Orthopedic Board Review MCQs: Knee & Trauma | Part 165

About This Board Review Set

This is Part 165 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 165

This module focuses heavily on: Cartilage, Deformity, Knee, Ligament, Trauma.

Sample Questions from This Set

Sample Question 1: A 35-year-old woman reports an 8-week history of neck pain radiating to her right upper extremity. She denies any history of trauma or provocative event. Examination reveals decreased pinprick sensation in her right middle finger, otherwise...

Sample Question 2: A previously asymptomatic 12-year-old girl sustained a direct blow to the right lateral knee from a baseball bat. Examination reveals an area of ecchymosis and tenderness over the lateral thigh. The patient can walk without pain, but range ...

Sample Question 3: Which of the following rehabilitation techniques is appropriate for initial nonsurgical management of an isolated grade 2 posterior cruciate ligament injury? Review Topic...

Sample Question 4: Which factor is a contraindication to surgical treatment of a symptomatic CAM deformity?...

Sample Question 5: A patient undergoes cartilage implantation requiring amplification of donor cells. Which of the following statements best describes the transplants?...

Why Active MCQ Practice Works

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

Comprehensive 100-Question Exam

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Question 1

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

Explanation

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

Question 2

A previously asymptomatic 12-year-old girl sustained a direct blow to the right lateral knee from a baseball bat. Examination reveals an area of ecchymosis and tenderness over the lateral thigh. The patient can walk without pain, but range of motion of the knee causes discomfort. Plain radiographs of the knee are shown in Figures 11a and 11b. To address the bone lesion, management should consist of

Explanation

DISCUSSION: The plain radiographs reveal a pedunculated osteochondroma with a fracture. There is a bony growth in the metaphysis of a long bone, on a stalk that is directed away from the nearby epiphysis. On the AP view, the host cortical and medullary bone are shown as “blending” with lesional bone. There is also a fracture through the lesion. Based on these radiographic findings, the diagnosis is an osteochondroma; therefore, initial management of an acute fracture of an osteochondroma is symptomatic treatment alone. Additional imaging studies are not indicated in this patient. At times it may be difficult to distinguish a sessile osteochondroma from a parosteal osteosarcoma. In the latter case, the host medullary bone and lesion bone are not confluent. A CT scan may be helpful to distinguish if the host medullary and cortical bone are confluent with the lesion.
REFERENCE: Davids JR, Glancy GL, Eilert RE: Fracture through the stalk of pedunculated osteochondromas: A report of three cases. Clin Orthop 1991;271:258-264.

Question 3

Which of the following rehabilitation techniques is appropriate for initial nonsurgical management of an isolated grade 2 posterior cruciate ligament injury? Review Topic

Explanation

Treatment should consist of relative protection for 10 to 14 days followed by early range of motion and gentle closed-chain quadriceps strengthening. Isolated grade 1 and grade 2 posterior cruciate ligament injuries can be successfully managed nonsurgically. Progression to global knee strengthening can begin 4 to 6 weeks after the injury, with return to functional activity when full range of motion and strength is established. Plyometric exercises involve rapid alteration of contraction and loading of a muscle and should not be used in the early rehabilitation of a ligament injury of the knee because it risks further injury to the ligament. Hamstring strengthening should be avoided until the ligament has healed (4 to 6 weeks) because the posterior force on the tibia will stress the injured posterior cruciate ligament. Immobilization may be used for a short time to allow swelling and pain to subside, but early range of motion is preferred to avoid unnecessary stiffness following the stable injury.

Question 4

Which factor is a contraindication to surgical treatment of a symptomatic CAM deformity?

Explanation

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

Question 5

A patient undergoes cartilage implantation requiring amplification of donor cells. Which of the following statements best describes the transplants?

Explanation

DISCUSSION: Chondrocytes are obtained from cartilage harvested from non-weight-bearing areas of the knee. The extracellular matrix is digested, and the chondrocytes are expanded for later transplantation. Cells implanted into a defect are secured with a flap of periosteum. Cells are expanded to obtain 20 to 50 times the original number of cells to transplant at a cell density of 3x10^-7 cells/mL. There is a direct relationship between cell number and biosynthetic activity. Osteochondral lesions of up to 8 mm may be treated with autologous transplant alone; larger depth lesions should be bone grafted at the time of harvest. Mesenchymal stem cells differentiate easily into fibrous tissue, bone, and fat; conversion of mesenchymal stem cells into cartilage in vitro currently is difficult to accomplish. Goldberg and Caplan, however, were able to obtain cartilage repair using mesenchymal stem cells transplanted into defects in rabbits in vivo. In animal studies, fluorescent-labeled cells persist for at least 14 weeks, integrate with the surrounding normal margins, and become part of the repaired tissue replete with sulfated proteoglycans and type II collagen.
REFERENCES: Brittberg M, Peterson L, Sjogren-Jansson E, et al: Articular cartilage engineering with autologous chondrocyte transplantation. J Bone Joint Surg Am

2003;85:109-115.
Caplan AI, Elyaderani M, Mochizuki Y, et al: Principles of cartilage repair and regeneration. Clin Orthop 1997;342:254-269.

Question 6

A 47-year-old man has left-sided motor weakness in the extensor digitorum longus and extensor hallucis longus, sensory loss in the lateral calf and dorsal foot, and no discernible reflex loss.

Explanation

DISCUSSION
Figures 72a and 72b are the T1-weighted MR images of a disk bulge. Disk bulges are common in asymptomatic people and are not predictive of pathology. Figures 72c and 72d show T1 MR images of a far lateral disk herniation at the L4-L5 level. This would affect the exiting or L4 nerve root. Radicular symptoms would occur at the L4 level. Figures 72e and 72f show an annular tear at the L4-L5 level. This pathology is associated with discogenic low-back pain. Figures 72g and 72h show the T1 MR images of a central lateral disk herniation at the L4-L5 level. This would affect the traversing or L5 nerve root. Radicular symptoms would occur at the L5 level.
RECOMMENDED READINGS
Jarvik JG, Hollingworth W, Heagerty PJ, Haynor DR, Boyko EJ, Deyo RA. Three-year incidence of low back pain in an initially asymptomatic cohort: clinical and imaging risk factors. Spine (Phila Pa 1976). 2005 Jul 1;30(13):1541-8; discussion 1549. PubMed PMID: 15990670.View Abstract at PubMed
Hoppenfeld S. Physical Exam of the Spine and Extremities. Stamford, CT: Appleton and Lange; 1995.
Madigan L, Vaccaro AR, Spector LR, Milam RA. Management of symptomatic lumbar degenerative disk disease. J Am Acad Orthop Surg. 2009 Feb;17(2):102-11. Review. PubMed PMID: 19202123.View Abstract at PubMed

Question 7

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

Explanation

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

Question 8

A study is proposed in which 2 groups of patients are randomized to treatment with bisphosphonates or placebo. This is an example of what study type?

Explanation

In a parallel design trial, participants are randomized to 2 or more groups, each of which receives a different treatment or intervention. For example, Group A receives the drug and Group B receives the placebo. This type of design allows for comparison between groups. In a crossover design clinical trial, both groups receive both interventions over a defined time period. For example, Groups A and B both receive the drug as well as the placebo. This allows for within-participant comparisons. In a cohort study, patient groups are followed over time on the basis of having or not having received an exposure. Cohort studies are not randomized. In a case series, patients often receive a particular treatment and the outcomes are then examined.

Question 9

A patient sustains a comminuted calcaneus fracture. Three months after the injury the patient complains of shoewear problems secondary to clawing of the lesser toes. What is the most likely explanation for this deformity?

Explanation

DISCUSSION: Contracture of the intrinsic flexor muscles of the foot can be the result of unrecognized foot compartment syndrome. Foot compartment syndrome is a known complication of calcaneus fractures.
Myerson reported 3/43 patients in his series below had chronic foot compartment syndrome. There are 9 compartments in the foot: (1) medial, (2) superficial, (3) lateral, (4) adductor, (5-8) four interossei, and (9) calcaneal. The plantar fascia limits the space available for hematoma and swelling, causing damage to the intrinsic flexors of the foot (particularly the lumbricals and interossei), resulting in clawtoes.

Question 10

A female cross-country runner has an insidious onset of right groin pain. Radiographs of the right hip reveal a tension-side stress fracture. History reveals that she was treated for a “foot” fracture 1 year ago. In addition to performing internal fixation of the femoral neck, which of the following should be obtained?

Explanation

DISCUSSION: Stress fractures in female long distance runners are frequently associated with the Female Athletic Triad. The triad consists of osteoporosis, amenorrhea, and altered eating habits. A thorough menstrual history, including age of menarche, history of amenorrhea, and use of oral contraceptives, is imperative. Amenorrhea leads to osteoporosis and predisposes the athlete to fractures. An MRI of the hip is not necessary because a fracture is evident on the radiograph. Serum calcium levels are normal in osteoporosis, a family history would be noncontributory, and it is highly unlikely that a contralateral hip radiograph will yield useful information.
REFERENCES: Bennell KL, Malcolm SA, Thomas SA, et al: Risk factors for stress fractures in track and field athletes: A twelve-month prospective study. Am J Sports Med 1996;24:810-818.
Barrow GW, Saha H: Menstrual irregularity and stress fractures in collegiate female distance runners. Am J Sports Med 1988;16:209-216.

Question 11

Figure 17 shows the AP radiograph of a 5-year old child who has mild short stature and a painless bilateral gluteus medius lurch. Initial work-up should include

Explanation

DISCUSSION: Bilateral flattening of the femoral heads suggests multiple epiphyseal dysplasia; therefore, a skeletal survey is indicated to look for involvement of other epiphyses. Unilateral flattening of the femoral head would suggest Legg-Perthes disease.
REFERENCES: Sponseller PD: Skeletal dysplasias, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 269-270.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 1, pp 689-691.

Question 12

Metastatic disease of several cancers create lytic lesions because these cancers:

Explanation

Several cancers directly produce receptor activator of nuclear factor kappa beta ligand (RANKL) which leads to bone resorption and the lytic lesions seen on radiographs.
Cancers that originate or metastasize to bone can be blastic, lytic, or mixed when viewed on radiographs. Lytic lesions appear radiolucent due to bone resorption that occurs around the cancer cells. This is secondary to direct production and release of RANKL by the cancer cells themselves. RANKL then stimulates osteoclastogenesis and an increase in local bone resorption. Denosumab is a monoclonal antibody against RANKL that has been shown to decrease rates of pathologic fractures.
Lynch et al. review the progression of metastatic disease. They note that cancer cells can stimulate both osteogenesis and osteolysis, and that this pathologic increase in bone matrix turnover is what allows the cancer to progressively expand or metastasize to distant sites. They discuss the role of matrix metalloproteinases as primary regulators of this process.
Illustration A is a diagram illustrating how the binding of RANKL to receptors on the surface of osteoclast precursors activates them and begins the process of bone resorption. Cancer cells can directly produce RANKL thus increasing the rate of local bone resorption.
Incorrect Answers:

Question 13

What property of titanium alloys accounts for their high corrosion resistance in vivo?

Explanation

DISCUSSION: In both room temperature air and physiologic fluids, titanium alloys self-passivate or spontaneously form a layer of titanium oxide very rapidly. This layer makes titanium alloys resistant to surface breakdown.
REFERENCES: Callaghan JJ, Rosenberg AG, Rubash HE, et al (eds): The Adult Knee. Philadelphia, PA, Lippincott, 2003, vol 1, pp 269-278.
Lemons JE: Metallic alloys, in Morrey BF (ed): Joint Replacement Arthroplasty, ed 3. Philadelphia, PA, Churchill-Livingstone, 2003, pp 19-27.

Question 14

Figure 3 is the clinical photograph of a 20-year-old college soccer player who has a 7-day history of worsening left ankle pain and swelling after being slide-tackled in a game. Radiograph findings of his ankle and foot are normal. He complains of malaise. His history includes a severe ankle sprain 3 months ago. The sprain caused him to miss half the season, but he was able to play in the last 2 games. What is the most appropriate treatment? Review Topic

Explanation

The clinical photograph shows a skin infection with an appearance consistent with methicillin-resistant Staphylococcus aureus. This infection should be clinically incised and allowed to drain and a course of antibiotics should follow. If this infection is not promptly treated with debridement, it likely will worsen and potentially spread to other teammates. Antibiotics are secondary to surgical debridement but are a necessary adjunct. Although this patient has a history of severe sprain, his malaise and skin appearance do not correlate with a ligament injury or fracture. Debridement in the training room is not appropriate and would likely not fully decompress the fluid collection.

Question 15

An 76-year-old woman falls from standing and sustains the injury shown in Figure A. Her most recent T score was -1.9, 3 months prior to presentation. If labwork were performed, which values would be consistent with her bone density score?

Explanation

In osteopenia, elevated parathyroid hormone (PTH), high alkaline phosphatase as well as low calcium (Ca), phosphorus and vitamin D would be expected.
In the setting of osteopenia/osteoporosis, there is a positive feedback to increase PTH in response to low serum calcium levels. In response, there is a corresponding increase in alkaline phosphatase and decrease in phosphorous and circulating vitamin D levels.
Fraser writes a concise, yet thorough synopsis on primary and secondary hyperparathyroidism. In the article, the summary regarding osteopenia/osteoporosis (typically a state of hypovitamin D) begins by stating an initial state of decreased ionised calcium, which increases PTH, results in 3 primary effects: an attempt to increase gut absorption of Ca, mobilize Ca from the bone via osteoclasts and activate vitamin D at the kidney (1,25-vitamin D).
Figure A exhibits a left femoral neck fracture, which is a fragility fracture associated with poor bone density. Illustration A is a figure from Fraser's article exhibiting the feedback loop from the hypothalamus, pituitary, adrenal/glandular axis.
Incorrect answers:

Question 16

Figure 33a shows a line drawing of a normal hemipelvis. The anterior acetabular rim is bold. Figure 33b illustrates a hemipelvis with a crossover sign, which is indicative of what acetabular pathology? Review Topic

Explanation

In a normal AP pelvis radiograph, the anterior rim of the acetabulum runs medially and distally, diverging from the posterior rim which runs much more vertically. In excessive acetabular retroversion, the anterior rim (bold line in Figure 33b) and posterior rim start laterally, and as these lines progress medially and distally, the anterior line crosses the posterior line. This predisposes to femoral acetabular impingement.

Question 17

03 A 23 year old sustains an isolated right knee dislocation in an MVA. A closed reduction is performed and confirmed with radiographs. What is the next appropriate study?

Explanation

This is simple A, B, Cs and doctoring. History and Physical exam come first. Noninvasive assessement includes visual inspection, clinical examination (feel pulses, check capillary refill, feel temperature of skin), and ABIs. X-ray, CT, and MRI would be good secondary studies to identify bony or soft tissue injuries—after initial reduction and splinting/stabilizatoin. Angiography would be indicated if there were asymmetric pulses or an ABI < 0.9, or if there was any other indication that a vessel injury may have occurred.
OKU Truama 2 says “the use of ABI with the blood pressure cuff and Doppler evaluation of the distal circulation has been proposed as effective in determining any occult vascular injury. A ratio > 0.9indicates a normal study.”[1] The referenced article confirms this. “Confirmation of the safety and accuracy of physical exam in the evaluation of knee dislocation for injury of the popliteal artery.” J. Trauma2002; 52: 247-252
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[1] OKU Trauma 2 pg 151-153

Question 18

Which of the following is the most sensitive parameter to detect the increased inflammatory response seen with both postoperative infection and the use of instrumentation in spinal surgery?

Explanation

CORRECT
DISCUSSION: The most sensitive parameter to detect inflammation elicited by implants and infection is the C-reactive protein (CRP).
CRP is an acute phase reactant that increases sharply immediately after surgery within 6 hours after tissue damage. CRP then peaks 2-3 days later and returns to normal levels 5-21 days after the inciting event. In contrast, ESR reaches its peak on days 4-11, then remains elevated for a prolonged period of time.
Takahashi et al performed a Level 3 study of patients who had undergone spinal surgery with and without instrumentation, with a primary outcome of infection. They concluded that renewed elevation of C-reactive protein, white blood cell count, and body temperature after postoperative days 4 to 7 may be a key indicator of postoperative infection.

Question 19

A computed tomography (CT) scan has been shown to be indicated for evaluation of all of the following aspects of acetabular fractures, EXCEPT:

Explanation

DISCUSSION: CT scanning is indicated in acetabular fractures for determination of surgical approach and techniques, evaluation of marginal impaction and presence of intra-articular loose bodies (especially after hip dislocation), and evaluation of fracture piece sizes and relative positions. Kellam et al reviewed their initial experience
with CT scanning and acetabular fractures, and noted a 25% change in surgical planning when CT was utilized versus plain radiographs; they also noted the ability to detect marginal impaction and fracture size/position was improved with CT.

Question 20

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 21

A 65-year-old woman has significant neck pain after falling and striking her head. A radiograph and sagittal CT scan are shown in Figures 23a and 23b. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiograph shows a displacement of C5 on C6 of approximately 25%. The CT scan shows a perched facet at C5-6. There is no evidence of a facet fracture. A bilateral facet dislocation would show a displacement of more than 50%.
REFERENCES: Rothman RH, Simeone FA (eds): The Spine, ed 4. Philadelphia PA, WB Saunders, 1999, pp 927-937.
Vaccaro AR, Betz RR, Zeidman SM (eds): Principles and Practice of Spine Surgery. St Louis, MO, Mosby, 2003, pp 455-458.

Question 22

Ten years after undergoing TKA, a 77-year-old woman experiences 2 weeks of pain, swelling, and erythema following a routine dental cleaning procedure (Figures 109a and 109b). Her erythrocyte sedimentation rate is 25 mm/h (reference range 0-20 mm/h), her C-reactive protein level is 1.7 mg/L (reference range, 0.08-3.1 mg/L), and alpha-defensin findings are negative.

