ABFAS Exam Questions With 100% Correct Answers | Verified | Updated, Exams of Advanced Education

Download ABFAS Exam Questions With 100% Correct Answers | Verified | Updated and more Exams Advanced Education in PDF only on Docsity! ABFAS Exam Questions With 100% Correct Answers | Verified | Updated Diastasis for Lisfranc = a fracture is present - Correct Answer-2-5 mm of diastis betwen 1st and second mt base Chronic lisfrancs--->ct=1 mm diastasis betwen 1st and 2nd mt or an increase of more than 15 degrees in the tarso- metatarsal joint signs of lisfranc on xray - Correct Answer-fleck sign (1 and 2 met bases) first ray elevated arch flattens MCC direction lisfranc displaces - Correct Answer-Dorsal and Lateral When to sx correct lisfranc - Correct Answer->2mm displaced wait 14 days if too much edema Approach to ORIF lisfranc fx - Correct Answer-middle cunii start proximal superior medical >to the base of the 2nd mt possibly, 3rd mt. the first lag screw=KEY to REDUCTION. T if needed do a few more lag screws from the the bases metatarsals >cuni. If cuni instability **screw across the cunis.communition=plates. Rules for bunions in the Juvenile pt - Correct Answer-14-16 yrs. Ideal time frame to do sx for them is near skel. Maturity 11-15 yoa. Don't do anything joint destructive /don't remove the fib sesamoid. take mt adductus into consideration in a peds patient. Which does not affect bone healing: 1. Nutritional status, Rheumatoid or methotrexate patient, DM, tobacco hx, extent of initial injury, osteoporosis, other metabolic diseases, neuropathy - Correct Answer-all do mcc for ex fix - Correct Answer-1. m/c complications involve bone healing and not infection others: 1. delayed, nonunion, implant loosening, fracture, chronic pain, soft tissue inflammation, ulceration, or gross infection including osteomyelitis blood supply to talus - Correct Answer-i.posterior tibial artery, artery of the tarsal canal dorsalis pedis artery, perforating peroneal artery. MCC of talar AVN - Correct Answer-post-traumatic talar fracture Pain, swelling, with a history of previous injury or trauma. May have mechanical symptoms such as clicking, locking, or grinding. - Correct Answer-AVN diagnose by a. Plain XR and MRI remain the most used and beneficial modalities. Classification of AVN - Correct Answer-i. Hawkins type I fractures are non displaced vertical neck fractures. AVN is 10%. ii. Hawkins type II fractures consist of a vertical talar neck fracture with either subluxation or displacement of the STJ. AVN is 42%. iii. Hawkins type 3 fractures are characterized by a vertical talar neck fracture with subluxation or dislocation of both the ankle and STJs. AVN 91%. iv. Hawkins type IV fractures vertical talar neck fracture with subluxation or dislocation of the ankle, STJ, and the TNJ. AVN of 100%. what is Hawkins sign - Correct Answer-AVN=Hawkins sign: subchondral radiolucent line along the superior aspect of the talar dome, which classically begins on the medial side of the talar dome, and appears 6-8 weeks after injury. indicative of talar revascularization; seen on AP or mortise view. MRI presentation of AVN - Correct Answer-i. MRI is the most widely used modality to dx and potentially prevent further talar damage due to AVN. a. Normal T1 images will show a strong SI due to bone marrow elements in trabecular bone. b. In early AVN, diffuse marrow edema produces low signal intensity on T1 images and high SI on T2. c. In advanced stages, the diagnosis of AVN on MRI includes decreased SI on both T1 and T2 weighted images indicative of areas of devascularization or necrotic bone. Why perform arthroscopy for AVN - Correct Answer-a. Arthroscopic Debridement and Core Decompression: i. Rationale: Thought to enhance revascularization and decrease intraosseous pressure. 1. Indicated in treatment of F&A stages I and II (partial AVN and those without collapse). ii. Technique: Standard AM and AL portals used for arthroscopy with a lateral sinus tarsi (lateral process) approach for retrograde drilling. i. Allows large portion of diseased talus to be excised and replaced. Discuss Fresh talar bulk allograft surgical technique: - Correct Answer-a. Often lateral, medial, or both malleoli OTs required for adequate exposure. b. MC, the MM is OT- curvilinear incision made over the medial gutter, and the MM is predrilled with 2 4.0mm cannulated cancellous screw guide pins. The wires are measured and the proximal cortex is overdrilled prior to removal of the guide pins. c. Chevron OT performed to flap down the MM with the deltoid ligaments still attached to expose the medial shoulder of the talar dome. Posterior structures must be protected. d. Access to lateral talar lesions may require transection of the lateral collateral ligaments or fibular OT. A 5-hole 1/3 tubular plate is contoured and pre-drilled to stabilize the lateral OT to assist in assuring exact reduction at the completion of the case; the OT is made transversely under power at the level of the AJ. e. An anterior approach is used for central defects or in cases in which the partial AVN affects the entire talar ankle joint surface (between EHL and TA tendons). f. Once exposure is adequate, the talar defect is inspected; margins of necrotic bone are probed and identified. This is debrided down to vascular, bleeding bone. g. The base and edges of diseased bone are cut squarely with a saw and the inner surfaces is cut with a curved osteotome to construct a geometric shape. h. The donor site is reinspected for viable bone and cartilage margins, making sure that all necrotic bone is resected. i. Location of AVN and dimensions of the recipient's excavated bone are used to determine the exact matching site for harvesting the donor allograft. It is advised