Orthopedic Surgery Board Review MCQs: Spine & Wrist | Part 1

Figure 57a and 57b show the radiographs of a 57-year-old man who has pain in the ulnar side of the wrist and hand. Examination shows tenderness at the base of the hypothenar area. Additional diagnostic testing should include

A 10-year-old boy with an L1 myelomeningocele has a low-grade fever and a swollen thigh that is warm to touch and erythematous. AP and lateral radiographs are shown in Figures 24a and 24b. Management should consist of

A paraplegic 32-year-old man was pulling himself up in bed by grasping the headboard rails when he felt a pop and immediate pain. A radiograph and CT scan are shown in Figures 2a and 2b. Based on these findings, management should consist of

Figure 22 reveals what anatomic variant of the lumbar spine?

After reduction and pinning, the radial pulse is absent by both palpation and Doppler. Capillary refill in the fingers appears normal. What is the most likely explanation?

A patient sustained a sharp laceration to the base of his left, nondominant thumb 4 months ago. Examination reveals no active flexion but full passive motion of the interphalangeal joint. What is the best treatment option?

A 29-year-old woman who underwent an anterior cruciate ligament (ACL) reconstruction 6 months ago now reports difficulty achieving full knee extension, and physical therapy fails to provide relief. The knee is stable on ligament testing. Figure 3 shows the findings at a repeat arthroscopy. Treatment should now include

Risks associated with vertebral compression fractures in the elderly population can be defined by which of the following? Review Topic

Os naviculare is present in which percentage of normal feet?

• A 30-year-old man underwent replantation of his dominant thumb at the metacarpophalangeal joint level 2 days ago. Since replantation, the temperature of the thumb has been between 87.8 F (31 C) and 93.2 F (34 C). The temperature is now 82.4 F (28 C), and there is brisk capillary refill and venous engorgement. Management at this time should include

What antithrombotic agent is a selective factor I0a inhibitor? Review Topic

A 20-year-old collegiate baseball pitcher has persistent deep shoulder pain. Examination reveals normal strength, 130 degrees of external rotation in abduction, 10 degrees of internal rotation in abduction, mild dynamic scapular winging, and equivocal findings on provocative tests for labral tears. Management should consist of

At a minimum 2-year follow-up and compared with the metacarpophalangeal (MCP) joint, pyrolytic carbon resurfacing arthroplasties of the proximal interphalangeal (PIP) joint

A 53-year-old patient is seen in the emergency department after sustaining a fall onto her left hip. A current radiograph is shown in Figure 40. What is the best treatment option?

Figures 12a and 12b show the radiographs of a 56-year-old man with diabetes mellitus who has had left foot swelling with no pain for the past several weeks. He denies any history of trauma. Examination reveals warmth, moderate swelling, no tenderness, and mild pes planus with standing. Pulses are palpable, and his sensory examination is grossly intact to light touch. Standing radiographs are shown in Figures 12c and 12d. What is the most likely diagnosis?

A 42 year-old-woman who underwent surgery for lumbar scoliosis 2 years ago now has fixed sagittal plane imbalance and severe back pain. Which of the following is considered a contraindication to isolated pedicle subtraction osteotomy for the treatment of iatrogenic flatback syndrome in this patient?

An otherwise healthy 16-year-old boy who has had thoracolumbar pain with an increasingly worse deformity for the past 2 years now reports that the pain is worse at night. He responded well to nonsteroidal anti-inflammatory drugs initially, but they have become less effective. He denies any neurologic or constitutional symptoms. Examination is consistent with a mild thoracolumbar scoliosis and is otherwise normal. Laboratory studies show a normal CBC, erythrocyte sedimentation rate, and C-reactive protein. Standing radiographs show a 20 degrees left thoracolumbar scoliosis, and he has a Risser stage of 4. A bone scan shows increased uptake at L2; a CT scan through this level is shown in Figure 18. Management should now consist of

Disadvantages of anterior-inferior plate fixation for acute clavicular fractures relative to superior plating include

-Radiographs are shown in Figures 89a through 89c. What is the most likely diagnosis?