Explanation

DISCUSSION
Managing complications following a failed TKA requires an understanding of the mode of failure and treatment principles. Generally, TKA can fail for the following reasons: infection, instability, aseptic loosening, stiffness, and extensor mechanism dysfunction.
Managing an infected TKA requires knowledge of the timing and circumstances surrounding the infected implant. Patients with acute infections (symptom duration of fewer than 3 weeks) are candidates for debridement and prosthesis retention. Chronic infections (symptoms lasting longer than 3 weeks and for more than 3 months from the time of index arthroplasty) should be treated with resection arthroplasty, parenteral antibiotics, and reimplantation surgery at a later date. Evaluation of possible acute infections should include aspiration, serology, and alpha-defensin.
Instability following TKA is a common cause of early failure and revision surgery. The etiology of instability can include overresection of the posterior condyles, collateral ligament insufficiency, and late rupture of the posterior cruciate ligament. Recognizing the cause of instability is critical to eventual successful revision. Typically, isolated polyethylene exchange is not effective or reliable to address instability. In many cases, component malrotation and ligament imbalance contribute to instability. Revision surgery focuses on restoration of the joint line, proper femoral and tibial component rotation, and restoration of the femur posterior condylar.
Component loosening and osteolysis are the common mechanisms of TKA failure. Prior to revision, concurrent infection must be ruled out as a source of failure. At the time of revision, proper fixation and rotation of the femoral and tibial components must be ensured. If the components are well fixed and rotated, successful isolated bearing exchange and bone grafting in the setting of osteolysis is possible. Isolated component exchanges also can be successfully performed, provided the remaining components are in an acceptable position. However, when in doubt, revision of both components generally yields more consistent results.
Stiffness following TKA can affect as many as 10% of patients following surgery. Depending on the timing and extent of arthrofibrosis, treatment options include manipulation under anesthesia or revision TKA. Manipulation typically is effective early during the postsurgical
course (for up to 4 months) and is most effective for loss of flexion. To address chronic stiffness and arthrofibrosis, revision TKA offers modest improvements in range of motion. Isolated polyethylene exchange has proven inconsistent in this setting, so revision of both components to ensure proper component rotation and joint line restoration offers the best chance to improve range of motion.
Extensor mechanism complications also can occur following TKA. Although the frequency is decreasing with improved component design and surgical techniques, periprosthetic patella fractures can occur. Treatment centers on the integrity of the extensor mechanism and fixation of the patellar component (if resurfaced). In general, if the extensor mechanism is intact, nonsurgical treatment is favored. Surgical treatment of periprosthetic patellar fractures following TKA has been associated with high complication rates and low healing rates.

Question 23

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

Explanation

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

Question 24

A 10-year-old girl is treated for a tibia/fibula fracture with a long leg cast. The on-call resident is called to evaluate the patient for increasing pain medicine requirements and tingling in her foot. Examination of the cast reveals that the ankle has been immobilized in 10 degrees of dorsiflexion. What ankle position results in the safest compartment pressures in a casted lower leg?

Explanation

DISCUSSION: Agitation, anxiety, and increasing analgesic requirments are the "3 A's" of pediatric compartment syndrome.
Weiner et al measured intramuscular compartment pressure in the anterior and deep posterior compartments of the leg in seven healthy adults who had long leg casts placed. They found that in a casted leg the intramuscular pressure in the anterior compartment was lowest with the ankle in neutral, and the deep posterior compartments was lowest when the ankle joint was in the resting position to approximately 37 degrees of plantar flexion. Based on this, they concluded that the safest ankle casting position regarding compartment pressure is between 0 and 37 degrees of plantar flexion. After the cast was bivalved, they noted a significant decrease in intramuscular pressure of 47 per cent in the anterior compartment and of 33 per cent in the deep posterior compartment. Constrictive casts and abberant ankle positioning can exacerbate pain/symptoms. Loosening of the cast by bivalving, spreading, and cutting underlying stockinette/softroll should always be the first step in management of possible compartment syndrome.

Question 25

A patient who underwent a L4-L5 hemilaminotomy and partial diskectomy for radiculopathy 8 weeks ago now reports increasing low back pain without neurologic symptoms. A sagittal T2-weighted MRI scan is shown in Figure 13a, and a contrast enhanced T1-weighted MRI scan is shown in Figure 13b. What is the most appropriate management for the patient’s symptoms? Review Topic

Explanation

The MRI scans show Modic changes in the L4-L5 vertebral bodies due to spondylosis. There is no increased fluid signal or enhancement in the L4-L5 disk to suggest infection or any other pathologic process. Therefore, the patient’s pain should be treated with a course of physical therapy and rehabilitation. There is no infection; therefore, IV antibiotics and debridement are not indicated. Similarly, a
pseudomeningocele is not present. A revision diskectomy is useful for recurrent radiculopathy but would not be helpful for degenerative low back pain.
(SBQ12SP.29) A 17-year-old female is undergoing posterior instrumented fusion from T5-T12 for adolescent idiopathic scoliosis. At the time of the correction maneuver, the neurophysiologist notifies you of a 60% decrease in somatosensory evoked potential (SSEP) amplitude throughout bilateral lower extremities. Which of the following is an acceptable approach to manage this finding? Review Topic
Immediate wake-up test with examination for clonus
Drop the mean arterial pressure (MAP) to ~60mmHg
Discontinue instrumentation and optimize MAP to 85mmHg or greater
Immediate infusion of intravenous corticosteroids
Modification of the anesthesia plan to include inhalational agents only followed by repeated SSEP testing
The patient has a significant drop in SSEP amplitudes at the completion of the corrective maneuver. The most appropriate response is to raise the MAP to 85 mmHg or greater, discontinue the instrumentation, re-evaluate the SSEPs, and if there is no improvement, to consider reversing the reduction of the deformity.
Intra-operative neurophysiologic monitoring is an effective method to monitor insults to the spinal cord and its exiting roots during spinal instrumentation. The common measurements include SSEPs, which monitor sensory potentials transmitted through the dorsal column system, and motor-evoked potentials (MEPs), which monitor motor response to a trans-cranial stimulus. Decreases in amplitude and latency of the circuits are recorded, however diminished signal amplitudes are more sensitive for neurologic injury, and decreases of of >50-60% being highly concerning. The wake-up test involves reversal of anesthesia so that an intra-operative neurologic examination can be performed.
Devlin et al. reviewed the basic science and practice of neurophysiologic monitoring in spine surgery. They proposed an algorithmic approach to managing intraoperative alerts which include discontinuation of inhalational anesthetics, increasing the MAP to >90 mmHg, discontinuing instrumentation, and performing a wake-up test if neurologic signals fail to normalize.
Herdmann et al. reviewed the practice of neurophysiologic monitoring and the effects of anesthesia upon signal transduction. They report that anesthesia affecting a neuron's intrinsic excitability can alter the results of monitoring. Inhalational anesthetics and decreased MAPs can be responsible for decreased amplitudes.
Vitale et. al. developed a consensus-based intraoperative checklist for management of lost neuromonitoring signals. In this checklist, the first steps across the surgical and anesthetic teams should include: stop the case and announce signal losses to the room, optimize the mean arterial pressure, discuss the status of anesthetic agents, and discuss reversible surgical actions just prior to signal loss.
Incorrect

Question 26

Figures 177a and 177b are the radiographs of a 7-year-old boy with spastic cerebral palsy. He has quadriparetic involvement and is unable to ambulate. He has very limited abduction, 30 degrees of flexion contractures, and pain on abduction. Bilateral varus osteotomies are scheduled with acetabular procedures to improve stability. Which type of acetabular osteotomy should be performed?

Explanation

Question 27

What structure provides the major blood supply to the humeral head?

Explanation

DISCUSSION: The ascending branch of the anterior circumflex humeral artery provides

the major blood supply to the humeral head. The posterior circumflex humeral artery

supplies a much smaller portion of the proximal humerus. The nutrient humeral artery is the main blood supply for the humeral shaft. The thoracoacromial artery is primarily a muscular branch. The rotator cuff insertions contribute some blood supply to the tuberosities but not a major contribution.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.
Cushner MA, Friedman RJ: Osteonecrosis of the humeral head. J Am Acad Orthop Surg 1997;5:339-346.

Question 28

Anteromedial approach (Ludloff)

Explanation

DISCUSSION
The lateral femoral cutaneous nerve can be injured during a direct anterior approach to the hip. The superior gluteal nerve enters the gluteus medius from posterior to anterior approximately 5 cm above the greater trochanter. This nerve can be injured during the direct lateral and anterolateral approaches to the hip. Branches of the inferior gluteal nerve as well as the sciatic nerve can be injured during the posterior approach, and the obturator nerve can be damaged when performing a medial approach to the hip.

Question 29

Where is the watershed zone for tarsal navicular vascularity?

Explanation

DISCUSSION: The central one third has been established as the watershed zone by angiographic studies, and has been borne out in clinical conditions involving the navicular, such as stress fractures and osteonecrosis. These findings account for the susceptibility to injury at this level.
REFERENCES: Nunley JA, Pfeffer GB, Sanders RW, et al (eds): Advanced Reconstruction: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004,

pp 239-242.
Sarrafian SK: Anatomy of the Foot and Ankle. Philadelphia, PA, JB Lippincott, 1983,

pp 299-302.

Question 30

A right-handed 44-year-old construction worker reports pain and limited range of motion in his right elbow that has limited his ability to work for the past year. Examination reveals range of motion from 60 to 90 degrees, and he has pain at the extremes of flexion and extension. Pronation and supination are minimally restricted. Anti-inflammatory drugs have failed to provide relief. A radiograph is shown in Figure 8. Management should now consist of

Explanation

DISCUSSION: The radiograph reveals primary osteoarthritis of the elbow; therefore, ulnohumeral arthroplasty is the preferred procedure. Patients with severely limited preoperative elbow extension of more than 60 degrees and flexion of less than 100 degrees are at risk for ulnar nerve dysfunction postoperatively and should undergo a concomitant ulnar nerve decompression. Nonsurgical methods are unlikely to improve his chronic condition. Elbow arthroplasty is contraindicated for patients in this age group and with this diagnosis.
REFERENCES: Antuna SA, Morrey BF, Adams RA, et al: Ulnohumeral arthroplasty for primary degenerative arthritis of the elbow: Long-term outcome and complications. J Bone Joint Surg Am 2002;84:2168-2173.
Phillips NJ, Ali A, Stanley D: Treatment of primary degenerative arthritis of the elbow by ulnohumeral arthroplasty: A long-term follow-up. J Bone Joint Surg Br 2003;85:347-350.

Question 31

The patient has no postsurgical complications and begins physical therapy rehabilitation. The boy and his parents stress they “want to get the therapy over with as fast as possible” to expedite his return to sports, and the surgeon and rehabilitation team consider their request. Compared to nonaccelerated rehabilitation, patients who follow an early accelerated rehabilitation protocol experience

Explanation

DISCUSSION
The MR image shows bone bruises (“kissing contusions”) consistent with an ACL tear. During the ACL subluxation event, the posterolateral tibia plateau subluxes anteriorly, making contact with the mid portion of the lateral femoral condyle and resulting in this characteristic bone bruise pattern on MRI. Randomized clinical trials comparing early accelerated vs nonaccelerated rehabilitation programs have demonstrated no significant differences in longterm results with regard to function, reinjury, and successful return to play. These studies did not address timing of return to play with an early accelerated rehabilitation program. At 2 and 3 years postsurgically, there are no differences in laxity, number of graft failures, or KOOS scores.

Question 32

Osteoporotic vertebral compression fractures are associated with Review Topic

Explanation

Osteoporotic vertebral compression fractures are associated with neurologic complications in less than 1% of patients. After the initial fracture however, patients have a 20% risk of further fractures. The mortality rate of patients with vertebral fractures exceeds that of patients with hip fractures when they are followed beyond 6 months.

Question 33

A 72-year-old man sustains a displaced four-part fracture of the proximal humerus with head split component following a fall. A primary shoulder arthroplasty has been recommended for acute management. In counseling the patient on pros and cons of hemiarthroplasty versus reverse arthroplasty, what statement can be made based on the available literature?

Explanation

As the indications for reverse shoulder arthroplasty have expanded, the role for shoulder hemiarthroplasty appears to be narrowing. Several recent systematic reviews have evaluated outcomes of shoulder hemiarthroplasty and reverse shoulder arthroplasty for acute proximal humerus fractures. Their results suggest that reverse arthroplasty results in superior functional results and comparable elevation, at the expense of increased complication rates and decreased shoulder rotation. One of the benefits of reverse shoulder
arthroplasty in the setting of fracture is that forward elevation is independent of tuberosity healing and relies mainly on the deltoid muscle. Active external rotation following a reverse total shoulder for fracture, however, does appear to depend on successful union of the greater tuberosity. In a randomized controlled trial, the incidence of tuberosity healing was higher and the incidence of tuberosity resorption was lower in reverse arthroplasty compared with hemiarthroplasty. Forward elevation following a hemiarthroplasty for fracture generally follows a bimodal distribution, whereas outcomes following a reverse total shoulder have been more
consistent.

Question 34

A 22-year-old wrestler who underwent an open anterior shoulder reconstruction to repair a dislocated shoulder 6 months ago now reports shoulder pain after attempting a takedown. Examination reveals external rotation that is 15 degrees greater than the contralateral side. He has pain associated with abduction and external rotation but no apprehension. Which of the following tests would most likely reveal positive findings?

Explanation

DISCUSSION: Postoperative subscapularis detachment can be identified with a positive lift-off test that reveals weakness in internal rotation. This complication does not necessarily compromise the anterior capsule repair. The load-and-sift maneuver and articular contrast studies may be normal. Supraspinatus tests for impingement and weakness should be negative.
REFERENCES: Gerber C, Krushell RJ: Isolated ruptures of the tendon of the subscapularis muscle: Clinical fractures in 16 cases. J Bone Joint Surg Br 1991;73:389-394.
Hawkins RJ, Bokor DJ: Clinical evaluation of the shoulder, in Rockwood CA, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1990, pp 149-177.

Question 35

Which of the following deformities is most common after the amputation shown in Figure A?

Explanation

The most common deformity after a midfoot amputation as shown in Figure A is an equinuovarus deformity due to the pull of the Achilles and plantarflexors in face of loss of the common extensors and distal insertion of the tibialis anterior.
Ng et al. review foot and ankle amputations, and review the issues inherent with each amputation level, including prosthesis fitting and use. They also mention that careful repair of all released or transected tendons is needed to maintain a plantigrade foot.
Early reviews the importance of soft tissue balancing with midfoot amputations. They note that the attachment of the resected tendons into the more proximal retained bones is critical for success in restoration of foot position and ambulation capabilities.
Figure A shows a midfoot amputation as the result of trauma. Illustration A shows the lateral view of the amputation, with an obvious equinus deformity.
Incorrect Answers:

Question 36

A 57-year-old woman had right total knee arthroplasty for varus gonarthrosis. Before surgery, her range of motion was 5 to 110 degrees. At skin closure, her range of motion was 0 to 120 degrees. Her range of motion at 10 weeks after surgery is 0 to 70 degrees. What is the best next treatment step?

Explanation

Question.18 . Figure 197 is the radiograph of a 62-year-old woman who is seen in the emergency department with a dislocated left total hip arthroplasty. This is her seventh dislocation during the last 3 months and she most recently had a liner revision. What is the best next treatment step?
Skeletal traction
Open reduction
Closed reduction
Component revision
Hip abduction orthosis

Question 37

Figure 46 shows the radiograph of a 65-year-old man who reports restricted range of motion and pain with sitting 18 months after undergoing right side revision total hip arthroplasty. What is the most appropriate management? L Intensive physiotherapy

Explanation

DISCUSSION: The presence of Brooker grade 1 or 2 heterotopic ossification (HO) does not influence the outcome of total hip arthroplasty, whereas restricted range of motion and pain may occur in patients with more severe grade 3 or 4 HO. Treatment may be nonsurgical or surgical. Nonsurgical management includes intensive physiotherapy during the maturation phase of the disease in an attempt to limit the final stiffness. There appears to be no data regarding the effectiveness of this treatment. There is no role for NSAIDs or radiotherapy as a treatment for preexisting HO. Surgical treatment involves excision of the heterotopic bone and can be expected to improve the functional outcome. Bisphosphonates have been used in the past, but their use has been discontinued as they only postpone ossification until treatment is stopped.
REFERENCES: Board TN, Karva A, Board RE, et al: The prophylaxis and treatment of heterotopic ossification following lower limb arthroplasty. J Bone Joint Surg Br 2007;89:434-440.
Harkess JW, Crockarell JR: Arthroplasty of the hip, in Canale ST, Beaty JH (eds): Campbell’s Operative
Orthopaedics, ed 11. Philadelphia, PA, Mosby Elsevier, 2008, vol 1, pp 314-483.

Question 38

All of the following conditions are associated with the female athlete triad EXCEPT? Review Topic

Explanation

All of the following listed are associated with the female athlete triad except for Low LDL cholesterol levels. In fact, these patients often have elevated levels of LDL due to the hypoestrogenism caused by menstrual dysfunction.
The female athlete triad is an interrelationship of menstrual dysfunction (i.e., amenorrhea or oligomenorrhea), low energy availability (insufficient caloric intake for demand, with or without an eating disorder) and decreased bone mineral density. It is relatively common among young women participating in sports. More recently, it has been suggested that endothelial dysfunction also results, due to an imbalance between vasodilating and vasoconstricting agents triggered from inappropirate levels of nitric oxide on the microscopic level, which predisposes these women to atherosclerotic changes and increases their risk of cardiovascular disease in the future.
Matheson et al. analyzed cases of 320 athletes with bone scan-positive stress fractures (M = 145, F = 175) seen over 3.5 years and assessed the results of conservative management. They found that conservative treatment of stress fractures in athletes is satisfactory in the majority of cases.
Constantini et al. evaluated the prevalence of vitamin D insufficiency and deficiency among young athletes and dancers. They found a higher rate of vitamin D insufficiency among participants who practice indoors, during the winter months, and in the presence of iron depletion.
Nazem et al. reviewed the major components and health consequences of the female athlete triad as well as strategies for diagnosis and treatment of the conditions. They concluded that treatment requires a multidisciplinary approach involving health care professionals as well as coaches and family members.
Yagi et al. followed 230 runners participating in high school running teams for a total of 3 years to report occurrence of medial tibial stress syndrome (MTSS) and stress fracture. Predictors of MTSS and stress fracture were investigated. The authors reported a significant relationship between BMI, internal hip rotation angle and MTSS infemales.
Incorrect Answers:

Question 39

A 12-year-old girl falls in gymnastics and sustains comminuted midshaft radius and ulna fractures. Closed reduction and cast immobilization are attempted but fracture redisplacement with 20 degrees of angulation occurs. Surgical treatment includes closed reduction and intramedullary fixation of both bones. What is the most common long-term complication for this fracture?

Explanation

DISCUSSION: Healing of forearm fractures in skeletally immature patients is the usual outcome. The use of intramedullary fixation has been reported to result in a lower frequency of refractures when compared to plate osteosynthesis due to the absence of diaphyseal holes after plate removal, which are considered stress risers. Regardless of implant technique, malunion and infection are infrequent. Loss of forearm pronation and supination is a common occurrence in surgically treated fractures due to the higher degree of soft-tissue injury, and periosteal stripping leads to fracture site instability and fracture comminution.
REFERENCES: Luhmann SJ, Gordon JE, Schoenecker PL: Intramedullary fixation of unstable both-bone forearm fractures in children. J Pediatr Orthop 1998;18:451-456.
Mehlman CT, Wall EJ: Injuries to the shafts of the radius and ulna, in Beaty JH, Kasser JR (eds): Fractures in Children, ed 6. Philadelphia, PA, Lippincott, 2006, pp 430-436.

