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

Small vesicles on the fingers of a health care worker suggest a herpetic infection, and the management of choice is observation. Incision and drainage may result in a bacterial infection. Marsupialization is used in the treatment of a chronic paronychia. Calcium gluconate is used for hydrofluoric acid burns, and copper sulfate is used for white phosphorus burns.
REFERENCES: Fowler JR: Viral Infections. Hand Clin 1989;5:613-627.
Jebsen PL: Infections of the fingertip: Paronychias and felons. Hand Clin 1998;14:547-555.

Fractures of the fifth metatarsal proximal metaphyseal-diaphyseal junction (Jones fracture)generally occur in young athletic patients and have relatively high rates of delayed union or nonunion with nonsurgical management. The fracture occurs in the hypovascular zone between the insertion of the peroneus brevis and tertius. These tendons cause a shearing across the fracture site, preventing stability and healing.
Nonsurgical functional bracing or casting may lead to a high rate of delayed union and nonunion. Internal fixation in the high-level athlete leads to the most predictable healing of the fracture in a timely fashion. The use of bone stimulators for this fracture is controversial.

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Ulnar neuropathy at the elbow is termed cubital tunnel syndrome, whereas ulnar nerve compression at the wrist is considered Guyon neuropathy. Patients with cubital tunnel syndrome have numbness on the dorsal ulnar aspect of the hand due to involvement of the dorsal ulnar sensory nerve branch (DUSN). Ulnar neuropathy at both the elbow and the wrist may manifest with abnormal sensation about the volar ring and small fingers and with weakness of the interosseous muscles, which can lead to a positive Froment sign. The Froment sign is considered positive when flexion of the thumb interphalangeal joint occurs to compensate for a lack of adductor function. Patients with a Guyon neuropathy do not have symptoms of numbness in the dorsal ulnar distribution, because the DUSN branch arises more proximally in the _forearm and is not compressed in the ulnar tunnel at the wrist._

- Distal first metatarsal chevron osteotomy

Anterior elbow release consists of lengthening of the lacertus fibrosus and the brachialis fascia. It may or may not include lengthening of the biceps tendon itself. Anterior elbow release effectively decreases the excessive flexion posture of the elbow during use, which one author has termed the âflexion posture angle.â It does not result in decreased (or increased) strength of elbow flexion if the biceps tendon is preserved. Unfortunately, increased use during bimanual activity and increased grip strength are usually not observed.

Distal femoral megaprosthetic reconstruction after tumor resection is a reliable oncologic procedure, but 5-year implant survival is as low as 74% with an approximate 8% deep infection rate. The amputation rate is as high as 8% because of infection or recurrence, and there is an overall 18% revision rate. More than 10% of distal femoral megaprosthetic reconstructions are performed to address metastatic disease.
Fixation failure and infection may occur with either procedure. Radiation may not be recommended after a megaprosthesis reconstruction unless margins are not free of tumor. Either operation may be equally successful in returning patients to functional activities. Overall disease-free survival is related to the aggressiveness of the tumor and not the type of reconstruction performed.
RECOMMENDED READINGS
4. [Henrichs MP, Krebs J, Gosheger G, Streitbuerger A, Nottrott M, Sauer T, Hoell S, Singh G, Hardes J. Modular tumor endoprostheses in surgical palliation of long-bone metastases: a reduction in tumor burden and a durable reconstruction. World J Surg Oncol. 2014 Nov 7;12:330. doi: 10.1186/1477-7819-12-330. PubMed PMID: 25376274.](http://www.ncbi.nlm.nih.gov/pubmed/25376274)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/25376274)
5. [Sharma S, Turcotte RE, Isler MH, Wong C. Cemented rotating hinge endoprosthesis for limb salvage of distal femur tumors. Clin Orthop Relat Res. 2006 Sep;450:28-32. ](http://www.ncbi.nlm.nih.gov/pubmed/16906068)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/16906068)

The sural nerve is at risk when incisions are placed near the Achilles tendon musculotendinous junction of the posterior calf. The nerve, which can be easily identified when the vein is visualized, is at risk during Achilles tendon recession procedures, and the vein provides a landmark with which to identify the nerve.
RECOMMENDED READINGS
1. [Eid EM, Hegazy AM. Anatomical variations of the human sural nerve and its role in clinical and surgical procedures .Clin Anat.2011Mar;24(2):237-45.doi: 10.1002/ ca.21068. Epub 2010 Oct 14.PubMed PMID: 20949489.](http://www.ncbi.nlm.nih.gov/pubmed/20949489)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/20949489)
2. Hoppenfeld S, deBoer P, Buckley R. Surgical Exposures in Orthopaedics. The Anatomic Approach. Philadelphia, PA: Lippincott Williams &Wilkins 2009:585-622.
3. [Aktan Ikiz ZA, Uçerler H, Bilge O. The anatomic features of the sural nerve with an emphasis on its clinical importance. Foot Ankle Int. 2005 Jul;26(7):560-7. PubMed PMID: 16045849.](http://www.ncbi.nlm.nih.gov/pubmed/16045849)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/16045849)

