I Review | Dr Hutaif General Orthopedics Review | Dr H - ...

Using the traditional concussion grading scale, the patient sustained a grade I concussion because he did not lose consciousness and his abnormal cognitive level lasted less than 1 hour. If this was the player’s first concussion, theoretically he could return to play later in the game provided that he had no confusion, headache, or associated symptoms. However, because it was the third concussion for the year, participation in contact sports should be terminated for the season.
REFERENCES: Guskiewwicz KM, Barth JT: Head injuries, in Schenk RC Jr (ed): Athletic Training and Sports Medicine. Rosemont, IL, American Academy of Orthopedic Surgeons, 1999, pp 143-167.
Kelly JP, Rosenberg JH: Diagnosis and management of concussion in sports. Neurology 1997;48:575-580.

The clavicle is a membranous bone, and osteochondromas do not arise in membranous bones.

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Bowed legs is a common presenting complaint in toddlers. Most of these children will have physiologic genu varum and will require no treatment other than parental reassurance. The physiologic deformity generally improves as the children approach 16 to 18 months-old, and the deformity itself rarely exceeds a tibiofemoral angle of 20°. The differential diagnosis includes Blount disease, skeletal dysplasias, and metabolic disorders, such as rickets. This radiograph shows physeal widening and metaphyseal flaring, which is consistent with rickets. Blood work will confirm the diagnosis and differentiate vitamin D-deficient rickets from vitamin Dresistant rickets, and renal osteodystrophy.

Results have been satisfactory in many patients; however, at long-term follow-up, examination of the affected shoulder often shows some decrease in range of motion compared with the contralateral side. Although range of motion often improves over time, it does not return to normal in 60% of patients. Pain improves but is often increased compared with the contralateral side.
REFERENCES: Griggs SM, Ahn A, Green A: Idiopathic adhesive capsulitis: A prospective functional outcome study of nonoperative treatment. J Bone Joint Surg Am 2000;82:1398-1407.
Shaffer B, Tibone JE, Kerlan RK: Frozen shoulder: A long-term follow-up. J Bone Joint Surg Am 1992;74:738-746.

The patient had an open fracture that was initially treated with what appears to be appropriate irrigation and debridement and intramedullary nail placement. The post-operative infection and need for rotational flap is worrisome, but she has not had any issues since the flap. She has abundant callus formation but the fracture line is still visible and unchanged on 2 sets of radiographs. The patient has persistent pain. The best initial evaluation is to ensure that there is no underlying infection with laboratory studies, including a complete blood count (CBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Nuclear medicine studies have questionable utility, but may be helpful if the inflammatory markers from laboratory studies come back elevated. A CT scan is not warranted because the sequential radiographs show persistent fracture lines and no changes. The patient has a hypertrophic nonunion. Originally, she had appropriate treatment and has shown the ability to make callus, thus her biologic capacity appears to be intact and bone grafting is not needed. The hypertrophic nature of her fracture nonunion indicates that she needs more stability. The best treatment for a hypertrophic nonunion of the tibia is exchange nailing. Based on successive radiographs and the lack of healing, observation is probably just delaying the inevitable. Plating with retention of the nail can be useful in recalcitrant long bone non-unions, especially in the femur.

- Proximal first metatarsal osteotomy

The osteon is a unique arrangement of bone cells and matrix surrounding a blood vessel. The osteon is an irregular branching, anastomosing cylinder composed of a centrally placed neurovascular canal surrounded by cell-permeated layers of bone matrix.
The bone remodeling unit refers to the cutting cone of leading osteoclasts and following osteoblasts.
Plexiform bone is a structural type of bone found in large animals where rapid bone growth occurs. There are alternating layers of lamellar and woven bone.
Volkman canals are the channels connecting different osteons or Haversian units.
Canaliculi are small channels through which the cell processes of the osteocytes connect to each other. Correct Answer: Osteon

Type I mallet injuries are by far the most common mallet injuries. There is no such classification as a type V injury.C orrect
Answer: Type I

The image shown is a transverse cut of the foot, which shows the inferior calcaneus, the cuboid, and the three cuneiform bones. The arrow points to a fractured cuboid. The lateral radiograph also shows fractures of the anterior process of the calcaneus and the lateral process of the talus.
RECOMMENDED READINGS
1. Sarrafian SK. Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional.
2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1993:393-406.
2. Hoppenfeld S, deBoer P. Surgical Exposures in Orthopaedics: The Anatomic Approach.
Philadelphia, PA: JB Lippincott; 1984:495-520.
83

One of the best ways to limit radiation exposure is to increase distance from the C -arm. Surgeons should always stand on the opposite side of the C -arm and remember the following methods for reducing radiation exposure:
Increase distance (doubling distance reduces exposure by a factor of 4) Inverted position of the C -arm (increases distance)
Shielding: 90% attenuated by 0.25-mm apron
C ollimation (reduces the size of the beam)
Foot pedal to control the fluoroscopy unit (decreases the amount of exposure)

The radiographs show a small minimally displaced radial head fracture that is amenable to nonsurgical management. Early range-of-motion exercises will best restore
function and minimize stiffness. A long arm cast for any length of time will result in severe elbow stiffness.
REFERENCES: Morrey BF: Radial head fracture, in Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 341-364.
Hotchkiss RN: Displaced fractures of the radial head: Internal fixation or excision? J Am Acad Orthop Surg 1997;5:1-10.

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

Plain radiographs have a high false-negative rate especially early in the clinical course of stress fracture.
Periosteal new bone formation is a hallmark finding.
Only 20% of bone scan positive foci correlate with positive radiographs. Positive radiographic findings include horizontal or linear patterns of sclerosis.
The âgray cortexâ may occur from increased osteoclastic resorption on the cortex. Correct Answe Plain radiographs have a low false-negative rate.

