Orthopedic Surgery Board Review MCQs: Shoulder, Spine, Foot & Ankle | Part 167

A 42-year-old woman who has had an 18-month history of severe low back pain is referred to your office for surgical evaluation. She reports that the pain initially began with right lower extremity pain and management consisted of oral analgesics, nonsteroidal anti-inflammatory drugs, and muscle relaxants. She has seen a chiropractor as well as a pain management specialist and she is status-post epidural steroid injections. She has also completed exhaustive physical therapy, as she is a certified athletic trainer and runs a health fitness program at a community hospital. Currently, she denies lower extremity pain and her pain is isolated to her low back and is subjectively graded as 8/10, with 10 being the worst pain she has ever experienced. The pain is interfering with her activities of daily living and she is seeking definitive treatment. Figures 32a through 32c show current MRI scans. Based on the current available medical literature, what is the most appropriate treatment?

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

Figures 18a through 18c show the clinical photograph, radiograph, and CT scan of a 21-year-old man who reports persistent pain after injuring his right shoulder 4 months ago. What is the most likely factor associated with this patient’s diagnosis?

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

Figures 9a and 9b are the radiographs of a 19-year-old woman with a painful juvenile bunion. The pathologic findings associated with this deformity include a

Which of the following is considered the best method for the prevention of wrong-site surgery?

A 35-year-old man presents one week after an acute right shoulder posterior dislocation after being electrocuted. He  is  evaluated in  the emergency department and  undergoes closed  reduction.  The  patient reports global right shoulder pain and limited active and passive range of motion. He has mild anterior and lateral bruising. He is distally neurovascularly intact. Current radiographs and an MRI scan are shown in Figures 1 through 3. What is the best next step?

• Figure 16 shoes the AP radiograph of a 32-year-old man with a fracture cephalad to the fovea of the femoral head. A CT scan shows a single head fragment. After closed reduction of the hip, there is 5 mm of residual articular incongruity. Management should now include

Which of the following findings is seen in the chest radiograph shown in Figure 13?

A 7-year-old boy with spastic diplegia is a limited community ambulator. He has a moderately severe crouched gait. The parents request a treatment that will result in a permanent decrease in lower extremity muscle tone. This is best accomplished with

What is the most common behavioral effect of anabolic steroid use in athletes?

Radiographs of a 15-year-old girl with knee pain reveal a radiopaque lesion of the distal femoral metaphysis and epiphysis with a small associated soft-tissue mass. A biopsy specimen shows osteoid and pleomorphic cells with multiple mitotic figures. Staging studies show no other sites of disease. Treatment should consist of

• The familial occurrence of Legg-Calve-Perthes disease may, in some cases, be attributed to

A 61-year-old woman has increasing pain in her left great toe. She states that she has had discomfort for years but now has pain with all shoe wear. A radiograph is shown in Figure 35. To provide the most predictable pain-free result, treatment should consist of

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

During revision total knee arthroplasty (TKA), there is significant laxity in 90° of flexion and 10° short of full extension. Correcting the gap imbalance is best achieved by

What is the primary problem in rickets osteomalacia?

Figures 74a through 74c are the postsurgical radiographs of a 74-year-old man who has stiffness in his right knee 8 weeks after undergoing elective right total knee arthroplasty (TKA). The surgery was performed for primary varus osteoarthritis and was uncomplicated. His range of motion is 5 to 80 degrees. What is the most appropriate next treatment step?

83A B year-old with the injury pattern seen on the left lower extremity in CT images in Figures 83a and 83b

A 6-year-old boy with spastic diplegic cerebral palsy has a crouched gait. Examination reveals hip flexion contractures of 15 degrees and popliteal angles of 70 degrees. Equinus contractures measure 10 degrees with the knees extended. Which of the following surgical procedures, if performed alone, will worsen the crouching?

Which is the best initial study for the diagnostic evaluation of diskogenic low back pain?

An orthopaedic surgeon in his first year of practice is negotiating with a private for-profit hospital to be their employed trauma specialist. The state of employment is known to have a high rate of malpractice claims because of a favorable plaintiff legal environment. During the course of negotiations, malpractice insurance is being discussed. The surgeon should ask the hospital to provide which type of malpractice insurance policy? Review Topic

Which examination finding points toward a brachial plexus injury rather than root avulsion?

