How will you proceed for the diagnosis?? It is inherited in an autosomal dominant fashion, Mutations in HME affect the prehypertrophic chondrocytes of the growth plate, It is caused by mutations in either EXT1, EXT2, or EXT3 genes, Radiographically, the exostoses are in direct connection to the medullary cavity, Radiographically, the exostoses grow towards the physis. (OBQ06.105) On physical exam she has weakness to ankle dorsiflexion and great toe extension on the right. (OBQ06.43) By using a trowel, but the first layer of concrete into the mold. Radiographs are shown in figure A. Worse outcomes in pain, physical function, and return to work status at 4 years. Femoral head is completely uncovered by the true acetabulum and has migrated superiorly and posteriorly. high energy. Orthobullets Team Trauma He requires a shoe lift to ambulate. hamstring tendons. The pelvic ring formed from 2 innominate bones, articulate posteriorly with the sacrum and anteriorly through pubis symphysis, Each innominate bone is composed of three fused bones: ilium, ischium, and pubis, iliopectineal eminence - region union between ilium and pubis, the anterior portion of the gluteus medius insertion and thickening of the iliac crest, important fixation pathway for fractures of the pelvis, transverse process of L4/L5 to posterior ilium, a fibrocartilaginous disc between innominate bones, bifurcates at L4 into common iliac system, continues as the common femoral artery (distal to the inguinal ligament), divides distal and posterior near the SI joint into, leads to the iliolumbar artery, lateral sacral artery, and terminates as the superior gluteal artery, leads to the obturator artery and inferior gluteal artery, terminating as the internal pudendal artery, vascular anastomosis that connects the external iliac artery (or inferior epigastric artery) and obturator artery, encountered during anterior approaches to pelvis (ilioinguinal and modified Stoppa), can result in brisk bleeding with rapid blood loss if not identified and ligated, injury in pelvic fractures can account for majority of blood loss, standard radiograph for all trauma patients, cranial tilt (x-ray tube angle toward head and photons beamed in a caudal direction), caudal tilt (x-ray tube angled toward feet and beamed in cranial direction), demonstrates cranial-caudal displacement of the pelvic ring and sacral morphology, pseudo-lateral (oblique) views of the pelvis designed to evaluate the columns and walls of the acetabulum, the views are reciprocal, meaning a LEFT iliac-oblique is the same as a RIGHT obturator-oblique, assessment of the ilioischial line of the posterior column, the roof of the acetabulum, the anterior acetabular wall, andIliac crest. A 39-year-old seasoned professional football player sustains an injury to his lower back during off-season training. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. patellar tendon. most common age of presentation 3-5 years, distal femur is the more common location of pathological deformity, physiologic progression of coronal alignment, genu valgum will peak at 3-4 years to a tibiofemoral angle of 15-20 degrees, after age 7 valgus should not be worse than 12 degrees of genu valgum, after age 7 the intermalleolar distance should be <8 cm, decreased growth from lateral physis relative to medial physis, lateral femoral condyle growth suppressed predisposing to lateral subluxation, normal lateral distal femoral angle (LDFA) = 85-90 degrees, normal medial proximal tibia angle (MPTA) = 85-90 degrees, hypoplastic lateral femoral condyle with shallow lateral femoral sulcus, composed of meniscofemoral and meniscotibial ligaments, increased combined lateral vector of quadricep and patellar tendon (increased q-angle), branch off sciatic nerve that winds laterally around fibular neck, innervates lateral compartment of leg which controls eversion of foot, innervates anterior compartment of leg which controls dorsiflexion, center of femoral head to center of ankle should pass through center of knee, lateral deviation of mechanical axis in genu valgum, lateral femoral condyle and lateral tibia, mechanical loading on physis modulates growth, greater proportion of change in growth rate from hypertrophic zone (75%) than proliferative (25%), greater effect on growth seen from change in size of chondrocytes than number, Physiologic genu valgum must be differentiated from pathologic causes, Chondroectodermal dysplasia (Ellis-van Creveld), medical and family history can help differentiate between physiological and pathological etiology, apparent genu valgum with excessive femoral anteversion or external tibial torsion, general exam to assess stigmata of associated conditions, excessive genu valgum clinically age group beyond which is expected of physiologic changes, patella should be facing forward to ensure proper positioning, lateral deviation of mechanical axis through knee, depends on suspected underlying medical conditions, urinalysis for excess muscopolysaccharides (ie keratan sulfate - Morquio), vast majority of physiological genu valgum will resolve spontaneously, medical management of underlying etiology may slow progression, bracing may provide temporary relief but is an ineffective long-term solution, intramalleolar distance of 10 cm after age 10 Surgical resection is indicated in cases of progressive and severe pain. Medialization of the acetabular component. Radiographs are shown in figure A. (OBQ13.271) A 22-year-old female with hereditary osteochondromas has difficulty supinating and pronating her forearm. What femoral characteristic is a typical concern in this patient? Left L2-3 foraminal herniated nucleus pulposis, Left L4-5 central herniated nucleus pulposis, Left L4-5 paracentral herniated nucleus pulposis, Left L4-5 foraminal herniated nucleus pulposis, Left L5-S1 paracentral herniated nucleus pulposis. 