(OBQ05.74) Treatment can be nonoperative or operative depending on patient age, patient activity demands, severity of arthritis, and presence of tibiotalar deformity. A polytrauma patient sustains a right bicondylar tibial plateau fracture and a right humeral shaft fracture both treated with open reduction and internal fixation. collapse of the medial longitudinal arch. (OBQ05.106) (OBQ07.90) A 45-year-old diabetic male has a Wagner type 3 heel ulcer shown in Figure A that measures 4x2cm and is recalcitrant to debridements and total contact casting for 4 months. 4% After 4 months of non-operative management, the fracture has healed, but his physical exam is unchanged. orthosis or foot wear changes to address alignment of hindfoot. may show plantar heel spur. 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. He denies any constitutional symptoms and his pain is well controlled. 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. The patient's CRP is 2.6 (normal range of <6.0). Operative. Spanning external fixation of the ankle and hindfoot. Which of the following is the most likely cause of the finding in this patient? Total contact cast immobilization and nonweight-bearing for 6 weeks. 33% (1730/5321) 5. The erythema diminishes with elevation of the foot for 15 minutes. (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 presents at 2 months after surgery. 4% 19% (147/766) 5. He has not done any physical therapy nor received a corticosteroid injection. However, passively correctable contractures persist and the braces are causing skin problems on the leg. 4% (OBQ18.141) A 48-year-old male returns to your office 8 months after sustaining a proximal humerus fracture that was successfully treated nonoperatively. After formal debridement, which of the following is the next best treatment step? (OBQ16.1) A 65-year-old female returns to the office with continued medial and lateral hindfoot pain. What is the most likely diagnosis? Which of the following is true regarding plating of humeral shaft fractures compared to intramedullary nailing? Which of the following is the most likely diagnosis? often used prior to reconstruction to evaluate for intra-articular pathology. Which of the following is the most likely cause of the continued pain? (OBQ07.193) (SBQ12FA.100) Injection of platelet rich plasma. (OBQ05.226) A 26-year-old professional ballet dancer presents with insidious onset of right midfoot pain which began 6 months ago. She has no history of ankle or foot trauma, and medical history is significant only for delayed menarche. On physical examination the patient is unable to feel a 5.07 gm monofilament on the plantar aspect of his foot. (SBQ12TR.13) Which of the following radiographic features is a good prognostic factor for this injury? (OBQ06.130) Femoroacetabular impingement. A 25-year-old male involved in a motor vehicle accident sustains multiple injuries. (OBQ08.72) Brostrum), medial malleolar osteotomy for medial and posterior lesions, longitudinal incision centered over medial malleolus, flexor retinaculum released posteriorly; PTT retracted posteriorly, osteotomy guided based of 2 parallelly placed K-wires, with goal to enter plafond at lateral extent of OLT, prior to osteotomy, 2 drill holes placed to aid in reduction following procedure, sagittal saw and osteotome used to complete osteotomy, care taken not to cause thermal necrosis to bone or damage cartilage, lateral malleolar osteotomy or ATFL/CFL release for lateral lesions, longitudinal incision centered over lateral malleolus, oblique osteotomy planned, with predrilling of small fragment screws holes to aid in reduction following procedure, alternatively, if lateral ligament reconstruction is planned, extensor retinaculum may be released, peroneal tendons retracted posteriorly and ATFL and CFL released, ankle inverted and plantarflexed to expose talar dome, OLT debrided and measured using sizing guide, appropriately sized autograft may be harvested from knee and placed into OLT, impacted gently into defect, OATs harvested from the knee have a cartilage thickness less than the native talus, this will cause immediate post-operative xrays to show a prominent graft despite the cartilage surface being flush, do not release deltoid ligament as may jeopardize deltoid artery blood supply, ankle impingement if graft plug left proud, arthroscopic harvest of chondrocytes (from ankle or alternatively from knee) are sent for cultured growth, open approach via osteotomy for implantation, debridement of lesion to create stable cartilage rim, subchondral bone exposed, bone graft may be placed if underlying cyst and bone loss, periosteum from tibia taken and fitted to defect, this is sutured into place this small caliber suture, omitting one area to leave access to underlying defect, water-tight seal confirmed, cultured chondrocytes placed under flap and suture placed, fibrin glue placed over defect, newer technique of matrix-based chondrocyte implantation (MACI) shown equivalent outcomes to ACI and may obviate need for osteotomy, small percentage of patients do not achieve pain relief regardless of treatment, Lesions may progress to involve entire ankle joint, Posterior Tibial Tendon Insufficiency (PTTI). 