Orthopedic Board Review MCQs: Hip, Nerve & Deformity

About This Board Review Set

This is Part 173 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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Topics Covered in Part 173

This module focuses heavily on: Deformity, Hip, Nerve.

Sample Questions from This Set

Sample Question 1: A 16-year-old girl has had anterior leg pain and a mass for the past 8 months. Figures 2a and 2b show a radiograph and an H & E histologic specimen. Which of the following disorders is believed to be a precursor of this lesion?...

Sample Question 2: A 24-year-old man has bilateral hip pain. An examination and imaging studies (plain radiographs and MR imaging) confirm evidence of femoroacetabular impingement (FAI) with a CAM deformity in both hips. The patient mentions that he has a 19-...

Sample Question 3: 30%...

Sample Question 4: Haversian canals are found in the center of an osteon in compact bone. They contain blood vessels and nerves....

Sample Question 5: A woman injures the metacarpophalangeal (MCP) joint of her thumb while skiing. Examination reveals tenderness along the ulnar aspect of the MCP joint. Radially directed stress of the joint in full extension produces 5° of angulation. When t...

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

Comprehensive 100-Question Exam

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Question 1

A 16-year-old girl has had anterior leg pain and a mass for the past 8 months. Figures 2a and 2b show a radiograph and an H & E histologic specimen. Which of the following disorders is believed to be a precursor of this lesion?

Explanation

DISCUSSION: The radiograph and pathology are consistent with adamantinoma. While the mechanism underlying adamantinoma has not been identified, it is believed to be closely related to osteofibrous dysplasia, which may represent a precursor. The other diagnoses are not known to give rise to adamantinoma.
REFERENCE: Springfield DS, Rosenberg AE, Mankin HJ, et al: Relationship between osteofibrous dysplasia and adamantinoma. Clin Orthop 1994;309:234-244.

Question 2

A 24-year-old man has bilateral hip pain. An examination and imaging studies (plain radiographs and MR imaging) confirm evidence of femoroacetabular impingement (FAI) with a CAM deformity in both hips. The patient mentions that he has a 19-year-old brother who has occasional hip pain. With respect to his brother’s pain, how should you counsel the patient?

Explanation

CLINICAL SITUATION FOR QUESTIONS 145 THROUGH 147
Figures 145a and 145b are the radiographs of a 56-year-old man who has had persistent pain in his right groin since undergoing primary total hip surgery 11 months ago. His erythrocyte sedimentation rate (ESR) is 38 mm/h (reference range [rr], 0-20 mm/h) and C-reactive protein (CRP) level is 28 mg/L (rr, 0.08-3.1 mg/L). A hip aspiration performed while the patient was taking antibiotics demonstrated 3200 white blood cells/µL with no growth. Treatment should consist of

Question 3

30%

Explanation

OrthoCash 2020
Which of the following fracture patterns would be most appropriately treated with open reduction and internal fixation with posteromedial and lateral plates via dual incisions?

The patient in Figure D has a bicondylar tibial plateau fracture with a posteromedial fracture fragment, which is an indication for lateral and posteromedial plating via dual incisions.
Bicondylar tibial plateau fractures are typically treated with open reduction internal fixation. Studies have shown that the posteromedial fragment is common in bicondylar tibial plateau fractures. Standard lateral implants do not gain adequate screw purchase in posteromedial bone. Posteromedial incisions using the interval between the semimembranosus and medial head of the gastrocnemius can be used to gain access to the fragment and provide exposure to place a posteromedial plate.
Barei et al. reviewed 57 OTA C-type bicondylar tibial plateau fractures, and found the presence of a posteromedial fragment in 74% of cases. They suggest
the use of alternate methods of fixation for the posteromedial fragment rather than lateral fixed-angle plates alone.
Higgins et al. reviewed 111 patients with bicondylar tibial plateaus that underwent CT scan evaluation. They found the incidence of a posteromedial fragment in 59% of the patients and on average accounted for 25% of the articular surface.
Barei et al. reviewed 83 patients treated with dual incisions for fixation of bicondylar tibial plateau fractures. They found deep infections in 8.4% of patients. Satisfactory articular reduction was found in 62% of patients, satisfactory coronal alignment in 91% of patients, satisfactory sagittal alignment in 72%, and satisfactory condylar width in 98%.
Figure A shows an AP and lateral radiograph of a split/depressed lateral tibial plateau fracture. Figure B shows an AP and lateral radiograph of a proximal third tibial shaft fracture with a proximal fibula fracture. Figure C shows an AP and lateral radiograph of a medial plateau fracture with articular depression. Figure D shows an AP and lateral radiograph of a bicondylar tibial plateau fracture. Figure E shows an AP and lateral radiograph of a tibial tubercle fracture in a tibia with open physes.
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OrthoCash 2020
Figure A shows the radiographs of a 87-year-old patient after a fall from standing. He lives in a nursing home and uses a walker to transfer from bed to chair. His past medical history includes recurrent urinary tract infections, congestive heart failure, angina and diabetes. Which of the following factors is associated with the best postoperative outcome in this patient?

Immediate surgical intervention
Postoperative epidural analgesia
Postoperative antibiotics
Pre-operative medical optimization
Choosing total hip arthroplasty instead of hemiarthroplasty Corrent answer: 4
Geriatric patient with hip fractures tends to have a number of coexisting medical conditions that impact surgical risk. A successful pre-operative medical evaluation has the greatest impact on surgical outcomes in this patient population.
Patients with complex past medical histories are at great risk of complications with surgery. This helped to drive the formation of the ASA classification system as a way to score patients out of 5 based on their anesthetic and surgical risks. Patients with significant systemic disease (ASA III and IV) have shown to demonstrate poorer outcomes as compared to patients with less severe medical comorbidities (ASA I and II).
Egol et al. looked at factors that impact the outcomes of hip fractures in geriatric patients. They showed that cardiac and pulmonary complications were most frequent complications post-operatively. It was stated that early mobilization and pre-operative evaluations have the greatest impact on outcomes.
Parvizi et al. looked at the thirty-day mortality following hip arthroplasty for acute fracture. They reviewed a database of 7774 consecutive patients that underwent hip arthroplasty for the treatment of an acute fractures. The overall mortality was 2.4%. Risk factors were found to be cemented implants, female patients, elderly patients, and patients with cardiorespiratory comorbidities.
Roberts et al reviewed the 2015 AAOS Clinical Practice Guideline: Management of Hip Fractures in the Elderly. Although pre-operative medial optimization was not mentioned in this review, there is strong evidence to support an interdisciplinary care program for patients with hip fractures.
Figure A shows a displaced left femoral neck fracture. Incorrect Answers:
more than 24-48 hours and a higher 1-year mortality rate. However, In patients with with more than 3 medical comorbidities, medical optimization has a greater impact on post-operative outcomes than time to surgery.
OrthoCash 2020
A 36-year-old male sustains severe injuries as a result of a motor vehicle collision. After 5 days, the patient is stabilized and transferred to your facility for continued management. After obtaining appropriate imaging, including the images shown in Figures A, B and C the patient should be given which of the following mobility restrictions?

Touch-down weight bearing on the left lower extremity, non-weightbearing on the right lower extremity
Weight bearing as tolerated on the left lower extremity, non-weightbearing on the right lower extremity
Non-weight bearing on the left lower extremity, non-weightbearing on the right lower extremity
Touch-down weight bearing on the left lower extremity, weight bearing as tolerated on the right lower extremity
Weight bearing as tolerated on the left lower extremity, weight bearing as tolerated on the right lower extremity
Figures B and C shows a stable, impacted lateral compression (LC) type I injury, which can be treated with immediate mobilization without restrictions. The right lower extremity has a pilon fracture, which should be treated with non-weight bearing.
LC-I injuries are stable patterns, as they involve an impaction injury to the anterior sacrum, which has some inherent stability. In addition, the posterior sacro-iliac (SI) soft tissue structures remain intact, which provides critical stability during immediate mobilization.
The reference by Tile is a review article on the principles of management of these injuries, and he reviews how the Tile classification system is important to help determine surgical need and where the stabilization is required. For the stable LC-1 type injury, no fixation is required.
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OrthoCash 2020
A 24-year-old male sustains the fracture dislocation shown in Figure A. How is this fracture pattern best classified?

Moore I
Moore II
Schatzker III
Schatzker V
OTA type 41B3 Corrent answer: 2
Figure A shows a Moore Type II fracture. Moore type II fractures consist of fractures involving the entire tibial condyle, where the fracture line begins in the opposite compartment and extends across the tibial eminence.
A number of classification systems are used to describe tibial plateau fractures. The main classification systems that are widely used include Schatzker, AO/OTA, Hohl and Moore. The Moore classification describes high energy fracture-subluxation injuries of the knee. This is thought to have clinical implications as the type of fracture pattern can indicate an associated soft-
tissue injury.
Moore retrospectively reviewed over a 1000 proximal tibia fractures to devise a classification systems based on the characteristic of five types of tibia plateau fracture patterns. He believed this system helped to better understand knee instability and concomitant soft-tissue injury. For example, Moore Type III fractures (rim avulsion) are associated with a high rate of neurovascular injury.
Figure A shows a fracture involving the entire tibial condyle. Illustration A shows a schematic diagram of the Moore classification (I - V). Illustration B shows a table that describes the Moore classification (I - V).
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OrthoCash 2020
A 19-year-old male football player plants and twists his right lower extremity sustaining a spiral fracture of his distal third tibial shaft. Of the following images, which is most commonly associated with distal third spiral tibial shaft fractures.

The patient has a spiral distal tibial shaft fracture. Spiral distal tibial shaft fractures are commonly associated with intraarticular fracture extension, usually in the form of a posterior malleolus fracture.
Spiral distal third tibial shaft fractures need to be evaluated for intraarticular extension prior to operative management. As this can be missed on x-rays, a CT scan of the ankle is recommended to identify this associated injury. This is important when intramedullary fixation is used for definitive management, as nail insertion can displace a previously non displaced intraarticular fracture.
Anteroposterior screw fixation prior to nailing may be useful in these cases.
Boraiah et al. found that in 62 patients with spiral distal tibial fractures, 39% (24 patients) had a posterior malleolus fracture. They recommended CT evaluation of the ankle to prevent missed intraarticular fractures.
Hou et al. found a posterior malleolus fracture in 9.7% (28 out of 288 cases) of patients with tibial shaft fractures. They recommended CT or MRI evaluation of the ankle prior to surgery.
Figure A shows an axial CT scan of a right ankle with a posterior malleolus
fracture. Figure B shows an AP radiograph of a right ankle with a vertical medial malleolus fracture. Figure C shows a coronal CT scan of a right ankle with a Tillaux fracture. Figure D shows a sagittal CT scan of a right ankle with a comminuted talus fracture. Figure E shows a lateral radiograph of a right knee showing a knee dislocation. Illustration A shows an AP radiograph of a left distal third spiral/oblique tibial shaft fracture. Illustration B shows a lateral radiograph of a left distal third spiral/oblique tibial shaft fracture. Illustration C shows a sagittal CT of a distal third spiral/oblique tibial shaft fracture with a posterior malleolus fracture.
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OrthoCash 2020
A 67-year-old female patient presents with increasing right hip/thigh pain over the past three months, which is now recalcitrant to anti-inflammatories. There is no history of trauma or constitutional symptoms. Her past medical history consists of hypertension, coronary artery disease, osteoporosis and gastric reflux. Physical examination reveals mild pain at the extremes of range of motion of the hip and a painful right sided limp. A radiograph of the right hip is seen in Figure
What would be the most appropriate treatment for this patient at this time?

Observation only
Referral to physiotherapy
MRI spine and hip
Total hip arthroplasty
Intramedullary femoral nail Corrent answer: 5
This osteoporotic female patient is presenting with subtrochanteric lateral cortical thickening and hip pain. This is consistent with an insufficiency fracture of the femur secondary to use of bisphosphonate medication for treatment of osteoporosis. The most appropriate treatment would be intramedullary femoral nail fixation.
Bisphosphonate medications have been shown to be associated with atypical (subtrochanteric) femur fractures. These patients often have prodromal hip pain and lateral cortical thickening on radiographs prior to fracture. In addition, there has shown to be a significantly increased risk of fracture in the presence of the “dreaded black line” that occurs at the site of thickening.
Lenart et al. examined a case series of patients using bisphosphonates for the treatment of osteoporosis. They identified 15 postmenopausal women who had
been receiving alendronate for a mean (±SD) of 5.4±2.7 years and who presented with atypical low-energy fractures. Cortical thickening was present in the contralateral femur in all the patients with this pattern.
Goh et al. retrospectively reviewed patients who had presented with a low-energy subtrochanteric fractures. They identified 13 women of whom nine were on long-term alendronate therapy. Five of these nine patients had prodromal pain in the affected hip in the months preceding the fall, and three demonstrated a stress reaction in the cortex in the contralateral femur.
Figure A shows a right hip radiograph with subtrochanteric lateral cortical thickening. There is mild arthritic changes in the hip. Illustration A shows a bone scan and radiographs of subtrochanteric lateral cortical thickening that resulted in fracture.
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OrthoCash 2020
A right-hand dominant female sustains a right proximal humerus fracture. The patient is provided a sling, and is recommended pendulum exercises with elbow range of motion to begin in 1 to 2
weeks. Which of the following would be an indication for surgical management?

Age greater than 70 years.
Fracture pattern in Figure A
Significant medical comorbidities.
Fracture pattern in Figure B
Fracture pattern in Figure C
The patient has been treated with non-operative management for her proximal humerus fracture. Operative management should be considered in patients with head splitting proximal humerus fractures and in those with dislocations that cannot be reduced.
Head splitting proximal humerus fractures should be treated with operative management. Open reduction internal fixation versus hemiarthroplasty are used to treat this type of fracture. Surgical management is also considered in proximal humerus fractures in young patients, in fractures where the greater tuberosity is displaced >5 mm, and in proximal humerus fractures associated with humeral shaft fractures.
Koval et al. studied 104 patients with one-part proximal humerus fractures treated non-operatively, and found 80% with good or excellent results. They also found that 90% of patients treated non-operatively had either no or mild pain about the shoulder at follow-up.
Lefevre-Colau et al. performed a randomized prospective study on 74 patients with an impacted proximal humerus fracture. One group was treated with early mobilization of the shoulder (within 3 days after the fracture) while the other group was immobilized for 3 weeks followed by physiotherapy. They concluded that early mobilization was safe and allowed for quicker return to functional use of the affected limb.
Figure A shows an AP radiograph of a right minimally displaced greater tuberosity proximal humerus fracture. Figure B shows AP and axillary radiographs of a right head split proximal humerus fracture that is posteriorly dislocated. Figure C shows an AP radiograph of a right minimally displaced Salter Harris II proximal humerus fracture. Illustration A shows an AP radiograph of a left valgus impacted proximal humerus fracture with a greater tuberosity fragment displaced >5mm treated with ORIF.
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OrthoCash 2020
A 37-year-old male arrives to the trauma slot following a high-speed motorcycle crash. His Glasgow Coma score is 14 and his only orthopaedic injury is exhibited in Figure A. His current vital signs are a BP of 90/60, HR 120, and a lactate of 2.5 mMol/L. Other findings include a grade 1 splenic laceration and bilateral pulmonary contusions seen on chest radiograph. Which of the following has been suggested as an indication to perform damage control orthopedic care?

HR >110
Bilateral pulmonary contusions seen on chest radiograph
SBP = 90mmHg
Unilateral femur fracture
Lactate = 2.5 mMol/L
Pulmonary contusion severe enough to be diagnosed on chest radiograph alone is an indicator that the patient may benefit from damage control orthopaedics (DCO).
Despite the patient's overall stable nature, suffering pulmonary injury severe enough to be seen on x-ray alone suggests that temporary stabilization with staged definitive fixation may avoid potential morbidity.
Pape et al. review the evolution and balance of early total care (ETC) and DCO. Summarizing the literature, the authors report several standalone indicators that would justify DCO regardless of stable status. This includes: Injury Severity Score of greater than 40, Injury Severity Score of greater than 20 with chest trauma, multiple injuries with severe pelvic/abdominal trauma/ hemorrhagic shock, bilateral femoral fractures, pulmonary contusion noted on radiographs alone, hypothermia of less than 35 degrees C), and a head injury with an Abbreviated Injury Score of 3 or greater.
Figure A exhibits a right femoral shaft fracture. Illustration A exhibits a summarized table stating the criterion used to determine the condition of a polytrauma patient. (Table from Pape et al, PMID: 19726738)
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implement DCO.

OrthoCash 2020
A 24-year-old patient presents after a fall from the balcony of a third story building in which he landed on his feet. He reports lumbar back pain and numbness in his perineum region. Radiographs of his hips and pelvis are seen in Figure A, while CT images are shown in Figures B and C. How is this fracture pattern best classified?

Young-Burgess APC Type II
Young-Burgess LC Type I
"U" Type Spinopelvic Dissociation
Denis Zone-I
Denis Zone-II
This patient has a Denis zone-III "U" Type Spinopelvic Dissociation of the sacrum.
The Denis classification system for sacral fractures is based on anatomical fracture zones. Zone-III fractures involve the spinal canal and have a high rate of associated neurologic injury. It is important to recognize bilateral sacral
fractures with a transverse component, as this often causes spinopelvic discontinuity and possible cauda equina. The lack of mechanical continuity between the spine and pelvis will most likely require reduction and fixation for initial stability. There may also be a need for sacral decompression with fixation mechanisms given the onset of neurologic symptoms.
Mehta et al. reviewed sacral fractures. They report that patients with a transverse sacral fracture involving more proximal sacral segments (S1, S2, or S3) tend to have a higher prevalence of bladder dysfunction than do those involving distal sacral segments (S4 or S5).
Schildhauer et al. report the best way to visualize Denis zone-III "U" type fractures is to obtain a lateral view of the sacrum or sagittal reformatted images with a CT scan. Standard pelvic radiographs often miss this injury.
Figure A shows an AP pelvis with suggestion of sacral irregularities. No fracture pattern can be indentified. Figures B and C show CT scan images showing a "U" Type fracture pattern with angulation and translational displacement of the cephalad and caudad parts of the sacrum. Illustration A shows examples of complex sacral Denis zone-III fractures.
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OrthoCash 2020
A 55-year-old male presents with the radiographs seen in Figures A and B after falling off his bike. Physical examination reveals an isolated, closed elbow injury. His limb is neurovascularly intact. Which complication would be most likely with surgical fixation of this injury?

Ulnar neuropathy
Posterior interosseous nerve injury
Early loss of fixation
Elbow flexion contracture
Avascular necrosis
This patient is presenting with a comminuted capitellar and trochlear fracture. If treated with open reduction internal fixation, the most likely post-operative complication would be elbow stiffness or contracture.
An axial compression force transmitted by the radial head to the capitellum with the elbow in a semiflexed position can result in a shear fracture of the anterior portion of the capitellum. AP, lateral, and radiocapitellar radiographs are recommended to identify these injuries. The lateral X-ray may reveal the “double arc” sign, which represents extension of the capitellum fracture into the trochlea. Extension of the fracture into the trochlea has important implications into the surgical approach to these injuries.
Ruchelsman et al. retrospectively reviewed the outcomes of sixteen patients with capitellar fractures treated with open reduction internal fixation. They found the presence of greater flexion contractures at the time of follow-up in elbows with Type-IV capitellar fractures. All fractures healed, and no elbows had instability or weakness with fixation.
Ring et al. retrospectively reviewed the outcomes of twenty one distal humerus articular fractures that were reduced and stabilized with implants buried beneath the articular surface. Ten patients required a second operation: (6) release of an elbow contracture; (2) treatment of ulnar neuropathy; (1) removal of hardware; (1) early loss of fixation.
Figures A and B show AP and lateral radiographs of the elbow with a comminuted fracture of the capitellum and trochlea. Note the “double arc” sign on the lateral view. Illustrations A and B show open reduction internal fixation of the fracture. Note fixation with multiple interfragmentary screws.
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OrthoCash 2020
Figure A shows a radiograph of a 30-year-old male who underwent fixation of a left leg injury just over two years ago. He presents with persistent pain and drainage from the distal wound despite 4 months of oral antibiotics. He has no systemic symptoms. He has a past medical history of Grave's disease and Irritable Bowel Syndrome. What would be the best management at this stage?

Chronic suppressive, culture-directed, antibiotic therapy
Above knee amputation
Endocrine consultation, irrigation and debridement, removal of hardware and negative-pressure wound therapy
Irrigation and debridement, removal of hardware, over-reaming medullary canal, external fixation and culture-directed antibiotics
Irrigation and debridement, retention of hardware, acute bone grafting and culture-directed antibiotics
This is a case of fracture nonunion in the setting of chronic osteomyelitis and infected hardware. The best treatment option available would be irrigation and debridement, removal of hardware, ring external fixator and culture directed antibiotics.
The management of infected nonunion in the setting of chronic osteomyelitis is technically demanding. The aims of treatment are to eradicate the infection and obtain bone union. Non-surgical options are largely unsuccessful in patients with draining chronic osteomyeltis in the setting of infected hardware and nonunion. Surgical options involve incision and debridement of necrotic tissue followed by reconstruction of bone and possible soft tissue (to provide
healthy viable coverage). The most common techniques are ringed fixator/circular frames, staged intramedullary device with or without external fixator, free tissue transfer, or radical debridement, bone grafting, and fixation.
Motsitsi et al. reviewed the management of infected nonunion of long bones. They suggest that the Ilizarov technique is regarded as a standard treatment in infected nonunion of the tibia. When there is bone defect after debridement, the bone can be shortened or treated with bone transport.
Egol et al look at a series of patients with chronic osteomyelitis. Limb salvage should be attempted in all patients. The presence of a chronic draining sinus requires surgical debridement and culture directed antibiotics. Infected hardware should be removed. A two-stage strategy is the best and well-proven treatment option.
Figure A shows a intramedullary nail in the left tibia. There is a moderate amount of bone loss at the fracture site with mixed sclerotic bone suggestive of osteomyelitis.
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OrthoCash 2020
A 32-year-old male sustained the injury seen in Figure A after a motor vehicle accident. Which of the following factors is most predictive of mortality with this type of injury?

Fracture classification
Number of blood transfusions in the first 24 hours
Gender
Time to operative fixation
Use of pelvic binders Corrent answer: 2
The best predictors of mortality with pelvic ring fractures include older age and hemodynamic shock at presentation. The amount of blood transfused indicates the severity of hemodynamic instability.
Pelvic ring fractures are typically high energy, blunt injuries. The leading cause of mortality with these injuries is hemorrhage and hemodynamic instability.
The most common source of hemorrhage include venous injury (80%), which is usually caused by a shearing injury of posterior thin walled venous plexus and bleeding cancellous bone. Other sources of hemorrhage include arterial injury (10-20%) from the superior gluteal artery (posterior ring injury, anterior posterior compression [APC] pattern), internal pudendal artery (anterior ring injury, lateral compression [LC] pattern) and obturator artery.
Smith et al. found fracture pattern and angiography/embolization were not predictive of mortality in patients with unstable pelvic injuries. The three factors they found to be predictive were: increased blood transfusions in the first 24 hours, age >60 years, and increased Injury Severity Scores (ISS) scores. Deaths were most commonly from exsanguination (<24 hours) or multiorgan failure (>24 hours).
Starr et al. demonstrated that age and shock on presentation were most predictive of mortality after pelvic ring injury.
Figure A shows a APC III pelvic fracture. Illustration A shows a table describing the Young-Burgress classification of pelvic ring fractures.
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OrthoCash 2020
Figure A shows intraoperative radiographs of a 45-year-old patient with a left elbow injury. What would be the next most appropriate step in this patients care?

Early range of motion
Hinged elbow brace for 4 weeks
Repair lateral collateral ligament
Remove and upsize implant
Remove and downsize implant Corrent answer: 5
The intraoperative images are consistent with overstuffing of the ulnohumeral joint during a radial head replacement. The most appropriate next step would be removing and downsizing the implant.
Overstuffing the radiohumeral joint by >2.5 mm can significantly alter elbow kinematics. It has also shown to lead to pain and early joint disease. The most sensitive method to assess for overstuffing of the joint is by direct visualisation intra-operatively. This can be performed by visualising the lateral aspect of the ulnohumeral joint when the radial head is resected and comparing this to when the trial radial head is reduced in place. In comparison, radiographic asymmetry of the medial ulnohumeral joint has been shown to be less sensitive. Radiographic findings of incongruity of ulnohumeral joint only occurs when significant overlengthening of the radius occurs.
Frank et al. examined the effect of radial head thickness in seven cadaver specimens. They found that incongruity of the medial ulnohumeral joint would only become apparent radiographically after overlengthening of the radius by
>or=6 mm.
Doornberg et al. examined seventeen computed tomography scans of the elbow to investigate the height of the radial head relative to the lateral edge and central ridge of the coronoid process. They found that the radial head was on average only 0.9 mm more proximal than the lateral edge of the coronoid process.
Figure A shows intraoperative radiographs of a patient that has undergone a radial head arthroplasty. There is significant widening of the medial ulnohumeral joint on an AP radiograph as well as widening of the ulnohumeral joint on the lateral radiograph,
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OrthoCash 2020
Aside from improving the intramedullary nail starting point in Figure A, the use of blocking screws could have been used at the time of fixation to prevent this post-operative deformity. What would have been the correct orientation of these screw(s) in the proximal fragment?

Medial only
Lateral only
Anterior and medial
Posterior and medial
Posterior and lateral Corrent answer: 5
The clinical presentation is consistent with a malunion of a proximal one-third tibia fracture with a valgus and procurvatum deformity. The correct orientation of Poller blocking screws to help prevent this malalignment would be in the posterior and lateral aspects of the metaphyseal fragment.
Insertion of the blocking screw lateral to the nail prevents valgus deformity, and insertion of the blocking screw posterior to the nail prevents apex anterior deformity. A more lateral starting point for nail insertion can also help to
prevent valgus deformity. The semiextended position of the knee for nail insertion also helps to eliminate the tendency for the fracture to flex, due to the avoidance of excessive knee flexion during the reduction.
Stedtfeld et al. describes the mechanical model for blocking screws. They state that two or more blocking screws can be placed in each plane (AP and lateral) alongside the nail to create a narrow canal for the nail. This allows for multiple points of fixation and realignment of the bone as the nail is passed.
Lindvall et al looked at a series of 56 extra-articular proximal tibial fractures treated with intramedullary nailing or percutaneous locked plating. Neither nailing or plating these fractures showed a distinct advantage in the overall outcomes. Apex anterior malreduction however was the most prevalent form of malreduction in both groups.
Lang et al. looked at a series of proximal third tibia fracture treated with intramedullary nailing. They reported that posterior tibial comminution will also contribute to apex anterior angulation. They states this occurs when the fracture hinges on the intact cortex anteriorly during nail insertion.
Figure A shows a proximal one third tibia fracture treated with an intramedullary nail. There is malreduction of the fracture with valgus and procurvatum deformity.
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OrthoCash 2020
When evaluating a fracture dislocation of the elbow, a varus and posteromedial rotation mechanism of injury typically results in what injury pattern?
A fracture of the radial head requiring ORIF
A highly comminuted radial head fracture requiring radial head arthroplasty or resection
An MCL injury requiring repair
A type I avulsion fracture of the coronoid
An anteromedial coronoid fracture
A varus and posteromedial rotation mechanism of injury typically results in a fracture of the anteromedial facet of the coronoid which frequently requires reduction and fixation to restore stability.
A varus and posteromedial mechanism of injury about the elbow presents with an injury pattern distinctly different from other injury patterns. A key part of treating this injury pattern is recognizing a fracture of the anteromedial facet of the coronoid, which often requires reduction and fixation to restore stability about the elbow. It is important to recognize this during preoperative planning since this injury typically requires a medial approach.
Steinman presents a review article describing coronoid fracture patterns and their mechanisms of injury.
Doornberg and Ring present a level 4 review showing that coronoid fracture patterns and their required treatments are predictable based on mechanism of injury. Varus and posteromedial mechanisms were found to reliably create a fracture of the anteromedial facet of the coronoid, and were associated with sparing of the MCL and radial head.
Doornberg and Ring also presented a Level 3 review of anteromedial facet cornoid fractures. They found that they could not be adequately visualized and treated from a lateral approach, and that they typically required reduction and fixation to restore adequate stability to the elbow. This stresses the importance of recognizing this injury pattern during preoperative planning.
Illustrations A and B are AP and lateral radiographs of an elbow following a varus/posteromedial injury with an anteromedial coronoid facet fracture.
Illustration C is a diagram demonstrating fracture lines that create an anteromedial facet fracture fragment. This fracture can be subclassified into three subtypes [anteromedial rim (a), rim plus tip (b), and rim and tip plus the sublime tubercle (c)]
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OrthoCash 2020
A 26-year-old female presented to the emergency department with the injury seen in Figure A after an awkward fall while intoxicated. She undergoes closed reduction and repeat radiographs are seen in Figure B. After a normal physical examination, including ranging the hip from 0-90 degrees, which of the following options would be the next most appropriate step in management?

