AAOS Orthopedics MCQs (Set 4): Adult Reconstruction, Sports & Trauma | 2026 Board Review

The patient has a compartment syndrome based on the firm compartments of the leg and the elevated compartment pressures measured at the diastolic pressure reading. Muscle ischemia occurs quickly when compartment pressures are elevated, and within 6 hours irreversible damage can occur. Emergent fasciotomies permit decompression of all four compartments and reestablishment of vascular supply to the muscles. Stabilization of the fracture prevents further soft-tissue injury.

Patient positioning that results in local nerve compression, plexus traction, or improper neck alignment is the most common nonanesthetic-related cause of changes in intraoperative neurophysiologic monitoring data during spinal surgery. Jones SC, Fernau R, Woeltjen BL: Use of somatosensory evoked potentials to detect peripheral ischemia and potential injury resulting from positioning of the surgical patient: Case reports and discussion. Spine J 2004;4:360-362.

Latissimus dorsi tendon transfer is considered a surgical option for treatment in patients with chronic supraspinatus and infraspinatus tendon tears. Preoperative subscapularis function is necessary for good clinical results. Additionally, men with active elevation to shoulder level and active external rotation to 20 degrees have predictably good results. Women with active shoulder elevation limited to below chest level have poor results from this procedure and should not be considered candidates. Postoperatively they lack pain control, active elevation, and active external rotation. Muscular atrophy in the latissimus dorsi does not occur, and glenohumeral arthritic changes frequently develop postoperatively. Gerber C, Maquieira G, Espinosa N: Latissimus dorsi transfer for the treatment of irreparable rotator cuff tears: Factors affecting outcome. J Bone Joint Surg Am 2006;88:113-120.

Nickel allergy is not an infrequent preoperative finding. The ramifications of such allergies in arthroplasty patients are poorly understood at this time. Stainless steel and cobalt-chromium alloys contain relatively high concentrations of nickel. Titanium, oxidized zirconium, and polyethylene do not contain significant amounts of nickel. Titanium is not a good surface for the articulating portion of the femoral component because of its propensity for metallosis. Oxidized zirconium is the only suitable femoral component for patients allergic to nickel. A modular titanium tibial component or an all-polyethylene tibial component would be satisfactory for these patients. Laskin RS: An oxidized Zr ceramic surfaced femoral component for total knee arthroplasty. Clin Orthop 2003;416:191-196.

All of the answers are possible complications of meniscal repair. There are large volumes of literature evaluating the results of meniscal repair, both for the all-inside technique, as well as the inside-out technique. Failure rates are similar. Intra-articular synovitis occurs with absorbable sutures and absorbable implants. Peroneal nerve injuries are more common with the lateral-sided repairs. Saphenous nerve injuries are more common with medial-sided tears. Because of the incision required and the technique of tying over soft tissue, the risk of a saphenous nerve injury is greater with an inside-out technique than with an all-inside technique. Farng E, Sherman O: Meniscal repair devices: A clinical and biomechanical literature review. Arthroscopy 2004;20:273-286.

The recent JBJS article by Kocher and associates defines the different psychometric properties that are used in outcome measures. Reliability is a measure of how reproducible a test is. This can be interobserver reliability (ie, reliability between people), or intraobserver reliability (ie, reliability for the same person doing the outcome measure at different occasions).

Ecchymosis on the medial side of the ankle is distributed in the posterior tibialis tendon sheath location, posterior to the medial malleolus, and extending inferiorly to the tendon's attachment on the navicular. MRI is the imaging study of choice to determine the extent of tendon damage. MRI will also help assess the deltoid ligament. Bone scans and CT are helpful in identifying osteochondral fractures and occult fractures; however, these studies are not indicated for this patient. Peroneal tendons are located lateral on the ankle. Arthroscopy of the ankle joint would not be helpful in assessing the posterior tibial tendons. Lutter LD, Mizel MS, Pfeffer GB (eds): Orthopaedic Knowledge Update: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 307-317.

Osteochondroma typically occurs as a bony projection or a sessile growth on the bone, and there can be flaring of the metaphysis. The radiograph shows continuity from the adjacent cancellous bone into the lesion itself. There is no soft-tissue mass or bone destruction to suggest osteosarcoma or Ewing's sarcoma. Periosteal chondroma has a scalloped out radiographic appearance. Chondroblastoma typically is an epiphyseal-based lesion.

The three primary constraints necessary for elbow stability in all directions are the ulnar part of the lateral collateral ligament (also called the lateral ulnar collateral ligament), the anterior band of the medial collateral ligament, and the coronoid. The radial head and capsule are secondary constraints to elbow instability. Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 283-294.

Ceramic-on-ceramic bearing surfaces have superior tribological properties and show lower linear wear than metal-on-metal implants. However, because of their lower strength and vulnerability to fracture, design considerations constrain the neck-length options available to ensure optimal taper fit.

Revision anterior exposure within 2 weeks of total disk replacement incurs relatively little additional morbidity because adhesion formation is minimal. Surgeons should have a low threshold for revising implants that are clearly dangerously malpositioned or show early migration within this 2-week window. Beyond this time period, a revision strategy must be individualized to the particular clinical situation. A posterior fusion with instrumentation with or without a laminectomy is currently the most effective salvage procedure.

Denis divided the sacrum into three zones: zone 1 represents the lateral ala, zone 2 represents the foramina, and zone 3 represents the central canal. A fracture is classified according to its most medial extension. Those in zone 3 are typically bursting-type fractures or fracture-dislocations and are most prone to neurologic sequelae. Denis F, Davis S, Comfort T: Sacral fractures: An important problem. A retrospective analysis of 236 cases. Clin Orthop Relat Res 1988;227:67-81.

The child sustained a brachial plexus injury at birth, and internal rotation/adduction contractures frequently develop at the shoulder. Initial treatment should consist of physical therapy to increase the range of motion. If this fails, as in this patient, MRI is used to evaluate the glenohumeral joint. Commonly, there is joint deformity with increased retroversion of the glenoid and even posterior shoulder subluxation. If the deformity is mild, an anterior release, coupled with teres major and latissimus transfers, is very effective. If the deformity is severe and the shoulder is unreconstructable, then humeral derotation osteotomy is the procedure of choice. MRI of the brain, a radiograph of the elbow, and aspiration of the shoulder would not be helpful. Waters PM: Update on management of pediatric brachial plexus palsy. J Pediatr Orthop B 2005;14:233-244. Waters PM, Bae DS: Effect of tendon transfers and extra-articular soft-tissue balancing on glenohumeral development in brachial plexus birth palsy. J Bone Joint Surg Am 2005;87:320-325.

The radiographs show a centrally located radiolucent lesion with cortical thinning and mild osseous expansion; these findings are the hallmarks of a simple bone cyst. Whereas this particular lesion does not demonstrate sclerosis, the distinct margin of this lesion with sharp transition to normal bone is common. The MRI scans reveal a purely cystic lesion with bright T2 signal, and the gadolinium image shows the classic rim enhancement of cystic lesions. Fibrous dysplasia with cystic degeneration might have a very similar appearance and should be considered in the differential diagnosis. Parsons TW: Benign bone tumors, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 1027-1035. May DA, Good RB, Smith DK, et al: MR imaging of musculoskeletal tumors and tumor mimickers with intravenous gadolinium: Experience with 242 patients. Skeletal Radiol 1997;26:2-15.

