Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5211_Библиотеки_им_академика_М_И_Перельмана
.pdf
Kiran Singisetti
Figure 8.11 Anterior and posterior knee referencing. (a) Anterior referencing device uses a boom to sit on the anterior cortex and the cut is
5 mm below. The posterior cortex is not involved in determining the posterior condyle cut. (b) Posterior referencing device has two legs that
sit under the posterior condyles. It measures 9 mm up from condyles. This is where the cut will occur.
174
Knee III Structured SBA
Figure 8.12 Flexion/extension gap knee
Other options are to use a thicker insert followed
by addressing tight flexion gap.
Changing the femoral component size only
affects the flexion gap, not the extension.
Joint line is influenced by the distal femoral
cut, but not proximal tibia cut.
41. Answer A. Eccentric exercises
The patient has typical features of chronic patella
tendinitis. The clinical presentation is variable:
often characterised by pain in the front part of
the knee which initially does not prevent activity
but over time, if not diagnosed and treated, progresses so that the pain is incapacitating, continues
after exercise, and may even cause difficulties in
everyday activities, for example causing pain when
walking, going downstairs, sitting, etc.
There are a wide range of possible treatment
options including shockwaves, low-intensity laser,
splints, injections (corticoids, heparin, dextrose,
glycosaminoglycan polysulphates (GAGPS), autologous growth factors (platelet-rich plasma), etc.)
cryotherapy, stretches, ultrasound.
It has been shown that eccentric exercises are
the preferred initial treatment in the rehabilitation
of patellar tendinopathy, given that they increase
the tendon’s resistance to traction, producing an
elongation of the tendinous muscle unit, meaning
the tendon bears less tension. Some of the physiological effects of the exercises on the tendon have
been proven. They are effective in encouraging
Figure 8.13 The patella
tendon should be palpated in
full extension and then tested
in 90° of flexion. In chronic
patella tendinosis, tenderness
in the proximal tendon is more
noticeable in extension
(Bassett’s sign) compared with
flexion. In flexion, the normal
superficial fibres cover the
damaged deep fibres, resulting
in less pain on palpation
the formation of tendon collagen fibres, improving its remodelling, and requiring less oxygen
consumption, greater muscle tension and less
energy expenditure.
42. Answer D. Rotating on a 20° flexed knee whilst
weight bearing on that side
Explanation:
A is the Appley grind test.
175
Kiran Singisetti
B is McMurray ’ s test.
D is Thessaly’s test – the most sensitive test
for meniscal pathology.
E is also a test for meniscal pathology. But
this is not sensitive. Squat and walk like a
duck! Childress’ test.
The diagnosis of a meniscal tear is usually from
the history and the presence of joint line tenderness. Meniscal stimulation tests have a wideranging sensitivity and specificity (the absence
of positive signs does not rule out a meniscal
tear).
The following clinical tests are infrequently
performed in a clinical setting, but the Thessaly
test has the highest accuracy in detecting a
meniscal tear with 94% for medial meniscal and
96% for lateral meniscal tears (Karachalios et al.
2005).
The Appley grind test is historical and
involves forcing the tibiofemoral surfaces
together to ‘catch’ the meniscus. In this test the
patient is prone with the knee flexed to 90° and
the examiner pushes downwards on the foot and
rotates the leg.
McMurray’s test was used to recreate dis-
placement of a meniscal tear which is painful
and probably not in the patient’s best interests.
A modification of this is a compression test to
produce discomfort along the joint line, which
may indicate pathology in the medial or lateral
compartment. The patient is supine with the
knee flexed. The examiner places one hand on
the top of the knee with the fingers and thumbs
positioned to palpate the joint line and the other
under the heel. The examiner can then compress
the joint by pushing down on the top hand while
the lower hand controls flexion and can also
rotate the leg thereby stressing each compartment in varying degrees of flexion. Thi s test is
most specific for a tear of the posterior horn of
the medial meniscus.
Thessaly’s test. Here the patient is asked to
stand on one leg at a time. First, the unaffected
leg as a trial, then the affected leg (Figure 8.14).
