Orthopedic Surgery Board Review MCQs: Arthroplasty, Foot & Ankle, Trauma | Part 141

A 61-year-old man reports right hip pain and limited motion after undergoing total hip arthroplasty for posttraumatic arthritis 1 year ago. Figure 6 shows an AP radiograph of the pelvis. To improve motion and relieve pain, management should consist of

Figures 11a and 11b show the radiographs of a 50-year-old man who was struck by a car. Treatment should consist of

A 17-year-old football player is injured during a play and reports abdominal pain that is soon followed by nausea and vomiting. What organ has most likely been injured?

A 13-year-old patient has foot drop and lateral knee pain. AP and lateral radiographs and an MRI scan are shown in Figures 49a through 49c. A biopsy specimen is shown in Figure 49d. What is the preferred method of treatment?

A further workup reveals elevations in serum cobalt and chromium levels and fluid collections surrounding the hip on MARS MR imaging. Revision THA is recommended. The most common complication following revision of a failed metal-on-metal hip arthroplasty is

03 A patient with carpometacarpal joint arthritis of the thumb undergoes trapezium excision and interposition arthroplasty. One year after treatment, radiographs reveal that there has been 25% subsidence of the thumb metacarpal compared with its preoperative height. This degree of subsidence will have what effect on the surgical outcome?

A 70-year-old female presents with right thigh ache for 6 months. Except for a history of osteoporosis, she is otherwise healthy. She has been on antiresorptive therapy for 8 years. Her radiograph is shown in Figure A. Four months later, she trips over a rug and falls, sustaining the injury shown in Figures B and C. Which of these statements is TRUE regarding surgical fixation of this fracture compared with conventional fractures?

Refers to the effectiveness of various antibiotics against a particular microorganism.

An obese patient undergoing total knee arthroplasty is at increased risk for which of the following complications?

Which of the following is NOT considered a risk factor for nonunion of a type II odontoid fracture?

What is the main benefit of using metal-backed tibial components in total knee arthroplasty?

What is the optimum position of immobilization of the foot and ankle immediately after Achilles tendon repair to maximize skin perfusion?

A 25-year-old man has ankle instability and a lateral foot callosity. Radiographs are shown in Figures 49a through 49c. Management options are best determined by the

Patient-specific instrumentation (PSI) reliably demonstrates which benefit over conventional intramedullary guidance systems?

What is the most common clinically significant preventable complication secondary to the treatment of a displaced talar neck fracture?

Figure 49 shows an acute axial MRI scan of a left knee. What is the most likely diagnosis?

-The Coleman block test is used to test for

Which of the following statements is true regarding articular cartilage?

Figure 27 shows the AP radiograph of a patient who has late instability. The problem most likely occurred as a result of

-An infant was born with complex syndactyly involving all 4 fingers of both hands, short and deformed thumbs, and similar syndactyly involving both feet. In addition, an altered facial appearance was noted with protruding eyes, a towered cranium, and midface hypoplasia. This appearance is characteristic of which syndrome?

What is the most reproducible landmark for the accurate anatomic placement of the tibial tunnel for an anterior cruciate ligament (ACL) reconstruction?

A 46-year-old man reports occasional squeaking of his hip 2 years after undergoing an uneventful total hip arthroplasty. History reveals no pain, physical examination cannot reproduce audible squeaking, and radiographs show appropriate implant position. What is the most appropriate management?

Etanercept is a recombinant genetically engineered fusion protein used to treat rheumatoid arthritis. What is its mode of action?

A 22-year-old competitive volleyball player has shoulder pain, and rest and a cortisone injection have failed to provide relief. Examination reveals atrophy along the posterior scapula, but an MRI scan does not reveal a rotator cuff tear or labral cyst. What is the most likely cause for the shoulder weakness?

Clinical staging of osteomyelitis using the Cierney-Mader classification system takes into account which of the following factors?

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

A 19-year-old man sustains a low-velocity gunshot wound to the forearm. What factor most strongly correlates with the development of compartment syndrome after this injury?

Figure 25 shows an arthroscopic thermal capsular shrinkage device being used in the anterior inferior quadrant of a patient with a subluxating shoulder. Which of the following neurologic complications is most frequently reported with this technique?

