Taro 2015 - Corrigido e Comentado

Universidade Federal do Amazonas Hospital Universitário Getúlio Vargas Serviço de Ortopedia e Traumatologia

TARO 2015 – GABARITO BASEADO NAS REFERÊNCIAS

Pesquisado por: José Henrique, Rafael Chang, Sandokan Costa, Érico Melo, Heyder Cabral, Talita Oliveira, Gustavo Oliveira, Eduardo Ditzel, Luis Fernando Tupinambá, Marcelo Gomes, Jaime Menezes e Luiz Felipe Tupinambá

1) A fratura da cavidade glenóide que envolve seu terço superior e inclui o processo coracóide é classificada segundo IDEBERG como tipo: C) III

Fonte: Rockwood and Green’s fractures in Adults 7th ed. 1155 pg. __________________________________________________ __________________________ ______________________________________ ______________

2) A Leucomalácia periventricular é

a lesão característica da:

A) Diplegia

Fonte: Lovell and Winter ’s Pediatric Orthopaedics 6th ed. 554 pg.

__________________________________________________ __________________________ _______________________________________ _______________

3)

A

artropatia

neuropática

do

ombro

está

relacionada

a:

C) Siringomielia cervical

Fonte: Canale & Beaty: Campbell ’s Operative Orthopaedics 11th 1045 pg. __________________________________________________ __________________________ _______________________________________ _______________

4) A síndrome medular central ocorre em idosos por mecanismo de: B) Hiperextensão, e cursa com tetraparesia que afeta mais os membros superiores

Canale & Beaty: Campbell ’s Operative Orthopaedics 12th 1572 pg. __________________________________________________ __________________________ _______________________________________ _______________

5) Nas lesões irreparáveis do manguito rotador envolvendo os tendões supraespinhal e infraespinhal, a transferência muscular quando indicada é feita com o: B) Grande Dorsal

__________________________________________________ __________________________ _______________________________________ _______________

3)

A

artropatia

neuropática

do

ombro

está

relacionada

a:

C) Siringomielia cervical

Fonte: Canale & Beaty: Campbell ’s Operative Orthopaedics 11th 1045 pg. __________________________________________________ __________________________ _______________________________________ _______________

4) A síndrome medular central ocorre em idosos por mecanismo de: B) Hiperextensão, e cursa com tetraparesia que afeta mais os membros superiores


5) Nas lesões irreparáveis do manguito rotador envolvendo os tendões supraespinhal e infraespinhal, a transferência muscular quando indicada é feita com o: B) Grande Dorsal


6) Na luxação glenoumeral anterior, a lesão do ligamento glenoumeral inferior ocorre na(s): C) inserção gleinodal


7) A dor lombar aguda, após exclusão de sinais de alarme, deve ser tratada com: D) Respouso no leito por 1 a 3 dias e progressão para programa de exercícios físicos


8) Na mão torta radial, a estabilização do punho utilizando os flexores superficiais deve incluir preferencialmente os tendões dos dedos: A) Médio e anular

Canale & Beaty: Campbell’s Operative Orthopaedics 12th 3722 pg. _________________________________________________________________

9- O cisto ósseo simples geralmente é detectado quando o paciente apresenta. B) Fratura patológica

Unicameral Bone Cysts UBCs are not always unicameral. They are also called simple bone cysts, but they may not be simple to treat. These common lesions are usually found when the patient sustains a pathologic fracture. Their radiographic appearance is so typical that most can be diagnosed without a biopsy (Fig. 14.26). The proximal humerus and the proximal femur are the sites that account for 90% of UBCs (383, 384, 385, 386, 387). Fonte: Lovell and Winter ’s Pediatric Orthopaedics 6 th ed. Página 526

10-A metastase óssea distal ao joelho ou ao cotovelo geralmente é decorrente de carcinoma C) pulmão The radiographic appearance of metastatic carcinoma varies. The appearance usually is aggressive, suggesting malignancy. The lesions may be lytic, blastic, or mixed. Breast cancer and prostate cancer typically produce blastic lesions. Kidney cancer and thyroid cancer usually are purely lytic. Lung cancer may produce a mixed appearance. If the lesion is distal to the elbow or knee, lung cancer is the most likely primary lesion. Additionally, metastatic lung cancer may have the distinct appearance of a “ bite” taken out of the cortex. Fonte:Canale & Beaty: Campbell’s Operative Orthopaedics 11th ed. Pagina 923

11- O fibroma ossificante localiza-se mais comumente. A) na tíbia

Osteofibrous Dysplasia Kempson (349) described the osteofibrous dysplasia lesion, which is found in the mandible and the anterior cortex of the tibia in children. It is benign, but may be locally aggressive. It is not a healing NOF. The patients usually do not have symptoms, and are brought to the physician's attention by a parent who has noticed an anterior bowing or mass in the tibia. The lesion is almost always located within the anterior cortex of the tibia, and is best seen on the lateral radiograph (Fig. 14.22). There are often numerous radiolucent lesions with a rim

of reactive bone. On the technetium-99 bone scan, there is increased uptake in the area of the lesion. Fonte: Lovell and Winter ’s Pediatric Orthopaedics 6 th ed. Página 521 ________________________________________________________________

12- Durante a puberdade o crescimento do tronco C) é mais acentuado que o crescimento dos membros inferiores.

Puberty During puberty (from 11 to 15 years in girls and from 13 to 17 years in boys) there is a dramatic increase in the growth rate. However, during this period, the growth is far more noticeable in the trunk than in the lower limbs: two thirds of the growth goes toward increasing sitting height and only one third is toward increasing subischial leg length. Fonte: Lovell and Winter ’s Pediatric Orthopaedics 6 th ed. Página 45

13-A fratura osteocondral do tálus na criança é mais comum na região A) Medial

FRACTURES OF THE OSTEOCHONDRAL SURFACE OF THE TALUS Damage to the osteochondral surface of the talus can be caused by direct trauma or may be due to an underlying osteochondal lesion (osteochondritis dissecans [OCD]) that may have been present for some time and has been made symptomatic by the injury. The pathogenesis and etiology of OCD is controversial; however, most authors report preceding trauma as a cause of the defects (Canale and Bedding25 80%, Letts et al.91 79%, Higuera et al. 65 63%, and Perumal et al.123 47%). The medial P.1026 lesion is usually deeper and cup shaped compared to the thinner โ €œwafer โ €• type lateral lesion. The lateral lesion is more often associated with trauma and more symptomatic than the medial lesions. It is postulated that the medial lesions may be due to more repetitive microtrauma. 25,26 Berndt and Harty,12 in 1959, used freshly amputated legs to biomechanically reproduce injuries to the ankle and observe the injuries inflicted. They showed that the anterolateral talus hits the medial aspect of the fibula with dorsiflexion and inversion and that plantarflexion and inversion caused posteromedial osteochondral lesions (Fig. 27-10). Fonte: Rockwood and Wilkins Fractures in Children, 7th ed. Pagina 1026

14-A fratura de estresse no pé da criança gerlmente ocorre A) no colo do segundo metatarsal

STRESS FRACTURES The second metatarsal is the most common bone in the foot to get a stress fracture. This usually occurs at the neck of the metatarsal at the junction of the mobile shaft and rigid metaphysis. Treatment involves rest and partial weight bearing in a moonboot for 4-6 weeks. Fonte: Rockwood and Wilkins Fractures in Children, 7th ed. Pagina 1054 15- A artralgia associada à picada do carrapato geralmente é observada no b) joelho

Lyme Disease Musculoskeletal symptoms include lower extremity cramping and a predisposition for a proximal lower extremity myositis. There may be a monarticular or migratory inflammatory arthritic presentation. Although the knee is most commonly involved, arthralgia in other joints (e.g., shoulder and wrist) frequently occurs and can recur later or become chronic. A chronic synovitis has been described with pannus formation. 16- O raquitismo induzido por medicamentos está principalmente ao uso de

relacionado

b) anticonvulsivantes

DRUG-INDUCED RICKETS Certain antiepileptic medications have been known to produce rachitic changes in children.[16,110,348] Seizure medications that affect the liver may induce the P450 microsomal enzyme system and decrease levels of vitamin D. Hypocalcemia develops, which can aggravate the seizure disorder. Treatment with vitamin D is very helpful. The condition should be suspected in neurologic patients with seizures who begin sustaining frequent fractures.[280,281] Fonte: Herring: tachdjian's pediatric_orthopaedics 4th edition. Pag 1921 _________________________________________________________________

17. A lesão de MONTEGGIA com fratura do terço médio ou proximal da ulna e fratura-luxação posterior da cabeça do rádio, é classificada por BADO como tipo: d) 4 Bado suggested classification into four types (Fig. 57-81): type 1, fracture of the middle or proximal third of the ulna with anterior dislocation of the radial head and characteristic apex anterior angulation of the ulna; type 2, fracture of the

middle or proximal third of the ulna (the apex usually is posteriorly angulated) with posterior dislocation of the radial head and often a fracture of the radial head; type 3, fracture of the ulna just distal to the coronoid process with lateral dislocation of the radial head; and type 4, fracture of the proximal or middle third of the ulna, anterior dislocation of the radial head, and fracture of the proximal third of the radius below the bicipital tuberosity.