The anterolateral branch of the anterior circumflex artery, called the arcuate artery terminally, provides blood supply to the entire humeral head, lesser tuberosity and greater tuberosity except for a small posterior area. The posterior portion of the greater tuberosity and a small posteroinferior portion of the humeral head are supplied by the posterior circumflex artery.
Gerber et al performed an anatomical study of the arteries of the humeral head to determine their intraosseous distributions. They injected a radiopaque suspension into the anterior circumflex, posterior circumflex, suprascapular, thoracoacromial, or subscapular artery and then analyzed the specimens macroscopically and radiographically. The humeral head was shown to have been perfused by the anterolateral ascending branch of the anterior circumflex artery in all specimens. The posterior circumflex artery vascularized only the posterior portion of the greater tuberosity and a small posteroinferior part of the head.
While previous literature suggested that the anterior humeral circumflex artery provided the main blood supply to the humeral head, more current literature supports the posterior circumflex humeral artery as the predominant blood supply. Despite the anterior humeral circumflex artery being disrupted in approximately 80% of proximal humeral fractures, the occurrence of resultant osteonecrosis is still infrequent. This inconsistency also suggests a greater role for the posterior humeral circumflex artery.
Hettrich et al. performed a cadaveric study assessing the vascularity of the proximal part of the humerus. They injected gadolinium into the axillary artery proximally, and then either the anterior humeral circumflex artery or the posterior humeral circumflex artery was ligated. MRI was then performed and the specimens were dissected to determine the dominant blood supply. They found that the posterior humeral circumflex artery provided 64% of the blood supply to the humeral head, whereas the anterior humeral circumflex artery supplied 36%. The posterior humeral circumflex artery also provided significantly more of the blood supply in three of the four quadrants of the humeral head.
Illustration A depicts the humeral head vascular supply with #2 being the posterior circumflex, #3 being the anterior circumflex arteries, and #4 being the anterolateral humeral circumflex artery.

The radiograph reveals a reverse obliquely subtrochanteric/intertrochanteric fracture. Open reduction and internal fixation should be accomplished with a 95° fixed angle device. An intramedullary nail with screw fixation into the head is another possible technique. Either method should correct the varus deformity. Exchange of a high-angled screw and plate device to a longer side plate and bone grafting does not afford any improvement in the mechanical stability. Hardware removal and retrograde intramedullary nailing is not indicated for this level of a proximal femoral injury. Placement of an implantable bone stimulator may change local biologic factors but would not enhance mechanical stability. The patient’s femoral head is intact without signs of collapse; therefore, hardware removal, proximal femoral resection, and total hip arthroplasty are not warranted.
REFERENCES: Haidukewych GJ, Israel TA, Berry DJ: Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643-650.
Koval KJ, Zuckerman JD: Intertrochanteric fractures, in Rockwood & Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 1635-1681.

This patient demonstrates symptoms consistent with posterior capsular tightness with loss of internal rotation. This can be evaluated by comparing internal rotation to the contralateral side with the arm in 90 degrees of abduction or by reaching behind the back. Treatment consists of posterior capsular stretching such as the sleeper stretch. MR imaging or MRI arthrogram findings would most likely be unremarkable and not change the initial treatment plan. Arthroscopic surgery would be indicated for failure of nonsurgical treatment, including a dedicated stretching program. Surgery would consist of arthroscopic release of the tight posterior capsule.
RECOMMENDED READINGS
19. [Kinsella SD, Thomas SJ, Huffman GR, Kelly JD 4th. The thrower's shoulder. Orthop Clin North Am. 2014 Jul;45(3):387-401. doi: 10.1016/j.ocl.2014.04.003. Review. ](http://www.ncbi.nlm.nih.gov/pubmed/24975765)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/24975765)
20. [Bach HG, Goldberg BA. Posterior capsular contracture of the shoulder. J Am Acad Orthop Surg. 2006 May;14(5):265-77. Review. PubMed PMID: 16675620.](http://www.ncbi.nlm.nih.gov/pubmed/16675620)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/16675620)

- Plain radiographs of both elbows PREFERRED RESPONSE: 1- To evaluate for apophyseal injury PREFERRED RESPONSE: 1- Ulnar collateral ligament

Upper extremity trauma has serious, acute psychological effects that can linger long after the physical injury. These effects may negatively affect patient-reported outcomes, and may also be associated with worsening pain complaints. Coping and stress management techniques can be reviewed with formal psychological counseling, and should be offered to all patients who have underwent an amputation.
Richards et al surveyed 34 patients who had emergency upper extremity surgery and found high levels of psychological distress in patients, including 29% with high levels of both depression and post-traumatic stress disorder (PTSD). They also found that disability was strongly related to pain, depression, and PTSD symptoms.
Mallette et al assessed the attitudes of hand surgery patients and hand surgeons regarding psychologic influences on illness and compared their attitudes with those of the general population. They found that surgeons underestimated the openness of patients to discuss psychological issues and that patients believed in the strong effect of psychologic factors on healing and pain.
Illustration A shows a myoelectric prosthesis in a military veteran. Incorrect Answers:
Answer 1: Formal function capacity testing is not typically necessary unless
Workers' Compensation is involved or formal disability proceedings occur. Answer 2: Final prosthetic fitting is not necessary for full release.
Answer 3: Prosthetic use will vary according to needs and patient factors such as pain.
Answer 4: Return to work does not have to wait for full return of elbow range of motion.

