Spine, Trauma, Foot & Wrist Orthopedic MCQs - Part 185

About This Board Review Set

This is Part 185 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

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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 185

This module focuses heavily on: Deformity, Dislocation, Foot, Fracture, Hip, Tendon, Wrist.

Sample Questions from This Set

Sample Question 1: A previously healthy 30-year-old woman has neck pain and bilateral hand and lower extremity tingling with weakness after falling down stairs. She is alert and oriented. Examination reveals incomplete quadriplegia at the C6 level that remain...

Sample Question 2: Which of the following are considered appropriate nonsurgical bracing/orthotic options for a supple adult-acquired flatfoot deformity with forefoot abduction, secondary to posterior tibial tendon insufficiency?...

Sample Question 3: A 14-year-old girl reports hip pain that is exacerbated by weight bearing. A radiograph and biopsy specimen are shown in Figures 16a and 16b. The best course of management should be...

Sample Question 4: A 25-year-old woman has had continuous pain after falling on her outstretched wrist 12 weeks ago. A current radiograph is shown in Figure 11. Management should consist of...

Sample Question 5: A 28-year-old man has had a 2-week history of right posterior leg pain, with numbness and tingling in the same distribution. He denies any problems with bowel or bladder function. Examination shows intact motor strength in his bilateral low...

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

A previously healthy 30-year-old woman has neck pain and bilateral hand and lower extremity tingling with weakness after falling down stairs. She is alert and oriented. Examination reveals incomplete quadriplegia at the C6 level that remains unchanged throughout her evaluation and initial treatment. Radiographs show a bilateral facet dislocation of C6 on C7 without fracture. Attempts at reduction with halo cervical traction up to her body weight are unsuccessful. What is the next most appropriate step?

Explanation

DISCUSSION: A facet dislocation that cannot be reduced in an alert, awake patient with some preservation of cord function requires MRI to evaluate the disk prior to a reduction under anesthesia. The presence or absence of a disk herniation must be assessed, as this factor may influence the method of reduction.
REFERENCES: Vaccaro AR, Falatyn SP, Flanders AE, et al: Magnetic resonance evaluation of the intervertebral disc, spinal ligaments, and spinal cord before and after closed traction reduction of cervical spine dislocations. Spine 1999;24:1210-1217.
Fardon DF, Garfin SR, Abitbol J (eds): Orthopaedic Knowledge Update: Spine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 247-262.
Eismont FJ, Arena MJ, Green BA: Extrusion of an intervertebral disc associated with traumatic subluxation or dislocation of cervical facets. J Bone Joint Surg Am 1991;73:1555-1560.
Cotler JM, Herbison GJ, Nasuti JF, et al: Closed reduction of traumatic cervical spine dislocation using traction weights up to 140 pounds. Spine 1993;18:386-390.

Question 2

Which of the following are considered appropriate nonsurgical bracing/orthotic options for a supple adult-acquired flatfoot deformity with forefoot abduction, secondary to posterior tibial tendon insufficiency?

Explanation

DISCUSSION: The initial stages of posterior tibial tendon insufficiency, where the deformity remains supple, may be treated with bracing or an orthotic for pain relief. The Arizona brace was introduced in 1988, and assists in pain relief and deformity correction by minimizing hindfoot valgus alignment, lateral calcaneal displacement, and medial ankle collapse. It is particularly helpful in those patients with advanced disease that cannot tolerate an ankle-foot orthosis. All other choices are incorrect because of the addition of lateral posting, which is not advantageous in valgus deformities. The addition of medial posting to any of the above choices would render them correct alternatives. A heel lift is applicable in Achilles tendon disorders, not posterior tibial tendon disorders.
REFERENCES: Chao W, Wapner KL, Lee TH, et al: Nonoperative management of posterior tibial tendon dysfunction. Foot Ankle Int 1996;17:736-741.
Imhauser CW, Abidi NA, Frankel DZ, et al: Biomechanical evaluation of the efficacy of external stabilizers in conservative treatment of acquired flat foot deformity. Foot Ankle Int 2002;23:727-737.

Question 3

A 14-year-old girl reports hip pain that is exacerbated by weight bearing. A radiograph and biopsy specimen are shown in Figures 16a and 16b. The best course of management should be

Explanation

DISCUSSION: The patient has a unicameral bone cyst. Because the subtrochanteric part of the femur is a high-stress region, the treatment of choice is bone curettage and grafting.
REFERENCES: Azouz EM, Karamitsos C, Reed MH, Baker L, Kozlowski K, Hoeffel JC: Types and complications of femoral neck fractures in children. Pediatr Radiol 1993;23:415-420.
Hecht AC, Gebhardt MC: Diagnosis and treatment of unicameral and aneurysmal bone cysts in children. Curr Opin Pediatr 1998;10:87-94.

