Treatment is nonoperative with bracing for first time dislocation without bony avulsion or presence of articular loose bodies. Knee Surg Sports Traumatol Arthrosc. resection arthroplasty and internal fixation of the fracture. Figure 10 shows the AP radiograph of an ambulatory 76-year-old patient. Which of the following has been shown to correlate most closely with good outcomes following ORIF of posterior wall fractures? Insufficiency fracture of the tibial plateau is an often missed diagnosis. Additional medical therapy can also include administration of prostaglandin I-1 and biphosphonates. What is the most appropriate reconstructive management on the femoral side? 2003 Aug;13(8):1843-8. doi: 10.1007/s00330-002-1775-6. Web5th metatarsal base fractures are common traumatic fractures among athletic populations that are notorious for nonunion due to tenuous blood supply. fractures occur in a bimodal distribution, fracture pattern predominately determined by, position of femoral head at time of injury, most commonly seen in transverse + posterior wall fracture patterns, most commonly affects the peroneal division of the sciatic nerve, mean lateral inclination of 40 to 48 degrees, acetabulum is supported by two columns of bone, connected to sacrum through sciatic buttress, anastomosis of external iliac (epigastric) and internal iliac (obturator) vessels, at risk with lateral dissection over superior pubic ramus, most common referenced classification system, anterior column (e.g., quadrilateral plate fractures), anterior column, posterior hemitransverse, Check for injury to superior gluteal NV bundle, More common in elderly patient with fall from standing, Axial CT shows anterior to posterior fx line, Only elementary fx to involve both columns, Characterized by dissociation of the articular surface from the innominate bone, Anterior column or wall + Post. Nonoperative. Which of the following associated type acetabular fracture patterns is defined based on the fact that all articular segments are detached from the intact portion of the ilium, which remains attached to the sacrum through the sacroiliac joint? Both prosthetic components are deemed to be stable. (OBQ11.148) Touch-down weight bearing of his right leg and observation of his sciatic nerve palsy, Skeletal traction on the distal femur to relax tension on the sciatic nerve. 0000044467 00000 n Diagnosis is made with plain elbow radiographs. (SAE07HK.49) Evangelopoulos DS, Heitkemper S, Eggli S, Haupt U, Exadaktylos AK, Benneker LM. Overall, your doctor should not only treat your injury but also work out why you developed this injury. MeSH WebSimple Fracture : A break in a bone without an accompanying wound at the fracture site. A 78-year-old woman who has a history of an uncomplicated right total hip arthroplasty presents after a fall. Classification. Which of the following is the most appropriate next step in surgical management? During the approach, what limb position minimizes tension placed on the sciatic nerve? sharing sensitive information, make sure youre on a federal Revision to a proximal femoral replacement, Open reduction and internal fixation with proximal femoral locking plate and cerclage cables, Open reduction and internal fixation with iliac crest bone grafting, Revision to a cementless long porous-coated femoral stem. He sustained a ground-level fall yesterday and he is now unable to bear any weight on the right leg. Surgical excision of the painful lesion is performed, and frozen section pathology demonstrates perineural fibrosis without fibrinoid necrosis. Vancouver C, revision to proximal femoral replacement, Vancouver B1, ORIF with impaction grafting, Vancouver B3, revision to proximal femoral replacement, Vancouver B2, ORIF with femoral strut allograft augmentation. A nondisplaced periprosthetic small posterior wall acetabular fracture is noted intra-operatively during total hip arthroplasty. Figure 36 shows the radiograph of a patient who has hip pain and is unable to ambulate. Revision of the acetabular component and ORIF of the femur with locking plates and cerclage wires, Revison of the femoral component, bypassing the fracture by two cortical diameters, Revision of the femoral component with impaction grafting and cerclage wires, Revision to a cemented component, bypassing the fracture by two cortical diameters, ORIF of the femur with locking plates and cerclage wires, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, 2021 ICJR 10th Annual Direct Anterior Approach Hip Course, Cemented Femoral Fixation in a High-Risk Cohort Diminishes Risk or Early Periprosthetic Fracture - Samuel Rodriguez, MD, ICJR 8th Annual Revision Hip & Knee Course, Video: Femoral Component Removal - Robert T. Trousdale, MD, Evaluation of Acetabular Bone Loss and Reconstruction Strategy Overview - James A. Browne, MD, Question SessionTHA Periprosthetic Fracture & Hallux Valgus. The posterior wall of the acetabulum is best visualized on which of the following radiographic views? 