Surgical excision of the painful lesion is performed, and frozen section pathology demonstrates perineural fibrosis without fibrinoid necrosis. (SAE13HK.10) reinforce with cerclage suture or wire from quadriceps tendon to tibial tubercle . (OBQ05.173) 2002 Oct;16(9):632-7. doi: 10.1097/00005131-200210000-00004. (OBQ17.97) Her THA was done 25 years ago. His current radiograph is shown in Figure A. 2010 Jul;18(7):911-5. doi: 10.1007/s00167-009-1003-x. Insert long porous-coated stem, augment with cortical allograft and cerclage wires, touch down weight bearing postoperatively. What is the next best course of action? 5% (127/2520) L 2 Figure A shows the image of a 72-year-old male who sustained a fall from standing. (OBQ09.223) Surgical decompression with partial meniscectomy versus meniscus repair may be indicated for persistently symptomatic What is the most appropriate reconstructive management on the femoral side? MRI studies may be needed to detect early disease. (OBQ12.217) Compared to a dorsal approach, a plantar approach is associated with: Improved clinical outcomes and patient satisfaction, Increased likelihood of complete neuroma excision. In the radiograph shown in Figure 42, the fracture pattern around this well-fixed stem is classified as Vancouver type. and transmitted securely. Which of the following is the most appropriate management? Treatment. views. Position of the screw cephalad to the sciatic notch, Screw starting point at the anterior inferior iliac spine, Screw starting point at the gluteal pillar, Screw position between the inner and outer tables of the ilium. WebTibial Plateau Fracture & Treatment | Orthopedic One Our Physicians What Hurts Services & Specialties Locations About Request Appointment For Patients For Physicians Online Bill Pay Careers Request Appointment Scott Van Steyn, M.D. An overview of tibial fractures in children is presented here. Surgical management is indicated for progressive pain, joint destruction and joint deformity. Arthroscopic labral debridement versus repair is indicated for patients with progressive symptoms who failed nonoperative management. Touch-down weight bearing of his right leg and observation of his sciatic nerve palsy, Skeletal traction on the distal femur to relax tension on the sciatic nerve. Web(OBQ04.148) A 34-year-old male presents with right knee pain, swelling, and symptoms of buckling 3 months after being involved in a motorcyle accident. WebSimple Fracture : A break in a bone without an accompanying wound at the fracture site. Operative management is indicated for chronic and recurrent patellar instability. (OBQ18.202) useful to diagnosis syndesmosis injury in high ankle sprain. In the same 5 patients a diagnosis of tibial plateau fracture was made by CT-scan in 3, and by MRI-scan in 2 patients. How would you classify this fracture and what is the appropriate treatment plan? A 74-year-old man falls, sustaining the injury shown in Figures A through C. In surgical planning, what is the best surgical approach to treat this injury? Am J Orthop (Belle Mead NJ). At what time point after the injury is there an increased risk of a poor outcome? Case Discussion Insufficiency fractures are a type of stress fracture, which are the result of normal stresses on abnormal bone. Shortly after the reduction, the patient continues to have a foot drop, but his sensation is slightly improved. Basic rehabilitation program for low-risk tibial stress fracture Basic rehabilitation program low-risk fibular stress fracture Figures Anterior anatomy of tibia and fibula Lateral anatomy of tibia and fibula Anterior knee anatomy Syndesmosis (interosseous ligament) Superficial fibular (peroneal) nerve Lateral ankle ligaments A 40-year-old female secretary presents with left forefoot pain that radiates to her 3rd and 4th toes. (OBQ06.51) Thank you. The greatest distance between the humerus and the fracture fragment is measured to be 2 mm. negative radiographs with high index of suspicion for tibial plateau fracture. The patient is taken to surgery, and the femoral stem is found to be loose. posterior wall fracture involving > 40-50%), factors considered for fiaxtion methodology, location (column and/or wall) and level (high or low) of the fracture pattern, associated hip dislocations should be reduced within 12 hours for improved outcomes, incarcerated fragments upon reduction can be treated with urgent ORIF or placement of skeletal traction and delayed ORIF, worse outcomes with fixation of fracture > 3 weeks from time of injury, earlier operative treatment associated with increased chance of anatomic reduction, clinical outcome correlates with quality of articular reduction, postoperative CT scan is most accurate way to determine posterior wall accuracy of reduction which has greatest correlation with clinical outcome, greatest stress on acetabular repair occurs when rising from a seated position using the