Question 4

A 25-year-old woman has had continuous pain after falling on her outstretched wrist 12 weeks ago. A current radiograph is shown in Figure 11. Management should consist of

Explanation

DISCUSSION: The patient has a scaphoid fracture with cystic resorption of the distal aspect of the midthird of the scaphoid. This fracture is unlikely to heal without intervention. Percutaneous pinning, closed manipulation, and bone grafting will not restore alignment. Treatment requires restoration of scaphoid length, bone grafting, and internal fixation to obtain healing with normal alignment.
REFERENCES: Cooney WP, Linscheid RL, Dobyns JH, Wood MB: Scaphoid nonunion: Role of anterior interpositional bone grafts. J Hand Surg Am 1988;13:635-650.
Fernandez DL: A technique for anterior wedge-shaped grafts for scaphoid nonunions with carpal instability. J Hand Surg Am 1984;9:733-737.
Stark HH, Rickard TA, Zemel NP, Ashworth CR: Treatment of ununited fractures of the scaphoid by illiac bone grafts and Kirschner-wire fixation. J Bone Joint Surg Am

1988;70:982-991.
Feldman MD, Manske PR, Welch RL, Szerzinski JM: Evaluation of Herbert screw fixation for the treatment of displaced scaphoid nonunions. Orthopedics 1997;20:325-328.

Question 5

A 28-year-old man has had a 2-week history of right posterior leg pain, with numbness and tingling in the same distribution. He denies any problems with bowel or bladder function. Examination shows intact motor strength in his bilateral lower extremities, with numbness to light touch in the lateral border of his right foot. Over the past 2 weeks, his leg pain has improved significantly. MRI scans are shown in Figures 57a and 57b. What is the most appropriate course of management? Review Topic

Explanation

MRI of lumbar spine
Repeat ESR/CRP and whole body bone scan
CT of lumbar spine
Dynamic flexion/extension plain film radiographs
Dynamic lateral bending plain film radiographs
This patient has clinical and radiographic features of failed spinal arthrodesis. CT scan have been shown to be the most relable method for assessing spinal fusion postoperatively.
Reported rates of nonunion following posterior spinal fusion range from 0-70%. Rates are variable due to the various operative techniques, underlying diagnoses as well as asymptomatic patients. Non-union may lead to changes in alignment, spinal instability and potential neurological injury. Static radiographs have long been used as a practical method of fusion assessment, but these tend to significantly overestimate the presence of a solid fusion. Lack of movement at a fused segment, on dynamic views, does not confirm fusion. CT offers excellent bony resolution and are less affected by metal artifact compared to MRI.
Patel et al. showed that tobacco use, malnutrition, oral anti-inflammatory use, multilevel fusion, prior spine surgery, and sagittal imbalance are all risk factors for spinal nonunion.
Mok et al. looked at erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels after spinal surgery and compared their usefulness as predictors of infectious complications in the early postoperative period. They found that CRP is more applicable, predictable, and responsive in the early postoperative period compared with ESR. Using a second rise or failure to decrease as expected for CRP is sensitive for infection.
Shelby et al. reviewed the radiological assessment of spinal fusion. They comment that fine-cut imaging, multiplanar reconstruction, and metal artifact reduction have increased the ability to assess fusion on CT.
Figure A shows a series of lateral radiographs of the lumbar spine with posterior spinal instrumentation. Illustration A shows a lateral CT scan image of multi-level pseudoarthrosis after posterior spinal instrumented fusion. Illustration B shows an
intra-operative
view
of
spinal
pseudoarthrosis
(white
arrow).
Incorrect
(SBQ12SP.19) A 41-year-old male presents with acute onset of low back pain that started when he was trying to lift a heavy box while helping his brother move apartments two days ago. The pain has been severe enough to cause him to miss work yesterday. He has no neurologic deficits. What are the chances he will return to work within 6 weeks? Review Topic
1 80 to 90%
2 70 to 80%
3 60 to 70%
4 50 to 60%
5 40 to 50%
Most adults (up to 80%) will experience an episode of low back pain in their lifetime. In those whose pain is severe enough to cause them to miss work, 60 to 70% will return by 6 weeks, and 80 to 90% will return by 12 weeks.
Low back pain is common in adults. Most patients experience resolution of symptoms quickly and have no lasting loss of function. However, 5 to 10% develop chronic pain. Recurrence of pain is common, and is part of the natural history, occurring in 20 to 72% of patients. After 12 weeks, return to work rates are slow.
Shen et al. review the nonoperative management of acute and chronic low back pain. The authors note that none of the available interventions has been proven by high quality large randomized controlled trials. The authors believe that low dose oral
steroids are safe in the short term and that injection therapy should not be used without a reasonable presumptive diagnosis.
Madigan et al. review the management of lumbar degenerative disease. The authors emphasize that the majority of patients improve within 6 weeks with or without treatment. For patients that do not, the authors do not recommend epidural injection, as there are no good studies to support their use in the treatment of discogenic back pain. When surgical treatment is indicated they state that arthrodesis is the gold standard, although the long term results of total disk arthroplasty are being elucidated.
Illustration A shows a table of available non-operative treatment modalities for back pain. Illustration B shows a list of possible diagnoses associated with acute low back pain, with those associated with neurogenic pain italicized. Illustration C shows a list of 'red flag' symptoms indicating serious/emergent causes of low back pain.
Incorrect
2:
Longer
to than
90%