Figure A shows an unstable, ankle fracture-dislocation in a otherwise healthy 48-year-old diabetic patient. The most appropriate management would be open reduction and internal fixation with an extended period of restricted weight-bearing.
Surgical treatment of unstable ankle fractures in diabetic patients is associated with a high complication rates. Diabetic patients are inherently poor healers due to the alterations in their microvascular system. Over-fixation of the fracture and extended immobilization has been shown to reduce wound and bone healing complications associated with diabetes. Surgical techniques typically call for multiple syndesmotic screws, stronger plates (vs 1/3 tubular plates) and prolonged periods of immobilization.
Jani et al. retrospectively examined a cohort of 15 patients with diabetes mellitus who sustained unstable ankle fractures. The combination of transarticular fixation (Retrograde transcalcaneal-talar-tibial fixation using large Steinmann pins or screws) and prolonged (>12 weeks), protected weightbearing provided 13 of 15 patients with a stable ankle for weight bearing.
Wukich et al. compared the complication rates of ankle fracture fixation in 46 patients with complicated diabetes and 59 patients with uncomplicated diabetes. They found that patients with complicated diabetes had 3.4 times increased risk of a non-infectious complications (eg. malunion, nonunion or Charcot arthropathy) and 5 times higher likelihood of needing revision surgery/arthrodesis.
Figure A shows AP and lat radiographs of SER4 ankle fracture-dislocation. Incorrect Answers:
Answer 1,2: Non-operative treatment would be appropriate in stable ankle
fractures. Again, these need to be treated with an extended period of immobilization.
Answer 3,4: Internal fixation would be warranted in this patient, however the duration of immobilization should more than double the typical period of immobilization.

The radiograph of the lateral lumbosacral spine reveals an isthmic spondylolysis with a Meyerding grade 1 spondylolisthesis. The incidence of spondylolysis in the general population is around 5%, and grade 1 or 2 slips are present in the majority of children with a spondylolysis. Many cases of spondylolysis are painless and discovered incidentally, but, when painful, hyperextension of the lumbar spine may stress the area of the pars defect and exacerbate a patient’s symptoms. A diagnosis can usually be determined with a lateral radiograph of the lumbar spine. Although oblique lumbar radiographs are frequently ordered, several studies have shown that they do not increase diagnostic or prognostic accuracy. Progression of an isthmic spondylolysis, with or without a grade 1 or 2 listhesis, to a serious slip that might
necessitate surgical intervention is rare and occurs in fewer than 5% of patients. Chance for progression diminishes with age, with patients at highest risk prior to the adolescent growth spurt. Spondylolysis may have a genetic component; an increased prevalence has been found in some families and in some ethnic groups, especially among the Native American population.

Figure 24a

Figure 24b

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Studies report a radiographic heterotopic ossification (HO) rate of >40% after long-term follow-up of cervical disk replacements. Therefore, cervical disk replacements do carry a significant rate of HO development. However, the clinical significance is difficult to determine, as most of those patients are not symptomatic. Long-term studies show a lower revision rate and lower radiographic adjacent segment degeneration with two-level cervical disk replacement compared with two-level ACDF. However, both treatment options are considered effective procedures for the treatment of cervical radiculopathy at two adjacent
levels.

The pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament are all parts of the normal fascia that contribute to the formation of the spiral cord. C leland's ligament is not involved at all in the disease process.

Gout is caused by the deposition of monosodium urate crystals in tissues, typically around joints. Common locations of gout include the great toe, heel, ankle, and knee. In approximately 50% of patients, the first affected location is the great toe. Gout commonly occurs inside a joint for two reasons - synovial fluid is a poorer solvent than plasma and lower temperatures (as in peripheral joints) favor crystallization.
Neutrophils ingest the crystals and release potent lysosomal enzymes. Punched lesions may be seen on radiographs in chroniCcases, and one can often see an overlying lip of cortex at the edge of the lesion.
Histologically, the tophi have several features: Acellular amorphous material
Macrophages
Foreign body giant cells
In this patient, the joint space is preserved on the plain radiographs. The MRI scans show periarticular erosions. The biopsy specimen has the characteristiCfeatures of gout - acellular amorphous material, macrophages, and foreign body giant cells.

The patient has posttraumatic arthritis of the elbow; therefore, the treatment of choice is hardware removal and soft-tissue releases with splinting to avoid recurrence of contractures. The combination of pain and stiffness in an elbow that has sustained significant joint surface damage renders it unresponsive to simple soft-tissue releases and heterotopic bone excision. Joint distraction and interposition arthroplasty offer the possibility of maintaining motion and relieving pain as a later salvage procedure. Joint replacement should not be performed in young, active, strong individuals because the prosthesis will fail quickly and complications will develop. Synovectomy and radial head excision are not indicated.
REFERENCES: Morrey BF: Distraction arthroplasty: Clinical applications. Clin Orthop 1993;293:46-54.
O’Driscoll SW: Elbow arthritis: Treatment options. J Am Acad Orthop Surg 1993;1:106-116.