affected leg, and occurs in the posterior superior portion of the acetabulum, functional outcomes most strongly correlate with hip muscle strength and restoration of gait postoperatively, significant osteopenia and/or significant comminution, patients older than 60 years have approx. A 25-year-old patient presents with a posterior wall/ posterior column acetabular fracture. Diagnosis can be made with plain radiographs of the affected hip and ipsilateral femur. Copyright 2022 Lineage Medical, Inc. All rights reserved. An 82-year-old male sustains a ground level fall and sustains the injury shown in Figure A. (OBQ13.214) (OBQ05.187) What is the next best step in management? There is approximately one quadrant of passive medial or lateral patellar glide. The https:// ensures that you are connecting to the Plain radiographs are frequently negative in the beginning. Medial tibial plateau morphology and stress fracture location: A magnetic resonance imaging study. The patient's mother is strongly opposed to operative intervention and he is placed in a cast. (OBQ09.140) Figure A is the radiograph obtained in the emergency department. 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. The patient should be advised she is at greater risk of stem subsidence and early revision, Female sex is a risk factor for intraoperative calcar fracture, A better outcome would be expected if a long-stem diaphyseal fixation stem had been inserted after recognition of the calcar fracture, Cementless press-fit technique is not a risk factor for intraoperative fracture, Minimally invasive surgical approach is not a risk factor for intraoperative fracture. Fifteen years ago, he underwent a right total hip replacement and he had been having progressive thigh start-up pain over the prior 5 months. What position of the leg exerts the least amount of intraneural pressure on the sciatic nerve? Freiberg's Disease is a rare foot condition characterized by infarction and fracture of the metatarsal head. An 85-year-old woman sustains a ground level fall. A 45-year-old male is involved in a motor vehicle accident and sustains the injury shown in Figures A-D. During impaction of a cementless acetabular component, the posterior column was fractured and found to be displaced. Of those, the rubric used by the Schatzker Obtain AP, frog leg lateral, Dunn view, and false profile hip radiographs, CT scan to obtain tibial tubercle-trochlear groove measurements, Physical therapy regimen focused on quadriceps and core muscle strengthening program, Physical therapy regimen focused on Graston, ASTYM, and iontophoresis techniques, Obtain chest CT, skeletal survey, and refer to an orthopaedic oncologist, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, Knee & SportsIdiopathic Chondromalacia Patellae, Patella & trochlear chondral lesions in 38F. She sustained a proximal tibial shaft periprosthetic fracture after a ground level fall. (SAE07HK.88) Osteoporotic tibial plateau fractures: an underestimated cause of knee pain in the elderly. A 79-year-old patient underwent a right hip hemiarthroplasty after sustaining a femoral neck fracture 8 weeks ago. (OBQ11.241) Three of the patients were referred to the orthopaedic department, as a fracture line was visible on the plain radiographs taken 3 to 6 weeks after the trauma. 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Arthroscopic Baker's Cyst Decompression - Dr. Raymond Whitehead. 1999 Jun;28(6):413-20. doi: 10.1016/s0049-0172(99)80007-9. 2016 Sep;7(3):126-34. doi: 10.1177/2151458516651310. [9] What acetabular component is best appreciated on an obturator oblique radiograph of the pelvis as seen in Figure A? During insertion of a cementless femoral stem, a nondisplaced fracture is noticed along the femoral calcar. Axial and lateral radiographs are shown in Figures A and B. The .gov means its official. Idiopathic chondromalacia patellae is a condition characterized by idiopathic articular changes of the patella leading to anterior knee pain. He denies any acute traumatic injuries. WebPediatric supracondylar fractures are one of the most common traumatic fractures see in children and most commonly occur in children 5-7 years of age, usually from a fall on an outstretched hand. Delayed diagnosis can cause pain and disability to the patient and can lead to deformity of the knee joint, due to structural collapse. WebTibial Stress Syndrome (Shin Splints) Tibial Shaft Stress FX Rib Stress Fracture Team Physician Team physician Exercise Science To bind chemotherapeutic ligands in the treatment of lymphoma of bone. WebFreiberg's Disease is a rare foot condition characterized by infarction and fracture of the metatarsal head. (OBQ10.180) There is tenderness with medial and lateral compression of the hindfoot and there is a negative syndesmosis squeeze test. During insertion of a metaphyseal fixation stem with a cementless press-fit technique, a crack in the