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74 Cards in this Set
- Front
- Back
1-mortality rate of 50% in ICU? |
1-ARDS |
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1-MC associated injury with acetabular fx? |
1-50% injury to another organ system, MC 36% LE inj |
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1-Dx/xrayF/ pathomneumic F & CTF (counterclockwise) |
1-AP =posterior rim shadow, subluxation of the femoral head and the posterior wall fragment. |
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1-Dx/xrayF/ pathomneumic F & CTF (counterclockwise) |
1-Post column |
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1-Dx/xrayF/ pathomneumic F & CTF (counterclockwise) |
1-Anterior column fx |
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1-Dx/xrayF/ pathomneumic F & CTF (counterclockwise) |
1-Anterior wall fx |
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A 35-year-old male undergoes closed reduction under sedation in the emergency department for a posterior hip dislocation with an associated posterior wall fracture. The post-reduction CT is seen in Figure A. What is the appropriate next step in management of this injury? 1. Nonoperative management based on the size of the posterior wall fragment 2. Operative management based on the size of the posterior wall fragment 3. Operative management based on the history of hip dislocation 4. Dynamic fluorscopic stress exam under anesthesia in the obturator oblique view 5. Dynamic fluorscopic stress exam under anesthesia in the iliac oblique view |
Joint stability is critical for successful nonoperative management of posterior wall acetabular fractures. Recent evidence has established that dynamic fluoroscopic stress examination is the best method to determine joint stability in the setting of a posterior wall fracture. The obturator oblique view allows for the best evaluation of hip joint stability during examination for posterior wall fractures.ans4 |
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A 35-year-old male suffers an anterior column acetabular fracture during a motor vehicle collision, and subsequently undergoes percutaneous acetabular fixation. Intraoperatively, fluoroscopy is positioned to obtain an obturator oblique-inlet view while placing a supraacetabular screw. Which of the following screw relationships is best evaluated with this view? 1. Intraarticular penetration of the screw 2. Position of the screw cephalad to the sciatic notch 3. Screw starting point at the anterior inferior iliac spine 4. Screw starting point at the gluteal pillar 5. Screw position between the inner and outer tables of the ilium |
The obturator oblique-inlet view, as seen in Illustration A, best demonstrates the position of a supra-acetabular screw or pin relative to the tables of the ilium. ans5 |
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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? 1. Kocher-Langenbeck 2. Watson-Jones 3. Extended iliofemoral 4. Ilioinguinal 5. Hardinge |
T-type fracture of the right acetabulum. The ilioinguinal approach provides access to the anterior wall and anterior column for fracture fixation, in addition to allowing fixation of the nondisplaced posterior transverse fracture line. The lateral femoral cutaneous nerve (LFCN) is at risk in the superficial part of the dissection. Another option for the approach would be the modified Stoppa, which would also allow excellent access to the anterior column as well as the internal aspect of the iliac wing and quadrilateral plate.ans4 |
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A 32-year-old male sustains a posterior wall acetabulum fracture as the result of a high-speed motor vehicle collision. Improved patient-reported outcomes after surgical treatment are associated with which of the following variables? 1. Increased age 2. Increased hip flexion-extension arc 3. Immediate weight-bearing 4. Increased hip muscle strength 5. Decreased stride length |
Patient functional outcomes after acetabular fractures have been shown to be related to postoperative hip strength, regardless of surgical approach. |
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When placing a percutaneous retrograde pubic rami screw for fixation of an acetabular fracture, which of the following radiographic views can best ensure that the screw does not exit the posterior aspect of the superior pubic ramus? 1. AP pelvis 2. Outlet obturator oblique view 3. Inlet iliac oblique view 4. Iliac oblique view 5. Obturator oblique view
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As reviewed in the referenced article by Starr et al, when placing a retrograde pubic rami screw, the pelvic inlet iliac oblique view will best determine the anteroposterior placement of the screw in the pubic ramus. To ensure placement outside of the joint, the outlet obturator oblique is best, but all other views should be incorporated into determination of the position of fixation, as the corridor for this screw placement is quite narrow. ans3 |
