Orthopedic Board Review MCQs: OITE & AAOS Prep Part 151

About This Board Review Set

This is Part 151 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

How to Use the Interactive Quiz

Two distinct learning modes are available:

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

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

Topics Covered in Part 151

This module focuses heavily on: Arthroplasty, Dislocation, Elbow, Fracture, Hip, Ligament, Osteoporosis, Tendon, Wrist.

Sample Questions from This Set

Sample Question 1: Rupture of the distal biceps tendon is predictably identified by the hook test, which is performed by bringing a finger from lateral to medial across the antecubital fossa of a flexed elbow, feeling for a cord-like structure on which the ex...

Sample Question 2: A 35-year-old skiier presents with pain in the left buttock and proximal posterior thigh after a fall. His clinical appearance is shown in Figure A. He is enrolled in 8 weeks of physical therapy after 2 weeks of rest, icing and NSAIDS. He r...

Sample Question 3: The fracture seen in Figure 1 is most likely associated with injury to what ligamentous structure?...

Sample Question 4: A 70-year-old woman is brought to the emergency department with a two-part greater tuberosity fracture with an anterior subcoracoid dislocation. One day after successful closed reduction, examination reveals marked swelling of the involved ...

Sample Question 5: A 77-year-old woman with osteoporosis who underwent cemented total hip arthroplasty 12 years ago fell down a flight of stairs. A radiograph is shown in Figure 15. What is the best option for treating this fracture?...

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

00:00

Start Quiz

Question 1

Rupture of the distal biceps tendon is predictably identified by the hook test, which is performed by bringing a finger from lateral to medial across the antecubital fossa of a flexed elbow, feeling for a cord-like structure on which the examiner can "hook" a finger. Bringing the finger from medial to lateral can cause a false-negative result, hooking the lacertus fibrosus, which can remain intact even with a ruptured distal biceps tendon. The Yergason test (option 3) and the Speed test (option 4) are used to assist in diagnosing proximal, not distal, biceps and labral pathology. Even if the distal biceps tendon is ruptured, the supinator remains intact. Although supination weakness may be present, an inability to supinate should not be observed. When treating a closed long finger central slip tendon rupture conservatively, what is the most appropriate plan of care?

Explanation

EXPLANATION:
Closed central slip injuries treated nonsurgically require extension splinting of the PIP joint. DIP joint active range of motion is allowed during this time period. This allows the connections between the lateral bands and the central slip to pull the central slip distally with DIP joint active motion, minimizing the gap
across the central tendon injury and keeping the DIP joint from getting stiff as well.

Question 2

A 35-year-old skiier presents with pain in the left buttock and proximal posterior thigh after a fall. His clinical appearance is shown in Figure A. He is enrolled in 8 weeks of physical therapy after 2 weeks of rest, icing and NSAIDS. He returns for follow-up 6 months after his injury and has persistent ischial tuberosity pain with running. Examination confirms focal ischial tuberosity tenderness. MRI images are seen in Figures B and C. Which surgical option is most appropriate? Review Topic

Explanation

This patient has a partial hamstring avulsion injury. If symptoms persist after a period of therapy and rest, operative repair to the ischial tuberosity is indicated.
Untreated partial hamstring ruptures may present with residual pain, weakness and hamstring dysfunction. The mechanism is eccentric lengthening (sprinting or cutting) A proposed treatment algorithm is: (1) Nonoperative management for single tendon avulsion with <2cm retraction. The ruptured tendon scars to intact tendons. (2) Repair for acute 3-tendon rupture (semitendinosus, semimembranosus, biceps femoris) with retraction >= 2cm. (3) Surgery for young (<50y) patients with 2 tendon avulsion and retraction >= 2cm.
Bowman et al. examined the outcomes of operative management of partial hamstring tears in 17 patients. They found no postoperative difficulties with ADLs, and no recurrent surgery was required. All patients returned to their preoperative level of activity. They concluded that surgery can lead to good function with low complications and is reserved for patients who have failed nonoperative management.
Hofmann et al. retrospectively reviewed 19 patients with nonoperatively managed complete hamstring avulsions. They found diminished SF-12 scores, diminished hamstring strength at 45° and 90° of flexion (62% and 66%, respectively) compared with the normal side. They concluded that nonsurgical management leads to both subjective functional and objective strength deficits.
Figure A shows pronounced bruising from hematoma tracking following the injury. Figures B and C are coronal and axial images showing partial avulsion of the right hamstring insertion. The images correspond with Illustration B, with arrows pointing to the "sickle sign" . Illustration A shows the origins of the hamstring tendons. Illustration C shows the origins of the hamstring group (bf, biceps femoris; st, semitendinosus; sm, semimembranosus; qf, quadratus femoris; am, adductor magnus)
Incorrect Answers:

Question 3

The fracture seen in Figure 1 is most likely associated with injury to what ligamentous structure?

Explanation

What is the most common organism implicated in periprosthetic infection of the shoulder?
A. Methicillin-resistant Staphylococcus aureus (MRSA)
B. Cutibacterium acnes
C. Enterococcus species
D. Staphylococcus epidermidis
C acnes is the most common organism recovered in prosthetic shoulder infections (33%), Coagulase-negative Staphylococcus is second (21%), Methicillin-sensitive S aureus (13%), and S epidermidis (10%). MRSA accounts for 5% and Enterococcus species, 1.5%.

Question 4

A 70-year-old woman is brought to the emergency department with a two-part greater tuberosity fracture with an anterior subcoracoid dislocation. One day after successful closed reduction, examination reveals marked swelling of the involved arm, forearm, and hand, as well as large amounts of “weeping” serous fluid but no obvious lacerations. The fingers are warm and pink, and the pulses are normal distally with good refill. Edema is present. There is no pain with passive and active motion of the elbow, wrist, and fingers. What is the next most appropriate step in management?

Explanation

DISCUSSION: Although not as common as arterial injury, venous thrombosis secondary to trauma of the subclavian or axillary vein can be problematic; therefore, venous duplex ultrasound scanning is the diagnostic study of choice. Arteriography may not show venous thrombosis in the venous run-off phase. The clinical history does not fit the usual presentation of a compartment syndrome or complex regional pain syndrome.
REFERENCE: Killewich LA, Bedford GR, Black KW, et al: Diagnosis of deep venous thrombosis: A prospective study comparing duplex scanning to contrast venography.

Circulation 1989;79:810.

Question 5

A 77-year-old woman with osteoporosis who underwent cemented total hip arthroplasty 12 years ago fell down a flight of stairs. A radiograph is shown in Figure 15. What is the best option for treating this fracture?

Explanation

DISCUSSION: Type I fractures are trochanteric fractures usually secondary to osteolysis. Type II fractures are located around the stem. Type III fractures are distal to the stem. If the fracture and prosthesis are stable, the fracture can be treated nonsurgically. If the fracture is unstable, the stability of the prosthesis should be assessed. If the prosthesis is unstable (type IIB), treatment should consist of revision to a long stem prosthesis that bypasses the fracture by two cortical diameters. If, as in this patient, the prosthesis is not loose (type IIA), open reduction and internal fixation is the appropriate option. Proximal femoral allograft is appropriate for type IIIC fractures in which the proximal bone is significantly compromised and the femoral component is loose.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 455-492.
Paprosky WG (ed): Revision Total Hip Arthroplasty. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2001, pp 64-69.

Question 6

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

Explanation

Yang and Weiland, from New York studied subsidence after trapezium excision and interposition arthroplasty. They compared preoperative and postoperative x-rays at rest as well as with maximal lateral key pinch stress. Lateral key
pinch stress causes a large amount of axial compressive force through the CMC joint. They also compared preoperative and postoperative functional measurements, including key pinch strength, tipto-tip pinch strength, grip strength, and thumb ROM. Their findings were that postoperatively the first metacarpal subsided 21% at rest (p=0.001). and it subsided another 10.5% during maximal lateral key pinch. Even with this degree of subsidence, the patients experienced increases in pinch strength and grip strength. Also, all patients except for one who had bony impingement reported that they were subjectively much better and more functional.
Lin et. al. also studied trapezium excision and interposition arthroplasty and found no significant differences between results in patients with varying degrees of subsidence. Thus, subsidence does not affect the results of interposition arthroplasty for basal thumb arthritis.
back to this question next question

Question 7

What is the effect on knee kinematics following placement of an anterior cruciate ligament (ACL) graft at the 12 o’clock position? Review Topic

Explanation

Endoscopic ACL reconstructive techniques may result in a vertical graft placement. The reconstructed ligament will resist anterior translation of the tibia but the graft will not restore rotatory stability. Decreased flexion and extension are caused by placement of the femoral tunnel too anterior and posterior, respectively. Impingement of the graft on the femoral notch is caused by anterior placement of the tibial tunnel or inadequate notchplasty.

Question 8

Which of the following body positions is associated with the highest intradiskal pressure?

Explanation

DISCUSSION: Intradiskal pressure is lowest when the patient is in the supine position. Sitting is associated with higher intradiskal pressures than standing. Flexion also increases intradiskal pressure. The combination of flexion and sitting produces the highest intradiskal pressure. Nachemson and Morris found that intradiskal pressure increases as position changes from lying supine, lying prone, standing, leaning forward, sitting, and sitting leaning forward. Twisting or straining in positions of relatively high intradiskal pressure may predispose patients to herniation of the intervertebral disk. Patients with a herniated disk may also notice their pain worsens with activities that increase the disk pressure, including the positions mentioned, or activities that increase intra-abdominal pressure (coughing, sneezing, straining).
REFERENCES: Nachemson A, Morris JM: In vivo measurements of intradiscal pressure.

J Bone Joint Surg Am 1964;46:1077-1092.
Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 547-556.

Question 9

Which of the following statements best describes the location of the nerve that is at risk in a direct posterior approach to the Achilles tendon?

Explanation

DISCUSSION: The sural nerve lies lateral to the Achilles tendon at the level of the foot but follows an oblique course proximally to lie directly over the tendon as it heads to the popliteal fossa. It is at risk with any proximal dissection from a direct posterior approach and in particular with procedures done at the musculotendinous junction. The nerve crosses over the lateral border of the Achilles tendon at an average of 9.8 cm above its insertion.
REFERENCES: Webb J, Moorjani N, Radford M: Anatomy of the sural nerve and its relation to the Achilles tendon. Foot Ankle Int 2000;21:475-477.
Fletcher MD, Warren PJ: Sural nerve injury associated with neglected tendo Achilles ruptures. Br J Sports Med 2001;35:131-132.

Question 10

Moderate distance running has what effect on knee articular cartilage in asymptomatic distance runners?

Explanation

Articular cartilage in the knee adapts to exercise by increasing the glycosaminoglycan (GAG) content. Increased GAG content is important to cartilage health. There is a higher glycosaminoglycan content in the lateral femoral cartilage compared to the medial femoral cartilage. Using T1 gadolinium enhanced MRI, the GAG content is seen to be increased in moderate distance runners. Moderate exercise may be a good treatment, not only to improve joint symptoms and function, but also to improve the knee cartilage GAG content in patients at high risk of developing osteoarthritis.

Question 11

Nerve conduction velocity is slowed by

Explanation

EXPLANATION:
A number of factors affect nerve conduction velocity; for example, increased body temperature increases nerve conduction velocity. Nerve conduction velocity is slowed by advancing age, compression, decreased blood flow, and fibrosis (from large imprecise sutures used for nerve repair). There is no association between hand dominance and nerve conduction velocity.

Question 12

Figure 1 is the radiograph of a 21-year-old college lacrosse player who has a 2-year history of progressive left groin pain that is exacerbated by activity. Pain is preventing him from participating with his team. Examination reveals a fit man without tenderness to palpation around the hip. No clicking or popping occurs with hip range of motion. Strength of all muscles about the hip is normal, but there is some mild pain with resisted hip flexion and hip adduction. While lying supine, progressive hip flexion with internal rotation and adduction reproduces his groin pain. The patient participates in physical therapy for 8 weeks with his team's trainer but notes little improvement. What is the most appropriate next diagnostic step to determine the cause of his pain?

Explanation

This clinical scenario describes a patient with FAI attributable to pincer (acetabular) deformity. This form of FAI, which involves prominence of the anterosuperior acetabular lip, may be more common among women. Decreased range of motion and pain occur secondary to the abutment of the femoral head against the acetabular labrum and rim. Hip flexion, combined with adduction and internal rotation, recreates this contact and causes pain, but CAM or pincer etiology remains unknown. The differential diagnosis of hip pain in a young athlete includes femoral neck stress reaction/fracture, sacroiliac arthritis, intra-articular loose body, trochanteric bursitis, osteitis pubis, and hernia. No information presented in this scenario suggests any of these causes. Diagnosis of FAI is best performed via MR imaging, with an arthrogram increasing the sensitivity and specificity for labral pathology. Ultrasonography may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping hip, but ultrasonography is not commonly
used to diagnose labral pathology. Although concomitant chondral lesions of the femoral head are uncommon, the forced leverage of the anterosuperior femoral neck upon the anterior acetabulum may result in a “contra-coup” chondral injury on the posteroinferior acetabulum. This is the most common location of chondral lesions in this scenario. Without bony resection to prevent further impingement, this patient will continue to experience symptoms. Because there is no evidence of femoral neck prominence (CAM lesion), there is no indication for osteoplasty of the femoral neck; resection of the pincer lesion is necessary. This will often require take-down of the labrum in this location. If possible, iatrogenic or traumatic labral tears should subsequently be repaired after pincer debridement because the labrum has important functions for hip stability and maintenance of the suction seal of the joint.

Question 13

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

Explanation

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

Question 14

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

Explanation

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

Question 15

-The main blood supply to the capital femoral epiphysis in a 10-year-old child is supplied from the

Explanation

Question 16

A 54-year-old woman with idiopathic carpal tunnel syndrome undergoes open carpal tunnel release with a flexor tenosynovectomy. The pathology from the tenosynovium is likely to show

Explanation

DISCUSSION: The tenosynovium excised at the time of a carpal tunnel release for idiopathic carpal tunnel syndrome rarely shows signs of acute or chronic inflammation. Fibrosis, edema, and vascular sclerosis are the most common histologic findings. A tenosynovectomy with a carpal tunnel release usually is not necessary in the treatment of idiopathic carpal tunnel syndrome.
REFERENCES: Shum C, Parisien M, Strauch RJ, et al: The role of flexor tenosynovectomy in the operative treatment of carpal tunnel syndrome. J Bone Joint Surg Am 2002;84:221-225.
Fuchs PC, Nathan PA, Myers LD: Synovial histology in carpal tunnel syndrome. J Hand Surg Am 1991;16:753-758.
Kerr CD, Sybert DR, Albarracin NS: An analysis of the flexor synovium in idiopathic carpal tunnel syndrome: Report of 625 cases. J Hand Surg Am 1992;17:1028-1030.

Question 17

A 52-year-old, right hand dominant man comes for evaluation of right shoulder pain that has been intermittently bothering him for three months. The pain is worse with overhead activities. He denies any history of trauma. His range of forward elevation in the plane of the scapula is painful and is limited to 145 degrees, compared to 170 degrees on his unaffected side. A radiograph is shown in Figure A. He saw another orthopedist a month ago, who ordered an MRI, which showed a small, partial thickness supraspinatus tendon tear. He received a subacromial injection of lidocaine at that time which temporarily relieved 90 percent of the pain he felt with passive forward elevation of his shoulder past 90 degrees. Today he is requesting a subacromial injection of platelet rich plasma (PRP). You tell him that with regard to pain, function and range of motion, subacromial injection of PRP: Review Topic

Explanation

At one year, quality of life, pain, disability and shoulder range of motion are the same for patients treated with therapy and placebo versus patients treated with therapy and
PRP injection.
Platelet rich plasma has been used for the treatment of chronic tendinopathy in different areas with mixed results. No benefit to patients with symptoms of subacromial impingement has been demonstrated for subacromial injection of PRP, when added to a standard therapy program.
Kesikburun et al. conducted a randomized controlled trial in which patients with rotator cuff tendinopathy or partial rotator cuff tears were randomized to receive ultrasound-guided subacromial injection of either PRP or lidocaine, followed by a standard six-week therapy program. The authors found no difference in pain, range of motion or validated outcome scores at one year follow up.
Hall et al. reviewed sports medicine applications for PRP. At that time (2009), with regard to PRP, they concluded that there was "little clinical evidence for its use."
Ketola et al. sought to determine the effectiveness of subacromial decompression for the treatment of subacromial impingement syndrome. They randomized 140 patients to a supervised exercise program or arthroscopic subacromial decompression followed by a supervised exercise program. They found no clinically important differences between the two groups at 24 months follow up.
Figure A shows a right shoulder radiograph without osseous pathology. Incorrect answers:

Question 18

Which of the following procedures is considered most appropriate in patients with rheumatoid arthritis?

Explanation

DISCUSSION: Synovectomy of the knee prior to loss of articular cartilage has been shown to consistently relieve pain in patients with rheumatoid arthritis. Partial knee replacement will not arrest the process of joint destruction. Osteotomy of the hip has not been found to be a successful procedure in patients with rheumatoid arthritis. Hip arthrodesis should not be considered because of the multiarticular involvement in patients with rheumatoid arthritis. Core decompression of the hip has not been shown to save the femoral head because the necrosis appears to occur simultaneously with the inflammatory joint process.
REFERENCES: Granberry WM, Brewer EJ Jr: Early surgery in juvenile rheumatoid arthritis, in Calundruccio RA (ed): Instructional Course Lectures XXIII. St Louis, MO, CV Mosby, 1974, pp 32-37.
Stuchin SA, Johanson NA, Lachiewicz PF, Mont MA: Surgical management of inflammatory arthritis of the adult hip and knee, in Zuckerman JD (ed): Instructional Course Lectures 48. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 93-109.

Question 19

A 77-year-old man who underwent right total knee replacement surgery 2 and a half years ago has had knee pain since surgery. The pain is diffuse, constant, and made worse with activity. He notes warmth and swelling in his knee. Examination shows a well-healed incision, no erythema, moderate warmth, synovitis, and an effusion. The knee is stable, and has an arc of flexion between 3° and 120°. Radiographs show well-fixed and well-aligned implants. What is the most appropriate initial treatment?

Explanation

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

Question 20

-Figures a through c are the MRI scans of a 21-year-old woman with recurrent shoulder instability and pain after an open anterior stabilization procedure. Positive belly-press test findings were positive.At surgery she was found to have an irreparable tear of the tendon injury identified preoperatively. The procedure to address the dynamic stabilizer deficit places which nerve at most risk?

Explanation

Question 21

A 17-year-old high school gymnast who has peripatellar knee pain has been unable to practice on a consistent basis for the past 3 years. She denies any specific injury events. Physical therapy for modalities, quadriceps strengthening, and hamstring stretching provide temporary relief. A trial of patellar taping significantly reduces her pain. Examination reveals an 15-degree Q angle, moderate lateral facet tenderness, negative patellar apprehension, and the inability to evert the patella. Radiographs show a moderate lateral patellar tilt. Treatment should now consist of

Explanation

DISCUSSION: The patient has patellofemoral stress and a tight lateral retinaculum that has failed to respond to nonsurgical management; therefore, the most appropriate treatment includes an arthroscopic lateral retinacular release. A patellar restraining brace may aggravate the peripatellar pain by increasing pressure on the lateral facet. There is no evidence of patellar instability or significant malalignment; therefore, medial retinacular repair or a tibial tubercle transfer is not indicated. A modified Maquet tibial tubercle elevation would be considered only for significant patellofemoral arthrosis.
REFERENCES: Gambardella RA: Techical pitfalls of patellofemoral surgery. Clin Sports Med 1999;18:897-903.
Post WR: Clinical evaluation of patients with patellofemoral disorders. Arthroscopy 1999;15:841-851.

Question 22

The Musculoskeletal Infection Society (MSIS) has adopted a definition of periprosthetic joint infection (PJI). This definition includes 2 major criteria and 5 minor criteria. Infection is present if 1 of 2 major criterions or 3 of 5 minor criterions are met. These criterions are

Explanation

DISCUSSION
In 2014, the MSIS published its revised PJI definition for clinical and research use. If 1 of 2 major criterions is met (phenotypically identical organisms obtained from 2 separate cultures or a draining sinus tract), then PJI is diagnosed. Alternatively, if 3 of 5 minor criterions are met, PJI is diagnosed.