Question 40

Kyphosis from a vertebral osteoporotic compression fracture often results in progressive kyphosis due to

Explanation

DISCUSSION: Kayanja and associates, in a number of biomechanical studies, showed that in a kyphotic spine the strain is located at the apex of the deformity, the force is transmitted to the superior adjacent vertebrae, and that realignment and cement augmentation effectively normalize the load transfer.
REFERENCES: Kayanja MM, Ferrara LA, Lieberman IH: Distribution of anterior cortical shear strain after a thoracic wedge compression fracture. Spine J 2004;4:76-87.
Kayanja MM, Togawa D, Lieberman IH: Biomechanical changes after the augmentation of experimental osteoporotic vertebral compression fractures in the cadaveric thoracic spine. Spine J 2005;5:55-63.
Kayanja MM, Schlenk R, Togawa D, et al: The biomechanics of 1, 2, and 3 levels of vertebral augmentation with polymethylmethacrylate in multilevel spinal segments. Spine 2006;31:769-774.
Kayanja M, Evans K, Milks R, et al: The mechanics of polymethylmethacrylate augmentation. Clin Orthop Relat Res 2006;443:124-130.

Question 41

Which of the following statements best describes the typical early presentation of osteochondritis dissecans of the elbow? Review Topic

Explanation

This condition is the result of repetitive valgus overload of the radiocapitellar joint in the immature elbow. The clinical presentation is of lateral elbow pain and loss of extension in a juvenile older than age 10 years. Panner's disease typically affects the capitellum in boys younger than age 10 years. Osteochondritis dissecans (OCD) of the elbow affects the capitellum and occasionally the radial head. Fracturing of the OCD region can lead to an unstable fragment with margins outlined on an MR arthrogram and can progress to loose bodies that cause clinical catching or locking. These are typically late signs with a poorer prognosis.

Question 42

A 29-year-old quarterback falls onto his dominant shoulder and sustains the injury shown in Figures 14a and 14b. Management should consist of

Explanation

DISCUSSION: Type V acromioclavicular dislocations are characterized by elevation of the clavicle of 100% to 300% and involve extensive soft-tissue stripping. The treatment of choice is surgical reduction of the acromioclavicular joint and some type of stabilization. Treatment of type III injuries is controversial.
REFERENCES: Lemos MJ: The evaluation and treatment of the injured acromioclavicular joint in athletes. Am J Sports Med 1998;26:137-144.
Rockwood CA Jr, Green DP, Bucholz RW, et al: Fractures in Adults, ed 5. Philadelphia, PA, Lippincott-Raven, 2001, pp 1209-1240.

Question 43

On an axial CT image, which of the following dimensions is considered to be indicative of a critical amount of lumbar spinal stenosis? Review Topic

Explanation

Lumbar central stenosis is defined by an AP canal diameter of less than 10 mm or a cross-sectional area of less than 100 mm2 as measured on CT.

Question 44

A 49-year-old male presents with right shoulder pain and weakness after undergoing open cervical lymph node biopsy approximately one year ago. A pertinent finding from the physical exam is seen in Figure A, with the patients arms by his side. Physical exam finding with the arms in a position of 90 degrees of forward elevation and 10 degrees of external rotation are shown in Figure B. What nerve is most likely injured? Review Topic

Explanation

The patient is presenting with LATERAL scapular winging which is a result of injury to the spinal accessory nerve and resultant trapezius muscle palsy.
The spinal accessory nerve is fundamental to scapulothoracic function and essential for scapulohumeral rhythm. This nerve is vulnerable along its superficial course. The majority of injuries to the spinal accessory nerve are iatrogenic and occur secondary to head and neck surgery. There is often a marked delay in recognition and initiating treatment. Surgical treatment with the Eden-Lange transfer lateralizes the levator scapulae and rhomboids (transfer from medial border to lateral border)
Camp et al. reviewed the results of 111 patients who underwent operative management of a lesion to the spinal accessory nerve. They found that the majority (~80%) of injuries were sustained iatrogenically and that diagnosis was delayed for approximately 12 months.
Pikkarainen et al. reviewed the natural history of isolated serratus palsy. They found that symptoms mostly recover in 2 years, but at least one-fourth of the patients will have long-lasting symptoms, especially pain.
Figure A depicts a patient with lateral scapular winging. Figure B demonstrates physical exam of this patient with their arms in a position of 90 degrees of forward elevation and 10 degrees of external rotation. Illustration A highlights the difference between medial and lateral scapular winging. Illustration B depicts another example of a patient with lateral scapular winging.
Incorrect Answers:
An injury to the long thoracic nerve would result in serratus anterior palsy which would lead to MEDIAL scapular winging.
An injury to the suprascapular nerve would result in weakness and wasting of the supraspinatus and/or infraspinatus.
An injury to the axillary nerve would result in deltoid muscle weakness.
An injury to the thoracodorsal nerve would result in latissimus dorsi weakness and would not cause scapular winging

Question 45

In a patient with a major head injury and a femoral shaft fracture, intraoperative hypotension during femoral fixation has been associated with which of the following?

Explanation

DISCUSSION: Hypoxia and hypotension are associated with lower GCS scores in polytrauma patients with major head injuries, but whether early fracture fixation adversely affect CNS outcomes has been controversial. New studies, however, have found no association between early surgery and decreased discharge GCS scores. The referenced study by Scalea et al reviewed 171 patients with pelvic or lower extremity fractures and head injuries; they showed no difference in CNS outcomes or mortality in patients who underwent early fixation. The second reference by Brundage et al showed improved outcomes (including high GCS scores at time of discharge) in those who had early fixation of femoral shaft fractures in the head-injured patient. The last referenced study by Jaicks et al found a lower discharge GCS in the early fracture fixation group compared with the late group. However, they also found that early fracture fixation was associated with hypoxemia and hypotension, as well as greater fluid administration.

Question 46

Figures 1 and 2 are the radiographs of a 17-year-old man who injured his wrist 6 months ago. He is experiencing pain and limited motion. What is the most effective treatment option?

Explanation

EXPLANATION:
Figures 1 and 2 show a scaphoid nonunion with substantial bone resorption at the nonunion site. Cast immobilization and bracing with bone stimulator use would not be successful treatments at this point because the fracture is 6 months old and there is considerable bone resorption at the fracture site. Scaphoid excision with intercarpal fusion is an option to use only after bone-grafting procedures have failed or arthritis is present. Bone-grafting procedures using both vascularized and nonvascularized graft sources are associated with a high success rate that decreases with avascular necrosis of the proximal pole. If left untreated, scaphoid nonunions can progress to carpal collapse and degenerative arthritis.

Question 47

If the site of the pathologic lesion is revealed in Figure 54f and not in Figure 54e after traumatic anterior shoulder dislocation, the mechanism of shoulder injury is likely

Explanation

DISCUSSION
For patients with anterior shoulder instability, most commonly, a Bankart lesion, or detachment of the anteroinferior labrum with the attached inferior glenohumeral ligament from the glenoid rim is found. A medialized anteroinferior capsulolabral attachment (ALPSA lesion) is a common finding in shoulders with chronic anterior instability. The anterior band of the inferior glenohumeral ligament is tightest with the arm in 90 degrees of abduction with the shoulder externally rotated, creating a “hammock” that supports the humeral head. At 45 degrees of shoulder
abduction, the capsuloligamentous components of the shoulder are at their loosest, resulting in the most total superior-inferior translation.
During traumatic anterior glenohumeral dislocation, associated injuries commonly occur. In a prospective database of 3633 patients who sustained a traumatic anterior glenohumeral dislocation, 13.5% had a neurologic deficit following reduction, the majority of which were injuries to the axillary nerve. The injuries typically were sensory but not motor deficits and resolved spontaneously over time. These isolated axillary nerve injuries were more common in young, athletic patients. Associated rotator cuff tears and greater tuberosity fractures are commonly associated with shoulder dislocation as well and are more common in patients 60 years of age and older.
Large, engaging posterior humeral head Hill-Sachs lesions are associated with increased rates of recurrent shoulder instability. At the time of surgical arthroscopy, the Hill-Sachs lesion should be assessed for engagement with the glenoid. In the absence of significant glenoid bone loss, some patients with engaging Hill-Sachs defects may be suitable for combined Bankart repair and Hill-Sachs remplissage at the time of surgery. When these procedures are combined, patients have an approximate 10-degree decreased shoulder external rotation with the arm at the side and in abduction when compared to the contralateral, uninjured shoulder. Rates of recurrent dislocation and return to sport are comparable to those for patients undergoing Bankart repair alone.
Humeral avulsion of the glenohumeral ligaments (HAGL) has become a well-recognized cause of recurrent shoulder instability and is reported in 1% to 9% of patients. HAGL lesions can occur in isolation or, more commonly, may be associated with other abnormalities such as a tear of the rotator cuff, Bankart lesion, Hill-Sachs deformity, or labral tear. Recurrence of shoulder instability is more likely to occur if there is failure to identify a HAGL lesion. HAGL lesions can result from trauma in the setting of combined hyperabduction and external rotation. This is in contrast to a Bankart lesion, which is a result of trauma when the shoulder is hyperabducted without substantial associated rotation.
RECOMMENDED READINGS
Warner JJ, Deng XH, Warren RF, Torzilli PA. Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint. Am J Sports Med. 1992 Nov-Dec;20(6):675-85. PubMed PMID: 1456361. View Abstract at PubMed
Robinson CM, Shur N, Sharpe T, Ray A, Murray IR. Injuries associated with traumatic anterior glenohumeral dislocations. J Bone Joint Surg Am. 2012 Jan 4;94(1):18-26. doi: 10.2106/JBJS.J.01795. PubMed PMID: 22218378. View Abstract at PubMed
Visser CP, Coene LN, Brand R, Tavy DL. The incidence of nerve injury in anterior dislocation of the shoulder and its influence on functional recovery. A prospective clinical and EMG study. J Bone Joint Surg Br. 1999 Jul;81(4):679-85. PubMed PMID: 10463745. View Abstract at PubMed
Boileau P, O'Shea K, Vargas P, Pinedo M, Old J, Zumstein M. Anatomical and functional results after arthroscopic Hill-Sachs remplissage. J Bone Joint Surg Am. 2012 Apr 4;94(7):618-26. doi: 10.2106/JBJS.K.00101. PubMed PMID: 22488618. View Abstract at PubMed
Bui-Mansfield LT, Banks KP, Taylor DC. Humeral avulsion of the glenohumeral ligaments: the HAGL lesion. Am J Sports Med. 2007 Nov;35(11):1960-6. Epub 2007 Apr 9. Review. PubMed PMID: 17420506. View Abstract at PubMed

Question 48

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

Explanation

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

Question 49

Figure 30 shows the radiograph of a 38-year-old man who reports persistent pain laterally and plantarly about the fifth metatarsal head. Examination reveals calluses dorsolaterally and plantarly about the fifth metatarsal head. Nonsurgical management has failed to provide relief. Surgical treatment should include

Explanation

DISCUSSION: The patient has painful lateral and plantar keratoses with metatarsus quintus valgus deformity. This combination of problems is best addressed with an oblique mid-diaphyseal osteotomy that allows the distal metatarsal to be displaced medially and dorsally. Lateral eminence resection alone will not address the painful plantar keratosis. A distal chevron osteotomy has a more limited ability to address the plantar keratosis (if translated medially and slight dorsally). Proximal diaphyseal osteotomies of the fifth metatarsal are associated with an increased risk of delayed union or nonunion secondary to the relative hypovascularity in the proximal diaphysis. Excision of the fifth metatarsal head can result in a floppy fifth toe and transfer metatarsalgia.
REFERENCES: Coughlin MJ: Treatment of bunionette deformity with longitudinal diaphyseal osteotomy with distal soft tissue repair. Foot Ankle 1991;11:195-203.
Moran MM, Claridge RJ: Chevron osteotomy for bunionette. Foot Ankle Int 1994;15:684-688.

Question 50

Figure 28 shows an arthroscopic view of a right shoulder in the lateral position through a posterior portal. What is the area between structure B (biceps) and SS (subscapularis tendon)? Review Topic

Explanation

The rotator cuff interval is located between the supraspinatus and subscapularis and the biceps tendon is deep to the interval. It is a triangular area where the base is the coracoid process and the apex is the transverse humeral ligament at the biceps sulcus. Closure or tightening of this area is often helpful in patients with shoulder instability. Conversely, this area is often contracted in patients with adhesive capsulitis and may need to be released.

Question 51

Tendons should have what ratio of matrix protein?

Explanation

Tendons consist of mainly type I collagen (95%); a small amount of collagen types III, V, VI; and proteoglycans (< 5%). Proteoglycans have highly charged glycosaminoglycan side chains that attract water and help keep tendons well hydrated. Decorin is the most common proteoglycan in tendons and has been shown to bind to collagen. Tenascin-C is a glycoprotein upregulated in tendinopathy.

Question 52

A 48-year-old woman reports bilateral thigh pain that is limiting her function as a librarian. A radiograph and a bone scan are shown in Figures 23a and 23b. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiograph reveals bilateral severe acetabular protrusio. The bone scan and history confirm involvement of multiple joints, including the knees and the hindfoot. Although the first four choices can all cause the acetabular protrusio, the associated multiple joint involvement suggests the diagnosis of rheumatoid arthritis. Arthrokatadysis, or primary protrusio acetabuli, is often associated with osteomalacia but not other joint disease. Developmental dysplasia is a common cause of bilateral hip pathology but does not have acetabular protrusio.
REFERENCES: Resnick D: Diagnosis of Bone and Joint Disorders, ed 3. Philadelphia, PA,

WB Saunders, 1995, pp 956-957.
Wheeless’ Textbook of Orthopaedics: Acetabular Protrusio. www.wheelessonline.com/ortho/acetabular_protrusio

Question 53

A 3-year-old girl has had pain and swelling in her left thigh for the past 3 weeks. Her mother states she has had a temperature as high as 100.4 degrees F (38 degrees C) and a weight loss of 5 pounds. A CBC shows a WBC count of 11,000/mm3, an erythrocyte sedimentation rate of 13 mm/h, and a C-reactive protein of 0.3. A radiograph is shown in Figure 2. What is the next step in management?

Explanation

DISCUSSION: The history and laboratory studies indicate that this is not an infection. A lesion in this location and in this age group is likely a Ewing’s sarcoma. The presentation is usually a painful mass. About 20% of patients have a fever. The radiograph shows a typical mottled, permeative lesion with periosteal reaction. An MRI scan should be obtained to further evaluate the soft-tissue mass. Staging of the lesion should take place before biopsy, which should be done by the surgeon who would be performing the next stage of surgical treatment, ideally an orthopaedic oncologist.
REFERENCES: Gibbs CP Jr, Weber K, Scarborough MT: Malignant bone tumors. Instr Course Lect 2002;51:413-428.
Meyer JS, Nadel HR, Marina N, et al: Imaging guidelines for children with Ewing sarcoma and osteosarcoma: A report from the Children’s Oncology Group Bone Tumor Committee. Pediatr Blood Cancer 2008;51:163-170.
T
AL-Madena Copy

Question 54

Which of the following surgical options after resection of a sarcoma about the knee would require a patient to expend the greatest amount of energy while walking?

Explanation

Discussion: The answer to this question is based on a study by Harris which tested the effeciency , rate and percent of max rate in ambulation in amputees, those with arthrodeses and arthroplasties. They found that Above knee amputees expended the most energy, followed by arthrodesis patients, and then arthroplasty patients.

Question 55

When conducted at near physiologic strain rates, tensile studies of the inferior glenohumeral ligament (IGHL) have shown that the

Explanation

DISCUSSION: Tensile testing of the inferior glenohumeral ligament at near physiologic strain rates has shown that the anterior band of the IGHL has the greatest stiffness of the three ligament regions and the glenoid insertion site shows greater strain than the ligament midsubstance.
REFERENCES: Bigliani LU, Pollock RG, Soslowsky LJ, Flatow EL, Pawluk RJ, Mow VC: Tensile properties of the inferior glenohumeral ligament. J Orthop Res 1992;10:187-197.
Ticker JB, Bigliani LU, Soslowsky LJ, Pawluk RJ, Flatow EL, Mow VC: Inferior glenohumeral ligament: Geometric and strain-rate dependent properties. J Shoulder Elbow Surg 1996;5:269-279.

Question 56

A patient with an unstable pelvic ring injury has just undergone an emergent laparotomy and currently has a packed abdomen. Stabilization of the pelvic ring is performed with an anterior external fixator. What is an advantage of using an external fixator with pins in the iliac crest rather than pins in the anterior inferior iliac spine?

Explanation

There are relative advantages to both types of these external fixators. A frame based on the iliac crest is oftentimes easier to place rapidly because it is less dependent on fluoroscopy. This is also advantageous in this clinical scenario because the patient may not be on a radiolucent table. A frame with pins in the anterior inferior iliac spines may be advantageous in that the pin sites will be away from any future needed incisions if an ilioinguinal approach is needed. There is, however, a higher risk of lateral femoral cutaneous nerve injury or intra-articular pin placement at the hip joint with this frame configuration. This technique is generally more dependent on fluoroscopy for pin placement. Some biomechanic studies have shown advantages to AIIS-based frames but this does not give a definite clinical advantage because neither frame alone is adequate to definitively treat an unstable associated posterior pelvic ring injury. There is no known difference in pin site infection rates between these frame types.

Question 57

What patient factor is predictive of better outcomes for surgical management of a displaced calcaneal fracture compared to nonsurgical management?

Explanation

DISCUSSION: A recent randomized trial of surgical versus nonsurgical management of calcaneal fractures showed that patients who were on workers’ compensation did poorly with surgical care. These patients had less favorable outcomes regardless of their initial management. Factors such as age, smoking, and vasculopathies compromise skin healing, leading to greater surgical risks. The best results were obtained in patients who are younger than age 40 years, have unilateral injuries and are injured during noncompensable activities. Women tend to do better with surgery than men.
REFERENCES: Howard JL, Buckley R, McCormack R, et al: Complications following management of displaced intra-articular calcaneal fractures: A prospective randomized trial comparing open reduction internal fixation with nonoperative management. J Orthop Trauma 2003;17:241-249.
Buckley R, Tough S, McCormack R, et al: Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: A prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2002;84:1733-1744.

Question 58

Which of the following methods best aids in diagnosis of an interdigital neuroma?

Explanation

DISCUSSION: History and physical examination are still the gold standard for diagnosis of an interdigital neuroma. Ultrasound and MRI may be helpful adjuncts but are dependent on equipment and operator expertise. Web space injection may be helpful for diagnostic and therapeutic purposes. Electromyography and nerve conduction velocity studies are of little benefit for distal lesions.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 145-147.
Bennett GL, Graham CE, Mauldin DM: Morton’s interdigital neuroma: A comprehensive treatment protocol. Foot Ankle Int 1995;16:760-763.

Question 59

An 11-year-old girl has had pain in the medial arch of her foot for the past 3 months. She reports that pain is present even with daily activities such as walking to class at school, and ibuprofen provides some relief. She denies any history of trauma. Examination reveals a flexible pes planus with focal tenderness over a prominent tarsal navicular tuberosity. Radiographs show a prominent accessory navicular. Management should consist of

Explanation

DISCUSSION: The patient has the classic symptoms, examination findings, and radiographs for a painful accessory navicular. Initial treatment should always be nonsurgical, specifically cast immobilization. Surgery should be reserved for those patients who fail nonsurgical management. Corticosteroids should not be injected into a posterior tibial tendon or insertion point because they can weaken the tendon and possibly cause tendon rupture. Triple arthrodesis and biopsy have no role in the management of a painful accessory navicular.
REFERENCE: Bordelon RL: Flatfoot in children and young adults, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 6. St Louis, MO, Mosby, 1993, pp 717-756.

