OITE & AAOS Orthopedic Board Review MCQs: Part 183

About This Board Review Set

This is Part 183 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.

How to Use the Interactive Quiz

Two distinct learning modes are available:

Study Mode — After selecting an answer, you immediately see whether you are correct or incorrect, together with a full clinical explanation and literature references.
Exam Mode — All feedback is hidden until you click Submit & See Results. A live timer tracks elapsed time. A percentage score and detailed breakdown are displayed upon submission.

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 183

This module focuses heavily on: Arthroplasty, Deformity, Knee, Shoulder, Spine.

Sample Questions from This Set

Sample Question 1: An active, right-handed 71-year-old woman fell on her left shoulder and sustained the injury shown in the radiographs in 52a and 52b and the CT scan in 52c. Management should consist of...

Sample Question 2: A 27-year-old professional soccer player sustained an injury to his cervical spine in a collision with another player. Initially he was diagnosed with a right C6 radiculopathy that resolved with rest, anti-inflammatory medications, and phys...

Sample Question 3: Increasing articular conformity of the tibial polyethylene insert of a fixed-bearing total knee arthroplasty (TKA) prosthesis will have which of the following biomechanical effects?...

Sample Question 4: A 29-year-old man who lifts weights states that he injured his left shoulder while performing a bench press 2 days ago. The following morning he noted ecchymosis and swelling in the left chest wall. Examination reveals ecchymosis and tender...

Sample Question 5: A 62-year-old man has cervical myelopathy with no evidence of cervical radiculopathy. MRI reveals stenosis at C4-5 and C5-6 with severe cord compression. Examination will most likely reveal which of the following findings?...

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

An active, right-handed 71-year-old woman fell on her left shoulder and sustained the injury shown in the radiographs in 52a and 52b and the CT scan in 52c. Management should consist of

Explanation

Prosthetic hemiarthroplasty is the accepted form of treatment for badly displaced fractures and fracture dislocations, including 4-part fractures, head splitting fractures and fractures with impression defects involving more than 45 % of the humeral head. Displacement is classified as >1cm or angulated > 45 degrees. About 15% of all shoulder fx’s are considered displaced.

Question 2

A 27-year-old professional soccer player sustained an injury to his cervical spine in a collision with another player. Initially he was diagnosed with a right C6 radiculopathy that resolved with rest, anti-inflammatory medications, and physical therapy. Following a fall in a game, he noted a recurrence of neck pain without radicular signs or symptoms. Additional nonsurgical management over the past few months has failed to provide relief. A cervical MRI scan shows a right-sided C5-6 herniation without any evidence of disk disease at other cervical levels. The patient desires to continue his career as a professional soccer player. What treatment offers the best long-term option for return to play?

Explanation

DISCUSSION: The patient has chronic neck pain that is affecting his career as a professional soccer player. Although he had signs and symptoms of a right C6 radiculopathy, neck pain is his only current symptom. Therefore, procedures to address the relief of radiculopathy (keyhole foraminotomy and transforaminal epidural steroid injection) are likely to be ineffective. Although Watkins and others have described continuing nonsurgical management for symptomatic herniated disks and return to play only when asymptomatic, the patient has not found relief with these modalities. A single-level cervical fusion (either postoperative or congenital) generally is not considered a contraindication for return to play in collision or

contact sports. Therefore, anterior cervical fusion at C5-6 offers the best long-term option for return to play.

REFERENCES: Watkins RG: Cervical spine injuries in athletes, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 373-386.
Watkins RG: Neck injuries in football players. Clin Sports Med 1986;5:215-246.
Morganti C, Sweeney CA, Albanese SA, et al: Return to play after cervical spine injury. Spine 2001;26:1131-1136.
Garvey T, Transfeldt EE, Malcolm JR, et al: Outcome of anterior cervical discectomy and fusion as perceived by patients treated for dominant axial-mechanical cervical spine pain. Spine 2002;27:1887-1895.

Question 3

Increasing articular conformity of the tibial polyethylene insert of a fixed-bearing total knee arthroplasty (TKA) prosthesis will have which of the following biomechanical effects?

Explanation

DISCUSSION: Increasing articular conformity increases the surface area for contact between the polyethylene and the femoral component. Advantages of this include lower peak contact stress within the polyethylene and less risk of polyethylene fatigue failure. Patellofemoral tracking is unchanged by increasing conformity unless gross component apposition is present. A potential disadvantage of increasing conformity includes some restriction in tibial rollback. Modest changes in conformity have not been shown to alter the rate of mechanical loosening. If conformity was increased to the extent of significant constraint, a potential increased risk of loosening would be expected, not a decrease. Design of modern TKAs includes a compromise in achieving enough constraint to lower polyethylene stress, without providing so much constraint as to limit kinematics and stress the fixation interfaces.
REFERENCES: D’Lima DD, Chen PC, Colwell CW Jr: Polyethylene contact stresses, articular congruity, and knee alignment. Clin Orthop 2001;392:232-238.
Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000,

pp 265-274.

Question 4

A 29-year-old man who lifts weights states that he injured his left shoulder while performing a bench press 2 days ago. The following morning he noted ecchymosis and swelling in the left chest wall. Examination reveals ecchymosis and tenderness and deformity in the left anterior chest wall and axillary fold that is accentuated with resisted adduction of the arm. Passive range of motion beyond 90 degrees of forward flexion and 45 degrees of external rotation is extremely painful. Glenohumeral stability is difficult to assess because of severe guarding. Figure 29 shows an MRI scan. Management should consist of

Explanation

DISCUSSION: Rupture of the pectoralis major tendon most commonly occurs during bench pressing. Wolfe and associates have shown that the most inferiorly located fibers of the sternal head lengthen disproportionately during the final 30 degrees of humeral extension during the bench press. This creates a mechanical disadvantage in the final portion of the eccentric phase of the lift; with forceful flexion of the shoulder these maximally stretched fibers may rupture. In most patients, particularly in young athletes, the treatment of choice is anatomic repair of the ruptured tendon to its insertion in the proximal humerus either with suture anchors or transosseous sutures. Following surgery, most patients experience a near normal return of strength and significant improvement in the cosmetic appearance of the deformity. While more technically challenging, repair of chronic rupture is possible and is indicated in some patients.
REFERENCES: Wolfe SW, Wickiewicz TL, Cavanaugh JT: Ruptures of the pectoralis major muscle: An anatomic and clinical analysis. Am J Sports Med 1992;20:587-593.
Schepsis AA, Grafe MW, Jones HP, Lemos MJ: Rupture of the pectoralis major muscle: Outcome after repair of acute and chronic injuries. Am J Sports Med 2000;28:9-15.

Question 5

A 62-year-old man has cervical myelopathy with no evidence of cervical radiculopathy. MRI reveals stenosis at C4-5 and C5-6 with severe cord compression. Examination will most likely reveal which of the following findings?

Explanation

DISCUSSION: Cervical myelopathy involves compression of the spinal cord and presents as an upper motor neuron disorder. Patients commonly have extremity spasticity and problems with ambulation and balance. Hoffman’s sign is often present and is elicited by suddenly extending the distal interphalangeal joint of the middle finger; reflexive finger flexion represents a positive finding. The extremities are usually hyperreflexic with myelopathy. With cervical radiculopathy (lower motor neuron disorder), reflexes are hyporeflexic, and patients report pain along a dermatomal distribution. A hyperactive jaw jerk reflex indicates pathology above the foramen magnum or in some cases, systemic disease. Flaccid paraparesis suggests a lower motor neuron problem.
REFERENCES: Sachs BL: Differential diagnosis of neck pain, arm pain and myelopathy, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 741-742.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 673-680.

Question 6

The main arterial supply to the humeral head is provided by which of the following arteries?

Explanation

DISCUSSION: The main arterial supply to the humeral head is provided by the ascending branch of the anterior humeral circumflex artery and its intraosseous continuation, the arcuate artery. There are significant intraosseous anastomoses between the arcuate artery, the posterior humeral circumflex artery through vessels entering the posteromedial aspect of the proximal humerus, the metaphyseal vessels, and the vessels of the greater and lesser tuberosities. Four-part fractures and dissection during exposure affect perfusion of the humeral head.
REFERENCES: Brooks CH, Revell WJ, Heatley FW: Vascularity of the humeral head after proximal humeral fractures: An anatomical cadaver study. J Bone Joint Surg Br 1993;75:132-136.
Gerber C, Schneeberger AG, Vinh TS: The arterial vascularization of the humeral head: An anatomical study. J Bone Joint Surg Am 1990;72:1486-1494.

Question 7

Which of the following best describes the mechanism of action of gentamycin?

Explanation

DISCUSSION: Gentamycin and the aminoglycosides (ie, streptomycin, tobramycin, amikacin, and neomycin) work by binding to the 30s ribosome subunit, leading to the misreading of mRNA. This misreading results in the synthesis of abnormal peptides that accumulate intracellularly and eventually lead to cell death. These antibiotics are bactericidal. Cephalosporins, vancomycin, and penicillins interfere with cell wall synthesis by inhibiting the transpeptidase enzyme. Polymyxin, nystatin, and amphotericin increase cell membrane permeability by disrupting the functional integrity of the cell membrane. The quinolones inhibit the enzyme, DNA gyrase. Lastly, metronidazole forms oxygen radicals that are toxic to anaerobic organisms because they lack the protective enzymes, superoxide dismutase and catalase.
REFERENCE: 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 217-236.

Question 8

Figure 1 is the right hand of a 65-year-old man with a history of hypertension and rheumatoid arthritis. He is taking immunosuppressive disease-modifying antirheumatic drugs (DMARDs) and is seen in the emergency department with rapid progression of erythema from his right thumb to his right arm during the last 12 hours. He is confused, lethargic, and has these vital signs: blood pressure 92/40, respiratory rate 45, temperature 39.7°C, pulse 135, and oxygen saturation 90% on 4 liters of oxygen by face mask. An examination of his right upper extremity reveals black bulla extending from the metacarpophalangeal down to the tip and no capillary refill at the pulp. Immediate treatment should consist of

Explanation

EXPLANATION:
This patient has multiple criteria for necrotizing soft-tissue infection (NSTI, also known as necrotizing fasciitis) including rapidly progressive infection, black bulla, hypotension and hypoxia, and a history of immune compromise. Aggressive emergent debridement including the removal of all necrotic tissue and IV antibiotics can decrease morbidity and mortality. Not all patients will have such obvious NSTI findings. In less clear cases, a scoring system using laboratory values (the Laboratory Risk Indicator for Necrotizing Fasciitis) can help clarify the diagnosis. IV antibiotics are key to treatment as well, but any delay in surgical treatment can increase morbidity and mortality. The black bulla and necrotic-appearing thumb indicate that this infection is not confined to the flexor sheath, therefore irrigation of the tendon sheath alone would be insufficient treatment. Although the thumb is dysvascular, this is because of an infection, and revascularization is not indicated.

Question 9

The most common complication associated with corticosteroid injection for the treatment of interdigital neuroma is

Explanation

DISCUSSION
Interdigital neuromas represent perineural fibrosis of the intermetatarsal nerve most commonly seen in the second and third web spaces. The photographs depict a neuroma in the second web space, which is less common than in the third space. Its hypoechoic appearance is characteristic on ultrasound. PVNS occurs in joints. Lipomas are fatty tumors. A ganglion cyst can occasionally occur adjacent to a nerve, but it has a cystic appearance.
The most popular theory on the etiology of interdigital neuromas is compression neuropathy by the intermetatarsal ligament. The plantar approach for the resection of interdigital neuromas has become more popular, especially for recurrent neuromas. The major advantage is better visualization and access to the neuromas.
Infection and allergic reactions such as hives are rare after steroid injection. CRPS is not known to occur in this setting. Hammertoe formation can occur, especially after multiple steroid injections into an interdigital neuroma.
RECOMMENDED READINGS
Schon LC, Reed MA. Disorder of the nerves. In: Coughlin MJ, Saltzman CL, Anderson RB, eds. Mann's Surgery of the Foot and Ankle. 9th ed. Philadelphia, PA: Elsevier-Saunders; 2014:622-641.
Gauthier G. Thomas Morton's disease: a nerve entrapment syndrome. A new surgical technique. Clin Orthop Relat Res. 1979 Jul-Aug;(142):90-2. PubMed PMID: 498653. View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 96 THROUGH 98
Figure 96 is the anteroposterior projection foot radiograph of a 35-year-old woman who is injured in a high-speed motorcycle collision. Her assessment reveals an isolated injury. Her pulses are palpable and her neuromotor examination is intact. There is tenting of skin with ecchymosis over the second metatarsal. The foot is extremely swollen but not tense. Passive toe range of motion is painless.

Question 10

A 28-year-old man reports an episode of buckling and giving-way of his right knee. Figure 54a and 54b show a radiograph and sagittal MRI scan. What is the most likely diagnosis? Review Topic

Explanation

The radiograph shows patella alta consistent with a rupture of the patellar tendon. The MRI scan confirms disruption of the patellar tendon from the inferior pole of the patella. The cruciate ligaments are not visualized in this image, and would not result in patella alta. Quadriceps tendon rupture would result in patella baja. There is no evidence of meniscal tearing on these images.

Question 11

Figure 61 is the radiograph of a 34-year-old woman who was involved in a rollover motor vehicle accident. On arrival at the trauma center she is hypotensive and tachycardic. An abdominal CT scan reveals a spleen laceration. The patient remains hypotensive despite resuscitation and is taken to surgery for an emergent laparotomy and splenectomy. After surgery her delta base is -9 mmol/L. What is the most appropriate management of her pelvic ring injury? Review Topic

Explanation

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

Question 12

A patient is scheduled to undergo total knee arthroplasty (TKA) following failure of nonsurgical management. History reveals that she underwent a patellectomy as a teenager as the result of a motor vehicle accident. Examination reveals normal ligamentous stability. For the most predictable outcome, which of the following implants should be used?

Explanation

DISCUSSION: Paletta and Laskins performed a retrospective study of the results of TKA with cement in 22 patients who had a previous patellectomy. Nine of the patients had insertion of a posterior cruciate ligament-substituting implant. Thirteen patients had insertion of a posterior cruciate ligament-sparing implant. The 5-year postoperative knee scores were 89 for the posterior cruciate ligament-substituting knee versus 67 for the posterior cruciate

ligament-sparing knee (P < 0.01). The patella functions to increase the lever arm of the extensor mechanism and to position the quadriceps tendon and the patellar ligament roughly parallel to the anterior cruciate ligament and posterior cruciate ligament, respectively. The patellar ligament thereby provides a strong reinforcing structure that functions to prevent excessive anterior translation of the femur during flexion of the knee. The absence of the patella results in the patellar ligament and the quadriceps tendon being relatively in line with one another. After a patellectomy, the resultant quadriceps force is no longer parallel to the posterior cruciate ligament. This results in loss of the reinforcing function of the patellar ligament. The authors believe this loss of reinforcing function may place increased stresses on the posterior cruciate ligament and posterior aspect of the capsule, which may result in stretching of these structures over time. They found a high rate of anteroposterior instability, a high prevalence of recurvatum, and a high rate of loss of full active extension compared with passive extension in the posterior cruciate ligament-sparing group, which supports their theory.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 559-582.
Paletta GA Jr, Laskins RS: Total knee arthroplasty after a previous patellectomy. J Bone Joint Surg Am 1995;77:1708-1712.

Question 13

Figures 45a and 45b show the AP and lateral radiographs of a 15-year old patient who is undergoing surgery to add 3 cm of length to the femur. Based on the radiographic findings, what is the next most appropriate step in management?

Explanation

DISCUSSION: Because the radiographs reveal poor regenerate bone, especially anteriorly and laterally, the first step in management is to slow the distraction rate. If this does not solve the problem, temporary reversal of the distraction, or “accordionization,” can be used to induce a greater healing response. Maintaining the same distraction rate will further impair regenerate formation and delay healing. Bone grafting should be reserved as an option if decreasing the distraction rate or alternating a week of compression with a week of distraction fails to improve the callus formation. Repeat corticotomy is performed in patients with premature consolidation.
REFERENCES: Raney EM: Limb-length discrepancy, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 1519-1526.
Ilizarov GA: Pseudarthroses and defects of long tubular bones, in Transosseous Osteosynthesis: Theoretical and Clinical Aspects of the Regeneration and Growth of Tissue. Berlin, Springer-Verlag, 1992, p 453.

Question 14

Reconstruction of the injured structure is performed. After surgery, the patient initially notes limitation in motion, and later develops recurrent instability of the knee. Which factor most likely contributed to the development of instability?

Explanation

DISCUSSION
The anteromedial bundle originates on the anterior and proximal aspect of the lateral femoral condyle and inserts on the anteromedial aspect of the anterior cruciate ligament (ACL) footprint on the proximal tibia. The posterolateral bundle originates posterior and distal to 63 the anteromedial bundle and inserts on the posterolateral aspect of the tibial footprint. The fibers are parallel when the knee is in an extended position. As the knee moves into flexion,
the fibers of the anteromedial bundle rotate externally with respect to the posterolateral bundle. The anteromedial bundle is tensioned in both flexion and extension. The posteromedial bundle is tensioned in extension, but relaxes as the knee moves into flexion.
The lateral meniscus is more commonly injured with an acute injury to the ACL. The medial meniscus is injured more commonly when the ACL is chronically unstable.
The ACL is an intra-articular and intrasynovial structure. It is innervated by posterior articular branches from the tibial nerve. Innervation of the ACL involves several types of mechanoreceptors (Ruffini, Pacini, Golgi tendon, and free-nerve endings) that may contribute to proprioceptive function of the knee and modulation of quadriceps function.
Injury to the ACL is predominantly associated with instability to anterior translation of the tibia in extension. The ACL plays a secondary role to limit internal rotation of the tibia, and a loss of ACL stability is confirmed by the reduction of the tibia from a position of anterior translation and internal rotation (pivot shift). The radiographs demonstrate anterior placement of the femoral tunnel. The convex shape of the lateral femoral condyle can make it more difficult to visualize the anatomic femoral origin of the ACL. Failure to identify the
anatomic footprint can result in anterior placement of the femoral tunnel. Anterior ACL graft placement can result in its impingement against the posterior cruciate ligament and early limitation of knee flexion. Over time, impingement on the graft may result in stretching of the graft and recurrent knee instability symptoms.
RECOMMENDED READINGS
Duthon VB, Barea C, Abrassart S, Fasel JH, Fritschy D, Ménétrey J. Anatomy of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc. 2006 Mar;14(3):204-13. Epub 2005 Oct 19. Review. PubMed PMID: 16235056. View Abstract at PubMed
Zantop T, Petersen W, Sekiya JK, Musahl V, Fu FH. Anterior cruciate ligament anatomy and function relating to anatomical reconstruction. Knee Surg Sports Traumatol Arthrosc. 2006 Oct;14(10):982-92. Epub 2006 Aug 5. Review. PubMed PMID: 16897068. View Abstract at PubMed

Question 15

Percutaneous placement of a lateral proximal tibial locking plate that extends down to the distal third of the leg is associated with postoperative decreased sensation of which of the following distributions?

Explanation

DISCUSSION: Placement of long lateral tibial plates have been shown to have a risk of iatrogenic injury to the superficial peroneal nerve, which has a sensory distribution to the dorsal foot. This risk is seen especially with percutaneous approaches, such as those used with the LISS plate. The first reference by Deangelis et al found a risk of superficial peroneal injury with percutaneous screw placement of holes 11-13 in the LISS plate. The second referenced article by Roberts et al noted a slightly increased distance to the neurovascular bundle when interlocking tibial nails in a lateral to medial direction (compared to medial to lateral locking) and slightly increased biomechanical strength when locking in a medial to lateral direction. The third referenced article by Wolinsky et al notes a risk of iatrogenic injury to the deep peroneal nerve and anterior tibial artery with an anterolateral approach to the distal tibia, but notes the superficial peroneal nerve is safe with an appropriate exposure.

Question 16

Figure 11 shows the anatomic dissection of the medial side of the knee joint after removal of the superficial fascia. The arrow is pointing to what structure?

Explanation

DISCUSSION: The semitendinosus and gracilis tendons lie beneath the superficial fascia and superficial to the medial collateral ligament. The semitendinosus is located more inferior to the gracilis tendon. The sartorius is more posterior and distal as is the medial collateral ligament. The semimembranosus is posterior.
REFERENCES: Pagnani MJ, Warner JJ, O’Brien SJ, Warren RF: Anatomic considerations in harvesting the semitendinosus and gracilis tendons and a technique of harvest. Am J Sports Med 1993;21:565-571.
Warren LF, Marshall JL: The supporting structures and layers on the medial side of the knee: An anatomical analysis. J Bone Joint Surg Am 1979;61:56-62.

