Orthopedic Board Review MCQs: Part 137 - OITE Prep

About This Board Review Set

This is Part 137 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

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Two distinct learning modes are available:

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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 137

This module focuses heavily on: Arthroplasty, Deformity, Elbow, Foot, Fracture, Hip, Knee, Shoulder, Tumor.

Sample Questions from This Set

Sample Question 1: Figure 37 shows the T2-weighted MRI scan of the hip joint. What structure is labeled A?...

Sample Question 2: During total hip arthroplasty, profuse bleeding is noted following predrilling for placement of an acetabular component screw. The drill most likely penetrated too deep in the...

Sample Question 3: A 60-year-old patient had the procedure shown in Figure 7 performed 5 years ago. When converting this patient to a total knee arthroplasty (TKA), what patellar problem is commonly encountered intraoperatively?...

Sample Question 4: A 35-year-old woman who underwent open reduction and internal fixation of a calcaneal fracture 14 months ago reports pain that has failed to respond to nonsurgical management. Examination reveals limited painful subtalar motion but no hindf...

Sample Question 5: Preoperative chemotherapy and wide excisionTumoral calcinosis is a heritable condition that is characterized by periarticular metastatic calcification. Most patients are black, and the inheritance is usually autosomal recessive. Metastatic ...

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

Figure 37 shows the T2-weighted MRI scan of the hip joint. What structure is labeled A?

Explanation

DISCUSSION: The obturator internus originates on the obturator membrane and adjacent bone, including the quadrilateral plate, and exits the lesser sciatic notch to insert on the posterior medial greater trochanter. The structure labeled C is the pectineus, B is the sartorius, and D is the gluteus medius.
REFERENCES: Last RJ: Anatomy: Regional and Applied, ed 6. London, England, Churchill Livingstone, 1978, pp 145-150, 324.
Anderson JE (ed): Grant’s Atlas of Anatomy, ed 7. Baltimore, MD, Williams & Wilkins, 1978, plate 4-46.

Question 2

During total hip arthroplasty, profuse bleeding is noted following predrilling for placement of an acetabular component screw. The drill most likely penetrated too deep in the

Explanation

DISCUSSION: The acetabular quadrants are defined by two lines: one drawn from the anterosuperior iliac spine to the posterior fovea, forming acetabular halves, and a second drawn perpendicular to the first at the midpoint of the acetabulum, forming four quadrants. The anterior quadrants should be avoided because improper screw placement may injure the external iliac artery and vein, as well as the obturator nerve, artery, and vein. These structures lie close to the pelvic bone, with little protective interposition of soft tissue.
REFERENCES: Wasielewski RC, Cooperstein LA, Kruger MP, et al: Acetabular anatomy and the transacetabular fixation of screws in total hip arthroplasty. J Bone Joint Surg Am 1990;72:501-508.
Keating EM, Ritter MA, Faris PM: Structures at risk from medially placed acetabular screws.

J Bone Joint Surg Am 1990;72:509-511.

Question 3

A 60-year-old patient had the procedure shown in Figure 7 performed 5 years ago. When converting this patient to a total knee arthroplasty (TKA), what patellar problem is commonly encountered intraoperatively?

Explanation

DISCUSSION: Patella baja is commonly encountered when converting a high tibial osteotomy (HTO) to a TKA. Patella baja most likely occurs because of scarring. Meding and associates’ study did not show an increased rate of lateral release when converting a knee that had undergone a previous HTO.
REFERENCES: Yoshino N, Shinro T: Total knee arthroplasty after failed high tibial osteotomy, in Callaghan JJ, Rosenberg AG, Rubash HE, et al (eds): The Adult Knee. Philadelphia, PA,

JB Lippincott, 2003, vol 2, pp 1265-1271.
Meding JB, Keating EM, Ritter MA, et al: Total knee arthroplasty after high tibial osteotomy:

A comparison study in patients who had bilateral total knee replacement. J Bone Joint Surg Am 2000;82:1252-1259.

Question 4

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

Explanation

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

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

Question 5

Preoperative chemotherapy and wide excision Tumoral calcinosis is a heritable condition that is characterized by periarticular metastatic calcification. Most patients are black, and the inheritance is usually autosomal recessive. Metastatic calcifications occur around joints and in the skin, marrow, teeth, and blood vessels. The periarticular masses may grow quite large and are attached to the fascia, but they are extra-articular. The masses may occur at the shoulder, hip, and elbow. Radiographically: The masses are composed of heavy, amorphous calcification in nodules. Laboratory:

Explanation

Slide 1 Slide 2
A 20-year-old woman has a large mass over the right hip. An anteroposterior and oblique radiographs are shown in Slides 1 and

Question 6

Figures 1 through 4 are the wrist MR images of a 43-year-old right-hand-dominant bricklayer who reports gradually progressive left hand weakness for 4 months. He describes difficulty gripping objects, tying his shoes, and holding utensils. He denies any numbness, paresthesias, or a previous injury. An examination reveals intact sensation in a median, radial, and ulnar nerve distribution. He has atrophy of hand interossei and a positive Froment sign finding. He has no Tinel sign finding at the wrist or elbow and no exacerbation of symptoms with elbow hyperflexion. Electromyography shows signs of denervation in an ulnar nerve distribution distal to the wrist. What is the best next step?

Explanation

The MR images show a lesion consistent with a ganglion cyst located near the hook of the hamate. The ulnar nerve divides into motor and sensory branches just proximal to this lesion. In this case, the ganglion cyst compresses the ulnar nerve motor branch but not the sensory branch, resulting in motor dysfunction but no sensory disturbance. Excision of the ganglion cyst should alleviate his symptoms. Compression of the ulnar nerve proximal to the motor branch take-off (in either the cubital tunnel or proximal Guyon’s canal) would cause both sensory and motor dysfunction. Although chronic nonunion of the hook of the hamate can cause ulnar nerve symptoms, the hook of the hamate appears intact on the MR image. The MR image shows a lesion that is well circumscribed with high intensity on T1 and T2 images, consistent with a benign ganglion cyst, and ganglion cysts are relatively common lesions in this area.

Question 7

Patients with which of the following primary carcinomas have the shortest overall survival rate after a solitary metastasis to bone?

Explanation

DISCUSSION: The median survival of patients after discovery of bone metastasis from primary lung carcinoma is shorter compared with other primary sites.
REFERENCE: CA, January/February 2000, vol 50, no. 1 (Cancer Statistics).

Question 8

A patient who had previously undergone a salvage pelvic (Chiari) osteotomy now requires a total hip arthroplasty. The most frequent complication of this procedure is

Explanation

The Chiari osteotomy is recommended for patients with inadequate femoral head coverage and an incongruous joint. The osteotomy shortens the affected leg. It also medializes the hip's center of rotation. The osteotomy involves cutting the ileum at a spot above the acetabulum, which in effect abducts the acetabulum into a more vertical and medial position. The iliac wing then serves as a superior buttress. Answer #1 makes no sense. Answer #2 is wrong because the articular portion of the acetabulum remains unchanged. Answer #3 is incorrect because inferior coverage remains unchanged. Answer #4 is completely incorrect because superior coverage INCREASES with a Chiari osteotomy.

Question 9

A coach of 3 football teams—the B team, junior varsity team, and varsity team—wants to study the average times in the 40-yard dash for his players. Which test would help him determine if the mean 40-yard dash times for the athletes on 1 team are different from those on the other teams?

Explanation

DISCUSSION
Data collected in research studies fall into 1 of 2 categories—continuous or discrete. Continuous data can be displayed on a curve. Examples include height, weight, and time recorded in a 40-yard dash. Discrete data represent data that fall into specific categories such as gender or the presence or absence of a risk factor.
ANOVA is used to determine statistical significance in mean values of continuous data when there are more than 2 independent samples. The 2-sample t test compares mean values of continuous data between 2 independent groups. The Chi-square test and Fisher's exact tests are tests used to analyze discrete data.
RESPONSES FOR QUESTIONS 58 THROUGH 61
Paresthesias in the fourth and fifth digits
Numbness on the lateral side of the forearm
Heterotopic ossification
Posterolateral rotatory instability of the elbow
Medial antebrachial cutaneous neuroma
For each surgical case described below, match the most likely related complication listed above.

Question 10

A 31-year-old man who is a recent immigrant from Guatemala has had pain in his back and thighs for the past 12 months. History notes a recent diagnosis of gout, and the patient reports falling a distance of 3 feet on his buttocks immediately before the pain began. Examination reveals that he is neurologically intact. Plain radiographs are shown in Figures 44a and 44b, and T2-weighted MRI scans are shown in Figures 44c and 44d. The most likely cause of the pathologic fracture is

Explanation

The plain films demonstrate lumbar AP and Lateral radiographs with 32 degree anteriorly wedged compression fracture of L1. On closer evaluation one notices the adjacent disc spaces are narrowed. The center of the vertebra is sclerotic with the anterior inferior endplate irregular.
The MR demonstrates involvement of L1 and adjacent disc spaces. With peri-vertebral edema and mass involving the posterior aspect of the vertebral body, placing pressure on the spinal cord. There is also involvement of the L2-3 disc with early signal changes.
The slow clinical course of the patients symptoms, being from a third world country and the findings on imaging studies, with an anterior wedge compression fracture. The level most commonly involved with TB is lower thoracic and upper lumbar. The anterior wedging results in the classic “Gibbus”.
Some of the MR findings are also consistent with metastatic disease, but with the localized mass, peri-vertebral abscess make this choice more unlikely.
The usual findings on MR found with TB are: Confluently decreased signal intensity of the vertebral bodies associated interspace with poor distinction between these on short TR/short TE images: Abnormal increased signal of the disk on long TR/long TE images with an abnormal configuration (i.e., absent intranuclear cleft): Increased signal of the vertebral endplates at the abnormal disk level on long TR/long TE images.

Question 11

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

Explanation

DISCUSSION: In a young individual with a chronic dislocation of the elbow and heterotopic bone formation, the treatment of choice is open reduction, heterotopic bone excision, anterior and posterior capsular releases, and a dynamic hinged fixator to begin protected early postoperative range of motion. It is important to understand that the fixator protects the reconstruction and allows early range of motion, but it does not maintain the reduction and should not be expected to do so. Pin fixation across the elbow delays early motion and is not recommended. Total elbow arthroplasty is not indicated, and ulnohumeral arthroplasty is for a primary arthritic condition.
REFERENCES: Garland DE, Hanscom DA, Keenan MA, et al: Resection of heterotopic ossification in the adult with head trauma. J Bone Joint Surg Am 1985;67:1261-1269.
Moor TJ: Functional outcome following surgical excision of heterotopic ossification in patients with traumatic brain injury. J Orthop Trauma 1993;7:11-14.

Question 12

The stiffness of a 16-mm femoral stem is mostly influenced by the

Explanation

DISCUSSION: The stiffness is most influenced by the geometry, in particular the diameter of the stem. The bending rigidity increases to the fourth power of the radius. The elastic modulus of the material increases as a direct linear relationship. The surface coating does not affect the bending rigidity greatly unless it increases the diameter significantly.
REFERENCE: Simon SR (ed): Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, p 458.

Question 13

A 52-year-old man who was a former high school pitcher now reports loss of elbow flexion and extension with pain at the extremes of motion. Nonsurgical management has failed to provide relief. Examination reveals movement from 50 degrees to 110 degrees and is painful only at the limits of motion. A radiograph is shown in Figure 12. Treatment should consist of

Explanation

DISCUSSION: Based on the history, examination, and radiograph, the patient has typical degenerative arthritis of the elbow. This condition is found almost exclusively in men, and there is almost universally a history of repetitive heavy use or overuse of the elbow. Patients report pain at terminal extension and usually have a flexion contracture. Radiographs reveal osteophytes on the coronoid and olecranon and in the coronoid and olecranon fossae. The osteophytes are often associated with loose bodies that sometimes are attached to the soft tissues. Treatment should consist of removal of all loose bodies and impinging osteophytes using open technique or by arthroscopy. The capsular contractures should be released at the same time.
REFERENCES: Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 283-294.
Morrey BF: Primary degenerative arthritis of the elbow: Treatment by ulnohumeral arthroplasty. J Bone Joint Surg Br 1992;74:409-413.
Redden JF, Stanley D: Arthroscopic fenestration of the olecranon fossa in the treatment of osteoarthritis of the elbow. Arthroscopy 1993;9:14-16.
O’Driscoll SW: Elbow arthritis: Treatment options. J Am Acad Orthop Surg 1993;1:106-116.

Question 14

A year-old man who underwent right total knee replacement surgery 2 and a half years ago has had knee pain since surgery. The pain is diffuse, constant, and made worse with activity. He notes warmth and swelling in his knee. Examination shows a well-healed incision, no erythema, moderate warmth, synovitis, and an effusion. The knee is stable, and has an arc of flexion between 3° and 120°. Radiographs show well-fixed and well-aligned implants. What is the most appropriate initial treatment?

Explanation

DISCUSSION:
This patient's history and physical findings are concerning for deep infection. Inflammatory markers, including ESR and CRP, should be obtained first. If the levels are elevated, knee aspiration should be performed for the synovial cell count and culture. A bone scan is not indicated in an initial investigation for deep infection; it is rarely helpful and is not cost effective. CT to assess implant rotation is an appropriate investigation for knee pain when the clinical scenario is not suspicious for a deep infection
and when infection has been excluded.

Question 15

A 54-year-old man undergoes revision surgery for loosening and osteolysis of a cementless acetabular component. The membrane obtained from behind the component at the time of surgery is analyzed for particulate debris particle size. Which particle size is most likely responsible for the membrane formation?

Explanation

In performing a posterior stabilized total knee arthroplasty (TKA), which component malpositioning is associated with the wear damage shown in this tibial component retrieval (Figure 1)?
A. Excessive femoral component flexion
B. Excessive anterior slope of the proximal tibia
C. Excessive tibial component varus
D. Excessive valgus resection of the distal femur

Question 16

What would be the most appropriate surgical indication for transferring fascicles of the ulnar nerve to the motor nerve of the biceps and fascicles of the median nerve to the motor nerve of the brachialis?

Explanation

(SBQ12FA.31) A 30-year-old male patient involved in a hang-gliding accident sustains a knee dislocation with multiligamentous knee injury and transection of his peroneal nerve. He undergoes multiple reconstructive surgeries. Two years later, he continues to have a foot drop and dynamic tendon transfer is recommended. This treatment most commonly involves transferring a tendon from which native insertion point to which new insertion point? Review Topic
Plantar distal phalanges to medial navicular
Medial navicular to dorsal lateral cuneiform
Plantar 1st metatarsal to dorsal lateral cuneiform
5th metatarsal base to dorsal medial cuneiform
Plantar distal phalanx of the hallux to dorsal distal phalanx of hallux
Dynamic tendon transfer to restore active dorsiflexion of the foot involves transferring the posterior tibial tendon (PTT) insertion on the medial navicular to the dorsal lateral cuneiform.
Common peroneal nerve (CPN) injuries following traumatic knee dislocation are common, with an incidence of 25-40%. CPN palsy is characterized by foot drop due to loss of ankle dorsiflexors with a steppage gait and eventual development of a supinated equinovarus foot secondary to the unopposed pull of the PTT. Nonsurgical management involves use of an ankle-foot orthosis and physical therapy. Surgical
options include acute primary repair, nerve grafting with either autologous sural nerve or nerve conduits and dynamic tendon transfer. The PTT is harvested from its insertion at the navicular, passed through the interosseous membrane (IOM) and anchored to the lateral cuneiform (see Illustration A). The classic bridle procedure involves concomitant anastamosis of the PTT to the tibialis anterior (TA) and peroneus longus (PL) tendons.
Garozzo et al reported a case series of 62 patients with post-traumatic CPN palsy who underwent a one-stage procedure consisting of nerve repair and PTT transfer. Nerve repair combined with PTT transfer improved postoperative outcomes compared to nerve repair alone. At 2-year follow up, neural regeneration was demonstrated in 90% of patients. The authors hypothesized that poor outcomes following nerve repair alone are due to force imbalance between the functioning flexors and paralyzed extensors, which is somewhat equalized by performing a PTT transfer at time of repair.
Niall et al reviewed 55 patients with traumatic knee dislocation and reported a 41% incidence of CPN injury, exclusively associated with dislocations involving disruption of the posterior cruciate ligament (PCL) and posterolateral corner (PLC). Complete neurologic recovery was found in only 21% of patients. The best prognosis was found with lesions in continuity, less than 7cm of nerve involvement, and short conduction block and muscle activity on nerve conduction and EMG studies.
Vigasio et al described a dynamic tendon transfer technique for traumatic complete CPN injury, involving transfer of the PTT to the TA rerouted to a new origin at the lateral cuneiform to restore ankle dorsiflexion and flexor digitorum longus (FDL) to the extensor digitorum longus (EDL) and extensor hallucis longus (EHL) to restore digit dorsiflexion. Rerouting the TA towards the transferred PTT ensures the PTT harvest length is sufficient. This avoids excessive tensioning of the PTT, which may limit tendon excursion and result in a static tenodesis rather than dynamic function, as well as the need for PTT lengthening which may decrease strength of the transfer
Illustration A is a series of intraoperative photographs demonstrating PTT transfer from Garg et al. An incision is made distal to the medial malleolus and the PTT is harvested subperiosteally (A). The PTT is delivered through a second incision ~15cm proximal to the medial malleolus (B-C). The PTT is then passed through the interosseous membrane and out a third incision over the anterior fibula (D). Lastly, the PTT is passed through a fourth incision over the dorsal midfoot and anchored to the lateral cuneiform (E).
Incorrect Responses:
nerve and therefore would not be functional. Answer 5: Transferring the flexor hallucis longus (FHL; insertion = plantar distal phalanx of the hallux) to the insertion of the EHL (dorsal distal phalanx of hallux) is recommended for correction of claw toe deformity and would not help restore foot dorsiflexion in this patient.

Question 17

What are the optimal conditions for leaving the acetabular shell in place, replacing the acetabular liner, and grafting the osteolytic defect shown in Figure 39?

Explanation

DISCUSSION: Dense pods of ingrowth into the porous coating of cementless ingrowth sockets are seen. Channels through the non-ingrown portion allow access to the trabecular bone of the ilium. Polyethylene wear debris can enter these areas through screw holes. Expansile, lytic lesions can result, which can become large without compromising implant fixation. Loosening is late and results from catastrophic loss of bone. A well-fixed acetabular component with a modular design, a well-designed locking mechanism, and a good survivorship history is a candidate for exchange of the liner and grafting of the osteolytic lesion.
REFERENCES: Ries MD: Complications in primary total hip arthroplasty: Avoidance and management. Wear. Instr Course Lect 2003;52:257-265.
Dumbleton JH, Manley MT, Edidin AA: A literature review of the association between wear rate and osteolysis in total hip arthroplasty. J Arthroplasty 2002;17:649-661.
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 175-180.

Question 18

The MRI scan shown in Figure 33 reveals the sequelae of an acute traumatic anteroinferior shoulder dislocation. The image reveals the typical separation of what two commonly injured structures? Review Topic

Explanation

The MRI scan reveals the sequelae of an anteroinferior dislocation, specifically separation of the anteroinferior labrum from the bony glenoid. The separation does not classically occur only at the cartilage-labral junction, but extends to the bony surface of the medial glenoid neck. Separation of the biceps tendon from its origin on the supraglenoid tubercle (SLAP lesion) or separation of the anterior capsule with the proximal humerus (HAGL lesion) may occur but are not the most common sequelae and are not demonstrated in this MRI image. Anteroinferior shoulder dislocations normally do not affect the posterior labral structures. In their landmark study, Rowe and associates noted that this demonstrated lesion was the most common lesion, present in 85% of their series.

Question 19

Based on the Young and Burgess classification of pelvic ring injuries, an anterior-posterior compression type II injury does not result in disruption of which of the following?

Explanation

DISCUSSION: An APC type 1 involves slight widening of pubic symphysis and/or anterior sacroiliac (SI) joint. An APC II is a continuation of this force, and additionally involves a disrupted anterior SI joint, as
well as sacrotuberous and sacrospinous ligaments. An APC III also involves disrupted posterior SI ligaments, causing complete SI joint disruption with potential translational and rotational displacement.
The reference by Young et al is a classic article that describes the Young and Burgess classification of pelvic ring injuries. They retrospectively analyzed pelvic ring radiographs and discussed four patterns of injury: anteroposterior compression, lateral compression, vertical shear, and a complex/combined pattern.
The reference by Burgess et al is a validation of the aforementioned classification and study, as they reviewed 210 consecutive patients who sustained a pelvic ring injury. They validated the classification scheme and found that overall blood replacement averaged: lateral compression, 3.6 units; anteroposterior compression, 14.8 units; vertical shear, 9.2 units; combined mechanical, 8.5 units. Overall mortality was: lateral compression, 7.0%; anteroposterior, 20.0%, vertical shear, 0%; combined mechanical, 18.0%.
Incorrect answers:
1,2,4,5: An APC - 2 pelvic ring injury involves injury to all of these structures.