Question 6

Figure 80a shows an arthroscopic view from an infralateral portal of a right knee. Figure 80b shows a coronal MRI scan, and Figures 80c through 80e show consecutive sagittal images of the knee. The images show what anatomic finding? Review Topic

Explanation

The arthroscopic view and the coronal MRI scan show a discoid lateral meniscus covering almost the entire lateral tibial plateau. The sagittal views show a contiguous meniscus or "bow tie" sign on three consecutive images, pathognomonic for a discoid meniscus. Lateral discoid menisci are much more common than medial. There is no evidence of abnormal signal to indicate meniscal tearing. A transverse meniscal ligament is best seen anterior to the anterior horn of the lateral meniscus on multiple views. There is no evidence of a loose body on the arthroscopic or MRI images.

Question 7

A 29-year-old male sustains the isolated lower extremity injury shown in Figure A. During open reduction, what structure must be kept intact in order to protect the remaining blood supply to the talar body?

Explanation

Figure A represents a type 3 Hawkins talar neck fracture. A type 3 injury is defined as a displaced fracture of the talar neck with dislocation of body of talus from both the subtalar joint and the tibiotalar joint. In these injuries, the talar body fragment typically rotates around intact deltoid ligament fibers to lie in soft tissues with the fracture surface pointing laterally and cephalad. Often, the deltoid branch of the posterior tibial artery, which lies between the leaves of the deltoid ligament and supplies up to 1/2 of the medial talar body, is the only remaining blood supply. Therefore, the deltoid ligament must be preserved to lower the risk of avascular necrosis. When performing a medial malleolar osteotomy, the deltoid ligament must remain in continuity with the malleolus to prevent disruption of the blood supply.
The review article by Fortin et al discusses talar blood supply, injury mechanisms and classifications, and treatment options. They state that the main artery to the body of the talus is the artery of the tarsal canal, which is a branch of the posterior tibial artery. The peroneal and anterior tibial artery also contribute branches to the talus.
Illustration A and B show the arterial network of the talus.

OrthoCash 2020

Question 8

An 18-year-old patient sustains a comminuted left femoral fracture starting 6.5cm distal to the lesser trochanter. He undergoes antegrade femoral nailing in the supine position on a radiolucent table. Upon completion of proximal and distal interlocking, both patellae are positioned facing the ceiling and a lateral radiographs confirms that the posterior condyles of both limbs are aligned. On AP imaging of both femora, it is noted that the lesser trochanter of the left (injured) side is larger than the right (uninjured) side. Assuming symmetrical anteversion, the left femur has been nailed Review Topic

Explanation

Pulmonary embolus
Periprosthetic fracture
Contralateral hip fracture
Osteonecrosis
Infection
This young male patient has sustained a displaced femoral neck fracture and underwent open reduction internal fixation with 3 cannulated screws. Based on the available options, the patient is most at risk of developing osteonecrosis of the femoral head.
Femoral neck fractures in young patients typically are the result of a high-energy trauma. Fracture displacement has been shown to disrupt vascular supply to the femoral head by interrupting retinacular vessels and ligament teres vascularization, as well as increasing intracapsular pressure, producing a tamponade effect. The incidence of osteonecrosis in patients younger than 60 years with displaced femoral neck fractures has been shown to be between 15-30%. Quality of reduction is one key factor that has been shown to influence outcomes postoperatively.
Loizou et al. prospectively studied 1,023 patients who sustained an intracapsular hip fracture that was treated with internal fixation using standard fixation modalities. They showed that osteonecrosis was less common for undisplaced (4.0%) than for displaced fractures (9.5%). The population at greatest risk were women younger than the age of 60 with displaced fractures.
Barnes et al. review subcapital hip fractures. They found that late segmental collapse was more common in displaced fractures in women younger than age 75 years than in those older than age 75 years treated with internal fixation.
Figure A shows a displaced, Garden 3/Pauwels I hip fracture. Figure B shows anatomical fixation with 3 cannulated screws.
Incorrect Answers:

