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

This patient sustained a posterior ankle fracture/dislocation. After closed reduction and splinting, the next best step should be to re-evaluate pulses.
With any dislocation, an immediate closed reduction should be performed. Though the initial vascular examination was abnormal in this case, the dislocation is contributing to this finding. This unique ankle fracture is known as the hyperplantarflexion variant. It is composed of a posterior tibial lip fracture with posterolateral and posteromedial fracture fragments separated by a vertical fracture line.
Gardner et al. review the hyperplantarflexion variant and found that the fracture of the posteromedial tibial rim was the main feature of this injury which is sustained by a hyperflexion mechanism. They also reported that posterior malleolus fractures are present in a majority of these injuries as well.
On MRI they determined that the deltoid and posterior tibiofibular ligaments were intact in all cases. They conclude, when treating these fractures with ORIF of the posteromedial and posterior fragments with antiglide fixation, excellent results were obtained.
Hinds et al. name the unique double cortical density at the inferomedial tibial metaphysis the "spur sign." They found the spur sign to be present in 79% of variant ankle fracture cases. They found the positive predictive value and negative predictive value to be 100% and 99%, respectively when this sign is present.
Figures A and B demonstrate the hyperplantarflexion variant ankle fracture. Illustration A demonstrates the spur sign, as indicated by the red arrow.
Incorrect Answers:
Answer 2: Vascular consultation may be obtained if the vascular exam is abnormal.
Answer 3: CT angiography may be obtained after closed reduction to aid in the diagnosis of vascular injury if the exam is abnormal after closed reduction.
Answer 4: A formal angiogram may be necessary if there is an abnormality in the vascular exam.
Answer 5: Surgical exploration and stabilization may eventually be necessary, but are not the next best step in treatment.

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

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The genitofemoral nerve is at risk at almost any level in the lateral transpsoas approach. The nerve provides sensory innervation to the anterior thigh and scrotum/labia. The ilioinguinal nerve provides sensory innervation to the mons pubis or labia in women and the upper scrotum in men. The femoral nerve is responsible for sensation to the anterior and medial aspects of the thigh, leg, and medial foot. It also provides innervation to knee extensor muscles. Prolonged decubitus positioning, especially with jackknife hyperextension, can cause stretching of the femoral nerve and transient weakness of the ipsilateral quadriceps.

- Continued observation

- hyperextension of the back.

With soft-tissue loss, local or free flap coverage may be necessary to treat exposed tendon and bone. However, a vacuum-assisted closure device is a good temporizing dressing. It prevents external contamination, reduces edema around the wound, increases oxygen tension in the wound, and promotes the formation of granulation tissue. The use of this negative pressure device has been described in both acute traumatic and in chronic wound scenarios. If sufficient granulation tissue forms, closure may be by split graft, avoiding a more complex coverage procedure. Immediate skin grafting over the exposed anterior tibial tendon and tibia would have a low likelihood of success. Dressing changes with sulfasalazine may be beneficial in a burn wound to assist with removal of skin slough; however, in a granulating wound, the material may be toxic to early epithelialization. Xenograft is a foreign body and should not be applied to an acute contaminated open wound. Historically, a cross-leg flap was a treatment alternative for lower extremity soft-tissue loss; however, its current applications are extremely limited.
REFERENCES: Webb LX: New techniques in wound management: Vacuum assisted wound closure. J Am Acad Orthop Surg 2002;10:303-311.
Clare MP, Fitzgibbons TC, McMullen ST, et al: Experience with the vacuum assisted closure negative pressure technique in the treatment of non-healing diabetic and dysvascular wounds. Foot Ankle Int 2002;23:896-901.

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

This patient’s clinical and MRI findings are consistent with a posterior paralabral cyst with compression of the suprascapular nerve, specifically at the spinoglenoid notch. Compression of the suprascapular nerve can occur at either the suprascapular or spinoglenoid notch. Compression of the nerve at the suprascapular notch affects innervation to both the supraspinatus and infraspinatus muscles, resulting in weakness in both shoulder abduction and external rotation. However, compression at the spinoglenoid notch only affects innervation to the infraspinatus muscle, resulting in isolated weakness in external rotation.
Compression at the spinoglenoid notch often is seen in overhead athletes, and studies have shown associated posterior labral tears (Piatt and associates). Several studies have addressed nonsurgical and surgical treatment options. The treatment decision should focus on the underlying cause (Martin and associates)—in this patient, the cyst. Nonsurgical treatment in the presence of a known lesion has been associated with a higher failure rate than addressing the lesion, which can result in functional improvement (Chen and associates, Cummins and associates). The best response in this scenario is decompression of the cyst at the spinoglenoid notch with possible labral repair.
42

Cruciate-retaining implants are typically used in the presence of a functioning posterior cruciate ligament (PCL). A posterior stabilized insert improves anteroposterior stability in the absence of a PCL but does not account for imbalance of the collateral ligaments. An uncorrectable laxity medially indicates insufficiency of the medial collateral ligament (MCL), which is best treated with a varus-valgus constrained component. A rotating hinge is generally reserved for complete absence of the MCL or both collateral ligaments.