Question 20

Figure 59 shows properties of a material being tested for use as an implant. What is represented by the portion of the stress-strain curve from point A to point B?

Explanation

DISCUSSION: The figure is a stress-strain diagram representing specific metal subjected to increasing tensile stress. The portion of the curve from A to B is a straight line demonstrating a proportional increase in strain for each increase in tensile stress. If the stress is removed at any point between A and C, the material will return to its original shape, returning back along the original curve without permanent deformation. This is termed elastic behavior. If the applied stress causes strain beyond point C, then permanent deformation occurs and returns along a different path to a different zero stress point. This is termed plastic behavior. The point C at which the material stops behaving in an elastic manner and begins behaving in a plastic manner is the elastic limit or yield point. Point D represents a point on the curve of plastic deformation. Point E is the fracture point when the stress on the material creates enough strain that the material fractures.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 45-46.
El-Ghannam A, Ducheyne P: Biomaterials, in Mow VC, Huiskes R (eds): Basic Orthopaedic Biomechanics and Mechano-Biology, ed 3. Philadelphia, PA, Lippincott-Raven, 2005, pp 501-503.

Question 21

A 68-year-old woman undergoes a complicated four-level anterior cervical diskectomy and fusion at C3-7 with iliac crest bone graft and instrumentation for multilevel cervical stenosis. Surgical time was approximately 6 hours and estimated blood loss was 800 mL. Neuromonitoring was stable throughout the procedure. The patient’s history is significant for smoking. The most immediate appropriate postoperative management for this patient should include

Explanation

DISCUSSION: Airway complications after anterior cervical surgery can be a catastrophic event necessitating emergent intubation for airway protection. Multilevel surgeries requiring long intubation and prolonged soft-tissue retraction as well as preexisting comorbidities may predispose a patient to postoperative airway complications. Sagi and associates reported that surgical times greater than 5 hours, blood loss greater than 300 mL, and multilevel surgery at or above C3-4 are risk factors for airway complications. In surgical procedures with the aforementioned factors, serious consideration should be given to elective intubation for 1 to 3 days to avoid urgent reintubation.
REFERENCES: Sagi HC, Beutler W, Carroll E, et al: Airway complications associated with surgery on the anterior cervical spine. Spine 2002;27:949-953.
Epstein NE, Hollingsworth R, Nardi D, et al: Can airway complications following multilevel anterior cervical surgery be avoided? J Neurosurg 2001;94:185-188.
Emery SE, Smith MD, Bohlman HH: Upper-airway obstruction after multi-level cervical corpectomy for myelopathy. J Bone Joint Surg Am 1991;73:544-551.

Question 22

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

Explanation

DISCUSSION: Gouty arthritis, pseudogout, and infection can all present with inflammatory arthritis and periarticular erosions. Strongly negative birefringent crystals are seen in gout. The histologic image shows elongated “needle-like” crystals of gout. Epidermal inclusion cysts are rarely painful and usually have a history of localized penetrating trauma.
REFERENCES: Hamilton W, Breedman KB, Haupt HM, Lackman R: Knee pain in a 40-year-old man. Clin Orthop 2001;383:282-285,290-292.
Mizel M, Miller R, Scioli M (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 301-302.

Question 23

A study was conducted in 500 patients to measure the effectiveness of a new growth factor in reducing healing time of distal radial fractures. The authors reported that average healing time was reduced from 9.2 to 8.9 weeks (P < 0.0001). Because the difference was highly statistically significant, they recommended routine clinical use of this drug despite its high cost. A more appropriate interpretation of these results is that they are

Explanation

DISCUSSION: The results are statistically significant (at the arbitrary level of P < 0.05). That is, they indicate a probability of only 1/10,000 that the observation that the drug is effective in reducing healing time by 0.3 weeks occurred by chance selection of the study subjects. However, because the statistical power of a study increases with the number of subjects included (sample size), a difference that is trivial clinically can occur with a very high level of statistical significance (a very small P-value) if enough patients are included in the study. Because of this, the P-value alone, no matter how small, does not establish clinical significance or importance. Rather, the clinical significance of the observed difference must be assessed taking into consideration the medical importance of the difference if it is, in fact, true in the general population. In this example, the reduction in healing time of only a few days is probably clinically unimportant, particularly if the use of the new growth factor is expensive, complex, and/or has substantial side effects.
REFERENCE: Ebramzadeh E, McKellop H, Dorey F, et al: Challenging the validity of conclusions based on P-values alone: A critique of contemporary clinical research design and methods. Instr Course Lect 1994;43:587-600.

Question 24

Which of the following activities can improve posterior capsular contractures?

Explanation

DISCUSSION: Posterior capsule stretching is performed in the cross-chest and behind the back positions. Stretching in internal rotation in the abducted shoulder will further stretch the posterior capsule. Wide grip stretch, and anterior capsule and strengthening exercises will not necessarily stretch the capsule.
REFERENCES: Ellenbacher TS: Shoulder internal and external rotation strength and range of motion of highly-skilled junior tennis players. Isokinetic Exercise Sci 1992;2:1-8.
Kibler WB, McMullen J, Uhl J: Shoulder rehabilitation strategies, guidelines, and practice. Op Tech Sports Med 2000;8:258-267.

Question 25

Which of the following is the only nonreversible effect of anabolic steroids?

Explanation

DISCUSSION: The loss of hair or alopecia, is the only nonreversible effect of anabolic steroid use.
Once anabolic steroids are stopped, muscle hypertrophy and training gains are quickly lost and the HDL/ LDL ratios return to their preexisting levels. Fortunately, the personality effects and the acute acne are reversible.
REFERENCES: Hartgens F, Kuipers H: Effects of androgenic-anabolic steroids in athletes. Sports Med 2004;34:513-554.
Evans NA: Current concepts in anabolic-androgenic steroids. Am J Sports Med 2004;32:534-542.

Question 26

Figure 89a is the radiograph of a 24-year-old man who was involved in a motor vehicle accident. A closed reduction is performed and a post-reduction CT scan is shown in Figure 89b. What is the next most appropriate step in management?

Explanation

The radiograph and CT scan show a posterior hip dislocation with an associated posterior wall acetabular fracture. The next step in management is assessment of hip instability. As suggested by Tornetta, assessment of hip instability with dynamic stress views is helpful to determine which posterior wall fractures are unstable and therefore require open reduction and internal fixation. Although protected weight bearing may be correct if the hip is stable, stability needs to be determined first. The CT scan reveals a small fragment in the cotyloid fossa. However, in this location, the presence of a loose body alone does not require surgical treatment. Hip instability needs to be assessed before determining if this fracture should be treated with open reduction and internal fixation. Total hip arthroplasty is not appropriate for a 24-year-old patient with a small posterior wall acetabular fracture.

Question 27

A 37-year-old man with a history of congenital flatfoot reports worsening pain on the medial aspect of his ankle for the past year. The pain is worse with weight bearing and is better with rest and the use of an ankle brace. What findings are shown on the MRI scans shown in Figures 18a through 18c?

Explanation

DISCUSSION: The MRI scans reveal an enlarged posterior tibial tendon, with degenerative signal within the tendon and an excessive amount of fluid in its sheath. This is a type II tear, as noted by Conti and associates, which is the most commonly seen tear.
REFERENCES: Slovenkai MP: Clinical and radiographic evaluation (Adult flatfoot: Posterior tibial tendon dysfunction). Foot Ankle Clin 1997;2:241-260.
Conti S, Michelson J, Jahss M: Clinical significance of magnetic resonance imaging in preoperative planning for reconstruction of posterior tibial tendon ruptures. Foot Ankle 1992;13:208-214.

Question 28

A 32 yr old man with oxalosis is scheduled for a surgical treatment of spinal stenosis. Which of the following organs is most likely to show signs of systemic oxalosis during a preoperative assessment?

Explanation

“Oxalosis is a genetic transmitted, autosomal recessive disorder of glyoxalate metabolism...Nephrolithiasis and nephrocalcinosis, secondary to calcium oxalate hypersaturation in the patient’s kidney, usually cause an initial presentation of renal colic and/or asymptomatic gross hematuria...[and later] chronic renal failure” This finding would be detected on either UA or BUN/Cr labs.

Question 29

All of the following are considered contraindications to the use of functional bracing of a humeral shaft fracture EXCEPT:

Explanation

DISCUSSION: A closed mid-diaphyseal humerus fracture with a radial nerve palsy on presentation is not a contraindication to functional brace management.
Commonly accepted parameters for closed treatment include less than 30 degrees of varus angulation, 20 degrees of anterior/posterior angulation, and 3 cm of shortening. Operative indications are: associated vascular injuries, bilateral humeral shaft fractures, polytrauma patient (including paraplegia), segmental fractures, injury to the brachial plexus, pathological fractures, floating elbow, and floating shoulder.
The article by Rutgers and Ring found that proximal one-third oblique humeral shaft fractures had an unacceptably high 29% rate of nonunion treated with a functional brace.
The article by Sarmiento et al found a 97% rate of union, a radial nerve palsy incidence of 11%, and no contraindication to the use of functional braces in humeral shaft fractures associated with radial nerve palsy.
The review article by Defranco and Lawton states that 70% of these radial nerve injuries recover spontaneously. They note that it "seems reasonable, however, to consider surgical intervention (radial nerve exploration) between 4 and 6 months based on the patient’s clinical course."

Question 30

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

Explanation

The radiograph and intraoperative photograph show osteonecrosis with near complete head loss/collapse. A stemmed implant is more appropriate in this patient because there is very little bone to support a resurfacing implant. In a younger patient, a glenoid implant should be delayed as long as possible because of the eventual need for revision secondary to glenoid loosening and wear, especially in a young active male. The hemiarthroplasty may be converted to a total shoulder arthroplasty in the future.

Question 31

What is the most likely diagnosis? Review Topic

Explanation

The MRI scan shows detachment of the subscapularis from its insertion on the lesser tuberosity. The examination finding is consistent with a positive lift-off test, also indicating a tear of the subscapularis.

Question 32

Which of the following is associated with the use of large femoral heads in total hip arthroplasty?

Explanation

DISCUSSION: Larger diameter femoral heads reduce the risk of hip dislocation by allowing greater range of motion before component impingement becomes a risk, and no reports have shown an increase in bearing wear. With modem bearings, volumetric wear should remain low, despite the increase in head diameter. Large femoral heads are available in all common bearing materials
REFERENCES: Peters CL, McPherson E, Jackson JD, et al: Reduction in early dislocation rate with large-diameter femoral heads in primary total hip arthroplasty. J Arthroplasty 2007;22:140-144.
Inoue A, Asaumi K, Endo H, et al: Assessment of head wear more than ten years after total hip arthroplasty: 22- mm zirconia vs metal heads. Acta Med Okayama 2006;60:311-318.

Question 33

During stabilization of a slipped capital femoral epiphysis, the screw penetrates into the joint. The screw is repositioned so that it is within the femoral head. This transient penetration of the hip joint will most likely lead to

Explanation

DISCUSSION: Chondrolysis may be associated with unrecognized permanent penetration of the joint space by a pin or screw. However, transient penetration by the guide wire or screw is not associated with this problem. One study described 11 hips in which there was transient intraoperative penetration of the joint space by a guide wire or screw. These patients were followed for at least 2 years, with none showing any clinical or radiographic evidence of chondrolysis. Another retrospective study of 55 slipped epiphyses described 11 hips with transient intraoperative pin penetration, with none showing development of chondrolysis. There are no studies to suggest that transient pin penetration leads to osteonecrosis, stiffness, or premature physeal closure.
REFERENCES: Zionts LE, Simonian PT, Harvey JP Jr: Transient penetration of the hip joint during in situ cannulated-screw fixation of slipped capital femoral epiphysis. J Bone Joint Surg Am 1991;73:1054-1060.
Vrettos BC, Hoffman EB: Chondrolysis in slipped upper femoral epiphysis: Long-term study of the etiology and natural history. J Bone Joint Surg Br 1993;75:956-961.

Question 34

Following irrigation and debridement, what is the preferred method of fixation for a displaced open tibia fracture with a 16-cm clean wound?

Explanation

Unreamed nails disrupt the diaphyseal cortical circulation by about 30% as compared to reamed nails that disrupt the circulation about 70%. This aids in healing of open fractures. Because of the smaller diameter used with unreamed nails they are weaker and therefore are made solid without cannulation for added strength. Unreamed nails have a lower rate of infection than plates. External fixators are used for periarticular fractures with compromised soft tissue and when the foreign body might attribute to higher rates of infection like a nail or plate.

Question 35

A 60-year-old woman with a history of breast cancer has progressive paraparesis. The MRI scan is shown in Figure 28. What form of management is most likely to restore or maintain ambulation?

Explanation

DISCUSSION: Surgical decompression and stabilization have been shown to be the most effective means of improving neurologic function. Decompression is most reliably done from the side of the compression, which is anterior in this patient.
REFERENCES: Harrington KD: Metastatic tumors of the spine: Diagnosis and treatment. J Am Acad Orthop Surg 1993;1:76-86.
Siegal T, Siegal T: Current considerations in the management of neoplastic spinal cord compression. Spine 1989;14:223-228.

Question 36

During an anterior approach to the shoulder, excessive traction on the conjoined tendon is most likely to result in loss of

Explanation

DISCUSSION: The musculocutaneous nerve travels through the conjoined tendon approximately 8 cm distal to the tip of the acromion. The musculocutaneous nerve innervates the biceps muscle and the bracialis muscle, both of which are responsible for elbow flexion. Shoulder flexion is facilitated by the anterior fibers of the deltoid muscle (axillary nerve) and the supraspinatus muscle (suprascapular nerve). The subscapular muscle facilitates internal rotation of the shoulder (upper and lower subscapularis nerve). Shoulder abduction is performed by the deltoid muscle (axillary nerve), and forearm pronation is facilitated by the pronator teres (median nerve).
REFERENCES: Hollinshead WH: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, pp 391-393.
Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach, ed 2. Philadelphia, PA, Lippincott-Raven, 1992, pp 2-49.

Question 37

Figure 2 shows the AP radiograph of an 18-year-old woman with progressive and severe right hip pain. Nonsteroidal anti-inflammatory drugs no longer control her pain. What is the next most appropriate step in management?

Explanation

DISCUSSION: A concentric hip with acetabular dysplasia in a symptomatic patient is best treated by periacetabular osteotomy. The Salter osteotomy is less optimal because the method has limited correction, is uniaxial, cannot be tailored to the deformity, and lateralizes the entire hip joint, thereby increasing the joint reactive forces. Because the hyaline cartilage of the joint is histologically normal, rotating the hyaline cartilage into an optimal position is preferable to augmenting the acetabulum with a shelf or by Chiari osteotomy. Varus intertrochanteric osteotomy has no significant role in the treatment of acetabular dysplasia. Total hip arthroplasty may be required in the future but should not be the first choice.
REFERENCE: Millis MB, Murphy SB, Poss R: Osteotomies about the hip for the prevention and treatment of osteoarthritis. Instr Course Lect 1996;45:209-226.

Question 38

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

Explanation

DISCUSSION
The radiographs show a hallux valgus deformity with a laterally deviated distal metatarsal articular surface, a large intermetatarsal angle with medial deviation at the first metatarsocuneiform joint, an elongated medial collateral ligament, and a contracted lateral collateral ligament. There is no distal 1-2 transverse intermetatarsal ligament. The distal transverse ligament in the first interspace extends from the second metatarsal to the lateral (fibular) sesamoid, remains intact, and keeps the sesamoids in a lateral position as the first metatarsal head migrates medially.
RECOMMENDED READINGS
Coughlin MJ. Roger A. Mann Award. Juvenile hallux valgus: etiology and treatment. Foot Ankle Int. 1995 Nov;16(11):682-97. PubMed PMID: 8589807.
View Abstract at PubMed
Coughlin MJ, Mann RA. Hallux valgus. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. 8th ed. Philadelphia, PA: Mosby Elsevier; 2007:183-226.

Question 39

With the arm abducted 90 degrees and fully externally rotated, which of the following glenohumeral ligaments resists anterior translation of the humerus?

Explanation

DISCUSSION: With the arm in the abducted, externally rotated position, the anterior band of the inferior glenohumeral ligament complex moves anteriorly, preventing anterior humeral head translation. Both the coracohumeral ligament and the superior glenohumeral ligament restrain the humeral head to inferior translation of the adducted arm, and to external rotation in the adducted position. The middle glenohumeral ligament is a primary stabilizer to anterior translation with the arm abducted to 45 degrees. The posterior band of the inferior glenohumeral ligament complex resists posterior translation of the humeral head when the arm is internally rotated.
REFERENCES: Harryman DT II, Sidles JA, Harris SL, et al: The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992;74:53-66.
Wang VM, Flatow EL: Pathomechanics of acquired shoulder instability: A basic science perspective. J Shoulder Elbow Surg 2005;14:2S-11S.

Question 40

Anteromedial approach (Ludloff)

Explanation

DISCUSSION
The lateral femoral cutaneous nerve can be injured during a direct anterior approach to the hip. The superior gluteal nerve enters the gluteus medius from posterior to anterior approximately 5 cm above the greater trochanter. This nerve can be injured during the direct lateral and anterolateral approaches to the hip. Branches of the inferior gluteal nerve as well as the sciatic nerve can be injured during the posterior approach, and the obturator nerve can be damaged when performing a medial approach to the hip.

Question 41

Figures 14a and 14b show the plain radiographs of an 85-year-old woman who has had severe pain in the right knee for the past 4 months. Management should consist of

Explanation

DISCUSSION: The patient has osteonecrosis of the lateral femoral condyle with collapse of the articular surface. Because there is already collapse of the articular surface, a total knee arthroplasty is the treatment of choice. The results of total knee arthroplasty in these patients are usually excellent. However, knee replacement is only a resurfacing procedure, and some patients with global osteonecrosis of the distal femur may have residual pain after knee replacement. High tibial osteotomy may be indicated in younger patients who have a varus deformity and localized osteonecrosis. Arthroscopic surgery would provide minimal relief for this patient because there is already collapse of the articular surface. A hinged knee brace will not adequately unload the joint. An osteochondral allograft should be considered only for younger patients with localized osteonecrosis.
REFERENCES: Bergman NR, Rand JA: Total knee arthroplasty in osteonecrosis. Clin Orthop 1991;273:77-82.
Lotke PA, Abend JA, Ecker ML: The treatment of osteonecrosis of the medial femoral condyle. Clin Orthop 1982;171:109-116.

Question 42

A 52-year-old woman has bicompartmental osteoarthritis following patellectomy. Treatment should consist of

Explanation

DISCUSSION: The patient has extensive degenerative changes in both the medial and lateral compartments within the knee; therefore, arthroscopic debridement or an osteotomy will not be helpful. A patellar arthroplasty will not address the medial and lateral compartments. Because the extensor mechanism provides a significant amount of anteroposterior stability, a posterior cruciate-substituting total knee arthroplasty is the treatment of choice for this patient.
REFERENCES: Martin SD, Haas SB, Insall JN: Primary total knee arthroplasty after patellectomy. J Bone Joint Surg Am 1995;77:1323-1330.
Pagnano MW, Cushner FD, Scott WN: Role of the posterior cruciate ligament in total knee arthroplasty. J Am Acad Orthop Surg 1998;6:176-187.

Question 43

In total hip arthroplasty, increasing the perpendicular distance from the center line of the femur to the center of rotation of the femoral head (femoral offset) results in

Explanation

The advantages to increasing femoral offset at THA are reported to
include an increased range of motion, better mechanical advantage for the abductors and decreased instability because of better soft tissue tension. According to Charnley,
increasing the femoral offset should improve the abductor lever arm which should decrease the abductor force required for walking, and therefore decrease the energy requirement for gait as well as the overall joint reactive force. The largest possible disadvantage of increasing the femoral offset is increasing the out of plane bending moment which puts stress on the prosthetic stem. Poly wear is a direct effect of surface area contact which is not changed with femoral Offset.

Question 44

An 11-year-old boy sustained an ankle injury while playing football. Figure 20 shows an AP radiograph obtained the day of injury. Treatment should consist of

Explanation

DISCUSSION: The child has an injury involving both the growth plate and the articular surface of the ankle. Because of the significant displacement, open reduction and internal fixation is indicated to realign the physis and joint surface. The best method of fixation to avoid growth arrest is one that does not cross the physis. This is usually achieved by a transverse epiphyseal screw parallel to the physis. If the metaphyseal fragment was large enough, a transverse metaphyseal screw could be used instead. The incidence of growth arrest following physeal ankle injuries is as high as 50%, and long-term follow-up is indicated.
REFERENCES: Cass JR, Peterson HA: Salter-Harris Type-IV injuries of the distal tibial epiphyseal growth plate, with emphasis on those involving the medial malleolus. J Bone Joint Surg Am 1983;65:1059-1070.
Barmada A, Gaynor T, Mubarak SJ: Premature physeal closure following distal tibia physeal fractures: A new radiographic predictor. J Pediatr Orthop 2003;23:733-739.

