Orthopedics Review | Dr Hutaif General Orthopedics Revi -...

Perilunate dislocations result from high-energy injuries to the extended wrist. The injury shown is a lunate dislocation. Two classification systems have been described, the Mayfield system and the Herzberg system. Mayfield described the four stages of progressive ligamentous instability following injury. In stage I, the radioscaphocapitate and scapholunate ligaments fail. Stage II involves dislocation of the lunocapitate joint, usually a dorsal dislocation of the capitate. In stage III, the lunotriquetral ligament fails. In stage IV, the dorsal radiocarpal ligament is torn, and the lunate dislocates volarly. The short radiolunate ligament is the only ligament that remains intact, resulting in rotation of the lunate volarly. Herzberg and associates further classified perilunate dislocations as stage I injuries and lunate dislocations as stage II injuries. Lunate dislocations were further classified into stage IIA, in which the lunate exhibits rotation less than 90°, and stage IIB, in which the lunate exhibits rotation greater than 90°. The radiographs _represent a Mayfield stage IV, Herzberg stage IIA injury._

The lateral ulnar collateral ligament (LUCL) is often injured with elbow dislocations, and is most commonly injured at the proximal origin.
McKee noted that in 62 consecutive operative elbow dislocations and fracture/dislocations, the LUCL was ruptured in all of the patients, proximally in 32, bony avulsion proximally in 5, midsubstance rupture in 18, ulnar detachment in 3, ulnar bony avulsion in only 1, and combined patterns in 3.
Pugh et al established a standard protocol to treat elbow fracture dislocations (terrible triad) which includes coronoid repair, radial head repair/replacement, LUCL repair, and MCL and/or external fixation as needed.

The MRI scan shows a C7 burst fracture. A CT scan of the cervical spine will allow for optimal evaluation of this C7 burst fracture. Specifically, it will provide additional osseous detail and will assist with the detection of additional fractures,
including those of the posterior elements. Additional CT imaging of the thoracic and lumbar spine is required to rule out concommitant injuries (which may be present in 10% to 15% of patients). Anteroposterior and lateral cervical spine radiographs would be a good option for further evaluation but are not included in the available choices here.
Cervical spine flexion and extension radiographs should not be obtained in a patient who is known to have a relatively unstable spine and a neurologic deficit. Electromyography and nerve conduction velocity studies are best used to evaluate for cervical radiculopathy secondary to degenerative abnormalities and are usually not indicated in the acute trauma setting.

Figure A is a lateral radiograph of the knee demonstrating a plate buttressing a posteromedial tibial plateau fracture.
Buttress plating is a construct that resists axial load by applying force at 90° to the axis of deformity. Compression plates function by compressing together the main fragments of a single fracture plane. They can result in absolute stability by eliminating interfragmentary movement. Neutralization plates protect fractures that are fixed with primary lag screw fixation. The lag screw exerts interfragmentary compression and the plate resists or neutralizes bending and rotational forces. Bridge plating is a technique which spans comminuted fractures and is attached to the main fragments. It is used to restore length, alignment, and rotation. It preserves the biology of the comminuted areas and allows for secondary bone healing and callus formation.
Zheng et al. performed a biomechanical study to examine four different fixation methods of posteromedial tibial plateau fractures. They stabilized 28 tibial models randomly with anteroposterior lag-screws, an anteromedial limited contact dynamic compression plate (LC-DCP), a lateral locking plate, or a posterior T-shaped buttress plate. They measured vertical subsidence and maximum load to failure. They found that the posterior T-shaped buttress plate allowed the least subsidence of the posteromedial fragment and produced the highest mean failure load.
Ratcliff et al. performed a study to compare the mechanical stability of a medial tibial plateau fracture model secured with a lateral locking periarticular plate versus a medial buttress plate in cyclic testing and load to failure. They created fractures in 6 matched pairs of fresh cadaveric tibias and randomly selected fixation. They found neither the mean maximum displacement during nor mean residual displacement after cyclic testing were statistically different, but the medial buttress plate constructs provided greater fixation strength with a greater load to failure. They conclude the medial buttress plate provides significantly greater stability in static loading.
Figure A is a lateral radiograph of the knee demonstrating a plate fixation of a posteromedial tibial plateau fracture. Figure B is an AP radiograph of the tibia and fibula demonstrating a tibia fracture stabilized with a plate. A fracture of the fibula is noted as well. Figure C is a lateral radiograph of the wrist demonstrating a dorsal spanning plate stabilizing a comminuted distal radius fracture. Figure D is an AP radiograph of the forearm demonstrating plate fixation of radial and ulnar shaft fractures. Figure E is a lateral of the wrist demonstrating lag screw and plate fixation of a radial shaft fracture.
Incorrect Answers:
Answer 2: The plate is stabilizing this fracture with a bridging technique which leads to relative stability and secondary bone healing.
Answer 3: The plate is stabilizing this fracture with a bridging technique which leads to relative stability and secondary bone healing.
Answer 4: These plates are functioning as compression plates which leads to absolute stability and primary bone healing.
Answer 5: Given the presence of a lag screw, this plate is functioning as a neutralization plate which leads to absolute stability and primary bone healing.