Question 17

A 57-year-old man reports right hip pain that has been progressive for the past several months. The pain is exacerbated by weight-bearing activities and improves somewhat with rest. A radiograph is shown in Figure 10a and a coronal T 1 -weighted MRI scan is shown in Figure 10b. What is the most likely diagnosis?

Explanation

DISCUSSION: These are classic findings of osteonecrosis of the hip. The radiograph reveals the subchondral sclerotic pattern commonly seen in osteonecrosis and is quite extensive in this patient. The MRI scan reveals the typical serpentine-like region of low signal intensity with a central zone where the signal is similar to fat.
REFERENCES: Resnick D (ed): Diagnosis of Bone and Joint Disorders. Philadelphia, PA,

WB Saunders, 2002, pp 3160-3162.
Sugano N: Osteonecrosis, in Fitzgerald R Jr, Kaufer H, Malkani A (eds): Orthopaedics. Philadelphia, PA, Mosby International, 2002, pp 877-887.

Question 18

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

Explanation

DISCUSSION: The rotator cuff interval is located between the supraspinatus and subscapularis and the biceps tendon is deep to the interval. It is a triangular area where the base is the coracoid process and the apex is the transverse humeral ligament at the biceps sulcus. Closure or tightening of this area is often helpful in patients with shoulder instability. Conversely, this area is often contracted in patients with adhesive capsulitis and may need to be released.
REFERENCES: Selecky MT, Tibone JE, Yang BY, et al: Glenohumeral joint translation after arthroscopic thermal capsuloplasty of the rotator interval. J Shoulder Elbow Surg 2003;12:139-143.
Harryman DT, Sidles JA, Harris SL, et al: The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992;74:53-66.

Question 19

A 9-year-old girl, who is an avid soccer player, has intermittent spontaneous snapping in her left knee that has worsened. There is no reported trauma or prior surgeries to her knee. Despite working with her trainer, she has developed anterior-based knee pain and lacks full extension. Her knee skin is unremarkable, but there is fullness to palpation on the lateral aspect of her knee. Her range of motion demonstrates a lack of 15° of terminal extension and ligamentous examination is unremarkable. Considering possible surgical treatments for this patient, what is the most appropriate surgical treatment?

Explanation

Surgical intervention of discoid meniscus is based on symptomatic patients. Complete discoid menisci are typically stable but are expected to have >4.5 times incidence of surgical intervention. Saucerization of symptomatic discoid meniscus is associated with better results with younger patients with increases of poor outcomes in adult-aged patients. Meniscal transplant may be an option, although long-term results are unknown.

Question 20

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

Explanation

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

Question 21

A 4-year-old boy with arthrogryposis has little active motion of his knees or elbows. Both elbows are in full extension with good triceps strength, but he is unable to bring his hand to his face or feed himself. Management should consist of

Explanation

DISCUSSION: Elbow release and triceps transfer to restore motion can be performed in children who are age 4 years and older. The ability to flex the elbow either actively or passively is of great assistance in activities of daily living.
REFERENCES: Van Heest A, Waters PM, Simmons BP: Surgical treatment of arthrogrypsosis of the elbow. J Hand Surg Am 1998;23:1063-1070.
Caroll RE, Hill NA: Triceps transfer to restore elbow flexion: A study of fifteen patients with paralytic lesions and arthrogryposis. J Bone Joint Surg Am 1970;52:239-244.

Question 22

Which of the following is considered a risk factor for the development of low back pain?

Explanation

DISCUSSION: Risk factors associated with low back pain include poor physical fitness, smoking, a history of repetitive bending or stooping on the job, or whole body vibration exposure. Some radiographic factors such as stenosis, spondyloarthropathy, severe deformity, or instability are also associated with low back pain. Gender, weight, transitional anatomy, or facet trophism are not associated with low back pain.
REFERENCE: Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 627-643.

Question 23

Excision of heterotopic bone about the forearm or elbow can be done with limited recurrence rates as early as which of the following after initial injury?

Explanation

DISCUSSION: Excision of heterotopic bone about the elbow and forearm was classically treated once the bone was mature and no further bone development was occuring (bone scan became negative). However, several studies have shown that earlier removal before this point in time is safe, when done in conjunction with radiation therapy (XRT).
The referenced study by McAuliffe et al is a retrospective review of heterotopic ossification (HO) about the elbow followed by 100 cGY (5 fractions over 1 week) of XRT as early as 3 months post-injury. They were able to achieve an average arc of motion > 100 degrees.
The other referenced study by Beingessner et al is a review of HO excision of the forearm. They found that excision and XRT, followed by 6 weeks of indomethacin, led to an increase of forearm motion from an average of 17 degrees to 136 degrees when the excision was done at 4 months post-injury.

Question 24

CLINICAL SITUATION Figure 1 is the radiograph taken 6 weeks ago of a 41-year-old woman with persistent pain in her right leg after sustaining a tibia fracture 12 months ago in a motor vehicle collision. On examination, she has well-healed scars and a well-healed flap on the medial aspect at the level of the fracture. She reports having an infection after the initial surgery, which resulted in debridement of the soft tissue and need for the local rotational flap. There are no changes at the fracture site as shown in the most recent radiograph (Figure 2). She is healthy and has no comorbidities. What is the best next step in the patient’s evaluation?

Explanation

Discussion: The patient had an open fracture that was initially treated with what appears to be appropriate irrigation and debridement and intramedullary nail placement. The post-operative infection and need for rotational flap is worrisome,
but she has not had any issues since the flap. She has abundant callus formation but the fracture line is still visible and unchanged on 2 sets of radiographs. The patient has persistent pain. The best initial evaluation is to ensure that there is no underlying infection with laboratory studies, including a complete blood count (CBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Nuclear medicine studies have questionable utility, but may be helpful if the inflammatory markers from laboratory studies come back elevated. A CT scan is not warranted because the sequential radiographs show persistent fracture lines and no changes. The patient has a hypertrophic nonunion. Originally, she had appropriate treatment and has shown the ability to make callus, thus her biologic capacity appears to be intact and bone grafting is not needed. The hypertrophic nature of her fracture nonunion indicates that she needs more stability. The best treatment for a hypertrophic nonunion of the tibia is exchange nailing. Based on successive radiographs and the lack of healing, observation is probably just delaying the inevitable. Plating with retention of the nail can be useful in recalcitrant long bone non-union, especially in the femur.

Question 25

A 65-year-old man has a painful mass of the middle finger. A clinical photograph, lateral radiograph, coronal MRI scan, and biopsy specimen are seen in Figures 20a through 20d. What is the most likely diagnosis?

Explanation

DISCUSSION: Although the degeneration of an isolated benign cartilaginous lesion into a chondrosarcoma is rare, it occurs in roughly 10% of patients with Ollier’s disease. Pain is the most common symptom of chondrosarcoma. The treatment of low-grade chondrosarcoma ranges from intralesional excision to wide amputation. The intent of the surgery is to remove all the disease to decrease the chance of local recurrence.
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.
Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 181-193.

Question 26

A 35-year-old man who is an avid weight lifter competing in local tournaments reports new onset pain and loss of motion in his dominant right shoulder. Examination reveals joint line tenderness, active elevation to 100 degrees, and external rotation to 10 degrees. His contralateral shoulder reveals 170 degrees forward elevation and 50 degrees external rotation. Radiographs are shown in Figures 46a and 46b. What is the next most appropriate step in management?

Explanation

DISCUSSION: New onset pain and stiffness in the young arthritic shoulder is a difficult problem to treat. Initial management should be aimed at reducing pain and improving motion in all planes. This patient’s activities and age preclude a shoulder arthroplasty at this time. If nonsurgical management fails to provide relief, then arthroscopic debridement and capsular release may be beneficial.
REFERENCES: Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 257-266.
Skedros JG, O’Rourke PJ, Zimmerman JM, et al: Alternatives to replacement arthroplasty for glenohumeral arthritis, in Iannotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 485-499.

Question 27

A patient who has had neck pain radiating down the arm for the past 4 weeks reports that the pain was excruciating during the first week. Management consisting of anti-inflammatory drugs and physical therapy has decreased the neck and arm symptoms from 10/10 to 3/10. He remains neurologically intact. MRI and CT scans are shown in Figures 5a and 5b. The best course of action should be

Explanation

DISCUSSION: Although the patient has a large herniated nucleus pulposus, the pain has decreased from 10/10 to 3/10 over a 4-week period and the patient is now free of any neurologic symptoms. It is quite likely that further nonsurgical management will continue to resolve his symptoms. In the absence of any neurologic deficits, there is no evidence that the patient is at significant risk for paralysis.
REFERENCES: Saal JS, Saal JA, Yurth EF: Nonoperative management of herniated cervical intervertebral disc with radiculopathy. Spine 1996;21:1877-1883.
Komori H, Shinomiya K, Nakai O, Yamaura I, Takeda S, Furuya K: The natural history of herniated nucleus pulposus with radiculopathy. Spine 1996;21:225-229.

Question 28

A 25-year-old man has had an insidious onset of left hip pain over the past 11 months. A radiograph, coronal MRI scan, and histopathologic specimens are seen in Figures 2a through 2d. What is the most likely diagnosis?

Explanation

DISCUSSION: Ewing’s sarcoma is the second most common primary sarcoma of bone in children and young adults. It is a malignant round cell tumor with uncertain histogenesis. Sheets of uniform small round blue cells with a high nuclear-to-cytoplasm ratio and the absence of osteoid formation differentiate this histologic diagnosis from the other conditions. Immunohistochemical staining and molecular diagnostic studies are useful to verify the diagnosis.
REFERENCE: Sucato DJ, Rougraff B, McGrath BE, et al: Ewing’s sarcoma of the pelvis: Long-term survival and functional outcome. Clin Orthop 2000;373:193-201.

Question 29

What normal tissue has a low signal intensity (appears black) on both T1- and T2-weighted images?

Explanation

DISCUSSION: Tendons, cortical bone, ligaments, menisci, and fibrous tissue will show low signal intensity (SI) on both T1- and T2-weighted images. Fat-containing tissues, such as subcutaneous fat and bone marrow, will show high SI on T1-weighted images and low SI on T2-weighted images. Tissues with high water content, such as joint fluid, intervertebral disk, and edema, will show low SI on T1-weighted images and high SI on T2-weighted images.
REFERENCES: Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 65-70.
Slucky AV, Potter HG: Use of magnetic resonance imaging in spinal trauma: Indications, techniques, and utility. J Am Acad Orthop Surg 1998;6:134-145.

Question 30

A 21-year-old professional ballet dancer reports a painful popping sensation over her right hip joint. Examination reveals that symptoms are reproduced with hip flexion and external rotation. Which of the following studies will best confirm the diagnosis?

Explanation

DISCUSSION: The patient has snapping hip syndrome of the internal type, which is more common in ballet dancers. It is caused by the iliopsoas tendon gliding over the iliopectineal line or the femoral head. The diagnosis usually can be made by the history and physical examination. Snapping is reproduced by hip flexion and extension or flexion with external rotation and abduction. Conventional and dynamic ultrasonography will confirm the snapping structure. Radiographs occasionally show calcifications near the lesser trochanter. MRI can be used to rule out other diagnoses that can simulate snapping hip.
REFERENCES: Gruen GS, Scioscia TN, Lowenstein JE: The surgical treatment of internal snapping hip. Am J Sports Med 2002;30:607-613.
Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 139-153.

Question 31

A 35-year-old woman who runs long distance has had posterior calf tenderness for the past 3 months. A clinical photograph is shown in Figure 10a, and MRI scans are shown in Figures 10b and 10c. Management at this point should consist of

Explanation

DISCUSSION: The initial treatment for peritendinitis should consist of calf stretching in an eccentric mode and physical therapy. In a recent study, this treatment has been found superior to surgical debridement in nonextensive peritendinitis and pantendinitis. A non-weight-bearing cast, while useful in reducing inflammation, will result in calf atrophy and poorly organized collagen repair. Cortisone is contraindicated because of the danger of tendon damage. Tendon debridement at this stage is not indicated.
REFERENCES: Alfredson H, Pietila T, Jansson P, Lorentzon R: Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998;26:360-366.
Angermann P, Hougaard D: Chronic Achilles tendinopathy in athletic individuals: Results of nonsurgical treatment. Foot Ankle Int 1999;20:304-306.

Question 32

The term anorexia athletica refers to a problem whose criteria include all of the following, EXCEPT Review Topic

Explanation

Anorexia athletica is a newer term that may generally replace the "triad" of disordered eating, menstrual dysfunction, and osteoporosis. True osteoporosis is actually relatively uncommon in the female athlete, and thus the traditional diagnostic criteria are rarely met. In anorexia athletica, multiple signs and symptoms are used to reach the diagnosis. Specifically, however, a diagnosis of anorexia athletica requires the absence of any affective disorder, such as depression.

Question 33

A 20-year-old football player has immediate pain in the midfoot and is unable to bear weight after an opposing player lands on the back of his plantar flexed foot. AP and lateral radiographs are shown in Figures 4a and 4b. Management should consist of

Explanation

DISCUSSION: The history and radiographs indicate a Lisfranc fracture-dislocation of the foot. The radiographs show the classic “fleck sign,” which is an avulsion of the Lisfranc ligament from the base of the second metatarsal. Most authors recommend open reduction and internal fixation of this injury. Closed reduction can be attempted, but anatomic reduction is unlikely because of the interposed bone fragments and soft tissues. Standard radiographs are not reliable in identifying 1 to 2 mm of subluxation of the tarsometatarsal joint. The tarsometatarsal joint has a poor tolerance to even mild subluxation, and the resulting decrease in joint contact area increases the likelihood of posttraumatic arthritis. Open reduction with the joint visible allows more anatomic reduction and internal fixation of larger osteochondral fragments or excision of smaller interposed fragments.
REFERENCES: Bellabarba C, Sanders R: Dislocations of the foot, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, vol 2, pp 1539-1558.
Murphy GA: Fractures and dislocations of the foot, in Canale ST (ed): Campbell’s Operative Orthopaedics, ed 9. St Louis, MO, Mosby, 1998, vol 2, pp 1956-1960.

Question 34

A 47-year-old obese man with a body mass index of 42 comes into the office with left knee pain 1 year after undergoing an uncomplicated left medial unicompartmental knee arthroplasty (UKA). Radiographs show a loose tibial component in varus. What is the most appropriate next step to treat this failed construct?

Explanation

DISCUSSION:
This patient likely is experiencing failure of the UKA secondary to poor patient selection. In this young, heavy man, the component likely loosened due to the ongoing varus alignment of the knee and his elevated
weight. Despite this likely scenario, the next step is determining whether an infection is the cause of his pain. Prior to obtaining an aspiration, the surgeon can order ESR and CRP studies to determine whether aspiration is warranted. If the laboratory studies are unremarkable, the surgeon likely can forgo the aspiration and proceed to a revision TKA with possible augments on standby.

Question 35

A 10-month-old boy has an untreated developmental hip dislocation.

Explanation

DISCUSSION
Early radiographic findings of avascular necrosis (AVN) of the hip include sclerosis and a subchondral lucency. A common presentation of Legg-Calve-Perthes disease (idiopathic pediatric hip AVN) is intermittent pain in the thigh, groin, or knee with an examination localizing to the hip; a Trendelenburg gait or sign; and painful, restricted passive hip range of motion. AVN also may be observed in association with a slipped capital femoral epiphysis (SCFE). AVN risk is highest in the setting of an unstable SCFE (10%-60%); risk is 0% to 1.4% when the SCFE is stable. A multicenter review of the modified Dunn procedure for treatment of unstable SCFE noted an AVN rate of 26%.
The most common deformity associated with SCFE is proximal femoral varus, flexion, and external rotation leading to an abnormal femoral head-neck junction offset. This causes a loss of passive hip flexion and internal rotation and the phenomenon of obligate external
rotation with flexion. The residual deformity frequently results in femoroacetabular impingement. Labral tears also are associated with cam impingement secondary to underlying osseous abnormalities including abnormal femoral head-neck junction offset.
Endocrinopathies potentially are associated with SCFE because of hormone-related physeal changes and subsequent mechanical insufficiency of the proximal femoral physis. With renal osteodystrophy, the physeal widening results from secondary hyperparathyroidism and progressive proximal femoral deformity may develop. Optimal medical management of hyperparathyroidism is essential. Surgical stabilization via in situ fixation of the proximal femur is indicated when SCFE is diagnosed.
The proximal femoral epiphysis secondary ossification center commonly appears between the ages of 4 and 7 months. In the setting of developmental hip dislocation, the appearance of the secondary ossification center is commonly delayed. After closed or open reduction of developmental dysplasia of the hip, failure of the femoral head ossific nucleus to appear within 12 months following the reduction is a sign of proximal femoral growth disturbance and AVN.

Question 36

Figure 18a shows the initial lateral radiograph of a 6-year-old girl who sustained a fracture in a motor vehicle accident and was treated in a cast 1 year ago. She now has the valgus deformity seen in Figure 18b. Treatment should consist of

Explanation

DISCUSSION: Proximal tibial metaphyseal fractures may result in late genu valgum as a result of asymmetric growth of the proximal tibia. These patients are best treated with observation because the deformity is likely to remodel. Osteotomy is not indicated and potentially will lead to recurrence. Stapling of the medial tibial physis is appropriate in patients who have a severe and progressive deformity.
REFERENCES: Cozen L: Knock-knee deformity in children: Congenital and acquired. Clin Orthop 1990;258:191-203.
Jackson DW, Cozen L: Genu valgum as a complication of proximal tibial metaphyseal fractures in children. J Bone Joint Surg Am 1971;53:1571-1578.
Brammar TJ, Rooker GD: Remodeling of valgus deformity secondary to proximal metaphyseal fracture of the tibia. Injury 1998;29:558-560.
Ogden JA, Ogden DA, Pugh L, et al: Tibia valga after proximal metaphyseal fractures in childhood: A normal biologic response. J Pediatr Orthop 1995;15:489-494.
Salter RB, Best TN: Pathogenesis of progressive valgus deformity following fractures of the proximal metaphyseal region of the tibia in young children. Instr Course Lect 1992;41:409-411.

Question 37

Figure 43 shows an arthroscopic view of the posteromedial compartment of a patient’s left knee using a 70-degree arthroscope placed through the intercondylar notch. The arrow is pointing to what structure?

Explanation

DISCUSSION: Passing the 70-degree arthroscope through the intercondylar notch provides excellent visualization of the posteromedial corner of the knee. This view should be part of every knee arthroscopy because these structures are often not well visualized from the anterior portals. If this view is omitted, tears of the peripheral posterior horn of the medial meniscus can be overlooked. The arrow points to the peripheral aspect of the posterior horn of the medial meniscus. With an intact medial meniscus, the medial tibial plateau should not be seen from this view. The semimembranosus and gastrocnemius tendons are extra-articular and not visualized.
REFERENCES: Miller MD: Basic arthroscopic principles, in DeLee JC, Drez D Jr, Miller MD (eds): Orthopaedic Sports Medicine, ed 2. Philadelphia, PA, Saunders, 2003, pp 224-237.
Gold DI, Schaner PJ, Sapega AA: The posteromedial portal in knee arthroscopy: An analysis of diagnostic and surgical utility. Arthoscopy 1995;11:139-145.

Question 38

An article in a leading orthopaedic journal describes a randomized controlled study comparing 2 popular and comparable surgical methods for fixation of hip fractures. Patients were randomized by a predetermined computer-generated list. There was approximately 20% crossover between treatment groups. Evaluation of study outcomes (clinical and radiographs) was performed by one of the surgeons participating in the study. Enrollment goals for appropriate power were achieved and final 1-year follow-up was obtained for 65% of patients. According to Oxford Group criteria, what is the appropriate level of evidence for this study? Review Topic

Explanation

Although this is a randomized controlled study, there is substantial crossover between the treatment groups, evaluation could not be blinded (radiographs) and was performed by one of the surgeons, and follow-up was moderate. According to Oxford Group criteria, this would be a Level II study.

Question 39

Figure 23 shows the postoperative radiograph of a patient who underwent an anterior cruciate ligament (ACL) reconstruction (with bone-patella tendon-bone autograft) that failed. He initially had loss of flexion postoperatively. What is the most likely cause of this failure? Review Topic

Explanation

The key to this question is the fact that the patient initially lost flexion postoperatively and this relates to anterior placement of the femoral tunnel, thus capturing the knee. The bone plug seen on the radiograph is actually from the tibial tunnel, but this occurred as the patient forced flexion until failure of the ACL graft and pullout of the plug from the tunnel. Although it could be argued that better tibial fixation would have prevented this failure, poor placement of the femoral tunnel led to the failure of this ACL reconstruction.