Question 45

The mother of a 3-month-old infant states that she has difficulty positioning the infant’s legs during diaper changes. Examination reveals limited abduction of both hips and a negative Ortolani sign. A radiograph reveals bilaterally dislocated hips. Initial management consists of guided reduction in a Pavlik harness, with weekly follow-up. Figures 57a and 57b show the radiograph and CT scan obtained after 6 weeks in the harness. Management should now consist of

Explanation

DISCUSSION: In an infant younger than age 6 months with a complete dislocation of the hip that is not initially reducible, the Pavlik harness may be used for a trial of guided reduction. When the harness is used in these patients, the infant should be followed at weekly intervals to see if reduction has been achieved. If the hip does not reduce after 3 to 4 weeks of harness wear, the harness should be discontinued, and closed or open reduction should be considered to avoid secondary deformation of the posterolateral acetabulum, also known as Pavlik harness pathology. Changing to other abduction braces is not indicated.
REFERENCES: Jones GT, Schoenecker PL, Dias LS: Developmental hip dysplasia potentiated by inappropriate use of the Pavlik harness. J Pediatr Orthop 1992;12:722-726.
Atar D, Lehman WB, Grant AD: Pavlik harness pathology. Isr J Med Sci 1991;27:325-330.
Weinstein SL: Developmental hip dysplasia and dislocation, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 4. Philadelphia, Pa, Lippincott-Raven, 1996, pp 903-950.

Question 46

A 7-year-old child is unresponsive, tachycardic, and has a systolic blood pressure of 50 mm Hg after being struck by a car. The patient is intubated and venous access is obtained. The secondary survey reveals an unstable pelvis. Despite adequate resuscitation, the patient continues to be hemodynamically unstable. What is the best course of action?

Explanation

DISCUSSION: The patient is hemodynamically unstable, so any treatment should be aimed at stabilization. Airway, breathing, and circulation are the most important areas to control initially; the patient has been intubated and has adequate venous access. Despite fluid resuscitation, the child remains hypotensive, indicating continued blood loss. With an unstable pelvic fracture there can be significant hemorrhage. Decreasing the pelvic volume can decrease blood loss related to the pelvic fracture. This can be done in the emergency department by applying a pelvic sling. Other means of decreasing pelvic volume include a pelvic clamp, a simple anterior frame pelvic external fixator, or a simple sheet tied around the pelvis. These maneuvers may stabilize the patient so that further evaluation and treatment can be undertaken. All of the other choices will delay stabilization and should be postponed until the patient is stabilized.
REFERENCES: Torode I, Zieg D: Pelvic fractures in children. J Pediatr Orthop 1985;5:76-84.
Eichelberger MR, Randolph JG: Pediatric trauma-initial resuscitation, in Moore EE, Eisman B, Van Way CE (eds): Critical Decisions in Trauma. St Louis, MO, CV Mosby, 1984, p 344.
Ganz R, Krushell RJ, Jacob RP, Kuffer J: The antishock pelvic clamp. Clin Orthop 1991;267:71-78.

Question 47

Figures 3a and 3b show the current radiographs of a 58-year-old man who underwent total knee arthroplasty with a cruciate ligament sparing prosthesis 7 years ago. Examination reveals boggy synovitis and moderate pain, particularly anteriorly. Management should consist of

Explanation

DISCUSSION: The patient has symptoms of synovitis that are most likely the result of the release of particles from the tibial polyethylene. While observation may be warranted in a completely asymtomatic knee, some intervention is indicated for this patient as there is clear radiographic evidence of lysis in both the tibia and femur. The decision about the extent of the revision should be made at the time of surgery. A limited incision technique is not indicated. Grafting (or using graft substitute) the defect is the most appropriate approach for treating the osteolytic lesions. While a posterior stabilized prosthesis might be the solution, surgical findings might dictate otherwise.
REFERENCE: Brassard MF, Insall JN, Scuderi GR: Complications of total knee arthroplasty, in Insall JN, Scott WN (eds): Surgery of the Knee, ed 3. Philadelphia, PA, Churchill Livingstone, 2001, vol 2, pp 1801-1844.

Question 48

A 37-year-old patient with type I diabetes mellitus has a flexor tenosynovitis of the thumb flexor tendon sheath following a kitchen knife puncture wound to the volar aspect of the thumb. Left unattended, this infection will likely first spread proximally creating an abscess in which of the following spaces of the palm?

Explanation

DISCUSSION: Flexor tenosynovitis of the thumb flexor tendon sheath can spread proximally and form an abscess within the thenar space of the palm. The flexor pollicis longus tendon does not pass through the central space of the palm or the hypothenar space of the palm. The flexor pollicis longus tendon does pass through the carpal tunnel, but this is not a palmar space. The three palmar spaces include the hypothenar space, the thenar space, and the central space. The posterior adductor space would likely only be involved secondarily after spread from a thenar space infection.
REFERENCES: Hollinshead W: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, vol 3, pp 478-479.
Lee D, Ferlic R, Neviaser R: Hand infections, in Berger R, Weiss AP (eds): Hand Surgery. Philadelphia, PA, Lippincott Williams & Wilkins, 2004, pp 1784-1785.

Question 49

Figures 4a through 4c show the clinical photographs and radiographs of a 12-month-old boy who has progressive difficulty wearing shoes because of the length of the second toe, as well as width of the forefoot. Management should consist of

Explanation

DISCUSSION: The patient has macrodactyly involving the second ray, with significant enlargement of the width and height of the foot. The radiographs show widening of the interval between the first and second metatarsal and between the second and third metatarsal. With this degree of involvement, amputation of the second ray with excision of the overgrowth of affected soft tissue provides the most consistent desired reduction in foot size. A threaded Steinmann pin should be inserted across the remaining metatarsals until healing has occurred. Patients with macrodactyly should be examined to exclude neurofibromatosis type 1 and Klippel-Trenaunay-Weber syndrome.
REFERENCE: Sullivan JA: The child’s foot, in Morrissy RT, Weinstein SL (eds): Lovell & Winter’s Pediatric Orthopaedics, ed 4. Philadelphia, Pa, Lippincott-Raven, 1996, pp 1077-1135.

Question 50

A 28-year-old hockey player has a shoulder deformity after being checked into the boards. Examination reveals that swelling has improved, but there is tenderness along the distal clavicle. Radiographs reveal a grade II acromioclavicular joint separation. Initial management should consist of

Explanation

DISCUSSION: The most common shoulder injury in hockey players is to the acromioclavicular joint. Early rest and control of pain and inflammation is the preferred management. Surgery is reserved for patients with significant coracoclavicular disruption that has failed to respond to nonsurgical management. Cross-chest stretches and overhead exercises may increase symptoms. A cortisone injection within the glenohumeral joint will have little effect.
REFERENCES: Nuber GW, Bowen MK: Acromioclavicular joint injuries and distal clavicle fractures. J Am Acad Orthop Surg 1997;5:11-18.
Weinstein DM, McCann PD, McIlveen SJ, Flatow EL, Bigliani LU: Surgical treatment of complete acromioclavicular dislocation. Am J Sports Med 1995;23:324-331.

Question 51

A 51-year-old male 2-pack per day smoker presents with a hyperkeratotic light brown plaque on the dorsum of his left ring finger that has been present for 7 years. It measures 14 mm by 13 mm. Initially, it responded to topical wart treatments, but has failed to do so recently so he sought evaluation by a dermatologist who biopsied the lesion. The results revealed squamous cell carcinoma (SCC) in situ, and he was referred for further surgical management. He has no other skin lesions, no history of SCC and no axillary lymphadenopathy. What is the next step in management?

Explanation

EXPLANATION:
SCC in situ is a low-grade malignancy that typically presents as painless lesions on areas of high sun exposure such as the dorsum of the hand and fingers. The recommended treatment for lesions smaller than 100 mm is wide excision with 4 mm margins to a depth 1 layer below the tumor, along with any adjacent area of induration. Sentinel lymph node biopsy is typically not indicated in the setting of a low-grade tumor such as this one and in the absence of axillary lymphadenopathy.

Question 52

A newborn girl is referred for evaluation of suspected hip instability. What information from her history would place her in the highest risk category?

Explanation

DISCUSSION: Breech positioning has been noted as the risk factor that most increases the relative risk of developmental dysplasia of the hip in multiple series and meta-analysis. All the other factors also increase the risk but to a lesser magnitude.
REFERENCES: Lehmann HP, Hinton R, Morello P, et al: Developmental dysplasia of the hip practice guideline: Technical report. Committee on Quality Improvement, and Subcommittee on Developmental Dysplasia of the Hip. Pediatrics 2000;105:E57.
Haynes RJ: Developmental dysplasia of the hip: Etiology, pathogenesis, and examination and physical findings in the newborn. Instr Course Lect 2001;50:535-540.

Question 53

What is the most appropriate treatment for a 17-year-old boy who sustained a gunshot wound to his forearm from a handgun with a muzzle-velocity of 1000 feet/second if he is neurovascularly intact and radiographs reveal no fracture?

Explanation

DISCUSSION: The question refers to appropriate management of a gunshot wound to the forearm. The first question that must be answered when evaluating gun shot injuries is whether the gunshot is low velocity or high velocity. Low-velocity wounds are less severe, are more common in the civilian population, and are typically attributed to bullets with muzzle velocities below 1,000 to 2,000 feet per second. Tissue damage is usually more substantial with higher-velocity (greater than 2,000 to 3,000 fps) military and hunting weapons. In this question, a muzzle velocity of 1,000 ft/sec is provided. Low velocity injuries with stable, non-operative fractures can be treated with local wound care and oral antibiotics.
The two referenced articles offer guidance for treating low-velocity gunshot injuries with stable, non-operative fracture patterns. The first article by Geissler et al is a retrospective study comparing 25 patients that prospectively received local irrigation and debridement, tetanus prophylaxis and a long acting cephalosporin intramuscularly to a random retrospective sample of 25 patients with similar ballistic-induced fractures and wounds managed by local debridement and 48h of intravenous antibiotics. One infection occurred in each group, requiring further therapy. It was concluded that patients with low-velocity gunshot induced fractures can be managed without the use of short-term intravenous antibiotics with no increased risk of infection.
In the second study, Dickey et al evaluated the efficacy of an outpatient management protocol for patients with a gunshot-induced fracture with a stable, non-operative configuration. 41 patients with a grade I or II open, nonoperative fracture secondary to a low-velocity bullet were treated with 1gm of cefazolin administered in the emergency room and a 7-day course of oral cephalexin. No patient developed a deep infection. Thus, local I&D, tetanus, and oral antibiotics for 2-3 days is adequate for low velocity gunshot wounds

Question 54

A patient who underwent a L4-L5 hemilaminotomy and partial diskectomy for radiculopathy 8 weeks ago now reports increasing low back pain without neurologic symptoms. A sagittal T2-weighted MRI scan is shown in Figure 13a, and a contrast enhanced T1-weighted MRI scan is shown in Figure 13b. What is the most appropriate management for the patient’s symptoms? Review Topic

Explanation

The MRI scans show Modic changes in the L4-L5 vertebral bodies due to spondylosis. There is no increased fluid signal or enhancement in the L4-L5 disk to suggest infection or any other pathologic process. Therefore, the patient’s pain should be treated with a course of physical therapy and rehabilitation. There is no infection; therefore, IV antibiotics and debridement are not indicated. Similarly, a
pseudomeningocele is not present. A revision diskectomy is useful for recurrent radiculopathy but would not be helpful for degenerative low back pain.
(SBQ12SP.29) A 17-year-old female is undergoing posterior instrumented fusion from T5-T12 for adolescent idiopathic scoliosis. At the time of the correction maneuver, the neurophysiologist notifies you of a 60% decrease in somatosensory evoked potential (SSEP) amplitude throughout bilateral lower extremities. Which of the following is an acceptable approach to manage this finding? Review Topic
Immediate wake-up test with examination for clonus
Drop the mean arterial pressure (MAP) to ~60mmHg
Discontinue instrumentation and optimize MAP to 85mmHg or greater
Immediate infusion of intravenous corticosteroids
Modification of the anesthesia plan to include inhalational agents only followed by repeated SSEP testing
The patient has a significant drop in SSEP amplitudes at the completion of the corrective maneuver. The most appropriate response is to raise the MAP to 85 mmHg or greater, discontinue the instrumentation, re-evaluate the SSEPs, and if there is no improvement, to consider reversing the reduction of the deformity.
Intra-operative neurophysiologic monitoring is an effective method to monitor insults to the spinal cord and its exiting roots during spinal instrumentation. The common measurements include SSEPs, which monitor sensory potentials transmitted through the dorsal column system, and motor-evoked potentials (MEPs), which monitor motor response to a trans-cranial stimulus. Decreases in amplitude and latency of the circuits are recorded, however diminished signal amplitudes are more sensitive for neurologic injury, and decreases of of >50-60% being highly concerning. The wake-up test involves reversal of anesthesia so that an intra-operative neurologic examination can be performed.
Devlin et al. reviewed the basic science and practice of neurophysiologic monitoring in spine surgery. They proposed an algorithmic approach to managing intraoperative alerts which include discontinuation of inhalational anesthetics, increasing the MAP to >90 mmHg, discontinuing instrumentation, and performing a wake-up test if neurologic signals fail to normalize.
Herdmann et al. reviewed the practice of neurophysiologic monitoring and the effects of anesthesia upon signal transduction. They report that anesthesia affecting a neuron's intrinsic excitability can alter the results of monitoring. Inhalational anesthetics and decreased MAPs can be responsible for decreased amplitudes.
Vitale et. al. developed a consensus-based intraoperative checklist for management of lost neuromonitoring signals. In this checklist, the first steps across the surgical and anesthetic teams should include: stop the case and announce signal losses to the room, optimize the mean arterial pressure, discuss the status of anesthetic agents, and discuss reversible surgical actions just prior to signal loss.
Incorrect

Question 55

Figure 15a shows the radiograph of a patient who has a chondrosarcoma of the acetabulum. Bone scans are shown in Figures 15b and 15c. Numerous soft subcutaneous masses are present. A clinical photograph of the hand is shown in Figure 15d. What is the most likely diagnosis?

Explanation

DISCUSSION: Chondrosarcomas associated with diffuse bone lesions (enchondromas) are characteristic of Ollier’s disease. When accompanied by subcutaneous masses (hemangiomas), the condition is called Maffucci’s syndrome. Multiple hereditary exostosis is characterized by diffuse osteochondromas. McCune-Albright syndrome is characterized by polyostotic fibrous dysplasia with cafe-au-lait spots and precocious puberty. Neurofibromatosis can have associated bone lesions but is not associated with chondrosarcomas.
REFERENCES: Sun TC, Swee TC: Chondrosarcoma in Maffucci’s syndrome. J Bone Joint Surg Am 1985;67:1214-1219.
Schwartz HS, Zimmerman NB, Simon MA, et al: The malignant potential of enchondromatosis. J Bone Joint Surg Am 1987;69:269-274.
Began WB: Dyschondroplasia and hemangiomata (Maffucci’s syndrome). Arch Intern Med 1958;102:544.

Question 56

A 12-year-old child with L4 myelomeningocele who is schedules for foot surgery has a functioning ventriculoperitoneal shunt and has no history of allergies. Management should include

Explanation

The high prevalence of latex allergy in patients with myelomeningocoele is thought to result from a heavy degree of latex exposure throughout life, including closure of the spinal defect, multiple orthopedic, urologic, and neurologic procedures, and repeat bladder catheterization. As many as 50% of these patients may have the allergy. Appropriate perioperative management includes utilization of a latexfree protocol.

Question 57

A 32-year-old male hockey player who is right-hand dominant was checked from behind and landed with full force into the boards. In the emergency department he reports shortness of breath. Figure 113 shows a 2-D CT scan. What is the best initial treatment for this injury?

Explanation

The CT scan shows a posterior sternoclavicular joint dislocation. Initial management involves attempted closed reduction in the operating room. This can be performed with a towel clip and anterior translation of the displaced clavicle. However, the orthopaedic surgeon should be prepared to open this injury and reconstruct the joint if necessary. Furthermore, it is recommended that a thoracic surgeon be available prior to beginning these procedures. Open reduction should be done only if closed reduction is unsuccessful.

Question 58

Figure 163 is the radiograph of an 81-year-old man who had primary total hip arthroplasty 12 years ago and now has a 3-month history of left hip weight-bearing thigh pain. The appropriate treatment at this time is

Explanation

DISCUSSION
This patient has a loose cemented femoral component. The implant has subsided and the femur has remodeled into a varus position. Although the component may be removable without an extended trochanteric osteotomy, the varus bow of the femur will not allow distal fixation without use of an extended trochanteric osteotomy. The acetabular component appears
to be well fixed, and, as a result, should be retained in this older patient. An evaluation of stability could lead to possible revision of the acetabulum, and implants should be available.

Question 59

..A lateral radiograph (Figure 131a), sagittal short tau inversion recovery MRI scan (Figure 131b), and an axial T1 contrast MRI scan (Figure 131c) were performed on a 15-year-old boy who has injured his right knee twice during the last 5 months. He has a reduced range of motion of the knee and posterior thigh tenderness. A biopsy showed bland spindle cells, giant cells, and blood-filled spaces without endothelial lining. What is the most appropriate treatment?

Explanation

CLINICAL SITUATION FOR QUESTIONS 132 THROUGH 134

Figure 132 is the bone scan of a 73-year-old man who is referred from his family doctor with diffuse bone pain, fatigue, and right knee pain. Examination is notable for pain with motion about the right knee and mild hyporeflexia.

Question 60

Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease that is characterized by Review Topic

Explanation

CTE is a neurodegenerative disease that occurs years or decades after recovery from acute or postacute effects of head trauma. The exact relationship between concussion and CTE is not entirely clear; however, early behavioral manifestations of CTE have been described by family and providers to include apathy, irritability, and suicidal ideation. For some patients, cognitive difficulty such as poor episodic memory and executive function may be the first signs of CTE. Onset most often occurs in midlife after athletes have completed their sports careers, with mean age of onset at 42 years. The effects on the brain are degenerative, leading to a permanent state of derangement. Autopsy findings demonstrate multiple gross pathological findings. The condition is more common among contact athletes.

Question 61

-Four months after injury, the tibia is showing evidence of slow healing on radiographs. What is the optimal treatment for this potential nonunion?

Explanation

DISCUSSION FOR QUESTIONS 108 THROUGH 110:
This patient is unstable and is not a good candidate for Early Total Care (ETC) and therefore should be managed by the tenets of Damage Control Orthopaedics (DCO). Débridement and external fixation is preferable for this patient. Intramedullary nails would be a component of ETC. Calcaneal traction is not considered ideal because it does not allow the patient to travel as easily. The S.P.R.I.N.T. study concluded that while reamed nails may offer benefit in closed fractures, there was no difference between reamed or unreamed nails in the treatment of open fractures of the tibia. Uniplanar external fixation and tibial plating are not considered the best options for open tibia fractures. Additional findings of the S.P.R.I.N.T. study conclude that delaying surgical intervention for at least 6 months after injury may reduce the need for reoperation.

Question 62

What spinal nerves in the cauda equina are primarily responsible for innervation of the bladder?

Explanation

DISCUSSION: The spinal nerves primarily responsible for bladder function are the S2, S3, and S4 nerve roots. With significant compression of the cauda equina by either disk herniation, tumor, or degenerative stenosis, bladder dysfunction may result.
REFERENCES: Hoppenfeld S: Physical Examination of the Spine and Extremities. Norwalk, CT, Appleton-Century-Crofts, 1976, p 254.
Pick TP, Howden R (edS): Gray’s Anatomy. New York, NY, Bounty Books, 1977, p 1004.

Question 63

Figure 11a shows the AP pelvis radiograph of a 25-year-old man who sustained a spinal cord injury 10 years ago. A bone scan and a CT scan are shown in Figures 11b and 11c. To prevent recurrence after resection, management should consist of

Explanation

DISCUSSION: The studies reveal significant heterotopic ossification that appears to be mature. Following resection, the most reliable way to prevent recurrence is with low-dose external-beam radiation therapy. Bisphosphonate therapy can be considered; however, when terminated, heterotopic bone may reform. Heterotopic ossification is unrelated to the patient’s endocrine status and is not associated with any metabolic abnormalities.
REFERENCES: Moore K, Goss K, Anglen J: Indomethacin versus radiation therapy for prophylaxis against heterotopic ossification in acetabular fracture. J Bone Joint Surg Br 1998;80:259.
Stover S, Niemann K, Tullos J: Experience with surgical resection of heterotopic bone in spinal cord injury patients. Clin Orthop 1991;263:71-77.