Key features of Pagetâs disease
Remodeling disease caused by excessive osteoclastiCactivity
Rarely diagnosed in patients younger than 40 years of age; most patients diagnosed after age 50
Most common sites include pelvis, femur, spine, skull, and tibia
Less common sites include clavicles, scapulae, ribs, and facial bones
Rarely found in the hands and feet
PagetiCbone
is more susceptible to fracture is less compact
is more vascular
tends to bow in weight bearing areas
GeographiCclustering (up to 4% in patients older than 55 years of age) England
Northern Europe North America Australia, New Zealand
Rare in Asia, China, Indonesia, Malaysia, and sub-Saharan Africa
Possibly a slow viral disease
RNA paramyxovirus (e.g., respiratory syncytial virus and measles) Correct Answer: Sub-Saharan Africa

Masses exceeding 5 cm in size and any deep mass should be evaluated with MRI prior to biopsy or excision to ensure the most viable tissue is sampled and to minimize morbidity and complications from an improperly placed biopsy site. Examinations are unreliable when attempting to determine if a mass is a simple lipoma, and any large or deep mass should be considered a sarcoma until proven otherwise. PET/CT is a staging examination to evaluate for metastatic or multifocal disease. These are expensive tests that should not be ordered prior to MR imaging of the primary lesion. For patients that are unable to obtain an MRI, CT of the mass is the preferred imaging modality.
RECOMMENDED READINGS
11. [Gilbert NF, Cannon CP, Lin PP, Lewis VO. Soft-tissue sarcoma. J Am Acad Orthop Surg. 2009 Jan;17(1):40-7. Review. PubMed PMID: 19136426.](http://www.ncbi.nlm.nih.gov/pubmed/19136426)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/19136426)
12. [Damron TA, Beauchamp CP, Rougraff BT, Ward WG Sr. Soft-tissue lumps and bumps. Instr Course Lect. 2004;53:625-37. Review. PubMed PMID: 15116652.](http://www.ncbi.nlm.nih.gov/pubmed/15116652)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/15116652)
13. Simon MA. Diagnostic Strategies. In: Simon MA, Springfield D, eds. _Surgery for Bone and Soft Tissue Tumors_. Philadelphia, PA: Lippincott-Raven; 1998:21-30.
CLINICAL SITUATION FOR QUESTIONS 9 THROUGH 11
Figures 9a through 9d are the anteroposterior and lateral radiographs, CT scan, and technetium bone scan of a 12-year-old boy who has experienced 7 months of pain in his lower leg. The pain limits his ability to participate in sports and he is having difficulty sleeping. He is afebrile, and laboratory study findings including an erythrocyte sedimentation rate, C-reactive protein, and complete blood count are within normal limits.

Nonsurgical management of OCD of the talus in skeletally immature individuals frequently results in a fairly rapid decrease in symptoms, but radiographic abnormalities can frequently be found even 6 months after treatment. Spontaneous resolution of this condition is rare. Hyperbaric oxygen treatment has not been shown to be beneficial for this condition. Progression of the condition to the point of requiring ankle fusion is rare.
REFERENCES: Perumal V, Wall E, Babekir N: Juvenile osteochondritis dissecans of the talus. J Pediat Orthop 2007;27:821-825.
Letts M, Davidson D, Ahmer A: Osteochondritis dissecans of the talus in children. J Pediatr Orthop 2003;23:617-625.

4
The question stem describes a patient with long-standing anterior glenohumeral joint instability. The axillary view plain radiograph shows blunting of the anterior glenoid rim. The axial cut from the MR arthrogram shows loss of anterior glenoid contour and tear and medialization of the anteroinferior labrum consistent with anterior glenohumeral joint instability. The sagittal cut shows loss of pear-shaped glenoid. With a patient describing innumerable dislocations and anterior glenoid bone loss, the best option is for coracoid transfer or Latarjet. Open or arthroscopic bankart repair does not address the bone loss. Glenoid osteotomy has been advocated for posterior shoulder instability and glenoid retroversion, which the patient does not have.

_A_ 4 _L_._-Ma_ P _de_ h _n_ y _a_ se _C_ a _o_ l _py_ bridge resection

2010 Pediatric Orthopaedic Examination
ook • 67

5. Lateral physeal hemiepiphysiodesis plate PREFERRED RESPONSE: 3
DISCUSSION: A diagnosis of Blount’s disease is indicated by the abnormal shape of the medial metaphysis of the tibia, the progressive nature of the deformity, and the focal nature of the angulation. A 4-year-old child with Blount’s disease should undergo surgical correction consisting of a tibial osteotomy before there is a permanent growth arrest that would require physeal bridge resection and/or repeated osteotomies. With a Langenskiold type IV lesion, bracing or hemiepiphyseal plate fixation is not expected to correct the deformity.

REFERENCES: Schoenecker PL, Meade WC, Pierron RL, et al: Blount’s disease: A retrospective review and recommendations for treatment. J Pediatr Orthop 1985;2:181-186.
Langenskiold A: Tibia Vara: A critical review. Clin Orthop Relat Res 1989;246:195-207.
Bowen RE, Dorey FJ, Moseley CF: Relative tibial and femoral varus as a predictor of varus deformities of the lower limbs in young children. J Pediatr Orthop 2002;22:105-111.

Figure 79

The radiographs reveal medial clear space widening and an oblique proximal fibula fracture (best seen on the lateral view overlapping the tibia). This is consistent with an unstable syndesmotic injury. Operative repair of the syndesmosis with reduction and fixation is warranted. Immobilization is the best option for a stable syndesmotic injury. Physical therapy and MRI are not warranted given the findings on the _radiographs._

The distal phalanx assumes a resting flexed posture. The patient is not able to actively extend the fingertip, but it can be passively extended.

DISCUSSION: Flexible retrograde intramedullary nailing is now the preferred treatment for most length- stable diaphyseal femur fractures in school-aged children. The most commonly described complication is irritation about the knee at the rod insertion sites that resolves with rod removal. Limb-length discrepancy and weakness have also been described at lower rates. Malunion or rod bending is usually related to
_AL-Madena Cop,_ ^SIONSE: 2

2010 Pediatric Orthopaedic Examination
ook • 49
placement of the rods in an unstable fracture pattern or in a larger patient.

REFERENCES: Flynn JM, Hresko T, Reynolds RA, et al: Titanium elastic nails for pediatric femur fractures: A multicenter study of early results with analysis of complications. J Pediatr Orthop 2001
;21:4- 8.
Flynn JM, Schwend RM: Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg 2004;12:347-359.