Question 40

Figures 10a and 10b show the radiographs of a 47-year-old man who reports pain in both shoulders. He has a history of leukemia that was treated with chemotherapy and high-dose cortisone. What is the most reliable treatment option for pain relief in this patient? Review Topic

Explanation

The radiographs reveal osteonecrosis with collapse. The most reliable and durable treatment for osteonecrosis of the humeral head remains prosthetic shoulder arthroplasty. Osteonecrosis of the humeral head may be seen after the use of steroids, and there is an increasing demand for shoulder arthroplasty in young people because of the use of high-dose steroids in chemotherapy regimes for the treatment of malignant tumors. The indications for most shoulder arthrodeses today include posttraumatic brachial plexus injury, paralytic disorders in infancy, insufficiency of the deltoid muscle and rotator cuff, chronic infection, failed revision arthroplasty, severe refractory instability, and bone deficiency following resection of a tumor in the proximal aspect of the humerus. Clearly, the role of arthroscopy and related minimally invasive techniques in the treatment of humeral head osteonecrosis remains unknown.

Question 41

What is the most common bone tumor in the hand?

Explanation

DISCUSSION: The most common bone tumor in the hand is an enchondroma. Forty-two percent of these lesions occur in the small tubular bones. They frequently present with a fracture in these locations. Fractures are usually treated nonsurgically. Indications for surgery include patients with symptomatic lesions or those who are considered high risk for recurrent fracture. The histologic appearance of an enchondroma in the hand is more cellular than enchondromas found in the long bones.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 103.
Kuur E, Hansen SL, Lindequist S: Treatment of solitary enchondromas in fingers. J Hand Surg Br 1989;14:109-112.

Question 42

Which of the following types of intra-articular pathology is associated with lateral meniscal cysts? Review Topic

Explanation

Lateral meniscal cysts often arise from myxoid degeneration that progresses from the meniscal center and then outside the meniscus. Horizontal cleavage tears are commonly associated with the condition. Cysts of the lateral meniscus are most commonly the consequence of a tear located in the medial third. If the tear communicates with the joint, arthroscopic partial meniscectomy and cyst decompression are indicated. If the tear does not open into the joint, arthroscopy should be followed by an open cystectomy.

Question 43

Which of the following is a relative contraindication to performing laminoplasty in a patient with cervical myelopathy? Review Topic

Explanation

Laminoplasty is one of the surgical options for decompressing the spinal cord in patients with cervical myelopathy. An ideal candidate is a patient with preserved cervical lordosis, as expansion of the canal relies on posterior drift of the spinal cord to achieve decompression. Posterior decompression, such as laminectomy and laminoplasty, are ideal for multilevel canal stenosis. Developed in Japan, laminoplasty is commonly performed in patients with OPLL as it avoids the dangers of working around the ossified posterior ligament. There is no age criterion for this procedure. As it is a motion-preserving procedure, 30 degrees of flexion-extension is not considered a contraindication.

Question 44

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

Explanation

DISCUSSION: The presence of drainage 3 weeks after surgery is a sign of wound infection. This infection most likely involves deep tissues until proven otherwise. Oral or IV antibiotics, in the absence of debridement, are not sufficient. Removal of the hardware would lead to rapid progression of the scoliosis in a spine that has been surgically destabilized by removal of the facet joints. The appropriate treatment is debridement with wound culture, IV antibiotics, and retention of hardware. The wound should be closed over drains.
REFERENCES: Theiss SM, Lonstein JE, Winter RB: Wound infections in reconstructive spine surgery. Orthop Clin North Am 1996;27:105-110.
Richards BS: Delayed infections following posterior spinal instrumentation for the treatment of idiopathic scoliosis. J Bone Joint Surg Am 1995;77:524-529.

Question 45

Figures 94a and 94b show T1 sagittal and coronal MR images of the right shoulder of a 45-year-old woman. She has insidious onset of dull, aching right shoulder pain localized at the superior aspect of her shoulder. The nerve that supplies the atrophied muscle arises from the upper trunk from contributions of which nerve roots? A B

Explanation

DISCUSSION
The suprascapular nerve innervates the supraspinatus muscle. Patients with suprascapular neuropathy usually have insidious onset of dull, aching shoulder pain at the superior or posterior aspect of the shoulder. There can be several causes of nerve compression, and the nerve is susceptible to compression at the suprascapular and spinoglenoid notches. Extrinsic compression can be secondary to joint-related fluid filled cysts of soft-tissue masses. Traction neuropathy may occur as the result of excessive nerve excursion during athletic activity (usually overhead sports) or after a massive, retracted rotator cuff tear. The suprascapular nerve originates from the upper trunk from predominantly the C5 and C6 nerve roots, with an occasional contribution from the C4 nerve root.
RECOMMENDED READINGS
Boykin RE, Friedman DJ, Higgins LD, Warner JJ. Suprascapular neuropathy. J Bone Joint Surg Am. 2010 Oct 6;92(13):2348-64. doi: 10.2106/JBJS.I.01743. Review. 81
PubMed PMID: 20926731. View Abstract at PubMed
Piasecki DP, Romeo AA, Bach BR Jr, Nicholson GP. Suprascapular neuropathy. J Am Acad Orthop Surg. 2009 Nov;17(11):665-76. Review. PubMed PMID: 19880677 View Abstract at PubMed

Question 46

A 42-year-old woman who observes traditional Muslim practices is seen in your office accompanied by her physician husband to discuss possible elective bunion correction. In considering the treatment of this patient, what is one of the most important considerations?

Explanation

DISCUSSION: In considering faith-based issues regarding treatment of this patient, the presence of her husband for the office visit would imply an agreement with her decision to have surgery. It also may facilitate her examination. Her role as caregiver, dietary concerns, and cleansing rituals are less important considerations with an outpatient-based procedure. Privacy concerns remain paramount to Muslim women, which include limited exposure during examination, during surgery, and in subsequent follow-up visits.
REFERENCE: Jimenez R, Lewis VO (eds): Culturally Competent Care Guidebook. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007.

Question 47

A 42-year-old female with chronic discogenic back pain undergoes lumbar spine surgery via retroperitoneal approach. Figure A is the postoperative radiograph of her lumbar spine. Six weeks after the surgery the patient develops worsening low back pain. You obtain a radiograph of her lumbar spine, pictured in Figure B. What is the next best step in management? Review Topic

Explanation

This patient has a failed lumbar total disc replacement (TDR) with anterior dislocation of the polyethylene inlay and requires revision surgery, either revision arthroplasty or anterior interbody fusion, via retroperitoneal approach.
Management of failed TDR is dictated by (1) patient symptoms and (2) radiographic implant position. Asymptomatic patients with implant subsidence without extrusion can be managed with close observation. Patients with persistent symptomatic back pain relating to facet joint or implant microinstability in the setting of an otherwise well-positioned TDR can be treated with posterior stabilization alone. Symptomatic patients with unacceptable implant position (i.e. complete dislodgement, fracture) require either revision arthroplasty or conversion to arthrodesis (anterior +/-
posterior).
Harrison et al. authored a report detailing a case of failed L5-S1 TDR with anterior dislocation of the polyethylene inlay and bilateral L5 pars fractures noted 2 weeks postoperatively. It is unclear whether the pars defect was missed following previous microdiscectomy, acquired during instrumentation, or acquired postoperatively due to abnormal endplate forces during rehabilitation. The patient underwent removal of TDR components and revision to anterior arthrodesis followed by percutaneous fixation of the bilateral L5 pars fractures.
Patel et al. published a review of the literature regarding revision lumbar TDR. Retroperitoneal revision procedures are complicated by higher risk of injury to vascular structures (16.7% versus 3.6% at primary surgery) and urogenital structures due to adhesions. Revision surgery should only be performed by surgeons familiar with the retroperitoneal approach to the spine. Alternative surgical approaches, such as the far lateral approach, should be considered to access the anterior spine at L4-L5 and above.
Madigan et al. reviewed the management of lumbar degenerative disc disease (DDD). They state that TDR is a motion-sparing surgical option designed to temper the problem of adjacent-segment disease. They report that long-term studies are limited, but point out that several short-term comparisons between TDR and ALIF show equivalent improvement in pain and function, equal complication rate, shorter hospitalization and lower rate of reoperation in the TDR group.
Figure A is a lateral radiograph of the lumbar spine showing L5-S1 total disc replacement. Figure B is a lateral radiograph of the lumbar spine showing L5-S1 total disc replacement with anterior dislocation of the polyethylene inlay.
Incorrect Responses:

Question 48

The parents of a 10-year-old boy with Down syndrome are seeking sports clearance for participation in the high jump at the Special Olympics. He is asymptomatic, and the neurologic examination is normal. The hips and patellae are clinically stable. Radiographs of the cervical spine in flexion and extension show a maximum atlanto-dens interval (ADI) of 6 mm. Based on these findings, what recommendation should be made?

Explanation

DISCUSSION: In approximately 15% of children with Down syndrome, atlantoaxial instability develops because of ligament laxity, making them susceptible to spinal cord injury with relatively minor trauma. The American Academy of Pediatrics recommends lateral flexion-extension views of the cervical spine in any patient with Down syndrome who wishes to participate in sports. A normal ADI is up to 4 mm. Patients with Down syndrome with an ADI of more than 5 mm should not participate in contact sports or sports with a high risk for neck injury, such as diving, gymnastics, high jump, or butterfly stroke. Cervical fusion has a very high rate of complications in patients with Down syndrome and is recommended only for patients who have myelopathic signs or symptoms.
REFERENCES: Atlantoaxial instability in Down syndrome: Subject review. American Academy of Pediatrics Committee on Sports Medicine and Fitness. Pediatrics 1995;96:151-154.
Tredwell SJ, Newman DE, Lockitch G: Instability of the upper cervical spine in Down syndrome. J Pediatr Orthop 1990;10:602-606.
Segal LS, Drummond DS, Zanotti RM, et al: Complications of posterior arthrodesis of the cervical spine in patients who have Down syndrome. J Bone Joint Surg Am 1991;73:1547-1554.

Question 49

Patient outcome after open reduction and internal fixation of tibial plateau fractures shows that patients older than 50 years of age when compared to younger patients have

Explanation

Several studies have shown worse functional results in patients older than 40 or 50 years of age compared to younger patients after open reduction and internal fixation of tibial plateau fractures. Two studies showed that older patients with less severe fractures performed less favorably than younger patients with more severe injuries. Only 35% of patients older than 50 years were satisfied with their results independent of fracture type.

Question 50

A B

Explanation

DISCUSSION
The radiographs reveal a tibial pilon fracture with an extruded and rotated anterior tibial fragment that lies deep to the anterior compartment neurovascular bundle, which contains the deep peroneal nerve. This nerve innervates the anterior compartment muscles and the extensor digitorum brevis and extensor hallucis brevis muscles and provides sensation to the dorsal aspect of the first interspace. An injury to the deep peroneal nerve at this level will only affect the innervation to the extensor digitorum brevis and extensor hallucis brevis muscles and the innervation of the first interspace. The superficial peroneal nerve innervates
the lateral compartment muscles above the level of this injury and innervates the dorsum of the foot. The medial forefoot is innervated by the saphenous nerve and the posterior tibial nerve innervates the posterior compartment muscles above the level of the injury. The sural nerve innervates the lateral foot and has no motor component, and the superficial peroneal nerve innervates the peroneus longus, which plantar flexes the first metatarsal above the level of the injury.
RECOMMENDED READINGS
Agur AM, Dalley AF, eds. Grant’s Atlas of Anatomy. 13th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins; 2013:362-370.
Hoppenfeld S, de Boer P, Buckley R, eds. Surgical Exposures in Orthopaedics: The Anatomic Approach. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:625-673.

Question 51

A 17-year-old high school football player injures his right ankle during a game. Examination reveals swelling and a closed ankle deformity, with normal foot circulation and sensation. Radiographs are shown in Figures 10a and 10b. In addition to closed reduction, management should include

Explanation

DISCUSSION: The examination and radiographs reveal a closed fracture-dislocation of the ankle with tibiofibular diastasis. Immediate fixation of the medial malleolus and plating of the fibula are indicated. If residual tibiofibular diastasis occurs with lateral translation of the fibula after plating, a syndesmotic screw is placed to stabilize the syndesmosis. Ankle fracture-dislocations associated with a proximal fibular fracture (Maisonneuve fracture) require syndesmotic fixation, but the fibula is not plated. Unstable ankle fractures require surgical treatment. If swelling is severe (fracture blisters, loss of skin wrinkling), a compressive splint is applied and surgery is delayed for 5 to 7 days.
REFERENCES: Browner BD, Jupiter JB, Levine AM, Trafton PG: Skeletal Trauma. Philadelphia, PA, WB Saunders, 1992, pp 1887-1957.
Stiehl JB: Ankle fractures with diastasis. Instr Course Lect 1990;39:95-103.

Question 52

Which of the following drawbacks is associated with the Ganz periacetabular osteotomy?

Explanation

DISCUSSION: Although technically challenging, the Ganz periacetabular osteotomy offers advantages over other rotational pelvic osteotomies. Posterior column integrity is maintained, as is the acetabular vascular supply. Free mobility of the fragment makes large corrections in the center edge angle possible. Because of the asymmetric cuts and the need to restore anterior coverage, there is a tendency to anterior displacement of the joint while flexing the acetabulum. The procedure is commonly performed through a Smith-Petersen incision.
REFERENCES: Trousdale RT, Ganz R: Periacetabular osteotomy, in Callaghan JJ, Rosenberg AG, Rubash HE (eds): The Adult Hip. Philadelphia, Pa, Lippincott-Raven, 1998, pp 789-802.
Ganz R, Klaue K, Vinh TS, Mast JW: A new periacetabular osteotomy for the treatment of hip dysplasias: Technique and preliminary results. Clin Orthop 1988;232:26-36.
MacDonald SJ, Hersche O, Ganz R: Periacetabular osteotomy in the treatment of neurogenic acetabular dysplasia. J Bone Joint Surg Br 1999;81:975-978.

Question 53

Figures below show the radiographs obtained from a 79-year-old woman who has been experiencing increasing tibial pain 10 years after undergoing revision total knee arthroplasty. No evidence of infection is seen. What is the most appropriate treatment?

Explanation

DISCUSSION:
Stems are available for cemented and press-fit implantation. To be effective, press-fit stems should engage the diaphysis, as shown in Figures 3 and 4. They also assist in obtaining correct limb alignment. Short metaphyseal-engaging stems are associated with failure rates that range between 16% and 29%. Cemented stems may be shorter than press-fit stems, because they do not have to engage the diaphysis. Short, fully cemented stems offer the advantage of metaphyseal fixation. Hybrid stem fixation makes use of the metaphysis for cement fixation with metaphyseal cones or sleeves and diaphyseal-engaging press-fit stems.

Question 54

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 55

A morbidly obese 80-year-old woman presents with back pain for 2 months. Sagittal T2-weighted, sagittal T1-weighted, coronal short tau inversion recovery (STIR) images are shown in Figures A through C, respectively. Which of the following statements is true of her diagnosis? Review Topic

Explanation

The MR fluid sign is highly suggestive of an osteoporotic vertebral compression fracture (VCF).
The MR signs suggestive of a benign, osteoporotic VCF include band-like low T1 signal, fluid sign, retropulsion of a vertebral bone fragment. Acute fractures show low signal on T1-weighted and high signal on T2-weighted and STIR images. The MR signs suggestive of malignant VCF include complete replacement of normal marrow signal, convex posterior vertebral border, pedicle involvement, focal paraspinal mass and epidural mass.
Kim et al. performed a literature review on management of the osteoporotic spine. They concluded that nonsurgical management should focus on pain control and maximizing function. Surgery remains controversial and should be reserved for those who fail nonoperative management. Surgical options include vertebroplasty, balloon tamp reduction, and decompression and instrumented fusion with structural graft and multiple fixation points.
Spivak et al. discussed percutaneous treatment of VCF. They recommend vertebroplasty for patients with unremitting pain and little deformity as it is less costly and does not require general anesthesia. They recommend kyphoplasty for cases with
greater vertebral collapse, especially subacute fractures where partial healing may hinder postural fracture reduction.
Figure A is a T2-weighted sagittal MR image showing a fluid-filled cleft ("fluid sign"). Figure B is a T1-weighted sagittal MR image showing loss of intensity (black) consistent with vertebral body edema. Figure C is a coronal STIR image showing the fluid-filled vertebral body cleft. An incidental renal cyst is noted. Illustration A shows different patterns of band-like signal abnormality on T1-weighted imaging. The black region represents low signal intensity (edema). Illustration B is a sagittal STIR image showing the MR fluid sign. Illustration C shows the band like signal abnormality on T1-weighted imaging. Illustration D shows metastatic disease with complete replacement of normal marrow intensity and diffuse convexity of the posterior vertebral border.
Incorrect

Question 56

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

Explanation

The MRI scan shows a Segond fracture, which is a small avulsion of the lateral joint capsule from the anterolateral aspect of the proximal tibia. It is almost always associated with anterior cruciate ligament rupture and often with a tear of either the medial or lateral meniscus.

Question 57

A 58-year-old woman has a fracture through a metacarpal lesion after a motor vehicle accident. She denies any preinjury symptoms and the fracture heals uneventfully. Based on the radiograph and MRI scans shown in Figures 22a through 22c obtained following fracture healing, follow-up management should consist of

Explanation

DISCUSSION: Enchondromas are the most common benign skeletal lesions identified in the bones of the hand. Most are incidentally found or initially become clinically evident after a pathologic fracture. If the patient has a fracture, the hand is immobilized until union. If the lesion is large and further pathologic fractures are expected, then an intralesional curettage and grafting procedure may be warranted. In this patient, the lesion has not significantly altered the size, shape, or morphology of the involved metacarpal head and recurrent fracture is unlikely. Observation with follow-up radiographs is considered appropriate management.
REFERENCES: Campanacci M: Bone and Soft Tissue Tumors, ed 2. New York, NY, Springer-Verlag, 1999, pp 213-228.
Marco RA, Gitelis S, Brebach GT, et al: Cartilage tumors: Evaluation and treatment. J Am Acad Orthop Surg 2000;8:292-304.

Question 58

Resurfacing the patella during a total knee replacement is strongly indicated when the diagnosis is

Explanation

A study by Boyd, et. al. was performed to determine patellar complications after TKA, with the use of an unconstrained prosthesis, with and without resurfacing of the patella. “Chronic pain (post-operative, peripatellar pain) in the group that had not had resurfacing was noted in 40 (13 percent) of the 300 knees that were affected by inflammatory arthritis (rheumatoid arthritis [RA], juvenile RA and miscellaneous subcategories), and in 11 (6 percent) of the 195 knees affected by degenerative osteoarthrosis…A revision to resurface the patella was performed in all 51 knees that caused chronic pain and had not had resurfacing of the patella.
Hence, chronic pain after TKA without resurfacing the patella was more common in knees affected by rheumatoid arthritis than in those affected by degenerative osteoarthritis. The authors of the study recommend that the patella be resurfaced when an unconstrained prosthesis is used in patients with a diagnosis of inflammatory arthritis and to a lesser degree osteoarthrosis.

Question 59

What preoperative factor correlates best with the outcome of rotator cuff repair?

Explanation

DISCUSSION: The size of the rotator cuff tear in both anteroposterior and mediolateral dimensions has been found to correlate best with outcome. Older patient age and rupture of the long head of the biceps tend to be associated with larger tears and, therefore, may be associated indirectly with a poorer outcome.
REFERENCES: Iannotti JP: Full-thickness rotator cuff tears: Factors affecting surgical outcome. J Am Acad Orthop Surg 1994;2:87-95.
Iannotti JP, Bernot MP, Kuhlman JR, Kelley MJ, Williams GR: Postoperative assessment of shoulder function: A prospective study of full-thickness rotator cuff tears. J Shoulder Elbow Surg 1996;5:449-457.

Question 60

Figure 32 shows the radiograph of a laborer who jammed his thumb in a fall. Examination reveals pain at the base of the thumb and proximal thenar eminence region. Management should consist of

Explanation

DISCUSSION: The radiographs are classic for a Bennett’s fracture, which involves a fracture of the palmar ulnar aspect of the proximal phalanx. This fracture fragment is still attached to the anterior oblique ligament. The deforming forces that cause subluxation of the base of the proximal phalanx include the pull of the abductor pollicis longus as well as the adductor pollicis. Adequate reduction can be achieved by closed reduction, percutaneous pin fixation, and casting. The fragment is too small for secure internal fixation.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999, pp 711-771.
Howard FM: Fracture of the basal joint of the thumb. Clin Orthop 1987;220:46-51.