The examiner holds the patient’s hands to prevent them overbalancing. The patient flexes their
knee to 5° and then internally rotates and externally rotates their knee and body three times.
This is repeated with the knee flexed to 20°.
(a) (b) (c)
Figure 8.14 Thessaly test. (a) The patient is supported and asked to stand on one leg in turn. The leg to be examined is flexed 5° and the
patient is asked to rotate 3 times. This is then repeated at 20°. (b) The patient should twist their body with the standing knee in either internal
or external rotation.
176
Knee III Structured SBA
Figure 8.15
Pain, locking or catching represents a positive
result. The test is more sensitive at 20° compared
with 5°.
Childress’ test. Another less specific test is to
ask the patient to fully squat, and if possible,
duck walk. This action compresses the posterior
horns of the menisci but can also cause patellofemoral pain.
Karachalios T et al. Diagnostic accuracy of
a new clinical test (the Thessaly test) for early
detection of meniscal tears. J Bone Joint Surg Am.
2005;87:955–962.
177
Section 2
Chapter
9
Adult Elective Orthopaedics and Spine
Foot and Ankle I Structured SBA
Gavin Heyes and Lyndon Mason
FOOT AND ANKLE I STRUCTURED SBA
QUESTIONS
Anatomy and Biomechanics
1. From the options listed below, please choose the
most appropriate description of the anatomy of
the spring ligament.
A. Originates on the lateral malleolus and inserts
onto the lateral aspect of the talus
B. Originates on the medial malleolus and inserts
onto the medial wall of the calcaneum
C. Originates on the medial malleolus and inserts
onto the medial aspect of the talus
C. Originates on the navicular and inserts onto
the medial cuneiform
E. Originates on the sustentaculum tali and
inserts onto the navicular
2. From the options listed below, please choose the
most appropriate anatomical structure to occur
in the third layer of the foot.
A. Abductor digiti minimi
B. Adductor hallucis
C. Peroneus longus
D. Plantar interossei
E. Quadratus plantae
3. From the options listed below, please choose the
most appropriate muscle that plantar flexes the
1st metatarsal.
A. Flexor hallucis brevis
B. Flexor hallucis longus
C. Peroneus longus
D. Tibialis anterior
E. Tibialis posterior
4. From the options listed in the next column,
please choose the most appropriate description
of the anatomy of the Lisfranc ligament.
A. Dorsal ligament between the medial cuneiform
and the 2nd metatarsal
B. Interosseous ligament between the medial
cuneiform and the 2nd metatarsal
C. Plantar ligament between the 2nd metatarsal
and 5th metatarsal
D. Plantar ligament between the intermediate
cuneiform and the 2nd metatarsal base
E. Plantar ligament between the medial cunei-
form and the 2nd metatarsal
5. What structure attaches to the plantar surface of
the hallucal sesamoids?
A. Abductor hallucis
B. Adductor hallucis
C. Flexor hallucis brevis
D. Lateral sesamoid ligament
E. Medial sesamoid ligament
6. What is the main blood supply of the talar body?
A. Anterior tibia artery
B. Artery of the sinus tarsi
C. Perforator artery
D. Peroneal artery
E. Posterior tibial artery
7. Which muscle contracts eccent rically during the
heel strike phase of the gait cycle?
A. Extensor hallucis longus
B. Lateral head of gastrocnemius
C. Medial head of gastrocnemius
D. Tibialis anterior
E. Tibialis posterior
8. What nerve supplies adductor hall ucis?
A. Baxter’s nerve
B. Deep peroneal nerve
C. Lateral plantar nerve
D. Medial plantar nerve
E. Superficial peroneal nerve
178
Foot and Ankle I Structured SBA
Achilles and Heel
9. What is the most common aetiological factor for
plantar fasciopathy?
A. Calf tightness
B. Depression
C. Job requiring standing
D. Obesity
E. Smoking
10. Which of the following best describes the react-
ive phase of Achilles tendinopathy?