Internal impingement occurs when the articular side of the supraspinatus abrades against the posterior superior glenoid in the cocking position. Damage may include a posterior labral tear where the contact occurs, not anteriorly as in a Bankart lesion. Biceps fraying and acromion spurs are more commonly seen in extrinsic impingement. Loose bodies may occur from multiple lesions associated with instability and articular cartilage disorders but are uncommon in internal impingement.
REFERENCES: Jobe CM: Posterior superior impingement of the rotator cuff on the glenoid rim as a cause of shoulder pain in the overhead athlete. Arthroscopy 1993;9:697-699.
McFarland EG, Hsu C, Neir C, O’Neil O: Internal impingement of the shoulder: A clinical and arthroscopic analysis. J Shoulder Elbow Surg 1999;8:458-460.

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Translation-rotation injuries typically yield fracture dislocations. This injury pattern involves the disruption of skeletal and ligamentous elements of the spine to cause a maximum loss of stability, subsequent deformity in three planes (coronal, axial, and sagittal), and catastrophic neurologic injury.
Compression injuries occur when a force is applied in flexion and injures the anterior column. Compression injuries are usually stable and rarely have neurologic sequelae. Burst fractures occur through axially applied forces, which in turn cause injury to the anterior and middle columns of the vertebrae at minimum. Neurologic injury can occur through direct compression of the neural elements by bone fragments or hematoma or by absorption of the transferred energy. Flexion distraction injuries typically occur as forces are transmitted from anterior to posterior, causing injury to the middle and posterior columns.

Vertebral destruction exceeds disc destruction in tuberculosis.
Bony changes occur earlier in tuberculosis than in pyogenic spondylitis.
Involvement of multiple contiguous levels is more common in tuberculosis than pyogenic spondylitis.
Bony erosions seen on computerized tomography are large in tuberclosis and small in pyogenic spondylitis. Magnetic resonance imaging often shows significant soft tissue involvement in both disorders.

This patient has persistent elbow instability likely secondary to medial collateral ligament (MCL) rupture and therefore should undergo repair of the MCL, followed by repeat fluoroscopic examination. Small coronoid fractures involving less than or equal to 10% of the coronoid tip do not confer major elbow instability and do not necessitate repair.
Terrible triad injuries of the elbow are characterized by: 1. Radial head fracture, 2. Coronoid fracture, and 3. Elbow dislocation. Whether to surgically address the coronoid fracture depends on the size of the fragment (Reagan-Morrey types I-III; Illustration A) as well as elbow stability. Reagan and Morrey suggested that small fractures of the coronoid tip (type I) involving less than 10% of the coronoid may represent anterior capsule avulsions; however, recent cadaveric studies demonstrate that the capsule inserts more distally on the tip and that small fractures often do not contain capsule insertion. Gross elbow instability in the presence of a type I fracture is most likely due to an independent MCL injury and NOT the coronoid avulsion. Surgical repair of type I fractures has not been shown to affect stability and may detrimentally affect elbow range of motion.
Matthew et al reviewed the terrible triad injury of the elbow. While the coronoid process provides substantial resistance to posterior subluxation, small fractures involving 10% of the coronoid process have been shown to have little effect on elbow stability. In a cadaveric study of a simulated terrible triad injury, when residual instability was present after radial head repair or arthroplasty and lateral ulnar collateral ligament (LUCL) repair, repair of the MCL was more effective than fixation of small coronoid fractures in restoring elbow stability. However, the authors note that in clinical series of terrible triad injuries, most coronoid fragments were larger than 10%, suggesting that fixation of the coronoid process is usually part of the treatment of terrible triad injuries.
Papatheodorou et al performed a retrospective analysis of 14 patients with acute terrible triad injuries and type I or type II coronoid fractures who
underwent radial head fixation or arthroplasty and LUCL repair without coronoid fixation. Intraoperative stability was confirmed under fluoroscopy. At 2 year follow up, none of the patients demonstrated elbow instability. Mean elbow flexion-extension was 123 and forearm rotation 145. The authors concluded that terrible triad injuries with type I or II coronoid fractures can be treated without coronoid fixation when intraoperative stability is restored with radial head repair or arthroplasty and LUCL repair.
Illustration A demonstrates the Regan-Morrey classification of coronoid fractures. Type I fractures involve < 10% of the coronoid tip and do not result in significant elbow instability. Type II fractures involve < 50% of the coronoid and may result in elbow instability secondary to loss of the anterior bony buttress that resists posterior displacement of the ulna, as well as loss of the anterior capsule insertion. These fractures are often repaired, particularly when associated with elbow instability. Type III fractures involve > 50% of the coronoid and often contain the insertion of the anterior band of the MCL (red arrow). The insertion of the brachialis (red triangle) may also be involved resulting in proximal displacement of the fracture fragment. Surgical repair of type III fractures is necessary to reconstitute the MCL and restore elbow stability. Illustration B is a CT scan of a type I coronoid fracture. Illustration C is a CT scan of a type II coronoid fracture. Illustration D is a CT scan of a type III coronoid fracture.
Incorrect Answers:
Answers 1: All possible ligamentous injuries should be addressed prior to proceeding with external fixation. If the elbow remains unstable following MCL repair, then external fixation may be considered.
Answer 2: Two part radial head fractures that involve more than 30% of the articular surface are most often treated with ORIF. Under-sizing the radial head arthroplasty component can result in residual valgus stability, as the radial head is a secondary stabilizer to valgus stress.
Answer 3: Coronoid fractures involving 10% of the coronoid tip do not affect elbow stability and therefore repair is not necessary.
Answer 5: Splinting at 90 degrees of flexion and full pronation is appropriate for a stable elbow following LCL repair in the presence of an uninjured MCL. This patient has a persistently unstable elbow likely secondary to a deficient MCL and therefore should not be splinted. Following MCL repair if the elbow remains persistently unstable, a hinged external fixator should be applied.

