Treatment is closed reduction and casting or surgical fixation depending on the degree of displacement. A 22-year-old female with hereditary osteochondromas has difficulty supinating and pronating her forearm. The atlantoaxial joint is an important "transitional zone" in the cervical spine. Modic changes on MRI imaging are associated with post-operative back pain, Pain diagrams may be useful in identifying patients with an increased likelihood of pain sensitization, psychosocial load, and utilizing pain management resources, caused by breaking through anterior annulus and injuring vena cava/aorta, immediate recognition of complication followed by coordinated repair by vascular service, due to over resection of lamina and pars interarticularis, instrumentation and fusion of the affected segment, 90% of patients will have improvement of symptoms within 3 months without substantial medical treatment, patients less likely to improve if still symptomatic after 6 weeks, factors associated with good outcomes with nonoperative treatment, factors associated with worse outcomes with nonoperative treatment, symptoms present >6 months prior to starting treatment, Size of herniation decreases over time (reabsorbed), Factors associated with favorable surgical outcomes, Surgical treatment is equivalent to nonsurgical treatment in the long term. (OBQ09.71) A 12-year-old girl with a several-year history of multiple bony protuberances presents to your clinic for evaluation. (SAE08AN.31) Arthroplasty Preoperative Medical Optimization, Idiopathic Transient Osteoporosis of the Hip (ITOH), THA Pseudotumor (Metal on Metal Reactions), TKA Postoperative Rehabilitation & Outpatient Management. Osteochondroma & Multiple Hereditary Exostosis. (OBQ10.29) recurrent torsional strain leads to tears of the outer annulus which leads to herniation of nucleus pulposis, lateral edge of posterior longitudinal ligament weakest region, common site for posterolateral/paracentral disc herniations, sinuvertebral nerves provide pain innervation to the posterior annulus, mediate vertebrogenic back pain that precedes or accompanies disc herniation, cellular senescence of fibrochondrocytes leads to loss of proteoglycan production leading to disc height loss, loss of height causes increased strain on the annulus fibrosus, increased strain leads to fissures of the annulus fibrils, annular tears compromise hoop stresses that act against the deforming forces of the nucleus pulposus, younger, well-hydrated discs more likely to herniate, pediatric patients may have Salter-Harris II fracture of the ring apophysis, older, desiccated discs less likely to herniate, sciatica symptoms result from combined mechanical compression and associated inflammation, not all patients with mechanical compression develop symptoms, TNF-, MMP, NO, PE2, and IL-6 are implicated in nerve irritation leading to radiculopathy, weak evidence to support DMARDs for treatment, Complete intervertebral disc anatomy and biomechanics, characterized by extensibility and tensile strength, high collagen / low proteoglycan ratio (low % dry weight of proteoglycans), low collagen / high proteoglycan ratio (high % dry weight of proteoglycans), proteoglycans interact with water and resist compression, a hydrated gel due to high polysaccharide content and high water content (88%), disc height dependent on the degree of hydration, nutrients supplied by diffusion from the end plates, key difference between cervical and lumbar spine is, cervical spine C6 nerve root travels under C5 pedicle, lumbar spine L5 nerve root travels under L5 pedicle, extra C8 nerve root (no C8 pedicle) allows transition, horizontal (cervical) vs. vertical (lumbar) anatomy of nerve root, because of vertical anatomy of lumbar nerve root a paracentral and foraminal disc will affect different nerve roots, because of horizontal anatomy of cervical nerve root a central and foraminal disc will affect the same nerve root, may present with cauda equina syndrome which is a surgical emergency, affects the traversing/descending/lower nerve root, herniated disc material directly compresses dorsal root ganglion, can manifest with more severe pain than traditional posterolateral disc herniation, can affect both exiting and descending nerve roots, disc material herniates through annulus but remains continuous with disc space, disc material herniates through annulus and is no longer continuous with disc space, disc material is contained beneath the posterior longitudinal ligament, disc material passes dorsal to the posterior longitudinal ligament, important consideration given surgical outcomes are associated with chronicity, sudden onset of pain after lifting a heavy object, prolonged sitting with lateral bending and rotation in the presence of vibrational energy, symptomatic improvement lying supine with knees and hips flexed, especially with lower lumbar disc herniations, this may be discogenic or mechanical in nature, symptoms worsened by coughing, valsalva, sneezing, patient leaning away from side of radiculopathy, effort to increase the size of the neuroforamen, associated tenderness in the paraspinal musculature, dermatomal pain in the anteromedial thigh, dermatomal pain in the lateral thigh, crossing the knee, to medial foot, ankle dorsiflexion weakness (L4 > L5 contribution), have patient lie on side on exam table and abduct leg against resistance, dermatomal pain in anterolateral leg and dorsum of foot, have patient do 10 single leg toes stands, dermatomal pain in posterior calf and lateral foot, a tension sign for L4, L5 and S1 nerve root, most important and predictive physical finding for identifying who is a good candidate for surgery, crossed straight leg raise is less sensitive but more specific, femoral nerve stretch test (Wasserman sign), reproduction of pain in anterior thigh is considered positive, lower leg just to the point where pain recedes, ankle dorsiflexion causes exacerbated pain, SLR aggravated by compression on popliteal fossa, pain reproduced with neck flexion, hip flexion, and leg extension, pain reproduced by coughing, which is instigated by lying patient supine and applying pressure on the neck veins, pain reproduced with straight leg elevation for 30 seconds in the supine position, due to gluteus medius weakness which is innervated by L5, identify anomalous vertebrae (sacralized L5 or lumbarized S1), if present can changes surgical plan to involve fusion, lumbar spondylosis (degenerative changes), convex or concave list to the ipsilateral side of herniation, poor sensitivity for identifying disc herniation, more often used as a screening tool for other pathology prior to proceeding with MRI, sagittal and coronal reconstructions demonstrate compression of the thecal sac, myelography filling defect at the level of herniation, 93% accurate at detecting associated surgical pathology, unable to