5% (127/2520) L 2 WebFor low grade fractures, without evidence for osteonecrosis, a fluid filled fracture line or cortical collapse, conservative treatment is recommended, consisting of NSAIDs and restricted weight bearing (toe touch weight bearing only). weakness. Web(OBQ18.22) A 79-year-old patient underwent a right hip hemiarthroplasty after sustaining a femoral neck fracture 8 weeks ago. His surgical sites are well healed and there are no signs of drainage. A 33-year-old male presents to the ER after a head-on motor vehicle collision complaining of severe left hip pain. Figure A is the radiograph obtained in the emergency department. Their mean age was 74 years (range 70-84). Kocher-Langenbeck; hip extended and knee extended, Kocher-Langenbeck; hip extended and knee flexed, Kocher-Langenbeck; hip flexed and knee extended, Ilioinguinal; hip extended and knee extended, Ilioinguinal; hip extended and knee flexed. Would you like email updates of new search results? They include, articulation between patella and intracondylar groove of femur, subchondral bone has weak potential to generate pain signals, Outerbridge MRI Classification of Chondromalacia, Surface intact and heterogenous; high signal intensity, Fissures and fragmentation extending down to the articular surface, Partial thickness defect, with focal ulceration, diffuse pain in the peripatellar or retropatellar area of the knee (major symptom), insidious onset and typically vague in nature, prolonged sitting with knee bent (known as theatre pain), always consider the physical, mental and social elements of knee pain, increased femoral anteversion or tibial external rotation, lateral subluxation of patella or loss of medial patellar mobility, compression of patella with knee range of motion or resisted knee extension, AP, lateral and notch radiographs of knee, shallow sulcus, patella alta/baja, or lateral patella tilt, best modality to assess articular cartilage, abnormal cartilage is usually of high signal compared to normal cartilage, mainstay of treatment and should be done for a minimum of one year, closed chain short arc quadriceps exercises, Outerbridge grade 2-3 chondromalacia patellofemoral joint, tight lateral retinacular capsule, loose medial capsule and lateral patellar tilt, severe symptoms that have failed to improve with extensive physical therapy, only elevate 1 cm or else risk of skin necrosis, superior medial arthrosis (scope before you perform the surgery), Spontaneous Osteonecrosis of the Knee (SONK), Osgood Schlatter's Disease (Tibial Tubercle Apophysitis), Anterior Superior Iliac Spine (ASIS) Avulsion, Anterior Inferior Iliac Spine Avulsion (AIIS), Concussions (Mild Traumatic Brain Injury). In patients without displacement of the fracture or the cartilage, there is a role for nonsurgical management. Delayed diagnosis can cause pain and disability to the patient and can lead to deformity of the knee joint, due to structural collapse. When viewing pelvic injury radiographs, which of the following describes the findings diagnostic of an isolated transverse acetabular fracture? A healthy, active 72-year-old man tripped and fell, landing on his left hip 10 weeks after an uncomplicated left primary uncemented total hip replacement. Anterior column/ posterior hemitransverse. The acetabular component is stable and well-fixed after implantation of an ingrowth acetabular shell during intraoperative examination. Transtectal transverse acetabular fracture, Anterior-posterior type III pelvic ring injury. Surgical decompression with partial meniscectomy versus meniscus repair may be indicated for persistently symptomatic A recent study on naval recruits showed prefabricated orthotics reduced MTSS [2] . Intraoperatively, fluoroscopy is positioned to obtain an obturator oblique-inlet view while placing a supraacetabular screw. Position of the screw cephalad to the sciatic notch, Screw starting point at the anterior inferior iliac spine, Screw starting point at the gluteal pillar, Screw position between the inner and outer tables of the ilium. The corona mortis artery joins the external illiac artery with which other major artery? A left hip radiograph is shown in Figure A, and the the abnormality in question is indicated by the white arrow. Figure 16 shows the radiograph of an otherwise healthy 62-year-old woman who fell. Retained femoral stem with open reduction internal fixation, Revision femoral stem to an uncemented long stem with strut allograft, Revision femoral stem to a cemented long stem with open reduction internal fixation, Revision femoral stem to an uncemented long stem with open reduction internal fixation. The patient fell down in the nursing home and noticed immediate pain and inability to bear weight. (SBQ10HK.77.1) His ESR and CRP are within normal limits. (OBQ10.108) Treatment is nonoperative for syndesmotic sprains without diastasis or ankle instability. She denies any history of dislocation or prodromal pain prior to her fall. What is the appropriate next step in management of this injury? Treatment may be nonoperative or operative depending on the location of the fracture and degree of fracture displacement. Improved patient-reported outcomes after surgical treatment are associated with which of the following