Orthopedic Surgery Board Review: 100 High-Yield MCQs

About This Board Review Set

This is Part 129 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.

How to Use the Interactive Quiz

Two distinct learning modes are available:

Study Mode — After selecting an answer, you immediately see whether you are correct or incorrect, together with a full clinical explanation and literature references.
Exam Mode — All feedback is hidden until you click Submit & See Results. A live timer tracks elapsed time. A percentage score and detailed breakdown are displayed upon submission.

Pro Tip: Use keyboard shortcuts A–E to select options, F to flag a question for review, and Enter to jump to the next unanswered question.

Topics Covered in Part 129

This module focuses heavily on: Foot, Fracture, Hip, Infection, Shoulder.

Sample Questions from This Set

Sample Question 1: Which of the following patient factors is associated with recurrent radicular pain following lumbar diskectomy for sciatica?...

Sample Question 2: Figures 29a and 29b show a clinical photograph and radiographs of a patient who sustained an open calcaneus fracture in a motor vehicle accident. The patient received immediate IV antibiotics and an emergent irrigation and debridement. The ...

Sample Question 3: Examination of a 4-year old child with obstetrical palsy reveals weak deltoids, pectoralis major strength of 4-5, and normal hand function. External rotation of the shoulder is limited. What is the most appropriate surgical procedure to res...

Sample Question 4: A 36-year-old man has a 2-day history of acute lower back pain with severe radicular symptoms in the left lower extremity. The patient has a positive straight leg test at 40 degrees on the left side and mild decreased sensation on the dorsu...

Sample Question 5: Figure 36 shows the hip arthrogram of a newborn. Which of the following structures is enclosed by the circle?...

Why Active MCQ Practice Works

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

Which of the following patient factors is associated with recurrent radicular pain following lumbar diskectomy for sciatica?

Explanation

DISCUSSION: A large annular defect at the site of a lumbar disk herniation is associated with persistent radicular pain postoperatively. Large sequestered herniations and a positive SLR preoperatively correlate with good outcomes after diskectomy. Neither symptoms of more than 3 months’ duration nor preoperative epidural steroid injections correlate with postoperative results after diskectomy.
REFERENCES: Carragee EJ, Han MY, Suen PW, et al: Clinical outcomes after lumbar discectomy for sciatica: The effects of fragment type and anular competence. J Bone Joint Surg Am 2003;85:102-108.
Fardon DF, Garfin SR, Abitbol J, et al (eds): Orthopedic Knowledge Update Spine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 323-332.

Question 2

Figures 29a and 29b show a clinical photograph and radiographs of a patient who sustained an open calcaneus fracture in a motor vehicle accident. The patient received immediate IV antibiotics and an emergent irrigation and debridement. The swelling has subsided by 3 weeks and the medial wound is clean. What do you tell the patient about the likelihood of infection if a formal open reduction and internal fixation via a lateral approach is performed?

Explanation

DISCUSSION: Multiple authors have shown similar infection rates for grade 1 and 2 open medial fractures and closed fractures that have been treated with an extensile lateral approach and open reduction and internal fixation. Patients only need IV antibiotics for 2 to 3 days after surgery. Formal open reduction and internal fixation is not recommended for grade 3 medial wounds and most lateral wounds.
REFERENCES: Heier KA, Infante AF, Walling AK, et al: Open fractures of the calcaneus: Soft-tissue injury determines outcome. J Bone Joint Surg Am 2003;85:2276-2282.
Buckley RE, Tough S: Displaced intra-articular calcaneal fractures. J Am Acad Orthop Surg 2004;12:172-178.

Question 3

Examination of a 4-year old child with obstetrical palsy reveals weak deltoids, pectoralis major strength of 4-5, and normal hand function. External rotation of the shoulder is limited. What is the most appropriate surgical procedure to restore external rotation?

Explanation

DISCUSSION: Transfer of the latissimus dorsi and teres major to the posterior rotator cuff will restore external rotation and some abduction. The procedure should be performed in children who are approximately age 4 years, following spontaneous recovery and prior to significant stiffness. External rotation osteotomy is more appropriate for an older child. Fusion should not be performed until skeletal maturity. Distal biceps rerouting restores pronation for a supination deformity. Latissimus dorsi and teres major transfer to the subscapularis would accentuate the internal rotation. In younger patients without significant bony deformity, a subscapularis slide or lengthening can restore external rotation.
REFERENCES: Strecker WB, McAllister JW, Manske PR, Schoenecker PL, Dailey LA: Sever-L’Episcopo transfers in obstetrical palsy: A retrospective review of twenty cases. J Pediatr Orthop 1990;10:442-444.
Hoffer MM, Wickenden R, Roper S: Brachial plexus birth palsies. J Bone Joint Surgery Am 1978;60:692-695.

Question 4

A 36-year-old man has a 2-day history of acute lower back pain with severe radicular symptoms in the left lower extremity. The patient has a positive straight leg test at 40 degrees on the left side and mild decreased sensation on the dorsum of the left foot. What is the most appropriate management at this time? Review Topic

Explanation

In the absence of any severe progressive neurologic deficits or other red flags, the most appropriate management for an acute lumbar disk herniation is nonsurgical care. Conservative treatments such as limited bed rest, anti-inflammatory medications, and judicious use of pain medications are appropriate in this clinical situation. Up to 90% of patients will experience a resolution of symptoms without the need for surgical intervention within a 3-month window. In the acute setting, with no neurologic deficits, immediate MRI of the lumbar spine is neither beneficial nor warranted. Likewise, without signs of an acute deficit, emergent surgical intervention and caudal epidural steroid injections are not needed.

Question 5

Figure 36 shows the hip arthrogram of a newborn. Which of the following structures is enclosed by the circle?

Explanation

DISCUSSION: The structure enclosed by the circle is the acetabular labrum. It is visible as the white point of tissue outlined by the darkly radiopaque contrast. The appearance of the contrast surrounding the sharp white point of a normal labrum is called the “rose thorn sign.” The limbus is the term reserved for a rounded, infolded labrum seen with arthrography. The pulvinar is the fatty tissue seen in the empty acetabulum when the hip is dislocated. The ligamentum teres is seen as a white stripe outlined by contrast coursing from the central acetabulum to the dislocated femoral head. The transverse acetabular ligament courses across the inferior portion of the acetabulum and is not clearly seen with arthrography.
REFERENCES: Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA,

WB Saunders, 2002, vol 1, pp 532-533.
Severin E: Contribution to the knowledge of congenital dislocation of the hip joint.

Acta Chir Scand 1941;84:1.

Question 6

The Coleman block test is used to evaluate the cavovarus foot. What is the most important information obtained from this test?

Explanation

DISCUSSION: Coleman block testing, performed by placing an elevation under the lateral border of the foot, is used to determine if the forefoot and/or plantar flexed first ray is causing a compensatory varus in the hindfoot. The block is placed under the lateral border of the foot, and therefore does not have any relation to the Achilles tendon and suppleness of the hindfoot.
REFERENCES: Holmes JR, Hansen ST Jr: Foot and ankle manifestations of Charcot-Marie-Tooth disease. Foot Ankle 1993;14:476-486.
Thometz JG, Gould JS: Cavus deformity, in The Child’s Foot and Ankle. New York, NY, Raven Press, 1992, pp 343-353.

Question 7

03 Fig 51c. What laboratory finding is most likely associated with this disease entity?

Explanation

The first question is what is it? The xray shows a mass in the leg with periosteal reaction in the fibula. The MRI shows a soft tissue mass arising from the fibula that looks aggressive. The path shows a bunch of small blue cells. The combination of small blue cells with a soft tissue mass and and onion skin appearance on xray in a patient in the 2nd decade of life has to scream Ewing’s sarcoma. 85% of Ewing’s sarcomas have the 11:22 translocation. None of the other answers are associated with Ewing’s.
Gibbs CP, Weber K, Scarborough MT: Malignant bone tumors. Inst Course Lect 2002;51:413-428
back to this question next question

Question 8

A 32-year-old volleyball player has dull posterior shoulder pain. An examination reveals moderate external rotation weakness with his arm at his side but normal strength on supraspinatus isolation. Deltoid and supraspinatus bulk appear normal, although there appears to be mild infraspinatus atrophy. Sensation is normal throughout the shoulder and shoulder girdle. What is the most likely diagnosis?

Explanation

This clinical scenario describes a patient with an isolated injury affecting the infraspinatus muscle. The anatomic location of such a lesion would be at the spinoglenoid notch, at which the suprascapular nerve may be compressed distal to its innervation of the supraspinatus but proximal to the infraspinatus innervation. A calcified transverse scapular ligament would also affect the suprascapular nerve but is proximal to the innervation of both muscles. Quadrilateral space syndrome would affect innervation of the deltoid (and teres minor). Parsonage-Turner syndrome is a more diffuse, and often severely painful, brachial plexus neuropathy.

Question 9

A woman injures the metacarpophalangeal (MCP) joint of her thumb while skiing. Examination reveals tenderness along the ulnar aspect of the MCP joint. Radially directed stress of the joint in full extension produces 5° of angulation. When the MCP joint is flexed 30°, a radially directed stress produces 45° of angulation. Radiographs are otherwise normal. Management should consist of

Explanation

DISCUSSION: Injuries to the ulnar collateral ligament of the MCP joint of the thumb commonly occur in recreational skiers. Historically, this injury has been referred to as “gamekeeper’s thumb.” The ligament consists of the proper collateral ligament and the more volar accessory collateral ligament. In extension, the accessory ligament is taut, and in flexion, the proper ligament is taut. For a complete tear of the ligament complex to occur, there must be laxity in full extension. Incomplete tears respond well to thumb spica splinting or casting for 2 to 3 weeks and gradual resumption of range of motion. Prolonged immobilization of incomplete injuries leads to higher rates of MCP joint stiffness.
REFERENCES: Stener B: Displacement of the ruptured ulnar collateral ligament of the metacarpo-phalangeal joint of the thumb: A clinical and anatomical study. J Bone Joint Surg Br 1971;44:869.
Heyman P: Injuries to the ulnar collateral ligament of the thumb metacarpophalangeal joint.

J Am Acad Orthop Surg 1997;5:224-229.

Question 10

A 56-year-old man with a history of chronic lower back pain from lumbar spondylosis reports a 2-day history of acute incapacitating back pain. He denies any history of acute trauma, although he reports the pain starting after a coughing spell. He also reports difficulty urinating and some fecal incontinence. Examination reveals generalized lower extremity weakness, saddle paresthesia, hyporeflexia in the lower extremities, and loss of rectal tone. What is the most appropriate management at this time?

Explanation

DISCUSSION: Cauda equina syndrome is a medical emergency that must be quickly diagnosed and treated to avoid long-term complications. Cauda equina syndrome typically presents with low back pain, unilateral or usually bilateral sciatica, saddle sensory disturbances, bladder and bowel dysfunction, and variable lower extremity motor and sensory loss. Although a number of pathologies can cause cauda equina syndrome, in a patient with a history of chronic back pain, disk pathology is the most common cause of acute onset cauda equina syndrome. Whereas radiographs may be useful in a traumatic onset of symptoms, MRI is the most appropriate study. Cauda equina syndrome should be evaluated on an emergent basis and admission for work-up is appropriate.
REFERENCES: Ahn UM, Ahn NU, Buchowski JM, et al: Cauda equina syndrome secondary to lumbar disc herniation: A meta-analysis of surgical outcomes. Spine 2000;25:1515-1522.
Small SA, Perron AD, Brady WJ: Orthopedic pitfalls: Cauda equina syndrome. Am J Emerg Med 2005;23:159-163.

Question 11

A 30-year-old man has had leg pain for 6 months. A lesion is identified in the proximal femur and biopsy it taken. Histology is shown in Figure A and is consistent with a low-grade intramedullary osteogenic sarcoma. Additional imaging studies confirm that this is an isolated lesion with no metastasis. What is the standard treatment for this type of lesion?

Explanation

Injury Severity Score (ISS )
Glascow Coma Scale (GCS )
Timing of knee reconstruction
Number of ligaments reconstructed
Open ligament reconstruction
Figure A shows a knee dislocation with cruciate ligament avulsion injuries. Development of significant heterotopic ossification (HO) formation has been shown to be most directly correlated to the ISS score.
Mills and Tejwani looked at multiple variables including injury severity score
( ISS), Glascow coma scale (GCS), closed head injury (CHI), timing of surgery (> or < 3 weeks) and type of surgery (open vs. arthroscopic, number of ligaments reconstructed) in its relation to the formation of HO following knee dislocation. In the final group the sensitivity and specificity of the ISS in relation to HO formation was 100%, while presence of CHI had a specificity of 97 %. Timing, type of surgery and approach did not influence HO formation.
A 52-year-old male presents with 6 months of swelling and pain in his leg. He states the lesion has not changed in size for several months and doesn't bother him. He is otherwise healthy and has no other complaints. Representative photograph and MRI are shown in Figures A through C. What is the best initial step in his management?

Follow-up in 6 months with repeat radiographs
Biopsy
Marginal excision
Radiation therapy
Neoadjuvant chemotherapy and wide excision
The initial step in management of a patient presenting with a large soft tissue mass deep to the fascia is to obtain a tissue diagnosis, via biopsy. Initiation of treatment prior to tissue diagnosis is inappropriate and can result in significant patient morbidity and potential mortality. While some soft tissue sarcomas may benefit from chemotherapy, this cannot be initiated prior to diagnosis.
Radiation therapy is used in the treatment of soft tissue sarcoma, but again, only after tissue diagnosis. Peabody et al review the appropriate evaluation and staging for musculoskeletal neoplasms and present flow-charts useful in the work-up of bone (Illustration A) and soft tissue (Illustration B) neoplasms. Skrzynski et al performed a comparison of outpatient core-needle biopsy with open surgical biopsy for musculoskeletal tumors. They found the diagnostic accuracy of core-needle biopsy was only 84% with many samples yielding no or different histological samples when compared to final resected specimens. They conclude that while core-needle biopsy is significantly less expensive
than surgical biopsy ($1106 vs. $7234), there is higher concern for sampling error or general diagnostic inaccuracy associated with a core-needle biopsy compared to open biopsy, the "gold standard".

What is the appropriate treatment for a 10-year-old boy with Ewing's sarcoma isolated to the proximal femur?
Neoadjuvant chemotherapy and surgical excision
Neoadjuvant chemotherapy, surgical excision, and radiation therapy
Neoadjuvant chemotherapy, surgical excision, and adjuvant chemotherapy
Neoadjuvant radiation therapy and surgical excision
Surgical excision and hormonal therapy
Ewing's sarcoma is a malignant small round blue cell neoplasm which has a predilection for long tubular bones, pelvis, and ribs. The radiographic appearance of "onion-skinning" seen in illustrations A and B is due to the body's periosteal reaction. Illustration C shows the large soft tissue extraosseous mass characteristic for Ewing's sarcoma. Finally, Illustration D shows the histology where the multiple small round blue neoplastic cells are seen.
Ewing's sarcoma is most commonly treated with neoadjuvant chemotherapy, surgical excision, and adjuvant chemotherapy - in particular for tumors located in bones which can be easily resected and reconstructed. For large tumors in areas which either cannot be completely excised or where excision is associated with significant morbidity, some centers consider chemotherapy and radiation therapy without surgical excision. There is a current trend towards surgical resection and away from irradiation for Ewing's sarcoma even though it is radiosensitive, because of the risk of secondary malignancy and growth disturbance due to radiation.
Pierz et al review many of the common bone tumors including Ewing's sarcoma and discuss the relevant diagnostic factors as well as specific treatment protocols for each tumor.

A 30-year-old female presents with a painful posterior knee mass. The mass gets larger and more painful with activity. Examination reveals a boggy soft tissue mass about her knee. Radiograph and MRI are shown in Figures A and B. What is the most likely diagnosis?

Synovial sarcoma
Hemangioma
Lipoma
Parosteal osteosarcoma
Pigmented villonodular synovitis (PVNS )
This patients history, physical exam, and imaging studies are suggestive of a hemangioma. Pain in hemangiomas is thought to occur due to vascular engorgement secondary to activity and increased blood flow to the lesion. The calcification on the plain radiograph and the fat of the T1 MRI are diagnostic for hemangioma. Current treatment for symptomatic hemangiomas includes some combination of sclerotherapy or vascular coiling, with surgical excision
reserved for few cases. The two attached reviews by Gilbert et al and Damron et al review the history, diagnosis, treatment, and controversial issues in soft tissue sarcomas and benign sarcoma like conditions such as hemangiomas.
Current treatment for soft tissue sarcomas includes radiotherapy and surgical excision. While many centers in the world use chemotherapy for soft tissue sarcomas, the data supporting its use is quite limited and likely too controversial to be tested. With regard to the other answer choices, synovial sarcoma and lipoma can show calcification on radiographs, but they are usually not painful and image differently on T1 MRI. Parosteal osteosarcoma typically occurs in this location (posterior distal femur) but occurs as a lesion stuck on the bone. PVNS can have a similar appearance on imaging, but doesn't cause this type of pain.

Question 12

Figure 16 shows the lateral radiograph of a patient who is scheduled to undergo an anterior cruciate ligament (ACL) reconstruction. If the graft is tensioned at 20° of flexion and the femoral tunnel is created by passing a reamer over the guide wire marked “A,” the resulting ligament reconstruction will excessively

Explanation

DISCUSSION: If the femoral tunnel is created using guide wire A, it will be too far anterior in the intercondylar notch. The distance between a central tibial insertion for the ACL and an anterior femoral tunnel will progressively increase as the knee is flexed. Therefore, if the graft is tensioned near extension, the ligament will excessively tighten as the knee flexes past 90°. This will result in restricted knee flexion or failure of the graft as full flexion is gained. There will be little effect on the ligament as it extends from 20° to 0° of flexion. If the graft is tensioned in significant flexion (greater than 60°), it will be excessively loose as the knee fully extends.
REFERENCES: Daniel DM, Fritschy D: Anterior cruciate ligament injuries, in DeLee JC, Drez D Jr (eds): Orthopaedic Sports Medicine: Principles and Practice. Philadelphia, PA, WB Saunders, 1994, pp 1313-1360.
Larson RL, Tailon M: Anterior cruciate ligament insufficiency: Principles of treatment. J Am Acad Orthop Surg 1994;2:26-35.

Question 13

Figure 13a shows the radiograph of a 9-year-old girl who sustained complete transverse fractures of the radial and ulnar shafts while in-line skating. A manipulative closed reduction is performed, and the result is seen in Figure 13b. What is the next most appropriate step in management?

Explanation

DISCUSSION: Bayonet apposition of the radius and ulnar shafts is quite acceptable, as long as the angulation is less than 10 degrees. The rotation must be acceptable as well. This patient went on to full healing, with full supination and pronation of the forearm and no cosmetic deformity.
REFERENCES: Price CT, Scott DS, Kurzner ME, Flynn JC: Malunited forearm fractures in children. J Pediatr Orthop 1990;10:705-712.
Vittas D, Larsen E, Torp-Pedersen S: Angular remodeling of midshaft forearm fractures in children. Clin Orthop 1991;265:261-264.

Question 14

What is the most likely contributory factor to this patient's problem?

Explanation

DISCUSSION
Proximal humeral epiphysiolysis (little leaguer’s shoulder) is an overuse condition of the proximal humeral physis. Patients report diffuse pain that is worse with throwing. Little leaguer’s shoulder is caused by rotational stress placed on the proximal humeral epiphysis during overhead throwing. The growth plate is weakest to torsion stress and is most susceptible to injury during periods of rapid growth commonly seen during puberty. Most chronic shoulder injuries occur in throwing athletes between 13 and 16 years of age. Factors that contribute to the condition include excessive throwing, improper throwing mechanics, and muscle-tendon imbalance. Radiographic findings typically are normal but may indicate subtle widening of the proximal humeral physis, and, in more severe cases, metaphyseal demineralization or fragmentation. Surgical fixation is not required for healing. An initial 3-month period of rest and activity modification will typically result in resolution of symptoms. Nonsteroidal anti-inflammatory drugs may be used as needed. After the rest period, a gradual return to throwing is implemented until the patient’s condition returns to baseline. This protocol has a long-term success rate exceeding 90%. Pitching coaches should evaluate throwing mechanics and maintain pitch counts. The most common cause of this condition is overuse, as is seen in pitchers who throw all year. Internal rotation deficit and internal impingement is typically a finding in older athletes without open physes. This patient had no evidence of rotation deficit upon examination, making this diagnosis unlikely.

