AAOS & ABOS Orthopedic MCQs (Set 5): Spine, Arthroplasty & Pediatric Cases | 2026 Board Prep

The photomicrograph demonstrates a wedge-shaped infarct with femoral head collapse; therefore, the diagnosis is osteonecrosis of the femoral head. Perthes disease and osteoarthritis do not involve a wedge-shaped defect. Tuberculosis of the hip joint results in greater destruction of the articular cartilage. Basset LW, Mirra JM, Cracchiolo A III: Ischemic necrosis of the femoral head: Correlation between magnetic resonance imaging and histologic sections. Clin Orthop 1987;223:181-187.

The MRI scan reveals a L4-L5 foraminal disk herniation originating from the L4-5 disk space that has migrated up into the foramen, compressing the left L4 nerve root. There is normal distribution of the roots in the cerebrospinal fluid, excluding arachnoiditis as a diagnosis, and disk herniation in this location would not result in cauda equina syndrome or myelopathy.

Articular chondrocyte implantation is best performed for focal chondral defects of one area of the joint. It is not indicated for osteoarthritis. Mandelbaum BR, Brown JE, Fu F, et al: Articular cartilage lesions of the knee. Am J Sports Med 1998;26:853-861. Minas T, Nehrer S: Current concepts in the treatment of articular cartilage defects. Orthopedics 1997;20:525-538.

Cubitus varus is a common complication of displaced supracondylar humeral fractures that are treated with closed reduction and cast immobilization. Treatment with closed reduction and percutaneous pinning decreases the incidence of this complication. Cubitus varus also can occur in minimally displaced fractures when unrecognized collapse of the medial column of the distal humerus is not corrected with manipulation. This can be detected on physical examination of the carrying angle or on radiographs measuring Baumann's angle, both in comparison to the opposite side. Cubitus varus may result in unacceptable cosmesis and may predispose the patient to fractures of the lateral condyle. The lateral radiograph demonstrates the crescent sign from overlap of the distal humerus with the olecranon seen in patients with cubitus varus. Patients with growth arrest to the medial trochlear physis would have atrophy of the trochlea on radiographs. Flynn JM, Sarwark JF, Waters PM, et al: The surgical management of pediatric fractures of the upper extremity. Instr Course Lect 2003;52:635-45. Papandrea R, Waters PM: Posttraumatic reconstruction of the elbow in the pediatric patient. Clin Orthop 2000;370:115-126.

The hallmark of neurogenic shock is hypotension without tachycardia. It is associated most commonly with high cervical spinal cord injuries and results from loss of function of the sympathetic nervous system. Because the peripheral vasculature is dilated due to loss of its sympathetic tone, continued rapid administration of fluid corrects the hypotension and can quickly lead to fluid overload and congestive heart failure. Therefore, neurogenic shock is best treated by the use of pressors. Cardioversion or administration of antibiotics or systemic steroids is not appropriate treatment for this patient's hypotension. Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 179-187.

The lesion has the typical "blown out" lytic radiographic appearance that is most commonly found in thyroid or renal cell metastases. Given the history of hematuria and histology findings, the most likely diagnosis is metastatic renal cell carcinoma. This tumor is relatively resistant to chemotherapy. Radiation therapy is used as a postoperative adjuvant treatment with varying response rates. Surgery should be performed after preoperative embolization to decrease the risk of intraoperative bleeding, as no tourniquet can be used in this location. Patients with metastatic renal cell carcinomas may survive for years, resulting in a higher likelihood of local tumor progression with ineffective adjuvant therapy. Intramedullary fixation combined with curettage and cementation will provide the best chance of local control while maintaining the patient's native shoulder and elbow joints. A total humeral resection is an extensive surgery with considerable morbidity and is not indicated for this patient because less extensive surgery is likely to be effective. Harrington KD, Sim FH, Enis JE, Johnston JO, Diok HM, Gristina AG: Methylmethacrylate as an adjunct in internal fixation of pathological fractures: Experience with three hundred and seventy-five cases. J Bone Joint Surg Am 1976;58:1047-1054. Sun S, Lang EV: Bone metastases from renal cell carcinoma: Preoperative embolization. J Vasc Interv Radiol 1998;9:263-269.

The use of nasotracheal intubation is less desirable in patients with respiratory arrest because placement of the tube is most reliable when the patient is breathing. Nasotracheal intubation is advantageous in patients with suspected cervical spine trauma because it does not require hyperextension of the neck. A nasotracheal tube may be more comfortable than an orally placed tube because it is fixed at several points and moves less freely within the larynx, subglottic area, and trachea. The presence of a hemothorax or pneumothorax does not affect the choice of airway control but does require placement of a chest tube. Colice GL: Prolonged intubation versus tracheostomy in the adult. J Intern Care Med 1987;2:85.

Although this patient had a hemothorax, the bleeding has stopped and he has been resuscitated to a euvolemic status with a small base deficit and good urine output. External fixation of both femurs is an option but an unnecessary step in the treatment algorithm. Nork SE, Agel J, Russell GV, et al: Mortality after reamed intramedullary nailing of bilateral femur fractures. Clin Orthop Relat Res 2003;415:272-278.

The projection of the sacroiliac joint on the outer surface of the ilium should be well understood to avoid violation of the joint during bone graft harvesting and to help in insertion of the screw across the joint. The sacroiliac joint has superior and inferior limbs. The average lengths of the superior and inferior limbs are 4.4 cm and 5.6 cm, respectively. The average width of each limb is 2.0 cm. The average distance from the longitudinal axis of the superior limb to the posterior superior iliac spine is 5.5 cm. The average longitudinal axis of the inferior limb is 1.2 cm superior to the inferior margin of the posterior inferior iliac spine. The average angle between the two axes is 93 degrees. Figure 21c most closely shows the projection of the sacroiliac joint on the outer table of the ilium. Waldrop JT, Ebraheim NA, Yeasting RA, Jackson WT: The location of the sacroiliac joint on the outer table of the posterior ilium. J Orthop Trauma 1993;7:510-513.

The MRI scan shows a dislocated peroneus brevis tendon with disruption of the peroneal retinaculum. This injury is commonly seen in skiers and is the result of peroneal contraction with the ankle everted and dorsiflexed. Nonsurgical management is rarely successful; therefore, repair of the peroneal retinaculum is the treatment of choice. Eckert WR, Davis EA Jr: Acute rupture of the peroneal retinaculum. J Bone Joint Surg Am 1976;58:670-672. Murr S: Dislocation of the peroneal tendons with marginal fracture of the lateral malleolus. J Bone Joint Surg Br 1961;43:563-565.

A herniated cervical disk at C5-6 causes a C6 radiculopathy. There are eight cervical nerve roots and seven cervical vertebrae, and C8 exits between the C7 and T1 vertebrae. The C6 nerve root typically innervates the biceps and wrist extensor. The deltoid is predominantly innervated by C5. The wrist flexor and triceps are predominantly innervated by C7. Grip strength is predominantly a function of C8.

The long-term effect of transient quadriplegia is unknown. Based on a history of one brief episode of transient quadriplegia and normal examination and MRI findings, the risk of permanent spinal cord injury with a return to play is low. There is a risk of recurrent episodes of transient quadriplegia after the initial episode. Morganti C, Sweeney CA, Albanese SA, et al: Return to play after cervical spine injury. Spine 2001;26:1131-1136. Odor JM, Watkins RG, Dillin WH, et al: Incidence of cervical spinal stenosis in professional and rookie football players. Am J Sports Med 1990;18:507-509. Torg JS, Naranja RJ Jr, Palov H, et al: The relationship of developmental narrowing of the cervical spinal canal to reversible and irreversible injury of the cervical spinal cord in football players. J Bone Joint Surg Am 1996;78:1308-1314.