A. Cell death, minimal fibrillar collagen
B. Collagen fibre dysrepair, increased chondro-
cytic cellularity
C. Increased production of large proteoglycans,
which bind with large amounts of water
D. Ingrowth of neovessels
E. Production of type III collagen
11. What is the most likely diagnosis with pain
occurring on calcaneal squeeze test?
A. Calcaneal fracture
B. Flexor hallucis longus tendinopathy
C. Plantar fasciopathy
D. Radiculopathy
E. Tarsal tunnel syndrome
12. What is the first-line treatment of plantar
fasciopathy?
A. Laser therapy
B. Mechanical overload reduction
C. Physiotherapy
D. Shockwave therapy
E. Ultrasound-guided pulse radiofrequ ency
13. What statement is true in regard to Achilles
tendon ruptures?
A. Functional rehabilitation is equal to surgical
treatment regarding the incidence of rerupture
B. Immobilisation increases load to failure
C. In the acute phase, collagen type I is the first
collagen that is layered down
D. Use extrinsic healing with passive motion
E. Use of heel wedges in functional rehabilita-
tion works by shortening tendon
Midfoot
14. Which statement is true in regard to Lisfranc
injuries?
A. A tightrope controls axial movement
B. Fusion improves functional outcome as com-
pared to fixation
C. MRI is indicated when radiographs show
diastasis
D. Quality of anatomical reduction is the best
predictor of functional outcomes
E. Transarticular screws reduce movement at
the tars ometatarsal joint as compared with
bridge plate
15. ‘Too many toes’ sign would most likely be seen
in which case?
A. Charcot–Marie–Tooth disease
B. Fibular hemimelia
C. Iselin’s disease
D. Stage IIA tibialis posterior tendon
dysfunction
E. Stage IIB tibialis posterior tendon
dysfunction
16. At the level of the navicular, when harvesting
flexor digitorum longus for tibialis posterior
tendon reconstruction, what structure lies
immediately dorsal or deep to it?
A. Adductor hallucis
B. Baxter’s nerve
C. Flexor hallucis longus
D. Lumbricals
E. Plantar fascia
17. A 53-year-old is currently being operated on for
a fixed flat foot deformity. The surgeon has just
completed preparation of the hindfoot for
fusion, reduced it and held it with guidewires.
The surgeon notes a forefoot deformity that
will require intervention. What is the deformity
likely to be?
A. Abduction and pronation deformity
B. Adduction deformity
C. Adduction and pronation deformity
D. Supination deformity
E. Valgus deformity
179
Gavin Heyes and Lyndon Mason
18. A patient attends clinic for the results of an
excision biopsy performed from a discrete firm
lesion in the foot. The histopathology report
included no cell atypia, myofibroblast proliferation and collagen proliferation of type III collagen more so than type I collagen.
What is the likely diagnosis?
A. Fibromyxoma
B. Gardner’s disease
C. Ledderhose disease
D. Lipoma
E. Synovial sarcoma
Forefoot
19. A 42-year-old female attends with a painful
bunion she has had for the past 2 years. She
has failed conservative measures. On examination, there is no first ray instability or pain on
grind test. Her radiographs reveal a hallux valgus
angle of 25° and intermetatarsal angle of 12°.
What is the most appropriate surgical
intervention?
A. Basal osteotomy
B. Distal chevron osteotomy
C. Lapidus fusion
D. Moberg osteotomy
E. Proximal phalanx osteotomy
20. A 42-year-female with a bunion presents with
gradual onset pain on shod weight bearing originating under the 2nd and 3rd metatarsal
heads. The patient had a negative Mulders
Click test.
Which of the following is the most likely
diagnosis?
A. Freiberg’s disease
B. Mallet toe
C. Morton’s neuroma
D. MTP joint synovit is
E. Plantar plate rupture
21. A 23-year-old professional footballer sustains
an undisplaced metadiaphyseal proximal 5th
metatarsal fracture during training after a few
weeks of grumbling about foot pain.