calcar is identified. MTPJ arthritis. Bone stock is otherwise preserved. A post-reduction radiograph is shown in Figure B. What is the most appropriate treatment for the femoral component? First Author Diagnosis is clinical with a history of anterior knee pain made worse with squatting, prolonged sitting or ascending stairs and pain on patellar compression in knee extension. (OBQ11.205) revision total hip arthroplasty with a cemented femoral component and adjuvant fracture fixation. To express high amounts of sonic hedgehog surface protein. acetabular fracture causes symptoms diagnosis treatment. Past medical history is significant for mild dementia and moderate coronary artery disease. Which of the following associated type acetabular fracture patterns is defined based on the fact that all articular segments are detached from the intact portion of the ilium, which remains attached to the sacrum through the sacroiliac joint? What are the fracture classification and most appropriate treatment? WebFemoral head fractures are rare traumatic injuries that are usually associated with hip dislocations. In patients with closed fractures and no sign of neurovascular compromise, initial management focuses on pain management, immobilization of the fracture, and reduction of swelling. 2018 Jul 21;19(1):244. doi: 10.1186/s12891-018-2170-z. Meniscus. Physical examination shows that her range of motion is full and there is no effusion. Treatment is either immobilization or surgery depending on location of fracture, degree of displacement, and athletic level of patient. (OBQ12.212) Revision total hip replacement with a proximally coated femoral stem, Open reduction, internal fixation with plate and cerclage wires, Proximal femoral replacement with megaprosthesis, Cortical strut allograft with cerclage wiring. She was previously ambulatory but with a significant limp. Diagnosis is made clinically with tenderness over the plantar aspect of the involved webspace with a palpable neuroma and a positive Mulder's click on examination. 3% (OBQ09.144) (SBQ11OS.20.1) (OBQ18.194) Which of the following acetabular fractures is classified as an elementary fracture pattern that involves two columns? Epidemiology. MB BULLETS Step 2 & 3 For 3rd and 4th Year Med Students. Anterior column/ posterior hemitransverse. Vancouver AG; nonoperative with partial weight bearing, Vancouver AG; open reduction internal fixation with trochanteric claw plate, Vancouver AL; open reduction internal fixation with trochanteric cables, Vancouver B1; open reduction internal fixation with lateral locking plate. Weightbearing foot radiographs demonstrate no fracture. A radiograph taken after the fall is shown in Figure 10b. Which of the following is the best treatment option? patellar stress fracture. Degree of displacement seen on preoperative AP pelvis view, Degree of displacement seen on preoperative Judet views, Degree of displacement seen on preoperative pelvic CT scan, Degree of displacement seen on postoperative Judet views, Degree of displacement seen on postoperative pelvic CT scan. (OBQ19.9) Open reduction internal fixation with a cable plate and allograft strut, Revision to a long femoral stem with allograft bone, Revision to a cemented revision femoral stem that bypasses the fracture site by 5 cm. While performing a cementless total hip arthroplasty in a healthy 68-year-old female, the surgeon notes an audible change while impacting the final broach. complications. Copyright 2022 Lineage Medical, Inc. All rights reserved. (OBQ06.180) (OBQ04.232) Treatment is a trial of nonoperative management with a wide shoe box with metatarsal pads. WebRadial head and neck fractures in children are a relatively common traumatic injury that usually affects the radial neck (metaphysis) in children 9-10 years of age. (OBQ09.112) An injury radiograph is provided in Figure A, while radiographs taken immediately following the initial total hip arthroplasty are provided in Figures B and C. The patient denies any prodromal groin pain prior to his fall. Treatment is activity modification and NSAIDs in early disease. Conservative treatment with delayed physical therapy and shoe lifts, Closed reduction and percutaneous fixation. During the approach, what limb position minimizes tension placed on the sciatic nerve? They include, articulation between patella and intracondylar groove of femur, subchondral bone has weak potential to generate pain signals, Outerbridge MRI Classification of Chondromalacia, Surface intact and heterogenous; high signal intensity, Fissures and fragmentation extending down to the articular surface, Partial thickness defect, with focal ulceration, diffuse pain in the peripatellar or retropatellar area of the knee (major symptom), insidious onset and typically vague in nature, prolonged sitting with knee bent (known as theatre pain), always consider the physical, mental and social elements of knee