Femoral skeletal traction
CT scan
Hip spica cast application
Observation only
Serial neurovascular examinations Corrent answer: 2
This patient has presented with a posterior left hip dislocation. The next most appropriate step would be performing a post-reduction CT scan to assess for joint reduction and congruity, associated fractures, or loose bodies.
Hip dislocations occur most commonly in young patients with high energy trauma. They are usually classified as simple or complex, with complex dislocations being those with associated fractures of the acetabulum or proximal femur. Urgent close reduction should occur within 6 hours from the time of injury. Post reduction CT scans must be performed for all traumatic hip dislocations to look for fractures or impacted areas of the femoral head or acetabulum, as well as incongruent reductions and free intra-articular joint fragments.
Calkins et al. looked at measurements of the posterior acetabulum on CT scans (the Acetabular Fracture Index) after hip dislocations to evaluate for hip stability. Hips were found to be unstable if less than 34% of the remaining posterior acetabulum was present after dislocation. Hips with greater than 55% were stable. In between 34 and 55% were indeterminate.
Moed et al. found that posterior wall fractures involving less than 20% of the posterior wall were considered stable. Fractures involving more than 40%-50% were unstable, leaving a wide range of posterior wall fractures classified as indeterminate.
Figure A shows a left posterior hip dislocation. Figure B shows a reduced left hip with no obvious fracture. Illustration A shows an axial CT scan image of the left hip. There is no acetabular fracture identified.
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OrthoCash 2020
A 40-year-old male sustained the injury seen in Figure A, and subsequently underwent the procedure shown in Figure B. One hour post-operatively he starts to complain of pain in the operative leg, and the pain is unchanged with active or passive stretch. The external dressing is released with little resolution of symptoms. His blood pressure is 115/78 mm Hg with compartment pressures in the leg measuring 31 to 35 mm Hg. His ABI index is 1.1 in the leg. What would be the next step in management?

MRI angiography of leg
Four-compartment fasciotomy
Follow-up examination the following day
Continued monitoring and serial examinations
EMG study
The patient is at risk for developing compartment syndrome of the leg. The next most appropriate step would be to support his systemic blood pressure and monitor compartment pressures.
A clinical assessment is the diagnostic cornerstone of acute compartment syndrome. However, the intracompartmental pressure measurement has been advocated to help confirm the diagnosis in patients where there remains uncertainty after clinical exam. An absolute compartment pressure >30 mm Hg or a difference in diastolic pressure and compartments pressure (delta p) <30 mm Hg may help to confirm the necessity for fasciotomy. However, the treatment of early compartment syndrome should be to initially improve the limbs perfusion pressure gradient. This can be done by treating underlying factors such as hypotension, coagulopathy, or vascular compromise due to either a true vascular injury or artificially by external compression. Frequent reassessment is then critical to effectively manage these patients. If clinical
diagnosis persists despite these efforts, urgent fasciotomy would be considered.
McQueen looked at 116 patients with tibial diaphyseal fractures who had continuous monitoring of anterior compartment pressure for 24 hours. They found that using an absolute pressure of 30 mmHg would have resulted in 50 patients (43%) treated with unnecessary fasciotomies. They conclude using a differential pressure of 30 mmHg is a more reliable indicator of compartment syndrome.
White et al. looked at 101 patients with tibial fractures with satisfactory Delta P measurements. THey found that patients with elevated intramuscular pressures >30 mm Hg after tibial fracture do not have a greater incidence of complications than those with low pressures, so long that Delta P <30 mm Hg.
Figure A shows a Shatzker V tibial plateau fracture. Figure B shows fixation of fracture seen in Figure A.
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OrthoCash 2020
A 10-year-old girl suffers a displaced tibia fracture. Initial numbness over the dorsum of the the foot resolved following an anatomic closed reduction and placement in a long leg cast performed in the emergency room. The cast was placed with the the ankle dorsiflexed just above neutral to prevent equinus contracture and then the cast and padding was adequately bivalved. Overnight, the patient began experiencing recurrent numbness and paresthesias in her exposed toes and a slight increase in her pain at the fracture site. Your next best step would be:
Repeat closed reduction under conscious sedation
Selective compartment fasciotomies
External fixation and compartment monitoring
compartment fasciotomies with fracture fixation done emergently
Modify the cast to reposition the ankle into slight plantarflexion Corrent answer: 5
Circumferential casting with the ankle dorsiflexed can cause increased intracompartmental pressures in the leg. However, this patient's cast has been adequately bivalved during initial cast placement. Therefore, the next best step is cast modification to allow the ankle to assume an angle between neutral and 30 degrees of plantar flexion and further reducing the compartment pressure.
Tibia fractures are one of many common underlying etiologies for the development of compartment syndrome in the leg. Fracture reduction as well as eliminating circumferential dressings are important early preventative steps to take. Bivalving casts - including splitting the cast padding - is often indicated in fractures of long bones that are treated with initial casting. While casting patients in a plantigrade or dorsiflexed position reduces the risk of equinus contractures and holds the ankle mortise reduced, dorsiflexing the ankle has been shown to increase the intracompartmental pressures throughout the leg compartments.
Weiner et al. placed pressure monitors into the anterior and deep posterior compartments in healthy volunteers to measure the effects of casting on compartment pressures. They found that the intramuscular pressures were lowest with the ankle positioned between plantigrade and a resting plantar flexion position (0-37 degrees), and that bivalving the cast reduced the pressures 33-47%.
Illustration A shows the needle trajectories for compartment pressure monitoring in the leg. This should be performed within 5 cm of the fracture to get accurate peak pressures.
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OrthoCash 2020
A 35-year-old male horseback rider was bucked into the air and then landed forcefully with his perineum on the saddlehorn of the saddle. At a one year follow-up, the only long term sequela of his injuries is erectile dysfunction. Which radiographic injury seen in Figures A-E is most commonly associated with this complication?

This patient has sustained a saddle-horn injury to the pelvis. An anterior posterior compression (APC) injury is the most common pelvic injury associated with this mechanism.
Saddle-horn injury to the pelvis occurs when a horseback rider is bucked into the air and then lands forcefully with his or her perineum on the saddlehorn of the saddle. The bony injury to the pelvis usually consists of a diastasis of the pubic symphysis with/without subsequent widening of the sacroiliac joints. The
majority of patients are able to return close to their pre-injury level of employment and activity after these injuries. However, sexual dysfunction is a common complication with this injury. Sexual dysfunction can be due to urethral, vascular, neurologic, and psychogenic injuries.
Collinge et al. looked at a series of male patients with injuries to the perineum after coming into contact with the saddle or saddle horn on a horse. Eighteen of the twenty patients were found to have sexual dysfunction at the time of the latest follow-up. A multi-disciplinary approach to these patients is needed when treating pelvic injuries.
Cannada et al. surveyed 71 women of childbearing age who had a pelvic fracture. She found that half the patients reported physical genitourinary complaints with 38 percent of women noting new onset pain with intercourse. In terms of psychological impact, they showed that 45 percent of patients answered affirmatively to decreased interest in intercourse and decreased orgasm frequency after the injury.
van Nieuwenhoven et al. describe three equestrians who suffered from straddle injuries with symphysis diastasis and rupture of sacroiliac ligaments after falls or kicks from horses. They show that these presumed low-energy injuries can cause extremely severe injuries to the pelvis itself and to the adjacent organs.
Figure A shows a Burgess APC Type II pelvic fracture. Figure B shows left ASIS avulsion fracture. Figure C shows a left hip dislocation. No pelvic fracture is identified. Figure D shows a subacute superior/inferior pubic rami fracture.
Figure E shows a right femoral neck fracture.
Incorrect Answers:
OrthoCash 2020
A 31-year-old male driver was involved in a high-speed motor vehicle accident. His injuries include a left subdural hematoma (Abbreviated Injury Score [AIS]=4), left segmental femur fracture (AIS=3), ruptured spleen (AIS=4), nasal fracture (AIS=2), fractured left ribs 4 to 7 (AIS=2), and a closed pelvic ring fracture (AIS=3). What is his Injury Severity Score (ISS)?

Question 4

Haversian canals are found in the center of an osteon in compact bone. They contain blood vessels and nerves.

Explanation

The multi-axis articulated foot assembly is the best prosthetic for ambulation over uneven ground, and functions best for below knee amputations. Low functioning patients who need a prosthesis for transfers would probably benefit from a solid ankle, cushioned heel prosthesis. Runners and athletes often require high end carbon fiber prostheses. Patients with above knee
amputations have several options to optimize ambulation including solid, energy storing, and multi-axial prothesis.
Aaron et al. reviews the important considerations for patient specific prostheses and new developments on the horizon to maximize ambulation in prosthesis users.
Mesenchymal stem cells have the capacity to differentiate into all the following cell types EXCEPT?
Osteoclasts
Chondrocytes
Adipocytes
Osteoblasts
Fibroblasts
Mesenchymal stem cells are multipotent stem cells which retain the ability to self-renew and to form cells of the mesenchymal lineage. They can therefore form muscle, fat, tendon (made from fibroblasts), bone, cartilage, and the marrow stromal cells. Mesenchymal stem cells do not however form osteoclasts, which are formed from the monocyte lineage - from hematopoietic stem cells.
Caterson et al review the use of mesenchymal stem cells in tissue engineering and regeneration of musculoskeletal tissue.
A 60 year-old male was brought into the operating room for total hip replacement. Before making the incision, what precautionary procedure must be performed by the entire staff to minimize surgical error?
Mark the word "No" on the nonoperative extremities
Use intraoperative fluoroscopic imaging
Perform "timeout"
Have blood products ready in the operating room
Use the newest prosthesis
Surgical "timeout" is now part of the standard procedure which must be performed before starting surgery to minimize surgical error such as wrong site surgery.
Which of the following statements regarding articular cartilage is TRUE?
Cartilage is an isotropic material
Most of the water in articular cartilage exists in the deep layer next to the calcified cartilage
Cartilage only heals if the injury does not pass through the tidemark
Calcified cartilage is the only place that type IV collagen is found
Cartilage exhibits stress shielding of the solid matrix components
Cartilage exhibits significant stress shielding of the solid matrix components due to its high water content, the non-compressibility of water, and the structural organization of collagen and proteoglycans. Cartilage is composed of a permeable porous matrix and 65 to 80% of the total weight of articular cartilage is made up of water. A pressure gradient causes the water to flow through the porous-permeable solid matrix. Significant flow of fluid through the solid matrix requires high hydrodynamic pressures because of the low
permeability of the solid matrix.
The other answers are incorrect because cartilage is anisotropic, most of the water is located in the superficial layers, it only heals if the injury does pass through the tidemark, type X collagen is found in calcified cartilage and is thought to be involved in mineralization. Type IV collagen is found in the basal lamina.
A 38-year-old patient presents 6 months after intramedullary nailing of a distal third tibia fracture with symptoms consistent with complex regional pain syndrome. During the early stage of the disease he was treated with intermittent splinting, elevation and massage, contrast baths, and transcutaneous electrical nerve stimulation. Despite these modalities, he continues to have severe and debilitating symptoms. Which of the following treatment options is indicated as a second line of treatment?
Long leg cast immobilization for 3 months
Walking boot with non weight bearing for three months
Exchange nailing to stimulate healing response to the limb
Epidural spinal cord stimulator
Surgical sympathectomy of the affected limb
Complex regional pain syndrome is a chronic progressive disease of unknown etiology characterized by pain, swelling and skin changes. If nonoperative modalities fail, a surgical sympathectomy of the affected limb is indicated.
The first line of treatment is physical therapy including intermittent splinting, elevation and massage, contrast baths, and transcutaneous electrical nerve stimulation. Aggressive passive range-of-motion exercises should be avoided. If nonoperative modalites fail and symptoms remain severe, a surgical sympathectomy of the affected limb is indicated.
Keys to successful treatment include early clinical suspicion and treatment. Late CRPS is highly refractory to treatment and often results in permanent disability.
Two forms of Complex regional pain syndrome exist: 1) Reflex sympathetic dystrophy
- which does not demonstrate nerve lesions, and 2) Causalgia - which is associated with damage to peripheral nerves. Diagnostic criteria include:
Major criteria: intense and prolonged pain, swelling, stiffness, and discoloration (vasomotor disturbances).
Minor criteria: trophic changes, osseous demineralization, temperature changes, and palmar fibromatosis.
Tran et al present their systemic review of 41 RCTs of the research regarding treatment of CRPS. Their data suggest that only bisphosphonates offer clear medicinal benefits in the treatment of CRPS. Evidence regarding a beneficial effect of lumbar sympathetic blocks, gabapentin, and physical therapy is lacking. As such, these authors advocate for further study thru well-designed RCTs to better evaluate appropriate and effective treatment strategies.
You are planning an intramedullary nail to treat a geriatric patient with a peritrochanteric femur fracture. Which of the following preoperative considerations is correct regarding your implant?
The radius of curvature of an intramedullary nail is generally greater than the radius of curvature of the femur
Closed section nails have less stiffness than slotted nails
The medial/lateral nail starting point relative to the greater trochanter does not affect varus/valgus position in the fracture
The bending stiffness of your nail is proportional to the second power of the radius
Intramedullary nails allow for mostly direct intramembranous bone healing
The radius of curvature of an intramedullary nail is generally greater than the radius of curvature of the femur, which is why anterior distal femur
penetration is a known complication of intramedullary nailing procedures.
Egol et al. evaluated the radius of curvature of 948 femurs (474 matched pairs) and compared those data with current intramedullary nails. He found the average femoral anterior radius of curvature was 120 cm (± 36 cm)
whereas the radius of curvature of the intramedullary nails ranged from 186 to 300 cm.
The other answers are incorrect because closed section nails have more stiffness than slotted nails. The starting position on the greater trochanter greatly affects the post- operative varus/valgus of the fracture. Intramedullary nails allow for mostly indirect enchondral bone healing due to relative motion at the fracture site.
All of the following antibiotics function by interfering with protein synthesis by inhibiting ribosomes EXCEPT
gentamicin
tobramycin
vancomycin
erythromycin
linezolid
Gentamicin and tobramycin are aminoglycosides that function by inhibition of bacterial protein synthesis via irreversible binding to ribosomal subunits. Erythromycin functions by binding to the 50s subunit of the bacterial 70s rRNA complex and thereby inhibits protein synthesis. Linezolid binds to the 23s portion of the ribosomal subunit and inhibits protein synthesis. In contrast, Vancomycin acts by inhibiting proper cell wall synthesis and does not inhibit the ribosome.
The bending rigidity of the implant shown in Figure A is proportional to what power of the measured radius of the implant?

Question 5

A woman injures the metacarpophalangeal (MCP) joint of her thumb while skiing. Examination reveals tenderness along the ulnar aspect of the MCP joint. Radially directed stress of the joint in full extension produces 5° of angulation. When the MCP joint is flexed 30°, a radially directed stress produces 45° of angulation. Radiographs are otherwise normal. Management should consist of

Explanation

DISCUSSION: Injuries to the ulnar collateral ligament of the MCP joint of the thumb commonly occur in recreational skiers. Historically, this injury has been referred to as “gamekeeper’s thumb.” The ligament consists of the proper collateral ligament and the more volar accessory collateral ligament. In extension, the accessory ligament is taut, and in flexion, the proper ligament is taut. For a complete tear of the ligament complex to occur, there must be laxity in full extension. Incomplete tears respond well to thumb spica splinting or casting for 2 to 3 weeks and gradual resumption of range of motion. Prolonged immobilization of incomplete injuries leads to higher rates of MCP joint stiffness.
REFERENCES: Stener B: Displacement of the ruptured ulnar collateral ligament of the metacarpo-phalangeal joint of the thumb: A clinical and anatomical study. J Bone Joint Surg Br 1971;44:869.
Heyman P: Injuries to the ulnar collateral ligament of the thumb metacarpophalangeal joint.

J Am Acad Orthop Surg 1997;5:224-229.

Question 6

Figures 78a and 78b show the CT scans of a 22-year-old man with back pain after falling out of a tree. Examination reveals no palpable spinal step-offs, posterior spinal pain, and normal neurologic function in the lower extremities. Normal perineal sensation and normal rectal tone are present. What is the best management? Review Topic

Explanation

The patient has a stable L2 burst fracture. There is no evidence of neurologic injury or disruption of the posterior ligamentous complex. According to the Thoracolumbar Injury Classification System (TLICS), the severity score for this injury is 2 and therefore nonsurgical management is recommended. The TLICS was developed to define injury based on three clinical characteristics: injury morphology, integrity of the posterior ligamentous complex, and neurologic status of the patient. Point values are assigned to each major category based on injury severity. The sum of these points represents the TLICS severity score, which may be used to guide treatment. The injury scores are totaled to produce a management grade that is, in turn, used to guide treatment. A score of >4 suggests the need for surgical treatment because of significant instability, whereas a score of <4 suggests nonsurgical management. The severity score offers prognostic information and is helpful in medical decision making. An external orthosis provides enough support to obviate the need for bed rest and avoid associated complications (deep venous thrombosis, pulmonary embolism, pneumonia, skin ulceration). Surgical treatment, either through an anterior or posterior approach, has been shown by Wood and associates to result in increased pain and disability and is therefore not indicated in this setting. Additionally, there is no need for decompression in the setting of a neurologically intact patient.

Question 7

Varus deformity after talar fractures is often seen due to collapse of the medial cortex. What artery supplies this portion of the talus?

Explanation

DISCUSSION: The artery of the tarsal canal is a branch of the posterior tibial artery. Among the branches of the artery of the tarsal canal is the deltoid artery. This arterial complex supplies the medial one third of the talar body. Disruption of this artery may lead to osteonecrosis of the medial body and subsequent collapse into varus. This is most commonly seen with talar body fractures but may be seen in Hawkins type 3 talar neck fractures. The artery of the tarsal sinus arises from the dorsalis pedis, lateral malleolar, and perforating peroneal arteries. The peroneal artery anastomoses with the calcaneal branches of the posterior tibial artery to form a plexus of vessels that supplies the posterior tubercle of the talus. Disruption of this artery would not result in collapse of the medial body, and thus would not lead to a varus deformity.
REFERENCES: Halibruton RA, Sullivan CR, Kelly PJ, et al: The extra-osseous and intra-osseous blood supply of the talus. J Bone Joint Surg Am 1958;40:1115.
Mulfinger GL, Trueta J: The blood supply of the talus. J Bone Joint Surg Br 1970;52:160-167.

Question 8

Figures below show the radiographs obtained from a 90-year-old woman who is seen in the emergency department after a fall from a height. She has right hip and thigh pain and is unable to bear weight. Based on this patient's history and imaging, what is the best next step?

Explanation

DISCUSSION:
Periprosthetic fracture is the third most common reason (after loosening and infection) for revision surgery after total hip arthroplasty (THA). Late periprosthetic fracture risk is 0.4% to 1.1% after primary
THA and 2.1% to 4% after revision THA. Risk factors for periprosthetic fracture include age over 70 years, decreasing bone mass, and loosening of implants and osteolysis. The risk of concomitant infection in the presence of a periprosthetic fracture is 11%, according to Chevillotte and associates. Obtaining presurgical aspiration or intrasurgical tissue for culture is recommended if concomitant infection is suspected.

Question 9

What is the most appropriate orthotic management for the lesion shown in Figure 6?

Explanation

DISCUSSION: The figure shows an intractable plantar keratosis (IPK). The keratoma usually forms beneath a bony prominence. This can occur under the sesamoids, most commonly the tibial sesamoid, or under the fibular condyle of a prominent metatarsal head. The initial treatment of an IPK consists of paring down the callused lesion and placing a metatarsal pad proximal to the lesion to provide posting to unload the bony prominence.
REFERENCE: Rudicel SA: Intractable plantar keratoses, in Gould J (ed): Operative Foot Surgery. Philadelphia, PA, WB Saunders, 1994, p 70.

Question 10

Figures 70a and 70b show the sagittal MRI scan and axial CT of a patient who has decreased range of motion in the cervical spine. In which of the following directions would the cervical motion be most significantly limited?

Explanation

MRI and CT demonstrate an abnormality in the alantoaxial region (C1-C2). See chart in reference. “C1-C2 -Flexion/Extension 30 degrees - Sidebending 10 degrees - Rotation – 70 degrees”

Question 11

below show the clinical photograph and radiograph obtained from a year-old man who has deformity and pain 1 year after primary total hip arthroplasty. What is the reason for the observed deformity?

Explanation

DISCUSSION:
Figure 1 reveals an external rotation deformity of the right lower extremity. This deformity can have numerous causes, including extra-articular deformity. Figure 2 reveals a loose, subsided femoral component. Femoral stems typically subside into retroversion due to proximal femoral biomechanics, which cause a compensatory external rotation deformity. The combined findings from both images suggest an external rotation deformity most likely related to subsidence into retroversion.

Question 12

A 29-year-old man reports a 2-week history of severe neck pain after being struck sharply on the back of the head and neck while moving a refrigerator down a flight of stairs. Initial evaluation in the emergency department revealed no obvious fracture and he was discharged in a soft collar. Neurologic examination is within normal limits, and radiographs taken in the office are shown in Figures 21a through 21c. Subsequent MRI scans show intra-substance rupture of the transverse atlantal ligament. What is the most appropriate treatment option at this time? Review Topic

Explanation

Dickman and associates classified injuries of the transverse atlantal ligament into two categories. Type I injuries are disruptions through the substance of the ligament itself. Type II injuries render the transverse ligament physiologically incompetent through fractures and avulsions involving the tubercle of insertion of the transverse ligament on the C1 lateral mass. Type I injuries are incapable of healing without supplemental internal fixation. Type II injuries can be treated with a rigid cervical orthosis with a success rate of 74%. Surgery may be required for type II injures that fail to heal with 3 to 4 months of nonsurgical management.
(SBQ13PE.82) A renal ultrasound should be obtained in a patient with which of the following diagnoses? Review Topic
Congenital pseudoarthrosis of the clavicle
Accessory navicular
Congenital scoliosis
Charcot-Marie-Tooth Disease
Congenital curly toe
A renal ultrasound should be obtained in a patient with congenital scoliosis.
Congenitial scoliosis has a prevalence that is estimated at 1% to 4% in general population. It is associated with systemic anomalies in up to 61% of cases. The most common anomalies are cardiac defects, genitourinary defects and spinal cord malformations. As such, additional imaging of these systems should be considered in the initial work-up of these patients.
Ruf et al. retrospectively investigated 56 consecutive operative cases of congenital scoliosis. The average age at surgery was 9.9 years (1.5–17 years). There was one wound complication, 2 hardware failures, 1 revision and no neurological complications. They concluded that one-stage posterior hemivertebra resection and instrumentation was safe in this population.
Xu et al. examined the efficacy of selective partial hemivertebra excision via posterior-only approach in 17 adolescent patients with congenital kyphoscoliosis. There were no postoperative infections and no neurological complications. They concluded that this approach may be most successful in patients aged 9 to 14 years old, with the Risser sign grades from 0–3 and Cobb angles <60°.
Illustration A from Erol et al (UPOJ, Vol 15, 2002;37-42) shows a diagram of 'types' of congenital scoliosis based on the morphology of the vertebrae.
Incorrect Answers:

Question 13

A 12-year-old girl has had pain in her right knee for 1 month that started as activity-related and progressed to night pain. Radiographs are shown in Figures 16a and 16b, and a biopsy specimen is shown in Figure 16c. What is the recommended treatment?

Explanation

DISCUSSION: This is a classic appearance for an osteosarcoma. The radiographs reveal a mixed osteolytic and osteoblastic lesion in a skeletally immature patient in the distal right femoral metaphysis. The pain pattern with progressive symptoms leading to the presence of night pain is also typical for this condition. The biopsy specimen reveals pleomorphic cells and the presence of osteoid. The current standard of care in the treatment of osteosarcoma is neoadjuvant chemotherapy followed by surgical resection or amputation followed by additional postoperative chemotherapy. Osteosarcoma is not radiosensitive.
REFERENCES: Wold LE, Adler CP, Sim FH, et al: Atlas of Orthopedic Pathology, ed 2. Philadelphia, PA, WB Saunders, 2003, p 179.
McCarthy EF, Frassica FJ: Pathology of Bone and Joint Disorders with Clinical and Radiographic Correlation. Philadelphia, PA, WB Saunders, 1998, p 205.

Question 14

The skeletal muscle length-tension relationship for voluntary force generation is observed with which of the following biomechanical paradigms? Review Topic

Explanation

Muscle force during isometric contractions (muscle not allowed to shorten) varies with starting length. If the length is too long, the sarcomeres generate little or no active tension. If a muscle is overstretched during certain surgical procedures, then the patient may generate less than 30% maximal force. The force-velocity relationship describes isotonic (constant load) conditions.

Question 15

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 16

When treating osteoporosis with alendronate, what is the most common side effect?

Explanation

DISCUSSION: Alendronate is a second-generation bisphosphonate, and it can cause epigastric distress in up to 30% of patients. This side effect can be minimized by gradually building up to therapeutic doses over a period of 4 to 8 weeks.
REFERENCES: Marshall JK, Rainsford KD, James C, et al: A randomized controlled trial to assess alendoronate-associated injury of the upper gastrointestinal tract. Aliment Pharmacol Ther 2000;14:1451-1457.
Lane JM, Sandhu HS: Osteoporosis of the spine, in Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 227-234.

Question 17

Glenohumeral inferior stability in the adducted shoulder position is primarily a function of the

Explanation

DISCUSSION: When the arm is adducted, the superior structures, including the superior glenohumeral ligament, are responsible in limiting the inferior translation. With the arm abducted, the inferior glenohumeral ligament complex is responsible for limiting inferior subluxation. Rotator cuff activity can actually depress the humeral head and does not play a role in preventing inferior subluxation. The long head of the biceps and the posterior glenohumeral ligament do not play a role in protecting the shoulder from inferior instability.
REFERENCES: 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.
Harryman DT II, Sidles JA, Harris SL, Matsen FA III: The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992;74:53-66.

Question 18

Figures 9a and 9b show the radiographs of a 12-year-old girl who has had right hip pain for the past 4 months. She reports that the pain is so severe that she is unable to walk and is now using a wheelchair. Examination reveals pain with any attempted range of motion. Management should include

Explanation

DISCUSSION: In addition to mild hip dysplasia, the radiograph shows an osteoblastic lesion of the right ilium. The patient’s symptoms are much more severe than is typical for late hip dysplasia. MRI can determine the extent of the lesion in the bone and soft tissues. Following work-up and biopsy, the patient was diagnosed with Ewing’s sarcoma.
REFERENCES: Springfield DS, Gebhardt MC: Bone and soft tissue tumors, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 507-518, 542-544.
Herring JA: Tachdjian’s Pediatric Orthopedics, ed 4. Philadelphia, PA, WB Saunders, 2002,

p 2030.

Question 19

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?

Explanation

The more severe the trauma, the higher the rate of subsequent clavicular nonunion. Neither duration nor type of immobilization has been clearly demonstrated to be a causative factor in the development of nonunion. Similarly, closed reduction has not been found to alter the healing course in midshaft clavicular fractures.

