162/189 A & B Daily Mastery Training Program (4/4 A & B 4/5)

Front 1

1 define deep gluteal syndrome
2-describe the pathoanatomy of entrapment of the sciatic nerve by the: piriformis M, obturator internus/gemellus M?
3-common anomalies compression sciatic nerve? (4)
4-MC condition causing piriformis syndrome? MC anatomical pattern of the sciatic nerve as it exits the pelvis?
5-coarse of travel of the sciatic nerve?
6-name the muscles ER hip and innervation? mn
7-what is the FAIR test? purpose,

Back 1

1-aka piriformis mus syndrome, A condition characterized by sciatic sx (leg pain) due to extrapelvic sciatic nerve compression at the hip
2-sciatic N is ANTERIOR-> piriformis M
sciatic N is POSTERIOR->obturator internus/Sup & inf gemellus M
3-bipartite pirformis, variations of sciatic N path, tumors, aneurysm of inf. gluteal A
4-femoracetabular impingement
-MC A pattern-> single nerve, ant-> single N antr-> pirif M
5-inf ->piriformis, sup -> gamellus superior
6-Play Gridiron, Or Get On Quaaludes
P-Piriforms-piriformis n
G-Gemellus Sup->N to sup gem from sacral plexus
O-Obtrator Internus->N to Obt intern from sacral plexus
G-Gemellis Inf-.Nerve to the quadratus femoris
O-Obturator Inf->Posterior division of obturator nerve inner most of the add magnus;
Q-Quadratus femoris-Quadratus femoris branch of nerve to the quadratus femoris and inferior gemellus (L5, S1) (L5, S1)
7-Flx, Add, Int Rot =hip produces sx of piriformis syndrome by putting the piriformis mus in stretch

Front 2

Adult c/o pain in the posterior gluteal region and migrating down the back of the leg burning pain, aching in nature PE=hip exam Flexion, Adduction, and Internal Rotation of hip reproduce sx.
1-KIF -->Dx
2-indications Tx
2.1first line of treatment
2.2-only indicated in refractory cases after failed conservative measures
3.Structures passing through greater sciatic foramen below pyriformis muscle:

Back 2

1-MRI r/o compression of sciatic N, dx piriformis syndr.
2.1-1st ine ts=rest, NSAIDS, muscle relaxants, PT, steroid injections
2.2-surgery-piriformis muscle release and external sciatic neurolysis
3-PIN & PINS "
Posterior cutaneous nerve of thigh
Inferior gluteal vessels and nerves
Nerve to quadratus femoris

Pudendal nerve
Internal pudendal vessels
Nerve to obturator internus
Sciatic nerve

Front 3

Which of the following is the most common anatomical pattern of the sciatic nerve as it exits the pelvis?
1. As a single nerve, anterior to the piriformis muscle
2. As a single nerve, posterior to the piriformis muscle
3. As two branches, both anterior to piriformis muscle
4. As two branches, one anterior to piriformis and one through the piriformis muscle
5. As two branches, both posterior to the piriformis muscle

Back 3

The most common anatomical pattern is a single sciatic nerve which passes anterior to the piriformis muscle, however it is important to note that there are other common anatomical variants.

Pokorny et al in a study of 91 cadavers found atypical anatomy of the sciatic nerve in almost 21% of cases. The normal anatomy seen in 79% is a single sciatic nerve exiting underneath (passing anterior) to the piriformis. The most common variant, seen in 14%, is the sciatic nerve splitting proximal to the piriformis with one branch passing anterior to and one branch passing through the piriformis.

Front 4

1- what does quadriceps active test for? describe test?
2-MoI for PCL inj non contact (2) & contact? aka
3-PCL is the primary restraint to __? isolated injuries to PCL cause the greatest instability at ___?
4-chronic PCL deficiency lead to__? PCL is > or< the ACL
5-PCL has 2 bundles which is tight in flex & which in ext mn; gold standard in diagnosing and quantifying PCL injuries
6-blood supple PCL, most important for ___stability at___; PCL lies between the meniscofemoral lig name these ligaments there location.mn
7 define grade 2 PCL injury & G1 G3
7.1-varus/valgus stress laxity at 0° indicates
7.2 varus/valgus stress laxity at 30°
7.3 posterior sag sign
7.4 posterior drawer test
7.5 dial test
7.6 quadriceps active test

Back 4

1-PCL tear (+) if ant redcn tib occurs relative to the fem
-attempt to extend a knee flex@ 90° to elicit quadriceps contraction
2-noncontact hyperflex w/ PF'd foot & hyperextnsn injury; contact=direct blow to prox tibia w/flex knee (aka=dashboard injury)
3-PCL is the 1^ restraint to post tibial transn; 90° of flex
4- incr contact press in the PFJ & med compart knee 2^ varus align; PCL=30% larger>ACL
5-PAL=AL tight in flex; PM=ext tight; later stress
6-middl geniculate A, most imprtnt->post stability @ 90°flex; (anterior) lig of Humphrey (posterior)->lig of Wrisberg: letter H Ahead letter W in alphabe
7-G2= complete w/6-10 mm post tibial trans ant tibia= flush w/ femo condyles
G1=part tear< 5mm post tibial trnsltn, tibia ant to fem condyles G3=combo PCL & capsuloliga/ACL >10 post tib transl
7.1-0=MCL/LCL & PCL inj
7.2-30=MCL/LCL inj
7.3-PCL post shift
7.4 isol PCL inj translt >10-12 IR 8 vs combo >15 IR>10
7.5 > 10° ER @ 30°= only PLC
@ 30° & 90°= PCL + PLC
7.6 #1

Front 5

Which of the following should be avoided in early rehabilitation following posterior cruciate ligament (PCL) reconstruction?
1. Quadcriceps muscle activation
2. Closed chain active terminal extension exercises
3. Prone passive flexion with active terminal extension
4. Prone hamstring curls
5. Active maximal ankle dosiflexion

Back 5

Resisted hamstring strengthening exercises (ex. hamstring curls) avoided in the early phase of rehab following PCL recon -bec/ hamstrings create a pos pull on the tibia which incr stress on the graft.
posterior shear forces exist during the flexion portion of isokinetic exercise and during extension exercises at knee joint angles >40 deg. The maximum posterior shear force was 1.7 body weight.
Incorrect :
1. & 2. Progressively obtaining a full range of motion is an initial goal of rehabilitation. Quadriceps muscles help to obtain extension and near terminal extension actually decrease force on the graft. Non-weight-bearing resisted knee extension (60° to 0°) is an acceptable exercise in the initial stages following PCL reconstruction.
3. Prone positioning allows the weight of the leg to help maintain an anterior force on the tibia, while passive flexion minimizes hamstring pull.
5. Active ankle exercises such as ankle pumps are encouraged. Ans4

Front 6

Which of the following rehabilitation principles is true regarding non-operative treatment of a grade II PCL tear?
1. Quadriceps strengthening and prone range of motion should begin as tolerated
2. Hamstring strengthening and supine range of motion should begin as tolerated
3. Resisted quadriceps and hamstring strengthening, no early range of motion
4. No strengthening for 6 weeks
5. No range of motion for 6 weeks

Back 6

Initial treatment for PCL tears is non-operative. Range of motion is typically initiated early. Flexion may be done in a prone position to limit posterior sag. While quadriceps strengthening is essential, resisted hamstring exercises are generally avoided initially because they pull the tibia in a relatively posterior position.
Ans1

Front 7

A 35-year-old construction worker presents with medial-sided knee pain. He has no instability complaints but at age 18, he sustained a Grade 1 PCL injury that was treated non-operatively. A radiograph is shown in Figure A. What surgical treatment is the best option given his age and occupation?
1. PCL reconstruction
2. Unicompartmental knee replacement
3. Total knee replacement
4. Lateral closing wedge osteotomy of the proximal tibia
5. Medial opening wedge osteotomy of the proximal tibia

Back 7

The radiographs show a knee with significant medial compartment narrowing. A frequently tested fact is that wear associated with chronic PCL instability occurs most commonly in the patellofemoral joint and the medial compartment of the knee. A young laborer is not an ideal candidate for arthroplasty because of early wear and loosening concerns. In addition, cruciate ligaments are required for the insertion of a unicompartmental knee replacement. Isolated PCL reconstruction would not be recommended as he already has arthritis and cruciate reconstruction in a mal-aligned knee is at increased risk of failure. Either valgus producing osteotomy is reasonable, but the opening wedge tends to increase posterior tibial slope which is helpful in PCL-deficient knees. ANs5