to slightly oversize measurements. j. The bulk talar allograft is press fit into the recipient's matching void. k. Chondral darts and resorbable or headless screws are used to permanently fixate the graft into place. Malleolar OT is realigned with MCC complication of AVN sx - Correct Answer-a. MC complication delayed or nonunion due to large amounts of necrotic talar bone present or the amount of nonliving graft used. 1. TTC arthrodesis for talar AVN surgical technique: - Correct Answer-1. TTC arthrodesis for talar AVN surgical technique: a. Incision made following the distal 1/3 of the fibula and brought distally in a J shape to the sinus tarsi. b. An OT of the fibula is made just proximal to the distal tibiofibula joint and the distal fibula is removed. c. This fibular autograft is morselized with a bone mill to provide rich and abundant autograft. d. The AJ and STJ are exposed, and all articular cartilage is denuded to bleeding cancellous bone. e. A medial arthrotomy incision is made just medial to the TA tendon exposing the medial gutter of the AJ. Arthrotomy completed. f. A 90 degree box cut is created at the intersection of the MM and distal tibia surfaces to allow medialization of the hindfoot and ankle on the tibia- the medullary canal of the tibia must be aligned with the central portion of the talus and calcaneus if retrograde nail fixation is to be used. The talus is also translated posteriorly. g. Hindfoot and ankle are temporarily fixated and an IM rod is inserted from the plantar aspect of the calcaneus with the foot and ankle held in the corrected position. h. After reaming, but prior to the insertion of the rod, the fibular autograft mixed with BMA is packed into the ankle and subtalar fusion sites. i. The nail is been inserted, compressed, and locked per protocol. j. Proximal locking of the nail is recommended for stability but not absolutely necessary. side of the ankle joint despite being well compensated for by the ample subtalar joint inversion motion available. Ankle recurvatum (apex posterior): compensation - Correct Answer-Compensated through the ankle joint by plantarflexion. jb.going down for compensation. Ankle procurvatum (apex anterior): - Correct Answer- Compensated through the ankle joint by dorsiflexion Normal ROM of the ankle Which has more compensation - Correct Answer-20 degrees of dorsiflexion, 50 degrees of plantarflexion the largest amount of deformity that can be compensated for is 50 degrees of recurvatum 20 degrees of procurvatum in the normal ankle joint what is tolerated better recurvatum or procurvatum? - Correct Answer-i. Procurvatum of the ankle or tibial plafond is less well tolerated than recurvatum because the available ankle joint dorsiflexion is less than that in plantarflexion- further limited by the anterior impingement of the neck of the talus on the anterior lip of the distal tibia. ii. Recurvatum better tolerated because of the large amount of available compensatory plantarflexion. Malunited AFx or fusion with internal rotation is compensated for by - Correct Answer-external hip rotation and foot pronation. Malunited AFx or fusion with external rotation is compensated for by - Correct Answer-internal hip rotation and foot supination. how much do u lengthen a short limb via ex fix perday? - Correct Answer-Lengthening performed at 0.5-0.75mm/day after a latency of approximately 5-7 days. ideal ankle fusion realignment position - Correct Answer-a. In the sagittal plane, the foot is placed at a right angle to the limb (plantigrade, 90°), tibial middiaphyseal line coincides with the lateral process of the talus. b. In the TV plane, the foot is externally rotated to the limb so that the thigh-foot axis is 10-15° externally rotated. c. In the axial plane, the calcaneal bisection line should be parallel or slightly valgus (0-2°) to the middiaphyseal line of the tibial. The middiaphyseal line of the tibia should pass through the center of the talus. d. The affected limb should be 1cm shorter than the unaffected limb. Calcaneus in the sagital plane - Correct Answer-sagittal plane, the plantar aspect of the calcaneus is inclined by approximately 20-30 degrees. Normal Bohler's angle and critical angle of Gissane -what happens to these angles in calc fx - Correct Answer-Bohler's angle (N=20-40°) and critical angle of Gissane (N=90-105°) - decrease in BA increase in CAG is seen. the posterior plafond in significant central comminution anterior plafond - Correct Answer-¥ A vertical impact while the foot is in a plantarflexed position will results in fracture of?? Wagstaffe tubercle: Fibula : Volkmann fracture: Posterior Mal (Tib) - Correct Answer- Tillaux-Chaput's (child) . (adult) Wagstaffe tubercle : Volkmann fracture i. vertebra compression fracture and a joint depression calcaneal fracture. ii. AT rupture or an anterior tibial axial compression or pilon fracture. iii. hip fracture or low back injury. iv. talar neck fracture. v. a supination or pronation subtalar joint dislocation. - Correct Answer-i perpendicular fall, knee extended and locked iii An anterior movement with the knee fully extended iii posterior movement iv A forced ankle DF movement with the knee flexed v . A lateral Transverse fall Brodens view calc axial - Correct Answer-Calc fx imaging Most commonly utilized intra-operatively when CT is not available for evaluation of reduction of the STJ. Patient is supine with central beam is directed 2-3cm anterodistal to the lateral malleolus with the foot and leg internally rotated 45°; 4 projections are taken: 10-40° in 10° increments. Beam approaches from posterior to anterior distal, 30° to the film, which is placed flat on the platform. Sanders CT - Correct Answer-Calc Fx Based on CT coronal projection of