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OITE 2008 Review

OITE 2008 Review. Abdulaziz Alomar, MD, MSc FRCSC Assistant Professor and consultant Orthopaedic surgeon. KKUH, KSU.

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OITE 2008 Review

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  1. OITE 2008 Review Abdulaziz Alomar, MD, MSc FRCSC Assistant Professor and consultant Orthopaedic surgeon.KKUH, KSU

  2. 226. A 56 y/o man with a Hx of NF reports burning pain in his foot. An MRI scan of the thigh reveals the mass shown in figure96a. A biopsy is most likely to reveal the histology in which of the following figures? • Figure 96b • Figure 96c • Figure 96d • Figure 96e • Figure 96f

  3. 3. Figure 96d

  4. 227. The nutritional supply of the tendon region shown in figure 97 primarily comes from the • Paratenon • Synovial sheath and fluid • Mesotenon/vinculae • Periosteum • Myotendinous junction

  5. 2. Synovial sheath and fluid • From their musculotendinous origin to the level of the A1 pulley, the flexor tendons receive their blood supply from the surrounding paratenon • Within the sheath, the only connection between the tendons and the periphery is at the level of the vincula, which are folds of mesotenon that carry a blood supply to the tendons within the sheath • each tendon within the sheath is supplied by 2 vincula, 1 long (vinculum longum) and 1 short (vinculum breve). • The FDS receives a short and long vinculum at the level of the PIP joint. • The FDS receives a long vinculum at the level of the PIP joint, and the • FDP receives a short vinculum at the level of the DIP joint. • Within the flexor sheath, the tendons are also known to receive a significant amount of nutrition by diffusion from the surrounding synovial fluid

  6. 228. During posterolateral approach for ORIF of a radial head #, the arm kept in which position to avoid injury to PIN? • Neutral forearm rotation • Elbow flextion • Elbow extension • Pronation • supination

  7. 4. Pronation Pronation of the forearm allowed safe exposure of at least the proximal 38 mm of the lateral aspect of the radius, with an average proximal safe zone of 52.0 ± 7.8 millimeters. Supination decreased this proximal safe zone to as little as 22 mm and an average of 33.4 ± 5.7 millimeters. The angle formed by the posterior interosseous nerve and the radial shaft in supination averaged 47.4 ± 6.8 degrees; this decreased to 27.8 ± 6.7 degrees with pronation. Anatomical Considerations Regarding the Posterior Interosseous Nerve During Posterolateral Approaches to the Proximal Part of the RadiusJ. Bone Joint Surg. Am., Jun 2000; 82: 809

  8. 229. When is it safe for most patients to return to driving after a THA • After 1 week • 2-3 weeks • 4-6 weeks • 10-12 weeks • After 12 weeks

  9. 3. 4-6 weeks • Decisions made regarding resumption of driving after total hip arthroplasty may be determined by a combination of factors including driving reaction time and when postsurgical precautions need no longer be adhered to. Ninety patients, ranging in age from 34 to 85 years old were recruited after total hip arthroplasty to measure driving reaction time preoperatively and from 1 to 52 weeks postoperatively. Driving reaction time worsened 1 week postoperatively for patients who had a right hip arthroplasty. The driving reaction time then improved up to 1 year postoperatively. Patients who had a left arthroplasty improved from 1 week postoperative. In general, patients reach their preoperative driving reaction time 4 to 6 weeks postoperatively and continue to improve. Ganz SB, Levin AZ, Peterson MG, et al: Improvement in driving reaction time after total hip arthroplasty. Clin Orthop Relat Res 2003;413:192-200.

  10. 230.What rotational differences are seen in the dominant shoulder of throwing athletes compared to their nondominant side? • Increase external rotation and decrease internal rotation • Increase external and internal rotation • Decrease external and internal rotation • Decrease external rotation and increase internal rotation • No difference between dominant and nondominant sides

  11. 1. Increase external rotation and decrease internal rotation • throwing athletes had a significant increase in the dominant shoulder versus the nondominant shoulder in humeral head retroversion, glenoid retroversion, external rotation at 90°, and external rotation in the scapular plane. Internal rotation was decreased in the dominant shoulder. Total range of motion, anterior glenohumeral laxity, and posterior glenohumeral laxity were found to be equal bilaterally. • A comparison of the dominant shoulders of the throwing athletes to nonthrowing subjects indicated that both external rotation at 90° and humeral head retroversion were significantly greater in the throwing group. Crockett HC, Gross LB, Wilk KE, et al: Osseous adaptation and range of motion at the glenohumeral joint in professional baseball pitchers. Am J Sports Med 2002;30:20-26.