Front 8

Figure A is an arthroscopic image of a left knee as viewed from an anterolateral viewing portal demonstrating the attachment footprint of a damaged structure. Strengthening of what muscle group most effectively counteracts the deficit that results from the damaged structure?
1. Hip flexors
2. Hip abductors
3. Gastroc-soleus
4. Quadriceps
5. Hamstrings

Back 8

The primary function of the PCL complex is to restrict posterior tibial translation. After acute PCL rupture or PCL reconstruction, resisted hamstring strengthening is avoided as it pulls the tibia posteriorly. Therefore, therapy should focus on quadriceps strengthening which pulls the tibia anteriorly. ANs4

Front 9

adult s/p mva with injury of knee on the dash board, c/o posterior knee pain Pe=quadriceps active test & posterior drawer test translate >10-12 mm in neutral rotation.
1-KIF(key image finding) -->Dx
1.2 PEF-> classification
2-indications-> Tx;
2.1 protected weight bearing & rehab? Dx? RTP
2.2 relative immobilization in extension for 4 wks
2.3 PCL repair of bony avulsion fractures or reconstruction?
2.4 postop protocol
2.5 chronic PCL deficiency
3-Complication

Back 9

1-lateral stress view, apply stress to anterior tibia with the knee flexed to 70°. AP/Lat-r/o avulsion fractures with acute injuries, assess for posterior tibiofemoral subluxation MRI-confirmatory study for the dx PCL injury
1.2-G2-complete PCL w/6-10 translation G3=PCL + ligaments w >10 G1=partial tear
2.1-PCL injry=isolated Grade I (partial) and II (complete isolated) RTP=2-4 wks
2.2-isol G3
2.3-PCL + ACL or PLC ;PCL + G3 MCL/LCL;
isolated G2/3 w/ bony avulsion; isolated chronic PCL w/ a functionally unstable knee; isolated G3 or surgery w/ young athlete/bony avulsions
2.4-immobilize in extension early & protect against gravity; early ROM should be in prone position
follow with quadriceps rehab
2.5 high tibial osteotomy-medial opening wedge osteotomy to treat both varus malalignment and PCL deficiency & high tibial osteotomy in a PCL deficient knee, increasing the tibial slope helps reduce the posterior sag of the tibia
3-Popliteal artery injury & PF pain

Front 10

1-which carpal bone is the origin of abductor digiti minimi, and located with ____tendon
2 associated w/ 50% of pisiform fx?
3- which bone acts as a fulcrum for forces transmitted from the forearm to the hand?
4-contributes to the stability of the ulnar column by preventing triquetral subluxation?
5-best view to see pisiform fracture? (2)

Back 10

1-pisiform is a sesamoid bone located within the FCU
2-distal radius, hamate, or triquetral fractures
3-pisiform
4-pisiform
5-lat w/30 deg of wrist supination OR utilizing the carpal tunnel view

Front 11

A 28-year-old man fell while ice skating 6 months ago and has had ulnar-sided wrist pain ever since. The patient's lateral radiograph of the wrist is shown in Figure A and a CT scan is shown in Figure B. What is the most appropriate treatment?
1. Scapholunate ligament repair
2. Excision of the hook hamate
3. Excision of the pisiform
4. Open reduction internal fixation of the hamate
5. Open reduction internal fixation of the pisiform

Back 11

1-Based on clinical history and imaging shown, this patient has developed a pisiform fracture nonunion. Treatment of symptomatic nonunions of the pisiform is by pisiformectomy.
Incorrect Answers
Answer 1: The scapholunate ligament is not affected in this clinical situation.
Answers 2, 4: Although the hook of hamate can be a source of ulnar sided pain, it is not implicated in this clinical situation
Answer 5: An ORIF of the pisiform is not typically used for symptomatic pisiform fracture nonunions.Ans3

Front 12

adult s/p fall on outstretched hand c/o ulnar sided wrist pain PE point tenderness ulnar wrist CT done.
1-KIF(key image finding) -->Dx & classification
2-Tx indications:
2.1-SAC w/ 30 deg wrist flexion & ulnar deviation for 6 weeks
2.2-painful nonunion

Back 12

1- lateral view with 30 deg of wrist supination or utilizing the carpal tunnel view->pisotriquetral joint
CT
2.1 first line of tx
2.2-pisiformectomy is a reliable way to relieve this pain and does not impair wrist function

Front 13

1-subluxation of the peroneal tendons leads to longitudinal tears over time which usually involves ___at fibular groove ? best test to reproduce sx c/o popping posterior to lat. malleolus?
2- MC type/direction tear seen w/ Peroneal tendon injury ?
3-MoI of peroneal tendon injury? what structure is injured?
4-nerve innervation of peroneal tendons?
5-function of Per. brevis & longus, location of P brevis to P longus at the level of later. malleolus
6-antagonist of P. brev & long?
7 best view to see Per tendon on xray, R/o

Back 13

1-peroneus brevis; resisted enersion?
2-longitudinal not transverse
3-rapid DF of inverted foot? inj=sup peroneal retinaculum
4-superficial peroneal nerve, S1
5-P brevis=1^ evertor of the foot; P longus=1^ PF foot & 1st MT. PB anterior & med to PL
6-Post tibialis
7 IR view r/o cortical avulsion off the distal tip of the lateral malleolus (rim fracture)

Front 14

What is the most appropriate management of the injury shown in Fig A & B?
1. Achilles tendon repair
2. Repair of superior peroneal retinaculum and deepening of the fibular groove
3. Posterior tibial tendon reconstruction with flexor hallucs longus transfer
4. Peroneus longus repair
5. Peroneus brevis repair

Back 14

The images demonstrate a peroneus longus tear and the most appropriate treatment is peroneus longus repair of the options provided. Peroneus longus tears occur less frequently than peroneus brevis tears and are related to direct trauma or sports injuries. The peroneus brevis sits anterior to the peroneus longus. Hypertrophy of the peroneal tubercle is commonly thought to be a contributing factor to peroneus longus tenosynovitis, tears, and rupture.
Incorrect Answers:
Answer 1,3,&5: The achilles,posterior tibial tendons, and peroneus brevis tendons are not ruptures.
Answer 2: The peroneus longus tendon is ruptured. If the tendon was intact and dislocated then repair of the superior peroneal retinaculum and deepening of the fibular groove would be appropriate.Ans4

Front 15

A 17-year-old tennis player sustained an ankle sprain 4 weeks ago and now complains of painful popping posterior to the lateral malleolus. What physical exam will reproduce his symptoms?
1. External rotation stress test
2. Resisted inversion
3. Resisted dorsiflexion
4. Resisted eversion
5. Resisted plantar flexion

Back 15

The peroneal tendons are located posterior to the lateral malleolus and are a common source of pathlogy in refractory ankle sprains. This patient is complaining of subluxating peroneal tendon(s) as a result of a torn superior retinaculum. This can be tested with resisted eversion as the peroneal tendons evert the ankle. Maffulli et al concluded that an anatomic repair of the retinaculum leads to good results in higher demand patients. Ans4

Front 16

young, active patients c/o felt a pop with a dorsiflexion ankle injury c/o clicking, popping and feelings of instability or pain on the lateral aspect of the ankle PE=swelling posterior to the lateral malleolus, 'pseudotumor' over the lateral ankle, voluntary subluxation of the tendons +/- a popping sound
1-KIF(key image finding) -->Dx
1.1 provocative test (2)
2-(indications->) Tx & rehab
2.1 all acute injuries in nonprofessional athletes
2.2 acute tendon dislocations in serious athletes who desire a quick return to a sport or active lifestyle
2.3 chronic/recurrent dislocation
2.4 presence of a longitudinal tears

Back 16

1-MRI anatomic anomalies leading to pathology
peroneus quartus muscle, low-lying peroneus brevis muscle belly->peroneal tendon injry
xrayIR view r/o cortical avulsion off the distal tip of the lateral malleolus (rim fracture) & needed to evaluate for varus hindfoot
1.1-apprehension=sensation of apprehension or subluxation with active DF & eversion against resistance cause subluxation/dislocation
compression test=pain with passive DF & eversion of the ankle
2.1-SLC PWB x 6 wks
2.2-acute repair of superior peroneal retinaculum and deepening of the fibular groove
2.3-groove-deepening with soft tissue transfer and/or osteotomy
2.4acute repair of superior peroneal retinaculum and deepening of the fibular groove

Front 17

0-what's the difference bt/ moore/Southern and Kocher-Langenbeck
1-(5)objective of exposure and surgical approach
1.1-(9)Indications Kocher-Langenbeck approach to hip***
1.2-internervous plane of poster approach to acetabul/hip? what nerve innervates ____which muscle & when does dissections stop in the Glut maximus?
1.3 what is the Vascular plane of poster approach to acetabul/hip? how to tell you are there anatomically?

