Orthopedic Surgery Board Review MCQs: Trauma, Spine & Hip | Part 175

A 35-year-old man who is left-hand dominant has pain and swelling around his left index metacarpal phalangeal (MCP) joint following a motor vehicle accident 2 months ago. Radiographs reveal no fractures. He has point tenderness over the radial side of the MCP joint and increased laxity with ulnarly applied stress. He has failed conservative treatment including 5 weeks of immobilization. If the patient elects to live with this condition and not have surgery, what would be the most common outcome?

A 16-year-old girl was involved in a motorcycle accident that resulted in a significant right tibial fracture with soft-tissue loss over the distal 4 cm of the anterior medial tibia. The patient has had two irrigations and debridements and recently had an intramedullary nail placed for the skeletal injury. Vacuum-assisted closure (VAC) has been used to cover the defect since the injury. The risk of infection developing in the tibia is

A year-old woman with a history of osteoporosis is involved in a high-speed motor vehicle accident, resulting in left hip pain and deformity. The initial radiograph from the trauma bay is shown in Postreduction CT is shown in 2 through What is the most appropriate definitive surgical treatment?

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

A 19-year-old college football player reports persistent weakness, tingling, and numbness of both upper extremities at half time. He states that these symptoms initially occurred after tackling an opposing player with his head early in the game. History reveals that he has had “burners” in the past that typically resolved within 15 to 30 minutes. Examination reveals pain-free cervical motion, weakness to shoulder abduction testing bilaterally, normal upper extremity reflexes, and decreased sensation over both shoulders and the upper arms. Appropriate initial management should consist of

A 32-year-old male sustains a posterior wall acetabulum fracture as the result of a high-speed motor vehicle collision. Improved patient-reported outcomes after surgical treatment are associated with which of the following variables?

The radiograph seen in Figure 67 reveals an ankle fracture in a 65-year-old woman who slipped on the ice. She has a history of diabetes mellitus for the past 7 years and reports that she maintains fair control of her diabetes; her last HgbA1c was 8%. The patient is a community ambulatory who lives independently. Examination reveals she has absent sensation with the 5.07 monofilament. When determining management, the physician must consider which of the following?

A patient sustained a puncture wound to the plantar aspect of his foot. He was wearing shoes and socks at the time of the injury. Systemic antibiotic administration with specific coverage for which bacterial species (in addition to Staphylococcus aureus) should be instituted?

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

When comparing the overall outcomes of surgical versus nonsurgical treatment of stable thoracolumbar burst fractures in patients without neurologic injury, 5 years following injury, the principle differences lie in Review Topic

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

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

The mother of a 2-year-old boy reports that he had pain in the right hip all night and refuses to walk on the leg this morning. He is afebrile. Examination reveals pain on hip extension and adduction, but he is able to internally and externally rotate the hip approximately 20 degrees in each direction without pain. Laboratory studies reveal a WBC count of 7,400/mm 3 , with 62% polymorphonuclear neutrophil leukocytes. The AP radiograph shown in Figure 15 reveals a left teardrop distance of 8 mm, while the right side measures 10 mm. Which of the following diagnostic studies will best help confirm the diagnosis?

Within the intervertebral disk, aggrecan is primarily responsible for: Review Topic

A 34-year-old man presents to clinic with 4 months of right elbow pain. He began going to the gym and playing squash about 3 months ago. On exam, he is tender over the lateral aspect of the elbow and has pain with resisted wrist extension. Which of the following choices lists the correct compartment of the muscle typically involved in this disease and then lists its antagonist muscle? Review Topic

A 45-year-old man reports that he awoke 2 weeks ago with severe pain in his right arm. Examination reveals weakness in the biceps, brachialis, and wrist extensors. There is decreased sensation in the thumb and index finger and a diminished brachioradialis reflex. Assuming this patient has a posterolateral herniated nucleus pulposus, what level is involved?

A 72-year-old woman who was doing well after undergoing total shoulder arthroplasty for arthritis 4 months ago is suddenly unable to elevate her arm. Examination reveals 70 degrees of external rotation compared with 45 degrees on the uninvolved side, and she is unable to lift her hand off her lower back. Radiographs are shown in Figures 43a through 43c. Treatment should consist of

A 56-year-old man who underwent a left total hip arthroplasty 8 years ago is seen following a fall from a standing height. A radiograph obtained at 2 years postoperatively is shown in Figure 55a and a current radiograph obtained in the emergency department is shown in Figure 55b. On further questioning, he reports pain in this thigh for the past 3 years that has been increasing in intensity. Appropriate management at this time includes which of the following?