Figure A shows an APC III injury, which is a rotationally and vertically unstable injury, with damage to the anterior ring, pelvic floor, and posterior ligamentous stabilizing structures.
The referenced study by Sagi et al found that biomechanically, a percutaneous iliosacral screw and anterior ring internal fixation was the most stable construct. In addition, he found no biomechanical support for addition of a second iliosacral screw.

Based upon large multicenter studies and registries including the MARS group and Danish registry, re-tear rates after revision ACL reconstruction are higher when allograft is used as compared with autograft. Sport function, as assessed by the IKDC, is better with the use of autograft. Furthermore, no differences in retear rates or function have been shown between soft tissue and bone patellar tendon bone autograft.
26

The radiograph reveals a Charcot shoulder. The atraumatic dissolving of the humeral head is concerning for a neuropathic etiology and necessitates MR imaging of the cervical spine to evaluate for the presence of a syrinx.
RECOMMENDED READINGS
71. [Drvaric DM, Rooks MD, Bishop A, Jacobs LH. Neuropathic arthropathy of the shoulder. A case report. Orthopedics. 1988 Feb;11(2):301-4. PubMed PMID: 3357846. ](http://www.ncbi.nlm.nih.gov/pubmed/3357846)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/3357846)
72. [Patel AY, Eagle KA, Vaishnava P. Cardiac Risk of Noncardiac Surgery. J Am Coll Cardiol. 2015 Nov 10;66(19):2140-8. doi: 10.1016/j.jacc.2015.09.026. Review. ](http://www.ncbi.nlm.nih.gov/pubmed/26541926)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/26541926)

The radiographs reveal a fractured malunited, shortened fibula with deltoid
instability.Corrective osteotomy with fibular lengthening has shown positive results. Nonsurgical management in an active, healthy patient will lead to rapid deterioration of the ankle joint. Without evidence of arthritis, a joint-sacrificing procedure should not be used.

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The preferred approach is posterolateral, placing the sural nerve most at risk. The dorsal intermediate cutaneous nerve is anterolateral to the ankle, and the medial and lateral plantar branches are medial and inferior to the surgical site. The saphenous nerve is anteromedial and away from the surgical approach.
REFERENCES: Swanson TV, Bray TJ, Holmes GB Jr: Fractures of the talar neck: A mechanical study of fixation. J Bone Joint Surg Am 1992;74:544-551.
Lawrence S, Botte M: The sural nerve of the foot and ankle: An anatomic study with clinical and surgical implications. Foot Ankle Int 1994;15:490-494.

Current literature on the management of humeral shaft fractures shows no difference in the rate of radial nerve palsy between nailing (IMN) or with plate fixation (ORIF).
Both ORIF and IMN are appropriate means of definitive fixation of diaphyseal humeral fractures. Numerous studies have directly compared the risks and
outcomes associated with each of the two methods, and the current literature supports that there is no difference in the rates of fracture union, radial nerve palsy, or surgical site infection. Findings on overall complication rates have varied among the literature. In some studies however, IMN has been associated with an increased rate of shoulder pain and as a result a higher reoperation rate as compared to ORIF, though functional outcomes at 1-year show no difference.
Zhao et al. performed a systematic review of recent meta-analyses of randomized clinical trials (RCTs) to compare IMN and plate fixation for treatment humeral shaft fractures. The authors concluded that there was no difference between IMN and plate fixation with respect to fracture union, radial nerve injury, or infection. But they did note that IMN significantly increased the risk of shoulder complications (shoulder impingement and shoulder ROM) and reoperation.
Chen et al. performed a retrospective cohort study evaluating the incidence of humeral shaft fractures within the non-cancer Medicare population and comparing differences between IMN and plate fixation with respect to procedure times, secondary operations, and 1-year mortality. The authors found that IMN was performed more often than plate fixation most years over a 15-year period and was associated with significantly less anesthesia time (27.1 minutes, P < 0.0001). They concluded that there were no significant differences in the complication rates between the 2 groups as measured by the incidence of secondary operations and 1-year mortality.
Bisaccia et al. compared IMN, ORIF, and external fixation for the treatment of midshaft humeral fractures in 79 patients with a median follow-up of 11.5 months. The authors performed clinical and radiographic evaluation at 6 weeks, 6 months and 12 months. They found no differences in the duration of hospitalization, SF-36 scores, or complications between the 3 treatment arms. There were 2 cases of non-union in the ORIF group, 1 case in the IMN group and no cases in the external fixation group, and there was one case of transient radial nerve palsy in the IMN cohort.
Figure A is a radiograph showing a displaced transverse midshaft humeral fracture.
Incorrect Answers:
Answer 1: Though some studies have suggested an increased rate of shoulder-related complications with IMN fixation, there is not significant difference in the rate of surgical site infections for humeral shaft fractures when treated with IMN or ORIF.
Answer 2: There is no significant difference in the rate of radial nerve palsy among humeral shaft fractures treated with IMN or ORIF.
Answer 3: There is no difference in the rate of fracture union for humeral shaft fractures treated with IMN or ORIF.
Answer 3: Some studies have found an increased rate of shoulder complications such as pain and impingement with IMN fixation, leading to an increased rate of revision surgery. However many large meta-analyses contradict these findings.