the articular surface. Higher prognostic value; Prognosis worsens with the increase of articular comminution. Essex Lopresti i. Tongue-type (A): Secondary fracture line extends directly posterior from the vertex of the angle of Gissane to the posterior tuber of the calcaneus, including one large posterior fragment that is usually divided into medial and lateral parts. ii. Joint Depression-type (B): Secondary fracture line extends posterior and dorsal to encircle lateral portion of the fractured articular surface of the posterior facet (called the "thalamus", or "thalamic portion"- depressed). - Correct Answer-Calc fx described 2 primary intra-articular fracture patterns with the same primary fracture line, Rowe - Correct Answer-Extra Articular Fx • Type I: nondisplaced posterior facet • Type II: one fx line in posterior facet (two fragments) • Type III: two fx lines in posterior facet (three fragments) i. Supination-External Rotation: 80% of ankle fractures. - Correct Answer-1.Stage 1: Rupture of the anterior syndesmosis, a bony avulsion of the anterior lateral aspect of the tibia (Tillaux-Chaput) or of the fibula (Wagstaffe). 2. Stage 2: Spiral oblique fracture of the fibula beginning at the level of the ankle joint and syndesmosis- anterior distal to proximal posterior (HALLMARK). 3. Stage 3: Rupture of the posterior syndesmotic ligament or a fracture of the posterior malleolus (Volkmann's fx) with the syndesmosis remaining intact 4. Stage 4: Rupture of the deltoid ligament or a transverse fracture of the medial malleolus. Pronation-External Rotation: i.e. baseball player sliding into base. - Correct Answer-1. Stage 1: Rupture of the deltoid ligament or transverse fracture of the medial malleolus. 2. Stage 2: Rupture of the anterior tibiofibular ligament and the interosseous ligament and membrane (or Tillaux- Chaput/Wagstaffe fracture). 3. Stage 3: Fracture of the fibula that occurs 5-7cm above the syndesmosis but can occur at any level more proximally. a. Fractures that occur at the fibular neck are known as Maisonneuve fractures. 4. Stage 4: Failure of the posterior syndesmosis or posterior tibial fracture. a. Danis-Weber Classification: - Correct Answer-i. Type A: Avulsion of the distal tip of the fibula by an intact calcaneal fibular ligament. The fracture is TV and is at or below the TV joint line. 1. Stage 1 SADD injury. ii. Type B: short oblique or spiral oblique pattern beginning at the articulation between the tibia and fibula. 1. PABD or SER. iii. Type C: occur above the ankle joint and correlate to LH PER fracture patterns. 1. Involves rupture of the syndesmotic ligament from the level of the ankle proximally to the level of the fibular fracture. deltoid ligament injury and lateral talar translation. - Correct Answer-i. Widening of medial joint space >4mm indicates 1mm of talar shift can result in a 42% decrease in tibiotalar contact - Correct Answer-1mm of talar shift can result in a _________decrease in tibiotalar contact talar tilit a. A distance of more than 2mm between these lines indicates an abnormal ankle. 2mm of lateral fibular displacement can result in 1-2mm of lateral talar tilt. - Correct Answer-1. reliable indicator of lateral ankle stability. Medial clear space >5mm on XR taken in DF/external rotation was - Correct Answer-xray views/findings most predictive of deep deltoid rupture after distal fibular fractures. DP Medial plantar artery - Correct Answer-blood supply to the midfoot end stage lisfranc arthrosis Anchovy resect base of 4/5 with articulation to cuboid. use a spacer (EDL/PT) of bases - Correct Answer-when to perform lateral ankle arthroplasty name procedure charcot, do not remove base of 4/5 - Correct Answer-when NOT to perform lateral ankle arthroplasty MC occurs in the dorsal talar neck. - Correct Answer- Osteoblastoma MM Osteogenic Sarcoma (Osteosarcoma - Correct Answer-most common malignant bone tumor 2nd most common (1st in adolescents/young teens) i. Pain, swelling (early); enlarging mass, gross deformity, and decreased ROM at neighboring joints (late). High propensity for metastasis lungs 75% of cases between 15-25 years Malignant bone tumor composed of a highly virulent stroma MC sites distal femur, proximal tibia, proximal humerus MC found in the metaphysis of long bones, can extend into diaphysis - Correct Answer-Osteogenic Sarcoma (Osteosarcoma Eccentric, ovoid, epimetaphyseal intramedullary zone of geographic destruction with a thinly sclerotic rim. 20-50 years old, 3rd decade MC, infrequent in patients before physeal closure or >55 Pain of insidious onset MC complaint, with or without ST mass. -I. 3x MC in LE than UE, with MC site distal femur/proximal tibia. MC misdiagnosed as ABC which can be removed intralesionally Recurrence rate as high as 40% with curettage and bone grafting associated with Paget's disease. - Correct Answer-Giant Cell Tumor (aka osteoclastoma Chondroma benign cartilage Encondroma Olliers-mult encondroma, younger Maffuci-mult encondroma - Correct Answer-Chondroma Encondroma Olliers Maffuci MC solitary lesion of phalanges centrally located in medullary canal Well-circumscribed, round to oval geographic lytic lesion of the metaphysis, often with lobulated contours, with thin, sclerotic margins. - Correct Answer-Enchondroma benign. painless bony mass. tumor bony projection covered by hyaline cartilage caused by trauma (salter harris injury) Aut dominant varriant with mult exostoses i. MC benign bone tumor, <20 yrs old (70%) and have predilection for femur, humerus, tibia, fibula. 