- Anterior interosseous nerve (AIN) palsy**

Several studies have reported an increased incidence of stress fractures in female athletes, including fractures of the foot and ankle in runners. The
female athlete triad describes a condition involving decreased bone density, anorexia, and amenorrhea. In addition to asking about this woman's exercise routine, the orthopaedic surgeon should obtain a comprehensive menstrual and dietary history in the context of multiple stress fractures. A review of genetics, rheumatology, and cardiovascular disorders is less likely to generate an etiology.
RECOMMENDED READINGS
Kasser JR, ed. Orthopaedic Knowledge Update 5: Home Study Syllabus. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1996:96-99.
Arendt EA. Osteoporosis in the athletic female: Amenorrhea and amenorrheic osteoporosis. In: Pearl AJ, ed. AOSSM: The Athletic Female. Champaign, IL: Human Kinetics; 1993:41-59. Brukner PD, Khan KM. Clinical Sports Medicine. Sydney: McGraw-Hill; 1991:17.
RESPONSES FOR QUESTIONS 10 THROUGH 13
1. Ankle replacement
2. Ankle fusion
3. Tibiotalocalcaneal fusion
4. Total contact cast
5. Intra-articular steroid injection
Match the appropriate treatment listed above with the patient scenario described below.

The patient had an open fracture that was initially treated with what appears to be appropriate irrigation and debridement and intramedullary nail placement. The post-operative infection and need for rotational flap is worrisome, but she has not had any issues since the flap. She has abundant callus formation but the fracture line is still visible and unchanged on 2 sets of radiographs. The patient has persistent pain. The best initial evaluation is to ensure that there is no underlying infection with laboratory studies, including a complete blood count (CBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Nuclear medicine studies have questionable utility, but may be helpful if the inflammatory markers from laboratory studies come back elevated. A CT scan is not warranted because the sequential radiographs show persistent fracture lines and no changes. The patient has a hypertrophic nonunion. Originally, she had appropriate treatment and has shown the ability to make callus, thus her biologic capacity appears to be intact and bone grafting is not needed. The hypertrophic nature of her fracture nonunion indicates that she needs more stability. The best treatment for a hypertrophic nonunion of the tibia is exchange nailing. Based on successive radiographs and the lack of healing, observation is probably just delaying the inevitable. Plating with retention of the nail can be useful in recalcitrant long bone nonunions, especially in the femur.

The suprascapular nerve innervates the supraspinatus muscle. Patients with suprascapular neuropathy usually have insidious onset of dull, aching shoulder pain at the superior or posterior aspect of the shoulder. There can be several causes of nerve compression, and the nerve is susceptible to compression at the suprascapular and spinoglenoid notches. Extrinsic compression can be secondary to joint-related fluid filled cysts of soft-tissue masses. Traction neuropathy may occur as the result of excessive nerve excursion during athletic activity (usually overhead sports) or after a massive, retracted rotator cuff tear. The suprascapular nerve originates from the upper trunk from predominantly the C5 and C6 nerve roots, with an occasional contribution from the C4 nerve root.
RECOMMENDED READINGS
1. Boykin RE, Friedman DJ, Higgins LD, Warner JJ. Suprascapular neuropathy. J Bone Joint Surg Am. 2010 Oct 6;92(13):2348-64. doi: 10.2106/JBJS.I.01743. Review. 81
[PubMed PMID: 20926731. ](http://www.ncbi.nlm.nih.gov/pubmed/20926731)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/20926731)
2. [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)

The EPL is the only tendon that will lift a thumb off of a table as described. It is the most frequently ruptured tendon associated with distal radius fractures. Rupture is more common with nondisplaced fractures. Rupture after a nondisplaced or minimally displaced fracture suggests an ischemic etiology. The patient will not be able to lift her thumb off of a table with her hand lying flat, palm-down. Direct repair is often difficult because of retraction of tendon ends, atrophy, and
fraying. The EIP has a similar amplitude and direction of pull. Prerequisites for the use of the EIP to EPL tendon transfer include independent extension of the index finger.
RECOMMENDED READINGS
14. Shah MA, Buford WL, Viegas SF. Effects of extensor pollicis longus transposition and extensor indicis proprius transfer to extensor pollicis longus on thumb mechanics. J Hand Surg Am. 2003 Jul;28(4):661-
8/. PubMed PMID: 12877857.
15. Gelb RI. Tendon transfer for rupture of the extensor pollicis longus. Hand Clin. 1995 Aug;11(3):411-
22/. Review. PubMed PMID: 7559819.

This patient has a large posterior wall fracture of the right acetabulum with an unstable hip. The most appropriate next step in treatment is open reduction and internal fixation.
Fixation of acetabular fractures during pregnancy is not contraindicated in the setting of stable fetal heart rate and no abnormalities on pelvic ultrasound.
There is, however, an increased risk of complications for the mother and fetus. Injury severity and mechanism are most closely associated with increased rate of fetal complications. The trimester of pregnancy is not associated with increased risk of complications.
Leggon et al. reviewed 101 cases of pelvic and acetabular fractures in pregnant patients and found mechanism of injury and injury severity were associated with higher mortality for both mother and fetus. Trimester of pregnancy was not associated with increased mortality.
Flik et al. reviewed orthopaedic trauma in a pregnant patients and recommended fetal ultrasound for assessment of fetal well-being in all pregnant patients.
Desai et al. investigated orthopaedic trauma during pregnancy and reported minimal radiation risk to the fetus when obtaining x-rays. They also advocate for LMWH as one of the safest choices for anticoagulation.
Figure A is an x-ray showing a right posterior wall acetabular fracture. Figures B and C are Judet views of the pelvis focusing on the right hip. A large posterior wall fragment is visible in Figure B.
Incorrect Answers:

,3,5: ORIF is the most appropriate treatment for this posterior wall fracture. There is no contraindication to ORIF.
Answer 4: There is no indication to delay treatment as the fetal heart rate is normal and ultrasound shows no abnormalities.