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Kingella kingae is becoming recognized as a frequent causative organism in musculoskeletal infections in the 6-month to 4-year age range. Patients present with milder symptoms compared with infection with other organisms so there can be a delay in diagnosis. Kingella kingae is notoriously difficult to culture; therefore, patients are often diagnosed with "culture negative" septic arthritis. Recently, PCR has been successfully used to increase diagnostic accuracy. Results can often be obtained in a matter of hours.
MRI will diagnose the inflammatory process and perhaps even show an associated bone or soft-tissue infection; however, MRI will not improve the diagnostic accuracy. One can also wait for the culture results, but as mentioned, Kingella kingae is very difficult to culture and only a small percentage will be positive. Kingella kingae is also difficult to culture from blood.

Important points to remember about Achilles tendon ruptures: A. Most common in middle-aged men
B. Often intermittent sports activity
C . Left more than right
D. Often the tendon is abnormal (degenerative) E. Mechanism
1/. Sudden forced plantarflexion
2/. Unexpected dorsiflexion
3/. Violent dorsiflexion of the plantar flexed foot
Factors which may make the patient more prone to rupture: A. Steroids
B. Fluoroquinolones

The history, examination findings, and studies are consistent with an osteoid osteoma. The CT scan shows a classic “target” lesion, and the bone scan has intense uptake at the site of the osteoid osteoma. The child has had a 2-year history of pain that even wakes her from sleep, so observation and anti-inflammatory drugs is not a preferred treatment. Bracing will not help with the discomfort because the pain is not mechanical in nature. MRI would not be needed in addition to the studies already completed. The osteoid osteoma is close to the spinal cord so radiofrequency ablation is not preferred. Surgical removal and biopsy is the treatment of choice.
REFERENCES: Frassica FJ, Waltrip RL, Sponseller PD, et al: Clinicopathologic features and treatment of osteoid osteoma and osteoblastoma in children and adolescents. Orthop Clin North Am 1996;27:559-
574/. Cantwell CP, Obyme J, Eustace S: Current trends in treatment of osteoid osteoma with an emphasis on radiofrequency ablation. Eur Radiol 2004;14:607-617.

Figure 72

Ice hockey injuries demand a thorough assessment because they have the potential to be significant. In hockey players, bone injuries in the foot and ankle can be missed or improperly diagnosed through routine radiographic imaging. MRI can display bone injuries that are not found radiographically; this is because _some fractures and contusions involve the medial ankle and midfoot bones._

Pediatric bone has less mineral and more vascular channels than adult bone. This gives it a lower bending strength and lower modules of elasticity than adult bone.

DISCUSSION: The arthroscopic photo shows a grasper removing a loose body from the posterolateral compartment through an accessory posterolateral portal. The blunt arthroscopic trocar is placed through the intercondylar notch in the direction of the posterior horn of the lateral meniscus. The trocar passes between the ACL and the posterior aspect of the lateral femoral condyle into the posterolateral compartment.
REFERENCES: Wu WH, Richmond JC: Arthroscopy of the knee: Basic setup and techniques, in McGinty JB (ed): Operative Arthroscopy, ed 3. Philadelphia, PA, Lippincott-Raven, 2003, pp 215-216. Kramer DE, Bahk MS, et al: Posterior knee arthroscopy: Anatomy, technique, application. J Bone Joint Surg Am 2006;88:110-121.

C heilectomy is the ideal treatment for correction of mild hallux rigidus. Although elevation of the first metatarsal rarely occurs (metatarsus primus elevatus) as the cause for hallux rigidus, osteotomy of the metatarsal should not be used as the treatment for correction of hallux rigidus with normal alignment of the first metatarsal.