variables? Once the diagnosis is made, the results are good with non-operative treatment. A 78-year-old male undergoes the procedure shown in Figure A for treatment of a femoral neck fracture. Alonso-Bartolom P, Martnez-Taboada VM, Blanco R, Rodriguez-Valverde V. Semin Arthritis Rheum. Physical examination shows that her range of motion is full and there is no effusion. Interdigital Neuromas, also known as Morton's neuroma, is a compressive neuropathy of the interdigital nerve that often leads to plantar forefoot pain. The patient undergoes the operative intervention depicted in Figure C through the extended iliofemoral approach. Spontaneous osteonecrosis of the knee associated with tibial plateau and femoral condyle insufficiency stress fracture. [9] ORIF of the posterior column and THA revision, Cage reconstruction of acetabular component, THA revision using a cemented acetabular component, Placement of a hip abductor brace and non-weight bearing in the affected limb, (SAE07HK.28) This particular injury is best treated with which of the following single approaches? She was noncompliant with her immediate postoperative weight-bearing instructions and went on to fixation failure. from acetabular reaming), Proximal metaphysis, displaced unstable fracture, ires/cables/claw plate for isolated GT fractures, Diaphyseal, cortical perforation (usually during cement removal), Diaphyseal, nondisplaced crack (from increased hoop stress during broaching or implant placement), Diaphyseal, displaced unstable fracture (usually during hip dislocation, cement removal, stem insertion), Distal to stem tip, cortical perforation (during cement removal), Distal to stem tip, nondisplaced fracture, Distal to stem tip, displaced unstable fracture, 0.1-3% for primary cementless total hip arthroplasties, cementless prosthesis tend to fracture in the first six months, likely caused by stress risers during reaming and broaching, wedge-fit tapered designs cause proximal fractures, cylindrical fully porous-coated stems tend to cause a distal split in the femoral shaft, cemented prosthesis tend to fracture later (5 years out), tend to fracture around the tip of the prosthesis or distal to it, often difficult to differentiate between B1 and B2 fractures based on radiographs alone, Revision of the femoral component to a long porous-coated cementless stems, Revision of the acetabular component if indicated, proximal bone that is poor quality or severely comminuted, Fracture occurs well below the prosthesis, non-displaced periprosthetic fractures of greater trochanter, non-displaced fractures of lesser trochanter, limiting abduction may decrease chances of displacement with greater trochanter fractures, displaced periprosthetic fractures of the greater trochanter, if osteolysis is present, use cancellous allograft to fill defects, typically place cerclage wires/cables proximally and bicortical screws distal to stem, may use unicortical locking screws proximally, Vancouver B3 fractures in elderly, low-demand patients. Epidemiology. Compound or Open Fracture : A break where the bone has penetrated the skin to the exterior, or the wound that broke the bone has exposed the broken ends. The abdominal work-up was negative, and her pain has since resolved, however, the pediatrician noted an abnormal radiographic finding in the left hip and requested a formal orthopedic evaluation. There is approximately one quadrant of passive medial or lateral patellar glide. During intraoperative assessment, the acetabular and femoral stems are found to be well fixed. While performing a cementless total hip arthroplasty in a healthy 68-year-old female, the surgeon notes an audible change while impacting the final broach. Insert long porous-coated stem, augment with cortical allograft and cerclage wires, touch down weight bearing postoperatively. (OBQ09.140) A 22-year-old female is involved in a motor vehicle collision and sustains the injury shown in Figures A through D. According to these images, what is the acetabular fracture classification? chest injury in up to 63%. You wish to further asses his injury pattern by ordering additional radiographs. (OBQ09.99) Etiology. (OBQ12.217) AJR Am J Roentgenol. A 40-year-old female secretary presents with left forefoot pain that radiates to her 3rd and 4th toes. 3% FOIA revision total hip arthroplasty with a cemented femoral component and adjuvant fracture fixation. What is the preferred treatment for this injury? WebTibial stress syndrome (also known as shin splints) is an overuse injury or repetitive-load injury of the shin area that leads to persistent dull anterior leg pain. (OBQ13.136) Orthopedic Trauma Robert T. Gorsline, M.D. The patient denies any history of hip trauma or pain. Post-operative radiographs are shown in Figure A. Which of the following treatment methods is most appropriate for treating this injury? Treatment is generally observation for patients who are asymptomatic. 