Orthopedic Surgery Board Exam MCQs: Shoulder & Sports

About This Board Review Set

This is Part 177 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

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Two distinct learning modes are available:

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

Topics Covered in Part 177

This module focuses heavily on: Fracture, Ligament, Revision, Shoulder, Tendon.

Sample Questions from This Set

Sample Question 1: At revision, the stem is retained and a new head with a polyethylene bearing is selected.The best option for the head is...

Sample Question 2: What procedure can eliminate a sulcus sign?...

Sample Question 3: A 24-year-old man sustains the injury shown in Figures 19a through 19e in a paragliding accident. He is neurologically intact. He also sustained fractures of his left femur and right distal radius. Which of the following represents the best...

Sample Question 4: What is the primary goal of the initial (acute) rehabilitation phase of an overhead athlete’s shoulder?...

Sample Question 5: When comparing surgical and nonsurgical extremities in patients who underwent anterior cruciate ligament (ACL) reconstruction using patellar tendon or hamstrings autografts, isokinetic strength measurements obtained 6 months after the surge...

Why Active MCQ Practice Works

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

Comprehensive 100-Question Exam

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Question 1

At revision, the stem is retained and a new head with a polyethylene bearing is selected. The best option for the head is

Explanation

DISCUSSION
Ceramic-on-ceramic is a controversial bearing surface typically reserved for younger patients such as this one. Some studies have suggested that the bearing is more expensive and does not really prolong the service life of the implant, although a recent meta-analysis of high-quality trials showed that there is a decreased revision rate with ceramic-on-ceramic, so its use may be justified. Complications of intraoperative bearing fracture and squeaking are more common than with conventional bearings, but pain and function scores are equivalent. Stripe wear associated with a vertical cup and morbid obesity are related to an increased risk for liner fracture. Concerns about head fractures with a new ceramic head and a damaged trunnion have led investigators to conclude that using a harder bearing than the initial bearing surface with a built-in titanium sleeve is probably the best solution when a stem is retained during revision surgery.

Question 2

What procedure can eliminate a sulcus sign?

Explanation

DISCUSSION: A sulcus sign represents inferior subluxation of the shoulder. The elimination of this sign and correction of the inferior subluxation is best achieved through either an open or arthroscopic rotator interval closure. A SLAP repair stabilizes the biceps anchor but does not affect the sulcus sign. A Bankart repair, which corrects anterior-inferior laxity, is not sufficient to eliminate a sulcus sign. Subacromial decompression and supraspinatus repairs have no effect on inferior subluxation.
REFERENCES: Field LD, Warren RF, O’Brien SJ, et al: Isolated closure of rotator interval defects for shoulder instability. Am J Sports Med 1995;23:557-563.
Cole BJ, Rodeo SA, O’Brien SJ, et al: The anatomy and histology of the rotator interval capsule of the shoulder. Clin Orthop 2001;390:129-137.

Question 3

A 24-year-old man sustains the injury shown in Figures 19a through 19e in a paragliding accident. He is neurologically intact. He also sustained fractures of his left femur and right distal radius. Which of the following represents the best option for management of the spinal injury?

Explanation

DISCUSSION: The injury pattern is that of a burst fracture at L1 contiguous with a compression fracture at T12. There is associated kyphosis and slight spondylolisthesis of T12 on L1. Treatment of this type of burst fracture in neurologically intact patients is somewhat controversial, with at least one study demonstrating equal long-term results comparing nonsurgical treatment to surgical treatment. In this study, however, body casts were used initially in the nonsurgical group. Moreover, because this patient has multiple fractures, spinal fracture stabilization should be considered to facilitate early mobilization. Surgical stabilization and fusion via a posterior approach is the best treatment option in this patient. Anterior decompression is not necessary since the patient is neurologically intact.
REFERENCES: McLain RF, Benson DR: Urgent surgical stabilization of spinal fractures in polytrauma patients. Spine 1999;24:1646-1654.
Wood K, Butterman G, Mehbod A, et al: Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit: A prospective, randomized study.

J Bone Joint Surg Am 2003;85:773-781.
Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 201-216.

Question 4

What is the primary goal of the initial (acute) rehabilitation phase of an overhead athlete’s shoulder?

Explanation

DISCUSSION: The goal in the initial phase of shoulder rehabilitation is to improve flexibility, reestablish baseline dynamic stability, normalize muscle balance, and restore proprioception. In the advanced strengthening and final phase, the goals are to initiate aggressive strengthening drills, enhance power and endurance, perform functional drills, and to gradually initiate throwing activities.
REFERENCES: Wilk KE, Meister K, Andrews JR: Current concepts in the rehabilitation of the overhead throwing athlete. Am J Sports Med 2002;30:136-151.
Wilk KE, Arrigo C: Current concepts in the rehabilitation of the athletic shoulder. J Orthop Sports Phys Ther 1993;18:365-378.

Question 5

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

Explanation

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

Question 6

A 26-year-old mixed martial arts fighter sustains a posterolateral elbow dislocation. The primary stabilizers of the elbow joint are the

Explanation

The primary stabilizers of the elbow are the ulnohumeral joint, the lateral collateral ligament (lateral epicondyle to the crista supinatoris), and the anterior band of the medial collateral ligament (anterior inferior medial epicondyle to the sublime tubercle). Secondary stabilizers are the radial head, the common flexor and
extensor origins, and the joint capsule. The muscles that cross the elbow joint act as dynamic stabilizers.

Question 7

A 42-year-old man has a symptomatic flatfoot deformity and walks with a slight limp after falling off a scaffold 9 months ago. He also reports that he has had difficulty returning to work. Orthotics have failed to provide relief. Current radiographs are shown in Figures 19a and 19b. To relieve his pain and return the patient to work, treatment should consist of

Explanation

DISCUSSION: Because the patient has sustained a tarsometatarsal injury with midfoot sag, the treatment of choice is a tarsometatarsal arthrodesis. The cause of his flatfoot deformity is secondary to the tarsometatarsal injury and not from posterior tibialis tendon deficiency. Lateral column lengthening, double arthrodesis, and calcaneal osteotomy are not indicated. Although open reduction and internal fixation may be performed late when arthritis is present, these procedures are less likely to succeed.
REFERENCES: Komenda GA, Myerson MS, Biddinger KR: Results of arthrodesis of the tarsometatarsal joints after traumatic injury. J Bone Joint Surg Am 1996;78:1665-1676.
Sangeorzan BJ, Veith RG, Hansen ST Jr: Salvage of Lisfranc’s tarsometatarsal joint by arthrodesis. Foot Ankle 1990;10:193-200.

Question 8

An active 36-year-old woman with rheumatoid arthritis has continued forefoot discomfort despite the use of orthotics and shoe wear modifications. A radiograph and a clinical photograph are shown in Figures 26a and 26b. Treatment at this point should consist of

Explanation

DISCUSSION: In a patient with inflammatory arthritis, advanced hallux valgus deformity in conjunction with lesser metatarsophalangeal joint destruction and subluxation warrants fusion of the first metatarsophalangeal joint and lesser metatarsal head resections. Hallux valgus correction will fail because of incompetent soft tissues. A Keller resection arthroplasty is not indicated in this age group. Synovectomy is contraindicated because of evidence of erosive changes of the lesser metatarsophalangeal joints.
REFERENCES: Ouzounian T: Rheumatoid arthritis of the foot & ankle, in Myerson MS (ed): Foot & Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, vol 2, pp 1189-1204.
Mann RA, Thompson FM: Arthrodesis of the first metatarsophalangeal joint for hallux valgus in rheumatoid arthritis. J Bone Joint Surg Am 1984;66:687-692.
Coughlin MJ: Rheumatoid forefoot reconstruction: A long-term followup study. J Bone Joint Surg Am 2000;82:322-341.

Question 9

Following a vertebroplasty of L2, cement is noted to protrude directly anterior to the L2 vertebral body. The cement is closest to which of the following structures?

Explanation

DISCUSSION: At the level of L2, the liver and the vena cava lie to the right. The pancreas

and duodenum are anterior to the aorta. The aorta lies in the midline just in front of the

vertebral body.
REFERENCES: Clement CD: Anatomy: A Regional Atlas of Human Anatomy, ed 3.

Baltimore, MD, Munich, Germany, Urban and Schwarzberg, 1987, Figure 331.
Netter FH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy, 1989, plate 328.

Question 10

Trabecular bone is remodeled through the formation of

Explanation

Trabecular bone is remodeled through osteoclast activation that creates a resorption pit known as a Howship lacuna. After the pit is formed, osteoclasts are replaced by osteoblasts that form new bone matrix. The cement line separates new bone formation from resorption. Cutting cones are created in cortical bone remodeling. Haversian canals carry nerves and blood vessels longitudinally in bone, while Volkmann canals connect different Haversian canals.

Question 11

What is the most common sequela of turf toe (hyperextension of the first metatarsophalangeal joint)?

Explanation

The reference article Turf Toe by Rodeo et al 1990 looked at 80 professional football players and occurrence of turf toe. This study consisted of a questionnaire and physical exam. In a nut shell, 85% of players with turf toe sustained their initial injury on artificial turf. Although turf toe accounted for 6 cases per year and ankle sprains 24.7 cases per year turf toe accounted for more missed games. The advent of artificial surfaces and lighter, more flexible shoes for use on artificial turf are suspected causes for the increased incidence of turf toe. The most common mechanism is a hyperextension injury to the MTPJ of a foot in a slightly dorsiflexed position. The injury is a sprain to the capsuloligamentous complex.
What they found was a decreased ROM of the first MTPJ in patients with turf toe and stated that it demonstrates the POSSIBILITY of long-term sequelae to the turf toe injury and that hallux rigidus must be considered in the athlete with progressively limited ROM. Other possible
sequelae cited were hallux valgus, production of a dorsal osteophyte, calcification in periarticular soft tissue, and chondromalacia of the head of the first metatarsal. NO MENTION WAS MADE OF THE MOST COMMON SEQUELAE OF TURF TOE!
Clanton & Schon Chapter 27 Mann Foot & Ankle state that it remains unclear whether these sprains (turf toe) will ultimately result in arthritic changes in the affected joint. No mention is made of hallux rigidus. Again in Mann Chapter 14 on hallux rigidus states that the etiology is degenerative arthritis of the first MTPJ and what predisposes the patient to degenerative arthritis is not known. No mention is made of turf toe.

Question 12

Stemless shoulder arthroplasty prostheses have recently been suggested as an alternative to traditional stemmed replacement. Advantages of the stemless surgical technique would include

Explanation

Glenoid exposure, while better than with surface replacements, is not improved over traditional stemmed replacements. Metaphyseal comminution would make it unlikely that a stemless implant could be used in most four-part fractures. Stemless replacement does have the unique advantage of allowing placement of a prosthesis with a malunion without an osteotomy, as the prosthesis is not constrained by the position of the stem. While early results are encouraging, there is no long-term data to suggest that survivorship is increased
with stemless arthroplasty.

Question 13

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?

Explanation

DISCUSSION: The patient has no clinical or observed signs of sepsis. The skin just proximal to the gangrenous tissue appears somewhat hyperemic and is clearly viable. These wounds should be managed much like burn wounds. Moist dressings should be used until the tissue clearly demarcates. Much of the insult may simply be superficial and only require late debridement.
REFERENCES: McAdams TR, Swenson DR, Miller RA: Frostbite: An orthopedic perspective.

Am J Orthop 1999;28:21-26.
Taylor MS: Cold weather injuries during peacetime military training. Milit Med 1992;157:602-604.

Question 14

A young male patient underwent intramedullary nail fixation for a diaphyseal femur fracture. A post-operative CT scanogram is performed to assess rotational alignment between the surgical and non-surgical femur. Which of the following measurement(s) are considered acceptable differences in regards to femoral rotational malreduction after intramedullary nail fixation as compared to the uninjured femur?

Explanation

All of the above Corrent answer: 4
The maximum acceptable difference in rotational malreduction between the surgical and contralateral legs for femoral version is 15°. Therefore, answers 1 and 2 are correct.
Normal femoral neck anteversion is approximately 11-13°, with a normal range between 5-20°. The variation within the same patients can also be up to 15° difference between limbs. Current literature has shown that this 15° difference is well tolerated by patients, including when this has occured as a result of rotational malreduction following intramedullary nail fixation for a diaphyseal femur fracture.
Ayalon et al. aimed to compare the difference in femoral version (DFV) after intramedullary nailing performed by a trauma-trained and non-trauma trained surgeon. The mean post-operative DFV was 8.7° in these patients, compared to 10.7° in those treated by surgeons of other subspecialties. Post-operative version or percentage of DFV >15° did not significantly differ between these two groups.
Omar et al. studied the utility of pre-operative 'virtual reduction' of bilateral femoral fractures that were initially stabilized with external fixation. After external fixation, the mean rotational difference between both legs was 15.0°
± 10.2°. Following virtual reduction, the mean rotational difference between both legs was 2.1° ± 1.2°, after intramedullary nailing, compared to 6.1° ±

Question 15

A 65-year-old woman with rheumatoid arthritis is unable to actively extend her index, middle, ring, and little fingers secondary to tendon rupture. In performing a flexor digitorum sublimis (FDS) of the middle/ring finger to extensor digitorum communis (EDC) transfer to restore active metacarpophalangeal (MCP) joint extension, the FDS should be passed

Explanation

Although the early use of FDS as a transfer to restore finger extension in patients with radial nerve palsy was performed by passing the tendon through the interosseous membrane, Nalebuff and Patel later modified this procedure for the rheumatoid arthritis patient by passing the FDS radially, around the radius in a dorsal direction. They felt that this provided a number of advantages, including: 1. technical ease, 2. avoidance of synovial disease on the dorsum of the wrist, and 3. correction of ulnar deviation of the fingers through the line of pull from the radial side of the forearm.

Question 16

A 24-year-old man is involved in a motor vehicle accident at 60 mph. He sustains multiple injuries including an intra-abdominal injury requiring a splenectomy and a closed right femoral shaft fracture. Which variable will best indicate the patient's resuscitation status when deciding whether to proceed with definitive care of the fracture at the conclusion of the laparotomy? Review Topic

Explanation

A metabolic parameter such as the base deficit or lactate level has been shown to better reflect the resuscitation status and survival after trauma. Normalization of hemodynamic parameters does not accurately reflect the resuscitation status and a patient can be in compensated shock (occult tissue hypoperfusion) despite normalization of the heart rate and blood pressure. The use of temporizing measures with delayed definitive fracture treatment has been shown to decrease systemic complications in these patients with occult hypoperfusion.

Question 17

Figure 23 is the T2 axial MRI scan of a 21-year-old man who was injured while playing for his college football team. His pain was aggravated with blocking maneuvers and alleviated with rest, and he had to stop playing because of the pain. What examination maneuver most likely will reproduce his pain? Review Topic

Explanation

This patient has a mechanism of injury and MRI consistent with a posterior labral tear and posterior instability. Flexion, adduction, and internal rotation produce a net posterior vector on the glenohumeral joint and should reproduce this patient's symptoms. Pain or instability with the arm elevated in the scapular plane describes an impingement sign. Pain or instability with the arm in external rotation and abduction describes the apprehension sign. Pain or instability with the arm in flexion and abduction is a nonspecific finding.

Question 18

A 10-lb, 2-oz infant who was born via a difficult breech delivery 12 hours ago is now being evaluated for hip pain. Although the infant is resting comfortably, examination reveals that the patient is not moving the right lower extremity and manipulation of the right hip causes the infant to cry. The Galeazzi sign is positive. An AP radiograph of the pelvis shows proximal and superior migration of the right proximal femoral metaphysis. What is the most likely diagnosis?

Explanation

DISCUSSION: Transphyseal fractures of the proximal femur at birth are more likely to occur in large newborns after a difficult delivery. At rest, the patients are comfortable and show a pseudoparalysis; however, passive motion of the lower extremity results in discomfort. Teratologic hip dislocations will have a positive Galeazzi sign, but are not painful. Development of a septic hip would be unlikely within 12 hours postpartum. Congenital coxa vara is typically painless. Postpartum ligamentous laxity might account for a positive Ortolani sign, but is painless.
REFERENCES: Weinstein JN, Kuo KN, Millar EA: Congenital coxa vara: A retrospective review. J Pediatr Orthop 1984;4:70-77.
Beaty JH: Orthopaedic Knowledge Update 6. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1999, pp 409-425.

Question 19

Compared with percutaneous pinning with Kirschner wires (K-wires), the treatment of metacarpal neck fractures with cannulated intramedullary screws is associated with

Explanation

EXPLANATION:
In a biomechanical study, headless compression screws showed superior load to failure, higher three-point bending strength, and greater strength in axial loading compared with percutaneous K-wire fixation for metacarpal neck fractures. Headless compression screws provide greater initial stability to allow earlier motion in the postoperative period. No data comparing infection rates between the two methods of fixation are available; however, it is assumed that K-wires placed outside of the skin would have increased rates of infection. Neither fixation method would increase the time to healing.

Question 20

A 26-year-old football player develops tachycardia and hot, dry skin during a game. He is found to have a temperature of 41 degrees C, but is not sweating. Further examination reveals the player is not oriented to time or place, and he soon develops convulsions. Which of the following is the most important next step in treatment? Review Topic

Explanation

The patient in the vignette has heat stroke; this condition is treated with rapid reduction in core body temperature through the use of ice immersion, cooling blankets, and/or internal cooling for a goal temperature below 39 C.
Heat stroke is a medical emergency with a high mortality rate. The hallmark features include central nervous system dysfunction and anhidrosis. Other symptoms include behavioral changes, such as confusion, disorientation, and staggering. Seizures and unconsciousness can also develop. The first modality of treatment is rapid reduction in temperature, which can be accomplished through ice water immersion, cooling blankets, or evaporative cooling methods including fans and cold water sprays. The goal in temperature reduction is 0.2 C per minute for a target temperature of 39 C.
Casa et al. reviewed current literature regarding the cause and care of exertional heat stroke. They stated that mortality from heat stroke remained significant, with the highest rates from sports existing between 2005 and 2009. They recommended accurate temperature assessment, prompt aggressive treatment using an efficient cooling modality (i.e. cold water or ice water immersion) prior to transport, and medically supervised return to play/duty as essential to preventing mortality.
Illustration A shows some of the visible differences between heat stroke and exhaustion, with the key discriminator being mental status changes present in heat stroke.
Incorrect Answers:

Question 21

The mechanism for the osseous destruction is attributable to

Explanation

DISCUSSION
This scenario is a classic example of the development of Charcot foot. A red, swollen, deformed foot without ulceration suggests neuroarthropathy. Normal inflammatory marker findings, no history of fever or chills, and radiographs demonstrating bone loss support the diagnosis. Limb elevation with dramatic reduction in erythema is also characteristic of this disease process and does not occur with infection. Total-contact casting is the cornerstone of treatment for acute Charcot disease. Hemoglobin A1C is an indicator of glucose averaged over a 3-month period, providing the most reliable indication of a patient's ongoing glucose control. The pathophysiology of bone destruction is believed to be hypervascularity of bone. Infection and Charcot disease may develop simultaneously, but the combination is rare.
RECOMMENDED READINGS
Kaynak G, Birsel O, Güven MF, Ogüt T. An overview of the Charcot foot pathophysiology. Diabet Foot Ankle. 2013 Aug 2;4. doi: 10.3402/dfa.v4i0.21117.Print 2013. PubMed PMID: 23919113.View Abstract at PubMed
Pinzur MS, Lio T, Posner M. Treatment of Eichenholtz stage I Charcot foot arthropathy with a weightbearing total contact cast. Foot Ankle Int. 2006 May;27(5):324-9. PubMed PMID: 16701052. View Abstract at PubMed

Question 22

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

Explanation

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

Question 23

A 25-year-old male polytrauma patient undergoes initial temporary external fixation for a femoral shaft fracture. He is converted to a femoral nail at 7 days. This management can be expected to result in

Explanation

DISCUSSION: Recently Harwood and associates investigated the principles of damage control orthopaedics (DCO) as they apply to patients with femoral shaft fractures. When they compared those who underwent initial external fixation of femoral shaft fractures with conversion to an intramedullary nail to those who underwent intramedullary nailing as their initial treatment, they found the following: overall infection rates were comparable in patients receiving DCO versus primary intramedullary fixation; open fracture was an independent risk factor for infection regardless of the treatment method; contamination rates in external fixator pin sites rose considerably when left in place more than 2 weeks and logistic regression analysis suggests that infection rates may increase when conversion to an intramedullary nail occurs after 2 weeks following external fixation; and there was no significant difference in time to union among treatment groups.
REFERENCES: Harwood PJ, Giannoudis PV, Probst C, et al: The risk of local infective complications after damage control procedures for femoral shaft fracture. J Orthop Trauma 2006;20:181-189.
Roberts CS, Pape HC, Jones AL, et al: Damage control orthopaedics: Evolving concepts in the treatment of patients who have sustained orthopaedic trauma. Instr Course Lect

2005;54:447-462.

Question 24

In a patient with a soft-tissue sarcoma treated by wide excision and radiation therapy, the risk of subsequent fracture is probably most influenced by

Explanation

DISCUSSION: While most pathologic fractures are in the lower extremity in patients treated for soft-tissue sarcomas by wide excision and adjuvant radiation therapy, risk factors for such fractures are bone resection associated with excision of the tumor and soft-tissue sarcomas of the thigh that require periosteal stripping at the time of resection. Such fractures can occur late, often more than 6 months after surgery, are difficult to treat, and often result in nonunion.
REFERENCES: Bell RS, O’Sullivan B, Nguyen C, et al: Fractures following limb-salvage surgery and adjuvant irradation for soft-tissue sarcoma. Clin Orthop 1991;271:265-271.
Lin PP, Boland PJ, Healey JH: Treatment of femoral fractures after irradiation. Clin Orthop 1998;352:168-178.

Question 25

Second impact syndrome (SIS) after head injury is characterized by which of the following? Review Topic

Explanation

SIS is a devastating but preventable complication of head injury. It occurs when return to activities is allowed prior to complete resolution of the symptoms of the first head injury. A second, sometimes trivial, head injury can lead to a devastating series of events that can result in sudden death. The symptoms tend to progress rapidly and often involve the brain stem. The prognosis is poor.

Question 26

A 3-year-old child has refused to walk for the past 2 days. Examination in the emergency department reveals a temperature of 102.2 degrees F (39 degrees C) and limited range of motion of the left hip. An AP pelvic radiograph is normal. Laboratory studies show a WBC count of 9,000/mm P 3 P , an erythrocyte sedimentation rate (ESR) of 65 mm/h, and a C-reactive protein level of 10.5 mg/L (normal < 0.4). What is the next most appropriate step in management?

Explanation

DISCUSSION: Examination reveals an irritable hip, creating a differential diagnosis of transient synovitis versus pyogenic hip arthritis. Kocher and associates described four criteria to help predict the presence of infection: inability to bear weight, fever, ESR of more than 40 mm/h, and a peripheral WBC count of more than 12,000/mmP³^P. This patient meets three of the four criteria, with a positive predictive value of 73% to 93% for joint infection. Therefore, aspiration of the hip is warranted, with a high likelihood that emergent hip arthrotomy will be indicated. Ideally, intravenous antibiotics should be administered after culture material has been obtained from needle aspiration of the hip. An urgent bone scan is better indicated as a screening test for sacroiliitis or diskitis. If the arthrocentesis proves negative, CT or MRI of the pelvis may be indicated to rule out a pelvic or psoas abscess.
REFERENCES: Del Beccaro MA, Champoux AN, Bockers T, et al: Septic arthritis versus transient synovitis of the hip: The value of screening laboratory tests. Ann Emerg Med 1992;21:1418-1422.
Kocher MS, Mandiga R, Zurakowski D, et al: Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am 2004;86:1629-1635.
Kocher MS, Zurakowski D, Kasser JR: Differentiating between septic arthritis and transient synovitis of the hip in children: An evidence-based clinical prediction algorithm. J Bone Joint Surg Am 1999;81:1662-1670.

Question 27

A 58-year-old man with a 50-year history of osteomyelitis of the left tibia has a painful ulceration of the anterior lower limb. Figure 1 is the clinical photograph of the wound, which had purulent discharge and an unpleasant odor. Figures 2 and 3 are radiographs of the left tibia. A biopsy reveals malignant degeneration. What are the most likely findings?

Explanation

Discussion: Squamous cell carcinoma is the most common type of malignant tumor deriving from chronic osteomyelitis. The most frequently affected site is the tibia, followed by the femur. When the neoplasm invades the bone, there is either osteolytic erosion or a pathological fracture. Diagnosis is confirmed by biopsy at all suspicious wound sites. The malignant transformation most often results in squamous cell carcinoma and much more rarely in fibrosarcoma, osteosarcoma, reticulosarcoma, malignant fibrous histiocytoma or angiosarcoma. Many experts accept amputation as the best treatment option for carcinomatous transformation of chronic bone infections.

Question 28

A 52-year-old woman with a 2-year history of a flexible (stage II) adult-acquired flatfoot deformity has failed to respond to nonsurgical management consisting of immobilization, custom orthotics, nonsteroidal anti-inflammatory drugs, and physical therapy. The patient is unable to perform a single limb heel rise. Weight-bearing radiographs are shown in Figures 30a through 30c. What is the most appropriate surgical correction?

Explanation

DISCUSSION: The patient has an atypical adult flatfoot deformity. The radiographs reveal forefoot abduction, mild loss of calcaneal pitch, and marked plantar flexion sag through the naviculocuneiform joint. The inability to perform a single limb heel rise indicates that the posterior tibial tendon is nonfunctional; however, the deformity remains flexible. In this patient, surgical treatment should include a tendon transfer, lateral column lengthening, medial column arthrodesis, and heel cord lengthening. Because a substantial portion of the deformity stems from the naviculocuneiform joint in this instance, tendon transfer and lateral column lengthening alone provide insufficient deformity correction. Triple arthrodesis and heel cord lengthening is best reserved for fixed flatfoot deformities. Soft-tissue procedures alone are associated with a high failure rate, as are attempted tendon repairs.
REFERENCES: Greisberg J, Assal M, Hansen ST Jr, et al: Isolated medial column stabilization improves alignment in adult-acquired flatfoot. Clin Orthop Relat Res 2005;435:197-202.
Greisberg J, Hansen ST Jr, Sangeorzan BJ: Deformity and degeneration in the hindfoot and midfoot joints of the adult acquired flatfoot. Foot Ankle Int 2003;24:530-534.

Question 29

Figures 1 through 3 show the radiographs obtained from a 40-year-old woman who injured her right index finger in a bicycle collision. Failure to restore sagittal plane alignment would likely result in

Explanation

EXPLANATION:
The radiographs reveal an extra-articular proximal phalanx fracture of the index finger. The fracture is comminuted with dorsal angulation of the distal fragment. The question specifically asks about the restoration of sagittal alignment. The fracture is comminuted with dorsal angulation of the distal fragment. The other options are incorrect, because overlapping of the digits occurs with rotational malalignment, the development of arthritis may occur with intra-articular fractures, and hyperextension would not occur with this type of deformity.

Question 30

Myositis ossificans is a recognized complication of contusion to the quadriceps muscle. During early rehabilitation, this condition is most likely to be exacerbated by

Explanation

DISCUSSION: Passive stretching is contraindicated during rehabilitation as it may potentiate the severity of the myositis ossificans. Electrical stimulation, iontophoresis, isometric exercise, and ice/heat contrast are not known to exacerbate this process.
REFERENCES: Brunet ME, Hontas RB: The thigh, in DeLee JC, Drez D (eds): Orthopaedic Sports Medicine. Philadelphia, PA, WB Saunders, 1994, pp 1086-1112.
Cushner FD, Morwessel RM: Myositis ossificans traumatica. Orthop Rev 1992;21:1319-1326.

Question 31

Long bone fracture repair following intramedullary stabilization occurs primarily through which of the following healing mechanisms?

Explanation

DISCUSSION: The mechanical environment represents a major factor in the type of healing that occurs after a fracture. Intramedullary nail fixation allows for motion at the fracture site, which promotes bone formation both directly (intramembranous ossification) and through a cartilage intermediate (endochondral ossification). Absolute stability, as would be obtained with a compression plate, favors healing through the direct formation of bone without a cartilage intermediate (intramembranous ossification), or primary fracture repair. This type of healing would include the remodeling of the bone ends through the direct contact of bone, often referred to as contact healing or haversian remodeling.
REFERENCES: Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 385-386.
Buckwalter JA, Einhorn TA, Bolander ME: Healing of the musculoskeletal tissues, in Rockwood CA Jr, Green DP, Bucholz RW, et al (eds): Rockwood and Green’s Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, pp 261-276.

Question 32

Figures 48a and 48b show the radiographs of a 26-year-old woman who fell down two steps and twisted her foot and ankle. What is the most appropriate treatment for this injury?

Explanation

DISCUSSION: The patient has a zone 1 base of the fifth metatarsal fracture (Pseudojones) that represents a less serious injury compared to zone 2 and 3 fractures with regard to healing potential. Treatment is symptomatic and casting is not necessary. These fractures are well treated with a hard-soled shoe for comfort and weight bearing as tolerated. Surgical intervention is not warranted.
REFERENCES: Vorlat P, Achtergael W, Haentjens P: Predictors of outcome of non-displaced fractures of the base of the fifth metatarsal. Int Orthop 2007;31:5-10.
Wiener BD, Linder JF, Giattini JF: Treatment of fractures of the fifth metatarsal: A prospective study. Foot Ankle Int 1997;18:267-269.
Early JS: Fractures and dislocations of the midfoot and forefoot, in Bucholz R, Heckman JD, Court-Brown CM (eds): Rockwood and Green’s Fractures in Adults. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, pp 2337-2400.

Question 33

What is the most important predictor of functional outcome in patients with myelomeningocele?

Explanation

DISCUSSION: The functional motor level of the patient is of prime importance in determining prognosis and outcome. Patients with thoracic and upper lumbar motor levels will need wheelchairs or hip-knee- ankle-foot orthoses to ambulate at all. Patients with midlumbar motor levels can be household or limited community walkers, whereas children with low lumbar or sacral motor levels are likely to be able to walk in the community.
REFERENCES: Abel MF (ed): Orthopaedic Knowledge Update: Pediatrics 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 117-120.
Swank M, Dias L: Myelomeningocele: A review of the orthopaedic aspects of 206 patients treated from birth with no selection criteria. Dev Med Child Neurol 1992;34:1047-1052.

Figure 46a Figure 46b

Question 34

A right-handed 35-year old man who underwent a Putti-Platt repair for recurrent anterior instability 20 years ago now has increasing shoulder pain and stiffness. Examination of the shoulder reveals internal rotation to the posterior superior iliac spine and external rotation to 10 degrees with the shoulder adducted. The supraspinatus and infraspinatus are moderately atrophied. What is the most likely diagnosis?

Explanation

Osteoarthrosis of the glenohumeral joint is a potential late complication of the anterior Putti-Platt capsulorrhaphy. Disabling pain in the shoulder began an average of 13.2 after a Putti-Platt repair that had been done for recurrent anterior unidirectional instability. Osteoarthrosis of the glenohumeral joint resulted in substantial limitation of motion. Complications of the Putti-Platt surgery include persistent pain, recurrent subluxation or dislocation, or residual weakness of the shoulder; paresthesias of the musculocutaneous nerve, and infection. This late complication develops when the repair is excessively tight, a 20-25 degree limitation of full external rotation is desired and expected after rehabilitation. The most direct correlation with the severity of osteoarthrosis was the degree of limitation of external rotation.

Question 35

What radiographic measurement is best used to assess the adequacy of deformity correction for the patient shown in Figure 22?

Explanation

DISCUSSION: Developmental coxa vara develops in early childhood and results in a progressive decrease in the proximal femoral neck-shaft angle with growth. The characteristic radiographic features are seen in this patient and include a decreased neck-shaft angle, a more vertical position of the physeal plate, and a triangular metaphyseal fragment in the inferior femoral neck, surrounded by an inverted radiolucent Y pattern. The main goal of surgery is to correct the varus angulation into a more normal range. Valgus overcorrection is preferred. A recent study emphasized the importance of adequately correcting the Hilgenreiner physeal angle to less than 38 degrees to minimize the risk of recurrent angulation. No study has documented the use of any of the other listed radiographic measurements to the outcome of treating developmental coxa vara.
REFERENCES: Carroll K, Coleman S, Stevens PM: Coxa vara: Surgical outcomes of valgus osteotomies. J Pediatr Orthop 1997;17:220-224.
Cordes S, Dickens DR, Cole WG: Correction of coxa vara in childhood: The use of Pauwels’ Y-shaped osteotomy. J Bone Joint Surg Br 1991;73:3-6.

Question 36

Figures 1 through 4 are the CT scans and intraoperative image of a 17-year-old boy who sustained a gunshot wound to his knee. What is the most appropriate definitive surgical management for his articular cartilage defect?

Explanation

The images show a full-thickness cartilage defect with significant bony involvement >4 cm2. Microfracture should be considered for lesions <2 cm2 without an underlying osseous defect. Autologous chondrocyte implantation, although used for lesions between 1 and 10 cm2, should be restricted for defects with minimal (<8 mm depth) bone loss. Osteochondral allograft transfer with the mosaicplasty technique (transfer of multiple plugs) would be well-suited for this large defect with significant osseous involvement. Dejour trochleoplasty is performed for patellar instability to correct trochlear dysplasia and would not be indicated in this case.

Question 37

A favorable outcome following nonsurgical management of a partial tear of the posterior cruciate ligament (PCL) is best associated with

Explanation

DISCUSSION: Rehabilitation of the quadriceps muscle following a partial tear of the PCL has been associated with a favorable outcome. The quadriceps acts an antagonist to the PCL because its contraction results in anterior tibial translation, which reduces the tensile stress on the injured ligament. Strengthening of the hamstring musculature increases posterior tibial translation and is contraindicated during the early rehabilitative phase following a PCL injury. Brace use has not been found to significantly alter the outcome following nonsurgical management of PCL tears.
REFERENCES: Parolie JM, Bergfeld JA: Long-term results of nonoperative treatment of isolated posterior cruciate ligament injuries in the athlete. Am J Sports Med 1986;14:35-38.
Griffin JR, Annunziata CC, Harner CD: Posterior cruciate ligament injuries in the adult, in Drez D, DeLee JD, Miller MD (eds): Orthopaedic Sports Medicine Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, pp 2083-2106.

Question 38

Which factor is most important when attempting to prevent interbody graft subsidence?

Explanation

DISCUSSION
Osteoporosis can affect all aspects of spinal stability and is the most critical factor regarding spinal implant failure. Burring of the end plates may decrease strength of the interface with the uncovering of "softer" cancellous bone. Increasing the surface contact area may help prevent subsidence but is not as important as bone quality. Stress shielding through rigid fixation may lead to construct failure.
RECOMMENDED READINGS
Benzel E (ed): Biomechanics of Spine Stabilization. Rolling Meadows, IL, American Association of Neurological Surgeons, 2001, pp 446-447.
Goldhahn J, Reinhold M, Stauber M, Knop C, Frei R, Schneider E, Linke B. Improved anchorage in osteoporotic vertebrae with new implant designs. J Orthop Res. 2006 May;24(5):917-25. PubMed PMID: 16583445. View Abstract at PubMed

Question 39

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 40

A 10-year-old boy has 2 months of right knee pain that started at summer camp. The patient denies constitutional symptoms. There is no lymphadenopathy present. CT of the chest shows no signs of metastatic disease. Imaging studies and biopsy results are shown in Figures A-E. What is the most likely diagnosis?

Explanation

The age, imaging and histology are consistent with an osteosarcoma. The radiograph shows an aggressive (lytic, mottled, sclerotic) appearing lesion around the distal femur metadiaphyseal region. The T2 weighted MRI image shows a significant soft tissue mass which appears to arise from the distal femur with destruction of the adjacent cortex. The biopsy shows an infiltrative pattern with elements of osteoid and bone.
Treatment for osteosarcoma includes neoadjuvant chemotherapy, wide resection, and adjuvant chemotherapy.

Question 41

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 42

A 35-year-old woman undergoes an L4-5 anterior fusion via a left retroperitoneal approach. Postoperative examination reveals that her right foot is cool and pale. Her neurologic examination is normal, and her pedal pulses are asymmetric. What is the most likely reason for the right foot finding?

Explanation

DISCUSSION: The lower extremity symptoms are consistent with a sympathectomy that is the result of an injury to the sympathetic chain, ipsilateral to the approach along the anterior border of the lumbar spine. This results in a warm, red foot, which creates the appearance that the normal cooler foot may have compromised circulation. The latter generally attracts greater attention because of the risks associated with limb ischemia. The condition usually is self-limited and does not require any specific treatment.
REFERENCES: Rothman RH, Simeone FA (eds): The Spine, ed 4. Philadelphia PA, WB Saunders, 1999, p1550.
Benzel EC (ed): Spine Surgery Techniques, Complication Avoidance and Management. New York, NY, Churchill Livingstone, 1999, p 190.

Question 43

A 35-year-old woman began to train for a half marathon. After 8 weeks of increasing her mileage, what changes can you expect in her Achilles tendon?

Explanation

Training increases turnover of type I collagen, promoting both synthesis and degradation of collagen and a net increase synthesis of type I collagen in tendon-related tissue. Strenuous endurance training has resulted in decreased collagen cross-links, suggesting increased collagen turnover, but decreased collagen maturation. In human studies, physical training results in increased turnover of collagen. Synthesis and degradation are elevated initially when beginning an exercise program, but degradation products decrease overall. It is not known if activity levels in humans affect the diameter of collagen fibrils or the cross-sectional area of tendons.

Question 44

A 75-year-old woman with rheumatoid arthritis and a long history of oral corticosteroid use sustains a comminuted intra-articular distal humerus fracture. What is the best surgical option?

Explanation

TEA is the best surgical option. McKee and associates published a multicenter randomized controlled trial comparing ORIF with TEA in elderly patients. TEA resulted in better 2-year clinical functional scores and more predictable outcomes compared with ORIF. TEA was also likely to result in a lower resurgical rate; one- quarter of patients with fractures randomized to ORIF could not achieve stable fixation. Further, Frankle and associates reported a comparative study of TEA versus ORIF in 24 elderly women. TEA outcomes were again
superior to ORIF at a minimum of 2 years of follow-up. TEA was especially useful in patients with comorbidities that compromise bone stock, including osteoporosis and oral corticosteroid use. Closed
reduction and percutaneous pinning studies have not been published on the adult population.

Question 45

Figure 54 is the lateral radiograph of a 55-year-old man who is evaluated for a 2-year history of pain and stiffness of his right metatarsophalangeal (MTP) joint. Upon examination he has dorsal bossing, severe crepitation, and pain with passive range of motion. There is pain with the "grind" test. Dorsiflexion is limited to 0 degrees. No sesamoid tenderness is present. What is the most appropriate surgical treatment?

Explanation

DISCUSSION
The radiograph reveals end-stage degenerative changes of the first MTP joint with a dorsal loose body. MTP arthritis and decreased joint dorsiflexion is referred to as hallux rigidus. A chevron bunionectomy is used to correct hallux valgus deformity without arthritis. The cheilectomy is used in lesser degrees of joint destruction. Resection of the proximal phalanx results in a floppy toe and is generally not recommended.
RECOMMENDED READINGS
McNeil DS, Baumhauer JF, Glazebrook MA. Evidence-based analysis of the efficacy for operative treatment of hallux rigidus. Foot Ankle Int. 2013 Jan;34(1):15-32. doi: 10.1177/1071100712460220. Review. PubMed PMID: 23386758.
View Abstract at PubMed
Deland JT, Williams BR. Surgical management of hallux rigidus. J Am Acad Orthop Surg. 2012 Jun;20(6):347-58. doi: 10.5435/JAAOS-20-06-347. Review. PubMed PMID: 22661564.
View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 55 THROUGH 58
Figures 55a and 55b are the anteroposterior and lateral radiographs of a 57-year-old man who fell off of a ladder 10 days ago and landed on his left foot. He is now unable to weight bear on the left. He has no history of trauma to this foot, and his medical history is unremarkable. Upon examination his left foot is swollen and tender. Pulses and sensation are intact.

A B

Question 46

A previously healthy 29-year-old man reports a 2-day history of severe atraumatic lower back pain. He denies any bowel or bladder difficulties and no constitutional signs. Examination is consistent with mechanical back pain. No focal neurologic deficits or pathologic reflexes are noted. What is the most appropriate management? Review Topic

Explanation

In general, a previously healthy patient with an acute onset of nontraumatic lower back pain does not need diagnostic imaging before proceeding with therapeutic treatment. In the absence of any “red flags” during the history and physical examination, such as trauma or constitutional symptoms (ie, fevers, chills, weight loss), the appropriate treatment for acute onset lower back pain is purely symptomatic treatment including limited analgesics and early range of motion. Diagnostic imaging is not necessary unless the initial treatment is unsuccessful and symptoms are prolonged. Miller and associates suggested that the use of radiographs can lead to better patient satisfaction but not necessarily better outcomes.

Question 47

Surgical restoration of sagittal balance of an adult spinal deformity will have which effect on outcome?

Explanation

DISCUSSION
The influence of sagittal balance on outcomes following fusion-based procedures for degenerative conditions of the lumbar spine has only recently been appreciated. Restoration of sagittal spinal balance improves low-back-pain outcomes and quality of life. Sagittal spinal balance has not been shown to relieve neurogenic claudication attributable to spinal stenosis.
RECOMMENDED READINGS
Li Y, Hresko MT. Radiographic analysis of spondylolisthesis and sagittal spinopelvic deformity. J Am Acad Orthop Surg. 2012 Apr;20(4):194-205. doi: 10.5435/JAAOS-20-04-194. Review. PubMed PMID: 22474089. View Abstract at PubMed
Korovessis P, Repantis T, Papazisis Z, Iliopoulos P. Effect of sagittal spinal balance, levels of posterior instrumentation, and length of follow-up on low back pain in patients undergoing posterior decompression and instrumented fusion for degenerative lumbar spine disease: a multifactorial analysis. Spine (Phila Pa 1976). 2010 Apr 15;35(8):898-905. doi: 10.1097/BRS.0b013e3181d51e84. PubMed PMID: 20354466. View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 99 AND 100
Figures 99a and 99b are MR images of a 59-year-old man with a history of intravenous (IV) drug abuse who arrives at the emergency department with malaise and fever. Upon admission, the patient's temperature is 38.9°C, his white blood cell count is 17000/µL (reference range [rr], 4500-11000/µL), his erythrocyte sedimentation rate is 98 mm/h (rr, 0-20 mm/h), and his C-reactive protein level is 45 mg/L (rr, 0.08-3.1 mg/L). He is admitted to the medical service to evaluate the source of his fevers. On hospital day 1, the patient reports weakness in his left arm and leg. Blood cultures are positive for methicillin-resistant Staphylococcus aureus.

