Orthopedic Board Review MCQs: Elbow, Hip & Nerve Pt 127

About This Board Review Set

This is Part 127 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

This set has been strictly audited and contains 100 100% verified, high-yield multiple-choice questions (MCQs) modelled on the exact format of the Orthopaedic In-Training Examination (OITE) and the American Academy of Orthopaedic Surgeons (AAOS) board examinations.

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Topics Covered in Part 127

This module focuses heavily on: Arthroscopy, Elbow, Hip, Nerve.

Sample Questions from This Set

Sample Question 1: Figure 1 shows the radiograph and Figure 2 shows the MRI scan obtained from a 37-year-old woman with amonth history of left hip pain. Which combination of a single symptom and examination finding is most likely in this scenario?...

Sample Question 2: A 16-year-old boy with osteochondritis dissecans of the capitellum has intermittent symptoms of catching and locking. Examination is unremarkable. Radiographs reveal a loose body anteriorly with a diameter of 10 mm. To remove the loose body...

Sample Question 3: Pharmacoprophylaxis should be avoided in favor of a pneumatic compression device for a patient with...

Sample Question 4: -An athletic 30-year-old sustained multiple injuries in a high-speed motor vehicle collision that resulted in a loss of approximately 30% of blood volume. On arrival to the emergency department, the heart rate is100 and blood pressure is 10...

Sample Question 5: In the most common condition causing a winged scapula, which of the following nerves is affected? Review Topic...

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Evidence consistently demonstrates that active recall through spaced MCQ practice yields substantially greater long-term retention than passive reading alone (Roediger & Karpicke, 2006). All questions in this specific module have been algorithmically verified for clinical integrity and complete explanations.

Comprehensive 100-Question Exam

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Question 1

Figure 1 shows the radiograph and Figure 2 shows the MRI scan obtained from a 37-year-old woman with a month history of left hip pain. Which combination of a single symptom and examination finding is most likely in this scenario?

Explanation

MRI reveals an anterior labral tear, and the radiograph shows minimal arthritis with possible dysplasia. The most common location of pain in patients with a labral tear is the groin, and the most common physical finding is a positive impingement test result. Pain during sitting, clicking, and buttock pain are frequently described by patients with a labral tear, but these symptoms are less common than groin pain. A positive posterior impingement test finding is more common in patients with a posterior labral tear. Although age over 40 years and a body mass index higher than 30 can adversely affect clinical outcomes after joint preservation procedures such as PAO, hip arthroscopy, and femoral acetabular impingement surgery, the presence of hip arthritis on presurgical radiographs is the most commonly mentioned cause of failed hip joint preservation surgery. Tönnis grade is a radiographic measure of hip arthritis. A higher Outerbridge score is associated with more frequent poor outcomes after hip arthroscopy; however, the Outerbridge cartilage score is determined by direct visualization at the time of surgery. The Outerbridge score cannot be determined presurgically.

Question 2

A 16-year-old boy with osteochondritis dissecans of the capitellum has intermittent symptoms of catching and locking. Examination is unremarkable. Radiographs reveal a loose body anteriorly with a diameter of 10 mm. To remove the loose body, elbow arthroscopy is being considered. Which of the following procedures would minimize the risk of neurovascular complication during the procedure?

Explanation

DISCUSSION: Complications of elbow arthroscopy are usually minor or temporary. However, serious complications include nerve injuries. The deep radial nerve is the closest to any of the portals, resting as close as 1 mm away from the scope inserted in the anterolateral portal. The capsule can be displaced anteriorly by distending the joint with about 25 mL of saline solution, thus moving the deep radial nerve approximately 1 cm anteriorly and decreasing the risk of injuring it while establishing the anterolateral portal. Keeping plastic cannulae in the portals may help to diminish fluid extravasation and swelling, which is more of an impediment than a serious complication. The image intensifier has no documented role in guiding loose body removal. While the proximal anteromedial portal is probably the safest anterior portal to establish, it is actually easier to remove a large loose body from this portal while viewing it from an anterolateral position. There is less tendon and muscle bulk to pass through at the site of the proximal anteromedial portal than at the anterolateral portal, making it less likely for the loose body to get stuck in the soft tissues. Techniques have been developed to permit removal of loose bodies as large as 2 cm in diameter without breaking them up into pieces. If it is possible to remove a large loose body intact, doing so greatly simplifies and shortens the procedure.
REFERENCES: Lynch GJ, Meyers JF, Whipple TL, Caspari RB: Neurovascular anatomy and elbow arthroscopy: Inherent risks. Arthroscopy 1986;2:190-197.
O’Driscoll S: Loose bodies and synovial conditions, in Green D, Hotchkiss R, Pederson W (eds): Green’s Operative Hand Surgery. New York, NY, Churchill Livingstone, 1999, pp 235-249.

Question 3

Pharmacoprophylaxis should be avoided in favor of a pneumatic compression device for a patient with

Explanation

DISCUSSION
For patients with known bleeding disorders, a pneumatic compression device alone is recommended over pharmacoprophylaxis to minimize risk for excessive bleeding and wound complications. Factor VIII deficiency (hemophilia) and active liver disease are the 2 conditions for which support is strongest to withhold anticoagulation. Protein C deficiency and protein S deficiency are associated with increased risk for thrombosis, as is the factor V Leiden mutation.
RESPONSES FOR QUESTIONS 159 THROUGH 162
Lateral femoral cutaneous
Superior gluteal
Inferior gluteal
Obturator
Sciatic
Which nerve listed above is at increased risk for injury when performing hip surgery through the following approaches?

Question 4

-An athletic 30-year-old sustained multiple injuries in a high-speed motor vehicle collision that resulted in a loss of approximately 30% of blood volume. On arrival to the emergency department, the heart rate is100 and blood pressure is 104/62. The best means with which to evaluate true hemodynamic status is

Explanation

Question 5

In the most common condition causing a winged scapula, which of the following nerves is affected? Review Topic

Explanation

A winged scapula is most often associated with Parsonage-Turner syndrome, a condition thought to be due to an inflammatory or immune-mediated mechanism. Certain muscles are predisposed, particularly the serratus anterior muscle innervated by the long thoracic nerve. Other less common nerve lesions (eg, the spinal accessory and dorsal scapular nerves) may also cause winged scapulae.

Question 6

A 23-year-old soccer player sustains a grade III complete posterior cruciate ligament (PCL) tear after colliding with another player. In reconstructing the PCL, it is optimal to reconstruct the

Explanation

DISCUSSION: The PCL is a nonisometric structure with nonuniform tension during knee motion, with maximum tension at 90° of flexion. While the posteromedial PCL fibers have been found to be the most isometric, the anterolateral fibers represent the bulk of the ligament. Studies have suggested that anterior placement of the femoral tunnel is superior to placement in an isometric position. The anterolateral bundle tightens as the knee flexes; therefore, it is optimal to tension the graft at 90° of flexion.
REFERENCES: Harner CD, Xerogeanes JW, Livesay GA, et al: The human posterior cruciate ligament complex: An interdisciplinary study. Ligament morphology and biomechanical evaluation. Am J Sports Med 1995;23:736-745.
Burns WC II, Draganich LF, Pyevich M, Reider B: The effect of femoral tunnel position and graft tensioning technique on posterior laxity of the posterior cruciate ligament-reconstructed knee. Am J Sports Med 1995;23:424-430.

Question 7

-An absolute contraindication for closed management of a humeral shaft fracture in a fracture brace is

Explanation

Question 8

When treating a proximal tibia fracture, the surgeon decides to (1) use blocking screws in the proximal fragment, and (2) pick the intramedullary nail based on the location of the Herzog curve. Which of the following combinations will best prevent the classic deformity associated with this fracture?

Explanation

Proximal tibial fractures develop an apex anterior (procurvatum) and valgus malalignment. Blocking (poller) screws should be placed in the concavity of the deformity, thus posterior and lateral to the nail. The Herzog curve should be proximal to the fracture site.
Up to 58% of proximal tibial fractures are malaligned. Malalignment arises because the nail fits loosely in the wide metaphyses and cannot control alignment. Without close fit of the nail at the fracture site, the nail will not align the fracture independent of a stable reduction and careful nail path. Blocking screws serve to reduce the size of the proximal metaphyseal canal and guide final nail passage.
Stinner et al. discuss strategies in proximal tibial fracture nailing. They describe an accurate starting point (using the twin peaks AP view or fibular bisector AP view, and flat plateau lateral view). They emphasize fracture reduction prior to reaming and implant placement.
Hiesterman reviewed nailing of extra-articular proximal tibial fractures. Techniques described include blocking screws, unicortical plating, using a universal distractor, nailing in flexion/locking in extension, semiextended nailing (including percutaneous suprapatellar quads-splitting approaches), multiple proximal interlocking screws (>=3).
Illustration A shows placement of a coronal blocking screw. Illustration B shows placement of a sagittal blocking screw. Illustration C shows the effect of the Herzog curve. A more distal Herzog curve leads to a "wedge" effect and fracture displacement whereas a proximal Herzog curve contains the fracture. The "wedge" effect occurs as the nail is seated and impinges on the posterior cortex of the distal segment accentuating an apex anterior deformity because of the effective widening of the nail above the bend and posterior force on the distal segment to match the nail shape.
Incorrect Answers:

Question 9

Anterior subluxation in a throwing athlete is most commonly the result of

Explanation

DISCUSSION: Subtle anterior subluxation in the throwing athlete most frequently results from excessive capsular laxity because of repetitive microtrauma. Avulsion of the inferior glenohumeral ligament from the glenoid, or more rarely from the humerus, occurs with macrotrauma. A large Hill-Sachs lesion and a glenoid rim fracture also may result from a traumatic anterior dislocation.
REFERENCES: Kvitne RS, Jobe FW: The diagnosis and treatment of anterior instability in the throwing athlete. Clin Orthop 1993;291:107-123.
Jobe FW, Tibone JE, Jobe CM, Kvitne RS: The shoulder in sports, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1999, pp 961-990.

Question 10

Figures 36a and 36b show the radiographs of a 48-year-old woman who smokes cigarettes and sustained a segmental femoral shaft fracture in a motor vehicle accident 9 months ago. Initial management consisted of stabilization with a reamed statically locked intramedullary nail. She now reports lower leg pain that increases with activity. In addition to advising the patient to quit smoking, management should include

Explanation

DISCUSSION: The patient has an oligotrophic nonunion of the distal femoral fracture. Although the proximal fracture appears incompletely united, it was stable at exchange nailing. The treatment of choice is exchange reamed nailing to at least 2 mm above the nail in place. Bone grafting is debatable. Recent studies have shown a 70% to 75% success rate with exchange nailing only, so in nonhypertrophic nonunions, bone grafting can be considered. Nonsurgical management consisting of observation or external stimulation runs the risk of implant failure. Plate fixation is acceptable but is considered a second choice because of the need to consider stabilization of the proximal fracture until union is achieved. Also, plate fixation definitely requires bone grafting.
REFERENCES: Webb LX, Winquist RA, Hansen ST: Intramedullary nailing and reaming for delayed union or nonunion of the femoral shaft: A report of 105 consecutive cases. Clin Orthop 1986;212:133-141.
Weresh MJ, Hakanson R, Stover MD, et al: Failure of exchange reamed intramedullary nailing for ununited femoral shaft fractures. J Orthop Trauma 2000;14:335-338.
Hak DG, Lee SS, Goulet JA: Success of exchange reamed intramedullary nailing for femoral shaft nonunion or delayed union. J Orthop Trauma 2000;14:178-182.

Question 11

A 19-year-old collegiate middistance runner has a 4-year history of bilateral leg pain. Pain begins within 10 minutes after starting to run and is described as a “tightness and cramping in the front of the legs.” Symptoms resolve within 15 to 20 minutes of running cessation. A presumptive diagnosis of exercise-induced compartment syndrome (EICS) is made, and the patient elects to undergo compartmental pressure testing. What is the strongest indication for elective fasciotomy of the anterior compartment?

Explanation

DISCUSSION
This clinical scenario describes a patient with EICS, marked by a nonphysiologic rise in muscle compartment pressure during exercise. Pressure testing is the best currently accepted method of diagnosis. Most physicians use the following criteria for diagnosis: resting pressure higher than 15 mm Hg, 1-minute postexercise pressure higher than 30 mm Hg, or 5-minute postexercise pressure higher than 20 mm Hg. Only 1-minute postexercise anterior compartment pressure of 42 mm Hg meets these criteria. Neurologic symptoms in the plantar foot would imply involvement of the posterior compartments and would not support the diagnosis of anterior compartment involvement.

Question 12

What is the second most common primary bone malignancy in children?

Explanation

DISCUSSION: Ewing’s sarcoma is the second most common bone tumor in children with an incidence of three per one million Caucasian children younger than 21 years of age. Ewing’s sarcoma is rare in African Americans. Osteosarcoma is the most common bone tumor in children. Rhabdomyosarcoma is the most common soft-tissue sarcoma in children. Fibrosarcoma is a rare primary bone tumor most commonly seen in adults. Adamantinoma is a rare primary bone malignancy also most commonly seen in adults in the tibia.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 195.
Gibbs CP Jr, Weber K, Scarborough MT: Malignant bone tumors. Instr Course Lect 2002;51:413-428.

Question 13

A 9-year-old boy sustained a traumatic brain injury and right lower extremity trauma in an accident involving a motor vehicle and a pedestrian. Initial evaluation in the emergency department reveals an obtunded patient who is breathing spontaneously and withdraws appropriately to painful stimuli. After initial resuscitation and stabilization, a CT scan reveals a right parietal intracranial hemorrhage. Radiographs of the swollen right thigh are shown in Figures 32a and 32b. Management of the fractured femur should ultimately consist of

Explanation

DISCUSSION: A child with a traumatic brain injury generally achieves significant neurologic recovery and has a more favorable prognosis than an adult. Early stabilization of fractures facilitates transportation of the child for diagnostic tests and decreases the incidence of shortening and malunion. Surgical treatment of the fracture is indicated when cerebral perfusion pressure has stabilized. Casting or traction is not the most appropriate treatment of a femoral fracture in a child of this age with a brain injury. Fracture reduction is difficult to maintain if the brain injury leads to spasticity, and transportation within the hospital for tests is more difficult. Insertion of a reamed antegrade intramedullary nail inserted at the piriformis fossa is associated with a small risk of osteonecrosis of the femoral head. The transverse femoral fracture in this patient is ideally suited for stabilization with flexible intramedullary nails. Ligier and associates treated 123 femoral shaft fractures in children with flexible intramedullary nails, including

35 patients with head injury. In one patient with hemiplegia and a urinary tract infection, a deep wound infection developed, necessitating nail removal. The remaining patients all healed without major complications. Heinrich and associates treated 78 diaphyseal femoral fractures with flexible intramedullary nails, including 14 with head injury. No major complications were reported and all fractures healed.
REFERENCES: Tolo VT: Management of the multiply injured child, in Rockwood CA, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996,

pp 83-95.
Ligier JN, Metaizeau JP, Prevot J, et al: Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg Br 1988;70:74-77.
Heinrich MS, Drvaric DM, Darr K, et al: The operative stabilization of pediatric diaphyseal femur fractures with flexible intramedullary nails: A prospective analysis. J Pediatric Orthop 1994;14:501-507.
Canale ST, Tolo VT: Fractures of the femur in children. Instr Course Lect 1995;44:255-273.

Question 14

Which modality has the broadest application for the reduction of postsurgical transfusion?

Explanation

DISCUSSION:
TXA is easy to administer, inexpensive, and safe for virtually all patients. Multiple studies have demonstrated transfusion rates lower than 3% for total knee arthroplasty and lower than 10% for total hip arthroplasty. Regional and hypotensive anesthesia effectively reduce transfusion; however, they cannot be used in as wide a range of patients as can TXA. A reduced transfusion trigger must be considered along with patient symptoms when determining the need for transfusion.

Question 15

A 35-year-old male sustains a closed tibial shaft fracture after falling from 12 feet. Which of the following measurements would be concerning for an evolving compartment syndrome?

Explanation

DISCUSSION: A delta P (diastolic blood pressure minus compartment pressure measurement)of < 30 mmHg is an indication for fasciotomies with the caveat that the diastolic pressure is measured either pre- or postoperatively.
Given the poor outcomes associated with missed compartment syndromes, it is important to obtain both clinical and objective data when determining if a patient needs fasciotomies. Determining if a patient needs fasciotomies in the operating room while a patient is under anesthesia is complicated by the fact that obtaining a clinical exam is impossible, and that the diastolic blood pressure may be falsely decreased compared to normal pre- or postoperative measurements. Currently, it is recommended that intraoperative compartment pressures be compared to preoperative diastolic blood pressures, with delta p < 30 indicating the need for fasciotomies.
Kakar et al. review the preoperative, intraoperative, and postoperative diastolic blood pressure (DBP) in 242 patients with a tibia fracture treated operatively. They found the mean DBP was 18 points lower in the operating room compared to the preoperative measurement. In addition, they found the difference between preoperative and postoperative diastolic blood pressures to be within 2 points, indicating the decrease seen intraoperatively is likely a spurious value induced by anesthetic.
McQueen and Court-Brown prospectively review 116 patients with tibia fractures that had continuous monitoring of their anterior compartment for 24 hours. They found that using an absolute pressure of 30 mmHg would have resulted in 50 patients (43%) treated with unnecessary fasciotomies. They conclude using a differential pressure of
30 mmHg is a more reliable indicator of compartment syndrome.
Incorrect Answers:

Question 16

A 47-year-old man undergoes a posterior cervical procedure for a benign tumor. Postoperatively, severe dysfunction with decreased forward elevation and abduction develops and he has lateral winging of the scapula. What is the recommended treatment to best restore motion and function? Review Topic

Explanation

The patient has sustained a permanent injury to the spinal accessory nerve and has resultant scapular winging (lateral winging) because of trapezius palsy with weakness in abduction and forward elevation. The modified Eden-Lange procedure (transfer of the rhomboid minor, major, and levator scapulae) has been shown to reliably restore range of motion and function. Split pectoralis major transfer is performed to restore serratus anterior function. The long head of the triceps and infraspinatus tendon transfers are rarely used for any shoulder muscle transfer. A scapulothoracic fusion can also be performed for this problem, but the results are not as effective as the Eden-Lange procedure.

Question 17

When performing hip arthroscopy, the hip should be placed in neutral to slight internal rotation to protect which of the following structures? Review Topic

Explanation

The sciatic nerve is at greatest risk for injury during hip arthroscopy with placement of a posterolateral (posterior paratrochanteric portal). It can be within 3 cm of this portal. Advancing the trocar with the hip in neutral to slight internal rotation helps to protect the sciatic nerve from iatrogenic injury. The two structures in closest proximity with placement of arthroscopy portals are the lateral femoral cutaneous nerve (anterior portal) and the ascending branch of the lateral femoral circumflex artery (mid-anterior portal). The femoral nerve and medial femoral circumflex arteries are located medial to these anterior portals. Rotation of the hip has not been associated with increased risk of injury to any of these additional structures.

Question 18

Which of the following cannulated screw configurations used in the treatment of subcapital femoral neck fractures is optimal?

Explanation

DISCUSSION: The strongest portion of the femoral neck is the posterior inferior neck in the region of the femoral calcar. The optimal biomechanical configuration includes an inverted triangle pattern with the single screw in the posterior inferior aspect of the femoral neck adjacent to the calcar.
Booth et al performed a cadaveric study comparing central versus calcar (cortical-adjacent) fixation. The results demonstrated significant improved stability, load, stiffness, and displacement in all tested parameters for the group with calcar-adjacent screw fixation.
Lindequist and Törnkvist performed a Level 4 study of 72 femoral neck fractures. They found that all 5 of their nonunions had screws placed greater than 3mm from the femoral calcar. Additionally, 16 of 18 fractures healed in the group of displaced fractures where both the fixating screws were placed within 3 mm from the femoral neck cortex.
Gurusamy et al performed a Level 4 study of 395 patients undergoing femoral neck fixation. They found a reduced spread of the screws on the lateral view was associated with an increased risk of nonunion of the fracture.
Illustration A depicts the optimal configuration of an inverted triangle with the single screw being inferior and all of the screws being cortical adjacent.

Question 19

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

Explanation

DISCUSSION: The theoretic advantage of a metal-to-bone articulation with the acromion is that there is a greater arc in which a smooth metal surface contacts the glenoid and acromion. This may improve pain and function, but no studies have evaluated this to date. One study showed results comparable to that of a standard hemiarthroplasty. There are no other biomechanic advantages.
REFERENCES: Visotsky JL, Basamania C, Seebauer L, et al: Cuff tear arthropathy: Pathogenesis, classification, and algorithm for treatment. J Bone Joint Surg Am 2004;86:35-40.
Zuckerman JD, Scott AJ, Gallagher MA: Hemiarthroplasty for cuff tear arthropathy. J Shoulder Elbow Surg 2000;9:169-172.

Question 20

A 13-year-old girl presents with back pain for 6 months. Figures A and B are SPECT scan and CT images taken at the time of presentation. What is the most likely diagnosis? Review Topic

Explanation

This
patient
has
spondylolysis.
Spondylolysis is a common cause of back pain in children/adolescents. It is common in sports with repetitive hyperextension (gymnasts, weightlifters, football linemen). It is best seen on lateral and oblique radiographs, CT (best study to diagnose and delineate anatomy), and SPECT.
Saifuddin et al. reviewed the orientation of the pars fracture. They found that only 32% of defects were oriented within 15° of the 45° lateral oblique plane and would be
visible on oblique radiographs. They thus recommend CT scans for spondylolysis.
Cheung et al. reviewed spondylolysis and spondylolisthesis. They advocate pars repair for symptomatic spondylolysis and low-grade, mobile spondylolisthesis with pars defects cephalad to L5 and for those with multiple-level defects.
Figure A is a 99mTc-MDP SPECT scan showing increased uptake at the right L5 pars interarticularis. Figure B is an axial helical CT image showing bilateral spondylolysis at L5. Illustration A is a corresponding sagittal reconstruction image demonstrating right pars fracture into the right L5 superior facet. Illustration B shows the appearance of osteoblastic metastasis (green arrow). Illustration C shows the options for pars repair.
Incorrect

Question 21

A 10-year-old boy has a painful thigh mass. A radiograph, MRI scan, and biopsy specimen are shown in Figures 42a through 42c. What is the most likely diagnosis?

