Which of the following would be a contraindication to closed management with a functional brace? Nailing is associated with a decreased rate of surgical site infections, Nailing is associated with a higher rate of transient radial nerve injury, Plating is associated with a higher rate of fracture union, Plating is associated with a higher re-operation rate, No difference between rate of radial nerve palsy between plating or nailing this injury. An orthotic with lateral hindfoot posting and first metatarsal head recess. criteria for acceptable alignment include: see relative operative indications section, radial nerve palsy is NOT a contraindication to functional bracing, increased risk with proximal third oblique or spiral fracture, varus angulation is common but rarely has functional or cosmetic sequelae, closed humerus fractures, including low velocity GSW, should be initially managed with a splint or sling, type of fixation after trauma should be directed by acceptable fracture alignment parameters, fracture pattern and associated injuries, ipsilateral forearm fracture (floating elbow), periprosthetic humeral shaft fractures at the tip of the stem, polytrauma or associated lower extremity fracture, allows early weight bearing through humerus, burns or soft tissue injury that precludes bracing, short oblique or transverse fracture pattern, overlying skin compromise limits open approach, adequately applied splint will extend up to axilla and over shoulder, common deformities include varus and extension, valgus mold to counter varus displacement, extends from 2.5 cm distal to axilla to 2.5 cm proximal to humeral condyles, sling should not be used to allow for gravity-assisted fracture reduction, shoulder extension used for more proximal fractures, weekly radiographs for first 3 weeks to ensure maintenance of reduction, anterior (brachialis split) approach to humerus, deep dissection through internervous plane of brachialis muscle, lateral fibers (radial n.) and medial fibers (musculocutaneous n.) in majority of patients (~80%), used for proximal third to middle third shaft fractures, distal extension of the deltopectoral approach, radial nerve identified between the brachialis and brachioradialis distally, used for distal to middle third shaft fractures although can be extensile, triceps may either be split or elevated with a lateral paratricipital exposure, radial nerve is found medial to the long and lateral heads and 2cm proximal to the deep head of the triceps, radial nerve exits the posterior compartment through lateral intramuscular septum 10 cm proximal to radiocapitellar joint, lateral brachial cutaneous/posterior antebrachial cutaneous nerve serves as an anatomic landmark leading to the radial nerve during a paratricipital approach, plate osteosynthesis commonly with 4.5mm plate (narrow or broad), absolute stability with lag screw or compression plating in simple patterns, apply plate in bridging mode in the presence of significant comminution, full crutch weight bearing shown to have no effect on union, nonunion rates not shown to be different between IMN and plating in recent meta-analyses, IM nailing associated with higher total complication rates, increased rate when compared to plating (16-37%), functional shoulder outcome scores (ASES scores) not shown to be different between IMN and ORIF, while controversial, a recent meta-analysis showed no difference between the incidence of radial nerve palsy between IMN and plating, radial nerve is at risk with a lateral to medial distal locking screw, musculocutaneous nerve is at risk with an anterior-posterior locking screw, no callous on radiograph and gross motion at the fracture site at 6 weeks from injury has a 90-100% PPV of going on to nonounion in closed humeral shaft fractures, increased incidence distal one-third fractures (22%), neuropraxia most common injury in closed fractures and neurotomesis in open fractures, iatrogenic radial nerve palsy is most common following ORIF via a lateral approach (20%) or posterior approach (11%), 85-90% of improve with observation over 3 months, spontaneous recovery found at an average of 7 weeks, with full recovery at an average of 6 months, indicated as initial treatment in closed humerus fractures, useful to determine extent of nerve damage, baseline of function, and to monitor recovery, brachioradialis first to recover, extensor indicis is the last, open fracture with radial nerve palsy (likely neurotomesis injury to the radial nerve), closed fracture that fails to improve over ~4-6 months, persistent radial nerve palsy - optimal timing debated, Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries. A 45-year-old man presents to your clinic with a closed mid-shaft humerus fracture after a fall 1 week prior. The pain is worsened with weightbearing and walking. Upon presentation, he is unable to extend his thumb, fingers, and wrist. You can rate this topic again in 12 months. He denies any known trauma. may be useful for surgical planning. (SBQ12TR.12) Reimplantation of the talar body followed by cast immobilization, Reduction of talar body, fracture fixation with smooth Steinman pins, and spanning fixator placement, Talar body allograft with internal fixation to native talar head, Fragment removal, antibiotic spacer placement and external fixation, Reduction of native talar body and ORIF of talar neck fracture. The overlying skin is intact. (OBQ08.197) (OBQ09.210) His x-ray is shown in Figure A. Examination reveals lateral elbow tenderness, and an 80 degree arc of flexion-extension and 60 degree arc of prono-supination, with extremes of motion limited by pain. Thank you. 13% WebThe pain is worsened with weightbearing and walking. He has a temperature of 100.3 degrees Fahrenheit. A post-reduction radiograph is seen in Figure C. Which of the following is the most appropriate treatment at this time? He is currently tender to palpation on the lateral border of the foot. Hindfoot Talar Neck FX Talus Fracture (other than neck) AIIS pins can place the lateral femoral cutaneous nerve at risk. After 4 months of non-operative management, the fracture has healed, but his physical exam is unchanged. A 65-year-old man complains of ankle pain refractory to bracing, physical therapy and NSAIDS. posteromedial impingement lesion of ankle. What would be the most appropriate definitive treatment? 