A B

Question 48

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

Explanation

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

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

Question 49

Figure 8 shows the CT scan of an 11-year-old boy who has had a 1-year history of worsening painful flatfeet. He reports pain associated with physical education at school, especially with running and jumping. Management consisting of activity restriction, anti-inflammatory drugs, and casting has failed to provide relief. Treatment should now consist of

Explanation

DISCUSSION: In most patients with symptomatic talocalcaneal coalition involving less than 50% of the subtalar joint, resection with fat graft interposition is preferred over a subtalar or triple arthrodesis, especially if reasonable range of motion can be achieved. This patient has a synchondrosis that is partially cartilaginous. Although patients may have a residual gait abnormality, most report pain relief after surgery.
REFERENCES: Scranton PE Jr: Treatment of symptomatic talocalcaneal coalition. J Bone Joint Surg Am 1987;69:533-539.
Kitaoka HB, Wikenheiser MA, Schaughnessy WJ, et al: Gait abnormalities following resection of talocalcaneal coalition. J Bone Joint Surg Am 1997;79:369-374.
Vincent KA: Tarsal coalition and painful flatfoot. J Am Acad Orthop Surg 1998;6:274-281.

Question 50

Figures 21a through 21c show the MRI scans of a 21-year-old football player who sustained a valgus knee injury while changing direction. Examination reveals swelling and tenderness along the medial aspect of the knee. There is a positive Lachman test, 3+ valgus laxity at 30 degrees, and 1+ valgus laxity at 0 degrees extension. The anterior drawer test is increased with the tibia in external rotation. The increase in the anterior drawer test with the tibia in external rotation is most likely the result of

Explanation

DISCUSSION: The injury mechanism involves a valgus load applied to the knee with the foot in external rotation. The primary stabilizer to valgus laxity is the medial collateral ligament. The secondary restraints to valgus rotation are the cruciate ligaments. Examination indicates disruption of the medial collateral and anterior cruciate ligaments. Valgus opening in extension should also arouse suspicion for an injury to the posterior cruciate ligament; however, in this patient, the valgus opening in extension is mild. The slight opening in extension and the increased anterior drawer, especially with external rotation, indicates disruption of the posteromedial capsule and posterior oblique ligament. Figure 21a shows complete disruption of the superficial and deep medial collateral ligaments involving the meniscofemoral ligament. Figure 21b shows a more posterior coronal section with a torn posterior oblique ligament. Figure 21c shows disruption of the anterior cruciate ligament, while the posterior cruciate ligament at the tibial insertion appears with a homogenous normal signal.
REFERENCES: Warren LA, Marshall JL, Girgis F: The prime static stabilizer of the medial side of the knee. J Bone Joint Surg Am 1974;56:665-674.
Indelicato PA: Injury to the medial capsuloligamentous complex of the knee, in Feagin J (ed): The Crucial Ligaments, ed 2. 1994, pp 351-360.

Question 51

Figures 65a and 65b show the MRI scans of a 33-year-old man with severe left leg pain. He has had symptoms for 3 months with progressive worsening pain and function. Examination reveals ankle plantar-flexor weakness and diminished light touch sensation on the plantar surface of the foot. What treatment provides the best outcome? Review Topic

Explanation

The patient's signs and symptoms are consistent with lumbar radiculopathy. Surgical treatment for this condition has been shown to yield significantly improved outcomes when compared with nonsurgical management. Surgical management is best performed with a laminotomy and removal of the sequestered disk herniation ("limited diskectomy"). A complete (ie, subtotal) diskectomy may reduce the rate of recurrence for disk herniation but has been shown to worsen back pain postoperatively. A laminectomy may be necessary for larger herniations with severe central stenosis; the patient does not meet those criteria and, as noted, a total diskectomy is not indicated. Arthrodesis in the setting of primary lumbar disk herniation is not indicated and is considered overly aggressive treatment.

Question 52

A 55-year-old man sustained an isolated closed fracture of the humerus. Initial neurologic examination reveals no active wrist or finger extension. Radiographs are shown in Figures 28a and 28b. Management should consist of

Explanation

DISCUSSION: The patient has an isolated closed injury involving the humeral diaphysis. The lack of wrist and finger extension indicates injury to the radial nerve. Based on these findings, ongoing observation of the nerve is warranted with delayed exploration after 3 to 4 months if there are no signs of progressive return of nerve function. Treatment of the fracture should include external immobilization and fracture bracing. An indication for nerve exploration and surgical stabilization would be an open fracture.
REFERENCES: Zuckerman JD, Kovil KJ: Fractures of the shaft of the humerus, in Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, pp 1025-1053.
Pollock FH, Drake D, Bovill EG, Day L, Trafton PG: Treatment of radial neuropathy associated with fractures of the humerus. J Bone Joint Surg Am 1981;63:239-243.

Question 53

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

Explanation

DISCUSSION: 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.
REFERENCES: Clarke HD, Scott WN, Insall JN: Anatomic aberrations, in Insall JN, Scott WN (eds): Surgery of the Knee, ed 4. Philadelphia, PA, Churchill Livingstone, 2006, vol 1, pp 67-85.
Patel D: Plica as a cause of anterior knee pain. Orthop Clin North Am 1986;17:273-277.

Question 54

What is the most common reason for reoperation in total knee arthroplasty?

Explanation

DISCUSSION: Patellar problems currently constitute the largest number of complications after total knee arthroplasty, affecting between 8% and 35% of patients. These problems include patellar instability, fracture, component loosening, surface erosion, and pain. Malalignment, as an isolated reason for revision, is uncommon, yet it contributes to accelerated wear of the components. Joint instability affects up to 6% of patients, and the infection rate in knee arthroplasty is around 1% to 2%.
REFERENCES: Blasier RB, Matthews LS: Complications of prosthetic knee arthroplasty, in Epps CH (ed): Complications in Orthopaedic Surgery. Philadelphia, PA, JP Lippincott, 1994, pp 1066-1069.
Rand JA: The patellofemoral joint in total knee arthroplasty. J Bone Joint Surg Am 1994;76:612-620.
Wilson MG, Kelley K, Thornhill TS : Infection as a complication of total knee-replacement arthroplasty: Risk factors and treatment in sixty-seven cases. J Bone Joint Surg Am 1990;72:878-883.

Question 55

In the treatment of thoracolumbar idiopathic scoliosis using an anterior single rod technique with interbody cages, which of the following variables has been associated with pseudoarthrosis. Review Topic

Explanation

In select patients with thoracolumbar idiopathic scoliosis, an anterior approach with a single rod and interbody cages may be indicated. Thoracic hyperkyphosis (>40 degrees ) is a risk factor for pseudoarthrosis in patients treated with this method.
In a prospective study, Sweet et al found anterior instrumented fusions using a single solid rod had good radiographic and clinical outcomes. In their treatment group they found common risk factors for pseudarthrosis were smoking, weight >70 kg, and T5-T12 hyperkyphosis of > 40 degrees. They recommend consideration should be given to alternate techniques in larger adolescents (>70 kg) with thoracic hyperkyphosis (>40 degrees ). The average coronal correction of thoracic curves was from 55 degrees to 29 degrees (47%). The average correction of thoracolumbar/lumbar curves was from 50 degrees to 15 degrees (70%). Neither of these variables were associated with pseudoarthrosis. In the sagittal plane, lordosis was maintained in thoracolumbar/lumbar fusions at -58 degrees (T12-sacrum). Improved maintenance of lumbar lordosis is considered one of the advantages of an anterior approach.
In an additional study from the same group at Wash U, Hurford et al designed a study to compare the results of anterior DUAL-rod instrumentation with their previous experience using single-rod constructs. They found the two technique were comparable in the amount of radiographic deformity correction obtained. However, they report the absence of any pseudarthroses in the 60 patients with dual-rod is a distinct advantage over the single rod technique.

Question 56

A 17-year-old football player continues to have discomfort after sustaining a blow to his midthigh during a game 8 weeks ago. A plain radiograph is shown in Figure 13. What is the most appropriate management?

Explanation

DISCUSSION: The patient has myositis ossificans. Rest of the involved area is important to help limit the continued irritation of the muscle, but range-of-motion exercises are important to limit stiffness. While immobilization for 1 or 2 days following a muscle contusion is appropriate, longer periods of immobilization result in muscle atrophy and fibrosis. Injections and irradiation have not been found to be of benefit for myositis ossificans. Excision is rarely required, and if performed, it should not be performed prior to maturation of the lesion, which is a minimum of 6 months.
REFERENCES: Lipscomb AB, Thomas ED, Johnston RK: Treatment of myositis ossificans traumatica in athletes. Am J Sports Med 1976;4:111-120.
Beiner JM, Jokl P: Muscle contusion injuries: Current treatment options. J Am Acad Orthop Surg 2001;9:227-237.
Ryan JB, Wheeler JH, Hopkins WJ, et al: Quadriceps contusions: West Point update. Am J Sports Med 1991;19:299-304.

Question 57

What adaptations occur in the dominant shoulder of throwers compared to their nondominant shoulder? Review Topic

Explanation

Pitchers change rotation during adolescent growth with external rotation of the proximal humerus. The result is increased external rotation and decreased internal rotation, resulting in a normal total arc of motion. External rotation lengthens the arc of acceleration, resulting in increased velocity. The shorter arc of internal rotation, associated with a tight posterior capsule, makes deceleration of the arm more difficult, which may lead to overuse injuries.

Question 58

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

Explanation

DISCUSSION: McCune-Albright syndrome is the combination of polyostotic fibrous dysplasia, café-au-lait lesions, and endocrine dysfunction. The most common endocrine presentation is precocious development of secondary sexual characteristics. Compared with bone lesions in patients without polyostotic disease, the skeletal lesions in patients with the syndrome tend to be larger, more persistent, and associated with more complications. Bisphosphonate therapy has been shown in several studies to decrease the pain associated with the skeletal lesions of fibrous dysplasia.
REFERENCES: DiCaprio MR, Enneking WF: Fibrous dysplasia: Pathophysiology, evaluation and treatment. J Bone Joint Surg Am 2005;87:1848-1864.
Zacharin M, O’Sullivan M: Intravenous pamidronate treatment of polyostotic fibrous dysplasia associated with McCune Albright syndrome. J Pediatr 2000;137:403-409.

Question 59

Figures 54a and 54b are the radiographs of a 23-year-old man who fell from a height and sustained an isolated injury to his right leg. Which of the following is a useful surgical technique to optimize alignment during intramedullary nailing?

Explanation

Full pronation
25 degrees pronation
Neutral
25 degrees supination
Full supination
Using the lateral approach (Kocher or Kaplan), the correct placement of the arm should be in a neutral position so that the plate can be placed on the bare area of the proximal radius.
Displaced radial head fractures with less than 3 fragments can be amendable to open reduction internal fixation. The methods of fixation include buried or headless screws, if placed at the articular surface, or posterolateral plating, if placed in the bare area. The safe zone for plating is located at a 90-110 arc from the radial styloid to Lister's tubercle with the arm in neutral rotation. This position helps to avoid impingement of ulna against the plate with forearm rotation. It should be noted that during the approach, that the forearm should be fully pronated to avoid injury to the posterior interosseous nerve.
Mathew et al. reviewed the concepts of terrible triad injuries of the elbow. Radial
head fractures are treated conservatively when there is an isolated minimally displaced (less than 2mm) fracture with no mechanical block to motion. Open reduction internal fixation is used for Mason II or III fractures with < 3 fragments. Radial head replacement is considered for comminuted fractures (Mason Type III) with 3 or more fragments.
Cheung et al. reviewed the surgical approaches to the elbow. The lateral approach (Kocher or Kaplan) is most commonly used with these injuries. The Kocher approach utilizes the intramuscular plane between anconeus and extensor carpi ulnaris. Kaplan utilizes the plane between extensor digitorum commons and extensor carpi radialis brevis.
Figure A and B show AP and lateral radiographs of the left elbow. There is a displaced radial head fracture. Illustration A shows a schematic diagram of the radial head "safe zone" between the radial styloid to Lister's tubercle.
Incorrect Answers:

Question 60

When compared to smokers who do not quit, an improvement in the rate of lumbar fusion is seen in patients who cease smoking for at least how many months postoperatively?

Explanation

DISCUSSION: The effects of cigarette smoking and smoking cessation on spinal fusion have been studied extensively. Although permanent smoking cessation is ideal, significant improvements in fusion rates are seen in patients who avoid smoking for greater than 6 months postoperatively.
REFERENCE: Glassman SD, Anagnost SC, Parker A, et al: The effect of cigarette smoking and smoking cessation on spinal fusion. Spine 2000;25:2608-2615.

Question 61

A 55-year-old woman with a 15-year history of systemic lupus erythematosus has had left shoulder pain for the past 3 months. She reports that the pain has grown progressively worse over the past few months, and her shoulder function is severely limited. She is presently being treated with azathioprine and has used corticosteroids in the past. AP and axillary radiographs are shown in Figures 19a and 19b, and MRI scans are shown in Figures 19c and 19d. Which of the following forms of management will yield the most predictable pain relief and return of shoulder function?

Explanation

DISCUSSION: Prosthetic shoulder arthroplasty has been shown to provide predictable results for treating stage III and stage IV osteonecrosis of the humeral head. The decision to resurface the glenoid (total shoulder arthroplasty versus humeral hemiarthroplasty) usually is made based on the radiographic and intraoperative appearance of the glenoid. Core decompression of the humeral head has been reported to be effective for earlier stages (pre collapse) but would not be appropriate for a patient with stage IV disease.
REFERENCES: Hattrup SJ, Cofield RH: Osteonecrosis of the humeral head: Results of replacement. J Shoulder Elbow Surg 2000;9:177-182.
L’Insalata JC, Pagnani MJ, Warren RF, et al: Humeral head osteonecrosis: Clinical course and radiographic predictors of outcome. J Shoulder Elbow Surg 1996;5:355-361.
Cruess RL: Steroid-induced avascular necrosis of the head of the humerus: Natural history and management. J Bone Joint Surg Br 1976;58:313-317.

Question 62

A 27-year-old man now reports dorsiflexion and inversion weakness after an automobile collision 6 months ago in which compartment syndrome developed isolated to the anterior and deep posterior compartments. Examination reveals the development of a progressive cavovarus deformity, but the ankle and hindfoot remain flexible. In addition to Achilles tendon lengthening, which of the following procedures is most likely to improve the motor balance of his foot and ankle?

Explanation

DISCUSSION: Compartment syndrome of the anterior and deep posterior compartments results in anterior tibialis and posterior tibialis tendon weakness, respectively. Furthermore, the long flexors to the hallux and lesser toes will be weak as well. The intact peroneus longus overpowers the weak anterior tibialis tendon, resulting in plantar flexion of the first metatarsal, cavus, and hindfoot varus. Therefore, transferring the peroneus longus to the dorsolateral midfoot reduces the first metatarsal plantar flexion torque, and possibly augments ankle dorsiflexion torque.
REFERENCES: Hansen ST: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott, Williams & Wilkins, 2000, pp 433-435.
Vienne P, Schoniger R, Helmy N, et al: Hindfoot instability in cavovarus deformity: Static and dynamic balancing. Foot Ankle Int 2007;28:96-102.

Question 63

A soccer player who sustained a twisting injury to the right ankle while making a cut is unable to bear weight and has diffuse tenderness over the anterior and lateral aspects of the ankle. Examination also shows a positive squeeze test. Plain radiographs and a stress radiograph are shown in Figures 26a through 26c. Radiographs of the leg and knee are normal. What is the most appropriate management?

Explanation

DISCUSSION: The mechanism of injury, physical examination, and radiographs indicate a “high” ankle sprain with disruption of the distal tibiofibular ligaments and interosseous membrane. These injuries typically involve pronation and external rotation forces. In addition, recovery is significantly delayed, often requiring 6 to 8 weeks to heal. Radiographs obtained months after recovery often show calcification within the distal syndesmosis, which is not typically symptomatic. This patient has gross instability, resulting in a high incidence of chronic diastasis and subluxation leading to impaired function. Treatment should consist of reduction and stabilization with a transsyndesmotic screw because this injury demonstrates a widened syndesmosis.
REFERENCES: Boytim MJ, Fisher DA, Neumann L: Syndesmotic ankle sprains. Am J Sports Med 1991;19:294-298.
Miller CD, Shelton WR, Barrett GR, et al: Deltoid and syndesmosis ligament injury of the ankle without fracture. Am J Sports Med 1995;23:746-750.

Question 64

A 40-year-old woman sustains a flexion injury to her neck. Physical examination is normal. A lateral radiograph of the cervical spine is shown in Figure 57a. MRI scans of the cervical spine are shown in Figures 57b and 57c. Treatment should include

Explanation

DISCUSSION: This is a classic bilateral facet dislocation. When there is no evidence of a disk herniation, treatment should include careful skeletal traction, closed reduction, and posterior fusion. There is no role for anterior procedures. These fractures are unstable and require surgical intervention.
REFERENCES: Herkowitz HN, Garfin SR, Eismont FJ: Rothman-Simone The Spine, ed 5. Philadelphia, PA, Saunders Elsevier, 2006, pp 1120-1128.
Coe JD, Warden KE, Sutterlin CE, et al: Biomechanical evaluation of cervical spinal stabilization methods in a human cadaveric model. Spine 1989;14:1122-1131.

Question 65

A 55-year-old woman develops posttraumatic arthritis in the elbow following a distal humerus fracture. What is the most likely mid-term (5- 10 years after surgery) complication following semiconstrained total elbow arthroplasty (TEA)?

Explanation

A 51-year-old man presents with persistent right shoulder pain several weeks after falling off a roof. On examination, he has pain with palpation over the greater tuberosity, active forward shoulder flexion of

60°, and passive forward shoulder flexion of 160°. He has 2/5 forward flexion and external rotation strength. Initial plain radiographs are unremarkable. A coronal MRI scan of his shoulder is shown in Figure 1. After a thorough discussion, the patient elects to proceed with surgical intervention. During intraoperative assessment, the surgeon contemplates performing a single versus a dual row repair. Currently, what is the consistent difference between the two repair techniques?

A. Dual row repairs result in superior objective clinical outcomes

B. Dual row repairs provide a larger footprint coverage.

C. Single row repairs have a reported higher complete retear rate.

D. Single row repairs have fewer points of tendon fixation.

Question 66

Which of the following positions of immobilization has been shown to best approximate the anterior labrum against the glenoid rim following anterior dislocation of the shoulder?

Explanation

DISCUSSION: Following anterior dislocation of the shoulder, the affected arm is typically placed in a sling with the shoulder in adduction and internal rotation. A recent study has shown that placement in this position actually results in laxity of the anterior supporting structures of the shoulder, allowing the postinjury hemarthrosis to push the labrum and capsular ligaments away from the anterior glenoid rim. Thus, immobilization in this position may actually impede healing of these structures. Alternatively, resting the arm in a position of adduction and external rotation allows the anterior supporting structures to abut against the anterior glenoid rim by forcing the hemarthrosis posteriorly. Placing the arm in this position following anterior dislocation is believed to allow for better healing of the anterior labrum and ligaments.
REFERENCE: Itoi E, Sashi R, Minagawa H, et al: Position of immobilization after dislocation of the glenohumeral joint: A study with use of magnetic resonance imaging. J Bone Joint Surg Am 2002;84:873-874.

Question 67

Pain associated with a proximal medial tibial osteochondroma in a 10-year-old patient is most commonly the result of

Explanation

DISCUSSION: Pain secondary to an osteochondroma is usually from soft-tissue irritation and bursal formation. This is particularly common for proximal medial tibia osteochondromas that irritate the pes anserine tendons. Malignant degeneration into a chondrosarcoma rarely occurs, is usually associated with multiple hereditary exostoses, and usually occurs after skeletal maturity.
REFERENCES: Borges AM, Huvos AG, Smith J: Bursa formation and synovial chondrometaplasia associated with osteochondromas. Am J Clin Pathol 1981;75:648-653.
Hudson TM, Springfield DS, Spanier SS, Enneking WF, Hamlin DJ: Benign exostoses and exostotic chondrosarcomas: Evaluation of cartilage thickness by CT. Radiology 1984;152:595-599.

Question 68

5 g/dL and his base deficit is 10mEq/L. What is the most appropriate next step in management?

Explanation

Posteromedial rotatory instability
Capitellum fracture
Radial head fracture and posterolateral ulnohumeral dislocation
Trans-olecranon fracture dislocation
Medial (ulnar) collateral ligament rupture Corrent answer: 3
The clinical presentation is consistent with a coronoid tip fracture. This fracture pattern is associated with a radial head fracture and posterolateral ulnohumeral dislocation - together making up the terrible triad injury.
A terrible triad injury is the result of a valgus and supination injury and involves posterolateral elbow dislocation or lateral collateral ligament injury, radial head fracture, and fracture of the coronoid process. The elbow may dislocate postero-laterally with the anterior bundle of the MCL intact, but if the MCL is injured it is typically the last structure to fail. The coronoid fracture is typically a small fragment isolated to the tip. This is a result of a posteriorly directed force driving the coronoid into the trochlea prior to posterior elbow dislocation. CT scan is a useful modality when small or comminuted fragments are difficult to visualize on plain radiographs.
Steinmann reviews the anatomy, diagnosis, classification and treatment of coronoid fractures with a focus on surgical exposures and fixation techniques.
Doornberg et al. reviewed 67 coronoid fractures to determine whether type of coronoid fracture correlated with pattern of instability. They found strong associations between (1) large coronoid fractures and trans-olecranon fracture-dislocations, (2) small fractures and terrible-triad injuries, and (3) anteromedial facet fractures and varus posteromedial rotational injury mechanisms.
Doornberg et al. evaluated 18 patients with a fracture of the anteromedial facet of the coronoid. They found that malalignment of the anteromedial facet fragment was associated with arthrosis and a fair or poor result.
Figures A through D show consecutive 2.00 mm sagittal CT reformats demonstrating a small coronoid fracture fragment which was addressed with suture fixation.
Incorrect Answers:
OrthoCash 2020
A 62-year-old right-hand-dominant school teacher sustains a mechanical fall at home and presents with right shoulder pain. Plain
radiographs of the right shoulder are pictured in Figures A and B. The patient asks you what she can expect in terms of recovery following this injury. Which of the following is the most appropriate statement?

At 1-year post-injury, the right shoulder range of motion will most likely be equal to the contralateral extremity.
At 1-year post-injury, you will most likely have returned to your baseline functional status.
Early range of motion exercises risk fracture displacement and should be avoided until at least 4 weeks post-injury.
Most patients do not return to work following this injury.
One in 5 patients with this fracture go on to nonunion and you may benefit from surgery in the future to address this.
This patient has a minimally displaced (1-part) proximal humerus fracture involving the humeral neck and greater tuberosity. This injury pattern is most commonly managed nonoperatively with the majority of patients returning to their baseline functional status by 1 year.
Proximal humerus fractures (PHF) can be classified by number of parts (Neer classification), with a part defined as a fracture fragment displaced > 1cm (> 5mm for greater tuberosity) or angulated > 45°. One-part PHF comprise ~80% of all PHF and are treated nonoperatively with a sling and early range of motion (ROM).
Tejwani et al performed a prospective study of 67 patients with 1-part PHF. At 1-year follow up the ASES score and functional status was similar to pre-injury status. However, ROM of the affected shoulder was diminished in both external and internal rotation. Forward flexion was preserved.
Hanson et al prospectively analyzed 160 patients with PHF of all types (1-4 parts and head-splitting) managed nonoperatively. At 1-year follow up, 93% showed solid union. Constant and DASH scores improved steadily over time but were still lower compared to the contralateral extremity. Of employed patients, 97.6% returned to work with a median time off of 10 weeks and no difference between manual and nonmanual workers.
Figures A and B are the AP and axillary radiographs of the right shoulder, respectively, demonstrating a 1-part PHF involving the humeral neck and greater tuberosity.
Incorrect Responses:
OrthoCash 2020
A 44-year-old male presents with the isolated injury seen in Figure A after a motor vehicle accident and underwent the operative treatment seen in Figure B within 8 hours from the time of incident. Which of the following complications is this patient at highest risk of developing?

Pulmonary embolus
Periprosthetic fracture
Contralateral hip fracture
Osteonecrosis
Infection
This young male patient has sustained a displaced femoral neck fracture and underwent open reduction internal fixation with 3 cannulated screws. Based on the available options, the patient is most at risk of developing osteonecrosis of the femoral head.
Femoral neck fractures in young patients typically are the result of a high-energy trauma. Fracture displacement has been shown to disrupt vascular supply to the femoral head by interrupting retinacular vessels and ligament teres vascularization, as well as increasing intracapsular pressure, producing a tamponade effect. The incidence of osteonecrosis in patients younger than 60 years with displaced femoral neck fractures has been shown to be between 15-30%. Quality of reduction is one key factor that has been shown to influence outcomes postoperatively.
Loizou et al. prospectively studied 1,023 patients who sustained an intracapsular hip fracture that was treated with internal fixation using standard fixation modalities. They showed that osteonecrosis was less common for undisplaced (4.0%) than for displaced fractures (9.5%). The population at greatest risk were women younger than the age of 60 with displaced fractures.
Barnes et al. review subcapital hip fractures. They found that late segmental collapse was more common in displaced fractures in women younger than age 75 years than in those older than age 75 years treated with internal fixation.
Figure A shows a displaced, Garden 3/Pauwels III hip fracture. Figure B shows anatomical fixation with 3 cannulated screws.
Incorrect Answers:
OrthoCash 2020
A 58-year-old male is involved in a motor vehicle collision and sustains the injury shown in Figure A in addition to right 5th and 6th rib fractures. Upon evaluation in the emergency department, he is noted to have a 2 centimeter laceration over the anterior aspect of his left leg with visible bone. Vitals and labs are normal. Which of the following statements is most accurate regarding surgical management for this patient?

Reamed intramedullary nailing is favored due to increased rates of union
Unreamed intramedullary nailing is favored due to presence of concomitant rib fractures
Reamed intramedullary nailing is favored due to decreased rates of infection
Unreamed intramedullary nailing is favored due to less local trauma
Both unreamed and reamed intramedullary nailing are equivalent Corrent answer: 5
Both unreamed and reamed intramedullary nailing are equivalent treatments in patients with open tibia fractures. Intramedullary nailing is the treatment of choice for stable patients with tibial shaft fractures.
Tibial shaft fractures can be the result of low energy twisting injuries or higher energy axial loads. Closed fractures with acceptable alignment can be often be treated with closed reduction and casting. Intramedullary nailing, unreamed or reamed, is the treatment of choice for open fractures except in the setting of damage control orthopaedics when an external fixator may be more appropriate.
Bhandari et al. investigated reamed and unreamed intramedullary nailing for tibial shaft fractures in a randomized trial ("SPRINT" Trial - Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures Investigators). They concluded that reamed nailing was more beneficial (decreased rate of primary outcome event: need for bone grafting, implant exchange or removal for infection, debridement for infection) for closed fractures, but had no benefit in open fractures.
Finkemeier et al. evaluated consecutive patients treated with unreamed and reamed intramedullary nailing and found similar rates of union in both open and closed tibial shaft fractures at six and twelve months.
Figures A shows AP and lateral xrays of the left tibia showing a tibial shaft fracture.
Incorrect Answers:
OrthoCash 2020
A 36-year-old male falls from a 10-ft scaffold and suffers the injuries shown in Figures A and B. The patient is placed in a spanning external fixator and brought back to the operating room once his soft tissues are amenable. Planning to use a dual-incision approach, what is the correct interval to use when approaching the medial side?

Popliteus and pes anserine
Lateral head of the gastrocnemius and pes anserine
Politeus and lateral head of the gastrocnemius
Iliotibial band and medial head of the gastrocnemius
Pes anserine and medial head of the gastrocnemius Corrent answer: 5
The posteromedial approach to the tibial plateau is between the the pes anserine tendons and the medial head of the gastrocnemius.
A dual-incision approach is often utilized to optimally place definitive fixation for bicondylar tibial plateau fractures. For fractures that require posterior or posteromedial fixation, the correct interval is between the pes anserine and the medial head of the gastrocnemius.
Higgins et al. in a large cohort morphological review, noted a high incidence of a posteromedial fragment in bicondylar fractures. Occurring at a high frequency, the authors recommended direct visualization and reduction via a dual approach rather than using indirect reduction techniques.
Falker et al. describes a step-by-step approach to utilizing the posteromedial approach for the tibial plateau and placing an anti-glide plate.
Figure A and B exhibit a bicondylar tibial plateau fracture with a posteromedial fragment noted on the lateral x-ray. Illustration A exhibits the surrounding anatomy and interval in between the medial head of the gastrocnemius and the pes anserine.
Incorrect answers:

OrthoCash 2020
A 25-year-old male presents to the emergency department with the injury seen in Figure A after a motorcycle collision. The patient has a blood pressure of 70 systolic, elevated lactate and a tense abdomen with positive FAST examination. Trauma surgery will be performing an emergent laparotomy. Orthopaedic surgery is consulted and places a pelvic external fixator intraoperatvely to assist with resuscitation. What is an advantage of supra-acetabular external fixator pins as compared with iliac crest pins?

Less interference with pelvic surgical incisions
Less risk of pin tract infection
Less risk of malreduction
Less control of posterior pelvic ring
No interference with laparotomy Corrent answer: 1
One advantage of supra-acetabular external fixator pins is that they do not interfere or contaminate future approaches to the pelvis or acetabulum involving the lateral window.
In multiply injured patients with pelvic trauma external fixation of the pelvic ring is a valuable tool to assist with resuscitation. Pelvic external fixation should be applied rapidly and allow full access to the abdomen for general surgery intervention. Regardless of the technique used, a pelvic external fixator should form a stable construct that minimizes motion of fracture surfaces and allows for clot formation.
Haidukewych et al evaluated the safety of supra-acetabular pin placement in a cadaveric study. The authors found that the lateral femoral cutaneous nerve (LFCN) was most at risk during pin placement.
Figure A demonstrates a widely displaced symphyseal dislocation with associated bilateral sacroiliac (SI) dislocations (APC 3). Illustration A demonstrates an outlet radiograph of a supra-acetabular external fixtator in conjunction with posterior pelvic ring fixation for an LC3 pelvic ring injury.
Illustration B is an illustration of iliac crest external fixation. The video demonstrates techniques for application of both supra-acetabular and iliac
crest external fixation pins.
Incorrect Answers:

OrthoCash 2020
What physical exam finding is most likely to be found in association with the injury shown in Figures A and B?

Numbness in the small finger and ulnar side of the ring finger
No elbow instability
Varus posteromedial rotatory instability
Valgus posterolateral rotatory instability
An anterior open wound Corrent answer: 3
The x-ray shows a fracture of the anteromedial facet of the coronoid with an intact radial head. Large anteromedial facet fractures are associated with varus posteromedial rotatory instability.
The anteromedial facet of the coronoid provides support to the medial elbow against varus stress. Varus and posteromedial force applied to the elbow results in disruption of the lateral collateral ligament (LCL) from its proximal origin. The coronoid is fractured as it is forced against the medial trochlea.
Coronoid fractures of significant size involving the sublime tubercle (insertion of medial collateral ligament) result in varus instability.
Steinmann reviews the anatomy, diagnosis, classification and treatment of coronoid fractures with a focus on surgical exposures and fixation techniques. He states that when a coronoid fracture is associated with a pattern of varus instability, it requires fixation with either suture, buttress plating or screw fixation. Concomitant LCL repair or reconstruction will also be necessary.
Doornberg et al. reviewed 67 coronoid fractures to determine whether type of coronoid fracture correlated with pattern of instability. They found strong
associations between (1) large coronoid fractures and trans-olecranon fracture-dislocations, (2) small fractures and terrible-triad injuries, and (3) anteromedial facet fractures and varus posteromedial rotational injury mechanisms.
Doornberg et al. evaluated 18 patients with a fracture of the anteromedial facet of the coronoid. They found that malalignment of the anteromedial facet fragment was associated with arthrosis and a fair or poor result.
Figure A is an AP view of an elbow with an anteromedial facet of the coronoid fractured. The lateral joint space is widened due to injury to the LCL. The medial joint space is narrowed and collapsed. A lateral view is shown in Figure
B. Illustrations A and B show AP and lateral views of a coronoid fracture fixed with buttress plating. The LCL origin was fixed with a suture anchor. Illustration C shows the O'Driscoll classification of coronoid fractures. Illustration D lists injury patterns that suggest posteromedial versus posterolateral rotatory instability.
Incorrect Answers:

OrthoCash 2020
A 35-year-old man presents to the ED as the restrained driver of a high speed motor vehicle collision complaining of hip, chest, and abdominal pain. He becomes diaphoretic, tachycardic, and hypotensive in the trauma bay and is noted to have diminished lower extremity pulses. He is found on ATLS workup to have mediastinal widening.
Which of the following injuries is most associated with thoracic aortic injury?

Thoracic aortic rupture is associated with posterior hip dislocation in deceleration trauma mechanism of injuries.
Posterior hip dislocations are infrequently associated with local vascular injuries. With bilateral perfusion deficits, more proximal large vessel trauma should be considered, and in this situation, thoracic surgery should be involved emergently. Screening chest x-ray in the trauma bay should be reviewed for widened mediastinum, suggestive of aortic injury, as shown in illustration A. Given the high energy mechanism associated with these injuries, a full ATLS trauma survey must be done for every patient.
Marymont et al. studies the association between posterior hip dislocation and thoracic aortic injury. They performed a retrospective chart review of 89 posterior hip dislocations and found 8% had an aortic injury. Although not statistically significant, they note the importance of evaluation for aortic injury in patients with posterior hip dislocations given its emergent life-threatening nature.
In addition to associated chest injuries, Schmidt et al. highlight the importance of evaluating the ipsilateral knee after high-energy traumatic hip dislocation. In a prospective study, they identified a 93% rate of ipsilateral knee injury on MRI including effusion (37%), bone bruising (33%), and meniscal tear (30%) as the most common. They recommend a thorough exam but also expanded use of knee MRI after hip dislocation.
Illustration A shows an example of chest x-ray with a widened mediastinum, suggestive of thoracic aortic injury.

OrthoCash 2020
A 31-year-old female smoker was involved in a skiing accident approximately 9 months ago and underwent open reduction internal fixation of the radius and ulna at the time of injury. She now returns to the clinic complaining of increasing pain with range of motion and activity. Radiographs from her most recent follow-up can be seen in Figure A. Laboratory tests show ESR, CRP and WBC count to be within normal limits. Which of the following options is the most appropriate next step in management?

Bone scan
Above elbow cast
Removable splint
Reamed intramedullary nail
Iliac crest bone grafting + compression plating Corrent answer: 5
This patient is presenting with an atrophic non-union of the ulna after open reduction internal fixation for a both bone forearm fracture 9 months ago. The most appropriate next step in management would be iliac crest bone grafting and compression plating of the ulna.
The primary issue with an atrophic nonunion is biological. The blood supply is poor and therefore incapable of purposeful fracture healing. Smokers, as in this vignette, are at high risk for nonunion. The treatment of an atrophic nonunion involves improving biology at the fracture site through use of autologous bone graft (e.g. iliac crest) and providing mechanical stability by means of compression plating (e.g. 3.5 mm LC-DCP).
dos Reis et al. reports excellent results of 31 cases of diaphyseal forearm fracture non-unions treated with autologous bone grafting and compression
plating. Thirty of thirty-one patients went on to bony union within 3.5 months of revision surgery.
Nadkarni et al. presented a case series of 11 patients with non-unions of various long bones initially managed with intradmedullary (IM) nail fixation. The authors successfully used locking compression plates while retaining the IM nails in the treatment of the nonunion in all cases.
Figure A shows an AP radiograph of a both bone forearm fracture. Figure B shows an AP and lateral radiograph of an atrophic non-union of the ulnar shaft. Illustration A shows a lateral x-ray of a fully healed radius and ulna after hardware removal 1 year after revision surgery.
Incorrect Answers:

OrthoCash 2020
A 27 year-old patient sustains a fracture-dislocation of the acetabulum. Pelvic radiographs (Figures A and B) are taken at initial presentation and a CT scan (Figures C and D) is performed after reduction of the hip in the emergency room. What is the importance of the finding highlighted in the CT scan cuts?

Comminution indicates a better result with non-operative management
Significant marginal impaction could compromise the results of the surgical reduction if the joint surface is not properly restored
The impacted fracture segment will heal without fixation because it is not gapped or translated
The CT scan finding highlighted indicates osteochondral defects to the femoral head, which can be addressed arthroscopically
Intraarticular fracture fragments should be discarded from the surgical field, as incorporation of the fragments into the fixation construct leads to a high rate of avascular necrosis
The CT images shown in Figures C and D display significant marginal impaction of the joint surface.
Marginal impaction is common in posterior wall fractures and fracture-dislocations. Critical review of CT imaging of posterior wall fractures can help with preoperative planning for identifying impaction of the articular surface of the acetabulum. Restoration of the sphericity of the acetabulum to match that of the femoral head is important for successful outcome following ORIF of posterior wall fractures. A common surgical technique to accomplish joint surface restoration includes freeing the impacted articular segments, bone grafting of the void created to support the articular segments, and buttress plating of the posterior wall fracture fragments.
Patel et al. discuss the challenge of interpreting imaging of the acetabulum for assessing fracture characteristics that may significantly impact success or surgical intervention. These characteristics include: articular displacement, marginal impaction, incongruity of the joint surface, intra-articular fragments, and osteochondral injury to the femoral head. Based on expert review of images, determination of significant marginal impaction had a poor intraobserver reliability, as did each of the other modifiers listed.
Figures A and B are radiographs of the posterior wall fracture and hip dislocation. They do not show the large amount of marginal impaction of the acetabular surface. Figure C (coronal reconstruction) and Figure D (sagittal reconstruction) point out a large a amount of marginal impaction of the acetabular. Note the disruption of the joint surface on the intact portion of the acetabulum.
Incorrect answers:
Comminuted posterior wall fractures still should be surgically stabilized if the joint is unstable
This impacted fragment on the margin of the main fracture line will likely heal regardless of restoration of the articular surface; however, this malreduction will lead to a incongruent joint surface
These CT cuts do not show any osteochondral defects of the femoral head; however if found in other CT cuts or intraoperatively, they should be appropriately addressed
Intraarticular fracture fragments should be removed from the joint, but if they make up a substantial portion of the joint surface, they should be incorporated in the fixation construct to obtain the goal of anatomic reduction of the joint surface
OrthoCash 2020
A 32-year-old female is involved in a motor vehicle collision and suffers a right hip dislocation. She is in the twelfth week of pregnancy.
Evaluation in the emergency department reveals no other injuries and ultrasound reveals a strong fetal heart rate and no abnormalities. She undergoes emergent closed reduction but the hip remains unstable and a traction pin is placed. Post-reduction films are shown in Figure
What is the most appropriate next step in management?

Acute open reduction internal fixation
Exam under anesthesia
Skeletal traction for 6-8 weeks
Fetal monitoring until 15 weeks followed by open reduction internal fixation
Percutaneous pinning
This patient has a large posterior wall fracture of the right acetabulum with an unstable hip. The most appropriate next step in treatment is open reduction and internal fixation.
Fixation of acetabular fractures during pregnancy is not contraindicated in the setting of stable fetal heart rate and no abnormalities on pelvic ultrasound.
There is, however, an increased risk of complications for the mother and fetus. Injury severity and mechanism are most closely associated with increased rate of fetal complications. The trimester of pregnancy is not associated with increased risk of complications.
Leggon et al. reviewed 101 cases of pelvic and acetabular fractures in pregnant patients and found mechanism of injury and injury severity were associated with higher mortality for both mother and fetus. Trimester of pregnancy was not associated with increased mortality.
Flik et al. reviewed orthopaedic trauma in a pregnant patients and recommended fetal ultrasound for assessment of fetal well-being in all pregnant patients.
Desai et al. investigated orthopaedic trauma during pregnancy and reported minimal radiation risk to the fetus when obtaining x-rays. They also advocate for LMWH as one of the safest choices for anticoagulation.
Figure A is an x-ray showing a right posterior wall acetabular fracture. Figures B and C are Judet views of the pelvis focusing on the right hip. A large posterior wall fragment is visible in Figure B.
Incorrect Answers:
OrthoCash 2020
Figure A is radiograph of a 50-year-old male science teacher that was involved in a motor vehicle accident. He underwent closed reduction as seen in Figure B and C. What would be the most appropriate treatment?

