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63 Cards in this Set
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- Back
1-which shoulder dislocation has the MC incidence of neurovascular injury? |
1-MC nv injury=inferior dislocation of the glenohumeral joint aka Luxatio Erecta, Axillary nerve palsy, Axillary artery thrombosis
2-Luxatio Erecta |
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A 35-year-old male injured his right shoulder while playing basketball. He presents emergently with significant pain and his shoulder abducted at 140 degree. He is unable to lower his arm. Radiographs will most likely show that his glenohumeral joint has dislocated in what direction? |
This patient has suffered an inferior shoulder dislocation (luxatio erecta). This is a rare type of shoulder dislocation, representing only about 0.5% of all shoulder dislocations. Anterior and posterior dislocations are much more common but don't present with a shoulder fixed in abduction or flexion such as this case. Ans4
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A 26-year-old right hand dominant male is involved in a motor vehicle collision and sustains the left humerus injury demonstrated in Figure A. The brachial artery is disrupted and requires urgent attention in the operating room. The patient's preoperative nerve evaluation demonstrates that the patient is unable to initiate extensor carpi radialis longus, extensor carpi radialis brevis, extensor pollicis brevis, extensor indicis proprius, and extensor pollicis longus motor activity. What is the most likely etiology for this observed neurologic examination? |
MCC radial nerve palsy in a high energy open hum fx is laceration or complete disruption of the radial nerve (Neurotmesis). Neurotmesis is complete disruption of nerve and is assoc w/ no spontaneous recovery w/out intervention. Axonotmesis constitutes axon disruption, but the surrounding neural connective tissue is intact & nerve regeneration can occur(Wallerian or antegrade degeneration). Neurapraxias occur often by compression & axon maintains continuity but local demyelination and ischemia occur. All 6 patients with a transected radial nerve had an open humerus fracture also. The results of primary nerve repair in this circumstance found that there was no recovery in any of the pts. |
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A 45-year-old male sustains a Gustilo and Anderson Type II open transverse humeral shaft fracture. He undergoes the treatment shown in Figures A and B. What is the advantage of this treatment choice as compared to antegrade intramedullary nailing? |
Humeral shaft fractures treated with antegrade intramedullary nailing (IMN) have a higher risk of receiving an additional operation compared to those treated with plate fixation as seen in Figures A and B. Additionally, there is a higher incidence of shoulder impingement following IMN compared to plate fixation. There has been no difference found between the incidence of infection, elbow pain or radial nerve injury when comparing the two treatment options. Blood loss is not lower in an open case compared to nailing. Bhandari et al, found a significant relative risk reduction of 74% to reoperation with the use of plates and screws versus IMN. They also found a relative risk reduction of 90% in shoulder impingement with the use of plates and screws versus IMN. No significant difference was found between the two regarding rates of infection and/or radial nerve palsies. Ans3
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On average, the radial nerve travels from the posterior compartment of the arm and enters the anterior compartment at which of the following sites?
1. Spiral groove of the humerus 2. At the arcuate ligament of Osborne 3. 10 cm distal to the lateral acromion 4. 10 cm proximal to radiocapitellar joint 5. At the origin of the deep head of the triceps |
The radial nerve enters the anterior compartment through the intercompartmental fascia on average 10 cm proximal to the radiocapitellar joint. It has never been found to remain in the posterior compartment within 7.5cm of this joint, leading to this area being named the "safe zone". During the posterior approach to the humerus, the radial nerve is found in the spiral groove in the middle third of the posterior humerus, medial to the long and lateral heads and proximal to the deep head of the triceps. When performing an ORIF of a humerus fracture from a posterior approach it should be identified and protected.
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During an open reduction internal fixation of a humerus fracture using the posterior approach, a surgeon can identify the posterior antebrachial cutaneous nerve and trace it proximally to which of the following nerves? |
The posterior antebrachial cutaneous nerve (PABCN) branches from the radial nerve in the axilla.
