Orthopedic Board Review MCQs: Knee & Spine Part 147

About This Board Review Set

This is Part 147 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

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Two distinct learning modes are available:

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

Topics Covered in Part 147

This module focuses heavily on: Arthroplasty, Knee, Revision.

Sample Questions from This Set

Sample Question 1: Spontaneous recovery of upper extremtiy motor function after a cerebrovascular accident occurs in which of the following predictable patterns?...

Sample Question 2: Five weeks after undergoing a successful L4-L5 diskectomy, with complete relief of his preoperative sciatica, a 36-year-old man has severe, relentless back and buttock pain. Examination and laboratory studies are unremarkable with the excep...

Sample Question 3: Which of the following physical examination findings is most likely present in the condition producing the MRI findings shown in Figure 92? Review Topic...

Sample Question 4: During primary total knee arthroplasty, what is the maximum distance the joint line can be raised or lowered before poor motion, joint instability, and increased chance of revision occur?...

Sample Question 5: Figures 21a and 21b show a transverse MRI scan at L4/5 and a lateral radiograph of a 75-year-old man with a 2-year history of worsening low back and bilateral leg pain that occurs with ambulation beyond approximately a half a block. Managem...

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

Spontaneous recovery of upper extremtiy motor function after a cerebrovascular accident occurs in which of the following predictable patterns?

Explanation

DISCUSSION: Recovery of upper extremity motor function after a cerebrovascular accident follows a predictable pattern. The greatest amount of recovery is seen within the first 6 weeks. Return of function proceeds from proximal to distal. Shoulder flexion occurs first, followed by return of flexion to the elbow, wrist, and fingers. Return of forearm supination follows the return of finger flexion.
REFERENCE: Waters RL, Keenan ME: Surgical treatment of the upper extremity after stroke, in Chapman MW (ed): Operative Orthopedics. Philadelphia, PA, JB Lippincott, 1988, vol 2,

pp 1449-1450.

Question 2

Five weeks after undergoing a successful L4-L5 diskectomy, with complete relief of his preoperative sciatica, a 36-year-old man has severe, relentless back and buttock pain. Examination and laboratory studies are unremarkable with the exception of an erythrocyte sedimentation rate (ESR) of 90 mm/h. What is the next most appropriate step in management?

Explanation

DISCUSSION: The patient’s history, including the timing and type of symptoms, is typical for postoperative diskitis. The elevated ESR, 5 weeks after surgery, is also consistent with infection; a normal WBC count is not unusual. Management should consist of MRI with gadolinium; if positive, this should be followed by percutaneous biopsy to confirm the organism. Open biopsy may be considered if the percutaneous biopsy is unsuccessful. Anterior debridement and interbody fusion is reserved for the occasional patient that fails to respond to intravenous antibiotics, bed rest, and immobilization.
REFERENCES: Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 257-271.
Beatty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 713-721.

Question 3

Which of the following physical examination findings is most likely present in the condition producing the MRI findings shown in Figure 92? Review Topic

Explanation

The T2-weighted sagittal MRI scan shows the classic "bone bruise" pattern seen with an anterior cruciate ligament (ACL) tear. These lesions are thought to represent subcortical trabecular hemorrhages and are manifested as an increase in signal intensity on T2-weighted images and diminished signal intensity on T1-weighted images. They are classically located in the mid-portion of the lateral femoral condyle and posterior aspect of the lateral tibial plateau. This is due to the fact that an ACL tear typically is the result of a valgus-external rotation of the femur on the fixed tibia. This places most of the weight-bearing stress on the lateral femoral condyle, which rotates laterally and impacts the posterior lip of the lateral tibial plateau. This may result in an impaction fracture if the force is great enough, but more frequently causes merely a microfracture of the involved subcortical trabeculae.

Question 4

During primary total knee arthroplasty, what is the maximum distance the joint line can be raised or lowered before poor motion, joint instability, and increased chance of revision occur?

Explanation

DISCUSSION: Positioning of the femoral and tibial components is a common cause of early failure of total knee arthroplasty. Two modes of possible position are raising or lowering the joint line from its anatomic level. Raising or lowering the joint line beyond an established threshold can cause limited range of motion, poor patellar function, and possible instability. It has been determined that a threshold of approximately 8 mm provides consistently good results after knee arthroplasty.
REFERENCE: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 339-365.

Question 5

Figures 21a and 21b show a transverse MRI scan at L4/5 and a lateral radiograph of a 75-year-old man with a 2-year history of worsening low back and bilateral leg pain that occurs with ambulation beyond approximately a half a block. Management consisting of physical therapy, anti-inflammatory medications, and muscle relaxants has failed to successfully resolve his symptoms. He has minimal medical comorbidities. What is the best treatment approach for this patient? Review Topic

Explanation

The patient has spinal stenosis and degenerative spondylolisthesis. Laminectomy and posterior spinal fusion have been demonstrated to be superior to both nonsurgical management and laminectomy without fusion in prospective randomized studies. The effect of instrumentation on improvement of clinical outcomes remains a matter of debate. This patient has exhausted physical therapy approaches per the history. Epidural steroid injections have not been shown to significantly alter the natural history of patients with degenerative lumbar spinal stenosis and spondylolisthesis. While minimal access decompression has been described, percutaneous endoscopic diskectomy would be more appropriate for a disk herniation.

Question 6

What is the most appropriate management at this time? Review Topic

Explanation

The CT scan reveals a right-sided lateral disk protrusion at L3-4 that has been symptomatic for more than 4 months despite appropriate nonsurgical management. Relative surgical indications include persistent radiculopathy despite an adequate trial of nonsurgical management, recurrent episodes of sciatica, persistent motor deficit with tension signs and pain, and pseudoclaudication caused by underlying stenosis. Whereas studies have shown improvement in patients with sciatica from a lumbar disk herniation treated either nonsurgically or surgically, those undergoing surgical treatment had an overall greater improvement of symptoms.

Question 7

A 48-year-old woman has knee pain that is worse with weight bearing. She reports no night pain or pain at rest. History reveals that she underwent total knee arthroplasty with cementless components 2 years ago. Examination reveals tenderness along the medial joint line. Figures 12a through 12c show radiographs and a bone scan. What is the most likely cause of the patient’s pain?

Explanation

DISCUSSION: The radiographs show a halo-like sclerotic margin around the tibial stem and lucency under the baseplate. The bone scan shows markedly increased uptake under the tibial component, particularly on the medial side (not diffusely through the knee as seen with infection). These studies indicate lack of bone ingrowth fixation of the cementless porous-coated tibial component. The recent report of Fehring and associates has identified failure of ingrowth of a porous-coated implant as a dominant mode of early failure of total knee arthroplasties.
REFERENCES: Fehring TK, Odum S, Griffin WL, Mason B, Nadaud M: Early failures of total knee arthroplasty. Clin Orthop 2001;392:315-318.
Fehring TK: Revision TJA corrects flexion extension gap imbalance. Orthop Today 2002;22:44.

Question 8

Figure 16a shows the radiograph of a 34-year-old woman who sustained a basicervical fracture of the femoral neck. The fracture was treated with a compression screw and side plate. Seven months postoperatively, she continues to have significant hip pain and cannot bear full weight on her hip. A recent radiograph is shown in Figure 16b. Management should now consist of

Explanation

DISCUSSION: The patient sustained a high-angle femoral neck fracture. The follow-up clinical findings and radiograph show that she now has a nonunion with failed internal fixation. The joint appears preserved. In a healthy, young patient, arthroplasty of the femoral head, although possible, is not ideal. Excellent healing and function can be obtained in 70% to 80% of patients with femoral neck nonunion with a valgus intertrochanteric osteotomy.
REFERENCES: Marti RK, Schuller HM, Raaymakers EL: Intertrochanteric osteotomy for non-union of the femoral neck. J Bone Joint Surg Br 1989;71:782-787.
Ballmer FT, Ballmer PM, Baumgaertel F, et al: Pauwels osteotomy for nonunions of the femoral neck. Orthop Clin North Am 1990;21:759-767.

Question 9

Familial (Leiden) thrombophilia is of importance in joint arthroplasty because of an abnormality in the clotting cascade. Which of the following statements best describes the condition?

Explanation

Factor V Leiden is a disease caused by an abnormality of factor V in which a single amino acid substitution of glutamine for arginine in the protein C cleavage region leads to decreased inactivation of factor V and thus a greater tendency to form clots. More than half of all individuals with Factor V Leiden will develop deep venous thrombosis in the presence of a single additional risk factor such as long bone fracture or total joint arthroplasty.

Question 10

A 26-year-old man was thrown from a car and sustained the injury seen in Figures 44a and 44b. Nonsurgical management of this injury is recommended. Which of the following factors increases the risk of nonunion?

Explanation

DISCUSSION: The patient has a displaced comminuted clavicle middle one third fracture from a high-energy mechanism. Recent literature on high-energy clavicular fractures suggests a higher rate of nonunion than previously reported. A nonunion rate of 30% has been reported by Hill and associates when the fracture fragments are displaced more than 1.5 cm. In addition, several patients had neurologic symptoms related to the injury. Robinson and associates reported an increased risk of nonunion in women, elderly patients, comminuted fractures, and injuries with a lack of cortical contact.
REFERENCES: Hill JM, McGuire MH, Crosby LA: Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br 1997;79:537-539.
Wick M, Muller EJ, Kollig E: Midshaft fractures of the clavicle with a shortening of more than

2 cm predispose to nonunion. Arch Orthop Trauma Surg 2001;121:207-211.
Robinson CM, Court-Brown CM, McQueen MM, et al: Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am

2004;86:1359-1365.

Question 11

You are staffing the prison clinic in a large public hospital when a 55-year-old African American male presents complaining of severe right hip pain. His pain has been ongoing for the past five years and limits his ambulation. He has never used medications for pain control or physical therapy. A radiograph is shown in figure

Explanation

The patient is an African American male prisoner with symptomatic right hip osteoarthritis. When formulating a treatment plan, it is important to understand the role of physician implicit bias in delivery of care and in creating disparities in
healthcare delivery.
Physician bias, prejudice, discrimination, and clinical uncertainty are all factors that contribute to health care disparities in the United States. Implicit and explicit attitudes are cognitive traits that influence physician delivery of care, and sometimes these attitudes do not perfectly correspond. It is important for a physician to understand that his implicit attitudes about a patient may unintentionally influence care despite his explicit attitudes. Physicians should be aware of their implicit biases in order to provide more effective decision-making and quality of care.
Stone et al. write about the issue of culturally competent delivery of care and the avoidance of unconscious bias in medical decision making. They argue that because unconscious stereotypes and prejudices can trigger biased medical decisions against specific groups, leading to the creation of differential diagnoses, disparities in treatment, and causing minorities to feel uncomfortable with seeking or complying with treatment plans. The authors suggest the integration of cultural competency training into medical education in order to help understand the perspective of the minority group patient.
Sabin et. al. compared the implicit and explicit biases of physicians with respect to race, gender, and age. They found that medical doctors showed an implicit bias of preferentially caring for White Americans relative to Black Americans, independent of the doctors’ self-report (explicit biases). Doctors'implicit biases exceeded their explicit biases in all race groups studied, except for African American physicians, who did not show an implicit bias toward patients.
Figure A demonstrates an AP pelvis x-ray with severe arthrosis of the right hip. The left hip demonstrates moderate disease.
Incorrect Answers:

Question 12

A patient with a documented allergy to nickel requires a total knee arthroplasty. Which of the following prostheses is most likely to provide long-term success in this individual?

Explanation

DISCUSSION: Nickel allergy is not an infrequent preoperative finding. The ramifications of such allergies in arthroplasty patients are poorly understood at this time. Stainless steel and cobalt-chromium alloys contain relatively high concentrations of nickel. Titanium, oxidized zirconium, and polyethylene do not contain significant amounts of nickel. Titanium is not a good surface for the articulating portion of the femoral component because of its propensity for metallosis. Oxidized zirconium is the only suitable femoral component for patients allergic to nickel. A modular titanium tibial component or an all-polyethylene tibial component would be satisfactory for these patients.
REFERENCES: Laskin RS: An oxidized Zr ceramic surfaced femoral component for total knee arthroplasty. Clin Orthop 2003;416:191-196.
Nasser S, Campbell PA, Kilgus D, et al: Cementless total joint arthroplasty prostheses with titanium-alloy articular surfaces: A human retrieval analysis. Clin Orthop 1990;261:171-185.

Question 13

A 12-year-old girl has painless bowing of the tibia. Radiographs and a biopsy specimen are shown in Figures 35a through 35c. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient has osteofibrous dysplasia. The radiographic differential diagnosis includes osteofibrous dysplasia, fibrous dysplasia, and adamantinoma. Histology shows a fibro-osseous lesion with prominent osteoblastic rimming but a lack of epithelial nests. Adamantinoma is a low-grade malignancy that typically is located in the anterior tibial cortex and has a soap bubble appearance. Histologically, it is similar to osteofibrous dysplasia but includes epithelial nests of cells. Treatment requires resection. Fibrous dysplasia usually does not require biopsy; however, in this patient the radiographs do not distinguish it from adamantinoma. The radiographic findings are not typical of Ewing’s sarcoma or osteosarcoma. Repeat biopsy should be considered if clinical or radiographic features change.
REFERENCE: Mirra J: Bone Tumors: Clinical, Radiologic, and Pathologic Correlations. Philadelphia, PA, Lea & Febiger, 1989, vol 2, ch 18.

Question 14

Soft-tissue sarcomas most commonly metastasize to the

Explanation

DISCUSSION: The most common location for soft-tissue tumors to metastasize is the lungs. Depending on the grade of the sarcoma, metastases develop in as many as 50% of patients with soft-tissue sarcomas. Tumor grade is considered the most significant prognostic factor in predicting risk of metastases, with high-grade lesions at greatest risk. Staging CT of the chest should be performed once the diagnosis of a soft-tissue sarcoma is suspected or confirmed. Regular surveillance of patients treated for soft-tissue sarcomas includes follow-up CT scans at regular intervals. Intra-abdominal metastases are uncommon but may occur, particularly in patients with myxoid liposarcoma. Regional metastases are relatively uncommon and occur in approximately 5% of all patients with soft-tissue sarcoma. The incidence of regional nodal metastases is higher for synovial sarcoma and epithelioid sarcomas than other soft-tissue sarcomas.
REFERENCES: Sim FH, Frassica FJ, Frassica DA: Soft-tissue tumors: Diagnosis, evaluation, and management. J Am Acad Orthop Surg 1994;2:202-211.
Enzinger FM, Weiss SW, Goldblum F: Soft Tissue Tumors, ed 4. Washington, DC, Mosby/AFIP, 2001.

Question 15

-The World Health Organization Fracture Risk Assessment Tool (FRAX) calculates which fracture risk?

Explanation

Question 16

A year-old woman experiences pain 1 year after total knee arthroplasty (TKA). She reports sharp anterior pain and a painful catching sensation that is aggravated by rising from a chair or climbing stairs. Physical examination reveals a mild effusion and a range of motion of 2° to 130°, with patellar crepitus. The symptoms are reproduced by resisted knee extension. Radiographs show a well-aligned posterior- stabilized TKA without evidence of component loosening. What is the most likely cause of this patient's pain?

Explanation

DISCUSSION:
Patellar clunk syndrome is caused by the development of a fibrous nodule on the posterior aspect of the quadriceps tendon at its insertion into the patella. It causes a painful catching sensation when the extensor mechanism traverses over the trochlear notch as the knee extends from 45° of flexion to 30° from full extension. It characteristically occurs in posterior stabilized total knee arthroplasties and appears to be related to femoral component design. The syndrome can usually be prevented by excising the residual synovial fold just proximal to the patella. Flexion gap instability can also cause a painful total knee arthroplasty but is less common in posterior stabilized implants. Femoral component malrotation can cause pain attributable to a flexion gap imbalance or patellar tracking problems. Polyethylene wear would be unlikely after just 1 year. Patellar clunk syndrome can usually be addressed successfully with arthroscopic synovectomy. Recurrence is uncommon. Physical therapy may help to strengthen the quadriceps following synovectomy but would not resolve the clunk syndrome symptoms. Femoral or tibial insert revision is not indicated if patellar clunk syndrome is the only problem resulting in a painful
total knee arthroplasty.

Question 17

In patients with suspected hepatitis C, which of the following tests is commonly used to confirm the diagnosis after a positive ELISA screening test?

Explanation

DISCUSSION: The basic diagnostic test for hepatitis C (HCV) is detection of an antibody to epitopes on an enzyme-linked immunosorbent anti-HCV assay (ELISA). The currently used ELISA has high sensitivity (92%) and specificity (95%). False positives, however, still occur. The currently used supplemental test for HCV is strip immunoblot assay, which is based on detection of several HCV epitopes on nitrocellulose paper by antibody-capture techniques. Molecular amplification by PCR technology is very sensitive, but difficult to standardize and susceptible to contamination. Microarray and proteomics are relatively recent molecular techniques used for analysis of genes or proteins, respectively. A Northern blot is used to detect mRNA levels of specific genes but is not used in this situation.
REFERENCES: de Medina M, Schiff ER: Hepatitis C: Diagnostic assays. Semin Liver Dis 1995;15:33-40.
McGrory BJ, Kilby AE: Hepatitis C virus infection: Review and implications for the orthopedic surgeon. Am J Orthop 2000;29:261-266.

