Shoulder And Elbow: Review | Dr Hutaif Shoulder & Elbow -...

images with tibial stress fractures.
5. #### After activity, pain persists longer with tibial stress fractures.
PREFERRED RESPONSE: 1
DISCUSSION: Anterior tibial pain can often be difficult to diagnose. A bone scan showing the tibial cortex in a diffuse, longitudinal orientation is consistent with shin splints compared to a more discreet, localized uptake more commonly seen with a stress fracture. Bone stress injuries are due to cyclical overuse of the bone. They are relatively common in athletes and military recruits but are also seem in otherwise healthy people who have recently started new or intensive physical activity. Diagnosis of bone stress injuries is based on the patient’s history of increased physical activity and on imaging findings.
The general symptom of a bone stress injury is stress-related pain. Bone stress injuries are difficult to diagnose based only on a clinical examination because the clinical symptoms may vary depending on the phase of the pathophysiological spectrum in the bone stress injury. Imaging studies are needed to ensure an early and exact diagnosis. If the diagnosis is made early, most bone stress injuries heal well without complications.
REFERENCES: Mubarak SJ, Gould RN, Lee YF, et al: The medial tibial stress syndrome: A cause of shin splints. Am J Sports Med 1982;10:201-205.
Knobloch K, Yoon U, Vogt PM: Acute and overuse injuries correlated to hours of training in master running athletes. Foot Ankle Int 2008:29:671-676.
Kiuru MJ, Pihlajamaki HK, Ahovuo JA: Bone stress injuries. Acta Radiol 2004;45:317-326.

DISCUSSION: The supplement is creatine. Approximately 17% of high school athletes and about 30% of high school football players use creatine. Creatine is a protein synthesized in the liver and the kidney, circulates in the bloodstream, and is incorporated into muscle. Its use is associated with increased muscle mass, short-term improvement in sprinting, and may allow for increased anaerobic resistance performance. Caffeine and ephedrine are taken orally but do not increase muscle mass. Testosterone and human growth hormone are both associated with increased body mass but must be injected.

PREFERRED RESPONSE: 1

REFERENCES: McGuine TA, Sullivan JC, Bernhardt DT: Creatine supplementation in high school football players. Clin J Sports Med 2001 ;11:247-253.
Rawson ES, Gunn B, Clarkson PM: The effects of creatine supplementation on exercise-induced muscle damage. J Strength Cond Res 2001; 15:178-184.
Branch JD: Effect of creatine supplementation on body composition and performance: A meta-analysis.
Int J Sport Nutr Exerc Metab 2003;13:198-226.

Intraoperative times approaching 3 hours have been associated with an increased risk of infection after undergoing ORIF of tibial plateau fractures.
The optimal treatment for displaced tibial plateau fractures is ORIF. The goals
of care are preservation of the soft tissues, restoration of the mechanical axis, and restoration of the articular surface. These injuries are associated with complications such as infections, arthrofibrosis, malunion/nonunion, and compartment syndromes. Infections have been associated with male gender, smoking, pulmonary disease, bicondylar fracture patterns, and intraoperative time over 3 hours. Modern techniques such as delay of definitive surgery, the use of temporary spanning external fixators, and dual incision approaches have improved the results of ORIF.
Basques et al. performed a database study to identify factors that are associated with short-term outcomes after ORIF of tibial plateau fractures. They examined adverse events (AAE), severe adverse events (SAEs), infectious complications, extended length of stay (LOS), and readmission within 30 days. They found that AAE was associated with increased ASA class and history of pulmonary disease. SAE was associated with male sex and increased ASA class. Infectious complications were associated with male sex, increased ASA class, smoking, pulmonary disease, and bicondylar fracture patterns.
Colman et al. performed a retrospective study to identify the relationship between surgical site infection and prolonged operative time in fractures of the tibial plateau. They found that mean operative time for patients who had an infection was 2.8 hours vs. 2.2 hours for patients without an infection. They also found that compartment syndromes that underwent fasciotomy had a higher infection rate than patients that did not develop this complication. Open fracture grade was also related to infection rate. They concluded that operative times approaching 3 hours and open fractures are related to an increased overall risk for surgical site infection.
Figure A is an AP radiograph of the knee demonstrating an intra-articular split of the lateral tibial plateau (Schatzker 2). Illustration A is an illustration of the Schatzker classification of tibial plateau fractures.
Incorrect Answers:
Answer 2: Age has not been associated with an increased risk of infection after ORIF of the tibial plateau.
Answer 3: An increased risk of infection after ORIF of the tibial plateau has been associated with bicondylar fracture patterns.
Answer 4: Well controlled diabetes and hypertension have not been associated with an increased risk of infection after ORIF of the tibial plateau.
Answer 5: Mechanism of injury has not been associated with an increased risk of infection after ORIF of the tibial plateau.

_Propionibacterium acnes (P. acnes) has emerged as the most likely cause of infection associated with shoulder arthroplasty. A gram-positive, aerotolerant anaerobic rod that lives in the skin, not on the skin, it is more difficult to diagnose and treat than more conventional organisms. As an anaerobe, it does not create pus, but rather a turbid fluid, and is associated with humeral stem loosening when a clinically significant infection is present. P. acnes remains sensitive to most antibiotics, and, although some resistance to clindamycin has been reported, highly resistant strains have not yet evolved._
_P. acnes often remains a diagnostic challenge. Conventional tests measuring C-reactive protein, sedimentation rate, Interleukin-6, and white cell counts are not highly accurate. Even aspiration and culture of the affected joint is not reliable. Cultures should be kept at least 2 weeks to avoid false-negative results with slow-growing organisms. Some investigators have advocated diagnostic arthroscopy with biopsy as another diagnostic alternative._
Treatment of shoulder replacements infected with _P. acnes_ is evolving. For shoulders associated with low clinical suspicion for infection but an unexpected positive culture result, treatment can be 1-stage reconstruction without an extended course of intravenous antibiotics. Most commonly, an infected shoulder arthroplasty is treated with a 2-stage reconstruction similar to that seen in the setting of hip and knee arthroplasty.
RECOMMENDED READINGS
23. Kelly JD 2nd, Hobgood ER. Positive culture rate in revision shoulder arthroplasty. Clin Orthop Relat Res. 2009 Sep;467(9):2343-8. doi: 10.1007/s11999-009-0875-x. Epub 2009 May 12. PubMed PMID:
[19434469/. ](http://www.ncbi.nlm.nih.gov/pubmed/19434469)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/19434469)
24. Dodson CC, Craig EV, Cordasco FA, Dines DM, Dines JS, Dicarlo E, Brause BD, Warren RF. Propionibacterium acnes infection after shoulder arthroplasty: a diagnostic challenge. J Shoulder Elbow Surg. 2010 Mar;19(2):303-7. doi: 10.1016/j.jse.2009.07.065. Epub 2009 Nov 1. PubMed PMID:
[19884021/. ](http://www.ncbi.nlm.nih.gov/pubmed/19884021)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/19884021)
25. Grosso MJ, Sabesan VJ, Ho JC, Ricchetti ET, Iannotti JP. Reinfection rates after 1-stage revision shoulder arthroplasty for patients with unexpected positive intraoperative cultures. J Shoulder Elbow Surg. 2012 Jun;21(6):754-8. doi: 10.1016/j.jse.2011.08.052. Epub 2012 Feb 3. PubMed PMID:
[22305921/. ](http://www.ncbi.nlm.nih.gov/pubmed/22305921)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/22305921)
26. [Pottinger P, Butler-Wu S, Neradilek MB, Merritt A, Bertelsen A, Jette JL, Warme WJ, Matsen FA 3rd. Prognostic factors for bacterial cultures positive for Propionibacterium acnes and other organisms in a large series of revision shoulder arthroplasties performed for stiffness, pain, or loosening. J Bone Joint Surg Am. 2012 Nov 21;94(22):2075-83. doi: 10.2106/JBJS.K.00861.](http://www.ncbi.nlm.nih.gov/pubmed/23172325)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23172325)

The radiograph shows a bony avulsion of the ACL attachment site on the tibial spine in this skeletally immature patient. In this age group, injury often results in failure of the bony attachment site rather than the substance of the ligament. Avulsion of the patellar tendon insertion site can occur, but this structure is located at the apophysis of the tibial tubercle. The attachment site of the PCL is much more posterior. In adults, bony avulsion is more commonly associated with PCL injuries than with ACL injuries. When a small bony avulsion of the lateral capsule from the lateral tibial plateau is seen on the AP view, this finding is considered pathognomonic of an ACL injury (Segond sign) in adults. The area of the pes anserinus is anterior and distal; avulsion would be unusual.
REFERENCES: Baxter MP, Wiley JJ: Fractures of the tibial spine in children: An evaluation of knee stability. J Bone Joint Surg Br 1988;70:228-230.
Meyers MH, McKeever FM: Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1970;52:1677-1684.
DeLee JC: Ligamentous injury of the knee, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine. Philadelphia, PA, WB Saunders, 1994, pp 406-432.

Perioperative neuropathies are multifocal in origin and not only related to positioning or pressure over the ulnar nerve. The most common major causes of neuropathy and ulnar neuropathies are stretch, compression, and ischemia, particularly associated with cardiac surgery. There can also be mechanical derangement of the nerve itself. Nerves that are asymptomatic but dysfunctional presurgically are susceptible to this injury during the surgical procedure. Symptoms are often bilateral.
Pure sensory lesions are frequently transient. Unlike motor lesions, most pure sensory lesions will improve within 3 to 5 days after diagnosis. Ulnar neuropathy is often bilateral, particularly for males, and can be detected by contralateral EMG studies. A nonsymptomatic limb often produces abnormal EMG study findings. Other factors that can be associated with ulnar neuropathy are body mass index of 35 or higher, prolonged bed rest, and history of substantial recent weight loss. With motor findings, these symptoms will probably be prolonged. EMG and nerve conduction studies are not indicated at this time, nor are radiographic cervical spine studies. The best thing to do initially is to protect the elbow and avoid the attitude of flexion.
RECOMMENDED READINGS
8. Alvine FG, Schurrer ME. Postoperative ulnar-nerve palsy. Are there predisposing factors? J Bone Joint Surg Am. 1987 Feb;69(2):255-9. PubMed PMID: 3805087.
9. Novak CB, Lee GW, Mackinnon SE, Lay L. Provocative testing for cubital tunnel syndrome. J Hand Surg Am. 1994 Sep;19(5):817-20. PubMed PMID: 7806810.

Implant materials and design features that have occurred with cementless TKA are flat polyethylene, heat-pressed polyethylene and patch porous- coated surfaces. Smooth metal surfaces that separate pads of porous coating produce metaphyseal and diaphyseal osteolysis by conducting debris along fibrous bridges that form in the smooth areas between the patches of porous metal.

Isolated infraspinatus atrophy and weakness is most commonly the result of compression of the suprascapular nerve at the spinoglenoid notch. This condition often is found in the setting of a labral tear and an associated spinoglenoid notch cyst. Compression of the supraspinatus nerve at the suprascapular notch would result in weakness of both the supraspinatus and infraspinatus muscles. Medial subluxation of the biceps is often seen with subscapularis tearing, and weakness with internal rotation can be expected. A massive rotator cuff tear with retraction of the supraspinatus and infraspinatus would likely result in weakness and atrophy of both the supraspinatus and infraspinatus.
RECOMMENDED READINGS
18. [Piasecki DP, Romeo AA, Bach BR Jr, Nicholson GP. Suprascapular neuropathy. J Am Acad Orthop Surg. 2009 Nov;17(11):665-76. Review. PubMed PMID: 19880677. ](http://www.ncbi.nlm.nih.gov/pubmed/19880677)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/19880677)
19. [Mall NA, Hammond JE, Lenart BA, Enriquez DJ, Twigg SL, Nicholson GP. Suprascapular nerve entrapment isolated to the spinoglenoid notch: surgical technique and results of open decompression. J Shoulder Elbow Surg. 2013 Nov;22(11):e1-8. doi: 10.1016/j.jse.2013.03.009. Epub 2013 May 8. PubMed PMID: 23664748.](http://www.ncbi.nlm.nih.gov/pubmed/23664748)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23664748)

Lateral condyle fractures in skeletally immature patients are uncommon. This is a displaced and rotated lateral condyle fracture. Although closed reduction could be attempted, these fractures are notoriously difficult to reduce even with an open approach.
The blood supply to the lateral condyle fragment enters posterolaterally. Disruption of the blood supply may lead to osteonecrosis of the capitellum, so great care should be taken during open approaches to the elbow in skeletally immature patients, especially during lateral condyle open reduction and internal fixation.
Treatment of lateral condyle fractures in skeletally immature patients may be fraught with danger. The most common complication is persistent stiffness.
Growth arrest is a surprisingly rare complication, considering the fracture usually involves the capitellar physis, and reduction of the physis is often radiographically imperfect even with open reduction. However, this may be an underrecognized complication because arrest of the capitellar physis may not be evident until 1 to 3 years postinjury—beyond the time at which some surgeons or patients believe follow-up is necessary. Growth arrest has been reported with smooth wire fixation and lag screw fixation. The average time to radiographic union of a lateral condyle fracture is 6 weeks.
RECOMMENDED READINGS
10. [Cardona JI, Riddle E, Kumar SJ. Displaced fractures of the lateral humeral condyle: criteria for implant removal. J Pediatr Orthop. 2002 Mar-Apr;22(2):194-7. PubMed PMID: 11856929. ](http://www.ncbi.nlm.nih.gov/pubmed/11856929)[View Abstract at](http://www.ncbi.nlm.nih.gov/pubmed/11856929)[ ](http://www.ncbi.nlm.nih.gov/pubmed/11856929)[PubMed](http://www.ncbi.nlm.nih.gov/pubmed/11856929)
11. [Stein BE, Ramji AF, Hassanzadeh H, Wohlgemut JM, Ain MC, Sponseller PD. Cannulated Lag Screw Fixation of Displaced Lateral Humeral Condyle Fractures Is Associated With Lower Rates of Open Reduction and Infection Than Pin Fixation. J Pediatr Orthop. 2015 Jul 17. [Epub ahead of print] PubMed PMID: 26192878. ](http://www.ncbi.nlm.nih.gov/pubmed/26192878)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/26192878)
12. [Das De S, Bae DS, Waters PM. Displaced humeral lateral condyle fractures in children: should we bury the pins? J Pediatr Orthop. 2012 Sep;32(6):573-8. doi: 10.1097/BPO.0b013e318263a25f. PubMed PMID: 22892618. ](http://www.ncbi.nlm.nih.gov/pubmed/22892618)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/22892618)
13. [Cates RA, Mehlman CT. Growth arrest of the capitellar physis after displaced lateral condyle fractures in children. J Pediatr Orthop. 2012 Dec;32(8):e57-62. doi: 10.1097/BPO.0b013e31826bb0d5. PubMed PMID: 23147632. ](http://www.ncbi.nlm.nih.gov/pubmed/23147632)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23147632)

Absence of the rotator cuff results in superior migration of the humeral head because of unopposed deltoid function. This proximal migration results in eccentric loading of glenoid components with early loosening. Hemiarthroplasty yields good pain relief with limited goals of active elevation of 90 degrees. The coracoacromial arch should be preserved. Achieving satisfactory subscapularis tension is preferred to the use of an oversized humeral component.
REFERENCES: Zeman CA, Arcand MA, Cantrell JS, Skedros JG, Burkhead WZ Jr: The rotator cuff-deficient arthritic shoulder: Diagnosis and surgical management. J Am Acad Orthop Surg 1998;6:337-348.
Arntz CT, Jackins S, Matsen FA III: Prosthetic replacement of the shoulder for the treatment of defects in the rotator cuff and the surface of the glenohumeral joint. J Bone Joint Surg Am 1993;75:485-491.
Williams GR Jr, Rockwood CA Jr: Hemiarthroplasty in rotator cuff-deficient shoulders. J Shoulder Elbow Surg 1996;5:362-367.
Zuckerman JD, Scott AJ, Gallagher MA: Hemiarthroplasty for cuff tear arthropathy. J Shoulder Elbow Surg 2000;9:169-172.