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A 33-year-old male sustains the injury seen in Figure A as a result of a high-speed motor vehicle collision. Based on this image, what is the most likely acetabular fracture pattern? 1. Both column 2. Anterior column 3. Anterior column posterior hemitransverse 4. Transverse 5. T-type |
The radiograph in Figure A shows a transverse acetabulum fracture. The iliopectineal (anterior column) and ilioischial lines (posterior column) are interrupted, revealing bicolumnar involvement; however, this is different than the both column fracture, as a transverse pattern has articular surface still in continuity with the axial skeleton via the sacroiliac joint. ans4 |
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A 22-year-old female is involved in a motor vehicle collision and sustains the injury shown in Figures A through D. According to these images, what is the acetabular fracture classification? 1. Anterior column posterior hemitransverse 2. Both column 3. Transverse 4. Transverse with posterior wall 5. Anterior column |
Figures A through D show a comminuted both column acetabular fracture. In this injury, both columns are involved, with the acetabulum losing all connection to the axial skeleton (sacrum). This differentiates it from all other patterns, where at least part of the acetabular cartilage maintains connection to the sacrum. Figure C shows the ischial spur, which is classically known as the spur sign and most easily seen on the obturator oblique radiograph. Incorrect Answers: |
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A 42-year-old female sustains the injury seen in the computed tomography images seen in Figures A and B. According to the Letournel classification, what is the injury pattern shown? 1. Posterior wall 2. Transverse 3. Anterior wall 4. Posterior column 5. Both column |
The axial CT cut and Judet radiographic view shown reveals a transverse fracture pattern according to the Letournel classification system. This can be determined by the fact that the articular surface of the acetabulum is attached to the intact portion of the ilium, which is connected to the axial skeleton posteriorly through the sacroiliac joint. This differs from a both-column fracture, in which the articular surface of the acetabulum has no attachments to the axial skeleton due to fracture line(s). The axial CT scan also shows a vertical fracture line which is typical of a transverse fracture pattern. ans2 |
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An 84-year-old community-ambulating female sustains a comminuted left acetabular fracture as a result of a fall from standing height. A radiograph is shown in Figure A. What is the most appropriate definitive treatment for this patient? 1. Skeletal traction 2. Conservative treatment with delayed physical therapy and shoe lifts 3. Open reduction and internal fixation 4. Open reduction and internal fixation with acute total hip arthroplasty 5. Closed reduction and percutaneous fixation |
The patient described in this question has sustained an insufficiency fracture, with the radiograph showing significant osteopenia with comminution of both columns, the dome and the medial wall. Treatment of this problem should include reduction and fixation of the column(s) and placement of a total hip arthroplasty (THA), with use of flanged and/or custom acetabular components as needed. |
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mnemonic to remember 7 bisphophonates-- 2 categories nitrogen containing NO nitrogen containing, name the drugs that are in each category and the mechanism of action |
nitrogen containing think nitrous oxide and 4 fast cars A- Audi A1-Alendronate P- PORCHE --Pamidronate tx OI Z -- 300 ZX-Zoledronate R -- CLA AMG is RIGHT for me!!!-Risedronate--inhibits cholesterol pathway & inhibits to GTP Ace
No O2 =death no nitrogen= apoptosis, death-RIP -- TEC -- Tiludronate, Etidronate, Clodronate--toxic ATP Ace |
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Longterm bisphosphonate usage has been shown to cause an increased risk of stress reaction leading to fracture at which of the following areas? 1. Jaw 2. Lumbar spine 3. Femoral neck 4. Subtrochanteric femur 5. Anterior cortex of tibia |
Subtrochanteric stress reaction and fracture is a known complication of longterm bisphosphonate use. Imaging typically shows lateral cortical thickening in the subtrochanteric femur (Illustration A). Without discontinuation of bisphosphonate use and prophylactic fixation, this stress reaction can go on to a transverse fracture (Illustration B.) ans4 |
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An 85-year-old patient diagnosed with osteoporosis is begun on a bisphosphonate. What can you tell her about her risk of vertebral fracture after 3 years of treatment? 1. remain the same 2. decrease by 20% 3. decrease by 40% 4. decrease by 60% 5. increase by 10% |
