OITE 2008 Review OITE 2008 Review
Abdulaziz Alomar, MD, MSc FRCSCAbdulaziz Alomar, MD, MSc FRCSC
Assistant Professor and consultant Assistant Professor and consultant Orthopaedic surgeon.Orthopaedic surgeon.
KKUH, KSUKKUH, KSU
226. A 56 y/o man with a Hx of NF reports 226. A 56 y/o man with a Hx of NF reports burning pain in his foot. An MRI scan of the burning pain in his foot. An MRI scan of the thigh reveals the mass shown in figure96a. A thigh reveals the mass shown in figure96a. A biopsy is most likely to reveal the histology in biopsy is most likely to reveal the histology in which of the following figures?which of the following figures?
1.1. Figure 96bFigure 96b2.2. Figure 96cFigure 96c3.3. Figure 96dFigure 96d4.4. Figure 96eFigure 96e5.5. Figure 96fFigure 96f
3. Figure 96d3. Figure 96d
227. The nutritional supply of the 227. The nutritional supply of the tendon region shown in figure 97 tendon region shown in figure 97 primarily comes from theprimarily comes from the
1.1. ParatenonParatenon
2.2. Synovial sheath and Synovial sheath and fluidfluid
3.3. Mesotenon/vinculaeMesotenon/vinculae
4.4. PeriosteumPeriosteum
5.5. Myotendinous Myotendinous junctionjunction
2. Synovial sheath and fluid2. Synovial sheath and fluid From their musculotendinous origin to From their musculotendinous origin to
the level of the A1 pulley, the flexor the level of the A1 pulley, the flexor tendons receive their blood supply tendons receive their blood supply from the surrounding paratenon from the surrounding paratenon
Within the sheath, the only connection Within the sheath, the only connection between the tendons and the between the tendons and the periphery is at the level of the vincula, periphery is at the level of the vincula, which are folds of mesotenon that which are folds of mesotenon that carry a blood supply to the tendons carry a blood supply to the tendons within the sheath within the sheath
each tendon within the sheath is each tendon within the sheath is supplied by 2 vincula, 1 long supplied by 2 vincula, 1 long (vinculum longum) and 1 short (vinculum longum) and 1 short (vinculum breve). (vinculum breve).
The FDS receives a short and long The FDS receives a short and long vinculum at the level of the PIP joint. vinculum at the level of the PIP joint.
The FDS receives a long vinculum at The FDS receives a long vinculum at the level of the PIP joint, and the the level of the PIP joint, and the
FDP receives a short vinculum at the FDP receives a short vinculum at the level of the DIP joint. level of the DIP joint.
Within the flexor sheath, the tendons Within the flexor sheath, the tendons are also known to receive a significant are also known to receive a significant amount of nutrition by diffusion from amount of nutrition by diffusion from the surrounding synovial fluid the surrounding synovial fluid
228. During posterolateral approach for 228. During posterolateral approach for ORIF of a radial head #, the arm kept in ORIF of a radial head #, the arm kept in which position to avoid injury to PIN?which position to avoid injury to PIN?
1.1. Neutral forearm rotationNeutral forearm rotation
2.2. Elbow flextionElbow flextion
3.3. Elbow extensionElbow extension
4.4. PronationPronation
5.5. supinationsupination
4. Pronation4. Pronation
Pronation of the forearm allowed safe exposure Pronation of the forearm allowed safe exposure of at least the proximal 38 mm of the lateral of at least the proximal 38 mm of the lateral aspect of the radius, with an average proximal aspect of the radius, with an average proximal safe zone of 52.0 ± 7.8 millimeters. Supination safe zone of 52.0 ± 7.8 millimeters. Supination decreased this proximal safe zone to as little as decreased this proximal safe zone to as little as 22 mm and an average of 33.4 ± 5.7 millimeters. 22 mm and an average of 33.4 ± 5.7 millimeters. The angle formed by the posterior interosseous The angle formed by the posterior interosseous nerve and the radial shaft in supination nerve and the radial shaft in supination averaged 47.4 ± 6.8 degrees; this decreased to averaged 47.4 ± 6.8 degrees; this decreased to 27.8 ± 6.7 degrees with pronation.27.8 ± 6.7 degrees with pronation.