The patient has a fracture through a unicameral bone cyst, as evidenced by the "falling leaf" sign on the radiograph. Following healing of the fracture, treatment should consist of corticosteroid injection or bone marrow injection. Some cysts heal with the fracture and do not require injections. Biopsy is unnecessary because the radiograph shows that the cyst is benign. Curettage and bone grafting are seldom necessary because these cysts regularly heal with injections. Corticosteroids are useful when injected into the cyst, but are not used systemically. Pulsed electromagnetic fields have not been used therapeutically in this condition.

The tenosynovium excised at the time of a carpal tunnel release for idiopathic carpal tunnel syndrome rarely shows signs of acute or chronic inflammation. Fibrosis, edema, and vascular sclerosis are the most common histologic findings. A tenosynovectomy with a carpal tunnel release usually is not necessary in the treatment of idiopathic carpal tunnel syndrome. Shum C, Parisien M, Strauch RJ, et al: The role of flexor tenosynovectomy in the operative treatment of carpal tunnel syndrome. J Bone Joint Surg Am 2002;84:221-225. Fuchs PC, Nathan PA, Myers LD: Synovial histology in carpal tunnel syndrome. J Hand Surg Am 1991;16:753-758.

The patient has a fixed deformity of the hindfoot and an Achilles tendon contracture; therefore, the treatment of choice is triple arthrodesis with Achilles tendon lengthening. Further bracing will not be helpful. Amputation is not indicated, and ankle arthrodesis will not address the hindfoot deformity. Palliative management would be more appropriate if the knee was unstable or the quadriceps were weak, because the equinus balances the ground reaction force across the knee. Perry J, Fontaine JD, Mulroy S: Findings in post-poliomyelitis syndrome: Weakness of muscles of the calf as a source of late pain and fatigue of muscles of the thigh after poliomyelitis. J Bone Joint Surg Am 1995;77:1148-1153.

The patient needs restrictions on his external rotation to allow healing of the subscapularis tendon repair. Limitation to 60 degrees is common if the tendon repair is robust and shows no evidence of tension on range-of-motion testing during the surgery. Restriction from external rotation stretching for even 3 weeks would compromise his ultimate functional recovery. Boardman ND III, Cofield RH, Bengston KA, et al: Rehabilitation after total shoulder arthroplasty. J Arthroplasty 2001;16:483-486.

Calcaneal apophysitis (Sever's disease) is a common cause of heel pain in children who are active in sports. The symptoms are most commonly bilateral and will often respond to a gastrocnemius-soleus complex stretching program. In addition, rest, anti-inflammatory drugs, and heel pads for the shoe may be prescribed. There is no effect on the long-term growth of the calcaneus. Micheli LJ, Ireland ML: Prevention and management of calcaneal apophysitis in children: An overuse syndrome. J Pediatr Orthop 1987;7:34-38.

Any of the above structures may be involved in a lateral patellar dislocation. However, biomechanic studies have found that the medial patellofemoral ligament is the major soft-tissue static restraint of lateral patellar displacement, providing at least 50% of this function. Desio SM, Burks RT, Bachus KN: Soft tissue restraints to lateral patellar translation in the human knee. Am J Sports Med 1998;26:59-65. Conlan T, Garth WP Jr, Lemons JE: Evaluation of the medial soft-tissue restraints of the extensor mechanism of the knee. J Bone Joint Surg Am 1993;75:682-693.

This is the first occurrence of diabetic foot-specific morbidity. The patient has a foot deformity, a history of a diabetic foot ulcer, and is insensate to the monofilament. He is at moderate risk for the development of a recurrent ulcer. This is best avoided with therapeutic footwear. Commercially available depth-inlay shoes should be combined with a custom accommodative foot orthosis to accommodative the deformity. Pinzur MS, Slovenkai MP, Trepman E, et al: Guidelines for diabetic foot care: Recommendations endorsed by the Diabetes Committee of the American Orthopaedic Foot and Ankle Society. Foot Ankle Int 2005;26:113-119.

The radiograph reveals primary osteoarthritis of the elbow; therefore, ulnohumeral arthroplasty is the preferred procedure. Patients with severely limited preoperative elbow extension of more than 60 degrees and flexion of less than 100 degrees are at risk for ulnar nerve dysfunction postoperatively and should undergo a concomitant ulnar nerve decompression. Nonsurgical methods are unlikely to improve his chronic condition. Elbow arthroplasty is contraindicated for patients in this age group and with this diagnosis. Antuna SA, Morrey BF, Adams RA, et al: Ulnohumeral arthroplasty for primary degenerative arthritis of the elbow: Long-term outcome and complications. J Bone Joint Surg Am 2002;84:2168-2173.

While Kohler's disease has a benign course, temporary cast immobilization has been shown to result in a shortened duration of symptoms. Core decompression or other surgery is not warranted because of the benign nature. Shoe inserts may be beneficial, but there are no studies to support their use. Borges JL, Guile JT, Bowen JR: Kohler's bone disease of the tarsal navicular. J Pediatr Orthop 1995;15:596-598.

The most likely diagnosis is postpolio syndrome, which is characterized by increasing weakness in both the paretic and previously normal muscles. Fatigability, joint pain, muscle atrophy, respiratory insufficiency, dysphagia, and sleep apnea are also seen. Gentle exercise and modification in lifestyle demands are generally recommended. Vigorous rehabilitation is likely to be detrimental in this condition. Further diagnostic work-up is not indicated at this time. Dalakas MC, Elder G, Hallett M, et al: A long-term follow-up study of patients with post-poliomyelitis neuromuscular symptoms. N Eng J Med 1986;314:959-963.

Patellar complications commonly occur after primary total knee arthroplasty; therefore, proper component positioning is critical in obtaining a successful result. This patient has lateral tilting and subluxation of the patellar component. Internal rotation of the femoral component has the most deleterious effect on patellar tracking. Lateral placement of the femoral component, medial placement of the patellar component, and external rotation of the tibial component have beneficial effects on patellar tracking. Elevation of the joint line, if not excessive, should not impact patellar tracking. Rand JA: Patellar resurfacing in total knee arthroplasty. Clin Orthop 1990;260:110-117.

In an adult with an anterior cortical tibial lesion, this is the classic histologic appearance and anatomic location for an adamantinoma. The histology reveals areas of epithelial cells (in a glandular pattern) within a fibrous stroma. The epithelial cells are shown in nests. They would stain positively for keratin. Adamantinoma is a rare malignant bone tumor with a propensity for late metastasis. It has a high incidence of local recurrence unless resected with a wide margin. Chemotherapy and radiation therapy are not helpful in the treatment of this disease. Amputation generally is not necessary because a diaphyseal resection is usually possible. McCarthy EF, Frassica FJ: Pathology of Bone and Joint Disorders with Clinical and Radiographic Correlation. Philadelphia, PA, WB Saunders, 1998, p 263.

Full exposure of the volar plate of the proximal interphalangeal joint of the finger is best accomplished by incision of the distal C1, A3, and proximal C2 pulleys; followed by gentle retraction of the flexor digitorum superficialis and profundus tendons. Sacrifice of the A3 pulley, although associated with some biomechanic disadvantage, can be tolerated without causing functionally limiting bowstringing of the flexor tendon. Sacrifice of even a portion of the A2 or A4 pulleys can decrease the biomechanic leverage provided by the flexor tendon sheath, leading to bowstringing of the flexor tendons. Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics, ed 2. Philadelphia, PA, Lippincott-Raven, 1994, pp 176-186. Strickland J: Flexor tendon-acute injuries, in Green DP, Hotchkiss RN, Pederson WC (eds): Green's Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone, 1999, vol 2, pp 1853-1855.