Question 18

The findings in Brown-Sequard syndrome include loss of which of the following? Review Topic

Explanation

Brown-Séquard syndrome is most commonly seen after penetrating injuries to the spinal cord and results in ipsilateral loss of motor function and contralateral loss of pain and temperature sensation. Patients with central cord syndrome have greater weakness in the upper extremities than in the lower extremities. Loss of proprioception is typically seen in patients with posterior cord syndrome.

Question 19

A 16-year-old boy has a symptomatic flatfoot deformity that is causing pain, skin breakdown, and shoe wear problems. Shoe modification and an orthosis have failed to provide relief. Examination reveals hindfoot valgus, talonavicular sag, and forefoot abduction that are all passively correctable. Treatment should consist of

Explanation

DISCUSSION: The patient has a supple planovalgus deformity that is passively fully correctable, and nonsurgical management has failed to provide relief. Lateral column lengthening with medial soft-tissue tightening will correct the deformity and maintain a flexible foot. Arthrodesis is not recommended for a supple, correctable deformity because of loss of motion and long-term degeneration of surrounding joints. Medial displacement calcaneal osteotomy is generally reserved for an adult-acquired flexible flatfoot.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 613-631.
Evans D: Calcaneo-valgus deformity. J Bone Joint Surg Br 1975;57:270-278.
Mosca VS: Calcaneal lengthening for valgus deformity of the hindfoot: Results in children who had severe, symptomatic flatfoot and skewfoot. J Bone Joint Surg Am 1995;77:500-512.

Question 20

A baseball player has had diffuse scapular soreness for the past 8 weeks. He reports that it began insidiously over several days and gradually has become worse. He denies any history of trauma. Examination reveals drooping of the shoulder, with lateral winging of the scapula at rest. He is otherwise neurologically intact. What is the best course of action?

Explanation

DISCUSSION: Lateral scapular winging is characteristic of trapezius palsy, whereas medial scapular winging is characteristic of long thoracic nerve palsy. During sports activity, injury to the spinal accessory nerve is rare but may occur with blunt or stretching trauma. Patients often report an asymmetric neckline, drooping shoulder, winging of the scapula, and weakness of forward elevation. Evaluation should include a complete electrodiagnostic examination.
REFERENCES: Wiater JM, Bigliani LU: Spinal accessory nerve injury. Clin Orthop 1999;368:5-16.
Wiater JM, Flatow EL: Long thoracic nerve injury. Clin Orthop 1999;368:17-27.
Mariani PP, Santoriello P, Maresca G: Spontaneous accessory nerve palsy. J Shoulder Elbow Surg 1998;7:545-546.
Porter P, Fernandez GN: Stretch-induced spinal accessory nerve palsy: A case report. J Shoulder Elbow Surg 2001;10:92-94.
Cohn BT, Brahms MA, Cohn M: Injury to the eleventh cranial nerve in a high school wrestler. Orthop Rev 1986;15:59-64.

Question 21

A 70-year-old man is experiencing neck pain, progressive weakness, and numbness in his arms and legs without bowel or bladder dysfunction or dysphagia. Upon examination, he has atrophy of his upper extremities but normal muscle bulk in his legs. Strength is diffusely 4/5 throughout. Cervical spine radiographs show spondylosis. Electromyography (EMG) reveals fibrillations with increased amplitude in the extensor carpi radialis and pronator teres. Nerve conduction studies demonstrate slowing conduction diffusely in the sural, peroneal, and ulnar nerves, and severe slowing in the median nerve. Testing of the tongue and thoracic paraspinal muscles does not show fibrillations or positive short waves. What is the most likely diagnosis? Review Topic

Explanation

Physical examination and presentation is consistent with possible cervical radiculopathy vs motor neuron disease. EMG findings are most consistent with cervical radiculopathy. There is denervation (fasciculations and positive short waves) of the C6 innervated muscles consistent with radiculopathy. However, evaluation of other body regions does not show evidence of denervation (tongue, thoracic paraspinal muscles). Fasciculations in the hand muscles were not widespread. Nerve conduction suggests the presence of a peripheral polyneuropathy with possible superimposed median neuropathy. Amyotrophic lateral sclerosis is a motor neuron disease that affects both upper and lower neurons. Presentation includes rapid progression of weakness, muscle atrophy, fasciculations, spasticity, dysarthria, dysphagia, and respiratory compromise.

Question 22

Figures 18a through 18c show injuries sustained by a 22-year-old woman after falling 45 feet while mountain climbing. After being airlifted to the nearest trauma center, her arterial blood gas was 7.21, pO2 84, pCO2 48, and delta base -11 mmol/L. Her Hgb is 8.7 and her resuscitation is ongoing. Based on this data, what would be the best management of her orthopaedic injuries?

Explanation

The patient is under-resuscitated and would benefit from minimally invasive stabilization of the pelvic ring and long bone fractures in a "damage-control" approach. External fixation of the pelvis and femur can be performed quickly and with minimal blood loss which should limit the "second hit" associated with more
prolonged, invasive surgery. Upper extremity fractures are best managed acutely with splints in this clinical setting. Definitive fracture fixation should be delayed until the patient is adequately resuscitated.

Question 23

The CT scan shows the involvement area is approximately 30% of the posterior facet. What is the most appropriate treatment?

Explanation

DISCUSSION
Radiographs reveal a talocalcaneal coalition. The incidence of tarsal coalition in the general population ranges between 2% and 13%. The incidence of tarsal coalition among patients with FGFR-related craniosynostosis syndromes is much higher than among the general population. Tarsal coalitions have been noted in FGFR-1-, FGFR-2-, and FGFR-3-related craniosynostosis syndromes of Apert, Pfeiffer, Crouzon, Jackson-Weiss, and Muenke, but not in Beare-Stevenson or Crouzonodermoskeletal syndromes. The FGFR genes are involved in cell proliferation, differentiation, migration, apoptosis, and pattern formation.
Additionally, nonsyndromic familial coalitions have been described with autosomal-dominant patterns of inheritance.
Cross-sectional imaging should always be obtained prior to resection of a radiographically evident coalition to define the extent of the coalition and determine the coexistence of an additional coalition. CT scan is the gold standard test; however, MRI can be helpful to define a suspected fibrous coalition if a CT scan is nondiagnostic. A bone scan may be useful if pain or history is atypical for a symptomatic coalition. Laboratory tests such as CBC, ESR, CRP, ANA, and RF may be indicated if the imaging evaluation does not confirm a tarsal coalition and if there is concern for malignancy, infection, or inflammatory arthritis.
Investigators have suggested that larger talocalcaneal coalitions with surface areas larger than 33% to 50% of the size of the posterior facet are unsuitable for resection and primary arthrodesis should be considered. However, a study by Koshbin and associates found that with long-term follow-up, favorable functional outcomes were seen even with resections of large talocalcaneal coalitions occupying more than 50% of surface area.

Question 24

A 35-year-old physical therapist presents with right-sided back and leg pain. For the last 4 months, he has taken anti-inflammatory medications and performed exercises on his own. While his back pain has improved slightly, his leg pain remain severe and interferes with his ability to sleep and work. Examination reveals positive ipsilateral and contralateral straight leg raise at 30 degrees. He has mildly diminished big toe dorsiflexion strength on the right side. There is a small patch of diminished sensation on the dorsum of the foot. MRI scans are shown in Figures A and B. What is the most appropriate next step in treatment? Review Topic

Explanation

The clinical presentation is consistent with a paracentral disc herniation at L4/5 that has failed nonoperative treatment and continues to limit is his activities of daily living. A laminotomy and discectomy (microdisckectomy) with a midline approach would be the next most appropriate treatment.
For lumbar disc herniation, the first line of treatment is rest, physical therapy and oral medications (NSAIDs, gabapentin, steroids). The second line of treatment is selective nerve root corticosteroid injections. The last line in treatment is laminotomy and discectomy.
Pearson et al. determined which individuals (as opposed to groups) in the SPORT (Spine Patients Outcomes Research Trial) would benefit from surgery. They found that disc herniation patients improved more with surgery than without.
Lurie et al. reviewed the 8 year outcomes of the SPORT. In patients with HNP on imaging and leg symptoms persisting for at least 6 weeks, surgery was superior to nonoperative treatment in relieving symptoms and improving function.
Figures A and B are sagittal and axial T2-weighted MRI images showing a large L4/L5 herniated disc causing neural foramina narrowing and impinging on the right L5 root.
Incorrect Answers:

Question 25

A 25-year-old woman returns for her first postoperative visit after arthroscopic thermal capsulorrhaphy for recurrent multidirectional instability. Examination reveals that the portals are healed, there is no swelling; and passive range of motion is within the normal range. However, she is unable to actively raise her arm. Shoulder radiographs are normal. What is the most likely cause of these findings?

Explanation

DISCUSSION: Treatment of shoulder instability with thermal devices has lead to numerous complications including recurrent instability, chondrolysis, stiffness, and capsular necrosis. This patient’s findings are consistent with a heat-induced axillary nerve injury. Normal radiographs exclude extensive chondrolysis.
REFERENCES: Levine WN, Bigliani LU, Ahmad CS: Thermal capsulorrhaphy. Orthopedics 2004;27:823-826.
McCarty EC, Warren RF, Deng XH, et al: Temperature along the axillary nerve during radiofrequency-induced thermal shrinkage. Am J Sports Med 2004;32:909-914.

Question 26

An adult with a distal humeral fracture underwent open reduction and internal fixation. What is the most common postoperative complication?

Explanation

DISCUSSION: Most patients lose elbow range of motion after open reduction and internal fixation of a distal humeral fracture. Ulnar nerve dysfunction, nonunion, and infection all occur less commonly.
REFERENCES: Webb LX: Distal humerus fractures in adults. J Am Acad Orthop Surg 1996;4:336-344.
McKee MD, Wilson TL, Winston L, et al: Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach. J Bone Joint Surg Am 2000;82:1701-1707.

Question 27

A 23-year-old man has had right posterolateral knee pain and occasional lateral calf dysesthesias for the past 8 months. A radiograph, CT scan, MRI scans, and a biopsy specimen are shown in Figures 62a through 62e. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiograph shows an eccentric, cortically based lytic lesion in the proximal fibula. The CT and MRI scans confirm that it is well circumscribed and cortically based with significant surrounding edema. The radiographic differential diagnosis would be a Brodie’s abscess or osteoid osteoma. An osteoblastoma would have to be greater than 2 cm in size. A chondroblastoma may also have significant edema around it, but it is an epiphyseal-based lesion, not cortically based. The well-circumscribed nature of the lesion is not consistent with osteosarcoma. The pathology shows a very cellular and vascular stroma with plump, but not atypical osteoblast cells making a matrix of immature woven bone. There are no abundant inflammatory cells or dead bone suggestive of osteomyelitis or a Brodie’s abscess. Therefore, the clinical and histologic picture is most consistent with an osteoid osteoma. Percutaneous radiofrequency ablation, usually with CT guidance, has become the preferred method for treating most cases of osteoid osteoma.
REFERENCES: Rosenthal DI: Radiofrequency treatment. Orthop Clin North Am 2006;37:475-484.
Ghanem I: The management of osteoid osteoma: Updates and controversies. Curr Opin Pediatr 2006;18:36-41.

Question 28

In children with isolated zone II lacerations of the flexor tendon, poor digital motion is best correlated with

Explanation

DISCUSSION: In a recent study on restoration of motion following zone I and zone II flexor tendon repairs in children, age was found to have no effect on the results of zone II tendon repairs. Early passive motion offered no better results than immobilization for 3 weeks. Immobilization for more than 4 weeks correlated with poorer results.
REFERENCE: O’Connell SJ, Moore MM, Strickland JW, Frazier GT, Dell PC: Results of zone I and zone II flexor tendon repairs in children. J Hand Surg Am 1994;19:48-52.

Question 29

When performing surgical excision of the lesion shown in the MRI scan in Figure 3, what nerve is most likely at risk?

Explanation

DISCUSSION: The MRI scan shows a large mass (lipoma) in the thenar muscles of the palm. The recurrent motor branch of the median nerve innervates the thenar muscles. The anterior interosseous nerve (AIN) in the proximal forearm innervates the flexor pollicis longus, pronator quadratus, and flexor digitorum pollicis to the index and frequently the middle finger. The terminal branch of the AIN innervates only the wrist capsule. The palmar cutaneous branch of the ulnar nerve is a sensory structure to the hypothenar area. There is no commonly described recurrent branch of the ulnar nerve.
REFERENCE: Kozin SH: The anatomy of the recurrent branch of the median nerve. J Hand Surg Am 1998;23:852-858.

Question 30

Which of the following is a significant risk factor for airway complications after anterior cervical surgery? Review Topic

Explanation

In a study of 311 patients undergoing anterior cervical surgery only, a surgical time of more than 5 hours and exposure of four or more vertebral bodies involving C4 or higher were found to be risk factors for postoperative airway complications. Surprisingly, preoperative pulmonary status, smoking history, absence of drainage, and myelopathy were not associated with airway complications.

Question 31

In 1980, a 32-year-old woman was found to have right breast mass, and a biopsy revealed adenocarcinoma. She underwent a mastectomy at that time, with no other treatment. Five years later, she noticed a lump in the left breast and underwent a left mastectomy. Seven lymph nodes were positive. In 2006, she now reports hip and thigh pain for the past 3 months. Figures 69a and 69b show AP and lateral radiographs of the femur. A bone scan shows a solitary lesion. Following radiographic staging, what is the next most appropriate step in management?

Explanation

DISCUSSION: Solitary bone lesions require biopsy, for there is the possibility that the lesion may represent a primary bone sarcoma, which will necessitate a different treatment plan. This is especially true in patients with remote histories of cancer. The most likely cause of a lytic bone lesion in a patient older than age 40 years is a metastatic lesion.
REFERENCES: Rougraff BT, Kneisl JS, Simon MA: Skeletal metastases of unknown origin: A prospective study of a diagnostic strategy. J Bone Joint Surg Am 1993;75:1276-1281.
Simon MA, Karluk MB: Skeletal metastases of unknown origin: Diagnostic strategy for orthopedic surgeons. Clin Orthop Relat Res 1982;166:96-103.

Question 32

The CT scan reveals a nondisplaced greater trochanteric fracture. The patient is now experiencing severe pain. What is the most appropriate treatment at this time?

Explanation

DISCUSSION
This patient presents with significant polyethylene wear, which can lead to both osteolysis and synovitis. However, synovitis usually manifests as a mild to moderate chronic ache, which should explain the discomfort. Although infection should always be ruled out with new-onset pain, no clinical parameters suggest acute hematogenous infection. Similarly, without any mention of back pain or neuropathy, radicular pain from the spine is unlikely. If this patient has a nondisplaced greater trochanteric fracture noted on MR imaging, the optimal immediate mode of treatment is to not rush into surgery despite the mild osteolysis. The patient’s severe pain is likely attributable to the nondisplaced greater trochanteric fracture rather than wear-induced synovitis, which typically presents as a mild to moderate ache. It is recommended to
allow the fracture to heal to avoid fracture displacement. Once the fracture is healed, a revision surgery with liner exchange can be recommended. Based on this clinical scenario, the acetabular component is within what is largely considered the “safe-zone” in THA. Despite this patient’s dislocations, the preferred treatment modality is to revise to a constrained liner. This patient had a well-functioning hip for longer than 15 years. Therefore, conversion to a constrained liner is the best treatment.

Question 33

A 47-year-old obese man with a body mass index of 42 comes into the office with left knee pain 1 year after undergoing an uncomplicated left medial unicompartmental knee arthroplasty (UKA). Radiographs show a loose tibial component in varus. What is the most appropriate next step to treat this failed construct?

Explanation

DISCUSSION:
This patient likely is experiencing failure of the UKA secondary to poor patient selection. In this young, heavy man, the component likely loosened due to the ongoing varus alignment of the knee and his elevated
weight. Despite this likely scenario, the next step is determining whether an infection is the cause of his pain. Prior to obtaining an aspiration, the surgeon can order ESR and CRP studies to determine whether aspiration is warranted. If the laboratory studies are unremarkable, the surgeon likely can forgo the aspiration and proceed to a revision TKA with possible augments on standby.

Question 34

Figure 1 shows the radiograph of an 18-year-old patient who has severe knee pain. Treatment consisting of osteotomy should be perfomed

Explanation

DISCUSSION: Very large corrections of tibial deformity can be achieved at or just below the tibial tubercle. This level of osteotomy maintains the relationship between the tubercle and the rest of the joint, does not alter patellofemoral mechanics, and avoids complicating possible future conversion to total knee arthroplasty. High tibial osteotomy is contraindicated for large corrections because of excessive elevation of the tibial tubercle and overhang of the lateral plateau. Correction in the tibial diaphysis creates a zig zag pattern in the tibia by correcting below the deformity and risks nonunion in cortical bone. There is no evidence that the femur is deformed; therefore, femoral osteotomy is not indicated.
REFERENCE: Murphy SB: Tibial osteotomy for genu varum: Indications, preoperative planning, and technique. Orthop Clin North Am 1994;25:477-482.

