Ortho Anatomy Review

1. Ortho Anatomy Review 2012

2. agenda • The exam • Little points • Commonly tested • Questions – breeze through • Jeopardy • Lab

3. The Exam • A mix of: • Short answer • Long Answer • Multiple Choice (aka guess) • Diagrams with fill-in-the-blanks • Photos/Imaging/Axial cuts

4. Why care? • Reviewed as part of ITER, WerierMtgs • Pride • The CUP • Recent winners: • Daneshvar PGY-4,5 • Butterwick PGY-2! • Abdelbary PGY-5 • Brown PGY-4 Brad & some other guy holding up the Anatomy Cup

5. Easy Points • Draw the Brachial Plexus • Seniors – LS Plexus • Nerve entrapment syndromes • Hand is high-yield • Know deformities (e.g. swan, bout,etc) and anatomic reasons

6. High Yield • Approaches • intervals • Risks • Common trivia

7. Where to focus? • No Abdominal • (aside from Spine/Pelvis crossover) • No Thoracic • (aside from Spine, and UE attachments) • No Head/Face • (aside from Spine/HALO) • Therefore: • Just about everything else • (‘cept gonads)

8. CAQ • Contents and borders of: • Sartorial Canal • Rotator Interval • Carpal Tunnel/ Guyon’s • Triangular space/interval • Quadrangular space

9. CAQ • Common approaches and their neuromuscular intervals • Ilioinguinal Approach • 3 windows and their borders • Cruciateanastamosis & Corona Mortis • Blood supply to: • Humeral head, Femoral head • Talus • Scaphoid

10. Wrist extensor compartments • Muscles with dual innervation • Intracapsular tendons • LHB & Popliteus • 5 semimembranous insertions • Anterior tibia • Post capsule (& medial meniscus – post horn) • Oblique poplitial ligament • Posterior Oblique Ligament • Popliteusaponeurosis • Arcuatecomplex of knee: includes posterior 1/3 of lateral supporting structures • LCL • Arcuatelig • extension of popliteus • Arcuatere-inforced by biceps femoris, popliteus, & lateral head of gastroc

11. Posterior latero-corner of knee: (APPPLL) • Arcuatelig • Popliteus • Posterolateral capsule • LCL • Popliteofibularlig • Lat head of gastroc • Knot Henry - FDL/FHL • Plantar Layers

12. Acetabular screw placement zones and risks

13. Questions

14. Q & AAnatomy course 2012 Elbow and Forearm William Desloges

15. Question # 1 • What are the superficial landmarks to identify the safe zone to apply hardware in the radial head?

16. Radial head fixation Safe Zone • Landmarks: • 90 degrees angle localized by palpation of the radial styloidand Lister's tubercle

17. Question # 2 • Name the components of the medial collateral ligaments of the elbow? • Which Bundle is most important in valgus stability? • Which band from that bundle is most important?

18. Ulnar Collateral Ligament

19. Anterior Bundle • Anterior Band: • more susceptible to valgus overload when the elbow was in extension or at a low flexion angle • Central band: • Aka: the isometric bundle • can maintain normal elbow kinematics and stability throughout the arc of flexion. • Posterior Band • more susceptible when the elbow was at higher flexion angles (J Shoulder Elbow Surg 2002;11:65-71.)

20. Question 3 • Name the primary stabilizers and secondary stabilizers to the elbow?

21. Elbow Stability • Primary Stabilizers: • Ulnohumeral articulation • MCL • LCL • Secondary Stabilizers: • Radial head • Joint capsule • The Common flexor and extensor origins

22. Question 4 • Name the potential sites of compression of the Median n.

23. Median n. site of Compression • Median n. • Supracondylar process of humerus and ligament of Struthers • Lacertus Fibrosis (Bicipital aponeurosis) • Pronator teres: Pronator Syndrome • Subliminus bridge: • fibrotendinousarcade that represents the origin of the FDS muscle • AIN • Pronator teres • FDS • Aberrant vessels • Accessory muscles: Gantzer’s accessory FPL muscle • Pronator syndrome and AIN syndrome are the 2 most frequently referenced compression neuropathies of the median nerve in the forearm

24. Question 5 • If you ask a patient to hold a piece of paper between their index and thumb and they do this, what is your diagnosis?

25. Answer • AIN palsy

26. Question 6 • Name the potential sites of compression of the ulnar n.

27. Ulnar n. Compression • Ligament of struthers • Medial intermuscular septum • Arcade of Struthers • Hypertrophied medial triceps muscle. • Cubital tunnel • Arcuateligament of Osborne • Two heads of FCU • Anconeusepitrochlearis • Ligament of Spinner: • distinct aponeurosis between the FDS of the ring finger and the humeral head of the FCU • Deep flexor pronator aponeurosis

28. Question 7 • A 28yo M at the Basic Science course in Montreal was partying at “Chez Paré”, when a stripper accidently slipped on stage and stabs him in the arm with her stellato. He sustains a complete laceration of his median n. at the level of his elbow. Suprisingly, he is unable to adduct his thumb after the injury. • Why?

