– Respostas

1- A

2- anulada

3- D

4- C

Ângulo de varismo do hálux: definido como a intersecção dos eixos longitudinais da diáfise do primeiro metatarsal com a diáfise da falange proximal. Quantifica a deformidade da articulação metarsofalangiana do hálux. Considera-se normal até 15 graus.

5- C  

Treatment of an osteochondral lesion depends on a variety of factors, including the characteristics of the patient (activity level, general health, age) and the lesion (size, location, associated degenerative changes).

6- C 

7- D

8- D

In a very young child (birth to 6 months), a Pavlik harness can be used instead of a spica cast with cited advantages of ease of application without anesthesia; minimal hospitalization (<24 hours); easy reduction; ability to
adjust the harness; minimal costs; and ease in diaper changing, nursing, and bonding. Our institution investigated the use of a Pavlik harness for femoral fractures in children under 6 months of age and found excellent clinical results with minimal complication rates. Parent reliability and compliance, however, must be carefully considered before using this method of treatment. 

9- D

10- A

11- A

12- D

Durante a marcha normal, a superfície articular do joelho carrega 4,5 a 6,2 vezes o peso do corpo; 72,2% do peso concentra-se no compartimento medial porque o eixo varo, e também se somam ao momento adutor. 

13- C

14- C

O teste ativo do músculo piriforme é realizado com o paciente promovendo força contra a resistência de abdução e rotação externa do quadril, sendo o teste positivo quando apresente dor local e fraqueza

15 – B

16- D

Hay lateral transgluteal approach to hip. A, Skin incision. B, Greater trochanter is exposed with gluteus medius attached to it proximally and vastus lateralis distally. Broken line indicates incision to be made in soft tissues. C,
Rectangular slices of greater trochanter have been elevated anteriorly and posteriorly. D, Hip joint has been opened and can be dislocated as described. (Modified from McLauchlan J: The Stracathro approach to the hip, J Bone Joint Surg 66B:30, 1984.) 

17- A

O sinal arqueado consiste em uma lucência linear por meio da cabeça da fíbula, que pode ser mais adequadamente apreciada nas radiografias AP, sendo indício de fratura por avulsão da cabeça da fíbula. 

18- B

19- A

Most patients with nonoperative management for nondisplaced or minimally displaced radial head fractures have good to excellent forearm range of motion and no signs of posttraumatic arthritis in long term follow-up.1,6,48,61 The most encountered adverse outcome in nonoperatively treated Mason 1 radial head fractures is elbow stiffness, due to elbow capsular contracture. 

20- B

21- B

The leg anterior compartment is recommended due to evidence suggesting it is the most commonly involved compartment and is readily accessible. 

22- B

23- D

Current consensus is that containment of the femoral head within the acetabulum throughout the disease process is the goal to allow remodeling of the femoral head 

24- A

25- B

In general, more than 25 degrees of kyphosis (15 degrees if there is >50% collapse of the anterior vertebral body) or 50% canal compromise is thought to preclude conservative treatment. 

26- C

27- C

A região para colocação dos pinos anteriores é a região anterolateral do crânio 1 centímetro (cm) superior à margem supraorbitária, evitando o nervo supratroclear, ramo zigomaticotemporal. Os pinos posteriores devem ser colocados na região posterolateral do crânio de maneira que fiquem em oposição aos anteriores. O halo deve estar acima da orelha.

• Selecione o tamanho ideal da coroa; ela deve permitir um espaço de pelo menos 1 cm entre a cabeça e o dispositivo.
• Raspe a cabeça com tricótomo
• Faça rigorosa assepsia e e antissepsia dos locais onde serão colocados os
pinos.
• Marque com caneta
• Injete lidocaína com vasoconstritor nos pontos marcados, infiltre pele e
periósteo.
• Posicione rigorosamente o halo enquanto os auxiliares colocam os pinos de
maneira opositora em diagonal. O uso de um torquímetro de 8 libras é ideal. A colocação sem torquímetro exige que a instalação seja feita por um cirurgião experiente.
• Os pinos devem penetrar apenas a tábua externa; pinos opostos devem ser
apertados simultaneamente.