Question 60

Which statement is true with respect to acetabular fracture surgery as the time between injury and surgery increases?

Explanation

DISCUSSION: Madhu et al showed time to surgery was a significant predictor of radiological and functional outcome for both elementary and associated displaced fractures of the acetabulum. Both anatomic reduction and functional outcome significantly worsened as time to surgery increased. It was found anatomic reduction was more likely when surgery was within 15 days for elementary fracture and 5 days for associated. Heterotopic ossification showed a trend towards increased odds with increased time to surgery but did not reach significance. Neurologic injury is more associated with the initial injury. Non-union is more frequent in non-anatomic reductions. Multi-organ failure was not commented on, but infection showed a trend towards being more likely with longer time to surgery.

Question 61

Figures 1 and 2 are the radiographs of a 24-year-old male wrestler who underwent surgery for recurrent shoulder dislocations using coracoid autograft. At his first postoperative visit, the patient complains of decreased sensation on the lateral aspect of his forearm. The patient’s symptoms are most likely due to injury of the

Explanation

The patient has undergone a Latarjet procedure as shown in the radiographs. After harvesting the coracoid graft, care must be taken to not place too much tension on or dissect excessively near the musculocutaneous nerve. The nerve is encountered 5 cm distal to the coracoid as it enters the conjoint tendon. The lateral antebrachial cutaneous nerve is the terminal branch of the musculocutaneous nerve and; therefore, injury can cause decreased sensation in the lateral forearm.

Question 62

Which of the following methods of treating a vertically oriented (eg, Pauwels III) femoral neck fracture is mechanically optimal?

Explanation

Hand dominance
Angulation of fracture
Smoking
Early physical therapy
Diet
This patient has an impacted varus proximal humerus fracture. Smoking has been shown to increase the nonunion risk up to 5.5 times with these fractures.
Impacted varus proximal humerus fractures can be managed effectively with nonoperative care. The major factors that influence non-union are age and smoking. Solid bony union can be seen in 93-98% of patients at 1 year, with more than 97% of people returning to pre-injury level of function. The angulation of fracture, hand dominance and physical therapy does not seem to influence bone union or functional outcomes with this fracture pattern.
Court-Brown et al. looked at the outcomes of impacted varus fractures. They determined that the age of the patient was the major factor in overall outcome. They showed that the best results occurred in younger patients, but results deteriorate with advancing age. Physical therapy was not found to impact outcome.
Hanson et al. showed that impacted varus fractures can be successfully managed with non-operative care. They found that overall fracture displacement had a minor impact of fracture healing and functional outcome. The predicted risk of delayed union and nonunion was 7% with patients that smoke. This was 5.5 times greater than nonsmokers.
Figure A shows an AP radiograph of a varus angulated proximal humerus fracture. This radiograph shows delayed atrophic union.
Incorrect Answers:

Question 63

The specificity of intraoperative frozen sections obtained for the evaluation of infected total hip arthroplasty may be improved by

Explanation

DISCUSSION: Lonner and associates conducted a prospective study to determine the reliability of analysis of intraoperative frozen sections for the identification of infection during 175 consecutive revision total joint arthroplasties (142 hips and 33 knees). The mean interval between the primary arthroplasty and the revision arthroplasty was 7.3 years (range, 3 months to 23 years). Of the 175 patients, 23 had at least 5 polymorphonuclear leukocytes per high-powered field on analysis of the frozen sections and were considered to have an infection. Of these 23 patients, five had 5 to 9 polymorphonuclear leukocytes per high-powered field and 18 had at least 10 polymorphonuclear leukocytes per high-powered field. The frozen sections for the remaining 152 patients were considered negative.
On the basis of cultures of specimens obtained at the time of the revision surgery, 19 of the 175 patients were considered to have an infection. Of the 152 patients who had negative frozen sections, three were considered to have an infection on the basis of the results of the final cultures. Of the 23 patients who had positive frozen sections, 16 were considered to have an infection on the basis of the results of the final cultures; all 16 had frozen sections that showed at least 10 polymorphonuclear leukocytes per high-powered field.
The sensitivity and specificity of the frozen sections were similar regardless of whether an index of 5 or 10 polymorphonuclear leukocytes per high-powered field was used. Analysis of the frozen sections had a sensitivity of 84% for both indices, whereas the specificity was 96% when the index was 5 polymorphonuclear leukocytes and 99% when it was 10 polymorphonuclear leukocytes. However, the positive predictive value of the frozen sections increased significantly (P < 0.05), from 70% to 89%, when the index increased from 5 to 10 polymorphonuclear leukocytes per high-powered field. The negative predictive value of the frozen sections was 98% for both indices. At least 10 polymorphonuclear leukocytes per high-powered field was predictive of infection, while 5 to 9 polymorphonuclear leukocytes per high-powered field was not necessarily consistent with infection. Less than 5 polymorphonuclear leukocytes per high-powered field reliably indicated the absence of infection.
REFERENCES: Feldman DS, Lonner JH, Desai P, Zuckerman JD: The role of intraoperative frozen sections in revision total joint arthroplasty. J Bone Joint Surg Am 1995;77:1807-1813.
Lonner JH, Desai P, Dicesare PE, Steiner G, Zuckerman JD: The reliability of analysis of intraoperative frozen sections for identifying active infection during revision hip or knee arthroplasty. J Bone Joint Surg Am 1996;78:1553-1558.
Spangehl MJ, Younger AS, Masri BA, Duncan CP: Diagnosis of infection following total hip arthroplasty, in Cannon WD Jr (ed): Instructional Course Lectures 47. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 285-295.
Della Valle CJ, Bogner E, Desai P: Analysis of frozen sections of intraoperative specimens obtained at the time of reoperation after hip or knee resection arthroplasty for the treatment of infection. J Bone Joint Surg Am 1999;81:684-689.

Question 64

A 40-year-old woman has had pain in the metatarsophal joint of the second toe for the past 6 months despite nonsurgical treatment. A dorsalplantar stress test reproduces the pain, and there is 10 mm of dorsal subluxation of the toe. Radiographs show a normal second metatarsophalangeal joint. Surgical treatment should consist of synovectomy and

Explanation

Number four is the correct answer because the flexor digitorum longus tendon will give excellent plantar support when transferred to the dorsum of the toe and this removes the main dynamic deforming force. Number one is incorrect because the planter plate will stretch in time and be insufficient. Number two is incorrect because the radiographs show a normal second metatarsophalangeal joint surface and it is not a fixed/dislocated joint and it is in a young patient. Number three is incorrect because it is not a frank dislocation. Number five is incorrect as this is reserved for mild deformity and would not be sufficient correction in this case.

Question 65

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

Explanation

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

Question 66

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

Explanation

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.

Question 67

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

Explanation

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

Question 68

The flap shown in the clinical photograph seen in Figure 51 is based on what arterial supply?

Explanation

DISCUSSION: The groin flap is based on the superficial circumflex iliac artery, an axial flap that has been a mainstay of providing soft-tissue coverage of the upper extremity. Flaps as large as 35 cm in length and 15 cm in width have been reported. An advantage of the flap is that when used as a pedicle flap, the donor site can be closed directly. A disadvantage of the flap is that it can be quite bulky and can have a thick layer of subcutaneous fat. The superficial circumflex iliac artery travels lateral and superficial to the fascia and below and parallel to the inguinal ligament. It is helpful to elevate the fascia at the medial border of the sartorius muscle to include the deep and superficial branches of the artery for improved flap survival.
REFERENCES: McGregor IA, Jackson IT: The groin flap. Br J Plast Surg 1972;25:3-9.
Lister GD, McGregor IA Jackson IT: The groin flap in hand injuries. Injury 1973;4:229.

Question 69

A 47-year-old man with Charcot-Marie-Tooth (CMT) disease was treated with a fifth metatarsal head resection for a symptomatic bunionette 2 years ago. What is the most likely complication seen at this time?

Explanation

DISCUSSION: CMT is characterized by a cavovarus foot position that increases weight-bearing stresses along the lateral border. Removal of the fifth metatarsal head carries the risk of creating a transfer lesion at the fourth metatarsal head, particularly with a cavovarus foot. Claw toes are common in CMT, but the fifth toe would be flail in this situation. Ulceration is unlikely given the lack of underlying bone. Peroneal atrophy is associated with CMT but would not be a complication of this procedure. Charcot arthropathy is a neuropathic process frequently seen in individuals with diabetes mellitus.
REFERENCES: Kitaoka HB, Holiday AD Jr: Metatarsal head resection for bunionette: Long-term followup. Foot Ankle 1991;11:345-349.
Coughlin MJ, Mann RA, Saltzman CL: Surgery of the Foot and Ankle, ed 8. Philadelphia, PA, Mosby, 2007, pp 1312-1315.

Question 70

A Spanish speaking child sustained the injury seen in Figure A after a fall at school. He was casted in the emergency department without the assistance of an interpreter and advised to return to see an orthopaedic surgeon in 1 week. However, the family returns to the emergency department with the child 3 months later, still in the cast. What is the most likely reason the child did not attend the recommended orthopaedic follow-up visit.?

Explanation

The most likely reason the child did not attend the recommended orthopaedic followup visit was a language barrier preventing effective communication of the intended follow-up instructions.
Communication skills and cultural competence is a key element in good orthopaedic care. Poor communication can often lead to devastating outcomes. In this example, poor communication resulted in this patient being lost to follow-up. Language barriers must be accommodated and alternative methods of communication must be utilized.
Levinson et al. examined how patients present their medical issues in clinical encounters and how physicians respond to these clues in routine primary care and surgical settings. They showed that good communication relies mostly on the physicians ability to identify patient clues within the clinical encounter. Poor communication between the physician tended to delay clinical visits, poor follow-up and unsatisfactory outcomes.
Figure A is an AP radiograph of the elbow in a skeletally immature patient. Figure B is a lateral radiograph of the elbow with a posterior fat pad sign, suggestive of an occult fracture.
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Question 71

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

Explanation

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

Question 72

Figure A shows immediate post-operative radiographs of a 75-year-old patient with primary osteoarthritis. She presents 3 years later with increasing pain and weakness in the shoulder despite home physical therapy. Examination reveals limited active range of motion, with forward elevation of 80 degrees and external rotation of 50 degrees. Her deltoid function is intact. Repeat radiographs are seen in Figure B.

Explanation

This patient presents with failed total shoulder arthroplasty. The best treatment option for functional outcome would be revision to reverse shoulder arthroplasty (rTSA).
RTSA is considered a viable treatment option for patients with failed shoulder arthroplasty. It allows for improved arm elevation and abduction in the setting of nonfunctional rotator cuff muscles, as seen in this example. Despite the expanding indications for rTSA, there are high complication rates in the revision setting. Complication rates for rTSA after failed shoulder arthroplasty have been reported to be between 11-36%. This procedure should, therefore, be performed by surgeons with extensive training in reconstructive shoulder arthroplasty.
Patel et al. retrospectively reviewed 31 patients (mean age, 68.7 years) who underwent rTSA for treatment of a failed shoulder arthroplasty. They found the greatest improvement with active forward elevation from 44° preoperatively to 108° postoperatively (P < .001). Complications occurred in 3 patients with periprosthetic fracture.
Hattrup et al. reviewed a series of 19 patients that underwent open rotator cuff repair after shoulder arthroplasty. Out of the 19 patients only 4 shoulders were successfully repaired. They concluded that successful rotator cuff repair after shoulder arthroplasty is possible but failure is more common.
Figure A shows a left total shoulder arthroplasty that is well reduced in the glenoid. Figure B shows antero-superior escape of the prosthesis, indicative of a massive rotator cuff tear.
Incorrect Answers:

Question 73

Figures 27a and 27b show the radiographs of a 32-year-old woman who was involved in a high-speed motor vehicle accident. She is neurologically intact. After stabilization and assessment, treatment should consist of

Explanation

DISCUSSION: The radiographs show a fracture-dislocation with translation in both the coronal and sagittal planes, evidence of significant instability requiring surgical stabilization. Anterior instrumentation is not as effective as posterior instrumentation in restoring stability, and because there is little bony destruction, the anterior column can be successfully reconstructed with simple realignment. The treatment of choice is multisegment posterior fusion with instrumentation.
REFERENCES: Lewandrowski KU, McLain RF: Thoracolumbar fractures: Evaluation, classification, and treatment, in Frymoyer JW, Wiesel SW (eds): The Adult and Pediatric Spine. Philadelphia, PA, Lippincott Williams and Wilkins, 2004, pp 817-843.
Carl AL: Adult spine trauma, in DeWald RL (ed): Spinal Deformities: A Comprehensive Text. New York, NY, Thieme, 2003, pp 406-423.

Question 74

During establishment of an anterior portal for hip arthroscopy, what structure is at greatest risk for injury? Review Topic

Explanation

The anterior portal for hip arthroscopy is approximately 6 cm distal to the anterior superior iliac spine, penetrating the muscle belly of the sartorius and the rectus femoris before entering through the anterior capsule. The lateral femoral cutaneous nerve is divided into three or more branches at the level of this portal and may be injured during portal placement. The femoral nerve and artery are more medial and at less risk. The superior gluteal and sciatic nerves are posterior and not at risk with an anterior portal.

Question 75

A 29-year-old male sustains the isolated lower extremity injury shown in Figure A. During open reduction, what structure must be kept intact in order to protect the remaining blood supply to the talar body?

Explanation

Figure A represents a type 3 Hawkins talar neck fracture. A type 3 injury is defined as a displaced fracture of the talar neck with dislocation of body of talus from both the subtalar joint and the tibiotalar joint. In these injuries, the talar body fragment typically rotates around intact deltoid ligament fibers to lie in soft tissues with the fracture surface pointing laterally and cephalad. Often, the deltoid branch of the posterior tibial artery, which lies between the leaves of the deltoid ligament and supplies up to 1/2 of the medial talar body, is the only remaining blood supply. Therefore, the deltoid ligament must be preserved to lower the risk of avascular necrosis. When performing a medial malleolar osteotomy, the deltoid ligament must remain in continuity with the malleolus to prevent disruption of the blood supply.
The review article by Fortin et al discusses talar blood supply, injury mechanisms and classifications, and treatment options. They state that the main artery to the body of the talus is the artery of the tarsal canal, which is a branch of the posterior tibial artery. The peroneal and anterior tibial artery also contribute branches to the talus.
Illustration A and B show the arterial network of the talus.

OrthoCash 2020

Question 76

An otherwise healthy 32-year-old man who underwent an uneventful L5-S1 lumbar microdiskectomy 6 weeks ago now reports increasing and severe back pain that awakens him from sleep. Examination reveals a benign-appearing wound, and the neurologic examination is normal. Laboratory studies show an erythrocyte sedimentation rate (ESR) of 90 mm/h and a WBC of 9,000/mm3. Plain radiographs are normal. What is the next most appropriate step in management?

Explanation

DISCUSSION: The patient’s history and laboratory studies are very suspicious for a postoperative diskitis. The predominant symptom often is back pain. An ESR of 90 mm/h is considered significantly elevated and normally would be expected to return to near baseline by 2 weeks postoperatively. A normal WBC result is not unusual with postoperative diskitis. Management should consist of an MRI with gadolinium to confirm the diagnosis, followed by a biopsy percutaneously to obtain tissues for pathology and microbiology. Surgical debridement is reserved for patients whose percutaneous biopsy results are negative and a high index of suspicion for diskitis remains, or when management consisting of IV antibiotics, bed rest, and spinal immobilization fails to provide relief.
REFERENCES: Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 257-271.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 713-721.

Question 77

All of the following have been shown to negatively affect clinical outcomes in treating displaced acetabular fractures, EXCEPT:

Explanation

DISCUSSION: Negative outcome factors have been shown to include: increasing patient age, time from injury to surgery (>3 weeks), intraoperative complications, femoral head bone or cartilage injury, and fracture reduction > 1-2mm from anatomic. Choice of surgical approach has not been shown to affect patient outcomes.
The referenced study by Matta evaluated outcomes of displaced acetabular fractures. The overall clinical result was excellent for 104 hips (40 per cent), good for ninety-five (36 per cent), fair for twenty-one (8 per cent), and poor for forty-two (16 per cent). The clinical result was related closely to the radiographic result. These findings indicate that in many patients who have a complex acetabular fracture the hip joint can be preserved and post-traumatic osteoarthrosis can be avoided if an anatomical reduction is achieved.

Question 78

There is a risk of impaired forearm rotation after tension band fixation of an olecranon fracture with which of the following?

Explanation

DISCUSSION: Impaired pronation/supination can be seen if the K-wire is advanced either too radial or too far through the volar (anterior) cortex of the proximal ulna. The anterior interosseous nerve is also at risk with overpenetration. Conversely, migration and loosening of the K-wire is reduced with involvement of the anterior cortex.
The referenced study by Candal-Couto et al is a cadaveric study that found that K-wire insertion in less than 30 degrees in an ulnar direction led to impingement of the K-wire on the radial head/neck, biceps or supinator. They recommend placing these wires away from this danger zone in order to minimize rotation blocks.
The referenced study by Matthews et al is a case series of two patients who had limited forearm rotation after K-wire fixation. The etiology of limited rotation was found to be from direct overpenetration of the K-wire, which led to a mechanical block.

Question 79

03 A 28-year-old man who sustained the injury shown in Figure 31 is hemodynamically unstable. In addition to fluid resuscitation, the next most appropriate step in management should include

Explanation

The radiograph shows us a pelvic inlet view of an APC II or III pelvic ring injury with syndesmotic disruption greater than 5cm, and a right SI joint disruption as well. APC (and some VS) injuries are associated with increases in pelvic volume allowing occult blood loss. All of the responses are viable options, but on a spectrum of timing. ORIF and CRPSF are both more elective options that require appropriate pre-operative planning and a stable patient, not to be undertaken in a hemodynamically unstable patient. The article referenced from JBJS 2002 reviewed 150 patients with pelvis fractures and the use of angiography for the management of “haemorrhage.” They concluded/recommended skeletal stabilization as the first line of treatment, followed by possible laparotomy and packing of pelvic retroperitoneum as a second line of treatment, with pelvic angiography and embolization only in those patients that were unresponsive to both previous interventions. They based their recommendations also on anatomical studies that suggested that the surfaces of the fracture and veins, rather than arteries, were the major sources of bleeding in these patients. External pelvic stabilization in their study included external fixators, pneumatic anti-shock garments, and pelvic clamps.
Cook RE, Keating JF, Gillespie I: The role of angiography in the management of haemorrhage from major fractures of the pelvis. J Bone Joint Surg Br 2002;84:178-182.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp395-405.
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Question 80

An otherwise healthy 31-year-old man has had right knee pain for the past 9 months. His former physician administered a cortisone injection and ordered 6 months of physical therapy. The patient later had an arthroscopy with debridement of the right knee by another physician and completed another course of physical therapy. The patient received minimal relief from these treatments and still is not able to walk longer distances or go on hikes. On examination, he is a healthy appearing male with a body mass index of 24 kg/m 2 . He has a small effusion, minimal quadriceps atrophy, no tenderness about the knee, full range of motion, stable to varus and valgus stress at 30° of flexion, a grade 1 Lachman test, and a normal posterior drawer. Figures 1 through 4 are his arthroscopic views, radiograph and MRI scan from his prior surgical procedure. What is the next most appropriate step in treatment?