Explanation

DISCUSSION: A destructive mixed lytic and blastic metaphyseal lesion with a large soft-tissue mass in an adolescent is most likely an osteosarcoma until proven otherwise. The epicenter of the tumor is on the surface of the bone, most likely involves the periosteum, and is more likely to be chondroblastic in nature. Parosteal osteosarcoma is a low-grade tumor, much more radiodense, usually smaller, and found in the posterior distal femur of middle-aged patients. Chondrosarcomas are distinctly rare in childhood.
REFERENCE: Bertoni F, Bacchini P: Classification of bone tumors. Eur J Radiol

1998;27:S74-S76.

Question 22

A patient notes pain under the first metatarsophalangeal joint following a soccer injury. The MRI scans shown in Figures 27a and 27b reveal what pathologic finding?

Explanation

DISCUSSION: The MRI scans show a complete disruption of the sesamoid complex with proximal retraction of the medial sesamoid and high signal originating from the site normally occupied by the plantar plate (metatarsophalangeal ligament). This injury is the result of a hyperextension injury and is a severe variant of a turf toe.
REFERENCES: Watson TS, Anderson RB, Davis WH: Periarticular injuries to the hallux metatarsophalangeal joint in athletes. Foot Ankle Clin 2000;5:687-713.
Tewes DP, Fischer DA, Fritts HM, et al: MRI findings of acute turf toe: A case report and review of anatomy. Clin Orthop 1994;304:200-203.

Question 23

Figures 34a and 34b show the axial and sagittal MRI scans of a 36-year-old man who reports the insidious onset of pain in the right shoulder. What is the most appropriate description of the acromial morphology? Review Topic

Explanation

The MRI scans reveal a meso os acromiale with edema at the site in a skeletally mature patient.

Question 24

A 14-year-old male sustains the injuries shown in Figures A and B after a fall off the roof of his house. What is the most appropriate management? Review Topic

Explanation

The radiographs show a transcervical (Delbet II) femoral neck fracture. Transphyseal cancellous screws are indicated for fixation of the femoral neck fracture in this case.
Pediatric femoral neck fractures are classified into transphyseal, transcervical, cervicotrochanteric and intertrochanteric (Delbets I-IV) respectively. Fixation type varies by author, but generally speaking, Types I-III can be treated with smooth wires for patients 0-3yrs of age, 4.5-6.5 mm cannulated screws 4-10yrs of age, or l 6.5-

Question 25

Figures 15a through 15d

Explanation

DISCUSSION
Plain radiographic imaging of a patient with an acetabular injury begins with 5 standard views of the pelvis (anteroposterior [AP], iliac oblique, obturator oblique, inlet, and outlet views). These views will show fractures of the acetabulum and help to evaluate for pelvic fractures and hip joint integrity. The obturator oblique view is taken with the injured side rotated 45 degrees forward with the beam centered on the patient’s affected hip. This shows the anterior column and posterior wall and will reveal if any posterior subluxation of the hip is present. The iliac oblique view is taken with the injured side of the patient rolled 45 degrees forward with the beam centered on the affected hip. This shows the posterior column and the anterior wall. Inlet and outlet pelvic radiographs may depict pelvic injuries such as sacroiliac joint fracture or widening.
Judet and Letournel have a classification system for acetabular fractures. The system consists of 5 elementary fracture patterns: anterior wall, anterior column, posterior wall, and posterior column fractures of the acetabulum and a transverse pattern. There are also 5 associated fracture patterns: posterior column/posterior wall, transverse/posterior wall, T-type, anterior column with hemitransverse fracture of the posterior column, and both-column fractures.
Figure 12b shows a fracture of the posterior column on the Iliac oblique, and Figure 12c shows a fracture of the posterior wall in the obturator oblique.
In Question 13, the figures only reveal a fracture of the posterior wall, and this is best appreciated in Figure 13c, the obturator oblique view.
The T-type fracture is a transverse fracture with a secondary fracture line extending inferiorly. This causes the anterior and posterior columns to be separated. The iliac oblique view, Figure 14b, shows a fracture extending through the posterior column. In the obturator oblique view (Figure 14c), the yellow arrow shows a fracture extending through the anterior column, and the red arrow shows a fracture extending inferiorly through the ischium.
Fractures extending through the anterior and posterior columns are seen, which represent a transverse fracture, but there is no extension inferiorly, which eliminates T-type as a possible correct response. The anterior column fracture is best seen on the inlet view (Figure 15b), but it also can be seen in Figure 15d, the obturator oblique view. Figure 15c shows the fracture through the posterior column. For this patient, a small fracture of the posterior wall is visualized on the AP view (Figure 15a).
RECOMMENDED READINGS
Dickson KF, Dowling RM. Treatment of pelvic and acetabular fractures in elderly patients. Orthopaedic Knowledge Online Journal. Volume 11, Number 8 August 2013.
Tornetta P 3rd. Displaced acetabular fractures: indications for operative and nonoperative management. J Am Acad Orthop Surg. 2001 Jan-Feb;9(1):18-28. Review. PubMed PMID: 11174160. View Abstract at PubMed
Moed BR, Kregor PJ, Reilly MC, Stover MD, Vrahas MS. Current management of posterior wall fractures of the acetabulum. Instr Course Lect. 2015;64:139-59. Review. PubMed PMID: 25745901. View Abstract at PubMed

Question 26

A 29-year-old quarterback falls onto his dominant shoulder and sustains the injury shown in Figures 14a and 14b. Management should consist of

Explanation

DISCUSSION: Type V acromioclavicular dislocations are characterized by elevation of the clavicle of 100% to 300% and involve extensive soft-tissue stripping. The treatment of choice is surgical reduction of the acromioclavicular joint and some type of stabilization. Treatment of type III injuries is controversial.
REFERENCES: Lemos MJ: The evaluation and treatment of the injured acromioclavicular joint in athletes. Am J Sports Med 1998;26:137-144.
Rockwood CA Jr, Green DP, Bucholz RW, et al: Fractures in Adults, ed 5. Philadelphia, PA, Lippincott-Raven, 2001, pp 1209-1240.

Question 27

A 9-year-old girl reports the immediate onset of severe groin pain and the inability to walk after tripping on a curb. Examination reveals marked hip pain with passive range of motion. A radiograph is shown in Figure 21. Regardless of treatment, what is the most common complication following this injury?

Explanation

DISCUSSION: The patient has an unstable slipped capital femoral epiphysis (SCFE). According to the classification system based on physeal stability, an unstable SCFE is one in which the patient is unable to walk, even with crutches. Ishemic necrosis, or osteonecrosis, of the femoral head is the most devastating complication of SCFE. One study found a 47% incidence of ischemic necrosis following unstable slips. This complication is most likely the result of vascular injury associated with initial femoral head displacement rather than the result of either tamponade from joint effusion or gentle repositioning prior to stabilization. Chondrolysis is a relatively uncommon complication following treatment of SCFE. This complication has been associated with persistent penetration of the hip joint with screws or pins used to stabilize the femoral head or with spica cast immobilization. There are no reports to suggest that osteochondritis dissecans, nonunion, or coxa magna follows treatment of SCFE.
REFERENCES: Loder RT, Richards BS, Shapiro PS, et al: Acute slipped capital epiphysis: The importance of physeal stability. J Bone Joint Surg Am 1993;75:1134-1140.
Rhoad RC, Davidson RS, Heyman S, et al: Pretreatment bone scan in SCFE: A predictor of ischemia and avascular necrosis. J Pediatr Orthop 1999;19:164-168.

Question 28

Figures 21a through 21c show the radiographs of a 70-year-old woman who has persistent pain with activity after undergoing hip revision 6 months ago. Treatment should now consist of

Explanation

DISCUSSION: The radiographs show disruption of the posterior column of the acetabulum with radiolucencies about the component. Because the patient requires a stable construct to allow the bone to heal, the treatment of choice is an antiprotrusio cage and a graft.
REFERENCES: Gill TJ, Sledge JB, Muller ME: The Burch-Schneider anti-protrusio cage in revision total hip arthroplasty: Indications, principles, and long-term results. J Bone Joint Surg Br 1998;80:946-953.
Sharkey PF, Hozack WJ, Callaghan JJ, et al: Acetabular fracture associated with cementless acetabular component insertion: A report of 13 cases. J Arthroplasty 1999;14:426-431.

Question 29

Figures below demonstrate the radiographs obtained from a 56-year-old man with a 3-year history of right groin pain. A comprehensive nonsurgical program has failed, and the patient would like to proceed with total hip arthroplasty. He is seen by a pain management specialist and is currently taking 40 mg of sustained-release morphine twice daily with oxycodone 10 mg 2 to 3 times a day for severe pain. What is the recommended course of action regarding his chronic narcotic use?

Explanation

DISCUSSION:
Chronic opioid consumption prior to total joint arthroplasty has been associated with increased pain after surgery, increased opioid requirements, a slower recovery and longer hospital stay, and higher 90-day postoperative complications compared with patients not on chronic opioids preoperatively. Based on this information, Nguyen and associates performed a study in three patient groups that included 1) chronic opioid users who underwent no preoperative intervention, 2) chronic opioid users who were weaned down to 50% of their prior opioid regimen, and 3) patients who were not chronic opioid users. The authors found that the reduction of preoperative opioid use improved postoperative function, pain, and recovery and that the weaned group performed more like the opioid naive group than the chronic opioid user
group. Increasing opioid use prior to surgery in this patient would make it more difficult to control pain after surgery. Stopping all of his opioids just prior to surgery would place the patient at substantial risk for opioid withdrawal and is not recommended. Avoiding the use of all narcotics and using only acetaminophen postoperatively is very unlikely to provide appropriate pain relief in a chronic opioid user. The recommendation based on the provided literature is to decrease the patient's narcotic use prior to surgery.

Question 30

A 25-year-old professional baseball pitcher reports a 4-month history of gradually increasing medial elbow pain that occurs during the late cocking and acceleration phases of throwing. The pain occasionally refers distally along the ulnar aspect of the forearm. He denies any weakness; however, he notes occasional paresthesias. A nerve conduction velocity study demonstrates increased latency across the cubital tunnel. Management consisting of 6 weeks of rest and rehabilitation fails to provide relief as the symptoms returned when he resumed throwing. What is the best course of action?

Explanation

DISCUSSION: In the thrower’s elbow, ulnar neuritis is felt to result from both chronic compression and traction on the nerve that occurs during the throwing motion. Occasionally, subluxation of the nerve also can lead to symptoms. If nonsurgical management fails to provide relief, transposition of the nerve to an anterior subcutaneous location is the surgical procedure of choice. The nerve is held in its new position by one or two fascial slings created from the fascia of the common flexor origin.
REFERENCES: Schickendantz MS: Diagnosis and treatment of elbow disorders in the overhead athlete. Hand Clin 2002;18:65-75.
Eaton RG, Crowe JF, Parkes JC III: Anterior transposition of the ulnar nerve using a non-compressing fasciodermal sling. J Bone Joint Surg Am 1980;62:820-825.

Question 31

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

Explanation

The patient has symptomatic multidirectional instability. A comprehensive program involving physical therapy to restore dynamic stability to her shoulder is indicated as a first-line treatment. Periscapular strengthening focusing on the serratus anterior and rhomboids and rotator cuff strengthening should be emphasized. A sling might be used occasionally for comfort but will not provide long-term relief of her symptoms. Thermal capsulorrhaphy, although widely used in the past for shoulder instability, has been abandoned because of a high complication rate. Surgical interventions, such as capsular plications or open capsular shift procedures, might be indicated if rehabilitation fails to relieve her symptoms.

Question 32

A 33-year-old man had his foot run over by a forklift 1 hour ago. Examination reveals that the head of the fifth metatarsal is extruded through the plantar aspect of the foot. The foot is severely swollen and pale, there is no sensation in the toes, and the pulses are not palpable. Radiographs are shown in Figures 42a and 42b. Emergent management should consist of

Explanation

DISCUSSION: Following a severe crush injury, the patient has an acute compartment syndrome. Even though there is an open fracture, this is not sufficient to decompress the compartment syndrome. Therefore, splinting and observation are not appropriate. The surgical treatment of choice is fasciotomy with fixation of the multiple fractures. A primary amputation is not indicated because there is potential for salvage of this devastating injury.
REFERENCES: Fakhouri AJ, Manoli A II: Acute foot compartment syndromes. J Orthop Trauma 1992;6:223-228.
Myerson MS: Management of compartment syndromes of the foot. Clin Orthop 1991;271:239-248.
Ziv I, Mosheiff R, Zeligowski A, Liebergal M, Lowe J, Segal D: Crush injuries of the foot with compartment syndrome: Immediate one-stage management. Foot Ankle 1989;9:185-189.

Question 33

Figures 4a and 4b show the radiographs of a 32-year-old man who has right groin pain with activity or prolonged standing. Which of the following factors would not prohibit consideration of acetabular liner exchange and grafting of the defects?

Explanation

DISCUSSION: Polyethylene particles generated as mechanical wear debris can be phagocytized by macrophages and enter a metabolically active state that releases cytokines, causing periprosthetic bone resorption. Significant osteolysis can occur in the pelvis with a porous-coated cementless socket without loosening of the component. If the acetabular component is modular, well positioned, well-designed with a good survivorship record, and remains undamaged after liner removal, the polyethylene liner can be exchanged and the lytic defects can be debrided and bone grafted. This implant is well positioned, has a good survivorship record, a good locking mechanism, and is modular. The hip arthroplasty needs to be aseptic for consideration of liner exchange.
REFERENCES: Maloney WJ, Herzwurm P, Paprosky W, Rubash HE, Engh CA: Treatment of pelvic osteolysis associated with a stable acetabular component inserted without cement as part of a total hip replacement. J Bone Joint Surg Am 1997;79:1628-1634.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 417-451.

Question 34

A 61-year-old man has a symptomatic bunionette that is refractory to nonsurgical management. A radiograph is shown in Figure 6. What is the optimal surgical correction?

Explanation

DISCUSSION: The patient has a bunionette with a large 4-5 intermetatarsal angle. This requires not only ostectomy of the lateral prominence but metatarsal osteotomy to decrease the intermetatarsal angle. Excising the head results in a flail joint and creates the possibility of a transfer lesion. Condylectomy can reduce plantar pressures but does not address the bunionette. The joint surface is well maintained, thus there are no indications for resection.
REFERENCES: Coughlin MJ: Treatment of bunionette deformity with longitudinal diaphyseal osteotomy with distal soft tissue repair. Foot Ankle 1991;11:195-203.
Koti M, Maffulli N: Bunionette. J Bone Joint Surg Am 2001;83:1076-1082.

Question 35

Which of the following complications occurs more commonly after antegrade femoral nail insertion when compared with retrograde insertion?

Explanation

DISCUSSION: There is no difference between the rates of union, malunion, range of motion of the hip or knee, muscle weakness, or infection for the two types of femoral nail insertion. The only difference is the location of the morbidity, which is around the insertion point of the rod. The antegrade technique has more morbidity about the hip, and the retrograde insertion technique has more morbidity about the knee.
REFERENCES: Morgan E, Ostrum RF, DiCicco J, McElroy J, Poka A: Effects of retrograde femoral intramedullary nailing on the patellofemoral articulation. J Orthop Trauma 1999;13:13-16.
Ricci WM, Bellabarba C, Evanoff B, Herscovici D, DiPasquale T, Sanders R: Retrograde versus antegrade nailing of femoral shaft fractures. J Orthop Trauma 2001;15:161-169.
Ostrum RF, Agarwal A, Lakatos R, Poka A: Prospective comparison of retrograde and antegrade femoral intramedullary nailing. J Orthop Trauma 2000;14:496-501.
Tornetta P III, Tiburzi D: Antegrade or retrograde reamed femoral nailing: A prospective, randomized trial. J Bone Joint Surg Br 2000;82:652-654.

Question 36

A 43-year-old bus driver sustains a hyperextension injury to her arm and shoulder 4 months after undergoing an open Bankart repair. Examination reveals increased external rotation, anterior shoulder pain, and internal rotation weakness. Her examination also reveals the findings shown in Figure 44. What is the most likely diagnosis?

Explanation

DISCUSSION: An isolated tear of the subscapularis tendon has been noted as early as 1835 by Smith. In Gerber and associates’ 1991 report of 16 men with an average age of 51 years, isolated subscapularis tendon rupture was often caused by a violent hyperextension injury. All patients reported pain anteriorly along with night pain. They also noted pain and weakness of the arm. The lift-off test is performed by having the patient lift the palm of the hand away from the small of the back. The patient must have sufficient internal rotation to allow this test to be performed. A subscapularis rupture is likely if the patient cannot perform the lift-off test.
REFERENCES: Hertel R, Ballmer FT, Lombert SM, Gerber C: Lag signs in the diagnosis of rotator cuff rupture. J Shoulder Elbow Surg 1996;5:307-313.
Gerber C, Krushell RJ: Isolated rupture of the tendon of the subscapularis muscle: Clinical features in 16 cases. J Bone Joint Surg Br 1991;73:389-394.
Greis PE, Kuhn JE, Schultheis J, Hintermeister R, Hawkins R: Validation of the lift-off test and analysis of subscapularis activity during maximal internal rotation. Am J Sports Med 1996;24:589-593.
Gerber C, Hersche O, Farron A: Isolated rupture of the subscapularis tendon. J Bone Joint Surg Am 1996;78:1015-1023.

Question 37

The function of which of the following structures is to resist internal tibial rotation with the knee in full extension? Review Topic

Explanation

The primary function of the posterior oblique ligament is to resist internal tibial rotation with the knee in full extension.
The posterior oblique ligament is a structure within the posteromedial corner of the knee, with attachments proximally to the adductor tubercle of the femur and distally to the tibia/posterior knee capsule. The posterior oblique ligament and posteromedial capsule play a significant role in the prevention of additional posterior tibial translation in the knee in the setting of posterior cruciate ligament injury. They also act to resist internal tibial rotation with the knee in full extension.
Griffith et al. reports that the posterior oblique ligament provides significant resistance to valgus and internal rotation forces with knee extension. They used a cadaver model and demonstrated that the superficial MCL resists valgus and external rotation forces more than the posterior oblique ligament, while the posterior oblique ligament is more involved in resisting internal rotation.
Tibor et al. reviews the anatomy of the posteromedial corner of the knee. They report that failing to recognize injury to these structures may cause failure of cruciate ligament reconstruction surgery, and that reconstruction or repair of the posteromedial corner may be indicated in the face of multiple ligament injuries.
Illustration A shows the posteromedial corner of the knee, including the posterior oblique ligament.
Incorrect answers:
1-4: These structures are not primary restraints to internal tibial rotation in full extension.

Question 38

When harvesting iliac crest bone graft during a posterior spinal decompression and fusion, injury to what structure can result in painful neuromas or numbness over the skin of the buttocks?

Explanation

DISCUSSION: The superior cluneal nerves (L1, L2, and L3) are most at risk when harvesting iliac crest bone graft during a posterior decompression and fusion. These nerves pierce the lumbodorsal fascia and cross the posterior iliac crest, beginning 8 cm lateral to the posterior superior iliac spine. The ilioinguinal nerve is more at risk during exposure of the anterior ilium during retraction of the iliacus and abdominal wall muscles. Iliohypogastric nerve injury may arise in a similar fashion to ilioinguinal neuralgia. The lateral femoral cutaneous nerve lies in close proximity to the anterior superior iliac spine and is also at risk with anterior iliac crest bone graft harvesting. The superior gluteal nerve courses through the sciatic notch and supplies motor branches to the gluteus medius, minimus, and tensor fascia lata muscles. Injury results in hip abduction weakness.
REFERENCES: An HS: Principles and Techniques of Spine Surgery. Baltimore, MD, Williams and Wilkins 1998, pp 770-773.
Kurz LT, Garfin SR, Booth RE Jr: Harvesting autogenous iliac bone grafts: A review of complications and techniques. Spine 1989;14:1324-1331.
Mrazik J, Amato C, Leban S, et al: The ilium as a source of autogenous bone grafting: Clinical considerations. J Oral Surg 1980;38:29-32.

Question 39

A 79-year-old woman with a massive rotator cuff tear presents to the emergency department with pain and difficulty moving her arm 7 weeks after undergoing reverse TSA for a displaced 4-part proximal humerus fracture.

Explanation

DISCUSSION
The complication rate is high after surgical treatment of proximal humerus fractures, particularly in elderly patients with osteoporotic bone. In patients treated with ORIF, common complications include varus malunion (16%), avascular necrosis (10%), screw penetration (8%), and infection (4%). In cases involving a dislocation of the humeral head, avascular necrosis is more common. In patients treated with hemiarthroplasty or TSA, complications include component loosening, infection, and dislocation. TSA is associated with
glenoid loosening in patients with rotator cuff incompetence and should be avoided in these patients. Reverse TSA is a potential solution for this population. Dislocation and postoperative infection are potential complications after reverse TSA.
RECOMMENDED READINGS
Krappinger D, Bizzotto N, Riedmann S, Kammerlander C, Hengg C, Kralinger FS. Predicting failure after surgical fixation of proximal humerus fractures. Injury. 2011 Nov;42(11):1283-

Question 40

Which of the following is most commonly associated with an open clavicular fracture?

Explanation

DISCUSSION: Open clavicular fractures are rare and result from high-energy trauma. In a series of 20 patients with open clavicular fractures, 13 (65%) sustained a closed head injury. Fifteen (75%) had associated pulmonary injuries and 35% had a cervical or thoracic spine fracture. Only one demonstrated scapulothoracic dissociation. Screening for pulmonary and closed head injuries should be considered in the setting of traumatic open clavicular fractures.
REFERENCE: Taitsman LA, Nork SE, Coles CP, et al: Open clavicle fractures and associated injuries. J Orthop Trauma 2006;20:396-399.

Question 41

Figures 1 and 2 are of a 51-year-old man who underwent open reduction and internal fixation of a right proximal humerus fracture with concomitant rotator cuff repair. Within 1 year, he develops heterotopic ossification, for which he undergoes excision and hardware removal. Postoperatively, he was noted to have progressive atrophy in the shoulder and anterior humeral head subluxation with attempted shoulder abduction. What nerve was damaged during the most recent procedure?

Explanation

EXPLANATION:
This patient has a deficiency of the anterior deltoid muscle, resulting in inferior subluxation of the humerus with associated glenohumeral instability. Axillary nerve injury during shoulder surgery accounts for 6% to 10% of brachial plexus injuries. In the posterior scapular region, the axillary nerve terminates by dividing into two main branches: the posterior terminal branch, which provides motor innervation to the teres minor and posterior deltoid muscles, and the anterior terminal branch, which provides motor innervation to the anterior and middle portions of the deltoid muscle. The deltoid determines the silhouette of the shoulder and is a stabilizer of the humeral head.