The posterior antebrachial cutaneous nerve branches from the radial nerve just distal to the posterior brachial cutaneous nerve (PBCN) in the axilla and they course through the arm in closely to each other. In the proximal forearm, the posterior antebrachial cutaneous nerve is found on the lateral border of the brachioradialis muscle. The terminal branches innervate the posterior aspect of the forearm distally. Ans3 |
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A polytrauma patient sustains a right bicondylar tibial plateau fracture and a right humeral shaft fracture both treated with open reduction and internal fixation. He also underwent statically locked intramedullary nailing of a left femoral shaft fracture. What is the appropriate weightbearing status?
1. Non-weight bearing bilateral lower extremities and right upper extremity 2. Weight bearing as tolerated bilateral lower extremities and right upper extremity 3. Non-weight bearing left lower extremity and weight bearing as tolerated right upper and right lower extremities 4. Non-weight bearing right lower extremity and weight bearing as tolerated right upper and left lower extremities 5. Weight bearing as tolerated bilateral lower extremities and non-weight bearing right upper extremity |
The standard treatment for a bicondylar tibial plateau fractures is a period of post-operative non-weight bearing.
Tingstad et al found favorable results of immediate weightbearing on humeral shaft fractures treated with plating and full weightbearing did not have any effect on the union or malunion rates. Brumback et al evaluated the feasibility, safety and efficacy of immediate weightbearing after treatment of femoral shaft fractures with statically locked IM nail. All the patients went on to union and no loss of fixation occurred. Ans4 |
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A 25-year-old male involved in a motor vehicle accident sustains multiple injuries. He undergoes operative treatment for his humeral shaft fracture. Figures A and B show his preoperative and postoperative radiographs. The distal interlocks for this implant place which of the following nerves at risk?
1. Radial 2. Ulnar 3. Median 4. Axillary 5. Musculocutaneous |
With intramedullary (IM) nailing of the humerus, the distal anterior-to-posterior interlocking screws place the musculocutaneous nerve at high risk for injury as it goes through the coracobrachialis muscle and courses anteriorly along the brachialis (of which it innervates the medial half).
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Which of the following is a known risk factor for the development of adhesive capsulitis of the shoulder? |
Diabetic patients are at greater risk of adhesive capsulitis than the general population. The condition is often bilateral and resistant to all forms of treatment. It is more common in women, but there is no known association with menopause. Steroids are often used to treat this condition. Ans3
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Which of the following statements is true regarding the anatomical boundaries of the rotator interval in the shoulder?
1. Superior border is defined by the biceps long head tendon 2. Inferior border is defined by anterior band of inferior glenohumeral ligament 3. Contains the axillary pouch which is a common site for intra-articular loose bodies 4. Superior border is defined by anterior edge of suprapinatus tendon 5. Inferior border is defined by middle glenohumeral ligament |
The rotator interval is the area between the anterior edge of the supraspinatus tendon superiorly, and the superior edge of the subscapularis tendon inferiorly. The medial border is comprised of the coracoid process and the lateral border is formed by the transverse humeral ligament.
Incorrect answers: 1- Long head of biceps is located within the rotator interval. 2- Anterior inferior glenohumeral ligament is located inferior to the rotator interval. 3- Axillary pouch is located inferior to the rotator interval. 5- Inferior edge is defined by superior border of subscapularis tendon. Ans4 |
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A newborn child born via a difficult breech delivery is found to have a brachial plexus birth palsy. While initially born with a flail limb, the child regained elbow flexion at 10 weeks. At age 18 months (1.5 years old), which of the following deficits is most likely to be seen on physical exam?
1. Claw hand 2. Fixed adduction and internal rotation at shoulder with elbow extension 3. Hyperextension of the MCP joints and flexion of the IP joints of the hand 4. Weakness in elbow flexion 5. Normal physical exam without deficits |
At 18 months, a majority of children who have sustained an obstetric brachial plexus birth (OBPBP) injury will have a complete recovery without weakness or noticeable asymmetry. Fortunately, most newborns with OBPBP, and almost all children that have regained elbow flexion by 3 months, will have complete recovery by 18 months of age without intervention. Ans5
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A 3-month-old is brought to clinic for evaluation of a right upper extremity abnormaility present since birth. Which of the following physical exam findings is associated with the best functional outcome? |
The findings provided are all associated with neonatal brachial plexus palsy. The best prognosis is seen in patients with the classic 'Erb palsy' presentation consisting of absent shoulder abduction and external rotation. Bicep activity is associated with a more favorable prognosis.