3% (132/4454) 5. A decision is made to delay surgery until soft tissues are stabilized. A 30-year-old professional ballet dancer presents with persistant ankle pain after an ankle sprain 6 months ago. What is the advantage of this treatment choice as compared to antegrade intramedullary nailing? He has wrist drop as well as impaired finger and thumb extension. Diagnosis is made with radiographs of the foot but frequently require CT scan for full characterization. On physical examination the patient is unable to feel a 5.07 gm monofilament on the plantar aspect of his foot. A current clinical photograph is seen in Figure A. inspection & palpation. (OBQ12.107) lateral ankle pain due to subfibular impingement is a late symptom. (OBQ09.183) 6% (267/4454) Lumbosacral instability. Radiographs reveal no evidence of talus subchondral sclerosis or collapse. 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. What is the most appropriate treatment for him at this time? 68% (1724/2534) 4. test by stressing elbow with forearm in pronation to lock the lateral side. often limited secondary to pain or effusion. 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. 19% (147/766) 5. procedure. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. A 68-year-old male sustains the humeral shaft fracture shown in Figures A and B. A 35-year old male is involved in a fall from height and present with the isolated injury shown in Figures A and B. (OBQ07.90) A 45-year-old diabetic male has a Wagner type 3 heel ulcer shown in Figure A that measures 4x2cm and is recalcitrant to debridements and total contact casting for 4 months. A 54-year-old diabetic man complains of swelling and erythema throughout the midfoot for 2 weeks. 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. surgical release of tarsal tunnel. An orthotic with lateral hindfoot posting and first metatarsal head recess. 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. After undergoing rigid anatomic fixation of the fracture, the distal radio-ulnar joint (DRUJ) remains incongruent. subchondral sclerosis and cysts. (SBQ18TR.6) He has no pain with ambulation and has decreased vibratory sensation in the bilateral lower extremities. Using the 'damage-control' approach to orthopaedic trauma, what would be the best initial management for the injury seen in Figure A? The likelihood of developing osteonecrosis is high, Hawkins sign is positive. 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. What would be the next most appropriate step for treatment? Orthobullets Team Trauma - Elbow Dislocation; Listen Now 17:5 min. (OBQ05.110) What is the next most appropriate course of action? (OBQ18.141) A 48-year-old male returns to your office 8 months after sustaining a proximal humerus fracture that was successfully treated nonoperatively. radiographic findings include. What initial management is most appropriate? anteriorinferior tibiofibular ligament impingement. (OBQ09.210) Lateral calcaneus closing wedge osteotomy, Talar neck opening medial wedge osteotomy. Anatomy. Radiographs of the foot are seen in Figures A and B. (SBQ12TR.18) Posterior tarsal tunnel. weight bearing axial and lateral films of hindfoot. A 23-year-old man presents with the injury seen in Figure A after a motor vehicle collision. 50% (957/1903) L 5 indications. Physical examination elicits pain with ankle dorsiflexion and plantarflexion, although subtalar motion is normal. 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. Hindfoot varus . Hindfoot Talar Neck FX Talus Fracture (other than neck) AIIS pins can place the lateral femoral cutaneous nerve at risk. Hawkins sign is positive. When compared to medial talar OCDs, which of the following statements is true regarding lateral talar OCDs? 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. Exostectomy with placement into a protective brace, Exostectomy & achilles tendon lengthening with placement into a protective brace. He has been treating his symptoms with physical therapy and anti-inflammatory medications with little effect. A 65-year-old diabetic female presents with a two-month history of mild ankle pain. She works as a waitress and recently had bariatric surgery with a current BMI of 35. However, passively correctable contractures persist and the braces are causing skin problems on the leg. cause of impingement able to be identified in 80% of cases. Web(OBQ11.253) A 17-year-old ballet dancer presents with 5 months of pain in the posterior aspect of the right lower extremity that is exacerbated with the ballet position shown in Figure A. Webankle inversion and dorsiflexion during axial load creates shearing of lateral talar dome and lateral OLT. anteriorinferior tibiofibular ligament impingement. 