Back 17

0-Kocher-Langenbeck ->acetablm is more extensile & posterior to greater troch vs moore/Southern is THA
1-post wall of acetablm, (2)lateral aspect of the post column of acetablm(3)indirect access to true pelvis (4)anterior aspect of post column through palpation(5)prox fem
1.1(5 hip + 4 acetabulum)
5 hip=post/moore/southern hip-THA, hemi, drainage of septic hip, pedicle BG, removal of loose body
4 acetblm=post acet/kocher-langenbeck=post wall, post colmn, post wall + poster colmn, ***simple Transverse<15 days, fx line located @ or below acetabular roof
1.2-no internervous plane, glut max innerv by inferior gluteal nerve
-nerve branches of upper 1/3 of muscle cross intended interval of dissection halfway between level of greater trochanter and PSIS
STOP muscle split is stopped when first nerve branch to upper part of muscle is encountered
1.3 vascular plane = sup gluteal Art-> upper 1/3 glut maximus & inf gluteal Art->lowr 2/3 glut max
-line of fat on surface marks interval

Front 18

1-what nerve innervates glut maximus?
1.1 how to prevent stretching of sciatic nerve?
1.2 which muscle___ will provide a landmark leading to the greater sciatic notch
1.3 contents of the greater sciatic notch BELOW pyriformis muscle include: ***mn not the __which is above
1.4 what ligament form greater sciatic notch?
2-description of skin incision from A-B & length/orientation?
2.1 befit of mini incision

Back 18

1-inferior gluteal nerve->glut max
1.1-sciatic nerve->ext hip & flex the knee
1.2-piriformis will provide a landmark leading to the greater sciatic notch
1.3***PIN-OI & PINS:-P-Posterior cutaneous nerve of thigh;I-Inferior gluteal Art& N; N-Nerve to quadratus femoris:::
P-Pudendal N;I-Internal pudendal Art(not nerve); N-Nerve to obturator internus
S-Sciatic nerve NOT the sup glut N & A which is above
1.4-sacrotuberous ligament which runs between the sacrum and the ischial tuberosity and the sacrospinous ligament which runs between the sacrum and the ischial spine.
2- A-start just below iliac crest, lateral to PSIS
extend ->
B-10 cm below tip of greater trochanter
-longitudinal incision centered over greater trochanter
2.1-mini-incision approach shows no longterm benefits to hip function

Front 19

3-superficial dissection to acet(KLB)/hip(M/S) (7 steps)

Back 19

3(1) "incise" through subcutaneous fat(2)incise fascia lata in lower half of incision(3)split gluteus maximus muscle along avascular plane(4)release portion of gluteal sling to aide in anterior retraction of muscle belly(5)detach short external rotators after tagging(6)the obturator internus should be tagged 1.5 cm from the greater trochanter and blunt dissection should be used to follow its origin to the lesser sciatic notch &posterior retraction will protect the sciatic nerve
(7)clear abductors and soft tissue to visualize posterior capsule and posterior wall region

Front 20

4-how to enlarge view with deep dissection
4.1technique to address difficult acetabular reconstructions may require wide exposure ___?
4.2deep dissection

Back 20

4-release of sacrospinous ligament
4.1- trochanteric osteotomy
4.2-no further dissection is needed in setting of isolated posterior wall fracture
(2)palpable exposure of quadrilateral plate to assess reduction of posterior column accomplished by elevation of obturator internus elevation
(3)perform marginal capsulotomy
capsular attachments to posterior wall fragments need to be kept intact to prevent devascularization

Front 21

5-(7)structures at risk, how to protect___ & PREVENT by___? mn-*P,*F
6-cross sectional anatomy
7-ischial spine and is the site of attachment of the ___ ligament

Back 21

5-PIMS SFO
*P-(1)1st Perfrtng branch of profunda femoris A
at risk prevnt-> release of glut max insertion
I-(2)Infr gluteal Art->leaves below piriformis prevnt->if cut and retracts, flip patient, open abdomen->tie off internal iliac A
M-(3)Muscle-Quadratus fem=prevtn excessive retraction->M-Med Circ Art
S-(4)Sciatic N->initially located along post surface quadratus fem M:::prevtn=ext hip & flex knee to prvnt inj
S-(5)Sup gluteal A & N-leaves the pelvis above piriformis & enters deep surface of the gluteus medius.prevnt->excess bleedg
*F-(6)Fem vessels @ risk w/ failure to protect ant aspect of acetblm: prevtn->placement of retractors ant to iliopsoas
O-(7) Ossification,heterotopic (HO)debride necrotic glut MINIMUS
5.1M-Muscle-Quadratus fem::prevtn excessive retraction->M-Med Circ Art
S-Sciatic N::prevtn->ext hip & flex knee
F-(6)Fem Art::prevtn->placement of retractors ant to iliopsoas
O-(7) Ossification,heter (HO) prevt->debride necrotic glut MINIMUS
7-sacrospinous

Front 22

Figure A is a cadaver specimen where a posterior approach to the hip has been performed after removal of part of the Gluteus maximus muscle. Which of the following choices correctly identifies structures A, B, and C in Figure A?
1. A: Gluteus minimus, B: Piriformis tendon, C: Sacrospinous ligament
2. A: Piriformis tendon, B: Superior gemellus tendon, C: Sacrospinous ligament
3. A: Gluteus minimus, B: Piriformis tendon, C: Sacrotuberous ligament
4. A: Piriformis tendon, B: Quadratus femorus tendon, C: Sacrotuberous ligament
5. A: Gluteus minimus, B: Superior gemellus tendon, C: Sacrotuberous ligament

Back 22

In Figure A, the arrow labeled A is pointing to the Gluteus minimus muscle, B is pointing to the tendon of the piriformis muscle, and C is pointing to the sacrotuberous ligament (Illustration A). These are all important landmarks and points of identification during a posterior approach to the hip. Ans3

Front 23

Which of the following structures does NOT exit the pelvis proximal to the anatomic landmark identified in Figure A
1. Sciatic nerve
2. Superior gluteal artery
3. Piriformis tendon
4. Inferior gluteal artery
5. Obturator internus

Back 23

The arrow points to the ischial spine and is the site of attachment of the sacrospinous ligament which anatomically divides the greater and lesser sciatic notches.

The contents of the greater sciatic notch include the piriformis, the superior and inferior gluteal vessels and nerves, the sciatic and posterior femoral cutaneous nerves, the internal pudendal vessels, and the nerves to the obturator internus and quadratus femoris.