On a lateral view of the wrist, when the lunate slips into a statically dorsiflexed position greater than 10°, the condition is defined as dorsal intercalated segmental instability (DISI). DISI deformity is also present when the scapholunate angle is greater than 60 degrees (45+/- 15 degrees is normal). The VISI deformity is seen on the lateral radiograph is characteristic of lunotriquetral dissociation. The other signs are seen on the anteroposterior projection.

The patient has a bicondylar tibial plateau fracture extending to the diaphysis (Schatzker VI). Given his swelling and fracture blisters, the most appropriate next step would be knee-spanning external fixation.
High energy injuries of the tibia are often accompanied by significant soft tissue damage and swelling. Tibial plateau fractures, and more often pilon fractures, with significant swelling or fracture blisters are best managed acutely with external fixation to allow swelling to improve before definitive fixation. This strategy, which typically applies more often to pilon fractures, helps to limit infection and wound healing complications.
Reahl et al. retrospectively reviewed 419 patients who underwent surgical management of tibial plateau fractures to determine risk factors for subsequent surgery for knee stiffness. They found that amount of time spent in external fixation and bilateral tibial plateau fractures were independent risk factors for need for later surgery for knee stiffness.
Egol et al. investigated a staged treatment protocol for high energy tibial plateau fractures. Initial treatment was with knee-spanning external fixation followed by definitive fixation at an average of 15 days later. While wound complications were low (5%), they do cite a potential downside of increased knee stiffness.
Figures A-D are knee x-rays and CT scan showing a bicondylar tibial plateau fracture with significant comminution.
Incorrect Answers:
Answer 1,2: A long leg splint or bivalve cast will not help maintain length and is not the most appropriate next step. Acute casting of a high energy fracture is not recommended
Answer 4,5: The presence of fracture blisters and soft tissue swelling indicate that immediate ORIF is not the most appropriate next step.

Patients with Ewing sarcoma need chemotherapy to treat micrometastatic disease. Historical outcomes of patients who receive local control alone without chemotherapy are dismal. Chemotherapy alone, however, is not adequate to control local bulky disease. Local control options include radiation therapy or wide surgical resection. Historically, it was believed that surgery should be recommended for expendable bones to minimize morbidity. More recent data support improved outcomes (vs outcomes associated with radiation alone to the primary site of disease) for patients who undergo wide surgical resection; consequently, chemotherapy plus wide surgical resection is the most effective regimen.
RECOMMENDED READINGS
19. [Rodriguez-Galindo C, Spunt SL, Pappo AS. Treatment of Ewing sarcoma family of tumors: current status and outlook for the future. Med Pediatr Oncol. 2003 May;40(5):276-87. Review. Erratum in: Med Pediatr Oncol. 2003 Dec;41(6):594. PubMed PMID: 12652615. ](http://www.ncbi.nlm.nih.gov/pubmed/12652615)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/12652615)
20. Bacci G, Toni A, Avella M, Manfrini M, Sudanese A, Ciaroni D, Boriani S, Emiliani E, Campanacci
[M. Long-term results in 144 localized Ewing's sarcoma patients treated with combined therapy. Cancer. 1989 Apr 15;63(8):1477-86. PubMed PMID: 2924256. ](http://www.ncbi.nlm.nih.gov/pubmed/2924256)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/2924256)
21. [Maheshwari AV, Cheng EY. Ewing sarcoma family of tumors. J Am Acad Orthop Surg. 2010 Feb;18(2):94-107. Review. PubMed PMID: 20118326. ](http://www.ncbi.nlm.nih.gov/pubmed/20118326)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/20118326)
22. Weis L. Ewing’s Sarcoma. In: Simon MA, Springfield D, eds. _Surgery for Bone and Soft Tissue Tumors_. Philadelphia, PA: Lippincott-Raven; 1998:287-298.
23. DuBois SG, Krailo MD, Gebhardt MC, Donaldson SS, Marcus KJ, Dormans J, Shamberger RC, Sailer S, Nicholas RW, Healey JH, Tarbell NJ, Randall RL, Devidas M, Meyer JS, Granowetter L, Womer RB, Bernstein M, Marina N, Grier HE. Comparative evaluation of local control strategies in localized
Ewing sarcoma of bone: a report from the Children's Oncology Group. Cancer. 2015 Feb 1;121(3):467-
[75/. doi: 10.1002/cncr.29065. Epub 2014 Sep 23. PubMed PMID: 25251206. ](http://www.ncbi.nlm.nih.gov/pubmed/25251206)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/25251206)