12/3/2019. Additionally, she describes intermittent episodes of an inability to fully extend her knee. The patella may reduce spontaneously. All of the following statements regarding hereditary multiple exostosis (HME) are correct EXCEPT? depends on metaplastic bone (fibrocartilge) for successful results. A patella dislocation occurs when the patella moves sideways out of the patella groove (Figure 1 right). WebPatellar resurfacing (PR) and peripheral patellar denervation (PD) are common surgical treatments for knee osteoarthritis (KOA) in total knee arthroplasty (TKA). What structure is located at the tip of the arrow in Figure 18? amplification of neural signaling within the central nervous system (CNS) that elicits pain hypersensitivity. Upon evaluation, he has difficulty bearing weight due to left hip pain and has tenderness to palpation superior to his left hip joint. THA Dislocation THA Sciatic Nerve Palsy THA Leg Length Discrepancy THA Vascular Injury & Bleeding THA Chronic Complications THA Aseptic Loosening THA Iliopsoas Impingement TKA Patellar Prosthesis Loosening During surgery there is no evidence of instability. An 18-year-old girl presents with a deformity of the left leg that limits her ability to play basketball and volleyball. Typically involving the posterior elements of the cervical spine. (OBQ11.3) What is the best treatment option at this time? Distal femoral osteotomy with plate fixation of bilateral distal femurs, Temporary hemiepiphysiodesis across the bilateral medial distal femoral growth plates, Temporary hemiepiphysiodesis across the right medial distal femoral growth plate, Temporary lateral hemiepiphysiodesis of the bilateral distal femoral growth plates, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list. Patellar Clunk Syndrome THA Dislocation is a complication following THA and may occur due to patient noncomplicance with post-operative restrictions, implant malposition, or soft-tissue deficiency. common peroneal nerve (15-29%) vascular injury. Femoral head within acetabulum despite some subluxation. the atlantoaxial joint provides ~50% of rotation in the cervical spine, this is enabled by the peg (C2)-ring(C1) anatomy, often appear late in disease process due to capacious nature of spinal canal at the C1 level, distance between odontoid process and the posterior border of the anterior arch of the atlas, must get preoperative flexion-extension radiographs to clear all high-risk patients for any type of surgery, space-available-cord (SAC) = posterior atlanto-dens-interval, distance from posterior surface of dens to anterior surface of posterior arch of atlas, lateral mass are connect by ring of C1, and therefore can only be displaced relative to each other if, there is a bony fracture (disruption of the ring), if > 8.1 mm, then a transverse ligament rupture is assured and the injury pattern is considered unstable, Traumatic Spondylolisthesis of Axis (Hangman's Fracture), Cervical Lateral Mass Fracture Separation, Extension Teardrop Fracture Cervical Spine, Clay-shoveler Fracture (Cervical Spinous Process FX), Chance Fracture (flexion-distraction injury), Osteoporotic Vertebral Compression Fracture, Ossification Posterior Longitudinal Ligament, DISH (Diffuse Idiopathic Skeletal Hyperostosis), Atlantoaxial Rotatory Displacement (AARD), Pediatric Intervertebral Disc Calcification, Pediatric Spondylolysis & Spondylolisthesis. 2% (17/707) 4. 595 plays. Treatment is closed reduction and casting or surgical fixation depending on the degree of displacement. THA Dislocation THA Sciatic Nerve Palsy THA Leg Length Discrepancy Patellar tendon rupture. Diagnosis can be suspected clinically with presence of a traumatic knee effusion with increased laxity on Lachman's test but requires MRI studies to confirm diagnosis. (OBQ20.108) A 21-year-old recreational hockey goalie presents to your clinic with 6 weeks of right hip and groin pain. A 47-year-old man presents for consultation for "potential spine surgery" after referral from his chiropractor. The sciatic nerve was well visualized and protected during the procedure. This is an AAOS Self Assessment Exam (SAE) question. Treatment is observation for genu valgum <15 degrees in a child <7 years of age. Team Orthobullets (AF) Trauma - Elbow Dislocation; Listen Now 31:52 min. Spine Infections, Tumors, & Systemic Conditions. A radiograph taken after the fall is shown in Figure 10b. On strength testing, he has graded 5/5 strength to knee extension, 5/5 ankle dorsiflexion and 4/5 ankle plantar flexion. Equivalent relief from symptoms and equivalent improvement in quality of life, Less relief from symptoms and less improvement in quality of life, Improved relief from symptoms and greater improvement in quality of life, Significantly decreased return to