The lesser sciatic notch is home to the tendon of the obturator internus, the nerve which supplies that muscle, and the internal pudendal vessels and nerve that course back through the lesser notch after having exited the greater notch.
Ans5

Front 24

All of the following structures pass below the piriformis through the greater sciatic foramen EXCEPT:
1. pudendal nerve
2. sciatic nerve
3. inferior gluteal nerve
4. obturator nerve
5. inferior gluteal artery

Back 24

pudendal N, sciatic N, inferior gluteal N inferior gluteal A all exit the sciatic foramen. The obturator nerve does not exit the sciatic foramen. The greater sciatic foramen is bounded as follows: anterolaterally by the greater sciatic notch of the illium, posteromedially by the sacrotuberous ligament, inferiorly by the sacrospinous ligament and ischial spine, and superiorly by the anterior sacroiliac ligament. It is partially filled up by the piriformis which leaves the pelvis through it. exit from the pelvis through the greater sciatic foramen above the piriformis: superior gluteal vessels and superior gluteal nerve.
Below the piriformis the following structures exit: inferior gluteal A, inferior gluteal N, internal pudendal A, pudendal N, sciatic N, posterior femoral cutaneous N, N ->OI-obturator internus, N ->quadratus femoris. PINS PIN. obturator N originates-> L2, L3, and L4.exits the pelvis through the obturator foramen, inner gracilis, add (L,B,M) & sensatn IM thigh.ans4

Front 25

Where is the origin of the muscle located between the anterior acetabulum and iliac vessels?
1. Anterior superior iliac spine
2. Obturator foramen
3. Anterior inferior iliac spine
4. Pubic tubercle
5. Lumbar transverse processes

Back 25

The psoas muscle serves to protect the iliac vessels from retractors/instruments anterior to the acetabulum, and this muscle originates off the transverse processes of L1-L5. The referenced article by Skaggs et el found that the iliac vessels were on average 1 cm away from the iliopsoas at the level of the pelvic brim, but could be as close as 4mm in children. They also found that the neurovascular structures were on average 3.1 cm away from the iliopsoas at the level of its insertion at the lesser trochanter. Ans5

Front 26

The medial femoral circumflex artery and first perforating branch of the profunda femoris artery anastamose at which of the following locations?
1. Medial to the gluteus medius insertion
2. Medial to the gluteus maximus insertion
3. Anterior to the adductor magnus
4. Within the gluteus minimus muscle belly
5. Medial to the ischial tuberosity

Back 26

The medial femoral circumflex artery is the primary blood supplier to the adult femoral head. This artery anastamoses with the first perforating branch of the profunda femoris just medial to the gluteus maximus insertion. This is important, as sectioning the gluteus maximus tendon during posterior approaches can put both of these vessels (and the anastamosis) at risk.
Ans2

Front 27

A 57-year-old female with degenerative hip arthritis has questions regarding mini-incision total hip arthroplasty (THA) with comparison to traditional THA. Which of the following statements is true regarding the mini-incision technique?
1. Reduced rate of hip dislocation
2. Increased hip range motion at 1 year
3. No significant difference in hip function at 1 year
4. Less chance of surgical complications
5. Less chance of limping at 1 year

Back 27

Mini-incision THA has not been shown to have any clinical benefit in terms of hip function at long term followup. Proponents of this technique claim less soft tissue damage may allow for faster recovery. Digioia et al, looked at mini-incision THA vs standard THA using navigation. Although limp, distance walked, and stair function was better at 6 months with mini-incision THA, there were no significant differences in pain, function, or motion at 1 year.Ans3

Front 28

1-benign chondrogenic lesion) which occur on surface of long bones

Back 28

1-Periosteal chondromas, under periosteum) in distal femur, proximal humerus, and proximal femur

Front 29

20 year-old c/o pain w/flexion of shoulder, see histo. xray=punctate mineralization (calcification) in 1/3.
1-KHF(key histo finding)-->DDX histo
1.1 KIF(key xray finding) -->ddx xray
1.2 KPEF (key PE & hx finding) --ddx
1.3 Dx,Define::: tx ::: B/M
2.1SAP-->(1)Sx/Age/PE(SAP):::
2.2T1 & T2:::
2.5tx/(RR/MetsR/5yrS)prog

Back 29

1.1hx=bland hyaline cartilage, small chondroid cells in lacunar spaces, similar to enchondroma except for increased cellularity and more malignant looking cells (can look like chondrosarcoma)
ddx=periosteal chondroma/ Enchondroma / Olliers / Marfuccis; Osteochondroma (MHE); Chondrosarcoma
xray/CT=surface lesion, well-demarcated, shallow cortical defect, punctate mineralization (calcification) in 1/3, saucerization of underlying bone,
ddx-Periosteal chondroma, Osteochondroma / MHE
Parosteal osteosarcoma, Periosteal osteosarcoma
KPEF=painful secondary to irritation of tendons
1.3 dx=periosteal, chondromas=chondroma (benign chondrogenic lesion) which occur on surface of long bones. Tx=marginal excision including underlying cortex->BENIGN
2.1 SAP-painful secondary to irritation of tendons/10-20/painful secondary to irritation of tendons
2.2T1/T2-well-demarcated, shallow cortical defect
2.5-marginal excision

Front 30

A 19-year-old male presents with 2 months of night pain in the right shoulder. A radiograph is shown in Figure A and axial CT scan images are found in Figure B and C. A needle biopsy is performed and the representative histology slide is shown in Figure D. What is the most appropriate treatment for this tumor?
1. Observation with serial radiographs
2. Irradiation treatment course with maximum dosage of 60 grays
3. Marginal excision including the underlying cortex
4. Wide surgical excision
5. Neoadjuvant chemotherapy, surgical excision, followed by adjuvant chemotherapy

Back 30

This case is an example of periosteal chondroma which is a rare benign surface lesion composed of cartilage. It can be similar in appearance and location to malignancies such as periosteal osteosarcoma or periosteal chondrosarcoma, so refining a differential diagnosis is important.

Figure A shows an eccentric, longitudinally oriented periosteal mass with an outer, sclerotic shell of reactive periosteum. Pressure from growth of the lesion may create a saucer shaped or complex shaped defect in the underlying bone. Periosteal chondromas can look similar to osteochondromas but they do not have a stalk or peduncle and myositis ossificans rarely involves the cortex like periosteal chondromas do.
Ans3

Front 31

1-CC of low back pain in children and adolescents?
2-one of the MCC of low back pain in children and adolescents? present at birth?
3-MOI of pedi spondi? high incidence in which athletes ? pelvic incidence = __ + __, significance?
4-MC location of spondi in peds vs adult? is there a risk of progression? ***pelvic tilt=?
5-what is the Wiltse-Newman Classification used for? describe which:dysplastic, isthmic, degen, traumatic, neoplastic
6-what is the Myerding Classification used for? describe which:50-70% 75-100%; 25-50%; <25%
7-listhetic crisis define, scotty dog sign def; best diagnostic adjunct when plain radiographs are negative

Back 31

1-continuum of disease =pars stress rxn,
spondylolysis, spondylolithesis
2-spondylolithesis, No, defects NOT present @ birth & develop over time
3-repetitive hyperext, gymnasts, wtlifters, football linemen)
-pelvic incidence = pelvic tilt + sacral slope=#1 line drawn = centr S1 endplate ->center of the fem head
#2 line is drawn=perpendicular line drawn along the S1 endplate, intersecting the point in the center of the S1 endplate;angle bt/ these 2 lines=PI=>severity of disease
4-L5-S1 (90%) = pedi (L4-5=adult; ti
-yes slip ang > 50 deg >> risk of progrn
dysplasic slips (Wiltse Type I) more likely to progress
*tilt=angle Z line 1, parallel w side
5-5 types; 1=dsplastic, congntl, more sign neurologic sx;2=isthmic 2c=acut fx 3=degen; 4=traum; 5=neoplastic
6-3=50-70% 4=75-100%; 2=25-50%; 1<25%
7-severe back pain aggravated by extension, relieved by rest, neurologic deficit
hamstring spasm - walk w/ a crouched gait; Sdog=elongation in pars interarticularis
-best=SPECT

Front 32

A 17-year-old high school football lineman was diagnosed with the condition shown in the Figure A radiograph. He continues to have pain despite 6 months of wearing a custom lumbar spine orthotic (LSO) and avoiding all sports activities. His physical exam is notable for pain with single-limb standing lumbar extension and a normal neurologic exam. How would the surgical management differ if this condition occurred at L3 instead of L5?
1. Pars interarticularis repair is indicated
2. Lumbosacral fusion is indicated
3. Gill procedure is indicated
4. Combined anterior interbody fusion and posterior decompression is indicated
5. Iliac crest bone grafting is indicated

Back 32

his clinical presentation is consistent with a symptomatic spondylolysis, without listhesis or neurologic deficits, that has failed nonoperative management. Pain with single-limb standing lumbar extension is a characteristic physical finding with this condition. The oblique radiograph demonstrates a defect in the pars interarticularis. at L4 and above treatment includes pars interarticularis repair whereas at L5-S1 treatment is in-situ fusion with bone grafting. A Gill procedure is a wide, bilateral decompression of the neural elements with removal of the loose lamina and is only indicated when the patient has signs of the neural compromise. Combined anterior/posterior fusion approaches are only a reasonable option in patients with spondylolisthesis.Ans1

