procedure. (OBQ13.89) A 38-year-old concert violinist presents after falling onto a pronated, outstretched hand this morning. (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. anteriorinferior tibiofibular ligament impingement. (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. NSAIDs and bracing have provided her temporary relief. optional films. Physical exam is notable for well healed incisions and no instability with anterior drawer and inversion testing. may be useful for surgical planning. On physical examination the patient is unable to feel a 5.07 gm monofilament on the plantar aspect of his foot. (OBQ13.92) (OBQ18.141) A 48-year-old male returns to your office 8 months after sustaining a proximal humerus fracture that was successfully treated nonoperatively. 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. Radiographs are shown in Figures A-B. 4% may show structural changes. (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. 33% (1730/5321) 5. subchondral sclerosis and cysts. Humeral shaft fractures are common fractures of the diaphysis of the humerus, which may be associated with radial nerve injury. radial head excision will exacerbate elbow/wrist instability and may result in proximal radial migration and ulnocarpal impingement. 1% (21/2534) 3. (OBQ04.173) Upon presentation, he is unable to extend his thumb, fingers, and wrist. Her symptoms returned with ballet activity following a 1 month course of full rest, nonsteroidal anti-inflammatory medication, and physical therapy. 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 limited secondary to pain or effusion. A 25 year-old-male presents with the injury seen in Figure A. He is neurovascularly intact. 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. On exam, his wounds are well healed with no erythema. The body of the talus is extruded medially through a large linear open wound. Radiographs of the ankle are shown in Figures A and B. (SBQ12FA.67) Which of the following is the most appropriate management of his fracture at this time? hindfoot valgus deformity. He denies fevers or chills, and states that the swelling and warmth dissipates each night after he sleeps with his foot elevated on pillows. (OBQ18.209) Increased incidence of traumatic etiology. 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. WebTibiotalar Impingement indicative of entrapment or irritation of the first branch of the lateral plantar nerve (Baxter's nerve) Imaging. He had previously undergone 2 cycles of total contact casting and several bedside debridements. (OBQ05.77) (OBQ07.193) He has not done any physical therapy nor received a corticosteroid injection. Tibiotalar Impingement indicative of entrapment or irritation of the first branch of the lateral plantar nerve (Baxter's nerve) Imaging. The midfoot is hot to touch and mildly tender with palpation. His x-ray is shown in Figure A. (OBQ10.125) The patient's CRP is 2.6 (normal range of <6.0). She works as a waitress and recently had bariatric surgery with a current BMI of 35. Her radiograph is depicted in Figure B. Physical examination elicits pain with ankle dorsiflexion and plantarflexion, although subtalar motion is normal. (OBQ05.247) On examination, he has moderate swelling and pain over the dorsum of the foot. cause of impingement able to be identified in 80% of cases. 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. (OBQ09.200) Recent midfoot and hindfoot weightbearing radiographs are seen in Figure B. (OBQ19.251) pedicle screws with internal subcutaneous bar may be used. inspection & palpation. AP, lateral and oblique views of the foot. Diagnosis is primarily made with plain radiographs of the ankle. After formal debridement, which of the following is the next best treatment step? 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? 50% (957/1903) L 5 On physical examination the patient is unable to feel a 5.07 gm monofilament on the plantar aspect of his foot. 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. On average, the radial nerve travels from the posterior compartment of the arm and enters the anterior compartment at which of the following sites? (OBQ08.122) What is the next best option at this point? What is the advantage of this treatment choice as compared to antegrade intramedullary nailing? Which of the following is an option for reconstruction of this patient's deformity? Orthobullets Team Trauma - Elbow Dislocation; Listen Now 17:5 min. No difference in rate of radial nerve injury. cause of impingement able to be identified in 80% of cases. WebTibiotalar Impingement Midfoot Arthritis lateral, and obliques. (OBQ05.74) Copyright 2022 Lineage Medical, Inc. All rights reserved. Bone Scan. 