Fonte: Canale e Beaty: Campbell’s Operative Orthopaedics 12th ed. 2886pg _________________________________________________________________

18. Na deformidade em botoeira, a imobilização para o tratamento conservador deve manter a IFP em extensão e a IFD: a) livre Buttonhole deformities that are diagnosed early in closed wounds before fixed contractures occur can be treated conservatively. If the patient can show some active extension of the proximal interphalangeal joint, this suggests that an incompletely ruptured central slip may be present. Conservative treatment consists of splinting the proximal interphalangeal joint in full extension while permitting the distal interphalangeal joint to be actively flexed. Fonte: Fonte: Canale e Beaty: Campbell’s Operative Orthopaedics 12th ed. 3294pg ________________________________________________________________

19. A capsulite adesiva do ombro tem maior incidência em: b) mulheres com mais de 50 anos. The incidence of frozen shoulder in the general population is approximately 2%, but several conditions are associated with an increased incidence, including female gender, age older than 49 years, diabetes mellitus (five times more), cervical disc disease, prolonged immobilization, hyperthyroidism, stroke or

myocardial infarction, the presence of autoimmune diseases, and trauma. Individuals between ages 40 and 70 are more commonly affected. Fonte: Canale e Beaty: Campbell’s Operative Orthopaedics 11th ed. 2625pg _________________________________________________________________

20. Na lesão do anel pélvico, as artérias do sistema ilíaco interno mais relacionadas à hemorragia são a glútea: b) superior e a pudenda. Arterial bleeding usually arises from branches of the internal iliac system, with the superior gluteal and pudendal arteries being the most commonly identified source. Fonte: Rockwood and Green’s fractures in adults 7th ed, p1419 _________________________________________________________________

21. No estágio II da insuficiência do tendão do tibial posterior, classificada por JOHNSON e STROM, encontramos no exame físico: c) compensação para inversão do pé utilizando o tibial anterior. Classification systems in general are useful only to the extent that they assist in planning treatment or in predicting the outcome of the condition. The classification system originally developed by Johnson and Strom in 1989 is useful in the management of posterior tibial tendon insufficiency. Stage I disease is characterized by swelling, pain, inflammation, and often effusion within the posterior tibial tendon sheath. Irritability is noted with passive eversion of the foot along the course of the posterior tibial tendon. Mild weakness to manual testing may be present; however, no deformity of the foot is demonstrated when compared with the opposite foot. The patient is able to invert the foot actively on a double-leg toe raise test and is able to perform a single-leg toe raise as described in the next section. Stage II disease is characterized by the loss of function of the posterior tibial tendon and inability to perform a single-leg toe raise. There is attempted compensation by use of the anterior tibial muscle and tendon unit as an accessory inverter of the hindfoot. In stage II disease the hindfoot remains flexible. With the hindfoot in neutral the forefoot can be brought into neutral. Generally, mild lateral or sinus tarsi impingement pain is present. In stage III disease function of the posterior tibial tendon is lost. A fixed hindfoot deformity with valgus abduction occurs and degenerative changes may be apparent on radiographs. Significant lateral sinus tarsi pain is present. Stage IV disease was described by Myerson et al. and involves valgus positioning and incongruency of the ankle joint in addition to stage III findings. Fonte: Canale e Beaty: Campbell’s Operative Orthopaedics 12th ed. 3908pg

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22. Na fratura do antebraço da criança que ocorre por mecanismo indireto, os segmentos mais vulneráveis ao trauma no rádio e na ulna são, respectivamente: a) transição médio-distal e diáfise The primary mechanism of injury associated with radial and ulnar shaft fractures is a fall on an outstretched hand that transmits indirect force to the bones of the forearm.3,70,165 Biomechanic studies have suggested that the junction of the middle and distal thirds of the radius and a substantial portion of the shaft of the ulna have an increased vulnerability to fracture. Fonte: Rockwood and Wilkins’s fractures in children 7th ed p350 _________________________________________________________________

23. Na pseudartrose após osteossíntese intramedular, o exame de imagem com maior sensibilidade para o diagnóstico é a: d) tomografia computadorizada

Não consegui a fonte original citada pelo TARO, mas achei este artigo que cita a TC com 100% de sensibilidade. Computed tomography scans displayed very good diagnostic accuracy. Intraobserver agreement was high (intraclass correlation coefficient = 0.89), the sensitivity for detecting nonunion was 100%, and the overall accuracy was 89.9%. Computed tomography was limited by a low specificity of 62%, as three patients who were diagnosed as having tibial nonunion with computed tomography underwent surgery and were found to have a healed fracture. Fonte: The accuracy of computed tomography for the diagnosis of tibial nonunion. J Bone Joint Surg Am. 2006 Apr;88(4):692-7. Em: http://www.ncbi.nlm.nih.gov/pubmed/16595457 _________________________________________________________________

24. A síndrome de REITER caracteriza-se por conjuntivite, uretrite e sinovite: d) assimétrica no homem Reiter syndrome is described as a triad of conjunctivitis, urethritis, and synovitis. The synovitis usually involves asymmetrically four or fewer joints. Heel pain, back pain, and nail deformities may occur in this syndrome, sometimes making it difficult to distinguish it from psoriatic arthritis. It affects the lower extremity

more often than the upper, and 90% of patients have remission of symptoms after several weeks; in about 10% the disease may become chronic. It is typically found in young men. Surgery rarely is indicated. Fonte: Canale e Beaty: Campbell’s Operative Orthopaedics 12th ed. 3558pg _________________________________________________________________

25. Na fratura diafisária do f êmur, a fixação interna com placa pela via aberta está mais bem indicada na presença de: d) fratura ipsilateral do colo do fêmur Fonte: Rockwood and Green’s fractures in adults 7th ed, p1668

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26. A fratura do colo do fêmur mais frequente na criança, segundo a classificação de DELBET & COLONNA, corresponde ao tipo: b) II

Type II Transcervical fractures are the most common fracture type (45% to 50% of all femoral neck fractures), 50 occur between the physis and are above the

intertrochanteric line, and by definition are consider intracapsular femoral neck fractures. Fonte: Rockwood and Wilkins’s fractures in children 7th ed p772 _________________________________________________________________

27. O granuloma eosinofílico em apresentação isolada é encontrado mais frequentemente: a) no crânio e no fêmur About two thirds of cases are diagnosed in individuals younger than 20 years of age, with most diagnoses made in the 5- to 10-year-old age group. The first symptom is localizing pain, occasionally accompanied by swelling and lowgrade fever. The erythrocyte sedimentation rate may be elevated. The skull is the most common site of involvement, followed by the femur . Approximately 40% of solitary eosinophilic granulomas are found at one of these two sites, and the skull and femur are also most commonly affected in cases with multiple lesions. Fonte: Herring: Tachdjian’s Pediatric Orthopaedics 4th ed, 227pg _________________________________________________________________

28. No mecanismo da luxação anterior traumática do quadril, o membro inferior está posicionado em rotação: d) lateral e abdução Anterior dislocations of the hip are uncommon and, according to Epstein, constitute only 12% of traumatic hip dislocations. They occur with the hip externally rotated and abducted. Fonte: Canale e Beaty: Campbell’s Operative Orthopaedics 11th ed. 3296pg _________________________________________________________________

29) Na ruptura fechada do tendão calcâneo, o mecanismo de lesão mais comum envolve: D) Flexão dorsal do pé com o joelho em extensão. “Most

commonly, the mechanisms of Achilles tendon rupture are pushing off with the weight-bearing forefoot while extending the knee, sudden unexpected dorsiflexion of the ankle, and violent dorsiflexion of the plantar flexed foot, as in a fall from a height. Disruption also can occur from a direct blow to the contracted tendon or from a laceration. ” Fonte: Campbell 12th, pg 2321

30) Na mielomeningocele, as fraturas ocorrem frequentemente na extremidade: A) Distal do fêmur “Patients

with myelomeningocele are susceptible to pathologic fractures of the lower extremities, particularly in the supracondylar femoral and supramalleolar tibial regions. Risk factors include inattention toward insensate parts by the patient or caretakers, joint contracture, postsurgical cast immobilization, and higher levels of paralysis.” Fonte: Tachdjian 5th. pg e136 (1906 do pdf)

31) A Fratura da Clavícula classificada segundo ROBINSON como 3A2 corresponde ao tipo: C) III de Neer

Fonte: Rockwood adulto 8th pg. 1438

32) A fratura de extremidade mais sugestiva de abuso infantil é a: A) Do canto The almost pathognomonic fracture of child abuse is the CML ( Classic Metaphyseal Lesion), commonly termed the “corner ” or “ bucket-handle fracture.”