This is a transverse proximal phalanx fracture with apex volar angulation. The fracture displaces into an apex volar angulated position under the pull of the central slip on the distal fragment and the interossei insertions at the base of proximal phalanx. Although it is possible to lose motion in flexion or extension of the MP or PIP joints, the biomechanics will not allow full extension of the PIP joint. If allowed to heal in apex palmar malunion, the predicted corresponding extensor lags are for a 10-degree lag at 16 degrees of angular deformity, a 24-degree lag at 27 degrees of deformity, and a 66-degree lag at 46 degrees of deformity. These fractures usually can be treated with closed reduction with or without percutaneous pinning. With surgical treatment, there may be loss of motion both at the MP and PIP joints.
RECOMMENDED READINGS
60. Henry MH. Fractures of the proximal phalanx and metacarpals in the hand: preferred methods of stabilization. J Am Acad Orthop Surg. 2008 Oct;16(10):586-95. Review. PubMed PMID: 18832602.
61. Faruqui S, Stern PJ, Kiefhaber TR. Percutaneous pinning of fractures in the proximal third of the proximal phalanx: complications and outcomes. J Hand Surg Am. 2012 Jul;37(7):1342-8. doi: 10.1016/j.jhsa.2012.04.019. PubMed PMID: 22721457.

Atlantoaxial instability, sometimes combined with stenosis of the atlas, is a frequent cause of myelopathy in spondyloepiphyseal dysplasia congenita.
Scoliosis does not account for developmental delay or myelopathy.
Foramen magnum stenosis is rare in spondyloepiphyseal dysplasia congenita.
Lumbar stenosis is rare with spondyloepiphyseal dysplasia congenita and would not account for myelopathy. Thoracolumbar kyphosis severe enough to cause myelopathy is rare in spondyloepiphyseal dysplasia congenita condition.

The tenosynovium excised at the time of a carpal tunnel release for idiopathic carpal tunnel syndrome rarely shows signs of acute or chronic inflammation. Fibrosis, edema, and vascular sclerosis are the most common histologic findings. A tenosynovectomy with a carpal tunnel release usually is not necessary in the treatment of idiopathic carpal tunnel syndrome.
REFERENCES: Shum C, Parisien M, Strauch RJ, et al: The role of flexor tenosynovectomy in the operative treatment of carpal tunnel syndrome. J Bone Joint Surg Am 2002;84:221-225.
Fuchs PC, Nathan PA, Myers LD: Synovial histology in carpal tunnel syndrome. J Hand Surg Am 1991;16:753-758.
Kerr CD, Sybert DR, Albarracin NS: An analysis of the flexor synovium in idiopathic carpal tunnel syndrome: Report of 625 cases. J Hand Surg Am 1992;17:1028-1030.

Fixation of the fibula in tibial plafond fractures has been shown to lead to higher overall complication rates.
Tibial plafond fractures result from high energy axial load patterns and are associated with notoriously high complication rates. Management strategies often include temporary external fixation to allow for soft tissue rest followed by definitive open reduction internal fixation. Fixation of the fibula can be performed during initial external fixation or during delayed open reduction internal fixation. Instrumentation of the fibula may be done to help with reduction of the tibia, however, malreduction of the fibula may lead to difficulties in reduction of the tibia and articular surface. Fixing or not fixing the fibula in these scenarios remains controversial but it appears that fixation of the fibula may lead to higher rates of complication and hardware removal.
Kurylo et al. reviewed 93 patients treated with surgical fixation for tibial plafond fractures. When comparing patients with the fibula fixed versus those without fibular fixation, they found no difference in post-operative or final radiographic alignment. They concluded that fibular fixation is not always necessary in treating tibial plafond fractures and leads to higher rates of hardware removal.
Babis et al. reviewed long-term outcomes of 67 tibial plafond fractures treated with open reduction internal fixation, external fixation, or a combination of the two. They found, at average follow up of 8.1 years, good outcomes were associated with lower Reudi-Allgower classification, use of AO technique, and adequacy of fracture reduction. They concluded that these three factors can predict subjective and objective outcomes following tibial plafond fractures.
Williams et al. retrospectively reviewed patients with tibial plafond fractures treated with definitive external fixation with or without fibular fixation. They found no difference in outcomes scores, radiographic arthrosis, or complication rates. They found different types of complications among the two groups with higher rates of fibular wound infection in the group with fibular fixation. They concluded that tibial plafond fractures treated with definitive external fixation can yield good clinical results without fixing the fibula.
Figures A and B show an AP and lateral of the right ankle, respectively, with a comminuted tibial plafond fracture and associated transverse fracture through the fibula
Incorrect Answers:
Answer 1, 2, 3, & 5: Fracture reduction, patient satisfaction scores, final
alignment and rates of radiographic arthrosis are not statistically different when comparing fibular fixation versus no fixation in tibial plafond fractures.