Question 61

A 30-year-old farmer undergoes replantation of an above-the-elbow amputation. What form of management is most important following this surgery?

Explanation

DISCUSSION: After major limb replantation, the occurrence of ischemic rhabdomyonecrosis can result in lactic acidosis and myoglobulinemia. These complications can be limited by rapid repair of the arterial supply, potentially using a shunt before skeletal stability. Repair of the venous system should be performed after repair of the artery. High volume fluid replacement will maintain a diuresis, thus limiting the complications from myoglobulinemia.
REFERENCES: Wood MB: Replantations about the elbow, in Morrey BF (ed): The Elbow and Its Disorders. Philadelphia, PA, WB Saunders, 1985, pp 472-480.
Goldner RD, Nunley JA: Replantation proximal to the wrist, in Wood MD (ed) Hand Clinics: Microsurgery. Philadelphia, PA, WB Saunders, 1992, pp 413-425.

Question 62

What is the most common malignancy involving the hand?

Explanation

DISCUSSION: Skin cancers far outnumber primary musculoskeletal malignancies of the hand and the most common of these is squamous cell carcinoma. Metatastic lung carcinoma, while classic for the carcinoma that metastasizes to the hand, does so at an extremely low rate.
REFERENCES: Fink JA, Akelman E: Nonmelanotic malignant skin tumors of the hand. Hand Clin 1995;11:255-264.
Fleegler EJ: Skin tumors, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, Churchill Livingstone, 1999, vol 2, pp 2184-2205.

Question 63

A healthy 27 year-old-male is brought into the emergency department after a fall from height. He has a suspected left C8-T1 nerve injury. Which of the following findings would most suggest a root avulsion injury rather than a brachial plexus injury at this level?

Explanation

Drooping of the left eyelid is a presenting feature of Horner's syndrome. Horner's syndrome represents a disruption of the sympathetic chain via C8 and/or T1 root avulsion after trauma.
Brachial plexus injuries are often classified as preganglionic vs. postganglionic injuries. Preganglionic injuries are typically avulsion injuries proximal to the dorsal root ganglion. Clinical features suggestive of lower root avulsion injury include a person falling from height clutching on object to save himself, Horner’s syndrome (drooping of the eyelid (ptosis), pupillary constriction (miosis) and anhidrosis), absence of a Tinel sign or tenderness to percussion in the neck, and a normal histamine test (C8-T1 sympathetic ganglion - intact triple response (redness, wheal, flare)).
Caporrino et al. reviewed 102 patients to assess the best modality (e.g. physical examination, MRI and nerve conduction studies [NCSs]) for diagnosing and localizing brachial plexus injuries. They found the best diagnostic performance with physical examination (sensitivity = 97.8%; specificity = 30.8%) and NCSs (sensitivity
= 98.9%; specificity = 23.1%). MRI had inferior performance for all measurements. They conclude that NCSs exhibited superior performance to MRI, and should be considered a more reliable supporting tool after detailed physical examination.
Incorrect Answers:

Question 64

A 79-year-old woman reports a history of left leg pain with walking. Her pain is exacerbated with walking and stair climbing, and her symptoms are improved by standing after she stops walking. Lumbar flexion does not provide any significant improvement of the symptoms and sitting does not significantly change symptoms. Her leg pain is worse at night and she obtains relief by hanging her leg over the side of the bed. The neurologic examination is essentially normal. Examination of the lower extremities demonstrates mild early trophic changes, and her pulses distally are palpable but are diminished bilaterally. Radiographs are shown in Figures 15a and 15b. What is the next most appropriate step in management?

Explanation

DISCUSSION: The patient has symptoms that are more consistent with vascular claudication than with the pseudoclaudication anticipated from lumbar spinal stenosis. Therefore, the patient is a candidate for further vascular work-up. The radiographs reveal early spinal stenosis and spondylolisthesis at L4-5 but also show significant calcification of the iliac arteries, suggestive of peripheral vascular disease. Vascular claudication is a manifestation of peripheral vascular disease and presents with crampy leg pain that is exacerbated by physical exertion. The pain is easily relieved by standing still or sitting. Unlike pseudoclaudication, a forward-flexed posture and/or sitting does not improve the symptoms. Night pain is common in vascular claudication due to the elevation of the extremities and patients often report pain improvement by hanging their extremities in a dependent position. In evaluation of a patient with suspected vascular claudication, the five “P’s” of vascular insufficiency should be monitored, including pulselessness, paralysis, paresthesia, pallor, and pain. While pain and paresthesias can be common in both vascular claudication and pseudoclaudication, the presence of any of the remaining symptoms is suggestive of vascular disease.
REFERENCES: Aufderheide TP: Peripheral arteriovascular disease, in Rosen P, Barkin R (eds): Emergency Medicine: Concepts and Clinical Practice, ed 4. St Louis, MO, Mosby, 1998,

pp 1826-1844.
Mirkovic S, Garfin SR: Spinal stenosis: History and physical examination. Instr Course Lect 1994;43:435-440.

Question 65

A young man sustains a lumbar strain in an on-the-job motor vehicle accident. Both he and his treating physician feel that he is capable of limited duty with appropriate restrictions shortly after the injury. What term best describes his work status?

Explanation

DISCUSSION: Because the man is only recently removed from his injury and is judged capable of returning to work with some restrictions, the term that best describes his work status is temporary partial disability.
REFERENCE: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 131-137.

Question 66

The structure that runs just beneath the peroneal tubercle of the calcaneus is the

Explanation

DISCUSSION
The peroneal tubercle is often a good landmark at which to identify the peroneus longus tendon surgically, and a hypertrophic tubercle has been associated with peroneus longus tendinopathy. Both peroneal tendons curve anteriorly around the tip of the fibula, with the peroneal tubercle separating the 2 tendons at the level of the calcaneus. The peroneus brevis runs in front of the tubercle and the longus behind. The flexor hallucis longus runs through a fibro-osseus tunnel posterior to the hindfoot formed by the posterolateral (os trigonum) and posteromedial tubercle of the talus. The calcaneal fibular ligament attaches to the calcaneus below the posterior facet of the subtalar joint and deep to the peroneal tendons.
RECOMMENDED READINGS
Hyer CF, Dawson JM, Philbin TM, Berlet GC, Lee TH. The peroneal tubercle: description, classification, and relevance to peroneus longus tendon pathology. Foot Ankle Int. 2005 Nov;26(11):947-50. Pub PMID: 16309609.View Abstract at PubMed
Bruce WD, Christofersen MR, Phillips DL. Stenosing tenosynovitis and impingement
of the peroneal tendons associated with hypertrophy of the peroneal tubercle. Foot Ankle Int. 1999 Jul;20(7):464-7. PubMed PMID: 10437932.View Abstract at PubMed

Question 67

What dominant intracellular proteins become directly phosphorylated as a result of bone morphogenetic protein (BMP) binding to its receptors? Review Topic

Explanation

BMP proteins, which are part of the larger transforming growth factor-beta super family, bind to serine/threonine receptors on the cell surface. This binding causes phosphorylation of SMAD proteins, which in turn forms a complex that enters the nucleus and initiates the transcription of several genes involved in osteoblastic
differentiation. Adenylate cyclase is a transmembrane protein that acts intracellularly to activate the G protein pathways. Myc is a proto-oncogene that encodes for a transcription factor involved in numerous cell-activation pathways, but is not directly phosphorylated by BMP receptor. ß-catenin is an intracellular molecule that plays a key role in the Wnt signaling pathway. This pathway is also involved in osteoblastic differentiation, but differs in target proteins within the cell.

Question 68

Figure 1 is the MR image of a 36-year-old athlete who is tackled from behind and falls forward onto his left knee. He has pain, swelling, and stiffness. Examination includes a moderate effusion, positive quadriceps active test, and normal Lachman test finding. If the patient chooses surgical reconstruction, he should be advised that, when compared with a transtibial technique, the tibial inlay technique has been shown to provide

Explanation

The clinical description and MR image point to an injury to the posterior cruciate ligament (PCL). This ligament is thought to be primarily composed of anterolateral and posteromedial bundles, with the former tightening in flexion and the latter in extension. Because of alterations in knee kinematics and increased varus alignment in PCL insufficiency, contact stresses and cartilage loads increase in the patellofemoral and medial compartments. Although good outcomes may be obtained with transtibial, open inlay, and arthroscopic inlay techniques, one major difference is the creation of the “killer-turn” during the transtibial approach. This sharp turn in the graft as it emerges from the tibia appears to lead to more pronounced attenuation and thinning of the graft during cyclic loading. The scenario describes a patient with chronic PCL and posterolateral corner (PLC) injury, as evidenced by the varus thrust and abnormal Dial test finding. A valgus-producing osteotomy may be effective, and, in fact, may be the only treatment necessary to address chronic PLC injury. Accordingly, an opening lateral osteotomy would not be
appropriate. Of the remaining responses, an osteotomy that increases tibial slope would also address the PCL deficiency by reducing posterior tibial sag. Vascular injury is an uncommon, but potentially devastating, complication associated with PCL surgery and may occur regardless of the technique used. Numerous strategies have been described to reduce the risk, including use of a posteromedial accessory incision to allow finger retraction of the popliteal neurovascular bundle, oscillating drills to prevent excessive soft-tissue entanglement, and tapered (rather than square) drill bits that may minimize cut-out of sharp edges as drilling reaches the posterior tibial cortex. Knee extension lessens, rather than increases, the distance between the posterior tibia and the neurovascular bundle and increases, not lessens, risk for vascular injury.

Question 69

Figures 29a and 29b show the radiograph and CT scan of a 48-year-old man who has diffuse spinal pain. What is the most likely diagnosis?

Explanation

DISCUSSION: The studies show marginal syndesmophyte formation characteristic of ankylosing spondylitis. These patients typically have diffuse ossification of the disk space without large osteophyte formation. DISH typically presents with large osteophytes, referred to as nonmarginal syndesmophytes. In this patient, the zygoapophyseal joints are fused rather than degenerative as would be seen in rheumatoid arthritis, and the costovertebral joints are also fused. Osteopetrosis does not normally ankylose the disk space.
REFERENCES: McCullough JA, Transfeldt EE: Macnab’s Backache, ed 3. Baltimore, MD, Williams and Wilkins, 1997, pp 190-194.
Frymoyer JW, Wiesel SW (eds): The Adult and Pediatric Spine, ed 3. Philadelphia, PA, Lippincott, Williams and Wilkins, 2003, pp 141-151.

Question 70

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

Explanation

DISCUSSION: The lesion has the typical “blown out” lytic radiographic appearance that is most commonly found in thyroid or renal cell metastases. Given the history of hematuria and histology findings, the most likely diagnosis is metastatic renal cell carcinoma. This tumor is relatively resistant to chemotherapy. Radiation therapy is used as a postoperative adjuvant treatment with varying response rates. Surgery should be performed after preoperative embolization to decrease the risk of intraoperative bleeding, as no tourniquet can be used in this location. Patients with metastatic renal cell carcinomas may survive for years, resulting in a higher likelihood of local tumor progression with ineffective adjuvant therapy. Intramedullary fixation combined with curettage and cementation will provide the best chance of local control while maintaining the patient’s native shoulder and elbow joints. A total humeral resection is an extensive surgery with considerable morbidity and is not indicated for this patient because less extensive surgery is likely to be effective.
REFERENCES: Harrington KD, Sim FH, Enis JE, Johnston JO, Diok HM, Gristina AG: Methylmethacrylate as an adjunct in internal fixation of pathological fractures: Experience with three hundred and seventy-five cases. J Bone Joint Surg Am 1976;58:1047-1054.
Sun S, Lang EV: Bone metastases from renal cell carcinoma: Preoperative embolization. J Vasc Interv Radiol 1998;9:263-269.
Katzner M, Schvingt E: Operative treatment of bone metastases secondary to renal carcinoma: Basic research and treatment of renal cell carcinoma metastasis. Prog Clin Biol Res EORTC 1990;348:151-168.

Question 71

Preoperative chemotherapy and wide excision Tumoral calcinosis is a heritable condition that is characterized by periarticular metastatic calcification. Most patients are black, and the inheritance is usually autosomal recessive. Metastatic calcifications occur around joints and in the skin, marrow, teeth, and blood vessels. The periarticular masses may grow quite large and are attached to the fascia, but they are extra-articular. The masses may occur at the shoulder, hip, and elbow. Radiographically: The masses are composed of heavy, amorphous calcification in nodules. Laboratory:

Explanation

Slide 1 Slide 2
A 20-year-old woman has a large mass over the right hip. An anteroposterior and oblique radiographs are shown in Slides 1 and

Question 72

A 23-year-old professional baseball pitcher reports shoulder pain and decreased velocity while pitching. Physical examination reveals a side-to-side internal rotation deficit of 25 degrees. The O’Brien sign is negative; Neer and Hawkins signs are negative. Rotator cuff strength is full. Radiographs are unremarkable. What is the next step in management?

Explanation

DISCUSSION: Throwing athletes with symptomatic internal rotation deficits often benefit from an intensive posterior capsular stretching program. Patients that fail to respond to nonsurgical management may benefit from an arthroscopic posterior capsular release.
REFERENCES: Wilk KE, Meister K, Andrews JR: Current concepts in rehabilitation of the overhead throwing athlete. Am J Sports Med 2002;30:136-151.
Myers JB, Laudner KG, Pasquale MR, et al: Glenohumeral range of motion deficits and posterior shoulder tightness in throwers with pathologic internal impingement. Am J Sports Med 2006;34:385-391.

Question 73

In a statement put forth by AAOS, the role of the orthopaedic surgeon in the face of domestic and family abuse includes all of the following EXCEPT: Review Topic

Explanation

Regardless of the social situation, the orthopaedic surgeon's primary role is to proceed and offer expeditious and appropriate care for the patient's injuries.
The statement put forth by the AAOS implores the orthopaedic surgeon to be aware of the integral components to identify, document, and care for minors, elders, and/or partners who are victims of domestic abuse.
Zilmer et al. in a JAAOS review and the basis for the AAOS statement emphasizes the ability to identify abuse, which includes, but is not limited to frequent/multiple injuries, temporal abnormalities in multiple injuries, frequent visits/utilization of the emergency department, and/or unusual injuries/fracture patterns not consistent with the clinical picture. Meticulous documentation is of paramount importance, in addition to communicating your concerns to the appropriate emergency department personnel.
Incorrect answers:

Question 74

Patient-specific instrumentation (PSI) reliably demonstrates which benefit over conventional intramedullary guidance systems?

Explanation

DISCUSSION
Cost is usually increased with PSI because the theoretical decreased number of surgical trays and shortened surgical time do not offset cost of presurgical imaging and extra cost associated with the necessary jigs. Studies do not demonstrate a reliable improvement in functional outcomes or coronal alignment when PSI is compared to standard instrumentation. Evidence reveals that PSI necessitates fewer trays than standard instrumentation.

Question 75

What is the predominant type of collagen in the tissue resulting from the surgical procedure shown in Figures 40a through 40c?

Explanation

DISCUSSION: The arthroscopic images show a microfracture procedure. Perforation of the subchondral bone results in so-called “marrow stimulation” that results in the formation of fibrocartilage. This reparative tissue is composed predominantly of type I collagen with a disorganized matrix lacking a true tidemark, as opposed to hyaline cartilage which is composed primarily of type II collagen. This operation is indicated for full-thickness chondral defects without associated degenerative arthrosis. Microfracture is most commonly performed in the knee, though it has also been applied to other joints. Type III collagen is not a predominant component of fibrocartilage. Type IX and X are minor collagenous components of cartilage.
REFERENCES: Magnussen RA, Dunn WR, Carey JL, et al: Treatment of focal articular cartilage defects in the knee: A systematic review. Clin Orthop Relat Res 2008;466:952-962.
Williams RJ III, Hamly HW: Microfracture: Indications, technique, and results. Instr Course Lect 2007;56:419-428.
Mithoefer K, Williams RJ III, Warren RF, et al: Chondral resurfacing of articular cartilage defects in the knee with the microfracture technique: Surgical technique. J Bone Joint Surg Am 2006;88:294-304.

Question 76

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

Explanation

The ZPA is located on the posterior (ulnar) margin of the limb bud. It expresses Shh protein. When tissue from ZPA is added to the anterior (radial) margin of the limb bud, ulnar dimelia, or mirror hand duplication, occurs.
The ZPA controls AP (radioulnar) growth. The signaling molecule is Shh, which is dose dependent. Higher Shh doses lead to posterior (ulnar) digits ulnar sided polydactyly. The extent of duplication is dose dependent (higher dose = more replication). Reduced Shh leads to loss of digits. Posterior elements (little finger/ulna) are formed EARLY prior to anterior elements which are formed LATE (radius/thumb). Disruption of AP patterning will result in loss of later forming elements (radius/thumb).
Al-Qattan et al. reviewed embryology of the upper limb. They summarized that embryology of the upper limb can be viewed in 2 distinct ways: the steps of limb development and the way that the limb is patterned along its 3 spatial axes. Cell signaling plays a major role in regulating growth and patterning of the vertebrate limbs. Signaling cell dysfunction results in congenital differences according to the affected signaling axis.
Illustration A shows an experiment to create ulnar dimelia by adding ZPA tissue to the anterior limb bud. The video shows development of the limb.
Incorrect Answers:

Question 77

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

Explanation

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

Question 78

A middle-aged man sustains traumatic loss of the second, third, and fourth toes in a lawnmower accident. The wound is grossly contaminated with soil. Penicillin is added to his antibiotic regimen for coverage of what bacteria? Review Topic

Explanation

In farm or soil-contaminated wounds, including lawnmower injuries, penicillin is added to broad-spectrum cephalosporin and aminoglycoside therapy to cover against Clostridium. Psuedomonas is frequently seen after puncture wounds through the shoes. Acinetobacter is generally a hospital-acquired infection.

Question 79

A 17-year-old high school football player sustains a traumatic anterior shoulder dislocation, resulting in a small bony Bankart lesion and small Hill-Sachs lesion. The patient undergoes an arthroscopic Bankart repair with incorporation of the bone fragment and returns to play football the following year. He has a recurrent dislocation at football practice but decides to finish the football season before considering additional treatment. He sustains nine additional dislocations, with the last dislocation occurring while sleeping.What diagnostic test is most appropriate when planning revision surgery?

Explanation

A failed bony Bankart repair with multiple dislocations can further erode the anteroinferior glenoid, changing the sagittal morphology of the glenoid into an “inverted pear.” Quantitative bone loss is best evaluated by CT scan with 3-D reconstructions and subtraction of the humeral head. MRI and ultrasonography can assist in evaluating soft-tissue injury, but they are not as helpful in determining bone loss compared with a CT scan. An arthrogram alone is not sufficient to evaluate bone loss. Bone loss >30% necessitates glenoid augmentation with either a Latarjet procedure or iliac crest bone grafting. A revision arthroscopic or open Bankart repair with capsular shift or remplissage do not address bone loss. The Latarjet procedure can effectively restore stability with glenoid bone loss and after failed stabilizing procedures. Patients with pain before surgery are
more likely to have pain after surgery. Age and activity level are lesser influences on satisfaction.

Question 80

Figures 20a and 20b show the AP and lateral radiographs of a 62-year-old man who has had hip pain for the past 3 weeks. Figure 20c shows a CT scan of the abdomen and pelvis. A needle biopsy specimen is shown in Figure 20d. Preoperative management should include which of the following?

Explanation

DISCUSSION: The histology shows findings consistent with metastatic renal cell carcinoma. Renal cell carcinoma metastases are extremely vascular. Preoperative embolization helps minimize the amount of blood loss during curettage of these lesions.
REFERENCES: Chatziioannou AN, Johnson ME, Pneumaticos SG, et al: Preoperative embolization of bone metastases from renal cell carcinoma. Eur Radiol 2000;10:593-596.
Sun S, Lang EV: Bone metastases from renal cell carcinoma: Preoperative embolization. J Vasc Interv Radiol 1998;9:263-269.

Question 81

Figures 1 through 4 are the wrist MR images of a 43-year-old right-hand-dominant bricklayer who reports gradually progressive left hand weakness for 4 months. He describes difficulty gripping objects, tying his shoes, and holding utensils. He denies any numbness, paresthesias, or a previous injury. An examination reveals intact sensation in a median, radial, and ulnar nerve distribution. He has atrophy of hand interossei and a positive Froment sign finding. He has no Tinel sign finding at the wrist or elbow and no exacerbation of symptoms with elbow hyperflexion. Electromyography shows signs of denervation in an ulnar nerve distribution distal to the wrist. What is the best next step?