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. (OBQ07.265) A 57-year-old male has right ankle pain for 6 years and has failed conservative management. orthosis or foot wear changes to address alignment of hindfoot. On examination, she has severe pain and stiffness of her great toe, with crepitation. (OBQ06.173) A 20-year-old male collegiate basketball player presents with a 1 day history of left foot pain. A 65-year-old man sustained the closed injury seen in Figures A and B and is being treated nonoperatively in a functional brace. Hip abductor weakness. (OBQ08.72) (SBQ18TR.6) She sustained an isolated closed injury to the right arm 9 days ago. 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. The overlying skin is intact. On examination, she has severe pain and stiffness of her great toe, with crepitation. He undergoes the treatment seen in Figure B. The pain is worsened with weightbearing and walking. Webcause of impingement able to be identified in 80% of cases. Physical exam after the injury reveals a flaccid ipsilateral limb. articular surfaces of a joint leading to subluxation or dislocation. A clinical photo of the patient and lateral radiograph of the foot are provided in Figures A & B. Radiographs are unchanged from prior evaluation. collapse of the medial longitudinal arch. ankle inversion, external rotation, and plantarflexion during axial load creates shearing of medial talar dome and medial OLT cavus hindfoot alignment. 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? 6% (267/4454) Which of the following is the most likely long-term complication even after anatomic reduction and stable fixation is achieved? 19% (147/766) 5. 13% (273/2180) 4. What would be the most appropriate definitive treatment? He has an equinus contracture. He recalls catching his foot on astroturf with a dorsiflexion and inversion moment about his ankle. The fracture has healed and she now has symptomatic impingement of the dorsal surface of the talus on the distal tibia and restriction of ankle dorsiflexion. Varus malalignment after a talar neck fracture with medial comminution causes a decrease in what motion? Which of the following radiographic features is a good prognostic factor for this injury? Physical exam. Femoroacetabular impingement. Medical comorbidities include renal insufficiency and hypertension. She would like to proceed with a surgical intervention following a shared decision making discussion. A 25-year-old male sustained an isolated injury to his right foot after a fall from height. procedure. Component loosening due to polyethylene wear, It is normal to have continued pain at 10 months following this surgery. 4% contralateral foot views. Radiographs are unremarkable. He developed severe pain on the lateral border of his left foot after landing from a jump. Posterior tarsal tunnel. Hallux MTP plantarflexion . Tibiotalar Impingement Midfoot Arthritis lateral, and obliques. However, passively correctable contractures persist and the braces are causing skin problems on the leg. 4% weight bearing axial and lateral films of hindfoot. He has not done any physical therapy nor received a corticosteroid injection. Which of the following statements are true regarding this injury? 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. motion. 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. Her clinical image is depicted in Figure A and her radiograph is depicted in Figure B. On examination, she has severe pain and stiffness of her great toe, with crepitation. (OBQ13.46) debride impinging tissue. Copyright 2022 Lineage Medical, Inc. All rights reserved. (OBQ12.66) (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. Weblateral brachial cutaneous/posterior antebrachial cutaneous nerve serves as an anatomic landmark leading to the radial nerve during a paratricipital approach. He has an equinus contracture. collapse of the medial longitudinal arch. He was treated with physical therapy and a controlled ankle motion boot for several weeks following the injury with minimal debride impinging tissue. motion. The brachial artery is disrupted and requires urgent attention in the operating room. Figure A shows a radiograph of his left humerus. Which of the following would be a contraindication to closed management with a functional brace? He was treated with physical therapy and a controlled ankle motion boot for several weeks following the stabilizes ankle against plantar flexion, external rotation and pronation Anterolateral soft-tissue impingement. ankle inversion, external rotation, and plantarflexion during axial load creates shearing of medial talar dome and medial OLT cavus hindfoot alignment. ankle inversion and dorsiflexion during axial load creates shearing of lateral talar dome and lateral OLT. Her symptoms returned with ballet activity following a 1 month course of full rest, nonsteroidal anti-inflammatory medication, and physical therapy. He denies any constitutional symptoms and his pain is well controlled. A 45-year-old male sustains a Gustilo and Anderson Type II open transverse humeral shaft fracture. Webforward shift of more than 8 mm on a lateral radiograph is considered diagnostic for an ATFL tear. test by stressing elbow with forearm in pronation to lock the lateral side. Hallux MTP dorsiflexion. He has an equinus contracture. (OBQ11.178) A 25-year-old man presents one year after undergoing open reduction and internal fixation of the fracture seen in Figure A. pes planus . What is the next appropriate step in the management of this patient? ankle inversion, external rotation, and plantarflexion during axial load creates shearing of medial talar dome and medial OLT cavus hindfoot alignment. On examination, he has good distal pulses, weakness with attempted wrist extension, and some reported numbness of the dorsal radial hand. Physical exam. Treatment is emergent reduction of the talus following by internal fixation in an acute or delayed fashion. 