Soft-tissue sarcomas generally are treated with radiation therapy and wide surgical resection. In this patient, involvement of most of the posterior calf compartment and circumferential involvement of the posterior tibial and peroneal neurovascular bundle makes limb salvage impractical. Any attempt at wide surgical resection would leave a poorly functioning limb with questionable surgical margins. A high below-knee amputation would be the best option. Radiation therapy alone is contraindicated. Lindberg RD, Martin RG, Romsdahl MM, et al: Conservative surgery and post-operative radiotherapy in 300 adults with soft tissue sarcoma. Cancer 1981;47:2391-2397. Sim FT, Frassica FS, Frassica DA: Soft tissue tumors: Diagnosis, evaluation, and management. J Am Acad Orthop Surg 1994;2:202-211.

The radiographs show posterior instability caused by an absent posterior cruciate ligament. The tibia is significantly displaced posteriorly with respect to the femur. This can be demonstrated with a lateral radiograph obtained with the knee in flexion. The anterior cruciate ligament has been resected but is not responsible for the instability shown.

During a posterior approach to the shoulder for either a scapular fracture, glenoid fracture, or posterior shoulder pathology, the interval between the teres minor and infraspinatus is split. Excessive superior retraction on the infraspinatus, or excessive dissection superomedially under the infraspinatus muscle and tendon can cause injury to the suprascapular nerve and/or artery. During dissection in this interval, the axillary artery and axillary nerve are well protected. A branch of the circumflex scapular artery ascends between the teres minor and infraspinatus muscle, but it is at risk during dissection on the scapula in the mid portion of the interval and not during superior retraction. The profunda brachii artery is not present in this interval. Jerosch JJ, Greig M, Peuker ET, et al: The posterior subdeltoid approach: A modified access to the posterior glenohumeral joint. J Shoulder Elbow Surg 2001;10:265-268. Judet R: Surgical treatment of scapular fractures. Acta Orthop Belg 1964;30:673-678.

Anatomic positioning of the acetabular component has been shown to be the optimal position for reconstruction of the acetabulum in total hip arthroplasty for DDH. The use of medialized component positioning has been shown to be successful at maximizing the host bone coverage and minimizing the use of bone graft to structurally support the acetabular component. A small acetabular component can be used successfully as long as the femoral head is also reduced in size to maintain the thickness of the acetabular polyethylene. High and lateral positioning for the acetabular reconstruction will result in an increase in the joint reaction forces. In addition, a high and lateral placement will not provide adequate bone to stabilize the reconstruction. Numair J, Joshi AB, Murphy JC, Porter ML, Hardinge K: Total hip arthroplasty for congenital dysplasia or dislocation of the hip: Survivorship analysis and long-term results. J Bone Joint Surg Am 1997;79:1352-1360. Dorr LD, Tawakkol S, Moorthy M, Long W, Wan Z: Medial protrusio technique for placement of a porous-coated, hemispherical acetabular component without cement in a total hip arthroplasty in patients who have acetabular dysplasia. J Bone Joint Surg Am 1999;81:83-92.

The degree of acetabular dysplasia and the age of the child are important considerations when choosing what type of osteotomy to perform. The ability to obtain concentric reduction is a prerequisite of all osteotomies that redirect the acetabulum. Procedures that cut all three pelvic bones allow more displacement and, therefore, correction of acetabular dysplasia. The closer the osteotomy is to the acetabulum, the greater the coverage of the femoral head. Compared with the other acetabular osteotomies, the Ganz periacetabular osteotomy provides the greatest potential for correcting acetabular deficiency because there are no bone or ligamentous restraints to limit correction, but it has the disadvantage of being a technically demanding procedure. The amount of coverage provided by the Salter osteotomy is limited. Millis MB, Poss R, Murphy SB: Osteotomies of the hip in the prevention and treatment of osteoarthritis, in Eilert RE (ed): Instructional Course Lectures XLI. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1992, pp 145-154.

Of the levels given, T5 has the most narrow pedicle in anatomic studies. One study in patients with scoliosis did note that T7 on the concave side was more narrow than T5, but T7 is not listed here as a possible answer. O'Brien MF, Lenke LG, Mardjetko S, et al: Pedicle morphology in thoracic adolescent idiopathic scoliosis: Is pedicle fixation an anatomically viable technique? Spine 2000;25:2285-2293.

Ceramic bearings, made of alumina, have the lowest in vivo wear rates of any bearing combination, 0.5 to 2.5 Mm per component per year. Laboratory wear rates for metal-on-metal are lower than those for metal-on-polyethylene bearings, ranging from 2.5 to 5.0 Mm per year. Titanium used for bearing surfaces has a high failure rate because of a poor resistance to wear and notch sensitivity. Wear rates for ceramic-on-polyethylene bearings have varied, ranging from 0 to 150 Mm. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 47-53.

The greater trochanter is raised as a by-product of varus osteotomy, and a temporary abductor lag and lurch is common for 6 months following surgery. In the absence of hip joint subluxation, varus intertrochanteric osteotomy has no effect on the center edge angle of Wiberg. Varus osteotomy typically increases femoral offset, thereby improving the abductor lever arm and reducing the hip joint reaction force. Even without taking a wedge, varus osteotomy always produces some degree of shortening.

Findings in patients with McCune-Albright syndrome include polyostotic fibrous dysplasia, multiple cafe-au-lait spots, and precocious puberty. The bone changes in NF-1 resemble nonossifying fibromas, not fibrous dysplasia. NF-2 has little bony change with typical ocular abnormalities. Paget's disease occurs in older individuals and does not present with cafe-au-lait spots. Ollier's disease (multiple enchondromatosis) may show bone changes but not the other findings. Albright F, Butler AM, Hampton AO, et al: Syndrome characterized by osteitis fibrosa disseminata, areas of pigmentation and endocrine dysfunction with precocious puberty in females. N Engl J Med 1937;216:727-746. Danon M, Robboy SJ, Kim S, Scully R, Crawford JD: Cushing syndrome, sexual precocity, and polyostotic fibrous dysplasia (Albright syndrome) in infancy. J Pediatr 1975;87:917-921.

The trapezius is innervated by the spinal accessory nerve. The nerve is superficial in the area of the posterior cervical triangle and is prone to injury during dissection. Paralysis of the trapezius causes loss of scapular stability when forward flexion or abduction of the shoulder is attempted. Vastamaki M, Solonen KA: Accessory nerve injury. Acta Orthop Scand 1984;55:296-299.

The Vancouver classifications describes periprosthetic hip fractures in the following way. Type A fractures are in the trochanteric region. Type B1 fractures occur around the stem or at the tip in the face of a well-fixed stem. These are usually treated with open reduction and internal fixation, usually including struts, cable, and/or cable plates. Type B2 fractures occur in the same region with a loose stem. Type B3 fractures occur with a loose stem where the proximal bone is of poor quality and/or severely comminuted. Type C fractures occur well below the stem. 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 149-154. Parvizi J, Rapuri VR, Purtill JJ, et al: Treatment protocol for proximal femoral periprosthetic fractures. J Bone Joint Surg Am 2004;86:8-16.

Results show that patients who underwent humeral head replacement for fracture almost routinely report pain relief, but functional reports vary. The most commonly reported difficulty is the use of weight in the overhead position with wide variation in active elevation. Factors found to affect active elevation include age, humeral offset, greater tuberosity positioning, and four-part (as compared with three-part) fractures. Goldman RT, Koval KJ, Cuomo F, Gallagher MA, Zuckerman JD: Functional outcome after humeral head replacement for acute three- and fourth-part proximal humeral fractures. J Shoulder Elbow Surg 1995;4:81-86.