Question 15

A 6-year-old girl has a painless spinal deformity. Examination reveals 2+ and equal knee jerks and ankle jerks, negative clonus, and a negative Babinski. The straight leg raising test is negative. Abdominal reflexes are asymmetrical. PA and lateral radiographs are shown in Figures 15a and 15b. What is the next most appropriate step in management?

Explanation

DISCUSSION: The patient has an abnormal neurologic exam as shown by the abnormal abdominal reflexes. Furthermore, she has a significant curve and is younger than age 10 years. These findings are not consistent with idiopathic scoliosis. MRI will best rule out syringomyelia or an intraspinal tumor. Bracing and surgery are not indicated for this small curvature prior to obtaining an MRI scan.
REFERENCES: Ginsburg GM, Bassett GS: Back pain in children and adolescents: Evaluation and differential diagnosis. J Am Acad Orthop Surg 1997;5:67-78.
Schwend RM, Hennrikus W, Hall JE, et al: Childhood scoliosis: Clinical indications for magnetic resonance imaging. J Bone Joint Surg Am 1995;77:46-53.

Question 16

This condition is most prevalent in people of which ancestry?

Explanation

DISCUSSION
The radiograph of the lateral lumbosacral spine reveals an isthmic spondylolysis with a Meyerding grade 1 spondylolisthesis. The incidence of spondylolysis in the general population is around 5%, and grade 1 or 2 slips are present in the majority of children with a spondylolysis. Many cases of spondylolysis are painless and discovered incidentally, but, when painful, hyperextension of the lumbar spine may stress the area of the pars defect and exacerbate a patient’s symptoms. A diagnosis can usually be determined with a lateral radiograph of the lumbar spine. Although oblique lumbar radiographs are frequently ordered, several studies have shown that they do not increase diagnostic or prognostic accuracy. Progression of an isthmic spondylolysis, with or without a grade 1 or 2 listhesis, to a serious slip that might
necessitate surgical intervention is rare and occurs in fewer than 5% of patients. Chance for progression diminishes with age, with patients at highest risk prior to the adolescent growth spurt. Spondylolysis may have a genetic component; an increased prevalence has been found in some families and in some ethnic groups, especially among the Native American population.

Question 17

A 22-month-old girl has cerebral palsy. Which of the following findings is a good prognostic indicator of the child’s ability to walk in the future?

Explanation

DISCUSSION: For the parachute test, the examiner holds the child prone and then lowers the child rapidly toward the floor. The parachute reaction is normal or positive if the child reaches toward the floor. The Moro or startle reflex should not be present beyond age 6 months. Asymmetric tonic neck reflex, extensor thrust, and absent foot placement are abnormal findings at any age.
REFERENCES: Bleck EE: Orthopaedic Management in Cerebral Palsy. Lavenham, Suffolk, The Lavenham Press, 1987, pp 121-139.
Tachdjian MO: The neuromuscular system: Cerebral palsy, in Wickland EH Jr (ed): Pediatric Orthopaedics, ed 2. Philadelphia, PA, WB Saunders, 1990, vol 2, p 1621.

Question 18

Elbow distraction interposition arthroplasty may be most appropriate treatment for which of the following patient profiles? Review Topic

Explanation

Elbow interposition arthroplasty is reserved for younger, active patients who may otherwise be candidates for prosthetic replacement. Osteoarthritis, posttraumatic arthritis, and rheumatoid arthritis patients may all be candidates for interposition arthroplasty if bone stock is preserved and the elbow maintains inherent stability. Primary osteoarthritis may also be treated with ulnohumeral arthroplasty (ie, Outerbridge) or arthroscopic debridement with release. Patients with destructive juvenile rheumatoid arthritis and distal humerus osteonecrosis would better benefit from prosthetic replacement because of bone loss issues.

Question 19

Which of the following increases radiation exposure to patients and personnel during surgery?

Explanation

DISCUSSION: Continuous fluoroscopy and cine radiography expose the patient and personnel to markedly increased levels of direct and scatter radiation exposure. Continuous fluoroscopy should be limited to only what is absolutely needed for safe completion of the procedure. By orienting the cathode ray tube beneath the patient and placing the image intensifier as close as clinically possible to the patient, scatter radiation exposure to the personnel is minimized.
REFERENCE: Wagner L, Archer B: Minimizing Risks from Fluoroscopic X-rays: A Credentialing Program for Anesthesiologists, Cardiologists, Surgeons, Radiologists, and Urologists, ed 3. The Woodlands, TX, Partners in Radiation Management, 2000.

Question 20

The direct anterior (Smith-Peterson) approach to hip arthroplasty is most commonly associated with injury to what nerve?

Explanation

DISCUSSION:
Some authors have reported the incidence of lateral femoral cutaneous nerve neuropraxia following hip arthroplasty with the direct anterior approach to be near 80%, but resolution of the sensory deficits has been observed in most patients over time. Femoral nerve palsy has been reported to occur in .64% to 2.3% direct lateral (Hardinge) and anterolateral (Watson-Jones) approaches, and the superior gluteal nerve may be injured with proximal extension of the abductor muscular dissection. The posterior approach has been reported to be associated with sciatic nerve injury, especially in cases of dysplasia. Pudendal nerve injury has not been reported with the anterior, anterolateral, direct lateral, or posterior approaches to hip
arthroplasty. It has been reported following hip arthroscopy and the use of a traction table, however.

Question 21

A 19-year-old linebacker for a collegiate football team has had two episodes of bilateral arm tingling and weakness after tackling; the symptoms resolved after 30 minutes of rest. Three follow-up neurologic examinations have been normal. Cervical spine CT and MRI scans are shown in Figures 13a through 13c. What is the next best step in management?

Explanation

DISCUSSION: Cervical spinal stenosis is a contraindication to participation in collision and contact sports. Previously, the risks of permanent quadriparesis from cervical spinal stenosis were thought to be unclear and athletes with cervical spinal stenosis were often allowed to play contact sports. In 1996, Torg and associates reported that developmental narrowing of the cervical canal in a stable patient does not appear to predispose an individual to permanent catastrophic neurologic injury and therefore should not preclude an athlete from participation in contact sports. However, the current understanding is that the actual risks of permanent neurologic injury from cervical stenosis are significant. The Torg ratio was previously used for diagnosis but is more recently thought to be of low predictive value as reported by Cantu. Current methods for diagnosis of cervical spinal stenosis rely on MRI and CT. Current diagnosis is based on comparisons of measurements with normal values. A cervical canal of less than 13 mm is considered stenotic whereas a diameter of less than 10 mm is considered absolute stenosis as reported by Crowl and Kong. This patient has symptomatic stenosis and should not be cleared for contact sports. A neck roll will not prevent neurologic injury in the presence of cervical spinal stenosis. Electrodiagnostic studies are not likely to add any additional significant findings with central canal stenosis. Cervical traction is not of value in the long-term. Epidural steroid injections or a methylprednisolone dose pack are not of value in this situation.
REFERENCES: Torg JS, Naranja RJ Jr, Pavlov H, et al: The relationship of developmental narrowing of the cervical spinal canal to reversible and irreversible injury of the cervical spinal cord in football players. J Bone Joint Surg Am 1996;78:1308-1314.
Cantu RC: The cervical spinal stenosis controversy. Clin Sports Med 1998;17:121-126. Crowl AC, Kong JF: Cervical Spine, in Johnson DL, Mair SD (eds): Clinical Sports Medicine. Philadelphia, PA, Mosby Elsevier, 2006, pp 143-149.

Question 22

A 51-year-old woman with shoulder pain responds transiently to a subacromial injection and physical therapy exercise program. When her symptoms recur, an arthroscopic subacromial decompression is recommended. During the surgery, a partial-thickness articular-sided supraspinatus tear is noted. The supraspinatus footprint is exposed for 3 mm from the articular margin. The remaining intra-articular structures are normal. Inspection from the bursal surface reveals the tendon to be intact. What is the most appropriate course of management? Review Topic

Explanation

The patient has a partial articular supraspinatus tendon avulsion (PASTA) lesion. Outcome studies suggest that articular-sided tears of this magnitude do well with arthroscopic decompression and debridement alone. Determination of lesion thickness is important in recommending treatment, and may be done with a variety of methods. Tears that involve exposure of less than 5 mm of the rotator cuff footprint likely measure less than half of the tendon thickness. In the absence of other associated pathology, bicipital tenotomy or synovectomy would be unnecessary. Completion of the tear or transtendinous repair would be considered for lesions of greater than 50% thickness.

Question 23

A 32-year-old man has swelling of the knee as a result of falling with the knee flexed and his foot in plantar flexion. A Lachman’s test reveals an apparent increase in anterior translation. Passive external tibial rotation at 30 degrees and 90 degrees is equal to the contralateral side, and the quadriceps active test is positive on the affected side. The neurovascular examination is normal. Treatment should consist of

Explanation

The question describes a patient with an isolated PCL injury. The mechanism of most athletic PCL injuries is a fall on the flexed knee with the foot in plantar flexion. The results of the physical examination—Lachman’s test with increased anterior translation and a positive quadriceps active test—suggests a PCL injury. The passive external tibial rotation at 30 degrees and 90 degrees being equal to the contralateral side suggest an intact posterolateral corner. In light of these findings, the patient appears to have an isolated PCL injury. In acute isolated posterior cruciate ligament tears with less than 10mm of posterior laxity at 90 degrees of flexion, current knowledge suggests nonoperative treatment that stresses aggressive quadriceps rehabilitation.

Question 24

A patient sustains a severe lower extremity injury. What can be said about his outcome at 2 years if he chooses reconstruction over amputation?

Explanation

DISCUSSION: Severe lower extremity injury patients undergoing reconstruction have a higher rate of rehospitalization at 2 years. This question is based on data published by the LEAP study group, a multi-centered study of severe extremity injuries treated with either amputation or reconstruction.
Bosse et al found that at 2 years the SIP score and return to work were not statistically signficantly different between amputation and reconstruction groups. Reconstruction patients had a higher risk of rehospitalization. The psychosocial subscale of SIP did not improve with time. Risk factors for poorer SIP score were: rehospitalization for a major complication, a low educational level, nonwhite race, poverty, lack of private health insurance, poor social-support network, low self-efficacy (the patient's confidence in being able to resume life activities), smoking, and involvement in disability-compensation litigation.
MacKenize et al evaluated factors influential in returning to work (RTW) after severe lower extremity injury. Characteristics that correlated with higher rates of RTW included younger age, higher education, higher income, the presence of strong social support, and employment in a white-collar job that was not physically demanding. Receipt of disability compensation had a strong negative effect on RTW.

Question 25

A 50-year-old woman reports a burning sensation on the plantar aspect of her left forefoot, distal to the metatarsal heads between her third and fourth digits. Palpation of the third web space recreates her symptoms. Which of the following will most accurately aid in confirming a diagnosis?

Explanation

DISCUSSION: The diagnosis of an interdigital neuroma is best made by a thorough history and careful physical examination. Radiographs are helpful in excluding other pathologic processes such as a metatarsal stress fracture. MRI and ultrasound have both been reported to aid in the diagnosis of an interdigital neuroma.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp 145-151.
Quinn TJ, Jacobson JA, Craig JG, et al: Sonography of Morton’s neuromas. Am J Roentgenol 2000;174:1723-1728.

Question 26

A 10-month-old boy has multiple skeletal lesions and a skin rash that he has had since he was a newborn. Based on the radiographs and biopsy specimens shown in Figures 79a through 79d, what is the most likely diagnosis?

Explanation

DISCUSSION: Langerhans cell histiocytosis or eosinophilic granuloma is a nonneoplastic lesion that is part of a spectrum of clinical diseases featuring histiocytes. Most occur during the first two decades of life within any bone. Radiographs show a radiolucent lesion, frequently diaphyseal in location. A periosteal response is occasionally seen and can resemble more aggressive lesions such as osteomyelitis or Ewing’s sarcoma. Histology demonstrates CD1a positive histiocytes with large oval-shaped nuclei with indentation, and a variable presence of eosinophils.
REFERENCES: Plasschaert F, Craig C, Bell R, et al: Eosinophilic granuloma: A different behaviour in children than in adults. J Bone Joint Surg Br 2002;84:870-872.
Campanacci M: Bone and Soft Tissue Tumors, ed 2. New York, NY, Springer-Verlag, 1999, pp 857-876.

Question 27

Which of the following statements most accurately describes the layers of articular cartilage?

Explanation

DISCUSSION: Normal articular cartilage is composed of three zones that are based on the shape of the chondrocytes and the distribution of the type II collagen. The tangential zone has flattened chondrocytes, condensed collagen fibers, and sparse proteoglycan. The intermediate zone is the thickest layer with round chondrocytes oriented in perpendicular or vertical columns paralleling the collagen fibers. The basal layer is deepest with round chondrocytes. The tidemark is deep to the basal layer and separates the true articular cartilage from the deeper cartilage that is a remnant of the cartilage anlage, which participated in endochondral ossification during longitudinal growth in childhood. The tidemark divides the superficial uncalcified cartilage from the deeper calcified cartilage and also is the division between nutritional sources for the chondrocytes. The tidemark is the zone in which chondrocyte renewal took place in childhood. The tidemark is found only in joints and not in the cap of an enchondroma. It is seen most prominently in the adult, nongrowing joint.
REFERENCE: Schiller AL: Pathology of osteoarthritis, in Kuettner KE, Goldberg VM (eds): Osteoarthritic Disorders. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1995,

pp 95-101.

Question 28

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

Explanation

The patient has a displaced four-part proximal humerus fracture. The humeral head is displaced and if allowed to heal in this position, the patient will likely have a stiff and painful shoulder. The humerus is at risk for osteonecrosis given the displacement of the fracture. Given a patient age of 82 years, replacement options of either hemiarthroplasty or reverse total shoulder arthoplasty, allow maximal restoration of function. Physical therapy is not indicated in this acute fracture. Closed reduction techniques will not be successful in this displaced fracture.

Question 29

A 4-year-old child sustains a spiral fracture to the tibia in an unwitnessed fall. History reveals three other fractures to long bones, and the parents are vague about the etiology of each. There is no family history of bone disease. The parents ask if the child has osteogenesis imperfecta (OI); however, there are no clinical or radiographic indications of this diagnosis. In addition to fracture care, management should include

Explanation

DISCUSSION: Child abuse and OI are frequently both in the differential diagnosis of a child with multiple fractures. If OI is suspected, testing is appropriate to confirm this diagnosis. This may include skull radiographs to look for wormian bones and/or fibroblast culturing and collagen analysis of a punch biopsy. Unfortunately, because of the large number of mutations that can yield the disease, DNA testing is not commercially available for OI. In this patient, however, the physician suspects nonaccidental trauma and is legally obligated in most states to notify child protective services. Because the child may be at considerable risk of further injury, hospitalization is indicated to protect the child until child protective services can complete a home investigation and assess the degree of risk. Work-up for both OI and child abuse can be done during the hospitalization.
REFERENCES: Rockwood CA, Wilkins KE, King RE (eds): Fractures in Children. Philadelphia, PA, JB Lippincott, 1984, vol 3, pp 173-175.
Kempe CH, Silverman FN, Stelle BF, Droegemueller W, Silver HK: The battered-child syndrome. JAMA 1962;181:17-24.
Akbarnia BA, Akbarnia NO: The role of the orthopedist in child abuse and neglect. Orthop Clin North Am 1976;7:733-742.

Question 30

A 40-year-old woman with history of intravenous drug abuse and ongoing Staphylococcus aureus septicemia is referred for intractable neck pain with radiation down her arm. She also complains of progressive hand weakness. Examination reveals long tract signs in the lower extremities. Her MRI scan is shown in Figure A. Besides intravenous antibiotics, what is the most appropriate next step in treatment? Review Topic

Explanation

This patient has spondylodiscitis of C5-C7 with neurological deficit, acute kyphotic deformity and anterior prevertebral and epidural abscess. The abscess and necrotic tissue need to be drained via an anterior approach, and the deformity needs to be corrected and stabilized both anteriorly and posteriorly.
Spinal epidural abscesses are more common in immunodeficient patients and IV drug abusers. They result in verebral body destruction and instability. In addition to draining the abscess and necrotic bone, the instability has to be addressed by instrumentation and fusion, even in the face of infection. Structural support can include cages with morselized bone graft, or structural allograft fixation of anterior and middle column and/or pedicle screw instrumentation of the posterior column.
Shousha et al. reviewed the treatment of cervical spondylodiscitis in 30 patients. They found an epidural abscess in 80% of patients, and noncontiguous discitis in 47% of cases. Thus, they recommend MRI of the entire spine in all cases, and surgery for intractable neck pain, septicemia, epidural abscess, neurological compromise, gross
kyphotic deformity with extensive destruction, and failure of conservative treatment.
Heyde et al. reviewed cervical spondylodiscitis in 20 patients. All cases had postoperative antibiotic therapy for 8–12 weeks. At 37 months (range 24–63), all cases went on to union and there were no recurrences of infection. There was improvement in preoperative neurological status in all cases, leading them to recommend early surgical intervention.
Figure A is an MRI scan showing spondylodiscitis C5–C7 with partial destruction of the vertebral bodies and epidural abscess formation. Illustration A shows the lateral xray (left) and MRI (right) of the same patient 9 months postoperatively after corpectomy C5 and C6 and posterior instrumentation.
Incorrect

Question 31

What is the most likely type of pathology seen in Figure 16?

Explanation

DISCUSSION: The figure shows the missing pedicle or “winking owl” sign that is characteristic of tumor involvement of the cortical bone of the pedicle. None of the other pathologic processes commonly gives this radiographic picture. Thinned, but not missing pedicles, have been described as a normal variant.
REFERENCES: McLain R, Weinstein J: Tumors of the spine, in Herkowitz HH (ed): The Spine, ed 4. Philadelphia, PA, WB Saunders, 1992, p 1173.
Charlton OP, Martinez S, Gehweiler JA Jr: Pedicle thinning at the thoracolumbar junction: A normal variant. Am J Roentgenol 1980;134:825-826.

Question 32

What structure is most at risk for injury from a retractor against the tracheoesophageal junction during an anterior approach to the cervical spine?

Explanation

DISCUSSION: Although any of these structures can be injured by pressure from the medial blade of a self-retaining retractor, the recurrent laryngeal nerve runs cephalad in the interval between the esophagus and trachea and is vulnerable to pressure if caught between the retractor and an inflated endotracheal tube balloon.
REFERENCES: Ebraheim NA, Lu J, Skie M, et al: Vulnerability of the recurrent laryngeal nerve in the anterior approach to the lower cervical spine. Spine 1997;22:2664-2667.
Kilburg C, Sullivan HG, Mathiason MA: Effect of approach side during anterior cervical discectomy and fusion on the incidence of recurrent laryngeal nerve injury. J Neurosurg Spine 2006;4:273-277.

Question 33

What is the most common cause of the new onset of amenorrhea in a female endurance athlete who is not sexually active?

Explanation

DISCUSSION: Insufficient caloric intake caused by either a poor diet or an eating disorder is the most common cause for the loss of menses in a female athlete. In the face of adequate caloric intake, stress is unlikely to cause amenorrhea. Oral contraceptives control menses but do not eliminate it. Diabetes mellitus does not cause the new onset of amenorrhea. Pregnancy can be a cause in a sexually active athlete. Chromosomal abnormalities can result in delayed or absent menarche but not the onset of amenorrhea in a postmenarchal female.
REFERENCES: Constantini NW: Clinical consequences of amenorrhea. Sports Med 1994;17:213-223.
Bennell KL, Malcolm SA, Thomas SA, et al: Risk factors for stress fractures in track and field athletes: A twelve-month prospective study. Am J Sports Med 1996;24:810-818.