1.5:1 M:F. - Correct Answer-Osteochondroma benign. cartilage tumor. rare. mild pain CC i. Small, sharply demarcated, lobulated lesions with spotty calcification in histologic "chicken-wire" or "picket fence" matrix pattern. i. MC occurs in patients 10-25 years of age, and in 70% of cases, the physes are still open. M>F 1.5:1, likely larger in lesions of the foot. ii. MC encountered geographic lytic lesion of the talus and/or calcaneus. - Correct Answer-CHondroblastoma least common tumor of cartilage i. MC in long bones (proximal humerus and femur); most cases in the foot present in the calcaneus. no pain/no pathologic fx i. Fluid filled (serum) which supports the theory that these lesions develop as a result of venous obstruction Tx i. Intralesional steroid injections have proven effective, along with surgical excision/curettage and packing with bone chips to prevent recurrence. . - Correct Answer-solitary bone cyst, UBC CPN: deep and superficial PN anterior leg anke between EHL and TA at ankle devides to med/lat branch med goes wth Dorsalis pedis*terminates to supply 1st interspace - Correct Answer-Deep Peroneal nerve most protective among inhaled anesthetics can increase HR by 50% - Correct Answer-Isoflurate Sevoflurane to improve DF *split TA and insert to the cuboid use for: equinovarus/forefoot varus/too strong invertors flexible equinovarus/DF - Correct Answer-STATT i. May be difficult to differentiate from UBC, howeber UBC typically present at an earlier age and do not have intralesional calcifications, which occurs in 60% of IL. Additionally, UBC do not typically demonstrate cortical expansion, which can occur in IL. - Correct Answer- Intraosseous Lipoma onion skin. codman's triangle. i. XR: aggressive, poorly defined area of permeative bone destruction, with grade III rate of growth. A ST mass is a constant finding in Ewing sarcoma that is easily detected in the extremities. Lesion of children and adolescents, 80-94% occurring in the first 2 decades, symptoms include pain with local tenderness at the site of a palpable mass. Systemic symptoms such as fever, general malaise, secondary anemia, leukocytosis, and an increased sedimentation rate - Correct Answer-Ewings Sarcoma MC malignant bone tumor MC complaint is bone pain fever, weight loss, lethargy, weakness, bleeding, neurologic signs. bone marrow aspirate. bence jones protein in urine. axial skeleton (hematopoietic red marrow- vertebral spine, ribs, skull, pelvis, proximal femur), resulting from uncontrolled proliferation of plasma cells. MM commonly presents in the 6th or 7th decade; rare in patients <30 hypercalcemia, renal dysfunction, and impaired immune dysfunction. 1. Pneumonia and renal failure are the two MC causes of death in this disease. - Correct Answer-Multiple Myeloma: hypnotic.amenestic used for induction high lipid solubility-->rapid onset, but short duration metab by liver (like amides) mech*GABA receptors/Na+ blocker soybean/egg/glycerol/lechitin*** - Correct Answer- characteristics of propofol 1. Actively immunized 0.5mL toxoid or absorbed tetanus toxoid( hypersensitivity to diphtheria toxoid ) 2. 0.5mL diphtheria toxoid ++ 250 to 500U of tetanus immunoglobulin intramuscularly - Correct Answer-Tetanus Status 1. Actively immunized within the past 10 years 2. Questionable immunization h 1. Type I: Skin laceration less than 1cm, results from an inside out perforation, little or no contamination; the fx is simple 2. Type II: Skin laceration is greater than 1cm but is associated with little or no contusion of the surrounding tissues; fractures displaced with some comminution and with minimal to moderate crushing component 3. Type III: Extensive soft tissue damage greater than 10cm, with or without severe contamination; the fracture is highly unstable Type IIIA: Adequate soft tissue coverage of bone Type IIIB: Extensive soft tissue loss occurs with periosteal stripping and exposed bone; severe contamination Type IIIC: An arterial injury is present that requires repair **I or II but 8h + - Correct Answer-Gustilo and Anderson Classification <1, 1, 10 cm+ 15-35 <5: poor healing - Correct Answer-Normal Prealbumin values 6 hours from injury to debridement of open fractures. **b/c bacteria will spread w/in 6H-->becomes infected** - Correct Answer- Treatment as Emergent/Golden Period compartment pressures are greater than 30 mmHg - Correct Answer-Define compartment syndrome pressure Indications for Amputation 1. Variables to look at 1. Limb Ischemia 2. Nerve Injury 3. Patient age 4. Shock 5. degree of skeletal and soft tissue injury 2. Can look at Mangled Extremity Score, Predictive Salvage Index, Limb Salvage Index and Hannover Fracture Scale-97. - Correct Answer-Indications for Amputation **Variables to look at 1. Type I fracture recommendation - cephalosporin (usually cefazolin) with or without an aminoglycoside. Clinda PCN allergy 2. Type II or III fracture - cephalosporin and an aminoglycoside multistick needle catheterization for intracompartmental pressure measurements- **although CS can be present in cases of normal compartment pressures i. Compartment pressures >30mmHg or if a compartment pressure is 10-30mmHg below the patient's diastolic blood pressure require open fasciotomy. Never use local (directly increases intercompartmental pressure) or regional anesthesia (causes vasodilation). Use conscious sedation if needed. - Correct Answer- Compartment Syndrome diagnosis DO NOT USE..... a. Always consider systemic hypothermia: core body temperature <95°F (35°C) and signs of shivering, slow mentation, muscle rigidity, hypotension, and depressed respiration. Mechanism Occurs through a process of extracellular and intracellular crystal formation followed by vasoconstriction, resulting in inadequate tissue perfusion. - Correct Answer-Diagnose Frostbite i. All patients with frostbite should be admitted to the hospital; rule out systemic hypothermia. Give Tetanus prophylaxis. ii. Rapid re-warming wrapping the