3% (132/4454) 5. MRI studies are helpful in determining the size of the lesion, the extent of bony edema, and identify unstable lesions. (SBQ12FA.100) On physical examination the patient is unable to feel a 5.07 gm monofilament on the plantar aspect of his foot. (OBQ13.46) (OBQ07.265) surgical release of tarsal tunnel. - James Stone, MD, Foot & AnkleOsteochondral Lesions of the Talus, Asymptomatic Medial Talar Dome OCD in a 17M, Osteochondral Lesions of the Talus with Midfoot Arthritis, Talus fracture, OCD, cartilage fragment, subchondral cyst. Femoroacetabular impingement. Web(OBQ11.253) A 17-year-old ballet dancer presents with 5 months of pain in the posterior aspect of the right lower extremity that is exacerbated with the ballet position shown in Figure A. A 30-year-old man is brought to your level 1 trauma center with a closed left diaphyseal humerus fracture, a closed left midshaft femur fracture, right sided rib fractures, and multiple facial fractures following a motorcycle accident. Avoidance of dancing with CAM walker boot for 2 weeks, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, Orthopaedic Summit Evolving Techniques 2021, Evolving Technique Update: Role Of An Osteotomy In The Treatment Of An Osteochondral Lesion Of The Talus - Phinit Phisitkul, MD, Orthopaedic Summit Evolving Techniques 2020, Evolving Technique Update: MSCs For Cartilage Repair: Let Me Show You How - Italy Guides The Way - Alberto Gobbi, MD, 2019 Orthopaedic Summit Evolving Techniques, Debridement And Abrasion: It's Simple And Yields Great Results: Watch Me! stabilizes ankle against plantar flexion, external rotation and pronation Anterolateral soft-tissue impingement. (OBQ12.66) (OBQ12.107) (OBQ19.213) Initial radiographic evaluation discovers a femoral shaft fracture, distal tibia fracture, and the injury shown in Figure A. (OBQ05.74) Orthobullets Team Lower rates of shoulder impingement. Diagnosis is made with radiographs of the foot but frequently require CT scan for full characterization. Hallux MTP dorsiflexion. (OBQ16.1) A 65-year-old female returns to the office with continued medial and lateral hindfoot pain. Orthobullets Team Lower rates of shoulder impingement. After undergoing rigid anatomic fixation of the fracture, the distal radio-ulnar joint (DRUJ) remains incongruent. optional films. Examination reveals lateral elbow tenderness, and an 80 degree arc of flexion-extension and 60 degree arc of prono-supination, with extremes of motion limited by pain. lateral ankle pain due to subfibular impingement is a late symptom. The brachial artery is disrupted and requires urgent attention in the operating room. Radiographs at the time were negative and his pain improved over the next two months. Webtest by stressing elbow with forearm in pronation to lock the lateral side. The patient's preoperative nerve evaluation demonstrates that the patient is unable to initiate extensor carpi radialis longus, extensor carpi radialis brevis, extensor pollicis brevis, extensor digitorum, extensor indicis proprius, and extensor pollicis longus motor activity. A 62-year-old gentleman with a 10-year history of Type II diabetes complains of warmth, swelling, and pain in his right foot that has progressively worsened over the past 6 weeks. She complains of lateral elbow pain. He has an equinus contracture. His injury films are shown in Figures A and B. (OBQ05.77) pedicle screws with internal subcutaneous bar may be used. Copyright 2022 Lineage Medical, Inc. All rights reserved. Radiographs of the ankle are shown in Figures A and B. (OBQ09.200) debride impinging tissue. A 25-year-old male involved in a motor vehicle accident sustains multiple injuries. What can the patient be told about his condition? A 21-year-old male is brought to the emergency department with multiple gun shot wounds. can try a period of short-leg cast. Total contact cast immobilization and nonweight-bearing for 6 weeks. He has an equinus contracture. On examination, there is significant soft tissue swelling without open wounds. Lisfranc injury. Non-weight bearing bilateral lower extremities and right upper extremity, Weight bearing as tolerated bilateral lower extremities and right upper extremity, Non-weight bearing left lower extremity and weight bearing as tolerated right upper and right lower extremities, Non-weight bearing right lower extremity and weight bearing as tolerated right upper and left lower extremities, Weight bearing as tolerated bilateral lower extremities and non-weight bearing right upper extremity. (SBQ18TR.6) A current clinical photograph is seen in Figure A. He had previously undergone 2 cycles of total contact casting and several bedside debridements. 4% (OBQ07.173) A 34-year-old female has an insidious onset of heel pain when first getting out of bed and at the end of the day after prolonged standing. (OBQ05.95) Kathryn OConnor 1University of Pennsylvania, Posterior Tibial Tendon Insufficiency (PTTI). pes planus . hindfoot valgus deformity. (OBQ09.207) An injection into her ankle joint provided temporary near-complete relief. A 70-year-old woman with type 2 diabetes presents with an erythematous, swollen, and warm left foot, as depicted in Figure A. The patient has palpable pulses, active drainage at the ulcer, and does not have protective sensation with a 5.07 Semmes-Weinstein filament. Femoroacetabular impingement. Compared with open reduction and internal fixation with a plate and screw construct, the treatment shown in Figure A is associated with all of the following EXCEPT? You can rate this topic again in 12 months. Current radiographs demonstrate a united fracture with no evidence of ostenecrosis, subtalar or tibiotalar arthritis. (OBQ11.253) A 17-year-old ballet dancer presents with 5 months of pain in the posterior aspect of the right lower extremity that is exacerbated with the ballet position shown in Figure A. A clinical photo of the patient and lateral radiograph of the foot are provided in Figures A & B. Radiographs are unchanged from prior evaluation. posteromedial impingement lesion of ankle. Anatomy. Femoroacetabular impingement. A 30-year-old male sustains the injury shown in figure A and undergoes successful open reduction and internal fixation. A 65-year-old male with insulin-dependent diabetes and chronic kidney disease presents for follow-up care for issues in his right lower extremity. He subsequently develops talar dome avascular necrosis and is treated with the surgery shown in Figures A and B. Webradial head excision will exacerbate elbow/wrist instability and may result in proximal radial migration and ulnocarpal impingement. A 30-year-old professional ballet dancer presents with persistant ankle pain after an ankle sprain 6 months ago. A 65-year-old man sustained the closed injury seen in Figures A and B and is being treated nonoperatively in a functional brace. His current radiographs demonstrate a subchondral radiolucency of the dome of the talus. (OBQ05.236) A 65-year-old female developed a right foot deformity 3 years ago following a cerebrovascular accident. (OBQ12.166) Hindfoot Talar Neck FX Talus Fracture (other than neck) AIIS pins can place the lateral femoral cutaneous nerve at risk. pes planus . Diagnosis is made with orthogonal radiographs of the humerus. He undergoes operative treatment for his humeral shaft fracture. There is no history of trauma and he has never seen a physician before. both the superficial and deep layers individually resist eversion of the hindfoot. Which muscle function is expected to be the LAST to return in this patient? The patient reports that 12 weeks ago he sustained a similar injury and underwent surgery on his foot by a different surgeon. He undergoes immediate closed reduction and the post-reduction CT is shown in Figures C and D. The patient undergoes percutaneous surgical screw fixation of the injury. 