Question 34

A resident arrives to the operating room late for a LEFT carpal tunnel release procedure. The patient is prepped and draped under general anaesthesia, and the attending surgeon and assistant are about to make an incision to the RIGHT carpal tunnel. The resident mentions to the attending surgeon that surgery was booked for the opposite limb, but he ignores the residents confers by saying the surgical mark is under the drape. What would be the most appropriate course of action for the resident at this time? Review Topic

Explanation

The most appropriate course of action for the resident at this time would be to perform a surgical timeout prior to the operation.
Wrong-site surgery is completely preventable by having the surgeon, in consultation with the patient when possible, place his or her initials on the operative site using a permanent marking pen and then operating through or adjacent to his or her initials. The intended site should be marked such that the mark will be visible after the patient has been prepped and draped. A "time-out" procedure should be done before the initiating of any surgical procedure to confirm the type of procedure, site, and side with all operating room personnel including residents.
Haynes et al. reviewed the effect of surgical safety checklists before surgery on the morbidity and mortality in a global population. They found the rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P=0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P<0.001).
Incorrect Answers:

Question 35

The tibiofibular overlap used to diagnose syndesmotic diastasis on an AP view is most commonly measured between the

Explanation

DISCUSSION: The tibiofibular overlap is measured between the medial border of the fibula and the lateral border of the anterior tibial tubercle. Plain radiographic assessment of the distal tibiofibular syndesmosis requires AP and mortise views. The following criteria have been used as the normal limits in adults: a talocrural angle of + or - 83 degrees with up to 5 degrees of normal difference between both sides, a medial clear space of less than 4 mm, a talar tilt of less than 2 mm, a tibiofibular clear space of less than 5 mm, a tibiofibular overlap of greater than or equal to 0 mm, and a talar subluxation that is a subjective assessment of congruity of the tibial articular surface and the talar dome; any incongruity is abnormal. It has been recommended to obtain the first three measurements on the mortise view and the other three on the AP view.
REFERENCES: Wuest TK: Injuries to the distal lower extremity syndesmosis. J Am Acad Orthop Surg 1997;5:172-181.
Stiehl JB: Ankle fractures with diastasis. Instr Course Lect 1990;39:95-103.

Question 36

In a patient with a C5-6 herniation, the most likely sensory deficit will be in the

Explanation

DISCUSSION: A C5-6 herniation compresses the C6 root, which innervates the radial forearm, thumb, and index finger. The lateral shoulder is innervated by C5. The dorsal forearm and the middle finger typically are innervated by C7. The ulnar forearm, ring finger, and little finger are innervated by C8. There is no specific nerve associated with the volar forearm and palm.
REFERENCE: Hoppenfeld S: Evaluation of nerve root lesions involving the upper extremity, in Orthopaedic Neurology. Philadelphia, PA, JB Lippincott, 1977, pp 7-23.

Question 37

When reconstructing the anterior cruciate ligament (ACL) with autograft, what is the most common source of surgical failure?

Explanation

Technical failure is the most common reason for ACL reconstruction failure. Tunnel position is the most frequent cause for technical failure. Malpositioning of the tunnel affects the length of the graft, causing either decreased range of motion or increased graft laxity. Although graft choice is an important factor when planning an ACL reconstruction, overall outcomes with autograft tissues are fairly similar. Fixation of the graft at the femoral or tibial end is not as important as tunnel position.

Question 38

The optimal method with which to diagnose component malrotation in total knee arthroplasty (TKA) is

Explanation

CLINICAL SITUATION FOR QUESTIONS 20 THROUGH 22
Figures 20a and 20b are the radiographs of an elderly woman who underwent total knee arthroplasty (TKA) several years ago. She now states that something is not right; her knee frequently swells and is diffusely painful, especially at the end of the day. She does not trust her knee, especially while going up and down stairs or getting up from a chair.

Question 39

An otherwise healthy 78-year-old woman has low back and buttock pain. Rectal examination reveals a large sacral mass. Figures 7a and 7b show a CT scan and a sagittal MRI scan of the lumbosacral spine. A biopsy specimen is shown in Figure 7c. What is the most likely diagnosis?

Explanation

DISCUSSION: A chordoma is a malignant neoplasm originating from remnants of the notochord. It is usually localized to the midline with 50% at the sacrococcygeal area, 35% at the skull base, and 15% at the mobile portion of the spine. Large vacuolated cells (physaliferous cells) are a characteristic of the tumor.
REFERENCES: Mindell ER: Chordoma. J Bone Joint Surg Am 1981;63:501-505.
Samson IR, Springfield DS, Suit HD, Mankin HJ: Operative treatment of sacrococcygeal chordoma: A review of twenty-one cases. J Bone Joint Surg Am 1993;75:1476-1484.

Question 40

Deep anterior compartment

Explanation

How many compartments exist in the foot:

Question 41

After performing a total hip arthroplasty through a posterolateral approach, an orthopaedic surgeon is unable to adequately externally rotate the leg and subsequently exposes the anterior capsule. When releasing the inferior aspect of the anterior capsule, pulsatile bleeding is encountered. A branch of which artery is most likely lacerated?

Explanation

DISCUSSION
Branches of the lateral femoral circumflex artery arise from the inferior aspect of the anterior hip capsule. They can be injured when removing the anterior capsule from any approach. The inferior gluteal artery supplies the gluteus maximus. The medial femoral circumflex artery enters the hip joint along the path of the obturator externus tendon. The femoral artery crosses the anterior hip joint in the superior-to-inferior direction and is located just medial to the hip joint.

Question 42

A 10-year-old boy has had a prominent scapula for the past year. He reports crepitus and aching over the area, but only when he is active. A radiograph and CT scans are shown in Figures 37a through 37c. What is the most likely diagnosis?

Explanation

DISCUSSION: The findings are typical for an osteochondroma. It is found as an outgrowth of bone and cartilage from those bones that arise from enchondral ossification. It may be flat, verrucous, or with a long stalk and cauliflower-like cap. Osteochondromas can become symptomatic secondary to irritation of the adjacent musculature. They cease to proliferate when epiphyseal growth ceases.
REFERENCE: Schmade GA, Conrad EV III, Raskind WH: The natural history of hereditary multiple exostoses. J Bone Joint Surg Am 1994;76:986-992.

Question 43

A 3-year-old patient with L3 myelomeningocele has bilateral dislocated hips. Management should consist of

Explanation

DISCUSSION: In patients with myelomeningocele, the presence of bilateral hip dislocation does not affect ambulation, bracing requirements, sitting ability, degree of scoliosis, or level of comfort. There is little evidence to support active treatment of bilateral hip dislocations in patients with myelomeningocele proximal to L4.
REFERENCES: Fraser RK, Hoffman EB, Sparks LT, et al: The unstable hip and mid-lumbar myelomeningocele. J Bone Joint Surg Br 1992;74:143-146.
Richards BS (ed): Orthopaedic Knowledge Update: Pediatrics. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 65-76.

Question 44

Deep posterior compartment

Explanation

DISCUSSION
The structures at risk are the anterior tibial artery and deep peroneal nerve in the anterior compartment, superficial peroneal nerve in the lateral compartment, sural nerve in the superficial posterior compartment, and posterior tibial nerve and posterior tibial and peroneal arteries and veins in the deep posterior compartment.

Question 45

Ceramic bone substitutes have which of the following properties?

Explanation

DISCUSSION: Ceramics have the following properties: They are resorbed at varying rates, and the chemical composition of the ceramic significantly affects the rate of resorption. For example, tricalcium phosphate (TCP) undergoes biologic resorption 10 to 20 times faster than hydroxyapatite. The partial conversion of TCP to hydroxyapatite once it is in the body significantly reduces the rate of resorption. Some segments of hydroxyapatite can remain in place in the body for 7 to 10 years. In clinical trials, TCP more readily remodels because of its porosity, but it is weaker. The success of converted corals as a bone graft substitute relies on a complex sequence of events of vascular ingrowth, differentiation of osteoprogenitor cells, bone remodeling, and graft resorption occurring together with host bone ingrowth into and on the porous coralline microstructure or voids left behind during resorption.
REFERENCES: Lane JM, Bostrom MP: Bone grafting and new composite biosynthetic graft materials. Instr Course Lect 1998;47:525-534.
Walsh WR, Chapman-Sheath PJ, Cain S, et al: A resorbable porous ceramic composite bone graft substitute in a rabbit metaphyseal defect model. J Orthop Res 2003;21:655-661.
Wright TM, Maher SA: Biomaterials, in Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations of Clinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, in press.

Question 46

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

Explanation

DISCUSSION: All the factors listed, with the exception of an ipsilateral femoral fracture, are representative of a low-energy stable tibial shaft fracture that will do well with closed reduction and immobilization in a long leg cast, followed by weight bearing as tolerated and then a functional brace or patellar tendon bearing cast until union is achieved. Shortening will not increase from that seen on these initial radiographs. The spiral fracture provides a broad surface for healing, and the fibular fracture at another level indicates a stable soft-tissue envelope which, with the immobilization device, will stabilize the fracture reduction. An ipsilateral femoral fracture is a strong indication to surgically stabilize both fractures.
REFERENCES: Trafton PG: Tibial shaft fractures, in Browner BD (ed): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 2153-2169.
Martinez A, Sarmiento A, Latta LL: Closed fractures of the proximal tibia treated with a functional brace. Clin Orthop 2003;417:293-302.

Question 47

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

Explanation

DISCUSSION: The femoral construct shown in the radiograph has failed to produce ingrowth of the stem. The stem has subsided and rotated. Impingement of the trochanter did not occur until after the stem subsided. There is no evidence of osteolysis or third-body wear debris from the cerclage wire. A larger femoral stem needs to be implanted to achieve rigid fixation.
REFERENCES: Pelicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update:

Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 217-238.
Peter CL, Rivero DP, Kull LR, et al: Revision total hip arthroplasty without cement: Subsidence of proximally porous-coated femoral components. J Bone Joint Surg Am 1995;77:1217-1226.

Question 48

Radiographs shown in Figures 1 through 3 show two different prosthetic design variations of the same knee implant. When compared with the design of right knee prosthesis, the left can be expected to have a

Explanation

A 76-year-old woman has had three hip revisions for instability. She presents to the emergency department with another dislocation that occurred while getting up from a low chair. Current radiographs are shown in Figures 1 and 2. Her prior AP pelvis radiograph is shown in Figure 3. ESR and CRP are normal. What is the best plan for definitive treatment?

Question 49

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

Explanation

DISCUSSION: The radiographs and CT scans show a displaced intra-articular calcaneal fracture, with loss of calcaneal height and length. Recent multicenter, randomized, prospective studies suggest that surgical treatment of displaced intra-articular calcaneal fractures is associated with an almost six-fold decrease in the risk of posttraumatic subtalar arthritis (necessitating subtalar arthrodesis) compared to nonsurgical treatment. Despite ongoing controversy, surgical treatment has not been shown to be advantageous with respect to activity, time to return to work, or subtalar joint range of motion. A nonunion of a calcaneal fracture is exceedingly rare regardless of the treatment method.
REFERENCES: Buckley R, Tough S, McCormack R, et al: Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: A prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2002;84:1733-1744.
Csizy M, Buckley R, Tough S, et al: Displaced intra-articular calcaneal fractures: Variables predicting late subtalar fusion. J Orthop Trauma 2003;17:106-112.

Question 50

A diskectomy is performed in which the disk space is not aggressively debrided. When compared to techniques that involve aggressive debridement of the disk space, this results in

Explanation

DISCUSSION
This patient has disk herniation at the left L5-S1 level. This will generally affect the traversing S1 nerve. The S1 dermatome is on the lateral aspect and sole of the foot.
Surgical treatment generally involves a diskectomy with removal of the herniated fragment. This can be performed via a conventional open approach or minimally invasive endoscopic technique. Several recent meta-analyses have demonstrated equivalent outcomes with regard to leg pain and clinical outcomes. Although minimally invasive techniques have been associated with an increased rate of dural tear, the overall complication rate between the 2 techniques is not significantly different. Several studies have demonstrated a substantial learning curve associated with minimally invasive techniques, and the rate of complications decreases significantly with surgeon experience.
When performing a diskectomy, the herniated fragment alone can be removed (sequestrectomy) or some of the disk that remains in the disk space can be removed (complete diskectomy). Studies have shown no change in surgical time, blood loss, length of stay, or surgical complications when performing a sequestrectomy (compared to a more complete diskectomy). A sequestrectomy is associated with a higher rate of recurrent disk herniation at the surgical level.
RECOMMENDED READINGS
Kamper SJ, Ostelo RW, Rubinstein SM, Nellensteijn JM, Peul WC, Arts MP, van Tulder MW. Minimally invasive surgery for lumbar disc herniation: a systematic review and meta-analysis.
Eur Spine J. 2014 May;23(5):1021-43. doi: 10.1007/s00586-013-3161-2. Epub 2014 Jan 18.
PubMed PMID: 24442183. View Abstract at PubMed
Dasenbrock HH, Juraschek SP, Schultz LR, Witham TF, Sciubba DM, Wolinsky JP, Gokaslan ZL, Bydon A. The efficacy of minimally invasive discectomy compared with open discectomy: a meta-analysis of prospective randomized controlled trials. J Neurosurg Spine. 2012 May;16(5):452-62. doi: 10.3171/2012.1.SPINE11404. Epub 2012 Mar 9. PubMed PMID:

Question 51

A 33-year old man sustains a posterior elbow dislocation after a fall. Attempts at closed reduction result in recurrent instability. What is the most common ligamentous injury found at the time of surgical stabilization?

Explanation

Classic posterior elbow dislocations result from a posterolateral rotatory mechanism, whereby the hand is fixed (typically on the ground) while the weight of the body creates a valgus and external rotation moment on the elbow. This results first in tearing of the lateral collateral ligament that proceeds medially through the anterior and posterior joint capsules, ending with potential involvement of the ulnar collateral ligament (but this is not universal). McKee and associates assessed the lateral soft-tissue injury pattern of elbow dislocations
with and without associated fractures at the time of surgery. Injury to the lateral collateral ligament complex was seen in every case, with avulsion from the distal humerus as the most common finding. Midsubstance
tears, proximal avulsions, and distal bony avulsions of the ulnar collateral ligament are less common.

Question 52

With the increasing availability of total hip arthroplasty (THA) to younger patients with hip osteoarthritis, there has been increased use of alternative bearing surfaces. Compared to a ceramic-on-ceramic articulation, which of the following is a specific advantage of a metal-on-metal bearing surface?

Explanation

DISCUSSION: Alternative bearing surfaces in THA have received much attention in recent years as more and more hip arthroplasties are being performed on younger patients with hip arthritis. The two most popular nonmetal-on-polyethylene bearing surfaces are metal-on-metal and ceramic-on-ceramic. There are arguments supporting the use of either, but ceramic bearings have been shown to have a theoretic increased risk of fracture compared with cobalt-chromium. This has been shown to be clinically relevant with zirconium ceramics. Newer alumina ceramics are being produced with lower porosity and grain size and with higher density and purity, resulting in lower fracture risk but still greater than that of cobalt-chromium.
REFERENCES: Heisel C, Silva M, Schmalzried TP: Bearing surface options for total hip replacement in young patients. Instr Course Lect 2004;53:49-65.
D’Antonio J, Capello W, Manley M, et al: New experience with alumina-on-alumina ceramic bearings for total hip arthroplasty. J Arthroplasty 2002;17:390-397.

Question 53

After humeral head replacement for four-part fractures, what is the most commonly reported difficulty?

Explanation

DISCUSSION: Results show that patients who underwent humeral head replacement for fracture almost routinely report pain relief, but functional reports vary. The most commonly reported difficulty is the use of weight in the overhead position with wide variation in active elevation. Factors found to affect active elevation include age, humeral offset, greater tuberosity positioning, and four-part (as compared with three-part) fractures.
REFERENCES: Goldman RT, Koval KJ, Cuomo F, Gallagher MA, Zuckerman JD: Functional outcome after humeral head replacement for acute three- and fourth-part proximal humeral fractures. J Shoulder Elbow Surg 1995;4:81-86.
Hawkins RJ, Switlyk P: Acute prosthetic replacement for severe fractures of the proximal humerus. Clin Orthop 1993;289:156-160.

Question 54

An olecranon fracture-dislocation of the elbow in which the fracture line exits distal to the coronoid process is best managed by open reduction and

Explanation

DISCUSSION: Fracture-dislocations of the elbow present difficult management problems. Standard olecranon fractures normally are not associated with a dislocation; however, the surgeon needs to recognize that some fractures that have a dislocation, in particular a posterior dislocation, represent a Monteggia equivalent. These injuries are not ulnar shaft fractures because they are fractured at or just distal to the coronoid; however, because of the unstable fracture-dislocation, the forces across this reduction are high. Two Kirschner wires and a tension band wire provide inadequate fixation. Therefore, the preferred method of fixation is plate osteosynthesis with a 3.5-mm low-contact dynamic compression plate or reconstruction plate.
REFERENCES: Jupiter JP, Kellam JF: Fractures of the forearm, in Browner BD, Jupiter JP, Levine AM, Trafton P (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998,

pp 421-454.
Quintero J: Fracture of the forearm, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 323-337.
Jupiter JB, Leibovic SJ, Ribbans W, Wilk RM: The posterior Monteggia lesion. J Orthop Trauma 1991;5:395-402.

Question 55

An 80-year-old patient presents 8 months postoperatively with right groin pain. Examination reveals a leg length discrepancy of 1.5cm. Recent radiographs are seen in Figures A and B. What is the most appropriate treatment plan?

Explanation

Age less than 30
Marijuana use
Use of negative pressure wound therapy
Male gender
Ability to return to work
The strongest factor to predict patient-reported outcomes after trauma-related lower extremity amputations is the patient's ability to return to work. This is likely due to the effect of the return to work on the physical, emotional, and financial aspects of the patient's life.
The LEAP study is a multicenter, prospective study evaluating multiple aspects of reconstruction versus amputation in the treatment of mangled extremity injuries. With regard to patient satisfaction, treatment variables such as decision for reconstruction versus amputation, or initial presence or absence of plantar sensation have little impact. In addition, demographic factors such as age, gender, socioeconomic status, and education level do not predict patient satisfaction. Instead, the most important predictors of patient satisfaction at 2 years after injury include the ability to return to work, absence of depression, faster walking speed, and decreased pain.
O'Toole et al reviewed 463 patients treated for limb-threatening lower-extremity injuries and identified factors associated with patient reported outcomes two years after surgery. They found that return to work was the most associated with outcomes, but that physical functioning, walking speed, pain levels, and presence of depression were also associated to a lesser extent with outcomes.
Bosse et al performed a multicenter, prospective study to assess outcomes of 569 patients with severe lower extremity limb injuries that resulted in either amputation or
limb salvage procedures. They found that at two years postoperatively, no significant differences were seen between groups in patient-reported outcome. Worse outcomes were associated with rehospitalization for a major complication, a low educational level, nonwhite race, poverty, lack of private health insurance, poor social-support network, low self-efficacy (the patient's confidence in being able to resume life activities), and involvement in disability-compensation litigation.
Figure A shows a clinical photograph of a Pirigoff amputation at early follow-up. This amputation is an end-bearing amputation that utilizes the plantar heel pad for weightbearing, and relies on a tibiocalcaneal arthrodesis.
Incorrect Answers:
1-4: These options are not as strong of a factor of patient satisfaction in long-term follow up after trauma-induced lower extremity amputation.

Question 56

In the treatment of ankle fractures, the superficial peroneal nerve is most commonly injured by

Explanation

DISCUSSION: In the treatment of ankle fractures, the superficial peroneal nerve is most commonly injured by the use of a direct lateral approach to the ankle. The superficial peroneal nerve and its branches exit the fascial hiatus approximately 9 cm to 10 cm proximal to the tip of the distal fibula with a range of 4 cm to 13 cm, and their course is typically anterior to the midlateral plane of the fibula. However, small branches may course across the surgical plane directly laterally. A posterior-lateral approach diminishes the risk of injury to the superficial peroneal nerve and its branches; however, by moving farther posterior, the sural nerve and its branches may be at increased risk. Cast immobilization may injure the cutaneous nerves about the ankle; however, the risks are greater with surgical intervention. A medial or anterior-medial approach to the ankle will not injure the superficial peroneal nerve at the ankle level.
REFERENCES: Redfern DJ, Sauve PS, Sakellariou A: Investigation of incidence of superficial peroneal nerve injury following ankle fracture. Foot Ankle Int 2003;24:771-774.
Miller SD: Ankle fractures, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1341-1366.

Question 57

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 58

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

Explanation

DISCUSSION: The long thoracic nerve, which innervates the serratus anterior, is prone to injury because of its superficial location along the chest wall. The long thoracic nerve is derived from the roots of C5, C6, and C7. The spinal accessory nerve innervates the trapezius, and the thoracodorsal nerve innervates the latissimus dorsi. The posterior cord of the brachial plexus provides the axillary and the radial nerves.
REFERENCES: Hollinshead WH: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, pp 259-340.
Marmor L, Bechtal CO: Paralysis of the serratus anterior due to electric shock relieved by transplantation of the pectoralis major muscle: A case report. J Bone Joint Surg Am 1983;45:156-160.