Which of the following is not a reported mode of failure for a constrained acetabular component?

A 70-year-old former baseball catcher reports long-standing pain in the ring and little fingers. A gradient-echo MRI scan is shown in Figure 26. What is the most likely diagnosis?

Figure 17 shows the radiograph of an 82-year-old right-hand dominant woman who fell while weeding her garden. She has severe right shoulder pain. She is neurovascularly intact. What is the most appropriate treatment? Review Topic

A 24-year-old man has bilateral hip pain. An examination and imaging studies (plain radiographs and MR imaging) confirm evidence of femoroacetabular impingement (FAI) with a CAM deformity in both hips. The patient mentions that he has a 19-year-old brother who has occasional hip pain. With respect to his brother’s pain, how should you counsel the patient?

Figures 1 and 2 are the MR arthrogram images of a 16-year-old, right-hand-dominant baseball player who injured his left shoulder 4 weeks ago during a game. He now has pain, weakness, and the inability to swing a bat and can no longer do push-ups. He denies prior injury to his left shoulder. Radiographs are unremarkable. If present, what is the most likely complication after surgical treatment in this scenario?

What is the most important preoperative factor predicting conversion to total hip arthroplasty after arthroscopic surgery of the hip?

A 77-year-old woman with osteoporosis who underwent cemented total hip arthroplasty 12 years ago fell down a flight of stairs. A radiograph is shown in Figure 15. What is the best option for treating this fracture?

Wear particles of ultra-high molecular weight polyethylene that are generated by total hip implants are predominantly of what diameter?

A 17-year-old girl who initially presented as a child with multiple skeletal lesions, café-au-lait spots, and precocious puberty now has bone pain. A recent bone scan reveals multiple areas of increased scintigraphic uptake, including bilateral proximal femurs. A radiograph is shown in Figure 19. Besides activity modification, what is the next best line of treatment for decreasing her pain? Review Topic

A previously healthy 30-year-old woman has neck pain and bilateral hand and lower extremity tingling with weakness after falling down stairs. She is alert and oriented. Examination reveals incomplete quadriplegia at the C6 level that remains unchanged throughout her evaluation and initial treatment. Radiographs show a bilateral facet dislocation of C6 on C7 without fracture. Attempts at reduction with halo cervical traction up to her body weight are unsuccessful. What is the next most appropriate step?

A healthy, active 72-year-old man trips and falls, landing on his left hip 10 weeks after an uncomplicated left primary uncemented total hip replacement. A radiograph taken 6 weeks after surgery and before the fall is shown in Figure 1. A radiograph taken after the fall is shown in Figure 2. He is unable to bear weight and is brought to the emergency department. Examination reveals a slightly shortened left lower extremity and some mild ecchymosis just distal to the left greater trochanteric region, but his skin is intact, without abrasions or lacerations. What is the most appropriate treatment?

What is the most important feature in choosing an outcome instrument to assess shoulder disorders?

What is the most common behavioral effect of anabolic steroid use in athletes?

A 70-year-old woman who underwent total knee replacement 18 months ago has had 3 weeks of moderate drainage from a previously healed wound. What is the most appropriate treatment?

A 47-year-old woman has a painful bunion of the right foot, and shoe wear modifications have failed to provide relief. Examination reveals a severe hallux valgus with dorsal subluxation of the second toe. Radiographs are shown in Figures 14a and 14b. The most appropriate management should include

At what age does the lateral epicondyle normally ossify in males?

A 24-year-old man sustains an injury to his right elbow after falling 10 feet. Radiographs are shown in Figures 41a and 41b. Treatment should consist of

An 18-year-old woman sustains a twisting injury of the knee while skiing. Figures 7a and 7b show the radiograph and coronal MRI scan of the knee. In addition to the injury shown, what is the most likely associated injury?