Elderly patients with femoral neck fractures (FNF) undergoing total hip arthroplasty (THA) are less likely to require reoperation than those undergoing internal fixation.
Intracapsular FNF are common in elderly patients after a fall from standing height. Treatment depends on physiological age and displacement (Garden's classification). For displaced fractures, physiologically young patients are treated with internal fixation while physiologically old patients are treated with
either hemiarthroplasty (debilitated, less active patients) or THA (more active patients, those with acetabular disease or preexisting inflammatory arthritis).
Chammout et al. retrospectively compared the long term (17 years) results of THA (cemented both component) and ORIF (2 cannulated screws) in elderly patients (>65 years). They found no difference in mortality. But hip scores were higher and pain was better in the THA group, while reoperation rates were higher in the ORIF group. Walking speed was initially faster in the THA group, but later did not differ between groups. They recommend THA for elderly patients with displaced FNF.
Rogmark et al. prospectively compared closed reduction and internal fixation (CRIF) with arthroplasty (combining hemiarthroplasty and THA) at 2 years in elderly patients (>70 years). Failure rates were higher, pain was worse, and walking was more impaired after CRIF. They recommend arthroplasty for patients >70 with FNF.
Incorrect Answers:
Answer 1: Patients undergoing THA are more likely to have less pain than internal fixation.
Answer 3: Patients undergoing THA have superior functional outcome scores. Answer 4: Patients undergoing THA perform ADL better in the short term. In the long term, there is no difference in ADL between the groups.
Answer 5: Mortality rates are similar after the two procedures.

A pseudotumor is a hemophilic subperiosteal hematoma. The pseudotumor expands by repeated bleeds and increasing osmotic pressure.
There was no periosteal reaction or intralesional calcification.
The bone wall itself is not expanded as in aneurysmal bone cyst.
There is nothing in the physical examination or patient history to point to infection.

This patient has the classic appearance of a collar button hand abscess. Although antibiotics, soaks, and elevation are important interventions, surgery is required. This infection rarely evolves into a flexor tenosynovitis, so decompression of the flexor tendon sheath is not indicated. Both volar and dorsal incisions often are required to effectively drain the abscess. Amputation is not appropriate as first-line treatment.
RECOMMENDED READINGS
26. McDonald LS, Bavaro MF, Hofmeister EP, Kroonen LT. Hand infections. J Hand Surg Am. 2011 Aug;36(8):1403-12. doi: 10.1016/j.jhsa.2011.05.035. Review. PubMed PMID: 21816297.
27. Osterman M, Draeger R, Stern P. Acute hand infections. J Hand Surg Am. 2014 Aug;39(8):1628-35; quiz 1635. doi: 10.1016/j.jhsa.2014.03.031. Review. PubMed PMID: 25070032.
**

- Semitendinosus and gracilis
The demonstration in Video 92 shows the tendons of the semitendinosus and gracilis muscles. They insert on the tibia deep to the sartorial fascia. The semimembranosus inserts more proximal and posterior on the tibia.
RECOMMENDED READINGS
1. Babb JR, Detterline AJ, Noyes FR. AAOS Orthopaedic Video Theater. The Key to the Knee: A Layer-by-Layer Video Demonstration of Medial and Anterior Anatomy. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2009.
2. Hoppenfeld S, deBoer P. Surgical Exposures in Orthopedics. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003:493-568.