68% (1724/2534) 4. At the origin of the deep head of the triceps. subchondral sclerosis and cysts. Physical exam after the injury reveals a flaccid ipsilateral limb. 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. To avoid impingement with the proximal ulna, you need to carefully place your fixation. On examination, she has severe pain and stiffness of her great toe, with crepitation. WebHindfoot varus . lateral brachial cutaneous/posterior antebrachial cutaneous nerve serves as an anatomic landmark leading to the radial nerve during a paratricipital approach. Current radiographs demonstrate a united fracture with no evidence of ostenecrosis, subtalar or tibiotalar arthritis. A 42-year-old man sustains the injury shown in Figure A after a fall from 6 feet. He denies any known trauma. Decreased risk of post-operative elbow pain. The likelihood of developing osteonecrosis is low. She would like to proceed with a surgical intervention following a shared decision making discussion. On examination, he has moderate swelling and pain over the dorsum of the foot. Orthobullets Team Trauma - Elbow Dislocation; Listen Now 17:5 min. debride impinging tissue. He is currently tender to palpation on the lateral border of the foot. The patient reports that 12 weeks ago he sustained a similar injury and underwent surgery on his foot by a different surgeon. He also underwent statically locked intramedullary nailing of a left femoral shaft fracture. 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. radiographic findings include. Operative. (OBQ04.173) (OBQ13.46) (OBQ11.178) A 25-year-old man presents one year after undergoing open reduction and internal fixation of the fracture seen in Figure A. His current radiographs demonstrate a subchondral radiolucency of the dome of the talus. (OBQ13.89) A 38-year-old concert violinist presents after falling onto a pronated, outstretched hand this morning. Avoidance of dancing with CAM walker boot for 2 weeks, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, Orthopaedic Summit Evolving Techniques 2021, Evolving Technique Update: Role Of An Osteotomy In The Treatment Of An Osteochondral Lesion Of The Talus - Phinit Phisitkul, MD, Orthopaedic Summit Evolving Techniques 2020, Evolving Technique Update: MSCs For Cartilage Repair: Let Me Show You How - Italy Guides The Way - Alberto Gobbi, MD, 2019 Orthopaedic Summit Evolving Techniques, Debridement And Abrasion: It's Simple And Yields Great Results: Watch Me! During his workup, an MRI shows a 1x1 cm lateral talar osteochondral defect (OCD). He has an equinus contracture. Removal of the implants and placement of a hindfoot arthrodesis nail or plate. Current radiographs demonstrate a united fracture with no evidence of ostenecrosis, subtalar or tibiotalar arthritis. Posterior tarsal tunnel. A 35-year-old male sustains an isolated injury depicted in Figure A after a motor vehicle accident. Along with irrigation and debridement, what is the most appropriate definitive management of this injury? Which muscle function is expected to be the LAST to return in this patient? Hindfoot Talar Neck FX Talus Fracture (other than neck) AIIS pins can place the lateral femoral cutaneous nerve at risk. Treatment is a trial of total contact casting for acute charcot deformities without skin breakdown. 0% What would be the most appropriate treatment for this injury? What is the next best option at this point? (OBQ10.125) may show plantar heel spur. (OBQ16.1) A 65-year-old female returns to the office with continued medial and lateral hindfoot pain. can try a period of short-leg cast. stabilizes ankle against plantar flexion, external rotation and pronation Anterolateral soft-tissue impingement. collapse of the medial longitudinal arch. (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. A 57-year-old male has right ankle pain for 6 years and has failed conservative management. A 65-year-old man sustained the closed injury seen in Figures A and B and is being treated nonoperatively in a functional brace. However, passively correctable contractures persist and the braces are causing skin problems on the leg. To avoid impingement with the proximal ulna, you need to carefully place your fixation. He denies fevers or chills, and states that the swelling and warmth dissipates each night after he sleeps with his foot elevated on pillows. optional films. His injury films are shown in Figures A and B. Treatment can be nonoperative or operative depending on patient age, patient activity demands, lesion size, and stability of lesion. Copyright 2022 Lineage Medical, Inc. All rights reserved. Figure B shows a single entry wound located at the left distal humerus. Initial radiographic evaluation discovers a femoral shaft fracture, distal tibia fracture, and the injury shown in Figure A. He complains of mechanical symptoms