Question 20

An active 49-year-old woman who sustained a diaphyseal fracture of the clavicle 8 months ago now reports persistent shoulder pain with daily activities. An AP radiograph is shown in Figure 8. Management should consist of

Explanation

DISCUSSION: The radiograph reveals an atrophic nonunion of the diaphysis of the clavicle. Electrical or ultrasound stimulation may be an option in diaphyseal nonunions that have

shown some healing response with callus formation, but these techniques are not successful

in an atrophic nonunion. The preferred technique for achieving union is open reduction and internal fixation with bone graft. Percutaneous fixation has no role in treatment of nonunions

of the clavicle.
REFERENCES: Boyer MI, Axelrod TS: Atrophic nonunion of the clavicle: Treatment by compression plating, lag-screw fixation and bone graft. J Bone Joint Surg Br 1997;79:301-303.
Simpson NS, Jupiter JB: Clavicular nonunion and malunion: Evaluation and surgical management. J Am Acad Orthop Surg 1996;4:1-8.

Question 21

A 57-year-old woman with diabetes mellitus has purulent drainage from a lateral incision after undergoing open reduction and internal fixation of a displaced ankle fracture 10 days ago. Examination reveals moderate erythema and a foul odor coming from the wound. Cultures are obtained. What is the next most appropriate step in management?

Explanation

DISCUSSION: Early postoperative wound infections after open reduction and internal fixation should be treated with aggressive debridement and maintenance of stability of the fracture. If infection persists following healing of the fracture, the hardware should be removed.
REFERENCES: Carragee EJ, Csongradi JJ, Bleck EE: Early complications in the operative treatment of ankle fractures: Influence of delay before operation. J Bone Joint Surg Br 1991;73:79-82.
Blotter RH, Connolly E, Wasan A, Chapman MW: Acute complications in the operative treatment of isolated ankle fractures in patients with diabetes mellitus. Foot Ankle Int 1999;20:687-694.

Question 22

What is the recommended treatment of a skeletally immature 12-year-old boy who has an anterior cruciate ligament-deficient knee?

Explanation

DISCUSSION: Traditional surgeries for anterior cruciate ligament-deficient knees carry the potential risk of premature physeal closure in young athletes. Therefore, most surgeons are reluctant to recommend intra-articular reconstruction using bone tunnels with bone-patellar tendon-bone autografts or hamstring tendons. The current recommendation for young athletes is activity modification, rehabilitation, and functional bracing until the patient is near skeletal maturity. At that time, for the very symptomatic patient, the treatment of choice is intra-articular repair of the anterior cruciate ligament. If a skeletally immature patient continues to have instability despite rehabilitation and bracing, a modification of the femoral tunnel to the over-the-top position will not place the lateral femoral physis at risk for premature closure and deformity. A centrally placed tibial tunnel will minimize the risk of angular deformity and minimize limb-length discrepancy if physeal arrest occurs.
REFERENCES: Barry P: Anterior cruciate ligament injuries, in Andrews JR, Timmerman LA (eds): Diagnostic and Operative Arthroscopy. Philadelphia, Pa, WB Saunders, 1997, p 358.
McCarroll JR, Shelbourne KD, Porter DA, Rettig AC, Murray S: Patellar tendon graft reconstruction for midsubstance anterior cruciate ligament rupture in junior high school athletes: An algorithm for management. Am J Sports Med 1994;22:478-484.
Nottage WM, Matsuura PA: Management of complete traumatic anterior cruciate ligament tears in the skeletally immature patient: Current concepts and review of the literature. Arthroscopy 1994;10:569-573.
Stanitski CL: Anterior cruciate ligament injury in the skeletally immature patient: Diagnosis and treatment. J Am Acad Orthop Surg 1995;3:146-158.

Question 23

When an acute infection of a total elbow arthroplasty is managed with irrigation and debridement, which of the following organisms is associated with the highest risk of persistent infection?

Explanation

DISCUSSION: Salvage of a total elbow arthroplasty is possible with early aggressive management of acute infection (symptoms for less than 30 days) with serial irrigation and debridement and antibiotic bead placement. This form of treatment is indicated when there are no radiographic or intraoperative signs of loosening. However, successful treatment is largely dependent on the organism. Staphylococcus epidermidis is associated with persistent infection because it is an encapsulating organism, and it is best treated with implant removal and

IV antibiotics.
REFERENCES: Yamaguchi K, Adams RA, Morrey BF: Infection after total elbow arthroplasty. J Bone Joint Surg Am 1998;80:481-491.
Schoifet SD, Morrey BF: Treatment of infection after total knee arthroplasty by debridement with retention of the components. J Bone Joint Surg Am 1990;72:1383-1390.

Question 24

Which of the following is considered a potential advantage in prophylaxis for the prevention of deep venous thrombosis associated with the use of low-molecular weight heparin (LMWH) as compared with fixed-dose unfractionated heparin?

Explanation

DISCUSSION: One possible reason for improved efficacy of LMWHs is the relative improved bioavailability compared with that of unfractionated heparin. This is, in part, the result of a more predictable dose response and a longer half-life. There is no alteration of venous flow, and the rate of bleeding complications is the same or slightly higher than that of other prophylactic agents.
REFERENCES: Colwell CW Jr, Spiro TE, Trowbridge AA: Use of enoxaparin, a low-molecular weight heparin, and unfractionated heparin for the prevention of deep venous thrombosis after elective hip replacement: A clinical trial comparing efficacy and safety. J Bone Joint Surg Am 1994;76:3-14.
Bara L, Billaud E, Kher A, Samama M: Increased anti-Xa bioavailability for a low-molecular weight heparin (PK 10169) compared with unfractionated heparin. Semin Thromb and Hemost 1985;11:316-317.
Paiement GD: Prevention and treatment of venous thromboembolic disease complications in primary hip arthroplasty patients, in Cannon WD Jr (ed): Instructional Course Lectures 47. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 331-335.

Question 25

Figures 1 and 2 show the intraoperative photographs obtained during surgical treatment for de Quervain tendonitis. For orientation purposes, dorsal is at the top. Figure 1 is obtained just after the initial first extensor compartment release, and Figure 2 shows the floor of the first extensor compartment. If the structure marked by the black dot is not addressed, the most common postoperative problem would be

Explanation

EXPLANATION:
The black dot identifies an accessory compartment of the extensor pollicis brevis (EPB) tendon. The incidence of accessory EPB compartment in patients undergoing surgical treatment for de Quervain syndrome ranges from 46% to 60%. Failure to release this compartment at the time of initial surgery can cause persistent postoperative pain. The patient would not experience altered sensation if this compartment were not released. Altered sensation would most commonly occur following injury to the dorsal radial sensory nerve branch during surgery. EPB tendon subluxation also would not occur should the accessory compartment not be released. For EPB tendon subluxation to occur, its own compartment would need to be released first. Finally, EPB tendon rupture would be an extremely uncommon complication of failure to release the accessory compartment.

Question 26

Optimal management of the injury shown in Figure 31 should include which of the following?

Explanation

DISCUSSION: The radiograph shows a displaced calcaneal beak fracture, a tongue-type fracture variant. The fracture fragment typically includes the insertion point of the Achilles tendon, which places marked tension on the thin overlying soft-tissue envelope and can lead to full-thickness necrosis if not acutely addressed. Cast immobilization does not adequately address the increased soft-tissue tension, as the fragment will be difficult to control. Arthroscopic-assisted techniques or primary arthrodesis are not indicated because calcaneal beak fractures are typically extra-articular.
REFERENCES: Sanders RW, Clare MP: Fractures of the calcaneus, in Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA, Mosby-Elsevier, 2007, vol 2, pp 2017-2073.
Sanders RW, Clare MP: Fractures of the calcaneus, in Bucholz RW, Heckman JD, Court-Brown C (eds): Rockwood and Green’s Fractures in Adults, ed 6. Philadelphia, PA, Lippincott Williams & Wilkins, 2006, vol 2, pp 2293-2336.

Question 27

A 60-year-old woman with rheumatoid arthritis has atlanto-axial instability and basilar invagination. What MRI findings would suggest the need for cervical fusion?

Explanation

DISCUSSION: The cervical medullary junction should be 135° or greater. An angle of 125° suggests compression of the cervical medullary junction. Other findings supporting surgical intervention include a cord diameter in flexion of less than 6 mm or less than 13 mm of space available for the cord.
REFERENCES: Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 1998, pp 700-701.
Monsey RB: Rheumatoid arthritis of the cervical spine. J Am Acad Orthop Surg

1997;5:240-248.
Bundschuh C, Modic MT, Kearney F, et al: Rheumatoid arthritis of the cervical spine: Surface-coil MR imaging. Am J Roentgenol 1988;151:181-187.

Question 28

Figure 35 is the MR image of an 18-year-old man who has had knee pain with running for 5 months. What is the most appropriate treatment?

Explanation

DISCUSSION
The MR image shows an osteochondritis dissecans (OCD), which is an acquired lesion of the subchondral bone. Patients with OCD initially report nonspecific pain and variable amounts of swelling. Initial radiographs help to identify the lesion and establish the physes status. MRI is useful for assessing potential for the lesion to heal with nonsurgical treatment. This lesion is unstable, considering the fluid line between the OCD and the underlying normal bone. Nonsurgical treatment is appropriate for small, stable lesions in patients with open physes and focuses on activity restriction for 3 to 9 months. Surgical treatment is necessary to address unstable or detached lesions. Stable lesions with intact articular cartilage can be treated with subchondral drilling to stimulate vascular ingrowth, with radiographic healing at an average of 4.4 months. Fixation is indicated for unstable or hinged lesions, and stabilization of the fragment can be achieved using a variety of implants through an arthroscopic or open approach. The fragment should be salvaged and the normal articular surface restored whenever possible.

Question 29

Which of the following nerves is most likely responsible for symptoms associated with plantar fasciitis?

Explanation

DISCUSSION: The first branch of the lateral calcaneal nerve innervates the abductor digiti minimi. It is reported to be trapped at the interval between the abductor hallucis and the quadratus plantae muscles.
REFERENCE: Baxter DE, Pfeffer GB, Thigpen M: Chronic heel pain: Treatment rationale. Orthop Clin North Am 1989;20:563-569.

Question 30

What factor is associated with a high risk of developing pseudotumors after metal-on-metal hip resurfacing?

Explanation

The recent experience of a large clinical cohort revealed the most likely risk factors as being female gender, age younger than 40, small components, and a diagnosis of hip dysplasia causing osteoarthritis. Failure was least likely among men and after procedures involving larger components. These data have prompted some authors to caution against using metal-on-metal hip resurfacing in women and to primarily target candidates who are men younger than age 50. Small components may be more prone to failure because of malpositioning and edge loading, which have been noted to be more common in dysplasia cases.

Question 31

A 7-year-old boy has had chronic left leg pain that is worse at night but is not activity related. Use of nonsteroidal anti-inflammatory drugs for the past 6 months has failed to provide relief. A CBC count with differential, erythrocyte sedimentation rate, and C-reactive protein are within normal limits. Radiographs and a CT scan are shown in Figures 31a through 31c. Management should consist of

Explanation

DISCUSSION: Osteoid osteomas are painful bone lesions, with radiographs revealing a dense sclerotic cortex surrounding a small radiolucency or nidus. Symptoms often are worse at night but usually are not activity related. While treatment in the past has consisted of open en bloc excision, current means of removal include percutaneous drilling under CT guidance and percutaneous radiofrequency coagulation. Success rates of percutaneous treatment are comparable to those seen following open procedures. The characteristic radiographic appearance of this lesion usually obviates the need for biopsy. Because the lesion is not caused by pyogenic organisms, antibiotics are not indicated.
REFERENCES: Donahue F, Ahmad A, Mnaymneh W, Pevsner NH: Osteoid osteoma: Computed tomography guided percutaneous excision. Clin Orthop 1999;366:191-196.
Rosenthal DI, Hornicek FJ, Wolfe MW, et al: Percutaneous radiofrequency coagulation of osteoid osteoma compared with operative treatment. J Bone Joint Surg Am 1998;80:815-821.

Question 32

A 63-year-old woman is seen 10 weeks after sustaining a closed minimally displaced distal radius fracture. She has been in a short-arm cast and reports minimal pain but notes that she is having difficulty using her thumb. An extensor pollicis longus (EPL) tendon rupture is suspected. Which examination finding would confirm lack of EPL function?

Explanation

EXPLANATION:
As many as to 5% of patients with a nondisplaced distal radius fracture experience EPL rupture. The extensor pollicis brevis (EPB) tendon often attaches to the extensor hood and sometimes continues more distally, providing weak metacarpophalangeal extension even in the setting of EPL disruption. However, because of the vector of its pull, the EPB cannot extend the thumb dorsal to the plane of the palm. A positive Froment sign is noted when flexion of the thumb interphalangeal joint with an attempted key pinch is caused by adductor pollicis weakness from ulnar nerve dysfunction. Compression of the median nerve in the carpal tunnel affects the recurrent motor branch of the abductor pollicis brevis, leading to thenar atrophy. The flexor pollicis longus tendon (FPL) is intact so the patient would not have difficulty flexing the thumb with the palm flat.

Question 33

A 69-year-old woman has just undergone an uncomplicated total shoulder arthroplasty for glenohumeral osteoarthritis. A press-fit humeral stem and a cemented all-polyethylene glenoid component were placed. At this point, what is the postoperative rehabilitation plan?

Explanation

DISCUSSION: The patient needs to immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side. Sling immobilization without stretching for either 3 or 6 weeks will result in severe stiffness that will compromise her ultimate range of motion. Since she has a good quality subscapularis tendon, there is no need to avoid beginning external rotation to the side. However, starting a strengthening program

at 3 weeks risks tearing the subscapularis tendon repair. Active strengthening should not begin for 6 weeks postoperatively to allow the subscapularis tendon repair time to heal.
REFERENCES: Boardman ND III, Cofield RH, Bengston KA, et al: Rehabilitation after total shoulder arthroplasty. J Arthroplasty 2001;16:483-486.
Matsen FA III, Lippitt SB, Sidles JA, et al: Practical Evaluation and Management of the Shoulder. Philadelphia, PA, WB Saunders, 1994, pp 215-218.

Question 34

In patients undergoing elective hip or knee arthroplasty who are not at elevated risk (beyond the risk associated with the surgery) for venous thromboembolism or bleeding, using pharmacologic agents and/or mechanical compressive devices for the prevention of venous thromboembolism was assigned what grade of recommendation by the 2011 AAOS Clinical Practice Guideline, Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty?

Explanation

DISCUSSION:
Using pharmacologic agents and/or mechanical compressive devices for the prevention of venous thromboembolism in patients undergoing elective hip or knee arthroplasty who are not at elevated risk beyond that of the surgery itself for venous thromboembolism or bleeding was given a moderate grade of
recommendation in the 2011 AAOS Clinical Practice Guideline referenced above.

Question 35

An 18-year-old man sustained closed humeral shaft and forearm fractures of his dominant arm in a motor vehicle accident. Neurovascular examination is intact, and his condition is stable. The best course of action for management of the injuries should be

Explanation

DISCUSSION: Fractures above and below the elbow constitute floating elbow injuries and are best treated with internal fixation to allow early range of motion and to prevent elbow stiffness. Use of a long arm cast would promote elbow stiffness. External fixation is indicated primarily for open injuries.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.
Bell MJ, Beachamp CG, Kellam JK, McMurtry RY: The results of plating humeral shaft fractures in patients with multiple injuries: The Sunnybrook experience. J Bone Joint Surg Br 1985;67:293-296.

Question 36

During the anterior approach for repair of a distal biceps tendon rupture, what structure, shown under the scissors in Figure 6, is at risk for injury?

Explanation

DISCUSSION: The most commonly injured neurovascular structure during an anterior approach for the repair of a distal biceps tendon rupture is the lateral antebrachial cutaneous nerve. This structure is located lateral to the biceps tendon and in a superficial location just deep to the subcutaneous layer. The antecubital vein is medial and superficial with the brachial artery and median nerve also medial to the biceps tendon but deep to the common flexors. The posterior interosseous nerve is deep within the supinator muscle and can be injured in the deep dissection or through the posterior approach when using a two-incision approach.
REFERENCES: Kelly EW, Morrey BF, O’Driscoll SW: Complications of repair of the distal biceps tendon with the modified two-incision technique. J Bone Joint Surg Am 2000;82:1575-1581.
Ramsey ML: Distal biceps tendon injuries: Diagnosis and management. J Am Acad Orthop Surg 1999;7:199-207.

Question 37

A 45-year-old woman has idiopathic scoliosis. Surgery is to include an anterior thoracic release through an open left thoracotomy. The thoracotomy will have what effect on the patient’s pulmonary function postoperatively?

Explanation

DISCUSSION: A thoracotomy in an adult with idiopathic scoliosis causes a reduction in pulmonary function that often does not return to preoperative levels. What pulmonary function that does recover, recovers over many months. Long-term improvement in pulmonary function, compared to preoperative function, is rarely seen. This should be considered in planning surgical intervention in adults with scoliosis.
REFERENCES: Graham EJ, Lenke LG, Lowe TG, et al: Prospective pulmonary function evaluation following open thoracotomy for anterior spinal fusion in adolescent idiopathic scoliosis. Spine 2000;25:2319-2325.
Kishan S, Bastrom T, Betz RR, et al: Thoracoscopic scoliosis surgery affects pulmonary function less than thoracotomy at 2 years postsurgery. Spine 2007;32:453-458.

Question 38

A 52-year-old man sustained the left elbow injury shown in Figure A while playing basketball 2.5 months ago. He underwent the procedure shown in Figure B. Post-operatively he was mobilized in a hinged brace. On examination today, his arc of elbow flexion is 75 degrees with loss of 45 degrees of full extension. His Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Measure score is 45 points. What initial treatment option will likely provide the greatest improvement in this patients DASH score and functional range of motion? Review Topic

Explanation

The clinical presentation is consistent with post-traumatic elbow stiffness following an elbow fracture-dislocation. Supervised exercise therapy with static elbow splinting over a 6 month period has shown to have a significant improvement on DASH scores and functional range of motion (ROM) in patients with post-traumatic elbow stiffness.
Post-traumatic elbow stiffness is often difficult to manage. The ultimate goal of treatment is to restore a functional range of elbow motion (30° to 130°). Nonoperative modalities are considered the first-line of treatment. Aggressive physical therapy has traditionally been advocated. However, the use of static progressive elbow splinting with a turnbuckle, alongside aggressive physical therapy, has shown to provide better functional outcomes. Treatment is usually maintained over a period of 6-12 months. Surgery is considered when nonoperative therapy fails.
Doornberg et al. looked at a retrospective case series of 29 patients with posttraumatic elbow stiffness. They showed that static progressive splinting can help gain additional motion when standard exercises fail to produce additional improvements.
Lindenhovius et al. randomized sixty-six patients with post-traumatic elbow stiffness into static progressive elbow splint therapy or dynamic elbow splinting over a 12 month period. There was no significant difference in outcomes between treatment modalities. ROM increased by 40° vs. 39° at six months, respectively. DASH scores improved from 50 vs 45 at enrollment to 32 vs. 25 at six months, respectively.
Figure A shows a posterior elbow dislocation with an associated medial epicondyle fracture. Figure B shows ORIF of the fracture seen in Figure A. Illustration A shows a static progressive turnbuckle elbow splint used for post-traumatic elbow stiffness.
Incorrect Answers:

Question 39

The most appropriate treatment for this fracture is

Explanation

DISCUSSION
Tibial fractures are classified on the basis of their anatomical location and the status of the prosthesis fixation. Type I fractures involve the tibial plateau, type II fractures occur adjacent to the stem of the tibial component, type III fractures are distal to the tibial stem, and type IV fractures involve the tibial tubercle. Subclassifications include A with a well-fixed implant; B with a loose implant; and C, which occur intraoperatively.
Treatment of periprosthetic tibial fractures is based on the location of the fracture and the status of the component fixation. Types II or III fractures associated with prosthetic loosening or instability are best managed with revision arthroplasty, usually with a diaphyseal-engaging intramedullary tibial stem. Supplemental internal fixation may be necessary. Type III fractures with well-fixed and stable implants are treated using the standard principles of tibial fracture management.

Question 40

Figures 92a through 92c are the radiographs of a 34-year-old man with low-back pain and an inability to walk upright. What is the appropriate surgical treatment? A B C

Explanation

DISCUSSION
This patient has a marked fixed sagittal imbalance and a mild coronal imbalance. His fused sacroiliac joints indicate ankylosing spondylitis. Sufficient correction likely can be achieved with a pedicle subtraction osteotomy in the midlumbar spine. Smith-Petersen osteotomies necessitate flexibility of the anterior column, which is not associated with this diagnosis. Also, osteoclasis can result in vascular injuries. Vertebral column resection should not be needed in this case.
RECOMMENDED READINGS
Patel NM, Jenis LG. Inflammatory arthritis of the spine. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:339-349.
Kim KT, Suk KS, Cho YJ, Hong GP, Park BJ. Clinical outcome results of pedicle subtraction osteotomy in ankylosing spondylitis with kyphotic deformity. Spine (Phila Pa 1976). 2002 Mar 15;27(6):612-8. PubMed PMID: 11884909. View Abstract at PubMed

Question 41

Which of the following conditions is typically associated with the ankle deformity shown in figure 14?

Explanation

Figure 14 depicts an X-ray of a child with a Ball-and-Socket ankle. This is a rare deformity associated with such pre-existing conditions as congenital shortening of the lower limb, coalition of tarsal bones, absent digital rays and aplasia or hypoplasia of the fibula. Ball-and-socket joint is not congenital, but is an acquired deformity formed in compensation for the loss of inversion and eversion caused by tarsal coalition or various other pre-existing congenital conditions.

Question 42

A 12-year-old boy with a family history of neurofibromatosis has anterolateral bowing of the left tibia. He has no pain and is ambulatory. Radiographs show a narrowed medullary canal but intact cortices. Treatment should consist of which of the following?

Explanation

DISCUSSION: Anterolateral bowing of the tibia is associated with confirmed neurofibromatosis in approximately 50% of patients. Although the risk of fracture with the development of pseudarthrosis exists, the initial treatment consists of bracing through maturity.
REFERENCES: Vander Have KL, Hensinger RN, Caird M, et al: Congenital pseudarthrosis of the tibia.
J Am Acad Orthop Surg 2008;16:228-236.
Vitale MG, Guha A, Skaggs DL: Orthopaedic manifestations of neurofibromatosis in children: An update. Clin Orthop Relat Res 2002;401:107-118.

Question 43

A 41-year-old male underwent intramedullary nailing for a low-energy left femoral shaft fracture. At his follow-up appointment, he complains that his feet are pointing in opposite directions when walking. Using the imaging study shown in Figure A, which of the following represents this patient's left femur malalignment?

Explanation

Figure A shows axial CT scan slices of the pelvis and knee. On the operative left side, there is an internal rotation malalignment of 21° compared to the contralateral side (44°-23°=21°).
Radiographic rotational malalignment after fixation of femoral shaft fractures may be measured by comparing the femoral anteversion of both femurs. This can be determined by measuring the angle between a line tangential to the dorsal bony contours of the femoral condyles and a line drawn through the axis of the femoral neck. Rotational differences of less than 10° are considered variations of normal.
Jaarsma et al. reviewed rotational malalignment after intramedullary nailing of femoral fractures. They report that rotational measurements by CT are superior to clinical assessment. They note a high incidence of malrotation after IM nailing of fractures. This has shown to be in the range 15% to 30%.
Figure A shows left femoral malrotation using CT-torsion measurements with axial cuts of the femoral neck and distal femoral condyles. Note the normal anteversion of the right femur (23 degrees; normal range 10-25).
Incorrect Answers:

Question 44

A 16-year-old high school football player has diffuse pain with attempted digital flexion after injuring the ring finger of the dominant hand 1 week ago. Examination reveals that he is unable to flex the distal interphalangeal joint. Management should consist of

Explanation

DISCUSSION: The patient has an avulsion of the flexor digitorum profundus. Treatment should include surgical exploration and tendon reinsertion. This is not an avulsion of the flexor digitorum superficialis because the patient’s deficiency is the inability to flex the distal interphalangeal joint, not the proximal interphalangeal joint. Surgical release of the anterior interosseous nerve is not indicated because the flexor digitorum profundus of the ring finger is innervated by the ulnar nerve. A median nerve contusion causes wrist pain and/or numbness and tingling in the median nerve distribution.
REFERENCES: Strickland JW: Flexor tendons: Acute injuries, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,

pp 1851-1897.
Leddy JP: Avulsions of the flexor digitorum profundus. Hand Clin 1985;1:77-83.

Question 45

A 17-year-old high school athlete comes in with a 6-month history of right midfoot pain. She has been treated with cast immobilization, crutches, and physical therapy. She still has significant pain with activities and cannot participate in sports. Her radiograph is shown in Figure 93a, and MR images are shown in Figures 93b and 93c. What is the most appropriate 79 next step? A B C

Explanation

This patient’s MR images are indicative of a nondisplaced navicular stress fracture, which is best treated with percutaneous lag screw fixation. She has persistent symptoms despite appropriate nonsurgical treatment. Although all of the above choices may allow successful healing of her navicular, surgery has been shown to result in a shorter recovery and a more predictable outcome, which is especially important to serious athletes. Use of bone morphogenic protein has not been established as a treatment for this injury.
RECOMMENDED READINGS
Lee S, Anderson RB. Stress fractures of the tarsal navicular. Foot Ankle Clin. 2004 Mar;9(1):85-104. Review. PubMed PMID: 15062216. View Abstract at PubMed
Anderson RB, Cohen BE. Stress fractures of the foot and ankle. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. Vol 2. 8th ed. Philadelphia, PA: Mosby; 2007:1590-1597.

Question 46

A 17-year-old boy who fell on a pitchfork in a barn 1 day ago now has a painful, swollen forearm. Examination reveals erythema, exquisite tenderness, and crepitus to palpation of the forearm. He has a pulse rate of 110/min and a blood pressure of 80/60 mm Hg. Radiographs show subcutaneous air and no fractures. Gram stain of wound drainage reveals a gram-positive bacillus. The next most appropriate step in management should consist of

Explanation

DISCUSSION: The successful treatment of necrotizing soft-tissue infections such as clostridial myonecrosis depends on prompt recognition and aggressive surgical debridement of all involved muscle, fascia, and soft tissue, resecting to a clearly normal healthy, viable margin. The effective antibiotic regimen for clostridial infection is high-dose penicillin; however, necrotizing infections are frequently polymicrobial so initially broad-spectrum antibiotics are indicated. Hyperbaric oxygen therapy may be used as an adjunct to surgical treatment but is insufficient as a primary therapy. Prolonged application of tourniquets and wound closure should be avoided.
REFERENCES: Pellegrini VD, Evarts CM: Complications, in Rockwood CA Jr, Green DP (eds): Fractures in Adults, ed 3. Philadelphia, PA, JB Lippincott, 1991, pp 365-370.
Gerding DN, Peterson LR: Infections caused by anaerobic bacteria, in Shulman ST, Phair JP, Peterson LR, Warren JR (eds): Infectious Diseases, ed 5. Philadelphia, PA, WB Saunders, 1997, pp 416-417.
Stephens DC: Myositis and fascitis, in Root RK (ed): Clinical Infectious Diseases, ed 1. Oxford, England, Oxford Press University, 1999, pp 769-770.

Question 47

Histologic studies of surgically resected tissue in lateral epicondylitis demonstrate which of the following findings? Review Topic

Explanation

The extensor carpi radialis brevis is most often cited as the anatomic location of pathology in lateral epicondylitis. Histologic examination demonstrates noninflammatory tissue, primarily angiofibroblastic tendinosis though normal tendon histology is also present. There is usually no evidence of acute inflammation or chondroblastic tissue, or significant calcium deposition.