13% (273/2180) 4. Hallux MTP plantarflexion . You are seeing a 62-year-old male for ankle and foot swelling (Figures A-C). A 23-year-old man presents with the injury seen in Figure A after a motor vehicle collision. weight bearing axial and lateral films of hindfoot. A polytrauma patient sustains a right bicondylar tibial plateau fracture and a right humeral shaft fracture both treated with open reduction and internal fixation. (OBQ05.106) During his workup, an MRI shows a 1x1 cm lateral talar osteochondral defect (OCD). 2% (103/5321) 4. (OBQ04.44) Copyright 2022 Lineage Medical, Inc. All rights reserved. (OBQ05.236) A 65-year-old female developed a right foot deformity 3 years ago following a cerebrovascular accident. On physical examination the patient is unable to feel a 5.07 gm monofilament on the plantar aspect of his foot. Injection of platelet rich plasma. Lumbosacral instability. (SBQ12TR.18) radiographic findings include. A radiograph is provided in Figure B. anteriorinferior tibiofibular ligament impingement. A 29-year-old male presents with left knee instability and progressive gait disturbance. Diagnosis can be made clinically with a warm and erythematous foot with erythema thatdecreases with foot elevation. A 45-year-old female presents to the office wearing a right upper arm splint with radiographs shown in Figure A and B. Which of the following is the most likely cause of the finding in this patient? He has wrist drop as well as impaired finger and thumb extension. Physical exam reveals some joint swelling but no ligamentous instability. pes planus . Her soft-tissues and neurological examination are normal. orthosis or foot wear changes to address alignment of hindfoot. procedure. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. orthosis or foot wear changes to address alignment of hindfoot. Custom orthotic with Jones bar and medial posting, AFO (ankle foot orthosis) with posterior leaf spring, Accomodative plastizote insole with depression cut into the midfoot and extra-depth shoes. He undergoes the treatment shown in Figures A and B. the medial and lateral plantar nerves can be compressed in their own sheath distal to tarsal tunnel. Weblateral ankle pain due to subfibular impingement is a late symptom. On average, the radial nerve travels from the posterior compartment of the arm and enters the anterior compartment at which of the following sites? Figure A is the AP radiograph of a 32-year-old right-hand dominant male who was involved in a motor vehicle accident and sustained an isolated injury. He also underwent statically locked intramedullary nailing of a left femoral shaft fracture. (OBQ07.193) (OBQ08.234) 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, Orthopaedic Summit Evolving Techniques 2020, Pro: MIS: The Arthroscope Will Get It Perfect - Let Me Show You How - Richard Ferkel, MD, Pro: Open Approach: Fix It With Plates Or Screws & Avoid Deformity & Arthritis - Michael Suk, MD, Feature Lecture Talus Fractures What I Have Learned & How I Avoid Complications - Bruce J. Sangeorzan, MD, Right Traumatic Talus Extrusion and Humeral Shaft Fracture in 64F, Hawkins III Talar neck fracture dislocation with a medial malleolus fracture, Contralateral Femur and Talus Fractures in 16F. often used prior to reconstruction to evaluate for intra-articular pathology. 4% Her symptoms returned with ballet activity following a 1 month course of full rest, nonsteroidal anti-inflammatory medication, and physical therapy. The distal interlocks for this implant place which of the following nerves at risk? Radiographs of the foot are seen in Figures A and B. Closed reduction and splinting in the emergency room, Irrigation and debridement, then splinting in the operating room, Irrigation and debridement, then spanning external fixation in the emergency room, Open reduction and internal fixation with a compression plate in the operating room, Irrigation and debridement, then intramedullary nailing of the humerus in the operating room. On examination, he has moderate swelling and pain over the dorsum of the foot. lateral brachial cutaneous/posterior antebrachial cutaneous nerve serves as an anatomic landmark leading to the radial nerve during a paratricipital approach. Which shoe modification, shown in Figure B-F, is most appropriate to prevent potential future skin breakdown by offloading the affected area in this patient? Hallux MTP dorsiflexion. Ankle Arthritis is degenerative joint disease of the tibiotalar joint that can be broken into three main types: osteoarthritis, post-traumatic arthritis, and inflammatory arthritis. An orthotic with lateral hindfoot posting and first metatarsal head recess. He recalls catching his foot on astroturf with a dorsiflexion and inversion moment about his ankle. What initial management is most appropriate? (OBQ05.110) (OBQ18.141) A 48-year-old male returns to your office 8 months after sustaining a proximal humerus fracture that was successfully treated nonoperatively. may be useful for surgical planning. Imaging is shown in Figure A. inspection & palpation. Operative management is indicated for recurrent infections, deformities, and severe skin breakdown. At the origin of the deep head of the triceps. She has a gastrocnemius contracture noted on Silverskiold testing. WebTibiotalar Impingement Midfoot Arthritis lateral, and obliques. Physical exam. 4% Posterior tarsal tunnel. A 47-year-old male sustains the closed injury seen in Figures A and B after failing to land a motorcycle jump. (OBQ08.115) 33% (1730/5321) 5. radiographic findings include. To avoid impingement with the proximal ulna, you need to carefully place your fixation. Non-operative management of the humerus and plating of the femur, Plating of the humerus and intramedullary nailing of the femur, Non-operative management of the humerus and intramedullary nailing of the femur, Intramedullary nailing of the humerus and plating of the femur. He is treated with ankle arthroplasty but continues to have pain and limited ambulation 10 months following surgery. forward shift of more than 8 mm on a lateral radiograph is considered diagnostic for an ATFL tear. Increased incidence of traumatic etiology. Tibiotalar Impingement indicative of entrapment or irritation of the first branch of the lateral plantar nerve (Baxter's nerve) Imaging. Hindfoot varus . The midfoot is hot to touch and mildly tender with palpation. The patient reports that 12 weeks