A 14-year-old boy has medial ankle pain, progressive unilateral flatfoot deformity, and pain with most activities of daily living. He denies any recent injury. His parents recall that at age 7 years he sustained an injury that was treated as a sprain. Examination reveals valgus deformity with painless, unrestricted passive motion of the ankle. He has grossly equal limb lengths. A radiograph of the affected ankle is shown in Figure 48a, and the contralateral ankle is shown in Figure 48b. Management should consist of

The safest surgical approach to the insertion of the tibial posterior cruciate ligament uses the interval between which of the following muscles?

Figure 23 shows the postoperative radiograph of a patient who underwent an anterior cruciate ligament (ACL) reconstruction (with bone-patella tendon-bone autograft) that failed. He initially had loss of flexion postoperatively. What is the most likely cause of this failure?

A 14-year-old female has anal hemorrhoids. The General Surgical team has asked for a consultation in regards to her history of hand, wrist, and ankle joint pain and swelling over the past 3 years. Her physical examination reveals a swollen left wrist, right knee and left ankle. Lab work shows low hemoglobin, low albumin, elevated erythrocyte sedimentation rate (ESR), elevated antinuclear antibody (ANA) count, and a negative rheumatoid factor. Radiography of the affected joints are normal. What additional work up is required prior to her rectal surgery? Review Topic

A 32-year-old male electrical worker complains of isolated left shoulder pain after a fall from 6 feet. Radiographs of the shoulder are seen in Figures A and B. The radiology technician was unable to obtain a good axillary view due to significant pain and muscle spasm. What would be the next most appropriate step in management? Review Topic

A 79-year-old woman with polyarticular rheumatoid arthritis has had progressively increasing right shoulder pain for the past year, and nonsurgical management has failed to provide relief. Her neurologic examination is entirely normal, but she is unable to elevate her arm against gravity. An AP radiograph is shown in Figure 13. Treatment should consist of

Which medication or supplement is recommended to promote healing of atypical subtrochanteric fractures?

A previously healthy 29-year-old man reports a 2-day history of severe atraumatic lower back pain. He denies any bowel or bladder difficulties and no constitutional signs. Examination is consistent with mechanical back pain. No focal neurologic deficits or pathologic reflexes are noted. What is the most appropriate management? Review Topic

The images reveal T2-weighted MRI sequences with edema isolated to the infraspinatus. In the absence of a tear in the infraspinatus tendon, the edema is most likely due to compression of the suprascapular nerve in the spinoglenoid notch. As this pathology persists, progressive muscle atrophy and fatty infiltration can result. Compression of the suprascapular nerve in the suprascapular notch would have resulted in edema and weakness in both the supra- and infraspinatus muscles. Compression is commonly caused by cysts from the joint secondary to labral tears. A rotator cuff tear of the infraspinatus is not identified on these images, and there is no history of trauma provided. There is no evidence of an anteroinferior labral tear, nor would this be expected to result in external rotation weakness or MRI abnormality of the infraspinatus. Quadrilateral space syndrome results in compression of the axillary nerve, which supplies the teres minor. Correcr answer : C 40- A 41-year-old right-hand-dominant man has been treated nonsurgically for right elbow arthritis. His radiographs reveal end-stage ulnohumeral arthritis with complete loss of the joint space. He reports pain during the mid-arc of elbow flexion and extension. During the last 8 years, he has attempted activity modification, medication, physical therapy, and multiple cortisone injections. His symptoms have progressed, resulting in constant pain, loss of a functional range of motion, and an inability to perform many activities of daily living. Secondary to his age and activity demands, he undergoes a soft-tissue interposition arthroplasty of his elbow with an Achilles allograft. Which presurgical finding correlates with elevated risk for postsurgical complications?

A 10-year-old boy has had wrist pain for the past 3 months. He denies any history of trauma. He reports mild tenderness associated with a palpable mass. A radiograph and biopsy specimens are shown in Figures 52a through 52c. What is the most likely diagnosis?

