Updated Orthopedic Review | Dr Hutaif General Orthopedi -...

The presence of a high signal intensity line at the interface between the lesion and the underlying bone suggests instability of an osteochondritis dissecans lesion.

DISCUSSION: Biomechanical in vitro studies of double-row fixation of rotator cuff tears during cyclic loading and tensile loading to failure have demonstrated that double-row fixation results in a higher ultimate tensile load when compared to single-row fixation. Peak-to-peak elongation, stiffness, and conditioning
elongation for double-row fixation were all similar to single-row fixation. These initial findings, however, may or may not lead to improved clinical outcomes.
REFERENCES: Ma CB, Comerford L, Wilson J, et al: Biomechanical evaluation of arthroscopic rotator cuff repairs: Double-row compared with single-row fixation. J Bone Joint Surg Am 2006;88:403-410. Kim DH, El

Attrache NS, Tibone JE, et al: Biomechanical comparison of single-row versus double-row suture anchor technique for rotator cuff repair. Am J Sports Med 2006;34:407-414.

An infection of the shoulder is considered a surgical emergency unless there are medical reasons that a patient cannot be taken to the operating room. If cultures of wound drainage are in question, then an aspiration should be done emergently, not several days later. The hallmark of infection in any major joint is increasing pain out of proportion to what is expected. Drainage occurring 1 to 2 days after an arthroscopic procedure is not normal, and it should be aggressively treated. Delay in diagnosis can result in sepsis and on a delayed basis, postinfectious arthritis. Both the glenohumeral joint and the subacromial space require debridement and irrigation, followed by antibiotics after both areas are cultured.
REFERENCES: Mansat P, Cofield RH, Kersten TE, Rowland CM: Complications of rotator cuff repair. Orthop Clin North Am 1997;28:205-213.
Settecerri JJ, Pitner MA, Rock MG, Hanssen AD, Cofield RH: Infection after rotator cuff repair. J Shoulder Elbow Surg 1999;8:1-5.
Ward WG, Eckardt JJ: Subacromial/subdeltoid bursa abscesses: An overlooked diagnosis. Clin Orthop 1993;288:189-194.
Ward WG, Goldner RD: Shoulder pyarthrosis: A concomittant process. Orthopedics 1994;17:591-595.

The radiographs reveal an extra-articular proximal phalanx fracture of the index finger. The fracture is comminuted with dorsal angulation of the distal fragment. The question specifically asks about the restoration of sagittal alignment. The fracture is comminuted with dorsal angulation of the distal fragment. The other options are incorrect, because overlapping of the digits occurs with rotational malalignment, the development of arthritis may occur with intra-articular fractures, and hyperextension would not occur _with this type of deformity._

In the immediate postoperative period following repair of an acute rotator cuff tear, passive forward elevation and external rotation should be performed within the safe zone determined at surgery. Early active range of motion (prior to tendon healing), internal rotation behind the back, and resistive exercises increase the risk of rupture of the repair.
REFERENCES: Iannotti JP: Full-thickness rotator cuff tear: Factors affecting surgical outcome. J Am Acad Orthop Surg 1994;2:87-95.
Bigliani LU, Cordasco FA, McIlveen ST, et al: Operative repair of massive rotator cuff tears: Long-term result. J Shoulder Elbow Surg 1992;1:120-130.

Basal cell carcinomas rarely metastasize. Malignant sweat gland tumors, malignant melanoma, and Merkel's cell carcinoma are aggressive. Treatment usually includes regional lymphadenectomy. Squamous cell carcinoma is one of the most common hand malignancies and has the capacity to metastasize via the lymphatics.

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

PLRI of the elbow is the most common form of chronic elbow instability. The mechanism occurs following a fall onto an outstretched hand, where a valgus force is applied to the elbow and the forearm rotates into progressive supination. This allows the radial head to translate posterior to the capitellum, with progressive injury from lateral to medial sides of the elbow. The pivot shift test is a useful examination maneuver to confirm the presence of PLRI. With the forearm in maximal supination and valgus stress applied to the elbow, the radial head is forced posterior to the capitellum as the elbow is brought into progressive extension, revealing a dimple on the lateral aspect of the elbow. This typically occurs at roughly 30° of flexion. As the elbow is flexed, the radial head reduces.