work status, Significantly improved return to work status. Worse outcome in return to work status with equivalence in pain and physical function at 4 years. Conversion of the exposure to a subvastus approach, Conversion of the exposure to a two-incision approach, Conversion of the exposure to a standard parapatellar arthrotomy, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, TKA - Varus Knee with Anterior Referencing and Gap Balancing Technique, TKA with Computer Navigation & Sensor-Guided Assessment for Soft Tissue Balancing - Dr. William Gall, Type in at least one full word to see suggestions list, Orthopaedic Summit Evolving Techniques 2021, Pro: Fixed-Bearing UKA: Computer-Guided - One & Done, Crushes His Opponents! Treatment is observation for asymptomatic or minimally symptomatic cases. Caused by mutation(s) in the EXT1/EXT2/EXT3 genes, Exostoses grow towards the joint in MHE but away from the joint in solitary osteochondromas, The most common joint affected is the knee, The rate of transformation to chondrosarcoma is less than 10% in MHE. (SBQ12TR.9) A 67-year-old male is involved in a motor vehicle accident and presents with the closed orthopedic injuries shown in Figures A and B. SI Dislocation & Crescent FX Medial parapatellar arthrotomy avoiding the patellar tendon. physical exam. On physical examination, he has pain with flexion, adduction, and internal rotation of the right hip and reports deep-seated groin pain when asked to perform a squat. Step 2. Osteochondromas are benign chondrogenic lesions derived from aberrant cartilage from the perichondral ring that may take the form of solitary osteochondroma, or Multiple Hereditary Exostosis. The second layer of concrete is added to the mold. Lumbar Disc Herniation is a very common cause of low back pain and unilateral leg pain, known as radiculopathy. Step 3. provides excellent detail of bony anatomy and can confirm pelvic ring/acetabular fractures that are not always visible on plain radiographs. His MRI is shown in Figure A. A 15-year-old boy presents with a painful mass over his great toe. common peroneal nerve. knee valgus (because of shortened fibula) and patellar dislocation. He visits a geneticist and genetic screening reveals he has a EXT 1 gene mutation. Physical exam shows normal strength in all four extremities and hyper-reflexic patellar tendons. Webpatella tracking (Figure 1 left). What should be his initial treatment? Positive apprehension sign with lateral patellar translation. Which of the following treatment modalities will allow the greatest improvement of physical functioning? The atlantoaxial joint is an important "transitional zone" in the cervical spine. At his one-year follow-up appointment, the patient notes pain in the peri-patellar region that is aggravated by palpation and kneeling. Her medical history is positive for asthma and eczema. Copyright 2022 Lineage Medical, Inc. All rights reserved. 126 plays. A 35-year-old physical therapist presents with right-sided back and leg pain. Diagnosis is made clinically and confirmed with an MRI studies of the lumbar spine. Diagnosis can be confirmed by physical exam and radiographs for complete tears. Team Orthobullets (J) Trauma - Proximal Third Tibia Fracture; Listen Now 19:10 min. usually medial-sided plateau fractures . A 45-year-old female returns to your clinic with 10-weeks of severe pain that starts in her back and extends down her right leg to the top of her foot. A 12-year-old skeletally immature female presents with a several year history of bilateral knee pain and lower extremity deformity with her knees rubbing together while she runs. Arthroplasty Preoperative Medical Optimization, Idiopathic Transient Osteoporosis of the Hip (ITOH), THA Pseudotumor (Metal on Metal Reactions), TKA Postoperative Rehabilitation & Outpatient Management. When compared to a median parapatellar approach which of the following approaches may lead to higher rates of component malposition? Flexion and extension radiographs show no evidence of spondylolisthesis. After a failure of nonoperative treatment, which of the following is the most appropriate surgical treatment? True Patellar "J Sign" Jonathan Cohen Pediatrics Orthobullets Team Pediatrics - Accessory Navicular ; Listen Now 14:0 min. He has noticed intermittent episodes of gait imbalance and difficulty with buttoning his shirt over the past 3 months. Knee dislocations are invariably associated with ligamentous injuries. Given this patient's presentation and family history, you initially recommend molecular genetic testing. (OBQ11.173) During a minimally invasive total knee arthroplasty with a quadriceps-sparing approach, the exposure is found to be limited and causing difficulties with jig alignment. Diagnosis is made with radiographs showing. What is his underlying diagnosis, and which mesenchymal tumor is he most at risk of developing? What intra-operative technique could have prevented this complication? Which muscle would you most likely expect to be weak in this patient? Hip Osteonecrosis, also known as avascular necrosis of the hip, represents a condition caused by reduced blood flow to the femoral head secondary to a variety of risk factors such as a traumatic event, sickle cell disease, steroid use, alcoholism, autoimmune disorders, and hypercoagulable states. His patellar