Orthopedic Surgery Board Review MCQs: OITE Part 163

About This Board Review Set

This is Part 163 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

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Two distinct learning modes are available:

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

Topics Covered in Part 163

This module focuses heavily on: Fracture, Ligament, Wrist.

Sample Questions from This Set

Sample Question 1: The thumb metacarpophalangeal (MCP) joint should be flexed to what degree to properly assess ligamentous stability?...

Sample Question 2: Figures 1 and 2 show the postreduction radiographs obtained from a 32-year-old man who fell from a ladder onto his outstretched right arm. He reports right wrist pain and dense numbness in his radial digits. What is the most appropriate tre...

Sample Question 3: A 64-year-old female sustains a nondisplaced distal radius fracture and undergoes closed treatment using a cast. Three months after the fracture she reports an acute loss of her ability to extend her thumb. What is the most likely etiology ...

Sample Question 4: An acetabular fracture with all segments of the articular surface detached from the intact posterior ilium is defined as what fracture pattern?...

Sample Question 5: Figure 21 shows the tomogram of a 26-year-old woman who sustained an axial load injury to her neck in a fall off a horse. What ligament is injured?...

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Evidence consistently demonstrates that active recall through spaced MCQ practice yields substantially greater long-term retention than passive reading alone (Roediger & Karpicke, 2006). All questions in this specific module have been algorithmically verified for clinical integrity and complete explanations.

Comprehensive 100-Question Exam

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Question 1

The thumb metacarpophalangeal (MCP) joint should be flexed to what degree to properly assess ligamentous stability?

Explanation

DISCUSSION: The collateral ligaments of the MCP joint of the thumb can be isolated by flexing the joint to 30 degrees. Full extension is best to assess the accessory collaterals and the palmar plate. The ulnar collateral ligament nearly always separates from the base of first phalanx of the thumb; it frequently becomes lodged between adductor pollicis aponeurosis and its normal position (Stener lesion). The creation of a Stener lesion requires significant radial deviation of the phalanx along with combined tears of the proper and accessory collateral ligaments in order for the ligament to be displaced above the adductor aponeurosis.
REFERENCES: Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgery, 2002, pp 339-358.
Stener B: Displacement of the ruptured ulnar collateral ligament of the MP joint of the thumb: A clinical and anatomical study. J Bone Joint Surg Br 1962;44:869-879.
33 • American Academy of Orthopaedic Surgeons

Question 2

Figures 1 and 2 show the postreduction radiographs obtained from a 32-year-old man who fell from a ladder onto his outstretched right arm. He reports right wrist pain and dense numbness in his radial digits. What is the most appropriate treatment option?

Explanation

EXPLANATION:
This patient sustained a lesser-arc perilunate dislocation. As a result of the injury, he also developed acute carpal tunnel syndrome. The closed reduction attempt was unsuccessful; therefore, this injury is best managed with emergent surgery, an open carpal tunnel release, an open reduction of the perilunate dislocation, scapholunate ligament repair, and intercarpal pinning. Outpatient surgery in a delayed fashion is not advised because of the acuity and severity of the carpal tunnel syndrome. Closed reduction and casting is not advised, because it commonly leads to continued carpal instability with subsequent dorsal
intercalated segment instability deformity and scaphoid lunate advanced collapse wrist arthritis.

Question 3

A 64-year-old female sustains a nondisplaced distal radius fracture and undergoes closed treatment using a cast. Three months after the fracture she reports an acute loss of her ability to extend her thumb. What is the most likely etiology of her new loss of function?

Explanation

DISCUSSION: According to the referenced article by Jupiter and Fernandez, the most common scenario of extensor pollicis longus rupture after a distal radius fracture is when the fracture is non or minimally displaced. The hypothesis is that the rupture happens at an area of relative hypovascularity and healing callus can aggravate this area, leading to a degenerative tear. Hove et al reported an incidence of delayed tendon rupture after distal radius fracture of 0.3 percent. In their series of 18 extensor pollicis longus tendon ruptures, 15 were treated with tendon transfers. They reported good results: nearly 100% patient satisfaction, all patients were able to elevate the thumb to the level of the palm, and full independent index finger movements.

Question 4

An acetabular fracture with all segments of the articular surface detached from the intact posterior ilium is defined as what fracture pattern?

Explanation

DISCUSSION: A both column acetabular fracture is defined as an acetabular fracture with no articular surface in continuity with the remaining posterior ilium (and therefore, axial skeleton). The spur sign is a radiological sign seen with these fractures, and is the posterio-inferior aspect of the intact posterior ilium. The spur sign and other
radiographic findings consistent with a both column acetabular fracture can be seen in Illustration A (AP), Illustration B (obturator oblique), and Illustration C (iliac oblique).

Question 5

Figure 21 shows the tomogram of a 26-year-old woman who sustained an axial load injury to her neck in a fall off a horse. What ligament is injured?

Explanation

DISCUSSION: Levine and Edwards, in their description of the classic C1 burst (Jefferson) fracture, noted that spread of the lateral masses of more than 7 mm is indicative of a transverse ligament rupture. Long-term C1-C2 instability, however, has not been described with this fracture pattern. Although long-term traction followed by halo vest immobilization has been described as the best technique for achieving an ideal result, treatment of this injury remains somewhat controversial.
REFERENCES: Levine AM, Edwards CC: Fractures of the atlas. J Bone Joint Surg Am 1991;73:680-691.
Kurz LT: Fractures of the first cervical vertebra, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 409-413.

Question 6

A 34-year-old man underwent open reduction and internal fixation of a closed both bones forearm fracture 11 months ago. The radiographs shown in Figures 32a and 32b reveal a 3-mm gap and loose screws. What is the best treatment option?

Explanation

DISCUSSION: In an atrophic nonunion with a good soft-tissue envelope, adequate plating with cancellous bone graft can be used to span defects of up to 6 cm. Cortical graft from the fibula or iliac crest is not necessary. BMP-7 is a bone graft substitute and should not be used alone in this patient because the hardware is loose.
REFERENCES: Ring D, Allende C, Jafarnia K, et al: Ununited diaphyseal forearm fractures with segmental defects: Plate fixation and autogenous cancellous bone-grafting. J Bone Joint Surg Am 2004;86:2440-2445.

Question 7

A 14-year-old gymnast presents after a fall from the balance beam with a hyperextension injury to her left knee. She could ambulate with pain but was unable to continue exercise due to pain. On examination she has a swollen knee with painful

Explanation

The patient has a mild to moderately displaced tibial eminence fracture, which can be treated with closed reduction, casting, and supportive care provided successful closed reduction is achieved.
Tibial eminence fractures are rare but occur more often in pediatric populations, often in the setting of sports-related injuries. Debate continues over operative vs nonoperative treatment, as well as fixation type (screw vs suture) for openly treated fractures. Past evidence suggested closed treatment was adequate but there has been an increase in operative management. Closed treatment is suggested for minimally displaced fractures (Type I and reducible Type II) and open treatment for completely displaced fractures (non-reducible Type II and Type III).
Wilfinger et al provide the results of a closed reduction protocol at their institution including 38 patients with long term followup. All patients underwent aspiration and closed reduction in the OR under fluoroscopic guidance followed by long leg casting in hyperextension and graduated weight bearing over weeks. No patients complained of persistent pain, swelling, giving way, or disability at follow up.
However, Edmonds et al in a retrospective review compare open reduction internal fixation (ORIF), arthroscopic-assisted internal fixation (AAIF), and closed reduction with casting (CRC) for pediatric patients with displaced tibial spine fractures. They report improved reduction but also increased arthrofibrosis in ORIF and AAIF groups
compared to CRC, but of the 24% of patients with long term followup results, there was no difference in functional outcomes across all 3 groups. There was a 17% rate of later operation for the CRC group patients. They suggest closed treatment for fractures with <5mm displacement, otherwise ORIF or AAIF.
Gans et al conducted a systematic review focused on the questions of open vs closed reduction, and screw vs suture fixation. The 26-article review found insufficient evidence to have any clear recommendations. They did find reduced laxity and improved range of motion for minimally displaced fractures that had an open reduction, and that completely displaced fractures treated nonoperative had higher rates of nonunion.
Figures A and B are AP and lateral knee radiographs demonstrating a moderately displaced (Meyers and McKeever Type II) tibial spine fracture in a skeletally immature patient.
Incorrect Responses

Question 8

Figures 28a and 28b show the posteroanterior and lateral radiographs of a 38-year-old woman with adult idiopathic scoliosis. She reports symptoms of long-standing lower back pain, progressive loss of height, and the inability to stand upright at the end of the day. What radiographic finding has been found to most closely correlate with symptoms of lower back pain? Review Topic

Explanation

Adult idiopathic scoliosis and adult "de-novo" scoliosis can present with a number of symptoms that relate to associated degenerative findings such as stenosis or spondylolisthesis. In the absence of these associated conditions, increased levels of pain in patients with scoliosis has been found to most closely correlate with sagittal imbalance. Thoracolumbar and lumbar curves and thoracolumbar kyphosis have both been found to closely correlate with increased symptoms and lower health-related quality of life (HRQL) outcome scores. Thoracic scoliosis, thoracic hypokyphosis, lumbar hyperlordosis, and lumbar disk degeneration have not been found to correlate with increased symptoms.

Question 9

Which of the following statements best describes the process of articular cartilage degeneration in osteoarthritis?

Explanation

DISCUSSION: Inflammation, overload, or decreased matrix production may lead to cartilage degeneration. During the second stage of articular cartilage degeneration with osteoarthritis, there is increased chondrocyte activity with proliferation and increased production of extracellular matrix. At the same time, there is an increase in catabolic activity with removal of damaged matrix to facilitate matrix remodeling. Chondrocyte repair response decreases with aging. Matrix degradation includes decreased proteoglycan production, less aggregation, and shorter glycosaminoglycan chains.
REFERENCE: Buckwalter JA, Mankin HJ, Grodzinsky AJ: Articular cartilage and osteoarthritis. Instr Course Lect 2005;54:465-480.

Question 10

A 22-year-old man sustained a cervical fracture-dislocation of the C5-6 level in a motor vehicle accident along with an associated spinal cord injury. Six months after his injury, he has 4 out of 5 biceps on the left, with 5 out of 5 biceps on the right. Deltoid is graded at 5 out of 5 bilaterally. There is 0 strength in the triceps, wrist flexors, wrist extensors, and digital extensors. He has neurogenic bowel and bladder with absent perianal sensation and no voluntary motor in the lower extremities. The patient's neurologic deficit is best categorized as which of the following? Review Topic

Explanation

The patient has a complete spinal cord injury. The level of a spinal cord injury is determined by the most distal intact (5/5) function. The lowest motor intact level in this patient is C5 based on the described examination. Central spinal cord injury and Brown-STquard injuries are both incomplete patterns of spinal cord injury.

Question 11

A 10-year-old boy with spastic diplegic cerebral palsy walks in a crouched position with the hips and knees flexed. Maximum knee flexion is 15 degrees during early swing phase. Instrumented gait analysis shows quadriceps activity from terminal stance throughout swing phase. Treatment should consist of

Explanation

DISCUSSION: The rectus femoris muscle spans two joints and is active during running, sprinting, and walking at a fast pace during the preswing and early swing phase of gait. In these situations, the muscle helps to generate power to initiate hip flexion while absorbing or controlling the rate of knee flexion during early swing phase. Quadriceps activity, including the rectus femoris, is not normally needed when walking at a routine cadence. However, rectus femoris activity is commonly noted during preswing and the swing phase in patients with cerebral palsy, particularly those with diplegia. In an effort to initiate swing phase, the rectus femoris is “overactive.” As a result, the knee flexion that commonly occurs at terminal stance and initial swing is restricted. Instead of achieving the normal 50 to 60 degrees of flexion during early swing, this patient’s knee flexion is limited to 15 degrees. The goal of treatment is to retain rectus femoris activity for initiation of hip flexion but to diminish its restraint on knee flexion. Studies have shown that transfer of the distal rectus femoris tendon provides more flexion of the knee during the swing phase of gait than simply releasing the tendon. V-Y lengthening of the quadriceps tendon or a Z lengthening of the patellar tendon causes too much weakening of the quadriceps muscle and worsens the crouch deformity. In addition to transfer of the rectus femoris tendon, other procedures are often done concomitantly to obtain the best balance and realignment of hip-knee-ankle activity.
REFERENCES: Aiona MD: Guidelines for managing lower extremity problems in cerebral palsy, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 1534-1541.
Chambers H, Laure A, Kaufman K, Cardelia M, Sutherland D: Prediction of outcome after rectus femoris surgery in cerebral palsy: The role of cocontraction of the rectus femoris and vastus lateralis. J Pediatr Orthop 1998;18:703-711.
Ounpuu S, Muik E, Davis RB, Gage JR, Deluca PA: Rectus femoris surgery in children with cerebral palsy. J Pediatr Orthop 1993;13:331-335.

Question 12

On average, the radial nerve travels from the posterior compartment of the arm to the anterior compartment at which of the following sites?

Explanation

DISCUSSION: The radial nerve enters the anterior compartment through the intercompartmental fascia on average 10 cm proximal to the radiocapitellar joint. It has never been found to remain in the posterior compartment within

Question 13

Figures 28a and 28b are the MR images of a 30-year-old man who has right shoulder pain and difficulty throwing a football. His history includes a shoulder injury from a skiing accident 2 years ago. He has not had a recent shoulder injury. Which shoulder motion is most likely to demonstrate weakness?

Explanation

DISCUSSION
The MR images reveal a large paralabral cyst extending into the spinoglenoid notch. This cyst can be expected to compress the branch of the suprascapular nerve to the infraspinatus. Compression of this branch could lead to weakness in the infraspinatus, which would manifest as external rotation weakness. Shoulder abduction would be unaffected because the axillary and main suprascapular nerves would be intact. Shoulder internal rotation and adduction would be unaffected because the subscapularis and pectoralis would be unaffected.

Question 14

Figure 53 shows the MRI scan of a 53-year-old carnival worker who has pain and swelling in the left shoulder as a result of attempting to stop a roller coaster car with his arm. Examination reveals decreased ROM, apprehension, and inability to move the dorsum of his hand away from his back. Treatment should consist of

Explanation

This patient has an acute tear of the subscapularis tendon both by MRI and physical exam. Treatment of choice is open repair. Nonoperative treatment is not indicated.

Question 15

All of the following techniques can help to prevent valgus angulation during intramedullary nailing of proximal one-third tibia fractures EXCEPT:

Explanation

DISCUSSION: Proximal tibial shaft fractures treated with intramedullary nails are most commonly malreduced with apex anterior and valgus deformities. Several techniques are available to overcome this malalignment: proximal and lateral nail starting point, usage of a femoral distractor or temporary plating, suprapatellar nailing, and lateral parapatellar approaches. Suprapatellar nailing portals do not affect coronal angulation - they only affect the apex anterior deformity.
A final technical trick is the usage of blocking (Poller) screws - the referenced article by Ricci et al had 100% correction and maintenance of reduction with usage of blocking screws without other adjunct techniques. These should be placed in the lateral aspect of the proximal and distal fragments when needed.
The referenced study by Krettek et al is a biomechanical evaluation of blocking screws in a tibial model that showed significantly increased strength when they were utilized.

Question 16

All of the following are advantages of supine over lateral positioning during intramedullary nailing of subtrochanteric femur fractures EXCEPT:

Explanation

DISCUSSION: Based on the references provided, the advantages of the lateral position include: facilitates the retraction of the vastus lateralis, allows hip flexion to aid reduction, improves access to the proximal segment (easier to get starting point). Disadvantages of the lateral position include: intraoperative imaging may be more difficult, rotation is more difficult to judge, and lateral positioning may not be practical in the polytraumatized patient.
Advantages of the supine position include: may help protect a potentially unstable spine, facilitates access to sites other than the injured femur, shorter setup time, rotational and angulatory deformities may be more easily appreciated. Disadvantages of the supine position include: starting point localization may be more difficult.

Question 17

-A 42-year-old woman has had right wrist pain for 2 years. She tried splint wear and naproxen and has had 3 steroid injections, each time experiencing less relief.

Explanation

Question 18

Radiographs shown in Figures 1 through 3 show two different prosthetic design variations of the same knee implant. When compared with the design of right knee prosthesis, the left can be expected to have a

Explanation

A 76-year-old woman has had three hip revisions for instability. She presents to the emergency department with another dislocation that occurred while getting up from a low chair. Current radiographs are shown in Figures 1 and 2. Her prior AP pelvis radiograph is shown in Figure 3. ESR and CRP are normal. What is the best plan for definitive treatment?

Question 19

Which of the following findings is a prerequisite for a high tibial valgus osteotomy for medial compartment gonarthrosis?

Explanation

DISCUSSION: The indications for high tibial valgus osteotomy include a physiologically young age, arthritis confined to the medial compartment, 10 to 15 degrees of varus alignment on weight-bearing radiographs, a preoperative arc of motion of at least 90 degrees, flexion contracture of less than 15 degrees, and a motivated, compliant patient. Contraindications include lateral compartment narrowing of the articular cartilage, lateral tibial subluxation of greater than 1 cm, medial compartment bone loss, ligamentous instability, and inflammatory arthritis.
REFERENCES: Naudie D, Bourne RB, Rorabeck CH, Bourne TT: The Insall Award: Survivorship of the high tibial valgus osteotomy. A 10- to 22-year followup study. Clin Orthop 1999;367:18-27.
Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000,
pp 255-264.

Question 20

Which of the following conditions precludes performing a tendon transfer?

Explanation

DISCUSSION: Several conditions must be met before a tendon transfer has the potential to correct a dynamic deformity. If the target joint cannot be passively corrected to neutral, it indicates that a static joint contracture or bony deformity exists that cannot be corrected with a dynamic tendon transfer. While in-phase muscles are best, out-of-phase muscles are often the only muscles available for transfer. Tendon transfer should pull in a straight line to avoid tethering and late failure.
REFERENCES: Canale ST (ed): Campbell’s Operative Orthopaedics, ed 10. St Louis, MO, Mosby, 2003, pp 1283-1287.
Coughlin MJ, Mann RA: Disorders of tendons, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 786-861.

Question 21

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

Explanation

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

Question 22

A 64-year-old man with a history of metastatic lung cancer reports increasing right hip pain over the period of several months. Radiographs are shown in Figures 3a and 3b. Initial management should consist of

Explanation

DISCUSSION: The patient has lung cancer metastatic to the right proximal femur. The lesion is large, has destroyed a portion of the cortex, and involves the peritrochanteric region. All of these findings put the patient at high risk for pathologic fracture. The lesion is amenable to intramedullary fixation in the form of some type of reconstruction nail. Chemotherapy alone will not restore the bone stock. Given the extent of the lesion, radiation therapy, chemotherapy, or embolization will not prevent fracture. A proximal femoral replacement would be indicated in patients with bone destruction extending into the femoral head and neck. Bisphosphonates may diminish the risk of subsequent lesions but are not sufficient to treat this high-risk lesion. Radiation therapy should be given postoperatively to prevent further bone destruction.
REFERENCE: Mirels H: Metastatic disease in long bones: A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop 1989;249:256-264.

Question 23

Radiographs of the cervical spine of a 73-year-old man who fell down stairs reveal cervical spondylosis without evidence of fracture or dislocation. MRI and CT scans are consistent with the plain radiographs. After 72 hours, neurologic evaluation reveals intact sensation; however, weakness of the upper extremities is greater than that of the lower extremities. What is the most likely diagnosis?

Explanation

Central cord syndrome is the correct answer. Common in the older patient, sacral sparing, upper extremity involvement greater than the lower extremity. Functional recovery expected in 75% of patients. 2-Anterior cord syndrome complete motor deficit; trunk and lower
extremity deep pressure and proprioceptive preserved. 3-Posterior cord syndrome is rare with loss of deep pressure, deep pain, and proprioception. 4-Brown-Sequard syndrome-Uncommon-Ipsilateral motor deficit, contralateral pain and temperature deficit. 5-Cervical nerve root injury- functional impairment of the cervical spine. Symptoms are often acute and severe, dependent on the level of the lesion. An infraforaminal protrusion may compress only the spinal root ganglion resulting in severe brachialgia with paresthesia and numbness but with little or no motor involvement.

Question 24

A 17-year-old girl who initially presented as a child with multiple skeletal lesions, café-au-lait spots, and precocious puberty now has bone pain. A recent bone scan reveals multiple areas of increased scintigraphic uptake, including bilateral proximal femurs. A radiograph is shown in Figure 19. Besides activity modification, what is the next best line of treatment for decreasing her pain? Review Topic

Explanation

McCune-Albright syndrome is the combination of polyostotic fibrous dysplasia, café-au-lait lesions, and endocrine dysfunction. The most common endocrine presentation is precocious development of secondary sexual characteristics. Compared with bone lesions in patients without polyostotic disease, the skeletal lesions in patients with the syndrome tend to be larger, more persistent, and associated with more complications. Bisphosphonate therapy has been shown in several studies to decrease the pain associated with the skeletal lesions of fibrous dysplasia.

Question 25

-Assuming that the lesion can be covered appropriately and there is no drainage from the lesion, when should the patient be allowed to safely return to wrestling?

