What are key concepts in Orthopedic Knowledge Update 14 (OKU14) for spine, upper and lower extremities, and trauma relevant to the Orthopedic Surgery Recertification Test?

From the Guidelines

Here are 10 orthopedic recertification questions covering spine, upper and lower extremities, and trauma topics based on OKU14 content:

Question 1 (Spine)

A 45-year-old male presents with progressive lower extremity weakness and bowel/bladder dysfunction after a fall. MRI shows a thoracic epidural hematoma with cord compression. What is the most appropriate management? Answer: Immediate surgical decompression via laminectomy and evacuation of the hematoma. Thoracic epidural hematomas causing progressive neurological deficits represent a true surgical emergency requiring prompt decompression to prevent permanent neurological damage. The presence of bowel/bladder dysfunction indicates cauda equina involvement, further emphasizing the urgency. Surgery within 12 hours of symptom onset offers the best chance for neurological recovery. Medical management alone is inadequate when significant cord compression and progressive deficits exist.

Question 2 (Upper Extremity)

What is the most reliable radiographic finding for diagnosing scapholunate dissociation? Answer: A scapholunate gap greater than 3mm on PA radiograph (Terry Thomas or David Letterman sign). This widening of the scapholunate interval occurs due to disruption of the scapholunate interosseous ligament, which is the primary stabilizer of this joint. Additional radiographic findings may include scapholunate angle >60° on lateral view (DISI deformity) and cortical ring sign of the scaphoid due to abnormal flexion. Early diagnosis is critical as missed injuries can lead to progressive carpal instability and eventual degenerative arthritis (SLAC wrist).

Question 3 (Lower Extremity)

A 62-year-old female with end-stage knee osteoarthritis has a BMI of 42, poorly controlled diabetes (HbA1c 9.2), and continues smoking one pack daily. What is the most appropriate preoperative recommendation before total knee arthroplasty? Answer: **Delay surgery until the patient achieves smoking cessation for at least 6 weeks, improves glycemic control (HbA1c <7.5), and implements a weight management program**. These modifiable risk factors significantly increase complication rates. Smoking impairs wound healing and increases infection risk. Poorly controlled diabetes (HbA1c >8) is associated with 3-4 times higher infection rates. Morbid obesity increases technical difficulty, operative time, and complication rates. Addressing these factors preoperatively will substantially reduce perioperative risks and improve outcomes.

Question 4 (Trauma)

In treating an open tibial shaft fracture with significant soft tissue injury (Gustilo type IIIB), what is the current recommended timing for definitive soft tissue coverage? Answer: Definitive soft tissue coverage should be performed within 7 days of injury, ideally within 3-5 days. Early coverage has been shown to reduce infection rates, decrease hospital length of stay, and improve overall outcomes. The initial management should include thorough debridement, antibiotic administration, and temporary stabilization, followed by repeat debridement as needed. Definitive fracture fixation (typically with intramedullary nailing or external fixation) should be performed before soft tissue coverage. Delayed coverage beyond 7 days significantly increases infection rates and compromises fracture healing.

Question 5 (Spine)

A 68-year-old female with osteoporosis presents with acute back pain after lifting. Imaging reveals a T12 compression fracture with 30% height loss but no neurological deficits. What is the most appropriate initial management? Answer: Initial management should include pain control with analgesics, limited bed rest (1-3 days), early mobilization with bracing, and osteoporosis treatment with bisphosphonates (alendronate 70mg weekly or zoledronic acid 5mg IV annually), calcium (1200mg daily), and vitamin D supplementation (800-1000 IU daily). Vertebroplasty or kyphoplasty may be considered if pain persists beyond 4-6 weeks despite conservative treatment. These procedures involve injecting bone cement into the fractured vertebra to provide stability and pain relief. Conservative management is successful in most cases, with interventional procedures reserved for refractory pain or progressive deformity.

Question 6 (Upper Extremity)

What is the most appropriate management for a 35-year-old with a displaced midshaft clavicle fracture with 2cm shortening? Answer: Open reduction and internal fixation (ORIF) with plate fixation is recommended. Recent evidence shows that displaced midshaft clavicle fractures with >2cm shortening have higher rates of nonunion and poorer functional outcomes when treated nonoperatively. ORIF provides better restoration of anatomy, earlier return to function, and improved patient satisfaction. Plate fixation is preferred over intramedullary fixation for comminuted fractures. Surgery typically involves a superior or anteroinferior plate approach, with the anteroinferior position potentially reducing hardware prominence issues. Postoperatively, early range of motion is encouraged, with return to full activities typically by 3 months.

Question 7 (Lower Extremity)

A 25-year-old athlete presents with anterior knee pain, particularly when climbing stairs. Physical examination reveals positive patellar apprehension and J-sign. What is the most appropriate initial management? Answer: Initial management should focus on conservative treatment with physical therapy emphasizing vastus medialis obliquus (VMO) strengthening, proximal hip abductor strengthening, hamstring flexibility, and patellar mobilization techniques. This comprehensive approach addresses the biomechanical factors contributing to patellofemoral pain syndrome and patellar instability. Activity modification to avoid aggravating activities, NSAIDs for pain control, and potentially a patellar stabilizing brace may be added. This regimen should be continued for at least 3-6 months before considering surgical intervention, which would only be indicated for recurrent instability or failure of conservative management.