Explanation

The patient has a symptomatic cartilage lesion of his medial femoral condyle, which has not responded to nonsurgical measures, and he failed a prior arthroscopy with debridement. Based on his examination and imaging, he is ligamentously stable, has normal mechanical alignment, and has intact menisci, making him a candidate for a cartilage restoration procedure. The accompanying MRI also indicates subchondral bone involvement with increased T2 signal underlying the cartilage defect. Osteochondral allograft is the only choice that addresses both the cartilage defect, as well as compromised subchondral bone. Depending on lesion size, osteochondral autograft transfer may also be considered, but this is not presented as an answer choice.Given the radiographic finding of neutral mechanical alignment, bracing would be less effective, and the patient has already tried extensive physical therapy. Lack of malalignment also excludes tibial osteotomy as a preferred answer choice. Microfracture is best for small cartilage lesions without significant bone marrow involvement.

Question 81

Which of the following is most frequently associated with heterotopic ossification about the shoulder?

Explanation

DISCUSSION: Multiple attempts at closed reduction, delayed surgery for proximal humeral fractures, and associated closed head injury all have been associated with a higher incidence of heterotopic ossification.
REFERENCES: Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1998, vol 1, p 291.
Neer CS: Displaced proximal humerus fractures: Part II. Treatment of three-part and four-part displacement. J Bone Joint Surg Am 1970;52:1090-1103.

Question 82

Figure 30 shows the MRI scan of a 68-year-old woman who has left hip pain. What is the most appropriate treatment?

Explanation

DISCUSSION: The patient has a large zone of osteonecrosis of the left femoral head. The wedge-shaped zone of decreased signal intensity on the T1 image in the subchondral region of the femoral head is typical. Based on these findings, total hip arthroplasty is the most appropriate treatment. Open reduction and internal fixation will not help this condition. Incisional biopsy is indicated only if the MRI scan shows a probable neoplasm. Resection of the proximal femur is indicated only for aggressive malignancy. Arthrodesis may be considered in a younger patient but not in a 68-year-old individual. Other treatments, not listed, such as core decompression, vascularized fibular transplant, and osteotomy may be options in selected patients.
REFERENCES: Urbaniak JR, Jones JP Jr (eds): Osteonecrosis: Etiology, Diagnosis, and Treatment. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 213-223.
Watson RM, Roach NA, Dalinka MK: Avascular necrosis and bone marrow edema syndrome. Radiol Clin North Am 2004;42:207-219.

Question 83

The superior glenohumeral ligament primarily restrains

Explanation

DISCUSSION: Several cutting studies have evaluated the primary static restraints and the role of the glenohumeral ligaments in providing static stability. With the arm at the side in adduction, the superior glenohumeral ligament and coracohumeral ligament are the primary restraints to inferior translation. The middle glenohumeral ligament functions with the arm in 45 degrees of abduction and resists anterior translation. The inferior glenohumeral ligament is the primary restraint to anterior translation at 90 degrees of abduction.
REFERENCES: Warner JJ, Deng XH, Warren RF, et al: Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint. Am J Sports Med 1992;20:675-685.
Griffin LY (ed): Orthopaedic Knowledge Update: Sports Medicine. Rosemont, IL, American Academy Orthopaedic Surgeons, 1994, pp 165-177.

Question 84

Spindled cells that are surrounded in mature osteoid that connect to other similar cells via canaliculi are best described as which of the following? Review Topic

Explanation

Osteocyte cell processes travel through canaliculi to interconnect with other osteocytes and cells on the bone surfaces. Osteoblasts are cells that produce bone matrix and are seen rimming immature bone. Osteoclasts are large multinucleated cells that resorb bone and are found in Howship's lacunae. Megakaryocytes and histiocytes are found in marrow but not mature bone cortex.

Question 85

An 8-year-old girl injures her elbow playing soccer. After attempted reduction in the emergency department, radiographs of the elbow are shown in Figures 35a through 35c. What is the next most appropriate step in treatment?

Explanation

DISCUSSION: Ninety percent of injuries to the proximal radius in children are radial neck fractures, and 50% of these fractures are through the metaphyseal bone. The remaining 50% are Salter-Harris type I or II fractures. These radiographs show a fracture of the radial head and subluxation of the radius anteriorly. Most congenital radial head dislocations are posterior lateral. Nonsurgical treatment modalities are unlikely to be successful due to the wide displacement of the fracture fragments, as well as dislocation of the radial head.
REFERENCES: Leung AG, Peterson HA: Fractures of the proximal radial head and neck in children with emphasis on those that involve the articular cartilage. J Pediatr Orthop

2000;20:7-14.
Hashemi-Nejad A, Goddard NJ: Radial head fractures. Br J Hosp Med 1994;51:223-226.
Rodriguez Merchan EC: Displaced fractures of the head and neck of the radius in children: Open reduction and temporary transarticular internal fixation. Orthopedics 1991;14:697-700.

Question 86

In overhead athletic activities, the kinetic chain generates what percentage of force from the leg and trunk segments of the chain?

Explanation

DISCUSSION: The leg and trunk provide a stable base for arm motion, supply rotational momentum for force generation, and generate 50% to 55% of the total force and kinetic energy in the tennis serve.
REFERENCES: Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, p 47.
McClure PW, Michener LA, Sennett BJ, et al: Direct 3-dimensional measurement of scapular kinematics during dynamic movements in vivo. J Shoulder Elbow Surg 2001;10:269-277.
Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spectrum of pathology. Part III: The SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy 2003;19:641-661.

Question 87

-What is the most likely area of injury?

Explanation

DISCUSSION FOR QUESTIONS 40 THROUGH 42
This patient likely has a physeal injury to the distal femoral physis. Stress radiographs or an MRI scan will most reliably reveal this diagnosis. The growth plate, when injured, is most commonly fractured through the hypertrophic zone of cartilage, its weakest point. This patient is optimally treated in a cylindrical or long-leg cast. Younger patients can be treated with a hip spica with a leg extension.

Question 88

A 10-year-old boy with severe hemophilia A (factor VIII) sustained an injury to his right forearm 2 hours ago when a classmate fell on his arm during a scuffle. Examination reveals moderate swelling in the forearm, decreased sensation in the distribution of the median and ulnar nerves, and pain on passive extension of the fingers. What is the most appropriate sequence of treatment?

Explanation

DISCUSSION: The patient has severe hemophilia with a volar forearm hemorrhage and an emerging compartment syndrome. Therefore, it is critical to normalize the clotting deficiency as the first step in treatment. In a patient who has a factor VIII level of less than 1% and no inhibitors to factor VIII, transfusion with 4 unit/kg will typically raise the factor VIII level to 100%. Continuous transfusion can then be used to maintain this level. Compartment pressures can be safely measured after infusion of factor VIII. Because the hemorrhage is of limited duration and any surgery is considered serious in a patient with hemophilia, the compartment pressure should be measured before making a decision regarding a fasciotomy. However, it is important to note that the use of factor VIII concentrates allows both emergency and elective surgery provided that adequate hematology backup is available. Splinting the elbow and wrist in flexion reduces the pressure in the volar compartments, protects the forearm from further trauma, and makes the patient more comfortable.
REFERENCES: Greene WB: Diseases related to the hematopoietic system, in Morrissy RT, Weinstein SL (eds): Lovell & Winter’s Pediatric Orthopaedics, ed 4. Philadelphia, Pa, Lippincott-Raven, 1996, pp 345-391.
Greene WB, McMillan CW: Nonsurgical management of hemophilic arthropathy, in Barr JS (ed): Instructional Course Lectures 38. Park Ridge, Ill, American Academy of Orthopaedic Surgeons, 1989, pp 367-381.
Naranja RJ Jr, Chan PS, High K, Esterhai JL Jr, Heppenstall RB: Treatment considerations in patients with compartment syndrome and an inherited bleeding disorder. Orthopedics 1997;20:706-711.

Question 89

A 58-year-old man has anterior knee pain after undergoing total knee arthroplasty for osteoarthritis 2 years ago. He denies any history of trauma. A Merchant view is shown in Figure 20. What is the most likely cause of his pain?

Explanation

DISCUSSION: The patient has a patellar stress fracture after resurfacing in a total knee arthroplasty. Several studies have shown that over-resection of the patella to less than 12 to 15 mm increases anterior patellar surface strains to a point where the risk of fracture is increased. Increasing the patellar thickness, positioning of the femoral component, lateral releases, and component types have not been clearly associated with increased fracture risk.
REFERENCES: Reuben JD, McDonald CL, Woodard PL, Hennington LJ: Effect of patella thickness on patella strain following total knee arthroplasty. J Arthroplasty 1991;6:251-258.
Hsu HC, Luo ZP, Rand JA, An KN: Influence of patellar thickness on patellar tracking and patellofemoral contact characteristics after total knee arthroplasty. J Arthroplasty 1996;11:69-80.
Greenfield MA, Insall JN, Case GC, Kelly MA: Instrumentation of the patellar osteotomy in total knee arthroplasty: The relationship of patellar thickness and lateral retinacular release. Am J Knee Surg 1996;9:129-131.

Question 90

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 91

Which of the following ligaments is the primary static restraint against inferior translation of the arm when the shoulder is in 0 degrees of abduction?

Explanation

DISCUSSION: The superior glenohumeral ligament (SGHL) and coracohumeral ligament serve as primary static restraints against inferior translation of the arm when the shoulder is in 0 degrees of abduction. Of these, the coracohumeral ligament has been shown to have a greater cross-sectional area, greater stiffness, and greater ultimate load than the SGHL. The inferior glenohumeral ligament plays a greater stabilizing role with increasing abduction of the arm. The coracoacromial ligament may help provide superior stability, especially when the rotator cuff is deficient. The coracoclavicular ligaments stabilize the acromioclavicular joint.
REFERENCES: Boardman ND, Debski RE, Warner JJ, et al: Tensile properties of the superior glenohumeral and coracohumeral ligaments. J Shoulder Elbow Surg 1996;5:249-254.
Warner JJ, Deng XH, Warren RF, Torzilli PA: Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint. Am J Sports Med 1992;20:675-685.

Question 92

A 45-year-old female returns to your clinic with 10-weeks of severe pain that starts in her back and extends down her right leg to the top of her foot. On physical exam she has decreased sensation on the dorsal aspect of her foot and 4/5 strength in her EHL. She has a positive straight leg raise on the right. The remaining physical exam is unremarkable, including normal achilles and patellar reflexes bilaterally, no clonus, and a down-going Babinski sign. Her pain has not been relieved by NSAIDs, epidural steroids or physical therapy. Figure A is a sagittal MRI and figure B is a axial MRI through the L4/5 disc space. What is the best treatment option at this time? Review Topic

Explanation

The patient has a herniated L4/5 disc leading to right L5 radicular pain. She continues to have severe symptoms despite 10 weeks of nonoperative treatment, so the next step is a right sided L4/5 microdiscectomy.
Patients with paracentral herniated lumbar discs present with radicular pain affecting the traversing (caudal) nerve root. Unless the patient develops progressive neurologic decline, patients with herniated lumbar discs should undergo no less than 6 weeks of conservative treatment consisting of anti-inflammatory medications, rest and therapy. Most patients improve with nonoperative modalities. If appropriate conservative care fails, the correct surgical option is a unilateral microdiscectomy.
In the Spine Patient Outcomes Research Trial (SPORT) Weinstein et al. reported on the results of 501 patients with herniated lumbar discs who had failed at least six weeks of non-operative care. The patients were randomized to operative or nonoperative care, however there was a high amount of crossover between the two groups. Because of this, there was no difference reported between the two groups at final follow-up using an intent-to-treat analysis.
Weinstein et al., because of the flaws with the intent-to-treat analysis, also published an observational study on 528 patients who received surgery and 191 who received nonoperative care for a herniated lumbar disc. They reported that while both groups had an improvement from baseline, at two years, patients who elected to undergo surgery had significantly better outcomes than those who chose conservative care.
Lurie et al. reported the eight-year results from the observational group of the SPORT data, and found that the patients who underwent surgery continued to have statistically superior outcomes compared to those who underwent conservative care at long-term follow-up.
Figure A is a T2 sagittal MRI of the lumbar spine demonstrating a right sided L4/5 disc herniation, and Figure B is an axial image again demonstrating a paracentral L4/5 disc herniation.
Incorrect answers:

Question 93

Figure 9 shows the radiograph of a 75-year-old woman who reports the sudden onset of disabling medial knee pain. What is the most likely diagnosis?

Explanation

DISCUSSION: Idiopathic osteonecrosis of the medial femoral condyle occurs predominantly in women older than age 60 years. It is characterized by pain centered in the medial anterior aspect of the knee, and onset is sudden. Flattening, sclerosis, and the radiolucent crescent sign are radiographic indicators of osteonecrosis. The radiographs show no narrowing of the joint space or osteophyte formation to indicate osteoarthritis, and there are no loose bodies to indicate synovial osteochondromatosis. A meniscal tear is not consistent with the radiographic findings shown here. Meniscal tears can coexist with osteonecrosis, but the pain is not eliminated merely by partial meniscectomy. Metastatic lesions to the distal femoral epiphysis are exceedingly rare.
REFERENCES: Urbaniak JR, Jones JP Jr (eds): Osteonecrosis: Etiology, Diagnosis, and Treatment. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 413-418.
Insall JN, Windsor RE, Scott WN, Kelly MA, Aglietti P (eds): Surgery of the Knee, ed 2. New York, NY, Churchill Livingstone, 1993, pp 609-634.

Question 94

The radiograph shown in Figure 27 shows measurement of what angle?

Explanation

DISCUSSION: The relationship between the distal articular surface of the first metatarsal head and the long axis of the first metatarsal is called the distal metatarsal articular angle. This angle has been validated by Richardson and associates to measure and determine the congruence of the first metatarsophalangeal joint. This angle is critical in determining the appropriate surgical procedure to perform on a patient with a bunion deformity because a congruent joint requires a procedure to maintain congruence of the articular surfaces following osteotomy. Therefore, a chevron becomes a biplanar chevron, and a Lapidus procedure adds a second osteotomy of the distal metatarsal to tilt the metatarsal head into a congruent location.
REFERENCES: Coughlin MJ: Juvenile hallux valgus: Etiology and treatment. Foot Ankle Int 1995;16:682-697.
Steel MW III, Johnson KA, DeWitz MA, et al: Radiographic measurements of the normal foot. Foot Ankle 1980;1:151-158.
Richardson EG, Graves SC, McClure JT, et al: First metatarsal head-shaft angle: A method of determination. Foot Ankle 1993;14:181-185.

Question 95

What neurovascular structure is in closest proximity to the probe in the arthroscopic view of the elbow shown in Figure 50?

Explanation

DISCUSSION: The image shows a view of the radiocapitellar joint from an anterior medial portal. The radial nerve lies on the elbow capsule at the midportion of the capitellum. It is at risk for injury when capsular excision is performed in this region.
REFERENCES: Field LD, Altchek DW, Warren RF, et al: Arthroscopic anatomy of the lateral elbow: A comparison of three portals. Arthroscopy 1994;10:602-607.
Andrews JR, Carson WG: Arthroscopy of the elbow. Arthroscopy 1985;1:97-107.

Question 96

When comparing surgical and nonsurgical extremities in patients who underwent anterior cruciate ligament (ACL) reconstruction using patellar tendon or hamstrings autografts, isokinetic strength measurements obtained 6 months after the surgery would most likely reveal

Explanation

DISCUSSION: Follow-up examination at 6 months revealed no statistically significant differences in quadricep or hamstring strength when comparing surgical versus nonsurgical extremities isokinetically. Therefore, the selection of autogenous hamstring or patellar tendon for ACL reconstruction should not be based solely on the assumption of the graft tissue source altering the recovery of quadricep and/or hamstring strength.
REFERENCES: Carter TR, Edinger S: Isokinetic evaluation of anterior cruciate ligament reconstruction: Hamstring versus patellar tendon. Arthroscopy 1999;15:169-172
Howell SM, Taylor MA: Brace-free rehabilitation, with early return to activity, for knees reconstructed with a double-looped semitendinosus and gracilis graft. J Bone Joint Surg Am 1996;78:814-825.
Shelbourne KD, Nitz P: Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med 1990;18:292-299.

Question 97

When performing a Kocher approach to the radial head for open reduction internal fixation the forearm is held in pronation. What structure is this maneuver attempting to protect?

Explanation

DISCUSSION: Dilberti et al quantified the dimensions of a surgically safe zone (with respect to the posterior interosseous nerve) when using the posterolateral approach to the radial head between the anconeus and the extensor carpi ulnaris. They found that the safe zone increased with pronation and decreased with supination.

Question 98

A 26-year-old man with chronic lateral ankle instability underwent a modified Broström procedure 8 months ago. He reports persistent pain and swelling of the lateral ankle. Examination reveals lateral ankle tenderness and swelling and a negative anterior drawer test. Laboratory studies show a WBC count of 6,500/mm 3 and an erythrocyte sedimentation rate of 15 mm/h. Radiographs of the ankle are normal. What is the most likely cause of this problem?

Explanation

DISCUSSION: Chronic lateral instability is commonly associated with a longitudinal split tear of the peroneus brevis tendon. The interrelationship of lateral ankle instability with superior retinacular laxity and resultant peroneus brevis split can account for persistent lateral ankle pain in this patient. Surgical treatment must identify and correct the underlying tendon pathology and should attempt to repair or debride the peroneus brevis tendon, reconstruct the superior peroneal retinaculum, flatten the posterior edge of the fibula by removing the sharp bony prominence, or deepening the fibular groove, along with addressing lateral ankle ligamentous instability. The laboratory values are not consistent with infection. A negative anterior drawer test confirms stability of the repair. Ankle arthritis is not seen on radiographs and usually takes longer than 3 months to develop.
REFERENCES: Bonnin M, Tavernier T, Bouysset M: Split lesions of the peroneus brevis tendon in chronic ankle laxity. Am J Sports Med 1997;25:699-703.
Sobel M, Geppert MJ, Warren RF: Chronic ankle instability as a cause of peroneal tendon injury. Clin Orthop Relat Res 1993;296:187-191.