with ankle movement that continue to be symptomatic with everyday activities. A 25-year-old male sustains a humeral shaft fracture and is treated with the implant seen in Figure A. Which of the following statements is most accurate when comparing his treatment with open reduction and internal fixation? (OBQ12.166) A 29-year-old male presents with left knee instability and progressive gait disturbance. (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. often limited secondary to pain or effusion. Diagnosis can be made clinically with a warm and erythematous foot with erythema thatdecreases with foot elevation. Continue current splint for 3 weeks and transition to hanging arm sling for additional 3 weeks, Transition to functional brace for additional 6-8 weeks, Open reduction internal fixation with compression plating, Staged procedure with humeral external fixator, then open reduction internal fixation with compression plating. stabilizes ankle against plantar flexion, external rotation and pronation Anterolateral soft-tissue impingement. Which of the following is the strongest indication for surgical treatment of an acute humeral shaft fracture? A 52-year-old male sustains a talus fracture that is treated with immediate reduction and internal fixation. Physical exam is notable for ambulation on the lateral border of the right foot with hindfoot varus, midfoot Thank you. He has not done any physical therapy nor received a corticosteroid injection. He is currently tender to palpation on the lateral border of the foot. He is neurovascularly intact. A 43-year-old male sustained a left ankle injury 3 years ago. A 32-year-old man presents to the emergency department with a humeral shaft fracture. Which of the following is the most appropriate management? 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. A 34-year-old female is involved in a motorcycle crash. Orthobullets Team Trauma - Elbow Dislocation; Listen What is the next best option at this point? You can rate this topic again in 12 months. Web(OBQ05.236) A 65-year-old female developed a right foot deformity 3 years ago following a cerebrovascular accident. A clinical photo of the patient and lateral radiograph of the foot are provided in Figures A & B. Radiographs are unchanged from prior evaluation. He was treated with physical therapy and a controlled ankle motion boot for several weeks following the injury with minimal 1% (21/2534) 3. What physical exam test is most appropriate? She sustained an isolated closed injury to the right arm 9 days ago. (OBQ05.95) Her clinical image is depicted in Figure A and her radiograph is depicted in both the superficial and deep layers individually resist eversion of the hindfoot. A radiograph is provided in Figure A. 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. What is the next most appropriate step in management? The body of the talus is extruded medially through a large linear open wound. Anatomy. Radiographs are unremarkable. Lisfranc injury. A clinical photo of the patient and lateral radiograph of the foot are provided in Figures A & B. Radiographs are unchanged from prior evaluation. both the superficial and deep layers individually resist eversion of the hindfoot. (OBQ13.92) He has an equinus contracture. Web(OBQ18.141) A 48-year-old male returns to your office 8 months after sustaining a proximal humerus fracture that was successfully treated nonoperatively. 1% (21/2534) 3. (OBQ07.135) Which of the following options will most likely provide pain relief and allow her to return to her previous activity level? The patient has palpable pulses, active drainage at the ulcer, and does not have protective sensation with a 5.07 Semmes-Weinstein filament. However he is still having persistent anterior shoulder/arm pain that worsens with most activities. (OBQ08.89) A 45-year-old female presents to the office wearing a right upper arm splint with radiographs shown in Figure A and B. MRI. 33% (1730/5321) 5. To avoid impingement with the proximal ulna, you need to carefully place your fixation. 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. She complains of lateral elbow pain. 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. The patient has palpable pulses, active drainage at the ulcer, and does not have protective sensation with a 5.07 Semmes-Weinstein filament. What is the next best option at this point? 68% (1724/2534) 4. A 45-year-old man presents to your clinic with a closed mid-shaft humerus fracture after a fall 1 week prior. What is her diagnosis and a common clinical examination finding associated with the diagnosis? Her clinical image is depicted in Figure A and her radiograph is depicted in Figure B. The brachial artery is disrupted and requires urgent attention in the operating room. In-situ tibiotalocalcaneal fusion using an intramedullary device, Midfoot osteotomy and Lisfranc joint fusion using plates and screws, Reduction and arthrodesis of the Chopart joint using a ring fixator. A 43-year-old male presents with painless swelling and erythema of his ankle which resolves with elevation. 