Treatment for pes planus revolves around 2 clinical parameters: pain and rigidity. In the absence of pain, no intervention is warranted because there are no other symptoms that can reasonably be linked to the foot shape. Flexible pes planus (that corrects with heel rise) is usually normal and does not cause symptoms, but it can be associated with a symptomatic accessory navicular, in which case the patient may have pain over the medial navicular from either traction by the tibialis posterior or the act of rubbing against the medial shoe counter. Rigid pes planus is most frequently associated with a tarsal coalition, which classically presents in late adolescence but can become symptomatic for the first time in adults. The initial treatment for painful pes planus, whether flexible or rigid, is immobilization, usually in a walking cast. This often is sufficient to relieve symptoms on a permanent basis. Surgery should be contemplated only when this treatment fails. Adult-acquired flatfoot is most commonly attributable to tibialis posterior tendon dysfunction. In stage 3, the pes planus is rigid. If it is painful, surgical treatment, which consists of a triple arthrodesis, may be considered. However, if medical constraints or patient preference preclude surgery, an Arizona brace can provide sufficient support to reduce symptoms to an acceptable level to perform activities of daily living.
RECOMMENDED READINGS
[Varner KE, Michelson JD. Tarsal coalition in adults. Foot Ankle Int. 2000 Aug;21(8):669-72. PubMed PMID: 10966365. ](http://www.ncbi.nlm.nih.gov/pubmed/10966365)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/10966365)
[Lin JL, Balbas J, Richardson EG. Results of non-surgical treatment of stage II posterior tibial tendon dysfunction: a 7- to 10-year followup. Foot Ankle Int. 2008 Aug;29(8):781-6. doi: 10.3113/FAI.2008.0781. PubMed PMID: 18752775. ](http://www.ncbi.nlm.nih.gov/pubmed/18752775)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/18752775)
[Chao W, Wapner KL, Lee TH, Adams J, Hecht PJ. Nonoperative management of posterior tibial tendon dysfunction. Foot Ankle Int. 1996 Dec;17(12):736-41. PubMed PMID: 8973895. ](http://www.ncbi.nlm.nih.gov/pubmed/8973895)[View](http://www.ncbi.nlm.nih.gov/pubmed/8973895)[ ](http://www.ncbi.nlm.nih.gov/pubmed/8973895)[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/8973895)
Cha SM, Shin HD, Kim KC, Lee JK. Simple excision vs the Kidner procedure for type 2 accessory navicular associated with flatfoot in pediatric population. Foot Ankle Int. 2013 Feb;34(2):167-72. doi: 10.1177/1071100712467616. Epub 2013 Jan 15. PubMed PMID:
[23413054/. ](http://www.ncbi.nlm.nih.gov/pubmed/%2023413054)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/%2023413054)
[Sullivan JA. Pediatric flatfoot: evaluation and management. J Am Acad Orthop Surg. 1999 Jan;7(1):44-53. PubMed PMID: 9916191.](http://www.ncbi.nlm.nih.gov/pubmed/9916191)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/9916191)
CLINICAL SITUATION FOR QUESTIONS 51 AND 52
Figure 51a demonstrates the sneaker wear pattern and Figures 51b and 51c are the weight-bearing radiographs of a 20-year-old National Collegiate Athletic Association Division I basketball player. Throughout his college career he has experienced pain in the lateral aspect of his right foot. He has been treated with a clamshell orthotic, but this preseason his pain is worse than ever. Upon examination he has tenderness to palpation over the fifth metatarsal and his peroneal strength is 5/5 bilaterally

A

B

C

**DISCUSSION** : A quadriceps snip is performed by extending a medial parapatellar approach superiorly and laterally across the quadriceps tendon. It is then repaired primarily at the end of the procedure. The primary advantage of this technique over other surgical maneuvers that improve exposure at the time of revision total knee arthroplasty is that the postoperative regimen for physical therapy does not need to be altered.

**

Scientific References

: Younger AS, Duncan CP, Masri BA: Surgical exposures in revision total knee arthroplasty. J Am Acad Orthop Surg 1998;6:55-64.
Della Valle CJ, Berger RA, Rosenberg AG: Surgical exposures in revision total knee arthroplasty. Clin Orthop Relat Res 2006;446:59-68.
Barrack RL, Smith P, Munn B, et al: The Ranawat Award. Comparison of surgical approaches in total knee
arthroplasty. Clin Orthop Relat Res 1998;356:16-21.

Question 2
A healthy 72-year-old woman is seen 14 days after cemented total knee arthroplasty. She reports increasing pain and swelling for the last 4 days accompanied by 4 days of wound drainage. Examination reveals that she is afebrile, and has erythema and moderate serosanguinous drainage from the wound. The knee is moderately swollen. Aspiration of the knee reveals no organisms on Gram stain. Culture results are expected back in 48 hours. Optimal management should consist of

1. ### initiation of a first-generation cephalosporin while awaiting culture results.
2. ### initiation of broad-spectrum antibiotics while awaiting culture results.
3. ### ultrasound to evaluate for fluid collection around the knee.
4. ### surgical debridement of the knee before culture results are available.
5. ### inpatient observation and no antibiotics until culture results are available.

PREFERRED RESPONSE: 4**

**DISCUSSION** : Increased pain, swelling, erythema, and drainage 2 weeks removed from the primary arthroplasty are all signs of a probable infection. Erythrocyte sedimentation rate and C-reactive protein may not be helpful as they are elevated postoperatively even in the absence of infection. Even in the absence of infection, persistent wound drainage is an indication for surgical debridement to prevent subsequent infection. When a postoperative infection is easily recognized by clinical examination, there is no need to wait for a positive culture before proceeding with debridement.

REFERENCES: Weiss AP, Krackow KA: Persistent wound drainage after primary total knee arthroplasty. J Arthroplasty 1993;8:285-289.
Jaberi FM, Parvizi J, Haytmanek CT, et al: Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty. Clin Orthop Relat Res 2008;466:1368-1371.
Insall JN, Windsor RE, Scott, WN: Surgery of the Knee, ed 2. New York, NY, Churchill Livingstone, 1993, pp 959-964.

Figure 3a Figure 3b

DISCUSSION: The question centers on the appropriate work-up for a failed total hip arthroplasty prior to revision surgery. The preoperative ESR is elevated and the CRP is at the upper end of normal. If either the ESR or CRP is elevated, further investigations are required to exclude infection as a cause of loosening, particularly in a patient only 3 years after the index procedure. A technetium scan alone is nonspecific and will show increased uptake because of the loose femoral component. An intraoperative frozen section is a helpful confirmatory investigation, but whenever possible the diagnosis should be made preoperatively to allow for appropriate surgical planning. Recently, investigators have shown the value of FDG-PET scanning as a useful investigation for diagnosing infection; however, it is no more accurate than the combined use of an ESR and CRP, and does not allow for identification of an infecting organism. At this point, a hip aspiration for culture is the most appropriate investigation.

REFERENCES: Bauer TW, Parvizi J, Kobayashi N, et al: Diagnosis of periprosthetic infection. J Bone Joint Surg Am 2006;88:869-882.
Pill SG, Parvizi J, Tang PH, et al: Comparison of fiuorodeoxyglucose positron emission tomography and (111
)indium-white blood cell imaging in the diagnosis of periprosthetic infection of the hip. J Arthroplasty 2006;21:91-97.
Spangehl MJ, Masri BA, O’Connell JX, et al: Prospective analysis of preoperative and intraoperative investigations for the diagnosis of infection at the sites of two hundred and two revision total hip arthroplasties. J Bone Joint Surg Am 1999;81:672-683.

Figure 5a Figure 5b

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1. Reference(s)
2. Bertoni F, Calderoni P, Bacchim P, et al: Benign fibrous histiocytoma of bone. J Bone Joint Surg 1986;68A:1225-1230. Unni KK: Dahlin's Bone Tumors: General Aspects and Data on 11,087 Cases, ed 4. Philadelphia, PA, JB Lippincott, 1996, pp 360-365.
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Recombinant human PTH benefits patients with osteoporosis by stimulating osteoblastic bone formation and reducing osteoblastic apoptosis. Treatment reduces vertebral fractures by 65%. PTH analogs act similarly and reduce vertebral fractures by 47%. Bisphosphonates reduce the resorptive activity of
osteoclasts and cause a dissociation of bone formation and resorption that favors bone formation and reduce vertebral fractures by 50% to 70%. Selective estrogen receptor modulators inhibit bone resorption and reduce vertebral fractures by 35%. Humanized monoclonal antibodies inhibit osteoclast formation and reduce vertebral fractures by 68%.
RECOMMENDED READINGS
[Castro-Lionard K, Dargent-Molina P, Fermanian C, Gonthier R, Cassou B. Use of calcium supplements, vitamin D supplements and specific osteoporosis drugs among French women aged 75-85 years: patterns of use and associated factors. Drugs Aging. 2013 Dec;30(12):1029-38. doi: 10.1007/s40266-013-0121-9. PubMed PMID: 24114665. ](http://www.ncbi.nlm.nih.gov/pubmed/24114665)[View](http://www.ncbi.nlm.nih.gov/pubmed/24114665)
[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/24114665)
[Papapoulos S, Makras P. Selection of antiresorptive or anabolic treatments for postmenopausal osteoporosis. Nat Clin Pract Endocrinol Metab. 2008 Sep;4(9):514-23. doi: 10.1038/ncpendmet0941. Review. PubMed PMID: 18714329. ](http://www.ncbi.nlm.nih.gov/pubmed/18714329)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/18714329) [Zhang J, Delzell E, Curtis JR, Hooven F, Gehlbach SH, Anderson FA Jr, Saag KG. Use of pharmacologic agents for the primary prevention of osteoporosis among older women with low bone mass. Osteoporos Int. 2014 Jan;25(1):317-24. doi: 10.1007/s00198-013-2444-0. Epub 2013 Aug 28. PubMed PMID: 23982799. ](http://www.ncbi.nlm.nih.gov/pubmed/23982799)[View Abstract at ](http://www.ncbi.nlm.nih.gov/pubmed/23982799)[PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23982799)

The MR images show a tear through a discoid lateral meniscus. A discoid meniscus is caused by a failure of apoptosis during development in utero and is considered a congenital abnormality. Discoid menisci are prone to tearing and can be caused by minimal trauma. There is no known genetic cause for this condition. Radiographic findings that may be present in the setting of a discoid meniscus include lateral joint space widening, squaring of the lateral femoral condyle, and cupping of the lateral tibial plateau. Contralateral discoid menisci are noted in 20% of patients. There are no other known associated conditions. Treatment _of a symptomatic discoid meniscus should include partial meniscectomy and saucerization or repair._

DISCUSSION: In patients with an osteomyelitic infection, radiographic findings at 1 to 5 days usually show soft-tissue swelling only. Seven to 14 days after symptoms begin, radiographs will most likely show the classic signs of acute osteomyelitis. Reactive bone formation would be expected by 6 months.
REFERENCES: Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 149-161.
Song KM, Sloboda JF: Acute hematogenous osteomyelitis in children. J Am Acad Orthop Surg 2001;9:166-175.

This patient has a pathologic fracture from a high-grade chondrosarcoma with encasement of the axillary contents. Meaningful wide resection necessitates amputation. Radiotherapy and chemotherapy do not have a defined role in the treatment of conventional chondrosarcoma. The resection of the axillary, musculocutaneous, or radial nerve or all 3 nerves is not an indication for a forequarter amputation. If the median or the ulnar nerve is expected to be resected, forequarter amputation should be seriously considered. An absolute indication of a forequarter amputation is encasement of the vascular bundle. Another strong indication is a pathologic fracture.
In 1 study that included both chondrosarcoma and dedifferentiated chondrosarcoma with pathologic fractures involving the proximal femur, the overall 5-year survival rates were 57% and 0%, respectively. In another study, local recurrence was a prelude to distant metastasis, and tumor grade and size and adequacy of the resection trended toward predictors of outcome.
RECOMMENDED READINGS
12. [Pant R, Yasko AW, Lewis VO, Raymond K, Lin PP. Chondrosarcoma of the scapula: long-term oncologic outcome. Cancer. 2005 Jul 1;104(1):149-58. ](http://www.ncbi.nlm.nih.gov/pubmed/15895373)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/15895373)
13. Bone sarcomas. In: Damron TA, ed. _Orthopaedic Surgery Essentials: Oncology and Basic Science_. Philadelphia, PA: Lippincott Williams and Wilkins; 2008:177-211.
14. [Chandrasekar CR, Grimer RJ, Carter SR, Tillman RM, Abudu AT, Jeys LM. Outcome of pathologic fractures of the proximal femur in nonosteogenic primary bone sarcoma. Eur J Surg Oncol. 2011 Jun;37(6):532-6. doi: 10.1016/j.ejso.2011.02.007. Epub 2011 Mar 4. ](http://www.ncbi.nlm.nih.gov/pubmed/21377313)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/21377313)
15. [Puri A, Shah M, Agarwal MG, Jambhekar NA, Basappa P. Chondrosarcoma of bone: does the size of the tumor, the presence of a pathologic fracture, or prior intervention have an impact on local control and survival? J Cancer Res Ther. 2009 Jan-Mar;5(1):14-9. ](http://www.ncbi.nlm.nih.gov/pubmed/19293483)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/19293483)
16. Malawer MM, Springfield D, Eckardt JJ, Peabody TJ. Shoulder girdle and proximal humerus. In: Simon MA, Springfield D, eds. _Surgery for Bone and Soft-Tissue Tumors_. Philadelphia, PA: Lippincott-Raven; 1998:299-321.

The first dorsal compartment encompasses the abductor pollicis longus and extensor pollicis brevis. Multiple slips of abductor pollicus brevis may be present, which is important in de Quervainâs release.

Virtually all patients with metatarsus adductus will improve with time in the absence of active treatment.
C asts are not needed for the majority of cases because spontaneous improvement is by far the most common outcome. Reverse last shoes are not needed in the majority of patients with metatarsus adductus.
Most patients will not need surgery.
Equinus of the hindfoot is not part of the pathology in metatarsus adductus.

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)

Trials comparing the results of open repair of acute Achilles tendon rupture to repairs done in a limited open fashion show no difference in rerupture rate, sural neuropathy, or calf circumference.The scarring observed was much less in the group treated in a limited open fashion. There was a significantly greater number of postoperative complications seen in the group treated in an open fashion compared with those treated with a limited open procedure.

This patient had an eccentric muscle contraction (muscle lengthening while contracting) of his biceps muscle while trying to stop a defender from getting around him. This in turn caused failure of the distal biceps tendon, as evidenced by pain in the antecubital fossa, lack of elbow supination strength, and his positive biceps active test finding (supination/pronation of the forearm showing no motion of the biceps muscle belly). Eccentric contractors
have the highest potential for building strength but also are at highest risk for injury. Concentric (muscle shortening with contraction), isometric (no change in muscle length with contracture), and isokinetic (constant velocity of muscle contraction with a variable force) do not describe the mechanism detailed. The loss of distal biceps attachment will result in loss of elbow supination strength in flexion (the biceps is the only supinator to cross the elbow) while still retaining elbow flexion (albeit weakened) because of the other elbow flexors (brachioradialis and brachialis). Consequently, treatment should be anatomic repair of the distal biceps insertion, which can be performed with a 2-incision or 1-incision technique. Although all of the listed complications have been reported with these techniques, LABC neuropraxia is by far the most common. Radiographs show that this athlete’s injury was repaired using a 1-incision technique with a cortical fixation device and a radial bone tunnel. This technique has gained favor because of its decreased incidence of heterotopic ossification and radioulnar synostosis compared with the 2-incision technique. The most troubling complication for most surgeons is the development of a posterior interosseous nerve (PIN) palsy, which this patient clearly demonstrates in addition to the more common LABCN upon postsurgical examination. Because the LABCN injury is typically a neuropraxia from retraction, a period of observation is indicated. PIN injury can result from excessive traction during surgical exposure or from entrapment by the fixation button. Considering the anatomy of the PIN, successful recovery of the nerve typically progresses based on the distance from the origin of the nerve to the muscle indicated. The extensor indicis proprius (EIP) muscle is the most distal muscle innervated and can be expected to recover last. First to return would be the EDC
followed by the ECU, EDQ, and, finally, the EIP.

This clinical scenario describes a patient with an isolated injury affecting the infraspinatus muscle. The anatomic location of such a lesion would be at the spinoglenoid notch, at which the suprascapular nerve may be compressed distal to its innervation of the supraspinatus but proximal to the infraspinatus innervation. A calcified transverse scapular ligament would also affect the suprascapular nerve but is proximal to the innervation of both muscles. Quadrilateral space syndrome would affect innervation of the deltoid (and teres minor). Parsonage-Turner syndrome is a more diffuse, and often severely painful, brachial plexus neuropathy.

DISCUSSION: The patient has an olecranon stress fracture due to overuse injury from pitching. The repetitive forceful contraction of the triceps coupled with varus and valgus torques about the elbow are felt to cause the olecranon epiphysis to separate from the adjacent epiphyseal plate as reported by Torg and Moyer. This may persist into late adolescence; Charlton and Chandler described five throwing athletes between the ages of 16 to 20 years with delayed closure of the olecranon epiphysis and inability to throw. The ulnar collateral ligament was intact in all. The patients in their study underwent open reduction and internal fixation with tension band wire, screw fixation, and autogenous bone graft in some of the cases.
At 32 months, all were asymptomatic despite a prolonged preoperative course (> 30 months) of limiting pain. It is important to recognize stress fractures about the elbow in a young pitching population and treat accordingly first with rest and cessation of throwing activities. If prolonged, surgical fixation provides reliable results.
REFERENCES: Charlton WP, Chandler RW: Persistence of the olecranon physis in baseball players: Results following operative management. J Shoulder Elbow Surg 2003;12:59-62.
Torg JS, Moyer RA: Non-union of a stress fracture through the olecranon epiphyseal plate observed in an
adolescent baseball pitcher. J Bone Joint Surg Am 1977;59:264-265.
Rettig AC, Wurth TR, Mieling P: Nonunion of olecranon stress fractures in adolescent baseball pitchers: A case series of 5 athletes. Am J Sports Med 2006;34:653-656.