Open reduction and internal fixation with medial bridge plate and lateral screw in non-lagging mode
Tibiotalocalcaneal arthrodesis
Open reduction and internal fixation with lateral and medial screw in lagging mode
Closed reduction and internal fixation with medial and lateral screw in non-lagging mode
Closed reduction with percutaneous pins Corrent answer: 1
This patient is presenting with a Hawkins II talar neck fracture with medial wall comminution. The most appropriate treatment of this patient would be open reduction internal fixation with medial plate and lateral screw in non-lagging mode.
The treatment of talar fractures is based on the severity of the fracture, soft-tissues, and patient factors. The fracture and subluxation of the subtalar joint should be reduced and stable anatomical fixation should be obtained. When there is comminution of either the superior, lateral or medial aspects of the talus, one should avoid shortening the medial wall as this will cause a varus malunion. The use of a medial or lateral plate can help to re-establish column length, which can often prevent this potential complication.
Sanders et al. showed significant complications after fixation of talar neck fractures. They showed the incidence of secondary reconstructive procedures following talar neck fractures increased from 24% +/- 5% at 1 year to 48%
+/- 10% at 10 years post-injury.
Vallier et al. retrospectively reviewed the records of 39 fractures of the talar neck treated with open reduction and internal fixation. Twenty-one (54%) of thirty-nine patients had development of posttraumatic arthritis, which was more common after comminuted fractures (p < 0.07) and open fractures (p = 0.09).
Vallier et al. reviewed 81 talar neck fractures to revisit the rate of osteonecrosis and post-traumatic arthritis based on the Hawkins Classification. They found that delaying definitive internal fixation does not increase the risk of developing osteonecrosis. Thirty-five patients (54%) developed posttraumatic arthritis, including 83% of those with an associated talar body fracture (p < 0.0001) and 59% of those with Hawkins type-III injuries (p < 0.01).
Figure A shows a Hawkins II talar neck fracture. Figures B and C are saggital and coronal CT images, respectively, of the foot. There is significant comminution of the medial wall of the talus with extension into the subtalar joint.
Incorrect Answers:
There is some research to suggest primarily subtalar arthrodesis with these injuries. However, to date, there is no high level evidence that has conclusively shown subtalar arthrodesis to be better than ORIF.
OrthoCash 2020
A 28-year-old male college student sustains a severe foot injury from gunshot-related violence, and subsequently undergoes a lower-extremity amputation as shown in Figure A. At long-term follow-up, which of the following is the strongest predictor of patient satisfaction as related to his injury?

Age less than 30
Marijuana use
Use of negative pressure wound therapy
Male gender
Ability to return to work Corrent answer: 5
The strongest factor to predict patient-reported outcomes after trauma-related lower extremity amputations is the patient's ability to return to work. This is likely due to the effect of the return to work on the physical, emotional, and financial aspects of the patient's life.
The LEAP study is a multicenter, prospective study evaluating multiple aspects of reconstruction versus amputation in the treatment of mangled extremity injuries. With regard to patient satisfaction, treatment variables such as decision for reconstruction versus amputation, or initial presence or absence of plantar sensation have little impact. In addition, demographic factors such as age, gender, socioeconomic status, and education level do not predict patient satisfaction. Instead, the most important predictors of patient satisfaction at 2 years after injury include the ability to return to work, absence of depression, faster walking speed, and decreased pain.
O'Toole et al reviewed 463 patients treated for limb-threatening lower-extremity injuries and identified factors associated with patient reported outcomes two years after surgery. They found that return to work was the most associated with outcomes, but that physical functioning, walking speed, pain levels, and presence of depression were also associated to a lesser extent with outcomes.
Bosse et al performed a multicenter, prospective study to assess outcomes of 569 patients with severe lower extremity limb injuries that resulted in either amputation or limb salvage procedures. They found that at two years postoperatively, no significant differences were seen between groups in patient-reported outcome. Worse outcomes were associated with rehospitalization for a major complication, a low educational level, nonwhite race, poverty, lack of private health insurance, poor social-support network, low self-efficacy (the patient's confidence in being able to resume life activities), and involvement in disability-compensation litigation.
Figure A shows a clinical photograph of a Pirigoff amputation at early follow-up. This amputation is an end-bearing amputation that utilizes the plantar heel pad for weightbearing, and relies on a tibiocalcaneal arthrodesis.
Incorrect Answers:
4: These options are not as strong of a factor of patient satisfaction in longterm follow up after trauma-induced lower extremity amputation.
OrthoCash 2020
A 34 year-old male falls off of motorcycle on an outstretched hand suffering the injuries shown in Figures A and B. He is brought to the operating room and undergoes radial head replacement and fixation and repair of the coronoid and the lateral collateral ligament (LCL). Prior to closing, the elbow is still unstable upon testing range of motion. What is the next best step in management?

Exchange radial head for larger implant
Complete resection of radial head
Cast at 90 degrees of flexion for 6-8 weeks
Reinforce LCL repair with non-absorbable suture
Repair the ulnar collateral ligament Corrent answer: 5
Following complete fixation and repair of a terrible triad, a final range of motion test should be performed prior to closure. If still unstable, the next step should be to assess and repair the ulnar collateral ligament. Another option
would be to placed a hinged external fixator.
Operative reconstruction of a terrible triad injury should be performed in a systematic fashion, working from deep to superficial. Working through a lateral incision and through the radial head fracture, the coronoid should be fixed first, followed by radial head fixation or replacement and then repair/reconstruction of the LCL. If still unstable, the medial side should be addressed, or the patient placed in a hinged external fixator.
Mathew et al review the anatomic, biomechanic, and operative principles (why the above step-by-step method works) to achieving appropriate stability in order to obtain early range of motion to maximize clinical outcome.
Pugh et al. in this retrospective, multi-center study report outcomes on 36 terrible triad injuries fixed with the standard protocol described above. The authors recommend following this systematic approach to achieve the best results.
Figures A and B are AP and lateral radiographs exhibiting a terrible triad elbow fracture-dislocation.
Incorrect answers:
OrthoCash 2020
When treating the pathology depicted in Figures A through D, which of the following is necessary to preserve the blood supply to the femoral head?

Dissection of the gluteal musculature off the iliac crest
Ligation of the ascending branches of the lateral femoral circumflex artery
Greater trochanteric osteotomy
Identification and detachment of the piriformis tendon
Supine positioning
Figures A-D show a femoral head with associated acetabular fracture (Pipkin IV). Both the posterior wall fracture and the femoral head fracture can be addressed through a surgical dislocation via greater trochanteric osteotomy.
Pipkin IV femoral head fracture (with associated acetabular fractures) are somewhat problematic in that the femoral head fracture is usually anterior, while the acetabular fracture usually involves the posterior wall. A Kocher-Langenbeck approach gives good access to the posterior wall but limited access to the articular surface and femoral head avascular necrosis (AVN) is a concern. A Smith-Peterson approach provides good access to the femoral head
but not to the posterior wall. Combined approaches significantly increase the amount of surgical dissection. Surgical dislocation with trochanteric flip osteotomy provides access to the femoral head and posterior wall while preserving blood supply to the femoral head.
Solberg et al. retrospectively reviewed 12 patients with Pipkin IV injuries treated via a trochanteric flip osteotomy. All patients healed their acetabular fractures. Eleven of 12 patients healed their femoral head fractures and one patient (8.3%) developed osteonecrosis.
Henle et al. likewise treated 12 patients with Pipkin IV injuries through a trochanteric flip osteotomy. Two of 12 patients (16.7%) developed osteonecrosis. The remaining 10 patients (83.3%) had good or excellent results. Heterotopic ossification occurred in five patients, causing significant range of motion loss in four of these.
Figure A is a pre-reduction AP pelvis in which the posterior wall fracture is apparent. Figure B is a post-reduction AP pelvis in which an infra-foveal femoral head fracture is apparent (Pipkin IV). Figure C is an axial CT cut which further characterizes the posterior wall fracture. Figure D is an obturator oblique showing femoral head dislocation and posterior wall fracture. The video shows a surgical hip dislocation technique.
Incorrect Answers:
OrthoCash 2020
A 42-year-old male presents to your clinic for the first time with the radiographs seen in Figure A. He sustained the injury 4 weeks ago while skiing overseas and treatment was provided by the local orthopaedic surgeon. The operative note states that he sustained an Gustilo Type I open fracture. After surgical fixation of this type of injury, what is the most common complication requiring reoperation?

Chronic elbow instability
Post-traumatic arthritis
Infection
Heterotopic ossification
Loss of elbow range of motion Corrent answer: 5
This patient sustained a terrible triad elbow fracture-dislocation. Reduced range of motion of the elbow joint is the most common complication REQUIRING reoperation with these injuries.
Terrible triad elbow fracture-dislocations are characterized by posterolateral dislocation/lateral collateral ligament (LCL) injury, radial head fracture and coronoid fracture. Displaced fractures result in elbow instability. Acute radial head stabilization, coronoid open reduction and internal fixation, and LCL +/-medial collateral ligament (MCL) repair/reconstruction is considered the most appropriate treatment for displaced fractures. Operative complications include elbow stiffness, recurrent instability, arthritis, failure of hardware, heterotopic ossification, posterior interosseous nerve palsy and infection.
Egol et al. looked at the functional outcomes of 27 patients that underwent fixation of terrible triad injuries. At one year follow-up, the average flexion-extension arc of elbow motion was 109 degrees +/- 27 degrees, and the average pronation-supination arc was 128 degrees +/- 44 degrees. Grip strength averaged 72% of the contralateral extremity. Although operative fixation led to functional elbow stability, results were poor.
They included a reference to McKee et al. to highlight that intra-articular fractures of the elbow have high rates of stiffness. While not specific to terrible
triads, they looked at the effectiveness of the posterior elbow approach in 25 patients that underwent internal fixation of intra-articular distal humerus fractures. They showed poor outcomes at a mean follow-up of 36 months with reduced range-of-motion, decreased strength and high re-operation rates.
Figure A shows AP fluoroscopic image of a terrible triad injury that has undergone operative fixation. The radial head and coronoid have undergone open reduction internal fixation, and the MCL bony avulsion has been repaired.
Incorrect Answers:
OrthoCash 2020
Figure A is a radiograph from a 59-year-old male that was transferred to a Level I trauma center five hours after a motor vehicle accident. Closed reduction and skeletal traction was successfully performed in the trauma bay. Which of the following factors has been shown to increase the risk of unsatisfactory clinical outcome for this patient?

Need for skeletal traction
Mechanism of injury
Gender
Age
Time to reduction Corrent answer: 4
Age greater than 55-years-old has been found to be an independent risk factor for inferior clinical outcome in patients with combined acetabular fractures and hip dislocations.
The most important initial step in management following resuscitation involves urgent reduction of the dislocated hip. This should be followed by a preoperative CT scan and ultimately surgical fixation of the combined acetabular fracture. Hip dislocations should be reduced within 6-12 hours for optimal outcome, although different critical times have been cited, particularly for dislocations with concomitant acetabular fractures. Skeletal traction may be required to maintain hip reduction.
Moed et. al. present a Level 3 retrospective review of 100 patients who had been treated with open reduction internal fixation of an acetabular fracture. The authors found that factors associated with unsatisfactory clinical outcomes included age greater than 55, intra-articular comminution, osteonecrosis, and delay of greater than 12 hours for reduction of an associated hip dislocation.
Additionally, they showed that there was a strong association of clinical outcome and final radiographic grade.
Figure A demonstrates an acetabular fracture with concomitant hip dislocation. Incorrect Answers:
injury, male gender, and time to reduction <6 hours have not been shown to be related to unsatisfactory outcomes.
OrthoCash 2020
A 37-year-old male cashier is shot in the leg. He sustains the injury shown in Figures A and B, and is subsequently taken to the operating room for intramedullary nailing. Figure C shows a radiograph of the nail starting point (*). What complication is most likely to result?

Varus malunion
Nonunion
Valgus malunion
Malrotation
Superficial peroneal nerve injury Corrent answer: 3
This patient is presenting with a comminuted fracture of the proximal third of the tibia. He is appropriately undergoing intramedullary nail fixation, however, the start point illustrated in Figure C is too medial and often leads to a valgus malunion.
Intramedullary nail fixation is more technically demanding in proximal tibial fractures than diaphyseal fractures. The valgus deformity is due to imbalanced muscle forces on the proximal fragment, which are then accentuated by a start point that is too medial. An apex anterior (procurvatum) deformity can also occur and results from the pull of the patellar tendon or a posteriorly directed nail that deflects off the posterior tibial cortex and rotates the proximal fragment. The ideal starting point for proximal tibial fractures is slightly lateral to the medial aspect of the lateral tibial spine on a true AP x-ray and very proximal and just anterior to the anterior margin of the articular surface.
Nork et al. reported the results of intramedullary nailing of proximal tibial fractures with emphasis on techniques of reduction. Various techniques were found to be successful including attention to the proper starting point, the use of unicortical plates, and the use of a femoral distractor applied to the tibia.
Lowe et al. describe surgical techniques for complex proximal tibial fractures. They describe the extended leg position, use of a femoral distractor, temporary plate fixation, blocking (Poller) screws, and use of percutaneous clamps as means to achieve reduction during fixation.
Figure A and B show an AP and lateral radiograph of a comminuted extra-articular fracture through the proximal third of the tibia. Figure C demonstrates a start point that is too medial (represented by the asterisk) for intramedullary nail fixation. Illustration A and B show the ideal start point for intramedullary nail fixation of the tibia on AP and lateral radiographs.
Incorrect Answers:
Varus malunion is more likely to occur in midshaft tibia fractures with an intact fibula.
Nonunion after a proximal tibial fracture treated with intramedullary nailing is less common than malunion.
Malrotation occurs most commonly after IM nailing of fractures through the distal third of the tibia.
The superficial peroneal nerve is at risk during distal screw fixation using a LISS plating technique for fracture fixation.

OrthoCash 2020
A 24-year-old motorcyclist is brought in as a polytrauma after striking a tree at 65 mph. He is found to have injuries involving the chest, abdomen, pelvis, as well as a left open femoral shaft fracture. He undergoes resuscitation in the trauma bay. Which of the following parameters best supports proceeding with irrigation, debridement and external fixation as opposed to immediate reamed intramedullary nailing?
Temperature = 35.5°C (95.9°F)
Fractures of ribs 2-3 with left apical pneumothorax
Grade IV liver laceration with SBP = 85 mmHg
Left superior and inferior pubic ramus fractures
Lactate = 2.3 mg/dL
Significant abdominal trauma with evidence of hemorrhagic shock (SBP < 90 mmHg) following resuscitation is an unstable parameter and therefore is an indication to proceed with damage control orthopaedics (irrigation and debridement of open fractures and temporizing external fixation) in a polytraumatized patient.
The management of orthopaedic injuries in a polytrauma patient depends on the physiological stability of the patient. In an unstable patient, damage control orthopaedics (DCO) is preferred over early total care (ETC) to avoid an iatrogenic second hit with development of adult respiratory distress syndrome (ARDS) and/or multiple organ failure. Clinical parameters indicative of instability include shock (BP < 90 mmHg, refractory to blood products, lactate
> 2.5 mg/dL), coagulopathy (platelet count < 90,000 mm3, fibrinogen < 1 g/L), hypothermia (< 35°C), and significant chest, abdomen or pelvis injuries (pulmonary contusions, severe liver/spleen lacerations, pelvic ring disruption).
Pape et al. (2009) authored a review article detailing the management of a multitrauma patient. Polytrauma patients can be classified as stable, borderline, unstable or in extremis using a variety of criteria pertaining to hemodynamic stability, coagulation, temperature and soft tissue injury.
Patients who are stable or borderline can undergo ETC, while patients who are unstable or in extremis should be managed with DCO.
Pape et al. (2008) concluded that all patients who underwent early femoral nailing demonstrated increased systemic inflammatory response compared to external fixation, regardless of clinical stability. However, unstable patients
with a preexisting elevation of inflammatory status are likely more impacted by this additional increase. Improved postoperative clinical status coincided with a less vigorous inflammatory response.
Illustration A is a table from Pape et al (2009) depicting the criteria used to determine clinical condition of a polytraumatized patient. Illustration B is an algorithm from Pape et al (2009) detailing management of the multitrauma patient.
Incorrect Responses:

OrthoCash 2020
A 92-year-old female sustains the injury shown in Figure A to her nondominant extremity as the result of a non-syncopal ground-level fall. She denies any previous injury or pain of the elbow, and her medical history is significant only for osteoporosis and hypothyroidism. What is the most appropriate treatment for her injury?

Immediate range of motion as tolerated with a sling for comfort
Long arm cast for 3 weeks, then physical therapy for motion
Open reduction and internal fixation
Radiocapitellar arthroplasty
Total elbow arthroplasty Corrent answer: 5
Use of total elbow arthroplasty (TEA) in the elderly is a well-recognized method of treatment of complex distal humerus fractures. This procedure allows for improved ROM, improved patient-reported outcomes, and decreased revision rates as compared to fixation.
TEA is a preferred alternative for ORIF in elderly patients with complex distal humeral fractures that are not amenable to stable fixation. Elderly patients appear to accommodate to objective limitations in function with time, which is important, as most recommendations list restrictions of lifting no more than 5-10 pounds postoperatively.
McKee et al conducted a prospective, randomized, controlled trial to compare functional outcomes, complications, and reoperation rates in elderly patients with displaced intra-articular, distal humeral fractures treated with open reduction-internal fixation (ORIF) or primary semiconstrained total elbow arthroplasty (TEA). Patients who underwent TEA had a quicker procedure, improved DASH scores at 6 months, improved elbow ROM, and decreased revision rates.
Athwal et al review TEA and the options available at the time of publication. They also report on the techniques and purported advantages of arthroplasty as compared to fixation of complex distal humerus fractures.
Frankle et al reviewed patients >65 years old with distal humerus fractures at a minimum of 2 years follow-up. Outcomes were excellent in 33% of cases undergoing ORIF and 92% excellent with TEA. They recommend TEA in instances of arthritis, osteoporosis, or other diagnoses requiring steroids.
Figure A shows a significantly comminuted distal humerus fracture in an osteoporotic patient. Illustration A shows the same patient after undergoing total elbow arthroplasty.
Incorrect Answers:
1:Immediate range of motion is not recommended for this injury, even with the "bag of bones" treatment method. A brief period of immobilization is generally recommended for this technique.
2: Casting is not indicated for this injury.
3: ORIF of this injury will lead to worse outcomes as compared to arthroplasty. 4: Isolated radiocapitellar replacement is not indicated for this injury.

OrthoCash 2020
A 56-year-old right hand dominant attorney falls from standing and sustains the closed injury shown in Figure A. The treating surgeon elects to fix her fracture using a plate and screw construct. Based on
the available imaging, which of the following fracture characteristics best justifies this fixation choice?

Fracture displacement
Intra-articular fracture extension
The fracture extends distal to the coronoid
Oblique fracture line
Fracture comminution
This patient has a displaced, intra-articular, comminuted olecranon fracture. Comminution is an indication for plate fixation.
Most displaced olecranon fractures are treated operatively. Options include tension band constructs, intramedullary screws, plate and screw fixation or fragment excision with triceps advancement. Any construct relying on interfragmentary compression (tension band, intramedullary screws) requires a non-comminuted fracture pattern. Plate fixation is indicated in the setting of comminution, extension past the coronoid, or in the setting of associated instability.
Bailey et al. retrospectively reviewed 25 patients who underwent plate fixation of displaced olecranon fractures. Twenty-two of 25 patients had good or excellent outcomes. Five of 25 patients (20%) of patients required plate removal for symptomatic hardware. The authors concluded that plate fixation
was an effective treatment for displaced olecranon fractures, with good functional outcomes.
Figure A shows a displaced, comminuted olecranon fracture without evidence of propagation past the coronoid.
Incorrect answers:
OrthoCash 2020
A 35-year-old male was involved in a high speed motorcycle accident. He has a closed head injury, bilateral pulmonary contusions and splenic rupture. His orthopaedic injuries are shown in Figure A. He has a blood pressure of 90/50 mm Hg and a heart rate of 115, despite aggressive resuscitation. An arterial blood gas reveals that his blood lactate is 3.5 and base deficit is -6 mmol/L. Following successful closed reduction of the right hip in the operating room with a percutaneous inserted Schantz pin, what is the next most appropriate treatment for his orthopaedic injuries?

Bilateral open reduction and internal fixation
Open reduction internal fixation on the right, reamed intramedullary nailing on the left
Temporizing external fixation on the right, open reduction and internal fixation on the left
Bilateral reamed intramedullary nailing
Bilateral temporizing external fixation Corrent answer: 5
This patient presents with features of hemodynamic instability and a high injury severity score. The next most appropriate treatment would be temporizing external fixation bilaterally. This patient meets the criteria for damage control orthopaedics.
Damage control orthopaedics is an approach that contains and stabilizes orthopaedic injuries so that the patient's overall physiology does not undergo further inflammatory insult. As a result, external fixation of femoral shaft fracture and pelvic stabilization is an effective treatment under this strategy. Other indications include vascular injury and severe open fracture.
Pallister et al. reviewed the effects of surgical fracture fixation on the systemic inflammatory response to major trauma. They show that early stabilization of major long bone fractures is beneficial in reducing the incidence of acute respiratory distress syndrome and multiple organ failure. However, early fracture surgery increases the post-traumatic inflammatory response, which
carries a higher complication rate compared to temporary fixation.
Tisherman et al. created clinical guidelines for the endpoints of resuscitation. Level I data found that standard hemodynamic parameters do not adequately quantify the degree of physiologic derangement in trauma patients. The initial base deficit, lactate level, or gastric pH should be used to stratify patients with regard to the need for ongoing fluid resuscitation.
Pape et al. retrospectively reviewed the impact of early total care vs. damage control orthopaedics in the treatment of femoral shaft fractures in polytrauma patients. They found a significantly higher incidence of acute respiratory distress syndrome (ARDS) with intramedullary nailing (15.1%) compared to external fixation (9.1%) when DCO subgroups were compared.
Figure A is a pelvic AP radiograph showing a right hip fracture-dislocation with an ipsilateral femoral shaft fracture. On the left side there is a displaced pertrochanteric hip fracture.
Incorrect Answers:
OrthoCash 2020
Which of the following has been shown to be the greatest risk factor for refracture after implant removal from a radial shaft?
Removal of locking screws
Removal of small fragment plates
Removal of metaphyseal implants
Removal of implants less than 1 year after insertion
Removal of protective splinting from limb earlier than 10 weeks postoperatively
Removal of implants earlier than 1 year after insertion is a risk factor for refracture of the bone after implant removal.
The risk of refracture after hardware removal is multifactorial. Multiple
variables have been studied such as protective splinting for 6 weeks after hardware removal, waiting 12 months or more prior to hardware removal, and the location of the fracture. The variable that seems to correlate most with the risk of refracture is a diaphyseal location of the initial fracture. Large fragment plates (4.5 mm), when removed, are also at higher risk for refracture in the forearm.
Deluca et. al reported on a case series of patients who sustained a refracture of a forearm after implant removal. They noted that radiolucency at the site of the original fracture was seen in most refractured patients when the plate was removed. They also recommend delaying implant removal to two years after insertion to minimize risk.
Rumball et. al reported that the incidence of refracture after forearm implant removal is 6% in their series. They found that early removal, lack of postoperative immobilization, and plate size are the most critical risk factors for refracture.
Illustration A shows a forearm with evidence of refracture after implant removal.
Incorrect Answers:

OrthoCash 2020
A 23-year-old male arrives to the trauma bay after a motorcycle crash caused by a drive-by shooting. The patient is awake and alert and following commands. Vital signs include a blood pressure of 145/90 and a heart rate of 117bpm. Initial lactate is reported as 2.4 mmol/L. The patient has 2 rib fractures on the right with a clear chest radiograph. The patient is neurovascularly intact with a 4cm transverse wound over the medial ankle. Figures A, B and C exhibit his orthopaedic injuries. What is the most appropriate management?

Irrigation, debridement and placement external fixator right ankle, external fixation femur and intramedullary fixation tibia
Irrigation, debridement and placement external fixator right ankle, intramedullary fixation femur and tibia
Irrigation, debridement and placement external fixator right ankle, intramedullary fixation femur and external fixation tibia
Irrigation, debridement and placement external fixator right ankle, femur and tibia
Irrigation, debridement and external fixation right ankle and skeletal traction
The patient is relatively hemodynamically stable. In this case the femur and tibia should be definitively fixed while the open ankle fracture can be irrigated and debrided and placed in a spanning external fixator, temporizing for later definitive fixation.
Aside from an elevated heart rate and mildly elevated lactate (normal < 2.5 mmol/L), the patient is relatively stable making him a good candidate for long bone stabilization and temporizing external fixation of the right ankle. Gross contamination of the open injury also supports temporizing fixation, which can be brought back for repeat I&D and possible fixation.
Pape et al. compared outcomes for intramedullary nailing (IMN) versus staged fixation for femur fractures in stable versus borderline patients. Borderline patients were defined as those with multi-system injury (especially to lungs) and exhibited higher lung complications following acute IMN when compared to stable patients with isolated orthopaedic injuries.
O'Brien reviewed the literature regarding early total care in regards to IMN stabilization of femur fractures. Summarized data noted isolated injuries treated with early IMN had good outcomes, whereas those with head or lung injury had worse outcomes and pulmonary complications.
Figure A exhibits a right open ankle fracture dislocation. Figure B exhibits a mid-shaft tibia fracture. Figure C exhibits a ballistic mid-shaft femur fracture.
Incorrect Answers:
OrthoCash 2020
Figure A is an anterior-posterior (AP) radiograph of a 27-year-old male who was a bicyclist struck by a motor vehicle. He was intubated in the field and unresponsive in the trauma slot. Ultrasound of his abdomen is positive for blood and he is brought to the operating room emergently for an exploratory laparotomy. He is found to have ischemic bowel and a grade 4 liver laceration. His lactate is 9.0 mg/dL. Which figure represents the next appropriate step in regard to his pelvic ring injury?

The radiograph exhibits an elevated left hemipelvis with complete sacroiliac disruption, which can be temporized with placement in skeletal traction.
The patient is unstable, as indicated by an elevated lactate level. The most appropriate next step is temporizing skeletal traction to reduce the left hemipelvis.
Langford et al. review the initial diagnosis, evaluation and resuscitation in the management of pelvic fractures. Reduction of pelvic volume can be achieved with pelvic binders and temporizing external fixation for anterior posterior compression (APC) and/or lateral compression (LC) fracture patterns, while skeletal traction can help do the same in vertical shear patterns.
Matullo et al. review the uses of skeletal traction in orthopaedic trauma, where lower extremity skeletal traction can be an efficient, fast, easy way to help reduce pelvic volume in vertical shear injuries, especially when the patient is unstable and not cleared for definitive fixation.
Figure A exhibits an elevated left hemipelvis indicative of a vertical shear injury and complete SI disruption. Figure B is an example of a pelvic binder. Figure C is a pelvic reconstruction plate. Figure D is a schematic of an anterior pelvic external fixator. Figure E is a schematic drawing of a patient in lower extremity
skeletal traction. Figure F is a radiograph exhibiting S1 and S2 sacroiliac (SI) screws.
Incorrect answers:
OrthoCash 2020
A 38-year-old man is involved in a motor vehicle collision and suffers the grossly open injury shown in Figure A. He subsequently undergoes irrigation and debridement and placement of an external fixator. In Figure B, if the proximal pin is placed at the red circle as compared to the black circle, the patient is at increased risk for which of the following?

Foot drop
Injury to the anterior tibial artery
Septic arthritis
Flexion contracture of the knee
Patellar tendon rupture Corrent answer: 3
The patient is at increased risk of septic arthritis when placing the proximal tibial pin too proximal due to penetration of the joint capsule. Pin site flora can track into the joint and lead to a septic knee.
Tibial external fixators can be used to temporize tibial shaft, pilon, and ankle fractures not ready for definitive management due to soft tissue concerns and/or practice of damage control orthopaedics. Intracapsular placement of fixator pins can lead to septic arthritis. The capsular reflection typically extends 14 mm distal to the subchondral line.
DeCoster et al. reported a cadaveric dissection study for safe placement of proximal tibia pins and determined that the capsule inserts 14 mm below the articular surface along the posteromedial and posterolateral surfaces. For fractures requiring extremely proximal pin placement, they recommend
anterior cortex penetration only at least 6 mm distal to articular surface.
Reid et al. investigated safe transtibial pin placement using MRI and cadaveric and volunteer knees. They found that pin placement 14 mm distal to subchondral bone will result in low likelihood of capsular penetration.
Figure A is an AP radiograph showing a segmental middle third tibia/fibula fracture. Figure B is a lateral diagram of the tibia showing potential sites of proximal pin placement.
Incorrect Answers:
OrthoCash 2020
Figures A and B are radiographs of a 43-year-old, right-hand dominant, male that injured his arm in a motor vehicle accident. What would be an absolute indication for surgical fixation of his injury?

Radial nerve palsy
Intra-articular extension
2mm fracture distraction, 5 degrees of rotational malignment
Ipsilateral proximal both bone forearm fracture
Bilateral fracture
This patient has a humeral shaft fracture. An absolute indication for surgery would include a floating elbow, i.e. ipsilateral both bone forearm fracture.
The primary causes of humeral fractures include motor vehicle accidents, falls, or violent injury. Almost all cases are treated non-operatively with functional bracing. The absolute indications for surgical management include: ipsilateral vascular injury, severe soft-tissue injury, open fracture, compartment syndrome, and associated ipsilateral forearm fracture, ie, floating elbow. The relative indications for surgical management include: segmental fracture, intraarticular extension, significant fracture distraction, bilateral humeral fracture, inability to maintain acceptable alignment, and polytrauma.
Klenerman et al. reviewed non-operative treatment of humeral shaft fractures. They showed that acceptable results could be achieved even after 20° of
anterior bowing, 30° of varus angulation, 15° of malrotation, and 3 cm of shortening.
Carroll et al. reviewed the management of humeral shaft fractures. They state the indications for operative fixation to be polytraumatic injuries, open fractures, vascular injury, ipsilateral articular fractures, floating elbow injuries, and fractures that fail nonsurgical management. Surgical techniques include external fixation, open reduction and internal fixation, minimally invasive percutaneous osteosynthesis, and antegrade or retrograde intramedullary nailing
Figure A and B shows a comminuted mid-shaft humeral fracture with intraarticular extension.
Incorrect Answers:
OrthoCash 2020
Which of the following findings is a contraindication in retrograde nailing of a periprosthetic distal femur fracture around a total knee arthroplasty?
Posterior-stabilized total knee implant
Cruciate retaining total knee implant
Spiral fracture pattern
Distal femoral replacement
Knee flexion contracture of 15 degrees Corrent answer: 4
A distal femoral replacement (TKA) implant will generally preclude placement of a retrograde nail due to the long stem on the femoral component.
Supracondylar femur fractures above a well-fixed TKA component are increasingly common. These fractures are often treated with a lateral locking plate, but can also be treated with a retrograde nail in certain circumstances. An important factor in determining if nailing is a viable option are knowing the TKA implant and it's design. In addition, if the TKA component is known, the maximum size of reamer head and nail can be determined preoperatively from the size of the femoral 'box'.
Schutz et al report on a prospective multicenter study of 112 patients who underwent fixation of a distal femur fracture with the LISS system. They report that 90% of fractures went on to union and they attribute all of the failures to either the high-energy nature of particular fractures or a lack of experience in applying the plate in an appropriate pattern. They also note that primary grafting of these fractures is not necessary.
Illustration A shows a periprosthetic femur fracture treated with a retrograde nail.
Incorrect Answers:
1: A posterior-stabilized implant can be treated with an intramedullary nail in many circumstances but can be technically challenging, depending on the components.
2: A cruciate retaining TKA is not a contraindication to use of a retrograde nail. 3: A spiral pattern periprosthetic supracondylar femur fracture can be treated with a femoral nail.
5: A knee flexion contracture will often provide the flexion necessary for access to the box of the femoral component. A knee extension contracture, however, can preclude access to this box for placement of a nail.

OrthoCash 2020
A patient falls and sustains the isolated injury seen in Figures A and B. The surgical plan includes open reduction and internal fixation with a small mini-fragment plate using a direct lateral approach. During the approach, the forearm was placed in a fully pronated position. What would be the correct position of the forearm during plate application?

Full pronation
25 degrees pronation
Neutral
25 degrees supination
Full supination
Using the lateral approach (Kocher or Kaplan), the correct placement of the arm should be in a neutral position so that the plate can be placed on the bare area of the proximal radius.
Displaced radial head fractures with less than 3 fragments can be amendable to open reduction internal fixation. The methods of fixation include buried or headless screws, if placed at the articular surface, or posterolateral plating, if placed in the bare area. The safe zone for plating is located at a 90-110 arc from the radial styloid to Lister's tubercle with the arm in neutral rotation. This position helps to avoid impingement of ulna against the plate with forearm rotation. It should be noted that during the approach, that the forearm should be fully pronated to avoid injury to the posterior interosseous nerve.
Mathew et al. reviewed the concepts of terrible triad injuries of the elbow. Radial head fractures are treated conservatively when there is an isolated minimally displaced (less than 2mm) fracture with no mechanical block to motion. Open reduction internal fixation is used for Mason II or III fractures with < 3 fragments. Radial head replacement is considered for comminuted
fractures (Mason Type III) with 3 or more fragments.
Cheung et al. reviewed the surgical approaches to the elbow. The lateral approach (Kocher or Kaplan) is most commonly used with these injuries. The Kocher approach utilizes the intramuscular plane between anconeus and extensor carpi ulnaris. Kaplan utilizes the plane between extensor digitorum commons and extensor carpi radialis brevis.
Figure A and B show AP and lateral radiographs of the left elbow. There is a displaced radial head fracture. Illustration A shows a schematic diagram of the radial head "safe zone" between the radial styloid to Lister's tubercle.
Incorrect Answers:

OrthoCash 2020
A 38-year-old male is involved in a high speed motor vehicle collision. He has a Glasgow Coma Scale of 13 and receives 2 liters of fluid en route to the emergency department. Upon evaluation in the emergency department, he is found to have a bilateral femoral shaft fractures, a right ankle fracture, and a left both bone forearm fracture. He also has 2 left sided rib fracture and a grade II liver laceration. His heart rate is 130 and blood pressure is 85/50. All of the following
would be indications to practice damage control orthopaedics in this patient except:
Bilateral femur fractures
Rib fractures
Lactate of 5.2
Urine output of 20 cc/hr
Heart rate and blood pressure Corrent answer: 2
Rib fractures without evidence of further thoracic trauma would not be an indication to practice damage control orthopaedics. This patient is underresuscitated based on his lactate level, urine output, and vital signs and definitive management should be delayed.
Damage control orthopaedics is the practice of delaying definitive management of fractures and utilizing temporary stabilization (such as an external fixator) until a patient has recovered from the initial physiologic insult of trauma.
Patients are at increased risk for perioperative complications such as ARDS and multi-system organ failure during the acute period after polytrauma. In addition to underresuscitation, other indications to practice damage control orthopaedics include: injury severity score>40 (or >20 with thoracic trauma), bilateral femoral fractures, hypothermia below 35 degrees Celsius, and pulmonary contusions.
Pape et al. (2007) studied the incidence of acute lung injuries in polytrauma patients undergoing either intramedullary nailing or external fixation and later definitive fixation of femoral shaft fractures. They found that patients undergoing immediate intramedullary nailing were nearly 6.7 times more likely to have acute lung injury
The Canadian Orthopedic Trauma Society studied the effect of reamed versus unreamed femoral nailing on incidence of ARDS for femoral shaft fractures in trauma patients using a randomized controlled study. They found no difference between the groups.
Pape et al. also examined the pathophysiological cascades that accompany soft tissue injuries of the extremities, abdomen, and pelvis and recommend a more comprehensive for evaluation of patients with these injuries.
Incorrect Answers:
OrthoCash 2020
The anterior intrapelvic (modified Stoppa) approach is most appropriate for which of the following fractures?

The anterior intrapelvic (AIP) or modified Stoppa approach provides access to the quadrilateral plate, which is a common location for fracture displacement in associated both column acetabulum fractures as seen in Figure D.
Compared to the traditional ilioinguinal approach, the modified Stoppa with a lateral window can offer comparable access to the quadrilateral plate, which can allow for its use in associated both column fracture patterns.
de Peretti et al. prospectively followed 25 patients with both column fractures
treated via an iliofemoral approach. Results led the authors to not recommend the extensile approach for both column fractures due to lack of efficiency and high complication rates.
Alonso et al. compared the extensile iliofemoral and triradiate approaches, and both reported acceptable results. However, concerning were the relatively high rates of heterotopic ossification, despite prophylaxis.
Bible al. performed a cadaver study to quantify the amount of access provided by the modified Stoppa approach. This approach provides access to approximately 80% of both the inner pelvis, and the quadrilateral plate, however, comparison to the ilioinguinal approach was not performed.
Shazar et al., in a cohort comparison between the ilioguinal and Stoppa approaches, noted better visualization and potential improve fracture reduction via the Stoppa approach for both column fractures. However, this study was limited in its retrospective and relative observer bias.
Figure A depicts a posterior wall fracture dislocation with concomitant femoral neck fracture. Figure B is an iliac oblique view which depicts a posterior column fracture. Figure C exhibits a posterior column + posterior wall fracture. Figure D depicts acetabular fracture with protrusio. Figure E exhibits a posterior wall fracture.
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OrthoCash 2020
Figure A is a radiograph of a 75-year-old woman that fell onto her non-dominant shoulder from a standing height. She was treated nonoperatively for 9 months but continues to complain of pain when she elevates her arm. In patients with this type of fracture pattern, what factor has the greatest impact on fracture healing?

Hand dominance
Angulation of fracture
Smoking
Early physical therapy
Diet
This patient has an impacted varus proximal humerus fracture. Smoking has been shown to increase the nonunion risk up to 5.5 times with these fractures.
Impacted varus proximal humerus fractures can be managed effectively with non-operative care. The major factors that influence non-union are age and smoking. Solid bony union can be seen in 93-98% of patients at 1 year, with more than 97% of people returning to pre-injury level of function. The angulation of fracture, hand dominance and physical therapy does not seem to influence bone union or functional outcomes with this fracture pattern.
Court-Brown et al. looked at the outcomes of impacted varus fractures. They determined that the age of the patient was the major factor in overall outcome. They showed that the best results occurred in younger patients, but results deteriorate with advancing age. Physical therapy was not found to
impact outcome.
Hanson et al. showed that impacted varus fractures can be successfully managed with non-operative care. They found that overall fracture displacement had a minor impact of fracture healing and functional outcome. The predicted risk of delayed union and nonunion was 7% with patients that smoke. This was 5.5 times greater than non-smokers.
Figure A shows an AP radiograph of a varus angulated proximal humerus fracture. This radiograph shows delayed atrophic union.
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OrthoCash 2020
A 26-year-old male epileptic patients presents with right shoulder pain and deformity after a grand mal seizure. After medical stabilization, he denies previous injury to his shoulder. Pre-reduction and post-reduction radiographs of the shoulder are shown in Figures A-C, respectively; physical examination reveals a normal upper extremity neurovascular examination. After shoulder immobilization, what would be the next most appropriate step in management of this patient?

Abduction brace for three weeks, followed by therapy
Right shoulder MR arthrogram
Open reduction and internal fixation
Hemiarthroplasty
Early range of motion Corrent answer: 3
This patient has presented with a fracture dislocation of the right shoulder. After urgent closed reduction, this patient requires open reduction internal fixation of the proximal humerus, and greater tuberosity fracture fragment in particular.
Isolated greater tuberosity fractures may be associated with shoulder dislocations. Careful review of imaging is critical to identify fracture lines that may extend into the humeral neck and head. If these extensions go undetected, catastrophic propagating fractures may occur during closed reduction maneuvers. Treatment is usually with open reduction internal fixation (ORIF). Young patients with proximal humerus fractures should be treated more aggressively with ORIF as compared to elderly patients. Another example would be a severely impacted valgus proximal humeral fracture in a young patient.
Erasmo et al. examined of 82 cases of humerus fracture dislocations treated with the lateral locking plates. Overall outcomes were excellent to good based on standard scoring systems. Complications included avascular necrosis (12%), varus positioning of the head (4.8%), impingement syndrome (3.6%), secondary screw perforation (3.6%), non-union (2.4%) and infection (1.2%).
Robinson et al. looked at severely impacted valgus proximal humeral fractures treated with open reduction internal fixation in young patients. Anatomic reduction is required with lateral plating to re-establish the normal head/neck angle. Good to excellent results can be achieved with fixation methods.
Figure A shows an anterior fracture-dislocation of the right shoulder. Figure B and C show post-reduction radiographs with a congruent glenohumeral joint. Displacement of the greater tuberosity (GT) fragment is greater than 5mm.
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OrthoCash 2020
Pelvic packing can be performed to temporarily treat a hemodynamically unstable patient with a pelvic ring fracture. Which of the following is the preferred location of the skin incision to perform pelvic packing?
Right anterior superior iliac spine (ASIS) to mid-symphysis, left lateral window incision
Left ASIS to mid-symphysis, right lateral window incision
Subumbilical incision
ASIS to ASIS bilaterally
Pararectus incision
The preferred skin incision location is a subumbilical incision, 6-8cm extending upwards from the pubic symphysis towards the umbilicus; this allows access to all of the appropriate areas for pelvic packing.
Following skin incision, the rectus fascia is then divided in the midline which allows for access to both sides of the bladder for packing deep in the pelvic
brim. On each side, 3 lap pads are placed from sacroiliac joint to the retropubic space, all placed below the level of the pelvic brim.
Hak et al. review the options for emergent treatment in life threatening hemorrhage secondary to pelvic fractures. The authors offer several options for emergent treatment, which includes the use of pelvic binders, the placement of external fixators, pelvic packing and interventional angiography. Goals include reduction of pelvic volume and stopping rapid hemorrhage to save a patient's life. Pelvic packing, properly performed, is done through a subumbilical incision, as described above.
Osborn et al. retrospectively reviewed and compared emergent pelvic packing to angiography in hemorrhagic pelvic fracture clinical scenarios. The authors noted comparable results in mortality with a noted decrease in need for post-procedure transfusions in the pelvic packing group.
Cothren et al. reported their outcomes following an institutional algorithmic change from pelvic ex-fix/angiography to pelvic packing and ex-fix. Since their institutional change, the authors noted a significant decrease in transfusions, need for angiography and mortality.
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OrthoCash 2020
A 28-year-old man is brought by ambulance to the emergency department after falling from the roof of his home four hours ago. Upon initial evaluation, he has visible deformities of his bilateral lower extremities and a positive FAST exam. Heart rate is 135, blood pressure 85/58, and urine output is 40 cc over 3 hours. According to ATLS guidelines, what percentage of his blood volume has this patient likely lost?

Question 69

You are counseling a 55-year-old woman for a right carpal tunnel release. What can you tell her about the treatment benefit (grip strength and paresthesia relief) 1 year after surgery compared with continued splinting, NSAID use, physical therapy, and a single steroid injection?