Because of the previously transferred bone block of coracoid and short arm flexors, the musculocutaneous nerve often scars along the anteroinferior glenohumeral capsule. Mobilization of this tissue places the nerve at greatest risk. The axillary nerve is also potentially at risk, but this is nonspecific to prior surgery, particularly the Bristow procedure.
REFERENCES: Norris TR: Complications following anterior instability repairs, in Bigliani LU (ed): Complications of Shoulder Surgery. Baltimore, MD, Williams and Wilkins, 1993,
pp 98-116.
Flatow EL, Bigliani LU, April EW: An anatomic study of the musculocutaneous nerve and its relationship to the coracoid process. Clin Orthop 1989;244:166-171.

Severe pilon fractures are generally the result of high energy trauma leading to bony comminution of the articular and metaphyseal bone. They are usually associated with significant soft tissue injury which prevents immediate definitive open reduction and internal fixation. In this situation, due to the soft tissue injury and open fracture, initial treatment should consist of irrigation and debridement and stabilization with external fixation. Definitive management such as open reduction and internal fixation is performed once the soft tissue swelling has improved and there is no evidence of infection. Sirkin et al published their results of a staged protocol for complex pilon injuries. Their data suggests the historically high rates of infection associated with ORIF of pilon fractures are likely due to attempts at immediate fixation through swollen, compromised soft tissues.

This is a Kirner deformity. Attributed to J. Kirner who described it in 1927, it is a rare congenital deformity of the distal phalanx of the small finger. It is often bilateral and sometimes familial. Radiographic appearance is characterized by narrow, apex-dorsal arching of the phalangeal shaft and a widened physis. The etiology is unknown, although several proposed mechanisms have proven unfounded with advanced imaging. This deformity usually is not associated with syndromes or other musculoskeletal abnormalities.
Clinically, the finger has a short distal phalangeal segment with a dorsally curved fingernail. Patients tend to seek an evaluation for this progressive deformity during adolescence. The deformity ceases to increase once a patient reaches skeletal maturity and the physis closes. This condition is frequently diagnosed as a partial growth arrest, but there is always a mysterious lack of a trauma history. Infection and inflammation are other possible causes, but laboratory studies and MRI do not show enhancement.
This deformity is largely cosmetic, although pain is occasionally reported. If patients find the deformity unacceptable, treatment is a palmarly based opening-wedge osteotomy. While this is an exceedingly rare condition, it is relevant for general orthopaedic surgeons to recognize the condition to avoid the consternation associated with misdiagnosis.
Vitamin D deficiency does not cause skeletal deformity in the hand. Frostbite typically is associated with wide, short phalanges with early growth arrest. Posttraumatic growth arrest occurs occasionally with a Seymour fracture but is most often a central or asymmetric arrest.
RECOMMENDED READINGS
5. [Dykes RG. Kirner's deformity of the little finger. J Bone Joint Surg Br. 1978 Feb;60(1):58-60. PubMed PMID: 627580.](http://www.ncbi.nlm.nih.gov/pubmed/627580)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/627580)
6. Khalid S, Khalid M, Zaheer S, Ahmad I, Ullah E. Kirner's Deformity Misdiagnosed as Fracture: A Case Report. Oman Med J. 2012 May;27(3):237-8. doi: 10.5001/omj.2012.53. PubMed PMID: 22811775.
[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/22811775)
7. Lee J, Ahn JK, Choi SH, Koh EM, Cha HS. MRI findings in Kirner deformity: normal insertion of the flexor digitorum profundus tendon without soft-tissue enhancement. Pediatr Radiol. 2010 Sep;40(9):1572-5. doi: 10.1007/s00247-010-1628-4. Epub 2010 Mar 25. PubMed PMID: 20336287.
[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/20336287)

If a single flexor digitorum profundus (FDP) tendon is debrided more than 1 cm prior to repair, the tendon is advanced too far distally, essentially shortening the musculotendon unit. The finger will likely develop a flexion posture. Because of the common muscle belly and interconnections of the profundi, the long and small fingers adjacent to the injured finger will be affected because of loss of some of their normal proximal excursion. The result is an inability of the adjacent fingers to completely flex. This condition, known as quadrigia, is named after the Roman chariot driver who held control of the reins of 4 horses, forcing them to move as 1. Quadrigia occurs when the FDP tendon is advanced too far distally, when a tendon graft is too short, or when the profundus is sutured over the end of an amputated digit. Intrinsic muscles of the hand flex the metacarpophalangeal (MP) joints and extend the PIP joint. Intrinsic tightness causes decreased PIP flexion when the MP joint is in extension. The lumbrical muscle modulates tension on the flexor profundus tendon. When a tendon graft to repair the profundus tendon is too long, a lumbrical plus deformity occurs. This is a paradoxical PIP extension as the finger is flexed. Disruption of the tendon
repair causes limited flexion of the injured finger.