The symptoms are consistent with tarsal tunnel syndrome. Ganglion cysts are a well-known cause of tarsal tunnel syndrome. The MRI scans show a high intensity, well-circumscribed mass in the tarsal tunnel that is consistent with a fluid-filled cyst. Patients usually respond well to excision of the ganglion and resolution of the tarsal tunnel symptoms. The surrounding fat is a different signal intensity on the MRI scans, which rules out a lipoma. Synovial cell sarcoma has a heterogeneous appearance on an MRI scan. Metastatic tumors are most commonly found in the osseous structures of the foot, not the soft tissues.
REFERENCES: Rozbruch SR, Chang V, Bohne WH, et al: Ganglion cysts of the lower extremity: An analysis of 54 cases and review of the literature. Orthopedics 1998;21:141-148.
Llauger J, Palmer J, Monill JM, et al: MR imaging of benign soft-tissue masses of the foot and ankle. Radiographics 1998;18:1481-1498.
Takakura Y, Kitada C, Sugimoto K, et al: Tarsal tunnel syndrome: Causes and results of operative treatment. J Bone Joint Surg Br 1991;73:125-128.

- Presurgical radiation therapy_
**

- noncompliance with postsurgical bracing.

Varus and valgus deformities are contributing factors for unilateral osteoarthritis. Leg alignment is a driving force in the management of weight distribution in the knee, and the HTO is biomechanically designed to realign the weight-bearing line (WBL) in the coronal plane. HTO shifts load in the tibial plateau away from the arthritic compartment toward the healthy compartment. Reducing tibiofemoral load and decreasing thrust moment arms in the affected compartment of the knee joint lessens pain and slows progression of osteoarthritis.

The mechanism of injury/dislocation is most consistent with anterior glenohumeral joint instability. The axial cuts of the MR arthrogram reveals an anteroinferior labral tear, as well as a posterior labral tear. A Hill-Sachs lesion is also consistent with anterior glenohumeral joint instability. At the time of examination under anesthesia, this patient exhibited 2+ anterior and 2+ posterior glenohumeral joint instability. Patients with pan-labral tears and 270° tears can be challenging to diagnose, because patients can report anterior or posterior shoulder instability alone. The
physical examination and advanced imaging in these patients are crucial in directing appropriate treatment.

■
The use of IV antibiotics for prophylaxis of surgical-site infection is supported by Level 1 evidence in spine surgery. It has been given a "B" recommendation by the North American Spine Society. The use of specific bathing solutions the day of surgery may be beneficial, but the evidence in spine surgery is lacking. Similarly, evidence for use of vancomycin (either topically or IV) is not supported by high-level studies, although retrospective and basic science studies support topical vancomycin use.

Bone overgrowth is a poorly understood phenomenon in which the bone end undergoes disorganized appositional growth following amputation in a skeletally immature patient. Overgrowth is the most common complication following transosseous amputation in pediatric patients.
Krajbich reviews the management of pediatric patients with lower-limb deficiences and amputations. He advocates disarticulation as opposed to transosseous amputation when possible as bone overgrowth has not been observed in bone ends covered by articular cartilage.
O'neal et al retrospectively reviewed their rates of surgical revision for bone overgrowth in pediatric and adolescent amputees. The highest rates of revision were seen with metaphyseal-level amputations (50%) and with traumatic amputations (43%).
Benevenia et al reviewed their rates of overgrowth in skeletally immature transosseous amputees using an autogenous epiphyseal transplant from the amputated limb to cap the medullary canal. They found that only 1 of 10 patients undergoing amputation with this technique had complications due to bone overgrowth, compared with 6 of 7 patients undergoing traditional transosseous amputation.
Illustration A is a clinical photo of bone overgrowth eroding through the soft tissue in a transhumeral amputee. Illustration B demonstrates the radiographic appearance of bone overgrowth in a transtibial amputation.
Incorrect Answers:

. Neurogenic pain is a concern for adults, but rarely occurs in children.
Answer 3. Flexion contracture is not a common complication following amputation in pediatric patients.
Answer 4. Adduction contracture is not a common complication following amputation in this patient population.
Answer 5. The proximal tibial physis, important for longitudinal growth of the limb, would be sacrificed with a knee disarticulation, meaning the residual limb will be shorter than if the patient had a transtibial amputation.

A 52-year-old woman reports mild pain localized to the left sternoclavicular joint. History is notable for chronic renal failure requiring dialysis for the last 5 years. A clinical photograph, chest radiograph, and bone scan are shown in Figures 58a through 58c. What is the most likely diagnosis?
1) Pseudogout

2) Spontaneous subluxation

3) Postmenopausal arthritis

4) Chronic osteomyelitis

5) Friedreich’s disease

Spontaneous swelling with the appearance of joint subluxation may be associated with an acute, subacute, or chronic bacterial infection of the sternoclavicular joint. Common causes of infection include bacteremia, rheumatoid arthritis, alcoholism, intravenous drug use, and chronic debilitating diseases. Subclavian vein catheterization and renal dialysis can predispose patients to sepsis and osteomyelitis of the sternoclavicular joint.

A 19-year-old man was struck by a car and is seen in the emergency department with a grade IIIC open distal tibia and fibula fracture. Examination reveals that the toes are cool and dusky with a sluggish capillary refill. Angiography reveals a lesion in the posterior tibial artery amenable to repair. There is no sensation on the plantar aspect of the foot, and he is unable to flex his toes. A clinical photograph and radiograph are shown in Figures 2a and 2b. What is the next most appropriate step in management?
1) Irrigation and debridement with immediate intramedullary fixation, vascular repair, and primary closure

2) Irrigation and debridement with external fixation, vascular repair, and delayed closure

3) Irrigation and debridement with external fixation, vascular repair, exploration of the tibial nerve, and delayed closure

4) Guillotine amputation at the fracture site with delayed closure

5) Immediate below-knee amputation

In the past, loss of plantar sensation in this grade IIIC tibial fracture would have been an indication for below-knee amputation regardless of the potential for vascular repair. However the 2002 LEAP study divided 55 patients with loss of plantar sensation into two groups, the insensate amputation group and the insensate limb salvage group, with 55% of patients in the insensate salvage group regaining normal sensation 2 years after injury. Furthermore, those in
the salvage group who remained insensate after 2 years had equivalent outcomes to those in the amputation group. Because of these findings, limb salvage with vascular repair and external stabilization with delayed closure is deemed appropriate treatment. Immediate intramedullary fixation is not indicated. Because ischemia, contusion, and stretch can adversely affect the tibial nerve, the additional insult of exploration of the nerve is also not advisable given the soft-tissue compromise.

A 27-year-old man now reports dorsiflexion and inversion weakness after an automobile collision 6 months ago in which compartment syndrome developed isolated to the anterior and deep posterior compartments. Examination reveals the development of a progressive cavovarus deformity, but the ankle and hindfoot remain flexible. In addition to Achilles tendon lengthening, which of the following procedures is most likely to improve the motor balance of his foot and ankle?

1) Anterior tibialis tendon transfer to the dorsolateral midfoot

2) Posterior tibialis tendon transfer to the dorsolateral midfoot

3) Peroneus longus tendon transfer to the dorsolateral midfoot

4) Peroneus brevis tendon transfer to the dorsolateral midfoot

5) Flexor hallucis longus tendon transfer to the peroneus brevis

Compartment syndrome of the anterior and deep posterior compartments results in anterior tibialis and posterior tibialis tendon weakness, respectively. Furthermore, the long flexors to the hallux and lesser toes will be weak as well. The intact peroneus longus overpowers the weak anterior tibialis tendon, resulting in plantar flexion of the first metatarsal, cavus, and hindfoot varus.
Therefore, transferring the peroneus longus to the dorsolateral midfoot reduces the first metatarsal plantar flexion torque, and possibly augments ankle dorsiflexion torque.

Figures 4a through 4c show the radiographs of a 43-year-old woman who sustained a twisting injury to her right ankle. She has ankle pain and tenderness medially and laterally. To help determine the optimal treatment, an external rotation stress radiograph of the
ankle is obtained. This test is designed to evaluate the integrity of what structure?
1) Posterior talofibular ligament

2) Distal tibiofibular syndesmosis

3) Anterior talofibular ligament

4) Deltoid ligament

5) Calcaneofibular ligament

In the presence of a supination external rotation-type fracture of the distal fibula (Weber type B), stability of the ankle is best assessed by performing an external rotation stress AP view of the ankle. This test is used to assess the integrity of the deltoid ligament. The presence of a deltoid ligament rupture results in instability and generally is best managed surgically. The gravity stress test can also be used.

A 29-year-old patient sustains a closed, displaced joint depression intra-articular calcaneus fracture. In discussing potential complications of surgical intervention through an extensile lateral approach, which of the following is considered the most common complication following surgery?

1) Nonunion

2) Deep infection

3) Delayed wound healing

4) Peroneal tendinitis

5) Posttraumatic arthritis

Delayed wound healing and wound dehiscence is the most common complication of surgical management of calcaneal fractures through an extensile lateral approach, occurring in up to 25% of patients. Most wounds ultimately heal with local treatment; the deep infection rate is approximately 1% to 4% in closed fractures. Posttraumatic arthritis may develop despite open reduction and internal fixation, but the percentages remain low. Peroneal tendinitis may occur from adhesions within the tendon sheath or from prominent hardware but is relatively uncommon. Nonunion of a calcaneal fracture is rare.

Twelve months after open reduction and internal fixation of a comminuted distal radius fracture as seen in Figure A and B, which of the following tendons is at greatest risk of rupture?
1) Abductor Pollicis Longus

2) Extensor Pollicis Brevis

3) Extensor Indicis Proprius

4) Flexor Pollicis Brevis

5) Flexor Pollicis Longus

Figure A shows a distal radius fracture treated with a volar locked plate. Historically, distal radius fractures treated with dorsal plates were notorious for extensor tendon irritation with some cited rates as high as 50%.
In the reference by Drobetz et al, they reviewed 50 fractures treated with a volar locked plate. They noted that in 6 (12%) of cases that there was rupture of the flexor pollicis longus (FPL) at a mean of 10 months post operatively.
The second reference by Douthit is a retrospective review of 46 fractures treated with a volar locked plate. Excellent initial and maintenance of reduction was noted in 85% of cases, but FPL rupture occurred in 2 patients. Prominent plates and sharp screws were cited as reasons for tendon rupture.

Figures 5a and 5b show the radiographs of a 56-year-old man who was seen in the emergency department following a twisting injury to his left ankle. Examination in your office 3 days later reveals marked swelling and diffuse tenderness to palpation about the ankle and leg. What is the next most appropriate step in management?
1) MRI of the ankle

2) CT of the ankle

3) Technetium bone scan

4) Radiographs of the tibia and fibula

5) Repeat radiographs of the ankle in 5 to 7 days

The radiographs show an isolated posterior malleolus fracture which, given the injury mechanism, is highly suspicious for a Maisonneuve injury. As with any suspected extremity injury, radiographs including the joints above and below the level of injury are acutely indicated. Although MRI may reveal a ligamentous injury to the ankle and CT may show asymmetry of the ankle mortise or syndesmosis, both studies are considerably more costly and are not indicated in the absence of a complete radiographic work-up. Technetium bone scan is nonspecific and would be of limited value in this instance, as would repeat radiographs of the ankle.

A 25-year-old woman with a healed proximal tibiofibular fracture treated with an intramedullary nail 2 years ago is currently wearing an ankle-foot orthosis (AFO) and reports a persistent foot drop. She is unhappy with the AFO and has not seen any functional improvement despite months of physical therapy. Serial electromyograms (EMG) show no recent change over the past year. Examination and EMG findings are consistent with a tibialis anterior 1/5, extensor hallucis longus 2/5, extensor digitorum longus 2/5, posterior tibial tendon (PTT) 5/5, peroneals 3/5, flexor hallucis longus 5/5, and gastrocsoleus 5/5. No discrete nerve lesion was identified. The patient has a flexible equinovarus contracture. What is the most appropriate management?

1) Continued AFO bracing and therapy

2) Ankle fusion

3) Exploration and release of the common peroneal nerve

4) Transfer of the PTT through the interosseous membrane with attachment to the tibialis anterior and peroneus tertius above the level of the ankle, debridement of the anterior compartment, and Achilles tendon lengthening

5) Transfer of the peroneus longus to the dorsum of the foot and Achilles tendon lengthening

This pattern of injury is consistent with an unrecognized compartment syndrome of the anterior and lateral compartments. Transfer of the PTT through a long incision in the interosseous membrane corrects the foot drop deformity, and allows adequate dorsiflexion provided that the tendon to be transferred has a strength of 5/5. Muscles/tendons typically lose one grade of strength after transfer. Transfer into the tendons at the level of the ankle prevents overtensioning or pullout of a PTT tendon that is not long enough.
Debridement of the scarred muscle in the anterior compartment decreases the risk of scarring down to the tendon transfer. Transfer of the peroneus longus is not preferred given its relative lack of strength and line of pull. Continued therapy and bracing are unlikely to lead to further improvement at 2 years after injury. An ankle fusion would correct the foot drop but would not address the tendon imbalances between the tibialis anterior and the peroneus longus, and the PTT and the peroneus brevis.

When using a two-incision approach for open reduction and internal fixation of a Hawkins III talar fracture-dislocation involving
the talar neck and body, what anatomic structure must be preserved to optimize outcome?

1) Deltoid branch of the artery of the tarsal canal

2) Dorsalis pedis artery

3) Tarsal sinus artery

4) Perforating peroneal artery

5) Navicular artery

A Hawkins III fracture-dislocation generally presents with posteromedial displacement with the deltoid ligament intact. Therefore, the only remaining blood supply is the deltoid branch of the artery of the tarsal canal originating from the posterior tibial artery. Often, the medial malleolus is fractured, assisting in reduction and visualization of fracture reduction. If the medial malleolus is intact, a medial malleolus osteotomy allows visualization of the reduction without compromising the last remaining blood supply to the talus.

A 68-year-old man fell off a 20-foot mountain cliff and was seen in the emergency department the following morning. A radiograph is shown in Figure 12. He is a nonsmoker with medical comorbidities of hypertension and hypercholesterolemia that is well controlled with medicine and diet. Capillary refill and sensation are intact distally and the patient is able to move his toes with mild discomfort.
Serosanguinous fracture blisters are present laterally, and the foot is swollen and red. What is the most appropriate management?
1) Short leg cast for 6 weeks

2) Splinting with early range of motion at 3 weeks

3) Immediate open reduction and internal fixation through a medial approach

4) Delayed open reduction and internal fixation

5) Fusion

Whereas a patient age of older than 50 years used to be a contraindication for open reduction and internal fixation of displaced intra-articular calcaneal fractures, new data suggest that the presence of associated medical comorbidities that affect wound healing such as smoking, diabetes mellitus, and peripheral vascular disease are more relevant to postoperative functional outcome. Surgical treatment of Sanders II and III displaced intra-articular calcaneal fractures with initial Bohler angles of > 15 degrees results in better outcomes as compared to nonsurgical management. Indications for primary fusion might include Sanders IV fractures in which articular congruity or Bohler angles cannot be restored. Given the condition of the soft tissues at presentation, delayed fixation is recommended.

A 45-year-old man is seen in the emergency department after returning from a 2-hour airplane flight. He is reporting severe pain in his right leg but has no trouble moving his ankle, leg, or knee. Venous doppler testing reveals no evidence of deep venous thrombosis. He is placed on IV cephazolin but continues to worsen. On the third day in the hospital he has increased pain, some respiratory distress, and trouble maintaining his blood pressure. His leg takes on the appearance seen in Figure 15. An urgent MRI scan shows thickening of the subcutaneous tissues and superficial swelling in the leg but no evidence of an abscess. What is the next most appropriate step in management?
1) Triple antibiotic coverage

2) Transfer to the ICU and a consult with infectious disease

3) Urgent irrigation and debridement with gentle skin closure

4) Urgent hyperbaric oxygen treatments and immunoglobulin

5) Urgent aggressive debridement of skin, subcutaneous fat, and fascia

The patient has necrotizing fasciitis, a rare and sometimes fatal disease that has many different etiologies. Signs that this is not a normal infection are the worsening clinical symptoms despite IV antibiotics and the systemic symptoms. He needs urgent surgical care before he becomes completely septic and unstable. He needs very aggressive debridement of his tissues. Hyperbaric oxygen and immunoglobulins are only anecdotally helpful, and would only be used after surgery.

Figures 17a through 17c show the radiographs of a 38-year-old man following a motorcycle accident. The posterior portion of the talus extruded through a posterolateral wound. The extruded talar body is visible in the wound along with some road debris. Management should now consist of surgical irrigation, debridement, and
1) removal of the extruded talus and placement of an external fixator.

2) immediate tibiocalcaneal fusion.

3) reimplantation of the talus, external fixation, and/or open reduction and internal fixation of the talar neck fracture.

4) reimplantation followed by primary tibiotalar arthrodesis.

5) Syme amputation.

The extruded talus should be placed in sterile bacitracin solution, irrigated thoroughly, gently debrided, and immediately replanted in the OR. Open reduction and internal fixation of the talar fracture may be attempted immediately depending on the soft-tissue envelope, or delayed after soft-tissue
stabilization with an external fixator. A retrospective study of 19 patients with an extruded talus reported that 12 patients had no subsequent surgery after definitive fixation, 7 had subsequent procedures, and 2 patients developed infections that were treated successfully at an average of 42-month follow-up. Successful outcome in this series was attributed to multiple debridements, soft-tissue stabilization, and primary wound closure.