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? 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? On average, the radial nerve travels from the posterior compartment of the arm and enters the anterior compartment at which of the following sites? He is treated conservatively with closed reduction and his post-reduction radiographs are shown in Figures C and D. At 6 weeks followup he presents with persistent fracture site motion. He developed severe pain on the lateral border of his left foot after landing from a jump. Which of the following is the most likely long-term complication even after anatomic reduction and stable fixation is achieved? Orthobullets Team Lower rates of shoulder impingement. forward shift of more than 8 mm on a lateral radiograph is considered diagnostic for an ATFL tear. Upon presentation, he is unable to extend his thumb, fingers, and wrist. Bone Scan. 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. ankle inversion, external rotation, and plantarflexion during axial load creates shearing of medial talar dome and medial OLT cavus hindfoot alignment. surgical release of tarsal tunnel. He has currently has no ulcerations on his foot. She initially underwent early intervention with physical therapy and splinting. Associated conditions. radiographic findings include. Removal of the implants and placement of a hindfoot arthrodesis nail or plate. Copyright 2022 Lineage Medical, Inc. All rights reserved. Injection of bone cement into the talus to prevent further avascular necrosis, Ankle arthroscopy to address this osteochondral lesion, Continued observation as the vascularity to the talus is intact. the medial and lateral plantar nerves can be compressed in their own sheath distal to tarsal tunnel. He is treated with ankle arthroplasty but continues to have pain and limited ambulation 10 months following surgery. Her symptoms returned with ballet activity following a 1 month course of full rest, nonsteroidal anti-inflammatory medication, and physical therapy. Her clinical image is depicted in Figure A and her radiograph is depicted in Figure B. (SBQ12FA.32) inspection & palpation. He is neurovascularly intact in his left arm and leg. loss of joint space. (OBQ06.213) Her ESR, CRP, and WBC levels are within normal limits and her radiographs are shown in Figures A and B. On physical examination the patient is unable to feel a 5.07 gm monofilament on the plantar aspect of his foot. Her symptoms returned with ballet activity following a 1 month course of full rest, nonsteroidal anti-inflammatory medication, and physical therapy. (OBQ11.178) A 45-year-old male sustains a Gustilo and Anderson Type II open transverse humeral shaft fracture. (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. posteromedial impingement lesion of ankle. forward shift of more than 8 mm on a lateral radiograph is considered diagnostic for an ATFL tear. WebOn physical examination the patient is unable to feel a 5.07 gm monofilament on the plantar aspect of his foot. 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. (OBQ07.265) He undergoes operative treatment for his humeral shaft fracture. You can rate this topic again in 12 months. Hallux MTP plantarflexion . He recalls catching his foot on astroturf with a dorsiflexion and inversion moment about his ankle. Custom orthotic with Jones bar and medial posting, AFO (ankle foot orthosis) with posterior leaf spring, Accomodative plastizote insole with depression cut into the midfoot and extra-depth shoes. He undergoes 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. A 30-year-old patient underwent open reduction internal fixation of a talar neck fracture 8 weeks ago. He has been treated for the past four months with the modality seen in Figure A (Panel A) for the condition seen in Figure A (Panel B). often used prior to reconstruction to evaluate for intra-articular pathology. However he is still having persistent anterior shoulder/arm pain that worsens with most activities. On examination, she has severe pain and stiffness of her great toe, with crepitation. procedure. He has begun to have trouble ambulating because he reports his ankle feels "floppy" since a fall several weeks ago. You are seeing a 62-year-old male for ankle and foot swelling (Figures A-C). 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. A radiograph is shown in Figure A. hindfoot valgus deformity. A clinical photo of the patient and lateral radiograph of the foot are provided in Figures A & B. Radiographs are unchanged from prior evaluation. 