Question 35

The Magnetic resonance imaging signal characteristics of a high-grade soft-tissue sarcoma are best described as

Explanation

After plain radiographs of the affected area have been obtained, magnetic resonance imaging modality is the best imaging modality for detecting and characterizing the lesion, regarding definition of normal muscle, fascial boundaries, and the tumor mass. Although MR imaging is not specific in determining whether lesions are benign or malignant, it can be useful in evaluation
other characteristics, such as size, pattern of growth, integrity of natural boundaries, and homogeneity.
Intravenous contrast agents are not necessary to evaluate neurovascular structures. Both the T1 & T2 weighted images are essential to detect and characterize soft tissue lesions.
Most Tumors have long T1 and T2 relaxation times, therefore, in most instances signal intensity alone is of limited benefit. Exceptions are lipoma, hematoma, intra-lesional hemorrhage.
Hemorrhage may occur in some soft tissue lesions, especially sarcomas, leading to the low T1 and high T2 intensity sound on MR. Miller, indicates that Water, CSF, acute hemorrhage and soft tissue tumors appear dark on T1 and light on T2.

Question 36

A 66-year-old female presents to your clinic complaining of back pain, difficulty standing-up straight, weakness in her legs, and neurogenic claudication. On upright thoracolumbar radiographs, there is a 75 degree thoracolumbar curve with the apex at L2, and the C7 plumb line falls 12 cm anterior to the posterosuperior corner of S1. Aside from a decompression of the stenotic levels, which of the following choices will lead to the MOST reliable decrease in overall disability? Review Topic

Explanation

This patient has a spinal deformity in both the coronal and sagittal planes. Among the options given, correction of the sagittal vertical axis (SVA) to +3 cm is the most reliable predictor of clinical improvement.
Spinal malalignment in Adult Spinal Deformity (ASD) challenges balance mechanisms used for maintenance of an upright posture to achieve the basic human needs of preserving level visual gaze and retaining the head over the pelvis. Severe malalignment can result in greater muscular effort and energy expenditure to maintain the erect posture as well as use of compensatory mechanisms. As such, surgical correction of these deformities are aimed at achieving proper spinopelvic alignment.
Glassman et al. performed a multi-center retrospective study of 298 adults with spinal deformity. Regardless of operative (129 patients) or non-operative care (172 patients) a positive sagittal balance was the found to be the most reliable predictor of clinical symptoms in both patient groups.
Schwab et al. published a current concepts review on operative management for adult spinal deformities and identified three major goals of surgery: (1) Correct the SVA to
within 5 cm of neutral, (2) Ensure the pelvic tilt is less than 20 degrees, (3) Ensure the lumbar lordosis is within 9 degrees of the pelvic incidence.
Illustration A demonstrates how to measure the SVA. Illustration B depicts the realignment objectives in the saggital plane as described by Schwab et al.
Incorrect

Question 37

A 24-year-old man sustained a bilateral C5-6 facet dislocation in a car accident and was intubated at the scene. He remains sedated in the intensive care unit

Explanation

The MRI finding that most consistently corresponds with a complete spinal injury is a hematoma within the cord. Cord edema can predict a poor prognosis if it is more extensive but is not considered as consistent a finding. Ligamentous injury about the neck can indicate musculoskeletal instability but it does not in and of itself indicate the presence or predict the severity of spinal cord injury. Likewise, soft-tissue edema anterior to the spine may indicate musculoskeletal injury but does not offer specific information regarding the presence or absence of cord injury.

Question 38

Dorsal intercalated segment instability (DISI) describes which carpal deformity?

Explanation

Figures 1 and 2 are the radiographs of a healthy 54-year-old right-hand dominant man 3 months after he fell onto his outstretched left hand. He was initially treated with 8 weeks of closed reduction and casting. He reports ongoing ulnar-sided wrist pain, stiffness, and diminished function. An examination reveals a clinical sag deformity with a loss of radial length but no substantial swelling. The distal radius is nontender, and rotation is nearly full. Wrist motion is limited, with 55° of flexion, 25° of extension, and full digital motion. The most appropriate treatment is

Question 39

preservation of the radioscaphocapitate ligament, the most radial of the palmar extrinsic ligaments, which prevents ulnar subluxation after proximal row carpectomy.

Explanation

A 37-year-old patient with type I diabetes mellitus has a flexor tenosynovitis of the thumb flexor tendon sheath following a kitchen knife puncture wound to the volar aspect of the thumb. Left unattended, this infection will likely first spread proximally creating an abscess in which of the following spaces of the palm?
Central space
Hypothenar space
Carpal tunnel
Posterior adductor space
Thenar space CORRECT ANSWER: 5
Flexor tenosynovitis of the thumb flexor tendon sheath can spread proximally and form an abscess within the thenar space of the palm. The flexor pollicis longus tendon does not pass through the central space of the palm or the hypothenar space of the palm. The flexor pollicis longus tendon does pass through the carpal tunnel, but this is not a palmar space. The three palmar spaces include the hypothenar space, the thenar space, and the central space. The posterior adductor space would likely only be involved secondarily after spread from a thenar space infection.
New painful paresthesias near the site of the incision after an ulnar nerve transposition is the result of injury to what nerve?
Medial antebrachial cutaneous
Lateral antebrachial cutaneous
Posterior antebrachial cutaneous
Medial brachial cutaneous
Dorsal antebrachial cutaneous
Branches of the medial antebrachial cutaneous nerve can often be identified during routine ulnar nerve surgery crossing the medial aspect of the elbow. It should be preserved to avoid development of painful paresthesias.
A 21-year-old man who was injured in a snowboarding accident 18 months ago now reports wrist pain. An MRI scan is shown in Figure

Question 40

The placement of supplemental screw fixation with acetabular component fixation is a typical adjunct measure but carries the greatest risk of vascular injury if placed in which of the following positions?

Explanation

DISCUSSION: Anatomic studies indicate that the safe areas for screws are superior and posterior. The external illiac artery is at risk with anteromedial placement, and the sciatic nerve may be compromised by posterior inferior screw placement.
REFERENCES: Lavemia CJ, Cook CC, Hernandez RA, et al: Neurovascular injury in acetabular reconstruction cage surgery: An anatomical study. J Arthroplasty 2007;22:124-132.
Wasielewski RC, Galat DD, Sheridan KC, et al: Acetabular anatomy and transacetabular screw fixation at the
high hip center. Clin Orthop Relat Res 2005 ;43 8:171 -176.

Question 41

A 65-year man has right hip pain after a fall. Radiographs reveal a reverse oblique intertrochanteric femoral fracture. Treatment consists of reduction and internal fixation. Which of the following implants is most commonly associated with nonunion and hardware failure?

Explanation

DISCUSSION: Reverse oblique intertrochanteric femoral fractures account for 5% of all intertrochanteric or subtrochanteric fractures. They are uncommon but not rare and will be encountered in practice. The sliding hip screw is associated with the most problems because of its design. When reverse oblique fractures are fixed with a sliding hip screw, the action of the construct causes medial displacement of the distal fragment rather than compression of the proximal and distal fragments. All of the other implants prevent medial displacement of the distal segment. It should not be assumed that simply using one of the other implants is reason for success. There is a significant failure rate for each of these implants with reverse oblique fractures. The implant must be ideally placed and the fracture must be reduced.
REFERENCES: Haidukewych GJ, Israel TA, Berry DB: Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643-650.
Sanders RW, Regazzoni P: Treatment of subtrochanteric femur fractures using the dynamic condylar screw. J Orthop Trauma 1989;3:206-213.
Baumgaertner MR, Chrostowski JH, Levy RN: Intertrochanteric hip fracture, in Browner BD, Jupiter JP, Levine AM, Trafton P (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 1833-1881.

Question 42

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

Explanation

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

Question 43

A 23-year-old national team rower reports pain over the radial dorsum of the forearm that is made worse with flexion and extension of the wrist during competition. His primary physician initially diagnosed de Quervain’s tenosynovitis, and a subsequent corticosteroid injection into the first dorsal compartment at the wrist provided no relief. The patient continues to report pain and audible crepitus that is noted 5 cm proximal to the wrist joint, on the radial aspect. What structures are involved in the continued pathology?

Explanation

DISCUSSION: Intersection syndrome is also known as “squeakers wrist,” “oarsmen wrist,” and crossover tendinitis. It occurs where the first and second dorsal wrist compartment structures pass over one another, resulting in fibrosis, muscular changes, and inflammation of the bursa in this area. The structures involved are the abductor pollicis longus and extensor pollicis brevis (first dorsal compartment) that pass across the second compartment structures (extensor carpi radialis brevis and extensor carpi radialis longus). An audible “squeak” is occasional y heard at the intersection point, which is approximately 4 to 5 cm proximal to the proximal dorsal wrist crease.
REFERENCES: Grundberg AB, Reagan DS: Pathologic anatomy of the forearm: Intersection syndrome. J Hand Surg Am 1985; 10:299-302.
Thorson E, Szabo RM: Common tendinitis problems in the hand and forearm. Orthop Clin North Am 1992;23:65-74.
Williams JG: Surgical management of traumatic non-infective tenosynovitis of the wrist extensors. J Bone Joint Surg Br 1977;59:408-410.
Wood MB, Dobyns JH: Sports-related extraarticular wrist syndromes. Clin Orthop Relat Res 1986;202:93-102.

Question 44

Lateral malleolus fractures can be treated with a variety of techniques, including posterior antiglide plating or lateral neutralization plating. What is an advantage of using lateral neutralization plating instead of posterior antiglide plating?

Explanation

DISCUSSION: Posterior antiglide plating is a technique that involves placement of a plate on the posterior aspect of the distal fibula, using the plate as a reduction tool and direct buttress against distal fracture fragment displacement.
Schaffer et al showed from a biomechanical standpoint that posterior antiglide plating was superior to lateral neutralization plating for distal fibula fracture fixation.
Weber et al reported a (30/70) 43% rate of plate removal secondary to peroneal discomfort. In addition, peroneal tendon lesions were found in 9 of the 30 patients.

Question 45

One of the serious potential complications of repair of distal biceps tendon ruptures is limited pronation and supination as a result of synostosis. What surgical approach and technique presents the highest risk for development of this complication?

Explanation

DISCUSSION: The risk of synostosis is imminent with any technique for repairing a distal biceps tendon rupture. However, the risk is quite low for all approaches that avoid exposure of the ulna, including the muscle-splitting two-incision technique.
REFERENCE: Norris TR: Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, p 342.

Question 46

Which of the following is an advantage of using blocking screws for tibial nailing?

Explanation

DISCUSSION: Blocking screws can be used to help obtain and maintain reductions, increase construct stiffness, and neutralize translational forces. There are no studies as of yet that find a blocking screw to decrease nail failure.
Krettek found that medial and lateral blocking screws can increase the primary stability of distal and proximal metaphyseal fractures after nailing and can be an effective tool for selected cases that exhibit malalignment and/or instability by decreasing mechanically measured deformation.
In a later clinical study, Krettek found that after using blocking screws, tibial healing was evident radiologically at a mean of 5.4 months with a decreased rate of malunions.
Ricci also found that blocking screws are effective to help obtain and maintain alignment of fractures of the proximal third of the tibial shaft treated with intramedullary nails.

Question 47

A 34-year-old man sustains an extra-articular fracture of the proximal phalanx of his right index finger in a fall. Examination reveals that the fracture is closed and oblique in orientation. Closed reduction and splinting fail to maintain the reduction. Management should now consist of

Explanation

DISCUSSION: The patient has an unstable oblique fracture of the proximal phalanx that is easily reducible but unstable; therefore, the treatment of choice is closed reduction and percutaneous pin fixation, followed by casting. Closed reduction and percutaneous pin fixation offers a better functional result than open reduction and plate fixation. Repeat closed reduction and buddy taping is inadequate because of the inherently unstable fracture pattern. Buddy taping will allow the dislocation to recur. The other options represent more aggressive surgical techniques than are necessary to treat this fracture.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,

pp 711-771.
Green DP, Anderson JR: Closed reduction and percutaneous pin fixation of fractured phalanges. J Bone Joint Surg Am 1973;55:1651-1653.

Question 48

A 38-year-old man sustains a complete avulsion with retraction of the ischial attachment of the hamstring muscles in a fall while water skiing. He indicates that he is an aggressive athlete who participates regularly in multiple running and cutting-type sports, and he strongly desires to continue his athletic competition. Management should consist of

Explanation

DISCUSSION: Several studies have identified a complete proximal avulsion of the hamstring muscles as an injury that leads to significant long-term disability, with a high percentage of athletes who must permanently restrict their activities following nonsurgical management. Early surgical repair and prolonged rehabilitation have yielded consistently better results than nonsurgical management.
REFERENCES: Orava S, Kujala UM: Rupture of the ischial origin of the hamstring muscles. Am J Sports Med 1995;23:702-705.
Clanton TO, Coupe KJ: Hamstring strains in the athlete: Diagnosis and treatment. J Am Acad Orthop Surg 1998;6:237-248.

Question 49

A 75-year-old woman who sustained a fall now reports neck pain and upper extremity weakness. Examination reveals 4 of 5 strength in the upper extremities and 5 of 5 strength in the lower extremities. Radiographs show multilevel degenerative disk disease. An MRI scan is shown in Figure 96. Her clinical presentation is most compatible with which of the following? Review Topic

Explanation

The MRI scan shows advanced multilevel degenerative changes and moderate to severe stenosis at C3-C4 and C4-C5 with associated cord signal change. The patient has greater weakness in the upper extremities than in the lower extremities. This pattern is most compatible with central cord syndrome. Patients with brachial plexus injury will have unilateral weakness. Patients with anterior cord syndrome will have greater weakness in the legs than in the arms, and those with Brown-Séquard syndrome will have ipsilateral motor deficits and contralateral pain and temperature deficits.

Question 50

Figure 1 is the radiograph of an 18-year-old right-hand-dominant man who has pain and stiffness 3 months after sustaining an injury to his dominant ring finger while playing basketball. An examination reveals significant proximal interphalangeal (PIP) joint swelling with active and passive PIP joint motion of 15/40 degrees of flexion. What is the best next step?

Explanation

EXPLANATION:
This patient has a subacute PIP joint dorsal fracture dislocation with involvement of 50% to 60% of the palmar articular surface of the base of P2. A "V sign" (Figure 2) is evident, indicating dorsal subluxation of the joint. In some cases, an ORIF is possible, but substantial comminution often precludes proper restoration of the critical volar buttress. Therapy is not the answer because the joint is dorsally subluxated and must be corrected. Dynamic external fixation on its own would not result in a reduced joint. The hemi-hamate autograft has proven useful in this type of scenario and serves to restore the volar buttress of P2 using an osteochondral autograft harvested from the distal articular aspect of the hamate at its articulation with the fourth/fifth metacarpal bases. Intraoperative clinical photographs and a postsurgical radiograph are shown in Figures 3 through 5.

Question 51

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

Explanation

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

Question 52

Which stress fracture location is reported most frequently among ballet dancers?

Explanation

DISCUSSION
Stress fractures are a frequent overuse injury among professional ballet dancers. The most common location is at the proximal metaphyseal-diaphyseal junction of the second metatarsal. Repetitive stress injuries and fractures of the tibial sesamoid, tarsal navicular, and base of the fifth metatarsal occur among other athletes.
RECOMMENDED READINGS
O'Malley MJ, Hamilton WG, Munyak J, DeFranco MJ. Stress fractures at the base of the second metatarsal in ballet dancers. Foot Ankle Int. 1996 Feb;17(2):89-94. PubMed PMID: 8919407. View Abstract at PubMed
Micheli LJ, Sohn RS, Solomon R. Stress fractures of the second metatarsal involving Lisfranc's joint in ballet dancers. A new overuse injury of the foot. J Bone Joint Surg Am. 1985 Dec;67(9):1372-5. PubMed PMID: 4077907. View Abstract at PubMed
Gehrmann RM, Renard RL. Current concepts review: Stress fractures of the foot. Foot Ankle Int. 2006 Sep;27(9):750-7. Review. PubMed PMID: 17038292. View Abstract at PubMed

Question 53

A 70-year-old man seen in the emergency department has had left shoulder pain and a fever of 101.5 degrees F (38.6 degrees C) for the past 3 days. He denies any history of trauma. Examination reveals tenderness anterosuperiorly and at the posterior glenohumeral joint line. He has very limited range of motion (passive and active). Laboratory studies show a WBC count of 12,000/mm 3 and an erythrocyte sedimentation rate of 48 mm/h. Initial management should consist of

Explanation

DISCUSSION: It appears that the patient has septic arthritis of the glenohumeral joint; therefore, initial management should consist of aspiration of the glenohumeral joint and subacromial space separately, followed by Gram stain and culture of the fluid. Based on the findings, broad-spectrum IV antibiotics should be started. If the diagnosis of septic arthritis is confirmed, then arthroscopic or open surgical drainage usually is indicated.
REFERENCES: Sawyer JR, Esterhai JL Jr: Shoulder infections, in Warner JJ, Iannotti JP, Gerber C (eds): Complex and Revision Problems in Shoulder Surgery. Philadelphia, PA, Lippincott-Raven, 1997.
Leslie BM, Harris JM, Driscoll D: Septic arthritis of the shoulder in adults. J Bone Joint Surg Am 1989;71:1516-1522.