Fonte: Rockwood criança 8th. pg 248

33) Na avaliação radiográfica do acetábulo, a dissociação entre a linha ilioisquiática e gota de lágrima de Kohler sugerem fratura: D) Da superfície quadrilátera. “Dissociation

of the teardrop and the ilioischial line indicates either rotation of the hemipelvis, or a fracture of the quadrilateral surface.” Anteroposterior (AP) radiograph of the pelvis. 1, iliopectineal line; 2, ilioischial line; 3, teardrop; 4, acetabular roof; 5, anterior rim of the acetabulum; 6, posterior rim of the acetabulum.

Fonte: Rockwood adulto 8th. pg. 1900

34) A ruptura do tendão do quadríceps é mais comumente associada a: A) Uremia, diabetes e hiperparatireoidismo “Quadriceps

rupture is more common in older patients and in patients with systemic disease or degenerative changes. Systemic diseases, such as lupus erythematosus, diabetes, gout, hyperparathyroidism, uremia, and obesity, have been associated with disruption of the quadriceps mechanism. A relationship between prior steroid injection, as well as use of corticosteroids or fluoroquinolone antibiotics, and tendon rupture has been documented. Fonte: Campbell 12th. pg. 2336-2337.

35) Na rigidez pós-traumática da articulação metacarpofalângica, a capsulotomia é contraindicada se o arco de movimento alcançar: D) 60º “METACARPOPHALANGEAL

JOINT CAPSULOTOMY: When metacarpophalangeal joint motion is 60 degrees, capsulotomy is contraindicated because only 60 to 70 degrees of motion usually can be expected after surgery even if the soft tissues around the joint are normal.” Fonte: Campbell 12th. pg 3361 (quadro azul)

36) Na luxação da aticulação acrômio-clavicular do tipo III de Rockwood, existe integridade dos ligamentos coracoclaviculares quando há fratura: D) do processo coracoide “Rarely,

complete AC dislocation will be accompanied by a fracture of the coracoid process rather than by disruption of the CC ligaments. Although the fracture of the coracoid process is difficult to visualize on routine radiographs, its presence should be suspected because of the presence of a complete AC separation and a normal CC distance, as compared with the uninjured shoulder. The ideal radiograph for visualizing the coracoid fracture is the Stryker notch view.” Fonte: Rockwood adulto 8th. pg. 1585

37 - Na confecção da banda de tensão para tratamento da fratura de olécrano, a colocação dos fios de KIRSCHNER em posição muito lateral esta relacionada com: C) Impacto na Tuberosidade bicipital Potential Pitfalls and Preventative Measures. Ten- sion-band wiring can be successful in properly selected patients. To avoid loss of fixation, an anatomic reduction is necessary and this technique should be used only in simple fracture pat- terns. Hardware prominence requiring removal is common. To decrease the incidence of symptomatic hardware, the K-wires should be buried under the triceps and the cerclage wire knots should be buried as well. If the wires are left too prominent on the anteromedial aspect of the ulna, median and ulnar nerve injury is possible. Avoid wires that exit laterally in the region of the biceps tuberosity to prevent impingement or heterotopic ossification and subsequent synostosis.

Fonte:Rockwood and Green’s Fractures in Aduldts 8 th ed. 1218 pg. _________________________________________________________________

38 - O condrossarcoma primário tem seu pico de incidência na faixa etária entre: C) 40 e 60 anos Chondrosarcoma constitutes about 9% of primary malignan- cies of bone, an incidence about half that of osteosarcoma. It is the second most common nonhematologic primary malignancy of bone. It occurs over a broad age range, with peaks between 40 and 60 years for primary chondrosarcoma and between 25 and 45 years for secondary chondrosarcoma. Fonte: Canale e Bealty: Campbell’s Operative Orthopedics 12th. 914 pg.

39) No exame físico da mão, se a articulação interfalângica proximal não flexiona passivamente com a metacarpofalângica em extensão e flexiona passivamente com a metacarpofalângica em flexão, deve-se pensar em: C) Retração dos músculos intrínsecos. “The

proper surgical release of established intrinsic muscle contractures depends on the severity of the contractures. When the contractures are mild (Fig. 74-9), the metacarpophalangeal joints can be passively extended completely, but while they are held extended, the proximal interphalangeal joints cannot be flexed (positive intrinsic tightness test).” Fonte: Campbell 12th . pg 3620

40) Na fratura do colo do fêmur do idoso tratada com redução anatômica e fixação interna, o fator mais frequentemente relacionado à reoperação é a: B) falha de osteossíntese

“Although

AVN (avascular necrosis of neck) is a well-recognized complication, the majority of reoperations are performed for early fixation failure in osteoporotic bone and nonunion.” Fonte: Rockwood adulto 8th. pg. 2047.

41) Na artrogripose, a cirurgia de STEINDLER tem como objetivo a correção da deformidade em: D) extensão do cotovelo.

Procedures to Achieve Active Elbow Flexion: Steindler Flexorplasty. The Steindler flexorplasty produces elbow flexion by transferring the flexor pronator origin from the medial epicondyle to the anterior humerus. It may be useful if the muscle can be isolated preoperatively and the wrist can be stabilized against excess flexion with the radial wrist extensors. Unfortunately, most children with arthrogryposis lack radial wrist extensors, and this transfer produces unacceptable wrist flexion unless these extensors are present. Thus this procedure is rarely indicated.” “

Fonte: Tachdjian 5th. pg e551 (2320 do pdf)

42) A artrose do quadril secundária a OTTO PELVIS ocorre com maior frequência em: a) Mulheres, bilateralmente. “Intrapelvic

protrusio acetabuli can be primary or secondary. The primary form, arthrokatadysis (Otto pelvis), involves both hips, occurs most often in younger women, and causes pain and limitation of motion at a relatively early age.The secondary form can be caused by migration of an endoprosthesis, septic arthritis, or prior acetabular fracture. It can be present bilaterally in Paget disease, arachnodactyly (Marfan syndrome), rheumatoid arthritis, ankylosing spondylitis, and osteomalacia. The radiographic hallmark of protrusion acetabuli is the medial migration of the femoral head beyond the ilioischial (Kohler) line. The deformity may progress until the greater trochanter impinges on the side of the pelvis. Frequently, there is an associated varus deformity of the femoral neck.” Fonte: Campbell 12th. Pg. 209.

43) Na fratura do escafoide, a síndrome naviculocapitato caracteriza-se por: C) Fratura do capitato com rotação do fragmento proximal

NAVICULOCAPITATE FRACTURE SYNDROME AND CAPITATE FRACTURES Although naviculocapitate fracture syndrome is rare, it should be considered among the associated injuries that can occur with a fracture of the scaphoid. Axial compression of a dorsiflexed wrist forces further dorsiflexion, and after the scaphoid fractures, the dorsal lip of the radius forcefully impacts the head of the capitate, causing it to fracture. As the wrist continues into further dorsiflexion, after the scaphoid and the capitate are fractured, the capitate head rotates 90 degrees. The hand, when returned to neutral position, brings the proximal fragment of the capitate into 180 degrees of rotation. This injury can be associated with dorsal perilunate dislocation or fractures of the distal end of the radius. Open reduction is necessary to derotate the capitates fragment. Some surgeons have excised this fragment, but others have replaced it, reduced the scaphoid and capitate fractures, and maintained them with internal fixation or cast immobilization. Osteonecrosis of the capitates may follow such injuries. If sufficiently symptomatic, osteonecrosis of the capitate may be treated with excisionalinterposition arthroplasty or midcarpal or capitate-hamate arthrodesis. Isolated fractures of the capitate are unusual. Nondisplaced fractures of the body of the capitate are treated nonoperatively. Displaced fractures, especially fractures involving the joint, usually require open reduction and internal fixation with Kirschner wires or screws.” “

”

Fonte: Campbell 12th. pg 3417

44) A paresiados músculos biceps braquial e extensores radiais do carpo, assim como a diminuição do reflexo estilo-radial, são características da lesão da raiz: B) C6

