Orthopedic Surgery Board Exam MCQs: Shoulder, Nerve, & Spine | Part 121

A 47-year-old landscaper presents with worsening left shoulder pain and weakness. Three years ago, he injured the left shoulder in a fall and elected for nonoperative management to minimize time off from work. Physical therapy was effective until 6 months ago when his shoulder function worsened to the point that he is now unable to work. Examination of his active range of motion reveals forward elevation 120° with pain, abduction 100°, IR at neutral to T8 and ER at neutral 5°. He has a positive ER lag sign and Hornblower's sign. Belly press and lift-off tests are normal. A recent radiograph is shown in Figures A. MRI images are shown in Figures B and C. Which of the following is the best treatment option? Review Topic

After performing an open distal clavicle excision and resecting 15 mm of distal clavicle, which potential concern for shoulder function could result?

A 45-year-old woman with a history of rheumatoid arthritis has C1-C2 instability with neurologic deterioration. Her posterior atlanto-dens interval is 10 mm. Which fixation technique will be the most biomechanically sound to facilitate fusion across the atlanto-axial junction?

• A 32-year-old has diffuse pain, weakness, and limited overhead motion in the shoulder as a result of falling on his outstretched arm 2 months ago. Examination reveals medial scapular winging, and an electromyogram shows denervation of the long thoracic nerve. Management should consist of

What is the function of the rotator cuff during throwing?

below show the radiographs obtained from a year-old woman with a year history of progressive hip pain in the left groin with activity, which is unresponsive to activity modification and physical therapy. Examination reveals normal range of motion, with pain on anterior impingement testing. What treatment is associated with the best long-term results?

Treatment of a cruciate-retaining total knee that is unstable in flexion is best accomplished by

Which of the following best describes the course of the median nerve at the elbow?

A study is conducted to measure the difference in bone mineral density between postmenopausal women taking a drug treatment versus those taking a placebo. What is the most important result to be reported from this study?

Figure below shows the radiograph obtained from a 68-year-old man who fell 3 weeks after undergoing a successful left primary total hip arthroplasty. He is experiencing a substantial increase in pain and an inability to bear weight. What is an appropriate treatment plan?

03 A 13 y/o girl sustains the injury shown in Figures 69a and 69b in a fall. Examination reveals this to be an isolated injury, and the patient’s neurologic and vascular examinations are normal. Based on these findings, management should consist of

What is the preferred treatment of displaced distal clavicle fractures in children less than eight years old?

Which of the following is considered the most appropriate shoe modification following transmetatarsal amputation?

A 42-year-old woman with a long-standing history of rheumatoid arthritis undergoes total shoulder arthroplasty for persistent pain that has failed to respond to nonsurgical management. Intraoperative radiographs reveal an oblique, minimally displaced fracture of the greater tuberosity. Based on these findings, what is the best course of action?

An MRI arthrogram of the elbow is shown in Figure 6. Based on these findings, what is the most likely diagnosis?

Figure 17 shows the AP radiograph of a 75-year-old man with right hip pain. The femoral component is loose. The mechanism of loosening is most likely secondary to

What is the most common complication associated with open reduction and internal fixation using a 90/90 plate configuration and olecranon osteotomy for an OTA type C2 distal humerus fracture?

A 55-year-old woman with a long history of low back and left lower extremity pain has failed to respond to exhaustive nonsurgical management. MRI scans show bulging and degeneration at L3-4 and L4-5 as well as a normal disk at L2-3 and L5-S1. She undergoes provocative lumbar diskography at L3-4, L4-5, and L5-S1. Post-diskography axial CT images of L3-4 and L4-5 are shown in Figures 6a and 6b, respectively. The injections at L3-4 and L4-5 produce no pain. The injection at L5-S1 produces 10/10 concordant back pain with radiation to the lower extremity. What is the most appropriate recommendation at this time?

A 46-year-old male sustains a patella fracture and is treated with cannulated screws and a tension band construct. Which of the following is correct regarding this treatment?