A 67-year-old retired steelworker was involved in a motor vehicle accident and sustained a midcervical spinal cord injury. Radiographs and MRI scans reveal severe cervical stenosis and spondylosis without fractures or dislocations. Neurologic examination reveals an ASIA C spinal cord impairment with greater motor involvement of the upper extremities than the lower extremities. What is the probability that the patient eventually will become ambulatory?

A 42-year-old man who is right-hand dominant injured his right shoulder when he fell from a ladder onto his outstretched arm 1 hour ago. Radiographs reveal a two-part greater tuberosity anterior fracture-dislocation. Initial management should consist of

Figure 36a shows the current radiograph of a 65-year-old woman who slipped and fell. History reveals that prior to the fall she was actively functioning without pain. Figure 36b shows a radiograph obtained 1 year ago. Based on the fracture pattern, the failure is most likely related to

A 35-year-old man has numbness and tingling in the index, middle, and ring fingers. History reveals that he also has had vague wrist pain and stiffness since being injured in a motorcycle accident 1 year ago. Radiographs are shown in Figures 47a through 47c. Management should consist of

A 15-year-old boy reports a 2-day history of progressive left buttock pain and severe limping. He denies any history of trauma or radiation of the pain. He has an oral temperature of 100.4 degrees F (38 degrees C). Examination reveals that the lumbar spine and left hip have unguarded motion. The abdomen is nontender. There is moderate tenderness of the left sacroiliac region with no palpable swelling. Pain is elicited when the left lower extremity is placed in the figure-4 position (FABER test). Laboratory studies show a peripheral WBC count of 11,500/mm P 3 P (normal to 10,500/mm P 3 P ) and an erythrocyte sedimentation rate of 38 mm/h (normal up to 20 mm/h). Radiographs of the pelvis, hips, and lumbar spine are normal. A nucleotide bone scan (posterior view) is shown in Figure 44. Initial management should consist of

A 7-year-old girl with spinal muscular atrophy (SMA) type II has popping of the left hip. Examination reveals painless subluxation of the joint in adduction with palpable reduction in abduction. Radiographs show coxa valga, subluxation of the left hip, and pelvic obliquity with elevation of the left hemipelvis. Treatment should consist of

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

• A clinical trial is being conducted on a new orthopaedic device that is different from existing devices that are moderately successful, but have frequent complications when used to treat fractures in the elderly. To comply with international standards for clinical trials, the investigator must include in the study design

What is the primary limiting membrane and mechanical support for the periphery of the physis?

A corset-type brace may help reduce symptoms during an episode of acute low back pain as the result of

03 An 18 month old child has bilateral “corner fractures” of the distal femoral metaphyses of unknown origin. Following a skeletal survey, the first step in management should consist of

A 40-year-old man reports an enlarging soft-tissue mass in his right shoulder. Based on the MRI scan and biopsy specimens shown in Figures 40a through 40c, what is the most likely diagnosis?

..A 75-year-old woman sustained a 4-part fracture dislocation of the proximal humerus with a comminuted humeral head. You decide to perform a reverse total shoulder replacement because of her age and activity level. This will be your first reverse total shoulder replacement. It is common practice in your hospital for an industry representative to be present when new implants are brought into the operating room. What information are you required to disclose?

Posterior inferior tibiofibular ligament (PITFL) The syndesmosis between the tibia and fibula at the ankle consists of five defined structures ( Slide ):

A 30-year-old man landed on his shoulder in a fall off his mountain bike. An AP radiograph and CT scan are shown in Figures 34a and 34b. Management should consist of

With the arm abducted 90 degrees and fully externally rotated, which of the following glenohumeral ligaments resists anterior translation of the humerus? Review Topic

Figures 28a through 28c show the MRI scans of a 30-year-old woman who weighs 290 lb and has low back and left leg pain. She also reports frequent urinary dribbling, which her gynecologist has advised her may be related to obesity. Examination will most likely reveal