Explanation

EXPLANATION:
Gerritsen and associates, Hui and associates, and Jarvik and associates compared the effectiveness of surgical versus nonsurgical treatment for the relief of carpal tunnel symptoms. All three studies showed that surgery was superior for the relief of paresthesias and the improvement of grip strength. According to the American Academy of Orthopaedic Surgeons Clinical Guidelines on the Treatment of Carpal Tunnel Syndrome, strong evidence supports the assertion that surgical treatment of carpal tunnel syndrome should have a greater treatment benefit at 6 and 12 months than splinting, NSAIDs, physical therapy, and a single steroid injection. The other choices, including no change in grip strength and
paresthesias, decrease in grip strength and increase in paresthesias, and increase in grip strength and paresthesias, are not supported by the evidence.

Question 70

The newborn foot deformity seen in Figures 64a and 64b should initially treated with Review Topic

Explanation

Mild to moderate metatarsus adductus is best treated with observation and possible passive stretching exercises because most of these feet will self correct. Numerous types of shoes, braces, and splints have been devised but the efficacy of these have not been determined. Serial casting is reserved for severe metatarsus adductus in the infant, although a medial surgical release may be indicated if the deformity is symptomatic and persists beyond age 4 years.

Question 71

A patient with a displaced and comminuted fracture of the radial head and neck also has pain and swelling about the ipsilateral distal radioulnar joint. Which treatment option may exacerbate the wrist disorder?

Explanation

A 50-year-old woman has had acute weakness in her dominant hand for 6 weeks. Before noticing the onset of weakness, she experienced several weeks of vague discomfort in her shoulder and forearm, generalized fatigue, and a low-grade fever. There is no history of trauma. An examination reveals weakness of thumb and index finger distal interphalangeal (DIP) joint flexion. Electrodiagnostic testing shows fibrillations and positive sharp waves in the flexor pollicis longus and index flexor digitorum profundus muscles. The next appropriate step is
A. observation.
B. corticosteroid injection.
C. immediate surgical decompression.
D. tendon transfers.

Question 72

A study is designed that examines fractures in children with osteogenesis imperfecta after being treated with bisphosphonates compared with a placebo. A difference is found for which the P value is greater than what is considered to be statistically significant. What is the next appropriate statistical analysis?

Explanation

DISCUSSION: When a study yields a negative result between treatment groups, the next step is to perform a power analysis. The power, by definition, is the probability of rejecting the null hypothesis: in this example the null hypothesis would be that children treated with bisphosphonates would have fewer fractures than the untreated control population. The power analysis helps answer the question as to whether the null hypothesis should be rejected and the finding is real, or whether the sample size was too small or the effect of treatment too subtle to demonstrate a difference between the treatment and control groups.
REFERENCES: Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, p 7.
Kocher MS, Zurakowski D: Clinical epidemiology and biostatistics: A primer for orthopaedic surgeons. J Bone Joint Surg Am 2004;86:607-620.

Question 73

A 12-year-old Little League pitcher reports lateral elbow pain and “catching.” Examination reveals painful pronation and supination and tenderness over the lateral elbow. Radiographs are shown in Figures 22a and 22b. Initial management should consist of

Explanation

DISCUSSION: Osteochondritis of the capitellum is a common problem in young throwing athletes and gymnasts. The mechanism of injury involves lateral compression and axial loading of the capitellum. Repetitive trauma causes ischemia with resultant osteochondral necrosis and sometimes eventual separation. Initial management includes rest for a minimum of 6 weeks; occasionally bracing is used. At long-term follow-up, there is typically an observed radiographic abnormality indicating incomplete healing even in asymptomatic patients. Arthroscopy with in situ drilling is reserved for symptomatic lesions that have an intact articular surface. Lesions with partial separation often require fixation. Lateral column osteotomy is a new investigational procedure designed to relieve lateral compression forces and may be used in salvage cases.
REFERENCES: Kobayashi K, Burton KJ, Rodner C, et al: Lateral compression injuries in the pediatric elbow: Panner’s disease and osteochondritis dissecans of the capitellum. J Am Acad Orthop Surg 2004;12:246-254.
Yadao MA, Field LD, Savoie FH III: Osteochondritis dissecans of the elbow. Instr Course Lect 2004;53:599-606.

Question 74

A 68-year-old woman underwent an uncemented medial/lateral tapered femoral placement during a total hip arthroplasty. The orthopaedic surgeon noticed a nondisplaced vertical fracture in the calcar region of the femoral neck during final implant insertion. What is the most appropriate treatment?

Explanation

DISCUSSION:
The recognized treatment for a proximal periprosthetic fracture is to first identify the extent and then optimize the correction of the fracture. Several studies indicate that proximal cerclage wiring is adequate to create "barrel hoop" stability of the proximal femur. Braided cables offer superior stability compared with twisted wires or Luque wires. Finally, the appropriate postoperative treatment is protected
weight bearing for 6 weeks, with periodic radiographs taken at 2-week intervals. Other options such as cementing the femoral stem and using a revision arthroplasty device are indicated for unstable fractures.

Question 75

A 66-year-old male sustains an open crush injury to his right lower leg with significant skin loss. His history is significant for COPD, diabetes controlled with an insluin pump, and testicular cancer treated with bleomycin twenty years ago. A radiograph of the chest shows a pneumothorax which is treated with a thoracostomy tube. Which of the following is not a contraindication to hyperbaric oxygen treatment for this patient?

Explanation

DISCUSSION: The presence of a crush injury to an extremity is an indication for hyperbaric oxygen (HBO) therapy. The remainder of the options listed are contraindications to hyperbaric oxygen treatment.
Hyperbaric oxygen therapy potentially can provide enhanced oxygen delivery to peripheral tissues affected by vascular disruption, cytogenic and vasogenic edema, and cellular hypoxia caused by extremity trauma. The idea behind HBO is to provide enhanced oxygen delivery to peripheral tissues affected by vascular disruption, cytogenic and vasogenic edema, and cellular hypoxia caused by extremity trauma.
Greensmith et al provide a review of HBO therapy and discuss the relative and absolute contraindications and indications for this treatment. They report in patients with crush injury or early compartment syndrome, hyperbaric oxygen therapy may reduce the penumbra of cells at risk for delayed necrosis and secondary ischemia. They report that both animal studies and prospective human clinical trials suggest the benefits of such therapy.
Buettner et al found that based on clinical evidence and cost analysis, medical institutions that treat open fractures and crush injuries are justified in incorporating HBO theray as a standard of care.
Illustration A shows an example of a hyperbaric oxygen(HBO) chamber. Incorrect Answers:

Question 76

A 67-year-old man who underwent humeral head arthroplasty for a four-part fracture 6 months ago reports that he is still unable to actively elevate his arm. Rehabilitation after surgery consisted of a sling with passive range-of-motion exercises for 2 weeks and then progressed to active-assisted and strengthening exercises at 3 weeks. Radiographs are shown in Figures 28a and 28b. What is the primary cause of his inability to elevate the arm?

Explanation

DISCUSSION: The radiographs show nonunion of both the greater and lesser tuberosities. Tuberosity pull-off and nonunion remain among the most common causes of failed humeral head arthroplasty for fracture. Strict attention to securing the tuberosities to each other and to the shaft, and autogenous bone grafting from the excised humeral head will decrease the incidence of pull-off and improve healing rates. Active-assisted range-of-motion and strengthening exercises should be delayed until tuberosity healing is noted radiographically, usually at 6 to 8 weeks postoperatively.
REFERENCES: Hartsock LA, Estes WJ, Murray CA, et al: Shoulder hemiarthroplasty for proximal humeral fractures. Orthop Clin North Am 1998;29:467-475.
Hughes M, Neer CS: Glenohumeral joint replacement and postoperative rehabilitation.

Phys Ther 1975;55:850-858.
Compito CA, Self EB, Bigliani LU: Arthroplasty and acute shoulder trauma. Clin Orthop 1994;307:27-36.

Question 77

A 61-year-old man with a body mass index of 31 had a 6-month gradual onset of right medial knee pain. Examination revealed a small effusion, stable ligaments, a normally tracking patella, and mild medial joint line tenderness. Standing radiographs show mild medial joint space narrowing. Effective treatment at this stage of early medial compartmental osteoarthritis includes

Explanation

DISCUSSION:
According to the 2008 AAOS Clinical Practice Guideline, Treatment of Osteoarthritis of the Knee (Nonarthroplasty), level 1 evidence confirms that weight loss and exercise benefit patients with knee osteoarthritis. The other responses have either inclusive evidence (a valgus-directing brace) or no evidence to support their use (glucosamine 1,500 mg/day and chondroitin sulfate 800 mg/day as well as arthroscopic debridement and lavage).

Question 78

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 79

A healthy, active, independent 74-year-old woman fell and sustained the elbow injury shown in Figures 41a and 41b. Management should consist of

Explanation

DISCUSSION: Open reduction and internal fixation of distal humeral fractures in elderly patients often fails. These fractures characteristically have a very small distal segment and poor bone quality, resulting in failure of fixation and nonunion. Nonunion is often painful and functionally debilitating. Total elbow arthroplasty provides good results when used for distal humeral fractures in elderly patients with osteopenic bone and fracture patterns thought to be irreconstructable. Long arm casting may result in union, but the resulting stiffness is unacceptable for an active patient. Elbow arthrodesis has few indications. A sling and range-of-motion exercises will often result in a painful and debilitating nonunion at the fracture site.
REFERENCES: Frankle MA, Herscovici D Jr, DiPasquale TG, et al: A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intra-articular distal humerus fractures in women older than 65. J Orthop Trauma 2003;17:473-480.
Cobb TK, Morrey BF: Total elbow arthroplasty as primary treatment for distal humerus fractures in elderly patients. J Bone Joint Surg Am 1997;79:826-832.
Obremskey WT, Bhandari M, Dirschl DR, et al: Internal fixation versus arthroplasty of comminuted fractures of the distal humerus. J Orthop Trauma 2003;17:463-465.

Question 80

A 65-year-old man has chronic Achilles insertional tendinitis that is refractory to nonsurgical management. A radiograph is shown in Figure 9. Preoperative counseling should include a discussion of the realistic duration of postoperative recovery. You should inform the patient that his expected recovery will last

Explanation

DISCUSSION: An older patient with calcaneal enthesopathy may take a year or more to recover after tendon debridement and calcaneal ostectomy. Young patients, and those with purely tendon pathology, may recover more quickly.
REFERENCES: McGarvey WC, Palumbo RC, Baxter DE, et al: Insertional Achilles tendinitis: Surgical treatment through a central tendon splitting approach. Foot Ankle Int 2002;23:19-25.
Watson AD, Anderson RB, Davis WH: Comparison of results of retrocalcaneal decompression for retrocalcaneal bursitis and insertional Achilles tendinosis with calcific spur. Foot Ankle Int 2000;21:638-642.

Question 81

What is the heaviest weight that can be safely applied to the adult cervical spine via Gardner-Wells tong traction?

Explanation

DISCUSSION: Cotler and associates reported on the use of awake skeletal traction to reduce facet fracture-dislocations in 24 patients. Seventeen patients required more than 50 pounds of traction (the “traditional” limit) to achieve reduction. More than 100 pounds of traction was safely used in one-third of the patients in this study. A cadaver study has supported the safe use of traction with weights in excess of 100 pounds.
REFERENCES: Cotler JM, Herbison GJ, Nasuti JF, et al: Closed reduction of traumatic cervical spine dislocation using traction weights up to 140 pounds. Spine 1993;18:386-390.
Anderson DG, Vacccaro AR, Gavin K: Cervical orthoses and cranioskeletal traction, in Clark CR (ed): The Cervical Spine, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 2005,

pp 110-121.

Question 82

Figure 91 shows the radiograph of a 57-year-old man who fell 6 feet off a ladder. He is neurovascularly intact but reports shoulder pain. What is the most appropriate acute treatment for this patient?

Explanation

The patient has sustained a traumatic surgical neck fracture of the humerus. Sling immobilization and a recheck in 1 week with radiographs is appropriate to check for maintenance of alignment. The fracture is minimally displaced and therefore does not require surgical stabilization or further diagnostic imaging. Surgical reduction and plating is not indicated in this nondisplaced fracture. Physical therapy and activity as tolerated at this point are contraindicated because of the acuity of the fracture.

Question 83

5cm. Recent radiographs are seen in Figures A and B. What is the most appropriate treatment plan?

Explanation

Posterior perforation of the distal femur
Varus malreduction
Comminution of the fracture site
Iatrogenic femoral neck fracture
Anterior perforation of the distal femur Corrent answer: 5
According to the study by Egol et al, the average femoral anterior radius of curvature was 120 cm (+/- 36 cm), and currently available femoral nails have a greater radius of curvature (i.e. more straight). This mismatch has been shown to lead to an increased risk of perforation of the anterior distal femur as the nail is impacted into the canal.
The referenced study by Tencer et al noted an increased risk of iatrogenic femoral fracture with anterior starting point >6mm from the anatomic axis.
They recommend starting in line with the femoral axis, or just a few millimeters anterior in order to minimize this risk.
Illustration A depicts anterior femoral cortex penetration secondary to nail/femur radius of curvature mismatch.

OrthoCash 2020
A 60-year-old woman is undergoing closed reduction and percutaneous pinning of a proximal humerus fracture. What structure is at greatest risk for injury from the pin marked by the red arrow in Figure A?

Anterior branch of the axillary nerve
Posterior humeral circumflex artery
Long head of the biceps tendon
Cephalic vein
Musculocutaneous nerve
Certain anatomic structures are at risk with percutaneous pinning of proximal humerus fractures. The red arrow in Figure A marks a proximal lateral pin that would place the anterior branch of the axillary nerve at risk.
Rowles and McGrory performed an anatomic study of the structures at risk with closed reduction and percuatneous pinning of the proximal humerus and found that proximal lateral pins were a mean of 3mm from the anterior branch of the axillary nerve. Pins placed through the anterior cortex and directed into the humeral head fragment were a mean of 2mm from the long head of the biceps tendon and greater tuberosity pins were found to be 8mm from the posterior humeral circumflex and 10mm from the main trunk of the axillary nerve as they penetrated the medial cortex of the humerus.
Jaberg et al retrospectively reviewed the clinical and radiographic results of 48 patients at an average of 3 years after undergoing closed reduction and percutaneous pinning of a proximal humerus fracture. 70% good to excellent results with their described technique, and the authors caution that radiographic malunion did not correlate with patient function.
Incorrect Answers

OrthoCash 2020
A 42-year-old female sustains the injury seen in the computed tomography images seen in Figures A and B. According to the Letournel classification, what is the injury pattern shown?

Posterior wall
Transverse
Anterior wall
Posterior column
Both column
The axial CT cut and Judet radiographic view shown reveals a transverse fracture pattern according to the Letournel classification system. This can be determined by the fact that the articular surface of the acetabulum is attached to the intact portion of the ilium, which is connected to the axial skeleton posteriorly through the sacroiliac joint. This differs from a both-column fracture, in which the articular surface of the acetabulum has no attachments to the axial skeleton due to fracture line(s). The axial CT scan also shows a vertical fracture line which is typical of a transverse fracture pattern.
Durkee et al review the classification schemes for these injuries, as well as comment on the importance of quality images (Judet views, CT, etc).
Figures A and B show a transverse acetabular fracture with mild displacement.

OrthoCash 2020
Which of the following is true regarding plating of humeral shaft fractures compared to intramedullary nailing?
worse functional results
higher need for subsequent surgeries
higher incidence of radial nerve injury
lower complication rates
decreased nonunion rates Corrent answer: 4
Controversy exists regarding nailing compared with plating of humeral shaft fractures, but the most recent and highest level evidence indicates decreased complication rates with open reduction and internal fixation of these injuries.
Lin et al found less blood loss with intramedullary nailing than plating, but nailing was also associated with increased shoulder surgery, likely due to disruption of the rotator cuff tendon during insertion.
Meekers et al found a higher union rate, better functional results and a lower reoperation rate after plate and screw fixation versus nailing. They concluded that plating was superior in most cases of humeral shaft fracture, however more recent studies have challenged these findings.
Heineman et al. (2012) have recently conducted an update on their meta-analysis to include more recent randomized studies. With the inclusion of newer studies the author found a statistically significant increase in total complication rate with the use of IM nailing compared with ORIF. The authors found no significant difference between the two treatment modalities for the secondary outcomes (nonunion, infection, nerve palsy, re-operation)
Incorrect Answers:
OrthoCash 2020
A 35-year-old male sustains the fracture seen in Figures A and B. Which of the following substances has been shown to result in the least radiographic subsidence when combined with open reduction and internal fixation?

Cancellous allograft bone chips
Autograft iliac crest
Femoral intramedullary reamings
Calcium phosphate cement
Calcium sulfate cement Corrent answer: 4
Figures A and B show a plateau fracture with a lateral split and depression of the articular surface. In treating tibial plateau fractures, calcium phosphate has been shown to have the least amount of articular subsidence on follow-up examinations due to its high compressive strength.
The study by Lobenhoffer et al noted improved radiographic outcomes and earlier weightbearing with usage of calcium phosphate cement. Welch and Zhang reproduced tibial plateau fractures in goats and compared cancellous autograft to calcium phosphate cement augmentation. At 24 hours, four of five specimens treated with autograft had subsidence of the fragment. Only two specimens from limbs treated with cement showed minimal subsidence; the remaining were congruent.
Yetkinler’s study compared cement to no cement treatment in a model of depressed plateau fractures. Calcium phosphate cement of high compressive
strength provided equivalent or better stability than conventional open reduction
and internal fixation with either auto/allograft bone which had both a lower compressive strength and reduced mechanical stability.
OrthoCash 2020
The modified Judet approach to the posterior scapula exploits the internervous interval between what two muscles?
Supraspinatus and infraspinatus
Supraspinatus and subscapularis
Infraspinatus and teres minor
Teres minor and teres major
Teres major and lattisimus Corrent answer: 3
The posterior or modified Judet approach to the scapula is typically used for internal fixation of scapular fractures. This approach utilizes a transverse incision over the scapular spine with detachment of the posterior deltoid. The interval between the infraspinatus (suprascapular n.) and teres minor (axillary n.) is identified and used to gain access to the posterior aspect of the scapula and glenoid.
The reference by Obremskey et al argues the approach "combines several important goals including: 1) exposure of all bony elements of the scapula which have adequate bone stock for internal fixation; 2) minimal trauma to the rotator cuff musculature; and 3) protection of the major neurologic structures (suprascapular nerve superiorly and axillary nerve laterally)." They believe "the main advantage of the exposure is limiting muscular dissection, which can potentially improve rehabilitation and limit morbidity of the operation."
OrthoCash 2020
An 82-year-old female sustains an intertrochanteric hip fracture and is treated with a sliding hip screw. What is the most appropriate definitive step in treating the failure seen in figure A?

Non-weight bearing
Valgus proximal femoral osteotomy
Total hip arthroplasty
Revision open reduction and internal fixation
Proximal femoral resection Corrent answer: 3
Figure A shows superior cutout of the lag screw from the sliding hip screw as well as the superior cannulated screw used for an "antirotation" device.
In the referenced review article by Haidukewych and Berry, salvage of failed treatment of hip fractures in the elderly is limited by bone quality and comorbidities. They recommend total hip arthroplasty in this instance to restore function, decrease pain, and limit periods of immobilization. They mention that the major challenges for arthroplasty are: assessing the need for acetabular resurfacing, selecting the femoral implant, and managing the greater trochanter.
OrthoCash 2020
A 13-year-old boy falls out of a tree and sustains the injury seen in Figures A and B. He is taken to the OR for fixation of his fracture.
The next morning, the patient’s blood pressure is 185/105 mm Hg and pulse rate is 130. He complains of pain that is not improved with opiates. On physical exam, the foot is firm. The decision is made to obtain compartment pressures to rule out compartment syndrome of the foot. Which of the following paths in Figure C marks the
appropriate location to measure the central compartment, and what would be considered abnormal values?

Path A, absolute value of 30-45 mmHg or delta p > 30mmHg
Path B, absolute value of 30-45 mmHg or delta p > 30mmHg
Path B, absolute value of 30-45 mmHg or delta p < 30mmHg
Path C, absolute value of 30-45 mmHg or delta p > 30mmHg
Path C, absolute value of 30-45 mmHg or delta p < 30mmHg Corrent answer: 3
The correct approach to measure pressures in the central compartment of the foot is by directing the needle lateral and plantar through the abductor hallicus, just under the base of the first metatarsal. Abnormal values indicating the need for decompression are an absolute value of 30-45 mmHg or a Δp < 30mmHg (the difference between the patient's diastolic blood pressure and compartment pressures).
The most common symptom of compartment syndrome in the extremities is intense pain. However, compartment syndrome can be difficult to diagnose in children and patients who are comatose, nonverbal, and/or mentally compromised because they may not be able to properly express their level of pain. Additionally, in compartment syndrome of the foot, pain on passive extension of the toes may or may not be present, and swelling and absence of the dorsalis pedis pulse may be expected findings with extensive trauma to the foot, making the clinical diagnosis even more difficult. Thus, for patients with equivocal findings on physical exam, foot compartment pressures should be measured in order to confirm the diagnosis. There are 8 compartments in the foot: lateral, medial, central, and 4 interosseous. The lateral compartment
contains the abductor digiti minimi and flexor digiti minimi brevis, and is measured by directing the needle 1cm medial and plantar under the midshaft of the 5th metatarsal. The medial compartment contains the abductor hallicus and flexor hallicus brevis, and is measured by directing the needle lateral and plantar under the base of the first metatarsal. The central compartment contains the oblique head of the adductor hallucis, and is measured through the same approach as the medial compartment after advancing the needle more deeply. The 4 interosseous compartments entail the 2nd, 3rd, and 4th web spaces, and can be measured by directing the needle plantar into each respective dorsal webspace.
Ojika et al. performed a systematic review on foot compartment syndrome. They found that the most common cause of foot compartment syndrome was crush injury to the foot, and that diagnosis was mostly made through a combination of clinical findings and compartment pressure measurements.
Badhe et al. reported 4 cases where competent sensate patients developed compartment syndromes without any significant pain. They found that pain is not a reliable clinical indicator for underlying compartment syndrome, so in a competent sensate patient, the absence of pain does not exclude compartment syndrome. They concluded that a high index of clinical suspicion must prevail in association with either continuous compartment pressure monitoring or frequent repeated documented clinical examination with a low threshold for pressure measurement.
Flynn et al. looked at the diagnosis and outcome of acute traumatic compartment syndrome of the leg in children. They found that a delay in diagnosis may occur because acute traumatic compartment syndrome manifests itself more slowly in children or because the diagnosis is harder to establish in this age group. They state that the results of the present study should raise awareness of late presentation and the importance of vigilance for developing compartment syndrome in the early days after injury.
Figures A and B are lateral and Harris radiographs of the foot demonstrating a calcaneus fracture. Figure C is a cross-sectional image of the foot. Illustration A is an image depicting the compartments of the foot.
Incorrect Answers:
compartment. Additionally, a Δp < 30mmHg (not > 30mmHg) is considered abnormal.

OrthoCash 2020
A 35-year-old female presents to the emergency room after a motor vehicle collision where her leg was pinned under the car for over 30 minutes. A clinical photo and radiographs are shown. Which of the following is the most accurate way to diagnose compartment syndrome?

surgeon's palpation of the leg compartments
paresthesias in her foot
diastolic blood pressure minus intra-compartmental pressure is less than 30 mmHg
diastolic blood pressure minus intra-compartmental pressure is greater than 30 mmHg
intra-compartmental pressure measurement of 25 mmHg Corrent answer: 3
The clinical picture is consistent with compartment syndrome. The most accurate way to make the diagnosis is to measure the difference between the diastolic blood pressure and intracompartmental pressure (delta p).
In a prospective study of 116 patients with tibial diaphyseal fractures, McQueen et al found that the use of a differential pressure of 30 mmHg as a threshold for fasciotomy led to no missed cases of acute compartment syndrome. They recommended that a fasciotomy should be performed if the differential pressure level drops to under 30 mmHg.
The cited study by Kakar et al found the intraoperative DBP is significantly lower than the preoperative DBP in patient undergoing IM nailing for tibia shaft
fractures. Therefore, they emphasize that the surgeon should recognize that intraoperative DeltaP may be lower than DeltaP once the patient is awakened in deciding whether to perform a fasciotomy versus awaken the patient and perform serial examinations and or compartment pressure measurements.
An absolute intra-compartmental value greater than 30 to 45mmHg can also be used to make the diagnosis of compartment syndrome, but is more controversial than the delta p according to Kakar and Amendola.
OrthoCash 2020
What is the most common mode of failure of the lateral ulnar collateral ligament associated with an elbow dislocation?
ligament avulsion off the humeral origin
ligament avulsion off the ulnar insertion
midsubstance rupture
bony avulsion of the humeral origin
combined proximal and distal ligament avulsions Corrent answer: 1
The lateral ulnar collateral ligament (LUCL) is often injured with elbow dislocations, and is most commonly injured at the proximal origin.
McKee noted that in 62 consecutive operative elbow dislocations and fracture/dislocations, the LUCL was ruptured in all of the patients, proximally in 32, bony avulsion proximally in 5, midsubstance rupture in 18, ulnar detachment in 3, ulnar bony avulsion in only 1, and combined patterns in 3.
Pugh et al established a standard protocol to treat elbow fracture dislocations (terrible triad) which includes coronoid repair, radial head repair/replacement, LUCL repair, and MCL and/or external fixation as needed.
OrthoCash 2020
A 24-year-old male sustains the injury seen in Figure A after being thrown from a motorcycle at a high speed. Which of the following fixation methods has been shown to be the most stable fixation construct for this injury?

Posterior bridge plating and anterior ring external fixation
Percutaneous iliosacral screw and anterior ring external fixation
Percutaneous iliosacral screw and anterior ring internal fixation
Transiliac screw
Two percutaneous iliosacral screws Corrent answer: 3
Figure A shows an APC III injury, which is a rotationally and vertically unstable injury, with damage to the anterior ring, pelvic floor, and posterior ligamentous stabilizing structures.
The referenced study by Sagi et al found that biomechanically, a percutaneous iliosacral screw and anterior ring internal fixation was the most stable construct. In addition, he found no biomechanical support for addition of a second iliosacral screw.
OrthoCash 2020
A 33-year-old male patient presents with a comminuted open tibia fracture after involvement in a motor vehicle crash. He has a history of smoking but is otherwise healthy. He is given antibiotics, and taken immediately for irrigation and debridement, followed by an un-reamed stainless steel intramedullary nail. Due to bone loss there is a non-circumferential cortical defect measuring 12 mm at the fracture site. All of the following factors in this patient's history and presentation increase his risk for adverse outcome EXCEPT:
High-energy mechanism of injury
Use of un-reamed nail
Implant material
Fracture gap
History of smoking Corrent answer: 2
Of the factors listed only the use of an un-reamed intramedullary nail for an open tibia fracture has not been shown to increase the risk of adverse outcome or need for reoperation.
The treatment of open tibia fractures with intramedullary nailing can be complicated by many factors. High energy mechanism of injury, use of a stainless steel nail, residual fracture gap greater than 1 cm, and a history of smoking have all been shown to increase the risk of adverse outcome. The use of reamed and un-reamed nails for open tibia fractures have been studied, and no significant difference in outcome has been found.
Schemitsch et al. present data from a prospective randomized trial of tibia fractures treated with reamed or unreamed intrameduallry nails. They found no difference in risk of adverse outcome between reamed and un-reamed nails in open tibia fractures. They did, however, find an increased risk of adverse outcomes in high-energy mechanisms, use of stainless steel (versus titanium) rods, and a residual fracture gap of greater than 1 cm. They comment that their data did not show a significant increase in risk due to history of smoking, but cite other studies that have demonstrated such a relationship.
Bhandari et al. present data from a prospective randomized study of patients with tibia fractures randomized to reamed or un-reamed tibial nails. For closed fractures they found a lower rate of primary events (most commonly need for dynamization) in the reamed group. However, they found no difference in outcomes for either technique in open fractures.
Incorrect answers:
OrthoCash 2020
Following antegrade intramedullary nailing of a femoral shaft fracture, the complication shown in Figure A occurs. Which of the following errors most likely resulted in this complication?

Applying external rotation torque on the proximal femur after placing proximal interlocking screws
Excessive interfragmentary compression of the fracture site prior to placing proximal interlocking screws
Using too anterior a starting point for a piriformis-entry point nail
Inserting a trochanteric-entry point nail through the piriformis fossa
Inserting a right femoral nail into the left femur Corrent answer: 3
Using a piriformis nail, a starting point that is too anterior will result in iatrogenic fracture ("bursting") of the proximal femur.
Antegrade nailing achieves fixation via 3-point fixation. In the sagittal plane, because of anterior sagittal bow, this is achieved at distal anterior cortex, middle posterior cortex (apex of curvature) and proximal anterior cortex. In the coronal plane, because of the lateral bow, this is achieved at the lateral distal femur, middle medial femur (apex of curvature), and proximal lateral femur (greater trochanter). Piriformis nails have a single sagittal bow.
Trochanteric nails are bowed in 2 planes, necessitating a twisting motion during insertion to negotiate both bows.
Papadakis et al. performed an experimental study on 18 cadaveric femora. Anterior bursting was found in 56% of nails placed too anteriorly. Bursting was not seen in nails placed through a more posterior entry point. They emphasize the location of the entry point when performing antegrade nailing.
Johnson et al. reviewed the biomechanical factors affecting fracture stability
and femoral bursting. They found that position of the starting hole was most important. Anterior displacement by >6mm led to high hoop stresses and bursting of the anterior cortex. This is important as an eccentrically reamed cortex may be difficult to recover from. They recommend either selecting a smaller diameter nail or overreaming by 1-2mm as a solution.
Figure A shows a fracture split of the proximal femur (left, without magnification; right, close-up). Illustration A shows anterior cortex pressures exceeding 100kPa for too-anterior entry points.
Incorrect Answers:
Wrong-side placement of a trochanteric entry nail would lead to varus malalignment at the fracture site, more so than placing a piriformis nail through the greater trochanter.

OrthoCash 2020
A 30-year-old male sustains a brachial plexus injury as the result of a motor vehicle collision. Palsy of which of the following muscles would not be expected with this injury if the injury was postganglionic in nature?
Rhomboid major
Extensor carpi radialis longus
Biceps brachii
Deltoid
Brachioradialis
A brachial plexus injury would involve all of the upper extremity muscles as well as most of the periscapular muscles. Complete plexus palsies are rare, and are often associated with scapulothoracic dissociation or other high-energy injuries.
Preganglionic injuries often involve the cervical paraspinal musculature as well as a complete plexus injury. EMG evidence of intact signals in the serratus anterior (long thoracic nerve) and rhomboids (dorsal scapular nerve) are suggestive of a postganglionic lesion/injury.
Tubbs et al. reported on the surgical anatomy of the dorsal scapular nerve in a cadaver study. They found that the nerve came off the C5 nerve root in 95%, ran 2.5cm medial to the spinal accessory nerve as it traveled on the anterior border of the trapezius muscle, and was intertwined with the dorsal scapular artery in all specimens.
Balakrishnan et al reported on the comparison of clinical exam and EMG in predicting site of lesions in brachial plexus injuries. The combination of EMG and exam localized the nerve injury in 80%, while the paraspinal EMG was the most sensitive solitary examination method (67%).
Illustration A shows a diagram of the brachial plexus. Incorrect Answers:
5: These muscles are all innervated by nerves that come from the brachial
plexus, and would be affected with a postganglionic injury.

OrthoCash 2020
A 40-year-old male sustains a fall from a height. He sustains the isolated injury shown in the radiograph and CT images seen in Figures A through C. Surgery is planned. Which of the following constructs is the most appropriate definitive fixation for this injury?

Lateral locked plating
Medial bridge plating
Medial buttress plate
Medial lag screw with washers
External fixation
This patient has a medial tibial plateau fracture. Medial buttress plating (MBP) is indicated.
Medial tibial plateau fractures (Schatzker IV, Hohl and Moore II) may represent fracture dislocations of the knee. Neurovascular injuries must be excluded. In these instances, the medial fragment represents the stable fragment, and the rest of the tibia is the fractured fragment, with the entire leg acting as the lever arm.
Berkson et al. reviewed high energy tibial plateau fractures. Medial fractures may be treated with a medial plate or external fixation. Open reduction may be necessary because of fracture line obliquity and propensity of the medial plateau to shorten and rotate in the sagittal plane. Meniscal injuries should be repaired and avulsed cruciates fixed early. Collateral ligaments should be reconstructed after obtaining bone healing and range of motion.
Ratcliff et al. compared the stability of lateral locked plates and medial buttress plates in a cadaver model. They found that the medial buttress plate had greater fixation strength/failure force (4136N) compared with the lateral locking plate (2895N), although maximum cyclic displacement and residual displacement results were not different. They concluded that for vertically
orientated medial tibial plateau fractures, medial buttress plates were more stable.
Figure A is a radiograph showing a medial tibial plateau fracture extending across the tibial eminence. This is also classified as a Hohl and Moore Type II fracture. Figures B and C are coronal and axial CT scan images confirming the medial tibial plateau fracture and excluding a bicondylar fracture. Illustration A shows a medial tibial plateau fracture fixed with a medial buttress plate (cadaveric model with fibula removed). Illustration B shows the Hohl and Moore Type II fracture involving the entire condyle.
Incorrect Answers:

OrthoCash 2020
A 39-year-old female presents with the following motor vehicle crash with the injury seen in Figure A (immobilized in a pelvic binder). The iatrogenic neurologic injury most commonly caused by placement of the anterior construct for this injury, as shown in Figure B, would cause which of the following?

Weakness of hip flexion
Weakness of ankle dorsiflexion
Numbness of the medial thigh
Numbness of the lateral thigh
Numbness of the perineum Corrent answer: 4
This patient was treated with posterior stabilization, and an anterior subcutaneous internal fixator (ASIF). The most common neurologic injury seen following placement of the ASIF construct is irritation of the lateral femoral cutaneous nerve (LFCN), causing numbness and/or pain of the lateral thigh.
Unstable pelvic fractures can be treated in a multitude of ways. The ASIF construct is typically created by placing long pelvic screws or polyaxial pedicle screws in the supraacetabular region, similar to the supraacetabular pins for an
anterior external fixator. Then a curved bar is placed subcutaneously and connected to the supraacetabular screws. They are typically removed after 3-4 months when fracture healing is complete.
Vaidya et al. present a retrospective review of the use of ASIF as definitive treatment of unstable pelvic fractures. All patients in the study tolerated the construct well. LFCN irritation was seen in 30% of patients, and resolved in all but one patient.
Müller et al. present a retrospective review of the use of posterior stabilization and ASIF. They report an acceptably low complication rate, and good to excellent outcomes in 64.5% of patients.
Figure A is a radiograph demonstrating a right APC3 and left APC2 pelvic injury, imaged in a pelvic binder. Figure B is a postoperative radiograph following posterior stabilization and ASIF.
Incorrect answers:
OrthoCash 2020
What would be the most appropriate surgical indication for transferring fascicles of the ulnar nerve to the motor nerve of the biceps and fascicles of the median nerve to the motor nerve of the brachialis?
C8 - T1 nerve root avulsion 3 months ago
C5 - C6 nerve root avulsion 2 months ago
Upper brachial plexus palsy 22 months ago
Medial and posterior cord injury from gunshot wound 2 months ago
C6 ASIA A spinal cord injury Corrent answer: 2
Transfer of fascicles from (1) ulnar nerve to the nerve to the biceps and (2) median nerve to the motor nerve of the brachialis would be appropriate in the
treatment of an acute (<3-6 months) upper brachial plexus palsy.
Upper trunk injury (C5, C6) often results from the avulsion of both the C5 and C6 nerve roots. Injuries of this nature usually result from a downward force on the shoulder with lateral bending of the cervical spine in the opposite direction. This results in what is commonly called an Erb-Duchenne palsy. Patients often present with a flail shoulder and loss of elbow flexion. Other common treatments for C5 and C6 root avulsion include neurotization of the musculocutaneous (MSC) nerve by the spinal accessory (SA) or intercostal nerve, and neurotization of the supra-scapular nerve by the SA.
Liverneaux et al. looked at short term results of (1) ulnar nerve fascicle transfer to the nerve to the biceps and (2) fascicle of the median nerve to the motor branch to the brachialis in 15 patients with acute C5 - C6 nerve root avulsion injuries. Grade 4 elbow flexion was restored in each of the 10 patients. There was no secondary deficit in grip strength or sensation.They concluded that this double nerve transfer technique will likely reduce the need for secondary procedures to augment elbow flexion.
Teboul et al. reviewed thirty-two patients with an upper nerve-root brachial plexus injury that underwent ulnar nerve fascicle transfer to the nerve of biceps to restore elbow flexion. After the nerve transfer, twenty-four patients achieved grade 3 elbow flexion strength or better. They note that this procedure will spare the C5 nerve root and other nerves for grafting or transfer elsewhere.
Illustration A shows harvesting of an ulnar nerve fascicle for transfer. Illustration B shows transfer of the fascicle of the ulnar nerve to the motor nerve of the biceps.
Incorrect Answers:
sensory quadriplegia. Nerve transfers using the ulnar nerve (C8-T1) would also be redundant as this nerve would be non-functional in this patient.

OrthoCash 2020
A 31-year-old female presents to the trauma bay following a motorcycle crash. Her blood pressure is 95/70 mmHg, heart rate is 115 bpm. Lactate measured in the trauma bay is 10 mmol/L. She has multiple rib fractures, pulmonary contusions, and a positive FAST exam requiring immediate exploratory laparotomy. After laparotomy her lacate remains unchanged. She has a closed right femur fracture and an open right tibia fracture as seen in Figures A and B. Besides antibiotics and thorough irrigation and debridement, which of the following would be an appropriate step in the immediate management of her fractures?

Reamed intramedullary nailing of the tibia and femur
Un-reamed intramedullary nailing of the tibia, and reamed intramedullary nailing of the femur
Reamed intramedullary nail of the tibia, and un-reamed intramedullary nail
of the femur
Posterior slab splint of the tibia, and 10 lbs skeletal traction of the femur
External fixation of the tibia and femur Corrent answer: 5
This patient is suffering from multiple injuries and has evidence of chest injury and incomplete resuscitation. The immediate treatment of her fractures should be external fixation for both the tibia and the femur.
For polytraumatized patients with multiple injuries including extremity fractures, damage control orthopaedics dictates that long bone fractures should be temporarily stabilized. Either inadequate stabilization, or early total care, such as a reamed or unreamed nails, can exacerbate the patient's condition and increase the risk of a second-hit phenomenon. For this patient with pulmonary contusions and continued elevation of lactate indicating end-organ hypoperfusion her extremities should have staged treatment according to damage control principles.
Morshed et al. present a retrospective review of polytraumatized patients with femur fractures and compared outcomes based on the time frame in which their fractures were definitively treated. They found delaying treatment at least 12 hours to allow appropriate resuscitation and treatment of other traumatic injuries led to a decrease in mortality of 50%. Patients with intra-abdominal injuries benefited most from staged treatment of the extremities.
Figure A is a radiograph showing a closed right femur fracture. Figure B is a radiograph of an open right tibia fracture.
Incorrect answers:
OrthoCash 2020
A 68-year-old woman undergoes a hemiarthroplasty for a proximal humerus fracture through a deltopectoral approach. What
range of motion exercise should not be utilized in the immediate postoperative period due to concerns about lesser tuberosity fixation?
Pendulums
Passive internal rotation of the shoulder to the plane of the body
Active forearm supination
Passive external rotation of the shoulder past 30 degrees
Passive forward flexin of the shoulder to 90 degrees Corrent answer: 4
Frankle et al found that passive external rotation of the shoulder placed the most stress on the lesser tuberosity fixation. The subscapularis tendon inserts on the lesser tuberosity and is the deforming force when placed under tension during external rotation. They also found that non-anatomic tuberosity reduction of 4-part proximal humerus fractures treated with hemiarthroplasty increased torque and impaired external rotation kinematics.
OrthoCash 2020
A 72-year-old female sustains a displaced intracapsular femoral neck fracture. Which of the following is TRUE regarding the long term differences between possible treatment options for this injury?
Patients undergoing total hip arthroplasty are more likely to experience persistent pain than those undergoing internal fixation
Patients undergoing total hip arthroplasty are less likely to require reoperation than those undergoing internal fixation
There is no difference in functional outcome scores between internal fixation and total hip arthroplasty
Patients undergoing internal fixation perform activities of daily living better than those undergoing total hip arthroplasty
Mortality rates are higher following total hip arthroplasty than internal fixation
Elderly patients with femoral neck fractures (FNF) undergoing total hip arthroplasty (THA) are less likely to require reoperation than those undergoing internal fixation.
Intracapsular FNF are common in elderly patients after a fall from standing height. Treatment depends on physiological age and displacement (Garden's classification). For displaced fractures, physiologically young patients are treated with internal fixation while physiologically old patients are treated with
either hemiarthroplasty (debilitated, less active patients) or THA (more active patients, those with acetabular disease or preexisting inflammatory arthritis).
Chammout et al. retrospectively compared the long term (17 years) results of THA (cemented both component) and ORIF (2 cannulated screws) in elderly patients (>65 years). They found no difference in mortality. But hip scores were higher and pain was better in the THA group, while reoperation rates were higher in the ORIF group. Walking speed was initially faster in the THA group, but later did not differ between groups. They recommend THA for elderly patients with displaced FNF.
Rogmark et al. prospectively compared closed reduction and internal fixation (CRIF) with arthroplasty (combining hemiarthroplasty and THA) at 2 years in elderly patients (>70 years). Failure rates were higher, pain was worse, and walking was more impaired after CRIF. They recommend arthroplasty for patients >70 with FNF.
Incorrect Answers:
OrthoCash 2020
A polytrauma patient underwent the following procedures: (1) statically locked intramedullary nailing for a right femoral shaft fracture; (2) open reduction with plate-and-screw fixation [ORIF] for a right simple distal fibula fracture; (3) ORIF right middle third radius and ulna fracture; and (4) ORIF left humeral shaft fracture. What is the appropriate weightbearing status for this patient?
Weight bearing as tolerated in all extremities
Early protected weight bearing right lower extremity in walking cast, weight bearing as tolerated left upper extremity, non-weight bearing right forearm
Weight bearing as tolerated in bilateral lower extremities and right upper extremity, non-weight bearing left upper extremity
Non-weight bearing bilateral upper extremities and right lower extremity
Non-weight bearing right upper and lower extremities, weight bearing as tolerated left upper and lower extremities without walking cast
The standard postoperative weightbearing for locked medullary nailing for femoral shaft fractures and humeral shaft fractures is weight bearing as tolerated (WBAT). Simple ORIF ankle fractures may be managed with early protected weight bearing. ORIF right middle third radius and ulna fracture should be managed with a period of non-weight bearing due to risk of secondary displacement of the fracture.
Tingstad et al. examined the effect of immediate weightbearing on plated fractures of the humeral shaft. They reported that immediate weightbearing on humeral shaft fractures, treated with plating and full weightbearing, did not have any negative effect on the union or malunion rates.
Brumback et al. evaluated the feasibility, safety and efficacy of immediate weightbearing after treatment of femoral shaft fractures with statically locked IM nail. Using biomechanical and clinical data, they showed that all fractures united with no loss of fixation or hardware failure.
Starkweather et al. retrospectively assessed the complications and loss of reduction in patients who bore weight in a short leg cast within 15 days after surgical repair of acute unilateral closed ankle fractures. Of the 81 ankle fracture radiographs, 80 (98.8%) showed no displacement in fracture reduction on the final follow-up examination. These results suggest early protected weightbearing may be safe.
Incorrect Answers:
OrthoCash 2020
A 22-year-old female falls off the back of a motorcycle and sustains the injury in Figure A. She is hemodynamically unstable and massive transfusion protocol is activated. What is the correct ratio of transfusion of packed red blood cells, platelets and plasma?