A 12-year-old girl has back pain after falling 20 feet and landing in the sitting position. She has no fractures or other injuries, and her neurologic examination is normal. A lateral radiograph, transverse CT scan, and reformatted sagittal CT scan are shown in Figures 25a through 25c. Which of the following methods is associated with the best long-term outcome? Review Topic

Figure 24 shows the sitting AP and lateral spinal radiographs of a nonambulatory 12½-year-old boy with Duchenne muscular dystrophy who is being evaluated for scoliosis. The lumbar curve from T12 to L5 measures 36 degrees, and the thoracic curve from T3 to T12 measures 24 degrees on the AP radiograph. He has 5 degrees of pelvic obliquity. His forced vital capacity is 45% of predicted for height and weight. What is the most appropriate treatment for the spinal deformity? Review Topic

An active 49-year-old woman who sustained a diaphyseal fracture of the clavicle 8 months ago now reports persistent shoulder pain with daily activities. An AP radiograph is shown in Figure 8. Management should consist of

A sagittal T1-weighted MRI scan of the knee joint is shown in Figure 23. What structure is identified by the arrow?

What complication is frequently associated with the Weil lesser metatarsal osteotomy (distal, oblique) in the treatment of claw toe deformities?

Figure A shows the 2 bundles of the ACL dissected from a cadaveric knee off their bony attachments. They are labeled Bundle A and Bundle B, respectively. Which of the following is true? Review Topic

At the time of arthroscopy, a 9-year-old boy was found to have a Watanabe type II discoid lateral meniscus. What is the most appropriate treatment? Review Topic

A 19-year-old soccer player feels a pop in his knee while making a cut and notes the development of an effusion over several hours. Examination reveals medial joint line tenderness, but the knee is stable to manual stress testing of all ligaments. Examination under anesthesia confirms a stable knee. What is the most critical factor in determining healing after repair of the lesion shown in Figure 14?

A 10-lb, 2-oz infant who was born via a difficult breech delivery 12 hours ago is now being evaluated for hip pain. Although the infant is resting comfortably, examination reveals that the patient is not moving the right lower extremity and manipulation of the right hip causes the infant to cry. The Galeazzi sign is positive. An AP radiograph of the pelvis shows proximal and superior migration of the right proximal femoral metaphysis. What is the most likely diagnosis?

BMP is FDA approved for well-defined medical conditions in limited patient populations. In which of the following clinical scenarios is use of rhBMP-2 FDA approved?

A 42-year-old female with chronic discogenic back pain undergoes lumbar spine surgery via retroperitoneal approach. Figure A is the postoperative radiograph of her lumbar spine. Six weeks after the surgery the patient develops worsening low back pain. You obtain a radiograph of her lumbar spine, pictured in Figure B. What is the next best step in management? Review Topic

A 14-year-old patient with an L3 myelomeningocele underwent anterior and posterior spinal fusion for a curve of 50°. Follow-up examination 1 week after the procedure now reveals persistent drainage from the posterior wound. Results of laboratory cultures show Streptococcus viridans, Staphylococcus aureus, and Enterococcus. In addition to IV antibiotics, surgical irrigation, and debridement, management should include

An 8-year-old boy falls and injures his thumb. A radiograph is shown in Figure 23. Initial management should consist of

03 Figure 33 shows the radiograph of a 48-year-old man who sustained a fracturedislocation of his dominant arm and a significant head injury in a fall from a roof. Eight days after injury he is medically cleared for surgery. Treatment should consist of

Late surgical treatment of posttraumatic cubitus varus (gunstock deformity) is usually necessitated by the patient reporting problems related to

At the first postoperative visit after mini-open carpal tunnel release, a patient reports hand weakness. Poor index finger interphalangeal joint extension and metacarpophalangeal joint flexion are present. This finding is most consistent with

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

What nerve is at the highest risk for injury with a percutaneous repair of an Achilles tendon injury?