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Lyme arthritis is also called ‘pseudoseptic’ due to its similarities in presentation to classic bacterial septic arthritis. As opposed to septic bacterial arthritis, lyme arthritis progesses relatively slowly; children often remain ambulatory, and fevers are less likely to be >38.5°C. Synovial fluid cell counts are often >50,000, leading aspirate to be less useful in differentiating septic and pseudoseptic arthritis. However, neutrophil differential in Lyme arthritis is typically <90%. In this case, symptoms are gradually progressive, fevers are low grade, and the exam findings are not as strikingly noxious as classic bacterial arthritis. Most importantly, the patient has a history of likely tick exposure – most published series reveal a significant percentage of patients without recollection of tick exposure or the classic erythema migrans rash. Clinical diagnosis is confirmed with serologic lyme testing and confirmatory Western blot analysis. Treatment includes a 28-day course of oral amoxicillin or doxycycline NSAIDs and does not require surgical lavage. There is no role for MRI imaging in the treatment algorithm for acute bacterial arthritis or Lyme arthritis of the knee. Observation and NSAIDs may be a relevant treatment option for transient synovitis of the knee, but the synovial fluid cell count in this case does not favor that diagnosis.

The radiographs reveal a displaced proximal humerus fracture in a skeletally immature patient. There is tremendous remodeling potential, and similar outcomes are seen in both operative and nonoperative treatment. Worse outcomes are seen with older patients, as the remodeling potential decreases. In a study of 32 pediatric proximal humeral fractures, subgroup analysis of the nonoperative cases showed that, for every 1-year increase in age at initial injury, the odds of a less than desirable outcome increased by a factor of 3.81.

DISCUSSION: The examination reveals that the patient has posterior capsular tightness. Surgery should not be considered until the patient has failed to respond to nonsurgical management. The internal rotation contracture (GIRD - glenohumeral internal rotation deficit) should be addressed with appropriate posterior capsular stretching. This should then be followed by appropriate rotator cuff and scapular stabilization exercises. Only if this management fails to relieve the patient’s symptoms should surgery be considered. This patient clearly does not need external rotation stretching given the fact that he has normal external rotation.
REFERENCES: Meister K: Injuries to the shoulder in the throwing athlete. Part two: evaluation/ treatment. Am J Sports Med 2000;28:587-601.
Liu SH, Boynton E: Posterior superior impingement of the rotator cuff on the glenoid rim as a cause of shoulder pain in the overhead athlete. Arthroscopy 1993;9:697-699.
Tyler TF, Nicholas SJ, Roy T, et al: Quantification of posterior capsule tightness and motion loss in patients with shoulder impingement. Am J Sports Med 2000;28:668-673.

2010 Sports Medicine Examination Answer Book • 21

The complication rate following elbow arthroscopy is reported at 5%. The most commonly reported complication is transient neurapraxia, with nerve transection remaining an unfortunate and rare event. While infection remains the most common serious complication, it is uncommon (0.8%). Synovial cutaneous fistula and compartment syndrome, while reported, are the least frequent complications of elbow arthroscopy.
REFERENCES: Kelly EW, Morrey BF, O’Driscoll SW: Complications of elbow arthroscopy.
J Bone Joint Surg Am 2001;83:25-34.
Morrey BF: Elbow complication, in Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2001, pp 519-522.

DISCUSSION:
The primary stabilizers of the elbow are the ulnohumeral joint, the lateral collateral ligament (lateral epicondyle to the crista supinatoris), and the anterior band of the medial collateral ligament (anterior inferior medial epicondyle to the sublime tubercle). Secondary stabilizers are the radial head, the common flexor and
extensor origins, and the joint capsule. The muscles that cross the elbow joint act as dynamic stabilizers.

