Orthopedic Board Review MCQs: Elbow & Fracture Management | Part 125

A 32-year-old amateur bowler has progressive pain in the lateral aspect of the proximal forearm and elbow. Nonsurgical management consisting of a tennis elbow brace, nonsteroidal anti-inflammatory drugs, and activity modification has failed to provide relief. Examination reveals tenderness in the lateral aspect of the proximal forearm and exacerbation of symptoms with resisted finger extension. Radiographs of the elbow reveal no abnormalities. Which of the following studies will aid in diagnosis?

A 20-year-old college pitcher reports medial elbow pain after 3 innings of hard throwing. He recalls no injury and reports no pain with light throwing. The examination shown in the clinical photograph in Figure 48 reproduces the elbow pain. What is the most likely diagnosis? Review Topic

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• A clinical trial is being conducted on a new orthopaedic device that is different from existing devices that are moderately successful, but have frequent complications when used to treat fractures in the elderly. To comply with international standards for clinical trials, the investigator must include in the study design

A 72-year-old male sustains the injury shown in Figure A as a result of a fall from a ladder. Which of the following factors has been shown to be associated with increased collapse or sliding displacement?

A football player injures his knee when he is tackled and falls awkwardly. He does not note any discreet “pop,” but pain prevents him from returning to the game. An effusion is noted the following day and an MRI scan is ordered. Selected images are shown in Figures 1 through 3. Based on these images, physical examination findings likely include

Which of the following findings best describes the acetabular fracture shown in Figure 38?

A 9-year-old girl has had bilateral knee and leg pain for the past 2 years. The family has noted increasing deformity in both lower extremities. She is less than the fifth percentile for height. Examination reveals bilateral femoral bowing, mild medial-lateral laxity of the knees, and the deformities shown in the radiograph seen in Figure 3. What is the most likely diagnosis? Review Topic

A 50-year-old man undergoes revision total knee arthroplasty (TKA). The tibial component shown in Figure 153 was retrieved at the time of revision. The wear damage demonstrated on the backside of the tibial component is most likely related to which wear mechanism(s)?

A 50-year-old woman undergoes an L4-S1 laminectomy and noninstrumented fusion for degenerative spondylolisthesis.

The arrow in Figure 11 points toward a finding consistent with which of the following?

A 52-year-old man underwent arthroscopic repair of a 1-cm supraspinatus tendon tear 3 weeks ago. He was doing well until he fell down three stairs. One week after the fall he continues to report pain similar to his preoperative pain. An MRI scan reveals a minimally retracted 1-cm supraspinatus tendon tear in the same location as his original tear. Management should now consist of Review Topic

A 10-month-old infant has a deformity of the right foot. Radiographs, including simulated weight-bearing AP and lateral views and a maximum plantar flexion lateral view, are shown in Figures 57a through 57c. Initial management of the foot should consist of Review Topic

Figures below show the radiographs, MRI, and MR arthrogram obtained from a 25-year-old collegiate soccer player who has new-onset left groin pain. He played competitive soccer from a young age and has competed or practiced 5 to 6 times per week since the age of 10. He denies any specific hip injury that necessitated treatment, but his trainer contends that he had a groin pull. He reports groin pain with passive flexion and internal rotation of the left hip, and his hip has less internal rotation than his asymptomatic right hip. He is otherwise healthy.When counseling patients who have a cam deformity, the orthopaedic surgeon should note that

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. A large intra-articular and intrapelvic pseudotumor has developed. What predominant histological feature(s) is/are present in such a lesion?

A 21-year-old man who underwent repair of a distal biceps tendon rupture using a two-incision approach 4 months ago now reports difficulty gaining rotation of his forearm. Figures 49a and 49b show the AP and lateral radiographs. What is the most likely cause of his problem?

Which 2 tendons are identified in the dissection shown in Video 92?

Figure 17 shows the radiograph of a 2-year-old girl who sustained a fracture of the femur in a fall while walking with her parents. History reveals that this is her third long bone fracture, having sustained a humerus fracture 1 year ago and a fracture of the opposite femur 9 months ago. There is no family history of any similar problem. Examination reveals distinctly blue sclerae, normal appearing teeth, and no skin lesions. What is the most likely cause of this patient’s disorder?

Figures 55a through 55c are the clinical photograph and radiographs of a 5-year-old boy who fell and injured his right elbow. His radial pulse is thready. Which neurologic deficit most commonly is associated with this injury?