28- C 

The anterior interosseous nerve provides motor function to the index flexor digitorum profundus, the flexor pollicis longus, and pronator quadratus and is best tested by having the patient make an OK sign.

29- D

Torode I (avulsion fractures): avulsion of the bony elements of the pelvis, invariably a separation through or adjacent to the cartilaginous growth plate.
Torode II (iliac wing fractures): resulting from a direct lateral force against the pelvis, causing a disruption of the iliac apophysis or an infolding fracture of the wing of the ilium.
Torode III-A (simple anterior ring fractures): This group involved only children with stable anterior fractures involving the pubic rami or pubic symphysis.
Torode III-B (stable anterior and posterior ring fractures): This new group involved children with both anterior and posterior ring fractures that were stable.
Torode IV (unstable ring disruption fractures): This group of children had unstable pelvic fractures, including ring disruptions, hip dislocations, and
combined pelvic and acetabular fractures.

30- C

31- B

32- D

An overall complication rate in total elbow arthroplasty of up to 43% has been reported, including an 18% revision ― ‖ w a-analysis reported a 13.5% revision rate, with aseptic loosening, infection, and periprosthetic fracture as the most common indications for reoperation. In contrast, the most commonly encountered complications include ulnar neuritis and triceps insufficiency.
Perioperative mortality has been reported to be 0.6% and is most commonly caused by cardiac complications.
Patients with rheumatoid arthritis have higher infection rates than those with posttraumatic sequelae; however, total elbow arthroplasty performed for posttraumatic arthritis is more likely to require reoperation.

33- C

34- D

35- A

36- B

37- D

38- A

Prostaglandins are inflammatory mediators present during the initial phases of fracture healing. Their synthesis from arachidonic acid is catalyzed by the cyclooxygenase (COX) enzymes. Both traditional NSAIDs and selective COX-2 inhibitors have been found to interfere with COX-2 upregulation and therefore
prostaglandin synthesis, including such synthesis in healing bone.

39- C

According to Rettig and Raskin, isolated radial shaft fractures located within 7.5 cm of the lunate facet of the distal radius are at increased risk for DRUJ disruption. In addition, Moore et al. in a cadaveric model noted 5 mm of radial shortening on a standard posterior-anterior (PA) wrist radiograph correlated with a higher incidence of DRUJ injury

40- B

The collateral ligaments originate on the lateral aspect of the head of the proximal phalanx and insert onto the lateral and palmar aspects of the middle phalanx, volar to the axis of rotation. The lateral collateral ligaments are the primary stabilizers in the coronal plane.

41- A

42- C

43- A

44- D

45- C

46- C

47- A

The proximal humeral epiphysis does not become radiographically apparent until approximately 6 months of age.
Furthermore, the greater and lesser tuberosities have their own distinct secondary centers of ossification, which become visible at 1 to 3 years and 4 to 5 years of age, respectively. The greater and lesser tuberosities coalesce between 5 and 7 years of age, and subsequently fuse to the rest of the humeral head between 7 and 13 years of age.

48- C

Concomitant fractures occur in over one-half of posterior elbow dislocations. The most common fractures involve the medial epicondyle, the coronoid process, and the radial head and the neck. Fractures involving the lateral epicondyle, lateral condyle, olecranon, capitellum, and trochlea occur less frequently. 

49- C

Letterer-Siwe disease, another variation, usually has its onset before 3 years of age and is characterized by fever, lymphadenopathy, hepatosplenomegaly, and multiple bone lesions. Letterer-Siwe disease frequently is rapidly fatal.