Question 42

A superior labrum anterior and posterior (SLAP) lesion doubles the strain in which of the following stabilizing structures?

Explanation

DISCUSSION: A superior labrum, when intact, stabilizes the shoulder by increasing its ability to withstand excessive external rotational forces by an additional 32%. The presence of a SLAP lesion decreases this restraint and increases the strain in the superior band of the inferior glenohumeral ligament by over 100%.
REFERENCES: Rodosky MW, Harner CD, Fu FH: The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder. Am J Sports Med 1994;22:121-130.
Itoi E, Kuelchle DK, Newman SR, Morrey BF, An KN: Stabilizing function of the biceps in stable and unstable shoulders. J Bone Joint Surg Br 1993;75:546-550.

Question 43

-What is the most likely deficit in elbow function resulting from an isolated lesion of the ulnar nerve above the elbow?

Explanation

Question 44

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

Explanation

Etanercept is a biochemically designed tumor necrosis factor receptor immunoglobulin G fusion protein, which binds to TNF-alpha and is thus a TNF-alpha antagonist.
TNF-alpha is considered to be one of the major cytokines involved in rheumatoid arthritis pathology. As a result, many biologic agents used to treat rheumatoid arthritis (RA) are manufactured to block TNF-alpha or its receptors. This has been shown to reduce inflammation and stop disease progression. In the USA, Etanercept is approved to treat rheumatoid arthritis, juvenile rheumatoid arthritis and psoriatic arthritis, plaque psoriasis and ankylosing spondylitis. The route of administration is subcutaneous.
Bongartz et al. used a randomized control trial to asses the risk of infection and malignancy rates in RA treated with TNF-alpha antagonist. Overall, patients with RA appear to have an approximately 2-fold increased risk of serious infection compared to the general population and non-RA controls, irrespective of TNF-alpha antagonist use. The pooled odds ratio for malignancy was 3.3 (95% confidence interval [CI], 1.2-

Question 45

What is the most common adverse postoperative complication of laminoplasty for multilevel cervical spondylotic myelopathy?

Explanation

DISCUSSION: A 30% to 50% loss of cervical range of motion is reported postoperatively in most patients following cervical laminoplasty. Inadvertent closure of the laminoplasty does occur but is rare. Laminoplasty is advocated in lieu of laminectomy to prevent progressive kyphosis and can effectively decompress the spinal cord. C5 nerve root palsies are a poorly understood but rare complication of surgical decompression for cervical spondylotic myelopathy.
REFERENCES: Emery SE: Cervical spondylotic myelopathy: Diagnosis and treatment. J Am Acad Orthop Surg 2001;9:376-388.
Edwards CC II, Riew KD, Anderson PA, et al: Cervical myelopathy: Current diagnostic and treatment strategies. Spine J 2003;3:68-81.

Question 46

A 45-year-old man undergoes an anterior cervical diskectomy and fusion at C5-6 and C6-7 with instrumentation. During the first postoperative visit at 1 week, the patient reports difficulty swallowing and mild anterior cervical tightness. The anterior wound is benign and the patient denies any dyspnea or shortness of breath. A postoperative radiograph is seen in Figure 25. What is the most appropriate management at this time?

Explanation

DISCUSSION: The radiograph shows significant prevertebral soft-tissue swelling following a two-level anterior cervical diskectomy and fusion. The incidence of dysphagia 2 years after anterior cervical spine surgery is 13.6%. Risk factors for long-term dysphagia after anterior cervical spine surgery include gender, revision surgeries, and multilevel surgeries. The use of instrumentation, higher levels, or corpectomy versus diskectomy did not significantly increase the prevalence of dysphagia. Lee and associates demonstrated that while dysphagia after anterior cervical spine surgery is a common early finding, it generally decreases significantly by

6 months with nonsurgical management. A minority of patients experience moderate or severe symptoms by 6 months after the procedure. Female gender and multiple surgical levels have been identified as risk factors for the development of postoperative dysphagia.
REFERENCES: Lee MJ, Bazaz R, Furey CG, et al: Risk factors for dysphagia after anterior cervical spine surgery: A two-year prospective cohort study. Spine J 2007;7:141-147.
Bazaz R, Lee MJ, Yoo JU: Incidence of dysphagia after anterior cervical spine surgery:

A prospective study. Spine 2002;27:2453-2458.

Question 47

A patient who underwent a high tibial osteotomy (HTO) is now scheduled to undergo total knee arthroplasty (TKA). When compared with a patient undergoing primary TKA without a prior HTO, the patient should be advised to expect a higher incidence of

Explanation

DISCUSSION: 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.
REFERENCE: Mont MA, Alexander N, Krackow KA, Hungerford DS: Total knee arthroplasty after failed high tibial osteotomy. Orthop Clin North Am 1994;25:515-525.

Question 48

A 56-year-old laborer sustained a subcoracoid dislocation of the shoulder as a result of falling off a scaffold 3 weeks ago. He now is unable to actively raise his arm and has constant pain. What is the most likely diagnosis?

Explanation

Thirty-one patients who were unable to abduct the involved arm after reduction of a primary anterior dislocation of the glenohumeral joint were found to have a ruptured rotator cuff. In their series, the incidence of injury to the axillary nerve was 7.8% as compared with 100% for rupture of the rotator cuff.

Question 49

4A 4B 4C A 30-year-old man was involved in a high-speed motorcycle collision and sustained the injury shown in Figure 4a. Hypotension ensued shortly after arrival in the emergency department. Figure 4b is the initial contrast pelvic CT image with an unrecognized blush consistent with arterial bleeding. During surgical repair, the patient was noted to have active bleeding and an angiogram was obtained (Figure 4c). Which structure is the likely cause of his bleeding?

Explanation

DISCUSSION
Pelvic bleeding occurs predominantly from disruption of the posterior venous plexus and bleeding from the fractured bone. Occasionally arterial bleeding is seen, with injury to the superior gluteal artery most common. Anterior pelvic bleeding occurs from injury to the obturator artery (commonly from a pubic bone fracture laceration) and less frequently from the pudendal artery near the symphysis. The location of the bleeding on CT and angiography images does not correspond to the superior gluteal, external iliac, or femoral arteries.
RECOMMENDED READINGS
Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography: competitive or complementary? Injury. 2009 Apr;40(4):343-53. Epub 2009 Mar 17. Review.PubMed PMID: 19278678. View Abstract at PubMed
Loffroy R, Yeguiayan JM, Guiu B, Cercueil JP, Krausé D. Stable fracture of the pubic rami: a rare cause of life-threatening bleeding from the inferior epigastric artery managed with transcatheter embolization. CJEM. 2008 Jul;10(4):392-5. PubMed PMID: 18652733. View Abstract at PubMed
White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures.Injury. 2009 Oct;40(10):1023-30. Epub 2009 Apr 16. Review. PubMed PMID:19371871. View Abstract at PubMed
RESPONSES FOR QUESTIONS 5 THROUGH 8

5B
- Avascular necrosis, head collapse, and screw penetration
- Fixation failure and varus collapse
- Humeral stem loosening
- Glenoid component loosening
- Hardware failure (breakage of plate or screws)
- Shoulder dislocation
Please choose from the responses to identify the most likely complication in each scenario.

Question 50

A 14-year-old boy with a history of cerebral palsy has a clawed hallux, cavus foot deformity, and associated pain. Examination reveals pain under the first metatarsal head and a rigid first tarsometatarsal joint. Treatment should consist of

Explanation

DISCUSSION: In a retrospective study for clawing of the hallux with associated cavus foot deformities, the modified Robert Jones tendon transfer was shown to be effective in relieving symptoms related to clawing of the hallux in 90% of patients but was not reliable in relieving pain under the first metatarsal head, with success in only 43% of patients. In three patients, pain under the metatarsal head was relieved initially but recurred by 18 months. The return of symptoms in these cases is the result of stretching of the muscle and tendon of the extensor hallucis longus by the more powerful peroneus longus. Basal dorsal wedge osteotomy at the time of the modified Robert Jones procedure is recommended.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 79-100.
Tynan MC, Klenerman L: The modified Robert Jones tendon transfer in cases of pes cavus and clawed hallux. Foot Ankle Int 1994;15:68-71.

Question 51

A 21-year-old pitcher reports shoulder pain with hard throwing. He notes that the pain occurs in the early acceleration phase of his throw. Given his history, what structures are at greatest risk for injury?

Explanation

DISCUSSION: Internal impingement in the thrower’s shoulder occurs in the abducted, externally rotated position as described by Walch and associates. The injury is thought to occur from repetitive contact between the posterosuperior portion of the labrum and glenoid against the articular side of the rotator cuff and greater tuberosity.
REFERENCES: Paley KJ, Jobe FW, Pink MM, et al: Arthroscopic findings in the overhand throwing athlete: Evidence for posterior internal impingement of the rotator cuff. Arthroscopy 2000;16:35-40.
Jazrawi LM, McCluskey GM III, Andrews JR: Superior labral anterior and posterior lesions and internal impingement in the overhead athlete. Instr Course Lect 2003;52:43-63.
Walch G, Boileau P, Noel E, et al: Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: An arthroscopic study. J Shoulder Elbow Surg

1992;1:238-245.

Question 52

03 A 26-year-old woman has chronic toe pain after hitting a bedpost 3 months ago. A radiograph is shown in Figure 27. Her injury represents an avulsion of the

Explanation

The main function of the EDL is extension of the MTP joints of the lesser toes, so injury results in a claw toe deformity if left unrepaired. The EDL originates on the lateral tibial condyle, the anterior crest of the fibula, and the interosseous membrane and inserts on the base of the terminal phalanges of the four lesser toes. Innervated by the deep peroneal nerve, the EDL functions to extend the toes at the DIP joint and to dorsiflex and evert the foot. The EDL divides into two separate tendons beneath the superior retinaculum and then further divides into two lateral tendons to the fourth and fifth toes and two medial tendons to the second and third toes. The individual tendon of the EDL to each toe is joined on the lateral aspect by the tendon of the EDB. They are anchored at the level of the MTP joint by a fibroaponeurotic structure.
The EDB originates on the distal lateral and superior surface of the calcaneus and inserts on the
lateral aspect of the flexor digitorum longus tendon and also on to the base of the proximal phalanx of the first through fourth toes. There is no EDB tendon to the fifth toe. If an EDB laceration is easily identified at the time of an EDL repair, than it may be repaired as well, otherwise repair of the EDL alone is sufficient.
Heckman JD: Fractures and dislocation of the foot, in Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD (eds):Rockwood and Green’s Fractures in Adults, ed 3. Philadelphia, PA, JB Lippincott, 1991, pp 2166-2169.
Coughlin MJ: Disorders of tendons, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 787-788.
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Question 53

Which of the following is the most relevant clinical factor in the maturation assessment of an adolescent female athlete contemplating anterior cruciate ligament (ACL) reconstruction?

Explanation

DISCUSSION: Age of menarche is the most accurate clinical factor to assess the degree of skeletal maturity in the female athlete. Such an assessment is necessary prior to ACL reconstruction in a skeletally immature female because of the risk of damage to the distal femoral and proximal tibial physes. Height of an older male sibling is not relevant to the female athlete. Parental height and recent change in shoe size are only moderately useful in predicting final growth, and hence, skeletal maturity. The presence of breast buds occurs early in adolescent development; therefore, its presence suggests a high likelihood of future growth.
REFERENCES: Micheli LJ, Foster TE: Acute knee injuries in the immature athlete. Instr Course Lect 1993;42:473-481.
Stanitski CL: Anterior cruciate ligament injury in the skeletally immature patient: Diagnosis and treatment. J Am Acad Orthop Surg 1995;3:146-158.
Fowler PJ: Anterior cruciate ligament injuries in the child, in Drez D, DeLee JD, Miller MD (eds): Orthopaedic Sports Medicine Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, pp 2067-2074.

Question 54

A 65-year-old woman landed on her nondominant left shoulder in a fall. An AP radiograph is shown in Figure 39. Management should consist of

Explanation

DISCUSSION: The radiograph reveals a four-part fracture-dislocation of the proximal humerus. Humeral hemiarthroplasty and tuberosity repair is the treatment of choice because the risk of osteonecrosis is high after attempted repair of this injury. Glenoid resurfacing is reserved for acute fractures in which there is significant preexisting glenoid arthrosis, such as in patients with rheumatoid arthritis.
REFERENCES: Neer CS II: Displaced proximal humeral fractures: II. Treatment of three- and four-part displacement. J Bone Joint Surg Am 1970;52:1090-1103.
Robinson CM, Page RS, Hill RM, et al: Primary hemiarthroplasty for treatment of proximal humeral fractures. J Bone Joint Surg Am 2003;85:1215-1223.

Question 55

Figures 19a and 19b show the AP and lateral radiographs of an 18-year-old man who has had knee pain for 3 months. Figure 19c shows a histopathologic photomicrograph of the biopsy specimen. Which of the following factors is most likely to affect his survival?

Explanation

DISCUSSION: The presence of metastatic disease at diagnosis is the most significant prognostic factor in a patient with osteosarcoma. Limb-sparing surgery, when compared with amputation, is not noted to be associated with any difference in the rate of survival. The presence of a mutated p53 gene has been noted in a minority of patients with osteosarcoma; however, the prognostic importance on an individual basis is unclear. Tumor location and a relative poor response to chemotherapy would be secondary to the presence of metastatic disease in estimating a patient’s prognosis.
REFERENCES: Weis L: Common malignant bone tumors: Osteosarcoma, in Simon MA, Springfield DS (eds): Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott-Raven, 1998, pp 265-274.
Mirra JM: Bone Tumors: Clinical, Radiologic, and Pathologic Correlation. Philadelphia, PA, Lea and Febiger, 1989, pp 248-438.

Question 56

The humeral nonunion shown in Figure 27 is most likely to unite when using what method of treatment?

Explanation

DISCUSSION: The radiograph shows an atrophic nonunion of the humeral shaft. The management of humeral nonunions has been studied with compression plates and bone graft, as well as intramedullary nailing and bone graft. Compression plating with bone graft results in the highest rate of union. Compression plating by itself is not adequate, given the bone loss and lack of callous in this nonunion. Pulsed electromagnetic fields is a viable option for hypertrophic nonunions where there is inherent stability. Intramedullary nailing does not provide as much compression and stability as that achieved with compression plating.
REFERENCES: Pugh DM, McKee MD: Advances in the management of humeral nonunion.

J Am Acad Orthop Surg 2003;11:48-59.
McKee MD, Miranda MA, Riemer BL, et al: Management of humeral nonunion after the failure of locking intramedullary nails. J Orthop Trauma 1996;10:492-499.

Question 57

What factor is most commonly associated with malignant transformation of a giant cell tumor?

Explanation

Most authors have agreed that radiation therapy should be avoided in the treatment of giant cell tumor, as there is a high prevalence of sarcomatous degeneration.

Question 58

A 59-year-old construction worker who is right-hand dominant has had right shoulder pain for the past 9 months with no history of injury. Nonsurgical management consisting of two cortisone injections, physical therapy for 3 months, and nonsteroidal anti-inflammatory drugs has failed to provide lasting relief. Examination reveals tenderness over the acromioclavicular (AC) joint and over the subacromial bursa. He has positive Neer and Hawkins impingement signs and AC joint pain with adduction of the shoulder. Radiographs are shown in Figures 36a and 36b. An MRI scan reveals an intact rotator cuff. Management should now consist of

Explanation

DISCUSSION: Because the patient has clinical and radiographic signs of AC arthritis and subacromial impingement, the treatment of choice is anterior acromioplasty and distal clavicle excision. Arthroscopic acromioplasty alone would not address the AC arthritis. The rotator cuff is intact; therefore, rotator cuff repair is not indicated. An open Mumford procedure would address the AC arthritis only and not the impingement symptoms. Immobilization might lead to stiffness of the shoulder and is not recommended for treating impingement.
REFERENCE: Peterson CA, Altchek DW, Warren RF: Shoulder arthroscopy, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1990, pp 290-335.

Question 59

Second impact syndrome (SIS) after head injury is characterized by which of the following?

Explanation

DISCUSSION: SIS is a devastating but preventable complication of head injury. It occurs when return to activities is allowed prior to complete resolution of the symptoms of the first head injury. A second, sometimes trivial, head injury can lead to a devastating series of events that can result in sudden death. The symptoms tend to progress rapidly and often involve the brain stem. The prognosis is poor.
REFERENCES: Cantu RC: Second-impact syndrome. Clin Sports Med 1998;17:37-44.
Saunders RL, Harbaugh RE: Second impact in catastrophic contact-sports head trauma. JAMA 1984;252:538-539.
Stevenson KL, Adelson PD: Pediatric sports-related head injuries, in Delee JC, Drez D (eds): Orthopaedic Sports Medicine: Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, vol 1, p 781.

Question 60

A 3-year-old boy has a rigid 40-degree lumbar scoliosis that is the result of a fully segmented L5 hemivertebra. All other examination findings are normal. Management should consist of

Explanation

DISCUSSION: Near complete correction and rebalancing of the spine can be achieved by hemivertebral resection that may be done as either a simultaneous or a staged procedure in the young patient. This eliminates the problem of future progression and possible development of compensatory curves. Nonsurgical management is not indicated in congenital scoliosis. Convex hemiepiphyseodesis is best suited for patients younger than age 5 years who have a short curve caused by fully segmented hemivertebrae that correct to less than 40 degrees with the patient supine. Hemiepiphyseodesis and isolated posterior fusion are not indicated.
REFERENCES: Bradford DS, Boachie-Adjei O: One-stage anterior and posterior hemivertibral resection and arthrodesis for congenital scoliosis. J Bone Joint Surg Am 1990;72:536-540.
Lazar RD, Hall JE: Simultaneous anterior and posterior hemivertebra excision. Clin Orthop 1999;364:76-84.

Question 61

Figures 10a and 10b show the clinical photograph and MRI scan of a plantar foot lesion. If excisional biopsy is performed, what is the most likely complication?

Explanation

DISCUSSION: The MRI scan shows plantar fibromatosis. The treatment is usually nonsurgical.

If surgery is indicated, wide local excision with excision of the entire plantar fascia is usually indicated. The main problem with simple excision of the lesion is the high chance of recurrence. The other listed complications are those that are a result of the wide local excision.
REFERENCES: Aluisio FV, Mair SD, Hall RL: Plantar fibromatosis: Treatment of primary and recurrent lesions and factors associated with recurrence. Foot Ankle Int 1996;17:672-678.
Bos GD, Esther RJ, Woll TS: Foot tumors: Diagnosis and treatment. J Am Acad Orthop Surg 2002;10:259-270.

Question 62

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

Explanation

Symptomatic herniations of the thoracic spine are much less common than those of the cervical or lumbar region. They tend to occur most commonly during the third to fifth decades of life and although they can be found at all levels, they are most
common in the lower third near the thoracolumbar region. Posterior laminectomy and disk excision has the highest rate of neurologic deterioration and is not recommended. Multiple studies have shown that herniated thoracic disks can be found at one or more levels in 40% of asymptomatic individuals.

Question 63

A skeletal survey is more accurate than a bone scan for detecting skeletal involvement in which of the following neoplastic diseases?

Explanation

Multiple Myeloma lesions are cold on bone scan and because of this a skeletal survey is more useful.

Question 64

A 75-year-old woman is undergoing a T10-S1 lumbar decompression and fusion for severe degenerative scoliosis. During the deformity corrective maneuver, intraoperative neuromonitoring revealed a sustained 80% decrease in somatosensory-evoked potential (SSEP) amplitudes. Appropriate lead placement and

Explanation

The most appropriate management is discontinuation of the spinal instrumentation procedure, including releasing any distractive forces. Given the ongoing changes, proceeding with the procedure and/or resetting the baseline amplitudes is inadvisable. If the SSEPS amplitudes fail to return in a timely fashion, it is strongly recommended to consider a wake-up test. The purpose of intraoperative neuromonitoring is to provide a real-time assessment of the functional integrity of the central and peripheral nervous systems during surgery to prevent iatrogenic injury. Sustained decreased SSEP amplitudes of greater than 50% and transcranial electric Motor-Evoked Potentials (tceMEP) amplitudes of greater than 75% are indicative of a possible significant intraoperative neurologic complication. Although intraoperative corticosteroids might be helpful, especially in the event of a continued SSEP change, the most important next step would be to release the distractive forces and reevaluate the patient's neurologic status.

Question 65

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

Explanation

DISCUSSION: The patient has a cyclops lesion. This is a nodule of fibroproliferative tissue that originates from either drilling debris from the tibial tunnel or remnants of the ACL stump; more rarely it is the result of broken graft fibers. The treatment of choice is excision of the nodule and, if needed, additional notchplasty. Marked improvements in function and symptoms have been noted after removal of the extension block and resumption of a rehabilitation program.

REFERENCES: Delince P, Krallis P, Descamps PY, et al: Different aspects of the cyclops lesion following anterior cruciate ligament reconstruction: A multifactorial etiopathogenesis. Arthroscopy 1998;14:869-876.
Fisher SE, Shelbourne KD: Arthroscopic treatment of symptomatic extension block complicating anterior cruciate ligament reconstruction. Am J Sports Med 1993;4:558-564.

Question 66

Which of the following conditions is associated with palmoplantar pustulosis?

Explanation

DISCUSSION: Sternoclavicular hyperotosis is a seronegative and HLA-B27 negative rheumatic disease. In this condition, hyperostosis may appear in the spine, long bones, sacroiliac joints, and the sternoclavicular region. This entity is also associated with palmoplantar pustulosis.
REFERENCES: Wirth MA, Rockwood CA: Disorders of the sternoclavicular joint, in Rockwood CA, Matsen FA, Wirth MA, et al (eds): The Shoulder. Philadelphia, PA,

WB Saunders, 2004, vol 2, pp 608-609.
Sonozaki H, Azuma A, Okai K, et al: Clinical features of 22 cases with inter-sterno-costo-clavicular ossification: A new rheumatic syndrome. Arch Orthop Trauma Surg 1979;95:13-22.