Explanation

The MR images show a lesion consistent with a ganglion cyst located near the hook of the hamate. The ulnar nerve divides into motor and sensory branches just proximal to this lesion. In this case, the ganglion cyst compresses the ulnar nerve motor branch but not the sensory branch, resulting in motor dysfunction but no sensory disturbance. Excision of the ganglion cyst should alleviate his symptoms. Compression of the ulnar nerve proximal to the motor branch take-off (in either the cubital tunnel or proximal Guyon’s canal) would cause both sensory and motor dysfunction. Although chronic nonunion of the hook of the hamate can cause ulnar nerve symptoms, the hook of the hamate appears intact on the MR image. The MR image shows a lesion that is well circumscribed with high intensity on T1 and T2 images, consistent with a benign ganglion cyst, and ganglion cysts are relatively common lesions in this area.

Question 82

What is the most appropriate plating technique utilized for the medial malleolus fracture typically seen in a displaced supination-adduction ankle fracture?

Explanation

DISCUSSION: A supination-adduction ankle fracture leads to a vertical fracture of the medial malleolus. Traditional fixation of the medial malleolus with oblique screws from the tip of the malleolus directed proximally will ineffectively protect against shear forces at the fracture site; these also are directed quite obliquely to the vertical fracture line, and therefore have poor biomechanical resistance to failure. An antiglide plate is used medially to prevent displacement of the fracture segment due to shear forces.
According to the referenced article by Toolan et al, placement of two horizontal (perpendicular to the fracture line) lag screws from medial to lateral are biomechanically the most important aspect of the construct whether a plate is used or not.

Question 83

Figures 113a and 113b are the radiographs of a 7-year-old girl who was evaluated for a visible elbow deformity by a foster parent. She thought the child fell, but her history was vague. On physical examination, a large prominence was seen over the posterolateral elbow, and the girl lacks the terminal 20 degrees of elbow extension. She has 75 degrees of elbow pronation and supination. She was nontender on examination. What is the most appropriate next treatment step? Review Topic

Explanation

The most appropriate management of this condition is observation. The patient most likely has a congenital dislocation of the radial head, although this may also represent a posttraumatic deformity. The absence of findings on physical examination speaks against an acute injury. The appearance of the radial head reveals the typical findings of a congenital dislocation, namely the convex appearance of the proximal radial articular surface. These children typically have very functional range of motion and do not require treatment unless they are symptomatic. There is nothing in this child's history to suggest abuse.

Question 84

A 36-year-old woman is placed in a short arm cast for a nondisplaced extra-articular distal radius fracture. Seven weeks later she notes the sudden inability to extend her thumb. What is the most likely cause of her condition?

Explanation

DISCUSSION: A recent review of 200 consecutive distal radius fractures noted that the overall incidence of extensor pollicis longus rupture was 3%. The causes are believed to be mechanical irritation, attrition, and vascular impairment. The fracture is usually nondisplaced and the patient notes weeks to months after injury the sudden, painless inability to extend the thumb. Treatment involves extensor indicis proprius tendon transfer or free palmaris longus tendon grafting.
REFERENCES: Skoff HD: Postfracture extensor pollicis longus tenosynovitis and tendon rupture: A scientific study and personal series. Am J Orthop 2003;32:245-247.
Bonatz E, Kramer TD, Masear VR: Rupture of the extensor pollicis longus tendon. Am J Orthop 1996;25:118-122.
Helal B, Chen SC, Iwegbu G: Rupture of the extensor pollicis longus tendon in undisplaced Colles’ type of fracture. Hand 1982;14:41-47.

Question 85

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 86

A 25-year-old female presents to the emergency room for the fourth time in the last week. She has vague complaints of extremity pain. Physical examination by a male ER resident has been limited each visit because she is terrified of the pain that the clinician may cause. On physical examination, she is withdrawn and frightened. Regions of ecchymosis are noted throughout chest and abdomen. She has requested multiple radiographs, MRI and CT scans. Today's imaging (radiographs, MRI, CT scan) has been unrevealing. What is the most likely diagnosis? Review Topic

Explanation

Based on the history and clinical presentation, the most likely diagnosis is intimate partner violence.
Domestic violence or intimate partner violence can be in the form of mental or physical abuse, neglect or abandonment. Close to 25% of women will experience domestic violence. Risk factors include young age (19-29 years of age), females, pregnancy and lower socioeconomic status. Affected patients will have repeated visits to the emergency room, find reasons to stay in a treatment facility for an extended period of time and constantly seek approval of their partner.
Shields et al. reviewed factors influence outcome in treatment of patients affected by domestic violence. They found that positive outcomes were associated with interdisciplinary approaches to management. This included better history assessment, providing written documentation regarding intervention and better access to information on community resources.
Illustration A is a chart documenting the frequency of female domestic violence throughout the world as of 2012.
Incorrect Answers

Question 87

An increase in advanced glycation end-products (AGEs) is characteristic of which of the following clinical conditions and results in which pathologic process?

Explanation

Advanced glycation end-products (AGEs) are found in aging and osteoarthritis (OA) and result in increased articular cartilage stiffness and increased brittleness.
AGEs are produced from spontaneous nonenzymatic glycation of proteins when sugars (glucose, fructose, ribose) react with lysine or arginine residues. Because of the low turnover, cartilage is susceptible to AGEs accumulation. The accumulation of AGEs has been thought to play a role in the development of OA of the knee and ankle.
Li et al. reviewed age-related changes in cartilage. They state that with aging, there is excessive collagen cross-linking increases cartilage stiffness, while shortening/degradation of aggrecan leads to loss of sugar side chains and water-binding ability, while increased levels of AGEs are associated with a decline in anabolic activity. There is also increased chondrocyte death and/or apoptosis.
Anderson et al. reviewed the relationship between osteoarthritis and aging. They state that knee cartilage thins with aging (especially on the femoral and patellar sides, suggesting a gradual loss of cartilage matrix. AGEs formation leads to modification of type II collagen by cross-linking of collagen molecules, increasing stiffness and brittleness and increasing susceptibility to fatigue failure.
Incorrect Answers:

Question 88

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 89

Following preoperative chemotherapy, the percent of tumor necrosis has been shown to be of prognostic value for which of the following tumors?

Explanation

DISCUSSION: The grading of response to chemotherapy for osteosarcoma was introduced by Huvos and associates. Patients with tumors that show more than 90% necrosis after neoadjuvant chemotherapy are considered to have had a good response and have better survival rates than those with less than 90% necrosis. However, it should be noted that survival rates for patients with a poor response are still better than in patients who do not receive neoadjuvant chemotherapy. More recently, similar results have been reported in patients with Ewing’s sarcoma. Chemotherapy is not typically used for giant cell tumor of bone.
REFERENCES: Meyers PA, Heller G, Healey J, Huvos A, Lane J, Marcove R, et al: Chemotherapy for nonmetastatic osteogenic sarcoma: The Memorial Sloan- Kettering experience. J Clin Oncol 1992;10:5-15.
Wunder JS, Paulian G, Huvos AG, Heller G, Meyers PA, Healey JH: The histological response to chemotherapy as a predictor of the oncological outcome of operative treatment of Ewing sarcoma. J Bone Joint Surg Am 1998;80:1020-1033.

Question 90

A 50-year-old man with metastatic renal cell carcinoma has right hip pain. A radiograph and CT scan are shown in Figures 48a and 48b. The first step in management should consist of

Explanation

DISCUSSION: These lesions are extremely vascular and can cause uncontrolled intraoperative bleeding; therefore embolization is the appropriate first treatment. Because the radiograph and CT scan show a lytic lesion in the supra-acetabular region that affects the weight-bearing dome and medial wall, the next step in treatment would most likely be a total hip arthroplasty and acetabular reconstruction. Treatment with bisphosphonates and radiation therapy will not prevent an acetabular fracture. Cementoplasty is an emerging technique in which cement is injected percutaneously into a lesion, but no long-term results have been reported. Radiofrequency ablation of bone metastases is also an emerging technique that provides palliative pain control.
REFERENCES: Layalle I, Flandroy P, Trotteur G, Dondelinger RF: Arterial embolization of bone metastases: Is it worthwhile? J Belge Radiol 1998;81:223-225.
Chatziioannou AN, Johnson ME, Pneumaticos SG, Lawrence DD, Carrasco CH: Preoperative embolization of bone metastases from renal cell carcinoma. Eur Radiol 2000;10:593-596.

Question 91

A 46-year-old woman had an ankle fracture and ORIF 6 years ago. She had subsequent removal of some of the hardware, but her pain has persisted (Figures 44a and 44b).

Explanation

DISCUSSION
Patients younger than 40 years of age who have ankle arthritis pose an ongoing clinical challenge. Nonsurgical treatment should be maximized, although distraction arthroplasty can be used in an effort to delay the need for fusion.
One of the strongest indications for ankle arthroplasty is a preexisting hindfoot fusion with a goal to retain some ankle/hindfoot motion. Ankle fusion is perhaps the most predictable surgical treatment for a relatively young, active patient with ankle arthritis. Moreover, there are concerns regarding implant loosening when performing TAA in active patients.
Outcome after syndesmosis ORIF has been linked to the quality of the reduction at the index procedure. Syndesmotic malreduction that is severe necessitates osteotomy and revision ORIF.
RECOMMENDED READINGS
Sagi HC, Shah AR, Sanders RW. The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up. J Orthop Trauma. 2012 Jul;26(7):439-43. doi: 10.1097/BOT.0b013e31822a526a. PubMed PMID: 22357084. View Abstract at PubMed
Smith NC, Beaman D, Rozbruch SR, Glazebrook MA. Evidence-based indications for distraction ankle arthroplasty. Foot Ankle Int. 2012 Aug;33(8):632-6. Review. View Abstract at PubMed
Kim BS, Knupp M, Zwicky L, Lee JW, Hintermann B. Total ankle replacement in association with hindfoot fusion: Outcome and complications. J Bone Joint Surg Br. 2010 Nov;92(11):1540-7. doi: 10.1302/0301-620X.92B11.24452. PubMed PMID: 21037349. View Abstract at PubMed
Daniels TR, Younger AS, Penner M, Wing K, Dryden PJ, Wong H, Glazebrook M. Intermediate-term results of total ankle replacement and ankle arthrodesis: a COFAS multicenter study. J Bone Joint Surg Am. 2014 Jan 15;96(2):135-42. doi: 10.2106/JBJS.L.01597. View Abstract at PubMed

Question 92

An 8-year-old sustains the injury shown in Figures A and B. Postoperative radiographs are shown in Figures C and D. After cast removal and in-office k-wire removal, elbow range of motion is found to be between 20-80 degrees of flexion. How soon after surgery is range of motion expected to be >90% of normal? Review Topic

Explanation

After closed reduction and percutaneous pinning of a displaced pediatric supracondylar fracture, it will take an average of 6 months for 94% of normal elbow range of motion to return.
Displaced pediatric supracondylar elbow fractures are often treated with closed reduction and percutaneous pinning. Risk of stiffness is low considering the extra-articular nature of the injury. Utility of physical therapy to improve range of motion after operative treatment of this injury is not supported in the literature.
Zionts et al. retrospectively evaluated elbow stiffness after treatment for pediatric supracondylar fractures. Ninety-four percent of normal range of motion was restored by 6 months after the operative procedure. Further improvement occurs up to one-year postoperatively
Lee et al. surveyed 76 orthopaedic surgeons on their treatment of pediatric supracondaylar injuries. They noted that general orthopaedic surgeons used passive exercises to assist with elbow stiffness after operative management of pediatric supracondylar fractures. In contrast, pediatric orthopaedists used active range of motion to improve elbow motion.
Keppler et al. retrospectively reviewed patients who had sustained supracondaylar fractures to ascertain the effect of postoperative physical therapy. At one year follow up, there was no difference in motion between patients who had received physical therapy and those who had not.
Figures A and B demonstrate the AP and lateral radiographs of a pediatric supracondylar fracture. Figures C and D are the postoperative radiographs after closed reduction and percutaneous pinning of the elbow injury.
Incorrect Answers:
(SBQ13PE.13) A 17-month-old boy is referred to your clinic by his pediatrician for a workup of "bowed legs." The patient's mother states that she has other children that grew out of it by age 3 or 4. Examination of the patient reveals a child whose measurements reside in the 75% percentile for height and weight. His gait appears appropriate for a toddler without varus thrust. Supine measurements show 10-degrees of symmetric, bilateral genu varus. Appropriate workup includes: Review Topic
Longterm clinical and radiographic monitoring to plan for guided growth until skeletal maturity
X-rays today and at age 4 to assure resolution of his genu varum
Genetic screening for metabolic causes of Rickets
Vitamin D levels drawn today and weekly 50,000 IU vitamin D injections assuming the value is low
Clinical observation and follow up to monitor resolution of genu varum
This patient has physiologic genu varum or tibia vara, which is common in toddlers less than 2 years of age. The mainstay of treatment is simple observation, as there is predictable resolution of this alignment as children
There are numerous etiologies of genu varum in children. Most common in the children under age 2 is a predictable pattern of genu varum and internal torsion in the first year or so after beginning to walk. Persistence of genu varum, severe (>20 degrees) or worsening deformity, limb asymmetry or varus thrust gait, and low height and weight percentiles should trigger further workup with x-rays and metabolic or genetic screening. A family history of genu varum is non-specific, and in isolation, does not indicate heritable causes of genu varum.
Kling and Hensinger's review article highlights normal angular and torsional deviations in growing children, including genu varum and genu valgum as well as hip and hind foot deformities. They emphasize that understanding the natural history of these deformities in growing children helps the treating physician identify those who need more than simple observation of their malalignment.
Staheli et al. published normal values of rotational profile physical exam maneuvers (including thigh foot axis, transmalleolar axis, prone internal and external hip rotation) to better understand the predictable changes in different age groups.
Birch provides an update on current treatment of Blount's disease. He suggests further radiographic evaluation in ambulatory infants with asymmetric varus deformity or varus deformity that persists after age 18 months. If these findings are present, radiographs are recommended. If the X-rays reveal metaphyseal-diaphyseal angle
>16° on AP radiographs and confirm the diagnosis of infantile Blount disease, he recommends anti-varus long leg bracing during ambulation for patients aged <=3 years with progressive deformity, clear radiographic evidence of infantile Blount disease, or lateral thrust with ambulation.
Illustration A shows pathologic metaphyseal beaking common in Blount's disease. There are no pathognomonic x-ray findings in physiological bowing as presented in this question.
Incorrect Answers:

Question 93

Figure 38 shows the radiograph of a 75-year-old woman who has had right shoulder pain, difficulty sleeping on the affected arm, and difficulties performing activities of daily living for the past 6 weeks. Initial nonsurgical management includes analgesics, a subacromial cortisone injection, and gentle range-of-motion exercises. However, these modalities have failed to provide relief, and the patient reports that she is unable to elevate her arm. Her pain is worse and she would like the most reliable treatment method for pain relief and functional improvement. What is the best surgical treatment?

Explanation

DISCUSSION: The authors of several studies conducted in Europe have reported promising results in the short- and medium-term with use of a reversed or inverted shoulder implant. The most recent investigation, a multicenter study in Europe in which 77 patients (80 shoulders) with glenohumeral osteoarthritis and a massive rupture of the rotator cuff were treated with the Delta III prosthesis, described an improvement in the mean constant score of 42 points, an increase of 65 degrees in forward elevation, and minimal or no pain in 96% of the patients. Hemiarthroplasty, the “nonconstrained” option, has long been the standard of care for rotator cuff tear arthropathy. However, careful examination of the literature reveals that the results have not been uniform.
REFERENCES: Favard L, Lautmann S, Sirveaux F, et al: Hemiarthroplasty versus reverse arthroplasty in the treatment of osteoarthritis with massive rotator cuff tear, in Walch G, Boileau P, Mole D (eds): 2000 Shoulder Prosthesis Two to Ten Year Follow-Up. Montpellier, France, Sauramps Medical, 2001, pp 261-268.
Frankle M, Siegal S, Pupello D, et al: The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency: A minimum two-year follow-up study of sixty patients. J Bone Joint Surg Am 2005;87:1697-1705.
Werner CM, Steinmann PA, Gilbart M, et al: Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am 2005;87:1476-1486.

Question 94

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

Explanation

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

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

Question 95

Tumoral calcinosis Tumoral calcinosis is a heritable condition that is characterized by periarticular metastatic calcification. Most patients are black, and the inheritance is usually autosomal recessive. Metastatic calcifications occur around joints and in the skin, marrow, teeth, and blood vessels. The periarticular masses may grow quite large and are attached to the fascia, but they are extra-articular. The masses may occur at the shoulder, hip, and elbow. Radiographically: The masses are composed of heavy, amorphous calcification in nodules. Laboratory:

Explanation

Slide 1 Slide 2
A 20-year-old patient who is otherwise healthy has a soft mass over her hip. The mass has formed over the past 2 years. The radiographs are shown in Slides 1 and 2. Which of the following would be a common finding:

Question 96

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

Explanation

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

Question 97

At the time of arthroscopy, a 9-year-old boy was found to have a Watanabe type II discoid lateral meniscus. What is the most appropriate treatment? Review Topic

Explanation

The Watanabe type II meniscus should only require saucerization for treatment because it is not unstable. The Watanabe classification defines 3 types of discoid mensici. In type I (stable, complete), the block-shaped lateral meniscus covers the entire lateral tibial plateau, whereas in type II (stable, partial), the lateral meniscus covers less than or equal to 80% of the tibial plateau. Type III discoid menisci (unstable, ligament of Wrisberg) appear to be normal except for a thickened posterior horn, but they lack posterior meniscal attachments, including the meniscotibial (ie, coronary) ligament. The type III discoid meniscus is stabilized only by the meniscofemoral ligament of Wrisberg. This results in hypermobility of the lateral meniscus at the posterior horn, which pulls into the intercondylar notch with knee extension, resulting in snapping knee syndrome. Complete menisectomy should be avoided if possible.

Question 98

An 8-month-old infant has an infection of the fingertip as shown in Figure 22. If neglected, the anticipated path of ascending infection is the fingertip, the flexor sheath, and the

Explanation

DISCUSSION: The flexor sheaths are in continuity with the deep spaces of the hand. The flexor sheaths of the thumb and little finger communicate with the radial and ulnar bursae, respectively, and these two bursae commonly communicate. The central digits do not communicate as readily with deep spaces of the hand but if flexor tendon sheath infection of the index, long, and right fingers is neglected, the potential exists for rupture into the deep midpalmar spaces.
REFERENCES: Peimer CA (ed): Surgery of the Hand and Upper Extremity: Acute and Chronic Sepsis. New York, NY, Mcgraw Hill, 1996, pp 1735-1741.
Trumble TE (ed): Hand Surgery Update 3: Hand, Elbow and Shoulder. Rosemont, IL, American Society for Surgery of the Hand, 2003, pp 445-446.

Question 99

A 45-year-old coach sustains a complete distal biceps tendon rupture at the elbow. Surgical repair is most indicated to Review Topic

Explanation

The biceps is primarily responsible for supination of the forearm. The brachialis muscle is primarily repsonsible for elbow flexion strength. Failure to repair the distal biceps tendon will result in loss of 40% supination strength and 10% loss in flexion strength. Therefore, surgical repair of a complete distal biceps tendon rupture is most indicated to maximize supination strength. Improved cosmesis should not be the primary indication for surgical repair. Degenerative changes of the elbow have no bearing on whether the distal biceps is repaired or not. Loss of terminal extension is common in distal biceps tendon repairs.

Question 100

What is the most frequent complication of both lateral closing wedge high tibial osteotomy and medial opening wedge osteotomy?