Question 54

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

Explanation

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

Question 55

A 2-year-old boy has been referred for musculoskeletal evaluation. Examination reveals shortened proximal limbs, hip and knee flexion contractures, an abducted thumb, and ear abnormalities. His parents are concerned about his deformed feet. What is the most common foot deformity associated with this patient’s diagnosis?

Explanation

DISCUSSION: The patient has diastrophic dysplasia. Affected individuals have rhizomelic short stature, cauliflower ears, severe joint contractures (especially knees and hips), hitchhiker’s thumb, and a cleft palate. The most common foot abnormality is a rigid equinovarus deformity. Surgical results are poorer than those for idiopathic clubfeet and often require bony procedures or talectomy.
REFERENCES: Ryoppy S, Poussa M, Merikanto J, Marttinen E, Kaitila I: Foot deformities in diastrophic dysplasia: An analysis of 102 patients. J Bone Joint Surg Br 1992;74:441-444.
Bussett GS: The osteochondrodysplasias, in Morrissy RT, Weinstein S (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, p 219.

Question 56

A 35-year-old woman reports an 8-week history of neck pain radiating to her right upper extremity. She denies any history of trauma or provocative event. Examination reveals decreased pinprick sensation in her right middle finger, otherwise sensation is intact bilaterally. Finger flexors and interossei demonstrate 5/5 motor strength bilaterally. Finger extensors are 4/5 on the right and 5/5 on the left. The triceps reflex is 1+ on the right and 2+ on the left. The most likely diagnosis is a herniated nucleus pulposus at what level?

Explanation

DISCUSSION: The patient’s neurologic examination is consistent with a C7 radiculopathy on the right side. In a patient with this symptom complex in the absence of trauma, a cervical disk herniation is the most common etiology for a C7 radiculopathy. There are eight cervical nerve roots and the C7 nerve exits at the C6-7 disk space and is most frequently impinged by a disk herniation at this level.
REFERENCES: Houten JK, Errico TJ: Cervical spondylotic myelopathy and radiculopathy: Natural history and clinical presentation, in Clark CR (ed): The Cervical Spine, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 2005, pp 985-990.
Hoppenfeld S: Orthopaedic Neurology: A Diagnostic Guide to Neurologic Levels. Philadelphia, PA, JB Lippincott, 1977, pp 7-43.

Question 57

A 17-year-old football player is unable to flex the distal interphalangeal (DIP) joint of his ring finger. He states that he injured the finger 6 weeks ago while attempting to tackle another player who pulled free from his grip, but he did not inform his coach at the time of the injury. Current radiographs show an observable fleck of bone volar to the base of the proximal phalanx. Treatment should consist of

Explanation

DISCUSSION: Flexor digitorum profundus ruptures are classified into three types. In type I, the tendon retracts into the palm. In type II, the tendon retracts to the level of the proximal phalanx, the vinculum remains intact, and the blood supply is preserved to the tendon. A small fleck of bony fragment observed at the A2 pulley is pathognomonic for a type II rupture. Successful primary repair of the type II rupture has been reported as late as 2 months after the injury. Type III injuries have large fragments of the distal phalanx attached and are caught distally by the A1 pulley. Type III ruptures can be repaired up to several months after the injury.
REFERENCES: Leddy JP: Avulsions of the flexor digitorum profundus. Hand Clin

1985;1:77-83.
Kiefhaber TR: Closed tendon injuries in the hand. Oper Tech Sports Med 1996;4:227-241.

Question 58

The failure of the acetabular component shown in Figure 15 is most likely the result of the use of a 32-mm head and

Explanation

DISCUSSION: Astion and associates analyzed 23 acetabular components, out of a total of 173 implanted, that had failed because of either migration or severe osteolysis. The radiographic appearance of osteolysis was positively associated with the duration that the implant had been in situ. The prevalence of osteolysis was also significantly greater in acetabular components with an outer diameter of 55 mm or less (a polyethylene thickness of 8.5 mm or less). Thirteen of the 23 components were revised at a mean of 70 months after the index operation. Examination of the retrieved acetabular components revealed extensive polyethylene damage on the articular and back surfaces of the liners. Cracks in the polyethylene rim of the liner and deformation of the antirotation notch in the polyethylene rim were common findings. The density of the polyethylene was greater than expected, and more particles than anticipated had not fused with the surrounding polyethylene. Factors related to both the design and the material contributed to the failure of these porous-coated anatomic acetabular components.
REFERENCE: Astion DJ, Saluan P, Stulberg BN, Rimnae CM, Li S: The porous-coated anatomic total hip prosthesis: Failure of the metal-backed acetabular component. J Bone Joint Surg Am 1996;78:755-766.

Question 59

The main blood supply to the lateral two thirds of the talar body is provided by the

Explanation

DISCUSSION: The main blood supply to the lateral two thirds of the talar body is derived from the artery of the tarsal canal, a branch of the posterior tibial artery. The peroneal artery helps form a vascular plexis over the posterior tubercle and combines with other arteries to form the artery of the sinus tarsi, which is the principal blood supply of the intrasinus structures of the talus. The anterior tibial arteries send branches to the superior surface of the talar head and give rise to the anterolateral malleolar artery, which may anastomose with other vessels to form the artery of the tarsal sinus.
REFERENCES: Sanders R: Fractures and fracture-dislocations of the talus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999,

pp 1465-1518.
Haliburton RA, Sullivan CR, Kelly PJ, et al: The extra-osseous and intra-osseous blood supply of the talus. J Bone Joint Surg Am 1958;40:1115-1120.

Question 60

You have been waiting to enroll a patient into your recent institutional review board (IRB)-approved clinical research protocol. A patient is admitted who, upon initial screening, meets all inclusion criteria. However, he has late-stage dementia, and you are told by your research coordinator that this condition is an exclusionary criterion. This scenario demonstrates the need for which aspect of proper informed consent?

Explanation

Proper informed consent for research protocols includes the same elements as consent for invasive procedures. Jurisdiction is not one of the 5 elements, although it must be recognized that the process of obtaining proper informed consent for participation in a study protocol is mandated by the local IRB. The 5 elements of informed consent are:

Question 61

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 62

In the Lauge-Hansen classification system, a pronation-abduction ankle fracture has what characteristic fibular fracture pattern?

Explanation

DISCUSSION: In the Lauge-Hansen classification, the characteristic fibular fracture pattern in a pronation-abduction injury is a comminuted fibular fracture above the level of the syndesmosis. In the first stage of this injury pattern, the deltoid fails in tension, or an avulsion fracture of the medial malleolus occurs. In the second stage, the anterior inferior tibiofibular ligament ruptures, or a small bony avulsion of this ligament's insertion/origin occurs. The final stage includes the creation of a comminuted fibular fracture above the level of the syndesmosis. The referenced article by Siegel et al noted that extraperiosteal bridge plating of these ankle injuries was safe and had excellent radiographic and clinical outcomes at final follow-up.

Question 63

A 5-year-old boy has a deformity of his right arm after falling from a jungle gym. A radiograph is shown in Figure 37. Management should consist of

Explanation

DISCUSSION: Monteggia fractures in children must be recognized. Early appropriate treatment is much easier than delayed reconstruction for a missed radial head dislocation. In younger children, attempts should be made to reduce the ulna fracture and radial head dislocation with traction and manual manipulation. Anterior Monteggia fractures are the most common, and in this variety the radius is much better stabilized in elbow flexion. Posterior Monteggia fractures are less common and may be managed in elbow extension. Closed reduction is much more successful in younger children; ulnar fixation with a rod or plate may be needed in older patients with unstable fractures. Annular ligament repair is rarely needed in the acute fracture.
REFERENCES: Wilkins KE: Changes in the management of Monteggia fractures. J Pediatr Orthop 2002;22:548-554.
Kay RM, Skaggs DL: The pediatric Monteggia fracture. Am J Orthop 1998;27:606-609.
Ring D, Jupiter JB, Waters PM: Monteggia fractures in children and adults. J Am Acad Orthop Surg 1998;6:215-224.

Question 64

Surgical treatment for symptomatic disk herniations is associated with which of the following?

Explanation

DISCUSSION: The recently published SPORT trial verifies that surgical treatment of symptomatic disk herniations is associated with early and sustained pain relief. The trial also verifies that nonsurgical management is associated with improved symptoms as well. Nerve root injury, recurrent herniation, and diskitis are known complications of surgery, but all are less common than described above.
REFERENCE: Weinstein JN, Lurie JD, Tosteson TD, et al: Surgical vs nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA 2006;296:2451-2459.

Question 65

A 27-year-old professional baseball pitcher who underwent arthroscopic olecranon debridement continues to have medial-sided elbow pain during late cocking. Physical examination reveals laxity and pain with valgus stress testing. What is the most likely cause of his pain?

Explanation

DISCUSSION: Both the medial collateral ligament and the olecranon contribute to valgus stability of the elbow. Excessive olecranon resection increases the demand placed on the medial collateral ligament in resisting valgus forces during throwing. Bone removal from the olecranon should be limited to osteophytes.
REFERENCES: Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 101-111.
Kamineni S, Hirahara H, Pomianowski S, et al: Partial posteromedial olecranon resection:
A kinematic study. J Bone Joint Surg Am 2003;85:1005-1011.

Question 66

A 53-year-old man with a history of severe left hip pain has a significant limp that is the result of a 5-cm limb-length discrepancy. An AP radiograph is shown in Figure 48. The underlying etiology is most likely related to a history of

Explanation

DISCUSSION: Radiographic abnormalities such as coxa magna, coxa breva secondary to growth arrest, and coxa plana and acetabular deformities are associated with healed Legg-Calve-Perthes disease. Femoral heads that were flat yet congruent with the acetabulum are at risk for disabling arthritis in the sixth decade of life in 50% of these untreated patients. As the normal ball-and-socket joint deforms to a flattened cylinder, the hip loses abduction and rotation capability, while retaining flexion and extension potential. If the femoral head is flat and is not concentric with the acetabulum, early severe arthritis occurs. Hinge abduction and anterior impingement are known sequelae of a flat, incongruent femoral head.
REFERENCE: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopedic Surgeons, 1999, pp 3-23.

Question 67

What is the most common turf toe mechanism of injury?

Explanation

DISCUSSION
Turf toe, or capsuloligamentous injury to the first MTP joint, most commonly is caused by an axial load being applied to a fixed, dorsiflexed great toe with the heel off the ground. The external force causes further dorsiflexion of the great toe, leading to injury to the capsuloligamentous complex. A less common mechanism of turf toe is hyperplantarflexion of the great toe with valgus stress, which is seen in beach volleyball players.
RECOMMENDED READINGS
Kadakia AR, Molloy A. Current concepts review: traumatic disorders of the first metatarsophalangeal joint and sesamoid complex. Foot Ankle Int. 2011 Aug;32(8):834-9. Review. PubMed PMID: 22049873. View Abstract at PubMed
Clanton TO, McGarvey W. Athletic Injuries to the soft tissues of the foot and ankle. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. 8th ed. Philadelphia, PA: Mosby-Elsevier; 2007:1526-1535

Question 68

In the treatment of all magnitudes of bunionette deformities, what is the most common complication associated with lateral condylectomy of the fifth metatarsal head?

Explanation

DISCUSSION: When a lateral condylectomy alone is performed for all bunionette deformities, a high recurrence rate is expected. Lateral condylectomy should be used alone when the primary deformity is an enlarged lateral condyle of the fifth metatarsal head. In cases with significant divergence of the fifth metatarsal shaft in relationship to the fourth metatarsal shaft or with lateral bowing of the distal fifth metatarsal shaft, the lateral fifth metatarsal prominence will not be effectively reduced and recurrent symptoms and deformity are expected. Transfer metatarsalgia and/or dislocation of the metatarsophalangeal joint can infrequently occur with excessive metatarsal head excision. Arthrosis of the metatarsophalangeal joint has not been frequently reported.
REFERENCES: Coughlin MJ, Mann RA: Keratotic disorders of the plantar skin, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 6. St Louis, MO, Mosby-Year Book, 1993, pp 413-465.
Kelikian H: Deformities of the lesser toe, in Kelikian H (ed): Hallux Valgus, Allied Deformities of the Forefoot and Metatarsalgia. Philadelphia, PA, WB Saunders, 1965, pp 327-330.
Kitaoka HB, Holiday AD Jr: Lateral condylar resection for bunionette. Clin Orthop 1992;278:183-192.

Question 69

A patient has a humeral shaft fracture and is scheduled to undergo open reduction and internal fixation with a plate. What surgical approach will provide the greatest amount of exposure?

Explanation

DISCUSSION: The modified posterior approach with elevation of the medial and lateral heads of the triceps can provide exposure of 94% of the humeral shaft. The traditional posterior triceps-splitting approach exposes 55% of the humeral shaft.
REFERENCES: DeFranco MJ, Lawton JN: Radial nerve injuries associated with humeral fractures. J Hand Surg Am 2006;31:655-663.
Gerwin M, Hotchkiss RN, Weiland AJ: Alternative operative exposure of the posterior aspect of the humeral diaphysis with reference to the radial nerve. J Bone Joint Surg Am 1996;78:1690-1695.

Question 70

Physiologic bowing of the lower extremities should spontaneously correct by what age?

Explanation

DISCUSSION: Physiologic bowing is common and benign. Bowing is typically symmetric, involves both the femur and tibia, and is usually most prominent in toddlers. It usually resolves by 2 years of age but there is great variability. By age 36 months, almost all children will correct spontaneously. In children with physiologic bowing, the screening examination is typically normal and a family history is absent; therefore, radiographs are not necessary. If the deformity has not resolved by age 2 years, an AP radiograph of the lower limbs should be obtained. This provides documentation of the severity of the bowing, permits measurement of the metaphyseal-diaphyseal angle and/or Langenskiold grade, and allows evaluation for conditions such as rickets or bony dysplasia. No treatment is indicated for physiologic bowing.
REFERENCES: Abel MF (ed): Orthopaedic Knowledge Update: Pediatrics 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, p 7.
Salenius P, Vankka E: The development of the tibiofemoral angle in children. J Bone Joint Surg Am
J V :

Question 71

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

Explanation

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

Question 72

Figures 1 and 2 are the radiographs of a 55-year-old woman homemaker with a 1-year history of insidious onset left wrist pain. She has failed conservative treatment and desires surgery. Her medical history is complicated by a smoking history of 1.5 packs of cigarettes per day. At the time of surgery her capitate articular surface is normal in appearance. The best procedure for her would be

Explanation

EXPLANATION:
This patient has Lichtman stage 3B Kienbock disease. She is 55 years old and is a "low-demand" patient; however, she is a heavy smoker. Based on her condition and her current smoking status, salvage treatment that does not require bone healing such as a proximal row carpectomy is likely the best treatment option. A radial shortening osteotomy and a capitate shortening osteotomy may be helpful in offloading the lunate, but both procedures require bone healing and are better options in earlier stages of Kienbock disease. A scaphoid excision and four-corner fusion is typically performed for scapholunate advanced collapse or scaphoid nonunion advanced collapse wrist arthritis and would not be recommended in this scenario, as the lunate is avascular.

Question 73

In an effort to reduce costs, a limited MRI sequence is planned to detect a possible occult hip fracture. What is the anticipated fracture signal?

Explanation

DISCUSSION: At present, radiologists perform multiple MRI images to rule out all possible diagnoses. The ability to specify the anticipated changes on MRI should become more important as a means of reducing costs. MRI is sensitive to changes in free water (or hemorrhage) and thus this will appear dark on T₁ and bright on T₂.
REFERENCES: Miller MD: Review of Orthopaedics, ed 3. Philadelphia PA, WB Saunders, 2000, p 116.
Guanche CA, Kozin SH, Levy AS, et al: The use of MRI in the diagnosis of occult hip fractures in the elderly: A preliminary review. Orthopedics 1994;17:327-330.

Question 74

A 32-year-old man sustains multiple injuries in a motorcycle accident including ipsilateral open right femur and comminuted tibia fractures. He has acute abdominal distention and tenderness to palpation. The pelvis is stable to examination. He has a blood pressure of 70/40 mm Hg despite appropriate fluid resuscitation and a pulse rate of 120/min; the pulse is thready. Which of the following procedures is considered the highest priority in the management of this patient?

Explanation

DISCUSSION: The patient is in hemorrhagic shock, and timely hemostasis in the operating room should be the highest priority. Further imaging and insertion of central lines carry the risk of further delays in arresting the source of the patient’s bleeding. Albumin (colloid) solutions have questionable indications, are expensive, and have been associated with increased mortality. Crystalloid solutions such as normal saline or lactated Ringer’s solution are the initial resuscitative fluid of choice until blood becomes available. Pneumatic antishock garments have been associated with higher mortality rates, particularly in patients with cardiac and thoracic vascular injuries.
REFERENCES: Krettek C, Simon RG, Tscherne H: Management priorities in patients with polytrauma. Langenbecks Arch Surg 1998;383:220-227.
Weigelt JA: Resuscitation and initial management. Crit Care Clin 1993;9:657-671.