Question 99

Posterior cruciate insufficiency diagnosed using the quadriceps active test is confirmed with tibial translation

Explanation

In the quadriceps active drawer test, with the subject supine, the leg is relaxed and supported with the knee flexed 70 to 90 degrees. The examiner must adequately support the patient’s thigh so that the subject’s muscles are completely relaxed. The patient is then asked to perform a gentle quadriceps contraction without extending the knee. In the normal knee in 90 degrees of flexion, the patellar ligament is already slightly posterior, and contraction of the quadriceps does not result in an anterior shift of the tibia. However if the PCL is ruptured, the tibia sags into a posteriorly subluxed position, and the patellar ligament is then directed anteriorly. In this situation, contraction of the quadriceps muscle in the posterior cruciate deficient knee results in an anterior shift of the tibia 2mm or more. The examiner can visualize this anterior shift of the tibia with the knee is 90 degrees of flexion.

Question 100

A 36-year-old skier sustains a grade III posterior cruciate ligament (PCL) tear. Where will increased contact pressures develop over time?

Explanation

DISCUSSION: Complete rupture of the PCL leads to increased contact pressures in the patellofemoral and medial compartments of the knee. However, whether degenerative arthritis will develop and in which compartments still remains controversial.
REFERENCE: Garrett WE, Speer KP, Kirkendall DT (eds): Principles & Practice of Orthopaedic Sports Medicine. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, p 767.

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

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

Correct Answer: C6-7

Explanation:

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

Question 2:

Options:

a three-phase bone scan.
CT.
MRI.
a repeat examination in 6 weeks.
a biopsy.

Correct Answer: a repeat examination in 6 weeks.

Explanation:

Question 3:

Which of the following rehabilitation techniques is appropriate for initial nonsurgical management of an isolated grade 2 posterior cruciate ligament injury? Review Topic

Options:

Immobilization in full extension for 4 weeks
Immobilization in 30 degrees of flexion for 4 weeks
Relative protection for 10 to 14 days, then range of motion with progressive plyometric exercises
Relative protection for 10 to 14 days, then range of motion with gentle open-chain hamstring strengthening
Relative protection for 10 to 14 days, then range of motion with gentle closed-chain quadriceps strengthening

Correct Answer: Relative protection for 10 to 14 days, then range of motion with gentle closed-chain quadriceps strengthening

Explanation:

Question 4:

Which factor is a contraindication to surgical treatment of a symptomatic CAM deformity?

Options:

Degenerative tear of the anterosuperior acetabular labrum
Superior hip joint space of 2 mm or less on radiographs
Ipsilateral knee instability
Lumbar spondylolisthesis

Correct Answer: Superior hip joint space of 2 mm or less on radiographs

Explanation:

Question 5:

A patient undergoes cartilage implantation requiring amplification of donor cells. Which of the following statements best describes the transplants?

Options:

There is a linear relationship between biosynthetic activity and the number of chondrocytes seeded.
Osteochondral lesions of 12 mm in size may be treated with chondrocyte transplantation alone.
Mesenchymal stem cells are harvested and allowed to differentiate to chondrocytes ex vivo.
The cellular carrier has no effect on biosynthetic activity.
In animal studies using fluorescent-labeled articular chondrocytes, donor cells are found to persist for up to 5 years.

Correct Answer: There is a linear relationship between biosynthetic activity and the number of chondrocytes seeded.

Explanation:

DISCUSSION: Chondrocytes are obtained from cartilage harvested from non-weight-bearing areas of the knee. The extracellular matrix is digested, and the chondrocytes are expanded for later transplantation. Cells implanted into a defect are secured with a flap of periosteum. Cells are expanded to obtain 20 to 50 times the original number of cells to transplant at a cell density of 3x10
-7
cells/mL. There is a direct relationship between cell number and biosynthetic activity. Osteochondral lesions of up to 8 mm may be treated with autologous transplant alone; larger depth lesions should be bone grafted at the time of harvest. Mesenchymal stem cells differentiate easily into fibrous tissue, bone, and fat; conversion of mesenchymal stem cells into cartilage in vitro currently is difficult to accomplish. Goldberg and Caplan, however, were able to obtain cartilage repair using mesenchymal stem cells transplanted into defects in rabbits in vivo. In animal studies, fluorescent-labeled cells persist for at least 14 weeks, integrate with the surrounding normal margins, and become part of the repaired tissue replete with sulfated proteoglycans and type II collagen.
REFERENCES: Brittberg M, Peterson L, Sjogren-Jansson E, et al: Articular cartilage engineering with autologous chondrocyte transplantation. J Bone Joint Surg Am
2003;85:109-115.
Caplan AI, Elyaderani M, Mochizuki Y, et al: Principles of cartilage repair and regeneration. Clin Orthop 1997;342:254-269.

Question 6:

A 47-year-old man has left-sided motor weakness in the extensor digitorum longus and extensor hallucis longus, sensory loss in the lateral calf and dorsal foot, and no discernible reflex loss.

Options:

Figure 72a Figure 72b
Figure 72c Figure 72d
Figure 72e Figure 72f
Figure 72g Figure 72h

Correct Answer: Figure 72g Figure 72h

Explanation:

DISCUSSION
Figures 72a and 72b are the T1-weighted MR images of a disk bulge. Disk bulges are common in asymptomatic people and are not predictive of pathology. Figures 72c and 72d show T1 MR images of a far lateral disk herniation at the L4-L5 level. This would affect the exiting or L4 nerve root. Radicular symptoms would occur at the L4 level. Figures 72e and 72f show an annular tear at the L4-L5 level. This pathology is associated with discogenic low-back pain. Figures 72g and 72h show the T1 MR images of a central lateral disk herniation at the L4-L5 level. This would affect the traversing or L5 nerve root. Radicular symptoms would occur at the L5 level.
RECOMMENDED READINGS
Jarvik JG, Hollingworth W, Heagerty PJ, Haynor DR, Boyko EJ, Deyo RA. Three-year incidence of low back pain in an initially asymptomatic cohort: clinical and imaging risk factors. Spine (Phila Pa 1976). 2005 Jul 1;30(13):1541-8; discussion 1549. PubMed PMID: 15990670.
View Abstract at PubMed
Hoppenfeld S. Physical Exam of the Spine and Extremities. Stamford, CT: Appleton and Lange; 1995.
Madigan L, Vaccaro AR, Spector LR, Milam RA. Management of symptomatic lumbar degenerative disk disease. J Am Acad Orthop Surg. 2009 Feb;17(2):102-11. Review. PubMed PMID: 19202123.
View Abstract at PubMed

Question 7:

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

Options:

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

Correct Answer: Surgical resection

Explanation:

Question 8:

A study is proposed in which 2 groups of patients are randomized to treatment with bisphosphonates or placebo. This is an example of what study type?

Options:

Crossover design trial
Parallel design trial
Cohort study
Case series

Correct Answer: Parallel design trial

Explanation:

Question 9:

Options:

Sural nerve injury
Tethering of the flexor hallucis longus by fracture fragments
Medial plantar nerve neuropathy
Weakness of the tibialis posterior
Unrecognized foot compartment syndrome

Correct Answer: Sural nerve injury

Explanation:

Question 10:

Options:

Menstrual history
Family history
Serum calcium level
MRI of the hip
Contralateral hip radiograph

Correct Answer: Menstrual history

Explanation:

Question 11:

Figure 17 shows the AP radiograph of a 5-year old child who has mild short stature and a painless bilateral gluteus medius lurch. Initial work-up should include

Options:

a bone scan.
a skeletal survey.
MRI of the hips.
CT of the hips.
a CBC count and a C-reactive protein.

Correct Answer: a skeletal survey.

Explanation:

DISCUSSION: Bilateral flattening of the femoral heads suggests multiple epiphyseal dysplasia; therefore, a skeletal survey is indicated to look for involvement of other epiphyses. Unilateral flattening of the femoral head would suggest Legg-Perthes disease.
REFERENCES: Sponseller PD: Skeletal dysplasias, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 269-270.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 1, pp 689-691.

Question 12:

Metastatic disease of several cancers create lytic lesions because these cancers:

Options:

directly produce osteoprotegerin
stimulate osteoblasts to produce osteoprotegerin
directly produce receptor activator of nuclear factor kappa beta ligand (RANKL)
stimulate osteoclasts to produce receptor activator of nuclear factor kappa beta ligand (RANKL)
directly produce an analog to calcitonin

Correct Answer: directly produce osteoprotegerin

Explanation:

Question 13:

What property of titanium alloys accounts for their high corrosion resistance in vivo?

Options:

Self-passivation
Ductility
Hardness
Modulus of elasticity
Conductivity

Correct Answer: Self-passivation

Explanation:

DISCUSSION: In both room temperature air and physiologic fluids, titanium alloys self-passivate or spontaneously form a layer of titanium oxide very rapidly. This layer makes titanium alloys resistant to surface breakdown.
REFERENCES: Callaghan JJ, Rosenberg AG, Rubash HE, et al (eds): The Adult Knee. Philadelphia, PA, Lippincott, 2003, vol 1, pp 269-278.
Lemons JE: Metallic alloys, in Morrey BF (ed): Joint Replacement Arthroplasty, ed 3. Philadelphia, PA, Churchill-Livingstone, 2003, pp 19-27.

Question 14:

Options:

Incision and drainage
Ice the ankle but don't let him play.
Topical antibiotics for 7 days with an occlusive dressing
Debridement in the training room followed by 5 days of oral antibiotics

Correct Answer: Incision and drainage

Explanation:

The clinical photograph shows a skin infection with an appearance consistent with methicillin-resistant
Staphylococcus aureus
. This infection should be clinically incised and allowed to drain and a course of antibiotics should follow. If this infection is not promptly treated with debridement, it likely will worsen and potentially spread to other teammates. Antibiotics are secondary to surgical debridement but are a necessary adjunct. Although this patient has a history of severe sprain, his malaise and skin appearance do not correlate with a ligament injury or fracture. Debridement in the training room is not appropriate and would likely not fully decompress the fluid collection.

Question 15:

Options:

High parathyroid hormone, normal calcium, normal alkaline phosphatase, low phosphorus, low vitamin D
High parathyroid hormone, low calcium, high alkaline phosphatase, low phosphorus, low vitamin D
Normal parathyroid hormone, high calcium, low alkaline phosphatase, low phosphorus, low vitamin D
Low parathyroid hormone, normal calcium, normal alkaline phosphatase, low phosphorus, low vitamin D
Low parathyroid hormone, low calcium, high alkaline phosphatase, low phosphorus, low vitamin D

Correct Answer: High parathyroid hormone, normal calcium, normal alkaline phosphatase, low phosphorus, low vitamin D

Explanation:

Question 16:

Options:

Low acetabular index
Excessive acetabular retroversion
Deficient anterior column bone
Labral detachment
Pelvic discontinuity

Correct Answer: Excessive acetabular retroversion

Explanation:

Question 17:

03 A 23 year old sustains an isolated right knee dislocation in an MVA. A closed reduction is performed and confirmed with radiographs. What is the next appropriate study?

Options:

CT of knee
MRI of knee
radiographs of femur and tibia
angiography of the leg
noninvasive assessment of lower extremity perfusion backanswer Question 43.03

Correct Answer: noninvasive assessment of lower extremity perfusion backanswer Question 43.03

Explanation:

This is simple A, B, Cs and doctoring. History and Physical exam come first. Noninvasive assessement includes visual inspection, clinical examination (feel pulses, check capillary refill, feel temperature of skin), and ABIs. X-ray, CT, and MRI would be good secondary studies to identify bony or soft tissue injuries—after initial reduction and splinting/stabilizatoin. Angiography would be indicated if there were asymmetric pulses or an ABI < 0.9, or if there was any other indication that a vessel injury may have occurred.
OKU Truama 2 says “the use of ABI with the blood pressure cuff and Doppler evaluation of the distal circulation has been proposed as effective in determining any occult vascular injury. A ratio > 0.9indicates a normal study.”
[1]
The referenced article confirms this. “Confirmation of the safety and accuracy of physical exam in the evaluation of knee dislocation for injury of the popliteal artery.” J. Trauma2002; 52: 247-252
back to this question next question
[1]
OKU Trauma 2 pg 151-153

Question 18:

Which of the following is the most sensitive parameter to detect the increased inflammatory response seen with both postoperative infection and the use of instrumentation in spinal surgery?

Options:

Patient temperature
WBC count
Erythrocyte sedimentation rate
C-reactive protein
Rheumatoid Factor

Correct Answer: Patient temperature

Explanation:

CORRECT
DISCUSSION: The most sensitive parameter to detect inflammation elicited by implants and infection is the C-reactive protein (CRP).
CRP is an acute phase reactant that increases sharply immediately after surgery within 6 hours after tissue damage. CRP then peaks 2-3 days later and returns to normal levels 5-21 days after the inciting event. In contrast, ESR reaches its peak on days 4-11, then remains elevated for a prolonged period of time.
Takahashi et al performed a Level 3 study of patients who had undergone spinal surgery with and without instrumentation, with a primary outcome of infection. They concluded that renewed elevation of C-reactive protein, white blood cell count, and body temperature after postoperative days 4 to 7 may be a key indicator of postoperative infection.

Question 19:

A computed tomography (CT) scan has been shown to be indicated for evaluation of all of the following aspects of acetabular fractures, EXCEPT:

Options:

Determination of surgical planning
Intra-articular loose bodies
Marginal impaction
Fracture piece size and position
Determination of pre-existing degenerative changes

Correct Answer: Determination of surgical planning

Explanation:

Question 20:

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 21:

A 65-year-old woman has significant neck pain after falling and striking her head. A radiograph and sagittal CT scan are shown in Figures 23a and 23b. What is the most likely diagnosis?

Options:

Degenerative spondylolisthesis
Superior facet fracture
Inferior facet fracture
Perched unilateral facet dislocation
Bilateral facet dislocation

Correct Answer: Perched unilateral facet dislocation

Explanation:

Question 22:

Options:

Immobilization/nonsurgical management
Irrigation and debridement
stage reimplantation total knee arthroplasty (TKA)
Increased constraint/polyethylene exchange
Revision of the femoral component only
Revision of the tibial component only
Revision of both components
Revision of the patellar component

Correct Answer: Immobilization/nonsurgical management

Explanation:

Question 23:

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

Options:

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

Correct Answer: Lateral dislocation of the patella

Explanation:

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

Question 24:

Options:

50 degrees of plantar flexion
20 degrees of ankle dorsiflexion
Neutral to 30 degrees of plantar flexion
Neutral to 10 degrees of dorsiflexion
Ankle position has no effect on calf compartment pressure

Correct Answer: 50 degrees of plantar flexion

Explanation:

Question 25:

Options:

Physical therapy
CT-guided needle biopsy and IV antibiotics
Revision laminotomy and diskectomy
L4-L5 anterior debridement and fusion
Open repair of the L4-L5 pseudomeningocele

Correct Answer: Physical therapy

Explanation:

The MRI scans show Modic changes in the L4-L5 vertebral bodies due to spondylosis. There is no increased fluid signal or enhancement in the L4-L5 disk to suggest infection or any other pathologic process. Therefore, the patient’s pain should be treated with a course of physical therapy and rehabilitation. There is no infection; therefore, IV antibiotics and debridement are not indicated. Similarly, a
pseudomeningocele is not present. A revision diskectomy is useful for recurrent radiculopathy but would not be helpful for degenerative low back pain.
(SBQ12SP.29) A 17-year-old female is undergoing posterior instrumented fusion from T5-T12 for adolescent idiopathic scoliosis. At the time of the correction maneuver, the neurophysiologist notifies you of a 60% decrease in somatosensory evoked potential (SSEP) amplitude throughout bilateral lower extremities. Which of the following is an acceptable approach to manage this finding?
Review Topic
Immediate wake-up test with examination for clonus
Drop the mean arterial pressure (MAP) to ~60mmHg
Discontinue instrumentation and optimize MAP to 85mmHg or greater
Immediate infusion of intravenous corticosteroids
Modification of the anesthesia plan to include inhalational agents only followed by repeated SSEP testing
The patient has a significant drop in SSEP amplitudes at the completion of the corrective maneuver. The most appropriate response is to raise the MAP to 85 mmHg or greater, discontinue the instrumentation, re-evaluate the SSEPs, and if there is no improvement, to consider reversing the reduction of the deformity.
Intra-operative neurophysiologic monitoring is an effective method to monitor insults to the spinal cord and its exiting roots during spinal instrumentation. The common measurements include SSEPs, which monitor sensory potentials transmitted through the dorsal column system, and motor-evoked potentials (MEPs), which monitor motor response to a trans-cranial stimulus. Decreases in amplitude and latency of the circuits are recorded, however diminished signal amplitudes are more sensitive for neurologic injury, and decreases of of >50-60% being highly concerning. The wake-up test involves reversal of anesthesia so that an intra-operative neurologic examination can be performed.
Devlin et al. reviewed the basic science and practice of neurophysiologic monitoring in spine surgery. They proposed an algorithmic approach to managing intraoperative alerts which include discontinuation of inhalational anesthetics, increasing the MAP to >90 mmHg, discontinuing instrumentation, and performing a wake-up test if neurologic signals fail to normalize.
Herdmann et al. reviewed the practice of neurophysiologic monitoring and the effects of anesthesia upon signal transduction. They report that anesthesia affecting a neuron's intrinsic excitability can alter the results of monitoring. Inhalational anesthetics and decreased MAPs can be responsible for decreased amplitudes.
Vitale et. al. developed a consensus-based intraoperative checklist for management of lost neuromonitoring signals. In this checklist, the first steps across the surgical and anesthetic teams should include: stop the case and announce signal losses to the room, optimize the mean arterial pressure, discuss the status of anesthetic agents, and discuss reversible surgical actions just prior to signal loss.
Incorrect

Question 26:

Options:

Dega iliac
Salter iliac
Pemberton iliac
Steele triple
Ganz or Bernese periacetabular

Correct Answer: Dega iliac

Question 27:

What structure provides the major blood supply to the humeral head?

Options:

Posterior circumflex humeral artery
Anterior circumflex humeral artery, ascending branch
Nutrient humeral artery
Thoracoacromial artery, deltoid branch
Small arteries of the rotator cuff insertions

Correct Answer: Anterior circumflex humeral artery, ascending branch

Explanation:

DISCUSSION: The ascending branch of the anterior circumflex humeral artery provides
the major blood supply to the humeral head. The posterior circumflex humeral artery
supplies a much smaller portion of the proximal humerus. The nutrient humeral artery is the main blood supply for the humeral shaft. The thoracoacromial artery is primarily a muscular branch. The rotator cuff insertions contribute some blood supply to the tuberosities but not a major contribution.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.
Cushner MA, Friedman RJ: Osteonecrosis of the humeral head. J Am Acad Orthop Surg 1997;5:339-346.

Question 28:

Anteromedial approach (Ludloff)

Options:

Lateral femoral cutaneous
Superior gluteal
Inferior gluteal
Obturator
Sciatic

Correct Answer: Obturator

Explanation:

Question 29:

Where is the watershed zone for tarsal navicular vascularity?