Figures 51a through 51c show the radiographs of a 7-year-old soccer player who reports a gradual onset of midfoot pain that began shortly after the start of soccer season. He states that the pain is worse with activity and is partially alleviated by rest. Examination reveals soft-tissue swelling, and tenderness and warmth in the region of the talonavicular and navicular cunieform joints. Management should consist of

In children between the ages of 4 and 8 years, the major blood supply to the femoral head comes from the

Presence of diabetes-induced peripheral neuropathy has been shown to be an independent risk factor for postoperative complications of which of the following injuries?

A 59-year-old construction worker who is right-hand dominant has had right shoulder pain for the past 9 months with no history of injury. Nonsurgical management consisting of two cortisone injections, physical therapy for 3 months, and nonsteroidal anti-inflammatory drugs has failed to provide lasting relief. Examination reveals tenderness over the acromioclavicular (AC) joint and over the subacromial bursa. He has positive Neer and Hawkins impingement signs and AC joint pain with adduction of the shoulder. Radiographs are shown in Figures 36a and 36b. An MRI scan reveals an intact rotator cuff. Management should now consist of

Which structure is the primary stabilizer of the lesser metatarsophalangeal (MTP) joint?

When comparing the failure load of an evenly tensioned four-stranded hamstring tendon anterior cruciate ligament autograft to a 10-mm bone-patellar tendon-bone autograft, the hamstring graft will fail at a tension

A large circumferential proximal femoral allograft is to be used in the reconstruction of a failed femoral component in a total hip arthroplasty. To enhance fixation of the graft to the implant, which of the following strategies should be used?

A diskectomy is performed in which the disk space is not aggressively debrided. When compared to techniques that involve aggressive debridement of the disk space, this results in

A 2-year-old boy has complete absence of the sacrum and lower lumbar spine. What is the most likely long-term outcome if no spinal pelvic stabilization is performed?

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

A research study is initiated on 500 patients undergoing total hip arthroplasty. The patients are followed and outcome is assessed according to body mass index (BMI). The effects of BMI on outcome should be reported as which of the following?

A 19-year-old man sustains a low-velocity gunshot wound to the forearm. What factor most strongly correlates with the development of compartment syndrome after this injury?

Figure 31 is the sagittal MR image of a 30-year-old man with a clear-cell sarcoma of the foot. There is no evidence of disease elsewhere after standard staging of a soft-tissue sarcoma.

Figure 16 shows an axial MRI scan through the knee joint. What structure is identified by the arrow?

A 10-month-old infant has a deformity of the right foot. Radiographs, including simulated weight-bearing AP and lateral views and a maximum plantar flexion lateral view, are shown in Figures 57a through 57c. Initial management of the foot should consist of Review Topic

An 11-year-old girl sustained an injury to her right foot when a 500-lb headstone fell on it. The headstone was removed after 3 minutes. Radiographs show multiple midfoot fractures. Examination reveals severe pain that is worse with passive toe motion. Clinical photographs are shown in Figure 28. Management should consist of

A 19-year-old collegiate offensive lineman injures his left elbow in a scrimmage. He reports reaching out with his left arm to prevent the defensive player from getting around him, and, as he grabbed the player, his elbow was forced into extension. He had immediate pain and weakness and heard a “pop.” He has mild swelling in the antecubital fossa and a prominent-appearing biceps muscle belly. His hook test result is abnormal at the elbow. The athlete undergoes repair of the injury, and postsurgical radiographs are shown in Figures 1 and 2. At his first postsurgical visit, he reports no pain but describes weakness in his hand and decreased sensation over his lateral forearm. Upon examination, he has decreased 2-point discrimination over the lateral forearm and an inability to actively extend his thumb and fingers at the metacarpophalangeal joints. He can extend at the finger interphalangeal joints. He can extend his wrist weakly, and it deviates radially as he extends. His distal sensation is intact. Considering his examination findings, which two nerves are injured?

What is the most common site of nerve compression in radial tunnel syndrome?

03 A 37 year-old woman with thoracic back pain has had hemoptysis and dyspnea for the past month. A thoracic spine radiograph shows a compression fracture of T-9 and a mass in the right lung. What is the best course of action?