Technical failure is the most common reason for ACL reconstruction failure. Tunnel position is the most frequent cause of technical failure. Malpositioning of the tunnel affects the length of the graft, causing either decreased range of motion or increased graft laxity. This patient has anterior and vertical placement of his femoral tunnel, which has been shown to cause stiffness in knee flexion. Although graft choice is an important factor when planning ACL reconstruction, overall outcomes with autograft tissues are fairly similar. Fixation of the graft at the femoral or tibial end is not as important as tunnel position. Fixing the graft in flexion can cause extension loss when isometry is not achieved, but this condition is not touched upon in this scenario.
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The patient has a symptomatic cartilage lesion of his medial femoral condyle, which has not responded to nonsurgical measures, and he failed a prior arthroscopy with debridement. Based on his examination and imaging, he is ligamentously stable, has normal mechanical alignment, and has intact menisci, making him a candidate for a cartilage restoration procedure. The accompanying MRI also indicates subchondral bone involvement with increased T2 signal underlying the cartilage defect. Osteochondral allograft is the only choice that addresses both the cartilage defect, as well as compromised subchondral bone. Depending on lesion size, osteochondral autograft transfer may also be considered, but this is not presented as an answer choice.Given the radiographic finding of neutral mechanical alignment, bracing would be less effective, and the patient has already tried extensive physical therapy. Lack of malalignment also excludes tibial osteotomy as a preferred answer choice. Microfracture is best for small cartilage lesions without _significant bone marrow involvement._

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_**DISCUSSION FOR QUESTIONS 107 AND 108:**_
The fracture at the insertion of the AITFL into the fibula represents a syndesmosis injury. In some cases, a direct repair of the fracture will stabilize the syndesmosis, but in most cases this injury should most likely be reinforced by placing a screw or suture tensioning device across the syndesmosis for additional support.A Brostrom or allograft reconstruction is indicated for an ankle sprain involving the ATFL or CFL.Simply excising the fragment will leave the patient with an incompetent syndesmosis. Repairing the SPR with or without a groove deepening procedure is indicated if there is evidence of subluxated or dislocated peroneal tendons, which is not demonstrated on the CT scans. The bone has been avulsed off the fibula by the portion of the AITFL that attaches to the fibula, therefore indicating that there is a syndesmosis injury. Allograft lateral ligament reconstruction and excision of loose body/fracture fragment are incorrect procedures based on location. The deltoid is a medial structure and this fracture is lateral. The ATFL and CFL attach at the inferior margin of the fibula near the lateral process of the talus and calcaneus. A SPR avulsion would present as an avulsion off the lateral wall of the fibula, not superior and not into the syndesmotic space as shown on the CT scans.

Skeletal survey is the most sensitive means of detecting lesions of eosinophilic granuloma (Langerhans cell histiocytosis). Bone scan detects most, but not all, of the lesions. Some lesions lack enough osteoblastic activity to appear on bone scan. Lesions are not detected on physical exam unless they are large enough to cause pain or tenderness. Indium labeled white cell studies are not used in this condition.

The stretched peroneus brevis muscle and tendon follow anterior to the fibula and are most likely incarcerated with reduction. The anterior talofibular ligament is too small to prevent reduction of the ankle joint itself. The extensor digitorum brevis originates from the talus; therefore, it is not involved in the tibiotalar joint. The posterior tibial tendon lies medially and would not be interposed into the ankle joint. Similarly, the anterior tibialis tendon also would not be involved.
REFERENCES: Pehlivan O, Akmaz I, Solakoglu C, et al: Medial peritalar dislocation. Arch Orthop Trauma Surg 2002;122:541-543.
Rivera F, Bertone C, De Martino M, et al: Pure dislocation of the ankle: Three case reports and literature review. Clin Orthop 2001;382:179-184.

Double blind placebo controlled randomized trials the use of perineural catheters led to improved pain scores, decreased narcotiCusage and narcotiCrelated side effects, and fewer sleep disturbances.
Length of stay was shortened by the use of perineural catheters as compared to epidural or IV PCA analgesia in several studies. In pilot studies, the use of perineural catheters in carefully selected patients allowed ambulatory total shoulder arthroplasty and single day admissions for total hip arthroplasty and total knee arthroplasty

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Oglesby and associates evaluated the incidence of VTE after 273,000 cervical procedures using a National Inpatient Sample Database (from 2002 to 2009). Risk factors for deep venous thrombosis (DVT) and pulmonary embolism were stratified. The overall rate of VTE was 5 per 1,000 procedures. Specific increased risk factors include: posterior cervical fusion with an incidence of 13.4 per 1,000 patients (odds ratio 2.3), male gender (odds ratio 1.8), fluid and electrolyte imbalance (odds ratio 2.2), postoperative anemia (odds ratio 4.8), and pulmonary vascular pathology (odds ratio 3.7).

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This is a 5-year-old girl with a new diagnosis of scoliosis, having an isolated right thoracic curve. This is considered juvenile onset idiopathic scoliosis, which presents between the ages of 3-9 years old. The initial radiographs show a curve measuring 41°. Any curve >20° in a patient with early onset scoliosis should undergo MRI of the entire spine to assess for intraspinal pathology, with an average of 20% of patients having underlying diagnoses, i.e. Arnold-Chiari, syringomyelia. Observation or TLSO bracing may be indicated; however, an MRI is still the first line of management in this patient. Physical therapy may be useful for adjunct treatment, but the MRI is still required at this stage of evaluation and diagnosis.