A 52-year-old woman slipped on ice in her driveway. Radiographs are shown in Figures 19a and 19b. The patient was treated in a short leg cast with weight bearing as tolerated for 6 weeks. Due to persistent tenderness at the fracture site, a CAM walker was used for an additional 8 weeks. Nine months after the injury, the patient still walks with a limp and reports pain with deep palpation at the fracture site. What is the next most appropriate step in management?
1) CT scan

2) Repeat period of immobilization

3) Referral to pain management for sympathetic blocks

4) Continued observation and physical therapy

5) Acupuncture

Persistent pain at the fracture site in the absence of infection is most likely due to a nonunion, best detected by CT. Walsh and DiGiovanni reported on a series of closed rotational fibular fractures in which nonunions were detected by CT in the absence of standard ankle radiographic findings. Repeat immobilization would not be appropriate at this late date. Pain management/sympathetic blocks would be considered if the patient displayed pain with light touch and disproportionate pain consistent with a complex mediated pain syndrome.
Acupuncture would be expected to be of limited benefit.

A 23-year-old woman has had a 14-month history of ankle pain after surgical treatment of multiple injuries resulting from a motor vehicle accident. Weight bearing began 4 months after surgery. The pain occurs with weight bearing and motion, but there is very little pain at rest. She has no pertinent medical history and does not smoke. Figures 23a and 23b show current radiographs. What is the most appropriate surgical option?
1) Talectomy

2) Revision open reduction and internal fixation (ORIF) with bone grafting

3) Ankle arthrodesis

4) Tibiotalocalcaneal arthrodesis

5) Triple arthrodesis

The radiographs reveal nonunion of a talar neck fracture. There is no radiographic evidence of osteonecrosis or significant degenerative arthritis. The results of talectomy are suboptimal. Arthrodesis would be indicated for degenerative arthritis. Revision ORIF is feasible and preserves motion. A vascularized graft should be considered whenever osteonecrosis is present, but the talar body appears viable in this case.

A 27-year-old man was struck by a taxi cab and sustained comminuted right distal third tibia and fibula fractures; treatment consisted of placement of an intramedullary nail in the tibia the following morning. At his 6-month follow-up, he has clawing of all five toes. Examination reveals flexion deformities of the distal and proximal interphalangeal joints that are flexible with plantar flexion and rigid with dorsiflexion. Calluses are present on the dorsum and tip of the toes. Single heel rise is normal. He has a mild equinus contracture (relative to the left leg) that is not relieved with knee flexion. What is the most appropriate treatment option?

1) Physical therapy and bracing

2) Reassurance that the deformity will resolve with time

3) Achilles tendon lengthening, and release or retromalleolar lengthening of the flexor digitorum longus (FDL) and flexor hallucis longus (FHL)

4) FDL and FHL tenotomies at the individual digits with transfer of the posterior tibial tendon to the dorsum of the foot

5) FDL and FHL tenotomies at the individual digits with midfoot capsular release and hallux interphalangeal fusion

This is an example of tethering of the flexor hallucis longus/flexor digitorum longus (FHL/FDL) to the fracture site. Additional time and/or physical therapy and bracing would not be expected to be of benefit. Release of the FHL and FDL from the fracture site or retromalleolar lengthening will address the posttraumatic claw toe deformity and Achilles tendon lengthening will address the mild equinus. Posterior tibial tendon transfer is not appropriate as the patient demonstrates a normal heel rise. Midfoot releases and hallux fusion are also not indicated.

A 24-year-old man reports the development of a foot drop following a knee dislocation 1 year ago. The common peroneal nerve was found to be in continuity at the time of surgical reconstruction of the posterolateral corner of the knee joint. He would like to eliminate the need for an ankle-foot orthosis. What is the best option to achieve elimination of the orthosis?

1) Repeat neurolysis of the common peroneal nerve at the knee level

2) Repeat neurolysis of the common peroneal nerve with cable grafting

3) Extensor hallucis longus transfer to the distal first metatarsal

4) Anterior transfer of the tibialis posterior tendon through the interosseous membrane

5) Ankle fusion

The ankle dorsiflexor muscles have been denervated for too long a period to expect reinnervation to be successful. Even if the extensor hallucis longus tendon was functional, it is unlikely to have sufficient strength to achieve dynamic ankle dorsiflexion. The tibialis posterior tendon transfer has been shown to predictably achieve these goals in a high percentage of patients.
Successful ankle fusion is likely to fail with time due to the development of forefoot equinus.

A 21-year-old male construction worker fell from a roof and sustained an injury to his left foot. Radiographs and CT scans are shown in Figures 24a through 24e. Compared to nonsurgical management, surgical treatment offers which of the following advantages?
1) Quicker return to activities

2) Quicker return to work

3) Increased subtalar joint range of motion

4) Decreased risk of nonunion

5) Decreased risk of posttraumatic arthritis

The radiographs and CT scans show a displaced intra-articular calcaneal fracture, with loss of calcaneal height and length. Recent multicenter, randomized, prospective studies suggest that surgical treatment of displaced intra-articular calcaneal fractures is associated with an almost six-fold decrease
in the risk of posttraumatic subtalar arthritis (necessitating subtalar arthrodesis) compared to nonsurgical treatment. Despite ongoing controversy, surgical treatment has not been shown to be advantageous with respect to activity, time to return to work, or subtalar joint range of motion. A nonunion of a calcaneal fracture is exceedingly rare regardless of the treatment method.

A 35-year-old man is seen in the emergency department with a bullet wound to the foot that occurred 2 hours ago. Examination reveals a 0.5-cm entrance wound on the dorsum of the foot and a 1.5-cm exit wound on the plantar aspect. Exploration of the plantar wound in the emergency department reveals bone and metal fragments.
Radiographs reveal a comminuted, unstable fracture of the base of the first metatarsal and cuneiform. Management should consist of tetanus toxoid, and

1) surface irrigation, sterile dressing, and a short leg cast.

2) surface irrigation, sterile dressing, a short leg cast, and oral antibiotics.

3) surface irrigation, sterile dressing, a short leg cast, and IV antibiotics.

4) surgical debridement, a short leg cast, and IV antibiotics.

5) surgical debridement, external or internal fixation, and IV antibiotics.

The patient sustained a type I unstable fracture that requires debridement of superficial fragments from the sole and surgical stabilization. Low-velocity wounds less than 8 hours old are considered type I open fractures. In contrast, gunshot wounds with associated fractures more than 8 hours old are considered type II open fractures using the Gustilo and Anderson classification. Gustilo type I stable fractures due to gunshot wounds and seen within 8 hours can be treated with tetanus toxoid (if no history of immunization or booster within 5 years), surface irrigation, and casting or a hard sole shoe. Antibiotics are not required unless gross contamination is present. However, if the extent of contamination is unclear, or if a joint is penetrated, then routine antibiotic prophylaxis is recommended. Indications for surgery include: articular involvement, unstable fractures, presentation 8 or more hours after injury, tendon involvement, and superficial fragments in the palm or sole. Type I unstable fractures may be stabilized with internal or external fixation. Type II unstable fractures should be treated with external fixation and repeat debridements until clean.

A 32-year-old laborer reports left ankle pain and deformity. History reveals that he sustained a left ankle fracture 2 years ago and was treated with closed reduction and casting. Radiographs are shown in Figures 25a through 25c. What is the most appropriate management?
1) Bracing and physical therapy

2) Intra-articular injection of steroids into the ankle joint, bracing, and physical therapy

3) Intra-articular injection of hyaluronic acid product into the ankle joint, bracing, and physical therapy

4) Ankle fusion

5) Corrective osteotomy of the fibula and medial malleolus with reconstruction of the syndesmosis if unstable

Corrective osteotomy of fibular malunions, with appropriate lengthening, even in the presence of early arthritis, has been shown to decrease ankle pain and increase stability. Reduction and bone grafting of the medial malleolar nonunion is also needed. There is no evidence supporting the use of intraarticular steroids or hyaluronic acid in the ankle joint. Lateral talar displacement of even 1 mm has been reproducibly shown to decrease tibiotalar contact by 40% to 42%, causing a predisposition to arthritis.

Figures 29a and 29b show a clinical photograph and radiographs of a patient who sustained an open calcaneus fracture in a motor vehicle accident. The patient received immediate IV antibiotics and an emergent irrigation and debridement. The swelling has subsided by 3 weeks and the medial wound is clean. What do you tell the patient
about the likelihood of infection if a formal open reduction and internal fixation via a lateral approach is performed?
1) There is no significant difference between the infection rate for this fracture and a similar closed fracture.

2) Due to the risk of infection, open reduction and internal fixation is not recommended for this fracture.

3) The infection rate is three to five times more likely with this fracture.

4) Due to the risk of infection from a lateral approach, treatment is confined to limited internal fixation or an external fixator.

5) The patient will need to undergo 3 weeks of IV antibiotics at home.

Multiple authors have shown similar infection rates for grade 1 and 2 open medial fractures and closed fractures that have been treated with an extensile lateral approach and open reduction and internal fixation. Patients only need IV antibiotics for 2 to 3 days after surgery. Formal open reduction and internal fixation is not recommended for grade 3 medial wounds and most lateral wounds.

A 24-year-old woman was struck by a mini van in a parking lot and sustained a closed segmental tibia fracture that was treated with an intramedullary nail the following morning. Follow-up examinations reveal a slowly progressive clawing of all five toes, a progressive equinocavovarus contracture, and the patient is unable to perform a single heel rise on the affected limb. At 1 year after surgery, the patient now has a 10-degree equinus contracture that is not relieved with knee flexion. Treatment should now consist of

1) physical therapy and bracing.

2) reassurance that these problems will resolve with time.

3) posterior capsule release, Achilles tendon lengthening, and excision of the scarred muscle and tendon in the leg and foot.

4) Achilles tendon lengthening, and flexor digitorum longus and flexor hallucis longus tenotomies at the individual digits with transfer of the posterior tibial tendon to the dorsum of the foot.

5) flexor digitorum longus and flexor hallucis longus tenotomies at the individual digits with midfoot capsular release and hallux interphalangeal fusion.

This is an example of a missed deep posterior compartment syndrome that typically presents 6 months after the injury with progressive clawing due to necrosis, scarring, and contracture of the posterior tibial tendon, flexor digitorum longus, and flexor hallucis longus. Treatment consists of debridement of necrotic muscle and scar tissue with corresponding tendon excision. After debridement and posterior capsule release, if the equinus is relieved with knee flexion, a gastrocnemius slide may be performed.
Otherwise, the lengthening should be at the level of the Achilles tendon. Bracing will not address the claw toes.

Optimal management of the injury shown in Figure 31 should include which of the following?
1) Cast immobilization in equinus

2) Open reduction and internal fixation once the acute soft-tissue swelling has resolved

3) Urgent reduction and fixation

4) Arthroscopic-assisted percutaneous fixation

5) Open reduction and internal fixation with primary subtalar arthrodesis

The radiograph shows a displaced calcaneal beak fracture, a tongue-type fracture variant. The fracture fragment typically includes the insertion point of the Achilles tendon, which places marked tension on the thin overlying soft-tissue envelope and can lead to full-thickness necrosis if not acutely addressed. Cast immobilization does not adequately address the increased soft-tissue tension, as the fragment will be difficult to control. Arthroscopic-assisted techniques or primary arthrodesis are not indicated because calcaneal beak fractures are typically extra-articular.

A 23-year-old man who was the restrained driver in a car involved in a high-speed motor vehicle accident sustained the closed injury shown in Figures 32a through 32c. Which of the following factors has the greatest impact on the risk of osteonecrosis?
1) Surgical stabilization within 6 to 8 hours of injury

2) Extent of initial fracture displacement

3) Nicotine use

4) Posterior-to-anterior screw fixation

5) Anatomic fracture reduction

The incidence of osteonecrosis following displaced talar neck fractures is most related to the extent of initial fracture displacement. With increasing fracture displacement, the tenuous vascular supply to the talar body is more at risk for damage, thereby increasing the risk of osteonecrosis. Although displaced talar neck fractures have historically been considered a surgical emergency, recent studies have shown that the timing of surgical intervention bears no impact on the development of osteonecrosis. While nicotine use has an influence on fracture healing, it has never been shown to be a factor in osteonecrosis, nor has posterior-to-anterior screw fixation or the quality of fracture reduction.

A 32-year-old woman sustained a closed calcaneus fracture 2 years ago and was treated nonsurgically. She now reports a 6-month history of progressively worsening pain over the anterior ankle and lateral hindfoot. Climbing stairs and ascending slopes is particularly difficult for her. Bracing and intra-articular corticosteroid injections have not provided sufficient relief. Figure 36 shows a weight-bearing lateral radiograph. What is the most appropriate surgical option?
1) Subtalar arthrodesis in situ with plantar flexion osteotomy of the talar neck

2) Distraction subtalar arthrodesis with a corticocancellous bone block autograft

3) Subtalar arthrodesis in situ

4) Triple arthrodesis

5) Subtalar arthrodesis in situ with anterior ankle exostectomy

Intra-articular fractures of the calcaneus often include depression of the posterior facet of the subtalar joint. This can lead to dorsiflexion of the talus because of diminished height posteriorly. In a weight-bearing position, the dorsal surface of the talar neck can impinge against the distal tibia, causing anterior ankle pain. In addition, posttraumatic arthritis of the subtalar joint typically occurs after a calcaneus fracture. The patient’s symptoms are consistent with both anterior ankle impingement and subtalar degenerative arthritis. The Bohler angle, approximately 15 degrees, confirms depression of the posterior facet. Distraction subtalar arthrodesis with a corticocancellous bone block autograft will improve talar declination, decrease anterior impingement, and address the subtalar degenerative arthritis simultaneously.

A 38-year-old man underwent a transtibial amputation for chronic posttraumatic foot and ankle pain and chronic calcaneal osteomyelitis. Postoperative radiographs are seen in Figures 41a and 41b. What is the proposed purpose of the surgical modification seen in the radiographs?
1) Reduces shrinkage of the residual limb

2) Creates a more stable platform for load transfer

3) Reduces wound healing complications by avoiding the soft-tissue dissection necessary to transect the fibula at a level proximal to the tibia

4) Connecting bone strut provides an attachment point for more effective
myodesis

5) Allows a more proximal resection level to decrease tension on the wound

The Ertl modification of a below-knee amputation has been proposed to create a more stable “platform” to aid in transferring the load of weight bearing between the residual limb and the prosthetic socket. It is felt that a stable platform allows total contact loading over an enlarged stable surface area.
Early studies have suggested that this modification may enhance the patient’s perceived functional outcome.

A 51-year-old man sustained an open fracture of his tibia in Korea 42 years ago. An infection developed and it was resolved with surgical treatment. For the past 6 months, an ulcer with mild drainage has developed over the medial tibia. The ulcer is small and there is minimal erythema at the ulcer site. A radiograph and MRI scan are shown in Figures 43a and Figure 43b. Initial cultures show Staphylococcus aureus susceptible to the most appropriate antibiotics. Laboratory studies show an erythrocyte sedimentation rate of 70 mm/h. What is the most appropriate surgical treatment at this time?
1) Irrigation and debridement of the cystic lesion and 6 weeks of IV antibiotics

2) Curettage, debridement of nonviable bone, and placement of absorbable
antibiotic beads, followed by a course of IV antibiotics from 1 to 4 weeks and a 6-week course of oral antibiotics

3) Complete resection of the infected portion of bone, placement of an external fixator to stabilize the tibia, and 6 weeks of IV antibiotics

4) Amputation

5) Local debridement of bone and the overlying skin and soft tissues, 6 weeks of IV antibiotics, and free-flap wound coverage

The patient has chronic tibial osteomyelitis that is due to low virulent bacteria. The history and studies do not suggest the need for an amputation or a free-flap procedure. This is a localized tibial infection that is in a healed bone; there is no need to resect the entire area of the tibia bone around the infection. The most appropriate treatment is curettage, debridement of nonviable bone, and placement of absorbable antibiotic beads, followed by a course of IV antibiotics from 1 to 4 weeks and a 6-week course of oral antibiotics. Studies have shown that in cases of localized osteomyelitis that are of low virulence, as little as 1 week of IV antibiotics followed by 6 weeks of oral antibiotics is successful.

A 59-year-old woman underwent open reduction and internal fixation (ORIF) of her ankle 6 months ago, with subsequent hardware removal 3 months later. She now reports persistent, diffuse ankle pain, swelling, and limited range of motion. Figure 48 shows an oblique radiograph of the ankle. What is the next most appropriate step in management?
1) Physical therapy

2) Hardware removal

3) Repeat placement of a syndesmotic screw

4) Deltoid ligament reconstruction

5) Revision ORIF with exploration of the syndesmosis and medial ankle

The radiographs demonstrate persistent widening of the medial clear space with an ossicle. This represents soft-tissue interposition-scar tissue, the deltoid ligament, or the posterior tibialis tendon. Physical therapy will not improve the symptomatic malalignment. Hardware removal would be indicated for pain localized to the lateral fibula. Repeat syndesmotic screw fixation alone will not reduce the malalignment. Deltoid ligament repair may be necessary but will need to be combined with debridement of the medial ankle and syndesmosis, as well as repeat placement of one or more syndesmotic screws to maintain the reduction.

A farmer is seen in the emergency department after falling out of a hay loft onto the barn floor below. He is unable to bear weight.
Exploration of a 0.5 cm laceration over the anterior tibia reveals bone. Radiographs reveal oblique displaced midshaft tibial and fibular fractures. Based on these findings, what is the most appropriate antibiotic prophylaxis?