Most closed simple dislocations are best managed with early range of motion. Posterior dislocation typically occurs through a posterolateral rotatory mechanism. When placed in pronation, the elbow has greater stability when the medial ligamentous structures are intact. In traumatic dislocations, MRI rarely provides additional information that will affect treatment. In elbows that remain unstable, primary repair is preferred over ligament reconstruction. Cast immobilization increases the risk of arthrofibrosis.

Open fractures in children have similar rates of short-term complications such as compartment syndrome, vascular injury, and nerve injury when compared to adult fractures. Primary wound closure should be used for Gustillo and Anderson type 1 or uncomplicated type 2 fractures after surgical debridement. Skeletal stabilization may consist of external fixation, flexible nails, or casting with or without supplementary pin fixation. For an open comminuted midshaft fracture, external fixation is the treatment of choice. Reamed intramedullary nailing is contraindicated in children with an open physis. Plate fixation has a high complication rate in severe open fractures. Jones BG, Duncan RD: Open tibial fractures in children under 13 years of age-10 years experience. Injury 2003;34:776-780. Bartlett CS III, Weiner LS, Yang EC: Treatment of type II and type III open tibia fractures in children. J Orthop Trauma 1997;11:357-362. Robertson P, Karol LA, Rab GT: Open fractures of the tibia and femur in children. J Pediatr Orthop 1996;16:621-626.

Articular cartilage is a highly organized viscoelastic material, and load transmission depends on the specific composition of the extracellular matrix. Articular cartilage is devoid of neural, lymphatic, and blood vessel tissue. The extracellular matrix consists of water, proteoglycans, and collagen. Water comprises most of the wet weight (65% to 80%). Type II collagen comprises 95% of the collagen. The collagen and proteoglycan (keratan sulfate and chondroitin sulfate) matrix and its high water content are responsible for the mechanical properties of the articular cartilage. Buckwalter JA, Mankin HJ: Articular cartilage: Degeneration and osteoarthritis, repair, regeneration, and transplantation. Inst Course Lect 1998;47:487-504.

The debate between reamed versus unreamed intramedullary nailing of the tibia continues. Although unreamed nailing was proposed for open fractures to minimize infection, its simplicity made it appealing for closed fractures. However, most studies to date show that the only advantage of unreamed nailing is less surgical time. All studies show higher nonunion rates with increased hardware failure and increased time to union for unreamed nailing. Even in open fractures graded up to Gustilo Grade IIIA, the reamed tibial nail performs better. Larsen LB, Madsen JE, Hoiness PR, et al: Should insertion of intramedullary nails for tibial fractures be with or without reaming? A prospective, randomized study with 3.8 years' follow-up. J Orthop Trauma 2004;18:144-149.

The MRI scans reveal an enlarged posterior tibial tendon, with degenerative signal within the tendon and an excessive amount of fluid in its sheath. This is a type II tear, as noted by Conti and associates, which is the most commonly seen tear. Slovenkai MP: Clinical and radiographic evaluation (Adult flatfoot: Posterior tibial tendon dysfunction). Foot Ankle Clin 1997;2:241-260.

Fibromatosis is a benign but aggressive fibrous lesion that principally arises from the connective tissue of muscle and the overlying fascia. The peak incidence is between the ages of 25 and 35 years. Most patients have a deep-seated, firm, poorly circumscribed mass that has grown insidiously and causes little or no pain. MRI is helpful in diagnosing the lesion and in assessing the extent of disease prior to surgical intervention. Histologically, the lesion is poorly circumscribed and infiltrates the surrounding tissue. The lesion appears bland with uniform spindle cells separated by abundant collagen, with little or no cell-to-cell contact. Despite its bland microscopic appearance, the tumor frequently behaves in an aggressive manner. These lesions do not metastasize but have a high incidence of recurrence. Treatment options consist of surgical resection, radiation therapy, chemotherapeutic protocols, hormone modulation, and/or anti-inflammatory medications. Weiss SW, Goldblum JR, Enzinger FM: Enzinger and Weiss's Soft Tissue Tumors, ed 4. Philadelphia, PA, Elsevier, 2001, pp 309-337.

The radiograph reveals destruction of the femoral head with loss of the articular cartilage. These findings are consistent with an infected hip, and aspiration will confirm the diagnosis. Although the patient could have advanced osteonecrosis, typically the cartilage interval is maintained and such destruction is rarely associated with osteonecrosis.

Conversion TKA following a previous HTO can be successful; however, it is associated with poorer clinical results when compared with other primary TKAs. There is an increased likelihood of poor range of motion that is partially affected by patella infera created from the osteotomy. Patella infera also results in difficulty with surgical exposure. There has been no reported increase in the rate of infection, fracture, or loosening.

Based on the mechanism of injury and findings of medial laxity, the most likely diagnosis is injury to either the growth plate or the medial collateral ligament. With the open physeal plate, this area of injury is presumed present until proven otherwise; therefore, stress radiographs should be obtained before implementing any treatment or ordering more extensive and expensive tests. DeLee JC: Ligamentous injury of the knee, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine. Philadelphia, PA, WB Saunders, 1994, vol 3, pp 406-432. Clanton TO, DeLee JC, Sanders B, Neidre A: Knee ligament injuries in children. J Bone Joint Surg Am 1979;61:1195-1201.

Congenital dislocation of the radial head is often confused with posttraumatic dislocation. The distinguishing feature here is the dome-shaped radial head. Some patients with congenital anomalies fail to recognize their limitations until an injury occurs. Soft-tissue contractures do not cause radial head dislocation nor do they usually cause this pattern of motion restriction (mainly flexion and rotation without significant loss of extension). There is no deformity of the ulna to suggest an old Monteggia lesion. Morrey BF (ed): The Elbow and Its Disorders, ed 2. Philadelphia, PA, WB Saunders, 1993, p 196.

Symptoms of activity-related low back pain, physical findings of pain with extension, lateral bending, and resuming an upright position, and relative hamstring tightness are consistent with spondylolysis. While the initial diagnostic work-up should include plain radiographs of the lumbosacral spine, the findings may be negative because it can take weeks or months for the characteristic changes to become apparent. SPECT has been a useful adjunct in the diagnosis of spondylolysis when plain radiographs are negative. Since the patient's pain is activity related and she is otherwise healthy, evaluation for infection is not indicated. Because the neurologic examination is normal, electromyography, nerve conduction velocity studies, and MRI are not indicated. CT can be used in those instances in which SPECT and bone scans are negative. Ciullo JV, Jackson DW: Pars interarticularis stress reaction, spondylolysis, and spondylolisthesis in gymnasts. Clin Sports Med 1985;4:95-110. Collier BD, Johnson RP, Carrera GF, et al: Painful spondylolysis or spondylolisthesis studied by radiography and single photon emission computed tomography. Radiology 1985;154:207-211. Jackson DW, Wiltse LL, Cirincione RT: Spondylolysis in the female gymnast. Clin Orthop 1976;117:68-73.

An os trigonum is usually asymptomatic, but this accessory bone has been associated with persistent posterior ankle pain, which has been described as os trigonum syndrome. This usually affects athletes and ballerinas. Forced plantar flexion leads to impingement of the os trigonum against the posterior tibial plafond, and flexor hallucis tendinitis may develop. It may be difficult to differentiate a fractured trigonal process from the os trigonum. MRI may reveal bone marrow edema that may aid in the diagnosis of os trigonum syndrome. Steroid injections may lead to tendon rupture. The results of excision of a symptomatic os trigonum through a posteromedial or lateral approach are favorable, with a rapid return to full function. The main complication of this procedure is sural nerve injury with a lateral approach. Hedrick MR, McBryde AM: Posterior ankle impingement. Foot Ankle Int 1994;15:2-8.