reflex is absent on the left, and 2+ on the right. Surgical microdiscectomy is only indicated for severe pain and/or motor deficit that have failed to respond to nonoperative management. A radiograph taken 6 weeks after surgery and before the fall is shown in Figure 10a. WebLink to video demonstrating this. While his back pain has improved slightly, his leg pain remain severe and interferes with his ability to sleep and work. Traumatic Spondylolisthesis of Axis (Hangman's Fracture), Cervical Lateral Mass Fracture Separation, Extension Teardrop Fracture Cervical Spine, Clay-shoveler Fracture (Cervical Spinous Process FX), Chance Fracture (flexion-distraction injury), Osteoporotic Vertebral Compression Fracture, Ossification Posterior Longitudinal Ligament, DISH (Diffuse Idiopathic Skeletal Hyperostosis), Atlantoaxial Rotatory Displacement (AARD), Pediatric Intervertebral Disc Calcification, Pediatric Spondylolysis & Spondylolisthesis. A merchant view is performed which shows no significant degenerative changes of the patellofemoral joint. A 33-year-old woman reports pain down her right leg and numbness across the dorsum of her right foot which started 3 months ago during a bowel movement. What is the most appropriate treatment? Team Orthobullets 4 Knee & Sports - Discoid Meniscus; Listen Now 6:33 min. Which of the following is true with respect to this patient's underlying disorder? Gently extend the lower leg. Then done tamping on the first layer (25 times) with the help of the rod. Which muscle function would be most likely to be affected in this patient? Surgical management is indicated for severe and progressive genu valum in a child > 7 years of age. This is an AAOS Self Assessment Exam (SAE) question. Range-of-motion is from -5 degrees to 130 degrees. Copyright 2022 Lineage Medical, Inc. All rights reserved. Tibial tubercle fractures are a common fracture that occurs in adolescent boys near the end of skeletal growth during athletic activity. Radiographs are shown in Figures A and B. Anatomy. A 42-year-old man undergoes right total hip arthroplasty for hip dysplasia. On the first post-operative day, the patient is noted to have weakness in ankle dorsiflexion with paresthesias over the dorsum of the foot. He reports pain and paresthesias to the right buttock, posterolateral lower leg and lateral foot. Which of the following is the most appropriate surgical treatment? Her clinical mechanical alignment, patellar tracking, meniscal examination, and ligamentous examination are all equivocal on physical examination. Counseling for the patient would include telling the patient that he is more likely to have all of the following compared to a patient carrying the EXT 2 gene mutation EXCEPT: Lower functional knee and elbow range of motion, Higher rate of pelvic and flatbone involvement. A 34-year-old female presents with chronic insidiously progressive left hip pain. A standing alignment radiograph is shown in Figure B with the mechanical lateral distal femoral angle measured at 73 (mLDFA 88, range 85-90), an mechanical medial proximal tibial angle of 87 (mMPTA 87, range 85-90), and a tibial femoral angle of 25(range 5-10). A T1 MRI is shown in Figure C. What is the next most appropriate step in management? The remaining physical exam is unremarkable, including normal achilles and patellar reflexes bilaterally, no clonus, and a down-going Babinski sign. Lateral closing wedge proximal femoral osteotomy with medial opening wedge tibial osteotomy. (OBQ09.111) Thank you. Nerves . THA Dislocation THA Sciatic Nerve Palsy THA Leg Length Discrepancy preserves patellar tendon and tibial tubercle. Elbow Dislocation - Pediatric predispose to patellar instability . A sagittal CT scan is shown in Figure C with a coronal reconstruction shown in Figure D. What is the most appropriate treatment? Multiple hereditary exostosis, chondrosarcoma, Multiple hereditary exostosis, enchondroma, Multiple enchondromatosis, chondroblastoma, Multiple hereditary exostosis, osteosarcoma. Figure 21 shows the radiograph of a 32-year-old patient with right hip pain that has failed to respond to nonsurgical management. Partial tears may need an MRI to confirm the diagnosis. Which of the following statements is most accurate about this diagram? Patellar instability is a condition characterized by patellar subluxation or dislocation episodes as a result of injury, ligamentous laxity or increased Q angle of the knee. He has mildly diminished big toe dorsiflexion strength on the right side. (SBQ16HK.2) A 65-year-old male presents to your office for evaluation of chronic debilitating left hip pain over the last 5 years. Improved outcome in pain and physical function at 4 years. An 18-year-old male presents with the radiographs shown in Figures A and B. WebPatellar Dislocation and Instability in Children (Unstable Kneecap) Your child's kneecap (patella) is usually right where it should beresting in a groove at the end of the thighbone (femur). Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. He denies any recent trauma. (SBQ16HK.2) Combined radius and ulna corrective osteotomy. Mutations in the tumor suppressor genes EXT1 and EXT2 gene leads to a condition characterized by which of the following images. Copyright 2022 Lineage Medical, Inc. All rights reserved. Slightly flex the hip (relaxes quadriceps tension). The patella, also known as the kneecap, is a flat, rounded triangular bone which articulates with the femur (thigh bone) and covers and protects the anterior articular surface of the knee joint.The patella is found in many tetrapods, such as mice, cats, birds and dogs, but not in whales, or most reptiles.. 