This lesion is a pyogenic granuloma, which is a common benign vascular lesion that can occur on skin or mucosa. The etiology is unclear, although this lesion tends to occur in areas of physical trauma. Initial treatment with silver nitrate with an average of 1.6 applications has a success rate of 85%. This patient, however, has failed silver nitrate applications. Wide surgical excision (Figures below) is associated with the lowest recurrence rate and offers the benefit of a single procedure. Other options often necessitate repeated procedures to completely eradicate this lesion.

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The most common complication is an injury to the superficial peroneal nerve at the lateral portal. Infection in ankle arthroscopy happens very infrequently. Vascular injury with an anterior scope is very rarely reported. Synovial fistulas are also reported as somewhat common.

Proximal diaphyseal/metadiaphyseal fifth metatarsal fractures have long been recognized as injuries that can be slow to heal, posing substantial risk for nonunion. Although there are treatment options, most authors believe that aggressive surgical treatment is most appropriate for patients who are active, especially athletes, because healing time can be shortened with surgery.
RECOMMENDED READINGS
24. [Portland G, Kelikian A, Kodros S. Acute surgical management of Jones' fractures. Foot Ankle Int. 2003 Nov;24(11):829-33. PubMed PMID: 14655886.](http://www.ncbi.nlm.nih.gov/pubmed/14655886)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/14655886)
25. [Fernández Fairen M, Guillen J, Busto JM, Roura J. Fractures of the fifth metatarsal in basketball players. Knee Surg Sports Traumatol Arthrosc. 1999;7(6):373-7. ](http://www.ncbi.nlm.nih.gov/pubmed/10639656)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/10639656)

Multiple hereditary exostoses is inherited in an autosomal-dominant manner with 90% penetrance.

DISCUSSION: The spectrum of causative bacteria and frequency of occurrence of specific pathogens in septic arthritis are similar to those seen in osteomyelitis, with Staphylococcus aureus being the most common. Other common causative organisms include Kingella Kingae, Streptococcus pneumonia, Klebsiella species, Salmonella, Brucella melitensis, and Haemophilus influenzae.
REFERENCES: Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, WB Saunders, 2008, p 2109.
Jackson MA, Nelson JD: Etiology and medical management of acute suppurative bone and joint infections in pediatric patients. J Pediatr Orthop 1982;2:313-323.

2010 Pediatric Orthopaedic Examination Answer Book • 71

This is a case of obstetric brachial plexus injury involving the C 8, T1 roots (Klumpke Palsy). Erbâs palsy involves upper roots only. C ombined nerve injuries can present in a similar fashion; however, low ulnar and median nerve lesions will not have weakness of flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS).
History of large baby, shoulder dystocia and clavicle fracture point to a difficult labor. The most common type of brachial plexus injury related to birth is Erbâs palsy, which is usually associated with a breech presentation. Isolated Klumpkeâs palsy is rare, and involvement of C 8, T1 usually occurs as part of global plexus injury.

- age at the time of injury is the most consistent risk factor for recurrent instability.
CLINICAL SITUATION FOR QUESTIONS 36 THROUGH 39
A 65-year-old man experienced 6 years of worsening shoulder pain. Examination demonstrates stiffness and crepitus with range of motion, but full rotator cuff strength in all planes. Radiographs show advanced shoulder osteoarthritis, and an MRI scan ordered by the patient's primary care physician shows an intact rotator cuff.

The management of patients with proximal femoral deformity can be difficult. Appropriate implant selection and preoperative templating are critical. In this patient, it would be difficult to avoid increasing the combined offset by too much, which could contribute to the overtensioning of the soft tissues and trochanteric pain. By medializing the acetabular component (decreasing the combined offset), using a low offset femoral component or a cemented component placed more valgus (decreasing the combined offset), and making a longer neck cut (to avoid shortening of the lower extremity), restoration of the patient’s native offset and leg length can be achieved.

Knee disarticulation level is associated with the worst functional result 2 years after injury (compared to transmetatarsal, Symes, AKA, or BKA). The prosthetic use is decreased with a knee disarticulation as compared to a transtibial amputation.
The cohort study by MacKenzie et al prospectively followed 161 patients that were part of the Lower Extremity Assessment Project (LEAP). These patients underwent an above-the-ankle amputation at a trauma center within 3 months following the injury and followed for 2 years. This study revealed that through-the-knee amputations had significantly worse scores for the objective performance measures of self-selected walking speed, independence in transfers, walking, and stair-climbing. Through-the-knee amputees also had worse SIP scores than AKA and BKA patients. Physicians were also less satisfied with both the clinical and the cosmetic recovery of the patients with a through-the-knee amputation. It should be noted that patients with a BKA had a faster walking speed than those with an AKA. Despite the worse SIP scores for through-the-knee amputations, patients actually reported less pain than those with an AKA or BKA, though this wasn't statistically significant.