Question 23

An operating room intervention that should be undertaken by anesthesia staff during the cementing of a femoral stem is to

Explanation

DISCUSSION
Young age is a risk factor for early failure of cementless femoral components. Surgeons could consider cementing for patients older than 80 years of age. The Dorr classification has been shown to favor a cemented femoral stem in Dorr type C bone. Dorr type B bone can potentially sustain a proximally porous ingrowth stem. Osteoporosis is a risk factor for early failure of cementless femoral components.
Earlier designs for cemented femoral stems used microtexture to interlock the stem into the cement mantle. If these stems became loose, they would abrade the cement and loosen the stem further. Successful cemented femoral components are polished and have smooth edges with tapered bodies. Collars do not add to the design of femoral stems.
Patients are at risk for hypotension during the femoral pressurization process. With that in mind, the surgeon should make sure the anesthesiologist is ready to respond to hypotension. The FiO2 should be increased. The IV fluid rate also should be increased, and the anesthesiologist should be prepared with phenylephrine to support the patient’s blood pressure if he or she becomes hypotensive.

Question 24

In a fracture such as the one shown in Figure 16 (Salter-Harris type I fracture of the distal femur), which of the following best describes the location of the fracture?

Explanation

DISCUSSION: The growth plate in the distal femur has an undulating topography, with prominences called mammillary bodies that interdigitate with other portions of the physis to provide stability at the distal femur. A typical distal femoral physeal fracture propagates through multiple layers of the growth plate as opposed to most Salter-Harris type I physeal fractures.
REFERENCES: Smith DG, Geist RW, Cooperman DR: Microscopic examination of a naturally occurring epiphyseal plate fracture. J Pediatr Orthop 1985;5:306-308.
Jaramillo D, Kammen BF, Shapiro F: Cartilaginous path of physeal fracture separations: Evaluation with MR
imaging: An experimental study with histologic correlation in rabbits. Radiology 2000;215:504-511. Question 17
A 14-year-old boy has had a 3-month history of low back pain with no known trauma. The pain is worse with activity and relieved by rest, although he does report difficulty with prolonged sitting in school.
The patient was on the football team but stopped participating because of the back pain during football practice. He reports no history of radicular pain and denies any numbness, tingling, or weakness in the legs.
Neurologic examination is normal. Back examination reveals slight tenderness over the lower back area but no swelling or skin defects. Strength testing is 5 over 5 in the lower extremities and the straight leg raise test is negative. Back range of motion is nearly full, but back extension is painful. The hamstrings are slightly tight. Initial radiographs, including AP, lateral and oblique views, are negative. What is the best test to determine the patient’s diagnosis?
Flexion and extension lateral radiographs
MRI
Myelogram
Diskogram
Bone scan with SPECT PREFERRED RESPONSE: 5
DISCUSSION: A bone scan with SPECT is very sensitive and specific for spondylolysis not seen on initial
radiographs. MRI can sometimes visualize spondylolysis, but it is not as sensitive nor as specific as a bone scan with SPECT. Flexion and extension views have no role in the evaluation of the patient who presents with classic spondylolysis-type symptoms. The most sensitive physical examination finding is pain with back extension. Oblique radiographs can be obtained, but they are not as sensitive or specific as a bone scan with SPECT. The patient does not have any signs of a disk problem; therefore, an evaluation of the disk is not helpful.
REFERENCES: Hu SS, Tribus CB, Diab M, et al: Spondylolisthesis and spondylolysis. J Bone Joint Surg Am 2008;90:656-671.
Lawrence JP, Greene HS, Grauer JN: Back pain in athletes. J Am Acad Orthop Surg 2006;14:726-735.

Figure 18a Figure 18b

Question 25

A 52-year-old man has shoulder pain and stiffness after undergoing a “mini-lateral” rotator cuff repair 6 months ago. Examination reveals that he is afebrile with normal vital signs. There is slight erythema but no drainage from the incision. Range of motion is limited in all planes, and there is weakness with resisted external rotation and abduction. Radiographs show a well-positioned metal implant within the greater tuberosity. Laboratory studies reveal a WBC count of 8,400/ mm 3 (normal 3,500 to 10,500/ mm 3 ) and an erythrocyte sedimentation rate of 63 mm/h (normal up to 20 mm/h). What is the next most appropriate step in management?

Explanation

DISCUSSION: Deep sepsis of the shoulder following rotator cuff repair is an uncommon problem. Patients with infections of this type typically report persistent pain and are not systemically ill. They may have signs of local wound problems such as erythema, drainage, and dehiscence. Laboratory studies can be helpful in making an accurate diagnosis. Most patients will not show a significant elevation of the WBC count; however, an elevated erythrocyte sedimentation rate is nearly always present and should alert the clinician to the presence of infection. Aspiration of both subacromial and glenohumeral joint spaces is necessary to confirm the diagnosis. The most effective treatment for deep shoulder sepsis following rotator cuff repair involves extensive surgical debridement, removing all suspicious soft tissue as well as implants. Administration of appropriate antibiotic therapy is needed for complete control of the infection.
REFERENCES: Mirzayan R, Itamura JM, Vangsness CT, et al: Management of chronic deep infection following rotator cuff repair. J Bone Joint Surg Am 2000;82:1115-1121.
Settecerri JJ, Pitnu MA, Rock MG, et al: Infection after rotator cuff repair. J Shoulder Elbow Surg 1994;8:105.
Herrera MF, Bauer G, Reynolds F, et al: Infection after mini-open rotator cuff repair. J Shoulder Elbow Surg 2002;11:605-608.

Question 26

A 17-year-old male soccer player sustains repeated lateral patellar dislocations refractory to physical therapy, bracing, and taping. After a workup including radiographs and MRI, the orthopaedic surgeon considers an isolated tibial tubercle osteotomy (TTO). He plans a 60-degree anteromedialization to address instability and to unload the patellofemoral joint. What is a relative contraindication to this procedure?

Explanation

CLINICAL SITUATION FOR QUESTIONS 37 THROUGH 41
A healthy, active 18-year-old man has acute-onset right knee pain and an inability to fully extend his knee following an attempt to stand from a seated position yesterday. He sustained a noncontact injury to his right knee while playing basketball 2 years ago and underwent primary anterior cruciate ligament (ACL) reconstruction with bone-patella-tendon-bone autograft and medial meniscus repair. He sustained another noncontact injury to the same knee 8 months later and underwent a revision ACL reconstruction using soft-tissue allograft and revision medial meniscus repair. He reports multiple episodes of “giving way” of his knee, but no pain prior to yesterday’s acute injury.

Question 27

Resuscitation of a trauma patient who has been in hypovolemic shock is complete when which of the following has occurred?

Explanation

DISCUSSION: Shock can be defined as inadequate tissue perfusion. Resuscitation or the resolution of shock is defined as when oxygen debt has been repaid, tissue acidosis is eliminated, and aerobic metabolism has been restored in all tissue beds. The end points for resuscitation are not clearly defined, but occult shock can still be present in the setting of normal vital signs and normal urine output due to selective perfusion of organ systems.
REFERENCES: Tisherman SA, Barie P, Bokhari F, et al: Clinical practice guideline: End point of resuscitation. J Trauma 2004;57:898-912.
Moore FA, McKinley BA, Moore EE, et al: Inflammation and the Host Response to Injury, a large-scale collaborative project: Patient-oriented research core--standard operating procedures for clinical care. III. Guidelines for shock resuscitation. J Trauma 2006;61:82-89.
Englehart MS, Schreiber MA: Measurement of acid-base resuscitation end points: Lactate, base deficit, bicarbonate or what? Curr Opin Crit Care 2006;12:569-574.

Question 28

Bioabsorbable polymers are used in a wide range of orthopaedic devices, including anchors, staples, pins, plates, and screws. What is the primary drawback for bioabsorbable implants?

Explanation

DISCUSSION: A number of bioabsorbable polymers are used in orthopaedic applications, and all have in common reports of foreign body reactions, which occur in more than 50% of patients in some series. In general, the high cost of these polymers is offset by the elimination of a second surgery to remove the implant. Bioabsorbable polymers are low strength in comparison to metallic alloys but of sufficient strength for many orthopaedic applications. The elastic modulus is not as high as many other orthopaedic biomaterials, making them suitable for applications where lower stiffness is an asset.
REFERENCES: Ambrose CG, Clanton TO: Bioabsorbable implants: Review of clinical experience in orthopedic surgery. Ann Biomed Eng 2004;32:171-177.
Bergsma JE, de Bruijn WC, Rozema FR, et al: Late degradation tissue response to poly

(L-lactide) bone plates and screws. Biomaterials 1995;16:25-31.

Question 29

A 50-year-old man with no history of trauma reports new-onset back pain after doing some yard work the previous day. He reports pain radiating down his leg posteriorly and into the first dorsal web space of his foot. MRI scans are shown in Figures 3a through 3c. What nerve root is affected?

Explanation

DISCUSSION: The MRI scans clearly show an extruded L4-5 disk that is affecting the L5 nerve root on the left side. In addition, the L5 nerve root has a cutaneous distribution in the first dorsal web space. S1 affects the lateral foot. L4 affects the medial calf.
REFERENCE: An HS: Principles and Techniques of Spine Surgery. Baltimore, MD,

Williams and Wilkins, 1998, pp 98-100.

Question 30

A high school athlete reports the sudden onset of low back pain while performing a dead lift. Examination reveals lumbar paraspinal spasm and a positive straight leg raising test. Deep tendon reflexes, motor strength, and sensation in the lower extremities are normal. Radiographic findings are normal. If symptoms persist for longer than a few weeks, what is the best course of action?

Explanation

DISCUSSION: In the adolescent population, a lumbar herniated disk is characterized by a paucity of clinical findings, with a positive straight leg raising test the only consistently positive finding. This may result in a prolonged period of nonsurgical management that fails to provide relief. Activities that place a significant shear load on the lumbar spine, such as the dead lift, are associated with an increased risk of central disk herniation. An adolescent who lifts weights and has a history of back pain that fails to respond to a short period of active rest should undergo MRI evaluation for the diagnosis of a lumber herniated disk.
REFERENCES: Epstein JA, Epstein NE, Marc J, et al: Lumbar intervertebral disk herniation in teenage children: Recognition and management of associated anomalies. Spine 1984;9:427-432.
Hashimoto K, Fujita K, et al: Lumbar disc herniation in children. J Pediatr Orthop

1990;10:394-396.

Question 31

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

Explanation

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

Question 32

A right-hand-dominant 45-year-old man sustains an injury to the anterior aspect of his right elbow while trying to lift a heavy load 3 days ago. He has ecchymosis in the anterior and medial elbow regions and has difficulty with resisted forearm supination with the elbow in a flexed position. A diagnosis of an acute distal biceps tendon rupture is made and surgical treatment is chosen. The anatomic relationship of the distal biceps tendon to the median nerve and recurrent radial artery within the antecubital fossa is such that the biceps tendon travels

Explanation

During surgical repair of a distal biceps tendon rupture, regardless of the surgical approach or technique, an understanding of the regional anatomy is important. The tendon passes distally into the antecubital fossa. The antecubital fossa is defined by the brachioradialis radially and the pronator teres ulnarly. A sheath surrounds the biceps tendon as it passes through the antecubital fossa toward its insertion on the radial tuberosity. The lateral antebrachial cutaneous nerve lies superficially in the subcutaneous tissue of the antecubital fossa. The nerve parallels the brachioradialis. While still superficial, the tendon is contiguous with the lacertus fibrosus that becomes confluent medially with the fascia overlying the flexor-pronator mass. The brachial artery lies just beneath the lacertus fibrosus at the level of the elbow flexion crease. The tendon travels just lateral (radial) to the median nerve within the antecubital fossa and passes posterior (deep) to the recurrent radial artery before it attaches to the radial tuberosity. Full forearm supination allows visualization of the tendinous insertion on
the radial tuberosity.

Question 33

What is the most appropriate treatment for a 50-year-old woman who sustains the injury shown in Figures 14a and 14b?

Explanation

DISCUSSION: This intra-articular distal humerus fracture with displacement at the joint surface is best treated with surgical fixation. The most biomechanically sound construct is two plates applied to either column 180 degrees from one another. Elbow arthroplasty is most appropriate for low demand elderly patients.
REFERENCES: Schemitsch EH, Tencer AF, Henley MB: Biomechanical evaluation of methods of internal fixation of the distal humerus. J Orthop Trauma 1994;8:468-475.
McCarty LP, Ring D, Jupiter JB: Management of distal humerus fractures. Am J Orthop 2005;34:430-438.
Kamineni S, Morrey BF: Distal humeral fractures treated with noncustom total elbow replacement: Surgical technique. J Bone Joint Surg Am 2005;87:41-50.

Question 34

Which of the following best characterizes the injury shown in Figure 53? Review Topic

Explanation

The injury shown is a flexion compression injury also known as "tear drop" fracture. It is characterized by the large anteroinferior fragment off the vertebral body and the retrolisthesis seen in this image. It is considered an unstable injury and should be distinguished from the more stable and minor extension tear drop avulsion where there is no vertebral malalignment and the anteroinferior fracture is a small avulsion of the annulus attachment. Other axial load injuries can be stable but have more of a compression or even burst pattern with loss of body height rather than the anteroinferior fragment. The radiograph does not demonstrate facet malalignment that would be seen with a facet dislocation.

Question 35

The patient is at highest risk for which complication?

Explanation

DISCUSSION
The quality of femoral neck fracture reduction was the key outcome factor in a number of studies. Capsulotomy is performed when achieving open reduction of the femoral neck. In rare cases in which acceptable closed reduction is achieved capsulotomy has been advocated, but poor anatomic reduction is more likely to negatively influence the outcome. Although some biomechanical data suggest that fixed-angle implants may be advantageous, this has not been demonstrated in well-controlled clinical studies. If reduction is not achieved, protecting postoperative weight bearing is not likely to improve outcomes.
Failure to achieve anatomic reduction of the femoral neck frequently leads to nonunion and varus collapse. Postoperative infection and/or heterotopic ossification are not typically seen in closed reduction and percutaneous stabilization of femoral neck fractures. Nonunion is more common than malunion of displaced femoral neck fractures.
RECOMMENDED READINGS
Duckworth AD, Bennet SJ, Aderinto J, Keating JF. Fixation of intracapsular fractures of the femoral neck in young patients: risk factors for failure. J Bone Joint Surg Br. 2011 Jun;93(6):811-6. doi: 10.1302/0301-620X.93B6.26432. PubMed PMID: 21586782. View
Abstract at PubMed
Yang JJ, Lin LC, Chao KH, Chuang SY, Wu CC, Yeh TT, Lian YT. Risk factors for nonunion in patients with intracapsular femoral neck fractures treated with three cannulated screws placed in either a triangle or an inverted triangle configuration. J Bone Joint Surg Am. 2013 Jan 2;95(1):61-9. doi: 10.2106/JBJS.K.01081. PubMed PMID: 23283374. View Abstract at
PubMed

Question 36

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

Explanation

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

Question 37

You are counseling a 55-year-old woman for a right carpal tunnel release. What can you tell her about the treatment benefit (grip strength and paresthesia relief) 1 year after surgery compared with continued splinting, NSAID use, physical therapy, and a single steroid injection?

Explanation

EXPLANATION:
Gerritsen and associates, Hui and associates, and Jarvik and associates compared the effectiveness of surgical versus nonsurgical treatment for the relief of carpal tunnel symptoms. All three studies showed that surgery was superior for the relief of paresthesias and the improvement of grip strength. According to the American Academy of Orthopaedic Surgeons Clinical Guidelines on the Treatment of Carpal Tunnel Syndrome, strong evidence supports the assertion that surgical treatment of carpal tunnel syndrome should have a greater treatment benefit at 6 and 12 months than splinting, NSAIDs, physical therapy, and a single steroid injection. The other choices, including no change in grip strength and
paresthesias, decrease in grip strength and increase in paresthesias, and increase in grip strength and paresthesias, are not supported by the evidence.

Question 38

Preservation or reconstruction of which of the following structures is essential to minimize the risk of hallux valgus developing after removal of part or all of the medial sesamoid?

Explanation

DISCUSSION: Complications of medial sesamoidectomy include stiffness, claw toe, and hallux valgus. Each sesamoid sits within its respective head of the flexor hallucis brevis tendon. Excision of one sesamoid can result in slack in its flexor hallucis brevis tendon; therefore, it is imperative to preserve or repair the flexor hallucis brevis tendon when removing the medial sesamoid.
REFERENCES: Dedmond BT, Cory JW, McBryde A Jr: The hallucal sesamoid complex. J Am Acad Orthop Surg 2006;14:745-753.
Lee S, James WC, Cohen BE, et al: Evaluation of hallux alignment and functional outcome after isolated tibial sesamoidectomy. Foot Ankle Int 2005;26:803-809.

Question 39

A 15-year-old girl who competes in gymnastics has immediate pain and giving way of the left elbow after falling from the uneven parallel bars and landing on her outstretched arms. Examination reveals swelling and tenderness about the elbow, especially over the medial side. Measurement of elbow motion shows 0° to 125° of flexion, and valgus stress at the elbow is painful. AP, lateral, and stress radiographs are shown in Figures 9a through 9c. Management should consist of

Explanation

DISCUSSION: While many low-demand patients with injuries to the ulnar collateral ligament can be treated nonsurgically, Jobe and associates described two situations in which ulnar collateral ligament reconstruction is indicated: (1) an acute complete rupture in a competitive athlete who uses the upper extremities extensively and who wishes to remain active; and (2) chronic pain or instability that does not improve after at least 3 months of nonsurgical management. Rarely is direct surgical repair of the ligament possible or able to withstand the valgus stresses applied to the elbow. Most authors recommend surgical reconstruction of the ulnar collateral ligament using a palmaris longus, plantaris, or fourth toe extensor tendon from the fourth autograft.
REFERENCES: Andrews JR, Jelsma RD, Joyce ME, et al: Open surgical procedures for injuries to the elbow in throwers. Oper Tech Sports Med 1994;4:109-133.
Jobe FW, Kvitne RS: Elbow instability in the athlete. Instr Course Lect 1991;40:17-23.
Smith GR, Altchek DW, Pagnani MJ, Keeley JR: A muscle-splitting approach to the ulnar collateral ligament of the elbow: Neuroanatomy and operative technique. Am J Sports Med 1996;24:575-580.

Question 40

Figures 10a through 10c show the plain radiograph and MRI scans of a 41-year-old man who has right hip pain. What is the most likely diagnosis?

Explanation

DISCUSSION: Transient osteoporosis is a self-limited painful but reversible disorder. Although first described in pregnant women, it is more common in young to middle-aged men. The radiograph shows loss of mineralization in the right hip relative to the left side. There is no osseous destruction or cortical expansion typical of metastasis or giant cell tumor. The process is confined to the femoral side of the joint unlike rheumatoid arthritis, which would be centered in the joint. Osteonecrosis is better defined with sharp but irregularly shaped margins, and there is no double-line sign. The MRI scans reveal diffuse edema in the femoral head and neck that is atypical for osteonecrosis. Transient osteoporosis may recur in the same or opposite hip.
REFERENCE: El-Khoury G: MRI of the Musculoskeletal System. Philadelphia, PA, JB Lippincott, 1998, p 241.

Question 41

A 15-year-old girl reports a 6-month history of activity-related knee pain and swelling. A radiograph, MRI scan, and biopsy specimen are shown in Figures 21a through 21c. What is the most likely diagnosis?