73% (518/707) 5. Proximal Tib-Fib Dislocation Knee Overuse injuries Patellar Tendinitis A traumatic rupture of the patellar tendon caused by a tension overload during activity in a patient at risk. This system divides tibial plateau fractures into six types: Schatzker I: wedge-shaped pure cleavage fracture of the lateral tibial plateau, originally defined as having less than 4 mm of depression or displacement Schatzker II: splitting and depression of the lateral tibial plateau; namely, type I fracture with a depressed component (generally considered may be treated with exostosis excision, ulnar lengthening and radial closing wedge osteotomy. A 12-year-old girl with a several-year history of multiple bony protuberances presents to your clinic for evaluation. A 45-year-old patient complains of leg pain associated with the pathology seen in Figure A. When the knee bends and straightens, the patella moves straight up and down within the groove. true incidence is unknown as many are asymptomatic, subungal exostosis (occurs most often at hallux). 10/19/2019. A 23-year-old male reports a firm, immobile mass behind his tibia that creates pain when he walks long distances or uses stairs. 241 plays. A 45-year-old man presents to clinic with low back and lower extremity pain. Right L4/5 minimally invasive transforaminal interbody fusion, Referral for EMG and nerve conduction studies, L4/5 posterior decompression and instrumented fusion. He says he required surgery for removal of these bony prominences when he was younger. no attempt to visualize articular surface. Figure A is a sagittal MRI and figure B is a axial MRI through the L4/5 disc space. (SBQ16HK.15) Fractures of the distal femur or proximal tibia are also common (~15%) 2,4 . Based on the radiograph shown in Figure 4, the innervation of what muscle is most at risk with total hip arthroplasty? ankle valgus (because of shortened fibula) radial bowing and radial head dislocation. All of the following are true of multiple hereditary exostoses (MHE) EXCEPT? (OBQ20.115) Treatment is surgical reduction and stabilization in majority of cases. (OBQ12.69) He has noticed intermittent episodes of gait imbalance and difficulty with buttoning his shirt over the past 3 months. The quadriceps is a group of muscles on the front of the thigh which straighten the knee. most common deformities include. Diagnosis is confirmed clinically with genu valgum, knee contractures and presence of a patella that is dislocated posterolaterally. inserts on anterolateral aspect of proximal tibia at Gerdy's tubercle. Patellar maltracking occurs as a result of imbalance of this relationship often secondary to anatomic morphologic abnormality. (SBQ18SP.62) Radiographs are shown in Figure A. 10/18/2019. (OBQ10.254) Which of the following treatment options is most appropriate? iliotibial band . 93 plays. if multiple incision, choose more lateral, generally safe to cross previous transverse incisions at right angles, exact length of skin bridge needed is controversial, "simple" primary knee arthroplasty approaches, "complex" primary or revision total knee arthroplasty, most commonly completed through a straight midline incision, excellent exposure even in challenging cases, possible failure of medial capsular repair, development of lateral patellar subluxation, access to lateral retinaculum less direct, may jeopardize patellar circulation if lateral release is performed, useful for addressing lateral contractures but difficult eversion of patella makes exposure challenging, allows direct access to lateral side in a valgus knee, medial eversion of patella is more difficult, similar approach to medial parapatellar that spares VMO insertion and may lead to quicker recovery, vastus medialis insertion on quad tendon is not disrupted, potentially allows accelerated rehab due to avoiding disruption of extensor mechanism, patellar tracking may be improved compared to medial parapatellar approach, exposure difficult with flexion contractures, muscle belly of vastus medialis is lifted off intermuscular septum, minimal need for lateral retinacular release, often need special instruments for exposure and implant insertion, data shows no clinically significant improvement in patient reported outcomes, gait patterns or quadriceps strength, quadriceps-sparing approach may lead to high rates of component malposition, Indications to convert to a standard parapatellar approach, patellar tendon starts to peel off the tibial tubercle, incision is too small for proper jig placement, snip made at apex of quadriceps tendon obliquely across tendon at a 45-degree angle into vastus lateralis, not as extensile as a turndown or tibial tubercle osteotomy, straight medial parapatellar arthrotomy with diverging incision down the vastus lateralis tendon towards lateral retinaculum, preserves patellar tendon and tibial tubercle, knee needs to be immobilized post-operatively, 6-10 cm bone fragment cut from medial to lateral, avoids extensor lag seen with V-Y