Anatomical Considerations Regarding the Posterior Interosseous Nerve During Posterolateral Approaches to the Proximal Part of the RadiusJ. Bone Joint Surg. Am., Jun 2000; 82: 809
229. When is it safe for most 229. When is it safe for most patients to return to driving patients to return to driving after a THAafter a THA
1.1. After 1 weekAfter 1 week
2.2. 2-3 weeks2-3 weeks
3.3. 4-6 weeks4-6 weeks
4.4. 10-12 weeks10-12 weeks
5.5. After 12 weeksAfter 12 weeks
3. 4-6 weeks3. 4-6 weeks
Decisions made regarding resumption of driving after Decisions made regarding resumption of driving after total hip arthroplasty may be determined by a total hip arthroplasty may be determined by a combination of factors including driving reaction time combination of factors including driving reaction time and when postsurgical precautions need no longer be and when postsurgical precautions need no longer be adhered to. Ninety patients, ranging in age from 34 to adhered to. Ninety patients, ranging in age from 34 to 85 years old were recruited after total hip arthroplasty 85 years old were recruited after total hip arthroplasty to measure driving reaction time preoperatively and to measure driving reaction time preoperatively and from 1 to 52 weeks postoperatively. Driving reaction from 1 to 52 weeks postoperatively. Driving reaction time worsened 1 week postoperatively for patients who time worsened 1 week postoperatively for patients who had a right hip arthroplasty. The driving reaction time had a right hip arthroplasty. The driving reaction time then improved up to 1 year postoperatively. Patients then improved up to 1 year postoperatively. Patients who had a left arthroplasty improved from 1 week who had a left arthroplasty improved from 1 week postoperative. In general, patients reach their postoperative. In general, patients reach their preoperative driving reaction time 4 to 6 weeks preoperative driving reaction time 4 to 6 weeks postoperatively and continue to improve.postoperatively and continue to improve.
Ganz SB, Levin AZ, Peterson MG, et al: Improvement in driving reaction time after total hip arthroplasty. Clin Orthop Relat Res 2003;413:192-200.
230.What rotational differences 230.What rotational differences are seen in the dominant shoulder are seen in the dominant shoulder of throwing athletes compared to of throwing athletes compared to their nondominant side? their nondominant side? 1.1. Increase external rotation and decrease Increase external rotation and decrease
internal rotationinternal rotation2.2. Increase external and internal rotationIncrease external and internal rotation3.3. Decrease external and internal rotationDecrease external and internal rotation4.4. Decrease external rotation and increase Decrease external rotation and increase
internal rotationinternal rotation5.5. No difference between dominant and No difference between dominant and
nondominant sidesnondominant sides
1. Increase external rotation and decrease 1. Increase external rotation and decrease internal rotationinternal rotation
• throwing athletes had a significant increase in the throwing athletes had a significant increase in the dominant shoulder versus the nondominant shoulder in dominant shoulder versus the nondominant shoulder in humeral head retroversion, glenoid retroversion, humeral head retroversion, glenoid retroversion, external rotation at 90°, and external rotation in the external rotation at 90°, and external rotation in the scapular plane. Internal rotation was decreased in the scapular plane. Internal rotation was decreased in the dominant shoulder. Total range of motion, anterior dominant shoulder. Total range of motion, anterior glenohumeral laxity, and posterior glenohumeral laxity glenohumeral laxity, and posterior glenohumeral laxity were found to be equal bilaterally. were found to be equal bilaterally.
• A comparison of the dominant shoulders of the throwing A comparison of the dominant shoulders of the throwing athletes to nonthrowing subjectsathletes to nonthrowing subjects indicated that both indicated that both external rotation at 90° and humeral head retroversion external rotation at 90° and humeral head retroversion were significantly greater in the throwing group. were significantly greater in the throwing group.
Crockett HC, Gross LB, Wilk KE, et al: Osseous adaptation and range of motion at the glenohumeral joint in professional baseball pitchers. Am J Sports Med 2002;30:20-26.
231. The Indications for a reverse 231. The Indications for a reverse total shoulder arthroplasty include:total shoulder arthroplasty include:1.1. A failed hemiarthroplasty secondary to glenoid A failed hemiarthroplasty secondary to glenoid
wear.wear.2.2. A malunited 4-part proximal humerus fracture A malunited 4-part proximal humerus fracture
in a 45 y/o sedentary individual.in a 45 y/o sedentary individual.3.3. A young laborer with degenerative arthritis A young laborer with degenerative arthritis
superimposed on a massive, irreparable rotator superimposed on a massive, irreparable rotator cuff tear.cuff tear.
4.4. An elderly Pt with painful shoulder motion An elderly Pt with painful shoulder motion limited to 140 degrees of forward flexion.limited to 140 degrees of forward flexion.
5.5. An elderly Pt with a painful, arthritic shoulder An elderly Pt with a painful, arthritic shoulder with active forward flexion of 30 degrees. with active forward flexion of 30 degrees.
5. An elderly Pt with a painful, arthritic 5. An elderly Pt with a painful, arthritic shoulder with active forward flexion of 30 shoulder with active forward flexion of 30 degrees.degrees.
The most reliable results are obtained with total semiconstrained prostheses. This is reason enough to aim for optimal repair of rotator cuff tears. Then, if glenohumeral disease develops subsequently, the head is centered, allowing use of a semi-constrained total prosthesis. In contrast, failure to repair a large rotator cuff tear may result in osteoarthritis with humeral head migration. In this case, the only effective treatment at present is reverse total prosthesis, whose medium-term results are not well known.
Goutallier D, Postel JM, Zilber S, et al: Shoulder surgery: From cuff repair to joint replacement: An update. J Bone Joint Surg Am 2003;70:422-432.
232. A 6-month-old child has a brachial plexus 232. A 6-month-old child has a brachial plexus birth palsy. Examination reveals a normal birth palsy. Examination reveals a normal trapezius, deficient shoulder abduction, no trapezius, deficient shoulder abduction, no external rotation, absent elbow flexion, no external rotation, absent elbow flexion, no forearm supination, and weak wrist extension. forearm supination, and weak wrist extension. The rest of examination is normal. The rest of examination is normal. Which of the following nerve roots have been Which of the following nerve roots have been injured?injured?