The Coleman block test is used to evaluate the effect of the forefoot on the rearfoot varus. If the deformity corrects with the block, then the hindfoot deformity is flexible and the varus position is secondary to the plantar flexed first ray or valgus position of the forefoot. A rearfoot orthotic will not correct the forefoot cause of the deformity. The patient still may need a lateralizing calcaneal osteotomy to realign the hindfoot. Younger AS, Hansen ST Jr: Adult cavovarus foot. J Am Acad Orthop Surg 2005;13:302-315.

The superior gluteal artery is most at risk with a posterior iliac crest bone graft harvest. The artery leaves the pelvis through the sciatic notch and can be injured by retractors or other sharp instruments entering the sciatic notch area. The deep circumflex iliac, iliolumbar, and fourth lumbar arteries supply the iliacus and iliopsoas muscles and can be damaged during anterior bone graft harvest. The ascending branch of the lateral femoral circumflex artery is at risk during the anterior approach to the hip. Guyer RD, Delmarter RB, Fulp T, Small SD: Complications of cervical spine surgery, in Herkowitz HN, Garfin SR, Balderston RA, Eismont FJ, Bell GR, Wiesel SW (eds): Rothman-Simeone The Spine, ed 4. Philadelphia, PA, WB Saunders, 1999, p 547. Kurz LT, Garfin SR, Booth RE Jr: Iliac bone grafting: Techniques and complications of harvesting, in Garfin SR (ed): Complications of Spine Surgery. Baltimore, MD, Williams and Wilkins, 1989, pp 330-331.

The patient has a comminuted fracture of the proximal femur and joint space narrowing of the acetabulum. Therefore, the prosthesis should be converted to a total hip arthroplasty. Because there is extensive comminution, the revision stem should bypass the area of bone loss by two bone diameters. A hemiarthroplasty is not indicated because the patient has no acetabular cartilage. Open reduction and internal fixation may not stabilize the prosthesis. A resection arthroplasty or treatment in traction will not leave the patient with adequate function. Garbuz DS, Masri BA, Duncan CP: Periprosthetic fractures of the femur: Principles of prevention and management, in Cannon WD Jr (ed): Instructional Course Lectures 47. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 237-242.

It is appropriate for orthopaedic surgeons to have relationships with industry as long as the relationship is for the good of the patient and no "quid pro quo" intent exists. A grant to cover registration at a CME event is appropriate but travel and hotel for a spouse is not. For orthopaedists who are faculty at a meeting sponsored by industry, it is appropriate for travel and expenses to be covered for that faculty member. Care must be exercised that the faculty member contributes in an amount appropriate for the expenses paid. The faculty member must ensure that information presented is unbiased and based on reasonable data and opinion. Consulting agreements should spell out specifically the duties of the agreement and payment should be appropriate for the time spent. There should be a defined work product for the consulting. Agreements that are thinly veiled payments for use of a company's products must be avoided. In all cases, the agreements must stand up to public scrutiny. Restricted grants for specific industry-sponsored programs aimed at residents are not appropriate. Unrestricted grants intended for attendance at approved CME courses are appropriate. Dinners at which information is presented about topics that can aid in patient care are appropriate as long as the expense is reasonable ($100 or less/person) and the guest list includes individuals who can use the information in a patient case. Clearly a "premium" dinner for office staff to review new surgical instrumentation would not pass this test.

Weinstein reported on 31 patients (45 feet) with congenital metatarsus adductus followed for an average of 33 years. Twenty-nine feet had moderate to severe deformities treated with manipulation and casting with a 90% success rate. In a young child, surgery is not indicated until nonsurgical management has failed. In patients 2 to 4 years of age, tarsometatarsal capsulotomies are indicated, whereas multiple metatarsal osteotomies are reserved for recalcitrant deformities in children older than 4 years of age. Mild or moderate metatarsus adductus that is passively correctable will resolve without treatment. Beaty J: Congenital anomalies of the lower extremity, in Canale ST (ed): Campbell's Operative Orthopaedics, ed 10. Philadelphia PA, Mosby, 2003, pp 983-988. Katz K, David R, Soudry M: Below-knee plaster cast for the treatment of metatarsus adductus. J Pediatr Orthop 1999;19:49-50.

Endoscopic ACL reconstructive techniques may result in a vertical graft placement. The reconstructed ligament will resist anterior translation of the tibia but the graft will not restore rotatory stability. Decreased flexion and extension are caused by placement of the femoral tunnel too anterior and posterior, respectively. Impingement of the graft on the femoral notch is caused by anterior placement of the tibial tunnel or inadequate notchplasty. Scopp JM, Jasper LE, Belkoff SM, et al: The effect of oblique femoral tunnel placement on rotational constraint of the knee reconstructed using patellar tendon autografts. Arthroscopy 2004;20:294-299.

The history and presentation are consistent with type I Charcot-Marie-Tooth (CMT), the most common form of hereditary peripheral motor sensory neuropathy. Type I CMT is the most common, occurring in 50% of patients with CMT, and is characterized by marked slowing of motor neuron velocities, and inconsistent slowing of sensory neuron velocities. Peroneus longus to brevis transfer is indicated to release the overpull of the peroneus longus, and restore the eversion and dorsiflexion function of the peroneus brevis. A lateralizing calcaneal osteotomy with proximal translation is indicated to correct heel varus given that the Coleman block only allows for partial correction of heel varus. Proximal translation of the posterior tuber corrects for the increased calcaneal dorsiflexion, improving the lever arm for the triceps surae. A medial column closing wedge osteotomy is often required to correct a rigid, or semirigid plantar flexed first ray to allow for a balanced, plantigrade foot. Triple arthrodesis is indicated for rigid, arthritic hindfoot deformities. Transfer of the posterior tibial tendon to the tibialis anterior is not indicated since it is an out-of-phase transfer. Transfer of the posterior tibial tendon, when performed, should be to the lateral aspect of the foot. A medializing calcaneal osteotomy would accentuate the heel varus. There is no indication for Botox in CMT; Botox injection of the calf would further weaken push-off during gait. Bracing of a progressive semirigid or rigid deformity is not recommended. Younger AS, Hansen ST Jr: Adult cavovarus foot. J Am Acad Orthop Surg 2005;13:302-315. Sammarco GJ, Taylor R: Cavovarus foot treated with combined calcaneus and metatarsal ostetotomies. Foot Ankle Int 2001;22:19-30.

Functional bracing has been demonstrated to have a very high rate of healing without any functional limitations in a large series of patients. Surgery is reserved for "floating elbows," open injuries, neurovascular injuries, and those fractures that go on to nonunion. Sarmiento A, Zagorski JB, Zych GA, et al: Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am 2000;82:478-486.

The radiographs show an osteochondritis dissecans (OCD) lesion in the medial femoral condyle of a skeletally immature patient. The lesion is not displaced from its bed. Nonsurgical management of a stable OCD lesion in a patient with open physes consists of a period of activity limitation and occasional immobilization. Unstable lesions, loose bodies, and patients with closed physes require more aggressive treatment. Most of the surgical procedures can be done arthroscopically. Because the radiographic appearance is typical, biopsy is unnecessary. The radiographs do not show an osteocartilaginous loose body, and the patient reports no catching or locking; therefore, removal of the loose body is not indicated. Linden B: Osteochondritis dissecans of the femoral condyles: A long term follow-up study. J Bone Joint Surg Am 1977;59:769-776. Cahill BR: Osteochondritis dissecans of the knee: Treatment of juvenile and adult forms. J Am Acad Orthop Surg 1995;3:237-247.

