(OBQ12.91) Lower rates of malunion. anteriorinferior tibiofibular ligament impingement. 50% (957/1903) L 5 The single rocker sole shoe modification is best indicated for relief of pain in patients with what foot or ankle pathology? often limited secondary to pain or effusion. Physical exam. Removal of the implants and placement of a hindfoot arthrodesis nail or plate. Copyright 2022 Lineage Medical, Inc. All rights reserved. MRI. Hindfoot varus . She works as a waitress and recently had bariatric surgery with a current BMI of 35. Exostectomy with placement into a protective brace, Exostectomy & achilles tendon lengthening with placement into a protective brace. Which of the following would be a contraindication to closed management with a functional brace? A 25 year-old-male presents with the injury seen in Figure A. Physical exam is notable for ambulation on the lateral border of the right foot with hindfoot varus, midfoot A 54-year-old diabetic man complains of swelling and erythema throughout the midfoot for 2 weeks. (OBQ12.74) A 30-year-old male sustains the injury shown in figure A and undergoes successful open reduction and internal fixation. A 42-year-old man sustains the injury shown in Figure A after a fall from 6 feet. What is the most likely deformity causing these symptoms? She has no history of ankle or foot trauma, and medical history is significant only for delayed menarche. pes planus . Thank you. Webradial head excision will exacerbate elbow/wrist instability and may result in proximal radial migration and ulnocarpal impingement. What is the next best option at this point? What is the most likely diagnosis? Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. (OBQ04.126) Physical therapy and NSAID's have not alleviated the symptoms. may show plantar heel spur. often limited secondary to pain or effusion. test by stressing elbow with forearm in pronation to lock the lateral side. A 21-year-old male reports right ankle pain after sustaining an inversion ankle injury 2 years ago. Webforward shift of more than 8 mm on a lateral radiograph is considered diagnostic for an ATFL tear. He has not done any physical therapy nor received a corticosteroid injection. Component loosening due to polyethylene wear, It is normal to have continued pain at 10 months following this surgery. Current radiographs demonstrate a united fracture with no evidence of ostenecrosis, subtalar or tibiotalar arthritis. 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. A radiograph is provided in Figure B. 6% (267/4454) (SBQ18TR.6) He reports that his physician released him to full activity 8 weeks ago because he had no pain. A radiograph is shown in Figure A. (OBQ09.188) To avoid impingement with the proximal ulna, you need to carefully place your fixation. 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. Figure B shows a single entry wound located at the left distal humerus. 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. On physical examination the patient is unable to feel a 5.07 gm monofilament on the plantar aspect of his foot. Tibiotalar Impingement Midfoot Arthritis lateral, and obliques. hindfoot valgus deformity. Physical examination elicits pain with ankle dorsiflexion and plantarflexion, although subtalar motion is normal. Injection of platelet rich plasma. Custom orthotics with first ray recession and lateral heel posting, Total contact cast and non-weight bearing, Talonavicular and tarsometarsal arthrodeses. What is her diagnosis and a common clinical examination finding associated with the diagnosis? 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. Lower rates of malunion. He has no pain with ambulation and has decreased vibratory sensation in the bilateral lower extremities. (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. What is the most appropriate initial treatment at this time? procedure. (SBQ18FA.45) 12/11/2019. A 27-year-old male is involved in a motor vehicle collision and presents to the ER with the right lower extremity injury shown in Figures A and B. (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. Spanning external fixation of the ankle and hindfoot. Orthobullets Team Trauma - Elbow Dislocation; Listen Removal of the implants and placement of a hindfoot arthrodesis nail or plate. A clinical photo of the patient and lateral radiograph of the foot are provided in Figures A & B. Radiographs are unchanged from prior evaluation. At 2 years follow-up, he presents with a supination deformity with decreased eversion of the foot at rest. orthosis or foot wear changes to address alignment of hindfoot. He has a temperature of 100.3 degrees Fahrenheit. (OBQ04.44) On physical examination the patient is unable to feel a 5.07 gm monofilament on the plantar aspect of his foot. He has an equinus contracture. A 43-year-old male sustained a left ankle injury 3 years ago. (OBQ09.183) What initial management is most appropriate? (SBQ12FA.67) Lumbosacral instability. However, passively correctable contractures persist and the braces are causing skin problems on the leg. hindfoot valgus deformity. 