reduced by 65% following one year of treatment and by 41% following 3 years of treatement. In addition to these findings, the authors noted a 39% decrease in incidence of non-vertebral fractures and a significant increase in bone mineral density. ans3 |
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Which of the following molecules binds to the surface of hydroxyapatite crystals and prevents protein prenylation? 1. Calcitonin 2. Parathyroid Hormone 3. Raloxifene 4. Calcium 5. Alendronate |
Bisphophonates accumulate in high concentration in bones due to their binding affinity to hydroxyapatite crystals. |
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there are 5 bacteriostatic antibioticand 8 bactericidal: antibiotics |
there are 8 KILLER antibiotics 2 cell wall symphysis inhibitors-- |
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A 62-year-old man undergoes an uncomplicated total shoulder replacement 9 months ago. What is an appropriate choice of prophylactic antibiotics to be taken prior to dental work if he has no allergies? 1. daptomycin 600 milligrams intravenous 2 hours prior to procedure 2. amoxicillin 4 grams oral 1 week prior to procedure 3. levaquin 500 milligrams oral 1 hour prior to procedure 4. trimethoprim-sulfamethoxazole 2 tablets double-strength oral 1 hour prior to procedure 5. cephalexin 2 grams oral 1 hour prior to procedure |
Patients not allergic to penicillin should take 2 grams of Amoxicillin, Cephalexin, or Cephadrine, by mouth one hour prior to the dental procedure. IV antibiotics are very rarely used in dental offices. If allergic to penicillin, clindamycin would be the next best alternative. |
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All of the following antibiotics function by interfering with cell wall synthesis EXCEPT 1. Cefazolin 2. Penicillin G 3. Vancomycin 4. Imipenem 5. Gentamicin |
Cephalosporins (cefazolin), penicillins, vancomycin, and imipenem function by interfering with cell wall synthesis. Gentamicin, an aminoglycoside, functions by inhibiting ribosomes and protein synthesis and does not affect cell wall synthesis. ans5 |
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A splenectomy is performed in a 7-year-old boy following a motor vehicle accident. All of the following are recommended for long-term management EXCEPT: 1. Pneumococcal vaccination 2. Haemophilus influenza type B vaccination 3. Meningococcal group C vaccination 4. Lifelong prophylactic antibiotics 5. Hepatitis A vaccination |
All of the responses are correct except the need for Hepatitis A vaccine. Hepatitis A is a virus with tropism for hepatocytes which causes infection from fecal-oral contaminated food/water, and shows no increased rate of either infectivity or morbidity in patients with hyposplenism.Basic recommendations for splenectomized patients include: |
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Which of the following antibiotic families inhibit bacterial DNA gyrase? 1. Quinolones 2. Penicillins 3. Aminoglycosides 4. Macrolides 5. Sulfonamides |
Quinolones are a class of antibiotics which act by inhibition of bacterial DNA gyrase. Penicillins interfere with bacterial cell wall synthesis. Aminoglycosides and macrolides interfere with bacterial protein synthesis by acting on the 30S and 50S ribosome subunits respectively. Sulfonamides interfere with bacterial folic acid metabolism. |
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as it relates to anticoagulation which factors involved in the
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Virchow's triad describes what risk factors for DVT? |
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which medication inhibits the production of prostaglandin and thromboxanes? |
aspirin |
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which medication enhances inability of antithrombin III? |
Heparin unfractionated heparinand low molecular weight heparin Lovenox |
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which medication inhibits factor X?(2) |
fundaparinux & Rivaroxaban |
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which medication of action is irreversible activation of cyclooxygenase enzyme |
aspirin |
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which medication is reversed by protamine? |
enoxaparin or Lovenox |
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which medication has a highest bleeding complications and is not to be used with epidurals |
Fondaparinux
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what is the mechanism of action of Coumadin |
it inhibits vitamin K 2, 3 peroxide reductase which prevents active vitamin K formation vitamin K is needed for the gamma caroxylation of glutamic acid for factors to factor VII factor IX factor X protein C and protein S |
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what 4 comorbid risk factors would have an adverse reaction with the patient taking Coumadin, what are the names of the medications? |
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they increase the rate of bleedingby acting on platelets |