Options:

Medial one third
Central one third
Lateral one third
Tuberosity
Inferior pole

Correct Answer: Central one third

Explanation:

DISCUSSION: The central one third has been established as the watershed zone by angiographic studies, and has been borne out in clinical conditions involving the navicular, such as stress fractures and osteonecrosis. These findings account for the susceptibility to injury at this level.
REFERENCES: Nunley JA, Pfeffer GB, Sanders RW, et al (eds): Advanced Reconstruction: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004,
pp 239-242.
Sarrafian
SK
: Anatomy of the Foot and Ankle. Philadelphia, PA, JB Lippincott, 1983,
pp 299-302.

Question 30:

Options:

observation.
physical therapy.
ulnohumeral arthroplasty.
ulnohumeral arthroplasty and ulnar nerve decompression.
semiconstrained elbow arthroplasty.

Correct Answer: ulnohumeral arthroplasty and ulnar nerve decompression.

Explanation:

Question 31:

Options:

increased laxity.
increased risk for graft failure.
no differences in long-term results.
lower Knee Injury and Osteoarthritis Outcome Scores (KOOS).

Correct Answer: no differences in long-term results.

Explanation:

Question 32:

Osteoporotic vertebral compression fractures are associated with Review Topic

Options:

neurologic deterioration in 33% of patients.
osteomalacia in 50% of patients.
a further fracture risk rate of 20%.
chronic pain in 75% of patients.
a 2-year mortality rate that is less than that associated with hip fractures.

Correct Answer: a further fracture risk rate of 20%.

Explanation:

Question 33:

Options:

The risk of tuberosity nonunion/malunion appears higher with hemiarthroplasty.
Functional outcomes tend to be more consistent with hemiarthroplasty.
Forward elevation of reverse shoulder arthroplasty depends on tuberosity union.
Active elevation is likely to be better following hemiarthroplasty.

Correct Answer: Active elevation is likely to be better following hemiarthroplasty.

Explanation:

Question 34:

Options:

Impingement injection test
Lift-off test
Weakness with “empty-can” abduction test
Load-and-sift maneuver
MRI with contrast

Correct Answer: Lift-off test

Explanation:

Question 35:

Which of the following deformities is most common after the amputation shown in Figure A?

Options:

Pes cavus
Pes planus
Hindfoot valgus
Equinovarus
Calcaneovalgus

Correct Answer: Pes cavus

Explanation:

Question 36:

Options:

Observation
Dynamic bracing
Manipulation under anesthesia
Revision with open adhesiolysis
Physical therapy with aggressive range of motion

Correct Answer: Revision with open adhesiolysis

Explanation:

Question.16 . When comparing the results of cemented all-polyethylene tibial components to metal-backed components,the all-polyethylene tibia
is more expensive.
is more susceptible to fracture.
is associated with an elevated risk for polyethylene wear.
has an equivalent rate of aseptic loosening.
has higher failure rates when used in patients younger than age 70.
Question. 17 . When the liquid monomer (monomethacrylate) is added to polymer powder (polymethylmethacrylate),the activator in the liquid monomer (N,N-Dimethyl-p-toluidine) comes in contact with the initiator in the polymer powder and polymerization is initiated. What is the initiator?
Hylamer
Polystyrene
Barium sulfate
Benzoyl peroxide
Zirconium dioxide
Question.18 . Figure 197 is the radiograph of a 62-year-old woman who is seen in the emergency department with a dislocated left total hip arthroplasty. This is her seventh dislocation during the last 3 months and she most recently had a liner revision. What is the best next treatment step?
Skeletal traction
Open reduction
Closed reduction
Component revision
Hip abduction orthosis

Question 37:

Options:

Alendronate
Indomethacin
Radiotherapy
Excision

Correct Answer: Alendronate

Explanation:

Question 38:

All of the following conditions are associated with the female athlete triad EXCEPT? Review Topic

Options:

Amenorrhea
Osteoporosis
Low LDL levels
Decreased immune function
Insufficient caloric intake

Correct Answer: Amenorrhea

Explanation:

Question 39:

Options:

Infection
Malunion
Loss of forearm rotation
Refracture
Delayed union/nonunion

Correct Answer: Loss of forearm rotation

Explanation:

DISCUSSION: Healing of forearm fractures in skeletally immature patients is the usual outcome. The use of intramedullary fixation has been reported to result in a lower frequency of refractures when compared to plate osteosynthesis due to the absence of diaphyseal holes after plate removal, which are considered stress risers. Regardless of implant technique, malunion and infection are infrequent. Loss of forearm pronation and supination is a common occurrence in surgically treated fractures due to the higher degree of soft-tissue injury, and periosteal stripping leads to fracture site instability and fracture comminution.
REFERENCES: Luhmann SJ, Gordon JE, Schoenecker PL: Intramedullary fixation of unstable both-bone forearm fractures in children. J Pediatr Orthop 1998;18:451-456.
Mehlman CT, Wall EJ: Injuries to the shafts of the radius and ulna, in Beaty JH, Kasser JR (eds): Fractures in Children, ed 6. Philadelphia, PA, Lippincott, 2006, pp 430-436.

Question 40:

Kyphosis from a vertebral osteoporotic compression fracture often results in progressive kyphosis due to

Options:

progressive increase in lumbar lordosis.
load transfer to the superior adjacent vertebra.
normalization of load transfer with working kyphosis.
reduced strain at the occipito-cervical junction.
reduced strain at the apex of the deformity.

Correct Answer: load transfer to the superior adjacent vertebra.

Explanation:

DISCUSSION: Kayanja and associates, in a number of biomechanical studies, showed that in a kyphotic spine the strain is located at the apex of the deformity, the force is transmitted to the superior adjacent vertebrae, and that realignment and cement augmentation effectively normalize the load transfer.
REFERENCES: Kayanja MM, Ferrara LA, Lieberman IH: Distribution of anterior cortical shear strain after a thoracic wedge compression fracture. Spine J 2004;4:76-87.
Kayanja MM, Togawa D, Lieberman IH: Biomechanical changes after the augmentation of experimental osteoporotic vertebral compression fractures in the cadaveric thoracic spine. Spine J 2005;5:55-63.
Kayanja MM, Schlenk R, Togawa D, et al: The biomechanics of 1, 2, and 3 levels of vertebral augmentation with polymethylmethacrylate in multilevel spinal segments. Spine 2006;31:769-774.
Kayanja M, Evans K, Milks R, et al: The mechanics of polymethylmethacrylate augmentation. Clin Orthop Relat Res 2006;443:124-130.

Question 41:

Which of the following statements best describes the typical early presentation of osteochondritis dissecans of the elbow? Review Topic

Options:

Often associated with loss of elbow extension
Often associated with catching or locking
Involves the capitellum or lateral trochlea
Presents in boys younger than age 10 years
Outlining of the margins of the lesion on MR arthrogram is a good prognostic sign

Correct Answer: Often associated with loss of elbow extension

Explanation:

Question 42:

A 29-year-old quarterback falls onto his dominant shoulder and sustains the injury shown in Figures 14a and 14b. Management should consist of

Options:

an arm sling.
nonsteroidal anti-inflammatory drugs and a rapid return to activity.
arthroscopic partial claviculectomy.
acromioclavicular joint reduction and stabilization.
acromionectomy.

Correct Answer: acromioclavicular joint reduction and stabilization.

Explanation:

Question 43:

On an axial CT image, which of the following dimensions is considered to be indicative of a critical amount of lumbar spinal stenosis? Review Topic

Options:

AP canal diameter of less than 20 mm
AP canal diameter of less than 50 mm
Cross-sectional area of less than 100 mm2
Cross-sectional area of less than 50 mm2
Circumferential area of less than 25 mm

Correct Answer: Cross-sectional area of less than 100 mm2

Explanation:

Lumbar central stenosis is defined by an AP canal diameter of less than 10 mm or a cross-sectional area of less than 100 mm2 as measured on CT.

Question 44:

Options:

Long thoracic
Suprascapular
Spinal accessory
Axillary
Thoracodorsal

Correct Answer: Spinal accessory

Explanation:

Question 45:

In a patient with a major head injury and a femoral shaft fracture, intraoperative hypotension during femoral fixation has been associated with which of the following?

Options:

Increased time needed for rehabilitation
Increased pneumonia rate
Increased intensive care unit length of stay
Decreased discharge Glascow Coma Scale
Decreased hospital length of stay

Correct Answer: Increased time needed for rehabilitation

Explanation:

Question 46:

Figures 1 and 2 are the radiographs of a 17-year-old man who injured his wrist 6 months ago. He is experiencing pain and limited motion. What is the most effective treatment option?

Options:

Long-arm thumb spica casting
Bracing and bone stimulation
Scaphoid excision with intercarpal fusion
Bone grafting with screw placement

Correct Answer: Bone grafting with screw placement

Explanation:

Question 47:

If the site of the pathologic lesion is revealed in Figure 54f and not in Figure 54e after traumatic anterior shoulder dislocation, the mechanism of shoulder injury is likely

Options:

axial loading of the glenohumeral joint.
isolated hyperabduction.
combined 45-degree abduction and external rotation.
combined hyperabduction and external rotation.

Correct Answer: combined hyperabduction and external rotation.

Explanation:

DISCUSSION
For patients with anterior shoulder instability, most commonly, a Bankart lesion, or detachment of the anteroinferior labrum with the attached inferior glenohumeral ligament from the glenoid rim is found. A medialized anteroinferior capsulolabral attachment (ALPSA lesion) is a common finding in shoulders with chronic anterior instability. The anterior band of the inferior glenohumeral ligament is tightest with the arm in 90 degrees of abduction with the shoulder externally rotated, creating a “hammock” that supports the humeral head. At 45 degrees of shoulder
abduction, the capsuloligamentous components of the shoulder are at their loosest, resulting in the most total superior-inferior translation.
During traumatic anterior glenohumeral dislocation, associated injuries commonly occur. In a prospective database of 3633 patients who sustained a traumatic anterior glenohumeral dislocation, 13.5% had a neurologic deficit following reduction, the majority of which were injuries to the axillary nerve. The injuries typically were sensory but not motor deficits and resolved spontaneously over time. These isolated axillary nerve injuries were more common in young, athletic patients. Associated rotator cuff tears and greater tuberosity fractures are commonly associated with shoulder dislocation as well and are more common in patients 60 years of age and older.
Large, engaging posterior humeral head Hill-Sachs lesions are associated with increased rates of recurrent shoulder instability. At the time of surgical arthroscopy, the Hill-Sachs lesion should be assessed for engagement with the glenoid. In the absence of significant glenoid bone loss, some patients with engaging Hill-Sachs defects may be suitable for combined Bankart repair and Hill-Sachs remplissage at the time of surgery. When these procedures are combined, patients have an approximate 10-degree decreased shoulder external rotation with the arm at the side and in abduction when compared to the contralateral, uninjured shoulder. Rates of recurrent dislocation and return to sport are comparable to those for patients undergoing Bankart repair alone.
Humeral avulsion of the glenohumeral ligaments (HAGL) has become a well-recognized cause of recurrent shoulder instability and is reported in 1% to 9% of patients. HAGL lesions can occur in isolation or, more commonly, may be associated with other abnormalities such as a tear of the rotator cuff, Bankart lesion, Hill-Sachs deformity, or labral tear. Recurrence of shoulder instability is more likely to occur if there is failure to identify a HAGL lesion. HAGL lesions can result from trauma in the setting of combined hyperabduction and external rotation. This is in contrast to a Bankart lesion, which is a result of trauma when the shoulder is hyperabducted without substantial associated rotation.
RECOMMENDED READINGS
Warner JJ, Deng XH, Warren RF, Torzilli PA. Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint. Am J Sports Med. 1992 Nov-Dec;20(6):675-85. PubMed PMID: 1456361.
View Abstract at PubMed
Robinson CM, Shur N, Sharpe T, Ray A, Murray IR. Injuries associated with traumatic anterior glenohumeral dislocations. J Bone Joint Surg Am. 2012 Jan 4;94(1):18-26. doi: 10.2106/JBJS.J.01795. PubMed PMID: 22218378.
View Abstract at PubMed
Visser CP, Coene LN, Brand R, Tavy DL. The incidence of nerve injury in anterior dislocation of the shoulder and its influence on functional recovery. A prospective clinical and EMG study. J Bone Joint Surg Br. 1999 Jul;81(4):679-85. PubMed PMID: 10463745.
View Abstract at PubMed
Boileau P, O'Shea K, Vargas P, Pinedo M, Old J, Zumstein M. Anatomical and functional results after arthroscopic Hill-Sachs remplissage. J Bone Joint Surg Am. 2012 Apr 4;94(7):618-26. doi: 10.2106/JBJS.K.00101. PubMed PMID: 22488618.
View Abstract at PubMed
Bui-Mansfield LT, Banks KP, Taylor DC. Humeral avulsion of the glenohumeral ligaments: the HAGL lesion. Am J Sports Med. 2007 Nov;35(11):1960-6. Epub 2007 Apr 9. Review. PubMed PMID: 17420506.
View Abstract at PubMed

Question 48:

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

Options:

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

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

Explanation:

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

Question 49:

Options:

simple lateral eminence resection.
distal chevron osteotomy of the fifth metatarsal.
oblique mid-diaphyseal osteotomy of the fifth metatarsal.
proximal diaphyseal osteotomy of the fifth metatarsal.
excision of the fifth metatarsal head.

Correct Answer: oblique mid-diaphyseal osteotomy of the fifth metatarsal.

Explanation:

Question 50:

Figure 28 shows an arthroscopic view of a right shoulder in the lateral position through a posterior portal. What is the area between structure B (biceps) and SS (subscapularis tendon)? Review Topic

Options:

Inferior glenohumeral ligament
Superior glenohumeral ligament
Rotator cuff interval
Subscapularis recess
Interior recess

Correct Answer: Rotator cuff interval

Explanation:

Question 51:

Tendons should have what ratio of matrix protein?

Options:

65% collagen type I and 35% proteoglycans
80% collagen type I and 20% collagen type VI
95% collagen type I and less than 5% collagen type III
95% proteglycans and 5% tenascin

Correct Answer: 95% collagen type I and less than 5% collagen type III

Explanation:

Question 52:

A 48-year-old woman reports bilateral thigh pain that is limiting her function as a librarian. A radiograph and a bone scan are shown in Figures 23a and 23b. What is the most likely diagnosis?

Options:

Ankylosing spondylitis
Arthrokatadysis
Osteomalacia
Rheumatoid arthritis
Developmental dysplasia

Correct Answer: Rheumatoid arthritis

Explanation:

DISCUSSION: The radiograph reveals bilateral severe acetabular protrusio. The bone scan and history confirm involvement of multiple joints, including the knees and the hindfoot. Although the first four choices can all cause the acetabular protrusio, the associated multiple joint involvement suggests the diagnosis of rheumatoid arthritis. Arthrokatadysis, or primary protrusio acetabuli, is often associated with osteomalacia but not other joint disease. Developmental dysplasia is a common cause of bilateral hip pathology but does not have acetabular protrusio.
REFERENCES: Resnick D: Diagnosis of Bone and Joint Disorders, ed 3. Philadelphia, PA,
WB Saunders, 1995, pp 956-957.
Wheeless’ Textbook of Orthopaedics: Acetabular Protrusio. www.wheelessonline.com/ortho/acetabular_protrusio

Question 53:

Options:

Biopsy and culture of the lesion
MRI of the left femur
IV antibiotics for 6 weeks
Incision and drainage of the left femur
Repeat radiograph in 3 months

Correct Answer: MRI of the left femur

Explanation:

Question 54:

Which of the following surgical options after resection of a sarcoma about the knee would require a patient to expend the greatest amount of energy while walking?

Options:

Arthrodesis
Rotationplasty
Above-knee amputation
Osteoarticular allograft
Endoprosthesis (custom arthroplasty)

Correct Answer: Above-knee amputation

Explanation:

Question 55:

When conducted at near physiologic strain rates, tensile studies of the inferior glenohumeral ligament (IGHL) have shown that the

Options:

anterior band of the IGHL has the greatest stiffness and the glenoid insertion site shows greater strain than the ligament midsubstance.
anterior band of the IGHL has the greatest stiffness and the ligament midsubstance shows greater strain than the glenoid insertion site.
axillary pouch of the IGHL has the greatest stiffness and the glenoid insertion site shows greater strain than the ligament midsubstance.
axillary pouch of the IGHL has the greatest stiffness and the ligament midsubstance shows greater strain than the glenoid insertion site.
posterior portion of the IGHL has the greatest stiffness and the glenoid insertion site shows greater strain than the ligament midsubstance.

Correct Answer: anterior band of the IGHL has the greatest stiffness and the glenoid insertion site shows greater strain than the ligament midsubstance.

Explanation:

Question 56:

Options:

Greater pelvic ring stability
Lower risk of pin tract infection
Less reliance on fluoroscopy for pin placement
Better ability to control a posterior pelvic injury
Less likely to interfere with future incisions for definitive pelvic internal fixation

Correct Answer: Less reliance on fluoroscopy for pin placement

Explanation:

Question 57:

What patient factor is predictive of better outcomes for surgical management of a displaced calcaneal fracture compared to nonsurgical management?

Options:

Young man injured at the work site
Young woman injured during recreational activities
Heavy smoker
Patient older than age 50 years
Patient with bilateral fractures

Correct Answer: Young woman injured during recreational activities

Explanation:

Question 58:

Which of the following methods best aids in diagnosis of an interdigital neuroma?

Options:

Ultrasound
MRI
Web space injection
Electromyography and nerve conduction velocity studies
History and physical examination

Correct Answer: History and physical examination

Explanation:

Question 59:

Options:

cast immobilization for 4 to 6 weeks.
posterior tibial tendon advancement and repair (Kidner procedure).
corticosteroid injection of the posterior tibial tendon insertion.
triple arthrodesis.
needle biopsy of the trochar.

Correct Answer: cast immobilization for 4 to 6 weeks.

Explanation:

Question 60:

Which statement is true with respect to acetabular fracture surgery as the time between injury and surgery increases?

Options:

decreased chance of anatomic fracture reduction
decreased risk of heterotopic ossification
decreased rate of neurologic injury
decreased rate of infection
decreased rate of multi-organ failure

Correct Answer: decreased chance of anatomic fracture reduction

Explanation:

Question 61:

Options:

axillary nerve.
musculocutaneous nerve.
median nerve.
radial nerve.

Correct Answer: musculocutaneous nerve.

Explanation:

Question 62:

Which of the following methods of treating a vertically oriented (eg, Pauwels III) femoral neck fracture is mechanically optimal?