Question 84

Osteonecrosis of the humeral head is a rare complication seen after dislocation of the glenohumeral joint in skeletally immature patients. When this complication is encountered, treatment should consist of

Explanation

DISCUSSION: This rare complication occurs after fracture-dislocation and has been seen after surgical stabilization in the adolescent. In most reported cases, prolonged observation has been shown to result in revascularization.
REFERENCES: Pateder DB, Park HB, Chronopoulos E, et al: Humeral head osteonecrosis after anterior shoulder stabilization in an adolescent: A case report. J Bone Joint Surg Am 2004;86:2290-2293.
Wang P Jr, Koval KJ, Lehman W, et al: Salter-Harris type III fracture-dislocation of the proximal humerus. J Pediatr Orthop B 1997;6:219-222.

Question 85

An 8-1/2-month-old male infant who has developmental dysplasia of the hip was treated in a Pavlick harness for 3 months. At follow-up, examination of the hip reveals full flexion and extension and abduction to 80 degrees. Figure 41a shows an AP arthrogram and Figure 41b an arthrographic view in flexion and abduction. Management should now consist of

Explanation

The arthrograms (which are actually reversed from the question) reveal a superiorly dislocated hip in both views. The head is lateral to Perkins’ line, superior to Hilgenreiners’ line, and Shenton’s line is broken. Tachdjian gives the following reasons for operative reduction: hip unreducible by closed means, hip requires extreme position to maintain reduction, unstable reduction, non-concentric reduction. Miller gives a little better explanation of treatment options: if under 6 mos. and reducible: Pavlick Harness (confirm the reduction with U/S or x-ray); if under 6 mos. and unreducible: Pavlick harness, and if unsuccessful then traction and closed reduction. A stable reduction must be demonstrated in the harness within 2 to 4 weeks. Abduction bracing may be used for residual dysplasia if the child is ambulating. If 6 to 18 months and unreducible: traction and closed reduction (check reduction with arthrogram; medial dye pool < 5mm is good; if failed closed reduction, then must operatively reduce), then cast for > 4 months followed with nighttime bracing. If 12 to 18 months who fail close reduction, must OR. If >3 years: OR with pelvic osteotomy.

Question 86

Which of the following is considered an advantage of the tibial inlay fixation compared to transtibial tunnel technique when used in posterior cruciate ligament reconstruction? Review Topic

Explanation

One of the most difficult aspects of posterior cruciate ligament reconstruction is placement of the tibial tunnel and passing of the graft through this tunnel. The tibial inlay technique requires a posteromedial approach to the tibia whereby the graft is directly fixed to the posterior aspect of the tibia. This obviates the need for a tibial tunnel. This technique has never been shown to be less invasive, more cosmetic, or require decreased surgical time. It has also never been shown in a published level I study to have superior clinical results. However, it does eliminate the need for the 90-degree critical "killer" turn and passing of the tibial graft through the tibial tunnel which may lead to graft failure.

Question 87

Glenohumeral disarticulation often leads to which of the following changes?

Explanation

Postural abnormalities are common after high upper extremity amputation. Normally the weight of the upper extremity and the shoulder girdle muscles keep the shoulder balanced. When the arm is amputated and the scapula remains, the shoulder girdle muscles are unopposed, resulting in upward movement often called "hiking" of the shoulder girdle. In a growing child, removal of the entire upper limb can result in scoliosis of the spine due to muscle imbalance. Abnormal shoulder elevation can often be minimized by corrective exercises and wearing a shoulder prosthesis.

Question 88

A 20-year-old man reports painless snapping about the lateral aspect of the right hip. He denies any history of trauma. Examination reveals no limp or tenderness. Hip range of motion is full, and there is good strength. Radiographs are normal. What anatomic structure is most likely causing these symptoms?

Explanation

DISCUSSION: Coxa saltans (snapping hip syndrome) can occur in two forms: external/lateral or interior/medial/anterior. This patient has the external/lateral form. The external/lateral form involves the iliotibial band, tensor fascia, or gluteus medius, which snaps over the greater trochanter. The external form usually can be treated with physical therapy alone; however, several recent studies report satisfactory results with surgical treatment. Faraj and associates reported good results from surgical Z-plasty in a series of 10 patients. White and associates reported good results in a series of 16 patients with 17 hips who underwent surgical release of an external snapping hip. The interior/medial/anterior form can involve the iliopsoas tendon, acetabular labrum, subluxation of the hip, and loose bodies.
REFERENCES: White RA, Hughes MS, Burd T, et al: A new operative approach in the correction of external coxa saltans: The snapping hip. Am J Sports Med 2004;32:1504-1508.
Faraj AA, Moulton A, Sirivastava VM: Snapping iliotibial band: Report of ten cases and review of the literature. Acta Orthop Belg 2001;67:19-23.
Choi YS, Lee SM, Song BY, et al: Dynamic sonography of external snapping hip syndrome.
J Ultrasound Med 2002;21:753-758.

Question 89

A 72-year-old woman is scheduled to undergo right total hip arthroplasty. Her preoperative radiograph is shown in Figure below. To avoid increasing this patient’s combined offset while maintaining her leg length, what is the most appropriate surgical plan?

Explanation

DISCUSSION:
The management of patients with proximal femoral deformity can be difficult. Appropriate implant selection and preoperative templating are critical. In this patient, it would be difficult to avoid increasing the combined offset by too much, which could contribute to the overtensioning of the soft tissues and trochanteric pain. By medializing the acetabular component (decreasing the combined offset), using a low offset femoral component or a cemented component placed more valgus (decreasing the combined offset), and making a longer neck cut (to avoid shortening of the lower extremity), restoration of the patient’s native offset and leg length can be achieved.

Question 90

-The main blood supply to the capital femoral epiphysis in a 10-year-old child is supplied from the

Explanation

Question 91

-Radiographs are shown in Figures 89a through 89c. What is the most likely diagnosis?

Explanation

Question 92

Figure 17 is the radiograph of a 3-year-old girl who has shoulder pain after a fall. What is the best next step?

Explanation

CLINICAL SITUATION FOR QUESTIONS 18 THROUGH 23
Figure 18 is the lateral radiograph of the lumbar spine of an 11-year-old boy who has had lower back pain for 2 months. There is no history of injury. He denies radiating pain to his legs, numbness, weakness, and bowel or bladder changes. His usual activities include soccer practices and games 3 to 5 times per week. He has used over-the-counter anti-inflammatory medications, but has had no other treatment.

Question 93

-A 10-year-old boy sustained a displaced Salter-Harris type II supination/plantar flexion fracture of the left ankle. He underwent closed reduction under conscious sedation; however, postreduction radiographs showed continued 5-mm anterior widening of the tibial physis. What is the most likely cause of the widening?

Explanation

Question 94

A 21-year-old hockey player who has recurrent shoulder subluxations undergoes an anterior capsulorrhaphy under general anesthesia, and an interscalene block is used to relieve postoperative pain. At the 1-week follow-up examination, he reports loss of sensation over the lateral region of the shoulder and is unable to actively contract the deltoid muscle. The remainder of the examination is normal. What is the best course of action at this time?

Explanation

DISCUSSION: The patient has an axillary nerve injury, which is relatively uncommon after surgery for instability. This type of injury generally is the result of a stretch injury rather than transection or a hematoma. Therefore, observation is indicated in the early postoperative period. After approximately 6 weeks, electromyography can be used to confirm and document the point of injury. Interscalene blocks can cause prolonged nerve injury but usually are not limited to the axillary nerve.
REFERENCE: Ho E, Cofield RH, Balm MR, et al: Neurologic complications of surgery for anterior shoulder instability. J Shoulder Elbow Surg 1999;8:266-270.

Question 95

A 22-month-old child has scrapes and bruises on his head and a severe deformity of the forearm after being thrown from a car as an unrestrained passenger in a motor vehicle accident. Examination reveals a Glasgow Coma Scale score of 12. Prior to treatment of the forearm, management should include

Explanation

DISCUSSION: As CT scanning has become available, the use of radiographs of the skull has decreased in importance for evaluation of head trauma. The indications for CT scanning for suspected head trauma include any degree of obtundation, focal neurologic deficit, history of a high-velocity injury, amnesia for the injury, progressive headache, persistent vomiting, children younger than age 2 years, serious facial injury, posttraumatic seizure, skull penetration, or a Glasgow Coma Scale score of 13 or less. Evidence of improved outcome with use of steroids in head trauma is lacking. Steroids are useful for increased intracranial pressure caused by brain tumors or abscesses. High-dose IV methylprednisolone is indicated for spinal cord trauma and improves the ultimate degree of recovery of function. When herniation is suspected in a patient with asymmetric neurologic findings or the patient’s condition is deteriorating rapidly, a mannitol infusion may be used.
REFERENCES: Hall DE: Head injuries, in Hoekelman RA (ed): Primary Pediatric Care. St Louis, Mo, Mosby, 1997, pp 1709-1712.
Nelson WE, Behrman RE, Kliegman RM (eds): Nelson Essentials of Pediatrics. Philadelphia, Pa, WB Saunders, 1998, p 712.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1999, pp 123-130.

Question 96

Dorsal intercalated segment instability (DISI) describes which carpal deformity?

Explanation

Figures 1 and 2 are the radiographs of a healthy 54-year-old right-hand dominant man 3 months after he fell onto his outstretched left hand. He was initially treated with 8 weeks of closed reduction and casting. He reports ongoing ulnar-sided wrist pain, stiffness, and diminished function. An examination reveals a clinical sag deformity with a loss of radial length but no substantial swelling. The distal radius is nontender, and rotation is nearly full. Wrist motion is limited, with 55° of flexion, 25° of extension, and full digital motion. The most appropriate treatment is

Question 97

Primary chondrosarcoma of bone most commonly occurs in which of the following locations?

Explanation

DISCUSSION: The most common location of chondrosarcoma is the pelvis (30%), followed by the proximal femur (20%) and shoulder girdle (15%). Chondrosarcoma rarely affects the spine or hand.
REFERENCES: Lee FY, Mankin HJ, Fondren G, et al: Chondrosarcoma of bone: An assessment of outcome. J Bone Joint Surg Am 1999;81:326-338.
Simon M, Springfield D, et al: Chondrosarcoma: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 276.

Question 98

Figures 27a through 27c show the AP radiograph, MRI scan, and biopsy specimen of an otherwise healthy man who has a painful wrist. Serum chemistry studies are normal. What is the most likely diagnosis?

Explanation

DISCUSSION: The osseous sites most frequently involved by giant cell tumor of bone are the distal femur, proximal tibia, and distal radius with approximately 10% of giant cell tumors involving the distal radius. The goals of treatment are to remove the tumor completely and to preserve maximum function of the extremity.
REFERENCE: Vander Griend RA, Funderburk CH: The treatment of giant-cell tumors of the distal part of the radius. J Bone Joint Surg Am 1993;75:899-908.

Question 99

A 32-year-old volleyball player has dull posterior shoulder pain. An examination reveals moderate external rotation weakness with his arm at his side but normal strength on supraspinatus isolation. Deltoid and supraspinatus bulk appear normal, although there appears to be mild infraspinatus atrophy. Sensation is normal throughout the shoulder and shoulder girdle. What is the most likely diagnosis?

Explanation

This clinical scenario describes a patient with an isolated injury affecting the infraspinatus muscle. The anatomic location of such a lesion would be at the spinoglenoid notch, at which the suprascapular nerve may be compressed distal to its innervation of the supraspinatus but proximal to the infraspinatus innervation. A calcified transverse scapular ligament would also affect the suprascapular nerve but is proximal to the innervation of both muscles. Quadrilateral space syndrome would affect innervation of the deltoid (and teres minor). Parsonage-Turner syndrome is a more diffuse, and often severely painful, brachial plexus neuropathy.

Question 100

An ulnar nerve palsy at the level of the wrist is typically associated with deficits in the palmaris brevis, the hypothenar muscles, and what other groups of muscles?

Explanation

DISCUSSION: The intrinsic muscles innervated by the ulnar nerve include the palmaris brevis, hypothenar muscles, all of the interossei, adductor pollicis, and the deep head of the flexor pollicis brevis. The superficial head of the flexor pollicis brevis is innervated by the

median nerve.
REFERENCES: Goldfarb CA, Stern PJ: Low ulnar nerve palsy. JASSH 2003;3:14-26.
Omer G: Ulnar nerve palsy, in Green DP, Hotchkiss R, Pederson W (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, Churchill Livingstone, 1999, pp 1526-1541.

Full Question & Answer Text (for Search Engines)

Question 1:

At revision, the stem is retained and a new head with a polyethylene bearing is selected. The best option for the head is

Options:

ceramic with a metal sleeve.
ceramic alone.
metal with a metal sleeve.
metal alone.

Correct Answer: ceramic with a metal sleeve.

Explanation:

Question 2:

What procedure can eliminate a sulcus sign?

Options:

Rotator interval closure
SLAP repair
Bankart repair
Supraspinatus repair
Subacromial decompression

Correct Answer: Rotator interval closure

Explanation:

Question 3:

Options:

Bed rest for 6 weeks, followed by mobilization in a thoracolumbosacral orthosis (TLSO) until the fracture has healed
Immediate mobilization in a TLSO, continuing until the fracture has healed
Anterior corpectomy with strut grafting and placement of anterior fixation
Anterior corpectomy and strut grafting followed by posterior spinal fusion and instrumentation
Posterior spinal fusion and instrumentation

Correct Answer: Posterior spinal fusion and instrumentation

Explanation:

DISCUSSION: The injury pattern is that of a burst fracture at L1 contiguous with a compression fracture at T12. There is associated kyphosis and slight spondylolisthesis of T12 on L1. Treatment of this type of burst fracture in neurologically intact patients is somewhat controversial, with at least one study demonstrating equal long-term results comparing nonsurgical treatment to surgical treatment. In this study, however, body casts were used initially in the nonsurgical group. Moreover, because this patient has multiple fractures, spinal fracture stabilization should be considered to facilitate early mobilization. Surgical stabilization and fusion via a posterior approach is the best treatment option in this patient. Anterior decompression is not necessary since the patient is neurologically intact.
REFERENCES: McLain RF, Benson DR: Urgent surgical stabilization of spinal fractures in polytrauma patients. Spine 1999;24:1646-1654.
Wood K, Butterman G, Mehbod A, et al: Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit: A prospective, randomized study.
J Bone Joint Surg Am 2003;85:773-781.
Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 201-216.

Question 4:

What is the primary goal of the initial (acute) rehabilitation phase of an overhead athlete’s shoulder?

Options:

Improve flexibility
Strengthen muscles
Enhance power and endurance
Regain neuromuscular control
Perform functional drills

Correct Answer: Improve flexibility

Explanation:

Question 5:

Options:

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

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

Explanation:

Question 6:

A 26-year-old mixed martial arts fighter sustains a posterolateral elbow dislocation. The primary stabilizers of the elbow joint are the

Options:

radiocapitellar joint, the posterior band of the medial collateral ligament, and the annular ligament.
ulnohumeral joint, the anterior band of the medial collateral ligament, and the lateral ulnar collateral ligament.
radiocapitellar joint, the anterior band of the medial collateral ligament, and the radial collateral ligament.
ulnohumeral joint, the anterior band of the medial collateral ligament, and the posterior band of the medial collateral ligament.

Correct Answer: ulnohumeral joint, the anterior band of the medial collateral ligament, and the lateral ulnar collateral ligament.

Explanation:

Question 7:

Options:

lateral column lengthening.
open reduction and internal fixation.
double arthrodesis (talonavicular and calcaneocuboid joints).
tarsometatarsal arthrodesis.
medial displacement calcaneal osteotomy and tendon transfer.

Correct Answer: tarsometatarsal arthrodesis.

Explanation:

Question 8:

Options:

hallux valgus correction and lesser metatarsophalangeal joint synovectomies.
hallux valgus correction and lesser metatarsal head resections.
first metatarsophalangeal joint fusion and lesser metatarsal head resections.
first metatarsophalangeal joint fusion and lesser metatarsophalangeal joint synovectomies.
Keller resection arthroplasty and lesser metatarsal head resections.

Correct Answer: first metatarsophalangeal joint fusion and lesser metatarsal head resections.

Explanation:

Question 9:

Following a vertebroplasty of L2, cement is noted to protrude directly anterior to the L2 vertebral body. The cement is closest to which of the following structures?

Options:

Inferior vena cava
Pancreas
Duodenum
Left lobe of the liver
Descending aorta

Correct Answer: Descending aorta

Explanation:

DISCUSSION: At the level of L2, the liver and the vena cava lie to the right. The pancreas
and duodenum are anterior to the aorta. The aorta lies in the midline just in front of the
vertebral body.
REFERENCES: Clement CD: Anatomy: A Regional Atlas of Human Anatomy, ed 3.
Baltimore, MD, Munich, Germany, Urban and Schwarzberg, 1987, Figure 331.
Netter FH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy, 1989, plate 328.

Question 10:

Trabecular bone is remodeled through the formation of

Options:

cutting cones.
Haversian canals.
Volkmann canals.
Howship lacunae.

Correct Answer: Howship lacunae.

Explanation:

Question 11:

- What is the most common sequela of turf toe (hyperextension of the first metatarsophalangeal joint)?

Options:

Hallux rigidus
Hallux valgus
Neuroma of the first web space
Fracture of the sesamoid
Rupture of the flexor hallucis longus

Correct Answer: Hallux rigidus

Explanation:

Question 12:

Stemless shoulder arthroplasty prostheses have recently been suggested as an alternative to traditional stemmed replacement. Advantages of the stemless surgical technique would include

Options:

better glenoid exposure than with stemmed prosthesis.
reliable use in four-part proximal humerus fracture surgery.
use in proximal humeral malunion without need for osteotomy.
improved long-term survivorship profile.

Correct Answer: use in proximal humeral malunion without need for osteotomy.

Explanation:

Question 13:

Options:

Moist dressings and continued observation
Debridement of the necrotic tissue
Amputation at the metatarsophalangeal level with open wound management
Closed forefoot amputation
Guillotine transtibial amputation

Correct Answer: Moist dressings and continued observation

Explanation:

DISCUSSION: The patient has no clinical or observed signs of sepsis. The skin just proximal to the gangrenous tissue appears somewhat hyperemic and is clearly viable. These wounds should be managed much like burn wounds. Moist dressings should be used until the tissue clearly demarcates. Much of the insult may simply be superficial and only require late debridement.
REFERENCES: McAdams TR, Swenson DR, Miller RA: Frostbite: An orthopedic perspective.
Am J Orthop 1999;28:21-26.
Taylor MS: Cold weather injuries during peacetime military training. Milit Med 1992;157:602-604.

Question 14:

Options:

9 degrees internal rotation
14 degrees external rotation
18 degrees internal rotation

Correct Answer: 9 degrees internal rotation

Explanation:

All of the above
Corrent answer: 4
The maximum acceptable difference in rotational malreduction between the surgical and contralateral legs for femoral version is 15°. Therefore, answers 1 and 2 are correct.
Normal femoral neck anteversion is approximately 11-13°, with a normal range between 5-20°. The variation within the same patients can also be up to 15° difference between limbs. Current literature has shown that this 15° difference is well tolerated by patients, including when this has occured as a result of rotational malreduction following intramedullary nail fixation for a diaphyseal femur fracture.
Ayalon et al. aimed to compare the difference in femoral version (DFV) after intramedullary nailing performed by a trauma-trained and non-trauma trained surgeon. The mean post-operative DFV was 8.7° in these patients, compared to 10.7° in those treated by surgeons of other subspecialties. Post-operative version or percentage of DFV >15° did not significantly differ between these two groups.
Omar et al. studied the utility of pre-operative 'virtual reduction' of bilateral femoral fractures that were initially stabilized with external fixation. After external fixation, the mean rotational difference between both legs was 15.0°
± 10.2°. Following virtual reduction, the mean rotational difference between both legs was 2.1° ± 1.2°, after intramedullary nailing, compared to 6.1° ±

Question 15:

Options:

ulnarly, around the ulna in a dorsal direction.
radially, around the radius in a dorsal direction.
through the interosseous membrane.
through the intermetacarpal spaces between the index, middle, ring, and little fingers.
through the lumbrical canals of the index, middle, ring, and little fingers.

Correct Answer: radially, around the radius in a dorsal direction.

Explanation:

Question 16:

Options:

Heart rate
Hematocrit
Base deficit
Urine output
Systolic blood pressure

Correct Answer: Base deficit

Explanation:

Question 17:

Options:

Forward elevation in the scapular plane
External rotation and abduction
Flexion, adduction, and internal rotation
Flexion and abduction

Correct Answer: Flexion, adduction, and internal rotation

Explanation:

Question 18:

Options:

Teratologic hip dislocation
Septic right hip
Congenital coxa vara
Transphyseal fracture of the proximal femur
Postpartum ligamentous laxity

Correct Answer: Transphyseal fracture of the proximal femur

Explanation:

Question 19:

Compared with percutaneous pinning with Kirschner wires (K-wires), the treatment of metacarpal neck fractures with cannulated intramedullary screws is associated with

Options:

increased rates of soft-tissue infection.
greater initial construct stiffness and peak load until failure.
a slower return of digital range of motion.
an earlier time to bony union.

Correct Answer: greater initial construct stiffness and peak load until failure.

Explanation:

EXPLANATION:
In a biomechanical study, headless compression screws showed superior load to failure, higher three-point bending strength, and greater strength in axial loading compared with percutaneous K-wire fixation for metacarpal neck fractures. Headless compression screws provide greater initial stability to allow earlier motion in the postoperative period. No data comparing infection rates between the two methods of fixation are available; however, it is assumed that K-wires placed outside of the skin would have increased
rates of infection. Neither fixation method would increase the time to healing.

Question 20:

Options:

Aggressive administration of IV fluids
Administer acetaminophen
Lay him supine with leg elevation
Rapid cooling with ice immersion
Administration of IV antibiotics

Correct Answer: Administration of IV antibiotics

Explanation:

Question 21:

The mechanism for the osseous destruction is attributable to

Options:

avascular necrosis.
tumor invasion.
hypervascularity.
infection.

Correct Answer: hypervascularity.

Explanation:

DISCUSSION
This scenario is a classic example of the development of Charcot foot. A red, swollen, deformed foot without ulceration suggests neuroarthropathy. Normal inflammatory marker findings, no history of fever or chills, and radiographs demonstrating bone loss support the diagnosis. Limb elevation with dramatic reduction in erythema is also characteristic of this disease process and does not occur with infection. Total-contact casting is the cornerstone of treatment for acute Charcot disease. Hemoglobin A1C is an indicator of glucose averaged over a 3-month period, providing the most reliable indication of a patient's ongoing glucose control. The pathophysiology of bone destruction is believed to be hypervascularity of bone. Infection and Charcot disease may develop simultaneously, but the combination is rare.
RECOMMENDED READINGS
Kaynak G, Birsel O, Güven MF, Ogüt T. An overview of the Charcot foot pathophysiology. Diabet Foot Ankle. 2013 Aug 2;4. doi: 10.3402/dfa.v4i0.21117.Print 2013. PubMed PMID: 23919113.
View Abstract at PubMed
Pinzur MS, Lio T, Posner M. Treatment of Eichenholtz stage I Charcot foot arthropathy with a weightbearing total contact cast. Foot Ankle Int. 2006 May;27(5):324-9. PubMed PMID: 16701052.
View Abstract at PubMed

Question 22:

Options:

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

Correct Answer: open subscapularis tendon repair

Explanation:

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

Question 23:

Options:

higher infection rates.
higher nonunion rates.
equal union and infection rates.
higher rate of ARDS.
higher mortality rate.

Correct Answer: equal union and infection rates.

Explanation:

DISCUSSION: Recently Harwood and associates investigated the principles of damage control orthopaedics (DCO) as they apply to patients with femoral shaft fractures. When they compared those who underwent initial external fixation of femoral shaft fractures with conversion to an intramedullary nail to those who underwent intramedullary nailing as their initial treatment, they found the following: overall infection rates were comparable in patients receiving DCO versus primary intramedullary fixation; open fracture was an independent risk factor for infection regardless of the treatment method; contamination rates in external fixator pin sites rose considerably when left in place more than 2 weeks and logistic regression analysis suggests that infection rates may increase when conversion to an intramedullary nail occurs after 2 weeks following external fixation; and there was no significant difference in time to union among treatment groups.
REFERENCES: Harwood PJ, Giannoudis PV, Probst C, et al: The risk of local infective complications after damage control procedures for femoral shaft fracture. J Orthop Trauma 2006;20:181-189.
Roberts CS, Pape HC, Jones AL, et al: Damage control orthopaedics: Evolving concepts in the treatment of patients who have sustained orthopaedic trauma. Instr Course Lect
2005;54:447-462.

Question 24:

In a patient with a soft-tissue sarcoma treated by wide excision and radiation therapy, the risk of subsequent fracture is probably most influenced by

Options:

location of the sarcoma in the lower extremity.
excision of cortical bone with en bloc resection.
a radiation dose of 60 Gy (6,000 cGy) versus 50 Gy (5,000 cGy).
the addition of adjuvant chemotherapy.
excision of the periosteum.

Correct Answer: excision of cortical bone with en bloc resection.

Explanation:

Question 25:

Second impact syndrome (SIS) after head injury is characterized by which of the following? Review Topic

Options:

Gradual progression of neurologic symptoms
Preventable by restricting return to play until symptom-free
Excellent prognosis for full recovery
Rarely involves brain stem compromise
CT rarely shows brain edema

Correct Answer: Preventable by restricting return to play until symptom-free

Explanation:

Question 26:

Options:

Technetium Tc 99m bone scan
Intravenous antibiotics
Oral antibiotics
CT of the hips
Aspiration of the left hip

Correct Answer: Aspiration of the left hip

Explanation:

DISCUSSION: Examination reveals an irritable hip, creating a differential diagnosis of transient synovitis versus pyogenic hip arthritis. Kocher and associates described four criteria to help predict the presence of infection: inability to bear weight, fever, ESR of more than 40 mm/h, and a peripheral WBC count of more than 12,000/mm
P
3
P
. This patient meets three of the four criteria, with a positive predictive value of 73% to 93% for joint infection. Therefore, aspiration of the hip is warranted, with a high likelihood that emergent hip arthrotomy will be indicated. Ideally, intravenous antibiotics should be administered after culture material has been obtained from needle aspiration of the hip. An urgent bone scan is better indicated as a screening test for sacroiliitis or diskitis. If the arthrocentesis proves negative, CT or MRI of the pelvis may be indicated to rule out a pelvic or psoas abscess.
REFERENCES: Del Beccaro MA, Champoux AN, Bockers T, et al: Septic arthritis versus transient synovitis of the hip: The value of screening laboratory tests. Ann Emerg Med 1992;21:1418-1422.
Kocher MS, Mandiga R, Zurakowski D, et al: Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am 2004;86:1629-1635.
Kocher MS, Zurakowski D, Kasser JR: Differentiating between septic arthritis and transient synovitis of the hip in children: An evidence-based clinical prediction algorithm. J Bone Joint Surg Am 1999;81:1662-1670.

Question 27:

Options:

Reticulosarcoma
Squamous cell carcinoma
Fibrosarcoma
Malignant fibrous histiocytoma

Correct Answer: Squamous cell carcinoma

Explanation:

Question 28:

Options:

Tendon transfer, lateral column lengthening, and heel cord lengthening
Triple arthrodesis and heel cord lengthening
Tendon transfer, lateral column lengthening, medial column arthrodesis, and heel cord lengthening
Tendon transfer, spring ligament repair, and heel cord lengthening
Tendon repair, medial displacement calcaneal osteotomy, and heel cord lengthening

Correct Answer: Tendon transfer, lateral column lengthening, medial column arthrodesis, and heel cord lengthening

Explanation:

DISCUSSION: The patient has an atypical adult flatfoot deformity. The radiographs reveal forefoot abduction, mild loss of calcaneal pitch, and marked plantar flexion sag through the naviculocuneiform joint. The inability to perform a single limb heel rise indicates that the posterior tibial tendon is nonfunctional; however, the deformity remains flexible. In this patient, surgical treatment should include a tendon transfer, lateral column lengthening, medial column arthrodesis, and heel cord lengthening. Because a substantial portion of the deformity stems from the naviculocuneiform joint in this instance, tendon transfer and lateral column lengthening alone provide insufficient deformity correction. Triple arthrodesis and heel cord lengthening is best reserved for fixed flatfoot deformities. Soft-tissue procedures alone are associated with a high failure rate, as are attempted tendon repairs.
REFERENCES: Greisberg J, Assal M, Hansen ST Jr, et al: Isolated medial column stabilization improves alignment in adult-acquired flatfoot. Clin Orthop Relat Res 2005;435:197-202.
Greisberg J, Hansen ST Jr, Sangeorzan BJ: Deformity and degeneration in the hindfoot and midfoot joints of the adult acquired flatfoot. Foot Ankle Int 2003;24:530-534.

Question 29:

Options:

overlapping of the digits.
index finger proximal interphalangeal (PIP) joint arthritis.
extensor lag at the PIP joint.
hyperextension at the PIP joint.

Correct Answer: extensor lag at the PIP joint.

Explanation:

Question 30:

Myositis ossificans is a recognized complication of contusion to the quadriceps muscle. During early rehabilitation, this condition is most likely to be exacerbated by

Options:

electrical stimulation.
iontophoresis.
isometric exercise.
ice/heat contrast.
passive stretching.

Correct Answer: passive stretching.

Explanation:

Question 31:

Long bone fracture repair following intramedullary stabilization occurs primarily through which of the following healing mechanisms?

Options:

Haversian remodeling
endosteal ossification only
Intramembranous ossification only
Endochondral ossification only
Intramembranous and endochondral ossification

Correct Answer: Intramembranous and endochondral ossification

Explanation:

Question 32:

Figures 48a and 48b show the radiographs of a 26-year-old woman who fell down two steps and twisted her foot and ankle. What is the most appropriate treatment for this injury?

Options:

Open reduction and internal fixation with a mini fragment plate and screws
Closed cannulated screw fixation
Short leg casting for 6 weeks
Hard-soled shoe and weight bearing as tolerated
Short leg cast and non-weight-bearing, followed by weight bearing as tolerated for 6 weeks in a fracture brace

Correct Answer: Hard-soled shoe and weight bearing as tolerated

Explanation:

DISCUSSION: The patient has a zone 1 base of the fifth metatarsal fracture (Pseudojones) that represents a less serious injury compared to zone 2 and 3 fractures with regard to healing potential. Treatment is symptomatic and casting is not necessary. These fractures are well treated with a hard-soled shoe for comfort and weight bearing as tolerated. Surgical intervention is not warranted.
REFERENCES: Vorlat P, Achtergael W, Haentjens P: Predictors of outcome of non-displaced fractures of the base of the fifth metatarsal. Int Orthop 2007;31:5-10.
Wiener BD, Linder JF, Giattini JF: Treatment of fractures of the fifth metatarsal: A prospective study. Foot Ankle Int 1997;18:267-269.
Early JS: Fractures and dislocations of the midfoot and forefoot, in Bucholz R, Heckman JD, Court-Brown CM (eds): Rockwood and Green’s Fractures in Adults. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, pp 2337-2400.

Question 33:

What is the most important predictor of functional outcome in patients with myelomeningocele?

Options:

Functional motor level
Sensory level
Dysplasia of the hip
Foot deformity
Hydrocephalus

Correct Answer: Functional motor level

Explanation:

Question 34:

- A right-handed 35-year old man who underwent a Putti-Platt repair for recurrent anterior instability 20 years ago now has increasing shoulder pain and stiffness. Examination of the shoulder reveals internal rotation to the posterior superior iliac spine and external rotation to 10 degrees with the shoulder adducted. The supraspinatus and infraspinatus are moderately atrophied. What is the most likely diagnosis?

Options:

C5 radiculopathy
Subscapularis rupture
Glenohumeral arthrosis
Rotator cuff arthropathy
Suprascapular nerve compression at the spinoglenoid notch

Correct Answer: Glenohumeral arthrosis

Explanation:

Question 35:

What radiographic measurement is best used to assess the adequacy of deformity correction for the patient shown in Figure 22?

Options:

Reimers index (migration index)
Acetabular index
Center edge angle of Wiberg
Hilgenreiner physeal angle
Head-shaft angle (Southwick angle)

Correct Answer: Hilgenreiner physeal angle

Explanation:

Question 36:

Options:

Microfracture
Autologous chondrocyte implantation
Osteochondral allograft transfer
Dejour trochleoplasty

Correct Answer: Osteochondral allograft transfer

Explanation:

The images show a full-thickness cartilage defect with significant bony involvement >4 cm
2
. Microfracture should be considered for lesions <2 cm
2
without an underlying osseous defect. Autologous chondrocyte implantation, although used for lesions between 1 and 10 cm
2
, should be restricted for defects with minimal (<8 mm depth) bone loss. Osteochondral allograft transfer with the mosaicplasty technique (transfer of multiple plugs) would be well-suited for this large defect with significant osseous involvement. Dejour trochleoplasty is performed for patellar instability to correct trochlear dysplasia and
would not be indicated in this case.

Question 37:

A favorable outcome following nonsurgical management of a partial tear of the posterior cruciate ligament (PCL) is best associated with

Options:

hamstring strength.
quadriceps strength.
a body mass index of less than 30.
anterior cruciate ligament stability.
compliance with brace use.

Correct Answer: quadriceps strength.

Explanation:

Question 38:

Which factor is most important when attempting to prevent interbody graft subsidence?

Options:

End plate burring
Surface contact area
Bone quality
Use of rigid fixation

Correct Answer: Bone quality

Explanation:

Question 39:

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 40:

Options:

Synovial sarcoma
Malignant fibrous histiocytoma
Chondrosarcoma
Ewing's sarcoma
Osteosarcoma

Correct Answer: Osteosarcoma

Explanation:

Question 41:

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:

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 42:

Options:

Injury to the lumbar sympathetic chain
Injury to the parasympathetic nerve
Immune response to the allograft bone
Occlusion of the left iliac vein
Prolonged retraction of the left iliac artery

Correct Answer: Injury to the lumbar sympathetic chain

Explanation:

Question 43:

A 35-year-old woman began to train for a half marathon. After 8 weeks of increasing her mileage, what changes can you expect in her Achilles tendon?

Options:

Net decrease of type I collagen
Net increase of type I collagen
Increased diameter of collagen fibrils
Increased cross-sectional area of the tendon

Correct Answer: Net increase of type I collagen

Explanation:

Question 44:

A 75-year-old woman with rheumatoid arthritis and a long history of oral corticosteroid use sustains a comminuted intra-articular distal humerus fracture. What is the best surgical option?

Options:

Open reduction internal fixation (ORIF) with parallel plates
ORIF with orthogonal plates and iliac crest bone grafting
Total elbow arthroplasty (TEA)
Closed reduction and percutaneous pinning

Correct Answer: Total elbow arthroplasty (TEA)

Explanation:

Question 45:

Options:

Chevron bunionectomy
Cheilectomy and removal of loose body
MTP arthrodesis
Resection of proximal phalanx

Correct Answer: MTP arthrodesis

Explanation:

Question 46:

Options:

Radiographs, including anterior, lateral, and oblique views
MRI of the lumbar spine and follow-up at the clinic in 1 week
Caudal epidural steroid injection
Reassurance, limited analgesics, and early range of motion as tolerated
Immediate MRI of the lumbar spine and possible urgent surgical decompression

Correct Answer: Reassurance, limited analgesics, and early range of motion as tolerated

Explanation:

Question 47:

Surgical restoration of sagittal balance of an adult spinal deformity will have which effect on outcome?

Options:

No effect
Improve leg-related symptoms but not back pain
Improve quality of life and back pain
Improve quality of life and leg-related symptoms

Correct Answer: Improve quality of life and back pain

Explanation:

DISCUSSION
The influence of sagittal balance on outcomes following fusion-based procedures for degenerative conditions of the lumbar spine has only recently been appreciated. Restoration of sagittal spinal balance improves low-back-pain outcomes and quality of life. Sagittal spinal balance has not been shown to relieve neurogenic claudication attributable to spinal stenosis.
RECOMMENDED READINGS
Li Y, Hresko MT. Radiographic analysis of spondylolisthesis and sagittal spinopelvic deformity. J Am Acad Orthop Surg. 2012 Apr;20(4):194-205. doi: 10.5435/JAAOS-20-04-194. Review. PubMed PMID: 22474089.
View Abstract at PubMed
Korovessis P, Repantis T, Papazisis Z, Iliopoulos P. Effect of sagittal spinal balance, levels of posterior instrumentation, and length of follow-up on low back pain in patients undergoing posterior decompression and instrumented fusion for degenerative lumbar spine disease: a multifactorial analysis. Spine (Phila Pa 1976). 2010 Apr 15;35(8):898-905. doi: 10.1097/BRS.0b013e3181d51e84. PubMed PMID: 20354466.
View
Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 99 AND 100
Figures 99a and 99b are MR images of a 59-year-old man with a history of intravenous (IV) drug abuse who arrives at the emergency department with malaise and fever. Upon admission, the patient's temperature is 38.9°C, his white blood cell count is 17000/µL (reference range [rr], 4500-11000/µL), his erythrocyte sedimentation rate is 98 mm/h (rr, 0-20 mm/h), and his C-reactive protein level is 45 mg/L (rr, 0.08-3.1 mg/L). He is admitted to the medical service to evaluate the source of his fevers. On hospital day 1, the patient reports weakness in his left arm and leg. Blood cultures are positive for methicillin-resistant Staphylococcus aureus.
A B

Question 48:

Options:

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

Correct Answer: passive range-of-motion exercises.

Explanation:

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

Question 49:

Options:

a subtalar arthroereisis with a titanium implant.
triple arthrodesis.
resection of the accessory navicular and advancement of the posterior tibial tendon bilaterally.
resection of the talocalcaneal middle facet coalition in each foot.
resection of the calcaneonavicular coalition in both feet.

Correct Answer: resection of the talocalcaneal middle facet coalition in each foot.

Explanation:

Question 50:

Options:

an occult fracture of the tibial plateau.
a tear of the medial collateral ligament and the posteromedial capsule.
a tear of the posterior cruciate ligament.
a tear of the anterior and posterior cruciate ligaments.
a tear of the anterior cruciate and medial collateral ligaments and the posteromedial capsule.

Correct Answer: a tear of the anterior cruciate and medial collateral ligaments and the posteromedial capsule.

Explanation:

Question 51:

Options:

Transforaminal epidural injection
Laminotomy and limited diskectomy
Laminotomy and complete diskectomy
Laminectomy and complete diskectomy
Laminotomy, diskectomy, and arthrodesis

Correct Answer: Laminotomy and limited diskectomy

Explanation:

Question 52:

Options:

closed treatment and observation for return of nerve function.
closed treatment and immediate tendon transfer.
open nerve exploration without internal fixation of the fracture.
open nerve exploration with plating of the fracture.
open nerve exploration with intramedullary rodding of the fracture.

Correct Answer: closed treatment and observation for return of nerve function.

Explanation:

Question 53:

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

Options:

Loose body
Plica
Displaced meniscus tear
Torn retinaculum
Osteochondral defect

Correct Answer: Plica

Explanation:

DISCUSSION: 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.
REFERENCES: Clarke HD, Scott WN, Insall JN: Anatomic aberrations, in Insall JN, Scott WN (eds): Surgery of the Knee, ed 4. Philadelphia, PA, Churchill Livingstone, 2006, vol 1, pp 67-85.
Patel D: Plica as a cause of anterior knee pain. Orthop Clin North Am 1986;17:273-277.

Question 54:

What is the most common reason for reoperation in total knee arthroplasty?