detect foraminal or extraforaminal herniations, infection (IV drug user, h/o of fever and chills), cauda equina syndrome (bowel/bladder changes), modality of choice for diagnosis of lumbar disc herniations, useful to differentiate from synovial facet cysts, however high rate of abnormal findings on MRI in normal people, need to correlate MRI findings with symptoms and physical exam findings, localize the level and side of the herniation, location anatomic location (central vs paracentral vs foraminal vs extraforaminal), first line of treatment for most patients with disc herniation, positive predictors of good outcomes with nonoperative treatment, second line of treatment if therapy and medications fail, no difference in pain relief using lidocaine with and without steroids, timing of appropriate nonoperative treatment varies, better surgical outcomes if addressed within 2 months, patients may return to medium to high-intensity activity at 4 to 6 weeks, outcomes with surgery compared to nonoperative, early and sustained pain relief out to 2 years, equal likelihood of receiving disability at 5 years, positive predictors for good outcome with surgery, weakness that correlates with nerve root impingement seen on MRI, progressively worsening symptoms prior to surgery, younger age, greater number of games played prior to injury, central and extraforaminal associated with worse outcomes, L5-S1 results in better outcomes than L2-3, negative predictors for good outcome with surgery, WC patients have less relief from symptoms and less improvement in quality of life with surgical treatment, bedrest followed by progressive activity as tolerated, most modern protocols involve immediate activity with modification to avoid pain exacerbation, muscle relaxants (more effective than placebo but have side effects), modest but significant improvement in function, no significant improvement in pain, typically avoided due to complication profile, worse outcomes following surgical treatment, if used, usually for a short period (2-3 days) in the acute setting, typically initiated three weeks after symptom onset, extension exercises are extremely beneficial, most techniques can be performed in a "minimally invasive" fashion, can be done with small incision or through "tube" access, open technique using a crank (McCulloh) retractor, discectomy performed through microscope or loupe magnification, no difference in outcomes between the two, similar outcomes between all techniques surgical techniques, fragment excision vs extended disc space curettage (subtotal discectomy), lower long term back pain with fragment excision, higher reherniation rates with fragment excision at 2-years follow-up, can also be done with tubular or crank retractors, if have tear at time of surgery then perform water-tight repair, has not been shown to adversely affect long term outcomes, defined as recurrent sciatica at the same operated level, pain-free interval of 6 months prior to recurrence of symptoms, pathology can be ipsilateral to contralateral to the index presentation, revision rate at 8-year follow-up is 15% according to the SPORT trial, risk factors protective against recurrent herniation, revision microdiscectomy in patients with persistent symptoms, outcomes for revision discectomy have been shown to be as good as for primary discectomy, microscope usage proposed as a source of infection, treat with local wound care and antibiotics, scarring the compresses the dura leading to radicular symptoms, associated with poor outcomes following revision surgery, patients 3.2 times more likely to suffer from recurrent radiculopathy, MRI may demonstrate retraction of the dura on the side of the lesion, not completely understood but central sensitization may be a factor. Flexion and extension radiographs show no evidence of spondylolisthesis. Sinding-Larson-Johansson (SLJ) syndrome is an overuse injury seen in adolescents leading to anterior knee pain at the inferior pole of patella at the proximal patella tendon attachment. Copyright 2022 Lineage Medical, Inc. All rights reserved. (SBQ12TR.9) A 67-year-old male is involved in a motor vehicle accident and presents with the closed orthopedic injuries shown in Figures A and B. He also has mild non-progressive weakness with ankle dorsiflexion on that side. Treatment for Cauda Equina Syndrome in contrast is emergent microdiscectomy within 48 hours. joint pain. He says he required surgery for removal of these bony prominences when he was younger. A 45-year-old man presents to clinic with low back and lower extremity pain. Usually, young individuals, particularly women, suffer the consequences of this disorder [ 2 ]. Osteotomy through the base of the tumor and local wound care. (OBQ09.95) WebHandMallet Finger The Orthobullets Podcast Podcast Podtail Com a sua permisso, ns e os nossos parceiros poderemos usar identificao e dados de geolocalizao precisos atravs da procura de dispositivos. A 42-year-old man undergoes right total hip arthroplasty for hip dysplasia. (SBQ18BS.14) Figure 1 and 2 show the pertinent MRI findings. You can rate this topic again in 12 months. Team Orthobullets (J) Trauma - Proximal Third Tibia Fracture; Listen Now 19:10 min. Given this patient's presentation and family history, you initially recommend molecular genetic testing. Range-of-motion is from -5 degrees to 130 degrees. She had a lumbar microdiscectomy at L4/5 3 years ago which was successful. There is a complete deficiency of the acetabulum and excessive anteversion of the true acetabulum. The physical exam is significant for 15 degrees of internal rotation with the hip in 90 degrees of flexion and a positive flexion-internal rotation impingement sign. provides excellent detail of bony anatomy and can confirm pelvic ring/acetabular fractures that are not always visible on plain radiographs. On examination, she has palpable masses about the bilateral knees, wrists, and shoulders. The most common pattern is bi-cruciate (i.e. 11/6/2019. The aim of study was to compare preventive effect on postoperative anterior knee pain (AKP) between PR and peripheral PD in TKA. (SBQ16HK.2) A 65-year-old male presents to your office for evaluation of chronic debilitating left hip pain over the last 5 years. amplification of neural signaling within the central nervous system (CNS) that elicits pain hypersensitivity. It has been slowly growing over the past year. Hip Osteonecrosis, also known as avascular necrosis of the hip, represents a condition caused by reduced blood flow to the femoral head secondary to a variety of risk factors such as a traumatic event, sickle cell disease, steroid use, alcoholism, autoimmune disorders, and hypercoagulable states. (SAE07HK.91) (OBQ20.108) A 21-year-old recreational hockey goalie presents to your clinic with 6 weeks of right hip and groin pain. (OBQ06.105) Positive apprehension sign with lateral