The arthroscopic images and the patient's history are consistent with a bucket handle tear of the medial meniscus. The ACL graft is intact and well- vascularized as shown in the arthroscopic image. The morphology of the meniscus and that the images are one of a left knee allows the determination that this is a tear of the medial and not the lateral meniscus. The image of the reduced bucket handle medial meniscus tear reveals plastic deformation and a large overlapping peripheral remnant that would make the possibility of healing after revision medial meniscus repair unlikely or suboptimal. The best treatment option for this patient is partial medial meniscectomy.
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After the designation of pain as the fifth vital sign, opioid analgesic use has steadily increased. Many surgeons routinely prescribe 30 or more pills after elective hand surgery. However, studies show that patients generally use fewer than 30 pills. Patients who underwent bone procedures used 14 pills, and those undergoing soft-tissue procedures used 9 pills. Education and decision aids may help physicians size prescriptions appropriately to avoid overmedication. Patients undergoing small soft-tissue surgeries such as trigger releases should not need narcotics. Those undergoing small-joint surgeries, carpal tunnel releases, and Dupuytren fasciectomy may benefit from a prescription of 10 pills. More extensive surgery, such as open fracture treatment, may justify more pills, but prescriptions should not exceed 40 tablets _under typical circumstances._

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

The genetiCdefect in achondroplasia involves fibroblast growth factor (FGF) receptor 3.
The other answers refer to:
| Condition | Protein/Defect | |---|---| | Osteogenesis imperfecta | Type I collagen | | Marfan syndrome | Fibrillin | | Spondyloepiphyseal dysplasia | Type II collagen | | Pseudoachondroplasia | Cartilage oligomeriCmatrix protein (COMP) | Correct Answer: Fibroblast growth factor (FGF) receptor 3

- Proximal avulsion of the lateral ulnar collateral ligament

Treatment of a displaced or unstable distal radius fracture with a volar plate is common. The differential diagnosis of flexor pollicis longus (FPL) dysfunction after volar plating of a distal radius fracture includes scar entrapment of the FPL tendon, hardware irritation, FPL impingement or rupture, and injury to the anterior interosseous nerve.
Prevalence of flexor tendon rupture after distal radius fracture is between 2% and 12%. The FPL tendon is the most common flexor tendon rupture associated with volar plating. It is usually seen with plates that are distal to the watershed line (W) and with plates extending volar to the critical line (C) (Figure 70d). The watershed line (W) is the location of the origin of the volar carpal ligaments and the bone prominence at which flexor tendons are most closely opposed to the distal radius (Figure 70d). In this scenario, the lateral radiograph shows that the plate is not distal to the watershed line (W) and is between the critical line (C) and the line parallel to the volar cortex of the radius (R). This is the optimal position for the plate. Placement of a volar locking plate distal to the watershed line of the distal radius and excessive plate prominence has been associated with FPL tendon rupture.
This patient is only 2 weeks past surgery and there is some FPL function. FPL weakness after volar distal radius plating is common and has been seen in as many as 50% of patients. This usually recovers spontaneously by 2 months, and no treatment is needed. A nerve conduction study would be indicated if an anterior interosseous nerve compression were considered, but it is too early for this test. A CT scan could be obtained to judge the alignment of the fracture fragment and position of the screws, but it is not indicated in this case. Exploration could be performed if an FPL rupture were considered, but, because it is only 2 weeks after surgery, there is some FPL function, the plate is proximal to the watershed line, and immediate exploration is not indicated. If this does not improve after 2 to 3 months, further investigation with ultrasound or MRI would be indicated.
RECOMMENDED READINGS
40. Chilelli BJ, Patel RM, Kalainov DM, Peng J, Zhang LQ. Flexor pollicis longus dysfunction after volar plate fixation of distal radius fractures. J Hand Surg Am. 2013 Sep;38(9):1691-7. doi: 10.1016/j.jhsa.2013.06.005. Epub 2013 Jul 30. PubMed PMID: 23910382.
41. Soong M, Earp BE, Bishop G, Leung A, Blazar P. Volar locking plate implant prominence and flexor tendon rupture. J Bone Joint Surg Am. 2011 Feb 16;93(4):328-35. doi: 10.2106/JBJS.J.00193. Epub 2011 Jan 14. PubMed PMID: 21239658.
42. Agnew SP, Ljungquist KL, Huang JI. Danger zones for flexor tendons in volar plating of distal radius fractures. J Hand Surg Am. 2015 Jun;40(6):1102-5. doi: 10.1016/j.jhsa.2015.02.026. Epub 2015 Apr
2/. PubMed PMID: 25843531.
43. Griffin JW, Chhabra AB. Complications after volar plating of distal radius fractures. J Hand Surg Am. 2014 Jun;39(6):1183-5; quiz 1186. doi: 10.1016/j.jhsa.2014.03.038. Epub 2014 May 5. Review.
PubMed PMID: 24810935.

Technical failure is the most common reason for ACL reconstruction failure. Tunnel position is the most frequent cause for technical failure. Malpositioning of the tunnel affects the length of the graft, causing either decreased range of motion or increased graft laxity. Although graft choice is an important factor when planning an ACL reconstruction, overall outcomes with autograft tissues are fairly similar. Fixation of the graft at the femoral or tibial end is not as important as tunnel position.