Explanation

DISCUSSION: Scuderi and associates reported on patellar height after a high tibial osteotomy. Eighty-nine percent of the patellae, as measured by the Insall-Salvati index, and 76.3 percent, as measured by the Blackburne-Peel index, were observed to be lowered. More recently, Wright and associates reported a 64% incidence of patella baja in patients undergoing a medial opening wedge osteotomy. The incidence of intra-articular fracture during medial opening wedge osteotomy has been reported to be as high as 11% by Hernigou and associates, whereas the incidence of intra-articular fracture during lateral closing wedge high tibial osteotomy has been reported to be 10% to 20% by Matthews and associates. The incidence of peroneal nerve palsy with a lateral closing wedge high tibial osteotomy ranges from 0% to 20%, according to Marti and associates, whereas the incidence of peroneal palsy following a medial opening wedge osteotomy has been reported to be 15.7% by Flierl and associates. The exact incidence of compartment syndrome after a high tibial osteotomy is not known; however, it does not reach the level of patella baja. The incidence of deep infection after a lateral closing wedge high tibial osteotomy ranges from 0% to 4% according to Billings and associates.
REFERENCES: Scuderi GR, Windsor RE, Insall JN: Observations on patellar height after proximal tibial osteotomy. J Bone Joint Surg Am 1989;71:245-248.
Wright JM, Crockett HC, Slawski DP, et al: High tibial osteotomy. J Am Acad Orthop Surg 2005;13:279-289.
Hernigou P, Medevielle D, Debeyre J, et al: Proximal tibial osteotomy for osteoarthritis

with varus deformity: A ten to thirteen-year follow-up study. J Bone Joint Surg Am 1987;69:332-354.
Matthews LS, Goldstein SA, Malvitz TA, et al: Proximal tibial osteotomy: Factors that influence the duration of satisfactory function. Clin Orthop 1988;229:193-200.
Marti CB, Gautier E, Wachtl SW, et al: Accuracy of frontal and sagittal plane correction in open-wedge high tibial osteotomy. Arthroscopy 2004;20:366-372.
Marti RK, Verhigan RA, Kerkhoffs GM, et al: Proximal tibial varus osteotomy: Indications, technique, and five to twenty-one-year results. J Bone Joint Surg Am 2001;83:164-170.
Flierl S, Sabo D, Hornig K, et al: Open wedge high tibial osteotomy using fractioned drill osteotomy: A surgical modification that lowers the complication rate. Knee Surg Sports Traumatol Arthrosc 1996;4:149-153.
Billings A, Scott DF, Camargo MP, et al: High tibial osteotomy with a calibrated osteotomy guide, rigid internal fixation, and early motion: Long-term follow-up. J Bone Joint Surg Am 2000;82:70-79.

Full Question & Answer Text (for Search Engines)

Question 1:

An active, right-handed 71-year-old woman fell on her left shoulder and sustained the injury shown in the radiographs in 52a and 52b and the CT scan in 52c. Management should consist of

Options:

hemiarthroplasty
open reduction and internal fixation
closed reduction and percutaneous pinning
a sling and early pedulum exercises
a sling and swathe for 6 weeks, followed by shoulder rehabilitation

Correct Answer: hemiarthroplasty

Explanation:

Question 2:

Options:

Right-sided posterior keyhole foraminotomy at C5-6
Transforaminal epidural steroid injection at C5-6
Single-level C5-6 anterior cervical fusion
Posterior C5-6 fusion
Continued nonsurgical management and counseling that his career as a professional athlete is over

Correct Answer: Single-level C5-6 anterior cervical fusion

Explanation:

DISCUSSION: The patient has chronic neck pain that is affecting his career as a professional soccer player. Although he had signs and symptoms of a right C6 radiculopathy, neck pain is his only current symptom. Therefore, procedures to address the relief of radiculopathy (keyhole foraminotomy and transforaminal epidural steroid injection) are likely to be ineffective. Although Watkins and others have described continuing nonsurgical management for symptomatic herniated disks and return to play only when asymptomatic, the patient has not found relief with these modalities. A single-level cervical fusion (either postoperative or congenital) generally is not considered a contraindication for return to play in collision or
contact sports. Therefore, anterior cervical fusion at C5-6 offers the best long-term option for return to play.
REFERENCES: Watkins RG: Cervical spine injuries in athletes, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 373-386.
Watkins RG: Neck injuries in football players. Clin Sports Med 1986;5:215-246.
Morganti C, Sweeney CA, Albanese SA, et al: Return to play after cervical spine injury. Spine 2001;26:1131-1136.
Garvey T, Transfeldt EE, Malcolm JR, et al: Outcome of anterior cervical discectomy and fusion as perceived by patients treated for dominant axial-mechanical cervical spine pain. Spine 2002;27:1887-1895.

Question 3:

Increasing articular conformity of the tibial polyethylene insert of a fixed-bearing total knee arthroplasty (TKA) prosthesis will have which of the following biomechanical effects?

Options:

Decreased contact stress within the polyethylene
Decreased risk of patellofemoral instability
Decreased risk of mechanical loosening
Increased risk of subsurface polyethylene cracking
Increased tibial rollback during flexion

Correct Answer: Decreased contact stress within the polyethylene

Explanation:

DISCUSSION: Increasing articular conformity increases the surface area for contact between the polyethylene and the femoral component. Advantages of this include lower peak contact stress within the polyethylene and less risk of polyethylene fatigue failure. Patellofemoral tracking is unchanged by increasing conformity unless gross component apposition is present. A potential disadvantage of increasing conformity includes some restriction in tibial rollback. Modest changes in conformity have not been shown to alter the rate of mechanical loosening. If conformity was increased to the extent of significant constraint, a potential increased risk of loosening would be expected, not a decrease. Design of modern TKAs includes a compromise in achieving enough constraint to lower polyethylene stress, without providing so much constraint as to limit kinematics and stress the fixation interfaces.
REFERENCES: D’Lima DD, Chen PC, Colwell CW Jr: Polyethylene contact stresses, articular congruity, and knee alignment. Clin Orthop 2001;392:232-238.
Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000,
pp 265-274.

Question 4:

Options:

proximal biceps tenodesis.
application of a sling for 3 weeks, followed by physical therapy.
anterior capsulolabral reconstruction.
repair of the subscapularis tendon.
repair of the pectoralis major tendon.

Correct Answer: repair of the pectoralis major tendon.

Explanation:

Question 5:

Options:

Spastic gait and a positive Hoffman’s sign
Severe arm pain with upper extremity hyporeflexia
Normal neurologic findings
Hyperactive jaw jerk reflex with extremity numbness
Flaccid paraparesis

Correct Answer: Spastic gait and a positive Hoffman’s sign

Explanation:

Question 6:

The main arterial supply to the humeral head is provided by which of the following arteries?

Options:

Anterior humeral circumflex
Posterior humeral circumflex
Thoracoacromial
Subscapular
Deep (profunda) brachial

Correct Answer: Anterior humeral circumflex

Explanation:

Question 7:

Which of the following best describes the mechanism of action of gentamycin?

Options:

Inhibits cell wall synthesis by inhibiting peptidyl traspeptidase
Increases cell membrane permeability
Binds to the 30s ribosome subunit interfering with protein synthesis
Inhibits DNA gyrase
Forms oxygen radicals leading to loss of helical structure and breakage of DNA strands

Correct Answer: Binds to the 30s ribosome subunit interfering with protein synthesis

Explanation:

Question 8:

Options:

intravenous (IV) antibiotics and admission to a medical intensive care unit.
emergent radical debridement including thumb amputation.
emergent revascularization of the thumb with a vein graft.
urgent irrigation of the thumb flexor tendon sheath.

Correct Answer: emergent radical debridement including thumb amputation.

Explanation:

EXPLANATION:
This patient has multiple criteria for necrotizing soft-tissue infection (NSTI, also known as necrotizing fasciitis) including rapidly progressive infection, black bulla, hypotension and hypoxia, and a history of immune compromise. Aggressive emergent debridement including the removal of all necrotic tissue and IV antibiotics can decrease morbidity and mortality. Not all patients will have such obvious NSTI findings. In less clear cases, a scoring system using laboratory values (the Laboratory Risk Indicator for Necrotizing Fasciitis) can help clarify the diagnosis. IV antibiotics are key to treatment as well, but any delay in surgical treatment can increase morbidity and mortality. The black bulla and necrotic-appearing thumb indicate that this infection is not confined to the flexor sheath, therefore irrigation of the tendon sheath alone would be insufficient treatment. Although the thumb is dysvascular, this is because of an
infection, and revascularization is not indicated.

Question 9:

The most common complication associated with corticosteroid injection for the treatment of interdigital neuroma is

Options:

Infection
Chronic regional pain syndrome (CRPS)
Hammertoe deformity
Hives

Correct Answer: Hammertoe deformity

Explanation:

DISCUSSION
Interdigital neuromas represent perineural fibrosis of the intermetatarsal nerve most commonly seen in the second and third web spaces. The photographs depict a neuroma in the second web space, which is less common than in the third space. Its hypoechoic appearance is characteristic on ultrasound. PVNS occurs in joints. Lipomas are fatty tumors. A ganglion cyst can occasionally occur adjacent to a nerve, but it has a cystic appearance.
The most popular theory on the etiology of interdigital neuromas is compression neuropathy by the intermetatarsal ligament. The plantar approach for the resection of interdigital neuromas has become more popular, especially for recurrent neuromas. The major advantage is better visualization and access to the neuromas.
Infection and allergic reactions such as hives are rare after steroid injection. CRPS is not known to occur in this setting. Hammertoe formation can occur, especially after multiple steroid injections into an interdigital neuroma.
RECOMMENDED READINGS
Schon LC, Reed MA. Disorder of the nerves. In: Coughlin MJ, Saltzman CL, Anderson RB, eds. Mann's Surgery of the Foot and Ankle. 9th ed. Philadelphia, PA: Elsevier-Saunders; 2014:622-641.
Gauthier G. Thomas Morton's disease: a nerve entrapment syndrome. A new surgical technique. Clin Orthop Relat Res. 1979 Jul-Aug;(142):90-2. PubMed PMID: 498653.
View
Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 96 THROUGH 98
Figure 96 is the anteroposterior projection foot radiograph of a 35-year-old woman who is injured in a high-speed motorcycle collision. Her assessment reveals an isolated injury. Her pulses are palpable and her neuromotor examination is intact. There is tenting of skin with ecchymosis over the second metatarsal. The foot is extremely swollen but not tense. Passive toe range of motion is painless.

Question 10:

A 28-year-old man reports an episode of buckling and giving-way of his right knee. Figure 54a and 54b show a radiograph and sagittal MRI scan. What is the most likely diagnosis? Review Topic

Options:

Anterior cruciate ligament rupture
Posterior cruciate ligament rupture
Quadriceps tendon rupture
Patellar tendon rupture
Displaced bucket-handle meniscus tear

Correct Answer: Patellar tendon rupture

Explanation:

Question 11:

Options:

Application of a pelvic binder
Application of skeletal traction
Open reduction and internal fixation
Placement of percutaneous iliosacral screws
Placement of an anterior pelvic external fixator

Correct Answer: Open reduction and internal fixation

Explanation:

The patient has a displaced iliac wing and bilateral rami fractures with superior migration of the right hip. To prevent further deformity, the patient's right hip should be placed into skeletal traction. A pelvic binder may worsen the deformity because of the iliac wing fracture. Anterior external fixation is problematic with an iliac wing fracture. Although the patient will eventually require open reduction and internal fixation and/or placement of iliosacral screws, she must be stabilized and resuscitated prior to this treatment.
(SBQ12TR.80) A 37-year-old male arrives to the trauma slot following a high-speed motorcycle crash. His Glasgow Coma score is 14 and his only orthopaedic injury is exhibited in Figure A. His current vital signs are a BP of 90/60, HR 120, and a lactate of 2.5 mMol/L. Other findings include a grade 1 splenic laceration and bilateral pulmonary contusions seen on chest radiograph. Which of the following has been suggested as an indication to perform damage control orthopedic care?
1 HR >110
Bilateral pulmonary contusions seen on chest radiograph
SBP = 90mmHg
Unilateral femur fracture
Lactate = 2.5 mMol/L
Pulmonary contusion severe enough to be diagnosed on chest radiograph alone is an indicator that the patient may benefit from damage control orthopaedics (DCO).
Despite the patient's overall stable nature, suffering pulmonary injury severe enough to be seen on x-ray alone suggests that temporary stabilization with staged definitive fixation may avoid potential morbidity.
Pape et al. review the evolution and balance of early total care (ETC) and DCO. Summarizing the literature, the authors report several standalone indicators that would justify DCO regardless of stable status. This includes: Injury Severity Score of greater than 40, Injury Severity Score of greater than 20 with chest trauma, multiple injuries with severe pelvic/abdominal trauma/ hemorrhagic shock, bilateral femoral fractures, pulmonary contusion noted on radiographs alone, hypothermia of less than 35 degrees C), and a head injury with an Abbreviated Injury Score of 3 or greater.
Figure A exhibits a right femoral shaft fracture. Illustration A exhibits a summarized table stating the criterion used to determine the condition of a polytrauma patient. (Table from Pape et al, PMID: 19726738)
Incorrect answers:

Question 12:

Options:

Mobile-bearing knee
Posterior cruciate ligament-sparing knee
Posterior cruciate ligament-substituting knee
Semiconstrained-style knee
Triaxial hinged knee

Correct Answer: Posterior cruciate ligament-substituting knee

Explanation:

DISCUSSION: Paletta and Laskins performed a retrospective study of the results of TKA with cement in 22 patients who had a previous patellectomy. Nine of the patients had insertion of a posterior cruciate ligament-substituting implant. Thirteen patients had insertion of a posterior cruciate ligament-sparing implant. The 5-year postoperative knee scores were 89 for the posterior cruciate ligament-substituting knee versus 67 for the posterior cruciate
ligament-sparing knee (P < 0.01). The patella functions to increase the lever arm of the extensor mechanism and to position the quadriceps tendon and the patellar ligament roughly parallel to the anterior cruciate ligament and posterior cruciate ligament, respectively. The patellar ligament thereby provides a strong reinforcing structure that functions to prevent excessive anterior translation of the femur during flexion of the knee. The absence of the patella results in the patellar ligament and the quadriceps tendon being relatively in line with one another. After a patellectomy, the resultant quadriceps force is no longer parallel to the posterior cruciate ligament. This results in loss of the reinforcing function of the patellar ligament. The authors believe this loss of reinforcing function may place increased stresses on the posterior cruciate ligament and posterior aspect of the capsule, which may result in stretching of these structures over time. They found a high rate of anteroposterior instability, a high prevalence of recurvatum, and a high rate of loss of full active extension compared with passive extension in the posterior cruciate ligament-sparing group, which supports their theory.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 559-582.
Paletta GA Jr, Laskins RS: Total knee arthroplasty after a previous patellectomy. J Bone Joint Surg Am 1995;77:1708-1712.

Question 13:

Options:

The distraction rate should be maintained.
The distraction rate should be decreased.
The distraction should be reversed.
The distraction gap should be managed with bone grafting in an open procedure.
A repeat corticotomy should be performed.

Correct Answer: The distraction rate should be decreased.

Explanation:

Question 14:

Options:

Inadequate graft strength
Failure to restore graft length
Malposition of the femoral tunnel
Malposition of the tibial tunnel

Correct Answer: Malposition of the femoral tunnel

Explanation:

DISCUSSION
The anteromedial bundle originates on the anterior and proximal aspect of the lateral femoral condyle and inserts on the anteromedial aspect of the anterior cruciate ligament (ACL) footprint on the proximal tibia. The posterolateral bundle originates posterior and distal to
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the anteromedial bundle and inserts on the posterolateral aspect of the tibial footprint. The fibers are parallel when the knee is in an extended position. As the knee moves into flexion,
the fibers of the anteromedial bundle rotate externally with respect to the posterolateral bundle. The anteromedial bundle is tensioned in both flexion and extension. The posteromedial bundle is tensioned in extension, but relaxes as the knee moves into flexion.
The lateral meniscus is more commonly injured with an acute injury to the ACL. The medial meniscus is injured more commonly when the ACL is chronically unstable.
The ACL is an intra-articular and intrasynovial structure. It is innervated by posterior articular branches from the tibial nerve. Innervation of the ACL involves several types of mechanoreceptors (Ruffini, Pacini, Golgi tendon, and free-nerve endings) that may contribute to proprioceptive function of the knee and modulation of quadriceps function.
Injury to the ACL is predominantly associated with instability to anterior translation of the tibia in extension. The ACL plays a secondary role to limit internal rotation of the tibia, and a loss of ACL stability is confirmed by the reduction of the tibia from a position of anterior translation and internal rotation (pivot shift). The radiographs demonstrate anterior placement of the femoral tunnel. The convex shape of the lateral femoral condyle can make it more difficult to visualize the anatomic femoral origin of the ACL. Failure to identify the
anatomic footprint can result in anterior placement of the femoral tunnel. Anterior ACL graft placement can result in its impingement against the posterior cruciate ligament and early limitation of knee flexion. Over time, impingement on the graft may result in stretching of the graft and recurrent knee instability symptoms.
RECOMMENDED READINGS
Duthon VB, Barea C, Abrassart S, Fasel JH, Fritschy D, Ménétrey J. Anatomy of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc. 2006 Mar;14(3):204-13. Epub 2005 Oct 19. Review. PubMed PMID: 16235056.
View
Abstract at PubMed
Zantop T, Petersen W, Sekiya JK, Musahl V, Fu FH. Anterior cruciate ligament anatomy and function relating to anatomical reconstruction. Knee Surg Sports Traumatol Arthrosc. 2006 Oct;14(10):982-92. Epub 2006 Aug 5. Review. PubMed PMID: 16897068.
View Abstract at PubMed

Question 15:

Options:

Medial hindfoot
Lateral hindfoot
First dorsal webspace
Dorsal midfoot
Plantar foot

Correct Answer: Medial hindfoot

Explanation:

Question 16:

Figure 11 shows the anatomic dissection of the medial side of the knee joint after removal of the superficial fascia. The arrow is pointing to what structure?

Options:

Semitendinosus tendon
Gracilis tendon
Sartorius tendon
Semimembranosus tendon
Medial collateral ligament

Correct Answer: Semitendinosus tendon

Explanation:

Question 17:

Options:

Osteoarthritis of the hip
Osteonecrosis of the hip
Metastatic carcinoma
Femoral head fracture
Rheumatoid arthritis of the hip

Correct Answer: Osteonecrosis of the hip

Explanation:

DISCUSSION: These are classic findings of osteonecrosis of the hip. The radiograph reveals the subchondral sclerotic pattern commonly seen in osteonecrosis and is quite extensive in this patient. The MRI scan reveals the typical serpentine-like region of low signal intensity with a central zone where the signal is similar to fat.
REFERENCES: Resnick D (ed): Diagnosis of Bone and Joint Disorders. Philadelphia, PA,
WB Saunders, 2002, pp 3160-3162.
Sugano N: Osteonecrosis, in Fitzgerald R Jr, Kaufer H, Malkani A (eds): Orthopaedics. Philadelphia, PA, Mosby International, 2002, pp 877-887.

Question 18:

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

Options:

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

Correct Answer: Rotator cuff interval

Explanation:

DISCUSSION: The rotator cuff interval is located between the supraspinatus and subscapularis and the biceps tendon is deep to the interval. It is a triangular area where the base is the coracoid process and the apex is the transverse humeral ligament at the biceps sulcus. Closure or tightening of this area is often helpful in patients with shoulder instability. Conversely, this area is often contracted in patients with adhesive capsulitis and may need to be released.
REFERENCES: Selecky MT, Tibone JE, Yang BY, et al: Glenohumeral joint translation after arthroscopic thermal capsuloplasty of the rotator interval. J Shoulder Elbow Surg 2003;12:139-143.
Harryman DT, Sidles JA, Harris SL, et al: The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992;74:53-66.

Question 19:

Options:

Arthroscopic lateral release with reconstruction of medial patellofemoral ligament
Growth plate sparing anterior cruciate ligament reconstruction
Arthroscopic meniscal saucerization
Microfracture versus stabilization of osteochondral lesion

Correct Answer: Arthroscopic meniscal saucerization

Explanation:

Question 20:

Options:

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

Correct Answer: Femoroacetabular osteoplasty and labral repair

Explanation:

Question 21:

Options:

observation.
serial casting.
flexion osteotomy of the distal humerus.
posterior soft-tissue elbow release and anterior triceps transfer.
adaptive equipment.

Correct Answer: posterior soft-tissue elbow release and anterior triceps transfer.

Explanation:

Question 22:

Which of the following is considered a risk factor for the development of low back pain?

Options:

Gender
Facet trophism
Vibration exposure
Weight
Transitional vertebrae

Correct Answer: Vibration exposure

Explanation:

Question 23:

Excision of heterotopic bone about the forearm or elbow can be done with limited recurrence rates as early as which of the following after initial injury?