ago he sustained a similar injury and underwent surgery on his foot by a different surgeon. Complete obliteration of the ankle joint space with bone-on-bone contact; valgus ankle alignment, No joint-space narrowing, but early ankle joint sclerosis and osteophyte formation; valgus ankle alignment, Symptomatic narrowing of the ankle joint space medially; varus ankle alignment, Symptomatic narrowing of the ankle joint space laterally; neutral ankle alignment, Obliteration of the medial joint space that extends to the roof of the talar dome; varus ankle alignment. both the superficial and deep layers individually resist eversion of the hindfoot. Exostectomy with placement into a protective brace, Exostectomy & achilles tendon lengthening with placement into a protective brace. A radiograph is provided in Figure A. He was treated with physical therapy and a controlled ankle motion boot for several weeks following the Ipsilateral knee and/or hip degenerative changes, Ipsilateral midfoot and/or hindfoot degenerative changes. posteromedial impingement lesion of ankle. Lumbosacral instability. (OBQ09.188) (OBQ11.178) You can rate this topic again in 12 months. What is the most likely deformity causing these symptoms? Osteochondral Lesions of the Talus are focal injuries to the talar dome with variable involvement of the subchondral bone and cartilage which may be caused by a traumatic event or repetitive microtrauma. Which of the following options will most likely provide pain relief and allow her to return to her previous activity level? He states that since he began weight-bearing he has progressive lateral foot pain and developed calluses on the lateral side of his foot that have become painful. He has not done any physical therapy nor received a corticosteroid injection. Webanteriorinferior tibiofibular ligament impingement. Web(SBQ18FA.38) A 57-year-old woman presents 2 years after undergoing bunion correction of her left foot with the inability to properly fit in her shoes in the last 4 months, despite shoe modification. (OBQ13.92) (SBQ12FA.67) Radiographs are shown in Figures A-B. A 29-year-old male sustains the isolated lower extremity injury shown in Figure A. A 25-year-old male sustained an isolated injury to his right foot after a fall from height. NSAIDs and bracing have provided her temporary relief. loss of joint space. Her clinical image is depicted in Figure A and her radiograph is depicted in Figure B. He complains of mechanical symptoms with ankle movement that continue to be symptomatic with everyday activities. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. 68% (1724/2534) 4. (OBQ08.177) A 35-year-old male fell and sustained an open talar neck fracture. (OBQ05.84) procedure. To avoid impingement with the proximal ulna, you need to carefully place your fixation. The erythema diminishes with elevation of the foot for 15 minutes. 33% (1730/5321) 5. Which of the following statements is most accurate when comparing his treatment with open reduction and internal fixation? Copyright 2022 Lineage Medical, Inc. All rights reserved. (OBQ04.173) Continue current splint for 3 weeks and transition to hanging arm sling for additional 3 weeks, Transition to functional brace for additional 6-8 weeks, Open reduction internal fixation with compression plating, Staged procedure with humeral external fixator, then open reduction internal fixation with compression plating. Figure C shows the corresponding MRI. WebHindfoot varus . (SBQ18FA.38) A 57-year-old woman presents 2 years after undergoing bunion correction of her left foot with the inability to properly fit in her shoes in the last 4 months, despite shoe modification. He has no pain with ambulation and has decreased vibratory sensation in the bilateral lower extremities. What is the next best option at this point? Physical exam is notable for ambulation on the lateral border of the right foot with hindfoot varus, midfoot supination and diminished subtalar motion compared with the contralateral side. After undergoing rigid anatomic fixation of the fracture, the distal radio-ulnar joint (DRUJ) remains incongruent. On physical examination the patient is unable to feel a 5.07 gm monofilament on the plantar aspect of his foot. Physical exam is notable for ambulation on the lateral border of the right foot with hindfoot varus, midfoot motion. A 30-year-old male undergoes successful surgical fixation of a displaced talar neck fracture. Talar neck fractures are high energy injuries to the hindfoot that are associated with a high incidence of talus avascular necrosis. (OBQ06.173) A 20-year-old male collegiate basketball player presents with a 1 day history of left foot pain. indications. Bone Scan. He is neurovascularly intact. lateral brachial cutaneous/posterior antebrachial cutaneous nerve serves as an anatomic landmark leading to the radial nerve during a paratricipital approach. Adjust Sarmiento brace and repeat followup in 3 weeks, Continue current management for another 6 weeks and then discontinue brace, Proceed with surgical management at this time, Continue current management for another 6 weeks and if no evidence of clinical union, proceed with surgical management, Discontinue sarmiento brace and allow for progressive weight-bearing at this time. She works as a waitress and recently had bariatric surgery with a current BMI of 35. He is treated conservatively with closed reduction and his post-reduction radiographs are shown in Figures C and D. At 6 weeks followup he presents with persistent fracture site motion. The midfoot is warm, red, and swollen with no skin disruptions on physical exam. (OBQ04.145) With respect to open reduction and internal fixation with a plate versus intramedullary nailing, what advice can you offer him? Associated conditions. A 35-year old male is involved in a fall from height and present with the isolated injury shown in Figures A and B. weight bearing axial and lateral films of hindfoot. Which of the following is a contraindication for a total ankle arthroplasty? WebHindfoot Talar Neck FX Talus Fracture (other than neck) AIIS pins can place the lateral femoral cutaneous nerve at risk. Orthobullets Team Trauma - Elbow Dislocation; Listen Now 17:5 min. (SBQ12TR.6) (OBQ04.111) (OBQ12.214) contralateral foot views. (OBQ08.89) 50% (957/1903) L 5 (OBQ09.183) Her symptoms returned with ballet activity following a 1 month course of full rest, nonsteroidal anti-inflammatory medication, and physical therapy. After formal debridement, which of the following is the next best treatment step? Her symptoms returned with ballet activity following a 1 month course of full rest, nonsteroidal anti-inflammatory medication, and physical therapy. Hawkins sign is positive. cause of impingement able to be identified in 80% of cases. (OBQ18.141) A 48-year-old male returns to your office 8 months after sustaining a proximal humerus fracture that was successfully treated nonoperatively. A current radiograph is provided in Figure B. At what time point after the injury does the lack of callus formation and motion at the fracture site first become concerning for nonunion? (OBQ10.125) A 21-year-old male reports right ankle pain after sustaining an inversion ankle injury 2 years ago. However, passively correctable contractures persist and the braces are causing skin problems on the leg. Figure A shows a radiograph of his left humerus. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. (OBQ07.90) A 45-year-old diabetic male has a Wagner type 3 heel ulcer shown in Figure A that measures 4x2cm and is recalcitrant to debridements and total contact casting for 4 months. Radiographs reveal no evidence of talus subchondral sclerosis or collapse. She has no history of ankle or foot trauma, and medical history is significant only for delayed menarche. What is the next most appropriate step in management? 68% (1724/2534) 4. She initially underwent early intervention with physical therapy and splinting. Physical exam. ankle inversion, external rotation, and plantarflexion during axial load creates shearing of medial talar dome and medial OLT cavus hindfoot alignment. ipsilateral lower extremity fractures common, via artery of tarsal canal (dominant supply), deltoid branch of posterior tibial artery, may be only remaining blood supply with a displaced fracture, Subtalar, tibiotalar, and talonavicular dislocation, best view to demonstrate talar neck fractures, technique is maximum equinus, 15 degrees pronated, xray 75 degrees cephalad from horizontal, best study to determine degree of displacement, comminution and articular congruity, CT scan also will assess for ipsilateral foot injuries (up to 89% incidence), all cases require emergent closed reduction in ER, CT to confirm nondisplaced without articular stepoff, extruded talus should be replaced and treated with ORIF, ~63% of reimplanations do not require secondary procedure, low incidence of infection with adequate I&D and antibiotic therapy, visualize medial and lateral neck to assess reduction, typical areas of comminution are dorsal and medial, between tibialis anterior and posterior tibialis, preserve soft tissue attachments, especially, between tibia and fibula proximally, in line with 4th ray, elevate extensor digitorum brevis and remove debris from subtalar joint, variety of implants used including mini and small fragment screws, cannulated screws and mini fragment plates, medial and lateral lag screws may be used in simple fracture patterns, consider mini fragment plates in comminuted fractures to buttress against varus collapse, subchondral lucency best seen on mortise Xray at, indicates intact vascularity with resorption of subchondral bone, associated with talar neck comminution and open fractures, delayed internal fixation is not associated with avascular necrosis, subtalar arthritis (50%) is the most common, treatment includes medial opening wedge osteotomy of talar neck, decreased motion with locked midfoot and hindfoot, weight bearing on the lateral border of the foot, Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries. pedicle screws with internal subcutaneous bar may be used. ankle inversion and dorsiflexion during axial load creates shearing of lateral talar dome and lateral OLT, ankle inversion, external rotation, and plantarflexion during axial load creates shearing of medial talar dome and medial OLT, possible repeitive microtrauma creates ischemic environment and loss of integrity of subchondral bone, leads to softening and disruption of overlying cartilage, among the thickest in the body (implications for osteochondral autografting), maintains tensile strength longer than femoral head with aging process, deltoid artery supplies majority of talar body and dome, ankle is a highly congruent mortise joint, oriented 15 degrees externally from midsagittal line of ankle, talus articulates with the medial malleolus medially, tibial plafond superiorly, posterior malleolus posteriorly, and fibula laterally, Berndt and Harty Radiographic Classification, Complete fragment detachment but not displaced, Cystic lesion within dome of talus with an intact roof on all view, Cystic lesion communication to talar dome surface, Open articular surface lesion with the overlying nondisplaced fragment, Cartilage injury with underlying fracture and surrounding bony edema, mechanical symptoms such as catching or locking, often limited secondary to pain or effusion, evaluate for ligamentous laxity or insufficiency, suspicion for OLT in setting of equivocal radiographs, helpful in evaluating subchondral bone and cysts, less reliable in purely cartilaginous lesions of nondisplaced OLTs, provides fine detail of lesions for pre-operative planning, persistent pain following injury, ankle sprains that do not heal with time, variable edema patterns, may overestimate degree of injury, unstable lesions show fluid deep to subchondral bone, predicts stability of lesion with 92% sensitivity, nondisplaced fragment with incomplete fracture, osteochondral grafting (osteochondral autograft transplantation, autologous chondrocyte implantation, bulk allograft), size > 1 cm and displaced lesions, shoulder lesions, salvage for failed marrow stimulation or drilling, period of immobilization in cast or boot for 6 weeks, followed by progressive weight bearing with physical therapy emphasizing peroneal strengthening, range of motion, and proprioceptive training, debridement of unstable cartilage flaps to create stable and contained defect using curettes or shaver, loose bodies and cartilage removed using shaver or grasper, microfracture awl placed perpendicular to surface and tapped into subchondral bone 2-4 mm deep, inflow stopped to allow fat or blood to emanate from holes, indicating adequate penetration, Kirschner wire can be passed using anterior portals, or transmalleolar for central or posterior lesions, talus dorsiflexed and plantar flex to necessitate only 1 transosseous passing of wire, articular cartilage delamination and graft failure, 65-90% improvement in patient reported outcomes, fibrocartilage formation at site of lesion in 60% of patients on second-look arthroscopy, no correlation noted with patient outcomes, evaluate cartilaginous surface for softening, dimpling with probe seen, Kirschner wire drilled from sinus tarsi into defect, fluoroscopy often helpful to confirm location, if bone grafting indicated, cannulated drill placed over K wire, dictated by location of OLT and concomitant procedures required (i.e. anteriorinferior tibiofibular ligament impingement. (OBQ11.10) Brostrum), medial malleolar osteotomy for medial and posterior lesions, longitudinal incision centered over medial malleolus, flexor retinaculum released posteriorly; PTT retracted posteriorly, osteotomy guided based