pain, increased femoral anteversion or tibial external rotation, lateral subluxation of patella or loss of medial patellar mobility, compression of patella with knee range of motion or resisted knee extension, AP, lateral and notch radiographs of knee, shallow sulcus, patella alta/baja, or lateral patella tilt, best modality to assess articular cartilage, abnormal cartilage is usually of high signal compared to normal cartilage, mainstay of treatment and should be done for a minimum of one year, closed chain short arc quadriceps exercises, Outerbridge grade 2-3 chondromalacia patellofemoral joint, tight lateral retinacular capsule, loose medial capsule and lateral patellar tilt, severe symptoms that have failed to improve with extensive physical therapy, only elevate 1 cm or else risk of skin necrosis, superior medial arthrosis (scope before you perform the surgery), Spontaneous Osteonecrosis of the Knee (SONK), Osgood Schlatter's Disease (Tibial Tubercle Apophysitis), Anterior Superior Iliac Spine (ASIS) Avulsion, Anterior Inferior Iliac Spine Avulsion (AIIS), Concussions (Mild Traumatic Brain Injury). 2010. Copyright 2022 Lineage Medical, Inc. All rights reserved. Open reduction and cerclage fixation of the fracture, Open reduction and revision of the femoral implant to a long cemented stem, Open reduction and revision of the femoral implant to a long fluted and tapered uncemented stem, Application of balanced traction and surgery after the ecchymosis has resolved. A 78-year-old male undergoes the procedure shown in Figure A for treatment of a femoral neck fracture. All patients except one had a DEXA-scan, which revealed osteopenia in 4 and osteoporosis in 3 patients; all 7 were treated with bisphosphonates. a 30% late conversion rate to THA after acetabular fractures, 10-year implant survival noted to be around 75-80%, obturator outlet best view to rule out joint penetration, iliac inlet view best to determine anteroposterior position of screw within the pubic ramus, obturator inlet view best to determine position of a supraacetabular screw within tables of the ilium, Increased HO risk compared with anterior approach, Damage to blood supply of femoral head (medial femoral circumflex), Some both column fxs (if posterior comminution is present), Access to quadrilateral plate to buttress comminuted medial wall fractures, Corona mortis must be exposed and ligated in this approach, 80% survival noted at 20 years for patients s/p ORIF, highest incidence with extensile approach, low dose external radiation (no difference shown in direct comparison), lowest incidence with anterior ilioinguinal approach, Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries. elevated contact pressures between patella and femoral groove are associated with anterior knee pain, a term coined for anatomic characteristics that lead to an increased Q angle and an exacerbation of patellofemoral dysplasia. AJR Am J Roentgenol. Complications: Recurrence common after resumption of heavy activity. Open reduction is indicated for dislocations associated with a medial epicondyle fracture with an incarcerated fragment. (OBQ10.203) Neoplasm. Treatment is typically operative fixation depending on degree of pelvis instability, fracture displacement and patient activity demands. 1% (19/2233) 3. According to the Letournel classification, what is the injury pattern shown? Additional medical therapy can also include administration of prostaglandin I-1 and biphosphonates. Transtectal transverse acetabular fracture, Anterior-posterior type III pelvic ring injury. Figure 10 shows the AP radiograph of an ambulatory 76-year-old patient. leads to eventual collapse of 2nd MT head. metatarsal stress fracture. open reduction and internal fixation of the fracture and retention of the original components. A left hip radiograph is shown in Figure A, and the the abnormality in question is indicated by the white arrow. Accessibility A 67-year-old man who underwent total hip arthroplasty (THA) 4 years ago fell on to his right hip. ORIF of the posterior column and THA revision, Cage reconstruction of acetabular component, THA revision using a cemented acetabular component, Placement of a hip abductor brace and non-weight bearing in the affected limb, (SAE07HK.28) The pelvic spur sign on plain radiography is indicative of the following injuries? Continued insertion of the stem, cerclage wiring around the fracture site, and non-weight bearing x6 weeks, Continued insertion of the stem, reduction of the hip, and non-weight bearing activity restrictions following surgery, Removal of the stem, cerclage wiring around the fracture site, and re-insertion of a stem, Removal of the stem and conversion to a cemented femoral stem, Removal of the stem, open reduction internal fixation of the femur with planned delayed femoral stem insertion following fracture healing. 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