Question 75

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

Explanation

DISCUSSION: There is almost universal acceptance that an athlete may return to play after blunt head trauma only if he or she is totally asymptomatic. Mild residual symptoms are considered an absolute contraindication for return to play. Returning to play after a cardiovascular challenge or sport-specific activities is permitted on the pretext that the athlete is totally asymptomatic prior to these maneuvers. Neuropsychiatric testing is being used more frequently to monitor residual cognitive effects after head trauma. It has not been used as a return to play criterion.
REFERENCES: Garrick J (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 29-48.
Guskiewicz KM, McCrea, Marshall SW, et al: Cumulative effects associated with recurrent concussion in collegiate football players: The NCAA Concussion Study. JAMA
2003;290:2549-2555.

Question 76

The best patient-related outcomes, following the surgical treatment of cauda equina syndrome secondary to a large L5-S1 disk herniation, are most closely related to which of the following? Review Topic

Explanation

The most predictable positive outcome from spinal surgery due to a cauda equina syndrome is early surgical intervention before any significant neurologic deficit develops. Meta-analysis studies demonstrate that surgical intervention more than 48 hours after the onset of cauda equina syndrome show an increased risk for poor outcomes.

Question 77

82 • American Academy of Orthopaedic Surgeons A 12-year-old girl is seen for left ankle pain. Radiographs reveal osteochondritis dissecans (OCD) involving the talus. What should the parents be told regarding management?

Explanation

DISCUSSION: Nonsurgical management of OCD of the talus in skeletally immature individuals frequently results in a fairly rapid decrease in symptoms, but radiographic abnormalities can frequently be found even 6 months after treatment. Spontaneous resolution of this condition is rare. Hyperbaric oxygen treatment has not been shown to be beneficial for this condition. Progression of the condition to the point of requiring ankle fusion is rare.
REFERENCES: Perumal V, Wall E, Babekir N: Juvenile osteochondritis dissecans of the talus. J Pediat Orthop 2007;27:821-825.
Letts M, Davidson D, Ahmer A: Osteochondritis dissecans of the talus in children. J Pediatr Orthop 2003;23:617-625.

Question 78

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

Explanation

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

Question 79

A 70-year-old woman who underwent total knee replacement 18 months ago has had 3 weeks of moderate drainage from a previously healed wound. What is the most appropriate treatment?

Explanation

DISCUSSION:
This situation represents a definitively and chronically infected knee replacement. Antibiotic therapy alone might suppress the infection but would not eradicate it. Debridement and polyethylene exchange would be appropriate treatment for an early postoperative infection. The treatment of choice is to perform a two-stage debridement and reconstruction. Although not among the listed choices, an aspiration or culture could be done presurgically and might help clinicians identify the best antibiotics to treat the condition. Antibiotic selection would not affect the need for the two-stage reconstruction, however.

Question 80

A 13-year-old gymnast presents with ongoing knee pain for the past few months. She tried conservative measures including kinesiotaping, physical therapy and rest. On physical exam, she has normal valgus alignment, negative patellar tilt and discomfort with resisted open chain knee extension. A representative radiographs are shown in Figure A-C. What is the most likely clinical diagnosis? Review Topic

Explanation

Based on history, physical examination and radiographic findings this patient has patellofemoral syndrome
Evaluation of a patient with patellofemoral pain requires a physical examination and plain radiographs. Appropriate examination of all structures around the knee is critical to rule out other diagnoses. An MRI is useful for evaluating intra-articular or intra-osseous lesions, if clinical suspicion is suggestive of this. Treatment is predominantly conservative, with focus on low impact exercises that maximize aerobic conditioning.
Earl et al. review the epidemiology, etiology and management of patellofemoral syndrome. They note that there is no clear cause of this issue, although issues related to the quadriceps and dynamic malalignment may be contributory.
Outerbridge et al. describe overuse injuries in the young athletic patient. They provide an overview of diagnosis and management specific to this patient population.
Figures A, B and C show AP, lateral and merchant radiographs of a normal knee in a skeletally immature individual. No osseous abnormalities are identified.
Incorrect

Question 81

A 12-year-old girl is seen after tripping and twisting her ankle earlier in the morning. She had immediate pain and swelling and was unable to bear weight. Radiographs are shown in Figures 80a through 80c. Appropriate treatment should consist of which of the following? Review Topic

Explanation

Salter Harris III and IV fractures of the medial malleolus often contain a large cartilaginous portion, larger than the apparent ossified fragment seen on radiographs. Consequently, articular incongruity is common. As such, open reduction and internal fixation is often required. Growth disturbance and angular deformity are also common complications of Salter Harris III and IV fractures of the distal tibia.

Question 82

A 68-year-old man presents with severe right shoulder pain. He had a prolonged course of physical therapy and received several cortisone injections for his pain without improvement. Examination reveals pseudoparalysis of the right shoulder with a 20-degree external rotation lag with the shoulder adducted. With the shoulder placed in 90 degrees of abduction, he can actively externally rotate his shoulder. The patient was treated with a medialized reverse prosthesis shown in Figure A. Which of the following statement is true regarding this treatment option? Review Topic

Explanation

The clinical presentation is consistent with a patient with pseudoparalysis that was treated with a reverse total shoulder arthroplasty (RTSA). The risk of postoperative instability is increased in patients with an irrepairable subscapularis when a medialized reverse prosthesis is used. Answers 1-4 are false statements.
RTSA is most commonly indicated for rotator cuff arthropathy. However, indications for use now include shoulder pseudoparalysis, anterosuperior escape of the humeral head, acute 3 or 4-part proximal humerus fractures, and greater tuberosity fracture nonunions. Contraindications to RTSA included deltoid dysfunction, insufficient glenoid bone stock, and bony deficiency of the acromion.
Edwards et al. prospectively evaluated the risk of shoulder dislocation after reverse TSA. They found a significantly increased risk of dislocation (p=0.012) in patients with an irreparable subscapularis at time of surgery. There were no dislocations in the reparable group. Dislocations were more likely in patients with proximal humeral nonunions and failed prior arthroplasty.
Mulieri et al. looked at the use of reverse TSA in patients with irreparable massive rotator cuff tears without evidence of glenohumeral arthritis. All outcomes were improved postoperatively, and they advocate for reverse TSA in this subset of patients. Survivorship was over 90% at more than 4 years average follow up.
Boileau et al. evaluated the clinical outcomes of isolated biceps tenotomy/tenodesis in patients with massive rotator cuff tears and a biceps lesion. They found that the procedure can effectively treat pain and improve function in these patients. There was no difference in patients undergoing tenotomy versus tenodesis.
Figure A is a right shoulder radiograph status post RTSA with components in adequate position.
Incorrect Answers:

Question 83

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

Explanation

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

Question 84

A 58-year-old man with a 50-year history of osteomyelitis of the left tibia has a painful ulceration of the anterior lower limb. Figure 1 is the clinical photograph of the wound, which had purulent discharge and an unpleasant odor. Figures 2 and 3 are radiographs of the left tibia. A biopsy reveals malignant degeneration. What are the most likely findings?

Explanation

Discussion: Squamous cell carcinoma is the most common type of malignant tumor deriving from chronic osteomyelitis. The most frequently affected site is the tibia, followed by the femur. When the neoplasm invades the bone, there is either osteolytic erosion or a pathological fracture. Diagnosis is confirmed by biopsy at all suspicious wound sites. The malignant transformation most often results in squamous cell carcinoma and much more rarely in fibrosarcoma, osteosarcoma, reticulosarcoma, malignant fibrous histiocytoma or angiosarcoma. Many experts accept amputation as the best treatment option for carcinomatous transformation of chronic bone infections.

Question 85

-A 75-year-old woman fell at home and sustained the injury seen in Figures 249a through 249c. What is the most appropriate treatment option?

Explanation

Question 86

While performing a total shoulder arthroplasty, excessive retraction is placed on the "strap muscles" (short head of biceps and coracobrachialis). Neurovascular examination would reveal weakness of which of the following? Review Topic

Explanation

The musculocutaneous nerve can be as close as 3 cm to the coracoid process; therefore, this relationship is important to keep in mind when performing surgery in
this area. Excessive traction on the musculocutaneous nerve could lead to a neurapraxia with resultant weakness of elbow flexion and forearm supinaton because of the loss of biceps function.

Question 87

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

Explanation

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

Question 88

What is the most likely cause of recurrent symptoms following excision of a third web space neuroma?

Explanation

DISCUSSION: When a recurrent neuroma forms at the end of the resected nerve, it does not retract far enough because either the transection was not proximal enough or it is tethered by plantar neural branches. The transverse intermetatarsal ligament may reform, but it is not associated with pathology. Synovial cysts and synovitis are part of the differential diagnosis but are not associated with neuroma excision. Complex regional pain syndrome may result from neuroma excision, but this is rare and the symptoms are different.
REFERENCES: Beskin JL: Recurrent interdigital neuromas, in Nunley JA, Pfeffer GB, Sanders RW, Trepman E (eds): Advanced Reconstruction: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 481-484.
Amis JA, Siverhus SW, Liwnicz BH: An anatomic basis for recurrence after Morton’s neuroma excision. Foot Ankle 1992;13:153-156.

Question 89

An 11-year-old basketball player reports that he felt a painful pop in the left knee when he stumbled while running. He is unable to bear weight on the extremity and cannot actively extend the knee against gravity. Examination reveals a large knee effusion. A lateral radiograph is shown in Figure 7. Management should consist of Review Topic

Explanation

The radiograph shows an avulsion fracture, or “sleeve fracture,” of the distal pole of the patella. The distal fragment is much larger than it appears on the radiograph because it largely consists of cartilage; therefore, excision of the fragment is contraindicated. The treatment of choice is open reduction and tension band fixation to correct patella alta and restore the extensor mechanism.

Question 90

A 10-month-old infant has no flexion at the elbows, mild flexion contractures at the wrist, a rigid clubfoot deformity on the left foot, and a rigid rocker bottom deformity on the right foot. Examination of the patient's hips reveals limited

Explanation

The patient has arthrogryposis. Szoke and associates performed open reduction through a medial approach on 40 hip dislocations in 26 patients with this condition and reported good results in 80% and fair results in 12%. Due to the stiffness associated with this disorder, closed reduction with or without skin or skeletal traction is not feasible. Open reduction through an anterior approach is reserved for older children.

Question 91

During the implantation of a cementless acetabular component in total hip arthroplasty, placement of a screw in the anterior superior quadrant puts which of the following structures at risk for damage?

Explanation

DISCUSSION: A knowledge of the safe quadrants for screw placement for acetabular component implantation is essential when performing total hip arthroplasty. The external iliac vessels are on the inner wall of the pelvis, corresponding to the anterior superior quadrant of the acetabulum.
REFERENCES: Keating EM, Ritter MA, Faris PM: Structures at risk from medially placed acetabular screws. J Bone Joint Surg Am 1990;72:509-511.
Wasielewski RC, Cooperstein L, Kruger MP, Rubash HE: Acetabular anatomy and the transacetabular fixation of screws in total hip arthroplasty. J Bone Joint Surg Am

1990;72:501-508.

Question 92

A 6-month-old child is seen in the emergency department with a spiral fracture of the tibia. The parents are vague about the etiology of the injury. There is no family history of a bone disease. In addition to casting of the fracture, initial management should include Review Topic

Explanation

Unwitnessed spiral fractures should raise the possibility of child abuse, especially prior to walking age. With nonaccidental trauma being considered in the differential diagnosis, a skeletal survey is indicated to determine if there are other fractures in various stages of healing.
(SBQ13PE.60) If a child develops dynamic supination after treatment of idiopathic clubfoot with Ponseti casting, at what age would it be appropriate to consider transfer of the tibialis anterior tendon to the lateral dorsum of the foot? Review Topic
In the first six months of life, immediately following failed cast treatment
12 months
4 years
12 years
15 years
Tibialis tendon transfer to the dorsum of the foot should be performed to address dynamic supination when the lateral cuneiform has ossified. This is typically after at least 2 years of age and usually not before age 3.

Question 93

A surgeon prepares a medial gastrocnemius rotational flap to cover a medial proximal tibia defect at the time of revision knee replacement surgery. To optimize coverage, the surgeon must optimally mobilize which artery?

Explanation

DISCUSSION:
The medial sural arteries vascularize the gastrocnemius, plantaris, and soleus muscles proximally. These arteries arise from the popliteal artery. If this artery is not adequately mobilized, a gastrocnemius soleus flap can be devascularized.

Question 94

A 16-year-old girl was involved in a motorcycle accident that resulted in a significant right tibial fracture with soft-tissue loss over the distal 4 cm of the anterior medial tibia. The patient has had two irrigations and debridements and recently had an intramedullary nail placed for the skeletal injury. Vacuum-assisted closure (VAC) has been used to cover the defect since the injury. The risk of infection developing in the tibia is

Explanation

DISCUSSION: The risk of infection in a 3B open tibia fracture is most directly related to the timing of the soft-tissue coverage and less related to the size or location of the wound. The wound VAC does not lower or raise the risk of infection in open fractures. It does appear to increase the window of time to obtain coverage without increasing the risk of infection. Additionally, the wound VAC may decrease the probability of needing free tissue coverage. Intramedullary nailing has not been shown to lower the risk of infection in 3B fractures.
REFERENCES: Godina M: Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78:285-292.
Dedmond BT, Kortesis B, Punger K, et al: The use of negative-pressure wound therapy (NPWT) in the temporary treatment of soft-tissue injuries associated with high-energy open tibia shaft fractures. J Orthop Trauma 2007;21:11-17.
Herscovici D Jr, Sanders RW, Scaduto JM, et al: Vacuum-assisted wound closure (VAC therapy) for the management of patients with high-energy soft tissue injuries. J Orthop Trauma 2003;17:683-688.

Question 95

Figure 49 shows the radiograph of a 3-year-old child with progressive bowlegs. Laboratory studies show a calcium level of 9.5 mg/dL (normal 9.0 to 11.0 mg/dL), a phosphorus level of 4.2 mg/dL (normal 3 to 5.7 mg/dL), and an alkaline phosphatase level of 305 IU/L (normal 104 to 345 IU/L). What is the most likely diagnosis?

Explanation

DISCUSSION: The patient has bowlegs associated with very wide physes, particularly noted at the hips. The widening of the growth plates is a classic sign of rickets; however, the normal levels of calcium, phosphorus, and alkaline phosphatase rule out both nutritional and hypophosphatemic rickets. Patients with nutritional rickets or hypophosphatemic rickets have hypophosphatemia and increased alkaline phosphatase levels. Jansen metaphyseal dysostosis has very severe radiographic findings that are not found in this patient; however, these radiographic findings are classic for Schmid metaphyseal dysostosis. This disorder is caused by a mutation in the gene for type X collagen, which is found only in the growth plates of growing children.
REFERENCES: Lachman RS, Rimoin DL, Spranger J: Metaphyseal chondrodysplasia - Schmid type: Clinical and radiographic delineation with a review of the literature. Pediatr Radiol 1988;18:93-102.
Warman ML, Abbot M, Apte SS, et al: A type X collagen mutation causes Schmid metaphyseal chondrodysplasia. Nat Genet 1993;5:79-82.

Question 96

Which of the following assessment tools most accurately reflects outcomes of well-being, daily function, and general health in a patient treated for cervical myelopathy?

Explanation

DISCUSSION: The short-form 36 is an excellent tool for measuring the patient’s perception of treatment outcome because it is a patient-generated, validated assessment of physical, social, and role function, emotional and mental health, energy/fatigue, pain, health perception, and health change. The Nurick criteria is an evaluation of physical function with gradations of ambulation and daily function. The Japanese Orthopaedic Association score gives points for function in activities of daily living but does not assess perception of general health. The neck disability index assesses the impact of neck pain on daily life, and the Odom criteria are the surgeon’s evaluations of degree of radicular pain and deficit.
REFERENCES: Albert TJ, Mesa JJ, Eng K, McIntosh TC, Balderston RA: Health outcome assessment before and after lumbar laminectomy for radiculopathy. Spine 1996;21:960-963.
Swiontkowski MF, Buckwalter JA, Keller RB, Haralson R: The outcomes movement in orthopaedic surgery: Where we are and where we should go. J Bone Joint Surgery Am 1999;81:732-740.
Ludwig SC, Albert TJ: Measuring outcomes in cervical myelopathy and radiculopathy.

Instr Course Lect 1999;48:417-421.

Question 97

Figure 53 is the radiograph obtained at the time of transfer to the trauma center of a 41-year-old man who was involved in a motor vehicle accident. What is the most appropriate initial management?

Explanation

The radiograph reveals a displaced transverse posterior wall acetabular fracture, and the hip is dislocated. On recognition of a hip dislocation, the hip should be promptly reduced. A time to reduction of greater than 12 hours has been associated with adverse outcomes. Although skeletal traction and a CT scan are essential elements in this patient's care, the hip should be reduced prior to these actions. An MRI scan is not indicated in this patient, particularly with the hip dislocated. The ultimate surgical treatment for this injury will be open reduction and internal fixation, but the patient should be stabilized, the hip reduced, and appropriate imaging obtained before taking the patient to surgery.