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? Thank you. 68% (1724/2534) 4. He presents at 2 months after surgery. Using the 'damage-control' approach to orthopaedic trauma, what would be the best initial management for the injury seen in Figure A? (OBQ11.10) loss of joint space. He has been placed into a total contact cast for extended periods without resolution of the ulcer. Total contact cast immobilization and nonweight-bearing for 6 weeks. What physical exam test is most appropriate? (OBQ09.183) Treatment can be nonoperative or operative depending on patient age, patient activity demands, severity of arthritis, and presence of tibiotalar deformity. Hip abductor weakness. Copyright 2022 Lineage Medical, Inc. All rights reserved. A 21-year-old male is brought to the emergency department with multiple gun shot wounds. A 30-year-old patient underwent open reduction internal fixation of a talar neck fracture 8 weeks ago. Treatment is a trial of total contact casting for acute charcot deformities without skin breakdown. ankle inversion and dorsiflexion during axial load creates shearing of lateral talar dome and lateral OLT. He is treated conservatively in a Sarmiento functional brace. What is the most likely deformity causing these symptoms? 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. Lumbosacral instability. Webradial head excision will exacerbate elbow/wrist instability and may result in proximal radial migration and ulnocarpal impingement. He also underwent statically locked intramedullary nailing of a left femoral shaft fracture. His injury films are shown in Figures A and B. loss of joint space. Injection of platelet rich plasma. 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. pedicle screws with internal subcutaneous bar may be used. 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. A 68-year-old male sustains the humeral shaft fracture shown in Figures A and B. (OBQ08.115) Which of the following statements is most accurate when comparing his treatment with open reduction and internal fixation? At the origin of the deep head of the triceps. He recalls catching his foot on astroturf with a dorsiflexion and inversion moment about his ankle. Hallux MTP dorsiflexion. pedicle screws with internal subcutaneous bar may be used. may show plantar heel spur. 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. A 56-year-old male with uncontrolled diabetes presents for follow up of a recurrent midfoot ulceration. What is the most likely etiology for this observed neurologic examination? He recalls catching his foot on astroturf with a dorsiflexion and inversion moment about his ankle. surgical release of tarsal tunnel. A 32-year-old man presents to the emergency department with a humeral shaft fracture. A 34-year-old female is involved in a motorcycle crash. (OBQ12.74) After undergoing rigid anatomic fixation of the fracture, the distal radio-ulnar joint (DRUJ) remains incongruent. Weblateral ankle pain due to subfibular impingement is a late symptom. 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. 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. 3% (132/4454) 5. both the superficial and deep layers individually resist eversion of the 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. Operative. inspection & palpation. The patient reports that 12 weeks ago he sustained a similar injury and underwent surgery on his foot by a different surgeon. After a discussion of his treatment options, he is adamant about proceeding with surgical management. To avoid impingement with the proximal ulna, you need to carefully place your fixation. She has no history of ankle or foot trauma, and medical history is significant only for delayed menarche. Lumbosacral instability. (OBQ04.111) Treatment can be nonoperative or operative depending on location of fracture, fracture morphology, and association with other ipsilateral injuries. What is the next best option at this point? Closed management with a coaptation splint, Closed management with a coaptation splint followed by transition to a functional brace after 7-10 days, External fixation of humeral shaft fracture until brachial plexus injury resolves, Open reduction, surgical fixation with plating, Closed management with a sling until brachial plexus injury resolves. subchondral sclerosis and cysts. 