A B Figures 60a and 60b are the postmyelography CT images of a 62-year-old man who has had low-back and bilateral lower-extremity pain. His pain began approximately 1 year ago and there was no precipitating event. The location of the pain is in the lower lumbar region in the midline and it radiates into the buttocks and thighs bilaterally. The pain is exacerbated by standing and walking and relieved by forward spine flexion. He reports no pain while sitting or lying supine. Upright radiographs demonstrate 4 mm of anterolisthesis of L4 on L5. What is the most appropriate surgical procedure?

The clinical photograph in Figure 27 shows a palsy of what nerve/associated muscle? Review Topic

A college basketball player is struck in the eye by a player’s hand while driving to the basket. Fluorescein evaluation reveals the injury shown in Figure 18. Management should consist of

In patients undergoing elective hip or knee arthroplasty who are not at elevated risk (beyond the risk associated with the surgery) for venous thromboembolism or bleeding, using pharmacologic agents and/or mechanical compressive devices for the prevention of venous thromboembolism was assigned what grade of recommendation by the 2011 AAOS Clinical Practice Guideline, Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty?

Which of the following is a recognized consequence of hip fusion?

Figure below shows the radiograph obtained from a 73-year-old woman who returns status post total hip arthroplasty 14 years earlier. She denies pain and has no discomfort on examination. She then undergoes revision total hip arthroplasty with head and liner exchange and bone grafting. After a physical therapy session two days after surgical intervention, she develops inability to dorsiflex the foot while she is sitting in a chair. The initial treatment should consist of

A 7-year-old girl with spinal muscular atrophy (SMA) type II has popping of the left hip. Examination reveals painless subluxation of the joint in adduction with palpable reduction in abduction. Radiographs show coxa valga, subluxation of the left hip, and pelvic obliquity with elevation of the left hemipelvis. Treatment should consist of

A 32-year-old man sustained a fracture of his upper arm in a motor vehicle accident. Radiographs are shown in Figure 32. Because of other associated injuries, surgical stabilization is chosen. What technique will result in the least complications and the best outcome?

An active 65-year-old man has pain in the left shoulder 5 years after undergoing a hemiarthroplasty. He has a remote history of two previous instability operations. Examination reveals that forward elevation is 140 degrees and external rotation is 40 degrees. Serologic studies for infection are negative. AP and axillary radiographs are shown in Figures 7a and 7b. What surgical procedure will provide the most predictable pain relief and function? Review Topic

The modified Brostrom lateral ankle ligamentous reconstruction uses which of the following structures to provide supplementary stabilization?

Figures 35a and 35b show the radiographs of a patient who underwent debridement of a chronically infected, fully constrained knee prosthesis and now reports pain and instability despite bracing. History reveals that the patient has had no drainage since undergoing the last debridement 6 months ago. A C-reactive protein level and aspiration are negative for infection. Treatment should now consist of

In the Lauge-Hansen classification system, a pronation-abduction ankle fracture has what characteristic fibular fracture pattern?

Figure 11 shows a consecutive sequence of MRI scans obtained in a 12-year-old boy who has had increasing lateral knee pain and catching for the past 6 months. Examination reveals pain localized to the lateral joint line. Range-of-motion testing reveals a 5-degree lack of full extension on the involved side. Plain radiographs and laboratory values are within normal limits. What is the most appropriate management?

Following application of a short leg cast, a patient reports a complete foot drop. A compression injury of the peroneal nerve at the fibular neck is confirmed by electrical studies. Which of the following muscles is expected to be the last to recover function during the ensuing months?

A 56-year-old woman who underwent axillary node dissection 4 months ago now reports shoulder pain, weakness of forward elevation, and obvious winging of the scapula. What structure has been injured?

Turf toe typically involves injury to which of the following structures of the great toe?

What radiographic measurement is best used to assess the adequacy of deformity correction for the patient shown in Figure 22?