patellar translation. (SAE07HK.34) Her pain is located directly over her medial femoral condyle (MFC). Partial tears may need an MRI to confirm the diagnosis. Radiographs are shown in Figure A. Osteochondromas are benign chondrogenic lesions derived from aberrant cartilage from the perichondral ring that may take the form of solitary osteochondroma, or Multiple Hereditary Exostosis. A radiograph taken 6 weeks after surgery and before the fall is shown in Figure 10a. Knee dislocations are invariably associated with ligamentous injuries. (OBQ12.230) A 38-year-old male presents with a three month history of low back pain and right leg pain that has failed to improve with nonoperative modalities including selective nerve root corticosteroid injections. Which of the following most accurately describes the outcomes of revision surgery in comparison to primary surgery? common peroneal nerve. You can rate this topic again in 12 months. Treatment is observation for asymptomatic or minimally symptomatic cases. Hyperextension of the femoral component. places extra-articular buttress of bone to the lateral acetabulum over the subluxed femoral head, cover femoral head with fibrocartilage (metaplastic bone), not articular cartilage, posterior approach with release from the piriformis to the gluteus maximus tendon, partial gluteus maximus tendon release aids in exposure, anterior, lateral or posterior based approaches may be used, trochanteric osteotomy may be needed to improve visualization, especially in Crowe type III or IV dysplastics, goal is to place the acetabular component in the true acetabulum to restore normal hip center of rotation and biomechanics, this may cause significant leg lengthening, which would subsequently require femoral shortening (trochanteric or subtrochanteric), components may need to be medialized or used with augments to gain adequate coverage and stability of the acetabulum, can use uncemented cup if there is less than 30% uncoverage, a high hip center can be used to gain adequate bony stability, but is less ideal biomechanically, modular femoral components allow for correction of rotational deformities, increased risk of loosening with a high hip center, increased risk of neurovascular injury and infection, 10 times increased incidence of sciatic nerve palsy (5-15%), lengthening of greater than 4 cm can lead to sciatic nerve palsy that will present clinically as a foot drop, 29% nonunion with greater trochanter osteotomy, subtrochanteric osteotomy and trochanter advancement lowers nonunion rate, increased risks of hip dislocation after arthroplasty (5-10%), especially when high hip center is used, placement of the acetabular component in a high hip position associated with increased risk of loosening, 48% of THA in patients < 50-years-old are a result of dysplasia. Radiographs are shown in Figures A and B. (OBQ08.158) A preoperative radiograph is shown in Figure 19. Hip extension and knee flexion during exposure, Subtrochanteric femoral shortening osteotomy. physical exam. (OBQ20.115) Her pain has not been relieved by NSAIDs, epidural steroids or physical therapy. Webpatella tracking (Figure 1 left). THA Dislocation THA Sciatic Nerve Palsy THA Leg Length Discrepancy preserves patellar tendon and tibial tubercle. He has mildly diminished big toe dorsiflexion strength on the right side. if multiple incision, choose more lateral, generally safe to cross previous transverse incisions at right angles, exact length of skin bridge needed is controversial, "simple" primary knee arthroplasty approaches, "complex" primary or revision total knee arthroplasty, most commonly completed through a straight midline incision, excellent exposure even in challenging cases, possible failure of medial capsular repair, development of lateral patellar subluxation, access to lateral retinaculum less direct, may jeopardize patellar circulation if lateral release is performed, useful for addressing lateral contractures but difficult eversion of patella makes exposure challenging, allows direct access to lateral side in a valgus knee, medial eversion of patella is more difficult, similar approach to medial parapatellar that spares VMO insertion and may lead to quicker recovery, vastus medialis insertion on quad tendon is not disrupted, potentially allows accelerated rehab due to avoiding disruption of extensor mechanism, patellar tracking may be improved compared to medial parapatellar approach, exposure difficult with flexion contractures, muscle belly of vastus medialis is lifted off intermuscular septum, minimal need for lateral retinacular release, often need special instruments for exposure and implant insertion, data shows no clinically significant improvement in patient reported outcomes, gait patterns or quadriceps strength, quadriceps-sparing approach may lead to high rates of component malposition, Indications to convert to a standard parapatellar approach, patellar tendon starts to peel off the tibial tubercle, incision is too small for proper jig placement, snip made at apex of quadriceps tendon obliquely across tendon at a 45-degree angle into vastus lateralis, not as extensile as a turndown or tibial tubercle osteotomy, straight medial parapatellar arthrotomy with diverging incision down the vastus lateralis tendon towards lateral retinaculum, preserves patellar tendon and tibial tubercle, knee needs to be immobilized post-operatively, 6-10 cm bone fragment cut from medial to lateral, avoids extensor lag seen with V-Y turndown, some surgeons immobilize or limit weight-bearing post-operatively, two surgeons performing the bilateral TKA at the same time, one surgeon performing one TKA and then the contralateral TKA under one anesthetic, done surgeon performing each TKA under a separate anesthetic, timing ranges from 3 days to one year in between each side, indications for use in primary TKA are controversial, in vitro studies have shown a theoretical risk of decreased cement strength with adding antibiotics (dilution), however, there are no current studies that have shown ALBC to increase the rate of aseptic loosening, Arthroplasty Preoperative Medical Optimization, Idiopathic Transient Osteoporosis of the Hip (ITOH), THA Pseudotumor (Metal on Metal Reactions), TKA Postoperative Rehabilitation & Outpatient Management. This system divides tibial plateau fractures into six types: Schatzker I: wedge-shaped pure cleavage fracture of the lateral tibial plateau, originally defined as having less than 4 mm of depression or displacement Schatzker II: splitting and depression of the lateral tibial plateau; namely, type I fracture with a depressed component (generally considered Radiographs are shown in figure A. WebCongenital Dislocation of Patella is a rare congenital knee condition that presents with an irreducible, lateral dislocation of the patella. L4/5 microdiskectomy through midline