1999 Jun;28(6):413-20. doi: 10.1016/s0049-0172(99)80007-9. She was initially closed reduced and splinted with the elbow joint in a reduced position and Percutaneous cement augmentation for the treatment of depression fractures of the tibial plateau. Posterior wall fragment; obturator oblique. Medial tibial plateau morphology and stress fracture location: A magnetic resonance imaging study. The stem is removed, two cable wires are passed around the calcar, and the same stem is reinserted. Revision arthroplasty using a cemented femoral component, Impaction allografting of the femoral component, Proximal femoral replacement arthroplasty. Past medical history is significant for hypertension. Knee Surg Sports Traumatol Arthrosc. (SBQ13HK.67.1) but is now painful when walking across campus. elevated contact pressures between patella and femoral groove are associated with anterior knee pain, a term coined for anatomic characteristics that lead to an increased Q angle and an exacerbation of patellofemoral dysplasia. (OBQ09.217) Bed rest and non-weight-bearing for 6 to 8 weeks, Component retention and open reduction and internal fixation, Revision arthroplasty with a long cemented stem, Revision arthroplasty with a long porous-coated cylindrical stem. The pain is exacerbated when she wears high heels. Treatment depends on the degree of angulation and is surgical if angulation remains greater than 30 degrees after closed reduction is attempted. (OBQ04.100) The cerclage cable was placed for a minimal medial calcar fracture seen during femoral preparation. Webfractures, the goals of treatment of tibial plateau fractures include achieving a stable knee, restoring the joint surface, and preserving functional ROM. WebA radiographic series is obtained and the fracture line is only appreciated on the internal oblique view. (OBQ11.80) HHS Vulnerability Disclosure, Help Metatarsal head osteonecrosis. Clipboard, Search History, and several other advanced features are temporarily unavailable. Stress fracture. His current radiograph is shown in Figure A. thought to be related to a disruption in the blood supply due to microtrauma or osteonecrosis and stress overloading. A 35-year-old male undergoes closed reduction under sedation in the emergency department for a posterior hip dislocation with an associated posterior wall fracture. WebSafe surgical dislocation with a trochanteric flip osteotomy has been shown to be a reliable technique that provides excellent exposure for treating femoral-head fractures with minimal complications. Diagnosis is confirmed with MRI studies of the knee. Fifteen years ago, he underwent a right total hip replacement and he had been having progressive thigh start-up pain over the prior 5 months. Degree of displacement seen on preoperative AP pelvis view, Degree of displacement seen on preoperative Judet views, Degree of displacement seen on preoperative pelvic CT scan, Degree of displacement seen on postoperative Judet views, Degree of displacement seen on postoperative pelvic CT scan. Narvez JA, Narvez J, De Lama E, Snchez A. Eur Radiol. Which of the following treatment options will best maintain motion and clinical function? (OBQ11.155) patella maltracking can create narrow contact pressure points and further attenuate pain. Bone scan. Right leg deformity, pain, and inability to bear weight are present on physical exam. Insufficiency fracture of the tibial plateau is an often missed diagnosis. Past medical history is significant for mild dementia and moderate coronary artery disease. Diagnosis can be made with plain radiographs of the affected hip and ipsilateral femur. Sports Medicine Bruce French, M.D. Impact of MRI on treatment plan and fracture classification of tibial plateau fractures. Treatment is a trial of nonoperative management with a wide shoe box with metatarsal pads. (OBQ04.232) WebTreatment usually includes a period of immobilization followed by physical therapy. Figures A and B are the radiographs of the right femur. (OBQ18.202) activity limitations, NSAIDS, immobilization. Treatment may be nonoperative or operative based on location of fracture, implant stability and bone stock available. Which of the following screw relationships is best evaluated with this view? (OBQ05.173) Yacoubian SV, Nevins RT, Sallis JG, Potter HG, Lorich DG. Web(OBQ11.233) A 48-year-old active female runner underwent percutaneous screw fixation of a minimally displaced femoral neck fracture six months ago. 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Radiographic Sclerosis and Pain of 2nd Toe. His pre-injury right hip film is seen in Figure A while films of his current injury are seen in Figures B and C. Prior to the fall he had no thigh or hip pain. (OBQ09.223) Unable to load your collection due to an error, Unable to load your delegates due to an error. Hip at 45 degrees, knee flexed to 90 degrees, Hip at 60 degrees, knee flexed to 90 degrees, Hip at 0 degrees, knee flexed to 90 degrees, Hip at 90 degrees, knee flexed to 90 degrees. 