of 2 parallelly placed K-wires, with goal to enter plafond at lateral extent of OLT, prior to osteotomy, 2 drill holes placed to aid in reduction following procedure, sagittal saw and osteotome used to complete osteotomy, care taken not to cause thermal necrosis to bone or damage cartilage, lateral malleolar osteotomy or ATFL/CFL release for lateral lesions, longitudinal incision centered over lateral malleolus, oblique osteotomy planned, with predrilling of small fragment screws holes to aid in reduction following procedure, alternatively, if lateral ligament reconstruction is planned, extensor retinaculum may be released, peroneal tendons retracted posteriorly and ATFL and CFL released, ankle inverted and plantarflexed to expose talar dome, OLT debrided and measured using sizing guide, appropriately sized autograft may be harvested from knee and placed into OLT, impacted gently into defect, OATs harvested from the knee have a cartilage thickness less than the native talus, this will cause immediate post-operative xrays to show a prominent graft despite the cartilage surface being flush, do not release deltoid ligament as may jeopardize deltoid artery blood supply, ankle impingement if graft plug left proud, arthroscopic harvest of chondrocytes (from ankle or alternatively from knee) are sent for cultured growth, open approach via osteotomy for implantation, debridement of lesion to create stable cartilage rim, subchondral bone exposed, bone graft may be placed if underlying cyst and bone loss, periosteum from tibia taken and fitted to defect, this is sutured into place this small caliber suture, omitting one area to leave access to underlying defect, water-tight seal confirmed, cultured chondrocytes placed under flap and suture placed, fibrin glue placed over defect, newer technique of matrix-based chondrocyte implantation (MACI) shown equivalent outcomes to ACI and may obviate need for osteotomy, small percentage of patients do not achieve pain relief regardless of treatment, Lesions may progress to involve entire ankle joint, Posterior Tibial Tendon Insufficiency (PTTI). Posterior tarsal tunnel. He is treated conservatively in a Sarmiento functional brace. He states that since he began weight-bearing he has progressive lateral foot pain and developed calluses on the lateral side of his foot that have become painful. AP, lateral and oblique views of the foot. indications. 33% (1730/5321) 5. hindfoot valgus deformity. Operative. What is the appropriate weightbearing status? A clinical photo of the patient and lateral radiograph of the foot are provided in Figures A & B. Radiographs are unchanged from prior evaluation. A 43-year-old male sustained a left ankle injury 3 years ago. ankle inversion, external rotation, and plantarflexion during axial load creates shearing of medial talar dome and medial OLT cavus hindfoot alignment. A 30-year-old patient underwent open reduction internal fixation of a talar neck fracture 8 weeks ago. Copyright 2022 Lineage Medical, Inc. All rights reserved. EMG and nerve conduction tests followed by possible surgical exploration, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Humerus Shaft Fracture ORIF with Anterolateral Approach, Humerus Shaft ORIF with Posterior Approach, Type in at least one full word to see suggestions list, Rockwood And Greens: Fractures in Adults, Rockwood and Green's Fractures in Adults. A 25 year-old-male presents with the injury seen in Figure A. Which of the following radiographic features is a good prognostic factor for this injury? radiographic findings include. What is her diagnosis and a common clinical examination finding associated with the diagnosis? Physical exam is notable for well healed incisions and no instability with anterior drawer and inversion testing. He states that since he began weight-bearing he has progressive lateral foot pain and developed calluses on the lateral side of his foot that have become painful. Diagnosis is primarily made with plain radiographs of the ankle. (OBQ11.178) A 25-year-old man presents one year after undergoing open reduction and internal fixation of the fracture seen in Figure A. On examination, he has good distal pulses, weakness with attempted wrist extension, and some reported numbness of the dorsal radial hand. Diabetic Charcot Neuropathy is a chronic and progressive disease that occurs as a result of loss of protective sensation which leads to the destruction of foot and ankle joints and surrounding bony structures. (OBQ13.14) Radiographs often reveal obliteration. often limited secondary to pain or effusion. WebOn physical examination the patient is unable to feel a 5.07 gm monofilament on the plantar aspect of his foot. Dynamization of the implants to allow controlled compression, Removal of the implants and placement of a hindfoot arthrodesis nail or plate, Revision ankle arthrodesis with bone grafting as needed. 1% (21/2534) 3. Hip abductor weakness. He undergoes the treatment seen in Figure B. orthosis or foot wear changes to address alignment of hindfoot. (SBQ06TR.1) A 36-year-old rancher is involved in a tractor roll-over accident and sustains the injury shown in Figure A to his dominant right arm. test by stressing elbow with forearm in pronation to lock the lateral side. A clinical photo of the patient and lateral radiograph of the foot are provided in Figures A & B. Radiographs are unchanged from prior evaluation. However he is still having persistent anterior shoulder/arm pain that worsens with most activities. motion. 1% (21/2534) 3. (SBQ18FA.45) hindfoot valgus deformity. On examination, she has severe pain and stiffness of her great toe, with crepitation. 19% (147/766) 5. Which motor function would be expected to recover last? (OBQ12.7) (OBQ12.91) He has been placed into a total contact cast for extended periods without resolution of the ulcer. Lower rates of malunion. (OBQ11.178) A 25-year-old man presents one year after undergoing open reduction and internal fixation of the fracture seen in Figure A. (OBQ05.226) A 26-year-old professional ballet dancer presents with insidious onset of right midfoot pain which began 6 months ago. A 52-year-old male sustains a talus fracture that is treated with immediate reduction and internal fixation. She sustained an isolated closed injury to the right arm 9 days ago. Webcause of impingement able to be identified in 80% of cases. 0% He was treated with physical therapy and a controlled ankle motion boot for several weeks following the injury with minimal During open reduction, what structure must be kept intact in order to protect the remaining blood supply to the talar body? A 34-year-old female is involved in a motorcycle crash. Component loosening due to polyethylene wear, It is normal to have continued pain at 10 months following this surgery. 13% (273/2180) 4. 