An extended head hemiarthroplasty (rotator cuff tear arthropathy head) has what theoretic advantage when compared to a standard hemiarthroplasty? Review Topic

An athletic 55-year-old man reports a painless mass in the anterior aspect of the thigh that appeared 3 weeks ago and has not changed in size. The patient denies any history of trauma. Examination reveals a firm, well-defined nontender mass in the anterior thigh and no inguinal adenopathy or cutaneous changes. Plain radiographs are unremarkable. T1- and T2-weighted MRI scans are shown in Figures 44a and 44b. What is the most likely diagnosis?

A 21-year-old man has had right groin pain for the past year. A radiograph, CT scan, MRI scans, and a biopsy specimen are shown in Figures 50a through 50e. What is the most likely diagnosis?

A 57-year-old woman  experiences pain 1 year  after  total knee arthroplasty (TKA).  She reports sharp anterior pain and a painful catching sensation that is aggravated by rising from a chair or climbing stairs. Physical examination reveals a mild effusion and a range of motion of 2° to 130°, with patellar crepitus. The symptoms are reproduced by resisted knee extension. Radiographs show a well-aligned posterior- stabilized TKA without evidence of component loosening. What is the recommended treatment for this patient?

Cortical bone demonstrates viscoelastic behavior as its mechanical properties are sensitive to strain rate and duration of applied load. Regarding longitudinal strain in cortical bone, which of the following statements regarding this characteristic is true?

Which of the following best describes the mechanism of action of gentamycin?

An 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 0 mg/L (reference range 08 to 1 mg/L). Left knee aspiration shows a white blood cell count of 800 and 20% neutrophils. What is the best next step?

During an anterior approach to the bicipital 53 tuberosity, you encounter a nerve overlying the brachioradialis fascia (Figure 58). It provides innervation to the

A 25-year-old male is involved in an high-speed motor vehicle collision and sustains a closed femoral shaft fracture. During further evaluation, a CT scan of the chest/abdomen/pelvis reveals a non-displaced ipsilateral femoral neck fracture. Which of the following treatment options will most likely achieve anatomic healing of both fractures, mobilize the patient, and minimize the risk of complications?

In recurrent posterior shoulder instability, what is the recommended approach to the posterior capsule?

Which of the following anatomic changes is observed as part of the normal aging process of the adult spine?

What type of nerve palsy is most common following elbow arthroscopy?

A patient underwent an open reduction and internal fixation of a calcaneus fracture 6 months ago via an extensile lateral approach. He now reports burning pain on the lateral side of his ankle and foot. A local cortisone injection at the site of the tenderness, about 7 cm above the lateral heel, provided temporary relief of the pain. What is the recommended course of management for the persistent burning pain?

Which Morton neuroma histology is most common?

A 14-year-old boy reports progressive right wrist pain. Radiographs are shown in Figure 3a, and a photomicrograph is shown in Figure 3b. What is the most likely diagnosis?

Which of the following muscles has dual innervation?

In the absence of developmental dysplasia of the hip, what is the most common cause of osteoarthritis? Review Topic

A 40-year-old male who sustained an open pilon fracture 2 weeks ago is scheduled for a below-the-knee amputation (BKA). What laboratory value is the best predictor for wound healing?

When comparing the addition of a trough at the greater tuberosity to direct repair of cortical bone, simulated rotator cuff repair in animal models has shown what type of change in the strength of the repair?

Which of the following best describes the use of epidural morphine and steroid paste after laminectomy?

Total hip arthroplasty is most appropriate for the injury shown in Figure A for which of the following patients?

Figure 76 is the MR image of a 16-year-old high school football player who sustained a traumatic dominant shoulder dislocation during a game. On-field reduction was unsuccessful. The shoulder is reduced in the emergency department, and the player and his family followup in clinic. Which factor is most associated with failure of surgical treatment in this scenario?

A 45-year-old man who underwent an ankle arthrodesis reports that for the first 6 years he had significant pain relief after the fusion healed. However, he now has increasing pain in the sinus tarsi. AP and lateral radiographs are shown in Figures 8a and 8b. What is the most likely cause of the patient’s symptoms?