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how does the omega-3 fish oil effect the body |
increases the INR and platelet aggregation and vitamin K dependent coagulation factors |
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what is the effective coenzme Q10, green tea, St. John's wort? |
reduces the INR agonist to warfarin and St. John's wort increases the catabolism of warfarin |
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Which of the following supplements affects blood clotting through its effect on platelets? 1. Ginkgo 2. Vitamin D 3. Ephedra 4. St. John's Wort 5. Selenium |
Ginkgo and ginseng are two common supplements used in the general population that have inhibitory effects of platelet function. Adverse peri-operative complications consisting of increased bleeding and hematoma formation have been reported with the use of these two herbal supplements. The most commonly used supplements that could have an effect in the peri-operative period include echinacea, ephedra, garlic, ginkgo, ginseng, kava, St John's wort, and valerian. Bleeding has been shown to be effected by garlic, ginkgo, and ginseng; cardiovascular instability from ephedra; and hypoglycemia from ginseng. Kava and valerian have pharmacodynamic herb-drug interactions that can increase the sedative effect of anesthetics. St John's wort has been shown to alter the metabolism of certain drugs used in the perioperative period. ans1 |
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as as it relates to adult spinal deformity how many_____ degrees effect pulmonary function and ______degrees increase the mortality |
60° effect pulmonary function 90° increase mortality |
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adult spinal deformity what is indication for an anterior procedure? |
large curves greater than 70° and rigid curve's |
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what is incidence of complication with adult spinal deformity surgery?
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10--20% |
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A 53-year-old woman is seen in the adult spine clinic for long-standing back pain. History reveals she had untreated scoliosis as a child. Her current radiographs are shown in Figures A and B. Due to discomfort with ADLs and progressive pain, surgical intervention is planned. Which of the following factors would increase her risk of nonunion? 1. An anterior thoracoabdominal approach 2. Preoperative Cobb angle of 60 degrees 3. Age greater than 35 years 4. A posterior midline approach 5. Positive sagittal balance < 5 cm
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n the surgical treatment of adult idiopathic scoliosis, a thoracoabdominal approach has been shown to have higher rates of pseudoarthrosis compared to posterior procedures.ans1 |
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In patients with adult scoliosis requiring long thoracolumbar fusions, which of the following is the major advantage of extending the fusion to the sacrum as opposed to ending at L5. 1. Improved function outcomes 2. Decreased pseudoarthosis rates 3. Decreased major medical complications 4. Improved correction and maintenance of sagittal balance 5. Improved curve correction in the coronal plane |
In adult patients with spinal deformity, extension of a long fusion to the sacrum is associated with improved correction and maintenance of sagittal balance. |
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In adult patients with scoliosis, severity of symptoms correlates with which of the following variables? 1. Coronal imbalance 2. Sagittal imbalance 3. Magnitude of coronal Cobb angle 4. Number of spine levels involved in the deformity 5. Level of the apex of the curve
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Sagittal balance is the most reliable radiographic predictor of clinical health status in adults with spinal deformity. |
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A 66-year-old female presents to your clinic complaining of back pain, difficulty standing-up straight, weakness in her legs, and neurogenic claudication. On upright thoracolumbar radiographs, there is a 75 degree thoracolumbar curve with the apex at L2, and the C7 plumb line falls 12 cm anterior to the posterosuperior corner of S1. Aside from a decompression of the stenotic levels, which of the following choices will lead to the most reliable decrease in overall disability? 1. Decreasing the cobb angle to less than 50 degrees 2. Decreasing the cobb angle to less than 30 degrees 3. Correcting the sagittal vertical axis to within 5 cm of neutral 4. Correcting the sagittal vertical axis to neutral 5. Stopping the fusion at L5
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The clinical scenario presents a 66-year-old female with a spinal deformity in both the coronal and sagittal plane. Correction of the sagittal plane to within 5cm of neutral is the most reliable predictor of clinical symptoms. ans3 |