Question 59

An 18-year-old collegiate football player injures his right shoulder during a tackle. He reports pain and numbness in the shoulder and numbness radiating to his fingers. His symptoms improve within 15 minutes and he has no residual symptoms. This condition is best known as Review Topic

Explanation

The condition described in this case is known as a stinger or burner. It is caused by stretching the upper trunk of the brachial plexus in the C5 and C6 nerve roots. The symptoms are temporary and last 15 to 20 minutes. There are no residual deficits, unless the patient has had multiple repetitive injuries. Once motor and sensory examination findings and reflexes have normalized, the athlete can return to play. Acute spinal cord injury may cause temporary complete paralysis in the upper and lower extremities with resolution of symptoms within 24 hours. Central cord syndrome affects the upper more than lower extermities and affects mostly elderly patients. Nerve root avulsions lead to permanent deficits and have a poor prognosis for return of function. Guillain-Barre syndrome is an autoimmune disease that presents as an ascending paralysis with weakness in the legs that spreads to the upper limbs and the face along with complete loss of deep tendon reflexes.

Question 60

A 15-year-old boy has hindfoot pain and very limited subtalar motion. A CT scan reveals a talocalcaneal coalition involving 40% of the middle facet. He has no degeneration of the posterior subtalar facet. Following failure of nonsurgical management, treatment should consist of

Explanation

DISCUSSION: The CT scan is an important test to help determine the extent of involvement of the talocalcaneal facet in a talocalcaneal coalition. In a young patient with no arthritis and joint involvement of less than 50%, resection of the coalition and fat pad interposition has been shown to be successful. A calcaneal osteotomy does not address the coalition. Subtalar arthroereisis has been used for treatment of a flexible flatfoot; tarsal coalition patients have a rigid-type flatfoot deformity.
REFERENCES: Sullivan JA: The child’s foot, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 2, pp 1077-1135.
Scranton PE Jr: Treatment of symptomatic talocalcaneal coalition. J Bone Joint Surg Am 1987;69:533-539.

Question 61

An infected total knee replacement with symptoms occurring within 4 weeks of surgery and no radiographic signs of osteomyelitis would be best managed with

Explanation

Treatment of an early infection demands thorough debridement of the wound and appropriate parenteral antibiotics. Systemic treatment with appropriate antimicrobial agents should continue for a minimum of 4 weeks following debridement for an early infection. An infection diagnosed later than 4 weeks following surgery is less likely to have a successful result without removal of the components. OKU V pg. 490.
Arthroscopic debridement not recommended secondary to missing cutaneous tracks and soft tissue/muscle involvement.

Question 62

A 13-year-old quarterback feels a “pop” in his knee while being tackled. Radiographs of the knee and results of a Lachman’s test are normal. Examination reveals tenderness over the distal femoral physis. To help confirm the diagnosis, management should first include

Explanation

Injuries involving the distal femoral epiphysis cartilage plate are fairly common. Appropriate management should include a complete knee exam with a standard series of X-rays. Of particular importance is to notice any varus or valgus deformity. Stephens et al. (JBJS 1974:56A) measured varus and valgus deformities clinically and roentgenographically. A varus or valgus deformity greater than 3 degrees as compared with the uninjured side was considered clinically significant. Such deformities are highly suggestive of a physeal injury. A MRI may show the injury, but is expensive as is an arthroscopy or examination under anesthesia.

Question 63

A 45-year-old woman has severe anterior knee pain. Her radiographs indicate end-stage patellofemoral compartment osteoarthritis. The tibiofemoral compartments are preserved. Extensive nonsurgical treatment has failed to provide relief, and she is offered patellofemoral arthroplasty (PFA). What is the most common long-term mode of failure for PFA using an implant with an onlay prosthesis design?

Explanation

DISCUSSION:
Contemporary onlay-design trochlear prostheses in PFA replace the entire anterior trochlear surface. Previous inlay designs were inset within the native trochlea and carried a higher risk of catching and patellar instability, particularly in patients with trochlear dysplasia; they also generally have higher failure rates. The current most common mode of failure is progression of arthritis throughout the knee, in some series as high as 25% at 15 years. Aseptic loosening, particularly of cemented implants, is less common. Infection is an uncommon long-term complication. Patients considering PFA should be advised of the risk of arthritis progression. Many authors routinely obtain a preoperative MRI to assess the status of the tibiofemoral compartments.

Question 64

An adult patient has a closed humeral fracture that was treated nonsurgically and a concomitant radial nerve injury. Six weeks after injury, electromyography shows no evidence of recovery. Management should now consist of

Explanation

DISCUSSION: In patients with radial nerve injuries with closed humeral fractures, it has been reported that 85% to 95% spontaneously recover. Based on this premise, most surgeons favor expectant management of these injuries. Even if there is no evidence of recovery at 6 weeks, repeat electromyography at 12 weeks is advocated. If there is no clinical or electromyographic signs of recovery at 6 months, exploration is recommended. If the nerve is in continuity at the time of exploration, nerve action potentials are useful in helping determine the need for neurolysis, excision, and grafting, or if excision and repair is the best option.
REFERENCES: Pollock FH, Drake D, Bovill EG, et al: Treatment of radial neuropathy associated with fractures of the humerus. J Bone Joint Surg Am 1981;63:239-243.
Mohler LR, Hanel DP: Closed fractures complicated by peripheral nerve injury. J Am Acad Orthop Surg 2006;14:32-37.

Question 65

An 18-year-old female Marine Corps recruit enters basic training. Her enlistment history and physical examination showed that she was an elite high school cross country runner. What is her most significant risk factor for a femoral or pelvic stress fracture during basic training?

Explanation

DISCUSSION: Approximately 5% of female recruits incur a stress fracture during the 13 weeks of Marine Corps basic training. Approximately 40% of these were femoral or pelvic stress fractures that were more severe than in civilian athletes or male military recruits. Only women who reported no menses during the previous year had a greater likelihood of femoral or pelvic stress fractures than did women who reported 10 to
12 menses. The referenced study did not find a statistically significant increase in risk of stress fracture in those recruits who had lesser menstrual irregularities in the year prior to recruit training, but there was a trend toward increased risk of stress fracture.
REFERENCES: Shaffer RA, Rauh MJ, Brodine SK, et al: Predictors of stress fracture susceptibility in young female recruits. Am J Sports Med 2006;34:108-115.
Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of
Orthopaedic Surgeons, 2004, pp 273-283.

Question 66

A surgeon decides to report outcomes for a new surgical procedure that he has performed on 10 patients who have a rare type of arthritis. He provides data on the functional and subjective patient outcomes. This type of study design is best described as a

Explanation

The type of study design in which a series of cases is presented with outcomes (without a control population or comparison group) is known as a case series. This type of study design, although frequently seen in orthopaedic literature, provides the lowest level of evidence. There is no control group and the population is usually poorly defined. This type of study can be helpful as a starting point for further analysis. A randomized trial provides the highest level of evidence in medical research, featuring a comparison group and randomized (and usually blinded) placement of subjects into study groups. In case-control studies, cases are compared to a control group. The control group has not been randomized, but may be a naturally occurring group of subjects who have not had the same exposure or intervention as the case group. A cohort study can be retrospective or prospective and usually looks at a large group of people over time to assess exposures and incidence of disease.

Question 67

Figure 37a is the initial radiograph of a 7-year-old boy who fell from monkey bars 4 hours ago. He has intact motor function in his fingers and normal capillary refill, but his radial pulse is not palpable. Figures 37b and 37c are the radiographs following closed reduction and pinning. This boy’s hand and fingers remain pink, but his radial pulse remains nonpalpable. What is the best next step?

Explanation

DISCUSSION
Figure 37a shows a completely displaced supracondylar humerus fracture. The first step in the situation described, which involves a pink pulseless hand, is to perform an urgent closed manipulation and pinning. The vascular examination should be reassessed following the reduction. When adequate reduction has been achieved and the pulse remains nonpalpable but the hand is pink and capillary refill is normal, the fracture may be splinted and the patient observed closely in the hospital. Arteriography is not useful and may delay revascularization or increase vessel spasm. Although some investigators have concluded that exploration of the brachial artery may be indicated, the algorithm that includes observation only is the most supported and the most commonly practiced treatment. The radiographs show adequate reduction and fixation without medial widening at the fracture site, which might indicate a site of brachial artery entrapment. Therefore, pin removal and fracture rereduction is not indicated.
RESPONSES FOR QUESTIONS 38 THROUGH 45
Sclerosis of the proximal femoral epiphysis with subchondral lucency
Abnormal femoral head-neck junction offset
Widening of the proximal femoral physis with normal femoral head-neck junction offset
Absence of the proximal femoral epiphysis secondary ossification center
For each clinical scenario below, select the most likely associated radiographic finding from the list above.

Question 68

A 10-year-old boy with a history of retinoblastoma now reports right knee pain. AP and lateral radiographs are shown in Figures 3a and 3b. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiographs show a bone-producing lesion in the femoral diaphysis. The radiographic appearance of small round cell tumors is more permeative with an elevated periosteum and no matrix production. The appearance of this lesion is most consistent with osteosarcoma. Patients who carry the Rb gene are predisposed to osteosarcoma. However, Ewing’s sarcoma, primitive neuroectodermal tumor, and osteomyelitis can all occur in this location.
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.
Chauveinc L, Mosseri V, Quintana E, Desjardins L, Schlienger P, Doz F, Dutrillaux B: Osteosarcoma following retinoblastoma: Age at onset and latency period. Ophthalmic Genet 2001;22:77-88.

Question 69

Figures 1 and 2 show the radiographs obtained from a 56-year-old man who has been experiencing progressive wrist pain since he felt a pop while throwing a 25-pound bag over his shoulder 6 months ago. Failure to address the injury surgically might lead to progressive arthritic changes in what order?

Explanation

EXPLANATION:
This patient demonstrates scapholunate dissociation with an associated dorsal intercalated segment instability deformity. Chronic scapholunate ligament tears lead to scapholunate advanced collapse (SLAC) wrist. Watson and Ballet describe SLAC wrist as having a predictable progression of arthritic changes, starting at the radial styloid, progressing to the radioscaphoid joint, and advancing to the lunocapitate joint. Some authors have described the radiolunate joint as being affected in very late-stage SLAC wrist.

Question 70

Figure 7 shows the CT scan of a 22-year-old professional baseball pitcher who has had elbow pain for the past 6 months despite rest from throwing. Management should consist of Review Topic

Explanation

The CT scan shows a stress fracture of the olecranon. This injury is the result of repetitive abutment of the olecranon into the olecranon fossa, traction from triceps activity during the deceleration phase of the throwing motion, and impaction of the medial olecranon onto the olecranon fossa from valgus forces. Fractures may be either transverse or oblique in orientation. Initial treatment consists of rest and temporary splinting. Electrical bone stimulation may also be considered. Open fixation with a large compression screw is recommended when nonsurgical management has failed to provide relief.

Question 71

At the time of revision knee arthroplasty, a surgeon performs a rectus snip to gain exposure to the knee. When compared to a standard parapatellar approach, what is the expected outcome?

Explanation

DISCUSSION
Rectus snip during total knee arthroplasty has no effect on motion or strength at long-term follow-up. It has not been associated with extensor mechanism lag.

RESPONSES FOR QUESTIONS 58 THROUGH 62
Nerve palsy
Skin necrosis
Flexion instability
Patellar instability
Anterior knee pain
Malalignment
Total knee arthroplasty (TKA) is performed to address each condition shown in Figures 58 through 62b. Which complication is most commonly associated with each image?

Question 72

Which of the following is not a cause of childhood osteomalacia (rickets)?

Explanation

Rickets is caused by a decrease in calcium and phosphate that affects mineralization at the physes of the long bones. This disease is characterized by brittle bones; physeal widening is seen on radiographs with long-bone bowing, Looser's lines, enlargement of costal cartilages, and dorsal kyphosis. All of the above-mentioned choices are known causes of osteomalacia or rickets except vitamin K deficiency.

Question 73

A 58-year-old patient suddenly develops cardiac arrest while undergoing a routine total knee arthoplasty. He is resuscitated with 20% lipid emulsion. What was the most likely causative agent for cardiac arrest?

Explanation

This patients cardiac arrest was likely caused by an intravascular bolus of Bupivacaine.
Bupivacaine is a long acting local anesthetic. It acts on intracellular voltage-gated sodium channels to block sodium influx into nerve cells, which prevents depolarization. If administered systemically, bupivacaine can cause serious complications to the cardiovascular system. Side effects include hypotension, arrhythmia, bradycardia, heart block, and cardiac arrest. Treatment should involve urgent administration of intravascular lipid emulsion alongside standard ACLS protocols.
Rosenblatt et al. describe the successful use of a 20% lipid emulsion to resuscitate a patient after a presumed bupivacaine-related cardiac arrest. Resuscitation involved a lipid emulsion bolus of 1 mL/kg given immediately, which was followed by a continuous infusion until the patient stabilized.
Corman et al. evaluated the use of lipid emulsion for reversal of local anesthetic-induced toxicity. They suggest that lipid emulsion may reverse local anesthetic toxicity by extracting lipophilic local anesthetics from aqueous plasma or tissues or by counteracting local anesthetic inhibition of myocardial fatty acid oxygenation.
Illustration A shows an ECG of a patient with clinical deterioration after systemic administration of bupivicaine. The ECG shows complete heart block with multifocal ventricular beats. The patient progressed to asystole.
Inncorrect Answers:

Question 74

A 66-year-old woman with known poorly controlled rheumatoid arthritis reports that for the past 4 weeks she has been unable to extend the metacarpophalangeal (MCP) joints of her right hand index, middle, ring and little fingers. She cannot hyperextend the thumb interphalangeal joint. Active wrist extension is possible, but shows radial deviation. Examination reveals mild synovitis at the wrist and MCP joints of the affected hand. There is no ulnar deviation at the MCP joints with normal alignment. When the MCP joints are passively extended, the patient is unable to maintain them in this position. There is no piano key sign at the distal ulna. Passive wrist motion shows a normal tenodesis effect. Which of the following would most likely confirm your diagnosis? Review Topic

Explanation

There are many causes of inability to extend the MCP joints in a patient with rheumatoid arthritis. The most common cause is rupture of the extensor tendons. An intact tenodesis test suggests that the extensor tendons are intact, thus surgical exploration is not indicated and would not confirm the diagnosis. The patient has normal alignment of the fingers without ulnar deviation, suggesting that there are no MCP dislocations to account for the inability to extend the MCP joints; therefore, radiographs would not confirm the diagnosis. The most likely cause of inability to extend the fingers in this patient is posterior interosseous nerve (PIN) palsy. Electrodiagnostic studies would confirm the presence of PIN palsy. An MRI of the elbow may show synovitis at the radiocapitellar joint, which can cause the PIN palsy. This finding however, is nonspecific and many patients without PIN palsy would also demonstrate synovitis at the radiocapitellar joint. Therefore, although an MRI would be helpful in localizing a potential cause of PIN compression, it would not in itself confirm the diagnosis.

Question 75

The modified Judet approach to the posterior scapula exploits the internervous interval between what two muscles?

Explanation

DISCUSSION: The posterior or modified Judet approach to the scapula is typically used for internal fixation of scapular fractures. This approach utilizes a transverse incision over the scapular spine with detachment of the posterior deltoid. The interval between the infraspinatus (suprascapular n.) and teres minor (axillary n.) is identified and used to gain access to the posterior aspect of the scapula and glenoid.
The reference by Obremskey et al argues the approach "combines several important goals including: 1) exposure of all bony elements of the scapula which have adequate bone stock for internal fixation; 2) minimal trauma to the rotator cuff musculature; and 3) protection of the major neurologic structures (suprascapular nerve superiorly and axillary nerve laterally)." They believe "the main advantage of the exposure is limiting muscular dissection, which can potentially improve rehabilitation and limit morbidity of the operation."

Question 76

Chemotherapy is routinely included in the treatment of which of the following soft-tissue sarcomas?

Explanation

DISCUSSION: Most soft-tissue sarcomas are treated with a combination of radiation therapy and wide resection. Rhabdomyosarcomas are an exception, where chemotherapy is included in all treatment plans. Chemotherapy for other soft-tissue sarcomas is controversial.
REFERENCES: Enzinger FM, Weiss SW: Rhabdomyosarcoma, in Soft Tissue Tumors, ed 3. St Louis, MO, CV Mosby, 1995, p 539.
Hays DM: Rhabdomyosarcoma. Clin Orthop 1993;289:36-49.

Question 77

A 22-year-old female collegiate javelin thrower has shoulder pain. She notes that her pain is primarily located in the posterior aspect of her shoulder, is exacerbated with throwing, and she experiences maximal tenderness in the extreme cocking phase of the throwing cycle. On examination, she reports deep posterior shoulder pain when the arm is abducted 90 degrees and maximally externally rotated to 110 degrees. This reproduces her symptoms precisely. Shoulder radiographs are normal. What is the most likely diagnosis? Review Topic

Explanation

The patient has internal impingement. Internal impingement is commonly seen in overhead throwing athletes. When positioned in the extreme cocking phase of the throwing cycle, the posterior glenoid impacts the articular surface of the infraspinatus and posterior fibers of the supraspinatus tendon. This impact can cause partial-thickness rotator cuff tearing and posterosuperior labral lesions. She has no evidence of anterior shoulder instability, and her range of motion is excellent which rules out adhesive capsulitis. Subacromial impingement is identified with anterolateral shoulder pain with internal rotation in the abducted position. A full-thickness rotator cuff tear in a 22-year-old individual would require significant trauma and would likely result in pain at rest and with lifting.

Question 78

A 43-year-old woman has a 2-week history of right shoulder pain. She denies any injury to initiate her symptoms but states that she has shoulder pain with range of motion and lifting objects. Examination reveals mild pain with abduction, empty can testing, and with the Neer and Hawkins impingement tests. Her range of motion with the right shoulder reveals passive forward flexion to 90 degrees, abduction to 90 degrees, external rotation at the side to 15 degrees, and internal rotation to her buttock. The uninvolved left shoulder has forward flexion to 160 degrees, abduction to 150 degrees, external rotation at the side to 60 degrees, and internal rotation to T6. Radiographs of the shoulder are normal. What is the next most appropriate step in management? Review Topic

Explanation

The patient has the recent onset of adhesive capsulitis, which is characterized by loss of both active and passive range of motion. A home exercise program is as helpful as organized therapy to improve her range of motion. While a sling might be appropriate for comfort, continuous use might increase her shoulder stiffness. Surgical treatments, such as a manipulation under anesthesia or arthroscopic capsular release, might be necessary if her motion cannot be restored with physical therapy and home exercises. However, the natural history of idiopathic adhesive capsulitis is self limited and does not usually require surgery. An arthroscopic rotator cuff repair is not indicated because she does not have a rotator cuff tear.

Question 79

For a patient with a type II odontoid fracture, which of the following factors best predicts the development of a nonunion with nonsurgical management? Review Topic

Explanation

All five factors have been found to be associated with nonunion for type II odontoid fractures. Of these, initial fracture displacement of greater than 6 mm has the greatest association with the development of fracture nonunion.

Question 80

A 17-year-old high school football player is seen for follow-up after sustaining an injury 3 days ago. He reports that he tackled a player, felt numbness throughout his body, and could not move for approximately 15 seconds. A spinal cord injury protocol was initiated on the field. Evaluation in the emergency department revealed a normal neurologic examination and full painless neck motion. He states that he has no history of a similar injury. An MRI scan of the cervical spine is normal. During counseling, the patient and his family should be informed that he has sustained

Explanation

DISCUSSION: The long-term effect of transient quadriplegia is unknown. Based on a history of one brief episode of transient quadriplegia and normal examination and MRI findings, the risk of permanent spinal cord injury with a return to play is low. There is a risk of recurrent episodes of transient quadriplegia after the initial episode.
REFERENCES: Morganti C, Sweeney CA, Albanese SA, et al: Return to play after cervical spine injury. Spine 2001;26:1131-1136.
Odor JM, Watkins RG, Dillin WH, et al: Incidence of cervical spinal stenosis in professional and rookie football players. Am J Sports Med 1990;18:507-509.
Torg JS, Naranja RJ Jr, Palov H, et al: The relationship of developmental narrowing of the cervical spinal canal to reversible and irreversible injury of the cervical spinal cord in football players. J Bone Joint Surg Am 1996;78:1308-1314.
Vaccaro AR, Watkins B, Albert TJ, et al: Cervical spine injuries in athletes: Current return-to-play criteria. Orthopedics 2001;24:699-703.

Question 81

There is increasing concern about the ethical relationship of orthopaedists to the orthopaedic equipment industry. Which of the following describes the most appropriate relationship?