Options:

Polyethylene insert failure
Malalignment of the knee
Ligamentous instability
Perioperative infection
Patellar-related complications

Correct Answer: Patellar-related complications

Explanation:

Question 55:

Options:

Thoracic curve coronal correction of > 40%
Thoracolumbar/lumbar curve coronal correction > 50%
Smaller adolescents (<50 kg)
Failure to maintain lumbar lordosis of > 45 degrees
Thoracic hyperkyphosis (>40 degrees )

Correct Answer: Thoracic hyperkyphosis (>40 degrees )

Explanation:

Question 56:

Options:

Immobilization
Rest with range-of-motion exercises
Steroid injection
Excision
Irradiation

Correct Answer: Rest with range-of-motion exercises

Explanation:

Question 57:

What adaptations occur in the dominant shoulder of throwers compared to their nondominant shoulder? Review Topic

Options:

Humeral anteversion with a normal total arc of motion
Tight posterior capsule with a normal total arc of motion
Lengthening of the anterior capsule with a decreased total arc of motion
Increased external rotation with a decreased total arc of motion
Decreased internal rotation with an increased total arc of motion

Correct Answer: Tight posterior capsule with a normal total arc of motion

Explanation:

Question 58:

Options:

Bisphosphonates
Calcitonin
Parathyroid hormone
Vitamin D and calcium
Methotrexate

Correct Answer: Bisphosphonates

Explanation:

DISCUSSION: McCune-Albright syndrome is the combination of polyostotic fibrous dysplasia, café-au-lait lesions, and endocrine dysfunction. The most common endocrine presentation is precocious development of secondary sexual characteristics. Compared with bone lesions in patients without polyostotic disease, the skeletal lesions in patients with the syndrome tend to be larger, more persistent, and associated with more complications. Bisphosphonate therapy has been shown in several studies to decrease the pain associated with the skeletal lesions of fibrous dysplasia.
REFERENCES: DiCaprio MR, Enneking WF: Fibrous dysplasia: Pathophysiology, evaluation and treatment. J Bone Joint Surg Am 2005;87:1848-1864.
Zacharin M, O’Sullivan M: Intravenous pamidronate treatment of polyostotic fibrous dysplasia associated with McCune Albright syndrome. J Pediatr 2000;137:403-409.

Question 59:

Options:

Move the starting point slightly medial
Move the starting point slightly lateral
Hyperflexion of the knee
Anterior blocking screw
Medial blocking screw

Correct Answer: Move the starting point slightly medial

Explanation:

Fractures of the proximal metadiaphysis of the tibia can be treated successfully with intramedullary nails, but previous studies showed rates of malalignment of up to 84%. The typical deformity is valgus and procurvatum. An ideal starting point is mandatory and should be slightly lateral to the medial border of the lateral tibial eminence on a true AP view and very proximal and anterior on a true lateral view with appropriate coronal and sagittal trajectory of the entry reamer. A medial start point will exacerbate valgus deformity and should be avoided. A reduction should be obtained and maintained during reaming, implant insertion, and interlocking. This can be facilitated via a variety of techniques including intraoperative external fixation, percutaneous reduction clamps or joysticks, semi-extended positioning, blocking screws that are typically inserted posterior and lateral to the nail, and ancillary plate fixation. With careful attention to these techniques, more recent studies report low rates of malalignment.
(SBQ12TR.65) A patient falls and sustains the isolated injury seen in Figures A and
B. The surgical plan includes open reduction and internal fixation with a small mini-fragment plate using a direct lateral approach. During the approach, the forearm was placed in a fully pronated position. What would be the correct position of the forearm during plate application?
Full pronation
25 degrees pronation
Neutral
25 degrees supination
Full supination
Using the lateral approach (Kocher or Kaplan), the correct placement of the arm should be in a neutral position so that the plate can be placed on the bare area of the proximal radius.
Displaced radial head fractures with less than 3 fragments can be amendable to open reduction internal fixation. The methods of fixation include buried or headless screws, if placed at the articular surface, or posterolateral plating, if placed in the bare area. The safe zone for plating is located at a 90-110 arc from the radial styloid to Lister's tubercle with the arm in neutral rotation. This position helps to avoid impingement of ulna against the plate with forearm rotation. It should be noted that during the approach, that the forearm should be fully pronated to avoid injury to the posterior interosseous nerve.
Mathew et al. reviewed the concepts of terrible triad injuries of the elbow. Radial
head fractures are treated conservatively when there is an isolated minimally displaced (less than 2mm) fracture with no mechanical block to motion. Open reduction internal fixation is used for Mason II or III fractures with < 3 fragments. Radial head replacement is considered for comminuted fractures (Mason Type III) with 3 or more fragments.
Cheung et al. reviewed the surgical approaches to the elbow. The lateral approach (Kocher or Kaplan) is most commonly used with these injuries. The Kocher approach utilizes the intramuscular plane between anconeus and extensor carpi ulnaris. Kaplan utilizes the plane between extensor digitorum commons and extensor carpi radialis brevis.
Figure A and B show AP and lateral radiographs of the left elbow. There is a displaced radial head fracture. Illustration A shows a schematic diagram of the radial head "safe zone" between the radial styloid to Lister's tubercle.
Incorrect Answers:

Question 60:

When compared to smokers who do not quit, an improvement in the rate of lumbar fusion is seen in patients who cease smoking for at least how many months postoperatively?

Options:

1 month
2 months
4 months
6 months
12 months

Correct Answer: 6 months

Explanation:

DISCUSSION: The effects of cigarette smoking and smoking cessation on spinal fusion have been studied extensively. Although permanent smoking cessation is ideal, significant improvements in fusion rates are seen in patients who avoid smoking for greater than 6 months postoperatively.
REFERENCE: Glassman SD, Anagnost SC, Parker A, et al: The effect of cigarette smoking and smoking cessation on spinal fusion. Spine 2000;25:2608-2615.

Question 61:

Options:

Stretching exercises with a physical therapist
Arthroscopic debridement
Core decompression of the humeral head
Humeral hemiarthroplasty
Resection of the proximal humerus

Correct Answer: Humeral hemiarthroplasty

Explanation:

Question 62:

Options:

Anterior tibialis tendon transfer to the dorsolateral midfoot
Posterior tibialis tendon transfer to the dorsolateral midfoot
Peroneus longus tendon transfer to the dorsolateral midfoot
Peroneus brevis tendon transfer to the dorsolateral midfoot
Flexor hallucis longus tendon transfer to the peroneus brevis

Correct Answer: Peroneus longus tendon transfer to the dorsolateral midfoot

Explanation:

DISCUSSION: Compartment syndrome of the anterior and deep posterior compartments results in anterior tibialis and posterior tibialis tendon weakness, respectively. Furthermore, the long flexors to the hallux and lesser toes will be weak as well. The intact peroneus longus overpowers the weak anterior tibialis tendon, resulting in plantar flexion of the first metatarsal, cavus, and hindfoot varus. Therefore, transferring the peroneus longus to the dorsolateral midfoot reduces the first metatarsal plantar flexion torque, and possibly augments ankle dorsiflexion torque.
REFERENCES: Hansen ST: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott, Williams & Wilkins, 2000, pp 433-435.
Vienne P, Schoniger R, Helmy N, et al: Hindfoot instability in cavovarus deformity: Static and dynamic balancing. Foot Ankle Int 2007;28:96-102.

Question 63:

Options:

Short leg non-weight-bearing cast for 6 weeks
Air-stirrup splint and limited activity in 3 to 6 weeks
Air-stirrup splint and resumption of activities as tolerated
Immediate repair of the peroneal retinaculum
Immediate reduction and placement of a syndesmotic screw

Correct Answer: Immediate reduction and placement of a syndesmotic screw

Explanation:

Question 64:

Options:

skeletal traction and reduction, followed by a halo jacket and nonsurgical stabilization.
skeletal traction, closed reduction, and posterior fixation/fusion.
skeletal traction, anterior decompression and fusion, followed by posterior stabilization and fusion.
skeletal traction and surgical posterior fusion, followed by anterior decompression and fusion.
general anesthesia, closed reduction, and a halo jacket for 3 to 4 months until stable.

Correct Answer: skeletal traction, closed reduction, and posterior fixation/fusion.

Explanation:

DISCUSSION: This is a classic bilateral facet dislocation. When there is no evidence of a disk herniation, treatment should include careful skeletal traction, closed reduction, and posterior fusion. There is no role for anterior procedures. These fractures are unstable and require surgical intervention.
REFERENCES: Herkowitz HN, Garfin SR, Eismont FJ: Rothman-Simone The Spine, ed 5. Philadelphia, PA, Saunders Elsevier, 2006, pp 1120-1128.
Coe JD, Warden KE, Sutterlin CE, et al: Biomechanical evaluation of cervical spinal stabilization methods in a human cadaveric model. Spine 1989;14:1122-1131.

Question 65:

Options:

Bushing wear
Infection
Aseptic component loosening
Component fracture TEA has been described for posttraumatic arthritis of the elbow and typically involves a young patient population with multiple previous operations on the affected elbow. Morrey and Schneeberger found aseptic component loosening to be uncommon (<10% of patients) and usually occurring >10 years after surgery. Prosthetic fracture, usually of the ulnar component, is also a late-term finding. Infection is the most common mode of early failure but usually occurs within the first 5 years and has an overall rate of approximately 5%. Bushing wear has been reported as the most common cause of mechanical TEA failure in this population at intermediate-term follow-up.

Correct Answer: Bushing wear

Explanation:

A 51-year-old man presents with persistent right shoulder pain several weeks after falling off a roof. On examination, he has pain with palpation over the greater tuberosity, active forward shoulder flexion of
60°, and passive forward shoulder flexion of 160°. He has 2/5 forward flexion and external rotation strength. Initial plain radiographs are unremarkable. A coronal MRI scan of his shoulder is shown in Figure 1. After a thorough discussion, the patient elects to proceed with surgical intervention. During intraoperative assessment, the surgeon contemplates performing a single versus a dual row repair. Currently, what is the consistent difference between the two repair techniques?
A. Dual row repairs result in superior objective clinical outcomes
B. Dual row repairs provide a larger footprint coverage.
C. Single row repairs have a reported higher complete retear rate.
D. Single row repairs have fewer points of tendon fixation.

Question 66:

Which of the following positions of immobilization has been shown to best approximate the anterior labrum against the glenoid rim following anterior dislocation of the shoulder?

Options:

Abduction and external rotation
Abduction and internal rotation
Adduction and external rotation
Adduction and internal rotation
Extension

Correct Answer: Adduction and external rotation

Explanation:

Question 67:

Pain associated with a proximal medial tibial osteochondroma in a 10-year-old patient is most commonly the result of

Options:

degeneration into a chondrosarcoma.
bursitis.
infection.
fracture through the base.
associated spinal stenosis.

Correct Answer: bursitis.

Explanation:

Question 68:

5 g/dL and his base deficit is 10mEq/L. What is the most appropriate next step in management?

Options:

Reamed intramedullary nailing bilateral femur fractures, irrigation and debridement followed by reamed intramedullary nailing right tibia, open reduction internal fixation left forearm
Reamed intramedullary nailing bilateral femur fractures, irrigation and debridement followed by external fixation right tibia, splinting left forearm
External fixation bilateral femur fractures, irrigation and debridement followed by external fixation right tibia, open reduction internal fixation left
forearm
External fixation bilateral femur fractures, irrigation and debridement followed by external fixation right tibia, splinting left forearm
External fixation right femur and right tibia following irrigation and debridement, reamed intramedullary nailing left femur, splinting left forearm

Correct Answer: External fixation bilateral femur fractures, irrigation and debridement followed by external fixation right tibia, splinting left forearm

Explanation:

With a base deficit of 10mEq/L, the patient is under-resuscitated and unstable. Thus, damage control orthopedics via external fixation of the long bone injuries with irrigation and debridement of the open tibia is the appropriate next step in management.
Of all of the reported values, the most important predictor of morbidity and mortality is the base deficit (normal range -2 to +2mEq/L), which represents overall resuscitation status. Another representative parameter of resuscitation status is lactate (normal <2mg/dL). Heart rate, blood pressure and hematocrit are not reliable predictors of normalized resuscitation status, morbidity or mortality.
Callaway et al. retrospectively reviewed a large cohort of blunt trauma patients over a 6 year period. Only base deficit and lactate levels were directly correlated with and were reliable predictors of mortality.
Paladino et al. retrospectively reviewed a prospective database of over 1400 patients. Base deficit and lactate were significant and useful predictors of triage upon initial presentation to denote severe versus non-severe injury.
Martin et al. retrospectively analyzed over 2000 sets of laboratory data in 427 ICU patients. Base deficit (anion status), even in ICU patients with normal lactate levels, were predictive of decreased survival.
Incorrect Answers:
OrthoCash 2020
A 26-year-old male sustains an elbow injury after a fall from a skateboard resulting in valgus and supination forces across the left elbow. A CT scan of the left elbow is shown in Figures A through D. This fracture pattern is most commonly associated with what other traumatic elbow pathology?
Posteromedial rotatory instability
Capitellum fracture
Radial head fracture and posterolateral ulnohumeral dislocation
Trans-olecranon fracture dislocation
Medial (ulnar) collateral ligament rupture
Corrent answer: 3
The clinical presentation is consistent with a coronoid tip fracture. This fracture pattern is associated with a radial head fracture and posterolateral ulnohumeral dislocation - together making up the terrible triad injury.
A terrible triad injury is the result of a valgus and supination injury and involves posterolateral elbow dislocation or lateral collateral ligament injury, radial head fracture, and fracture of the coronoid process. The elbow may dislocate postero-laterally with the anterior bundle of the MCL intact, but if the MCL is injured it is typically the last structure to fail. The coronoid fracture is typically a small fragment isolated to the tip. This is a result of a posteriorly directed force driving the coronoid into the trochlea prior to posterior elbow dislocation. CT scan is a useful modality when small or comminuted fragments are difficult to visualize on plain radiographs.
Steinmann reviews the anatomy, diagnosis, classification and treatment of coronoid fractures with a focus on surgical exposures and fixation techniques.
Doornberg et al. reviewed 67 coronoid fractures to determine whether type of coronoid fracture correlated with pattern of instability. They found strong associations between (1) large coronoid fractures and trans-olecranon fracture-dislocations, (2) small fractures and terrible-triad injuries, and (3) anteromedial facet fractures and varus posteromedial rotational injury mechanisms.
Doornberg et al. evaluated 18 patients with a fracture of the anteromedial facet of the coronoid. They found that malalignment of the anteromedial facet fragment was associated with arthrosis and a fair or poor result.
Figures A through D show consecutive 2.00 mm sagittal CT reformats demonstrating a small coronoid fracture fragment which was addressed with suture fixation.
Incorrect Answers:
OrthoCash 2020
A 62-year-old right-hand-dominant school teacher sustains a mechanical fall at home and presents with right shoulder pain. Plain
radiographs of the right shoulder are pictured in Figures A and B. The patient asks you what she can expect in terms of recovery following this injury. Which of the following is the most appropriate statement?
At 1-year post-injury, the right shoulder range of motion will most likely be equal to the contralateral extremity.
At 1-year post-injury, you will most likely have returned to your baseline functional status.
Early range of motion exercises risk fracture displacement and should be avoided until at least 4 weeks post-injury.
Most patients do not return to work following this injury.
One in 5 patients with this fracture go on to nonunion and you may benefit from surgery in the future to address this.
This patient has a minimally displaced (1-part) proximal humerus fracture involving the humeral neck and greater tuberosity. This injury pattern is most commonly managed nonoperatively with the majority of patients returning to their baseline functional status by 1 year.
Proximal humerus fractures (PHF) can be classified by number of parts (Neer classification), with a part defined as a fracture fragment displaced > 1cm (> 5mm for greater tuberosity) or angulated > 45°. One-part PHF comprise ~80% of all PHF and are treated nonoperatively with a sling and early range of motion (ROM).
Tejwani et al performed a prospective study of 67 patients with 1-part PHF. At 1-year follow up the ASES score and functional status was similar to pre-injury status. However, ROM of the affected shoulder was diminished in both external and internal rotation. Forward flexion was preserved.
Hanson et al prospectively analyzed 160 patients with PHF of all types (1-4 parts and head-splitting) managed nonoperatively. At 1-year follow up, 93% showed solid union. Constant and DASH scores improved steadily over time but were still lower compared to the contralateral extremity. Of employed patients, 97.6% returned to work with a median time off of 10 weeks and no difference between manual and nonmanual workers.
Figures A and B are the AP and axillary radiographs of the right shoulder, respectively, demonstrating a 1-part PHF involving the humeral neck and greater tuberosity.
Incorrect Responses:
OrthoCash 2020
A 44-year-old male presents with the isolated injury seen in Figure A after a motor vehicle accident and underwent the operative treatment seen in Figure B within 8 hours from the time of incident. Which of the following complications is this patient at highest risk of developing?
Pulmonary embolus
Periprosthetic fracture
Contralateral hip fracture
Osteonecrosis
Infection
This young male patient has sustained a displaced femoral neck fracture and underwent open reduction internal fixation with 3 cannulated screws. Based on the available options, the patient is most at risk of developing osteonecrosis of the femoral head.
Femoral neck fractures in young patients typically are the result of a high-energy trauma. Fracture displacement has been shown to disrupt vascular supply to the femoral head by interrupting retinacular vessels and ligament teres vascularization, as well as increasing intracapsular pressure, producing a tamponade effect. The incidence of osteonecrosis in patients younger than 60 years with displaced femoral neck fractures has been shown to be between 15-30%. Quality of reduction is one key factor that has been shown to influence outcomes postoperatively.
Loizou et al. prospectively studied 1,023 patients who sustained an intracapsular hip fracture that was treated with internal fixation using standard fixation modalities. They showed that osteonecrosis was less common for undisplaced (4.0%) than for displaced fractures (9.5%). The population at greatest risk were women younger than the age of 60 with displaced fractures.
Barnes et al. review subcapital hip fractures. They found that late segmental collapse was more common in displaced fractures in women younger than age 75 years than in those older than age 75 years treated with internal fixation.
Figure A shows a displaced, Garden 3/Pauwels III hip fracture. Figure B shows anatomical fixation with 3 cannulated screws.
Incorrect Answers:
OrthoCash 2020
A 58-year-old male is involved in a motor vehicle collision and sustains the injury shown in Figure A in addition to right 5th and 6th rib fractures. Upon evaluation in the emergency department, he is noted to have a 2 centimeter laceration over the anterior aspect of his left leg with visible bone. Vitals and labs are normal. Which of the following statements is most accurate regarding surgical management for this patient?
Reamed intramedullary nailing is favored due to increased rates of union
Unreamed intramedullary nailing is favored due to presence of concomitant rib fractures
Reamed intramedullary nailing is favored due to decreased rates of infection
Unreamed intramedullary nailing is favored due to less local trauma
Both unreamed and reamed intramedullary nailing are equivalent
Corrent answer: 5
Both unreamed and reamed intramedullary nailing are equivalent treatments in patients with open tibia fractures. Intramedullary nailing is the treatment of choice for stable patients with tibial shaft fractures.
Tibial shaft fractures can be the result of low energy twisting injuries or higher energy axial loads. Closed fractures with acceptable alignment can be often be treated with closed reduction and casting. Intramedullary nailing, unreamed or reamed, is the treatment of choice for open fractures except in the setting of damage control orthopaedics when an external fixator may be more appropriate.
Bhandari et al. investigated reamed and unreamed intramedullary nailing for tibial shaft fractures in a randomized trial ("SPRINT" Trial - Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures Investigators). They concluded that reamed nailing was more beneficial (decreased rate of primary outcome event: need for bone grafting, implant exchange or removal for infection, debridement for infection) for closed fractures, but had no benefit in open fractures.
Finkemeier et al. evaluated consecutive patients treated with unreamed and reamed intramedullary nailing and found similar rates of union in both open and closed tibial shaft fractures at six and twelve months.
Figures A shows AP and lateral xrays of the left tibia showing a tibial shaft fracture.
Incorrect Answers:
OrthoCash 2020
A 36-year-old male falls from a 10-ft scaffold and suffers the injuries shown in Figures A and B. The patient is placed in a spanning external fixator and brought back to the operating room once his soft tissues are amenable. Planning to use a dual-incision approach, what is the correct interval to use when approaching the medial side?
Popliteus and pes anserine
Lateral head of the gastrocnemius and pes anserine
Politeus and lateral head of the gastrocnemius
Iliotibial band and medial head of the gastrocnemius
Pes anserine and medial head of the gastrocnemius
Corrent answer: 5
The posteromedial approach to the tibial plateau is between the the pes anserine tendons and the medial head of the gastrocnemius.
A dual-incision approach is often utilized to optimally place definitive fixation for bicondylar tibial plateau fractures. For fractures that require posterior or posteromedial fixation, the correct interval is between the pes anserine and the medial head of the gastrocnemius.
Higgins et al. in a large cohort morphological review, noted a high incidence of a posteromedial fragment in bicondylar fractures. Occurring at a high frequency, the authors recommended direct visualization and reduction via a dual approach rather than using indirect reduction techniques.
Falker et al. describes a step-by-step approach to utilizing the posteromedial approach for the tibial plateau and placing an anti-glide plate.
Figure A and B exhibit a bicondylar tibial plateau fracture with a posteromedial fragment noted on the lateral x-ray. Illustration A exhibits the surrounding anatomy and interval in between the medial head of the gastrocnemius and the pes anserine.
Incorrect answers:
OrthoCash 2020
A 25-year-old male presents to the emergency department with the injury seen in Figure A after a motorcycle collision. The patient has a blood pressure of 70 systolic, elevated lactate and a tense abdomen with positive FAST examination. Trauma surgery will be performing an emergent laparotomy. Orthopaedic surgery is consulted and places a pelvic external fixator intraoperatvely to assist with resuscitation. What is an advantage of supra-acetabular external fixator pins as compared with iliac crest pins?
Less interference with pelvic surgical incisions
Less risk of pin tract infection
Less risk of malreduction
Less control of posterior pelvic ring
No interference with laparotomy
Corrent answer: 1
One advantage of supra-acetabular external fixator pins is that they do not interfere or contaminate future approaches to the pelvis or acetabulum involving the lateral window.
In multiply injured patients with pelvic trauma external fixation of the pelvic ring is a valuable tool to assist with resuscitation. Pelvic external fixation should be applied rapidly and allow full access to the abdomen for general surgery intervention. Regardless of the technique used, a pelvic external fixator should form a stable construct that minimizes motion of fracture surfaces and allows for clot formation.
Haidukewych et al evaluated the safety of supra-acetabular pin placement in a cadaveric study. The authors found that the lateral femoral cutaneous nerve (LFCN) was most at risk during pin placement.
Figure A demonstrates a widely displaced symphyseal dislocation with associated bilateral sacroiliac (SI) dislocations (APC 3). Illustration A demonstrates an outlet radiograph of a supra-acetabular external fixtator in conjunction with posterior pelvic ring fixation for an LC3 pelvic ring injury.
Illustration B is an illustration of iliac crest external fixation. The video demonstrates techniques for application of both supra-acetabular and iliac
crest external fixation pins.
Incorrect Answers:
OrthoCash 2020
What physical exam finding is most likely to be found in association with the injury shown in Figures A and B?
Numbness in the small finger and ulnar side of the ring finger
No elbow instability
Varus posteromedial rotatory instability
Valgus posterolateral rotatory instability
An anterior open wound
Corrent answer: 3
The x-ray shows a fracture of the anteromedial facet of the coronoid with an intact radial head. Large anteromedial facet fractures are associated with varus posteromedial rotatory instability.
The anteromedial facet of the coronoid provides support to the medial elbow against varus stress. Varus and posteromedial force applied to the elbow results in disruption of the lateral collateral ligament (LCL) from its proximal origin. The coronoid is fractured as it is forced against the medial trochlea.
Coronoid fractures of significant size involving the sublime tubercle (insertion of medial collateral ligament) result in varus instability.
Steinmann reviews the anatomy, diagnosis, classification and treatment of coronoid fractures with a focus on surgical exposures and fixation techniques. He states that when a coronoid fracture is associated with a pattern of varus instability, it requires fixation with either suture, buttress plating or screw fixation. Concomitant LCL repair or reconstruction will also be necessary.
Doornberg et al. reviewed 67 coronoid fractures to determine whether type of coronoid fracture correlated with pattern of instability. They found strong
associations between (1) large coronoid fractures and trans-olecranon fracture-dislocations, (2) small fractures and terrible-triad injuries, and (3) anteromedial facet fractures and varus posteromedial rotational injury mechanisms.
Doornberg et al. evaluated 18 patients with a fracture of the anteromedial facet of the coronoid. They found that malalignment of the anteromedial facet fragment was associated with arthrosis and a fair or poor result.
Figure A is an AP view of an elbow with an anteromedial facet of the coronoid fractured. The lateral joint space is widened due to injury to the LCL. The medial joint space is narrowed and collapsed. A lateral view is shown in Figure
B. Illustrations A and B show AP and lateral views of a coronoid fracture fixed with buttress plating. The LCL origin was fixed with a suture anchor. Illustration C shows the O'Driscoll classification of coronoid fractures. Illustration D lists injury patterns that suggest posteromedial versus posterolateral rotatory instability.
Incorrect Answers:
OrthoCash 2020
A 35-year-old man presents to the ED as the restrained driver of a high speed motor vehicle collision complaining of hip, chest, and abdominal pain. He becomes diaphoretic, tachycardic, and hypotensive in the trauma bay and is noted to have diminished lower extremity pulses. He is found on ATLS workup to have mediastinal widening.
Which of the following injuries is most associated with thoracic aortic injury?
Thoracic aortic rupture is associated with posterior hip dislocation in deceleration trauma mechanism of injuries.
Posterior hip dislocations are infrequently associated with local vascular injuries. With bilateral perfusion deficits, more proximal large vessel trauma should be considered, and in this situation, thoracic surgery should be involved emergently. Screening chest x-ray in the trauma bay should be reviewed for widened mediastinum, suggestive of aortic injury, as shown in illustration A. Given the high energy mechanism associated with these injuries, a full ATLS trauma survey must be done for every patient.
Marymont et al. studies the association between posterior hip dislocation and thoracic aortic injury. They performed a retrospective chart review of 89 posterior hip dislocations and found 8% had an aortic injury. Although not statistically significant, they note the importance of evaluation for aortic injury in patients with posterior hip dislocations given its emergent life-threatening nature.
In addition to associated chest injuries, Schmidt et al. highlight the importance of evaluating the ipsilateral knee after high-energy traumatic hip dislocation. In a prospective study, they identified a 93% rate of ipsilateral knee injury on MRI including effusion (37%), bone bruising (33%), and meniscal tear (30%) as the most common. They recommend a thorough exam but also expanded use of knee MRI after hip dislocation.
Illustration A shows an example of chest x-ray with a widened mediastinum, suggestive of thoracic aortic injury.
OrthoCash 2020
A 31-year-old female smoker was involved in a skiing accident approximately 9 months ago and underwent open reduction internal fixation of the radius and ulna at the time of injury. She now returns to the clinic complaining of increasing pain with range of motion and activity. Radiographs from her most recent follow-up can be seen in Figure A. Laboratory tests show ESR, CRP and WBC count to be within normal limits. Which of the following options is the most appropriate next step in management?
Bone scan
Above elbow cast
Removable splint
Reamed intramedullary nail
Iliac crest bone grafting + compression plating
Corrent answer: 5
This patient is presenting with an atrophic non-union of the ulna after open reduction internal fixation for a both bone forearm fracture 9 months ago. The most appropriate next step in management would be iliac crest bone grafting and compression plating of the ulna.
The primary issue with an atrophic nonunion is biological. The blood supply is poor and therefore incapable of purposeful fracture healing. Smokers, as in this vignette, are at high risk for nonunion. The treatment of an atrophic nonunion involves improving biology at the fracture site through use of autologous bone graft (e.g. iliac crest) and providing mechanical stability by means of compression plating (e.g. 3.5 mm LC-DCP).
dos Reis et al. reports excellent results of 31 cases of diaphyseal forearm fracture non-unions treated with autologous bone grafting and compression
plating. Thirty of thirty-one patients went on to bony union within 3.5 months of revision surgery.
Nadkarni et al. presented a case series of 11 patients with non-unions of various long bones initially managed with intradmedullary (IM) nail fixation. The authors successfully used locking compression plates while retaining the IM nails in the treatment of the nonunion in all cases.
Figure A shows an AP radiograph of a both bone forearm fracture. Figure B shows an AP and lateral radiograph of an atrophic non-union of the ulnar shaft. Illustration A shows a lateral x-ray of a fully healed radius and ulna after hardware removal 1 year after revision surgery.
Incorrect Answers:
OrthoCash 2020
A 27 year-old patient sustains a fracture-dislocation of the acetabulum. Pelvic radiographs (Figures A and B) are taken at initial presentation and a CT scan (Figures C and D) is performed after reduction of the hip in the emergency room. What is the importance of the finding highlighted in the CT scan cuts?
Comminution indicates a better result with non-operative management
Significant marginal impaction could compromise the results of the surgical reduction if the joint surface is not properly restored
The impacted fracture segment will heal without fixation because it is not gapped or translated
The CT scan finding highlighted indicates osteochondral defects to the femoral head, which can be addressed arthroscopically
Intraarticular fracture fragments should be discarded from the surgical field, as incorporation of the fragments into the fixation construct leads to a high rate of avascular necrosis
The CT images shown in Figures C and D display significant marginal impaction of the joint surface.
Marginal impaction is common in posterior wall fractures and fracture-dislocations. Critical review of CT imaging of posterior wall fractures can help with preoperative planning for identifying impaction of the articular surface of the acetabulum. Restoration of the sphericity of the acetabulum to match that of the femoral head is important for successful outcome following ORIF of posterior wall fractures. A common surgical technique to accomplish joint surface restoration includes freeing the impacted articular segments, bone grafting of the void created to support the articular segments, and buttress plating of the posterior wall fracture fragments.
Patel et al. discuss the challenge of interpreting imaging of the acetabulum for assessing fracture characteristics that may significantly impact success or surgical intervention. These characteristics include: articular displacement, marginal impaction, incongruity of the joint surface, intra-articular fragments, and osteochondral injury to the femoral head. Based on expert review of images, determination of significant marginal impaction had a poor intraobserver reliability, as did each of the other modifiers listed.
Figures A and B are radiographs of the posterior wall fracture and hip dislocation. They do not show the large amount of marginal impaction of the acetabular surface. Figure C (coronal reconstruction) and Figure D (sagittal reconstruction) point out a large a amount of marginal impaction of the acetabular. Note the disruption of the joint surface on the intact portion of the acetabulum.
Incorrect answers:
Comminuted posterior wall fractures still should be surgically stabilized if the joint is unstable
This impacted fragment on the margin of the main fracture line will likely heal regardless of restoration of the articular surface; however, this malreduction will lead to a incongruent joint surface
These CT cuts do not show any osteochondral defects of the femoral head; however if found in other CT cuts or intraoperatively, they should be appropriately addressed
Intraarticular fracture fragments should be removed from the joint, but if they make up a substantial portion of the joint surface, they should be incorporated in the fixation construct to obtain the goal of anatomic reduction of the joint surface
OrthoCash 2020
A 32-year-old female is involved in a motor vehicle collision and suffers a right hip dislocation. She is in the twelfth week of pregnancy.
Evaluation in the emergency department reveals no other injuries and ultrasound reveals a strong fetal heart rate and no abnormalities. She undergoes emergent closed reduction but the hip remains unstable and a traction pin is placed. Post-reduction films are shown in Figure
What is the most appropriate next step in management?
Acute open reduction internal fixation
Exam under anesthesia
Skeletal traction for 6-8 weeks
Fetal monitoring until 15 weeks followed by open reduction internal fixation
Percutaneous pinning
This patient has a large posterior wall fracture of the right acetabulum with an unstable hip. The most appropriate next step in treatment is open reduction and internal fixation.
Fixation of acetabular fractures during pregnancy is not contraindicated in the setting of stable fetal heart rate and no abnormalities on pelvic ultrasound.
There is, however, an increased risk of complications for the mother and fetus. Injury severity and mechanism are most closely associated with increased rate of fetal complications. The trimester of pregnancy is not associated with increased risk of complications.
Leggon et al. reviewed 101 cases of pelvic and acetabular fractures in pregnant patients and found mechanism of injury and injury severity were associated with higher mortality for both mother and fetus. Trimester of pregnancy was not associated with increased mortality.
Flik et al. reviewed orthopaedic trauma in a pregnant patients and recommended fetal ultrasound for assessment of fetal well-being in all pregnant patients.
Desai et al. investigated orthopaedic trauma during pregnancy and reported minimal radiation risk to the fetus when obtaining x-rays. They also advocate for LMWH as one of the safest choices for anticoagulation.
Figure A is an x-ray showing a right posterior wall acetabular fracture. Figures B and C are Judet views of the pelvis focusing on the right hip. A large posterior wall fragment is visible in Figure B.
Incorrect Answers:
OrthoCash 2020
Figure A is radiograph of a 50-year-old male science teacher that was involved in a motor vehicle accident. He underwent closed reduction as seen in Figure B and C. What would be the most appropriate treatment?
Open reduction and internal fixation with medial bridge plate and lateral screw in non-lagging mode
Tibiotalocalcaneal arthrodesis
Open reduction and internal fixation with lateral and medial screw in lagging mode
Closed reduction and internal fixation with medial and lateral screw in non-lagging mode
Closed reduction with percutaneous pins
Corrent answer: 1
This patient is presenting with a Hawkins II talar neck fracture with medial wall comminution. The most appropriate treatment of this patient would be open reduction internal fixation with medial plate and lateral screw in non-lagging mode.
The treatment of talar fractures is based on the severity of the fracture, soft-tissues, and patient factors. The fracture and subluxation of the subtalar joint should be reduced and stable anatomical fixation should be obtained. When there is comminution of either the superior, lateral or medial aspects of the talus, one should avoid shortening the medial wall as this will cause a varus malunion. The use of a medial or lateral plate can help to re-establish column length, which can often prevent this potential complication.
Sanders et al. showed significant complications after fixation of talar neck fractures. They showed the incidence of secondary reconstructive procedures following talar neck fractures increased from 24% +/- 5% at 1 year to 48%
+/- 10% at 10 years post-injury.
Vallier et al. retrospectively reviewed the records of 39 fractures of the talar neck treated with open reduction and internal fixation. Twenty-one (54%) of thirty-nine patients had development of posttraumatic arthritis, which was more common after comminuted fractures (p < 0.07) and open fractures (p = 0.09).
Vallier et al. reviewed 81 talar neck fractures to revisit the rate of osteonecrosis and post-traumatic arthritis based on the Hawkins Classification. They found that delaying definitive internal fixation does not increase the risk of developing osteonecrosis. Thirty-five patients (54%) developed posttraumatic arthritis, including 83% of those with an associated talar body fracture (p < 0.0001) and 59% of those with Hawkins type-III injuries (p < 0.01).
Figure A shows a Hawkins II talar neck fracture. Figures B and C are saggital and coronal CT images, respectively, of the foot. There is significant comminution of the medial wall of the talus with extension into the subtalar joint.
Incorrect Answers:
There is some research to suggest primarily subtalar arthrodesis with these injuries. However, to date, there is no high level evidence that has conclusively shown subtalar arthrodesis to be better than ORIF.
OrthoCash 2020
A 28-year-old male college student sustains a severe foot injury from gunshot-related violence, and subsequently undergoes a lower-extremity amputation as shown in Figure A. At long-term follow-up, which of the following is the strongest predictor of patient satisfaction as related to his injury?
Age less than 30
Marijuana use
Use of negative pressure wound therapy
Male gender
Ability to return to work
Corrent answer: 5
The strongest factor to predict patient-reported outcomes after trauma-related lower extremity amputations is the patient's ability to return to work. This is likely due to the effect of the return to work on the physical, emotional, and financial aspects of the patient's life.
The LEAP study is a multicenter, prospective study evaluating multiple aspects of reconstruction versus amputation in the treatment of mangled extremity injuries. With regard to patient satisfaction, treatment variables such as decision for reconstruction versus amputation, or initial presence or absence of plantar sensation have little impact. In addition, demographic factors such as age, gender, socioeconomic status, and education level do not predict patient satisfaction. Instead, the most important predictors of patient satisfaction at 2 years after injury include the ability to return to work, absence of depression, faster walking speed, and decreased pain.
O'Toole et al reviewed 463 patients treated for limb-threatening lower-extremity injuries and identified factors associated with patient reported outcomes two years after surgery. They found that return to work was the most associated with outcomes, but that physical functioning, walking speed, pain levels, and presence of depression were also associated to a lesser extent with outcomes.
Bosse et al performed a multicenter, prospective study to assess outcomes of 569 patients with severe lower extremity limb injuries that resulted in either amputation or limb salvage procedures. They found that at two years postoperatively, no significant differences were seen between groups in patient-reported outcome. Worse outcomes were associated with rehospitalization for a major complication, a low educational level, nonwhite race, poverty, lack of private health insurance, poor social-support network, low self-efficacy (the patient's confidence in being able to resume life activities), and involvement in disability-compensation litigation.
Figure A shows a clinical photograph of a Pirigoff amputation at early follow-up. This amputation is an end-bearing amputation that utilizes the plantar heel pad for weightbearing, and relies on a tibiocalcaneal arthrodesis.
Incorrect Answers:
4: These options are not as strong of a factor of patient satisfaction in longterm follow up after trauma-induced lower extremity amputation.
OrthoCash 2020
A 34 year-old male falls off of motorcycle on an outstretched hand suffering the injuries shown in Figures A and B. He is brought to the operating room and undergoes radial head replacement and fixation and repair of the coronoid and the lateral collateral ligament (LCL). Prior to closing, the elbow is still unstable upon testing range of motion. What is the next best step in management?
Exchange radial head for larger implant
Complete resection of radial head
Cast at 90 degrees of flexion for 6-8 weeks
Reinforce LCL repair with non-absorbable suture
Repair the ulnar collateral ligament
Corrent answer: 5
Following complete fixation and repair of a terrible triad, a final range of motion test should be performed prior to closure. If still unstable, the next step should be to assess and repair the ulnar collateral ligament. Another option
would be to placed a hinged external fixator.
Operative reconstruction of a terrible triad injury should be performed in a systematic fashion, working from deep to superficial. Working through a lateral incision and through the radial head fracture, the coronoid should be fixed first, followed by radial head fixation or replacement and then repair/reconstruction of the LCL. If still unstable, the medial side should be addressed, or the patient placed in a hinged external fixator.
Mathew et al review the anatomic, biomechanic, and operative principles (why the above step-by-step method works) to achieving appropriate stability in order to obtain early range of motion to maximize clinical outcome.
Pugh et al. in this retrospective, multi-center study report outcomes on 36 terrible triad injuries fixed with the standard protocol described above. The authors recommend following this systematic approach to achieve the best results.
Figures A and B are AP and lateral radiographs exhibiting a terrible triad elbow fracture-dislocation.
Incorrect answers:
OrthoCash 2020
When treating the pathology depicted in Figures A through D, which of the following is necessary to preserve the blood supply to the femoral head?
Dissection of the gluteal musculature off the iliac crest
Ligation of the ascending branches of the lateral femoral circumflex artery
Greater trochanteric osteotomy
Identification and detachment of the piriformis tendon
Supine positioning
Figures A-D show a femoral head with associated acetabular fracture (Pipkin IV). Both the posterior wall fracture and the femoral head fracture can be addressed through a surgical dislocation via greater trochanteric osteotomy.
Pipkin IV femoral head fracture (with associated acetabular fractures) are somewhat problematic in that the femoral head fracture is usually anterior, while the acetabular fracture usually involves the posterior wall. A Kocher-Langenbeck approach gives good access to the posterior wall but limited access to the articular surface and femoral head avascular necrosis (AVN) is a concern. A Smith-Peterson approach provides good access to the femoral head
but not to the posterior wall. Combined approaches significantly increase the amount of surgical dissection. Surgical dislocation with trochanteric flip osteotomy provides access to the femoral head and posterior wall while preserving blood supply to the femoral head.
Solberg et al. retrospectively reviewed 12 patients with Pipkin IV injuries treated via a trochanteric flip osteotomy. All patients healed their acetabular fractures. Eleven of 12 patients healed their femoral head fractures and one patient (8.3%) developed osteonecrosis.
Henle et al. likewise treated 12 patients with Pipkin IV injuries through a trochanteric flip osteotomy. Two of 12 patients (16.7%) developed osteonecrosis. The remaining 10 patients (83.3%) had good or excellent results. Heterotopic ossification occurred in five patients, causing significant range of motion loss in four of these.
Figure A is a pre-reduction AP pelvis in which the posterior wall fracture is apparent. Figure B is a post-reduction AP pelvis in which an infra-foveal femoral head fracture is apparent (Pipkin IV). Figure C is an axial CT cut which further characterizes the posterior wall fracture. Figure D is an obturator oblique showing femoral head dislocation and posterior wall fracture. The video shows a surgical hip dislocation technique.
Incorrect Answers:
OrthoCash 2020
A 42-year-old male presents to your clinic for the first time with the radiographs seen in Figure A. He sustained the injury 4 weeks ago while skiing overseas and treatment was provided by the local orthopaedic surgeon. The operative note states that he sustained an Gustilo Type I open fracture. After surgical fixation of this type of injury, what is the most common complication requiring reoperation?
Chronic elbow instability
Post-traumatic arthritis
Infection
Heterotopic ossification
Loss of elbow range of motion
Corrent answer: 5
This patient sustained a terrible triad elbow fracture-dislocation. Reduced range of motion of the elbow joint is the most common complication REQUIRING reoperation with these injuries.
Terrible triad elbow fracture-dislocations are characterized by posterolateral dislocation/lateral collateral ligament (LCL) injury, radial head fracture and coronoid fracture. Displaced fractures result in elbow instability. Acute radial head stabilization, coronoid open reduction and internal fixation, and LCL +/-medial collateral ligament (MCL) repair/reconstruction is considered the most appropriate treatment for displaced fractures. Operative complications include elbow stiffness, recurrent instability, arthritis, failure of hardware, heterotopic ossification, posterior interosseous nerve palsy and infection.
Egol et al. looked at the functional outcomes of 27 patients that underwent fixation of terrible triad injuries. At one year follow-up, the average flexion-extension arc of elbow motion was 109 degrees +/- 27 degrees, and the average pronation-supination arc was 128 degrees +/- 44 degrees. Grip strength averaged 72% of the contralateral extremity. Although operative fixation led to functional elbow stability, results were poor.
They included a reference to McKee et al. to highlight that intra-articular fractures of the elbow have high rates of stiffness. While not specific to terrible
triads, they looked at the effectiveness of the posterior elbow approach in 25 patients that underwent internal fixation of intra-articular distal humerus fractures. They showed poor outcomes at a mean follow-up of 36 months with reduced range-of-motion, decreased strength and high re-operation rates.
Figure A shows AP fluoroscopic image of a terrible triad injury that has undergone operative fixation. The radial head and coronoid have undergone open reduction internal fixation, and the MCL bony avulsion has been repaired.
Incorrect Answers:
OrthoCash 2020
Figure A is a radiograph from a 59-year-old male that was transferred to a Level I trauma center five hours after a motor vehicle accident. Closed reduction and skeletal traction was successfully performed in the trauma bay. Which of the following factors has been shown to increase the risk of unsatisfactory clinical outcome for this patient?
Need for skeletal traction
Mechanism of injury
Gender
Age
Time to reduction
Corrent answer: 4
Age greater than 55-years-old has been found to be an independent risk factor for inferior clinical outcome in patients with combined acetabular fractures and hip dislocations.
The most important initial step in management following resuscitation involves urgent reduction of the dislocated hip. This should be followed by a preoperative CT scan and ultimately surgical fixation of the combined acetabular fracture. Hip dislocations should be reduced within 6-12 hours for optimal outcome, although different critical times have been cited, particularly for dislocations with concomitant acetabular fractures. Skeletal traction may be required to maintain hip reduction.
Moed et. al. present a Level 3 retrospective review of 100 patients who had been treated with open reduction internal fixation of an acetabular fracture. The authors found that factors associated with unsatisfactory clinical outcomes included age greater than 55, intra-articular comminution, osteonecrosis, and delay of greater than 12 hours for reduction of an associated hip dislocation.
Additionally, they showed that there was a strong association of clinical outcome and final radiographic grade.
Figure A demonstrates an acetabular fracture with concomitant hip dislocation. Incorrect Answers:
injury, male gender, and time to reduction <6 hours have not been shown to be related to unsatisfactory outcomes.
OrthoCash 2020
A 37-year-old male cashier is shot in the leg. He sustains the injury shown in Figures A and B, and is subsequently taken to the operating room for intramedullary nailing. Figure C shows a radiograph of the nail starting point (*). What complication is most likely to result?
Varus malunion
Nonunion
Valgus malunion
Malrotation
Superficial peroneal nerve injury
Corrent answer: 3
This patient is presenting with a comminuted fracture of the proximal third of the tibia. He is appropriately undergoing intramedullary nail fixation, however, the start point illustrated in Figure C is too medial and often leads to a valgus malunion.
Intramedullary nail fixation is more technically demanding in proximal tibial fractures than diaphyseal fractures. The valgus deformity is due to imbalanced muscle forces on the proximal fragment, which are then accentuated by a start point that is too medial. An apex anterior (procurvatum) deformity can also occur and results from the pull of the patellar tendon or a posteriorly directed nail that deflects off the posterior tibial cortex and rotates the proximal fragment. The ideal starting point for proximal tibial fractures is slightly lateral to the medial aspect of the lateral tibial spine on a true AP x-ray and very proximal and just anterior to the anterior margin of the articular surface.
Nork et al. reported the results of intramedullary nailing of proximal tibial fractures with emphasis on techniques of reduction. Various techniques were found to be successful including attention to the proper starting point, the use of unicortical plates, and the use of a femoral distractor applied to the tibia.
Lowe et al. describe surgical techniques for complex proximal tibial fractures. They describe the extended leg position, use of a femoral distractor, temporary plate fixation, blocking (Poller) screws, and use of percutaneous clamps as means to achieve reduction during fixation.
Figure A and B show an AP and lateral radiograph of a comminuted extra-articular fracture through the proximal third of the tibia. Figure C demonstrates a start point that is too medial (represented by the asterisk) for intramedullary nail fixation. Illustration A and B show the ideal start point for intramedullary nail fixation of the tibia on AP and lateral radiographs.
Incorrect Answers:
Varus malunion is more likely to occur in midshaft tibia fractures with an intact fibula.
Nonunion after a proximal tibial fracture treated with intramedullary nailing is less common than malunion.
Malrotation occurs most commonly after IM nailing of fractures through the distal third of the tibia.
The superficial peroneal nerve is at risk during distal screw fixation using a LISS plating technique for fracture fixation.
OrthoCash 2020
A 24-year-old motorcyclist is brought in as a polytrauma after striking a tree at 65 mph. He is found to have injuries involving the chest, abdomen, pelvis, as well as a left open femoral shaft fracture. He undergoes resuscitation in the trauma bay. Which of the following parameters best supports proceeding with irrigation, debridement and external fixation as opposed to immediate reamed intramedullary nailing?
Temperature = 35.5°C (95.9°F)
Fractures of ribs 2-3 with left apical pneumothorax
Grade IV liver laceration with SBP = 85 mmHg
Left superior and inferior pubic ramus fractures
Lactate = 2.3 mg/dL
Significant abdominal trauma with evidence of hemorrhagic shock (SBP < 90 mmHg) following resuscitation is an unstable parameter and therefore is an indication to proceed with damage control orthopaedics (irrigation and debridement of open fractures and temporizing external fixation) in a polytraumatized patient.
The management of orthopaedic injuries in a polytrauma patient depends on the physiological stability of the patient. In an unstable patient, damage control orthopaedics (DCO) is preferred over early total care (ETC) to avoid an iatrogenic second hit with development of adult respiratory distress syndrome (ARDS) and/or multiple organ failure. Clinical parameters indicative of instability include shock (BP < 90 mmHg, refractory to blood products, lactate
> 2.5 mg/dL), coagulopathy (platelet count < 90,000 mm3, fibrinogen < 1 g/L), hypothermia (< 35°C), and significant chest, abdomen or pelvis injuries (pulmonary contusions, severe liver/spleen lacerations, pelvic ring disruption).
Pape et al. (2009) authored a review article detailing the management of a multitrauma patient. Polytrauma patients can be classified as stable, borderline, unstable or in extremis using a variety of criteria pertaining to hemodynamic stability, coagulation, temperature and soft tissue injury.
Patients who are stable or borderline can undergo ETC, while patients who are unstable or in extremis should be managed with DCO.
Pape et al. (2008) concluded that all patients who underwent early femoral nailing demonstrated increased systemic inflammatory response compared to external fixation, regardless of clinical stability. However, unstable patients
with a preexisting elevation of inflammatory status are likely more impacted by this additional increase. Improved postoperative clinical status coincided with a less vigorous inflammatory response.
Illustration A is a table from Pape et al (2009) depicting the criteria used to determine clinical condition of a polytraumatized patient. Illustration B is an algorithm from Pape et al (2009) detailing management of the multitrauma patient.
Incorrect Responses:
OrthoCash 2020
A 92-year-old female sustains the injury shown in Figure A to her nondominant extremity as the result of a non-syncopal ground-level fall. She denies any previous injury or pain of the elbow, and her medical history is significant only for osteoporosis and hypothyroidism. What is the most appropriate treatment for her injury?
Immediate range of motion as tolerated with a sling for comfort
Long arm cast for 3 weeks, then physical therapy for motion
Open reduction and internal fixation
Radiocapitellar arthroplasty
Total elbow arthroplasty
Corrent answer: 5
Use of total elbow arthroplasty (TEA) in the elderly is a well-recognized method of treatment of complex distal humerus fractures. This procedure allows for improved ROM, improved patient-reported outcomes, and decreased revision rates as compared to fixation.
TEA is a preferred alternative for ORIF in elderly patients with complex distal humeral fractures that are not amenable to stable fixation. Elderly patients appear to accommodate to objective limitations in function with time, which is important, as most recommendations list restrictions of lifting no more than 5-10 pounds postoperatively.
McKee et al conducted a prospective, randomized, controlled trial to compare functional outcomes, complications, and reoperation rates in elderly patients with displaced intra-articular, distal humeral fractures treated with open reduction-internal fixation (ORIF) or primary semiconstrained total elbow arthroplasty (TEA). Patients who underwent TEA had a quicker procedure, improved DASH scores at 6 months, improved elbow ROM, and decreased revision rates.
Athwal et al review TEA and the options available at the time of publication. They also report on the techniques and purported advantages of arthroplasty as compared to fixation of complex distal humerus fractures.
Frankle et al reviewed patients >65 years old with distal humerus fractures at a minimum of 2 years follow-up. Outcomes were excellent in 33% of cases undergoing ORIF and 92% excellent with TEA. They recommend TEA in instances of arthritis, osteoporosis, or other diagnoses requiring steroids.
Figure A shows a significantly comminuted distal humerus fracture in an osteoporotic patient. Illustration A shows the same patient after undergoing total elbow arthroplasty.
Incorrect Answers:
1:Immediate range of motion is not recommended for this injury, even with the "bag of bones" treatment method. A brief period of immobilization is generally recommended for this technique.
2: Casting is not indicated for this injury.
3: ORIF of this injury will lead to worse outcomes as compared to arthroplasty. 4: Isolated radiocapitellar replacement is not indicated for this injury.
OrthoCash 2020
A 56-year-old right hand dominant attorney falls from standing and sustains the closed injury shown in Figure A. The treating surgeon elects to fix her fracture using a plate and screw construct. Based on
the available imaging, which of the following fracture characteristics best justifies this fixation choice?
Fracture displacement
Intra-articular fracture extension
The fracture extends distal to the coronoid
Oblique fracture line
Fracture comminution
This patient has a displaced, intra-articular, comminuted olecranon fracture. Comminution is an indication for plate fixation.
Most displaced olecranon fractures are treated operatively. Options include tension band constructs, intramedullary screws, plate and screw fixation or fragment excision with triceps advancement. Any construct relying on interfragmentary compression (tension band, intramedullary screws) requires a non-comminuted fracture pattern. Plate fixation is indicated in the setting of comminution, extension past the coronoid, or in the setting of associated instability.
Bailey et al. retrospectively reviewed 25 patients who underwent plate fixation of displaced olecranon fractures. Twenty-two of 25 patients had good or excellent outcomes. Five of 25 patients (20%) of patients required plate removal for symptomatic hardware. The authors concluded that plate fixation
was an effective treatment for displaced olecranon fractures, with good functional outcomes.
Figure A shows a displaced, comminuted olecranon fracture without evidence of propagation past the coronoid.
Incorrect answers:
OrthoCash 2020
A 35-year-old male was involved in a high speed motorcycle accident. He has a closed head injury, bilateral pulmonary contusions and splenic rupture. His orthopaedic injuries are shown in Figure A. He has a blood pressure of 90/50 mm Hg and a heart rate of 115, despite aggressive resuscitation. An arterial blood gas reveals that his blood lactate is 3.5 and base deficit is -6 mmol/L. Following successful closed reduction of the right hip in the operating room with a percutaneous inserted Schantz pin, what is the next most appropriate treatment for his orthopaedic injuries?
Bilateral open reduction and internal fixation
Open reduction internal fixation on the right, reamed intramedullary nailing on the left
Temporizing external fixation on the right, open reduction and internal fixation on the left
Bilateral reamed intramedullary nailing
Bilateral temporizing external fixation
Corrent answer: 5
This patient presents with features of hemodynamic instability and a high injury severity score. The next most appropriate treatment would be temporizing external fixation bilaterally. This patient meets the criteria for damage control orthopaedics.
Damage control orthopaedics is an approach that contains and stabilizes orthopaedic injuries so that the patient's overall physiology does not undergo further inflammatory insult. As a result, external fixation of femoral shaft fracture and pelvic stabilization is an effective treatment under this strategy. Other indications include vascular injury and severe open fracture.
Pallister et al. reviewed the effects of surgical fracture fixation on the systemic inflammatory response to major trauma. They show that early stabilization of major long bone fractures is beneficial in reducing the incidence of acute respiratory distress syndrome and multiple organ failure. However, early fracture surgery increases the post-traumatic inflammatory response, which
carries a higher complication rate compared to temporary fixation.
Tisherman et al. created clinical guidelines for the endpoints of resuscitation. Level I data found that standard hemodynamic parameters do not adequately quantify the degree of physiologic derangement in trauma patients. The initial base deficit, lactate level, or gastric pH should be used to stratify patients with regard to the need for ongoing fluid resuscitation.
Pape et al. retrospectively reviewed the impact of early total care vs. damage control orthopaedics in the treatment of femoral shaft fractures in polytrauma patients. They found a significantly higher incidence of acute respiratory distress syndrome (ARDS) with intramedullary nailing (15.1%) compared to external fixation (9.1%) when DCO subgroups were compared.
Figure A is a pelvic AP radiograph showing a right hip fracture-dislocation with an ipsilateral femoral shaft fracture. On the left side there is a displaced pertrochanteric hip fracture.
Incorrect Answers:
OrthoCash 2020
Which of the following has been shown to be the greatest risk factor for refracture after implant removal from a radial shaft?
Removal of locking screws
Removal of small fragment plates
Removal of metaphyseal implants
Removal of implants less than 1 year after insertion
Removal of protective splinting from limb earlier than 10 weeks postoperatively
Removal of implants earlier than 1 year after insertion is a risk factor for refracture of the bone after implant removal.
The risk of refracture after hardware removal is multifactorial. Multiple
variables have been studied such as protective splinting for 6 weeks after hardware removal, waiting 12 months or more prior to hardware removal, and the location of the fracture. The variable that seems to correlate most with the risk of refracture is a diaphyseal location of the initial fracture. Large fragment plates (4.5 mm), when removed, are also at higher risk for refracture in the forearm.
Deluca et. al reported on a case series of patients who sustained a refracture of a forearm after implant removal. They noted that radiolucency at the site of the original fracture was seen in most refractured patients when the plate was removed. They also recommend delaying implant removal to two years after insertion to minimize risk.
Rumball et. al reported that the incidence of refracture after forearm implant removal is 6% in their series. They found that early removal, lack of postoperative immobilization, and plate size are the most critical risk factors for refracture.
Illustration A shows a forearm with evidence of refracture after implant removal.
Incorrect Answers:
OrthoCash 2020
A 23-year-old male arrives to the trauma bay after a motorcycle crash caused by a drive-by shooting. The patient is awake and alert and following commands. Vital signs include a blood pressure of 145/90 and a heart rate of 117bpm. Initial lactate is reported as 2.4 mmol/L. The patient has 2 rib fractures on the right with a clear chest radiograph. The patient is neurovascularly intact with a 4cm transverse wound over the medial ankle. Figures A, B and C exhibit his orthopaedic injuries. What is the most appropriate management?
Irrigation, debridement and placement external fixator right ankle, external fixation femur and intramedullary fixation tibia
Irrigation, debridement and placement external fixator right ankle, intramedullary fixation femur and tibia
Irrigation, debridement and placement external fixator right ankle, intramedullary fixation femur and external fixation tibia
Irrigation, debridement and placement external fixator right ankle, femur and tibia
Irrigation, debridement and external fixation right ankle and skeletal traction
The patient is relatively hemodynamically stable. In this case the femur and tibia should be definitively fixed while the open ankle fracture can be irrigated and debrided and placed in a spanning external fixator, temporizing for later definitive fixation.
Aside from an elevated heart rate and mildly elevated lactate (normal < 2.5 mmol/L), the patient is relatively stable making him a good candidate for long bone stabilization and temporizing external fixation of the right ankle. Gross contamination of the open injury also supports temporizing fixation, which can be brought back for repeat I&D and possible fixation.
Pape et al. compared outcomes for intramedullary nailing (IMN) versus staged fixation for femur fractures in stable versus borderline patients. Borderline patients were defined as those with multi-system injury (especially to lungs) and exhibited higher lung complications following acute IMN when compared to stable patients with isolated orthopaedic injuries.
O'Brien reviewed the literature regarding early total care in regards to IMN stabilization of femur fractures. Summarized data noted isolated injuries treated with early IMN had good outcomes, whereas those with head or lung injury had worse outcomes and pulmonary complications.
Figure A exhibits a right open ankle fracture dislocation. Figure B exhibits a mid-shaft tibia fracture. Figure C exhibits a ballistic mid-shaft femur fracture.
Incorrect Answers:
OrthoCash 2020
Figure A is an anterior-posterior (AP) radiograph of a 27-year-old male who was a bicyclist struck by a motor vehicle. He was intubated in the field and unresponsive in the trauma slot. Ultrasound of his abdomen is positive for blood and he is brought to the operating room emergently for an exploratory laparotomy. He is found to have ischemic bowel and a grade 4 liver laceration. His lactate is 9.0 mg/dL. Which figure represents the next appropriate step in regard to his pelvic ring injury?
The radiograph exhibits an elevated left hemipelvis with complete sacroiliac disruption, which can be temporized with placement in skeletal traction.
The patient is unstable, as indicated by an elevated lactate level. The most appropriate next step is temporizing skeletal traction to reduce the left hemipelvis.
Langford et al. review the initial diagnosis, evaluation and resuscitation in the management of pelvic fractures. Reduction of pelvic volume can be achieved with pelvic binders and temporizing external fixation for anterior posterior compression (APC) and/or lateral compression (LC) fracture patterns, while skeletal traction can help do the same in vertical shear patterns.
Matullo et al. review the uses of skeletal traction in orthopaedic trauma, where lower extremity skeletal traction can be an efficient, fast, easy way to help reduce pelvic volume in vertical shear injuries, especially when the patient is unstable and not cleared for definitive fixation.
Figure A exhibits an elevated left hemipelvis indicative of a vertical shear injury and complete SI disruption. Figure B is an example of a pelvic binder. Figure C is a pelvic reconstruction plate. Figure D is a schematic of an anterior pelvic external fixator. Figure E is a schematic drawing of a patient in lower extremity
skeletal traction. Figure F is a radiograph exhibiting S1 and S2 sacroiliac (SI) screws.
Incorrect answers:
OrthoCash 2020
A 38-year-old man is involved in a motor vehicle collision and suffers the grossly open injury shown in Figure A. He subsequently undergoes irrigation and debridement and placement of an external fixator. In Figure B, if the proximal pin is placed at the red circle as compared to the black circle, the patient is at increased risk for which of the following?
Foot drop
Injury to the anterior tibial artery
Septic arthritis
Flexion contracture of the knee
Patellar tendon rupture
Corrent answer: 3
The patient is at increased risk of septic arthritis when placing the proximal tibial pin too proximal due to penetration of the joint capsule. Pin site flora can track into the joint and lead to a septic knee.
Tibial external fixators can be used to temporize tibial shaft, pilon, and ankle fractures not ready for definitive management due to soft tissue concerns and/or practice of damage control orthopaedics. Intracapsular placement of fixator pins can lead to septic arthritis. The capsular reflection typically extends 14 mm distal to the subchondral line.
DeCoster et al. reported a cadaveric dissection study for safe placement of proximal tibia pins and determined that the capsule inserts 14 mm below the articular surface along the posteromedial and posterolateral surfaces. For fractures requiring extremely proximal pin placement, they recommend
anterior cortex penetration only at least 6 mm distal to articular surface.
Reid et al. investigated safe transtibial pin placement using MRI and cadaveric and volunteer knees. They found that pin placement 14 mm distal to subchondral bone will result in low likelihood of capsular penetration.
Figure A is an AP radiograph showing a segmental middle third tibia/fibula fracture. Figure B is a lateral diagram of the tibia showing potential sites of proximal pin placement.
Incorrect Answers:
OrthoCash 2020
Figures A and B are radiographs of a 43-year-old, right-hand dominant, male that injured his arm in a motor vehicle accident. What would be an absolute indication for surgical fixation of his injury?
Radial nerve palsy
Intra-articular extension
2mm fracture distraction, 5 degrees of rotational malignment
Ipsilateral proximal both bone forearm fracture
Bilateral fracture
This patient has a humeral shaft fracture. An absolute indication for surgery would include a floating elbow, i.e. ipsilateral both bone forearm fracture.
The primary causes of humeral fractures include motor vehicle accidents, falls, or violent injury. Almost all cases are treated non-operatively with functional bracing. The absolute indications for surgical management include: ipsilateral vascular injury, severe soft-tissue injury, open fracture, compartment syndrome, and associated ipsilateral forearm fracture, ie, floating elbow. The relative indications for surgical management include: segmental fracture, intraarticular extension, significant fracture distraction, bilateral humeral fracture, inability to maintain acceptable alignment, and polytrauma.
Klenerman et al. reviewed non-operative treatment of humeral shaft fractures. They showed that acceptable results could be achieved even after 20° of
anterior bowing, 30° of varus angulation, 15° of malrotation, and 3 cm of shortening.
Carroll et al. reviewed the management of humeral shaft fractures. They state the indications for operative fixation to be polytraumatic injuries, open fractures, vascular injury, ipsilateral articular fractures, floating elbow injuries, and fractures that fail nonsurgical management. Surgical techniques include external fixation, open reduction and internal fixation, minimally invasive percutaneous osteosynthesis, and antegrade or retrograde intramedullary nailing
Figure A and B shows a comminuted mid-shaft humeral fracture with intraarticular extension.
Incorrect Answers:
OrthoCash 2020
Which of the following findings is a contraindication in retrograde nailing of a periprosthetic distal femur fracture around a total knee arthroplasty?
Posterior-stabilized total knee implant
Cruciate retaining total knee implant
Spiral fracture pattern
Distal femoral replacement
Knee flexion contracture of 15 degrees
Corrent answer: 4
A distal femoral replacement (TKA) implant will generally preclude placement of a retrograde nail due to the long stem on the femoral component.
Supracondylar femur fractures above a well-fixed TKA component are increasingly common. These fractures are often treated with a lateral locking plate, but can also be treated with a retrograde nail in certain circumstances. An important factor in determining if nailing is a viable option are knowing the TKA implant and it's design. In addition, if the TKA component is known, the maximum size of reamer head and nail can be determined preoperatively from the size of the femoral 'box'.
Schutz et al report on a prospective multicenter study of 112 patients who underwent fixation of a distal femur fracture with the LISS system. They report that 90% of fractures went on to union and they attribute all of the failures to either the high-energy nature of particular fractures or a lack of experience in applying the plate in an appropriate pattern. They also note that primary grafting of these fractures is not necessary.
Illustration A shows a periprosthetic femur fracture treated with a retrograde nail.
Incorrect Answers:
1: A posterior-stabilized implant can be treated with an intramedullary nail in many circumstances but can be technically challenging, depending on the components.
2: A cruciate retaining TKA is not a contraindication to use of a retrograde nail. 3: A spiral pattern periprosthetic supracondylar femur fracture can be treated with a femoral nail.
5: A knee flexion contracture will often provide the flexion necessary for access to the box of the femoral component. A knee extension contracture, however, can preclude access to this box for placement of a nail.
OrthoCash 2020
A patient falls and sustains the isolated injury seen in Figures A and B. The surgical plan includes open reduction and internal fixation with a small mini-fragment plate using a direct lateral approach. During the approach, the forearm was placed in a fully pronated position. What would be the correct position of the forearm during plate application?
Full pronation
25 degrees pronation
Neutral
25 degrees supination
Full supination
Using the lateral approach (Kocher or Kaplan), the correct placement of the arm should be in a neutral position so that the plate can be placed on the bare area of the proximal radius.
Displaced radial head fractures with less than 3 fragments can be amendable to open reduction internal fixation. The methods of fixation include buried or headless screws, if placed at the articular surface, or posterolateral plating, if placed in the bare area. The safe zone for plating is located at a 90-110 arc from the radial styloid to Lister's tubercle with the arm in neutral rotation. This position helps to avoid impingement of ulna against the plate with forearm rotation. It should be noted that during the approach, that the forearm should be fully pronated to avoid injury to the posterior interosseous nerve.
Mathew et al. reviewed the concepts of terrible triad injuries of the elbow. Radial head fractures are treated conservatively when there is an isolated minimally displaced (less than 2mm) fracture with no mechanical block to motion. Open reduction internal fixation is used for Mason II or III fractures with < 3 fragments. Radial head replacement is considered for comminuted
fractures (Mason Type III) with 3 or more fragments.
Cheung et al. reviewed the surgical approaches to the elbow. The lateral approach (Kocher or Kaplan) is most commonly used with these injuries. The Kocher approach utilizes the intramuscular plane between anconeus and extensor carpi ulnaris. Kaplan utilizes the plane between extensor digitorum commons and extensor carpi radialis brevis.
Figure A and B show AP and lateral radiographs of the left elbow. There is a displaced radial head fracture. Illustration A shows a schematic diagram of the radial head "safe zone" between the radial styloid to Lister's tubercle.
Incorrect Answers:
OrthoCash 2020
A 38-year-old male is involved in a high speed motor vehicle collision. He has a Glasgow Coma Scale of 13 and receives 2 liters of fluid en route to the emergency department. Upon evaluation in the emergency department, he is found to have a bilateral femoral shaft fractures, a right ankle fracture, and a left both bone forearm fracture. He also has 2 left sided rib fracture and a grade II liver laceration. His heart rate is 130 and blood pressure is 85/50. All of the following
would be indications to practice damage control orthopaedics in this patient except:
Bilateral femur fractures
Rib fractures
Lactate of 5.2
Urine output of 20 cc/hr
Heart rate and blood pressure
Corrent answer: 2
Rib fractures without evidence of further thoracic trauma would not be an indication to practice damage control orthopaedics. This patient is underresuscitated based on his lactate level, urine output, and vital signs and definitive management should be delayed.
Damage control orthopaedics is the practice of delaying definitive management of fractures and utilizing temporary stabilization (such as an external fixator) until a patient has recovered from the initial physiologic insult of trauma.
Patients are at increased risk for perioperative complications such as ARDS and multi-system organ failure during the acute period after polytrauma. In addition to underresuscitation, other indications to practice damage control orthopaedics include: injury severity score>40 (or >20 with thoracic trauma), bilateral femoral fractures, hypothermia below 35 degrees Celsius, and pulmonary contusions.
Pape et al. (2007) studied the incidence of acute lung injuries in polytrauma patients undergoing either intramedullary nailing or external fixation and later definitive fixation of femoral shaft fractures. They found that patients undergoing immediate intramedullary nailing were nearly 6.7 times more likely to have acute lung injury
The Canadian Orthopedic Trauma Society studied the effect of reamed versus unreamed femoral nailing on incidence of ARDS for femoral shaft fractures in trauma patients using a randomized controlled study. They found no difference between the groups.
Pape et al. also examined the pathophysiological cascades that accompany soft tissue injuries of the extremities, abdomen, and pelvis and recommend a more comprehensive for evaluation of patients with these injuries.
Incorrect Answers:
OrthoCash 2020
The anterior intrapelvic (modified Stoppa) approach is most appropriate for which of the following fractures?
The anterior intrapelvic (AIP) or modified Stoppa approach provides access to the quadrilateral plate, which is a common location for fracture displacement in associated both column acetabulum fractures as seen in Figure D.
Compared to the traditional ilioinguinal approach, the modified Stoppa with a lateral window can offer comparable access to the quadrilateral plate, which can allow for its use in associated both column fracture patterns.
de Peretti et al. prospectively followed 25 patients with both column fractures
treated via an iliofemoral approach. Results led the authors to not recommend the extensile approach for both column fractures due to lack of efficiency and high complication rates.
Alonso et al. compared the extensile iliofemoral and triradiate approaches, and both reported acceptable results. However, concerning were the relatively high rates of heterotopic ossification, despite prophylaxis.
Bible al. performed a cadaver study to quantify the amount of access provided by the modified Stoppa approach. This approach provides access to approximately 80% of both the inner pelvis, and the quadrilateral plate, however, comparison to the ilioinguinal approach was not performed.
Shazar et al., in a cohort comparison between the ilioguinal and Stoppa approaches, noted better visualization and potential improve fracture reduction via the Stoppa approach for both column fractures. However, this study was limited in its retrospective and relative observer bias.
Figure A depicts a posterior wall fracture dislocation with concomitant femoral neck fracture. Figure B is an iliac oblique view which depicts a posterior column fracture. Figure C exhibits a posterior column + posterior wall fracture. Figure D depicts acetabular fracture with protrusio. Figure E exhibits a posterior wall fracture.
Incorrect answers:
OrthoCash 2020
Figure A is a radiograph of a 75-year-old woman that fell onto her non-dominant shoulder from a standing height. She was treated nonoperatively for 9 months but continues to complain of pain when she elevates her arm. In patients with this type of fracture pattern, what factor has the greatest impact on fracture healing?
Hand dominance
Angulation of fracture
Smoking
Early physical therapy
Diet
This patient has an impacted varus proximal humerus fracture. Smoking has been shown to increase the nonunion risk up to 5.5 times with these fractures.
Impacted varus proximal humerus fractures can be managed effectively with non-operative care. The major factors that influence non-union are age and smoking. Solid bony union can be seen in 93-98% of patients at 1 year, with more than 97% of people returning to pre-injury level of function. The angulation of fracture, hand dominance and physical therapy does not seem to influence bone union or functional outcomes with this fracture pattern.
Court-Brown et al. looked at the outcomes of impacted varus fractures. They determined that the age of the patient was the major factor in overall outcome. They showed that the best results occurred in younger patients, but results deteriorate with advancing age. Physical therapy was not found to
impact outcome.
Hanson et al. showed that impacted varus fractures can be successfully managed with non-operative care. They found that overall fracture displacement had a minor impact of fracture healing and functional outcome. The predicted risk of delayed union and nonunion was 7% with patients that smoke. This was 5.5 times greater than non-smokers.
Figure A shows an AP radiograph of a varus angulated proximal humerus fracture. This radiograph shows delayed atrophic union.
Incorrect Answers:
OrthoCash 2020
A 26-year-old male epileptic patients presents with right shoulder pain and deformity after a grand mal seizure. After medical stabilization, he denies previous injury to his shoulder. Pre-reduction and post-reduction radiographs of the shoulder are shown in Figures A-C, respectively; physical examination reveals a normal upper extremity neurovascular examination. After shoulder immobilization, what would be the next most appropriate step in management of this patient?
Abduction brace for three weeks, followed by therapy
Right shoulder MR arthrogram
Open reduction and internal fixation
Hemiarthroplasty
Early range of motion
Corrent answer: 3
This patient has presented with a fracture dislocation of the right shoulder. After urgent closed reduction, this patient requires open reduction internal fixation of the proximal humerus, and greater tuberosity fracture fragment in particular.
Isolated greater tuberosity fractures may be associated with shoulder dislocations. Careful review of imaging is critical to identify fracture lines that may extend into the humeral neck and head. If these extensions go undetected, catastrophic propagating fractures may occur during closed reduction maneuvers. Treatment is usually with open reduction internal fixation (ORIF). Young patients with proximal humerus fractures should be treated more aggressively with ORIF as compared to elderly patients. Another example would be a severely impacted valgus proximal humeral fracture in a young patient.
Erasmo et al. examined of 82 cases of humerus fracture dislocations treated with the lateral locking plates. Overall outcomes were excellent to good based on standard scoring systems. Complications included avascular necrosis (12%), varus positioning of the head (4.8%), impingement syndrome (3.6%), secondary screw perforation (3.6%), non-union (2.4%) and infection (1.2%).
Robinson et al. looked at severely impacted valgus proximal humeral fractures treated with open reduction internal fixation in young patients. Anatomic reduction is required with lateral plating to re-establish the normal head/neck angle. Good to excellent results can be achieved with fixation methods.
Figure A shows an anterior fracture-dislocation of the right shoulder. Figure B and C show post-reduction radiographs with a congruent glenohumeral joint. Displacement of the greater tuberosity (GT) fragment is greater than 5mm.
Incorrect Answers:
OrthoCash 2020
Pelvic packing can be performed to temporarily treat a hemodynamically unstable patient with a pelvic ring fracture. Which of the following is the preferred location of the skin incision to perform pelvic packing?
Right anterior superior iliac spine (ASIS) to mid-symphysis, left lateral window incision
Left ASIS to mid-symphysis, right lateral window incision
Subumbilical incision
ASIS to ASIS bilaterally
Pararectus incision
The preferred skin incision location is a subumbilical incision, 6-8cm extending upwards from the pubic symphysis towards the umbilicus; this allows access to all of the appropriate areas for pelvic packing.
Following skin incision, the rectus fascia is then divided in the midline which allows for access to both sides of the bladder for packing deep in the pelvic
brim. On each side, 3 lap pads are placed from sacroiliac joint to the retropubic space, all placed below the level of the pelvic brim.
Hak et al. review the options for emergent treatment in life threatening hemorrhage secondary to pelvic fractures. The authors offer several options for emergent treatment, which includes the use of pelvic binders, the placement of external fixators, pelvic packing and interventional angiography. Goals include reduction of pelvic volume and stopping rapid hemorrhage to save a patient's life. Pelvic packing, properly performed, is done through a subumbilical incision, as described above.
Osborn et al. retrospectively reviewed and compared emergent pelvic packing to angiography in hemorrhagic pelvic fracture clinical scenarios. The authors noted comparable results in mortality with a noted decrease in need for post-procedure transfusions in the pelvic packing group.
Cothren et al. reported their outcomes following an institutional algorithmic change from pelvic ex-fix/angiography to pelvic packing and ex-fix. Since their institutional change, the authors noted a significant decrease in transfusions, need for angiography and mortality.
Incorrect answers:
OrthoCash 2020
A 28-year-old man is brought by ambulance to the emergency department after falling from the roof of his home four hours ago. Upon initial evaluation, he has visible deformities of his bilateral lower extremities and a positive FAST exam. Heart rate is 135, blood pressure 85/58, and urine output is 40 cc over 3 hours. According to ATLS guidelines, what percentage of his blood volume has this patient likely lost?

Question 69:

Options:

No change in paresthesias and grip strength
Increase in grip strength and decrease in paresthesias
Decrease in grip strength and increase in paresthesias
Increase in grip strength and paresthesias

Correct Answer: Increase in grip strength and decrease in paresthesias

Explanation:

Question 70:

The newborn foot deformity seen in Figures 64a and 64b should initially treated with Review Topic

Options:

observation with possible stretching.
serial casting.
medial surgical release.
posterior medial surgical release.
dynamic ankle-foot orthosis.

Correct Answer: observation with possible stretching.

Explanation:

Question 71:

Options:

Cross-pinning of the radius and ulna
Open reduction and internal fixation (ORIF) of the radial head and neck fracture
Metallic radial head implant arthroplasty
Radial head excision his scenario describes a forearm-axial instability pattern, which must be recognized before pursuing treatment. Fracture or dislocation of the lateral elbow compartment (radial head/capitellum) associated with ipsilateral distal radioulnar joint derangement is a form of radioulnar dissociation commonly known as Essex-Lopresti fracture dislocation. Radial head excision sets off a chain of events, and delayed diagnosis can result in considerable morbidity following these injuries. Excision of the radial head allows proximal migration of the radius, causing potential problems at both the elbow and wrist. After such proximal migration has occurred, there is no reliable method of forearm reconstruction. There are a number of treatments for this condition. Salvage of the radial head by open reduction and internal fixation is preferable if possible. However, in cases of marked comminution, radial metallic head implant arthroplasty is an acceptable substitute. The need for soft-tissue repair or pin stabilization of the distal radioulnar joint has not been defined, although some form of forearm immobilization is necessary to allow healing of the injured interosseous membrane.

Correct Answer: Radial head excision his scenario describes a forearm-axial instability pattern, which must be recognized before pursuing treatment. Fracture or dislocation of the lateral elbow compartment (radial head/capitellum) associated with ipsilateral distal radioulnar joint derangement is a form of radioulnar dissociation commonly known as Essex-Lopresti fracture dislocation. Radial head excision sets off a chain of events, and delayed diagnosis can result in considerable morbidity following these injuries. Excision of the radial head allows proximal migration of the radius, causing potential problems at both the elbow and wrist. After such proximal migration has occurred, there is no reliable method of forearm reconstruction. There are a number of treatments for this condition. Salvage of the radial head by open reduction and internal fixation is preferable if possible. However, in cases of marked comminution, radial metallic head implant arthroplasty is an acceptable substitute. The need for soft-tissue repair or pin stabilization of the distal radioulnar joint has not been defined, although some form of forearm immobilization is necessary to allow healing of the injured interosseous membrane.

Explanation:

Question 72:

Options:

Repeated measures analysis of variance
F test
Power analysis
Analysis of variance
Kruskal-Wallis test

Correct Answer: Power analysis

Explanation:

Question 73:

Options:

rest and repeat examination and radiographs until complete healing occurs.
rest and resumption of play when he is asymptomatic and examination shows restoration of painless range of motion.
arthroscopic in situ drilling.
arthroscopic drilling and internal fixation.
arthroscopy with removal of the loose body, followed by lateral column osteotomy.

Correct Answer: rest and resumption of play when he is asymptomatic and examination shows restoration of painless range of motion.

Explanation:

Question 74:

Options:

Removal of the press-fit implant and cementing of the same femoral stem
Removal of the uncemented femoral component and placement of a revision modular taper-fluted femoral stem
Removal of the implant, placement of a cerclage wire around the femoral neck above the lesser trochanter, and reinsertion of the implant
Final seating of the uncemented femoral component without additional measures

Correct Answer: Removal of the implant, placement of a cerclage wire around the femoral neck above the lesser trochanter, and reinsertion of the implant

Explanation:

Question 75:

Options:

Presence of an acute open fracture and crush injury
History of COPD
History of bleomycin treatment
Presence of a thoracostomy tube
Presence of an insulin pump

Correct Answer: History of COPD

Explanation:

Question 76:

Options:

Rotator cuff tear
inadequate strengthening exercises
Instability
Tuberosity nonunion
Prosthetic loosening

Correct Answer: Tuberosity nonunion

Explanation:

DISCUSSION: The radiographs show nonunion of both the greater and lesser tuberosities. Tuberosity pull-off and nonunion remain among the most common causes of failed humeral head arthroplasty for fracture. Strict attention to securing the tuberosities to each other and to the shaft, and autogenous bone grafting from the excised humeral head will decrease the incidence of pull-off and improve healing rates. Active-assisted range-of-motion and strengthening exercises should be delayed until tuberosity healing is noted radiographically, usually at 6 to 8 weeks postoperatively.
REFERENCES: Hartsock LA, Estes WJ, Murray CA, et al: Shoulder hemiarthroplasty for proximal humeral fractures. Orthop Clin North Am 1998;29:467-475.
Hughes M, Neer CS: Glenohumeral joint replacement and postoperative rehabilitation.
Phys Ther 1975;55:850-858.
Compito CA, Self EB, Bigliani LU: Arthroplasty and acute shoulder trauma. Clin Orthop 1994;307:27-36.

Question 77:

Options:

glucosamine 1,500 mg/day and chondroitin sulfate 800 mg/day.
weight loss through dietary management and low-impact aerobic exercises.
arthroscopic debridement and lavage.
a valgus-directing brace.

Correct Answer: weight loss through dietary management and low-impact aerobic exercises.

Explanation:

Question 78:

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 79:

A healthy, active, independent 74-year-old woman fell and sustained the elbow injury shown in Figures 41a and 41b. Management should consist of

Options:

a sling and early elbow range-of-motion exercises.
a long arm cast for 6 weeks.
open reduction and internal fixation.
total elbow arthroplasty.
elbow arthrodesis.

Correct Answer: total elbow arthroplasty.

Explanation:

Question 80:

Options:

6 weeks.
12 weeks.
3 to 6 months.
9 months.
12 months.

Correct Answer: 12 months.

Explanation:

DISCUSSION: An older patient with calcaneal enthesopathy may take a year or more to recover after tendon debridement and calcaneal ostectomy. Young patients, and those with purely tendon pathology, may recover more quickly.
REFERENCES: McGarvey WC, Palumbo RC, Baxter DE, et al: Insertional Achilles tendinitis: Surgical treatment through a central tendon splitting approach. Foot Ankle Int 2002;23:19-25.
Watson AD, Anderson RB, Davis WH: Comparison of results of retrocalcaneal decompression for retrocalcaneal bursitis and insertional Achilles tendinosis with calcific spur. Foot Ankle Int 2000;21:638-642.

Question 81:

What is the heaviest weight that can be safely applied to the adult cervical spine via Gardner-Wells tong traction?

Options:

40 pounds
50 pounds
75 pounds
100 pounds
Greater than 100 pounds

Correct Answer: Greater than 100 pounds

Explanation:

DISCUSSION: Cotler and associates reported on the use of awake skeletal traction to reduce facet fracture-dislocations in 24 patients. Seventeen patients required more than 50 pounds of traction (the “traditional” limit) to achieve reduction. More than 100 pounds of traction was safely used in one-third of the patients in this study. A cadaver study has supported the safe use of traction with weights in excess of 100 pounds.
REFERENCES: Cotler JM, Herbison GJ, Nasuti JF, et al: Closed reduction of traumatic cervical spine dislocation using traction weights up to 140 pounds. Spine 1993;18:386-390.
Anderson DG, Vacccaro AR, Gavin K: Cervical orthoses and cranioskeletal traction, in Clark CR (ed): The Cervical Spine, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 2005,
pp 110-121.

Question 82:

Options:

Physical therapy for range of motion, advancing to strengthening as tolerated
Sling immobilization and a recheck in 1 week with radiographs
CT scan of the shoulder
Open reduction and surgical stabilization with plates and screws
Ice, nonsteroidal anti-inflammatory drugs, and activity as tolerated

Correct Answer: Sling immobilization and a recheck in 1 week with radiographs

Explanation:

Question 83:

5cm. Recent radiographs are seen in Figures A and B. What is the most appropriate treatment plan?