Split posterior tibial tendon transfers are best performed in patients with spastic cerebral palsy who are between the ages of 4 and 7 years and have flexible equinovarus deformities. Rigid deformities typically require bony reconstruction procedures. Tendon transfers in patients with athetosis are unpredictable. Green NE, Griffin PP, Shiavi R: Split posterior tibial-tendon transfer in spastic cerebral palsy. J Bone Joint Surg Am 1983;65:748-754.

The MRI scan shows significant dural ectasia, which is seen in more than 60% of patients with Marfan syndrome. It is also relatively common in patients with neurofibromatosis, but this patient has no skin lesions. It has also been described in Ehlers-Danlos syndrome but is less common. Ahn NU, Sponseller PD, Ahn UM, Nallamshetty L, Kuszyk BS, Zinreich SJ: Dural ectasia is associated with back pain in Marfan' syndrome. Spine 2000;25:1562-1568.

The radiographs show a grade I slipped capital femoral epiphysis (SCFE) that is classified as stable because the child is able to bear weight. The elevated TSH level indicates possible hypothyroidism. SCFE usually occurs in boys age 12 to 14 years. Because of the patient's young age and hypothyroidism, he is at increased risk for slippage of the contralateral hip; therefore, prophylactic pinning of the uninvolved side also should be considered. Because of the risk of slip progression, crutch treatment and nonsteroidal anti-inflammatory drugs are not indicated. Realignment osteotomy is not indicated for grade I SCFE. Traction to reduce the slip, followed by pinning, has been advocated for unstable slips but is not indicated here. Loder RT, Wittenberg B, DeSilva G: Slipped capital femoral epiphysis associated with endocrine disorders. J Pediatr Orthop 1995;15:349-356.

The preferred approach is posterolateral, placing the sural nerve most at risk. The dorsal intermediate cutaneous nerve is anterolateral to the ankle, and the medial and lateral plantar branches are medial and inferior to the surgical site. The saphenous nerve is anteromedial and away from the surgical approach. Swanson TV, Bray TJ, Holmes GB Jr: Fractures of the talar neck: A mechanical study of fixation. J Bone Joint Surg Am 1992;74:544-551.

The images show a complex, lobular lesion of the thigh that has signal characteristics that follow fat. The size of the lesion, the areas of stranding within the mass, along with mild uptake on the gadolinium sequences and the mild edema within the lesion on the T2-weighted image make liposarcoma the most likely diagnosis and simple intramuscular lipoma far less likely. All other diagnoses listed would not follow fat characteristics shown on the MRI sequences.

Using the traditional concussion grading scale, the patient sustained a grade I concussion because he did not lose consciousness and his abnormal cognitive level lasted less than 1 hour. If this was the player's first concussion, theoretically he could return to play later in the game provided that he had no confusion, headache, or associated symptoms. However, because it was the third concussion for the year, participation in contact sports should be terminated for the season. Guskiewwicz KM, Barth JT: Head injuries, in Schenk RC Jr (ed): Athletic Training and Sports Medicine. Rosemont, IL, American Academy of Orthopedic Surgeons, 1999, pp 143-167.

The extensor carpi radialis brevis, supinator muscle, arcade of Frohse, and leash of Henry are potential sites of compression for the posterior interosseous nerve. The most common location of spontaneous entrapment is the arcade of Frohse. The lateral intermuscular septum is a site of compression for the radial nerve.

All of the above can be associated with myelomeningocele, but talipes equinovarus occurs in 50% to 90% of patients with myelomeningocele. Congenital vertical talus is rarely associated with any neuromuscular diseases other than myelomeningocele but is not the most common deformity in myelomeningocele. Stans AA, Kehl DK: The pediatric foot, in Baratz ME, Watson AD, Imbriglia JE (eds): Orthopaedic Surgery: The Essentials. New York, NY, Thieme, 1999, pp 702-703.

The radiographs reveal a blastic lesion of the proximal tibial metaphysis with cortical destruction, mineralization extending into the soft tissue laterally, indistinct margins, and destruction of the normal trabecular pattern. In this age group, with this aggressive appearance, osteosarcoma is the most likely diagnosis. Chondroblastoma and giant cell tumor are generally geographic and lytic. Chondrosarcoma is rare in this age group and would likely be a secondary lesion from an underlying chondroid tumor that is not present here. Whereas infection can have a wide variety of appearances, it tends to be more lytic in the acute presentation. Sanders TG, Parsons TW: Radiographic imaging of musculoskeletal neoplasia. Cancer Control 2001;8:221-231.

The patient has a periprosthetic fracture below the femoral stem. The component is porous coated and well fixed. Open reduction and internal fixation, leaving the stem in place, can be performed when bone quality is good. Plating with or without allograft struts and supplemental cerclage fixation generally is acceptable. If the component is loose, revision to a longer device is recommended with appropriate stabilization of the fracture using the aforementioned methods. If bone loss has occurred, allograft supplementation or a tumor prosthesis may be indicated. Fractures located well below the stem tip can be treated without regard for the prosthesis. Closed reduction and bracing is not associated with good results for periprosthetic femoral fractures. Retrograde intramedullary nailing is not appropriate for this fracture. Duncan CP, Masri BA: Fractures of the femur after hip replacement. Instr Course Lect 1995;44:293-304.

The images demonstrate a L5 selective root block as it exits the L5-S1 foramen. This root block best helps relieve pain or paresthesias in the L5 distribution, which is the dorsal first web space and the great toe. The lateral foot is an S1 distribution and would need to be blocked through the posterior first sacral foramen. The anterior shin and thigh represent the L4 root which exits a level above this at the L4-5 foramen. A stocking distribution is nonanatomic and not indicative of a specific root. Magee D: Principles and concepts, in Orthopaedic Physical Assessment, ed 3. Philadelphia, PA, WB Saunders, 1997, pp 1-18.

The middle genicular artery supplies the posterior capsule and intracapsular structures (anterior cruciate ligament, posterior cruciate ligament, posterior horns of the meniscus). The medial and lateral inferior geniculates anastomose anteriorly to form a capillary network to supply the fat pad, synovial cavity, and patellar tendon. The lateral superior and inferior genicular arteries supply the lateral retinaculum. Insall J, Scott WN: Anatomy, in Surgery of the Knee, ed 3. Philadelphia, PA, Churchill Livingstone, 2001, pp 64-70.

The clinical presentation of this patient is consistent with both acute osteomyelitis and Ewing's sarcoma. Both entities can be noted in the distal femoral metaphysis although Ewing's sarcoma is classically noted in the diaphysis. The histology reveals a mixed inflammatory cell infiltrate with neutrophils, plasma cells, lymphocytes, and histiocytes. Ewing's sarcoma would be a uniform population of small round blue cells without an inflammatory component. Eosinophilic granuloma (EG) is characterized by Langerhans histiocytes and eosinophils. Treatment of EG often consists of an intralesional steroid injection. Treatment of acute osteomyelitis includes surgical debridement and antibiotics. McCarthy JJ, Dormans JP, Kozin SH, et al: Musculoskeletal infections in children: Basic treatment principles and recent advancements. Instr Course Lect 2005;54:515-528.

The radiographs show the characteristic features of osteopetrosis. The condition results from defective resorption of immature bone by osteoclasts. There are three distinct clinical forms: (1) infantile-malignant, which is autosomal recessive and fatal in the first few years of life if untreated; (2) intermediate autosomal recessive; and (3) autosomal dominant. These conditions do not follow a malignant course, and patients have normal life expectancy with orthopaedic problems and anemia. In the malignant form, the clinical features include frequent fractures, macrocephaly, progressive deafness and blindness, hepatosplenomegaly, and severe anemia beginning in early infancy or in utero. Deafness and blindness are generally thought to represent effects of pressure on nerves and usually occur later in life. The anemia is caused by encroachment of bone on marrow, resulting in obliteration, and the hepatosplenomegaly is caused by compensatory extramedullary hematopoiesis. Dental caries and abscesses, as well as osteomyelitis of the mandible, are also seen. Most patients have normal intelligence. Treatment of the malignant form includes high dose 1,25 dihydroxy vitamin D with a low-calcium diet to stimulate bone resorption, not because there are vitamin deficiencies. Bone marrow transplant has also been successful. Herring JA: Tachdjian's Pediatric Orthopedics, ed 4. Philadelphia, PA, WB Saunders, 2002, p 1550. Zaleske DJ: Metabolic and endocrine abnormalities, in Morrissy RT, Weinstein SL (eds): Lovell and Winter's Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 212-214.