Explanation

DISCUSSION FOR QUESTIONS 48 AND 49
This patient has cellulitis, which is typically caused by group A Streptococcus or Staphylococcus. The patient’s lack of improvement with first-line antibiotics is concerning for methicillin-resistant Staphylococcus aureus (MRSA) infection. MRSA cellulitis is becoming more prevalent in young athletes,and a high index of suspicion is required to provide appropriate intervention during this
aggressive disease process. The diagnosis is typically made clinically without the use of cultures. Oral trimethoprimsulfamethoxazole (a sulfonamide-class drug) double strength twice daily for 10 to 14 days or doxycycline (a tetracycline-class drug) 100 mg twice daily for 10 to 14 days are recommended for first-line treatment of suspected MRSA cellulitis. There is no indication to proceed with irrigation and debridement; however, if the patient develops a soft-tissue abscess or the underlying joint becomes involved, this would be an appropriate intervention. Switching the athlete to an IV cephalosporin (cefazolin) is not likely to be effective against the presumed resistant bacteria.
Ciprofloxacin (a fluoroquinolone-class drug) is effective against many bacteria, but not MRSA. The current recommendation for wrestlers with cellulitis is that return to competition be allowed after 72 hours of antibiotic treatment if there has been no extension of the cellulitis for 48 hours, the lesion can be covered, and there is no drainage from the lesion. The other responses are not current recommendations for return to competition.

Question 26

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

Explanation

DISCUSSION: The radiographs show localized diffuse cortical thickening that is characteristic of melorheostosis. The condition may be monostotic or it may involve many bones in one extremity (monomelic) in the distribution of a sclerotome. Bone scans will show increased uptake at the site or sites of skeletal involvement. Long tubular bones are most commonly involved. Melorheostosis is usually asymptomatic and requires no treatment. On rare occasions, there may be associated soft-tissue contractures.
REFERENCES: Dorfman H, Czerniak B: Bone Tumors. St Louis, MO, Mosby Inc, 1998, pp 1105-1107.
Campbell CJ, Papademetriou T, Bonfiglio M: Melorheostosis: A report of the clinical, roentgenographic, and pathological findings in fourteen cases. J Bone Joint Surg Am 1968;50:1281-1304.
Hove E, Sury B: Melorheostosis: Report on 5 cases with follow-up. Acta Orthop Scand 1971;42:315-319.

Question 27

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

Explanation

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

Question 28

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

Explanation

Patients with dysplasia often have a hypertrophic labrum. Abnormal contact between the femoral neck and the acetabular rim leads to labral injury, especially in the anterior-superior acetabular zone. Typically, young patients with the condition report pain with activity or long periods of sitting or driving. The hips often have limited motion, in particular in internal rotation and flexion. Forceful adduction with the maneuver causes pain.
(SBQ13PE.10) Which statement is true regarding discoid menisci? Review Topic
Most commonly involves the medial meniscus
Bilateral in >75% of cases
Asymptomatic discoid meniscus should undergo saucerization
Radiographs will commonly show a hyperplastic lateral intercondylar spine
Radiographs will commonly show squaring of affected condyle with cupping of tibial plateau
Radiographs of knees with discoid menisci will commonly show squaring of affected condyle (lateral>medial) with cupping of tibial plateau.
Discoid meniscus refers to the abnormal development of a hypertrophic and discoid shaped meniscus. It occurs in 3-5% of the population and it is considered the most common cause of a symptomatic clicking or clunking in a childs knee. The lateral meniscus is most commonly affected and it will occur bilaterally in 25% of affected
people. The Watanabe Classification describes the 3 types of discoid menisci. Type 1
= Incomplete, Type 2 = Complete, Type 3 = Wrisberg (lack of posterior meniscotibial attachment to tibia)
Kramer et al. looked at the presentation of pediatric knee pain. They showed that the lateral meniscus is more commonly affected than the medial meniscus. The majority of discoid tears occur in the posterior or middle aspect of the discoid meniscus.
Lee et al. retrospectively reviewed 36 patients aged less than 15 years who underwent arthroscopic procedures for torn discoid menisci. The mean patient age at the time of surgery was 9.5 years. They showed that partial meniscectomy yielded better radiologic results than subtotal/total meniscectomy for torn discoid menisci in this population.
Illustration A shows the 3 classifications of discoid menisus as originally described by Watanabe. Type 4 is a ring type discoid that was not originally described by Watanabe in his 1978 paper. Illustration B shows an AP and lateral radiograph of a discoid meniscus knee. Note squaring of affected lateral condyle in the presence of a lateral discoid meniscus. Illustration C shows 4 consecutive sagittal MRI images with meniscus continuity. It is important to note that the diagnosis of discoid menisci can be made when 3 or more 5mm sagittal images show meniscal continuity.
Incorrect Answers:

Question 29

Examination of a 13-year-old boy with asymptomatic poor posture reveals increased thoracic kyphosis that is fairly rigid and accentuates during forward bending. The neurologic examination is normal. Spinal radiographs show 10 degrees of scoliosis at Risser stage 2, and there is no evidence of spondylolisthesis. A standing lateral view of the thoracic spine is shown in Figure 41. The kyphosis corrects to 50 degrees. Management should consist of Review Topic

Explanation

The radiograph shows excessive thoracic kyphosis (normal 20 degrees to 50 degrees) with multiple contiguous vertebral wedging and end plate irregularity, all consistent with the diagnosis of Scheuermann’s kyphosis. The patient is skeletally immature; therefore, there is the potential for progression of the kyphotic deformity. Extension bracing has shown efficacy in the treatment of Scheuermann’s kyphosis that measures 50 degrees to 74 degrees, and has actually reduced the curvature permanently in some patients. A thoracolumbosacral orthosis may be used if the apex of kyphosis is at T7 or lower. Indications for surgical treatment are controversial, but spinal fusion most likely should not be considered for a painless kyphosis measuring less than 75 degrees.

Question 30

MRI results are shown in Figure 1 for a 22-year-old, right-hand dominant collegiate athlete who reports a 6-month history of progressive weakness in his right arm. He denies any specific traumatic event. He has altered his weight-lifting activities and tried over-the-counter ibuprofen without benefit. No appreciable deformity or atrophy is found on examination of the upper extremities. He demonstrates full active shoulder range of motion, and there is no weakness with abduction in the plane of the scapula. Belly press test findings are normal, but weakness is seen in external rotation with the arm in adduction. He does not demonstrate anterior apprehension, and there is no instability with load and shift testing. Radiographs are unremarkable. What is the best surgical option?

Explanation

A 45-year-old woman diagnosed with lateral epicondylitis undergoes an open debridement of the extensor carpi radialis brevis. During surgery, resection extends posterior to the equator of the radiocapitellar joint. Postoperatively, she complains of persistent pain, despite appropriate rehabilitation. What other physical examination finding is she likely to have?
A. Pain with elbow extension in forearm pronation
B. Mechanical symptoms when rising from a chair
C. Valgus instability
D. Tenderness over the medial collateral ligament (MCL)
Excessive resection of the common extensor origin posterior to the equator of the radiocapitellar joint may lead to iatrogenic lateral collateral ligament (LCL) injury, causing posterior lateral rotatory instability (PLRI). Patients may present with lateral elbow pain, a positive lateral pivot shift test, or mechanical symptoms/subjective instability when pushing up from a chair (positive chair rise test). PLRI is often provoked with combined elbow extension and forearm supination, as the posterior support for the radiocapitellar joint has been lost. Therefore, placing the forearm in pronation during elbow extension places the radiocapitellar joint in a more stable position and is less likely to induce pain or mechanical symptoms. Valgus instability and MCL tenderness would be associated with an MCL injury.
56- A 75-year-old man presents with complaints of shoulder pain, bruising, and weakness following a fall onto his outstretched hand. He underwent an uncomplicated anatomic total shoulder arthroplasty 5 years prior with good range of motion and strength. His current radiographs are shown in Figures 1 and 2. What is the most appropriate next step to restore this patient’s function?

Question 31

An 82-year-old man has had episodic right thigh pain after undergoing a total hip arthroplasty 10 years ago. Initial postoperative radiographs are shown in Figures 26a and 26b, and current radiographs are shown in Figures 26c and 26d. What is the most likely cause of his pain?

Explanation

DISCUSSION: These radiographs are dominated by the subsidence of the femoral component. There is also evidence of polyethylene wear and femoral osteolysis in the region of the greater trochanter. There is no evidence of proximal (calcar) stress shielding, and there is a thick distal pedestal. Engh and associates defined two major signs of osseointegration - the absence of radiolucent lines around the porous-surfaced portion of the implant and new bone bridging the gap between the endosteal surface and the porous portion of the implant. Implant migration indicates failure of ingrowth. Osteolysis is a periprosthetic loss of bone secondary to particulate debris and it is often clinically silent unless it is accompanied by pathologic fracture. It is often globular. Acetabular loosening is based on radiolucent lines and implant migration. The current radiographs demonstrate subsidence of the stem with pedestal formation.
REFERENCES: Engh CA, Massin P, Suthers KE: Roentgenographic assessment of biologic fixation of porous-surface femoral components. Clin Orthop Relat Res 1990;257:107-128.
Engh CA, Hooten JP, Zettl-Schaffer KF, et al: Evaluation of bone ingrowth in proximally and extensively porous-coated anatomic medullary locking prostheses retrieved at autopsy. J Bone Joint Surg Am 1995;77:903-910.

Question 32

A 22-year-old ballet dancer undergoes hip arthroscopy for increasing hip pain and popping with activity. She experiences complete resolution of signs and symptoms post-operatively. Her pre- and post-operative magnetic resonance sagittal images shown in Figure A (left, pre-operative; right, post-operative). Which of the following pre-operative physical examination findings may have been positive? Review Topic

Explanation

This patient has internal snapping hip (coxa saltans), which is caused by the psoas tendon sliding over femoral head, iliopectineal ridge, lesser trochanter exostoses, or iliopsoas bursa.
Snapping hip exists in 3 forms: (1) external snapping hip, which is caused by the iliotibial band (ITB) sliding over the greater trochanter, (2) internal snapping hip, and
(3) intraarticular snapping hip, which is caused by loose bodies (traumatic, or from synovial chondromatoses) or labral tears. While painless snapping hip requires no treatment, painful snapping hip may be addressed with activity modification, physical therapy, steroid injections. Surgical release (ITB z-plasty or psoas tenotomy) is indicated if nonoperative management is unsuccessful.
Ilizaliturri et al. evaluated the results of endoscopic iliopsoas tendon release at the lesser trochanter (10 patients) vs endoscopic transcapsular psoas release from the peripheral compartment (9 patients). There were improvements in WOMAC scores in both groups, and no difference between groups. They conclude that both techniques are equally effective.
Marquez Arabia et al. evaluated if the psoas tendon regenerates after tenotomy in 27 patients. At 23 months, they found that tendon regeneration occurred in all patients, to
a mean circumference of 84% of the original. One patient had persistent pain, but all had 5/5 hip flexion strength. They hypothesize that the bulk of iliopsoas muscle fibers attaches directly to the proximal femoral shaft without a tendon, preventing retraction and allowing regeneration to occur easily.
Figure A shows pre- and post-operative arthroscopic psoas tenotomy magnetic resonance sagittal images. Illustration A shows the psoas tendon (white arrows) prior to transection. Illustration B shows the psoas tendon after transection (green arrows, proximal tendon segment; yellow arrows, distal segment). Illustration C and D are diagrams showing release at the level of the lesser trochanter and hip joint respectively.
Incorrect
90 degrees, but full external rotation. Answer 2: Decreased internal rotation and a positive impingement test (forced
flexion, adduction, femoroacetabular Answer 4: These
and internal
rotation) are classic findings
findings may
be found with intra-articular
for cam-type impingement loose bodies.

Question 33

An axial T 1 -weighted MRI scan of the pelvis is shown in Figure 35. Which of the following structures is enclosed by the circle?

Explanation

DISCUSSION: The obturator vessels and nerve pass along the lateral pelvic wall along the true pelvic brim (nerve lies anterior to the vessels and lies on the obturator internus muscle) and descend into the obturator groove at the upper portion of the obturator foramen.
REFERENCES: Higuchi T: Normal anatomy and magnetic resonance appearance of the pelvis, in Takahashi HE, Morita T, Hotta T, et al (eds): Operative Treatment of Pelvic Tumors. Tokyo, Japan, Springer-Verlag, 2003, pp 4-21.
Berquist TH: Pelvis, hips and thigh, in Berquist TH (ed): MRI of the Musculoskeletal System,

ed 4. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 210-238.

Question 34

An 18-year-old girl with quadriplegic cerebral palsy underwent posterior spinal fusion from T2 to the pelvis 3 weeks ago. She now has a low-grade fever and mild midline erythema in a 1-cm area from which there is slight clear yellowish drainage. What is the next most appropriate step in management?

Explanation

DISCUSSION: The presence of drainage 3 weeks after surgery is a sign of wound infection. This infection most likely involves deep tissues until proven otherwise. Oral or IV antibiotics, in the absence of debridement, are not sufficient. Removal of the hardware would lead to rapid progression of the scoliosis in a spine that has been surgically destabilized by removal of the facet joints. The appropriate treatment is debridement with wound culture, IV antibiotics, and retention of hardware. The wound should be closed over drains.
REFERENCES: Theiss SM, Lonstein JE, Winter RB: Wound infections in reconstructive spine surgery. Orthop Clin North Am 1996;27:105-110.
Richards BS: Delayed infections following posterior spinal instrumentation for the treatment of idiopathic scoliosis. J Bone Joint Surg Am 1995;77:524-529.

Question 35

An otherwise healthy 26-year-old woman is involved in a high speed motor vehicle accident and sustains the injury shown in Figure 54 to her dominant right arm. Appropriate treatment of this injury complex includes

Explanation

DISCUSSION: This Galeazzi fracture is an injury that requires surgical treatment in an adult. The algorithm includes anatomic reduction of the radial shaft and closed reduction of the DRUJ with assessment of stability. If the DRUJ remains unstable, supination of the wrist may reduce the DRUJ. If not, either open or closed reduction with pinning is undertaken. The closer the radius fracture is to the DRUJ, the more likely it is to be unstable.
REFERENCE: Rettig ME, Raskin KB: Galeazzi fracture-dislocation: A new treatment-oriented classification. J Hand Surg Am 2001;26:228-235.

Question 36

A 47-year-old, healthy, active patient presents with a sub-acute, full-thickness supraspinatus tear. His physical examination reveals significant weakness and pain with abduction. There was no glenohumeral instability. Radiographs demonstrate a type 1 acromion. An MRI scan shows a crescent shaped tear with 2-cm of tendinous retraction and no tendinous fatty changes. A subacromial corticosteroid injection 6 weeks ago provided him with 24 hours of pain relief but no improvement in strength. What would be the most appropriate treatment option? Review Topic QID:4501

Explanation

This patient has an isolated supraspinatus rotator cuff tear with symptomatic weakness. The most appropriate treatment would be isolated rotator cuff repair.
The primary purpose of rotator cuff repair is to restore muscle function. Secondary outcomes include reduction of pain and prevention of irreversible cuff changes, specifically muscular atrophy. Non-operative treatment (exercise, therapy and pain medications) are recommended for partial thickness tears. The indication of surgical repair includes, isolated supraspinatus weakness +/- pain that correlates with MRI imaging of a respective full thickness tear. Routine acrominoplasty is not recommended in conjunction with rotator cuff repair, especially with no previous symptoms of impingement.
Pedowitz et al. developed clinical practice guidelines for the treatment of rotator cuff pathology. The strongest supporting evidence in current literature was given a grade of 'moderate' with four treatment recommendations. These were,
Exercise and non-steroidal anti-inflammatory drugs can be used to manage partial thickness tears,
Routine acromioplasty is not required the time of cuff repair,
Non-cross-linked, porcine small intestine submucosal xenograft patches should not be used to manage cuff tears, and
Surgeons can advise patients that workers' compensation status correlates with a less favorable outcome after rotator cuff surgery.
Illustration A shows the different shapes of rotator cuff tears. Incorrect Answers:

Question 37

A 12-year-old girl who is Risser stage 3 has had intermittent mild midback pain for the past 4 weeks. The pain is worse after prolonged sitting and after carrying a heavy backpack at school. She occasionally takes acetaminophen, but the pain does not limit sport activities. Examination reveals a mild right rib prominence during forward bending. Neurologic examination is normal. Radiographs show a 20-degree right thoracic scoliosis with no congenital anomalies or lytic lesions. Management should consist of Review Topic

Explanation

Mild scoliosis is not a painful condition, but it usually presents during adolescence. Intermittent back pain is reported by 25% to 30% of adolescents whether or not scoliosis is present. Such pain is often attributed to muscle strain from tight muscles, poor posture, or heavy school backpacks. The clinician must distinguish typical pain (mild, intermittent, nonlimiting) from atypical pain. The latter requires more careful examination and imaging studies (bone scan or MRI) to determine the source of pain. The patient’s age and right thoracic curve pattern are typical for idiopathic scoliosis; therefore, imaging of the neuroaxis is not necessary to look for cord syrinx, tethering,
or tumor. Brace treatment is not required for this small curve unless future progression is demonstrated.

Question 38

An otherwise healthy 25-year-old man sustained a wound with a 1-cm by 1.5-cm soft-tissue loss over the volar aspect of the middle phalanx of his middle finger. After appropriate debridement and irrigation, the flexor digitorum profundus tendon and neurovascular bundles are visible. The wound should be treated with a

Explanation

DISCUSSION: The wound described indicates loss of soft tissue directly to the level of the tendon, precluding use of skin grafts if excursion of the tendon is desired. A cross-finger

flap is ideal for small wounds on the volar aspect of digits. A thenar flap is suitable for tip injuries. A lateral arm flap will not reach the fingers. A Moberg flap is limited to distal injuries of the thumb.
REFERENCES: Kappel DA, Burech JG: The cross-finger flap: An established reconstructive procedure. Hand Clin 1985;1:677-683.
Lister GD: Skin flaps, in Green DP, Hotchkiss RN (eds): Operative Hand Surgery, ed 3. New York, NY, Churchill Livingstone, 1993, p 1741.

Question 39

Figure 46 shows the MRI scan of a patient who has a mass in the calf that has been fluctuating in size. Radiographs are negative. Which of the following procedures will most quickly aid in confirming the diagnosis?

Explanation

DISCUSSION: The bright signal on the T2-weighted MRI scan suggests fluid. The multiloculated appearance in proximity to the proximal tibiofibular joint suggests that the most likely diagnosis is a ganglion. They typically increase and decrease in size and can be diagnosed by the classic gelatinous fluid obtained through needle aspiration.
REFERENCES: Bianchi S, Abdelwahab IF, Kenan S, Zwass A, Ricci G, Palomba G: Intramuscular ganglia arising from the superior tibiofibular joint: CT and MR evaluation. Skeletal Radiol 1995;24:253-256.
Feldman F, Singson RD, Staron RB: Magnetic resonance imaging of para-articular and ectopic ganglia. Skeletal Radiol 1989;18:353-358.

Question 40

A 22-year-old man sustained a stable pelvic fracture, bilateral femur fractures, and a left closed humeral shaft fracture in a motor vehicle accident. Examination 24 hours after injury reveals that the patient is confused and has shortness of breath. A clinical photograph of his conjunctiva is shown in Figure 44. He has a temperature of 101 degrees F (38.3 degrees C) and a pulse rate of 120/min. Laboratory studies show a hemoglobin level of 8 g/dL, a platelet count of 50,000/mm3, and a PaO2 of 57 mm Hg on 2L of oxygen. What is the most likely diagnosis?

Explanation

DISCUSSION: The major criteria for the diagnosis of fat embolism syndrome include hypoxemia (PaO2 of less than 60 mm Hg), central nervous system depression, and a petechial rash that is most often located in the axillae, conjunctivae, and palate. The rash is often transient. Tachycardia, pyrexia, anemia, thrombocytopenia, and the presence of fat in the urine are all considered minor criteria. To establish the diagnosis of fat embolism syndrome, one major and four minor signs should be present. Pulmonary embolism, which is the major differential diagnosis, usually is not associated with conjunctival petechia or thrombocytopenia.
REFERENCE: 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 308-316.

Question 41

A 2-week-old infant has had diminished movement of the right upper extremity since birth. Examination reveals weakness of shoulder abduction and external rotation, elbow flexion, and forearm supination. Both pupils are equally round and responsive to light. The remainder of the examination is normal. Radiographs of the upper limb show a healing middle-third clavicle fracture. Management should consist of

Explanation

DISCUSSION: The patient has a classic Erb’s palsy with weakness of the muscles innervated by the fifth and sixth cervical roots. Horner syndrome, a poor prognostic indicator for recovery, is absent in this infant. All infants with brachial plexus birth palsies initially should be monitored for spontaneous recovery during the first 3 to 6 months of life. During this period of observation, glenohumeral motion, especially external rotation, should be maintained. Many infants will begin to show recovery within the first 6 to 8 weeks after birth and continue on to normal function. The timing of microsurgery is controversial. A recent study found that the outcome of microsurgical repair in patients who had no recovery of biceps function within 3 months after birth was similar compared to those who had recovery of biceps function between 3 and 6 months and no microsurgical repair. The author concluded that microsurgical repair was effective in improving function in those infants who had no evidence of recovery of biceps function within the first 6 months of life.
REFERENCES: Waters PM: Comparison of the natural history, the outcome of microsurgical repair, and the outcome of operative reconstruction in brachial plexus birth palsy. J Bone Joint Surg Am 1999;81:649-659.
Greenwald AG, Schute PC, Shiveley JL: Brachial plexus birth palsy: A 10-year report on the incidence and prognosis. J Pediatr Orthop 1984;4:689-692.