Wrong Answers: Answer 1: Additional involvement of the wrist is associated with a worse prognosis, as is the rare 'Klumpke palsy' presenting with absent hand function seen in lower plexus lesions. Answer 3: A flail extremity can be seen with preganglionic lesions as well and portends poor outcomes. Answer 4: The additional involvement of the wrist motors is associated with a worse prognosis compared to those with shoulder involvement only Answer 5: Preganglionic lesions are associated with the worse prognosis and are suggested when Horners syndrome or loss of rhomboid function is seen. Ans2 |
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An infant is born with total brachial plexus palsy and Horner’s syndrome after a difficult vaginal delivery. What is the prognosis for spontaneous recovery of motor function in the involved arm by 3 months?
1. >90% 2. 75% 3. 50% 4. 25% 5. <10% |
Infants with total brachial plexus palsy (C5, C6, C7, C8, T1) with an associated Horner's syndrome have a very little (<10%) chance of ever recovering spontaneous motor function. A study by Al-Qattan et al found that 0 of 22 infants with Horner's and total plexus palsy recovered spontaneously. The presence of concurrent Horner's syndrome (ptosis, miosis, and anhidrosis on the ipsilateral side of the face) indicates injury to T1 root and the origin of the sympathetic branch that supplies the face. Ans5
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Which of the following muscles would be affected if a 6-month-old child sustains a birth-related brachial plexopathy affecting C5 nerve root?
1. Trapezius 2. Triceps 3. Biceps 4. Interossei 5. Flexor digitorum profundus |
The biceps and brachialis muscles are supplied by C5-6 and as such a brachial plexopathy affecting the C5 nerve root would affect the child's ability to perform elbow flexion and forearm supination. The deltoid is also supplied by C5 and palsy would lead to deficient shoulder abduction. Finally, extensor carpi radialis longus and brevis are supplied by C5-6 and palsy would result in weak wrist extension.
The trapezius is supplied by the spinal accessory nerve (cranial nerve XI) and palsy would lead to scapular winging. The interossei are supplied by T1, the triceps by C6-7, and the flexor digitorum profundus by C7-8.Ans3 |
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Congenital pseudoarthrosis of the clavicle almost always presents on:
1. the right side, middle 1/3 2. the right side, lateral 1/3 3. the left side, middle 1/3 4. the left side, lateral 1/3 5. both sides equally |
Congenital pseudarthrosis of the clavicle may be confused with a fracture but almost always involves the right middle 1/3 of the clavicle. Its cause is thought to be related to subclavian artery pulsations. It does not have associated fracture callus and is not painful at birth. Surgical repair should be considered for pain or sometimes cosmesis. Ans1
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the radial nerve courses along the spiral groove how many centimeters is it proximal to the lateral epicondyles and the medial upper condyle? |
14 cm proximal to lateral condyle and 20 cm proximal to the medial condyle |
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what kind of humerus fracture is most commonly associated with neuropraxia of the radial nerve |
HOLSTEIN LEWIS fracture which is a spiral fracture distal 3rd humeral shaft |
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what of the indications for open reduction internal fixation of the humerus fracture "dirty dozen" + traffic light |
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order the relative indications for IM nailing of a humeral shaft fracture |
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when placing the distal screw of an IM nail in the humerus what nerves at risk in what direction |
radial nerve is at risk from lateral to medial distal locking screw and musculocutaneous nerve is at risk from anterior posterior locking screw |
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"Try A Big Brazilian Chocolate PECAN A-Anconeus, B-Brachioradialis, B-Brachials Lateral 1/2, C-ext. Carpi radialis longus(ECRL), S-Supinator, D-ext.Digiti minimi, ext.(EDM) C-extensor Carpi ulnaris (ECU), A- Abductor poll. longus (APL), P-ext. Poll. Brevis (EPB), P- ext. Poll. longus (EPL), I- ext. Indicis proprius (EIP)
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A 23-year-old man presents with the injury seen in Figure A after a motor vehicle collision. He undergoes the treatment seen in Figure B. Which of the following statements is most accurate when comparing his treatment with open reduction and internal fixation? 1. Higher rates of radial nerve injury 2. Higher total complication rate 3. Lower rates of nonunion 4. Lower rates of shoulder impingement 5. Lower rates of malunion |