Injury to the latissimus dorsi tendon recently has been reported as a cause of pain in the thrower’s shoulder. The etiology of this injury is felt to be eccentric overload during the follow-through of the throwing motion. Recommended management for this unusual injury consists of a short period of rest, followed by physical therapy to restore shoulder motion and strength. Throwing is allowed when the athlete demonstrates full, pain-free motion and good strength and balance of the rotator cuff and scapular rotator muscles. Currently there are no defined indications for surgical repair.
REFERENCES: Schickendantz MS, Ho CP, Keppler L, et al: MR imaging of the thrower’s shoulder: Internal impingement, latissimus dorsi/subscapularis strains and related injuries.
Magn Reson Imaging Clin N Am 1999;7:39-49.
Livesey JP, Brownson P, Wallace WA: Traumatic latissimus dorsi: Tendon rupture. J Shoulder Elbow Surg 2002;11:642-644.

Demineralized bone matrix is weakly osteoinductive.
The term osteogenic refers to direct transmittal of cells capable of making bone. Demineralized bone matrix is not osteogenic.
Demineralized bone matrix varies in efficacy between different forms and different methods of sterilization. The term osteoconduction refers to provision of a favorable scaffold and environment for bone formation. Demineralized bone matrix is osteoconductive.

The guidelines for the daily elemental calcium requirement are as follows:
Children 500 mg to 700 mg
Growth spurt to young adult
(10 to 25 years of age)
1,300 mg
Adult male 750 mg
Adult female
Postmenopausal Elderly Pregnancy Lactation
  Â
1,500 mg
1,200 mg
1,500 mg
2,000 mg
Note: 1 daily equivalent = 250 mg elemental calcium (one glass of milk) Correct Answer: 1,500 mg

The timing of definitive fixation of tibial plateau fractures in patients with fasciotomies has no impact on infection risk.
The incidence of compartment syndrome is high in tibial plateau fractures. In the presence of tense anterior and lateral tibial compartments, combined with pain with passive stretch of involved muscles or unrelenting pain, compartment pressures should be measured and fasciotomies performed when necessary.
Schatzker type V and VI fractures are more likely to have this potential complication. Examination of leg compartments should be repeated at regular intervals because compartment syndrome may occur 24 hours or more after injury.
Zura et al. performed a study to analyze whether there is an association between infection and the timing of definitive fracture fixation in relation to fasciotomy closure or coverage. They found that no statistical difference in the rate of infection when tibial plateau fractures with four-compartment fasciotomies were treated with open reduction and internal fixation before fasciotomy closure, at fasciotomy closure, or after fasciotomy closure. They conclude that timing of definitive fracture treatment can be determined by the medical condition of the patient.
Shah et al. performed a retrospective chart review of all bicondylar tibial plateau fractures that had fixation with two incisions. They reported an infection rate of 13.8% which is lower than historical reports. They concluded that the lower infection rate was due to their treatment algorithm that requires recovery of the soft tissue envelope prior to definitive fixation.
Figure A demonstrates a bicondylar tibial plateau fracture. Figure B demonstrates fixation of a tibial plateau fracture through a dual plating technique.
Incorrect Answers:
Answers 1, 2, 3, and 4 are incorrect as infection risk is unchanged with timing of definitive fracture fixation.

The MRI scans show a full-thickness tear of the supraspinatus, infraspinatus, subscapularis and medial subluxation of the long head of biceps tendon. Teres minor appears intact on the images. Although the tear of the subscapularis is not as well-visualized, medial subluxation of the long head of biceps is reliably correlated with a subscapularis tear.

Type II collagen is the predominant type found in articular cartilage. Type IV collagen is the predominant type found in the basement membranes of neurovascular structures. Collagenase _Clostridium_ __histolyticum__ _injection targets type I and type III collagen._

DISCUSSION: Computer navigation has been shown to improve the accuracy of placement of TKA components with fewer outliers. However, the surgical time and cost are increased. No studies to date have demonstrated improved clinical outcomes or implant survivorship.

REFERENCE: Haaker RG, Stockheim M, Kamp M, et al: Computer-assisted navigation increases precision of component placement in total knee arthroplasty. Clin Orthop Relat Res 2005;433:152-159.

DISCUSSION: Although stress shielding has not been associated with adverse clinical outcomes to date, it is a commonly observed process after cementless total hip arthroplasty. Factors that increase the magnitude of stress shielding include the use of distally fixed cobalt-chrome stems, particularly in patients with osteoporosis. Large diameter femoral components (larger than 18 mm in diameter) have also been associated with an increased prevalence of stress shielding.

REFERENCE: Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 345-368.