Question 48

Following surgery for an ankle fracture, which of the following is considered the most important factor in achieving a satisfactory outcome? Review Topic

Explanation

The only factor that is prognostic for outcomes is the quality of the reduction. None of the other factors has any effect on the outcome. Early range of motion or physical therapy may offer temporary effects, but these small advantages do not last beyond 3 months after surgery.

Question 49

Lymphangioma

Explanation

In classic hemophilia, a natural factor-VIII level of less than what percentage will lead to severe bleeding and complications:

Question 50

The lateral arm flap is based on what arterial supply?

Explanation

DISCUSSION: The lateral arm flap is based on the posterior radial collateral artery, a branch of the profunda brachial artery.
REFERENCES: Katsaros J, Tan E, Zoltie N: The use of the lateral arm flap in upper limb surgery. J Hand Surg 1991;16:598-604.
Katsaros J, Schusterman M, Beppu M, et al: The lateral upper arm flap: Anatomy and clinical applications. Ann Plast Surg 1984;12:489-499.

Question 51

A 23-year-old man who was the restrained driver in a car involved in a high-speed motor vehicle accident sustained the closed injury shown in Figures 32a through 32c. Which of the following factors has the greatest impact on the risk of osteonecrosis?

Explanation

DISCUSSION: The incidence of osteonecrosis following displaced talar neck fractures is most related to the extent of initial fracture displacement. With increasing fracture displacement, the tenuous vascular supply to the talar body is more at risk for damage, thereby increasing the risk of osteonecrosis. Although displaced talar neck fractures have historically been considered a surgical emergency, recent studies have shown that the timing of surgical intervention bears no impact on the development of osteonecrosis. While nicotine use has an influence on fracture healing, it has never been shown to be a factor in osteonecrosis, nor has posterior-to-anterior screw fixation or the quality of fracture reduction.
REFERENCES: Lindvall E, Haidukewych G, Dipasquale T, et al: Open reduction and stable fixation of isolated, displaced talar neck and body fractures. J Bone Joint Surg Am 2004;86:2229-2234.
Vallier HA, Nork SE, Barei DP, et al: Talar neck fractures: Results and outcomes. J Bone Joint Surg Am 2004;86:1616-1624.

Question 52

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

Explanation

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

Question 53

In treating a lateral split-depression type tibial plateau fracture, which of the following adjuncts has been shown to have the least articular surface subsidence when used to fill the bony void?

Explanation

DISCUSSION: In treating tibial plateau fractures, calcium phosphate has been shown to have the least amount of articular subsidence on follow-up examinations.
The referenced study by Russell et al noted a significantly increased rate of subsidence at 12 months with autograft as compared to calcium phosphate cement (in types I-VI).
The other referenced study by Lobenhoffer et al noted improved radiographic outcomes and earlier weightbearing with usage of calcium phosphate cement.

Question 54

A 27-year-old woman reports the acute atraumatic onset of burning pain in her right shoulder followed a week later by significant weakness and the inability to abduct her shoulder. One week prior to this incident she had recovered from a flu-like syndrome. Examination reveals full passive motion of the shoulder and the inability to actively raise the arm. Sensation in the right upper extremity is normal. Cervical spine examination is normal. Radiographs of the shoulder and cervical spine are normal. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient has symptoms and examination findings of acute brachial neuritis which is often a diagnosis of exclusion. The recent viral flu-like symptoms have shown a correlation with the development of this disorder. The acute, severe shoulder weakness excludes calcific tendinitis, impingement, and poliomyelitis. A normal cervical spine examination makes cervical disk disease unlikely.
REFERENCES: Turner JW, Parsonage MJ: Neuralgic amyotrophy (paralytic brachial neuritis). Lancet 1957;2:209-212.
Omer GE, Spinner M, Van Beek AL (eds): Management of Peripheral Nerve Problems, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 101-104.

Question 55

Figure 14 shows a lateral radiograph of a knee joint. The bony structure indicated by the arrow is a sesamoid bone that resides in what tendon?

Explanation

DISCUSSION: The radiograph shows a fabella, a sesamoid bone that is usually found within the tendon of the lateral head of the gastrocnemius. It can be confused with a loose body on radiographs. It occurs in 18% of patients and is often bilateral.
REFERENCES: Anderson JE (ed): Grant’s Atlas of Anatomy, ed 7. Baltimore, MD, Williams & Wilkins, 1978, pp 4-69.
Weissman BNW, Sledge CB (ed): Orthopaedic Radiology. Philadelphia, PA, WB Saunders, 1986, p 514.

Question 56

The most common reason for proximal femur fracture fixation failure (Figure 15) is secondary to which common deformity?

Explanation

DISCUSSION
Malposition of a proximal lag screw may result in cut-out similar to that seen with a sliding hip screw. Varus malreduction also can result in implant failure. Studies have shown no difference in complication or healing rates when comparing short and long cephallomedullary nails.
RECOMMENDED READINGS
Kleweno C, Morgan J, Redshaw J, Harris M, Rodriguez E, Zurakowski D, Vrahas M, Appleton
P. Short versus Long Cephalomedullary Nails for the Treatment of Intertrochanteric Hip Fractures in Patients over 65 Years. J Orthop Trauma. 2013 Nov 13. [Epub ahead of print] PubMed PMID: 24231580.View Abstract at PubMed
Haidukewych GJ. Intertrochanteric fractures: ten tips to improve results. Instr Course Lect. 2010;59:503-9. Review. PubMed PMID: 20415401. View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 16 THROUGH 20
A 23-year-old man sustains multiple injuries in a high-speed motor vehicle collision. Among his injuries are a right transverse-posterior wall acetabular fracture, a left open tibia fracture with compartment syndrome, and a right calcaneus fracture.

Question 57

Figure 1 is the MRI scan of a 35-year-old female soccer player who injured her knee during a game. Given the findings of the scan, physical examination is most likely to reveal

Explanation

The MRI scan clearly reveals bone bruises in the mid lateral femoral condyle and posterior tibial plateau. These MRI findings are commonly associated with acute anterior cruciate ligament injuries. Therefore, the preferred answer would be a positive pivot shift examination. A positive posterior drawer and positive quad active test are associated with posterior cruciate ligament injuries. A positive dial test would be suggestive of a posterolateral instability of the knee.

Question 58

A 14-year-old patient has anterior knee pain. Radiographs, an MRI scan, and biopsy specimens are shown in Figures 6a through 6e. What is the most likely diagnosis?

Explanation

DISCUSSION: Although the imaging studies are consistent with a unicameral bone cyst, aneurysmal bone cyst, or giant cell tumor, the histology shows small round blue cells that are typical of Ewing’s sarcoma. Although Ewing’s sarcoma frequently occurs in the diaphysis, it can occur in the metaphysis.
REFERENCE: Mirra J: Bone Tumors: Clinical, Radiologic, and Pathologic Correlations. Philadelphia, PA, Lea & Febiger, 1989, vol 2, ch 18.

Question 59

A 67-year-old woman is seen in the emergency department after falling at home. Radiographs before and after treatment are shown in Figures 49a and

Explanation

Patients older than age 40 years at the time of initial anterior dislocation have low rates of redislocation; however, 15% of these patients experience a rotator cuff tear. Moreover, there is a dramatic increase (up to 40%) in the incidence of rotator cuff tears in patients older than age 60 years. Axillary nerve injury may occur but is less common than rotator cuff tear.

Question 60

A 13-year-old boy has a radiographically mild, clinically stable slipped capital femoral epiphysis (SCFE). What is the most appropriate treatment? Review Topic

Explanation

The accepted treatment of a stable SCFE lesion involves fixation of the epiphysis in situ with a single screw that is perpendicular to the epiphysis and central in both the AP and lateral planes. Constructs such as the three-screw inverted triangle configuration have increased rates of penetration of the femoral head as well as femoral head osteonecrosis. Spica casting was once a popular treatment modality but is associated with a high incidence of chondrolysis and is no longer recommended. Closed reduction attempts increase the risk of osteonecrosis.
(SBQ13PE.46) What developmental milestones are likely to be present in a 30-month-old child? Review Topic
Hand dominance established
Hops on one foot
Heel-to-toe walk
Puts shoes on correct feet
Manages buttons
Hand dominance is usually established in the third year of life.
Normally, children younger than 2 years of age are ambidextrous. In some normal cases this persists after 2 years. Although there is some variability in this timing, strong hand preference in a younger child may be the result of a neurologic deficit.
Frankenburg et al. used the Denver Developmental Screening Test (DDST) to evaluate 1036 Denver area children from 2 to 6.4 years. The ages at which 25, 50, 75 and 90 percent of children could perform tasks were calculated to establish norms for the sample. The authors stress that the DDST is not an intelligence test, but rather a screening test to be used in clinical practice to determine whether a child's development is within the normal range.
Illustration
A
shows
the
DDST.
Incorrect
2:
Normal
for

Question 61

Early postoperative infections following primary total hip arthroplasty are most likely caused by which organism?

Explanation

DISCUSSION:
S aureus is the most common organism cultured in early (fewer than 4 weeks postoperative) periprosthetic infections. Methicillin-resistant S aureus is becoming a more common pathogen in certain patient populations. B hemolytic Streptococcus and some gram-negative infections can also be found in early postoperative infections. S epidermidis, S viridans, and P acnes are more commonly found in late (more than 4 weeks postoperative) infections.

Question 62

When counseling a patient with hypophosphatemic rickets, which of the following scenarios will always result in a child with the same disorder?

Explanation

DISCUSSION: Hypophosphatemic rickets is an inherited disorder that is transmitted by a unique sex-linked dominant gene. Therefore, if a male patient has a female offspring, his affected X chromosome will be transmitted and all of his female children will have hypophosphatemic rickets. All male offspring of a male patient will be unaffected. All offspring of a female patient have a 50% chance of having the disorder. Understanding the inheritance of hypophosphatemic rickets facilitates early diagnosis and early treatment. Medical treatment with phosphorus and some types of vitamin D (most authors recommend calcitriol) improves, but does not fully correct, the mineralization defect in hypophosphatemic rickets. However, if medical treatment is begun before the child begins walking, the growth plate is then adequately protected and a bowleg deformity will most likely be prevented.
REFERENCES: Evans GA, Arulanantham K, Gage JR: Primary hypophosphatemic rickets: Effect of oral phosphate and vitamin D on growth and surgical treatment. J Bone Joint Surg Am 1980;62:1130-1138.
Greene WB, Kahler SG: Hypophosphatemic rickets: Still misdiagnosed and inadequately treated. South Med J 1985;78:1179-1184.

Question 63

A 40-year-old female recreational basketball player notes pain deep within her shoulder that occurs with activity. Pain began insidiously 6 months previously. She has completed a physical therapy program, and an intra-articular corticosteroid injection provided excellent temporary relief. Physical examination shows symmetric range of motion of her shoulder. She has a positive O'Brien’s active compression test. There is no pain with cross-arm adduction or tenderness to palpation over the acromioclavicular joint. Resisted abduction is nonpainful and strong. MRI shows increased signal in the substance of the superior labrum, low-grade bursal surface fraying of the supraspinatus, and mild degenerative changes within the acromioclavicular joint. What is the best treatment option?

Explanation

A 50-year-old man sustained an external rotation traction injury to his right arm. He felt a pop in the anterior aspect of his shoulder associated with immediate pain and swelling. The MRI scan shows a tear of the subscapularis tendon, as shown in Figures 1 and 2. The arrow points to what anatomic structure?

Question 64

A 35-year-old man presents with mechanical knee pain after a fall. An arthroscopic picture taken during diagnostic arthroscopy is shown in Figure A. His surgeon considers treatment with Technique B and Technique C, which are shown in Figures B and C, respectively. Which of the following statement is true with respect to Technique B and C? Review Topic

Explanation

Microfracture (Technique B) heals with fibrocartilage, predominantly Type I collagen. Mosaicplasty/OAT (Technique C) transfers articular cartilage, containing predominantly Type II collagen.
The initial treatment for small articular cartilage defects is rest, NSAIDS and bracing. For larger defects (<2-4cm2), options include marrow stimulation procedures (abrasion chondroplasty, microfracture, osteochondral drilling) and autograft procedures (Mosaicplasty, a technique of osteochondral autograft transfer (OAT).
Alford et al. reviewed cartilage restoration. They defined a spectrum of treatment option ranging from (1) palliative (debridement/lavage), intended to reduce irritation
and inflammation, (2) reparative (marrow stimulation techniques), intended to recruit stem cells to proliferate fibrocartilage repair tissue, to (3) restorative (osteochondral grafting), designed to replace articular cartilage and subchondral bone as a single unit.
Magnussen et al. reviewed the treatment of cartilage defects in the knee. They compared autologous chondrocyte implantation (ACI), OATs, matrix-induced ACI, and microfracture. No one technique was superior to the rest. Outcomes for microfracture tended to be worse in larger lesions.
Figures A is an arthroscopic picture showing a grade IV chondral defect. Figure B shows microfracture. Figure C shows the multiple cylindrical plugs of mosaicplasty, a technique of osteochondral autograft transfer (OAT). Illustration A shows donor and recipient sites in mosaicplasty. Illustration B shows the spectrum of treatment options defined by Alford et al (MST = marrow stimulation; ACI = autologous chondrocyte implantation; OCG = osteochondral grafting with autograft/allograft).
Incorrect Answers:

Question 65

When treating a proximal tibia fracture, the surgeon decides to (1) use blocking screws in the proximal fragment, and (2) pick the intramedullary nail based on the location of the Herzog curve. Which of the following combinations will best prevent the classic deformity associated with this fracture?

Explanation

Proximal tibial fractures develop an apex anterior (procurvatum) and valgus malalignment. Blocking (poller) screws should be placed in the concavity of the deformity, thus posterior and lateral to the nail. The Herzog curve should be proximal to the fracture site.
Up to 58% of proximal tibial fractures are malaligned. Malalignment arises because the nail fits loosely in the wide metaphyses and cannot control alignment. Without close fit of the nail at the fracture site, the nail will not align the fracture independent of a stable reduction and careful nail path. Blocking screws serve to reduce the size of the proximal metaphyseal canal and guide final nail passage.
Stinner et al. discuss strategies in proximal tibial fracture nailing. They describe an accurate starting point (using the twin peaks AP view or fibular bisector AP view, and flat plateau lateral view). They emphasize fracture reduction prior to reaming and implant placement.
Hiesterman reviewed nailing of extra-articular proximal tibial fractures. Techniques described include blocking screws, unicortical plating, using a universal distractor, nailing in flexion/locking in extension, semiextended nailing (including percutaneous suprapatellar quads-splitting approaches), multiple proximal interlocking screws (>=3).
Illustration A shows placement of a coronal blocking screw. Illustration B shows placement of a sagittal blocking screw. Illustration C shows the effect of the Herzog curve. A more distal Herzog curve leads to a "wedge" effect and fracture displacement whereas a proximal Herzog curve contains the fracture. The "wedge" effect occurs as the nail is seated and impinges on the posterior cortex of the distal segment accentuating an apex anterior deformity because of the effective widening of the nail above the bend and posterior force on the distal segment to match the nail shape.
Incorrect Answers:

Question 66

A 23-year-old woman has had vague left knee pain for the past 6 months. A radiograph and CT scan are shown in Figures 50a and 50b. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiographic appearance of the lesion emanating from the posterior cortex of the left distal femur is consistent with a surface bone-producing lesion; therefore, the most likely diagnosis is a parosteal osteosarcoma. In an osteochondroma, the cortex and medullary cavity of the lesion are in continuity with that of the native bone. A dedifferentiated chondrosarcoma has histologic components of a high-grade sarcoma plus a benign or low-grade malignant cartilage tumor. Tumoral calcinosis is characterized by amorphous calcium in the soft tissues and does not emanate from the bone itself. While often confused with parosteal osteosarcoma, myositis ossificans is usually more mature at the periphery of the lesion rather than the center. In addition, myositis ossificans does not involve the underlying cortex but remains separate from the bone.
REFERENCES: Unni KK: Dahlin’s Bone Tumors: General Aspects and Data on 11,087 Cases, ed 5. Philadelphia, PA, Lippincott-Raven, 1996, pp 185-196.
Okada K, Frassica FJ, Sim FH, Beabout JW, Bond JR, Unni KK: Parosteal osteosarcoma. A clinicopathological study. J Bone Joint Surg Am 1994;76:366-378.

Question 67

What cell type causes the bone destruction in metastatic lesions?

Explanation

DISCUSSION: The main consequence of tumor invading the bone is activation of both osteoblasts and osteoclasts. However, the osteoclastic effect predominates in the majority of tumors early after the invasion of bone by tumor cells, causing resorption of bone.
REFERENCES: Cramer SF, Fried L, Carter KJ: The cellular basis of metastatic bone disease in patients with lung cancer. Cancer 1981;48:2649-2660.
Clohisy DR, Palkert D, Ramnaraine ML, Pekurovsky I, Oursler MJ: Human breast cancer induces osteoclast activation and increases the number of osteoclasts at sites of tumor osteolysis. J Orthop Res 1996;14:396-402.

Question 68

A defect in the gene coding for fibrillin-1 would lead to which diagnosis? Review Topic

Explanation

A defect in fibrillin-1 is the underlying cause of Marfan Syndrome.
Marfan Syndrome is a genetic disorder of connective tissue typically caused by a mutation in the gene coding for the fibrillin-1 protein. Affected patients are typically very tall with long limbs and thin fingers and toes. Marfan Syndrome patients have many common features including ectopic lens, aortic root dilation, scoliosis, protrusio acetabuli, and ligamentous laxity.
Shirley et al. present a review of Marfan Syndrome with emphasis on the musculoskeletal manifestations including ligamentous laxity, protrusio acetabuli, and scoliosis. They note that scoliosis in these patients, when compared to those with idiopathic scoliosis, commonly progresses faster, is more resistant to bracing, and has a higher association with dural ectasia.
Dean presents a review of Marfan Syndrome and its underlying genetic cause of a mutation in fibrillin. They state that diagnosis can be made using the Ghent nosology (see Illustration A) which can diagnose or rule out the condition in 86% of patients. They caution using these criteria in young children as some features of Marfan Syndrome may not present until later ages.
Illustration A is a summary of the 2010 Revised Ghent nosology for diagnosing Marfan Syndrome.
Incorrect Answers:

Question 69

A 43-year-old woman has had pain in the left hip for the past 2 months. A radiograph, CT scan, MRI scan, and biopsy specimens are shown in Figures 16a through 16e. What is the most likely diagnosis?

Explanation

DISCUSSION: The imaging studies are consistent with a chondrosarcoma. The radiograph shows a radiolucent lesion in the pelvis, and there are stippled calcifications on the CT scan. The histology shows a low-grade cellular hyaline cartilage neoplasm with stellate, occasionally binucleated chondrocytes. Enchondroma has a more benign histologic appearance.
REFERENCE: Mirra JM, Gold R, Downs J, Eckardt JJ: A new histologic approach to the differentiation of enchondroma and chondrosarcoma of the bones: A clinicopathologic analysis of 51 cases. Clin Orthop 1985;201:214-237.

Question 70

According to Musculoskeletal Infection Society (MSIS) guidelines, which set of patient laboratory study results fits the definition of chronic prosthetic joint infection?

Explanation

DISCUSSION:
The MSIS definition of periprosthetic joint infection was updated in 2014 with two major and six minor criteria. The presence of one major criterion or three minor criteria is diagnostic for infection. The major criteria are two positive cultures with the same organism or a draining sinus tract. The current MSIS minor criteria are 1) an elevated ESR (more than 30 mm/hr) and CRP level (more than 10 mg/L), 2) an elevated synovial WBC count (more than 3,000 cells per/microliter), 3) an elevated synovial fluid polymorphonuclear count (more than 80%), 4) a positive histological analysis of periprosthetic tissue, and 5) a single positive culture.

Question 71

A 52-year-old man with a BMI of 40 and primary osteoarthritis undergoes total hip arthroplasty through a posterolateral approach. To retract the femur anteriorly when exposing the acetabulum, the surgeon places a sharp curved retractor over (anterior to) the anterior inferior iliac spine. Pulsatile bleeding is encountered. A branch of which artery has been injured?

Explanation

DISCUSSION

Video 182 for reference
The femoral artery crosses the hip joint anterior to the anterior hip capsule. The medial femoral circumflex artery enters the joint along the route of the obturator externus. The obturator artery enters the hip joint beneath the transverse acetabular ligament. The iliac circumflex vessel arises superior to the hip joint.

RESPONSES FOR QUESTIONS 183 THROUGH 188
For each clinical scenario described below, identify the corresponding anteroposterior pelvic radiographic image shown above.

Question 72

Which of the following structures is most commonly involved in lateral epicondylitis?

Explanation

DISCUSSION: The most common specific site of involvement is the origin of the extensor carpi radialis brevis. It is usually caused by overuse activities, such as the eccentric overload exhibited during a backhand in tennis. In most patients, the characteristic friable, grayish tissue described as angiofibroblastic hyperplasia or hyaline degeneration is seen at the extensor carpi radialis brevis origin.
REFERENCES: Nirschl RP: Elbow tendinosis/tennis elbow. Clin Sports Med 1992;11:851-870.
Regan W, Wold LE, Coonrad R, Morrey BF: Microscopic histopathology of chronic refractory lateral epicondylitis. Am J Sports Med 1992;20:746-749.

Question 73

Preventing "missed" femoral neck fractures associated with ipsilateral femoral shaft fractures is best achieved with

Explanation

DISCUSSION
Ipsilateral femoral neck and shaft fractures occur in up to 6% of femur fractures. A femoral neck fracture is often vertical and nondisplaced. A high degree of suspicion is necessary to avoid "missed" femoral neck fractures in patients with this condition. Although an examination and dedicated hip radiographs help to avoid missed injuries, a significant decrease in missed
injuries has been described with the use of thin-cut pelvic CT images. In patients who undergo trauma, a pelvic CT scan is often performed to assess for associated injuries and is easily reviewed to examine the femoral neck. Although MRI is advocated to identify isolated occult femoral neck fractures, CT has been described as the method of choice with which to identify ipsilateral femoral neck and shaft fractures in the trauma population. Currently, no literature supports the use of MRI in this population.
RECOMMENDED READINGS
Tornetta P 3rd, Kain MS, Creevy WR. Diagnosis of femoral neck fractures in patients with a femoral shaft fracture. Improvement with a standard protocol. J Bone Joint Surg Am. 2007 Jan;89(1):39-43. PubMed PMID: 17200308.View Abstract at PubMed
Kuhn KM, Agarwal A. Femoral fractures. In: Cannada LK, ed. Orthopaedic Knowledge Update

Question 74

A 5-year-old girl sustains an isolated injury to the right shoulder area after falling off the monkey bars. Examination reveals intact neurovascular function in the extremity distally, but she is quite uncomfortable. An AP radiograph of the proximal humerus is shown in Figure 24. Her parents state that she is a very talented gymnast. Considering her age and potential athletic career, management should consist of

Explanation

DISCUSSION: In this age group, bayonet apposition can produce very good results. Healing occurs rapidly, and remodeling usually is complete in less than 1 year. All of the other methods have significant risks of complications and are unnecessary for this fracture.
REFERENCES: Martin RF: Fractures of the proximal humerus and humeral shaft, in Letts RM (ed): Management of Pediatric Fractures. New York, NY, Churchill Livingstone, 1994,

pp 144-148.
Sanders JO, Rockwood CA Jr, Curtis RJ: Fractures and dislocation of the humeral shaft and shoulder, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 937-939.

Question 75

Which of the following factors has been shown to increase the risk of peroneal tendon pathology in patients who have undergone posterior plating of lateral malleolar fractures?

Explanation

Low plate positioning with a prominent screw head in the most distal hole of the plate was shown to be correlated with peroneal tendon lesions. Distal plate placement in the absence of prominent screws was not associated with tendon lesions. Trimmed plates, locked plates, and uncontoured plates have not been shown to increase the risk of peroneal tendon pathology.

Question 76

Figure 51 shows an arthroscopic view of the patellofemoral joint from an inferolateral portal. The arrow points to which of the following structures? Review Topic

Explanation

Synovial folds or plicae are the result of incomplete or partial resorption of the synovial membranes during fetal development of the knee. The arthroscopic view shows a medial patellar plica, which has been noted in 5% to 55% of all individuals but becomes symptomatic in only a small number of patients. Symptoms may include crepitus, pain, snapping, and swelling and often respond to nonsurgical management.

Question 77

Figure 11 shows the radiograph of a 3-year-old girl who sustained a proximal radius injury. Appropriate initial management should include

Explanation

DISCUSSION: The patient has a displaced radial neck fracture. Displaced radial neck fractures with angulation of more than 30° to 45° require reduction. Methods of attempted closed reduction include wrapping the arm with an Esmarch’s bandage and applying direct pressure over the maximum deformity of the radial head. More aggressive methods include a Kirschner wire used as a joystick or intramedullary reduction as described by the Metaizeau technique. Open reduction should be avoided because of complications such as stiffness or osteonecrosis. Indications for open reduction are irreducible displacement of more than 45° with severe restriction of forearm rotation.
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.
Radomisli TE, Rosen AL: Controversies regarding radial neck fractures in children. Clin Orthop 1998;353:30-39.
Skaggs DL, Mirzayan R: The posterior fat pad sign in association with occult fracture of the elbow in children. J Bone Joint Surg Am 1999;81:1429-1433.
Gonzalez-Herranz P, Alvarez-Romera A, Burgos J, et al: Displaced radial neck fractures in children treated by closed intramedullary pinning (Metaizeau technique). J Pediatr Orthop 1997;17:325-331.

Question 78

A tall, thin 17-year-old basketball player and his parents request an evaluation of his flexible (hypermobile) pes planus/planovalgus foot deformities. As part of his evaluation, the orthopaedic surgeon notes pectus excavatum, disproportionately long arms, and scoliosis. In addition to providing treatment of his feet, what test or evaluation should the patient be referred for? Review Topic

Explanation

The current diagnostic criteria for Marfan syndrome, called the Ghent criteria, are based on clinical findings and family history. The role of genetic testing in establishing the diagnosis is limited, because testing for FBN1 mutations is neither sensitive nor specific for Marfan syndrome. By making the diagnosis and arranging for cardiovascular evaluation, the orthopaedic surgeon can help prevent sudden death in these patients. The cardiovascular manifestations, including dissection and dilation of the ascending aorta and mitral valve prolapse, are responsible for nearly all of the precocious deaths of patients with Marfan syndrome. Patients with Marfan syndrome do have problems with protrusio acetabuli, scoliosis, and opthalmologic problems but the life-threatening problem that must be considered is the risk of cardiovascular sudden death.

Question 79

A 70-year-old woman with a body mass index (BMI) of 34 and a history of hypercholesterolemia has elected to undergo total hip arthroplasty. Her son recently learned he has factor V Leiden following an episode of pulmonary embolism. What are this patient's risk factors for thromboembolic disease?

Explanation

DISCUSSION:
Risk stratification is one of the most critical clinical evaluations to undertake before performing total joint arthroplasty. Many factors have been identified that increase the risk for venous thromboembolism (VTE) The major factors include previous VTE, obesity, type of surgery (such as total joint arthroplasty), hypercoagulable states, myocardial infarction, congestive heart failure, family history of VTE, and hormone replacement therapy. Hypercholesterolemia is not a risk factor for thromboembolic disease.