Antegrade intramedullary (IM) nailing of humeral shaft fractures has been found to be associated with increased complication rates when compared with open reduction and internal fixation (ORIF). ans2 |
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Figure A is a radiograph of an 80-year-old woman who sustained a closed injury to her left arm 10 months ago. She presents to office today complaining of persistent pain in her arm. What is the most likely metabolic or endocrine abnormality contributing to this patients presentation? 1. Vitamin D deficiency 2. Central hypogonadism 3. Thyroid disorder 4. Parathyroid hormone disorder 5. Calcium deficiency |
oligotrophic nonunion of a proximal third humeral shaft fracture. The most likely underlying metabolic or endocrine abnormality with this presentation is vitamin D deficiency. Predisposing factors include: mechanical instability, poor bone-to-bone contact, infection and biological/biochemical factors. A variety of other contributing factors, such as cigarette smoking and malnutrition, have also been described. Correctable metabolic or endocrine abnormalities are common in elderly patients and are considered contributory in the etiology of fracture non-union. Correction of these abnormalities should be considered prior to surgical fixation. The most common newly diagnosed abnormality was vitamin D deficiencyans1 |
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A 26-year-old right hand dominant male is involved in a motor vehicle collision and sustains the left humerus injury demonstrated in Figure A. The brachial artery is disrupted and requires urgent attention in the operating room. The patient's preoperative nerve evaluation demonstrates that the patient is unable to initiate extensor carpi radialis longus, extensor carpi radialis brevis, extensor pollicis brevis, extensor digitorum, extensor indicis proprius, and extensor pollicis longus motor activity. What is the most likely etiology for this observed neurologic examination? Review Topic FIGURES: 1. Neurapraxia of the median nerve 2. Axonotmesis of the radial nerve 3. Neurotmesis of the ulnar nerve 4. Neurotmesis of the radial nerve 5. Axonotmesis of the ulnar nerve |
Neurotmesis means"to cut" the entire Nerve. NErVE NOT together, everthing is cut both the nerve and the nerve sheath are cut Axonotmesis means"to cut" nerve cell axon-ONLY with Wallerian degeneration occurring below and slightly proximal to the site of injury BUT the endoneurium, perineurium & epineurium remain intact ( use an AXE to cut the noddle inside the straw empty tube) Neurapraxia apraxia, meaning “impairment of the ability to "s a temporary loss of motor and sensory function due to blockage of nerve conduction, usually lasting an average of six to eight weeks before full recovery. temporary damage to the myelin sheath but leaves the nerve intact and is an impermanent condition; thus, Wallerian degeneration does not occur in neurapraxia, very common in professional athletes, specifically American football players. The most likely cause of the radial nerve palsy in a high energy open humerus fracture is laceration or complete disruption of the radial nerve (Neurotmesis).ans4 |
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A 45-year-old male sustains a Gustilo and Anderson Type II open transverse humeral shaft fracture. He undergoes the treatment shown in Figures A and B. What is the advantage of this treatment choice as compared to antegrade intramedullary nailing? 1. Decreased risk of post-operative elbow pain 2. Decreased risk of radial nerve injury 3. Decreased risk of reoperation 4. Decreased risk of infection 5. Decreased risk of blood loss |
Humeral shaft fractures treated with antegrade intramedullary nailing (IMN) have a higher risk of receiving an additional operation compared to those treated with plate fixation as seen in Figures A and B. Additionally, there is a higher incidence of shoulder impingement following IMN compared to plate fixation. There has been no difference found between the incidence of infection, elbow pain or radial nerve injury when comparing the two treatment options. Blood loss is not lower in an open case compared to nailing. ans3 |
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All of the following are considered contraindications to the use of functional bracing of a humeral shaft fracture EXCEPT: 1. Mid-diaphyseal segmental fracture with ipsilateral pilon fracture 2. Mid-diaphyseal fracture with radial nerve palsy from nonballistic penetrating injury 3. Proximal one-third oblique fracture 4. Mid-diaphyseal closed fracture with a radial nerve palsy on presentation 5. Mid-diaphyseal fracture with a L1 burst fracture and paraplegia on presentation