You perform an ACL reconstruction with bone-patella tendon-bone (BTB) autograft and are explaining the postoperative rehabilitation protocol to your patient. Which of the following is associated with increased quadriceps volume and improved quadriceps strength at 1 year without a higher risk of knee instability? Review Topic

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

A 69-year-old man has a painful slow-growing lesion of the distal phalanx of his thumb. History reveals that he has had chronic osteomyelitis of the thumb for the past 12 years. The radiograph and biopsy specimens are seen in Figures 9a through 9c. Treatment should consist of

-Postsurgically, the patient recovers well and is fully rehabilitated. He demonstrates full motion with no instability or pain and is cleared to return to play 12 months after the surgery. He asks for your advice regarding use of a functional brace for playing basketball following his reconstruction. What is the most appropriate recommendation?

Figures 8a through 8c show the lateral radiograph and T1- and T2-weighted MRI scans of a 14-year-old soccer player who reports aching thigh pain. The next most appropriate step in management should consist of

• A 40-year old man has limited, painful motion in dorsiflexion at the metatarsophalangeal (MTP) joint of the right great toe, despite nonsurgical treatment. Radiographs show dorsal and medial osteophytes and minimal narrowing of the articular space. Treatment should consist of

Figure 1 is an arthroscopic view of the intercondylar notch of a right knee from an anterolateral portal. What is the main function of the structure delineated by the black asterisks?

Which of the following is accurate regarding low-molecular-weight heparin used for deep venous thrombosis (DVT) prophylaxis in total joint arthroplasty?

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

Which of the following is a long-term complication of ankle arthrodesis for posttraumatic arthritis?

Figure 48 shows the radiograph of a 17-year-old boy who sustained a gunshot wound to his forearm. There is a small entrance wound on the volar surface. The exit wound is dorsal and more than 15 cm in size, with loss of skin and an extensive amount of devitalized muscle hanging out of the wound. Vascular supply to the hand is excellent, the ulnar and median nerves are intact in the hand, but the radial sensory nerve function is absent. After repeated surgical debridements of the wound and bone, definitive treatment for the fracture would most likely be which of the following? Review Topic

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

A newborn girl is referred for evaluation of suspected hip instability. What information from her history would place her in the highest risk category?

In Dupuytren’s disease, the retrovascular cord typically displaces the radial proper digital nerve of the ring finger in what direction?

A 32-year-old powerlifter who was performing a dead lift 3 days ago noted a sharp pain in the front of his dominant right arm just after beginning to lower the weight. He now reports pain in the anterior aspect of the arm that worsens when he opens a door. Examination reveals moderate ecchymosis and swelling of the forearm and tenderness in the antecubital fossa. The MRI scans are shown in Figures 15a and 15b. If the injury is left unrepaired, the greatest functional deficit will most likely be the loss of

A 28-year-old professional football player reports painless loss of ankle motion after sustaining a “severe” ankle sprain 12 months ago. A mortise radiograph is shown in Figure 1. Surgical treatment should be reserved for which of the following conditions?

An otherwise healthy 50-year-old man who is a smoker undergoes a posterior spine fusion with instrumentation for spondylolisthesis. What can the patient do to minimize his risk for pseudarthrosis?

The direct anterior (Smith-Peterson) approach to hip arthroplasty is most commonly associated with injury to what nerve?

Figure 26 shows the radiograph of a 48-year-old woman who has right arm pain and hematuria. A bone scan reveals increased uptake in the left ribs and thoracic spine. A needle biopsy specimen shows that the lesion is highly keratin positive and composed primarily of clear cells. What is the best course of action?

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

Acetabular reconstruction followed by external beam irradiation The plain radiographs show a purely lytic destructive lesion that is poorly marginated. The technetium bone scan does not show any major uptake. The computerized tomography scan shows purely lytic bone destruction with breakthrough of the cortical bone. Complete destruction of the cortical bone is suggestive of a malignancy. The magnetic resonance image shows a lesion that is homogenously low on T1-weighted images and high on T2-weighted images. Surgeons cannot make a definitive diagnosis based upon the radiographic features. The most common malignancies in this age group are:

Figures 1 and 2 are the radiographs of a 40-year-old woman who sustained a twisting injury to her lower extremity. What additional information or studies are important in determining treatment options?

• What posterior pelvic ring injury is most commonly associated with neurologic compromise?