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Osteoclasts are derived from cells of the monocyte/macrophage lineage. They are multinucleated and develop by fusion of mononuclear precursors, a process that requires receptor activator for nuclear factor kappa-B ligand (RANKL) and macrophage-colony stimulating factor (M-CSF). RANKL is secreted by osteoblasts in response to inflammatory signals and is a key component of inflammation-mediated osteolysis. OPG binds to and sequesters RANKL, thus inhibiting osteoclast differentiation and activity.
BMP and IGF-1 are potent regulators of osteoblast differentiation and activation. TNF is a cytokine secreted by macrophages and degranulating platelets infiltrated in the fracture site and impacts a variety of cells, not osteoclasts.

This patient has a malunion of the fibula that does not appear to be associated with ankle arthritis, despite the radiographic changes. The valgus tilt of the ankle joint is common with shortening of the fibula and does not imply arthritis. Therefore, arthrodesis and ankle replacement are not indicated. Lengthening osteotomy of the fibular combined with excision of the medial joint scar is ideal to realign the tibiotalar joint. Although ankle arthroscopy may be performed in conjunction with the fibular osteotomy, it is not sufficient treatment.

- A genetic defect in the type I collagen gene

Hydrocephalus is rare because most patients have lipomeningocele, not myelomeningocele.
Omphalocele is common in cloacal exstrophy.
Most patients with cloacal exstrophy have a lipomeningocele that is a form of spinal dysrhaphism. Many patients have malformations of the sacroiliac joints.
Approximately 25% of patients have dislocations of at least one hip.

Although all of the above are potential complications after arthroscopic capsular release for adhesive capsulitis, the most common problem is the failure to regain normal glenohumeral motion. An immediate physical therapy program is critical to prevent this complication.
REFERENCES: Ghalambor N, Warner JJP: Arthroscopic capsular release: Evolution of the technique and its applications. Tech Shoulder Elbow Surg 2000;1:52-60.
Pollock RG, Duralde XA, Flatow EL, Bigliani LU: The use of arthroscopy in the treatment of resistant frozen shoulder. Clin Orthop 1994;304:30-36.

C ore binding factor alpha 1 (C bfa1) and its gene (Cbfa1) have been described as anabolic regulators of bone. C bfa1 is a transcription factor and is responsible for the differentiation of precursor cells into osteoblasts. It also enhances differentiation of chondrocytes during enchondral bone formation. When there is deficiency of C bfa1, there can be abnormal bone development as in cleidocranial dysplasia.

C harcot-Marie-Tooth disease (C MT) is a neuropathic process resulting in muscle atrophy, therefore, muscle enzyme studies will not be helpful.
Electromyography (EMG) will confirm the diagnosis by displaying increased amplitude and duration of signals, both of which are indicative of a neuropathic process.
Nerve conduction velocity (NC V) will also confirm the diagnosis by displaying decreased motor and sensory conduction velocities.
Nerve biopsy can be helpful by showing loss of myelinated fibers and fibrosis. Muscle biopsy will show diffuse atrophy, fibrosis, and adipose tissue within muscle.

Because the patient has clinical and radiographic signs of AC arthritis and subacromial impingement, the treatment of choice is anterior acromioplasty and distal clavicle excision. Arthroscopic acromioplasty alone would not address the AC arthritis. The rotator cuff is intact; therefore, rotator cuff repair is not indicated. An open Mumford procedure would address the AC arthritis only and not the impingement symptoms. Immobilization might lead to stiffness of the shoulder and is not recommended for treating impingement.
REFERENCE: Peterson CA, Altchek DW, Warren RF: Shoulder arthroscopy, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1990, pp 290-335.

The structure is the volar plate ligament. This ligament may assume a pathologic role in claw toe deformity and instability of the metatarsophalangeal joint.

Iontophoresis is effective in soft tissue conditions such as rotator cuff bursitis and lateral epicondylitis.

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Development of proximal tibial valgus is an uncommon, but well-documented, complication of proximal tibial metaphyseal fractures in children. There are multiple theories as to the origin, but the exact etiolgy is unknown. Management with a guide-growth procedure is rarely required, because most patients ultimately achieve spontaneous correction.