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

Figures  1  and  2  demonstrate  the  radiographs  obtained  from  a  35-year-old  woman  with  end-stage debilitating osteoarthritis of the right hip. She is contemplating total hip arthroplasty (THA). She has a history of right hip dysplasia and underwent hip osteotomy as an adolescent. Over the years, nonsurgical treatment,  including  weight  loss,  activity  modifications,  and  intra-articular  injections,  has  failed.  Her infection  work-up  reveals  laboratory  findings  within  defined  limits.The  patient  undergoes  successful primary THA  with  a  metal-on-metal  bearing.  At  1-year  follow-up,  she  reports  no  pain  and  is  highly satisfied with the procedure. However, 3 years after the index procedure, she reports atraumatic right hip pain  that  worsens  with  activities.  Radiographs  reveal  the  implants  in  good  position  with  no  sign  of loosening or lysis. An initial laboratory evaluation reveals a normal sedimentation rate and C-reactive protein (CRP) level. The most appropriate next diagnostic step is

Figures 33a and 33b show the standing posteroanterior and lateral radiographs of a 59-year-old woman with adult idiopathic scoliosis. She underwent a prior decompressive laminectomy and fusion at L4-S1 to address lumbar stenosis. She now reports progressive lower back pain and a feeling of being shifted to the right. If surgical intervention is considered, what is the most important goal in improving her health-related quality of life (HRQL) outcomes? Review Topic

What is the most common clinical presentation of a patient with a malignant bone tumor?

Figure 40 shows the AP radiograph of a 55-year-old man who reports left knee pain. Which of the following conditions is least likely to produce this radiographic presentation?

After trial placement of components in a primary total knee arthroplasty, the knee is unable to come to full extension, but the flexion gap is appropriately balanced. After adequate soft-tissue releases have been performed, what is the next most appropriate action to balance the reconstruction?

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

An obese 10-year-old boy has had left groin pain and a limp for the past 2 months. Examination reveals decreased abduction and internal rotation. Laboratory studies show normal renal function and an elevated thyroid-stimulating hormone (TSH) level. AP and frog lateral radiographs of the pelvis are shown in Figures 30a and 30b. What is the best course of action?

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?

A further workup reveals elevations in serum cobalt and chromium levels and fluid collections surrounding the hip on MARS MR imaging. Revision THA is recommended. The most common complication following revision of a failed metal-on-metal hip arthroplasty is

A 36-year-old woman is brought to the emergency department intubated and sedated following a motor vehicle accident. She is moving her upper and lower extremities spontaneously. She cannot follow commands. CT scans are shown in Figures 7a through 7c. The initial survey does not reveal any other injuries. Initial management of the cervical injury should consist of immediate

• A patient sustained a joint depression-type fracture of the calcaneus that healed despite lack of treatment. The loss of dorsiflexion the patient is now experiencing is most likely the result of

A displaced pediatric supracondylar humerus fracture is treated with closed manipulation and placement of 2 Kirschner wires placed from the lateral side. What would be the effect of adding a third pin from the lateral side? Review Topic

-A 42-year-old patient with a right distal radius fracture underwent open reduction and internal fixation. To reduce the likelihood of complex regional pain syndrome, the most appropriate medication is

Figure 30 shows an axial T1-weighted MRI scan of a patient’s right shoulder. The arrows are pointing to what normal structure?

Which structure(s) is/are most at risk with surgical treatment of displaced clavicle fractures with ORIF?

Which of the follow scenarios is most likely to be amenable to a complete repair of a massive rotator cuff tear? Review Topic

An inverted radial reflex is associated with

Figure 25 shows the clinical photograph of a 48-year-old man who has had a forefoot ulcer for the past 4 months. History reveals that he has had type II diabetes mellitus for the past 10 years. Examination reveals sensory and motor neuropathy, with weak ankle dorsiflexion. The ankle cannot be passively dorsiflexed past a neutral position. Initial management should consist of

The vessel seen in the clinical photographs shown in Figures 50a and 50b (1,2 intercompartmental supraretinacular artery) is being dissected to be used as a source of vascularized bone graft for a patient who is scheduled to undergo internal fixation of a scaphoid nonunion. This vessel is a branch of what artery?

If a laminectomy for spinal stenosis is performed, which of the following is an indication for concomitant arthrodesis at that level?

Which intervention most effectively prevents surgical-site infections following spine surgery?