Figure A is radiograph of a 50-year-old male science teacher that was involved in a motor vehicle accident. He underwent closed reduction as seen in Figure B and C. What would be the most appropriate treatment?
1) Open reduction and internal fixation with medial bridge plate and lateral screw in non-lagging mode

2) Tibiotalocalcaneal arthrodesis

3) Open reduction and internal fixation with lateral and medial screw in lagging mode

4) Closed reduction and internal fixation with medial and lateral screw in non-lagging mode

5) Closed reduction with percutaneous pins

This patient is presenting with a Hawkins II talar neck fracture with medial wall comminution. The most appropriate treatment of this patient would be open reduction internal fixation with medial plate and lateral screw in non-lagging mode.
The treatment of talar fractures is based on the severity of the fracture, soft-tissues, and patient factors. The fracture and subluxation of the subtalar joint should be reduced and stable anatomical fixation should be obtained. When there is comminution of either the superior, lateral or medial aspects of the talus, one should avoid shortening the medial wall as this will cause a varus malunion. The use of a medial or lateral plate can help to re-establish column length, which can often prevent this potential complication.
Sanders et al. showed significant complications after fixation of talar neck fractures. They showed the incidence of secondary reconstructive procedures following talar neck fractures increased from 24% +/- 5% at 1 year to 48%
+/- 10% at 10 years post-injury.
Vallier et al. retrospectively reviewed the records of 39 fractures of the talar neck treated with open reduction and internal fixation. Twenty-one (54%) of thirty-nine patients had development of posttraumatic arthritis, which was more common after comminuted fractures (p
A 28-year-old male college student sustains a severe foot injury from gunshot-related violence, and subsequently undergoes a lower-extremity amputation as shown in Figure A. At long-term follow-up, which of the following is the strongest predictor of patient satisfaction as related to his injury?
1) Age less than 30

2) Marijuana use

3) Use of negative pressure wound therapy

4) Male gender

5) Ability to return to work

The strongest factor to predict patient-reported outcomes after trauma-related lower extremity amputations is the patient's ability to return to work. This is likely due to the effect of the return to work on the physical, emotional, and financial aspects of the patient's life.
The LEAP study is a multicenter, prospective study evaluating multiple aspects of reconstruction versus amputation in the treatment of mangled extremity injuries. With regard to patient satisfaction, treatment variables such as decision for reconstruction versus amputation, or initial presence or absence of plantar sensation have little impact. In addition, demographic factors such as age, gender, socioeconomic status, and education level do not predict patient satisfaction. Instead, the most important predictors of patient satisfaction at 2 years after injury include the ability to return to work, absence of depression, faster walking speed, and decreased pain.
O'Toole et al reviewed 463 patients treated for limb-threatening lower-extremity injuries and identified factors associated with patient reported outcomes two years after surgery. They found that return to work was the most associated with outcomes, but that physical functioning, walking speed, pain levels, and presence of depression were also associated to a lesser extent with outcomes.
Bosse et al performed a multicenter, prospective study to assess outcomes of 569 patients with severe lower extremity limb injuries that resulted in either amputation or limb salvage procedures. They found that at two years postoperatively, no significant differences were seen between groups in patient-reported outcome. Worse outcomes were associated with rehospitalization for a major complication, a low educational level, nonwhite race, poverty, lack of private health insurance, poor social-support network, low self-efficacy (the patient's confidence in being able to resume life activities), and involvement in disability-compensation litigation.
Figure A shows a clinical photograph of a Pirigoff amputation at early follow-up. This amputation is an end-bearing amputation that utilizes the plantar heel pad for weightbearing, and relies on a tibiocalcaneal arthrodesis.
Incorrect Answers:
1-4: These options are not as strong of a factor of patient satisfaction in longterm follow up after trauma-induced lower extremity amputation.

A 34 year-old male falls off of motorcycle on an outstretched hand suffering the injuries shown in Figures A and B. He is brought to the operating room and undergoes radial head replacement and fixation and repair of the coronoid and the lateral collateral ligament (LCL). Prior to closing, the elbow is still unstable upon testing range of motion. What is the next best step in management?
1) Exchange radial head for larger implant

2) Complete resection of radial head

3) Cast at 90 degrees of flexion for 6-8 weeks

4) Reinforce LCL repair with non-absorbable suture

5) Repair the ulnar collateral ligament

Following complete fixation and repair of a terrible triad, a final range of motion test should be performed prior to closure. If still unstable, the next step should be to assess and repair the ulnar collateral ligament. Another option
would be to placed a hinged external fixator.
Operative reconstruction of a terrible triad injury should be performed in a systematic fashion, working from deep to superficial. Working through a lateral incision and through the radial head fracture, the coronoid should be fixed first, followed by radial head fixation or replacement and then repair/reconstruction of the LCL. If still unstable, the medial side should be addressed, or the patient placed in a hinged external fixator.
Mathew et al review the anatomic, biomechanic, and operative principles (why the above step-by-step method works) to achieving appropriate stability in order to obtain early range of motion to maximize clinical outcome.
Pugh et al. in this retrospective, multi-center study report outcomes on 36 terrible triad injuries fixed with the standard protocol described above. The authors recommend following this systematic approach to achieve the best results.
Figures A and B are AP and lateral radiographs exhibiting a terrible triad elbow fracture-dislocation.
Incorrect answers:
Answer 1. Overstuffing the radial head should be avoided.
Answer 2. Resection of the radial head is contraindicated in an unstable elbow. Answer 3. While casting the extremity may provide initial immobilization, you are unable to monitor the wound and truly assess stability, especially when swelling subsides.
Answer 4. Reinforcing the LCL will not make increase any stability not already achieved.

When treating the pathology depicted in Figures A through D, which of the following is necessary to preserve the blood supply to the femoral head?
1) Dissection of the gluteal musculature off the iliac crest