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

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

In patients who have undergone nonsurgical management for idiopathic adhesive capsulitis, long-term follow-up studies have shown which of the following results?

A 17-year-old high school football player reports wrist pain 5 months after the conclusion of the football season. A radiograph and MRI scan are shown in Figures 29a and 29b. What is the recommended intervention?

A 10-year-old girl with a history of an obstetrical brachial plexus palsy has been referred for evaluation. Examination reveals a severe adduction internal rotation contracture of the shoulder and a mild flexion contracture of the elbow. Hand function is normal. Radiographs show mild glenohumeral joint incongruity. To achieve the best functional outcome, management should consist of

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

..Figures 87a through 87e are the radiograph, MRI scans, and biopsy specimen of an 83-year-old woman who is experiencing pain in her distal thigh with activity and at night. She has undergone total hip arthroplasty for hip osteoarthritis. The most appropriate treatment is

0 mmol/L (normal < 2.5), 1 hour postinjury it was 3.5 mmol/L, and it is now 5 mmol/L. His core temperature is 93 degrees F (34 degrees C). What is the most appropriate management for the femoral shaft fracture at this point?

A 57-year-old man with type II diabetes mellitus was successfully treated for a first occurrence forefoot full-thickness (Wagner II) diabetic foot ulcer underlying the third metatarsal head with associated hammertoe with a series of weight-bearing total contact casts. There was no evidence of osteomyelitis. The ulcer is now fully healed. He is insensate to the Semmes-Weinstein 5.07 (10 gm) monofilament. What is the next most appropriate step in management?

Figure 42 shows the radiograph of a patient with spinal muscular atrophy. Examination reveals good upper extremity function, and she can tie her shoes and propel a manual wheelchair. Posterior instrumentation and fusion may result in

Two years after undergoing a total shoulder arthroplasty, a patient reports increasing pain, stiffness, and swelling, and has an increased white blood cell count. Radiographs show lucencies around the glenoid and humeral components. You suspect infection. Which of the following is the most likely responsible organism? Review Topic

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

CLINICAL SITUATION Figures 1 and 2 are the radiographs of a 35-year-old man who has elbow pain after falling from a ladder onto an outstretched hand. Examination reveals elbow pain, swelling, limited motion, and normal neurologic function. A pathognomonic radiographic feature of this injury is a

A 47-year-old male tennis player has pain in his nondominant shoulder that has failed to respond to 4 months of nonsurgical management. Examination reveals acromial tenderness and pain at the supraspinatus tendon insertion. He has a positive impingement sign, pain on forward elevation, and minimal cuff weakness. The MRI scans are shown in Figures 30a and 30b. To completely resolve his symptoms, treatment should consist of

The plate seen in Figure 48a was applied to the fracture seen in Figure 48b, and is functioning in what capacity?

A 45-year-old man sustained the injury seen in Figure 130a 6 weeks ago. He denies any prior injury to his shoulder. After treatment of the injury in the emergency department, he was noted to have significant weakness with empty can testing and external rotation at the side. He has full passive range of motion with forward flexion, abduction, and internal and external rotation, but has difficulty initiating abduction with his arm at his side. He has negative apprehension and relocation signs. A detailed neurologic examination shows no deficits. A coronal image from a follow-up MRI scan is seen in Figure 130b. Follow-up radiographs reveal no fractures. What is the most appropriate next step in his treatment? Review Topic

In patients with displaced radial neck fractures treated with open reduction and internal fixation with a plate and screws, the plate must be limited to what surface of the radius to avoid impingement on the proximal ulna?

Which of the following factors is most commonly associated with mechanical failure of a cemented total hip arthroplasty?

Hip pain of 1-month duration has developed in a 72-year-old man with a previous total hip arthroplasty. He underwent dental work 6 weeks ago. Aspiration shows a white blood cell count of more than 6,000 cells/μL (reference range 4,500 to 11,000 cells/μL) and the presence of gram-positive cocci in clusters on Gram  stain.  The orthopaedic  surgeon recommends urgent  debridement  and irrigation. Fixation of  the components is judged to be stable, and the surgeon elects to retain the implants. The patient has a final culture  that  reveals  methicillin-resistant Staphylococcus  aureus (MRSA).  If  the  attending  physician recommends the two-stage protocol, including the use of an antibiotic-cement spacer, what is the most likely prognosis for this patient?