Question 42

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.
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Question 43

Which of the following parameters is considered most important when assessing an acetabular fracture for surgical indications?

Explanation

DISCUSSION: The most important aspect in the decision for surgery in an acetabular fracture is the ability of the femoral head to remain concentrically reduced under the dome in AP and Judet oblique views of the pelvis. If this parameter is present, then the need for surgery is determined by other aspects such as fragmentation, age, incongruity, and displacement. If the head remains stable under the dome without traction, there is sufficient acetabular dome to provide stability, and nonsurgical treatment may be appropriate.
REFERENCES: Tile M: Assessment and management of acetabular fractures, in Tile M (ed): Pelvic and Acetabular Fractures, ed 2. Baltimore, MD, Williams and Wilkins, 1995, pp 305-354.
Letournel E: Acetabular fractures: Classification and management. Clin Orthop 1980;151:81-106.
Letournel E, Judet R: Fractures of the Acetabular, ed 2. Berlin, Springer-Verlag, 1993, pp 29-49.

Question 44

During a posterior cruciate ligament-sacrificing total knee arthroplasty with anterior referencing, 8 mm of distal femur is resected. It is noted that the flexion gap is tight and the extension gap appears stable. What is the next most appropriate step in management?

Explanation

DISCUSSION: If the flexion gap is tight and the extension gap is correct, it is preferable to change only the flexion gap and leave the extension gap unchanged; therefore, the treatment of choice is to decrease the size of the femoral component. The smaller component will be smaller in both medial-lateral as well as anterior-posterior dimensions. A smaller anterior-posterior size will allow more space for the flexion gap without significantly affecting the extension gap. Decreasing the size of the tibial polyethylene insert thickness or cutting more proximal tibia will affect both the flexion and extension gaps. Cutting more distal femur will increase the extension gap and not change the flexion gap, making the described situation worse. Cutting both the proximal tibia and distal femur will increase both the flexion and extension gaps.
REFERENCE: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 281-286, 339-365.

Question 45

Biomechanical in vitro studies of double-row anchor fixation of rotator cuff tears show what initial advantage over single-row anchor fixation? Review Topic

Explanation

Biomechanical in vitro studies of double-row fixation of rotator cuff tears during cyclic loading and tensile loading to failure have demonstrated that double-row fixation results in a higher ultimate tensile load when compared to single-row fixation. Peak-to-peak elongation, stiffness, and conditioning elongation for double-row fixation were all similar to single-row fixation. These initial findings, however, may or may not lead to improved clinical outcomes.

Question 46

A 63-year-old woman reports giving way of the knee and pain after undergoing primary total knee arthroplasty (TKA) 1 year ago. Examination reveals that the knee is stable in full extension but has gross anteroposterior instability at 90 degrees of flexion. The patient can fully extend her knee with normal quadriceps strength. Studies for infection are negative. AP and lateral radiographs are shown in Figures 12a and 12b, respectively. What is the appropriate management?

Explanation

DISCUSSION: The radiographs show posterior flexion instability that is the result of a

flexion-extension gap imbalance and posterior cruciate ligament incompetence after a posterior cruciate ligament-retaining TKA. The femur is anteriorly displaced on the tibia, with lift-off of the femoral component from the tibial polyethylene. Revision to a larger femoral component will address the larger flexion gap relative to the extension gap, and a posterior stabilized implant will address the posterior cruciate ligament insufficiency. Pagnano and associates, reporting on a series of painful TKAs previously diagnosed as pain of unknown etiology, showed that the pain was secondary to flexion instability. Pain relief was achieved by revision to a posterior stabilized implant.
REFERENCES: Pagnano MW, Hanssen AD, Lewallen DG, et al: Flexion instability after primary posterior cruciate retaining total knee arthroplasty. Clin Orthop 1998;356:39-46.
Fehring TK, Valadie AL: Knee instability after total knee arthroplasty. Clin Orthop 1994;299:157-162.
Fehring TK, Odum S, Griffin WL, et al: Early failures in total knee arthroplasty. Clin Orthop 2001;392:315-318.

Question 47

Figures 4a through 4c show the radiographs of a 43-year-old woman who sustained a twisting injury to her right ankle. She has ankle pain and tenderness medially and laterally. To help determine the optimal treatment, an external rotation stress radiograph of the ankle is obtained. This test is designed to evaluate the integrity of what structure?

Explanation

DISCUSSION: In the presence of a supination external rotation-type fracture of the distal fibula (Weber type B), stability of the ankle is best assessed by performing an external rotation stress AP view of the ankle. This test is used to assess the integrity of the deltoid ligament. The presence of a deltoid ligament rupture results in instability and generally is best managed surgically. The gravity stress test can also be used.
REFERENCES: Egol KA, Amirtharajah M, Tejwani NC, et al: Ankle stress test for predicting the need for surgical fixation of isolated fibular fractures. J Bone Joint Surg Am 2004;86:2393-2398.
McConnell T, Creevy W, Tornetta P III: Stress examination of supination external rotation-type fibular fractures. J Bone Joint Surg Am 2004;86:2171-2178.
Schock HJ, Pinzur M, Manion L, et al: The use of the gravity or manual-stress radiographs in the assessment of supination-external rotation fractures of the ankle. J Bone Joint Surg Br 2007;89:1055-1059.

Question 48

The nerve to the abductor digiti quinti, implicated in some patients who have chronic heel pain, is most commonly a branch of what larger nerve?

Explanation

DISCUSSION: The nerve to the abductor digiti quinti is the first branch of the lateral plantar nerve. It branches off while the nerve is still on the medial side of the foot and also innervates a portion of the plantar fascia. It can become entrapped beneath the deep fascia of the abductor hallucis muscle and has been associated with some forms of chronic heel pain.
REFERENCES: Baxter DE, Pfeffer GB: Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve. Clin Orthop 1992;279:229-236.
Schon LC, Glennon TP, Baxter DE: Heel pain syndrome: Electrodiagnostic support for nerve entrapment. Foot Ankle 1993;14:129-135.

Question 49

A B Figures 82a and 82b are the clinical photograph and radiograph of a 60-year-old man with a 30-year history of diabetes complicated by borderline chronic renal failure, heart failure controlled by medication, and bilateral lower extremity neuropathy. He is currently wheelchair bound because of his cardiopulmonary limitations, but uses his legs for transfers. He has had a progressive left ankle deformity that has progressed to the point at which he cannot use his leg for pivot transfers. He is adamant that something should be done to improve his living situation. Which surgical option can best achieve his goal of using the leg for transfers?

Explanation

DISCUSSION
The indications for surgery in a Charcot joint are an unbraceable deformity or recurrent ulceration despite use of adequate bracing. Any significant varus/valgus deformity of the ankle or hindfoot (as in this patient) is unbraceable, whereas midfoot Charcot deformities usually can be treated nonsurgically. The goal of surgery is to provide a stable aligned foot and ankle to permit activities and reduce risk for recurrent ulceration. This does not mean that there has to be a radiographic fusion because many patients with diabetes achieve a stable nonunion without pain. The only surgical construct that will provide long-term inherent stability and alignment in this situation is use of a hindfoot fusion rod. It provides better stability and purchase than screw fixation and can be left in indefinitely (unlike an external fixator).
RECOMMENDED READINGS
Dalla Paola L, Volpe A, Varotto D, Postorino A, Brocco E, Senesi A, Merico M, De Vido D, Da Ros R, Assaloni R. Use of a retrograde nail for ankle arthrodesis in Charcot neuroarthropathy: a limb salvage procedure. Foot Ankle Int. 2007 Sep;28(9):967-70. PubMed PMID: 17880869. View Abstract at PubMed
Pinzur MS. Benchmark analysis of diabetic patients with neuropathic (Charcot) foot deformity. Foot Ankle Int. 1999 Sep;20(9):564-7. PubMed PMID: 10509683. View Abstract at PubMed Pinzur M. Surgical versus accommodative treatment for Charcot arthropathy of the midfoot. Foot Ankle Int. 2004 Aug;25(8):545-9. PubMed PMID: 15363375. View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 83 THROUGH 87

Figures 83a and 83b are the clinical photographs of a 42-year-old woman with a BMI of 31 who has had a 1-year history of right heel pain.
A

Question 50

A 38-year-old man sustains a terrible triad injury consisting of an elbow dislocation, comminuted and displaced radial head fracture, and a type I coronoid fracture. Intraoperative findings after radial head replacement and lateral collateral ligament complex repair reveal persistent instability consisting of medial opening on valgus stress and posteromedial subluxation of the ulnohumeral and radiocapitellar joints. What is the best next step?

Explanation

Terrible triad injuries of the elbow are common, and the management of type I coronoid tip fractures remains controversial. Type I coronoid fractures result in only small changes in elbow kinematics that have been shown to be uncorrected with suture repair. A type I coronoid tip fracture is not amenable to buttress plate fixation. The radial collateral ligament is a component of the lateral collateral ligament complex and has already been repaired. The persistent medial laxity and posteromedial joint subluxation noted is indicative of ongoing instability. The next step would be repair or reconstruction of the medial collateral ligament, which will
normally correct the medial instability. Articulated versus static external fixation can be considered if
restoration of the ligamentous constraint of the medial side of the elbow cannot be accomplished surgically.

Question 51

A 27-year-old man has recurrent right shoulder instability. He first dislocated his shoulder in college while playing rugby and was treated nonsurgically. Since then, he has sustained nearly 1 dozen dislocations and says that his shoulder always feels “loose.” The shoulder recently dislocated in his sleep and while he was putting on clothes. Which factor is a contraindication to an arthroscopic soft-tissue repair?

Explanation

CLINICAL SITUATION FOR QUESTIONS 90 THROUGH 92
Figure 90 is the radiograph of a 14-year-old pitcher who plays in a year-round baseball program and has vague pain in his dominant shoulder. The pain occurs with throwing, and it has been worsening for 2 months. Pain typically occurs during the late cocking phase of throwing. He has no tenderness of the rotator cuff and 5/5 rotator cuff strength. His arc of motion is symmetric between his dominant and nondominant arms. The sulcus sign is negative.

Question 52

Figure 45 shows the current radiograph of an 11-year-old girl who sustained a simple nondisplaced fracture of the distal radius 4 weeks ago. Management at the time of injury consisted of application of a short arm cast but no manipulation. What is the major concern at this time?

Explanation

DISCUSSION: The fracture pattern represents a Peterson type I physeal injury, which is a comminuted metaphyseal fracture in which the fracture lines extend up to the physis. Because there is no displacement of the physis and the fracture lines do not cross the physis, there may be a tendency to dismiss this injury as a simple metaphyseal fracture with no significant sequelae. A small percentage of patients (3% in Peterson’s series) experience growth arrest. In this patient, a disabling ulnar plus deformity, defined as increased ulnar length in relationship to the distal radius, developed.
REFERENCES: Peterson HA: Physeal fractures: Part 2. Two previously unclassified types. J Pediatr Orthop 1994;14:431-438.
Peterson HA: Physeal and apophyseal injuries, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 108-109.

Question 53

A patient who underwent intramedullary nailing of a femoral shaft fracture 2 weeks ago now reports groin pain. What is the next most appropriate step in management?

Explanation

Whereas ipsilateral fractures of the femoral neck and shaft are uncommon, it is critical to recognize a femoral neck fracture that may occur in conjunction with a femoral shaft fracture. The combined injury is seen in 2% to 9% of femoral shaft fractures and may initially be missed in as many as one third of the cases. Preoperative examination of a thin cut CT scan and dedicated AP internal rotation views of the femoral neck can help identify this injury. In addition, the intraoperative AP and lateral hip fluoroscopic view should be examined, and a dedicated radiograph of the hip obtained at the conclusion of the surgery. At follow-up, Tornetta and associates has recommended
obtaining a dedicated AP radiograph of the hip with the leg internally rotated 15 to 20 degrees. Because the femoral neck is anteverted, 15 to 20 degrees of internal rotation of the hip offers the best view of the femoral neck. Whereas associated lumbar spine pathology may cause groin pain, the presence of a missed femoral neck fracture must first be ruled out prior to investigating other sources of pain.

Question 54

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

Explanation

Proper soft-tissue tension is critical to prevent instability of a reverse total shoulder implanted with the deltopectoral approach; dislocation of the prosthesis is exceedingly rare if the superior approach is employed. The arm position implicated in reverse total shoulder instability is extension, adduction, and internal rotation,
such as pushing out of a chair. The other positions described do not involve extension of the shoulder.

Question 55

Compared to postoperative radiation therapy, preoperative radiation therapy has a higher rate of what complication?

Explanation

DISCUSSION: Radiation therapy is commonly used as an adjuvant in the treatment of soft-tissue sarcomas, but a controversy exists whether it should be preoperative or postoperative. Radiation therapy can be given prior to or following resection of the tumor. Postoperative radiation is usually given in a higher dose to a larger treatment field. This commonly results in a higher incidence of fibrosis and lymphedema. There is no statistical difference in local recurrence rate between the two radiation treatment plans. Neuropathy is more commonly a complication of chemotherapy. Preoperative radiation therapy has been shown to have a higher wound complication rate than postoperative radiation.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 197-215.
Davis AM, O’Sullivan B, Turcotte R, et al: Late radiation morbidity following randomization to preoperative versus postoperative radiotherapy in extremity soft tissue sarcoma. Radiother Oncol 2005;75:48-53.

Question 56

5 degrees medial and 10 degrees cephalad

Explanation

The C1 lateral mass can safely accommodate screw fixation. Trajectory of 10 degrees medial and 22 degrees cephalad was safely applied in a series of 50 patients. Postoperative CT scans confirmed the safe trajectory. The benefit of lateral mass screws is that they can be safely placed despite the existence of an anomalous vertebral artery that could preclude the safe placement of transarticular screws.

Question 57

Figures 1 through 4 are the radiographs and MR images of a healthy 21-year-old woman who has had persistent dorsal wrist pain despite immobilization and no history of trauma. The surgical procedure associated with the best prognosis in this scenario is

Explanation

EXPLANATION:
This patient has osteonecrosis of the capitate. The MR images show evidence of osteonecrosis with decreased signal on the T1-weighted image. The radiographs are unremarkable, with the exception of lunotriquetral coalition, which does not necessitate treatment. The etiology of osteonecrosis of the capitate may be related to trauma, abnormal Interosseous vascular supply, and hypermobility. Surgery is an option for patients with persistent symptoms despite immobilization. Vascularized bone graft should be considered in this scenario because there is no evidence of capitate collapse or arthritic change about the wrist. Free and local vascularized bone grafts have produced satisfactory results. Capitate excision with interposition arthroplasty is indicated for patients with proximal pole capitate collapse. Total wrist fusion is a salvage procedure and would be considered if there were evidence of collapse and arthritic change. PRC would leave the capitate articulating with the radius and is not indicated.

Question 58

A 32-year-old woman with systemic lupus erythematosus treated with methotrexate and oral corticosteroids reports right groin pain with ambulation and night pain. Examination reveals pain with internal and external rotation and flexion that is limited to 105 degrees because of discomfort. Laboratory studies show a serum WBC of 9.0/mm 3 and an erythrocyte sedimentation rate of 35 mm/h. Figures 5a and 5b show AP and lateral radiographs of the right hip. Further evaluation should include

Explanation

DISCUSSION: The radiographs show Ficat and Arlet stage 2 osteonecrosis. The femoral head remains round, and there are sclerotic changes in the superolateral quadrant. Patients with systemic lupus erythematosus are at risk for osteonecrosis because of prednisone use and the underlying metabolic changes associated with the condition (hypofibrinolysis and thrombophilia). MRI is the best diagnostic method for detecting osteonecrosis, with a greater than 98% sensitivity and specificity. For this patient, an MRI can assess the contralateral hip for any involvement and can quantify the extent of the lesion.
REFERENCES: Mont MA, Jones LC, Sotereanos DG, Amstutz HC, Hungerford DS: Understanding and treating osteonecrosis of the femoral head. Instr Course Lect
2000;49:169-185.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont , IL, American Academy of Orthopaedic Surgeons, 2002, pp 417-451.

Question 59

What anatomic site is considered at highest risk for pathologic fracture?

Explanation

DISCUSSION: The subtrochanteric femur has been identified as an anatomic site that is particularly prone to pathologic fracture. An avulsion fracture of the lesser trochanter is a sign of impending femoral fracture. While the other anatomic locations are also frequently involved in metastatic bone disease, pathologic fractures occur less commonly.
REFERENCES: Simon MA, Springfield DS, et al: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 683.
Harrington KD, Sim FH, Enis JE, Johnston JO, Diok HM, Gristina AG: Methylmethacrylate as an adjunct in internal fixation of pathological fractures: Experience with three hundred and seventy-five cases. J Bone Joint Surg Am 1976;58:1047-1055.

Question 60

A 46-year-old male construction worker has right hip pain that has failed to respond to nonsurgical management. His body mass index (BMI) is 32, he is 6’2” tall, and he has no other medical comorbidities. AP and lateral radiographs of the right hip are shown in Figures 23a and 23b. The patient inquires about his suitability for metal-on-metal hip resurfacing. The patient should be educated that he is at higher risk for failure secondary to which of the following?

Explanation

DISCUSSION: This young patient has osteonecrosis of the femoral head with a large area of collapse.
The results of hip resurfacing arthroplasty have been reported to be best in young, male patients who are younger than 55 years of age with a diagnosis of osteoarthritis. Although some authors advocate metal- on-metal hip resurfacing as an option for patients with osteonecrosis of the femoral head, in this particular patient, given the size of the necrotic segment, he would be at higher risk for failure and a conventional total hip arthroplasty would be a more conservative option. As the acetabulum is resurfaced in metal- on-metal hip resurfacing, the secondary changes of the acetabulum are not an issue and his BMI is in an acceptable range for the procedure.
REFERENCES: Mont MA, Ragland PS, Etienne G, et al: Hip resurfacing arthroplasty. J Am Acad Orthop Surg 2006;14:454-463.
Revell MP, McBryde CW, Bhatnagar S, et al: Metal-on-metal hip resurfacing in osteonecrosis of the femoral head. J Bone Joint Surg Am 2006;88:98-103.
Buergi ML, Walter WL: Hip resurfacing arthroplasty: The Australian experience. J Arthroplasty 2007;22:61-65. Question 24
A 31-year-old woman had disabling right knee pain. An arthroscopic assessment reveals chondromalacia of both the lateral femoral condyle and tibial plateau. The standing femorotibial axis measures 10 degrees of valgus. The
optimum treatment of this condition should include
distal femoral varus osteotomy.
osteoarticular transplant to the lateral femoral condyle.
unicondylar arthroplasty.
high tibial osteotomy.
Fulkerson tibial tubercle transfer. PREFERRED RESPONSE: 1
DISCUSSION: The long-term outcome of a distal femoral varus osteotomy has been quite favorable and should remain the primary choice for this young active woman. Sharma and associates have shown that a 5-degree valgus malalignment has a five-fold chance of progressing at least one grade within 18 months, making a corrective osteotomy the most important surgical maneuver.
REFERENCES: Sharma L, Song J, Felson DT, et al: The role of knee alignment in disease progression and function decline in knee osteoarthritis. JAMA 2001 ;286:188-195.
Murray PB, Rand JA: Symptomatic valgus knee: The surgical options. J Am Acad Orthop Surg 1993; 1:19.

Figure 25a Figure 25b Figure 25c

Question 61

A 58-year-old woman with rheumatoid arthritis and a severe hindfoot valgus deformity now reports recurrent lateral ankle pain. Examination reveals pain over the fibula and sinus tarsi, with a valgus hindfoot that is passively correctable. Despite the use of an ankle-foot orthosis, this is the second time this problem has occurred. Radiographs and a clinical photograph are shown in Figures 28a through 28c. What is the next most appropriate step in treatment?

Explanation

DISCUSSION: Excessive hindfoot valgus can lead to abutment between the calcaneus and fibula. This valgus force can lead to a stress fracture of the distal fibula. Surgery may be required if an insufficiency fracture recurs despite orthotic management. Of the choices listed, a subtalar arthrodesis is most likely to achieve rebalancing of the foot at the level of the deformity.
REFERENCES: Stephens HM, Walling AK, Solmen JD, Tankson CJ: Subtalar repositional arthrodesis for adult acquired flatfoot. Clin Orthop 1999;365:69-73
Easley ME, Trnka HJ, Schon LC, Myerson MS: Isolated subtalar arthrodesis. J Bone Joint Surg Am 2000;82:613-624.