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atlas fracture AKA ×2 |
JEFFERSON fracture AKA C1 fracture |
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if looking at an open mouth odontoid view, much displacement is considered significant? (2) |
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the patient has a C1 fracture after trauma what is the next most appropriate step in the management of this fracture pattern? |
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what is the treatment of a C1 cervical fracture with an intact transverse ligament type 1,2,3 |
the stable injuries and the treatment is halo immobilization ×6-12 weeks or hard cervical orthoses |
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what is the treatment of an unstable type II unstable type III that is transverse ligament rupture |
posterior C1/C2 fusion oroccipital cervical fusion |
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A Gallie C1-2 fusion with sublaminar wiring of C1 to the spinous process of C2 is a valid treatment option for which of the following injury patterns? 1. occipital-cervical dissociation 2. comminuted C1 burst fracture 3. type I odontoid fracture 4. type III odontoid fracture 5. transverse ligament disruption |
A C1-2 fusion with sublaminar wiring or modern screw-rod constructs is indicated in transverse ligament injuries. ans5 |
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most common location for bipartite patella? |
superior lateral and a 50% bilateral |
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A 14-year-old high school running back strikes his left knee on an opposing players helmet during practice. He is able to continue playing for 10 more minutes before seeking medical attention. On examination, he has soft tissue swelling at the anterior knee and early ecchymosis formation. His range of motion was full and no palpable crepitus over the patella was noted. His knee is stable to varus and valgus at 30 degrees. He has a grade one Lachman examination and the medial tibial plateau is anterior to the medial femoral condyle upon a posteriorly directed force on the proximal tibia. There is less than one-quartile of medial and lateral patellar translation with a negative "J" sign. Radiographs are shown in Figures A-C. What is the most appropriate next step in management. 1. Magnetic resonance imaging (MRI) for ligament reconstruction planning 2. Immobilize in 120 degrees of knee flexion for 24 hours and return-to-play in 2 weeks 3. Open reduction and internal fixation with interfragmentary screws with return-to-play in 5 months 4. Symptomatic treatment with return-to-play as tolerated 5. Long leg cast for 6 weeks with toe-touch weightbearing precautions with return-to-play in 2 months |
he patient has a benign exam and radiographs demonstrate a bipartite patella. No further evaluation is necessary and symptomatic treatment with RICE and return-to-play as tolerated is most appropriate. |
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the child develops a torticollis after respiratory infection 3 months ago and the CAT scan shows subluxation of C1 on C2 what is the next step in management? |
posterior Atlantaaxial fusion if greater than 3 months |
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An 3-year-old girl developed torticollis after a severe respiratory tract infection 8 months ago. A dynamic computed tomographic (CT) is performed and shows fixed rotatory subluxation of C1 and C2 despite maximum rotation of the head. What is the most appropriate next step in management? 1. Closed reduction under conscious sedation 2. Neck immobilization in a soft cervical collar 3. Traction with maximal tolerated weight followed by halo brace 4. Occipitocervical fusion 5. Posterior atlantoaxial fusion |
The clinical presentation is consistent with torticollis caused by rotatory atlantoaxial instability. Common causes of this condition include trauma and infection. Diagnosis is made with standard radiographs and a dynamic CT (CT with the head turned maximally to either side and at neutral). If the symptoms are chronic (> 3 months), nonoperative modalities have failed, or if there are any neurologic deficits, then a posterior atlantoaxial fusion is indicated. |
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atlantoaxial instability name 5 causes in an adult |
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atlantoaxial instability name 3 causes in the pediatric patients |
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A 11-year-old male complains of one year duration of neck pain. He denies any recent trauma. He has noticed intermittent episodes of gait imbalance and difficulty with buttoning his shirt over the past 3 months. Physical exam shows normal strength in all four extremities and hyper-reflexic patellar tendons. Neutral and flexion radiographs are shown in Figure A and B. A sagittal CT scan is shown in Figure C with a coronal reconstruction shown in Figure D. What is the most appropriate treatment? 1. PT to strengthen the dynamic stabilizers of the neck 2. Soft collar wear during any athletic activities 3. Cessation of all contact sports with no surgical intervention 4. Posterior C1-C2 fusion 5. Anterior C1-2 fusion |