The patient has HMSN-III or Dejerine-Sottas syndrome. This form of HMSN progresses very rapidly and frequently results in severe foot deformity in early childhood. The changes are progressive and are the result of muscle imbalance during growth. Balancing of the foot musculature is essential, particularly during the phases of rapid growth of the foot. However, this cannot be accomplished using the anterior tibial muscle because it is already weak and the transfer will further weaken it. Bony procedures also may be required, and tendon transfers cannot be depended on to correct bony deformity. However, these procedures can be deferred until the foot is closer to adult size. Surgeries that lead to joint arthrodesis, such as triple arthrodesis and some midfoot osteotomies, are contraindicated because the feet may lose protective sensation as the disease progresses. Fusions in insensate feet are less successful than realignment procedures that maintain mobility. Wetmore RS, Drennan JC: Long-term results of triple arthrodesis in Charcot-Marie-Tooth disease. J Bone Joint Surg Am 1989;71:417-422. Roper BA, Tibrewal SB: Soft tissue surgery in Charcot-Marie-Tooth. J Bone Joint Surg Br 1989;71:17-20.

The radiographs reveal a geographic lesion of the proximal femur with the classic "ground glass" appearance noted in fibrous dysplasia. This intramedullary lesion is modestly expansile, demonstrates some minimal cortical thinning, and has no aggressive features. Chondroblastoma, giant cell tumor, and osteoblastoma are more lytic in appearance, and the location is not typical for giant cell tumor or chondroblastoma. While enchondroma may be considered, the uniform ground glass appearance, lack of punctuate mineralization, and distinct margination of the lesion make that diagnosis less likely.

Open reduction and subscapularis and lesser tuberosity transfer into the defect is the treatment of choice in young individuals who have defects that involve between 20% to 45% of the head. Disimpaction and bone grafting is an option in injuries that are less than 3 weeks old. Closed reduction 2 to 3 months after injury usually is unsuccessful and increases the risk of fracture or neurovascular injury. Total shoulder arthroplasty is reserved for defects of greater than 50% or with associated glenoid surface damage. Hemiarthroplasty should be avoided in young individuals unless 50% or more of the head is involved. Gerber C: Chronic locked anterior and posterior dislocations, in Warner JJ, Iannotti JP, Gerber C (eds): Complex and Revision Problems in Shoulder Surgery. Philadelphia, PA, Lippincott-Raven, 1997, pp 99-113.

Acetabular component loosening has been reported as the most common mode of failure following total hip arthroplasty in patients with a previous acetabular fracture. Following acetabular fracture and subsequent open reduction and internal fixation, the bone quality and vascularity are compromised, thus reducing the success rate of acetabular component cementless fixation. Jimenez ML, Tile M, Schenk RS: Total hip replacement after acetabular fracture. Orthop Clin 1997;28:435-446.

The elbow usually is stable after reduction in most elbow dislocations. Ross and associates reported that supervised motion begun immediately after reduction was effective in uncomplicated dislocations. The elbow will become stiff if immobilization is applied for an extended period of time. Immediate open treatment is not indicated for a simple elbow dislocation. Ross G, McDevitt ER, Chronister R, et al: Treatment of simple elbow dislocation using an immediate motion protocol. Am J Sports Med 1999;27:308-311.

In patients with flexion-distraction injuries of the thoracolumbar spine, 50% have associated, potentially life-threatening, visceral injuries that occasionally are diagnosed hours or even days after admission. Based on these findings, consultation with a general surgeon is recommended. Blunt and penetrating injuries to the cardiopulmonary system or aorta sometimes can be seen with this type of injury, but they are no more common than with other types of thoracolumbar fractures because of the relatively mild bony injury anteriorly. Neurologic trauma with this type of fracture is also somewhat rare. Levine AM (ed): Orthopaedic Knowledge Update: Trauma. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 351-360.

Surgical treatment is indicated for a symptomatic tarsal coalition that has failed to respond to nonsurgical management. In this patient, the radiographs reveal a calcaneonavicular coalition and no degenerative changes. The patient is symptomatic, and two attempts at use of a short leg walking cast have failed to provide relief. For calcaneonavicular coalitions, good results have been reported following resection and interposition of the extensor digitorum brevis. A retrospective study of this procedure achieved good to excellent results in 58 of 75 feet (77%). Degenerative arthritis or persistent pain following resection of a coalition is a reasonable indication for a triple arthodesis. A medial closing wedge osteotomy of the calcaneus may be indicated for a rigid flatfoot with severe valgus deformity. There are no studies documenting the long-term effectiveness of a manipulation under general anesthesia for this condition. Gonzalez P, Kumar SJ: Calcaneonavicular coalition treated by resection and interpostion of the extensor digitorum brevis muscle. J Bone Joint Surg Am 1990;72:71-77.

Passive glycation of articular cartilage occurs over decades. One of the consequences of this glycation appears to be the stiffening of collagen. This phenomenon appears to be associated with an increased collagen degradation and development of osteoarthrosis. Passive glycation also results in a relatively yellow appearance. Passive glycation does not directly influence chondrocyte proliferation. DeGroot J, Verzijl N, Wenting-van Wijk MJ, et al: Accumulation of advanced glycation end products as a molecular mechanism for aging as a risk factor in osteoarthritis. Arthritis Rheum 2004;50:1207-1215.

Intrafocal pinning allows the Kirschner wires to be placed through a site of comminution and then drilled through intact cortex. Generally Kapandji intrafocal pinning is done for dorsal comminuted extra-articular dorsal bending fractures, but it also may be used to elevate and buttress radial comminution. Simple intra-articular fractures can also be treated with pinning alone. Intrafocal pinning works best as a dorsal or radial buttress to prevent shortening. When there is volar comminution, the fracture is prone to shortening and supplemental external fixation or plating is recommended. Trumble TE, Wagner W, Hanel DP, et al: Intrafocal (Kapandji) pinning of distal radius fractures with and without external fixation. J Hand Surg Am 1998;23:381-394. Choi KY, Chan WS, Lam TP, et al: Percutaneous Kirschner-wire pinning for severely displaced distal radial fractures in children: A report of 157 cases. J Bone Joint Surg Br 1995;77:797-801.

The examination and radiographs reveal a closed fracture-dislocation of the ankle with tibiofibular diastasis. Immediate fixation of the medial malleolus and plating of the fibula are indicated. If residual tibiofibular diastasis occurs with lateral translation of the fibula after plating, a syndesmotic screw is placed to stabilize the syndesmosis. Ankle fracture-dislocations associated with a proximal fibular fracture (Maisonneuve fracture) require syndesmotic fixation, but the fibula is not plated. Unstable ankle fractures require surgical treatment. If swelling is severe (fracture blisters, loss of skin wrinkling), a compressive splint is applied and surgery is delayed for 5 to 7 days. Browner BD, Jupiter JB, Levine AM, Trafton PG: Skeletal Trauma. Philadelphia, PA, WB Saunders, 1992, pp 1887-1957.