limbs in multiple pre- heated blankets, administering warm IV NS, and/or Bair Hugger. If whirlpool bath is available, may submerge affected feet for 15-30 minutes at 104°F-108°F. Pain management. iii. IV abx prophylaxis with good staph and strep coverage (first generation cephalosporin). - Correct Answer-Frostbite Treatment IF 8 hours ++ or greater - Correct Answer-When do you not closes lacerations? Abx should be considered in wounds that are heavily contaminated or in immunocompromised patients. MC organism found in pedal traumatic lacerations is Staph aureus- - Correct Answer-When to use Abx in laceration? MCC bug to grow? the skin dermal and epidermal layers with the accumulation of clear, sterile fluid between the layers - Correct Answer- Define blister drained, de-roofed, and underlying skin treated as an ulceration - Correct Answer-Tx hemorrhagic blister The thin 0.008 to 0.012 inches, intermediate 0.012 to 0.016 inches thick is 0.016 to 0.020 inches. - Correct Answer-STSG. thin,G*,Thick 4. FTSG contain epidermis and dermis and its appendages 1. Can obtain from sinus tarsi, anterior ankle, medial arch, inguinal regions and popliteal fossa. - Correct Answer-FTSG, sites of harvest i. MC diagnosed STS; 5 subtypes: pleomorphic, myxoid, giant cell, inflammatory, and angiomatoid. ii. Occur in patients between 50-70 yrs, except angiomatoid (adolescence). MC in males. iii. Pain in extremity as well as inflammatory syndrome (fever, chills, myalgia) may be associated with the tumor, most located below the deep fascia. iv. Require wide surgical margins. - Correct Answer- Malignant Fibrous Histiocytoma: Malignant Fibrous Histiocytoma: Solitary, encapsulated mass that is freely movable because of its location in the SQ. Usually <2cm at time of presentation. - Correct Answer-Angioleiomyoma: traumatic causes epidermal cells into the subepidermal layer. >produces keratin, >forms mass ii. A sinus tract >cheesy material containing keratin and cell debris. - Correct Answer-Epidermal Inclusion Cyst: MC STM in the foot/ankle. i. Origin: myxoid degeneration of connective tissue of either the tendon sheath or peri-capsular tissue. ii. Well-circumscribed, soft, fluid-filled, freely moveable, located in subcutaneous tissue, transilluminates, and most commonly found on the dorsum of the foot. iii. Lesion should be removed with adjacent capsular tissue, intralesional excision assocated with high recurrence rate. iv. MRI: Low to intermediate signal intensity on T1 weighted images, high signal intensity on T2. Well demarcated, homogeneous. - Correct Answer-Ganglion Cyst subcutaneous thickening of the plantar fascia, most commonly involving the medial or central bands. i. Most commonly in males, 20-40 years old. BL in 10-50% of patients. ii. Excision through plantar zig-zag lesion, should remove portions of uninvolved fascia adjacent, distal, and proximal to the mass. - Correct Answer-Plantar Fibroma: MC benign STT in the body. i. Subcutaneous, soft, moveable, asymptomatic. ii. Most commonly in middle decades, obese patients. iii. Cutaneous/Superficial (more common and well- circumscribed) or Deep-seated (rare and not well- circumscribed). iv. Excision is extracapsular marginal. v. MRI: Low signal intensity identical to subcutaneous fat. Well-circumscribed, lobulated mass, often traversed by thin, fibrous septa. - Correct Answer-Lipoma iv. Chest Radiography: when a malignant lesion is diagnosed, CXR should be obtained to rule out metastatic spread, if CXR is unequivocal, a whole-lung CT scan should be done. First site of metastatic spread is usually pulmonary, and about 15% of patients presenting with ST sarcoma have a pulmonary metastatic lesion. - Correct Answer-Why is chest xray imporant in treating soft tissue masses Closed Biopsy: Disadvantages- retrieval of insufficient tissue for interpretation/inaccuracy of diagnosis. Fine-Needle Aspiration: 25 gauge needle and a small syringe to aspirate the ST mass. Core-needle Biopsy Open Biopsy: Incisional: Removing a portion of the tumor and leaving the remaining main mass in situ. MC for larger tumors ** tumors malignant (less potential for tumor spread). Excisional: removal of entire tumor . Indicated for small lesions (<2cm in diameter), for shallow tumors - Correct Answer-Closed Vs Open Biopsy Incisional Vs. Excisional Biopsy (portion) ( E-entire) heel cord lengthening will benefit equinus while making cavus worse - Correct Answer-How to differentiate Pes CAVUS VS Equinus Tx Cole - Correct Answer-Surgical Procedure for Purely Sag deformity of Cavus Frontal: forefoot valgus or PF 1st ray, and a varus (inverted) heel. • Valgus FF compensates in the hindfoot through the STJ and MTJ and this leads to a varus (rigid) or inverted (flexible) heel. - Correct Answer-Frontal plane abnormalities of Cavus foot Dwyer: • Varus heel deformity is corrected by removal of a laterally based wedge through the body of the calcaneus; • Typically a 1-1.5cm lateral wedge of bone is removed - Correct Answer-Treatment of frontal plane deformity cavus Foot 70-80 % long bones, tibia tx: en block resection prox amputation i. Extremely rare primary malignant bone tumor ii. Considered tumor of long bones and of adolescents and younger adults, avg. age 35 years . Soap bubble app. may contain cyst like cavities - Correct Answer-Adamantinoma: i. Cast should be placed at time of surgery and can be changed at 4 weeks, if bone work was done then cast for up to 6 weeks. ii. Bivalve can be used and around 3 weeks to start minimal passive ROM. - Correct Answer-immobilization/casting after tendon repair a. Movement: i. Early movement is important to prevent adhesions. ii. Start just after 3 weeks post-op. iii. Lack of tension beyond 3 weeks leaves the repair cells and fibers