Front 33

A 12-year-old gymnast has had progressive low back and buttock pain refractory to conservative management for two years. A sagittal MRI is shown in Figure A. Surgical management with reduction of L5 on S1 would most likely lead to which of the following neurologic complications?
1. Decreased patellar reflexes
2. Weakness to hip flexion
3. Weakness to great toe extension
4. Weakness to knee extension
5. Weakness to ankle plantar flexion

Back 33

The patient described in the clinical scenario has a high-grade L5/S1 spondylolisthesis. Surgical reduction of this condition places the L5 nerve root at risk. Injury to the L5 nerve root can manifest as weakness to hip abduction, EHL, and tibialis anterior (dual innervation with L4). Sensory manifestations would include pain or paresthesia over the lateral calf and dorsal foot. Incorrect Answers:
1. Decreased patellar reflexes would be caused by an L4 nerve injury.
2. Weakness to hip flexion would be caused by injury to L1-3.
4. Weakness to knee extension would be caused by an L4 nerve injury.
5. Weakness to ankle plantar flexion would be caused by an S1 nerve injury.
Ans3

Front 34

girl gymnasts c/o insidious onset of activity related low back pain and/or buttock pain, PE=flattened lumbar lordosis, pain with single-limb standing lumbar extension.
1-KIF(key image finding) -->Dx
1.1KSxF(key image finding)-(4)
1.2KPEF(key image finding)-(7)
1.3-best diagnostic adjunct when plain radiographs are negative
1.4 best study to diagnose and delineate anatomy of lesion
1.5most sensitive (however lesion may be cold)
1.6indicated if ____;r/o

Back 34

1AP/lat/oblique=r/o on oblique sclerosis, elongation in pars interarticularis (scotty dog sign)->Pedi Spondylolisthesis
1.1sx=most cases of spondylolysis are asymp, (2)activity related LBP and/or buttock pain, (3)r/o bowel & bladder sx, (4)listhetic crisis=severe back pain aggravated by extension relieved by rest, neurologic deficit, walk w/ crouched gait 2^ hamstring spasm
1.2PE=flattened lumbar lordosis, (2)palpable step off of spinous process, (3)limitation lumbar flex & exten,(4)pain w/ single-limb standing lumbar exten, straight leg raise,(5) may be (+)rectal exam if BB Sx present(6)hamstring tightness MC & knee contracture(7)
radicular pain (L5 nerve root)
1.3-Single photon emission computer tomography (SPECT)
1.4 CT
1.5 bonne scan
1.6 MRI=only if neuro sx present, r/o stenosis central & foraminal

Front 35

2-indications Tx & Rehab/Time
2.1-Pedi asymptomatic pts with low-grade spondylolithesis or spondylolysis
2.2-Pedi sx isthmic spondylolysis
symptomatic low grade spondylolithesis
2.3Pedi- acute pars stress reaction spondylolysis
isthmic spondylolysis that has failed to improve with physical therapy
2.4***L1 to L4 isthmic defect that has failed nonop management, multiple pars defects
2.5 L5 spondylolysis that has failed nonop tx
low grade spondylolithesis <50%
is progressive,(+) neurologic deficits
2.6high grade isthmic spondlylithesis (Meyerding Grade III, IV, V
3-Complication
3.1 L4-S1 posterolateral fusion +/- reduction complications?
3.2 potential Complications (4)

Back 35

2.1 asymp=observ NO activity limitations
2.2 sx isthmic=physical therapy and activity restriction
2.3 sx isthmic fail 6 mth PT=TLSO bracing for 6 to 12 weeks
2.4 ***L1-L4=par interarticularis repair
2.5 L5 spondylolysis & spndi<50%= L5-S1 in-situ posterolateral fusion w/ BG
2.6 spondi>50%=L4-S1 posterolateral fusion, +/- reduction, (+/- ALIF)
3.1reduc=L5 and S1 nerve root injuries, sexual dysfunction, catastrophic neurologic injury
3.2 Neurologic deficits, Pseudoarthrosis,Progression of slippage, Hardware failure

Front 36

1-MCC of death in children
2- which type of injury highest pedi morbidity/mortality overall? which type of fx highest morbidity/mortality among musculoskeletal injuries?
3-which type of injury are more common in children <8-yo; spine board when transporting children <6 y.o must have what?
4-MC access if have difficulty obtaining venous access? Pedi "triad of death" reflects inadequate resusitation and is characterized by:
5-estimate of blood volume for pediatric patients is?
6-PTS __ should be sent to designated peds trauma center? GCS ___correlates w/ a higher rate of mortality
7-___ & ___post-injury are both prognostic of long-term neurologic recovery, MCC following pedi TBI

Back 36

1-trauma
2-pedi highest M & M injury=CNS injuries
pedi highest M & M fx=spine fx
3->>in pedi<8=cervical spine, bc/due to fact that restraints do not fit young children
-pedi<6 spine board=occiput cut out
4-cann't get IV access=>IO (intraosseous);
3=acidosis, hypothermia, coagulopathy
5-est pedi blood volume=75 - 80 mL/kg
6-PTS go trauma center=< 8
higher M & M=GCS<8
7-neurorecovery =O2 sat at presentation & GCS
72hrs post-injury
MCC p/ TBI=HO

Front 37

Which of the following injuries is associated with the highest risk of morbidity and mortality in a pediatric trauma patient?
1. Pelvic fracture
2. Scapula fracture
3. Spine fracture
4. Femur fracture
5. Tibia fracture

Back 37

The femur was the most commonly fractured bone, and overall mortality was 3% in the group studied. The trauma patients with associated scapula or pelvic fractures had an 11% mortality rate, whereas those patients with spine fractures had a 16% mortality rate. children have a lower mortality than adults, and that CNS injury is the predominant and most common cause of pediatric traumatic death.Ans 3

Front 38

A 4-year-old child involved in a motor vehicle collision sustains multiple injuries including splenic rupture, bilateral open femur fractures, lumbar burst fracture with compression of the neural elements, and a closed head injury requiring a ventriculostomy. Of these injuries, which is likely to cause the greatest long-term morbidity?
1. Traumatic brain injury
2. Peripheral nerve injury
3. Vertebral column injury
4. Intra-abdominal injury
5. Open fractures

Back 38

Long-term morbidity from trauma in children is most commonly secondary to central nervous system injury, including traumatic brain injury.

Key et al reported closed head injuries are the most common cause of long-term disability in children following polytrauma. They also note that the death rate in pediatric polytrauma patients is most closely correlated with the presence and severity of traumatic brain injury. Ans1

Front 39

1-GCS mnemonic
2-lowest possible GCS (deep coma or death)

Back 39

1-4 eyes 4= opens eyes spontaneously
verbal roman # 5 V nl speech= 5
motor= 6 v6 motor nl full strength
M2=decerebrate response, decerebrate rigidity, or extensor posturing. It describes the involuntary extension of the upper extremities in response to external stimuli. In decerebrate posturing, the head is arched back, the arms are extended by the sides, and the legs are extended.[6] A hallmark of decerebrate posturing is extended elbows
M3=decorticate response, decorticate rigidity, flexor posturing, or, colloquially, mummy baby.[11] Patients with decorticate posturing present with the arms flexed, or bent inward on the chest, the hands are clenched into fists, and the legs extended and feet turned inward. A person displaying decorticate posturing in response to pain gets a score of three in the motor section of the
V2=Incomprehensible sounds
V3=Utters inappropriate words
2-lowest=(the sum) is 3