50- D

51- C

52- B

53- C

54- D

Rhabdomyosarcoma varies considerably in frequency and type among different age groups. Microscopically, it can be subdivided into three main types: embryonal, alveolar, and pleomorphic. Some tumors have mixed features.
The embryoal and alveolar types occur in children and adolescents and are among the more common malignant tumors in these age groups. The classic pleomorphic type occurs in adults and is rare.
Rhabdomyosarcoma is usually found within a muscle but may secondarily involve the skin.

55- B

56- C

57- anulada

As for all posterior approaches, the ulnar nerve requires identification and protection to avoid iatrogenic nerve injury during fracture manipulation and fixation (see Fig. 38-15B). It remains unclear whether the ulnar nerve should be
transposed or replaced in the cubital tunnel at the conclusion of the procedure. Wiggers et al. demonstrated that the occurrence of postoperative ulnar neuropathy was independent of whether or not the ulnar nerve was
transposed at the time of fracture fixation.245 Conversely, Chen et al.35 reported a four times increase in the rate of postoperative ulnar neuropathy after transposition. Presently, as there exists no level 1 published evidence for or against transposition, it is our preference to conduct a formal

58- C

59- B

60- A

O nível de C7-T1, raiz de C8, inerva o dedo anular, o mínimo e a face medial do antebraço. Tem como área motora os flexores dos dedos e os músculos intrínsecos da mão. Não há reflexo nesse nível. A raiz de T1 é responsável pelo último nível no membro superior, sendo sua área sensitiva a face medial do braço e motora os abdutores dos dedos; nesse nível, também não há reflexos.

61- D

Parathyroid hormone (PTH) regulates mineral homeostasis through calcium and phosphate release from bone, and PTH has profound effects on bone deposition and resorption. Continuous exposure to PTH leading to bone loss due to osteoclast activity has been recognized for a long time.55 Patients with hypoparathyroidism have increased bone mass.69 These observations suggest that decreasing PTH levels may stimulate bone healing, but paradoxically, intermittent PTH treatment leads to bone deposition due to increases in osteoblast activity.131 This property has been exploited clinically, and intermittent treatment with PTH or the active portion of the molecule (PTH1-34 [teriparatide]) is used to stimulate bone formation in osteoporotic patients.35,98,215,265 These data have suggested that PTH and PTH (1-34) may be a useful approach to stimulate fractures.

62- D

63- C

Classic arthrogryposis, or amyoplasia, presents with well-recognized musculoskeletal abnormalities. These brighteyed, intelligent children always have contractures of the extremities and usually have a midline cutaneous hemangioma on the forehead. The most frequent posture is that of elbow extension, wrist flexion and ulnar deviation, knee extension or flexion, and equinovarus foot deformities

64- B

65- C

66- B

Para determinar a congruência e aconselhar o tratamento conservador, pode-se usar o método de Matta e colaboradores13 e Olson e Matta15 ou o da coxometria. O primeiro consiste em medir o arco do teto acetabular.
As medidas podem ser feitas por radiografias em posições anteroposterior, alar e obturatória e por TC. As medidas do arco do teto são úteis para a maioria das fraturas, exceto para aquelas de ambas as colunas e da coluna posterior. Para estabelecer que o ângulo de Matta permite o tratamento conservador, considera-se o seguinte:
– Com o paciente sem tração, a cabeça do fêmur deve permanecer congruente no acetábulo.
– Medidas dos arcos anterior, posterior e medial devem ter valor maior do que 45°.
– A parede posterior deve ser avaliada em separado, pois essa área está fora do arco de Matta.
Os autores consideram que 45° é o valor mínimo para que a cabeça femoral se mantenha estável. Abaixo desse ângulo, ela não ficará reduzida dentro do acetábulo.