Question 80

A 70-year-old male with longstanding diabetic neuropathy sustains a fall down a flight of stairs and sustains the injury shown in Figures A and B. In the operating room, direct reduction of the fracture is performed. The syndesmosis is assessed and found to be intact. The fibula is fixed with a small fragment locking plate and the medial malleolus is fixed with screws. What is the next best step? Review Topic

Explanation

Ankle fractures in diabetics with neuropathy should be treated with enhanced fixation comprising stiff plates with syndesmotic screws, even in the absence of syndesmotic injury. Weightbearing should be delayed for 8 to 12 weeks after surgery, rather than 4-8 weeks (as for normal patients).
Diabetics with ankle fractures are prone to complications. Nonoperatively treated cases have up to a 50% incidence of skin breakdown in a cast. Surgically treated patients have up to 40% complication rate. Supplemental fixation can include include multiple syndesmotic screws, spanning external fixation, tibio-talar Steinmann pins, more rigid fibular plates, supplemental intramedulary fibular pinning. Weightbearing after surgery should be delayed (8-12weeks).
McCormack and Leith reviewed the complications in 26 diabetic ankle fractures. 19 patients had surgery. The incidence of complications was 42%. Two required amputation and died. None of the non-diabetic control group had complications. They concluded that in the older, diabetic patient with lower demands, especially if insulin-dependent, it may be preferable to accept a loss of reduction and malunion rather than risk the potentially devastating complications associated with operative intervention. If surgery is necessary, the results of this study provides a more accurate prognosis and allows for better discussion of surgical risks with the patient.
Roseunbaum et al polled AOFAS members on the treatment of diabetic ankle fractures. (1) For nondisplaced bimalleolar fracture with diabetic neuropathy, respondents preferred casting and nonweightbearing (NWB) for 8-12 weeks. (2) For Weber B fracture dislocation without neuropathy, without syndesmotic injury,
respondents preferred either 1/3 tubular or small fragment locking plates with syndesmotic screws and NWB for 8-12 weeks. (3) For bimalleolar fracture dislocation with neuropathy, without syndesmotic injury, respondents preferred small fragment locking plates with syndesmotic screws and NWB for 8-12 weeks.
Wukich and Kline reviewed the management of ankle fractures in diabetics. They found that neuropathy is more prevalent in patients with ankle fractures than without. They stress that 1% reduction in HbA1C results in 30% reduction in complication rate. Fracture healing is slower, callus is smaller, with less stiffness, tensile strength and collagen content. Amputation rate is up to 5% for patients treated operatively or nonoperatively. Complications are higher in patients with vasculopathy, neuropathy, or Charcot arthropathy.
Incorrect Answers:

Question 81

A year-old man who underwent left partial knee arthroplasty 6 months earlier was doing well until he experienced left knee pain and swelling for 4 weeks following a dental procedure. The left knee aspirate was bloody, with a white blood cell count of 8,000 and 70% neutrophils. Culture grew group B Streptococcus ( Granulicatella adiacens ), and serologies were elevated, with an erythrocyte sedimentation rate of 55 mm/h (reference range: 0 to 20 mm/h) and a C-reactive protein level of 24 mg/L (reference range: 08 to 1 mg/L). What is the best next step?

Explanation

DISCUSSION:
This complication is best addressed with either a single-stage or two-stage total knee arthroplasty. A recent report suggests that a single-stage arthroplasty can be effective, although many surgeons would perform a two-stage procedure with an articulating or static spacer. Arthroscopic would be non-effective, especially given 4 weeks of symptoms. Resection arthroplasty without a spacer would leave an unstable and poorly functioning extremity. Knee fusion should be used as a salvage procedure.
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Question 82

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

Explanation

Closed treatment is geared toward padding the heel externally. The horizontal talus may abut the tibia anteriorly. This is caused by a joint depression type fracture. The primary fracture line begins in the sinus tarsi and propagates obliquely across the posterior facet to the medial wall. The posterior facet is no longer under the talus and the talus settles into a position parallel to the ground. When the talus is parallel to the floor, it is often fully dorsiflexed, even with the foot in neutral position. The changes in the subtalar joint also affects the transverse tarsal joint. Because of the relative positions of the calcaneus at the cuboid (neutral) and the talus at the navicular (dorsiflexed) are different, this has the net effect of locking the transverse tarsal joint.

Question 83

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

Explanation

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

Question 84

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 85

Osteopenia is defined by the World Health Organization (WHO) as a bone mineral density (BMD) that is

Explanation

DISCUSSION: Osteopenia, decreased bone mass without fracture risk as defined by the WHO criteria for diagnosis of osteoporosis, is when a woman’s T-score is within -1 to -2.5 SD.

The T-score represents a comparison to young normals or optimum peak density. The Z-score represents a comparison of BMD to age-matched normals. Measurements of bone mineral density (BMD) at various skeletal sites help in predicting fracture risk. Hip BMD best predicts fracture of the hip, as well as fractures at other sites.
REFERENCE: Kanis JA, Johnell O, Oden A, et al: Risk of hip fracture according to the World Health Organization criteria for osteopenia and osteoporosis. Bone 2000;27:585-590.

Question 86

A 21-year-old man who was injured in a snowboarding accident 18 months ago now reports wrist pain. An MRI scan is shown in Figure 37. Based on the image findings, what is the most likely diagnosis?

Explanation

DISCUSSION: The coronal MRI scan of the wrist shows the scaphoid. There is a subtle fracture line with a step-off at the radial surface consistent with a nonunion. The signal intensity is markedly different between the two fragments of the scaphoid. This strongly suggests osteonecrosis. Preiser’s disease is osteonecrosis typically involving most or all of the scaphoid. Kienbock’s disease involves the lunate. Intraosseous ganglia are easily diagnosed on MRI but typically have a fluid-filled area surrounded by denser bone in the periphery. Scapholunate dissociation can be seen on MRI as an injury to the scapholunate ligament and widening of the scapholunate interval, neither of which is seen on this image.
REFERENCE: Perlik PC, Guilford WB: Magnetic resonance imaging to assess vascularity of scaphoid nonunions. J Hand Surg Am 1991;16:479-484.

Question 87

A 23-year-old woman with a history of bilateral recurrent ankle sprains, progressive cavovarus feet, and a family history of high arches and foot deformities is seen for evaluation. Management consisting of bracing and physical therapy has been poorly tolerated. Heel varus is partially corrected with a Coleman block. There are thick calluses under the first metatarsal heads. Sensation to touch and

Explanation

The history and presentation are consistent with type I Charcot-Marie-Tooth (CMT), the most common form of hereditary peripheral motor sensory neuropathy. Type I CMT is the most common, occurring in 50% of patients with CMT, and is characterized by marked slowing of motor neuron velocities, and inconsistent slowing of sensory neuron velocities. Peroneus longus to brevis transfer is indicated to release the overpull of the peroneus longus, and restore the eversion and dorsiflexion function of the peroneus brevis. A lateralizing calcaneal osteotomy with proximal translation is indicated to correct heel varus given that the Coleman block only allows for partial correction of heel varus. Proximal translation of the posterior tuber corrects for the increased calcaneal dorsiflexion, improving the lever arm for the triceps surae. A medial column closing wedge osteotomy is often required to correct a rigid, or semirigid plantar flexed first ray to allow for a balanced, plantigrade foot. Triple arthrodesis is indicated for rigid, arthritic hindfoot deformities. Transfer of the posterior tibial tendon to the tibialis anterior is not indicated since it is an out-of-phase transfer. Transfer of the posterior tibial tendon, when performed, should be to the lateral aspect of the foot. A medializing calcaneal osteotomy would accentuate the heel varus. There is no indication for Botox in CMT; Botox injection of the calf would further weaken push-off during gait. Bracing of a progressive semirigid or rigid deformity is not recommended.

Question 88

What fibers of the anterior cruciate ligament tighten with extension of the knee? Review Topic

Explanation

The anterior cruciate ligament consists of two functional bundles: anteromedial and posterolateral. During extension of the knee, the posterolateral bundle becomes taut. In flexion, the anteromedial bundle is tight and the posterolateral bundle relaxes. Traditionally, anterior cruciate ligament reconstruction primarily recreates the anteromedial bundle. Recently, techniques for double bundle reconstruction have been described to recreate the normal anatomic relationship of the two bundles.

Question 89

Six weeks after onset, what is the most clearly accepted indication for surgical management for lumbar disk herniation?

Explanation

DISCUSSION: In the absence of a cauda equina syndrome or progressive weakness, the best indication for surgical management is refractory radicular pain. Surgical decision-making should not be based on the size of the herniation. Large extruded herniations tend to resolve more predictably than smaller herniations. Stable motor weakness and numbness resolve similarly in both surgical and nonsurgical management, although surgery hastens the process. When intractable radicular pain is the strict indication for surgery, surgical intervention provides substantial and more rapid pain relief than nonsurgical care.
REFERENCES: Rhee JM, Schaufele M, Abdu WA: Radiculopathy and the herniated lumbar disc: Controversies regarding pathophysiology and management. J Bone Joint Surg Am 2006;88:2070-2080.
Atlas SJ, Keller RB, Wu YA, et al: Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the Maine lumbar spine study. Spine 2005;30:927-935.

Question 90

In recurrent posterior shoulder instability, what is the recommended approach to the posterior capsule? Review Topic

Explanation

Using an infraspinatus-splitting incision allows for excellent exposure of the posterior capsule and minimizes the risk of injury to the axillary nerve which lies inferior to the teres minor in the quadrilateral space.

Question 91

Figure 3a is the initial radiograph of a 19-year-old man who sustained a closed clavicle fracture. Figures 3b and 3c show postoperative radiographs. If the patient had been treated nonsurgically, which of the following would most likely occur?

Explanation

Recent studies comparing surgical treatment with nonsurgical management in displaced clavicle fractures have revealed a decreased rate of malunion and nonunion with surgery. In addition, significant malunions can lead to functional deficits at the shoulder. Thus, with open reduction and internal fixation and anatomic or near-anatomic reduction, there should be a higher likelihood of normal shoulder strength and function. Infection and local sensory deficits would not be expected with nonsurgical management, whereas surgical treatment has a small risk of infection and a high likelihood of sensory deficits from iatrogenic damage to the supraclavicular nerves.

Question 92

What type of brace is shown in Figures 22a and 22b?

Explanation

DISCUSSION: The figures show a Charcot restraining orthotic walker (CROW). This brace has been used as a customized total contact fit removable brace to maintain foot alignment as the patient evolves from Eichenholz stage 1 to Eichenholz stage 3 Charcot arthropathy.
REFERENCES: Mehta JA, Brown C, Sargeant N: Charcot restraint orthotic walker. Foot Ankle Int 1998;19:619-623.
Morgan JM, Biehl WC III, Wagner FW Jr: Management of neuropathic arthropathy with the Charcot restraint orthotic walker. Clin Orthop 1993;296:58-63.

Question 93

A 15-year-old boy with a type I hereditary sensory motor neuropathy (Charcot-Marie-Tooth disease) reports recurrent ankle sprains and significant pain in the hindfoot and midfoot despite orthotic management. Examination reveals that he walks with a drop foot and has dynamic clawing of the toes. Clinical photographs of the left foot are shown in Figure 7. Management should consist of

Explanation

DISCUSSION: The clinical photographs show a patient with a type I hereditary sensory motor neuropathy who has cavus feet with a flexible hindfoot. The Coleman block test shows that the hindfoot corrects into valgus. To prevent progressive cavus, patients with this condition may benefit from soft-tissue releases at a younger age while the foot is flexible. Once there is fixed deformity, combined soft-tissue and bone procedures usually are necessary. Metatarsal osteotomies will correct the cavus, but will do nothing for the drop foot. Transfer of the extensor hallucis longus to the neck of the first metatarsal and modified transfer of the extensor digitorum longus to the dorsum of the foot will prevent further claw toes and improve foot dorsiflexion. Anterior transfer of the posterior tibialis tendon will also aid in dorsiflexion. Calcaneal osteotomy should be reserved for fixed hindfoot varus that does not correct with block testing, and triple arthrodesis should be avoided as long as possible because the long-term outcome is poor.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1999, pp 235-245.
Coleman SS: Complex Foot Deformities in Children. Philadelphia, Pa, Lea & Febiger, 1983, pp 147-165.
Thometz JG, Gould JS: Cavus deformity, in Drennan JC (ed): The Child’s Foot and Ankle. New York, NY, Raven Press, 1992, pp 343-353.

Question 94

Steroids are thought to prevent neurologic deterioration after traumatic spinal cord injury by which of the following mechanisms? Review Topic

Explanation

The proposed mechanisms by which steroids such as methylprednisolone are thought to prevent neurologic deterioration by limiting secondary insult, include: decreasing the area of ischemia in the cord, reducing TNF-alpha expression and NF-kB binding activity, decreasing free radical oxidation and thus stabilizing cell and lysosomal membranes, and checking the influx of calcium into the injured cells, thus reducing cord edema.

Question 95

A 22-year-old patient has had severe groin pain for many months and is unable to engage in any physical activity. The AP radiograph of the pelvis shows minimal arthritis. The lateral radiograph of the hip is shown in Figure 33a. An MR-arthrogram is shown in Figure 33b. What is the most appropriate treatment at this stage? Review Topic

Explanation

The patient has femoroacetabular impingement. The prominence on the femoral neck has resulted in a labral tear and detachment. An MR-arthrogram is the most appropriate modality for diagnosis of a labral tear. The diagnosis of a labral tear per se is not an indication for surgical intervention because the natural incidence of this condition is not known. Labral debridement without addressing the underlying anatomic abnormality is likely to result in a suboptimal outcome. The most appropriate treatment, when indicated, is shaving down of the femoral neck to remove the bony prominence and attachment of the labrum. Femoral osteotomy has no role in the treatment of this condition. The patient has minimal arthritis; therefore, arthroplasty is not indicated.

Question 96

Figure 10 shows patellar radiographs of a 68-year-old woman who underwent bilateral total knee arthroplasty 2 months ago. Following a recent fall onto the left side, she now reports anterior pain in the left knee. A CT scan shows that the femoral and tibial components are appropriately externally rotated and radiographs show acceptable axial alignment and no evidence of loosening. What is the most appropriate treatment option?

Explanation

DISCUSSION: Treatment of patellofemoral instability after total knee arthroplasty (TKA) is directed by its etiology. In instances of component malpositioning, revision of one or both components is indicated.
If the components are determined to be in satisfactory position, soft-tissue procedures can be pursued. Lateral retinacular release is usually the first soft-tissue procedure used to improve patellofemoral mechanics. In this patient, the patellar fracture fragment is so small that it can be excised. Distal realignment is not usually used as the first line of treatment for patellar maltracking following TKA.
REFERENCES: Fehring TK, Christie MJ, Lavemia C, et al: Revision total knee arthroplasty: Planning, management, and controversies. Instr Course Lect 2008;57:341-363.
Patel J, Ries MD, Bozic KJ: Extensor mechanism complications after total knee arthroplasty. Instr Course Lect 2008;57:283-294.

Question 97

Figures 1 and 2 are intrasurgical photographs from the posterolateral viewing portal that were taken at the beginning and end of a right shoulder arthroscopic procedure performed on a 54-year-old man. This technique demonstrates superior results compared with traditional arthroscopic techniques when evaluating which outcome?

Explanation

The images reveal a medium-sized tear of the rotator cuff. As more clinical studies are published comparing double-row with single-row rotator cuff repair, it has become clear that the retear rate is lower with a double-row construct for small and medium-sized tears. This may be attributable to the stronger time-zero repair construct that double-row repair provides. No study to date has demonstrated a significant difference in clinical outcomes (functional and pain scores at any time) or time to healing between the two techniques.

Question 98

Risks associated with vertebral compression fractures in the elderly population can be defined by which of the following? Review Topic

Explanation

In the US, about 1.5 million fractures occur annually. Each year, 250,000 new vertebral compression fractures are diagnosed, and more than 80% of these are related to weakened vertebral bodies secondary to osteoporosis. Patients with vertebral
fractures are more likely to fall and are five times more likely to sustain subsequent fractures than individuals without such a fracture. Analysis of data from Medicare patients with a vertebral fracture had an overall mortality rate that was approximately twice that of the matched controls. The survival rates following a fracture diagnosis, as estimated with the Kaplan-Meier method, were 53.9%, 30.9%, and 10.5% at 3, 5, and 7 years, respectively which were significantly lower than the rates for the controls. The mortality risk following a fracture was greater for men than for women. The mortality risk was greater when the fracture occurred at a younger age. The adjusted hazard ratio was 1.8 compared to the non-fracture group

Question 99

A 23-year-old man cut the dorsal and ulnar aspects of his long finger on a table saw. The dorsal and ulnar skin over the middle phalanx is missing, with a 2-cm x 2-cm area of loss. There is a 50% loss of the extensor tendon (ulnar), and the remaining tendon has no tenosynovium. The physician should recommend irrigation and debridement and

Explanation

EXPLANATION:
The patient has exposed bone and tendon and a partial tendon injury. The remaining radial tendon is satisfactory and no tendon repair is required. The exposed bone and tendon necessitate vascularized tissue coverage. A reversed cross-finger flap from the ring finger is suitable for coverage of the dorsal surface of an adjacent digit.

Question 100

A 10-year-old boy tripped as he was running down a hill, felt a painful pop in his right knee, and was unable to bear weight on the involved lower extremity. Examination reveals a tense effusion and an extensor lag of the right knee. Figures 36a and 36b show AP and lateral radiographs. Management should consist of

Explanation

DISCUSSION: The examination and radiographs are consistent with a sleeve fracture of the patella, which is an avulsion fracture of the distal pole of the patella with a disruption of the extensor mechanism. Treatment is open reduction and internal fixation of the patella, and repair of the extensor mechanism.
The distal fragment can be much larger than it appears on the radiographs because it consists largely of cartilage.
REFERENCES: Wu CD, Huang SC, Liu TK: Sleeve fracture of the patella in children: A report of five cases. Am J Sports Med 1991;19:525-528.
Grogan DP, Carey TP, Leffers D, et al: Avulsion fractures of the patella. J Pediatr Orthop 1990; 10:721 - 730. Question 37
When addressing a proximal intertrochanteric or subtrochanteric fracture in a juvenile with open growth plates, the arterial supply from what artery at the neck must be preserved?
Lateral femoral circumflex
Medial femoral circumflex
Superior gluteal
Inferior gluteal
Obturator
DISCUSSION: The medial femoral circumflex artery supplies blood to the femoral head. Its position along the posterior-superior femoral neck places this structure at risk with intramedullary nailing of the femur. Therefore, lateral entry through the greater trochanter is preferred when intramedullary fixation is performed.
REFERENCES: Gordon JE, Swenning TA, Burd TA, et al: Proximal femoral radiographic changes after lateral transtrochanteric intramedullary nail placement in children. J Bone Joint Surg Am 2003;85:1295- 1301.
Green NE, Swiontkowski MF: Skeletal Trauma in Children, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 419-424.

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

Nonossifying fibroma
Fibrous dysplasia
Unicameral bone cyst
Osteogenesis imperfecta
Osteofibrous dysplasia

Correct Answer: Osteofibrous dysplasia

Explanation:

Question 2:

Options:

His younger brother’s hip pain is almost certainly attributable to some other cause
His younger brother’s hip pain likely represents established osteoarthritis of the hip
His younger brother’s hip pain may be related to FAI
There is no known genetic influence in the etiology of FAI

Correct Answer: His younger brother’s hip pain may be related to FAI

Explanation:

DISCUSSION
Evidence suggests that FAI is more common in siblings of patients with FAI, particularly those with a CAM deformity. It is unlikely this patient has well-established osteoarthritis, even in the presence of FAI.
CLINICAL SITUATION FOR QUESTIONS 145 THROUGH 147
Figures 145a and 145b are the radiographs of a 56-year-old man who has had persistent pain in his right groin since undergoing primary total hip surgery 11 months ago. His erythrocyte sedimentation rate (ESR) is 38 mm/h (reference range [rr], 0-20 mm/h) and C-reactive protein (CRP) level is 28 mg/L (rr, 0.08-3.1 mg/L). A hip aspiration performed while the patient was taking antibiotics demonstrated 3200 white blood cells/µL with no growth. Treatment should consist of

Question 3:

30%

Options:

40%
50%
>50%

Correct Answer: 40%

Explanation:

This patient has likely lost 30-40% of his blood volume and is likely in stage III hemorrhagic shock on the basis of his heart rate, blood pressure, and urine output.
Initial assessment of a trauma patient should involve evaluation of airway, breathing and circulation. An average adult has approximately 5 L of circulating blood volume. Class III and IV hemorrhagic shock, approximated by loss of greater than 30% of blood volume, typically requires resuscitation with fluids and blood products. Lactate level (normal <2.5) is typically the most sensitive indicator of adequate perfusion.
According to ATLS guidelines, the emphasis of the initial assessment is to assume the worst injury and begin treatment before diagnosis. In cases of hemorrhagic shock, treatment involves aggressive resuscitation with crytalloid and/or blood products.
Illustration A is a chart showing the physiological changes associated with different levels of hemorrhagic shock
Incorrect Answers:
1: Blood loss of <15% typically leads to no changes in vital signs
2: Blood loss of 15-30% typically leads to heart rate >100 and diminished urine output
4, 5: Blood loss of greater than >40% typically leads to heart rate >140, decreased blood pressure and negligible urine output.
OrthoCash 2020
Which of the following fracture patterns would be most appropriately treated with open reduction and internal fixation with posteromedial and lateral plates via dual incisions?
The patient in Figure D has a bicondylar tibial plateau fracture with a posteromedial fracture fragment, which is an indication for lateral and posteromedial plating via dual incisions.
Bicondylar tibial plateau fractures are typically treated with open reduction internal fixation. Studies have shown that the posteromedial fragment is common in bicondylar tibial plateau fractures. Standard lateral implants do not gain adequate screw purchase in posteromedial bone. Posteromedial incisions using the interval between the semimembranosus and medial head of the gastrocnemius can be used to gain access to the fragment and provide exposure to place a posteromedial plate.
Barei et al. reviewed 57 OTA C-type bicondylar tibial plateau fractures, and found the presence of a posteromedial fragment in 74% of cases. They suggest
the use of alternate methods of fixation for the posteromedial fragment rather than lateral fixed-angle plates alone.
Higgins et al. reviewed 111 patients with bicondylar tibial plateaus that underwent CT scan evaluation. They found the incidence of a posteromedial fragment in 59% of the patients and on average accounted for 25% of the articular surface.
Barei et al. reviewed 83 patients treated with dual incisions for fixation of bicondylar tibial plateau fractures. They found deep infections in 8.4% of patients. Satisfactory articular reduction was found in 62% of patients, satisfactory coronal alignment in 91% of patients, satisfactory sagittal alignment in 72%, and satisfactory condylar width in 98%.
Figure A shows an AP and lateral radiograph of a split/depressed lateral tibial plateau fracture. Figure B shows an AP and lateral radiograph of a proximal third tibial shaft fracture with a proximal fibula fracture. Figure C shows an AP and lateral radiograph of a medial plateau fracture with articular depression. Figure D shows an AP and lateral radiograph of a bicondylar tibial plateau fracture. Figure E shows an AP and lateral radiograph of a tibial tubercle fracture in a tibia with open physes.
Incorrect Answers:
OrthoCash 2020
Figure A shows the radiographs of a 87-year-old patient after a fall from standing. He lives in a nursing home and uses a walker to transfer from bed to chair. His past medical history includes recurrent urinary tract infections, congestive heart failure, angina and diabetes. Which of the following factors is associated with the best postoperative outcome in this patient?
Immediate surgical intervention
Postoperative epidural analgesia
Postoperative antibiotics
Pre-operative medical optimization
Choosing total hip arthroplasty instead of hemiarthroplasty
Corrent answer: 4
Geriatric patient with hip fractures tends to have a number of coexisting medical conditions that impact surgical risk. A successful pre-operative medical evaluation has the greatest impact on surgical outcomes in this patient population.
Patients with complex past medical histories are at great risk of complications with surgery. This helped to drive the formation of the ASA classification system as a way to score patients out of 5 based on their anesthetic and surgical risks. Patients with significant systemic disease (ASA III and IV) have shown to demonstrate poorer outcomes as compared to patients with less severe medical comorbidities (ASA I and II).
Egol et al. looked at factors that impact the outcomes of hip fractures in geriatric patients. They showed that cardiac and pulmonary complications were most frequent complications post-operatively. It was stated that early mobilization and pre-operative evaluations have the greatest impact on outcomes.
Parvizi et al. looked at the thirty-day mortality following hip arthroplasty for acute fracture. They reviewed a database of 7774 consecutive patients that underwent hip arthroplasty for the treatment of an acute fractures. The overall mortality was 2.4%. Risk factors were found to be cemented implants, female patients, elderly patients, and patients with cardiorespiratory comorbidities.
Roberts et al reviewed the 2015 AAOS Clinical Practice Guideline: Management of Hip Fractures in the Elderly. Although pre-operative medial optimization was not mentioned in this review, there is strong evidence to support an interdisciplinary care program for patients with hip fractures.
Figure A shows a displaced left femoral neck fracture. Incorrect Answers:
more than 24-48 hours and a higher 1-year mortality rate. However, In patients with with more than 3 medical comorbidities, medical optimization has a greater impact on post-operative outcomes than time to surgery.
OrthoCash 2020
A 36-year-old male sustains severe injuries as a result of a motor vehicle collision. After 5 days, the patient is stabilized and transferred to your facility for continued management. After obtaining appropriate imaging, including the images shown in Figures A, B and C the patient should be given which of the following mobility restrictions?
Touch-down weight bearing on the left lower extremity, non-weightbearing on the right lower extremity
Weight bearing as tolerated on the left lower extremity, non-weightbearing on the right lower extremity
Non-weight bearing on the left lower extremity, non-weightbearing on the right lower extremity
Touch-down weight bearing on the left lower extremity, weight bearing as tolerated on the right lower extremity
Weight bearing as tolerated on the left lower extremity, weight bearing as tolerated on the right lower extremity
Figures B and C shows a stable, impacted lateral compression (LC) type I injury, which can be treated with immediate mobilization without restrictions. The right lower extremity has a pilon fracture, which should be treated with non-weight bearing.
LC-I injuries are stable patterns, as they involve an impaction injury to the anterior sacrum, which has some inherent stability. In addition, the posterior sacro-iliac (SI) soft tissue structures remain intact, which provides critical stability during immediate mobilization.
The reference by Tile is a review article on the principles of management of these injuries, and he reviews how the Tile classification system is important to help determine surgical need and where the stabilization is required. For the stable LC-1 type injury, no fixation is required.
Incorrect Answers:
OrthoCash 2020
A 24-year-old male sustains the fracture dislocation shown in Figure A. How is this fracture pattern best classified?
Moore I
Moore II
Schatzker III
Schatzker V
OTA type 41B3
Corrent answer: 2
Figure A shows a Moore Type II fracture. Moore type II fractures consist of fractures involving the entire tibial condyle, where the fracture line begins in the opposite compartment and extends across the tibial eminence.
A number of classification systems are used to describe tibial plateau fractures. The main classification systems that are widely used include Schatzker, AO/OTA, Hohl and Moore. The Moore classification describes high energy fracture-subluxation injuries of the knee. This is thought to have clinical implications as the type of fracture pattern can indicate an associated soft-
tissue injury.
Moore retrospectively reviewed over a 1000 proximal tibia fractures to devise a classification systems based on the characteristic of five types of tibia plateau fracture patterns. He believed this system helped to better understand knee instability and concomitant soft-tissue injury. For example, Moore Type III fractures (rim avulsion) are associated with a high rate of neurovascular injury.
Figure A shows a fracture involving the entire tibial condyle. Illustration A shows a schematic diagram of the Moore classification (I - V). Illustration B shows a table that describes the Moore classification (I - V).
Incorrect Answers:
OrthoCash 2020
A 19-year-old male football player plants and twists his right lower extremity sustaining a spiral fracture of his distal third tibial shaft. Of the following images, which is most commonly associated with distal third spiral tibial shaft fractures.
The patient has a spiral distal tibial shaft fracture. Spiral distal tibial shaft fractures are commonly associated with intraarticular fracture extension, usually in the form of a posterior malleolus fracture.
Spiral distal third tibial shaft fractures need to be evaluated for intraarticular extension prior to operative management. As this can be missed on x-rays, a CT scan of the ankle is recommended to identify this associated injury. This is important when intramedullary fixation is used for definitive management, as nail insertion can displace a previously non displaced intraarticular fracture.
Anteroposterior screw fixation prior to nailing may be useful in these cases.
Boraiah et al. found that in 62 patients with spiral distal tibial fractures, 39% (24 patients) had a posterior malleolus fracture. They recommended CT evaluation of the ankle to prevent missed intraarticular fractures.
Hou et al. found a posterior malleolus fracture in 9.7% (28 out of 288 cases) of patients with tibial shaft fractures. They recommended CT or MRI evaluation of the ankle prior to surgery.
Figure A shows an axial CT scan of a right ankle with a posterior malleolus
fracture. Figure B shows an AP radiograph of a right ankle with a vertical medial malleolus fracture. Figure C shows a coronal CT scan of a right ankle with a Tillaux fracture. Figure D shows a sagittal CT scan of a right ankle with a comminuted talus fracture. Figure E shows a lateral radiograph of a right knee showing a knee dislocation. Illustration A shows an AP radiograph of a left distal third spiral/oblique tibial shaft fracture. Illustration B shows a lateral radiograph of a left distal third spiral/oblique tibial shaft fracture. Illustration C shows a sagittal CT of a distal third spiral/oblique tibial shaft fracture with a posterior malleolus fracture.
Incorrect Answers:
OrthoCash 2020
A 67-year-old female patient presents with increasing right hip/thigh pain over the past three months, which is now recalcitrant to anti-inflammatories. There is no history of trauma or constitutional symptoms. Her past medical history consists of hypertension, coronary artery disease, osteoporosis and gastric reflux. Physical examination reveals mild pain at the extremes of range of motion of the hip and a painful right sided limp. A radiograph of the right hip is seen in Figure
What would be the most appropriate treatment for this patient at this time?
Observation only
Referral to physiotherapy
MRI spine and hip
Total hip arthroplasty
Intramedullary femoral nail
Corrent answer: 5
This osteoporotic female patient is presenting with subtrochanteric lateral cortical thickening and hip pain. This is consistent with an insufficiency fracture of the femur secondary to use of bisphosphonate medication for treatment of osteoporosis. The most appropriate treatment would be intramedullary femoral nail fixation.
Bisphosphonate medications have been shown to be associated with atypical (subtrochanteric) femur fractures. These patients often have prodromal hip pain and lateral cortical thickening on radiographs prior to fracture. In addition, there has shown to be a significantly increased risk of fracture in the presence of the “dreaded black line” that occurs at the site of thickening.
Lenart et al. examined a case series of patients using bisphosphonates for the treatment of osteoporosis. They identified 15 postmenopausal women who had
been receiving alendronate for a mean (±SD) of 5.4±2.7 years and who presented with atypical low-energy fractures. Cortical thickening was present in the contralateral femur in all the patients with this pattern.
Goh et al. retrospectively reviewed patients who had presented with a low-energy subtrochanteric fractures. They identified 13 women of whom nine were on long-term alendronate therapy. Five of these nine patients had prodromal pain in the affected hip in the months preceding the fall, and three demonstrated a stress reaction in the cortex in the contralateral femur.
Figure A shows a right hip radiograph with subtrochanteric lateral cortical thickening. There is mild arthritic changes in the hip. Illustration A shows a bone scan and radiographs of subtrochanteric lateral cortical thickening that resulted in fracture.
Incorrect Answers
OrthoCash 2020
A right-hand dominant female sustains a right proximal humerus fracture. The patient is provided a sling, and is recommended pendulum exercises with elbow range of motion to begin in 1 to 2
weeks. Which of the following would be an indication for surgical management?
Age greater than 70 years.
Fracture pattern in Figure A
Significant medical comorbidities.
Fracture pattern in Figure B
Fracture pattern in Figure C
The patient has been treated with non-operative management for her proximal humerus fracture. Operative management should be considered in patients with head splitting proximal humerus fractures and in those with dislocations that cannot be reduced.
Head splitting proximal humerus fractures should be treated with operative management. Open reduction internal fixation versus hemiarthroplasty are used to treat this type of fracture. Surgical management is also considered in proximal humerus fractures in young patients, in fractures where the greater tuberosity is displaced >5 mm, and in proximal humerus fractures associated with humeral shaft fractures.
Koval et al. studied 104 patients with one-part proximal humerus fractures treated non-operatively, and found 80% with good or excellent results. They also found that 90% of patients treated non-operatively had either no or mild pain about the shoulder at follow-up.
Lefevre-Colau et al. performed a randomized prospective study on 74 patients with an impacted proximal humerus fracture. One group was treated with early mobilization of the shoulder (within 3 days after the fracture) while the other group was immobilized for 3 weeks followed by physiotherapy. They concluded that early mobilization was safe and allowed for quicker return to functional use of the affected limb.
Figure A shows an AP radiograph of a right minimally displaced greater tuberosity proximal humerus fracture. Figure B shows AP and axillary radiographs of a right head split proximal humerus fracture that is posteriorly dislocated. Figure C shows an AP radiograph of a right minimally displaced Salter Harris II proximal humerus fracture. Illustration A shows an AP radiograph of a left valgus impacted proximal humerus fracture with a greater tuberosity fragment displaced >5mm treated with ORIF.
Incorrect Answers:
OrthoCash 2020
A 37-year-old male arrives to the trauma slot following a high-speed motorcycle crash. His Glasgow Coma score is 14 and his only orthopaedic injury is exhibited in Figure A. His current vital signs are a BP of 90/60, HR 120, and a lactate of 2.5 mMol/L. Other findings include a grade 1 splenic laceration and bilateral pulmonary contusions seen on chest radiograph. Which of the following has been suggested as an indication to perform damage control orthopedic care?
HR >110
Bilateral pulmonary contusions seen on chest radiograph
SBP = 90mmHg
Unilateral femur fracture
Lactate = 2.5 mMol/L
Pulmonary contusion severe enough to be diagnosed on chest radiograph alone is an indicator that the patient may benefit from damage control orthopaedics (DCO).
Despite the patient's overall stable nature, suffering pulmonary injury severe enough to be seen on x-ray alone suggests that temporary stabilization with staged definitive fixation may avoid potential morbidity.
Pape et al. review the evolution and balance of early total care (ETC) and DCO. Summarizing the literature, the authors report several standalone indicators that would justify DCO regardless of stable status. This includes: Injury Severity Score of greater than 40, Injury Severity Score of greater than 20 with chest trauma, multiple injuries with severe pelvic/abdominal trauma/ hemorrhagic shock, bilateral femoral fractures, pulmonary contusion noted on radiographs alone, hypothermia of less than 35 degrees C), and a head injury with an Abbreviated Injury Score of 3 or greater.
Figure A exhibits a right femoral shaft fracture. Illustration A exhibits a summarized table stating the criterion used to determine the condition of a polytrauma patient. (Table from Pape et al, PMID: 19726738)
Incorrect answers:
implement DCO.
OrthoCash 2020
A 24-year-old patient presents after a fall from the balcony of a third story building in which he landed on his feet. He reports lumbar back pain and numbness in his perineum region. Radiographs of his hips and pelvis are seen in Figure A, while CT images are shown in Figures B and C. How is this fracture pattern best classified?
Young-Burgess APC Type II
Young-Burgess LC Type I
"U" Type Spinopelvic Dissociation
Denis Zone-I
Denis Zone-II
This patient has a Denis zone-III "U" Type Spinopelvic Dissociation of the sacrum.
The Denis classification system for sacral fractures is based on anatomical fracture zones. Zone-III fractures involve the spinal canal and have a high rate of associated neurologic injury. It is important to recognize bilateral sacral
fractures with a transverse component, as this often causes spinopelvic discontinuity and possible cauda equina. The lack of mechanical continuity between the spine and pelvis will most likely require reduction and fixation for initial stability. There may also be a need for sacral decompression with fixation mechanisms given the onset of neurologic symptoms.
Mehta et al. reviewed sacral fractures. They report that patients with a transverse sacral fracture involving more proximal sacral segments (S1, S2, or S3) tend to have a higher prevalence of bladder dysfunction than do those involving distal sacral segments (S4 or S5).
Schildhauer et al. report the best way to visualize Denis zone-III "U" type fractures is to obtain a lateral view of the sacrum or sagittal reformatted images with a CT scan. Standard pelvic radiographs often miss this injury.
Figure A shows an AP pelvis with suggestion of sacral irregularities. No fracture pattern can be indentified. Figures B and C show CT scan images showing a "U" Type fracture pattern with angulation and translational displacement of the cephalad and caudad parts of the sacrum. Illustration A shows examples of complex sacral Denis zone-III fractures.
Incorrect Answers:
OrthoCash 2020
A 55-year-old male presents with the radiographs seen in Figures A and B after falling off his bike. Physical examination reveals an isolated, closed elbow injury. His limb is neurovascularly intact. Which complication would be most likely with surgical fixation of this injury?
Ulnar neuropathy
Posterior interosseous nerve injury
Early loss of fixation
Elbow flexion contracture
Avascular necrosis
This patient is presenting with a comminuted capitellar and trochlear fracture. If treated with open reduction internal fixation, the most likely post-operative complication would be elbow stiffness or contracture.
An axial compression force transmitted by the radial head to the capitellum with the elbow in a semiflexed position can result in a shear fracture of the anterior portion of the capitellum. AP, lateral, and radiocapitellar radiographs are recommended to identify these injuries. The lateral X-ray may reveal the “double arc” sign, which represents extension of the capitellum fracture into the trochlea. Extension of the fracture into the trochlea has important implications into the surgical approach to these injuries.
Ruchelsman et al. retrospectively reviewed the outcomes of sixteen patients with capitellar fractures treated with open reduction internal fixation. They found the presence of greater flexion contractures at the time of follow-up in elbows with Type-IV capitellar fractures. All fractures healed, and no elbows had instability or weakness with fixation.
Ring et al. retrospectively reviewed the outcomes of twenty one distal humerus articular fractures that were reduced and stabilized with implants buried beneath the articular surface. Ten patients required a second operation: (6) release of an elbow contracture; (2) treatment of ulnar neuropathy; (1) removal of hardware; (1) early loss of fixation.
Figures A and B show AP and lateral radiographs of the elbow with a comminuted fracture of the capitellum and trochlea. Note the “double arc” sign on the lateral view. Illustrations A and B show open reduction internal fixation of the fracture. Note fixation with multiple interfragmentary screws.
Incorrect Answers:
OrthoCash 2020
Figure A shows a radiograph of a 30-year-old male who underwent fixation of a left leg injury just over two years ago. He presents with persistent pain and drainage from the distal wound despite 4 months of oral antibiotics. He has no systemic symptoms. He has a past medical history of Grave's disease and Irritable Bowel Syndrome. What would be the best management at this stage?
Chronic suppressive, culture-directed, antibiotic therapy
Above knee amputation
Endocrine consultation, irrigation and debridement, removal of hardware and negative-pressure wound therapy
Irrigation and debridement, removal of hardware, over-reaming medullary canal, external fixation and culture-directed antibiotics
Irrigation and debridement, retention of hardware, acute bone grafting and culture-directed antibiotics
This is a case of fracture nonunion in the setting of chronic osteomyelitis and infected hardware. The best treatment option available would be irrigation and debridement, removal of hardware, ring external fixator and culture directed antibiotics.
The management of infected nonunion in the setting of chronic osteomyelitis is technically demanding. The aims of treatment are to eradicate the infection and obtain bone union. Non-surgical options are largely unsuccessful in patients with draining chronic osteomyeltis in the setting of infected hardware and nonunion. Surgical options involve incision and debridement of necrotic tissue followed by reconstruction of bone and possible soft tissue (to provide
healthy viable coverage). The most common techniques are ringed fixator/circular frames, staged intramedullary device with or without external fixator, free tissue transfer, or radical debridement, bone grafting, and fixation.
Motsitsi et al. reviewed the management of infected nonunion of long bones. They suggest that the Ilizarov technique is regarded as a standard treatment in infected nonunion of the tibia. When there is bone defect after debridement, the bone can be shortened or treated with bone transport.
Egol et al look at a series of patients with chronic osteomyelitis. Limb salvage should be attempted in all patients. The presence of a chronic draining sinus requires surgical debridement and culture directed antibiotics. Infected hardware should be removed. A two-stage strategy is the best and well-proven treatment option.
Figure A shows a intramedullary nail in the left tibia. There is a moderate amount of bone loss at the fracture site with mixed sclerotic bone suggestive of osteomyelitis.
Incorrect Answers:
OrthoCash 2020
A 32-year-old male sustained the injury seen in Figure A after a motor vehicle accident. Which of the following factors is most predictive of mortality with this type of injury?
Fracture classification
Number of blood transfusions in the first 24 hours
Gender
Time to operative fixation
Use of pelvic binders
Corrent answer: 2
The best predictors of mortality with pelvic ring fractures include older age and hemodynamic shock at presentation. The amount of blood transfused indicates the severity of hemodynamic instability.
Pelvic ring fractures are typically high energy, blunt injuries. The leading cause of mortality with these injuries is hemorrhage and hemodynamic instability.
The most common source of hemorrhage include venous injury (80%), which is usually caused by a shearing injury of posterior thin walled venous plexus and bleeding cancellous bone. Other sources of hemorrhage include arterial injury (10-20%) from the superior gluteal artery (posterior ring injury, anterior posterior compression [APC] pattern), internal pudendal artery (anterior ring injury, lateral compression [LC] pattern) and obturator artery.
Smith et al. found fracture pattern and angiography/embolization were not predictive of mortality in patients with unstable pelvic injuries. The three factors they found to be predictive were: increased blood transfusions in the first 24 hours, age >60 years, and increased Injury Severity Scores (ISS) scores. Deaths were most commonly from exsanguination (<24 hours) or multiorgan failure (>24 hours).
Starr et al. demonstrated that age and shock on presentation were most predictive of mortality after pelvic ring injury.
Figure A shows a APC III pelvic fracture. Illustration A shows a table describing the Young-Burgress classification of pelvic ring fractures.
Incorrect Answers:
OrthoCash 2020
Figure A shows intraoperative radiographs of a 45-year-old patient with a left elbow injury. What would be the next most appropriate step in this patients care?
Early range of motion
Hinged elbow brace for 4 weeks
Repair lateral collateral ligament
Remove and upsize implant
Remove and downsize implant
Corrent answer: 5
The intraoperative images are consistent with overstuffing of the ulnohumeral joint during a radial head replacement. The most appropriate next step would be removing and downsizing the implant.
Overstuffing the radiohumeral joint by >2.5 mm can significantly alter elbow kinematics. It has also shown to lead to pain and early joint disease. The most sensitive method to assess for overstuffing of the joint is by direct visualisation intra-operatively. This can be performed by visualising the lateral aspect of the ulnohumeral joint when the radial head is resected and comparing this to when the trial radial head is reduced in place. In comparison, radiographic asymmetry of the medial ulnohumeral joint has been shown to be less sensitive. Radiographic findings of incongruity of ulnohumeral joint only occurs when significant overlengthening of the radius occurs.
Frank et al. examined the effect of radial head thickness in seven cadaver specimens. They found that incongruity of the medial ulnohumeral joint would only become apparent radiographically after overlengthening of the radius by
>or=6 mm.
Doornberg et al. examined seventeen computed tomography scans of the elbow to investigate the height of the radial head relative to the lateral edge and central ridge of the coronoid process. They found that the radial head was on average only 0.9 mm more proximal than the lateral edge of the coronoid process.
Figure A shows intraoperative radiographs of a patient that has undergone a radial head arthroplasty. There is significant widening of the medial ulnohumeral joint on an AP radiograph as well as widening of the ulnohumeral joint on the lateral radiograph,
Incorrect Answers:
OrthoCash 2020
Aside from improving the intramedullary nail starting point in Figure A, the use of blocking screws could have been used at the time of fixation to prevent this post-operative deformity. What would have been the correct orientation of these screw(s) in the proximal fragment?
Medial only
Lateral only
Anterior and medial
Posterior and medial
Posterior and lateral
Corrent answer: 5
The clinical presentation is consistent with a malunion of a proximal one-third tibia fracture with a valgus and procurvatum deformity. The correct orientation of Poller blocking screws to help prevent this malalignment would be in the posterior and lateral aspects of the metaphyseal fragment.
Insertion of the blocking screw lateral to the nail prevents valgus deformity, and insertion of the blocking screw posterior to the nail prevents apex anterior deformity. A more lateral starting point for nail insertion can also help to
prevent valgus deformity. The semiextended position of the knee for nail insertion also helps to eliminate the tendency for the fracture to flex, due to the avoidance of excessive knee flexion during the reduction.
Stedtfeld et al. describes the mechanical model for blocking screws. They state that two or more blocking screws can be placed in each plane (AP and lateral) alongside the nail to create a narrow canal for the nail. This allows for multiple points of fixation and realignment of the bone as the nail is passed.
Lindvall et al looked at a series of 56 extra-articular proximal tibial fractures treated with intramedullary nailing or percutaneous locked plating. Neither nailing or plating these fractures showed a distinct advantage in the overall outcomes. Apex anterior malreduction however was the most prevalent form of malreduction in both groups.
Lang et al. looked at a series of proximal third tibia fracture treated with intramedullary nailing. They reported that posterior tibial comminution will also contribute to apex anterior angulation. They states this occurs when the fracture hinges on the intact cortex anteriorly during nail insertion.
Figure A shows a proximal one third tibia fracture treated with an intramedullary nail. There is malreduction of the fracture with valgus and procurvatum deformity.
Incorrect Answers:
OrthoCash 2020
When evaluating a fracture dislocation of the elbow, a varus and posteromedial rotation mechanism of injury typically results in what injury pattern?
A fracture of the radial head requiring ORIF
A highly comminuted radial head fracture requiring radial head arthroplasty or resection
An MCL injury requiring repair
A type I avulsion fracture of the coronoid
An anteromedial coronoid fracture
A varus and posteromedial rotation mechanism of injury typically results in a fracture of the anteromedial facet of the coronoid which frequently requires reduction and fixation to restore stability.
A varus and posteromedial mechanism of injury about the elbow presents with an injury pattern distinctly different from other injury patterns. A key part of treating this injury pattern is recognizing a fracture of the anteromedial facet of the coronoid, which often requires reduction and fixation to restore stability about the elbow. It is important to recognize this during preoperative planning since this injury typically requires a medial approach.
Steinman presents a review article describing coronoid fracture patterns and their mechanisms of injury.
Doornberg and Ring present a level 4 review showing that coronoid fracture patterns and their required treatments are predictable based on mechanism of injury. Varus and posteromedial mechanisms were found to reliably create a fracture of the anteromedial facet of the coronoid, and were associated with sparing of the MCL and radial head.
Doornberg and Ring also presented a Level 3 review of anteromedial facet cornoid fractures. They found that they could not be adequately visualized and treated from a lateral approach, and that they typically required reduction and fixation to restore adequate stability to the elbow. This stresses the importance of recognizing this injury pattern during preoperative planning.
Illustrations A and B are AP and lateral radiographs of an elbow following a varus/posteromedial injury with an anteromedial coronoid facet fracture.
Illustration C is a diagram demonstrating fracture lines that create an anteromedial facet fracture fragment. This fracture can be subclassified into three subtypes [anteromedial rim (a), rim plus tip (b), and rim and tip plus the sublime tubercle (c)]
Incorrect answers:
OrthoCash 2020
A 26-year-old female presented to the emergency department with the injury seen in Figure A after an awkward fall while intoxicated. She undergoes closed reduction and repeat radiographs are seen in Figure B. After a normal physical examination, including ranging the hip from 0-90 degrees, which of the following options would be the next most appropriate step in management?
Femoral skeletal traction
CT scan
Hip spica cast application
Observation only
Serial neurovascular examinations
Corrent answer: 2
This patient has presented with a posterior left hip dislocation. The next most appropriate step would be performing a post-reduction CT scan to assess for joint reduction and congruity, associated fractures, or loose bodies.
Hip dislocations occur most commonly in young patients with high energy trauma. They are usually classified as simple or complex, with complex dislocations being those with associated fractures of the acetabulum or proximal femur. Urgent close reduction should occur within 6 hours from the time of injury. Post reduction CT scans must be performed for all traumatic hip dislocations to look for fractures or impacted areas of the femoral head or acetabulum, as well as incongruent reductions and free intra-articular joint fragments.
Calkins et al. looked at measurements of the posterior acetabulum on CT scans (the Acetabular Fracture Index) after hip dislocations to evaluate for hip stability. Hips were found to be unstable if less than 34% of the remaining posterior acetabulum was present after dislocation. Hips with greater than 55% were stable. In between 34 and 55% were indeterminate.
Moed et al. found that posterior wall fractures involving less than 20% of the posterior wall were considered stable. Fractures involving more than 40%-50% were unstable, leaving a wide range of posterior wall fractures classified as indeterminate.
Figure A shows a left posterior hip dislocation. Figure B shows a reduced left hip with no obvious fracture. Illustration A shows an axial CT scan image of the left hip. There is no acetabular fracture identified.
Incorrect Answers:
OrthoCash 2020
A 40-year-old male sustained the injury seen in Figure A, and subsequently underwent the procedure shown in Figure B. One hour post-operatively he starts to complain of pain in the operative leg, and the pain is unchanged with active or passive stretch. The external dressing is released with little resolution of symptoms. His blood pressure is 115/78 mm Hg with compartment pressures in the leg measuring 31 to 35 mm Hg. His ABI index is 1.1 in the leg. What would be the next step in management?
MRI angiography of leg
Four-compartment fasciotomy
Follow-up examination the following day
Continued monitoring and serial examinations
EMG study
The patient is at risk for developing compartment syndrome of the leg. The next most appropriate step would be to support his systemic blood pressure and monitor compartment pressures.
A clinical assessment is the diagnostic cornerstone of acute compartment syndrome. However, the intracompartmental pressure measurement has been advocated to help confirm the diagnosis in patients where there remains uncertainty after clinical exam. An absolute compartment pressure >30 mm Hg or a difference in diastolic pressure and compartments pressure (delta p) <30 mm Hg may help to confirm the necessity for fasciotomy. However, the treatment of early compartment syndrome should be to initially improve the limbs perfusion pressure gradient. This can be done by treating underlying factors such as hypotension, coagulopathy, or vascular compromise due to either a true vascular injury or artificially by external compression. Frequent reassessment is then critical to effectively manage these patients. If clinical
diagnosis persists despite these efforts, urgent fasciotomy would be considered.
McQueen looked at 116 patients with tibial diaphyseal fractures who had continuous monitoring of anterior compartment pressure for 24 hours. They found that using an absolute pressure of 30 mmHg would have resulted in 50 patients (43%) treated with unnecessary fasciotomies. They conclude using a differential pressure of 30 mmHg is a more reliable indicator of compartment syndrome.
White et al. looked at 101 patients with tibial fractures with satisfactory Delta P measurements. THey found that patients with elevated intramuscular pressures >30 mm Hg after tibial fracture do not have a greater incidence of complications than those with low pressures, so long that Delta P <30 mm Hg.
Figure A shows a Shatzker V tibial plateau fracture. Figure B shows fixation of fracture seen in Figure A.
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A 10-year-old girl suffers a displaced tibia fracture. Initial numbness over the dorsum of the the foot resolved following an anatomic closed reduction and placement in a long leg cast performed in the emergency room. The cast was placed with the the ankle dorsiflexed just above neutral to prevent equinus contracture and then the cast and padding was adequately bivalved. Overnight, the patient began experiencing recurrent numbness and paresthesias in her exposed toes and a slight increase in her pain at the fracture site. Your next best step would be:
Repeat closed reduction under conscious sedation
Selective compartment fasciotomies
External fixation and compartment monitoring
compartment fasciotomies with fracture fixation done emergently
Modify the cast to reposition the ankle into slight plantarflexion
Corrent answer: 5
Circumferential casting with the ankle dorsiflexed can cause increased intracompartmental pressures in the leg. However, this patient's cast has been adequately bivalved during initial cast placement. Therefore, the next best step is cast modification to allow the ankle to assume an angle between neutral and 30 degrees of plantar flexion and further reducing the compartment pressure.
Tibia fractures are one of many common underlying etiologies for the development of compartment syndrome in the leg. Fracture reduction as well as eliminating circumferential dressings are important early preventative steps to take. Bivalving casts - including splitting the cast padding - is often indicated in fractures of long bones that are treated with initial casting. While casting patients in a plantigrade or dorsiflexed position reduces the risk of equinus contractures and holds the ankle mortise reduced, dorsiflexing the ankle has been shown to increase the intracompartmental pressures throughout the leg compartments.
Weiner et al. placed pressure monitors into the anterior and deep posterior compartments in healthy volunteers to measure the effects of casting on compartment pressures. They found that the intramuscular pressures were lowest with the ankle positioned between plantigrade and a resting plantar flexion position (0-37 degrees), and that bivalving the cast reduced the pressures 33-47%.
Illustration A shows the needle trajectories for compartment pressure monitoring in the leg. This should be performed within 5 cm of the fracture to get accurate peak pressures.
Incorrect Answers:
OrthoCash 2020
A 35-year-old male horseback rider was bucked into the air and then landed forcefully with his perineum on the saddlehorn of the saddle. At a one year follow-up, the only long term sequela of his injuries is erectile dysfunction. Which radiographic injury seen in Figures A-E is most commonly associated with this complication?
This patient has sustained a saddle-horn injury to the pelvis. An anterior posterior compression (APC) injury is the most common pelvic injury associated with this mechanism.
Saddle-horn injury to the pelvis occurs when a horseback rider is bucked into the air and then lands forcefully with his or her perineum on the saddlehorn of the saddle. The bony injury to the pelvis usually consists of a diastasis of the pubic symphysis with/without subsequent widening of the sacroiliac joints. The
majority of patients are able to return close to their pre-injury level of employment and activity after these injuries. However, sexual dysfunction is a common complication with this injury. Sexual dysfunction can be due to urethral, vascular, neurologic, and psychogenic injuries.
Collinge et al. looked at a series of male patients with injuries to the perineum after coming into contact with the saddle or saddle horn on a horse. Eighteen of the twenty patients were found to have sexual dysfunction at the time of the latest follow-up. A multi-disciplinary approach to these patients is needed when treating pelvic injuries.
Cannada et al. surveyed 71 women of childbearing age who had a pelvic fracture. She found that half the patients reported physical genitourinary complaints with 38 percent of women noting new onset pain with intercourse. In terms of psychological impact, they showed that 45 percent of patients answered affirmatively to decreased interest in intercourse and decreased orgasm frequency after the injury.
van Nieuwenhoven et al. describe three equestrians who suffered from straddle injuries with symphysis diastasis and rupture of sacroiliac ligaments after falls or kicks from horses. They show that these presumed low-energy injuries can cause extremely severe injuries to the pelvis itself and to the adjacent organs.
Figure A shows a Burgess APC Type II pelvic fracture. Figure B shows left ASIS avulsion fracture. Figure C shows a left hip dislocation. No pelvic fracture is identified. Figure D shows a subacute superior/inferior pubic rami fracture.
Figure E shows a right femoral neck fracture.
Incorrect Answers:
OrthoCash 2020
A 31-year-old male driver was involved in a high-speed motor vehicle accident. His injuries include a left subdural hematoma (Abbreviated Injury Score [AIS]=4), left segmental femur fracture (AIS=3), ruptured spleen (AIS=4), nasal fracture (AIS=2), fractured left ribs 4 to 7 (AIS=2), and a closed pelvic ring fracture (AIS=3). What is his Injury Severity Score (ISS)?

Question 4:

Haversian canals are found in the center of an osteon in compact bone. They contain blood vessels and nerves.