DISCUSSION: Internal impingement is characterized by articular-sided partial-thickness rotator cuff tears and superior glenoid labral tears. The capsule is characterized by laxity anteriorly and tightness posteriorly.

Scientific References

: Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, p 82.
Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spectrum of pathology. Part I:
Pathoanatomy and biomechanics. Arthroscopy 2003;19:404-420.

Figure 27

Sagittal balance is the most reliable predictor of clinical symptoms and HRQL outcomes on the SRS 29, SF-12, and Oswestry Disability Index. Coronal balance, shoulder balance,curve magnitude, and degree of curve correction are less critical in determining clinical symptoms and outcomes.

The patient has a pectoralis major rupture, an injury that occurs most commonly during weight lifting. Grade III injuries represent complete tears of either the musculotendinous junction or an avulsion of the tendon from the humerus, the most common injury site. Examination will most likely reveal ecchymoses and swelling in the proximal arm and axilla, and strength testing will show weakness with internal rotation and in adduction and forward flexion. Axillary webbing, caused by a more defined inferior margin of the anterior deltoid as the result of rupture of the pectoralis, can be seen as the swelling diminishes. Surgical repair is the treatment of choice for complete ruptures. Nonsurgical treatment is associated with significant losses in adduction, flexion, internal rotation, strength, and peak torque. The pectoralis major originates from the proximal clavicle and the border of the sternum, including ribs two through six. The pectoralis major inserts (rather than originates) on the humerus. The coracoid process is the insertion site for the pectoralis minor, as well as the origin for the conjoined tendon. The pectoralis major has no attachment or origin from the scapula. The anterior deltoid originates from the lateral one third of the clavicle and the anterior acromion.
REFERENCES: Miller MD, Johnson DL, Fu FH, Thaete FL, Blanc RO: Rupture of the pectoralis major muscle in a collegiate football player: Use of magnetic resonance imaging in early diagnosis. Am J Sports Med 1993;21:475-477.
Wolfe SW, Wickiewicz TL, Cavanaugh JT: Ruptures of the pectoralis major muscle: An anatomic and clinical analysis. Am J Sports Med 1992;20:587-593.

- instability of the fracture.

- Well-fixed uncemented stem with stress shielding_

Ideal values of micromotion that stimulate bone ingrowth are 28 microns to 150 microns. Values greater than 150 microns are associated with fibrous ingrowth

There are different snake bite protocols depending on the species of snake. However, common steps in all snake bite protocols include keeping the patient emotionally and physically still, calling for help immediately, applying a moderately tight tourniquet proximally to prevent further spread of venom, and capture or identification of the snake. Local injection of the antivenin in the fingers or toes is contraindicated.

The terminal hypertrophiCchondrocytes in the hypertrophiCzone produce Type X collagen. The appearance of Type X collagen heralds ossification. Remember that Type II collagen is the most abundant collagen in the hypertrophiCzone

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

**

Scientific References

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

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

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

PREFERRED RESPONSE: 4**

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

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

Figure 3a Figure 3b

This is a classic presentation of an acute traumatic distal biceps tendon rupture. In the dominant extremity of a manual laborer, this injury can result in approximately 40% loss of supination strength. Although not required, an MRI scan can confirm
the diagnosis. In general, a single incision anterior or two incision anterior/ posterior repair can be utilized for surgical intervention with similar success rates. Although the percentage of complications is similar between surgical approaches, the type of complications can vary. Anterior only repairs have a
20
higher risk of traction injury to the lateral antebrachial cutaneous nerve (LABC) secondary to the degree of retraction required for exposure in muscular patients. Posterior repairs have a higher risk for radiographic heterotopic bone formation. Fortunately, most LABC injuries are neuropraxias and resolve with observation, but resolution may take up to 6 months. In this case, ongoing observation is appropriate, with surgical exploration being considered only in chronic cases. Patients should be appropriately counseled about this issue prior to surgery.