Options:

Once ankylosis of the forearm or elbow occurs
6 weeks
6 months
12 months
18 months

Correct Answer: Once ankylosis of the forearm or elbow occurs

Explanation:

Question 24:

Options:

Complete metabolic workup
Advanced imaging with a CT scan
Laboratory studies for CBC, ESR and CRP
Nuclear medicine studies

Correct Answer: Laboratory studies for CBC, ESR and CRP

Explanation:

Question 25:

Options:

Giant cell tumor
Chondrosarcoma
Osteosarcoma
Infection
Paget’s disease

Correct Answer: Chondrosarcoma

Explanation:

Question 26:

Options:

Total shoulder arthroplasty
Hemiarthroplasty with glenoid interposition
Surface replacement hemiarthroplasty
Arthroscopic debridement
Anti-inflammatory drugs and a range-of-motion stretching program

Correct Answer: Anti-inflammatory drugs and a range-of-motion stretching program

Explanation:

DISCUSSION: New onset pain and stiffness in the young arthritic shoulder is a difficult problem to treat. Initial management should be aimed at reducing pain and improving motion in all planes. This patient’s activities and age preclude a shoulder arthroplasty at this time. If nonsurgical management fails to provide relief, then arthroscopic debridement and capsular release may be beneficial.
REFERENCES: Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 257-266.
Skedros JG, O’Rourke PJ, Zimmerman JM, et al: Alternatives to replacement arthroplasty for glenohumeral arthritis, in Iannotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 485-499.

Question 27:

Options:

immediate hospital admission and surgery because of the risk of paralysis.
surgery within 24 hours.
surgery within the next several days.
elective surgery at the next available surgical date.
additional nonsurgical management.

Correct Answer: additional nonsurgical management.

Explanation:

Question 28:

Options:

Metastatic lung cancer
Osteomyelitis
Osteosarcoma
Ewing’s sarcoma
Eosinophilic granuloma

Correct Answer: Ewing’s sarcoma

Explanation:

Question 29:

What normal tissue has a low signal intensity (appears black) on both T1- and T2-weighted images?

Options:

Tendon
Fat
Joint fluid
Intervertebral disk
Bone marrow

Correct Answer: Tendon

Explanation:

Question 30:

Options:

Radiographs
Bone scan
CT
Ultrasonography
MRI

Correct Answer: Ultrasonography

Explanation:

Question 31:

Options:

a non-weight-bearing cast for 4 weeks.
eccentric calf stretching and physical therapy.
a cortisone injection.
tendon debridement.
tendon debridement and augmentation.

Correct Answer: eccentric calf stretching and physical therapy.

Explanation:

Question 32:

The term anorexia athletica refers to a problem whose criteria include all of the following, EXCEPT Review Topic

Options:

gastrointestinal complaints.
restriction of caloric intake.
presence of an affective disorder.
weight loss.
menstrual dysfunction.

Correct Answer: presence of an affective disorder.

Explanation:

Question 33:

Options:

closed reduction and a non-weight-bearing cast.
closed reduction and a weight-bearing cast.
closed reduction and percutaneous pinning.
open reduction and casting.
open reduction and internal fixation.

Correct Answer: open reduction and internal fixation.

Explanation:

Question 34:

Options:

Aspiration of joint fluid to obtain a cell count
Revision of the UKA using primary total knee arthroplasty (TKA) components
Revision of the UKA using a revision TKA with augments
Procurement of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level

Correct Answer: Procurement of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level

Explanation:

Question 35:

A 10-month-old boy has an untreated developmental hip dislocation.

Options:

Sclerosis of the proximal femoral epiphysis with subchondral lucency
Abnormal femoral head-neck junction offset
Widening of the proximal femoral physis with normal femoral head-neck junction offset
Absence of the proximal femoral epiphysis secondary ossification center

Correct Answer: Absence of the proximal femoral epiphysis secondary ossification center

Explanation:

Question 36:

Options:

observation.
high tibial osteotomy.
MRI and assessment for growth arrest and bar excision.
stapling of the lateral tibial physis.
external fixation and hemichondrodiastasis.

Correct Answer: observation.

Explanation:

Question 37:

Options:

Posterior horn of the medial meniscus
Semimembranosus tendon
Medial tibial plateau
Medial head of the gastrocnemius tendon
Medial plica

Correct Answer: Posterior horn of the medial meniscus

Explanation:

Question 38:

Options:

Level I
Level II
Level III
Level IV

Correct Answer: Level II

Explanation:

Question 39:

Options:

Fixation in the tibial tunnel
Fixation in the femoral tunnel
Posterior placement of the tibial tunnel
Anterior placement of the femoral tunnel
Size of the patellar autograft

Correct Answer: Anterior placement of the femoral tunnel

Explanation:

Question 40:

Options:

Arthroscopic debridement
Arthrodesis
Resection arthroplasty
Hemiarthroplasty
Cortisone injection

Correct Answer: Hemiarthroplasty

Explanation:

Question 41:

What is the most common bone tumor in the hand?

Options:

Periosteal chondroma
Subungual exostosis
Chondrosarcoma
Osteoid osteoma
Enchondroma

Correct Answer: Enchondroma

Explanation:

DISCUSSION: The most common bone tumor in the hand is an enchondroma. Forty-two percent of these lesions occur in the small tubular bones. They frequently present with a fracture in these locations. Fractures are usually treated nonsurgically. Indications for surgery include patients with symptomatic lesions or those who are considered high risk for recurrent fracture. The histologic appearance of an enchondroma in the hand is more cellular than enchondromas found in the long bones.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 103.
Kuur E, Hansen SL, Lindequist S: Treatment of solitary enchondromas in fingers. J Hand Surg Br 1989;14:109-112.

Question 42:

Which of the following types of intra-articular pathology is associated with lateral meniscal cysts? Review Topic

Options:

Discoid meniscus
Posterolateral corner injury
Vertical meniscal tears
Middle third lateral meniscal tears
Popliteus tendon tears

Correct Answer: Middle third lateral meniscal tears

Explanation:

Question 43:

Which of the following is a relative contraindication to performing laminoplasty in a patient with cervical myelopathy? Review Topic

Options:

Ossification of the posterior longitudinal ligament (OPLL)
Cervical kyphosis measuring 20 degrees
30 degrees of sagittal mobility on flexion-extension views
Multilevel canal stenosis
Patient age older than 55 years

Correct Answer: Cervical kyphosis measuring 20 degrees

Explanation:

Question 44:

Options:

Oral antibiotics empirically
Culture of the drainage and oral antibiotics
Aspiration of the wound and IV antibiotics empirically
Wound culture with incision and debridement, IV antibiotics, and retention of instrumentation
Wound culture with incision and debridement, IV antibiotics, and removal of instrumentation followed by bracing

Correct Answer: Wound culture with incision and debridement, IV antibiotics, and retention of instrumentation

Explanation:

DISCUSSION: The presence of drainage 3 weeks after surgery is a sign of wound infection. This infection most likely involves deep tissues until proven otherwise. Oral or IV antibiotics, in the absence of debridement, are not sufficient. Removal of the hardware would lead to rapid progression of the scoliosis in a spine that has been surgically destabilized by removal of the facet joints. The appropriate treatment is debridement with wound culture, IV antibiotics, and retention of hardware. The wound should be closed over drains.
REFERENCES: Theiss SM, Lonstein JE, Winter RB: Wound infections in reconstructive spine surgery. Orthop Clin North Am 1996;27:105-110.
Richards BS: Delayed infections following posterior spinal instrumentation for the treatment of idiopathic scoliosis. J Bone Joint Surg Am 1995;77:524-529.

Question 45:

Options:

C4 and C5 with occasional contribution from C3
C4 and C5 with occasional contribution from C6
C5 and C6 with occasional contribution from C4
C5 and C6 with occasional contribution from C7

Correct Answer: C5 and C6 with occasional contribution from C4

Explanation:

DISCUSSION
The suprascapular nerve innervates the supraspinatus muscle. Patients with suprascapular neuropathy usually have insidious onset of dull, aching shoulder pain at the superior or posterior aspect of the shoulder. There can be several causes of nerve compression, and the nerve is susceptible to compression at the suprascapular and spinoglenoid notches. Extrinsic compression can be secondary to joint-related fluid filled cysts of soft-tissue masses. Traction neuropathy may occur as the result of excessive nerve excursion during athletic activity (usually overhead sports) or after a massive, retracted rotator cuff tear. The suprascapular nerve originates from the upper trunk from predominantly the C5 and C6 nerve roots, with an occasional contribution from the C4 nerve root.
RECOMMENDED READINGS
Boykin RE, Friedman DJ, Higgins LD, Warner JJ. Suprascapular neuropathy. J Bone Joint Surg Am. 2010 Oct 6;92(13):2348-64. doi: 10.2106/JBJS.I.01743. Review.
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PubMed PMID: 20926731.
View Abstract at PubMed
Piasecki DP, Romeo AA, Bach BR Jr, Nicholson GP. Suprascapular neuropathy. J Am Acad Orthop Surg. 2009 Nov;17(11):665-76. Review. PubMed PMID: 19880677
View Abstract at PubMed

Question 46:

Options:

The role her husband will play in the decision to proceed with surgery
Her role as primary caregiver in the household
Dietary concerns during her hospitalization
Daily cleansing rituals that may affect wound care
The importance of maintaining modesty precautions during examination, surgery, and postoperative appointments

Correct Answer: The importance of maintaining modesty precautions during examination, surgery, and postoperative appointments

Explanation:

DISCUSSION: In considering faith-based issues regarding treatment of this patient, the presence of her husband for the office visit would imply an agreement with her decision to have surgery. It also may facilitate her examination. Her role as caregiver, dietary concerns, and cleansing rituals are less important considerations with an outpatient-based procedure. Privacy concerns remain paramount to Muslim women, which include limited exposure during examination, during surgery, and in subsequent follow-up visits.
REFERENCE: Jimenez R, Lewis VO (eds): Culturally Competent Care Guidebook. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007.

Question 47:

Options:

Facet joint injection and lumbosacral orthosis
Posterior stabilization
Revision arthroplasty via far lateral approach
Revision to arthrodesis via far lateral approach
Revision to arthrodesis via retroperitoneal approach

Correct Answer: Facet joint injection and lumbosacral orthosis

Explanation:

Question 48:

Options:

Clearance for all sports activities
Avoidance of contact sports, high jump, and diving
Application of a hard cervical collar during sports events
Application of a halo vest
Posterior atlantoaxial arthrodesis

Correct Answer: Avoidance of contact sports, high jump, and diving

Explanation:

DISCUSSION: In approximately 15% of children with Down syndrome, atlantoaxial instability develops because of ligament laxity, making them susceptible to spinal cord injury with relatively minor trauma. The American Academy of Pediatrics recommends lateral flexion-extension views of the cervical spine in any patient with Down syndrome who wishes to participate in sports. A normal ADI is up to 4 mm. Patients with Down syndrome with an ADI of more than 5 mm should not participate in contact sports or sports with a high risk for neck injury, such as diving, gymnastics, high jump, or butterfly stroke. Cervical fusion has a very high rate of complications in patients with Down syndrome and is recommended only for patients who have myelopathic signs or symptoms.
REFERENCES: Atlantoaxial instability in Down syndrome: Subject review. American Academy of Pediatrics Committee on Sports Medicine and Fitness. Pediatrics 1995;96:151-154.
Tredwell SJ, Newman DE, Lockitch G: Instability of the upper cervical spine in Down syndrome. J Pediatr Orthop 1990;10:602-606.
Segal LS, Drummond DS, Zanotti RM, et al: Complications of posterior arthrodesis of the cervical spine in patients who have Down syndrome. J Bone Joint Surg Am 1991;73:1547-1554.

Question 49:

Patient outcome after open reduction and internal fixation of tibial plateau fractures shows that patients older than 50 years of age when compared to younger patients have

Options:

equal results for all fracture types.
better outcomes in high-energy fractures.
better outcomes in low-energy fractures.
a higher wound complication rate.
worse outcomes in low-energy fractures.

Correct Answer: worse outcomes in low-energy fractures.

Explanation:

Question 50:

A B

Options:

in her first interspace and an inability to dorsiflex her toes.
over her lateral forefoot and an inability to evert her foot.
over her medial forefoot and an inability to invert her foot.
over her lateral forefoot and an inability to plantar flex her first metatarsal.

Correct Answer: in her first interspace and an inability to dorsiflex her toes.

Explanation:

Question 51:

Options:

cast immobilization.
delayed fixation of the medial malleolus.
immediate fixation of the medial malleolus and plating of the fibula.
immediate fixation of the medial malleolus, plating of the fibula, and placement of a syndesmotic screw.
immediate fixation of the medial malleolus and placement of a syndesmotic screw.

Correct Answer: immediate fixation of the medial malleolus, plating of the fibula, and placement of a syndesmotic screw.

Explanation:

Question 52:

Which of the following drawbacks is associated with the Ganz periacetabular osteotomy?

Options:

The tendency to anterior displacement of the hip joint
The need for two incisions
Limited potential for acetabular reorientation
Posterior column disruption
Devascularization of the acetabulum

Correct Answer: The tendency to anterior displacement of the hip joint

Explanation:

Question 53:

Options:

Retain the components, and implant a tibial strut allograft.
Revise the tibial component with a metaphyseal cone and metaphyseal uncemented stem.
Revise the tibial component with a metaphyseal cone and a press-fit diaphyseal-engaging stem.
Revise the tibial component with a long cemented diaphyseal-engaging stem.

Correct Answer: Revise the tibial component with a metaphyseal cone and a press-fit diaphyseal-engaging stem.

Explanation:

Question 54:

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 55:

Options:

MR fluid sign suggests that this is an osteoporotic vertebral compression fracture
Convex posterior vertebral border suggests that this is an osteoporotic vertebral compression fracture
Replacement of the normal marrow signal suggests that this is a malignant vertebral compression fracture
Retropulsion of a vertebral body fragment suggests that this is a malignant vertebral compression fracture
The band-like low T1 signal suggests that this is a malignant vertebral compression fracture

Correct Answer: Retropulsion of a vertebral body fragment suggests that this is a malignant vertebral compression fracture

Explanation:

Question 56:

Options:

Medial collateral ligament rupture
Patellar dislocation
Patellar tendon rupture
Anterior cruciate ligament rupture
Posterior cruciate ligament rupture

Correct Answer: Anterior cruciate ligament rupture

Explanation:

Question 57:

Options:

curettage.
radiation therapy.
observation.
bisphosphonates.
ray resection.

Correct Answer: observation.

Explanation:

DISCUSSION: Enchondromas are the most common benign skeletal lesions identified in the bones of the hand. Most are incidentally found or initially become clinically evident after a pathologic fracture. If the patient has a fracture, the hand is immobilized until union. If the lesion is large and further pathologic fractures are expected, then an intralesional curettage and grafting procedure may be warranted. In this patient, the lesion has not significantly altered the size, shape, or morphology of the involved metacarpal head and recurrent fracture is unlikely. Observation with follow-up radiographs is considered appropriate management.
REFERENCES: Campanacci M: Bone and Soft Tissue Tumors, ed 2.
New York, NY, Springer-Verlag, 1999, pp 213-228.
Marco RA, Gitelis S, Brebach GT, et al: Cartilage tumors: Evaluation and treatment. J Am Acad Orthop Surg 2000;8:292-304.

Question 58:

- Resurfacing the patella during a total knee replacement is strongly indicated when the diagnosis is

Options:

Rheumatoid arthritis
Posttraumatic arthritis
Degenerative osteoarthritis
Osteonecrosis of the tibial plateau
Osteonecrosis of the medial femoral condyle

Correct Answer: Rheumatoid arthritis

Explanation:

Question 59:

What preoperative factor correlates best with the outcome of rotator cuff repair?

Options:

Size of the tear
Age of the patient
Arm dominance
Rupture of the long head of the biceps
Preoperative pain score

Correct Answer: Size of the tear

Explanation:

Question 60:

Figure 32 shows the radiograph of a laborer who jammed his thumb in a fall. Examination reveals pain at the base of the thumb and proximal thenar eminence region. Management should consist of

Options:

open reduction and internal fixation.
closed reduction, percutaneous pin fixation, and casting.
dynamic thumb traction.
external fixation.
functional bracing followed by occupational therapy.

Correct Answer: closed reduction, percutaneous pin fixation, and casting.

Explanation:

Question 61:

A 30-year-old farmer undergoes replantation of an above-the-elbow amputation. What form of management is most important following this surgery?

Options:

High volume diuresis with alkalinization of the urine
Systemic heparinization of the patient for 72 hours
Elevation of the extremity, with maintanence of the patient’s room temperature at 80 degrees F (26.6 degrees C)
Satellite ganglion continuous sympathetic block
Daily IV administration of low-molecular-weight dextran

Correct Answer: High volume diuresis with alkalinization of the urine

Explanation:

Question 62:

What is the most common malignancy involving the hand?

Options:

Epithelioid sarcoma
Synovial sarcoma
Metastatic lung carcinoma
Chondrosarcoma
Squamous cell carcinoma

Correct Answer: Squamous cell carcinoma

Explanation:

DISCUSSION: Skin cancers far outnumber primary musculoskeletal malignancies of the hand and the most common of these is squamous cell carcinoma. Metatastic lung carcinoma, while classic for the carcinoma that metastasizes to the hand, does so at an extremely low rate.
REFERENCES: Fink JA, Akelman E: Nonmelanotic malignant skin tumors of the hand. Hand Clin 1995;11:255-264.
Fleegler EJ: Skin tumors, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, Churchill Livingstone, 1999, vol 2, pp 2184-2205.

Question 63:

Options:

Reduced radial artery pulse
Double break in the ipsilateral superior shoulder suspensory complex
Elevated hemidiaphragm
Musculocutaneous nerve deficit
Drooping of the left eyelid

Correct Answer: Reduced radial artery pulse

Explanation:

Question 64:

Options:

Decompression and posterior fusion at L4-L5
Epidural steroid injection at L4-5
Nonsteroidal medications and physical therapy for 6 weeks
Measurement of the ankle-brachial index
CT myelogram

Correct Answer: Measurement of the ankle-brachial index

Explanation:

DISCUSSION: The patient has symptoms that are more consistent with vascular claudication than with the pseudoclaudication anticipated from lumbar spinal stenosis. Therefore, the patient is a candidate for further vascular work-up. The radiographs reveal early spinal stenosis and spondylolisthesis at L4-5 but also show significant calcification of the iliac arteries, suggestive of peripheral vascular disease. Vascular claudication is a manifestation of peripheral vascular disease and presents with crampy leg pain that is exacerbated by physical exertion. The pain is easily relieved by standing still or sitting. Unlike pseudoclaudication, a forward-flexed posture and/or sitting does not improve the symptoms. Night pain is common in vascular claudication due to the elevation of the extremities and patients often report pain improvement by hanging their extremities in a dependent position. In evaluation of a patient with suspected vascular claudication, the five “P’s” of vascular insufficiency should be monitored, including pulselessness, paralysis, paresthesia, pallor, and pain. While pain and paresthesias can be common in both vascular claudication and pseudoclaudication, the presence of any of the remaining symptoms is suggestive of vascular disease.
REFERENCES: Aufderheide TP: Peripheral arteriovascular disease, in Rosen P, Barkin R (eds): Emergency Medicine: Concepts and Clinical Practice, ed 4. St Louis, MO, Mosby, 1998,
pp 1826-1844.
Mirkovic S, Garfin SR: Spinal stenosis: History and physical examination. Instr Course Lect 1994;43:435-440.

Question 65:

Options:

Temporary total disability
Temporary partial disability
Temporary partial illness
Permanent total disability
Permanent partial disability

Correct Answer: Temporary partial disability

Explanation:

Question 66:

The structure that runs just beneath the peroneal tubercle of the calcaneus is the

Options:

flexor hallucis longus tendon.
peroneus brevis tendon.
peroneus longus tendon.
calcaneal fibular ligament.

Correct Answer: peroneus longus tendon.

Explanation:

DISCUSSION
The peroneal tubercle is often a good landmark at which to identify the peroneus longus tendon surgically, and a hypertrophic tubercle has been associated with peroneus longus tendinopathy. Both peroneal tendons curve anteriorly around the tip of the fibula, with the peroneal tubercle separating the 2 tendons at the level of the calcaneus. The peroneus brevis runs in front of the tubercle and the longus behind. The flexor hallucis longus runs through a fibro-osseus tunnel posterior to the hindfoot formed by the posterolateral (os trigonum) and posteromedial tubercle of the talus. The calcaneal fibular ligament attaches to the calcaneus below the posterior facet of the subtalar joint and deep to the peroneal tendons.
RECOMMENDED READINGS
Hyer CF, Dawson JM, Philbin TM, Berlet GC, Lee TH. The peroneal tubercle: description, classification, and relevance to peroneus longus tendon pathology. Foot Ankle Int. 2005 Nov;26(11):947-50. Pub PMID: 16309609.
View Abstract at PubMed
Bruce WD, Christofersen MR, Phillips DL. Stenosing tenosynovitis and impingement
of the peroneal tendons associated with hypertrophy of the peroneal tubercle. Foot Ankle Int. 1999 Jul;20(7):464-7. PubMed PMID: 10437932.
View Abstract at PubMed

Question 67:

What dominant intracellular proteins become directly phosphorylated as a result of bone morphogenetic protein (BMP) binding to its receptors? Review Topic

Options:

Myc
SMADs
Beta-catenin (ß-catenin)
Adenylate cyclase

Correct Answer: SMADs

Explanation:

Question 68:

Options:

stronger initial graft fixation.
more anatomic positioning of tibial fixation.
more natural knee kinematics during deep flexion.
more graft protection during cyclic loading.