Painful incisional neuromas after bunion surgery frequently involve the dorsomedial cutaneous branch of the superficial peroneal nerve. This is the medial branch of the superficial peroneal nerve that terminates as the dorsomedial cutaneous nerve to the hallux. Branches of the deep peroneal nerve to this area are rare, and no branches to this area exist from the sural nerve. The saphenous nerve branches are generally more proximal, and the medial plantar nerve lies plantarly.
REFERENCES: Kenzora JE: Sensory nerve neuromas: Leading to failed foot surgery. Foot Ankle 1986;7:110-117.
Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993.

- Open reduction and internal fixation

This patient had an unplanned resection of a high-grade soft-tissue sarcoma. The MR image shows that the unplanned resection extended deep to the fascia. Errors in this case include failure to obtain cross-sectional imaging of a tumor deep to the fascia prior to resection and use of a transverse incision. Flap coverage for unplanned soft-tissue sarcoma resection can increase the complexity of soft-tissue reconstruction. Radiation therapy would have been indicated for a high-grade soft-
tissue sarcoma deep to the fascia regardless of the biopsy technique. Overall, mortality does not correlate with errors in biopsy technique. Although many studies demonstrate increased local recurrence risk is associated with unplanned resection, amputation is not indicated in most cases. Radiation therapy and wide re-resection with salvage of the involved limb is the treatment of choice.
RECOMMENDED READINGS
51. [Jones DA, Shideman C, Yuan J, Dusenbery K, Carlos Manivel J, Ogilvie C, Clohisy DR, Cheng EY, Shanley R, Chinsoo Cho L. Management of Unplanned Excision for Soft-Tissue Sarcoma With Preoperative Radiotherapy Followed by Definitive Resection. Am J Clin Oncol. 2014 May 29. [Epub ahead of print] PubMed PMID: 24879470.](http://www.ncbi.nlm.nih.gov/pubmed/24879470)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/24879470)
52. [Pretell-Mazzini J, Barton MD Jr, Conway SA, Temple HT. Unplanned excision of soft-tissue sarcomas: current concepts for management and prognosis. J Bone Joint Surg Am. 2015 Apr 1;97(7):597-603. doi: 10.2106/JBJS.N.00649. Review. PubMed PMID: 25834085.](http://www.ncbi.nlm.nih.gov/pubmed/25834085)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/25834085)
53. [Qureshi YA, Huddy JR, Miller JD, Strauss DC, Thomas JM, Hayes AJ. Unplanned excision of soft tissue sarcoma results in increased rates of local recurrence despite full further oncological treatment. Ann Surg Oncol. 2012 Mar;19(3):871-7. doi: 10.1245/s10434-011-1876-z. Epub 2011 Jul 27. PubMed PMID: 21792512.](http://www.ncbi.nlm.nih.gov/pubmed/21792512)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/21792512)

Two indications for nerve exploration are open fractures and high-velocity injuries. Nerve exploration under these circumstances can improve outcomes. Intramedullary fixation is associated with higher revision surgery and complication rates vs open reduction and internal fixation. Nonsurgical treatment in the setting of a high-energy injury is associated with a higher nonunion rate.
RECOMMENDED READINGS
10. [Heineman DJ, Poolman RW, Nork SE, Ponsen KJ, Bhandari M. Plate fixation or intramedullary fixation of humeral shaft fractures. Acta Orthop. 2010 Apr;81(2):216-23. doi: 10.3109/17453671003635884. Review. Erratum in: Acta Orthop. 2010 Oct;81(5):647. PubMed PMID: 20170424. ](http://www.ncbi.nlm.nih.gov/pubmed/20170424)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/20170424)
11. [Bishop J, Ring D. Management of radial nerve palsy associated with humeral shaft fracture: a decision analysis model. J Hand Surg Am. 2009 Jul-Aug;34(6):991-6.e1. doi: 10.1016/j.jhsa.2008.12.029. Epub 2009 Apr 10. PubMed PMID: 19361935. ](http://www.ncbi.nlm.nih.gov/pubmed/19361935)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/19361935)

Rheumatoid arthritis remains a common inflammatory arthropathy that can lead to progressive synovitis of the elbow joint. Patients often present with recalcitrant elbow pain and loss of motion. In the early
stages, the joint space can be fairly well preserved. With progressive synovitis, cartilage destruction leads to symmetric joint space narrowing and joint destruction. For the younger patient with recalcitrant synovitis and a relatively well-preserved joint space, open or arthroscopic synovectomy provides successful improvement for 70% to 80% of patients. In most cases, radial head resection is not required. Synovitis that encircles the radial head and neck can lead to pain and crepitus with forearm rotation. Preserving the radial head prevents the rapid progression of wear at the ulnohumeral joint. A total elbow replacement, while a successful treatment modality for the older, lower demand patient with rheumatoid arthritis, would not be ideal for the younger patient given the significant postoperative restrictions imparted.

- His activity levels after surgery
PREFERRED RESPONSE: 4- sensory axillary nerve palsy from his dislocation.

- instability of the fracture.