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

A radiograph of a 27 month old child with bilateral genu valgum and internal tibial torsion shows the metaphyseal-diaphyseal angle of Levine and Drennen is 12 degrees on the right and 13 degrees on the left. Based on this finding, management should consist of

A 41-year-old right-hand-dominant man has been treated nonsurgically for right elbow arthritis. His radiographs reveal end-stage ulnohumeral arthritis with complete loss of the joint space. He reports pain during the mid-arc of elbow flexion and extension. During the last 8 years, he has attempted activity modification, medication, physical therapy, and multiple cortisone injections. His symptoms have progressed, resulting in constant pain, loss of a functional range of motion, and an inability to perform many activities of daily living. Secondary to his age and activity demands, he undergoes a soft-tissue interposition arthroplasty of his elbow with an Achilles allograft. Which presurgical finding correlates with elevated risk for postsurgical complications?

A 15-year-old wrestler sustains an abduction, hyperextension, and external rotation injury to his right shoulder. The MRI scan findings shown in Figures 27a and 27b are most consistent with Review Topic

A 75-year-old man sustains an anterior dislocation of his reverse total shoulder arthroplasty. What activity places the arm in the position most commonly associated with reverse total shoulder dislocation?

What is the main function of collagen found within articular cartilage?

Intermittent daily administration of recombinant parathyroid hormone (rhPTH) is an FDA-approved treatment for osteoporosis. Intermittent rhPTH treatment targets which of the following cells in osteoporotic patients?

Sciatic nerve

Figure 23 shows the radiograph of a 7 year-old girl with a low thoracic-level myelomeningocele. She has a history of skin ulcers over the apex of the deformity, but her current skin condition is good. Management of the spinal deformity should consist of

What is the most common associated pathology in patients who have suprascapular nerve entrapment secondary to ganglion cysts?

In total knee arthroplasty, in vitro testing has shown that cross-linking can diminish the rate of polyethylene wear by 30% to 80%. What other change in material properties is possible when polyethylene is highly cross-linked?

Which of the following nerves is most likely responsible for symptoms associated with plantar fasciitis?

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

A 72-year-old woman who is right hand-dominant has severe pain in the right shoulder that has failed to respond to nonsurgical management. She reports night pain and significant disability. Examination reveals 30 degrees of active forward elevation. An AP radiograph is shown in Figure 27. Which of the following treatment options will provide the best functional improvement?

A healthy, active 72-year-old man trips and falls, landing on his left hip 10 weeks after an uncomplicated left primary uncemented total hip replacement. A radiograph taken 6 weeks after surgery and before the fall is shown in Figure 1. A radiograph taken after the fall is shown in Figure 2. He is unable to bear weight and is brought to the emergency department. Examination reveals a slightly shortened left lower extremity and some mild ecchymosis just distal to the left greater trochanteric region, but his skin is intact, without abrasions or lacerations. What is the most appropriate treatment?

What structure is most at risk with anterior penetration of C1 lateral mass screws?

-A 3-year-old child with achondroplasia is hypotonic, and sleep studies reveal central apneic episodes. An initial workup should evaluate for what diagnosis?

A patient with a 5-cm synovial sarcoma located in the distal portion of the rectus femoris muscle undergoes excision of the mass. The procedure is performed through a 10-cm longitudinal incision. Only a portion of the rectus femoris is removed; the vast majority of the muscle is preserved. The plane of dissection is beyond the reactive zone, and the pathology reveals that the margins are negative. This procedure is classified as

CLINICAL SITUATION Figures 1 and 2 are the radiographs of a 35-year-old man who is brought into the emergency department after a motor vehicle collision. He is complaining of isolated knee pain. Examination reveals swelling, blood filled blisters, popliteal ecchymosis, joint line pain, and limited knee joint motion. His pulses and sensation are normal. The surgical approach for definitive reduction and stabilization of this pattern is

An 83-year-old woman with a long history of her foot slowly and progressively “turning out” now reports significant ankle pain. History reveals that she has significant cardiac disease and exercise-induced angina. Examination reveals a deficiency in the posterior tibial tendon; however, the hindfoot remains moderately supple. Radiographs reveal a valgus tilt of the tibiotalar joint and early arthrosis. What is the most appropriate orthotic management?

