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Introduction
  • Clinical definition
  • Epidemiology
    • incidence
      • 2 to 10% in nonoperative management
      • 5 to 10% with surgical management
    • demographics
      • male : female ratio
      • age bracket
    • location
      • where in the body/bone
    • risk factors
      • distraction at the fracture site on injury films 
      • open fracture
      • metabolic/endocrine abnormalities (Vitamin D deficiency most common) 
      • segmental fracture
      • infection
      • shoulder or elbow stiffness (motion directed to fracture site)
      • patient factors (smoking, obesity, malnutrition, noncompliance)
  • Pathophysiology
    • mechanism of injury (trauma)
      • this is the mechanism of injury (valgus force on knee)
    • pathophysiology
      • this is the physiology (hormone feedback loop)
    • pathobiology
      • this is the molecular or cell biology of disease
    • pathoantomy
      • this is the anatomic cascade of disease
  • Genetics
    • inheritance pattern
      • autosomal dominant
    • mutations
      • chromosome
      • gene
      • protein encoded for
  • Associated conditions
    • orthopaedic manifestations
    • medical conditions & comorbidities
  • Prognosis
    • natural history of disease
    • prognostic variable
      • favorable
      • negative
    • survival with treatment
Anatomy
  • Osteology
    • x
  • Muscles
    • muscles a
  • Ligament
    • ligament a
  • Blood Supply
    • x
  • Biomechanics
    • x
Classification
 
 Classification A
Type A  • Characteristic A
 • Characteristic A
 
Type B  • Characteristic B
 • Characteristic B

Type C  • Characteristic C
Type D  • Characteristic D
 
 
Presentation
  • History (optional)
    • this is a specific event the patient cites. "Heard a pop"
  • Symptoms
    • common symptoms
      • location
      • duration
      • severity
  • Physical exam
    • inspection
      • varus or valgus deformity
      • ecchymosis & swelling
      • diffuse tenderness
    • motion
      • document flexion-extension and pronation-supination
        • crepitus should be noted
      • varus/valgus instability stress test
        • challenging but important for an accurate diagnosis
    • neurovascular
    • provocative tests
Imaging
  • Radiographs
    • recommended views
      • xrays that should alwasy be obtained on evaluation
    • optional views
      • secondary views that might give additional information
    • findings
      • disc space narrowing
    • measuerment
      • measurement A (Cobb angle)
      • measurement A (pelvic incidence)
    • sensitivity and specificity
  • CT
    • indications
      • when do you order
    • views
      • best seen on sagital
    • findings
    • sensitivity and specificity
  • MRI
    • indications
      • when do you order
    • views
      • best seen on T2 axial
    • sensitivity and specificity
  • Bone scan
    • indications
      • when do you order
    • sensitivity and specificity
Studies
  • Serum Labs
  • Invasive Studies
Histology
  • Gross anatomy
  • Histology
  • Immunostaining
Differential
  • Key differential (top 5)
    • key distinguishing factor
  • Complete differential tables
Treatment
  • Nonoperative
    • nonoperative treatment A
      • indications
        • first line of treatment
      • modalities
        • heparin, aspirin, clopidogrel, IV thrombolysis, glycoprotein IIb/IIIa antagonists (abciximab, eptifibatide, tirofiban)
  • Operative
    • compression plating with bone grafting   
      • indications
        • indication a
        • indication b
      • outcomes
        • shown to be superior to both IM nailing with bone grafting and compression plating alone 
        • lateral, posterior or paratricipital (Gerwin) approach to allow exploration of the radial nerve 
    • intramedullar nailing
      • indications
        • indication a
        • indication b
Techniques
  • Operative treatment A
    • approach
    • soft tissue
    • bone work
    • instrumentation
    • complications specific to this treatment
    • outcomes
  • Operative treatment B
    • approach
    • soft tissue
    • bone work
    • instrumentation
    • complications specific to this treatment
    • outcomes
Complications
  • Compliation A
    • incidence
    • risk factors
    • treatment
      • tested treatment in bold blue
        • indications
          • indication A
  • Compliation B
    • incidence
    • risk factors
    • treatment
      • tested treatment in bold blue
        • indications
          • indication A
 

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Questions (4)
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(OBQ05.85) A 42-year-old man reports persistent arm pain after undergoing intramedullary nailing of a humeral shaft fracture 13 months ago. Physical exam shows near normal shoulder and elbow range-of-motion. Infection work-up is normal. A radiograph is shown in Figure A. What is the next most appropriate step in treatment? Review Topic

QID: 971
FIGURES:
1

Exchange nailing

11%

(197/1759)

2

Manipulation under anesthesia

0%

(3/1759)

3

Nail removal and plate fixation

82%

(1441/1759)

4

Percutaneous locked plating

1%

(19/1759)

5

Nail dynamization

5%

(96/1759)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ04.229) A patient sustained a transverse humeral shaft fracture 6 months ago and presently complains of pain and instability at the area of injury. A plain radiograph is shown in Figure A and on exam there is gross motion at the fracture site. What is the most appropriate definitive treatment? Review Topic

QID: 1334
FIGURES:
1

ultrasound therapy to nonunion site

0%

(4/1025)

2

oral bisphosphonates

0%

(2/1025)

3

open reduction internal fixation with autologous bone graft

95%

(973/1025)

4

antegrade intramedullary nail

4%

(36/1025)

5

retrograde intramedullary nail

0%

(3/1025)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ04.96) A 33-year-old male presents 7 months after a fall from 15 feet. He complains of continued pain over his left arm and you elicit pain and gross movement with palpation of his humerus. Infectious workup is negative and a radiograph is shown in Figure A. What is the most appropriate next step in his management? Review Topic

QID: 1201
FIGURES:
1

Reassurance and appropriate followup

1%

(4/353)

2

Sarmiento bracing

1%

(2/353)

3

Use of a bone stimulator

3%

(9/353)

4

Exchange humeral nailing

12%

(44/353)

5

IM nail removal, open reduction internal fixation with bone grafting

82%

(289/353)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
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