Question 98

Figure 17 shows the clinical photograph of a 45-year-old female tennis player who has right arm pain and weakness with elevation after undergoing a cervical biopsy several months ago. The cause of her shoulder weakness is damage to the

Explanation

DISCUSSION: The patient has primary scapulotrapezius winging caused by surgical damage to the spinal accessory nerve during a lymph node biopsy. Other causes include blunt trauma, traction, and penetrating injuries. With spinal accessory palsy, the shoulder appears depressed and laterally translated because of unopposed serratus anterior muscle function. With primary serratus anterior winging that is the result of long thoracic nerve palsy, the scapula assumes a position of elevation and medial translation with the inferior angle rotated medially. The thoracodorsal nerve innervates the latissimus dorsi and is not associated with scapular winging.
REFERENCES: Kuhn JE, Plancher KD, Hawkins RJ: Scapular winging. J Am Acad Orthop Surg 1995;3:319-325.
Wright TA: Accessory spinal nerve injury. Clin Orthop 1975;109:15-18.

Question 99

Figures 1 and 2 display the radiographs obtained from a woman who had volar plating of the distal radius 8 months earlier. Two days ago, she noticed she could not actively extend her thumb. What is the most appropriate treatment that would restore active thumb extension?

Explanation

EXPLANATION:
Although the fracture is aligned in anatomic position, prominence of a least one of the distal screws is evident on the lateral radiographic view. The prominent screw is the most likely cause of the EPL tendon rupture. If the patient chooses surgical treatment, the best option would be removal of the offending hardware combined with extensor indicis proprius to EPL tendon transfer. Intercalary grafting would also be an acceptable option. If the tendon transfer were to be performed alone, the prominent screw(s) could rupture the transferred tendon as well. Also, it is rarely possible to repair the EPL tendon primarily in such cases, because this rupture is an attrition type. Casting would obviously not provide any benefit in this situation, and IP arthrodesis would not be the first surgical treatment option. This problem can be avoided by using shorter screws or not placing screws in plate holes that direct screws into the third dorsal extensor compartment. Intraoperative fluoroscopy and special views, such as the carpal shoot-through view, are useful for avoiding this complication.

Question 100

A large circumferential proximal femoral allograft is to be used in the reconstruction of a failed femoral component in a total hip arthroplasty. To enhance fixation of the graft to the implant, which of the following strategies should be used?

Explanation

DISCUSSION: The optimum treatment is cementing the implant to the allograft. Press-fit stability is unreliable. Wires and screws may be used for an incomplete proximal femoral allograft but cannot be used to anchor a complete proximal femoral allograft.
REFERENCES: Allan DG, Lavoie GJ, Rudan JF, et al: The use of allograft bone in revision total hip arthroplasty, in Friedlaender GE, Goldberg VM (eds): Bone and Cartilage Allografts: Biology and Clinical Applications. Park Ridge, IL, American Academy of Orthopaedic Surgeons, 1991, pp 263-264.
Gross AE, Lavoie MV, McDermott P, Marks P: The use of allograft bone in revision of total hip arthroplasty. Clin Orthop 1985;197:115-122.
Head WC, Berklacich FM, Malinin TI, Emerson RH Jr: Proximal femoral allografts in revision total hip arthroplasty. Clin Orthop 1987;225:22-36.

Full Question & Answer Text (for Search Engines)

Question 1:

Spontaneous recovery of upper extremtiy motor function after a cerebrovascular accident occurs in which of the following predictable patterns?

Options:

Shoulder flexion, elbow flexion, wrist flexion, finger flexion
Shoulder flexion, forearm supination, wrist flexion, finger flexion
Shoulder extension, elbow extension, wrist extension, finger extension
Finger flexion, wrist extension, elbow flexion, shoulder flexion
Finger flexion, wrist flexion, elbow flexion, shoulder flexion

Correct Answer: Shoulder flexion, elbow flexion, wrist flexion, finger flexion

Explanation:

Question 2:

Options:

Broad-spectrum intravenous antibiotics
AP, lateral, and flexion-extension lateral radiographs
MRI with gadolinium
Open biopsy of the surgical disk space
Anterior debridement and interbody fusion

Correct Answer: MRI with gadolinium

Explanation:

Question 3:

Which of the following physical examination findings is most likely present in the condition producing the MRI findings shown in Figure 92? Review Topic

Options:

Valgus laxity at 30 degrees of knee flexion
Varus laxity at 30 degrees of knee flexion
Posterior drawer
Pivot shift
Patellar apprehension

Correct Answer: Pivot shift

Explanation:

Question 4:

During primary total knee arthroplasty, what is the maximum distance the joint line can be raised or lowered before poor motion, joint instability, and increased chance of revision occur?

Options:

4 mm
8 mm
12 mm
16 mm
20 mm

Correct Answer: 8 mm

Explanation:

Question 5:

Options:

Initiation of lumbar flexion and core strengthening exercises
Laminectomy and posterior spinal fusion of L4/5
Laminectomy of L4 without fusion
Percutaneous endoscopic diskectomy
A course of three epidural steroid injections

Correct Answer: Laminectomy and posterior spinal fusion of L4/5

Explanation:

Question 6:

What is the most appropriate management at this time? Review Topic

Options:

Repeat epidural steroid injections
Wide lumbar laminectomy
Microdiskectomy from either a midline approach or far lateral approach
Referral to pain management
Minimally invasive posterior lumbar interbody fusion

Correct Answer: Microdiskectomy from either a midline approach or far lateral approach

Explanation:

Question 7:

Options:

Deep infection
Malalignment
Fibrous ingrowth of the femoral component
Fibrous ingrowth of the tibial component
Patellar component loosening

Correct Answer: Fibrous ingrowth of the tibial component

Explanation:

Question 8:

Options:

continued non-weight-bearing and a bone stimulator.
removal of the hardware, bone grafting of the femoral neck, and refixation.
removal of the hardware and hemiarthroplasty.
removal of the hardware and total hip arthroplasty.
removal of the hardware and a valgus osteotomy.

Correct Answer: removal of the hardware and a valgus osteotomy.

Explanation:

Question 9:

Familial (Leiden) thrombophilia is of importance in joint arthroplasty because of an abnormality in the clotting cascade. Which of the following statements best describes the condition?

Options:

It is a disease caused by an abnormality of platelets that leads to increased blood clotting.
It is a disease caused by an abnormality of vascular endothelium that leads to increased blood clotting.
It is a disease caused by an abnormality of hepatic metabolism that leads to decreased production of factor V and decreased blood clotting.
It is a disease caused by an abnormality of factor V that leads to decreased inactivation of factor Va by activated protein C (aPC) and increased blood clotting.
It is a familial, genetic disease that requires placement of a Greenfield filter in all individuals who have the abnormality, prior to surgery.

Correct Answer: It is a disease caused by an abnormality of factor V that leads to decreased inactivation of factor Va by activated protein C (aPC) and increased blood clotting.

Explanation:

Question 10:

Options:

Male gender
Diaphyseal location
Comminuted displaced fracture
Young age
Associated injuries

Correct Answer: Comminuted displaced fracture

Explanation:

DISCUSSION: The patient has a displaced comminuted clavicle middle one third fracture from a high-energy mechanism. Recent literature on high-energy clavicular fractures suggests a higher rate of nonunion than previously reported. A nonunion rate of 30% has been reported by Hill and associates when the fracture fragments are displaced more than 1.5 cm. In addition, several patients had neurologic symptoms related to the injury. Robinson and associates reported an increased risk of nonunion in women, elderly patients, comminuted fractures, and injuries with a lack of cortical contact.
REFERENCES: Hill JM, McGuire MH, Crosby LA: Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br 1997;79:537-539.
Wick M, Muller EJ, Kollig E: Midshaft fractures of the clavicle with a shortening of more than
2 cm predispose to nonunion. Arch Orthop Trauma Surg 2001;121:207-211.
Robinson CM, Court-Brown CM, McQueen MM, et al: Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am
2004;86:1359-1365.

Question 11:

Options:

When formulating his treatment plan, it is important to:
Guarantee the success of total hip arthroplasty
Recommend simultaneous bilateral total hip arthroplasty
Understand the role of implicit bias as a determinant of health care delivery disparity
Request the patient reveal the reason for his incarceration
Suggest referral to a pain management clinic

Correct Answer: When formulating his treatment plan, it is important to:

Explanation:

Question 12:

A patient with a documented allergy to nickel requires a total knee arthroplasty. Which of the following prostheses is most likely to provide long-term success in this individual?

Options:

All-polyethylene tibial component and pure titanium femoral component
All-polyethylene tibial component and cobalt-chromium alloy femoral component
Cobalt-chromium alloy tibial component and cobalt-chromium alloy femoral component
Modular titanium tibial component and pure titanium femoral component
Modular titanium tibial component and oxidized zirconium femoral component

Correct Answer: Modular titanium tibial component and oxidized zirconium femoral component

Explanation:

DISCUSSION: Nickel allergy is not an infrequent preoperative finding. The ramifications of such allergies in arthroplasty patients are poorly understood at this time. Stainless steel and cobalt-chromium alloys contain relatively high concentrations of nickel. Titanium, oxidized zirconium, and polyethylene do not contain significant amounts of nickel. Titanium is not a good surface for the articulating portion of the femoral component because of its propensity for metallosis. Oxidized zirconium is the only suitable femoral component for patients allergic to nickel. A modular titanium tibial component or an all-polyethylene tibial component would be satisfactory for these patients.
REFERENCES: Laskin RS: An oxidized Zr ceramic surfaced femoral component for total knee arthroplasty. Clin Orthop 2003;416:191-196.
Nasser S, Campbell PA, Kilgus D, et al: Cementless total joint arthroplasty prostheses with titanium-alloy articular surfaces: A human retrieval analysis. Clin Orthop 1990;261:171-185.

Question 13:

A 12-year-old girl has painless bowing of the tibia. Radiographs and a biopsy specimen are shown in Figures 35a through 35c. What is the most likely diagnosis?

Options:

Osteofibrous dysplasia
Adamantinoma
Osteosarcoma
Ewing’s sarcoma
Fibrous dysplasia

Correct Answer: Osteofibrous dysplasia

Explanation:

Question 14:

Soft-tissue sarcomas most commonly metastasize to the

Options:

liver.
lung.
bone.
regional nodes.
distant nodes.

Correct Answer: lung.

Explanation:

Question 15:

-The World Health Organization Fracture Risk Assessment Tool (FRAX) calculates which fracture risk?

Options:

year risk for hip fracture
year risk for distal radius fracture
year risk for any fragility fracture
year risk for hip fracture
year risk for distal radius fracture

Correct Answer: year risk for hip fracture

Question 16:

Options:

Patellar clunk syndrome
Flexion gap instability
Polyethylene wear
Femoral component malrotation

Correct Answer: Patellar clunk syndrome

Explanation:

Question 17:

In patients with suspected hepatitis C, which of the following tests is commonly used to confirm the diagnosis after a positive ELISA screening test?

Options:

Polymerase chain reaction (PCR)
Northern blot
Immunoblot assay
Microarray
Proteomics

Correct Answer: Immunoblot assay

Explanation:

Question 18:

The findings in Brown-Sequard syndrome include loss of which of the following? Review Topic

Options:

Greater loss of upper extremity motor function than lower extremity function
Ipsilateral motor function and ipsilateral pain and temperature sensation
Ipsilateral motor function and contralateral pain and temperature sensation
Contralateral motor function and ipsilateral pain and temperature sensation
Lower of extremity proprioception and balance

Correct Answer: Ipsilateral motor function and contralateral pain and temperature sensation

Explanation:

Question 19:

Options:

medial soft-tissue tightening.
medial soft-tissue tightening with lateral column lengthening.
medial soft-tissue tightening with talonavicular fusion.
medial displacement osteotomy with flexor digitorum longus transfer into the tarsal navicular.
triple arthrodesis with lateral column lengthening.

Correct Answer: medial soft-tissue tightening with lateral column lengthening.

Explanation:

Question 20:

Options:

Immediate MRI of the brain
Electromyography and nerve conduction velocity studies
Physical therapy and observation
Lyme titer
Psychiatric consultation

Correct Answer: Electromyography and nerve conduction velocity studies

Explanation:

Question 21:

Options:

Amyotrophic lateral sclerosis
Cubital tunnel syndrome
Normal aging
Cervical radiculopathy

Correct Answer: Cervical radiculopathy

Explanation:

Question 22:

Options:

External fixation of the pelvis, external fixation of the distal femur, and splinting of the humerus
External fixation of the pelvis, external fixation of the distal femur, and intramedullary nailing of the humerus
External fixation of the pelvis, open reduction and internal fixation of the distal femur, and splinting of the humerus
Open reduction and internal fixation of the pelvis, open reduction and internal fixation of the distal femur, and intramedullary nailing of the humerus
Open reduction and internal fixation of the pelvis, open reduction and internal fixation of the distal femur, and open reduction and internal fixation of the humerus

Correct Answer: External fixation of the pelvis, external fixation of the distal femur, and splinting of the humerus

Explanation:

Question 23:

The CT scan shows the involvement area is approximately 30% of the posterior facet. What is the most appropriate treatment?

Options:

Surgical resection
Lateral column lengthening
Coalition resection and lateral column lengthening
Triple arthrodesis

Correct Answer: Surgical resection

Explanation:

Question 24:

Options:

Continued rest, formal physical therapy and anti-inflammatory medications
Targeted chemonucleolysis of the L4-5 disc
Discectomy and interbody fusion L4-5
Discectomy utilizing a midline approach between the spinous process and multifidus
Discectomy utilizing an intermuscular approach between multifidus and longissimus

Correct Answer: Discectomy and interbody fusion L4-5

Explanation:

Question 25:

Options:

Adhesive capsulitis
Sling immobilization
Thermal chondrolysis
Subacromial impingement
Axillary nerve injury

Correct Answer: Axillary nerve injury

Explanation:

DISCUSSION: Treatment of shoulder instability with thermal devices has lead to numerous complications including recurrent instability, chondrolysis, stiffness, and capsular necrosis. This patient’s findings are consistent with a heat-induced axillary nerve injury. Normal radiographs exclude extensive chondrolysis.
REFERENCES: Levine WN, Bigliani LU, Ahmad CS: Thermal capsulorrhaphy. Orthopedics 2004;27:823-826.
McCarty EC, Warren RF, Deng XH, et al: Temperature along the axillary nerve during radiofrequency-induced thermal shrinkage. Am J Sports Med 2004;32:909-914.

Question 26:

An adult with a distal humeral fracture underwent open reduction and internal fixation. What is the most common postoperative complication?

Options:

Loss of elbow range of motion
Nonunion
Malunion
Infection
Ulnar nerve dysfunction

Correct Answer: Loss of elbow range of motion

Explanation:

Question 27:

Options:

Osteoid osteoma
Brodie’s abscess
Osteoblastoma
Chondroblastoma
Osteosarcoma

Correct Answer: Osteoid osteoma

Explanation:

DISCUSSION: The radiograph shows an eccentric, cortically based lytic lesion in the proximal fibula. The CT and MRI scans confirm that it is well circumscribed and cortically based with significant surrounding edema. The radiographic differential diagnosis would be a Brodie’s abscess or osteoid osteoma. An osteoblastoma would have to be greater than 2 cm in size. A chondroblastoma may also have significant edema around it, but it is an epiphyseal-based lesion, not cortically based. The well-circumscribed nature of the lesion is not consistent with osteosarcoma. The pathology shows a very cellular and vascular stroma with plump, but not atypical osteoblast cells making a matrix of immature woven bone. There are no abundant inflammatory cells or dead bone suggestive of osteomyelitis or a Brodie’s abscess. Therefore, the clinical and histologic picture is most consistent with an osteoid osteoma. Percutaneous radiofrequency ablation, usually with CT guidance, has become the preferred method for treating most cases of osteoid osteoma.
REFERENCES: Rosenthal DI: Radiofrequency treatment. Orthop Clin North Am 2006;37:475-484.
Ghanem I: The management of osteoid osteoma: Updates and controversies. Curr Opin Pediatr 2006;18:36-41.

Question 28:

In children with isolated zone II lacerations of the flexor tendon, poor digital motion is best correlated with

Options:

a patient age of less than 5 years.
a patient age of greater than 15 years.
early passive motion.
immobilization for 3 weeks.
immobilization for 6 weeks.

Correct Answer: immobilization for 6 weeks.

Explanation:

Question 29:

When performing surgical excision of the lesion shown in the MRI scan in Figure 3, what nerve is most likely at risk?

Options:

Deep branch of the ulnar nerve
Anterior interosseous branch of the median nerve
Recurrent branch of the median nerve
Recurrent branch of the ulnar nerve
Palmar cutaneous branch of the ulnar nerve

Correct Answer: Recurrent branch of the median nerve

Explanation:

DISCUSSION: The MRI scan shows a large mass (lipoma) in the thenar muscles of the palm. The recurrent motor branch of the median nerve innervates the thenar muscles. The anterior interosseous nerve (AIN) in the proximal forearm innervates the flexor pollicis longus, pronator quadratus, and flexor digitorum pollicis to the index and frequently the middle finger. The terminal branch of the AIN innervates only the wrist capsule. The palmar cutaneous branch of the ulnar nerve is a sensory structure to the hypothenar area. There is no commonly described recurrent branch of the ulnar nerve.
REFERENCE: Kozin SH: The anatomy of the recurrent branch of the median nerve. J Hand Surg Am 1998;23:852-858.