What is the most appropriate treatment?
A. Cast immobilisation and non-weight
bearing
B. Internal fixation
C. Metatarsal strapping and full weight bearing
D. Metatarsal strapping and non-weight
bearing
E. Stiff shoe
22. What is the most frequent iatrogenic compli-
cation of excision of both tibial and fibular
sesamoids of the hallux?
A. Flexor hallucis longus tendonitis
B. Hallux valgus
C. Hallux varus
D. Intractable keratosis
E. Weakness on tip toe stance
23. Floating toe is an iatrogenic complication
most frequently associated with which
procedure?
A. Keller’s resection arthroplasty
B. Kidner’s procedure
C. Morton’s neuroma excision
D. Stainsby procedure
E. Weil metatarsal osteotomy
24. What force on the proximal phalanx is created
by the abductor hallucis in a hallux valgus
deformity?
A. Adduction
B. Adduction and supination
C. Dorsiflexion and pronation
D. Plantar flexion
E. Plantar flexion and pronation
25. A fit and healthy 75-year-old presents to clinic
with pain, stiffness, swelling, erythema over her
left 1st metatarsal phalangeal joint (MTPJ)
following a silastic 1st MTPJ arthroplasty performed 12 years ago. Radiographs demonstrate
osteolysis around the component and a valgus
deformity. Blood tests are normal with regard
to full blood picture, erythrocyte sedimentation
rate and C-reactive protein.
What is the appropriate treatment?
A. First stage of two-stage 1st MTPJ fusion
B. Revision to 1st MTPJ fusion with inlay bone
graft
C. Revision to excision arthroplasty
D. Revision to silastic arthroplasty
E. Steroid injection
180
Foot and Ankle I Structured SBA
26. An 18-year-old young woman presents with
forefoot pain and stiffness of the 2nd metatarsal
phalangeal joint. Pain worsened on axial
loading of the joint. Radiographs demonstrate
arthrosis and flattening of the metatarsal head.
What is the likely diagnosis?
A. Freiberg’s disease
B. Kohler’s disease
C. Mueller–Weiss syndrome
D. Sever’s disease
E. Turf toe
27. A 1-year-old female infant is brought into your
clinic. Her mother is concerned about her 4th
toes bilaterally. They appear to be shortened
and overlapping the 5th toes. Radiographs demonstrate disruption of Mae stro’s parab ola and
premature closure of the 4th metatarsal physis.
You also notice the child to be smaller than
average, with a short, webbed neck.
What condition could this child have?
A. Klippel–Feil syndrome
B. Poland syndrome
C. Sprengel deformity
D. Trisomy 21
E. Turner’s syndrome
28. An 83-year-old nursing home patient presents
with pain over 2nd toe, inability to fit into shoes,
chronic paronychia and an ulcer over the 2nd toe
proximal interphalangeal joint (PIPJ). The PIPJ
is fixed in flexion, the metatarsal phalangeal joint
(MTPJ) is slightly extended and the distal interphalangeal joint (DIPJ) is hyperextended and
flexible.
What is the most appropriate treatment?
A. Amputation through proximal one-third of
proximal phalanx
B. MTPJ release + DIPJ fusion
C. MTPJ release + flexor to extensor transfer +
temporary K-wire fixation
D. MTPJ release + MTPJ replacement
E. MTPJ release + PIPJ fusion + temporary K-
wire fixation
29. A 46-year-old man presents with pain in the
right 1st metatarsal phalangeal joint (MTPJ).
He recalls a rugby injury to the joint 20 years
ago. On examination he has moderate pain on
end range of motion, reduced range of motion
(10° dorsiflexion, 50° plantar flexion) and pain
on axial loading of the 1st MTPJ. Radiographs
demonstrate around 40% joint space narrowing
with dorsal osteophyte on the metatarsal and
phalanx. He has failed conservative treatment
and still wishes to play rugby.
What is the most appropriate treatment?