19% (147/766) 5. Lateral calcaneus closing wedge osteotomy, Talar neck opening medial wedge osteotomy. To avoid impingement with the proximal ulna, you need to carefully place your fixation. (OBQ16.1) A 65-year-old female returns to the office with continued medial and lateral hindfoot pain. MRI. A 42-year-old man sustains the injury shown in Figure A after a fall from 6 feet. most common etiology, accounting for greater than 2/3 of all ankle arthritis, accounts for less than 10% of all ankle arthritis, other etiologies include rheumatoid arthritis, osteonecrosis, neuropathic, septic, gout, and hemophiliac, nonanatomic fracture healing alters the joint contact forces of the ankle and changes the load bearing mechanics of the ankle joint, loss of cartilage on the talar body and tibial plafond results in joint space narrowing, subchondral sclerosis and eburnation, a ginglymus joint that includes the tibia, talus, and fibula, talar dome is biconcave with a central sulcus, Early sclerosis and osteophyte formation, no joint space narrowing, Narrowing of medial joint space (no subchondral bone contact), Obliteration of joint space at the medial malleolus, with subchondral bone contact, Obliteration of joint space over roof of talar dome, with subchondral bone contact, Obliteration of joint space with complete tibiotalar contact, pain with ROM testing, loss of ROM compared to the contralateral side, angular deformity may be present depending on the history of trauma, activity modification, bracing to immobilize the ankle, and NSAIDS, indicated as first line of treatment in mild disease, indicated upon failure of conservative treatment in a patient with radiographic evidence of ankle arthritis, ideal candidate younger than 45 yrs with post-traumatic arthritis, minimal talar-tilt or varus heel alignment, stage 2 or 3a according to the Takakura-Tanaka classification for varus-type osteoarthritis, posttraumatic or inflammatory arthritis, malalignment (with osteotomy), reliable relief of pain and return to activities of daily living, 50% of patients demonstrated subtalar arthrosis 10 years following ankle arthrodesis in one study, risk factors for nonunion include smoking, adjacent joint fusion, history of failed previous arthrodesis, and avascular necrosis, revision arthrodesis union rates are 85% or greater, posttraumatic or inflammatory arthritis, elderly patient, uncorrectable deformity, severe osteoporosis, talus osteonecrosis, charcot joint, ankle instability, obesity, and young laborers increase the risk of failure and revision, new generation arthroplasty minimizes bony resection, retains soft tissue stabilizers, and relies on anatomic balancing, recent 5-10 year outcome studies demonstrate up to 90% good to excellent clinical results, long-term studies are still pending on the newest generation of ankle arthroplasty, include wound infection, deep infection, and osteolysis. He has begun to have trouble ambulating because he reports his ankle feels "floppy" since a fall several weeks ago. The likelihood of developing osteonecrosis is high, Hawkins sign is positive. (OBQ13.89) A 38-year-old concert violinist presents after falling onto a pronated, outstretched hand this morning. He recalls catching his foot on astroturf with a dorsiflexion and inversion moment about his ankle. However he is still having persistent anterior shoulder/arm pain that worsens with most activities. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Web(SBQ06TR.1) A 36-year-old rancher is involved in a tractor roll-over accident and sustains the injury shown in Figure A to his dominant right arm. He denies fevers or chills, and states that the swelling and warmth dissipates each night after he sleeps with his foot elevated on pillows. (SBQ06TR.1) A 36-year-old rancher is involved in a tractor roll-over accident and sustains the injury shown in Figure A to his dominant right arm. Which of the following is the most appropriate management of his fracture at this time? Midfoot prominences associated with Charcot arthropathy, End-stage tibiotalar arthritis with limited motion. (OBQ06.130) An orthotic with lateral hindfoot posting and first metatarsal head recess. stabilizes ankle against plantar flexion, external rotation and pronation Anterolateral soft-tissue impingement. 6% (267/4454) Orthobullets Team Trauma - Elbow Dislocation; Listen Now 17:5 min. Weblateral brachial cutaneous/posterior antebrachial cutaneous nerve serves as an anatomic landmark leading to the radial nerve during a paratricipital approach. (OBQ08.72) All of the following are possible etiologies for this condition EXCEPT: 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, 30th Annual Baltimore Limb Deformity Course, Midfoot Charcot Rocker Bottom: Hexapod Frame - Noman A. Siddiqui, MD, Failed TTC (tibio-talo-calcaneal)fusion left foot. (SBQ18FA.38) A 57-year-old woman presents 2 years after undergoing bunion correction of her left foot with the inability to properly fit in her shoes in the last 4 months, despite shoe modification. She denies any specific injury and she does not have any foot ulcerations or wounds; her foot and ankle are edematous with erythema that resolves upon elevation. The patient has palpable pulses, active drainage at the ulcer, and does not have protective sensation with a 5.07 Semmes-Weinstein filament. inspection & palpation. She sustains a talus fracture with associated dislocation of the subtalar joint and maintained congruence of the tibiotalar and talonavicular joints as shown in Figure A. Decreased risk of post-operative elbow pain. Web(OBQ07.90) A 45-year-old diabetic male has a Wagner type 3 heel ulcer shown in Figure A that measures 4x2cm and is recalcitrant to debridements and total contact casting for 4 months. During an open reduction internal fixation of a humerus fracture using the posterior approach, a surgeon can identify the posterior antebrachial cutaneous nerve and trace it proximally to which of the following nerves? Current radiographs demonstrate a united fracture with no evidence of ostenecrosis, subtalar or tibiotalar arthritis. may show structural changes. What would be the next most appropriate step for treatment? often limited secondary to pain or effusion. Recent midfoot and hindfoot weightbearing radiographs are seen in Figure B. What is the most appropriate initial treatment at this time? (OBQ18.209) She plays tennis and regularly walks 5 miles a day for exercise, but has had to give up these activities over the last few months because of pain. motion. 6% (267/4454) both the superficial and deep layers individually resist eversion of the hindfoot. Tibiotalar Impingement Midfoot Arthritis lateral, and obliques. She would like to proceed with a surgical intervention following a shared decision making discussion. After a discussion of his treatment options, he is adamant about proceeding with surgical management. 