A year-old active woman undergoes elective total hip replacement in which a posterior approach is used. She has minimal pain and is discharged to home 2 days after surgery. Four weeks later, she dislocates her hip while shaving her legs. She undergoes a closed reduction in the emergency department. Postreduction radiographs show a reduced hip with well-fixed components in satisfactory alignment. What is the most appropriate management of this condition from this point forward?

An open biopsy specimen of a radiodense distal clavicle lesion in a 12-year-old girl shows chronic polyclonal inflammatory cells without granuloma formation. Laboratory studies show that bacterial, fungal, and acid-fast bacillus cultures are negative. Subsequently, a similar lesion is noted in the fibula. The next most appropriate step in management should consist of

Figure 81 is a lateral thoracic spine radiograph of a 76-year-old man with a history of ankylosing spondylitis who falls and strikes his back. He has moderate thoracic discomfort. An initial examination does not reveal neurologic deficits. He is discharged home that day, but returns 3 days later with profound weakness in his legs. Which imaging study should have been obtained at his initial presentation?

Which of the following is considered the treatment of choice for a 3-cm chondroblastoma of the distal femoral epiphysis with no intra-articular extension?

In Gustilo type III open tibial diaphyseal fractures, which of the following factors is associated with an increased risk of a poor functional outcome?

A 43-year-old former professional hockey player reports severe pain in his chest after being checked from the side in a pick-up hockey game. An MRI scan and plain radiographs are shown in Figures 25a through 25c. What is the most likely diagnosis?

Patients in compensated shock (normal vital signs) are thought to be at risk for which of the following?

Figures 54a and 54b show the radiograph and MRI scan of a 7-year-old boy who has a painful right thoracic scoliosis that measures 35°. Neurologic examination is normal. Management should consist of

A 62-year-old man has a severe pes planus and pain in the hindfoot. Radiographs show advanced degenerative changes at the talonavicular and subtalar joints with good preservation of the ankle joint. What is the most appropriate surgical procedure to alleviate his pain?

Which method of flexor tendon repair that necessitates excursion through the A2 pulley allows for the most thorough assessment of tendon gliding?

Which 2 tendons are identified in the dissection shown in Video 92?

A 45-year-old man is seeking evaluation of an injury sustained in a motor vehicle accident 10 weeks ago. Current radiographs are shown in Figures 2a and 2b. Based on the radiographic findings, what is the most likely diagnosis?

A 7-year-old girl is hit by a motor vehicle and sustains the isolated ipsilateral injuries shown in Figures 16a and 16b. What is the optimal definitive method of treatment?

An extended head hemiarthroplasty (rotator cuff tear arthropathy head) has what theoretic advantage when compared to a standard hemiarthroplasty?

Figures 1 and 2 are the T2-weighted MR images of a 54-year-old woman with medial knee pain and catching of 6 months’ duration. Which treatment option is most likely to be associated with a favorable outcome?

Which of the following is considered the most appropriate shoe modification following transmetatarsal amputation?

Myodesis of which muscle group is most important for optimal outcome after transfemoral amputation?

Figures below show the radiographs, and the CT obtained from a 58-year-old woman who underwent cementless left total hip arthroplasty. Nine months after surgery, she continued to have groin pain when actively flexing her hip. She has trouble walking up stairs and getting out of her car. What is the most likely diagnosis?

1 and 2 show the radiographs obtained from a year-old morbidly obese man who underwent left total hip replacement 7 years ago and did well, with no symptoms prior to the current presentation. He recently rose from a seated position and felt a pop in the hip, with immediate pain and inability to bear weight. Any pressure on the left foot now produces a painful, grinding sensation with loss of left hip stability. What is the best next step?

Which of the following indicates resolution of a postoperative wound infection? Review Topic

What is the most common pediatric soft-tissue sarcoma?