2) Ligation of the ascending branches of the lateral femoral circumflex artery

3) Greater trochanteric osteotomy

4) Identification and detachment of the piriformis tendon

5) Supine positioning

Figures A-D show a femoral head with associated acetabular fracture (Pipkin IV). Both the posterior wall fracture and the femoral head fracture can be addressed through a surgical dislocation via greater trochanteric osteotomy.
Pipkin IV femoral head fracture (with associated acetabular fractures) are somewhat problematic in that the femoral head fracture is usually anterior, while the acetabular fracture usually involves the posterior wall. A Kocher-Langenbeck approach gives good access to the posterior wall but limited access to the articular surface and femoral head avascular necrosis (AVN) is a concern. A Smith-Peterson approach provides good access to the femoral head
but not to the posterior wall. Combined approaches significantly increase the amount of surgical dissection. Surgical dislocation with trochanteric flip osteotomy provides access to the femoral head and posterior wall while preserving blood supply to the femoral head.
Solberg et al. retrospectively reviewed 12 patients with Pipkin IV injuries treated via a trochanteric flip osteotomy. All patients healed their acetabular fractures. Eleven of 12 patients healed their femoral head fractures and one patient (8.3%) developed osteonecrosis.
Henle et al. likewise treated 12 patients with Pipkin IV injuries through a trochanteric flip osteotomy. Two of 12 patients (16.7%) developed osteonecrosis. The remaining 10 patients (83.3%) had good or excellent results. Heterotopic ossification occurred in five patients, causing significant range of motion loss in four of these.
Figure A is a pre-reduction AP pelvis in which the posterior wall fracture is apparent. Figure B is a post-reduction AP pelvis in which an infra-foveal femoral head fracture is apparent (Pipkin IV). Figure C is an axial CT cut which further characterizes the posterior wall fracture. Figure D is an obturator oblique showing femoral head dislocation and posterior wall fracture. The video shows a surgical hip dislocation technique.
Incorrect Answers:
Answer 1: The extended iliofemoral approach exposes the entire innominate bone, which is not necessary to treat this injury.
Answer 2: The Smith-Peterson anterior approach provides access to the anterior femoral head but not the posterior wall of the acetabulum.
Answer 4: Detachment of the short external rotators is not necessary for surgical dislocation.
Answer 5: Surgical dislocation with greater trochanteric osteotomy is described in the lateral position. Supine positioning is not necessary.

A 42-year-old male presents to your clinic for the first time with the radiographs seen in Figure A. He sustained the injury 4 weeks ago while skiing overseas and treatment was provided by the local orthopaedic surgeon. The operative note states that he sustained an Gustilo Type I open fracture. After surgical fixation of this type of injury, what is the most common complication requiring reoperation?
1) Chronic elbow instability

2) Post-traumatic arthritis

3) Infection

4) Heterotopic ossification

5) Loss of elbow range of motion

This patient sustained a terrible triad elbow fracture-dislocation. Reduced range of motion of the elbow joint is the most common complication REQUIRING reoperation with these injuries.
Terrible triad elbow fracture-dislocations are characterized by posterolateral dislocation/lateral collateral ligament (LCL) injury, radial head fracture and coronoid fracture. Displaced fractures result in elbow instability. Acute radial head stabilization, coronoid open reduction and internal fixation, and LCL +/-medial collateral ligament (MCL) repair/reconstruction is considered the most appropriate treatment for displaced fractures. Operative complications include elbow stiffness, recurrent instability, arthritis, failure of hardware, heterotopic ossification, posterior interosseous nerve palsy and infection.
Egol et al. looked at the functional outcomes of 27 patients that underwent fixation of terrible triad injuries. At one year follow-up, the average flexion-extension arc of elbow motion was 109 degrees +/- 27 degrees, and the average pronation-supination arc was 128 degrees +/- 44 degrees. Grip strength averaged 72% of the contralateral extremity. Although operative fixation led to functional elbow stability, results were poor.
They included a reference to McKee et al. to highlight that intra-articular fractures of the elbow have high rates of stiffness. While not specific to terrible
triads, they looked at the effectiveness of the posterior elbow approach in 25 patients that underwent internal fixation of intra-articular distal humerus fractures. They showed poor outcomes at a mean follow-up of 36 months with reduced range-of-motion, decreased strength and high re-operation rates.
Figure A shows AP fluoroscopic image of a terrible triad injury that has undergone operative fixation. The radial head and coronoid have undergone open reduction internal fixation, and the MCL bony avulsion has been repaired.
Incorrect Answers:
Answer 1: Chronic elbow instability is more common following type I or II coronoid fracture when not operatively managed.
Answer 2: Post-traumatic arthritis results from chondral damage at time of injury and/or residual instability.
Answer 3: Infection is more prevalent with open fractures, however Type I injuries are usually not associated with increase in infection rates.
Answer 4: Heterotopic ossification is a common complication after fixation of these injuries. However, it does not always necessitate reoperation.

Figure A is a radiograph from a 59-year-old male that was transferred to a Level I trauma center five hours after a motor vehicle accident. Closed reduction and skeletal traction was successfully performed in the trauma bay. Which of the following factors has been shown to increase the risk of unsatisfactory clinical outcome for this patient?
1) Need for skeletal traction

2) Mechanism of injury

3) Gender

4) Age

5) Time to reduction

Age greater than 55-years-old has been found to be an independent risk factor for inferior clinical outcome in patients with combined acetabular fractures and hip dislocations.
The most important initial step in management following resuscitation involves urgent reduction of the dislocated hip. This should be followed by a preoperative CT scan and ultimately surgical fixation of the combined acetabular fracture. Hip dislocations should be reduced within 6-12 hours for optimal outcome, although different critical times have been cited, particularly for dislocations with concomitant acetabular fractures. Skeletal traction may be required to maintain hip reduction.
Moed et. al. present a Level 3 retrospective review of 100 patients who had been treated with open reduction internal fixation of an acetabular fracture. The authors found that factors associated with unsatisfactory clinical outcomes included age greater than 55, intra-articular comminution, osteonecrosis, and delay of greater than 12 hours for reduction of an associated hip dislocation.
Additionally, they showed that there was a strong association of clinical outcome and final radiographic grade.
Figure A demonstrates an acetabular fracture with concomitant hip dislocation. Incorrect Answers:
Answer 1-3, and 5: Placement and need for skeletal traction, mechanism of
injury, male gender, and time to reduction
A 37-year-old male cashier is shot in the leg. He sustains the injury shown in Figures A and B, and is subsequently taken to the operating room for intramedullary nailing. Figure C shows a radiograph of the nail starting point (*). What complication is most likely to result?
1) Varus malunion

2) Nonunion

3) Valgus malunion

4) Malrotation

5) Superficial peroneal nerve injury

This patient is presenting with a comminuted fracture of the proximal third of the tibia. He is appropriately undergoing intramedullary nail fixation, however, the start point illustrated in Figure C is too medial and often leads to a valgus malunion.
Intramedullary nail fixation is more technically demanding in proximal tibial fractures than diaphyseal fractures. The valgus deformity is due to imbalanced muscle forces on the proximal fragment, which are then accentuated by a start point that is too medial. An apex anterior (procurvatum) deformity can also occur and results from the pull of the patellar tendon or a posteriorly directed nail that deflects off the posterior tibial cortex and rotates the proximal fragment. The ideal starting point for proximal tibial fractures is slightly lateral to the medial aspect of the lateral tibial spine on a true AP x-ray and very proximal and just anterior to the anterior margin of the articular surface.
Nork et al. reported the results of intramedullary nailing of proximal tibial fractures with emphasis on techniques of reduction. Various techniques were found to be successful including attention to the proper starting point, the use of unicortical plates, and the use of a femoral distractor applied to the tibia.
Lowe et al. describe surgical techniques for complex proximal tibial fractures. They describe the extended leg position, use of a femoral distractor, temporary plate fixation, blocking (Poller) screws, and use of percutaneous clamps as means to achieve reduction during fixation.
Figure A and B show an AP and lateral radiograph of a comminuted extra-articular fracture through the proximal third of the tibia. Figure C demonstrates a start point that is too medial (represented by the asterisk) for intramedullary nail fixation. Illustration A and B show the ideal start point for intramedullary nail fixation of the tibia on AP and lateral radiographs.
Incorrect Answers:

The child is not ready for surgery. Although surgery may coincide with the patient beginning school, this does not always occur. At this time, additional examination and testing are recommended.

Threaded pins are frequently inserted into the femoral shaft and tibial shafts or proximal tibia to attach arrays for tracking devices. There have been case reports of fractures propagating through the pin tracks, which is a complication unique to computer navigation. Intercondylar fractures can occur following posterior stabilized TKA. Vascular injury, ligament disruption, and nerve palsy are rare complications following TKA performed with or without computer navigation.
Figures 1 through 5 are the radiographs and MR arthrograms of a 19-year-old woman who presents with right hip pain that has been present for 4 years that is insidious in onset. The pain is located in the groin and lateral hip and is worse with weight-bearing activity. Flexion, adduction and internal rotation reproduces her pain, and she has a positive external log roll for pain. She has tried NSAIDs, physical therapy and activity modification. What is the best next step?
53
A. Dry needling therapy to the gluteus medius tendon insertion
B. Hip arthroscopy with acetabuloplasty and labral advancement
C. Open hip dislocation with osteochondroplasty and labral repair
D. Periacetabular osteotomy with arthrotomy and labral repair
The patient has hip dysplasia with acetabular index of 14.4 and a lateral center- edge (LCE) angle of 17. MRI scan reveals a labral tear with mild acetabular retroversion. Dry needling may be an effective treatment for chronic lateral hip pain, but would not treat intra-articular pathology. Although hip arthroscopy for labral pathology in the setting of borderline hip dysplasia (LCE 18-25°) may be successful, in higher degrees of dysplasia with potential for additional resection to address mild retroversion, arthroscopy may be associated with high rates of failure. Open hip surgery offers no advantage over arthroscopic treatment in the treatment of labral tears in dysplasia. Periacetabular osteotomy may be combined with open or arthroscopic treatment of intra-articular pathology with good results.
Correct answer : D
54
When performing a cruciate-retaining total knee arthroplasty, trial components are inserted. The knee comes to full extension but is tight in flexion. The surgeon should consider
A. flexing the femoral component.
B. releasing the posterior cruciate ligament.
C. downsizing the tibial insert thickness.
D. resecting more distal femur.
In this scenario, the flexion gap needs to be increased. Increase in flexion gap can be accomplished by downsizing the femoral component and increasing posterior tibial slope. In posterior cruciate-retaining TKA procedures, recession or release of the posterior cruciate ligament can loosen the flexion gap, allowing for an increase in flexion. Flexing the femoral component tightens the flexion gap, and downsizing the tibial insert thickness decreases flexion and extension gaps, while resection of the distal femur only increases the extension gap.
Correct answer : B
Figures 1 through 3 are the radiographs of a 78-year-old woman with a severe valgus deformity and worsening pain in her right knee. She has failed all nonsurgical management and is interested in pursuing a total knee arthroplasty (TKA). When performing a TKA on this patient, attention should be directed toward avoiding what intraoperative femoral component positioning error?
55
A. Oversize
B. External rotation
C. Flexion
D. Internal rotation
Patients who present with a severe valgus knee deformity often have a hypoplastic lateral femoral condyle, which must be assessed intraoperatively. If using a measured resection technique in the setting of a hypoplastic femoral condyle, the femoral component may end up internally rotated, which can lead to issues with patellofemoral tracking and overall extremity rotational alignment. Care must be taken to avoid internal rotation of the femoral component in patients with a hypoplastic lateral femoral condyle.
Correct answer : D

A foot salvage amputation, including the transarticular ankle amputation (Symeâs amputation), will not work in the presence of a disrupted heel pad (with or without ulceration) and infection of the heel.

■
The patient has autosomal dominant osteopetrosis type II, which is also known as AlbersSchonberg disease. It can be associated with sclerosis of the skull base, leading to cranial nerve dysfunction such as hearing loss. It is also associated with marrow replacement leading to anemia and can be associated with fractures. The images show increased bone density, and osteopetrosis type II can be associated with a “bone within a bone” type appearance. CTSK mutations are associated with pyknodysostosis, and TNSALP is associated with hypophosphatasia. Lead poisoning would not present with these findings.

This patient has sustained a significant concussion or minor brain injury. Although all answer options reflect important steps in her management, the initial primary concern in any player who is confused or combative is protection of the cervical spine until formal clearance can be performed. This patient requires immediate immobilization, collar placement, and, ultimately, transportation to a hospital. Cervical immobilization should be achieved before transport, given her complaints of neck pain and inability to provide a reliable examination.

- Revision open reduction and internal fixation of the ulnar fracture

There have been many prospective and retrospective studies evaluating outcomes after surgical and nonsurgical treatment of displaced middle third clavicle fractures. Surgery results in a lower nonunion rate and higher patient reported outcomes. However, approximately 30% of these patients will have symptoms of hardware irritation and request subsequent plate removal. Nonunion is very low with plate fixation and is more common with nonsurgical treatment. AC joint instability is unlikely to be an issue with middle third clavicle fractures, and there is no evidence of AC malalignment on the images provided. Deltoid origin stripping is necessary for anterior plating, but is much less of an issue with superior plating, as was performed in this patient. Anterior plating is biomechanically inferior to superior plating but may pose a lower risk to neurovascular structures and has the theoretic opportunity to decrease implant irritation, although this has not been clearly demonstrated in the literature.