Question 64

Parosteal osteosarcoma

Explanation

Chemotherapy has no role in the treatment of which of the following tumors:

Question 65

A construction worker sustained a comminuted calcaneus fracture 2 years ago. He now reports progressive hindfoot pain with the recent onset of anterior ankle pain. A lateral hindfoot radiograph is shown in Figure 31. Treatment should consist of

Explanation

DISCUSSION: The patient has subtalar arthrosis, a loss of heel height with anterior ankle impingement. The mechanics of the ankle are impaired, and dorsiflexion is painful and limited. The talar declination angle is measured by drawing a line through the longitudinal axis of the talus and the plane of support of the foot on a weight-bearing lateral radiograph. Anterior impingement is suggested with any value below 20 . By performing a distraction arthrodesis through the subtalar joint, the normal declination of the talus is reestablished, eliminating the anterior ankle impingement. Tibiotalocalaneal fusion would be inappropriate because the patient does not have arthritic symptoms in the ankle. Ankle arthroscopy or in situ arthrodesis would not reestablish appropriate ankle mechanics, and the osteophytes would be prone to redevelop. Lateral wall ostectomy may help with impingement at the level of the fibula or the lateral ankle but would provide no benefit to anterior ankle impingement.
REFERENCES: Carr JB, Hansen ST, Benirschke SK: Subtalar distraction bone block fusion for late complications of os calcis fractures. Foot Ankle 1988;9:81-86.
Myerson M, Quill GE Jr: Late complications of fractures of the calcaneus. J Bone Joint Surg Am 1993;75:331.

Question 66

A 52-year-old man with a BMI of 40 and primary osteoarthritis undergoes total hip arthroplasty through a posterolateral approach. To retract the femur anteriorly when exposing the acetabulum, the surgeon places a sharp curved retractor over (anterior to) the anterior inferior iliac spine. Pulsatile bleeding is encountered. A branch of which artery has been injured?

Explanation

DISCUSSION

Video 182 for reference
The femoral artery crosses the hip joint anterior to the anterior hip capsule. The medial femoral circumflex artery enters the joint along the route of the obturator externus. The obturator artery enters the hip joint beneath the transverse acetabular ligament. The iliac circumflex vessel arises superior to the hip joint.

RESPONSES FOR QUESTIONS 183 THROUGH 188
For each clinical scenario described below, identify the corresponding anteroposterior pelvic radiographic image shown above.

Question 67

Clinical evidence suggests that grafts for replacing a torn anterior cruciate ligament often stretch after surgery. What is the most probable mechanism for this behavior?

Explanation

DISCUSSION: The stretching of the graft occurs over time as the graft is loaded. Time-dependent deformation under load is called creep and is common in viscoelastic materials such as ligament tissue. Creep can occur under both static and cyclic load conditions; time-dependent deformation will occur as long as load is applied to the tissue. Similarly, when a graft is initially tensioned to a given deformation at surgery, the load generated in the graft will decrease over time; this behavior is called stress relaxation and also is indicative of a viscoelastic material. Water content may affect the viscoelastic properties by changing the friction between collagen fibers, but studies have shown little difference in water content between grafts and normal ligaments. Fatigue failures may manifest themselves through damage to the ligament tissue, but this would require higher loads than are routinely experienced by grafts. Elastic stretch is recoverable and, therefore, does not contribute to a permanent stretch. Similarly, gross failure at the attachment would not cause a stretch, but rather a catastrophic instantaneous instability.
REFERENCES: Boorman RS, Thornton GM, Shrive NG, et al: Ligament grafts become more susceptible to creep within days after surgery. Acta Orthop Scand 2002;73:568-574.
Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 596-609.
Lu L, Kaufman KR, Yaszemski MJ: Biomechanics, 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 68

A 2-year-old child refused to walk 3 days prior to being seen because of pain in the left hip. The pain has gradually subsided and the child is now walking. He is afebrile and has full motion of the hips. Laboratory studies show a normal CBC with differential and C-reactive protein. An ultrasound shows a joint effusion in the right hip. What is the most likely diagnosis?

Explanation

DISCUSSION: The most likely diagnosis is toxic synovitis, and the normal C-reactive protein supports that diagnosis. Juvenile inflammatory arthritis is extremely rare to present with hip involvement. The child most likely does not have a bacterial infection because he has improved rapidly without treatment. A normal CBC with differential precludes the diagnosis of leukemia.
REFERENCES: Herring JA (ed): Tachdjian’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, WB Saunders, 2008, pp 2068-2070.
Del Beccaro MA, Champoux AN, Bockers T, et al: Septic arthritis versus transient synovitis of the hip: The value of screening laboratory tests. Ann Emerg Med 1992;21:1418-1422.
Kocher MS, Mandiga R, Zurakowski D, et al: Validation of a clinical prediction rule for the differentiation between
2010 Pediatric Orthopaedic Examination Answer Book • 11
septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am 2004:86:1629-1635.
AL-Madena Copy
12 • American Academy of Orthopaedic Surgeons

Figure 7a Figure 7b

Question 69

A 17-year-old male football player is seen 1 week after developing symptoms of infectious mononucleosis in the middle of the season. Examination reveals evidence of splenomegaly. He and his parents want to know if he can play in a game the following day. What is the most appropriate recommendation? Review Topic

Explanation

Infectious mononucleosis (IMN) is a self-limiting viral (Epstein-Barr virus) infection that affects mostly adolescents. One of the clinical findings in IMN is splenomegaly. Unfortunately, the splenomegaly is palpable only 50% of the time. The risk for spontaneous splenic rupture is highest 3 weeks after the onset of symptoms. Thus, most clinicians recommend return to contact sports after 4 weeks from the onset of symptoms. This patient presented 1 week after the onset of symptoms, so he can return to play in 3-4 weeks from the time he was examined. The athlete should be afebrile, well hydrated, and asymptomatic. Airway obstruction is usually not of concern. Disease transmission to teammates is possible in the acute phases.

Question 70

A 12-year-old gymnast has had elbow pain for 4 weeks. She denies any specific trauma to the elbow. Examination reveals lateral pain and no instability on testing. Range of motion is as follows: 15 degrees, loss of elbow extension, normal flexion, and normal pronation and supination. Radiographs reveal a 3- x 7-mm radiolucency of the capitellum. A T1-weighted MRI scan reveals a single solitary lesion, and T2-weighted images show no signal around the lesion. There are no intra-articular loose bodies. Appropriate management should include which of the following? Review Topic

Explanation

This is a typical presentation for an osteochondral lesion of the capitellum. This patient is young and has, by definition, a stable lesion and has excellent potential to heal this lesion with nonsurgical management. However, the patient should stop her activities (gymnastics) to prevent further damage and the possible development of an unstable lesion that might then necessitate surgery. Surgical procedures are generally not necessary for the treatment of these lesions.

Question 71

50%

Explanation

By 5 years, the allograft cartilage will be completely acellular, so there will be no residual donor chondrocytes.
Enneking et al. conducted both radiographic and histologic studies of sixteen massive retrieved human allografts four to sixty-five months after implantation. Analysis of the articular cartilage revealed no evidence that any chondrocytes had survived, even when the graft had been cryoprotected before it was preserved by freezing.
A 64-year-old woman with a longstanding history of rheumatoid arthritis complains of finger dysfunction for the past 6 months. Figure A displays her hand during active extension of all fingers. Figure B displays her hand maintaining her fingers extended following passive extension. What is the next most appropriate treatment for the ring finger?
Spiral oblique retinacular ligament reconstruction
Sagittal band reconstruction
Lateral band reconstruction
Central slip reconstruction
Triangular ligament and transverse retinacular ligament reconstruction
Sagittal band disruption is often associated with rheumatoid arthritis. When this patient attempts to actively extend the affected digit, the extensor tendon
subluxates ulnarly as a result of the sagittal band rupture, and is left with an extensor lag. If one passively extends the finger fully, the patient is able to maintain this position, as the tendon is intact.
Sagittal band reconstruction can be performed with Watson's technique of creating a distally based tendon graft harvested from the central third of the extensor tendon, passed deep to the intermetacarpal ligament and sutured back to itself. Illustration A depicts an intraoperative view of the tendon before reconstruction and Illustration B displays tendon following sagittal band reconstruction. Illustration C displays all of the anatomic locations
of the options listed above.
A splenectomy is performed in a 7-year-old boy following a motor vehicle accident. All of the following are recommended for long-term management EXCEPT:
Pneumococcal vaccination
Haemophilus influenza type B vaccination
Meningococcal group C vaccination
Lifelong prophylactic antibiotics
Hepatitis A vaccination
All of the responses are correct except the need for Hepatitis A vaccine. Hepatitis A is a virus with tropism for hepatocytes which causes infection from fecal-oral contaminated food/water, and shows no increased rate of either infectivity or morbidity in patients with hyposplenism.
Basic recommendations for splenectomized patients include:
All splenectomized patients and those with functional hyposplenism should receive pneumococcal immunization.
Patients not previously immunized should receive haemophilus influenza type B vaccine.
Patients not previously immunized should receive meningococcal group C conjugate vaccine.
Influenza immunization should be given.
Lifelong prophylactic antibiotics are still recommended (oral phenoxymethylpenicillin or erythromycin). This is seemingly despite lack of good data demonstrating a role for lifelong chemoprophylaxis and the acknowledgement that long-term compliance may be problematic.
Davies et al review the current level of evidence supporting these guidelines
for infection prevention in patients with hyposplenism. New to these guidelines are issues regarding occupational exposure and the use of the meningococcal group C and the seven-valent pneumococcal vaccine in non-immunized hyposplenic patients.
Gandhi et al evaluated their nonoperative management of blunt splenic injury in pediatric trauma care. They found compared to historical controls, children with blunt splenic injuries who were hemodynamically stable could be safely monitored with a protocol which required 4 days of inpatient care, 3 weeks of quiet home activities, and 3 months of light activity. This protocol seems to allow for safe return to unrestricted activity.
Incorrect Answer:
Ligaments attach to bone by both direct insertion and indirect insertion. Which of the following most accurately describes the order of the four transition zones of direct insertion?
Ligament > fibrocartilage > mineralized fibrocartilage > bone
Ligament > mineralized fibrocartilage > fibrocartilage > bone
Ligament > mineralized fibrocartilage > periosteum > bone
Ligament > Sharpey's fiber > periosteum > bone
Ligament > periosteum > fibrocartilage > bone
There are two types of tendon/ligament insertion into bone: direct and indirect insertion. The more common, indirect insertion, occurs when the superficial ligament fibers insert into the periosteum. Direct insertion of tendon/ligaments
into bone occurs through a transition of 4 distinct phases: 1) ligament, 2) fibrocartilage, 3) mineralized fibrocartilage, and 4) bone.
While flexing the elbow to perform a biceps curl, what type of muscle contraction is occuring?
Isometric
Isokinetic
Plyometric
Eccentric
Concentric
Concentric muscle contractions occur when a muscle shortens during contraction, as in the upward motion when performing a biceps curl. An eccentric contraction occurs when a muscle lengthens with contraction, as in the "negative" or lowering motion of a biceps curl. An example of an isometric (muscle contracts while maintaining constant length) contraction would be pushing against an immovable object. An example of an isokinetic (muscle has constant speed of contraction) occurs with specialized equipment like Cybex machines. Plyometric contractions occur when a muscle rapidly lengthens just prior to contraction - like during repetitive box jumping.
Woo and Buckwalter describe the mechanisms, barriers, and molecular processes involved in ligament and tendon injury and repair.
A 34-year-old laborer has her left foot crushed in a piece of farming equipment as shown in Figure A. All of the following are reasons for a poor outcome following a crush injury to the foot EXCEPT:
Workers compensation injury
Development of reflex sympathetic dystrophy (complex regional pain syndrome)
Delayed soft-tissue coverage in mangled extremities
Immediate skeletal stabilization
Ongoing litigation
This patient has a mangled extremity. Rigid skeletal stabilization is recommended to enhance soft-tissue healing.
Level 4 evidence from Myerson et al found that delayed soft-tissue coverage in mangled extremities correlated with poor outcome. Poor results also occurred
if treatment was not immediately initiated (immediate debridement shown in Illustration A), if patients subsequently had neuritis or reflex sympathetic dystrophy, or if patients were involved in ongoing workers' compensation and litigation. Neuroischemia following substantial soft-tissue injury likely plays a role in the development of chronic pain after crush injuries to the foot, either through direct trauma to the peripheral nerves or by intraneural or extraneural fibrosis. This trauma to the nerve may cause chronic neuritis, which then triggers a sympathetically mediated reflex sympathetic dystrophy (complex regional pain syndrome).
A 65-year-old man undergoes total knee replacement and is found to have deep vein thrombosis two days later. What molecule is
thought to be involved in this process when it is released during surgical dissection?
Prothrombin
RANKL
IL-1b
Thromboplastin
Factor XI Corrent answer: 4
Thromboplastin is also known more commonly as Tissue Factor (TF), which is involved in the Extrinsic Pathology of the coagulation cascade.
During surgical dissection, insults occur to the endothelial walls of blood vessels. There are three ways in which the body reacts to form a clot so that the patient does not bleed excessively. One is via vessel contraction, another is by collagen release, and a third is by tissue thromboplastin release. Thromboplastin release is part of the extrinsic coagulation pathway (see
Illustration A). Thromboplastin release activates Factor VII which activates Factor X which converts prothrombin to thrombin. Thrombin is the catalyst for converting fibrinogen to fibrin which induces clot formation. While this is useful for decreasing bleeding, it is the same mechanism by which a deep venous thrombosis (DVT) develops.
Which of the following materials has a Young's modulus of elasticity that is most similar to cortical bone
Titanium
Zirconia
Stainless steel
Ceramic (Al2O3)
Alloy (Co-Cr-Mo)
Of the materials listed Titanium has an elastic moduli closest to cortical bone. Titanium is extra-ordinarily light, strong, highly ductile, and corrosion resistant. Titanium is however very notch sensitive and has poor wear resistance.
Young Modulus of Elasticity is defined as the stiffness (ability to maintain
shape under external loading) of a material. On the stress vs. strain curve it is defined as the slope of the line in the elastic zone (see Illustration A). Young’s modulus is constant and different for each material. The relevant moduli (unit GPa) are approximated below:

Question 72

Figure 36 shows the radiograph of a 28-year-old man who injured his shoulder in a motocross race. Management should consist of

Explanation

DISCUSSION: Fractures of the distal one third of the clavicle have a high incidence of delayed union (45% to 67%) and nonunion (22% to 33%) with nonsurgical management. Surgical stabilization with tension band techniques or a combination of plate and screw techniques is indicated, especially in young, active patients. In this patient, significant displacement of the fracture implies injury to the coracoclavicular ligaments with a higher risk of delayed union or nonunion. Various surgical treatments have been recommended, but the use of smooth wires is not indicated because of the potential for hardware migration.
REFERENCES: Jupiter JB, Ring D: Fractures of the clavicle, in Ianotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management, ed 1. Philadelphia, PA, Lippincott, Williams and Wilkins, 1999, pp 709-736.
Kona J, Bosse MJ, Staehli JW, Rosseau RL: Type II distal clavicle fractures: A retrospective review of surgical treatment. J Orthop Trauma 1990;4:115-120.

Question 73

The primary function of structure “A” in Figure 29 is to limit

Explanation

DISCUSSION: The primary function of the popliteofibular ligament is to resist posterolateral rotation of the tibia on the femur, although it also secondarily resists varus angulation and posterior displacement of the tibia on the femur. The posterior cruciate ligament resists posterior tibial displacement, especially at 90 degrees of flexion. The lateral collateral ligament primarily resists varus displacement at 30 degrees of flexion but also resists posterolateral rotatory displacement with flexion that is less than approximately 50 degrees. The anterior and posterior cruciate ligaments resist varus displacement (along with the lateral collateral ligament) at 0 degrees of flexion. The anterior cruciate ligament primarily resists anterolateral displacement of the tibia on the femur.
REFERENCES: Sugita T, Amis AA: Anatomic and biomechanical study of the lateral collateral and popliteofibular ligaments. Am J Sports Med 2001;29:466-472.
Veltri DM, Deng XH, Torzilla PA, et al: The role of the cruciate and posterolateral ligaments in stability of the knee: A biomechanical study. Am J Sports Med 1995;23:436-443.

Question 74

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

Explanation

DISCUSSION: The patient has chronic tibial osteomyelitis that is due to low virulent bacteria. The history and studies do not suggest the need for an amputation or a free-flap procedure. This is a localized tibial infection that is in a healed bone; there is no need to resect the entire area of the tibia bone around the infection. The most appropriate treatment is curettage, debridement of nonviable bone, and placement of absorbable antibiotic beads, followed by a course of IV antibiotics from 1 to 4 weeks and a 6-week course of oral antibiotics. Studies have shown that in cases of localized osteomyelitis that are of low virulence, as little as 1 week of IV antibiotics followed by 6 weeks of oral antibiotics is successful.
REFERENCES: Patzakis MJ, Zalavras CG: Chronic posttraumatic osteomyelitis and infected nonunion of the tibia: Current management concepts. J Am Acad Orthop Surg 2005;13:417-427.
Beals RK, Bryant RE: The treatment of chronic open osteomyelitis of the tibia in adults.

Clin Orthop Relat Res 2005;433:212-217.

Question 75

Which treatment is associated with decreased complications related to femoral nerve blocks for TKA?

Explanation

DISCUSSION
TKA among elderly patients can be problematic, considering their potential for complex comorbidities including diminished cognitive function. As patients age, their tolerance for certain medications diminishes. Regional anesthesia is an important adjunct to a multimodal pain program, which can reduce narcotic pain medication use and improve cognitive function through less reliance on systemic medications. With regional pain management such as femoral nerve blocks comes potential for an increase in complications such as falls. Femoral nerve blocks improve pain but also have a large impact on quadriceps and motor function, which places patients at higher risk for falls.

Question 76

A 52-year-old woman reports nagging shoulder pain that has been present for months and is slowly progressive in nature. The patient also reports nocturnal pain and notes that the pain is not activity related. Figures 27a and 27b show the radiograph and bone scan, and Figures 27c through 27e show T 1 -weighted, T 2 -weighted, and gadolinium MRI scans, respectively. Based on these findings, what is the most likely diagnosis?

Explanation

DISCUSSION: The radiograph reveals a metaphyseal lesion with some stippled mineralization suggesting a chondroid tumor. The bone scan shows increased uptake, beyond what is expected for a simple enchondroma, and beyond the limits of the lesion. The MRI sequences shows a lobular lesion on the T₁- and T₂-weighted (bright on the T₂ sequence) images with inhomogeneous uptake of gadolinium; both findings are typical for a chondroid lesion. The history of pain, the positive bone scan, the age of the patient, the size of the lesion, and the central location (enostotic) of the lesion all suggest a malignant cartilage tumor. The images are not consistent with the other diagnoses. In particular, plasmacytoma is more uniformly bright on T₂-weighted images and often has a negative bone scan.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 187-194.
Resnick D (ed): Diagnosis of Bone and Joint Disorders. Philadelphia, PA, WB Saunders, 2002, pp 3897-3904.

Question 77

A 21-year-old woman has a nontraumatic rupture of the Achilles tendon. Which of the following commonly prescribed medications has been associated with this condition?

Explanation

DISCUSSION: Fluoroquinolones have been associated with increased rates of tendinitis, with special predilection for the Achilles tendon. Tenocytes in the Achilles tendon have exhibited degenerative changes when viewed microscopically after fluoroquinolone administration. Recent clinical studies have shown an increased relative risk of Achilles tendon rupture of 3.7. The other listed drugs have no known increase in tendon rupture rates nor tendinitis.
REFERENCES: van der Linden PD, van de Lei J, Nab HW, et al: Achilles tendinitis associated with fluoroquinolones. Br J Clin Pharmacol 1999;48:433-437.
Bernard-Beaubois K, Hecquet C, Hayem G, et al: In vitro study of cytotoxicity of quinolones on rabbit tenocytes. Cell Biol Toxicol 1998;14:283-292.
Maffulli N: Rupture of the Achilles tendon. J Bone Joint Surg Am 1999;81:1019-1036.

Question 78

-A 16-year-old girl was seen after a motor vehicle collision. Imaging studies including plain radiographs,MRI scans, and CT scans confirm bilateral jumped facets at C5-6 without disk herniation. She is alert,oriented, and neurologically intact. What is the most appropriate next step?

Explanation

Question 79

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 80

A 25-year-old recreational soccer player has recurrent shoulder dislocations. He first dislocated his shoulder playing football in high school, was treated in a sling for 6 weeks, and returned to play for the remainder of the season. He did well until 2 years later when he reinjured the shoulder. He says that his shoulder dislocates with little injury and always "feels loose." Examination reveals anterior instability and an MR arthrogram reveals an anterior-inferior labral tear and surgical treatment is recommended. He inquires about the benefits of arthroscopic vs open procedure. Which of the following statements reflects an advantage associated with arthroscopic procedures compared to open stabilization? Review Topic

Explanation

There is much debate in the literature regarding optimal techniques for treatment of shoulder instability. Most studies have suggested a slightly better range of motion of the shoulder after an arthroscopic repair. Recurrent instability rates have been slightly higher with arthroscopic procedures in some studies, while others show the rates are not statistically different. Return to work and/or sports has been shown to be equal or slightly better with open procedures.