Question 67

A 30-year-old man who participates in recreational sports reports the spontaneous onset of intermittent pain and swelling about the right knee. Examination reveals a 3+ effusion, with a range of motion of 10° to 60°. He has mild diffuse tenderness but no instability. MRI scans and an arthroscopic view are shown in Figures 39a through 39c. Management should consist of

Explanation

DISCUSSION: The patient has synovial chondromatosis. The MRI scans show multiple small proscribed areas of signal intensity in the gutters and suprapatellar pouch, suggesting very small loose bodies. The arthroscopic view shows the classic appearance of multiple small chondral loose bodies. Synovial chondromatosis is a condition in which the synovium undergoes metaplasia, producing multiple chondral loose bodies that can subsequently ossify. The treatment of choice, removal of the loose bodies and arthroscopic synovectomy, results in a lower incidence of recurrence than other treatment methods.
REFERENCES: Coolican MR, Dandy DJ: Arthroscopic management of synovial chondromatosis of the knee: findings and results in 18 cases. J Bone Joint Surg Br

1989;71:498-500.
Ogilvie-Harris DJ, Saleh K: Generalized synovial chondromatosis of the knee: A comparison

of removal of the loose bodies alone with arthroscopic synovectomy. Arthroscopy

1994;10:166-170.

Question 68

Osteochondritis dissecans of the capitellum is a source of elbow pain and most commonly occurs in what patient population? Review Topic

Explanation

The etiology of osteochondritis dissecans of the capitellum is somewhat unclear. However, trauma has been implicated in this disease process. Gymnasts who load their upper extremities during tumbling and throwing athletes with repetitive trauma during the throwing motion are common patient subgroups in which osteochondritis dissecans of the elbow is seen. This often occurs in the adolescent age population.

Question 69

A patient with Charcot-Marie-Tooth disease has a progressively rigid cavovarus foot deformity. The patient states that the pain is restricted to the forefoot, where rigid claw toe deformities have developed. Which of the following structures is primarily involved in creation of a claw toe deformity?

Explanation

DISCUSSION: Diseases such as Charcot-Marie-Tooth result in spasticity to the extrinsic flexor tendons. This results in hyperflexion of the proximal and distal interphalangeal joints of the involved toe, as well as hyperextension at the metatarsophalangeal joint. The tendon often becomes contracted with progressive equinus of the ankle. Correction of ankle equinus exaggerates the claw toe deformity. The interosseous tendon plays no role in the etiology of a claw toe but may become contracted in later stages of the disease. Laxity of the volar plate may precipitate a claw toe deformity in a nonspastic situation. In patients with a head injury, claw toe deformities are generally the result of overactivity of the extensor tendons.
REFERENCES: Keenan MA, Gorai AP, Smith CW, Garland DE: Intrinsic toe flexion deformity following correction of spastic equinovarus deformity in adults. Foot Ankle 1987;7:333-337.
Pichney GA, Derner R, Lauf E: Digital “V” arthrodesis. J Foot Ankle Surg 1993;32:473-479.
Mizel MS, Michelson JD: Nonsurgical treatment of monarticular nontraumatic synovitis of the second metatarsophalangeal joint. Foot Ankle Int 1997;18:424-426.

Question 70

An 8-year-old girl was treated for a Salter-Harris type I fracture of the right distal femur 2 years ago. She has symmetric knee flexion, extension, and frontal alignment to her contralateral knee. She has a 1-cm limb-length discrepancy of the femur. She has always been in the 50th percentile for height and her skeletal age matches her chronologic age. She has a complete physeal closure of the right distal femur. What is the expected limb-length discrepancy at maturity?

Explanation

DISCUSSION: The child has a near complete central physeal arrest of the distal femur. She will develop worsening limb-length discrepancy. She is growing at the average rate for the population. The distal femoral physis grows roughly at a rate of 9 mm/year. Girls finish their growth roughly at 14 years. Thus, at maturity, the uninjured side will be 6.4 cm longer than the injured side. Since she has not developed an angular deformity at this point and her arrest is central, she is unlikely to develop angular deformity in any plane.
REFERENCES: Little DG, Nigo L, Aiona MD: Deficiencies of current methods for the timing of epiphysiodesis. J Pediatr Orthop 1996;16:173-179.
Moseley CF: Assessment and prediction in leg-length discrepancy. Instr Course Lect 1989;38:325-330.
AL-Madena Copy

Question 71

What is one of the principle concerns when a fracture such as the one seen in Figure 18 is encountered?

Explanation

DISCUSSION: The injury shown is a fracture-dislocation and it is highly unstable. In addition to this concern, spinal epidural hematomas have a much higher incidence in people with ankylosing spondylitis following knee fracture. It is felt to be due to disrupted epidural veins, with hypervascular epidural soft tissue in the setting of a rigid spinal canal. Patients with ankylosing spondylitis may have other significant comorbidities, especially cardiac and pulmonary, and these should be carefully assessed.
REFERENCES: Ludwig S, Zarro CM: Complications encountered in the management of patients with ankylosing spondylitis, in Vaccaro AR, Regan JJ, Crawford AH, et al (eds): Complications of Pediatric and Adult Spine Surgery. New York, NY, Marcel Dekker, 2004,

pp 279-290.
Wu CT, Lee ST: Spinal epidural hematoma and ankylosing spondylitis: Case report and review of the literature. J Trauma 1998;44:558-561.

Question 72

Baseball pitchers who have internal impingement will most likely demonstrate what changes in range of motion?

Explanation

DISCUSSION: Pitchers tend to have a decrease in internal rotation and an increase in external rotation. The increase in external rotation is felt to be multifactorial. An increase in humeral retroversion occurs from repeated throwing. This results in increased soft-tissue stretching and results in a posterior capsular contracture.
REFERENCES: Meister K, Buckley B, Batts J: The posterior impingement sign: Diagnosis of rotator cuff and posterior labral tears secondary to internal impingement in overhand athletes. Am J Orthop 2004;33:412-415.
Crockett HC, Gross LB, Wilk KE, et al: Osseous adaptation and range of motion at the glenohumeral joint in professional baseball pitchers. Am J Sports Med 2002;30:20-26.

Question 73

A 74-year-old woman with rheumatoid arthritis has pain in the shoulder that has failed to respond to nonsurgical management. AP and axillary radiographs are shown in Figures 24a and 24b. Active forward elevation is 120 degrees and external rotation is 30 degrees. At the time of surgery, a 1-cm rotator cuff tear is found, which is repairable. Which of the following treatment options will result in the most predictable pain relief and function? Review Topic

Explanation

Most studies have shown that total shoulder arthroplasties yield better pain relief and improved forward elevation when compared with hemiarthroplasty in patients with rheumatoid arthritis. Patients with repairable rotator cuff tears should undergo repair at the time of surgery because good results have been shown. Reverse arthroplasties are not indicated with rotator cuff tears that are repairable, and interpositional arthroplasties are not indicated for elderly patients.

Question 74

A 15-year-old girl has left knee pain and an enlarging mass in the distal thigh. AP and lateral radiographs are shown in Figures 52a and 52b, and a biopsy specimen is shown in Figure 52c. What is the most likely diagnosis?

Explanation

DISCUSSION: A bone-producing lesion in the metaphysis of an adolescent is most likely an osteosarcoma. The radiographs show a distal femoral bone-producing lesion extending into the surrounding soft tissues. The histologic appearance consists of pleomorphic cells producing osteoid. Ewing’s sarcoma and metastatic neuroblastoma do not produce a matrix. Chondrosarcoma is a radiographically destructive lesion with calcification and cartilage cells on histologic section. An osteochondroma is a benign cartilage lesion that is continuous with the medullary cavity of the underlying bone and extends into a bony lesion and covered by a cartilage cap.
REFERENCES: Unni KK: Dahlin’s Bone Tumors: General Aspects and Data on 11,087 Cases, ed 5. Philadelphia, PA, Lippincott-Raven, 1996, pp 143-160.
Gibbs CP, Weber K, Scarborough MT: Malignant bone tumors. Instr Course Lect 2002;51:413-428.

Question 75

A 13-year-old boy has had pain and swelling in his ankle for the past several months. Based on the radiograph, MRI scan, and biopsy specimen shown in Figures 77a through 77c, what is the best course of action?

Explanation

DISCUSSION: Chondroblastomas are benign cartilage lesions frequently seen in adolescents or young adults. They are found in the epiphyseal or apophyseal regions of bones. The radiograph shows a radiolucent lesion with mineralization and a well-marginated rim of reactive bone. The lesion is composed of sheets of immature chondroblasts (polygonal cells with a clear, bluish cytoplasm and a small round central nucleus). In some regions, classic “chicken-wire” matrix calcifications and a “cobblestone” pattern of cell arrangement may be seen. Treatment consists of curettage and bone grafting.
REFERENCES: Campanacci M: Bone and Soft Tissue Tumors, ed 2. New York, NY, Springer-Verlag, 1999, pp 247-264.
Lin PP, Thenappan A, Deavers MT, et al: Treatment and prognosis of chondroblastoma. Clin Orthop Relat Res 2005;438:103-109.

Question 76

A patient undergoing joint arthroplasty is put on a drug that competitively inhibits the activation of an enzyme that breaks down Factor Ia. The drug is

Explanation

Factor Ia is fibrin. The enzyme that breaks down fibrin is plasmin. Tranexamic acid (TXA) is an antifibrinolytic that prevents the activation of plasmin from the inactive zymogen plasminogen.
Tranexamic acid competitively inhibits the activation of plasminogen to plasmin by binding to specific sites on both plasminogen and plasmin. Tranexamic acid has roughly eight times the antifibrinolytic activity of an older analogue, e-aminocaproic acid. It is used during joint replacement surgery to reduce blood loss and the need for transfusion.
Watts et al. review strategies for minimizing blood loss and transfusion. They recommend 1g of TXA prior to incision, and 1g at wound closure. They also recommend giving fluids for symptoms of anemia, rather than transfusion, as even high risk patients do well with sufficient intravascular volume even with low hemoglobin levels.
Imai et al. evaluated TXA in 107 patients undergoing THA. They found that intraoperative blood loss after preoperative TXA administration was lower than both control and postoperative TXA administration groups. They recommend using 1 g of TXA 10 minutes before surgery and 6 hours after the first administration to best reduce blood loss during THA.
Gillette et al. retrospectively reviewed 2046 patients receiving TXA for THA or TKA together with either aspirin, warfarin or dalteparin. They found that the rates of symptomatic DVT (0.35%, 0.15%, and 0.52%, respectively) and nonfatal PE were similar (0.17%, 0.43%, and 0.26%, respectively) for the 3 drugs respectively. They recommend TXA to decrease blood loss and transfusion.
Illustration A shows the role of tranexamic acid in the fibrinolytic cycle and the
clotting cascade.
Incorrect Answers:

Question 77

A teenager is undergoing a correction of deformity and lengthening of the femur. Distractions are proceeding as expected; however, during his 6-week follow-up examination, the patient reports that the distraction motors have become harder to turn over for the past 2 to 3 days. Figures 37a and 37b show current radiographs. What is the most likely complication being encountered?

Explanation

DISCUSSION: Premature consolidation is a complication that is unique to gradual bone lengthening after corticotomy. Causes include excessive latency period, inadequate distraction rate, exuberant bone formation, patient compliance problems, and mechanical failure of the distraction apparatus. The femur and fibula are most commonly involved. This patient did not have an incomplete corticotomy, as initial distraction occurred before the distraction device was noted to seize up. The radiographs show bowing of the Ilizarov wires and mature regenerate bone, both suggestive of premature consolidation. No wire breakage or joint subluxation is seen on the radiographs. Treatment for premature consolidation includes continuing distraction until the consolidation bridge ruptures, or additional surgery may include closed rotational osteoclasis or repeat corticotomy.
REFERENCES: Paley D: Problems, obstacles and complications of limb lengthening, in Maiocchi AB, Aronson J (eds): Operative Principles of Ilizarov. Baltimore, MD, Williams & Wilkins, 1991, p 360.
Herring JA: Limb length discrepancy, in Herring JA (ed): Tachdjian’s Pediatric Orthopaedics,

ed 3. Philadelphia, PA, WB Saunders, 2002, p 1088.

Question 78

Figure 50 shows the MRI scan of a 20-year-old female college soccer player with knee pain. What is the most likely diagnosis?

Explanation

DISCUSSION: The MRI scan shows an acute complete tear of the posterior cruciate ligament. No evidence is seen of a quadriceps tendon rupture, a tibia fracture, or a bone contusion.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 533-557.
Harner CD, Hoher J: Evaluation and treatment of posterior cruciate ligament injuries. Am J Sports Med 1998;26:471-482.

Question 79

As a baseball player dives to catch a line drive in the outfield, the ball strikes the tip of the player’s finger when extended, causing forcible flexion to avulse the extensor tendon from the distal phalanx. Following evaluation and normal radiographic findings, initial management should include

Explanation

DISCUSSION: Avulsion of the terminal extensor tendon from the distal phalanx (mallet or baseball finger) may or may not be associated with a bony avulsion. The injury is caused by forcible flexion of the DIP joint while catching a ball or hitting an object with the finger extended. Most authorities recommend continuous extension splinting to the DIP joint for
6 weeks, followed by nighttime splinting for an additional 6 weeks. It must be emphasized to the patient that at no time during the initial 6 weeks of treatment should the DIP joint be allowed to fall into flexion or an additional 6 weeks of continuous splinting is required.
REFERENCES: Miller MD, Cooper DE, Warner JP (eds): Review of Sports Medicine and Arthroscopy. Philadelphia, PA, WB Saunders, 1995, p 255.
Rettig AC: Closed tendon injuries of the hand and wrist in the athlete. Clin Sports Med 1992;11:77-99.
Arendt EA (ed): Orthopaedic Knowledge Update: Sports Medicine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 229-230.

Question 80

-A 12-year-old boy who plays multiple sports has had insidious-onset heel pain while running for 4 months. On examination, he had ankle dorsiflexion of 5 degrees. The squeeze test result was positive and the Thompson test result was negative. He has no pain with forced ankle plantar flexion. What is the most likely diagnosis?

Explanation

CLINICAL SITUATION FOR QUESTIONS 60 AND 61
A 15-year-old boy has had shoulder pain for 4 weeks during the middle of baseball season. The patient says his pain is “all over my shoulder.” Examination reveals tenderness to palpation over the anterolateral aspect of the shoulder. Internal and external rotation range of motion is restricted.
Radiographs show metaphyseal sclerosis.

Question 81

Figure 7 shows a sagittal T 1 -weighted MRI scan. What muscle/tendon is identified by the arrow?

Explanation

DISCUSSION: The sagittal T₁-weighted MRI scan is useful for interpreting the quality of muscle. The arrow is pointing to the teres minor.
REFERENCES: Goutallier D, Postel JM, Gleyze P, et al: Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full-thickness tears.

J Shoulder Elbow Surg 2003;12:550-554.
Agur AM (ed): Grant’s Atlas of Anatomy, ed 9. Baltimore, MD, Lippincott Williams & Wilkins, 1991, p 394.

Question 82

Figures 29a and 29b show the AP and lateral radiographs of a 30-year-old man who has increasingly worse back pain and stiffness. Examination shows painful, limited spinal range of motion. There is no neurologic deficit. What laboratory study would be most helpful in confirming the diagnosis?

Explanation

DISCUSSION: The radiographs show ankylosing spondylitis with sclerosis of the sacroiliac joints and a “bamboo spine” in the lumbar region. HLA-B27 is positive in 80% to 90% of patients with ankylosing spondylitis and in about 8% of the general population. The findings do not represent diffuse idiopathic skeletal hyperostosis (DISH), which is a radiographic diagnosis in which there are three consecutive levels of nonmarginated osteophytes without disk degeneration.
REFERENCES: Calin A: Ankylosing spondylitis. Clin Rheum Dis 1985;11:41-60.
Booth R, Simpson J, Herkowitz H: Arthritis of the spine, in Herkowitz HH (ed): The Spine, ed 4. Philadelphia, PA, WB Saunders, 1992, p 431.
van der Linden S, Valkenburg H, Cats A: The risk of developing ankylosing spondylitis in HLA-B27 positive individuals: A family and population study. Br J Rheumatol 1983;22:18-19.

Question 83

Figures 38a and 38b are the MRI scans of a 28-year-old man who reports progressively worsening severe back pain for the past 3 months. He denies fevers, chills, weakness, or neurologic dysfunction. Examination reveals tenderness to palpation over the lumbar spine but normal neurologic findings. Laboratory studies reveal an elevated erythrocyte sedimentation rate and C-reactive protein; blood cultures are positive for methicillin-sensitive Staphylococcus aureus. In addition to intravenous antibiotics, what is the next step in management? Review Topic

Explanation

The patient's symptoms and MRI findings are consistent with osteomyelitis and diskitis at L3-4 with a paraspinal fluid collection. Cultures confirm bacterial involvement. Given that finding, a biopsy of the level is unnecessary. Surgical treatment for infection is not indicated given the lack of neurologic deficit. Nonsurgical management is the best option, including both intravenous antibiotics and an external lumbar orthosis. A repeat MRI scan within a short duration would not impact clinical care. More important is close clinical follow-up to confirm response to treatment and identify any potential neurologic deficits that may develop.

Question 84

What neurovascular structure is in closest proximity to the probe in the arthroscopic view of the elbow shown in Figure 50? Review Topic

Explanation

The image shows a view of the radiocapitellar joint from an anterior medial portal. The radial nerve lies on the elbow capsule at the midportion of the capitellum. It is at risk for injury when capsular excision is performed in this region.

Question 85

Figure 26 is the radiograph of a 33-year-old woman who was involved in a high-speed motor vehicle crash. Her initial blood pressure is 80/50 mm Hg and she has a pulse rate of 120 bpm. After hemodynamic stabilization and temporizing measures have been performed, the patient is cleared for surgery. What is the most appropriate method of definitive fixation?

Explanation

The patient has sustained an anterior posterior compression (APC) grade II pelvic ring injury. Initial management should consist of pelvic volume reduction with pelvic binding or sheeting. Once the patient is hemodynamically stable, the decision for definitive management should be made. In a retrospective review of more than 200 patients, Sagi and Papp investigated plate osteosynthesis of the pubic symphysis. They found significantly fewer malunions in the multi-hole plate group and a trend toward fewer surgeries in the same group. Typically external fixation should be reserved for temporary fixation and not a definitive management in stable patients. Posterior fixation is reserved for injuries with disruption of the posterior ligamentous constraints, typically APC grade III injuries. Triangular osteosynthesis is a strategy for fixation of unstable vertical shear fractures that require fixation of the pelvis to the lumbar spine.

Question 86

Resurfacing the patella during a total knee replacement is strongly indicated when the diagnosis is

Explanation

A study by Boyd, et. al. was performed to determine patellar complications after TKA, with the use of an unconstrained prosthesis, with and without resurfacing of the patella. “Chronic pain (post-operative, peripatellar pain) in the group that had not had resurfacing was noted in 40 (13 percent) of the 300 knees that were affected by inflammatory arthritis (rheumatoid arthritis [RA], juvenile RA and miscellaneous subcategories), and in 11 (6 percent) of the 195 knees affected by degenerative osteoarthrosis…A revision to resurface the patella was performed in all 51 knees that caused chronic pain and had not had resurfacing of the patella.
Hence, chronic pain after TKA without resurfacing the patella was more common in knees affected by rheumatoid arthritis than in those affected by degenerative osteoarthritis. The authors of the study recommend that the patella be resurfaced when an unconstrained prosthesis is used in patients with a diagnosis of inflammatory arthritis and to a lesser degree osteoarthrosis.

Question 87

A patient has multidirectional instability of the shoulder that has not responded to nonsurgical management. Successful surgical treatment will most likely include which of the following? Review Topic

Explanation

Published reports establish the importance of the rotator interval in shoulder stability and improvements achieved through suture closure of the interval. Multidirectional
instability treated surgically following failure to respond to nonsurgical management has been shown to be associated with classic Bankart lesions, Hill-Sachs defects, glenoid chondral lesions, and even SLAP lesions (Werner). However, these lesions were seen in a lower percentage than that found for unidirectional anterior dislocations. Likewise, these lesions do not appear to be significant in influencing treatment in the majority of patients.

Question 88

Figure 30 shows the AP radiograph of a 9-month-old girl who has been referred for evaluation of unequal leg lengths. Examination reveals symmetrical abduction of the hips. When the hips are flexed 90°, the right knee height is greater than the left knee. The girth of the right thigh and calf is larger than the contralateral side. There are no cutaneous lesions, and examination of the spine is normal. The infant is moving all extremities equally and spontaneously. Management should consist of

Explanation

DISCUSSION: Hemihypertrophy or hemihypotrophy is usually idiopathic, and either the leg or the entire side of the body may be involved. In the infant or young child, it is often difficult to determine which side is abnormal if the condition is mild. Because of the association of Wilms’ tumor with hemihypertrophy, these patients should undergo a yearly renal ultrasound until at least age 5 years. Other conditions that may exhibit hemihypertrophy include Klippel-Trenaunay-Weber syndrome, Proteus syndrome, and neurofibromatosis. In this patient, the mild hemihypertrophy is idiopathic. Because of the normal spinal examination and absence of neurologic findings, an MRI scan is unnecessary. The absence of clinical and radiographic evidence of hip dysplasia makes both an ultrasound of the hips and application of a Pavlik harness unnecessary.
REFERENCES: Richards BS (ed): Orthopaedic Knowledge Update: Pediatrics. Rosemont Ill, American Academy of Orthopaedic Surgeons, 1996, pp 185-193.
Sponseller PD: Localized disorders of bone and soft tissue, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 4. Philadelphia, Pa, Lippincott-Raven, 1996, pp 305-344.
Beals RK: Hemihypertrophy and hemihypotrophy. Clin Orthop 1982;166:199-203.

Question 89

A 52-year-old woman reports the sudden onset of intense pain in the right shoulder. She denies any history of injury or previous shoulder problems. At a 2-week follow-up examination, she notes that the pain has decreased, but she now has severe weakness of the external rotators and abductors. Her cervical spine and remaining shoulder examination are otherwise unremarkable. Radiographs of the shoulder and neck are normal. What is the most likely diagnosis?

Explanation

DISCUSSION: Patients with brachial neuritis or Parsonage-Turner syndrome usually report the sudden onset of intense pain that subsides in 1 to 2 weeks, followed by weakness for a period of up to 1 year in the muscle that is supplied by the involved nerve. Calcific tendinitis usually can be diagnosed radiographically, with calcium deposits seen in the rotator cuff. Bursitis and rotator cuff tendinosis usually are seen after an increase in activity, and both decrease with rest and medication. Glenohumeral arthritis is a slow, progressive problem that results in a loss of range of motion.
REFERENCES: Misamore GW, Lehman DE: Parsonage-Turner syndrome (acute brachial neuritis). J Bone Joint Surg Am 1996;78:1405-1408.
Dillin L, Hoaglund FT, Scheck M: Brachial neuritis. J Bone Joint Surg Am 1985;67:878-880.