Question 62

During the application of halo skeletal fixation, the most appropriate position for the placement of the anterior halo pins is approximately 1 cm above the superior orbital rim and

Explanation

DISCUSSION: Halo fixation is the most rigid form of cervical orthosis, but complications can arise from improper placement of the initial halo ring. A relatively safe zone for anterior pin placement is located 1 cm above the orbital rim and superior to the lateral two thirds of the orbit. This position avoids the supraorbital and supratrochlear nerves and arteries over the medial one third of the orbit. The more lateral positions in the temporal fossa have very thin bone and can interfere with the muscles of mastication. Posterior pin site locations are less critical; positioning on the posterolateral aspect of the skull, diagonal to the contralateral anterior pins, is generally desirable.
REFERENCES: Botte MJ, Byrne TP, Abrams RA, et al: Halo skeletal fixation: Techniques of application and prevention of complications. J Am Acad Orthop Surg 1996;4:44-53.
Garfin SR, Botte MJ, Nickel VL: Complications in the use of the halo fixation device. J Bone Joint Surg Am 1987;69:954.

Question 63

A 35-year-old man who is an avid weight lifter competing in local tournaments reports new onset pain and loss of motion in his dominant right shoulder. Examination reveals joint line tenderness, active elevation to 100 degrees, and external rotation to 10 degrees. His contralateral shoulder reveals 170 degrees forward elevation and 50 degrees external rotation. Radiographs are shown in Figures 46a and 46b. What is the next most appropriate step in management?

Explanation

DISCUSSION: New onset pain and stiffness in the young arthritic shoulder is a difficult problem to treat. Initial management should be aimed at reducing pain and improving motion in all planes. This patient’s activities and age preclude a shoulder arthroplasty at this time. If nonsurgical management fails to provide relief, then arthroscopic debridement and capsular release may be beneficial.
REFERENCES: Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 257-266.
Skedros JG, O’Rourke PJ, Zimmerman JM, et al: Alternatives to replacement arthroplasty for glenohumeral arthritis, in Iannotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 485-499.

Question 64

-The patient requests anatomic double-bundle ACL reconstruction. Compared with transtibial singlebundle ACL reconstruction, anatomic double-bundle ACL reconstruction is more likely to

Explanation

DISCUSSION FOR QUESTIONS 65 THROUGH 67
The radiograph shows a Segond fracture, an avulsion fracture involving the lateral capsular ligament.
This radiographic finding has been associated with ACL rupture in 75% to 100% of cases. Drilling the femoral tunnel through the anteromedial portal allows for independent access to the native femoral attachment. Fiber orientation is more oblique than with a transtibial technique and more closely resembles that of the native ligament. Double-bundle reconstruction attempts to duplicate native ACL anatomy.Biomechanical studies have shown that double-bundle reconstruction more
closely reproduces normal knee kinematics; however, this technique does not offer a clear advantage in terms of clinical outcomes.The iliotibial band inserts onto Gerdy’s tubercle. The popliteus tendon originates from the lateral femoral condyle. The lateral meniscus attaches near the intercondylar eminence at the anterior and posterior meniscal roots. Recent advances in ACL reconstruction focus on restoring the native ACL anatomy.Studies have determined that a knee flexion angle of 110 degrees is optimal to avoid blowout of the back wall and injury to the lateral structures while drilling.
Femoral tunnel length is typically shorter than with a transtibial approach and decreases with higher-flexion angles. Double-bundle reconstruction is associated with higher surgical costs because of the need for additional fixation and, in the case of allograft reconstruction, a second graft.

Question 65

A 35-year-old man reports a 2-year history of right groin pain. The pain is made worse with hip flexion, prolonged sitting, and cycling. A radiograph and MRI scan are shown in Figures 16a and 16b. Nonsurgical management has failed to provide relief. What is the best surgical option?

Explanation

DISCUSSION: The patient has cam-type femoral acetabular impingement. He still has a well-maintained joint space without significant degenerative changes, and given his age a joint preserving procedure would be the procedure of choice. A reverse periacetabular osteotomy may be considered in a retroverted acetabulum; however, that is not the case here. A femoral neck osteochondroplasty is required to remove the cam of bone and reshape the femoral head- neck junction to improve the femoral head/neck ratio (femoral head offset). Typically, in isolated cam impingement, cartilage damage in the anterior-superior acetabulum precedes labral damage. Labral debridement alone does not address the pathology of impingement. In cases where labral detachment is present, reattachment has been shown to be superior to labral resection.
REFERENCES: Espinosa N, Rothenfluh DA, Beck M, et al: Treatment of femoro-acetabular impingement: Preliminary results of labral refixation. J Bone Joint Surg Am 2006;88:925-935.
Parvizi J, Leunig M, Ganz R: Femoroacetabular impingement. J Am Acad Orthop Surg 2007;15:561-570. Trousdale RT: Acetabular osteotomy: Indications and results. Clin Orthop Relat Res 2004;429:182-187.

Question 66

Five weeks after the patient completes a 6-week course of antibiotics, his ESR is 24 mm/h and CRP level is 10 mg/L, which is similar to the levels at 6 weeks. What is the most appropriate treatment at this time?

Explanation

DISCUSSION
This patient has both serologic and synovial fluid findings that are concerning for indolent infection. He was taking antibiotics at the time of aspiration. The AAOS clinical practice guideline, The Diagnosis of Periprosthetic Joint Infections of the Hip and Knee, suggests that patients discontinue antibiotics for a minimum of 2 weeks and that a repeat aspiration should be performed in cases of contradictory findings. In this situation, the cell count is elevated
along with an elevated ESR and CRP level. As a result, the appropriate treatment at this time is to reaspirate his hip.
This patient has a periprosthetic joint infection with a draining sinus tract. He has had symptoms for several months and, as a result, irrigation and debridement are not indicated. A single-stage surgery may be performed in some centers for healthy patients with susceptible organisms. However, single-stage reconstructions are generally performed with cemented implants in patients without a draining sinus tract. A 2-stage procedure with an antibiotic spacer is the surgical treatment modality most likely to eradicate this infection.
Serologic findings have significantly improved since the time of the prior surgical procedure. Surgical intervention does not need to be delayed until these values have completely normalized.

Question 67

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

Explanation

The clinical picture is one of infection and deep venous thrombosis. The MRI scan is consistent with osteomyelitis. Deep venous thrombosis in association with musculoskeletal infection is more common in osteomyelitis caused by methicillin-resistant Staphylococcus aureus. Presenting C-reactive protein levels generally are higher than 6 mg/L and are higher than with other causative organisms. The presence of the Panton-Valentine leukocidin gene encoded in strains of bacteria may explain the deep venous thrombosis.

Question 68

A 67-year-old woman has a painful, arthritic proximal interphalangeal (PIP) joint, and nonsurgical measures have failed to improve the pain. What implant and joint replacement approach combination has been demonstrated to have the lowest rate of revision surgery?

Explanation

EXPLANATION:
A recent systematic review compared silicone replacement, pyrocarbon replacement, and surface replacement arthroplasty for PIP arthritis. Silicone arthroplasty through a volar approach showed the greatest gains in arc of motion and had the lowest rate of revision surgeries. The rates of revision surgeries from low to high for each type of arthroplasty were 6% for silicone volar, 10% for silicone lateral, 11%
Surface replacement arthroplasty through a volar
for silicone dorsal, 18% for surface replacement dorsal, and 37% for surface replacement volar. Revision surgeries include implant replacement (to silicone or maintaining the surface replacement), arthrodesis, explantation, amputation, and other procedures.
approach showed the highest revision rate, the worst gain in arc of motion, and the greatest extension lag. However, substantial pain relief and higher satisfaction still were reported after surface replacement arthroplasty, regardless of the complications.

Question 69

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

Explanation

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

Question 70

03 5.

Explanation

In long bones, radiographs initially show a radiolucency in the metaphysis that progresses into the diaphysis. The entire progression of the disease takes years.
The radiograph here shows the typical Paget’s lesion in the right iliac wing with mixed lytic and sclerotic areas.

Question 71

A 20-year-old man involved in a motor vehicle accident is brought to the emergency department with a C6-7 unilateral facet dislocation. His neurologic examination reveals a focal left-sided C7 nerve root palsy. He is awake and cooperative with questioning and has no other obvious traumatic injuries. What is the most appropriate treatment at this time?

Explanation

DISCUSSION: In the patient who is neurologically intact or has an incomplete injury from a cervical facet dislocation, a closed reduction with weighted tong traction is appropriate when the patient is awake, alert, and cooperative. Although there is a risk that a cervical facet dislocation could occur with an underlying cervical disk herniation, Vaccaro and associates have shown that closed reduction can be safely carried out in the awake, responsive patient. Closed reduction can be performed in the emergency department with traction with skull tongs or a halo ring. A slow stepwise application of weight is added until a reduction is achieved. Any worsening of the neurologic status of the patient requires immediate termination of the closed reduction and further diagnostic imaging before proceeding with further treatment.
REFERENCES: Vaccaro AR, Falatyn SP, Flanders AE, et al: Magnetic resonance evaluation of the intervertebral disc, spinal ligaments, and spinal cord before and after closed traction reduction of cervical spine dislocations. Spine 1999;24:1210-1217.
Hart RA: Cervical facet dislocation: When is magnetic resonance imaging indicated? Spine 2002;27:116-117.
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.

Question 72

What is the most appropriate surgical treatment for a stage III symptomatic scapholunate advanced collapsed (SLAC) wrist?

Explanation

DISCUSSION: SLAC is the end result of chronic scapholunate instability. The arthritis follows a predictable pattern. Stage I disease involves cartilage loss between the waist of the scaphoid and the radial styloid. In stage II, the arthritis progresses to include the proximal pole of the scaphoid and the scaphoid fossa of the radius. Finally, stage III goes on to include arthritis of the capitolunate joint. The only treatment option that addresses all of the sites of arthritis is the scaphoid excision and four corner fusion.
REFERENCES: Ashmead DT IV, Watson HK, Damon C, et al: Scapholunate advanced collapse wrist salvage. J Hand Surg Am 1994;19:741-750.
Sauerbier M, Trankle M, Linsner G, et al: Midcarpal arthrodesis with complete scaphoid excision and interposition bone graft in the treatment of advanced carpal collapse (SNAC/SLAC wrist): Operative technique and outcome assessment. J Hand Surg Br 2000;25:341-345.

Question 73

..The optimal method to treat a recurrent presentation of pigmented villonodular synovitis (PVNS) with diffuse joint involvement in a 24-year-old woman with pain and symptomatic effusions is

Explanation

Question 74

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

Explanation

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

Question 75

Figures 9a and 9b show the radiographs of a 28-year-old woman who sustained a head injury and a closed injury, without soft-tissue compromise, to her right lower extremity in a motor vehicle accident. Appropriate management of the foot injury should include

Explanation

DISCUSSION: The displaced talar neck fracture should be treated with open reduction and internal fixation using screws. Closed reduction and casting will not maintain position, and percutaneous pinning is not able to maintain reduction to allow union. External fixation and amputation are not necessary for this injury unless there is severe soft-tissue loss.
REFERENCE: Adelaar RS: Fractures of the talus. Instr Course Lect 1990;39:147-156.

Question 76

An MRI arthrogram of the elbow is shown in Figure 6. Based on these findings, what is the most likely diagnosis?

Explanation

DISCUSSION: MRI arthrography is the imaging study of choice for evaluation of medial collateral ligament injuries.
REFERENCES: Carrino JA, Morrison WB, Zou KH, et al: Noncontrast MR imaging and MR arthrography of the ulnar collateral ligament of the elbow: Prospective evaluation of two-dimensional pulse sequences for detection of complete tears. Skeletal Radiol 2001;30:625-632.
Munshi M, Pretterklieber ML, Chung CB, et al: Anterior bundle of ulnar collateral ligament: Evaluation of anatomic relationships by using MR imaging, MR arthrography, and gross anatomic and histologic analysis. Radiology 2004;231:797-803.

Question 77

Figures 5a and 5b show axial and coronal MRI images of the left ankle of a patient with lateral ankle pain. What is the most likely diagnosis?

Explanation

DISCUSSION: The figures show a longitudinal split within the peroneus brevis tendon as it courses posterior to the fibula. The peroneus longus tendon has been driven between the medial and lateral components of the peroneus brevis tendon. Peroneal split syndrome is a cause of lateral ankle pain but may be less asymptomatic in the elderly. It may be associated with tendon subluxation following a tear of the superior peroneal retinaculum.
REFERENCE: Mink JH: Tendons, in Deutsch AL, Mink JH, Kerr R (eds): MRI of the Foot and Ankle. New York, NY, Raven Press, 1992, pp 135-172.

Question 78

In a patient with rheumatoid arthritis of the wrist, which of the following extensor tendons is most at risk of rupture?

Explanation

DISCUSSION: The tendon most prone to rupture in a patient with rheumatoid arthritis of the wrist is the extensor digiti quinti. It can be a silent injury since the extensor digitorum communis can provide extension to the fifth finger. The extensor digiti quinti is at high risk since it is overlying the ulnar head where it is prone to attritional rupture (Vaughan-Jackson syndrome).
REFERENCES: Vaughan-Jackson OJ: Rupture of extensor tendons by attrition at the inferior radioulnar joint: A report of two cases. J Bone Joint Surg Br 1948;30:528-530.
Papp SR, Athwal GS, Pichora DR: The rheumatoid wrist. J Am Acad Orthop Surg

2006;14:65-77.

Question 79

Which of the following is most important to acheive a good outcome following a Syme amputation?

Explanation

DISCUSSION: A Syme amputation is effectively a tibiotalar disarticulation, which provides an end-bearing stump that could potentially allow ambulation without a prosthesis over short distances. It works better for tumor and trauma, but the heel pad must be viable. The two most common problems are 1) skin sloughing from compromised vascular supply and 2) migration of the heel pad due to instability. A hypermobile heel pad can cause difficulty with prosthesis wear and damage to the soft tissues which can eventually lead to failure. Both malleoli are usually removed in the procedure, except in children or during the first stage procedure of a diabetic or infection case. The tibialis anterior is usually tenodesed to the anterior heel pad along with the EDL tendon to avoid posterior migration of the heel pad.

Question 80

Figure 29a shows the clinical photograph of a 26-year-old woman who has had the leg deformity since birth. She reports difficulty with walking and weight bearing and notes increased discomfort and swelling when the leg is dependent. She denies any history of trauma or family history of a similar disorder. Examination reveals a fixed equinovarus deformity of the foot but no evidence of a limb-length discrepancy. No other cutaneous findings or soft-tissue masses are noted. Sagittal and axial T1- and T2-weighted MRI scans are shown in Figures 29b and 29c. What is the most likely diagnosis?

Explanation

DISCUSSION: Because the MRI scans show marked dilation and proliferation of lymphatic channels that completely involve all the leg muscles and the clinical photograph shows the severe swelling associated with this disease, the most likely diagnosis is lymphangiomatosis. Poliomyelitis affects the anterior horn cells and manifests as muscle atrophy. Neurofibromatosis can have a similar clinical appearance but usually is associated with other systemic and cutaneous findings. Congenital band syndrome results in amputated or shortened extremities. Chronic venous stasis disease usually is not associated with joint contractures, and typically it affects older individuals. Surgical excision is the only known treatment; this patient underwent an above-knee amputation.
REFERENCES: Berquist TH (ed): MRI of the Musculoskeletal System, ed 3. Philadelphia, PA, Lippincott Raven, 1997, p 771.
Enzinger FM, Weiss SW: Soft Tissue Tumors, ed 3. St. Louis, MO, Mosby Year Book, 1995, p 688.

Question 81

Surgical treatment of an adult cavovarus foot with fixed forefoot valgus that does not correct on Coleman block testing should consist of Review Topic

Explanation

Cavovarus feet are characterized by plantar flexion of the first metatarsal and hindfoot varus. A rigid cavovarus hindfoot does not correct on Coleman block testing. Correction of these rigid deformities requires either lateral displacement or lateral closing wedge osteotomies of the calcaneus and dorsiflexion osteotomies of the involved metatarsals. Lateral column lengthening procedures are used to correct painful flatfoot deformities.

Question 82

A 32-year-old woman sustained an injury to her left upper extremity in a motor vehicle accident. Examination reveals a 2-cm wound in the mid portion of the dorsal surface of the upper arm and deformities at the elbow and forearm; there are no other injuries. Her vital signs are stable, and she has a base deficit of minus 1 and a lactate level of less than 2. Radiographs are shown in Figures 9a and 9b. In addition to urgent debridement of the humeral shaft fracture, management should include

Explanation

DISCUSSION: With a severe injury to the upper extremity, the best opportunity for achieving a good functional result for a floating elbow is immediate debridement of the open fracture, followed by internal fixation of the fractures. The ability to do this depends on the patient’s physiologic status. In this patient, the procedure is acceptable because she has normal vital signs and no chest or abdominal injuries, and normal physiologic parameters (base excess and lactate) show adequate peripheral perfusion. The surgical approaches will be determined by the associated injury patterns and open wounds. In this patient, the humerus was debrided and stabilized through a posterior approach as was the medial condyle fracture. The ulna was fixed through an extension of the posterior incision and the radius through a separate dorsal approach.
REFERENCES: Solomon HB, Zadnik M, Eglseder WA: A review of outcomes in 18 patients with floating elbow. J Orthop Trauma 2003;17:563-570.
Pape HC, Hildebrand F, Pertschy S, et al: Changes in the management of femoral shaft fractures in polytrauma patients: From early total care to damage control orthopedic surgery. J Trauma 2002;53:452-461.

Question 83

Your 25-year-old patient complains of anterior knee pain after retrograde femoral nailing for a diaphyseal fracture and asks you why you didn’t perform antegrade nailing as he has seen on the internet. You tell him that retrograde nailing is your preferred technique over antergrade nailing for diaphyseal femoral fractures because it has been shown to have?

Explanation

DISCUSSION: Patients with retrograde femoral nails commonly have knee pain, while antegrade nails commonly have hip pain, abductor weakness and heterotopic ossification of the abductors. Ostrum’s randomized prospective study of 100 patients with reamed femoral nails found 22% of antegrade nail patients had proximal hip pain, weak hip abductors or trendelenburg gait. No significant difference was found in set-up time, operative time, knee motion or pain, or infection rates. Ricci performed a retrospective study of 293 fractures and found that the antegrade femoral nail group had more hip pain (10% vs 4%) and the retrograde nail group had more knee pain (36% vs 9%). There was no difference in healing, malunion, non-union or other complications. Tornetta performed a randomized controlled comparison of 69 femur fractures and found more problems of length and rotation using a retrograde nailing. There was no difference in time to union, operating time, blood loss, complications, size of nail or reamer, or transfusion requirements

Question 84

Intradiskal electrothermal therapy (IDET) uses an intradiskal catheter to deliver controlled thermal energy to the inner periphery of the annulus fibrosis of a chronically painful intervertebral disk. Lumbar diskography is used diagnostically to identify the presumed pain generator to be targeted with IDET. Based on the medical literature, what can be said about the current status of IDET?

Explanation

DISCUSSION: Intradiskal electrothermal therapy (IDET) initial clinical results were reported in 2000. The early case series were quite encouraging with reported therapeutic success rates of 60% to 80%. Early enthusiasm was high as IDET provided a nonsurgical treatment option for an otherwise complex and difficult clinical entity, chronic diskogenic low back pain. The actual mechanism of action was not well understood, and while the theoretic explanation made good sense, it did not hold up under laboratory testing. Soon clinical results from the field did not meet the high expectations set by the developers of the technique. Since those early case studies, a few level I evidence studies have been conducted, one by Freeman and associates and one by Pauza and associates. These randomized, placebo-controlled trials demonstrated no significant benefit of IDET over the placebo.
REFERENCES: Freeman BJ, Fraser RD, Cain CM, et al: A randomized, double-blind, controlled trial: Intradiscal electrothermal therapy versus placebo for the treatment of chronic discogenic low back pain. Spine 2005;30:2369-2377.
Pauza KJ, Howell S, Dreyfuss P, et al: A randomized, placebo-controlled trial of intradiscal electrothermal therapy for the treatment of discogenic low back pain. Spine J 2004;4:27-35.
Wetzel FT, McNally TA: Treatment of chronic discogenic low back pain with intradiskal electrothermal therapy. J Am Acad Orthop Surg 2003;11:6-11.

Question 85

Massive cortical structural allografts are commonly used in oncologic and arthroplasty surgery. What percent of cortical structural allografts fracture due to insufficiency?

Explanation

Allograft is available in particulate and structural forms. Particulate allograft has a higher rate of incorporation than structural but adds little structural support. Cortical allograft incorporation occurs slowly and the bulk of the graft fails to remodel and remains devascularized. Stress fractures eventually occur in approximately 25% of structural grafts used in tumor surgery.