Question 9

The stability of the longitudinal arch of the foot during standing with equal weight on both feet is due primarily to

Explanation

The longitudinal arch is stabilized by heavy ligamentous structures surrounding the tarsal joints with passive assistance from the plantar aponeurosis. EMG studies have shown little or no intrinsic muscle activity during quiet standing.

Question 10

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

Explanation

DISCUSSION: The patient sustained an incomplete spinal cord injury known as central cord syndrome. Central cord syndrome characteristically has disproportionate involvement of the upper extremities with the lower extremities being relatively spared. It is most commonly seen after cervical injuries in elderly patients with spondylosis and spinal stenosis, often without fracture. Penrod and associates noted that 23 of 59 patients with central cord syndrome

(ASIA C and D) ultimately walked. The poorest prognosis, however, was in ASIA C patients older than age 50, in which only 40% walked.
REFERENCES: Penrod LE, Hegde SK, Ditunno JF Jr: Age effect on prognosis for functional recovery in acute, traumatic central cord syndrome. Arch Phys Med Rehab 1990;71:963-968.
Northrup BE: Acute injuries to the spine and spinal cord: Evaluation and early treatment, in Clark CR (ed): The Cervical Spine, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 2005, p 735.

Question 11

What is the most consistent finding regarding glenohumeral kinematics in patients with symptomatic tears of the rotator cuff?

Explanation

DISCUSSION: Normal glenohumeral kinematics are represented by ball-and-socket modeling when the rotator cuff is intact. This is true for motion that involves more than 30 degrees of abduction. In patients with shoulder pain and symptomatic rotator cuff tears, superior translation occurs with abduction beyond 30 degrees. This is quite evident in massive tears but is seen consistently to a lesser degree with smaller tears.
REFERENCES: Yamaguchi K, Sher JS, Anderson WK, et al: Glenohumeral motion in patients with rotator cuff tears: A comparison of asymptomatic and symptomatic shoulders. J Shoulder Elbow Surg 2000;9:6-11.
Poppen NK, Walker PS: Normal and abnormal motion of the shoulder. J Bone Joint Surg Am 1976;58:195-201.

Question 12

A 32-year-old man who sustained a tarsometatarsal (Lisfranc) injury 3 years ago now reports increasing pain in the left foot. Orthotics, nonsteroidal anti-inflammatory drugs, and injections have provided only temporary relief. Examination reveals swelling and tenderness over the tarsometatarsal joints. Radiographs show advanced arthrosis of the first and second tarsometatarsal joints. Management should now include

Explanation

DISCUSSION: The patient has advanced arthrosis of the midfoot, and orthotic management has failed to provide relief. Therefore, the treatment of choice is midfoot arthrodesis. Shock wave treatment has not been shown to be beneficial for arthritis. An ankle-foot orthosis would not be appropriate based on findings of a normal ankle joint. Triple arthrodesis would not be helpful because the hindfoot joint is not affected in a Lisfranc injury.
REFERENCES: Sangeorzan BJ, Veith GR, Hansen ST Jr: Salvage of Lisfranc’s tarsometatarsal joints by arthrodesis. Foot Ankle 1990;10:193-200.
Komenda GA, Myerson MS, Biddinger KR: Results of arthrodesis of the tarsometatarsal joints after traumatic injury. J Bone Joint Surg Am 1996;78:1665-1676.

Question 13

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

Explanation

EXPLANATION:
Wide-awake repair under only local anesthesia, regardless of the technique, allows direct inspection of the tendon repair and active excursion. Regional anesthesia and Bier block anesthesia do not allow active motion (Bier block necessitates continued use of a tourniquet, which limits muscle function). The A2
pulley should be preserved, especially the distal 50%, to maintain tendon function. All of the listed techniques for suture repair are acceptable options.

Question 14

-A 15-year-old boy with mild type I osteogenesis imperfecta (OI) has a midshaft radius/ulna fracture that is in bayonet apposition with loss of the radial bow and 40-degree apex volar and ulnar angulation. Closed reduction improves the angulation to 20 degrees; the bayonet apposition and loss of radial bow remains.His contralateral forearm has a normal appearance upon examination. What is the best treatment for this fracture?