Options:

A prosthetic foot which incorporates a multi-axis articulated foot assembly is recommended for which of the following amputees?
Low functioning diabetic who needs to transfer bed to chair
Long distance runner with below knee amputation
Elderly male with above knee amputation
Below knee amputee who needs to regularly walk on uneven ground
year-old male with above knee amputation from osteosarcoma

Correct Answer: Long distance runner with below knee amputation

Explanation:

The multi-axis articulated foot assembly is the best prosthetic for ambulation over uneven ground, and functions best for below knee amputations. Low functioning patients who need a prosthesis for transfers would probably benefit from a solid ankle, cushioned heel prosthesis. Runners and athletes often require high end carbon fiber prostheses. Patients with above knee
amputations have several options to optimize ambulation including solid, energy storing, and multi-axial prothesis.
Aaron et al. reviews the important considerations for patient specific prostheses and new developments on the horizon to maximize ambulation in prosthesis users.
Mesenchymal stem cells have the capacity to differentiate into all the following cell types EXCEPT?
Osteoclasts
Chondrocytes
Adipocytes
Osteoblasts
Fibroblasts
Mesenchymal stem cells are multipotent stem cells which retain the ability to self-renew and to form cells of the mesenchymal lineage. They can therefore form muscle, fat, tendon (made from fibroblasts), bone, cartilage, and the marrow stromal cells. Mesenchymal stem cells do not however form osteoclasts, which are formed from the monocyte lineage - from hematopoietic stem cells.
Caterson et al review the use of mesenchymal stem cells in tissue engineering and regeneration of musculoskeletal tissue.
A 60 year-old male was brought into the operating room for total hip replacement. Before making the incision, what precautionary procedure must be performed by the entire staff to minimize surgical error?
Mark the word "No" on the nonoperative extremities
Use intraoperative fluoroscopic imaging
Perform "timeout"
Have blood products ready in the operating room
Use the newest prosthesis
Surgical "timeout" is now part of the standard procedure which must be performed before starting surgery to minimize surgical error such as wrong site surgery.
Which of the following statements regarding articular cartilage is TRUE?
Cartilage is an isotropic material
Most of the water in articular cartilage exists in the deep layer next to the calcified cartilage
Cartilage only heals if the injury does not pass through the tidemark
Calcified cartilage is the only place that type IV collagen is found
Cartilage exhibits stress shielding of the solid matrix components
Cartilage exhibits significant stress shielding of the solid matrix components due to its high water content, the non-compressibility of water, and the structural organization of collagen and proteoglycans. Cartilage is composed of a permeable porous matrix and 65 to 80% of the total weight of articular cartilage is made up of water. A pressure gradient causes the water to flow through the porous-permeable solid matrix. Significant flow of fluid through the solid matrix requires high hydrodynamic pressures because of the low
permeability of the solid matrix.
The other answers are incorrect because cartilage is anisotropic, most of the water is located in the superficial layers, it only heals if the injury does pass through the tidemark, type X collagen is found in calcified cartilage and is thought to be involved in mineralization. Type IV collagen is found in the basal lamina.
A 38-year-old patient presents 6 months after intramedullary nailing of a distal third tibia fracture with symptoms consistent with complex regional pain syndrome. During the early stage of the disease he was treated with intermittent splinting, elevation and massage, contrast baths, and transcutaneous electrical nerve stimulation. Despite these modalities, he continues to have severe and debilitating symptoms. Which of the following treatment options is indicated as a second line of treatment?
Long leg cast immobilization for 3 months
Walking boot with non weight bearing for three months
Exchange nailing to stimulate healing response to the limb
Epidural spinal cord stimulator
Surgical sympathectomy of the affected limb
Complex regional pain syndrome is a chronic progressive disease of unknown etiology characterized by pain, swelling and skin changes. If nonoperative modalities fail, a surgical sympathectomy of the affected limb is indicated.
The first line of treatment is physical therapy including intermittent splinting, elevation and massage, contrast baths, and transcutaneous electrical nerve stimulation. Aggressive passive range-of-motion exercises should be avoided. If nonoperative modalites fail and symptoms remain severe, a surgical sympathectomy of the affected limb is indicated.
Keys to successful treatment include early clinical suspicion and treatment. Late CRPS is highly refractory to treatment and often results in permanent disability.
Two forms of Complex regional pain syndrome exist: 1) Reflex sympathetic dystrophy
- which does not demonstrate nerve lesions, and 2) Causalgia - which is associated with damage to peripheral nerves. Diagnostic criteria include:
Major criteria: intense and prolonged pain, swelling, stiffness, and discoloration (vasomotor disturbances).
Minor criteria: trophic changes, osseous demineralization, temperature changes, and palmar fibromatosis.
Tran et al present their systemic review of 41 RCTs of the research regarding treatment of CRPS. Their data suggest that only bisphosphonates offer clear medicinal benefits in the treatment of CRPS. Evidence regarding a beneficial effect of lumbar sympathetic blocks, gabapentin, and physical therapy is lacking. As such, these authors advocate for further study thru well-designed RCTs to better evaluate appropriate and effective treatment strategies.
You are planning an intramedullary nail to treat a geriatric patient with a peritrochanteric femur fracture. Which of the following preoperative considerations is correct regarding your implant?
The radius of curvature of an intramedullary nail is generally greater than the radius of curvature of the femur
Closed section nails have less stiffness than slotted nails
The medial/lateral nail starting point relative to the greater trochanter does not affect varus/valgus position in the fracture
The bending stiffness of your nail is proportional to the second power of the radius
Intramedullary nails allow for mostly direct intramembranous bone healing
The radius of curvature of an intramedullary nail is generally greater than the radius of curvature of the femur, which is why anterior distal femur
penetration is a known complication of intramedullary nailing procedures.
Egol et al. evaluated the radius of curvature of 948 femurs (474 matched pairs) and compared those data with current intramedullary nails. He found the average femoral anterior radius of curvature was 120 cm (± 36 cm)
whereas the radius of curvature of the intramedullary nails ranged from 186 to 300 cm.
The other answers are incorrect because closed section nails have more stiffness than slotted nails. The starting position on the greater trochanter greatly affects the post- operative varus/valgus of the fracture. Intramedullary nails allow for mostly indirect enchondral bone healing due to relative motion at the fracture site.
All of the following antibiotics function by interfering with protein synthesis by inhibiting ribosomes EXCEPT
gentamicin
tobramycin
vancomycin
erythromycin
linezolid
Gentamicin and tobramycin are aminoglycosides that function by inhibition of bacterial protein synthesis via irreversible binding to ribosomal subunits. Erythromycin functions by binding to the 50s subunit of the bacterial 70s rRNA complex and thereby inhibits protein synthesis. Linezolid binds to the 23s portion of the ribosomal subunit and inhibits protein synthesis. In contrast, Vancomycin acts by inhibiting proper cell wall synthesis and does not inhibit the ribosome.
The bending rigidity of the implant shown in Figure A is proportional to what power of the measured radius of the implant?

Question 5:

Options:

a thumb spica cast and reassessment in 3 weeks.
a thumb spica cast and reassessment in 6 weeks.
repair of the ulnar collateral ligament of the MCP joint.
adductor pollicis advancement on the proximal phalanx.
repair of the MCP joint dorsal capsule.

Correct Answer: a thumb spica cast and reassessment in 3 weeks.

Explanation:

Question 6:

Options:

Bed rest
External orthosis
Anterior corpectomy and arthrodesis
Posterior instrumented arthrodesis
Posterior decompression and instrumented arthrodesis

Correct Answer: External orthosis

Explanation:

Question 7:

Varus deformity after talar fractures is often seen due to collapse of the medial cortex. What artery supplies this portion of the talus?

Options:

Artery of the tarsal sinus
Artery of the tarsal canal
Peroneal
Perforating branch of the dorsalis pedis artery
Lateral malleolar

Correct Answer: Artery of the tarsal canal

Explanation:

Question 8:

Options:

Hip revision and implantation of a proximal femoral replacement
Hip revision and implantation of a tapered fluted stem
Open reduction and internal fixation with a locked plate and allograft struts
Erythrocyte sedimentation rate and C-reactive protein laboratory studies

Correct Answer: Erythrocyte sedimentation rate and C-reactive protein laboratory studies

Explanation:

Question 9:

What is the most appropriate orthotic management for the lesion shown in Figure 6?

Options:

Metatarsal pad
Morton’s extension orthosis
Medial longitudinal arch support
Budin splint
Viscoelastic heel lift

Correct Answer: Metatarsal pad

Explanation:

Question 10:

Options:

Flexion
Extension
Axial rotation
Left lateral bending
Right lateral bending

Correct Answer: Axial rotation

Explanation:

MRI and CT demonstrate an abnormality in the alantoaxial region (C1-C2). See chart in reference. “C1-C2 -Flexion/Extension 30 degrees - Sidebending 10 degrees - Rotation – 70 degrees”

Question 11:

below show the clinical photograph and radiograph obtained from a year-old man who has deformity and pain 1 year after primary total hip arthroplasty. What is the reason for the observed deformity?

Options:

A Vancouver type B1 fracture
Residual leg-length discrepancy
Loosening and subsidence of the femoral stem into anteversion
Loosening and subsidence of the femoral stem into retroversion

Correct Answer: Loosening and subsidence of the femoral stem into retroversion

Explanation:

Question 12:

Options:

Discontinue use of the soft collar and encourage range of motion
Semi-rigid collar immobilization for 6 to 8 weeks
Surgical stabilization
Halo skeletal fixation
Outpatient physical therapy with isometric neck exercises

Correct Answer: Discontinue use of the soft collar and encourage range of motion

Explanation:

Dickman and associates classified injuries of the transverse atlantal ligament into two categories. Type I injuries are disruptions through the substance of the ligament itself. Type II injuries render the transverse ligament physiologically incompetent through fractures and avulsions involving the tubercle of insertion of the transverse ligament on the C1 lateral mass. Type I injuries are incapable of healing without supplemental internal fixation. Type II injuries can be treated with a rigid cervical orthosis with a success rate of 74%. Surgery may be required for type II injures that fail to heal with 3 to 4 months of nonsurgical management.
(SBQ13PE.82) A renal ultrasound should be obtained in a patient with which of the following diagnoses?
Review Topic
Congenital pseudoarthrosis of the clavicle
Accessory navicular
Congenital scoliosis
Charcot-Marie-Tooth Disease
Congenital curly toe
A renal ultrasound should be obtained in a patient with congenital scoliosis.
Congenitial scoliosis has a prevalence that is estimated at 1% to 4% in general population. It is associated with systemic anomalies in up to 61% of cases. The most common anomalies are cardiac defects, genitourinary defects and spinal cord malformations. As such, additional imaging of these systems should be considered in the initial work-up of these patients.
Ruf et al. retrospectively investigated 56 consecutive operative cases of congenital scoliosis. The average age at surgery was 9.9 years (1.5–17 years). There was one wound complication, 2 hardware failures, 1 revision and no neurological complications. They concluded that one-stage posterior hemivertebra resection and instrumentation was safe in this population.
Xu et al. examined the efficacy of selective partial hemivertebra excision via posterior-only approach in 17 adolescent patients with congenital kyphoscoliosis. There were no postoperative infections and no neurological complications. They concluded that this approach may be most successful in patients aged 9 to 14 years old, with the Risser sign grades from 0–3 and Cobb angles <60°.
Illustration A from Erol et al (UPOJ, Vol 15, 2002;37-42) shows a diagram of 'types' of congenital scoliosis based on the morphology of the vertebrae.
Incorrect Answers:

Question 13:

Options:

Resection of the distal femur and postoperative chemotherapy
Preoperative chemotherapy followed by radiation therapy, then resection of the distal femur
Preoperative chemotherapy followed by surgical resection of the lesion and postoperative chemotherapy
Preoperative chemotherapy followed by radiation therapy, resection of the distal femur, then postoperative chemotherapy
Resection of the distal femur followed by radiation therapy

Correct Answer: Preoperative chemotherapy followed by surgical resection of the lesion and postoperative chemotherapy

Explanation:

DISCUSSION: This is a classic appearance for an osteosarcoma. The radiographs reveal a mixed osteolytic and osteoblastic lesion in a skeletally immature patient in the distal right femoral metaphysis. The pain pattern with progressive symptoms leading to the presence of night pain is also typical for this condition. The biopsy specimen reveals pleomorphic cells and the presence of osteoid. The current standard of care in the treatment of osteosarcoma is neoadjuvant chemotherapy followed by surgical resection or amputation followed by additional postoperative chemotherapy. Osteosarcoma is not radiosensitive.
REFERENCES: Wold LE, Adler CP, Sim FH, et al: Atlas of Orthopedic Pathology, ed 2. Philadelphia, PA, WB Saunders, 2003, p 179.
McCarthy EF, Frassica FJ: Pathology of Bone and Joint Disorders with Clinical and Radiographic Correlation. Philadelphia, PA, WB Saunders, 1998, p 205.

Question 14:

The skeletal muscle length-tension relationship for voluntary force generation is observed with which of the following biomechanical paradigms? Review Topic

Options:

Isometric
Isotonic
Isokinetic
Concentric
Eccentric

Correct Answer: Isometric

Explanation:

Question 15:

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 16:

When treating osteoporosis with alendronate, what is the most common side effect?

Options:

Diarrhea
Epigastric distress
Dry mucous membranes
Drowsiness
Insomnia

Correct Answer: Epigastric distress

Explanation:

Question 17:

Glenohumeral inferior stability in the adducted shoulder position is primarily a function of the

Options:

rotator cuff.
posterior glenohumeral ligament.
long head of the biceps tendon.
inferior glenohumeral ligament complex.
superior glenohumeral ligament.

Correct Answer: superior glenohumeral ligament.

Explanation:

Question 18:

Options:

right innominate osteotomy.
right varus upper femoral osteotomy.
open reduction of the right hip.
crutches, physical therapy, and an abduction brace.
MRI of the pelvis.

Correct Answer: MRI of the pelvis.

Explanation:

Question 19:

Options:

Shortening of 3 cm
Severity of trauma
Duration of immobilization
Type of immobilization
Closed reduction

Correct Answer: Severity of trauma

Explanation:

Question 20:

Options:

external electrical stimulation.
external ultrasound stimulation.
implanted electrical stimulation.
closed reduction and percutaneous fixation.
open reduction and internal fixation with bone graft.

Correct Answer: open reduction and internal fixation with bone graft.

Explanation:

DISCUSSION: The radiograph reveals an atrophic nonunion of the diaphysis of the clavicle. Electrical or ultrasound stimulation may be an option in diaphyseal nonunions that have
shown some healing response with callus formation, but these techniques are not successful
in an atrophic nonunion. The preferred technique for achieving union is open reduction and internal fixation with bone graft. Percutaneous fixation has no role in treatment of nonunions
of the clavicle.
REFERENCES: Boyer MI, Axelrod TS: Atrophic nonunion of the clavicle: Treatment by compression plating, lag-screw fixation and bone graft. J Bone Joint Surg Br 1997;79:301-303.
Simpson
NS
, Jupiter JB: Clavicular nonunion and malunion: Evaluation and surgical management. J Am Acad Orthop Surg 1996;4:1-8.

Question 21:

Options:

Oral cephalosporin
IV cephalexin and dressing changes
Betadine dressing and a short leg cast
Debridement of the wound and removal of the hardware
Debridement of the wound and maintenance of the hardware

Correct Answer: Debridement of the wound and maintenance of the hardware

Explanation:

Question 22:

What is the recommended treatment of a skeletally immature 12-year-old boy who has an anterior cruciate ligament-deficient knee?

Options:

Reduced activity, rehabilitation exercises, and functional bracing until the patient is near skeletal maturity
Bone-patellar tendon-bone autograft reconstruction
Allograft reconstruction
Hamstring tendon intra-articular repair using a centrally placed tibial tunnel and an over-the-top femoral attachment
Extra-articular repair

Correct Answer: Reduced activity, rehabilitation exercises, and functional bracing until the patient is near skeletal maturity

Explanation:

Question 23:

When an acute infection of a total elbow arthroplasty is managed with irrigation and debridement, which of the following organisms is associated with the highest risk of persistent infection?

Options:

Enterococcus cloacae
Klebsiella
Staphylococcus aureus
Staphylococcus epidermidis
Streptococcus

Correct Answer: Staphylococcus epidermidis

Explanation:

DISCUSSION: Salvage of a total elbow arthroplasty is possible with early aggressive management of acute infection (symptoms for less than 30 days) with serial irrigation and debridement and antibiotic bead placement. This form of treatment is indicated when there are no radiographic or intraoperative signs of loosening. However, successful treatment is largely dependent on the organism. Staphylococcus epidermidis is associated with persistent infection because it is an encapsulating organism, and it is best treated with implant removal and
IV antibiotics.
REFERENCES: Yamaguchi K, Adams RA, Morrey BF: Infection after total elbow arthroplasty. J Bone Joint Surg Am 1998;80:481-491.
Schoifet SD, Morrey BF: Treatment of infection after total knee arthroplasty by debridement with retention of the components. J Bone Joint Surg Am 1990;72:1383-1390.

Question 24:

Options:

Reduction in free fibrinogen radicals
Reduction in bleeding complications
Increased venous flow
Improved bioavailability
Inhibition of factors V, VI, and IX

Correct Answer: Improved bioavailability

Explanation:

Question 25:

Options:

persistent pain.
tendon subluxation.
altered sensation.
tendon rupture.

Correct Answer: persistent pain.

Explanation:

Question 26:

Optimal management of the injury shown in Figure 31 should include which of the following?

Options:

Cast immobilization in equinus
Open reduction and internal fixation once the acute soft-tissue swelling has resolved
Urgent reduction and fixation
Arthroscopic-assisted percutaneous fixation
Open reduction and internal fixation with primary subtalar arthrodesis

Correct Answer: Urgent reduction and fixation

Explanation:

Question 27:

A 60-year-old woman with rheumatoid arthritis has atlanto-axial instability and basilar invagination. What MRI findings would suggest the need for cervical fusion?

Options:

Cervical medullary angle of 125°
Space available for the cord of 15 mm
Cord diameter in flexion of 10 mm
C3-4 subluxation of 2 mm
Erosion of the tip of the odontoid

Correct Answer: Cervical medullary angle of 125°

Explanation:

DISCUSSION: The cervical medullary junction should be 135° or greater. An angle of 125° suggests compression of the cervical medullary junction. Other findings supporting surgical intervention include a cord diameter in flexion of less than 6 mm or less than 13 mm of space available for the cord.
REFERENCES: Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 1998, pp 700-701.
Monsey RB: Rheumatoid arthritis of the cervical spine. J Am Acad Orthop Surg
1997;5:240-248.
Bundschuh C, Modic MT, Kearney F, et al: Rheumatoid arthritis of the cervical spine: Surface-coil MR imaging. Am J Roentgenol 1988;151:181-187.

Question 28:

Figure 35 is the MR image of an 18-year-old man who has had knee pain with running for 5 months. What is the most appropriate treatment?

Options:

Arthroscopic or open reduction and internal fixation with possible bone grafting
Arthroscopic chondroplasty
No weight-bearing activity for 6 weeks and then re-evaluate
Retrograde subchondral drilling without fixation

Correct Answer: Arthroscopic or open reduction and internal fixation with possible bone grafting

Explanation:

Question 29:

Which of the following nerves is most likely responsible for symptoms associated with plantar fasciitis?

Options:

Medial plantar
Medial calcaneal
First branch of lateral plantar
Lateral plantar
Lateral calcaneal

Correct Answer: Lateral calcaneal

Explanation:

Question 30:

What factor is associated with a high risk of developing pseudotumors after metal-on-metal hip resurfacing?

Options:

Large-diameter components
Age 40 or older for men
Age 40 or younger for women
Diagnosis of primary osteoarthritis

Correct Answer: Age 40 or younger for women

Explanation:

Question 31:

Options:

intralesional curettage followed by 6 weeks of parenteral antibiotics.
local curettage and autogenous bone graft.
neoadjuvant chemotherapy followed by surgical resection and additional chemotherapy.
percutaneous radiofrequency coagulation.
closed needle biopsy.

Correct Answer: percutaneous radiofrequency coagulation.

Explanation:

Question 32:

Options:

Positive froment sign with the ulnar palm flat on a table
Weak thumb abduction with the dorsal palm flat on a table
Inability to flex the thumb with the palm flat on a table
Inability to extend the thumb with the palm flat on a table

Correct Answer: Inability to extend the thumb with the palm flat on a table

Explanation:

Question 33:

Options:

Maintain sling immobilization for 6 weeks, and then begin a global range-of-motion program.
Maintain sling immobilization for 3 weeks, and then begin a global range-of-motion program.
Immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side.
Immediately begin a passive range-of-motion program for forward elevation only; no external rotation is allowed for 6 weeks.
Immediately begin active range of motion in forward elevation and external rotation to the side with a progression to full rotator cuff strengthening in 3 weeks.

Correct Answer: Immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side.

Explanation:

DISCUSSION: The patient needs to immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side. Sling immobilization without stretching for either 3 or 6 weeks will result in severe stiffness that will compromise her ultimate range of motion. Since she has a good quality subscapularis tendon, there is no need to avoid beginning external rotation to the side. However, starting a strengthening program
at 3 weeks risks tearing the subscapularis tendon repair. Active strengthening should not begin for 6 weeks postoperatively to allow the subscapularis tendon repair time to heal.
REFERENCES: Boardman ND III, Cofield RH, Bengston KA, et al: Rehabilitation after total shoulder arthroplasty. J Arthroplasty 2001;16:483-486.
Matsen FA III, Lippitt SB, Sidles JA, et al: Practical Evaluation and Management of the Shoulder. Philadelphia, PA, WB Saunders, 1994, pp 215-218.

Question 34:

Options:

Strong
Moderate
Limited
Inconclusive

Correct Answer: Moderate

Explanation:

Question 35:

Options:

external fixation of the forearm fracture and functional bracing of the humeral shaft fracture.
external fixation of both fractures.
open reduction and internal fixation of both fractures.
open reduction and the internal fixation of the forearm fracture and functional bracing of the humeral shaft fracture.
application of a long arm cast.

Correct Answer: open reduction and internal fixation of both fractures.

Explanation:

Question 36:

During the anterior approach for repair of a distal biceps tendon rupture, what structure, shown under the scissors in Figure 6, is at risk for injury?

Options:

Brachial artery
Median nerve
Posterior interosseous nerve
Lateral antebrachial cutaneous nerve
Antecubital vein

Correct Answer: Lateral antebrachial cutaneous nerve

Explanation:

Question 37:

Options:

Unaffected
Transiently reduced postoperatively but ultimately improves to greater than preoperative function
Transiently reduced immediately postoperatively but then quickly returns to preoperative levels
Improves postoperatively due to correction of the scoliosis and is maintained long term
Reduced postoperatively and often remains reduced long term

Correct Answer: Reduced postoperatively and often remains reduced long term

Explanation:

DISCUSSION: A thoracotomy in an adult with idiopathic scoliosis causes a reduction in pulmonary function that often does not return to preoperative levels. What pulmonary function that does recover, recovers over many months. Long-term improvement in pulmonary function, compared to preoperative function, is rarely seen. This should be considered in planning surgical intervention in adults with scoliosis.
REFERENCES: Graham EJ, Lenke LG, Lowe TG, et al: Prospective pulmonary function evaluation following open thoracotomy for anterior spinal fusion in adolescent idiopathic scoliosis. Spine 2000;25:2319-2325.
Kishan S, Bastrom T, Betz RR, et al: Thoracoscopic scoliosis surgery affects pulmonary function less than thoracotomy at 2 years postsurgery. Spine 2007;32:453-458.

Question 38:

Options:

Self-directed exercise therapy
Supervised exercise therapy
Supervised exercise therapy with static progressive elbow splinting
Continuous passive motion device
Closed manipulation under anesthesia

Correct Answer: Continuous passive motion device

Explanation:

Question 39:

The most appropriate treatment for this fracture is

Options:

revision TKA.
revision of the tibial component with a stem extension.
cast immobilization.
open reduction and internal fixation of the fracture.

Correct Answer: open reduction and internal fixation of the fracture.

Explanation:

Question 40:

Figures 92a through 92c are the radiographs of a 34-year-old man with low-back pain and an inability to walk upright. What is the appropriate surgical treatment? A B C

Options:

Smith-Peterson osteotomies at T12-L1, L1-L2 and L2-3.
Vertebral column resection through a posterior approach
Anterior-posterior osteotomy
Pedicle subtraction osteotomy at L3

Correct Answer: Pedicle subtraction osteotomy at L3

Explanation:

Question 41:

Which of the following conditions is typically associated with the ankle deformity shown in figure 14?

Options:

Genu varum
Tarsal coalition
Degenerative ankle arthrosis
Osteochondritis dissecans of the talus
Hemihypertrophy of the ipsilateral lower extremity

Correct Answer: Tarsal coalition

Explanation:

Question 42:

Options:

Ankle-foot orthosis with anterior shell
Vascularized fibular graft
Intramedullary nailing of the left tibia
Amputation
Physical therapy

Correct Answer: Ankle-foot orthosis with anterior shell

Explanation:

Question 43:

Options:

Internal rotation malalignment of 44 degrees
External rotation malalignment of 44 degrees
Internal rotation malalignment of 21 degrees
External rotation malalignment of 21 degrees
Internal rotation malalignment of 63 degrees

Correct Answer: Internal rotation malalignment of 44 degrees

Explanation:

Question 44:

Options:

surgical exploration and tendon reinsertion of the flexor digitorum profundis.
surgical exploration and tendon reinsertion of the flexor digitorum superficialis.
steroids and physical therapy.
surgical release of the anterior interosseous nerve.
surgical release of the median nerve.

Correct Answer: surgical exploration and tendon reinsertion of the flexor digitorum profundis.

Explanation:

DISCUSSION: The patient has an avulsion of the flexor digitorum profundus. Treatment should include surgical exploration and tendon reinsertion. This is not an avulsion of the flexor digitorum superficialis because the patient’s deficiency is the inability to flex the distal interphalangeal joint, not the proximal interphalangeal joint. Surgical release of the anterior interosseous nerve is not indicated because the flexor digitorum profundus of the ring finger is innervated by the ulnar nerve. A median nerve contusion causes wrist pain and/or numbness and tingling in the median nerve distribution.
REFERENCES: Strickland JW: Flexor tendons: Acute injuries, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,
pp 1851-1897.
Leddy JP: Avulsions of the flexor digitorum profundus. Hand Clin 1985;1:77-83.

Question 45:

Options:

Repeat treatment with a nonweight-bearing cast
Percutaneous lag screw fixation
Addition of a bone stimulator
Injection of bone morphogenic protein

Correct Answer: Percutaneous lag screw fixation

Explanation:

This patient’s MR images are indicative of a nondisplaced navicular stress fracture, which is best treated with percutaneous lag screw fixation. She has persistent symptoms despite appropriate nonsurgical treatment. Although all of the above choices may allow successful healing of her navicular, surgery has been shown to result in a shorter recovery and a more predictable outcome, which is especially important to serious athletes. Use of bone morphogenic protein has not been established as a treatment for this injury.
RECOMMENDED READINGS
Lee S, Anderson RB. Stress fractures of the tarsal navicular. Foot Ankle Clin. 2004 Mar;9(1):85-104. Review. PubMed PMID: 15062216.
View Abstract at PubMed
Anderson RB, Cohen BE. Stress fractures of the foot and ankle. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. Vol 2. 8th ed. Philadelphia, PA: Mosby; 2007:1590-1597.

Question 46:

Options:

surgical debridement with wound closure and IV antibiotics.
surgical debridement with wound closure over suction drains and IV antibiotics.
surgical debridement with open wound management and IV antibiotics.
IV antibiotics alone.
hyperbaric oxygen therapy.

Correct Answer: surgical debridement with open wound management and IV antibiotics.

Explanation:

Question 47:

Histologic studies of surgically resected tissue in lateral epicondylitis demonstrate which of the following findings? Review Topic

Options:

Chondroblastic proliferation
Angiofibroblastic tendinosis
Significant active inflammation
Primarily calcium deposition
No normal tendon histology

Correct Answer: Angiofibroblastic tendinosis

Explanation:

Question 48:

Following surgery for an ankle fracture, which of the following is considered the most important factor in achieving a satisfactory outcome? Review Topic

Options:

Physical therapy
Early weight bearing
Anatomic alignment
Early range of motion of the ankle
Calcium and vitamin D administration

Correct Answer: Anatomic alignment

Explanation:

Question 49:

Lymphangioma

Options:

Pseudotumor
A pseudotumor is a hemophilic subperiosteal hematoma. The pseudotumor expands by repeated bleeds and increasing osmotic pressure.
There was no periosteal reaction or intralesional calcification. The bone wall itself is not expanded as in aneurysmal bone cyst.
There is nothing in the physical examination or patient history to point to infection.