Correct Answer: more graft protection during cyclic loading.

Explanation:

Question 69:

Figures 29a and 29b show the radiograph and CT scan of a 48-year-old man who has diffuse spinal pain. What is the most likely diagnosis?

Options:

Rheumatoid arthritis
Diffuse idiopathic skeletal hyperostosis (DISH)
Normal findings
Ankylosing spondylitis
Osteopetrosis

Correct Answer: Ankylosing spondylitis

Explanation:

Question 70:

Options:

Interleukin-2-based chemotherapy
Embolization followed by curettage, intramedullary fixation, and cementation
Embolization followed by curettage and cementation
External beam radiation
Total humeral resection and prosthetic reconstruction

Correct Answer: Embolization followed by curettage, intramedullary fixation, and cementation

Explanation:

Question 71:

Options:

Serum calcium normal
Serum alkaline phosphatase normal
Urine calcium is low
Serum phosphate is often high When symptomatic, the masses are excised. This lesion is benign and removal of normal tissue and radiation therapy are not necessary.

Correct Answer: Serum calcium normal

Explanation:

Slide 1 Slide 2
A 20-year-old woman has a large mass over the right hip. An anteroposterior and oblique radiographs are shown in Slides 1 and

Question 72:

Options:

MRI-arthrogram to evaluate the rotator cuff
Rotator cuff strengthening program
Posterior capsular stretching program
Shoulder arthroscopy with SLAP repair
Shoulder arthroscopy with posterior capsular release

Correct Answer: Posterior capsular stretching program

Explanation:

DISCUSSION: Throwing athletes with symptomatic internal rotation deficits often benefit from an intensive posterior capsular stretching program. Patients that fail to respond to nonsurgical management may benefit from an arthroscopic posterior capsular release.
REFERENCES: Wilk KE, Meister K, Andrews JR: Current concepts in rehabilitation of the overhead throwing athlete. Am J Sports Med 2002;30:136-151.
Myers JB, Laudner KG, Pasquale MR, et al: Glenohumeral range of motion deficits and posterior shoulder tightness in throwers with pathologic internal impingement. Am J Sports Med 2006;34:385-391.

Question 73:

In a statement put forth by AAOS, the role of the orthopaedic surgeon in the face of domestic and family abuse includes all of the following EXCEPT: Review Topic

Options:

Be aware that he or she may be the first physician to be caring for the victims
Ensure that they maintain comprehensive and accurate medical records documenting the events and examinations
Care should resume once the patient's social situation is evaluated and assessed
Transfer an elderly victim who is in immediate danger to a hospital emergency department and notify the emergency department physician of the transfer and the reasons for your concern
Advocate for appropriate legislation and public policy

Correct Answer: Be aware that he or she may be the first physician to be caring for the victims

Explanation:

Question 74:

Patient-specific instrumentation (PSI) reliably demonstrates which benefit over conventional intramedullary guidance systems?

Options:

Lower cost
Improved functional outcomes
Better coronal alignment
Fewer trays

Correct Answer: Fewer trays

Explanation:

Question 75:

What is the predominant type of collagen in the tissue resulting from the surgical procedure shown in Figures 40a through 40c?

Options:

Type I
Type II
Type III
Type IX
TypeX

Correct Answer: Type I

Explanation:

Question 76:

Options:

Site A is the apical ectodermal ridge (AER). Site A tissue expresses Shh protein.
Site A is the AER. Site A tissue expresses FGF8.
Site A is the zone of polarizing activity (ZPA). Site A tissue expresses Shh protein.
Site A is the zone of polarizing activity (ZPA). Site A tissue expresses FGF8 protein.
Site A is non-AER ectoderm. Site A tissue expresses WNT7a.

Correct Answer: Site A is the apical ectodermal ridge (AER). Site A tissue expresses Shh protein.

Explanation:

Question 77:

Options:

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

Correct Answer: Menstrual history

Explanation:

Question 78:

Options:

Clostridium
Acinetobacter
Pseudomonas
Mycobacterium
Staphylococcus aureus

Correct Answer: Clostridium

Explanation:

Question 79:

Options:

CT scan with 3D reconstructions
Ultrasonography
MRI scan
Fluoroscopically-guided arthrogram

Correct Answer: CT scan with 3D reconstructions

Explanation:

Question 80:

Options:

Lymphocentigraphy
Colonoscopy
Bronchoscopy
Embolization of the femoral lesion
Bone marrow aspiration

Correct Answer: Embolization of the femoral lesion

Explanation:

DISCUSSION: The histology shows findings consistent with metastatic renal cell carcinoma. Renal cell carcinoma metastases are extremely vascular. Preoperative embolization helps minimize the amount of blood loss during curettage of these lesions.
REFERENCES: Chatziioannou AN, Johnson ME, Pneumaticos SG, et al: Preoperative embolization of bone metastases from renal cell carcinoma. Eur Radiol 2000;10:593-596.
Sun S, Lang EV: Bone metastases from renal cell carcinoma: Preoperative embolization. J Vasc Interv Radiol 1998;9:263-269.

Question 81:

Options:

Cubital tunnel release
Guyon's canal release
Hook-of-hamate excision
Excision of the ganglion cyst

Correct Answer: Excision of the ganglion cyst

Explanation:

Question 82:

What is the most appropriate plating technique utilized for the medial malleolus fracture typically seen in a displaced supination-adduction ankle fracture?

Options:

Tension band plating
Antiglide plating
Bridge plating
Neutralization plating
Submuscular plating

Correct Answer: Tension band plating

Explanation:

Question 83:

Options:

Child abuse workup
Closed reduction
Open reduction with possible osteotomy
Observation

Correct Answer: Observation

Explanation:

Question 84:

Options:

Posterior interosseous nerve palsy
Cervical disk herniation
Entrapment of the flexor pollicis longus tendon
Rupture of the extensor pollicis longus tendon
Metacarpophalangeal joint dislocation

Correct Answer: Rupture of the extensor pollicis longus tendon

Explanation:

DISCUSSION: A recent review of 200 consecutive distal radius fractures noted that the overall incidence of extensor pollicis longus rupture was 3%. The causes are believed to be mechanical irritation, attrition, and vascular impairment. The fracture is usually nondisplaced and the patient notes weeks to months after injury the sudden, painless inability to extend the thumb. Treatment involves extensor indicis proprius tendon transfer or free palmaris longus tendon grafting.
REFERENCES: Skoff HD: Postfracture extensor pollicis longus tenosynovitis and tendon rupture: A scientific study and personal series. Am J Orthop 2003;32:245-247.
Bonatz E, Kramer TD, Masear VR: Rupture of the extensor pollicis longus tendon. Am J Orthop 1996;25:118-122.
Helal B, Chen SC, Iwegbu G: Rupture of the extensor pollicis longus tendon in undisplaced Colles’ type of fracture. Hand 1982;14:41-47.

Question 85:

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 86:

Options:

Malingering
Complex regional pain syndrome
Anxiety disorder
Intimate partner violence
Fibromyalgia

Correct Answer: Malingering

Explanation:

Question 87:

An increase in advanced glycation end-products (AGEs) is characteristic of which of the following clinical conditions and results in which pathologic process?

Options:

Increased AGES is characteristic of aging articular cartilage and results in decreased articular cartilage stiffness
Increased AGES is characteristic of osteoarthritis and results in increased articular cartilage stiffness
Increased AGES is characteristic of unresurfaced patellar cartilage after total knee arthroplasty and results in articular cartilage thinning
Increased AGES is characteristic of rheumatoid arthritis and results in synovial thickening
Increased AGES is characteristic hemarthrosis and results in articular cartilage staining

Correct Answer: Increased AGES is characteristic of aging articular cartilage and results in decreased articular cartilage stiffness

Explanation:

Question 88:

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 89:

Following preoperative chemotherapy, the percent of tumor necrosis has been shown to be of prognostic value for which of the following tumors?

Options:

Rhabdomyosarcoma
Chondrosarcoma
Metastatic adenocarcinoma
Osteosarcoma
Giant cell tumor of bone

Correct Answer: Osteosarcoma

Explanation:

Question 90:

A 50-year-old man with metastatic renal cell carcinoma has right hip pain. A radiograph and CT scan are shown in Figures 48a and 48b. The first step in management should consist of

Options:

administration of intravenous bisphosphonates.
cemented right total hip arthroplasty with acetabular reconstruction.
external beam radiation.
embolization of the lesion.
percutaneous cementoplasty.

Correct Answer: embolization of the lesion.

Explanation:

Question 91:

A 46-year-old woman had an ankle fracture and ORIF 6 years ago. She had subsequent removal of some of the hardware, but her pain has persisted (Figures 44a and 44b).

Options:

Tibial and/or fibular osteotomy with open reduction and internal fixation (ORIF)
Ankle distraction arthroplasty
Ankle fusion
Total ankle arthroplasty (TAA)

Correct Answer: Tibial and/or fibular osteotomy with open reduction and internal fixation (ORIF)

Explanation:

DISCUSSION
Patients younger than 40 years of age who have ankle arthritis pose an ongoing clinical challenge. Nonsurgical treatment should be maximized, although distraction arthroplasty can be used in an effort to delay the need for fusion.
One of the strongest indications for ankle arthroplasty is a preexisting hindfoot fusion with a goal to retain some ankle/hindfoot motion. Ankle fusion is perhaps the most predictable surgical treatment for a relatively young, active patient with ankle arthritis. Moreover, there are concerns regarding implant loosening when performing TAA in active patients.
Outcome after syndesmosis ORIF has been linked to the quality of the reduction at the index procedure. Syndesmotic malreduction that is severe necessitates osteotomy and revision ORIF.
RECOMMENDED READINGS
Sagi HC, Shah AR, Sanders RW. The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up. J Orthop Trauma. 2012 Jul;26(7):439-43. doi: 10.1097/BOT.0b013e31822a526a. PubMed PMID: 22357084.
View Abstract at PubMed
Smith NC, Beaman D, Rozbruch SR, Glazebrook MA. Evidence-based indications for distraction ankle arthroplasty. Foot Ankle Int. 2012 Aug;33(8):632-6. Review.
View Abstract at PubMed
Kim BS, Knupp M, Zwicky L, Lee JW, Hintermann B. Total ankle replacement in association with hindfoot fusion: Outcome and complications. J Bone Joint Surg Br. 2010 Nov;92(11):1540-7. doi: 10.1302/0301-620X.92B11.24452. PubMed PMID: 21037349.
View Abstract at PubMed
Daniels TR, Younger AS, Penner M, Wing K, Dryden PJ, Wong H, Glazebrook M. Intermediate-term results of total ankle replacement and ankle arthrodesis: a COFAS multicenter study. J Bone Joint Surg Am. 2014 Jan 15;96(2):135-42. doi: 10.2106/JBJS.L.01597.
View Abstract at PubMed

Question 92:

Options:

2 months after surgery
3 months after surgery
6 months after surgery
9 months after surgery
12 months after surgery

Correct Answer: 2 months after surgery

Explanation:

After closed reduction and percutaneous pinning of a displaced pediatric supracondylar fracture, it will take an average of 6 months for 94% of normal elbow range of motion to return.
Displaced pediatric supracondylar elbow fractures are often treated with closed reduction and percutaneous pinning. Risk of stiffness is low considering the extra-articular nature of the injury. Utility of physical therapy to improve range of motion after operative treatment of this injury is not supported in the literature.
Zionts et al. retrospectively evaluated elbow stiffness after treatment for pediatric supracondylar fractures. Ninety-four percent of normal range of motion was restored by 6 months after the operative procedure. Further improvement occurs up to one-year postoperatively
Lee et al. surveyed 76 orthopaedic surgeons on their treatment of pediatric supracondaylar injuries. They noted that general orthopaedic surgeons used passive exercises to assist with elbow stiffness after operative management of pediatric supracondylar fractures. In contrast, pediatric orthopaedists used active range of motion to improve elbow motion.
Keppler et al. retrospectively reviewed patients who had sustained supracondaylar fractures to ascertain the effect of postoperative physical therapy. At one year follow up, there was no difference in motion between patients who had received physical therapy and those who had not.
Figures A and B demonstrate the AP and lateral radiographs of a pediatric supracondylar fracture. Figures C and D are the postoperative radiographs after closed reduction and percutaneous pinning of the elbow injury.
Incorrect Answers:
(SBQ13PE.13) A 17-month-old boy is referred to your clinic by his pediatrician for a workup of "bowed legs." The patient's mother states that she has other children that grew out of it by age 3 or 4. Examination of the patient reveals a child whose measurements reside in the 75% percentile for height and weight. His gait appears appropriate for a toddler without varus thrust. Supine measurements show 10-degrees of symmetric, bilateral genu varus. Appropriate workup includes:
Review Topic
Longterm clinical and radiographic monitoring to plan for guided growth until skeletal maturity
X-rays today and at age 4 to assure resolution of his genu varum
Genetic screening for metabolic causes of Rickets
Vitamin D levels drawn today and weekly 50,000 IU vitamin D injections assuming the value is low
Clinical observation and follow up to monitor resolution of genu varum
This patient has physiologic genu varum or tibia vara, which is common in toddlers less than 2 years of age. The mainstay of treatment is simple observation, as there is predictable resolution of this alignment as children
There are numerous etiologies of genu varum in children. Most common in the children under age 2 is a predictable pattern of genu varum and internal torsion in the first year or so after beginning to walk. Persistence of genu varum, severe (>20 degrees) or worsening deformity, limb asymmetry or varus thrust gait, and low height and weight percentiles should trigger further workup with x-rays and metabolic or genetic screening. A family history of genu varum is non-specific, and in isolation, does not indicate heritable causes of genu varum.
Kling and Hensinger's review article highlights normal angular and torsional deviations in growing children, including genu varum and genu valgum as well as hip and hind foot deformities. They emphasize that understanding the natural history of these deformities in growing children helps the treating physician identify those who need more than simple observation of their malalignment.
Staheli et al. published normal values of rotational profile physical exam maneuvers (including thigh foot axis, transmalleolar axis, prone internal and external hip rotation) to better understand the predictable changes in different age groups.
Birch provides an update on current treatment of Blount's disease. He suggests further radiographic evaluation in ambulatory infants with asymmetric varus deformity or varus deformity that persists after age 18 months. If these findings are present, radiographs are recommended. If the X-rays reveal metaphyseal-diaphyseal angle
>16° on AP radiographs and confirm the diagnosis of infantile Blount disease, he recommends anti-varus long leg bracing during ambulation for patients aged <=3 years with progressive deformity, clear radiographic evidence of infantile Blount disease, or lateral thrust with ambulation.
Illustration A shows pathologic metaphyseal beaking common in Blount's disease. There are no pathognomonic x-ray findings in physiological bowing as presented in this question.
Incorrect Answers:

Question 93:

Options:

Reverse shoulder arthroplasty
Hemiarthroplasty
Resurfacing of the humeral head
Arthroscopic debridement
Shoulder fusion

Correct Answer: Reverse shoulder arthroplasty

Explanation:

Question 94:

Options:

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

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

Explanation:

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

Question 95:

Options:

Serum calcium normal
Serum alkaline phosphatase normal
Urine calcium is low
Serum phosphate is often high When symptomatic, the masses are excised. This lesion is benign and removal of normal tissue and radiation therapy are not necessary. Notice the lobules of amorphous calcification that are centered about the hip joint. This is the characteristic appearance of tumoral calcinosis.

Correct Answer: Serum phosphate is often high When symptomatic, the masses are excised. This lesion is benign and removal of normal tissue and radiation therapy are not necessary. Notice the lobules of amorphous calcification that are centered about the hip joint. This is the characteristic appearance of tumoral calcinosis.

Explanation:

Slide 1 Slide 2
A 20-year-old patient who is otherwise healthy has a soft mass over her hip. The mass has formed over the past 2 years. The radiographs are shown in Slides 1 and 2. Which of the following would be a common finding:

Question 96:

Options:

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

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

Explanation:

Question 97:

At the time of arthroscopy, a 9-year-old boy was found to have a Watanabe type II discoid lateral meniscus. What is the most appropriate treatment? Review Topic

Options:

Saucerization of the meniscus only
Saucerization and stabilization of the meniscus
Stabilization of the meniscus only
Complete menisectomy

Correct Answer: Saucerization of the meniscus only

Explanation:

Question 98:

An 8-month-old infant has an infection of the fingertip as shown in Figure 22. If neglected, the anticipated path of ascending infection is the fingertip, the flexor sheath, and the

Options:

midpalmar space.
thenar space.
hypothenar space.
ulnar bursa.
radial bursa.

Correct Answer: midpalmar space.

Explanation:

Question 99:

A 45-year-old coach sustains a complete distal biceps tendon rupture at the elbow. Surgical repair is most indicated to Review Topic

Options:

restore full supination strength.
restore full elbow flexion strength.
restore full range of motion.
improve cosmesis.
prevent degenerative changes of the elbow.

Correct Answer: restore full supination strength.

Explanation:

Question 100:

What is the most frequent complication of both lateral closing wedge high tibial osteotomy and medial opening wedge osteotomy?

Options:

Patella baja
Fracture
Peroneal nerve palsy
Compartment syndrome
Infection

Correct Answer: Patella baja

Explanation:

DISCUSSION: Scuderi and associates reported on patellar height after a high tibial osteotomy. Eighty-nine percent of the patellae, as measured by the Insall-Salvati index, and 76.3 percent, as measured by the Blackburne-Peel index, were observed to be lowered. More recently, Wright and associates reported a 64% incidence of patella baja in patients undergoing a medial opening wedge osteotomy. The incidence of intra-articular fracture during medial opening wedge osteotomy has been reported to be as high as 11% by Hernigou and associates, whereas the incidence of intra-articular fracture during lateral closing wedge high tibial osteotomy has been reported to be 10% to 20% by Matthews and associates. The incidence of peroneal nerve palsy with a lateral closing wedge high tibial osteotomy ranges from 0% to 20%, according to Marti and associates, whereas the incidence of peroneal palsy following a medial opening wedge osteotomy has been reported to be 15.7% by Flierl and associates. The exact incidence of compartment syndrome after a high tibial osteotomy is not known; however, it does not reach the level of patella baja. The incidence of deep infection after a lateral closing wedge high tibial osteotomy ranges from 0% to 4% according to Billings and associates.
REFERENCES: Scuderi GR, Windsor RE, Insall JN: Observations on patellar height after proximal tibial osteotomy. J Bone Joint Surg Am 1989;71:245-248.
Wright JM, Crockett HC, Slawski DP, et al: High tibial osteotomy. J Am Acad Orthop Surg 2005;13:279-289.
Hernigou P, Medevielle D, Debeyre J, et al: Proximal tibial osteotomy for osteoarthritis
with varus deformity: A ten to thirteen-year follow-up study. J Bone Joint Surg Am 1987;69:332-354.
Matthews LS, Goldstein SA, Malvitz TA, et al: Proximal tibial osteotomy: Factors that influence the duration of satisfactory function. Clin Orthop 1988;229:193-200.
Marti CB, Gautier E, Wachtl SW, et al: Accuracy of frontal and sagittal plane correction in open-wedge high tibial osteotomy. Arthroscopy 2004;20:366-372.
Marti RK, Verhigan RA, Kerkhoffs GM, et al: Proximal tibial varus osteotomy: Indications, technique, and five to twenty-one-year results. J Bone Joint Surg Am 2001;83:164-170.
Flierl S, Sabo D, Hornig K, et al: Open wedge high tibial osteotomy using fractioned drill osteotomy: A surgical modification that lowers the complication rate. Knee Surg Sports Traumatol Arthrosc 1996;4:149-153.
Billings A, Scott DF, Camargo MP, et al: High tibial osteotomy with a calibrated osteotomy guide, rigid internal fixation, and early motion: Long-term follow-up. J Bone Joint Surg Am 2000;82:70-79.

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

Orthopedic Surgery Board Review MCQs: Spine, Arthroplasty, Knee & Shoulder | Part 183

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 183

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index