29. Martin-Gruber Anastomosis • Prevalence of 15-32 % • This anastomosis involves axons leaving either the main trunk of median nerve or the anterior interosseousnerve, crossing through the forearm to join the main trunk of the ulnar nerve and ultimately innervating the intrinsic hand muscles • Intrinsic muscles often affected: • First dorsal interosseous • Adductor pollicis • Abductor digitiquinti • Less commonly: 2nd and 3rd dorsal interosseous • High ulnar n. laceration: • Preservation of intrinsic muscle function, along with loss of function of the FCU and FDP to the ulnar two fingers • High median n. laceration: • Loss of some of the intrinsic muscles usually innervated by the ulnar n.

30. Question 8 • What is the internervous plane of the volar Henry approach?

31. Anterior (Henry) Approach • Position: • supine, armboard • Landmarks & Incision: • Biceps, mobile wad, styloid process • Interval: • Superficial • Prox- BR (radial), PT (median) • Distal - BR (radial), FCR (median) • Deep: • Supinator • FDS • FDP • Pronator quadratus • Dangers: • PIN - radial neck under supinator • Sup Rad N – under BR • Radial A – under BR - recurrent leash back to elbow

32. Question 9 • What is the internervous plane of the Thompson approach?

33. Posterior (Thompson) Approach • Distal extension of Kaplan approach to elbow • Internervous plane • ECRB (radial n.) • EDC (PIN)

34. FOOT • Plantaris tendon insertion – • Blood supply to talus – • Name 5 Ligamentous components of the syndesmosis   AITFL – anterior/inferior tib-fib lig•      PITFL – posterior/inferior tib-fib lig•     IOL – Interosseouslig -      Thickened distal IOM•     IOM - Interosseous membrane•     ITL – inferior transverse ligament•     Fibrocartilaginous•      Really the distal part of PITFL

35. Match the eponym • Anterolateral tubercle tibia • Anterior tubercle of fibular • Posterolateraltubercle of tibia • (Volkmans Fragment) • (Chaput Fragment)· • (Wagstaff Fragment)·  

36. Describe the 3 components of the Lisfranc ligaments and their insertions and origins-          • Also - which is the strongest?

37. Which accessory bone is located posterior to the talus? • Which tubercle of the posterior process of the talus is this associated with

38. What is the knot of Henry – • How many compartments are in the foot? • Which tendon passes immediately deep to the sustentaculumtali –

39. From which nerve does baxter’s nerve originate?-     • Name the interval for the posterolateral approach to the ankle – • Which structures does the sural nerve runs with? and on which side of it

40.   Which two structures combine to form the sural nerve –  • How many cm above the tip of the distal fibula does the superficial Peroneal nerve pierce the fascia and become subcutaneous –

41. Spine • Smallest diameter pedicle overall: • Artery of Adamkiewicz, side and levels most commonly • Main motor pathway • Which facet is anterior (superior or inferior articulating)

42. Level of bifurcation of Iliac Vessels Level of bifurcation of Aorta • Between what and what does recurrent laryngeal lie? • 8. Occiput is thickest in what location? • 9. 3 fascial layers (in order) of smith robinson approach • 10. Cutoff for Jefferson Fracture • 11. Cutoff for PADI

43. Thigh/Knee • Q contents of Adductor/Hunter's Canal? • Q. CruciateAnastomosis? • Q. Number of facets of patella? • Q. What bands of ACL and PCL are tight in flexion?

44. Q. Where does the MPFL insert on the patella? • Q. In an isolated posterolateral corner injury the most accurate test is _____ and the major finding is _____

45. Shoulder/Elbow • 1Q. Interval posterior approach shoulder?1A.  Infraspinatus (suprascapular) / Teres Minor (Axillary • )2Q.  Contents quadrangular space?2A. Axillary nerve, posterior circumflex humeral artery • 3Q. 4 preclavicular branches of brachial plexus? • 3A.  Dorsal scapular, long thoracic, suprascapular, nerve to subclavius4Q. Innervation brachialis?4A. Dual- musculocutaneous, radial

46. InnervationTrapezius?. • Describe the rotator interval. • List 5 attachments to coracoid • What is the primary static restraint against anteroinferior dislocation of GH joint in 90 degrees abduction and external rotation? • What are the boundaries of the posterior triangle of the neck? • Injury to what nerve might cause medial scapular winging?