A 30 year-old male is involved in a motor vehicle collision and sustains a scapular fracture. In patients with scapular fractures, what other fracture is MOST commonly observed?

273 In an athlete who has full, painless range of motion and a normal neurological examination, which of the following is considered an absolute contraindication to participation in a collision sport such as football?

Figures 78a and 78b show the CT scans of a 22-year-old man with back pain after falling out of a tree. Examination reveals no palpable spinal step-offs, posterior spinal pain, and normal neurologic function in the lower extremities. Normal perineal sensation and normal rectal tone are present. What is the best management? Review Topic

An 85-year-old obese woman has left knee pain. She had surgery 5 years ago for a patellar nonunion after total knee arthroplasty that was complicated by infection, which was treated with implant removal and patellectomy. She has not been ambulatory since then. She states she is no longer on antibiotics. She has moderate pain, but her primary problem is instability of the knee. She has a 40° extensor lag. Darkening of the skin is present distal to the incision consistent with venous stasis changes. The erythrocyte sedimentation rate is 12 mm/h (reference range 0 to 20 mm/h) and her C-reactive protein level is 1.0 mg/L (reference range 0.08 to 3.1 mg/L). Left knee aspiration shows a white blood cell count of 800 and 20% neutrophils. What is the best next step?

A 28-year-old man sustained numerous injuries in an accident including a dislocation of the elbow and a severe closed head injury that resulted in unconsciousness. The elbow was reduced in the emergency department. After 1 month of rehabilitation, the patient reports pain and stiffness. A radiograph is shown in Figure 23. Management should now consist of

A 67-year-old woman is seen in the emergency department after falling at home. Radiographs before and after treatment are shown in Figures 49a and

A football lineman who sustained a traumatic injury while blocking during a game now reports that his shoulder is slipping while pass blocking. Examination reveals no apprehension in abduction and external rotation; however, he reports pain with posterior translation of the shoulder. He has full strength in external rotation, internal rotation, and supraspinatus testing. What is the pathology most likely responsible for his symptoms?

CLINICAL SITUATION Figures 1 through 3 are the radiographs of a 25-year-old man who is brought to the emergency department after a motorcycle collision. He is complaining of isolated knee pain. Examination reveals swelling, popliteal ecchymosis, joint line pain, and limited knee joint motion. His pulses and sensation are normal. Initial surgical management should consist of

A 21-year-old college defensive lineman sustains a minimally displaced (less than 1 mm) midthird scaphoid fracture during the first game of the season. Management should consist of

The parents of a 14-year-old female soccer player are concerned about any future injury. They have been advised that she has the potential to play for the US Olympic team. They are especially concerned about the anterior cruciate ligament (ACL). What should you advise them? Review Topic

A 60-year-old right hand-dominant women fell on her outstretched arm and sustained an anterior shoulder dislocation. The shoulder is reduced in the emergency department and she is seen for follow-up 1 week later wearing a sling. Examination reveals that she has significant difficulty raising her arm in forward elevation and has excessive external rotation compared to the contralateral shoulder. What is the next most appropriate step in management? Review Topic

Figure 18a shows the clinical photograph of a 31-year-old man who has a slowly growing nodule on his right middle finger. It is minimally tender, and there is no erythema on examination. A biopsy specimen is shown in Figure 18b. What is the most likely diagnosis?

Figure 31 shows the radiograph of an 8-year-old boy who has a swollen forearm after falling out of a tree. Examination reveals that all three nerves are functionally intact, and there is no evidence of circulatory embarrassment. Management should consist of

The patient experiences little improvement with activity modification and more physical therapy. An intra-articular corticosteroid injection provides excellent relief, but relief only lasts for 1 month. The player requests further treatment for his hip and is counseled regarding surgical intervention. Hip arthroscopy is performed. Intrasurgically, a capsulolabral separation is observed with an underlying pincer lesion. No articular cartilage injury is seen. Which treatment is most appropriate considering these findings?