Explanation

DISCUSSION: It is appropriate for orthopaedic surgeons to have relationships with industry as long as the relationship is for the good of the patient and no “quid pro quo” intent exists. A grant to cover registration at a CME event is appropriate but travel and hotel for a spouse is not. For orthopaedists who are faculty at a meeting sponsored by industry, it is appropriate for travel and expenses to be covered for that faculty member. Care must be exercised that the faculty member contributes in an amount appropriate for the expenses paid. The faculty member must ensure that information presented is unbiased and based on reasonable data and opinion. Consulting agreements should spell out specifically the duties of the agreement and payment should be appropriate for the time spent. There should be a defined work product for the consulting. Agreements that are thinly veiled payments for use of a company’s products must be avoided. In all cases, the agreements must stand up to public scrutiny. Restricted grants for specific industry-sponsored programs aimed at residents are not appropriate. Unrestricted grants intended for attendance at approved CME courses are appropriate. Dinners at which information is presented about topics that can aid in patient care are appropriate as long as the expense is reasonable ($100 or less/person) and the guest list includes individuals who can use the information in a patient case. Clearly a “premium” dinner for office staff to review new surgical instrumentation would not pass this test.
REFERENCE: Opinions on ethics and professionalism, in Guide to The Ethical Practice of Orthopaedic Surgery, ed 6. American Academy of Orthopaedic Surgeons, Rosemont, IL, 2006, pp 38-42.

Question 82

The usual presentation of traumatic subscapularis tears is most often seen after forced Review Topic

Explanation

The typical mechanism of injury is a fall and the patient grasps something to prevent the fall. This maneuver forces the arm into external rotation against resistance.

Question 83

Figure 1 shows the radiograph and Figure 2 shows the MRI scan obtained from a 37-year-old woman with a 2-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 84

A 27-year-old right hand dominant construction worker falls off a scaffold onto his outstretched arm. Figure A exhibits the radiograph taken at a local emergency room. Following treatment, he is placed in a sling and follows up at your office two weeks later. He complains of a feeling that his arm is going to 'pop out'. Which specific physical examination finding is likely to be present? Review Topic

Explanation

The patient suffered a posterior shoulder dislocation, likely injuring the posterior capsule and/or labrum. Out of all the answer choices, Kim's test assesses posterior structures. Thus, Kim's test is the physical examination finding most likely to be present.
Posterior dislocations occur less frequently than anterior dislocations, and are often missed. Following closed reduction, persistent instability can occur, usually associated with posterior capsular or labral pathology. Posteriorly directed provocative maneuvers, such as the Kim test can be positive.
Robinson et al. performed an epidemiologic analysis on 120 posterior dislocations. Recurrent instability occurred at a rate of 17.7%. Risk factors for recurrent instability included age less than 40-years-old, dislocation during seizure, and a large reverse Hill-sachs (>1.5 cm3).
Kim et al. describe the Kim lesion, a separation between the posteroinferior labrum and the articular cartilage without complete detachment of the labrum, which cause persistent posterior instability.
Figure A depicts a posterior dislocation on xray. Illustration A depicts the Kim test, which is performed by having the patient seated, arm at 90° abduction, followed by flexing the shoulder to 45° forward flexion while simultaneously applying axial load on the elbow and posterior-inferior force on the upper humerus. The test is positive when there is pain. Video 1 depicts the proper way to perform a Kim Test.
Incorrect answers:

Question 85

An adult patient with a grade I isthmic spondylolisthesis at L5-S1 is most likely to have weakness of the

Explanation

DISCUSSION: Adult patients with isthmic spondylolisthesis most commonly have neurologic symptoms due to foraminal stenosis at the level of the spondylolisthesis. In this scenario, the patient is most likely to have weakness of the L5 myotome, which would cause weakness of the extensor hallucis longus.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 311-317.
Lauerman WC, Cain JE: Isthmic spondylolisthesis in the adult. J Am Acad Orthop Surg 1996;4:201-208.

Question 86

A 32-year-old professional skydiver lands awkwardly during a jump. He presents to the emergency room with bilateral knee injuries. Following successful closed reduction of both extremities, both feet are warm and pulses are present. Bedside doppler assessment is performed and the results are seen in Figure A. What would be the most appropriate next step in treatment?

Explanation

The ankle-brachial index (ABI) of left and right limbs are 0.78 and 0.96 respectively. CT angiography (or conventional angiography) of the left lower extremity is indicated because of abnormal ABI <0.9. It is sufficient to observe the right lower extremity (ABI >0.9).
Injury to the popliteal artery is present in 10-40% of knee dislocations (KD). ABI
<0.9 has sensitivity of 87% and specificity of 97% for the diagnosis of arterial disruption. Delayed recognition of an occlusive injury (>8 hours) is likely to result in above knee amputation.
Stannard et al. examined the role of selective arteriography based on serial physical examination. They found arterial injury in 7% (9 out of 134 knees), and abnormal physical findings in 10 patients, with only 1 false positive. They recommend arteriography for patients with decreased pulses, color or temperature, expanding knee hematoma, or an abnormal physical examination prior to presentation in the emergency department.
Mills et al. reviewed the value of ABI for diagnosing arterial injury after knee dislocation. They found that of the 29% with ABI <0.9, all required surgery for arterial injury. Of the remaining patients with ABI >0.9, none had vascular injury. They concluded ABI >0.9 has negative predictive value of 100%.
Nicandri et al. reviewed an algorithm for selective angiography. They recommend the following: (1) Intact pulses and ABI >0.9, observation for 24 hours. (2) Asymmetric pulses or ABI <0.9, arteriogram. (3) Hard signs of vascular injury (absent distal pulses, distal ischemia, active hemorrhage, expanding pulsatile hematoma), surgical exploration.
Figure A is a table showing systolic pressure readings at different sites. To calculate the ABI, the highest measured arterial pressure in the ankle or foot is divided by the higher brachial arterial pressure from both upper extremities.
Incorrect Answers:

Question 87

-A 14-year-old girl has a painless deformity of the right tibia. A radiograph from 2 years ago is seen in Figure a; nothing was done at that time. Her current radiograph is seen in Figure b. She has no pain, fever, or drainage. What is the most likely diagnosis?

Explanation

Question 88

Figures 32a and 32b show the AP and lateral radiographs of an 11-year-old boy who has a severe limp, a fever, and swelling and tenderness of the thigh. Aspiration of the bone reveals purulent material. The patient has most likely been symptomatic for

Explanation

DISCUSSION: In patients with an osteomyelitic infection, radiographic findings at 1 to 5 days usually show soft-tissue swelling only. Seven to 14 days after symptoms begin, radiographs will most likely show the classic signs of acute osteomyelitis. Reactive bone formation would be expected by 6 months.
REFERENCES: Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 149-161.
Song KM, Sloboda JF: Acute hematogenous osteomyelitis in children. J Am Acad Orthop Surg 2001;9:166-175.

Question 89

After completion of bone cuts and ligament balancing of a severe valgus knee during primary total knee arthroplasty, there is a 5-mm increased medial gap that cannot be corrected. In this scenario, what is the most appropriate level of constraint?

Explanation

DISCUSSION
Cruciate-retaining implants are typically used in the presence of a functioning posterior cruciate ligament (PCL). A posterior stabilized insert improves anteroposterior stability in the absence of a PCL but does not account for imbalance of the collateral ligaments. An
uncorrectable laxity medially indicates insufficiency of the medial collateral ligament (MCL), which is best treated with a varus-valgus constrained component. A rotating hinge is generally reserved for complete absence of the MCL or both collateral ligaments.
Change of IV antibiotics and splinting
Arthroscopic irrigation and debridement
CT-guided needle aspiration
Open debridement
DISCUSSION
In an acutely febrile child with bone pain and elevated acute-phase reactants, osteomyelitis is suspected. Blood cultures will yield the offending organism in 30% to 60% of patients and are the most appropriate next step. Knee aspiration in the absence of an effusion likely will not be helpful. Although a bone scan may show an osteomyelitic focus, an indium-labeled WBC scan is unnecessarily complex and costly in this case. Pelvic radiographs would add little to the unremarkable femur films.
Initiating IV antibiotics after obtaining blood cultures is appropriate, even in the presence of an MRI with normal findings. Observation or discharge may be considered, but suspicion for infection should be strong in this clinical situation and delay is not warranted. A CT scan of the knee in the setting of normal MRI findings will not be helpful.
Most hematogenous osteomyelitis cases among children are attributable to S. aureus. In many areas of the country, MRSA is endemic, and initial coverage for resistance is appropriate. The other listed organisms would rarely be seen in this scenario.
The MR images show early abscess formation in the distal medial femoral metaphysis. Because the formation developed during antibiotic treatment, surgical drainage (rather than a change of antibiotic) is appropriate. Arthroscopy is not helpful because this is not an intra-articular process. Although aspiration prior to surgical debridement could be considered, the organism has already been identified from the blood culture, and CT guidance is not needed to locate this large abscess in such an accessible area.

Question 90

A 30-year-old man who sustained a work-related injury 6 weeks ago reports persistent back and left-sided buttock pain that has been attributed to lumbar transverse process fractures. A pelvic radiograph and CT scans obtained 2 days ago are seen in Figures 17a through 17c. What is the best treatment for his injury?

Explanation

DISCUSSION: Fortunately, surgical treatment of sub-acute pelvic ring injuries is relatively uncommon as acute management has become more common. Delayed reconstruction of pelvic ring malunion and impending malunion is rare. Nonsurgical management may have a role as long as the hemipelvis does not flex, shorten, and/or externally rotate. The AP pelvic radiograph suggests that all three motions are happening in this patient. These are just a few of the indications to repair the pelvic ring and this is best done with anterior and posterior fixation. Anterior symphyseal plating will help correct most of the deformity. Posterior fixation can and should be added to lessen the forces on the anterior ring reconstruction when repair is performed in a sub-acute or delayed fashion. Posterior fixation can help obtain a more anatomic reduction and helps decrease the risk of anterior hardware failure.
REFERENCES: Mears DC: Management of pelvic pseudarthroses and pelvic malunion. Orthopade 1996;25:441-448.
Matta JM, Dickson KF, Markovich GD: Surgical treatment of pelvic nonunions and malunions. Clin Orthop Relat Res 1996;329:199-206.
McLaren AC, Rorabeck CH, Halpenny J: Long-term pain and disability in relation to residual deformity after displaced pelvic ring fractures. Can J Surg 1990;33:492-494.

Question 91

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

Explanation

Anterior-inferior plate fixation of midshaft clavicular fractures has evolved to be an alternative plate location compared to superior plating. The advantages of anterior-interior plating are reduced prominence of the hardware compared to the subcutaneous superior plates; the potential for placement of longer screws as the clavicle is wider front to back than top to bottom, especially laterally; and a potential for decreased risk to the subclavian structures. A relative disadvantage of anterior-inferior plating is a need to detach a small portion of the deltoid origin. Union rates for anterior-inferior plating are similar to those with superior plating.

Question 92

Nutritional rickets in the US occurs more frequently in infants older than 6 months of age who do not receive vitamin D supplementation and are Review Topic

Explanation

Numerous reports suggest an increased frequency of nutritional rickets in the US in children with dark skin pigmentation who are breast fed past 6 months of age without vitamin D supplementation. Nutritional rickets is rare in light-skinned children or those who are formula fed.

Question 93

A 22-year-old man has mild hip pain bilaterally and multiple skeletal lesions. Based on the pelvic radiograph shown in Figure 30, what is the inheritance pattern for his disorder?

Explanation

DISCUSSION: Multiple hereditary exostoses (MHE) is an autosomal dominant disorder manifested by multiple osteochondromas and characteristic skeletal involvement. EXT1 on 8q24.1 and EXT2 on 11p13 are the two genes most strongly associated with MHE. Mutations in these genes affect proper development of endochondral bone, such that in all affected individuals exostoses develop adjacent to the growth plates of long bones, and some exhibit additional bone deformities. Defects in the EXT genes result in increased chondrocyte proliferation and delayed hypertrophic differentiation.
REFERENCES: Stieber JR, Dormans JP: Manifestations of hereditary multiple exostoses. J Am Acad Orthop Surg 2005;13:110-120.
Hilton MJ, Gutierrez L, Martinez DA, et al: EXT1 regulates chondrocyte proliferation and differentiation during endochondral bone development. Bone 2005;36:379-386.

Question 94

A 38-year-old woman has a lesion on her left foot that has increased in size over the past 6 months. The clinical photograph is shown in Figure 17a, and a photomicrograph of the biopsy specimen is shown in Figure 17b. What is the most likely diagnosis?

Explanation

DISCUSSION: Melanoma comprises 25% of lower extremity lesions and is the most common malignant tumor of the foot. The preferred treatment is wide resection.
REFERENCES: Hughes LE, Horgan K, Taylor BA, Laidler P: Malignant melanoma of the hand and foot: Diagnosis and management. Br J Surg 1985;72:811-815.
Fortin PT, Freiberg AA: Malignant melanoma of the foot and ankle. J Bone Joint Surg Am 1995;77:1396-1403.

Question 95

A 21-year-old basketball player inverts his foot during practice. Examination reveals obvious deformity of the hindfoot with a prominence of the talar head dorsolaterally and medial displacement of the forefoot. A radiograph is shown in Figure 17. What is the most likely obstacle to closed reduction?

Explanation

DISCUSSION: The patient has a medial subtalar dislocation. These injuries should be reduced as soon as possible to minimize risk to the skin. Most often, this can be done easily, and further radiographic evaluation then can be performed as necessary. On rare occasions, closed reduction is not possible because of fractures of the articular surface of the talus, navicular, interposed extensor digitorum brevis, or transverse fibers of the cruciate crural ligament. The posterior tibial tendon is the most common obstruction to closed reduction in lateral subtalar dislocations, which are less common than medial dislocations. The majority of both injuries can be managed by closed reduction and immobilization.
REFERENCES: Mulroy RD: The tibialis posterior tendon as an obstacle to reduction of a lateral anterior subtalar dislocation. J Bone Joint Surg Am 1953;37:859-863.
Heckman JD: Fractures and dislocations of the foot, in Rockwood CA, Green DP, Bucholz RW (eds): Fractures in Adults. Philadelphia, PA, JB Lippincott, 1991, pp 2093-2100.
Saltzman C, Marsh JL: Hindfoot dislocations: When are they not benign? J Am Acad Orthop Surg 1997;5:192-198.

Question 96

Figure 1 is the T2 axial MRI scan of a 21-year-old man who was injured while playing for his college football team. His pain was aggravated with blocking maneuvers and alleviated with rest, and he had to stop playing because of the pain. What examination maneuver most likely will reproduce his pain?

Explanation

This patient has a mechanism of injury and MRI scan consistent with a posterior labral tear and posterior instability. Flexion, adduction, and internal rotation produce a net posterior vector on the glenohumeral joint and should reproduce this patient's symptoms. Pain or instability with the arm elevated in the scapular plane describes an impingement sign. Pain or instability with the arm in external rotation and abduction describes the apprehension sign. Pain or instability with the arm in flexion and abduction is a nonspecific finding.

Question 97

A 35-year-old woman with type 1 diabetes mellitus has been treated for the past 2 years at a wound care center for persistent bilateral fifth metatarsal head ulcers. Management has consisted of shoe wear modifications, treatment with multiple enzymatic ointments, and a fifth metatarsal head resection on the left side. Physical examination reveals intact pulses, minimal ankle dorsiflexion, neutral hindfoot, and a persistent ulcer under the fifth metatarsal heads. What treatment will best help heal the ulcers?

Explanation

DISCUSSION: The patient likely has a significant Achilles contracture that causes her to always bear more weight on her forefoot. A gastrocnemius recession takes the ankle out of plantar flexion and she will be able to return to a normal gait and reduce the pressures on her forefoot. A forefoot amputation is a salvage option. The other choices are appropriate; however, the patient has had this problem for 2 years and she has already had multiple attempts at shoe wear modification.
REFERENCES: Laughlin RT, Calhoun JH, Mader JT: The diabetic foot. J Am Acad Orthop Surg 1995;3:218-225.
Aronow MS, Diaz-Doran V, Sullivan RJ, et al: The effect of triceps surae contracture force on plantar foot pressure distribution. Foot Ankle Int 2006;27:43-52.

Question 98

When performing a long fusion to the sacrum in an osteopenic patient in whom optimal sagittal balance is restored, which of the following is a benefit of extending the distal fixation to the pelvis, rather than the sacrum alone? Review Topic

Explanation

In osteopenic individuals, even those with excellent obtained or maintained balance, long instrumented fusions to the sacrum impart a high degree of strain, and the sacrum may fail in a transverse fracture or fracture-dislocation pattern. The risk of proximal functional kyphosis is unrelated to distal fixation as are coronal plane correction and rod contouring. Pubic ramus fractures have been shown to be associated with both fixation to the sacrum alone as well as to the ilium.

Question 99

At which joint do degenerative changes occur first in a patient with chronic, untreated scapholunate dissociation?

Explanation

EXPLANATION:
Stage I of scapholunate advanced collapse (SLAC) is characterized by the presence of radioscaphoid arthritis. A predictable pattern exists of the progression of degenerative changes for SLAC wrist, including stage I (radial styloid involvement at the scaphoid fossa), stage II (scaphoid and entire scaphoid facet involvement), stage III (degeneration between the capitate and lunate), and stage IV (pancarpal involvement). The radiolunate joint is often spared.

Question 100

Which of the following acetabular/femoral head components would be expected to show an optimal combination of linear and volumetric wear?

Explanation

The size of the femoral head and the calculated mean annual rate of volumetric wear has a significant relationship. Rate of volumetric wear was highest in assoc with 32 mm femoral lowest in assoc with 22 mm heads. The predominant mechanisms of wear of the polyethylene were abrasion and adhesions rather than fatigue-cracking or delamination on the subsurface. Decreased thickness of the polyethylene has an adverse effect on the rate of wear of the metal-backed components. Rate of linear wear is highest in assoc. with 22-mm heads and lowest in relation to 32-mm heads, so the optimal size of a femoral head should be 28 mm where there is minimal linear and volumetric wear.

Full Question & Answer Text (for Search Engines)

Question 1:

Which of the following patient factors is associated with recurrent radicular pain following lumbar diskectomy for sciatica?

Options:

Initial symptoms of more than 3 months’ duration
Large annular defects seen intraoperatively
Large sequestered disk herniations
Initial treatment with lumbar epidural steroid injections prior to diskectomy
Preoperative reproduction of sciatica with straight leg raising (SLR)

Correct Answer: Large annular defects seen intraoperatively

Explanation:

Question 2:

Options:

There is no significant difference between the infection rate for this fracture and a similar closed fracture.
Due to the risk of infection, open reduction and internal fixation is not recommended for this fracture.
The infection rate is three to five times more likely with this fracture.
Due to the risk of infection from a lateral approach, treatment is confined to limited internal fixation or an external fixator.
The patient will need to undergo 3 weeks of IV antibiotics at home.

Correct Answer: There is no significant difference between the infection rate for this fracture and a similar closed fracture.

Explanation:

DISCUSSION: Multiple authors have shown similar infection rates for grade 1 and 2 open medial fractures and closed fractures that have been treated with an extensile lateral approach and open reduction and internal fixation. Patients only need IV antibiotics for 2 to 3 days after surgery. Formal open reduction and internal fixation is not recommended for grade 3 medial wounds and most lateral wounds.
REFERENCES: Heier KA, Infante AF, Walling AK, et al: Open fractures of the calcaneus: Soft-tissue injury determines outcome. J Bone Joint Surg Am 2003;85:2276-2282.
Buckley RE, Tough S: Displaced intra-articular calcaneal fractures. J Am Acad Orthop Surg 2004;12:172-178.

Question 3:

Options:

Distal rerouting of the biceps tendon
Glenohumeral fusion with external rotation
External rotation osteotomy of the proximal humerus
Latissimus dorsi and teres major transfer to the posterior rotator cuff
Latissimus dorsi and teres major transfer to the subscapularis

Correct Answer: Latissimus dorsi and teres major transfer to the posterior rotator cuff

Explanation:

Question 4:

Options:

Urgent admission to the hospital for surgical intervention
Immediate MRI of the lumbar spine as an outpatient
Anti-inflammatory medications and activity modification
Caudal epidural steroid injection
Electromyography

Correct Answer: Anti-inflammatory medications and activity modification

Explanation:

Question 5:

Figure 36 shows the hip arthrogram of a newborn. Which of the following structures is enclosed by the circle?