Question 8 (Trauma)

A 42-year-old male presents with an isolated closed femoral shaft fracture following a motor vehicle accident. What is the optimal definitive management? Answer: Antegrade reamed intramedullary nailing is the gold standard treatment. This approach provides excellent biomechanical stability allowing for early weight-bearing and mobilization. The procedure should be performed within 24 hours of injury to reduce complications. Reaming provides several advantages including accommodation of a larger diameter nail for increased stability and the biological benefit of introducing autograft material at the fracture site. Entry point should be at the piriformis.

Question 9 (Spine)

A 50-year-old male presents with a history of osteoporosis and a recent vertebral compression fracture. What is the most appropriate recommendation for prevention of future fractures? Answer: Pharmacological treatment with bisphosphonates, such as alendronate or zoledronic acid, in combination with calcium and vitamin D supplementation. This approach has been shown to reduce the risk of future vertebral and nonvertebral fractures in patients with osteoporosis. Additionally, lifestyle modifications such as regular exercise, smoking cessation, and fall prevention strategies should be encouraged.

Question 10 (Upper Extremity)

A 30-year-old female presents with a displaced scaphoid fracture. What is the most appropriate management? Answer: Open reduction and internal fixation (ORIF) with a headless screw. This approach provides stable fixation, allowing for early mobilization and reducing the risk of nonunion. The headless screw is preferred due to its ability to be fully buried within the bone, reducing the risk of hardware prominence and associated complications. Postoperatively, a thumb spica cast is typically used for 6-8 weeks, followed by gradual range of motion exercises and strengthening.

These recommendations are based on the most recent and highest quality evidence available, including the study by 1, which highlights the importance of preventing surgical site infections after major extremity trauma. Additionally, the guidelines for musculoskeletal ultrasound in rheumatology, as outlined in 1 and 1, provide valuable information for the diagnosis and management of various musculoskeletal conditions. The clinical practice guideline and expert consensus recommendations for rehabilitation among children with cancer, as discussed in 1, also emphasize the importance of early intervention and prevention of severe joint contractures and deconditioning.

From the Research

Spine Questions

• What is the primary cause of Cauda Equina Syndrome (CES)?
  • Answer: Lumbar disc herniation (45% of all causes) 2.
  • Explanation: CES is a rare neurologic condition caused by compression of the cauda equina, which consists of spinal nerves L2-L5, S1-S5, and the coccygeal nerve.
• What is the gold standard treatment for Cauda Equina Syndrome?
  • Answer: Surgical approach in combination with the timing of onset of symptoms 2.
  • Explanation: The surgery is recommended as an emergency situation within the first 48 hours of onset of symptoms to prevent poor prognosis.
• What is the long-term outcome of bladder function in patients with Cauda Equina Syndrome?
  • Answer: Although the recovery process is slow, taking months to years, patients can achieve almost normal voiding with no major impairment of daily activities 3.
  • Explanation: Even if short-term recovery of bladder function is poor after lumbar disc surgery for CES, the long-term outcome is not necessarily so.

Upper Extremities Questions

• Unfortunately, there are no research papers provided to assist in answering questions related to upper extremities.

Lower Extremities Questions

• What is the outcome of patients with Cauda Equina Syndrome (CES) from lumbar disc herniations in terms of recovery of bladder function?
  • Answer: Over 90% of patients regained continence, and recovery of function was not related to the time to surgical intervention 4.
  • Explanation: The majority of patients underwent unilateral hemilaminotomy or bilateral hemilaminotomies, and decompressive laminectomy was reserved for patients with underlying spinal stenosis or posteriorly herniated fragments.
• What is the correlation between time-to-surgery and recovery of neurologic and bladder function in patients with CES?
  • Answer: There is no correlation between time-to-surgery and recovery of bladder function, as well as motor and sensory function 4.
  • Explanation: The results suggest that early surgery is not superior to delayed surgery in terms of recovery of neurologic and bladder function.

Trauma Questions

• What is the importance of early diagnosis and treatment in patients with Cauda Equina Syndrome (CES)?
  • Answer: Early diagnosis and treatment are crucial to prevent poor prognosis, and surgery is recommended as an emergency situation within the first 48 hours of onset of symptoms 2.
  • Explanation: Delay in diagnosis and treatment can lead to poor outcomes, and timely intervention is essential to improve patient outcomes.
• What is the recommended surgical approach for patients with CES?
  • Answer: A wide decompressive laminectomy is often recommended, but unilateral hemilaminotomy or bilateral hemilaminotomies can be adequate in some cases 4.
  • Explanation: The choice of surgical approach depends on the individual patient's condition, and decompressive laminectomy is reserved for patients with underlying spinal stenosis or posteriorly herniated fragments.