50% (957/1903) L 5 What is the advantage of this treatment choice as compared to antegrade intramedullary nailing? loss of joint space. Examination reveals lateral elbow tenderness, and an 80 degree arc of flexion-extension and 60 degree arc of prono-supination, with extremes of motion limited by pain. The patient's CRP is 2.6 (normal range of <6.0). The likelihood of developing osteonecrosis is high, Hawkins sign is negative. Radiographs are unremarkable. (OBQ13.191) A 55-year-old man is referred to you for management of a recalcitrant diabetic foot ulcer. subchondral sclerosis and cysts. Avascular necrosis is more common following this injury than post-traumatic arthritis, Delayed internal fixation of displaced fractures does not increase the risk of avascular necrosis, Fracture comminution is associated with a decreased avascular necrosis rate, Delayed internal fixation increased the risk of secondary surgical procedures, Fracture displacement is not associated with avascular necrosis. Spanning external fixation of the ankle and hindfoot. Physical exam after the injury reveals a flaccid ipsilateral limb. What is the most appropriate treatment for him at this time? In which of the following scenarios would this procedure be most appropriate? On examination, she has severe pain and stiffness of her great toe, with crepitation. A radiograph is shown in Figure A. He is neurovascularly intact in his left arm and leg. Current radiographs demonstrate a united fracture with no evidence of ostenecrosis, subtalar or tibiotalar arthritis. procedure. A 54-year-old diabetic man complains of swelling and erythema throughout the midfoot for 2 weeks. surgical release of tarsal tunnel. Removal of the implants and placement of a hindfoot arthrodesis nail or plate. He has an equinus contracture. Orthobullets Team Lower rates of shoulder impingement. Webforward shift of more than 8 mm on a lateral radiograph is considered diagnostic for an ATFL tear. Web(OBQ17.175) A 22-year-old collegiate football player presents with persistent left lateral ankle pain 6 months after sustaining an ankle sprain during a game. He presents at 2 months after surgery. subchondral sclerosis and cysts. 50% (957/1903) L 5 Which of the following is the most likely cause of the continued pain? Tibiotalar Impingement Midfoot Arthritis lateral, and obliques. When compared to medial talar OCDs, which of the following statements is true regarding lateral talar OCDs? Physical exam. Cellulitis; erythema decreases after elevation, Cellulitis; abnormal Semmes-Weinstein monofilament testing, Complex regional pain syndrome (CRPS); erythema decreases after elevation, Charcot arthropathy; erythema decreases after elevation, Charcot arthropathy; erythema increases after elevation. A clinical photo of the patient and lateral radiograph of the foot are provided in Figures A & B. Radiographs are unchanged from prior evaluation. ankle inversion and dorsiflexion during axial load creates shearing of lateral talar dome and lateral OLT. Injection of platelet rich plasma. can try a period of short-leg cast. often used prior to reconstruction to evaluate for intra-articular pathology. (OBQ13.245) Chapter 36: HUMERAL SHAFT FRACTURES, Orthopaedic Summit Evolving Techniques 2020, Evolving Technique: Distal Articular Fractures Of The Humerus: 7 Tips & Tricks For A Great Outcome - Michael McKee, MD, Cleveland Combined Hand Fellowship Lecture Series 2021-2022, Humerus Fractures with Radial Nerve Palsy - Michael Webber, MD, The Reproducible Humeral Exposure: 7 Tips, 7 Minutes - Joseph Iannotti, MD, Middle Atlantic Shoulder & Elbow Society Annual Meeting, Left diaphyseal humeral shaft fracture in a 25M. Varus malalignment after a talar neck fracture with medial comminution causes a decrease in what motion? WebTibiotalar Impingement Midfoot Arthritis Neurologic Conditions occurs with forefoot fixed and hindfoot or leg rotating. He underwent operative fixation of his fracture. No difference in rate of radial nerve injury. (OBQ19.251) (SBQ18FA.64) Figures A and B show his preoperative and postoperative radiographs. test by stressing elbow with forearm in pronation to lock the lateral side. An MRI is performed that reveals nerve root avulsions from C5-T1. Which of the following is the most appropriate management? He is only able to ambulate with the assistance of crutches or a walker. 7.5% of patients with diabetes and neuropathy, typically presents in 5th decade (20-25 years following diagnosis), typically presents in 6th decade (5-10 years following diagnosis), often leads to ligamentous instability and bone loss, body unable to adopt protective mechanisms to compensate for microtrauma due to abnormal sensation, inflammatory cytokines may cause destruction, IL-1 and TNF-alpha lead to increased production of, Involves tarsometatarsal and naviculocuneiform joints, Collapse leads to fixed rocker-bottom foot with valgus angulation, Involves subtalar, talonavicular or calcaneocuboid joints, Unstable, requires long periods of immobilization (up to 2 years), Late varus or valgus deformity produces ulceration and osteomyelitis of malleoli, Late deformity results in distal foot changes or proximal migration of the tuberosity, Radiographs show osseous fragmentation with joint dislocation, Radiographs show coalescence of fragments and absorption of fine bone debris, Radiographs show consolidation and remodeling of fracture fragments, average of 3.3 degrees C warmer than contralateral side, Semmes-Weinstein monofilament (5.07) testing, sensitivity of 40-95% in diagnosing neuropathy, obtain standard AP and lateral of foot, complete ankle series, degenerative changes may mimic osteoarthritis, scattered "chunks" of bone in fibrous tissue, may be positive for a neuropathic joint and osteomyelitis, negative (cold) for neuropathic joints and positive (hot) for osteomyelitis, most sensitive in diagnosing soft tissue and/or osteomyelitis, difficult to differentiate infection from Charcot arthropathy on MRI, detritic synovitis (cartilage and bone distributed in synovium), total contact casting, shoewear modifications, medications, casts changed every 2-4 weeks for 2-4 months, Charcot restraint orthotic walker (CROW) boot can be used after contact casting, in Eichenholtz stage 3 double rocker shoe modifications will best reduce risk for ulceration at the plantar apex of the deformity, resection of bony prominences (exostectomy) and TAL, "braceable" foot with equinus deformity and focal bony prominences causing skin breakdown, goal is to achieve plantigrade foot that allows ambulation without skin compromise, deformity correction, arthrodesis +/- osteotomies, failed previous surgery (unstable arthrodesis), goal is for a partial or limited amputation if vascularity allows, used when bone quality is poor or soft tissues are compromised, Posterior Tibial Tendon Insufficiency (PTTI). 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