The contents of the anterior tarsal tunnel are the extensor hallucis longus, tibialis anterior, extensor digitorum longus, dorsalis pedis artery, and the deep peroneal nerve. The term "anterior tarsal tunnel syndrome" is used to specifically describe the compression of the deep peroneal nerve under the inferior extensor retinaculum. With nerve compression, patients report a burning sensation across the dorsum of the foot with paresthesias in the first web space. There also may be wasting and weakness of the extensor digitorum brevis. Kuritz HM: Anterior entrapment syndromes. J Foot Surg 1976;15:143-148.

The recurrent laryngeal nerve provides innervation to the vocal cords and was the most common neurologic injury reported in a series of 36,000 patients. The nerve is felt to be more vulnerable during a right-sided approach because of its anatomic course. A recent study has also suggested a role for increased endotracheal cuff pressures in this nerve injury. Flynn TB: Neurologic complications of anterior cervical interbody fusion. Spine 1982;7:536-539.

Fractures that occur through the primary spongiosa at the subphyseal region of the metaphysis are highly specific for child abuse. On radiographic studies, the metaphyseal lucency in these injuries may appear as either the so-called "bucket-handle" or "metaphyseal corner" fracture. These fractures are not typical features of osteogenesis imperfecta or vitamin D-resistant rickets. The ingestion of lead may lead to thick, transverse bands of increased density at the distal metaphysis. Fractures in the subphyseal region of the metaphysis are not typically seen in children who have osteomyelitis. Kocher MS, Kasser JR: Orthopaedic aspects of child abuse. J Am Acad Orthop Surg 2000;8:10-20.

Based on these findings, the most likely diagnosis is fibrous dysplasia. Twenty percent of patients with fibrous dysplasia have multifocal disease. The lesions show a typical ground glass appearance. Fibrous dysplasia frequently involves the diaphysis of the long bones. There is no associated soft-tissue mass and no periosteal reactions to these lesions, suggesting a benign lesion. The histology shows proliferating fibroblasts in a dense collagen matrix. Trabeculae are arranged in an irregular or "Chinese letter" appearance. Osteogenic sarcoma and Ewing's sarcoma have a much different radiographic appearance of malignant osteoid and small round blue cells. Periosteal chondroma does occur in the proximal humerus but is not typically multifocal. It appears as a surface lesion with saucerization of the underlying bone and a bony buttress adjacent to the lesion. Some patients with multifocal lesions have associated endocrine abnormalities (McCune-Albright syndrome). Wold LA, et al: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990, pp 118-119.

In a young individual with a chronic dislocation of the elbow and heterotopic bone formation, the treatment of choice is open reduction, heterotopic bone excision, anterior and posterior capsular releases, and a dynamic hinged fixator to begin protected early postoperative range of motion. It is important to understand that the fixator protects the reconstruction and allows early range of motion, but it does not maintain the reduction and should not be expected to do so. Pin fixation across the elbow delays early motion and is not recommended. Total elbow arthroplasty is not indicated, and ulnohumeral arthroplasty is for a primary arthritic condition. Garland DE, Hanscom DA, Keenan MA, et al: Resection of heterotopic ossification in the adult with head trauma. J Bone Joint Surg Am 1985;67:1261-1269.

The hypoglossal nerve exits from the ansa cervicalis at approximately the C2-3 level and can be injured during retraction up to the C2 level. The superior laryngeal nerve lies at about C4-5. The facial nerve is much higher. The vagus nerve runs with the internal jugular and carotid much more laterally. The phrenic nerve exits posteriorly. Chang U, Lee MC, Kim DH: Anterior approach to the midcervical spine, in Kim DH, Henn JS, Vaccaro AR, et al (eds): Surgical Anatomy and Techniques to the Spine. Philadelphia, PA, Saunders Elsevier, 2006, pp 45-54.

A discoid meniscus is a large disk-like meniscus. It is seen in the lateral meniscus in 3% of the population; a discoid medial meniscus is much less common. It can be identified on the coronal view by noting meniscal tissue extending into the tibial spine at the intercondylar notch. The average width of a normal meniscus is less than 11 mm. A bow-tie appearance should not be seen on more than two consecutive sagittal images because the conventional thickness of the sagittal slices is 3 mm and the interval between two consecutive slices is 1.5 mm. Two sagittal slices will cover a 9-mm thickness. A discoid meniscus can be diagnosed on the sagittal views by noting a bow-tie appearance on more than two consecutive images. Helms CA: MR image of the knee, in Fundamentals of Skeletal Radiology, ed 2. Philadelphia, PA, WB Saunders, 1995, pp 172-191.

Diabetes mellitus, obesity, and exposure to steroids have all been associated with the development of Achilles tendinopathy. In addition, Achilles tendinopathy has been associated with a history of hormone replacement therapy and the use of oral contraceptives. Quinolone antibiotics have also been linked to Achilles tendinopathy. Holmes GB, Lin J: Etiologic factors associated with symptomatic Achilles tendinopathy. Foot Ankle Int 2006;27:952-959.

Ultrasound is best at imaging abrupt changes in the density of adjacent tissue and therefore is best at imaging wood in the soft tissues of the foot. Mizel MS, Steinmetz ND, Trepman E: Detection of wooden foreign bodies in muscle tissue: Experimental comparison of computed tomography, magnetic resonance imaging, and ultrasonography. Foot Ankle Int 1994;15:437-443.

Multidirectional instability is a common finding in young female athletes. The anatomic structures are all intact but are hypermobile; therefore, CT and bone scans and scapular Y-views are often normal. Obtaining a weighted or AP stress view while applying downward traction on the arm will document instability and hypermobility of the joint. MRI generally is not indicated in this condition. Ultrasound is used primarily for rotator cuff pathology. Neer CS II, Foster CR: Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder: A preliminary report. J Bone Joint Surg Am 1980;62:897-908.

The Allen and Ferguson mechanistic classification system is a useful tool for evaluating cervical spine injuries. Cervical fractures are classified as compressive extension, distractive extension, compressive flexion, distractive flexion, vertical compression, and lateral flexion. The patient has a distractive flexion injury.

The central one third has been established as the watershed zone by angiographic studies, and has been borne out in clinical conditions involving the navicular, such as stress fractures and osteonecrosis. These findings account for the susceptibility to injury at this level. Nunley JA, Pfeffer GB, Sanders RW, et al (eds): Advanced Reconstruction: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 239-242.

The presence of any curve greater than 20 degrees in a nonambulatory patient with Duchenne muscular dystrophy is an indication for posterior fusion with instrumentation. Because of progressive cardiomyopathy and pulmonary deficiency, waiting until the curve is larger can increase the risk of pulmonary or cardiac complications during or following surgery. There is some disagreement as to whether all such fusions must extend to the pelvis. Bracing or other nonsurgical management is ineffective and is not indicated in this situation. Sussman M: Duchenne muscular dystrophy. J Am Acad Orthop Surg 2002;10:138-151.

Neurologic injury after shoulder replacement is relatively uncommon, occurring in 4% of shoulders in one large series. The importance of identifying and protecting the musculocutaneous and axillary nerves cannot be overemphasized; it is especially critical during revision arthroplasty when the normal anatomic relationships have been distorted. The long deltopectoral approach leaving the deltoid attached to the clavicle was found to be significant in the development of postoperative neurologic complications. A correlation was found between surgical time and postoperative neurologic complications, with long surgical times being associated with more neurologic complications. The presumed mechanism of injury is traction on the plexus that occurs during the surgery. A neurologic injury after total shoulder arthroplasty usually does not interfere with the long-term outcome of the arthroplasty itself; it is best managed by protective measures with passive range of motion of the involved extremity. Wirth MA, Rockwood CA Jr: Complications of shoulder arthroplasty. Clin Orthop 1994;307:47-69.