An active 36-year-old woman with rheumatoid arthritis has continued forefoot discomfort despite the use of orthotics and shoe wear modifications. A radiograph and a clinical photograph are shown in Figures 26a and 26b. Treatment at this point should consist of

In a patient with rheumatoid arthritis of the wrist, which of the following extensor tendons is most at risk of rupture?

A 23-year-old woman with recurrent anterior instability undergoes an open Bankart procedure. Six months after surgery the patient reports shoulder

Two years after undergoing a total shoulder arthroplasty, a patient reports increasing pain, stiffness, and swelling, and has an increased white blood cell count. Radiographs show lucencies around the glenoid and humeral components. You suspect infection. Which of the following is the most likely responsible organism? Review Topic

A 6-year-old girl sustains an ankle injury after falling on roller blades. An AP radiograph is shown in Figure 68. Treatment should consist of which of the following?

A 13-year-old boy was evaluated for leg length difference. His pelvis balanced when a 1-inch (2.54 cm) block was placed under his left foot. History revealed he had a left distal femur physeal fracture treated with casting at age 10. Radiographs show normal limb alignment, but his left distal femoral physis is closed and his left femur is 2.5 cm shorter than the right. All other physes are open. His bone age is equal to his chronologic age. What surgical treatments will best equalize his discrepancy? Review Topic

What imaging study should be obtained next to further evaluate this patient? Review Topic

A 12-year-old boy who pitches on two “select” baseball teams has had pain in his dominant right shoulder for the past 6 weeks. The pain is present only with throwing and is associated with decreased throwing velocity and control. He has no radiation of pain or paraesthesias of the upper extremity. An AP radiograph and MRI scan are shown in Figures 19a and 19b, respectively. Management should consist of Review Topic

What is the most commonly reported complication following elbow arthroscopy?

Figures 4a through 4c show the radiographs, CT scans, and T1-weighted MRI scan of a 19-year old man who has had increasing right hip pain and decreasing range of motion for the past several years. He also reports intermittent “locking” of the hip. What is the most likely diagnosis?

Figure 10 shows the AP radiograph of an ambulatory 76-year-old patient. What is the most appropriate surgical treatment option for this patient?

A 21-year-old football player had severe pain and immediate swelling in the left anteromedial chest wall while bench pressing near maximal weights several days ago. Examination at the time of injury revealed a mass on the anteromedial chest wall. Follow-up examination now reveals decreased swelling, and axillary webbing is observed. The patient has weakness to adduction and forward flexion. The injured muscle originates from the

You are asked to evaluate the patient whose current clinical photographs are shown in Figures 46a and 46b following aortic valve replacement 9 days ago. He is currently taking anticoagulation medication. He has no systemic signs of sepsis. What is the best management?

An 83-year-old man has a painful mass of the great toe. Radiographs and a biopsy specimen are seen in Figures 22a and 22b. What is the most likely diagnosis?

A 25-year-old woman has had continuous pain after falling on her outstretched wrist 12 weeks ago. A current radiograph is shown in Figure 11. Management should consist of

A 40-year-old man has a palpable mass over the dorsum of the ankle. He reports no history of direct trauma but notes that he sustained a laceration to the middle of his leg 6 weeks ago. Examination reveals a 4-cm x 1-cm mass. T 1 - and T 2 -weighted MRI scans are shown in Figures 12a and 12b. An intraoperative photograph and biopsy specimen are shown in Figures 12c and 12d. What is the most likely diagnosis?

Based on the findings seen in the radiograph in Figure 26, emergent management should consist of

Figures 18a and 18b show the radiographs of a 13-year-old baseball player who sustained a patellar dislocation with an associated lateral femoral condyle fracture. What ligament is attached to this fragment?