Fonte: Rockwood adulto 8th. pg 1689 _______________________________________________________________

45. Na ruptura do ligamento cruzado anterior, a largura do túnel intercondilar é menor D) nas mulheres e interfere na ocorrência de lesão Referência: Campbell ed 11 A number of investigators have studied the epidemiology of anterior cruciate ligament – deficient knees and have implicated gender and femoral intercondylar notch width as factors contributing to injury of the anterior cruciate ligament. Numerous investigators have reported that athletes sustaining noncontact anterior cruciate ligament tears have statistically significant intercondylar notch stenosis. Souryal and Freeman formulated the notch width index, which is the ratio of the width of the intercondylar notch to the width of the distal femur at the level of the popliteal groove measured on a tunnel view radiograph of the knee (Fig. 45101). The normal intercondylar notch ratio was 0.231 ± 0.044. The intercondylar notch width index for men was larger than that for women. They found noncontact anterior cruciate ligament injuries to be more frequent in athletes who had a notch width index that was at least 1 standard deviation below the mean. Shelbourne et al. studied a group of patients who had anterior cruciate ligament reconstruction and found that women had statistically significantly narrower notches than men did, but the incidence of tearing the autograft was the same between groups presumably because a notchplasty had been performed. Data from the National College Athletic Association Injury Surveillance System as well as several studies have shown significantly higher anterior cruciate ligament injury rates in female soccer, basketball, and rugby players than in male players. Possible causative factors for the increased incidence in women may be extrinsic (body move- ment, muscle strength, shoesurface interface, and skill level) or intrinsic (joint laxity, hormonal influences, limb alignment, notch dimensions, and ligament size). Female sex hor- mones (i.e., estrogen, progesterone, and relaxin) fluctuate radically during the menstrual cycle and are reported to increase ligamentous laxity and to decrease neuromuscular performance. _________________________________________________________________

46. No pé torto congênito unilateral tratado pelo método de PONSETI, a órtese de DENIS BROWNE no pé normal deve ser utilizada com rotação lateral de A) 40 graus After removal of the last cast, a foot abduction orthosis (often called a Denis Browne bar and shoes) is prescribed to prevent recurrence of the deformity, to favor remodeling of the joints with the bones in proper alignment, and to increase

leg and foot muscle strength. The orthosis consists of two straight-last open-toe shoes connected by a bar that allows the shoes to be placed at shoulder width (Fig. 23-47). The bar should hold the shoes at 70 degrees of external rotation and 5 to 10 degrees of dorsiflexion. In unilateral cases, the normal foot should be in 40 degrees of outward rotation. Maintaining the feet at shoulder width facilitates foot abduction . The orthosis is worn full time for at least 3 to 4 months, and afterward it is worn at nap and nighttime for 2 to 4 years. Fonte: Tachdjian 4 ed pag. 1081 _________________________________________________________________ 47. Na fratura da diáfise da tíbia, a lesão neurológica mais comum após osteossíntese intramedular é a do nervo D) fibular comum

A lesão neurológica mais comum após a osteossítese intramedular de uma fratura tibial é a lesão do nervo fibular. Koval et al. Documentaram uma prevalência das lesões neurológicas de aproximadamente 30% em uma revisão retrospectiva de 60 pacientes tratados com uma haste intramedular com fresagem, mas afirmaram que, na maioria do casos, eram pequenas neuropraxias sensitivas; 89% dessas lesões foram temporárias e ficaram curadas em 3 a 6 meses. No entanto, 2 pacientes em sua série continuaram a exibir deficiência nervosa um ano depois do procedimento (nível de evidência 4). Fonte:Rockwood 7 ed pag. 1903 _________________________________________________________________ 48. A ruptura da banda sargital do capuz extensor dos dedos da mão ocorre mais comumente do lado B) ulnar do dedo médio Traumatic Dislocation of the Extensor Tendon at the Metacarpophalangeal Joint Traumatic dislocation of the extensor tendon toward the ulnar aspect of the metacarpophalangeal joint occurs most commonly in the long finger. The dislocation usually occurs as a result of a tear in the proximal radial portion of the shroud ligament (sagittal bands) and the more proximal fascia as the finger is suddenly extended against a force, as in a flicking or thumping motion. Ulnar side disruption with radial displacement of the tendon is rare. More violent mechanisms may cause collateral ligament and joint surface injury. If seen within the first few days, this dislocation can be treated effectively with splinting of the metacarpophalangeal joint and wrist in extension for about 3 to 4 weeks, followed by 3 to 4 weeks of removable splinting or buddy taping to the adjacent finger on the radial side in the case of ulnar displacement. If the condition goes undetected and becomes chronic, a repair using a section of the central fibers of

the extensor mechanism at the metacarpophalangeal joint can be successful. Rayan and Murray described three clinical types of sagittal band injuries (Fig. 63-75): type I injuries show no extensor instability, type II injuries are injuries with extensor tendon subluxation, and type III injuries have extensor tendon dislocation. In their series of 28 nonrheumatoid patients, those treated within 3 weeks of injury achieved satisfactory results with nonoperative splinting. Patients with more severe or chronic involvement frequently required operative treatment _________________________________________________________________

49. O fator mais importante para a luxação recidivante da patela é D) a competência do ligamento patelofemoral medial PATELLA Recurrent dislocation of the patella can follow a violent initial dislocation, but it occurs more often in knees with one or more underlying anatomical abnormalities that predispose the patella to dislocation or subluxation. In these knees, minor trauma is needed for the initial dislocation to occur. The underlying pathological condition causes an abnormal excursion of the extensor mechanism over the femoral condyles. Several anatomical factors should be considered when evaluating a patient with recurrent dislocation of the patella. Anatomical studies by Lieb and Berry have shown the contributions of the various portions of the quadriceps muscle to knee extension. They showed that the vastus lateralis pulls laterally to the frontal plane of the femur at an angle of 7 to 10 degrees. The vastus medialis is divided into two parts — the vastus medialis longus (with its muscle fibers pulling at 15 to 18 degrees medially) and the vastus medialis obliquus (with its muscle fibers pulling at a relatively horizontal 50 to 55 degrees medially). The primary function of the vastus medialis obliquus muscle is to stabilize the patella against the lateral pull of the vastus lateralis, making the vastus medialis obliquus the dynamic stabilizer of the patella. Static factors, the primary stabilizers of the patella, include the shape of the patella, the femoral sulcus, a patellar tendon of appropriate length, and a normally tensioned medial capsule reinforced by the patellofemoral and patellotibial ligaments. The main factor that results in recurrent patellar dislocation is incompetence of the medial patellofemoral ligament (MPFL). The MPFL is an extrasynovial ligament, as is the medial collateral ligament. Injury may result in minimal long-term damage with return of full function, mild-to-moderate laxity, or incompetence from avulsion or interligamentous failure with resultant instability. MRI to evaluate the site and extent of injury is indicated for instability. __ _______________________________________________________________

50. Na doença de LEGG-CALVÉ-PERTHES, a subluxação e o achatamento da cabeça femoral ocorrem na fase de B) fragmentação

Waldenström's observation that the clinical course of the disease is variable remains true today.[351] He observed that although some children experienced only minor symptoms and minimal changes in the shape of the femoral head, most had a more severe course, resulting in pain while walking and greater loss of limb motion. Waldenström defined the stages of the disease as shown in Table 17-1. His classification has been modified by most authors to the four stages of initial, fragmentation, healing (reossification), and residual phases. In a retrospective study, we found that the time from first radiographic evidence of disease to the start of fragmentation was a mean of 6 months (range, 1 to 14 months), the fragmentation phase lasted 8 months (range, 2 to 35 months), and the healing stage occupied 51 months (range, 2 to 122 months).[143] Clinical findings correspond to some degree with the radiographic stages of the disease (Table 17-2). During the early stage of the disorder, radiographs show only increased density of the femoral head, and the patient may experience recurrent aggravation and alleviation of symptoms and signs. There may be only mild limp and pain for a time, interrupted by episodes of moderate discomfort lasting a couple of weeks. During the latter phase, a subchondral fracture is frequently noted on radiographs (Salter's sign), and the patient's clinical status may worsen.[307]

Table 17-2 -- Association between Clinical Findings and Radiographic Stages of Disease Stage

Clinical Findings

Radiographic Changes

Increased density stage

Limp and pain variable, Increased density of femoral often mild and intermittent head, with/without subchondral fracture

Fragmentati Pain and limp may worsen; Head shows fragmentation, may on stage may lose range of motion lateralize and flatten Reossificati on stage