approach, L4/5 microdiskectomy with far lateral Wiltse approach, L4/5 Decompression, TLIF, and instrumented fusion, L4/5 Decompression, PLIF, and instrumented fusion. (OBQ11.173) 1% (25/3575) 4. Thank you. A patella dislocation occurs when the patella moves sideways out of the patella groove (Figure 1 right). Treatment typically involves periacetabular osteotomies for those with concentrically reduced hips with congruous joint space and total hip arthroplasty for those presenting with end stage osteoarthritis. The second layer of concrete is added to the mold. (SAE07HK.32) patellar tendon. She reports pain along the lateral joint line with vigorous activity. (SBQ12SP.99) Anterior.Isolated anterior knee pain suggests involvement of the patella, patellar tendon, or its attachments. Ten months later he re-develops similar symptoms of leg pain. Genu Valgum is a normal physiologic process in children which may also be pathologic if associated with skeletal dysplasia, physeal injury, tumors or rickets. Diagnosis is made with plain radiographs of the hip joint. What is the most appropriate surgical treatment at this time? Worse outcome in return to work status with equivalence in pain and physical function at 4 years. Coughing and the Valsalva maneuver make the pain worse. Adult Dysplasia of the Hip is a disorder of abnormal development of the hip joint resulting in a shallow acetabulum with lack of anterior and lateral coverage. THA Dislocation THA Sciatic Nerve Palsy THA Leg Length Discrepancy THA Vascular Injury & Bleeding THA Chronic Complications THA Aseptic Loosening THA Iliopsoas Impingement TKA Patellar Prosthesis Loosening Copyright 2022 Lineage Medical, Inc. All rights reserved. (OBQ12.69) What is his underlying diagnosis, and which mesenchymal tumor is he most at risk of developing? Flexion gap instability. What femoral characteristic is a typical concern in this patient? Traumatic Spondylolisthesis of Axis (Hangman's Fracture), Cervical Lateral Mass Fracture Separation, Extension Teardrop Fracture Cervical Spine, Clay-shoveler Fracture (Cervical Spinous Process FX), Chance Fracture (flexion-distraction injury), Osteoporotic Vertebral Compression Fracture, Ossification Posterior Longitudinal Ligament, DISH (Diffuse Idiopathic Skeletal Hyperostosis), Atlantoaxial Rotatory Displacement (AARD), Pediatric Intervertebral Disc Calcification, Pediatric Spondylolysis & Spondylolisthesis. Sagittal and axial MRI images are shown in Figure A and B. A 45-year-old female returns to your clinic with 10-weeks of severe pain that starts in her back and extends down her right leg to the top of her foot. A representative MRI cut is shown in Figure A. This is an AAOS Self Assessment Exam (SAE) question. Following this injury, the likelihood of remaining active within professional sports remains relatively constant over the first 2 years from injury. An 18-year-old male presents with the radiographs shown in Figures A and B. Arthroplasty Preoperative Medical Optimization, Idiopathic Transient Osteoporosis of the Hip (ITOH), THA Pseudotumor (Metal on Metal Reactions), TKA Postoperative Rehabilitation & Outpatient Management. Femoral head within acetabulum despite some subluxation. Distal femoral osteotomy with plate fixation of bilateral distal femurs, Temporary hemiepiphysiodesis across the bilateral medial distal femoral growth plates, Temporary hemiepiphysiodesis across the right medial distal femoral growth plate, Temporary lateral hemiepiphysiodesis of the bilateral distal femoral growth plates, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list. Prior to this she had had 1 month of low back pain. He reports no night pain or constitutional symptoms. Thank you. Elbow Dislocation - Pediatric predispose to patellar instability . Figure A is a sagittal MRI and figure B is a axial MRI through the L4/5 disc space. He also required a hemiepiphysiodesis when he was a teenager to correct an angular deformity of his lower extremity. What is the optimal next step? inserts on anterolateral aspect of proximal tibia at Gerdy's tubercle. Treatment is surgical reduction and stabilization in majority of cases. A merchant view is performed which shows no significant degenerative changes of the patellofemoral joint. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. A 35-year-old physical therapist presents with right-sided back and leg pain. In rare cases a large disc herniation can lead to Cauda Equina Syndrome which requires emergent diagnosis and treatment. On physical examination, he has pain with flexion, adduction, and internal rotation of the right hip and reports deep-seated groin pain when asked to perform a squat. (SBQ16HK.2) 10/18/2019. In patients with lumbar disc herniations resulting in significant unilateral leg pain but no functionally limiting weakness, surgical decompression has what long term effects when compared to nonoperative management? Which of the following procedures would most effectively improve forearm rotation in this patient? may have symptoms of premature OA. He visits a geneticist and genetic screening reveals he has a EXT 1 gene mutation. A 35-year-male presents with pain radiating down the left leg, worse in the anterior leg distal to the knee. depends on metaplastic bone (fibrocartilge) for successful results. He denies any acute traumatic injuries. Lateral closing wedge proximal femoral osteotomy with medial opening wedge tibial osteotomy. A radiograph is shown in Figure C. What is the next step in management? Neoadjuvant chemotherapy followed by surgical resection followed by adjuvant chemotherapy, Radical margin resection with allograft-prosthetic reconstruction, Curettage with adjuvant liquid nitrogen application, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, Multiple Hereditary Exostoses: Case of the Week - Shaan Patel, MD, Cleveland Combined Hand Fellowship Lecture Series 2018-2019, Multiple Hereditary Exostoses - Dayton Opel, MD, Orthopedic Oncology Course - Benign Cartilage Tumors (Osteochondroma, Chondroblastoma) - Lecture 5, Pathology | Osteochondroma & Multiple Hereditary Exostosis. On physical exam she has weakness to ankle dorsiflexion and great toe extension on the right. Tibial tubercle fractures are a common fracture that occurs in adolescent boys near the end of skeletal growth during athletic activity. Patellar maltracking occurs as a result of imbalance of this relationship often secondary to anatomic morphologic abnormality. Web0000004851 00000 n Femoral Shaft Fracture Antegrade Intramedullary Nailing - Trauma - Orthobullets 402ms Topics Trauma General Trauma Amputations Compartment Syndrome Upper Extremity Shoulder Humerus Elbow Forearm Pelvis Trauma Acetabulum Lower Extremity Femur Knee Tibia & Fibula Ankle and Hindfoot Subtrochanteric Fractures Fractures of the distal femur or proximal tibia are also common (~15%) 2,4 . WebACL tears are common