In a report of more than 70 hips treated by surgical dislocation, iatrogenic osteonecrosis failed to develop in any of the hips.

The child has isolated ipsilateral femoral shaft and tibial shaft fractures. Spica cast immobilization is unlikely to accommodate for shortening and alignment in this child with multiple levels of injury. In this instance, efforts should be made to mobilize a least one level of the limb; therefore, treatment should include flexible nailing of the femur and tibia. Rigid reamed nails are not indicated in this young patient secondary to risk of a growth arrest and osteonecrosis of the proximal femur. Poolman RW, Kocher MS, Bhandari M: Pediatric femoral fractures: A systematic review of 2422 cases. J Orthop Trauma 2006;20:648-654. Anglen JO, Choi L: Treatment options in pediatric femoral shaft fractures. J Orthop Trauma 2005;19:724-733.

The median nerve has an intimate association with the palmaris longus and the flexor carpi radialis at the proximal aspect of the carpal canal. The median nerve lies just ulnar and dorsal to the flexor carpi radialis tendon. Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics, ed 2. Philadelphia, PA, Lippincott-Raven, 1994, pp 118-131.

The quadrangular space is bordered superiorly by the teres minor, medially by the long head of the triceps, laterally by the humerus, and inferiorly by the teres major. The posterior circumflex humeral artery and the axillary nerve lie in this space. Rockwood CA Jr, Matsen FA III: The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1998, vol 1, pp 70-71.

The clinical result in this patient has been good, with no dislocations, suggesting that the components are in reasonably good position. The radiograph and examination at the time of surgery suggest that the acetabular component is well fixed. The surrounding bone of the acetabulum is osteopenic and there would most likely be considerable bone loss if the acetabular component is removed. Access to the osteolytic lesions is possible. Cementing an acetabular component into the retained socket will cause the least amount of bone loss, shorten the procedure, and most likely result in a functional hip. Maloney WJ: Socket retention: Staying in place. Orthopedics 2000;23:965-966.

Serum lactate levels can be used to evaluate the effectiveness of the resuscitation of patients who have multiple injuries. Even after resuscitation, patients may have occult hypoperfusion as defined by a serum lactate level of greater than 2.5 mmol/L. The studies referenced indicate that these patients are at increased risk of perioperative complications such as organ failure or adult respiratory distress syndrome if definitive surgical fixation of the orthopaedic injuries is pursued prior to correction of the occult hypoperfusion. The other markers may be an indication of current physiology but have not been correlated with perioperative risks. Blow O, Magliore L, Claridge JA, et al: The golden hour and silver day: Detection and correction of occult hypoperfusion within 24 hours improves outcomes from major trauma. J Trauma 1999;47:964-977. Crowl A, Young JS, Kahler DM, et al: Occult hypoperfusion is associated with increased morbidity in patients undergoing early femur fracture fixation. J Trauma 2000;48:260-267.

Most soft-tissue sarcomas are treated with a combination of radiation therapy and wide resection. Rhabdomyosarcomas are an exception, where chemotherapy is included in all treatment plans. Chemotherapy for other soft-tissue sarcomas is controversial. Enzinger FM, Weiss SW: Rhabdomyosarcoma, in Soft Tissue Tumors, ed 3. St Louis, MO, CV Mosby, 1995, p 539.

This Galeazzi fracture is an injury that requires surgical treatment in an adult. The algorithm includes anatomic reduction of the radial shaft and closed reduction of the DRUJ with assessment of stability. If the DRUJ remains unstable, supination of the wrist may reduce the DRUJ. If not, either open or closed reduction with pinning is undertaken. The closer the radius fracture is to the DRUJ, the more likely it is to be unstable.

Type 2A hangman's fractures are thought to have a flexion mechanism rather than extension and axial loading. This allows them to rotate around the anterior longitudinal ligament into flexion. Anterior translation of greater than 3 mm and angulation distinguish type 2 fractures from type 1 fractures. Although there is an association between C1 ring fractures and C2 fractures, this does not factor into the classification. If a C2-3 facet dislocation exists in combination with a C2 pars fracture, it is considered a type 3 fracture. Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 197-217.

The anterior cruciate ligament is attached to a portion of the lateral femoral condyle. The posterior cruciate ligament attaches to the medial femoral condyle. The lateral collateral and oblique popliteal ligaments attach proximal to this fragment. The intermeniscal ligament attaches the anterior horns of the menisci. Jobe CM, Wright M: Anatomy of the knee, in Fu FH, Harner CD, Vince KG (eds): Knee Surgery. Baltimore, MD, Williams & Wilkins, 1994, pp 1-54.

In a multivariate analysis, the strongest factor for the development of compartment syndrome is fracture of the proximal third of the forearm. However, compartment syndrome can still occur without a fracture. Therefore, these patients should be followed with a high level of suspicion for the development of compartment syndrome. Moed BR, Fakhouri AJ: Compartment syndrome after low-velocity gunshot wounds to the forearm. J Orthop Trauma 1991;5:134-137.

Adult patients with isthmic spondylolisthesis most commonly have neurologic symptoms due to foraminal stenosis at the level of the spondylolisthesis. In this scenario, the patient is most likely to have weakness of the L5 myotome, which would cause weakness of the extensor hallucis longus. Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 311-317.

The failure load of an evenly tensioned four-stranded hamstring tendon autograft has been reported to be 4,500 Newtons. The failure load of a 10-mm patellar tendon autograft has been estimated at 2,600 Newtons. The intact anterior cruciate ligament failure load has been calculated at 1,725 Newtons. Corry IS, Webb JM, Clingeleffer AJ, Pinczewski LA: Arthroscopic reconstruction of the anterior cruciate ligament: A comparison of patellar tendon autograft and four-strand hamstring tendon autograft. Am J Sports Med 1999;27:448-454. Hamner DL, Brown CH Jr, Steiner ME, et al: Hamstring tendon grafts for reconstruction of the anterior cruciate ligament: Biomechanical evaluation of the use of multiple strands and tensioning techniques. J Bone Joint Surg Am 1999;81:549-557.

Larsen grade I and II rheumatoid arthritis is best treated with synovectomy with arthroplasty reserved for later stages, especially in younger patients. Open synovectomy with or without a radial head excision has yielded good results for pain and function, with arthroscopic synovectomies yielding similar results. Arthroscopic synovectomy has been shown to be more effective in restoring function in patients with a flexion arc of less than 90 degrees. Tanaka N, Sakahashi H, Hirose K, et al: Arthroscopic and open synovectomy of the elbow in rheumatoid arthritis. J Bone Joint Surg Am 2006;88:521-525. Horiuchi K, Momohara S, Tomatsu T, et al: Arthroscopic synovectomy of the elbow in rheumatoid arthritis. J Bone Joint Surg Am 2002;84:342-347.