1) Cephalosporin

2) Cephalosporin and aminoglycoside

3) Cephalosporin and penicillin

4) Cephalosporin and vancomyacin

5) Cephalosporin, aminoglycoside, and penicillin

A farm injury is automatically considered a grade III (Gustillo classification) injury regardless of size, energy, or additional soft-tissue injury due to the likelihood of substantial contamination. Antibiotic recommendations for grade III injuries include a first- or second-generation cephalosporin with an aminoglycoside or fluoroquinolone within 3 hours of injury, with penicillin added for farm injuries.

Which of the following have been found to affect the rate of perioperative infections or wound complication rates in foot and ankle surgery?

1) Methotrexate

2) Gold

3) Hydroxychloroquine

4) TNF-a inhibitors

5) Smoking

Clinical studies have shown that smoking cessation for 4 weeks reduces the risk of infection to the level of nonsmokers. Adverse effects on wound healing caused by chemotherapy used to treat rheumatoid arthritis has not been borne out in the literature.

Your 25-year-old patient complains of anterior knee pain after retrograde femoral nailing for a diaphyseal fracture and asks you why you didn’t perform antegrade nailing as he has seen on the internet.
You tell him that retrograde nailing is your preferred technique over antergrade nailing for diaphyseal femoral fractures because it has been shown to have which of the following?

1) Increased rate of union

2) Decreased rate of infection

3) Shorter operative time

4) Lower rates of hip pain

5) Lower rates of knee pain

Patients with retrograde femoral nails commonly have knee pain, while antegrade nails commonly have hip pain, abductor weakness and heterotopic ossification of the abductors.
Ostrum’s randomized prospective study of 100 patients with reamed femoral nails found 22% of antegrade nail patients had proximal hip pain, weak hip abductors or trendelenburg gait. No significant difference was found in set-up time, operative time, knee motion or pain, or infection rates.
Ricci performed a retrospective study of 293 fractures and found that the antegrade femoral nail group had more hip pain (10% vs 4%) and the retrograde nail group had more knee pain (36% vs 9%). There was no difference in healing, malunion, non-union or other complications.
Tornetta performed a randomized controlled comparison of 69 femur fractures and found more problems of length and rotation using a retrograde nailing.
There was no difference in time to union, operating time, blood loss, complications, size of nail or reamer, or transfusion requirements.

Sacral fractures are most likely to be associated with neurologic deficits when they involve what portion of the sacrum?

1) Zone 1 (the ala)

2) Zone 2 (the foramina)

3) Zone 3 (the central canal)

4) Zones 1 and 2

5) The sacral laminae

Denis divided the sacrum into three zones: zone 1 represents the lateral ala, zone 2 represents the foramina, and zone 3 represents the central canal. A fracture is classified according to its most medial extension. Those in zone 3
are typically bursting-type fractures or fracture-dislocations and are most prone to neurologic sequelae.

A 31-year-old male sustains the injury shown in Figure A. As compared to treatment with a simple sling, what is the primary advantage of treatment with a figure-of-eight brace?
1) Decreased sleep disturbance

2) Decreased personal care and hygiene impairment

3) Decreased rates of malunion

4) Improved long-term clinical outcomes

5) No advantage, equivalent result between a simple sling and figure-of-eight brace

Figure of eight braces have been shown to have no differences as compared to simple slings in regard to healing times, healing rates, and alignment at final follow-up.
The referenced study by Andersen et al is a Level 1 randomized controlled study showing equivalent cosmetic and clinical outcomes with sling versus figure of eight bracing despite increased sleep disturbances and increased rate of personal care impairment in those treated with a figure of eight brace.
The second referenced study by Nordqvist et al is a Level 4 case series designed to analyze the long-term outcome of mid-clavicle fractures in adults and to evaluate the clinical importance of displacement and fracture
comminution. They found a 39/225 rate of moderate shoulder pain with figure of eight bracing. Overall they concluded that few patients with fractures of the mid-part of the clavicle require operative treatment.

A 26-year-old woman sustained a nondisplaced femoral neck fracture and treatment consisted of use of percutaneous cannulated screws. At her 3-month follow-up visit, she reports hip pain and is unable to ambulate. A radiograph is shown in Figure 1. What is the next most appropriate treatment?
1) Bone grafting and revision open reduction and internal fixation

2) Hemiarthroplasty

3) Dynamic hip screw without angular correction

4) Valgus intertrochanteric osteotomy

5) Core decompression

Femoral neck fracture nonunion is a challenging problem for orthopaedic surgeons. Vertical fractures are more prone to nonunion due to shear stress rather than compressive forces across the fracture site. Several authors have suggested these fractures are more common in young adults due to injury type and bone composition. It is widely regarded that an effort should be made to salvage the femoral head if vascularity remains. The most common method to treat this complication is valgus intertrochanteric osteotomy of the femur. This functionally makes a vertical fracture more horizontal, converting shear into
compressive forces. It also helps correct the varus position of the fracture nonunion.

Which of the following choices best describes the fracture pattern shown in Figures 2a through 2c?
1) Anterior column

2) Anterior wall

3) Posterior column

4) Both column

5) Transverse

The fracture pattern shown in the radiographs is a fracture of the posterior column. The only line interrupted on the AP pelvis is the ilioischial line. The obturator oblique view shows that the iliopectineal line is intact as is the outline of the posterior wall. The iliac oblique view shows an interruption of the ilioischial line and an intact anterior wall. Therefore, this fracture is a fracture of the posterior column.

Figures 4a and 4b show the radiographs of a 53-year-old woman who was injured in a fall. After initial closed reduction, what is the preferred treatment for this fracture?
1) Open reduction and internal fixation of the radial head and immobilization

2) Medial collateral ligament repair

3) Radial head replacement, ulnar nerve transposition, and external fixation

4) Coronoid repair, radial head replacement, and lateral ligamentous repair

5) Nonsurgical management in a hinged elbow brace

This elbow fracture-dislocation involves a radial head fracture, coronoid fracture, and ulnohumeral dislocation (terrible triad). Several algorithms exist for treatment; surgical treatment is indicated. The treatment should address the radial head. Studies have shown replacement to be superior to repair in comminuted fractures. The coronoid may be addressed in unstable cases at the time of radial head excision and replacement. Lateral ligamentous repair is carried out during closure of the lateral elbow capsule. Medial ligamentous repair also may be undertaken but usually in concert with bony repair. Hinged
external fixation remains an option when instability exists following bony and soft-tissue repair. Acute ulnar nerve transposition is rarely indicated.

A 29-year-old woman was injured in a high-speed motor vehicle accident 3 hours ago. Radiographs are shown in Figures 7a through 7e. Her right foot injury is open and contaminated. Her associated injuries include a closed head injury and a ruptured spleen requiring resection. She has had 6 units of packed red blood cells and the trauma surgeon has turned her care over to you. Her current base deficit is 10 and her urinary output has averaged 0.4 mL/kg for the last 2 hours. What is the best treatment at this time?
1) Irrigation and debridement, external fixation of the ankle and foot, traction and pinning of the femur, open reduction and internal fixation of the forearm

2) Irrigation and debridement, external fixation of the ankle, foot, and femur, splinting of the forearm

3) Irrigation and debridement and open reduction and internal fixation of the ankle and foot, intramedullary nailing of the femur, open reduction and internal fixation of the forearm

4) Irrigation and debridement and open reduction and internal fixation of the ankle and foot, intramedullary nailing of the femur, splinting of the forearm

5) Irrigation and debridement, external fixation of the foot and ankle, intramedullary nailing of the femur, open reduction and internal fixation of the forearm

The patient appears to be a borderline or unstable surgical patient following her initial trauma and spleenectomy (high base excess and low urine output). She needs continued resuscitation and minimal additional blood loss. This is best accomplished with irrigation and debridement of the ankle, external fixation of the ankle, foot, and femur, and splinting of the forearm. A traction pin for the femoral fracture will not control bleeding as well as an external fixator. Intramedullary nailing of the femur and open reduction and internal fixation of the forearm would be appropriate in patients that are euvolemic and stable.

Which of the following is most commonly associated with an open clavicular fracture?

1) Scapulothoracic dissociation

2) Closed head injury

3) Calcaneus fracture

4) Pelvic ring injury

5) Open tibial fracture

Open clavicular fractures are rare and result from high-energy trauma. In a series of 20 patients with open clavicular fractures, 13 (65%) sustained a closed head injury. Fifteen (75%) had associated pulmonary injuries and 35% had a cervical or thoracic spine fracture. Only one demonstrated scapulothoracic dissociation. Screening for pulmonary and closed head injuries should be considered in the setting of traumatic open clavicular fractures.

A 26-year-old man falls off a motorcycle and injures his left wrist. There are no open wounds and the neurovascular examination is normal. Radiographs are shown in Figures 10a and 10b. Definitive management should consist of
1) closed reduction and casting.

2) external fixation and percutaneous pinning of the distal radius.

3) open reduction and internal fixation of the distal radius.

4) open reduction and internal fixation of the distal radius and open repair of the ulnar styloid.

5) nonbridging external fixation of the distal radius.

The patient has a high-energy injury with resultant comminution of the distal radius metaphysis. Cast immobilization is likely to lead to radial shortening and angulation due to the comminution. Similarly, while external fixation and pinning has been successful in the past, some loss of radial length and volar angulation is typically noted. Present plate fixation devices for the distal radius employing locking screw technology have a superior ability to resist radial shortening and dorsal angulation. Fixation of the ulnar styloid is warranted when there is distal radioulnar joint instability or significant displacement of the styloid. This is more likely to occur with a fracture at the base of the styloid. In this instance, the distal radioulnar joint does not appear to be disrupted.

Following fixation of a displaced intra-articular fracture of the distal humerus through a posterior approach, what is the expected outcome?

1) Development of arthritic changes at 1 year

2) Restoration of full elbow range of motion

3) Loss of approximately 25% of elbow flexion strength

4) Posterolateral rotatory instability

5) Olecranon nonunion

Following repair of a displaced intra-articular distal humerus fracture, the ability to regain full elbow range of motion is rare. Recent reports of olecranon osteotomy have yielded healing rates of between 95% to 100%. According to McKee and associates, patients can be expected to have residual loss of elbow flexion strength of 25%.

A 28-year-old cowgirl was injured while herding cattle 1 week ago. A radiograph and CT scans are shown in Figures 13a through 13c. What is the most appropriate management for this injury?
1) Nonsurgical management and gradual weight bearing as tolerated

2) Nonsurgical management and restricted weight bearing

3) Placement of a pelvic binder

4) Open reduction and internal fixation of the symphysis

5) Open reduction and internal fixation of the symphysis and iliosacral screws

The patient has an AP I pelvic ring disruption with minimal symphyseal widening. The best treatment is nonsurgical management and weight bearing as tolerated. This will help close the anterior pelvic ring during the healing process. Pelvic binders are excellent for acute treatment of widely displaced pelvic fractures but are not recommended for long-term use. Open reduction and internal fixation is not indicated for this injury and furthermore, the posterior ring is not injured.

As reflected by the SF-36 scores, patients with which of the following conditions demonstrate the most disability in physical function?

1) AIDS

2) Polytrauma

3) Pelvic fracture

4) Pilon fracture

5) Acute myocardial infarction (AMI)

Pollak and associates found that the average SF-36 score for patients who sustained a pilon fracture was significantly lower than patients with diabetes mellitus, AIDS, hypertension, asthma, migraines, pelvic fracture, polytrauma, and AMI. Moreover, patients having undergone pilon fixation scored lower on all but three of the SF-36 scales (vitality, mental health, and emotional health).

A 25-year-old man is involved in a motor vehicle accident and brought to the emergency department at 4 am on Sunday morning. He has a closed distal third femoral shaft fracture. His leg is initially pulseless but after applying inline traction, a distal pulse can be palpated and the limb appears to be viable. The pulse in the injured limb “feels” different than the pulse in the uninjured limb. What is the next step in assessing the vascular status of this limb?

1) Serial physical examinations

2) Angiography

3) Duplex ultrasound examination

4) Ankle-brachial index (ABI)

5) Measurement of compartment pressures

The patient initially has a distal third femoral fracture and a pulseless limb. The first step is to reduce the fracture and reassess the vascular status. Although the pulse returns, it feels different than the quality of the pulse in the contralateral uninjured extremity. There is a risk of a vascular injury with this fracture pattern due to tethering of the femoral vessels at the adductor hiatus; therefore, the vascular status needs further assessment since the pulses are not symmetrical. A physical examination is not very accurate in assessing whether a vascular injury is present; therefore, serial examinations are not appropriate. Angiography is very sensitive and specific but is time consuming and can cause complications secondary to the dye and the arterial puncture required to perform it. Duplex ultrasound is effective but is very operator-dependent and may not be available 24 hours a day. The ABI is easily performed and has been shown to be sensitive and specific. If the value is greater than 0.9, the negative predictive value is 99% and when the value is less than 0.9, it is 95% sensitive and 97% specific for a major arterial injury. It has been shown to be useful for blunt lower extremity injuries as well as knee dislocations.

What is the most appropriate treatment for a 50-year-old woman who sustains the injury shown in Figures 14a and 14b?
1) Total elbow arthroplasty

2) Functional hinge bracing

3) Long arm casting

4) Crossed Kirschner wires

5) Dual column plates

This intra-articular distal humerus fracture with displacement at the joint surface is best treated with surgical fixation. The most biomechanically sound construct is two plates applied to either column 180 degrees from one another. Elbow arthroplasty is most appropriate for low demand elderly patients.

A 20-year-old man is brought to the emergency department after a high-speed motor vehicle accident. His initial blood pressure is 70/40 mm Hg. He is currently receiving intravenous fluids as well as blood. His Focused Assessment with Sonography for Trauma examination did not show any free fluid in his abdomen and his chest radiograph is unremarkable. An AP pelvis radiograph is shown in Figure 15. What is the next most appropriate step in the management of his pelvic injury?
1) Inlet and outlet views of the pelvis to better delineate the injury

2) Angiography

3) Laparotomy

4) Open reduction and internal fixation of the pelvis

5) Placement of a pelvic binder around the patient

This hypotensive patient has an obvious open book injury of the pelvic ring on the AP pelvis radiograph and further radiographs are not needed prior to the
initiation of treatment. Although angiography may be indicated if he does not respond to stabilization of his pelvis and fluid/blood administration, temporary stabilization of the pelvis with a sheet or binder should be performed first because it is simple, quick, and has been shown to be effective. This patient does not need a laparotomy at this point since the FAST examination did not show any free intra-abdominal fluid and his chest radiograph was unremarkable, leaving the most likely source of bleeding the pelvic fracture.
Open reduction with internal fixation of a pelvic injury is not indicated in an acutely ill patient.

A 220-lb 20-year-old man was involved in a motor vehicle accident. His work-up reveals that he has multiple long bone fractures as well as a splenic injury that is currently being managed nonsurgically. His initial blood pressure in the trauma bay was 70/30 mm Hg. After receiving 4 liters of fluid and 3 units of packed red blood cells, his blood pressure is currently 110/70, his heart rate is 100, his urine output is 90 mL/h (normal 0.5 to 1 mL/kg/h), and his core temperature is 97.9 degrees F (36.5 degrees C). At this point, the patient’s resuscitation can be described as which of the following?

1) Complete based on the normalization of his blood pressure, urine output, and heart rate

2) Cannot be determined based on the data presented

3) Incomplete based on his fluid requirements calculated using his initial blood pressure as a measure of blood volume loss

4) Incomplete since he will need surgery on the long bone fractures and should be “tanked up” prior to losing blood in the operating room

5) Incomplete based on his heart rate

Although the end points of resuscitation are still unclear, what is known is that normalization of the standard hemodynamic parameters (blood pressure, heart rate, and urine output) is not adequate. Up to 85% of patients with normal hemodynamic parameters can still have inadequate tissue oxygenation or uncompensated shock. The initial base deficit, lactate level, or gastric pHi can be used to stratify patients for resuscitation needs, risks of death, and multiple organ failure (level 1 evidence). The time it takes to normalize the base deficit, the lactate level, or gastric pHi, can predict survival (level 2 evidence). Patients who have been in uncompensated shock (abnormal vital signs) should have their resuscitation monitored using data other than vital signs.

A 30-year-old man who sustained a work-related injury 6 weeks ago reports persistent back and left-sided buttock pain that has been attributed to lumbar transverse process fractures. A pelvic radiograph and CT scans obtained 2 days ago are seen in Figures 17a through 17c. What is the best treatment for his injury?
1) Continued nonsurgical management

2) Posterior open reduction and internal fixation with tension band plating

3) Posterior iliosacral screws

4) Anterior open reduction and internal fixation

5) Anterior open reduction and internal fixation and posterior fixation

Fortunately, surgical treatment of sub-acute pelvic ring injuries is relatively uncommon as acute management has become more common. Delayed reconstruction of pelvic ring malunion and impending malunion is rare.
Nonsurgical management may have a role as long as the hemipelvis does not flex, shorten, and/or externally rotate. The AP pelvic radiograph suggests that all three motions are happening in this patient. These are just a few of the indications to repair the pelvic ring and this is best done with anterior and posterior fixation. Anterior symphyseal plating will help correct most of the deformity. Posterior fixation can and should be added to lessen the forces on the anterior ring reconstruction when repair is performed in a sub-acute or delayed fashion. Posterior fixation can help obtain a more anatomic reduction and helps decrease the risk of anterior hardware failure.