Explanation

DISCUSSION: The epiphyseal location on the radiograph and MRI scan and the histologic findings of polyhedral cells separated by a chondroid matrix with pericellular, lattice-like “chicken wire” calcification all suggest chondroblastoma. Although giant cell tumors of bone typically occupy an epiphyseal location, they are rare in children and when present are often metaphyseal in skeletally immature patients. Enchondromas and osteoblastomas are generally metaphyseal and, along with giant cell tumors, have very different histology than seen here. Chondromyxoid fibromas are typically metaphyseal in location.
REFERENCES: Huvos AG: Bone Tumors: Diagnosis, Treatment, and Prognosis. Philadelphia, PA, WB Saunders, 1991, pp 295-313.
Lin PP, Thenappan A, Deavers MT, et al: Treatment and prognosis of chondroblastoma. Clin Orthop Relat Res 2005;438:103-109.

Question 42

A 29-year-old male sustained a mid-shaft femur fracture in a motor cycle accident. Even if asymptomatic, what additional radiographs must be obtained either preoperatively or intraoperatively before performing intramedullary nailing of the femoral shaft fracture?

Explanation

DISCUSSION: Ipsilateral femoral neck fractures are seen in 1-9% of femoral shaft fractures and the femoral neck must be properly imaged either preoperatively or intraoperatively in any patient with a femoral shaft fracture. Dedicated hip films, possibly including an internal rotation AP, should be obtained before entering the OR. Daffner et al reported that in 11 of 20 cases of combined femoral shaft and neck fractures, the initial preoperative radiographs did not demonstrate the femoral neck fracture. Intraoperative fluoroscopy should also be used to evaluate for a femoral neck fracture both before (to evaluate for unrecognized fx) and after (to evaluate for iatrogenic fx) IM nailing. Tornetta et al also describe using preoperative CT scans to evaluate for a femoral neck fracture and found that they were able to reduce the number of missed ipsilateral femoral neck fractures.

Question 43

The brachialis muscle is innervated by what two nerves?

Explanation

DISCUSSION: The brachialis is innervated by two nerves: medially, the musculocutaneous nerve; laterally, the radial nerve. The muscle is split longitudinally to approach the humerus anteriorly.
REFERENCES: Henry AK: The distal part of the humerus and front of the forearm, in Henry AK (ed): Extensile Exposure, ed 2. Edinburgh, UK, Churchill Livingstone, 1973, pp 90-115.
King A, Johnston GH: A modification of Henry’s anterior approach to the humerus. J Shoulder Elbow Surg 1998;7:210-212.

Question 44

During total knee arthroplasty using a posterior cruciate-retaining design, excessive tightness in flexion is noted, while the extension gap is felt to be balanced. Which of the following actions will effectively balance the knee?

Explanation

DISCUSSION: Excessive flexion gap tightness can be addressed with a variety of techniques; including: (a) recess and release the posterior cruciate ligament; (b) resect a posterior slope in the tibia; (c) avoid an oversized femoral component that moves the posterior condyles more distally; (d) resect more posterior femoral condyle and use a smaller femoral component placed more anteriorly; and (e) release the tight posterior capsule and balance the collateral ligaments.
REFERENCE: Ayers DC, Dennis DA, Johanson NA, Pelligrini VD: Common complications of total knee arthroplasty. J Bone Joint Surg Am 1997;79:278-311.

Question 45

Antibiotic-loaded bone cement prostheses, such as that shown in Figure 8, are best created by using which of the following methods?

Explanation

DISCUSSION: In a review of the practical applications of antibiotic-loaded bone cement for the treatment of the infected total joint arthroplasties, Hanssen and Spangehl described commercially available antibiotic-loaded bone cement as low-dose antibiotic cements. These cements generally contained 0.5 g of either tobramycin or gentamicin per 40 g of cement. They are indicated for use in prophylaxis and not for treatment of infected total joint arthroplasties.

High-dose antibiotic-loaded bone cements are described as those containing greater than 1.0 g of antibiotic per 40 g of cement. Effective elution levels have been documented with 3.6 g tobramycin and 1.0 g vancomycin per 40 g of bone cement. This was documented by Penner and associates. Furthermore, it was shown that the combination of the two antibiotics in the bone cement improved the elution of both antibiotics.
REFERENCES: Hanssen AD, Spangehl MJ: Practical applications of antibiotic-loaded bone cement for treatment of infected joint replacements. Clin Orthop 2004;427:79-85.
Penner MJ, Masri BA, Duncan CP: Elution characteristics of vancomycin and tobramycin combined in acrylic bone-cement. J Arthroplasty 1996;11:939-944.

Question 46

A 40-year-old man has intractable pain following 2 years of nonsurgical management for high-grade spondylolisthesis. What is the best surgical option?

Explanation

DISCUSSION: Circumferential fusion is the preferred choice for patients undergoing revision surgery following failed posterolateral fusions for isthmic spondylolisthesis as well as for those patients having primary surgery for high-grade isthmic spondylolisthesis.
REFERENCE: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 311-317.

Question 47

Venous thromboembolism may occur after total joint arthroplasty. The risk of this complication is elevated in patients with

Explanation

DISCUSSION:
Obesity, a prior history of venous thromboembolism, and metabolic syndrome have all been associated with an increased risk of thromboembolism. A recent meta-analysis showed that diabetes had no significant relationship with venous thromboembolism following hip or knee arthroplasty. Tranexamic acid is an antifibrinolytic agent that has been shown to reduce blood loss substantially following hip and knee arthroplasty. It has also been shown to be safe in patients with severe medial comorbidities and a prior history of venous thromboembolism.

Question 48

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

Explanation

DISCUSSION: The clinical photographs and radiographs reveal a distal phalangeal amputation with soft-tissue coverage over nonexposed bone. This is an ideal circumstance to allow healing by secondary intention with wet-to-dry dressing changes. There are few complications and the aesthetics surpass that of any soft-tissue reconstruction procedure. Volar advancement flaps (Moberg flaps) are limited to small defects about the thumb. A thenar flap will provide good coverage; however, the results are not comparable to simple dressing changes. A V-Y flap is useful when there is more tissue loss dorsally.
REFERENCES: Jebson PL, Louis DS: Amputations, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 1947.
Fassler PR: Fingertip injuries: Evaluation and treatment. J Am Acad Orthop Surg 1996;4:84-92.

Question 49

Patients who have osteonecrosis of the humeral head and who have the best prognosis are those with which of the following conditions?

Explanation

DISCUSSION: The natural history of nontraumatic osteonecrosis varies greatly, so it is difficult to predict which patients will have severe arthrosis develop. Patients with sickle cell disease tend to have the most benign course. The most commonly reported cause of nontraumatic osteonecrosis is corticosteroid therapy. Fortunately, the incidence of osteonecrosis among patients treated with long-term systemic corticosteroids has fallen from more than 25% to less than 5% in recent years, owning to judicious steroid use and dosing. The interval between corticosteroid administration and the onset of shoulder symptoms is also variable, ranging from 6 to 18 months in one large series. This is comparable to the interval leading up to the onset of hip symptoms, which ranges from 6 months to 3 years or longer. The incidence of humeral head involvement has not been shown to vary with the underlying indication for steroid use.
REFERENCES: Hasan SS, Romeo AA: Nontraumatic osteonecrosis of the humeral head.

J Shoulder Elbow Surg 2002;11:281-298.
Mansat P, Huser L, Mansat M, et al: Shoulder arthroplasty for atraumatic avascular necrosis of the humeral head: Nineteen shoulders followed up for a mean of seven years. J Shoulder Elbow Surg 2005;14:114-120.

Question 50

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

Explanation

DISCUSSION
This patient has symptoms consistent with neurogenic claudication secondary to lumbar spinal stenosis and degenerative spondylolisthesis. Her symptoms are chronic and she has undergone an appropriate course of nonsurgical care. Nevertheless, her symptoms are worsening and surgical intervention is a
reasonable consideration. Studies have shown that patients with lumbar spinal stenosis with associated degenerative spondylolisthesis benefit most from decompression of the neural elements that are stenotic and subsequent fusion across the degenerative slip. Anterior lumbar interbody fusion likely will not address stenosis at the level of the slip and may not result in adequate neurologic decompression. Partial laminotomy and diskectomy likely will not provide adequate neural decompression because these procedures would only address unilateral compression and this patient has bilateral issues. Lumbar laminectomy without fusion could be performed but has been associated with results inferior to lumbar laminectomy with fusion when addressing stenosis with spondylolisthesis.
RECOMMENDED READINGS
Weinstein JN, Lurie JD, Tosteson TD, Zhao W, Blood EA, Tosteson AN, Birkmeyer N, Herkowitz H, Longley M, Lenke L, Emery S, Hu SS. Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am. 2009 Jun;91(6):1295-304. PubMed PMID: 19487505. View Abstract at PubMed
Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am. 1991 Jul;73(6):802-8. PubMed PMID: 2071615. View Abstract at PubMed
Lombardi JS, Wiltse LL, Reynolds J, Widell EH, Spencer C 3rd. Treatment of degenerative spondylolisthesis. Spine (Phila Pa 1976). 1985 Nov;10(9):821-7. PubMed PMID: 4089657. View Abstract at PubMed
RESPONSES FOR QUESTIONS 66 THROUGH 69
Deep surgical-site infection
Adjacent segment degeneration
Pressure ulcers
Iatrogenic neurologic injury
Incidental durotomy
Hardware failure
Match the frequently encountered complication listed above with the appropriate clinical scenario below.

Question 51

What is the heaviest weight that can be safely applied to the adult cervical spine via Gardner-Wells tong traction?

Explanation

DISCUSSION: Cotler and associates reported on the use of awake skeletal traction to reduce facet fracture-dislocations in 24 patients. Seventeen patients required more than 50 pounds of traction (the “traditional” limit) to achieve reduction. More than 100 pounds of traction was safely used in one-third of the patients in this study. A cadaver study has supported the safe use of traction with weights in excess of 100 pounds.
REFERENCES: Cotler JM, Herbison GJ, Nasuti JF, et al: Closed reduction of traumatic cervical spine dislocation using traction weights up to 140 pounds. Spine 1993;18:386-390.
Anderson DG, Vacccaro AR, Gavin K: Cervical orthoses and cranioskeletal traction, in Clark CR (ed): The Cervical Spine, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 2005,

pp 110-121.

Question 52

A 67-year-old woman is seen in the emergency department after falling at home. Radiographs before and after treatment are shown in Figures 49a and 49b, respectively. Which of the following best explains the 8-week postinjury clinical findings seen in Figure 49c?

Explanation

DISCUSSION: Patients older than age 40 years at the time of initial anterior dislocation have low rates of redislocation; however, 15% of these patients experience a rotator cuff tear. Moreover, there is a dramatic increase (up to 40%) in the incidence of rotator cuff tears in patients older than age 60 years. Axillary nerve injury may occur but is less common than rotator cuff tear.
REFERENCES: Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 273-284.
Neviaser RJ, Neviaser TJ, Neviaser JS: Anterior dislocation of the shoulder and rotator cuff rupture. Clin Orthop Relat Res 1993;291:103-106.

Question 53

Which of the following best describes the mechanical response of the inferior glenohumeral ligament to repetitive subfailure strains?

Explanation

DISCUSSION: Repetitive subfailure strains have been shown to affect the mechanical behavior of the inferior glenohumeral ligament, producing dramatic declines in the peak load response and length increases that are largely unrecoverable. In another study, anteroinferior subluxation was found to result in nonrecoverable strain in the anteroinferior capsule, varying from 3% to 7% through a range of joint subluxation.
REFERENCES: Pollock RG, Wang VM, Bucchieri JS, et al: Effects of repetitive subfailure strains on the mechanical behavior of the inferior glenohumeral ligament. J Shoulder Elbow Surg 2000;9:427-435.
Malicky DM, Kuhn JE, Frisancho JC, et al: Nonrecoverable strain fields of the anteroinferior glenohumeral capsule under subluxation. J Shoulder Elbow Surg 2002;11:529-540.

Question 54

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

Explanation

The loss of hair or alopecia, is the only nonreversible effect of anabolic steroid use. Once anabolic steroids are stopped, muscle hypertrophy and training gains are quickly lost and the HDL/LDL ratios return to their preexisting levels. Fortunately, the personality effects and the acute acne are reversible.

Question 55

After the patient's wound has healed, which intervention is critical to prevent future ulceration?

Explanation

DISCUSSION
The most common etiology for plantar ulcers in patients with diabetes is neuropathy; 80% of these patients have adequate vascularity. The pathobiology is increased pressure applied on skin that lacks protective sensation (detected by lack of sensation to Semmes-Weinstein monofilament 5.07). The presence of sensation to light touch is not predictive of ulcer risk, but absent Semmes-Weinstein sensation at 5.07 carries a 30% risk for developing an ulcer. Intact light touch sensation does not rule out loss of protective sensation, and, therefore, does not rule out sensory neuropathy. The grading of an ulcer primarily depends on the existence of deep infection, either an abscess or osteomyelitis. In the presence of deep infection, formal surgical debridement is required. The surgery should be limited to the tissues
that are compromised, without an attempt at primary closure (which increases risk for recurrent infection). Negative-pressure dressings are a significant advance in postsurgical treatment by permitting delayed healing without further surgical intervention. Once healed, the key to preventing recurrent ulceration is the use of orthopaedic shoes with custom-molded soft inserts that accommodate the contours of the feet. This is particularly true when surgery has removed a portion of the foot; the foot otherwise will shift in a shoe that does not include a custom molded insert incorporating a filler that occupies the space left by the surgical resection.
RECOMMENDED READINGS
Pham H, Armstrong DG, Harvey C, Harkless LB, Giurini JM, Veves A. Screening techniques to identify people at high risk for diabetic foot ulceration: a prospective multicenter trial. Diabetes Care. 2000 May;23(5):606-11. PubMed PMID: 10834417. View Abstract at PubMed Pinzur MS, Slovenkai MP, Trepman E, Shields NN; Diabetes Committee of American Orthopaedic Foot and Ankle Society. Guidelines for diabetic foot care: recommendations endorsed by the Diabetes Committee of the American Orthopaedic Foot and Ankle Society. Foot Ankle Int. 2005 Jan;26(1):113-9. PubMed PMID: 15680122. View Abstract at PubMed Chantelau E. Effectiveness of diabetic therapeutic footwear in preventing reulceration: response to Maciejewski et al. Diabetes Care. 2004 Dec;27(12):3024-5; author reply 3025-

Question 56

Figures 11a and 11b show the AP and lateral radiographs of a 32-year-old patient on hemodialysis who has increasing elbow pain and a visibly growing mass over the extensor surface. Figure 11c shows the photomicrograph of the biopsy specimen. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiographic findings are classic for tumoral calcinosis; they are not consistent with myositis ossificans, fungal granuloma, or hemochromatosis. The condition typically appears as large aggregations of dense calcified lobules confined to the surrounding soft tissues. Hyperphosphatemia is a fundamental factor in many patients with this condition. Tumoral calcinosis also occurs in the setting of chronic renal failure when mineral homeostasis is not controlled. The histologic appearance is essentially a foreign body granuloma reaction. Multilocular cysts with purplish amorphous material are surrounded by thick connective tissue capsules. The fibrous walls contain numerous foreign body giant cells. Surgical excision is indicated if the tumor causes discomfort or interferes with function.
REFERENCES: Sisson HA, Murray RO, Kemp HBS (eds): Orthopaedic Diagnosis: Clinical, Radiological and Pathological Coordinates. New York, NY, Springer-Verlag, 1984.
Boskey AL, Vigorita VJ, Sencer O, Stuchin SA, Lane JM: Chemical, microscopic, and ultrastructural characterization of the mineral deposits in tumoral calcinosis. Clin Orthop 1983;178:258-269.

Question 57

A 24-year-old athlete has a painful right shoulder. Figure 30 shows an intra-articular photograph that was obtained through a posterior portal during arthroscopy; the labrum is indicated by the arrow. Based on these findings, management should consist of

Explanation

DISCUSSION: The photograph shows a normal variant that is a sublabral hole beneath the anterosuperior labrum. In some instances, the labrum will become confluent with the middle glenohumeral ligament as a stout band. Because this variant is not abnormal, no treatment is necessary. Securing this portion of the labrum to the capsule may tighten the middle glenohumeral ligament complex and restrict external rotation of the arm.
REFERENCES: Andrews JR, Guerra JJ, Fox GM: Normal and pathologic arthroscopic anatomy of the shoulder, in Andrews JR, Timmerman LA (eds): Diagnostic and Operative Arthroscopy, ed 1. Philadelphia, PA, WB Saunders, 1997, pp 60-76.
Williams MM, Snyder SJ, Buford D Jr: The Buford complex: The “cord-like” middle glenohumeral ligament and absent anterosuperior labrum complex. A normal anatomic capsulolabral variant. Arthroscopy 1994;10:241-247.

Question 58

Evaluation of the percent of necrosis in the resected specimen after preoperative chemotherapy is of prognostic value for what type of sarcoma?

Explanation

DISCUSSION: To date, only the percent of necrosis after induction chemotherapy in high-grade osteosarcomas seems to be of prognostic value. The value in soft-tissue sarcoma and rhabdomyosarcoma is being evaluated but has not been substantiated. Chondrosarcomas and parosteal osteosarcomas are not treated with chemotherapy.
REFERENCES: Rosen G, Marcove RC, Caparros B, Nirenberg A, Kosloff C, Huvos AG: Primary osteogenic sarcoma: The rationale for pre-operative chemotherapy and delayed surgery. Cancer 1979,43:2163-2177.
Davis AM, Bell RS, Goodwin PJ: Prognostic factors in osteosarcoma: A critical review. J Clin Oncol 1994;12:423-431.
Wunder JS, Paulian G, Huvos AG, Heller G, Meyers PA, Healey JH: The histological response to chemotherapy as a predictor of the oncological outcome of operative treatment of Ewing sarcoma. J Bone Joint Surg Am 1998;80:1020-1033.
FOR ALL MCQS CLICK THE LINK ORTHO MCQ BANK

Question 59

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

Explanation

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

Question 60

1 and 2 demonstrate the radiographs obtained from a year-old woman with end-stage debilitating osteoarthritis of the right hip. She is contemplating total hip arthroplasty (THA). She has a history of right hip dysplasia and underwent hip osteotomy as an adolescent. Over the years, nonsurgical treatment, including weight loss, activity modifications, and intra-articular injections, has failed. Her infection work-up reveals laboratory findings within defined limits. Which bearing surface is contraindicated for this patient?

Explanation

DISCUSSION:
THA has proven durable and reliable for pain relief and improving function for patients with end-stage arthritis. Appropriate bearing selection is critical to minimize wear and hip complications. A metal-on- metal articulation is associated with excellent wear rates in vitro. With its capacity to offer a low wear rate with large femoral heads, it is an attractive bearing choice for THA. However, local soft-tissue reactions, pseudotumors, and potential systemic reactions including renal failure, cardiomyopathy, carcinogenesis, and potential teratogenesis with potential transfer of metal ions across the placental barrier make metal-on-metal bearings less desirable and relatively contraindicated for younger women of child- bearing age. The workup of a painful metal-on-metal hip arthroplasty necessitates a systematic approach. Several algorithms have been proposed. Routine laboratory studies including sedimentation rate, CRP, and serum cobalt and chromium ion levels should be obtained for all patients with pain. Advanced imaging including MARS MRI should be performed to evaluate for the presence of fluid collections, pseudotumors, and abductor mechanism destruction. Infection can coexist with metal-on-metal reactions, so, when indicated (if the CRP level is elevated), a hip arthrocentesis should be obtained. However, in this setting, a manual cell count and differential should be obtained because an automated cell counter may provide falsely elevated cell counts. The results of revision surgery for a failed metal-on-metal hip prosthesis can be variable. The amount of local tissue destruction and the integrity of the hip abductor mechanism can greatly influence outcomes. Instability is the most common complication following revision of failed metal-on-metal hip replacements.

Question 61

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

Explanation

The MR images show a tear through a discoid lateral meniscus. A discoid meniscus is caused by a failure of apoptosis during development in utero and is considered a congenital abnormality. Discoid menisci are prone to tearing and can be caused by minimal trauma. There is no known genetic cause for this condition. Radiographic findings that may be present in the setting of a discoid meniscus include lateral joint space widening, squaring of the lateral femoral condyle, and cupping of the lateral tibial plateau. Contralateral discoid menisci are noted in 20% of patients. There are no other known associated conditions. Treatment of a symptomatic discoid meniscus should include partial meniscectomy and saucerization or repair.