Success of a meniscal allograft transplantation is strongly dependent on accurate graft sizing, typically within 5% of the native meniscus. Previous studies have established that donor cell viability is not mandatory for the survival of these grafts since they are replaced by the recipient's cells (at least peripherally) within several weeks. Thus, cryopreservation of the graft to ensure cell viability is not necessary. There is a limited immune response to musculoskeletal allografts; therefore, immunosuppression, as is required for visceral organ transplantation, is not indicated. Wirth CA, Kohn D: Meniscal transplantation and replacement, in Fu FH, Harner CD, Vince JG (eds): Knee Surgery. Baltimore, MD, Williams & Wilkins, 1994, vol 1, pp 631-641. Brautigan BE, Johnson DL, Caborn DM, et al: Allograft tissues, in Drez D, DeLee JD, Miller MD (eds): Orthopaedic Sports Medicine: Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, pp 205-213.

The Achilles tendon insertion encompasses a broad area on the posterior area of the calcaneus. A biomechanical study has shown that up to 50% of the Achilles tendon insertion point can be detached before the strength of the attachment point starts to weaken. It is recommended that if more than this amount is detached to remove the posterior superior calcaneal prominence, consideration should be given to either securing the tendon to the bone with suture anchors or performing a tendon transfer. Kolodziej P, Glisson RR, Nunley JA: Risk of avulsion of the Achilles tendon after partial excision for treatment of insertional tendinitis and Haglund's deformity: A biomechanical study. Foot Ankle Int 1999;20:433-437.

Loss of external rotation can lead to degenerative joint disease following an anterior stabilization procedure. A tight anterior capsule will prevent internal impingement. Risk of thoracic outlet syndrome should not be increased. Subscapularis detachment is a risk following open anterior repair; however, a gain in external rotation would be noted. In time, this patient's shoulder may show increased posterior glenohumeral wear but should not have symptoms of recurrent subluxation unless multidirectional instability is present. Hawkins RJ, Angelo RL: Glenohumeral osteoarthrosis: A late complication of the Putti-Platt repair. J Bone Joint Surg Am 1990;72:1193-1197.

The extensor digiti mini quinti is most typically a tendon with two slips. The abductor pollicis longus has multiple slips that insert in order of frequency on the base of the first metacarpal, trapezium, and thenar muscles. The extensor pollicis longus, extensor carpi radialis brevis, and extensor indicis proprius consistantly have only one slip. von Schroeder HP, Botte MJ: Anatomy of the extensor tendons of the fingers: Variations and multiplicity. J Hand Surg Am 1995;20:27-34.

Emboli are created during TKA. Usually there is an increased incidence with the use of intramedullary rods that disrupt the marrow contents. These are not fat emboli per se. They are material composed of fat cells and marrow that act like pulmonary emboli to obstruct small arterioles in the lung. They are different from free fat emboli that are seen in fractures and that lead to chemical injury to the lung rather than obstructive injury. Markel DC, Femino JE, Farkas P, et al: Analysis of lower extremity embolic material after total knee arthroplasty in a canine model. J Arthroplasty 1999;14:227-232. Pell AC, Christie J, Keating JF, et al: The detection of fat embolism by transoesophageal echocardiography during reamed intramedullary nailing: A study of 24 patients with femoral and tibial fractures. J Bone Joint Surg Br 1993;75:921-925.

The patient has a scaphoid fracture involving the proximal pole. Surgical treatment is recommended for such fractures because of the prolonged period of cast immobilization necessary and the increased risk of delayed union, nonunion, and/or osteonecrosis with nonsurgical management. A cannulated compression screw, inserted in the central scaphoid via a dorsal approach, is biomechanically advantageous and provides greater stability for fracture healing than Kirschner wires. Recently, good outcomes have been reported with arthroscopic-assisted percutaneous fixation of nondisplaced or minimally displaced scaphoid fractures. Rettig ME, Raskin KB: Retrograde compression screw fixation of acute proximal pole scaphoid fractures. J Hand Surg Am 1999;24:1206-1210. Chan KW, McAdams TR: Central screw placement in percutaneous screw scaphoid fixation: A cadaveric comparison of proximal and distal techniques. J Hand Surg Am 2004;29:74-79. Bedi A, Jebson PJ, Hayden RJ, et al: Internal fixation of acute non-displaced scaphoid waist fractures via a limited dorsal approach: An assessment or radiographic and functional outcomes. J Hand Surg Am 2007;32:326-333.

It appears that the patient has septic arthritis of the glenohumeral joint; therefore, initial management should consist of aspiration of the glenohumeral joint and subacromial space separately, followed by Gram stain and culture of the fluid. Based on the findings, broad-spectrum IV antibiotics should be started. If the diagnosis of septic arthritis is confirmed, then arthroscopic or open surgical drainage usually is indicated. Sawyer JR, Esterhai JL Jr: Shoulder infections, in Warner JJ, Iannotti JP, Gerber C (eds): Complex and Revision Problems in Shoulder Surgery. Philadelphia, PA, Lippincott-Raven, 1997.

Fluoroquinolones have been associated with increased rates of tendinitis, with special predilection for the Achilles tendon. Tenocytes in the Achilles tendon have exhibited degenerative changes when viewed microscopically after fluoroquinolone administration. Recent clinical studies have shown an increased relative risk of Achilles tendon rupture of 3.7. The other listed drugs have no known increase in tendon rupture rates nor tendinitis. van der Linden PD, van de Lei J, Nab HW, et al: Achilles tendinitis associated with fluoroquinolones. Br J Clin Pharmacol 1999;48:433-437. Bernard-Beaubois K, Hecquet C, Hayem G, et al: In vitro study of cytotoxicity of quinolones on rabbit tenocytes. Cell Biol Toxicol 1998;14:283-292.

Ankle arthrodesis for posttraumatic ankle arthrosis provides reliable pain relief. However, the long-term sequela of joint arthrodesis is the development of arthrosis in the surrounding joints. Over time, following ankle arthrodesis, the ipsilateral hindfoot and midfoot joints show signs of joint space wear, and this may be symptomatic. With a stable ankle arthrodesis, progressive limb-length discrepancy or talar osteonecrosis is not expected. Ankle arthrodesis has not been definitively linked to ipsilateral knee arthritis or contralateral ankle arthritis. Coester LM, Saltzman CL, Leupold J, Pontarelli W: Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am 2001;83:219-228.

The radiograph shows myositis ossificans within the quadriceps muscle. This condition occurs as a complication of muscle injury. Initial treatment should include rest, ice, compression, and elevation. While gentle active range of motion is encouraged in the functional recovery from this injury, passive stretching is contraindicated as it can enhance hemorrhage and accentuate the development of myositis ossificans. Ultrasound is similarly contraindicated because it can enhance the development of myositis ossificans and has no proven efficacy in this patient; electrical stimulation also has no proven benefits. Massage is contraindicated in the initial management of this injury because of its influence on increasing local blood flow. Anderson JE (ed): Grant's Atlas of Anatomy. Baltimore, MD, Williams & Wilkins, 1978, pp 4.39-4.49. Brumet ME, Hontas RB: The thigh, in DeLee JC, Drez D Jr (eds): Orthopaedic Sports Medicine. Philadelphia, PA, WB Saunders, 1994, pp 1086-1112. Antao NA: Myositis of the hip in a professional soccer player: A case report. Am J Sports Med 1988;16:82-83.