A 19-year-old collegiate offensive lineman injures his left elbow in a scrimmage. He reports reaching out with his left arm to prevent the defensive player from getting around him, and, as he grabbed the player, his elbow was forced into extension. He had immediate pain and weakness and heard a “pop.” He has mild swelling in the antecubital fossa and a prominent-appearing biceps muscle belly. His hook test result is abnormal at the elbow. The athlete undergoes repair of the injury, and postsurgical radiographs are shown in Figures 1 and 2. At his first postsurgical visit, he reports no pain but describes weakness in his hand and decreased sensation over his lateral forearm. Upon examination, he has decreased 2-point discrimination over the lateral forearm and an inability to actively extend his thumb and fingers at the metacarpophalangeal joints. He can extend at the finger interphalangeal joints. He can extend his wrist weakly, and it deviates radially as he extends. His distal sensation is intact. Considering his examination findings, which two nerves are injured?

A 9-year-old boy is injured while playing soccer. His examination reveals painful range of motion between 5° and 75°. There is tenderness on the medial side of his knee. There is no effusion, a grade 1A Lachman test, and severe pain over the medial epicondyle of the knee. Varus stress is negative and pain is elicited with valgus stress. Initial radiographs were negative for abnormality. Stress radiographs show a 2-mm medial physeal widening with valgus stress. What is the best initial treatment strategy for this patient?

2010 Pediatric Orthopaedic Examination Answer Book • 9 A 9-year-old girl has had bilateral knee and leg pain for the past 2 years. The family has noted increasing deformity in both lower extremities. She is less than the fifth percentile for height. Examination reveals bilateral femoral bowing, mild medial-lateral laxity of the knees, and the deformities shown in the radiograph seen in Figure 3. What is the most likely diagnosis?

A 35-year-old man reports the development of a painful 2-cm nodule on his dorsal wrist over the past 3 years. A surgeon excised the lesion with a presumptive diagnosis of a ganglion cyst. Histology sections from the excision are shown in Figures 11a and 11b. What is the most likely diagnosis?

A 21-year-old pregnant female arrives in the trauma bay with a closed head injury as well as an open ankle injury. During evaluation, what positioning is recommended to limit positional hypotension?

• A 12-year-old Little League pitcher has had pain in the dominant shoulder for the past week that prevents him from pitching. Examination reveals normal strength, full range of motion, normal stability, and mild tenderness about the proximal humerus. Radiographs with comparison views of the opposite shoulder show widening of the proximal humerus physis. Management should include

Figures 1 through 4 are the radiographs and MR images of a healthy 21-year-old woman who has had persistent dorsal wrist pain despite immobilization and no history of trauma. The surgical procedure associated with the best prognosis in this scenario is

A 45-year-old male karate instructor sustained the injury shown in Figures 40a through 40c while practicing karate. The decision to proceed with surgery depends on which of the following factors?

A 14-year-old boy has an asymptomatic mass on the right arm. MRI scans and biopsy specimens are shown in Figures 51a through 51d. Immunostaining is positive for desmin. Additional staging studies should include

Figure 27 shows the radiograph of a 26-year-old man who sustained a closed head injury and a closed elbow dislocation 6 weeks ago. Examination reveals 65 degrees to 115 degrees of flexion, and intensive physical therapy has resulted in no improvement. A decision regarding the timing of surgical correction of the contracture should be based on

What mechanism is associated with the spontaneous resorption of herniated nucleus pulposus?

What is the most appropriate treatment?

An orthopaedic surgeon in his first year of practice is negotiating with a private for-profit hospital to be their employed trauma specialist. The state of employment is known to have a high rate of malpractice claims because of a favorable plaintiff legal environment. During the course of negotiations, malpractice insurance is being discussed. The surgeon should ask the hospital to provide which type of malpractice insurance policy? Review Topic

A 2-year-old girl has the fracture shown in Figures 5a and 5b. This fracture is most commonly associated with which of the following entities? Review Topic

You are counseling a 55-year-old woman for a right carpal tunnel release. What can you tell her about the treatment benefit (grip strength and paresthesia relief) 1 year after surgery compared with continued splinting, NSAID use, physical therapy, and a single steroid injection?