disoriented for a weaker union. - Correct Answer-how soon to start motion after tendon repair i. Early passive ROM after 3 weeks to stimulate collage fibers to realign themselves parallel for strength. Progressive WB and strengthening should be used. - Correct Answer- importance of movement of tendons after repair i. Technique: approached and performed in the same manner of PL transfer. ii. Goals and Indications: Same as Longus transfer. Results/Complications: Will change phase spontaneously when required to do so; choice for most ankle stabilizations - Correct Answer-Peroneus Brevis Tendon Transfer: Initial incision at junction of middle and lower third of the lateral leg, the PL tendon lies superficial to the brevis The second incision along the lateral cuboid, where the PL courses inferiorly into the plantar peroneal tunnel. t is sutured to the brevis transferred into the anterior compartment through the anterolateral intermuscular septum. is delivered down the extensor sheath, beneath cruciate retinaculum and attached to base of 3rd metatarsal or 3rd cuneiform, or is split and sutured into the tendons of tibialis anterior and peroneus tertius. ii. Indications: Anterior muscle group weakness or paralysis, dropfoot deformity. iv. Complications: skin slough, dorsal anesthesia, tendonitis of the long extensor tendons beneath the cruciate ligaments due to excessive tension. - Correct Answer-Hibbs Tenosuspension: i. Technique: 1. Requires 3 incisions to move ½ of the TA laterally: Incision is made first near the TA tendon's insertion; the second is over the tibialis anterior at the anterior surface of the leg just above transverse cruciate ligaments. The tendon is split to its insertion, the lateral fibers are pulled proximally through the second incision, and a 3rd incision is made over the peroneus tertius tendon, 1 inch proximal to insertion. The foot is placed in slight eversion with dorsiflexion to neutral and the lateral fibers are placed through peroneus tertius - Correct Answer-a. Split Tibialis Anterior Tendon Transfer: i. Goals: increase the true DF of the foot by balancing power laterally. ii. Adjunct procedures: DF osteotomy of 1st met, claw toe correction, calc osteotomy, triceps lengthening. iii. Indications: spastic rearfoot varus, spastic equinovarus, fixed equinovarus, excessive invertor power, FF equinus with extensor substitution and claw toes, flexible cavovarus, excessive supination, dorsiflexory weakness. iv. Complications - tenosynovitis (MC), nerve damage, simple procedure with little danger of overcorrection. - Correct Answer-a. Split Tibialis Anterior Tendon Transfer: Technique: The EHL is transected at the HIPJ, then rerouted through a medial-to-lateral drill hole in the head of the 1st MT and sutured back onto itself dorsally. Tendon can also be attached to the neck of the 1st MT with a bone anchor. The stump of the EHL should be attached to the EHB to maintain some extensor function to the great toe. 1. To prevent hammering of the hallux, the HIPJ requires arthrodesis. - Correct Answer-Jones Tenosuspension: i. Goals: Used to correct or prevent cockup of the hallux by eliminating the deforming force on the digit. ii. Indication: flexible cavus foot, flexible PF 1st ray, prophylaxis for hammered hallux when sesamoids are removed, and relieve lesser metatarsalgia. iii. Results and Complications: Unsatisfactory in young children because the long extensor tends to regenerate and return to its normal insertion at the distal phalanx. - Correct Answer-a. Jones Tenosuspension: a. wing phase: Tibialis anterior, extensor hallucis longus, extensor digitorum longus and peroneus tertius b. Stance phase: All others - Correct Answer-swing vs stance phase muscles Muscles transferred to function out of phase were generally unable to fire in their new position - Correct Answer-what happens when u take muscles out of their phase 1. Muscles tend to produce their greatest force at 120% of their resting length, therefore it is important to reestablish normal muscle tension in the transfer of a musculotendinous unit, which is accomplished by maintaining their physiologic length. 2. This is done by approximating the origin and insertion of a muscle, placing the foot in the position produced by maximal contraction of the transfer, and then removing all the slack from the tendon. - Correct Answer-T/F Muscles tend to produce their greatest force at 100% of their resting length i. 3 factors work in concert to contribute to adhesion formation: immobilization, suture, sheath excision - Correct Answer-what contribute to adhesion formation 1. Inflammatory (exudative) phase: 48-72 hours 2days 2. Fibroblastic (formative) phase: 5-15 days 2 weeks 1. Provides 80% of blood supply to bone 1. Periosteum is continuous with the joint capsule and is connected to bone by Sharpey fibers. - Correct Answer-1. Periosteal dissection Define: Sharpey fibers The lis franc ligament is the main stabilizer of this joint, it the strongest interosseous ligament - Correct Answer-lis franc ligament There are inter metatarsal ligaments between 2-5, Nothing between 1 and 2. - Correct Answer-Is there a ligament between met base 1 and 2. fusion of the entire TMT joint complex is not recommended, lateral column is rarely indicated. - Correct Answer-do u fuse the tmt? Posttraumatic or primary arthritis almost always involves the medial column pronation and abduction of the FF will cause pain and discomfort. - Correct Answer-how to excacerbate TMT arthritis aka trephine fusion of the midfoot Preferable to maintain length or overall anatomy of the osseous segments such as when a short first ray or medial column fusion is present 1. More difficult to see bridging on x-ray so the patient will begin initial