Question 81

A 23-year-old male college quarterback presents with acute left shoulder pain after being tackled. A radiograph of the injury is shown in figure A. After successful closed reduction, what shoulder position should be avoided in order to minimize the risk of a repeat injury? Review Topic

Explanation

The patient presents with a traumatic posterior shoulder dislocation and radiographic evidence of a reverse Hill-Sachs type injury. The patient should avoid adduction, 90 degrees flexion, and internal rotation in order to decrease the risk of re-dislocation.
Shoulder stability is achieved through the both dynamic and static stabilizers. The static stabilizers include the bony morphology of the joint, glenoid labrum, capsule, and glenohumeral ligaments. The contributions of the glenohumeral ligaments to shoulder stability are dependent upon the position of the humerus relative to the glenoid. Posterior stability is afforded to the joint by the superior glenohumeral ligament (SGHL) and the posterior band of the inferior glenohumeral ligament (IGHL). The SGHL specifically is taught and provides posterior stability with the shoulder in flexion, adduction, and internal rotation.
Kim et. al. reviewed their experience treating 27 athletes diagnosed with traumatic posterior shoulder instability and treated with arthroscopic posterior labral repair and capsular shift. Most patients were found to have an incompletely stripped posterior capsulolabral complex. After arthroscopic repair and shift, all 26 of the 27 patients treated had improved shoulder function and objective scores, a stable shoulder, and were able to return to sport.
Millett et. al. reviewed posterior shoulder instability. They describe the static restraints of the posterior shoulder as the SGHL, posterior band of IGHL, and the coraohumeral ligament (CHL). The SGHL and CHL are both taught in the position of flexion, adduction, and internal rotation, whereas the posterior band of the IGHL is taught in abduction. They describe posterior instability occuring secondary to overhead sports due to repetitive microtrauma causing gradual capsular failure.
Figure A is an axillary radiograph of the left shoulder demonstrating a posterior dislocation and an engaging reverse Hill-Sachs lesion.
Incorrect Answers:

Question 82

Figure 1 shows the radiograph obtained from a 54-year-old woman with rheumatoid arthritis who has thumb pain and dysfunction. Nonsurgical treatment, including splinting, oral NSAIDs, activity modification, and steroid injections, has failed. What is the most appropriate surgical intervention?

Explanation

EXPLANATION:
Various options exist to treat thumb CMC arthritis: trapezial resection alone, trapezial resection with ligament suspensionplasty or tendon interposition, trapezial resection with both ligament suspensionplasty and tendon interposition, CMC fusion, and CMC replacement. MCP hyperextension can develop in long-standing CMC arthritis, contributing to CMC instability as well as thumb pain and weakness. In patients with concomitant MCP hyperextension that exceeds 30°,
correction of the deformity of the MCP joint must also be addressed and can be done with MCP capsulodesis, extensor pollicis brevis tendon transfer, or MCP fusion. Fusion of both the thumb CMC and MP joints is not recommended as this would result in marked stiffness and dysfunction.

Question 83

A 30-year-old woman has had pain in her right leg for the past 6 months. A lytic lesion is noted in the anterior cortex of the midtibia, extending 5 cm in length without a soft-tissue mass. A radiograph and a biopsy specimen are shown in Figures 35a and 35b. What is the preferred treatment?

Explanation

DISCUSSION: In an adult with an anterior cortical tibial lesion, this is the classic histologic appearance and anatomic location for an adamantinoma. The histology reveals areas of epithelial cells (in a glandular pattern) within a fibrous stroma. The epithelial cells are shown in nests. They would stain positively for keratin. Adamantinoma is a rare malignant bone tumor with a propensity for late metastasis. It has a high incidence of local recurrence unless resected with a wide margin. Chemotherapy and radiation therapy are not helpful in the treatment of this disease. Amputation generally is not necessary because a diaphyseal resection is usually possible.
REFERENCES: McCarthy EF, Frassica FJ: Pathology of Bone and Joint Disorders with Clinical and Radiographic Correlation. Philadelphia, PA, WB Saunders, 1998, p 263.
Moon NF, Mori H: Adamantinoma of the appendicular skeleton: Updated. Clin Orthop Relat Res 1986;204:215-237.

Question 84

A 55-year-old woman fell and sustained an elbow dislocation with a coronoid fracture and a radial head fracture. The elbow is reduced and splinted. What is the most common early complication?

Explanation

DISCUSSION: The patient has a dislocation of the elbow with displaced coronoid process and radial head fractures. The elbow is extremely unstable after this injury, and recurrent dislocation in a splint is the most common early complication. Skeletal stabilization of the fractures is required to restore stability of the joint. Characteristics of the fractures will determine the techniques required to restore stability.
REFERENCES: Ring D, Jupiter JB, Zilberfarb J: Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am 2002;84:547-551.
Ring D, Jupiter JB: Fracture-dislocation of the elbow. J Bone Joint Surg Am 1998;80:566-580.

Question 85

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

Explanation

DISCUSSION: Curettage and bone grafting typically is the preferred method of treatment for chondroblastoma, with local recurrence rates of approximately 10%. Some clinicians advocate the addition of adjuvants such as phenol. Left alone, these lesions can destroy bone and invade the joint. Large intra-articular lesions may require major joint reconstruction. Wide local excision rarely is required to eradicate the tumor. Radiation therapy rarely is indicated and only for unresectable or multiply recurrent lesions.
REFERENCES: Springfield DS, Capanna R, Gherlinzoni F, Picci P, Campanacci M: Chondroblastoma: A review of seventy cases. J Bone Joint Surg Am 1985;67:748-755.
Simon MA, Springfield DS, et al: Chondroblastoma: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 190.

Question 86

A skeletally mature 15-year-old girl who was thrown from the car in a rollover accident sustained the injuries shown in Figures 23a through 23d. Examination reveals no neurologic deficit, but the patient has moderate posterior spinal tenderness at the level of the injury. What is the most appropriate treatment?

Explanation

DISCUSSION: The majority of patients with thoracolumbar burst fractures without neurologic deficit can be effectively treated with a TLSO or a hyperextension body cast. Indications for surgery are neurologic deficit and/or significant deformity (greater than 50% loss of anterior vertebral body height or marked kyphosis).
REFERENCES: Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 197-217.
Chow GH, Nelson BJ, Gebhard JS, Brugman JL, Brown CW, Donaldson DH: Functional outcome of thoracolumbar burst fractures managed with hyperextension casting or bracing and early mobilization. Spine 1996;21:2170-2175.

Question 87

A 58-year-old man reports a 2-month onset of groin pain with no history of trauma. Examination reveals that range of motion of the hip is mildly restricted, and he has pain with both weight bearing and at rest. An MRI scan is shown in Figure 20. Treatment should consist of

Explanation

DISCUSSION: The MRI findings show highly increased signal through the entire femoral head and neck on STIR imaging, diagnostic of transient osteoporosis of the femoral head. This disease entity can be seen in middle-aged men, and should be treated nonsurgically. The natural history is that of self-resolution.
REFERENCES: Guerra JJ, Steinberg ME: Distinguishing transient osteoporosis from avascular necrosis of the hip. J Bone Joint Surg Am 1995;77:616-624.
Urbanski SR, de Lange EE, Eschenroeder HC Jr: Magnetic resonance imaging of transient osteoporosis of the hip: A case report. J Bone Joint Surg Am 1991;73:451-455.

Question 88

Figure 77 shows the clinical photograph of a 21-year-old male ice hockey player who sustained a blow to the jaw from another player’s hockey stick. Examination reveals an unstable jaw, mild bleeding with exposed bone, and malocclusion. What is the most serious acute complication of this injury?

Explanation

DISCUSSION: The most serious, acute complication of severe maxillofacial trauma is airway obstruction that can result in early death. It is most likely to be associated with multiple mandibular fractures or combined maxillary, mandibular, and nasal fractures as reported by Seyfer and Hansen and Rohrich and Shewmaker.
The mandible suspends the tongue anteriorly. When the mandible is fractured and the patient is supine, the tongue falls posteriorly and obstructs the airway. Soft-tissue swelling around the injured oronasal structures can also result in a loss of airway patency. Endotracheal or nasotracheal intubation is often impossible and a surgical airway may often have to be created to prevent death by asphyxiation. Other injuries that may require immediate attention include head or cervical spine injury and hemorrhage. A cerebrovascular accident is also less common but is associated with injury to the common carotid artery or its branches. Periodontal disease is generally a long-term complication from dental injuries. Hearing loss is not a common complication of dental and facial trauma.
REFERENCES: Seyfer AE, Hansen JE: Facial trauma, in Moore EF, Feliciano DV, Maddox KL (eds): Trauma, ed 5. New York, NY, McGraw-Hill, 2004, pp 423-444.
Rohrich RJ, Shewmake KB: Evolving concepts of craniomaxillofacial fracture management. Clin Plast
Surg 1992;19:1-10.

Question 89

A 35-year-old man is seen for evaluation of his left ankle following multiple previous ankle sprains and frequent episodes of the ankle giving way. Examination reveals marked laxity about the lateral ankle with associated tenderness along the peroneal tendons. Physical therapy, anti-inflammatory drugs, and supportive bracing have failed to provide relief. An MRI scan shows peroneal tenosynovitis and a possible tear. He elects to undergo a peroneal tendon repair and lateral ligament reconstruction. Which of the following best describes the structure labeled “A” in Figure 45?

Explanation

DISCUSSION: The structure labeled “A” is a peroneus quartus, a supernumary muscle arising most commonly from the peroneus brevis. The presence of peroneus quartus is not uncommon, with an incidence of up to 21%, and is associated with lateral ankle pain and peroneal tendon symptoms, theoretically as a result of mass effect within the peroneal tendon sheath.
REFERENCES: Zammit J, Singh D: The peroneus quartus muscle: Anatomy and clinical relevance. J Bone Joint Surg Br 2003;85:1134-1137.
Sobel M, Levy ME, Bohne WH: Congenital variations of the peroneus quartus muscle: An anatomic study. Foot Ankle 1990;11:81-89.

Question 90

An 18-year old man has a simple oblique fracture of the humeral shaft that requires surgical stabilization to maintain reduction and facilitate mobilization. Which of the following methods will provide the best outcome?

Explanation

DISCUSSION: The patient has a simple fracture pattern that can be reduced anatomically and stabilized with absolute stability by interfragmental compression and protection plating. This will guarantee a 95% to 98% union rate with no radial nerve palsy. Intramedullary nailing does not equal these results in a simple fracture pattern in the humerus. Bridge plating is indicated for multifragmented fracture patterns when anatomic reduction and absolute stability cannot be achieved. External fixation is reserved for severe open fractures.
REFERENCES: Chapman JR, Henley MP, Agel J, Benca PJ: Randomized prospective study of humeral shaft fracture fixation: Intramedullary nails versus plates. J Orthop Trauma 2000;14:162-166.
Farragos AF, Schemitsch EH, McKee MD: Complications of intramedullary nailing for fractures of the humeral shaft: A review. J Orthop Trauma 1999;13:258-267.
Modabber M, Jupiter JB: Operative management of diaphyseal fractures of the humerus: Plate versus nail. Clin Orthop 1998;347:93-104.

Question 91

A healthy 64-year-old man just underwent an uncomplicated shoulder arthroplasty for severe glenohumeral osteoarthritis. Intraoperatively, 60 degrees of external rotation was obtained. Postoperatively, he starts on a range-of-motion program. What limitations are recommended?

Explanation

DISCUSSION: The patient needs restrictions on his external rotation to allow healing of the subscapularis tendon repair. Limitation to 60 degrees is common if the tendon repair is robust and shows no evidence of tension on range-of-motion testing during the surgery. Restriction from external rotation stretching for even 3 weeks would compromise his ultimate functional recovery.
REFERENCES: Boardman ND III, Cofield RH, Bengston KA, et al: Rehabilitation after total shoulder arthroplasty. J Arthroplasty 2001;16:483-486.
Matsen FA III, Lippitt SB, Sidles JA, et al: Practical Evaluation and Management of the Shoulder. Philadelphia, PA, WB Saunders, 1994, pp 215-218.

Question 92

Closed-chain exercise differs from open-chain exercise in which of the following ways?

Explanation

DISCUSSION: Closed-chain exercise requires the distal portion of the extremity to be fixed. It is more commonly used in lower extremity exercise, and movement is produced by co-contraction of muscles. Joint compression is increased, and multiple joints are involved with closed-chain exercise. In open-chain exercise, the distal portion of the extremity is free.
REFERENCES: Braddom RL (ed): Physical Medicine and Rehabilitation, ed 2. Philadelphia, PA, Saunders, 2000, pp 975-976.
Childs DC, Irrang JJ: The language of exercise and rehabilitation, in Delee JC, Drez D (eds): Orthopaedic Sports Medicine, ed 2. Philadelphia, PA, WB Saunders, 2003, vol 1, p 329.

Question 93

Which of the following methods best aids in diagnosis of an interdigital neuroma?

Explanation

DISCUSSION: History and physical examination are still the gold standard for diagnosis of an interdigital neuroma. Ultrasound and MRI may be helpful adjuncts but are dependent on equipment and operator expertise. Web space injection may be helpful for diagnostic and therapeutic purposes. Electromyography and nerve conduction velocity studies are of little benefit for distal lesions.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 145-147.
Bennett GL, Graham CE, Mauldin DM: Morton’s interdigital neuroma: A comprehensive treatment protocol. Foot Ankle Int 1995;16:760-763.

Question 94

A 35-year-old woman who runs long distance has had posterior calf tenderness for the past 3 months. A clinical photograph is shown in Figure 10a, and MRI scans are shown in Figures 10b and 10c. Management at this point should consist of

Explanation

DISCUSSION: The initial treatment for peritendinitis should consist of calf stretching in an eccentric mode and physical therapy. In a recent study, this treatment has been found superior to surgical debridement in nonextensive peritendinitis and pantendinitis. A non-weight-bearing cast, while useful in reducing inflammation, will result in calf atrophy and poorly organized collagen repair. Cortisone is contraindicated because of the danger of tendon damage. Tendon debridement at this stage is not indicated.
REFERENCES: Alfredson H, Pietila T, Jansson P, Lorentzon R: Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998;26:360-366.
Angermann P, Hougaard D: Chronic Achilles tendinopathy in athletic individuals: Results of nonsurgical treatment. Foot Ankle Int 1999;20:304-306.

Question 95

-Figures 156a and 156b are the radiographs of a 38-year-old man with diabetes mellitus who fell 8 feet from a ladder and sustained an isolated closed injury of his leg. Examination revealed swollen but soft compartments. His neurovascular examination was unremarkable. A damage-control fixator was initially applied, and his soft-tissue envelope is now amenable to further intervention. What is the most appropriate treatment?

Explanation

Question 96

Figure 39 shows the sagittal T1-weighted MRI scan of a 27-year-old man who twisted his knee 2 weeks ago. The arrow is pointing to

Explanation

DISCUSSION: The arrow identifies a transverse dark line that represents primary trabeculae of the physeal scar. A similar finding is seen in the proximal tibia. These lines may persist indefinitely. They do not represent ongoing growth, an abnormally open physeal plate, a stress fracture, or Looser’s line (fatigue fracture in osteomalacia).
REFERENCE: El-Khoury G: MRI of the Musculoskeletal System. Philadelphia, PA, JB Lippincott, 1998, p 123.

Question 97

A 15-year-old girl reports popping and clicking at the sternoclavicular joint and an intermittent asymmetrical prominence of the medial head of the clavicle. She denies any history of trauma or other symptoms. Management should consist of

Explanation

DISCUSSION: Atraumatic subluxation or dislocation of the sternoclavicular joint typically occurs in individuals with generalized ligamentous laxity. It is generally not painful, has no long-term sequelae, and needs no treatment. In fact, it is more likely to be painful following surgery than if managed nonsurgically.
REFERENCES: Rockwood CA Jr, Odor JM: Spontaneous atraumatic anterior subluxation of the sternoclavicular joint. J Bone Joint Surg Am 1989;71:1280-1288.
Rockwood CA, Matsen FA (eds): The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1998,

p 583.

Question 98

A 12-year-old boy with an ankle fracture undergoes closed reduction under sedation in the emergency department. Figure 27 shows a lateral radiograph of the ankle after two attempts at closed reduction. Based on these findings, treatment should now consist of Review Topic

Explanation

The widening of the physis associated with incomplete reduction of this fracture suggests that periosteum is interposed at the fracture site. Clinical and animal study findings suggest that the interposed periosteum may lead to premature physeal closure. Repeated forceful attempts at reduction may subject the physis to further injury and should be avoided. Growth problems are common in children with Salter-Harris type I fractures of the lower extremities. Nonunions are rare in children with Salter-Harris type I fractures.

Question 99

A 29-year-old male sustains the isolated lower extremity injury shown in Figure A. During open reduction, what structure must be kept intact in order to protect the remaining blood supply to the talar body?

Explanation

Figure A represents a type 3 Hawkins talar neck fracture. A type 3 injury is defined as a displaced fracture of the talar neck with dislocation of body of talus from both the subtalar joint and the tibiotalar joint. In these injuries, the talar body fragment typically rotates around intact deltoid ligament fibers to lie in soft tissues with the fracture surface pointing laterally and cephalad. Often, the deltoid branch of the posterior tibial artery, which lies between the leaves of the deltoid ligament and supplies up to 1/2 of the medial talar body, is the only remaining blood supply. Therefore, the deltoid ligament must be preserved to lower the risk of avascular necrosis. When performing a medial malleolar osteotomy, the deltoid ligament must remain in continuity with the malleolus to prevent disruption of the blood supply.
The review article by Fortin et al discusses talar blood supply, injury mechanisms and classifications, and treatment options. They state that the main artery to the body of the talus is the artery of the tarsal canal, which is a branch of the posterior tibial artery. The peroneal and anterior tibial artery also contribute branches to the talus.
Illustration A and B show the arterial network of the talus.

OrthoCash 2020

Question 100

A 37-year-old man pulled his hamstring playing softball 3 weeks ago. The patient had not noted any mass prior to his injury. MRI scans of the posterior thigh are shown in Figures 4a and 4b. Figure 4c shows the biopsy specimen from a needle biopsy. What is the most likely diagnosis?

Explanation

DISCUSSION: Malignant fibrous histiocytoma (MFH) is the most common soft-tissue sarcoma. MFH typically presents as a large mass, deep to the fascia with heterogeneous signal on MRI. The MRI scans show a heterogeneous lesion in the posterior thigh. There is significant high signal uptake on the T₂-weighted image. The histology shows malignant histiocytic cells with marked atypia and pleomorphism. Histology of a hematoma would show only old hemorrhage and some granulation tissue. Lipoma and liposarcoma are both seen as a fat-containing lesion on histology. No significant fat tissue is seen in this histologic specimen. Histology of myositis ossificans would show bone formation.
REFERENCES: Simon SR (ed): Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 219-276.
Campanacci M: Bone and Soft Tissue Tumors, ed 2. New York, NY, Springer-Verlag, 1999, pp 965-981.

Full Question & Answer Text (for Search Engines)

Question 1:

Figure 37 shows the T2-weighted MRI scan of the hip joint. What structure is labeled A?

Options:

Ischiofemoral ligament
Ligamentum teres
Obturator internus
Piriformis
Coccygeus

Correct Answer: Obturator internus

Explanation:

Question 2:

During total hip arthroplasty, profuse bleeding is noted following predrilling for placement of an acetabular component screw. The drill most likely penetrated too deep in the

Options:

anterior-superior acetabular quadrant.
posterior-superior acetabular quadrant.
posterior-inferior acetabular quadrant.
medial acetabular wall.
ischial body.

Correct Answer: anterior-superior acetabular quadrant.

Explanation:

Question 3:

Options:

Fracture
Patella baja
Patella alta
Osteonecrosis
Maltracking

Correct Answer: Patella baja

Explanation:

DISCUSSION: Patella baja is commonly encountered when converting a high tibial osteotomy (HTO) to a TKA. Patella baja most likely occurs because of scarring. Meding and associates’ study did not show an increased rate of lateral release when converting a knee that had undergone a previous HTO.
REFERENCES: Yoshino N, Shinro T: Total knee arthroplasty after failed high tibial osteotomy, in Callaghan JJ, Rosenberg AG, Rubash HE, et al (eds): The Adult Knee. Philadelphia, PA,
JB Lippincott, 2003, vol 2, pp 1265-1271.
Meding JB, Keating EM, Ritter MA, et al: Total knee arthroplasty after high tibial osteotomy:
A comparison study in patients who had bilateral total knee replacement. J Bone Joint Surg Am 2000;82:1252-1259.

Question 4:

Options:

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

Correct Answer: subtalar joint arthrodesis.

Explanation:

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

Question 5:

Options:

Serum calcium normal
Serum alkaline phosphatase normal
Urine calcium is low
Serum phosphate is often high When symptomatic, the masses are excised. This lesion is benign and removal of normal tissue and radiation therapy are not necessary.