Question 62

Figure 44 shows the radiograph of an 11-year-old girl who has hip pain. Further diagnostic workup should include

Explanation

DISCUSSION: The patient has severe acetabular protrusio, a condition that is frequently associated with Marfan syndrome. An echocardiogram is necessary to rule out the most serious consequence of this syndrome, aortic root widening, which can lead to aortic valve dysfunction or fatal aortic rupture. An electromyogram may be indicated for Charcot-Marie-Tooth disease, which is associated with acetabular dysplasia, but not protrusio. The renal ultrasound, the MRI scan, and the biopsy would be of no value in this patient. Protrusio can also be seen in patients with osteogenesis imperfecta and juvenile rheumatoid arthritis.
REFERENCES: Steel HH: Protrusio acetabuli: Its occurrence in the completely expressed Marfan syndrome and its musculoskeletal component and a procedure to arrest the course of protrusion in the growing pelvis. J Pediatr Orthop 1996;16:704-718.
Wenger DR, Ditkoff TJ, Herring JA, Mauldin DM: Protrusio acetabuli in Marfan’s syndrome. Clin Orthop 1980;147:134-138.

Question 63

Figures 9a and 9b show the radiographs of a 4-year-old child who sustained an elbow injury. What is the most likely complication resulting from this fracture if treated in a cast?

Explanation

DISCUSSION: The radiographs show a lateral condyle fracture with 2 mm of displacement. As opposed to other pediatric elbow fractures, lateral condyle fractures have a higher incidence of nonunion. This may be due to minimal metaphyseal bone on the distal fragment, the intra-articular nature of the fracture, or from further displacement when treated nonsurgically. These fractures with 2 mm and greater of displacement should be treated with reduction and stabilization. Osteonecrosis and fishtail deformity may be seen in very rare cases of lateral condyle fractures. The incidence is certainly less than the rates of nonunion seen in nonsurgically treated fractures with 2 mm and greater of displacement. Varus malunion from overgrowth and elbow stiffness are more likely seen in fractures treated surgically.
REFERENCES: Pirker ME, Weinberg AM, Hollwarth ME, et al: Subsequent displacement of initially nondisplaced and minimally displaced fractures of the lateral humeral condyle in children. J Trauma 2005;58:1202-1207.
Finnbogason T, Karlsson G, Lindberg L, et al: Nondisplaced and minimally displaced fractures of the lateral humeral condyle in children: A prospective radiographic investigation of fracture stability. J Pediatr Orthop 1995;15:422-425.
Flynn JC: Nonunion of slightly displaced fractures of the lateral humeral condyle in children: An update. J Pediatr Orthop 1989;9:691-696.

Question 64

Figure 27 shows the radiograph of a 26-year-old man who sustained a closed head injury and a closed elbow dislocation 6 weeks ago. Examination reveals 65 degrees to 115 degrees of flexion, and intensive physical therapy has resulted in no improvement. A decision regarding the timing of surgical correction of the contracture should be based on

Explanation

DISCUSSION: The patient has heterotopic ossification, a more common finding in patients who have sustained head injuries. Treatment will require removal of the heterotopic bone and anterior and posterior capsulectomies. The main concern about timing is the possible recurrence of heterotopic bone. While an extended wait was once thought necessary, this is no longer true. The timing is based on the time since injury and evidence of bone maturation on plain radiographs. A sharp marginal demarcation of the new bone and a trabecular pattern within it are usually present 3 to 6 months after onset, indicating that it is safe to proceed with surgical excision. It is not necessary to wait more than 6 months. Bone scan results are not good indicators because they may remain “hot” for long periods of time. The levels of alkaline phosphatase and serum calcium-phosphorus product do not need to be measured.
REFERENCE: Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 325-335.

Question 65

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

Explanation

DISCUSSION: It is common for patients with ankylosing spondylitis to sustain extension-type fractures, typically near the cervicothoracic junction. These fractures can be minimally displaced, making them difficult to diagnose. In addition, the vertebral bodies are vascular and their canals are relatively enclosed, making them vulnerable to epidural bleeding. The MRI scan shows an epidural hematoma posteriorly compressing the cord.
REFERENCES: Bohlman HH: Acute fractures and dislocations of the cervical spine. J Bone Joint Surg Am 1979;61:1119-1142.
Weinstein PR, Karpman RR, Gall EP, et al: Spinal cord injury, spine fracture and spinal stenosis in ankylosing spondylitis. J Neurosurg 1982;57:609-616.
Johnson T, Steinbach L (eds): Essentials of Musculoskeletal Imaging. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, p 44.

Question 66

A 45-year-old woman awakens with the acute onset of burning left shoulder pain that radiates toward the axilla. She denies any history of trauma. On examination, she is unable to abduct her arm but has full passive shoulder motion. Her sensation is intact. Cervical spine examination reveals full range of motion and a negative Spurling’s test. Radiographs and MRI studies are normal for the cervical spine and shoulder. What is the most likely diagnosis? Review Topic

Explanation

The definition of brachial neuritis or Parsonage-Turner syndrome is a rare disorder of unknown etiology that causes pain or weakness of the shoulder and upper extremity. The loss of active motion excludes cervical C6-7 radiculopathy and impingement. A normal MRI scan and full passive motion exclude a rotator cuff tear and adhesive capsulitis, respectively.

Question 67

Work-related injuries to the lower back are most often related to which of the following risk factors?

Explanation

The strongest variable for predicting subsequent low back pain is current or prior low back pain, defined at time loss for back pain during the previous 6 months or at the time of initial examination; relative risk 60%. Smoking was associated with a 40% increased risk of reporting back pain.

Question 68

Figure 4 shows the MRI scan of a patient who has had bilateral leg pain, weakness, diffuse numbness, and urinary retention for the past week. Examination reveals that motor strength is diffusely decreased, although it may be secondary to pain. The patient is numb throughout both legs, and reflexes in the lower extremities are absent. Rectal examination shows decreased tone, but voluntary tightening is present. Management should consist of

Explanation

DISCUSSION: The patient has a cauda equina syndrome. The fact that he has decreased rectal tone and urinary retention suggests the need for urgent surgery. Patients who are left untreated will have a poor prognosis for return of function. Although most patients who have insidious onset of symptoms with urinary retention will regain normal motor function following decompression, nearly one third will continue to have abnormal voiding patterns or sexual dysfunction of varying degrees.
REFERENCES: Kostuik JP, Harrington I, Alexander D, Rand W, Evans D: Cauda equina syndrome and lumbar disc herniation. J Bone Joint Surg Am 1986;68:386-391.
Wisneski RJ, Garfin SR, Rothman RH, Lutz GE: Lumbar disk disease, in Herkowitz HN, Garfin SR, Balderston RA, et al (eds): The Spine, ed 4. Philadelphia, PA,WB Saunders, 1992, vol 1,

pp 613-679.

Question 69

Which clinical signs are consistent with the diagnosis of cauda equina syndrome?

Explanation

DISCUSSION
Cauda equina syndrome is a lower-motor neuron deficit. Hyperreflexia, clonus, and other upper-motor neuron findings would not be seen. Saddle anesthesia, motor weakness, and neurogenic bladder are elements critical to the diagnosis of cauda equina syndrome.
RECOMMENDED READINGS
Kostuik JP, Harrington I, Alexander D, Rand W, Evans D. Cauda equina syndrome and lumbar disc herniation. J Bone Joint Surg Am. 1986 Mar;68(3):386-91. PubMed PMID: 2936744. View Abstract at PubMed
Spector LR, Madigan L, Rhyne A, Darden B 2nd, Kim D. Cauda equina syndrome. J Am Acad Orthop Surg. 2008 Aug;16(8):471-9. Review. PubMed PMID: 18664636. View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 78 THROUGH 80
Figures 78a and 78b are the axial and sagittal MR images of an otherwise healthy 24-year-old woman who has had 8 weeks of severe leg pain without weakness.

A B

Question 70

Which of the following methodologies has been proven to be effective in reducing the use of homologous blood transfusion following total hip arthroplasty (THA)?

Explanation

DISCUSSION: A variety of methodologies have been used to decrease the need for homologous blood transfusions following THA. Some of the effective strategies include preoperative donation of autologous units, intraoperative salvage and recycling, preoperative injection of erythropoietin, and regional anesthesia. Cementless fixation and use of wound drains have been shown to increase the blood loss with THA.
REFERENCES: Huo MH, Paly WL, Keggi KJ: Effect of preoperative autologous blood donation and intraoperative and postoperative blood recovery on homologous blood transfusion requirement in cementless total hip replacement operation. J Am Coll Surg 1995;180:561-567.
Bierbaum BE, Callaghan JJ, Galante JO, Rubash HE, Tooms RE, Welch RB: An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg Am 1999;81:2-10.
Ritter MA, Keating EM, Faris PM: Closed wound drainage in total hip or total knee replacement: A prospective, randomized study. J Bone Joint Surg Am 1994;76:35-38.

Question 71

A college athlete on a scholarship has a medical condition that you feel presents a life-threatening risk to him with participation in athletics. Because of the gravity of this decision and the potential effect it can have on the student/athlete's future, the college asks for your guidance. As the team physician for the college, what is your ethical obligation?

Explanation

There is legal precedent for banning a scholarship athlete from participation in college athletics if the physician feels that it presents a significant physical risk to the athlete. The courts have decided that the athlete has no constitutional right to participate in NCAA sports, and as a team physician you must advise your athlete and the school as to the best course of action. The athlete must be allowed to keep his or her college scholarship.

Question 72

What method of spinal fixation requires the largest force to disrupt the bone-implant interface?

Explanation

Pedicle screws have been established to produce a superior bone-implant interface in the nonosteoporotic spine according to numerous studies, but, interestingly, clinical outcomes using the varied implants have not been different.

Question 73

The arrow in Figure 39 is pointing to which of the following ligaments?

Explanation

DISCUSSION: The lunotriquetral interosseous ligament stabilizes the lunotriquetral joint. The scapholunate interosseous ligament stabilizes the scapholunate joint. The ulnolunate ligament originates from the base of the ulnar styloid and inserts in the lunate. The ulnotriquetral ligament originates from the base of the ulnar styloid and inserts on the triquetrum. The ulnolunate and the ulnotriquetral ligaments are important stabilizers to the ulnar side of the wrist. The short radiolunate ligament originates on the volar ulnar margin of the distal radius and inserts in the ulnar margin of the lunate.
REFERENCES: Berger RA: Ligament anatomy, in Cooney WP, Linscheid RL, Dobyns JH (eds): The Wrist, Diagnosis and Operative Management. St Louis, MO, Mosby, 1998,

pp 73-105.
Adams BD, Divelbiss BJ: Anatomy of the wrist ligaments, in Trumble TE (ed): Carpal Fracture-Dislocatons. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 1-5.

Question 74

A 17-year-old high school football player injures his right ankle during a game. Examination reveals swelling and a closed ankle deformity, with normal foot circulation and sensation. Radiographs are shown in Figures 10a and 10b. In addition to closed reduction, management should include

Explanation

DISCUSSION: The examination and radiographs reveal a closed fracture-dislocation of the ankle with tibiofibular diastasis. Immediate fixation of the medial malleolus and plating of the fibula are indicated. If residual tibiofibular diastasis occurs with lateral translation of the fibula after plating, a syndesmotic screw is placed to stabilize the syndesmosis. Ankle fracture-dislocations associated with a proximal fibular fracture (Maisonneuve fracture) require syndesmotic fixation, but the fibula is not plated. Unstable ankle fractures require surgical treatment. If swelling is severe (fracture blisters, loss of skin wrinkling), a compressive splint is applied and surgery is delayed for 5 to 7 days.
REFERENCES: Browner BD, Jupiter JB, Levine AM, Trafton PG: Skeletal Trauma. Philadelphia, PA, WB Saunders, 1992, pp 1887-1957.
Stiehl JB: Ankle fractures with diastasis. Instr Course Lect 1990;39:95-103.

Question 75

A 20-year-old male lacrosse player sustains an anterior dislocation of the shoulder. He is extremely concerned about recurrent dislocations. Which of the following treatments has been shown to reduce the risk of recurrent dislocation?

Explanation

DISCUSSION: Recent evidence has shown that the position of immobilization of the shoulder after a dislocation influences the reduction of the Bankart lesion. In an MRI study in patients who sustained an anterior dislocation, the Bankart lesion was reduced to the glenoid anatomically with the arm in 30 degrees of external rotation. Subsequently, a clinical follow-up study has shown a reduction in recurrence rates when the arm is immobilized in external rotation compared to internal rotation.
REFERENCES: Itoi E, Hatakeyama Y, Kido T, et al: A new method of immobilization after traumatic anterior dislocation of the shoulder: A preliminary study. J Shoulder Elbow Surg 2003;12:413-415.
Itoi E, Sashi R, Minagawa H, et al: Position of immobilization after dislocation of the glenohumeral joint: A study with use of magnetic resonance imaging. J Bone Joint Surg Am 2001;83:661-667.

Question 76

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

Explanation

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

Question 77

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

Explanation

Question 78

The injury seen in the CT scan shown in Figure 56 is related to or associated with injury to which of the following structures?

Explanation

DISCUSSION: The right syndesmosis appears disrupted on the CT scan when compared to the normal left side. CT can be helpful in determining injury to the syndesmosis, especially with occult clinical findings.
REFERENCES: Ebraheim NA, Lu J, Yang H, et al: The fibular incisure of the tibia on CT scan: A cadaver study. Foot Ankle Int 1998;19:318-321.
Ebraheim NA, Lu J, Yang H, et al: Radiographic and CT evaluation of tibiofibular syndesmotic diastasis: A cadaver study. Foot Ankle Int 1997;18:693-698.
Harper MC: Delayed reduction and stabilization of the tibiofibular syndesmosis. Foot Ankle Int 2001;22:15-18.

Question 79

A 50-year-old patient who plays tennis sustained the deformity shown in Figure 27 following a high volley. Further diagnostic work-up should include

Explanation

DISCUSSION: The patient has a rupture of the long head of the biceps; however, patients older than age 45 years are at greater risk of having an associated rotator cuff tear. An MRI scan should be ordered to avoid missing concomitant rotator cuff pathology. While patients may report pain radiating down the arm at the time of the tendon rupture, an EMG is not indicated. The short head of the biceps is intact and needs no further work-up, even though the muscle descends in most cases. The anterior labrum can be injured but is not associated with this deformity.
REFERENCES: Neer CS II, Bigliani LU, Hawkins RJ: Rupture of the long head of the biceps related to the subacromial impingement. Orthop Trans 1977;1:114.
Hawkins RJ, Murnaghan JP: The shoulder, in Gruess RL, Ronnie WRJ (eds): Adult Orthopaedics. New York, NY, Churchill Livingstone, 1984, pp 945-1054.

Question 80

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

Explanation

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

Question 81

Figures 114a and 114b are the radiographs of a 5-year-old girl who fell from monkey bars. What is the first consideration regarding treatment for this injury? Review Topic

Explanation

The radiographs show an ulnar shaft fracture with a radial head dislocation (Monteggia fracture). The ulnar shaft fracture requires reduction, either closed or open. Once the ulnar fracture has been reduced, usually the radiocapitallar joint will relocate with closed manipulation. In patients for whom the radiocapitallar joint does not relocate after ulnar reduction, or in patients with missed Monteggia injury, reduction of the radiocapitellar joint usually requires opening of the elbow capsule and reconstruction of the annular ligament.

Question 82

Figures 51a and 51b show the AP and lateral radiographs of the elbow of a 26-year-old man who fell. Closed reduction was performed in the emergency department, and management consisted of immobilization for 3 weeks prior to the initiation of motion. At 12 weeks after injury, he reports continued feelings of instability and catching in his elbow when using his arms to rise from a chair. Which of the following procedures needs to be performed, at a minimum, to reestablish stability of the elbow? Review Topic

Explanation

The patient has chronic posterolateral instability of the elbow following dislocation. The lateral collateral ligament complex is responsible for maintaining stability of the elbow. Because of the chronicity of the injury, the ligamentous tissues are frequently attenuated and not amenable to simple repair; while the native ligament can be imbricated, reconstruction with allograft or autograft is recommended. Medial collateral ligament reconstruction or hinged external fixation is needed only if restoration of the lateral ligamentous complex does not restore elbow stability; however, these procedures are rarely required. Lateral elbow pain when rising from a chair is equivalent to a positive pivot shift test.

Question 83

A 19-year-old man was in a motorcycle accident. He sustained a grade IIIB open tibia fracture with a wide zone of injury to the surrounding soft tissue and a closed-head injury. The patient was treated emergently with irrigation, debridement, and external fixation. What is the most accurate statement regarding long-term functional and financial outcomes?

Explanation

DISCUSSION
Lower Extremity Assessment Project data suggest that long-term functional outcomes and patient satisfaction at 7 years are equivalent between those
who undergo limb-salvage and primary amputations. Return to work is essentially the same between the 2 groups. The projected lifetime healthcare cost for patients treated with amputation is nearly 3 times higher than costs for those who are treated with limb-salvage procedures.
RECOMMENDED READINGS
Busse JW, Jacobs CL, Swiontkowski MF, Bosse MJ, Bhandari M; Evidence-Based Orthopaedic Trauma Working Group. Complex limb salvage or early amputation for severe lower-limb injury: a meta-analysis of observational studies. J Orthop Trauma. 2007 Jan;21(1):70-6. PubMed PMID: 17211275. View Abstract at PubMed
MacKenzie EJ, Jones AS, Bosse MJ, Castillo RC, Pollak AN, Webb LX, Swiontkowski MF, Kellam JF, Smith DG, Sanders RW, Jones AL, Starr AJ, McAndrew MP, Patterson BM, Burgess AR. Health-care costs associated with amputation or reconstruction of a limb-threatening injury. J Bone Joint Surg Am. 2007 Aug;89(8):1685-92. PubMed PMID: 17671005. View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 85 THROUGH 88
Figures 85a and 85b are the plain radiographs of a 38-year-old man who fell off the roof of a 2-story house and sustained an isolated injury to his right knee. Examination reveals a swollen leg with a knee effusion. The skin is intact, but there are some abrasions and an obvious deformity. His neurovascular examination reveals active dorsiflexion and plantar flexion with some pain and symmetric palpable pulses

85A

Question 84

A 14-year-old boy has had a 3-month history of low back pain with no known trauma. The pain is worse with activity and relieved by rest, although he does report difficulty with prolonged sitting in school. The patient was on the football team but stopped participating because of the back pain during football practice. He reports no history of radicular pain and denies any numbness, tingling, or weakness in the legs. Neurologic examination is normal. Back examination reveals slight tenderness over the lower back area but no swelling or skin defects. Strength testing is 5 over 5 in the lower extremities and the straight leg raise test is negative. Back range of motion is nearly full, but back extension is painful. The hamstrings are slightly tight. Initial radiographs, including AP, lateral and oblique views, are negative. What is the best test to determine the patient's diagnosis? Review Topic

Explanation

A bone scan with SPECT is very sensitive and specific for spondylolysis not seen on initial radiographs. MRI can sometimes visualize spondylolysis, but it is not as sensitive nor as specific as a bone scan with SPECT. Flexion and extension views
have no role in the evaluation of the patient who presents with classic spondylolysis-type symptoms. The most sensitive physical examination finding is pain with back extension. Oblique radiographs can be obtained, but they are not as sensitive or specific as a bone scan with SPECT. The patient does not have any signs of a disk problem; therefore, an evaluation of the disk is not helpful.
(SBQ13PE.79) A 17-year-old male American football lineman presents with low back pain of insidious onset that is somewhat worse with activity. He has no neurologic complaints, night pain or fevers. His symptoms have been present for a few years but this is the first time he has sought medical attention. What physical examination finding is most likely to be found in this clinical scenario? Review Topic
Popliteal angle of 5 degrees
Heel cord tightness
Increased femoral anteversion
Pain with lumbar extension in single leg stance
Numbness of the skin of the anterolateral calf and dorsum of the foot
The patient demographics and clinical presentation are consistent with lumbar spondylolysis. Pain with lumbar extension is the most common physical exam finding.
Office assessment of the patient with spondylolysis should note pertinent negatives that would signify other causes of back pain. The history is most commonly negative for neurologic symptoms such as weakness or numbness, although patients will occasionally have radicular pain. On exam, patients may have localized spasm or tenderness, step off (if there is spondylolisthesis), hamstring tightness. The most common finding is pain with lumbar extension.
McCleary et al. review the diagnosis and treatment of spondylolysis in athletes. They identify three types of patients with spondylolysis: (1) female dancer or gymnast who is hyperlordotic, with increased motion and flexibility, (2) male weightlifter or football player undergoing a growth spurt, with decreased motion and flexiblity, especially of the spinal erectors, and (3) a novice athlete undergoing vigorous preparation for a new sport, with poor core strength and flexibility.
Incorrect

Question 85

Using methylmethacrylate to fill a biopsy hole in the diaphysis of a femur theoretically achieves what purpose?