Question 86

An awake and alert patient with neck pain arrives at the emergency department after an automobile crash. Upon examination he is weak in the left deltoid and biceps muscles (3/5 strength). CT scans performed 2 hours after admission are shown in Figures 70a and 70b. His weakness deteriorates to 1/5 strength in the upper and lower extremities. What is the most appropriate treatment? A B

Explanation

DISCUSSION
Facet subluxation reduction may be performed in awake patients. Posterior spinal laminectomy and fusion can result in worsening neurologic status and is not recommended in this setting. Generally, corpectomy in the setting of facet subluxation is not recommended because it does not facilitate reduction or fully alleviate spinal cord compression. High-dose steroid use is not supported by current literature.
RECOMMENDED READINGS
Fehlings MG, Perrin RG. The timing of surgical intervention in the treatment of spinal cord injury: a systematic review of recent clinical evidence. Spine (Phila Pa 1976). 2006 May 15;31(11 Suppl):S28-35; discussion S36. Review. PubMed PMID: 16685233. View Abstract at PubMed
Lee AS, MacLean JC, Newton DA. Rapid traction for reduction of cervical spine dislocations. J Bone Joint Surg Br. 1994 May;76(3):352-6. PubMed PMID: 8175833.View Abstract at PubMed

Question 87

A 42-year-old woman who observes traditional Muslim practices is seen in your office accompanied by her physician husband to discuss possible elective bunion correction. In considering the treatment of this patient, what is one of the most important considerations?

Explanation

DISCUSSION: In considering faith-based issues regarding treatment of this patient, the presence of her husband for the office visit would imply an agreement with her decision to have surgery. It also may facilitate her examination. Her role as caregiver, dietary concerns, and cleansing rituals are less important considerations with an outpatient-based procedure. Privacy concerns remain paramount to Muslim women, which include limited exposure during examination, during surgery, and in subsequent follow-up visits.
REFERENCE: Jimenez R, Lewis VO (eds): Culturally Competent Care Guidebook. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007.

Question 88

A 72-year-old woman who fell on her right shoulder while using a treadmill is now unable to elevate her right arm. An MRI scan is shown in Figure 7. What is the most likely diagnosis?

Explanation

DISCUSSION: The MRI scan reveals a large chronic rotator cuff tear with retraction and fatty infiltration atrophy of the supraspinatus and infraspinatus tendons. This tear is responsible for the patient’s severe weakness and inability to elevate the arm.
REFERENCE: Gerber C, Myer DC, Schneeberger AG, et al: Effect of tendon release and delayed repair on the structure of the muscles of the rotator cuff: An experimental study in sheep. J Bone Joint Surg Am 2004;86:1973-1982.

Question 89

This image represents the end stage of an uncompensated rotator cuff tear.

Explanation

DISCUSSION
Axillary lateral and anteroposterior (AP) images of the right shoulder (Figures 59c and 59d) reveal osteoarthrosis of the glenohumeral joint, which typically is not associated with significant rotator cuff pathology. An examination often shows limitations in range of motion, crepitance, and pain with motion. An AP radiographic image of the right shoulder (Figure 59b) reveals proximal humeral migration, which normally correlates with rotator cuff tear size. Tears extending into the infraspinatus tendon are associated with more humeral migration than is seen with isolated supraspinatus tears. Presenting complaints are usually of pain and weakness. Examination findings include subacromial crepitance and weakness during rotator cuff testing. Rarely, this may be associated with pseudoparalysis in large uncompensated rotator cuff tears. The CT image of the right shoulder (Figure 59a) shows superior migration of the humerus with respect to the glenoid surface and end-stage
degenerative changes at the glenohumeral joint. These changes are classified as rotator cuff arthropathy. Pain and weakness are common, as is the presence of pseudoparalysis and limited range of motion.
RECOMMENDED READINGS
Kelly JD Jr, Norris TR. Decision making in glenohumeral arthroplasty. J Arthroplasty. 2003 Jan;18(1):75-82. Review. PubMed PMID: 12555187. View Abstract at PubMed
Keener JD, Wei AS, Kim HM, Steger-May K, Yamaguchi K. Proximal humeral migration in shoulders with symptomatic and asymptomatic rotator cuff tears. J Bone Joint Surg Am. 2009 Jun;91(6):1405-13. doi: 10.2106/JBJS.H.00854. PubMed PMID:

Question 90

A 63-year-old woman who sustained a distal radial fracture 2 months ago now reports that she is unable to achieve active extension of the thumb at the interphalangeal joint. What type of trauma may lead to this clinical finding?

Explanation

DISCUSSION: Nondisplaced distal radial fractures have a higher rate of spontaneous rupture of the extensor pollicis longus tendon. The extensor mechanism is felt to impinge on the tendon following a nondisplaced fracture and causes either a mechanical attrition of the tendon or a local area of ischemia in the tendon.
REFERENCES: Helal B, Chen SC, Iwegbu G: Rupture of the extensor pollicis longus tendon in undisplaced Colles’ type of fracture. Hand 1982;14:41-47.
Hirasawa Y, Katsumi Y, Akiyoshi T, et al: Clinical and microangiographic studies on the rupture of the EPL tendon after distal radial fractures. J Hand Surg Br 1990;15:51-57.

Question 91

A 7-year-old boy sustained a 2-cm laceration to the anterior aspect of his left knee after falling on a rock. Examination reveals that the joint surface is not visible through the wound. Radiographs show no evidence of a foreign body or free air in the joint. Management should consist of

Explanation

DISCUSSION: The possibility of an open joint injury should be considered in any patient who has a small periarticular laceration. Failure to promptly diagnose and treat such injuries may lead to septic arthritis. The diagnosis of an open joint is easily made when there is visible communication of the joint through the traumatic wound, or when intra-articular air is present on a radiograph. In the absence of these findings, the diagnosis of an open joint may be established by the saline load test, in which a volume of saline is injected into the joint under sterile conditions. If fluid extravasates through the traumatic wound, the diagnosis of an open joint is established. Voit and associates used a saline load test in 50 patients with periarticular lacerations suggestive of joint penetration. When they compared the clinical prediction of whether or not the laceration had penetrated the joint and the test results, the authors reported a false-positive clinical result in 39% of patients and a false-negative clinical result in 43%. The authors concluded that the saline load test was valuable in evaluating periarticular lacerations.
REFERENCES: Voit GA, Irvine G, Beals RK: Saline load test for penetration of periarticular lacerations. J Bone Joint Surg Br 1996;78:732-733.
Leffers D: Dislocations and soft tissue injuries of the knee, in Browner BD (ed): Skeletal Trauma, ed 1. Philadelphia, PA, WB Saunders, 1992, pp 1717-1743.

Question 92

Among patients with adolescent idiopathic scoliosis, a thoracolumbosacral orthosis is most effective for which type of curve?

Explanation

DISCUSSION
A thoracolumbosacral orthosis is most effective for bracing of curves when the apex is at T7 or below. Bracing is used for patients who are skeletally immature (Risser stage 0, 1, or 2), and it is recommended that the brace be worn 16 to 23 hours per day and continued until skeletal maturity or until the curve progresses to beyond 45 degrees, at which point bracing is no longer considered effective.
RECOMMENDED READINGS
Luhmann SJ, Skaggs DL: Pediatric spine conditions, in Lieberman JR (ed): AAOS Comprehensive Orthopaedic Review. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2009, pp 245-265.
Shaughnessy WJ. Advances in scoliosis brace treatment for adolescent idiopathic scoliosis. Orthop Clin North Am. 2007 Oct;38(4):469-75, v. Review. PubMed PMID: 17945126. View Abstract at PubMed

Question 93

A B Figures 60a and 60b are the postmyelography CT images of a 62-year-old man who has had low-back and bilateral lower-extremity pain. His pain began approximately 1 year ago and there was no precipitating event. The location of the pain is in the lower lumbar region in the midline and it radiates into the buttocks and thighs bilaterally. The pain is exacerbated by standing and walking and relieved by forward spine flexion. He reports no pain while sitting or lying supine. Upright radiographs demonstrate 4 mm of anterolisthesis of L4 on L5. What is the most appropriate surgical procedure?

Explanation

DISCUSSION
This patient radiographically has L4-5 degenerative stenosis and a low-grade spondylolisthesis. The axial images demonstrate a gap in the facet joint, more on the left than the right, which is highly suggestive of dynamic instability. Thus, this patient would most benefit from a laminectomy and fusion of L4-5. A microdiskectomy would not be helpful as this patient does not have a disk herniation. Patients undergoing posterior decompression alone experience an unacceptably high rate of recurrent stenosis and/or progression of spondylolisthesis. Early studies demonstrated that adding an intertransverse process fusion to posterior decompression significantly improved clinical outcomes. Anterior interbody fusion likely will not decompress the spinal canal sufficiently, though there is some thought that indirect decompression can be effective in some cases.
RECOMMENDED READINGS
Frymoyer JW. Degenerative Spondylolisthesis: Diagnosis and Treatment. J Am Acad Orthop Surg. 1994 Jan;2(1):9-15. PubMed PMID: 10708989. Majid K, Fischgrund JS. Degenerative lumbar spondylolisthesis: trends in management. J Am Acad Orthop Surg. 2008 Apr;16(4):208-15. Review. PubMed PMID: 18390483. View Abstract at PubMed
Carlisle E, Fischgrund JS. Lumbar spinal stenosis and degenerative spondylolisthesis. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006: 299-317.
Puschak TJ, Sasso RC. Spondylolysis-spondylolisthesis. In: Vaccaro AR, ed. Orthopaedic Knowledge Update 8. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2005:553-563.

Question 94

During shoulder motion with the elbow controlled in a brace, electromyographic studies of the supraspinatus show significant activity with all range-of-motion testing. Concurrent electromyographic studies of the long head of the biceps will most likely show

Explanation

DISCUSSION: During electromyographic studies, the long head of the biceps has been shown to have little activity throughout a wide range of shoulder motion as long as the elbow is immobilized. The supraspinatus is active throughout the range of shoulder motion. Rotator cuff tears do not influence biceps activity as long as the elbow is controlled.
REFERENCES: Yamaguchi K, Riew KD, Galutz LM, et al: Biceps activity during shoulder motion: An electromyographic analysis. Clin Orthop 1997;336:122-129.
Levy AS, Kelly BT, Lintner SA, et al: Function of the long head of the biceps at the shoulder: Electromyographic analysis. J Shoulder Elbow Surg 2001;10:250-255.

Question 95

A 17-year-old male lacrosse player sustains an ACL tear. Imaging reveals closed physes and you recommend a transphyseal ACL reconstruction. His mother asks whether a “cadaver tendon” can be used to reconstruct his ACL instead of using his own tendon. What is the most appropriate response regarding the use of allograft compared to autograft for ACL reconstruction in an active adolescent? Review Topic

Explanation

In an active adolescent, anterior cruciate ligament reconstruction (ACLR) with allograft has a significantly higher risk of graft failure and need for revision surgery compared to ACLR with autograft.
The incidence of anterior cruciate ligament (ACL) injuries in adolescent athletes has significantly increased over the recent years, now comprising 24.5% of all ligamentous knee injuries in high school athletes. In skeletally mature adolescents, transphyseal ACLR is often performed, similar to adult patients. Proposed advantages of allograft reconstruction in patients of all ages include lack of donor-site morbidity, absence of size limitation, preservation of knee flexor/extensor mechanism, less risk of postoperative knee stiffness/pain and cosmetic appearance. Benefits of autografts include strong structural and fixation properties as well as optimal biologic incorporation.
Kraeutler et al. performed a meta-analysis comparing bone-patellar tendon-bone (BPTB) autograft to allograft for ACLR. Patients who underwent ACLR with BPTB autograft demonstrated lower rates of graft rupture, lower levels of knee laxity, improved single-legged hop test results and were more satisfied postoperatively compared to ACLR with BPTB allograft. The authors therefore recommended BPTB
autograft
ACLR,
particularly
in
young
active
patients.
Engelman et al. performed a case-control study comparing ACLR in an adolescent cohort using autograft or allograft. Postoperative knee laxity and use of allograft were significantly related to graft failure and need for revision surgery. There was no difference in functional outcome scores, knee range of motion, infection or growth disturbance. There was no difference in graft survival between low-dose (<2 Mrad) gamma-irradiated allografts and nonirradiated allografts.
Pallis et al reported a prospective cohort study of 122 ACLR performed in cadets prior to matriculation at the United States Military Academy (USMA). Cadets who entered the USMA with an allograft ACLR were 7.7 times more likely to experience graft failure compared to BPTB and hamstring (HS) autograft groups. There was no significant difference in failure between the BPTB and HS autograft groups. The authors recommend autograft ACLR for young, active individuals.
Incorrect
Responses:

Question 96

A 60-year-old man is evaluated in the ICU after a rollover motor vehicle accident 3 days ago. He has multiple upper and lower extremity trauma and was found unresponsive at the accident scene. Surgery is planned for the extremity trauma once the patient is medically stable. He remains intubated and the cervical spine is immobilized in a semi-rigid collar. Examination reveals mild erythema in the posterior occipital cervical region. Initial AP and lateral radiographs of the cervical spine have not revealed any obvious fracture. What is the most appropriate treatment option at this time?

Explanation

DISCUSSION: Ackland and associates demonstrated that the failure to achieve early spinal clearance in an unconscious blunt trauma patient predisposed the patient to increased morbidity secondary to the prolonged used of cervical immobilization. They demonstrated that the four significant predictors of collar-related ulcers were ICU admission, mechanical ventilation, the necessity for cervical MRI, and the time to cervical spine clearance and collar removal. The risk of pressure-related ulceration increased by 66% for every 1-day increase in Philadelphia collar time and this highlights the need for definitive C-spine clearance.
REFERENCES: Ackland HM, Cooper DJ, Malham GM, et al: Factors predicting cervical collar-related decubitus ulceration in major trauma patients. Spine 2007;32:423-428.
Hewitt S: Skin necrosis caused by semi-rigid cervical collar in a ventilated patient with multiple injuries. Injury 1994;25:323-324.

Question 97

The mother of a healthy 8-month-old boy reports that her son refuses to use his left arm. Examination reveals that the arm hangs limp at his side in an adducted and internally rotated position, and the affected shoulder subluxates posteriorly. Passive external rotation measures 15 degrees. Management should consist of

Explanation

DISCUSSION: Injury to the upper trunk of the brachial plexus during birth (Erb’s palsy) occurs in approximately 1 in 3,000 births. In a complete lesion, paralysis of the deltoid, supraspinatus, infraspinatus, teres minor, biceps, and brachioradialis results in the findings described above. Spontaneous recovery may occur for up to 2 years. Passive exercises administered daily by the parents are the initial recommended treatment at this age. If significant contracture results in posterior dislocation, surgical correction may be considered.
REFERENCES: Neer CS: Shoulder Reconstruction. Philadelphia, PA, WB Saunders, 1990,

pp 452-454.
Pearl ML: Arthroscopy release of shoulder contracture secondary to birth palsy: An early report on findings and surgical technique. Arthroscopy 2003;19:577-582.
Pearl ML, Edgerton BW, Kon DS, et al: Comparison of arthroscopic findings with MRI and arthrography in children with GH deformity secondary to brachial plexus birth palsy. J Bone Joint Surg Am 2003;85:890-898.

Question 98

The anterior portal of a hip arthroscopy places what structure at greatest risk for injury?

Explanation

DISCUSSION: The average location of the anterior portal is 6.3 cm distal to the anterior superior iliac spine. The lateral femoral cutaneous nerve typically has divided into three or more branches at the level of the anterior portal. The portal usually passes within several millimeters of the most medial branch. Injury to the nerve can lead to meralgia paresthetica. The femoral nerve lies an average minimum distance of 3.2 cm from the anterior portal. The ascending branch of the lateral circumflex artery lies approximately 3.7 cm inferior to the anterior portal. Neither the ascending branch of the medial circumflex artery nor the superior gluteal nerve are

at risk.
REFERENCES: Byrd JWT: Operative Hip Arthroscopy. New York, NY, Thieme Medical Publishers, 1998, pp 83-91.
Arendt EA (ed): Orthopaedic Knowledge Update: Sports Medicine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 281-289.

Question 99

A 78-year-old man is seen in the emergency room 3 hours after a fall from a standing position. The patient sustained a mild scalp laceration and the injury shown in Figure 90. He reports severe neck pain and is unable to move his hands and legs. Examination reveals absent motor function in the wrist flexors, triceps, and fingers. He cannot move his lower extremities during motor testing. The patient has some sensation in the lower extremities. Bulbocavernosus reflex is absent. Based on examination findings and the imaging findings, what is the most definitive treatment option? Review Topic

Explanation

Custom orthosis prescription to initiate bracing
Physical therapy referral and observation
Bending and lumbar oblique radiographs
Total spine CT
Total spine MRI
A left thoracic curve is an abnormal finding and warrants further work-up with a total axis MRI in order to rule out concomitant neurologic abnormalities such as a spinal cord cyst and/or syrinx.
In adolescent idiopathic scoliosis (AIS), the most commonly occurring curve is a right thoracic curve. Left thoracic curves are not as common, and warrants total axis MRI in order to rule out concomitant central axis abnormalities. This is imperative not only during initial work-up, but most importantly for operative planning.
Spiegel et al. performed a a retrospective radiographic review on 41 patients with scoliosis associated with a Chiari I malformation and/or syringomyelia. Approximately 50% of patients had an "atypical" pattern (left thoracic, double thoracic, triple, long right thoracic). The authors recommend that MRI should be considered in these patients.
Gillingham et al. provides a thorough review of early onset scoliosis and notes the relatively high incidence of concurrent central axis abnormalities, even in patients with normal neurologic exams. Rates have been reported upwards of 21.7%, with malformations including Chiari Type 1, dural ectasias, syrinx, and spinal cord cysts.
Figure A exhibits a left thoracic curve. Further imaging in this patient revealed a syrinx which required decompression.
Incorrect answers:
thoracic
curve.

Question 100

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

Explanation

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

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

Full Question & Answer Text (for Search Engines)

Question 1:

The thumb metacarpophalangeal (MCP) joint should be flexed to what degree to properly assess ligamentous stability?

Options:

30 degrees of flexion to test the proper collateral ligament and full extension to test the accessory collateral ligament and the palmar plate
30 degrees of flexion to test the accessory collateral ligament and full extension to test the proper collateral ligament and the palmar plate
45 degrees of flexion to test the accessory collateral ligament, the proper collateral ligament, and the palmar plate
90 degrees of flexion to test the proper collateral ligament and full extension to test the acces sory collateral ligament and the palmar plate
90 degrees of flexion to test the accessory collateral ligament and full extension to test the proper collateral ligament and the palmar plate

Correct Answer: 30 degrees of flexion to test the proper collateral ligament and full extension to test the accessory collateral ligament and the palmar plate

Explanation:

Question 2:

Options:

Emergent surgery, including open carpal tunnel release, open reduction of the perilunate dislocation, repair of the scapholunate ligament, and intercarpal pinning
Emergent surgery, including open carpal tunnel release, closed reduction of the perilunate dislocation, and casting
Elective outpatient surgery, including open carpal tunnel release, open reduction of the perilunate dislocation, repair of the scapholunate ligament, and intercarpal pinning
Emergent surgery, including open reduction of the perilunate dislocation, repair of the scapholunate ligament, and intercarpal pinning

Correct Answer: Emergent surgery, including open carpal tunnel release, open reduction of the perilunate dislocation, repair of the scapholunate ligament, and intercarpal pinning

Explanation:

Question 3:

Options:

Posterior interosseous nerve entrapment
Extensor pollicis longus rupture
Extensor pollicis longus entrapment
Distal radius malunion
Intersection syndrome

Correct Answer: Posterior interosseous nerve entrapment

Explanation:

Question 4:

An acetabular fracture with all segments of the articular surface detached from the intact posterior ilium is defined as what fracture pattern?

Options:

Transverse
Both column
Anterior column posterior hemitransverse
Posterior column with posterior wall
Anterior column with anterior wall

Correct Answer: Transverse

Explanation:

Question 5:

Figure 21 shows the tomogram of a 26-year-old woman who sustained an axial load injury to her neck in a fall off a horse. What ligament is injured?

Options:

Anterior longitudinal
Posterior longitudinal
Alar
Apical
Transverse

Correct Answer: Transverse

Explanation:

Question 6:

Options:

Vascularized fibular graft
Locked intramedullary rodding
Tricortical iliac crest grafting and compression plating
Cancellous autograft and plating
BMP-7

Correct Answer: Cancellous autograft and plating

Explanation:

Question 7:

Options:

Immediate weight-bearing as tolerated with hinged knee brace 0-90 degrees
Transphyseal ACL reconstruction with hamstring autograft
Physeal spearing ACL reconstruction with hamstring autograft
Application of long leg cast following successful fluoroscopic closed reduction
Application of long leg cast for 1-2 weeks with transition to hinged knee brace 0-90 degrees, progressive weight-bearing, and physical therapy for quadriceps strengthening

Correct Answer: Immediate weight-bearing as tolerated with hinged knee brace 0-90 degrees

Explanation:

Question 8:

Options:

Thoracic scoliosis
Thoracic hypokyphosis
Lumbar disk degeneration
Thoracolumbar kyphosis
Lumbar hyperlordosis

Correct Answer: Thoracolumbar kyphosis

Explanation:

Question 9:

Which of the following statements best describes the process of articular cartilage degeneration in osteoarthritis?