In the last stage of osteoarthritis, there is reduced chondrocyte proliferation and function, which may be secondary to reduced ability to respond to anabolic factors (down regulation). There may be accumulation of molecules that bind to the anabolic factors (and keep the factors from the chondrocytes) such as decorin and insulin-dependent growth factor binding protein.

Patients with comminuted radial neck and head fractures and associated wrist pain have a significant injury to the elbow and forearm. Nonsurgical management is an option, but initial casting will result in stiffness and early range of motion is likely to be unsuccessful secondary to pain. Surgical treatment with open reduction and internal fixation, although possible, is technically demanding and results are unpredictable with comminuted fractures. Excision alone in the face of wrist pain may lead to radial shortening. The treatment of choice is excision and metallic radial head arthroplasty. Silastic implants have been associated with synovitis and wear debris.
REFERENCES: Furry KL, Clinkscales CM: Comminuted fractures of the radial head: Arthroplasty versus internal fixation. Clin Orthop 1998;353:40-52.
Ring D, Quintero J, Jupiter JB: Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg Am 2002;84:1811-1815.

The injury mechanism involves a valgus load applied to the knee with the foot in external rotation. The primary stabilizer to valgus laxity is the medial collateral ligament. The secondary restraints to valgus rotation are the cruciate ligaments. Examination indicates disruption of the medial collateral and anterior cruciate ligaments. Valgus opening in extension should also arouse suspicion for an injury to the posterior cruciate ligament; however, in this patient, the valgus opening in extension is mild. The slight opening in extension and the increased anterior drawer, especially with external rotation, indicates disruption of the posteromedial capsule and posterior oblique ligament. Figure 21a shows complete disruption of the superficial and deep medial collateral ligaments involving the meniscofemoral ligament. Figure 21b shows a more posterior coronal section with a torn posterior oblique ligament. Figure 21c shows disruption of the anterior cruciate ligament, while the posterior cruciate ligament at the tibial insertion appears with a homogenous normal signal.
REFERENCES: Warren LA, Marshall JL, Girgis F: The prime static stabilizer of the medial side of the knee. J Bone Joint Surg Am 1974;56:665-674.
Indelicato PA: Injury to the medial capsuloligamentous complex of the knee, in Feagin J (ed): The Crucial Ligaments, ed 2. 1994, pp 351-360.

Recurrent dislocations with extension past 50° represent a significant injury to the elbow and require a stabilization period. Instability to valgus stress represents injury to the anterior band of the medial collateral ligament of the elbow and will heal with protected motion. The majority of radial head fractures (Mason type I and II) that are less than 30º of the radial head and less than 30º angulation heal with good functional results. Most dislocations will have osteochondral lesions. Ulnar nerve parathesias can be associated with dislocations but is not an indication for operative fixation.

With an ESR of 30 mm/hr to 35 mm/hr, sensitivities have been reported from 0.60 to 0.96 and specificities from 0.65 to
1

An unconstrained prosthesis dislocation is a disconcerting problem that is not easily resolved; however, revision to a semiconstrained prosthesis would best achieve both pain relief and stability. Removal of the components and distraction arthroplasty or conversion to a resection arthroplasty are options, but the results would be unpredictable with regards to pain relief, postoperative motion, or elbow stability. Arthrodesis is poorly tolerated. With revision to another unconstrained prosthesis, there is the risk of continued redislocation because of chronic ligamentous insufficiency.
REFERENCES: Linscheid RL: Resurfacing elbow replacement arthroplasty: Rationale, technique and results, in Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 602-610.
Morrey BF, King GJ: Revision of failed total elbow arthroplasty, in Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 685-700.

Two studies have shown that supplemental vitamin C reduces the risk of developing complex regional pain syndrome following a distal radius fracture. The recommended dose is 500 mg daily for 50 days. Supplemental vitamin C is a recommendation of the AAOS evidence-based Clinical Practice Guidelines
and has moderate evidence. The vitamin supplements listed as alternative options have not been shown to prevent disproportionate pain following a distal radius fracture.

A Latarjet procedure is similar to a Bristow procedure, but with the Latarjet procedure a larger portion of the coracoid is transferred to the scapular neck at the anteroinferior glenoid. As in a Bristow procedure, if the fragment is pulled or twisted during the dissection or during fixation, the musculocutaneous nerve can be injured. With loss of biceps function, elbow flexion and forearm supination will be weaker.
REFERENCES: Ho E, Cofield RH, Balm MR, Hattrup SJ, Rowland CM: Neurologic complications of surgery for anterior shoulder instability. J Shoulder Elbow Surg 1999;8:266-270.
Boardman ND 3rd, Cofield RH: Neurologic complications of shoulder surgery. Clin Orthop 1999;368:44-53.
Allain J, Goutallier D, Glorion C: Long-term results of the Latarjet procedure for the treatment of anterior instability of the shoulder. J Bone Joint Surg Am 1998;80:841-852.