DISCUSSION: The late cocking phase of the overhand throw places a marked valgus moment across the medial elbow. This repetitive force reaches the tensile limits of the medial collateral ligament.
REFERENCES: Fleisig GS, Andrews JR, Dillman CJ, et al: Kinetics of baseball pitching with implications about injury mechanisms. Am J Sports Med 1995;23:233-239.
Lynch JR, Waitayawinyu T, Hanel DP, et al: Medial collateral ligament injury in the overhand-throwing athlete. J Hand Surg 2008;33:430-437.

Figure 5a Figure 5b

Metaphyseal-diaphyseal junction fractures of the fifth metatarsal require careful evaluation. In athletes, early intervention with a 4.5-mm intramedullary screw correlates with an earlier return to activity. One study examining the failure of surgically managed Jones fractures revealed that use of anything other than a 4.5-mm malleolar screw for internal fixation correlated with failure.
REFERENCES: Glasgow MT, Naranja RJ Jr, Glasgow SG, et al: Analysis of failed surgical management of fractures of the base of the fifth metatarsal distal to the tuberosity: The Jones fracture. Foot Ankle Int 1996;17:449-457.
Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 243-252.

In most patients with symptomatic talocalcaneal coalition involving less than 50% of the subtalar joint, resection with fat graft interposition is preferred over a subtalar or triple arthrodesis, especially if reasonable range of motion can be achieved. This patient has a synchondrosis that is partially cartilaginous. Although patients may have a residual gait abnormality, most report pain relief after surgery.
REFERENCES: Scranton PE Jr: Treatment of symptomatic talocalcaneal coalition. J Bone Joint Surg Am 1987;69:533-539.
Kitaoka HB, Wikenheiser MA, Schaughnessy WJ, et al: Gait abnormalities following resection of talocalcaneal coalition. J Bone Joint Surg Am 1997;79:369-374.
Vincent KA: Tarsal coalition and painful flatfoot. J Am Acad Orthop Surg 1998;6:274-281.

A hard fall on an outstretched arm often results in injury to the glenoid labrum. A significant tear of the anterior/inferior labrum often leads to instability, pain, and mechanical symptoms of the shoulder. The MRI scan shows no obvious labral tear or Hill-Sachs lesion to suggest an anterior dislocation. Recent clinical studies have suggested that early stabilization of initial anterior dislocations may lead to better results than nonsurgical management in young, athletic patients. However, there are no data to support early surgery for anterior labral tears resulting from traumatic subluxation without dislocation. Initial treatment should consist of a short period of rest and immobilization, followed by a physical therapy rehabilitation program designed to restore motion, strength, and dynamic stability to the shoulder. If the athlete cannot return to play following nonsurgical management, surgical repair of the labrum, either through an open or arthroscopic approach, is indicated. There is no role for immediate thermal capsular shift in this setting.
REFERENCES: Abrams JS, Savoie FH III, Tauro JC, et al: Recent advances in the evaluation and treatment of shoulder instability: Anterior, posterior and multidirectional. Arthroscopy 2002;18:1-13.
DeBerardino TM, Arciero RA, Taylor DC, et al: Prospective evaluation of arthroscopic stabilization of acute, initial anterior shoulder dislocations in young athletes: Two- to five-year follow-up. Am J Sports Med 2001;29:586-592.

The patient has a varus malunion of his left proximal humerus. There are no signs of advanced glenohumeral arthrosis or osteonecrosis. After failed nonsurgical treatment, the surgery most likely to improve his symptoms is a valgus-producing osteotomy of the proximal humerus. Arthroscopic tuberoplasty addresses
massive rotator cuff tears or greater tuberosity malunions, but does not address the varus alignment of the articular surface. Humeral hemiarthroplasty can address the deformity but would sacrifice an otherwise normal humeral head in a relatively young patient. Reverse total shoulder arthroplasty would not be indicated in a patient this age with an intact rotator cuff.

