OITE Orthopedic Surgery Board Review MCQs: Part 145

About This Board Review Set

This is Part 145 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

How to Use the Interactive Quiz

Two distinct learning modes are available:

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

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

Topics Covered in Part 145

This module focuses heavily on: Deformity, Dislocation, Hip, Osteoporosis, Shoulder, Spine, Trauma.

Sample Questions from This Set

Sample Question 1: Figures 27a through 27c show the radiographs and CT scan of a 27-year-old man who sustained a low-velocity gunshot wound to the neck. He is quadriplegic (ASIA A), hemodynamically stable, and does not have drainage from his wound. After init...

Sample Question 2: A 56-year-old laborer sustained a subcoracoid dislocation of the shoulder as a result of falling off a scaffold 3 weeks ago. He now is unable to actively raise his arm and has constant pain. What is the most likely diagnosis?...

Sample Question 3: 5 g/dL and his base deficit is 10mEq/L. What is the most appropriate next step in management?...

Sample Question 4: Ayear-oldwomanwithahistoryofosteoporosisisinvolvedinahigh-speedmotorvehicleaccident,resultinginlefthippainanddeformity.TheinitialradiographfromthetraumabayisshowninPostreductionCTisshownin2throughWhatisthemostappropriatedefinitivesurgical t...

Sample Question 5: A biopsy of the involved physis in a patient with slipped capital femoral epiphysis (SCFE) would most likely reveal...

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

Figures 27a through 27c show the radiographs and CT scan of a 27-year-old man who sustained a low-velocity gunshot wound to the neck. He is quadriplegic (ASIA A), hemodynamically stable, and does not have drainage from his wound. After initial resuscitation and stabilization, the cervical spine and spinal cord injuries are best managed by

Explanation

DISCUSSION: Although the spinal canal has been penetrated, the lateral masses are intact bilaterally with only partial destruction of the vertebral body and penetration of the lamina on one side, thus the cervical spine is not unstable and surgical stabilization is not indicated. Dural repair is not indicated since there is no external cerebrospinal fluid leakage. Surgical treatment should be based on the need to treat extraspinal pathology only.
REFERENCES: Bono CM, Heary RF: Gunshot wounds to the spine. Spine J 2004;4:230-240.
Punjabi MM, Jue JJ, Dvorak J, et al: Cervical spine kinematics and clinical instability, in Clark CR (ed): The Cervical Spine, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 2005,

pp 55-87.

Question 2

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

Explanation

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

Question 3

5 g/dL and his base deficit is 10mEq/L. What is the most appropriate next step in management?

Explanation

Posteromedial rotatory instability
Capitellum fracture
Radial head fracture and posterolateral ulnohumeral dislocation
Trans-olecranon fracture dislocation
Medial (ulnar) collateral ligament rupture Corrent answer: 3
The clinical presentation is consistent with a coronoid tip fracture. This fracture pattern is associated with a radial head fracture and posterolateral ulnohumeral dislocation - together making up the terrible triad injury.
A terrible triad injury is the result of a valgus and supination injury and involves posterolateral elbow dislocation or lateral collateral ligament injury, radial head fracture, and fracture of the coronoid process. The elbow may dislocate postero-laterally with the anterior bundle of the MCL intact, but if the MCL is injured it is typically the last structure to fail. The coronoid fracture is typically a small fragment isolated to the tip. This is a result of a posteriorly directed force driving the coronoid into the trochlea prior to posterior elbow dislocation. CT scan is a useful modality when small or comminuted fragments are difficult to visualize on plain radiographs.
Steinmann reviews the anatomy, diagnosis, classification and treatment of coronoid fractures with a focus on surgical exposures and fixation techniques.
Doornberg et al. reviewed 67 coronoid fractures to determine whether type of coronoid fracture correlated with pattern of instability. They found strong associations between (1) large coronoid fractures and trans-olecranon fracture-dislocations, (2) small fractures and terrible-triad injuries, and (3) anteromedial facet fractures and varus posteromedial rotational injury mechanisms.
Doornberg et al. evaluated 18 patients with a fracture of the anteromedial facet of the coronoid. They found that malalignment of the anteromedial facet fragment was associated with arthrosis and a fair or poor result.
Figures A through D show consecutive 2.00 mm sagittal CT reformats demonstrating a small coronoid fracture fragment which was addressed with suture fixation.
Incorrect Answers:
OrthoCash 2020
A 62-year-old right-hand-dominant school teacher sustains a mechanical fall at home and presents with right shoulder pain. Plain
radiographs of the right shoulder are pictured in Figures A and B. The patient asks you what she can expect in terms of recovery following this injury. Which of the following is the most appropriate statement?

At 1-year post-injury, the right shoulder range of motion will most likely be equal to the contralateral extremity.
At 1-year post-injury, you will most likely have returned to your baseline functional status.
Early range of motion exercises risk fracture displacement and should be avoided until at least 4 weeks post-injury.
Most patients do not return to work following this injury.
One in 5 patients with this fracture go on to nonunion and you may benefit from surgery in the future to address this.
This patient has a minimally displaced (1-part) proximal humerus fracture involving the humeral neck and greater tuberosity. This injury pattern is most commonly managed nonoperatively with the majority of patients returning to their baseline functional status by 1 year.
Proximal humerus fractures (PHF) can be classified by number of parts (Neer classification), with a part defined as a fracture fragment displaced > 1cm (> 5mm for greater tuberosity) or angulated > 45°. One-part PHF comprise ~80% of all PHF and are treated nonoperatively with a sling and early range of motion (ROM).
Tejwani et al performed a prospective study of 67 patients with 1-part PHF. At 1-year follow up the ASES score and functional status was similar to pre-injury status. However, ROM of the affected shoulder was diminished in both external and internal rotation. Forward flexion was preserved.
Hanson et al prospectively analyzed 160 patients with PHF of all types (1-4 parts and head-splitting) managed nonoperatively. At 1-year follow up, 93% showed solid union. Constant and DASH scores improved steadily over time but were still lower compared to the contralateral extremity. Of employed patients, 97.6% returned to work with a median time off of 10 weeks and no difference between manual and nonmanual workers.
Figures A and B are the AP and axillary radiographs of the right shoulder, respectively, demonstrating a 1-part PHF involving the humeral neck and greater tuberosity.
Incorrect Responses:
OrthoCash 2020
A 44-year-old male presents with the isolated injury seen in Figure A after a motor vehicle accident and underwent the operative treatment seen in Figure B within 8 hours from the time of incident. Which of the following complications is this patient at highest risk of developing?

Pulmonary embolus
Periprosthetic fracture
Contralateral hip fracture
Osteonecrosis
Infection
This young male patient has sustained a displaced femoral neck fracture and underwent open reduction internal fixation with 3 cannulated screws. Based on the available options, the patient is most at risk of developing osteonecrosis of the femoral head.
Femoral neck fractures in young patients typically are the result of a high-energy trauma. Fracture displacement has been shown to disrupt vascular supply to the femoral head by interrupting retinacular vessels and ligament teres vascularization, as well as increasing intracapsular pressure, producing a tamponade effect. The incidence of osteonecrosis in patients younger than 60 years with displaced femoral neck fractures has been shown to be between 15-30%. Quality of reduction is one key factor that has been shown to influence outcomes postoperatively.
Loizou et al. prospectively studied 1,023 patients who sustained an intracapsular hip fracture that was treated with internal fixation using standard fixation modalities. They showed that osteonecrosis was less common for undisplaced (4.0%) than for displaced fractures (9.5%). The population at greatest risk were women younger than the age of 60 with displaced fractures.
Barnes et al. review subcapital hip fractures. They found that late segmental collapse was more common in displaced fractures in women younger than age 75 years than in those older than age 75 years treated with internal fixation.
Figure A shows a displaced, Garden 3/Pauwels III hip fracture. Figure B shows anatomical fixation with 3 cannulated screws.
Incorrect Answers:
OrthoCash 2020
A 58-year-old male is involved in a motor vehicle collision and sustains the injury shown in Figure A in addition to right 5th and 6th rib fractures. Upon evaluation in the emergency department, he is noted to have a 2 centimeter laceration over the anterior aspect of his left leg with visible bone. Vitals and labs are normal. Which of the following statements is most accurate regarding surgical management for this patient?

Reamed intramedullary nailing is favored due to increased rates of union
Unreamed intramedullary nailing is favored due to presence of concomitant rib fractures
Reamed intramedullary nailing is favored due to decreased rates of infection
Unreamed intramedullary nailing is favored due to less local trauma
Both unreamed and reamed intramedullary nailing are equivalent Corrent answer: 5
Both unreamed and reamed intramedullary nailing are equivalent treatments in patients with open tibia fractures. Intramedullary nailing is the treatment of choice for stable patients with tibial shaft fractures.
Tibial shaft fractures can be the result of low energy twisting injuries or higher energy axial loads. Closed fractures with acceptable alignment can be often be treated with closed reduction and casting. Intramedullary nailing, unreamed or reamed, is the treatment of choice for open fractures except in the setting of damage control orthopaedics when an external fixator may be more appropriate.
Bhandari et al. investigated reamed and unreamed intramedullary nailing for tibial shaft fractures in a randomized trial ("SPRINT" Trial - Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures Investigators). They concluded that reamed nailing was more beneficial (decreased rate of primary outcome event: need for bone grafting, implant exchange or removal for infection, debridement for infection) for closed fractures, but had no benefit in open fractures.
Finkemeier et al. evaluated consecutive patients treated with unreamed and reamed intramedullary nailing and found similar rates of union in both open and closed tibial shaft fractures at six and twelve months.
Figures A shows AP and lateral xrays of the left tibia showing a tibial shaft fracture.
Incorrect Answers:
OrthoCash 2020
A 36-year-old male falls from a 10-ft scaffold and suffers the injuries shown in Figures A and B. The patient is placed in a spanning external fixator and brought back to the operating room once his soft tissues are amenable. Planning to use a dual-incision approach, what is the correct interval to use when approaching the medial side?

Popliteus and pes anserine
Lateral head of the gastrocnemius and pes anserine
Politeus and lateral head of the gastrocnemius
Iliotibial band and medial head of the gastrocnemius
Pes anserine and medial head of the gastrocnemius Corrent answer: 5
The posteromedial approach to the tibial plateau is between the the pes anserine tendons and the medial head of the gastrocnemius.
A dual-incision approach is often utilized to optimally place definitive fixation for bicondylar tibial plateau fractures. For fractures that require posterior or posteromedial fixation, the correct interval is between the pes anserine and the medial head of the gastrocnemius.
Higgins et al. in a large cohort morphological review, noted a high incidence of a posteromedial fragment in bicondylar fractures. Occurring at a high frequency, the authors recommended direct visualization and reduction via a dual approach rather than using indirect reduction techniques.
Falker et al. describes a step-by-step approach to utilizing the posteromedial approach for the tibial plateau and placing an anti-glide plate.
Figure A and B exhibit a bicondylar tibial plateau fracture with a posteromedial fragment noted on the lateral x-ray. Illustration A exhibits the surrounding anatomy and interval in between the medial head of the gastrocnemius and the pes anserine.
Incorrect answers:

OrthoCash 2020
A 25-year-old male presents to the emergency department with the injury seen in Figure A after a motorcycle collision. The patient has a blood pressure of 70 systolic, elevated lactate and a tense abdomen with positive FAST examination. Trauma surgery will be performing an emergent laparotomy. Orthopaedic surgery is consulted and places a pelvic external fixator intraoperatvely to assist with resuscitation. What is an advantage of supra-acetabular external fixator pins as compared with iliac crest pins?

Less interference with pelvic surgical incisions
Less risk of pin tract infection
Less risk of malreduction
Less control of posterior pelvic ring
No interference with laparotomy Corrent answer: 1
One advantage of supra-acetabular external fixator pins is that they do not interfere or contaminate future approaches to the pelvis or acetabulum involving the lateral window.
In multiply injured patients with pelvic trauma external fixation of the pelvic ring is a valuable tool to assist with resuscitation. Pelvic external fixation should be applied rapidly and allow full access to the abdomen for general surgery intervention. Regardless of the technique used, a pelvic external fixator should form a stable construct that minimizes motion of fracture surfaces and allows for clot formation.
Haidukewych et al evaluated the safety of supra-acetabular pin placement in a cadaveric study. The authors found that the lateral femoral cutaneous nerve (LFCN) was most at risk during pin placement.
Figure A demonstrates a widely displaced symphyseal dislocation with associated bilateral sacroiliac (SI) dislocations (APC 3). Illustration A demonstrates an outlet radiograph of a supra-acetabular external fixtator in conjunction with posterior pelvic ring fixation for an LC3 pelvic ring injury.
Illustration B is an illustration of iliac crest external fixation. The video demonstrates techniques for application of both supra-acetabular and iliac
crest external fixation pins.
Incorrect Answers:

OrthoCash 2020
What physical exam finding is most likely to be found in association with the injury shown in Figures A and B?

Numbness in the small finger and ulnar side of the ring finger
No elbow instability
Varus posteromedial rotatory instability
Valgus posterolateral rotatory instability
An anterior open wound Corrent answer: 3
The x-ray shows a fracture of the anteromedial facet of the coronoid with an intact radial head. Large anteromedial facet fractures are associated with varus posteromedial rotatory instability.
The anteromedial facet of the coronoid provides support to the medial elbow against varus stress. Varus and posteromedial force applied to the elbow results in disruption of the lateral collateral ligament (LCL) from its proximal origin. The coronoid is fractured as it is forced against the medial trochlea.
Coronoid fractures of significant size involving the sublime tubercle (insertion of medial collateral ligament) result in varus instability.
Steinmann reviews the anatomy, diagnosis, classification and treatment of coronoid fractures with a focus on surgical exposures and fixation techniques. He states that when a coronoid fracture is associated with a pattern of varus instability, it requires fixation with either suture, buttress plating or screw fixation. Concomitant LCL repair or reconstruction will also be necessary.
Doornberg et al. reviewed 67 coronoid fractures to determine whether type of coronoid fracture correlated with pattern of instability. They found strong
associations between (1) large coronoid fractures and trans-olecranon fracture-dislocations, (2) small fractures and terrible-triad injuries, and (3) anteromedial facet fractures and varus posteromedial rotational injury mechanisms.
Doornberg et al. evaluated 18 patients with a fracture of the anteromedial facet of the coronoid. They found that malalignment of the anteromedial facet fragment was associated with arthrosis and a fair or poor result.
Figure A is an AP view of an elbow with an anteromedial facet of the coronoid fractured. The lateral joint space is widened due to injury to the LCL. The medial joint space is narrowed and collapsed. A lateral view is shown in Figure
B. Illustrations A and B show AP and lateral views of a coronoid fracture fixed with buttress plating. The LCL origin was fixed with a suture anchor. Illustration C shows the O'Driscoll classification of coronoid fractures. Illustration D lists injury patterns that suggest posteromedial versus posterolateral rotatory instability.
Incorrect Answers:

OrthoCash 2020
A 35-year-old man presents to the ED as the restrained driver of a high speed motor vehicle collision complaining of hip, chest, and abdominal pain. He becomes diaphoretic, tachycardic, and hypotensive in the trauma bay and is noted to have diminished lower extremity pulses. He is found on ATLS workup to have mediastinal widening.
Which of the following injuries is most associated with thoracic aortic injury?

Thoracic aortic rupture is associated with posterior hip dislocation in deceleration trauma mechanism of injuries.
Posterior hip dislocations are infrequently associated with local vascular injuries. With bilateral perfusion deficits, more proximal large vessel trauma should be considered, and in this situation, thoracic surgery should be involved emergently. Screening chest x-ray in the trauma bay should be reviewed for widened mediastinum, suggestive of aortic injury, as shown in illustration A. Given the high energy mechanism associated with these injuries, a full ATLS trauma survey must be done for every patient.
Marymont et al. studies the association between posterior hip dislocation and thoracic aortic injury. They performed a retrospective chart review of 89 posterior hip dislocations and found 8% had an aortic injury. Although not statistically significant, they note the importance of evaluation for aortic injury in patients with posterior hip dislocations given its emergent life-threatening nature.
In addition to associated chest injuries, Schmidt et al. highlight the importance of evaluating the ipsilateral knee after high-energy traumatic hip dislocation. In a prospective study, they identified a 93% rate of ipsilateral knee injury on MRI including effusion (37%), bone bruising (33%), and meniscal tear (30%) as the most common. They recommend a thorough exam but also expanded use of knee MRI after hip dislocation.
Illustration A shows an example of chest x-ray with a widened mediastinum, suggestive of thoracic aortic injury.

OrthoCash 2020
A 31-year-old female smoker was involved in a skiing accident approximately 9 months ago and underwent open reduction internal fixation of the radius and ulna at the time of injury. She now returns to the clinic complaining of increasing pain with range of motion and activity. Radiographs from her most recent follow-up can be seen in Figure A. Laboratory tests show ESR, CRP and WBC count to be within normal limits. Which of the following options is the most appropriate next step in management?

Bone scan
Above elbow cast
Removable splint
Reamed intramedullary nail
Iliac crest bone grafting + compression plating Corrent answer: 5
This patient is presenting with an atrophic non-union of the ulna after open reduction internal fixation for a both bone forearm fracture 9 months ago. The most appropriate next step in management would be iliac crest bone grafting and compression plating of the ulna.
The primary issue with an atrophic nonunion is biological. The blood supply is poor and therefore incapable of purposeful fracture healing. Smokers, as in this vignette, are at high risk for nonunion. The treatment of an atrophic nonunion involves improving biology at the fracture site through use of autologous bone graft (e.g. iliac crest) and providing mechanical stability by means of compression plating (e.g. 3.5 mm LC-DCP).
dos Reis et al. reports excellent results of 31 cases of diaphyseal forearm fracture non-unions treated with autologous bone grafting and compression
plating. Thirty of thirty-one patients went on to bony union within 3.5 months of revision surgery.
Nadkarni et al. presented a case series of 11 patients with non-unions of various long bones initially managed with intradmedullary (IM) nail fixation. The authors successfully used locking compression plates while retaining the IM nails in the treatment of the nonunion in all cases.
Figure A shows an AP radiograph of a both bone forearm fracture. Figure B shows an AP and lateral radiograph of an atrophic non-union of the ulnar shaft. Illustration A shows a lateral x-ray of a fully healed radius and ulna after hardware removal 1 year after revision surgery.
Incorrect Answers:

OrthoCash 2020
A 27 year-old patient sustains a fracture-dislocation of the acetabulum. Pelvic radiographs (Figures A and B) are taken at initial presentation and a CT scan (Figures C and D) is performed after reduction of the hip in the emergency room. What is the importance of the finding highlighted in the CT scan cuts?

Comminution indicates a better result with non-operative management
Significant marginal impaction could compromise the results of the surgical reduction if the joint surface is not properly restored
The impacted fracture segment will heal without fixation because it is not gapped or translated
The CT scan finding highlighted indicates osteochondral defects to the femoral head, which can be addressed arthroscopically
Intraarticular fracture fragments should be discarded from the surgical field, as incorporation of the fragments into the fixation construct leads to a high rate of avascular necrosis
The CT images shown in Figures C and D display significant marginal impaction of the joint surface.
Marginal impaction is common in posterior wall fractures and fracture-dislocations. Critical review of CT imaging of posterior wall fractures can help with preoperative planning for identifying impaction of the articular surface of the acetabulum. Restoration of the sphericity of the acetabulum to match that of the femoral head is important for successful outcome following ORIF of posterior wall fractures. A common surgical technique to accomplish joint surface restoration includes freeing the impacted articular segments, bone grafting of the void created to support the articular segments, and buttress plating of the posterior wall fracture fragments.
Patel et al. discuss the challenge of interpreting imaging of the acetabulum for assessing fracture characteristics that may significantly impact success or surgical intervention. These characteristics include: articular displacement, marginal impaction, incongruity of the joint surface, intra-articular fragments, and osteochondral injury to the femoral head. Based on expert review of images, determination of significant marginal impaction had a poor intraobserver reliability, as did each of the other modifiers listed.
Figures A and B are radiographs of the posterior wall fracture and hip dislocation. They do not show the large amount of marginal impaction of the acetabular surface. Figure C (coronal reconstruction) and Figure D (sagittal reconstruction) point out a large a amount of marginal impaction of the acetabular. Note the disruption of the joint surface on the intact portion of the acetabulum.
Incorrect answers:
Comminuted posterior wall fractures still should be surgically stabilized if the joint is unstable
This impacted fragment on the margin of the main fracture line will likely heal regardless of restoration of the articular surface; however, this malreduction will lead to a incongruent joint surface
These CT cuts do not show any osteochondral defects of the femoral head; however if found in other CT cuts or intraoperatively, they should be appropriately addressed
Intraarticular fracture fragments should be removed from the joint, but if they make up a substantial portion of the joint surface, they should be incorporated in the fixation construct to obtain the goal of anatomic reduction of the joint surface
OrthoCash 2020
A 32-year-old female is involved in a motor vehicle collision and suffers a right hip dislocation. She is in the twelfth week of pregnancy.
Evaluation in the emergency department reveals no other injuries and ultrasound reveals a strong fetal heart rate and no abnormalities. She undergoes emergent closed reduction but the hip remains unstable and a traction pin is placed. Post-reduction films are shown in Figure
What is the most appropriate next step in management?

Acute open reduction internal fixation
Exam under anesthesia
Skeletal traction for 6-8 weeks
Fetal monitoring until 15 weeks followed by open reduction internal fixation
Percutaneous pinning
This patient has a large posterior wall fracture of the right acetabulum with an unstable hip. The most appropriate next step in treatment is open reduction and internal fixation.
Fixation of acetabular fractures during pregnancy is not contraindicated in the setting of stable fetal heart rate and no abnormalities on pelvic ultrasound.
There is, however, an increased risk of complications for the mother and fetus. Injury severity and mechanism are most closely associated with increased rate of fetal complications. The trimester of pregnancy is not associated with increased risk of complications.
Leggon et al. reviewed 101 cases of pelvic and acetabular fractures in pregnant patients and found mechanism of injury and injury severity were associated with higher mortality for both mother and fetus. Trimester of pregnancy was not associated with increased mortality.
Flik et al. reviewed orthopaedic trauma in a pregnant patients and recommended fetal ultrasound for assessment of fetal well-being in all pregnant patients.
Desai et al. investigated orthopaedic trauma during pregnancy and reported minimal radiation risk to the fetus when obtaining x-rays. They also advocate for LMWH as one of the safest choices for anticoagulation.
Figure A is an x-ray showing a right posterior wall acetabular fracture. Figures B and C are Judet views of the pelvis focusing on the right hip. A large posterior wall fragment is visible in Figure B.
Incorrect Answers:
OrthoCash 2020
Figure A is radiograph of a 50-year-old male science teacher that was involved in a motor vehicle accident. He underwent closed reduction as seen in Figure B and C. What would be the most appropriate treatment?

Open reduction and internal fixation with medial bridge plate and lateral screw in non-lagging mode
Tibiotalocalcaneal arthrodesis
Open reduction and internal fixation with lateral and medial screw in lagging mode
Closed reduction and internal fixation with medial and lateral screw in non-lagging mode
Closed reduction with percutaneous pins Corrent answer: 1
This patient is presenting with a Hawkins II talar neck fracture with medial wall comminution. The most appropriate treatment of this patient would be open reduction internal fixation with medial plate and lateral screw in non-lagging mode.
The treatment of talar fractures is based on the severity of the fracture, soft-tissues, and patient factors. The fracture and subluxation of the subtalar joint should be reduced and stable anatomical fixation should be obtained. When there is comminution of either the superior, lateral or medial aspects of the talus, one should avoid shortening the medial wall as this will cause a varus malunion. The use of a medial or lateral plate can help to re-establish column length, which can often prevent this potential complication.
Sanders et al. showed significant complications after fixation of talar neck fractures. They showed the incidence of secondary reconstructive procedures following talar neck fractures increased from 24% +/- 5% at 1 year to 48%
+/- 10% at 10 years post-injury.
Vallier et al. retrospectively reviewed the records of 39 fractures of the talar neck treated with open reduction and internal fixation. Twenty-one (54%) of thirty-nine patients had development of posttraumatic arthritis, which was more common after comminuted fractures (p < 0.07) and open fractures (p = 0.09).
Vallier et al. reviewed 81 talar neck fractures to revisit the rate of osteonecrosis and post-traumatic arthritis based on the Hawkins Classification. They found that delaying definitive internal fixation does not increase the risk of developing osteonecrosis. Thirty-five patients (54%) developed posttraumatic arthritis, including 83% of those with an associated talar body fracture (p < 0.0001) and 59% of those with Hawkins type-III injuries (p < 0.01).
Figure A shows a Hawkins II talar neck fracture. Figures B and C are saggital and coronal CT images, respectively, of the foot. There is significant comminution of the medial wall of the talus with extension into the subtalar joint.
Incorrect Answers:
There is some research to suggest primarily subtalar arthrodesis with these injuries. However, to date, there is no high level evidence that has conclusively shown subtalar arthrodesis to be better than ORIF.
OrthoCash 2020
A 28-year-old male college student sustains a severe foot injury from gunshot-related violence, and subsequently undergoes a lower-extremity amputation as shown in Figure A. At long-term follow-up, which of the following is the strongest predictor of patient satisfaction as related to his injury?

Age less than 30
Marijuana use
Use of negative pressure wound therapy
Male gender
Ability to return to work Corrent answer: 5
The strongest factor to predict patient-reported outcomes after trauma-related lower extremity amputations is the patient's ability to return to work. This is likely due to the effect of the return to work on the physical, emotional, and financial aspects of the patient's life.
The LEAP study is a multicenter, prospective study evaluating multiple aspects of reconstruction versus amputation in the treatment of mangled extremity injuries. With regard to patient satisfaction, treatment variables such as decision for reconstruction versus amputation, or initial presence or absence of plantar sensation have little impact. In addition, demographic factors such as age, gender, socioeconomic status, and education level do not predict patient satisfaction. Instead, the most important predictors of patient satisfaction at 2 years after injury include the ability to return to work, absence of depression, faster walking speed, and decreased pain.
O'Toole et al reviewed 463 patients treated for limb-threatening lower-extremity injuries and identified factors associated with patient reported outcomes two years after surgery. They found that return to work was the most associated with outcomes, but that physical functioning, walking speed, pain levels, and presence of depression were also associated to a lesser extent with outcomes.
Bosse et al performed a multicenter, prospective study to assess outcomes of 569 patients with severe lower extremity limb injuries that resulted in either amputation or limb salvage procedures. They found that at two years postoperatively, no significant differences were seen between groups in patient-reported outcome. Worse outcomes were associated with rehospitalization for a major complication, a low educational level, nonwhite race, poverty, lack of private health insurance, poor social-support network, low self-efficacy (the patient's confidence in being able to resume life activities), and involvement in disability-compensation litigation.
Figure A shows a clinical photograph of a Pirigoff amputation at early follow-up. This amputation is an end-bearing amputation that utilizes the plantar heel pad for weightbearing, and relies on a tibiocalcaneal arthrodesis.
Incorrect Answers:
4: These options are not as strong of a factor of patient satisfaction in longterm follow up after trauma-induced lower extremity amputation.
OrthoCash 2020
A 34 year-old male falls off of motorcycle on an outstretched hand suffering the injuries shown in Figures A and B. He is brought to the operating room and undergoes radial head replacement and fixation and repair of the coronoid and the lateral collateral ligament (LCL). Prior to closing, the elbow is still unstable upon testing range of motion. What is the next best step in management?

Exchange radial head for larger implant
Complete resection of radial head
Cast at 90 degrees of flexion for 6-8 weeks
Reinforce LCL repair with non-absorbable suture
Repair the ulnar collateral ligament Corrent answer: 5
Following complete fixation and repair of a terrible triad, a final range of motion test should be performed prior to closure. If still unstable, the next step should be to assess and repair the ulnar collateral ligament. Another option
would be to placed a hinged external fixator.
Operative reconstruction of a terrible triad injury should be performed in a systematic fashion, working from deep to superficial. Working through a lateral incision and through the radial head fracture, the coronoid should be fixed first, followed by radial head fixation or replacement and then repair/reconstruction of the LCL. If still unstable, the medial side should be addressed, or the patient placed in a hinged external fixator.
Mathew et al review the anatomic, biomechanic, and operative principles (why the above step-by-step method works) to achieving appropriate stability in order to obtain early range of motion to maximize clinical outcome.
Pugh et al. in this retrospective, multi-center study report outcomes on 36 terrible triad injuries fixed with the standard protocol described above. The authors recommend following this systematic approach to achieve the best results.
Figures A and B are AP and lateral radiographs exhibiting a terrible triad elbow fracture-dislocation.
Incorrect answers:
OrthoCash 2020
When treating the pathology depicted in Figures A through D, which of the following is necessary to preserve the blood supply to the femoral head?

Dissection of the gluteal musculature off the iliac crest
Ligation of the ascending branches of the lateral femoral circumflex artery
Greater trochanteric osteotomy
Identification and detachment of the piriformis tendon
Supine positioning
Figures A-D show a femoral head with associated acetabular fracture (Pipkin IV). Both the posterior wall fracture and the femoral head fracture can be addressed through a surgical dislocation via greater trochanteric osteotomy.
Pipkin IV femoral head fracture (with associated acetabular fractures) are somewhat problematic in that the femoral head fracture is usually anterior, while the acetabular fracture usually involves the posterior wall. A Kocher-Langenbeck approach gives good access to the posterior wall but limited access to the articular surface and femoral head avascular necrosis (AVN) is a concern. A Smith-Peterson approach provides good access to the femoral head
but not to the posterior wall. Combined approaches significantly increase the amount of surgical dissection. Surgical dislocation with trochanteric flip osteotomy provides access to the femoral head and posterior wall while preserving blood supply to the femoral head.
Solberg et al. retrospectively reviewed 12 patients with Pipkin IV injuries treated via a trochanteric flip osteotomy. All patients healed their acetabular fractures. Eleven of 12 patients healed their femoral head fractures and one patient (8.3%) developed osteonecrosis.
Henle et al. likewise treated 12 patients with Pipkin IV injuries through a trochanteric flip osteotomy. Two of 12 patients (16.7%) developed osteonecrosis. The remaining 10 patients (83.3%) had good or excellent results. Heterotopic ossification occurred in five patients, causing significant range of motion loss in four of these.
Figure A is a pre-reduction AP pelvis in which the posterior wall fracture is apparent. Figure B is a post-reduction AP pelvis in which an infra-foveal femoral head fracture is apparent (Pipkin IV). Figure C is an axial CT cut which further characterizes the posterior wall fracture. Figure D is an obturator oblique showing femoral head dislocation and posterior wall fracture. The video shows a surgical hip dislocation technique.
Incorrect Answers:
OrthoCash 2020
A 42-year-old male presents to your clinic for the first time with the radiographs seen in Figure A. He sustained the injury 4 weeks ago while skiing overseas and treatment was provided by the local orthopaedic surgeon. The operative note states that he sustained an Gustilo Type I open fracture. After surgical fixation of this type of injury, what is the most common complication requiring reoperation?

Chronic elbow instability
Post-traumatic arthritis
Infection
Heterotopic ossification
Loss of elbow range of motion Corrent answer: 5
This patient sustained a terrible triad elbow fracture-dislocation. Reduced range of motion of the elbow joint is the most common complication REQUIRING reoperation with these injuries.
Terrible triad elbow fracture-dislocations are characterized by posterolateral dislocation/lateral collateral ligament (LCL) injury, radial head fracture and coronoid fracture. Displaced fractures result in elbow instability. Acute radial head stabilization, coronoid open reduction and internal fixation, and LCL +/-medial collateral ligament (MCL) repair/reconstruction is considered the most appropriate treatment for displaced fractures. Operative complications include elbow stiffness, recurrent instability, arthritis, failure of hardware, heterotopic ossification, posterior interosseous nerve palsy and infection.
Egol et al. looked at the functional outcomes of 27 patients that underwent fixation of terrible triad injuries. At one year follow-up, the average flexion-extension arc of elbow motion was 109 degrees +/- 27 degrees, and the average pronation-supination arc was 128 degrees +/- 44 degrees. Grip strength averaged 72% of the contralateral extremity. Although operative fixation led to functional elbow stability, results were poor.
They included a reference to McKee et al. to highlight that intra-articular fractures of the elbow have high rates of stiffness. While not specific to terrible
triads, they looked at the effectiveness of the posterior elbow approach in 25 patients that underwent internal fixation of intra-articular distal humerus fractures. They showed poor outcomes at a mean follow-up of 36 months with reduced range-of-motion, decreased strength and high re-operation rates.
Figure A shows AP fluoroscopic image of a terrible triad injury that has undergone operative fixation. The radial head and coronoid have undergone open reduction internal fixation, and the MCL bony avulsion has been repaired.
Incorrect Answers:
OrthoCash 2020
Figure A is a radiograph from a 59-year-old male that was transferred to a Level I trauma center five hours after a motor vehicle accident. Closed reduction and skeletal traction was successfully performed in the trauma bay. Which of the following factors has been shown to increase the risk of unsatisfactory clinical outcome for this patient?

Need for skeletal traction
Mechanism of injury
Gender
Age
Time to reduction Corrent answer: 4
Age greater than 55-years-old has been found to be an independent risk factor for inferior clinical outcome in patients with combined acetabular fractures and hip dislocations.
The most important initial step in management following resuscitation involves urgent reduction of the dislocated hip. This should be followed by a preoperative CT scan and ultimately surgical fixation of the combined acetabular fracture. Hip dislocations should be reduced within 6-12 hours for optimal outcome, although different critical times have been cited, particularly for dislocations with concomitant acetabular fractures. Skeletal traction may be required to maintain hip reduction.
Moed et. al. present a Level 3 retrospective review of 100 patients who had been treated with open reduction internal fixation of an acetabular fracture. The authors found that factors associated with unsatisfactory clinical outcomes included age greater than 55, intra-articular comminution, osteonecrosis, and delay of greater than 12 hours for reduction of an associated hip dislocation.
Additionally, they showed that there was a strong association of clinical outcome and final radiographic grade.
Figure A demonstrates an acetabular fracture with concomitant hip dislocation. Incorrect Answers:
injury, male gender, and time to reduction <6 hours have not been shown to be related to unsatisfactory outcomes.
OrthoCash 2020
A 37-year-old male cashier is shot in the leg. He sustains the injury shown in Figures A and B, and is subsequently taken to the operating room for intramedullary nailing. Figure C shows a radiograph of the nail starting point (*). What complication is most likely to result?