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Spinal fractures in patients with ankylosing spondylitis are unstable and generally necessitate surgical intervention. In a patient with a spinal fracture in the setting of ankylosing spondylitis, posterior instrumented fusion is an appropriate surgical procedure. Treatment with a thoracolumbar orthosis is not an option for patients with extension distraction injuries in the setting of an ankylosed spine because of risk for displacement. Similarly, simply checking upright radiographs is generally not advocated. Laminectomy alone is inappropriate for this patient because there is no cord compression and neurologic symptoms are absent. Stabilization is the treatment goal.

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

DISCUSSION: The patient has an intertrochanteric fracture malunion with protrusion of the hardware and penetration into the acetabulum. To restore leg length and relieve pain, total hip arthroplasty is necessary. Valgus osteotomy is appropriate for fracture nonunion with an intact femoral head with no signs of osteonecrosis. Bipolar hemiarthroplasty with acetabular erosion will most likely lead to pain as will removal of the hardware with or without physical therapy.

REFERENCE: Said GZ, Farouk O, El-Sayed A, et al: Salvage of failed dynamic hip screw fixation of intertrochanteric fractures. Injury 2006;37:194-202.

Figure 6

- proximal metatarsal bunionectomy.

DISCUSSION: The history, physical examination, and laboratory studies suggest a septic hip. Recent studies indicate that a child with elevated ESR, a WBC count of greater than 12,000/mm3, a temperature of greater than 38.5 degrees, and unwillingness to walk is very likely to have septic arthritis of the hip versus toxic synovitis. The best way to confirm the diagnosis is by hip aspiration. No medications should be started until a diagnosis is made. Toxic synovitis is common, but significantly less likely if three of the above criteria are present. This condition usually responds well to ibuprofen, but requires close observation. Septic hips are considered urgent conditions and therefore a repeat evaluation in 2 weeks is inappropriate.
REFERENCES: Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, WB Saunders, 2008, pp 2109-2113.
Abel MF (ed): Orthopaedic Knowlede Update: Pediatrics 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 62-65.
Kocher MS, Mandiga R, Murphy JM, et al: A clinical practice guideline for treatment of septic arthritis
in children: Efficacy in improving process of care and effect on outcome of septic arthritis of the hip. J Bone Joint Surg Am 2003;85:994-999.
Kocher MS, Mandiga R, Zurakowski D, et al: Validation of a clinica l prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am 2004;86:1629-1635.

"Ream and run" shoulder arthroplasty can allow for arthroplasty without the complications of a polyethylene glenoid. Ten-year conversion to total shoulder arthroplasty has been shown in one study to be 12%. Recovery is reported to be slower and requires more rehabilitation than arthroplasty done with glenoid resurfacing. Careful patient selection has been emphasized by the pioneering surgeon.

The translation and shortening are not problems and the amount of angulation will easily remodel with this fracture. There is nothing to be gained from operative reduction.

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Buried pins require additional return to the operating room for removal, do not decrease infection rate, or improve outcome. The additional return to the operating room significantly increases cost associated with treatment.

Neurotization is appropriate in preganglionic lesions. Around 6 months with no evidence of recovery is ideal time for plexus exploration. Further observation will not change the picture and tendon transfers are reconstructive procedures, which are done at a later stage.

The contracted Achilles tendon leads to increased forefoot pressure, thus increasing the risk for ulceration in neuropathic patients. Several studies have shown the benefit of Achilles tendon lengthening to heal and prevent forefoot ulceration in these patients. The flexor hallucis longus transfer is used for chronically torn/deficient Achilles tendons, not a contracted Achilles tendon. The Jones procedure works well for the first ray but does not help to alleviate pressure under the second ray. Peripheral bypass surgery is unnecessary because the ulcer healed during the initial treatment, indicating that the patient has adequate circulation. The posterior tibial tendon transfer is used for foot drop or other neuromuscular conditions to correct deformity and increase function. It is not used for forefoot ulcers in patients with diabetes mellitus.
REFERENCES: Armstrong DG, Stacpoole-Shea S, Nguyen H, et al: Lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot. J Bone Joint Surg Am 1999;81:535-538.
Meuller MJ, Sinacore DR, Hastings MK, et al: Effect of Achilles tendon lengthening on neuropathic plantar ulcers: A randomized clinical trial. J Bone Joint Surg Am
2003;85:1436-1445.