This patient requires revision open reduction and internal fixation of her syndesmosis as post-operative radiographs demonstrate a severely malaligned ankle with obvious syndesmosis widening and fibular shortening.
Malalignment following ankle fracture fixation can alter the anatomical axis of the joint, articular congruency, and normal load distribution. This predisposes the patient to the development of chronic pain, functional impairment, and finally early post-traumatic ankle arthritis.
Marti et al. retrospectively reviewed the outcomes of 31 patients with malunited ankle fractures who underwent reconstructive osteotomies. The authors found that reconstruction resulted in good or excellent results in the majority of patients. They also note that minor post-traumatic arthritis was not a contraindication to reconstruction.
Ramsey et al. evaluated 23 cadaveric ankles using a carbon black transference technique to determine the contact area in the dissected tibiotalar articulations, with the talus in neutral position and displaced one, two, four, and six millimeters laterally. They found that 1 mm of lateral talar displacement resulted in a 42% decrease in tibiotalar contact area.
Figure A is a x-ray demonstrating severe malalignment of a bimalleolar ankle fracture following fixation of the fibula and medial malleolus. There is obvious shortening of the fibula and lateral shift and valgus tilt of the talus associated with a disrupted syndesmosis.
Incorrect Answers:
Answer 1 & 2: Physical therapy and short leg bracing are not indicated at this point as the anatomical malalignment needs to first be addressed via revision surgery.
Answer 4: The addition of a syndesmosis screw will not successfully reduce the syndesmosis as it has been chronically malreduced and will require open reduction and debridement prior to syndesmosis screw fixation.
Answer 5: Open medial ankle ligament reconstruction is insufficient in isolation to provide mechanical stability to the ankle fractures with syndesmosis disruption.

DISCUSSION: Stress fractures can be seen in female athletes who develop the female athletic triad including amenorrhea, osteoporosis, and eating disorders. Any female athlete with a history of stress fractures should undergo a workup for this disorder. Workup should include obtaining a menstrual history, obtaining a nutritional consultation, and obtaining a bone density. When properly counseled, these athletes may return to high endurance sports activities. Although these athletes may require a change in training intensity or psychiatric consultation, it would not be the next step in management. Psychiatric consultation may not be necessary unless an eating disorder has been diagnosed. Serum calcium levels are normal in these patients.
Tension-sided stress fractures of the femoral neck require surgical stabilization with internal fixation as opposed to compression-sided stress fractures that can be treated with rest and nonsurgical management.
REFERENCES: Feingold D, Hame SL: Female athlete triad and stress fractures. Orthop Clin North Am 2006;37:575-583.
Joy EA, Campbell D: Stress fractures in the female athlete. Curr Sports Med Rep 2005;4:323-328.

Low-grade cartilage lesions are among the few diagnoses for which proceeding to definitive surgical treatment without a definitive histologic diagnosis is appropriate. Extended curettage with adjuvants is an acceptable treatment option for both enchondroma and low-grade chondrosarcoma of the extremities; as such, it is appropriate to proceed to definitive treatment when these are the only diagnoses in the differential. There is no consensus regarding the number and type of adjuvants used in intralesional curettage. There is also lack of consensus regarding how to reconstruct the resultant defect, with some favoring cement and others favoring bone grafting. A wide resection with intercalary resection is not indicated. Most commonly, serial radiologic studies are recommended to ensure no change occurs over time when the lesion is found incidentally, as in this patient.
The t(9;22) translocation occurs in extraskeletal myxoid chondrosarcoma, which is not a consideration for this patient based upon location, imaging, and the biopsy interpretation. Repeat core needle biopsy is not indicated because the value of core needle biopsy in general for low-grade cartilage lesions is questionable in light of sampling error concerns and the inability of expert pathologists to reliably distinguish between enchondroma and low-grade chondrosarcoma. Many orthopaedic oncologists favor proceeding directly to curettage with adjuvants without any biopsy
when the imaging is classic for a low-grade cartilage tumor without any evidence of dedifferentiation. Enchondromas are frequently positron emission tomography (PET) avid, and PET is not used to distinguish enchondroma from low-grade chondrosarcoma.
RECOMMENDED READINGS
30. [Hickey M, Farrokhyar F, Deheshi B, Turcotte R, Ghert M. A systematic review and meta-analysis of intralesional versus wide resection for intramedullary grade I chondrosarcoma of the extremities. Ann Surg Oncol. 2011 Jun;18(6):1705-9. doi: 10.1245/s10434-010-1532-z. Epub 2011 Jan 22. Review. PubMed PMID: 21258968. ](http://www.ncbi.nlm.nih.gov/pubmed/21258968)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/21258968)
31. [Meftah M, Schult P, Henshaw RM. Long-term results of intralesional curettage and cryosurgery for treatment of low-grade chondrosarcoma. J Bone Joint Surg Am. 2013 Aug 7;95(15):1358-64. doi: 10.2106/JBJS.L.00442. PubMed PMID: 23925739. ](http://www.ncbi.nlm.nih.gov/pubmed/23925739)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23925739)
32. [Skeletal Lesions Interobserver Correlation among Expert Diagnosticians (SLICED) Study Group. Reliability of histopathologic and radiologic grading of cartilaginous neoplasms in long bones. J Bone Joint Surg Am. 2007 Oct;89(10):2113-23. PubMed PMID: 17908885. ](http://www.ncbi.nlm.nih.gov/pubmed/17908885)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/17908885)
33. Jesus-Garcia R, Osawa A, Filippi RZ, Viola DC, Korukian M, de Carvalho Campos Neto G, Wagner
[J. Is PET-CT an accurate method for the differential diagnosis between chondroma and chondrosarcoma? Springerplus. 2016 Feb 29;5:236. doi: 10.1186/s40064-016-1782-8. eCollection 2016. PubMed PMID: 27026930. ](http://www.ncbi.nlm.nih.gov/pubmed/27026930)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/27026930)
CLINICAL SITUATION FOR QUESTIONS 18 THROUGH 21
Figures 18a through 18c are the radiographs and bone scan of a 23-year-old woman.