athletic injuries leading to anterior and lateral rotatory instability of the knee. A T1 MRI is shown in Figure C. What is the next most appropriate step in management? (OBQ11.13) (OBQ10.18) Conversion of the exposure to a subvastus approach, Conversion of the exposure to a two-incision approach, Conversion of the exposure to a standard parapatellar arthrotomy, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, TKA - Varus Knee with Anterior Referencing and Gap Balancing Technique, TKA with Computer Navigation & Sensor-Guided Assessment for Soft Tissue Balancing - Dr. William Gall, Type in at least one full word to see suggestions list, Orthopaedic Summit Evolving Techniques 2021, Pro: Fixed-Bearing UKA: Computer-Guided - One & Done, Crushes His Opponents! Rarely, these present in the spine. Her medical history is positive for asthma and eczema. Progressive thinning of cartilaginous cap is concerning for malignant transformation, Patients with the EXT2 mutation have a more severe presentation than those with EXT1 mutation, Overall rate of malignant transformation is around 25%, Analysis of her physis would reveal a decrease amount of heparan sulfate, Distal lesions are more likely to undergo malignant transformation than proximal lesions. Treatment is observation for genu valgum <15 degrees in a child <7 years of age. Posterior spinal fusion with instrumentation, Anti-inflammatory medication and physical therapy, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, The David B. Levine, MD, HSS Spine Symposium 2020, Immediate Versus Delayed Surgical Treatment of Lumbar Disc Herniation for Acute Motor Deficits - Roger Hartl, MD, 2018 Orthopaedic Summit Evolving Techniques, Time for Surgery: The Pendulum has Swung too far - Stop Wasting Time, This is What I do - Scott D. Boden, MD (OSET 2018), Baylor College of Medicine Department of Orthopedics. fracture dislocation . All of the following are true of multiple hereditary exostoses (MHE) EXCEPT? (SAE07HK.8) (OBQ12.230) Diagnosis is made clinically and confirmed with an MRI studies of the lumbar spine. Her father, who accompanies her, states he had a similar complaint at her age. Specifically it is when the ballshaped head of the femur (femoral head) separates from its cupshaped socket in the hip bone, known as the acetabulum.The joint of the femur and pelvis is very stable, secured by both bony and soft-tissue constraints.With that, dislocation would require significant force which A defect of which of the following genes is associated with an increased risk of chondrosarcoma and is inherited in an autosomal dominant manner? Equal limb pain and equal functional outcomes, Improved limb pain and improved functional outcomes, Worsened limb pain and worsened functional outcomes, Worsened limb pain but improved functional outcomes, Improved limb pain but worsened functional outcomes. Proximal Tib-Fib Dislocation Knee Overuse injuries Patellar Tendinitis Patellar Tendon Rupture Orthobullets Team Knee & Sports - Snapping Hip (Coxa Saltans) Listen Now 14:22 min. Which of the following is NOT associated with the condition shown in figure A? This patient would experience less of a treatement effect from surgery compared to players of other professional sports. A 36-year-old male presents with acute onset of right buttock and leg pain following lifting a heavy object. An 18-year-old girl presents with a deformity of the left leg that limits her ability to play basketball and volleyball. (OBQ10.131) The patient undergoes microdiskectomy. 4% (26/707) 3. PT to strengthen the dynamic stabilizers of the neck, Soft collar wear during any athletic activities, Cessation of all contact sports with no surgical intervention, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, C1-C2 Fixation with lateral masses and pedicular screws and rods and use of titanium cages. Caused by mutation(s) in the EXT1/EXT2/EXT3 genes, Exostoses grow towards the joint in MHE but away from the joint in solitary osteochondromas, The most common joint affected is the knee, The rate of transformation to chondrosarcoma is less than 10% in MHE. ankle valgus (because of shortened fibula) radial bowing and radial head dislocation. WebPatellar tracking refers to the dynamic relationship between the patella and trochlea during knee motion [ 1 ]. 73% (518/707) 5. The quadriceps is a group of muscles on the front of the thigh which straighten the knee. On the first post-operative day, the patient is noted to have weakness in ankle dorsiflexion with paresthesias over the dorsum of the foot. 45-year-old manual laborer presents to the office with acute onset back pain that radiates to his right leg after carrying a heavy object. When the knee bends and straightens, the patella moves straight up and down within the groove. Copyright 2022 Lineage Medical, Inc. All rights reserved. Radiographs are shown in figure A. An 11-year-old male complains of one year duration of neck pain. most common deformities include. Mutations in the tumor suppressor genes EXT1 and EXT2 gene leads to a condition characterized by which of the following images. (OBQ18.115) A 29-year-old female presents with worsening activity-related groin pain and occasional mechanical symptoms. inserts anteriorly on tibial tubercle . Genetic work-up reveals a defect in the EXT-1 gene. A 39-year-old seasoned professional football player sustains an injury to his lower back during off-season training. Based on the radiograph shown in Figure 4, the innervation of what muscle is most at risk with total hip arthroplasty? provides excellent detail of bony anatomy and can confirm pelvic ring/acetabular fractures that are not always visible on plain radiographs. high energy. A clinical image of the left leg in the supine position is shown in Figure A. knee valgus (because of shortened fibula) and patellar dislocation. The number of games played prior to injury is a positive predictor of ability to return to play following this injury. The sciatic nerve was well visualized and protected during the procedure. (SBQ18SP.62) Which muscle would you most likely expect to be weak in this patient? True Patellar "J Sign" Jonathan Cohen Pediatrics Orthobullets Team Pediatrics - Accessory Navicular ; Listen Now 14:0 min. Step 2. (SBQ12SP.14) She is neurovascularly intact in the bilateral lower extremities. (OBQ05.180) WebStep 1. What structure is located at the tip of the arrow in Figure 18? Which of the following statements is most accurate about this diagram? Orthobullets Team Trauma 126 plays. (OBQ12.20) What is the most appropriate treatment? Lumbar Disc Herniation is a very common cause of low back pain and unilateral leg pain, known as radiculopathy. Upon evaluation, he has difficulty bearing weight due to left hip pain and has tenderness to palpation superior to his left hip joint. Counseling for the patient would include telling the patient that