A. Dorsal cheilectomy
B. Keller’s procedure
C. MTPJ arthrodesis
D. MTPJ arthroplasty
E. Synovectomy
30. When performing a scarf osteotomy in an
otherwise normally aligned foot, to avoid
shortening or lengthening the 1st metatarsal,
what landmark or reference point should be
used for your distal transverse cut?
A. Parallel to proximal phalanx base joint
surface
B. Parallel with the 5th metatarsal phalangeal
(MTP) joint
C. Perpendicular to 1st metatarsal
D. Perpendicular to 2nd metatarsal
E. Perpendicular to cut surface after removing
medial eminence
31.
An 18-month-old presents to your clinic with
bilateral deformities of their 4th and 5th toes.
On examination, there is a flexion and varus
deformity to all toes.
What is the likely cause of the deformities?
A. Absence of extensor digitorum
B. Central nervous system lesion
C. Congenital bands around toes
D. Contracture of flexor digitorum longus and/
or brevis
E. Delta phalanx
Ankle
32. A 28-year-old man is seen in a nurse-led dressings clinic 2 weeks after arthroscopic ankle surgery. He is complaining of persistent numbness
over the dorsum of his foot but not in the first
web space.
What is the most likely cause of this
complication?
181
Gavin Heyes and Lyndon Mason
A. Anterocentral portal placement
B. Anterolatera l portal placement
C. Anteromedial portal placement
D. Posterolateral portal placement
E. Posteromedial portal placement
33. A normally fit and well 32-year-old woman is
taken to theatre for examination under anaesthesia for chronic ankle instability despite several
courses of physiotherapy. On the lateral image,
10mm of forward shift is demonstrated during
an anterior drawer test compared with the
unaffected ankle.
Which ligament is most likely damaged?
A. Anterior inferior tibiofibular ligament
B. Anterior talar fibular ligament
C. Calcaneofibular ligament
D. Posterior inferior tibiofibular ligament
E. Posterior talar fibular ligament
34. A 43-year-old man sustains a pronation external
rotation injury to his left ankle while playing
football. Initial radiographs show increased
tibio-fibular clear space.
Which of these is the correct group of ligaments which form the structure that is injured,
resulting in the increased tibiofibular clear
space?
A. AITFL, ATFL, PITFL
B. AITFL, IOL, CFL
C. AITFL, IOL, PITFL
D. PITFL, CFL, ATFL
E. PITFL, IOL, ATFL
35. A patient is brought into the ED after sustaining
an ankle injury while playing basketball. The
ankle is grossly swollen and tender.
Radiographs show a pronation external rotation
injury pattern.
Which answer best describes the sequence of
injury?
A. ATFL disruption, oblique fibula fracture at
the lev el of the syndesmosis, PITFL disruption or posterior malleolus fracture, transverse medial malleolus fracture or deltoid
ligament injury
B. Medial malleolus transverse fracture or del-
toid disruption, ATFL disruption, lateral
short oblique fracture or spiral fracture of
the fibula above the syndesmosis, PITFL
avulsion or posterior malleolus fracture
C. Medial malleolus transverse fracture or del-
toid disruption, ATFL disruption, lateral
short oblique/spiral fracture of the fibula
below the syndesmosis, PITFL avulsion or
posterior malleolus fracture
D. Medial malleolus transverse fracture or del-
toid disruption, ATFL disruption, transverse
or comminuted fibula fracture above the level
of the syndesmosis
E. Vertical medial malleolus fracture, ATFL
disruption or fibula fracture below the joint
line
36. A 30-year-old keen cro ss-country runner presents to a foot and ankle clinic with non-specific
ankle pain and occasional swelling. They describe
a couple of episodes of mild ankle sprains over
the past couple of years. An osteochondral defect
of the talus is suspected.
What is the most common location for these
injuries on the talus?
A. Anterior lateral talar dome
B. Central anterior talar dome
C. Central lateral talar dome
D. Central medial talar dome
E. Posterior medial talar dome
37. A 70-year-old man presents to an elective foot
and ankle clinic with pain in his right ankle. He
had an ankle injury 30 years ago, which he was
told could not be operated on at the time and was
managed in a cast. Weight bearing ankle radiographs show end stage ankle arthritis. The
patient has decided on an ankle arthrodesis for
treatment.