The image demonstrates a rotational fluoroscopic view of the lateral distal radius while attempting to recreate the inclination of the distal radius. This view is most useful to ensure against intra-articular screw penetration. The overall alignment of the joint surface is best viewed with a posteroanterior tilt of 11 degrees. The alignment of the sigmoid notch is not seen well on lateral images. Carpal alignment is seen
well on lateral images. Dorsal screw penetration is best viewed dynamically with a flexed wrist tangential _view._

The debate between reamed versus unreamed intramedullary nailing of the tibia continues. Although unreamed nailing was proposed for open fractures to minimize infection, its simplicity made it appealing for closed fractures. However, most studies to date show that the only advantage of unreamed nailing is less surgical time. All studies show higher nonunion rates with increased hardware failure and increased time to union for unreamed nailing. Even in open fractures graded up to Gustilo Grade IIIA, the reamed tibial nail performs better.
REFERENCES: Larsen LB, Madsen JE, Hoiness PR, et al: Should insertion of intramedullary nails for tibial fractures be with or without reaming? A prospective, randomized study with 3.8 years’ follow-up. J Orthop Trauma 2004;18:144-149.
Blachut PA, O’Brien PJ, Meek RN, et al: Interlocking intramedullary nailing with or without reaming for the treatment of closed fractures of the tibial shaft: A prospective randomized study. J Bone Joint Surg Am 1997;79:640-646.

This patient has a metastatic neuroendocrine tumor. Surgical treatment should prioritize palliation of her symptoms. She has high-grade spinal cord compression without neurologic signs or symptoms. Steroids are beneficial for patients with high-grade spinal cord compression caused by tumors, and these drugs should be administered in the acute setting. This patient was appropriately initially treated with conventional radiation. However, she is not a candidate for further radiation because of spinal cord tolerance limits and insufficient clearance between the tumor and spinal cord. Consequently, stereotactic radiation is not an option.
The goal of surgical treatment of this tumor should be palliation of her symptoms rather than cure. A costotransversectomy approach offers the advantage of ventral and dorsal spinal cord access, which is necessary in this case. A sternotomy or transthoracic approach would offer ventral access, but dorsal access would be less than optimal.
RECOMMENDED READINGS
[Rose PS, Buchowski JM. Metastatic disease in the thoracic and lumbar spine: evaluation and management. J Am Acad Orthop Surg. 2011 Jan;19(1):37-48. Review. PubMed PMID: 21205766.](http://www.ncbi.nlm.nih.gov/pubmed/21205766)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/21205766)
Rades D, Abrahm JL. The role of radiotherapy for metastatic epidural spinal cord compression. Nat Rev Clin Oncol. 2010 Oct;7(10):590-8. doi: 10.1038/nrclinonc.2010.137. Epub 2010 Aug
[31/. Review. PubMed PMID: 20808299. ](http://www.ncbi.nlm.nih.gov/pubmed/20808299)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/20808299)

Imaging studies in the evaluation of plantar fasciitis should always include weight-bearing foot radiographs to reveal alignment and exclude calcaneal stress fracture, tumor, subtalar arthritis, and insertional posterior spurs. MRI is occasionally indicated in problematic cases. Ultrasound can be helpful to evaluate thickening and disease in the proximal plantar fascia. Ultrasound is quick and much more cost effective than MRI. Laboratory screenings to evaluate inflammatory arthritis are indicated only for patients with bilateral heel pain who may be more likely to have systemic disease.
In the nonsurgical treatment of plantar fasciitis, high-impact loading exercises may make the condition worse. Corticosteroid injections may provide short-term relief only and can occasionally cause plantar fascia rupture. They should be used with caution. PRP injections are expensive and currently not covered by insurance. Studies have not demonstrated long-term pain relief with PRP. Plantar fascia-specific stretching has been shown more effective than Achilles tendon stretching alone.
Surgical treatment is indicated for fewer than 5% of patients. It is not necessary to resect the heel spur because the spur is not attached to the plantar fascia and rarely contributes to a patient's pain. The open extensile approach is associated with a much longer recovery than the open or endoscopic approaches and is no longer justified. Multiple studies have demonstrated the efficacy of endoscopic and open plantar fasciotomy techniques.
RECOMMENDED READINGS
Bader L, Park K, Gu Y, O'Malley MJ. Functional outcome of endoscopic plantar fasciotomy. Foot Ankle Int. 2012 Jan;33(1):37-43. doi: 10.3113/FAI.2012.0037. PubMed PMID:
[22381234.](http://www.ncbi.nlm.nih.gov/pubmed/22381234)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/22381234)
Lareau CR, Sawyer GA, Wang JH, DiGiovanni CW. Plantar and medial heel pain: diagnosis and management. J Am Acad Orthop Surg. 2014 Jun;22(6):372-80. doi: 10.5435/JAAOS-22-06-
[372/. PubMed PMID: 24860133.](http://www.ncbi.nlm.nih.gov/pubmed/24860133)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/24860133)

A higher risk of nonunion and the need for prolonged immobilization is seen after nonsurgical management of proximal pole fractures of the scaphoid. Because of the relatively poor blood supply of the proximal pole, surgical treatment with a compression screw is advocated for fractures of the proximal third of the scaphoid.
REFERENCES: Clay NR, Dias JJ, Costigan PS, et al: Need the thumb be immobilized in scaphoid fractures? A randomised prospective trial. J Bone Joint Surg Br 1991;73:828-832.
Ring D, Jupiter JB, Herndon JH: Acute fractures of the scaphoid. J Am Acad Orthop Surg 2000;8:225-231.