- Meniscal repair

Osteotomy and tendon transfer is the management of choice. The previous bunion correction resulted in excessive translation of the metatarsal head. The orthopaedic surgeon must first correct the bony deformity and allow the proximal phalanx to sit in a congruent position. The next step is to reconstruct the soft-tissue components and this can be done by releasing the medial capsule,and transferring part of the extensor hallucis longus tendon into the proximal phalanx, under the intermetatarsal ligament laterally. All three procedures are needed to adequately correct this deformity. A great toe fusion is indicated for an uncorrectable deformity or in an older patient.

The most common cause of acquired adult flatfoot deformity (AAFD) is dysfunction of the posterior tibial tendon. Tearing of the calcaneonavicular (spring) ligament and gastrocnemius contracture results from longer-standing attenuation of the posterior tibial tendon. Tarsal coalitions typically cause rigid flatfoot deformity. The calcaneonavicular ligament comprises superomedial and inferomedial bands. More than 70% of patients with AAFD have tearing of the superomedial band. Tearing of the inferior band is seen less commonly. Deltoid ligament insufficiency can be seen in long-standing valgus foot deformity. Initial treatment should start with ankle-foot orthosis bracing and physical therapy.
The radiographs reveal loss of arch, significant uncoverage of the talar head by the navicular, and lack of significant arthritis. Fusion procedures are not indicated considering the patient's flexible deformity and the absence of hindfoot arthritis. Realignment osteotomy must be combined with flexor digitorum longus tendon transfer to successfully alleviate this patient's symptoms. Lateral column lengthening will correct the forefoot abduction and talonavicular subluxation. A medial sliding osteotomy can achieve additional correction and decompress subfibular impingement. A dorsal opening plantar flexion (Cotton) osteotomy of the medial cuneiform is an adjunct procedure that is needed to balance the foot in cases of residual forefoot varus, as seen in the clinical photograph.
RECOMMENDED READINGS
Pinney SJ, Lin SS. Current concept review: acquired adult flatfoot deformity. [Foot Ankle Int. 2006 Jan;27(1):66-75. Review. PubMed PMID: 16442033. ](http://www.ncbi.nlm.nih.gov/pubmed/16442033)[View Abstract at](http://www.ncbi.nlm.nih.gov/pubmed/16442033)[ ](http://www.ncbi.nlm.nih.gov/pubmed/16442033)[PubMed](http://www.ncbi.nlm.nih.gov/pubmed/16442033)
[Bluman EM, Title CI, Myerson MS. Posterior tibial tendon rupture: a refined classification system. Foot Ankle Clin. 2007 Jun;12(2):233-49, v. Review. PubMed PMID: 17561198. ](http://www.ncbi.nlm.nih.gov/pubmed/17561198)[View](http://www.ncbi.nlm.nih.gov/pubmed/17561198)[ ](http://www.ncbi.nlm.nih.gov/pubmed/17561198)[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/17561198)
Haddad SL, Mann RA. Flatfoot deformity in adults. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. 8th ed. Philadelphia, PA: Mosby Elsevier; 2007:1007-1085.

- MRI

This patient has isolated posttraumatic ankle arthritis with significantly decreased ankle range of motion that is best treated with an isolated ankle arthrodesis to eliminate pain. Because this patient is younger than 50 years of age and has limited presurgical range of motion, she is not a candidate for ankle arthroplasty. Additionally, TAA outcomes among patients who have a posttraumatic etiology are worse than for those with osteoarthritis. Tibiotalocalcaneal arthrodesis is suited for patients with associated subtalar
arthritis or rigid hindfoot deformity that necessitates correction. Anterior tibial exostectomy will not resolve the underlying arthritic pain and is not indicated.
RECOMMENDED READINGS
[Easley ME, Adams SB Jr, Hembree WC, DeOrio JK. Results of total ankle arthroplasty. J Bone Joint Surg Am. 2011 Aug 3;93(15):1455-68. doi: 10.2106/JBJS.J.00126. Review. PubMed PMID: 21915552. ](http://www.ncbi.nlm.nih.gov/pubmed/21915552)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/21915552)
[Spirt AA, Assal M, Hansen ST Jr. Complications and failure after total ankle arthroplasty. J Bone Joint Surg Am. 2004 Jun;86-A(6):1172-8. PubMed PMID: 15173289. ](http://www.ncbi.nlm.nih.gov/pubmed/15173289)[View Abstract at](http://www.ncbi.nlm.nih.gov/pubmed/15173289)[ ](http://www.ncbi.nlm.nih.gov/pubmed/15173289)[PubMed](http://www.ncbi.nlm.nih.gov/pubmed/15173289)
[Ajis A, Henriquez H, Myerson M. Postoperative range of motion trends following total ankle arthroplasty. Foot Ankle Int. 2013 May;34(5):645-56. doi: 10.1177/1071100713481433. Epub 2013 Mar 11. PubMed PMID: 23478890. ](http://www.ncbi.nlm.nih.gov/pubmed/23478890)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23478890)
[Thomas R, Daniels TR, Parker K. Gait analysis and functional outcomes following ankle arthrodesis for isolated ankle arthritis. J Bone Joint Surg Am. 2006 Mar;88(3):526-35. PubMed PMID: 16510818. ](http://www.ncbi.nlm.nih.gov/pubmed/16510818)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/16510818)
[Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am. 2001 Feb;83-A(2):219-28. PubMed PMID: 11216683. ](http://www.ncbi.nlm.nih.gov/pubmed/11216683)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/11216683)

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.

The perichondrial ring of La Croix is the source of cells which differentiate into chondrocytes and results in latitudinal physeal enlargement.
The other answers refer to specifiCgrowth plate zones which have functions. The reserve zone is for matrix production and storage. The proliferative zone is for matrix production and cellular proliferation. The hypertrophiCzone contains the zone of maturation, degeneration, and provisional calcification.