What type of cementless femoral fixation results in the highest rate of distal femoral osteolysis?

A 16-year-old female gymnast reports a 2-month history of back pain since falling off the parallel bars, and she has been unable to return to gymnastics. She has no numbness or tingling. Examination reveals lower back tenderness, some paravertebral muscle spasm, range of motion of the lumbosacral spine is 20 degrees of flexion and 20 degrees of extension, and an equivocal straight leg raise. Lumbosacral spine radiographs demonstrate Schomorl’s nodes but no evidence of spondylolisthesis. What is the next best step in management?

The preferred surgical approach to the elbow of a child with an irreducible type III supracondylar distal humerus fracture and pulseless extremity is through which of the following muscle intervals?

Figures 12a and 12b show the radiographs of a 50-year-old patient who reports acute knee pain after sustaining a twisting injury while playing tennis. Examination is unremarkable. The next most appropriate step in management should consist of

The incidence of ipsilateral phrenic nerve blockade after an interscalene block approaches

A 69-year-old man sustains a traumatic amputation to the distal phalanx of his little finger while working with power tools. Radiographs are shown in Figures 27a and 27b. The patient was instructed how to perform wet-to-dry dressing changes in the emergency department. Clinical pictures taken in the office are shown in Figures 27c through 27e. What is the most appropriate management of this soft-tissue wound?

What type of brace is shown in Figures 22a and 22b?

Figures 113a and 113b are the radiographs of a 7-year-old girl who was evaluated for a visible elbow deformity by a foster parent. She thought the child fell, but her history was vague. On physical examination, a large prominence was seen over the posterolateral elbow, and the girl lacks the terminal 20 degrees of elbow extension. She has 75 degrees of elbow pronation and supination. She was nontender on examination. What is the most appropriate next treatment step? Review Topic

An otherwise healthy 33-year-old man who works in construction reports a 3-month history of knee pain. Radiographs are shown in Figures 9a and 9b. An axial T 1 -weighted MRI scan with contrast, an angiogram, and histologies are shown in Figures 9c through 9f. What is the most likely diagnosis?

A college athlete has a knee injury requiring surgery. He has acne, gynecomastia, and well-developed muscles related to the use of anabolic steroids. What association with steroid use is concerning for surgery and anesthesia? Review Topic

The rate of complications after in situ pinning of a chronic slipped capital femoral epiphysis is highest with placement of the screw in what quadrant of the femoral head?

Figure 54 shows the preoperative radiograph of a 45-year-old woman who is considering total hip arthroplasty with her orthopaedic surgeon. What femoral characteristic is a typical concern in this patient?

As a diaphyseal fracture heals, peripheral callus forms about the shaft axis, creating a structure with a substantially larger diameter than the original diaphyseal shaft. What biomechanical properties does this callus impart to the healing fracture site?

When performing a bunionectomy with a release of the lateral soft-tissue structures, the surgeon is cautioned against releasing the conjoined tendon that inserts along the lateral base of the proximal phalanx of the great toe. This conjoined tendon is made up of what two muscles?

A 26-year-old male underwent statically locked intramedullary nail fixation for a comminuted left femur fracture. An early post-operative computed tomography (CT) scanogram was taken to check rotational alignment, as shown in Figure A. What would be the next best step in the management of this patient?

Hip pain of 1-month duration has developed in a 72-year-old man with a previous total hip arthroplasty. He underwent dental work 6 weeks ago. Aspiration shows a white blood cell count of more than 6,000 cells/μL (reference range 4,500 to 11,000 cells/μL) and the presence of gram-positive cocci in clusters on Gram stain. The orthopaedic surgeon recommends urgent debridement and irrigation. Fixation of the components is judged to be stable, and the surgeon elects to retain the implants. The patient has a final culture that reveals methicillin-resistant Staphylococcus aureus (MRSA). If the attending physician recommends the two-stage protocol, including the use of an antibiotic-cement spacer, what is the most likely prognosis for this patient?