Explanation

DISCUSSION: Placing cement over a bone biopsy site prevents tumor contamination by controlling hematoma. Even though the use of cement may impart some strength, the femur is still at significant risk for fracture. The use of bone cement in this manner has not been cleared by the FDA, but many physicians feel that it is appropriate when the patient’s health status has been given careful consideration, and the physician has the necessary knowledge and training. The other options are not important reasons to use methylmethacrylate in biopsies.
REFERENCES: Simon MA, Springfield DS, et al: Biopsy: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, pp 55-65.
Simon MA: Biopsy of musculoskeletal tumors. J Bone Joint Surg Am 1982;64:1253-1257.

Question 86

Plate fixation without bone grafting

Explanation

(3787) Q2-7569:
Which of the following stress fractures most often requires internal fixation:

Question 87

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 88

A 58-year-old woman is seen in the emergency department after falling at home. History reveals that she underwent right total knee arthroplasty 2 years ago. Radiographs are shown in Figures 56a and 56b. What is the most appropriate treatment?

Explanation

DISCUSSION: The radiographs show an oblique periprosthetic distal femoral fracture. Of the options listed, open reduction and internal fixation is the most appropriate surgical option because a well-fixed, posterior stabilized closed box femoral component is present. Nonsurgical methods are not favored because of the highly displaced, unstable fracture pattern and prolonged immobility. Revision with a stemmed component is an option but would sacrifice more bone stock in this younger patient.
REFERENCES: Moran MC, Brick GW, Sledge CB, et al: Supracondylar femoral fracture following total knee arthroplasty. Clin Orthop 1996;324:196-209.
Raab GE, Davis CM III: Early healing with locked condylar plating of periprosthetic fractures around the knee. J Arthroplasty 2005;20:984-989.
Tharani R, Nakasone C, Vince KG: Periprosthetic fractures after total knee arhtroplasty.
J Arthroplasty 2005;20:27-32.

Question 89

A 3-year-old girl developed torticollis eight months ago after a severe respiratory tract infection. A initial trial of halter traction was attempted without success. A trial of halo traction was then performed for 3 weeks and then a dynamic computed tomographic (CT) was obtained and shown in Figure A. Panel (a) shows an axial image with maximal rotation to the left. Panel (b) shows an axial image with maximal rotation to the right. What is the most appropriate next step in management? Review Topic

Explanation

Lumbar epidural injection
Physical therapy with core strengthening and anti-inflammatory medications as needed
Lumbar decompression
Lumbar decompression and fusion
MRI of the cervical and thoracic spine
The clinical scenario is consistent with a patient with symptoms of degenerative spondylolisthesis AND symptoms of myelopathy. Myelopathy must be ruled out by performing an MRI of the cervical and thoracic spine.
Tandem stenosis occurs in approximately 5 to 25% of patients. Because of the stepwise progressive nature of myelopathy, treatment of myelopathy often takes precedence over lumbar spinal stenosis.
Rhee et al. found that the sensitivity and specificity of specific physical exam findings varies. Both the upward babinski reflex and the presence of clonus were found to be very non-sensitive (13%). The most sensitive provacative test was found to be the Hoffman sign (59%).
Salvi et al. reviewed the classic presentations for cervical myelopathy including demographics, history, and physical exam findings (the inability to preform a tandem gait, hyperreflexia, an abnormal babinksi and hoffman reflex, the inability to preform rapid movements and bilateral muscle weakness). Additionally they identify other potential causes for myelopathy, including multiple sclerosis, amyotrophic lateral sclerosis, multifocal motor neuropathy, and Guillain-Barre´syndrome.
Maezawa et al. showed that gait analysis can identify a pattern in patients with myelopathy. Patients with severe myelopathy have a characteristic gait with hyperextension of the knee in the stance phase without plantar flexion of the ankle in the swing phase. They also have decreased walking speed and stride length with a prolonged stance phase.
Figure A and B show a classic degenerative spondylolisthesis.
Incorrect Answers:

Question 90

Which of the following nonunions is appropriately treated with exchange reamed nailing without bone graft augmentation?

Explanation

DISCUSSION: Exchange nailing is indicated for nonunions of diaphyseal femoral and tibia fractures in the absence of infection, comminution, or segmental bone loss. Hypertrophic nonunions need better stability (increased nail diameter) to acheive union. Where as atrophic nonunions often need better biology (bone graft, flap coverage, etc.) The referenced article by Brinker et al reviews the indications for exchange nailing. They argue, on the basis of the available literature, that exchange nailing is an excellent choice for aseptic nonunions of noncomminuted diaphyseal femoral and tibia fractures. Zelle et al. demonstrated 95% success with reamed exchange nailing for the treatment of aseptic tibial shaft nonunions that were initially treated with nonreamed intramedullary nailing.

Question 91

Which of following side effects is most commonly seen in a pediatric patient undergoing ketamine anesthesia?

Explanation

DISCUSSION: The most common deleterious side effect of ketamine is increased salivation and tracheobronchial secretions. For this reason, an antisialagogue agent should be given. While lack of sufficient respiratory depression is one of the major advantages of using ketamine, apnea can occur if the drug is given too rapidly intravenously. Emergence phenomena is common in adults but relatively rare in children.
REFERENCES: Furman JR: Sedation and analgesia in the child with a fracture, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 62-63.
White PF, Way WL, Trevor AJ: Ketamine: Its pharmacology and therapeutic uses. Anesthesiology 1982;56:119-136.
McCarty EC, Mencio GA, Walker LA, Green NE: Ketamine sedation for the reduction of children’s fractures in the emergency department. J Bone Joint Surg Am 2000;82:912-918.

Question 92

A 26-year-old elite female swimmer underwent a left medial meniscal allograft transplantation. She returns to clinic 3 years later with knee pain. What is the most likely cause for late presenting knee pain in this patient population? Review Topic

Explanation

The most common long-term complication after meniscal transplantation is meniscal graft tear. Graft failure that results from graft tears is thought to be related to the acellularity of graft tissue.
Meniscal allograft transplantation is considered a salvage treatment option for young patients (<50 years old) with symptomatic meniscal deficiencies. The overall complication rate ranges from 4-36%, which include meniscal tearing, acute immune rejection, superficial and deep infection, chronic knee pain, etc. Graft tears make up
>50% of these complications.
Rath et al. evaluated 18 of 23 patients who had underwent meniscal allograft transplantation. They showed that 8 of 22 allograft menisci (36%) tore during the 8-year study period. They believe the decreased biologic activity of the graft over time may be a major factor that contributes to the high frequency of graft re-tearing.
Sekiya et al. reviewed meniscal allograft transplantation. They concluded that meniscal allograft transplantation may partially restore native meniscal function. Data has also shown that the progression of degenerative arthritic changes in transplanted meniscus-deficient knee compartments is slowed with this procedure.
Illustration A shows a basic schematic of meniscal transplantation. Here the graft is secured by anterior + posterior bone plugs and sutures to secure the transplanted meniscus into its native anatomical position.
Incorrect
<1%.

Question 93

This condition is most prevalent in people of which ancestry?

Explanation

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

Question 94

A high school distance runner reports a 3-week history of heel pain while running. Examination elicits no pain with dorsiflexion or with palpitation of the plantar fascia; however, pain is evident with palpitation over the muscular origin of the abductor hallucis. What is the most likely etiology of the pain?

Explanation

The tibial nerve gives off two branches. In the distal 1/3 of the leg, the tibial nerve curves anteroinferiorily into the sole of the foot behind the medial malleolus, deep to the flexor retinaculum and between the tendons of the flexor hallicus longus and the flexor digitorum longus muscles. Just distal to the flexor retinaculum, the tibial nerve divides into the medial and lateral plantar nerve. At this site, the lateral plantar nerve gives off its first branch which lies anterior and adjacent to the abductor hallicus.

Question 95

-is the photograph of a 2-month-old infant with a left leg deformity. The mother’s pregnancy and delivery were unremarkable, and the infant is otherwise healthy. What is the most appropriate course of action?

Explanation

Question 96

Figure 57 is the radiograph of a 58-year-old woman who is right-hand dominant and has fallen on her flexed right elbow and is seen in the emergency department reporting isolated episodes of right elbow pain. Examination reveals that the skin is contused but intact, and her distal neurovascular examination is normal. What is the most appropriate treatment? Review Topic

Explanation

The patient has sustained an isolated, closed fracture of the olecranon without associated instability. The bone is radiographically osteopenic and the fracture is displaced, comminuted, and includes articular marginal impaction. Plate fixation is preferred in the presence of comminution or associated transolecranon or radiocapitellar instability. Displaced fractures are generally treated surgically in an effort to restore articular congruity, restore extensor function, and to allow for early mobilization in an effort to maximize functional outcomes. A tension band wire
construct is a commonly used technique but is reserved for simple fracture patterns without comminution. Excision and triceps advancement can be considered in elderly, low-demand patients that have small unreconstructable fracture patterns without associated elbow instability.

Question 97

A 62-year-old runner injured his right ankle 8 weeks ago. He has ongoing lateral ankle pain and swelling that did not improve with 4 weeks of immobilization and 4 weeks of physical therapy. MR images demonstrate a longitudinal tear of the peroneus brevis tendon. Treatment should involve

Explanation

DISCUSSION
Additional nonsurgical treatment is not beneficial for peroneal tendon tears. Early repair of longitudinal tears reduces risk for progression to a full-thickness tear that would necessitate peroneus brevis to peroneus longus tenodesis. Platelet-rich plasma has no role in peroneal tendon tears.
RECOMMENDED READINGS
Arbab D, Tingart M, Frank D, Abbara-Czardybon M, Waizy H, Wingenfeld C. Treatment of isolated peroneus longus tears and a review of the literature. Foot Ankle Spec. 2014 Apr;7(2):113-8. doi: 10.1177/1938640013514273. Epub 2013 Dec 30. Review. PubMed
PMID: 24381076.View Abstract at PubMed
Coughlin MJ, Schon LC. Disorders of tendons. In: Coughlin MJ, Saltzman CL, Anderson RB, eds. Mann's Surgery of the Foot and Ankle. 9th ed. Philadelphia, PA: Elsevier-Saunders; 2014: 1188-1291.
RESPONSES FOR QUESTIONS 71 THROUGH 75
Lapidus procedure
First metatarsophalangeal (MTP) joint arthrodesis and lesser metatarsal head resection
Proximal first metatarsal osteotomy
Distal first metatarsal chevron osteotomy
Biplanar distal first metatarsal osteotomy
Match the appropriate surgical procedure listed above with the clinical scenario described below.

Question 98

Figures 10a and 10b show the clinical photograph and MRI scan of a plantar foot lesion. If excisional biopsy is performed, what is the most likely complication?

Explanation

DISCUSSION: The MRI scan shows plantar fibromatosis. The treatment is usually nonsurgical.

If surgery is indicated, wide local excision with excision of the entire plantar fascia is usually indicated. The main problem with simple excision of the lesion is the high chance of recurrence. The other listed complications are those that are a result of the wide local excision.
REFERENCES: Aluisio FV, Mair SD, Hall RL: Plantar fibromatosis: Treatment of primary and recurrent lesions and factors associated with recurrence. Foot Ankle Int 1996;17:672-678.
Bos GD, Esther RJ, Woll TS: Foot tumors: Diagnosis and treatment. J Am Acad Orthop Surg 2002;10:259-270.

Question 99

-An otherwise healthy 15-year-old wrestler has a 6-cm cutaneous lesion on the posterior aspect of his right elbow that he reports as a spider bite. What is the most likely diagnosis?

Explanation

CLINICAL SITUATION FOR QUESTIONS 44 AND 45
Figure 44 is the MRI scan of a 14-year-old soccer player who injured his right knee during a game.He describes feeling a “pop” and he needed help walking off the field. His knee is visibly swollen. A Lachman test demonstrates asymmetry with no endpoint.

Question 100

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

Explanation

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

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

Splint the proximal interphalangeal (PIP) joint in flexion with early motion of the distal interphalangeal (DIP) joint
Allow early motion of the PIP joint with DIP extension joint splinting
Splint both the PIP and DIP joints in full extension
Splint the PIP joint in extension with early motion of the DIP joint

Correct Answer: Splint the PIP joint in extension with early motion of the DIP joint

Explanation:

Question 2:

Options:

Sciatic nerve decompression
Arthroscopic labral repair
Repair to the intertrochanteric crest
Repair to the femoral shaft
Repair to the ischial tuberosity

Correct Answer: Sciatic nerve decompression

Explanation:

Question 3:

The fracture seen in Figure 1 is most likely associated with injury to what ligamentous structure?

Options:

Inferior glenohumeral ligament
Acromioclavicular (AC) ligaments
Coracoclavicular ligaments
Coracoacromial ligament The radiograph shows an extra-articular distal clavicle fracture lateral to the clavicular attachment point of the coracoclavicular ligaments (conoid and trapezoid). However, unlike a scenario featuring a typical Neer type I fracture, the interval between coracoid and clavicle is clearly widened, and there is marked fracture displacement. This signifies disruption to the coracoclavicular ligaments. The inferior glenohumeral ligament is important to glenohumeral joint stability, but has no effect on the relationship between clavicle and scapula. The AC ligaments are thickenings of the AC joint capsule. They have been shown to be responsible for 90% of anteroposterior stability of the AC joint. The coracoclavicular ligaments are responsible for 77% of stability for superior translation (as in this case). The coracoacromial ligament connects two parts of the scapula (coracoid and acromion) and is part of the arch that supports the rotator cuff.

Correct Answer: Acromioclavicular (AC) ligaments

Explanation:

Question 4:

Options:

Sympathetic stellate block
Emergent fasciotomy
Emergent arterial thrombectomy
Venous duplex ultrasound studies
Arteriography

Correct Answer: Venous duplex ultrasound studies

Explanation:

Question 5:

Options:

Revision to a long stem prosthesis with impaction grafting
Revision to a long stem prosthesis, bypassing the defect
Proximal femoral allograft reconstruction
Cable plate fixation with cortical strut graft augmentation
Cable fixation alone

Correct Answer: Cable plate fixation with cortical strut graft augmentation

Explanation:

Question 6:

Options:

Will not affect functional outcome
Will result in diminished thumb motion
Will result in diminished pinch strength
Will result in diminished grip strength
Will result in moderate activity-related pain back answer Question 61.03

Correct Answer: Will not affect functional outcome

Explanation:

Question 7:

What is the effect on knee kinematics following placement of an anterior cruciate ligament (ACL) graft at the 12 o’clock position? Review Topic

Options:

Decreased rotational stability
Decreased anterior-posterior stability
Decreased flexion
Decreased extension
Graft failure secondary to impingement

Correct Answer: Decreased rotational stability

Explanation:

Question 8:

Which of the following body positions is associated with the highest intradiskal pressure?

Options:

Standing, bending forward
Standing, bending back
Sitting, bending forward
Sitting, bending back
Supine, lateral decubitus

Correct Answer: Sitting, bending forward

Explanation:

DISCUSSION: Intradiskal pressure is lowest when the patient is in the supine position. Sitting is associated with higher intradiskal pressures than standing. Flexion also increases intradiskal pressure. The combination of flexion and sitting produces the highest intradiskal pressure. Nachemson and Morris found that intradiskal pressure increases as position changes from lying supine, lying prone, standing, leaning forward, sitting, and sitting leaning forward. Twisting or straining in positions of relatively high intradiskal pressure may predispose patients to herniation of the intervertebral disk. Patients with a herniated disk may also notice their pain worsens with activities that increase the disk pressure, including the positions mentioned, or activities that increase intra-abdominal pressure (coughing, sneezing, straining).
REFERENCES: Nachemson A, Morris JM: In vivo measurements of intradiscal pressure.
J Bone Joint Surg Am 1964;46:1077-1092.
Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 547-556.

Question 9:

Which of the following statements best describes the location of the nerve that is at risk in a direct posterior approach to the Achilles tendon?

Options:

The tibial nerve crosses the Achilles tendon 10 cm above its insertion.
The sural nerve crosses the Achilles tendon 5 cm above its insertion.
The sural nerve crosses the Achilles tendon 10 cm above its insertion.
The superficial peroneal nerve crosses the Achilles tendon 5 cm above its insertion.
The superficial peroneal nerve crosses the Achilles tendon 10 cm above its insertion.

Correct Answer: The sural nerve crosses the Achilles tendon 10 cm above its insertion.

Explanation:

Question 10:

Moderate distance running has what effect on knee articular cartilage in asymptomatic distance runners?

Options:

Increased loss of collagen tensile integrity in the superficial zone
Increased production of glycosaminoglycans
Decreased collagen in the middle zone
Loss of cartilage thickness that correlates with the total distance run during the course of adult life
Collagen loss in the medial compartment and collagen increase in the lateral compartment

Correct Answer: Increased production of glycosaminoglycans

Explanation:

Question 11:

Nerve conduction velocity is slowed by

Options:

increased skin temperature.
increased perineural blood flow.
external compression.
hand dominance.

Correct Answer: external compression.

Explanation:

EXPLANATION:
A number of factors affect nerve conduction velocity; for example, increased body temperature increases nerve conduction velocity. Nerve conduction velocity is slowed by advancing age, compression, decreased blood flow, and fibrosis (from large imprecise sutures used for nerve repair). There is no
association between hand dominance and nerve conduction velocity.

Question 12:

Options:

Diagnostic arthroscopy of the hip
Hip bone scan
Hip MRI arthrogram
Hip ultrasonography

Correct Answer: Hip MRI arthrogram

Explanation:

This clinical scenario describes a patient with FAI attributable to pincer (acetabular) deformity. This form of FAI, which involves prominence of the anterosuperior acetabular lip, may be more common among women. Decreased range of motion and pain occur secondary to the abutment of the femoral head against the acetabular labrum and rim. Hip flexion, combined with adduction and internal rotation, recreates this contact and causes pain, but CAM or pincer etiology remains unknown. The differential diagnosis of hip pain in a young athlete includes femoral neck stress reaction/fracture, sacroiliac arthritis, intra-articular loose body, trochanteric bursitis, osteitis pubis, and hernia. No information presented in this scenario suggests any of these causes. Diagnosis of FAI is best performed via MR imaging, with an arthrogram increasing the sensitivity and specificity for labral pathology. Ultrasonography may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping hip, but ultrasonography is not commonly
used to diagnose labral pathology. Although concomitant chondral lesions of the femoral head are uncommon, the forced leverage of the anterosuperior femoral neck upon the anterior acetabulum may result in a “contra-coup” chondral injury on the posteroinferior acetabulum. This is the most common location of chondral lesions in this scenario. Without bony resection to prevent further impingement, this patient will continue to experience symptoms. Because there is no evidence of femoral neck prominence (CAM lesion), there is no indication for osteoplasty of the femoral neck; resection of the pincer lesion is necessary. This will often require take-down of the labrum in this location. If possible, iatrogenic or traumatic labral tears should subsequently be repaired after pincer debridement because the labrum has
important functions for hip stability and maintenance of the suction seal of the joint.