Varus malunion
Nonunion
Valgus malunion
Malrotation
Superficial peroneal nerve injury Corrent answer: 3
This patient is presenting with a comminuted fracture of the proximal third of the tibia. He is appropriately undergoing intramedullary nail fixation, however, the start point illustrated in Figure C is too medial and often leads to a valgus malunion.
Intramedullary nail fixation is more technically demanding in proximal tibial fractures than diaphyseal fractures. The valgus deformity is due to imbalanced muscle forces on the proximal fragment, which are then accentuated by a start point that is too medial. An apex anterior (procurvatum) deformity can also occur and results from the pull of the patellar tendon or a posteriorly directed nail that deflects off the posterior tibial cortex and rotates the proximal fragment. The ideal starting point for proximal tibial fractures is slightly lateral to the medial aspect of the lateral tibial spine on a true AP x-ray and very proximal and just anterior to the anterior margin of the articular surface.
Nork et al. reported the results of intramedullary nailing of proximal tibial fractures with emphasis on techniques of reduction. Various techniques were found to be successful including attention to the proper starting point, the use of unicortical plates, and the use of a femoral distractor applied to the tibia.
Lowe et al. describe surgical techniques for complex proximal tibial fractures. They describe the extended leg position, use of a femoral distractor, temporary plate fixation, blocking (Poller) screws, and use of percutaneous clamps as means to achieve reduction during fixation.
Figure A and B show an AP and lateral radiograph of a comminuted extra-articular fracture through the proximal third of the tibia. Figure C demonstrates a start point that is too medial (represented by the asterisk) for intramedullary nail fixation. Illustration A and B show the ideal start point for intramedullary nail fixation of the tibia on AP and lateral radiographs.
Incorrect Answers:
Varus malunion is more likely to occur in midshaft tibia fractures with an intact fibula.
Nonunion after a proximal tibial fracture treated with intramedullary nailing is less common than malunion.
Malrotation occurs most commonly after IM nailing of fractures through the distal third of the tibia.
The superficial peroneal nerve is at risk during distal screw fixation using a LISS plating technique for fracture fixation.

OrthoCash 2020
A 24-year-old motorcyclist is brought in as a polytrauma after striking a tree at 65 mph. He is found to have injuries involving the chest, abdomen, pelvis, as well as a left open femoral shaft fracture. He undergoes resuscitation in the trauma bay. Which of the following parameters best supports proceeding with irrigation, debridement and external fixation as opposed to immediate reamed intramedullary nailing?
Temperature = 35.5°C (95.9°F)
Fractures of ribs 2-3 with left apical pneumothorax
Grade IV liver laceration with SBP = 85 mmHg
Left superior and inferior pubic ramus fractures
Lactate = 2.3 mg/dL
Significant abdominal trauma with evidence of hemorrhagic shock (SBP < 90 mmHg) following resuscitation is an unstable parameter and therefore is an indication to proceed with damage control orthopaedics (irrigation and debridement of open fractures and temporizing external fixation) in a polytraumatized patient.
The management of orthopaedic injuries in a polytrauma patient depends on the physiological stability of the patient. In an unstable patient, damage control orthopaedics (DCO) is preferred over early total care (ETC) to avoid an iatrogenic second hit with development of adult respiratory distress syndrome (ARDS) and/or multiple organ failure. Clinical parameters indicative of instability include shock (BP < 90 mmHg, refractory to blood products, lactate
> 2.5 mg/dL), coagulopathy (platelet count < 90,000 mm3, fibrinogen < 1 g/L), hypothermia (< 35°C), and significant chest, abdomen or pelvis injuries (pulmonary contusions, severe liver/spleen lacerations, pelvic ring disruption).
Pape et al. (2009) authored a review article detailing the management of a multitrauma patient. Polytrauma patients can be classified as stable, borderline, unstable or in extremis using a variety of criteria pertaining to hemodynamic stability, coagulation, temperature and soft tissue injury.
Patients who are stable or borderline can undergo ETC, while patients who are unstable or in extremis should be managed with DCO.
Pape et al. (2008) concluded that all patients who underwent early femoral nailing demonstrated increased systemic inflammatory response compared to external fixation, regardless of clinical stability. However, unstable patients
with a preexisting elevation of inflammatory status are likely more impacted by this additional increase. Improved postoperative clinical status coincided with a less vigorous inflammatory response.
Illustration A is a table from Pape et al (2009) depicting the criteria used to determine clinical condition of a polytraumatized patient. Illustration B is an algorithm from Pape et al (2009) detailing management of the multitrauma patient.
Incorrect Responses:

OrthoCash 2020
A 92-year-old female sustains the injury shown in Figure A to her nondominant extremity as the result of a non-syncopal ground-level fall. She denies any previous injury or pain of the elbow, and her medical history is significant only for osteoporosis and hypothyroidism. What is the most appropriate treatment for her injury?

Immediate range of motion as tolerated with a sling for comfort
Long arm cast for 3 weeks, then physical therapy for motion
Open reduction and internal fixation
Radiocapitellar arthroplasty
Total elbow arthroplasty Corrent answer: 5
Use of total elbow arthroplasty (TEA) in the elderly is a well-recognized method of treatment of complex distal humerus fractures. This procedure allows for improved ROM, improved patient-reported outcomes, and decreased revision rates as compared to fixation.
TEA is a preferred alternative for ORIF in elderly patients with complex distal humeral fractures that are not amenable to stable fixation. Elderly patients appear to accommodate to objective limitations in function with time, which is important, as most recommendations list restrictions of lifting no more than 5-10 pounds postoperatively.
McKee et al conducted a prospective, randomized, controlled trial to compare functional outcomes, complications, and reoperation rates in elderly patients with displaced intra-articular, distal humeral fractures treated with open reduction-internal fixation (ORIF) or primary semiconstrained total elbow arthroplasty (TEA). Patients who underwent TEA had a quicker procedure, improved DASH scores at 6 months, improved elbow ROM, and decreased revision rates.
Athwal et al review TEA and the options available at the time of publication. They also report on the techniques and purported advantages of arthroplasty as compared to fixation of complex distal humerus fractures.
Frankle et al reviewed patients >65 years old with distal humerus fractures at a minimum of 2 years follow-up. Outcomes were excellent in 33% of cases undergoing ORIF and 92% excellent with TEA. They recommend TEA in instances of arthritis, osteoporosis, or other diagnoses requiring steroids.
Figure A shows a significantly comminuted distal humerus fracture in an osteoporotic patient. Illustration A shows the same patient after undergoing total elbow arthroplasty.
Incorrect Answers:
1:Immediate range of motion is not recommended for this injury, even with the "bag of bones" treatment method. A brief period of immobilization is generally recommended for this technique.
2: Casting is not indicated for this injury.
3: ORIF of this injury will lead to worse outcomes as compared to arthroplasty. 4: Isolated radiocapitellar replacement is not indicated for this injury.

OrthoCash 2020
A 56-year-old right hand dominant attorney falls from standing and sustains the closed injury shown in Figure A. The treating surgeon elects to fix her fracture using a plate and screw construct. Based on
the available imaging, which of the following fracture characteristics best justifies this fixation choice?

Fracture displacement
Intra-articular fracture extension
The fracture extends distal to the coronoid
Oblique fracture line
Fracture comminution
This patient has a displaced, intra-articular, comminuted olecranon fracture. Comminution is an indication for plate fixation.
Most displaced olecranon fractures are treated operatively. Options include tension band constructs, intramedullary screws, plate and screw fixation or fragment excision with triceps advancement. Any construct relying on interfragmentary compression (tension band, intramedullary screws) requires a non-comminuted fracture pattern. Plate fixation is indicated in the setting of comminution, extension past the coronoid, or in the setting of associated instability.
Bailey et al. retrospectively reviewed 25 patients who underwent plate fixation of displaced olecranon fractures. Twenty-two of 25 patients had good or excellent outcomes. Five of 25 patients (20%) of patients required plate removal for symptomatic hardware. The authors concluded that plate fixation
was an effective treatment for displaced olecranon fractures, with good functional outcomes.
Figure A shows a displaced, comminuted olecranon fracture without evidence of propagation past the coronoid.
Incorrect answers:
OrthoCash 2020
A 35-year-old male was involved in a high speed motorcycle accident. He has a closed head injury, bilateral pulmonary contusions and splenic rupture. His orthopaedic injuries are shown in Figure A. He has a blood pressure of 90/50 mm Hg and a heart rate of 115, despite aggressive resuscitation. An arterial blood gas reveals that his blood lactate is 3.5 and base deficit is -6 mmol/L. Following successful closed reduction of the right hip in the operating room with a percutaneous inserted Schantz pin, what is the next most appropriate treatment for his orthopaedic injuries?

Bilateral open reduction and internal fixation
Open reduction internal fixation on the right, reamed intramedullary nailing on the left
Temporizing external fixation on the right, open reduction and internal fixation on the left
Bilateral reamed intramedullary nailing
Bilateral temporizing external fixation Corrent answer: 5
This patient presents with features of hemodynamic instability and a high injury severity score. The next most appropriate treatment would be temporizing external fixation bilaterally. This patient meets the criteria for damage control orthopaedics.
Damage control orthopaedics is an approach that contains and stabilizes orthopaedic injuries so that the patient's overall physiology does not undergo further inflammatory insult. As a result, external fixation of femoral shaft fracture and pelvic stabilization is an effective treatment under this strategy. Other indications include vascular injury and severe open fracture.
Pallister et al. reviewed the effects of surgical fracture fixation on the systemic inflammatory response to major trauma. They show that early stabilization of major long bone fractures is beneficial in reducing the incidence of acute respiratory distress syndrome and multiple organ failure. However, early fracture surgery increases the post-traumatic inflammatory response, which
carries a higher complication rate compared to temporary fixation.
Tisherman et al. created clinical guidelines for the endpoints of resuscitation. Level I data found that standard hemodynamic parameters do not adequately quantify the degree of physiologic derangement in trauma patients. The initial base deficit, lactate level, or gastric pH should be used to stratify patients with regard to the need for ongoing fluid resuscitation.
Pape et al. retrospectively reviewed the impact of early total care vs. damage control orthopaedics in the treatment of femoral shaft fractures in polytrauma patients. They found a significantly higher incidence of acute respiratory distress syndrome (ARDS) with intramedullary nailing (15.1%) compared to external fixation (9.1%) when DCO subgroups were compared.
Figure A is a pelvic AP radiograph showing a right hip fracture-dislocation with an ipsilateral femoral shaft fracture. On the left side there is a displaced pertrochanteric hip fracture.
Incorrect Answers:
OrthoCash 2020
Which of the following has been shown to be the greatest risk factor for refracture after implant removal from a radial shaft?
Removal of locking screws
Removal of small fragment plates
Removal of metaphyseal implants
Removal of implants less than 1 year after insertion
Removal of protective splinting from limb earlier than 10 weeks postoperatively
Removal of implants earlier than 1 year after insertion is a risk factor for refracture of the bone after implant removal.
The risk of refracture after hardware removal is multifactorial. Multiple
variables have been studied such as protective splinting for 6 weeks after hardware removal, waiting 12 months or more prior to hardware removal, and the location of the fracture. The variable that seems to correlate most with the risk of refracture is a diaphyseal location of the initial fracture. Large fragment plates (4.5 mm), when removed, are also at higher risk for refracture in the forearm.
Deluca et. al reported on a case series of patients who sustained a refracture of a forearm after implant removal. They noted that radiolucency at the site of the original fracture was seen in most refractured patients when the plate was removed. They also recommend delaying implant removal to two years after insertion to minimize risk.
Rumball et. al reported that the incidence of refracture after forearm implant removal is 6% in their series. They found that early removal, lack of postoperative immobilization, and plate size are the most critical risk factors for refracture.
Illustration A shows a forearm with evidence of refracture after implant removal.
Incorrect Answers:

OrthoCash 2020
A 23-year-old male arrives to the trauma bay after a motorcycle crash caused by a drive-by shooting. The patient is awake and alert and following commands. Vital signs include a blood pressure of 145/90 and a heart rate of 117bpm. Initial lactate is reported as 2.4 mmol/L. The patient has 2 rib fractures on the right with a clear chest radiograph. The patient is neurovascularly intact with a 4cm transverse wound over the medial ankle. Figures A, B and C exhibit his orthopaedic injuries. What is the most appropriate management?

Irrigation, debridement and placement external fixator right ankle, external fixation femur and intramedullary fixation tibia
Irrigation, debridement and placement external fixator right ankle, intramedullary fixation femur and tibia
Irrigation, debridement and placement external fixator right ankle, intramedullary fixation femur and external fixation tibia
Irrigation, debridement and placement external fixator right ankle, femur and tibia
Irrigation, debridement and external fixation right ankle and skeletal traction
The patient is relatively hemodynamically stable. In this case the femur and tibia should be definitively fixed while the open ankle fracture can be irrigated and debrided and placed in a spanning external fixator, temporizing for later definitive fixation.
Aside from an elevated heart rate and mildly elevated lactate (normal < 2.5 mmol/L), the patient is relatively stable making him a good candidate for long bone stabilization and temporizing external fixation of the right ankle. Gross contamination of the open injury also supports temporizing fixation, which can be brought back for repeat I&D and possible fixation.
Pape et al. compared outcomes for intramedullary nailing (IMN) versus staged fixation for femur fractures in stable versus borderline patients. Borderline patients were defined as those with multi-system injury (especially to lungs) and exhibited higher lung complications following acute IMN when compared to stable patients with isolated orthopaedic injuries.
O'Brien reviewed the literature regarding early total care in regards to IMN stabilization of femur fractures. Summarized data noted isolated injuries treated with early IMN had good outcomes, whereas those with head or lung injury had worse outcomes and pulmonary complications.
Figure A exhibits a right open ankle fracture dislocation. Figure B exhibits a mid-shaft tibia fracture. Figure C exhibits a ballistic mid-shaft femur fracture.
Incorrect Answers:
OrthoCash 2020
Figure A is an anterior-posterior (AP) radiograph of a 27-year-old male who was a bicyclist struck by a motor vehicle. He was intubated in the field and unresponsive in the trauma slot. Ultrasound of his abdomen is positive for blood and he is brought to the operating room emergently for an exploratory laparotomy. He is found to have ischemic bowel and a grade 4 liver laceration. His lactate is 9.0 mg/dL. Which figure represents the next appropriate step in regard to his pelvic ring injury?

The radiograph exhibits an elevated left hemipelvis with complete sacroiliac disruption, which can be temporized with placement in skeletal traction.
The patient is unstable, as indicated by an elevated lactate level. The most appropriate next step is temporizing skeletal traction to reduce the left hemipelvis.
Langford et al. review the initial diagnosis, evaluation and resuscitation in the management of pelvic fractures. Reduction of pelvic volume can be achieved with pelvic binders and temporizing external fixation for anterior posterior compression (APC) and/or lateral compression (LC) fracture patterns, while skeletal traction can help do the same in vertical shear patterns.
Matullo et al. review the uses of skeletal traction in orthopaedic trauma, where lower extremity skeletal traction can be an efficient, fast, easy way to help reduce pelvic volume in vertical shear injuries, especially when the patient is unstable and not cleared for definitive fixation.
Figure A exhibits an elevated left hemipelvis indicative of a vertical shear injury and complete SI disruption. Figure B is an example of a pelvic binder. Figure C is a pelvic reconstruction plate. Figure D is a schematic of an anterior pelvic external fixator. Figure E is a schematic drawing of a patient in lower extremity
skeletal traction. Figure F is a radiograph exhibiting S1 and S2 sacroiliac (SI) screws.
Incorrect answers:
OrthoCash 2020
A 38-year-old man is involved in a motor vehicle collision and suffers the grossly open injury shown in Figure A. He subsequently undergoes irrigation and debridement and placement of an external fixator. In Figure B, if the proximal pin is placed at the red circle as compared to the black circle, the patient is at increased risk for which of the following?

Foot drop
Injury to the anterior tibial artery
Septic arthritis
Flexion contracture of the knee
Patellar tendon rupture Corrent answer: 3
The patient is at increased risk of septic arthritis when placing the proximal tibial pin too proximal due to penetration of the joint capsule. Pin site flora can track into the joint and lead to a septic knee.
Tibial external fixators can be used to temporize tibial shaft, pilon, and ankle fractures not ready for definitive management due to soft tissue concerns and/or practice of damage control orthopaedics. Intracapsular placement of fixator pins can lead to septic arthritis. The capsular reflection typically extends 14 mm distal to the subchondral line.
DeCoster et al. reported a cadaveric dissection study for safe placement of proximal tibia pins and determined that the capsule inserts 14 mm below the articular surface along the posteromedial and posterolateral surfaces. For fractures requiring extremely proximal pin placement, they recommend
anterior cortex penetration only at least 6 mm distal to articular surface.
Reid et al. investigated safe transtibial pin placement using MRI and cadaveric and volunteer knees. They found that pin placement 14 mm distal to subchondral bone will result in low likelihood of capsular penetration.
Figure A is an AP radiograph showing a segmental middle third tibia/fibula fracture. Figure B is a lateral diagram of the tibia showing potential sites of proximal pin placement.
Incorrect Answers:
OrthoCash 2020
Figures A and B are radiographs of a 43-year-old, right-hand dominant, male that injured his arm in a motor vehicle accident. What would be an absolute indication for surgical fixation of his injury?

Radial nerve palsy
Intra-articular extension
2mm fracture distraction, 5 degrees of rotational malignment
Ipsilateral proximal both bone forearm fracture
Bilateral fracture
This patient has a humeral shaft fracture. An absolute indication for surgery would include a floating elbow, i.e. ipsilateral both bone forearm fracture.
The primary causes of humeral fractures include motor vehicle accidents, falls, or violent injury. Almost all cases are treated non-operatively with functional bracing. The absolute indications for surgical management include: ipsilateral vascular injury, severe soft-tissue injury, open fracture, compartment syndrome, and associated ipsilateral forearm fracture, ie, floating elbow. The relative indications for surgical management include: segmental fracture, intraarticular extension, significant fracture distraction, bilateral humeral fracture, inability to maintain acceptable alignment, and polytrauma.
Klenerman et al. reviewed non-operative treatment of humeral shaft fractures. They showed that acceptable results could be achieved even after 20° of
anterior bowing, 30° of varus angulation, 15° of malrotation, and 3 cm of shortening.
Carroll et al. reviewed the management of humeral shaft fractures. They state the indications for operative fixation to be polytraumatic injuries, open fractures, vascular injury, ipsilateral articular fractures, floating elbow injuries, and fractures that fail nonsurgical management. Surgical techniques include external fixation, open reduction and internal fixation, minimally invasive percutaneous osteosynthesis, and antegrade or retrograde intramedullary nailing
Figure A and B shows a comminuted mid-shaft humeral fracture with intraarticular extension.
Incorrect Answers:
OrthoCash 2020
Which of the following findings is a contraindication in retrograde nailing of a periprosthetic distal femur fracture around a total knee arthroplasty?
Posterior-stabilized total knee implant
Cruciate retaining total knee implant
Spiral fracture pattern
Distal femoral replacement
Knee flexion contracture of 15 degrees Corrent answer: 4
A distal femoral replacement (TKA) implant will generally preclude placement of a retrograde nail due to the long stem on the femoral component.
Supracondylar femur fractures above a well-fixed TKA component are increasingly common. These fractures are often treated with a lateral locking plate, but can also be treated with a retrograde nail in certain circumstances. An important factor in determining if nailing is a viable option are knowing the TKA implant and it's design. In addition, if the TKA component is known, the maximum size of reamer head and nail can be determined preoperatively from the size of the femoral 'box'.
Schutz et al report on a prospective multicenter study of 112 patients who underwent fixation of a distal femur fracture with the LISS system. They report that 90% of fractures went on to union and they attribute all of the failures to either the high-energy nature of particular fractures or a lack of experience in applying the plate in an appropriate pattern. They also note that primary grafting of these fractures is not necessary.
Illustration A shows a periprosthetic femur fracture treated with a retrograde nail.
Incorrect Answers:
1: A posterior-stabilized implant can be treated with an intramedullary nail in many circumstances but can be technically challenging, depending on the components.
2: A cruciate retaining TKA is not a contraindication to use of a retrograde nail. 3: A spiral pattern periprosthetic supracondylar femur fracture can be treated with a femoral nail.
5: A knee flexion contracture will often provide the flexion necessary for access to the box of the femoral component. A knee extension contracture, however, can preclude access to this box for placement of a nail.

OrthoCash 2020
A patient falls and sustains the isolated injury seen in Figures A and B. The surgical plan includes open reduction and internal fixation with a small mini-fragment plate using a direct lateral approach. During the approach, the forearm was placed in a fully pronated position. What would be the correct position of the forearm during plate application?

Full pronation
25 degrees pronation
Neutral
25 degrees supination
Full supination
Using the lateral approach (Kocher or Kaplan), the correct placement of the arm should be in a neutral position so that the plate can be placed on the bare area of the proximal radius.
Displaced radial head fractures with less than 3 fragments can be amendable to open reduction internal fixation. The methods of fixation include buried or headless screws, if placed at the articular surface, or posterolateral plating, if placed in the bare area. The safe zone for plating is located at a 90-110 arc from the radial styloid to Lister's tubercle with the arm in neutral rotation. This position helps to avoid impingement of ulna against the plate with forearm rotation. It should be noted that during the approach, that the forearm should be fully pronated to avoid injury to the posterior interosseous nerve.
Mathew et al. reviewed the concepts of terrible triad injuries of the elbow. Radial head fractures are treated conservatively when there is an isolated minimally displaced (less than 2mm) fracture with no mechanical block to motion. Open reduction internal fixation is used for Mason II or III fractures with < 3 fragments. Radial head replacement is considered for comminuted
fractures (Mason Type III) with 3 or more fragments.
Cheung et al. reviewed the surgical approaches to the elbow. The lateral approach (Kocher or Kaplan) is most commonly used with these injuries. The Kocher approach utilizes the intramuscular plane between anconeus and extensor carpi ulnaris. Kaplan utilizes the plane between extensor digitorum commons and extensor carpi radialis brevis.
Figure A and B show AP and lateral radiographs of the left elbow. There is a displaced radial head fracture. Illustration A shows a schematic diagram of the radial head "safe zone" between the radial styloid to Lister's tubercle.
Incorrect Answers:

OrthoCash 2020
A 38-year-old male is involved in a high speed motor vehicle collision. He has a Glasgow Coma Scale of 13 and receives 2 liters of fluid en route to the emergency department. Upon evaluation in the emergency department, he is found to have a bilateral femoral shaft fractures, a right ankle fracture, and a left both bone forearm fracture. He also has 2 left sided rib fracture and a grade II liver laceration. His heart rate is 130 and blood pressure is 85/50. All of the following
would be indications to practice damage control orthopaedics in this patient except:
Bilateral femur fractures
Rib fractures
Lactate of 5.2
Urine output of 20 cc/hr
Heart rate and blood pressure Corrent answer: 2
Rib fractures without evidence of further thoracic trauma would not be an indication to practice damage control orthopaedics. This patient is underresuscitated based on his lactate level, urine output, and vital signs and definitive management should be delayed.
Damage control orthopaedics is the practice of delaying definitive management of fractures and utilizing temporary stabilization (such as an external fixator) until a patient has recovered from the initial physiologic insult of trauma.
Patients are at increased risk for perioperative complications such as ARDS and multi-system organ failure during the acute period after polytrauma. In addition to underresuscitation, other indications to practice damage control orthopaedics include: injury severity score>40 (or >20 with thoracic trauma), bilateral femoral fractures, hypothermia below 35 degrees Celsius, and pulmonary contusions.
Pape et al. (2007) studied the incidence of acute lung injuries in polytrauma patients undergoing either intramedullary nailing or external fixation and later definitive fixation of femoral shaft fractures. They found that patients undergoing immediate intramedullary nailing were nearly 6.7 times more likely to have acute lung injury
The Canadian Orthopedic Trauma Society studied the effect of reamed versus unreamed femoral nailing on incidence of ARDS for femoral shaft fractures in trauma patients using a randomized controlled study. They found no difference between the groups.
Pape et al. also examined the pathophysiological cascades that accompany soft tissue injuries of the extremities, abdomen, and pelvis and recommend a more comprehensive for evaluation of patients with these injuries.
Incorrect Answers:
OrthoCash 2020
The anterior intrapelvic (modified Stoppa) approach is most appropriate for which of the following fractures?

The anterior intrapelvic (AIP) or modified Stoppa approach provides access to the quadrilateral plate, which is a common location for fracture displacement in associated both column acetabulum fractures as seen in Figure D.
Compared to the traditional ilioinguinal approach, the modified Stoppa with a lateral window can offer comparable access to the quadrilateral plate, which can allow for its use in associated both column fracture patterns.
de Peretti et al. prospectively followed 25 patients with both column fractures
treated via an iliofemoral approach. Results led the authors to not recommend the extensile approach for both column fractures due to lack of efficiency and high complication rates.
Alonso et al. compared the extensile iliofemoral and triradiate approaches, and both reported acceptable results. However, concerning were the relatively high rates of heterotopic ossification, despite prophylaxis.
Bible al. performed a cadaver study to quantify the amount of access provided by the modified Stoppa approach. This approach provides access to approximately 80% of both the inner pelvis, and the quadrilateral plate, however, comparison to the ilioinguinal approach was not performed.
Shazar et al., in a cohort comparison between the ilioguinal and Stoppa approaches, noted better visualization and potential improve fracture reduction via the Stoppa approach for both column fractures. However, this study was limited in its retrospective and relative observer bias.
Figure A depicts a posterior wall fracture dislocation with concomitant femoral neck fracture. Figure B is an iliac oblique view which depicts a posterior column fracture. Figure C exhibits a posterior column + posterior wall fracture. Figure D depicts acetabular fracture with protrusio. Figure E exhibits a posterior wall fracture.
Incorrect answers:
OrthoCash 2020
Figure A is a radiograph of a 75-year-old woman that fell onto her non-dominant shoulder from a standing height. She was treated nonoperatively for 9 months but continues to complain of pain when she elevates her arm. In patients with this type of fracture pattern, what factor has the greatest impact on fracture healing?

Hand dominance
Angulation of fracture
Smoking
Early physical therapy
Diet
This patient has an impacted varus proximal humerus fracture. Smoking has been shown to increase the nonunion risk up to 5.5 times with these fractures.
Impacted varus proximal humerus fractures can be managed effectively with non-operative care. The major factors that influence non-union are age and smoking. Solid bony union can be seen in 93-98% of patients at 1 year, with more than 97% of people returning to pre-injury level of function. The angulation of fracture, hand dominance and physical therapy does not seem to influence bone union or functional outcomes with this fracture pattern.
Court-Brown et al. looked at the outcomes of impacted varus fractures. They determined that the age of the patient was the major factor in overall outcome. They showed that the best results occurred in younger patients, but results deteriorate with advancing age. Physical therapy was not found to
impact outcome.
Hanson et al. showed that impacted varus fractures can be successfully managed with non-operative care. They found that overall fracture displacement had a minor impact of fracture healing and functional outcome. The predicted risk of delayed union and nonunion was 7% with patients that smoke. This was 5.5 times greater than non-smokers.
Figure A shows an AP radiograph of a varus angulated proximal humerus fracture. This radiograph shows delayed atrophic union.
Incorrect Answers:
OrthoCash 2020
A 26-year-old male epileptic patients presents with right shoulder pain and deformity after a grand mal seizure. After medical stabilization, he denies previous injury to his shoulder. Pre-reduction and post-reduction radiographs of the shoulder are shown in Figures A-C, respectively; physical examination reveals a normal upper extremity neurovascular examination. After shoulder immobilization, what would be the next most appropriate step in management of this patient?

Abduction brace for three weeks, followed by therapy
Right shoulder MR arthrogram
Open reduction and internal fixation
Hemiarthroplasty
Early range of motion Corrent answer: 3
This patient has presented with a fracture dislocation of the right shoulder. After urgent closed reduction, this patient requires open reduction internal fixation of the proximal humerus, and greater tuberosity fracture fragment in particular.
Isolated greater tuberosity fractures may be associated with shoulder dislocations. Careful review of imaging is critical to identify fracture lines that may extend into the humeral neck and head. If these extensions go undetected, catastrophic propagating fractures may occur during closed reduction maneuvers. Treatment is usually with open reduction internal fixation (ORIF). Young patients with proximal humerus fractures should be treated more aggressively with ORIF as compared to elderly patients. Another example would be a severely impacted valgus proximal humeral fracture in a young patient.
Erasmo et al. examined of 82 cases of humerus fracture dislocations treated with the lateral locking plates. Overall outcomes were excellent to good based on standard scoring systems. Complications included avascular necrosis (12%), varus positioning of the head (4.8%), impingement syndrome (3.6%), secondary screw perforation (3.6%), non-union (2.4%) and infection (1.2%).
Robinson et al. looked at severely impacted valgus proximal humeral fractures treated with open reduction internal fixation in young patients. Anatomic reduction is required with lateral plating to re-establish the normal head/neck angle. Good to excellent results can be achieved with fixation methods.
Figure A shows an anterior fracture-dislocation of the right shoulder. Figure B and C show post-reduction radiographs with a congruent glenohumeral joint. Displacement of the greater tuberosity (GT) fragment is greater than 5mm.
Incorrect Answers:
OrthoCash 2020
Pelvic packing can be performed to temporarily treat a hemodynamically unstable patient with a pelvic ring fracture. Which of the following is the preferred location of the skin incision to perform pelvic packing?
Right anterior superior iliac spine (ASIS) to mid-symphysis, left lateral window incision
Left ASIS to mid-symphysis, right lateral window incision
Subumbilical incision
ASIS to ASIS bilaterally
Pararectus incision
The preferred skin incision location is a subumbilical incision, 6-8cm extending upwards from the pubic symphysis towards the umbilicus; this allows access to all of the appropriate areas for pelvic packing.
Following skin incision, the rectus fascia is then divided in the midline which allows for access to both sides of the bladder for packing deep in the pelvic
brim. On each side, 3 lap pads are placed from sacroiliac joint to the retropubic space, all placed below the level of the pelvic brim.
Hak et al. review the options for emergent treatment in life threatening hemorrhage secondary to pelvic fractures. The authors offer several options for emergent treatment, which includes the use of pelvic binders, the placement of external fixators, pelvic packing and interventional angiography. Goals include reduction of pelvic volume and stopping rapid hemorrhage to save a patient's life. Pelvic packing, properly performed, is done through a subumbilical incision, as described above.
Osborn et al. retrospectively reviewed and compared emergent pelvic packing to angiography in hemorrhagic pelvic fracture clinical scenarios. The authors noted comparable results in mortality with a noted decrease in need for post-procedure transfusions in the pelvic packing group.
Cothren et al. reported their outcomes following an institutional algorithmic change from pelvic ex-fix/angiography to pelvic packing and ex-fix. Since their institutional change, the authors noted a significant decrease in transfusions, need for angiography and mortality.
Incorrect answers:
OrthoCash 2020
A 28-year-old man is brought by ambulance to the emergency department after falling from the roof of his home four hours ago. Upon initial evaluation, he has visible deformities of his bilateral lower extremities and a positive FAST exam. Heart rate is 135, blood pressure 85/58, and urine output is 40 cc over 3 hours. According to ATLS guidelines, what percentage of his blood volume has this patient likely lost?

Question 4

A year-old woman with a history of osteoporosis is involved in a high-speed motor vehicle accident, resulting in left hip pain and deformity. The initial radiograph from the trauma bay is shown in Postreduction CT is shown in 2 through What is the most appropriate definitive surgical treatment?

Explanation

DISCUSSION:
The radiograph shows a posterior wall acetabular fracture-dislocation. Post reduction CT indicates a large comminuted posterior wall fracture with marginal impaction of the articular surface. A comminuted femoral head fracture also is seen extending to the superior weight-bearing surface. Given the marginal
impaction of the acetabulum and the considerable comminution of the femoral head (which is likely unreconstructible), this injury would have a high risk of causing posttraumatic arthritis if treated with ORIF of the fractures alone. Considering this fact and the patient’s age, ORIF of the posterior wall and acute total hip arthroplasty would likely have the best functional result and the lowest risk of reoperation. Hemiarthroplasty is inappropriate for this injury considering the acetabular fracture. Skeletal traction currently plays a limited role in the definitive treatment of acetabular fractures.

Question 5

A biopsy of the involved physis in a patient with slipped capital femoral epiphysis (SCFE) would most likely reveal

Explanation

DISCUSSION: Vascular invasion, histologically similar to granulation tissue, has been noted between the columns in the zone of hypertrophy, leading to the theory of microtrauma as an etiology. SCFE is also associated with conditions that increase the height of the zone of hypertrophy, including the adolescent growth spurt and endocrinopathies. The perichondral ring has been shown to decrease in thickness with age. Normal undulations in the growth plate also decrease during this time, possibly further destabilizing the physis. Abnormal accumulations of proteoglycan have been reported.
REFERENCES: Chung SM, Batterman SC, Brighton CT: Shear strength of the human femoral capital epiphyseal plate. J Bone Joint Surg Am 1976;58:94-103.
Raney EM, Ogden JA: Slipped capital femoral epiphysis. Current Ortho 1995;9:111-116.

Question 6

A 58-year-old patient who underwent bilateral hip arthroplasty 12 years ago now reports pain in his hips and difficulty with ambulation to the point where he now uses crutches. A radiograph of the hip and pelvis is shown in Figure 26. What is the best treatment option for this patient?

Explanation

DISCUSSION: The radiographs reveal acetabular component failure with bone loss. There

are several treatment options available. The best option for survivorship is a cementless

porous-coated acetabular component. This patient may or may not require structural bone graft, which may need to be determined at the time of surgery. Bipolar implants and cemented acetabular components for revision surgery have not demonstrated long-term success. The use of a protrusio ring is reserved primarily for massive bone loss such as a Paprosky type III bone loss with significant superior migration of the acetabular component. The best clinical results for acetabular component revision have been achieved with cementless porous-coated implants.
REFERENCES: Haddad FS, Masri BA, Garbuz DS, et al: Acetabulum, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 923-936.
D’Antonio JA: Periprosthetic bone loss of the acetabulum: Classification and management. Orthop Clin North Am 1992;23:279-290.
Rubash HE, Sinha RK, Paprosky W, et al: A new classification system for the management of acetabular osteolysis after total hip arthroplasty. Instr Course Lect 1999;48:37-42.

Question 7

A 12-year-old girl has had right knee pain for the past 3 months. Radiographs and a coronal T 2 -weighted MRI scan are shown in Figures 10a through 10c. A biopsy specimen is shown in Figure 10d. What is the most appropriate treatment for this lesion?

Explanation

DISCUSSION: The radiographs show a lytic lesion in the right proximal tibia that has a high fluid content based on the MRI findings. The radiographic appearance is consistent with either telangiectatic osteosarcoma or aneurysmal bone cyst. Low-magnification histology shows a lesion resembling an aneurysmal bone cyst, with blood lakes separated by cellular septa. However, high-magnification shows severe cytologic atypia, indicative of a telangiectatic osterosarcoma. The appropriate treatment is neoadjuvant chemotherapy followed by wide resection and reconstruction of the lesion.
REFERENCES: Unni KK: Dahlin’s Bone Tumors: General Aspects and Data on 11,087 Cases, ed 5. Philadelphia, PA, Lippincott-Raven, 1996, pp 143-160.
Arndt CA, Crist WM: Common musculoskeletal tumors of childhood and adolescence. N Engl J Med 1999;341:342-352.