Front 40

1-child leg grow ___mm/yr? prox & dist fem, prox & dist tibia; how old when boys vs skeletal maturity ?
2 unique fx patterns only in pedi pts? why,
3-most active physes in UE & LE ? open physes (growth plates) can allow extensive bone deformity remodeling potential most rapidly where?
4-4 zones of physes?
4.1where is collagen 10 found,
4.2MC location SHfx?
4.3lowest oxygen tension zone?
4.4 define Thurston Holland fragment?
4.5 MC SH fx?
4.6 which Zone of physes Highest rate of extracellular matrix production
4.7 zone where ca takes place?
5-major source of nutrition to physis
6-which zone:
6.1-Gaucher's
6.2 Gigantism
6.3 diastrophic dysplasia
6.4 SCFE
6.5 Scurvy
6.6 Renal SCFE
6.7 SED & MED
7.1 tx of < 50% physeal involvement & > 2 years or 2cm growth remaining
7.2 Tx > 50% physeal involvement
7.3 describe SH classification mn

Back 40

1-leg grows 23 mm/yr, w/ knee (15 mm/yr)
prox fem - 3/ yr
dist fem - 9/ yr
prox tib- 6/ yr (1/4 in)
dis tib- 5 / yr
-boys=16 yrs & girls=14
2-buckle fx, greenstick fx 2^> elasticity
3-UE=prox hum (80% long growth)
LE=dist fem
-most rapid=plane of joint motion
4-B-Reserve z,C=Proliferative Z, D=Hypertrophic Z, E-1^ spongiosa
4.1-10=Hypertronic
4.2 SH fx= provisional CA of hypertrophic zone
4.3 lowest=reserve Z
4.4 TH fx-T2 fx metaphysis
4.5MC SH-T2 metaphysis
4.6 highest excell matrix=proliferative
4.7 hypertrophic-Provisional ca zone:
5-major nutrition=perichondral Art
6.1Gaucher's=Resve
6.2 Gigantism=provisional
6.3diastrophic dysplasia=reseve
6.4 SCFE=hypertrophic
6.5 Scurvy=1^ spongiosa
6.6 Renal SCFE=2^ spongiosa
6.7 6.7 SED & MED=hypertrophic Z
7.1-<50 >2 yr>2 cm=bar resection w/interposition
7.2 >50=comb w/ contralateral epiphysiodesis and/or ipsilateral lengthening
7.3 SH=SALTR;S - slipped-1; A - above-2; L-lower 3-
T-transv=4 R-cRush=5

Front 41

Growth at the distal humerus physis accounts for what percentage of humeral length?
1. 20%
2. 40%
3. 50%
4. 60%
5. 80%

Back 41

80% of growth in the humerus bone occured from the proximal humerus. Therefore, the distal humerus is responsible for the remaining 20% of growth. As remembering the specific contributions to length from each physis can be cumbersome, it may be helpful to recall that growth primarily occurs at the knee in the lower extremitiy and away from the elbow in the upper extremity. Ans1

Front 42

1-MCC Painful, usually mild scoliosis ___ MC located _?
2-DDx for pathologic scoli vs idiopathic
3- if nidus in bone <1 cm=__ if >1.5cm =?

Back 42

1-benign bone tumor & MC in post elements of spine
curves are typically non-flexible
2-path scoli= osteoid osteoma & osteoblastoma, curves are typically non-flexible
3-<1=OO & >1.5=osteoblastoma

Front 43

Which of the following statements regarding osteoid osteomas in the spine is correct?
1. Scoliosis caused by osteoid osteoma is typically a flexible curve
2. Osteoid osteomas in the spine cannot be treated by radiofrequency ablation
3. Spinal osteoid osteomas typically occur on the concave side of the curve
4. Osteoid osteomas always occur in the vertebral body of the spine
5. Osteoid osteomas in the spine show more malignant histological behavior than those in the extremity

Back 43

Scoliosis caused by osteoid osteomas are typically non-flexible curves where the osteoid osteoma occurs on the concavity of the curve. While peripheral osteoid osteomas, far away from the neural elements CAN be treated with radiofrequency ablation, treating osteoid osteomas of the spine with RFA needs to be done on a case by case basis - depending on how close the lesion is to the neural elements. Osteoid osteomas can occur in either the vertebral body or the posterior elements of the spine, but typically occur in the posterior elements. Histologically, osteoid osteomas of the spine are identical to those in the extremity. Ans3

Front 44

adult c/o back pain most commonly at night & pain relieved by anti-inflammatories PE= mild scoli.
1-KIF(key image finding) -->Dx
1.2 other images
2-indications Tx
2.1 NSAIDs, observation
2.2 painful, progressive scoliosis
2.3 painful, progressive scoliosis NOT near neurologic structures of spine?

Back 44

1-KIFAP/Lateral of spine r/o scoli & radiolucent nidus
Dx-OO<1 cm & Osteblastoma >1.5
1.2 CT-fine cut best for outlining lesion and determining treatment plan
MRI-good for showing proximity to neurovascular structures
bone scan-markedly increased uptake in area of lesion
2.1 mild curve=NSAIDs, observation
2.2 painful, progressive scoliosis=en bloc resection of lesion
2.3 NOT near neurologic structures of spine=radiofrequency ablation of lesion

Front 45

1. what is 3 common mechanism of PCL injury
2. what purpose of the PCL

Back 45

1. direct blow to the proximal tibia with a flexed knee i.e. dashboard injury
2. Noncontact hyperflexion with plantar flexed foot
3. Hyperextension injury

• the PCL to primary restraints and posterior tibial translation prevents hyperflexion and sliding isolated injury consequently instability at 90° of flexion

Front 46

patient in a motor vehicle accidentat past point injury to the knee

1. with the diagnosis
2. What 3 physical exam findings confirmed the diagnosis, most accurate, which  to physical exam findings confirm multi-ligament injury
3. what is the  treatment

Back 46

1. PCL injury

• most accurate-posterior drawer test (at 90° flexion)
• quadriceps active test,
• dial test with ER @ >10° at 30° only
• ML=dial test with ER @ 10° at 90° &  30= PLC and PCL injury
• ML=varus/valgus stress
• laxity at 0° = MCL/LCL & PCL injury

1. grade 1 and 2R treated with physical therapy focusing on extensor strengthening of the quad
2. Grade 3 injury with bony avulsion T with surgery
3. Chronic PCL as functionally unstable treated with surgery plus or minus high tibial osteotomy medial opening wedge treated varus malalignment increasing the tibial slope reduces the posterior sag of the tibia
4. PCL plus ACL or PCL plus grade 3 MCL or LCL

Front 47

At what angle of knee flexion should the graft be tensioned at during posterior cruciate ligament (PCL) reconstruction with a single bundle graft?

1.  5 degrees hyperextension

2.  0 degrees flexion

3.  15 degrees flexion

4.  30 degrees flexion

5.  90 degrees flexion

Back 47

For single bundle reconstructions, the PCL is usually tensioned in flexion and the ACL is tensioned in more extension. While not truly isometric, these positions are closest to the isometric points which means that the graft will not have excess strain or laxity as it is taken through a full range of motion. The Margheritini et al. paper describes 2 different methods of tibial fixation, but were performed at 90 degs of flexion. The Sekiya paper describes the technique and results of single bundle PCL reconstructions.ans5

Front 48

A 35-year-old construction worker presents with medial-sided knee pain. He has no instability complaints but at age 18, he sustained a Grade 1 PCL injury that was treated non-operatively. A radiograph is shown in Figure A. What surgical treatment is the best option given his age and occupation?

1.  PCL reconstruction

2.  Unicompartmental knee replacement

3.  Total knee replacement

4.  Lateral closing wedge osteotomy of the proximal tibia

5.  Medial opening wedge osteotomy of the proximal tibia

 

Back 48

Either valgus producing osteotomy is reasonable, but the opening wedge tends to increase posterior tibial slope which is helpful in PCL-deficient knees. 
radiographs show a knee with significant medial compartment narrowing. A frequently tested fact is that wear associated with chronic PCL instability occurs most commonly in the patellofemoral joint and the medial compartment of the knee. A young laborer is not an ideal candidate for arthroplasty because of early wear and loosening concerns. In addition, cruciate ligaments are required for the insertion of a unicompartmental knee replacement. Isolated PCL reconstruction would not be recommended as he already has arthritis and cruciate reconstruction in a mal-aligned knee is at increased risk of failure. Either valgus producing osteotomy is reasonable, but the opening wedge tends to increase posterior tibial slope which is helpful in PCL-deficient knees. ans5

Front 49

patient patient presents to the office after 20 years total hip arthroplasty now complains of the groin pain what is most likely the cause of his  revision total hip replacement

Back 49

groin plain = acetabulum

Front 50

patient presents to the office 18 years of total hip arthroplasty now complaining of thigh pain  with the most likely cause of his revision total hip replacement

Back 50

thigh pain =femoral stem

Front 51

patient returns to the office today 22 years of the total hip replacement now complaining of start up pain with most likely cause for his need for revision total hip replacement

Back 51

start up pain = component loosening

Front 52

patient returns to the office 25 years after total hip replacement now complaining of night pain was most likely cause of his need for revision total hip replacement

Back 52

night pain=infection

Front 53

x-rays done confirming patient needs revision total hip what is the next most appropriate study in the preparation for his surgery

Back 53

CT scan because x-rays frequently underestimated the extent of osteolysis

Front 54

Which of the following statements is true regarding the thirty-year follow-up data obtained from the Charnley "low-friction" total hip arthroplasty?