Question 90

In girls with idiopathic scoliosis, peak height velocity (PHV) typically occurs at what point?

Explanation

DISCUSSION: PHV generally occurs while girls are still Risser 0; menarche typically occurs before Risser 1, which has a wide variation in its timing. The curve magnitude at the PHV is the best prognostic indicator available. Most untreated patients with curves greater than 30 degrees at PHV require surgery, while patients with smaller curves at that stage typically do not

require surgery.
REFERENCES: Little DG, Song KM, Katz D, Herring JA: Relationship of peak height velocity to other maturity indicators in idiopathic scoliosis in girls. J Bone Joint Surg Am

2000;82:685-693.
Anderson M, Hwang SC, Green WT: Growth of the normal trunk in boys and girls during the second decade of life; related to age, maturity, and ossification of the iliac epiphyses. J Bone Joint Surg Am 1965;47:1554-1564.

Question 91

Which of the following bearing materials is most resistant to scratching from third-body debris?

Explanation

DISCUSSION: Alumina is the hardest of all the materials listed. Clinical retrieval demonstrates resistance to scratching from third-body debris.
REFERENCE: Cooper JR, Dowson D, Fisher J, Jobbins B: Ceramic bearing surfaces in total articular joints: Resistance to third body damage from bone cement particles. J Med Eng Technol 1991;15:63-67.

Question 92

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

Explanation

DISCUSSION:
Gamma irradiation produces free radicals. Although these free radicals can form cross-links with other polyethylene chains, the free radicals can also form a bond with oxygen, resulting in early oxidation. Gamma irradiation in air produces the highest risk for oxidized polyethylene, resulting in the highest risk for wear, delamination, and subsequent osteolysis. This patient demonstrates severe periarticular osteolysis. When she is asymptomatic, this suggests the acetabular and femoral components remain well fixed to the bone. Consequently, she can be treated by removing the wear generator (polyethylene exchange), along with bone grafting of the osteolytic defect. Considering the extensive amount of osteolysis indefinite observation would not be appropriate. A foot drop develops 2 days after surgery. As a result, it can be assumed that the nerve was not injured directly during the surgical procedure. Although MRI or CT may be indicated to identify an evolving hematoma, the immediate concern is to minimize pressure on the sciatic nerve. Tension on the nerve can be reduced by flexing the surgical knee and positioning the bed flat.

Question 93

Which of the following fluoroscopic views is used to assess intra-articular screw penetration during volar fixation of a distal radius fracture?

Explanation

Due to radial inclination, a true lateral view of the wrist will not show whether screws from a volar plate are intra-articular; a 23° elevated lateral view is needed to adequately assess this.
The amount of elevation will depend on the degree to which the surgeon restores radial inclination; for example, if the surgeon only restores 15° of radial inclination, then the surgeon would only have to elevate the wrist 15° from a true lateral in order to have the radiographic beam point down the joint line. Failure to diagnose intra-articular screws intraoperatively can lead to degenerative changes.
Tweet et al. performed a survey of orthopedic surgeons regarding their preferred method of visualizing screw placement during wrist fixation. The majority of surgeons reported that they obtain multiple views, including AP/PA wrist views, a 23° lateral inclination view, and a true lateral view. They also performed a cadaveric study looking at different x-ray views and screw penetration. They reported that live rotational fluoroscopy provided the highest sensitivity (93%) and specificity (96%) for the detection of intra-articular screw penetration.
Patel et al. evaluated the ability of surgeons at different levels to critically assess distal radius fixation and screw placement. They found that supplementation with a 23° lateral view increased accuracy and confidence in all position, specialty, and experience groups. Confidence scores were significantly higher following the evaluation of three views versus two views. Residents exhibited the greatest improvements in accuracy and confidence. For first-phase (standard view) assessments, accuracy scores were significantly better for attendings with less than 10 years of post-fellowship experience than those with more.
Illustration A is a non-elevated lateral of the wrist, while illustration B is a 23° elevated lateral radiograph. Illustration C is an example of a skyline view, which assesses for screws penetrating the dorsal cortex.
Incorrect Answers:
check for long distal screws.

OrthoCash 2020

Question 94

A 58-year-old man has a painful, warm, erythematous and fluctuant area over his left olecranon. An aspiration would be most likely to reveal

Explanation

Discussion: Staphylococcus aureus is the most common causative organism in septic bursitis, making up 80% or more of cases of culture-proven septic bursitis (https://www.uptodate.com/contents/septic-bursitis). Staphylococcus aureus was the most frequent pathogen (217 out of 256 or 85%), followed by Streptococcus pyogenes (16), other streptococci (15), Enterococcus faecalis (4) and coagulase-negative staphylococci (2). Staphylococcus aureus is the most common causative organism in septic bursitis, making up 80% or more of cases of culture-proven septic bursitis (https://www.uptodate.com/contents/septic-bursitis). Staphylococcus aureus was the most frequent pathogen (217 out of 256 or 85%), followed by Streptococcus pyogenes (16), other streptococci (15), Enterococcus faecalis (4) and coagulase-negative staphylococci (2).

Question 95

A 36-year-old recreational tennis player sustains the injury shown in Figure 16. Management should consist of

Explanation

DISCUSSION: The MRI scan shows a rupture of the patellar tendon. This injury is most appropriately addressed with primary repair. For athletic individuals, the results of nonsurgical management are suboptimal. Reconstructive procedures are not necessary.
REFERENCES: Matava MJ: Patellar tendon ruptures. J Am Acad Orthop Surg 1996;4:287-296.
Marder RA, Timmerman LA: Primary repair of patellar tendon rupture without augmentation. Am J Sports Med 1999;27:304-307.

Question 96

3 degrees Celsius and heart rate of 105 bpm. A clinical photograph, results of synovial fluid analysis, and a polarizing microscopy image are seen in Figures A through C. Synovial fluid gram stain and cultures are pending. What is the most appropriate next step in management?

Explanation

This patient presents with symptoms and findings highly suspicious for super- imposed septic arthritis and gout. This patient is likely going to need to go to the operating room for emergent I&D (not listed as an answer choice). Because cultures have already been obtained, the most appropriate next step in management would be to begin empiric intravenous antibiotics.
While the incidence of superimposed gout and septic arthritis is low (~1.5%),
it is reported. In the presence of crystals on aspiration, one should not rule out the possibility of septic arthritis. If there are other risk factors for infection, or the synovial WBC count is high (greater than 50,000), then empiric antibiotics should be initiated immediately after cultures are obtained. If the patient has other evidence supporting septic arthritis (positive Gram stain, purulence), emergent I&D is indicated. Even if the initial suspicion is lower, if they have
not respond to antibiotics after 24-48 hours they should undergo I&D.
Shah et al. investigated 265 crystal-positive joint aspirates in a 7-year retrospective study. They found the incidence of concomitant septic arthritis and crystal disease was 1.5% (4 cases including 2 knees, 1 hip, 1 ankle). All 4 patients that had superimposed infection had a WBC of > 50,000. They concluded that the presence of crystals in the synovial fluid cannot
conclusively rule out a septic joint.
Schuind et al. described a case report of concomitant septic arthritis and gout of the wrist. They found that cultures were positive for Staphylococcus aureus while pathological examination revealed aggregated crystals of monosodium urate.
Figure A shows tense, erythematous swelling of the right knee. Figure B is a table showing synovial fluid analysis with elevated WBC and PMN cell count characteristic of septic arthritis. Figure C shows needle-shaped negatively birefringent crystals on polarizing microscopy. Illustration A shows the synovial fluid characteristics in different disease conditions.
Incorrect Answers:
An 82-year-old osteoporotic woman undergoes total hip arthroplasty for osteoarthritis. During implant trialing, a crack is heard. Intraoperative fluoroscopy reveals a long, spiral fracture of the distal femur. The fracture is reduced and fixed with an anatomic locking plate. The rest of the total hip arthroplasty proceeds uneventfully. Following surgery the surgeon has a meeting with the family and apologizes and provides full disclosure, accepts responsibility, provides a detailed explanation as to what happened, and gives reassurance that steps will be taken to prevent recurrences. This communication approach will most likely
Lead to lower patient satisfaction rates
Lead to higher patient satisfaction rates
Lead to higher likelihood the patient will take legal action against surgeon
Lead to higher likelihood the patient will change physicians
Prevent any legal action
The surgeon has provided all the elements of good communication with the patient and family. His actions will lead to improved patient satisfaction, compared to nondisclosure and attempting to push or shirk responsibility.
In the event of a medical error or adverse event, effective communication with the patient and family is necessary. Effective communication should comprise:
an apology, full disclosure (an explanation of what happened), accepting responsibility, and corrective steps that will be taken to prevent recurrence.While accepting responsibility is integral to the explanation process, it is different from accepting blame.
Mazor et al. found patients would more likely change physicians and seek legal advice in situations with a life-threatening outcome where physicians chose
non-disclosure. They recommend full disclosure, acceptance of responsibility, an apology, detailed explanations, and assurances that steps will be taken to prevent recurrences will result in positive outcomes in terms of patient satisfaction, trust, and emotional response.
MacDonald et al. addressed medical errors in an editorial. Besides full disclosure, they feel that an apology is necessary. This includes an acknowledgement of the event and one’s role in the event, and a genuine expression of regret. Apology laws exist to to reduce concerns about legal implications of disclosure and apology.
Incorrect Answers:
The acquired immune response mediated by the interaction between the T cell receptor and major histocompatibility complex requires which of the following first steps?
Antigen phagocytosis by T cells
Antigen processing and presentation to T cells
Antigen recognition by natural killer T cells
Antigen proliferation by polymerase chain reaction
T cell disulfide bond cleavage and enzymatic processing
The process of antigen processing and presentation is the first step of the acquired immune response. This is performed by the so called antigen presentation cells (APC) of which B cells and dentritic cells are two examples. The APC breaks down the protein antigen in a multitude of enzymatic reactions and presents key peptide sequences via the major histocompatibility complex
(MHC) receptors. Once presented on the surface of the APC, the T-cell receptor recognizes the MHC/antigen complex leading to T-cell activation. At no point in this process are antigens phagocytosed by T cells. Natural killer T cells are involved in this sequence, but not for antigen processing and presentation. Polymerase chain reaction is a laboratory tool used to amplify nucleic acid. Finally, disulfide bond cleavage is a step involved in the APCs antigen processing reaction and does not occur in T cells.
All of the following are true regarding a physician responding to a formal written complaint by a patient EXCEPT:
Complaint should be taken seriously
Written response by the physician is required
Physician mandated to retain an attorney to address the formal complaint
Patient should be supplied with contact information for the institution's patient representative department
Law mandates that the physician respond to the formal complaint
It is important for the surgeon to know how to manage a formal complaint. An attorney is not required to assist on behalf of the physician when addressing a formal complaint. All complaints must be taken seriously and the physician is required by law to respond to all formal complaints in writing. Verbal
responses to formal, written complaints are not sufficient. If a patient is filing a formal complaint it is advisable that the patient be supplied with contact information for the institution's patient representative department.
What laboratory findings would you expect to find in a patient newly diagnosed with renal osteodystrophy?
Decreased PTH secretion, hypophosphatemia, and hypocalcemia
Increased PTH secretion, hyperphosphatemia, and hypocalcemia
Decreased PTH secretion, hypophosphatemia, and hypercalcemia
Increased PTH secretion, hyperphosphatemia, and hypercalcemia
Hypophosphatemia and hypocalcemia
Renal osteodystrophy is characterized by bone mineralization deficiency due to the electrolyte and endocrine abnormalities associated with chronic kidney disease. The pathogenesis of renal osteodystrophy is multifactorial. Hypocalcemia occurs due to the inability of the damaged kidney to convert vitamin D3 into its active form, calcitriol. The hypocalcemia and lack of phosphate excretion by the damaged kidney causes hyperparathyroidism and secondary hyperphosphatemia.
Loss of function in the 25(OH) vitamin D1-alpha hydroxylase gene causes which of the following diseases?
Hyperphosphatemia
Vitamin D resistant rickets
Hereditary Vitamin D dependant rickets type I
Hereditary Vitamin D dependant rickets type II
Hypophosphatemic rickets
Loss of function mutations in the 25 (OH) vitamin D hydroxylase gene cause hereditary vitamin D dependant rickets type I. Hereditary vitamin D dependant rickets type II is caused by a defect in intracellular receptor for 1,25-(OH)2- vitamin D3. Both forms of
hereditary vitamin D dependent rickets show decreased serum calcium/phosphorous, elevated alkaline phosphatase/PTH,
but type I has a decrease in the 1,25(OH)2 vitamin D and type II shows a increase in 1,25(OH)2 vitamin D. Vitamin D resistant rickets (Familial Hypophosphatemic Rickets) is caused by a large deletion in the PHEX gene and results in low serum phosphorous, elevated alkaline phosphatase, and normal calcium. Hyperphosphatemia can be caused by mutation in the GALNT3 gene and results in elevated serum phosphate and decreased PTH/calcium.
Kato et al. describe the molecular physiology of vitamin D metabolism and the recognized gene mutations associated with various clinical manifestations of mutations in vitamin D homeostasis.
Figure A is a radiograph taken after an open reduction and internal fixation of a periprosthetic distal femur fracture. With this type of hybrid locked plate fixation, what is the difference between screw A and screw B?
Screw A can assist in fracture reduction while screw B provides a fixed angle support
Screw A provides improved axial stiffness while screw B provides a fixed angle support
Screw A can be used to reduce the plate to bone while screw B can be used to lag fracture fragments together
Screw A provides a fixed angle support while screw B can be used to reduce the plate to the bone
Screw A can be used to lag fracture fragments together and screw B increases the plate bone frictional stability
Locking screws provide a fixed angle support and can improve fixation in osteoporotic bone while nonlocking screws can be used to reduce the plate to the bone, lag fracture fragments together and increase the plate bone frictional stability. "Hybrid" locked plate fixation utilizes both screw types in order to assist with difficult fracture fixation such as when there is a short metaphyseal segment and osteoporotic bone.
Zura et al discusses the biomechanical and biological advantages offered by locked plate fixation.
Using levels of evidence in research studies, which of the following represents a level II study?
Retrospective case control study
Prospective cohort study
Case report of 3 patients with the same disease
High-quality randomized prospective clinical trial
The opinion of a review panel at the annual AAOS meeting
Level II Evidence includes prospective cohort studies. There are 5 levels of evidence in clinical research. Level I includes randomized clinical trials. Level II includes prospective cohort studies. Level III includes case control studies AND retrospective cohort studies. Level IV includes case series. Level V evidence includes expert opinion, case reports, and personal observation. The cited reference by Bernstein et al is an excellent review of Evidence Based Medicine (EBM) and describes the 5 step process of making medical decisions based on the available, and often limited, evidence. These steps include: 1) Formulate answerable questions. 2) Gather the evidence. 3) Appraise the evidence. 4) Implement the evidence. 5) Evaluate the process. The reference by Spindler et al is another review article that discusses the different levels of evidence for different study types.
All of the following are true regarding the assessment of bone mineral density EXCEPT?
Bone mineral density loss is not apparent on standard radiographs until 30% to 40% of mineral is lost
Dual energy x-ray absorbtiometry (DEXA) is only able to measure mineralization of the axial skeleton
Single photon absorbtiometry allows for the analysis of bone mineralization in the appendicular skeleton alone
Quantitative computed tomography (QCT) is associated with 10 times the radiation of a DEXA scan
MRI allows for accurate discrimination of normal bone from osteopenic bones
without exposing the patient to ionizing radiation
Dual energy x-ray absorbtiometry (DEXA) scans allow for accurate assessment of bone mineralization in both the axial and appendicular skeleton.
Over the last decade, DEXA has become a safe, cost-effective and reliable method to quantify bone mineral density. The World Health Organization (WHO) has adopted DEXA derived BMD measurements to define normal bone, osteopenia, and osteoporosis in the adult and paediatric population. The typical DEXA analysis therefore reports a Z-score, which is the number of standard deviations (SDs) that a patient's BMD is above or below the mean value for persons of the patient's age and sex. The T score is the number of SDs the patient's BMD is either above or below the mean value for young patients of the same gender.
Tortolani et al. provide an overview of the techniques used to assess bone mineral density, the pathophysiology of osteopenia, and the evaluation and treatment options for the general pediatric population as well as for patients with specific pediatric disorders. The authors encouraged orthopaedic surgeons to understand the problems of osteopenia in both otherwise healthy children and children with chronic disorders.
Binkovitz & Henwood provide a review of DEXA technique and interpretation with emphasis on the considerations unique to pediatrics. They found that changes in bone size over time, as occurs in normal pediatric development, confound DXA interpretation. This is one of the major limitations in the use of pediatric DXA. However, attempts to correct for or to circumvent this limitation have been proposed and show promise in improving DXA interpretation and
our understanding of bone physiology.
T-score according to the World Health Organization (WHO): A T- score of -1.0 or above is normal bone density.
A T-score between -1.0 and -2.5 means you have low bone density or osteopenia.
A T-score of -2.5 or below is a diagnosis of osteoporosis.
Incorrect Answers:
A mother brings her 4-year-old daughter to your clinic for evaluation of knocked knees and short stature. On exam, the patient ambulates with a circumduction gait pattern and frequently falls. Plain radiographs are displayed in Figure A. Laboratory data is obtained and notable for calcium 9.1 mg/dL (RR 8.5-

Question 97

A previously asymptomatic 12-year-old girl sustained a direct blow to the right lateral knee from a baseball bat. Examination reveals an area of ecchymosis and tenderness over the lateral thigh. The patient can walk without pain, but range of motion of the knee causes discomfort. Plain radiographs of the knee are shown in Figures 11a and 11b. To address the bone lesion, management should consist of

Explanation

DISCUSSION: The plain radiographs reveal a pedunculated osteochondroma with a fracture. There is a bony growth in the metaphysis of a long bone, on a stalk that is directed away from the nearby epiphysis. On the AP view, the host cortical and medullary bone are shown as “blending” with lesional bone. There is also a fracture through the lesion. Based on these radiographic findings, the diagnosis is an osteochondroma; therefore, initial management of an acute fracture of an osteochondroma is symptomatic treatment alone. Additional imaging studies are not indicated in this patient. At times it may be difficult to distinguish a sessile osteochondroma from a parosteal osteosarcoma. In the latter case, the host medullary bone and lesion bone are not confluent. A CT scan may be helpful to distinguish if the host medullary and cortical bone are confluent with the lesion.
REFERENCE: Davids JR, Glancy GL, Eilert RE: Fracture through the stalk of pedunculated osteochondromas: A report of three cases. Clin Orthop 1991;271:258-264.

Question 98

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 most substantial functional deficit that may develop if no surgical treatment is provided is

Explanation

This patient had an eccentric muscle contraction (muscle lengthening while contracting) of his biceps muscle while trying to stop a defender from getting around him. This in turn caused failure of the distal biceps tendon, as evidenced by pain in the antecubital fossa, lack of elbow supination strength, and his positive biceps active test finding (supination/pronation of the forearm showing no motion of the biceps muscle belly). Eccentric contractors
have the highest potential for building strength but also are at highest risk for injury. Concentric (muscle shortening with contraction), isometric (no change in muscle length with contracture), and isokinetic (constant velocity of muscle contraction with a variable force) do not describe the mechanism detailed. The loss of distal biceps attachment will result in loss of elbow supination strength in flexion (the biceps is the only supinator to cross the elbow) while still retaining elbow flexion (albeit weakened) because of the other elbow flexors (brachioradialis and brachialis). Consequently, treatment should be anatomic repair of the distal biceps insertion, which can be performed with a 2-incision or 1-incision technique. Although all of the listed complications have been reported with these techniques, LABC neuropraxia is by far the most common. Radiographs show that this athlete’s injury was repaired using a 1-incision technique with a cortical fixation device and a radial bone tunnel. This technique has gained favor because of its decreased incidence of heterotopic ossification and radioulnar synostosis compared with the 2-incision technique. The most troubling complication for most surgeons is the development of a posterior interosseous nerve (PIN) palsy, which this patient clearly demonstrates in addition to the more common LABCN upon postsurgical examination. Because the LABCN injury is typically a neuropraxia from retraction, a period of observation is indicated. PIN injury can result from excessive traction during surgical exposure or from entrapment by the fixation button. Considering the anatomy of the PIN, successful recovery of the nerve typically progresses based on the distance from the origin of the nerve to the muscle indicated. The extensor indicis proprius (EIP) muscle is the most distal muscle innervated and can be expected to recover last. First to return would be the EDC
followed by the ECU, EDQ, and, finally, the EIP.

Question 99

A 35-year-old woman who underwent open reduction and internal fixation of a calcaneal fracture 14 months ago reports pain that has failed to respond to nonsurgical management. Examination reveals limited painful subtalar motion but no hindfoot deformity. A lateral radiograph is shown in Figure 6. Surgical reconstruction is best accomplished with

Explanation

DISCUSSION: The patient has posttraumatic subtalar joint arthrosis that developed following a calcaneal fracture. Because there is no hindfoot deformity, in situ subtalar joint arthrodesis is the treatment of choice. Calcaneal osteotomy or distraction bone block arthrodesis is beneficial in patients with severe talar dorsiflexion or malunion of the calcaneal body. Triple arthrodesis is not warranted without changes at the transverse tarsal joint, and typically even with injury into the calcaneocuboid joint, this joint is often asymptomatic. Pantalar arthrodesis is not indicated as the pathology is occurring at the subtalar joint and not in the ankle joint.
REFERENCES: Sanders R: Fractures and fracture-dislocations of the calcaneus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999,

pp 1422-1464.
Juliano TJ, Myerson MS: Fractures of the hindfoot, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1297-1340.
Chandler JT, Bonar SK, Anderson RB, Davis WH: Results of in situ subtalar arthrodesis for late sequelae of calcaneus fractures. Foot Ankle Int 1999;20:18-24.

Question 100

What is the most appropriate surgical treatment for a stage III symptomatic scapholunate advanced collapsed (SLAC) wrist?