What antithrombotic agent is a selective factor I0a inhibitor? Review Topic

When counseling a patient with hypophosphatemic rickets, which of the following scenarios will always result in a child with the same disorder?

A 78-year-old woman falls onto her nondominant left elbow and sustains the injury shown in Figure A. What treatment option allows her the shortest recovery time and highest likelihood of good function and range of motion? Review Topic

A 21-year-old right hand-dominant male collegiate swimmer reports painful clicking in the right shoulder. He states that he can occasionally feel his shoulder “slip out” when he is working out. AP, true AP, and axillary radiographs are shown in Figures 39a through 39c. What is the next most appropriate step in management?

Figure 65 is the lumbar spine MR image of a 63-year-old woman who has a 3-year history of increasingly bothersome back pain and bilateral buttock and leg pain. She has performed 6 weeks of physical therapy, received epidural injections, and experienced some good short-term results, but her leg pain continues to worsen. What is the most appropriate course of treatment?

A favorable outcome following nonsurgical management of a partial tear of the posterior cruciate ligament (PCL) is best associated with

A B C D E Figures 45a through 45c are the MR images of a 22-year-old woman who has had 6 months of ankle pain related to activities of daily living. She recently completed a course of cast immobilization and protected weight bearing without symptom resolution. Figures 45d and 45e are the intraoperative arthroscopy images after minimal probing. What is the most appropriate treatment?

A 4-month-old infant is unable to flex her elbow as a result of an obstetrical brachial plexus palsy. This most likely illustrates a predominate injury to what structure?

Figure 71 is the MRI scan of a 2-year-old girl who has been febrile for 1 week and has refused to bear weight on her left lower extremity for 3 days. Her entire left lower extremity is markedly swollen. Doppler ultrasound shows a deep venous thrombosis of the internal iliac vein. Her white blood cell count is 19000/ µL (reference range, 4500-11000/ µL) and her C-reactive protein level is higher than 20 mg/L (reference range, 0.08-3.1 mg/L). If blood cultures yield positive results, what is the most likely organism? Review Topic

An year-old obese woman has left knee pain. She had surgery 5 years ago for a patellar nonunion after total knee arthroplasty that was complicated by infection, which was treated with implant removal and patellectomy. She has not been ambulatory since then. She states she is no longer on antibiotics. She has moderate pain, but her primary problem is instability of the knee. She has a 40° extensor lag. Darkening of the skin is present distal to the incision consistent with venous stasis changes. The erythrocyte sedimentation rate is 12 mm/h (reference range 0 to 20 mm/h) and her C-reactive protein level is 0 mg/L (reference range 08 to 1 mg/L). Left knee aspiration shows a white blood cell count of 800 and 20% neutrophils. What is the best next step?

Figure  below  shows  the  abdominal  radiograph  obtained  from  a  70-year-old  woman  who  experiences nausea and abdominal tightness 48 hours following left total knee arthroplasty performed under general anesthesia. She received 24 hours of cefazolin antibiotic prophylaxis and a patient-controlled analgesia narcotic pump for pain management. She has been receiving warfarin for thromboembolic prophylaxis. Her severe abdominal distension and markedly decreased bowel sounds are most likely secondary to the administration of

If the structure marked by the tip of the probe in Figure 94 is repaired to the bony glenoid with suture anchors during an arthroscopic stabilization procedure, what is the most likely result? Review Topic

Which of the following medications has been shown to improve skeletal muscle regeneration and decrease fibrosis following muscle injury in an animal model? Review Topic

Figures 1 through 5 are the MR images of a 12-year-old boy with left lateral-sided knee pain following a football injury. He has a several-year history of recurrent knee pain that improves with rest. An examination reveals a moderate effusion. Range of motion is 0° to 90° and is limited by pain in deep flexion. He has tenderness to palpation along the lateral joint line, and no instability is noted. What is the underlying cause of the pathology noted in the figures?