Correct Answer: Pseudotumor

Explanation:

In classic hemophilia, a natural factor-VIII level of less than what percentage will lead to severe bleeding and complications:

Question 50:

The lateral arm flap is based on what arterial supply?

Options:

Posterior radial collateral
Anterior radial collateral
Brachial
Subscapular
Circumflex scapular

Correct Answer: Posterior radial collateral

Explanation:

Question 51:

Options:

Surgical stabilization within 6 to 8 hours of injury
Extent of initial fracture displacement
Nicotine use
Posterior-to-anterior screw fixation
Anatomic fracture reduction

Correct Answer: Extent of initial fracture displacement

Explanation:

DISCUSSION: The incidence of osteonecrosis following displaced talar neck fractures is most related to the extent of initial fracture displacement. With increasing fracture displacement, the tenuous vascular supply to the talar body is more at risk for damage, thereby increasing the risk of osteonecrosis. Although displaced talar neck fractures have historically been considered a surgical emergency, recent studies have shown that the timing of surgical intervention bears no impact on the development of osteonecrosis. While nicotine use has an influence on fracture healing, it has never been shown to be a factor in osteonecrosis, nor has posterior-to-anterior screw fixation or the quality of fracture reduction.
REFERENCES: Lindvall E, Haidukewych G, Dipasquale T, et al: Open reduction and stable fixation of isolated, displaced talar neck and body fractures. J Bone Joint Surg Am 2004;86:2229-2234.
Vallier HA, Nork SE, Barei DP, et al: Talar neck fractures: Results and outcomes. J Bone Joint Surg Am 2004;86:1616-1624.

Question 52:

Options:

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

Correct Answer: proximal row carpectomy.

Explanation:

Question 53:

In treating a lateral split-depression type tibial plateau fracture, which of the following adjuncts has been shown to have the least articular surface subsidence when used to fill the bony void?

Options:

Crushed cancellous allograft
Hydroxyapatite
Calcium phosphate cement
Autogenous iliac crest
Fibular allograft

Correct Answer: Crushed cancellous allograft

Explanation:

Question 54:

Options:

Calcific tendinitis
Poliomyelitis
Diskogenic cervical spine disease
Impingement
Brachial neuritis

Correct Answer: Brachial neuritis

Explanation:

DISCUSSION: The patient has symptoms and examination findings of acute brachial neuritis which is often a diagnosis of exclusion. The recent viral flu-like symptoms have shown a correlation with the development of this disorder. The acute, severe shoulder weakness excludes calcific tendinitis, impingement, and poliomyelitis. A normal cervical spine examination makes cervical disk disease unlikely.
REFERENCES: Turner JW, Parsonage MJ: Neuralgic amyotrophy (paralytic brachial neuritis). Lancet 1957;2:209-212.
Omer GE, Spinner M, Van Beek AL (eds): Management of Peripheral Nerve Problems, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 101-104.

Question 55:

Figure 14 shows a lateral radiograph of a knee joint. The bony structure indicated by the arrow is a sesamoid bone that resides in what tendon?

Options:

Biceps femoris
Lateral gastrocnemius
Semimembranosus
Semitendinosus
Popliteus

Correct Answer: Lateral gastrocnemius

Explanation:

Question 56:

The most common reason for proximal femur fracture fixation failure (Figure 15) is secondary to which common deformity?

Options:

- Varus
- Valgus
- Malrotation
- Shortening

Correct Answer: - Varus

Explanation:

DISCUSSION
Malposition of a proximal lag screw may result in cut-out similar to that seen with a sliding hip screw. Varus malreduction also can result in implant failure. Studies have shown no difference in complication or healing rates when comparing short and long cephallomedullary nails.
RECOMMENDED READINGS
Kleweno C, Morgan J, Redshaw J, Harris M, Rodriguez E, Zurakowski D, Vrahas M, Appleton
P. Short versus Long Cephalomedullary Nails for the Treatment of Intertrochanteric Hip Fractures in Patients over 65 Years. J Orthop Trauma. 2013 Nov 13. [Epub ahead of print] PubMed PMID: 24231580.
View Abstract at PubMed
Haidukewych GJ. Intertrochanteric fractures: ten tips to improve results. Instr Course Lect. 2010;59:503-9. Review. PubMed PMID: 20415401.
View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 16 THROUGH 20
A 23-year-old man sustains multiple injuries in a high-speed motor vehicle collision. Among his injuries are a right transverse-posterior wall acetabular fracture, a left open tibia fracture with compartment syndrome, and a right calcaneus fracture.

Question 57:

Figure 1 is the MRI scan of a 35-year-old female soccer player who injured her knee during a game. Given the findings of the scan, physical examination is most likely to reveal

Options:

grade 2 pivot shift.
positive Thessaly test.
positive quadriceps active test.
positive dial test at 30°.

Correct Answer: grade 2 pivot shift.

Explanation:

Question 58:

A 14-year-old patient has anterior knee pain. Radiographs, an MRI scan, and biopsy specimens are shown in Figures 6a through 6e. What is the most likely diagnosis?

Options:

Unicameral bone cyst
Aneurysmal bone cyst
Giant cell tumor
Chondromalacia
Ewing’s sarcoma

Correct Answer: Ewing’s sarcoma

Explanation:

Question 59:

A 67-year-old woman is seen in the emergency department after falling at home. Radiographs before and after treatment are shown in Figures 49a and

Options:

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

Correct Answer: Rotator cuff tear

Explanation:

Question 60:

A 13-year-old boy has a radiographically mild, clinically stable slipped capital femoral epiphysis (SCFE). What is the most appropriate treatment? Review Topic

Options:

Spica casting
Open reduction and internal fixation
Single screw in situ fixation of the epiphysis
Two-screw in situ fixation of the epiphysis
Crutches and no weight bearing for 6 weeks

Correct Answer: Spica casting

Explanation:

The accepted treatment of a stable SCFE lesion involves fixation of the epiphysis in situ with a single screw that is perpendicular to the epiphysis and central in both the AP and lateral planes. Constructs such as the three-screw inverted triangle configuration have increased rates of penetration of the femoral head as well as femoral head osteonecrosis. Spica casting was once a popular treatment modality but is associated with a high incidence of chondrolysis and is no longer recommended. Closed reduction attempts increase the risk of osteonecrosis.
(SBQ13PE.46) What developmental milestones are likely to be present in a 30-month-old child?
Review Topic
Hand dominance established
Hops on one foot
Heel-to-toe walk
Puts shoes on correct feet
Manages buttons
Hand dominance is usually established in the third year of life.
Normally, children younger than 2 years of age are ambidextrous. In some normal cases this persists after 2 years. Although there is some variability in this timing, strong hand preference in a younger child may be the result of a neurologic deficit.
Frankenburg et al. used the Denver Developmental Screening Test (DDST) to evaluate 1036 Denver area children from 2 to 6.4 years. The ages at which 25, 50, 75 and 90 percent of children could perform tasks were calculated to establish norms for the sample. The authors stress that the DDST is not an intelligence test, but rather a screening test to be used in clinical practice to determine whether a child's development is within the normal range.
Illustration
A
shows
the
DDST.
Incorrect
2:
Normal
for

Question 61:

Early postoperative infections following primary total hip arthroplasty are most likely caused by which organism?

Options:

Staphylococcus epidermidis
Streptococcus viridans
Propionibacterium acnes
Staphylococcus aureus

Correct Answer: Staphylococcus aureus

Explanation:

DISCUSSION:
S aureus
is the most common organism cultured in early (fewer than 4 weeks postoperative) periprosthetic infections. Methicillin-resistant
S aureus
is becoming a more common pathogen in certain patient populations. B hemolytic
Streptococcus
and some gram-negative infections can also be found in early postoperative infections.
S epidermidis
,
S viridans
, and
P acnes
are more commonly found in late (more than 4 weeks postoperative) infections.

Question 62:

When counseling a patient with hypophosphatemic rickets, which of the following scenarios will always result in a child with the same disorder?

Options:

Female patient who has a female child
Female patient who has a male child
Male patient who has a female child
Male patient who has a male child
Disorder not inherited

Correct Answer: Male patient who has a female child

Explanation:

Question 63:

Options:

Biceps tenodesis
Superior labrum anterior to posterior (SLAP) repair
Rotator cuff repair
Distal clavicle excision The patient has a clinical history and physical examination consistent with degenerative superior labral pathology, which is supported by the MRI scan. She has failed appropriate nonoperative treatment, and surgical intervention would be indicated. In a middle-aged patient with a degenerative superior labral tear, biceps tenodesis has been shown to have better outcomes and return to sport than SLAP repair. In a young patient with a traumatic superior labral tear, repair would be indicated. The other MRI findings noted are incidental and asymptomatic in this patient. As a result, rotator cuff repair or distal clavicle excision is not indicated.

Correct Answer: Biceps tenodesis

Explanation:

Question 64:

Options:

A diminished immune response to transplanted chondrocytes is seen in Technique C because the dense cartilage matrix acts as a barrier that limits antigen exposure.
In Technique C, healing is initiated by mesenchymal stem cell migration from subchondral bone. In Technique B, healing is initiated by allogeneic chondrocytes reimplanted beneath a periosteal patch.
Grafts in Technique C are transferred to an antibiotic solution to kill microorganisms and stored at 4°C until use.
A biopsy of the repair site at 3 months will reveal more Type I collagen in Technique B than in Technique C.
Technique C is a 2-stage procedure. Technique B is a single-stage procedure.

Correct Answer: In Technique C, healing is initiated by mesenchymal stem cell migration from subchondral bone. In Technique B, healing is initiated by allogeneic chondrocytes reimplanted beneath a periosteal patch.

Explanation:

Question 65:

Options:

Place blocking screws medial and posterior to the nail. Use a nail with a Herzog curve proximal to the fracture site.
Place blocking screws medial and posterior to the nail. Use a nail with a Herzog curve distal to the fracture site.
Place blocking screws lateral and posterior to the nail. Use a nail with a Herzog curve proximal to the fracture site.
Place blocking screws lateral and posterior to the nail. Use a nail with a Herzog curve distal to the fracture site.
Place blocking screws lateral and anterior to the nail. Use a nail with a Herzog curve proximal to the fracture site.

Correct Answer: Place blocking screws medial and posterior to the nail. Use a nail with a Herzog curve proximal to the fracture site.

Explanation:

Question 66:

A 23-year-old woman has had vague left knee pain for the past 6 months. A radiograph and CT scan are shown in Figures 50a and 50b. What is the most likely diagnosis?

Options:

Myositis ossificans
Osteochondroma
Parosteal osteosarcoma
Dedifferentiated chondrosarcoma
Tumoral calcinosis

Correct Answer: Parosteal osteosarcoma

Explanation:

Question 67:

What cell type causes the bone destruction in metastatic lesions?

Options:

Osteoblast
Osteoclast
Macrophage
T lymphocyte
Null killer cells

Correct Answer: Osteoclast

Explanation:

Question 68:

A defect in the gene coding for fibrillin-1 would lead to which diagnosis? Review Topic

Options:

Osteogenesis Imperfecta
Neurofibromatosis
Achondroplasia
Pseudoachondroplasia
Marfan Syndrome

Correct Answer: Osteogenesis Imperfecta

Explanation:

Question 69:

A 43-year-old woman has had pain in the left hip for the past 2 months. A radiograph, CT scan, MRI scan, and biopsy specimens are shown in Figures 16a through 16e. What is the most likely diagnosis?

Options:

Osteosarcoma
Osteochondroma
Chondrosarcoma
Chordoma
Enchondroma

Correct Answer: Chondrosarcoma

Explanation:

Question 70:

According to Musculoskeletal Infection Society (MSIS) guidelines, which set of patient laboratory study results fits the definition of chronic prosthetic joint infection?

Options:

Erythrocyte sedimentation rate (ESR) 50 mm/hr, C-reactive protein (CRP) 8 mg/L, joint aspiration white blood cell (WBC) count 542, 62% neutrophils, and positive leukocyte esterase
ESR 42 mm/hr, CRP 12 mg/L, joint aspiration WBC count 3,540, 72% neutrophils, and positive leukocyte esterase
ESR 20 mm/hr, CRP 15 mg/L, joint aspiration WBC count 4,135, 54% neutrophils, and negative leukocyte esterase
ESR 25 mm/hr, CRP 7 mg/L, joint aspiration WBC count 252, 82% neutrophils, and negative leukocyte esterase

Correct Answer: ESR 42 mm/hr, CRP 12 mg/L, joint aspiration WBC count 3,540, 72% neutrophils, and positive leukocyte esterase

Explanation:

Question 71:

Options:

Medial femoral circumflex
Obturator
Iliac circumflex
Femoral

Correct Answer: Femoral

Explanation:

DISCUSSION
Video 182 for reference
The femoral artery crosses the hip joint anterior to the anterior hip capsule. The medial femoral circumflex artery enters the joint along the route of the obturator externus. The obturator artery enters the hip joint beneath the transverse acetabular ligament. The iliac circumflex vessel arises superior to the hip joint.
RESPONSES FOR QUESTIONS 183 THROUGH 188
For each clinical scenario described below, identify the corresponding anteroposterior pelvic radiographic image shown above.

Question 72:

Which of the following structures is most commonly involved in lateral epicondylitis?

Options:

Anconeus
Extensor digitorum communis
Extensor carpi radialis longus
Extensor carpi radialis brevis
Extensor carpi ulnaris

Correct Answer: Extensor carpi radialis brevis

Explanation:

Question 73:

Preventing "missed" femoral neck fractures associated with ipsilateral femoral shaft fractures is best achieved with

Options:

- an examination.
- dedicated anteroposterior and lateral hip radiographs.
- thin-cut pelvic CT images with coronal and sagittal reconstructions.
- MRI.

Correct Answer: - thin-cut pelvic CT images with coronal and sagittal reconstructions.

Explanation:

DISCUSSION
Ipsilateral femoral neck and shaft fractures occur in up to 6% of femur fractures. A femoral neck fracture is often vertical and nondisplaced. A high degree of suspicion is necessary to avoid "missed" femoral neck fractures in patients with this condition. Although an examination and dedicated hip radiographs help to avoid missed injuries, a significant decrease in missed
injuries has been described with the use of thin-cut pelvic CT images. In patients who undergo trauma, a pelvic CT scan is often performed to assess for associated injuries and is easily reviewed to examine the femoral neck. Although MRI is advocated to identify isolated occult femoral neck fractures, CT has been described as the method of choice with which to identify ipsilateral femoral neck and shaft fractures in the trauma population. Currently, no literature supports the use of MRI in this population.
RECOMMENDED READINGS
Tornetta P 3rd, Kain MS, Creevy WR. Diagnosis of femoral neck fractures in patients with a femoral shaft fracture. Improvement with a standard protocol. J Bone Joint Surg Am. 2007 Jan;89(1):39-43. PubMed PMID: 17200308.
View Abstract at PubMed
Kuhn KM, Agarwal A. Femoral fractures. In: Cannada LK, ed. Orthopaedic Knowledge Update

Question 74:

Options:

a shoulder spica cast with the upper extremity in the salute position.
a sling and swathe for 3 weeks, followed by gradual motion and strengthening.
closed reduction and antegrade intramedullary pinning.
closed reduction and retrograde intramedullary nailing.
open reduction and internal fixation with small plates and screws.

Correct Answer: a sling and swathe for 3 weeks, followed by gradual motion and strengthening.

Explanation:

DISCUSSION: In this age group, bayonet apposition can produce very good results. Healing occurs rapidly, and remodeling usually is complete in less than 1 year. All of the other methods have significant risks of complications and are unnecessary for this fracture.
REFERENCES: Martin RF: Fractures of the proximal humerus and humeral shaft, in Letts RM (ed): Management of Pediatric Fractures. New York, NY, Churchill Livingstone, 1994,
pp 144-148.
Sanders JO, Rockwood CA Jr, Curtis RJ: Fractures and dislocation of the humeral shaft and shoulder, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 937-939.

Question 75:

Which of the following factors has been shown to increase the risk of peroneal tendon pathology in patients who have undergone posterior plating of lateral malleolar fractures?

Options:

Use of cut or trimmed plates
Use of straight (uncontoured) plates
Use of locked plating
Low plate placement with a prominent screw head in the distal hole
Low antiglide plate placement

Correct Answer: Low plate placement with a prominent screw head in the distal hole

Explanation:

Question 76:

Figure 51 shows an arthroscopic view of the patellofemoral joint from an inferolateral portal. The arrow points to which of the following structures? Review Topic

Options:

Loose body
Plica
Displaced meniscus tear
Torn retinaculum
Osteochondral defect

Correct Answer: Plica

Explanation:

Question 77:

Figure 11 shows the radiograph of a 3-year-old girl who sustained a proximal radius injury. Appropriate initial management should include

Options:

open reduction.
closed reduction and transarticular pinning.
closed reduction.
a sling and early range of motion.
radial head excision.

Correct Answer: closed reduction.

Explanation:

DISCUSSION: The patient has a displaced radial neck fracture. Displaced radial neck fractures with angulation of more than 30° to 45° require reduction. Methods of attempted closed reduction include wrapping the arm with an Esmarch’s bandage and applying direct pressure over the maximum deformity of the radial head. More aggressive methods include a Kirschner wire used as a joystick or intramedullary reduction as described by the Metaizeau technique. Open reduction should be avoided because of complications such as stiffness or osteonecrosis. Indications for open reduction are irreducible displacement of more than 45° with severe restriction of forearm rotation.
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.
Radomisli TE, Rosen AL: Controversies regarding radial neck fractures in children. Clin Orthop 1998;353:30-39.
Skaggs DL, Mirzayan R: The posterior fat pad sign in association with occult fracture of the elbow in children. J Bone Joint Surg Am 1999;81:1429-1433.
Gonzalez-Herranz P, Alvarez-Romera A, Burgos J, et al: Displaced radial neck fractures in children treated by closed intramedullary pinning (Metaizeau technique). J Pediatr Orthop 1997;17:325-331.

Question 78:

Options:

Cardiovascular evaluation
Ophthalmologic evaluation
MRI of the spine
Radiographs of the hip
Genetic testing

Correct Answer: Cardiovascular evaluation

Explanation:

Question 79:

Options:

Type of surgery, age, and BMI
Type of surgery, hypercholesterolemia, and age
Age, BMI, and hypercholesterolemia
BMI, type of surgery, and hypercholesterolemia

Correct Answer: Type of surgery, age, and BMI

Explanation:

Question 80:

Options:

No syndesmotic fixation. Immediate touch-down weightbearing in CAM walker boot.
No syndesmotic fixation. Non-weightbearing for 4 to 6 weeks, followed by progressive weightbearing in CAM walker boot.
No syndesmotic fixation. Non-weightbearing for 8 to 12 weeks.
Syndesmotic screws. Non-weightbearing for 4 to 8 weeks.
Syndesmotic screws. Non-weightbearing for 8 to 12 weeks.

Correct Answer: No syndesmotic fixation. Immediate touch-down weightbearing in CAM walker boot.

Explanation:

Question 81:

Options:

Arthroscopic debridement
Two-stage total knee revision arthroplasty
Resection arthroplasty without an antibiotic impregnated cement spacer
Knee fusion

Correct Answer: Two-stage total knee revision arthroplasty

Explanation:

DISCUSSION:
This complication is best addressed with either a single-stage or two-stage total knee arthroplasty. A recent report suggests that a single-stage arthroplasty can be effective, although many surgeons would perform a two-stage procedure with an articulating or static spacer. Arthroscopic would be non-effective, especially given 4 weeks of symptoms. Resection arthroplasty without a spacer would leave an unstable
and poorly functioning extremity. Knee fusion should be used as a salvage procedure.
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Question 82:

- 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

Options:

widening and shortening of the heel.
weakness of the gastrocnemius-soleus complex.
anterior impingement from a horizontal talus.
unrecognized compartment syndrome of the foot.
degenerative arthritis of the tibiotalar joint.

Correct Answer: anterior impingement from a horizontal talus.

Explanation:

Question 83:

Options:

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

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

Explanation:

Question 84:

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 85:

Osteopenia is defined by the World Health Organization (WHO) as a bone mineral density (BMD) that is

Options:

within 1 standard deviation of aged-matched normals.
within 1 and 2.5 standard deviations below aged-matched normals.
within 1 standard deviation of young normals.
within 1 and 2.5 standard deviations below young normals.
more than 2.5 standard deviations below aged-matched normals.

Correct Answer: within 1 and 2.5 standard deviations below young normals.

Explanation:

DISCUSSION: Osteopenia, decreased bone mass without fracture risk as defined by the WHO criteria for diagnosis of osteoporosis, is when a woman’s T-score is within -1 to -2.5 SD.
The T-score represents a comparison to young normals or optimum peak density. The Z-score represents a comparison of BMD to age-matched normals. Measurements of bone mineral density (BMD) at various skeletal sites help in predicting fracture risk. Hip BMD best predicts fracture of the hip, as well as fractures at other sites.
REFERENCE: Kanis JA, Johnell O, Oden A, et al: Risk of hip fracture according to the World Health Organization criteria for osteopenia and osteoporosis. Bone 2000;27:585-590.

Question 86:

A 21-year-old man who was injured in a snowboarding accident 18 months ago now reports wrist pain. An MRI scan is shown in Figure 37. Based on the image findings, what is the most likely diagnosis?

Options:

Preiser’s disease
Scaphoid nonunion and osteonecrosis
Kienbock’s disease
Intraosseous ganglion
Scapholunate dissociation

Correct Answer: Scaphoid nonunion and osteonecrosis

Explanation:

DISCUSSION: The coronal MRI scan of the wrist shows the scaphoid. There is a subtle fracture line with a step-off at the radial surface consistent with a nonunion. The signal intensity is markedly different between the two fragments of the scaphoid. This strongly suggests osteonecrosis. Preiser’s disease is osteonecrosis typically involving most or all of the scaphoid. Kienbock’s disease involves the lunate. Intraosseous ganglia are easily diagnosed on MRI but typically have a fluid-filled area surrounded by denser bone in the periphery. Scapholunate dissociation can be seen on MRI as an injury to the scapholunate ligament and widening of the scapholunate interval, neither of which is seen on this image.
REFERENCE: Perlik PC, Guilford WB: Magnetic resonance imaging to assess vascularity of scaphoid nonunions. J Hand Surg Am 1991;16:479-484.

Question 87:

Options:

Continued bracing, physical therapy, and Botox injections in the triceps surae
Peroneus longus to brevis transfer, medializing calcaneal osteotomy, and transfer of the extensor digitorum longus to the peroneus tertius
Peroneus longus to brevis transfer, and transfer of the posterior tibial tendon to the tibialis anterior tendon
Peroneus longus to brevis transfer, first metatarsal cuneiform dorsal closing wedge osteotomy, and lateralizing calcaneal osteotomy with proximal translation
Triple arthrodesis

Correct Answer: Peroneus longus to brevis transfer, first metatarsal cuneiform dorsal closing wedge osteotomy, and lateralizing calcaneal osteotomy with proximal translation

Explanation:

Question 88:

What fibers of the anterior cruciate ligament tighten with extension of the knee? Review Topic

Options:

Anterolateral
Anteromedial
Posterolateral
Posteromedial
Posterior oblique

Correct Answer: Posterolateral

Explanation:

Question 89:

Six weeks after onset, what is the most clearly accepted indication for surgical management for lumbar disk herniation?

Options:

Stable sensory loss
Stable motor weakness
Refractory radicular pain
Size of the herniation
Lost time at work

Correct Answer: Refractory radicular pain

Explanation:

DISCUSSION: In the absence of a cauda equina syndrome or progressive weakness, the best indication for surgical management is refractory radicular pain. Surgical decision-making should not be based on the size of the herniation. Large extruded herniations tend to resolve more predictably than smaller herniations. Stable motor weakness and numbness resolve similarly in both surgical and nonsurgical management, although surgery hastens the process. When intractable radicular pain is the strict indication for surgery, surgical intervention provides substantial and more rapid pain relief than nonsurgical care.
REFERENCES: Rhee JM, Schaufele M, Abdu WA: Radiculopathy and the herniated lumbar disc: Controversies regarding pathophysiology and management. J Bone Joint Surg Am 2006;88:2070-2080.
Atlas SJ, Keller RB, Wu YA, et al: Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the Maine lumbar spine study. Spine 2005;30:927-935.

Question 90:

In recurrent posterior shoulder instability, what is the recommended approach to the posterior capsule? Review Topic

Options:

A teres minor-splitting approach
An infraspinatus-splitting approach
Between the infraspinatus and teres minor
Between the supraspinatus and infraspinatus
In the rotator interval

Correct Answer: An infraspinatus-splitting approach

Explanation:

Question 91:

Options:

Normal shoulder strength and function
Local sensory deficits
Fracture union
Infection
Malunion

Correct Answer: Malunion

Explanation:

Question 92:

What type of brace is shown in Figures 22a and 22b?

Options:

Charcot restraining orthotic walker (CROW)
University of California Biomechanics Laboratory (UCBL) orthosis
Double upright ankle-foot orthosis
Chopart’s prosthesis
Below-knee prosthesis

Correct Answer: Charcot restraining orthotic walker (CROW)

Explanation:

Question 93:

Options:

revision of the current orthotics.
metatarsal osteotomies to correct cavus.
a sliding calcaneal osteotomy to correct hindfoot varus.
triple arthrodesis, with anterior transfer of the posterior tibialis.
extensor transfer to the metatarsal necks, soft-tissue releases, and anterior transfer of the posterior tibialis tendon.

Correct Answer: extensor transfer to the metatarsal necks, soft-tissue releases, and anterior transfer of the posterior tibialis tendon.

Explanation:

Question 94:

Steroids are thought to prevent neurologic deterioration after traumatic spinal cord injury by which of the following mechanisms? Review Topic

Options:

Maintains calcium influx into damaged cells
Destabilizes lysosomal membranes in the zone of injury
Reduces TNF-alpha expression
Increases NF-kB binding capacity
Maintains free radical oxidation

Correct Answer: Reduces TNF-alpha expression

Explanation:

Question 95:

Options:

Hip arthroscopy and labral debridement
Femoroacetabular osteoplasty and labral repair
Femoral osteotomy
Hemiarthroplasty
Total hip arthroplasty

Correct Answer: Femoroacetabular osteoplasty and labral repair

Explanation:

Question 96:

Options:

Fracture fixation and bracing
Lateral retinacular release with proximal realignment
Tibial component revision
Distal realignment by medialization of the tibial tubercle
Revision of the patellar component

Correct Answer: Lateral retinacular release with proximal realignment

Explanation:

Question 97:

Options:

Time to healing
Retear rate
Functional outcome scores
Postsurgical pain scores

Correct Answer: Retear rate

Explanation:

Question 98:

Risks associated with vertebral compression fractures in the elderly population can be defined by which of the following? Review Topic

Options:

No differences in mortality risk were found between cases and controls.
Greater mortality risk was found for men than women with vertebral compression fractures.
Lifetime mortality risk was lower when the fracture occurred at a younger age.
Mortality within the case or control groups was not affected by duration of follow up.
Risk of additional fractures was not affected by vertebral fracture status.

Correct Answer: Greater mortality risk was found for men than women with vertebral compression fractures.

Explanation:

Question 99:

Options:

tendon repair, and thenar flap coverage.
full-thickness skin graft.
reversed cross-finger flap from the ring finger.
cross-finger flap coverage from the ring finger.

Correct Answer: reversed cross-finger flap from the ring finger.

Explanation:

Question 100:

Options:

long leg casting in 30 degrees of flexion for 6 weeks.
a long leg cast in full extension for 6 weeks.
knee arthroscopy to rule out internal derangement.
physical therapy for range of motion and quadriceps strengthening.
open reduction and internal fixation.

Correct Answer: a long leg cast in full extension for 6 weeks.

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

Orthopedic Board Review MCQs: Deformity, Hip & Nerve Surgery | Part 173

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 173

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index