2018 Jul 21;19(1):244. doi: 10.1186/s12891-018-2170-z. A 45-year-old male is involved in a motor vehicle accident and sustains the injury shown in Figures A-D. To express high amounts of sonic hedgehog surface protein. Insert standard press-fit stem, weight bearing as tolerated postoperatively, Apply cerclage wire, insert standard press-fit stem, weight bearing as tolerated postoperatively, Insert long porous-coated stem, touch down weight bearing postoperatively, Insert long cemented stem, weight bearing as tolerated postoperatively. (OBQ17.97) First metatarsal base stress fracture. Management should consist of. There is a negative Tinel's sign at the tibial nerve. Associated injuries. A 25-year-old male is involved in a motor vehicle accident and presents with the injury shown in Figure A. Treatment is nonoperative with NSAIDs, activity modifications and physical therapy with most cases resolving over time. eCollection 2017 Jun 18. (OBQ09.163) In Figure A, the two red arrows point to which of the following two arteries? WebMB BULLETS Step 1 For 1st and 2nd Year Med Students. Idiopathic chondromalacia patellae is a condition characterized by idiopathic articular changes of the patella leading to anterior knee pain. What position of the leg exerts the least amount of intraneural pressure on the sciatic nerve? Dynamic fluoroscopic examination of the hip under anesthesia. Traction for 6 weeks followed by slow return to weight bearing, Revision to a long, cementless femoral stem, Revision to a long, cementless stem with strut allograft. (OBQ12.78) Comminuted Fracture : Bone is crushed or splintered. A 65-year-old woman with a history of right total hip arthroplasty presents with a fall. (SAE07HK.59) ER rotation stress view. A 73-year-old man who underwent a cementless total hip arthroplasty 8 years ago was in a high-speed motor vehicle accident and sustained the injury seen in Figure A. most commonly seen in patients 13-18 years, more common in female adolescent athletes, most often seen in 2nd metatarsal (MT) head, more common in patients with long 2nd metatarsals, thought to be related to a disruption in the blood supply due to, microtrauma or osteonecrosis and stress overloading, leads to eventual collapse of 2nd MT head, Dorsal collapse of articular surface on plain radiographs, Collapse of dorsal MT head, with plantar articular portion intact, Collapse of entire MT head, joint space narrowing, Severe arthritic changes and joint space obliteration, forefoot pain, swelling and stiffness localized to head of the second MT, exacerbated by distraction (early stages) and compaction (later stages), defect is usually located in the upper half of the articular surface of the MT head, activity limitations, NSAIDS, immobilization, short leg walking cast or boot for 4-6 weeks, can be used if symptoms are severe and do not improve with orthotics, only if extensive nonoperative management fails, dorsal disease involvement of bone and cartilage, plantar cartilage is not sufficient to reconstruct joint, can consider adding capsular interposition after joint debridement, drilling of metatarsal head, subchondral bone grafting, and interposition arthroplasty using EDL tendon, metatarsal head resection should be avoided due to increased loads on adjacent metatarsal heads, shortening offloads stress on metatarsal head, resects collapsed dorsal diseased bone and cartilage, bring less affected plantar cartilage into contact with proximal phalanx, Posterior Tibial Tendon Insufficiency (PTTI). She reports no constitutional symptoms and notes the pain is worse with using stairs or sitting for long periods of time in the backseat of a car. approach. Insufficiency fractures of the tibia and fibula. Revision total hip replacement with a proximally coated femoral stem, Open reduction, internal fixation with plate and cerclage wires, Proximal femoral replacement with megaprosthesis, Cortical strut allograft with cerclage wiring. MRI is sensitive to bone marrow oedema/ bone bruising, even in the osteoporotic tibial condyle. An 85-year-old woman sustains a ground level fall. Epub 2016 Jun 6. long bone fractures in 50%. Which of the following is most appropriate for management of the femoral side? WebA pattern of bone marrow edema (arrows) in the tibial plateau particularly medially is associated with a horizontal fracture line (circular dashed line) consistent with an insufficiency fracture. (OBQ05.124) A 74-year-old man falls, sustaining the injury shown in Figures A through C. In surgical planning, what is the best surgical approach to treat this injury? Treatment can be nonoperative for non-displaced fractures but displaced injuries require anatomic open reduction and internal fixation to minimize development of post-traumatic osteoarthritis. All of the following have been shown to negatively affect clinical outcomes in treating displaced acetabular fractures, EXCEPT: (OBQ07.114) 2% (110/5874) 5. Operative management is indicated for chronic and recurrent patellar instability. A 35-year-old male sustains a posterior column/posterior wall acetabular fracture. between the metatarsal heads (3rd webspace), compression/tension of the interdigital nerve around the, perineural fibrosis and entrapment of the interdigital nerve, transverse intermetatarsal ligament between the, confluence branches of the lateral and medial plantar nerves, relief of symptoms by removing shoes and massaging foot, most commonly on the plantar aspect