The sciatic nerve is formed by the roots of the lumbosacral plexus. It exits the pelvis through the greater sciatic notch and appears in the buttock anterior to the piriformus. From that point, the sciatic nerve passes posteriorly over the superior gemellus, obturator internus, inferior gemellus, and quadratus femoris before it passes deep to the biceps femoris. The tendon of the obturator internus passes through the lesser sciatic notch. Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippincott, 1984, p 347. Anderson JE: Grant's Atlas of Anatomy, ed 7. Baltimore, MD, Lippincott Williams & Wilkins, 1978, pp 4-34, 4-36.

Osteochondral fractures involving the talar dome have been classified based on radiographic and MRI findings. A nondisplaced and incomplete fracture may be treated effectively with a short leg cast and no weight bearing for 6 weeks. This patient has a complete, separated, and displaced osteochondral fragment involving the midlateral talar dome that will most likely cause pain, mechanical symptoms, and effusion if treated nonsurgically. In addition, there is very little bone remaining on the fragment, making the likelihood of healing with open reduction and internal fixation problematic. The treatment of choice includes arthroscopy, removal of the loose fragment, curettage or drilling of the base, and a rehabilitation program that emphasizes peroneal strengthening, range of motion, and proprioceptive training. Lutter LD, Mizel MS, Pfeffer GB (eds): Orthopaedic Knowledge Update: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 205-226.

The patient has a Bado type IV Monteggia lesion. It involves dislocation of the radial head and fractures of both the radial and ulnar shafts. These fractures are very difficult to manage by closed reduction alone. The radial and ulnar shafts first have to be stabilized surgically to give a lever arm to reduce the radial head. In this age group, intramedullary pins are easy to insert percutaneously and cause less tissue trauma than plates and screws. In these types of injuries, the focus is often on the forearm fracture; the radial head dislocation may not be appreciated as was the case with this patient. Gibson WK, Timperlake RW: Operative treatment of a type IV Monteggia fracture-dislocation in a child. J Bone Joint Surg Br 1992;74:780-781.

Flexor tenosynovitis of the thumb flexor tendon sheath can spread proximally and form an abscess within the thenar space of the palm. The flexor pollicis longus tendon does not pass through the central space of the palm or the hypothenar space of the palm. The flexor pollicis longus tendon does pass through the carpal tunnel, but this is not a palmar space. The three palmar spaces include the hypothenar space, the thenar space, and the central space. The posterior adductor space would likely only be involved secondarily after spread from a thenar space infection. Hollinshead W: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, vol 3, pp 478-479.

The iliacus muscle is a frequent site of hemorrhage in patients with severe or moderate hemophilia. In patients with moderate hemophilia, hemorrhage into the iliacus muscle often follows play or sporting events that include forceful contraction of the hip flexor muscles. An expanding iliacus hematoma compresses the adjacent femoral nerve, with one study reporting 60% complete femoral nerve palsy in hemophiliacs with an iliacus or iliopsoas hemorrhage. Femoral nerve compression typically includes paresthesias in the distribution of the terminal saphenous nerve branch. Hip joint hemarthrosis may occur, but this condition is not as frequent in hemophiliacs as muscle hemorrhage into the iliacus muscle. More importantly, a hip joint hemarthrosis is not associated with significant compression of the femoral nerve. Avulsion fractures of the anterior superior iliac spine typically occur during adolescence and are not associated with saphenous nerve paresthesias. Slipped capital femoral epiphysis does not have an increased association with hemophilia and usually occurs during the adolescent years. Greene WB: Diseases related to the hematopoietic system, in Morrissy RT, Weinstein SL (eds): Lovell and Winter's Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 379-426.

The MRI scan shows increased signal intensity along the deep fibers of the supraspinatus near its insertion. This is typical of tendinosis and a probable partial-thickness rotator cuff tear. Herzog RJ: Magnetic resonance imaging of the shoulder. Instr Course Lect 1998;47:3-20.

A supracondylar fracture of the femur that occurs after total knee replacement can be treated effectively by a number of methods. For this fracture, the use of a retrograde supracondylar nail has been found to be effective in several series. The treatment of these complex injuries needs to be individualized based on the stability of the implant, the quality of the bone, and the extent of comminution of the fracture. Revision with the use of an unstemmed implant will not result in effective stabilization of the knee or the fracture.

Adult articular cartilage has less than 5% of the synthesis rate of type II collagen than that seen in developing teenagers. Both synthesis and degradation of type II collagen in normal adult articular cartilage is very low compared to children. In osteoarthrosis, both synthesis and degradation are increased, but the collagen does not properly incorporate into the matrix. Lippiello L, Hall D, Mankin HJ: Collagen synthesis in normal and osteoarthritic human cartilage. J Clin Invest 1977;59:593-600.

The incidence of injury associated with horseback rising is estimated to be one per 350 riding hours to one per 1,000 riding hours. Of these injuries, approximately 15% to 27% are severe enough to warrant hospital admission. Significant and serious injuries in equestrian activities are associated with recreational riders and those not wearing a helmet. Head and spine injuries are more common in recreational and nonhelmeted riders. Extremity injuries are more common in professional and helmeted riders. Professional riders are less likely to be admitted to the hospital than recreational riders, and are about half as likely to be disabled at 6 months after injury as recreational riders. Lim J, Puttaswamy V, Gizzi M, et al: Pattern of equestrian injuries presenting to a Sydney teaching hospital. ANZ J Surg 2003;73:567-571.

Cadaver and clinical studies have shown that the sural nerve is at the highest risk for injury with a percutaneous repair of the Achilles tendon.

Because the patient has sustained a tarsometatarsal injury with midfoot sag, the treatment of choice is a tarsometatarsal arthrodesis. The cause of his flatfoot deformity is secondary to the tarsometatarsal injury and not from posterior tibialis tendon deficiency. Lateral column lengthening, double arthrodesis, and calcaneal osteotomy are not indicated. Although open reduction and internal fixation may be performed late when arthritis is present, these procedures are less likely to succeed. Komenda GA, Myerson MS, Biddinger KR: Results of arthrodesis of the tarsometatarsal joints after traumatic injury. J Bone Joint Surg Am 1996;78:1665-1676.

Essex-Lopresti injuries affect axial stability of the forearm. Injury to the interosseous membrane or the triangular fibrocartilage complex can result in proximal migration of the radius. Morrey BF, Chao EY, Hui FC: Biomechanical study of the elbow following excision of the radial head. J Bone Joint Surg Am 1979;61:63-68.

Ceramics have the following properties: They are resorbed at varying rates, and the chemical composition of the ceramic significantly affects the rate of resorption. For example, tricalcium phosphate (TCP) undergoes biologic resorption 10 to 20 times faster than hydroxyapatite. The partial conversion of TCP to hydroxyapatite once it is in the body significantly reduces the rate of resorption. Some segments of hydroxyapatite can remain in place in the body for 7 to 10 years. In clinical trials, TCP more readily remodels because of its porosity, but it is weaker. The success of converted corals as a bone graft substitute relies on a complex sequence of events of vascular ingrowth, differentiation of osteoprogenitor cells, bone remodeling, and graft resorption occurring together with host bone ingrowth into and on the porous coralline microstructure or voids left behind during resorption. Lane JM, Bostrom MP: Bone grafting and new composite biosynthetic graft materials. Instr Course Lect 1998;47:525-534. Walsh WR, Chapman-Sheath PJ, Cain S, et al: A resorbable porous ceramic composite bone graft substitute in a rabbit metaphyseal defect model. J Orthop Res 2003;21:655-661.