An otherwise healthy 37-year-old man fell off the flatbed of a delivery truck and landed directly on his dominant left hand. Surgical stabilization of a distal radius fracture is performed. An intraoperative radiograph is shown in Figure 22. What is the next most appropriate step in management?
1) Immobilization of the wrist in ulnar deviation for 4 weeks before starting range-of-motion exercises

2) In situ Kirschner wire fixation of the carpal bones for 6 weeks

3) Extending the volar incision used for fracture fixation and repairing the injured structures in addition to percutaneous Kirschner wire fixation

4) Performing a separate dorsal incision and repairing the injured structures in addition to percutaneous Kirschner wire fixation

5) Arthroscopic repair of the injured structures and percutaneous Kirschner wire fixation

The intraoperative radiograph reveals a scapholunate ligament disruption. Repair of the stout dorsal scapholunate interosseous ligaments is required. Interestingly, the results of scapholunate ligament injuries associated with distal radius fractures appear to be superior to those of isolated ligament injuries.

A 36-year-old woman is placed in a short arm cast for a nondisplaced extra-articular distal radius fracture. Seven weeks later she notes the sudden inability to extend her thumb. What is the most likely cause of her condition?

1) Posterior interosseous nerve palsy

2) Cervical disk herniation

3) Entrapment of the flexor pollicis longus tendon

4) Rupture of the extensor pollicis longus tendon

5) Metacarpophalangeal joint dislocation

A recent review of 200 consecutive distal radius fractures noted that the overall incidence of extensor pollicis longus rupture was 3%. The causes are believed to be mechanical irritation, attrition, and vascular impairment. The fracture is usually nondisplaced and the patient notes weeks to months after injury the sudden, painless inability to extend the thumb. Treatment involves extensor indicis proprius tendon transfer or free palmaris longus tendon grafting.

In Gustilo type III open tibial diaphyseal fractures, which of the following factors is associated with an increased risk of a poor functional outcome?

1) Soft-tissue coverage within 3 days of injury

2) Bone grafting 3 months after injury

3) Wound debridement within 6 to 24 hours from injury

4) Definitive treatment with external fixation

5) Free tissue transfer for soft-tissue coverage

According to the published outcomes analyses from the Lower Extremity Assessment Project (LEAP) study group of patients prospectively followed for 2 to 7 years, definitive fixation with an intramedullary nail has shown improved outcomes when compared to definitive external fixation. The findings showed that the timing of wound debridement (within 6 hours from injury as compared to within 6 to 24 hours), the timing of soft-tissue coverage (3 days or less from injury as compared to more than 3 days), and the timing of bone grafting after injury (within or after 3 months) did not impact the infection or union rates and had no effect on functional outcome. The LEAP study has shown at 7-year follow-up that patients who are definitively treated with external fixation have a significantly longer time to union, poorer functional outcomes, longer time to achieve full weight bearing, and more time in the hospital.

Figures 23a and 23b show the radiographs of a 75-year-old woman who sustained an injury to her nondominant hand. Initial treatment should consist of
1) closed reduction and splinting.

2) open reduction and internal fixation through a volar approach.

3) external fixation and Kirschner wire fixation.

4) intrafocal pinning and casting.

5) acceptance of alignment and bracing.

Definitive treatment decisions for displaced distal radius fractures in the elderly are based on a number of factors related to the fracture pattern and patient demographics. The first step in any treatment algorithm is a closed reduction and splinting with reassessment of alignment parameters. This is an extra-articular fracture with dorsal angulation. Low-demand elderly patients can be treated well with accepted minor malreduction.

A 43-year-old man sustained a closed, intra-articular pilon fracture. It has now been 1 year since he underwent open reduction and internal fixation. Which of the following statements most accurately describes his perceived outcome?

1) His clinical outcome will correlate closely with his initial reduction.

2) His outcome will correlate with his radiographic score on the Ankle Osteoarthritis Score.

3) He will likely require a late ankle arthrodesis.

4) He will demonstrate marked limitations with regard to recreational activities.

5) He will perceive improvements for a period of over 2 years.

Marsh and associates retrospectively reviewed 56 tibial plafond fractures and found that the patients perceived improvement in their function and pain for an average of 2.4 years. They demonstrated some limitations in recreational activities but not marked limitations. Patients were unlikely to need a late arthrodesis (13%), and their outcomes did not correlate well with assessments of reduction or arthritis scores.

The injury shown in Figure 24 was most likely caused by what mechanism of injury?
1) Anterior posterior compression

2) Lateral compression

3) Vertical shear

4) Combined mechanism

5) Flexion-rotation

The CT cut shows a fracture through the posterior portion of the iliac wing or a crescent fracture. This occurs after a laterally directed force is applied to the anterior part of the involved iliac wing.

A 32-year-old man has an open comminuted humeral shaft fracture. Examination reveals absence of sensation in the first web space and he is unable to fully extend the thumb, fingers, and wrist. What is the recommended treatment following irrigation and debridement of the fracture?

1) Functional bracing

2) Hanging long arm cast immobilization

3) Intramedullary nailing

4) Open reduction and internal fixation, radial nerve exploration

5) External bone stimulator

There is a high incidence of partial or complete laceration of the radial nerve with high-energy open fractures of the humeral shaft. The recommended treatment is irrigation and debridement of the fracture followed by open reduction and internal fixation and exploration of the radial nerve. If the nerve is completely lacerated, primary repair may be performed but poor outcomes have been reported. If a large zone of nerve injury is identified, delayed nerve grafting is advocated.

Which of the following is most predictive of a medial side ankle injury in the presence of a fibula fracture above the level of the joint?

1) Severe medial ankle tenderness

2) Severe medial ankle ecchymosis

3) Stress radiographs showing the medial clear space measuring 6 mm and the superior joint space measuring 3 mm

4) Inability to ambulate

5) Medial ankle swelling

Isolated Lauge-Hansen supination-external rotation-type ankle fractures comprise 20% to 40% of ankle fractures and nonsurgical management is effective for managing SER-2 ankle fractures. Tornetta and associates recently showed that medial ankle tenderness, ecchymosis, and swelling are not reliable findings when trying to determine deltoid competence. Stress radiographs showing a medial clear space of greater than 4 mm or one that is also 1 mm greater than the superior joint space, or any lateral talar subluxation are indicative of deltoid incompetence and indicative of a SER-4 ankle fracture.

A 57-year-old man involved in a motor vehicle accident sustains an injury to his right shoulder. A spot AP radiograph is shown in Figure
34/. What is the next most appropriate step in the orthopaedic management of this patient?
1) Axillary view

2) CT of the shoulder

3) Closed reduction

4) Sling and close follow-up

5) Functional brace

The next step in the management of this injury is completion of the shoulder trauma series. An axillary radiograph, which can be quickly performed in the emergency department, must be obtained to accurately assess the humeral head relationship to the glenoid. If difficulty is encountered, a “Velpeau” axillary may be substituted. If that fails to elucidate the status of the glenohumeral joint, a CT scan should be obtained.

Which of the following findings best describes the acetabular fracture shown in Figure 38?
1) Posterior column with articular impaction and a free fragment

2) Anterior column with articular impaction

3) Posterior wall with an intra-articular fragment

4) Posterior wall with articular impaction and a free intra-articular fragment

5) Posterior wall with articular impaction

The CT scan shows a posterior wall fracture with impaction of the articular surface and a free fragment within the joint. Proper treatment of this injury requires not only reduction and fixation of the posterior wall fragment but also removal of the free fragment and elevation of the depressed articular segment.

A 28-year-old female firefighter fell from the top of a three-story building in the line of duty. She sustained a displaced pelvic fracture with more than 5 mm displacement. Compared to normal healthy controls, these patients have a higher incidence of

1) normal sexual function and normal vaginal childbirth.

2) sexual dysfunction (dyspareunia) and normal vaginal childbirth.

3) normal sexual function and caesarean section childbirth.

4) sexual dysfunction (dyspareunia) and caesarean section childbirth.

5) normal sexual function and caesarean section childbirth until hardware removal.

Pelvic trauma in women has been shown to increase the risk of sexual dysfunction and dyspareunia. Additionally, caesarean section childbirth is
almost universal following pelvic trauma regardless of whether anterior pelvic hardware is present or not.

A 30-year-old man falls off a 7-foot ladder and sustains the injury seen in the radiograph and the CT scan shown in Figures 39a and 39b. Medical history is negative. Management of this injury should include which of the following?
1) Closed treatment and casting

2) Open reduction and internal fixation

3) Primary subtalar arthrodesis

4) Percutaneous fixation

5) External fixation

A Sanders type 2 intra-articular calcaneus fracture in a young healthy nonsmoker is best treated with open reduction and internal fixation. Whereas nonsurgical management is an option, Buckley and associates have shown that these fractures have a better outcome with surgical care. Percutaneous fixation is reserved for tongue-type fractures and subtalar arthrodesis is used in some type 4 fractures. External fixation has not been shown to be advantageous in closed fractures.

A 24-year-old woman fell from a horse and landed on her outstretched right arm. Radiographs reveal an elbow dislocation with a type II coronoid fracture and a nonreconstructable comminuted radial head fracture. What is the most appropriate management?

1) Radial head resection, open reduction and internal fixation of the coronoid, and medial collateral ligament repair

2) Radial head resection and lateral collateral ligament repair

3) Radial head arthroplasty alone

4) Radial head arthroplasty and lateral collateral ligament repair

5) Radial head arthroplasty, open reduction and internal fixation of the coronoid, and lateral collateral ligament repair

The combination of an elbow dislocation and a fracture of the radial head and coronoid is known as a terrible triad injury. To restore elbow stability, each injury must be addressed. The nonreconstructable radial head fracture requires implant arthroplasty. Open reduction and internal fixation of the coronoid is also necessary as is repair of the lateral collateral ligament complex which is usually avulsed from the lateral epicondyle region.

A 30-year-old man is brought to the emergency department after a motor vehicle accident. He has a closed midshaft femoral fracture and an intra-abdominal injury. He is currently in the operating room and the exploration of his abdomen has been completed. His initial blood pressure was 70/30 mm Hg and is now 90/50 mm Hg after 4 liters of fluid and 2 units of blood. His initial serum lactate was 3.0 mmol/L (normal
1) Reamed intramedullary nailing

2) Traction

3) External fixation

4) Open plating

5) Mast suit

The patient has several indications that he is not ready for definitive fixation of the femoral shaft fracture at this point. He is cold with a core temperature of 93 degrees F, and hypothermia of less than 95 degrees F (35 degrees C) has been shown to be associated with an increased mortality rate in trauma patients. The patient has also not been resuscitated based on his increasing lactate levels and although controversial, it has been shown that temporary external fixation leads to a lower incidence of multiple organ failure and acute respiratory distress syndrome.

A 45-year-old male karate instructor sustained the injury shown in Figures 40a through 40c while practicing karate. The decision to proceed with surgery depends on which of the following factors?
1) MRI scan

2) Physical examination

3) Workers’ compensation status

4) Surgeon availability

5) Patient age

The most important criteria in determining the need for surgery following a nondisplaced or minimally displaced tibial plateau fracture is knee stability to varus/valgus stress. Soft-tissue injury noted on MRI may be addressed at a later time following fracture healing. This fracture pattern is amenable to nonsurgical management. Decisions regarding surgical intervention may be made up to 2 weeks after injury.

A 32-year-old man has a Glasgow Coma Scale score of 8 and an open pelvic fracture. The patient’s family reports that he is a Jehovah’s Witness. Initial hemodynamic instability has resolved. In the operating room during a washout, the patient’s blood pressure becomes unstable. What is the most appropriate action?

1) Consult the ethics committee before giving blood.

2) Use cell saver blood.

3) Ask the patient’s family for consent to give blood.

4) Use plasma expanders.

5) Give the patient blood.

Certain medical procedures involving blood are specifically prohibited in the belief system of a Jehovah’s Witness whereas others are not doctrinally prohibited. For procedures where there is no specific doctrinal prohibition, a Jehovah’s Witness should obtain the details from medical personnel and make his or her own decision. Transfusions of allogeneic whole blood or its constituents or preoperative donated autologous blood are prohibited. Other procedures, while not doctrinally prohibited, are not promoted such as hemodilution, intraoperative cell salvage, use of a heart-lung machine, dialysis, epidural blood patch, plasmapheresis, white blood cell scans (labeling or tagging of removed blood returned to the patient), platelet gel, erythropoietin, or blood substitutes. The patient should not be given blood. Plasma expanders should be used first to restore hemodynamic stability. Cell saver blood from an open wound is not recommended nor would there likely be enough from an open pelvic fracture to salvage. The patient’s family may be expressing their own beliefs rather than the patient’s beliefs and it would be better to ask the patient when he or she is more alert to determine what procedures they would allow. A consult with the ethics committee will unnecessarily delay an intervention that should restore hemodynamic stability.

Figure 50 shows the radiograph of a 26-year-old man who sustained an isolated open injury to his foot. Examination reveals no gross contamination in the wound. There is a palpable dorsalis pedis pulse and sensation is present on the dorsal and plantar aspects of the foot. Initial treatment should consist of wound debridement, antibiotics, and
1) talectomy.

2) reimplantation of the talus.

3) reimplantation of the talus with acute triple arthrodesis.

4) Syme amputation.

5) transtibial amputation.

The radiograph shows a complete extrusion of the talus. Reimplantation of the talus after wound debridement has been reported to be safe and successful, and provides for flexibility with any future reconstructive procedures.

Which of the following long bone fracture patterns occurs after a pure bending force is exerted to the bone?

1) Spiral

2) Oblique

3) Transverse

4) Segmental

5) Comminuted

A pure bending force produces a transverse fracture pattern. Spiral fractures are mainly rotational, oblique are uneven bending, segmental are four-point bending, and comminuted are either a high-speed torsion or crush mechanism.

A 38-year-old woman fell from a ladder onto her right hip. The radiographs and CT scan are shown in Figures 52a through 52d. What is the best surgical approach for this fracture?
1) Kocher-Langenbeck

2) Iliofemoral

3) Ilioinguinal

4) Extended iliofemoral

5) Triradiate approach

The fracture is an associated both column fracture. The best approach for this fracture is the ilioinguinal. The Kocher-Langenbeck is best for posterior injuries to the acetabulum and some transverse fractures. The iliofemoral alone is limited to high anterior column injuries. The extended iliofemoral and triradiate
approaches although useful for this fracture, have a higher rate of complications.

An otherwise healthy 26-year-old woman is involved in a high speed motor vehicle accident and sustains the injury shown in Figure 54 to her dominant right arm. Appropriate treatment of this injury complex includes
1) plating of the radial shaft fracture then open repair of the triangular fibrocartilage complex.

2) open reduction and internal fixation of the radius and ulna.

3) plating of the radius then closed reduction and evaluation of the distal radioulnar joint (DRUJ).

4) closed reduction of the radius and DRUJ.

5) plating of the radius then pinning of the DRUJ in pronation.

This Galeazzi fracture is an injury that requires surgical treatment in an adult. The algorithm includes anatomic reduction of the radial shaft and closed reduction of the DRUJ with assessment of stability. If the DRUJ remains unstable, supination of the wrist may reduce the DRUJ. If not, either open or closed reduction with pinning is undertaken. The closer the radius fracture is to the DRUJ, the more likely it is to be unstable.

A 40-year-old laborer sustains the injury shown in the radiograph and CT scan in Figures 56a and 56b. What is the most common complication associated with surgical intervention?
1) Chronic osteomyelitis

2) Planovalgus hindfoot

3) Plantar nerve entrapment

4) Wound dehiscence

5) Painful hardware

The patient has a severe Sanders type 4 calcaneus fracture. By far the most common complication associated with surgical treatment of calcaneus fractures is wound dehiscence.

Patients in compensated shock (normal vital signs) are thought to be at risk for which of the following?

1) A primed immune system with an increased risk of a systemic inflammatory response

2) Nothing since they are no longer in uncompensated shock and their vital signs have normalized

3) Higher nonunion rates after fracture fixation

4) Higher infection rates after definitive fracture fixation

5) Higher complication rates after temporizing external fixation of long bone fractures

Patients who are in compensated shock have normal vital signs but still have hypoperfusion of organ beds such as the splanchnic circulation due to preferential perfusion of the heart and brain. The response to this continued hypoperfusion may be the development of a systemic inflammatory response that may lead to multiple organ failure. The patients are thought to be at risk for a “primed” immune system due to the ongoing stimulation of the immune system and may have an exaggerated response to a second stimulus such as surgery or infection. Other markers of resuscitation should be used besides vital signs to determine when resuscitation has been completed. The use of temporizing fixation has been shown to lower systemic complication rates, and the infection and union rate after staged fixation is not altered.