Correct Answer: Serum calcium normal

Explanation:

Slide 1 Slide 2
A 20-year-old woman has a large mass over the right hip. An anteroposterior and oblique radiographs are shown in Slides 1 and

Question 6:

Options:

Cubital tunnel release
Guyon's canal release
Hook-of-hamate excision
Excision of the ganglion cyst

Correct Answer: Excision of the ganglion cyst

Explanation:

Question 7:

Patients with which of the following primary carcinomas have the shortest overall survival rate after a solitary metastasis to bone?

Options:

Prostate
Breast
Thyroid
Lung
Renal cell

Correct Answer: Lung

Explanation:

Question 8:

- A patient who had previously undergone a salvage pelvic (Chiari) osteotomy now requires a total hip arthroplasty. The most frequent complication of this procedure is

Options:

fracture of the acetabulum
protrusion of the acetabulum
inadequate inferior coverage
inadequate superior coverage
inadequate anterior and posterior coverage

Correct Answer: inadequate anterior and posterior coverage

Explanation:

Question 9:

Options:

Independent 2-sample t test
Analysis of variance (ANOVA)
Chi-square test
Fisher’s exact test

Correct Answer: Analysis of variance (ANOVA)

Explanation:

Question 10:

- A 31-year-old man who is a recent immigrant from Guatemala has had pain in his back and thighs for the past 12 months. History notes a recent diagnosis of gout, and the patient reports falling a distance of 3 feet on his buttocks immediately before the pain began. Examination reveals that he is neurologically intact. Plain radiographs are shown in Figures 44a and 44b, and T2-weighted MRI scans are shown in Figures 44c and 44d. The most likely cause of the pathologic fracture is

Options:

gout.
osteoporosis.
eosinophilic granuloma.
tuberculosis of the spine.
metastatic disease of the spine.

Correct Answer: tuberculosis of the spine.

Explanation:

Question 11:

Options:

semiconstrained total elbow arthroplasty.
ulnohumeral arthroplasty and anterior and posterior capsular releases.
closed reduction and external fixation.
open reduction, heterotopic bone excision, anterior and posterior capsular releases, and a hinged elbow fixator.
open reduction, heterotopic excision, anterior and posterior capsular releases, and pin fixation across the joint for 3 weeks.

Correct Answer: open reduction, heterotopic bone excision, anterior and posterior capsular releases, and a hinged elbow fixator.

Explanation:

Question 12:

The stiffness of a 16-mm femoral stem is mostly influenced by the

Options:

elastic modulus of the material.
surface coating or treatment.
diameter of the femoral stem.
length of the femoral stem.
ultimate tensile strength.

Correct Answer: diameter of the femoral stem.

Explanation:

Question 13:

Options:

excision of the osteophytes and loose bodies and anterior and posterior capsular releases.
removal of the loose bodies.
anterior capsular release.
anterior and posterior capsular releases.
interposition arthroplasty.

Correct Answer: excision of the osteophytes and loose bodies and anterior and posterior capsular releases.

Explanation:

Question 14:

Options:

Knee aspiration for culture
CT of the knee to assess implant rotation
Indium-111 leukocyte/technetium-99m sulfur colloid scan of the knee
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) laboratory studies

Correct Answer: Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) laboratory studies

Explanation:

Question 15:

Options:

1 to 1 micron
>1 to 10 microns
>10 to 100 microns
>100 to 1000 microns For many years, it was believed that large particles incited the histiocytic response. It is now well established that submicron-size particles stimulate this response. 77- Increased osteolysis in cementless total knee arthroplasty (TKA) has been associated with what design features?
Patches of porous coating separated by smooth metal surfaces
Highly porous surfaces with properties resembling trabecular bone
Polyethylene locking mechanisms that limit micromotion and hydraulic pressure
Hydroxyapatite added to the porous surface Implant materials and design features that have occurred with cementless TKA are flat polyethylene, heat-pressed polyethylene and patch porous- coated surfaces. Smooth metal surfaces that separate pads of porous coating produce metaphyseal and diaphyseal osteolysis by conducting debris along fibrous bridges that form in the smooth areas between the patches of porous metal.

Correct Answer: 1 to 1 micron

Explanation:

Question 16:

Options:

C8 - T1 nerve root avulsion 3 months ago
C5 - C6 nerve root avulsion 2 months ago
Upper brachial plexus palsy 22 months ago
Medial and posterior cord injury from gunshot wound 2 months ago
C6 ASIA A spinal cord injury PREFERRED RESPONSE 2 Transfer of fascicles from (1) ulnar nerve to the nerve to the biceps and (2) median nerve to the motor nerve of the brachialis would be appropriate in the treatment of an acute (<3-6 months) upper brachial plexus palsy. Upper trunk injury (C5, C6) often results from the avulsion of both the C5 and C6 nerve roots. Injuries of this nature usually result from a downward force on the shoulder with lateral bending of the cervical spine in the opposite direction. This results in what is commonly called an Erb-Duchenne palsy. Patients often present with a flail shoulder and loss of elbow flexion. Other common treatments for C5 and C6 root avulsion include neurotization of the musculocutaneous (MSC) nerve by the spinal accessory (SA) or intercostal nerve, and neurotization of the supra-scapular nerve by the SA. Liverneaux et al. looked at short term results of (1) ulnar nerve fascicle transfer to the nerve to the biceps and (2) fascicle of the median nerve to the motor branch to the brachialis in 15 patients with acute C5 - C6 nerve root avulsion injuries. Grade 4 elbow flexion was restored in each of the 10 patients. There was no secondary deficit in grip strength or sensation.They concluded that this double nerve transfer technique will likely reduce the need for secondary procedures to augment elbow flexion. Teboul et al. reviewed thirty-two patients with an upper nerve-root brachial plexus injury that underwent ulnar nerve fascicle transfer to the nerve of biceps to restore elbow flexion. After the nerve transfer, twenty-four patients achieved grade 3 elbow flexion strength or better. They note that this procedure will spare the C5 nerve root and other nerves for grafting or transfer elsewhere. Illustration A shows harvesting of an ulnar nerve fascicle for transfer. Illustration B shows transfer of the fascicle of the ulnar nerve to the motor nerve of the biceps. Incorrect Answers:

Correct Answer: C8 - T1 nerve root avulsion 3 months ago

Explanation:

(SBQ12FA.31) A 30-year-old male patient involved in a hang-gliding accident sustains a knee dislocation with multiligamentous knee injury and transection of his peroneal nerve. He undergoes multiple reconstructive surgeries. Two years later, he continues to have a foot drop and dynamic tendon transfer is recommended. This treatment most commonly involves transferring a tendon from which native insertion point to which new insertion point?
Review
Topic
Plantar distal phalanges to medial navicular
Medial navicular to dorsal lateral cuneiform
Plantar 1st metatarsal to dorsal lateral cuneiform
5th metatarsal base to dorsal medial cuneiform
Plantar distal phalanx of the hallux to dorsal distal phalanx of hallux
Dynamic tendon transfer to restore active dorsiflexion of the foot involves transferring the posterior tibial tendon (PTT) insertion on the medial navicular to the dorsal lateral cuneiform.
Common peroneal nerve (CPN) injuries following traumatic knee dislocation are common, with an incidence of 25-40%. CPN palsy is characterized by foot drop due to loss of ankle dorsiflexors with a steppage gait and eventual development of a supinated equinovarus foot secondary to the unopposed pull of the PTT. Nonsurgical management involves use of an ankle-foot orthosis and physical therapy. Surgical
options include acute primary repair, nerve grafting with either autologous sural nerve or nerve conduits and dynamic tendon transfer. The PTT is harvested from its insertion at the navicular, passed through the interosseous membrane (IOM) and anchored to the lateral cuneiform (see Illustration A). The classic bridle procedure involves concomitant anastamosis of the PTT to the tibialis anterior (TA) and peroneus longus (PL) tendons.
Garozzo et al reported a case series of 62 patients with post-traumatic CPN palsy who underwent a one-stage procedure consisting of nerve repair and PTT transfer. Nerve repair combined with PTT transfer improved postoperative outcomes compared to nerve repair alone. At 2-year follow up, neural regeneration was demonstrated in 90% of patients. The authors hypothesized that poor outcomes following nerve repair alone are due to force imbalance between the functioning flexors and paralyzed extensors, which is somewhat equalized by performing a PTT transfer at time of repair.
Niall et al reviewed 55 patients with traumatic knee dislocation and reported a 41% incidence of CPN injury, exclusively associated with dislocations involving disruption of the posterior cruciate ligament (PCL) and posterolateral corner (PLC). Complete neurologic recovery was found in only 21% of patients. The best prognosis was found with lesions in continuity, less than 7cm of nerve involvement, and short conduction block and muscle activity on nerve conduction and EMG studies.
Vigasio et al described a dynamic tendon transfer technique for traumatic complete CPN injury, involving transfer of the PTT to the TA rerouted to a new origin at the lateral cuneiform to restore ankle dorsiflexion and flexor digitorum longus (FDL) to the extensor digitorum longus (EDL) and extensor hallucis longus (EHL) to restore digit dorsiflexion. Rerouting the TA towards the transferred PTT ensures the PTT harvest length is sufficient. This avoids excessive tensioning of the PTT, which may limit tendon excursion and result in a static tenodesis rather than dynamic function, as well as the need for PTT lengthening which may decrease strength of the transfer
Illustration A is a series of intraoperative photographs demonstrating PTT transfer from Garg et al. An incision is made distal to the medial malleolus and the PTT is harvested subperiosteally (A). The PTT is delivered through a second incision ~15cm proximal to the medial malleolus (B-C). The PTT is then passed through the interosseous membrane and out a third incision over the anterior fibula (D). Lastly, the PTT is passed through a fourth incision over the dorsal midfoot and anchored to the lateral cuneiform (E).
Incorrect Responses:
nerve and therefore would not be functional. Answer 5: Transferring the flexor hallucis longus (FHL; insertion = plantar distal phalanx of the hallux) to the insertion of the EHL (dorsal distal phalanx of hallux) is recommended for correction of claw toe deformity and would not help restore foot dorsiflexion in this patient.

Question 17:

What are the optimal conditions for leaving the acetabular shell in place, replacing the acetabular liner, and grafting the osteolytic defect shown in Figure 39?

Options:

Nonmodular implant
Instability
Well-designed, well-fixed modular implant
Complete radiolucency of the acetabular component
Migration of the acetabular component

Correct Answer: Well-designed, well-fixed modular implant

Explanation:

DISCUSSION: Dense pods of ingrowth into the porous coating of cementless ingrowth sockets are seen. Channels through the non-ingrown portion allow access to the trabecular bone of the ilium. Polyethylene wear debris can enter these areas through screw holes. Expansile, lytic lesions can result, which can become large without compromising implant fixation. Loosening is late and results from catastrophic loss of bone. A well-fixed acetabular component with a modular design, a well-designed locking mechanism, and a good survivorship history is a candidate for exchange of the liner and grafting of the osteolytic lesion.
REFERENCES: Ries MD: Complications in primary total hip arthroplasty: Avoidance and management. Wear. Instr Course Lect 2003;52:257-265.
Dumbleton JH, Manley MT, Edidin AA: A literature review of the association between wear rate and osteolysis in total hip arthroplasty. J Arthroplasty 2002;17:649-661.
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 175-180.

Question 18:

Options:

Anteroinferior labrum from the bony glenoid
Anteroinferior labrum from the cartilaginous surface of the glenoid
Biceps tendon from its origin on the supraglenoid tubercle
Anterior capsule from the proximal humerus
Posteroinferior labrum from the bony glenoid

Correct Answer: Anteroinferior labrum from the bony glenoid

Explanation:

Question 19:

Based on the Young and Burgess classification of pelvic ring injuries, an anterior-posterior compression type II injury does not result in disruption of which of the following?

Options:

pubic symphysis
anterior sacroiliac ligaments
posterior sacroiliac ligaments
sacrospinous ligament
sacrotuberous ligament

Correct Answer: pubic symphysis

Explanation:

Question 20:

Figure 59 shows properties of a material being tested for use as an implant. What is represented by the portion of the stress-strain curve from point A to point B?

Options:

Elastic limit
Nonproportional behavior
Plastic behavior
Elastic behavior
Fracture point

Correct Answer: Elastic behavior

Explanation:

Question 21:

Options:

normal postoperative orders with frequent neurologic evaluations for the first 24 hours.
administration of IV steroids and placement of a soft cervical collar for 24 hours.
placement of both deep and superficial surgical drains prior to wound closure.
administration of IV mannitol and placement of a soft collar.
maintaining intubation for up to 24 to 48 hours.

Correct Answer: maintaining intubation for up to 24 to 48 hours.

Explanation:

DISCUSSION: Airway complications after anterior cervical surgery can be a catastrophic event necessitating emergent intubation for airway protection. Multilevel surgeries requiring long intubation and prolonged soft-tissue retraction as well as preexisting comorbidities may predispose a patient to postoperative airway complications. Sagi and associates reported that surgical times greater than 5 hours, blood loss greater than 300 mL, and multilevel surgery at or above C3-4 are risk factors for airway complications. In surgical procedures with the aforementioned factors, serious consideration should be given to elective intubation for 1 to 3 days to avoid urgent reintubation.
REFERENCES: Sagi HC, Beutler W, Carroll E, et al: Airway complications associated with surgery on the anterior cervical spine. Spine 2002;27:949-953.
Epstein NE, Hollingsworth R, Nardi D, et al: Can airway complications following multilevel anterior cervical surgery be avoided? J Neurosurg 2001;94:185-188.
Emery SE, Smith MD, Bohlman HH: Upper-airway obstruction after multi-level cervical corpectomy for myelopathy. J Bone Joint Surg Am 1991;73:544-551.

Question 22:

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

Options:

Gout
Pseudogout
Infection
Epidermal inclusion cyst
Charcot joint

Correct Answer: Gout

Explanation:

Question 23:

Options:

clinically significant.
statistically significant but perhaps not clinically significant.
statistically and clinically significant.
not statistically or clinically significant.
nonconclusive.

Correct Answer: statistically significant but perhaps not clinically significant.

Explanation:

Question 24:

Which of the following activities can improve posterior capsular contractures?

Options:

Theraband exercises to strengthen the external rotator
Latissimus pull-down exercises to the chest
Seated rows
Internal rotation stretch at 90 degrees abduction with scapular stabilization
Bench press with wide grip

Correct Answer: Internal rotation stretch at 90 degrees abduction with scapular stabilization

Explanation:

Question 25:

Which of the following is the only nonreversible effect of anabolic steroids?

Options:

Muscle hypertrophy
Alterations in high density lipoprotein (HDL) and low density lipoprotein (LDL) ratios
Alopecia
Personality effects
Acne

Correct Answer: Alopecia

Explanation:

Question 26:

Options:

Total hip arthroplasty
Removal of loose bodies
Protected weight bearing
Assessment of hip stability
Open reduction and internal fixation

Correct Answer: Assessment of hip stability

Explanation:

Question 27:

Options:

The flexor digitorum longus tendon is ruptured.
The posterior tibial tendon has a normal appearance.
The posterior tibial tendon has a physiologic amount of fluid in its sheath.
The posterior tibial tendon is completely ruptured and retracted (type III tear).
The posterior tibial tendon has a chronic longitudinal split with enlargement (type II tear).

Correct Answer: The posterior tibial tendon has a chronic longitudinal split with enlargement (type II tear).

Explanation:

Question 28:

Options:

Skin
Lung
Brain
Heart
Kidney

Correct Answer: Kidney

Explanation:

Question 29:

All of the following are considered contraindications to the use of functional bracing of a humeral shaft fracture EXCEPT:

Options:

Mid-diaphyseal segmental fracture with ipsilateral pilon fracture
Mid-diaphyseal fracture with radial nerve palsy from penetrating injury
Proximal one-third oblique fracture
Mid-diaphyseal closed fracture with a radial nerve palsy on presentation
Mid-diaphyseal fracture with a L1 burst fracture and paraplegia on presentation

Correct Answer: Mid-diaphyseal segmental fracture with ipsilateral pilon fracture

Explanation:

Question 30:

Options:

Resurfacing hemiarthroplasty
Resurfacing hemiarthroplasty with fascial glenoid resurfacing
Resurfacing hemiarthroplasty with cemented glenoid component
Stemmed hemiarthroplasty
Stemmed total shoulder arthroplasty

Correct Answer: Stemmed hemiarthroplasty

Explanation:

Question 31:

What is the most likely diagnosis? Review Topic

Options:

Pectoralis major tendon rupture
Supraspinatus rupture
Subscapularis rupture
Bankart tear
Humeral avulsion of the inferior glenohumeral ligament

Correct Answer: Subscapularis rupture

Explanation:

Question 32:

Which of the following is associated with the use of large femoral heads in total hip arthroplasty?

Options:

Increased risk of total hip dislocation
Decreased range of motion
Fewer options for femoral head bearing material
Acceptable wear with modern bearing surfaces
Increased component impingement

Correct Answer: Acceptable wear with modern bearing surfaces

Explanation:

Question 33:

Options:

an increased risk of chondrolysis.
an increased risk of osteonecrosis.
an increased risk of stiffness.
an increased time to closure of the physis.
no deleterious effect.

Correct Answer: no deleterious effect.

Explanation:

Question 34:

Following irrigation and debridement, what is the preferred method of fixation for a displaced open tibia fracture with a 16-cm clean wound?

Options:

Closed reduction and cast immobilization
Uniplanar external fixation
Open reduction and internal fixation with a dynamic compression plate
Unreamed intramedullary rod
Multiple plane external fixator

Correct Answer: Unreamed intramedullary rod

Explanation:

Question 35:

A 60-year-old woman with a history of breast cancer has progressive paraparesis. The MRI scan is shown in Figure 28. What form of management is most likely to restore or maintain ambulation?

Options:

Radiation therapy and a thoracolumbosacral orthosis
Laminectomy alone
Laminectomy and radiation therapy
Laminectomy and posterior fusion
Anterior decompression and stabilization

Correct Answer: Anterior decompression and stabilization

Explanation:

Question 36:

During an anterior approach to the shoulder, excessive traction on the conjoined tendon is most likely to result in loss of

Options:

elbow flexion.
shoulder flexion.
shoulder internal rotation.
shoulder abduction.
forearm pronation.

Correct Answer: elbow flexion.

Explanation:

Question 37:

Options:

Total hip arthroplasty
Single innominate (Salter) osteotomy
Chiari osteotomy
Periacetabular osteotomy
Varus intertrochanteric osteotomy

Correct Answer: Periacetabular osteotomy

Explanation:

Question 38:

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

Options:

Laterally deviated distal metatarsal articular surface, a
lax or disrupted distal 1-2 transverse intermetatarsal 12
ligament, and a contracted lateral collateral (lateral first
metatarsophalangeal) ligament.
Laterally deviated distal metatarsal articular surface, a contracted lateral collateral (lateral first metatarsophalangeal) ligament, and a medially deviated or hypermobile first metatarsocuneiform joint.
Medially deviated or hypermobile first metatarsocuneiform joint, a lax or disrupted distal 1-2 transverse intermetatarsal ligament, and a contracted lateral collateral (lateral first metatarsophalangeal) ligament.
Lax or disrupted distal 1-2 transverse intermetatarsal ligament, laterally deviated distal metatarsal articular surface, and a medially deviated or hypermobile first metatarsocuneiform joint.

Correct Answer: lax or disrupted distal 1-2 transverse intermetatarsal 12

Explanation:

Question 39:

With the arm abducted 90 degrees and fully externally rotated, which of the following glenohumeral ligaments resists anterior translation of the humerus?

Options:

Coracohumeral
Superior glenohumeral
Middle glenohumeral
Anterior band of the inferior glenohumeral ligament complex
Posterior band of the inferior glenohumeral ligament complex

Correct Answer: Anterior band of the inferior glenohumeral ligament complex

Explanation:

DISCUSSION: With the arm in the abducted, externally rotated position, the anterior band of the inferior glenohumeral ligament complex moves anteriorly, preventing anterior humeral head translation. Both the coracohumeral ligament and the superior glenohumeral ligament restrain the humeral head to inferior translation of the adducted arm, and to external rotation in the adducted position. The middle glenohumeral ligament is a primary stabilizer to anterior translation with the arm abducted to 45 degrees. The posterior band of the inferior glenohumeral ligament complex resists posterior translation of the humeral head when the arm is internally rotated.
REFERENCES: Harryman DT II, Sidles JA, Harris SL, et al: The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992;74:53-66.
Wang VM, Flatow EL: Pathomechanics of acquired shoulder instability: A basic science perspective. J Shoulder Elbow Surg 2005;14:2S-11S.

Question 40:

Anteromedial approach (Ludloff)

Options:

Lateral femoral cutaneous
Superior gluteal
Inferior gluteal
Obturator
Sciatic

Correct Answer: Obturator

Explanation:

Question 41:

Figures 14a and 14b show the plain radiographs of an 85-year-old woman who has had severe pain in the right knee for the past 4 months. Management should consist of

Options:

a hinged knee brace.
arthroscopic debridement.
high tibial osteotomy.
total knee arthroplasty.
osteochondral grafts.