A 15-year-old boy with a type I hereditary sensory motor neuropathy (Charcot-Marie-Tooth disease) reports recurrent ankle sprains and significant pain in the hindfoot and midfoot despite orthotic management. Examination reveals that he walks with a drop foot and has dynamic clawing of the toes. Clinical photographs of the left foot are shown in Figure 7. Management should consist of

Radiographs of the femur are unremarkable. A radionuclide bone scan demonstrates abnormal uptake in the mid-femur. A radionuclide bone marrow scan demonstrates decreased uptake within the marrow. Which of the following is the best step in management?

When performing the exposure for an anterior approach to the cervical spine, the surgical dissection should not enter the plane between the trachea and the esophagus and excessive retraction should be avoided to prevent injury to the

Etanercept modifies the natural history of inflammatory arthropathies through what mechanism?

A 48-year-old woman reports bilateral thigh pain that is limiting her function as a librarian. A radiograph and a bone scan are shown in Figures 23a and 23b. What is the most likely diagnosis?

Which of the following is true regarding intimate partner violence (IPV)?

A 21-year-old woman with Marfan syndrome is seeking evaluation of her scoliosis. She reports no back or leg pain, and the neurologic examination is normal. Lateral and bending radiographs are shown in Figures 7a through 7e. Management should consist of

Collagen orientation is parallel to the joint surface in what articular cartilage zone?

• Which of the following radiographic findings would be characteristic of the knee joints of a patient with neuropathic osteoarthropathy of the knee?

A 21-year-old patient has had pain and a marked decrease in active and passive shoulder motion after having had a seizure 2 months ago as the result of alcohol abuse. Current AP and axillary radiographs and a CT scan are shown in Figures 26a through 26c. Management should consist of

Figure below shows the standing AP radiograph obtained from a 55-year-old man who has a 5-year history of daily left knee medial joint line pain with weight-bearing activities. He denies night pain or symptoms of instability. On examination, his range of motion is 0° to 140°. He has a mild, fully correctable varus deformity and a negative Lachman test result. Nonsurgical treatment has failed. Unicompartmental knee arthroplasty (UKA) is discussed with the patient. The most appropriate next radiographic evaluation should be

Figure 1 shows the radiograph obtained from a 78-year-old woman who has a recent history of increasing thigh pain 12 years after undergoing total hip arthroplasty. Figure 2 depicts the radiograph obtained after she fell and was unable to ambulate. What is the most appropriate treatment?

An acetabular reinforcement cage is most often indicated for which of the following conditions?

Which of the following statements best describes the anatomic considerations of the popliteal artery posterior to the knee joint?

When performing a saline load test to evaluate for a traumatic arthrotomy of the knee, a mininum of how much saline should be utilized?

A 32-year-old motorcycle rider is involved in a motor vehicle accident and radiographs show a burst fracture at L2 with 20 degrees of kyphosis. The neurologic examination is consistent with unilateral motor and sensory involvement of the L5, S1, S2, S3, and S4 nerve roots. He has no other injuries. CT demonstrates 20% anterior canal compromise with displaced laminar fractures at the level of injury. What is the best option for management of this patient? Review Topic

Figures 2a and 2b show the clinical photograph and radiograph of a 16-year-old cheerleader who fell on her left lower extremity while performing a pyramid. Following adequate sedation, closed reduction is performed, but an incomplete reduction is noted. What structure is most likely preventing a reduction?

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

A 16-year-old boy has abdominal and back pain after being involved in a high-velocity head-on motor vehicle accident. He was restrained in the rear of the automobile by a lap belt only. A radiograph and CT scan are shown in Figure 47. The patient has no other injuries. Optimal management should include

A Canale view best visualizes which of the following structures?

A 16-year-old competitive female swimmer has a 1-year history of left shoulder pain. She denies any specific injury to her shoulder. She reports that the pain is worse with swimming but also has pain with daily activities. She also notes similar occasional symptoms in her right shoulder. Examination reveals symmetric range of motion and rotator cuff strength. Examination of the left shoulder reveals 2+ anterior and posterior translation with pain in both directions and a 2-cm sulcus sign. The right shoulder also has 2+ anterior and posterior translation and a 2-cm sulcus sign with no pain. She also has hyperextension of the elbows and the ability to touch the radial border of her thumb to her forearm. What is the next step in management? Review Topic

Which of the following conditions is transmitted by an autosomal dominant trait?

Rickets can be best characterized by which of the following radiographic changes in children?

Figures 51a and 51b show subluxation of the

A 13-year-old girl injures her ankle playing soccer. Radiographs reveal a displaced Tillaux fracture. CT scans are shown in Figure 25. What is the most important consideration for appropriate management?