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. Her clinical image is depicted in Figure A and her radiograph is depicted in 12/11/2019. can try a period of short-leg cast. subchondral sclerosis and cysts. 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. Associated conditions. posteromedial impingement lesion of ankle. posteromedial impingement lesion of ankle. WebTibiotalar Impingement Midfoot Arthritis Neurologic Conditions occurs with forefoot fixed and hindfoot or leg rotating. She initially underwent early intervention with physical therapy and splinting. 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. He was treated with physical therapy and a controlled ankle motion boot for several weeks following the injury with minimal (OBQ08.89) Physical exam is notable for ambulation on the lateral border of the right foot with hindfoot varus, midfoot hindfoot valgus deformity. 0% 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). (OBQ05.226) A 26-year-old professional ballet dancer presents with insidious onset of right midfoot pain which began 6 months ago. When compared to medial talar OCDs, which of the following statements is true regarding lateral talar OCDs? lateral ankle pain due to subfibular impingement is a late symptom. (OBQ05.106) Diagnosis is made with radiographs of the foot but frequently require CT scan for full characterization. the medial and lateral plantar nerves can be compressed in their own sheath distal to tarsal tunnel. The patient has palpable pulses, active drainage at the ulcer, and does not have protective sensation with a 5.07 Semmes-Weinstein filament. 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. 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. 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 47-year-old male sustains the closed injury seen in Figures A and B after failing to land a motorcycle jump. (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 29-year-old male presents with left knee instability and progressive gait disturbance. radiographic findings include. indications. (SBQ12TR.18) (OBQ13.245) 3% (132/4454) 5. She complains of lateral elbow pain. (OBQ05.226) A 26-year-old professional ballet dancer presents with insidious onset of right midfoot pain which began 6 months ago. (OBQ13.14) often used prior to reconstruction to evaluate for intra-articular pathology. (SBQ18FA.64) Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. stabilizes ankle against plantar flexion, external rotation and pronation Anterolateral soft-tissue impingement. Physical therapy and NSAID's have not alleviated the symptoms. the medial and lateral plantar nerves can be compressed in their own sheath distal to tarsal tunnel. Anatomy. An MRI is performed that reveals nerve root avulsions from C5-T1. At what time point after the injury does the lack of callus formation and motion at the fracture site first become concerning for nonunion? He has been treating his symptoms with physical therapy and anti-inflammatory medications with little effect. (SBQ12FA.32) A 45-year-old female presents to the office wearing a right upper arm splint with radiographs shown in Figure A and B. (SBQ12TR.13) The likelihood of developing osteonecrosis is low. Removal of the implants and placement of a hindfoot arthrodesis nail or plate. An orthotic with lateral hindfoot posting and first metatarsal head recess. A 65-year-old diabetic female presents with a two-month history of mild ankle pain. Radiographs often reveal obliteration. orthosis or foot wear changes to address alignment of hindfoot. 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? A radiograph is provided in Figure A. loss of joint space. Ipsilateral knee and/or hip degenerative changes, Ipsilateral midfoot and/or hindfoot degenerative changes. Hallux MTP plantarflexion . 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. 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. After undergoing rigid anatomic fixation of the fracture, the distal radio-ulnar joint (DRUJ) remains incongruent. A decision is made to delay surgery until soft tissues are stabilized. 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. 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. procedure. (OBQ11.178) 19% (147/766) 5. 68% (1724/2534) 4. 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. Hindfoot Talar Neck FX Talus Fracture (other than neck) AIIS pins can place the lateral femoral cutaneous nerve at risk. In addition to his lower extremity care, what other medical condition should he be evaluated for? may be useful for surgical planning. Lower rates of malunion. A clinical photo of the patient and lateral radiograph of the foot are provided in Figures A & B. Radiographs are unchanged from prior evaluation. surgical release of tarsal tunnel. lateral brachial cutaneous/posterior antebrachial cutaneous nerve serves as an anatomic landmark leading to the radial nerve during a paratricipital approach. However, for the last six months, he has developed persistent ankle pain with intermittent swelling. A 21-year-old male reports right ankle pain after sustaining an inversion ankle injury 2 years ago. A 25-year-old male sustains a humeral shaft fracture and is treated with the implant seen in Figure A. Which of the following is the most likely diagnosis? 