/18315967)
[Ha'Eri GB, Fornasier VL, Schatzker J. Morton's neuroma--pathogenesis and ultrastructure. Clin Orthop Relat Res. 1979 Jun;(141):256-9. PubMed PMID: 477115. ](http://www.ncbi.nlm.nih.gov/pubmed/477115)[View Abstract at](http://www.ncbi.nlm.nih.gov/pubmed/477115)[ ](http://www.ncbi.nlm.nih.gov/pubmed/477115)[PubMed](http://www.ncbi.nlm.nih.gov/pubmed/477115)
[Graham CE, Graham DM. Morton's neuroma: a microscopic evaluation. Foot Ankle. 1984 Nov-Dec;5(3):150-3. PubMed PMID: 6519606. ](http://www.ncbi.nlm.nih.gov/pubmed/6519606)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/6519606)

The elbow dislocates by a three-dimensional movement of supination and valgus during flexion. Additional trauma during reduction is minimized by recreating the deformity and reducing the elbow in supination. The actual maneuver includes full supination (actually hypersupination) of the elbow in a valgus position. This is followed by pushing the olecranon distally in line with the long axis of the ulna while swinging the elbow into varus, and then relaxing the supination torque. Postreduction stability is enhanced in pronation, except when the soft-tissue disruption is extensive.
REFERENCES: O’Driscoll SW: Elbow dislocations, in Morrey BF (ed): The Elbow and Its Disorders, ed 2. Philadelphia, PA, WB Saunders, 1993, p 414.
Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 345-354.

The hallmark for RSD or SMP is the presence of pain that is out of proportion to that expected for the degree of the injury. SMP often extends well beyond the involved area and is present in a nonanatomic distribution. The pain is frequently described as a burning sensation, with extreme sensitivity to light touch. Joint stiffness can be present but is a nonspecific finding. There may be cold intolerance, but this is not a cardinal symptom. Sweating actually may be increased. Osteopenia, if present, is a late finding.
REFERENCES: Lindenfeld TN, Bach BR Jr, Wojtys EM: Reflex sympathetic dystrophy and pain dysfunction in the lower extremity. Instr Course Lect 1997;46:261-268.
O’Brien SJ, Ngeow J, Gibney MA, Warren RF, Fealy S: Reflex sympathetic dystrophy of the knee: Causes, diagnosis, and treatment. Am J Sports Med 1995;23:655-659.

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The physical and radiographic findings are consistent with a diagnosis of osteogenesis imperfecta (OI). Approximately 90% of cases of OI are secondary to defects in the COLIA1 or COLIA2 genes, which affect the production of type 1 collagen. The incidence of OI is between 1 in 10,000 and 1 in 20,000. Type II collagen abnormalities have been associated with achondrogenesis type 2. Type IV abnormalities with Alport syndrome, and type X defects with Schmid metaphyseal chondrodysplasia.

This patient has a localized pelvic chondrosarcoma. Treatment is wide surgical resection. There is no defined role for chemotherapy or radiotherapy in the setting of conventional chondrosarcoma. Additionally, while intralesional treatment may be used for select low-grade extremity chondrosarcomas, it is not indicated for axial lesions. Treatment involving less than a wide surgical margin correlates with local recurrence.
RECOMMENDED READINGS
43. [Pring ME, Weber KL, Unni KK, Sim FH. Chondrosarcoma of the pelvis. A review of sixty-four cases. J Bone Joint Surg Am. 2001 Nov;83-A(11):1630-42. Review. PubMed PMID: 11701784. ](http://www.ncbi.nlm.nih.gov/pubmed/11701784)[View](http://www.ncbi.nlm.nih.gov/pubmed/11701784)[ ](http://www.ncbi.nlm.nih.gov/pubmed/11701784)[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/11701784)
44. [Mavrogenis AF, Angelini A, Drago G, Merlino B, Ruggieri P. Survival analysis of patients with chondrosarcomas of the pelvis. J Surg Oncol. 2013 Jul;108(1):19-27. doi: 10.1002/jso.23351. Epub 2013 May 16. PubMed PMID: 23681650.](http://www.ncbi.nlm.nih.gov/pubmed/23681650)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23681650)