of web space, bursal click may be elicited by squeezing metatarsals together, Drawer test at metatarsal phalangeal joint (MTPJ), non-palpable neuroma with clear clinical presentation, oval, hypoechoic mass oriented parallel to the metatarsal bones, may be used to rule out other pathologies, confirmatory for accurate diagnosis of interdigital neuroma, numbness over lateral surface of toe with relief of patient reported pain, consider if there is no relief of pain after well positioned digit nerve block, wide shoe box with firm sole and metatarsal pad, approximately 20% of patients will have complete resolution of symptoms, adding anti-inflammatory medications rarely provide any benefit, usually approached dorsal after isolating the neuroma with palpation or ultrasound, suggested to provide symptomatic benefit in short term randomized control studies, dorsal or plantar approach (dorsal most common), neurectomy with nerve burial (bury proximal stump within intrinsic muscles), transverse intermetatarsal ligament release, 3 to 4 cm incision just proximal to the involved webspace, blunt dissection to avoid injury to branches of superficial peroneal nerve, spread the metatarsal bones to visualize the webspace, as well as tension the transverse intermetatarsal ligament, protecting the neurovacular bundle, transect the transverse intermetatarsal ligament, identify the interdigital nerve proximal and distal to the nerve bifurcation, resect the nerve at least 3 cm proximal to intermetatarsal ligament, reapproximate and repair the transverse intermetatarsal ligament to avoid intermetatarsal head instability, inadequate retraction (traction neuritis), caused by tethering of plantar neural branches that prevent retraction following resection, nerve should be resected at least 3 cm proximal to intermetatarsal ligament, resect through plantar or dorsal incision, increased risk (5%) with plantar incision, Posterior Tibial Tendon Insufficiency (PTTI). Obtain AP, frog leg lateral, Dunn view, and false profile hip radiographs, CT scan to obtain tibial tubercle-trochlear groove measurements, Physical therapy regimen focused on quadriceps and core muscle strengthening program, Physical therapy regimen focused on Graston, ASTYM, and iontophoresis techniques, Obtain chest CT, skeletal survey, and refer to an orthopaedic oncologist, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, Knee & SportsIdiopathic Chondromalacia Patellae, Patella & trochlear chondral lesions in 38F. WebTibial Plateau Fracture & Treatment | Orthopedic One Our Physicians What Hurts Services & Specialties Locations About Request Appointment For Patients For Physicians Online Bill Pay Careers Request Appointment Scott Van Steyn, M.D. (SAE07HK.62) During surgery, the trauma surgeon replaces the radial head and repairs the lateral collateral ligament complex. The evaluation and management of specific types of tibial fractures in children is discussed (OBQ07.230) In patients with closed fractures and no sign of neurovascular compromise, initial management focuses on pain management, immobilization of the fracture, and reduction of swelling. Treatment is usually closed reduction and percutanous pinning (CRPP), with the urgency depending on whether the hand remains perfused or not. A 14-year-old presents on the request of her pediatrician for evaluation of her left hip. Open reduction and cerclage fixation of the fracture, Open reduction and revision of the femoral implant to a long cemented stem, Open reduction and revision of the femoral implant to a long fluted and tapered uncemented stem, Application of balanced traction and surgery after the ecchymosis has resolved. An official website of the United States government. MB BULLETS Step 2 & 3 For 3rd and 4th Year Med Students. A radiograph taken after the fall is shown in Figure 10b. Which of the following would be the most appropriate treatment? (OBQ04.244) 8600 Rockville Pike He denies any fevers or chills. (OBQ06.166) The authors have performed a retrospective study of 8 patients, all elderly females, seen in the period 2002-2004 with insufficiency fractures of the tibial plateau. Nonoperative management based on the size of the posterior wall fragment, Operative management based on the size of the posterior wall fragment, Operative management based on the history of hip dislocation, Dynamic fluoroscopic stress exam under anesthesia in the obturator oblique view, Dynamic fluoroscopic stress exam under anesthesia in the iliac oblique view. An 74-year-old community-ambulating male presents with complaints of right hip pain for 4 months. WebTreatment can be nonoperative or operative depending on location of fracture, implant stability, available bone stock, and patient comorbidities. The chief resident orders a CT scan which demonstrates a coronoid fracture involving 50% the height with no involvement of the anteromedial facet. World J Orthop. (OBQ08.268) Radiographs show no evidence of a stress fracture, an alpha angle of 45 degrees, and a lateral center edge angle of 30 degrees. An acetabular fracture with all segments of the articular surface detached from the intact posterior ilium is defined as what fracture pattern? Tibial Plateau Fractures in Elderly Patients. 