Options:

Two parallel fully threaded screws
Three parallel partially threaded screws
Three parallel fully threaded screws
Four parallel partially threaded screws
Sliding hip screw and side plate

Correct Answer: Two parallel fully threaded screws

Explanation:

Vertical fractures have a higher rate of displacement and nonunion because of shearing forces across the fracture. Biomechanical and clinical studies indicate that for the vertically oriented fracture of the femoral neck, the most stable fixation construct is a sliding hip screw and side plate. Antirotation screws may be used as well. Nonsurgical management carries a high risk of early displacement because of shear forces. Three screws are loaded as a cantilever and have less resistance to displacement compared with a fixed-angle device with a side plate. Fully threaded screws will not allow any compression and have the same drawbacks as partially threaded screws. The addition of a fourth screw has not been shown to be of benefit.
(SBQ12TR.68) Figure A is a radiograph of a 75-year-old woman that fell onto her non-dominant shoulder from a standing height. She was treated non-operatively for 9 months but continues to complain of pain when she elevates her arm. In patients with this type of fracture pattern, what factor has the greatest impact on fracture healing?
Hand dominance
Angulation of fracture
Smoking
Early physical therapy
Diet
This patient has an impacted varus proximal humerus fracture. Smoking has been shown to increase the nonunion risk up to 5.5 times with these fractures.
Impacted varus proximal humerus fractures can be managed effectively with nonoperative care. The major factors that influence non-union are age and smoking. Solid bony union can be seen in 93-98% of patients at 1 year, with more than 97% of people returning to pre-injury level of function. The angulation of fracture, hand dominance and physical therapy does not seem to influence bone union or functional outcomes with this fracture pattern.
Court-Brown et al. looked at the outcomes of impacted varus fractures. They determined that the age of the patient was the major factor in overall outcome. They showed that the best results occurred in younger patients, but results deteriorate with advancing age. Physical therapy was not found to impact outcome.
Hanson et al. showed that impacted varus fractures can be successfully managed with non-operative care. They found that overall fracture displacement had a minor impact of fracture healing and functional outcome. The predicted risk of delayed union and nonunion was 7% with patients that smoke. This was 5.5 times greater than nonsmokers.
Figure A shows an AP radiograph of a varus angulated proximal humerus fracture. This radiograph shows delayed atrophic union.
Incorrect Answers:

Question 63:

The specificity of intraoperative frozen sections obtained for the evaluation of infected total hip arthroplasty may be improved by

Options:

setting the threshold for diagnosis to 10 polymorphonuclear leukocytes per high-powered field.
setting the threshold for diagnosis to 15 polymorphonuclear leukocytes per high-powered field.
ensuring that each sample is obtained and submitted in a truly random fashion.
ensuring that polymorphonuclear leukocyte counts are obtained in a truly random fashion.
correlating the frozen section results with those of the intraoperative Gram stain.

Correct Answer: setting the threshold for diagnosis to 10 polymorphonuclear leukocytes per high-powered field.

Explanation:

Question 64:

- A 40-year-old woman has had pain in the metatarsophal joint of the second toe for the past 6 months despite nonsurgical treatment. A dorsalplantar stress test reproduces the pain, and there is 10 mm of dorsal subluxation of the toe. Radiographs show a normal second metatarsophalangeal joint. Surgical treatment should consist of synovectomy and

Options:

Advancement of the plantar plate
Resection of the second metatarsal head
Dorsiflexion osteotomy of the second metatarsal neck
Transfer of the flexor digitorum longus tendon to the dorsum of the toe
Transfer of the extensor digitorum comminus tendon to the metatarsal neck

Correct Answer: Transfer of the flexor digitorum longus tendon to the dorsum of the toe

Explanation:

Question 65:

Options:

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

Correct Answer: Legg-Calve-Perthes disease.

Explanation:

Question 66:

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

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:

Question 67:

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

Options:

3 months
6 months
12 months
36 months
72 months

Correct Answer: 36 months

Explanation:

Question 68:

The flap shown in the clinical photograph seen in Figure 51 is based on what arterial supply?

Options:

Superficial circumflex iliac
Femoral lateral accessory
Inferior epigastric
Inferior inguinal
Lateral obturator

Correct Answer: Superficial circumflex iliac

Explanation:

Question 69:

Options:

Transfer lesion to the fourth metatarsal head
Fifth toe fixed claw toe deformity
Ulceration at the level of the resected head
Peroneal atrophy
Charcot arthropathy with midfoot collapse and forefoot abduction

Correct Answer: Transfer lesion to the fourth metatarsal head

Explanation:

DISCUSSION: CMT is characterized by a cavovarus foot position that increases weight-bearing stresses along the lateral border. Removal of the fifth metatarsal head carries the risk of creating a transfer lesion at the fourth metatarsal head, particularly with a cavovarus foot. Claw toes are common in CMT, but the fifth toe would be flail in this situation. Ulceration is unlikely given the lack of underlying bone. Peroneal atrophy is associated with CMT but would not be a complication of this procedure. Charcot arthropathy is a neuropathic process frequently seen in individuals with diabetes mellitus.
REFERENCES: Kitaoka HB, Holiday AD Jr: Metatarsal head resection for bunionette: Long-term followup. Foot Ankle 1991;11:345-349.
Coughlin MJ, Mann RA, Saltzman CL: Surgery of the Foot and Ankle, ed 8. Philadelphia, PA, Mosby, 2007, pp 1312-1315.

Question 70:

Options:

The child is a victim of neglect
The child had no symptoms of pain
He was allowed to return to school wearing the cast
Concerns of cost
Follow-up instructions were not effectively communicated

Correct Answer: The child is a victim of neglect

Explanation:

Question 71:

Options:

Enchondroma
Giant cell tumor
Chondroblastoma
Osteoblastoma
Chondromyxoid fibroma

Correct Answer: Chondroblastoma

Explanation:

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

Question 72:

Options:

Open tendon transfer
Corticosteriod injection and supervised physical therapy
Open rotator cuff repair, subacromial decompression and distal clavical excision
Revision to reverse shoulder arthroplasty
Revision to cuff arthropathy hemiarthroplasty

Correct Answer: Revision to cuff arthropathy hemiarthroplasty

Explanation:

Question 73:

Options:

measurement for a thoracolumbosacral orthosis.
bed rest with gradual mobilization.
anterior corpectomy and interbody fusion with instrumentation.
kyphoplasty.
posterior fusion with instrumentation.

Correct Answer: posterior fusion with instrumentation.

Explanation:

Question 74:

During establishment of an anterior portal for hip arthroscopy, what structure is at greatest risk for injury? Review Topic

Options:

Lateral femoral cutaneous nerve
Femoral nerve
Femoral artery
Superior gluteal nerve
Sciatic nerve

Correct Answer: Lateral femoral cutaneous nerve

Explanation:

Question 75:

Options:

Medial malleolus
Deltoid ligament
Anterior talofibular ligament
Lateral malleolus
Calcaneonavicular ligament

Correct Answer: Deltoid ligament

Explanation:

Question 76:

Options:

Oral antibiotics for staphylococcus
Repeat laboratory studies in 1 week to recheck the ESR
MRI with gadolinium
Biopsy of the surgical disk space
Irrigation and debridement of the surgical wound in the operating room

Correct Answer: MRI with gadolinium

Explanation:

Question 77:

All of the following have been shown to negatively affect clinical outcomes in treating displaced acetabular fractures, EXCEPT:

Options:

Increased age
Intraoperative complications
Ipsilateral femoral head injury
Involvement of both columns
Non-anatomic fracture reduction

Correct Answer: Increased age

Explanation:

Question 78:

There is a risk of impaired forearm rotation after tension band fixation of an olecranon fracture with which of the following?

Options:

Ipsilateral proximal humerus fracture
Protrusion of Kirschner wire fixation through the volar cortex of the proximal ulna
Use of ulnar intramedullary Kirschner wire fixation
Olecranon fracture comminution
Lack of triceps tendon repair

Correct Answer: Ipsilateral proximal humerus fracture

Explanation:

Question 79:

03 A 28-year-old man who sustained the injury shown in Figure 31 is hemodynamically unstable. In addition to fluid resuscitation, the next most appropriate step in management should include

Options:

angiography and embolization.
an emergent exploratory laparotomy.
external pelvic stabilization.
open reduction and internal fixation.
closed reduction and percutaneous screw fixation. backanswer Question 112.03

Correct Answer: external pelvic stabilization.

Explanation:

Question 80:

Options:

Bracing with physical therapy focusing on quadriceps/vastus medialis obliquus (VMO) and hamstring strengthening
Osteotomy
Osteochondral allograft to femoral condyle
Arthroscopy with femoral condyle microfracture

Correct Answer: Osteochondral allograft to femoral condyle

Explanation:

Question 81:

Which of the following is most frequently associated with heterotopic ossification about the shoulder?

Options:

Acute anterior dislocation
Acute posterior dislocation
Multiple attempts at closed reduction of chronic unreduced fracture-dislocations
Immediate open reduction and internal fixation of greater tuberosity fractures
Open reduction of midshaft clavicular fractures

Correct Answer: Multiple attempts at closed reduction of chronic unreduced fracture-dislocations

Explanation:

Question 82:

Figure 30 shows the MRI scan of a 68-year-old woman who has left hip pain. What is the most appropriate treatment?

Options:

Open reduction and internal fixation
Total hip arthroplasty
Incisional biopsy
Proximal femoral resection and reconstruction
Arthrodesis

Correct Answer: Total hip arthroplasty

Explanation:

DISCUSSION: The patient has a large zone of osteonecrosis of the left femoral head. The wedge-shaped zone of decreased signal intensity on the T1 image in the subchondral region of the femoral head is typical. Based on these findings, total hip arthroplasty is the most appropriate treatment. Open reduction and internal fixation will not help this condition. Incisional biopsy is indicated only if the MRI scan shows a probable neoplasm. Resection of the proximal femur is indicated only for aggressive malignancy. Arthrodesis may be considered in a younger patient but not in a 68-year-old individual. Other treatments, not listed, such as core decompression, vascularized fibular transplant, and osteotomy may be options in selected patients.
REFERENCES: Urbaniak JR, Jones JP Jr (eds): Osteonecrosis: Etiology, Diagnosis, and Treatment. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 213-223.
Watson RM, Roach NA, Dalinka MK: Avascular necrosis and bone marrow edema syndrome. Radiol Clin North Am 2004;42:207-219.

Question 83:

The superior glenohumeral ligament primarily restrains

Options:

posterior translation of the humeral head with the arm in 90 degrees of abduction.
inferior translation of the humeral head with the arm in adduction.
anterior translation of the humeral head in 90 degrees of abduction.
anterior translation of the humeral head with the arm in 45 degrees of abduction.
anterior translation of the humeral head with the arm in 90 degrees of abduction and external rotation.

Correct Answer: inferior translation of the humeral head with the arm in adduction.

Explanation:

Question 84:

Spindled cells that are surrounded in mature osteoid that connect to other similar cells via canaliculi are best described as which of the following? Review Topic

Options:

Osteoblasts
Osteoclasts
Osteocytes
Histiocytes
Megakaryocytes

Correct Answer: Osteocytes

Explanation:

Question 85:

Options:

Cast immobilization for 2 weeks followed by early motion
Minimal treatment for this congenital radial head dislocation
Open reduction and internal fixation
Annular ligament reconstruction
Attempt a repeat closed reduction

Correct Answer: Open reduction and internal fixation

Explanation:

DISCUSSION: Ninety percent of injuries to the proximal radius in children are radial neck fractures, and 50% of these fractures are through the metaphyseal bone. The remaining 50% are Salter-Harris type I or II fractures. These radiographs show a fracture of the radial head and subluxation of the radius anteriorly. Most congenital radial head dislocations are posterior lateral. Nonsurgical treatment modalities are unlikely to be successful due to the wide displacement of the fracture fragments, as well as dislocation of the radial head.
REFERENCES: Leung AG, Peterson HA: Fractures of the proximal radial head and neck in children with emphasis on those that involve the articular cartilage. J Pediatr Orthop
2000;20:7-14.
Hashemi-Nejad A, Goddard NJ: Radial head fractures. Br J Hosp Med 1994;51:223-226.
Rodriguez Merchan EC: Displaced fractures of the head and neck of the radius in children: Open reduction and temporary transarticular internal fixation. Orthopedics 1991;14:697-700.

Question 86:

In overhead athletic activities, the kinetic chain generates what percentage of force from the leg and trunk segments of the chain?

Options:

20% to 30%
30% to 40%
50% to 60%
60% to 70%
80% to 90%

Correct Answer: 50% to 60%

Explanation:

Question 87:

-What is the most likely area of injury?

Options:

Femoral attachment of the medial collateral ligament
Tibial attachment of the medial collateral ligament
Hypertrophic zone of the growth plate
Proliferative zone of the growth plate

Correct Answer: Hypertrophic zone of the growth plate

Explanation:

DISCUSSION FOR QUESTIONS 40 THROUGH 42
This patient likely has a physeal injury to the distal femoral physis. Stress radiographs or an MRI scan will most reliably reveal this diagnosis. The growth plate, when injured, is most commonly fractured through the hypertrophic zone of cartilage, its weakest point. This patient is optimally treated in a cylindrical or long-leg cast. Younger patients can be treated with a hip spica with a leg extension.

Question 88:

Options:

Measurement of volar compartment pressures and, if elevated, a bolus transfusion of 4 unit/kg of factor VIII concentrate, followed by continuous transfusion of factor VIII
Splinting of the extremity with the elbow flexed and the wrist in extension, elevation of the extremity, observation, and if no improvement, continuous transfusion of factor VIII (4 unit/kg)
A bolus transfusion of 4 unit/kg of factor VIII concentrate, followed by continuous transfusion of factor VIII, measurement of forearm compartment pressures, splinting of the extremity with the elbow and wrist flexed, and surgical release of the volar forearm compartments if pressures are elevated
A bolus transfusion of 4 unit/kg of factor VIII concentrate, followed by continuous transfusion of factor VIII and an emergency fasciotomy
A bolus transfusion of 4 unit/kg of factor VIII concentrate, laboratory studies consisting of serum electrolytes and creatine phosphokinase levels, IV injections of bicarbonate to alkalize the urine, and renal dialysis

Correct Answer: A bolus transfusion of 4 unit/kg of factor VIII concentrate, followed by continuous transfusion of factor VIII, measurement of forearm compartment pressures, splinting of the extremity with the elbow and wrist flexed, and surgical release of the volar forearm compartments if pressures are elevated

Explanation:

Question 89:

Options:

External rotation of the femoral component
Overstuffing of the patellofemoral joint
Less than 12 mm of bony patella remaining after resection
Lateral retinacular release
Use of a cemented patellar component

Correct Answer: Less than 12 mm of bony patella remaining after resection

Explanation:

Question 90:

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 91:

Which of the following ligaments is the primary static restraint against inferior translation of the arm when the shoulder is in 0 degrees of abduction?

Options:

Middle glenohumeral
Inferior glenohumeral
Coracoacromial
Coracoclavicular
Coracohumeral

Correct Answer: Coracohumeral

Explanation:

Question 92:

Options:

Continued oral anti-inflammatories
Right L4/5 microdiscectomy
Right L4/5 minimally invasive transforaminal interbody fusion
Referral for EMG and nerve conduction studies
L4/5 posterior decompression and instrumented fusion

Correct Answer: Referral for EMG and nerve conduction studies

Explanation:

Question 93:

Figure 9 shows the radiograph of a 75-year-old woman who reports the sudden onset of disabling medial knee pain. What is the most likely diagnosis?

Options:

Osteoarthritis
Osteonecrosis
Meniscal tear
Metastatic lesion
Synovial osteochondromatosis

Correct Answer: Osteonecrosis

Explanation:

Question 94:

The radiograph shown in Figure 27 shows measurement of what angle?

Options:

Hallux valgus
Distal metatarsal articular
Intermetatarsal
Sesamoid divergence
Angle of joint congruence

Correct Answer: Distal metatarsal articular

Explanation:

Question 95:

What neurovascular structure is in closest proximity to the probe in the arthroscopic view of the elbow shown in Figure 50?

Options:

Ulnar nerve
Radial nerve
Posterior interosseous nerve
Superficial radial nerve
Median nerve

Correct Answer: Radial nerve

Explanation:

DISCUSSION: The image shows a view of the radiocapitellar joint from an anterior medial portal. The radial nerve lies on the elbow capsule at the midportion of the capitellum. It is at risk for injury when capsular excision is performed in this region.
REFERENCES: Field LD, Altchek DW, Warren RF, et al: Arthroscopic anatomy of the lateral elbow: A comparison of three portals. Arthroscopy 1994;10:602-607.
Andrews JR, Carson WG: Arthroscopy of the elbow. Arthroscopy 1985;1:97-107.

Question 96:

Options:

significant quadricep weakness in the pateller tendon compared with the hamstring.
significant quadricep weakness in the hamstring compared with the pateller tendon.
significant weakness in the hamstring compared with the patellar tendon.
significant hamstring weakness in the pateller tendon compared with the hamstring.
no significant difference between the hamstring and the pateller tendon.

Correct Answer: no significant difference between the hamstring and the pateller tendon.

Explanation:

Question 97:

When performing a Kocher approach to the radial head for open reduction internal fixation the forearm is held in pronation. What structure is this maneuver attempting to protect?

Options:

median nerve
brachial artery
anterior interosseous nerve
radial nerve
posterior interosseous nerve

Correct Answer: median nerve

Explanation:

Question 98:

Options:

Deep infection
Failure of repair
Peroneus longus tear
Peroneus brevis tear
Tibiotalar arthritis

Correct Answer: Peroneus brevis tear

Explanation:

DISCUSSION: Chronic lateral instability is commonly associated with a longitudinal split tear of the peroneus brevis tendon. The interrelationship of lateral ankle instability with superior retinacular laxity and resultant peroneus brevis split can account for persistent lateral ankle pain in this patient. Surgical treatment must identify and correct the underlying tendon pathology and should attempt to repair or debride the peroneus brevis tendon, reconstruct the superior peroneal retinaculum, flatten the posterior edge of the fibula by removing the sharp bony prominence, or deepening the fibular groove, along with addressing lateral ankle ligamentous instability. The laboratory values are not consistent with infection. A negative anterior drawer test confirms stability of the repair. Ankle arthritis is not seen on radiographs and usually takes longer than 3 months to develop.
REFERENCES: Bonnin M, Tavernier T, Bouysset M: Split lesions of the peroneus brevis tendon in chronic ankle laxity. Am J Sports Med 1997;25:699-703.
Sobel M, Geppert MJ, Warren RF: Chronic ankle instability as a cause of peroneal tendon injury. Clin Orthop Relat Res 1993;296:187-191.

Question 99:

- Posterior cruciate insufficiency diagnosed using the quadriceps active test is confirmed with tibial translation

Options:

Anteriorly at 20 to 30 degrees of flexion
Anteriorly at 70 to 90 degrees of flexion
Posteriorly at 20 to 30 degrees of flexion
Posteriorly at 70 to 90 degrees of flexion
Anteriorly with the knee in full flexion

Correct Answer: Anteriorly at 70 to 90 degrees of flexion

Explanation:

Question 100:

A 36-year-old skier sustains a grade III posterior cruciate ligament (PCL) tear. Where will increased contact pressures develop over time?

Options:

Ligament of Humphrey
Patellar ligament
Quadriceps tendon
Lateral compartment
Medial compartment

Correct Answer: Medial compartment

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

Orthopedic Board Review MCQs: Spine, Knee & Trauma | Part 165

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 165

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index