Barsky described macrodactyly as either static or progressive. Static macrodactyly is present at birth, and the affected digit grows larger as the child develops. In the progressive type of macrodactyly, growth begins soon after birth. This form of the disorder is more common than static macrodactyly.

DISCUSSION: Direct measurement and finite element modeling results show that
approximately 20% of the vertical load is borne by the posterior structures of the lumbar
spine in the upright position.

Scientific References

: Adams MA, Hutton WC: The effect of posture on the role of the apophyseal joints in resisting intervertebral compressive forces. J Bone Joint Surg Br 1980;62:358-362.
Goel VK, Kong W, Han JS, Weinstein JN, Gilbertson LG: A combined finite element and optimization investigation of lumbar spine mechanics with and without muscles. Spine 1993;18:1531-1541.

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

This patient has a dorsally dislocated MP joint. In these cases, the volar plate can be displaced dorsal to the metacarpal head, preventing reduction. Although early publications described a “noose effect” of the lumbrical and flexor tendons, the primary block to reduction is the volar plate. Simple MP dislocations can be reduced closed by flexing the wrist and then gently sliding the base of the proximal phalanx over the end of the metacarpal. Longitudinal traction on the finger will only incarcerate the volar plate further and should be avoided. Patients with complex dislocations that fail closed reduction require open
reduction.

DISCUSSION
Internal impingement occurs when there is repetitive contact of the posterior superior aspect of the glenoid with the humeral head causing damage to the undersurface of the supraspinatus and anterior aspect of the infraspinatus tendons, as well as posterior superior glenoid labrum. This occurs when the arm is in maximum abduction and external rotation such as during the late cocking phase of the normal throwing motion. The 6 phases of throwing are wind up, early cocking, late cocking, deceleration, and follow through. When the arm is repeatedly placed in the abducted externally rotated position, the anterior capsule can become lax and posterior capsular contractures can develop. When there are kinetic chain abnormalities such as scapular internal rotation or muscle fatigue, there is exacerbation of abnormal anterior humeral head translation and increased contact of the rotator cuff on the posterior glenoid rim, with concomitant increased risk of injury
and symptoms.

The radiograph reveals disruption of the symphysis pubis and a displaced left sacral fracture. A posterior injury with displacement of greater than 1 cm is unstable, and a sacral fracture is particularly unstable. Surgical stabilization is required for these unstable anterior and posterior injuries. External fixation provides little stability to an unstable posterior pelvic injury. Reduction and internal fixation of the symphysis pubis and sacral fracture will provide the most stable pelvis with the least resultant deformity and allow patient mobilization.
REFERENCES: Tile M: Management of pelvic ring injuries, in Tile M, Helfet DL, Kellam JF (eds): Fractures of the Pelvis and Acetabulum, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 168-202.
Kabak S, Halici M, Tuncel M, et al: Functional outcome of open reduction and internal fixation for completely unstable pelvic ring fractures (type C): A report of 40 cases. J Orthop Trauma 2003;17:555-562.

This patient’s examination and history indicate recurrent patellar dislocations. Radiographs show an osseous or osteochondral loose fragment. There is no evidence of an obvious nondisplaced fracture or physeal changes. In the setting of suspected patella dislocation or subluxation with loose fragment seen on radiograph, an MRI is indicated. Lateral release alone is seldom indicated in a knee that is normal before injury. The examination and MRI do not indicate a need for medial collateral ligament repair. Treatment should consist of arthroscopy or arthrotomy and attempted internal fixation of this fragment. If fixation is not possible, the loose body can be removed. Normal TT-TG values, an increased lateral patellar glide, and a history of recurrent patellar dislocations after trauma suggest MPFL incompetence and the need for reconstruction.