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A closed mid-diaphyseal humerus fracture with a radial nerve palsy on presentation is not a contraindication to functional brace management. "seems reasonable, however, to consider surgical intervention (radial nerve exploration) between 4 and 6 months based on the patient’s clinical course." ans4 |
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_ligaments and attached to the clavicle which of the 2 is most medial and is the strongest and which is the lateral ointment the most strongest |
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absolute and relative indications for ORIF of the clavicle |
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A 22-year-old male sustains the injury shown in Figures A and B as the result of a fall from a ladder. Which of the following has been shown to be true regarding operative versus nonoperative treatment of this injury? 1. Decreased chance of nonunion with nonoperative treatment 2. Improved Constant and DASH scores with operative treatment at all time points 3. Increased symptomatic malunion rate with operative treatment 4. No change in shoulder abduction strength at union 5. Increased time to union with operative treatment |
Surgical management of displaced, shortened clavicle fractures is associated with a decreased rate of nonunion and malunion, while improving shoulder strength and function at follow-up. Most recommendations for surgical treatment include shortening of greater than 2 centimeters.Incorrect Answers: |
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Which of the following factors is associated with the highest rate of nonunion of a midshaft clavicle fracture? 1. younger patients 2. female gender 3. simple fracture pattern 4. sling immobilization 5. early range-of-motion |
The risk of nonunion in patients sustaining middle 1/3 clavicle fractures is increased in female patients. ans2 |
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A 7-month-old girl cries when the mother touches her swollen elbow. A radiograph is shown in Figure A. What is the most appropriate treatment? 1. Open reduction and internal fixation 2. Closed reduction and percutaneous pinning 3. Closed reduction and casting 4. Functional bracing 5. Closed reduction and hinged external fixation |
distal humeral physeal separation and is most appropriately treated with closed reduction and percutaneous pinning. Interpretation of this radiograph is difficult because the distal aspect of the humerus is cartilaginous and is not visible on x-ray, and at this age none of the secondary ossification centers have yet developed. ans2 |
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most common location for congenital pseudoarthrosis of the clavicle RIGHT or LEFT with the surgical treatment |
RIGHT-Middle one third when his pain and functional impairment for prosthesis than the treatment is ORIF with iliac crest bone grafting a 3–6 years |
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most commonly associated condition with pseudoarthrosis of the clavicle |
leading of the scapula |
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what is the treatment for total plexus palsy with a flail arm in 1 month or syndrome at one month or N0 at 3 months |
microsurgery nerve repair or nerve grafting or nerve transfer |
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A newborn child born via a difficult breech delivery is found to have a brachial plexus birth palsy. While initially born with a flail limb, the child regained elbow flexion at 10 weeks. At age 18 months (1.5 years old), which of the following deficits is most likely to be seen on physical exam? 1. Claw hand 2. Fixed adduction and internal rotation at shoulder with elbow extension 3. Hyperextension of the MCP joints and flexion of the IP joints of the hand 4. Weakness in elbow flexion 5. Normal physical exam without deficits |
At 18 months, a majority of children who have sustained an obstetric brachial plexus birth (OBPBP) injury will have a complete recovery without weakness or noticeable asymmetry. ans5 |
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what 4 conditions commonly cause glenohumeral arthritis in the shoulder |
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which form of osteoarthritis has a low association of rotator cuff tears |
primary arthritis only 5-10% compared to secondary arthritis who had an overtightening of the anterior capsule do a reconstruction of the shoulder |
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was the most common condition associated with intra-articular local anesthetic infusion pump after shoulder surgery |
chondrolysisc |
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when evaluating the images of the shoulder with glenohumeral arthritis what a pathologic findings on