turndown, some surgeons immobilize or limit weight-bearing post-operatively, two surgeons performing the bilateral TKA at the same time, one surgeon performing one TKA and then the contralateral TKA under one anesthetic, done surgeon performing each TKA under a separate anesthetic, timing ranges from 3 days to one year in between each side, indications for use in primary TKA are controversial, in vitro studies have shown a theoretical risk of decreased cement strength with adding antibiotics (dilution), however, there are no current studies that have shown ALBC to increase the rate of aseptic loosening, Arthroplasty Preoperative Medical Optimization, Idiopathic Transient Osteoporosis of the Hip (ITOH), THA Pseudotumor (Metal on Metal Reactions), TKA Postoperative Rehabilitation & Outpatient Management. recurrent torsional strain leads to tears of the outer annulus which leads to herniation of nucleus pulposis, lateral edge of posterior longitudinal ligament weakest region, common site for posterolateral/paracentral disc herniations, sinuvertebral nerves provide pain innervation to the posterior annulus, mediate vertebrogenic back pain that precedes or accompanies disc herniation, cellular senescence of fibrochondrocytes leads to loss of proteoglycan production leading to disc height loss, loss of height causes increased strain on the annulus fibrosus, increased strain leads to fissures of the annulus fibrils, annular tears compromise hoop stresses that act against the deforming forces of the nucleus pulposus, younger, well-hydrated discs more likely to herniate, pediatric patients may have Salter-Harris II fracture of the ring apophysis, older, desiccated discs less likely to herniate, sciatica symptoms result from combined mechanical compression and associated inflammation, not all patients with mechanical compression develop symptoms, TNF-, MMP, NO, PE2, and IL-6 are implicated in nerve irritation leading to radiculopathy, weak evidence to support DMARDs for treatment, Complete intervertebral disc anatomy and biomechanics, characterized by extensibility and tensile strength, high collagen / low proteoglycan ratio (low % dry weight of proteoglycans), low collagen / high proteoglycan ratio (high % dry weight of proteoglycans), proteoglycans interact with water and resist compression, a hydrated gel due to high polysaccharide content and high water content (88%), disc height dependent on the degree of hydration, nutrients supplied by diffusion from the end plates, key difference between cervical and lumbar spine is, cervical spine C6 nerve root travels under C5 pedicle, lumbar spine L5 nerve root travels under L5 pedicle, extra C8 nerve root (no C8 pedicle) allows transition, horizontal (cervical) vs. vertical (lumbar) anatomy of nerve root, because of vertical anatomy of lumbar nerve root a paracentral and foraminal disc will affect different nerve roots, because of horizontal anatomy of cervical nerve root a central and foraminal disc will affect the same nerve root, may present with cauda equina syndrome which is a surgical emergency, affects the traversing/descending/lower nerve root, herniated disc material directly compresses dorsal root ganglion, can manifest with more severe pain than traditional posterolateral disc herniation, can affect both exiting and descending nerve roots, disc material herniates through annulus but remains continuous with disc space, disc material herniates through annulus and is no longer continuous with disc space, disc material is contained beneath the posterior longitudinal ligament, disc material passes dorsal to the posterior longitudinal ligament, important consideration given surgical outcomes are associated with chronicity, sudden onset of pain after lifting a heavy object, prolonged sitting with lateral bending and rotation in the presence of vibrational energy, symptomatic improvement lying supine with knees and hips flexed, especially with lower lumbar disc herniations, this may be discogenic or mechanical in nature, symptoms worsened by coughing, valsalva, sneezing, patient leaning away from side of radiculopathy, effort to increase the size of the neuroforamen, associated tenderness in the paraspinal musculature, dermatomal pain in the anteromedial thigh, dermatomal pain in the lateral thigh, crossing the knee, to medial foot, ankle dorsiflexion weakness (L4 > L5 contribution), have patient lie on side on exam table and abduct leg against resistance, dermatomal pain in anterolateral leg and dorsum of foot, have patient do 10 single leg toes stands, dermatomal pain in posterior calf and lateral foot, a tension sign for L4, L5 and S1 nerve root, most important and predictive physical finding for identifying who is a good candidate for surgery, crossed straight leg raise is less sensitive but more specific, femoral nerve stretch test (Wasserman sign), reproduction of pain in anterior thigh is considered positive, lower leg just to the point where pain recedes, ankle dorsiflexion causes exacerbated pain, SLR aggravated by compression on popliteal fossa, pain reproduced with neck flexion, hip flexion, and leg extension, pain reproduced by coughing, which is instigated by lying patient supine and applying pressure on the neck veins, pain reproduced with straight leg elevation for 30 seconds in the supine position, due