Question 30:

Which of the following is a significant risk factor for airway complications after anterior cervical surgery? Review Topic

Options:

Smoking history
Pulmonary disease
Absence of drainage from surgical drains
Surgical time of more than 5 hours
Myelopathy

Correct Answer: Surgical time of more than 5 hours

Explanation:

Question 31:

Options:

Protected weight bearing and radiation therapy
Intramedullary rodding of the femur with curettage and cementation
Intramedullary rodding of the femur without curettage and cementation
Biopsy of the lesion
Resection and reconstruction

Correct Answer: Biopsy of the lesion

Explanation:

DISCUSSION: Solitary bone lesions require biopsy, for there is the possibility that the lesion may represent a primary bone sarcoma, which will necessitate a different treatment plan. This is especially true in patients with remote histories of cancer. The most likely cause of a lytic bone lesion in a patient older than age 40 years is a metastatic lesion.
REFERENCES: Rougraff BT, Kneisl JS, Simon MA: Skeletal metastases of unknown origin: A prospective study of a diagnostic strategy. J Bone Joint Surg Am 1993;75:1276-1281.
Simon MA, Karluk MB: Skeletal metastases of unknown origin: Diagnostic strategy for orthopedic surgeons. Clin Orthop Relat Res 1982;166:96-103.

Question 32:

The CT scan reveals a nondisplaced greater trochanteric fracture. The patient is now experiencing severe pain. What is the most appropriate treatment at this time?

Options:

Liner exchange
Revision of the entire acetabular component
Revision of both the femoral and acetabular components
Partial weight-bearing activity for 4 to 6 weeks

Correct Answer: Partial weight-bearing activity for 4 to 6 weeks

Explanation:

Question 33:

Options:

Aspiration of joint fluid to obtain a cell count
Revision of the UKA using primary total knee arthroplasty (TKA) components
Revision of the UKA using a revision TKA with augments
Procurement of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level

Correct Answer: Procurement of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level

Explanation:

Question 34:

Figure 1 shows the radiograph of an 18-year-old patient who has severe knee pain. Treatment consisting of osteotomy should be perfomed

Options:

above the tibial tubercle.
at or just below the tibial tubercle.
in the tibial diaphysis.
on both the femur and tibia.
on the femur alone.

Correct Answer: at or just below the tibial tubercle.

Explanation:

Question 35:

- The Magnetic resonance imaging signal characteristics of a high-grade soft-tissue sarcoma are best described as

Options:

T1-low, T2-low.
T1-low, T2-high.
T1-moderate, T2-low.
T1-high, T2-low.
T1-high, T2-high.

Correct Answer: T1-low, T2-high.

Explanation:

Question 36:

Options:

Ensuring the lumbar lordosis is within 15 degrees of the pelvic incidence
Decreasing the cobb angle to less than 25 degrees
Correcting the sagittal vertical axis to +3 cm from neutral
Increasing the pelvic tilt to greater than 20 degrees
Stopping the fusion at L5

Correct Answer: Ensuring the lumbar lordosis is within 15 degrees of the pelvic incidence

Explanation:

Question 37:

A 24-year-old man sustained a bilateral C5-6 facet dislocation in a car accident and was intubated at the scene. He remains sedated in the intensive care unit

Options:

mm rostral caudal cord edema
Disruption of the anterior longitudinal ligament
Edema in the soft tissue anterior to the spine
Diffuse cord edema
mm cord hematoma

Correct Answer: mm cord hematoma

Explanation:

Question 38:

Dorsal intercalated segment instability (DISI) describes which carpal deformity?

Options:

Scaphoid extension
Lunate extension
Lunate flexion
Triquetral flexion The DISI deformity (Figure 1) simply describes dorsal lunate tilt or lunate extension on a lateral radiograph. DISI deformity usually occurs after dissociation between the lunate and the scaphoid (as in a scapholunate ligament tear). The scaphoid has a tendency to flex, and, when the scapholunate ligament is torn, the lunate loses its attachment to the scaphoid and shifts into an extended position. The scaphoid does not extend when the scapholunate ligament is torn. The triquetral bone extends with the lunate, assuming there is an intact lunotriquetral ligament. The midcarpal joint and capitate extend when the lunate flexes. Conversely, when the lunate extends into a DISI deformity, the midcarpal joint tends to compensate with flexion at the capitolunate joint.

Correct Answer: Lunate extension

Explanation:

Question 39:

preservation of the radioscaphocapitate ligament, the most radial of the palmar extrinsic ligaments, which prevents ulnar subluxation after proximal row carpectomy.

Options:

The arrows in the axial T 1 -weighted MRI scan shown in Figure 25 show which of the following structures?
Ulnar artery and accompanying vein
Deep and superficial branches of the ulnar nerve
Radial and ulnar digital nerves to the little finger
Palmar cutaneous and thenar motor branch of the median nerve
Dorsal cutaneous branch of the ulnar nerve and common digital artery to the fourth web

Correct Answer: The arrows in the axial T 1 -weighted MRI scan shown in Figure 25 show which of the following structures?

Explanation:

The arrows in the figure show the deep branch of the ulnar nerve (more radial) and the superficial branch of the ulnar nerve within Guyon’s canal. Guyon’s canal is approximately 4 cm long beginning at the proximal extent of the transverse carpal ligament and ends at the aponeurotic arch of the hypothenar muscles. Many structures comprise the boundaries of Guyon’s canal. The floor, for example, consists of the transverse carpal ligament, the pisohamate and pisometacarpal ligaments, and the opponens digiti minimi. Within Guyon’s canal, the ulnar nerve bifurcates into the superficial and deep branches. The ulnar artery is immediately adjacent and radial to the ulnar nerve. The median nerve is visualized within the carpal tunnel, and the palmar cutaneous branch is more radial to Guyon’s canal and volar to the carpal tunnel. The radial and ulnar digital nerves to the little finger are branches off of the superficial branch of the ulnar nerve distal to its emergence from Guyon’s canal. The ulnar artery is the round structure located radial to the branches of the ulnar nerve within Guyon’s canal. Adjacent to the ulnar artery are two small veins. The dorsal cutaneous branch of the ulnar nerve branches from the ulnar nerve in the distal forearm, well proximal to Guyon’s canal. The common digital artery to the fourth web branches from the superficial palmar arch distal to Guyon’s canal. The hook of the hamate is clearly seen in the figure, orienting the observer to the ulnar side of the wrist
A 37-year-old patient with type I diabetes mellitus has a flexor tenosynovitis of the thumb flexor tendon sheath following a kitchen knife puncture wound to the volar aspect of the thumb. Left unattended, this infection will likely first spread proximally creating an abscess in which of the following spaces of the palm?
Central space
Hypothenar space
Carpal tunnel
Posterior adductor space
Thenar space
CORRECT ANSWER: 5
Flexor tenosynovitis of the thumb flexor tendon sheath can spread proximally and form an abscess within the thenar space of the palm. The flexor pollicis longus tendon does not pass through the central space of the palm or the hypothenar space of the palm. The flexor pollicis longus tendon does pass through the carpal tunnel, but this is not a palmar space. The three palmar spaces include the hypothenar space, the thenar space, and the central space. The posterior adductor space would likely only be involved secondarily after spread from a thenar space infection.
New painful paresthesias near the site of the incision after an ulnar nerve transposition is the result of injury to what nerve?
Medial antebrachial cutaneous
Lateral antebrachial cutaneous
Posterior antebrachial cutaneous
Medial brachial cutaneous
Dorsal antebrachial cutaneous
Branches of the medial antebrachial cutaneous nerve can often be identified during routine ulnar nerve surgery crossing the medial aspect of the elbow. It should be preserved to avoid development of painful paresthesias.
A 21-year-old man who was injured in a snowboarding accident 18 months ago now reports wrist pain. An MRI scan is shown in Figure

Question 40:

Options:

Superior
Posterior superior
Posterior inferior
Superior lateral
Anterior superior

Correct Answer: Anterior superior

Explanation:

Question 41:

Options:

Sliding hip screw
Dynamic condylar screw
95 blade plate
Cephalomedullary nail
Intramedullary hip screw

Correct Answer: Sliding hip screw

Explanation:

Question 42:

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

Options:

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

Correct Answer: inadequate anterior and posterior coverage

Explanation:

Question 43:

Options:

Abductor pollicis brevis and extensor pollicis brevis
Abductor pollicis brevis and extensor pollicis longus
Abductor pollicis longus and extensor pollicis brevis
Abductor pollicis longus and extensor pollicis longus
Adductor pollicis and extensor pollicis longus

Correct Answer: Abductor pollicis longus and extensor pollicis brevis

Explanation:

DISCUSSION: Intersection syndrome is also known as “squeakers wrist,” “oarsmen wrist,” and crossover tendinitis. It occurs where the first and second dorsal wrist compartment structures pass over one another, resulting in fibrosis, muscular changes, and inflammation of the bursa in this area. The structures involved are the abductor pollicis longus and extensor pollicis brevis (first dorsal compartment) that pass across the second compartment structures (extensor carpi radialis brevis and extensor carpi radialis longus). An audible “squeak” is occasiona
l
y heard at the intersection point, which is approximately 4 to 5 cm proximal to the proximal dorsal wrist crease.
REFERENCES: Grundberg AB, Reagan DS: Pathologic anatomy of the forearm: Intersection syndrome. J Hand Surg Am 1985; 10:299-302.
Thorson E, Szabo RM: Common tendinitis problems in the hand and forearm. Orthop Clin North Am 1992;23:65-74.
Williams JG: Surgical management of traumatic non-infective tenosynovitis of the wrist extensors. J Bone Joint Surg Br 1977;59:408-410.
Wood MB, Dobyns JH: Sports-related extraarticular wrist syndromes. Clin Orthop Relat Res 1986;202:93-102.

Question 44:

Options:

Decreased joint penetration of distal screws
Increased rigidity
Decreased need for delayed hardware removal
Decreased peroneal irritation
Improved distal fixation

Correct Answer: Decreased joint penetration of distal screws

Explanation:

Question 45:

Options:

Single incision, anterior approach with fixation through drill holes in the radius
Single incision, anterior approach with suture anchor fixation to the radius
Single incision, anterior approach through a drill hole in the radius with sutures tied over bolster or button on the posterior forearm
Dual incision, limited anterior and posterior approach along the ulna with attachment through drill holes
Dual incision, limited anterior and posterior muscle-splitting approach (supinator and extensor muscles) with attachment through drill holes

Correct Answer: Dual incision, limited anterior and posterior approach along the ulna with attachment through drill holes

Explanation:

Question 46:

Which of the following is an advantage of using blocking screws for tibial nailing?

Options:

Decrease risk of nail breakage
Eliminate use of interlocking screws
Allow for larger nail use
Enhance construct stiffness
Decrease torsional rigidity

Correct Answer: Decrease risk of nail breakage

Explanation:

Question 47:

Options:

repeat closed reduction and buddy taping.
closed reduction and percutaneous pin fixation, followed by casting.
open reduction and plate fixation, followed by casting.
open reduction and screw fixation, followed by splinting and early motion.
open reduction and intramedullary fixation with absorbable implants.

Correct Answer: closed reduction and percutaneous pin fixation, followed by casting.

Explanation:

DISCUSSION: The patient has an unstable oblique fracture of the proximal phalanx that is easily reducible but unstable; therefore, the treatment of choice is closed reduction and percutaneous pin fixation, followed by casting. Closed reduction and percutaneous pin fixation offers a better functional result than open reduction and plate fixation. Repeat closed reduction and buddy taping is inadequate because of the inherently unstable fracture pattern. Buddy taping will allow the dislocation to recur. The other options represent more aggressive surgical techniques than are necessary to treat this fracture.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,
pp 711-771.
Green DP, Anderson JR: Closed reduction and percutaneous pin fixation of fractured phalanges. J Bone Joint Surg Am 1973;55:1651-1653.

Question 48:

Options:

ultrasound, iontophoresis, and stretching, with an early return to sports.
a local corticosteroid injection and strengthening, with a delayed return to sports.
immobilization and rehabilitation, with a delayed return to sports.
early surgical repair, prolonged rehabilitation, and a return to sports.
rehabilitation, with delayed surgical repair if the patient is unable to return to sports.

Correct Answer: early surgical repair, prolonged rehabilitation, and a return to sports.

Explanation:

Question 49:

Options:

Brachial plexus injury
Anterior cord syndrome
Posterior cord syndrome
Central cord syndrome
Brown-Séquard syndrome

Correct Answer: Central cord syndrome

Explanation:

Question 50:

Options:

Supervised hand therapy
Hemi-hamate autograft
Dynamic external fixation
Open reduction and internal fixation (ORIF)

Correct Answer: Hemi-hamate autograft

Explanation:

Question 51:

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

Options:

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

Correct Answer: total knee arthroplasty.

Explanation:

Question 52:

Which stress fracture location is reported most frequently among ballet dancers?

Options:

Base of the second metatarsal
Base of the fifth metatarsal
Tibial sesamoid
Central third of the tarsal navicular

Correct Answer: Base of the second metatarsal

Explanation:

DISCUSSION
Stress fractures are a frequent overuse injury among professional ballet dancers. The most common location is at the proximal metaphyseal-diaphyseal junction of the second metatarsal. Repetitive stress injuries and fractures of the tibial sesamoid, tarsal navicular, and base of the fifth metatarsal occur among other athletes.
RECOMMENDED READINGS
O'Malley MJ, Hamilton WG, Munyak J, DeFranco MJ. Stress fractures at the base of the second metatarsal in ballet dancers. Foot Ankle Int. 1996 Feb;17(2):89-94. PubMed PMID: 8919407.
View Abstract at PubMed
Micheli LJ, Sohn RS, Solomon R. Stress fractures of the second metatarsal involving Lisfranc's joint in ballet dancers. A new overuse injury of the foot. J Bone Joint Surg Am. 1985 Dec;67(9):1372-5. PubMed PMID: 4077907.
View Abstract at PubMed
Gehrmann RM, Renard RL. Current concepts review: Stress fractures of the foot. Foot Ankle Int. 2006 Sep;27(9):750-7. Review. PubMed PMID: 17038292.
View Abstract at PubMed

Question 53:

Options:

an oral cephalosporin antibiotic and discharge home.
IV oxacillin and gentamicin.
arthroscopic drainage of the glenohumeral joint.
open irrigation and drainage of the glenohumeral joint.
aspiration of the glenohumeral joint and subacromial space with Gram stain and culture of the fluid.

Correct Answer: aspiration of the glenohumeral joint and subacromial space with Gram stain and culture of the fluid.

Explanation:

Question 54:

Options:

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

Correct Answer: Closure of the rotator interval

Explanation:

Question 55:

Options:

Pes calcaneovalgus
Fixed pes planovalgus
Rigid equinovarus
Metatarsus adductus
Skewfoot (forefoot adduction and heel valgus)

Correct Answer: Rigid equinovarus

Explanation:

Question 56:

Options:

C3-4
C4-5
C5-6
C6-7
C7-T 1

Correct Answer: C6-7

Explanation:

DISCUSSION: The patient’s neurologic examination is consistent with a C7 radiculopathy on the right side. In a patient with this symptom complex in the absence of trauma, a cervical disk herniation is the most common etiology for a C7 radiculopathy. There are eight cervical nerve roots and the C7 nerve exits at the C6-7 disk space and is most frequently impinged by a disk herniation at this level.
REFERENCES: Houten JK, Errico TJ: Cervical spondylotic myelopathy and radiculopathy: Natural history and clinical presentation, in Clark CR (ed): The Cervical Spine, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 2005, pp 985-990.
Hoppenfeld S: Orthopaedic Neurology: A Diagnostic Guide to Neurologic Levels. Philadelphia, PA, JB Lippincott, 1977, pp 7-43.

Question 57:

Options:

fusion of the DIP joint with no reconstruction of the tendon.
advancement and repair of the tendon to the base of the distal phalanx.
two-stage reconstruction of the profundus tendon.
Z-plasty advancement of the profundus tendon.
tenodesis of the distal tendon remnant with the flexor digitorum sublimis.

Correct Answer: advancement and repair of the tendon to the base of the distal phalanx.

Explanation:

DISCUSSION: Flexor digitorum profundus ruptures are classified into three types. In type I, the tendon retracts into the palm. In type II, the tendon retracts to the level of the proximal phalanx, the vinculum remains intact, and the blood supply is preserved to the tendon. A small fleck of bony fragment observed at the A2 pulley is pathognomonic for a type II rupture. Successful primary repair of the type II rupture has been reported as late as 2 months after the injury. Type III injuries have large fragments of the distal phalanx attached and are caught distally by the A1 pulley. Type III ruptures can be repaired up to several months after the injury.
REFERENCES: Leddy JP: Avulsions of the flexor digitorum profundus. Hand Clin
1985;1:77-83.
Kiefhaber TR: Closed tendon injuries in the hand. Oper Tech Sports Med 1996;4:227-241.

Question 58:

The failure of the acetabular component shown in Figure 15 is most likely the result of the use of a 32-mm head and

Options:

the material properties of the polyethylene.
the initial alignment of the component.
overuse of the component by the patient.
failure to stabilize the cup with screws.
increased femoral head offset.

Correct Answer: the material properties of the polyethylene.

Explanation:

Question 59:

The main blood supply to the lateral two thirds of the talar body is provided by the

Options:

peroneal artery.
anterior tibial artery.
anterior lateral malleolar artery.
artery of the tarsal sinus.
artery of the tarsal canal.