Options:

Nail dynamization
Hardware removal, correction of alignment with a Taylor spatial frame, insertion of bone autograft
Exchange unreamed nailing with a longer, larger implant
Augmentative plate fixation without nail removal, insertion of bone autograft
Hardware removal, correction of alignment, plate fixation, insertion of bone autograft

Correct Answer: Nail dynamization

Explanation:

This patient has atrophic non-union (NU) and varus collapse following cephalomedullary nailing of a subtrochanteric fracture. The ideal treatment involves nail removal, correction of alignment, fracture fixation, and bone grafting. Fixation can be achieved with a nail or plate.
Subtrochanteric fractures can be treated with cephalomedullary nailing or fixed angle plates. Nailing of these fractures is technically challenging because the fracture must be reduced prior to nail passage. Failure to do so leads to varus and procurvatum malreduction.
Bellabarba et al. reviewed plating of femoral nonunions after intramedullary nailing. Of 23 nonunions, 21 healed at an average of 12 weeks. The remaining 2 cases required repeat plating (at 2 and 8 weeks) for hardware breakage because of noncompliance with weightbearing restrictions. They advocate plating because it allows for correction of malalignment and provides a biomechanically superior tension band construct.
Incorrect Answers:
OrthoCash 2020
A 38-year-old male was struck by a truck and sustained the injury seen in figure A. Treating this injury with an intramedullary nail with a larger radius of curvature can lead to what complication?
Posterior perforation of the distal femur
Varus malreduction
Comminution of the fracture site
Iatrogenic femoral neck fracture
Anterior perforation of the distal femur
Corrent answer: 5
According to the study by Egol et al, the average femoral anterior radius of curvature was 120 cm (+/- 36 cm), and currently available femoral nails have a greater radius of curvature (i.e. more straight). This mismatch has been shown to lead to an increased risk of perforation of the anterior distal femur as the nail is impacted into the canal.
The referenced study by Tencer et al noted an increased risk of iatrogenic femoral fracture with anterior starting point >6mm from the anatomic axis.
They recommend starting in line with the femoral axis, or just a few millimeters anterior in order to minimize this risk.
Illustration A depicts anterior femoral cortex penetration secondary to nail/femur radius of curvature mismatch.
OrthoCash 2020
A 60-year-old woman is undergoing closed reduction and percutaneous pinning of a proximal humerus fracture. What structure is at greatest risk for injury from the pin marked by the red arrow in Figure A?
Anterior branch of the axillary nerve
Posterior humeral circumflex artery
Long head of the biceps tendon
Cephalic vein
Musculocutaneous nerve
Certain anatomic structures are at risk with percutaneous pinning of proximal humerus fractures. The red arrow in Figure A marks a proximal lateral pin that would place the anterior branch of the axillary nerve at risk.
Rowles and McGrory performed an anatomic study of the structures at risk with closed reduction and percuatneous pinning of the proximal humerus and found that proximal lateral pins were a mean of 3mm from the anterior branch of the axillary nerve. Pins placed through the anterior cortex and directed into the humeral head fragment were a mean of 2mm from the long head of the biceps tendon and greater tuberosity pins were found to be 8mm from the posterior humeral circumflex and 10mm from the main trunk of the axillary nerve as they penetrated the medial cortex of the humerus.
Jaberg et al retrospectively reviewed the clinical and radiographic results of 48 patients at an average of 3 years after undergoing closed reduction and percutaneous pinning of a proximal humerus fracture. 70% good to excellent results with their described technique, and the authors caution that radiographic malunion did not correlate with patient function.
Incorrect Answers
OrthoCash 2020
A 42-year-old female sustains the injury seen in the computed tomography images seen in Figures A and B. According to the Letournel classification, what is the injury pattern shown?
Posterior wall
Transverse
Anterior wall
Posterior column
Both column
The axial CT cut and Judet radiographic view shown reveals a transverse fracture pattern according to the Letournel classification system. This can be determined by the fact that the articular surface of the acetabulum is attached to the intact portion of the ilium, which is connected to the axial skeleton posteriorly through the sacroiliac joint. This differs from a both-column fracture, in which the articular surface of the acetabulum has no attachments to the axial skeleton due to fracture line(s). The axial CT scan also shows a vertical fracture line which is typical of a transverse fracture pattern.
Durkee et al review the classification schemes for these injuries, as well as comment on the importance of quality images (Judet views, CT, etc).
Figures A and B show a transverse acetabular fracture with mild displacement.
OrthoCash 2020
Which of the following is true regarding plating of humeral shaft fractures compared to intramedullary nailing?
worse functional results
higher need for subsequent surgeries
higher incidence of radial nerve injury
lower complication rates
decreased nonunion rates
Corrent answer: 4
Controversy exists regarding nailing compared with plating of humeral shaft fractures, but the most recent and highest level evidence indicates decreased complication rates with open reduction and internal fixation of these injuries.
Lin et al found less blood loss with intramedullary nailing than plating, but nailing was also associated with increased shoulder surgery, likely due to disruption of the rotator cuff tendon during insertion.
Meekers et al found a higher union rate, better functional results and a lower reoperation rate after plate and screw fixation versus nailing. They concluded that plating was superior in most cases of humeral shaft fracture, however more recent studies have challenged these findings.
Heineman et al. (2012) have recently conducted an update on their meta-analysis to include more recent randomized studies. With the inclusion of newer studies the author found a statistically significant increase in total complication rate with the use of IM nailing compared with ORIF. The authors found no significant difference between the two treatment modalities for the secondary outcomes (nonunion, infection, nerve palsy, re-operation)
Incorrect Answers:
OrthoCash 2020
A 35-year-old male sustains the fracture seen in Figures A and B. Which of the following substances has been shown to result in the least radiographic subsidence when combined with open reduction and internal fixation?
Cancellous allograft bone chips
Autograft iliac crest
Femoral intramedullary reamings
Calcium phosphate cement
Calcium sulfate cement
Corrent answer: 4
Figures A and B show a plateau fracture with a lateral split and depression of the articular surface. In treating tibial plateau fractures, calcium phosphate has been shown to have the least amount of articular subsidence on follow-up examinations due to its high compressive strength.
The study by Lobenhoffer et al noted improved radiographic outcomes and earlier weightbearing with usage of calcium phosphate cement. Welch and Zhang reproduced tibial plateau fractures in goats and compared cancellous autograft to calcium phosphate cement augmentation. At 24 hours, four of five specimens treated with autograft had subsidence of the fragment. Only two specimens from limbs treated with cement showed minimal subsidence; the remaining were congruent.
Yetkinler’s study compared cement to no cement treatment in a model of depressed plateau fractures. Calcium phosphate cement of high compressive
strength provided equivalent or better stability than conventional open reduction
and internal fixation with either auto/allograft bone which had both a lower compressive strength and reduced mechanical stability.
OrthoCash 2020
The modified Judet approach to the posterior scapula exploits the internervous interval between what two muscles?
Supraspinatus and infraspinatus
Supraspinatus and subscapularis
Infraspinatus and teres minor
Teres minor and teres major
Teres major and lattisimus
Corrent answer: 3
The posterior or modified Judet approach to the scapula is typically used for internal fixation of scapular fractures. This approach utilizes a transverse incision over the scapular spine with detachment of the posterior deltoid. The interval between the infraspinatus (suprascapular n.) and teres minor (axillary n.) is identified and used to gain access to the posterior aspect of the scapula and glenoid.
The reference by Obremskey et al argues the approach "combines several important goals including: 1) exposure of all bony elements of the scapula which have adequate bone stock for internal fixation; 2) minimal trauma to the rotator cuff musculature; and 3) protection of the major neurologic structures (suprascapular nerve superiorly and axillary nerve laterally)." They believe "the main advantage of the exposure is limiting muscular dissection, which can potentially improve rehabilitation and limit morbidity of the operation."
OrthoCash 2020
An 82-year-old female sustains an intertrochanteric hip fracture and is treated with a sliding hip screw. What is the most appropriate definitive step in treating the failure seen in figure A?
Non-weight bearing
Valgus proximal femoral osteotomy
Total hip arthroplasty
Revision open reduction and internal fixation
Proximal femoral resection
Corrent answer: 3
Figure A shows superior cutout of the lag screw from the sliding hip screw as well as the superior cannulated screw used for an "antirotation" device.
In the referenced review article by Haidukewych and Berry, salvage of failed treatment of hip fractures in the elderly is limited by bone quality and comorbidities. They recommend total hip arthroplasty in this instance to restore function, decrease pain, and limit periods of immobilization. They mention that the major challenges for arthroplasty are: assessing the need for acetabular resurfacing, selecting the femoral implant, and managing the greater trochanter.
OrthoCash 2020
A 13-year-old boy falls out of a tree and sustains the injury seen in Figures A and B. He is taken to the OR for fixation of his fracture.
The next morning, the patient’s blood pressure is 185/105 mm Hg and pulse rate is 130. He complains of pain that is not improved with opiates. On physical exam, the foot is firm. The decision is made to obtain compartment pressures to rule out compartment syndrome of the foot. Which of the following paths in Figure C marks the
appropriate location to measure the central compartment, and what would be considered abnormal values?
Path A, absolute value of 30-45 mmHg or delta p > 30mmHg
Path B, absolute value of 30-45 mmHg or delta p > 30mmHg
Path B, absolute value of 30-45 mmHg or delta p < 30mmHg
Path C, absolute value of 30-45 mmHg or delta p > 30mmHg
Path C, absolute value of 30-45 mmHg or delta p < 30mmHg
Corrent answer: 3
The correct approach to measure pressures in the central compartment of the foot is by directing the needle lateral and plantar through the abductor hallicus, just under the base of the first metatarsal. Abnormal values indicating the need for decompression are an absolute value of 30-45 mmHg or a Δp < 30mmHg (the difference between the patient's diastolic blood pressure and compartment pressures).
The most common symptom of compartment syndrome in the extremities is intense pain. However, compartment syndrome can be difficult to diagnose in children and patients who are comatose, nonverbal, and/or mentally compromised because they may not be able to properly express their level of pain. Additionally, in compartment syndrome of the foot, pain on passive extension of the toes may or may not be present, and swelling and absence of the dorsalis pedis pulse may be expected findings with extensive trauma to the foot, making the clinical diagnosis even more difficult. Thus, for patients with equivocal findings on physical exam, foot compartment pressures should be measured in order to confirm the diagnosis. There are 8 compartments in the foot: lateral, medial, central, and 4 interosseous. The lateral compartment
contains the abductor digiti minimi and flexor digiti minimi brevis, and is measured by directing the needle 1cm medial and plantar under the midshaft of the 5th metatarsal. The medial compartment contains the abductor hallicus and flexor hallicus brevis, and is measured by directing the needle lateral and plantar under the base of the first metatarsal. The central compartment contains the oblique head of the adductor hallucis, and is measured through the same approach as the medial compartment after advancing the needle more deeply. The 4 interosseous compartments entail the 2nd, 3rd, and 4th web spaces, and can be measured by directing the needle plantar into each respective dorsal webspace.
Ojika et al. performed a systematic review on foot compartment syndrome. They found that the most common cause of foot compartment syndrome was crush injury to the foot, and that diagnosis was mostly made through a combination of clinical findings and compartment pressure measurements.
Badhe et al. reported 4 cases where competent sensate patients developed compartment syndromes without any significant pain. They found that pain is not a reliable clinical indicator for underlying compartment syndrome, so in a competent sensate patient, the absence of pain does not exclude compartment syndrome. They concluded that a high index of clinical suspicion must prevail in association with either continuous compartment pressure monitoring or frequent repeated documented clinical examination with a low threshold for pressure measurement.
Flynn et al. looked at the diagnosis and outcome of acute traumatic compartment syndrome of the leg in children. They found that a delay in diagnosis may occur because acute traumatic compartment syndrome manifests itself more slowly in children or because the diagnosis is harder to establish in this age group. They state that the results of the present study should raise awareness of late presentation and the importance of vigilance for developing compartment syndrome in the early days after injury.
Figures A and B are lateral and Harris radiographs of the foot demonstrating a calcaneus fracture. Figure C is a cross-sectional image of the foot. Illustration A is an image depicting the compartments of the foot.
Incorrect Answers:
compartment. Additionally, a Δp < 30mmHg (not > 30mmHg) is considered abnormal.
OrthoCash 2020
A 35-year-old female presents to the emergency room after a motor vehicle collision where her leg was pinned under the car for over 30 minutes. A clinical photo and radiographs are shown. Which of the following is the most accurate way to diagnose compartment syndrome?
surgeon's palpation of the leg compartments
paresthesias in her foot
diastolic blood pressure minus intra-compartmental pressure is less than 30 mmHg
diastolic blood pressure minus intra-compartmental pressure is greater than 30 mmHg
intra-compartmental pressure measurement of 25 mmHg
Corrent answer: 3
The clinical picture is consistent with compartment syndrome. The most accurate way to make the diagnosis is to measure the difference between the diastolic blood pressure and intracompartmental pressure (delta p).
In a prospective study of 116 patients with tibial diaphyseal fractures, McQueen et al found that the use of a differential pressure of 30 mmHg as a threshold for fasciotomy led to no missed cases of acute compartment syndrome. They recommended that a fasciotomy should be performed if the differential pressure level drops to under 30 mmHg.
The cited study by Kakar et al found the intraoperative DBP is significantly lower than the preoperative DBP in patient undergoing IM nailing for tibia shaft
fractures. Therefore, they emphasize that the surgeon should recognize that intraoperative DeltaP may be lower than DeltaP once the patient is awakened in deciding whether to perform a fasciotomy versus awaken the patient and perform serial examinations and or compartment pressure measurements.
An absolute intra-compartmental value greater than 30 to 45mmHg can also be used to make the diagnosis of compartment syndrome, but is more controversial than the delta p according to Kakar and Amendola.
OrthoCash 2020
What is the most common mode of failure of the lateral ulnar collateral ligament associated with an elbow dislocation?
ligament avulsion off the humeral origin
ligament avulsion off the ulnar insertion
midsubstance rupture
bony avulsion of the humeral origin
combined proximal and distal ligament avulsions
Corrent answer: 1
The lateral ulnar collateral ligament (LUCL) is often injured with elbow dislocations, and is most commonly injured at the proximal origin.
McKee noted that in 62 consecutive operative elbow dislocations and fracture/dislocations, the LUCL was ruptured in all of the patients, proximally in 32, bony avulsion proximally in 5, midsubstance rupture in 18, ulnar detachment in 3, ulnar bony avulsion in only 1, and combined patterns in 3.
Pugh et al established a standard protocol to treat elbow fracture dislocations (terrible triad) which includes coronoid repair, radial head repair/replacement, LUCL repair, and MCL and/or external fixation as needed.
OrthoCash 2020
A 24-year-old male sustains the injury seen in Figure A after being thrown from a motorcycle at a high speed. Which of the following fixation methods has been shown to be the most stable fixation construct for this injury?
Posterior bridge plating and anterior ring external fixation
Percutaneous iliosacral screw and anterior ring external fixation
Percutaneous iliosacral screw and anterior ring internal fixation
Transiliac screw
Two percutaneous iliosacral screws
Corrent answer: 3
Figure A shows an APC III injury, which is a rotationally and vertically unstable injury, with damage to the anterior ring, pelvic floor, and posterior ligamentous stabilizing structures.
The referenced study by Sagi et al found that biomechanically, a percutaneous iliosacral screw and anterior ring internal fixation was the most stable construct. In addition, he found no biomechanical support for addition of a second iliosacral screw.
OrthoCash 2020
A 33-year-old male patient presents with a comminuted open tibia fracture after involvement in a motor vehicle crash. He has a history of smoking but is otherwise healthy. He is given antibiotics, and taken immediately for irrigation and debridement, followed by an un-reamed stainless steel intramedullary nail. Due to bone loss there is a non-circumferential cortical defect measuring 12 mm at the fracture site. All of the following factors in this patient's history and presentation increase his risk for adverse outcome EXCEPT:
High-energy mechanism of injury
Use of un-reamed nail
Implant material
Fracture gap
History of smoking
Corrent answer: 2
Of the factors listed only the use of an un-reamed intramedullary nail for an open tibia fracture has not been shown to increase the risk of adverse outcome or need for reoperation.
The treatment of open tibia fractures with intramedullary nailing can be complicated by many factors. High energy mechanism of injury, use of a stainless steel nail, residual fracture gap greater than 1 cm, and a history of smoking have all been shown to increase the risk of adverse outcome. The use of reamed and un-reamed nails for open tibia fractures have been studied, and no significant difference in outcome has been found.
Schemitsch et al. present data from a prospective randomized trial of tibia fractures treated with reamed or unreamed intrameduallry nails. They found no difference in risk of adverse outcome between reamed and un-reamed nails in open tibia fractures. They did, however, find an increased risk of adverse outcomes in high-energy mechanisms, use of stainless steel (versus titanium) rods, and a residual fracture gap of greater than 1 cm. They comment that their data did not show a significant increase in risk due to history of smoking, but cite other studies that have demonstrated such a relationship.
Bhandari et al. present data from a prospective randomized study of patients with tibia fractures randomized to reamed or un-reamed tibial nails. For closed fractures they found a lower rate of primary events (most commonly need for dynamization) in the reamed group. However, they found no difference in outcomes for either technique in open fractures.
Incorrect answers:
OrthoCash 2020
Following antegrade intramedullary nailing of a femoral shaft fracture, the complication shown in Figure A occurs. Which of the following errors most likely resulted in this complication?
Applying external rotation torque on the proximal femur after placing proximal interlocking screws
Excessive interfragmentary compression of the fracture site prior to placing proximal interlocking screws
Using too anterior a starting point for a piriformis-entry point nail
Inserting a trochanteric-entry point nail through the piriformis fossa
Inserting a right femoral nail into the left femur
Corrent answer: 3
Using a piriformis nail, a starting point that is too anterior will result in iatrogenic fracture ("bursting") of the proximal femur.
Antegrade nailing achieves fixation via 3-point fixation. In the sagittal plane, because of anterior sagittal bow, this is achieved at distal anterior cortex, middle posterior cortex (apex of curvature) and proximal anterior cortex. In the coronal plane, because of the lateral bow, this is achieved at the lateral distal femur, middle medial femur (apex of curvature), and proximal lateral femur (greater trochanter). Piriformis nails have a single sagittal bow.
Trochanteric nails are bowed in 2 planes, necessitating a twisting motion during insertion to negotiate both bows.
Papadakis et al. performed an experimental study on 18 cadaveric femora. Anterior bursting was found in 56% of nails placed too anteriorly. Bursting was not seen in nails placed through a more posterior entry point. They emphasize the location of the entry point when performing antegrade nailing.
Johnson et al. reviewed the biomechanical factors affecting fracture stability
and femoral bursting. They found that position of the starting hole was most important. Anterior displacement by >6mm led to high hoop stresses and bursting of the anterior cortex. This is important as an eccentrically reamed cortex may be difficult to recover from. They recommend either selecting a smaller diameter nail or overreaming by 1-2mm as a solution.
Figure A shows a fracture split of the proximal femur (left, without magnification; right, close-up). Illustration A shows anterior cortex pressures exceeding 100kPa for too-anterior entry points.
Incorrect Answers:
Wrong-side placement of a trochanteric entry nail would lead to varus malalignment at the fracture site, more so than placing a piriformis nail through the greater trochanter.
OrthoCash 2020
A 30-year-old male sustains a brachial plexus injury as the result of a motor vehicle collision. Palsy of which of the following muscles would not be expected with this injury if the injury was postganglionic in nature?
Rhomboid major
Extensor carpi radialis longus
Biceps brachii
Deltoid
Brachioradialis
A brachial plexus injury would involve all of the upper extremity muscles as well as most of the periscapular muscles. Complete plexus palsies are rare, and are often associated with scapulothoracic dissociation or other high-energy injuries.
Preganglionic injuries often involve the cervical paraspinal musculature as well as a complete plexus injury. EMG evidence of intact signals in the serratus anterior (long thoracic nerve) and rhomboids (dorsal scapular nerve) are suggestive of a postganglionic lesion/injury.
Tubbs et al. reported on the surgical anatomy of the dorsal scapular nerve in a cadaver study. They found that the nerve came off the C5 nerve root in 95%, ran 2.5cm medial to the spinal accessory nerve as it traveled on the anterior border of the trapezius muscle, and was intertwined with the dorsal scapular artery in all specimens.
Balakrishnan et al reported on the comparison of clinical exam and EMG in predicting site of lesions in brachial plexus injuries. The combination of EMG and exam localized the nerve injury in 80%, while the paraspinal EMG was the most sensitive solitary examination method (67%).
Illustration A shows a diagram of the brachial plexus. Incorrect Answers:
5: These muscles are all innervated by nerves that come from the brachial
plexus, and would be affected with a postganglionic injury.
OrthoCash 2020
A 40-year-old male sustains a fall from a height. He sustains the isolated injury shown in the radiograph and CT images seen in Figures A through C. Surgery is planned. Which of the following constructs is the most appropriate definitive fixation for this injury?
Lateral locked plating
Medial bridge plating
Medial buttress plate
Medial lag screw with washers
External fixation
This patient has a medial tibial plateau fracture. Medial buttress plating (MBP) is indicated.
Medial tibial plateau fractures (Schatzker IV, Hohl and Moore II) may represent fracture dislocations of the knee. Neurovascular injuries must be excluded. In these instances, the medial fragment represents the stable fragment, and the rest of the tibia is the fractured fragment, with the entire leg acting as the lever arm.
Berkson et al. reviewed high energy tibial plateau fractures. Medial fractures may be treated with a medial plate or external fixation. Open reduction may be necessary because of fracture line obliquity and propensity of the medial plateau to shorten and rotate in the sagittal plane. Meniscal injuries should be repaired and avulsed cruciates fixed early. Collateral ligaments should be reconstructed after obtaining bone healing and range of motion.
Ratcliff et al. compared the stability of lateral locked plates and medial buttress plates in a cadaver model. They found that the medial buttress plate had greater fixation strength/failure force (4136N) compared with the lateral locking plate (2895N), although maximum cyclic displacement and residual displacement results were not different. They concluded that for vertically
orientated medial tibial plateau fractures, medial buttress plates were more stable.
Figure A is a radiograph showing a medial tibial plateau fracture extending across the tibial eminence. This is also classified as a Hohl and Moore Type II fracture. Figures B and C are coronal and axial CT scan images confirming the medial tibial plateau fracture and excluding a bicondylar fracture. Illustration A shows a medial tibial plateau fracture fixed with a medial buttress plate (cadaveric model with fibula removed). Illustration B shows the Hohl and Moore Type II fracture involving the entire condyle.
Incorrect Answers:
OrthoCash 2020
A 39-year-old female presents with the following motor vehicle crash with the injury seen in Figure A (immobilized in a pelvic binder). The iatrogenic neurologic injury most commonly caused by placement of the anterior construct for this injury, as shown in Figure B, would cause which of the following?
Weakness of hip flexion
Weakness of ankle dorsiflexion
Numbness of the medial thigh
Numbness of the lateral thigh
Numbness of the perineum
Corrent answer: 4
This patient was treated with posterior stabilization, and an anterior subcutaneous internal fixator (ASIF). The most common neurologic injury seen following placement of the ASIF construct is irritation of the lateral femoral cutaneous nerve (LFCN), causing numbness and/or pain of the lateral thigh.
Unstable pelvic fractures can be treated in a multitude of ways. The ASIF construct is typically created by placing long pelvic screws or polyaxial pedicle screws in the supraacetabular region, similar to the supraacetabular pins for an
anterior external fixator. Then a curved bar is placed subcutaneously and connected to the supraacetabular screws. They are typically removed after 3-4 months when fracture healing is complete.
Vaidya et al. present a retrospective review of the use of ASIF as definitive treatment of unstable pelvic fractures. All patients in the study tolerated the construct well. LFCN irritation was seen in 30% of patients, and resolved in all but one patient.
Müller et al. present a retrospective review of the use of posterior stabilization and ASIF. They report an acceptably low complication rate, and good to excellent outcomes in 64.5% of patients.
Figure A is a radiograph demonstrating a right APC3 and left APC2 pelvic injury, imaged in a pelvic binder. Figure B is a postoperative radiograph following posterior stabilization and ASIF.
Incorrect answers:
OrthoCash 2020
What would be the most appropriate surgical indication for transferring fascicles of the ulnar nerve to the motor nerve of the biceps and fascicles of the median nerve to the motor nerve of the brachialis?
C8 - T1 nerve root avulsion 3 months ago
C5 - C6 nerve root avulsion 2 months ago
Upper brachial plexus palsy 22 months ago
Medial and posterior cord injury from gunshot wound 2 months ago
C6 ASIA A spinal cord injury
Corrent answer: 2
Transfer of fascicles from (1) ulnar nerve to the nerve to the biceps and (2) median nerve to the motor nerve of the brachialis would be appropriate in the
treatment of an acute (<3-6 months) upper brachial plexus palsy.
Upper trunk injury (C5, C6) often results from the avulsion of both the C5 and C6 nerve roots. Injuries of this nature usually result from a downward force on the shoulder with lateral bending of the cervical spine in the opposite direction. This results in what is commonly called an Erb-Duchenne palsy. Patients often present with a flail shoulder and loss of elbow flexion. Other common treatments for C5 and C6 root avulsion include neurotization of the musculocutaneous (MSC) nerve by the spinal accessory (SA) or intercostal nerve, and neurotization of the supra-scapular nerve by the SA.
Liverneaux et al. looked at short term results of (1) ulnar nerve fascicle transfer to the nerve to the biceps and (2) fascicle of the median nerve to the motor branch to the brachialis in 15 patients with acute C5 - C6 nerve root avulsion injuries. Grade 4 elbow flexion was restored in each of the 10 patients. There was no secondary deficit in grip strength or sensation.They concluded that this double nerve transfer technique will likely reduce the need for secondary procedures to augment elbow flexion.
Teboul et al. reviewed thirty-two patients with an upper nerve-root brachial plexus injury that underwent ulnar nerve fascicle transfer to the nerve of biceps to restore elbow flexion. After the nerve transfer, twenty-four patients achieved grade 3 elbow flexion strength or better. They note that this procedure will spare the C5 nerve root and other nerves for grafting or transfer elsewhere.
Illustration A shows harvesting of an ulnar nerve fascicle for transfer. Illustration B shows transfer of the fascicle of the ulnar nerve to the motor nerve of the biceps.
Incorrect Answers:
sensory quadriplegia. Nerve transfers using the ulnar nerve (C8-T1) would also be redundant as this nerve would be non-functional in this patient.
OrthoCash 2020
A 31-year-old female presents to the trauma bay following a motorcycle crash. Her blood pressure is 95/70 mmHg, heart rate is 115 bpm. Lactate measured in the trauma bay is 10 mmol/L. She has multiple rib fractures, pulmonary contusions, and a positive FAST exam requiring immediate exploratory laparotomy. After laparotomy her lacate remains unchanged. She has a closed right femur fracture and an open right tibia fracture as seen in Figures A and B. Besides antibiotics and thorough irrigation and debridement, which of the following would be an appropriate step in the immediate management of her fractures?
Reamed intramedullary nailing of the tibia and femur
Un-reamed intramedullary nailing of the tibia, and reamed intramedullary nailing of the femur
Reamed intramedullary nail of the tibia, and un-reamed intramedullary nail
of the femur
Posterior slab splint of the tibia, and 10 lbs skeletal traction of the femur
External fixation of the tibia and femur
Corrent answer: 5
This patient is suffering from multiple injuries and has evidence of chest injury and incomplete resuscitation. The immediate treatment of her fractures should be external fixation for both the tibia and the femur.
For polytraumatized patients with multiple injuries including extremity fractures, damage control orthopaedics dictates that long bone fractures should be temporarily stabilized. Either inadequate stabilization, or early total care, such as a reamed or unreamed nails, can exacerbate the patient's condition and increase the risk of a second-hit phenomenon. For this patient with pulmonary contusions and continued elevation of lactate indicating end-organ hypoperfusion her extremities should have staged treatment according to damage control principles.
Morshed et al. present a retrospective review of polytraumatized patients with femur fractures and compared outcomes based on the time frame in which their fractures were definitively treated. They found delaying treatment at least 12 hours to allow appropriate resuscitation and treatment of other traumatic injuries led to a decrease in mortality of 50%. Patients with intra-abdominal injuries benefited most from staged treatment of the extremities.
Figure A is a radiograph showing a closed right femur fracture. Figure B is a radiograph of an open right tibia fracture.
Incorrect answers:
OrthoCash 2020
A 68-year-old woman undergoes a hemiarthroplasty for a proximal humerus fracture through a deltopectoral approach. What
range of motion exercise should not be utilized in the immediate postoperative period due to concerns about lesser tuberosity fixation?
Pendulums
Passive internal rotation of the shoulder to the plane of the body
Active forearm supination
Passive external rotation of the shoulder past 30 degrees
Passive forward flexin of the shoulder to 90 degrees
Corrent answer: 4
Frankle et al found that passive external rotation of the shoulder placed the most stress on the lesser tuberosity fixation. The subscapularis tendon inserts on the lesser tuberosity and is the deforming force when placed under tension during external rotation. They also found that non-anatomic tuberosity reduction of 4-part proximal humerus fractures treated with hemiarthroplasty increased torque and impaired external rotation kinematics.
OrthoCash 2020
A 72-year-old female sustains a displaced intracapsular femoral neck fracture. Which of the following is TRUE regarding the long term differences between possible treatment options for this injury?
Patients undergoing total hip arthroplasty are more likely to experience persistent pain than those undergoing internal fixation
Patients undergoing total hip arthroplasty are less likely to require reoperation than those undergoing internal fixation
There is no difference in functional outcome scores between internal fixation and total hip arthroplasty
Patients undergoing internal fixation perform activities of daily living better than those undergoing total hip arthroplasty
Mortality rates are higher following total hip arthroplasty than internal fixation
Elderly patients with femoral neck fractures (FNF) undergoing total hip arthroplasty (THA) are less likely to require reoperation than those undergoing internal fixation.
Intracapsular FNF are common in elderly patients after a fall from standing height. Treatment depends on physiological age and displacement (Garden's classification). For displaced fractures, physiologically young patients are treated with internal fixation while physiologically old patients are treated with
either hemiarthroplasty (debilitated, less active patients) or THA (more active patients, those with acetabular disease or preexisting inflammatory arthritis).
Chammout et al. retrospectively compared the long term (17 years) results of THA (cemented both component) and ORIF (2 cannulated screws) in elderly patients (>65 years). They found no difference in mortality. But hip scores were higher and pain was better in the THA group, while reoperation rates were higher in the ORIF group. Walking speed was initially faster in the THA group, but later did not differ between groups. They recommend THA for elderly patients with displaced FNF.
Rogmark et al. prospectively compared closed reduction and internal fixation (CRIF) with arthroplasty (combining hemiarthroplasty and THA) at 2 years in elderly patients (>70 years). Failure rates were higher, pain was worse, and walking was more impaired after CRIF. They recommend arthroplasty for patients >70 with FNF.
Incorrect Answers:
OrthoCash 2020
A polytrauma patient underwent the following procedures: (1) statically locked intramedullary nailing for a right femoral shaft fracture; (2) open reduction with plate-and-screw fixation [ORIF] for a right simple distal fibula fracture; (3) ORIF right middle third radius and ulna fracture; and (4) ORIF left humeral shaft fracture. What is the appropriate weightbearing status for this patient?
Weight bearing as tolerated in all extremities
Early protected weight bearing right lower extremity in walking cast, weight bearing as tolerated left upper extremity, non-weight bearing right forearm
Weight bearing as tolerated in bilateral lower extremities and right upper extremity, non-weight bearing left upper extremity
Non-weight bearing bilateral upper extremities and right lower extremity
Non-weight bearing right upper and lower extremities, weight bearing as tolerated left upper and lower extremities without walking cast
The standard postoperative weightbearing for locked medullary nailing for femoral shaft fractures and humeral shaft fractures is weight bearing as tolerated (WBAT). Simple ORIF ankle fractures may be managed with early protected weight bearing. ORIF right middle third radius and ulna fracture should be managed with a period of non-weight bearing due to risk of secondary displacement of the fracture.
Tingstad et al. examined the effect of immediate weightbearing on plated fractures of the humeral shaft. They reported that immediate weightbearing on humeral shaft fractures, treated with plating and full weightbearing, did not have any negative effect on the union or malunion rates.
Brumback et al. evaluated the feasibility, safety and efficacy of immediate weightbearing after treatment of femoral shaft fractures with statically locked IM nail. Using biomechanical and clinical data, they showed that all fractures united with no loss of fixation or hardware failure.
Starkweather et al. retrospectively assessed the complications and loss of reduction in patients who bore weight in a short leg cast within 15 days after surgical repair of acute unilateral closed ankle fractures. Of the 81 ankle fracture radiographs, 80 (98.8%) showed no displacement in fracture reduction on the final follow-up examination. These results suggest early protected weightbearing may be safe.
Incorrect Answers:
OrthoCash 2020
A 22-year-old female falls off the back of a motorcycle and sustains the injury in Figure A. She is hemodynamically unstable and massive transfusion protocol is activated. What is the correct ratio of transfusion of packed red blood cells, platelets and plasma?

Question 84:

Options:

humeral head arthroplasty.
observation.
arthroscopic capsular release.
grafting of the humeral head defect.
electrical stimulation.

Correct Answer: observation.

Explanation:

DISCUSSION: This rare complication occurs after fracture-dislocation and has been seen after surgical stabilization in the adolescent. In most reported cases, prolonged observation has been shown to result in revascularization.
REFERENCES: Pateder DB, Park HB, Chronopoulos E, et al: Humeral head osteonecrosis after anterior shoulder stabilization in an adolescent: A case report. J Bone Joint Surg Am 2004;86:2290-2293.
Wang P Jr, Koval KJ, Lehman W, et al: Salter-Harris type III fracture-dislocation of the proximal humerus. J Pediatr Orthop B 1997;6:219-222.

Question 85:

- An 8-1/2-month-old male infant who has developmental dysplasia of the hip was treated in a Pavlick harness for 3 months. At follow-up, examination of the hip reveals full flexion and extension and abduction to 80 degrees. Figure 41a shows an AP arthrogram and Figure 41b an arthrographic view in flexion and abduction. Management should now consist of

Options:

application of a hip abduction brace for 22 hours per day
application of a hip spica under anesthesia
discontinuance of all bracing and repeat radiographs in 3 months
open reduction of the hip and application of a spica cast
open reduction, varus osteotomy, and application of a spica cast

Correct Answer: open reduction of the hip and application of a spica cast

Explanation:

Question 86:

Which of the following is considered an advantage of the tibial inlay fixation compared to transtibial tunnel technique when used in posterior cruciate ligament reconstruction? Review Topic

Options:

Less invasive
Superior published clinical results
Decreased surgical time
Elimination of the critical 90-degree turn at the tibial aperture of the tunnel
Improved cosmesis

Correct Answer: Elimination of the critical 90-degree turn at the tibial aperture of the tunnel

Explanation:

Question 87:

Glenohumeral disarticulation often leads to which of the following changes?

Options:

Hiking of the shoulder girdle
Hypertrophy of the amputated shoulder girdle
Improvement in thoracic spinal deformity
Protraction of the shoulder
Winging of the scapula

Correct Answer: Hiking of the shoulder girdle

Explanation:

Question 88:

Options:

Acetabular labrum
Iliopsoas
Loose body
Piriformis
Iliotibial band

Correct Answer: Iliotibial band

Explanation:

Question 89:

Options:

Lateralize the acetabular component, use a low offset femoral component, and make a shorter neck cut
Medialize the acetabular component, use a low offset femoral component, and make a longer neck cut
Lateralize the acetabular component, use a high offset femoral component, and make a shorter neck cut
Medialize the acetabular component, use a high offset femoral component, and make a longer neck cut

Correct Answer: Medialize the acetabular component, use a low offset femoral component, and make a longer neck cut

Explanation:

Question 90:

-The main blood supply to the capital femoral epiphysis in a 10-year-old child is supplied from the

Options:

artery of the ligamentum teres.
epiphyseal branch of the lateral femoral circumflex artery.
posterosuperior and posteroinferior retinacular branches of the lateral femoral circumflex artery.
posterosuperior and posteroinferior retinacular branches of the medial femoral circumflex artery. DISCUSSION-Before the age of 4 years, blood to the femoral head is supplied by the medial and lateral femoral circumflex arteries as well as the artery of the ligamentum teres. After the age of 4, the blood supply through the artery of the ligamentum teres diminishes. The lateral femoral circumflex system regresses,and its flow into the physis and epiphysis diminishes significantly so the medial femoral circumflex artery becomes the predominant blood supply to the metaphysis. The medial femoral circumflex artery provides the principal blood supply to the proximal femur via its posterosuperior and posteroinferior retinacular branches.

Correct Answer: posterosuperior and posteroinferior retinacular branches of the medial femoral circumflex artery. DISCUSSION-Before the age of 4 years, blood to the femoral head is supplied by the medial and lateral femoral circumflex arteries as well as the artery of the ligamentum teres. After the age of 4, the blood supply through the artery of the ligamentum teres diminishes. The lateral femoral circumflex system regresses,and its flow into the physis and epiphysis diminishes significantly so the medial femoral circumflex artery becomes the predominant blood supply to the metaphysis. The medial femoral circumflex artery provides the principal blood supply to the proximal femur via its posterosuperior and posteroinferior retinacular branches.

Question 91:

-Radiographs are shown in Figures 89a through 89c. What is the most likely diagnosis?

Options:

Medial tibial plateau fracture
Chronic medial collateral ligament injury
Anterior cruciate ligament (ACL) rupture
Acute lateral collateral ligament rupture

Correct Answer: Anterior cruciate ligament (ACL) rupture

Question 92:

Figure 17 is the radiograph of a 3-year-old girl who has shoulder pain after a fall. What is the best next step?

Options:

4 to 6 weeks of immobilization
Incisional biopsy followed by curettage and bone grafting
Irrigation and debridement and then antibiotics based on culture findings
Radical excision

Correct Answer: 4 to 6 weeks of immobilization

Explanation:

DISCUSSION
Patients with a pathologic fracture of a unicameral bone cyst or simple bone cyst should first pursue nonsurgical treatment and 4 to 6 weeks of immobilization. Spontaneous healing occurs in fewer than 10% of patients, possibly due to cyst decompression. The most appropriate form of surgical treatment is controversial. Many substances have been injected with variable results. Injection with steroid, bone marrow, demineralized bone matrix, and calcium phosphate/calcium sulfate have been attempted. Curettage and bone grafting and
decompression have been attempted. Indications for treatment are based on cyst size, symptoms, and location. Unicameral bone cysts typically resolve as patients reach skeletal maturity.
CLINICAL SITUATION FOR QUESTIONS 18 THROUGH 23
Figure 18 is the lateral radiograph of the lumbar spine of an 11-year-old boy who has had lower back pain for 2 months. There is no history of injury. He denies radiating pain to his legs, numbness, weakness, and bowel or bladder changes. His usual activities include soccer practices and games 3 to 5 times per week. He has used over-the-counter anti-inflammatory medications, but has had no other treatment.

Question 93:

Options:

Interposed bony fragment
Interposition of the periosteum
Interposition of the anterior tibial tendon
Persistent malrotation of the physis
Fibular plastic deformation and malalignment

Correct Answer: Interposition of the periosteum

Question 94:

Options:

Early exploration and possible repair of the axillary nerve
Urgent electromyography to assess for level of nerve injury
Continued normal postoperative care and observation of the nerve injury
Consultation with the anesthesiologist regarding a complication of the interscalene block
MRI to evaluate for a possible hematoma compressing the neurovascular bundle

Correct Answer: Continued normal postoperative care and observation of the nerve injury

Explanation:

Question 95:

Options:

a mannitol infusion of 0.25 to 1 g/kg.
high-dose IV methylprednisolone, consisting of a 30 mg/kg bolus, followed by 5.4 mg/kg/h for 23 hours.
an immediate CT scan.
an electroencephalogram.
radiographs of the skull.

Correct Answer: an immediate CT scan.

Explanation:

Question 96:

Dorsal intercalated segment instability (DISI) describes which carpal deformity?

Options:

Scaphoid extension
Lunate extension
Lunate flexion
Triquetral flexion The DISI deformity (Figure 1) simply describes dorsal lunate tilt or lunate extension on a lateral radiograph. DISI deformity usually occurs after dissociation between the lunate and the scaphoid (as in a scapholunate ligament tear). The scaphoid has a tendency to flex, and, when the scapholunate ligament is torn, the lunate loses its attachment to the scaphoid and shifts into an extended position. The scaphoid does not extend when the scapholunate ligament is torn. The triquetral bone extends with the lunate, assuming there is an intact lunotriquetral ligament. The midcarpal joint and capitate extend when the lunate flexes. Conversely, when the lunate extends into a DISI deformity, the midcarpal joint tends to compensate with flexion at the capitolunate joint.

Correct Answer: Lunate extension

Explanation:

Question 97:

Primary chondrosarcoma of bone most commonly occurs in which of the following locations?

Options:

Hand
Knee
Shoulder
Spine
Pelvis

Correct Answer: Pelvis

Explanation:

Question 98:

Options:

Aneurysmal bone cyst
Giant cell tumor
Renal cell carcinoma
Osteomyelitis
Brown tumor

Correct Answer: Giant cell tumor

Explanation:

Question 99:

Options:

Calcified transverse scapular ligament
Parsonage-Turner syndrome
Spinoglenoid notch cyst
Quadrilateral space syndrome

Correct Answer: Spinoglenoid notch cyst

Explanation:

Question 100:

An ulnar nerve palsy at the level of the wrist is typically associated with deficits in the palmaris brevis, the hypothenar muscles, and what other groups of muscles?

Options:

Volar interossei, adductor pollicis, and the deep head of the flexor pollicis brevis
Dorsal interossei, adductor pollicis, and the deep head of the flexor pollicis brevis
Dorsal interossei, adductor pollicis, and both heads of the flexor pollicis brevis
All of the interossei and the abductor pollicis brevis
All of the interossei, adductor pollicis, and the deep head of the flexor pollicis brevis

Correct Answer: All of the interossei, adductor pollicis, and the deep head of the flexor pollicis brevis

Explanation:

DISCUSSION: The intrinsic muscles innervated by the ulnar nerve include the palmaris brevis, hypothenar muscles, all of the interossei, adductor pollicis, and the deep head of the flexor pollicis brevis. The superficial head of the flexor pollicis brevis is innervated by the
median nerve.
REFERENCES: Goldfarb CA, Stern PJ: Low ulnar nerve palsy. JASSH 2003;3:14-26.
Omer G: Ulnar nerve palsy, in Green DP, Hotchkiss R, Pederson W (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, Churchill Livingstone, 1999, pp 1526-1541.

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

Orthopedic Surgery Board Exam MCQs: Shoulder, Sports Medicine & Revision Part 177

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 177

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index