Deep freezing is the simplest and most widely used method of ligament allograft storage. All cells in the tissue are destroyed with the freezing. However, for this reason, it is not a preferred storage method for menisci or cartilage allografts. Although this method may enhance success because it removes potential antigens located on the cells, it cannot guarantee elimination of HIV transmission. The advantage of cryopreservation storage is that a significant number of cells will survive the process, a factor important in meniscal allograft survival after implantation. No deleterious effects are noted clinically because of the acellularity of the tissue. Shelton WR, Treacy SH, Dukes AD, Bomboy AL: Use of allografts in knee reconstruction: I. Basic science aspects and current status. J Am Acad Orthop Surg 1998;6:165-168.

Injury to the upper trunk of the brachial plexus during birth (Erb's palsy) occurs in approximately 1 in 3,000 births. In a complete lesion, paralysis of the deltoid, supraspinatus, infraspinatus, teres minor, biceps, and brachioradialis results in the findings described above. Spontaneous recovery may occur for up to 2 years. Passive exercises administered daily by the parents are the initial recommended treatment at this age. If significant contracture results in posterior dislocation, surgical correction may be considered. Neer CS: Shoulder Reconstruction. Philadelphia, PA, WB Saunders, 1990, pp 452-454. Pearl ML: Arthroscopy release of shoulder contracture secondary to birth palsy: An early report on findings and surgical technique. Arthroscopy 2003;19:577-582.

Numerous experimental studies have shown that vertical suture techniques are superior to all of the other noted methods. In fact, vertical sutures have been shown to be twice as strong as several of these techniques. DeHaven KE: Meniscus repair. Am J Sports Med 1999;27:242-250. Dervin GF, Downing KJ, Keene GC, McBride DG: Failure strengths of suture versus biodegradable arrow for meniscal repair: An in vitro study. Arthroscopy 1997;13:296-300.

Arthrodesis of the talonavicular joint eliminates almost all hindfoot motion. Arthrodesis of the subtalar joint eliminates 74% of talonavicular motion and 44% of calcaneocuboid motion. Arthrodesis of the calcaneocuboid joint eliminates 33% of talonavicular motion and 8% of subtalar motion. Arthrodesis of the naviculocuneiform or cuboid-fifth metatarsal joint has limited effect on hindfoot motion. Astion DJ, Deland JT, Otis JC, et al: Motion of the hindfoot after simulated arthrodesis. J Bone Joint Surg Am 1997;79:241-246.

Freiberg's infraction is believed to be an osteochondrosis of the second metatarsal head. It is the only osteochondrosis that has a predilection for females. The typical patient is an athletically active adolescent female. The radiograph shows stage II disease wherein reossification is occurring; it is at this time that the second metatarsal head is most susceptible to deformation. Therefore, initial management should consist of a short leg walking cast.

The anterior border of the PCL is the most accurate and reproducible landmark for appropriate placement of the tibial tunnel for an ACL reconstruction. The central sagittal insertion point of the ACL is consistently 10 to 11 mm anterior to the anterior border of the PCL ligament. The anterior border of the tibia is not well visualized and does not serve as a reference point. While the posterior border of the anterior horn of the lateral meniscus could be used as a reference point, it has twice the variability of the PCL reference point. The posterior border of the tibia is difficult to identify and has greater variability than the PCL relative to the AP dimension of the proximal tibial surface. The anterior horn of the medial meniscus is also more variable than the PCL. Hutchinson MR, Bae TS: Reproducibility of anatomic tibial landmarks for anterior cruciate ligament reconstructions. Am J Sports Med 2001;29:777-780.

The acromial branch of the thoracoacromial trunk courses along the coracoacromial ligament. This artery enters the ligament approximately 5 mm below the acromial edge. Division of the ligament at its insertion on the acromion minimizes the risk of bleeding. Esch JC, Baker CL: Arthroscopic anatomy and normal variations, in Whipple TL (ed): Surgical Arthroscopy: The Shoulder and Elbow. Philadelphia, PA, JB Lippincott, 1993, pp 63-76.

The patient has an early prosthesis infection as a result of hematogenous seeding from dental surgery. Irrigation and debridement with polyethylene exchange and IV antibiotics have been successful in early postoperative infections; it is less likely to be effective for a late hematogenous infection. Immediate total component exchange also may be effective, but it should be reserved for failure of irrigation and debridement. Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 323-337.

The radiographs show a complex dislocation of the little finger metacarpophalangeal joint. This is characterized by obvious dislocation on the AP and lateral views and a type of bayonet apposition best visualized on the lateral view. Irreducibility of this injury is caused by displacement of the volar plate that has been traumatically avulsed from its origin on the metacarpal, with subsequent displacement into the metacarpophalangeal joint. This abnormal position of the volar plate causes irreducibility that can be corrected only by open reduction. This can be effected either by dorsal or palmar approaches. Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC (eds): Green's Operative Hand Surgery, ed 4. Philadelphia, PA, 1999, pp 711-771. Becton JL, Christian JD Jr, Goodwin HN, Jackson JG III: A simplified technique for treating the complex dislocation of the index metacarpophalangeal joint. J Bone Joint Surg Am 1975;57:698-700.

The development of a valgus deformity after this type of fracture is a well-known occurrence, and the patient's parents should be informed about this risk. In a patient who is age 4 years, the natural history is one of gradual correction by the development of a physiologic varus deformity at the distal tibial physis; therefore, no active intervention is needed at this time. Bracing has no effect on the deformity, and the child is too young for any procedure on the growth plate. Proximal tibial osteotomy is reserved until the patient nears skeletal maturity because of the risk of recurrence of the deformity. Lateral stapling can be done near skeletal maturity if the deformity persists, but this is unlikely to be necessary. Zionts LE, MacEwen GD: Spontaneous improvement of posttraumatic tibia valga. J Bone Joint Surg Am 1986;68:680-687.

The atlanto-occipital joint is inherently unstable and would easily dislocate without the supporting ligaments. The apical ligament attaches to the basion and tip of the dens but does not provide adequate stability to the joint. Werne demonstrated that dividing the tectorial membrane and the alar ligaments resulted in gross joint instability. The anterior longitudinal ligament turns into the anterior atlanto-occipital membrane. This is called a membrane rather than a ligament because it is not strong enough to support these two structures. Werne S: Studies in spontaneous atlas dislocation. Acta Orthopaedica Scandinavica 1977;23(supplement).

A ganglion cyst arising from the posterior labrum of the shoulder is a known cause of suprascapular nerve impingement. The MRI characteristics of low-signal intensity on T1 and high-signal intensity on T2 are seen in lesions with a high fluid content. The histology shows a cavity with a thin fibrous lining. Ferrick MR, Marzo JM: Suprascapular entrapment neuropathy and ganglion cysts about the shoulder. Orthopedics 1999;22:430-434.

Burks and Schaffer described an approach to the tibial insertion of the posterior cruciate ligament that uses the interval between the semimembranosus and the medial gastrocnemius. The medial gastrocnemius muscle is retracted laterally and protects the neurovascular bundle. This approach is used to repair an avulsion of the posterior cruciate ligament tibial attachment or for performing a posterior cruciate ligament tibial inlay reconstruction. Berg EE: Posterior cruciate ligament tibial inlay reconstruction. Arthroscopy 1995;8:95-99.