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. He denies any constitutional symptoms and his pain is well controlled. He has been treating his symptoms with physical therapy and anti-inflammatory medications with little effect. often used prior to reconstruction to evaluate for intra-articular pathology. Upon presentation, he is unable to extend his thumb, fingers, and wrist. With respect to open reduction and internal fixation with a plate versus intramedullary nailing, what advice can you offer him? Decreased risk of post-operative elbow pain. Her ESR, CRP, and WBC levels are within normal limits and her radiographs are shown in Figures A and B. Hallux MTP dorsiflexion. (OBQ16.1) A 65-year-old female returns to the office with continued medial and lateral hindfoot pain. Thank you. Tibiotalar Impingement Midfoot Arthritis lateral, and obliques. On examination, he has moderate swelling and pain over the dorsum of the foot. On physical examination the patient is unable to feel a 5.07 gm monofilament on the plantar aspect of his foot. A 32-year-old man presents to the emergency department with a humeral shaft fracture. You are seeing a 62-year-old male for ankle and foot swelling (Figures A-C). Lumbosacral instability. Hindfoot Talar Neck FX Talus Fracture (other than neck) AIIS pins can place the lateral femoral cutaneous nerve at risk. 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. He has currently has no ulcerations on his foot. He is treated with ankle arthroplasty but continues to have pain and limited ambulation 10 months following surgery. (OBQ16.1) A 65-year-old female returns to the office with continued medial and lateral hindfoot pain. Hallux MTP plantarflexion . 2% (103/5321) 4. (OBQ09.210) His x-ray is shown in Figure A. Humeral shaft fractures are common fractures of the diaphysis of the humerus, which may be associated with radial nerve injury. She has a gastrocnemius contracture noted on Silverskiold testing. lateral brachial cutaneous/posterior antebrachial cutaneous nerve serves as an anatomic landmark leading to the radial nerve during a paratricipital approach. (OBQ06.130) However he is still having persistent anterior shoulder/arm pain that worsens with most activities. You can rate this topic again in 12 months. She complains of lateral elbow pain. He has an equinus contracture. Operative. Diagnosis can be made with plain ankle radiographs. ankle inversion and dorsiflexion during axial load creates shearing of lateral talar dome and lateral OLT. Current radiographs demonstrate a united fracture with no evidence of ostenecrosis, subtalar or tibiotalar arthritis. A 45-year-old male sustains a Gustilo and Anderson Type II open transverse humeral shaft fracture. When compared to medial talar OCDs, which of the following statements is true regarding lateral talar OCDs? She initially underwent early intervention with physical therapy and splinting. WebHindfoot Talar Neck FX Talus Fracture (other than neck) AIIS pins can place the lateral femoral cutaneous nerve at risk. (OBQ18.209) radial head excision will exacerbate elbow/wrist instability and may result in proximal radial migration and ulnocarpal impingement. Operative management is indicated for recurrent infections, deformities, and severe skin breakdown. Which of the following statements are true regarding this injury? A 34-year-old female is involved in a motorcycle crash. the medial and lateral plantar nerves can be compressed in their own sheath distal to tarsal tunnel. What is the next most appropriate step in management? 1% (21/2534) 3. A 30-year-old professional ballet dancer presents with persistant ankle pain after an ankle sprain 6 months ago. Which of the following is the most likely long-term complication even after anatomic reduction and stable fixation is achieved? both the superficial and deep layers individually resist eversion of the hindfoot. She initially underwent early intervention with physical therapy and splinting. MRI. both the superficial and deep layers individually resist eversion of the hindfoot. may be useful for surgical planning. Imaging is shown in Figure A. (OBQ07.265) 0% Copyright 2022 Lineage Medical, Inc. All rights reserved. posteromedial impingement lesion of ankle. 