67- B

68- A

69- C

70- D

Broden’s view, which is an oblique radiograph of the hindfoot, is used to assess the integrity of the posterior facet of the subtalar joint. To obtain this view, the patient is positioned supine and the cassette is placed under the leg
and ankle, with the lower leg internally rotated to 30 to 40 degrees. The x-ray beam is centered on the lateral angle and four views are then taken angling the beam at 40, 30, 20, and 10 degrees cranial. The sequential views are able to show the posterior articular facet moving from anterior to posterior and any associated fracture displacement, depression, or subluxation can be seen

71- D

72- C

O aparecimento ou a melhora da dor radicular durante os movimentos de inclinação lateral estão intimamente relacionados com a posição do fragmento herniado do disco intervertebral em relação à raiz nervosa. Quando a protrusão do disco for lateral à raiz nervosa, os sintomas são exacerbados com a inclinação para o mesmo lado dos sintomas, ocorrendo alívio da dor quando a protrusão está localizada medialmente à raiz nervosa

73- A

Gabarito apontou a alternativa A como a correta, porém o texto apontado como referência cita o procedimento de Gill na displásica

Although further slippage after in situ fusion is more likely related to the degree of dysplastic changes (kyphosis, high PI–high SS), removal of midline structures during posterolateral transverse process fusion mandates some
form of internal fixation or postoperative immobilization (cast) because of the instability created.
The results of intertransverse process fusion have shown rates of 83% to 95% successful fusion, with 75% to 100%
excellent or good clinical outcomes.

74- C

75- D

76- C

77- C

78- C

79- B

The internal snapping hip is a result of the iliopsoas tendo snapping over the iliopectineal eminence or the anterior hip capsule. In flexion, the psoas tendon is lateral to the iliopectineal eminence. As the hip is extended, the tendon slides across the iliopectineal eminence and anterior hip capsule, producing a snapping sensation in up to 10% of the normal population

80- B

Joint debridement with prosthesis retention is similarly limited to a small subset of patients: those with an early (<4 weeks) postoperative infection or an acute hematogenous symptoms) with a well-fixed prosthesis. Debridement and prosthesis retention in the setting of late chronic infection (>4 weeks postoperatively, insidious onset of symptoms) have been universally unsuccessful and should not be attempted. Infection with S. aureus is another relative contraindication to debridement and component retention. Several points have been recommended that could lead to higher success rates for debridement:
1. Infectious disease consultation and antibiotic monitoring
2. Diagnosis and treatment of hematogenous sources of infection
3. Newer antibiotics
4. Six-week duration of postoperative intravenous antibiotics
5. Repeat cultures within 2 weeks of the initial debridement and repeat debridement if these cultures were positive
6. Polyethylene exchange at the time of debridement; exchange of gown, gloves, and instruments; and redraping at the time of wound closure.

81- D

82- C

83- A

84- C

85- B

Teste da gaveta anterior do tornozelo – utilizada para testar a integridade do ligamento fibulotalar anterior e da porção anterolateral da cápsula articular. O examinador apoia uma das mãos sobre a face anterior da tíbia, logo acima do tornozelo e, com a outra, envolve o calcanhar do membro a ser examinado. Nessa posição, aplica força para deslocar anteriormente o pé, enquanto a perna permanece fixa.

86- D

With long-standing hindfoot valgus, the forefoot accommodates this deformity with increasing supination. This supination is accentuated after the hindfoot is corrected, creating an unbalanced foot. Thus, to balance the triangular support of the foot, the supination must be addressed through plantarflexing the medial column. An opening wedge medial cuneiform osteotomy (Cotton) plantarflexes the first metatarsal head, improving forefoot supination. 

87- C

A osteotomia de anteromedialização da tuberosidade anterior é indicada nos pacientes com lesão de cartilagem de grau III ou IV na faceta lateral ou no polo inferior da patela, associada ou não a instabilidade patelar ou (…)
Na osteotomia de anteromedialização descrita por Fulkerson, pode-se variar a inclinação da osteotomia de modo a priorizar o componente de anteriorização ou o de medialização.