Limp and pain gradually Femoral head gradually resolve, range of motion reossifies; flattening of head may improves improve

Healed stage

Occasional limp; occasional May develop locking, popping lesion

osteochondrotic

At the beginning of the fragmentation stage, the femoral head starts to collapse and may extrude from the acetabulum. The patient's limp and pain are more pronounced, and there is a greater loss of range of motion of the affected limb. Because the femoral head is deformed, resting the hip usually does not return normal motion to the joint. In mild cases, where there is minimal change in the shape of the femoral head, symptoms and signs may be limited. Patients who have a very brief fragmentation stage are asymptomatic. In more severe cases, however, clinical symptoms and signs progressively worsen

throughout the fragmentation phase. The beginning of the healing stage is characterized radiographically by the development of new bone in the subchondral regions of the femoral head. By this time, pain and limp have usually started to resolve, but there is still some limitation of motion. The degree of motion restriction is directly related to the extent of change in the shape of the femoral head. Usually the child gradually resumes normal activities without complaints. Symptoms are normally absent as the femoral head becomes completely reossified. If reossification in the central segment of the femoral head is significantly delayed, the patient may begin to experience pain after a number of asymptomatic years. A loose fragment or osteochondritis dissecans lesion may subsequently develop in this soft portion of the head. The child complains of locking and popping of the joint, and crepitus may be present on physical examination. Fonte: Tachjian 4 ed. _________________________________________________________________

51. Na fratura do calcâneo tratada pela via lateral estendida, a principal fonte vascular do retalho fasciocutâneo é a artéria A) calcaneana lateral Lateral Approach The original lateral approach was a standard Kocher approach.62,108,119,121,159 This approach offered limited access to the body of the calcaneus, often resulted in scarring of the peroneal tendons, and frequently damaged the sural nerve. In 1984, Fernandez64 first described the extensile posterolateral approach (Fig. 5923A). In this approach, an incision was made halfway between the fibula and Achilles tendon and starting three fingerbreadths above the tip of the lateral malleolus. This was extended around the malleolus, following the course of the sural nerve and small saphenous vein toward the fifth metatarsal P.2078 base. The sural nerve was identified and protected, and then full-thickness flaps were developed to bone. After the peroneal tendons were dislocated over the tip of the malleolus, the calcaneofibular was cut off the calcaneus and then retracted anteriorly such that the subtalar joint and sinus tarsi were exposed. Seligson described a very similar incision in a report by Gould82 that same year (Fig. 59-23B). The goal of the incision was to expose the entire lateral face of the calcaneus to the level of the calcaneocuboid joint. This approach combines the posterior approach for the ankle, described by Picot in 1924,162 with a unique plantar limb that undulated so that the final closure could be tension free. The incision was made just lateral to the Achilles tendon and carried vertically to the superior pole of the calcaneus. The incision was then curved gently following a line where the thinner skin of the lateral side of the hindfoot met the skin of the

heel pad. The incision was carried to the base of the fifth metatarsal. The author stressed that in the gentle curved portion of the incision, the knife should be taken straight to bone with the skin, subcutaneous layer, and periosteum kept as a single layer. The lateral flap was then developed as a single, P.2079 thick flap. The peroneal tendons were subsequently elevated from the peroneal tubercle and reflected dorsally, while the calcaneofibular ligament was detached from the calcaneus. After subtalar capsulotomy, the entire lateral calcaneus, calcaneocuboid, and subtalar joints were exposed. Many surgeons reported problems with the sural nerve and with wound healing using a form of the lateral approach. 13,186,243 Borelli21 described the arterial blood supply of the subcutaneous tissues of the lateral hindfoot and defined the relationships between these arteries and the lateral extensile incision used for ORIF of calcaneal fractures (Fig. 59-24). Three arteries — the lateral calcaneal, the lateral malleolar, and the lateral tarsal artery — were consistently found along the lateral aspect of the hindfoot. The lateral calcaneal artery appeared to be responsible for the majority of the blood supply to the corner of the flap and, because of its proximity to the vertical portion of the typical incision, it appeared most likely to be injured from inaccurate placement of the incision. As a result of this work, and to protect the sural nerve, the authors recommended that the vertical limb of the incision be started just anterior to the lateral edge of the Achilles tendon and at the crease of the heel pad and lateral foot. This study therefore supports the original description of Seligson.82 Fonte: Rockwood 7 ed _________________________________________________________________

52. O eixo de flexo-extensão do cotovelo no plano lateral encontra-se A) no centro da tróclea The elbow is composed of two independent uniaxial joints. One is the humeroulnar joint, which is a hinged, or ginglymoid, joint. The other consists of the humeroradial and proximal radioulnar articulations, a pivoted, or trochoid, joint, allowing two degrees of freedom in the elbow joint. Motion in the elbow involves rotation of the ulna around the humerus during flexion and extension and rotation of the radius around the ulna during supination and pronation. The instant center of flexion and extension for the elbow is at the center of concentric circles formed by the lateral projection of the capitellum and trochlea of the distal humerus, is about 2 to 3 mm in diameter, and is located in the center of the trochlea when viewed from the lateral aspect (Fig. 8-34). The axis of rotation of the elbow lies anterior to the humeral midline and on a line drawn along the anterior cortex of the humerus. Morrey and Chao found that the carrying angle varied from 11 degrees of valgus with the elbow in full extension to 6 degrees of varus with the elbow in full flexion (Fig. 8-35). The joint surfaces slide until the extremes of full flexion and extension are reached, and then bony impingement occurs. The transverse axis of rotation of the radiohumeral joint coincides with

the ulnohumeral axis. The longitudinal axis of the forearm passes through the radial head proximally and the ulnar head distally and is oblique to the longitudinal axes of the radius and ulna. The normal range of motion of the elbow is from 0 degrees (full extension) to approximately 150 degrees (full flexion). _________________________________________________________________

53) Na artroplastia total do quadril displásico dos tipos 3 e 4 de Crowe, a principal complicaçãoo neurológica é a lesão do nervo D) Isquiático For Crowe type III and type IV hips, femoral length is more problematic. When the prosthetic socket has been placed in the true acetabulum, the femur must be translated distally several centimeters to reduce the prosthetic femoral head into the acetabulum. Often the tissues most limiting this distal translation are the hamstrings and rectus femoris rather than the abductors. In such cases, a femoral shortening osteotomy allows reduction of the femoral head into the true acetabulum without extensive soft tissue release. Osteotomy of the greater trochanter and resection of 2 to 3 cm from the proximal femoral metaphysis may be necessary to permit reduction of the joint without causing undue tension on the sciatic nerve or fracture of the femoral shaft (Fig. 3-77) Fonte: Campbell 11 th ed. Pag. 378 _________________________________________________________________

54) No punho reumatoide a lesão de Mannerfelt é relacionada a ruptura do tendão do D) flexor longo do polegar Although flexor tenosynovitis at the wrist may not be as apparent as that seen on the extensor surface, the bulk of the tenosynovium interferes with finger motion, compresses the median nerve in the carpal tunnel, and leads to tendon rupture. Erosion of the volar capsule and ligaments over radial osteophytes contribute to flexor pollicis longus rupture in the carpal tunnel (Mannerfelt lesion) Fonte: Campbell 11 th ed 4218 _________________________________________________________________

55) As lesões musculares são mais comuns em músculos: D) biarticulares e naqueles com predominância de fibras tipo II

Strains most commonly occur in muscles that cross two joints, in muscles that have a higher percentage of type II fast-twitch muscle fibers , and in the weaker muscle of an agonist-antagonist muscle group. One factor contributing to muscle overload is fatigue, which makes the muscle unable to absorb as much eccentric force before overload. Another factor that can lead to strain in a muscle is intrinsic tightness in the muscle, especially in muscles that cross two joints, such as the hamstrings, the rectus femoris, and the gastrocnemius. ESTA AFIRMAÇÃO EXISTE NO CAMPBELL 11ª ed E FOI OMITIDA NO CAMPBELL 12ª ed Fonte: Campbell 11 th ed. 2747 _________________________________________________________________

56) Uma fratura AO 43A3 com exposição de 3cm e lesão isolada da artéria tibial anterior deve ser classificada, segundo gustilo et al, como do tipo A) II

Fonte: Rockwood 7 th ed. 288 ________________________________________________________________

57) No paciente obeso com fratura subtrocantérica de fêmur, o implante mais recomendado é: B) haste intramedular anterógrada Fonte: Jupter J:. Skeletal Trauma 4 th ed. 2021 _________________________________________________________________

58) Na osteogênese imperfeita classificada segundo SILENCE, a fragilidade óssea é mais grave no tipo: B) II

Fonte: Tachdjian 4th. Pg 1947 _________________________________________________________________

59) Na fratura isolada da cabeça do rádio classificada por MASON como tipo II, é indicação absoluta de tratamento cirúrgico: A) Restrição da rotação do antebraço The indications for open reduction and internal fixation remain controversial. Clear indications include displaced, non- comminuted fractures of the radial head limit forearm rotation, or radial head fractures fixed as a component of the surgical repair of an elbow fracture-dislocation. It has been suggested that fractures displaced greater than 2 mm and involving greater than 30% of the articular surface (a Type II fracture in the modified Mason classification) might be best treated with surgery; however, this remains unproven.