Survival rates for children with soft-tissue sarcoma other than rhabdomyosarcoma are best correlated with

A 13-year-old pitcher is hit in the left intercostal space by a line drive ball. He collapses, is apneic and unresponsive, and his radial pulse is absent. What is the next step in management? Review Topic

Figures 51a through 51c show the radiographs of a 7-year-old soccer player who reports a gradual onset of midfoot pain that began shortly after the start of soccer season. He states that the pain is worse with activity and is partially alleviated by rest. Examination reveals soft-tissue swelling, and tenderness and warmth in the region of the talonavicular and navicular cunieform joints. Management should consist of

A 63-year-old woman had a primary total hip arthroplasty 7 years ago that included a proximally coated titanium stem, a cobalt alloy femoral head, a titanium hemispherical acetabular component, and a polyethylene liner. She did well for 4 years but has now had two dislocations and reports pain and weakness around the left hip. She denies any fevers, chills, or constitutional symptoms. On examination, the patient walks well without any signs of an antalgic or Trendelenburg gait. Her abductor mechanism demonstrates good strength. Her erythrocyte sedimentation rate and C-reactive protein level are normal. On radiographs, all components appear well fixed and in good alignment. What is the most appropriate treatment at this time?

Which of the following bones is most frequently involved in stress fractures in athletes? Review Topic

A 21-year-old male construction worker fell from a roof and sustained an injury to his left foot. Radiographs and CT scans are shown in Figures 24a through 24e. Compared to nonsurgical management, surgical treatment offers which of the following advantages?

Figures below show the radiograph and the MRI scan obtained from a 37-year-old woman with a 2-month history of left hip pain. Which presurgical factor is most commonly associated with a poor outcome after a hip joint salvage procedure?

A patient with a valgus knee and lateral compartment bone loss undergoes a total knee arthroplasty using posterior condylar referencing instrumentation. Six months after surgery, the patient reports significant anterior knee pain, and radiographs reveal severe lateral patellar tilt. Management should consist of

A 25-year-old male sustains the isolated injury shown in Figure A. Antegrade intramedullary nailing is planned for definite fixation within the next 12 hours. After obtaining lateral radiographs of the injury site, what would be the next best step in management of this patient?

Which of the following is considered the treatment of choice for a chondroblastoma of the proximal tibial epiphysis without intra-articular extension?

With comparison to a below the knee amputation, each of the following are disadvantages of a through the knee amputation EXCEPT:

Which osseous landmark indicates the proximal border of the femoral insertion of the posterior cruciate ligament?

Sudden cardiac death in the young athlete is most frequently caused by

Internal impingement is characterized by which of the following anatomic lesions? Review Topic

Closed chain kinetic exercises are differentiated from open chain exercises by which of the following? Review Topic

A 38-year-old man who is an avid tennis player has had persistent pain over the medial aspect of his knee for the past 6 years. He notes that the pain occurs on a daily basis with any significant activity. Nonsteroidal anti-inflammatory drugs have failed to provide relief. Radiographs are shown in Figures 22a and 22b. What is the best course of action?

A 68-year-old man had a 3-year history of shoulder pain that failed to respond to nonsurgical management. Examination reveals forward elevation to 120 degrees and external rotation to 30 degrees. True AP and axillary radiographs and an axial CT scan are shown in Figures 1a through 1c. What management option would lead to the best long-term results? Review Topic

Figure 30 shows an axial T1-weighted MRI scan of a patient’s right shoulder. The arrows are pointing to what normal structure?

This medication, a factor Xa inhibitor, currently is not approved for venous thromboembolism (VTE) prophylaxis.

What structure has been described as having a risk of injury with retractor placement on the sacrum during combined acetabular-pelvic ring surgery using the Stoppa approach with a lateral window?

In the treatment of rheumatoid arthritis, which medication is an antagonist of tumor necrosis factor-alpha?

Which of the following complications is more likely with an inside-out repair technique compared to an all-inside techniques for a medial meniscus tear?

A 42-year-old patient has had painful inferior subluxation of the glenohumeral joint following a recent cerebrovascular accident (CVA). Figure 34 shows the AP radiograph of the shoulder. Management should consist of