The patient has a flexible hallux varus that is a complication of the bunion surgery. With joints that are not arthritic and still flexible, a medial release is necessary to realign the joint. The extensor hallucis longus split transfer helps maintain position and still preserve motion at the interphalangeal joint level. Arthrodesis is a salvage procedure. Soft-tissue releases alone are most likely inadequate. Excision of the lateral sesamoid is contraindicated because that further compromises the forces resisting hallux varus. Phalangeal osteotomy would not address the medial subluxation at the metatarsophalangeal joint. Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 27-32.

Avulsion of the terminal extensor tendon from the distal phalanx (mallet or baseball finger) may or may not be associated with a bony avulsion. The injury is caused by forcible flexion of the DIP joint while catching a ball or hitting an object with the finger extended. Most authorities recommend continuous extension splinting to the DIP joint for 6 weeks, followed by nighttime splinting for an additional 6 weeks. It must be emphasized to the patient that at no time during the initial 6 weeks of treatment should the DIP joint be allowed to fall into flexion or an additional 6 weeks of continuous splinting is required. Miller MD, Cooper DE, Warner JP (eds): Review of Sports Medicine and Arthroscopy. Philadelphia, PA, WB Saunders, 1995, p 255. Rettig AC: Closed tendon injuries of the hand and wrist in the athlete. Clin Sports Med 1992;11:77-99.

Knowledge of intermuscular and internervous planes allows safe exposures throughout the body. The posterior (Thompson) approach to the proximal forearm uses the interval between the extensor carpi radialis brevis and extensor digitorum communis. The anterior (Henry) approach to the proximal forearm uses the interval between the brachioradialis and the flexor carpi radialis. Spinner M: Injuries to the Major Branches of Peripheral Nerves of the Forearm, ed 2. Philadelphia, PA, WB Saunders, 1978, pp 66-77.

Acute cauda equina syndrome, including saddle hypesthesia and bowel/bladder incontinence, is a red flag that demands emergent evaluation with MRI and urgent surgery if compression is confirmed. Results appear to be improved if surgery is performed within 48 hours. The other treatment approaches listed are not indicated if a cauda equina syndrome is present. Ahn UM, Ahn NU, Buchowski JM, et al: Cauda equina syndrome secondary to lumbar disc herniation: A meta-analysis of surgical outcomes. Spine 2000;25:1515-1522. Shapiro S: Medical realities of cauda equina syndrome secondary to lumbar disc herniation. Spine 2000;25:348-351.

A large number of etiologies of rotator cuff injury have been proposed. Both intrinsic and extrinsic mechanisms have been suggested. In the young athlete the common underlying mechanism is overuse. Contributing factors include increased laxity, anatomic variation in the coracoacromial arch, and altered kinematics. Wilkins KE: Shoulder injuries: Epidemiology, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine. Philadelphia, PA, WB Saunders, 1994, pp 175-182.

Osteoblastomas are benign lesions that represent less than 5% of benign bone tumors. Most lesions are located in the spine, followed by the femur, tibia, and skull. Patients with spinal lesions usually have pain that may be associated with scoliosis. The most common location in the spine is within the posterior elements.

The imaging studies reveal a predominantly blastic lesion in the distal femur with posterolateral periosteal changes. The bone scan shows increased uptake in the distal femur, beyond that expected with radiography. Cross-sectional imaging confirms the presence of a soft-tissue mass extending from the lateral aspect of the femur, with diffuse intramedullary signal changes. This aggressive presentation, particularly in this location and in a patient of this age, is most consistent with osteosarcoma. The mineralization in the soft tissue strongly suggests neoplasm, not the reactive bony changes seen in an infectious process. Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 175-186.

Pectoralis major ruptures typically occur in avid weightlifters (often on supplements) and typically while bench-pressing. Clinically there is significant discoloration/bruising over the pectoralis and into the axilla. MRI helps confirm the diagnosis and may help determine if the tear is in the muscle belly or at the bone-tendon junction. Bal GK, Basamania CJ: Pectoralis major tendon ruptures: Diagnosis and treatment. Tech Shoulder Elbow Surg 2005;6:128-134.

Co-planing the distal clavicle may lead to painful acromioclavicular joints in up to 35% of patients; this is felt to be related to destabilizing the distal clavicle. Intra-articular diagnosis of synovitis, degenerative joint disease, and superior labrum anterior and posterior lesions would have been identified at initial arthroscopy (not necessarily seen in open surgery). Ganglions are seen on MRI. Fischer BW, Gross RM, McCarthy JA: Incidence of acromioclavicular joint complications after arthroscopic subacromial decompression. Arthroscopy 1999;15:241-248. Hazel RM, Tasto JP, Klassen J: Arthroscopic subacromial decompression: A 9-year follow-up. Arthroscopy 1998;14:419.

The patient has a chronic flexor tendon laceration. There are options to restore motion and strength; therefore, fusion is not necessary. Full range of motion is present so the soft tissues are suitable for a tendon transfer. A transfer of the flexor digitorum superficialis of the ring finger to the insertion of the flexor pollicis longus on the distal phalanx provides good results with a one-stage operation. Schneider LH, Wiltshire D: Restoration of flexor pollicis longus function by flexor digitorum superficialis transfer. J Hand Surg Am 1983;8:98-101.

Although inadequate correction, obesity, patient age of older than 5 years and an increased metaphyseal-diaphyseal angle are all associated with a poorer outcome, the radiographs show a growth arrest of the medial tibial physis. If not recognized and treated with early surgery, progressive genu varum will occur with continued growth of the lateral physis. In addition to repeat osteotomy, options for treating the arrest include physeal bar resection or, as necessary, completion of the growth arrest by epiphyseodesis of the lateral physes, followed by a limb equalization procedure at a later date. Brooks WC, Gross RH: Genu varum in children: Diagnosis and treatment. J Am Acad Orthop Surg 1995;3:326-335. Herring JA: Tachdjian's Pediatric Orthopedics, ed 4. Philadelphia, PA, WB Saunders, 2002, pp 840-950.

The acetabular quadrants are defined by two lines: one drawn from the anterosuperior iliac spine to the posterior fovea, forming acetabular halves, and a second drawn perpendicular to the first at the midpoint of the acetabulum, forming four quadrants. The anterior quadrants should be avoided because improper screw placement may injure the external iliac artery and vein, as well as the obturator nerve, artery, and vein. These structures lie close to the pelvic bone, with little protective interposition of soft tissue. Wasielewski RC, Cooperstein LA, Kruger MP, et al: Acetabular anatomy and the transacetabular fixation of screws in total hip arthroplasty. J Bone Joint Surg Am 1990;72:501-508.

The most common location of osteosarcoma is the knee area (50% to 55%), followed by the proximal humerus and iliac wing. The most commonly involved long bone is the femur (40% to 45%), followed by the tibia (15% to 25%). Within these bones, tumors are typically adjacent to the epiphyses in most patients. The flat bones of the pelvis and spine are less frequently involved. Malawer MM, Sugarbaker PH, Malawer M: Musculoskeletal Cancer Surgery: Treatment of Sarcomas and Allied Diseases. Kluwer Academic Publishers, 2001.

Ewing's sarcoma is the second most common primary sarcoma of bone in children and young adults. It is a malignant round cell tumor with uncertain histogenesis. Sheets of uniform small round blue cells with a high nuclear-to-cytoplasm ratio and the absence of osteoid formation differentiate this histologic diagnosis from the other conditions. Immunohistochemical staining and molecular diagnostic studies are useful to verify the diagnosis.