Correct Answer: total knee arthroplasty.

Explanation:

Question 42:

A 52-year-old woman has bicompartmental osteoarthritis following patellectomy. Treatment should consist of

Options:

high tibial osteotomy.
arthroscopic debridement.
patella arthroplasty.
total knee arthroplasty.
knee arthrodesis.

Correct Answer: total knee arthroplasty.

Explanation:

Question 43:

In total hip arthroplasty, increasing the perpendicular distance from the center line of the femur to the center of rotation of the femoral head (femoral offset) results in

Options:

decreased tissue tension
decreased abductor lever arm
decreased joint reaction force
increased body weight over lever arm
increased polyethylene wear rate

Correct Answer: decreased joint reaction force

Explanation:

Question 44:

An 11-year-old boy sustained an ankle injury while playing football. Figure 20 shows an AP radiograph obtained the day of injury. Treatment should consist of

Options:

closed manipulation and a long leg cast.
closed manipulation and a short leg walking cast.
a long leg cast and long-term follow-up to rule out growth arrest.
open reduction and internal fixation with a transphyseal lag screw and a non-weight-bearing cast.
open reduction and internal fixation with fixation parallel to the physis and a non-weight-bearing cast.

Correct Answer: open reduction and internal fixation with fixation parallel to the physis and a non-weight-bearing cast.

Explanation:

DISCUSSION: The child has an injury involving both the growth plate and the articular surface of the ankle. Because of the significant displacement, open reduction and internal fixation is indicated to realign the physis and joint surface. The best method of fixation to avoid growth arrest is one that does not cross the physis. This is usually achieved by a transverse epiphyseal screw parallel to the physis. If the metaphyseal fragment was large enough, a transverse metaphyseal screw could be used instead. The incidence of growth arrest following physeal ankle injuries is as high as 50%, and long-term follow-up is indicated.
REFERENCES: Cass JR, Peterson HA: Salter-Harris Type-IV injuries of the distal tibial epiphyseal growth plate, with emphasis on those involving the medial malleolus. J Bone Joint Surg Am 1983;65:1059-1070.
Barmada A, Gaynor T, Mubarak SJ: Premature physeal closure following distal tibia physeal fractures: A new radiographic predictor. J Pediatr Orthop 2003;23:733-739.

Question 45:

Options:

placement of the hips in wider abduction and continued use of the harness.
increased flexion of the hips and continued use of the harness.
removal of the harness and application of an Ilfeld splint.
removal of the harness and application of a von Rosen splint.
removal of the harness, followed by closed or open reduction.

Correct Answer: removal of the harness, followed by closed or open reduction.

Explanation:

Question 46:

Options:

CT of the pelvis to delineate the fracture pattern
Application of a pelvic sling
Radiographs of the long bones
Angiography to stem the flow of retroperitoneal bleeding
Immediate open reduction of the fracture

Correct Answer: Application of a pelvic sling

Explanation:

Question 47:

Options:

follow-up radiographs.
alendronate, with follow-up examinations every 6 months.
revision to a posterior stabilized prosthesis.
exchange of the tibial insert through a limited incision.
surgical exploration with revision or exchange based on the findings.

Correct Answer: surgical exploration with revision or exchange based on the findings.

Explanation:

Question 48:

Options:

Central space
Hypothenar space
Carpal tunnel
Posterior adductor space
Thenar space

Correct Answer: Thenar space

Explanation:

DISCUSSION: Flexor tenosynovitis of the thumb flexor tendon sheath can spread proximally and form an abscess within the thenar space of the palm. The flexor pollicis longus tendon does not pass through the central space of the palm or the hypothenar space of the palm. The flexor pollicis longus tendon does pass through the carpal tunnel, but this is not a palmar space. The three palmar spaces include the hypothenar space, the thenar space, and the central space. The posterior adductor space would likely only be involved secondarily after spread from a thenar space infection.
REFERENCES: Hollinshead W: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, vol 3, pp 478-479.
Lee D, Ferlic R, Neviaser R: Hand infections, in Berger R, Weiss AP (eds): Hand Surgery. Philadelphia, PA, Lippincott Williams & Wilkins, 2004, pp 1784-1785.

Question 49:

Options:

form-fitted shoes.
amputation of the second toe at the metatarsophalangeal joint.
amputation of the first ray and amputation of the second toe.
amputation of the second ray.
an MRI scan of the foot, a CT scan of the chest, and a biopsy of the foot with the possibility of ankle disarticulation amputation.

Correct Answer: amputation of the second ray.

Explanation:

Question 50:

Options:

a sling, ice, and isometric exercises.
a glenohumeral cortisone injection.
surgical repair of the coracoclavicular ligaments.
chin-ups and latissimus pull-down exercises.
cross-chest stretches.

Correct Answer: a sling, ice, and isometric exercises.

Explanation:

Question 51:

Options:

Continued observation and re-evaluation in 6 months
Sentinel lymph node biopsy
Wide excision
Primary ray resection

Correct Answer: Wide excision

Explanation:

Question 52:

A newborn girl is referred for evaluation of suspected hip instability. What information from her history would place her in the highest risk category?

Options:

History of maternal diabetes mellitus
Frank breech presentation
Female gender
Concomitant metatarsus adductus
Twin gestation

Correct Answer: Frank breech presentation

Explanation:

DISCUSSION: Breech positioning has been noted as the risk factor that most increases the relative risk of developmental dysplasia of the hip in multiple series and meta-analysis. All the other factors also increase the risk but to a lesser magnitude.
REFERENCES: Lehmann HP, Hinton R, Morello P, et al: Developmental dysplasia of the hip practice guideline: Technical report. Committee on Quality Improvement, and Subcommittee on Developmental Dysplasia of the Hip. Pediatrics 2000;105:E57.
Haynes RJ: Developmental dysplasia of the hip: Etiology, pathogenesis, and examination and physical findings in the newborn. Instr Course Lect 2001;50:535-540.

Question 53:

Options:

Irrigation and local wound care in the emergency department followed by 3 days of oral antibiotics
Emergent irrigation and debridement in the operating room with vacuum-assisted wound closure
Emergent irrigation and debridement in the operating room with 7 days of intravenous antibiotics
Wound closure in the emergency department with follow-up wound check in 1 week
Exploration and removal of all bullet fragments in the emergency department and 10 day course of oral antibiotics

Correct Answer: Irrigation and local wound care in the emergency department followed by 3 days of oral antibiotics

Explanation:

Question 54:

Options:

Physical therapy
CT-guided needle biopsy and IV antibiotics
Revision laminotomy and diskectomy
L4-L5 anterior debridement and fusion
Open repair of the L4-L5 pseudomeningocele

Correct Answer: Physical therapy

Explanation:

The MRI scans show Modic changes in the L4-L5 vertebral bodies due to spondylosis. There is no increased fluid signal or enhancement in the L4-L5 disk to suggest infection or any other pathologic process. Therefore, the patient’s pain should be treated with a course of physical therapy and rehabilitation. There is no infection; therefore, IV antibiotics and debridement are not indicated. Similarly, a
pseudomeningocele is not present. A revision diskectomy is useful for recurrent radiculopathy but would not be helpful for degenerative low back pain.
(SBQ12SP.29) A 17-year-old female is undergoing posterior instrumented fusion from T5-T12 for adolescent idiopathic scoliosis. At the time of the correction maneuver, the neurophysiologist notifies you of a 60% decrease in somatosensory evoked potential (SSEP) amplitude throughout bilateral lower extremities. Which of the following is an acceptable approach to manage this finding?
Review Topic
Immediate wake-up test with examination for clonus
Drop the mean arterial pressure (MAP) to ~60mmHg
Discontinue instrumentation and optimize MAP to 85mmHg or greater
Immediate infusion of intravenous corticosteroids
Modification of the anesthesia plan to include inhalational agents only followed by repeated SSEP testing
The patient has a significant drop in SSEP amplitudes at the completion of the corrective maneuver. The most appropriate response is to raise the MAP to 85 mmHg or greater, discontinue the instrumentation, re-evaluate the SSEPs, and if there is no improvement, to consider reversing the reduction of the deformity.
Intra-operative neurophysiologic monitoring is an effective method to monitor insults to the spinal cord and its exiting roots during spinal instrumentation. The common measurements include SSEPs, which monitor sensory potentials transmitted through the dorsal column system, and motor-evoked potentials (MEPs), which monitor motor response to a trans-cranial stimulus. Decreases in amplitude and latency of the circuits are recorded, however diminished signal amplitudes are more sensitive for neurologic injury, and decreases of of >50-60% being highly concerning. The wake-up test involves reversal of anesthesia so that an intra-operative neurologic examination can be performed.
Devlin et al. reviewed the basic science and practice of neurophysiologic monitoring in spine surgery. They proposed an algorithmic approach to managing intraoperative alerts which include discontinuation of inhalational anesthetics, increasing the MAP to >90 mmHg, discontinuing instrumentation, and performing a wake-up test if neurologic signals fail to normalize.
Herdmann et al. reviewed the practice of neurophysiologic monitoring and the effects of anesthesia upon signal transduction. They report that anesthesia affecting a neuron's intrinsic excitability can alter the results of monitoring. Inhalational anesthetics and decreased MAPs can be responsible for decreased amplitudes.
Vitale et. al. developed a consensus-based intraoperative checklist for management of lost neuromonitoring signals. In this checklist, the first steps across the surgical and anesthetic teams should include: stop the case and announce signal losses to the room, optimize the mean arterial pressure, discuss the status of anesthetic agents, and discuss reversible surgical actions just prior to signal loss.
Incorrect

Question 55:

Options:

Multiple hereditary exostosis
Ollier’s disease
Maffucci’s syndrome
McCune-Albright syndrome
Neurofibromatosis

Correct Answer: Maffucci’s syndrome

Explanation:

Question 56:

A 12-year-old child with L4 myelomeningocele who is schedules for foot surgery has a functioning ventriculoperitoneal shunt and has no history of allergies. Management should include

Options:

Use of regional rather than general anesthesia
Observation of a latex-avoidance protocol
Latex skin allergen testing
Premedication with corticosteroids and antihistamines
Avoidance of prophylactic antibiotics derived from penicillin

Correct Answer: Observation of a latex-avoidance protocol

Explanation:

Question 57:

Options:

Observation
Closed reduction with a towel clip
Open reduction
Open reduction and internal fixation
Open reduction and sternoclavicular ligament allograft reconstruction

Correct Answer: Closed reduction with a towel clip

Explanation:

Question 58:

Options:

acetabular revision and femoral revision without an extended trochanteric osteotomy.
acetabular revision and femoral revision with an extended trochanteric osteotomy.
femoral revision without an extended trochanteric osteotomy.
femoral revision with an extended trochanteric osteotomy.

Correct Answer: femoral revision with an extended trochanteric osteotomy.

Explanation:

Question 59:

Options:

Chemotherapy and wide local excision
Chemotherapy and radiotherapy
Marginal excision
Extended intralesional curettage DISCUSSION.. The imaging shows an aneurysmal bone cyst with a destructive, eccentric metaphyseal lesion with fluid-fluid levels on MR imaging. The described histology confirms this. The differential diagnosis would include telangiectactic osteosarcoma, although there is no associated soft-tissue mass on imaging and no malignant stroma described on histology. Treatment is extended intralesional curettage. Serial embolization is used in surgically inaccessible spaces. Chemotherapy and/or radiotherapy are not indicated for this benign lesion. Intralesional treatment rather than excision is the appropriate surgical option.

Correct Answer: Extended intralesional curettage DISCUSSION.. The imaging shows an aneurysmal bone cyst with a destructive, eccentric metaphyseal lesion with fluid-fluid levels on MR imaging. The described histology confirms this. The differential diagnosis would include telangiectactic osteosarcoma, although there is no associated soft-tissue mass on imaging and no malignant stroma described on histology. Treatment is extended intralesional curettage. Serial embolization is used in surgically inaccessible spaces. Chemotherapy and/or radiotherapy are not indicated for this benign lesion. Intralesional treatment rather than excision is the appropriate surgical option.

Explanation:

CLINICAL SITUATION FOR QUESTIONS 132 THROUGH 134
Figure 132 is the bone scan of a 73-year-old man who is referred from his family doctor with diffuse bone pain, fatigue, and right knee pain. Examination is notable for pain with motion about the right knee and mild hyporeflexia.

Question 60:

Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease that is characterized by Review Topic

Options:

onset most often by age 30.
a temporary state of neuronal and axonal derangement.
manifestations of affect such as apathy, irritability, and suicidal ideation.
absence of gross pathological brain changes upon autopsy.

Correct Answer: manifestations of affect such as apathy, irritability, and suicidal ideation.

Explanation:

Question 61:

-Four months after injury, the tibia is showing evidence of slow healing on radiographs. What is the optimal treatment for this potential nonunion?

Options:

Convert to circular external fixation
Exchange nailing and autograft
Exchange nailing and bone morphogenetic protein
Tibial plate
Observation until 6 months after injury

Correct Answer: Observation until 6 months after injury

Explanation:

DISCUSSION FOR QUESTIONS 108 THROUGH 110:
This patient is unstable and is not a good candidate for Early Total Care (ETC) and therefore should be managed by the tenets of Damage Control Orthopaedics (DCO). Débridement and external fixation is preferable for this patient. Intramedullary nails would be a component of ETC. Calcaneal traction is not considered ideal because it does not allow the patient to travel as easily. The S.P.R.I.N.T. study concluded that while reamed nails may offer benefit in closed fractures, there was no difference between reamed or unreamed nails in the treatment of open fractures of the tibia. Uniplanar external fixation and tibial plating are not considered the best options for open tibia fractures. Additional findings of the S.P.R.I.N.T. study conclude that delaying surgical intervention for at least 6 months after injury may reduce the need for reoperation.

Question 62:

What spinal nerves in the cauda equina are primarily responsible for innervation of the bladder?

Options:

L1, L2, and L3
L4 and L5
L5 and S1
S2, S3, and S4
Filum terminale

Correct Answer: S2, S3, and S4

Explanation:

Question 63:

Options:

radiation therapy.
bisphosphonate therapy.
antitubercular therapy.
parathyroidectomy.
a diet low in phosphate.

Correct Answer: radiation therapy.

Explanation:

Question 64:

Parosteal osteosarcoma

Options:

Chemotherapy has dramatically improved the survival rate of patients with high-grade intramedullary osteosarcoma and Ewingâs tumor. The disease-free survival rate without chemotherapy is less than 20% for patients, whereas with modern multi-agent regimens, the disease-free survival rate approaches 70%. Periosteal osteosarcoma is an intermediate-grade osteosarcoma (risk of pulmonary metastases is 15% to 25%), which is generally treated with the same chemotherapy regimen as high-grade intramedullary osteosarcoma.
Chemotherapy has been used for a number of high-grade sarcomas with disappointing results: Dedifferentiated chondrosarcoma
High-grade intramedullary chondrosarcoma Sarcoma following Pagetâs disease
Chemotherapy has no use with low-grade sarcomas:
Well-differentiated intramedullary osteosarcoma Parosteal osteosarcoma
Low-grade intramedullary chondrosarcoma Adamantinoma
Chordoma

Correct Answer: Well-differentiated intramedullary osteosarcoma Parosteal osteosarcoma

Explanation:

Chemotherapy has no role in the treatment of which of the following tumors:

Question 65:

Options:

in situ subtalar fusion.
tibiotalocalcaneal arthrodesis using an intramedullary rod.
ankle arthroscopy with debridement of osteophytes.
subtalar distraction bone block arthrodesis.
lateral wall ostectomy of the calcaneus.

Correct Answer: subtalar distraction bone block arthrodesis.

Explanation:

Question 66:

Options:

Medial femoral circumflex
Obturator
Iliac circumflex
Femoral

Correct Answer: Femoral

Explanation:

DISCUSSION
Video 182 for reference
The femoral artery crosses the hip joint anterior to the anterior hip capsule. The medial femoral circumflex artery enters the joint along the route of the obturator externus. The obturator artery enters the hip joint beneath the transverse acetabular ligament. The iliac circumflex vessel arises superior to the hip joint.
RESPONSES FOR QUESTIONS 183 THROUGH 188
For each clinical scenario described below, identify the corresponding anteroposterior pelvic radiographic image shown above.

Question 67:

Clinical evidence suggests that grafts for replacing a torn anterior cruciate ligament often stretch after surgery. What is the most probable mechanism for this behavior?

Options:

Gross failure at the attachment sites
Fatigue failure of the ligament tissue
Creep of the graft material
Water absorption by the graft material
Elastic stretch of collagen fibers

Correct Answer: Creep of the graft material

Explanation:

DISCUSSION: The stretching of the graft occurs over time as the graft is loaded. Time-dependent deformation under load is called creep and is common in viscoelastic materials such as ligament tissue. Creep can occur under both static and cyclic load conditions; time-dependent deformation will occur as long as load is applied to the tissue. Similarly, when a graft is initially tensioned to a given deformation at surgery, the load generated in the graft will decrease over time; this behavior is called stress relaxation and also is indicative of a viscoelastic material. Water content may affect the viscoelastic properties by changing the friction between collagen fibers, but studies have shown little difference in water content between grafts and normal ligaments. Fatigue failures may manifest themselves through damage to the ligament tissue, but this would require higher loads than are routinely experienced by grafts. Elastic stretch is recoverable and, therefore, does not contribute to a permanent stretch. Similarly, gross failure at the attachment would not cause a stretch, but rather a catastrophic instantaneous instability.
REFERENCES: Boorman RS, Thornton GM, Shrive NG, et al: Ligament grafts become more susceptible to creep within days after surgery. Acta Orthop Scand 2002;73:568-574.
Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 596-609.
Lu L, Kaufman KR, Yaszemski MJ: Biomechanics, 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 68:

Options:

Juvenile inflammatory arthritis
Septic arthritis
Osteomyelitis of the femur
Leukemia
Toxic synovitis

Correct Answer: Toxic synovitis

Explanation:

DISCUSSION: The most likely diagnosis is toxic synovitis, and the normal C-reactive protein supports that diagnosis. Juvenile inflammatory arthritis is extremely rare to present with hip involvement. The child most likely does not have a bacterial infection because he has improved rapidly without treatment. A normal CBC with differential precludes the diagnosis of leukemia.
REFERENCES: Herring JA (ed): Tachdjian’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, WB Saunders, 2008, pp 2068-2070.
Del Beccaro MA, Champoux AN, Bockers T, et al: Septic arthritis versus transient synovitis of the hip: The value of screening laboratory tests. Ann Emerg Med 1992;21:1418-1422.
Kocher MS, Mandiga R, Zurakowski D, et al: Validation of a clinical prediction rule for the differentiation between
2010 Pediatric Orthopaedic Examination Answer Book • 11
septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am 2004:86:1629-1635.
AL-Madena Copy
12 • American Academy of Orthopaedic Surgeons
Figure 7a Figure 7b

Question 69:

Options:

It is safe to return to play right away.
It is safe to return to play if there is no airway obstruction from adenopathy.
It is safe to play due to the low risk of disease transmission to other players.
It is safe to play after 3 to 4 weeks.
It is unsafe to play the next season.

Correct Answer: It is safe to play after 3 to 4 weeks.