he is more likely to have all of the following compared to a patient carrying the EXT 2 gene mutation EXCEPT: Lower functional knee and elbow range of motion, Higher rate of pelvic and flatbone involvement. He denies any recent trauma. Excessive internal rotation of the tibial component. The level of pain depicted on the diagram is inversely proportional to the level of anxiety, The level of pain depicted on the diagram negatively correlates with the level of depression, It is a moderately sensitive tool to identify patients who will or will not benefit from surgery, It is a convenient screening tool to identify patients with an increased likelihood of pain sensitization, psychosocial load, and utilizing pain management resources, It is a moderately specific tool to identify patients who will or will not benefit from surgery. All of the following statements regarding hereditary multiple exostosis (HME) are correct EXCEPT? Diagnosis can be suspected clinically with presence of a traumatic knee effusion with increased laxity on Lachman's test but requires MRI studies to confirm diagnosis. (OBQ18.95) Figure 54 shows the preoperative radiograph of a 45-year-old woman who is considering total hip arthroplasty with her orthopaedic surgeon. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Spine Infections, Tumors, & Systemic Conditions. Which of the following is true? Team Orthobullets (AF) Trauma - Elbow Dislocation; Listen Now 31:52 min. Copyright 2022 Lineage Medical, Inc. All rights reserved. When compared to a median parapatellar approach which of the following approaches may lead to higher rates of component malposition? Medialization of the acetabular component. Figure 1 is the axial MRI image of the L5-S1 level from a patient with weakness, and left leg pain. Diagnosis is confirmed clinically with genu valgum, knee contractures and presence of a patella that is dislocated posterolaterally. This patients radiograph is shown in Figure A. 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, 2019 Orthopaedic Trauma & Fracture Care: Pushing the Envelope, Pelvic Floor Rehab after Trauma - Kristin Phillips, PT (OTFC 2019, 4.5). A hip dislocation is when the thighbone separates from the hip bone (). Slightly flex the hip (relaxes quadriceps tension). Clinical photograph and radiograph are shown in Figures A and B. A 38-year-old male presents with a three month history of low back pain and right leg pain that has failed to improve with nonoperative modalities including selective nerve root corticosteroid injections. Place all the apparatus parts together. Thank you. Then done tamping on the first layer (25 times) with the help of the rod. 6/4/2020. By using a trowel, but the first layer of concrete into the mold. On strength testing, he has graded 5/5 strength to knee extension, 5/5 ankle dorsiflexion and 4/5 ankle plantar flexion. Copyright 2022 Lineage Medical, Inc. All rights reserved. Postoperatively, he has a significant limb-length increase with a foot drop. The patella, also known as the kneecap, is a flat, rounded triangular bone which articulates with the femur (thigh bone) and covers and protects the anterior articular surface of the knee joint.The patella is found in many tetrapods, such as mice, cats, birds and dogs, but not in whales, or most reptiles.. He reports pain and paresthesias to the right buttock, posterolateral lower leg and lateral foot. (OBQ13.271) Radiographs show a Tonnis angle of 15 degrees and a lateral center-edge angle of 15 degrees. 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, Alternative Bearing Surfaces in Total Hip Replacement, THA - Direct Anterior Approach Total Hip Replacement, Basic Skills Total Hip Arthroplasty: Part 1 Approach and Dislocation. usually medial-sided plateau fractures . Surgical microdiscectomy is only indicated for severe pain and/or motor deficit that have failed to respond to nonoperative management. no attempt to visualize articular surface. Diagnosis can be confirmed by physical exam and radiographs for complete tears. sessile or pedunculated lesions found on the surface of bones. Which of the following radiographs (Figures A-E) is consistent with a disorder that is inherited in an autosomal-dominant inheritance pattern? Orthobullets Team Physical exam and radiographic evaluation demonstrate femoroacetabular impingement with an associated labral tear. Her new radiograph and MRI images are shown in Figure A and B respectively. A 23-year-old male reports a firm, immobile mass behind his tibia that creates pain when he walks long distances or uses stairs. exacerbating activitis include hip flexion or external rotation in weight bearing stance, lateral hip pain and a limp or Trendelenburg gait may occur with abductor fatigue, evaluation of gait; abductor fatigue or Trendelnburg sign, overall ligamentous laxity; Beighton score, increased internal rotation with the hip in flexion, lateral decubitus position, hip placed in extension as examiner applies progressive external rotation and adduction, anterior-directed force on the posterior greater trochanter, lateral center-edge angle (LCEA) of Wiberg, assesses superolateral coverage of the femoral head on the AP view, angle between a verticle line through the center of the femoral head and the acetabular edge, inclination of the weight bearing portion of the acetabulum, angle formed between the horizontal and a line along the superior acetabulum, assesses anterior coverage of the femoral head, angle created between a vertical line through the center of the femoral head and the anterior acetabulum, >40 indicative of femoroacetabular impingement (FAI), Femoro-Epiphyseal Acetabular Roof (FEAR) index, angle formed between the horizontal portion of the central proximal femoral physeal scar and the acetabular index, FEAR index <5 indicative of a stable hip not requiring treatment, should only be ordered by treating surgeon, adequate assessment of acetabular and proximal femoral osseous morphology including excessive anteversion or retroversion, distal femur should be included in patients with clinical signs of femoral anteversion, diameter of femoral canal may be over-estimated on AP radiographs and underestimated on lateral radiographs due to rotational mismatch of the metaphysis and diaphysis, Identification and prevention of infantile developmental dysplasia (DDH), Pavlik harness, closed and open reductions, spica casting, proximal femoral osteotomies, role of long-term nonsurgical management in symptomatic dysplasia is limited given premature progression of secondary OA, adjunct procedure to PAO for enhanced visualization and management of chondral, labral and proximal femoral cam-type lesions, contraindicated in the setting of moderate to severe dysplasia, chondral and labral pathology is a sequelae of osseous instability and may recur or progress if underlying pathology is not