A 24-year-old woman has a spleen laceration and hypotension. Radiographs reveal a pulmonary contusion and a displaced mid-diaphyseal fracture of the femur. The trauma surgeon clears her for stabilization of the femoral fracture. What technique will offer the least potential for initial complications?

Figures 39a through 39c show a clinical photograph and the radiographs of a 32-year-old woman who has been unable to actively extend her dominant ring and small finger for the past two weeks. She has no history of trauma and has minimal pain. Examination reveals full passive range of motion (ROM) of the fingers. Active ROM of the wrist is extension of 40 degrees and flexion of 35 degrees. Active forearm pronation is 45 degrees, and supination is 50 degrees. Treatment should consist of

What nerve is most likely to develop a traumatic neuroma following open reducation and internal fixation of a talar neck fracture via a posterolateral approach?

A 26-year-old man was thrown from a car and sustained the injury seen in Figures 44a and 44b. Nonsurgical management of this injury is recommended. Which of the following factors increases the risk of nonunion?

A 7-month-old girl has had a severe flatfoot deformity since birth. The talar head is prominent in the medial plantar arch of the foot. No other deformities of the spine or extremities are present. Motor and sensory examinations of the extremities are normal. Figures 37a through 37c show simulated weight-bearing AP and lateral radiographs and a planter flexion lateral view. What is the most likely diagnosis?

Patients in compensated shock (normal vital signs) are thought to be at risk for which of the following?

Figures 20a and 20b show the sagittal and coronal T1-weighted MRI scans of a patient’s left knee. Abnormal findings include

In children with isolated zone II lacerations of the flexor tendon, poor digital motion is best correlated with

A 45-year-old woman sustains an injury to her lower leg. Examination reveals that there is a deformity with no neurologic or vascular problems. The skin is intact. Radiographs are shown in Figures 46a and 46b. Which of the following factors would make closed management the least appropriate choice for this injury?

What is the most likely complication following treatment of the humeral shaft fracture shown in Figure 6?

Figure 21 shows the tomogram of a 26-year-old woman who sustained an axial load injury to her neck in a fall off a horse. What ligament is injured?

A 51-year-old woman who underwent a total knee arthroplasty 14 months ago for severe degenerative arthritis now reports progressive pain, swelling, and buckling of the knee. She must use crutches and is unable to negotiate stairs. Laboratory testing reveals a normal erythrocyte sedimentation rate and C-reactive protein. Radiographs of the patient are shown in Figures 17a through 17c. What is the most important test to further evaluate this problem?

Which of the following is most important to acheive a good outcome following a Syme amputation?

The flap shown in the clinical photograph seen in Figure 51 is based on what arterial supply?

What is the most appropriate next step in the work-up of a patient with the asymptomatic lesion shown in Figure 23?

Epithelioid sarcoma most commonly occurs in which of the following anatomic locations?

A 32-year-old woman has an isolated left posterior wall acetabular fracture in which about 25% of the wall surface is involved. Which of the following criteria would indicate the need for surgical reduction and fixation?

A 3-year-old boy with severe cerebral palsy is unable to sit independently and does not crawl. Examination reveals a 40-degree hip flexion contracture by the Thomas test and 25 degrees of passive abduction. A radiograph of the pelvis shows subluxation of both hips, with a migration index of 30%. Management should consist of

A year-old man with a history of Legg-Calve-Perthes disease underwent a right hip resurfacing 3 years ago with no perioperative complications. Hip pain has developed gradually during the last 4 months. Radiographs show no evidence of fixation loosening or any adverse changes at the femoral neck. No periarticular osteolysis is evident. What is the most appropriate management of this condition?

Figures 9a and 9b are the radiographs of a 19-year-old woman with a painful juvenile bunion. The pathologic findings associated with this deformity include a

Figures 48a and 48b are the axial and sagittal T1-weighted MR images of the L4-5 disc level of a 38-year-old man. He is symptomatic from the pathology shown. A surgeon would expect the neurological findings to include