WB without definitive radiographic evidence of fusion. - Correct Answer-when to perform dowel fusion 1. Pain, instability, but with alignment suitable 2. Less soft tissue disruption cant correct large malalignment talus remains seated within the ankle mortise (until later in the disease in which deltoid insufficiency leads to a valgus talar tilt). The calcaneus subluxes posteriorly, creating a valgus position relative to the talus. TNJ and CCJ axes become more parallel, leading to increased flexibility of the MTJ. With correction of the STJ axis, the TNJ and CCJ axial relationship is restored providing stability and alignment to the MTJs. - Correct Answer-STJ arthritis pathomechanics why it requires fusion i. Release of equinus contracture is performed. ii. Incision for STJ fusion begins at the tip of the fibula to the CCJ. just superior to the peroneals tendons and sural nerve and inferior to the course of the IDCN refelct EDB retract Peroneals down - Correct Answer-WHat is an adjunct procedure to STJ fusion Where is the incision? i. Guide wire from 6.5 to 8mm screw set is driven from posterior inferior to anterior superior through the calcaneus into the talus, and screws should be perpendicular to the posterior facet. ii. Screws should be within the central bodies of the talus and calcaneus and should not violate the ankle joint. - Correct Answer-Screw sizes and orientation for STJ fusion 1. The CCJ is usually the primary site for delayed healing - Correct Answer-#1 problem for STJ fusion appear deep and cup shaped in appearance. medial talar dome lesions can be obtained by taking the AP view with the foot plantar flexed - Correct Answer-medial ocd mechanism xray position Bernt/Harty 1 compression/bruising 2 partial avulsion 3 avulsion, not displaced 4 detached displaced - Correct Answer-OCD classification* 1. OATS procedure - Harvest initially then after growth is chondrocytes take patient back to OR 2 to 3 weeks later. Subchondral bleeding will allow marrow to contaminate the chondrocytes. A periosteal graft has to be taken from the ipsilateral knee, which will be secured over the defect with vicryl with the cambium layer facing toward the bon. Fibrin glue is placed over the surrounding articular cartilage. Chondrycytes are placed within the defect. NWB for 6 to 7 weeks. - Correct Answer-1. OATS procedure - 1. Majority of lateral OCD lesions are anterior or middle dome and are easily accessible through an anterolateral arthrotomy. 2. Most of the medial lesions are in the middle or posterior aspect of the talus and are obscured by the malleolus Sometimes a medial malleolar osteotomy is needed - Correct Answer-easier access for repair? medial or lateral OCD 1. Calcaneal Apophysitis - by far the most common cause of heel pain in the adolescent population 2. Athletic boys 6 to 13, aggravated with activity and relieved with rest 3. Physical Exam 1. no erythema, no edema, no warmth. Pain with direct palpation of the posterior calc. Classic sign is tenderness with medial to lateral compression - Correct Answer-1. Sever Disease 1. heel lifts, viscoelastic heel cups, arch supports, taping and orthoses in conjunction with ice, NSAIDs and stretch are helpful. 2. Severe or recalcitrant forms - short leg walking cast applied for 2 to 4 weeks. If does not improve and eventually goes on to surgery than can perform tendo-achilles lengthening - Correct Answer-tx sever's disesase 1. Osteochondrosis of the Navicular 1. Usually seen in children between 2 and 9 yo. 2. m/c in boys and b/l 20% to 30% of cases 3. Most with this disease have a delay in ossification of the navicular which increases the risk for vascular insult 4. Symptoms 1. painful limp, pain around the medial longitudinal arch, edema, warmth and pain with compression. - Correct Answer-1. Kohler Disease 1. X-rays indicate increased density and thinning bone distal to proximal direction. A case of coalition has been heard of following Kohler's disease 1. similar as Kohler but seen in adults 2. More common in women and 20 to 75 3. b/l conditions is more common that in Kohlers 4. Caused by chronic compression from adjacent joints, leading to avascular necrosis 3. Minimal edema, erythema and warmth 5. Best seen on lateral oblique radiographs - enlargement and fragmentation of the epiphysis, along with widening of the junction between the primary and secondary centers. - Correct Answer-Iselin Disease head of lesser metatarsals 1. Ages of 13 to 18 most commonly, Female:Male ratio of 5:1 2. Etiology 1, poor mechanics, repetitive micro-trauma, rigid metatarsal, hypermobility of adjacent metatarsals, short 1st, high heeled shoes, activity, vascular disruption, iatrogenic. 3. Clinical Presentation 1. Pain and limited motion - pain worse with activity and WB, relieved with rest. 2. Periarticular edema and soft tissue thickening secondary to synovitis 4. Increased temp, plantar callosities, mild erythema, post static dyskinesia - Correct Answer-1. Freiberg Disease 1. Surgical Treatment 1. Joint-Sparing Procedures 1. Removal of loose bodies, excision of osteophytes, partial synovectomy 2. Currettage of the avascular bone, reduction of the collapsed articular surface and use of autogenous cancellous grafts for stages I through III. 3. Autogenous epiphysiodesis to decrease stresses at the affected metatarsal head 4. Core decompression of the metatarsal head 5. Dorsal closing wedge osteotomy at metatarsal neck 6. Decompression - can develop floating toe 7. Interpositional arthroplasty 2. Joint-Sacrificing Procedures 1. Metatarsal head resection and joint replacement arthroplasty - fallen out of favor owing to associated complications 1. transfer metatarsalgisa, hyperkeratosis and a shortened, floating, retracted digit. 