1983 Jun;140(6):1211-5. doi: 10.2214/ajr.140.6.1211. 2010 Jul;18(7):911-5. doi: 10.1007/s00167-009-1003-x. A 78-year-old male falls at home four months following a right total hip arthroplasty. special care when using cementless prosthesis in poor bone (RA, osteoporosis), if evaluated intraoperatively and found to be, consider protected weight-bearing for 8-12 weeks, ORIF of acetabular fracture with revision of acetabular component, if posterior column is compromised, ORIF + revision is most stable construct, may add bone graft from reamings if patient has poor bone stock, may occur during implant insertion from dimension mismatch, usually occur when excessive force is used during, usually occur when tip of a straight-stem prosthesis, minimally invasive techniques (controversial), Vancouver classification (intraoperative), C - distal to stem tip (not amenable to insertion of longest revision stem), intraoperative radiographs are required when there is a concern for fracture, complete (two-part) fractures of middle region, distal tip of stem must bypass distal extent of fracture by 2 cortical diameters, may use cortical allograft struts for added stability, distal fractures that cannot be bypassed with a long-stemmed prosthesis, Proximal metaphysis, cortical perforation, Bone graft alone (e.g. Surgical decompression with partial meniscectomy versus meniscus repair may be indicated for persistently symptomatic patients who fail conservative management. Osteoporotic tibial plateau fractures: an underestimated cause of knee pain in the elderly. nonunion. (OBQ10.180) (OBQ18.221) What is the most appropriate treatment? A 33-year-old male sustains the injury seen in Figure A as a result of a high-speed motor vehicle collision. Shortly after the reduction, the patient continues to have a foot drop, but his sensation is slightly improved. The patient should be advised she is at greater risk of stem subsidence and early revision, Female sex is a risk factor for intraoperative calcar fracture, A better outcome would be expected if a long-stem diaphyseal fixation stem had been inserted after recognition of the calcar fracture, Cementless press-fit technique is not a risk factor for intraoperative fracture, Minimally invasive surgical approach is not a risk factor for intraoperative fracture. Complications: Recurrence common after resumption of heavy activity. The radiographic finding is most consistent with which of the following? WebRadial head and neck fractures in children are a relatively common traumatic injury that usually affects the radial neck (metaphysis) in children 9-10 years of age. This site needs JavaScript to work properly. Web(OBQ20.15) Figure A is the radiograph of a 55-year-old female who is a poorly-controlled diabetic with neuropathy and peripheral vascular disease (PVD) that underwent ankle open reduction internal fixation (ORIF) two years ago at an outside facility. Meniscal cysts are a condition characterized by a local collection of synovial fluid within or adjacent to the meniscus most commonly as result of a meniscal tear. Initial AP pelvis x-rays are shown in Figure A. small lesions of fluid within the meniscus, medial cysts are slightly more common than lateral, 2:1 ratio (although literature data are conflicting), lateral cysts = anterior horn or mid-portion, extruded fluid outside the meniscus (most common), meniscal tear functions as a one-way valve, synovial fluid extrudes and then concentrates to form gel-like material, horizontal and complex tears, usually = parameniscal cysts, radial or vertical tears, usually = perimeniscal cysts, interlacing network of collagen, proteoglycan, glycoproteins, and cellular elements, stretched-out, C-shape with triangular cross section, supplies peripheral 20-30% of medial meniscus, supplies peripheral 10-25% of lateral meniscus, central 75% of meniscus' receive nutrition through diffusion, localized to medial/lateral joint line or back of knee, weakness or claudication (neaurovascular impingement), best visualized with the knee in extension, should be normal in young patients with an acute meniscal injury or cyst, necrotic tissue, nerve sheath tissue, and pus can all resemble cysts on T2-weighted MRIs, indicated as first line of treatment for small perimeniscal cysts and parameniscal cysts, trial of medical therapy to observe patients pain response, may be effective in population with degenerative tears, ultrasound guided injection into the cyst, poor outcomes in older degenerative mensical tears with associated cysts, perimeniscal cysts with an associated tear that is not amenable to repair (e.g., complex, degenerative, radial tear patterns), incomplete meniscal resection may lead to recurrence, incomplete resection may lead to recurrence, interval between medial head of gastrocnemius and semimembranosus, sharp dissection of cyst margins to joint capsule, Spontaneous Osteonecrosis of the Knee (SONK), Osgood Schlatter's Disease (Tibial Tubercle Apophysitis), Anterior Superior Iliac Spine (ASIS) Avulsion, Anterior