Options:

In the second stage there is decreased catabolic activity with less matrix breakdown.
In the second stage there is less chondrocyte proliferation and decreased matrix production.
Matrix degradation includes increased proteoglycan production, more proteoglycan
production, and longer glycosaminoglycan chains.
Cartilage degeneration may be initiated by inflammation, overload, or decreased matrix production.
Chondrocyte repair responses improve with aging.

Correct Answer: production, and longer glycosaminoglycan chains.

Explanation:

Question 10:

Options:

Incomplete C5 spinal cord injury
Complete C5 spinal cord injury
Complete C6 spinal cord injury
Central spinal cord injury
Brown-STquard syndrome

Correct Answer: Complete C5 spinal cord injury

Explanation:

Question 11:

Options:

proximal release of the proximal tendon of the rectus femoris.
release of the distal tendon of the rectus femoris.
transfer of the distal rectus femoris tendon.
V-Y lengthening of the quadriceps tendon.
Z lengthening of the patellar tendon.

Correct Answer: transfer of the distal rectus femoris tendon.

Explanation:

Question 12:

On average, the radial nerve travels from the posterior compartment of the arm to the anterior compartment at which of the following sites?

Options:

Spiral groove of the humerus
At the arcuate ligament of Osborne
10 cm distal to the lateral acromion
10 cm proximal to radiocapitellar joint
At the origin of the deep head of the triceps

Correct Answer: Spiral groove of the humerus

Explanation:

Question 13:

Options:

Shoulder abduction
Shoulder internal rotation
Shoulder external rotation
Shoulder adduction

Correct Answer: Shoulder external rotation

Explanation:

Question 14:

Options:

open acromioplasty
open Bankart repair
open subscapularis tendon repair
inferior capsular shift
a supervised physical therapy program

Correct Answer: open subscapularis tendon repair

Explanation:

This patient has an acute tear of the subscapularis tendon both by MRI and physical exam. Treatment of choice is open repair. Nonoperative treatment is not indicated.

Question 15:

All of the following techniques can help to prevent valgus angulation during intramedullary nailing of proximal one-third tibia fractures EXCEPT:

Options:

Use of a blocking screw lateral to midline in the proximal segment
Use of a blocking screw lateral to midline in the distal segment
Use of a lateral tibial nail starting point
Use of supplementary plate and screw fixation
Suprapatellar nailing portal

Correct Answer: Use of a blocking screw lateral to midline in the proximal segment

Explanation:

Question 16:

All of the following are advantages of supine over lateral positioning during intramedullary nailing of subtrochanteric femur fractures EXCEPT:

Options:

Can be protective to an injured spine
Facilitates access to other injured sites in the polytrauma patient
Provides easier fluoroscopic imaging
Allows for easy reduction of the distal fragment to the flexed proximal fragment
Easier to assess rotation

Correct Answer: Can be protective to an injured spine

Explanation:

Question 17:

-A 42-year-old woman has had right wrist pain for 2 years. She tried splint wear and naproxen and has had 3 steroid injections, each time experiencing less relief.

Options:

Examination revealed tenderness at and just proximal to the radial styloid, with pain exacerbated with thumb flexion and wrist ulnar deviation. What
is the best next step in treatment?
Physical therapy
Continued splint wear
Repeat injection into the first dorsal wrist compartment
Incision of the first dorsal wrist compartment at the volar edge
Incision of the first dorsal wrist compartment at the dorsal edge

Correct Answer: Repeat injection into the first dorsal wrist compartment

Question 18:

Options:

higher incidence of patellar clunk and similar implant survivorship.
higher incidence of patellar clunk and superior implant survivorship.
lower incidence of patellar clunk and superior implant survivorship.
lower incidence of patellar clunk and similar implant survivorship. The images show a left posterior stabilized knee prosthesis and a right cruciate sacrificing (ultracongruent / dished type) knee prosthesis. Posterior stabilized designs have a risk of patellar clunk due to the presence of the femoral box with some designs, such as the one shown, exhibiting higher rates. Clinical outcomes are similar between cruciate-retaining, cruciate- sacrificing and posterior stabilized designs.

Correct Answer: higher incidence of patellar clunk and similar implant survivorship.

Explanation:

Question 19:

Which of the following findings is a prerequisite for a high tibial valgus osteotomy for medial compartment gonarthrosis?

Options:

Inflammatory arthritis
Ligamentous instability
Lateral tibial subluxation
Preoperative arc of motion of at least 90 degrees
Narrowing of the lateral compartment cartilaginous joint space

Correct Answer: Preoperative arc of motion of at least 90 degrees

Explanation:

Question 20:

Which of the following conditions precludes performing a tendon transfer?

Options:

The target joint has a full passive range of motion.
The range of motion of the target joint only occurs in the direction of correction.
The target joint cannot be passively corrected to its neutral position.
The muscle to be transferred is out-of-phase.
There is no pulley to assist the transferred muscle’s fulcrum.

Correct Answer: The target joint cannot be passively corrected to its neutral position.

Explanation:

DISCUSSION: Several conditions must be met before a tendon transfer has the potential to correct a dynamic deformity. If the target joint cannot be passively corrected to neutral, it indicates that a static joint contracture or bony deformity exists that cannot be corrected with a dynamic tendon transfer. While in-phase muscles are best, out-of-phase muscles are often the only muscles available for transfer. Tendon transfer should pull in a straight line to avoid tethering and late failure.
REFERENCES: Canale ST (ed): Campbell’s Operative Orthopaedics, ed 10. St Louis, MO, Mosby, 2003, pp 1283-1287.
Coughlin MJ, Mann RA: Disorders of tendons, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 786-861.

Question 21:

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

Options:

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

Correct Answer: Two-stage debridement and reconstruction

Explanation:

Question 22:

Options:

intramedullary fixation.
radiation therapy.
embolization.
segmental resection and proximal femoral replacement.
chemotherapy.

Correct Answer: intramedullary fixation.

Explanation:

Question 23:

- Radiographs of the cervical spine of a 73-year-old man who fell down stairs reveal cervical spondylosis without evidence of fracture or dislocation. MRI and CT scans are consistent with the plain radiographs. After 72 hours, neurologic evaluation reveals intact sensation; however, weakness of the upper extremities is greater than that of the lower extremities. What is the most likely diagnosis?

Options:

Central cord syndrome
Anterior cord syndrome
Posterior cord syndrome
Brown-Sequard syndrome
Cervical nerve root injury

Correct Answer: Central cord syndrome

Explanation:

Question 24:

Options:

Bisphosphonates
Calcitonin
Parathyroid hormone
Vitamin D and calcium
Methotrexate

Correct Answer: Bisphosphonates

Explanation:

Question 25:

-Assuming that the lesion can be covered appropriately and there is no drainage from the lesion, when should the patient be allowed to safely return to wrestling?

Options:

When the absence of pain is reported by the wrestler for 3 consecutive days
When 72 hours of antibiotics have been administered and there is no extension of the lesion for 48 hours
When laboratory values are within defined limits and the patient remains afebrile for 3 days
When the lesion has decreased in size by 50%

Correct Answer: When 72 hours of antibiotics have been administered and there is no extension of the lesion for 48 hours

Explanation:

DISCUSSION FOR QUESTIONS 48 AND 49
This patient has cellulitis, which is typically caused by group A Streptococcus or Staphylococcus. The patient’s lack of improvement with first-line antibiotics is concerning for methicillin-resistant Staphylococcus aureus (MRSA) infection. MRSA cellulitis is becoming more prevalent in young athletes,and a high index of suspicion is required to provide appropriate intervention during this
aggressive disease process. The diagnosis is typically made clinically without the use of cultures. Oral trimethoprimsulfamethoxazole (a sulfonamide-class drug) double strength twice daily for 10 to 14 days or doxycycline (a tetracycline-class drug) 100 mg twice daily for 10 to 14 days are recommended for first-line treatment of suspected MRSA cellulitis. There is no indication to proceed with irrigation and debridement; however, if the patient develops a soft-tissue abscess or the underlying joint becomes involved, this would be an appropriate intervention. Switching the athlete to an IV cephalosporin (cefazolin) is not likely to be effective against the presumed resistant bacteria.
Ciprofloxacin (a fluoroquinolone-class drug) is effective against many bacteria, but not MRSA. The current recommendation for wrestlers with cellulitis is that return to competition be allowed after 72 hours of antibiotic treatment if there has been no extension of the cellulitis for 48 hours, the lesion can be covered, and there is no drainage from the lesion. The other responses are not current recommendations for return to competition.

Question 26:

Options:

observation.
a biopsy.
CT of the chest.
MRI of the femur.
wide local excision.

Correct Answer: observation.

Explanation:

Question 27:

Options:

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

Correct Answer: Abductor pollicis longus and extensor pollicis brevis

Explanation:

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

Question 28:

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

Options:

Hip is internally rotated, passively flexed to 90 degrees, and adducted
Hip is internally rotated, passively flexed to 90 degrees, and abducted
Hip is externally rotated, maximally flexed to 90 degrees, and adducted
Hip is externally rotated, passively flexed to 90 degrees, and abducted
Hip is externally rotated, maximally flexed, and abducted

Correct Answer: Hip is internally rotated, passively flexed to 90 degrees, and adducted

Explanation:

Patients with dysplasia often have a hypertrophic labrum. Abnormal contact between the femoral neck and the acetabular rim leads to labral injury, especially in the anterior-superior acetabular zone. Typically, young patients with the condition report pain with activity or long periods of sitting or driving. The hips often have limited motion, in particular in internal rotation and flexion. Forceful adduction with the maneuver causes pain.
(SBQ13PE.10) Which statement is true regarding discoid menisci?
Review Topic
Most commonly involves the medial meniscus
Bilateral in >75% of cases
Asymptomatic discoid meniscus should undergo saucerization
Radiographs will commonly show a hyperplastic lateral intercondylar spine
Radiographs will commonly show squaring of affected condyle with cupping of tibial plateau
Radiographs of knees with discoid menisci will commonly show squaring of affected condyle (lateral>medial) with cupping of tibial plateau.
Discoid meniscus refers to the abnormal development of a hypertrophic and discoid shaped meniscus. It occurs in 3-5% of the population and it is considered the most common cause of a symptomatic clicking or clunking in a childs knee. The lateral meniscus is most commonly affected and it will occur bilaterally in 25% of affected
people. The Watanabe Classification describes the 3 types of discoid menisci. Type 1
= Incomplete, Type 2 = Complete, Type 3 = Wrisberg (lack of posterior meniscotibial attachment to tibia)
Kramer et al. looked at the presentation of pediatric knee pain. They showed that the lateral meniscus is more commonly affected than the medial meniscus. The majority of discoid tears occur in the posterior or middle aspect of the discoid meniscus.
Lee et al. retrospectively reviewed 36 patients aged less than 15 years who underwent arthroscopic procedures for torn discoid menisci. The mean patient age at the time of surgery was 9.5 years. They showed that partial meniscectomy yielded better radiologic results than subtotal/total meniscectomy for torn discoid menisci in this population.
Illustration A shows the 3 classifications of discoid menisus as originally described by Watanabe. Type 4 is a ring type discoid that was not originally described by Watanabe in his 1978 paper. Illustration B shows an AP and lateral radiograph of a discoid meniscus knee. Note squaring of affected lateral condyle in the presence of a lateral discoid meniscus. Illustration C shows 4 consecutive sagittal MRI images with meniscus continuity. It is important to note that the diagnosis of discoid menisci can be made when 3 or more 5mm sagittal images show meniscal continuity.
Incorrect Answers:

Question 29:

Options:

electrical stimulation.
a Charleston bending brace at night.
an extension-type spinal orthosis.
posterior spinal fusion with instrumentation.
anterior spinal release and posterior spinal instrumentation.

Correct Answer: an extension-type spinal orthosis.

Explanation:

Question 30:

Options:

Arthroscopic labral debridement and biceps tenodesis
Shoulder arthroscopy with undersurface cuff debridement and acromioplasty
Cyst decompression at the spinoglenoid notch with possible labral repair
Cyst decompression at the suprascapular notch with possible labral repair This patient’s clinical and MRI findings are consistent with a posterior paralabral cyst with compression of the suprascapular nerve, specifically at the spinoglenoid notch. Compression of the suprascapular nerve can occur at either the suprascapular or spinoglenoid notch. Compression of the nerve at the suprascapular notch affects innervation to both the supraspinatus and infraspinatus muscles, resulting in weakness in both shoulder abduction and external rotation. However, compression at the spinoglenoid notch only affects innervation to the infraspinatus muscle, resulting in isolated weakness in external rotation. Compression at the spinoglenoid notch often is seen in overhead athletes, and studies have shown associated posterior labral tears (Piatt and associates). Several studies have addressed nonsurgical and surgical treatment options. The treatment decision should focus on the underlying cause (Martin and associates)—in this patient, the cyst. Nonsurgical treatment in the presence of a known lesion has been associated with a higher failure rate than addressing the lesion, which can result in functional improvement (Chen and associates, Cummins and associates). The best response in this scenario is decompression of the cyst at the spinoglenoid notch with possible labral repair.

Correct Answer: Shoulder arthroscopy with undersurface cuff debridement and acromioplasty

Explanation:

Question 31:

Options:

Acetabular osteolysis
Femoral osteolysis
Acetabular loosening
Femoral loosening
Femoral and acetabular loosening

Correct Answer: Femoral loosening

Explanation:

DISCUSSION: These radiographs are dominated by the subsidence of the femoral component. There is also evidence of polyethylene wear and femoral osteolysis in the region of the greater trochanter. There is no evidence of proximal (calcar) stress shielding, and there is a thick distal pedestal. Engh and associates defined two major signs of osseointegration - the absence of radiolucent lines around the porous-surfaced portion of the implant and new bone bridging the gap between the endosteal surface and the porous portion of the implant. Implant migration indicates failure of ingrowth. Osteolysis is a periprosthetic loss of bone secondary to particulate debris and it is often clinically silent unless it is accompanied by pathologic fracture. It is often globular. Acetabular loosening is based on radiolucent lines and implant migration. The current radiographs demonstrate subsidence of the stem with pedestal formation.
REFERENCES: Engh CA, Massin P, Suthers KE: Roentgenographic assessment of biologic fixation of porous-surface femoral components. Clin Orthop Relat Res 1990;257:107-128.
Engh CA, Hooten JP, Zettl-Schaffer KF, et al: Evaluation of bone ingrowth in proximally and extensively porous-coated anatomic medullary locking prostheses retrieved at autopsy. J Bone Joint Surg Am 1995;77:903-910.

Question 32:

Options:

Pain with internal and external rotation of her hip with her hip and knee in an extended position
Limited motion when moving the hip from flexion-abduction-external rotation to flexion-adduction-internal rotation
Moving from hip flexion-abduction-external rotation to neutral triggers a popping sensation
Limitation in active hip range of motion with catching, locking and grinding noted on passive motion
Pain with a half sit-up and tenderness at the pubic ramus

Correct Answer: Pain with a half sit-up and tenderness at the pubic ramus

Explanation:

Question 33:

An axial T 1 -weighted MRI scan of the pelvis is shown in Figure 35. Which of the following structures is enclosed by the circle?

Options:

Obturator vessels and nerve
Tendinous origin of the obturator internus muscle
Tendinous origin of the obturator externus muscle
Seminal vesicle
Suprapubic pelvic lymph nodes

Correct Answer: Obturator vessels and nerve

Explanation:

DISCUSSION: The obturator vessels and nerve pass along the lateral pelvic wall along the true pelvic brim (nerve lies anterior to the vessels and lies on the obturator internus muscle) and descend into the obturator groove at the upper portion of the obturator foramen.
REFERENCES: Higuchi T: Normal anatomy and magnetic resonance appearance of the pelvis, in Takahashi HE, Morita T, Hotta T, et al (eds): Operative Treatment of Pelvic Tumors. Tokyo, Japan, Springer-Verlag, 2003, pp 4-21.
Berquist TH: Pelvis, hips and thigh, in Berquist TH (ed): MRI of the Musculoskeletal System,
ed 4. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 210-238.

Question 34:

Options:

Oral antibiotics empirically
Culture of the drainage and oral antibiotics
Aspiration of the wound and IV antibiotics empirically
Wound culture with incision and debridement, IV antibiotics, and retention of instrumentation
Wound culture with incision and debridement, IV antibiotics, and removal of instrumentation followed by bracing

Correct Answer: Wound culture with incision and debridement, IV antibiotics, and retention of instrumentation

Explanation:

DISCUSSION: The presence of drainage 3 weeks after surgery is a sign of wound infection. This infection most likely involves deep tissues until proven otherwise. Oral or IV antibiotics, in the absence of debridement, are not sufficient. Removal of the hardware would lead to rapid progression of the scoliosis in a spine that has been surgically destabilized by removal of the facet joints. The appropriate treatment is debridement with wound culture, IV antibiotics, and retention of hardware. The wound should be closed over drains.
REFERENCES: Theiss SM, Lonstein JE, Winter RB: Wound infections in reconstructive spine surgery. Orthop Clin North Am 1996;27:105-110.
Richards BS: Delayed infections following posterior spinal instrumentation for the treatment of idiopathic scoliosis. J Bone Joint Surg Am 1995;77:524-529.

Question 35:

Options:

plating of the radial shaft fracture and open repair of the triangular fibrocartilage complex.
open reduction and internal fixation of the radius and ulna.
plating of the radius with closed reduction and evaluation of the distal radioulnar joint (DRUJ).
closed reduction of the radius and DRUJ.
plating of the radius and pinning of the DRUJ in pronation.

Correct Answer: plating of the radius with closed reduction and evaluation of the distal radioulnar joint (DRUJ).

Explanation:

DISCUSSION: This Galeazzi fracture is an injury that requires surgical treatment in an adult. The algorithm includes anatomic reduction of the radial shaft and closed reduction of the DRUJ with assessment of stability. If the DRUJ remains unstable, supination of the wrist may reduce the DRUJ. If not, either open or closed reduction with pinning is undertaken. The closer the radius fracture is to the DRUJ, the more likely it is to be unstable.
REFERENCE: Rettig ME, Raskin KB: Galeazzi fracture-dislocation: A new treatment-oriented classification. J Hand Surg Am 2001;26:228-235.

Question 36:

Options:

Repeat subacromial corticosteriod injection
Biological augmentation of rotator cuff with porcine small intestine xenograft
Rotator cuff repair
Rotator cuff repair plus acromioplasty
Rotator cuff repair, remplissage procedure, bicep tenodesis and distal clavicle excision

Correct Answer: Repeat subacromial corticosteriod injection

Explanation:

Question 37:

Options:

back muscle stretching and reduced weight in the backpack.
consultation with a pain management specialist.
MRI of the thoracic spine.
a technetium Tc 99m bone scan.
a thoracolumbosacral orthosis.

Correct Answer: back muscle stretching and reduced weight in the backpack.

Explanation:

Question 38:

Options:

split-thickness skin graft.
thenar flap.
cross-finger flap.
lateral arm flap.
Moberg (volar advancement) flap.

Correct Answer: cross-finger flap.

Explanation:

DISCUSSION: The wound described indicates loss of soft tissue directly to the level of the tendon, precluding use of skin grafts if excursion of the tendon is desired. A cross-finger
flap is ideal for small wounds on the volar aspect of digits. A thenar flap is suitable for tip injuries. A lateral arm flap will not reach the fingers. A Moberg flap is limited to distal injuries of the thumb.
REFERENCES: Kappel DA, Burech JG: The cross-finger flap: An established reconstructive procedure. Hand Clin 1985;1:677-683.
Lister GD: Skin flaps, in Green DP, Hotchkiss RN (eds): Operative Hand Surgery, ed 3. New York, NY, Churchill Livingstone, 1993, p 1741.

Question 39:

Options:

Open biopsy
Needle aspiration
Arthroscopy
CT
Arthrography

Correct Answer: Needle aspiration

Explanation:

Question 40:

Options:

Pulmonary embolism
Fat embolism syndrome
Sepsis
Pneumonia
Pneumothorax

Correct Answer: Fat embolism syndrome

Explanation:

Question 41:

Options:

cervical spine radiographs.
MRI of the shoulder.
decompressive osteotomy of the clavicle.
microsurgical repair of the brachial plexus.
observation and range-of-motion exercises.

Correct Answer: observation and range-of-motion exercises.

Explanation:

Question 42:

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 43:

Which of the following parameters is considered most important when assessing an acetabular fracture for surgical indications?

Options:

Age of the patient
Failure to maintain reduction of the head under the dome without traction
Presence of a femoral head impaction lesion
Direction of the femoral head displacement
Fragmentation of the fracture

Correct Answer: Failure to maintain reduction of the head under the dome without traction

Explanation:

Question 44:

Options:

Cut more proximal tibia.
Cut more distal femur.
Cut both the proximal tibia and distal femur.
Decrease the size of the femoral component.
Decrease the tibial polyethylene insert thickness.

Correct Answer: Decrease the size of the femoral component.