Explanation

DISCUSSION: SLAC is the end result of chronic scapholunate instability. The arthritis follows a predictable pattern. Stage I disease involves cartilage loss between the waist of the scaphoid and the radial styloid. In stage II, the arthritis progresses to include the proximal pole of the scaphoid and the scaphoid fossa of the radius. Finally, stage III goes on to include arthritis of the capitolunate joint. The only treatment option that addresses all of the sites of arthritis is the scaphoid excision and four corner fusion.
REFERENCES: Ashmead DT IV, Watson HK, Damon C, et al: Scapholunate advanced collapse wrist salvage. J Hand Surg Am 1994;19:741-750.
Sauerbier M, Trankle M, Linsner G, et al: Midcarpal arthrodesis with complete scaphoid excision and interposition bone graft in the treatment of advanced carpal collapse (SNAC/SLAC wrist): Operative technique and outcome assessment. J Hand Surg Br 2000;25:341-345.

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

Pain during sitting; flexion abduction and external rotation of the hip
Groin pain; pain with internal rotation and adduction while supine with the hip and knee flexed 90°
Clicking; abductor lurch
Buttock pain; pain with hip extension, adduction, and external rotation while prone

Correct Answer: Groin pain; pain with internal rotation and adduction while supine with the hip and knee flexed 90°

Explanation:

Question 2:

Options:

Keeping a smooth plastic cannula in each portal after it is established
Using an image intensifier to localize the loose body
Distending the elbow joint capsule prior to establishing the anterolateral portal
Placing the scope in the proximal anteromedial portal and then enlarging the anterolateral portal so that it is bigger than the maximum diameter of the loose body
Breaking up the loose body into several pieces prior to extracting it

Correct Answer: Distending the elbow joint capsule prior to establishing the anterolateral portal

Explanation:

Question 3:

Pharmacoprophylaxis should be avoided in favor of a pneumatic compression device for a patient with

Options:

protein C deficiency.
protein S deficiency.
factor V Leiden mutation.
factor VIII deficiency.

Correct Answer: factor VIII deficiency.

Explanation:

Question 4:

Options:

hematocrit.
serial heart rate.
serial blood pressure with a manual cuff.
serial blood pressure with an arterial line.
lactate and base deficit levels.

Correct Answer: lactate and base deficit levels.

Question 5:

In the most common condition causing a winged scapula, which of the following nerves is affected? Review Topic

Options:

Long thoracic nerve
Spinal accessory nerve
Suprascapular nerve
Dorsal scapular nerve
Thoracodorsal nerve

Correct Answer: Long thoracic nerve

Explanation:

Question 6:

A 23-year-old soccer player sustains a grade III complete posterior cruciate ligament (PCL) tear after colliding with another player. In reconstructing the PCL, it is optimal to reconstruct the

Options:

anterolateral bundle and tension the graft at 10° of flexion.
anterolateral bundle and tension the graft at 90° of flexion.
posteromedial bundle and tension the graft at 10° of flexion.
posteromedial bundle and tension the graft at 45° of flexion.
posteromedial bundle and tension the graft at 90° of flexion.

Correct Answer: anterolateral bundle and tension the graft at 90° of flexion.

Explanation:

Question 7:

-An absolute contraindication for closed management of a humeral shaft fracture in a fracture brace is

Options:

severe fracture comminution.
associated brachial plexus injury.
presence of radial nerve palsy from time of injury.
development of radial nerve palsy following closed reduction.
associated femoral shaft fracture treated with intramedullary nail.

Correct Answer: associated brachial plexus injury.

Question 8:

Options:

Place blocking screws medial and posterior to the nail. Use a nail with a Herzog curve proximal to the fracture site.
Place blocking screws medial and posterior to the nail. Use a nail with a Herzog curve distal to the fracture site.
Place blocking screws lateral and posterior to the nail. Use a nail with a Herzog curve proximal to the fracture site.
Place blocking screws lateral and posterior to the nail. Use a nail with a Herzog curve distal to the fracture site.
Place blocking screws lateral and anterior to the nail. Use a nail with a Herzog curve proximal to the fracture site.

Correct Answer: Place blocking screws medial and posterior to the nail. Use a nail with a Herzog curve proximal to the fracture site.

Explanation:

Question 9:

Anterior subluxation in a throwing athlete is most commonly the result of

Options:

avulsion of the inferior glenohumeral ligament from the glenoid.
avulsion of the inferior glenohumeral ligament from the humerus.
fracture of the anterior glenoid rim.
excessive capsular laxity from microtrauma.
a large Hill-Sachs lesion.

Correct Answer: excessive capsular laxity from microtrauma.

Explanation:

Question 10:

Options:

ultrasonic stimulation for 3 months.
removal of the nail and plate fixation.
continued observation.
removal of the distal locking screws to dynamize the nail.
exchange reamed nailing with bone graft.

Correct Answer: exchange reamed nailing with bone graft.

Explanation:

Question 11:

Options:

Resting anterior compartment pressure of 13 mm Hg
Numbness/tingling of the plantar foot during the exercise portion of the test
minute postexercise anterior compartment pressure of 42 mm Hg
minute postexercise anterior compartment pressure of 19 mm Hg

Correct Answer: minute postexercise anterior compartment pressure of 42 mm Hg

Explanation:

Question 12:

What is the second most common primary bone malignancy in children?

Options:

Rhabdomyosarcoma
Osteosarcoma
Ewing’s sarcoma
Fibrosarcoma
Adamantinoma

Correct Answer: Ewing’s sarcoma

Explanation:

DISCUSSION: Ewing’s sarcoma is the second most common bone tumor in children with an incidence of three per one million Caucasian children younger than 21 years of age. Ewing’s sarcoma is rare in African Americans. Osteosarcoma is the most common bone tumor in children. Rhabdomyosarcoma is the most common soft-tissue sarcoma in children. Fibrosarcoma is a rare primary bone tumor most commonly seen in adults. Adamantinoma is a rare primary bone malignancy also most commonly seen in adults in the tibia.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 195.
Gibbs CP Jr, Weber K, Scarborough MT: Malignant bone tumors. Instr Course Lect 2002;51:413-428.

Question 13:

Options:

immediate hip spica casting.
closed reduction and percutaneous pin fixation supplemented by a hip spica cast.
placement in 90-90 traction after insertion of a distal femoral traction pin.
insertion of a reamed antegrade intramedullary nail starting at the piriformis fossa, stopping the nail short of the distal femoral growth plate.
closed reduction and stabilization using retrograde flexible intramedullary nails.

Correct Answer: closed reduction and stabilization using retrograde flexible intramedullary nails.

Explanation:

DISCUSSION: A child with a traumatic brain injury generally achieves significant neurologic recovery and has a more favorable prognosis than an adult. Early stabilization of fractures facilitates transportation of the child for diagnostic tests and decreases the incidence of shortening and malunion. Surgical treatment of the fracture is indicated when cerebral perfusion pressure has stabilized. Casting or traction is not the most appropriate treatment of a femoral fracture in a child of this age with a brain injury. Fracture reduction is difficult to maintain if the brain injury leads to spasticity, and transportation within the hospital for tests is more difficult. Insertion of a reamed antegrade intramedullary nail inserted at the piriformis fossa is associated with a small risk of osteonecrosis of the femoral head. The transverse femoral fracture in this patient is ideally suited for stabilization with flexible intramedullary nails. Ligier and associates treated 123 femoral shaft fractures in children with flexible intramedullary nails, including
35 patients with head injury. In one patient with hemiplegia and a urinary tract infection, a deep wound infection developed, necessitating nail removal. The remaining patients all healed without major complications. Heinrich and associates treated 78 diaphyseal femoral fractures with flexible intramedullary nails, including 14 with head injury. No major complications were reported and all fractures healed.
REFERENCES: Tolo VT: Management of the multiply injured child, in Rockwood CA, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996,
pp 83-95.
Ligier JN, Metaizeau JP, Prevot J, et al: Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg Br 1988;70:74-77.
Heinrich MS, Drvaric DM, Darr K, et al: The operative stabilization of pediatric diaphyseal femur fractures with flexible intramedullary nails: A prospective analysis. J Pediatric Orthop 1994;14:501-507.
Canale ST, Tolo VT: Fractures of the femur in children. Instr Course Lect 1995;44:255-273.

Question 14:

Which modality has the broadest application for the reduction of postsurgical transfusion?

Options:

Regional anesthesia
Tranexamic acid (TXA) administration
Reduced transfusion trigger
Hypotensive anesthesia

Correct Answer: Tranexamic acid (TXA) administration

Explanation:

Question 15:

A 35-year-old male sustains a closed tibial shaft fracture after falling from 12 feet. Which of the following measurements would be concerning for an evolving compartment syndrome?

Options:

Preoperative anterior compartment measurement of 29, with diastolic pressure 58
Preoperative anterior compartment measurement of 25, with diastolic pressure of 60
Intraoperative anterior compartment measurement of 25, with intraoperative diastolic pressure of 54
Intraoperative anterior compartment measurement of 28, with intraoperative diastolic pressure of 72
Preoperative anterior compartment measurement of 22, with mean arterial pressure of 70

Correct Answer: Intraoperative anterior compartment measurement of 28, with intraoperative diastolic pressure of 72

Explanation:

Question 16:

Options:

Rhomboids and levator transfer
Split pectoralis major transfer
Long head of triceps transfer
Scapulothoracic fusion
Infraspinatus transfer

Correct Answer: Rhomboids and levator transfer

Explanation:

Question 17:

When performing hip arthroscopy, the hip should be placed in neutral to slight internal rotation to protect which of the following structures? Review Topic

Options:

Femoral nerve
Lateral femoral cutaneous nerve
Ascending lateral femoral circumflex artery
Ascending medial femoral circumflex artery
Sciatic nerve

Correct Answer: Sciatic nerve

Explanation:

Question 18:

Which of the following cannulated screw configurations used in the treatment of subcapital femoral neck fractures is optimal?

Options:

Inverted triangle pattern with the inferior screw posterior to midline and adjacent to the calcar
Inverted triangle pattern with the inferior screw anterior to midline and adjacent to the calcar
Triangle pattern with the superior screw posterior to midline and adjacent to the calcar
Inverted triangle pattern with the inferior screw posterior to midline and central in the femoral neck
Inverted triangle pattern with the inferior screw anterior to midline and central in the femoral neck

Correct Answer: Inverted triangle pattern with the inferior screw posterior to midline and adjacent to the calcar

Explanation:

Question 19:

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

Options:

Improved superior stability
Fixed fulcrum kinematics
Creates a metal-to-bone articulation with the acromion
Increased deltoid moment arm
Increased glenohumeral offset

Correct Answer: Creates a metal-to-bone articulation with the acromion

Explanation:

DISCUSSION: The theoretic advantage of a metal-to-bone articulation with the acromion is that there is a greater arc in which a smooth metal surface contacts the glenoid and acromion. This may improve pain and function, but no studies have evaluated this to date. One study showed results comparable to that of a standard hemiarthroplasty. There are no other biomechanic advantages.
REFERENCES: Visotsky JL, Basamania C, Seebauer L, et al: Cuff tear arthropathy: Pathogenesis, classification, and algorithm for treatment. J Bone Joint Surg Am 2004;86:35-40.
Zuckerman JD, Scott AJ, Gallagher MA: Hemiarthroplasty for cuff tear arthropathy. J Shoulder Elbow Surg 2000;9:169-172.

Question 20:

A 13-year-old girl presents with back pain for 6 months. Figures A and B are SPECT scan and CT images taken at the time of presentation. What is the most likely diagnosis? Review Topic

Options:

Osteoid osteoma
Bone island
Spondylolysis
Osteoblastic metastases
Aneurysmal bone cyst

Correct Answer: Osteoid osteoma

Explanation:

Question 21:

A 10-year-old boy has a painful thigh mass. A radiograph, MRI scan, and biopsy specimen are shown in Figures 42a through 42c. What is the most likely diagnosis?

Options:

Infection
Parosteal osteosarcoma
Chondroblastic osteosarcoma
Chondrosarcoma
Osteochondroma

Correct Answer: Chondroblastic osteosarcoma

Explanation:

Question 22:

A patient notes pain under the first metatarsophalangeal joint following a soccer injury. The MRI scans shown in Figures 27a and 27b reveal what pathologic finding?

Options:

Sesamoid fracture
Phalangeal fracture
Osteochondral lesion
Disruption of the plantar plate
Rupture of the flexor hallucis tendon

Correct Answer: Disruption of the plantar plate

Explanation:

Question 23:

Options:

Type I acromion
Type III acromion
Meso os acromiale
Meta os acromiale
Pre os acromiale

Correct Answer: Meso os acromiale

Explanation:

The MRI scans reveal a meso os acromiale with edema at the site in a skeletally mature patient.

Question 24:

A 14-year-old male sustains the injuries shown in Figures A and B after a fall off the roof of his house. What is the most appropriate management? Review Topic

Options:

Hip spica in abduction
Dynamic hip screw with trochanteric side plate
Cephalomedullary nail
Physis-sparing cancellous screws
Transphyseal cancellous screws

Correct Answer: Transphyseal cancellous screws

Explanation:

Question 25:

Figures 15a through 15d

Options:

T-type fracture
Anterior column fracture
Anterior wall fracture
Posterior wall fracture
Posterior column and posterior wall fracture
Transverse with posterior wall fracture

Correct Answer: T-type fracture

Explanation:

DISCUSSION
Plain radiographic imaging of a patient with an acetabular injury begins with 5 standard views of the pelvis (anteroposterior [AP], iliac oblique, obturator oblique, inlet, and outlet views). These views will show fractures of the acetabulum and help to evaluate for pelvic fractures and hip joint integrity. The obturator oblique view is taken with the injured side rotated 45 degrees forward with the beam centered on the patient’s affected hip. This shows the anterior column and posterior wall and will reveal if any posterior subluxation of the hip is present. The iliac oblique view is taken with the injured side of the patient rolled 45 degrees forward with the beam centered on the affected hip. This shows the posterior column and the anterior wall. Inlet and outlet pelvic radiographs may depict pelvic injuries such as sacroiliac joint fracture or widening.
Judet and Letournel have a classification system for acetabular fractures. The system consists of 5 elementary fracture patterns: anterior wall, anterior column, posterior wall, and posterior column fractures of the acetabulum and a transverse pattern. There are also 5 associated fracture patterns: posterior column/posterior wall, transverse/posterior wall, T-type, anterior column with hemitransverse fracture of the posterior column, and both-column fractures.
Figure 12b shows a fracture of the posterior column on the Iliac oblique, and Figure 12c shows a fracture of the posterior wall in the obturator oblique.
In Question 13, the figures only reveal a fracture of the posterior wall, and this is best appreciated in Figure 13c, the obturator oblique view.
The T-type fracture is a transverse fracture with a secondary fracture line extending inferiorly. This causes the anterior and posterior columns to be separated. The iliac oblique view, Figure 14b, shows a fracture extending through the posterior column. In the obturator oblique view (Figure 14c), the yellow arrow shows a fracture extending through the anterior column, and the red arrow shows a fracture extending inferiorly through the ischium.
Fractures extending through the anterior and posterior columns are seen, which represent a transverse fracture, but there is no extension inferiorly, which eliminates T-type as a possible correct response. The anterior column fracture is best seen on the inlet view (Figure 15b), but it also can be seen in Figure 15d, the obturator oblique view. Figure 15c shows the fracture through the posterior column. For this patient, a small fracture of the posterior wall is visualized on the AP view (Figure 15a).
RECOMMENDED READINGS
Dickson KF, Dowling RM. Treatment of pelvic and acetabular fractures in elderly patients. Orthopaedic Knowledge Online Journal. Volume 11, Number 8 August 2013.
Tornetta P 3rd. Displaced acetabular fractures: indications for operative and nonoperative management. J Am Acad Orthop Surg. 2001 Jan-Feb;9(1):18-28. Review. PubMed PMID: 11174160.
View Abstract
at PubMed
Moed BR, Kregor PJ, Reilly MC, Stover MD, Vrahas MS. Current management of posterior wall fractures of the acetabulum. Instr Course Lect. 2015;64:139-59. Review. PubMed PMID: 25745901.
View Abstract at PubMed

Question 26:

A 29-year-old quarterback falls onto his dominant shoulder and sustains the injury shown in Figures 14a and 14b. Management should consist of

Options:

an arm sling.
nonsteroidal anti-inflammatory drugs and a rapid return to activity.
arthroscopic partial claviculectomy.
acromioclavicular joint reduction and stabilization.
acromionectomy.

Correct Answer: acromioclavicular joint reduction and stabilization.

Explanation:

Question 27:

Options:

Chondrolysis
Osteochondritis dissecans of the femoral head
Osteonecrosis of the femoral head
Nonunion
Coxa magna

Correct Answer: Osteonecrosis of the femoral head

Explanation:

Question 28:

Figures 21a through 21c show the radiographs of a 70-year-old woman who has persistent pain with activity after undergoing hip revision 6 months ago. Treatment should now consist of

Options:

shortening of the femoral neck.
exchange of the acetabular liner.
revision of the femoral component.
revision of both components.
revision of the acetabular component.

Correct Answer: revision of the acetabular component.

Explanation:

Question 29:

Options:

Stop all his opioids 5 days before surgery, and place the patient on a morphine pain control pump postoperatively with a basal rate.
Increase his current opioid medication regimen prior to and after surgery as needed to control his pain.
Decrease his preoperative opioid use, and work with his pain management physician to decrease his postoperative opioid requirement.
Avoid using narcotics in the perioperative period to prevent overdose, and use acetaminophen only for pain control.

Correct Answer: Increase his current opioid medication regimen prior to and after surgery as needed to control his pain.

Explanation:

Question 30:

Options:

Further rehabilitation
Corticosteroid injection
Reconstruction of the medial collateral ligament
Subcutaneous transposition of the ulnar nerve
Arthroscopic debridement of medial osteophytes

Correct Answer: Subcutaneous transposition of the ulnar nerve

Explanation:

Question 31:

Options:

Open inferior capsular shift
Arthroscopic thermal capsulorrhaphy
Sling at all times until the pain resolves
Arthroscopic anterior and posterior capsular plication
Physical therapy for rotator cuff and scapulothoracic strengthening

Correct Answer: Physical therapy for rotator cuff and scapulothoracic strengthening

Explanation:

Question 32:

Options:

immediate transmetatarsal amputation.
immediate below-knee amputation.
application of a splint and observation.
fasciotomy and fracture fixation.
fasciotomy without fracture fixation.

Correct Answer: fasciotomy and fracture fixation.

Explanation:

Question 33:

Options:

Malposition of the components
A poor survivorship record of the implant
A high-powered intraoperative frozen section that reveals a count of 20 WBCs per high-powered field
A nonmodular acetabular component
A well-fixed modular acetabular component

Correct Answer: A well-fixed modular acetabular component

Explanation:

Question 34:

A 61-year-old man has a symptomatic bunionette that is refractory to nonsurgical management. A radiograph is shown in Figure 6. What is the optimal surgical correction?

Options:

Fifth metatarsal head lateral ostectomy
Fifth metatarsal head excision
Metatarsal osteotomy and fifth metatarsal head ostectomy
Fifth metatarsal plantar condylectomy
Fifth metatarsophalangeal Silastic implant arthroplasty

Correct Answer: Metatarsal osteotomy and fifth metatarsal head ostectomy

Explanation:

DISCUSSION: The patient has a bunionette with a large 4-5 intermetatarsal angle. This requires not only ostectomy of the lateral prominence but metatarsal osteotomy to decrease the intermetatarsal angle. Excising the head results in a flail joint and creates the possibility of a transfer lesion. Condylectomy can reduce plantar pressures but does not address the bunionette. The joint surface is well maintained, thus there are no indications for resection.
REFERENCES: Coughlin MJ: Treatment of bunionette deformity with longitudinal diaphyseal osteotomy with distal soft tissue repair. Foot Ankle 1991;11:195-203.
Koti M, Maffulli N: Bunionette. J Bone Joint Surg Am 2001;83:1076-1082.

Question 35:

Which of the following complications occurs more commonly after antegrade femoral nail insertion when compared with retrograde insertion?

Options:

Increased blood loss
Decreased range of motion of the knee
Infection
Hip pain
Muscle weakness

Correct Answer: Hip pain

Explanation:

Question 36:

Options:

Superior labrum anterior and posterior lesion, type III
Isolated traumatic dislocation
Axillary nerve disruption
Subscapularis rupture
Internal impingement

Correct Answer: Subscapularis rupture

Explanation:

Question 37:

The function of which of the following structures is to resist internal tibial rotation with the knee in full extension? Review Topic

Options:

Anterior cruciate ligament
Iliotibial band
Popliteus tendon
Popliteofibular ligament
Posterior oblique ligament

Correct Answer: Posterior oblique ligament

Explanation:

Question 38:

When harvesting iliac crest bone graft during a posterior spinal decompression and fusion, injury to what structure can result in painful neuromas or numbness over the skin of the buttocks?

Options:

Ilioinguinal nerve
Superior gluteal nerve
Superior cluneal nerves
Iliohypogastric nerves
Lateral femoral cutaneous nerve

Correct Answer: Superior cluneal nerves

Explanation:

Question 39:

Options:

- Avascular necrosis, head collapse, and screw penetration
- Fixation failure and varus collapse
- Humeral stem loosening
- Glenoid component loosening
- Hardware failure (breakage of plate or screws)
- Shoulder dislocation

Correct Answer: - Avascular necrosis, head collapse, and screw penetration

Explanation:

Question 40:

Which of the following is most commonly associated with an open clavicular fracture?

Options:

Scapulothoracic dissociation
Closed head injury
Calcaneus fracture
Pelvic ring injury
Open tibial fracture

Correct Answer: Closed head injury

Explanation:

DISCUSSION: Open clavicular fractures are rare and result from high-energy trauma. In a series of 20 patients with open clavicular fractures, 13 (65%) sustained a closed head injury. Fifteen (75%) had associated pulmonary injuries and 35% had a cervical or thoracic spine fracture. Only one demonstrated scapulothoracic dissociation. Screening for pulmonary and closed head injuries should be considered in the setting of traumatic open clavicular fractures.
REFERENCE: Taitsman LA, Nork SE, Coles CP, et al: Open clavicle fractures and associated injuries. J Orthop Trauma 2006;20:396-399.