to gluteus medius weakness which is innervated by L5, identify anomalous vertebrae (sacralized L5 or lumbarized S1), if present can changes surgical plan to involve fusion, lumbar spondylosis (degenerative changes), convex or concave list to the ipsilateral side of herniation, poor sensitivity for identifying disc herniation, more often used as a screening tool for other pathology prior to proceeding with MRI, sagittal and coronal reconstructions demonstrate compression of the thecal sac, myelography filling defect at the level of herniation, 93% accurate at detecting associated surgical pathology, unable to detect foraminal or extraforaminal herniations, infection (IV drug user, h/o of fever and chills), cauda equina syndrome (bowel/bladder changes), modality of choice for diagnosis of lumbar disc herniations, useful to differentiate from synovial facet cysts, however high rate of abnormal findings on MRI in normal people, need to correlate MRI findings with symptoms and physical exam findings, localize the level and side of the herniation, location anatomic location (central vs paracentral vs foraminal vs extraforaminal), first line of treatment for most patients with disc herniation, positive predictors of good outcomes with nonoperative treatment, second line of treatment if therapy and medications fail, no difference in pain relief using lidocaine with and without steroids, timing of appropriate nonoperative treatment varies, better surgical outcomes if addressed within 2 months, patients may return to medium to high-intensity activity at 4 to 6 weeks, outcomes with surgery compared to nonoperative, early and sustained pain relief out to 2 years, equal likelihood of receiving disability at 5 years, positive predictors for good outcome with surgery, weakness that correlates with nerve root impingement seen on MRI, progressively worsening symptoms prior to surgery, younger age, greater number of games played prior to injury, central and extraforaminal associated with worse outcomes, L5-S1 results in better outcomes than L2-3, negative predictors for good outcome with surgery, WC patients have less relief from symptoms and less improvement in quality of life with surgical treatment, bedrest followed by progressive activity as tolerated, most modern protocols involve immediate activity with modification to avoid pain exacerbation, muscle relaxants (more effective than placebo but have side effects), modest but significant improvement in function, no significant improvement in pain, typically avoided due to complication profile, worse outcomes following surgical treatment, if used, usually for a short period (2-3 days) in the acute setting, typically initiated three weeks after symptom onset, extension exercises are extremely beneficial, most techniques can be performed in a "minimally invasive" fashion, can be done with small incision or through "tube" access, open technique using a crank (McCulloh) retractor, discectomy performed through microscope or loupe magnification, no difference in outcomes between the two, similar outcomes between all techniques surgical techniques, fragment excision vs extended disc space curettage (subtotal discectomy), lower long term back pain with fragment excision, higher reherniation rates with fragment excision at 2-years follow-up, can also be done with tubular or crank retractors, if have tear at time of surgery then perform water-tight repair, has not been shown to adversely affect long term outcomes, defined as recurrent sciatica at the same operated level, pain-free interval of 6 months prior to recurrence of symptoms, pathology can be ipsilateral to contralateral to the index presentation, revision rate at 8-year follow-up is 15% according to the SPORT trial, risk factors protective against recurrent herniation, revision microdiscectomy in patients with persistent symptoms, outcomes for revision discectomy have been shown to be as good as for primary discectomy, microscope usage proposed as a source of infection, treat with local wound care and antibiotics, scarring the compresses the dura leading to radicular symptoms, associated with poor outcomes following revision surgery, patients 3.2 times more likely to suffer from recurrent radiculopathy, MRI may demonstrate retraction of the dura on the side of the lesion, not completely understood but central sensitization may be a factor. Copyright 2022 Lineage Medical, Inc. All rights reserved. Again the (25 times) tamping was done with the rod. WebCradle the affected lower leg in one arm. Orthobullets Team Pediatrics - Genu Valgum (knocked knees) Listen Now 11:53 min. 