Options:

Limbus
Pulvinar
Ligamentum teres
Transverse acetabular ligament
Acetabular labrum

Correct Answer: Acetabular labrum

Explanation:

DISCUSSION: The structure enclosed by the circle is the acetabular labrum. It is visible as the white point of tissue outlined by the darkly radiopaque contrast. The appearance of the contrast surrounding the sharp white point of a normal labrum is called the “rose thorn sign.” The limbus is the term reserved for a rounded, infolded labrum seen with arthrography. The pulvinar is the fatty tissue seen in the empty acetabulum when the hip is dislocated. The ligamentum teres is seen as a white stripe outlined by contrast coursing from the central acetabulum to the dislocated femoral head. The transverse acetabular ligament courses across the inferior portion of the acetabulum and is not clearly seen with arthrography.
REFERENCES: Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA,
WB Saunders, 2002, vol 1, pp 532-533.
Severin E: Contribution to the knowledge of congenital dislocation of the hip joint.
Acta Chir Scand 1941;84:1.

Question 6:

The Coleman block test is used to evaluate the cavovarus foot. What is the most important information obtained from this test?

Options:

Determines the patient’s ability to balance
Determines hindfoot flexibility
Determines forefoot flexibility
Assesses the patient for Achilles tendon contractures
Evaluates peroneus longus strength

Correct Answer: Determines hindfoot flexibility

Explanation:

Question 7:

03 Fig 51c. What laboratory finding is most likely associated with this disease entity?

Options:

acid fast bacilli
gram-positive cocci
translocation (9:22)
translocation (11:22)
mutation of the Rb gene back answer

Correct Answer: translocation (11:22)

Explanation:

The first question is what is it? The xray shows a mass in the leg with periosteal reaction in the fibula. The MRI shows a soft tissue mass arising from the fibula that looks aggressive. The path shows a bunch of small blue cells. The combination of small blue cells with a soft tissue mass and and onion skin appearance on xray in a patient in the 2
nd
decade of life has to scream Ewing’s sarcoma. 85% of Ewing’s sarcomas have the 11:22 translocation. None of the other answers are associated with Ewing’s.
Gibbs CP, Weber K, Scarborough MT: Malignant bone tumors. Inst Course Lect 2002;51:413-428
back to this question next question

Question 8:

Options:

Calcified transverse scapular ligament
Parsonage-Turner syndrome
Spinoglenoid notch cyst
Quadrilateral space syndrome

Correct Answer: Spinoglenoid notch cyst

Explanation:

Question 9:

Options:

a thumb spica cast and reassessment in 3 weeks.
a thumb spica cast and reassessment in 6 weeks.
repair of the ulnar collateral ligament of the MCP joint.
adductor pollicis advancement on the proximal phalanx.
repair of the MCP joint dorsal capsule.

Correct Answer: a thumb spica cast and reassessment in 3 weeks.

Explanation:

Question 10:

Options:

Immediate MRI of the lumbar spine
General reassurance, anti-inflammatory drugs, and an early home exercise program
Immediate radiographs of the lumbar spine and pain medications with 2 days of bed rest if the radiographs are normal
Office caudal epidural steroid injection with follow-up in 1 week
Outpatient MRI of the lumbar spine with follow-up in 1 week for test results

Correct Answer: Immediate MRI of the lumbar spine

Explanation:

DISCUSSION: Cauda equina syndrome is a medical emergency that must be quickly diagnosed and treated to avoid long-term complications. Cauda equina syndrome typically presents with low back pain, unilateral or usually bilateral sciatica, saddle sensory disturbances, bladder and bowel dysfunction, and variable lower extremity motor and sensory loss. Although a number of pathologies can cause cauda equina syndrome, in a patient with a history of chronic back pain, disk pathology is the most common cause of acute onset cauda equina syndrome. Whereas radiographs may be useful in a traumatic onset of symptoms, MRI is the most appropriate study. Cauda equina syndrome should be evaluated on an emergent basis and admission for work-up is appropriate.
REFERENCES: Ahn UM, Ahn NU, Buchowski JM, et al: Cauda equina syndrome secondary to lumbar disc herniation: A meta-analysis of surgical outcomes. Spine 2000;25:1515-1522.
Small SA, Perron AD, Brady WJ: Orthopedic pitfalls: Cauda equina syndrome. Am J Emerg Med 2005;23:159-163.

Question 11:

Options:

chemotherapy and surgery
chemotherapy only
surgery only
radiation and surgery
radiation only

Correct Answer: chemotherapy only

Explanation:

The histology shows "lacey" osteoid with minimal cellular atypia. This is consistent with low-grade intramedullary osteogenic sarcoma. Low grade central osteogenic sarcoma is an uncommon form of osteosarcoma that is characterized by a long premorbid history and is compatible with prolonged survival after treatment. Treatment is surgery with wide margins alone and chemotherapy and radiation are not indicated. Good local control is associated with an excellent long term survival.
Choong et al. reviewed the long term follow-up of 20 patients diagnosed with low grade osteogenic sarcoma and found the 5 year survival rate was 90% and at 10 years was 85%. Local recurrence is a key feature in most cases and is typically the result of inadequate surgical margins frequently arising from initial misdiagnosis. Although amputation generally is successful for primary and recurrent tumors, limb salvage surgery is a definite option.
Kurt et al reviewed 80 well-differentiated osteosarcomas. They found local excision was almost always associated with recurrence. Wide excision was
almost never followed by recurrence. The recurrent tumor was a high-grade, conventional osteosarcoma in 15% of the patients, and this was associated with a poor prognosis. They recommend wide excision as the treatment of choice for this very rare variant of osteosarcoma.
A 32-year-old male sustains a the injury shown in Figure A after a high-speed motor vehicle collision. Which factor has been found to have the highest direct correlation with severe heterotopic ossification after traumatic knee dislocation?
Injury Severity Score (ISS )
Glascow Coma Scale (GCS )
Timing of knee reconstruction
Number of ligaments reconstructed
Open ligament reconstruction
Figure A shows a knee dislocation with cruciate ligament avulsion injuries. Development of significant heterotopic ossification (HO) formation has been shown to be most directly correlated to the ISS score.
Mills and Tejwani looked at multiple variables including injury severity score
( ISS), Glascow coma scale (GCS), closed head injury (CHI), timing of surgery (> or < 3 weeks) and type of surgery (open vs. arthroscopic, number of ligaments reconstructed) in its relation to the formation of HO following knee dislocation. In the final group the sensitivity and specificity of the ISS in relation to HO formation was 100%, while presence of CHI had a specificity of 97 %. Timing, type of surgery and approach did not influence HO formation.
A 52-year-old male presents with 6 months of swelling and pain in his leg. He states the lesion has not changed in size for several months and doesn't bother him. He is otherwise healthy and has no other complaints. Representative photograph and MRI are shown in Figures A through C. What is the best initial step in his management?
Follow-up in 6 months with repeat radiographs
Biopsy
Marginal excision
Radiation therapy
Neoadjuvant chemotherapy and wide excision
The initial step in management of a patient presenting with a large soft tissue mass deep to the fascia is to obtain a tissue diagnosis, via biopsy. Initiation of treatment prior to tissue diagnosis is inappropriate and can result in significant patient morbidity and potential mortality. While some soft tissue sarcomas may benefit from chemotherapy, this cannot be initiated prior to diagnosis.
Radiation therapy is used in the treatment of soft tissue sarcoma, but again, only after tissue diagnosis. Peabody et al review the appropriate evaluation and staging for musculoskeletal neoplasms and present flow-charts useful in the work-up of bone (Illustration A) and soft tissue (Illustration B) neoplasms. Skrzynski et al performed a comparison of outpatient core-needle biopsy with open surgical biopsy for musculoskeletal tumors. They found the diagnostic accuracy of core-needle biopsy was only 84% with many samples yielding no or different histological samples when compared to final resected specimens. They conclude that while core-needle biopsy is significantly less expensive
than surgical biopsy ($1106 vs. $7234), there is higher concern for sampling error or general diagnostic inaccuracy associated with a core-needle biopsy compared to open biopsy, the "gold standard".
What is the appropriate treatment for a 10-year-old boy with Ewing's sarcoma isolated to the proximal femur?
Neoadjuvant chemotherapy and surgical excision
Neoadjuvant chemotherapy, surgical excision, and radiation therapy
Neoadjuvant chemotherapy, surgical excision, and adjuvant chemotherapy
Neoadjuvant radiation therapy and surgical excision
Surgical excision and hormonal therapy
Ewing's sarcoma is a malignant small round blue cell neoplasm which has a predilection for long tubular bones, pelvis, and ribs. The radiographic appearance of "onion-skinning" seen in illustrations A and B is due to the body's periosteal reaction. Illustration C shows the large soft tissue extraosseous mass characteristic for Ewing's sarcoma. Finally, Illustration D shows the histology where the multiple small round blue neoplastic cells are seen.
Ewing's sarcoma is most commonly treated with neoadjuvant chemotherapy, surgical excision, and adjuvant chemotherapy - in particular for tumors located in bones which can be easily resected and reconstructed. For large tumors in areas which either cannot be completely excised or where excision is associated with significant morbidity, some centers consider chemotherapy and radiation therapy without surgical excision. There is a current trend towards surgical resection and away from irradiation for Ewing's sarcoma even though it is radiosensitive, because of the risk of secondary malignancy and growth disturbance due to radiation.
Pierz et al review many of the common bone tumors including Ewing's sarcoma and discuss the relevant diagnostic factors as well as specific treatment protocols for each tumor.
A 30-year-old female presents with a painful posterior knee mass. The mass gets larger and more painful with activity. Examination reveals a boggy soft tissue mass about her knee. Radiograph and MRI are shown in Figures A and B. What is the most likely diagnosis?
Synovial sarcoma
Hemangioma
Lipoma
Parosteal osteosarcoma
Pigmented villonodular synovitis (PVNS )
This patients history, physical exam, and imaging studies are suggestive of a hemangioma. Pain in hemangiomas is thought to occur due to vascular engorgement secondary to activity and increased blood flow to the lesion. The calcification on the plain radiograph and the fat of the T1 MRI are diagnostic for hemangioma. Current treatment for symptomatic hemangiomas includes some combination of sclerotherapy or vascular coiling, with surgical excision
reserved for few cases. The two attached reviews by Gilbert et al and Damron et al review the history, diagnosis, treatment, and controversial issues in soft tissue sarcomas and benign sarcoma like conditions such as hemangiomas.
Current treatment for soft tissue sarcomas includes radiotherapy and surgical excision. While many centers in the world use chemotherapy for soft tissue sarcomas, the data supporting its use is quite limited and likely too controversial to be tested. With regard to the other answer choices, synovial sarcoma and lipoma can show calcification on radiographs, but they are usually not painful and image differently on T1 MRI. Parosteal osteosarcoma typically occurs in this location (posterior distal femur) but occurs as a lesion stuck on the bone. PVNS can have a similar appearance on imaging, but doesn't cause this type of pain.

Question 12:

Options:

tighten as the knee extends past 10° of flexion.
tighten as the knee flexes past 90°.
loosen as the knee extends past 10° of flexion.
loosen as the knee flexes past 30°.
loosen as the knee flexes past 90°.

Correct Answer: tighten as the knee flexes past 90°.

Explanation:

Question 13:

Options:

Wedge the cast to correct angulation.
Accept the present alignment and continue follow-up.
Perform open reduction and internal fixation of both the radius and ulna with plates and screws.
Perform open reduction and internal fixation of both the radius and ulna with intramedullary rods.
Remanipulate both the radius and ulna and stabilize with an external fixator.

Correct Answer: Accept the present alignment and continue follow-up.

Explanation:

Question 14:

What is the most likely contributory factor to this patient's problem?

Options:

Throwing curveballs
Year-round throwing
Poor calcium intake
Shoulder laxity

Correct Answer: Year-round throwing

Explanation:

Question 15:

Options:

MRI of the spinal axis
Physical therapy
A brace for scoliosis
Observation, with reevaluation in 6 to 12 months
Posterior spinal fusion from T6 to T12

Correct Answer: MRI of the spinal axis

Explanation:

DISCUSSION: The patient has an abnormal neurologic exam as shown by the abnormal abdominal reflexes. Furthermore, she has a significant curve and is younger than age 10 years. These findings are not consistent with idiopathic scoliosis. MRI will best rule out syringomyelia or an intraspinal tumor. Bracing and surgery are not indicated for this small curvature prior to obtaining an MRI scan.
REFERENCES: Ginsburg GM, Bassett GS: Back pain in children and adolescents: Evaluation and differential diagnosis. J Am Acad Orthop Surg 1997;5:67-78.
Schwend RM, Hennrikus W, Hall JE, et al: Childhood scoliosis: Clinical indications for magnetic resonance imaging. J Bone Joint Surg Am 1995;77:46-53.

Question 16:

This condition is most prevalent in people of which ancestry?

Options:

Northern European
Asian
Native American
Sub-Saharan African

Correct Answer: Native American

Explanation:

Question 17:

A 22-month-old girl has cerebral palsy. Which of the following findings is a good prognostic indicator of the child’s ability to walk in the future?

Options:

Asymmetric tonic neck reflex
Moro reflex
Extensor thrust
Positive parachute reaction
Absent foot placement

Correct Answer: Positive parachute reaction

Explanation:

DISCUSSION: For the parachute test, the examiner holds the child prone and then lowers the child rapidly toward the floor. The parachute reaction is normal or positive if the child reaches toward the floor. The Moro or startle reflex should not be present beyond age 6 months. Asymmetric tonic neck reflex, extensor thrust, and absent foot placement are abnormal findings at any age.
REFERENCES: Bleck EE: Orthopaedic Management in Cerebral Palsy. Lavenham, Suffolk, The Lavenham Press, 1987, pp 121-139.
Tachdjian MO: The neuromuscular system: Cerebral palsy, in Wickland EH Jr (ed): Pediatric Orthopaedics, ed 2. Philadelphia, PA, WB Saunders, 1990, vol 2, p 1621.

Question 18:

Elbow distraction interposition arthroplasty may be most appropriate treatment for which of the following patient profiles? Review Topic

Options:

year-old woman with destructive juvenile rheumatoid arthritis
year-old male laborer with posttraumatic arthritis of the elbow
year-old woman with distal humerus osteonecrosis and collapse
year-old man with painful primary elbow osteoarthritis
year-old sedentary woman with end-stage rheumatoid arthritis

Correct Answer: year-old male laborer with posttraumatic arthritis of the elbow

Explanation:

Question 19:

Which of the following increases radiation exposure to patients and personnel during surgery?

Options:

Orienting the beam in the opposite direction of the working team and keeping the team outside a 6-foot radius of the fluoroscopy machine
Orienting the cathode ray tube beneath the patient with the image intensifier receptor as close to the patient as possible
Limiting the beam on time to only what is clinically important
The use of continuous fluoroscopy whenever possible to ensure proper placement of implants
The use of lead glasses, a thyroid shield, and a lead apron with an equivalent lead thickness of 0.25 mm

Correct Answer: The use of continuous fluoroscopy whenever possible to ensure proper placement of implants

Explanation:

Question 20:

The direct anterior (Smith-Peterson) approach to hip arthroplasty is most commonly associated with injury to what nerve?

Options:

Lateral femoral cutaneous
Sciatic
Pudendal
Superior gluteal

Correct Answer: Lateral femoral cutaneous

Explanation:

Question 21:

Options:

The addition of a neck roll to the helmet and continuation of play
Electrodiagnostic studies
A series of epidural steroid injections, followed by a return to play
Methylprednisolone dose pack, followed by a return to play in 1 week
No further participation in football

Correct Answer: No further participation in football

Explanation:

DISCUSSION
: Cervical spinal stenosis is a contraindication to participation in collision and contact sports. Previously, the risks of permanent quadriparesis from cervical spinal stenosis were thought to be unclear and athletes with cervical spinal stenosis were often allowed to play contact sports. In 1996, Torg and associates reported that developmental narrowing of the cervical canal in a stable patient does not appear to predispose an individual to permanent catastrophic neurologic injury and therefore should not preclude an athlete from participation in contact sports. However, the current understanding is that the actual risks of permanent neurologic injury from cervical stenosis are significant. The Torg ratio was previously used for diagnosis but is more recently thought to be of low predictive value as reported by Cantu. Current methods for diagnosis of cervical spinal stenosis rely on MRI and CT. Current diagnosis is based on comparisons of measurements with normal values. A cervical canal of less than 13 mm is considered stenotic whereas a diameter of less than 10 mm is considered absolute stenosis as reported by Crowl and Kong. This patient has symptomatic stenosis and should not be cleared for contact sports. A neck roll will not prevent neurologic injury in the presence of cervical spinal stenosis. Electrodiagnostic studies are not likely to add any additional significant findings with central canal stenosis. Cervical traction is not of value in the long-term. Epidural steroid injections or a methylprednisolone dose pack are not of value in this situation.
REFERENCES: Torg JS, Naranja RJ Jr, Pavlov H, et al: The relationship of developmental narrowing of the cervical spinal canal to reversible and irreversible injury of the cervical spinal cord in football players. J Bone Joint Surg Am 1996;78:1308-1314.
Cantu RC: The cervical spinal stenosis controversy. Clin Sports Med 1998;17:121-126. Crowl AC, Kong JF: Cervical Spine, in Johnson DL, Mair SD (eds): Clinical Sports Medicine. Philadelphia, PA, Mosby Elsevier, 2006, pp 143-149.

Question 22:

Options:

Completion of the tear from the bursal surface and rotator cuff repair
Arthroscopic long head biceps tenotomy
Arthroscopic glenohumeral synovectomy
Arthroscopic tendon debridement and subacromial decompression
Transtendinous rotator cuff repair

Correct Answer: Arthroscopic tendon debridement and subacromial decompression

Explanation:

Question 23:

- A 32-year-old man has swelling of the knee as a result of falling with the knee flexed and his foot in plantar flexion. A Lachman’s test reveals an apparent increase in anterior translation. Passive external tibial rotation at 30 degrees and 90 degrees is equal to the contralateral side, and the quadriceps active test is positive on the affected side. The neurovascular examination is normal. Treatment should consist of

Options:

An anterior cruciate functional knee brace.
A physical therapy program.
Reconstruction of the posterior cruciate ligament and the posterolateral corner.
Reconstruction of the posterior cruciate ligament.
Reconstruction of the anterior cruciate ligament.

Correct Answer: A physical therapy program.

Explanation:

Question 24:

A patient sustains a severe lower extremity injury. What can be said about his outcome at 2 years if he chooses reconstruction over amputation?

Options:

He has a higher risk of rehospitalization
He has a higher chance of returning to work
He will have a higher overall SIP (Sickness Impact Profile) score
His psychosocial SIP score will improve with time
He will have a better SIP score if he did not complete high school

Correct Answer: He has a higher risk of rehospitalization

Explanation:

Question 25:

Options:

History and physical examination
Ultrasonography
MRI
Radiographs
Nerve conduction velocity studies

Correct Answer: History and physical examination

Explanation:

Question 26:

Options:

Osteomyelitis
Langerhan’s cell histiocytosis
Ewing’s sarcoma
Lymphoma
Neuroblastoma

Correct Answer: Langerhan’s cell histiocytosis

Explanation:

DISCUSSION: Langerhans cell histiocytosis or eosinophilic granuloma is a nonneoplastic lesion that is part of a spectrum of clinical diseases featuring histiocytes. Most occur during the first two decades of life within any bone. Radiographs show a radiolucent lesion, frequently diaphyseal in location. A periosteal response is occasionally seen and can resemble more aggressive lesions such as osteomyelitis or Ewing’s sarcoma. Histology demonstrates CD1a positive histiocytes with large oval-shaped nuclei with indentation, and a variable presence of eosinophils.
REFERENCES: Plasschaert F, Craig C, Bell R, et al: Eosinophilic granuloma: A different behaviour in children than in adults. J Bone Joint Surg Br 2002;84:870-872.
Campanacci M: Bone and Soft Tissue Tumors, ed 2.
New York, NY, Springer-Verlag, 1999, pp 857-876.

Question 27:

Which of the following statements most accurately describes the layers of articular cartilage?

Options:

The superficial zone has condensed proteoglycan and sparse collagen.
The intermediate zone transition is the thinnest layer and the chondrocytes are oriented tangentially.
The basal zone (middle, radial, deep) contains flattened chondrocytes.
Tidemark is found only in joints and not in the growing cartilage cap of an enchondroma.
Tidemark is more prominent in newborn joints.

Correct Answer: Tidemark is found only in joints and not in the growing cartilage cap of an enchondroma.

Explanation:

Question 28:

Options:

Rest, ice, nonsteroidal anti-inflammatory drugs, activity as tolerated, and follow-up in 4 weeks
Coaptation splinting and follow-up in 4 weeks
Surgical replacement with hemiarthroplasty or reverse total shoulder arthroplasty
Physical therapy for range-of-motion exercises
Closed reduction, splinting, and follow-up in 4 weeks

Correct Answer: Surgical replacement with hemiarthroplasty or reverse total shoulder arthroplasty

Explanation:

Question 29:

Options:

notification of child protective services and hospital admission.
a punch biopsy of skin for collagen analysis.
DNA testing for OI.
calcium, phosphate, and alkaline phosphatase studies.
placement of intramedullary rods to prevent further fractures.