Fonte: Rockwood adulto 7th. Pg 913-914 _________________________________________________________________

60) A osteomielite hematogênica aguda do terço proximal do fêmur apresenta maior possibilidade de evolução para osteonecrose da epífise na faixa etária entre:

a) 0 a 18 meses It is important to bear in mind that continued vigilance is necessary when treating osteoarticular infections of the large joints in this age category, particularly up to age 18 months, when long-term sequelae from osteonecrosis and growth disturbance may result.[16,45,115,135] For this reason, I endorse early aspiration and surgical debridement of the hip and shoulder whenever sepsis is encountered in early childhood. Fonte: Canale & Beaty: Campbell's Operative Orthopaedics, 11th ed. _________________________________________________________________ 61 – O teste de McMURRAY para lesão meniscal do joelho é realizado: B) de flexão para extensão, em decúbito dorsal. The McMurray test (Fig. 43-37) is probably best known and is carried out as follows. With the patient supine and the knee acutely and forcibly flexed, the examiner can check the medial meniscus by palpating the posteromedial margin of the joint with one hand while grasping the foot with the other hand. Keeping the knee completely flexed, the leg is externally rotated as far as possible and then the knee is slowly extended. As the femur passes over a tear in the meniscus, a click may be heard or felt. The lateral meniscus is checked by palpating the posterolateral margin of the joint, internally rotating the leg as far as possible, and slowly extending the knee while listening and feeling for a click. A click produced by the McMurray test usually is caused by a posterior peripheral tear of the meniscus and occurs between complete flexion of the knee and 90 degrees. Popping, which occurs with greater degrees of extension when it is definitely localized to the joint line, suggests a tear of the middle and anterior portions of the meniscus. The position of the knee when the click occurs thus may help locate the lesion. A McMurray click localized to the joint line is additional evidence that the meniscus is torn; a negative result of the McMurray test does not rule out a tear.

Fig. 43-37 McMurray test for meniscal injury (see text). (From Tria AJ Jr: Clinical examination of the knee. In Scott WN, ed: Insall & Scott su rgery of the knee, 4th ed, Philadelphia, 2006, Churchill Livingstone Elsevier.)

Canale & Beaty: Campbell´s Operative Orthopedics 11 th ed. 2424 pg 62 – No cordoma sacrococcígeo, o diagnóstico radiográfico é dificultado pela: A) presença de gás intestinal. Radiographically, chordomas appear as destructive lesions (Fig. 22-11). They virtually always arise from the midline. Sacrococcygeal lesions often are missed on the initial radiographic examination because of overlying bowel gas. They usually are seen more easily on a lateral view of the sacrum. Likewise, radioisotope accumulation in the bladder can obscure a sacral tumor on bone scan. More than 50% of chordomas exhibit radiographically detectable calcification. CT may be better for detecting calcification (which may help with the diagnosis), but MRI is better for determining the full extent of the lesion and its relationship to other anatomical structures. A common pitfall in the evaluation of a patient with a chordoma and low back pain is ordering an MRI of only the lumbar spine; this study usually misses a sacrococcygeal chordoma because most arise below S3.

Fig. 22-11 A and B, Anteroposterior and lateral views of sacrum of patient with sacrococcygeal chordoma. This lesion could be missed easily because of overlying bowel gas. C, MRI clearly shows lesion. D, Typical microscopic appearance of chordoma. Cells with abundant vacuolated cytoplasm (physaliferous cells) are arranged in cords with mucinous background. Canale & Beaty: Campbell´s Operative Orthopedics 11 th ed. 914 pg 63 – Na artroplastia total de joelho, o corte posterior dos condilos femorais deve ser feito com: C) 3° de rotação lateral

Bone Preparation: Bone surface preparation is based on the following principles: appropriate sizing of the individual components, alignment of the components to restore the mechanical axis, recreation of equally balanced soft tissues in flexion and extension, and optimal patellar tracking. TECHNIQUE 6-2

Make the distal femoral cut at a valgus angle (usually 5 to 7 degrees) perpendicular to the predetermined mechanical axis of the femur. The amount of bone removed generally is the same as that to be replaced by the femoral component. If a significant preoperative flexion contracture is present, remove additional bone from the distal femur at this time to widen the extension gap. • The anterior and posterior femoral cuts determine the rotation of the femoral component and the shape of the flexion gap. Excessive external rotation widens the flexion gap medially and may result in flexion instability. Internal rotation of the femoral component can cause lateral patellar tilt or patellofemoral instability. Femoral component rotation can be determined by one of several • methods. The transepicondylar axis, anteroposterior axis, posterior femoral condyles, and cut surface of the proximal tibia all can serve as reference points. If the transepicondylar axis is used, make the posterior femoral cut • parallel to a line drawn between the medial and lateral femoral epicondyles. Determine the anteroposterior axis by drawing a line between the bottom of the sulcus of the femur and the top of the intercondylar notch, and make the posterior femoral cut perpendicular to this axis (Fig. 6-32). When the posterior condyles are referenced, make the cut in 3 degrees • of external rotation off a line between them. A valgus knee with a hypoplastic lateral femoral condyle may lead to an internally rotated femoral component if the posterior condyles alone are referenced (Fig. 6-33). •

Fig. 6-32 Alignment axes in knee with normal condylar shape. Resection perpendicular to anteroposterior axis (AP) or parallel to epicondylar axis (epi) results in resection line (x) that is slightly externally rotated relative to posterior condylar axis (PC). This results in correct positioning of the femoral component. (From Arima J, Whiteside LA, McCarthy DS, et al: Femoral rotational alignment, based on the anteroposterior axis, in total knee arthroplasty in a valgus knee: a technical note, J Bone Joint Surg 77A:1331, 1995.)

Fig. 6-33 Hypoplastic lateral condyle causes relative internal rotation of posterior condylar axis Canale & Beaty: Campbell´s Operative Orthopedics 11 th ed. 265 pg

64 – No ombro, o estabilizador primário da transição ântrero-posterior da cabeça do úmero é: D) o ligamento glenoumeral inferior. The inferior glenohumeral ligament consists of three different components: the superior band, the anterior axillary pouch, and the posterior axillary pouch. 197 This ligament originates from the anteroinferior aspect of the labrum and extends to the inferior aspect of the lesser tuberosity. The inferior glenohumeral ligament complex has been compared to a hammock-like swing that surrounds and supports the humeral head when the shoulder is abducted.199 As such, this ligament has been demonstrated to be the primary stabilizer against anterior and

posterior translation of the humeral head, as well as being a restraint against excessive external rotation of the abducted shoulder.

Rockwood and Green´s fractures in Adults 7 th ed. 1165-66 65 – Na fratura do processo odontóide, a fixação com parafuso é contraindicada se houver: D) traço de fratura de ântero-inferior para póstero-superior. Indications: Beyond the general surgical indications outlined earlier, anterior odontoid screw fixation requires additional consideration of several factors. Concerning fracture pattern, transverse fractures or oblique fractures in which the fracture line runs from anterosuperior to posteroinferior can be stabilized by an odontoid screw. Importantly, odontoid screws are contraindicated in fractures that pass from anteroinferior to posterosuperior, as compression will worsen fracture displacement (Fig. 42-44). Nearly anatomical reduction is required for odontoid screw insertion. As screw trajectory is a critical factor, screw insertion may not be technically possible in patients with barrelshaped chests or

pronounced cervical kyphosis. Odontoid screws are most appropriate for type II fractures. They should not be considered for type I and most type III fractures. Some type III fractures that pass through the superior aspect of the C2 vertebral body (closer to the odontoid waist) are amenable to screw fixation.

Rockwood and Green´s fractures in Adults 7 th ed. 1350 66 – Na incidência radiográfica em perfil da escápula, a posição da cabeça do úmero em relação ao centro do Y é: D) central.