The patient has aseptic loosening of the original semiconstrained prosthesis and significant proximal ulnar bone destruction; therefore, the treatment of choice is revision arthroplasty using a semiconstrained design. Although orthotic stabilization could be used, it will not provide long-term pain relief. Resection arthroplasty after removal of the components may lead to painful instability. Elbow arthrodesis would be difficult with the bone stock loss and is not considered the best option. Two main contraindications to the use of an unconstrained prosthesis are significant bone loss and previous use of a hinged or semiconstrained prosthesis. An ulnar allograft could be combined with the use of a semiconstrained long-stemmed ulnar prosthesis as a treatment modification. Ewald FC, Simmons ED Jr, Sullivan JA, et al: Capitellocondylar total elbow replacement in rheumatoid arthritis: Long-term results. J Bone Joint Surg Am 1993;75:498-507.

Brown-Sequard syndrome results from an injury to one half of the spinal cord and is characteristically seen in penetrating injuries. The spinothalamic fibers cross the midline below the level of the lesion, resulting in contralateral loss of pain and temperature sensation. The posterior columns and corticospinal tracts carry vibratory, position, and light touch sensation, as well as motor function from the ipsilateral side of the body. This results in the characteristic neurologic findings seen with Brown-Sequard syndrome. Northrup BE, Evaluation and early treatment of acute injuries to the spine and spinal cord, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 541-549.

Posterior sternoclavicular dislocations are commonly associated with tracheal compression, which can be a life-threatening condition requiring immediate reduction. The other listed complications are less common. Brooks AL, Henning GD: Injury to the proximal clavicular epiphysis, abstracted. J Bone Joint Surg Am 1972;54:1347-1348.

These lesions are emboli related to the cardiac surgery, and the patient is already on anticoagulation medication. The foot reveals no signs consistent with gangrene or infection. Unless the patient shows local or systemic signs of sepsis, the best management is observation. It is unlikely that formal debridement will be necessary. Bowker JH, Pfeiffer MA (eds): The Diabetic Foot. St Louis, MO, Mosby, 2001, pp 219-260.

This is a "borderline trauma" patient where serious consideration for damage control orthopaedic surgery is required. His prolonged hypotension, abdominal injury, and chest injury put him at higher risk for serious postinjury complications. Further surgery, such as definitive fracture fixation, adds metabolic load and injury to his system. It is prudent to consider femoral fracture stabilization with an external fixator until he is physiologically recovered as evidenced by a normal base excess and/or lactate acid levels, as well as all other parameters of resuscitation. A borderline patient has been described as polytrauma with an ISS > 20 and thoracic trauma (AIS > 2); polytrauma and abdominal/pelvic trauma (Moore > 3) and hemodynamic shock (initial BP < 90 mm Hg); ISS > 40; bilateral lung contusions on radiographs; initial mean pulmonary arterial pressure > 24 mm Hg; pulmonary artery pressure increase during intramedullary nailing > 6 mm Hg. Factors that worsen the situation following surgery include multiple long bones and truncal injury (AIS > 2), estimated surgery time of more than 6 hours, arterial injury and hemodynamic instability, and exaggerated inflammatory response (eg, Il-6 > 800 pg/mL). It is incumbent on the orthopaedic surgeon who is a member of the trauma team to make sure that he or she is aware of these factors and guides the team to the best patient care. Pape HC, Hildebrand F, Pertschy S, et al: Changes in the management of femoral shaft fractures in polytrauma patients: From early total care to damage control orthopaedic surgery. J Trauma 2002;53:452-461.

Histologically, there is metaplastic cartilage arising from the synovium. These lobules of zonates hyaline cartilage are of variable size, are embedded within edematous synovium, and protrude into the joint. The lobules calcify and ossify, leading to the characteristic radiographic appearance. Inflammatory synovitis is not characteristic of synovial chondromatosis. The fluid is clear and serosanguin, not blood tinged. Milgram JM: Synovial osteochondromatosis: A histopathological study of thirty cases. J Bone Joint Surg Am 1977;l59:792-801.

The radiograph shows a fabella, a sesamoid bone that is usually found within the tendon of the lateral head of the gastrocnemius. It can be confused with a loose body on radiographs. It occurs in 18% of patients and is often bilateral. Anderson JE (ed): Grant's Atlas of Anatomy, ed 7. Baltimore, MD, Williams & Wilkins, 1978, pp 4-69.

Treatment of shoulder instability with thermal devices has lead to numerous complications including recurrent instability, chondrolysis, stiffness, and capsular necrosis. This patient's findings are consistent with a heat-induced axillary nerve injury. Normal radiographs exclude extensive chondrolysis. Levine WN, Bigliani LU, Ahmad CS: Thermal capsulorrhaphy. Orthopedics 2004;27:823-826.

The loss of consciousness indicates a grade 2 concussion, which necessitates a 4-week period out of sport. The last week prior to return must be symptom-free and the athlete should not have symptoms in practice. Cantu RC: Return to play guidelines after a head injury. Clin Sports Med 1998;17:45-60.

The MRI scans show vertebral diskitis/osteomyelitis. The treatment of spinal infection in adults should be organism specific; therefore, initial management should consist of CT-guided closed biopsy prior to administration of antibiotic coverage. An open biopsy is indicated for a failed closed biopsy or failure of nonsurgical management. Although Staphylococcus aureus is the most common bacteria, a history of intravenous drug abuse raises suspicion for other organisms, including Pseudomonas. Tay BK, Deckey J, Hu SS: Spinal Infections. J Am Acad Orthop Surg 2002;10:188-197.

Long-term radiographic analysis of cemented total hips supports the creation of a 2- to 5-mm cement mantle in the proximal medial region. Autopsy studies have shown that the incidence of crack formation was greatest when the cement mantle was less than 2 mm. Ebramzadeh E, Sarmiento A, McKellop HA, Llinas A, Gogan W: The cement mantle in total hip arthroplasty: Analysis of long-term radiographic results. J Bone Joint Surg Am 1994;76:77-87. Jasty M, Maloney WJ, Bragdon CR, O'Connor DO, Haire T, Harris WH: The initiation of failure in cemented femoral components of hip arthroplasty. J Bone Joint Surg Br 1991;73:551-558.

Developmental coxa vara develops in early childhood and results in a progressive decrease in the proximal femoral neck-shaft angle with growth. The characteristic radiographic features are seen in this patient and include a decreased neck-shaft angle, a more vertical position of the physeal plate, and a triangular metaphyseal fragment in the inferior femoral neck, surrounded by an inverted radiolucent Y pattern. The main goal of surgery is to correct the varus angulation into a more normal range. Valgus overcorrection is preferred. A recent study emphasized the importance of adequately correcting the Hilgenreiner physeal angle to less than 38 degrees to minimize the risk of recurrent angulation. No study has documented the use of any of the other listed radiographic measurements to the outcome of treating developmental coxa vara. Carroll K, Coleman S, Stevens PM: Coxa vara: Surgical outcomes of valgus osteotomies. J Pediatr Orthop 1997;17:220-224.

The radiograph reveals disruption of the symphysis pubis and a displaced left sacral fracture. A posterior injury with displacement of greater than 1 cm is unstable, and a sacral fracture is particularly unstable. Surgical stabilization is required for these unstable anterior and posterior injuries. External fixation provides little stability to an unstable posterior pelvic injury. Reduction and internal fixation of the symphysis pubis and sacral fracture will provide the most stable pelvis with the least resultant deformity and allow patient mobilization. Tile M: Management of pelvic ring injuries, in Tile M, Helfet DL, Kellam JF (eds): Fractures of the Pelvis and Acetabulum, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 168-202.