Which of the following illustrations shown in Figures 21a through 21e correctly shows the projection of the sacroiliac joint on the outer table of the ilium?

The great medullary artery, also known as the Adamkiewicz artery, originates from which of the following arteries?

A 35-year-old woman who is a recreational runner reports posterior knee pain and tightness in the knee with flexion during running. She denies any history of trauma. Examination reveals normal patellar glide and tilt and no patellar apprehension. Range of motion is 5 degrees to 120 degrees, and quadriceps function and knee ligamentous examination are normal. Radiographs are normal. An MRI scan is shown Figure 18. What is the most likely diagnosis?

Figures 14a and 14b show the clinical photographs of a patient who was stranded in a subzero region for several days. The photographs were taken the morning after arrival in the hospital. The patient is otherwise healthy and fit, and takes no medication. He has no clinical signs of sepsis. He reports burning pain and tingling in both feet. What is the best treatment?

What is the primary indication for performing an arthroscopic synovectomy on a patient with hemophilia that is the result of factor VIII deficiency? Review Topic

Talar compression syndrome in ballet dancers typically involves injury to which of the following structures?

A patient reports a sudden recurrence of sciatica on her left side after undergoing a successful left L4-L5 diskectomy 15 months ago. Which of the following imaging modalities is most accurate in differentiating recurrence of the disk herniation from postoperative epidural scar tissue?

A 15-year-old girl sustained the injury shown in Figures 70a and 70b when she jumped from the back of a moving truck. She is seen in the emergency department 2 hours after her injury. She has no other injuries. Her foot is warm and she has a normal motor and sensory examination. Pulses are only evident on Doppler. What is the most appropriate management? Review Topic

A 36-year-old softball player sustains a shoulder dislocation making a diving catch. The shoulder is successfully reduced in the emergency department. A postreduction MRI is shown in Figure 35. What anatomic lesion is a result of the dislocation? Review Topic

Figure 1 is the radiograph of an 18-year-old, right hand-dominant man who has right side thumb pain after a tackle during a rugby game. Examination shows ecchymosis and swelling of the right thumb along with tenderness to palpation about the thumb CMC joint and metacarpal base. What ligament is holding the small fracture fragment in anatomical location to the trapezium?

A 14-year-old boy is involved in a motor vehicle accident and sustains the injury shown in Figures 18a and 18b. What is the most likely diagnosis? Review Topic

A 58-year-old man with insulin-dependent diabetes mellitus underwent primary total knee arthroplasty (TKA). A full-thickness skin slough measuring 3 cm by 4 cm developed, with postsurgical exposure of the patellar tendon. No change is observed in the appearance of the wound after 2 weeks of wet-to-dry dressing changes. What is the best next treatment step for the soft-tissue defect?

-Figure 235 is the radiograph of a 75-year-old woman who is seen in the emergency department following a low-energy fall. What is the most appropriate treatment based on her radiographic findings?

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?

A researcher experimenting with limb patterning removes some tissue from 1 part of the limb bud (which we shall call Site A) and transplants it along the anteroposterior (AP) axis to create a mirror-hand duplication. Which of the following is true?

A 17-year-old pitcher reports pain over the medial aspect of the elbow that occurs during the acceleration phase of throwing, and it prevents him from throwing at the velocity needed to be competitive. What structure is most likely injured in this patient? Review Topic

Figure 21 is the intraoperative fluoroscopic image of a 40-year-old man who felt a pop during a twisting injury to his right ankle. He underwent open reduction and internal fixation (ORIF) of a bimalleolar ankle fracture. During the surgery the medial and lateral malleoli fractures were reduced and rigidly was internally fixed. Following fracture fixation, which additional test is recommended to ensure mortise stability?

A 7-year-old girl sustains the fracture shown in Figure 29a. Casting results in uneventful healing. Ten months later, the patient has a progressive valgus deformity of the right lower extremity. A radiograph is shown in Figure 29b. Management should now consist of

A 70-year-old woman reports anterior knee pain after undergoing an uncomplicated total knee arthroplasty 6 months ago. Examination reveals prepatellar tenderness, with no extensor lag. The radiographs shown in Figures 25a through 25c reveal a well-fixed patellar component. Management should consist of

Deep venous thromboses are primarily composed of red blood cells and fibrin. What is fibrin?

When compared with the normal anterior cruciate ligament (ACL), placement of an anterior cruciate ligament graft in the over-the-top position on the femoral side has what effect on its function?