Correct Answer: notification of child protective services and hospital admission.

Explanation:

Question 30:

Options:

Percutaneous CT guided aspiration, hard cervical orthosis until bony union.
Percutaneous CT guided aspiration, hard cervical orthosis, repeat aspiration at 6-12 weeks followed by anterior corpectomy and fusion if repeat aspiration is sterile.
Anterior cervical debridement and anterior corpectomy without instrumentation
Posterior cervical debridement and instrumented posterior fusion.
Anterior cervical debridement, corpectomy and fusion followed by a posterior instrumented stabilization procedure

Correct Answer: Posterior cervical debridement and instrumented posterior fusion.

Explanation:

Question 31:

What is the most likely type of pathology seen in Figure 16?

Options:

Tumor
Infection
Inflammatory
Congenital
Trauma

Correct Answer: Tumor

Explanation:

Question 32:

What structure is most at risk for injury from a retractor against the tracheoesophageal junction during an anterior approach to the cervical spine?

Options:

Esophagus
Trachea
Superior laryngeal nerve
Recurrent laryngeal nerve
Sympathetic chain

Correct Answer: Recurrent laryngeal nerve

Explanation:

DISCUSSION: Although any of these structures can be injured by pressure from the medial blade of a self-retaining retractor, the recurrent laryngeal nerve runs cephalad in the interval between the esophagus and trachea and is vulnerable to pressure if caught between the retractor and an inflated endotracheal tube balloon.
REFERENCES: Ebraheim NA, Lu J, Skie M, et al: Vulnerability of the recurrent laryngeal nerve in the anterior approach to the lower cervical spine. Spine 1997;22:2664-2667.
Kilburg C, Sullivan HG, Mathiason MA: Effect of approach side during anterior cervical discectomy and fusion on the incidence of recurrent laryngeal nerve injury. J Neurosurg Spine 2006;4:273-277.

Question 33:

What is the most common cause of the new onset of amenorrhea in a female endurance athlete who is not sexually active?

Options:

Insufficient caloric intake
Physical stress
Use of oral contraceptives
Diabetes mellitus
Chromosomal abnormalities

Correct Answer: Insufficient caloric intake

Explanation:

Question 34:

Options:

Ask the nurse to call the medical director
Ask the surgeon to revisit the surgical safety checklist
Assume the booking form was incorrect and proceed with the operation
Leave the operating room to ask a family member
Read the last clinical note for clarification

Correct Answer: Ask the nurse to call the medical director

Explanation:

Question 35:

The tibiofibular overlap used to diagnose syndesmotic diastasis on an AP view is most commonly measured between the

Options:

lateral border of the fibula and the medial border of the posterior tibial tubercle.
medial border of the fibula and the lateral border of the posterior tibial tubercle.
medial border of the fibula and the medial border of the deepest point of the incisura fibularis.
medial border of the fibula and the lateral border of the anterior tibial tubercle.
medial border of the fibula and the lateral border of the deepest point of the incisura fibularis.

Correct Answer: medial border of the fibula and the lateral border of the anterior tibial tubercle.

Explanation:

Question 36:

In a patient with a C5-6 herniation, the most likely sensory deficit will be in the

Options:

lateral shoulder.
radial forearm, thumb, and index finger.
dorsal forearm and middle finger.
ulnar forearm, ring finger, and little finger.
volar forearm and palm.

Correct Answer: radial forearm, thumb, and index finger.

Explanation:

Question 37:

When reconstructing the anterior cruciate ligament (ACL) with autograft, what is the most common source of surgical failure?

Options:

Graft choice
Tunnel position
Tibial fixation
Femoral fixation

Correct Answer: Tunnel position

Explanation:

Question 38:

The optimal method with which to diagnose component malrotation in total knee arthroplasty (TKA) is

Options:

clinical assessment of foot position and patellar tracking.
radiographic skyline view of the patella.
CT scan with metal artifact suppression.
MR imaging with metal artifact reduction sequences.

Correct Answer: CT scan with metal artifact suppression.

Explanation:

DISCUSSION
The epicondylar axis and tibial tubercle can be used as references on CT scans to quantitatively measure rotational alignment of the femoral and tibial components. This technique has been used to determine whether rotational malalignment is present and whether revision of 1 or both components may be indicated. Although clinical assessment is useful, malrotation can occur as a result of deformities unrelated to the arthroplasty. Similarly, an isolated radiographic skyline view of the patella may indicate a problem with patellar maltracking, but cannot quantitatively assess malrotation of the components. MR imaging proves useful for evaluating painful TKA, but it is dependent on the center’s quality and has not yet been shown to quantify component malrotation.
CLINICAL SITUATION FOR QUESTIONS 20 THROUGH 22
Figures 20a and 20b are the radiographs of an elderly woman who underwent total knee arthroplasty (TKA) several years ago. She now states that something is not right; her knee frequently swells and is diffusely painful, especially at the end of the day. She does not trust her knee, especially while going up and down stairs or getting up from a chair.

Question 39:

Options:

Chondrosarcoma
Chordoma
Metastatic renal cell carcinoma
Metastatic breast cancer
Infection

Correct Answer: Chordoma

Explanation:

Question 40:

Deep anterior compartment

Options:

Anterior compartment
Compartment syndrome is most commonly missed in the deep posterior compartment. Like the anterior compartment, the deep posterior compartment is enveloped in fascia and is immediately adjacent to the tibia; however, the deep posterior compartment is more difficult to clinically assess secondary to its deep location. Associated findings include pain with passive extension of the toes and plantar foot numbness.
Compartment syndrome involving the superficial posterior compartment, lateral compartment, and anterior compartment is easy to detect because it is readily palpable on examination.
There is no deep anterior compartment in the leg.

Correct Answer: Compartment syndrome is most commonly missed in the deep posterior compartment. Like the anterior compartment, the deep posterior compartment is enveloped in fascia and is immediately adjacent to the tibia; however, the deep posterior compartment is more difficult to clinically assess secondary to its deep location. Associated findings include pain with passive extension of the toes and plantar foot numbness.

Explanation:

How many compartments exist in the foot:

Question 41:

Options:

Inferior gluteal
Medial femoral circumflex
Lateral femoral circumflex
Femoral

Correct Answer: Lateral femoral circumflex

Explanation:

Question 42:

Options:

Enchondroma
Osteochondroma
Chondroblastoma
Ewing’s sarcoma
Chondrosarcoma

Correct Answer: Osteochondroma

Explanation:

Question 43:

A 3-year-old patient with L3 myelomeningocele has bilateral dislocated hips. Management should consist of

Options:

observation.
bilateral open reduction.
bilateral open reduction and psoas transfers.
bilateral open reduction and external oblique transfers.
bilateral valgus osteotomies.

Correct Answer: observation.

Explanation:

Question 44:

Deep posterior compartment

Options:

Anterior tibial artery
Posterior tibial artery
Superficial peroneal nerve
Deep peroneal nerve

Correct Answer: Posterior tibial artery

Explanation:

Question 45:

Ceramic bone substitutes have which of the following properties?

Options:

There is vascular ingrowth and subsequent graft resorption with host bone ingrowth.
Their interconnectivity is similar to that of cancellous bone.
They are brittle with significant tensile strength.
They are resorbed at a fairly constant rate.
Due to their strength, rigid stabilization of the surrounding bone is not necessary.

Correct Answer: There is vascular ingrowth and subsequent graft resorption with host bone ingrowth.

Explanation:

Question 46:

Options:

Spiral fracture pattern
Low-energy mechanism
Amount of shortening
Fracture of the fibula at a different level
Ipsilateral femoral fracture

Correct Answer: Ipsilateral femoral fracture

Explanation:

DISCUSSION: All the factors listed, with the exception of an ipsilateral femoral fracture, are representative of a low-energy stable tibial shaft fracture that will do well with closed reduction and immobilization in a long leg cast, followed by weight bearing as tolerated and then a functional brace or patellar tendon bearing cast until union is achieved. Shortening will not increase from that seen on these initial radiographs. The spiral fracture provides a broad surface for healing, and the fibular fracture at another level indicates a stable soft-tissue envelope which, with the immobilization device, will stabilize the fracture reduction. An ipsilateral femoral fracture is a strong indication to surgically stabilize both fractures.
REFERENCES: Trafton PG: Tibial shaft fractures, in Browner BD (ed): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 2153-2169.
Martinez
A, Sarmiento A, Latta LL: Closed fractures of the proximal tibia treated with a functional brace. Clin Orthop 2003;417:293-302.

Question 47:

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

Options:

osteolysis.
fatigue failure of the implant.
failure of bone ingrowth.
wear debris from cerclage wire.
trochanteric impingement.

Correct Answer: failure of bone ingrowth.

Explanation:

DISCUSSION: The femoral construct shown in the radiograph has failed to produce ingrowth of the stem. The stem has subsided and rotated. Impingement of the trochanter did not occur until after the stem subsided. There is no evidence of osteolysis or third-body wear debris from the cerclage wire. A larger femoral stem needs to be implanted to achieve rigid fixation.
REFERENCES: Pelicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update:
Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 217-238.
Peter CL, Rivero DP, Kull LR, et al: Revision total hip arthroplasty without cement: Subsidence of proximally porous-coated femoral components. J Bone Joint Surg Am 1995;77:1217-1226.

Question 48:

Options:

higher incidence of patellar clunk and similar implant survivorship.
higher incidence of patellar clunk and superior implant survivorship.
lower incidence of patellar clunk and superior implant survivorship.
lower incidence of patellar clunk and similar implant survivorship. The images show a left posterior stabilized knee prosthesis and a right cruciate sacrificing (ultracongruent / dished type) knee prosthesis. Posterior stabilized designs have a risk of patellar clunk due to the presence of the femoral box with some designs, such as the one shown, exhibiting higher rates. Clinical outcomes are similar between cruciate-retaining, cruciate- sacrificing and posterior stabilized designs.

Correct Answer: higher incidence of patellar clunk and similar implant survivorship.

Explanation:

Question 49:

Options:

Quicker return to activities
Quicker return to work
Increased subtalar joint range of motion
Decreased risk of nonunion
Decreased risk of posttraumatic arthritis

Correct Answer: Decreased risk of posttraumatic arthritis

Explanation:

DISCUSSION: The radiographs and CT scans show a displaced intra-articular calcaneal fracture, with loss of calcaneal height and length. Recent multicenter, randomized, prospective studies suggest that surgical treatment of displaced intra-articular calcaneal fractures is associated with an almost six-fold decrease in the risk of posttraumatic subtalar arthritis (necessitating subtalar arthrodesis) compared to nonsurgical treatment. Despite ongoing controversy, surgical treatment has not been shown to be advantageous with respect to activity, time to return to work, or subtalar joint range of motion. A nonunion of a calcaneal fracture is exceedingly rare regardless of the treatment method.
REFERENCES: Buckley R, Tough S, McCormack R, et al: Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: A prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2002;84:1733-1744.
Csizy M, Buckley R, Tough S, et al: Displaced intra-articular calcaneal fractures: Variables predicting late subtalar fusion. J Orthop Trauma 2003;17:106-112.

Question 50:

A diskectomy is performed in which the disk space is not aggressively debrided. When compared to techniques that involve aggressive debridement of the disk space, this results in

Options:

less intraoperative blood loss.
an increased rate of recurrent disk herniation.
a shorter length of hospital stay.
a higher rate of surgical complications.

Correct Answer: an increased rate of recurrent disk herniation.

Explanation:

DISCUSSION
This patient has disk herniation at the left L5-S1 level. This will generally affect the traversing S1 nerve. The S1 dermatome is on the lateral aspect and sole of the foot.
Surgical treatment generally involves a diskectomy with removal of the herniated fragment. This can be performed via a conventional open approach or minimally invasive endoscopic technique. Several recent meta-analyses have demonstrated equivalent outcomes with regard to leg pain and clinical outcomes. Although minimally invasive techniques have been associated with an increased rate of dural tear, the overall complication rate between the 2 techniques is not significantly different. Several studies have demonstrated a substantial learning curve associated with minimally invasive techniques, and the rate of complications decreases significantly with surgeon experience.
When performing a diskectomy, the herniated fragment alone can be removed (sequestrectomy) or some of the disk that remains in the disk space can be removed (complete diskectomy). Studies have shown no change in surgical time, blood loss, length of stay, or surgical complications when performing a sequestrectomy (compared to a more complete diskectomy). A sequestrectomy is associated with a higher rate of recurrent disk herniation at the surgical level.
RECOMMENDED READINGS
Kamper SJ, Ostelo RW, Rubinstein SM, Nellensteijn JM, Peul WC, Arts MP, van Tulder MW. Minimally invasive surgery for lumbar disc herniation: a systematic review and meta-analysis.
Eur Spine J. 2014 May;23(5):1021-43. doi: 10.1007/s00586-013-3161-2. Epub 2014 Jan 18.
PubMed PMID: 24442183.
View Abstract at PubMed
Dasenbrock HH, Juraschek SP, Schultz LR, Witham TF, Sciubba DM, Wolinsky JP, Gokaslan ZL, Bydon A. The efficacy of minimally invasive discectomy compared with open discectomy: a meta-analysis of prospective randomized controlled trials. J Neurosurg Spine. 2012 May;16(5):452-62. doi: 10.3171/2012.1.SPINE11404. Epub 2012 Mar 9. PubMed PMID:

Question 51:

Options:

Midsubstance tear of the lateral ulnar collateral ligament
Proximal avulsion of the ulnar collateral ligament
Proximal avulsion of the lateral ulnar collateral ligament
Distal bony avulsion of the ulnar collateral ligament from the sublime tubercle

Correct Answer: Proximal avulsion of the lateral ulnar collateral ligament

Explanation:

Question 52:

Options:

Increased wettability
Increased hardness
Increased fracture toughness
Decreased surface roughness
Lower coefficient of friction

Correct Answer: Increased fracture toughness

Explanation:

DISCUSSION: Alternative bearing surfaces in THA have received much attention in recent years as more and more hip arthroplasties are being performed on younger patients with hip arthritis. The two most popular nonmetal-on-polyethylene bearing surfaces are metal-on-metal and ceramic-on-ceramic. There are arguments supporting the use of either, but ceramic bearings have been shown to have a theoretic increased risk of fracture compared with cobalt-chromium. This has been shown to be clinically relevant with zirconium ceramics. Newer alumina ceramics are being produced with lower porosity and grain size and with higher density and purity, resulting in lower fracture risk but still greater than that of cobalt-chromium.
REFERENCES: Heisel C, Silva M, Schmalzried TP: Bearing surface options for total hip replacement in young patients. Instr Course Lect 2004;53:49-65.
D’Antonio J, Capello W, Manley M, et al: New experience with alumina-on-alumina ceramic bearings for total hip arthroplasty. J Arthroplasty 2002;17:390-397.

Question 53:

After humeral head replacement for four-part fractures, what is the most commonly reported difficulty?

Options:

Pain
Inability to carry 10 lb at the side
Inability to wash the opposite axilla
Reaching to the back pocket
Working at shoulder level or above

Correct Answer: Working at shoulder level or above

Explanation:

Question 54:

An olecranon fracture-dislocation of the elbow in which the fracture line exits distal to the coronoid process is best managed by open reduction and

Options:

tension band wire fixation of the olecranon.
plate fixation of the olecranon.
elbow bridging external fixation
transarticular Kirschner wire fixation.
cast immobilization.

Correct Answer: plate fixation of the olecranon.

Explanation:

DISCUSSION: Fracture-dislocations of the elbow present difficult management problems. Standard olecranon fractures normally are not associated with a dislocation; however, the surgeon needs to recognize that some fractures that have a dislocation, in particular a posterior dislocation, represent a Monteggia equivalent. These injuries are not ulnar shaft fractures because they are fractured at or just distal to the coronoid; however, because of the unstable fracture-dislocation, the forces across this reduction are high. Two Kirschner wires and a tension band wire provide inadequate fixation. Therefore, the preferred method of fixation is plate osteosynthesis with a 3.5-mm low-contact dynamic compression plate or reconstruction plate.
REFERENCES: Jupiter JP, Kellam JF: Fractures of the forearm, in Browner BD, Jupiter JP, Levine AM, Trafton P (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998,
pp 421-454.
Quintero J: Fracture of the forearm, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 323-337.
Jupiter JB, Leibovic SJ, Ribbans W, Wilk RM: The posterior Monteggia lesion. J Orthop Trauma 1991;5:395-402.

Question 55:

Options:

Nail dynamization
Hardware removal, correction of alignment with a Taylor spatial frame, insertion of bone autograft
Exchange unreamed nailing with a longer, larger implant
Augmentative plate fixation without nail removal, insertion of bone autograft
Hardware removal, correction of alignment, plate fixation, insertion of bone autograft

Correct Answer: Hardware removal, correction of alignment, plate fixation, insertion of bone autograft

Explanation:

This patient has atrophic non-union (NU) and varus collapse following cephalomedullary nailing of a subtrochanteric fracture. The ideal treatment involves nail removal, correction of alignment, fracture fixation, and bone grafting. Fixation can be achieved with a nail or plate.
Subtrochanteric fractures can be treated with cephalomedullary nailing or fixed angle plates. Nailing of these fractures is technically challenging because the fracture must be reduced prior to nail passage. Failure to do so leads to varus and procurvatum malreduction.
Bellabarba et al. reviewed plating of femoral nonunions after intramedullary nailing. Of 23 nonunions, 21 healed at an average of 12 weeks. The remaining 2 cases required repeat plating (at 2 and 8 weeks) for hardware breakage because of noncompliance with weightbearing restrictions. They advocate plating because it allows for correction of malalignment and provides a biomechanically superior tension band construct.
Incorrect Answers:
(SBQ12TR.48) A 28-year-old male college student sustains a severe foot injury from gunshot-related violence, and subsequently undergoes a lower-extremity amputation
as shown in Figure A. At long-term follow-up, which of the following is the strongest predictor of patient satisfaction as related to his injury?
Age less than 30
Marijuana use
Use of negative pressure wound therapy
Male gender
Ability to return to work
The strongest factor to predict patient-reported outcomes after trauma-related lower extremity amputations is the patient's ability to return to work. This is likely due to the effect of the return to work on the physical, emotional, and financial aspects of the patient's life.
The LEAP study is a multicenter, prospective study evaluating multiple aspects of reconstruction versus amputation in the treatment of mangled extremity injuries. With regard to patient satisfaction, treatment variables such as decision for reconstruction versus amputation, or initial presence or absence of plantar sensation have little impact. In addition, demographic factors such as age, gender, socioeconomic status, and education level do not predict patient satisfaction. Instead, the most important predictors of patient satisfaction at 2 years after injury include the ability to return to work, absence of depression, faster walking speed, and decreased pain.
O'Toole et al reviewed 463 patients treated for limb-threatening lower-extremity injuries and identified factors associated with patient reported outcomes two years after surgery. They found that return to work was the most associated with outcomes, but that physical functioning, walking speed, pain levels, and presence of depression were also associated to a lesser extent with outcomes.
Bosse et al performed a multicenter, prospective study to assess outcomes of 569 patients with severe lower extremity limb injuries that resulted in either amputation or
limb salvage procedures. They found that at two years postoperatively, no significant differences were seen between groups in patient-reported outcome. Worse outcomes were associated with rehospitalization for a major complication, a low educational level, nonwhite race, poverty, lack of private health insurance, poor social-support network, low self-efficacy (the patient's confidence in being able to resume life activities), and involvement in disability-compensation litigation.
Figure A shows a clinical photograph of a Pirigoff amputation at early follow-up. This amputation is an end-bearing amputation that utilizes the plantar heel pad for weightbearing, and relies on a tibiocalcaneal arthrodesis.
Incorrect Answers:
1-4: These options are not as strong of a factor of patient satisfaction in long-term follow up after trauma-induced lower extremity amputation.

Question 56:

In the treatment of ankle fractures, the superficial peroneal nerve is most commonly injured by

Options:

a posterior-lateral approach.
a lateral approach.
a medial approach.
an anterior-medial approach.
rigid cast immobilization.

Correct Answer: a lateral approach.

Explanation:

Question 57:

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 58:

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

Options:

Long thoracic nerve
Spinal accessory nerve
Thoracodorsal nerve
Lower trunk of the brachial plexus
Posterior cord of the brachial plexus

Correct Answer: Long thoracic nerve

Explanation:

Question 59:

Options:

acute and transient spinal cord injury.
central cord syndrome.
nerve root avulsion.
Guillain-Barre syndrome.
stinger/burner.