Question 8

-What is the most appropriate course of action for this patient’s condition?

Explanation

DISCUSSION FOR QUESTIONS 7 THROUGH 9
The anterior drawer test is performed with the ankle in 10 degrees of plantar flexion, which results in the greatest amount of translation. The test investigates the integrity of the anterior talofibular ligament with a key distance of translation being 8 to 10 mm. While the patient is sitting and has her knees flexed over the edge of a table or bench, the physician or examiner uses one hand to stabilize the distal leg and with the other applies an anterior force to the heel in an attempt to gap the talus anteriorly from under the tibia. The anterior talofibular ligament and calcaneofibular ligament are both compromised based on the examination findings. The anterior drawer test result reflects injury to the anterior talofibular ligament and a possible injury to the calcaneofibular ligament. A lateral talar tilt test angle measurement greater than 15 degrees reflects a rupture of both anterior talofibular ligament and calcaneofibular ligaments.The diagnosis is a severe lateral ligament complex sprain. Considering the involvement of the anterior talofibular ligament and calcaneofibular ligaments, early mobilization with a cast or controlled ankle movement walker boot has been documented to result in better patient outcomes than compression or air casting.

Question 9

A 72-year-old woman is scheduled to undergo right total hip arthroplasty. Her preoperative radiograph is shown in Figure below. To avoid increasing this patient’s combined offset while maintaining her leg length, what is the most appropriate surgical plan?

Explanation

DISCUSSION:
The management of patients with proximal femoral deformity can be difficult. Appropriate implant selection and preoperative templating are critical. In this patient, it would be difficult to avoid increasing the combined offset by too much, which could contribute to the overtensioning of the soft tissues and trochanteric pain. By medializing the acetabular component (decreasing the combined offset), using a low offset femoral component or a cemented component placed more valgus (decreasing the combined offset), and making a longer neck cut (to avoid shortening of the lower extremity), restoration of the patient’s native offset and leg length can be achieved.

Question 10

Figure 10 shows the radiograph of an active 75-year-old woman who reports severe leg pain after a fall. Management should consist of

Explanation

DISCUSSION: The patient has a comminuted fracture of the proximal femur and joint space narrowing of the acetabulum. Therefore, the prosthesis should be converted to a total hip arthroplasty. Because there is extensive comminution, the revision stem should bypass the area of bone loss by two bone diameters. A hemiarthroplasty is not indicated because the patient has no acetabular cartilage. Open reduction and internal fixation may not stabilize the prosthesis. A resection arthroplasty or treatment in traction will not leave the patient with adequate function.
REFERENCES: Garbuz DS, Masri BA, Duncan CP: Periprosthetic fractures of the femur: Principles of prevention and management, in Cannon WD Jr (ed): Instructional Course Lectures 47. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 237-242.
Montijo H, Ebert FR, Lennox DA: Treatment of proximal femur fractures associated with total hip arthroplasty. J Arthroplasty 1989;4:115-123.

Question 11

A 28-year-old man underwent open reduction and internal fixation of a closed, displaced, intra-articular calcaneal fracture 8 weeks ago. Examination now reveals that the lateral wound is red and draining purulent material. Cultures obtained from the wound grow out Staphylococcus aureus. Radiographs show early healing of the fracture. What is the next most appropriate step in management?

Explanation

DISCUSSION: Intravenous antibiotics alone will not adequately treat this infection. At 8 weeks after surgery, the hardware must be removed because Staphylococcus aureus is a virulent microbe. VAC therapy alone is not adequate without debridement and hardware removal, but it may play a role in postoperative wound care. Calcanectomy is a salvage procedure for calcaneal osteomyelitis or recalcitrant heel ulceration.
REFERENCES: Benirschke SK, Kramer PA: Wound healing complications in closed and open calcaneal fractures. J Orthop Trauma 2004;18:1-6.
Lim EV, Leung JP: Complications of intra-articular calcaneal fractures. Clin Orthop

2001;391:7-16.
Folk JW, Starr AJ, Early JS: Early wound complications of operative treatment of calcaneus fractures: Analysis of 190 fractures. J Orthop Trauma 1999;13:369-372.

Question 12

What pathology is most likely to result in failure of an arthroscopic Bankart repair?

Explanation

DISCUSSION: Recent studies have documented that an arthroscopic Bankart repair performed with good technique can produce success rates similar to an open repair. However, the results of an arthroscopic repair deteriorate significantly if there is a 25% or greater anterior-inferior glenoid rim defect (inverted pear configuration) or an engaging Hill-Sachs lesion in which the humeral head defect keys onto the glenoid rim in abduction and external rotation. If either of these entities exist or there is multidirectional instability with pathologic hyperextensible tissue laxity, an open repair is recommended. An associated SLAP lesion would not significantly affect the result of the Bankart procedure. Not infrequently, the anterior glenoid labrum is partially or completely disrupted and, in itself, is not a contraindication to arthroscopic Bankart repair. In almost all patients with predominantly unidirectional instability, some degree of capsular/anterior-inferior glenohumeral ligament attenuation is present and can be addressed during the arthroscopic repair.
REFERENCES: Burkhart SS, De Beer JF: Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 2000;16:677-694.
Cole BJ, Romeo AA: Arthroscopic shoulder stabilization with suture anchors: Technique, technology, and pitfalls. Clin Orthop 2001;390:17-30.

Question 13

A 7-year-old girl who sustained a type III posteromedial extension supracondylar fracture underwent a closed reduction at the time of injury. Figure 27a shows the position of the fracture fragments prior to percutaneous medial and lateral pin fixation. Following surgery, healing was uneventful and the patient regained a full painless range of motion. Fifteen months after the injury, she now reports loss of elbow motion and moderate pain with activity. A current AP radiograph is shown in Figure 27b. What is the most likely cause of her symptoms?

Explanation

DISCUSSION: The patient sustained a very distal supracondylar fracture of the humerus. Fractures in this area can disrupt the blood vessels supplying the lateral ossification center of the trochlea. With disturbance of the blood supply in this area, local osteonecrosis occurs and disrupts the support for the overlying articular surface, producing joint incongruity and localized degenerative arthritis.
REFERENCES: Haraldsson S: The interosseous vasculature of the distal end of the humerus with special reference to the capitellum. Acta Orthop Scand 1957;27:81-93.
Morrissy RT, Wilkins KE: Deformities following distal humeral fracture in childhood. J Bone Joint Surg Am 1984;66:557-562.

Question 14

A 40-year-old man with an acetabular chondrosarcoma has a small soft-tissue mass. Treatment should consist of

Explanation

DISCUSSION: The treatment of choice for pelvic chondrosarcoma is wide resection via an internal hemipelvectomy. Chondrosarcoma requires surgical resection for control and does not respond to traditional chemotherapy or external beam radiation. Hip arthroplasty with acetabular reconstruction and curettage and cementation of the lesion are intralesional procedures that result in a higher incidence of local recurrence of tumor.
REFERENCES: Pring M, Weber KL, Unni K, Sim FH: Chondrosarcoma of the pelvis: A review of sixty-four cases. J Bone Joint Surg Am 2001;83:1630-1642.
Sheth DS, Yasko AW, Johnson ME, Ayala AG, Murray JA, Romsdahl MM: Chondrosarcoma of the pelvis: Prognostic factors for 67 patients treated with definitive surgery. Cancer 1996;78:745-750.

Question 15

A healthy 70-year-old man has a swollen knee after undergoing a knee replacement 10 years ago. Aspiration of the knee reveals cloudy, viscous synovial fluid. Laboratory studies show an erythrocyte sedimentation rate of 10 mm/h and a C-reactive protein level of less than 0.5. What is the most likely diagnosis?

Explanation

DISCUSSION: Polyethylene wear debris can result in significant synovitis and subsequent cloudy appearing synovial fluid. Typically, laboratory studies show a WBC of less than 30,000/mm³ and no left shift. Cytologic examination can reveal intra-articular polyethylene particles. Infected total knee arthroplasty is extremely uncommon in a healthy, immune-competent patient who has a normal preoperative erythrocyte sedimentation rate and C-reactive protein level.
REFERENCE: Barrack RL, Jennings RW, Wolfe MW, Bertot AJ: The value of preoperative aspiration before total knee revision. Clin Orthop 1997;345:8-16.

Question 16

The MRI scans reveal a root tear of the medial meniscus. Studies demonstrate that this tear pattern greatly increases the tibiofemoral contact forces. These forces, and meniscal extrusion, worsen with increasing flexion. Correct answer : B 69- A 45-year-old postmenopausal smoker with a body mass index (BMI) of 22 has had severe knee pain for the past year. The pain has been progressing and the patient is now only able to perform activities of daily living. Knee radiographs reveal medial compartment osteoarthritis without any involvement of the patellofemoral joint or the lateral compartment. What is the contraindication for a high tibial osteotomy (HTO) in this patient?

Explanation

In an asymptomatic athlete, what condition represents an absolute contraindication to returning to contact or collision sports?
A. Healed one-level anterior cervical fusion
B. Congenital atlanto-occipital fusion
C. Cervical disk herniation previously treated nonoperatively
D. Spina bifida occulta
The one overriding principle regarding the return to any collision sport, as Torg and associates has described, is that the athlete be "neurologically intact, asymptomatic, and pain-free and have full strength and full cervical range of motion". Forces exerted on the cervical spine can be absorbed by the "elasticity of the intervertebral disk, the mobility of the spine itself, and the impact of absorbing capabilities of the cervical paravertebral musculature". The C1 and C2 levels (atlanto-occipital level) control movement of the skull and articulate the large motion movements. Specifically, partial or complete 56
congenital fusion of the atlas to the base of the occiput results in progressive cord compression by the posterior lip of the foramen magnum. It can result in sudden death.
A cervical disk herniation that was previously treated nonsurgically and is not causing cord compression in the currently asymptomatic patient is not a contraindication to return to collision sports. Spina bifida occulta is common (10-20% of healthy individuals). It is typically an incidental finding and does not result in neurologic problems. If individuals have a healed anterior, lateral or posterior disk herniation that is treated nonsurgically and they are currently asymptomatic, then there is no contraindication to participation in contact sports. If they require a diskectomy and fusion and they have a solid/healed fusion, are asymptomatic and neurologically intact with full and pain-free range of motion, then there is no contraindication to return to collision sports. An acute disk herniation, a disk herniation with associated pain or neurologic symptoms, or the presence of cord compression or loss of normal lordosis are all contraindications.
71- Based on the injury shown on the axial MRI scan of the shoulder in Figure 1, what other pathology should be closely examined for during surgery?
A. Subscapularis tear
B. Supraspinatus tear
C. Superior labral anterior- posterior (SLAP) tear
D. Bankart tear
The axial MRI scan reveals a subluxated biceps tendon. In the study by Koh and associates, 85% of patients with a biceps subluxation on MRI were found to have a subscapularis tear at the time of arthroscopy. These are not always obvious on the MRI, and close inspection of the leading edge/upper border of the subscapularis tendon at the time of arthroscopy is necessary. Although supraspinatus tears, SLAP tears, and Bankart tears can all occur in conjunction with a biceps subluxation, none have been shown to be strongly correlated with this pathology, nor as specific to this pathology.
73- Figures 1 through 4 are the MRI scans of a 24-year-old former collegiate basketball player who injured his left knee while playing recreational basketball 10 days prior to presentation. He landed from a jump awkwardly and reported that his knee gave out. He heard a pop at the time of injury and was unable to continue playing. He complains of medial and lateral knee pain and difficulty with weight bearing. On physical examination, he has a moderate effusion and his range of motion is from 10° to 80°. Ligament examination reveals a 2B Lachman, negative posterior drawer as well as negative varus and valgus stress testing. What is the diagnosis?
A. Meniscus tear
B. Anterior cruciate ligament (ACL) tear
C. ACL tear and posterior cruciate ligament (PCL) tear
D. ACL tear and medial meniscus tear

Question 17

A 12-year-old girl who has a history of frequent tripping and falling also has bilateral symmetric hand weakness, high arched feet, absent patellar and Achilles tendon reflexes, and excessive wear on the lateral border of her shoes. She reports that she has multiple paternal family members with similar deformities. She most likely has a defect of what protein?

Explanation

DISCUSSION: The girl shows clinical features of hereditary motor sensory neuropathy type 1, Charcot-Marie-Tooth disease. The most common type of this autosomal-dominant disease is due to an underlying defect in the gene coding for peripheral myelin protein-22 on chromosome 17. Many other less common mutations have been identified in this family of neuropathies. Dystrophin is a protein that is abnormal in Duchenne’s muscular dystrophy, which affects males and is diagnosed earlier. Type I collagen is defective in osteogenesis imperfecta.

Alpha-L-iduronidase is defective in mucopolysaccharidosis type I, Hurler’s syndrome. Defective cartilage oligomeric matrix protein is associated with some forms of multiple epiphyseal dysplasia.
REFERENCES: Patel PI, Roa BB, Welcher AA, et al: The gene for the peripheral myelin protein PMP-22 is a candidate for Charcot-Marie-Tooth disease type 1A. Nat Genet 1992;1:159-165.
Harding AE: From the syndrome of Charcot, Marie and Tooth to disorders of peripheral myelin proteins. Brain 1995;118:809-818.

Question 18

Figure 28 shows an AP radiograph of a 54-year-old woman who underwent lumbar laminectomy and fusion at the L4 and L5 levels with placement of a bone stimulator 8 years ago. She also underwent a left total hip arthroplasty 2 years ago; aspiration of that joint now reveals that it is infected with a gram-positive cocci organism. History is also significant for IV drug use and human immunodeficiency virus (HIV). The patient reports fever, chills, and left flank and abdominal pain. Examination reveals significant pain with resisted left hip flexion and passive hip extension. She also has lumbar hyperlordosis. Which of the following studies would best identify the underlying cause of her infection?

Explanation

DISCUSSION: The patient’s clinical signs (fever and flank, hip, and abdominal pain) suggest a primary iliopsoas abscess. With an increased patient population who abuse drugs and/or who are HIV-positive, iliopsoas abscess may be more prevalent because of systemic bacterial seeding and may be potentially unrecognized. Diagnostic imaging studies provide a better understanding of the anatomic magnitude of the infection, give concrete confirmation of the diagnosis, and may suggest an underlying cause. Neither standard abdominal radiographs nor ultrasound studies are sensitive enough to be diagnostic of this disease process. CT has been established as the standard study for identifying the underlying cause of this abscess. The hip infection has most likely developed as a result of hematogenous spread from an infected skin lesion from the patient’s IV drug use.
REFERENCES: Santaella RO, Fishman EK, Lipsett PA: Primary vs secondary iliopsoas abscess: Presentation, microbiology, and treatment. Arch Surg 1995;130:1309-1313.
Malhotra R, Singh KD, Bhan S, Dave PK: Primary pyogenic abscess of the psoas muscle. J Bone Joint Surg Am 1992;74:278-284.

Question 19

Figure 23 shows the postoperative radiograph of a patient who underwent an anterior cruciate ligament (ACL) reconstruction (with bone-patella tendon-bone autograft) that failed. He initially had loss of flexion postoperatively. What is the most likely cause of this failure?

Explanation

DISCUSSION: The key to this question is the fact that the patient initially lost flexion postoperatively and this relates to anterior placement of the femoral tunnel, thus capturing the knee. The bone plug seen on the radiograph is actually from the tibial tunnel, but this occurred as the patient forced flexion until failure of the ACL graft and pullout of the plug from the tunnel. Although it could be argued that better tibial fixation would have prevented this failure, poor placement of the femoral tunnel led to the failure of this ACL reconstruction.
REFERENCES: Fu FH, Bennett CH, Latterman C, et al: Current trends in anterior cruciate ligament reconstruction: Part 1. Biology and biomechanics of reconstruction. Am J Sports Med 1999;27:821-830.
Fu FH, Bennett CH, Ma CB, et al: Current trends in anterior cruciate ligament reconstruction: Part II. Operative procedures and clinical correlations. Am J Sports Med 2000;28:124-130.

Question 20

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 21

What are the five major compartments of the foot?

Explanation

DISCUSSION: The five major compartments of the foot are medial, lateral, central, interosseous, and calcaneal. There is no dorsal compartment in the foot.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 262-264.
Shereff MJ: Compartment syndromes of the foot. Instr Course Lect 1990;39:127-132.

Question 22

-The fracture shown in Figure 82 is scheduled to be fixed with a retrograde nail. An arthrotomy should be performed during the procedure because it

Explanation

Question 23

Which of the following findings is considered a poor prognostic factor for postoperative neurologic recovery in patients with rheumatoid arthritis?

Explanation

DISCUSSION: When markedly diminished space available for the cord (demonstrated by a posterior atlantoaxial interval of less than 10 mm) is seen, there is a poor prognosis for recovery (25% of Ranawat class IIIb patients) following surgery. A posterior atlantoaxial interval of 14 mm or less is a predictor of increased risk of paralysis, but patients with an interval between 10 mm and 14 mm have a greater chance of recovery. Space available for the cord that is at least 14 mm is not associated with an increased risk of neurologic deficit.
REFERENCES: Boden SD, Dodge LD, Bohlman HH, et al: Rheumatoid arthritis of the cervical spine: A long-term analysis with predictors of paralysis and recovery. J Bone Joint Surg Am 1993;75:1282-1297.
Casey AT, Crockard HA, Bland JM, et al: Predictors of outcome in the quadriparetic nonambulatory myelopathic patient with rheumatoid arthritis: A prospective study of 55 surgically treated Ranawat Class IIIb patients. J Neurosurg 1996;85:574-581.
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Question 24

Glenohumeral disarticulation often leads to which of the following changes?

Explanation

Postural abnormalities are common after high upper extremity amputation. Normally the weight of the upper extremity and the shoulder girdle muscles keep the shoulder balanced. When the arm is amputated and the scapula remains, the shoulder girdle muscles are unopposed, resulting in upward movement often called "hiking" of the shoulder girdle. In a growing child, removal of the entire upper limb can result in scoliosis of the spine due to muscle imbalance. Abnormal shoulder elevation can often be minimized by corrective exercises and wearing a shoulder prosthesis.

Question 25

A 70-year-old woman had poliomyelitis as a young child, and the residual weakness she has as an adult principally involves the lower extremities. She now notes progressive weakness in both legs and she tires easily. What is the best course of action?

Explanation

DISCUSSION: The most likely diagnosis is postpolio syndrome, which is characterized by increasing weakness in both the paretic and previously normal muscles. Fatigability, joint pain, muscle atrophy, respiratory insufficiency, dysphagia, and sleep apnea are also seen. Gentle exercise and modification in lifestyle demands are generally recommended. Vigorous rehabilitation is likely to be detrimental in this condition. Further diagnostic work-up is not indicated at this time.
REFERENCES: Dalakas MC, Elder G, Hallett M, et al: A long-term follow-up study of patients with post-poliomyelitis neuromuscular symptoms. N Eng J Med 1986;314:959-963.
Kasser JE (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 683-687.

Question 26

What is the most important preoperative factor predicting conversion to total hip arthroplasty after arthroscopic surgery of the hip?

Explanation

DISCUSSION:
The authors cited in the references examined large databases to determine the risk factors for conversion to total hip arthroplasty after arthroscopic surgery of the hip. In the study by Kester and associates, obesity had an odds ratio (OR) of 5.6 for conversion to hip arthroplasty, whereas age over 60 years had an OR of

Question 27

A 35-year-old male suffers an anterior column acetabular fracture during a motor vehicle collision, and subsequently undergoes percutaneous acetabular fixation. Intraoperatively, fluoroscopy is positioned to obtain an obturator oblique-inlet view while placing a supraacetabular screw. Which of the following screw relationships is best evaluated with this view?

Explanation

DISCUSSION: The obturator oblique-inlet view, as seen in Illustration A, best demonstrates the position of a supraacetabular screw or pin relative to the tables of the ilium.
Starr et al review their initial results and technique of closed or limited open reduction and percutaneous fixation of acetabular fractures. They defined two groups of patients who may benefit from this technique; elderly patients with multiple comorbidities to facilitate early mobilization and restore hip morphology, and young patients with elementary fracture patterns and multiple associated injuries.
Starr et al describe their operative technique and outcomes for a case series of 3 patients using percutaneous acetabular fixation to augment open reduction of acetabular fractures. The authors state that, for placement of an
anterior colum ramus screw, an iliac oblique-inlet (not obturator oblique-inlet) will ensure that the screw is within the medullary canal of the ramus and does not exit anterior or posterior.
Gardner and Nork describe a technique for placement of a large femoral distractor in the supra-acetabular region to compress displaced posterior pelvic ring injuries. They note that the obturator oblique-inlet view is necessary to view the entire length of the pin as well as to ensure that pin remains in bone.
Incorrect answers:

Question 28

A 17-year-old girl develops chronic posterolateral rotatory instability (PLRI) of the elbow following closed treatment of an elbow dislocation. Advanced imaging reveals incompetence of the lateral collateral ligament complex, and ligament reconstruction is planned. Examination under anesthesia is performed with the forearm in maximal supination and valgus force applied to the elbow, demonstrated in Video 1. As the elbow is brought through a range of motion assessment, the radial head is

Explanation

Figure 1 is the MRI of a 45-year-old woman with a medical history significant for rheumatoid arthritis who returns to your office with persistent right elbow pain. Her rheumatologist has maximized her disease-modifying anti-rheumatoid drug regimen. She complains of diffuse joint pain and swelling. On examination, she has a pronounced joint effusion, elbow flexion arc of 45°, and crepitus with forearm rotation. Her elbow radiograph reveals preservation of her joint space. What is the most appropriate surgical treatment at this time?

Question 29

A 72-year-old woman with diabetes mellitus who underwent a total shoulder arthroplasty for degenerative arthritis 5 years ago now reports the sudden onset of shoulder pain following recent hospitalization for pneumonia. Laboratory values show a WBC count of 11,400/mm3 and an erythrocyte sedimentation rate of 52mm/h. What is the most appropriate action? Review Topic

Explanation

The patient has the preliminary diagnosis of an infected shoulder arthroplasty; therefore, shoulder radiographs and joint aspiration for organism identification should be the first steps in the work-up. The patient is at risk for hematogenous spread given the recent history of pneumonia and her history of diabetes mellitus. Although she has stiffness, a stretching program is not indicated with the possibility of infection. Scheduling for revision arthroplasty, or irrigation and debridement will depend on multiple factors including identification of the infecting organism, the organism’s
susceptibility to antibiotics, and implant stability. An MRI scan to evaluate for a rotator cuff tear is not indicated at this time.

Question 30

A patient reports persistent pain in the wrist 6 months after undergoing open reduction and internal fixation of a Galleazi fracture. Radiographs of the wrist in a neutral position are normal. Which of the following studies would best evaluate the reduction of the distal radioulnar joint?

Explanation

If late instability is suspected after the associated fractures have healed, comparison scans in pronation (to detect volar subluxation) neutral (dorsal subluxation and diastasis of the DRUJ) and supination (to confirm the degree of reduction) If early a single axial CT in any position can aid in diagnosis. As described by Mino, a line drawn on both the dorsal and volar radial ulnar borders will place an adequately reduced ulna between them

Question 31

Figures A and B show routine postoperative radiographs obtained 2 weeks after anterior cruciate ligament (ACL) reconstruction with autologous patellar tendon graft. Based on these findings, what is the next most appropriate action? Review Topic

Explanation

The radiographs reveal an intra-articular position of the femoral bone plug; therefore, revision ACL surgery is indicated. Recognized early, this graft may be suitable to use for the revision, but an alternate should be available.

Question 32

What is the most commonly reported complication following elbow arthroscopy?

Explanation

DISCUSSION: The complication rate following elbow arthroscopy is reported at 5%. The most commonly reported complication is transient neurapraxia, with nerve transection remaining an unfortunate and rare event. While infection remains the most common serious complication, it is uncommon (0.8%). Synovial cutaneous fistula and compartment syndrome, while reported, are the least frequent complications of elbow arthroscopy.
REFERENCES: Kelly EW, Morrey BF, O’Driscoll SW: Complications of elbow arthroscopy.

J Bone Joint Surg Am 2001;83:25-34.
Morrey BF: Elbow complication, in Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2001, pp 519-522.

Question 33

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

Explanation

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

Question 34

A 20-year-old football player has immediate pain in the midfoot and is unable to bear weight after an opposing player lands on the back of his plantar flexed foot. AP and lateral radiographs are shown in Figures 4a and 4b. Management should consist of

Explanation

DISCUSSION: The history and radiographs indicate a Lisfranc fracture-dislocation of the foot. The radiographs show the classic “fleck sign,” which is an avulsion of the Lisfranc ligament from the base of the second metatarsal. Most authors recommend open reduction and internal fixation of this injury. Closed reduction can be attempted, but anatomic reduction is unlikely because of the interposed bone fragments and soft tissues. Standard radiographs are not reliable in identifying 1 to 2 mm of subluxation of the tarsometatarsal joint. The tarsometatarsal joint has a poor tolerance to even mild subluxation, and the resulting decrease in joint contact area increases the likelihood of posttraumatic arthritis. Open reduction with the joint visible allows more anatomic reduction and internal fixation of larger osteochondral fragments or excision of smaller interposed fragments.
REFERENCES: Bellabarba C, Sanders R: Dislocations of the foot, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, vol 2, pp 1539-1558.
Murphy GA: Fractures and dislocations of the foot, in Canale ST (ed): Campbell’s Operative Orthopaedics, ed 9. St Louis, MO, Mosby, 1998, vol 2, pp 1956-1960.

Question 35

A 70-year-old man reports symptomatic medial knee pain that has become progressively worse during the past year. MRI reveals a complex, posterior horn medial meniscus tear with associated medial lateral and patellofemoral cartilage defects. Radiographs reveal medial joint space narrowing and osteophytes in the other compartments. What treatment is most likely to provide long-term, durable relief of symptoms?

Explanation

DISCUSSION:
Total knee replacement is a well-established surgery for diffuse, symptomatic osteoarthritis of the knee joint, and its efficacy has been shown in many studies. According to the 2008 AAOS Clinical Practice Guideline, Treatment of Osteoarthritis of the Knee, arthroscopy in the setting of existing osteoarthritis is efficacious for relieving the signs and symptoms of a torn meniscus but not for osteoarthritis. Likewise, in young and active patients, clinical outcomes show improvement after realignment osteotomy for single-compartment osteoarthritis. Unicondylar knee replacement is not indicated for tricompartmental disease of the knee.

Question 36

A cord-like middle glenohumeral ligament and absent anterosuperior labrum complex can be a normal anatomic capsulolabral variant. If this normal variation is repaired during arthroscopy, it will cause Review Topic

Explanation

If the Buford complex is mistakenly reattached to the neck of the glenoid, severe painful restriction of external rotation will occur.

Question 37

At the time of the revision surgery shown in Figure 14, the acetabular component was found to be stable. Polyethylene exchange with a standard ultra-high molecular weight polyethylene liner and grafting was performed. The patient is at significantly increased risk for

Explanation

DISCUSSION: Maloney and associates reported a 35% increased risk of pelvic osteolysis after total hip arthroplasty with a porous-coated acetabular component without cement. All components were stable at the time of revision. Only liners were exchanged and debridement of the granuloma with or without bone graft was performed. No defects progressed and one third of the lesions were no longer visible on radiographs, regardless of bone grafting. Unfortunately, despite the technical ease of many of these types of revisions, the dislocation rate for these cases is significant. Precautions should be taken postoperatively, and patients should be educated about this risk preoperatively.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 411-424.
Boucher HR, Lynch C, Young AM, et al: Dislocation after polyethylene liner exchange in total hip arthroplasty. J Arthroplasty 2003;18:654-657.
Maloney WJ, Herzwurm P, Paprosky W, et al: Treatment of pelvic osteolysis associated with a stable acetabular component inserted without cement as part of a total hip replacement. J Bone Joint Surg Am 1997;79:1628-1634.

Question 38

The presence of S100B tumor marker typically corresponds with which of the following as being the most likely source of the metastasis?

Explanation

DISCUSSION: Advances in development of new tumor markers and techniques of antigen retrieval have enhanced the sensitivity and reliability of identifying the primary source of metastasis. New markers such as CK7, CK20, CA125, and thyroid transcription factor-1

(TTF-1) can help to determine the origin of an adenocarcinoma or aid in the recognition of other tumors. In patients who do not have an obvious primary site of disease or screening radiographs, these new markers can help focus the search for and guide the treatment of the underlying lesion. CA125 is positive in patients with ovarian cancer, CK7 is positive in patients with breast and lung carcinoma, and CK20 is indicative of colon carcinoma if the CK7 marker is negative. Gastrointestinal stromal tumor (GIST) is positive for CD117 (c-kit) and CD34, whereas 75% of bronchogenic carcinomas are positive for TTF-1. Histochemical staining of the S100 protein family has been used for many years in the diagnosis of malignant melanoma. Recent markers HMB-45, MART-1, and Melan-A have proved to be useful in diagnosis of melanoma. S100B protein has been implicated in downregulation of p53 (oncosuppressor gene).
REFERENCES: Harpio R, Einarsson R: S100 proteins as cancer biomarkers with focus on S100B in malignant melanoma. Clin Biochem 2004;37:512-518.
Roodman GD: Mechanisms of bone metastasis. N Engl J Med 2004;350:1655-1664.

Question 39

A 40-year-old man is thrown off his motorcycle and sustains an open Type IIIA fracture shown in Figure A. He is taken to the operating room for debridement and reamed intramedullary nailing with a 10mm diameter nail. He returns at 10 months with persistent pain at the fracture site with ambulation. Examination reveals healed wounds with no erythema, warmth or tenderness. Erythrocyte sedimentation rate and C-reactive protein levels are within normal limits. Radiographs taken at that time are shown in Figure B. What is the next best treatment step?

Explanation

This man had a mid-diaphyseal tibial fracture that has gone into nonunion. Reamed exchange nailing is indicated.
Tibial delayed union can be defined as lack of union from 20-26 weeks post-injury, while nonunion is defined as lack of healing at >9mths post-injury, or absence of progressive signs of healing on radiographs for 3 consecutive months. Persistent pain is a symptom of nonunion. ESR and CRP are performed to rule out infection.
Bhandari et al. performed a blinded, multicenter trial on 622 reamed tibial nails and 604 unreamed tibial nails. In closed fractures, patients in the unreamed nail group were at greater risk of primary events than the reamed nail group. There was no difference in groups for open fractures. Primary events were defined as bone-grafting, implant exchange/removal, dynamization, and debridement.
Hak reviewed aseptic tibial nonunion. They discuss exchanged reamed nailing for diaphyseal nonunion, adjunctive plate fixation for metaphyseal nonunion, and nail removal and plating for metadiaphyseal nonunion, external fixation for infected nonunion and distraction osteogenesis of defects.
Figure A shows a mid-diaphyseal tibial fracture Figure B shows nonunion following
IM nailing of the fracture. Illustration A shows union following exchange nailing with a larger 12mm diameter nail.
Incorrect Answers:

Question 40

The recurrent motor branch of the median nerve innervates which of the following muscles?

Explanation

DISCUSSION: The recurrent motor branch of the median nerve supplies the thenar muscles (abductor pollicis brevis, flexor pollicis brevis, and opponens pollicis) that are primarily responsible for thumb opposition. The nerve can be injured in carpal tunnel release. A branch of the nerve also supplies the first lumbrical. The adductor pollicis and the interossei are supplied by the ulnar nerve.
REFERENCES: Last RJ: Anatomy: Regional and Applied, ed 6. London, England, Churchill Livingstone, 1978, p 109.
Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippincott, 1984, p 170.

Question 41

What is a known risk factor for lateral distal femoral locking plate failure when used for the fixation of comminuted extra-articular fractures?

Explanation

From the following options, a short working length of the construct is a known risk factor for femoral plate failure.
Implant failure is common in distal femur fractures stabilized with plate fixation. Contributors to failure include a short working length of the construct, plate-screw density more than 0.5 and short plate lengths. This will lead to failure as it causes increased strain on the plate over a short segment, and
does not allow enough motion at the fracture site to form bone for healing by secondary intention.
Ricci et al. reviewed 355 cases of distal femur plate fixation. 64 patients (19%) required reoperation to promote union, including 30 that had a planned staged bone grafting. Risk factors for proximal implant failure included open fracture, smoking, increased body mass index, and shorter plate length.
Kregor et al. reviewed 119 patients with distal femoral plate fixation. They found that 93% fractures healed without acute bone grafting. Complications included 5 losses of proximal fixation, 2 nonunions, and 3 acute infections.
Illustration A is an AP of the distal femur demonstrating a comminuted distal femur fracture which has failed fixation with a laterally based distal femur locking plate. It has undergone varus collapse which is a common mechanism of failure for these injuries. Illustration B is a series of AP radiographs of the distal femur of the same patient that was revised to an intramedullary retrograde nail. Illustration C and D show the concepts of plate length, plate-to-screw density and the working length of the plate.
Incorrect Answers:

OrthoCash 2020

Question 42

When compared to smokers who do not quit, an improvement in the rate of lumbar fusion is seen in patients who cease smoking for at least how many months postoperatively? Review Topic

Explanation

The effects of cigarette smoking and smoking cessation on spinal fusion have been studied extensively. Although permanent smoking cessation is ideal, significant improvements in fusion rates are seen in patients who avoid smoking for greater than 6 months postoperatively.

Question 43

In Ewing’s sarcoma, neoplastic properties are thought to be related to a

Explanation

DISCUSSION: In 95% of patients with Ewing’s sarcoma, there is a translocation, t(l 1:22). This results in EWS/FLI-1 transcription factor that results in tumor cell proliferation. Other mechanisms causing
tumor cell proliferation include inactivation of tumor suppressor genes, or activation of proto-oncogenes.
REFERENCES: Arndt CA, Crist WM: Common musculoskeletal tumors of childhood and adolescence. N Engl J Med 1999;341:342-352.
Pierz KA, Womer RB, Dormans JP: Pediatric bone tumors: Osteosarcoma Ewing’s sarcoma, and chondrosarcoma associated with multiple hereditary osteochondromatosis. J Pediatr Orthop 2001
;21:412- 418.

Question 44

Antegrade femoral nailing has an increased rate of which of the following when compared to retrograde femoral nailing?

Explanation

DISCUSSION: In the referenced study by Ricci et al, antegrade femoral nailing was shown to have an increased rate of hip pain as compared to retrograde femoral nailing, while having a similar rate of union, time to union, rate of malalignment, and operative time. Hip pain was signficantly higher in the antegrade nailing group, while knee pain
was significantly greater in the retrograde group. The referenced study by Winquist et al noted a 99.1% union rate with intramedullary nailing. The referenced study by Moed et al noted a 6% nonunion rate in non-reamed retrograde femoral nailing with nail dynamization at 6-12 weeks and early weightbearing.