The femoral nerve is the most lateral structure in the anterior neurovascular bundle. The femoral artery and vein lie medial to the nerve. Retractors placed in the anterior acetabular lip should be safe, although neurapraxia of the femoral nerve may occur if retraction is prolonged or forceful leading to quadriceps weakness. The femoral artery and nerve are well protected by the interposed psoas muscle. Damage to the lateral femoral cutaneous nerve, causing numbness over the anterolateral thigh, can occur while developing the interval between the tensor fascia latae and sartorious in the anterior (Smith-Petersen) approach but less likely in the Watson-Jones approach. Superior gluteal injury and accompanying abductor insufficiency may occur during excessive splitting of the glutei during the direct lateral (Hardinge) approach. Foot drop secondary to sciatic injury is more common with a posterior exposure or posterior retractor placement. Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippincott, 1984, p 325.

Acceptable alignment in both bone forearm fractures is related to age and location. In children younger than age 9 years, angulations of 15 degrees and malrotation of 45 degrees are acceptable. In children older than age 9 years, acceptable alignment is 10 degrees of angulation and 30 degrees of malrotation. Bayonet apposition is acceptable provided that the angular and rotational reductions are held within these guidelines. A long arm cast provides better control of deforming forces than a short arm cast. Do TT, Strub WM, Foad SL, et al: Reduction versus remodeling in pediatric distal forearm fractures: A preliminary cost analysis. J Pediatr Orthop B 2003;12:109-115. Flynn JM: Pediatric forearm fractures: Decision making, surgical techniques, and complications. Instr Course Lect 2002;51:355-360. Ring D, Waters PM, Hotchkiss RN, et al: Pediatric floating elbow. J Pediatr Orthop 2001;21:456-459.

The reported failure rate is in the range of 15%, which may be the result of incorrect diagnosis, improper web space selection, or formation of a stump neuroma. Therefore, the procedure should be approached with caution, measures should be taken to ensure that the diagnosis is accurate, and nonsurgical options should be exhausted. Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 101-111. Beskin JL: Nerve entrapment syndromes of the foot and ankle. J Am Acad Orthop Surg 1997;5:261-269.

The patient is in hemorrhagic shock, and timely hemostasis in the operating room should be the highest priority. Further imaging and insertion of central lines carry the risk of further delays in arresting the source of the patient's bleeding. Albumin (colloid) solutions have questionable indications, are expensive, and have been associated with increased mortality. Crystalloid solutions such as normal saline or lactated Ringer's solution are the initial resuscitative fluid of choice until blood becomes available. Pneumatic antishock garments have been associated with higher mortality rates, particularly in patients with cardiac and thoracic vascular injuries. Krettek C, Simon RG, Tscherne H: Management priorities in patients with polytrauma. Langenbecks Arch Surg 1998;383:220-227.

A compression or burst injury occurs with vertical loading of the spine, such as from a blow to the vertex with the neck flexed (eg, spear tackling in football). This leads to vertebral end plate fractures before disk injury. At higher forces, the entire vertebra and disk may explode into the spinal canal. Analysis has shown this to be the major mechanism of cervical fracture, dislocation, and quadriplegia. With the normal head-up posture, the cervical spine has a gentle lordotic curve, and forces transmitted to the head are largely dissipated in the cervical muscles. When the neck is flexed, the cervical spine becomes straight, with the vertebral bodies lined up under one another. This allows for minimal dissipation of the impact forces to be absorbed by the neck muscles. Cantu RC: Head and spine injuries in youth sports. Clin Sports Med 1995;14:517-532. Proctor MR, Cantu RC: Head and neck injuries in young athletes. Clin Sports Med 2000;19:693-715.

Clubfoot (talipes equinovarus) in patients with arthrogryposis is a rigid and resistant deformity. However, multiple studies document limited success with nonsurgical management. Manipulation and casting are generally a preliminary treatment before surgery; successful correction will most like require a talectomy. Guidera KJ, Drennan JC: Foot and ankle deformities in arthrogryposis multiplex congenita. Clin Orthop 1985;194:93-98. Handelsman JE, Badalamente MA: Neuromuscular studies in clubfoot. J Pediatr Orthop 1981;1:23-32.

Hypophosphatemic rickets is an inherited disorder that is transmitted by a unique sex-linked dominant gene. Therefore, if a male patient has a female offspring, his affected X chromosome will be transmitted and all of his female children will have hypophosphatemic rickets. All male offspring of a male patient will be unaffected. All offspring of a female patient have a 50% chance of having the disorder. Understanding the inheritance of hypophosphatemic rickets facilitates early diagnosis and early treatment. Medical treatment with phosphorus and some types of vitamin D (most authors recommend calcitriol) improves, but does not fully correct, the mineralization defect in hypophosphatemic rickets. However, if medical treatment is begun before the child begins walking, the growth plate is then adequately protected and a bowleg deformity will most likely be prevented. Evans GA, Arulanantham K, Gage JR: Primary hypophosphatemic rickets: Effect of oral phosphate and vitamin D on growth and surgical treatment. J Bone Joint Surg Am 1980;62:1130-1138.

Rupture of the central slip of the extensor mechanism and a varying degree of lateral band volar migration are the pathologic entities in an acute boutonniere injury. Splinting the proximal interphalangeal joint in full extension allows reapproximation of the central slip to the base of the middle phalanx. Distal interphalangeal joint flexion is permitted to allow movement of the lateral bands distally and dorsally, preventing contracture. Newport ML: Extensor tendon injuries in the hand. J Am Acad Orthop Surg 1997;5:59-66.

Salvage of a total elbow arthroplasty is possible with early aggressive management of acute infection (symptoms for less than 30 days) with serial irrigation and debridement and antibiotic bead placement. This form of treatment is indicated when there are no radiographic or intraoperative signs of loosening. However, successful treatment is largely dependent on the organism. Staphylococcus epidermidis is associated with persistent infection because it is an encapsulating organism, and it is best treated with implant removal and IV antibiotics. Yamaguchi K, Adams RA, Morrey BF: Infection after total elbow arthroplasty. J Bone Joint Surg Am 1998;80:481-491.

Studies have shown that when compared with fixation to the sacrum alone, the success rate of fusion across the lumbosacral junction increases when both the sacrum and ilium are included in the posterolateral construct. Curve correction, coronal balance, and pelvic balance are all attended to within the thoracolumbar spine and are not directly related to the pelvic fixation. Fretting and corrosion are a byproduct of metal-to-metal connections. Islam NC, Wood KB, Transfeldt EE, et al: Extension of fusions to the pelvis in idiopathic scoliosis. Spine 2001;26:166-173.

Treatment of patients with unplanned excision of soft-tissue sarcomas is challenging. If the margins are positive or unclear, the patient is best managed with repeat excision of the tumor bed, and radiation therapy if the repeat excision does not yield wide margins. In patients with no detectable tumor on physical examination or imaging after unplanned excision, some studies have shown that up to 35% of patients will have residual disease and a poorer local recurrence rate (22% versus 7%). Therefore, whenever feasible, a reexcision of the tumor bed is recommended.

Onlay grafts can provide more structural support than morcellized grafts. They are more easily incorporated into the host femur than bulk segmental total femur allografts; however, the incorporation is never complete. The use of onlay grafts is principally directed at addressing segmental defects of the femur; their use can be applied with either cementless or cement fixation of the femoral stem. Emerson RH Jr, Malinin TI, Cuellar AD, Head WC, Peters PC: Cortical strut allografts in the reconstruction of the femur in revision total hip arthroplasty: A basic science and clinical study. Clin Orthop 1992;285:35-44. Pak JH, Paprosky WG, Jablonsky WS, Lawrence JM: Femoral strut allografts in cementless revision total hip arthroplasty. Clin Orthop 1993;295:172-178.

There are four ways in which a plate acts: compression, tension bend, bridge or spanning, and buttress. Since there is no cortical contact with the large span of comminution, this plate is acting as a bridge plate. A bridge plate is defined as when the plate is used as an extramedullary splint attached to the two main fragments, leaving the comminution untouched.