Correct Answer: stinger/burner.

Explanation:

Question 60:

Options:

resection of the coalition with fat graft interposition.
Grice extra-articular subtalar arthrodesis.
subtalar arthroereisis.
intra-articular subtalar fusion.
medial sliding calcaneal osteotomy.

Correct Answer: resection of the coalition with fat graft interposition.

Explanation:

DISCUSSION: The CT scan is an important test to help determine the extent of involvement of the talocalcaneal facet in a talocalcaneal coalition. In a young patient with no arthritis and joint involvement of less than 50%, resection of the coalition and fat pad interposition has been shown to be successful. A calcaneal osteotomy does not address the coalition. Subtalar arthroereisis has been used for treatment of a flexible flatfoot; tarsal coalition patients have a rigid-type flatfoot deformity.
REFERENCES: Sullivan JA: The child’s foot, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 2, pp 1077-1135.
Scranton
PE
Jr: Treatment of symptomatic talocalcaneal coalition. J Bone Joint Surg Am 1987;69:533-539.

Question 61:

- An infected total knee replacement with symptoms occurring within 4 weeks of surgery and no radiographic signs of osteomyelitis would be best managed with

Options:

Knee fusion
Open irrigation and debridement
Arthroscopic irrigation and debridement
One-stage exchange arthroplasty
Two-stage exchange arthroplasty

Correct Answer: Open irrigation and debridement

Explanation:

Question 62:

- A 13-year-old quarterback feels a “pop” in his knee while being tackled. Radiographs of the knee and results of a Lachman’s test are normal. Examination reveals tenderness over the distal femoral physis. To help confirm the diagnosis, management should first include

Options:

an MRI scan
arthroscopic examination
AP and frog-lateral radiographs of the pelvis and hips
varus and valgus stress radiographs of the knee
physical examination of the knee under anesthesia

Correct Answer: varus and valgus stress radiographs of the knee

Explanation:

Question 63:

Options:

Infection
Patellar instability
Aseptic loosening
Progression of tibiofemoral arthritis

Correct Answer: Progression of tibiofemoral arthritis

Explanation:

Question 64:

Options:

exploration and neurolysis/repair.
MRI of the arm.
functional electrical stimulation.
radial nerve tendon transfers.
observation.

Correct Answer: observation.

Explanation:

DISCUSSION: In patients with radial nerve injuries with closed humeral fractures, it has been reported that 85% to 95% spontaneously recover. Based on this premise, most surgeons favor expectant management of these injuries. Even if there is no evidence of recovery at 6 weeks, repeat electromyography at 12 weeks is advocated. If there is no clinical or electromyographic signs of recovery at 6 months, exploration is recommended. If the nerve is in continuity at the time of exploration, nerve action potentials are useful in helping determine the need for neurolysis, excision, and grafting, or if excision and repair is the best option.
REFERENCES: Pollock FH, Drake D, Bovill EG, et al: Treatment of radial neuropathy associated with fractures of the humerus. J Bone Joint Surg Am 1981;63:239-243.
Mohler LR, Hanel DP: Closed fractures complicated by peripheral nerve injury. J Am Acad Orthop Surg 2006;14:32-37.

Question 65:

Options:

Running mileage during the 2 months prior to basic training
Self-rated fitness
Running frequency during the 2 months prior to basic training
No menstrual bleeding during the year prior to basic training
Race/ethnicity

Correct Answer: No menstrual bleeding during the year prior to basic training

Explanation:

Question 66:

Options:

case series.
case-control study.
cohort study.
randomized clinical trial.

Correct Answer: case series.

Explanation:

Question 67:

Options:

An arteriogram to evaluate the brachial artery
Open exploration and repair of the brachial artery
Pin removal to rereduce the fracture
Additional splinting and continued observation in the hospital

Correct Answer: Additional splinting and continued observation in the hospital

Explanation:

Question 68:

A 10-year-old boy with a history of retinoblastoma now reports right knee pain. AP and lateral radiographs are shown in Figures 3a and 3b. What is the most likely diagnosis?

Options:

Ewing’s sarcoma
Primitive neuroectodermal tumor
Osteosarcoma
Osteonecrosis
Osteomyelitis

Correct Answer: Osteosarcoma

Explanation:

Question 69:

Options:

Lunocapitate, radioscaphoid, radial styloid, radiolunate
Radioscaphoid, radial styloid, lunocapitate, radiolunate
Radial styloid, radioscaphoid, lunocapitate, radiolunate
Radial styloid, radioscaphoid, radiolunate, lunocapitate

Correct Answer: Radial styloid, radioscaphoid, lunocapitate, radiolunate

Explanation:

Question 70:

Figure 7 shows the CT scan of a 22-year-old professional baseball pitcher who has had elbow pain for the past 6 months despite rest from throwing. Management should consist of Review Topic

Options:

cast immobilization for 6 weeks.
brief immobilization followed by rest for 6 weeks.
internal fixation with a compression screw.
internal fixation with a tension band wire.
bone stimulation.

Correct Answer: internal fixation with a compression screw.

Explanation:

Question 71:

At the time of revision knee arthroplasty, a surgeon performs a rectus snip to gain exposure to the knee. When compared to a standard parapatellar approach, what is the expected outcome?

Options:

Improvement in range of motion
Reduction in range of motion
Increase in extensor mechanism lag
No differences in motion and strength

Correct Answer: No differences in motion and strength

Explanation:

DISCUSSION
Rectus snip during total knee arthroplasty has no effect on motion or strength at long-term follow-up. It has not been associated with extensor mechanism lag.
RESPONSES FOR QUESTIONS 58 THROUGH 62
Nerve palsy
Skin necrosis
Flexion instability
Patellar instability
Anterior knee pain
Malalignment
Total knee arthroplasty (TKA) is performed to address each condition shown in Figures 58 through 62b. Which complication is most commonly associated with each image?

Question 72:

Which of the following is not a cause of childhood osteomalacia (rickets)?

Options:

Vitamin D deficiency
Renal osteodystrophy
X-linked hypophosphatemia
Vitamin D malabsorption
Vitamin K deficiency

Correct Answer: Vitamin K deficiency

Explanation:

Question 73:

Options:

Epinephrine
Bisoprolol
Bupivacaine
Fentanyl
Rocuronium

Correct Answer: Bisoprolol

Explanation:

Question 74:

Options:

Radiographs of the hand
Radiographs of the cervical spine
Electrodiagnostic studies of the affected upper extremity
Surgical exploration of the extensor tendon ruptures
MRI of the elbow

Correct Answer: Electrodiagnostic studies of the affected upper extremity

Explanation:

Question 75:

The modified Judet approach to the posterior scapula exploits the internervous interval between what two muscles?

Options:

Supraspinatus and infraspinatus
Supraspinatus and subscapularis
Infraspinatus and teres minor
Terers minor and teres major
Teres major and lattisimus

Correct Answer: Supraspinatus and infraspinatus

Explanation:

Question 76:

Chemotherapy is routinely included in the treatment of which of the following soft-tissue sarcomas?

Options:

Angiosarcoma
Malignant fibrous histiocytoma
Liposarcoma
Rhabdomyosarcoma
Clear cell sarcoma

Correct Answer: Rhabdomyosarcoma

Explanation:

Question 77:

Options:

Anterior shoulder instability
Early adhesive capsulitis
Internal impingement
Subacromial impingement
Full-thickness rotator cuff tear

Correct Answer: Internal impingement

Explanation:

Question 78:

Options:

Home exercise program
Sling at all times until her pain decreases
Closed manipulation under anesthesia
Arthroscopic rotator cuff repair
Arthroscopic anterior and posterior capsular release

Correct Answer: Home exercise program

Explanation:

Question 79:

For a patient with a type II odontoid fracture, which of the following factors best predicts the development of a nonunion with nonsurgical management? Review Topic

Options:

Frontal oblique pattern
Magnitude of fracture displacement
Degree of posterior angulation
Age
Patient history of diabetes mellitus

Correct Answer: Magnitude of fracture displacement

Explanation:

Question 80:

Options:

a spinal cord injury and he cannot participate in contact sports.
no obvious injury and can return to all sports without risk of recurrence.
no obvious injury, but he is at a high risk for breaking his neck in athletic competition.
transient quadriplegia only, but this places him at greater risk for future spinal cord injury and he should refrain from all contact sports.
transient quadriplegia and that there is no evidence of increased risk of permanent spinal cord injury should he return to contact sports.

Correct Answer: transient quadriplegia and that there is no evidence of increased risk of permanent spinal cord injury should he return to contact sports.

Explanation:

DISCUSSION: The long-term effect of transient quadriplegia is unknown. Based on a history of one brief episode of transient quadriplegia and normal examination and MRI findings, the risk of permanent spinal cord injury with a return to play is low. There is a risk of recurrent episodes of transient quadriplegia after the initial episode.
REFERENCES: Morganti C, Sweeney CA, Albanese SA, et al: Return to play after cervical spine injury. Spine 2001;26:1131-1136.
Odor JM, Watkins RG, Dillin WH, et al: Incidence of cervical spinal stenosis in professional and rookie football players. Am J Sports Med 1990;18:507-509.
Torg JS, Naranja RJ Jr, Palov H, et al: The relationship of developmental narrowing of the cervical spinal canal to reversible and irreversible injury of the cervical spinal cord in football players. J Bone Joint Surg Am 1996;78:1308-1314.
Vaccaro
AR
, Watkins B, Albert TJ, et al: Cervical spine injuries in athletes: Current return-to-play criteria. Orthopedics 2001;24:699-703.

Question 81:

There is increasing concern about the ethical relationship of orthopaedists to the orthopaedic equipment industry. Which of the following describes the most appropriate relationship?

Options:

Industry-paid travel, hotel (for the surgeon and spouse), and registration at a university-sponsored CME course
Industry-paid travel and hotel for a faculty member at an industry-sponsored meeting that is not CME approved
Consultation agreement ($50,000/annum) between the surgeon and the company for evaluation of the implant system with required oral reporting of impressions
A restricted grant from a company to an orthopaedic residency program with the stipulation that the third year residents be sent to an industry-sponsored course
Industry-paid dinner at a premium restaurant ($200/person) for surgeon and office staff at which a new set of surgical instrumentation is presented

Correct Answer: Industry-paid travel and hotel for a faculty member at an industry-sponsored meeting that is not CME approved

Explanation:

DISCUSSION: It is appropriate for orthopaedic surgeons to have relationships with industry as long as the relationship is for the good of the patient and no “quid pro quo” intent exists. A grant to cover registration at a CME event is appropriate but travel and hotel for a spouse is not. For orthopaedists who are faculty at a meeting sponsored by industry, it is appropriate for travel and expenses to be covered for that faculty member. Care must be exercised that the faculty member contributes in an amount appropriate for the expenses paid. The faculty member must ensure that information presented is unbiased and based on reasonable data and opinion. Consulting agreements should spell out specifically the duties of the agreement and payment should be appropriate for the time spent. There should be a defined work product for the consulting. Agreements that are thinly veiled payments for use of a company’s products must be avoided. In all cases, the agreements must stand up to public scrutiny. Restricted grants for specific industry-sponsored programs aimed at residents are not appropriate. Unrestricted grants intended for attendance at approved CME courses are appropriate. Dinners at which information is presented about topics that can aid in patient care are appropriate as long as the expense is reasonable ($100 or less/person) and the guest list includes individuals who can use the information in a patient case. Clearly a “premium” dinner for office staff to review new surgical instrumentation would not pass this test.
REFERENCE: Opinions on ethics and professionalism, in Guide to The Ethical Practice of Orthopaedic Surgery, ed 6. American Academy of Orthopaedic Surgeons, Rosemont, IL, 2006, pp 38-42.

Question 82:

The usual presentation of traumatic subscapularis tears is most often seen after forced Review Topic

Options:

internal rotation.
external rotation.
extension.
abduction.
forward flexion.

Correct Answer: external rotation.

Explanation:

The typical mechanism of injury is a fall and the patient grasps something to prevent the fall. This maneuver forces the arm into external rotation against resistance.

Question 83:

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 84:

Options:

Hornblower's Test
Jobe's Test
Apprehension Sign with shoulder abducted and externally rotated
Speed's Test
Kim's Test

Correct Answer: Hornblower's Test

Explanation:

Question 85:

An adult patient with a grade I isthmic spondylolisthesis at L5-S1 is most likely to have weakness of the

Options:

anterior tibialis.
quadriceps.
gastrocsoleus.
extensor hallucis longus.
iliopsoas.

Correct Answer: extensor hallucis longus.

Explanation:

DISCUSSION: Adult patients with isthmic spondylolisthesis most commonly have neurologic symptoms due to foraminal stenosis at the level of the spondylolisthesis. In this scenario, the patient is most likely to have weakness of the L5 myotome, which would cause weakness of the extensor hallucis longus.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 311-317.
Lauerman WC, Cain JE: Isthmic spondylolisthesis in the adult. J Am Acad Orthop Surg 1996;4:201-208.

Question 86:

Options:

Long-leg splinting of bilateral lower extremities, monitoring of bilateral pedal pulses for 48 hours
Intravenous dextran administration, repeat doppler evaluation at 6 hourly intervals
Perform CT angiography for bilateral lower extremities
Perform CT angiography for the left lower extremity, monitor right pedal pulses for 48 hours
Surgical exploration of bilateral lower extremities

Correct Answer: Intravenous dextran administration, repeat doppler evaluation at 6 hourly intervals

Explanation:

Question 87:

Options:

Adamantinoma
Fibrous dysplasia
Osteofibrous dysplasia
Nonossifying fibroma
Chronic osteomyelitis

Correct Answer: Osteofibrous dysplasia

Question 88:

Options:

24 hours.
2 days.
5 days.
7 to 14 days.
6 months.

Correct Answer: 7 to 14 days.

Explanation:

Question 89:

Options:

Cruciate-retaining
Posterior stabilized
Varus-valgus constrained
Rotating hinge

Correct Answer: Rotating hinge

Explanation:

Question 90:

Options:

Continued nonsurgical management
Posterior open reduction and internal fixation with tension band plating
Posterior iliosacral screws
Anterior open reduction and internal fixation
Anterior open reduction and internal fixation and posterior fixation

Correct Answer: Anterior open reduction and internal fixation and posterior fixation

Explanation:

DISCUSSION: Fortunately, surgical treatment of sub-acute pelvic ring injuries is relatively uncommon as acute management has become more common. Delayed reconstruction of pelvic ring malunion and impending malunion is rare. Nonsurgical management may have a role as long as the hemipelvis does not flex, shorten, and/or externally rotate. The AP pelvic radiograph suggests that all three motions are happening in this patient. These are just a few of the indications to repair the pelvic ring and this is best done with anterior and posterior fixation. Anterior symphyseal plating will help correct most of the deformity. Posterior fixation can and should be added to lessen the forces on the anterior ring reconstruction when repair is performed in a sub-acute or delayed fashion. Posterior fixation can help obtain a more anatomic reduction and helps decrease the risk of anterior hardware failure.
REFERENCES: Mears DC: Management of pelvic pseudarthroses and pelvic malunion. Orthopade 1996;25:441-448.
Matta JM, Dickson KF, Markovich GD: Surgical treatment of pelvic nonunions and malunions. Clin Orthop Relat Res 1996;329:199-206.
McLaren AC, Rorabeck CH, Halpenny J: Long-term pain and disability in relation to residual deformity after displaced pelvic ring fractures. Can J Surg 1990;33:492-494.

Question 91:

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

Options:

more prominent implants leading to higher rate of reoperation for implant removal.
a higher nonunion rate.
inferior fixation due to shorter screw lengths laterally.
an increased need to detach the deltoid origin.
an increased risk for injury to subclavian structures.

Correct Answer: an increased need to detach the deltoid origin.

Explanation:

Question 92:

Nutritional rickets in the US occurs more frequently in infants older than 6 months of age who do not receive vitamin D supplementation and are Review Topic

Options:

Caucasian and formula fed.
Caucasian and breast fed.
African American and formula fed.
African American and breast fed.
Asian and formula fed.

Correct Answer: African American and breast fed.

Explanation:

Question 93:

A 22-year-old man has mild hip pain bilaterally and multiple skeletal lesions. Based on the pelvic radiograph shown in Figure 30, what is the inheritance pattern for his disorder?

Options:

X-linked
Autosomal recessive
Autosomal dominant
Mitochondral inheritance
Germline mutation

Correct Answer: Autosomal dominant

Explanation:

DISCUSSION: Multiple hereditary exostoses (MHE) is an autosomal dominant disorder manifested by multiple osteochondromas and characteristic skeletal involvement. EXT1 on 8q24.1 and EXT2 on 11p13 are the two genes most strongly associated with MHE. Mutations in these genes affect proper development of endochondral bone, such that in all affected individuals exostoses develop adjacent to the growth plates of long bones, and some exhibit additional bone deformities. Defects in the EXT genes result in increased chondrocyte proliferation and delayed hypertrophic differentiation.
REFERENCES: Stieber JR, Dormans JP: Manifestations of hereditary multiple exostoses. J Am Acad Orthop Surg 2005;13:110-120.
Hilton MJ, Gutierrez L, Martinez DA, et al: EXT1 regulates chondrocyte proliferation and differentiation during endochondral bone development. Bone 2005;36:379-386.

Question 94:

Options:

Kaposi sarcoma
Squamous cell carcinoma
Pigmented basal cell carcinoma
Melanoma
Basillary angiomatosis

Correct Answer: Melanoma

Explanation:

Question 95:

Options:

Posterior tibial tendon
Impaction fracture of the head of the talus
Posterior tibial neurovascular bundle
Achilles tendon
Calcaneus fracture

Correct Answer: Impaction fracture of the head of the talus

Explanation:

Question 96:

Options:

Forward elevation in the scapular plane
External rotation and abduction
Flexion, adduction, and internal rotation
Flexion and abduction

Correct Answer: Flexion, adduction, and internal rotation

Explanation:

Question 97:

Options:

Plastizote orthotics with a metatarsal pad and a cutout under the fifth metatarsal head
Hyperbaric oxygen and prolonged non-weight-bearing
A healing shoe that completely alleviates any weight bearing on the forefoot
A gastrocnemius release and supportive wound care
A transmetatarsal amputation

Correct Answer: A gastrocnemius release and supportive wound care

Explanation:

DISCUSSION: The patient likely has a significant Achilles contracture that causes her to always bear more weight on her forefoot. A gastrocnemius recession takes the ankle out of plantar flexion and she will be able to return to a normal gait and reduce the pressures on her forefoot. A forefoot amputation is a salvage option. The other choices are appropriate; however, the patient has had this problem for 2 years and she has already had multiple attempts at shoe wear modification.
REFERENCES: Laughlin RT, Calhoun JH, Mader JT: The diabetic foot. J Am Acad Orthop Surg 1995;3:218-225.
Aronow MS, Diaz-Doran V, Sullivan RJ, et al: The effect of triceps surae contracture force on plantar foot pressure distribution. Foot Ankle Int 2006;27:43-52.

Question 98:

Options:

Decreased risk of sacral fractures
Decreased risk of proximal functional kyphosis
Easier contouring of the instrumentation
Reduced risk of late pubic ramus fractures
Improved coronal plane correction

Correct Answer: Decreased risk of sacral fractures

Explanation:

Question 99:

At which joint do degenerative changes occur first in a patient with chronic, untreated scapholunate dissociation?

Options:

Radioscaphoid
Radiolunate
Scapholunate
Capitolunate

Correct Answer: Radioscaphoid

Explanation:

EXPLANATION:
Stage I of scapholunate advanced collapse (SLAC) is characterized by the presence of radioscaphoid arthritis. A predictable pattern exists of the progression of degenerative changes for SLAC wrist, including stage I (radial styloid involvement at the scaphoid fossa), stage II (scaphoid and entire scaphoid facet involvement), stage III (degeneration between the capitate and lunate), and stage IV (pancarpal
involvement). The radiolunate joint is often spared.

Question 100:

- Which of the following acetabular/femoral head components would be expected to show an optimal combination of linear and volumetric wear?

Options:

mm femoral head in combination with a metal-backed polyethylene component
mm femoral head in combination with an all-polyethylene acetabular component
mm femoral head in combination with a metal-backed polyethylene component
mm femoral head in combination with an all-polyethylene component
mm femoral head in combination with a metal-backed polyethylene component

Correct Answer: mm femoral head in combination with a metal-backed polyethylene component

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

Orthopedic Surgery Board Review MCQs: Foot, Fracture, Hip, Infection, Shoulder | Part 129

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 129

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index