FIGURE 38-17 Interpretation of the scapula lateral, also known as the “Y” view radiograph. The obtained view of the scapula is projected as the letter Y. As shown in the schematic (A), the lower limb represents the scapula body whereas

the upper limbs represent the coracoid process and the scapular spine. Scapula lateral radiograph of a cadaveric scapula (B) highlights the fact that the glenoid surface lies in the middle of the letter Y. Therefore in these radiographs, the humeral head should lie directly over the glenoid in the middle of the Y (C).

Fonte: Rockwood and Green´s fractures in Adults 7 th ed. 991

67 – Na displasia do desenvolvimento do quadril diagnosticada tardiamente, o obstáculo intra-articular mais significativo para a redução é: A) a constrição da cápsula articular. Late Diagnosis - In the late-diagnosed case, the c:maa.rticular obstacles to reduction include the contracted adductor longus and the iliopsoas. These muscles are shortened because of the hip being in the subluxated or dislocated position, allowing secondary muscle shortening. The intr.wticular obstacles to reduction in late-diagnosed DDH include the ligamenwm teres, the trans\lerse acetabular ligament, the constricted anteromedial joint capsule, and, rarely; an inverted and hypertrophied labrum (32, 120). The most significant intraarticular obstacle ro reduction, however, is some degree of anteromedial hip capsular constriction (32, 121-125). The ligamentum teres may be thickened, and it may become the primary obstacle to reduction in some cases. In children of walking or crawling age, the ligamentum teres may be significandy elongated and enlarged. Its sheer bulk precludes concent.ric reduction without excision of the ligament. The t.tansverse acetabular ligamenrum may hypert.tophy secondary to the constant pull of the ligamentum teres on its attachment at the base of the acetabulum (32, 125). This efli:ct decreases the diameter of the acetabulum.

Fonte: Lovell and Winter´s Pediatric Orthopaedics 7 th ed. 991pg 68 – A deformidade em rotação interna dos ossos da perna é associada ao pé: B) torto congênito. Controversy exists concerning the presence or absence of excessive medial or internal tibial torsion. Evidence for[76,97,103] and against[27,66,154] this deformity has been reported, and it is our experience that true medial tibial torsion can exist in the presence of clubfoot but is generally unusual. More important is the intra-articular (interosseous) deformity known as medial, or internal, spin. This deformity, which involves both the talus and the calcaneus within the mortise, is also a source of controversy.

Fonte: Herring: Tachdjian´s Pediatric Orthopaedics 11 th ed 1103pg

69) Na fratura Toracolombar avaliada segundo a classificação de distribuição de carga (Load Sharing Classification), a via anterior é indicada quando o somatório de pontos é: D) > 6 Other classification systems have been developed with the goal of guiding treatment and providing prognostic information about these injuries. After reviewing the radiographs and CT scans of 100 thoracolumbar fractures, McAfee 105 et al. separated these injuries into six discrete groups: wedge-compression, stable and unstable burst, Chance, flexion – distraction, and trans- lational. With its emphasis on the mechanism by which the middle column failed, this scheme was able to determine which type of instrumentation (i.e., distraction or 106 compression) was most suitable for each fracture. McCormack et al. devised the “load-sharing classification,” which uses a grading system to assess vertebral body comminution, displacement of bony frag- ments, and posttraumatic kyphosis as a means of establishing which injuries may be appropriately managed with immobilization alone or short-segment transpedicular constructs limited to the levels immediately above and below the fracture site (Fig. 45-13). By identifying cases that were complicated by implant breakage, the authors suggested that a point total greater than 6 required a concomitant anterior arthrodesis with a strut graft. The load sharing classification algorithm has since been vali- dated by both in vitro biomechanical experiments and other clinical series” “

Fonte: RW 8ª Edição, 1768 p.

_________________________________________________________________ 70) A complicação nervosa mais frequente observada na lesão de Monteggia é a lesão do: D) Interósseo Posterior no entanto, o nervo Interósseo Posterior é, de longe, o mais comumente lesionando, especialmente em associação com uma fratura-luxação de Monteggia” “…


_________________________________________________________________ 71) Na infecção vertebral, a principal via de disseminação é: A) Hematogênica Arterial

Spinal infection can occur by direct infection of the disc itself, usually through surgical manipulation directly or percutaneously, or by local spread from contiguous structures. Contiguous spread has been reported to occur from the colon via subphrenic abscesses and from abdominal abscess extension from gunshot wounds without direct spinal injury. The most common method of spinal infection is through the arterial spread of pyogenic bacteria . This arterially spread infection originates in the end plate of the vertebra, probably in the venous channels, or in the vertebral body itself and spreads to the disc secondarily as the infection progresses.” “

Fonte: Campbell 12ª Edição, 1967 p.

_________________________________________________________________ 72) Na fratura diafisária proximal do radio, o desvio do fragment superior ocorre pela ação dos músculos: D) Supinador e Bíceps Braquial Em fraturas da parte superior do radio, abaixo da inserção do supinador e acima da da inserção do pronador redondo, dois músculos robustos (biceps e supinador) exercem uma força sem obstáculo que promove a supinação do fragmento radial.” “

Fonte: RW, 7ª Edição, 887 p.

_________________________________________________________________ 73) A Doença de Dupuytren caracteriza-se por: C) Acometer 10x mais os homens Commonly occurring in adults in their 40s to 60s, Dupuytren contracture occurs 10 times more frequently in men than in women.” “


_________________________________________________________________ 74) Na fratura da extremidade proximal do úmero, a complicação mais comum é: B) Rigidez Articular The most common complication of proximal humeral fractures is loss of motion (stiffness). Early physical therapy is associated with improved motion, but many patients do not recover full motion even with early physical therapy. Impinge- ment from high-riding tuberosities or subacromial scarring also can limit motion” “


_________________________________________________________________ 75) O padrão mais simples de fratura-luxação do cotovelo é: B) Luxação Posterior com Fratura da Cabeça do Rádio O padrão mais simples de fratura-luxação do cotovelo é a luxação posterior do cotovelo com fratura da cabeça do radio” “


_________________________________________________________________ 76) A principal complicação da artroplastia semiconstrita do cotovelo é: B) Soltura A principal complication of constrained total elbow arthroplasty has been loosening, usually of the humeral component (Table 12-7). For semi-constrained prostheses, loosening of the humeral component, previously the most common cause for revision, has been reduced to less than 5% overall with improvements in prosthesis design, changes in operative technique, and better understanding of the anatomy and function of the elbow.” “


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77 – Na escoliose idiopatica do adolescente, o risco de progress da deformidade entes da maturidade esquelética está associado com C) Acometimento do sexo feminino Adolescent Idiopathic Scoliosis

Prevalence The prevalence of radiographic curves measuring at least 10 degrees ranges from 1.5% to 3.0%, that of curves exceeding 20 degrees is between 0.3% and 0.5%, and that of curves exceeding 30 degrees is between 0.2% and 0.3%. A definite relationship between idiopathic scoliosis and sex has been noted, particularly as the magnitude of the curve increases. The ratio of affected females to males has been reported to be 1 : 1 for curves between 6 and 10 degrees, 1.4 : 1 for curves between 11 and 20 degrees, 5.4 : 1 for curves exceeding 21 degrees but not requiring treatment, and 7.2 : 1 for curves requiring orthopaedic intervention. 650 This sex prevalence in idiopathic scoliosis — that is, an equal prevalence between the sexes for small curves (<10 degrees), with increasing female prevalence for larger and progressive curves — has been reported by several authors.29,162,454,650 The clinical significance of these observations is that curve progression is more common in girls. Natural History Few current natural history studies have examined curve progression in the untreated, skeletally immature scoliosis population,96,455,534 and consensus is lacking in the literature regarding the definition of curve progression. Measurable increases in curve size of 5, 6, and 10 degrees have all been reported as being representative of progression.* Most studies use increases of more than 5 or 6 degrees as indicative of definite progression. Fonte: Herring: Tachdjian`s Pediatric Orthopaedics 5th Ed. Página 206

78 – Na Tibia vara de Blount o Angulo de LEVINE-DRENNAN A) Pouco confiável quando usado isoladamente Levine and Drennan measured the tibial metaphyseal – diaphyseal angle (MDA), the angle created by the intersection of a line connecting the most prominent medial portion of the proximal tibial metaphysis (the “ beak ”) and the most prominent lateral point of the metaphysis with a line drawn perpendicular to the long axis of the tibial diaphysis (Fig. 22-5). Blount lesions visible on radiographs subsequently developed in 29 of 30 patients whose MDA was greater than 11 degrees, whereas such changes developed in only 3 of 58 patients with an angulation of 11 degrees or less.131 However, subsequent studies measuring the MDA, the tibiofemoral

angle, or the mechanical axis have not improved early detection of infantile tibia vara,135,185 nor have radiographic measurements been helpful in establishing the severity of disease once the condition is present. Any limb malrotation during radiographic examination can affect the measured MDA and the tibiofemoral angle.94,212 Thus, although measurement of the MDA may have some prognostic accuracy,71 it has not by itself been reliable to diagnose impending infantile tibia vara.61,6