1.  Acetabular component failure was the least common reason for revision surgery

2.  The number of revisions required for periprosthetic fractures was higher than that for deep infections

3.  Acetabular component failure was a more common reason for revision than deep infection

4.  Femoral component failure was a more common reason for revision than acetabular component failure

5.  Deep infection was the most common reason for revision

Back 54

Failure of the acetabular component was the most common reason for revision at thirty-years for the Charnley "low-friction" total hip arthroplasty. Incorrect Answers:
Answer 1: Acetabular component failure was the most common reason for revision.
Answer 2: Revision for deep infection was more common than for fracture.
Answer 4: Acetabular component failure was more common than femoral component failure. 
Answer 5: Acetabular component failure was the most common reason for revision.

ans3

Front 55

 A 71 year old gentleman underwent left total hip arthroplasty 10 years ago. Eighteen months ago he began having hip and thigh pain. Over the past 6 weeks, the pain has become excruciating and he has been unable to ambulate, even with the aid of a walker. He has mild pain with passive internal and external rotation of the hip. He is unable to ambulate in the office. Laboratory values are notable for a WBC of 10,300, CRP of 0.2, and ESR of 13. A radiograph is provided in figure A. Which of the following is the best treatment option?

1.  Radionuclide bone scan and MRI

2.  Open reduction internal fixation with a cable plate and allograft strut

3.  Revision arthroplasty with a fully coated cementless stem, cable wiring, and bone graft

4.  Revision arthroplasty with a modular, tapered stem and bone grafting of the diaphyseal fixation

5.  Revision arthroplasty with a total femur prosthesis

Back 55

The radiograph is consistent with a periprosthetic femur fracture, with a loose femoral stem, and a Paprosky IIIA femoral defect. This is best treated with a fully-coated cementless stem with metaphyseal onlay allograft.  Type I: minimal metaphyseal bone loss and intact diaphyseal fixation
Type II: extensive metaphyseal bone loss with intact diaphyseal fixation.Radiograph A shows a total hip arthroplasty with severe metaphyseal bone loss and a supportive diaphysis. 

Incorrect Answers:
Answer 1: No additional work-up is required prior to revision arthroplasty if laboratory results are negative for infection.
Answer 2: Given the amount of bone loss and the loose femoral stem, fixation of the fracture/defect would not be advisable.
Answers 4,5: These would be reasonable options if extensive bone loss was seen in the diaphysis. ans3
Type IIIA: severe metaphyseal bone loss with greater than 4 cm of diaphyseal bone preservation for distal fixation.
Type IIIB: severe metaphyseal bone loss and less than 4 cm of diaphyseal bone preservation for distal fixation
Type IV: extensive metaphyseal and diaphyseal bone loss. ans3

Front 56

 A 72-year old female who underwent an uncemented right total hip arthroplasty 2 years ago complains of right hip pain after a fall. Figure A shows her current radiograph. Which acetabular bone defect classification and treatment option best describes this scenario?

1.  AAOS Type III - anti-protrusio cage with augmentation and a posterior column plate

2.  AAOS Type IV - anti-protrusio cage with screw fixation and a posterior column plate

3.  AAOS Type II - jumbo cup with augmentation and a posterior column plate

4.  AAOS Type I - total acetabular allograft with a cemented cup

5.  AAOS Type II - custom triflange acetabular component

Back 56

Figure A shows pelvic discontinuity, which is consistent with a AAOS Type IV defect. Acetabular antiprotrusio cage with screw fixation and a posterior column plate is a reasonable treatment option for this condition. 

Acetabular bone loss following total hip arthroplasty is a challenging problem with a wide variety of treatment options available. The two most widely accepted classification systems are the AAOS and Paprosky classifications. AAOS type I defects are segmental, type II are cavitary, type III are combined cavitary and segmental, type IV is discontinuity, and type V is arthrodesis. All of the treatment options listed above are described for pelvic discontinuity, with none being described as superior. Incorrect Answers:
Answer 1: Type III defects are combined cavitary and segmental. 
Answer 3: Type II defects are cavitary.
Answer 4: Type I defects are segmental.
Answer 5: Type II defects are cavitary.

 

ans2

Front 57

A 72-year-old female returns to clinic for 15 year follow up of left total hip arthroplasty. She ambulates without any assistive devices, has no pain, and denies any recent fevers or systemic illness. A radiograph is provided in figure A. Which of the following is the best treatment option? 

1.  Follow up radiographs in 1 year

2.  Follow up radiographs in 5 years

3.  Revision surgery with femoral head and polyethylene exchange and retroacetabular bone grafting

4.  Revision of acetabular component with jumbo cup and femoral head exchange

5.  Revision of acetabular component with jumbo cup and femoral stem revision

Back 57

The radiograph demonstrates osteolytic lesions behind the acetabular cup and eccentric wear of the polyethylene with superior migration of the femoral head within the cup. Options 1 and 2 are poor choices because the osteolysis must be addressed to prevent further bone loss and eventual loosening of the implant. The acetabular cup remains in acceptable position and does not need to be revised unless found to be grossly loose intraoperatively. The osteolytic lesions need to be addressed with bone grafting to prevent cavitary bone loss. The femoral stem shows no indication of loosening or osteolysis around the stem and can be retained. ans3

Front 58

A 75-year-old man who underwent total hip arthroplasty 20 years ago now complains of thigh pain for the past four months. Laboratory studies show a normal white blood cell count (WBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). An aspiration of the hip is performed and is negative for infection. A radiograph is shown in Figure A. Which of the following is the best management option for the femoral implant?

1.  Bone scan to look for loosening

2.  Touch down weight bearing and physical therapy

3.  Revision with a tumor prosthesis

4.  Revision of femoral component with metaphyseal cement fixation of the stem

5.  Revision to a cementless femoral component with diaphyseal press-fit fixation of the stem

Back 58

The radiograph shows lucency around the femoral stem cement mantle consistent with osteolysis. There is significant bone loss in the proximal femur. Diaphyseal fixation is required. Revision to a cementless femoral stem is the most appropriate management.
Paprosky et al described their results of cementless revision of femoral components and report 95% surviorship with a minimum of 10 years follow up. ans5

Front 59

patient's is gymnast and reports low back pain no neurologic symptoms

1. diagnosis
2. with the treatment
3. most common location
4. best diagnostic studies confirmed diagnosis

Back 59

1. spondylolisthesis secondary to repetitive hyperextension
2. in this patient treat with physical therapy and activity restriction pain was x-rays show
3. most common location and its child is L5/S1  compared to and L4/L5
4. X-rays are negative the best test is single-photon emission computed tomography SPECT

Front 60

1. what the most sensitive test for spondylolisthesis in a child
2. what the best fit diagnose and delineate anatomy of the lesion
3. Which test may showed a defect 80% of the time
4. With the best test.  Neurologic symptoms present

 

Back 60

1. most sensitive test =bone scan however it may be cold, excellent screening total low back pain and children
2. CT scan equal delineate the anatomy of lesion axillary for pars stress reaction will show sclerosis
3. X-ray lateral may show pars defect oblique radiograph SCOTTY dog sign elongation of the pars interarticularis
4. MRI

Front 61

1. grade  slip is associated with the greater risk of progression
2. if bowel or bladder symptoms are present what is Physical exam test that must be done

Back 61

1. 50°
2. Rectal exam

Front 62

what does pelvic incidents equal

Back 62

pelvic tilt + sacral slope = severity of disease

Front 63

1.  the patient has a grade 1-2 spondylolisthesis with the treatment
2. grade 2 spondylolisthesis with neurologic symptoms with the treatment
3. grade 3 spondylolisthesis what is the treatment

Back 63

1. physical therapy and activity restriction including hamstring stretching abdominal strengthening of pelvic tilt , brace if there is acute stress reaction spondylolysi
2. L5/S1 in situ  posterior lateral fusion with bone graft
3. L4-S1 posterior lateral fusion plus or minus reduction plus or minus a ALIF

Front 64

A 13-year-old gymnast reports the acute onset of low back pain that began four weeks ago. Radiographs are unremarkable. A single-photon-emission-computer-tomography (SPECT) is shown in Figure A. Initial treatment should consist of? 