• A 76-year-old woman who underwent primary total knee arthroplasty 9 months ago falls and sustains a transverse fracture of the proximal third of the patella that is displaced 5 mm. Although the knee is painful, she is able to ambulate and has a 5-degree extension lag. The component appears to be well fixed. Treatment should now include

A 43-year-old man who works as a plumber has a painful stiff elbow in his dominant arm. He notes that while he recalls no single event of injury, he thinks the many years of pulling wrenches and soldering pipes have resulted in his problem. He reports that he has pain with any motion in bending his arm and can no longer straighten his elbow. Examination reveals generalized swelling of the elbow, both medial and lateral with a range of motion that lacks 45 degrees of extension and flexes only to 110 degrees. Pronation and supination are also limited to 45 degrees. Audible crepitus is perceived but there is no instability. Radiographs reveal advanced osteoarthritis at the radiocapitellar and ulnohumeral joints with complete loss of articular cartilage. What is the most appropriate initial treatment option? Review Topic

Figures 155a and 155b are the plain radiographs of a 17-year-old boy who recently noted painless swelling in his distal thigh. Examination reveals a firm, fixed, deep distal thigh mass. There is no associated tenderness. What is the best next treatment step?

Figure 31 shows the radiograph of an 8-year-old boy who has a swollen forearm after falling out of a tree. Examination reveals that all three nerves are functionally intact, and there is no evidence of circulatory embarrassment. Management should consist of

An 85-year-old right hand dominant male sustains a fall onto his elbow while trying to get out of the car. His past medical history is significant for diabetes, congestive heart failure, and COPD. He lives in a nursing home, and is able to ambulate at baseline without and assistive devices. What would be the ideal definitive surgical treatment options in this patient? Review Topic

Which of the following provocative tests would most likely be positive in a patient with medial epicondylitis? Review Topic

An 18-year-old woman sustains a twisting injury of the knee while skiing. Figures 7a and 7b show the radiograph and coronal MRI scan of the knee. In addition to the injury shown, what is the most likely associated injury?

Bisphosphonates are indicated in the treatment of osteoporosis in patients who have a DEXA T-score of

The most important radiographic predictor of a good clinical outcome following adult spinal deformity surgery is correction of Review Topic

Osteolysis after total knee arthroplasty can be minimized through prosthetic design features such as

A 26-year-old man is brought to the emergency department unresponsive and intubated after being found lying on the side of the road. He has a Glasgow Coma Scale score of 6. A chest tube has been inserted on the right side of the chest for a pneumothorax. An abdominal CT scan reveals a small liver laceration and minimal intraperitoneal hematoma. A pneumatic antishock garment (PASG) is on but not inflated. He has bilateral tibia fractures. A pelvic CT scan shows an anterior minimally displaced left sacral ala fracture and left superior and inferior rami fractures. He has received 2 L of saline solution and 4 units of blood but remains hemodynamically unstable. What is the next most appropriate step in management?

Which of the following benign bone lesions can develop lung metastases?

A 40-year-old woman reports the atraumatic onset of severe knee pain and swelling after undergoing an uncomplicated elective cholecystectomy 1 week ago. She denies any history of diabetes mellitus or HIV but has had occasional episodes of mild knee pain and swelling that have always responded to nonsteroidal anti-inflammatory drugs. Radiographs are shown in Figures 5a and 5b. A knee aspiration yields a WBC count of 35,000/mm 3 . The aspirate should also yield which of the following findings?

An otherwise healthy 25-year-old man with an isolated closed mid-diaphyseal femoral fracture undergoes intramedullary nailing. Compared with nonreamed nailing, reamed femoral nailing is associated with a higher rate of Review Topic

What neurovascular structure is most at risk when performing an inside-out repair of the posterior horn of the medial meniscus?

Figures below depict the AP and lateral radiographs obtained from a 64-year-old man with long-standing right knee osteoarthritis and pain that is unresponsive to nonsurgical treatment. The patient undergoes navigated cruciate-retaining right total knee arthroplasty. After surgery, this patient continues to experience pain and swelling of the knee with recurrent effusions. He returns to the office reporting continued pain 2 years after surgery. He describes instability, particularly when descending stairs. On examination, range of motion of 0° to 120° is observed, with no extensor lag. Slope of the tibial component is 7°. The knee is stable to varus and valgus stress in extension, but flexion instability is present in both the anterior-posterior direction and the varus-valgus direction. Bracing leads to a slight decrease in symptoms but is not well tolerated. Isokinetic testing demonstrates decreased knee extension velocity at mid push. Radiographs demonstrate well-aligned and fixed knee implants. An infection work-up is negative. What is the most appropriate surgical intervention at this time?

8 degrees respectively. Isolated LCL repair neutralized varus laxity, suggesting that repair of this structure was more important thatn radial head replacement for gross stability of the elbow.