Question 13:

Options:

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

Correct Answer: Osteonecrosis of the trochlea, producing joint incongruity

Explanation:

Question 14:

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

Options:

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

Correct Answer: observation.

Explanation:

Question 15:

-The main blood supply to the capital femoral epiphysis in a 10-year-old child is supplied from the

Options:

artery of the ligamentum teres.
epiphyseal branch of the lateral femoral circumflex artery.
posterosuperior and posteroinferior retinacular branches of the lateral femoral circumflex artery.
posterosuperior and posteroinferior retinacular branches of the medial femoral circumflex artery. DISCUSSION-Before the age of 4 years, blood to the femoral head is supplied by the medial and lateral femoral circumflex arteries as well as the artery of the ligamentum teres. After the age of 4, the blood supply through the artery of the ligamentum teres diminishes. The lateral femoral circumflex system regresses,and its flow into the physis and epiphysis diminishes significantly so the medial femoral circumflex artery becomes the predominant blood supply to the metaphysis. The medial femoral circumflex artery provides the principal blood supply to the proximal femur via its posterosuperior and posteroinferior retinacular branches.

Correct Answer: posterosuperior and posteroinferior retinacular branches of the medial femoral circumflex artery. DISCUSSION-Before the age of 4 years, blood to the femoral head is supplied by the medial and lateral femoral circumflex arteries as well as the artery of the ligamentum teres. After the age of 4, the blood supply through the artery of the ligamentum teres diminishes. The lateral femoral circumflex system regresses,and its flow into the physis and epiphysis diminishes significantly so the medial femoral circumflex artery becomes the predominant blood supply to the metaphysis. The medial femoral circumflex artery provides the principal blood supply to the proximal femur via its posterosuperior and posteroinferior retinacular branches.

Question 16:

A 54-year-old woman with idiopathic carpal tunnel syndrome undergoes open carpal tunnel release with a flexor tenosynovectomy. The pathology from the tenosynovium is likely to show

Options:

fibrosis and edema.
polymorphonuclear cells.
negatively birefringent crystals.
macrophages and lymphocytes.
fibrinous degeneration of collagen fibers.

Correct Answer: fibrosis and edema.

Explanation:

Question 17:

Options:

Will result in improvement in pain but no difference in function or range of motion compared to therapy alone.
Will result in greater improvement in pain and function compared to therapy alone, with equivalent range of motion at one year
Will prevent development of rotator cuff arthropathy in patients with rotator cuff tears.
Will likely have no effect on pain, function or range of motion at one year, compared to therapy alone.
Will result in worse outcomes in terms of pain, function and range of motion, compared with therapy alone.

Correct Answer: Will result in worse outcomes in terms of pain, function and range of motion, compared with therapy alone.

Explanation:

Question 18:

Which of the following procedures is considered most appropriate in patients with rheumatoid arthritis?

Options:

Hip arthrodesis
Osteotomy of the hip
Core decompression of the hip
Synovectomy of the knee
Unicondylar knee arthroplasty

Correct Answer: Synovectomy of the knee

Explanation:

Question 19:

Options:

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

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

Explanation:

Question 20:

Options:

Ulnar
Radial
Axillary
Median
Musculocutaneous

Correct Answer: Musculocutaneous

Question 21:

Options:

a lateral patellar restraining brace for practice and competition.
arthroscopic lateral retinacular release.
open medial retinacular plication.
medial tibial tubercle transfer.
Maquet tibial tubercle elevation.

Correct Answer: arthroscopic lateral retinacular release.

Explanation:

Question 22:

Options:

major: 3 positive cultures, gross purulence. Minor: elevated C-reactive protein (CRP) level and erythrocyte sedimentation rate (ESR), elevated synovial white blood cell (WBC) count, elevated synovial neutrophil count, elevated systemic WBC count, dr
major: draining sinus and elevated synovial WBC count. Minor: elevated CRP and ESR, positive frozen section, purulence at surgery, elevated systemic WBC count, febrile episodes, and a single positive culture from periprosthetic tissue.
major: gross purulence at surgery and a draining sinus. Minor: 2 positive cultures from periprosthetic tissues, an elevated synovial WBC count, elevated synovial neutrophil percentage, elevated CRP and ESR, febrile episodes, and an elevated systemic
major: a draining sinus communicating with the joint and 2 positive cultures with the same organism. Minor: elevated synovial WBC count, elevated synovial neutrophil percentage, elevated CRP and ESR, increased WBCs per high-power field on frozen sec

Correct Answer: major: a draining sinus communicating with the joint and 2 positive cultures with the same organism. Minor: elevated synovial WBC count, elevated synovial neutrophil percentage, elevated CRP and ESR, increased WBCs per high-power field on frozen sec

Explanation:

Question 23:

An operating room intervention that should be undertaken by anesthesia staff during the cementing of a femoral stem is to

Options:

decrease the fraction of inspired oxygen (FiO2).
decrease the intravenous (IV) fluid rate.
have phenylephrine on standby.
redose epidural anesthesia.

Correct Answer: have phenylephrine on standby.

Explanation:

Question 24:

In a fracture such as the one shown in Figure 16 (Salter-Harris type I fracture of the distal femur), which of the following best describes the location of the fracture?

Options:

The fracture occurs through the zone of hypertrophy of the physis.
The fracture occurs through the zone of proliferation of the physis.
The fracture is generally confined to the germinal zone, which explains the high rate of growth arrest in these fractures.
The fracture generally propagates through multiple layers of the physis.
The fracture is generally confined to the zone of endochondral ossification.

Correct Answer: The fracture generally propagates through multiple layers of the physis.

Explanation:

Question 25:

Options:

Subacromial corticosteroid injection
Aspiration of the subacromial and glenohumeral joint spaces
Nonsteroidal anti-inflammatory drugs
Extensive surgical debridement
Diagnostic arthroscopy

Correct Answer: Aspiration of the subacromial and glenohumeral joint spaces

Explanation:

Question 26:

Options:

Grade III chondrosis of the proximal patella
Caton-Deschamps ratio of 1:1
Tibial tubercle-trochlear groove (TT-TG) distance of 21 mm
Q angle of 17 degrees

Correct Answer: Grade III chondrosis of the proximal patella

Explanation:

DISCUSSION
TTO is a common treatment for patellofemoral instability. The angle of correction must be customized to each patient’s anatomy. For this patient, the orthopaedic surgeon plans an osteotomy that will both anteriorize and medialize the tubercle. This will consistently result in
a change of patellofemoral kinematics and contact pressures. Medialization decreases lateral and increases medial patellofemoral contact pressures, and anteriorization shifts contact pressures from distal to proximal. Significant anteriorization may not be desired in a patient with proximal patellar chondrosis unless a concomitant chondral procedure is performed as well. The patellar height (Caton-Deschamps ratio) is normal, precluding the need for distalization but not medialization. The TT-TG distance, at more than 20 mm, is a strong indication for osteotomy. The Q angle, although a less precise indicator of malalignment, is also elevated and would be considered an indication for osteotomy.
CLINICAL SITUATION FOR QUESTIONS 37 THROUGH 41
A healthy, active 18-year-old man has acute-onset right knee pain and an inability to fully extend his knee following an attempt to stand from a seated position yesterday. He sustained a noncontact injury to his right knee while playing basketball 2 years ago and underwent primary anterior cruciate ligament (ACL) reconstruction with bone-patella-tendon-bone autograft and medial meniscus repair. He sustained another noncontact injury to the same knee 8 months later and underwent a revision ACL reconstruction using soft-tissue allograft and revision medial meniscus repair. He reports multiple episodes of “giving way” of his knee, but no pain prior to yesterday’s acute injury.

Question 27:

Resuscitation of a trauma patient who has been in hypovolemic shock is complete when which of the following has occurred?

Options:

The mean arterial blood pressure is above 90 mm Hg.
The pulse pressure has normalized.
Urine output is greater than 0.5 to 1 mL/kg/h.
Oxygen delivery has been maximized.
Aerobic metabolism has been restored in all tissue beds.

Correct Answer: Aerobic metabolism has been restored in all tissue beds.

Explanation:

DISCUSSION: Shock can be defined as inadequate tissue perfusion. Resuscitation or the resolution of shock is defined as when oxygen debt has been repaid, tissue acidosis is eliminated, and aerobic metabolism has been restored in all tissue beds. The end points for resuscitation are not clearly defined, but occult shock can still be present in the setting of normal vital signs and normal urine output due to selective perfusion of organ systems.
REFERENCES: Tisherman SA, Barie P, Bokhari F, et al: Clinical practice guideline: End point of resuscitation. J Trauma 2004;57:898-912.
Moore FA, McKinley BA, Moore EE, et al: Inflammation and the Host Response to Injury, a large-scale collaborative project: Patient-oriented research core--standard operating procedures for clinical care. III. Guidelines for shock resuscitation. J Trauma 2006;61:82-89.
Englehart MS, Schreiber MA: Measurement of acid-base resuscitation end points: Lactate, base deficit, bicarbonate or what? Curr Opin Crit Care 2006;12:569-574.

Question 28:

Bioabsorbable polymers are used in a wide range of orthopaedic devices, including anchors, staples, pins, plates, and screws. What is the primary drawback for bioabsorbable implants?

Options:

High cost
Increased rates of infection
High elastic modulus
Brittleness
Foreign body reaction

Correct Answer: Foreign body reaction

Explanation:

DISCUSSION: A number of bioabsorbable polymers are used in orthopaedic applications, and all have in common reports of foreign body reactions, which occur in more than 50% of patients in some series. In general, the high cost of these polymers is offset by the elimination of a second surgery to remove the implant. Bioabsorbable polymers are low strength in comparison to metallic alloys but of sufficient strength for many orthopaedic applications. The elastic modulus is not as high as many other orthopaedic biomaterials, making them suitable for applications where lower stiffness is an asset.
REFERENCES: Ambrose CG, Clanton TO: Bioabsorbable implants: Review of clinical experience in orthopedic surgery. Ann Biomed Eng 2004;32:171-177.
Bergsma JE, de Bruijn WC, Rozema FR, et al: Late degradation tissue response to poly
(L-lactide) bone plates and screws. Biomaterials 1995;16:25-31.

Question 29:

Options:

Left L4
Right L4
Left L5
Right L5
Left S1

Correct Answer: Left L5

Explanation:

Question 30:

Options:

Electromyography and nerve conduction velocity studies
MRI
CT
Bone scan
Psychiatric evaluation

Correct Answer: MRI

Explanation:

Question 31:

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

Options:

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

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

Explanation:

Question 32:

Options:

lateral (radial) to the median nerve and posterior (deep) to the recurrent radial artery.
lateral (radial) to the median nerve and anterior (superficial) to the recurrent radial artery.
medial (ulnar) to the median nerve and posterior (deep) to the recurrent radial artery.
medial (ulnar) to the median nerve and anterior (superficial) to the recurrent radial artery.

Correct Answer: lateral (radial) to the median nerve and posterior (deep) to the recurrent radial artery.

Explanation:

Question 33:

What is the most appropriate treatment for a 50-year-old woman who sustains the injury shown in Figures 14a and 14b?

Options:

Total elbow arthroplasty
Functional hinge bracing
Long arm casting
Crossed Kirschner wires
Dual column plates

Correct Answer: Dual column plates

Explanation:

DISCUSSION: This intra-articular distal humerus fracture with displacement at the joint surface is best treated with surgical fixation. The most biomechanically sound construct is two plates applied to either column 180 degrees from one another. Elbow arthroplasty is most appropriate for low demand elderly patients.
REFERENCES: Schemitsch EH, Tencer AF, Henley MB: Biomechanical evaluation of methods of internal fixation of the distal humerus. J Orthop Trauma 1994;8:468-475.
McCarty LP, Ring D, Jupiter JB: Management of distal humerus fractures. Am J Orthop 2005;34:430-438.
Kamineni S, Morrey BF: Distal humeral fractures treated with noncustom total elbow replacement: Surgical technique. J Bone Joint Surg Am 2005;87:41-50.

Question 34:

Which of the following best characterizes the injury shown in Figure 53? Review Topic

Options:

Stable tear drop extension injury
Facet dislocation
Unstable flexion compression injury
Stable axial load injury
Burst fracture

Correct Answer: Unstable flexion compression injury

Explanation:

Question 35:

The patient is at highest risk for which complication?

Options:

- Postoperative infection
- Heterotopic ossification
- Malunion
- Nonunion

Correct Answer: - Nonunion

Explanation:

DISCUSSION
The quality of femoral neck fracture reduction was the key outcome factor in a number of studies. Capsulotomy is performed when achieving open reduction of the femoral neck. In rare cases in which acceptable closed reduction is achieved capsulotomy has been advocated, but poor anatomic reduction is more likely to negatively influence the outcome. Although some biomechanical data suggest that fixed-angle implants may be advantageous, this has not been demonstrated in well-controlled clinical studies. If reduction is not achieved, protecting postoperative weight bearing is not likely to improve outcomes.
Failure to achieve anatomic reduction of the femoral neck frequently leads to nonunion and varus collapse. Postoperative infection and/or heterotopic ossification are not typically seen in closed reduction and percutaneous stabilization of femoral neck fractures. Nonunion is more common than malunion of displaced femoral neck fractures.
RECOMMENDED READINGS
Duckworth AD, Bennet SJ, Aderinto J, Keating JF. Fixation of intracapsular fractures of the femoral neck in young patients: risk factors for failure. J Bone Joint Surg Br. 2011 Jun;93(6):811-6. doi: 10.1302/0301-620X.93B6.26432. PubMed PMID: 21586782.
View
Abstract at PubMed
Yang JJ, Lin LC, Chao KH, Chuang SY, Wu CC, Yeh TT, Lian YT. Risk factors for nonunion in patients with intracapsular femoral neck fractures treated with three cannulated screws placed in either a triangle or an inverted triangle configuration. J Bone Joint Surg Am. 2013 Jan 2;95(1):61-9. doi: 10.2106/JBJS.K.01081. PubMed PMID: 23283374.
View Abstract at
PubMed

Question 36:

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

Options:

X-linked
Autosomal recessive
Autosomal dominant
Mitochondral inheritance
Germline mutation

Correct Answer: Autosomal dominant

Explanation:

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

Question 37:

Options:

No change in paresthesias and grip strength
Increase in grip strength and decrease in paresthesias
Decrease in grip strength and increase in paresthesias
Increase in grip strength and paresthesias

Correct Answer: Increase in grip strength and decrease in paresthesias

Explanation:

Question 38:

Preservation or reconstruction of which of the following structures is essential to minimize the risk of hallux valgus developing after removal of part or all of the medial sesamoid?

Options:

Flexor hallucis longus tendon
Flexor hallucis brevis tendon
Abductor hallucis tendon
Adductor hallucis tendon
Extensor hallucis brevis tendon

Correct Answer: Flexor hallucis brevis tendon

Explanation:

DISCUSSION: Complications of medial sesamoidectomy include stiffness, claw toe, and hallux valgus. Each sesamoid sits within its respective head of the flexor hallucis brevis tendon. Excision of one sesamoid can result in slack in its flexor hallucis brevis tendon; therefore, it is imperative to preserve or repair the flexor hallucis brevis tendon when removing the medial sesamoid.
REFERENCES: Dedmond BT, Cory JW, McBryde A Jr: The hallucal sesamoid complex. J Am Acad Orthop Surg 2006;14:745-753.
Lee S, James WC, Cohen BE, et al: Evaluation of hallux alignment and functional outcome after isolated tibial sesamoidectomy. Foot Ankle Int 2005;26:803-809.

Question 39:

Options:

arthroscopic repair of the ulnar collateral ligament.
direct surgical repair of the ulnar collateral ligament.
reconstruction of the ulnar collateral ligament with a palmaris longus tendon autograft.
a hinged elbow brace to allow early protected range of motion.
immobilization of the elbow to allow healing of the ulnar collateral ligament.

Correct Answer: reconstruction of the ulnar collateral ligament with a palmaris longus tendon autograft.

Explanation:

Question 40:

Figures 10a through 10c show the plain radiograph and MRI scans of a 41-year-old man who has right hip pain. What is the most likely diagnosis?

Options:

Giant cell tumor
Rheumatoid arthritis
Metastatic carcinoma
Osteonecrosis
Transient osteoporosis

Correct Answer: Transient osteoporosis

Explanation:

Question 41:

Options:

Enchondroma
Giant cell tumor
Chondroblastoma
Osteoblastoma
Chondromyxoid fibroma

Correct Answer: Chondroblastoma

Explanation:

DISCUSSION: The epiphyseal location on the radiograph and MRI scan and the histologic findings of polyhedral cells separated by a chondroid matrix with pericellular, lattice-like “chicken wire” calcification all suggest chondroblastoma. Although giant cell tumors of bone typically occupy an epiphyseal location, they are rare in children and when present are often metaphyseal in skeletally immature patients. Enchondromas and osteoblastomas are generally metaphyseal and, along with giant cell tumors, have very different histology than seen here. Chondromyxoid fibromas are typically metaphyseal in location.
REFERENCES: Huvos AG: Bone Tumors: Diagnosis, Treatment, and Prognosis. Philadelphia, PA, WB Saunders, 1991, pp 295-313.
Lin PP, Thenappan A, Deavers MT, et al: Treatment and prognosis of chondroblastoma. Clin Orthop Relat Res 2005;438:103-109.

Question 42:

Options:

ipsilateral foot/calcaneus
ipsilateral hip
contralateral hip
ipsilateral tibia/fibula
thoracic spine

Correct Answer: ipsilateral foot/calcaneus

Explanation:

Question 43:

The brachialis muscle is innervated by what two nerves?

Options:

Radial and musculocutaneous
Lateral and medial brachial cutaneous
Axillary and medial and lateral pectoral
Radial and ulnar
Ulnar and musculocutaneous

Correct Answer: Radial and musculocutaneous

Explanation:

Question 44:

Options:

Resect more distal femur.
Resect more anterior tibia.
Use a larger femoral component.
Use a smaller polyethylene insert.
Recess the posterior cruciate ligament.

Correct Answer: Recess the posterior cruciate ligament.

Explanation:

Question 45:

Antibiotic-loaded bone cement prostheses, such as that shown in Figure 8, are best created by using which of the following methods?

Options:

Using commercially available antibiotic-loaded bone cement
Adding 0.5 g vancomycin to commercially available antibiotic-loaded bone cement
Adding 0.5 g tobramycin and 0.5 g vancomycin/unit of standard bone cement
Adding either 1.0 g vancomycin or 1.2 g tobramycin per 40 g of standard bone cement
Adding a minimum of 3.6 g tobramycin and 1.0 g vancomycin per 40 g of bone cement

Correct Answer: Adding a minimum of 3.6 g tobramycin and 1.0 g vancomycin per 40 g of bone cement

Explanation:

DISCUSSION: In a review of the practical applications of antibiotic-loaded bone cement for the treatment of the infected total joint arthroplasties, Hanssen and Spangehl described commercially available antibiotic-loaded bone cement as low-dose antibiotic cements. These cements generally contained 0.5 g of either tobramycin or gentamicin per 40 g of cement. They are indicated for use in prophylaxis and not for treatment of infected total joint arthroplasties.
High-dose antibiotic-loaded bone cements are described as those containing greater than 1.0 g of antibiotic per 40 g of cement. Effective elution levels have been documented with 3.6 g tobramycin and 1.0 g vancomycin per 40 g of bone cement. This was documented by Penner and associates. Furthermore, it was shown that the combination of the two antibiotics in the bone cement improved the elution of both antibiotics.
REFERENCES: Hanssen AD, Spangehl MJ: Practical applications of antibiotic-loaded bone cement for treatment of infected joint replacements. Clin Orthop 2004;427:79-85.
Penner MJ, Masri BA, Duncan CP: Elution characteristics of vancomycin and tobramycin combined in acrylic bone-cement. J Arthroplasty 1996;11:939-944.

Question 46:

A 40-year-old man has intractable pain following 2 years of nonsurgical management for high-grade spondylolisthesis. What is the best surgical option?