Question 45

Examination of a 30-year-old professional singer who has persistent neck and shoulder pain reveals a positive Hoffman’s sign and clonus because of anterior C2-3 cord compression. The MRI scan shown in Figure 11a and the cervical CT scan shown in Figure 11b reveal focal anterior cord compression at the C2-3 level. Which of the following surgical approaches would least affect her professional career?

Explanation

DISCUSSION: Protection of the superior laryngeal nerve is critical in a professional singer. The nerve is easily injured with retraction when using vertical extension of common anterior surgical approaches to gain exposure to the C2-3 level. McAfee and associates reported on 17 patients with C1-2 and C2-3 pathology. They used a modified submandibular approach as an anterior retropharyngeal exposure with modification of the superior extension of the Smith-Robinson technique that allows visualization of the superior laryngeal nerve and surrounding structures. No incidences of superior laryngeal nerve injury were recorded. The transoral approach should be avoided because of the high rate of infection and limited exposure.
REFERENCES: McAfee PC, Bohlman HH, Reilly LH Jr, Robinson RA, Southwick WO, Nachlas NE: The anterior retropharyngeal approach to the upper part of the cervical spine. J Bone Joint Surgery Am 1987;69:1371-1383.
Lu J, Ebraheim NA, Nadim Y, Huntoon M: Anterior approach to the cervical spine: Surgical anatomy. Orthopedics 2000;23:841-845.

Question 46

Optimal management of the injury shown in Figure 31 should include which of the following?

Explanation

DISCUSSION: The radiograph shows a displaced calcaneal beak fracture, a tongue-type fracture variant. The fracture fragment typically includes the insertion point of the Achilles tendon, which places marked tension on the thin overlying soft-tissue envelope and can lead to full-thickness necrosis if not acutely addressed. Cast immobilization does not adequately address the increased soft-tissue tension, as the fragment will be difficult to control. Arthroscopic-assisted techniques or primary arthrodesis are not indicated because calcaneal beak fractures are typically extra-articular.
REFERENCES: Sanders RW, Clare MP: Fractures of the calcaneus, in Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA, Mosby-Elsevier, 2007, vol 2, pp 2017-2073.
Sanders RW, Clare MP: Fractures of the calcaneus, in Bucholz RW, Heckman JD, Court-Brown C (eds): Rockwood and Green’s Fractures in Adults, ed 6. Philadelphia, PA, Lippincott Williams & Wilkins, 2006, vol 2, pp 2293-2336.

Question 47

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

Explanation

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

Question 48

Which of the following activities produces greater hip joint contact pressures than full weight bearing during normal gait?

Explanation

Rising from a seated position on a chair on the affected leg has been shown to create the highest contact pressure within the hip, even higher than full weight-bearing during walking.
Limiting activities that create high contact pressures is important in situations such as after internal fixation of an acetabular fracture. Full weight bearing during a normal gait cycle is often considered too much contact pressure and considered a risk for early failure of fixation. During the postoperative period weight bearing and activities are limited to prevent this. It has been shown that the highest contact pressures, even higher than normal walking, are seen when rising from a chair on the affected leg.
Brand et al. analyzed joint reactive forces in patients walking with and without a cane. Compared to age matched controls they estimate that using a cane decreases the contact pressure in the hip to about 60% of normal.
Hodge et al. looked at data from an implanted hip prosthesis with pressure sensors. They found that some activities common to the early rehabilitative period, such as using a bed pan and performing isometric exercises about the hip, can create pressure approaching those of normal walking. The highest pressures recorded were when rising from a chair.
Incorrect answers:

Question 49

A 56-year-old woman sustains a type IIIB open tibial shaft fracture. She undergoes irrigation and debridement and intramedullary nailing with flap coverage 24 hours later. Cultures are taken pre-debridement and post-debridement. She develops a surgical site infection at 6 weeks, which requires removing the hardware and placing show Commented [1]: an external fixator. Deep cultures are most likely to pathogens found in

Explanation

Discussion: One study found only 8% of organisms grown on pre-debridement cultures eventually caused infection; 7% of cases with negative pre-debridement cultures became infected. Of cases that did become infected, pre-debridement cultures grew the infecting organism only 22% of the time. Post-debridement cultures were more accurate in predicting infection. However, of cases that became infected, the infecting organism was present on post-debridement cultures only 42% of the time. It is concluded that pre-debridement and post-debridement bacterial cultures from open fracture wounds are of essentially no value. It is recommended that they not be done.
In another study, before any interventions were performed, initial aerobic and anaerobic cultures of the wounds of 117 consecutive open extremity fractures grades I through III were obtained. The results of these cultures were correlated with the development of a wound infection. If an infection occurred, the organism grown from the infected wound was compared with any organism grown from the primary wound cultures. Of the initial cultures, 76% (89/117) did not demonstrate any growth, while the other 24% (28/117) only grew skin flora. There were only 7 (6%) wound infections, and 71% (5/7) initially did not grow any organisms. Of the isolates that grew from the initial cultures, none were the organisms that eventually led to

Question 50

Figures below depict the radiographs obtained from a 76-year-old woman who comes to the emergency department after experiencing a fall. She is an unassisted community ambulator with a history of right hip pain. What is the most appropriate surgical treatment for this fracture?

Explanation

DISCUSSION:
This patient has pre-existing right hip osteoarthritis. The most correct option for the treatment of this active patient is a right total hip arthroplasty. Hemiarthroplasty would not address the patient's pain from osteoarthritis, and open reduction and internal fixation would not fix the femoral head issue or the
osteoarthritis.

Question 51

A 70-year old woman undergoes revision total knee arthroplasty for tibial component aseptic loosening. She is concerned about recurrent loosening, and tibial stem fixation options during revision are reviewed. Figure below displays a radiograph of the revision technique used for this patient. What is the incidence of intraoperative tibial shaft fracture that is associated with this type of revision surgery?

Explanation

DISCUSSION:
Using press-fit tibial stems during a hybrid revision total knee arthroplasty is associated with a 3% to 5% incidence of intraoperative tibial shaft fracture. Diaphyseal fixation of press-fit stems has the advantage of setting component alignment, dispersing forces on the proximal tibia, and offers excellent clinical results. The disadvantages include proximal and distal tibia anatomic mismatch and tibial shaft fracture. Cipriano and associates reported a tibial shaft fracture incidence of 4.9% in a series of 420 consecutive
knee revisions. All fractures healed with nonsurgical management, and none led to implant loosening. In this patient, it is important to recognize on the radiograph that this technique is a hybrid method of revision total knee arthroplasty, with cementation along the tibial tray and metaphysis and with press-fit fixation of the diaphyseal engaging stem. Then, it is important to know the risk and management of intraoperative diaphyseal tibial fractures. Cemented tibial stems are associated with a low rate of intraoperative fracture, because the implant is typically undersized to allow for an appropriate cement mantle. Option C is incorrect, because this revision is not cemented. Option A underestimates the incidence of fracture, whereas D overestimates the rate of fracture.

Question 52

A 16-year-old girl sustains the closed injury shown in Figure 1. On physical examination, she is found to have a complete radial nerve palsy. Her fracture is treated nonsurgically, and her nerve palsy is followed clinically for improvement. What muscle is most likely to improve last as her nerve recovers?

Explanation

A 35-year-old man reports ulnar sided wrist pain. Radiographs show ulnar positive variance with cystic changes in the ulnar head and lunate. His body mass index (BMI) is 22, and he has had a 1.5-pack-per-day smoking history for the past 10 years. He undergoes an oblique ulnar shortening osteotomy with volar placement of the plate. Nine months after surgery, he reports continued pain, and radiographs reveal a nonunion. Of the factors cited for this patient, which has been shown to most likely increase the risk of nonunion?

Question 53

A 39-year-old man has had persistent right shoulder pain for the past 6 months. A formal physical therapy program has failed to provide relief, and an injection several months ago provided only short-term relief. Examination reveals a positive Neer and Hawkins test. There is no instability and the neurovascular examination is normal. Arthroscopy reveals a partial rotator cuff tear on the bursal side measuring 60% of the tendon thickness. What is the next most appropriate step in management?

Explanation

DISCUSSION: Although arthroscopic debridement with or without subacromial decompression is a reasonable response, the patient has positive impingement signs. Several recent studies regarding the surgical treatment of partial rotator cuff tears have demonstrated good to excellent results after repair of tears involving more than 50% of the tendon thickness. This was shown specifically for bursal-sided tears and joint-side tears. Biceps tenotomy is not indicated in a young patient.
REFERENCES: Matava MJ, Purcell DB, Rudzki JR: Partial-thickness rotator cuff tears.

Am J Sports Med 2005;33:1405-1417.
Fukuda H: The management of partial-thickness tears of the rotator cuff. J Bone Joint Surg Br 2003;85:3-11.

Question 54

A 25-year-old male is involved in an high-speed motor vehicle collision and sustains a closed femoral shaft fracture. During further evaluation, a CT scan of the chest/abdomen/pelvis reveals a non-displaced ipsilateral femoral neck fracture. Which of the following treatment options will most likely achieve anatomic healing of both fractures, mobilize the patient, and minimize the risk of complications?

Explanation

DISCUSSION: An ipsilateral femoral neck fracture occurs in approximately 6% to 9% of all femoral shaft fractures. A comminuted midshaft femoral fracture secondary to axial loading should alert the treating physician to the possibility of an associated femoral neck fracture. As a result, trauma CT scans should be reviewed for non to minimally displaced femoral neck fractures during the initial work up. Watson et al did a retrospective review of 13 patients who had healing complications develop after their index surgical procedure for ipsilateral femoral shaft and neck fractures. Six of the eight (75%) femoral neck nonunions occurred after the use of a second generation, reconstruction-type intramedullary nail. Factors contributing to nonunion of the femoral shaft were the presence of an open fracture, use of an unreamed, small diameter intramedullary nail, and prolonged delay to weightbearing. Lag screw fixation of the femoral neck fracture and reamed intramedullary nailing for shaft fracture stabilization were associated with the fewest complications. Peljovich et al discuss that several treatment options are described in the literature, but no clear consensus exists regarding the optimal treatment of neck/shaft fractures. Due to the the potentially devastating complications of the femoral neck fracture in young patients (avascular necrosis, nonunion, and malunion), the neck fracture should be treated first followed by the shaft. Current recommendations involve treating the neck with a sliding hip screw versus cannulated screws followed by intramedullary nailing of the femoral shaft.

Question 55

When compared with patients having a body mass index (BMI) lower than 35, patients with a BMI above 40 who undergo primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) are likely to have

Explanation

DISCUSSION:
The obesity epidemic is increasing, and the number of patients with a BMI higher than 35 undergoing THA and TKA also is growing. Controversy exists over the optimal BMI cutoff and the ability to perform joint replacements safely in patients who are morbidly obese. Several clinical series and national database analyses have shown that morbidly obese patients undergoing THA or TKA are at increased risk for wound complications as well as 30-day and 90-day readmissions. These patients’ incisions are typically larger because of the size of the soft-tissue envelope. Although the clinical scores following successful THA or TKA often are lower than the scores of controls, the overall changes in clinical function and satisfaction are equivalent in nonobese and obese patients.

Question 56

Nonsurgical management of pectoralis major tears is likely to result in weakness of glenohumeral

Explanation

DISCUSSION: Nonsurgical management is considered for proximal tears as well as partial tears in some individuals. Surgical management is often not appropriate in older or sedentary patients. However, patients treated nonsurgically will have a significant cosmetic defect, as well as weakness in adduction and internal rotation.
REFERENCES: Schepsis AA, Grafe MW, Jones HP, et al: Rupture of the pectoralis major muscle: Outcome or repair of acute and chronic injuries: Am J Sports Med 2000;28:9-15.
Petilon J, Carr DR, Sekiya JK, et al: Pectoralis major muscle injuries: Evaluation and management. J Am Acad Orthop Surg 2005;13:59-68.

Question 57

-The center of rotation of the knee can be best described as

Explanation

Question 58

Which of the following definitions best describes Batson’s vertebral vein system?

Explanation

DISCUSSION: The venous plexus was described by Batson and helps to explain the common distribution of metastatic cells to the vertebrae, skull, ribs, and proximal long bones. Batson studied the vertebral vein system extensively by using contrast agents in human cadavers and live monkeys. Batson’s plexus is a valveless system that allows retrograde embolism from the major organs such as the breast, prostate, lung, kidney, and thyroid. It is located within the thoracoabdominal cavity and has connections to the proximal long bones and an intercommunicating network of thin-walled veins with a low intraluminal pressure.
REFERENCES: Batson OV: Function of vertebral veins and their role in spread of metastases. Ann Surg 1940;112:138-149.
Coman DR, de Long RP: Role of vertebral venous system in metastasis of cancer to spinal column: Experiments with tumor-cell suspensions in rats and rabbits. Cancer 1951;4:610-618.

Question 59

What is the most common cause of rotator cuff injury in high school athletes?

Explanation

DISCUSSION: A large number of etiologies of rotator cuff injury have been proposed. Both intrinsic and extrinsic mechanisms have been suggested. In the young athlete the common underlying mechanism is overuse. Contributing factors include increased laxity, anatomic variation in the coracoacromial arch, and altered kinematics.
REFERENCES: Wilkins KE: Shoulder injuries: Epidemiology, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine. Philadelphia, PA, WB Saunders, 1994, pp 175-182.
Sher JS: Anatomy, biomechanics, and pathophysiology of rotator cuff disease, in Iannnotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA, Lippincott Williams and Wilkins, 1999, pp 3-30.

Question 60

In patients with Crowe types III and IV developmental dysplasia of the hip with high hip centers, acetabular reconstruction often requires lowering the acetabular component into the native acetabulum. In doing so, considerable risk for limb lengthening beyond 4 cm exists, making the hip difficult to reduce and raising the risk for nerve injury. Which technique is used to overcome this problem?

Explanation

DISCUSSION:
When substantial lengthening of a dysplastic hip will occur because a high dislocation is relocated into a considerably lower acetabulum, a femoral shortening may be necessary to reduce the hip and avoid a stretch injury to the sciatic nerve. No other choice specifically addresses the need for femoral shortening, and high offset stems and lateralized liners may exacerbate the problem if used alone and without femoral shortening.

Question 61

Which of the following clinical scenarios represents the strongest indication for locked plating technique in a 70-year-old woman?

Explanation

Locking screw fixation is a relatively new option in the armamentarium of orthopaedic surgeons treating fractures. The understanding of the biomechanics, implications to healing, and optimal indications and surgical techniques is still in evolution. A periprosthetic proximal femur fracture with a stable prosthesis is best treated with open reduction and internal fixation with locking proximal fixation with or without cerclage cables. Diaphyseal fractures treated with compression plating or bridge plating can be treated well with conventional implants unless osteoporosis is severe. An AO/OTA B-type partial articular fracture is also better suited to standard buttress plating with periarticular rafting lag screws. Locking fixation is not always required for a transverse displaced midshaft clavicle fracture.

Question 62

A collegiate golfer sustains a hook of the hamate fracture. After 12 weeks of splinting and therapy, the hand is still symptomatic. What is the most appropriate management to allow return to competitive activity?

Explanation

DISCUSSION: Excision of the fracture fragment typically leads to rapid return to function. Fixation techniques are difficult to perform because of the size of the bone; hardware prominence is common. Nerve deficits are not typically noted in this injury. The motor branch of the ulnar nerve in Guyon’s canal must be protected during the surgical approach.
REFERENCES: Kulund DN, McCue FC III, Rockwell DA, et al: Tennis injuries: Prevention and treatment: A review. Am J Sports Med 1979;7:249-253.
Morgan WJ, Slowman LS: Acute hand and wrist injuries in athletes: Evaluation and management. J Am Acad Orthop Surg 2001;9:389-400.

Question 63

Treatment of a cruciate-retaining total knee that is unstable in flexion is best accomplished by

Explanation

DISCUSSION: Pagnano and associates revised 25 painful primary posterior cruciate-retaining total knee arthroplasties for flexion instability. The patients shared typical clinical presentations that included a sense of instability without frank giving way, recurrent knee joint effusion, soft-tissue tenderness involving the pes anserine tendons and the retinacular tissue, posterior instability of 2+ or 3+ with a posterior drawer or a posterior sag sign at 90° of flexion, and above-average motion of the total knee arthroplasty. Twenty-two of the knee replacements were revised to posterior stabilized implants, and three underwent tibial polyethylene liner exchange only. Nineteen of the 22 knee replacements revised to a posterior stabilized implant showed marked improvement after the revision surgery. Only one of the three knee replacements that underwent tibial polyethylene exchange was improved. Flexion instability can be a cause of persistent pain and functional impairment after posterior cruciate-retaining total knee arthroplasty. Revision surgery that focuses on balancing the flexion and extension spaces, in conjunction with a posterior stabilized knee implant, seems to be a reliable treatment for symptomatic flexion instability after posterior cruciate-retaining total knee arthroplasty.
REFERENCE: Pagnano MW, Hanssen AD, Lewallen DG, Stuart MJ: Flexion instability after primary posterior cruciate-retaining total knee arthroplasty. Clin Orthop 1998;356:39-46.

Question 64

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

Explanation

DISCUSSION: The MRI scan shows bone bruises in the medial aspect of the patella and the lateral aspect of the lateral femoral condyle. Both of these signs are typical for a lateral dislocation of the patella with spontaneous reduction. In addition, there may be associated tearing of the medial retinaculum or distal aspect of the vastus medialis.
REFERENCES: Elias DA, White LM, Fithian DC: Acute lateral patellar dislocation at MR imaging: Injury patterns of medial patellar soft-tissue restraints and osteochondral injuries of the inferomedial patella. Radiology 2002;225:736-743.
Sanders TG, Miller MD: A systematic approach to magnetic resonance imaging interpretation of sports medicine injuries of the knee. Am J Sports Med 2005;33:131-148.
Miller TT: Magnetic resonance imaging of the knee, in Insall JN, Scott WN (eds): Surgery of the Knee, ed 4. Philadelphia, PA, Churchill Livingstone, 2006, vol 1, pp 201-224.

Question 65

A 61-year-old right-hand-dominant woman falls down the stairs, resulting in a left anteroinferior dislocation and noncomminuted greater tuberosity fracture. A closed glenohumeral reduction with intravenous sedation is performed in the emergency department. After reduction, the greater tuberosity fragment remains displaced by 2 mm. What is the most appropriate treatment?

Explanation

Greater tuberosity fractures and rotator cuff tears associated with a traumatic dislocation are more commonly seen in women >60 years. Greater tuberosity fractures that are displaced <5 mm in the general population and
<3 mm in laborers and professional athletes can be treated successfully without surgery. Early passive range
of motion is important to avoid stiffness.

Question 66

Which lower extremity muscle is first weakened in Charcot-Marie-Tooth (CMT) disease?

Explanation

DISCUSSION
Although many of the lower extremity muscles may be affected in CMT, those innervated by the longest axons have been shown to be affected first. In the lower extremity the muscles innervated by the longest axons are the intrinsic foot muscles. The tibialis anterior and the peroneus brevis may be severely affected but not before the foot intrinsics. The peroneus longus typically is spared, resulting in the cavus.
RECOMMENDED READINGS
Pareyson D, Marchesi C. Diagnosis, natural history, and management of Charcot-Marie-Tooth disease. Lancet Neurol. 2009 Jul;8(7):654-67. Review. PubMed PMID: 19539237. View Abstract at PubMed
Wenz W, Dreher T. Charcot-Marie-Tooth disease and the cavovarus foot. In: Pinzur MS, ed. Orthopaedic Knowledge Update: Foot and Ankle 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:291-306.
CLINICAL SITUATION FOR QUESTIONS 60 THROUGH 63
Figure 60 is the standing radiograph of a 27-year-old man who played football throughout his teen years. During those years, he noted that he had less mobility of his left foot and ankle. He twisted his left foot and ankle 8 months ago and has tried over-the-counter nonsteroidal anti-inflammatory drugs and a brace. He now has pain and edema in the left sinus tarsi area. Upon examination the following arcs of motion are identified: ankle dorsiflexion-right, 5 degrees/left, 5 degrees; ankle plantar flexion-right, 30 degrees/left 30 degrees; foot inversion-right, 10 degrees/left, 5 degrees; foot eversion-right, 10 degrees/left 5 degrees.

Question 67

An osteoprogenitor cell is expected to commit to a bone lineage in the presence of what transcription factor?

Explanation

Mesenchymal stem cells are pluripotent cells that can differentiate into many lineages including osteoblasts, adipocytes, myoblasts, chondroblasts, and fibroblasts. Runx2 and Osx appear to be required for differentiation to osteoblastic lines. PPARy2 and
C/EBPa are transcription factors leading to adipocytes, MyoD promotes myoblasts, and Sox 9 corresponds to chondroblasts.

Question 68

Figure 13 is the photograph of 18-month-old triplets with a lower-limb condition. What is the best initial treatment? Review Topic

Explanation

Brodie's Abscess
Osteomyelitis of the humeral metaphysis
Subperiosteal abscess of the humerus
Presence of subcutaneous air
High risk of proximal humeral growth arrest
This patient has osteomyelitis of the humerus with a large subperiosteal abscess. The presence of subperiosteal abscess necessitates surgical intervention for irrigation and debridement (I&D).
The diagnosis of acute osteomyelitis in children is made based upon a constellation of findings including pain, systemic signs of infection, elevated serum inflammatory markers, and imaging studies demonstrative of osseous infection. It is most commonly hematogenously spread to the metaphysis of immature bone, which is highly vascular prior to skeletal maturity. Treatment involves obtaining specimen for culture, empiric antibiotic treatment, and surgical irrigation and debridement of known abscesses. The end-point of treatment is return of pain-free functionality and the resolution of local/systemic signs of infection.
Conrad reviewed the management of acute hematogenous osteomyelitis and emphasized that surgical intervention in the presence of abscess can be both therapeutic and diagnostic: I&D can obtain culture and narrow the antibiotic plan.
Jones et. al. reviewed chronic pediatric osteomyelitis and report that surgery is the mainstay of treatment because removal of dead bone is essential for resolution of infection. This may be performed with sequestrectomy and curettage, with an emphasis on prevention of pathologic fracture, growth disturbances, bone loss, joint involvement, and permanent loss of function.
Figure A is a coronal STIR MRI image of the humerus demonstrating osteomyelitis
with extensive subperiosteal abscess.
Incorrect Answers:
Brodie's abscess is a type of subacute osteomyelitis which remains indolent and creates a focal intra-osseous abscess. This is not demonstrated in the clinical image.
The patient does have osteomyelitis of the humeral metaphysis, but this alone is not the indication for surgery. Uncomplicated osteomyelitis may be treated effectively with antibiotics alone.
Presence of subcutaneous air is suggestive of necrotizing fasciitis, which is a surgical emergency. The MRI however does not demonstrate this finding.
The infection and its surgical management both increase risk of injury to the proximal humeral physis and has the potential for growth arrest or angular deformity.
(SBQ13PE.3) Figure A demonstrates a physical examination maneuver in a 1 month old infant. What is this maneuver? Review Topic

Ortolani Test
Barlow Test
Galeazzi Sign
Patrick test
Teratologic Sign
Figure A shows a schematic image of the Ortalani test.
The Ortolani test, or Ortolani maneuver, is part of the physical examination for developmental dysplasia of the hip. It is used alongside the Barlow test to detect subluxated hips that are either reducible or irreducible. A positive sign is a distinctive 'clunk' which can be heard and felt as the femoral head relocates anteriorly into the acetabulum.
Guille et al. showed that the use of Pavlik harness has become the mainstay of initial treatment for the infant who has not yet begun to stand. If concentric reduction of the hip cannot be obtained, surgical reduction of the dislocated hip is the next step before they are able to stand.
Video V is a lecture discussing the hip examination of the infant. Incorrect Answers:
pressure on the knee, directing the force the femoral head posteriorly. A positive Barlow test would result in posterior subluxation/dislocation of the hip. Answer 3: Galeazzi test is performed by flexing an infant's knees in the supine position so that the ankles touch the buttocks. If the knees are not level then the test is positive, which indicates a potential congenital hip issue (e.g. DDH). Answer 4: Patrick or Faber test (flexion, abduction, external rotation) has been described both for stressing the SI joint and for isolating symptoms to the hip Answer 5: Teratologic dislocation of the hip is a term used to imply that the hip joint did not develop normally in utero, thus the hip is in a fixed dislocated position at birth.

Question 69

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

Explanation

Multiple studies have confirmed that cam or pincer anatomy is commonly present in asymptomatic hips. According to a large systematic review, cam deformities are present in approximately one-third of asymptomatic hips in young adults, and the proportion is higher than 50% in the subgroup of athletes. Ganz and associates proposed that femoral acetabular impingement is the root cause of osteoarthritis in most nontraumatic, nondysplastic hips, and functional improvement with surgical correction of the deformity has been demonstrated. Despite the link between cam deformity and hip osteoarthritis, a corresponding link between the correction of the deformity and prevention of osteoarthritis has never been proven. The results of cam deformity correction, typically including repair of the degenerative labral tear, are much poorer when substantial joint space loss is present. A typical joint space cutoff of 2 mm or less is used to recommend against hip preservation surgery.

Question 70

Figure 48 shows an MRI scan of the knee. The arrow is pointing to what structure?

Explanation

DISCUSSION: The arrow points to the biceps femoris, which is inserted onto the fibula. The biceps femoris lies at the posterolateral aspect of the thigh. The semimembranosus and the semitendinous lie at the posterior medial aspect of the thigh.
REFERENCES: Gray H: Anatomy of the Human Body. Philadelphia, PA, Lea and Febiger, 1918, 2000.
Netter FH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy, 1989, pp 464-465.

Question 71

A 23-year-old man sustained an injury to his left foot when a forklift rolled over it at work. Examination reveals marked swelling of the midfoot and forefoot, with tenderness to palpation over the medial hindfoot and dorsomedial forefoot. The distal dorsalis pedis pulse is audible on Doppler examination, and his sensation is intact to touch. Radiographs are shown in Figures 33a and 33b. Management should consist of

Explanation

DISCUSSION: The best results after dislocations of the tarsometatarsal joints are seen with anatomic reduction; this is best achieved by open reduction and maintained with internal fixation with either pins or screws. Open reduction provides a means of debriding small bony fragments from the joint and allowing direct inspection of the reduction. Associated crush or shearing fractures of the cuboid or tarsal navicula are signs that suggest a Lisfranc injury. Because patients can function quite well despite the development of arthrosis in the Lisfranc joint, primary arthrodesis is not indicated in the management of this injury.
REFERENCES: Resch S, Stenstrom A: The treatment of tarsometatarsal injuries. Foot Ankle 1990;11:117-123.
Schenck RC Jr, Heckman JD: Fractures and dislocations of the forefoot: Operative and nonoperative treatment. J Am Acad Orthop Surg 1995;3:70-78.
Kuo RS, Tejwani NC, Digiovanni CW, et al: Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am 2000;82:1609-1618.

Question 72

A 55-year-old man underwent cementless total hip arthroplasty for advanced painful osteoarthritis of the hip 2 years ago. The follow-up radiograph shown in Figure 30 shows

Explanation

DISCUSSION: The radiograph shows a well-osseointegrated tapered stem with a metaphyseal porous coating, spot welds in the porous region, and calcar rounding. Trochanteric stress shielding and distal cortical hypertrophy are also signs of ingrown stems but are seen more frequently in association with extensively porous-coated stems exhibiting diaphyseal ingrowth. There is no evidence of lucent lines or a pedestal, signs that suggest instability. Femoral stem subsidence can be determined only by a review of sequential radiographs.
REFERENCES: Engh CA, Massin P, Suthers KE: Roentgenographic assessment of the biologic fixation of porous-surfaced femoral components. Clin Orthop 1990;257:107-128.
Vresilovic E, Hozack WJ, Rothman RH: Radiographic assessment of cementless femoral components: Correlation with intraoperative mechanical stability. J Arthroplasty 1994;9:137-141.

Question 73

A 45-year-old woman has had intense pain in her foot for the last 3 days. She also reports a mild fever and difficulty with shoe wear. Examination reveals a swollen, slightly erythematous warm foot with tenderness at the great toe metatarsophalangeal joint and pain with passive motion of the joint. An AP radiograph is shown in Figure 13. Which of the following will best aid in determining a definitive diagnosis?

Explanation

DISCUSSION: The patient has gouty arthropathy of the first metatarsophalangeal joint. This definitive diagnosis is achieved with aspiration of the joint and polarized light microscopy that shows needle-shaped negatively birefringent monosodium urate crystals. Differential diagnoses of infectious arthritis and pseudogout are also definitively made through joint aspiration. Although rheumatoid arthritis is a possibility, a serum rheumatoid factor is not always diagnostic and a patient with rheumatoid arthritis may have concomitant gouty arthritis. The radiographic findings are not typical of diabetes mellitus or of a patient with Charcot arthropathy.
REFERENCES: Wise CM, Agudelo CA: Diagnosis and management of complicated gout. Bull Rheum Dis 1998;47:2-5.
Harris MD, Siegel LB, Alloway JA: Gout and hyperuricemia. Am Fam Physician 1999;59:925-934.

Question 74

Tension band wire fixation is best indicated for which of the following types of olecranon fractures?

Explanation

Tension band wiring may not provide adequate stability to prevent displacement in a comminuted fracture. Plate fixation is most commonly recommended for comminuted fractures of the olecranon. Additionally, plate fixation is used for oblique fractures distal to the midpoint of the trochlear notch, fractures that involve the coronoid process, and those associated with Monteggia fracture-dislocations. Tension band wiring is best indicated for simple transverse fractures through the midpoint of the trochlear notch.

Question 75

A 23-year-old woman falls from a bicycle and sustains a right knee injury. Figures 12a through 12d show radiographs and MRI scans of the knee. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiographs and MRI scans both show an avulsion of the anterior cruciate ligament, which has been described by Meyers and McKeever in three different fracture patterns. Type I fractures are nondisplaced or have minimal displacement of the anterior margin. Type II fractures have superior displacement of their anterior aspect with an intact posterior hinge. Type III fractures are completely displaced. Although the injury is visible on the radiographs, it is more subtle in adults than children. Thus, MRI is helpful in clarifying this injury in adults. Open or arthroscopic reduction and internal fixation is recommended for type II and type III fractures that do not respond to closed reduction.
REFERENCES: Meyers MH, McKeever FM: Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1970;52:1677-1684.
Wiss DA, Watson JT: Fractures of the tibial plateau, in Rockwood CA, Green DP, Bucholz RW, et al (eds): Rockwood and Green’s Fractures in Adults. Philadelphia, PA, Lippincott-Raven, 1996, pp 1920-1953.
Lubowitz JH, Elson WS, Guttmann D: Arthroscopic treatment of tibial plateau fractures: Intercondylar eminence avulsion fractures. Arthroscopy 2005;21:86-92.

Question 76

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 77

A 16-year-old boy sustains a twisting injury to the left knee while wrestling. MRI scans are shown in Figures 22a through 22c. What is the most likely diagnosis?

Explanation

DISCUSSION: The MRI scans show a displaced bucket-handle medial meniscus tear that can be visualized on coronal, sagittal, and axial views. The sagittal view shows the typical “double posterior cruciate ligament sign,” in which the low-signal bucket-handle fragment parallels the normal low-signal posterior cruciate ligament. The coronal and axial images both show the displaced medial meniscus in the notch.
REFERENCES: Sanders TG, Miller MD: A systematic approach to magnetic resonance imaging interpretation of sports medicine injuries of the knee. Am J Sports Med 2005;33:131-148.
Miller TT: Magnetic resonance imaging of the knee, in Insall JN, Scott WN (eds): Surgery of the Knee, ed 4. Philadelphia, PA, Churchill Livingstone, 2006, vol 1, pp 201-224.

Question 78

A 78-year-old woman underwent total hip arthroplasty 15 years ago. She reports a recent history of increasing thigh pain prior to a fall and is now unable to ambulate. Radiographs are shown in Figures 87a and 87b. What is the best treatment for this condition?

Explanation

DISCUSSION: Severe periprosthetic fractures after total hip arthroplasty with a loose implant and progressive bone loss are difficult problems for orthopaedic surgeons, with a high complication rate. Recent literature favors the use of long fluted tapered stems that have a long distal taper that may optimally engage the remaining femoral shaft isthmus. Plating options are problematic because the ability to use screws with the plate is limited by the intramedullary stem. Although not the only solution to this problem (such as allograft-prosthetic composites, impaction grafting, tumor prostheses), long distally fixed stems circumvent this problem by enhancing fracture healing and create a long-term prosthetic solution in these most difficult cases.
REFERENCES: Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 475503.
Kwong LM, Miller AJ, Lubinus P: A modular distal fixation option for proximal bone loss in revision total hip
arthroplasty: A 2- to 6-year follow-up study. J Arthroplasty 2003;18:94-97.

Question 79

Passive glycation of articular cartilage results in

Explanation

DISCUSSION: Passive glycation of articular cartilage occurs over decades. One of the consequences of this glycation appears to be the stiffening of collagen. This phenomenon appears to be associated with an increased collagen degradation and development of osteoarthrosis. Passive glycation also results in a relatively yellow appearance. Passive glycation does not directly influence chondrocyte proliferation.
REFERENCES: DeGroot J, Verzijl N, Wenting-van Wijk MJ, et al: Accumulation of advanced glycation end products as a molecular mechanism for aging as a risk factor in osteoarthritis. Arthritis Rheum 2004;50:1207-1215.
Chen AC, Temple MM, Ng DM, et al: Induction of advanced glycation end products and alterations of the tensile properties of articular cartilage. Arthritis Rheum 2002;46:3212-3217.

Question 80

The management of a complex multifragmentary diaphyseal fracture of either the tibia or femur has changed during the last decade. Which of the following principles of treatment is now considered less important?

Explanation

DISCUSSION: Although the original concept of internal fixation was one of anatomic reduction and stable fixation, over the past 10 to 15 years there has been a change based on the advent of intramedullary nailing and bridge plating. It is now appreciated that in a multifragmentary diaphyseal fracture, particularly of the lower extremity, the achievement of axis alignment (mechanical and anatomic axis) is all that is required. Healing will occur by callus. Relatively stable fixation is achieved through intramedullary nailing or bridge plating, providing adequate pain relief for functional aftercare.
REFERENCES: Perren SM, Claes L: Biology and mechanics of fracture management, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000,

pp 7-32.
deBoer P: Diaphyseal fractures: Principles, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 93-104.
Mast J, Jakob R, Ganz R: Planning and Reduction Techniques in Fracture Surgery. Berlin, Springer-Verlag, 1989.

Question 81

Which of the following methods accurately describes the measurement of tip-apex-distance as it relates to placement of a lag screw in the femoral head?