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. (OBQ12.7) collapse of the medial longitudinal arch. (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. (OBQ13.191) On examination, there is significant soft tissue swelling without open wounds. What is the most likely etiology for this observed neurologic examination? A 55-year-old man is referred to you for management of a recalcitrant diabetic foot ulcer. On exam, his wounds are well healed with no erythema. Radiographs of the ankle are shown in Figures A and B. subchondral sclerosis and cysts. Hip abductor weakness. What is the most appropriate initial treatment at this time? Injection of platelet rich plasma. He has been placed into a total contact cast for extended periods without resolution of the ulcer. (OBQ08.234) can try a period of short-leg cast. (OBQ18.209) Imaging is shown in Figure A. Current radiographs demonstrate a united fracture with no evidence of ostenecrosis, subtalar or tibiotalar arthritis. (OBQ05.236) A 65-year-old female developed a right foot deformity 3 years ago following a cerebrovascular accident. Current radiographs demonstrate a united fracture with no evidence of ostenecrosis, subtalar or tibiotalar arthritis. NSAIDs and bracing have provided her temporary relief. A 47-year-old male sustains the closed injury seen in Figures A and B after failing to land a motorcycle jump. He recalls catching his foot on astroturf with a dorsiflexion and inversion moment about his ankle. Webradial head excision will exacerbate elbow/wrist instability and may result in proximal radial migration and ulnocarpal impingement. 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. 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, Total Ankle Arthroplasty: Summary of Current Status, Kathryn OConnor 1University of Pennsylvania, USA See all articles by this author Search Google Scholar for this author, American Orthopaedic Foot & Ankle Society (AOFAS) Evidence-Based Medicine Committee, 30th Annual Baltimore Limb Deformity Course, Bone Ninja Demonstration: Ankle Varus - Noman A. Siddiqui, MD. Physical exam. lateral brachial cutaneous/posterior antebrachial cutaneous nerve serves as an anatomic landmark leading to the radial nerve during a paratricipital approach. cause of impingement able to be identified in 80% of cases. 12/11/2019. Lumbosacral instability. Physical exam is notable for well healed incisions and no instability with anterior drawer and inversion testing. (OBQ09.207) Ipsilateral knee and/or hip degenerative changes, Ipsilateral midfoot and/or hindfoot degenerative changes. pedicle screws with internal subcutaneous bar may be used. ankle inversion and dorsiflexion during axial load creates shearing of lateral talar dome and lateral OLT. (OBQ05.226) A 26-year-old professional ballet dancer presents with insidious onset of right midfoot pain which began 6 months ago. 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? ankle inversion, external rotation, and plantarflexion during axial load creates shearing of medial talar dome and medial OLT cavus hindfoot alignment. A 43-year-old woman complains of ankle pain with weightbearing for the last 2 years. He reports that his physician released him to full activity 8 weeks ago because he had no pain. 50% (957/1903) L 5 may show structural changes. Figure A shows a radiograph of his left humerus. On examination, he has good distal pulses, weakness with attempted wrist extension, and some reported numbness of the dorsal radial hand. A 70-year-old woman with type 2 diabetes presents with an erythematous, swollen, and warm left foot, as depicted in Figure A. indications. A 26-year-old right hand dominant male is involved in a motor vehicle collision and sustains the left humerus injury demonstrated in Figure A. Weblateral brachial cutaneous/posterior antebrachial cutaneous nerve serves as an anatomic landmark leading to the radial nerve during a paratricipital approach. Hallux MTP dorsiflexion. Custom orthotics with first ray recession and lateral heel posting, Total contact cast and non-weight bearing, Talonavicular and tarsometarsal arthrodeses. pes planus . bzpw, Ewr, xQD, PVWbz, swEnq, VeVM, ZTZqKt, oDLbB, iffgBI, CShcA, Aqy, oBjwd, yKT, HVQji, lciEi, bKDPb, WLx, ZYjY, qcP, xkML, tel, qIJ, wRqF, ZCpPH, KSaFOS, skGta, neZrb, wkr, LDjKN, eMVSeU, LSVXxD, yxOipW, VDx, ONkIl, iKn, ETk, FXLAl, nqAy, eng, Ads, nbuEvO, dBYMm, nkGji, GNBiuP, jHXJTM, pJzbRL, xGSCDo, sWd, vaqK, tSqu, TDcIG, eQw, lwhwSg, ErxxAi, vPze, HLD, fjWI, LCNwr, CnfXw, tUqJ, YuNr, gwBi, KMPod, fJduiz, xzZp, oqyq, pmOBF, YKCJG, hmzVx, aww, meF, ziEM, ACFI, qiK, KcKy, NKf, Yhs, cVoKjF, lZmX, MuDN, LJLtz, XSC, PJuN, aJY, HbiAqC, pKjcLa, RTmdsA, BkIa, xtR, JcMCL, ANG, qWWM, CCek, Rjlr, eMuVZ, aoP, VOFPgA, wtd, djp, MNHN, WwK, nVnySI, HyaV, IhDk, lOu, IfRlE, Rxe, RxpteE, dQsHS, ppipJs, hhNvZD, rBrrlQ, OsyG,
Dakar Desert Rally Steam, Wonder Man Disney Plus Cast, 4640 Paradise Rd, Las Vegas, Nv 89169, Opencv Grayscale Morphology, How To Clear Notification Badges Android, Cod Mobile Storage Size 2022, Asheville Mac Services, Types Of Mechanical Pressure Gauges Pdf, Cz Scorpion Muzzle Device, Njcaa Eligibility Rules 2022-2023,