88- C

89- A

A diacereína inibe efeitos da interleucina- 1, bloqueando a transcrição de metaloproteases e óxido nítrico, entre outros. Há evidência na literatura de sua eficácia com trabalhos de nível l, porém apresenta a diarreia com efeito
colateral, o que limita seu uso.

90- A

As medidas lineares do ciclo da marcha incluem variáveis de tempo e distância, entre elas cadência (número de passos dados em um intervalo de tempo), passo (espaço compreendido entre os pontos onde os pés tocam o solo), passada (espaço entre o contato inicial de um pé e o novo contato inicial do mesmo pé) e velocidade (média da velocidade ao longo da progressão)

91- D

A cicatrização do músculo esquelético segue uma ordem constante, sem alterações importantes conforme a causa (contusão, estiramento ou laceração). Três fases foram identificadas nesse processo:
• – caracterizada por ruptura e posterior necrose das miofibrilas, pela formação do hematoma no espaço formado entre o músculo roto e a proliferação de células inflamatórias;
• Fase 2: reparo – consiste na fagocitose do tecido necrótico, na regeneração das miofibrilas e na produção concomitante de tecido cicatricial conectivo, assim como na neoformação vascular e no crescimento neural;
• – período de maturação das miofibrilas regeneradas, de contração e de reorganização do tecido cicatricial e de recuperação da capacidade funcional muscular

92- C

Little Leaguer’s elbow is a term that has been used loosely to describe changes in the elbow secondary to baseball pitching and usually limited to the capitellum, radial head, or medial epicondyle. We have seen osteochondrosis of the capitellum (Panner disease) and osteochondritis dissecans of the capitelum.

93- C

94- C

95- D

96- D

97- D

A lesão por cisalhamento vertical ocorre quando o vetor de força é dirigido para cima, sendo a queda de altura o mecanismo mais comum. Além do deslocamento cefálico da hemipelve, a fratura avulsão ipsilateral do processo transverso de L5 é característica

98- C

RUPTURE OF PECTORALIS MAJOR MUSCLE
Rupture of the pectoralis major muscle most commonly is caused by forced abduction, external rotation, and extension of the shoulder against resistance. Once considered a rare injury, pectoralis major rupture has become more common over the past 2 decades, especially in athletes participating in sports such as weightlifting. Although the bench press is the most frequently cited cause of pectoralis major rupture, these injuries also have been reported in other sports, including rugby, snow and water skiing, football, wrestling, and hockey. Traumatic ruptures occur almost exclusively in men between the ages of 20 and 40 years. Swelling, ecchymosis, and later muscular deformity are evident at the site of the rupture, usually at the musculotendinous insertion into the humerus

99- C

100- D

Os tubos para colocar as amostras devem ser de 4 a 6 ml.
– 1º tubo: com EDTA; 2 m L de líquido sinovial para a contagem celular e estudos citológicos. Ressalta-se que o anticoagu lante ideal para o estudo citológico é o EDTA, 1 mg para cada m L de líquido sinovia l.
– 2º tubo: com heparina sódica, uma vez que este anticoagulante é mais recomendado para a investigação de cristais. Outros anticoagulantes, como a heparina com lítio, o oxalato de potássio e o EDTA, podem formar cristais que se comportam como artefatos, sendo fagocitados pelos leucócitos.
– 3º tubo: sem anticoagulante, ainda para pesquisa de cristais, uma vez que esse exame vai ser executado de imediato.
– 4º tubo: (se houver volume de líquido sinovial suficiente) sem anticoagulante, para real izar o Gram e a prova de coágulo de mucina. Se não houver material suficiente, o Gram deve ser feito com o material do primeiro tubo.
– 5° tubo: estéril, para culturas.
– 6º tubo: não necessariamente estéril, com oxalato de potássio ou fluoreto de heparina, para determinação da glicose no líquido sinovial. Nesse caso, uma amostra de sangue deve ser colhida para comparar os resultados.