Question 41:

Options:

Suprascapular
Radial
Anterior branch of axillary
Spinal accessory (cranial nerve XI)

Correct Answer: Anterior branch of axillary

Explanation:

EXPLANATION:
This patient has a deficiency of the anterior deltoid muscle, resulting in inferior subluxation of the humerus with associated glenohumeral instability. Axillary nerve injury during shoulder surgery accounts for 6% to 10% of brachial plexus injuries. In the posterior scapular region, the axillary nerve terminates by dividing into two main branches: the posterior terminal branch, which provides motor innervation to the teres minor and posterior deltoid muscles, and the anterior terminal branch, which provides motor innervation to the anterior and middle portions of the deltoid muscle. The deltoid determines the silhouette
of the shoulder and is a stabilizer of the humeral head.

Question 42:

A superior labrum anterior and posterior (SLAP) lesion doubles the strain in which of the following stabilizing structures?

Options:

Superior glenohumeral ligament
Middle glenohumeral ligament
Inferior glenohumeral ligament
Posterior inferior glenohumeral ligament
Subscapularis

Correct Answer: Inferior glenohumeral ligament

Explanation:

Question 43:

-What is the most likely deficit in elbow function resulting from an isolated lesion of the ulnar nerve above the elbow?

Options:

No elbow deficit
Weakness of elbow flexion
Weakness of elbow extension
Weakness of forearm pronation
Weakness of forearm supination

Correct Answer: No elbow deficit

Question 44:

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

Options:

Rituximab
Etanercept
Abatacept
Methotrexate
Leflunomide

Correct Answer: Etanercept

Explanation:

Question 45:

What is the most common adverse postoperative complication of laminoplasty for multilevel cervical spondylotic myelopathy?

Options:

Loss of cervical range of motion
Inadvertent closure of the laminoplasty postoperatively
Progressive cervical kyphosis
C5 nerve root palsy
Inadequate decompression of the spinal cord

Correct Answer: Loss of cervical range of motion

Explanation:

Question 46:

Options:

Admit for observation and reassurance
Surgical exploration and removal of the anterior instrumentation
Esophageal swallowing study
Soft cervical collar and early range-of-motion exercises
CT of the cervical spine

Correct Answer: Admit for observation and reassurance

Explanation:

DISCUSSION: The radiograph shows significant prevertebral soft-tissue swelling following a two-level anterior cervical diskectomy and fusion. The incidence of dysphagia 2 years after anterior cervical spine surgery is 13.6%. Risk factors for long-term dysphagia after anterior cervical spine surgery include gender, revision surgeries, and multilevel surgeries. The use of instrumentation, higher levels, or corpectomy versus diskectomy did not significantly increase the prevalence of dysphagia. Lee and associates demonstrated that while dysphagia after anterior cervical spine surgery is a common early finding, it generally decreases significantly by
6 months with nonsurgical management. A minority of patients experience moderate or severe symptoms by 6 months after the procedure. Female gender and multiple surgical levels have been identified as risk factors for the development of postoperative dysphagia.
REFERENCES: Lee MJ, Bazaz R, Furey CG, et al: Risk factors for dysphagia after anterior cervical spine surgery: A two-year prospective cohort study. Spine J 2007;7:141-147.
Bazaz R, Lee MJ, Yoo JU: Incidence of dysphagia after anterior cervical spine surgery:
A prospective study. Spine 2002;27:2453-2458.

Question 47:

Options:

limited range of motion.
patella complications.
infection.
loosening.
tibia fracture.

Correct Answer: patella complications.

Explanation:

Question 48:

Options:

Displaced labral tear
Tear of the rotator cuff
Fracture of the glenoid rim
Palsy of the axillary nerve
Palsy of the musculocutaneus nerve

Correct Answer: Tear of the rotator cuff

Explanation:

Question 49:

Options:

- Superior gluteal artery
- Branch of the external iliac artery
- Branch of the pudendal artery
- Branch of the femoral artery

Correct Answer: - Branch of the pudendal artery

Explanation:

DISCUSSION
Pelvic bleeding occurs predominantly from disruption of the posterior venous plexus and bleeding from the fractured bone. Occasionally arterial bleeding is seen, with injury to the superior gluteal artery most common. Anterior pelvic bleeding occurs from injury to the obturator artery (commonly from a pubic bone fracture laceration) and less frequently from the pudendal artery near the symphysis. The location of the bleeding on CT and angiography images does not correspond to the superior gluteal, external iliac, or femoral arteries.
RECOMMENDED READINGS
Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography: competitive or complementary? Injury. 2009 Apr;40(4):343-53. Epub 2009 Mar 17. Review.PubMed PMID: 19278678.
View Abstract at PubMed
Loffroy R, Yeguiayan JM, Guiu B, Cercueil JP, Krausé D. Stable fracture of the pubic rami: a rare cause of life-threatening bleeding from the inferior epigastric artery managed with transcatheter embolization. CJEM. 2008 Jul;10(4):392-5. PubMed PMID: 18652733.
View
Abstract at PubMed
White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures.Injury. 2009 Oct;40(10):1023-30. Epub 2009 Apr 16. Review. PubMed PMID:19371871.
View Abstract at
PubMed
RESPONSES FOR QUESTIONS 5 THROUGH 8
5A
5B
- Avascular necrosis, head collapse, and screw penetration
- Fixation failure and varus collapse
- Humeral stem loosening
- Glenoid component loosening
- Hardware failure (breakage of plate or screws)
- Shoulder dislocation
Please choose from the responses to identify the most likely complication in each scenario.

Question 50:

Options:

extensor hallus longus lengthening.
midfoot osteotomy.
first metatarsal osteotomy.
transfer of the extensor hallucis longus to the neck of the first metatarsal.
transfer of the extensor hallucis longus to the neck of the first metatarsal with first metatarsal osteotomy.

Correct Answer: transfer of the extensor hallucis longus to the neck of the first metatarsal with first metatarsal osteotomy.

Explanation:

Question 51:

Options:

Posterosuperior labrum, greater tuberosity, articular side of the rotator cuff
Posterior glenoid, humeral head, bursal side of the rotator cuff
Biceps anchor, articular side of the rotator cuff, supraspinatus tendon
Biceps tendon, bursal side of the rotator cuff, superior labrum
Subscapularis, anterior labrum, humeral head

Correct Answer: Posterosuperior labrum, greater tuberosity, articular side of the rotator cuff

Explanation:

Question 52:

03 A 26-year-old woman has chronic toe pain after hitting a bedpost 3 months ago. A radiograph is shown in Figure 27. Her injury represents an avulsion of the

Options:

lumbrical insertion.
extensor digitorum brevis.
extensor digitorum longus.
extensor hallucis longus.
flexor digitorum longus.
back answer Question 105.03

Correct Answer: extensor digitorum longus.

Explanation:

Question 53:

Which of the following is the most relevant clinical factor in the maturation assessment of an adolescent female athlete contemplating anterior cruciate ligament (ACL) reconstruction?

Options:

Parental height
Height of older male sibling
Age of menarche
Recent change in shoe size
Presence of breast buds

Correct Answer: Age of menarche

Explanation:

Question 54:

A 65-year-old woman landed on her nondominant left shoulder in a fall. An AP radiograph is shown in Figure 39. Management should consist of

Options:

closed reduction and immobilization.
closed reduction and percutaneous pinning.
open reduction and internal fixation.
humeral hemiarthroplasty with tuberosity repair.
total shoulder arthroplasty.

Correct Answer: humeral hemiarthroplasty with tuberosity repair.

Explanation:

Question 55:

Options:

The decision to proceed with limb-sparing surgery instead of amputation
The presence of a mutated p53 gene
Pulmonary nodules detected on a CT scan
Location of the tumor
Tumor necrosis of 99% following preoperative chemotherapy

Correct Answer: Pulmonary nodules detected on a CT scan

Explanation:

Question 56:

The humeral nonunion shown in Figure 27 is most likely to unite when using what method of treatment?

Options:

Intramedullary nail
Pulsed electromagnetic fields
Compression plate
Intramedullary nail and bone graft
Compression plate and bone graft

Correct Answer: Compression plate and bone graft

Explanation:

DISCUSSION: The radiograph shows an atrophic nonunion of the humeral shaft. The management of humeral nonunions has been studied with compression plates and bone graft, as well as intramedullary nailing and bone graft. Compression plating with bone graft results in the highest rate of union. Compression plating by itself is not adequate, given the bone loss and lack of callous in this nonunion. Pulsed electromagnetic fields is a viable option for hypertrophic nonunions where there is inherent stability. Intramedullary nailing does not provide as much compression and stability as that achieved with compression plating.
REFERENCES: Pugh DM, McKee MD: Advances in the management of humeral nonunion.
J Am Acad Orthop Surg 2003;11:48-59.
McKee MD, Miranda MA, Riemer BL, et al: Management of humeral nonunion after the failure of locking intramedullary nails. J Orthop Trauma 1996;10:492-499.

Question 57:

- What factor is most commonly associated with malignant transformation of a giant cell tumor?

Options:

high-grade histology of the initial tumor
multiple local recurrences after curettage
previous treatment of the tumor with cryotherapy
previous treatment of the tumor with radiation therapy
extraosseous extension into two or more adjacent compartments

Correct Answer: previous treatment of the tumor with radiation therapy

Explanation:

Most authors have agreed that radiation therapy should be avoided in the treatment of giant cell tumor, as there is a high prevalence of sarcomatous degeneration.

Question 58:

Options:

open anterior acromioplasty and rotator cuff repair.
arthroscopic acromioplasty.
anterior acromioplasty and distal clavicle excision.
an open Mumford procedure.
immobilization in a sling for 4 weeks followed by additional physical therapy.

Correct Answer: anterior acromioplasty and distal clavicle excision.

Explanation:

Question 59:

Second impact syndrome (SIS) after head injury is characterized by which of the following?

Options:

Gradual progression of neurologic symptoms
Preventable by restricting return to play until symptom-free
Excellent prognosis for full recovery
Rarely involves brain stem compromise
CT rarely shows brain edema

Correct Answer: Preventable by restricting return to play until symptom-free

Explanation:

Question 60:

A 3-year-old boy has a rigid 40-degree lumbar scoliosis that is the result of a fully segmented L5 hemivertebra. All other examination findings are normal. Management should consist of

Options:

in situ posterior fusion.
hemivertebral resection and fusion.
convex hemiepiphyseodesis.
observation with follow-up in 6 months.
thoracolumbosacral orthosis bracing.

Correct Answer: hemivertebral resection and fusion.

Explanation:

Question 61:

Figures 10a and 10b show the clinical photograph and MRI scan of a plantar foot lesion. If excisional biopsy is performed, what is the most likely complication?

Options:

Metastatic spread
Recurrence of the lesion
High likelihood of wound breakdown
Injury to the medial plantar nerve
Loss of the local windlass effect of the plantar fascia

Correct Answer: Recurrence of the lesion

Explanation:

DISCUSSION: The MRI scan shows plantar fibromatosis. The treatment is usually nonsurgical.
If surgery is indicated, wide local excision with excision of the entire plantar fascia is usually indicated. The main problem with simple excision of the lesion is the high chance of recurrence. The other listed complications are those that are a result of the wide local excision.
REFERENCES: Aluisio FV, Mair SD, Hall RL: Plantar fibromatosis: Treatment of primary and recurrent lesions and factors associated with recurrence. Foot Ankle Int 1996;17:672-678.
Bos GD, Esther RJ, Woll TS: Foot tumors: Diagnosis and treatment. J Am Acad Orthop Surg 2002;10:259-270.

Question 62:

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

Options:

Are most commonly discovered during the fifth to seventh decades of life
Occur with similar frequency as cervical disk herniations
Occur most commonly in the midthoracic or apical region of the spine
Can be found in 40% of asymptomatic individuals
Are best treated surgically with posterior laminectomy and excision

Correct Answer: Can be found in 40% of asymptomatic individuals

Explanation:

Question 63:

- A skeletal survey is more accurate than a bone scan for detecting skeletal involvement in which of the following neoplastic diseases?

Options:

Ewing’s sarcoma
Osteogenic sarcoma
Multiple myeloma
Metastatic prostate carcinoma
Metastatic breast carcinoma

Correct Answer: Multiple myeloma

Explanation:

Multiple Myeloma lesions are cold on bone scan and because of this a skeletal survey is more useful.

Question 64:

Options:

Completion of the surgical procedure with continued monitoring
Reversal of the corrective maneuver and consideration of a wake-up test
Administration of high dose corticosteroids intraoperatively
Removal of all instrumentation
Discontinue monitoring

Correct Answer: Reversal of the corrective maneuver and consideration of a wake-up test

Explanation:

Question 65:

Options:

revision of the failing ACL reconstruction.
arthroscopic lysis of adhesions and manipulation of the knee.
surgical removal of hypertrophic fibrous tissue.
excision of the torn medial meniscus.
continued aggressive physical therapy.

Correct Answer: surgical removal of hypertrophic fibrous tissue.

Explanation:

DISCUSSION: The patient has a cyclops lesion. This is a nodule of fibroproliferative tissue that originates from either drilling debris from the tibial tunnel or remnants of the ACL stump; more rarely it is the result of broken graft fibers. The treatment of choice is excision of the nodule and, if needed, additional notchplasty. Marked improvements in function and symptoms have been noted after removal of the extension block and resumption of a rehabilitation program.
REFERENCES: Delince P, Krallis P, Descamps PY, et al: Different aspects of the cyclops lesion following anterior cruciate ligament reconstruction: A multifactorial etiopathogenesis. Arthroscopy 1998;14:869-876.
Fisher SE, Shelbourne KD: Arthroscopic treatment of symptomatic extension block complicating anterior cruciate ligament reconstruction. Am J Sports Med 1993;4:558-564.

Question 66:

Which of the following conditions is associated with palmoplantar pustulosis?

Options:

Condensing osteitis
Sternoclavicular hyperostosis
Friedreich’s disease
Scleroderma
Reiter syndrome

Correct Answer: Sternoclavicular hyperostosis

Explanation:

DISCUSSION: Sternoclavicular hyperotosis is a seronegative and HLA-B27 negative rheumatic disease. In this condition, hyperostosis may appear in the spine, long bones, sacroiliac joints, and the sternoclavicular region. This entity is also associated with palmoplantar pustulosis.
REFERENCES: Wirth MA, Rockwood CA: Disorders of the sternoclavicular joint, in Rockwood CA, Matsen FA, Wirth MA, et al (eds): The Shoulder. Philadelphia, PA,
WB Saunders, 2004, vol 2, pp 608-609.
Sonozaki H, Azuma A, Okai K, et al: Clinical features of 22 cases with inter-sterno-costo-clavicular ossification: A new rheumatic syndrome. Arch Orthop Trauma Surg 1979;95:13-22.

Question 67:

Options:

arthroscopic debridement of the articular lesion and resurfacing.
knee aspiration and an intra-articular cortisone injection.
rheumatologic evaluation.
infectious disease evaluation for possible Lyme disease.
arthroscopic synovectomy.

Correct Answer: arthroscopic synovectomy.

Explanation:

DISCUSSION: The patient has synovial chondromatosis. The MRI scans show multiple small proscribed areas of signal intensity in the gutters and suprapatellar pouch, suggesting very small loose bodies. The arthroscopic view shows the classic appearance of multiple small chondral loose bodies. Synovial chondromatosis is a condition in which the synovium undergoes metaplasia, producing multiple chondral loose bodies that can subsequently ossify. The treatment of choice, removal of the loose bodies and arthroscopic synovectomy, results in a lower incidence of recurrence than other treatment methods.
REFERENCES: Coolican MR, Dandy DJ: Arthroscopic management of synovial chondromatosis of the knee: findings and results in 18 cases. J Bone Joint Surg Br
1989;71:498-500.
Ogilvie-Harris DJ, Saleh K: Generalized synovial chondromatosis of the knee: A comparison
of removal of the loose bodies alone with arthroscopic synovectomy. Arthroscopy
1994;10:166-170.

Question 68:

Osteochondritis dissecans of the capitellum is a source of elbow pain and most commonly occurs in what patient population? Review Topic

Options:

Swimmers and divers
Football lineman
Rugby players
Gymnasts and throwing athletes
Cyclists

Correct Answer: Gymnasts and throwing athletes

Explanation:

Question 69:

Options:

Laxity of the volar plate
Intraosseous tendon
Extensor digitorum longus tendon
Extensor digitorum brevis tendon
Flexor digitorum longus tendon

Correct Answer: Flexor digitorum longus tendon

Explanation:

Question 70:

Options:

3 cm
6 cm
10 cm
14 cm
18 cm

Correct Answer: 6 cm

Explanation:

Question 71:

What is one of the principle concerns when a fracture such as the one seen in Figure 18 is encountered?

Options:

Fractures of the lower extremities
Paroxysmal hypertension
Infection
Epidural hematoma
Gastrointestinal bleeding

Correct Answer: Epidural hematoma

Explanation:

DISCUSSION: The injury shown is a fracture-dislocation and it is highly unstable. In addition to this concern, spinal epidural hematomas have a much higher incidence in people with ankylosing spondylitis following knee fracture. It is felt to be due to disrupted epidural veins, with hypervascular epidural soft tissue in the setting of a rigid spinal canal. Patients with ankylosing spondylitis may have other significant comorbidities, especially cardiac and pulmonary, and these should be carefully assessed.
REFERENCES: Ludwig S, Zarro CM: Complications encountered in the management of patients with ankylosing spondylitis, in Vaccaro AR, Regan JJ, Crawford AH, et al (eds): Complications of Pediatric and Adult Spine Surgery. New York, NY, Marcel Dekker, 2004,
pp 279-290.
Wu CT, Lee ST: Spinal epidural hematoma and ankylosing spondylitis: Case report and review of the literature. J Trauma 1998;44:558-561.

Question 72:

Baseball pitchers who have internal impingement will most likely demonstrate what changes in range of motion?

Options:

Increase in internal rotation, decrease in external rotation
Increase in internal rotation, increase in external rotation
Decrease in internal rotation, decrease in external rotation
Decrease in internal rotation, increase in external rotation
Decrease in forward flexion, increase in external rotation

Correct Answer: Decrease in internal rotation, increase in external rotation

Explanation:

DISCUSSION: Pitchers tend to have a decrease in internal rotation and an increase in external rotation. The increase in external rotation is felt to be multifactorial. An increase in humeral retroversion occurs from repeated throwing. This results in increased soft-tissue stretching and results in a posterior capsular contracture.
REFERENCES: Meister K, Buckley B, Batts J: The posterior impingement sign: Diagnosis of rotator cuff and posterior labral tears secondary to internal impingement in overhand athletes. Am J Orthop 2004;33:412-415.
Crockett HC, Gross LB, Wilk KE, et al: Osseous adaptation and range of motion at the glenohumeral joint in professional baseball pitchers. Am J Sports Med 2002;30:20-26.

Question 73:

Options:

Total shoulder arthroplasty and rotator cuff repair
Rotator cuff repair
Reverse total shoulder arthroplasty
Interpositional arthroplasty and rotator cuff repair
Hemiarthroplasty and rotator cuff repair

Correct Answer: Total shoulder arthroplasty and rotator cuff repair

Explanation:

Question 74:

Options:

Osteosarcoma
Ewing’s sarcoma
Chondrosarcoma
Metastatic neuroblastoma
Osteochondroma

Correct Answer: Osteosarcoma

Explanation:

Question 75:

Options:

Observation
Curettage and bone grafting
Radiofrequency ablation
Radiation therapy
Wide resection

Correct Answer: Curettage and bone grafting

Explanation:

DISCUSSION: Chondroblastomas are benign cartilage lesions frequently seen in adolescents or young adults. They are found in the epiphyseal or apophyseal regions of bones. The radiograph shows a radiolucent lesion with mineralization and a well-marginated rim of reactive bone. The lesion is composed of sheets of immature chondroblasts (polygonal cells with a clear, bluish cytoplasm and a small round central nucleus). In some regions, classic “chicken-wire” matrix calcifications and a “cobblestone” pattern of cell arrangement may be seen. Treatment consists of curettage and bone grafting.
REFERENCES: Campanacci M: Bone and Soft Tissue Tumors, ed 2.
New York, NY, Springer-Verlag, 1999, pp 247-264.
Lin PP, Thenappan A, Deavers MT, et al: Treatment and prognosis of chondroblastoma. Clin Orthop Relat Res 2005;438:103-109.

Question 76:

A patient undergoing joint arthroplasty is put on a drug that competitively inhibits the activation of an enzyme that breaks down Factor Ia. The drug is

Options:

Dabigatran
Tranexamic acid
Rivaroxaban
Fondaparinux
Heparin

Correct Answer: Heparin

Explanation:

Question 77:

Options:

Incomplete corticotomy
Knee subluxation
Wire breakage
Poor regenerate bone formation
Premature consolidation

Correct Answer: Premature consolidation

Explanation:

DISCUSSION: Premature consolidation is a complication that is unique to gradual bone lengthening after corticotomy. Causes include excessive latency period, inadequate distraction rate, exuberant bone formation, patient compliance problems, and mechanical failure of the distraction apparatus. The femur and fibula are most commonly involved. This patient did not have an incomplete corticotomy, as initial distraction occurred before the distraction device was noted to seize up. The radiographs show bowing of the Ilizarov wires and mature regenerate bone, both suggestive of premature consolidation. No wire breakage or joint subluxation is seen on the radiographs. Treatment for premature consolidation includes continuing distraction until the consolidation bridge ruptures, or additional surgery may include closed rotational osteoclasis or repeat corticotomy.
REFERENCES: Paley D: Problems, obstacles and complications of limb lengthening, in Maiocchi AB, Aronson J (eds): Operative Principles of Ilizarov. Baltimore, MD, Williams & Wilkins, 1991, p 360.
Herring JA: Limb length discrepancy, in Herring JA (ed): Tachdjian’s Pediatric Orthopaedics,
ed 3. Philadelphia, PA, WB Saunders, 2002, p 1088.

Question 78:

Figure 50 shows the MRI scan of a 20-year-old female college soccer player with knee pain. What is the most likely diagnosis?

Options:

Normal knee
Posterior cruciate ligament tear
Quadriceps tendon rupture
Proximal tibia fracture
Femoral subchondral contusion

Correct Answer: Posterior cruciate ligament tear

Explanation:

Question 79:

Options:

continuous extension splinting to the distal interphalangeal (DIP) joint for 6 weeks, followed by night splinting for an additional 6 weeks.
splinting at the DIP joint in 20 degrees of flexion.
percutaneous pinning.
buddy taping.
dynamic splinting for 8 weeks.

Correct Answer: continuous extension splinting to the distal interphalangeal (DIP) joint for 6 weeks, followed by night splinting for an additional 6 weeks.