A 14-year-old boy sustains a right leg injury after being thrown from his motorcycle while racing. He reports diffuse right leg pain starting at his knee and proceeding distally to include his foot. After the injury the patient’s mother reports the tibia moving posteriorly then anteriorly while she was supporting the leg. In the emergency department 4 hours after injury, examination reveals a large knee effusion, firm compartments of the leg, a palpable posterior tibialis pulse with a warm, pink foot, and capillary refill of 2 seconds at the toes. His blood pressure is 100/50 mm Hg. Motor examination is
intact, but there is decreased sensation in the dorsal first interspace and plantar aspect of the foot. Compartment pressure measurement reveals all four compartments with pressures of 33, 36, 33, and 38 mm Hg respectively. Radiographs are shown in Figure 59a and 59b. The remainder of the skeletal examination is normal. What is the optimal management for this injury?
1) Emergent four compartment fasciotomies

2) Emergent four compartment fasciotomies and open reduction and internal fixation of the fracture

3) Elevation of the limb overnight and four compartment fasciotomies in the morning

4) Elevation of the limb overnight and a recheck of compartment pressures in the morning

5) Emergent MRI of the knee and leg

The patient has a compartment syndrome based on the firm compartments of the leg and the elevated compartment pressures measured at the diastolic pressure reading. Muscle ischemia occurs quickly when compartment pressures are elevated, and within 6 hours irreversible damage can occur. Emergent fasciotomies permit decompression of all four compartments and reestablishment of vascular supply to the muscles. Stabilization of the fracture prevents further soft-tissue injury.

Resuscitation of a trauma patient who has been in hypovolemic shock is complete when which of the following has occurred?

1) The mean arterial blood pressure is above 90 mm Hg.

2) The pulse pressure has normalized.

3) Urine output is greater than 0.5 to 1 mL/kg/h.

4) Oxygen delivery has been maximized.

5) Aerobic metabolism has been restored in all tissue beds.

Shock can be defined as inadequate tissue perfusion. Resuscitation or the resolution of shock is defined as when oxygen debt has been repaid, tissue acidosis is eliminated, and aerobic metabolism has been restored in all tissue beds. The end points for resuscitation are not clearly defined, but occult shock can still be present in the setting of normal vital signs and normal urine output due to selective perfusion of organ systems.

A 12-year-old girl falls in gymnastics and sustains comminuted midshaft radius and ulna fractures. Closed reduction and cast immobilization are attempted but fracture redisplacement with 20 degrees of angulation occurs. Surgical treatment includes closed reduction and intramedullary fixation of both bones. What is the most common long-term complication for this fracture?

1) Infection

2) Malunion

3) Loss of forearm rotation

4) Refracture

5) Delayed union/nonunion

Healing of forearm fractures in skeletally immature patients is the usual outcome. The use of intramedullary fixation has been reported to result in a lower frequency of refractures when compared to plate osteosynthesis due to the absence of diaphyseal holes after plate removal, which are considered stress risers. Regardless of implant technique, malunion and infection are infrequent. Loss of forearm pronation and supination is a common occurrence in surgically treated fractures due to the higher degree of soft-tissue injury, and periosteal stripping leads to fracture site instability and fracture comminution.

The teardrop shape marked with an asterisk in Figure 61 represents what anatomic structure?
1) Anterior superior iliac spine

2) Sciatic buttress

3) A column of bone running from the anterior inferior iliac spine (AIIS) to the posterior superior iliac spine (PSIS)

4) The most superior portion of the roof of the acetabulum

5) Iliopectineal line

The teardrop can be visualized on the obturator outlet view of the pelvis and represents a thick column of bone that runs from the AIIS to the PSIS. Half pins for eternal fixation frames or screws can be inserted into this column for fixation of fractures.

A patient was treated with a revision reamed intramedullary nail for a nonunion 6 months ago. A current radiograph is shown in Figure
62/. Based on these findings, what is the most appropriate treatment?
1) Electrical stimulation

2) Bone grafting

3) No weight bearing

4) Bone grafting and compression plating

5) Free vascularized bone transport

Nonunions after intramedullary nails are often treated with exchange reamed nailing. In a recent study, this resulted in a union rate of 53%. After failed exchange nailing, bone grafting and compression plating should be used. The other options resulted in less satisfactory results as compared to bone grafting and compression plating.

Figure 63 shows the radiographs of a 23-year-old man who sustained a twisting injury at work. Swelling, tenderness, and ecchymosis are noted about the entire midfoot. What associated injury is most likely to be problematic?
1) Peroneal tendon tear

2) Lateral process talus fracture

3) Talar neck fracture

4) Lisfranc injury

5) Deltoid ligament tear

This cuboid compression fracture (“nutcracker” injury) is associated with subtle injury to the Lisfranc complex. This diagnosis must be made to ensure proper treatment.

A 24-year-old man is ejected from his motorcycle and sustains a significant hip injury. The fracture shown in Figures 64a through 64e is best described as what type of fracture?
1) Posterior column/posterior wall acetabular

2) Associated both column acetabular

3) Transverse plus posterior wall acetabular

4) Anterior column posterior hemitransverse acetabular

5) Anterior column acetabular

The radiographs and CT scans reveal an anterior column acetabular fracture. The fracture has quadrilateral plate extension but does not exit out the posterior column. The CT scans confirm an intact posterior column and no wall fracture. A transverse fracture is best seen on the CT scan and runs in the sagittal plane, not the coronal plane.

A 71-year-old woman who reports long-term use of oral steroids for asthma is referred for treatment of a distal humerus fracture.
Radiographs reveal diffuse osteopenia and a severely comminuted intra-articular fracture. What is the most appropriate treatment?

1) Long arm cast immobilization

2) Total elbow arthroplasty

3) Open reduction and internal fixation

4) Osteoarticular allograft

5) Resection arthroplasty

Several studies have documented the satisfactory outcomes of total elbow arthroplasty when osteosynthesis is not feasible for fixation of a distal humerus fracture, particularly in the physiologically older patient with low functional demands. Total elbow arthroplasty should be considered when a comminuted intra-articular distal humerus fracture occurs in a woman older than age 65 years, particularly with such associated comorbidities as systemic steroid use, osteoporosis, or rheumatoid arthritis.

A 14-year-old boy sustained a 100% displaced distal radius Salter-Harris type II fracture. Neurologic examination demonstrates normal motor examination and two-point discrimination. He undergoes fracture reduction to the anatomic position with the application of a long arm cast. Postreduction he reports increasing hand and wrist pain with diminution of two-point discrimination to 10 mm over the index and middle fingers over the next several hours after surgery. The cast is bivalved and the padding released relieving all external pressure over the arm. Reevaluation reveals increasing sensory deficit over the affected area. What is the next most appropriate management intervention?

1) Cast removal and measurement of carpal canal pressure

2) Immediate carpal tunnel release and pinning of the fracture

3) Continued observation

4) Surgical reduction and pinning of the fracture

5) Electromyography/nerve conduction velocity studies

The patient has an evolving acute carpal tunnel syndrome. Initial management for this injury is to relieve all external pressure that may elevate the neural
compression. Surgical decompression of the median nerve at the carpal tunnel is the optimal intervention. Further nonsurgical interventions (cast removal or further bivalving) are insufficient to alleviate the neural compression.

A 25-year-old male polytrauma patient undergoes initial temporary external fixation for a femoral shaft fracture. He is converted to a femoral nail at 7 days. This management can be expected to result in

1) higher infection rates.

2) higher nonunion rates.

3) equal union and infection rates.

4) higher rate of ARDS.

5) higher mortality rate.

Recently Harwood and associates investigated the principles of damage control orthopaedics (DCO) as they apply to patients with femoral shaft fractures.
When they compared those who underwent initial external fixation of femoral shaft fractures with conversion to an intramedullary nail to those who underwent intramedullary nailing as their initial treatment, they found the following: overall infection rates were comparable in patients receiving DCO versus primary intramedullary fixation; open fracture was an independent risk factor for infection regardless of the treatment method; contamination rates in external fixator pin sites rose considerably when left in place more than 2 weeks and logistic regression analysis suggests that infection rates may increase when conversion to an intramedullary nail occurs after 2 weeks following external fixation; and there was no significant difference in time to union among treatment groups.

Which of the following is the most stable construct for fixation of an unstable transforaminal sacral fractures?

1) External fixation

2) Iliosacral osteosynthesis

3) Combined iliosacral and lumbopelvic fixation (triangular osteosynthesis)

4) Anterior pelvic ring plating with bilateral sacroilliac percutaenous screw fixation

5) Transiliac bars with anterior pelvic ring plating

Combined iliosacral and lumbopelvic fixation (triangular osteosynthesis) for sacral fractures has the greatest stiffness when used for an unstable sacral fracture.
The referenced article by Schildhauer et al is a cadaveric study that examined the biomechanical properties of different fixation constructs under cyclic loading and demonstrates that triangular osteosynthesis for unstable transforaminal sacral fractures provides significantly greater stability than iliosacral screw fixation under in-vitro cyclical loading.
Illustration below shows the radiographic appearance of lumbopelvic fixation. The addition of iliosacral fixation would complete triangular osteosynthesis.

The Cotton test evaluates which of the following structures?

1) Calcaneofibular ligament

2) Lateral ulnar collateral ligament of the elbow

3) Ligamentum flavum

4) Anterior talofibular ligament

5) Ankle syndesmosis

The inferior tibiofibular syndesmosis is a fibrous articulation consisting of four ligaments; the elasticity of these ligaments permits axial, vertical, anterior, posterior, and mediolateral motion at the ankle syndesmosis during weight bearing.
Of note, the Cotton test was originally described around 1910 by Frederic J. Cotton as the "talar glide test" evaluating the medial/lateral translation of the talus in the mortise. A positive result indicates disruption of the ankle syndesmosis in the face of an ankle injury.
Nielson et al reported that the level of the fibular fracture does not correlate reliably with the integrity or extent of the interosseous membrane (IOM) tears identified on MRI in operative ankle fractures. Therefore, one cannot consistently estimate the integrity of the IOM and subsequent need for transsyndesmotic fixation based solely on the level of the fibular fracture. This supports the need for intraoperative stress testing (ie, external rotation stress or Cotton test) of the ankle syndesmosis in all operative ankle fractures.
The study by Leeds et al noted a correlation between syndesmosis reduction (initial and final) and outcomes (radiographic and clinical).
The attached video shows the Cotton test during an ankle fixation procedure.

A comminuted femoral shaft fracture is treated with an intramedullary nail locked with a single distal screw. What is the most likely mode of failure of the screw?

1) Screw pulls out of the cortical shaft

2) Screw head breaks off due to bending stresses

3) Shaft of the screw fractures in the region that is inside the nail

4) Screw threads are damaged by fretting against the edges of the holes in the nail

5) Screw bends excessively

The screw is being loaded and pushed distally at the two points where it contacts the walls of the nail, and it is being pushed proximally at the two points where it contacts the cortex, ie, near the head and tip of the screw. This places the screw in four-point bending, producing tensile stresses on the
inferior side of the screw and compressive stresses on the superior side. The tensile stresses, combined with stress risers at the screw threads, eventually could lead to fatigue fracture of the screw. Because the cortices in the metaphysis are far apart, the bending moment is large and, therefore, stresses near the midshaft of the screw produced by bending are much larger than shear stresses in this case. Pullout of the screw is unlikely because the loads are not directed along the axis of the screw. There are no bending stresses at the ends of the screw. A bent screw may be difficult to remove, but this would not likely cause failure of the fixation.

A 30-year-old female presents with the injury shown in Figure A after falling on her outstretched arm. During operative treatment of the fracture, anatomic reduction of the radius is achieved. However, the surgeon is unable to reduce the distal radioulnar joint. What structure is most likely impeding the reduction?
1) Median nerve

2) Flexor carpi radialis

3) Pronator quadratus

4) Extensor carpi ulnaris

5) Flexor carpi ulnaris

Figure A shows a Galeazzi fracture (distal 1/3 radial shaft fracture with associated distal radioulnar joint dislocation). In this injury, an inability to reduce the distal radioulnar joint in a closed fashion is most commonly secondary to interposition of the extensor carpi ulnaris tendon. Early recognition of the dislocation of the ulna and ECU into the DRUJ and their significance may avoid poor results.
The referenced study by Biyani et al reports a case in which both the extensor carpi ulnaris and extensor digiti minimi tendons were displaced on either side of the ulnar head.
The referenced study by Budgen et al presents a case of a Galeazzi fracture dislocation with an irreducible distal radioulnar joint.
The referenced study by Paley et al reports two cases of distal radioulnar joint (DRUJ) disruption and diastasis secondary to distal radial fractures that were associated with displacement of the ulnar styloid and extensor carpi ulnaris (ECU) into the DRUJ. Both cases had a palpable empty ECU tendon sulcus.

What is the antibiotic of choice for gonococcal septic arthritis of the knee?

1) Erythromycin

2) Penicillin

3) Tetracycline

4) Ceftriaxone

5) Vancomycin

Gonococcal septic arthritis, caused by the gram-negative diplococcus Neisseria gonorrhoeae, typically affects two age groups: newborns and adolescents. The level of penicillin and tetracycline resistance in Neisseria gonorrhoeae is so high that it is completely ineffective in most parts of the world. A third-generation cephalosporin such as ceftriaxone is recommended in most areas. Fluoroquinolones may be an alternative treatment option if antimicrobial susceptibility can be documented by culture. In areas where co-infection with chlamydia is common, doxycycline may be used with ceftriaxone.

An above-the-knee amputation is performed 12 cm above the joint line. What is the best management of the adductor muscle group?

1) Resection of the adductors to prevent adductor contracture

2) Shortening and reattachment to the mid-femur to improve biomechanics

3) Myodesis to the distal end of the bone

4) Transfer to the quadriceps to improve hip flexion

5) Attachment to the hamstrings

The best socket fit requires resection of the wide flair of the condyles and amputation approximately 12 cm above the joint line. The adductor magnus is a very important muscle that participates in achieving a more efficient gait.
Myodesis of the bone through drill holes near the cut end of the bone has been shown to improve biomechanics.

In determining the FRAX score (fracture risk assessment tool), the World Health Organization determined that which of the following risk factors is not contributory to the clinical risk of fracture in its population cohorts?

1) BMI (body mass index)

2) Spine T-score from DEXA scan (dual-energy absorptiometry)

3) Current smoking activity

4) Parental history of hip fracture

5) Prior history of fracture before age 50

The FRAX score calculates the clinical risk of fracture using bone mineral density of the femoral neck, BMI, current smoking activity, history of parental hip fracture, and prior personal history of fracture before age 50. The World Health Organization has developed this new fracture risk assessment tool to identify individuals at high risk of osteoporotic fracture. The current standard, which bases treatment decisions largely on bone mineral density measurement, has proven to be specific, but not sensitive, for the identification of patients at high risk of fracture. Because nearly 50% of postmenopausal women in the community older than age 50 years who suffer an osteoporotic fracture do not have osteoporosis defined by a BMD test and because of the limited availability of BMD in many countries, clinical risk factors were added to BMD to identify patients at high risk for osteoporotic fractures. The site and
reference technology is DEXA at the femoral neck. T-scores are based on the National Health and Nutrition Examination Survey reference values for women aged 20 to 29 years. The same absolute values are used in men. Although the model is constructed for BMD at the femoral neck, the total hip site is thought to predict fracture equivalently in women.

Glenohumeral disarticulation often leads to which of the following changes?

1) Hiking of the shoulder girdle

2) Hypertrophy of the amputated shoulder girdle

3) Improvement in thoracic spinal deformity

4) Protraction of the shoulder

5) Winging of the scapula

Postural abnormalities are common after high upper extremity amputation. Normally the weight of the upper extremity and the shoulder girdle muscles keep the shoulder balanced. When the arm is amputated and the scapula remains, the shoulder girdle muscles are unopposed, resulting in upward movement often called "hiking" of the shoulder girdle. In a growing child, removal of the entire upper limb can result in scoliosis of the spine due to muscle imbalance. Abnormal shoulder elevation can often be minimized by corrective exercises and wearing a shoulder prosthesis.

A 10-day-old girl has decreased active motion of the left upper extremity. The mother reports a difficult vaginal delivery with presumed shoulder dystocia. Examination shows full passive range of motion of the shoulder, elbow, and wrist but only active flexion of the fingers and wrist. Factors predictive of a good outcome include which of the following?

1) Breech delivery

2) Absence of an ipsilateral clavicle fracture

3) Horner's sign and an APGAR score of 10 at 1 minute

4) Return of active biceps before 3 months and preservation of full passive shoulder range of motion

5) Absent Moro and Babinski reflexes

Return of active biceps before 3 months and preservation of full passive shoulder range of motion are predictors of a good outcome. Breech delivery is usually associated with preganglionic injury. Preganglionic injury can result in a Horner's sign, which includes ptosis, myosis, and anhydrosis. Preganglionic injuries are unlikely to recover. The Moro reflex is elicited by dropping a baby's head a short distance and observing active elbow extension and fanning of the fingers, followed by elbow flexion and crying. Absence of the Moro reflex suggests a poor prognosis.

An 18-month-old child was involved in a motor vehicle accident and sustained an isolated injury to the left upper extremity. A radiograph is shown in Figure 33. What is the most appropriate management for this injury?
1) Hanging arm cast

2) Closed reduction with flexible intramedullary nail fixation

3) Coaptation splinting and bandaging the arm to the thorax

4) Closed reduction and external fixation

5) Locking plate fixation

Humeral shaft fractures in infants and young children heal rapidly and have excellent remodeling potential. Appropriate treatment in this age group is immobilization with a coaptation splint and bandaging the arm to the thorax for comfort. Internal fixation is appropriate in multiple trauma, and external fixation may be useful when soft-tissue injury is extensive.

If a percutaneous iliosacral screw is placed too anteriorly, and the screw exits anterior to the sacral ala before re-entering the sacral body, what will be the most likely finding postoperatively?