Inferior Iliac Spine Avulsion (AIIS), Concussions (Mild Traumatic Brain Injury). (OBQ04.93) All patients except one had a DEXA-scan, which revealed osteopenia in 4 and osteoporosis in 3 patients; all 7 were treated with bisphosphonates. A post-reduction radiograph is shown in Figure B. Physical exam demonstrates no palpable lesion, but pain is reproduced with forefoot squeeze. Treatment is activity restriction with protected weight-bearing in most cases. Which of the following images will be the MOST helpful in visualizing the left posterior column? Am J Orthop (Belle Mead NJ). malunion. What is the most appropriate treatment? THA Periprosthetic Fractures are a complication of a total hip prosthesis with increasing incidence as a result of increased arthroplasty procedures and high-demands of elderly patients. The patient has failed an appropriate course of conservative management and remains symptomatic. Web(OBQ04.148) A 34-year-old male presents with right knee pain, swelling, and symptoms of buckling 3 months after being involved in a motorcyle accident. WebTreatment is usually nonoperative with long leg casting but is tailored to the injury type and patient age. Radiographs of the right knee are found in Figures A-C. What is the next most appropriate step in management? reinforce with cerclage suture or wire from quadriceps tendon to tibial tubercle . At what time point after the injury is there an increased risk of a poor outcome? WebMedial Tibial Stress Syndrome (MTSS) is a common overuse injury of the lower extremity. WebTreatment is either immobilization or surgical fixation depending on fracture displacement and integrity of the extensor mechanism. Treatment is generally nonoperative with physical therapy and NSAIDs. (OBQ10.26) All 8 patients were treated conservatively with a cast brace, for 6 to 12 weeks, with a good result. rule out an occult fracture. A 67-year-old man 6 years status post right total hip arthroplasty falls while walking his dog. Compared to a dorsal approach, a plantar approach is associated with: Improved clinical outcomes and patient satisfaction, Increased likelihood of complete neuroma excision. A previously healthy 68-year-old woman falls and sustains the fracture seen in Figure A. Which of the following correctly pairs his Vancouver classification and appropriate surgical intervention? Trochanteric bursitis . Higher likelihood of being discharged to home as opposed to a rehab facility. A 32-year-old male sustains a posterior wall acetabulum fracture as the result of a high-speed motor vehicle collision. (OBQ18.80) First Author The patient has been optimized for surgical intervention. During the ilioinguinal approach to the pelvis, the corona mortis artery must be identified and ligated if present. She is RF negative but ANA positive. Her injury radiographs are depicted in Figure A. What is the best treatment option? (OBQ08.119) He complains of pain and is unable to bear weight through the right leg. Web- Percutaneous clamping of spiral and oblique fractures of the tibial shaft: a safe and effective reduction aid during intramedullary nailing.. - rotational alignment: - once the nail crosses the fracture site, great care must be taken to restore rotational alignment; - use flouro or the bi-malleolar axis to determine proper alignment; Arthroscopic labral debridement versus repair is indicated for patients with progressive symptoms who failed nonoperative management. views. All 8 patients were treated conservatively with a cast brace, for 6 to 12 weeks, with a good result. A 75-year-old male sustains a ground-level fall while ambulating at home. Meniscus. Please enable it to take advantage of the complete set of features! metatarsal stress fracture. Traction for 3 weeks followed by 2 months of non-weight bearing mobilization, Open reduction and plate fixation with cable augmentation proximally, Revision arthroplasty with a cementless long stem bypassing the fracture site by two cortical diameters, Revision arthroplasty with cemented femoral stem bypassing the fracture site by two cortical diameters, Revision arthroplasty with cementless long stem bypassing the fracture site by two cortical diameters and allograft strut augmentation. WebKnee pain affects approximately 25% of adults, and its prevalence has increased almost 65% over the past 20 years, accounting for nearly 4 million primary care visits annually. The .gov means its official. Plain radiographs are frequently negative in the beginning. WebTreatment is often ORIF in the acute setting versus delayed fixation after soft tissue swelling subsides. Federal government websites often end in .gov or .mil. Careers. Arthroplasty Preoperative Medical Optimization, Idiopathic Transient Osteoporosis of the Hip (ITOH), THA Pseudotumor (Metal on Metal Reactions), TKA Postoperative Rehabilitation & Outpatient Management. Acetabulum fractures are pelvis fractures that involve the articular surface of the hip joint and may involve one or two columns, one or two walls, or the roof within the pelvis. He denies any acute traumatic injuries. 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