A 45-year-old man has a draining sinus and recurrent infection of his right total knee arthroplasty. He has had two prior revision surgeries after the primary procedure and three other surgeries before his initial replacement,  including  a  proximal  tibial  osteotomy  and  subsequent  hardware  removal.  On  clinical examination, he has a draining sinus in the mid portion of his surgical scar and a range of motion of 5° to 85°. AP and lateral radiographs of the right knee are shown in Figures below. During surgery, the femoral component  is  found  to  be  grossly  loose,  but  the  tibial  component  is  well  fixed.  What  is  the  most appropriate  extensile  approach  that  would  provide  adequate  exposure  and  aid  in  tibial  component extraction?

Bleeding is encountered while developing the internervous plane between the tensor fascia lata and the sartorius during the anterior approach to the hip. The most likely cause is injury to what artery?

A 35-year-old construction worker has developed isolated lateral compartment arthritis. He has lost 50 pounds, now has a body mass index of 30, and still has pain that limits his activities of daily living and work despite receiving a 4-month course of nonsteroidal anti-inflammatory medications and 2 intra-articular cortisone injections. His range of motion is 5 to 110 degrees, and his mechanical axis is 18 degrees of valgus. What is the most appropriate surgical treatment for this patient?

below shows the standing AP radiograph obtained from a year-old man who has a year history of daily left knee medial joint line pain with weight-bearing activities. He denies night pain or symptoms of instability. On examination, his range of motion is 0° to 140°. He has a mild, fully correctable varus deformity and a negative Lachman test result. Nonsurgical treatment has failed. Unicompartmental knee arthroplasty (UKA) is discussed with the patient. The most appropriate next radiographic evaluation should be

Which of the following is a true statement regarding thoracic disk herniations?

When placing a percutaneous retrograde pubic rami screw for fixation of an acetabular fracture, which of the following radiographic views can best ensure that the screw does not exit the posterior aspect of the superior pubic ramus?

A patient sustains a comminuted calcaneus fracture. Three months after the injury the patient complains of shoewear problems secondary to clawing of the lesser toes. What is the most likely explanation for this deformity?

A coach of three football teams—the B team, junior varsity team, and varsity team—wants to study the average times in the 40-yard dash for his players. Which test would help him determine if the mean 40-yard dash times for the athletes on one team are different from those on the other teams?

Figure 40 shows the MRI scan of a 23-year-old man with a history of recurrent anterior shoulder instability. What is the most likely diagnosis? Review Topic

• Figures 59a and 59b show the plain radiographs, and Figures 59c and 59d show the CT scan of a 77-year-old woman who has had pain in her back and both buttocks for the past 6 months. She reports that the pain radiates down her right thigh and leg when she is standing. What is the most likely diagnosis?

Examination of a 13-year-old boy with asymptomatic poor posture reveals increased thoracic kyphosis that is fairly rigid and accentuates during forward bending. The neurologic examination is normal. Spinal radiographs show 10 degrees of scoliosis at Risser stage 2, and there is no evidence of spondylolisthesis. A standing lateral view of the thoracic spine is shown in Figure 41. The kyphosis corrects to 50 degrees. Management should consist of

Which of the following best characterizes the antigenicity of allograft bone?

Which of the following is an indication for surgical management of a Weber type B distal fibular fracture?

A 28-year-old man sustained a shoulder dislocation 2 years ago. It remained dislocated for 3 weeks and required an open reduction. He now reports constant pain and has only 60 degrees of forward elevation and 10 degrees of external rotation. He desires to return to some sporting activities. An AP radiograph and intraoperative photograph (a view of the humeral head through a deltopectoral approach) are shown in Figures 31a and 31b. What is the best treatment option to decrease pain and improve function?

The mechanism for the osseous destruction is attributable to

What approach should be chosen for the injury seen in Figure 67? Review Topic

A 51-year-old man sustained an open fracture of his tibia in Korea 42 years ago. An infection developed and it was resolved with surgical treatment. For the past 6 months, an ulcer with mild drainage has developed over the medial tibia. The ulcer is small and there is minimal erythema at the ulcer site. A radiograph and MRI scan are shown in Figures 43a and Figure 43b. Initial cultures show Staphylococcus aureus susceptible to the most appropriate antibiotics. Laboratory studies show an erythrocyte sedimentation rate of 70 mm/h. What is the most appropriate surgical treatment at this time?