Options:

Posterolateral fusion
Posterolateral fusion with instrumentation
Circumferential fusion
Transforaminal lumbar interbody fusion
Anterior lumbar interbody fusion

Correct Answer: Circumferential fusion

Explanation:

DISCUSSION: Circumferential fusion is the preferred choice for patients undergoing revision surgery following failed posterolateral fusions for isthmic spondylolisthesis as well as for those patients having primary surgery for high-grade isthmic spondylolisthesis.
REFERENCE: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 311-317.

Question 47:

Venous thromboembolism may occur after total joint arthroplasty. The risk of this complication is elevated in patients with

Options:

a BMI lower than 30.
diabetes mellitus, with a hemoglobin A1c test result less than 7.
tranexamic acid use.
metabolic syndrome.

Correct Answer: metabolic syndrome.

Explanation:

Question 48:

Options:

Continue wet-to-dry dressing changes until the wound heals by secondary intention.
Perform a volar advancement flap (ie, Moberg flap).
Perform a V-Y advancement flap.
Perform a thenar flap.
Perform a cross-finger flap to the ring finger.

Correct Answer: Continue wet-to-dry dressing changes until the wound heals by secondary intention.

Explanation:

DISCUSSION: The clinical photographs and radiographs reveal a distal phalangeal amputation with soft-tissue coverage over nonexposed bone. This is an ideal circumstance to allow healing by secondary intention with wet-to-dry dressing changes. There are few complications and the aesthetics surpass that of any soft-tissue reconstruction procedure. Volar advancement flaps (Moberg flaps) are limited to small defects about the thumb. A thenar flap will provide good coverage; however, the results are not comparable to simple dressing changes. A V-Y flap is useful when there is more tissue loss dorsally.
REFERENCES: Jebson PL, Louis DS: Amputations, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 1947.
Fassler PR: Fingertip injuries: Evaluation and treatment. J Am Acad Orthop Surg 1996;4:84-92.

Question 49:

Patients who have osteonecrosis of the humeral head and who have the best prognosis are those with which of the following conditions?

Options:

Sickle cell disease
Associated malunion
Alcoholic-induced disease
Previously received high-dose steroids
Postradiation necrosis

Correct Answer: Sickle cell disease

Explanation:

DISCUSSION: The natural history of nontraumatic osteonecrosis varies greatly, so it is difficult to predict which patients will have severe arthrosis develop. Patients with sickle cell disease tend to have the most benign course. The most commonly reported cause of nontraumatic osteonecrosis is corticosteroid therapy. Fortunately, the incidence of osteonecrosis among patients treated with long-term systemic corticosteroids has fallen from more than 25% to less than 5% in recent years, owning to judicious steroid use and dosing. The interval between corticosteroid administration and the onset of shoulder symptoms is also variable, ranging from 6 to 18 months in one large series. This is comparable to the interval leading up to the onset of hip symptoms, which ranges from 6 months to 3 years or longer. The incidence of humeral head involvement has not been shown to vary with the underlying indication for steroid use.
REFERENCES: Hasan SS, Romeo AA: Nontraumatic osteonecrosis of the humeral head.
J Shoulder Elbow Surg 2002;11:281-298.
Mansat P, Huser L, Mansat M, et al: Shoulder arthroplasty for atraumatic avascular necrosis of the humeral head: Nineteen shoulders followed up for a mean of seven years. J Shoulder Elbow Surg 2005;14:114-120.

Question 50:

Options:

Anterior lumbar interbody fusion L4-5
L4-5 hemilaminotomy and diskectomy
Lumbar laminectomy L4-L5 posterior fusion
Lumbar laminectomy at L4-5

Correct Answer: Lumbar laminectomy L4-L5 posterior fusion

Explanation:

DISCUSSION
This patient has symptoms consistent with neurogenic claudication secondary to lumbar spinal stenosis and degenerative spondylolisthesis. Her symptoms are chronic and she has undergone an appropriate course of nonsurgical care. Nevertheless, her symptoms are worsening and surgical intervention is a
reasonable consideration. Studies have shown that patients with lumbar spinal stenosis with associated degenerative spondylolisthesis benefit most from decompression of the neural elements that are stenotic and subsequent fusion across the degenerative slip. Anterior lumbar interbody fusion likely will not address stenosis at the level of the slip and may not result in adequate neurologic decompression. Partial laminotomy and diskectomy likely will not provide adequate neural decompression because these procedures would only address unilateral compression and this patient has bilateral issues. Lumbar laminectomy without fusion could be performed but has been associated with results inferior to lumbar laminectomy with fusion when addressing stenosis with spondylolisthesis.
RECOMMENDED READINGS
Weinstein JN, Lurie JD, Tosteson TD, Zhao W, Blood EA, Tosteson AN, Birkmeyer N, Herkowitz H, Longley M, Lenke L, Emery S, Hu SS. Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am. 2009 Jun;91(6):1295-304. PubMed PMID: 19487505.
View Abstract at
PubMed
Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am. 1991 Jul;73(6):802-8. PubMed PMID: 2071615.
View
Abstract at PubMed
Lombardi JS, Wiltse LL, Reynolds J, Widell EH, Spencer C 3rd. Treatment of degenerative spondylolisthesis. Spine (Phila Pa 1976). 1985 Nov;10(9):821-7. PubMed PMID: 4089657.
View Abstract at PubMed
RESPONSES FOR QUESTIONS 66 THROUGH 69
Deep surgical-site infection
Adjacent segment degeneration
Pressure ulcers
Iatrogenic neurologic injury
Incidental durotomy
Hardware failure
Match the frequently encountered complication listed above with the appropriate clinical scenario below.

Question 51:

What is the heaviest weight that can be safely applied to the adult cervical spine via Gardner-Wells tong traction?

Options:

40 pounds
50 pounds
75 pounds
100 pounds
Greater than 100 pounds

Correct Answer: Greater than 100 pounds

Explanation:

DISCUSSION: Cotler and associates reported on the use of awake skeletal traction to reduce facet fracture-dislocations in 24 patients. Seventeen patients required more than 50 pounds of traction (the “traditional” limit) to achieve reduction. More than 100 pounds of traction was safely used in one-third of the patients in this study. A cadaver study has supported the safe use of traction with weights in excess of 100 pounds.
REFERENCES: Cotler JM, Herbison GJ, Nasuti JF, et al: Closed reduction of traumatic cervical spine dislocation using traction weights up to 140 pounds. Spine 1993;18:386-390.
Anderson DG, Vacccaro AR, Gavin K: Cervical orthoses and cranioskeletal traction, in Clark CR (ed): The Cervical Spine, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 2005,
pp 110-121.

Question 52:

Options:

Axillary nerve palsy
Spinal accessory nerve palsy
Deltoid avulsion
Rotator cuff tear
Unreduced posterior glenohumeral dislocation

Correct Answer: Rotator cuff tear

Explanation:

DISCUSSION: Patients older than age 40 years at the time of initial anterior dislocation have low rates of redislocation; however, 15% of these patients experience a rotator cuff tear. Moreover, there is a dramatic increase (up to 40%) in the incidence of rotator cuff tears in patients older than age 60 years. Axillary nerve injury may occur but is less common than rotator cuff tear.
REFERENCES: Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 273-284.
Neviaser RJ, Neviaser TJ, Neviaser JS: Anterior dislocation of the shoulder and rotator cuff rupture. Clin Orthop Relat Res 1993;291:103-106.

Question 53:

Which of the following best describes the mechanical response of the inferior glenohumeral ligament to repetitive subfailure strains?

Options:

Decreased peak load response and length decreases
Decreased peak load response and recoverable length increases
Decreased peak load response and unrecoverable length increases
Increased peak load response and recoverable length increases
Increased peak load response and unrecoverable length increases

Correct Answer: Decreased peak load response and unrecoverable length increases

Explanation:

Question 54:

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

Options:

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

Correct Answer: Alopecia

Explanation:

Question 55:

After the patient's wound has healed, which intervention is critical to prevent future ulceration?

Options:

A well-fitted prosthesis on the left
Making sure he wears large shoes to decrease pressure on his feet
A bilateral ankle-foot orthoses fitting
Custom-molded soft shoe inserts

Correct Answer: Custom-molded soft shoe inserts

Explanation:

DISCUSSION
The most common etiology for plantar ulcers in patients with diabetes is neuropathy; 80% of these patients have adequate vascularity. The pathobiology is increased pressure applied on skin that lacks protective sensation (detected by lack of sensation to Semmes-Weinstein monofilament 5.07). The presence of sensation to light touch is not predictive of ulcer risk, but absent Semmes-Weinstein sensation at 5.07 carries a 30% risk for developing an ulcer. Intact light touch sensation does not rule out loss of protective sensation, and, therefore, does not rule out sensory neuropathy. The grading of an ulcer primarily depends on the existence of deep infection, either an abscess or osteomyelitis. In the presence of deep infection, formal surgical debridement is required. The surgery should be limited to the tissues
that are compromised, without an attempt at primary closure (which increases risk for recurrent infection). Negative-pressure dressings are a significant advance in postsurgical treatment by permitting delayed healing without further surgical intervention. Once healed, the key to preventing recurrent ulceration is the use of orthopaedic shoes with custom-molded soft inserts that accommodate the contours of the feet. This is particularly true when surgery has removed a portion of the foot; the foot otherwise will shift in a shoe that does not include a custom molded insert incorporating a filler that occupies the space left by the surgical resection.
RECOMMENDED READINGS
Pham H, Armstrong DG, Harvey C, Harkless LB, Giurini JM, Veves A. Screening techniques to identify people at high risk for diabetic foot ulceration: a prospective multicenter trial. Diabetes Care. 2000 May;23(5):606-11. PubMed PMID: 10834417.
View Abstract at PubMed
Pinzur MS, Slovenkai MP, Trepman E, Shields NN; Diabetes Committee of American Orthopaedic Foot and Ankle Society. Guidelines for diabetic foot care: recommendations endorsed by the Diabetes Committee of the American Orthopaedic Foot and Ankle Society. Foot Ankle Int. 2005 Jan;26(1):113-9. PubMed PMID: 15680122.
View Abstract at PubMed
Chantelau E. Effectiveness of diabetic therapeutic footwear in preventing reulceration: response to Maciejewski et al. Diabetes Care. 2004 Dec;27(12):3024-5; author reply 3025-

Question 56:

Options:

Myositis ossificans
Tumoral calcinosis
Synovial cell sarcoma
Fungal granuloma
Hemochromatosis

Correct Answer: Tumoral calcinosis

Explanation:

Question 57:

Options:

stabilization with suture anchors.
debridement only.
no treatment.
stabilization using absorbable tacks with the arm in external rotation.
release of the attachment to the middle glenohumeral ligament, followed by stabilization with any device.

Correct Answer: no treatment.

Explanation:

Question 58:

Evaluation of the percent of necrosis in the resected specimen after preoperative chemotherapy is of prognostic value for what type of sarcoma?

Options:

Chondrosarcoma
Soft-tissue sarcoma
Rhabdomyosarcoma
Parosteal osteosarcoma
Osteosarcoma

Correct Answer: Osteosarcoma

Explanation:

Question 59:

Options:

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

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

Explanation:

Question 60:

Options:

Ceramic-on-ceramic
Ceramic-on-highly cross-linked polyethylene (HXPE)
Metal-on-HXPE
Metal-on-metal

Correct Answer: Metal-on-metal

Explanation:

Question 61:

Options:

anterior cruciate ligament reconstruction with lateral meniscus repair.
partial lateral meniscectomy with saucerization.
lateral meniscus transplant.
protected weight bearing with referral for genetic testing.

Correct Answer: partial lateral meniscectomy with saucerization.

Explanation:

The MR images show a tear through a discoid lateral meniscus. A discoid meniscus is caused by a failure of apoptosis during development in utero and is considered a congenital abnormality. Discoid menisci are prone to tearing and can be caused by minimal trauma. There is no known genetic cause for this condition. Radiographic findings that may be present in the setting of a discoid meniscus include lateral joint space widening, squaring of the lateral femoral condyle, and cupping of the lateral tibial plateau. Contralateral discoid menisci are noted in 20% of patients. There are no other known associated conditions. Treatment
of a symptomatic discoid meniscus should include partial meniscectomy and saucerization or repair.

Question 62:

Figure 44 shows the radiograph of an 11-year-old girl who has hip pain. Further diagnostic workup should include

Options:

a renal ultrasound.
an echocardiogram.
an electromyogram.
an MRI scan of the spine.
an iliac crest biopsy.

Correct Answer: an echocardiogram.

Explanation:

Question 63:

Figures 9a and 9b show the radiographs of a 4-year-old child who sustained an elbow injury. What is the most likely complication resulting from this fracture if treated in a cast?

Options:

Elbow stiffness
Nonunion
Osteonecrosis
Varus malunion from overgrowth
Fishtail deformity

Correct Answer: Nonunion

Explanation:

DISCUSSION: The radiographs show a lateral condyle fracture with 2 mm of displacement. As opposed to other pediatric elbow fractures, lateral condyle fractures have a higher incidence of nonunion. This may be due to minimal metaphyseal bone on the distal fragment, the intra-articular nature of the fracture, or from further displacement when treated nonsurgically. These fractures with 2 mm and greater of displacement should be treated with reduction and stabilization. Osteonecrosis and fishtail deformity may be seen in very rare cases of lateral condyle fractures. The incidence is certainly less than the rates of nonunion seen in nonsurgically treated fractures with 2 mm and greater of displacement. Varus malunion from overgrowth and elbow stiffness are more likely seen in fractures treated surgically.
REFERENCES: Pirker ME, Weinberg AM, Hollwarth ME, et al: Subsequent displacement of initially nondisplaced and minimally displaced fractures of the lateral humeral condyle in children. J Trauma 2005;58:1202-1207.
Finnbogason T, Karlsson G, Lindberg L, et al: Nondisplaced and minimally displaced fractures of the lateral humeral condyle in children: A prospective radiographic investigation of fracture stability. J Pediatr Orthop 1995;15:422-425.
Flynn JC: Nonunion of slightly displaced fractures of the lateral humeral condyle in children: An update. J Pediatr Orthop 1989;9:691-696.

Question 64:

Options:

bone scan results returning to normal.
a decline in intensity on serial bone scans.
the serum levels of alkaline phosphatase measured over time.
the level of serum calcium-phosphorus product.
the time since injury and evidence of bone maturation on plain radiographs.

Correct Answer: the time since injury and evidence of bone maturation on plain radiographs.

Explanation:

Question 65:

Options:

Epidural hematoma
Herniated disk
Tumor
Extruded epidural bony fragment
Abscess

Correct Answer: Epidural hematoma

Explanation:

Question 66:

Options:

Cervical C6-7 radiculopathy
Impingement
Rotator cuff tear
Brachial neuritis
Adhesive capsulitis

Correct Answer: Brachial neuritis

Explanation:

Question 67:

- Work-related injuries to the lower back are most often related to which of the following risk factors?

Options:

Female gender
History of cigarette smoking
L5-S1 spondylolisthesis on pre-employment radiography
Decreased strength of the lower extremities on pre-employment testing
Decreased flexibility of the lumbar spine on pre-employment testing

Correct Answer: History of cigarette smoking

Explanation:

Question 68:

Options:

physical therapy and nonsteroidal anti-inflammatory drugs for 4 to 6 weeks.
physical therapy, nonsteroidal anti-inflammatory drugs for 4 to 6 weeks, and methylprednisolone.
epidural steroid injections.
elective surgery.
urgent surgery.

Correct Answer: urgent surgery.

Explanation:

Question 69:

Which clinical signs are consistent with the diagnosis of cauda equina syndrome?

Options:

Saddle anesthesia, hyperreflexia, quadriceps weakness
Decreased motor function in the quadriceps and gastrocnemius, hyperreflexia,? and saddle anesthesia
More than 5 beats of clonus, saddle anesthesia, and bowel incontinence
Urinary retention, saddle anesthesia, and extensor hallucis longus weakness

Correct Answer: Urinary retention, saddle anesthesia, and extensor hallucis longus weakness

Explanation:

DISCUSSION
Cauda equina syndrome is a lower-motor neuron deficit. Hyperreflexia, clonus, and other upper-motor neuron findings would not be seen. Saddle anesthesia, motor weakness, and neurogenic bladder are elements critical to the diagnosis of cauda equina syndrome.
RECOMMENDED READINGS
Kostuik JP, Harrington I, Alexander D, Rand W, Evans D. Cauda equina syndrome and lumbar disc herniation. J Bone Joint Surg Am. 1986 Mar;68(3):386-91. PubMed PMID: 2936744.
View
Abstract at PubMed
Spector LR, Madigan L, Rhyne A, Darden B 2nd, Kim D. Cauda equina syndrome. J Am Acad Orthop Surg. 2008 Aug;16(8):471-9. Review. PubMed PMID: 18664636.
View Abstract at
PubMed
CLINICAL SITUATION FOR QUESTIONS 78 THROUGH 80
Figures 78a and 78b are the axial and sagittal MR images of an otherwise healthy 24-year-old woman who has had 8 weeks of severe leg pain without weakness.
A B

Question 70:

Which of the following methodologies has been proven to be effective in reducing the use of homologous blood transfusion following total hip arthroplasty (THA)?

Options:

Type of postoperative anticoagulation
Preoperative autologous blood donation
General anesthesia
Cementless fixation of the components
The use of wound drains

Correct Answer: Preoperative autologous blood donation

Explanation:

Question 71:

Options:

Ban the athlete from sports participation.
Allow the athlete to participate as it is his constitutional right to do so.
Advise the college to revoke the athlete's college scholarship.
Offer no opinion as it is a matter strictly between the college and the athlete.
Recuse yourself from all decision making and advise the athlete to get an opinion from a third-party physician who is not employed by the college or university.

Correct Answer: Ban the athlete from sports participation.

Explanation:

Question 72:

What method of spinal fixation requires the largest force to disrupt the bone-implant interface?

Options:

Sublaminar cables
Laminar hooks
Pedicle hooks
Pedicle screws

Correct Answer: Pedicle screws

Explanation:

Question 73:

The arrow in Figure 39 is pointing to which of the following ligaments?

Options:

Scapholunate interosseous
Lunotriquetral interosseous
Ulnolunate
Ulnotriquetral
Short radiolunate

Correct Answer: Lunotriquetral interosseous

Explanation:

DISCUSSION: The lunotriquetral interosseous ligament stabilizes the lunotriquetral joint. The scapholunate interosseous ligament stabilizes the scapholunate joint. The ulnolunate ligament originates from the base of the ulnar styloid and inserts in the lunate. The ulnotriquetral ligament originates from the base of the ulnar styloid and inserts on the triquetrum. The ulnolunate and the ulnotriquetral ligaments are important stabilizers to the ulnar side of the wrist. The short radiolunate ligament originates on the volar ulnar margin of the distal radius and inserts in the ulnar margin of the lunate.
REFERENCES: Berger RA: Ligament anatomy, in Cooney WP, Linscheid RL, Dobyns JH (eds): The Wrist, Diagnosis and Operative Management. St Louis, MO, Mosby, 1998,
pp 73-105.
Adams BD, Divelbiss BJ: Anatomy of the wrist ligaments, in Trumble TE (ed): Carpal Fracture-Dislocatons. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 1-5.

Question 74:

Options:

cast immobilization.
delayed fixation of the medial malleolus.
immediate fixation of the medial malleolus and plating of the fibula.
immediate fixation of the medial malleolus, plating of the fibula, and placement of a syndesmotic screw.
immediate fixation of the medial malleolus and placement of a syndesmotic screw.

Correct Answer: immediate fixation of the medial malleolus, plating of the fibula, and placement of a syndesmotic screw.

Explanation:

Question 75:

Options:

Functional rehabilitation and return to play when he has pain-free range of motion
Immobilization in internal rotation for 6 weeks
Immobilization in internal rotation for 3 weeks, followed by 3 weeks of supervised rehabilitation
Immobilization with the arm in neutral rotation
Immobilization with the arm in 30 degrees of external rotation

Correct Answer: Immobilization with the arm in 30 degrees of external rotation

Explanation:

Question 76:

Options:

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

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

Explanation:

Question 77:

Options:

Adamantinoma
Fibrous dysplasia
Osteofibrous dysplasia
Nonossifying fibroma
Chronic osteomyelitis

Correct Answer: Osteofibrous dysplasia

Question 78:

The injury seen in the CT scan shown in Figure 56 is related to or associated with injury to which of the following structures?