The clinical presentation and imaging studies are consistent with Os odontoideum with neurologic deficits. A posterior C1-C2 fusion is the most appropriate treatment.ans4 |
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what is the standard of care treatment for an adult pyogenic osteomyelitis of the spine? |
bracing and long-term antibiotics 6-8 weeks no surgery |
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what is the treatment of adult pyogenic osteomyelitis of the spine with neurologic deficits or spinal instability? |
anterior debridement and strut grafting plus or minus posterior instrumentation with the patella below |
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A 33-year-old man with a history of IV drug abuse presents with low back pain of increasing intensity. His neurologic examination is intact. Laboratory studies reveal a WBC count of 11,000/mm3 and erythrocyte sedimentation rate of 82 mm/h. Blood cultures are negative. Plain radiographs are shown in Fig A. An MRI T1-weighted images and a post gadolinium fat-suppressed T1-weighted images are shown in Fig B. Initial management should consist of: 1. Physical therapy with supportive therapy 2. IV antibiotics 3. Open surgical decompression and biopsy 4. CT-guided closed biopsy 5. Repeat MRI in 6 weeks
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The clinical presentation is consistent with pyogenic vertebral osteomyelitis. A CT guided biopsy is the most appropriate next step in management to identify an organism and direct antimicrobial therapy.ans4 |
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A 69-year-old male presents to the emergency room with low back pain for 1 week duration. His past medical history is significant for diabetes and coronary artery disease that was treated with stenting 7 years prior. Recently he was hospitalized for a urinary tract infection which was treated with oral antibiotics. On physical exam he is afebrile and has no neurologic deficits in his lower extremity. Laboratory studies show a white blood cell count of 10,300/mm3, an erythrocyte sedimentation rate of 35 mm/h (reference range, 0-25 mm/h), and C-reactive protein of 13 mg/L (reference range, 0-5.0 mg/L). A radiograph and MRI are performed and shown in Figure A and B respectively. Repeat blood cultures x2 are performed and both show methicillin-sensitive Staphylococcus aureus. What is the most appropriate next step in treatment. 1. CT guided biopsy 2. Referral to an orthopaedic pathologist 3. Organism specific intravenous antibiotics 4. Posterior lumbar debridement 5. Anterior lumbar debridement
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The clinical presentation is consistent with discitis and vertebral osteomyelitis in a patient without neurologic deficits and an identified organism. Organism specific intravenous antibiotics would be the most appropriate next step in treatment.ans3 |
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A 45-year-old female IV drug user presents to the emergency department with a chief complaint of severe focal low back pain that has progressed over the past 10 days. She now reports the pain is severe enough that it is difficult for her to walk. She reports night sweats, fluctuating fever, and a loss of appetite. Physical exam shows exquisite pain with flexion and extension of the lumbar spine. Routine urinalysis by the ER physician shows evidence of a urinary tract infection. Her blood leukocyte count is 12,600 per mm3, and erythrocyte sedimentation rate is 78 mm/h. A lateral radiograph is shown in Figure A. Which of the following is the best choice in management? 1. Discharge from the ER with a course of oral antibiotics 2. Admission to the hospital with empirical IV antibiotics 3. Admission, antibiotics, and MRI of the lumbar spine with and without gadolinium 4. Nuclear medicine bone scan 5. Renal ultrasound
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The clinical presentation is consistent with spondylodiscitis. Although the patient has risk factors for spinal tuberculosis, a CT guided biopsy should be performed to establish a diagnosis. |
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1- pt c/o dyspnea, fever PE-cyanotic skin, intercostal retractions, tachypnea labs Pulmonary capillary wedge pressure < 12 (normal) PaO2 / FIO2 ratio < 200 mm Hg, Pulmonary artery wedge pressure < 18 mmHg |
1.1 ARDS tx-mechanical ventilation in ICU w/ moderate-to-high levels of PEEP of 5 cmH2O; goal oxygen satur=88-95% or (PO2) of 55-80. |
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patient presents to the emergency room after trauma and bilateral femur fractures with persistent hypoxemia intercostal retractions rales/crackles rhonchi tachypnea dyspnea fever and cyanotic skin with the
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