Explanation:

Question 70:

Options:

Arthroscopic debridement of the elbow
Open repair of the lesion
Open biopsy of the lesion
Continued participation in gymnastics until symptoms worsen
No participation in gymnastics until symptoms resolve and motion recovers

Correct Answer: No participation in gymnastics until symptoms resolve and motion recovers

Explanation:

Question 71:

50%

Options:

greater than 50%
None, by 5 years the allograft cartilage will be completely acellular

Correct Answer: greater than 50%

Explanation:

By 5 years, the allograft cartilage will be completely acellular, so there will be no residual donor chondrocytes.
Enneking et al. conducted both radiographic and histologic studies of sixteen massive retrieved human allografts four to sixty-five months after implantation. Analysis of the articular cartilage revealed no evidence that any chondrocytes had survived, even when the graft had been cryoprotected before it was preserved by freezing.
A 64-year-old woman with a longstanding history of rheumatoid arthritis complains of finger dysfunction for the past 6 months. Figure A displays her hand during active extension of all fingers. Figure B displays her hand maintaining her fingers extended following passive extension. What is the next most appropriate treatment for the ring finger?
Spiral oblique retinacular ligament reconstruction
Sagittal band reconstruction
Lateral band reconstruction
Central slip reconstruction
Triangular ligament and transverse retinacular ligament reconstruction
Sagittal band disruption is often associated with rheumatoid arthritis. When this patient attempts to actively extend the affected digit, the extensor tendon
subluxates ulnarly as a result of the sagittal band rupture, and is left with an extensor lag. If one passively extends the finger fully, the patient is able to maintain this position, as the tendon is intact.
Sagittal band reconstruction can be performed with Watson's technique of creating a distally based tendon graft harvested from the central third of the extensor tendon, passed deep to the intermetacarpal ligament and sutured back to itself. Illustration A depicts an intraoperative view of the tendon before reconstruction and Illustration B displays tendon following sagittal band reconstruction. Illustration C displays all of the anatomic locations
of the options listed above.
A splenectomy is performed in a 7-year-old boy following a motor vehicle accident. All of the following are recommended for long-term management EXCEPT:
Pneumococcal vaccination
Haemophilus influenza type B vaccination
Meningococcal group C vaccination
Lifelong prophylactic antibiotics
Hepatitis A vaccination
All of the responses are correct except the need for Hepatitis A vaccine. Hepatitis A is a virus with tropism for hepatocytes which causes infection from fecal-oral contaminated food/water, and shows no increased rate of either infectivity or morbidity in patients with hyposplenism.
Basic recommendations for splenectomized patients include:
All splenectomized patients and those with functional hyposplenism should receive pneumococcal immunization.
Patients not previously immunized should receive haemophilus influenza type B vaccine.
Patients not previously immunized should receive meningococcal group C conjugate vaccine.
Influenza immunization should be given.
Lifelong prophylactic antibiotics are still recommended (oral phenoxymethylpenicillin or erythromycin). This is seemingly despite lack of good data demonstrating a role for lifelong chemoprophylaxis and the acknowledgement that long-term compliance may be problematic.
Davies et al review the current level of evidence supporting these guidelines
for infection prevention in patients with hyposplenism. New to these guidelines are issues regarding occupational exposure and the use of the meningococcal group C and the seven-valent pneumococcal vaccine in non-immunized hyposplenic patients.
Gandhi et al evaluated their nonoperative management of blunt splenic injury in pediatric trauma care. They found compared to historical controls, children with blunt splenic injuries who were hemodynamically stable could be safely monitored with a protocol which required 4 days of inpatient care, 3 weeks of quiet home activities, and 3 months of light activity. This protocol seems to allow for safe return to unrestricted activity.
Incorrect Answer:
Ligaments attach to bone by both direct insertion and indirect insertion. Which of the following most accurately describes the order of the four transition zones of direct insertion?
Ligament > fibrocartilage > mineralized fibrocartilage > bone
Ligament > mineralized fibrocartilage > fibrocartilage > bone
Ligament > mineralized fibrocartilage > periosteum > bone
Ligament > Sharpey's fiber > periosteum > bone
Ligament > periosteum > fibrocartilage > bone
There are two types of tendon/ligament insertion into bone: direct and indirect insertion. The more common, indirect insertion, occurs when the superficial ligament fibers insert into the periosteum. Direct insertion of tendon/ligaments
into bone occurs through a transition of 4 distinct phases: 1) ligament, 2) fibrocartilage, 3) mineralized fibrocartilage, and 4) bone.
While flexing the elbow to perform a biceps curl, what type of muscle contraction is occuring?
Isometric
Isokinetic
Plyometric
Eccentric
Concentric
Concentric muscle contractions occur when a muscle shortens during contraction, as in the upward motion when performing a biceps curl. An eccentric contraction occurs when a muscle lengthens with contraction, as in the "negative" or lowering motion of a biceps curl. An example of an isometric (muscle contracts while maintaining constant length) contraction would be pushing against an immovable object. An example of an isokinetic (muscle has constant speed of contraction) occurs with specialized equipment like Cybex machines. Plyometric contractions occur when a muscle rapidly lengthens just prior to contraction - like during repetitive box jumping.
Woo and Buckwalter describe the mechanisms, barriers, and molecular processes involved in ligament and tendon injury and repair.
A 34-year-old laborer has her left foot crushed in a piece of farming equipment as shown in Figure A. All of the following are reasons for a poor outcome following a crush injury to the foot EXCEPT:
Workers compensation injury
Development of reflex sympathetic dystrophy (complex regional pain syndrome)
Delayed soft-tissue coverage in mangled extremities
Immediate skeletal stabilization
Ongoing litigation
This patient has a mangled extremity. Rigid skeletal stabilization is recommended to enhance soft-tissue healing.
Level 4 evidence from Myerson et al found that delayed soft-tissue coverage in mangled extremities correlated with poor outcome. Poor results also occurred
if treatment was not immediately initiated (immediate debridement shown in Illustration A), if patients subsequently had neuritis or reflex sympathetic dystrophy, or if patients were involved in ongoing workers' compensation and litigation. Neuroischemia following substantial soft-tissue injury likely plays a role in the development of chronic pain after crush injuries to the foot, either through direct trauma to the peripheral nerves or by intraneural or extraneural fibrosis. This trauma to the nerve may cause chronic neuritis, which then triggers a sympathetically mediated reflex sympathetic dystrophy (complex regional pain syndrome).
A 65-year-old man undergoes total knee replacement and is found to have deep vein thrombosis two days later. What molecule is
thought to be involved in this process when it is released during surgical dissection?
Prothrombin
RANKL
IL-1b
Thromboplastin
Factor XI
Corrent answer: 4
Thromboplastin is also known more commonly as Tissue Factor (TF), which is involved in the Extrinsic Pathology of the coagulation cascade.
During surgical dissection, insults occur to the endothelial walls of blood vessels. There are three ways in which the body reacts to form a clot so that the patient does not bleed excessively. One is via vessel contraction, another is by collagen release, and a third is by tissue thromboplastin release. Thromboplastin release is part of the extrinsic coagulation pathway (see
Illustration A). Thromboplastin release activates Factor VII which activates Factor X which converts prothrombin to thrombin. Thrombin is the catalyst for converting fibrinogen to fibrin which induces clot formation. While this is useful for decreasing bleeding, it is the same mechanism by which a deep venous thrombosis (DVT) develops.
Which of the following materials has a Young's modulus of elasticity that is most similar to cortical bone
Titanium
Zirconia
Stainless steel
Ceramic (Al2O3)
Alloy (Co-Cr-Mo)
Of the materials listed Titanium has an elastic moduli closest to cortical bone. Titanium is extra-ordinarily light, strong, highly ductile, and corrosion resistant. Titanium is however very notch sensitive and has poor wear resistance.
Young Modulus of Elasticity is defined as the stiffness (ability to maintain
shape under external loading) of a material. On the stress vs. strain curve it is defined as the slope of the line in the elastic zone (see Illustration A). Young’s modulus is constant and different for each material. The relevant moduli (unit GPa) are approximated below:

Question 72:

Figure 36 shows the radiograph of a 28-year-old man who injured his shoulder in a motocross race. Management should consist of

Options:

sling and swathe immobilization.
early mobilization and strengthening exercises.
an airplane abduction orthosis.
stabilization with percutaneous smooth pins.
open stabilization with coracoclavicular ligament repair and reconstruction.

Correct Answer: open stabilization with coracoclavicular ligament repair and reconstruction.

Explanation:

Question 73:

The primary function of structure “A” in Figure 29 is to limit

Options:

posterior tibial displacement at 90 degrees of flexion.
varus knee laxity at 30 degrees of flexion.
varus knee laxity at 0 degrees of flexion.
anterolateral rotation of the tibia on the femur.
posterolateral rotation of the tibia on the femur.

Correct Answer: posterolateral rotation of the tibia on the femur.

Explanation:

Question 74:

Options:

Irrigation and debridement of the cystic lesion and 6 weeks of IV antibiotics
Curettage, debridement of nonviable bone, and placement of absorbable antibiotic beads, followed by a course of IV antibiotics from 1 to 4 weeks and a 6-week course of oral antibiotics
Complete resection of the infected portion of bone, placement of an external fixator to stabilize the tibia, and 6 weeks of IV antibiotics
Amputation
Local debridement of bone and the overlying skin and soft tissues, 6 weeks of IV antibiotics, and free-flap wound coverage

Correct Answer: Curettage, debridement of nonviable bone, and placement of absorbable antibiotic beads, followed by a course of IV antibiotics from 1 to 4 weeks and a 6-week course of oral antibiotics

Explanation:

DISCUSSION: The patient has chronic tibial osteomyelitis that is due to low virulent bacteria. The history and studies do not suggest the need for an amputation or a free-flap procedure. This is a localized tibial infection that is in a healed bone; there is no need to resect the entire area of the tibia bone around the infection. The most appropriate treatment is curettage, debridement of nonviable bone, and placement of absorbable antibiotic beads, followed by a course of IV antibiotics from 1 to 4 weeks and a 6-week course of oral antibiotics. Studies have shown that in cases of localized osteomyelitis that are of low virulence, as little as 1 week of IV antibiotics followed by 6 weeks of oral antibiotics is successful.
REFERENCES: Patzakis MJ, Zalavras CG: Chronic posttraumatic osteomyelitis and infected nonunion of the tibia: Current management concepts. J Am Acad Orthop Surg 2005;13:417-427.
Beals RK, Bryant RE: The treatment of chronic open osteomyelitis of the tibia in adults.
Clin Orthop Relat Res 2005;433:212-217.

Question 75:

Which treatment is associated with decreased complications related to femoral nerve blocks for TKA?

Options:

Knee immobilizer
Compression stockings
Tranexamic acid
Celecoxib

Correct Answer: Knee immobilizer

Explanation:

Question 76:

Options:

Aneurysmal bone cyst
Enchondroma
Plasmacytoma
Giant cell tumor
Chondrosarcoma

Correct Answer: Chondrosarcoma

Explanation:

DISCUSSION: The radiograph reveals a metaphyseal lesion with some stippled mineralization suggesting a chondroid tumor. The bone scan shows increased uptake, beyond what is expected for a simple enchondroma, and beyond the limits of the lesion. The MRI sequences shows a lobular lesion on the T
1
- and T
2
-weighted (bright on the T
2
sequence) images with inhomogeneous uptake of gadolinium; both findings are typical for a chondroid lesion. The history of pain, the positive bone scan, the age of the patient, the size of the lesion, and the central location (enostotic) of the lesion all suggest a malignant cartilage tumor. The images are not consistent with the other diagnoses. In particular, plasmacytoma is more uniformly bright on T
2
-weighted images and often has a negative bone scan.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 187-194.
Resnick D (ed): Diagnosis of Bone and Joint Disorders. Philadelphia, PA, WB Saunders, 2002, pp 3897-3904.

Question 77:

A 21-year-old woman has a nontraumatic rupture of the Achilles tendon. Which of the following commonly prescribed medications has been associated with this condition?

Options:

Ibuprofen
Fluoroquinolones
Bisphosphonates
Metoprolol
Simvistatin

Correct Answer: Fluoroquinolones

Explanation:

Question 78:

Options:

Awake closed reduction
Application of a halo orthosis
Placement of a cervical collar
Open reduction under anesthesia
Closed reduction under anesthesia

Correct Answer: Awake closed reduction

Question 79:

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 80:

Options:

Range of motion might be slightly better after an arthroscopic procedure.
Rate of recurrent instability is lower after an arthroscopic procedure.
Rates of return to work are higher after an arthroscopic procedure.
Rates of return to sports are higher after an arthroscopic procedure.

Correct Answer: Range of motion might be slightly better after an arthroscopic procedure.

Explanation:

Question 81:

Options:

Abduction to 90 degrees with maximal external rotation
Forward elevation to 170 degrees with neutral rotation
Cross-body adduction at 90 degrees flexion, with internal rotation
Extension with maximal internal rotation
Flexion to 90 degrees with maximal external rotation

Correct Answer: Abduction to 90 degrees with maximal external rotation

Explanation:

Question 82:

Options:

Thumb carpometacarpal (CMC) arthroplasty with ligament suspensionplasty
Thumb CMC and thumb metacarpophalangeal (MCP) joint fusion
Thumb CMC arthroplasty with ligament suspensionplasty and thumb MCP joint stabilization
Trapezial resection and distraction arthroplasty

Correct Answer: Thumb CMC arthroplasty with ligament suspensionplasty and thumb MCP joint stabilization

Explanation:

Question 83:

Options:

Debridement and IV antibiotics
Wide resection of the lesion
Chemotherapy alone
Observation
Amputation

Correct Answer: Wide resection of the lesion

Explanation:

DISCUSSION: In an adult with an anterior cortical tibial lesion, this is the classic histologic appearance and anatomic location for an adamantinoma. The histology reveals areas of epithelial cells (in a glandular pattern) within a fibrous stroma. The epithelial cells are shown in nests. They would stain positively for keratin. Adamantinoma is a rare malignant bone tumor with a propensity for late metastasis. It has a high incidence of local recurrence unless resected with a wide margin. Chemotherapy and radiation therapy are not helpful in the treatment of this disease. Amputation generally is not necessary because a diaphyseal resection is usually possible.
REFERENCES: McCarthy EF, Frassica FJ: Pathology of Bone and Joint Disorders with Clinical and Radiographic Correlation. Philadelphia, PA, WB Saunders, 1998, p 263.
Moon NF, Mori H: Adamantinoma of the appendicular skeleton: Updated. Clin Orthop Relat Res 1986;204:215-237.

Question 84:

A 55-year-old woman fell and sustained an elbow dislocation with a coronoid fracture and a radial head fracture. The elbow is reduced and splinted. What is the most common early complication?

Options:

Brachial artery intimal tear
Recurrent dislocation
Forearm compartment syndrome
Posterior interosseous nerve injury
Ulnar nerve palsy

Correct Answer: Recurrent dislocation

Explanation:

Question 85:

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

Options:

Observation
Curettage and bone grafting
Wide local excision
Wide local excision and radiation therapy
Radiation therapy only

Correct Answer: Curettage and bone grafting

Explanation:

Question 86:

Options:

Chairback brace
Thoracolumbosacral orthosis (TLSO) molded in extension
Posterior stabilization of the fracture with segmental fixation and iliac crest bone grafting
Anterior corpectomy, strut grafting, and plating
Combined anterior corpectomy, structural grafting and plating, and posterior stabilization and fusion

Correct Answer: Thoracolumbosacral orthosis (TLSO) molded in extension

Explanation:

Question 87:

Options:

protected weight bearing and anti-inflammatory drugs.
core decompression of the femoral head.
vascularized free fibular grafting to the femoral head.
bipolar hemiarthroplasty of the hip.
total hip arthroplasty.

Correct Answer: protected weight bearing and anti-inflammatory drugs.

Explanation:

DISCUSSION: The MRI findings show highly increased signal through the entire femoral head and neck on STIR imaging, diagnostic of transient osteoporosis of the femoral head. This disease entity can be seen in middle-aged men, and should be treated nonsurgically. The natural history is that of self-resolution.
REFERENCES: Guerra JJ, Steinberg ME: Distinguishing transient osteoporosis from avascular necrosis of the hip. J Bone Joint Surg Am 1995;77:616-624.
Urbanski SR, de Lange EE, Eschenroeder HC Jr: Magnetic resonance imaging of transient osteoporosis of the hip: A case report. J Bone Joint Surg Am 1991;73:451-455.

Question 88:

Options:

Blood loss
Airway obstruction
Cerebrovascular accident
Periodontal disease
Hearing loss

Correct Answer: Airway obstruction

Explanation:

Question 89:

Options:

Longitudinal split tear in the peroneus longus
Longitudinal split tear in the peroneus brevis
Plantaris
Peroneus accessorius
Peroneus quartus

Correct Answer: Peroneus quartus

Explanation:

DISCUSSION: The structure labeled “A” is a peroneus quartus, a supernumary muscle arising most commonly from the peroneus brevis. The presence of peroneus quartus is not uncommon, with an incidence of up to 21%, and is associated with lateral ankle pain and peroneal tendon symptoms, theoretically as a result of mass effect within the peroneal tendon sheath.
REFERENCES: Zammit J, Singh D: The peroneus quartus muscle: Anatomy and clinical relevance. J Bone Joint Surg Br 2003;85:1134-1137.
Sobel M, Levy ME, Bohne WH: Congenital variations of the peroneus quartus muscle: An anatomic study. Foot Ankle 1990;11:81-89.

Question 90:

Options:

Unreamed intramedullary nail
Reamed statically locked intramedullary nail
External fixation
Plate fixation and interfragmentary compression
Bridge plate stabilization

Correct Answer: Plate fixation and interfragmentary compression

Explanation:

Question 91:

Options:

No external rotation stretching for the first 6 weeks.
No external rotation stretching for the first 3 weeks.
Limit external rotation to the side to 60 degrees for the first 6 weeks.
Limit external rotation to the side to 60 degrees for the first 3 weeks.
No restrictions on external rotation stretching.

Correct Answer: Limit external rotation to the side to 60 degrees for the first 6 weeks.

Explanation:

DISCUSSION: The patient needs restrictions on his external rotation to allow healing of the subscapularis tendon repair. Limitation to 60 degrees is common if the tendon repair is robust and shows no evidence of tension on range-of-motion testing during the surgery. Restriction from external rotation stretching for even 3 weeks would compromise his ultimate functional recovery.
REFERENCES: Boardman ND III, Cofield RH, Bengston KA, et al: Rehabilitation after total shoulder arthroplasty. J Arthroplasty 2001;16:483-486.
Matsen FA III, Lippitt SB, Sidles JA, et al: Practical Evaluation and Management of the Shoulder. Philadelphia, PA, WB Saunders, 1994, pp 215-218.

Question 92:

Closed-chain exercise differs from open-chain exercise in which of the following ways?

Options:

Distal portion of the extremity is free during exercise
More commonly used in upper extremity exercise
Predictable movement is produced by co-contraction of muscles
Joint compression is decreased
Usually involves a single joint

Correct Answer: Predictable movement is produced by co-contraction of muscles

Explanation:

Question 93:

Which of the following methods best aids in diagnosis of an interdigital neuroma?

Options:

Ultrasound
MRI
Web space injection
Electromyography and nerve conduction velocity studies
History and physical examination

Correct Answer: History and physical examination

Explanation:

Question 94:

Options:

a non-weight-bearing cast for 4 weeks.
eccentric calf stretching and physical therapy.
a cortisone injection.
tendon debridement.
tendon debridement and augmentation.

Correct Answer: eccentric calf stretching and physical therapy.

Explanation:

Question 95:

Options:

Conversion to a peri-articular hybrid frame
Open reduction and internal fixation with a lateral locking plate
Open reduction and internal fixation with a lateral nonlocking plate
Open reduction and internal fixation with medial and lateral plates
Open reduction and internal fixation with posteromedial and lateral plates

Correct Answer: Open reduction and internal fixation with posteromedial and lateral plates

Question 96:

Figure 39 shows the sagittal T1-weighted MRI scan of a 27-year-old man who twisted his knee 2 weeks ago. The arrow is pointing to

Options:

a physeal scar.
a femoral stress fracture.
a normal growth plate.
Looser’s line.
an abnormal growth plate.

Correct Answer: a physeal scar.

Explanation:

Question 97:

Options:

figure-of-8 splinting to maintain the clavicle in a reduced position.
an exercise program to stabilize the joint in a reduced position.
elective reconstruction of the sternoclavicular joint ligaments.
reassurance and local symptomatic treatment.
closed reduction and temporary pin fixation to stabilize the joint.

Correct Answer: reassurance and local symptomatic treatment.

Explanation:

Question 98:

Options:

at least two more attempts at closed reduction in the emergency department before the patient’s sedation wears off.
at least two attempts at closed reduction in the operating room under general anesthesia with muscle relaxation.
acceptance of the reduction because the alignment is satisfactory and growth problems are rare with Salter-Harris type I fractures.
open reduction, extraction of any interposed periosteum, and smooth wire fixation to prevent nonunion.
open reduction, extraction of any interposed periosteum, and smooth wire fixation to decrease the chance of premature physeal closure.

Correct Answer: open reduction, extraction of any interposed periosteum, and smooth wire fixation to decrease the chance of premature physeal closure.

Explanation:

Question 99:

Options:

Medial malleolus
Deltoid ligament
Anterior talofibular ligament
Lateral malleolus
Calcaneonavicular ligament

Correct Answer: Deltoid ligament

Explanation:

Question 100:

Options:

Intramuscular hematoma
Lipoma
Myositis ossificans
Malignant fibrous histiocytoma
Liposarcoma

Correct Answer: Malignant fibrous histiocytoma

Explanation:

DISCUSSION: Malignant fibrous histiocytoma (MFH) is the most common soft-tissue sarcoma. MFH typically presents as a large mass, deep to the fascia with heterogeneous signal on MRI. The MRI scans show a heterogeneous lesion in the posterior thigh. There is significant high signal uptake on the T
2
-weighted image. The histology shows malignant histiocytic cells with marked atypia and pleomorphism. Histology of a hematoma would show only old hemorrhage and some granulation tissue. Lipoma and liposarcoma are both seen as a fat-containing lesion on histology. No significant fat tissue is seen in this histologic specimen. Histology of myositis ossificans would show bone formation.
REFERENCES: Simon SR (ed): Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 219-276.
Campanacci M: Bone and Soft Tissue Tumors, ed 2.
New York, NY, Springer-Verlag, 1999, pp 965-981.

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

Orthopedic Board Review MCQs: Arthroplasty, Fracture & Tumor | Part 137

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 137

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index