Explanation

DISCUSSION: TIp-apex distance (TAD) as it relates to a lag screw in the femoral head is the summation of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs. This is shown in Illustration A.
TAD is a useful intraoperative indicator of deep and central placement of the lag screw in the femoral head, regardless of whether a nail or a plate is chosen to fix a fracture. A TAD of <25mm has been shown to minimize the risk of fixation cut-out in stable and unstable intertrochanteric hip fractures.
Baumgaertner et al examined factors leading to the failure of sliding hip screws (SHS) in the treatment of 198 intertrochanteric fractures. They determined that the tip-apex distance (TAD) is a reproducible, standard measurement to predict SHS failure. The average TAD for successful fractures was 24mm while the average TAD for failures was 38mm. No screw with a TAD <25mm failed. Calculation of the TAD is shown in Illustration B.
Kyle et al reviewed 622 intertrochanteric fractures. For unstable patterns, a SHS was superior to a fixed angle nail. Early ambulation and weight bearing contributed to improved results

Question 82

A 37-year-old electrician is diagnosed with a frozen shoulder after sustaining an electrical injury at work 2 weeks ago. Examination reveals that he cannot actively or passively externally rotate or abduct the arm. The glenohumeral joint and scapula move in a 1:1 ratio. Radiographs are shown in Figures 15a and 15b. The best course of action should be

Explanation

DISCUSSION: The patient’s history, examination, and radiographs are classic for locked posterior dislocation of the glenohumeral joint. Posterior dislocation of the shoulder remains the most commonly missed dislocation of a major joint. Up to 80% are missed on initial presentation. The primary cause for failure to accurately diagnose this injury is inadequate radiographic evaluation. The typical presentation is a shoulder locked in internal rotation with loss of abduction. An axillary view not only will make the definitive diagnosis but will help assess the size of the articular surface defect and help plan treatment. This view can be done expediently as part of every trauma series. The AP view is suspicious for a posteriorly dislocated humerus with loss of the humeral neck profile, a vacant glenoid sign, and an anterior humeral head compression fracture (reverse Hill-Sachs lesion).
REFERENCES: Hawkins RJ, Neer CS II, Pianta RM, Mendoza FX: Locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1987;69:9-18.
Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosement, IL, American Academy of Orthopaedic Surgeons, 1997, pp 181-189.
Rockwood CA Jr, Thomas SC, Matsen FA III: Subluxations and dislocations about the glenohumeral joint, in Rockwood CA Jr, Green DP, Bucholz RW (eds): Fractures in Adults, ed 3. Philadelphia, PA, JB Lippincott, 1991, vol 1, pp 1058-1065.

Question 83

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

Explanation

DISCUSSION
This injury is a type III supracondylar humerus fracture with posterolateral displacement. The area of ecchymosis is anteromedial, corresponding to the proximal spike of the humeral metaphysis. The brachial artery is likely tented over this spike, leading to diminished perfusion. The median nerve also resides in this area, and any neurological deficit is likely in its most vulnerable fibers, those of the anterior interosseous nerve (AIN). The AIN contains no sensory fibers, and its motor function involves flexion of both the thumb IP joint and the index distal IP joint.
First dorsal web space anesthesia and an inability to extend the fingers would indicate radial nerve neuropraxia, which would be more likely with posteromedially displaced fractures and lead to anterolateral ecchymosis. Finger abduction is controlled by the ulnar nerve, which most often is injured in flexion injuries and iatrogenically by medially placed pins.

Question 84

A 69-year-old man reports pain over his bunion while wearing shoes and pain in the joint with push-off when barefoot. Nonsurgical management has failed to provide relief. Radiographs are shown in Figures 8a and 8b. What is the surgical procedure of choice?

Explanation

DISCUSSION: Arthrodesis is indicated for severe bunion and hallux valgus deformities, but particularly with extensive degenerative disease of the first metatarsophalangeal joint. The other bunionectomy procedures have different indications, none of which include symptomatic first metatarsophalangeal degenerative disease.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 3-15.
Tourne Y, Saragaglia D, Zattara A, et al: Hallux valgus in the elderly: Metatarsophalangeal arthrodesis of the first ray. Foot Ankle Int 1997;18:195-198.

Question 85

Which of the following surgical devices employed for stabilization of the sternoclavicular joint is associated with the highest incidence of life-threatening complications?

Explanation

DISCUSSION: Numerous reports have documented serious complications including death from migration of intact or broken Kirschner wires or Steinmann pins into hilar structures such as the heart, pulmonary artery, and the aorta.
REFERENCES: Gilot GJ, Wirth MA, Rockwood CA: Injuries to the sternoclavicular joint, in Bucholz RW, Heckman JD, Court-Brown C (eds): Fractures in Adults. Philadelphia, PA, Lippincott, Williams and Wilkins, 2006, vol 2, pp 1373-1374.
Lyons FA, Rockwood CA Jr: Migration of pins used in operations of the shoulder. J Bone Joint Surg Am 1990;72:1262-1267.

Question 86

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

Explanation

DISCUSSION: The radiographs show early ectopic bone formation originating between the ulna and the radius. The development of ectopic bone in this area following a two-incision approach for anatomic repair of the distal biceps tendon is thought to be related to exposure of the periosteum of the lateral ulna during surgery. This can be avoided by the use of a muscle-splitting incision between the extensor carpi ulnaris and common extensor muscles. Full pronation of the forearm allows for the necessary exposure of the radial tuberosity during the procedure and for fixation of the tendon at its maximal length.
REFERENCES: Morrey BF: Tendon injuries about the elbow, in Morrey BF (ed): The Elbow and Its Disorders, ed. 2. Philadelphia, PA, WB Saunders, 1993, pp 492-503.
Failla JM, Amadio PC, Morrey BF, Beckenbaugh RD: Proximal radioulnar synostosis after repair of distal biceps brachii rupture by the two-incision technique: Report of four cases. Clin Orthop 1990;253:133-136.

Question 87

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

Explanation

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

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

Question 88

A 60-year-old woman has activity-related hip pain after undergoing arthroplasty 5 years ago. She has severe Parkinsonism and denies fevers or chills. Radiographs are shown in Figures 45a and 45b. What is the most likely cause of her pain?

Explanation

DISCUSSION: The radiographs reveal both cement debonding at the lateral shoulder of the prosthesis and a cement mantle fracture. Both of these indicate a loose femoral component. The radiographs show a stress fracture with reactive bone on the lateral femoral cortex in conjunction with the cement mantle fracture. The acetabular component shows no evidence of loosening. Heterotopic bone usually is not a source of pain when it is Brooker grade I, as in this case. Parkinsonism generally is not associated with hip pain.
REFERENCES: Harris WH, McCarthy JC, O’Neill DA: Femoral component loosening using contemporary techniques of femoral cement fixation. J Bone Joint Surg Am 1982;64:1063-1067.
Callaghan JJ, Rosenberg AG, Rubash H (eds): The Adult Hip. Philadelphia, PA, Lippincott-Raven, 1998, pp 960, 1228-1229.
Maloney WJ, Schmalzreid T, Harris WH: Analysis of long-term cemented total hip arthroplasty retrievals. Clin Orthop Relat Res 2002;405:70-78.

Question 89

A 26-year-old professional rodeo bull rider sustained a grade III midshaft femoral fracture after being thrown from his bull. He underwent closed interlocking intermedullary nailing with a titanium rod, and his recovery was uneventful. Prior to returning to competition, the patient must

Explanation

DISCUSSION: While it is recommended that a patient gain full range of motion, pain-free function, and symmetric strength prior to returning to vigorous activities, it is absolutely essential that radiographs of the fracture site reveal a circumferential external bridging callus to prevent refracture. This is particularly important for comminuted femoral fractures with various sized fragments. It is also recommended that a return to rodeo riding be postponed for at

least 1 year.
REFERENCES: Brumback RJ, Ellison TS: Intermedullary nailing of femoral stress fractures. J Bone Joint Surg Am 1992;74:106-112.
Bucholz RW, Jones A: Fractures of the shaft of the femur. J Bone Joint Surg Am

1991;73:1561-1566.
Butler MS, Brumback RJ: Interlocking nailing for ipsilateral fractures of the femur, femoral shaft, and distal part of the femur. J Bone Joint Surg Am 1991;73:1492-1502.

Question 90

A well-healed bulk proximal tibia osteoarticular allograft is removed 10 years after implantation due to arthropathy. Histologic examination of the host allograft junction site will most likely reveal

Explanation

Retrieval studies of well-fixed bulk allografts reveal that the junction site heals with bridging external callus and there is persistence of callus perpendicular to the junction site. External callus is annealed to the surface of the allograft. There is very little penetration of the allograft and the bone graft is not remodeled. Direct osteonal penetration of the allograft with haversian remodeling defines primary bone healing seen in fractures, which does not occur with allografts. Fibrovascular tissue is seen early in the healing phase of the cancellous portion of the allografts.

Question 91

An 18-year-old man recently underwent an uncomplicated arthroscopic partial medial meniscectomy that was complicated by reflex sympathetic dystrophy (RSD), also termed “sympathetically maintained pain” (SMP). What is the most common finding of this condition?

Explanation

DISCUSSION: The hallmark for RSD or SMP is the presence of pain that is out of proportion to that expected for the degree of the injury. SMP often extends well beyond the involved area and is present in a nonanatomic distribution. The pain is frequently described as a burning sensation, with extreme sensitivity to light touch. Joint stiffness can be present but is a nonspecific finding. There may be cold intolerance, but this is not a cardinal symptom. Sweating actually may be increased. Osteopenia, if present, is a late finding.
REFERENCES: Lindenfeld TN, Bach BR Jr, Wojtys EM: Reflex sympathetic dystrophy and pain dysfunction in the lower extremity. Instr Course Lect 1997;46:261-268.
O’Brien SJ, Ngeow J, Gibney MA, Warren RF, Fealy S: Reflex sympathetic dystrophy of the knee: Causes, diagnosis, and treatment. Am J Sports Med 1995;23:655-659.

Question 92

Staged open reduction and internal fixation with free flap soft tissue reconstruction is the most appropriate definitive treatment method for which of the following tibial injuries?

Explanation

DISCUSSION: By definition, with Type IIIB injuries, there is exposed bone after debridement which will require a local or a free flap for coverage. Distal third IIIB tibial shaft fracture are unique in that they usually require a free flap or reverse sural rotational flap to obtain adequate coverage. As stated in Skeletal Trauma, "As local donor muscles in the distal third of the tibia are almost non-existent, closure of an open plafond fracture, or any extensive Type IIIB injury in this area will usually require free tissue transfer. The primary options are latissimus dorsi or rectus abdominus for large defects, and gracilis for smaller wounds." In addition to the flaps mentioned here, others, including fasciocutaneous flaps and radial forearm flaps, are also utilized with success in this area.
Typically, treatment of Type IIIB tibial shaft fractures should be staged. Initially tetanus prophylaxis, antibiotics with gram negative and positive coverage, and application of an external fixator with repeat I&D’s are employed for immediate fracture care. Plating is usually required in the presence of significant intra-articular fracture involvement.
Incorrect Answers: Typically, proximal third tibia fractures requiring soft tissue coverage can be treated with a gastrocnemius rotation flap and middle third tibia fractures with soft tissue defects can be reliably covered with a soleus rotation flap. Therefore, a free flap is rarely indicated in the proximal and middle tibia.

Question 93

A 47-year-old man has acute right shoulder pain after falling off a ladder. The MRI scan shown in Figure 9 reveals

Explanation

DISCUSSION: The MRI scan reveals a full-thickness rotator cuff tear with retraction and increased signal in the subacromial space indicating joint fluid.
REFERENCES: Herzog RJ: Magnetic resonance imaging of the shoulder. Instr Course Lect 1998;47:3-20.
Iannotti JP, Zlatkin MB, Esterhai JL, et al: Magnetic resonance imaging of the shoulder: Sensitivity, specificity, and predictive value. J Bone Joint Surg Am 1991;73:17-29.

Question 94

What tendon is closest to an appropriately placed anterolateral portal for ankle arthroscopy?

Explanation

DISCUSSION: The appropriate placement of the anterolateral portal provides access to the lateral gutter of the joint while avoiding the superficial peroneal nerve. The safest location for the portal is approximately 4 mm lateral to the peroneus tertius tendon, the closest of the tendons listed to the anterolateral portal. Because the superficial peroneal nerve location is variable, attempts to visualize, palpate, or transilluminate the nerve are mandatory.
REFERENCE: Ogut T, Akgun I, Kesmezacar H, et al: Navigation for ankle arthroscopy: Anatomical study of the anterolateral portal with reference to the superficial peroneal nerve. Surg Radiol Anat 2004;26:268-274.

Question 95

What is the most common complication following reverse total shoulder arthroplasty?

Explanation

A 75-year-old woman with rheumatoid arthritis and a long history of oral corticosteroid use sustains a comminuted intra-articular distal humerus fracture. What is the best surgical option?
A. Open reduction internal fixation (ORIF) with parallel plates
B. ORIF with orthogonal plates and iliac crest bone grafting
C. Total elbow arthroplasty (TEA)
D. Closed reduction and percutaneous pinning
TEA is the best surgical option. McKee and associates published a multicenter randomized controlled trial comparing ORIF with TEA in elderly patients. TEA resulted in better 2-year clinical functional scores and more predictable outcomes compared with ORIF. TEA was also likely to result in a lower reoperation rate; one-quarter of patients with fractures randomized to ORIF could not achieve stable fixation. Further, Frankle and associates reported a comparative study of TEA versus ORIF in 24 elderly women. TEA outcomes were again superior to ORIF at a minimum of 2 years of follow-up. TEA was especially useful in patients with comorbidities that compromise bone stock, including osteoporosis and oral corticosteroid use. Closed reduction and percutaneous pinning studies have not been published on the adult population. Correct answer : C

Question 96

Exostoses in which of the following anatomic locations is the most likely to undergo malignant transformation in a patient with multiple hereditary exostosis (MHE)?

Explanation

DISCUSSION: Although osteochondromas can occur in almost every bone in patients with MHE, proximally located lesions are more likely to undergo malignant transformation. Annual radiographs of the shoulder girdles and pelvis are indicated in patients with MHE. Any enlarging osteochondromas are a concern as possible malignancies.
REFERENCES: Peterson HA: Multiple hereditary osteochondromata. Clin Orthop 1989;239:222.
McCornack EB: The surgical management of hereditary multiple exostosis. Orthop Rev 1981;10:57.

Question 97

What is the plasma half-life of warfarin?

Explanation

Warfarin, which is dosed daily, can take 72 to 96 hours to reach therapeutic levels. It has a plasma half-life of 36 to 42 hours. Low-molecular heparins have a plasma half-life of 4 to 5 hours, and fondaparinux has a half-life of 17 to 21 hours. Warfarin will not affect the International Normalized Ratio (INR) until 2 to 3 days after it is given. Patients on chronic warfarin therapy should have treatment stopped 3 to 5 days before elective surgery to allow the INR to normalize.

Question 98

Figure 7 shows the MRI scan of a 23-year-old competitive rugby player who has anterior ankle pain and swelling. He states that he has been playing for many years and has sprained his ankle several times. Examination will reveal what specific hallmark feature?

Explanation

DISCUSSION: The history and MRI findings indicate the presence of anterior tibiotalar osteophytes. This is frequently observed in soccer, rugby, and football athletes who play on grass or turf surfaces and repetitively push off and change directions. Examination may reveal an effusion but no loss of subtalar motion. A positive external rotation (Klieger) test is described as pain at the distal ankle with external rotation of the foot and is observed in patients with syndesmosis sprains. This patient may have an increased anterior drawer because of a history of sprains; however, this finding is not specific for anterior impingement of tibiotalar osteophytes. The most specific finding on physical examination is pain with forced dorsiflexion.
REFERENCES: Ogilvie-Harris DJ, Mahomed N, Demaziere A: Anterior impingement of the ankle of the ankle treated by arthroscopic removal of bony spurs. J Bone Joint Surg Br 1993;75:437-440.
Cannon LB, Hackney RG: Anterior tibiotalar impingement associated with chronic ankle instability. J Foot Ankle Surg 2000;39:383-386.

Question 99

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

Explanation

Question 100

The injection shown in Figures 1a and 1b would most benefit a patient who reports which of the following symptoms?

Explanation

DISCUSSION: The images demonstrate a L5 selective root block as it exits the L5-S1 foramen. This root block best helps relieve pain or paresthesias in the L5 distribution, which is the dorsal first web space and the great toe. The lateral foot is an S1 distribution and would need to be blocked through the posterior first sacral foramen. The anterior shin and thigh represent the

L4 root which exits a level above this at the L4-5 foramen. A stocking distribution is nonanatomic and not indicative of a specific root.
REFERENCES: Magee D: Principles and concepts, in Orthopaedic Physical Assessment, ed 3. Philadelphia, PA, WB Saunders, 1997, pp 1-18.
Aeschbach A, Mekhail NA: Common nerve blocks in chronic pain management. Anesthesiol Clin North Am 2000;18:429-459.

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

wound debridement, anterior corpectomy, spinal cord decompression, dural repair, and anterior fusion with strut graft and anterior plating.
wound debridement, anterior corpectomy, spinal cord decompression, dural repair, anterior fusion with strut graft and anterior plating followed by posterior laminectomy, and spinal cord decompression and dural repair with excision of the bullet fragment.
wound debridement, anterior corpectomy, spinal cord decompression, dural repair, anterior fusion with strut graft and anterior plating followed by laminectomy and posterior fusion, and spinal cord decompression and dural repair with excision of the bullet fragment.
laminectomy and posterior fusion, and spinal cord decompression and dural repair with excision of the bullet fragment.
surgical treatment based on extraspinal pathology with orthotic treatment of the spinal fractures.

Correct Answer: surgical treatment based on extraspinal pathology with orthotic treatment of the spinal fractures.

Explanation:

DISCUSSION: Although the spinal canal has been penetrated, the lateral masses are intact bilaterally with only partial destruction of the vertebral body and penetration of the lamina on one side, thus the cervical spine is not unstable and surgical stabilization is not indicated. Dural repair is not indicated since there is no external cerebrospinal fluid leakage. Surgical treatment should be based on the need to treat extraspinal pathology only.
REFERENCES: Bono CM, Heary RF: Gunshot wounds to the spine. Spine J 2004;4:230-240.
Punjabi MM, Jue JJ, Dvorak J, et al: Cervical spine kinematics and clinical instability, in Clark CR (ed): The Cervical Spine, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 2005,
pp 55-87.

Question 2:

Options:

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

Correct Answer: Tear of the rotator cuff

Explanation:

Question 3:

5 g/dL and his base deficit is 10mEq/L. What is the most appropriate next step in management?

Options:

Reamed intramedullary nailing bilateral femur fractures, irrigation and debridement followed by reamed intramedullary nailing right tibia, open reduction internal fixation left forearm
Reamed intramedullary nailing bilateral femur fractures, irrigation and debridement followed by external fixation right tibia, splinting left forearm
External fixation bilateral femur fractures, irrigation and debridement followed by external fixation right tibia, open reduction internal fixation left
forearm
External fixation bilateral femur fractures, irrigation and debridement followed by external fixation right tibia, splinting left forearm
External fixation right femur and right tibia following irrigation and debridement, reamed intramedullary nailing left femur, splinting left forearm

Correct Answer: External fixation bilateral femur fractures, irrigation and debridement followed by external fixation right tibia, splinting left forearm

Explanation:

With a base deficit of 10mEq/L, the patient is under-resuscitated and unstable. Thus, damage control orthopedics via external fixation of the long bone injuries with irrigation and debridement of the open tibia is the appropriate next step in management.
Of all of the reported values, the most important predictor of morbidity and mortality is the base deficit (normal range -2 to +2mEq/L), which represents overall resuscitation status. Another representative parameter of resuscitation status is lactate (normal <2mg/dL). Heart rate, blood pressure and hematocrit are not reliable predictors of normalized resuscitation status, morbidity or mortality.
Callaway et al. retrospectively reviewed a large cohort of blunt trauma patients over a 6 year period. Only base deficit and lactate levels were directly correlated with and were reliable predictors of mortality.
Paladino et al. retrospectively reviewed a prospective database of over 1400 patients. Base deficit and lactate were significant and useful predictors of triage upon initial presentation to denote severe versus non-severe injury.
Martin et al. retrospectively analyzed over 2000 sets of laboratory data in 427 ICU patients. Base deficit (anion status), even in ICU patients with normal lactate levels, were predictive of decreased survival.
Incorrect Answers:
OrthoCash 2020
A 26-year-old male sustains an elbow injury after a fall from a skateboard resulting in valgus and supination forces across the left elbow. A CT scan of the left elbow is shown in Figures A through D. This fracture pattern is most commonly associated with what other traumatic elbow pathology?
Posteromedial rotatory instability
Capitellum fracture
Radial head fracture and posterolateral ulnohumeral dislocation
Trans-olecranon fracture dislocation
Medial (ulnar) collateral ligament rupture
Corrent answer: 3
The clinical presentation is consistent with a coronoid tip fracture. This fracture pattern is associated with a radial head fracture and posterolateral ulnohumeral dislocation - together making up the terrible triad injury.
A terrible triad injury is the result of a valgus and supination injury and involves posterolateral elbow dislocation or lateral collateral ligament injury, radial head fracture, and fracture of the coronoid process. The elbow may dislocate postero-laterally with the anterior bundle of the MCL intact, but if the MCL is injured it is typically the last structure to fail. The coronoid fracture is typically a small fragment isolated to the tip. This is a result of a posteriorly directed force driving the coronoid into the trochlea prior to posterior elbow dislocation. CT scan is a useful modality when small or comminuted fragments are difficult to visualize on plain radiographs.
Steinmann reviews the anatomy, diagnosis, classification and treatment of coronoid fractures with a focus on surgical exposures and fixation techniques.
Doornberg et al. reviewed 67 coronoid fractures to determine whether type of coronoid fracture correlated with pattern of instability. They found strong associations between (1) large coronoid fractures and trans-olecranon fracture-dislocations, (2) small fractures and terrible-triad injuries, and (3) anteromedial facet fractures and varus posteromedial rotational injury mechanisms.
Doornberg et al. evaluated 18 patients with a fracture of the anteromedial facet of the coronoid. They found that malalignment of the anteromedial facet fragment was associated with arthrosis and a fair or poor result.
Figures A through D show consecutive 2.00 mm sagittal CT reformats demonstrating a small coronoid fracture fragment which was addressed with suture fixation.
Incorrect Answers:
OrthoCash 2020
A 62-year-old right-hand-dominant school teacher sustains a mechanical fall at home and presents with right shoulder pain. Plain
radiographs of the right shoulder are pictured in Figures A and B. The patient asks you what she can expect in terms of recovery following this injury. Which of the following is the most appropriate statement?
At 1-year post-injury, the right shoulder range of motion will most likely be equal to the contralateral extremity.
At 1-year post-injury, you will most likely have returned to your baseline functional status.
Early range of motion exercises risk fracture displacement and should be avoided until at least 4 weeks post-injury.
Most patients do not return to work following this injury.
One in 5 patients with this fracture go on to nonunion and you may benefit from surgery in the future to address this.
This patient has a minimally displaced (1-part) proximal humerus fracture involving the humeral neck and greater tuberosity. This injury pattern is most commonly managed nonoperatively with the majority of patients returning to their baseline functional status by 1 year.
Proximal humerus fractures (PHF) can be classified by number of parts (Neer classification), with a part defined as a fracture fragment displaced > 1cm (> 5mm for greater tuberosity) or angulated > 45°. One-part PHF comprise ~80% of all PHF and are treated nonoperatively with a sling and early range of motion (ROM).
Tejwani et al performed a prospective study of 67 patients with 1-part PHF. At 1-year follow up the ASES score and functional status was similar to pre-injury status. However, ROM of the affected shoulder was diminished in both external and internal rotation. Forward flexion was preserved.
Hanson et al prospectively analyzed 160 patients with PHF of all types (1-4 parts and head-splitting) managed nonoperatively. At 1-year follow up, 93% showed solid union. Constant and DASH scores improved steadily over time but were still lower compared to the contralateral extremity. Of employed patients, 97.6% returned to work with a median time off of 10 weeks and no difference between manual and nonmanual workers.
Figures A and B are the AP and axillary radiographs of the right shoulder, respectively, demonstrating a 1-part PHF involving the humeral neck and greater tuberosity.
Incorrect Responses:
OrthoCash 2020
A 44-year-old male presents with the isolated injury seen in Figure A after a motor vehicle accident and underwent the operative treatment seen in Figure B within 8 hours from the time of incident. Which of the following complications is this patient at highest risk of developing?
Pulmonary embolus
Periprosthetic fracture
Contralateral hip fracture
Osteonecrosis
Infection
This young male patient has sustained a displaced femoral neck fracture and underwent open reduction internal fixation with 3 cannulated screws. Based on the available options, the patient is most at risk of developing osteonecrosis of the femoral head.
Femoral neck fractures in young patients typically are the result of a high-energy trauma. Fracture displacement has been shown to disrupt vascular supply to the femoral head by interrupting retinacular vessels and ligament teres vascularization, as well as increasing intracapsular pressure, producing a tamponade effect. The incidence of osteonecrosis in patients younger than 60 years with displaced femoral neck fractures has been shown to be between 15-30%. Quality of reduction is one key factor that has been shown to influence outcomes postoperatively.
Loizou et al. prospectively studied 1,023 patients who sustained an intracapsular hip fracture that was treated with internal fixation using standard fixation modalities. They showed that osteonecrosis was less common for undisplaced (4.0%) than for displaced fractures (9.5%). The population at greatest risk were women younger than the age of 60 with displaced fractures.
Barnes et al. review subcapital hip fractures. They found that late segmental collapse was more common in displaced fractures in women younger than age 75 years than in those older than age 75 years treated with internal fixation.
Figure A shows a displaced, Garden 3/Pauwels III hip fracture. Figure B shows anatomical fixation with 3 cannulated screws.
Incorrect Answers:
OrthoCash 2020
A 58-year-old male is involved in a motor vehicle collision and sustains the injury shown in Figure A in addition to right 5th and 6th rib fractures. Upon evaluation in the emergency department, he is noted to have a 2 centimeter laceration over the anterior aspect of his left leg with visible bone. Vitals and labs are normal. Which of the following statements is most accurate regarding surgical management for this patient?
Reamed intramedullary nailing is favored due to increased rates of union
Unreamed intramedullary nailing is favored due to presence of concomitant rib fractures
Reamed intramedullary nailing is favored due to decreased rates of infection
Unreamed intramedullary nailing is favored due to less local trauma
Both unreamed and reamed intramedullary nailing are equivalent
Corrent answer: 5
Both unreamed and reamed intramedullary nailing are equivalent treatments in patients with open tibia fractures. Intramedullary nailing is the treatment of choice for stable patients with tibial shaft fractures.
Tibial shaft fractures can be the result of low energy twisting injuries or higher energy axial loads. Closed fractures with acceptable alignment can be often be treated with closed reduction and casting. Intramedullary nailing, unreamed or reamed, is the treatment of choice for open fractures except in the setting of damage control orthopaedics when an external fixator may be more appropriate.
Bhandari et al. investigated reamed and unreamed intramedullary nailing for tibial shaft fractures in a randomized trial ("SPRINT" Trial - Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures Investigators). They concluded that reamed nailing was more beneficial (decreased rate of primary outcome event: need for bone grafting, implant exchange or removal for infection, debridement for infection) for closed fractures, but had no benefit in open fractures.
Finkemeier et al. evaluated consecutive patients treated with unreamed and reamed intramedullary nailing and found similar rates of union in both open and closed tibial shaft fractures at six and twelve months.
Figures A shows AP and lateral xrays of the left tibia showing a tibial shaft fracture.
Incorrect Answers:
OrthoCash 2020
A 36-year-old male falls from a 10-ft scaffold and suffers the injuries shown in Figures A and B. The patient is placed in a spanning external fixator and brought back to the operating room once his soft tissues are amenable. Planning to use a dual-incision approach, what is the correct interval to use when approaching the medial side?
Popliteus and pes anserine
Lateral head of the gastrocnemius and pes anserine
Politeus and lateral head of the gastrocnemius
Iliotibial band and medial head of the gastrocnemius
Pes anserine and medial head of the gastrocnemius
Corrent answer: 5
The posteromedial approach to the tibial plateau is between the the pes anserine tendons and the medial head of the gastrocnemius.
A dual-incision approach is often utilized to optimally place definitive fixation for bicondylar tibial plateau fractures. For fractures that require posterior or posteromedial fixation, the correct interval is between the pes anserine and the medial head of the gastrocnemius.
Higgins et al. in a large cohort morphological review, noted a high incidence of a posteromedial fragment in bicondylar fractures. Occurring at a high frequency, the authors recommended direct visualization and reduction via a dual approach rather than using indirect reduction techniques.
Falker et al. describes a step-by-step approach to utilizing the posteromedial approach for the tibial plateau and placing an anti-glide plate.
Figure A and B exhibit a bicondylar tibial plateau fracture with a posteromedial fragment noted on the lateral x-ray. Illustration A exhibits the surrounding anatomy and interval in between the medial head of the gastrocnemius and the pes anserine.
Incorrect answers:
OrthoCash 2020
A 25-year-old male presents to the emergency department with the injury seen in Figure A after a motorcycle collision. The patient has a blood pressure of 70 systolic, elevated lactate and a tense abdomen with positive FAST examination. Trauma surgery will be performing an emergent laparotomy. Orthopaedic surgery is consulted and places a pelvic external fixator intraoperatvely to assist with resuscitation. What is an advantage of supra-acetabular external fixator pins as compared with iliac crest pins?
Less interference with pelvic surgical incisions
Less risk of pin tract infection
Less risk of malreduction
Less control of posterior pelvic ring
No interference with laparotomy
Corrent answer: 1
One advantage of supra-acetabular external fixator pins is that they do not interfere or contaminate future approaches to the pelvis or acetabulum involving the lateral window.
In multiply injured patients with pelvic trauma external fixation of the pelvic ring is a valuable tool to assist with resuscitation. Pelvic external fixation should be applied rapidly and allow full access to the abdomen for general surgery intervention. Regardless of the technique used, a pelvic external fixator should form a stable construct that minimizes motion of fracture surfaces and allows for clot formation.
Haidukewych et al evaluated the safety of supra-acetabular pin placement in a cadaveric study. The authors found that the lateral femoral cutaneous nerve (LFCN) was most at risk during pin placement.
Figure A demonstrates a widely displaced symphyseal dislocation with associated bilateral sacroiliac (SI) dislocations (APC 3). Illustration A demonstrates an outlet radiograph of a supra-acetabular external fixtator in conjunction with posterior pelvic ring fixation for an LC3 pelvic ring injury.
Illustration B is an illustration of iliac crest external fixation. The video demonstrates techniques for application of both supra-acetabular and iliac
crest external fixation pins.
Incorrect Answers:
OrthoCash 2020
What physical exam finding is most likely to be found in association with the injury shown in Figures A and B?
Numbness in the small finger and ulnar side of the ring finger
No elbow instability
Varus posteromedial rotatory instability
Valgus posterolateral rotatory instability
An anterior open wound
Corrent answer: 3
The x-ray shows a fracture of the anteromedial facet of the coronoid with an intact radial head. Large anteromedial facet fractures are associated with varus posteromedial rotatory instability.
The anteromedial facet of the coronoid provides support to the medial elbow against varus stress. Varus and posteromedial force applied to the elbow results in disruption of the lateral collateral ligament (LCL) from its proximal origin. The coronoid is fractured as it is forced against the medial trochlea.
Coronoid fractures of significant size involving the sublime tubercle (insertion of medial collateral ligament) result in varus instability.
Steinmann reviews the anatomy, diagnosis, classification and treatment of coronoid fractures with a focus on surgical exposures and fixation techniques. He states that when a coronoid fracture is associated with a pattern of varus instability, it requires fixation with either suture, buttress plating or screw fixation. Concomitant LCL repair or reconstruction will also be necessary.
Doornberg et al. reviewed 67 coronoid fractures to determine whether type of coronoid fracture correlated with pattern of instability. They found strong
associations between (1) large coronoid fractures and trans-olecranon fracture-dislocations, (2) small fractures and terrible-triad injuries, and (3) anteromedial facet fractures and varus posteromedial rotational injury mechanisms.
Doornberg et al. evaluated 18 patients with a fracture of the anteromedial facet of the coronoid. They found that malalignment of the anteromedial facet fragment was associated with arthrosis and a fair or poor result.
Figure A is an AP view of an elbow with an anteromedial facet of the coronoid fractured. The lateral joint space is widened due to injury to the LCL. The medial joint space is narrowed and collapsed. A lateral view is shown in Figure
B. Illustrations A and B show AP and lateral views of a coronoid fracture fixed with buttress plating. The LCL origin was fixed with a suture anchor. Illustration C shows the O'Driscoll classification of coronoid fractures. Illustration D lists injury patterns that suggest posteromedial versus posterolateral rotatory instability.
Incorrect Answers:
OrthoCash 2020
A 35-year-old man presents to the ED as the restrained driver of a high speed motor vehicle collision complaining of hip, chest, and abdominal pain. He becomes diaphoretic, tachycardic, and hypotensive in the trauma bay and is noted to have diminished lower extremity pulses. He is found on ATLS workup to have mediastinal widening.
Which of the following injuries is most associated with thoracic aortic injury?
Thoracic aortic rupture is associated with posterior hip dislocation in deceleration trauma mechanism of injuries.
Posterior hip dislocations are infrequently associated with local vascular injuries. With bilateral perfusion deficits, more proximal large vessel trauma should be considered, and in this situation, thoracic surgery should be involved emergently. Screening chest x-ray in the trauma bay should be reviewed for widened mediastinum, suggestive of aortic injury, as shown in illustration A. Given the high energy mechanism associated with these injuries, a full ATLS trauma survey must be done for every patient.
Marymont et al. studies the association between posterior hip dislocation and thoracic aortic injury. They performed a retrospective chart review of 89 posterior hip dislocations and found 8% had an aortic injury. Although not statistically significant, they note the importance of evaluation for aortic injury in patients with posterior hip dislocations given its emergent life-threatening nature.
In addition to associated chest injuries, Schmidt et al. highlight the importance of evaluating the ipsilateral knee after high-energy traumatic hip dislocation. In a prospective study, they identified a 93% rate of ipsilateral knee injury on MRI including effusion (37%), bone bruising (33%), and meniscal tear (30%) as the most common. They recommend a thorough exam but also expanded use of knee MRI after hip dislocation.
Illustration A shows an example of chest x-ray with a widened mediastinum, suggestive of thoracic aortic injury.
OrthoCash 2020
A 31-year-old female smoker was involved in a skiing accident approximately 9 months ago and underwent open reduction internal fixation of the radius and ulna at the time of injury. She now returns to the clinic complaining of increasing pain with range of motion and activity. Radiographs from her most recent follow-up can be seen in Figure A. Laboratory tests show ESR, CRP and WBC count to be within normal limits. Which of the following options is the most appropriate next step in management?
Bone scan
Above elbow cast
Removable splint
Reamed intramedullary nail
Iliac crest bone grafting + compression plating
Corrent answer: 5
This patient is presenting with an atrophic non-union of the ulna after open reduction internal fixation for a both bone forearm fracture 9 months ago. The most appropriate next step in management would be iliac crest bone grafting and compression plating of the ulna.
The primary issue with an atrophic nonunion is biological. The blood supply is poor and therefore incapable of purposeful fracture healing. Smokers, as in this vignette, are at high risk for nonunion. The treatment of an atrophic nonunion involves improving biology at the fracture site through use of autologous bone graft (e.g. iliac crest) and providing mechanical stability by means of compression plating (e.g. 3.5 mm LC-DCP).
dos Reis et al. reports excellent results of 31 cases of diaphyseal forearm fracture non-unions treated with autologous bone grafting and compression
plating. Thirty of thirty-one patients went on to bony union within 3.5 months of revision surgery.
Nadkarni et al. presented a case series of 11 patients with non-unions of various long bones initially managed with intradmedullary (IM) nail fixation. The authors successfully used locking compression plates while retaining the IM nails in the treatment of the nonunion in all cases.
Figure A shows an AP radiograph of a both bone forearm fracture. Figure B shows an AP and lateral radiograph of an atrophic non-union of the ulnar shaft. Illustration A shows a lateral x-ray of a fully healed radius and ulna after hardware removal 1 year after revision surgery.
Incorrect Answers:
OrthoCash 2020
A 27 year-old patient sustains a fracture-dislocation of the acetabulum. Pelvic radiographs (Figures A and B) are taken at initial presentation and a CT scan (Figures C and D) is performed after reduction of the hip in the emergency room. What is the importance of the finding highlighted in the CT scan cuts?
Comminution indicates a better result with non-operative management
Significant marginal impaction could compromise the results of the surgical reduction if the joint surface is not properly restored
The impacted fracture segment will heal without fixation because it is not gapped or translated
The CT scan finding highlighted indicates osteochondral defects to the femoral head, which can be addressed arthroscopically
Intraarticular fracture fragments should be discarded from the surgical field, as incorporation of the fragments into the fixation construct leads to a high rate of avascular necrosis
The CT images shown in Figures C and D display significant marginal impaction of the joint surface.
Marginal impaction is common in posterior wall fractures and fracture-dislocations. Critical review of CT imaging of posterior wall fractures can help with preoperative planning for identifying impaction of the articular surface of the acetabulum. Restoration of the sphericity of the acetabulum to match that of the femoral head is important for successful outcome following ORIF of posterior wall fractures. A common surgical technique to accomplish joint surface restoration includes freeing the impacted articular segments, bone grafting of the void created to support the articular segments, and buttress plating of the posterior wall fracture fragments.
Patel et al. discuss the challenge of interpreting imaging of the acetabulum for assessing fracture characteristics that may significantly impact success or surgical intervention. These characteristics include: articular displacement, marginal impaction, incongruity of the joint surface, intra-articular fragments, and osteochondral injury to the femoral head. Based on expert review of images, determination of significant marginal impaction had a poor intraobserver reliability, as did each of the other modifiers listed.
Figures A and B are radiographs of the posterior wall fracture and hip dislocation. They do not show the large amount of marginal impaction of the acetabular surface. Figure C (coronal reconstruction) and Figure D (sagittal reconstruction) point out a large a amount of marginal impaction of the acetabular. Note the disruption of the joint surface on the intact portion of the acetabulum.
Incorrect answers:
Comminuted posterior wall fractures still should be surgically stabilized if the joint is unstable
This impacted fragment on the margin of the main fracture line will likely heal regardless of restoration of the articular surface; however, this malreduction will lead to a incongruent joint surface
These CT cuts do not show any osteochondral defects of the femoral head; however if found in other CT cuts or intraoperatively, they should be appropriately addressed
Intraarticular fracture fragments should be removed from the joint, but if they make up a substantial portion of the joint surface, they should be incorporated in the fixation construct to obtain the goal of anatomic reduction of the joint surface
OrthoCash 2020
A 32-year-old female is involved in a motor vehicle collision and suffers a right hip dislocation. She is in the twelfth week of pregnancy.
Evaluation in the emergency department reveals no other injuries and ultrasound reveals a strong fetal heart rate and no abnormalities. She undergoes emergent closed reduction but the hip remains unstable and a traction pin is placed. Post-reduction films are shown in Figure
What is the most appropriate next step in management?
Acute open reduction internal fixation
Exam under anesthesia
Skeletal traction for 6-8 weeks
Fetal monitoring until 15 weeks followed by open reduction internal fixation
Percutaneous pinning
This patient has a large posterior wall fracture of the right acetabulum with an unstable hip. The most appropriate next step in treatment is open reduction and internal fixation.
Fixation of acetabular fractures during pregnancy is not contraindicated in the setting of stable fetal heart rate and no abnormalities on pelvic ultrasound.
There is, however, an increased risk of complications for the mother and fetus. Injury severity and mechanism are most closely associated with increased rate of fetal complications. The trimester of pregnancy is not associated with increased risk of complications.
Leggon et al. reviewed 101 cases of pelvic and acetabular fractures in pregnant patients and found mechanism of injury and injury severity were associated with higher mortality for both mother and fetus. Trimester of pregnancy was not associated with increased mortality.
Flik et al. reviewed orthopaedic trauma in a pregnant patients and recommended fetal ultrasound for assessment of fetal well-being in all pregnant patients.
Desai et al. investigated orthopaedic trauma during pregnancy and reported minimal radiation risk to the fetus when obtaining x-rays. They also advocate for LMWH as one of the safest choices for anticoagulation.
Figure A is an x-ray showing a right posterior wall acetabular fracture. Figures B and C are Judet views of the pelvis focusing on the right hip. A large posterior wall fragment is visible in Figure B.
Incorrect Answers:
OrthoCash 2020
Figure A is radiograph of a 50-year-old male science teacher that was involved in a motor vehicle accident. He underwent closed reduction as seen in Figure B and C. What would be the most appropriate treatment?
Open reduction and internal fixation with medial bridge plate and lateral screw in non-lagging mode
Tibiotalocalcaneal arthrodesis
Open reduction and internal fixation with lateral and medial screw in lagging mode
Closed reduction and internal fixation with medial and lateral screw in non-lagging mode
Closed reduction with percutaneous pins
Corrent answer: 1
This patient is presenting with a Hawkins II talar neck fracture with medial wall comminution. The most appropriate treatment of this patient would be open reduction internal fixation with medial plate and lateral screw in non-lagging mode.
The treatment of talar fractures is based on the severity of the fracture, soft-tissues, and patient factors. The fracture and subluxation of the subtalar joint should be reduced and stable anatomical fixation should be obtained. When there is comminution of either the superior, lateral or medial aspects of the talus, one should avoid shortening the medial wall as this will cause a varus malunion. The use of a medial or lateral plate can help to re-establish column length, which can often prevent this potential complication.
Sanders et al. showed significant complications after fixation of talar neck fractures. They showed the incidence of secondary reconstructive procedures following talar neck fractures increased from 24% +/- 5% at 1 year to 48%
+/- 10% at 10 years post-injury.
Vallier et al. retrospectively reviewed the records of 39 fractures of the talar neck treated with open reduction and internal fixation. Twenty-one (54%) of thirty-nine patients had development of posttraumatic arthritis, which was more common after comminuted fractures (p < 0.07) and open fractures (p = 0.09).
Vallier et al. reviewed 81 talar neck fractures to revisit the rate of osteonecrosis and post-traumatic arthritis based on the Hawkins Classification. They found that delaying definitive internal fixation does not increase the risk of developing osteonecrosis. Thirty-five patients (54%) developed posttraumatic arthritis, including 83% of those with an associated talar body fracture (p < 0.0001) and 59% of those with Hawkins type-III injuries (p < 0.01).
Figure A shows a Hawkins II talar neck fracture. Figures B and C are saggital and coronal CT images, respectively, of the foot. There is significant comminution of the medial wall of the talus with extension into the subtalar joint.
Incorrect Answers:
There is some research to suggest primarily subtalar arthrodesis with these injuries. However, to date, there is no high level evidence that has conclusively shown subtalar arthrodesis to be better than ORIF.
OrthoCash 2020
A 28-year-old male college student sustains a severe foot injury from gunshot-related violence, and subsequently undergoes a lower-extremity amputation as shown in Figure A. At long-term follow-up, which of the following is the strongest predictor of patient satisfaction as related to his injury?
Age less than 30
Marijuana use
Use of negative pressure wound therapy
Male gender
Ability to return to work
Corrent answer: 5
The strongest factor to predict patient-reported outcomes after trauma-related lower extremity amputations is the patient's ability to return to work. This is likely due to the effect of the return to work on the physical, emotional, and financial aspects of the patient's life.
The LEAP study is a multicenter, prospective study evaluating multiple aspects of reconstruction versus amputation in the treatment of mangled extremity injuries. With regard to patient satisfaction, treatment variables such as decision for reconstruction versus amputation, or initial presence or absence of plantar sensation have little impact. In addition, demographic factors such as age, gender, socioeconomic status, and education level do not predict patient satisfaction. Instead, the most important predictors of patient satisfaction at 2 years after injury include the ability to return to work, absence of depression, faster walking speed, and decreased pain.
O'Toole et al reviewed 463 patients treated for limb-threatening lower-extremity injuries and identified factors associated with patient reported outcomes two years after surgery. They found that return to work was the most associated with outcomes, but that physical functioning, walking speed, pain levels, and presence of depression were also associated to a lesser extent with outcomes.
Bosse et al performed a multicenter, prospective study to assess outcomes of 569 patients with severe lower extremity limb injuries that resulted in either amputation or limb salvage procedures. They found that at two years postoperatively, no significant differences were seen between groups in patient-reported outcome. Worse outcomes were associated with rehospitalization for a major complication, a low educational level, nonwhite race, poverty, lack of private health insurance, poor social-support network, low self-efficacy (the patient's confidence in being able to resume life activities), and involvement in disability-compensation litigation.
Figure A shows a clinical photograph of a Pirigoff amputation at early follow-up. This amputation is an end-bearing amputation that utilizes the plantar heel pad for weightbearing, and relies on a tibiocalcaneal arthrodesis.
Incorrect Answers:
4: These options are not as strong of a factor of patient satisfaction in longterm follow up after trauma-induced lower extremity amputation.
OrthoCash 2020
A 34 year-old male falls off of motorcycle on an outstretched hand suffering the injuries shown in Figures A and B. He is brought to the operating room and undergoes radial head replacement and fixation and repair of the coronoid and the lateral collateral ligament (LCL). Prior to closing, the elbow is still unstable upon testing range of motion. What is the next best step in management?
Exchange radial head for larger implant
Complete resection of radial head
Cast at 90 degrees of flexion for 6-8 weeks
Reinforce LCL repair with non-absorbable suture
Repair the ulnar collateral ligament
Corrent answer: 5
Following complete fixation and repair of a terrible triad, a final range of motion test should be performed prior to closure. If still unstable, the next step should be to assess and repair the ulnar collateral ligament. Another option
would be to placed a hinged external fixator.
Operative reconstruction of a terrible triad injury should be performed in a systematic fashion, working from deep to superficial. Working through a lateral incision and through the radial head fracture, the coronoid should be fixed first, followed by radial head fixation or replacement and then repair/reconstruction of the LCL. If still unstable, the medial side should be addressed, or the patient placed in a hinged external fixator.
Mathew et al review the anatomic, biomechanic, and operative principles (why the above step-by-step method works) to achieving appropriate stability in order to obtain early range of motion to maximize clinical outcome.
Pugh et al. in this retrospective, multi-center study report outcomes on 36 terrible triad injuries fixed with the standard protocol described above. The authors recommend following this systematic approach to achieve the best results.
Figures A and B are AP and lateral radiographs exhibiting a terrible triad elbow fracture-dislocation.
Incorrect answers:
OrthoCash 2020
When treating the pathology depicted in Figures A through D, which of the following is necessary to preserve the blood supply to the femoral head?
Dissection of the gluteal musculature off the iliac crest
Ligation of the ascending branches of the lateral femoral circumflex artery
Greater trochanteric osteotomy
Identification and detachment of the piriformis tendon
Supine positioning
Figures A-D show a femoral head with associated acetabular fracture (Pipkin IV). Both the posterior wall fracture and the femoral head fracture can be addressed through a surgical dislocation via greater trochanteric osteotomy.
Pipkin IV femoral head fracture (with associated acetabular fractures) are somewhat problematic in that the femoral head fracture is usually anterior, while the acetabular fracture usually involves the posterior wall. A Kocher-Langenbeck approach gives good access to the posterior wall but limited access to the articular surface and femoral head avascular necrosis (AVN) is a concern. A Smith-Peterson approach provides good access to the femoral head
but not to the posterior wall. Combined approaches significantly increase the amount of surgical dissection. Surgical dislocation with trochanteric flip osteotomy provides access to the femoral head and posterior wall while preserving blood supply to the femoral head.
Solberg et al. retrospectively reviewed 12 patients with Pipkin IV injuries treated via a trochanteric flip osteotomy. All patients healed their acetabular fractures. Eleven of 12 patients healed their femoral head fractures and one patient (8.3%) developed osteonecrosis.
Henle et al. likewise treated 12 patients with Pipkin IV injuries through a trochanteric flip osteotomy. Two of 12 patients (16.7%) developed osteonecrosis. The remaining 10 patients (83.3%) had good or excellent results. Heterotopic ossification occurred in five patients, causing significant range of motion loss in four of these.
Figure A is a pre-reduction AP pelvis in which the posterior wall fracture is apparent. Figure B is a post-reduction AP pelvis in which an infra-foveal femoral head fracture is apparent (Pipkin IV). Figure C is an axial CT cut which further characterizes the posterior wall fracture. Figure D is an obturator oblique showing femoral head dislocation and posterior wall fracture. The video shows a surgical hip dislocation technique.
Incorrect Answers:
OrthoCash 2020
A 42-year-old male presents to your clinic for the first time with the radiographs seen in Figure A. He sustained the injury 4 weeks ago while skiing overseas and treatment was provided by the local orthopaedic surgeon. The operative note states that he sustained an Gustilo Type I open fracture. After surgical fixation of this type of injury, what is the most common complication requiring reoperation?
Chronic elbow instability
Post-traumatic arthritis
Infection
Heterotopic ossification
Loss of elbow range of motion
Corrent answer: 5
This patient sustained a terrible triad elbow fracture-dislocation. Reduced range of motion of the elbow joint is the most common complication REQUIRING reoperation with these injuries.
Terrible triad elbow fracture-dislocations are characterized by posterolateral dislocation/lateral collateral ligament (LCL) injury, radial head fracture and coronoid fracture. Displaced fractures result in elbow instability. Acute radial head stabilization, coronoid open reduction and internal fixation, and LCL +/-medial collateral ligament (MCL) repair/reconstruction is considered the most appropriate treatment for displaced fractures. Operative complications include elbow stiffness, recurrent instability, arthritis, failure of hardware, heterotopic ossification, posterior interosseous nerve palsy and infection.
Egol et al. looked at the functional outcomes of 27 patients that underwent fixation of terrible triad injuries. At one year follow-up, the average flexion-extension arc of elbow motion was 109 degrees +/- 27 degrees, and the average pronation-supination arc was 128 degrees +/- 44 degrees. Grip strength averaged 72% of the contralateral extremity. Although operative fixation led to functional elbow stability, results were poor.
They included a reference to McKee et al. to highlight that intra-articular fractures of the elbow have high rates of stiffness. While not specific to terrible
triads, they looked at the effectiveness of the posterior elbow approach in 25 patients that underwent internal fixation of intra-articular distal humerus fractures. They showed poor outcomes at a mean follow-up of 36 months with reduced range-of-motion, decreased strength and high re-operation rates.
Figure A shows AP fluoroscopic image of a terrible triad injury that has undergone operative fixation. The radial head and coronoid have undergone open reduction internal fixation, and the MCL bony avulsion has been repaired.
Incorrect Answers:
OrthoCash 2020
Figure A is a radiograph from a 59-year-old male that was transferred to a Level I trauma center five hours after a motor vehicle accident. Closed reduction and skeletal traction was successfully performed in the trauma bay. Which of the following factors has been shown to increase the risk of unsatisfactory clinical outcome for this patient?
Need for skeletal traction
Mechanism of injury
Gender
Age
Time to reduction
Corrent answer: 4
Age greater than 55-years-old has been found to be an independent risk factor for inferior clinical outcome in patients with combined acetabular fractures and hip dislocations.
The most important initial step in management following resuscitation involves urgent reduction of the dislocated hip. This should be followed by a preoperative CT scan and ultimately surgical fixation of the combined acetabular fracture. Hip dislocations should be reduced within 6-12 hours for optimal outcome, although different critical times have been cited, particularly for dislocations with concomitant acetabular fractures. Skeletal traction may be required to maintain hip reduction.
Moed et. al. present a Level 3 retrospective review of 100 patients who had been treated with open reduction internal fixation of an acetabular fracture. The authors found that factors associated with unsatisfactory clinical outcomes included age greater than 55, intra-articular comminution, osteonecrosis, and delay of greater than 12 hours for reduction of an associated hip dislocation.
Additionally, they showed that there was a strong association of clinical outcome and final radiographic grade.
Figure A demonstrates an acetabular fracture with concomitant hip dislocation. Incorrect Answers:
injury, male gender, and time to reduction <6 hours have not been shown to be related to unsatisfactory outcomes.
OrthoCash 2020
A 37-year-old male cashier is shot in the leg. He sustains the injury shown in Figures A and B, and is subsequently taken to the operating room for intramedullary nailing. Figure C shows a radiograph of the nail starting point (*). What complication is most likely to result?
Varus malunion
Nonunion
Valgus malunion
Malrotation
Superficial peroneal nerve injury
Corrent answer: 3
This patient is presenting with a comminuted fracture of the proximal third of the tibia. He is appropriately undergoing intramedullary nail fixation, however, the start point illustrated in Figure C is too medial and often leads to a valgus malunion.
Intramedullary nail fixation is more technically demanding in proximal tibial fractures than diaphyseal fractures. The valgus deformity is due to imbalanced muscle forces on the proximal fragment, which are then accentuated by a start point that is too medial. An apex anterior (procurvatum) deformity can also occur and results from the pull of the patellar tendon or a posteriorly directed nail that deflects off the posterior tibial cortex and rotates the proximal fragment. The ideal starting point for proximal tibial fractures is slightly lateral to the medial aspect of the lateral tibial spine on a true AP x-ray and very proximal and just anterior to the anterior margin of the articular surface.
Nork et al. reported the results of intramedullary nailing of proximal tibial fractures with emphasis on techniques of reduction. Various techniques were found to be successful including attention to the proper starting point, the use of unicortical plates, and the use of a femoral distractor applied to the tibia.
Lowe et al. describe surgical techniques for complex proximal tibial fractures. They describe the extended leg position, use of a femoral distractor, temporary plate fixation, blocking (Poller) screws, and use of percutaneous clamps as means to achieve reduction during fixation.
Figure A and B show an AP and lateral radiograph of a comminuted extra-articular fracture through the proximal third of the tibia. Figure C demonstrates a start point that is too medial (represented by the asterisk) for intramedullary nail fixation. Illustration A and B show the ideal start point for intramedullary nail fixation of the tibia on AP and lateral radiographs.
Incorrect Answers:
Varus malunion is more likely to occur in midshaft tibia fractures with an intact fibula.
Nonunion after a proximal tibial fracture treated with intramedullary nailing is less common than malunion.
Malrotation occurs most commonly after IM nailing of fractures through the distal third of the tibia.
The superficial peroneal nerve is at risk during distal screw fixation using a LISS plating technique for fracture fixation.
OrthoCash 2020
A 24-year-old motorcyclist is brought in as a polytrauma after striking a tree at 65 mph. He is found to have injuries involving the chest, abdomen, pelvis, as well as a left open femoral shaft fracture. He undergoes resuscitation in the trauma bay. Which of the following parameters best supports proceeding with irrigation, debridement and external fixation as opposed to immediate reamed intramedullary nailing?
Temperature = 35.5°C (95.9°F)
Fractures of ribs 2-3 with left apical pneumothorax
Grade IV liver laceration with SBP = 85 mmHg
Left superior and inferior pubic ramus fractures
Lactate = 2.3 mg/dL
Significant abdominal trauma with evidence of hemorrhagic shock (SBP < 90 mmHg) following resuscitation is an unstable parameter and therefore is an indication to proceed with damage control orthopaedics (irrigation and debridement of open fractures and temporizing external fixation) in a polytraumatized patient.
The management of orthopaedic injuries in a polytrauma patient depends on the physiological stability of the patient. In an unstable patient, damage control orthopaedics (DCO) is preferred over early total care (ETC) to avoid an iatrogenic second hit with development of adult respiratory distress syndrome (ARDS) and/or multiple organ failure. Clinical parameters indicative of instability include shock (BP < 90 mmHg, refractory to blood products, lactate
> 2.5 mg/dL), coagulopathy (platelet count < 90,000 mm3, fibrinogen < 1 g/L), hypothermia (< 35°C), and significant chest, abdomen or pelvis injuries (pulmonary contusions, severe liver/spleen lacerations, pelvic ring disruption).
Pape et al. (2009) authored a review article detailing the management of a multitrauma patient. Polytrauma patients can be classified as stable, borderline, unstable or in extremis using a variety of criteria pertaining to hemodynamic stability, coagulation, temperature and soft tissue injury.
Patients who are stable or borderline can undergo ETC, while patients who are unstable or in extremis should be managed with DCO.
Pape et al. (2008) concluded that all patients who underwent early femoral nailing demonstrated increased systemic inflammatory response compared to external fixation, regardless of clinical stability. However, unstable patients
with a preexisting elevation of inflammatory status are likely more impacted by this additional increase. Improved postoperative clinical status coincided with a less vigorous inflammatory response.
Illustration A is a table from Pape et al (2009) depicting the criteria used to determine clinical condition of a polytraumatized patient. Illustration B is an algorithm from Pape et al (2009) detailing management of the multitrauma patient.
Incorrect Responses:
OrthoCash 2020
A 92-year-old female sustains the injury shown in Figure A to her nondominant extremity as the result of a non-syncopal ground-level fall. She denies any previous injury or pain of the elbow, and her medical history is significant only for osteoporosis and hypothyroidism. What is the most appropriate treatment for her injury?
Immediate range of motion as tolerated with a sling for comfort
Long arm cast for 3 weeks, then physical therapy for motion
Open reduction and internal fixation
Radiocapitellar arthroplasty
Total elbow arthroplasty
Corrent answer: 5
Use of total elbow arthroplasty (TEA) in the elderly is a well-recognized method of treatment of complex distal humerus fractures. This procedure allows for improved ROM, improved patient-reported outcomes, and decreased revision rates as compared to fixation.
TEA is a preferred alternative for ORIF in elderly patients with complex distal humeral fractures that are not amenable to stable fixation. Elderly patients appear to accommodate to objective limitations in function with time, which is important, as most recommendations list restrictions of lifting no more than 5-10 pounds postoperatively.
McKee et al conducted a prospective, randomized, controlled trial to compare functional outcomes, complications, and reoperation rates in elderly patients with displaced intra-articular, distal humeral fractures treated with open reduction-internal fixation (ORIF) or primary semiconstrained total elbow arthroplasty (TEA). Patients who underwent TEA had a quicker procedure, improved DASH scores at 6 months, improved elbow ROM, and decreased revision rates.
Athwal et al review TEA and the options available at the time of publication. They also report on the techniques and purported advantages of arthroplasty as compared to fixation of complex distal humerus fractures.
Frankle et al reviewed patients >65 years old with distal humerus fractures at a minimum of 2 years follow-up. Outcomes were excellent in 33% of cases undergoing ORIF and 92% excellent with TEA. They recommend TEA in instances of arthritis, osteoporosis, or other diagnoses requiring steroids.
Figure A shows a significantly comminuted distal humerus fracture in an osteoporotic patient. Illustration A shows the same patient after undergoing total elbow arthroplasty.
Incorrect Answers:
1:Immediate range of motion is not recommended for this injury, even with the "bag of bones" treatment method. A brief period of immobilization is generally recommended for this technique.
2: Casting is not indicated for this injury.
3: ORIF of this injury will lead to worse outcomes as compared to arthroplasty. 4: Isolated radiocapitellar replacement is not indicated for this injury.
OrthoCash 2020
A 56-year-old right hand dominant attorney falls from standing and sustains the closed injury shown in Figure A. The treating surgeon elects to fix her fracture using a plate and screw construct. Based on
the available imaging, which of the following fracture characteristics best justifies this fixation choice?
Fracture displacement
Intra-articular fracture extension
The fracture extends distal to the coronoid
Oblique fracture line
Fracture comminution
This patient has a displaced, intra-articular, comminuted olecranon fracture. Comminution is an indication for plate fixation.
Most displaced olecranon fractures are treated operatively. Options include tension band constructs, intramedullary screws, plate and screw fixation or fragment excision with triceps advancement. Any construct relying on interfragmentary compression (tension band, intramedullary screws) requires a non-comminuted fracture pattern. Plate fixation is indicated in the setting of comminution, extension past the coronoid, or in the setting of associated instability.
Bailey et al. retrospectively reviewed 25 patients who underwent plate fixation of displaced olecranon fractures. Twenty-two of 25 patients had good or excellent outcomes. Five of 25 patients (20%) of patients required plate removal for symptomatic hardware. The authors concluded that plate fixation
was an effective treatment for displaced olecranon fractures, with good functional outcomes.
Figure A shows a displaced, comminuted olecranon fracture without evidence of propagation past the coronoid.
Incorrect answers:
OrthoCash 2020
A 35-year-old male was involved in a high speed motorcycle accident. He has a closed head injury, bilateral pulmonary contusions and splenic rupture. His orthopaedic injuries are shown in Figure A. He has a blood pressure of 90/50 mm Hg and a heart rate of 115, despite aggressive resuscitation. An arterial blood gas reveals that his blood lactate is 3.5 and base deficit is -6 mmol/L. Following successful closed reduction of the right hip in the operating room with a percutaneous inserted Schantz pin, what is the next most appropriate treatment for his orthopaedic injuries?
Bilateral open reduction and internal fixation
Open reduction internal fixation on the right, reamed intramedullary nailing on the left
Temporizing external fixation on the right, open reduction and internal fixation on the left
Bilateral reamed intramedullary nailing
Bilateral temporizing external fixation
Corrent answer: 5
This patient presents with features of hemodynamic instability and a high injury severity score. The next most appropriate treatment would be temporizing external fixation bilaterally. This patient meets the criteria for damage control orthopaedics.
Damage control orthopaedics is an approach that contains and stabilizes orthopaedic injuries so that the patient's overall physiology does not undergo further inflammatory insult. As a result, external fixation of femoral shaft fracture and pelvic stabilization is an effective treatment under this strategy. Other indications include vascular injury and severe open fracture.
Pallister et al. reviewed the effects of surgical fracture fixation on the systemic inflammatory response to major trauma. They show that early stabilization of major long bone fractures is beneficial in reducing the incidence of acute respiratory distress syndrome and multiple organ failure. However, early fracture surgery increases the post-traumatic inflammatory response, which
carries a higher complication rate compared to temporary fixation.
Tisherman et al. created clinical guidelines for the endpoints of resuscitation. Level I data found that standard hemodynamic parameters do not adequately quantify the degree of physiologic derangement in trauma patients. The initial base deficit, lactate level, or gastric pH should be used to stratify patients with regard to the need for ongoing fluid resuscitation.
Pape et al. retrospectively reviewed the impact of early total care vs. damage control orthopaedics in the treatment of femoral shaft fractures in polytrauma patients. They found a significantly higher incidence of acute respiratory distress syndrome (ARDS) with intramedullary nailing (15.1%) compared to external fixation (9.1%) when DCO subgroups were compared.
Figure A is a pelvic AP radiograph showing a right hip fracture-dislocation with an ipsilateral femoral shaft fracture. On the left side there is a displaced pertrochanteric hip fracture.
Incorrect Answers:
OrthoCash 2020
Which of the following has been shown to be the greatest risk factor for refracture after implant removal from a radial shaft?
Removal of locking screws
Removal of small fragment plates
Removal of metaphyseal implants
Removal of implants less than 1 year after insertion
Removal of protective splinting from limb earlier than 10 weeks postoperatively
Removal of implants earlier than 1 year after insertion is a risk factor for refracture of the bone after implant removal.
The risk of refracture after hardware removal is multifactorial. Multiple
variables have been studied such as protective splinting for 6 weeks after hardware removal, waiting 12 months or more prior to hardware removal, and the location of the fracture. The variable that seems to correlate most with the risk of refracture is a diaphyseal location of the initial fracture. Large fragment plates (4.5 mm), when removed, are also at higher risk for refracture in the forearm.
Deluca et. al reported on a case series of patients who sustained a refracture of a forearm after implant removal. They noted that radiolucency at the site of the original fracture was seen in most refractured patients when the plate was removed. They also recommend delaying implant removal to two years after insertion to minimize risk.
Rumball et. al reported that the incidence of refracture after forearm implant removal is 6% in their series. They found that early removal, lack of postoperative immobilization, and plate size are the most critical risk factors for refracture.
Illustration A shows a forearm with evidence of refracture after implant removal.
Incorrect Answers:
OrthoCash 2020
A 23-year-old male arrives to the trauma bay after a motorcycle crash caused by a drive-by shooting. The patient is awake and alert and following commands. Vital signs include a blood pressure of 145/90 and a heart rate of 117bpm. Initial lactate is reported as 2.4 mmol/L. The patient has 2 rib fractures on the right with a clear chest radiograph. The patient is neurovascularly intact with a 4cm transverse wound over the medial ankle. Figures A, B and C exhibit his orthopaedic injuries. What is the most appropriate management?
Irrigation, debridement and placement external fixator right ankle, external fixation femur and intramedullary fixation tibia
Irrigation, debridement and placement external fixator right ankle, intramedullary fixation femur and tibia
Irrigation, debridement and placement external fixator right ankle, intramedullary fixation femur and external fixation tibia
Irrigation, debridement and placement external fixator right ankle, femur and tibia
Irrigation, debridement and external fixation right ankle and skeletal traction
The patient is relatively hemodynamically stable. In this case the femur and tibia should be definitively fixed while the open ankle fracture can be irrigated and debrided and placed in a spanning external fixator, temporizing for later definitive fixation.
Aside from an elevated heart rate and mildly elevated lactate (normal < 2.5 mmol/L), the patient is relatively stable making him a good candidate for long bone stabilization and temporizing external fixation of the right ankle. Gross contamination of the open injury also supports temporizing fixation, which can be brought back for repeat I&D and possible fixation.
Pape et al. compared outcomes for intramedullary nailing (IMN) versus staged fixation for femur fractures in stable versus borderline patients. Borderline patients were defined as those with multi-system injury (especially to lungs) and exhibited higher lung complications following acute IMN when compared to stable patients with isolated orthopaedic injuries.
O'Brien reviewed the literature regarding early total care in regards to IMN stabilization of femur fractures. Summarized data noted isolated injuries treated with early IMN had good outcomes, whereas those with head or lung injury had worse outcomes and pulmonary complications.
Figure A exhibits a right open ankle fracture dislocation. Figure B exhibits a mid-shaft tibia fracture. Figure C exhibits a ballistic mid-shaft femur fracture.
Incorrect Answers:
OrthoCash 2020
Figure A is an anterior-posterior (AP) radiograph of a 27-year-old male who was a bicyclist struck by a motor vehicle. He was intubated in the field and unresponsive in the trauma slot. Ultrasound of his abdomen is positive for blood and he is brought to the operating room emergently for an exploratory laparotomy. He is found to have ischemic bowel and a grade 4 liver laceration. His lactate is 9.0 mg/dL. Which figure represents the next appropriate step in regard to his pelvic ring injury?
The radiograph exhibits an elevated left hemipelvis with complete sacroiliac disruption, which can be temporized with placement in skeletal traction.
The patient is unstable, as indicated by an elevated lactate level. The most appropriate next step is temporizing skeletal traction to reduce the left hemipelvis.
Langford et al. review the initial diagnosis, evaluation and resuscitation in the management of pelvic fractures. Reduction of pelvic volume can be achieved with pelvic binders and temporizing external fixation for anterior posterior compression (APC) and/or lateral compression (LC) fracture patterns, while skeletal traction can help do the same in vertical shear patterns.
Matullo et al. review the uses of skeletal traction in orthopaedic trauma, where lower extremity skeletal traction can be an efficient, fast, easy way to help reduce pelvic volume in vertical shear injuries, especially when the patient is unstable and not cleared for definitive fixation.
Figure A exhibits an elevated left hemipelvis indicative of a vertical shear injury and complete SI disruption. Figure B is an example of a pelvic binder. Figure C is a pelvic reconstruction plate. Figure D is a schematic of an anterior pelvic external fixator. Figure E is a schematic drawing of a patient in lower extremity
skeletal traction. Figure F is a radiograph exhibiting S1 and S2 sacroiliac (SI) screws.
Incorrect answers:
OrthoCash 2020
A 38-year-old man is involved in a motor vehicle collision and suffers the grossly open injury shown in Figure A. He subsequently undergoes irrigation and debridement and placement of an external fixator. In Figure B, if the proximal pin is placed at the red circle as compared to the black circle, the patient is at increased risk for which of the following?
Foot drop
Injury to the anterior tibial artery
Septic arthritis
Flexion contracture of the knee
Patellar tendon rupture
Corrent answer: 3
The patient is at increased risk of septic arthritis when placing the proximal tibial pin too proximal due to penetration of the joint capsule. Pin site flora can track into the joint and lead to a septic knee.
Tibial external fixators can be used to temporize tibial shaft, pilon, and ankle fractures not ready for definitive management due to soft tissue concerns and/or practice of damage control orthopaedics. Intracapsular placement of fixator pins can lead to septic arthritis. The capsular reflection typically extends 14 mm distal to the subchondral line.
DeCoster et al. reported a cadaveric dissection study for safe placement of proximal tibia pins and determined that the capsule inserts 14 mm below the articular surface along the posteromedial and posterolateral surfaces. For fractures requiring extremely proximal pin placement, they recommend
anterior cortex penetration only at least 6 mm distal to articular surface.
Reid et al. investigated safe transtibial pin placement using MRI and cadaveric and volunteer knees. They found that pin placement 14 mm distal to subchondral bone will result in low likelihood of capsular penetration.
Figure A is an AP radiograph showing a segmental middle third tibia/fibula fracture. Figure B is a lateral diagram of the tibia showing potential sites of proximal pin placement.
Incorrect Answers:
OrthoCash 2020
Figures A and B are radiographs of a 43-year-old, right-hand dominant, male that injured his arm in a motor vehicle accident. What would be an absolute indication for surgical fixation of his injury?
Radial nerve palsy
Intra-articular extension
2mm fracture distraction, 5 degrees of rotational malignment
Ipsilateral proximal both bone forearm fracture
Bilateral fracture
This patient has a humeral shaft fracture. An absolute indication for surgery would include a floating elbow, i.e. ipsilateral both bone forearm fracture.
The primary causes of humeral fractures include motor vehicle accidents, falls, or violent injury. Almost all cases are treated non-operatively with functional bracing. The absolute indications for surgical management include: ipsilateral vascular injury, severe soft-tissue injury, open fracture, compartment syndrome, and associated ipsilateral forearm fracture, ie, floating elbow. The relative indications for surgical management include: segmental fracture, intraarticular extension, significant fracture distraction, bilateral humeral fracture, inability to maintain acceptable alignment, and polytrauma.
Klenerman et al. reviewed non-operative treatment of humeral shaft fractures. They showed that acceptable results could be achieved even after 20° of
anterior bowing, 30° of varus angulation, 15° of malrotation, and 3 cm of shortening.
Carroll et al. reviewed the management of humeral shaft fractures. They state the indications for operative fixation to be polytraumatic injuries, open fractures, vascular injury, ipsilateral articular fractures, floating elbow injuries, and fractures that fail nonsurgical management. Surgical techniques include external fixation, open reduction and internal fixation, minimally invasive percutaneous osteosynthesis, and antegrade or retrograde intramedullary nailing
Figure A and B shows a comminuted mid-shaft humeral fracture with intraarticular extension.
Incorrect Answers:
OrthoCash 2020
Which of the following findings is a contraindication in retrograde nailing of a periprosthetic distal femur fracture around a total knee arthroplasty?
Posterior-stabilized total knee implant
Cruciate retaining total knee implant
Spiral fracture pattern
Distal femoral replacement
Knee flexion contracture of 15 degrees
Corrent answer: 4
A distal femoral replacement (TKA) implant will generally preclude placement of a retrograde nail due to the long stem on the femoral component.
Supracondylar femur fractures above a well-fixed TKA component are increasingly common. These fractures are often treated with a lateral locking plate, but can also be treated with a retrograde nail in certain circumstances. An important factor in determining if nailing is a viable option are knowing the TKA implant and it's design. In addition, if the TKA component is known, the maximum size of reamer head and nail can be determined preoperatively from the size of the femoral 'box'.
Schutz et al report on a prospective multicenter study of 112 patients who underwent fixation of a distal femur fracture with the LISS system. They report that 90% of fractures went on to union and they attribute all of the failures to either the high-energy nature of particular fractures or a lack of experience in applying the plate in an appropriate pattern. They also note that primary grafting of these fractures is not necessary.
Illustration A shows a periprosthetic femur fracture treated with a retrograde nail.
Incorrect Answers:
1: A posterior-stabilized implant can be treated with an intramedullary nail in many circumstances but can be technically challenging, depending on the components.
2: A cruciate retaining TKA is not a contraindication to use of a retrograde nail. 3: A spiral pattern periprosthetic supracondylar femur fracture can be treated with a femoral nail.
5: A knee flexion contracture will often provide the flexion necessary for access to the box of the femoral component. A knee extension contracture, however, can preclude access to this box for placement of a nail.
OrthoCash 2020
A patient falls and sustains the isolated injury seen in Figures A and B. The surgical plan includes open reduction and internal fixation with a small mini-fragment plate using a direct lateral approach. During the approach, the forearm was placed in a fully pronated position. What would be the correct position of the forearm during plate application?
Full pronation
25 degrees pronation
Neutral
25 degrees supination
Full supination
Using the lateral approach (Kocher or Kaplan), the correct placement of the arm should be in a neutral position so that the plate can be placed on the bare area of the proximal radius.
Displaced radial head fractures with less than 3 fragments can be amendable to open reduction internal fixation. The methods of fixation include buried or headless screws, if placed at the articular surface, or posterolateral plating, if placed in the bare area. The safe zone for plating is located at a 90-110 arc from the radial styloid to Lister's tubercle with the arm in neutral rotation. This position helps to avoid impingement of ulna against the plate with forearm rotation. It should be noted that during the approach, that the forearm should be fully pronated to avoid injury to the posterior interosseous nerve.
Mathew et al. reviewed the concepts of terrible triad injuries of the elbow. Radial head fractures are treated conservatively when there is an isolated minimally displaced (less than 2mm) fracture with no mechanical block to motion. Open reduction internal fixation is used for Mason II or III fractures with < 3 fragments. Radial head replacement is considered for comminuted
fractures (Mason Type III) with 3 or more fragments.
Cheung et al. reviewed the surgical approaches to the elbow. The lateral approach (Kocher or Kaplan) is most commonly used with these injuries. The Kocher approach utilizes the intramuscular plane between anconeus and extensor carpi ulnaris. Kaplan utilizes the plane between extensor digitorum commons and extensor carpi radialis brevis.
Figure A and B show AP and lateral radiographs of the left elbow. There is a displaced radial head fracture. Illustration A shows a schematic diagram of the radial head "safe zone" between the radial styloid to Lister's tubercle.
Incorrect Answers:
OrthoCash 2020
A 38-year-old male is involved in a high speed motor vehicle collision. He has a Glasgow Coma Scale of 13 and receives 2 liters of fluid en route to the emergency department. Upon evaluation in the emergency department, he is found to have a bilateral femoral shaft fractures, a right ankle fracture, and a left both bone forearm fracture. He also has 2 left sided rib fracture and a grade II liver laceration. His heart rate is 130 and blood pressure is 85/50. All of the following
would be indications to practice damage control orthopaedics in this patient except:
Bilateral femur fractures
Rib fractures
Lactate of 5.2
Urine output of 20 cc/hr
Heart rate and blood pressure
Corrent answer: 2
Rib fractures without evidence of further thoracic trauma would not be an indication to practice damage control orthopaedics. This patient is underresuscitated based on his lactate level, urine output, and vital signs and definitive management should be delayed.
Damage control orthopaedics is the practice of delaying definitive management of fractures and utilizing temporary stabilization (such as an external fixator) until a patient has recovered from the initial physiologic insult of trauma.
Patients are at increased risk for perioperative complications such as ARDS and multi-system organ failure during the acute period after polytrauma. In addition to underresuscitation, other indications to practice damage control orthopaedics include: injury severity score>40 (or >20 with thoracic trauma), bilateral femoral fractures, hypothermia below 35 degrees Celsius, and pulmonary contusions.
Pape et al. (2007) studied the incidence of acute lung injuries in polytrauma patients undergoing either intramedullary nailing or external fixation and later definitive fixation of femoral shaft fractures. They found that patients undergoing immediate intramedullary nailing were nearly 6.7 times more likely to have acute lung injury
The Canadian Orthopedic Trauma Society studied the effect of reamed versus unreamed femoral nailing on incidence of ARDS for femoral shaft fractures in trauma patients using a randomized controlled study. They found no difference between the groups.
Pape et al. also examined the pathophysiological cascades that accompany soft tissue injuries of the extremities, abdomen, and pelvis and recommend a more comprehensive for evaluation of patients with these injuries.
Incorrect Answers:
OrthoCash 2020
The anterior intrapelvic (modified Stoppa) approach is most appropriate for which of the following fractures?
The anterior intrapelvic (AIP) or modified Stoppa approach provides access to the quadrilateral plate, which is a common location for fracture displacement in associated both column acetabulum fractures as seen in Figure D.
Compared to the traditional ilioinguinal approach, the modified Stoppa with a lateral window can offer comparable access to the quadrilateral plate, which can allow for its use in associated both column fracture patterns.
de Peretti et al. prospectively followed 25 patients with both column fractures
treated via an iliofemoral approach. Results led the authors to not recommend the extensile approach for both column fractures due to lack of efficiency and high complication rates.
Alonso et al. compared the extensile iliofemoral and triradiate approaches, and both reported acceptable results. However, concerning were the relatively high rates of heterotopic ossification, despite prophylaxis.
Bible al. performed a cadaver study to quantify the amount of access provided by the modified Stoppa approach. This approach provides access to approximately 80% of both the inner pelvis, and the quadrilateral plate, however, comparison to the ilioinguinal approach was not performed.
Shazar et al., in a cohort comparison between the ilioguinal and Stoppa approaches, noted better visualization and potential improve fracture reduction via the Stoppa approach for both column fractures. However, this study was limited in its retrospective and relative observer bias.
Figure A depicts a posterior wall fracture dislocation with concomitant femoral neck fracture. Figure B is an iliac oblique view which depicts a posterior column fracture. Figure C exhibits a posterior column + posterior wall fracture. Figure D depicts acetabular fracture with protrusio. Figure E exhibits a posterior wall fracture.
Incorrect answers:
OrthoCash 2020
Figure A is a radiograph of a 75-year-old woman that fell onto her non-dominant shoulder from a standing height. She was treated nonoperatively for 9 months but continues to complain of pain when she elevates her arm. In patients with this type of fracture pattern, what factor has the greatest impact on fracture healing?
Hand dominance
Angulation of fracture
Smoking
Early physical therapy
Diet
This patient has an impacted varus proximal humerus fracture. Smoking has been shown to increase the nonunion risk up to 5.5 times with these fractures.
Impacted varus proximal humerus fractures can be managed effectively with non-operative care. The major factors that influence non-union are age and smoking. Solid bony union can be seen in 93-98% of patients at 1 year, with more than 97% of people returning to pre-injury level of function. The angulation of fracture, hand dominance and physical therapy does not seem to influence bone union or functional outcomes with this fracture pattern.
Court-Brown et al. looked at the outcomes of impacted varus fractures. They determined that the age of the patient was the major factor in overall outcome. They showed that the best results occurred in younger patients, but results deteriorate with advancing age. Physical therapy was not found to
impact outcome.
Hanson et al. showed that impacted varus fractures can be successfully managed with non-operative care. They found that overall fracture displacement had a minor impact of fracture healing and functional outcome. The predicted risk of delayed union and nonunion was 7% with patients that smoke. This was 5.5 times greater than non-smokers.
Figure A shows an AP radiograph of a varus angulated proximal humerus fracture. This radiograph shows delayed atrophic union.
Incorrect Answers:
OrthoCash 2020
A 26-year-old male epileptic patients presents with right shoulder pain and deformity after a grand mal seizure. After medical stabilization, he denies previous injury to his shoulder. Pre-reduction and post-reduction radiographs of the shoulder are shown in Figures A-C, respectively; physical examination reveals a normal upper extremity neurovascular examination. After shoulder immobilization, what would be the next most appropriate step in management of this patient?
Abduction brace for three weeks, followed by therapy
Right shoulder MR arthrogram
Open reduction and internal fixation
Hemiarthroplasty
Early range of motion
Corrent answer: 3
This patient has presented with a fracture dislocation of the right shoulder. After urgent closed reduction, this patient requires open reduction internal fixation of the proximal humerus, and greater tuberosity fracture fragment in particular.
Isolated greater tuberosity fractures may be associated with shoulder dislocations. Careful review of imaging is critical to identify fracture lines that may extend into the humeral neck and head. If these extensions go undetected, catastrophic propagating fractures may occur during closed reduction maneuvers. Treatment is usually with open reduction internal fixation (ORIF). Young patients with proximal humerus fractures should be treated more aggressively with ORIF as compared to elderly patients. Another example would be a severely impacted valgus proximal humeral fracture in a young patient.
Erasmo et al. examined of 82 cases of humerus fracture dislocations treated with the lateral locking plates. Overall outcomes were excellent to good based on standard scoring systems. Complications included avascular necrosis (12%), varus positioning of the head (4.8%), impingement syndrome (3.6%), secondary screw perforation (3.6%), non-union (2.4%) and infection (1.2%).
Robinson et al. looked at severely impacted valgus proximal humeral fractures treated with open reduction internal fixation in young patients. Anatomic reduction is required with lateral plating to re-establish the normal head/neck angle. Good to excellent results can be achieved with fixation methods.
Figure A shows an anterior fracture-dislocation of the right shoulder. Figure B and C show post-reduction radiographs with a congruent glenohumeral joint. Displacement of the greater tuberosity (GT) fragment is greater than 5mm.
Incorrect Answers:
OrthoCash 2020
Pelvic packing can be performed to temporarily treat a hemodynamically unstable patient with a pelvic ring fracture. Which of the following is the preferred location of the skin incision to perform pelvic packing?
Right anterior superior iliac spine (ASIS) to mid-symphysis, left lateral window incision
Left ASIS to mid-symphysis, right lateral window incision
Subumbilical incision
ASIS to ASIS bilaterally
Pararectus incision
The preferred skin incision location is a subumbilical incision, 6-8cm extending upwards from the pubic symphysis towards the umbilicus; this allows access to all of the appropriate areas for pelvic packing.
Following skin incision, the rectus fascia is then divided in the midline which allows for access to both sides of the bladder for packing deep in the pelvic
brim. On each side, 3 lap pads are placed from sacroiliac joint to the retropubic space, all placed below the level of the pelvic brim.
Hak et al. review the options for emergent treatment in life threatening hemorrhage secondary to pelvic fractures. The authors offer several options for emergent treatment, which includes the use of pelvic binders, the placement of external fixators, pelvic packing and interventional angiography. Goals include reduction of pelvic volume and stopping rapid hemorrhage to save a patient's life. Pelvic packing, properly performed, is done through a subumbilical incision, as described above.
Osborn et al. retrospectively reviewed and compared emergent pelvic packing to angiography in hemorrhagic pelvic fracture clinical scenarios. The authors noted comparable results in mortality with a noted decrease in need for post-procedure transfusions in the pelvic packing group.
Cothren et al. reported their outcomes following an institutional algorithmic change from pelvic ex-fix/angiography to pelvic packing and ex-fix. Since their institutional change, the authors noted a significant decrease in transfusions, need for angiography and mortality.
Incorrect answers:
OrthoCash 2020
A 28-year-old man is brought by ambulance to the emergency department after falling from the roof of his home four hours ago. Upon initial evaluation, he has visible deformities of his bilateral lower extremities and a positive FAST exam. Heart rate is 135, blood pressure 85/58, and urine output is 40 cc over 3 hours. According to ATLS guidelines, what percentage of his blood volume has this patient likely lost?