  12. 231. The Indications for a reverse total shoulder arthroplasty include: • A failed hemiarthroplasty secondary to glenoid wear. • A malunited 4-part proximal humerus fracture in a 45 y/o sedentary individual. • A young laborer with degenerative arthritis superimposed on a massive, irreparable rotator cuff tear. • An elderly Pt with painful shoulder motion limited to 140 degrees of forward flexion. • An elderly Pt with a painful, arthritic shoulder with active forward flexion of 30 degrees.

  13. 5. An elderly Pt with a painful, arthritic shoulder with active forward flexion of 30 degrees. The most reliable results are obtained with total semiconstrained prostheses. This is reason enough to aim for optimal repair of rotator cuff tears. Then, if glenohumeral disease develops subsequently, the head is centered, allowing use of a semi-constrained total prosthesis. In contrast, failure to repair a large rotator cuff tear may result in osteoarthritis with humeral head migration. In this case, the only effective treatment at present is reverse total prosthesis, whose medium-term results are not well known. Goutallier D, Postel JM, Zilber S, et al: Shoulder surgery: From cuff repair to joint replacement: An update. J Bone Joint Surg Am 2003;70:422-432.

  14. 232. A 6-month-old child has a brachial plexus birth palsy. Examination reveals a normal trapezius, deficient shoulder abduction, no external rotation, absent elbow flexion, no forearm supination, and weak wrist extension. The rest of examination is normal. Which of the following nerve roots have been injured? • C5 • C5 and C6 • C5, C6, and C7 • C5, C6, C7, and C8 • C5, C6, C7, C8, and T1

  15. 2. C5 and C6

  16. 233. A 21-year-old man seen in ER with grade II open femur fracture. Because of significant head injury, he is unable to give informed consent and no family members are available. How should you proceed? • Schedule the Pt for I&D, and definitive fracture management in the OR. • Perform an I&D in the ER and place the Pt in traction until a family member or guardian is contacted • Ask a colleague with similar expertise and knowledge in femoral fracture management to confirm the necessity of the procedure before proceeding with definitive fracture care • Obtain approval for care from hospital administrator • Document the medical necessity of the procedure in the chart prior to proceeding with fracture care.

  17. 3. Ask a colleague with similar expertise and knowledge in femoral fracture management to confirm the necessity of the procedure before proceeding with definitive fracture care

  18. 234. Radiographs obtained 2 months after ORIF of a displaced talar neck # show a subchondral radiolucency in the talar dome. What dose this finding represent? • Osteonecrosis of the talus due to vascular disruption • An unrecognized osteochondral injury to the talar dome • Preserved vascularity of the talar body • Subchondral bone collapse in the talar dome • Cystic changes associated with post traumatic arthritis

  19. 3. Preserved vascularity of the talar body • The Hawkins sign showed a sensitivity of 100% and a specificity of 57.7%. The Hawkins sign (if present) appeared between the 6th and the 9th week after trauma • The Hawkins sign is a good indicator of talus vascularity following fracture. If a full or partial positive Hawkins sign is detected, it is unlikely that AVN will develop at a later stage after injury Tezval M, Dumont C, Sturmer KM: Prognostic reliability of the Hawkins sign in fractures of the talus. J Orthop Trauma 2007;21:538-543.

  20. 235. Which of the following most improve functional outcome after transfemoral amputation? • Adductor myodesis • Femoral flexor extensor myoplasty • Posterior based skin flap • Residual limb that can use a suction fit socket • Abductor advancement

  21. 1. Adductor myodesis Adductor myodesis is important for maintaining femoral adduction during the stance phase in order to allow optimum prosthetic function. The major deforming force is toward abduction and flexion. Adductor myodesis at normal muscle tension eliminates the problem of adductor roll in the groin. Transecting the adductor magnus results in a loss of 70% of the adductor pull

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