1.  Bracing with a molded lumbosacral orthosis

2.  Aggressive physical therapy

3.  CT guided biopsy

4.  In-situ posterolateral fusion of L5-S1

5.  Epidural steroid injection

Back 64

The question presents a 13-year-old gymnast with the acute onset of low back pain that is activity related. Her radiographs are normal, but a SPECT scan shows increased signal of the L5 pars, indicative of impending or acute stress reaction spondylolysis. The reference by Cohen & Stuecker demonstrated that bracing and avoiding strenuous activities prevented the formation of pars defects in patients with impending spondylolysis. Early diagnosis was made with MRI. Patients should wear a lumbosacral orthosis full time for 6 to 12 weeks. ans1

Front 65

1. most common mechanism of injury of the peroneal tendon
2. If there isperoneus  tendon tear which tendon is usually involved
3. where is the perineal brevis compared to the longus

Back 65

1. rapid dorsiflexion in an inverted foot leading to injury of the superior retinacular ligament
2. peroneal brevis at the fibular groove is most likely a longitudinal tear as opposed to transverse
3. The brevis is anterior and medial to the longus at the level of the lateral malleolus

Front 66

patient is a pop and has pain and lateral ankle while playing soccer he states his ankle was in a dorsiflexed position and on physical exam he has apprehension with eversion resistance

1. what is the diagnosis
2. what is the treatment
3. what the next best diagnostic study to confirm the diagnosis

Back 66

1. peroneal tendon injury
2. Acute injury and actively the treatment is repaired the superior peroneal retinaculum and deepening of fibular groove
3. MRI – to visualize it is a longitudinal detail and which tendon is involved

Front 67

Which of the following mechanisms of injury to the ankle is most likely to result in disruption of the superior peroneal retinaculum with subsequent peroneal tendon instability?

 

1.  Plantarflexion and eversion

2.  Neutral ankle position

3.  Neutral ankle flexion and inversion

4.  Dorsiflexion and inversion

5.  Plantarflexion and inversion

 

Back 67

eroneal tendon instability can occur during an inversion injury to a dorsiflexed ankle with rapid reflexive contraction of the peroneus longus and peroneus brevis tendons. ans4

Front 68

what kind of pediatric trauma as a hiatus mortality and morbidity overall

Back 68

CNS injuries

Front 69

we'll contact fracture has the highest mortality and morbidity among musculoskeletal injuries injuries

Back 69

spine fracture

Front 70

1. a pediatric patient what reflex in adequately recessed visitation and his the triad of death
2. with the estimated blood Pediatric patient

Back 70

1. acidosis
2. Hypothermia
3. Coagulopathy

• 75-80 mL/kg

Front 71

1. what injury scalecorrelates with a higher rate of mortality
2. Order to prognostic long-term neurologic recovery indicators

Back 71

1. GCS <8
2. O2 sat presentation and GCS at 72 hours post injury

Front 72

1. posterior approach to the hip which to broaches using the same interval
2. What is the interval

Back 72

1. approaches to the acetabulum equals  KOKER Langenbach approach and Southern/MOORE approach
2. NO nervous planesplit the gluteus maximus which is innervated by the inferior gluteal nerve

Front 73

1. posterior approach to the hip was the piriformis the leading landmark for
2. where the contents of the greater sciatic notch mn
3. which ligament contributes deforming this notchif viewed from behind posteriorly

 

Back 73

1. greater sciatic notch
2. P.I.N and P.I.N.S

P – posterior cutaneous nerve to the thigh

I – inferior  Gluteal vessels and nerves

N – nerve to the quadratus femoris

P – pudendal nerve

I – internal pudendal vessels

N – nerve to the obturator internus

S – sciatic nerve

sacrotuberous ligament

 

 

Front 74

Figure A is a cadaver specimen where a posterior approach to the hip has been performed after removal of part of the Gluteus maximus muscle. Which of the following choices correctly identifies structures A, B, and C in Figure A?

1.  A: Gluteus minimus, B: Piriformis tendon, C: Sacrospinous ligament

2.  A: Piriformis tendon, B: Superior gemellus tendon, C: Sacrospinous ligament

3.  A: Gluteus minimus, B: Piriformis tendon, C: Sacrotuberous ligament

4.  A: Piriformis tendon, B: Quadratus femorus tendon, C: Sacrotuberous ligament

5.  A: Gluteus minimus, B: Superior gemellus tendon, C: Sacrotuberous ligament

Back 74

In Figure A, the arrow labeled A is pointing to the Gluteus minimus muscle, B is pointing to the tendon of the piriformis muscle, and C is pointing to the sacrotuberous ligament (Illustration A). These are all important landmarks and points of identification during a posterior approach to the hip. 

Illustrations B and C demonstrate the relationship of the ischial spine and ischial tuberosity in relation to the hip joint and the associated ligaments. The superior gemellus originates from the ischial spine. ans3

Front 75

Which of the following structures exists distal to the anatomic landmark identified in Figure A 

1.  Sciatic nerve

2.  Superior gluteal artery

3.  Piriformis tendon

4.  Inferior gluteal artery

5.  Obturator internus

Back 75

The arrow points to the ischial spine and is the site of attachment of the sacrospinous ligament which anatomically divides the greater and lesser sciatic notches. The contents of the greater sciatic notch include the piriformis, the superior and inferior gluteal vessels and nerves, the sciatic and posterior femoral cutaneous nerves, the internal pudendal vessels, and the nerves to the obturator internus and quadratus femoris. The lesser sciatic notch is home to the tendon of the obturator internus, the nerve which supplies that muscle, and the internal pudendal vessels and nerve that course back through the lesser notch after having exited the greater notch. 

Front 76

All of the following structures pass below the piriformis through the greater sciatic foramen EXCEPT:

1.  pudendal nerve

2.  sciatic nerve

3.  inferior gluteal nerve

4.  obturator nerve

5.  inferior gluteal artery

Back 76

The pudendal nerve, sciatic nerve, inferior gluteal nerve, and inferior gluteal artery all exit the sciatic foramen. The obturator nerve does not exit the sciatic foramen. The greater sciatic foramen is bounded as follows: anterolaterally by the greater sciatic notch of the illium, posteromedially by the sacrotuberous ligament, inferiorly by the sacrospinous ligament and ischial spine, and superiorly by the anterior sacroiliac ligament. It is partially filled up by the piriformis which leaves the pelvis through it. The following structures make their exit from the pelvis through the greater sciatic foramen above the piriformis: superior gluteal vessels and superior gluteal nerve. Below the piriformis the following structures exit: inferior gluteal vessels, inferior gluteal nerve, internal pudendal vessels, pudendal nerve, sciatic nerve, posterior femoral cutaneous nerve, nerve to obturator internus, and nerve to quadratus femoris. The obturator nerve originates from the L2, L3, and L4 nerve roots, exits the pelvis through the obturator foramen, innervates the gracilis, adductors (longus, brevis, magnus), and provides sensation to the inferomedial thigh.

 

Front 77

mc fx in combo occur with distal radius, 

Back 77

Pisiform Fracture

Front 78

• pain in the posterior gluteal region and migrating down the back of the leg

1. what is dx
2. whats tx
3. whats confirming PEF

Back 78

1. pirformis syndrome
2. 1st line=stretching the piriformis muscle and short external rotators
3. corticosteroid injection directed near the piriformis muscles
4.  refractory cases after failed conservative =piriformis muscle release and external sciatic neurolysis