1) Lack of ankle dorsiflexion

2) Lack of ankle plantarflexion

3) Lack of knee extension

4) Loss of bowel and/or bladder control

5) Lack of great toe extension

This question is a simple review of anatomy and nerve innervation. The L5 root is at risk with an "in-out-in" screw, as described in the question, as the nerve root is just anterior to the sacral ala as it enters the true pelvis. L5 is primarily evaluated by extensor hallucis longus function. L4 is tested with tibialis anterior function and S1 by gastroc-soleus function (ankle plantarflexion).

A 10-year-old boy is struck by a car and sustains open left tibia and fibula fractures with bone protruding through a 7-cm laceration, multiple deep and superficial abrasions over the anterior leg, and road gravel is present in the wounds. His foot is warm and well-perfused with normal sensation and he has no pain with passive range of motion of the toes. Optimal treatment should consist of

1) irrigation and debridement of the fractures and application of an external fixator.

2) irrigation and debridement of the fractures and a reamed intramedullary nail.

3) irrigation and debridement of the fracture and percutaneous Kirschner wire fixation.

4) submuscular plating.

5) reduction and a short leg cast.

The patient has a grade 2 open fracture and therefore needs wound debridement as a first step, followed by fracture stabilization preferably with an external fixator. A reamed intramedullary nail is not indicated in a 10-year-old child with open growth plates. Submuscular plating is not needed in an open fracture and there is no mention of fracture debridement. Percutaneous Kirschner wires will not provide adequate fracture stabilization, nor will a short leg cast. Flexible nailing should be considered as another form of fixation.

Figures 5a and 5b show the radiographs of a 21-year-old wrestler who reports that his leg was rolled over while wrestling. The patient has decreased sensation and function in the distribution of the peroneal nerve, and he has absent pulses. What is the most appropriate initial management at this time?
1) Acute reconstruction of all ligamentous structures

2) Emergency MRI and reconstruction of all ligamentous structures

3) Emergency arteriogram followed by MRI

4) Emergency surgery with open reduction and repair of all torn structures with vascular surgery available

5) Closed reduction in the emergency room and reevaluation of the vascular status

The patient has an acute traumatic anteromedial dislocation of the knee with occlusion of the popliteal artery with a possible tear. Treatment should include reduction and reevaluation of the vascular status. At this time, if pulses are symmetric, observation may be appropriate without surgical intervention of the artery, but documentation with studies would be appropriate. Delayed reconstruction of injured structures is appropriate.

A 26-year-old male presents after a motor vehicle accident. Work-up reveals a closed left femoral shaft fracture, and an ipsilateral posterior wall fracture. He undergoes intramedullary nailing of the femur, and open reduction internal fixation of the posterior wall. He is treated with 25 mg of indomethacin three times daily for 6 weeks following an initial dose on the evening of surgery for heterotopic ossification prophylaxis. Which of the following is true regarding this post-operative treatment protocol?

1) It is associated with an increased rate of femoral shaft nonunion

2) It has no effect on the healing time of the posterior wall fracture

3) It is associated with a faster time to union

4) Indomethacin is superior to radiation treatment in the prevention of heterotopic ossification

5) There is a decreased rate of revision surgery needed when indomethacin is administered post-operatively

Heterotopic ossification (HO) prophylaxis with indomethacin has been shown to increase the risk of long-bone nonunion.
Indomethacin therapy has been shown to be an effective means of preventing HO formation, however literature has shown that it increases the risk of long bone and acetabular nonunion. Indomethacin works primarily by inhibiting IGF-1, which is a different mechanism from other NSAID's which typically inhibit the COX enzymes. IGF-1 is important for bone healing, and its inhibition may be a risk factor for delayed bone healing.
Burd et al performed a study to determine if patients with an acetabular fracture, who received indomethacin for prophylaxis against HO, were at risk of delayed healing or nonunion of any associated fractures of long bones. The study group consisted of 112 patients who had sustained at least one concomitant fracture of a long bone; of which 36 needed no prophylaxis, 38 received focal radiation and 38 received indomethacin. When comparing patients who received indomethacin with those who did not, a significant difference was noted in the rate of long bone nonunion (26% vs 7%).
Jordan et al performed a study to document the efficacy of variable treatment durations with indomethacin prophylaxis for HO and its effect on union of the posterior wall (PW) in operatively treated acetabular fractures. Patients were randomly assigned to one of four treatment groups: (1) placebo for 6 weeks,
(2) 3 days of indomethacin followed by placebo for a total of 6 weeks, (3) 1

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Displaced greater tuberosity fractures often will block abduction and/or external rotation by impinging on the underside of the acromion or posterior glenoid. The indications for open reduction and internal fixation are 1 cm of displacement or 45 degrees of rotation of the tuberosity fracture. Surgical treatment has recently been recommended for 0.5 cm of tuberosity displacement.
REFERENCES: Neer CS II: Displaced proximal humeral fractures: II. Treatment of three-part and four-part displacement. J Bone Joint Surg Am 1970;52:1090-1103.
Flatow EL, Cuomo F, Maday MG, et al: Open reduction and internal fixation of two-part displaced fractures of the greater tuberosity of the proximal part of the humerus. J Bone Joint Surg Am 1991;73:1213-1218.

An important indication for early exploration is the recovery of a distally supplied muscle, EC RLâC 6, in the absence of a proximally supplied muscle, bicepsâC 5. Trick movements are adaptive movements employed by the patient by recruiting other muscles, for example, the use of flexor-pronator as elbow flexors in this patient. Bony deformity is a late sequelae and biceps recovery at 3 months is important in obstetric brachial palsy.

TEA is the best surgical option. McKee and associates published a multicenter randomized controlled trial comparing ORIF with TEA in elderly patients. TEA resulted in better 2-year clinical functional scores and more predictable outcomes compared with ORIF. TEA was also likely to result in a lower reoperation rate; one-quarter of patients with fractures randomized to ORIF could not achieve stable fixation. Further, Frankle and associates reported a comparative study of TEA versus ORIF in 24 elderly women. TEA outcomes were again superior to ORIF at a minimum of 2 years of follow-up. TEA was especially useful in patients with comorbidities that compromise bone stock, including osteoporosis and oral corticosteroid use. Closed reduction and percutaneous pinning studies have not been published on the adult population.
25

The etiology of extensor mechanism disruption after TKA is unknown. Researchers suggest that disruption of the vascular supply to the patella and patellar mechanism during the exposure may cause weakening of the patella and extensor mechanism. In addition, the frequency of extensor mechanism disruption has been reportedly increased in patients who have a preoperative limited range of motion or difficult surgical exposure

The focus should be on the pictured plan. This shows a medialized cup and a stem that has insufficient offset (distance between the center of rotation and a line down the center of the femoral shaft) to recreate the patient’s anatomy. The cup sets the hip center of rotation (dot in the middle of the cup), and the femoral head reduces to this point. In this patient, inadequate offset could lead to a decrease in abductor efficiency and a Trendelenburg gait and even worse dislocation due to component impingement and/or muscular insufficiency. Compromised THA with a high likelihood of persistent trochanteric bursitis would be accurate if too much offset was restored for the patient. Regarding limb lengths, it appears the height of the implant is sufficient and as it stands would likely not change the leg lengths much at all. The concepts of limb length and offset restoration are critical to performing a successful THA and limiting adverse events and poor outcomes from an acquired limb length discrepancy, limb instability or persistent trochanteric bursitis.

The posterior position of the sciatic nerve in relation to the acetabulum and the lateral peroneal division makes the peroneal division of the sciatic nerve the portion of the nerve that is most likely to be injured in a posterior traumatic hip dislocation, accounting for up to 10% of concomitant nerve injuries with posterior hip dislocation. The corona mortis is an anatomic variant that results in vascular anastomosis between the obturator and either the external iliac or inferior epigastric arteries. This variant occurs in approximately 80% of patients and varies in its position, being located 4 cm to 9 cm lateral to the symphysis pubis. The obturator vascular bundle is situated in the fat medial to the obturator internus muscle and must be mobilized to access the quadrilateral plate. Dissection may be carried out both above and below this vascular leash. The Kocher-Langenbeck approach is indicated for fractures involving the posterior wall and/or posterior column of the acetabulum and for both column fractures that require direct posterior visualization. This approach is not indicated for direct reduction of the anterior wall or column when direct visualization is required anteriorly. The L5 nerve root is located on the anterior sacrum and is indicated by the arrow.
The position of this neural structure must be considered whether the surgeon is stabilizing 31 the sacroiliac (SI) joint with percutaneous iliosacral screws or with anterior SI plating through the lateral window of the ilioinguinal approach.
RECOMMENDED READINGS
1. [Cornwall R, Radomisli TE. Nerve injury in traumatic dislocation of the hip. Clin Orthop Relat Res. 2000 Aug;(377):84-91. Review. PubMed PMID: 10943188. ](http://www.ncbi.nlm.nih.gov/pubmed/10943188)[View](http://www.ncbi.nlm.nih.gov/pubmed/10943188)[ ](http://www.ncbi.nlm.nih.gov/pubmed/10943188)[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/10943188)
2. [Darmanis S, Lewis A, Mansoor A, Bircher M. Corona mortis: an anatomical study with clinical implications in approaches to the pelvis and acetabulum. Clin Anat. 2007 May;20(4):433-9. PubMed PMID: 16944498. ](http://www.ncbi.nlm.nih.gov/pubmed/16944498)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/16944498)
3. [Archdeacon MT, Kazemi N, Guy P, Sagi HC. The modified Stoppa approach for acetabular fracture. J Am Acad Orthop Surg. 2011 Mar;19(3):170-5. PubMed PMID: 21368098. ](http://www.ncbi.nlm.nih.gov/pubmed/21368098)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/21368098)
4. Rommens P. The Kocher-Langenbeck approach for the treatment of acetabular fractures. Operat Orthop Traumatol 2004; 16:59-74.
5. [Langford JR, Burgess AR, Liporace FA, Haidukewych GJ. Pelvic fractures: part 2. Contemporary indications and techniques for definitive surgical management. J Am Acad Orthop Surg. 2013 Aug;21(8):458-68. doi: 10.5435/JAAOS-21-08-458. Review. PubMed PMID: 23908252.](http://www.ncbi.nlm.nih.gov/pubmed/23908252)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23908252)

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.

Bae and Waters have shown that adolescents with significant posttraumatic elbow flexion contractures can gain an average of 54Â
° of motion with surgical release. They believe postoperative physical therapy and continuous passive motion are considered critical to success of surgical release. Lengthening of the biceps or triceps is not recommended. Measures to prevent postoperative heterotopic ossification did not influence the outcome.

This patient has cam-type femoroacetabular impingement. Decreased internal rotation and a positive impingement test (forced flexion, adduction, and internal rotation) are classic findings. The lack of pain with resisted hip flexion makes hip flexor strain unlikely, and the lack of tenderness at the greater trochanter renders trochanteric bursitis unlikely. Although athletic pubalgia can be a source of long-
standing groin pain, he lacks the pain with a resisted sit-up and tenderness along the pubic ramus that is frequently noted in patients with pubalgia. His radiographs reveal a focal femoral neck prominence consistent with cam impingement, although pistol grip deformities and flattening of the lateral femoral head are often present as well. His MRI scan shows a labral tear, which is common in cam impingement. Surgical treatment for cam impingement can be effective for symptomatic patients. Even among high-level athletes, open surgical dislocation of the hip has been shown to have good results. Most patients with cam impingement can be treated with arthroscopic osteoplasty and achieve results comparable with those realized with open surgical dislocation. The literature describes success in terms of athletes returning to sports (even professional athletes) to be approximately 90% after arthroscopic treatment. Byrd and Jones described five patients who developed transient neurapraxias that resolved uneventfully. The patients in his series who had concomitant microfracture had a 92% return to sports within the follow-up period. Cam impingement has long been thought to be associated with a history of a slipped capital femoral epiphysis. The capitis in these patients is displaced posteriorly, resulting in a prominent anterior femoral neck and decreased hip internal rotation. Pincer impingement is associated with a deep acetabulum, such as protrusion acetabula and acetabular retroversion. A patient who underwent a
periacetabular osteotomy can develop a more retroverted acetabulum as well.

The patient has heterotopic ossification, a more common finding in patients who have sustained head injuries. Treatment will require removal of the heterotopic bone and anterior and posterior capsulectomies. The main concern about timing is the possible recurrence of heterotopic bone. While an extended wait was once thought necessary, this is no longer true. The timing is based on the time since injury and evidence of bone maturation on plain radiographs. A sharp marginal demarcation of the new bone and a trabecular pattern within it are usually present 3 to 6 months after onset, indicating that it is safe to proceed with surgical excision. It is not necessary to wait more than 6 months. Bone scan results are not good indicators because they may remain “hot” for long periods of time. The levels of alkaline phosphatase and serum calcium-phosphorus product do not need to be measured.
REFERENCE: Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 325-335.

Disorders of the hip can mimic and/or coexist with lumbar spine disorders. The prevalence of hip pain lasting longer than 1 month in patients ages 65 to 74 years is 19%. There is often overlap between their respective signs and symptoms. In a patient with failed back surgery syndrome, hip pathology may have been present before back surgery and not recognized. Osteoarthritis of
the hip typically causes groin and anterior thigh pain. Meralgia paraesthetica is more likely to manifest immediately after surgery. Trochanteric bursitis usually affects the proximal lateral thigh and often can radiate to the distal thigh. Facet joint pain causes low-back pain that can be referred to the gluteal region. Epidural hematoma 6 weeks after surgery is highly unlikely.
RECOMMENDED READINGS
Bolt PM, Wahl MM, Schofferman J: The roles of the hip, spine, sacroiliac joint, and other structures in patients with persistent pain after back surgery. Seminars in Spine surgery 2008;20:14-19.
[Brown MD, Gomez-Marin O, Brookfield KF, Li PS. Differential diagnosis of hip disease versus spine disease. Clin Orthop Relat Res. 2004 Feb;(419):280-4. PubMed PMID: 15021166. ](http://www.ncbi.nlm.nih.gov/pubmed/15021166)[View](http://www.ncbi.nlm.nih.gov/pubmed/15021166)[ ](http://www.ncbi.nlm.nih.gov/pubmed/15021166)[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/15021166)

**
Although the early use of FDS as a transfer to restore finger extension in patients with radial nerve palsy was performed by passing the tendon through the interosseous membrane, Nalebuff and Patel later modified this procedure for the rheumatoid arthritis patient by passing the FDS radially, around the radius in a dorsal direction. They felt that this provided a number of advantages, including: 1. technical ease, 2. avoidance of synovial disease on the dorsum of the wrist, and 3. correction of ulnar deviation of the fingers through the line of pull from the radial side of the forearm.

The radiograph reveals an excellent postsurgical metacarpal scaphoid joint space, so revision of the CMC joint or fusion is not appropriate. The scaphoid trapezoid joint is irregular (Figure 48b) and is a common cause of the described symptoms. The sensitivity of the radiographic diagnosis of scaphoid trapezium trapezoid arthritis is 44%, and the specificity is 86%. The true prevalence of scaphotrapezoid arthritis is approximately 62%. Resection of the proximal trapezoid is not associated with morbidity. Routine intraoperative assessment of the scaphoid trapezoid joint is recommended so that proximal trapezoid excision (Figures 48c and 48d) can be performed if degenerative change (Figure 48b) is present.
RECOMMENDED READINGS
51. [Tomaino MM, Vogt M, Weiser R. Scaphotrapezoid arthritis: prevalence in thumbs undergoing trapezium excision arthroplasty and efficacy of proximal trapezoid excision. J Hand Surg Am. 1999 Nov;24(6):1220-4. PubMed PMID: 10584944. ](http://www.ncbi.nlm.nih.gov/pubmed/10584944)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/10584944)
52. [Eaton RG, Glickel SZ, Littler JW. Tendon interposition arthroplasty for degenerative arthritis of the trapeziometacarpal joint of the thumb. J Hand Surg Am. 1985 Sep;10(5):645-54. PubMed PMID: 4045141. ](http://www.ncbi.nlm.nih.gov/pubmed/4045141)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/4045141)

The radiograph shows a posterior wall acetabular fracture-dislocation. Post reduction CT indicates a large comminuted posterior wall fracture with marginal impaction of the articular surface. A comminuted femoral head fracture also is seen extending to the superior weight-bearing surface. Given the marginal
impaction of the acetabulum and the considerable comminution of the femoral head (which is likely unreconstructible), this injury would have a high risk of causing posttraumatic arthritis if treated with ORIF of the fractures alone. Considering this fact and the patient’s age, ORIF of the posterior wall and acute total hip arthroplasty would likely have the best functional result and the lowest risk of reoperation. Hemiarthroplasty is inappropriate for this injury considering the acetabular fracture. Skeletal traction currently plays a limited role in the definitive treatment of acetabular fractures.

The patient has a Vancouver type B1 fracture of the femur with a well-fixed femoral component. When comparing the two radiographs, the proximal femoral component position has not changed and remodeling is seen around the component. Nonsurgical management is associated with the complications of extended recumbency. As the femoral component is well-fixed, revision of the femoral component is not necessary.
REFERENCES: Masri BA, Meek RM, Duncan CP: Periprosthetic fractures evaluation and treatment. Clin Orthop Relat Res 2004;420:80-95.
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 475-503.
Ricci WM, Bolhofner BR, Lofitus T, et al: Indirect reduction and plate fixation, without grafting, for
periprosthetic femoral shaft fractures about a stable intramedullary implant. J Bone Joint Surg Am 2005;87:2240-2245.