Options:

Anterior talofibular ligament
Calcaneofibular ligament
Subtalar joint
Syndesmosis
Superior peroneal retinaculum

Correct Answer: Syndesmosis

Explanation:

Question 79:

A 50-year-old patient who plays tennis sustained the deformity shown in Figure 27 following a high volley. Further diagnostic work-up should include

Options:

an electromyogram (EMG) of the upper extremity.
an ultrasound of the short head of the biceps.
an MRI scan of the rotator cuff.
a CT scan with contrast of the anterior labrum.
a subclavian venogram.

Correct Answer: an MRI scan of the rotator cuff.

Explanation:

Question 80:

Options:

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

Correct Answer: Additional splinting and continued observation in the hospital

Explanation:

Question 81:

Figures 114a and 114b are the radiographs of a 5-year-old girl who fell from monkey bars. What is the first consideration regarding treatment for this injury? Review Topic

Options:

Open reduction of the radiocapitellar joint
Reconstruction of the annular ligament
Closed reduction of the radial head dislocation and placement of a pin across the radiocapitellar joint
Accomplishing and maintaining a reduction of the ulnar fracture

Correct Answer: Accomplishing and maintaining a reduction of the ulnar fracture

Explanation:

Question 82:

Options:

Medial collateral ligament repair
Medial collateral ligament reconstruction
Hinged external fixation
Lateral collateral ligament repair
Lateral collateral ligament reconstruction

Correct Answer: Lateral collateral ligament reconstruction

Explanation:

Question 83:

Options:

- Patients undergoing limb reconstruction are more satisfied.
- Long-term functional outcomes are superior in the amputation group.
- The percentage of patients who undergo amputation and return to work at 2 years is higher than the percentage of patients who undergo limb salvage who return to work at 2 years.
- The cost of amputation is 3 times higher than the cost of limb reconstruction.

Correct Answer: - The cost of amputation is 3 times higher than the cost of limb reconstruction.

Explanation:

DISCUSSION
Lower Extremity Assessment Project data suggest that long-term functional outcomes and patient satisfaction at 7 years are equivalent between those
who undergo limb-salvage and primary amputations. Return to work is essentially the same between the 2 groups. The projected lifetime healthcare cost for patients treated with amputation is nearly 3 times higher than costs for those who are treated with limb-salvage procedures.
RECOMMENDED READINGS
Busse JW, Jacobs CL, Swiontkowski MF, Bosse MJ, Bhandari M; Evidence-Based Orthopaedic Trauma Working Group. Complex limb salvage or early amputation for severe lower-limb injury: a meta-analysis of observational studies. J Orthop Trauma. 2007 Jan;21(1):70-6. PubMed PMID: 17211275.
View
Abstract at PubMed
MacKenzie EJ, Jones AS, Bosse MJ, Castillo RC, Pollak AN, Webb LX, Swiontkowski MF, Kellam JF, Smith DG, Sanders RW, Jones AL, Starr AJ, McAndrew MP, Patterson BM, Burgess AR. Health-care costs associated with amputation or reconstruction of a limb-threatening injury. J Bone Joint Surg Am. 2007 Aug;89(8):1685-92. PubMed PMID: 17671005.
View Abstract at
PubMed
CLINICAL SITUATION FOR QUESTIONS 85 THROUGH 88
Figures 85a and 85b are the plain radiographs of a 38-year-old man who fell off the roof of a 2-story house and sustained an isolated injury to his right knee. Examination reveals a swollen leg with a knee effusion. The skin is intact, but there are some abrasions and an obvious deformity. His neurovascular examination reveals active dorsiflexion and plantar flexion with some pain and symmetric palpable pulses
85A
B

Question 84:

Options:

Flexion and extension lateral radiographs
MRI
Myelogram
Diskogram
Bone scan with SPECT

Correct Answer: Bone scan with SPECT

Explanation:

A bone scan with SPECT is very sensitive and specific for spondylolysis not seen on initial radiographs. MRI can sometimes visualize spondylolysis, but it is not as sensitive nor as specific as a bone scan with SPECT. Flexion and extension views
have no role in the evaluation of the patient who presents with classic spondylolysis-type symptoms. The most sensitive physical examination finding is pain with back extension. Oblique radiographs can be obtained, but they are not as sensitive or specific as a bone scan with SPECT. The patient does not have any signs of a disk problem; therefore, an evaluation of the disk is not helpful.
(SBQ13PE.79) A 17-year-old male American football lineman presents with low back pain of insidious onset that is somewhat worse with activity. He has no neurologic complaints, night pain or fevers. His symptoms have been present for a few years but this is the first time he has sought medical attention. What physical examination finding is most likely to be found in this clinical scenario?
Review
Topic
Popliteal angle of 5 degrees
Heel cord tightness
Increased femoral anteversion
Pain with lumbar extension in single leg stance
Numbness of the skin of the anterolateral calf and dorsum of the foot
The patient demographics and clinical presentation are consistent with lumbar spondylolysis. Pain with lumbar extension is the most common physical exam finding.
Office assessment of the patient with spondylolysis should note pertinent negatives that would signify other causes of back pain. The history is most commonly negative for neurologic symptoms such as weakness or numbness, although patients will occasionally have radicular pain. On exam, patients may have localized spasm or tenderness, step off (if there is spondylolisthesis), hamstring tightness. The most common finding is pain with lumbar extension.
McCleary et al. review the diagnosis and treatment of spondylolysis in athletes. They identify three types of patients with spondylolysis: (1) female dancer or gymnast who is hyperlordotic, with increased motion and flexibility, (2) male weightlifter or football player undergoing a growth spurt, with decreased motion and flexiblity, especially of the spinal erectors, and (3) a novice athlete undergoing vigorous preparation for a new sport, with poor core strength and flexibility.
Incorrect

Question 85:

Using methylmethacrylate to fill a biopsy hole in the diaphysis of a femur theoretically achieves what purpose?

Options:

Local tumor control by chemical cytotoxic effect
Local tumor kill from heat generation
Minimizes tumor contamination
Decreases rate of wound infection
Reinforces the bone to prevent fracture

Correct Answer: Minimizes tumor contamination

Explanation:

Question 86:

Plate fixation without bone grafting

Options:

The majority of stress fractures are treated with rest and protected weight-bearing. When the patient rests, strain on the affected bone is reduced and formation exceeds resorption, leading to bone healing.
Electrical stimulation and ultrasound have not been shown to increase the rate of healing. For most stress fractures, surgery is not necessary.

Correct Answer: The majority of stress fractures are treated with rest and protected weight-bearing. When the patient rests, strain on the affected bone is reduced and formation exceeds resorption, leading to bone healing.

Explanation:

(3787) Q2-7569:
Which of the following stress fractures most often requires internal fixation:

Question 87:

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 88:

Options:

Closed reduction and casting
Bed rest and skeletal traction
Open reduction and internal fixation
Retrograde intramedullary nailing
Revision of the femoral component with a stemmed component

Correct Answer: Open reduction and internal fixation

Explanation:

DISCUSSION: The radiographs show an oblique periprosthetic distal femoral fracture. Of the options listed, open reduction and internal fixation is the most appropriate surgical option because a well-fixed, posterior stabilized closed box femoral component is present. Nonsurgical methods are not favored because of the highly displaced, unstable fracture pattern and prolonged immobility. Revision with a stemmed component is an option but would sacrifice more bone stock in this younger patient.
REFERENCES: Moran MC, Brick GW, Sledge CB, et al: Supracondylar femoral fracture following total knee arthroplasty. Clin Orthop 1996;324:196-209.
Raab GE, Davis CM III: Early healing with locked condylar plating of periprosthetic fractures around the knee. J Arthroplasty 2005;20:984-989.
Tharani R, Nakasone C, Vince KG: Periprosthetic fractures after total knee arhtroplasty.
J Arthroplasty 2005;20:27-32.

Question 89:

Options:

No further treatment
Closed reduction under conscious sedation
Closed reduction under general anesthesia in the operating room with neurologic monitoring
Occipitocervical fusion
Posterior atlantoaxial fusion

Correct Answer: No further treatment

Explanation:

The clinical presentation is consistent with chronic torticollis caused by Atlantoaxial rotatory displacement (AARD). Because both halter traction and halo traction were attempted and failed, the next most appropriate next step in management is posterior atlantoaxial fusion.
Common causes of Atlantoaxial rotatory displacement (AARD) include infection, trauma, and recent neck surgery. Diagnosis is challenging and is best confirmed with dynamic CT (CT with the head turned maximally to either side and at neutral). If the symptoms are acute (less than 7 days) then initial treatment with a soft collar and anti-inflammatory medications is indicated. If the condition has been present for more than a week, more aggressive treatment with halter traction (present 1 week to 1 month) or halo traction (present for 1-3 months) is indicated. If nonoperative modalities fail, the condition has been present for > 3 months, or the patient has neurologic deficits, then posterior C1-C2 fusion is indicated.
Copley et al discuss the evaluation and treatment of various congenital and traumatic conditions of the pediatric cervical spine. They report that the underlying mechanism of Atlantoaxial rotatory displacement (AARD) is inflammation and spasm which can be caused by infection, prior surgery, trauma, and rheumatoid arthritis.
Subach et al reviewed at 20 children with atlantoaxial rotatory subluxation. They found that of the 20 patients treated overall, conservative management failed in 6 (30%), and they required posterior fusion because of recurrence of the atlantoaxial rotatory subluxation or unsuccessful reduction. The major factor predicting the failure of conservative management was the duration of subluxation before initial reduction. Patients with long-standing subluxation were more likely to experience recurrence and require surgery.
Figure A shows an asymmetric placed odontoid within the ring of C1. There is an increased distance from the odontoid to the right arch of C1 which is fixed and minimally changes with maximal rotation to the left. This radiographic finding is indicative of fixed subluxation. Illustration A further demonstrates this.
Incorrect
(SBQ12SP.1) A 65-year-old female with a history of breast cancer presents with bilateral buttock and leg pain that is worse with walking and improves with sitting. In addition, she reports that she feels unsteady on her feet and requires holding the railing when going up and down stairs. On physical exam she is unable to complete a tandem gait and has hip flexion weakness, ankle dorsiflexion weakness, and ankle plantar flexion weakness. Her reflex exam shows 3+ bilateral patellar reflexes. Radiographs and an MRI are shown in Figure A and B. What is the next most appropriate step in management.
Review
Topic
Lumbar epidural injection
Physical therapy with core strengthening and anti-inflammatory medications as needed
Lumbar decompression
Lumbar decompression and fusion
MRI of the cervical and thoracic spine
The clinical scenario is consistent with a patient with symptoms of degenerative spondylolisthesis AND symptoms of myelopathy. Myelopathy must be ruled out by performing an MRI of the cervical and thoracic spine.
Tandem stenosis occurs in approximately 5 to 25% of patients. Because of the stepwise progressive nature of myelopathy, treatment of myelopathy often takes precedence over lumbar spinal stenosis.
Rhee et al. found that the sensitivity and specificity of specific physical exam findings varies. Both the upward babinski reflex and the presence of clonus were found to be very non-sensitive (13%). The most sensitive provacative test was found to be the Hoffman sign (59%).
Salvi et al. reviewed the classic presentations for cervical myelopathy including demographics, history, and physical exam findings (the inability to preform a tandem gait, hyperreflexia, an abnormal babinksi and hoffman reflex, the inability to preform rapid movements and bilateral muscle weakness). Additionally they identify other potential causes for myelopathy, including multiple sclerosis, amyotrophic lateral sclerosis, multifocal motor neuropathy, and Guillain-Barre´syndrome.
Maezawa et al. showed that gait analysis can identify a pattern in patients with myelopathy. Patients with severe myelopathy have a characteristic gait with hyperextension of the knee in the stance phase without plantar flexion of the ankle in the swing phase. They also have decreased walking speed and stride length with a prolonged stance phase.
Figure A and B show a classic degenerative spondylolisthesis.
Incorrect Answers:

Question 90:

Which of the following nonunions is appropriately treated with exchange reamed nailing without bone graft augmentation?

Options:

Infected tibial shaft nonunion 6 months status post intramedullary nail fixation
Oligotrophic humeral shaft nonunion 7 months status post non-operative management
Hypertrophic tibial shaft nonunion 7 months status post intramedullary nail fixation
Comminuted open tibial shaft nonunion with segmental bone loss 8 months status post intramedullary nail fixation
Supracondylar femoral shaft nonunion 6 months status post intramedullary nail fixation with 4 distal locking screws

Correct Answer: Infected tibial shaft nonunion 6 months status post intramedullary nail fixation

Explanation:

Question 91:

Which of following side effects is most commonly seen in a pediatric patient undergoing ketamine anesthesia?

Options:

Respiratory depression
Increased salivary secretion
Hypertension
Emergence phenomena
Cerebral vasoconstriction

Correct Answer: Increased salivary secretion

Explanation:

Question 92:

Options:

Late immune rejection of the meniscal graft
Loss of graft fixation
Osteoarthritis
Graft tear due to acellularity
Late-onset graft infection

Correct Answer: Osteoarthritis

Explanation:

Question 93:

This condition is most prevalent in people of which ancestry?

Options:

Northern European
Asian
Native American
Sub-Saharan African

Correct Answer: Native American

Explanation:

Question 94:

- A high school distance runner reports a 3-week history of heel pain while running. Examination elicits no pain with dorsiflexion or with palpitation of the plantar fascia; however, pain is evident with palpitation over the muscular origin of the abductor hallucis. What is the most likely etiology of the pain?

Options:

Heel spur
Plantar fascitis
Dysfunction of the tibialis posterior tendon
Compression of the first branch of the lateral plantar nerve
Compression of the calcaneal nerve

Correct Answer: Compression of the first branch of the lateral plantar nerve

Explanation:

Question 95:

Options:

Osteotomy of the tibia and fibula
Clamshell knee-ankle-foot orthotic
Serial casts
Observation and a repeat visit in 4 months DISCUSSION-The photograph shows posteromedial bowing of the tibia. The child should be followed for later limblength discrepancy, which may need treatment. Treatment with bracing or serial casts has not been shown to alter this condition. Surgery is not indicated in infancy because much of the deformity corrects with time. At a later age, treatment of a limb-length discrepancy or residual deformity can be addressed.

Correct Answer: Observation and a repeat visit in 4 months DISCUSSION-The photograph shows posteromedial bowing of the tibia. The child should be followed for later limblength discrepancy, which may need treatment. Treatment with bracing or serial casts has not been shown to alter this condition. Surgery is not indicated in infancy because much of the deformity corrects with time. At a later age, treatment of a limb-length discrepancy or residual deformity can be addressed.

Question 96:

Options:

Percutaneous pinning
Closed reduction and extension casting
Fragment excision and triceps advancement
Open reduction and internal fixation with plate fixation
Open reduction and internal fixation with tension band wire construct

Correct Answer: Open reduction and internal fixation with plate fixation

Explanation:

Question 97:

Options:

peroneus brevis tendon repair.
peroneus longus to peroneus brevis tenodesis.
6 weeks in short-leg cast.
platelet-rich plasma injection.

Correct Answer: peroneus brevis tendon repair.

Explanation:

DISCUSSION
Additional nonsurgical treatment is not beneficial for peroneal tendon tears. Early repair of longitudinal tears reduces risk for progression to a full-thickness tear that would necessitate peroneus brevis to peroneus longus tenodesis. Platelet-rich plasma has no role in peroneal tendon tears.
RECOMMENDED READINGS
Arbab D, Tingart M, Frank D, Abbara-Czardybon M, Waizy H, Wingenfeld C. Treatment of isolated peroneus longus tears and a review of the literature. Foot Ankle Spec. 2014 Apr;7(2):113-8. doi: 10.1177/1938640013514273. Epub 2013 Dec 30. Review. PubMed
PMID: 24381076.
View Abstract at PubMed
Coughlin MJ, Schon LC. Disorders of tendons. In: Coughlin MJ, Saltzman CL, Anderson RB, eds. Mann's Surgery of the Foot and Ankle. 9th ed. Philadelphia, PA: Elsevier-Saunders; 2014: 1188-1291.
RESPONSES FOR QUESTIONS 71 THROUGH 75
Lapidus procedure
First metatarsophalangeal (MTP) joint arthrodesis and lesser metatarsal head resection
Proximal first metatarsal osteotomy
Distal first metatarsal chevron osteotomy
Biplanar distal first metatarsal osteotomy
Match the appropriate surgical procedure listed above with the clinical scenario described below.

Question 98:

Figures 10a and 10b show the clinical photograph and MRI scan of a plantar foot lesion. If excisional biopsy is performed, what is the most likely complication?

Options:

Metastatic spread
Recurrence of the lesion
High likelihood of wound breakdown
Injury to the medial plantar nerve
Loss of the local windlass effect of the plantar fascia

Correct Answer: Recurrence of the lesion

Explanation:

DISCUSSION: The MRI scan shows plantar fibromatosis. The treatment is usually nonsurgical.
If surgery is indicated, wide local excision with excision of the entire plantar fascia is usually indicated. The main problem with simple excision of the lesion is the high chance of recurrence. The other listed complications are those that are a result of the wide local excision.
REFERENCES: Aluisio FV, Mair SD, Hall RL: Plantar fibromatosis: Treatment of primary and recurrent lesions and factors associated with recurrence. Foot Ankle Int 1996;17:672-678.
Bos GD, Esther RJ, Woll TS: Foot tumors: Diagnosis and treatment. J Am Acad Orthop Surg 2002;10:259-270.

Question 99:

-An otherwise healthy 15-year-old wrestler has a 6-cm cutaneous lesion on the posterior aspect of his right elbow that he reports as a spider bite. What is the most likely diagnosis?

Options:

Psoriasis
Tinea corporis
Herpes simplex virus
Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) DISCUSSION-Patients who have skin and soft-tissue infections caused by CA-MRSA often describe the lesion as a spider bite. The cytotoxin Panton-Valentine leukocidin that is produced by many strains of CA-MRSA causes tissue necrosis, resulting in rapid development of an abscess and the appearance of a spider bite.Patients with psoriasis have thick, red skin with flaky, silver-white patches. Tinea corporis is a general term for a cutaneous fungal infection. The lesion appears as a well-demarcated erythematous plaque with a raised border and central hypopigmentation, giving it a ring-like appearance. Primary infection with herpes simplex virus can produce constitutional symptoms with burning, tingling, or stinging at the site. Grouped vesicles with clear fluid 1 to 2 mm in size form on an erythematous base and then rupture,leaving moist ulcers or crusted plaques.

Correct Answer: Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) DISCUSSION-Patients who have skin and soft-tissue infections caused by CA-MRSA often describe the lesion as a spider bite. The cytotoxin Panton-Valentine leukocidin that is produced by many strains of CA-MRSA causes tissue necrosis, resulting in rapid development of an abscess and the appearance of a spider bite.Patients with psoriasis have thick, red skin with flaky, silver-white patches. Tinea corporis is a general term for a cutaneous fungal infection. The lesion appears as a well-demarcated erythematous plaque with a raised border and central hypopigmentation, giving it a ring-like appearance. Primary infection with herpes simplex virus can produce constitutional symptoms with burning, tingling, or stinging at the site. Grouped vesicles with clear fluid 1 to 2 mm in size form on an erythematous base and then rupture,leaving moist ulcers or crusted plaques.

Explanation:

CLINICAL SITUATION FOR QUESTIONS 44 AND 45
Figure 44 is the MRI scan of a 14-year-old soccer player who injured his right knee during a game.He describes feeling a “pop” and he needed help walking off the field. His knee is visibly swollen. A Lachman test demonstrates asymmetry with no endpoint.

Question 100:

Options:

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

Correct Answer: observation.

Explanation:

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

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

Orthopedic Board Review MCQs: Trauma, Adult Reconstruction & Upper Extremity | Part 151

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 151

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index