1.1. C5C5
2.2. C5 and C6C5 and C6
3.3. C5, C6, and C7C5, C6, and C7
4.4. C5, C6, C7, and C8C5, C6, C7, and C8
5.5. C5, C6, C7, C8, and T1C5, C6, C7, C8, and T1
2. C5 and C62. C5 and C6
PalsyPalsy RootRoot DeficitDeficit PrognosiPrognosis s
Erb-Erb-Duchenne Duchenne
C5,CC5,C6 6
Deltoid, rotator cuff, Deltoid, rotator cuff, elbow flexors, wrist elbow flexors, wrist and hand extensors and hand extensors “Waiter's tip” “Waiter's tip”
Best Best
Klumpke Klumpke C8,TC8,T1 1
Wrist flexors, Wrist flexors, intrinsics, Horner intrinsics, Horner syndrome syndrome
Poor Poor
Total Total plexus plexus
C5-C5-T1 T1
Flaccid arm Flaccid arm Worst Worst
233. A 21-year-old man seen in ER with grade II 233. A 21-year-old man seen in ER with grade II open femur fracture. Because of significant open femur fracture. Because of significant head injury, he is unable to give informed head injury, he is unable to give informed consent and no family members are available. consent and no family members are available. How should you proceed?How should you proceed?1.1. Schedule the Pt for I&D, and definitive fracture Schedule the Pt for I&D, and definitive fracture
management in the OR.management in the OR.2.2. Perform an I&D in the ER and place the Pt in traction Perform an I&D in the ER and place the Pt in traction
until a family member or guardian is contacteduntil a family member or guardian is contacted3.3. Ask a colleague with similar expertise and knowledge Ask a colleague with similar expertise and knowledge
in femoral fracture management to confirm the in femoral fracture management to confirm the necessity of the procedure before proceeding with necessity of the procedure before proceeding with definitive fracture caredefinitive fracture care
4.4. Obtain approval for care from hospital administratorObtain approval for care from hospital administrator5.5. Document the medical necessity of the procedure in Document the medical necessity of the procedure in
the chart prior to proceeding with fracture care.the chart prior to proceeding with fracture care.
3. Ask a colleague with similar expertise and 3. Ask a colleague with similar expertise and knowledge in femoral fracture management to knowledge in femoral fracture management to confirm the necessity of the procedure before confirm the necessity of the procedure before proceeding with definitive fracture careproceeding with definitive fracture care
234. Radiographs obtained 2 months after ORIF 234. Radiographs obtained 2 months after ORIF of a displaced talar neck # show a subchondral of a displaced talar neck # show a subchondral radiolucency in the talar dome. What dose this radiolucency in the talar dome. What dose this finding represent?finding represent?
1.1. Osteonecrosis of the talus due to vascular Osteonecrosis of the talus due to vascular disruptiondisruption
2.2. An unrecognized osteochondral injury to the An unrecognized osteochondral injury to the talar dometalar dome
3.3. Preserved vascularity of the talar bodyPreserved vascularity of the talar body
4.4. Subchondral bone collapse in the talar domeSubchondral bone collapse in the talar dome
5.5. Cystic changes associated with post traumatic Cystic changes associated with post traumatic arthritisarthritis
3. Preserved vascularity of the 3. Preserved vascularity of the talar bodytalar body
The Hawkins sign showed a sensitivity of 100% and a specificity of 57.7%. The Hawkins sign (if present) appeared between the 6th and the 9th week after trauma
The Hawkins sign is a good indicator of talus vascularity following fracture. If a full or partial positive Hawkins sign is detected, it is unlikely that AVN will develop at a later stage after injury
Tezval M, Dumont C, Sturmer KM: Prognostic reliability of the Hawkins sign in fractures of the talus. J Orthop Trauma 2007;21:538-543.
235. Which of the following most 235. Which of the following most improve functional outcome after improve functional outcome after transfemoral amputation?transfemoral amputation?
1.1. Adductor myodesisAdductor myodesis
2.2. Femoral flexor extensor myoplastyFemoral flexor extensor myoplasty
3.3. Posterior based skin flapPosterior based skin flap
4.4. Residual limb that can use a suction fit Residual limb that can use a suction fit socketsocket
5.5. Abductor advancementAbductor advancement
1. Adductor myodesis1. Adductor myodesis
Adductor myodesis is important for Adductor myodesis is important for maintaining femoral adduction during maintaining femoral adduction during the stance phase in order to allow the stance phase in order to allow optimum prosthetic function. The major optimum prosthetic function. The major deforming force is toward abduction and deforming force is toward abduction and flexion. Adductor myodesis at normal flexion. Adductor myodesis at normal muscle tension eliminates the problem muscle tension eliminates the problem of adductor roll in the groin. Transecting of adductor roll in the groin. Transecting the adductor magnus results in a loss of the adductor magnus results in a loss of 70% of the adductor pull 70% of the adductor pull