Fonte: Herring: Tachdjian`s Pediatric Orthopaedics 5th Ed. Página 714-16

79- Na fratura supracondiliana do úmero em extensão, o desvio mais comum do fragmento distal é D) Posterior e Medial

Extension type: Hyperextension occurs during fall onto an outstretched hand with or without varus/valgus force. If the hand is pronated, posteromedial displacement occurs. If the hand is supinated, posterolateral displacement occurs. Posteromedial displacement is more common. Generally, medial displacement of the distal fragment is more common than lateral displacement, occurring in approximately 75% of patients in most series. Fonte: Rockwood and Wilkin`s fractures in Children 8th ed. Página 583

80- A fusão do arco posterior do atlas ocorre na faixa etária entre A) 3 a 4 anos

Atlas The atlas ultimately comprises three ossification centers, one for each lateral mass and one for the body, which does not appear until 1 year of age. The posterior arches fuse by approximately 3 or 4 years of age, and the lateral masses fuse to the body at the neurocentral synchondroses at age 7 years 103 (Fig. 11-1). As a result the final internal diameter of the atlas is present by approximately age 7 years, whereas further growth of the external diameter of the atlas occurs through appositional bone deposition. Fonte: Herring: Tachdjian`s Pediatric Orthopaedics 5th Ed. Página 167

81 – O corte transversal do radio nas suas porções proximal, média e distal é respectivamente: C- Cilíndrico, Triangular e Oval Anatomy The anatomy of the forearm is responsible for some of the unique features of fractures of the forearm. Fractures are more common distally for several reasons. First, although both bones are thick-walled throughout the greater part of their shafts, the cross section of the radius flattens distally. Proximally, it is cylindric; it becomes triangular in the midshaft and ovoid distally. This geometric change produces a structural weakness in the radius that has been shown to fracture first in both-bone forearm fractures.260 Second, the muscular envelope of the proximal part of the forearm provides more protection to the underlying bone than distally, where it becomes tendinous. Fonte: Herring: Tachdjian`s Pediatric Orthopaedics 5th Ed. Página 1333

82 – Na síndrome do túnel radial, a compressão do nervo interósseo posterior ocorre D) Na origem do músculo extensor radial curto do carpo According to Spinner, posterior interosseous nerve entrapment is of two types. In one type, all the muscles supplied by the nerve are completely paralyzed; these include the extensor digitorum communis, extensor indicis proprius, extensor digiti quinti, extensor carpi ulnaris, abductor pollicis longus, and extensor

pollicis brevis. In the second type, only one or a few of these muscles are paralyzed. Entrapment of the posterior interosseous nerve can cause chronic and refractory tennis elbow. Such entrapment is called radial tunnel syndrome and can occur at four potentially compressive anatomical structures: (1) the origin of the extensor carpi radialis brevis, (2) adhesions around the radial head, (3) the radial recurrent arterial fan, and (4) the arcade of Frohse as the posterior interosseous nerve enters the supinator Fonte Oficial: Canale & Beaty: Campbell`s Operative Orthopaedics 11th ed Pag 3981 Fonte Utilizada: Canale & Beaty: Campbell`s Operative Orthopaedics 12th ed Pag 3100

83- Nas fraturas da metáfise proximal da tibia em crianças, a complicação tardia associada a interposição da pata de ganso é c) Deformidade em Valgo Recent studies suggest that the postfracture tibia valga is the result of an injury to the pes anserinus tendon plate. It is suggested that the pes anserinus tethers the medial aspect of the physis, just as the fibula appears to tether the lateral aspect of the proximal tibial physis. Multiple authors believe that the proximal tibial fracture disrupts the tendon plate, producing a loss of the tethering effect. This, then, may lead to medial physeal overgrowth and a functional hemichondrodiastasis (physeal lengthening).6,27,29,158,164 Exploration of the fracture, followed by removal and repair of the infolded periosteum that forms the foundation of the pes anserinus tendon plate, has been suggested as an approach that may decrease the risk of a developmental valgus deformity. This theory is supported by the work of Houghton and Rooker, who demonstrated that division of the periosteum around the medial half of the proximal proximal tibia in rabbits induced a valgus deformity. They hypothesized that the increasing valgus angulation was because of a mechanical release of the restraints that the periosteum imposes on activity of the physis.71 Fonte Oficial: Skeletal Trauma in Children 5th Página 440 Fonte utilizada para a resposta: Fonte: Rockwood and Wilkin`s fractures in Children 8th ed. Página 1141

84 – A vascularização da cabeça do femur depende predominantemente dos vasos capsulares localizados nas regiões d) Superior e Posterior

Injury to the vascular supply of the femoral head is an important factor in hip dislocations. In adults, the primary blood supply to the head derives from the cervical arteries. These arteries originate from the extracapsular ring at the base of the femoral neck (Fig. 48-15). This ring is formed by contributions from the medial femoral circumflex artery (MFCA) posteriorly and the lateral femoral circumflex anteriorly.84 The capital vessels traverse the capsule close to its insertion on the neck and the trochanteric ridge and ascend parallel to the neck, entering the head adjacent to the inferior articular surface.35,73,78 The superior and posterior vessels, which are derived primarily from the MFCA, have been shown to be the dominant blood supply to the femoral head.67,70,90 In addition, the MFCA supplies the inferior retinacular branch that runs along the ligament of Weitbrecht and supplies the inferior medial portion of the femoral head.67,70,90 In addition to the cervical vessels, a minor contribution to the head arises from the foveal artery, a branch of the obturator artery that lies within the ligamentum teres. This artery makes a significant contribution to the epiphyseal portion of the femoral head vasculature in approximately 75% of hips

Fonte: Rockwood and Wilkin`s fractures in Adult 8th ed. Página 1996

85) É contrindicacao absoluta para artroplastia total do joelho: d) Recurvato por fraqueza muscular

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86) Na hérnia discal cervical, a compressão nervosa de C6 causa alteração da sensibilidade no dedo:

d) Indicador _________________________________________________________________ 87) Na doença de SCHUERMANN, o diagnostico mais comum é: a) cifose postural

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88) No pé diabético, segundo a classificacao de WAGNER, a presença de exposição de tendões corresponde ao grau: b) 2

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89) Na fratura do planalto tibial, o acesso póstero-lateral é realizado no intervalo entre os músculos: d) gastrocnêmio lateral e bíceps femoral

_________________________________________________________________ 90) A fratura da tuberosidade da tíbia em crianças classificada por SALTERHARRIS como tipo I, corresponde na classificação de WATSON-JONES ao tipo: d) IV

_________________________________________________________________ 91) No hálux rígido, segundo a classificação de COUGHLIN e SHURNAS, a presença de dor mais constante, moderada diminuição do espaço articular e moderada restrição da mobilidade, corresponde ao grau:

b) 2

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92) O tratamento cirurgico da fratura de coluna vertebral secundaria à osteoporose está indicado na presença de d) dor refrataria ao tratamento conservador

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93) Nas fraturas do tornozelo, é considerado parâmetro radiografia de boa redução o: d) espaço entre a parede medial da fíbula e a superfície da incisura da tíbia de 3mm no AP.

_________________________________________________________________ 94) Na pesquisa clinica da ruptura do tendão calcâneo, pede-se para o paciente em decúbito central e com as pernas fora da mesa de exame que realize a flexão ativa dos joelhos até 90º. Neste momento observa-se a posição do pé, se está em flexão plantar, neutro ou flexão dorsal. este teste foi descrito por:

a) Matles

_________________________________________________________________ 95) A Sindactilia da mão ocorre mais frequentemente entre o:

c) 3º e 4º dedos

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96) A doença de Kienbock ocorre mais frequentemente em: a) Mulheres entre 15 e 40 anos

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97) Nas fraturas difamarias estáveis do fêmur acima dos 11 anos de idade, tratamento definitivo recomendado é c) osteossintese intramedular rígida com entrada trocantérica

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98) Na síndrome compartimentar aguda, o coeficiente Delta-P é obtido subtraindo-se a pressão d) intracopartimental da pressão arterial diastólica

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99) A fratura do termo distal do rádio na criança tem indicação de tratamento emergencial quando houver:

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