The superior glenohumeral ligament identified as “A” in the figure functions primarily as a restraint to inferior glenohumeral translation of the adducted arm. The middle glenohumeral ligament is highly variable and pooly defined in up to 40% of the population and functions to restrain anterior translation of the externally rotated arm in the midrange of abduction. The anterior band of the inferior glenohumeral ligament is the primary restraint to anterior/inferior translation of the head with the shoulder abducted to 90 degrees and in maximum external rotation.
REFERENCES: Ticker JB, Bigliani LU, Soslowskiy LJ, et al: Inferior glenohumeral ligament: Geometric and strain-rate dependent properties. J Shoulder Elbow Surg 1996;5:269-279.
Owen MD, Kregel KC, Wall PT, Gisolfi CV: Effects of ingesting carbohydrate beverages during exercise in the heat. Med Sci Sports Exerc 1986;18:568-575.

Hip stability is augmented by thickened portions of the articular capsule. A sectioning study of the hip capsular ligaments identified the ischiofemoral ligament to have the most significant effect in limiting hip internal rotation in both extension and flexion. The strongest of the capsular ligaments is the iliofemoral ligament. The medial arm of the iliofemoral ligament provides the most significant restraint against anterior hip translation with hip extension and external rotation. The lateral arm of the iliofemoral ligament provides restriction to both internal and external rotation with the hip in extension. The pubofemoral ligament augments stability of the hip against external rotation in extension.
RECOMMENDED READINGS
1. Martin HD, Savage A, Braly BA, Palmer IJ, Beall DP, Kelly B. The function of the hip capsular ligaments: a quantitative report. Arthroscopy. 2008 Feb;24(2):188-95. doi: 10.1016/j.arthro.2007.08.024. Epub 2007 Nov 26. PubMed PMID: 18237703.
[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/18237703)
2. Wasielewski RC.The Hip. In: Callaghan J, Rosenberg A, Rubash H, The Adult Hip. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:53.
CLINICAL SITUATION FOR QUESTIONS 22 THROUGH 25
A 22-year-old man sustains an injury to his right knee in a motor vehicle collision. Figure 22a is the posterior stress radiograph of the involved knee, and Figure 22b is a selected MR image that identifies the injured structure.
A

B

This patient presents with HO 4 months after undergoing THA. Symptomatic HO may complicate nearly
7% of primary THA cases. Improvement in pain is expected within 6 months, and most patients will not need surgical treatment. Surgical excision may be warranted for symptomatic patients after full maturation of the HO, usually 6 to 18 months after the surgery. Patients can be followed with repeated serum alkaline phosphatase levels, which are elevated initially and should return to normal upon maturation of the HO. Alternatively, a bone scan can show decreased activity after the HO has matured. Twenty-five milligrams of indomethacin 3 times daily for 6 weeks or 1 dose of irradiation at 700 to 800 Gy is effective in the prevention of HO but not for the treatment of established HO.

Eighty percent of infantile digital fibromata appear before a child's first birthday. They are exclusive to the fingers and toes and are usually painless. Infantile digital fibromata are often small and the same color as the skin. On histological examination, intracytoplasmic inclusion bodies are present. Although benign, the fibromata are locally aggressive. They do not metastaaize, but recurrences after wide local excision are common. Surgery is indicated when deformity or contracture is imminent.

Proximal tibial metaphyseal fractures may result in late genu valgum as a result of asymmetric growth of the proximal tibia. These patients are best treated with observation because the deformity is likely to remodel. Osteotomy is not indicated and potentially will lead to recurrence. Stapling of the medial tibial physis is appropriate in patients who have a severe and progressive deformity.
REFERENCES: Cozen L: Knock-knee deformity in children: Congenital and acquired. Clin Orthop 1990;258:191-203.
Jackson DW, Cozen L: Genu valgum as a complication of proximal tibial metaphyseal fractures in children. J Bone Joint Surg Am 1971;53:1571-1578.
Brammar TJ, Rooker GD: Remodeling of valgus deformity secondary to proximal metaphyseal fracture of the tibia. Injury 1998;29:558-560.
Ogden JA, Ogden DA, Pugh L, et al: Tibia valga after proximal metaphyseal fractures in childhood: A normal biologic response. J Pediatr Orthop 1995;15:489-494.
Salter RB, Best TN: Pathogenesis of progressive valgus deformity following fractures of the proximal metaphyseal region of the tibia in young children. Instr Course Lect 1992;41:409-411.

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.