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. A clinical photo of the patient and lateral radiograph of the foot are provided in Figures A & B. Radiographs are unchanged from prior evaluation. Her radiograph is depicted in Figure B. Diagnosis can be made clinically with a warm and erythematous foot with erythema thatdecreases with foot elevation. Medical comorbidities include renal insufficiency and hypertension. What is the next appropriate step in the management of this patient? (OBQ13.245) (OBQ13.191) 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. Which of the following is an option for reconstruction of this patient's deformity? What is the most appropriate treatment for him at this time? 6% (267/4454) 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. (OBQ11.178) Medial opening wedge supramalleolar osteotomy is considered a treatment option for ankle osteoarthritis. Varus malalignment after a talar neck fracture with medial comminution causes a decrease in what motion? loss of joint space. 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). 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. elderly, osteopenic patients with low-energy injuries, intramedullary canal terminates 2 to 3 cm proximal to the olecranon fossa, fracture pattern: simple:A, wedge:B, complex:C, fracture location: proximal, middle or distal third, fracture pattern: spiral, transverse, comminuted, a spiral fracture of the distal one-third of the humeral shaft commonly associated with neuropraxia of the radial nerve (, will often present with shortening and in varus, preoperative or pre-reduction neurovascular exam is critical, examine and document status of radial nerve pre and post-reduction, be sure to include joint above and below the site of injury, may give better appreciation of sagittal plane deformity, rotating the patient prevents rotation of the distal fragment avoiding further nerve or soft tissue injury, may be necessary for fractures with significant shortening, proximal or distal extension but not routinely indicated, oaptation splint followed by functional brace. (OBQ13.92) WebOn physical examination the patient is unable to feel a 5.07 gm monofilament on the plantar aspect of his foot. lateral brachial cutaneous/posterior antebrachial cutaneous nerve serves as an anatomic landmark leading to the radial nerve during a paratricipital approach. 50% (957/1903) L 5 subchondral sclerosis and cysts. Which of the following is the most likely cause of the continued pain? surgical release of tarsal tunnel. 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. Diagnosis is primarily made with plain radiographs of the ankle. Operative. What is the next best option at this point? In addition to his lower extremity care, what other medical condition should he be evaluated for? The midfoot is hot to touch and mildly tender with palpation. 33% (1730/5321) 5. Radiographs at the time were negative and his pain improved over the next two months. 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). may be useful for surgical planning. At the origin of the deep head of the triceps. 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. After a discussion of his treatment options, he is adamant about proceeding with surgical management. (OBQ08.122) (OBQ05.106) On average, the radial nerve travels from the posterior compartment of the arm and enters the anterior compartment at which of the following sites? He recalls catching his foot on astroturf with a dorsiflexion and inversion moment about his ankle. He undergoes the treatment seen in Figure B. He has not done any physical therapy nor received a corticosteroid injection. After undergoing rigid anatomic fixation of the fracture, the distal radio-ulnar joint (DRUJ) remains incongruent. He was treated with physical therapy and a controlled ankle motion boot for several weeks following the injury with minimal (OBQ06.213) A decision is made to delay surgery until soft tissues are stabilized. inspection & palpation. (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 clinical photo of the patient and lateral radiograph of the foot are provided in Figures A & B. Radiographs are unchanged from prior evaluation. A 25-year-old male sustained an isolated injury to his right foot after a fall from height. He also underwent statically locked intramedullary nailing of a left femoral shaft fracture. Which of the following is the most likely cause of the finding in this patient? articular surfaces of a joint leading to subluxation or dislocation. Kathryn OConnor 1University of Pennsylvania, Posterior Tibial Tendon Insufficiency (PTTI). Copyright 2022 Lineage Medical, Inc. All rights reserved. On examination, she has severe pain and stiffness of her great toe, with crepitation. weight bearing axial and lateral films of hindfoot. 