A 12-year-old boy who pitches on two “select” baseball teams has had pain in his dominant right shoulder for the past 6 weeks. The pain is present only with throwing and is associated with decreased throwing velocity and control. He has no radiation of pain or paraesthesias of the upper extremity. An AP radiograph and MRI scan are shown in Figures 19a and 19b, respectively. Management should consist of Review Topic

A patient reports pain in the hip with functional positioning. With the patient supine, pain in which of the following positions would be typical for femoral acetabular impingement? Review Topic

Figure 10 shows the radiograph of a 7-year-old patient who has a bilateral Trendelenburg limp and limited range of hip motion but no pain. His work-up should include

use of a true lateral to assess the DRUJ, 4) beginning early range of motion of the wrist after stable fixation and 5) use vitamin C to help mitigate intractable pain.

What is the preferred treatment of a symptomatic curly toe deformity in a 6-year-old child?

Which of the following can be seen in the heart of a well-conditioned athlete? Review Topic

A 74-year-old woman with rheumatoid arthritis reports shoulder pain that has failed to respond to nonsurgical management. AP and axillary radiographs are shown in Figures 23a and 23b. Examination reveals active forward elevation to 120 degrees and external rotation to 30 degrees. What treatment option results in the most predictable pain relief and function? Review Topic

• An MRI scan of the brain of a patient with spastic diplegia will most likely show

A 30-year-old elite marathon runner reports chronic pain over the lateral aspect of the distal right leg and dysesthesia over the dorsum of the foot with active plantar flexion and inversion of the foot. Examination reveals a tender soft-tissue fullness approximately 10 cm proximal to the lateral malleolus. The pain is exacerbated by passive plantar flexion and inversion of the ankle. There is also a positive Tinel’s sign over the site of maximal tenderness. There is no motor weakness, and deep tendon reflexes are normal. Radiographs and MRI of the leg are normal. What is the next most appropriate step in management?

An elderly woman with osteoporosis falls from a standing height, sustaining a low-energy fracture of the acetabulum. What structures are most likely fractured?

A 24-year-old dancer sustains the injury shown in Figure 28. Management should consist of

A 13-year-old boy has pain and a firm mass in his left knee. A radiograph and MRI scan are shown in Figures 2a and 2b, and a biopsy specimen is shown in Figure 2c. Based on these findings, what is the most likely diagnosis?

A 14-year-old girl has a painful hallux valgus deformity that has not responded to shoe modifications. Figure 21 shows a standing AP radiograph. What is the most appropriate surgical procedure?

A 65-year-old man with ankylosing spondylitis sustains an extension injury to his cervical spine. Two days later, a progressive neurologic deficit develops at the C6 level. An MRI scan is shown in Figure 1. What is the most likely diagnosis?

A 20-year-old collegiate football player who sustained blunt head trauma during the first half of a game is emotional and confused. During the halftime intermission, his affect, memory, and disorientation are totally resolved and have returned to preinjury baseline. The only residual finding is a very mild headache. He wants to play the second half. What is the most appropriate course of action?

Figure 93 shows the axial T2-weighted MRI scan of the lumbar spine of a 70-year-old man. The arrow points to which of the following structures? Review Topic

A 47-year-old male tennis player has pain in his nondominant shoulder that has failed to respond to 4 months of nonsurgical management. Examination reveals acromial tenderness and pain at the supraspinatus tendon insertion. He has a positive impingement sign, pain on forward elevation, and minimal cuff weakness. The MRI scans are shown in Figures 30a and 30b. To completely resolve his symptoms, treatment should consist of

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

Which structure is indicated by the arrow in Figure 33?

A patient who underwent an L5-S1 hemilaminotomy and partial diskectomy for radiculopathy 3 weeks ago now reports increasing leg and back pain with radicular signs. An axial T2-weighted MRI scan is shown in Figure 97a, an axial T1-weighted MRI scan is shown in Figure 97b, and a contrast enhanced T1-weighted MRI scan is shown in Figure 97c. What is the most appropriate management for the patient's symptoms? Review Topic

Which of the following is considered a potential advantage of arthroscopic repair for anterior instability of the shoulder? Review Topic

Figure 48a shows the full-leg standing radiograph of a patient with a prior femoral fracture. Figure 48b shows the lateral view of the same joint. The patient is scheduled to undergo total knee arthroplasty. Because the mechanical axis of the lower extremity in patients with a prior femoral fracture may be disrupted, which of the following should be used during surgery to restore the mechanical axis of the lower extremity in this patient?