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, Alternative Bearing Surfaces in Total Hip Replacement, THA - Direct Anterior Approach Total Hip Replacement, Basic Skills Total Hip Arthroplasty: Part 1 Approach and Dislocation. Which of the following radiographs represent typical findings seen with a mutation of the EXT1, EXT2, or EXT3 genes? Classification. (OBQ11.236) His WBC, LDH, and Alkaline phosphatase are normal. What is the optimal next step? (OBQ10.18) Sinding-Larson-Johansson (SLJ) syndrome is an overuse injury seen in adolescents leading to anterior knee pain at the inferior pole of patella at the proximal patella tendon attachment. There is a complete absence of the superior wall. A preoperative radiograph is shown in Figure 19. joint pain. (OBQ08.225) Excessive internal rotation of the tibial component. (OBQ12.102) Place all the apparatus parts together. Specifically it is when the ballshaped head of the femur (femoral head) separates from its cupshaped socket in the hip bone, known as the acetabulum.The joint of the femur and pelvis is very stable, secured by both bony and soft-tissue constraints.With that, dislocation would require significant force which prone to instability by both degenerative and traumatic processes. On physical exam she has decreased sensation on the dorsal aspect of her foot and 4/5 strength in her EHL. The most common pattern is bi-cruciate (i.e. The patient undergoes surgical treatment with a left THA, and his intra-op radiographs reveal equal leg lengths. exacerbating activitis include hip flexion or external rotation in weight bearing stance, lateral hip pain and a limp or Trendelenburg gait may occur with abductor fatigue, evaluation of gait; abductor fatigue or Trendelnburg sign, overall ligamentous laxity; Beighton score, increased internal rotation with the hip in flexion, lateral decubitus position, hip placed in extension as examiner applies progressive external rotation and adduction, anterior-directed force on the posterior greater trochanter, lateral center-edge angle (LCEA) of Wiberg, assesses superolateral coverage of the femoral head on the AP view, angle between a verticle line through the center of the femoral head and the acetabular edge, inclination of the weight bearing portion of the acetabulum, angle formed between the horizontal and a line along the superior acetabulum, assesses anterior coverage of the femoral head, angle created between a vertical line through the center of the femoral head and the anterior acetabulum, >40 indicative of femoroacetabular impingement (FAI), Femoro-Epiphyseal Acetabular Roof (FEAR) index, angle formed between the horizontal portion of the central proximal femoral physeal scar and the acetabular index, FEAR index <5 indicative of a stable hip not requiring treatment, should only be ordered by treating surgeon, adequate assessment of acetabular and proximal femoral osseous morphology including excessive anteversion or retroversion, distal femur should be included in patients with clinical signs of femoral anteversion, diameter of femoral canal may be over-estimated on AP radiographs and underestimated on lateral radiographs due to rotational mismatch of the metaphysis and diaphysis, Identification and prevention of infantile developmental dysplasia (DDH), Pavlik harness, closed and open reductions, spica casting, proximal femoral osteotomies, role of long-term nonsurgical management in symptomatic dysplasia is limited given premature progression of secondary OA, adjunct procedure to PAO for enhanced visualization and management of chondral, labral and proximal femoral cam-type lesions, contraindicated in the setting of moderate to severe dysplasia, chondral and labral pathology is a sequelae of osseous instability and may recur or progress if underlying pathology is not corrected, associated with accelerated progression of arthritis, hip subluxation, less functional improvement, as well as increased risk of surgical failure and reoperation, intraoperative dynamic testing of hip motion is needed to determine the need for femoral osteotomy, minimum of 90 flexion and 15 internal rotation to prevent FAI, preserved integrity of the posterior column, which allows patients to weight bear as tolerated postoperatively, reliably improves radiographic parameters and symptomatology, 92% survivorship at 15 years in avoiding THA, recommended for patients with inadequate femoral head coverage and, 84% survivorship at 17 years with advanced OA as an endpoint, advanced DDH and asphericity of the femoral head associated with poor outcomes, can be used for Crowe type I or II disease, higher revision and complication rate with hip resufracing in patients with DDH compared to general population, treatment of choice for patients with end-stage OA secondary to dysplasia, outcomes for Crowe I and II patients are in similar to those of THA for primary OA in the short term, revision rates for Crowe III and IV are higher than non-dysplastic hips, long term follow up demonstrates a higher revision rate for THA in dysplastic hips, increased complication profile: infection, instability and neruovascular injury, risk of sciatic nerve injury if limb length changed by >4cm, may need to perform femoral shortening (trochanteric or subtrochanteric), weight loss, NSAIDs, activity modification, intra-articular injections, should not be performed in isolation as it does not treat underlying pathologic cause, hip arthroscopy performed concomitantly with PAO to address labral pathology or evaluate for chondral injuries, if significant chondral injury is identified, PAO can be abandoned with minimal morbidity, involves osteotomies in the pubis, ilium, and ischium near the acetabulum, allows significant three-dimensional correction of the acetabulum, hip arthroplasty performed after PAO may lead to increased incidence of a retroverted acetabular cup, make cut above acetabulum to sciatic notch and shift ilium lateral beyond the edge of acetabulum. 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