68% (1724/2534) 4. A 56-year-old male with uncontrolled diabetes presents for follow up of a recurrent midfoot ulceration. Posterior tarsal tunnel. can try a period of short-leg cast. (OBQ19.251) A radiograph is provided in Figure A. Lisfranc injury. He has been treated for the past four months with the modality seen in Figure A (Panel A) for the condition seen in Figure A (Panel B). debride impinging tissue. Along with irrigation and debridement, what is the most appropriate definitive management of this injury? He shows no evidence of healing at 12 months postoperatively and has continuous pain with ambulation; his incisions are well-healed and his subtalar motion remains full and pain-free upon examination. motion. A CT scan image is seen Figures C. When consenting the patient for open reduction and internal fixation of this injury, what would you document as the most common complication? (OBQ05.77) Treatment is a trial of total contact casting for acute charcot deformities without skin breakdown. He undergoes operative treatment for his humeral shaft fracture. 68% (1724/2534) 4. inspection & palpation. Webankle inversion and dorsiflexion during axial load creates shearing of lateral talar dome and lateral OLT. (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. Ipsilateral knee and/or hip degenerative changes, Ipsilateral midfoot and/or hindfoot degenerative changes. can try a period of short-leg cast. However, passively correctable contractures persist and the braces are causing skin problems on the leg. However he is still having persistent anterior shoulder/arm pain that worsens with most activities. 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. To avoid impingement with the proximal ulna, you need to carefully place your fixation. What is the advantage of this treatment choice as compared to antegrade intramedullary nailing? Operative. Copyright 2022 Lineage Medical, Inc. All rights reserved. Radiographs of the ankle are shown in Figures A and B. Her symptoms returned with ballet activity following a 1 month course of full rest, nonsteroidal anti-inflammatory medication, and physical therapy. Radiographs are unremarkable. Treatment can be nonoperative or operative depending on patient age, patient activity demands, lesion size, and stability of lesion. (OBQ11.10) A 25-year-old male sustains a humeral shaft fracture and is treated with the implant seen in Figure A. An orthotic with lateral hindfoot posting and first metatarsal head recess. Femoroacetabular impingement. (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. 13% An MRI is performed that reveals nerve root avulsions from C5-T1. The patient has palpable pulses, active drainage at the ulcer, and does not have protective sensation with a 5.07 Semmes-Weinstein filament. Orthobullets Team Trauma - Elbow Dislocation; Listen Now 17:5 min. pes planus . On examination, she has severe pain and stiffness of her great toe, with crepitation. Hindfoot Talar Neck FX Talus Fracture (other than neck) AIIS pins can place the lateral femoral cutaneous nerve at risk. often limited secondary to pain or effusion. A 57-year-old male has right ankle pain for 6 years and has failed conservative management. contralateral foot views. A 50-year-old male with long-standing type 1 diabetes presents with redness, swelling and crepitus in his foot two weeks after a twisting injury. His current imaging studies are shown in Figures E and F. Which of the following is the best next step in management? (OBQ08.115) may show plantar heel spur. Physical exam reveals some joint swelling but no ligamentous instability. Hindfoot varus . Weblateral brachial cutaneous/posterior antebrachial cutaneous nerve serves as an anatomic landmark leading to the radial nerve during a paratricipital approach. 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. (OBQ05.110) A clinical photo of the patient and lateral radiograph of the foot are provided in Figures A & B. Radiographs are unchanged from prior evaluation. (OBQ12.66) A 60-year-old male with a history of diabetes presents to the trauma bay after sustaining a ground-level fall onto his right arm. 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. Figure A shows a radiograph of his left humerus. He was treated with physical therapy and a controlled ankle motion boot for several weeks following the posteromedial impingement lesion of ankle. Midfoot prominences associated with Charcot arthropathy, End-stage tibiotalar arthritis with limited motion. Which of the following is the most appropriate management? An orthotic with lateral hindfoot posting and first metatarsal head recess. Her clinical image is depicted in Figure A and her radiograph is depicted in He undergoes the treatment shown in Figures A and B. Anatomy. In-situ tibiotalocalcaneal fusion using an intramedullary device, Midfoot osteotomy and Lisfranc joint fusion using plates and screws, Reduction and arthrodesis of the Chopart joint using a ring fixator. (OBQ08.89) (SBQ12TR.6) At long-term follow-up, patients undergoing the procedure shown in Figure A have been shown to have significant rates of findings of which of the following? Figure C shows the corresponding MRI. The pain is worsened with weightbearing and walking. 