Fretting corrosion occurs when micromotion exists between two metals in contact. One of the most common examples of fretting corrosion is micromotion between a modular femoral head and the tapered neck junction. Modular components, such as the S- ROM system (DePuy Orthopaedics Inc., Warsaw, Ind), are subject to fretting corrosion at each of the junctions.
Techniques to minimize fretting corrosion include:
Making sure the head-neck junctions are dry and clean
Eliminating micromotion but having an exact fit (ie, not mixing manufacturers)
The other responses refer to:
Galvanic corrosion: Impurities within a metal implant C revice corrosion: At a surface defect of an implant Galvanic corrosion: At sites of electrochemical gradients
Oxidative degradation: Irradiation of high-density polyethylene in an ambient environment
C orrect Answer: Relative micromotion under load

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An occurrence policy provides coverage for all claims made during employment irrespective of when it is filed (during or postemployment) and therefore is the best option. Claims made policy only covers suits for the time employed. A prepurchased "tail" is needed to provide coverage for cases that occurred during employment but filed postemployment. Nose coverage is applicable if the surgeon was previously employed and did not have tail coverage from previous employment, but this surgeon just emerged from training where it is not applicable. Claims made without tail coverage is unwise because the surgeon would be unprotected or have to purchase his own policy postemployment.
Only in certain situations does sovereign immunity exist, and generally not in a for-profit system. Occurrence coverage with nose coverage
is incorrect because it does not apply to this surgeon with no previous employment or claims policy lacking tail coverage.

DISCUSSION: The patient has external-type snapping hip (coxa saltans). It is not uncommon for patients to have a very long duration of symptoms that limit running or other sporting activities, and commonly affects the downward leg (usually the left leg when running on the left side of the road). The snapping causes a profound bursitis at the greater trochanter, and occasionally corticosteroid injections may be helpful. Her physical examination does not suggest an intra-articular process, and is not consistent with an internal-type snapping hip, usually caused by the iliopsoas tendon as it moves over the iliopectineal eminence. Stretching is the mainstay of treatment, as testing with a positive Ober signifies a tight iliotibial band as the thigh has difficulty crossing the midline with adduction. Various iliotibial band lengthening procedures have been described, including a Z-plasty near the proximal origin of the iliotibial band. Release at Gerdy’s tubercle has not been described.
REFERENCES: Provencher MT, Hofmeister EP, Muldoon MP: The surgical treatment of external coxa saltans (the snapping hip) by Z-plasty of the iliotibial band. Am J Sports Med 2004;32:470-476.
Faraj A A, Moulton A, Sirivastava VM: Snapping iliotibial band: Report of ten cases and review of the literature. Acta Orthop Belg 2001;67:19-23.
Brignall CG, Stainsby GD: The snapping hip: Treatment by Z-plasty. J Bone Joint Surg Br 1991 ;73:253-
254.

In one series, 23% of arthroplasty revisions became re-infected by a different organism even after a two-stage revision. However, re-infection is usually, although not always, caused by the same microorganism that caused the initial infection. Once the white blood cell count, sedimentation rate, and C-reactive protein count return to normal, it is usually safe to re-implant the prosthesis

Frankle et al found that passive external rotation of the shoulder placed the most stress on the lesser tuberosity fixation. The subscapularis tendon inserts on the lesser tuberosity and is the deforming force when placed under tension during external rotation. They also found that non-anatomic tuberosity reduction of 4-part proximal humerus fractures treated with hemiarthroplasty increased torque and impaired external rotation kinematics.

The ESR takes more than a year to return to normal after a total hip replacement

Patients with diastrophic dysplasia rarely have instability of the upper cervical spine.
Babies with diastrophic dysplasia often have rigid equinovarus feet that require surgery to become plantigrade and wear normal shoes.
A number of patients with diastrophic dysplasia develop progressive scoliosis that requires surgical treatment. Degenerative disease of the hips is common and often requires arthroplasty in early adulthood.
Degenerative disease of the knees is common and often requires arthroplasty in early adulthood.

This patient has a septic distal interphalangeal joint, which was treated with antibiotics alone. As a result, the patient developed osteomyelitis with bone destruction and abscess. The best way to treat this problem is to perform surgical débridement of bone and soft tissue, along with abscess drainage and an appropriate antibiotic regimen. Antibiotic treatment without surgery would not be successful in eliminating this particular infection. Bone scan with biopsy is not the correct option, because this problem is an infection _and not a tumor, and MRI already has provided enough diagnostic information._