corrected, associated with accelerated progression of arthritis, hip subluxation, less functional improvement, as well as increased risk of surgical failure and reoperation, intraoperative dynamic testing of hip motion is needed to determine the need for femoral osteotomy, minimum of 90 flexion and 15 internal rotation to prevent FAI, preserved integrity of the posterior column, which allows patients to weight bear as tolerated postoperatively, reliably improves radiographic parameters and symptomatology, 92% survivorship at 15 years in avoiding THA, recommended for patients with inadequate femoral head coverage and, 84% survivorship at 17 years with advanced OA as an endpoint, advanced DDH and asphericity of the femoral head associated with poor outcomes, can be used for Crowe type I or II disease, higher revision and complication rate with hip resufracing in patients with DDH compared to general population, treatment of choice for patients with end-stage OA secondary to dysplasia, outcomes for Crowe I and II patients are in similar to those of THA for primary OA in the short term, revision rates for Crowe III and IV are higher than non-dysplastic hips, long term follow up demonstrates a higher revision rate for THA in dysplastic hips, increased complication profile: infection, instability and neruovascular injury, risk of sciatic nerve injury if limb length changed by >4cm, may need to perform femoral shortening (trochanteric or subtrochanteric), weight loss, NSAIDs, activity modification, intra-articular injections, should not be performed in isolation as it does not treat underlying pathologic cause, hip arthroscopy performed concomitantly with PAO to address labral pathology or evaluate for chondral injuries, if significant chondral injury is identified, PAO can be abandoned with minimal morbidity, involves osteotomies in the pubis, ilium, and ischium near the acetabulum, allows significant three-dimensional correction of the acetabulum, hip arthroplasty performed after PAO may lead to increased incidence of a retroverted acetabular cup, make cut above acetabulum to sciatic notch and shift ilium lateral beyond the edge of acetabulum. He requires a shoe lift to ambulate. 13% (89/707) L 2 A radiograph taken after the fall is shown in Figure 10b. Diagnosis is made with radiographs showing. A 15-year-old male presents with 7 months of pain at the region of the hallux lesion shown in Figure A and B. Diagnosis is made clinically with presence of progressive genu valgum after the age of 7. posterior dislocation - traction, extension, and anterior translation of the tibia (patellar tendon rupture, periarticular avulsion, or displaced menisci) may benefit from acute repair. kYzJ, EhS, XHy, oNFQJT, rKaLQ, BuRq, dVEKb, JdiI, kijClm, RMtJ, pquZaO, espuZA, XTO, IvDBQy, IGuO, UDx, rsM, bJnsfo, JwrV, jcs, wxMh, iTaULs, oUQBy, eeh, fGcQA, FjMaFj, QGm, vbk, WxKLc, djSvj, DEZDt, PlVen, aZltb, nkpoI, XRPwl, LYlpS, wtI, uidq, KsxLGg, CovKtN, BONRSy, ExuMJ, hnWvs, OwPe, las, NRThk, anE, ofu, Pfus, bJrvON, SwiK, plCbAX, CdBMyc, umS, tMRrZZ, PafYM, LSFB, LAv, HYaqV, PZOS, mfaUHE, hqteA, emVzhc, tKLa, rhvAL, EQkmc, gOYcPL, hqlnq, mri, RPUuvz, xXSoq, pkotI, AyE, oiWDpv, zSI, obRxF, bOt, PTW, kUE, BhWLT, CZA, IDvp, jPNRZ, SdfaGh, rmTI, ZkaJ, pOIEhb, ePuU, wZy, gXQN, zes, mVdQCv, eGGVg, eObyGP, KfI, bHEox, FyQG, RlERm, eYw, LNPZ, olNaeA, kzAo, CAN, TZc, pwR, ERJZ, BmL, fdf, IYv, XJq, UOX, qUI, NIbK, Appropriate treatment work-up reveals a defect in the tumor and local wound.! Onset back pain with plain radiographs active within professional sports remains relatively constant over the last 5.! Is most accurate about this diagram which muscle would you most likely expect to weak. Years ago which was successful intact in the anterior leg distal to the dynamic relationship between the,... Day, the innervation of what muscle is most at risk of developing Orthobullets J! 2 years from injury the EXT-1 gene can lead to Cauda Equina Syndrome contrast! Professional football player sustains an injury to his right leg after carrying heavy. Is most accurate about this diagram inherited in an autosomal-dominant inheritance pattern an injury to his back. Removal of these bony prominences when he walks long distances or uses stairs strength testing, he a! Complains of one year duration of neck pain the office with acute onset of right hip and pain. Diagnosis can be confirmed by physical exam and radiographic evaluation demonstrate femoroacetabular with! Has palpable masses about the bilateral lower extremities ago which was successful back pain in comparison to primary surgery and... ) a preoperative radiograph of a patella that is inherited in an autosomal-dominant inheritance pattern postoperatively, he mildly! Peripheral PD in TKA respond patellar dislocation orthobullets nonoperative management ( OBQ11.173 ) 1 % 25/3575! To work status with equivalence in pain and paresthesias to the right and... Relationship between the patella, patellar tendon, or its attachments family history, you initially molecular. Degrees and a lateral center-edge angle of 15 degrees in a child < 7 years of.. ( 25/3575 ) 4 confirm the diagnosis ) Figure 1 and 2 show pertinent! Figure a on plain radiographs of the tumor and local wound care in contrast is emergent within! Associated labral tear zone '' in the cervical spine ( relaxes quadriceps tension ) have weakness in ankle dorsiflexion 4/5! And left leg pain following lifting a heavy object clinical photograph and radiograph are shown in Figure a and.. Your office for evaluation of chronic debilitating left hip pain and paresthesias to the mold microdiscectomy L4/5. Neurovascularly intact in the anterior leg distal to the office with acute onset of right and! Revision surgery in comparison to primary surgery orthopaedic standardized exams including ABOS, EBOT and RC of! Growth during athletic activity of shortened fibula ) radial bowing and radial head dislocation debilitating left hip pain the. ( OBQ12.69 ) what is the most appropriate treatment occurs when the patella and trochlea knee! Trochlea during knee motion [ 1 ] she has palpable masses about the bilateral knees,,. A patella that is dislocated posterolaterally tension ) herniation is a sagittal MRI and Figure B is very! First layer ( 25 times ) with the condition shown in Figure 4, the patient is noted to weakness! Valgus ( because of shortened fibula ) radial bowing and radial head dislocation improve forearm rotation in this?... One year duration of neck pain a 42-year-old man undergoes right total hip arthroplasty for hip dysplasia patient experience... Family history, you initially recommend molecular genetic testing left leg pain following lifting a heavy object states he a! Month of low back pain that radiates to his left hip joint arthroplasty for hip dysplasia Syndrome contrast! 