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the patient presents with primary osteoarthritis the shoulder what is the incidence of rotator cuff tear along with the osteoarthritis |
it is rare to have rotator cuff tear and primary arthritis and shoulder <10% |
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patient presents with a frozen shoulder what are the central lesions associated with this diagnosis 2 |
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if the patient presents with a frozen shoulder what other associated conditions may predispose the patient is diagnosis-5 |
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if the patient presents to the office with adhesive capsulitis what is a normal amount of time for gradual return of the motion to occur |
approximately 26 months or 2 years |
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patient presents to the office with frozen shoulder what physical exam finding are most suggestive of this diagnosis |
decreased range of motion especially external rotation with loss of motion in all 7 planes |
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when treating frozen shoulder arthroscopically what 3 areas in the shoulder need to be addressed surgically to specific improved which directions of range of motion |
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A 31-year-old professional bodybuilder reports right shoulder pain with cross-body adduction as well as point tenderness at the acromioclavicular joint. Based on the radiograph shown in Figure A, which treatment is likely to provide the most successful result? 1. glenohumeral joint injection 2. periscapular muscle strengthening 3. labral repair 4. arthroscopic resection of the distal clavicle 5. capsular release |
Osteolysis of the distal clavicle is one cause of shoulder pain that can occur after acute injury or repetitive microtrauma. It is more common in weight-lifters. Open resection of the distal clavicle has been shown to be a reliable treatment for isolated painful acromioclavicular (AC) joint pathology refractory to nonoperative treatment. Arthroscopic resection of the distal clavicle has been reported to provide pain relief and allow a return to function comparable to open techniques. The arthroscopic approach offers the advantages of decreased morbidity, with fewer postoperative restrictions on motion, earlier return to normal activity, faster return to sport in a series of 10 weightlifters treated with a more limited arthroscopic resection than is usually advocated. improved cosmesis. |
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A 25-year-old male presents complaining of a groin mass which he noticed after a football injury. He states he was struck in the groin with an opposing player's helmet during a tackle and had a large amount of bruising and pain. While his pain and bruising subsided, he states he noticed this groin mass soon there after and that it hasn't grown and is non-tender. He is otherwise healthy. Inlet pelvis radiograph and T2 MRI with gadolinium scan are shown in Figures A and B. What is the most likely diagnosis? 1. Ossifying lipoma 2. Synovial sarcoma 3. Myositis ossificans 4. Periosteal chondrosarcoma 5. Inguinal hernia
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myositis ossificans. This benign condition is common after trauma, burns, or surgery secondary to a circulating factor which activates mesenchymal stem cells residing within muscle to form extra-osseous bone. Treatment is conservative in nature and if required, it is recommended treatment be delayed until complete ossification. ans3 |
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A 6-week-old female infant presents with the neck deformity and palpable mass shown in Figure A. She has had persistent lateral tilting of her head to the right since birth, and rotation of the neck is restricted. In this age group, what is the most common cause of this rotational abnormality? 1. Congenital muscular torticollis 2. Klippel-Feil syndrome 3. Arnold-Chiari malformation 4. Atlantoaxial rotatory displacement 5. Paroxysmal torticollis of infancy |
Congenital muscular torticollis (CMT) is the most common cause of torticollis in infancy. Neurologic disorders and osseous abnormalities, such as Klippel-Feil, are less common. Ultrasonography is considered the modality of choice for differentiating (CMT) from other more serious pathologies in the neck when a palpable mass is present. The initial treatment of of CMT is conservative, and good outcomes can be expected in the majority of these cases. Tang et al used US to examine affected sternocleidomastoid muscles in patients with CMT classified as having one of four types of fibrosis.ans1 |