Posterior shoulder dislocations are most commonly the result of seizures and electrical shock. Collision athletic events, postpolio syndrome, and traction injury are rarely associated with posterior shoulder dislocations. The bony defect caused by impaction of the anterior superior humeral head on the posterior glenoid has been referred to as a “reverse Hill-Sachs lesion.”
RECOMMENDED READINGS
1. McLaughlin HL: Posterior dislocation of the shoulder. J Bone Joint Surg Am 1952;64:1584-1590.
2. [Kowalsky MS, Levine WN. Traumatic posterior glenohumeral dislocation: classification, pathoanatomy, diagnosis, and treatment. Orthop Clin North Am. 2008 Oct;39(4):519-33, viii. doi: 10.1016/j.ocl.2008.05.008. Review. PubMed PMID: 18803981.](http://www.ncbi.nlm.nih.gov/pubmed/18803981)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/18803981)

The clinical description and MR image point to an injury to the posterior cruciate ligament (PCL). This ligament is thought to be primarily composed of anterolateral and posteromedial bundles, with the former tightening in flexion and the latter in extension. Because of alterations in knee kinematics and increased varus alignment in PCL insufficiency, contact stresses and cartilage loads increase in the patellofemoral and medial compartments. Although good outcomes may be obtained with transtibial, open inlay, and arthroscopic inlay techniques, one major difference is the creation of the “killer-turn” during the transtibial approach. This sharp turn in the graft as it emerges from the tibia appears to lead to more pronounced attenuation and thinning of the graft during cyclic loading. The scenario describes a patient with chronic PCL and posterolateral corner (PLC) injury, as evidenced by the varus thrust and abnormal Dial test finding. A valgus-producing osteotomy may be effective, and, in fact, may be the only treatment necessary to address chronic PLC injury. Accordingly, an opening lateral osteotomy would not be
appropriate. Of the remaining responses, an osteotomy that increases tibial slope would also address the PCL deficiency by reducing posterior tibial sag. Vascular injury is an uncommon, but potentially devastating, complication associated with PCL surgery and may occur regardless of the technique used. Numerous strategies have been described to reduce the risk, including use of a posteromedial accessory incision to allow finger retraction of the popliteal neurovascular bundle, oscillating drills to prevent excessive soft-tissue entanglement, and tapered (rather than square) drill bits that may minimize cut-out of sharp edges as drilling reaches the posterior tibial cortex. Knee extension lessens, rather than increases, the distance between the posterior tibia and the neurovascular bundle and increases, not lessens, risk for _vascular injury._

This patient had a septic DIP joint that was treated with antibiotics alone. As a result, he developed osteomyelitis with bone destruction and an abscess. The correct answer is debridement of both bone and soft tissue with abscess drainage. Antibiotic treatment without surgery would not successfully eliminate this infection. A bone scan and biopsy are not appropriate because this problem is an infection and not a tumor, and the MR imaging provided enough diagnostic information. Amputation is not indicated prior to an attempt to salvage the digit. Amputation through the DIP joint would not remove the infected bone in the middle phalanx and would provide an inadequate level of resection.
RECOMMENDED READINGS
5. [Robinson LG, Kourtis AP. Tale of a toothpick: Eikenella corrodens osteomyelitis. Infection. 2000 Sep;28(5):332-3. PubMed PMID: 11073145. ](http://www.ncbi.nlm.nih.gov/pubmed/11073145)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/11073145)
6. [Cuenca-Estrella M, Ramos JM, Esteban J, Soriano F, Vallejo JV. Eikenella corrodens thumb osteomyelitis. Postgrad Med J. 1996 Mar;72(845):188.](http://www.ncbi.nlm.nih.gov/pubmed/8731720)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/8731720)
7. [Schmidt DR, Heckman JD. Eikenella corrodens in human bite infections of the hand. J Trauma. 1983 Jun;23(6):478-82. PubMed PMID: 6345799. ](http://www.ncbi.nlm.nih.gov/pubmed/%206345799)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/%206345799)
8. [Rayan GM, Putnam JL, Cahill SL, Flournoy DJ. Eikenella corrodens in human mouth flora. J Hand Surg Am. 1988 Nov;13(6):953-6. PubMed PMID: 3066818. ](http://www.ncbi.nlm.nih.gov/pubmed/3066818)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/3066818)

- Palliative spinal cord decompression and stabilization

Patients with homocystinuria may phenotypically resemble patients with Marfan syndrome. Patients with homocystinuria and
Marfan syndrome are tall with long limbs, arachnodactyly, scoliosis, chest wall deformities, and lens dislocations.
Achondroplasia is characterized by short stature, frontal bossing, and rhizomelic shortening of the limbs. Larsen's syndrome is a disorder characterized by short stature and multiple joint dislocations.
Gaucher's disease is a lysosomal storage disease characterized by accumulation of cerebroside in cells of the reticuloendothelial system. As in patients with homocystinuria, patients with Gaucher's disease have osteoporosis, however, they do not develop any of the other phenotypic features seen in homocystinuria.
Noonan's syndrome effects boys and clinical features include short stature, a webbed neck, and cubitus valgus deformities.

Several recent studies have shown that while there is an increased risk of complications following ORIF of displaced ankle fractures in diabetic patients compared with nondiabetic patients,the overall risks of treatment are less than that associated with nonsurgical treatment in diabetics. There is also the possibility that ORIF of unstable ankle fractures may forestall the development of Charcot changes in the ankle, although this is not definitively known. Extra rigid fixation may be required because of the patient’s size and poorly controlled diabetes. Nonsurgical management is associated with poorer functional outcomes (due to arthritis secondary to poor reduction of the fracture) and a higher rate of skin breakdown, due to the need for higher skin pressures from the use of highly molded casting used to maintain a closed reduction.

The anterior border of the PCL is the most accurate and reproducible landmark for appropriate placement of the tibial tunnel for an ACL reconstruction. The central sagittal insertion point of the ACL is consistently 10 to 11 mm anterior to the anterior border of the PCL ligament. The anterior border of the tibia is not well visualized and does not serve as a reference point. While the posterior border of the anterior horn of the lateral meniscus could be used as a reference point, it has twice the variability of the PCL reference point. The posterior border of the tibia is difficult to identify and has greater variability than the PCL relative to the AP dimension of the proximal tibial surface. The anterior horn of the medial meniscus is also more variable than the PCL.
REFERENCES: Hutchinson MR, Bae TS: Reproducibility of anatomic tibial landmarks for anterior cruciate ligament reconstructions. Am J Sports Med 2001;29:777-780.
McGuire DA, Hendricks SD, Sanders HM: The relationship between anterior cruciate ligament reconstruction tibial tunnel location and the anterior aspect of the posterior cruciate ligament insertion. Arthroscopy 1997;13:465-473.

The tibial cut is perpendicular to the tibial axis, the femoral cut is made in 4° to 6° valgus, and the knee aligned in 4° to 6° of valgus provided the ligaments are balanced