Explanation:

Question 45:

Biomechanical in vitro studies of double-row anchor fixation of rotator cuff tears show what initial advantage over single-row anchor fixation? Review Topic

Options:

Increased peak-to-peak elongation
Decreased stiffness
Higher ultimate tensile load
Decreased contact area
Increased conditioning elongation

Correct Answer: Higher ultimate tensile load

Explanation:

Question 46:

Options:

Anti-inflammatory drugs
Knee brace
Physical therapy for quadriceps strengthening
Revision to a thicker polyethylene insert
Revision to a larger, posterior stabilized implant

Correct Answer: Revision to a larger, posterior stabilized implant

Explanation:

DISCUSSION: The radiographs show posterior flexion instability that is the result of a
flexion-extension gap imbalance and posterior cruciate ligament incompetence after a posterior cruciate ligament-retaining TKA. The femur is anteriorly displaced on the tibia, with lift-off of the femoral component from the tibial polyethylene. Revision to a larger femoral component will address the larger flexion gap relative to the extension gap, and a posterior stabilized implant will address the posterior cruciate ligament insufficiency. Pagnano and associates, reporting on a series of painful TKAs previously diagnosed as pain of unknown etiology, showed that the pain was secondary to flexion instability. Pain relief was achieved by revision to a posterior stabilized implant.
REFERENCES: Pagnano MW, Hanssen AD, Lewallen DG, et al: Flexion instability after primary posterior cruciate retaining total knee arthroplasty. Clin Orthop 1998;356:39-46.
Fehring TK, Valadie AL: Knee instability after total knee arthroplasty. Clin Orthop 1994;299:157-162.
Fehring TK, Odum S, Griffin WL, et al: Early failures in total knee arthroplasty. Clin Orthop 2001;392:315-318.

Question 47:

Options:

Posterior talofibular ligament
Distal tibiofibular syndesmosis
Anterior talofibular ligament
Deltoid ligament
Calcaneofibular ligament

Correct Answer: Deltoid ligament

Explanation:

DISCUSSION: In the presence of a supination external rotation-type fracture of the distal fibula (Weber type B), stability of the ankle is best assessed by performing an external rotation stress AP view of the ankle. This test is used to assess the integrity of the deltoid ligament. The presence of a deltoid ligament rupture results in instability and generally is best managed surgically. The gravity stress test can also be used.
REFERENCES: Egol KA, Amirtharajah M, Tejwani NC, et al: Ankle stress test for predicting the need for surgical fixation of isolated fibular fractures. J Bone Joint Surg Am 2004;86:2393-2398.
McConnell T, Creevy W, Tornetta P III: Stress examination of supination external rotation-type fibular fractures. J Bone Joint Surg Am 2004;86:2171-2178.
Schock HJ, Pinzur M, Manion L, et al: The use of the gravity or manual-stress radiographs in the assessment of supination-external rotation fractures of the ankle. J Bone Joint Surg Br 2007;89:1055-1059.

Question 48:

The nerve to the abductor digiti quinti, implicated in some patients who have chronic heel pain, is most commonly a branch of what larger nerve?

Options:

Lateral plantar
Lateral calcaneal
Medial plantar
Medial calcaneal
Sural

Correct Answer: Lateral plantar

Explanation:

Question 49:

Options:

Local debridement of the ankle with long-term bracing
Attempted fusion using a multiplanar external fixation
Attempted fusion using an intramedullary rod
Attempted fusion using screw fixation

Correct Answer: Attempted fusion using an intramedullary rod

Explanation:

DISCUSSION
The indications for surgery in a Charcot joint are an unbraceable deformity or recurrent ulceration despite use of adequate bracing. Any significant varus/valgus deformity of the ankle or hindfoot (as in this patient) is unbraceable, whereas midfoot Charcot deformities usually can be treated nonsurgically. The goal of surgery is to provide a stable aligned foot and ankle to permit activities and reduce risk for recurrent ulceration. This does not mean that there has to be a radiographic fusion because many patients with diabetes achieve a stable nonunion without pain. The only surgical construct that will provide long-term inherent stability and alignment in this situation is use of a hindfoot fusion rod. It provides better stability and purchase than screw fixation and can be left in indefinitely (unlike an external fixator).
RECOMMENDED READINGS
Dalla Paola L, Volpe A, Varotto D, Postorino A, Brocco E, Senesi A, Merico M, De Vido D, Da Ros R, Assaloni R. Use of a retrograde nail for ankle arthrodesis in Charcot neuroarthropathy: a limb salvage procedure. Foot Ankle Int. 2007 Sep;28(9):967-70. PubMed PMID: 17880869.
View
Abstract at PubMed
Pinzur MS. Benchmark analysis of diabetic patients with neuropathic (Charcot) foot deformity. Foot Ankle Int. 1999 Sep;20(9):564-7. PubMed PMID: 10509683.
View Abstract at PubMed
Pinzur M. Surgical versus accommodative treatment for Charcot arthropathy of the midfoot. Foot Ankle Int. 2004 Aug;25(8):545-9. PubMed PMID: 15363375.
View
Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 83 THROUGH 87
Figures 83a and 83b are the clinical photographs of a 42-year-old woman with a BMI of 31 who has had a 1-year history of right heel pain.
A
B

Question 50:

Options:

Medial collateral ligament repair or reconstruction
Reconstruction of the radial collateral ligament
Resection of the type I coronoid fracture and capsular repair to the remaining coronoid
Open reduction and buttress plating of the coronoid fracture

Correct Answer: Medial collateral ligament repair or reconstruction

Explanation:

Question 51:

Options:

A 270-degree labral tear
His intention to continue contact sport activities
Anterior bony loss measuring 30% of inferior glenoid width
An inferior glenohumeral ligament avulsion (HAGL) lesion

Correct Answer: Anterior bony loss measuring 30% of inferior glenoid width

Explanation:

DISCUSSION
There is much debate in the literature regarding optimal techniques for treatment of shoulder instability. Although some studies suggest that open stabilization may result in lower recurrence rates in contact athletes, this approach is now under scrutiny. Extensive labral involvement (posterior labral involvement in this scenario) is likely more accessible via arthroscopic methods. Although HAGL lesions may be more easily accessible via an open approach (particularly for inexperienced arthroscopists), numerous authors describe successful repair via arthroscopic techniques. Among these responses, the strongest indication for an open approach, including possible bony transfer, is high-grade glenoid bone loss. Although the critical amount of bone loss is a topic of debate, most surgeons and authors suggest a cutoff of 20% to 25%.
CLINICAL SITUATION FOR QUESTIONS 90 THROUGH 92
Figure 90 is the radiograph of a 14-year-old pitcher who plays in a year-round baseball program and has vague pain in his dominant shoulder. The pain occurs with throwing, and it has been worsening for 2 months. Pain typically occurs during the late cocking phase of throwing. He has no tenderness of the rotator cuff and 5/5 rotator cuff strength. His arc of motion is symmetric between his dominant and nondominant arms. The sulcus sign is negative.

Question 52:

Options:

Stiffness of the wrist joint
Physeal growth arrest
Physeal overgrowth
Osteonecrosis of the metaphysis
Posttraumatic arthritis

Correct Answer: Physeal growth arrest

Explanation:

Question 53:

A patient who underwent intramedullary nailing of a femoral shaft fracture 2 weeks ago now reports groin pain. What is the next most appropriate step in management?

Options:

Obtain a radiograph of the hip
Obtain radiographs of the lumbar spine
Obtain an MRI scan of the lumbar spine
Review the radiographic report from the time of injury
Reassure the patient that the pain will improve and order physical therapy

Correct Answer: Obtain a radiograph of the hip

Explanation:

Question 54:

Options:

Scratching the opposite shoulder
Pushing off ipsilateral chair armrest while standing up
Tying shoelaces on the contralateral foot
Reaching up to comb hair

Correct Answer: Pushing off ipsilateral chair armrest while standing up

Explanation:

Question 55:

Compared to postoperative radiation therapy, preoperative radiation therapy has a higher rate of what complication?

Options:

Fibrosis
Lymphedema
Wound necrosis
Local recurrence
Neuropathy

Correct Answer: Wound necrosis

Explanation:

DISCUSSION: Radiation therapy is commonly used as an adjuvant in the treatment of soft-tissue sarcomas, but a controversy exists whether it should be preoperative or postoperative. Radiation therapy can be given prior to or following resection of the tumor. Postoperative radiation is usually given in a higher dose to a larger treatment field. This commonly results in a higher incidence of fibrosis and lymphedema. There is no statistical difference in local recurrence rate between the two radiation treatment plans. Neuropathy is more commonly a complication of chemotherapy. Preoperative radiation therapy has been shown to have a higher wound complication rate than postoperative radiation.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 197-215.
Davis AM, O’Sullivan B, Turcotte R, et al: Late radiation morbidity following randomization to preoperative versus postoperative radiotherapy in extremity soft tissue sarcoma. Radiother Oncol 2005;75:48-53.

Question 56:

5 degrees medial and 10 degrees cephalad

Options:

10 degrees medial and 22 degrees cephalad
10 degrees lateral and 22 degrees cephalad
20 degrees medial and 22 degrees caudal

Correct Answer: 20 degrees medial and 22 degrees caudal

Explanation:

Question 57:

Options:

capitate excision with interposition arthroplasty.
capitate proximal pole excision and drilling.
proximal row carpectomy (PRC).
vascularized bone graft.

Correct Answer: vascularized bone graft.

Explanation:

EXPLANATION:
This patient has osteonecrosis of the capitate. The MR images show evidence of osteonecrosis with decreased signal on the T1-weighted image. The radiographs are unremarkable, with the exception of lunotriquetral coalition, which does not necessitate treatment. The etiology of osteonecrosis of the capitate may be related to trauma, abnormal Interosseous vascular supply, and hypermobility. Surgery is an option for patients with persistent symptoms despite immobilization. Vascularized bone graft should be considered in this scenario because there is no evidence of capitate collapse or arthritic change about the wrist. Free and local vascularized bone grafts have produced satisfactory results. Capitate excision with interposition arthroplasty is indicated for patients with proximal pole capitate collapse. Total wrist fusion is a salvage procedure and would be considered if there were evidence of collapse and arthritic change.
PRC would leave the capitate articulating with the radius and is not indicated.

Question 58:

Options:

examination under fluoroscopy.
MRI.
a bone scan.
arthrography.
aspiration and arthrography.

Correct Answer: MRI.

Explanation:

Question 59:

What anatomic site is considered at highest risk for pathologic fracture?

Options:

Humeral neck
Humeral diaphysis
Subtrochanteric femur
Femoral diaphysis
Pelvis

Correct Answer: Subtrochanteric femur

Explanation:

Question 60:

Options:

BMI >30
Presence of secondary changes of the acetabulum
Osteonecrosis of the femoral head
Age of younger than 55 years old
Male gender

Correct Answer: Osteonecrosis of the femoral head

Explanation:

Question 61:

Options:

Intramedullary screw fixation of the fibula
Plating of the fibula with a one third tubular plate
Subtalar arthrodesis with deformity correction
Varus producing distal tibial osteotomy
Ankle arthrodesis

Correct Answer: Subtalar arthrodesis with deformity correction

Explanation:

Question 62:

During the application of halo skeletal fixation, the most appropriate position for the placement of the anterior halo pins is approximately 1 cm above the superior orbital rim and

Options:

lateral placement, directly within the temporalis muscle.
lateral to the medial third of the orbit.
lateral to the lateral aspect of the orbit.
above the medial third of the orbit.
lateral between the temporalis muscle and zygomatic temporal nerve.

Correct Answer: lateral to the medial third of the orbit.

Explanation:

DISCUSSION: Halo fixation is the most rigid form of cervical orthosis, but complications can arise from improper placement of the initial halo ring. A relatively safe zone for anterior pin placement is located 1 cm above the orbital rim and superior to the lateral two thirds of the orbit. This position avoids the supraorbital and supratrochlear nerves and arteries over the medial one third of the orbit. The more lateral positions in the temporal fossa have very thin bone and can interfere with the muscles of mastication. Posterior pin site locations are less critical; positioning on the posterolateral aspect of the skull, diagonal to the contralateral anterior pins, is generally desirable.
REFERENCES: Botte MJ, Byrne TP, Abrams RA, et al: Halo skeletal fixation: Techniques of application and prevention of complications. J Am Acad Orthop Surg 1996;4:44-53.
Garfin SR, Botte MJ, Nickel VL: Complications in the use of the halo fixation device. J Bone Joint Surg Am 1987;69:954.

Question 63:

Options:

Total shoulder arthroplasty
Hemiarthroplasty with glenoid interposition
Surface replacement hemiarthroplasty
Arthroscopic debridement
Anti-inflammatory drugs and a range-of-motion stretching program

Correct Answer: Anti-inflammatory drugs and a range-of-motion stretching program

Explanation:

DISCUSSION: New onset pain and stiffness in the young arthritic shoulder is a difficult problem to treat. Initial management should be aimed at reducing pain and improving motion in all planes. This patient’s activities and age preclude a shoulder arthroplasty at this time. If nonsurgical management fails to provide relief, then arthroscopic debridement and capsular release may be beneficial.
REFERENCES: Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 257-266.
Skedros JG, O’Rourke PJ, Zimmerman JM, et al: Alternatives to replacement arthroplasty for glenohumeral arthritis, in Iannotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 485-499.

Question 64:

-The patient requests anatomic double-bundle ACL reconstruction. Compared with transtibial singlebundle ACL reconstruction, anatomic double-bundle ACL reconstruction is more likely to

Options:

restore improved knee kinematics.
allow for earlier return to sports.
result in better clinical outcomes scores.
be associated with lower surgery cost.

Correct Answer: restore improved knee kinematics.

Explanation:

Question 65:

Options:

Arthroscopic labral debridement
Reverse periacetabular osteotomy
Resurfacing hip arthroplasty
Femoral neck osteochondroplasty and resection of the detached labrum
Femoral neck osteochondroplasty and reattachment of the labrum

Correct Answer: Femoral neck osteochondroplasty and reattachment of the labrum

Explanation:

Question 66:

Options:

Delay further surgical intervention until his ESR and CRP level normalize
Delay further surgical intervention until his ESR normalizes
Delay further surgical intervention until his CRP level normalizes
Proceed with surgical intervention if the patient’s condition is medically optimized

Correct Answer: Proceed with surgical intervention if the patient’s condition is medically optimized

Explanation:

Question 67:

Options:

Methicillin-resistant Staphylococcus aureus
Salmonella typhii
Escherichia coli
Vancomycin-resistant Enterococcus

Correct Answer: Methicillin-resistant Staphylococcus aureus

Explanation:

The clinical picture is one of infection and deep venous thrombosis. The MRI scan is consistent with osteomyelitis. Deep venous thrombosis in association with musculoskeletal infection is more common in osteomyelitis caused by methicillin-resistant
Staphylococcus aureus
. Presenting C-reactive protein levels generally are higher than 6 mg/L and are higher than with other causative organisms. The presence of the Panton-Valentine leukocidin gene encoded in strains of bacteria may explain the deep venous thrombosis.

Question 68:

Options:

Silicone replacement arthroplasty through a volar approach
Surface replacement arthroplasty through a volar approach
Silicone replacement arthroplasty through a dorsal approach
Surface replacement arthroplasty through a dorsal approach

Correct Answer: Silicone replacement arthroplasty through a volar approach

Explanation:

EXPLANATION:
A recent systematic review compared silicone replacement, pyrocarbon replacement, and surface replacement arthroplasty for PIP arthritis. Silicone arthroplasty through a volar approach showed the greatest gains in arc of motion and had the lowest rate of revision surgeries. The rates of revision surgeries from low to high for each type of arthroplasty were 6% for silicone volar, 10% for silicone lateral, 11%
Surface replacement arthroplasty through a volar
for silicone dorsal, 18% for surface replacement dorsal, and 37% for surface replacement volar. Revision surgeries include implant replacement (to silicone or maintaining the surface replacement), arthrodesis, explantation, amputation, and other procedures.
approach showed the highest revision rate
,
the worst gain in arc of motion
, and
the greatest extension lag.
However, substantial pain relief and higher satisfaction still were reported after surface replacement
arthroplasty, regardless of the complications.

Question 69:

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

Options:

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

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

Explanation:

Question 70:

03 5.

Options:

Second only to osteoperosis as the most common metabolic bone disease, Paget’s disease is most often asymptomatic and diagnosed incidentally on routine x-rays. There three distinct histologic phases:
increase in bone resorption with increase in the number and size of osteoclasts, AKA the “hot” phase.
Rapid increase in osteoblast activity and new bone formation, AKA the “intermediate” phase
Decrease in both osteoclastic and osteoblastic activity, AKA “cold” phase

Correct Answer: Second only to osteoperosis as the most common metabolic bone disease, Paget’s disease is most often asymptomatic and diagnosed incidentally on routine x-rays. There three distinct histologic phases:

Explanation:

Question 71:

Options:

Further imaging studies, including MRI
An awake closed reduction with Gardner-Wells traction with neurologic examination
Immobilization in a halo skeletal fixation for definitive treatment
Closed reduction under general anesthesia
Immediate open reduction and internal fixation in the surgical suite

Correct Answer: An awake closed reduction with Gardner-Wells traction with neurologic examination

Explanation:

DISCUSSION: In the patient who is neurologically intact or has an incomplete injury from a cervical facet dislocation, a closed reduction with weighted tong traction is appropriate when the patient is awake, alert, and cooperative. Although there is a risk that a cervical facet dislocation could occur with an underlying cervical disk herniation, Vaccaro and associates have shown that closed reduction can be safely carried out in the awake, responsive patient. Closed reduction can be performed in the emergency department with traction with skull tongs or a halo ring. A slow stepwise application of weight is added until a reduction is achieved. Any worsening of the neurologic status of the patient requires immediate termination of the closed reduction and further diagnostic imaging before proceeding with further treatment.
REFERENCES: Vaccaro AR, Falatyn SP, Flanders AE, et al: Magnetic resonance evaluation of the intervertebral disc, spinal ligaments, and spinal cord before and after closed traction reduction of cervical spine dislocations. Spine 1999;24:1210-1217.
Hart RA: Cervical facet dislocation: When is magnetic resonance imaging indicated? Spine 2002;27:116-117.
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.

Question 72:

What is the most appropriate surgical treatment for a stage III symptomatic scapholunate advanced collapsed (SLAC) wrist?

Options:

Radioscapholunate arthrodesis
Scaphotrapeziotrapezoid arthrodesis
Scaphocapitate arthrodesis
Proximal row carpectomy
Scaphoid excision and capitate-lunate-triquetrum-hamate arthrodesis

Correct Answer: Scaphoid excision and capitate-lunate-triquetrum-hamate arthrodesis

Explanation:

DISCUSSION: SLAC is the end result of chronic scapholunate instability. The arthritis follows a predictable pattern. Stage I disease involves cartilage loss between the waist of the scaphoid and the radial styloid. In stage II, the arthritis progresses to include the proximal pole of the scaphoid and the scaphoid fossa of the radius. Finally, stage III goes on to include arthritis of the capitolunate joint. The only treatment option that addresses all of the sites of arthritis is the scaphoid excision and four corner fusion.
REFERENCES: Ashmead DT IV, Watson HK, Damon C, et al: Scapholunate advanced collapse wrist salvage. J Hand Surg Am 1994;19:741-750.
Sauerbier M, Trankle M, Linsner G, et al: Midcarpal arthrodesis with complete scaphoid excision and interposition bone graft in the treatment of advanced carpal collapse (SNAC/SLAC wrist): Operative technique and outcome assessment. J Hand Surg Br 2000;25:341-345.

Question 73:

..The optimal method to treat a recurrent presentation of pigmented villonodular synovitis (PVNS) with diffuse joint involvement in a 24-year-old woman with pain and symptomatic effusions is

Options:

700 cGy of radiation therapy.
open arthrotomy with synovectomy.
imatinib therapy.
observation. DISCUSSION.. Local control of recurrent diffuse PVNS is best accomplished with open arthrotomy and complete synovectomy. Arthroscopic methods in the setting of persistent diffuse PVNS are associated with an unacceptably high rate of recurrence. Radiation therapy (700 cGy) is the typical dose administered for heterotopic ossification prophylaxis, but this dose is not high enough to achieve local control in PVNS. Imatinib, a colony-stimulating factor inhibitor, has been described for recurrent/refractory disease, but is not considered as effective as open surgical treatment.

Correct Answer: open arthrotomy with synovectomy.

Question 74:

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

Options:

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

Correct Answer: a physeal scar.

Explanation:

Question 75:

Options:

external fixation with a circular frame.
open reduction and internal fixation with screws.
closed reduction and percutaneous pinning.
closed reduction and cast immobilization.
amputation.

Correct Answer: open reduction and internal fixation with screws.

Explanation:

Question 76:

An MRI arthrogram of the elbow is shown in Figure 6. Based on these findings, what is the most likely diagnosis?

Options:

Rupture of the medial collateral ligament
Rupture of the lateral collateral ligament
Intra-articular loose body
Flexor-pronator injury
Extensor origin avulsion

Correct Answer: Rupture of the medial collateral ligament

Explanation:

DISCUSSION: MRI arthrography is the imaging study of choice for evaluation of medial collateral ligament injuries.
REFERENCES: Carrino JA, Morrison WB, Zou KH, et al: Noncontrast MR imaging and MR arthrography of the ulnar collateral ligament of the elbow: Prospective evaluation of two-dimensional pulse sequences for detection of complete tears. Skeletal Radiol 2001;30:625-632.
Munshi M, Pretterklieber ML, Chung CB, et al: Anterior bundle of ulnar collateral ligament: Evaluation of anatomic relationships by using MR imaging, MR arthrography, and gross anatomic and histologic analysis. Radiology 2004;231:797-803.