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? A 35-year-old male sustains an isolated injury depicted in Figure A after a motor vehicle accident. During his workup, an MRI shows a 1x1 cm lateral talar osteochondral defect (OCD). radiographic findings include. He has an equinus contracture. He is currently tender to palpation on the lateral border of the foot. On examination, she has severe pain and stiffness of her great toe, with crepitation. All of the following are considered contraindications to the use of functional bracing of a humeral shaft fracture EXCEPT: Mid-diaphyseal segmental fracture with ipsilateral pilon fracture, Mid-diaphyseal fracture with radial nerve palsy from nonballistic penetrating injury, Mid-diaphyseal closed fracture with a radial nerve palsy on presentation, Mid-diaphyseal fracture with a L1 burst fracture and paraplegia on presentation. (OBQ19.213) A post-reduction radiograph is seen in Figure C. Which of the following is the most appropriate treatment at this time? Which of the following is the most likely diagnosis? What would be the most appropriate definitive treatment? procedure. (OBQ05.226) A 26-year-old professional ballet dancer presents with insidious onset of right midfoot pain which began 6 months ago. On exam, his wounds are well healed with no erythema. (OBQ12.7) 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. The likelihood of developing osteonecrosis is high, Hawkins sign is negative. Lateral calcaneus closing wedge osteotomy, Talar neck opening medial wedge osteotomy. procedure. (OBQ08.177) His current radiographs demonstrate a subchondral radiolucency of the dome of the talus. Which of the following options will most likely provide pain relief and allow her to return to her previous activity level? often used prior to reconstruction to evaluate for intra-articular pathology. Radiographs reveal no evidence of talus subchondral sclerosis or collapse. Web(OBQ11.178) A 25-year-old man presents one year after undergoing open reduction and internal fixation of the fracture seen in Figure A. (OBQ07.135) However, for the last six months, he has developed persistent ankle pain with intermittent swelling. Treatment can be nonoperative or operative depending on location of fracture, fracture morphology, and association with other ipsilateral injuries. (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. 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. Radiographs of the foot are seen in Figures A and B. 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. The erythema diminishes with elevation of the foot for 15 minutes. loss of joint space. He recalls catching his foot on astroturf with a dorsiflexion and inversion moment about his ankle. (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. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. optional films. subchondral sclerosis and cysts. Copyright 2022 Lineage Medical, Inc. All rights reserved. (OBQ16.1) A 65-year-old female returns to the office with continued medial and lateral hindfoot pain. 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! Physical exam. Injection of bone cement into the talus to prevent further avascular necrosis, Ankle arthroscopy to address this osteochondral lesion, Continued observation as the vascularity to the talus is intact. ankle inversion, external rotation, and plantarflexion during axial load creates shearing of medial talar dome and medial OLT cavus hindfoot alignment. A 23-year-old man presents with the injury seen in Figure A after a motor vehicle collision. 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. She initially underwent early intervention with physical therapy and splinting. The likelihood of developing osteonecrosis is low. He recalls catching his foot on astroturf with a dorsiflexion and inversion moment about his ankle. 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. A 35-year old male is involved in a fall from height and present with the isolated injury shown in Figures A and B. Hawkins sign is positive. (OBQ12.214) orthosis or foot wear changes to address alignment of hindfoot. She has no history of ankle or foot trauma, and medical history is significant only for delayed menarche. Thank you. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Physical exam after the injury reveals a flaccid ipsilateral limb. anteriorinferior tibiofibular ligament impingement. collapse of the medial longitudinal arch. (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. optional films. forward shift of more than 8 mm on a lateral radiograph is considered diagnostic for an ATFL tear. A 70-year-old woman with type 2 diabetes presents with an erythematous, swollen, and warm left foot, as depicted in Figure A. may show structural changes. Bone Scan. (OBQ08.197) stabilizes ankle against plantar flexion, external rotation and pronation Anterolateral soft-tissue impingement. 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