2. Complications from arthroplasty - floating toes, bone resorption at the implant interface, loosening of the prosthesis, fracture of the prosthesis, dendritic s - Correct Answer-Sx tx of Freibergs scalloped snowflake metaphysis - Correct Answer-chondrosarcoma encondroma and osteocondroma (Cap) - Correct Answer-in phalanges chicken wire/white picket fence epiphesys - Correct Answer-cbe. chondroblastoma in the epiphysis bundle of grapes nonossifying fibroma - Correct Answer-mcc bening bone tumor fallen fragment sign - Correct Answer-pathopneumonic for true cystic lesions cocade sign-calcification inside the lesion cortical expansions - Correct Answer-intraosseous lipoma codman, onion skin. diaphysis.boys - Correct Answer-ewings bence jones (urine). mcc bone tumor malignant renal/hypercalcemia/immune disfunction a. Must be distinguished from a fracture of the posterior process of the talus (Shepard's fracture). - Correct Answer- Ddx of os trigonometry 1. Very common, Inversion, adduction, on a plantarflexed foot, which causes ATFL with CFL and PTFL injury - Correct Answer-mech for ATFL with CFL and PTFL injury 1. Anterior drawer sign, greater than 4mm represents laxity 2. CFL is tested with talar tilt. Different of 5 to 15 degrees between limbs is significant 3. Syndesmosis can be tested with external rotation. If painful it is positive 4. Tibial-fibular squeeze test, positive if painful - Correct Answer-ankle ligament tests Bifurcate ligament attaches the os trigonum medially and laterally i. FHL runs through the bifurcate ligament, where it contacts the os trigonum. - Correct Answer-2 structures close to os trigonum a. Pediatric flexible flatfoot, pediatric tarsal coalitions following resection, and stage II PTTD. - Correct Answer- indication of arthroresis As the foot pronates, the talus adducts and plantarflexes and the lateral aspect of the talus rotates forward, until the lateral process of the talus contacts the floor of the sinus tarsi, - Correct Answer-what happens to talus when foot pronates pronate 2-4 degrees - Correct Answer-normal pronation allowed blocks excessive CKCP that the arthroereisis is meant to restrict, by resetting the maximally pronated position of the STJ (less calcaneal eversion and foot abduction). By restricting excessive pronation, the arthroereisis stabilizes the foot for propulsion during pronation the lateral process of the talus contacts the floor of the sinus tarsi, the talus is then blocked from further pronation b. By elevating the floor of the sinus tarsi, there will be a decrease in pronation (Chambers) - Correct Answer-How does arthroresis work STJ is a triplanar joint; axis courses posterior, plantar, lateral to anterior, dorsal, medial 30 degrees: 20° inversion/10° eversion. close kinetic chain calcaneal eversion and/or talar tibial inversion, talar plantarflexion and adduction - Correct Answer-STJ biomechanics Special attention needs to be paid to patients with met adductus: In the pronated foot with the abduction of the FF on the RF, met adductus may be hidden (skew foot, serpentine foot); Flexible FF varus or supinatus may also be present: needs to be reducible. If present with equinus deformity then the equinus needs be addressed - Correct Answer-what else to watch before arthroresis Patients with rigid flatfoot secondary to coalition can have success with arthroereisis following coalition resection to realign the rearfoot. - Correct Answer-Contraindications: arthritic STJ or joints adjacent to the STJ, rigid flat foot. Sagittal plane deformity of the foot that is characterized by a high-arch foot typ Differentiation via Lat XR: Equinus CIA <15; Cavus CIA>15. Determination important - Correct Answer-cavus vs equinus?? both will present with limited DF in the swing phase ¥ Varus heel deformity is corrected by removal of a laterally based wedge through the body of the calcaneus; ¥ The more anterior the OT, the greater degree of correction- the dorsal exit point should be 1-2cm posterior to the STJ and the plantar exit point should be 1-2cm proximal to the CCJ Typically a 1-1.5cm lateral wedge of bone is removed - Correct Answer-¥ Dwyer OT of the Calcaneus Dwyer +DFWO should be used the deformity that is semirigid and frontal plane dominant Subtalar arthrodesis with DFWO should be used in patients with valgus FF with unstable/arthritis STJ with or without peroneal pathology Cole OT with DFWO should be used in patients with sagittal plane dominant cavus with FF valgus (PF 1st ray) - Correct Answer-¥ correcting Frontal + TV plane deformities: triple fusion In addition to a triple arthrodesis, a 1st MT DFWO is required if there is residual FF valgus (PF 1st MT) In longstanding deformities where there is ankle varus and degenerative arthritis that has occurred, a pan-talar arthrodesis or triple plus ankle fusion neurological weakness may demonstrate a dropfoot deformity, >muscle-tendon balancing + bony correction; **goal of tendon transfers is to weaken the deforming forces and augment swing-phase DF - Correct Answer-Severe, Rigid, Multiplane Pes Cavus MC used in transfer procedures, however in lesser degree deformities, PL can be released distally and anastomosed to the PB, which eliminates its effect of PF the 1st ay and assists in everting the midfoot. - Correct Answer-PT and peroneus longus MC used (and MC implicated in causing cavus) ¥ Pes cavus is a sagittal plane deformity within the foot that compensates through the adjacent joints available ROM Frontal plane FF valgus deformities compensate through the RF via heel inversion, ¥ deformity exceeds the ability of the foot to compensate for frontal plane contractures, the ankle joint will become unstable and arthritis in the direction of varus - Correct Answer-Biomechanics of pes cavus