A patient with this injury represents a high-energy fracture in a high demand individual. The patient will require incision and drainage of his open wound, open reduction with internal fixation, and carpal tunnel release. Bone grafting would not be appropriate in a patient with open fracture.

This patient's history and physical findings are concerning for deep infection. Inflammatory markers, including ESR and CRP, should be obtained first. If the levels are elevated, knee aspiration should be performed for the synovial cell count and culture. A bone scan is not indicated in an initial investigation for deep infection; it is rarely helpful and is not cost effective. CT to assess implant rotation is an appropriate investigation for knee pain when the clinical scenario is not suspicious for a deep infection
and when infection has been excluded.

Osteochondromas are the most common primary benign bony tumors.

At 3 years of age, children do well with nonsurgical treatment with early spica casting and early mobilization. There is no indication to perform surgical stabilization in such a closed isolated injury. The fracture is not shortened unacceptably according to clinical practice guidelines, and traction for this fracture is unnecessary. Traction also may be problematic for the family and healthcare system.
RESPONSES FOR QUESTIONS 57 THROUGH 62
1. Cortical thickening in the region of the lesion
2. Erosive metaphyseal lesion with loss of cortical integrity
3. Normal bony anatomy on radiographs
4. Diffuse articular erosion with loss of joint space
5. Round, expansive, well-circumscribed metaphyseal lesion with thinning of the cortex
6. Eccentric well-circumscribed metaphyseal lesion with a scalloped border
Match the orthopaedic condition described below with the expected radiographic finding listed above.

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This patient has a fracture of the olecranon, which is a common injury seen in children with osteogenesis imperfecta (OI), particularly type 1 OI. The genetic abnormality in OI is either autosomal dominant or recessive, with a mutation in collagen type 1, affecting COL1A1 and COL1A2 genes. FGFR3 mutations are associated with achondroplasia. DTDST mutations are seen in diastophic dysplasia. COL2A1 mutations are seen in spondyloepiphyseal dysplasia (SED), Kniest dysplasia, and Stickler syndrome.

Iliotibial band syndrome (ITBS) is a common cause of lateral knee pain in runners. Potential etiologies for the pain include repetitive friction, compression, and bursal inflammation. An Ober test is used to assess iliotibial band tightness. With the patient lying on the unaffected side, the affected leg is abducted and extended. The test result is positive if the examiner is unable to adduct the leg from this position. An MRI scan can be helpful in making the diagnosis, but a negative MRI scan does not rule out ITBS. Studies have reported increased signal intensity on T2-weighted images deep to the iliotibial band adjacent to the lateral epicondyle, with thickening of the iliotibial band. Nonsurgical treatment is most appropriate initially and involves activity modification, ice, anti-inflammatory medications, and stretching. Corticosteroid injection to the iliotibial bursa is also an option to treat acute pain. After the initial inflammation improves, a strengthening program is started. Multiple surgical procedures have been described for recalcitrant cases, including iliotibial band excision, Z-lengthening, and iliotibial band bursectomy.
43

This patient likely has a soft-tissue reaction (pseudotumor) related to metal-on- metal articulation. Although the components are well positioned, patient gender and small head size are both known risk factors for failure of hip resurfacing arthroplasties. Metal ion levels are elevated but are not always markedly increased in the setting of a problematic metal-on-metal articulation. The patient should have a metal artifact reduction sequence MR imaging study to confirm the presence of a pseudotumor. Chronic infection is very unlikely in the setting of normal ESR and CRP findings. Impingement and lumbar disk disease would not explain the swelling around the hip.