Question 4:

Options:

Open reduction and internal fixation (ORIF) of the acetabular fracture with concomitant acute total hip arthroplasty
ORIF of the acetabular fracture and ORIF of the femoral head fracture fragments
ORIF of the acetabular fracture and hemiarthroplasty
Skeletal traction with delayed total hip arthroplasty after the acetabular fracture has healed

Correct Answer: Open reduction and internal fixation (ORIF) of the acetabular fracture with concomitant acute total hip arthroplasty

Explanation:

DISCUSSION:
The radiograph shows a posterior wall acetabular fracture-dislocation. Post reduction CT indicates a large comminuted posterior wall fracture with marginal impaction of the articular surface. A comminuted femoral head fracture also is seen extending to the superior weight-bearing surface. Given the marginal
impaction of the acetabulum and the considerable comminution of the femoral head (which is likely unreconstructible), this injury would have a high risk of causing posttraumatic arthritis if treated with ORIF of the fractures alone. Considering this fact and the patient’s age, ORIF of the posterior wall and acute total hip arthroplasty would likely have the best functional result and the lowest risk of reoperation. Hemiarthroplasty is inappropriate for this injury considering the acetabular fracture. Skeletal traction currently plays a limited role in the definitive treatment of acetabular fractures.

Question 5:

A biopsy of the involved physis in a patient with slipped capital femoral epiphysis (SCFE) would most likely reveal

Options:

a dense perichondral ring.
an abnormally thick zone of proliferation.
increased undulations or irregularity of the growth plate.
granulation tissue between the columns in the zone of hypertrophy.
normal proteoglycan content.

Correct Answer: granulation tissue between the columns in the zone of hypertrophy.

Explanation:

Question 6:

Options:

Revision hip arthroplasty with a bipolar implant
Revision hip arthroplasty with impaction grafting on the femoral and acetabular side
Revision hip arthroplasty with a cemented jumbo acetabular component
Revision hip arthroplasty with a cementless acetabular component
Acetabular component revision with a tri-flange protrusio ring

Correct Answer: Revision hip arthroplasty with a cementless acetabular component

Explanation:

DISCUSSION: The radiographs reveal acetabular component failure with bone loss. There
are several treatment options available. The best option for survivorship is a cementless
porous-coated acetabular component. This patient may or may not require structural bone graft, which may need to be determined at the time of surgery. Bipolar implants and cemented acetabular components for revision surgery have not demonstrated long-term success. The use of a protrusio ring is reserved primarily for massive bone loss such as a Paprosky type III bone loss with significant superior migration of the acetabular component. The best clinical results for acetabular component revision have been achieved with cementless porous-coated implants.
REFERENCES: Haddad FS, Masri BA, Garbuz DS, et al: Acetabulum, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 923-936.
D’Antonio JA: Periprosthetic bone loss of the acetabulum: Classification and management. Orthop Clin North Am 1992;23:279-290.
Rubash HE, Sinha RK, Paprosky W, et al: A new classification system for the management of acetabular osteolysis after total hip arthroplasty. Instr Course Lect 1999;48:37-42.

Question 7:

Options:

Chemotherapy and radiation therapy
Neoadjuvant chemotherapy followed by wide resection and reconstruction
Curettage and bone grafting
Curettage and intravenous antibiotics
Above-knee amputation

Correct Answer: Neoadjuvant chemotherapy followed by wide resection and reconstruction

Explanation:

Question 8:

-What is the most appropriate course of action for this patient’s condition?

Options:

Early mobilization and a guided proprioceptive and strengthening rehabilitation program
Extended immobilization in a cast
Surgical intervention
Weight bearing as tolerated in an ankle brace for 6 weeks

Correct Answer: Early mobilization and a guided proprioceptive and strengthening rehabilitation program

Explanation:

DISCUSSION FOR QUESTIONS 7 THROUGH 9
The anterior drawer test is performed with the ankle in 10 degrees of plantar flexion, which results in the greatest amount of translation. The test investigates the integrity of the anterior talofibular ligament with a key distance of translation being 8 to 10 mm. While the patient is sitting and has her knees flexed over the edge of a table or bench, the physician or examiner uses one hand to stabilize the distal leg and with the other applies an anterior force to the heel in an attempt to gap the talus anteriorly from under the tibia. The anterior talofibular ligament and calcaneofibular ligament are both compromised based on the examination findings. The anterior drawer test result reflects injury to the anterior talofibular ligament and a possible injury to the calcaneofibular ligament. A lateral talar tilt test angle measurement greater than 15 degrees reflects a rupture of both anterior talofibular ligament and calcaneofibular ligaments.The diagnosis is a severe lateral ligament complex sprain. Considering the involvement of the anterior talofibular ligament and calcaneofibular ligaments, early mobilization with a cast or controlled ankle movement walker boot has been documented to result in better patient outcomes than compression or air casting.

Question 9:

Options:

Lateralize the acetabular component, use a low offset femoral component, and make a shorter neck cut
Medialize the acetabular component, use a low offset femoral component, and make a longer neck cut
Lateralize the acetabular component, use a high offset femoral component, and make a shorter neck cut
Medialize the acetabular component, use a high offset femoral component, and make a longer neck cut

Correct Answer: Medialize the acetabular component, use a low offset femoral component, and make a longer neck cut

Explanation:

Question 10:

Figure 10 shows the radiograph of an active 75-year-old woman who reports severe leg pain after a fall. Management should consist of

Options:

a total hip arthroplasty with a long-stem prosthesis.
a resection arthroplasty with skeletal traction.
hemiarthroplasty with a long-stem prosthesis.
retention of the prosthesis and open reduction and internal fixation.
closed treatment with skeletal traction.

Correct Answer: a total hip arthroplasty with a long-stem prosthesis.

Explanation:

Question 11:

Options:

Intravenous antibiotics
Debridement of the wound without hardware removal
Debridement of the wound with hardware removal
Vacuum-assisted closure (VAC) and negative pressure therapy
Total calcanectomy

Correct Answer: Debridement of the wound with hardware removal

Explanation:

DISCUSSION: Intravenous antibiotics alone will not adequately treat this infection. At 8 weeks after surgery, the hardware must be removed because Staphylococcus aureus is a virulent microbe. VAC therapy alone is not adequate without debridement and hardware removal, but it may play a role in postoperative wound care. Calcanectomy is a salvage procedure for calcaneal osteomyelitis or recalcitrant heel ulceration.
REFERENCES: Benirschke SK, Kramer PA: Wound healing complications in closed and open calcaneal fractures. J Orthop Trauma 2004;18:1-6.
Lim EV, Leung JP: Complications of intra-articular calcaneal fractures. Clin Orthop
2001;391:7-16.
Folk JW, Starr AJ, Early JS: Early wound complications of operative treatment of calcaneus fractures: Analysis of 190 fractures. J Orthop Trauma 1999;13:369-372.

Question 12:

What pathology is most likely to result in failure of an arthroscopic Bankart repair?

Options:

A 25% or greater anterior-inferior glenoid rim defect
Nonengaging moderate Hill-Sachs defect
Associated type IV superior labrum anterior and posterior (SLAP) lesion
Absence of an intact cartilaginous labrum
Atttenuated anterior-inferior capsule and glenohumeral ligament complex

Correct Answer: A 25% or greater anterior-inferior glenoid rim defect

Explanation:

Question 13:

Options:

Latent osteomyelitis from the percutaneous pins
Muscle weakness because of a lack of postinjury rehabilitation
Tardy ulnar nerve paralysis from injury by the medial pin
Osteonecrosis of the trochlea, producing joint incongruity
A new acute process

Correct Answer: Osteonecrosis of the trochlea, producing joint incongruity

Explanation:

Question 14:

A 40-year-old man with an acetabular chondrosarcoma has a small soft-tissue mass. Treatment should consist of

Options:

chemotherapy with ifosfamide and doxorubicin hydrochloride.
external beam radiation.
wide resection.
curettage and cementation of the pelvic lesion.
cemented total hip arthroplasty with acetabular reconstruction.

Correct Answer: wide resection.

Explanation:

Question 15:

Options:

Infected total knee arthroplasty
Polyethylene wear-related synovitis
Rheumatoid arthritis synovitis
Gout
Tibial component loosening

Correct Answer: Polyethylene wear-related synovitis

Explanation:

DISCUSSION: Polyethylene wear debris can result in significant synovitis and subsequent cloudy appearing synovial fluid. Typically, laboratory studies show a WBC of less than 30,000/mm
3
and no left shift. Cytologic examination can reveal intra-articular polyethylene particles. Infected total knee arthroplasty is extremely uncommon in a healthy, immune-competent patient who has a normal preoperative erythrocyte sedimentation rate and C-reactive protein level.
REFERENCE: Barrack RL, Jennings RW, Wolfe MW, Bertot AJ: The value of preoperative aspiration before total knee revision. Clin Orthop 1997;345:8-16.

Question 16:

Options:

Smoking status
Postmenopausal status
BMI
Radiographic findings The principal contraindications to valgus-producing HTO include (1) lateral compartment degenerative joint disease, (2) loss of a significant portion of the lateral meniscus, (3) symptomatic patellofemoral degenerative joint disease, (4) nonconcordant pain (ie, patellofemoral pain with medial compartment osteoarthritis), (5) smoking, (6) patient unwillingness to accept the anticipated cosmetic appearance of the desired amount of angular correction, and (7) inflammatory arthritis.

Correct Answer: Smoking status

Explanation:

Question 17:

Options:

Peripheral myelin protein-22
Dystrophin
Type I collagen
Alpha-L-iduronidase
Cartilage oligomeric matrix protein

Correct Answer: Peripheral myelin protein-22

Explanation:

DISCUSSION: The girl shows clinical features of hereditary motor sensory neuropathy type 1, Charcot-Marie-Tooth disease. The most common type of this autosomal-dominant disease is due to an underlying defect in the gene coding for peripheral myelin protein-22 on chromosome 17. Many other less common mutations have been identified in this family of neuropathies. Dystrophin is a protein that is abnormal in Duchenne’s muscular dystrophy, which affects males and is diagnosed earlier. Type I collagen is defective in osteogenesis imperfecta.
Alpha-L-iduronidase is defective in mucopolysaccharidosis type I, Hurler’s syndrome. Defective cartilage oligomeric matrix protein is associated with some forms of multiple epiphyseal dysplasia.
REFERENCES: Patel PI, Roa BB, Welcher AA, et al: The gene for the peripheral myelin protein PMP-22 is a candidate for Charcot-Marie-Tooth disease type 1A. Nat Genet 1992;1:159-165.
Harding AE: From the syndrome of Charcot, Marie and Tooth to disorders of peripheral myelin proteins. Brain 1995;118:809-818.

Question 18:

Options:

Abdominal and pelvic ultrasound
CT of the abdomen and pelvis
Technetium Tc 99m three-phase bone scan
Abdominal radiographic series
Gallium-67 citrate scan

Correct Answer: CT of the abdomen and pelvis

Explanation:

Question 19:

Options:

Fixation in the tibial tunnel
Fixation in the femoral tunnel
Posterior placement of the tibial tunnel
Anterior placement of the femoral tunnel
Size of the patellar autograft

Correct Answer: Anterior placement of the femoral tunnel

Explanation:

Question 20:

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 21:

What are the five major compartments of the foot?

Options:

Medial, lateral, central, interosseous, and calcaneal
Medial, lateral, central, interosseous, and dorsal
Medial, lateral, central, dorsal, and calcaneal
Medial, lateral, dorsal, interosseous, and calcaneal
Dorsal, lateral, central, interosseous, and calcaneal

Correct Answer: Medial, lateral, central, interosseous, and calcaneal

Explanation:

Question 22:

-The fracture shown in Figure 82 is scheduled to be fixed with a retrograde nail. An arthrotomy should be performed during the procedure because it

Options:

ensures proper nail depth.
provides control of the distal fragment.
allows assessment for occult infection.
allows protection of the polyethylene liner.
allows assessment of the loosening component requiring revision.

Correct Answer: allows protection of the polyethylene liner.

Question 23:

Which of the following findings is considered a poor prognostic factor for postoperative neurologic recovery in patients with rheumatoid arthritis?

Options:

Anterior atlantoaxial interval of more than 5 mm
Subaxial subluxation of more than 3.5 mm
Subaxial subluxation and space available for the cord equal to 14 mm
Cervicomedullary angle of 135°
Posterior atlantoaxial interval that is less than or equal to 10 mm

Correct Answer: Posterior atlantoaxial interval that is less than or equal to 10 mm

Explanation:

Question 24:

Glenohumeral disarticulation often leads to which of the following changes?

Options:

Hiking of the shoulder girdle
Hypertrophy of the amputated shoulder girdle
Improvement in thoracic spinal deformity
Protraction of the shoulder
Winging of the scapula

Correct Answer: Hiking of the shoulder girdle

Explanation:

Question 25:

Options:

Gentle physical therapy and lifestyle modification to reduce demands on the symptomatic muscles
Vigorous physical therapy to rehabilitate the weak muscle groups
Muscle biopsy
MRI of the lumbosacral spine
Electromyography and nerve conduction velocity studies

Correct Answer: Gentle physical therapy and lifestyle modification to reduce demands on the symptomatic muscles

Explanation:

Question 26:

What is the most important preoperative factor predicting conversion to total hip arthroplasty after arthroscopic surgery of the hip?

Options:

Age over 60 years
Morbid obesity
Diagnosis of osteoarthritis
Tobacco use

Correct Answer: Morbid obesity

Explanation:

Question 27:

Options:

Intraarticular penetration of the screw
Position of the screw cephalad to the sciatic notch
Screw starting point at the anterior inferior iliac spine
Screw starting point at the gluteal pillar
Screw position between the inner and outer tables of the ilium

Correct Answer: Intraarticular penetration of the screw

Explanation:

Question 28:

Options:

dislocating posteriorly in extension and reducing in flexion.
dislocating posteriorly in flexion and reducing in extension.
dislocating anteriorly in extension and reducing in flexion.
dislocating anteriorly in flexion and reducing in extension. PLRI of the elbow is the most common form of chronic elbow instability. The mechanism occurs following a fall onto an outstretched hand, where a valgus force is applied to the elbow and the forearm rotates into progressive supination. This allows the radial head to translate posterior to the capitellum, with progressive injury from lateral to medial sides of the elbow. The pivot shift test is a useful examination maneuver to confirm the presence of PLRI. With the forearm in maximal supination and valgus stress applied to the elbow, the radial head is forced posterior to the capitellum as the elbow is brought into progressive extension, revealing a dimple on the lateral aspect of the elbow. This typically occurs at roughly 30° of flexion. As the elbow is flexed, the radial head reduces.

Correct Answer: dislocating posteriorly in extension and reducing in flexion.

Explanation:

Question 29:

Options:

Begin a stretching program.
Obtain shoulder radiographs and aspirate the shoulder joint.
Obtain an MRI scan to evaluate for a rotator cuff tear.
Schedule for irrigation and debridement.
Schedule for revision shoulder arthroplasty.

Correct Answer: Obtain shoulder radiographs and aspirate the shoulder joint.

Explanation:

Question 30:

- A patient reports persistent pain in the wrist 6 months after undergoing open reduction and internal fixation of a Galleazi fracture. Radiographs of the wrist in a neutral position are normal. Which of the following studies would best evaluate the reduction of the distal radioulnar joint?

Options:

Arthrogram of the wrist
MRI scan of both wrists
CT scan of both wrists in the same position
Radiographs of the wrist in supination and pronation
Radiographs of the opposite wrist in the same position

Correct Answer: CT scan of both wrists in the same position

Explanation:

Question 31:

Options:

CT
Routine ACL rehabilitation
Modified ACL rehabilitation to limit weight bearing
Modified ACL rehabilitation to limit flexion
Revision ACL surgery

Correct Answer: Revision ACL surgery

Explanation:

Question 32:

What is the most commonly reported complication following elbow arthroscopy?

Options:

Synovial cutaneous fistula
Nerve transection
Compartment syndrome
Infection
Transient neurapraxia

Correct Answer: Transient neurapraxia

Explanation:

DISCUSSION: The complication rate following elbow arthroscopy is reported at 5%. The most commonly reported complication is transient neurapraxia, with nerve transection remaining an unfortunate and rare event. While infection remains the most common serious complication, it is uncommon (0.8%). Synovial cutaneous fistula and compartment syndrome, while reported, are the least frequent complications of elbow arthroscopy.
REFERENCES: Kelly EW, Morrey BF, O’Driscoll SW: Complications of elbow arthroscopy.
J Bone Joint Surg Am 2001;83:25-34.
Morrey BF: Elbow complication, in Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2001, pp 519-522.

Question 33:

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

Options:

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

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

Explanation:

Question 34:

Options:

closed reduction and a non-weight-bearing cast.
closed reduction and a weight-bearing cast.
closed reduction and percutaneous pinning.
open reduction and casting.
open reduction and internal fixation.

Correct Answer: open reduction and internal fixation.

Explanation:

Question 35:

Options:

High tibial osteotomy
Total knee replacement
Unicondylar knee replacement
Arthroscopic partial meniscectomy

Correct Answer: Total knee replacement

Explanation:

Question 36:

Options:

anterior translation of the humeral head.
loss of external rotation.
excessive tightening of the biceps tendon.
superior migration of the humeral head.
no excessive changes

Correct Answer: loss of external rotation.

Explanation:

If the Buford complex is mistakenly reattached to the neck of the glenoid, severe painful restriction of external rotation will occur.

Question 37:

Options:

loosening of the femoral component.
loosening of the acetabular component.
prosthetic hip dislocation.
rapid wear of the polyethylene.
continued expansion of the lytic defects.

Correct Answer: prosthetic hip dislocation.

Explanation:

DISCUSSION: Maloney and associates reported a 35% increased risk of pelvic osteolysis after total hip arthroplasty with a porous-coated acetabular component without cement. All components were stable at the time of revision. Only liners were exchanged and debridement of the granuloma with or without bone graft was performed. No defects progressed and one third of the lesions were no longer visible on radiographs, regardless of bone grafting. Unfortunately, despite the technical ease of many of these types of revisions, the dislocation rate for these cases is significant. Precautions should be taken postoperatively, and patients should be educated about this risk preoperatively.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 411-424.
Boucher HR, Lynch C, Young AM, et al: Dislocation after polyethylene liner exchange in total hip arthroplasty. J Arthroplasty 2003;18:654-657.
Maloney WJ, Herzwurm P, Paprosky W, et al: Treatment of pelvic osteolysis associated with a stable acetabular component inserted without cement as part of a total hip replacement. J Bone Joint Surg Am 1997;79:1628-1634.

Question 38:

The presence of S100B tumor marker typically corresponds with which of the following as being the most likely source of the metastasis?

Options:

Thyroid adenocarcinoma
Breast carcinoma
Gastrointestinal carcinoma
Melanoma
Astrocytoma

Correct Answer: Melanoma

Explanation:

DISCUSSION: Advances in development of new tumor markers and techniques of antigen retrieval have enhanced the sensitivity and reliability of identifying the primary source of metastasis. New markers such as CK7, CK20, CA125, and thyroid transcription factor-1
(TTF-1) can help to determine the origin of an adenocarcinoma or aid in the recognition of other tumors. In patients who do not have an obvious primary site of disease or screening radiographs, these new markers can help focus the search for and guide the treatment of the underlying lesion. CA125 is positive in patients with ovarian cancer, CK7 is positive in patients with breast and lung carcinoma, and CK20 is indicative of colon carcinoma if the CK7 marker is negative. Gastrointestinal stromal tumor (GIST) is positive for CD117 (c-kit) and CD34, whereas 75% of bronchogenic carcinomas are positive for TTF-1. Histochemical staining of the S100 protein family has been used for many years in the diagnosis of malignant melanoma. Recent markers HMB-45, MART-1, and Melan-A have proved to be useful in diagnosis of melanoma. S100B protein has been implicated in downregulation of p53 (oncosuppressor gene).
REFERENCES: Harpio R, Einarsson R: S100 proteins as cancer biomarkers with focus on S100B in malignant melanoma. Clin Biochem 2004;37:512-518.
Roodman GD: Mechanisms of bone metastasis. N Engl J Med 2004;350:1655-1664.

Question 39:

Options:

Adjunctive plate fixation without nail removal
Nail removal and plating
Partial fibulectomy at the same level as the tibia fracture and weightbearing cast application
Exchange nailing
Local administration of rhBMP-2

Correct Answer: Adjunctive plate fixation without nail removal

Explanation:

Question 40:

The recurrent motor branch of the median nerve innervates which of the following muscles?

Options:

Abductor pollicis brevis, first dorsal interosseous, opponens pollicis
Abductor pollicis brevis, flexor pollicis brevis, opponens pollicis
Adductor pollicis, first dorsal interosseous, opponens pollicis
Adductor pollicis, flexor pollicis brevis (deep and superficial heads)
Adductor pollicis, flexor pollicis brevis, opponens pollicis

Correct Answer: Abductor pollicis brevis, flexor pollicis brevis, opponens pollicis

Explanation:

Question 41:

What is a known risk factor for lateral distal femoral locking plate failure when used for the fixation of comminuted extra-articular fractures?