Correcting the tibiofemoral angle between 4° to 6° transfers 80% of the weight to the medial angle

- Charcot foot

The plain radiographs show a destructive lesion in the wrist in the distal radius and at the scaphotrapezial joint. The joint spaces are preserved. The histology shows the features of gout: acellular amorphous tissue, macrophages, and giant cells.
Gout is caused by the deposition of monosodium urate crystals in tissues typically around joints. Common locations include the great toe, heel, ankle, and knee. In approximately 50% of patients, the first attack is in the great toe. Gout commonly occurs inside a joint for two reasons:
The synovial fluid is a poorer solvent than plasma
Lower temperatures (as in peripheral joints) favor crystallization
Neutrophils ingest the crystals and then release potent lysosomal enzymes. Histologically, the tophi have several features: Acellular amorphous material
Macrophages
Foreign body giant cells
The first line of treatment is nonsteroidal anti-inflammatory medications. Correct Answer: Nonsteroidal anti-inflammatory medications

The initial radiographs reveal a fourth and fifth carpometacarpal (CMC) joint fracture dislocation. The injury is associated with a shear fracture of the dorsal rim of the hamate. Further assessment with CT might be helpful in fully evaluating the extent of injury. Extensor carpi ulnaris is a deforming force at the base of the fifth metacarpal. This unstable fracture dislocation could be treated with closed reduction and pinning if the patient presented within a few days of injury. However, because he presented in a delayed fashion (3 weeks after injury), open reduction with internal fixation was required (Figures 4 and 5). In the series by Zhang and associates, patients with fourth and fifth CMC fracture dislocations presenting in a delayed fashion and treated nonsurgically had suboptimal results. Therefore, closed reduction and casting are not appropriate. An arthrodesis and resection arthroplasty are salvage procedures considered for a painful arthritic joint and would less likely should not be considered for this acute injury.

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The patient has sustained a complex proximal humerus fracture with head split component and multiple articular fragments. When the articular surface is significantly compromised, arthroplasty procedures are favored. The only procedure listed that addresses the damaged humeral head is hemiarthroplasty, making it the correct response. Although a possible option, ORIF would be difficult due to the fragmented humeral head, and there would be a high risk for fracture collapse or avascular necrosis. IM nailing will not provide enough control of the fracture pieces, nor will it replace the damaged articular surface. Closed reduction is not an option given the complex nature of the fracture.

This patient has ischiofemoral impingement, in which there is abnormal contact between the lesser trochanter and the lateral border of the ischium. Patients typically present with posteriorly based hip pain and do not respond to intra-articular diagnostic injections. Examination can demonstrate pain with long strides, pain with palpation over the area, as well as reproduction of symptoms with the patient in the contralateral decubitus position and taking the affected hip into passive extension (ischiofemoral impingement test). MRI demonstrates a narrowed ischiofemoral space, as well as increased signal within the quadratus femoris muscle. The diagnosis can be confirmed with a diagnostic injection into this area. Treatment is typically nonsurgical, with surgical intervention consisting of resection of the lesser _trochanter reserved for refractory cases._

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The degree of vascular injury is considered a local factor in fracture healing. Other such factors include degree of local trauma, type of bone affected, degree of bone loss, degree of immoblization, infection and local pathologiCconditions. SystemiCfactors include age of the patient, hormone function, functional activity, nerve function and nutritional state

DISCUSSION: In 95% of patients with Ewing’s sarcoma, there is a translocation, t(l 1:22). This results in EWS/FLI-1 transcription factor that results in tumor cell proliferation. Other mechanisms causing

2010 Pediatric Orthopaedic Examination Answer Book • 47
tumor cell proliferation include inactivation of tumor suppressor genes, or activation of proto-oncogenes.

REFERENCES: Arndt CA, Crist WM: Common musculoskeletal tumors of childhood and adolescence. N Engl J Med 1999;341:342-352.
Pierz KA, Womer RB, Dormans JP: Pediatric bone tumors: Osteosarcoma Ewing’s sarcoma, and chondrosarcoma associated with multiple hereditary osteochondromatosis. J Pediatr Orthop 2001
;21:412- 418.