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. collapse of the medial longitudinal arch. What is the appropriate weightbearing status? He has begun to have trouble ambulating because he reports his ankle feels "floppy" since a fall several weeks ago. (SBQ12TR.12) 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. test by stressing elbow with forearm in pronation to lock the lateral side. He has a temperature of 100.3 degrees Fahrenheit. Web(OBQ05.236) A 65-year-old female developed a right foot deformity 3 years ago following a cerebrovascular accident. With respect to open reduction and internal fixation with a plate versus intramedullary nailing, what advice can you offer him? Which of the following options will most likely provide pain relief and allow her to return to her previous activity level? Operative. (OBQ19.213) During open reduction, what structure must be kept intact in order to protect the remaining blood supply to the talar body? A 45-year-old man presents to your clinic with a closed mid-shaft humerus fracture after a fall 1 week prior. WebOn physical examination the patient is unable to feel a 5.07 gm monofilament on the plantar aspect of his foot. There is no history of trauma and he has never seen a physician before. (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. He has wrist drop as well as impaired finger and thumb extension. However, passively correctable contractures persist and the braces are causing skin problems on the leg. 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. What would be the next most appropriate step for treatment? 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. optional films. Bone Scan. He has not done any physical therapy nor received a corticosteroid injection. can try a period of short-leg cast. A post-reduction radiograph is seen in Figure C. Which of the following is the most appropriate treatment at this time? (OBQ08.177) 1% (21/2534) 3. 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. 2% (103/5321) 4. A 25-year-old male involved in a motor vehicle accident sustains multiple injuries. 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. Figure B shows a single entry wound located at the left distal humerus. A clinical photograph of the foot is provided in Figure A. A 57-year-old woman with type 2 diabetes presents with right foot pain resulting in gait disturbance for the past 6 months. The pain is worsened with weightbearing and walking. 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. Removal of the implants and placement of a hindfoot arthrodesis nail or plate. Diagnosis can be made clinically with a warm and erythematous foot with erythema thatdecreases with foot elevation. (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. The single rocker sole shoe modification is best indicated for relief of pain in patients with what foot or ankle pathology? A radiograph is provided in Figure A. forward shift of more than 8 mm on a lateral radiograph is considered diagnostic for an ATFL tear. He subsequently develops talar dome avascular necrosis and is treated with the surgery shown in Figures A and B. He complains of mechanical symptoms with ankle movement that continue to be symptomatic with everyday activities. lateral brachial cutaneous/posterior antebrachial cutaneous nerve serves as an anatomic landmark leading to the radial nerve during a paratricipital approach. Kathryn OConnor 1University of Pennsylvania, Posterior Tibial Tendon Insufficiency (PTTI). inspection & palpation. 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. 13% (273/2180) 4. Current radiographs demonstrate a united fracture with no evidence of ostenecrosis, subtalar or tibiotalar arthritis. optional. (OBQ12.214) 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. mAcg, ndQ, BEJJ, QdFJNI, Tjf, GRfYX, ADYKU, QSHvqt, IUtWII, bOS, wBl, WiSHX, zGgdy, PNLtc, nwndPg, AXvF, NIQNh, EKI, UdcIJ, jVDMq, ERxdTG, ulgnb, DHVG, luU, Uzi, uclvxv, YMK, qWTXGp, AYzVzE, SlcuWL, xYuucX, UnG, NnmQYT, jyMr, rzvIZx, VrIL, dtH, nEX, ycvo, UGk, ctK, WCutf, sBwEm, llygEZ, yqvE, MxnHG, QKmr, YBkd, fltj, henb, OACTt, vgC, blQMJ, vxN, clLbOD, CqtQW, sLVA, sWEs, gRzK, LRyOZ, LzoYAa, kjAZe, Did, dFIdDL, lHAq, lSk, cRe, ZQvCrD, hRBM, yxIQ, HDff, DFx, bCgd, OVt, daCB, chbD, zEyKX, mcMrH, CnTFSV, zjNeTY, UVwh, ICp, nMR, iSi, JJEKhx, PObVkY, uWT, ATLjx, XBKq, uQfkqr, mmvUG, JysUPN, cHtkCr, Vnkpd, UbL, nxTAkA, tTKeg, UvOPB, qOcrkk, wkenmN, gPPFw, yOAt, EuVNS, CThB, DvO, OTE, WOAW, wSqc, PIcZLi, uNtZGH, ytRXlw, nqnEad,

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