Question 77:

Figures 5a and 5b show axial and coronal MRI images of the left ankle of a patient with lateral ankle pain. What is the most likely diagnosis?

Options:

Peroneus brevis tendon tear
Posterior tibialis tendon tear
Talar dome osteochondral loose body
Talar fracture
Flexor hallucis tenosynovitis

Correct Answer: Peroneus brevis tendon tear

Explanation:

Question 78:

In a patient with rheumatoid arthritis of the wrist, which of the following extensor tendons is most at risk of rupture?

Options:

Extensor digiti quinti
Abductor pollicis longus
Extensor pollicis longus
Extensor carpi radialis brevis
Extensor carpi ulnaris

Correct Answer: Extensor digiti quinti

Explanation:

DISCUSSION: The tendon most prone to rupture in a patient with rheumatoid arthritis of the wrist is the extensor digiti quinti. It can be a silent injury since the extensor digitorum communis can provide extension to the fifth finger. The extensor digiti quinti is at high risk since it is overlying the ulnar head where it is prone to attritional rupture (Vaughan-Jackson syndrome).
REFERENCES: Vaughan-Jackson OJ: Rupture of extensor tendons by attrition at the inferior radioulnar joint: A report of two cases. J Bone Joint Surg Br 1948;30:528-530.
Papp SR, Athwal GS, Pichora DR: The rheumatoid wrist. J Am Acad Orthop Surg
2006;14:65-77.

Question 79:

Which of the following is most important to acheive a good outcome following a Syme amputation?

Options:

trimming any dog ears
a viable and stable heel pad
achilles tendon lengthening
preserving the malleoli
tenodesing the extensor digitorum longus to the tibial shaft

Correct Answer: trimming any dog ears

Explanation:

Question 80:

Options:

Poliomyelitis
Neurofibromatosis (von Recklinghausen disease)
Lymphangiomatosis
Congenital band syndrome
Chronic venous stasis disease

Correct Answer: Lymphangiomatosis

Explanation:

Question 81:

Surgical treatment of an adult cavovarus foot with fixed forefoot valgus that does not correct on Coleman block testing should consist of Review Topic

Options:

lateral column lengthening through the calcaneal anterior process.
a medial displacement calcaneal osteotomy.
first metatarsal-cuneiform fusion in increased plantar flexion.
dorsiflexion osteotomy of the first metatarsal and a medial displacement calcaneal osteotomy.
dorsiflexion osteotomy of the first metatarsal and a lateral displacement calcaneal osteotomy.

Correct Answer: dorsiflexion osteotomy of the first metatarsal and a lateral displacement calcaneal osteotomy.

Explanation:

Question 82:

Options:

closed management of the medial condyle and humeral shaft fractures and open reduction and internal fixation of the both bones forearm fracture.
closed management of the humeral shaft fracture and open reduction and internal fixation of the medial condyle and the both bones forearm fractures.
open reduction and internal fixation of the humeral shaft, medial condyle, and the both bones forearm fractures.
open reduction and internal fixation of the medial condyle and both bones forearm fractures, and external fixation of the humeral shaft fracture.
delayed stabilization of all fractures after the open wound has healed.

Correct Answer: open reduction and internal fixation of the humeral shaft, medial condyle, and the both bones forearm fractures.

Explanation:

Question 83:

Options:

Increased rate of union
Decreased rate of infection
Shorter operative time
Lower rates of hip pain
Lower rates of knee pain

Correct Answer: Increased rate of union

Explanation:

Question 84:

Options:

IDET has been proven to seal annular tears in the annulus fibrosis.
IDET restores segmental stability by shrinking collagen fibrils in the disk.
IDET has demonstrated no significant benefit over placebo in controlled trials.
IDET is an unsafe procedure with significant risk of permanent complications.
IDET has demonstrated poor clinical results in all reported series to date.

Correct Answer: IDET has demonstrated no significant benefit over placebo in controlled trials.

Explanation:

DISCUSSION: Intradiskal electrothermal therapy (IDET) initial clinical results were reported in 2000. The early case series were quite encouraging with reported therapeutic success rates of 60% to 80%. Early enthusiasm was high as IDET provided a nonsurgical treatment option for an otherwise complex and difficult clinical entity, chronic diskogenic low back pain. The actual mechanism of action was not well understood, and while the theoretic explanation made good sense, it did not hold up under laboratory testing. Soon clinical results from the field did not meet the high expectations set by the developers of the technique. Since those early case studies, a few level I evidence studies have been conducted, one by Freeman and associates and one by Pauza and associates. These randomized, placebo-controlled trials demonstrated no significant benefit of IDET over the placebo.
REFERENCES: Freeman BJ, Fraser RD, Cain CM, et al: A randomized, double-blind, controlled trial: Intradiscal electrothermal therapy versus placebo for the treatment of chronic discogenic low back pain. Spine 2005;30:2369-2377.
Pauza KJ, Howell S, Dreyfuss P, et al: A randomized, placebo-controlled trial of intradiscal electrothermal therapy for the treatment of discogenic low back pain. Spine J 2004;4:27-35.
Wetzel FT, McNally TA: Treatment of chronic discogenic low back pain with intradiskal electrothermal therapy. J Am Acad Orthop Surg 2003;11:6-11.

Question 85:

Massive cortical structural allografts are commonly used in oncologic and arthroplasty surgery. What percent of cortical structural allografts fracture due to insufficiency?

Options:

1 0% to 5%
2 15% to 30%
3 50% to 60%
4 70% to 80%
80% to 100%

Correct Answer: 2 15% to 30%

Explanation:

Question 86:

Options:

Immediate closed reduction in the intensive care unit while the patient is awake
Posterior spinal laminectomy and fusion with instrumentation
Anterior cervical diskectomy, corpectomy, and plating
High-dose methylprednisolone

Correct Answer: Immediate closed reduction in the intensive care unit while the patient is awake

Explanation:

DISCUSSION
Facet subluxation reduction may be performed in awake patients. Posterior spinal laminectomy and fusion can result in worsening neurologic status and is not recommended in this setting. Generally, corpectomy in the setting of facet subluxation is not recommended because it does not facilitate reduction or fully alleviate spinal cord compression. High-dose steroid use is not supported by current literature.
RECOMMENDED READINGS
Fehlings MG, Perrin RG. The timing of surgical intervention in the treatment of spinal cord injury: a systematic review of recent clinical evidence. Spine (Phila Pa 1976). 2006 May 15;31(11 Suppl):S28-35; discussion S36. Review. PubMed PMID: 16685233.
View Abstract
at PubMed
Lee AS, MacLean JC, Newton DA. Rapid traction for reduction of cervical spine dislocations. J Bone Joint Surg Br. 1994 May;76(3):352-6. PubMed PMID: 8175833.
View Abstract at
PubMed

Question 87:

Options:

The role her husband will play in the decision to proceed with surgery
Her role as primary caregiver in the household
Dietary concerns during her hospitalization
Daily cleansing rituals that may affect wound care
The importance of maintaining modesty precautions during examination, surgery, and postoperative appointments

Correct Answer: The importance of maintaining modesty precautions during examination, surgery, and postoperative appointments

Explanation:

DISCUSSION: In considering faith-based issues regarding treatment of this patient, the presence of her husband for the office visit would imply an agreement with her decision to have surgery. It also may facilitate her examination. Her role as caregiver, dietary concerns, and cleansing rituals are less important considerations with an outpatient-based procedure. Privacy concerns remain paramount to Muslim women, which include limited exposure during examination, during surgery, and in subsequent follow-up visits.
REFERENCE: Jimenez R, Lewis VO (eds): Culturally Competent Care Guidebook. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007.

Question 88:

A 72-year-old woman who fell on her right shoulder while using a treadmill is now unable to elevate her right arm. An MRI scan is shown in Figure 7. What is the most likely diagnosis?

Options:

Axillary nerve injury
Anterior dislocation
Extension of a chronic large rotator cuff tear
Suprascapular nerve entrapment from a ganglion cyst
Greater tuberosity avulsion

Correct Answer: Extension of a chronic large rotator cuff tear

Explanation:

Question 89:

This image represents the end stage of an uncompensated rotator cuff tear.

Options:

Figure 59a is the CT image of an 86-year-old woman with acromiohumeral distance of less than 2 mm, night pain, and an inability to actively raise the affected arm above shoulder level.
Figure 59b is the radiograph of a 45-year-old man with acromiohumeral distance equal to 7 mm. He is able to actively raise his arm above shoulder level, has lateral arm pain,
and abduction and external rotation weakness. 56
Figures 59c and 59d are the radiographs of a 72-year-old man with night pain and reduced range of motion.

Correct Answer: Figure 59a is the CT image of an 86-year-old woman with acromiohumeral distance of less than 2 mm, night pain, and an inability to actively raise the affected arm above shoulder level.

Explanation:

DISCUSSION
Axillary lateral and anteroposterior (AP) images of the right shoulder (Figures 59c and 59d) reveal osteoarthrosis of the glenohumeral joint, which typically is not associated with significant rotator cuff pathology. An examination often shows limitations in range of motion, crepitance, and pain with motion. An AP radiographic image of the right shoulder (Figure 59b) reveals proximal humeral migration, which normally correlates with rotator cuff tear size. Tears extending into the infraspinatus tendon are associated with more humeral migration than is seen with isolated supraspinatus tears. Presenting complaints are usually of pain and weakness. Examination findings include subacromial crepitance and weakness during rotator cuff testing. Rarely, this may be associated with pseudoparalysis in large uncompensated rotator cuff tears. The CT image of the right shoulder (Figure 59a) shows superior migration of the humerus with respect to the glenoid surface and end-stage
degenerative changes at the glenohumeral joint. These changes are classified as rotator cuff arthropathy. Pain and weakness are common, as is the presence of pseudoparalysis and limited range of motion.
RECOMMENDED READINGS
Kelly JD Jr, Norris TR. Decision making in glenohumeral arthroplasty. J Arthroplasty. 2003 Jan;18(1):75-82. Review. PubMed PMID: 12555187.
View Abstract at PubMed
Keener JD, Wei AS, Kim HM, Steger-May K, Yamaguchi K. Proximal humeral migration in shoulders with symptomatic and asymptomatic rotator cuff tears. J Bone Joint Surg Am. 2009 Jun;91(6):1405-13. doi: 10.2106/JBJS.H.00854. PubMed PMID:

Question 90:

Options:

Nondisplaced fracture
Open fracture
Severely comminuted fracture
Dorsal perilunate dislocation
Repeated attempts at reduction

Correct Answer: Nondisplaced fracture

Explanation:

Question 91:

Options:

debridement of the skin edges, closure of the wound, and administration of an oral cephalosporin for 10 days.
a saline load test.
arthroscopic examination of the knee.
leaving the wound open, administration of an oral cephalosporin, and reevaluation in 48 hours.
injection of contrast material into the laceration, followed by radiographic studies.

Correct Answer: a saline load test.

Explanation:

Question 92:

Among patients with adolescent idiopathic scoliosis, a thoracolumbosacral orthosis is most effective for which type of curve?

Options:

Apex of the curve is at T3
Apex of the curve is at T8
Apex of the curve is at L1
Apex of the curve is at L2

Correct Answer: Apex of the curve is at T8

Explanation:

DISCUSSION
A thoracolumbosacral orthosis is most effective for bracing of curves when the apex is at T7 or below. Bracing is used for patients who are skeletally immature (Risser stage 0, 1, or 2), and it is recommended that the brace be worn 16 to 23 hours per day and continued until skeletal maturity or until the curve progresses to beyond 45 degrees, at which point bracing is no longer considered effective.
RECOMMENDED READINGS
Luhmann SJ, Skaggs DL: Pediatric spine conditions, in Lieberman JR (ed):
AAOS Comprehensive Orthopaedic Review. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2009, pp 245-265.
Shaughnessy WJ. Advances in scoliosis brace treatment for adolescent idiopathic scoliosis. Orthop Clin North Am. 2007 Oct;38(4):469-75, v. Review. PubMed PMID: 17945126.
View Abstract at PubMed

Question 93:

Options:

Microdiskectomy
Posterior decompression
Posterior decompression and fusion
Anterior lumbar interbody fusion

Correct Answer: Posterior decompression and fusion

Explanation:

DISCUSSION
This patient radiographically has L4-5 degenerative stenosis and a low-grade spondylolisthesis. The axial images demonstrate a gap in the facet joint, more on the left than the right, which is highly suggestive of dynamic instability. Thus, this patient would most benefit from a laminectomy and fusion of L4-5. A microdiskectomy would not be helpful as this patient does not have a disk herniation. Patients undergoing posterior decompression alone experience an unacceptably high rate of recurrent stenosis and/or progression of spondylolisthesis. Early studies demonstrated that adding an intertransverse process fusion to posterior decompression significantly improved clinical outcomes. Anterior interbody fusion likely will not decompress the spinal canal sufficiently, though there is some thought that indirect decompression can be effective in some cases.
RECOMMENDED READINGS
Frymoyer JW. Degenerative Spondylolisthesis: Diagnosis and Treatment. J Am Acad Orthop Surg. 1994 Jan;2(1):9-15. PubMed PMID: 10708989. Majid K, Fischgrund JS. Degenerative lumbar spondylolisthesis: trends in management. J Am Acad Orthop Surg. 2008 Apr;16(4):208-15. Review. PubMed PMID: 18390483.
View
Abstract at PubMed
Carlisle E, Fischgrund JS. Lumbar spinal stenosis and degenerative spondylolisthesis. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006: 299-317.
Puschak TJ, Sasso RC. Spondylolysis-spondylolisthesis. In: Vaccaro AR, ed. Orthopaedic Knowledge Update 8. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2005:553-563.

Question 94:

Options:

minimal activity.
moderate activity compared to the supraspinatus.
significant activity with a supraspinatus tear.
significant activity with an intact supraspinatus.
significant activity with both intact and torn rotator cuffs.

Correct Answer: minimal activity.

Explanation:

Question 95:

Options:

There is a significantly higher risk of infection.
There is a significantly higher risk of growth disturbance.
There is a significantly higher risk of arthrofibrosis and loss of knee motion.
There is a significantly higher risk of graft failure and need for revision surgery.
There is a significantly higher risk of graft failure in low-dose (<2 Mrad) gamma-irradiated allografts only.

Correct Answer: There is a significantly higher risk of infection.

Explanation:

Question 96:

Options:

Continued semi-rigid immobilization until the extremity surgeries are completed
Halo skeletal fixation prior to the extremity surgery
Definitive clearance of the cervical spine with CT and/or MRI
Removal of the semi-rigid collar and physical examination when the patient is responsive
Soft collar immobilization and local wound care

Correct Answer: Definitive clearance of the cervical spine with CT and/or MRI

Explanation:

DISCUSSION: Ackland and associates demonstrated that the failure to achieve early spinal clearance in an unconscious blunt trauma patient predisposed the patient to increased morbidity secondary to the prolonged used of cervical immobilization. They demonstrated that the four significant predictors of collar-related ulcers were ICU admission, mechanical ventilation, the necessity for cervical MRI, and the time to cervical spine clearance and collar removal. The risk of pressure-related ulceration increased by 66% for every 1-day increase in Philadelphia collar time and this highlights the need for definitive C-spine clearance.
REFERENCES: Ackland HM, Cooper DJ, Malham GM, et al: Factors predicting cervical collar-related decubitus ulceration in major trauma patients. Spine 2007;32:423-428.
Hewitt S: Skin necrosis caused by semi-rigid cervical collar in a ventilated patient with multiple injuries. Injury 1994;25:323-324.

Question 97:

Options:

release of the latissimus dorsi and teres major.
release of the subscapularis and pectoralis major.
passive range-of-motion exercises.
exploration of the brachial plexus.
functional bracing.

Correct Answer: passive range-of-motion exercises.

Explanation:

DISCUSSION: Injury to the upper trunk of the brachial plexus during birth (Erb’s palsy) occurs in approximately 1 in 3,000 births. In a complete lesion, paralysis of the deltoid, supraspinatus, infraspinatus, teres minor, biceps, and brachioradialis results in the findings described above. Spontaneous recovery may occur for up to 2 years. Passive exercises administered daily by the parents are the initial recommended treatment at this age. If significant contracture results in posterior dislocation, surgical correction may be considered.
REFERENCES: Neer CS: Shoulder Reconstruction. Philadelphia, PA, WB Saunders, 1990,
pp 452-454.
Pearl ML: Arthroscopy release of shoulder contracture secondary to birth palsy: An early report on findings and surgical technique. Arthroscopy 2003;19:577-582.
Pearl ML, Edgerton BW, Kon DS, et al: Comparison of arthroscopic findings with MRI and arthrography in children with GH deformity secondary to brachial plexus birth palsy. J Bone Joint Surg Am 2003;85:890-898.

Question 98:

The anterior portal of a hip arthroscopy places what structure at greatest risk for injury?

Options:

Ascending branch of the lateral circumflex femoral artery
Ascending branch of the medial circumflex femoral artery
Femoral nerve
Lateral femoral cutaneous nerve
Superior gluteal nerve

Correct Answer: Lateral femoral cutaneous nerve

Explanation:

DISCUSSION: The average location of the anterior portal is 6.3 cm distal to the anterior superior iliac spine. The lateral femoral cutaneous nerve typically has divided into three or more branches at the level of the anterior portal. The portal usually passes within several millimeters of the most medial branch. Injury to the nerve can lead to meralgia paresthetica. The femoral nerve lies an average minimum distance of 3.2 cm from the anterior portal. The ascending branch of the lateral circumflex artery lies approximately 3.7 cm inferior to the anterior portal. Neither the ascending branch of the medial circumflex artery nor the superior gluteal nerve are
at risk.
REFERENCES: Byrd JWT: Operative Hip Arthroscopy. New York, NY, Thieme Medical Publishers, 1998, pp 83-91.
Arendt EA (ed): Orthopaedic Knowledge Update: Sports Medicine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 281-289.

Question 99:

Options:

Closed reduction and immobilization in a halo-thoracic vest
Halo application and cervical traction for 6 weeks, followed by 8 weeks of immobilization in a halo-thoracic vest
Open reduction, decompression, and fusion with anterior-posterior stabilization
Open reduction, anterior decompression, and fusion
Uninstrumented posterior fusion spanning the injured segment

Correct Answer: Open reduction, decompression, and fusion with anterior-posterior stabilization

Explanation:

The patient has a hyperostotic condition of the cervical spine, most likely ankylosing spondylitis. Because of a rigid and osteoporotic spine, relatively minor falls can result in unstable spinal injuries with significant instability and a high risk for neurologic sequelae. The patient has an unstable injury at C6 with an incomplete spinal cord injury, necessitating urgent decompression and stabilization. Studies have shown that, in patients with ankylosing spondylitis, stand-alone anterior stabilization results in a high failure rate. Halo-thoracic vests carry a high risk of septic and pulmonary issues, especially in the elderly. Uninstrumented fusion will provide insufficient stability in such patients.
(SBQ13PE.22) A 11-year-old male is referred for evaluation of scoliosis by his primary care physician. He has a normal birth and development history and denies any neurologic deficits or pain. On physical examination, he is neurologically intact with normal reflexes and tone. A PA radiograph is shown in Figure A. What is the next best step?
Review Topic
Custom orthosis prescription to initiate bracing
Physical therapy referral and observation
Bending and lumbar oblique radiographs
Total spine CT
Total spine MRI
A left thoracic curve is an abnormal finding and warrants further work-up with a total axis MRI in order to rule out concomitant neurologic abnormalities such as a spinal cord cyst and/or syrinx.
In adolescent idiopathic scoliosis (AIS), the most commonly occurring curve is a right thoracic curve. Left thoracic curves are not as common, and warrants total axis MRI in order to rule out concomitant central axis abnormalities. This is imperative not only during initial work-up, but most importantly for operative planning.
Spiegel et al. performed a a retrospective radiographic review on 41 patients with scoliosis associated with a Chiari I malformation and/or syringomyelia. Approximately 50% of patients had an "atypical" pattern (left thoracic, double thoracic, triple, long right thoracic). The authors recommend that MRI should be considered in these patients.
Gillingham et al. provides a thorough review of early onset scoliosis and notes the relatively high incidence of concurrent central axis abnormalities, even in patients with normal neurologic exams. Rates have been reported upwards of 21.7%, with malformations including Chiari Type 1, dural ectasias, syrinx, and spinal cord cysts.
Figure A exhibits a left thoracic curve. Further imaging in this patient revealed a syrinx which required decompression.
Incorrect answers:
thoracic
curve.

Question 100:

Options:

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

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

Explanation:

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

Orthopedic Surgery Board Review MCQs: Arthroplasty, Trauma & Spine Part 255

Orthopedic Surgery Board Review MCQs: Trauma, Hand, Ligament | Part 163

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 163

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index