Correct Answer: artery of the tarsal canal.

Explanation:

DISCUSSION: The main blood supply to the lateral two thirds of the talar body is derived from the artery of the tarsal canal, a branch of the posterior tibial artery. The peroneal artery helps form a vascular plexis over the posterior tubercle and combines with other arteries to form the artery of the sinus tarsi, which is the principal blood supply of the intrasinus structures of the talus. The anterior tibial arteries send branches to the superior surface of the talar head and give rise to the anterolateral malleolar artery, which may anastomose with other vessels to form the artery of the tarsal sinus.
REFERENCES: Sanders R: Fractures and fracture-dislocations of the talus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999,
pp 1465-1518.
Haliburton RA, Sullivan CR, Kelly PJ, et al: The extra-osseous and intra-osseous blood supply of the talus. J Bone Joint Surg Am 1958;40:1115-1120.

Question 60:

Options:

Provision of information
Competency
Understanding
Jurisdiction

Correct Answer: Competency

Explanation:

Question 61:

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 62:

In the Lauge-Hansen classification system, a pronation-abduction ankle fracture has what characteristic fibular fracture pattern?

Options:

Transverse fracture at or below the level of the syndesmosis
Short oblique fracture running from anteroinferior to posteriosuperior
Short oblique fracture running from posteroinferior to anteriosuperior
Comminuted fracture above the level of the syndesmosis
Wagstaff fracture

Correct Answer: Transverse fracture at or below the level of the syndesmosis

Explanation:

Question 63:

A 5-year-old boy has a deformity of his right arm after falling from a jungle gym. A radiograph is shown in Figure 37. Management should consist of

Options:

closed reduction of the ulna and transcapitellar pinning of the radial head.
closed reduction of the ulna and radial head dislocation.
closed reduction of the ulna and annular ligament repair.
open reduction of the radius and plating of the ulna.
open reduction of the ulna and immobilization in an extension cast.

Correct Answer: closed reduction of the ulna and radial head dislocation.

Explanation:

Question 64:

Surgical treatment for symptomatic disk herniations is associated with which of the following?

Options:

Substantial rate of nerve root injury
Early relief of pain sustained out to 2 years
Recurrent herniation rate of 35%
Outcomes that are substantially worse than nonsurgical management
10% rate of infectious diskitis

Correct Answer: Early relief of pain sustained out to 2 years

Explanation:

Question 65:

Options:

Ulnar neuritis
Excessive olecranon resection
Osteochondritis dissecans of the capitellum
Olecranon stress fracture
Valgus extension overload

Correct Answer: Excessive olecranon resection

Explanation:

Question 66:

Options:

septic arthritis.
slipped capital femoral epiphysis.
femoral head fracture (Pipkin I).
developmental dysplasia of the hip.
Legg-Calve-Perthes disease.

Correct Answer: Legg-Calve-Perthes disease.

Explanation:

Question 67:

What is the most common turf toe mechanism of injury?

Options:

Hyperdorsiflexion of the first metatarsophalangeal (MTP) joint and axial load with the foot fixed in equinus
Hyperdorsiflexion of the first MTP joint with valgus thrust
Hyperplantarflexion of the first MTP joint axial load with the foot fixed in equinus
Hyperplantarflexion of the first MTP joint with valgus thrust

Correct Answer: Hyperdorsiflexion of the first metatarsophalangeal (MTP) joint and axial load with the foot fixed in equinus

Explanation:

DISCUSSION
Turf toe, or capsuloligamentous injury to the first MTP joint, most commonly is caused by an axial load being applied to a fixed, dorsiflexed great toe with the heel off the ground. The external force causes further dorsiflexion of the great toe, leading to injury to the capsuloligamentous complex. A less common mechanism of turf toe is hyperplantarflexion of the great toe with valgus stress, which is seen in beach volleyball players.
RECOMMENDED READINGS
Kadakia AR, Molloy A. Current concepts review: traumatic disorders of the first metatarsophalangeal joint and sesamoid complex. Foot Ankle Int. 2011 Aug;32(8):834-9. Review. PubMed PMID: 22049873.
View Abstract at PubMed
Clanton TO, McGarvey W. Athletic Injuries to the soft tissues of the foot and ankle. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. 8th ed. Philadelphia, PA: Mosby-Elsevier; 2007:1526-1535

Question 68:

In the treatment of all magnitudes of bunionette deformities, what is the most common complication associated with lateral condylectomy of the fifth metatarsal head?

Options:

Metatarsophalangeal arthrosis
Transfer metatarsalgia
Recurrent deformity
Overcorrection of the deformity
Dislocation of the metatarsophalangeal joint

Correct Answer: Recurrent deformity

Explanation:

Question 69:

A patient has a humeral shaft fracture and is scheduled to undergo open reduction and internal fixation with a plate. What surgical approach will provide the greatest amount of exposure?

Options:

Modified posterior approach with elevation of the medial and lateral heads of the triceps
Posterior triceps-splitting approach
Posterior triceps-splitting approach with radial nerve mobilization
Posteromedial approach
Lateral approach with radial nerve mobilization

Correct Answer: Modified posterior approach with elevation of the medial and lateral heads of the triceps

Explanation:

DISCUSSION: The modified posterior approach with elevation of the medial and lateral heads of the triceps can provide exposure of 94% of the humeral shaft. The traditional posterior triceps-splitting approach exposes 55% of the humeral shaft.
REFERENCES: DeFranco MJ, Lawton JN: Radial nerve injuries associated with humeral fractures. J Hand Surg Am 2006;31:655-663.
Gerwin M, Hotchkiss RN, Weiland AJ: Alternative operative exposure of the posterior aspect of the humeral diaphysis with reference to the radial nerve. J Bone Joint Surg Am 1996;78:1690-1695.

Question 70:

Physiologic bowing of the lower extremities should spontaneously correct by what age?

Options:

3 months
6 months
12 months
36 months
72 months

Correct Answer: 36 months

Explanation:

Question 71:

Options:

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

Correct Answer: Anterior branch of axillary

Explanation:

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

Question 72:

Options:

radial shortening osteotomy.
capitate shortening osteotomy.
scaphoid excision and four-corner fusion.
proximal row carpectomy.

Correct Answer: proximal row carpectomy.

Explanation:

Question 73:

In an effort to reduce costs, a limited MRI sequence is planned to detect a possible occult hip fracture. What is the anticipated fracture signal?

Options:

Bright on T 1 and T 2
Dark on T 1 and T 2
Dark on T 1 , bright on T 2
Bright on T 1 , dark on T 2
Enhancement by gadolinium

Correct Answer: Dark on T 1 , bright on T 2

Explanation:

DISCUSSION: At present, radiologists perform multiple MRI images to rule out all possible diagnoses. The ability to specify the anticipated changes on MRI should become more important as a means of reducing costs. MRI is sensitive to changes in free water (or hemorrhage) and thus this will appear dark on T
1
and bright on T
2
.
REFERENCES: Miller MD: Review of Orthopaedics, ed 3. Philadelphia PA, WB Saunders, 2000, p 116.
Guanche CA, Kozin SH, Levy AS, et al: The use of MRI in the diagnosis of occult hip fractures in the elderly: A preliminary review. Orthopedics 1994;17:327-330.

Question 74:

Options:

Emergent CT of the abdomen and pelvis
Insertion of a Swan-Ganz catheter to monitor the cardiac index
Administration of albumin solution
Emergent laparotomy in the operating room
Application of a pneumatic antishock garment

Correct Answer: Emergent laparotomy in the operating room

Explanation:

Question 75:

Options:

Permit him to play after a 15-minute cardiovascular challenge.
Permit him to play after he satisfactorily completes “field-ready” neuropsychiatric testing.
Do not permit return to play until he can perform sport-specific skills.
Do not permit return to play for 1 week.
Do not permit return to play until all symptoms have resolved.

Correct Answer: Do not permit return to play until all symptoms have resolved.

Explanation:

Question 76:

Options:

Extent of bowel and bladder dysfunction
Extent of the motor deficit
Extent of the perianal saddle anesthesia
Timing of surgery
Location of the herniation

Correct Answer: Timing of surgery

Explanation:

Question 77:

Options:

No treatment is required because spontaneous healing is common.
Nonsurgical management typically relieves pain and results in radiographic healing in less than 12 weeks.
Nonsurgical management frequently relieves pain but often may not result in radiographic healing even 6 months after treatment.
Hyperbaric oxygen treatment is helpful.
Ankle fusion is frequently necessary.

Correct Answer: Nonsurgical management frequently relieves pain but often may not result in radiographic healing even 6 months after treatment.

Explanation:

Question 78:

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

Options:

Gout
Pseudogout
Infection
Epidermal inclusion cyst
Charcot joint

Correct Answer: Gout

Explanation:

Question 79:

A 70-year-old woman who underwent total knee replacement 18 months ago has had 3 weeks of moderate drainage from a previously healed wound. What is the most appropriate treatment?

Options:

Vacuum-assisted wound closure dressing
Intravenous antibiotics for 6 weeks, followed by long-term oral antibiotic administration
Irrigation and debridement, followed by polyethylene exchange
Two-stage debridement and reconstruction

Correct Answer: Two-stage debridement and reconstruction

Explanation:

Question 80:

Options:

Patellofemoral syndrome
Bipartite patella
Stress fracture of the distal femur
Patella alta
Patella baja

Correct Answer: Patellofemoral syndrome

Explanation:

Question 81:

Options:

Short leg cast with no weight bearing for the first 3 weeks
Short leg cast with immediate weight bearing
Long leg cast with no weight bearing for the first 3 weeks
Open reduction and internal fixation, avoiding the physeal growth plate and joint
CAM walker with immediate weight bearing

Correct Answer: Open reduction and internal fixation, avoiding the physeal growth plate and joint

Explanation:

Question 82:

Options:

It is contraindicated in patients with shoulder pseudoparalysis
It can be used in patients with deltoid dysfunction when combined with latissimus dorsi transfer
It shifts the center of rotation of the shoulder superior and lateral
The risk of scapular notching is increased with inferior placement of the glenoid component
The risk of instability is increased with an irreparable subscapularis

Correct Answer: It is contraindicated in patients with shoulder pseudoparalysis

Explanation:

Question 83:

Options:

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

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

Explanation:

Question 84:

Options:

Reticulosarcoma
Squamous cell carcinoma
Fibrosarcoma
Malignant fibrous histiocytoma

Correct Answer: Squamous cell carcinoma

Explanation:

Question 85:

-A 75-year-old woman fell at home and sustained the injury seen in Figures 249a through 249c. What is the most appropriate treatment option?

Options:

Stand pivot transfer only
Bed rest with bathroom privileges
Partial weight bearing on the right
Weight bearing only after surgical intervention
Bilateral weight bearing as tolerated

Correct Answer: Bilateral weight bearing as tolerated

Question 86:

Options:

Shoulder abduction
Shoulder external rotation
Shoulder internal rotation
Elbow extension
Forearm supination

Correct Answer: Forearm supination

Explanation:

Question 87:

Options:

Enchondroma
Osteochondroma
Chondroblastoma
Ewing’s sarcoma
Chondrosarcoma

Correct Answer: Osteochondroma

Explanation:

Question 88:

What is the most likely cause of recurrent symptoms following excision of a third web space neuroma?

Options:

Traumatic neuroma tethered by plantar neural branches
Regeneration of the transverse intermetatarsal ligament
Development of an intermetatarsal synovial cyst
Complex regional pain syndrome
Metatarsophalangeal joint synovitis

Correct Answer: Traumatic neuroma tethered by plantar neural branches

Explanation:

Question 89:

Options:

physical therapy for quadriceps strengthening exercises.
a long leg cast with the knee fully extended.
excision of the fragment.
suture reattachment of the patellar tendon to the tibial tuberosity.
open reduction and tension band fixation.

Correct Answer: open reduction and tension band fixation.

Explanation:

Question 90:

Options:

Preliminary skin traction followed by closed reduction under general anesthesia
Immediate closed reduction under anesthesia
Preliminary skeletal traction followed by closed reduction under general anesthesia
Bilateral open reduction performed through a medial approach
Bilateral open reduction performed through an anterior approach

Correct Answer: Bilateral open reduction performed through a medial approach

Explanation:

Question 91:

Options:

Sciatic nerve
Internal iliac vessels
External iliac vessels
Femoral vessels
Obturator vessels

Correct Answer: External iliac vessels

Explanation:

Question 92:

Options:

a skeletal survey to rule out other fractures.
a punch biopsy of the skin for collagen analysis to rule out osteogenesis imperfecta.
DNA testing for osteogenesis imperfecta.
blood studies for calcium, phosphorus, and alkaline phosphate levels.
blood studies for parathyroid hormone levels.

Correct Answer: DNA testing for osteogenesis imperfecta.

Explanation:

Unwitnessed spiral fractures should raise the possibility of child abuse, especially prior to walking age. With nonaccidental trauma being considered in the differential diagnosis, a skeletal survey is indicated to determine if there are other fractures in various stages of healing.
(SBQ13PE.60) If a child develops dynamic supination after treatment of idiopathic clubfoot with Ponseti casting, at what age would it be appropriate to consider transfer of the tibialis anterior tendon to the lateral dorsum of the foot?
Review Topic
In the first six months of life, immediately following failed cast treatment
12 months
4 years
12 years
15 years
Tibialis tendon transfer to the dorsum of the foot should be performed to address dynamic supination when the lateral cuneiform has ossified. This is typically after at least 2 years of age and usually not before age 3.

Question 93:

Options:

Profunda femoris B. Middle genicular C. Medial sural
Inferior medial genicular

Correct Answer: Profunda femoris B. Middle genicular C. Medial sural

Explanation:

Question 94:

Options:

higher than previous reports because of the use of the wound VAC.
related mainly to the location of the soft-tissue defect.
related mainly to the timing of soft-tissue coverage.
lower than previous reports because of the use of the wound VAC.
lower than previous reports because of the intramedullary nailing.

Correct Answer: related mainly to the timing of soft-tissue coverage.

Explanation:

DISCUSSION: The risk of infection in a 3B open tibia fracture is most directly related to the timing of the soft-tissue coverage and less related to the size or location of the wound. The wound VAC does not lower or raise the risk of infection in open fractures. It does appear to increase the window of time to obtain coverage without increasing the risk of infection. Additionally, the wound VAC may decrease the probability of needing free tissue coverage. Intramedullary nailing has not been shown to lower the risk of infection in 3B fractures.
REFERENCES: Godina M: Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78:285-292.
Dedmond BT, Kortesis B, Punger K, et al: The use of negative-pressure wound therapy (NPWT) in the temporary treatment of soft-tissue injuries associated with high-energy open tibia shaft fractures. J Orthop Trauma 2007;21:11-17.
Herscovici D Jr, Sanders RW, Scaduto JM, et al: Vacuum-assisted wound closure (VAC therapy) for the management of patients with high-energy soft tissue injuries. J Orthop Trauma 2003;17:683-688.

Question 95:

Options:

Blount’s disease
Hypophosphatemic rickets
Nutritional rickets
Schmid metaphyseal dysostosis
Jansen metaphyseal dysostosis

Correct Answer: Schmid metaphyseal dysostosis

Explanation:

Question 96:

Which of the following assessment tools most accurately reflects outcomes of well-being, daily function, and general health in a patient treated for cervical myelopathy?

Options:

Short-form 36
Japanese Orthopaedic Association score
Nurick criteria
Odom criteria
Neck disability index

Correct Answer: Short-form 36

Explanation:

Question 97:

Figure 53 is the radiograph obtained at the time of transfer to the trauma center of a 41-year-old man who was involved in a motor vehicle accident. What is the most appropriate initial management?

Options:

MRI scan
CT scan of the pelvis
Application of skeletal traction
Closed reduction of the right hip
Open reduction and internal fixation

Correct Answer: Closed reduction of the right hip

Explanation:

Question 98:

Options:

spinal accessory nerve, causing shoulder elevation with the scapula translated and the inferior angle rotated medially.
spinal accessory nerve, causing shoulder depression with the scapula translated laterally and the inferior angle rotated laterally.
long thoracic nerve, causing shoulder elevation with the scapula translated medially and the inferior angle rotated medially.
long thoracic nerve, causing shoulder depression with the scapula translated laterally and the inferior angle rotated laterally.
thoracodorsal nerve, causing shoulder depression with the scapula translated laterally and the inferior angle rotated laterally.

Correct Answer: spinal accessory nerve, causing shoulder depression with the scapula translated laterally and the inferior angle rotated laterally.

Explanation:

Question 99:

Options:

Removal of hardware with tendon transfer
Repair of the extensor pollicis longus (EPL) tendon primarily
Thumb interphalangeal (IP) arthrodesis
Nonsurgical treatment with cast placement keeping the thumb in a fully extended position for 4 weeks

Correct Answer: Removal of hardware with tendon transfer

Explanation:

Question 100:

Options:

Modern cement technique
Porous-coated stem
Nonporous press-fit stem
Hydroxyapatite-coated stem
Cerclage wire fixation

Correct Answer: Modern cement technique

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

Orthopedic Board Review MCQs: Knee Arthroplasty, Revision & Spine - Part 147

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 147

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index