Options:

Early post-operative knee range of motion
Delayed weightbearing
Short working length of the construct
Bridge plate fixation
Plate-screw density less than 0.5

Correct Answer: Plate-screw density less than 0.5

Explanation:

Question 42:

When compared to smokers who do not quit, an improvement in the rate of lumbar fusion is seen in patients who cease smoking for at least how many months postoperatively? Review Topic

Options:

1 month
2 months
4 months
6 months
12 months

Correct Answer: 6 months

Explanation:

Question 43:

In Ewing’s sarcoma, neoplastic properties are thought to be related to a

Options:

environmental toxins.
a prior history of osteomyelitis.
a prior history of viral illness.
a prior history of trauma.
translocation of chromosomes.

Correct Answer: translocation of chromosomes.

Explanation:

Question 44:

Antegrade femoral nailing has an increased rate of which of the following when compared to retrograde femoral nailing?

Options:

Varus malalignment
Union rate
Operative time
Subsequent operative procedures
Hip pain

Correct Answer: Varus malalignment

Explanation:

Question 45:

Options:

Transoral, transmucosal direct anterior approach to C2-3
Left-sided anterior approach to C2-3 (Smith-Robinson)
Right-sided posterior retropharyngeal approach to C2-3 (Whitesides)
Right-sided anterior approach to C2-3 (Smith-Robinson)
Right-sided anterior retropharyngeal approach with extended vertical incision (superior extension Smith-Robinson)

Correct Answer: Right-sided anterior retropharyngeal approach with extended vertical incision (superior extension Smith-Robinson)

Explanation:

Question 46:

Optimal management of the injury shown in Figure 31 should include which of the following?

Options:

Cast immobilization in equinus
Open reduction and internal fixation once the acute soft-tissue swelling has resolved
Urgent reduction and fixation
Arthroscopic-assisted percutaneous fixation
Open reduction and internal fixation with primary subtalar arthrodesis

Correct Answer: Urgent reduction and fixation

Explanation:

Question 47:

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

Options:

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

Correct Answer: Determines hindfoot flexibility

Explanation:

Question 48:

Which of the following activities produces greater hip joint contact pressures than full weight bearing during normal gait?

Options:

Performing isometric hip exercises
Getting on a bed pan
Ambulating with a cane
Rising from a chair using the affected leg
Toe-touch weight bearing with passive hip abduction

Correct Answer: Performing isometric hip exercises

Explanation:

Question 49:

Options:

pre-debridement cultures.
post-debridement cultures.
neither debridement culture.
anaerobic specimens.

Correct Answer: neither debridement culture.

Explanation:

Question 50:

Options:

Cemented unipolar hemiarthroplasty B. Cemented bipolar hemiarthroplasty C. Total hip replacement
Open reduction and internal fixation

Correct Answer: Cemented unipolar hemiarthroplasty B. Cemented bipolar hemiarthroplasty C. Total hip replacement

Explanation:

Question 51:

Options:

0% to 1% with press-fit tibial stems
3% to 5% with press-fit tibial stems
3% to 5% with cemented tibial stems
More than 5% with press-fit tibial stems

Correct Answer: 3% to 5% with press-fit tibial stems

Explanation:

Question 52:

Options:

Brachioradialis (BR)
Extensor carpi radialis brevis (ECRB)
Extensor carpi ulnaris (ECU)
Extensor indicis proprius (EIP) The incidence of radial nerve palsy after a humeral shaft fracture has been estimated as being between 7% and 22%. Controversy remains regarding the need for early exploration in a patient presenting with a closed humerus fracture and concurrent radial nerve palsy, because approximately 77% of patients treated without exploration have spontaneous recovery of radial nerve function. Within 3 to 4 months of the injury, the BR and extensor carpi radialis longus (ECRL) should begin to show signs of reinnervation. Anatomic studies have demonstrated a relatively consistent order of the radial nerve motor branches in the forearm (proximal to distal): BR, ECRL, supinator, ECRB, extensor digitorum communis, ECU, extensor digit quinti, abductor pollicis longus, extensor pollicis longus, extensor pollicis brevis, and EIP. Because the EIP is the last motor branch from the radial nerve, it is likely to be the last to recover following a high radial nerve palsy.

Correct Answer: Extensor indicis proprius (EIP) The incidence of radial nerve palsy after a humeral shaft fracture has been estimated as being between 7% and 22%. Controversy remains regarding the need for early exploration in a patient presenting with a closed humerus fracture and concurrent radial nerve palsy, because approximately 77% of patients treated without exploration have spontaneous recovery of radial nerve function. Within 3 to 4 months of the injury, the BR and extensor carpi radialis longus (ECRL) should begin to show signs of reinnervation. Anatomic studies have demonstrated a relatively consistent order of the radial nerve motor branches in the forearm (proximal to distal): BR, ECRL, supinator, ECRB, extensor digitorum communis, ECU, extensor digit quinti, abductor pollicis longus, extensor pollicis longus, extensor pollicis brevis, and EIP. Because the EIP is the last motor branch from the radial nerve, it is likely to be the last to recover following a high radial nerve palsy.

Explanation:

Question 53:

Options:

Arthroscopic debridement alone of the partial rotator cuff tear
Repair of the partial rotator cuff tear and subacromial decompression
Arthroscopic debridement combined with subacromial decompression
Arthroscopic subacromial decompression
Biceps tenotomy

Correct Answer: Repair of the partial rotator cuff tear and subacromial decompression

Explanation:

DISCUSSION: Although arthroscopic debridement with or without subacromial decompression is a reasonable response, the patient has positive impingement signs. Several recent studies regarding the surgical treatment of partial rotator cuff tears have demonstrated good to excellent results after repair of tears involving more than 50% of the tendon thickness. This was shown specifically for bursal-sided tears and joint-side tears. Biceps tenotomy is not indicated in a young patient.
REFERENCES: Matava MJ, Purcell DB, Rudzki JR: Partial-thickness rotator cuff tears.
Am J Sports Med 2005;33:1405-1417.
Fukuda H: The management of partial-thickness tears of the rotator cuff. J Bone Joint Surg Br 2003;85:3-11.

Question 54:

Options:

Retrograde femoral nail followed by compression hip screw
Lag screw fixation followed by plating of the femoral shaft
Antegrade femoral nail followed by lag screw fixation
Lag screw fixation followed by retrograde femoral nail
Proximal femoral locking plate

Correct Answer: Retrograde femoral nail followed by compression hip screw

Explanation:

Question 55:

Options:

smaller incisions.
more wound complications.
fewer 30-day and 90-day readmissions.
lower rates of patient satisfaction.

Correct Answer: more wound complications.

Explanation:

Question 56:

Nonsurgical management of pectoralis major tears is likely to result in weakness of glenohumeral

Options:

abduction and external rotation.
abduction and internal rotation.
adduction and external rotation.
adduction and internal rotation.
external rotation and forward flexion.

Correct Answer: adduction and internal rotation.

Explanation:

Question 57:

-The center of rotation of the knee can be best described as

Options:

remaining fixed during flexion.
moving posterior as flexion increases.
shifting forward and then back with flexion.
shifting posterior on the lateral side with flexion.
sliding forward on the medial side with increasing flexion.

Correct Answer: shifting posterior on the lateral side with flexion.

Question 58:

Which of the following definitions best describes Batson’s vertebral vein system?

Options:

A system of valves that allows retrograde embolism
A vascular system that bypasses organs such as the breast, prostate, lung, kidney, and thyroid
A system of veins within the thoracoabdominal cavity that are not subject to compression or collapse by increases in intra-abdominal pressure
A series of valveless veins that allow tumor cell extravasation
A longitudinal vein system with a segmental distribution to the vertebra that extends from the dural venous sinuses of the skull to the sacrum

Correct Answer: A series of valveless veins that allow tumor cell extravasation

Explanation:

Question 59:

What is the most common cause of rotator cuff injury in high school athletes?

Options:

A curved or type III acromion
A tight coracoacromial ligament
Overuse
Limited internal rotation
Scapulothoracic dyskinesia

Correct Answer: Overuse

Explanation:

Question 60:

Options:

Subtrochanteric osteotomy with femoral shortening
An offset femoral component
A lateralized liner
Extended trochanteric osteotomy

Correct Answer: Subtrochanteric osteotomy with femoral shortening

Explanation:

Question 61:

Which of the following clinical scenarios represents the strongest indication for locked plating technique in a 70-year-old woman?

Options:

Segmentally comminuted ulnar fracture
Simple diaphyseal fracture of the humerus
Transverse midshaft displaced clavicle fracture
Periprosthetic femur fracture distal to a well-fixed total hip arthroplasty
Schatzker 2 fracture of the tibia with severe joint depression and comminution

Correct Answer: Periprosthetic femur fracture distal to a well-fixed total hip arthroplasty

Explanation:

Question 62:

Options:

Continued observation
Open reduction and internal fixation of the fracture
Excision of the hook of the hamate
Carpal tunnel release
Guyon’s canal release

Correct Answer: Excision of the hook of the hamate

Explanation:

Question 63:

Treatment of a cruciate-retaining total knee that is unstable in flexion is best accomplished by

Options:

revising the implant to a posterior stabilized device.
revising the implant with a thinner polyethylene insert.
revising the implant with a larger femoral component.
limiting flexion to only 90°.
using quadriceps conditioning exercises and a derotation brace.

Correct Answer: revising the implant to a posterior stabilized device.

Explanation:

Question 64:

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

Options:

Patellar tendon rupture
Lateral dislocation of the patella
Quadriceps tendon rupture
Anterior cruciate ligament rupture
Posterior cruciate ligament rupture

Correct Answer: Lateral dislocation of the patella

Explanation:

DISCUSSION: The MRI scan shows bone bruises in the medial aspect of the patella and the lateral aspect of the lateral femoral condyle. Both of these signs are typical for a lateral dislocation of the patella with spontaneous reduction. In addition, there may be associated tearing of the medial retinaculum or distal aspect of the vastus medialis.
REFERENCES: Elias DA, White LM, Fithian DC: Acute lateral patellar dislocation at MR imaging: Injury patterns of medial patellar soft-tissue restraints and osteochondral injuries of the inferomedial patella. Radiology 2002;225:736-743.
Sanders TG, Miller MD: A systematic approach to magnetic resonance imaging interpretation of sports medicine injuries of the knee. Am J Sports Med 2005;33:131-148.
Miller TT: Magnetic resonance imaging of the knee, in Insall JN, Scott WN (eds): Surgery of the Knee, ed 4. Philadelphia, PA, Churchill Livingstone, 2006, vol 1, pp 201-224.

Question 65:

Options:

Open reduction internal fixation with transosseous sutures
Arthroscopic fixation using a suture bridge technique
Nonsurgical treatment with early passive range of motion
Nonsurgical treatment with sling immobilization for 4 weeks

Correct Answer: Nonsurgical treatment with early passive range of motion

Explanation:

Question 66:

Which lower extremity muscle is first weakened in Charcot-Marie-Tooth (CMT) disease?

Options:

Peroneus brevis
Peroneus longus
Foot intrinsics
Tibialis anterior

Correct Answer: Foot intrinsics

Explanation:

DISCUSSION
Although many of the lower extremity muscles may be affected in CMT, those innervated by the longest axons have been shown to be affected first. In the lower extremity the muscles innervated by the longest axons are the intrinsic foot muscles. The tibialis anterior and the peroneus brevis may be severely affected but not before the foot intrinsics. The peroneus longus typically is spared, resulting in the cavus.
RECOMMENDED READINGS
Pareyson D, Marchesi C. Diagnosis, natural history, and management of Charcot-Marie-Tooth disease. Lancet Neurol. 2009 Jul;8(7):654-67. Review. PubMed PMID: 19539237.
View
Abstract at PubMed
Wenz W, Dreher T. Charcot-Marie-Tooth disease and the cavovarus foot. In: Pinzur MS, ed. Orthopaedic Knowledge Update: Foot and Ankle 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:291-306.
CLINICAL SITUATION FOR QUESTIONS 60 THROUGH 63
Figure 60 is the standing radiograph of a 27-year-old man who played football throughout his teen years. During those years, he noted that he had less mobility of his left foot and ankle. He twisted his left foot and ankle 8 months ago and has tried over-the-counter nonsteroidal anti-inflammatory drugs and a brace. He now has pain and edema in the left sinus tarsi area. Upon examination the following arcs of motion are identified: ankle dorsiflexion-right, 5 degrees/left, 5 degrees; ankle plantar flexion-right, 30 degrees/left 30 degrees; foot inversion-right, 10 degrees/left, 5 degrees; foot eversion-right, 10 degrees/left 5 degrees.

Question 67:

An osteoprogenitor cell is expected to commit to a bone lineage in the presence of what transcription factor?

Options:

PPARy2
MyoD
Sox 9
C/EBPa
Runx2

Correct Answer: Runx2

Explanation:

Question 68:

Figure 13 is the photograph of 18-month-old triplets with a lower-limb condition. What is the best initial treatment? Review Topic

Options:

Vitamin D supplementation and serum level monitoring
Mechanical axis alignment measurements on serial standing knee radiographs
Genetic testing and counseling for short-stature syndrome
Observation and clinical follow-up.

Correct Answer: Mechanical axis alignment measurements on serial standing knee radiographs

Explanation:

These triplets exhibit genu varum and internal tibial torsion that can be part of normal development. Fetal packing is the likely major contributing cause for these triplets, however. Observation and follow-up will be sufficient. Bowing and torsion can be clinical features of vitamin D deficiency, Blount disease, and short-stature syndromes, but these are not the most likely diagnoses. Radiographic diagnosis of Blount disease may not be accurate at this age.
(SBQ13PE.56) A 22-month-old female is hospitalized with a fever and malaise. She is found to be bacteremic, and blood cultures grow methicillin-sensitive Staphylococcus aureus (MSSA). During her hospitalization, the pediatrician notices her arm is slightly swollen and appears painful to use. MRI is obtained and demonstrated in figure A. Which feature of the MRI suggests the need for surgical management?
Review Topic
Brodie's Abscess
Osteomyelitis of the humeral metaphysis
Subperiosteal abscess of the humerus
Presence of subcutaneous air
High risk of proximal humeral growth arrest
This patient has osteomyelitis of the humerus with a large subperiosteal abscess. The presence of subperiosteal abscess necessitates surgical intervention for irrigation and debridement (I&D).
The diagnosis of acute osteomyelitis in children is made based upon a constellation of findings including pain, systemic signs of infection, elevated serum inflammatory markers, and imaging studies demonstrative of osseous infection. It is most commonly hematogenously spread to the metaphysis of immature bone, which is highly vascular prior to skeletal maturity. Treatment involves obtaining specimen for culture, empiric antibiotic treatment, and surgical irrigation and debridement of known abscesses. The end-point of treatment is return of pain-free functionality and the resolution of local/systemic signs of infection.
Conrad reviewed the management of acute hematogenous osteomyelitis and emphasized that surgical intervention in the presence of abscess can be both therapeutic and diagnostic: I&D can obtain culture and narrow the antibiotic plan.
Jones et. al. reviewed chronic pediatric osteomyelitis and report that surgery is the mainstay of treatment because removal of dead bone is essential for resolution of infection. This may be performed with sequestrectomy and curettage, with an emphasis on prevention of pathologic fracture, growth disturbances, bone loss, joint involvement, and permanent loss of function.
Figure A is a coronal STIR MRI image of the humerus demonstrating osteomyelitis
with extensive subperiosteal abscess.
Incorrect Answers:
Brodie's abscess is a type of subacute osteomyelitis which remains indolent and creates a focal intra-osseous abscess. This is not demonstrated in the clinical image.
The patient does have osteomyelitis of the humeral metaphysis, but this alone is not the indication for surgery. Uncomplicated osteomyelitis may be treated effectively with antibiotics alone.
Presence of subcutaneous air is suggestive of necrotizing fasciitis, which is a surgical emergency. The MRI however does not demonstrate this finding.
The infection and its surgical management both increase risk of injury to the proximal humeral physis and has the potential for growth arrest or angular deformity.
(SBQ13PE.3) Figure A demonstrates a physical examination maneuver in a 1 month old infant. What is this maneuver?
Review Topic
Ortolani Test
Barlow Test
Galeazzi Sign
Patrick test
Teratologic Sign
Figure A shows a schematic image of the Ortalani test.
The Ortolani test, or Ortolani maneuver, is part of the physical examination for developmental dysplasia of the hip. It is used alongside the Barlow test to detect subluxated hips that are either reducible or irreducible. A positive sign is a distinctive 'clunk' which can be heard and felt as the femoral head relocates anteriorly into the acetabulum.
Guille et al. showed that the use of Pavlik harness has become the mainstay of initial treatment for the infant who has not yet begun to stand. If concentric reduction of the hip cannot be obtained, surgical reduction of the dislocated hip is the next step before they are able to stand.
Video V is a lecture discussing the hip examination of the infant. Incorrect Answers:
pressure on the knee, directing the force the femoral head posteriorly. A positive Barlow test would result in posterior subluxation/dislocation of the hip. Answer 3: Galeazzi test is performed by flexing an infant's knees in the supine position so that the ankles touch the buttocks. If the knees are not level then the test is positive, which indicates a potential congenital hip issue (e.g. DDH). Answer 4: Patrick or Faber test (flexion, abduction, external rotation) has been described both for stressing the SI joint and for isolating symptoms to the hip Answer 5: Teratologic dislocation of the hip is a term used to imply that the hip joint did not develop normally in utero, thus the hip is in a fixed dislocated position at birth.

Question 69:

Options:

osteoarthritis of the hip is likely to occur later in life.
correction prevents later development of osteoarthritis.
most acetabular tears are symptomatic, and surgical treatment will be necessary.
this is an inherited deformity.

Correct Answer: osteoarthritis of the hip is likely to occur later in life.

Explanation:

Question 70:

Figure 48 shows an MRI scan of the knee. The arrow is pointing to what structure?

Options:

Iliotibial bone
Popliteal tendon
Biceps femoris
Peroneal nerve
Adductor longus

Correct Answer: Biceps femoris

Explanation:

Question 71:

Options:

closed reduction and cast immobilization for 6 weeks.
closed reduction and percutaneous pin fixation.
open reduction of the tarsal navicular and closed management of the Lisfranc joint.
open reduction and internal fixation of the Lisfranc joint, the tarsal navicula, and second metatarsal neck fractures.
open reduction and primary arthrodesis of the Lisfranc joint and internal fixation of the tarsal navicula and second metatarsal neck fractures.

Correct Answer: open reduction and internal fixation of the Lisfranc joint, the tarsal navicula, and second metatarsal neck fractures.

Explanation:

Question 72:

A 55-year-old man underwent cementless total hip arthroplasty for advanced painful osteoarthritis of the hip 2 years ago. The follow-up radiograph shown in Figure 30 shows

Options:

spot welds and calcar atrophy.
subsidence.
distal cortical hypertrophy.
distal pedestal formation.
complete lucent line around the stem.

Correct Answer: spot welds and calcar atrophy.

Explanation:

Question 73:

Options:

Gadolinium-enhanced MRI of the great toe
Serum uric acid level, C-reactive protein, and erythrocyte sedimentation rate
Serum rheumatoid factor
Aspiration of the first metatarsophalangeal joint
Fasting serum glucose level

Correct Answer: Aspiration of the first metatarsophalangeal joint

Explanation:

DISCUSSION: The patient has gouty arthropathy of the first metatarsophalangeal joint. This definitive diagnosis is achieved with aspiration of the joint and polarized light microscopy that shows needle-shaped negatively birefringent monosodium urate crystals. Differential diagnoses of infectious arthritis and pseudogout are also definitively made through joint aspiration. Although rheumatoid arthritis is a possibility, a serum rheumatoid factor is not always diagnostic and a patient with rheumatoid arthritis may have concomitant gouty arthritis. The radiographic findings are not typical of diabetes mellitus or of a patient with Charcot arthropathy.
REFERENCES: Wise CM, Agudelo CA: Diagnosis and management of complicated gout. Bull Rheum Dis 1998;47:2-5.
Harris MD, Siegel LB, Alloway JA: Gout and hyperuricemia. Am Fam Physician 1999;59:925-934.

Question 74:

Tension band wire fixation is best indicated for which of the following types of olecranon fractures?

Options:

Comminuted fractures
Fractures that involve the coronoid process
Fractures associated with Monteggia fracture-dislocations
Oblique fractures distal to the midpoint of the trochlear notch
Transverse fractures through the midpoint of the trochlear notch

Correct Answer: Transverse fractures through the midpoint of the trochlear notch

Explanation:

Question 75:

A 23-year-old woman falls from a bicycle and sustains a right knee injury. Figures 12a through 12d show radiographs and MRI scans of the knee. What is the most likely diagnosis?

Options:

Posterior cruciate ligament avulsion from the tibia
Anterior cruciate ligament avulsion from the tibia
Avulsion of the lateral meniscus anterior horn
Midsubstance posterior cruciate ligament rupture
Midsubstance anterior cruciate ligament rupture

Correct Answer: Anterior cruciate ligament avulsion from the tibia

Explanation:

DISCUSSION: The radiographs and MRI scans both show an avulsion of the anterior cruciate ligament, which has been described by Meyers and McKeever in three different fracture patterns. Type I fractures are nondisplaced or have minimal displacement of the anterior margin. Type II fractures have superior displacement of their anterior aspect with an intact posterior hinge. Type III fractures are completely displaced. Although the injury is visible on the radiographs, it is more subtle in adults than children. Thus, MRI is helpful in clarifying this injury in adults. Open or arthroscopic reduction and internal fixation is recommended for type II and type III fractures that do not respond to closed reduction.
REFERENCES: Meyers MH, McKeever FM: Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1970;52:1677-1684.
Wiss DA, Watson JT: Fractures of the tibial plateau, in Rockwood CA, Green DP, Bucholz RW, et al (eds): Rockwood and Green’s Fractures in Adults. Philadelphia, PA, Lippincott-Raven, 1996, pp 1920-1953.
Lubowitz JH, Elson WS, Guttmann D: Arthroscopic treatment of tibial plateau fractures: Intercondylar eminence avulsion fractures. Arthroscopy 2005;21:86-92.

Question 76:

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 77:

A 16-year-old boy sustains a twisting injury to the left knee while wrestling. MRI scans are shown in Figures 22a through 22c. What is the most likely diagnosis?

Options:

Anterior cruciate ligament rupture
Posterior cruciate ligament rupture
Bucket-handle medial meniscus tear
Lateral meniscus tear
Osteochondral lesion

Correct Answer: Bucket-handle medial meniscus tear

Explanation:

DISCUSSION: The MRI scans show a displaced bucket-handle medial meniscus tear that can be visualized on coronal, sagittal, and axial views. The sagittal view shows the typical “double posterior cruciate ligament sign,” in which the low-signal bucket-handle fragment parallels the normal low-signal posterior cruciate ligament. The coronal and axial images both show the displaced medial meniscus in the notch.
REFERENCES: Sanders TG, Miller MD: A systematic approach to magnetic resonance imaging interpretation of sports medicine injuries of the knee. Am J Sports Med 2005;33:131-148.
Miller TT: Magnetic resonance imaging of the knee, in Insall JN, Scott WN (eds): Surgery of the Knee, ed 4. Philadelphia, PA, Churchill Livingstone, 2006, vol 1, pp 201-224.

Question 78:

Options:

Surgical traction for 6 weeks followed by application of a cast brace
Application of a femoral cable plate
Femoral revision with a cemented long stem prosthesis
Application of cerclage wired double allograft femoral struts
Femoral revision with a cementless long taper fluted modular stem and proximal allograft strut supplementation

Correct Answer: Femoral revision with a cementless long taper fluted modular stem and proximal allograft strut supplementation

Explanation:

Question 79:

Passive glycation of articular cartilage results in

Options:

protection of collagen from degradation.
increased collagen stiffness and degradation.
increased chondrocyte proliferation.
increased proteoglycan association with type II collagen.
decreased synthesis of new collagen.

Correct Answer: increased collagen stiffness and degradation.

Explanation:

Question 80:

Options:

Anatomic alignment
Indirect reduction
Anatomic reduction of the fragments
Relatively stable fixation
Functional aftercare

Correct Answer: Anatomic reduction of the fragments

Explanation:

DISCUSSION: Although the original concept of internal fixation was one of anatomic reduction and stable fixation, over the past 10 to 15 years there has been a change based on the advent of intramedullary nailing and bridge plating. It is now appreciated that in a multifragmentary diaphyseal fracture, particularly of the lower extremity, the achievement of axis alignment (mechanical and anatomic axis) is all that is required. Healing will occur by callus. Relatively stable fixation is achieved through intramedullary nailing or bridge plating, providing adequate pain relief for functional aftercare.
REFERENCES: Perren SM, Claes L: Biology and mechanics of fracture management, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000,
pp 7-32.
deBoer P: Diaphyseal fractures: Principles, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 93-104.
Mast J, Jakob R, Ganz R: Planning and Reduction Techniques in Fracture Surgery. Berlin, Springer-Verlag, 1989.

Question 81:

Which of the following methods accurately describes the measurement of tip-apex-distance as it relates to placement of a lag screw in the femoral head?

Options:

Summation of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs
Distance from the acetabular teardrop to the tip of the screw on an AP radiograph of the hip
Multiplication of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs
Distance from the center of the lesser trochanter to the tip of the screw on an AP hip radiograph
Summation of the distance between the tip of the greater trochanter and end of the screw on AP and lateral hip radiographs

Correct Answer: Summation of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs

Explanation:

Question 82:

Options:

vigorous physical therapy for passive range of motion.
manipulation of the shoulder under anesthesia.
an intra-articular steroid injection.
an axillary radiograph.
MRI.

Correct Answer: an axillary radiograph.

Explanation:

Question 83:

Options:

Anesthesia in the first dorsal web space
Inability to extend the fingers
Inability to abduct the fingers
Inability to flex the thumb interphalangeal (IP) joint

Correct Answer: Inability to flex the thumb interphalangeal (IP) joint

Explanation:

Question 84:

Options:

First metatarsophalangeal arthrodesis
Distal chevron osteotomy and bunionectomy with closing wedge osteotomy and soft-tissue release
Bunionectomy with proximal metatarsal osteotomy
Bunionectomy with first metatarsal cuneiform fusion
Bunionectomy with proximal phalanx osteotomy and distal chevron osteotomy

Correct Answer: First metatarsophalangeal arthrodesis

Explanation:

DISCUSSION: Arthrodesis is indicated for severe bunion and hallux valgus deformities, but particularly with extensive degenerative disease of the first metatarsophalangeal joint. The other bunionectomy procedures have different indications, none of which include symptomatic first metatarsophalangeal degenerative disease.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 3-15.
Tourne Y, Saragaglia D, Zattara A, et al: Hallux valgus in the elderly: Metatarsophalangeal arthrodesis of the first ray. Foot Ankle Int 1997;18:195-198.

Question 85:

Which of the following surgical devices employed for stabilization of the sternoclavicular joint is associated with the highest incidence of life-threatening complications?

Options:

Percutaneous pins
Cannulated screws
Cerclage wire
Balser plate
AO locking plate

Correct Answer: Percutaneous pins

Explanation:

DISCUSSION: Numerous reports have documented serious complications including death from migration of intact or broken Kirschner wires or Steinmann pins into hilar structures such as the heart, pulmonary artery, and the aorta.
REFERENCES: Gilot GJ, Wirth MA, Rockwood CA: Injuries to the sternoclavicular joint, in Bucholz RW, Heckman JD, Court-Brown C (eds): Fractures in Adults. Philadelphia, PA, Lippincott, Williams and Wilkins, 2006, vol 2, pp 1373-1374.
Lyons FA, Rockwood CA Jr: Migration of pins used in operations of the shoulder. J Bone Joint Surg Am 1990;72:1262-1267.

Question 86:

Options:

Inadequate physical therapy
Exposure of the periosteum of the lateral ulna during surgery
Inappropriate location of the suture anchor
Fixation of the tendon with the forearm fully pronated
Subluxation of the radial head

Correct Answer: Exposure of the periosteum of the lateral ulna during surgery

Explanation:

Question 87:

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

Options:

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

Correct Answer: No differences in motion and strength

Explanation:

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

Question 88:

Options:

Chronic deep infection
Heterotopic bone
Femoral loosening
Parkinsonism
Acetabular loosening

Correct Answer: Femoral loosening

Explanation:

DISCUSSION: The radiographs reveal both cement debonding at the lateral shoulder of the prosthesis and a cement mantle fracture. Both of these indicate a loose femoral component. The radiographs show a stress fracture with reactive bone on the lateral femoral cortex in conjunction with the cement mantle fracture. The acetabular component shows no evidence of loosening. Heterotopic bone usually is not a source of pain when it is Brooker grade I, as in this case. Parkinsonism generally is not associated with hip pain.
REFERENCES: Harris WH, McCarthy JC, O’Neill DA: Femoral component loosening using contemporary techniques of femoral cement fixation. J Bone Joint Surg Am 1982;64:1063-1067.
Callaghan JJ, Rosenberg AG, Rubash H (eds): The Adult Hip. Philadelphia, PA, Lippincott-Raven, 1998, pp 960, 1228-1229.
Maloney WJ, Schmalzreid T, Harris WH: Analysis of long-term cemented total hip arthroplasty retrievals. Clin Orthop Relat Res 2002;405:70-78.

Question 89:

Options:

be able to run and walk without pain.
refrain from vigorous activity for 6 months.
achieve full hip and knee range of motion.
achieve symmetric lower extremity strength.
have radiographic evidence of a circumferential external bridging callus.

Correct Answer: have radiographic evidence of a circumferential external bridging callus.

Explanation:

DISCUSSION: While it is recommended that a patient gain full range of motion, pain-free function, and symmetric strength prior to returning to vigorous activities, it is absolutely essential that radiographs of the fracture site reveal a circumferential external bridging callus to prevent refracture. This is particularly important for comminuted femoral fractures with various sized fragments. It is also recommended that a return to rodeo riding be postponed for at
least 1 year.
REFERENCES: Brumback RJ, Ellison TS: Intermedullary nailing of femoral stress fractures. J Bone Joint Surg Am 1992;74:106-112.
Bucholz RW, Jones A: Fractures of the shaft of the femur. J Bone Joint Surg Am
1991;73:1561-1566.
Butler MS, Brumback RJ: Interlocking nailing for ipsilateral fractures of the femur, femoral shaft, and distal part of the femur. J Bone Joint Surg Am 1991;73:1492-1502.

Question 90:

Options:

bridging external callus along the allograft and perpendicular callus at the junction site.
direct osteonal penetration of the allograft with haversian remodeling.
complete incorporation of the allograft with obliteration of the host allograft junction site.
fibrovascular invasion with absence of callus formation.
gap formation with resorption of the allograft surface.

Correct Answer: bridging external callus along the allograft and perpendicular callus at the junction site.

Explanation:

Question 91:

Options:

Joint stiffness
Cold intolerance
Decreased sweating
Osteopenia
Disproportionate pain

Correct Answer: Disproportionate pain

Explanation:

Question 92:

Staged open reduction and internal fixation with free flap soft tissue reconstruction is the most appropriate definitive treatment method for which of the following tibial injuries?

Options:

Type IIIB intra-articular distal tibia fracture
Type IIIB segmental midshaft tibia fracture
Type IIIB transverse midshaft tibia fracture
Type IIIB Schatzker I proximal tibia fracture
Type IIIB Schatzker IV proximal tibia fracture

Correct Answer: Type IIIB intra-articular distal tibia fracture

Explanation:

Question 93:

A 47-year-old man has acute right shoulder pain after falling off a ladder. The MRI scan shown in Figure 9 reveals

Options:

aseptic necrosis of the humeral head.
a nondisplaced anatomic neck fracture.
a partial-thickness rotator cuff tear.
a full-thickness rotator cuff tear.
a bony Bankart defect.

Correct Answer: a full-thickness rotator cuff tear.

Explanation:

Question 94:

What tendon is closest to an appropriately placed anterolateral portal for ankle arthroscopy?

Options:

Peroneus brevis
Extensor digitorum longus
Extensor hallucis
Tibialis anterior
Peroneus tertius

Correct Answer: Peroneus tertius

Explanation:

Question 95:

What is the most common complication following reverse total shoulder arthroplasty?

Options:

Scapula spine/acromial fracture
Dislocation/instability
Implant loosening
Periprosthetic fracture Complications encountered following reverse total shoulder arthroplasty include dislocation, infection, hardware failure, hematoma, neurologic injury, periprosthetic fracture, scapular notching, and acromial/scapular spine fractures. The incidence and risks of these complications are related to the indication for the procedure. Dislocation is the most common complication, with an incidence of 1.5% to 31%. Risk factors associated with postoperative dislocation include male sex, previous shoulder surgery, proximal humeral bone loss, axillary nerve injury, and subscapularis deficiency. Commonly used methods to prevent instability include lateralization of the glenosphere and/or baseplate, eccentric baseplate placement, humeral lateralization or distalization, use of large glenosphere, and increased socket constraint.

Correct Answer: Dislocation/instability

Explanation:

Question 96:

Exostoses in which of the following anatomic locations is the most likely to undergo malignant transformation in a patient with multiple hereditary exostosis (MHE)?

Options:

Distal humerus
Distal radius
Distal femur
Lumbar spine
Scapula

Correct Answer: Scapula

Explanation:

Question 97:

What is the plasma half-life of warfarin?

Options:

1 to 2 hours
4 to 6 hours
12 to 18 hours
36 to 42 hours

Correct Answer: 36 to 42 hours

Explanation:

Question 98:

Options:

A palpable effusion
Positive anterior drawer test
Positive external rotation test
Pain with forced dorsiflexion
Loss of subtalar motion

Correct Answer: Pain with forced dorsiflexion

Explanation:

Question 99:

Options:

osteoarthritis of the hip is likely to occur later in life.
correction prevents later development of osteoarthritis.
most acetabular tears are symptomatic, and surgical treatment will be necessary.
this is an inherited deformity.

Correct Answer: osteoarthritis of the hip is likely to occur later in life.

Explanation:

Question 100:

The injection shown in Figures 1a and 1b would most benefit a patient who reports which of the following symptoms?

Options:

Dorsal foot pain extending into the great toe
Foot pain extending along the lateral border of the foot
Pain extending into the foot in a stocking distribution
Anterior thigh and shin pain ending at the ankle
Lateral foot paresthesias

Correct Answer: Dorsal foot pain extending into the great toe

Explanation:

DISCUSSION: The images demonstrate a L5 selective root block as it exits the L5-S1 foramen. This root block best helps relieve pain or paresthesias in the L5 distribution, which is the dorsal first web space and the great toe. The lateral foot is an S1 distribution and would need to be blocked through the posterior first sacral foramen. The anterior shin and thigh represent the
L4 root which exits a level above this at the L4-5 foramen. A stocking distribution is nonanatomic and not indicative of a specific root.
REFERENCES: Magee D: Principles and concepts, in Orthopaedic Physical Assessment, ed 3. Philadelphia, PA, WB Saunders, 1997, pp 1-18.
Aeschbach A, Mekhail NA: Common nerve blocks in chronic pain management. Anesthesiol Clin North Am 2000;18:429-459.

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

Orthopedic Surgery Board Review MCQs: Spine, Trauma, Hip & Shoulder | Part 145

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 145

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index