During ankle arthrodesis surgery, what is the
ideal position of the ankle?
A. 10° dorsiflexion, 10° external rotation, 5°
hindfoot valgus
B. 10° dorsiflexion, neutral external rotation, 5°
hindfoot valgus
C. Neutral dorsiflexion, 10° external rotation, 5°
hindfoot valgus
D. Neutral dorsiflexion, 10° external rotation, 5°
hindfoot varus
E. Neutral dorsiflexion, neutral external rota-
tion, 5° hindfoot valgus
182
Foot and Ankle I Structured SBA
38. What ankle position at the time of sustaining a
Pilon fracture results in the worst outcomes?
A. Dorsiflexion
B. Neutral
C. Plantar flexion
D. Valgus
E. Varus
39. What is the most common malignancy of the
foot?
A. Ewing’s sarcoma
B. Liposarcoma
C. Metastasis
D. Osteosarcoma
E. Synovial sarcoma
Diabetes
40. A patient with diabetes type 2 develops a midfoot
collapse with ulceration. A tissue viability nurse
describes the ulcer as grade 2. The radiographs
are reported as a ‘rocker bottom deformity with
osseous fragmentation’.
What is the most appropriate management?
A. Exostectomy
B. Midfoot plantar flexion osteotomy and fix-
ation with a mega construct
C. Negative pressure dressing and an ankle–foot
orthosis
D. Range of motion walker
E. Total contact casting
41. A 49-year-old male patient with a history of type
2 diabetes, neuropathy and retinopathy presents
to the diabetic foot and ankle MDT clinic with a
chronic foot ulcer.
Which of the following is a negative predictor
for diabetic ulcer wound healing?
A. Arterial brachial pressure index ratio of 0.5
B. Inability to feel a 5.07 Semmes–Weinstein
monofilament around the ulcerated area
C. Serum albumin 2.9g/dL
D. Total lymphocyte count 2.8 (109/L)
E. Transcutaneous oxygen pressure 41mm Hg
General
42. A patient presents to you with a Hallux valgus
deformity with HVA of 35° and IMA of 12°.
Operative treatment is undertaken. During the
surgical approach, an osteotomy is performed.
On follow up, it is noted that the metatarsal
head has undergone avascular necrosis.
What factor is most likely to cause iatrogenic
avascular necrosis?
A. Akin osteotomy
B. Distal short Chevron osteotomy
C. Proximal dome osteotomy
D. Scarf osteotomy
E. Single medial incision
43. What is true of posterior malleolar fractures
of the ankle?
A. All posterior malleolar fractures should be
fixed through a posterolateral approach
B. Morphology of fracture determines func-
tional outcome in fixed posterior malleolar
fractures
C. Percentage of joint involved should dictate
surgical treatment
D. Plain radiographs are accurate at estimation
of the size of the posterior malleolar fracture
fragment
E. Posterior malleolar fracture fixation negates
the need for syndesmosis fixation
44. During a Morton’s neuroma excision in the
3rd webspace, what ligament must be cut to
visualise the neuroma from a dorsal
approach?
A. Intermetatarsal ligament
B. Interphalangeal ligament
C. Lisfranc ligament
D. Metatarsophalangeal ligamen t
E. Transverse metatarsal ligament
45. A 14-year-old female hockey player presents to
you with pain for 2 weeks over the 2nd MT
head. On X-ray, you find that the 1st MT is
shorter than the second and the 2nd MTPJ
space is increased. She complains of sustaining
an injury to the hindfoot of the same side 2
months prior which settled in a week and she
resumed her sporting activities.
What is the best treatment for her condition?
A. Ankle brace
B. Dorsal closing wedge osteotomy
C. Extensor digitorum arthrodesis
183
Соседние файлы в папке Библиотека им академика М.И. Перельмана