Residual end-organ hypoperfusion in a polytraumatized patient is shown by which of the following?

Following an episode of transient quadriplegia in contact sports, an athlete’s return to play is absolutely contraindicated when

A 45-year-old male auto mechanic presents to your office with left lateral elbow pain for 6 weeks. On physical exam he has tenderness to palpation over the lateral epicondyle and pain with resisted wrist extension. An MRI is shown in figures A and B. After failing non-surgical treatment modalities, he undergoes arthroscopic surgical management. At 3 months post-operatively, the patient reports persistent left elbow pain and an audible clicking since surgery which occurs when he lifts heavy objects and when he pushes himself up out of a chair. What is the best surgical treatment option? Review Topic

Which of the following growth factors binds and activates the lipoprotein receptor-related protein 5/6 (LRP5/6) during bone development? Review Topic

Figure 50 shows the cross table lateral radiograph of a 31-year-old paratrooper who has recalcitrant groin pain. The pain is worse after activities such as standing or sitting (driving). Examination reveals that pain can be reproduced by internal rotation of the leg with the hip and knee in 90 degrees of flexion. Extensive nonsurgical management has failed to provide relief. What is the treatment of choice?

Which of the following is true regarding changes in the vascularity of the adult intervertebral disc with age? Review Topic

A 30-year-old man landed on his shoulder in a fall off his mountain bike. An AP radiograph and CT scan are shown in Figures 34a and 34b. Management should consist of

Figures 42a through 42c show the MRI scans of a 56-year-old woman with progressively worsening low back and bilateral lower extremity pain. Based on these images, what muscle or muscle group would be expected to be weak on physical examination? Review Topic

A 29-year-old female has sustained the acute injury shown in Figure A. Which of the following is an indication for open reduction internal fixation in this patient?

Figure 62 is an arthroscopic view of the intercondylar notch of a right knee from an anterolateral portal. What is the main function of the structure delineated by the black asterisks? Review Topic

A 17-year-old cross country athlete runs 7 miles per day, 6 days per week. She has new-onset right groin pain. Passive flexion of her hip is normal, but internal rotation of the hip, resisted hip flexion, and knee extension reproduce the pain. Hip radiograph findings are normal. What is the best next step?

Immobilization with a sling

Second-impact syndrome following a concussion

A 13-year-old boy sustains a valgus stress injury to the knee while playing football, and he is unable to bear weight after the injury. Examination reveals tenderness medially superior to the joint line. The knee is held in flexion, and he has a large effusion and localized medial swelling. Plain radiographs show no obvious fracture. What is the next diagnostic step?

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?

Among patients with lumbar degenerative disk disease and low back pain, what factor is most predictive of clinical outcomes after surgical management? Review Topic

The use of posting (a wedge added to the medial or lateral side of an insole) is useful to balance forefoot or hindfoot malalignment. Assuming normal subtalar joint pronation, what is the maximum amount of recommended hindfoot posting?

A 47-year-old woman has a right bunion that has been symptomatic despite modifications in shoe wear. She requests surgical correction. An AP radiograph is shown in Figure 37. Treatment should consist of

Evaluation of the percent of necrosis in the resected specimen after preoperative chemotherapy is of prognostic value for what type of sarcoma?

A patient undergoes excision of a 3- x 3-cm soft-tissue sarcoma. The final histology results show tumor at the surgical margin. The surgical procedure performed is classified as

A patient reports progessive bilateral hand clumsiness and ataxia. Examination reveals a positive Hoffmann’s sign and intrinsic atrophy. MRI reveals multilevel cervical spondylosis, and lateral flexion and extension radiographs show cervical kyphosis in the neutral position, with restoration of lordosis on extension. Which of the following procedures is most likely to result in poor long-term results?

A 16-year-old cheerleader reports an ache in the right shoulder and arm that is worse after activity. She denies any history of acute trauma. Examination reveals a positive sulcus sign and an AP glide test with a posterior and anterior apprehension sign. To confirm a diagnosis of multidirectional instability, which of the following imaging studies is most appropriate?

Compared to metal-on-polyethylene total hip bearing surfaces, the debris particles generated by metal-on-metal articulations are

In addition to radiographs of the primary lesion and chest, MRI of the primary lesion, and CT of the chest, staging studies for Ewing’s sarcoma should include which of the following?