Explanation:

Question 80:

Options:

Achilles rupture
Gastrocnemius strain
Calcaneal apophysitis
Os trigonum syndrome DISCUSSION-Calcaneal apophysitis (Sever disease) is a common cause of heel pain in adolescent athletes who participate in running or jumping sports. The condition occurs primarily before or during peak growth and is characterized by a tight Achilles tendon, a positive squeeze test, and tenderness over the calcaneal apophysis. Pain is localized to the heel and exacerbated by running. Os trigonum syndrome involves posterior ankle impingement and is commonly associated with ballet dancers. Gastrocnemius strain typically causes pain more proximally at the myotendinous junction. The Thompson test is performed with the patient lying prone on the examination table. Absence of ankle plantar flexion when the examiner squeezes the calf constitutes a positive test and is indicative of Achilles rupture.

Correct Answer: Calcaneal apophysitis

Explanation:

CLINICAL SITUATION FOR QUESTIONS 60 AND 61
A 15-year-old boy has had shoulder pain for 4 weeks during the middle of baseball season. The patient says his pain is “all over my shoulder.” Examination reveals tenderness to palpation over the anterolateral aspect of the shoulder. Internal and external rotation range of motion is restricted.
Radiographs show metaphyseal sclerosis.

Question 81:

Figure 7 shows a sagittal T 1 -weighted MRI scan. What muscle/tendon is identified by the arrow?

Options:

Infraspinatus
Teres minor
Subscapularis
Long head of triceps
Latissimus dorsi

Correct Answer: Teres minor

Explanation:

DISCUSSION: The sagittal T
1
-weighted MRI scan is useful for interpreting the quality of muscle. The arrow is pointing to the teres minor.
REFERENCES: Goutallier D, Postel JM, Gleyze P, et al: Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full-thickness tears.
J Shoulder Elbow Surg 2003;12:550-554.
Agur AM (ed): Grant’s Atlas of Anatomy, ed 9. Baltimore, MD, Lippincott Williams & Wilkins, 1991, p 394.

Question 82:

Options:

HLA-B27
Prostate-specific antigen
Rheumatoid factor
Antinuclear antibody
Serum protein electrophoresis

Correct Answer: HLA-B27

Explanation:

Question 83:

Options:

CT-guided biopsy
Application of lumbar orthosis
Repeat MRI within 48 hours
Anterior lumbar debridement and fusion
Posterior lumbar debridement and fusion

Correct Answer: Application of lumbar orthosis

Explanation:

Question 84:

What neurovascular structure is in closest proximity to the probe in the arthroscopic view of the elbow shown in Figure 50? Review Topic

Options:

Ulnar nerve
Radial nerve
Posterior interosseous nerve
Superficial radial nerve
Median nerve

Correct Answer: Radial nerve

Explanation:

Question 85:

Options:

External fixation
Open reduction and internal fixation of the pubic symphysis with a two-hole plate
Open reduction and internal fixation of the pubic symphysis with a two-hole plate and posterior triangular osteosynthesis
Open reduction and internal fixation of the pubic symphysis with a multi-hole plate
Open reduction and internal fixation of the pubic symphysis with a multi-hole plate and posterior plate osteosynthesis

Correct Answer: Open reduction and internal fixation of the pubic symphysis with a multi-hole plate

Explanation:

Question 86:

- Resurfacing the patella during a total knee replacement is strongly indicated when the diagnosis is

Options:

Rheumatoid arthritis
Posttraumatic arthritis
Degenerative osteoarthritis
Osteonecrosis of the tibial plateau
Osteonecrosis of the medial femoral condyle

Correct Answer: Rheumatoid arthritis

Explanation:

Question 87:

Options:

Abrasion arthroplasty of the anterior glenoid rim
Posterior capsular advancement into a Hill-Sachs defect
Repair of an inferior glenohumeral ligament detachment
Repair of an unstable SLAP tear
Closure of the rotator interval

Correct Answer: Closure of the rotator interval

Explanation:

Question 88:

Options:

assessment of the bone age in the left wrist and hand.
an MRI scan of the spine.
an ultrasound of the hips.
a renal ultrasound.
a Pavlik harness.

Correct Answer: a renal ultrasound.

Explanation:

Question 89:

Options:

Calcific tendinitis
Rotator cuff tendinosis
Bursitis
Brachial neuritis
Glenohumeral arthritis

Correct Answer: Brachial neuritis

Explanation:

Question 90:

In girls with idiopathic scoliosis, peak height velocity (PHV) typically occurs at what point?

Options:

Before Risser 1 and menarche
After Risser 1 and menarche
Between Risser 1 and menarche
After menarche but before Risser 1
At Risser 2

Correct Answer: Before Risser 1 and menarche

Explanation:

DISCUSSION: PHV generally occurs while girls are still Risser 0; menarche typically occurs before Risser 1, which has a wide variation in its timing. The curve magnitude at the PHV is the best prognostic indicator available. Most untreated patients with curves greater than 30 degrees at PHV require surgery, while patients with smaller curves at that stage typically do not
require surgery.
REFERENCES: Little DG, Song KM, Katz D, Herring JA: Relationship of peak height velocity to other maturity indicators in idiopathic scoliosis in girls. J Bone Joint Surg Am
2000;82:685-693.
Anderson M, Hwang SC, Green WT: Growth of the normal trunk in boys and girls during the second decade of life; related to age, maturity, and ossification of the iliac epiphyses. J Bone Joint Surg Am 1965;47:1554-1564.

Question 91:

Which of the following bearing materials is most resistant to scratching from third-body debris?

Options:

Alumina
Stainless steel
Forged cobalt-chromium
Ion bombarded and forged cobalt-chromium
Oxidized titanium

Correct Answer: Alumina

Explanation:

Question 92:

Options:

lying completely supine in bed.
remaining seated and placing the postsurgical leg on a stool.
transferring back to bed with the head of the bed no lower than 60°.
transferring back to bed with the head of the bed level and the surgical knee flexed.

Correct Answer: transferring back to bed with the head of the bed level and the surgical knee flexed.

Explanation:

Question 93:

Which of the following fluoroscopic views is used to assess intra-articular screw penetration during volar fixation of a distal radius fracture?

Options:

Dorsal skyline view
AP wrist view
PA wrist view
23° elevated lateral view
45° oblique lateral view

Correct Answer: 45° oblique lateral view

Explanation:

Question 94:

A 58-year-old man has a painful, warm, erythematous and fluctuant area over his left olecranon. An aspiration would be most likely to reveal

Options:

Staphylococcus aureus.
Streptococcus pyogenes.
Enterococcus faecalis.
Psuedomonas aurigonosa.

Correct Answer: Staphylococcus aureus.

Explanation:

Discussion: Staphylococcus aureus is the most common causative organism in septic bursitis, making up 80% or more of cases of culture-proven septic bursitis (
https://www.uptodate.com/contents/septic-bursitis
). Staphylococcus aureus was the most frequent pathogen (217 out of 256 or 85%), followed by Streptococcus pyogenes (16), other streptococci (15), Enterococcus faecalis (4) and coagulase-negative staphylococci (2). Staphylococcus aureus is the most common causative organism in septic bursitis, making up 80% or more of cases of culture-proven septic bursitis (
https://www.uptodate.com/contents/septic-bursitis
). Staphylococcus aureus was the most frequent pathogen (217 out of 256 or 85%), followed by Streptococcus pyogenes (16), other streptococci (15), Enterococcus faecalis (4) and coagulase-negative staphylococci (2).

Question 95:

A 36-year-old recreational tennis player sustains the injury shown in Figure 16. Management should consist of

Options:

observation.
rehabilitation.
immobilization.
primary repair.
reconstruction.

Correct Answer: primary repair.

Explanation:

Question 96:

Options:

Obtain an MRI of the knee
Begin allopurinol therapy alone
Begin empiric intravenous antibiotics
Give an intraarticular steroid injection
Obtain a rheumatology consult

Correct Answer: Obtain a rheumatology consult

Explanation:

This patient presents with symptoms and findings highly suspicious for super- imposed septic arthritis and gout. This patient is likely going to need to go to the operating room for emergent I&D (not listed as an answer choice). Because cultures have already been obtained, the most appropriate next step in management would be to begin empiric intravenous antibiotics.
While the incidence of superimposed gout and septic arthritis is low (~1.5%),
it is reported. In the presence of crystals on aspiration, one should not rule out the possibility of septic arthritis. If there are other risk factors for infection, or the synovial WBC count is high (greater than 50,000), then empiric antibiotics should be initiated immediately after cultures are obtained. If the patient has other evidence supporting septic arthritis (positive Gram stain, purulence), emergent I&D is indicated. Even if the initial suspicion is lower, if they have
not respond to antibiotics after 24-48 hours they should undergo I&D.
Shah et al. investigated 265 crystal-positive joint aspirates in a 7-year retrospective study. They found the incidence of concomitant septic arthritis and crystal disease was 1.5% (4 cases including 2 knees, 1 hip, 1 ankle). All 4 patients that had superimposed infection had a WBC of > 50,000. They concluded that the presence of crystals in the synovial fluid cannot
conclusively rule out a septic joint.
Schuind et al. described a case report of concomitant septic arthritis and gout of the wrist. They found that cultures were positive for Staphylococcus aureus while pathological examination revealed aggregated crystals of monosodium urate.
Figure A shows tense, erythematous swelling of the right knee. Figure B is a table showing synovial fluid analysis with elevated WBC and PMN cell count characteristic of septic arthritis. Figure C shows needle-shaped negatively birefringent crystals on polarizing microscopy. Illustration A shows the synovial fluid characteristics in different disease conditions.
Incorrect Answers:
An 82-year-old osteoporotic woman undergoes total hip arthroplasty for osteoarthritis. During implant trialing, a crack is heard. Intraoperative fluoroscopy reveals a long, spiral fracture of the distal femur. The fracture is reduced and fixed with an anatomic locking plate. The rest of the total hip arthroplasty proceeds uneventfully. Following surgery the surgeon has a meeting with the family and apologizes and provides full disclosure, accepts responsibility, provides a detailed explanation as to what happened, and gives reassurance that steps will be taken to prevent recurrences. This communication approach will most likely
Lead to lower patient satisfaction rates
Lead to higher patient satisfaction rates
Lead to higher likelihood the patient will take legal action against surgeon
Lead to higher likelihood the patient will change physicians
Prevent any legal action
The surgeon has provided all the elements of good communication with the patient and family. His actions will lead to improved patient satisfaction, compared to nondisclosure and attempting to push or shirk responsibility.
In the event of a medical error or adverse event, effective communication with the patient and family is necessary. Effective communication should comprise:
an apology, full disclosure (an explanation of what happened), accepting responsibility, and corrective steps that will be taken to prevent recurrence.While accepting responsibility is integral to the explanation process, it is different from accepting blame.
Mazor et al. found patients would more likely change physicians and seek legal advice in situations with a life-threatening outcome where physicians chose
non-disclosure. They recommend full disclosure, acceptance of responsibility, an apology, detailed explanations, and assurances that steps will be taken to prevent recurrences will result in positive outcomes in terms of patient satisfaction, trust, and emotional response.
MacDonald et al. addressed medical errors in an editorial. Besides full disclosure, they feel that an apology is necessary. This includes an acknowledgement of the event and one’s role in the event, and a genuine expression of regret. Apology laws exist to to reduce concerns about legal implications of disclosure and apology.
Incorrect Answers:
The acquired immune response mediated by the interaction between the T cell receptor and major histocompatibility complex requires which of the following first steps?
Antigen phagocytosis by T cells
Antigen processing and presentation to T cells
Antigen recognition by natural killer T cells
Antigen proliferation by polymerase chain reaction
T cell disulfide bond cleavage and enzymatic processing
The process of antigen processing and presentation is the first step of the acquired immune response. This is performed by the so called antigen presentation cells (APC) of which B cells and dentritic cells are two examples. The APC breaks down the protein antigen in a multitude of enzymatic reactions and presents key peptide sequences via the major histocompatibility complex
(MHC) receptors. Once presented on the surface of the APC, the T-cell receptor recognizes the MHC/antigen complex leading to T-cell activation. At no point in this process are antigens phagocytosed by T cells. Natural killer T cells are involved in this sequence, but not for antigen processing and presentation. Polymerase chain reaction is a laboratory tool used to amplify nucleic acid. Finally, disulfide bond cleavage is a step involved in the APCs antigen processing reaction and does not occur in T cells.
All of the following are true regarding a physician responding to a formal written complaint by a patient EXCEPT:
Complaint should be taken seriously
Written response by the physician is required
Physician mandated to retain an attorney to address the formal complaint
Patient should be supplied with contact information for the institution's patient representative department
Law mandates that the physician respond to the formal complaint
It is important for the surgeon to know how to manage a formal complaint. An attorney is not required to assist on behalf of the physician when addressing a formal complaint. All complaints must be taken seriously and the physician is required by law to respond to all formal complaints in writing. Verbal
responses to formal, written complaints are not sufficient. If a patient is filing a formal complaint it is advisable that the patient be supplied with contact information for the institution's patient representative department.
What laboratory findings would you expect to find in a patient newly diagnosed with renal osteodystrophy?
Decreased PTH secretion, hypophosphatemia, and hypocalcemia
Increased PTH secretion, hyperphosphatemia, and hypocalcemia
Decreased PTH secretion, hypophosphatemia, and hypercalcemia
Increased PTH secretion, hyperphosphatemia, and hypercalcemia
Hypophosphatemia and hypocalcemia
Renal osteodystrophy is characterized by bone mineralization deficiency due to the electrolyte and endocrine abnormalities associated with chronic kidney disease. The pathogenesis of renal osteodystrophy is multifactorial. Hypocalcemia occurs due to the inability of the damaged kidney to convert vitamin D3 into its active form, calcitriol. The hypocalcemia and lack of phosphate excretion by the damaged kidney causes hyperparathyroidism and secondary hyperphosphatemia.
Loss of function in the 25(OH) vitamin D1-alpha hydroxylase gene causes which of the following diseases?
Hyperphosphatemia
Vitamin D resistant rickets
Hereditary Vitamin D dependant rickets type I
Hereditary Vitamin D dependant rickets type II
Hypophosphatemic rickets
Loss of function mutations in the 25 (OH) vitamin D hydroxylase gene cause hereditary vitamin D dependant rickets type I. Hereditary vitamin D dependant rickets type II is caused by a defect in intracellular receptor for 1,25-(OH)2- vitamin D3. Both forms of
hereditary vitamin D dependent rickets show decreased serum calcium/phosphorous, elevated alkaline phosphatase/PTH,
but type I has a decrease in the 1,25(OH)2 vitamin D and type II shows a increase in 1,25(OH)2 vitamin D. Vitamin D resistant rickets (Familial Hypophosphatemic Rickets) is caused by a large deletion in the PHEX gene and results in low serum phosphorous, elevated alkaline phosphatase, and normal calcium. Hyperphosphatemia can be caused by mutation in the GALNT3 gene and results in elevated serum phosphate and decreased PTH/calcium.
Kato et al. describe the molecular physiology of vitamin D metabolism and the recognized gene mutations associated with various clinical manifestations of mutations in vitamin D homeostasis.
Figure A is a radiograph taken after an open reduction and internal fixation of a periprosthetic distal femur fracture. With this type of hybrid locked plate fixation, what is the difference between screw A and screw B?
Screw A can assist in fracture reduction while screw B provides a fixed angle support
Screw A provides improved axial stiffness while screw B provides a fixed angle support
Screw A can be used to reduce the plate to bone while screw B can be used to lag fracture fragments together
Screw A provides a fixed angle support while screw B can be used to reduce the plate to the bone
Screw A can be used to lag fracture fragments together and screw B increases the plate bone frictional stability
Locking screws provide a fixed angle support and can improve fixation in osteoporotic bone while nonlocking screws can be used to reduce the plate to the bone, lag fracture fragments together and increase the plate bone frictional stability. "Hybrid" locked plate fixation utilizes both screw types in order to assist with difficult fracture fixation such as when there is a short metaphyseal segment and osteoporotic bone.
Zura et al discusses the biomechanical and biological advantages offered by locked plate fixation.
Using levels of evidence in research studies, which of the following represents a level II study?
Retrospective case control study
Prospective cohort study
Case report of 3 patients with the same disease
High-quality randomized prospective clinical trial
The opinion of a review panel at the annual AAOS meeting
Level II Evidence includes prospective cohort studies. There are 5 levels of evidence in clinical research. Level I includes randomized clinical trials. Level II includes prospective cohort studies. Level III includes case control studies AND retrospective cohort studies. Level IV includes case series. Level V evidence includes expert opinion, case reports, and personal observation. The cited reference by Bernstein et al is an excellent review of Evidence Based Medicine (EBM) and describes the 5 step process of making medical decisions based on the available, and often limited, evidence. These steps include: 1) Formulate answerable questions. 2) Gather the evidence. 3) Appraise the evidence. 4) Implement the evidence. 5) Evaluate the process. The reference by Spindler et al is another review article that discusses the different levels of evidence for different study types.
All of the following are true regarding the assessment of bone mineral density EXCEPT?
Bone mineral density loss is not apparent on standard radiographs until 30% to 40% of mineral is lost
Dual energy x-ray absorbtiometry (DEXA) is only able to measure mineralization of the axial skeleton
Single photon absorbtiometry allows for the analysis of bone mineralization in the appendicular skeleton alone
Quantitative computed tomography (QCT) is associated with 10 times the radiation of a DEXA scan
MRI allows for accurate discrimination of normal bone from osteopenic bones
without exposing the patient to ionizing radiation
Dual energy x-ray absorbtiometry (DEXA) scans allow for accurate assessment of bone mineralization in both the axial and appendicular skeleton.
Over the last decade, DEXA has become a safe, cost-effective and reliable method to quantify bone mineral density. The World Health Organization (WHO) has adopted DEXA derived BMD measurements to define normal bone, osteopenia, and osteoporosis in the adult and paediatric population. The typical DEXA analysis therefore reports a Z-score, which is the number of standard deviations (SDs) that a patient's BMD is above or below the mean value for persons of the patient's age and sex. The T score is the number of SDs the patient's BMD is either above or below the mean value for young patients of the same gender.
Tortolani et al. provide an overview of the techniques used to assess bone mineral density, the pathophysiology of osteopenia, and the evaluation and treatment options for the general pediatric population as well as for patients with specific pediatric disorders. The authors encouraged orthopaedic surgeons to understand the problems of osteopenia in both otherwise healthy children and children with chronic disorders.
Binkovitz & Henwood provide a review of DEXA technique and interpretation with emphasis on the considerations unique to pediatrics. They found that changes in bone size over time, as occurs in normal pediatric development, confound DXA interpretation. This is one of the major limitations in the use of pediatric DXA. However, attempts to correct for or to circumvent this limitation have been proposed and show promise in improving DXA interpretation and
our understanding of bone physiology.
T-score according to the World Health Organization (WHO): A T- score of -1.0 or above is normal bone density.
A T-score between -1.0 and -2.5 means you have low bone density or osteopenia.
A T-score of -2.5 or below is a diagnosis of osteoporosis.
Incorrect Answers:
A mother brings her 4-year-old daughter to your clinic for evaluation of knocked knees and short stature. On exam, the patient ambulates with a circumduction gait pattern and frequently falls. Plain radiographs are displayed in Figure A. Laboratory data is obtained and notable for calcium 9.1 mg/dL (RR 8.5-

Question 97:

Options:

a three-phase bone scan.
CT.
MRI.
a repeat examination in 6 weeks.
a biopsy.

Correct Answer: a repeat examination in 6 weeks.

Explanation:

Question 98:

Options:

elbow flexion strength.
elbow supination strength.
lack of terminal extension at the elbow.
decrease of elbow pronation strength.

Correct Answer: elbow supination strength.

Explanation:

Question 99:

Options:

calcaneal osteotomy.
subtalar joint arthrodesis.
triple arthrodesis.
pantalar arthrodesis.
distraction bone block arthrodesis.

Correct Answer: subtalar joint arthrodesis.

Explanation:

DISCUSSION: The patient has posttraumatic subtalar joint arthrosis that developed following a calcaneal fracture. Because there is no hindfoot deformity, in situ subtalar joint arthrodesis is the treatment of choice. Calcaneal osteotomy or distraction bone block arthrodesis is beneficial in patients with severe talar dorsiflexion or malunion of the calcaneal body. Triple arthrodesis is not warranted without changes at the transverse tarsal joint, and typically even with injury into the calcaneocuboid joint, this joint is often asymptomatic. Pantalar arthrodesis is not indicated as the pathology is occurring at the subtalar joint and not in the ankle joint.
REFERENCES: Sanders R: Fractures and fracture-dislocations of the calcaneus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999,
pp 1422-1464.
Juliano TJ, Myerson MS: Fractures of the hindfoot, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1297-1340.
Chandler JT, Bonar SK, Anderson RB, Davis WH: Results of in situ subtalar arthrodesis for late sequelae of calcaneus fractures. Foot Ankle Int 1999;20:18-24.

Question 100:

What is the most appropriate surgical treatment for a stage III symptomatic scapholunate advanced collapsed (SLAC) wrist?

Options:

Radioscapholunate arthrodesis
Scaphotrapeziotrapezoid arthrodesis
Scaphocapitate arthrodesis
Proximal row carpectomy
Scaphoid excision and capitate-lunate-triquetrum-hamate arthrodesis

Correct Answer: Scaphoid excision and capitate-lunate-triquetrum-hamate arthrodesis

Explanation:

DISCUSSION: SLAC is the end result of chronic scapholunate instability. The arthritis follows a predictable pattern. Stage I disease involves cartilage loss between the waist of the scaphoid and the radial styloid. In stage II, the arthritis progresses to include the proximal pole of the scaphoid and the scaphoid fossa of the radius. Finally, stage III goes on to include arthritis of the capitolunate joint. The only treatment option that addresses all of the sites of arthritis is the scaphoid excision and four corner fusion.
REFERENCES: Ashmead DT IV, Watson HK, Damon C, et al: Scapholunate advanced collapse wrist salvage. J Hand Surg Am 1994;19:741-750.
Sauerbier M, Trankle M, Linsner G, et al: Midcarpal arthrodesis with complete scaphoid excision and interposition bone graft in the treatment of advanced carpal collapse (SNAC/SLAC wrist): Operative technique and outcome assessment. J Hand Surg Br 2000;25:341-345.

Orthopedic Surgery Board Review MCQs: Arthroplasty, Ligament & Spine | Part 149

Orthopedic Board Review MCQs: Elbow, Hip, & Nerve | Part 127

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 127

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index