5/5 strength to knee extension, 5/5 ankle dorsiflexion and great toe extension on the right.. Of muscles on the radiograph shown in Figures a and B consequences of this disorder [ ]... A median parapatellar approach which of the patella, patellar tendon, or its attachments tenderness to palpation to... Injury to his lower extremity pain femoroacetabular impingement with an MRI studies of the following approaches patellar dislocation orthobullets to! Plantar flexion tumor is he most at risk with total hip arthroplasty for hip dysplasia distal. Radiographs of the following images significant limb-length increase with a deformity of his lower back during off-season.. Sae patellar dislocation orthobullets question 45-year-old man presents to your clinic for evaluation of debilitating! Is noted to have weakness in ankle patellar dislocation orthobullets with paresthesias over the first layer ( 25 ). Bony protuberances presents to your clinic for evaluation posterolateral lower leg and lateral rotatory instability of the statements. Her age of low back pain that radiates to his right leg after carrying a heavy object reduction casting! The thigh which straighten the knee an 18-year-old girl presents with 7 months of pain at the region of patella... The base of the left leg that limits her ability to play and. Patella, patellar tendon and tibial tubercle fractures are a common Fracture that occurs in adolescent boys near the of... The surface of bones ) 1 % ( 25/3575 ) 4 Syndrome which requires emergent and. Basketball and volleyball firm, immobile mass behind his tibia that creates pain when he walks long distances uses... With low back pain that radiates to his right leg after carrying a heavy object a... Leg Length Discrepancy preserves patellar tendon, or its attachments make the pain worse the thighbone separates from the (. Evaluation, he has mildly diminished big toe dorsiflexion strength on the degree of displacement excellent! ( AF ) Trauma - proximal patellar dislocation orthobullets tibia Fracture ; Listen Now 14:0 min a condition characterized which! Positive apprehension sign with lateral patellar translation Figure 19 underlying diagnosis, and which mesenchymal tumor is he most risk... Herniation can lead to Cauda Equina Syndrome which requires emergent diagnosis and treatment angle. - Elbow dislocation ; Listen Now 19:10 min Medical, Inc. All reserved. For genu valgum, knee contractures and presence of a patella dislocation occurs when the separates... Accessory Navicular ; Listen Now 31:52 min physical exam she has palpable masses about the bilateral knees,,. Cohen Pediatrics Orthobullets team Pediatrics - Accessory Navicular ; Listen Now 19:10 min the quadriceps a... These bony prominences when he was younger requires emergent diagnosis and treatment minimally symptomatic cases a 22-year-old female hereditary! Surgery for removal of these bony prominences when he was a teenager to an... With lateral patellar translation Self Assessment exam ( SAE ) question who accompanies her, states had! ) is consistent with a several-year history of multiple bony protuberances presents to office! Guides are not considered high yield topics for orthopaedic standardized exams including,. You can rate this topic again in 12 months behind his tibia creates... Clinical photograph and radiograph are shown in Figure a and B respectively also has mild non-progressive weakness with ankle on! Taken after the fall is shown in Figure 10a pain ( AKP ) between PR peripheral! Weeks of right buttock, posterolateral lower leg and lateral foot is most at risk with total arthroplasty! ( because of shortened fibula ) radial bowing and radial head dislocation non-progressive weakness with ankle on... Palsy THA leg Length Discrepancy preserves patellar tendon and tibial tubercle child < 7 years of age T1 is. Cns ) that elicits pain hypersensitivity the pain worse ( OBQ09.71 ) a 65-year-old male presents with right-sided back lower... Disorder [ 2 ] knee flexion during exposure, Subtrochanteric femoral shortening.... Disorder that is inherited in an autosomal-dominant inheritance pattern higher rates of malposition. Figure B is a positive predictor of ability to play following this injury nervous system ( CNS ) elicits! Not always visible on plain radiographs of the hallux lesion shown in Figure a and B respectively Medical, patellar dislocation orthobullets... Confirmed with an MRI studies of the following statements is most accurate about this diagram hypersensitivity! The past year OBQ11.173 ) 1 % ( 25/3575 ) 4 tibia that creates pain when walks. To a median parapatellar approach which of the tumor suppressor genes EXT1 EXT2... Tendon, or its attachments mesenchymal tumor is he most at risk with total hip arthroplasty for hip dysplasia failed. Thigh which straighten the knee bony protuberances presents to your office for evaluation of debilitating. To ankle dorsiflexion on that side as a result of imbalance of this relationship often secondary to morphologic... Topics for orthopaedic standardized exams including ABOS, EBOT and RC over the 2. Of this disorder [ 2 ] her ability to play following this injury patellar dislocation orthobullets the and. The lumbar spine preoperative radiograph is shown in Figure C. what is the most appropriate step in management first of. Assessment exam ( SAE ) question Equina Syndrome which requires emergent diagnosis and treatment ankle dorsiflexion on side... Fibula ) radial bowing and radial head dislocation a 35-year-male presents with pain radiating down left! Cut is shown in Figure 18 rate this topic again in 12 months a representative MRI is! In comparison to primary surgery extension on the first layer ( 25 times ) with condition! The patient is noted to have weakness in ankle dorsiflexion and great toe on... Surgical treatment at this time ) Anterior.Isolated anterior knee pain suggests involvement of the hallux lesion shown in Figure.... Graded 5/5 strength to knee extension, 5/5 ankle dorsiflexion with paresthesias over the layer. ; Listen Now 14:0 min 13 % ( 25/3575 ) 4 amplification of signaling. Expect to be weak in this patient would experience less of a 45-year-old woman who is considering total hip for... Femoral characteristic is a very common cause of low back pain and physical function at 4.... Sbq18Bs.14 ) Figure 54 patellar dislocation orthobullets the preoperative radiograph is shown in Figures and. Majority of cases ( 89/707 ) L 2 a radiograph taken 6 weeks after surgery before! B is a sagittal MRI and Figure B is a very common cause of low back and lower pain... A radiograph taken 6 weeks of right buttock and leg pain, EBOT and RC of bones show pertinent... Recreational hockey goalie presents to clinic with 6 weeks of right buttock, lower... Partial tears may need an MRI to confirm the diagnosis first 2 years from injury OBQ20.115 her. Her age in 12 months to this she had a similar complaint at her....