Explanation

Question 15

Figure 65 is the lumbar spine MR image of a 63-year-old woman who has a 3-year history of increasingly bothersome back pain and bilateral buttock and leg pain. She has performed 6 weeks of physical therapy, received epidural injections, and experienced some good short-term results, but her leg pain continues to worsen. What is the most appropriate course of treatment?

Explanation

DISCUSSION
This patient has symptoms consistent with neurogenic claudication secondary to lumbar spinal stenosis and degenerative spondylolisthesis. Her symptoms are chronic and she has undergone an appropriate course of nonsurgical care. Nevertheless, her symptoms are worsening and surgical intervention is a
reasonable consideration. Studies have shown that patients with lumbar spinal stenosis with associated degenerative spondylolisthesis benefit most from decompression of the neural elements that are stenotic and subsequent fusion across the degenerative slip. Anterior lumbar interbody fusion likely will not address stenosis at the level of the slip and may not result in adequate neurologic decompression. Partial laminotomy and diskectomy likely will not provide adequate neural decompression because these procedures would only address unilateral compression and this patient has bilateral issues. Lumbar laminectomy without fusion could be performed but has been associated with results inferior to lumbar laminectomy with fusion when addressing stenosis with spondylolisthesis.
RECOMMENDED READINGS
Weinstein JN, Lurie JD, Tosteson TD, Zhao W, Blood EA, Tosteson AN, Birkmeyer N, Herkowitz H, Longley M, Lenke L, Emery S, Hu SS. Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am. 2009 Jun;91(6):1295-304. PubMed PMID: 19487505. View Abstract at PubMed
Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am. 1991 Jul;73(6):802-8. PubMed PMID: 2071615. View Abstract at PubMed
Lombardi JS, Wiltse LL, Reynolds J, Widell EH, Spencer C 3rd. Treatment of degenerative spondylolisthesis. Spine (Phila Pa 1976). 1985 Nov;10(9):821-7. PubMed PMID: 4089657. View Abstract at PubMed
RESPONSES FOR QUESTIONS 66 THROUGH 69
Deep surgical-site infection
Adjacent segment degeneration
Pressure ulcers
Iatrogenic neurologic injury
Incidental durotomy
Hardware failure
Match the frequently encountered complication listed above with the appropriate clinical scenario below.

Question 16

Figure A is an AP radiograph of a 68-year-old man who presents to clinic with shoulder pain and dysfunction. On examination of his shoulder, he has pseudoparalysis with attempt at forward elevation and a positive hornblower's sign while demonstrating normal belly press test. Treatment should consist of: Review Topic

Explanation

The clinical presentation and radiograph is consistent with a diagnosis of a massive posterosuperior rotator cuff tear and arthropathy. Of the options listed, a reverse total shoulder arthroplasty (RTSA) with latissmus dorsi transfer (LDT) is most appropriate.
RTSA can improve pain and function in shoulders with forward elevation pseudoparalysis secondary to rotator cuff tear arthropathy. Following arthroplasty, the deltoid alone can restore overhead elevation but it does not address active external rotation deficit. LDT is a well described procedure for treatment of irreparable posterosuperior rotator cuff tear. Combining RTSA and LDT can address both deficits and in select patients yields significant pain relief and restoration of function.
Walch et al found that hornblower's sign had 100% sensitivity and 93% specificity for irreparable degeneration of teres minor.
Puskas et al present clinical outcomes of RTSA combined with LDT for treatment of chronic combined pseudoparesis of elevation and external rotation of the shoulder in 40 patients. At a mean follow-up of 53 months, the author report excellent clinical outcomes.
Figure A demonstrates a proximal migration of the humerus resulting in femoralization of the humeral head and acetabularization of the acromion from a massive rotator cuff tear.
Incorrect answers:

Question 17

The mother of a 24-month-old girl reports that the child cannot rotate her right forearm. She also notes delayed development, with the child first walking at 18 months. The child has a five-word vocabulary and has not begun using simple phrases. Examination reveals that the right forearm is fixed in 80 degrees of pronation. The remainder of the examination of both upper extremities is otherwise normal. A radiograph is shown in Figure 41. Which of the following studies will best aid in diagnosis?

Explanation

DISCUSSION: The patient has classic radioulnar synostosis. Patients with this disorder frequently have duplication of sex chromosomes. Synostosis is often seen in females with 48-XXXX or 49-XXXXX in association with delayed development and mental retardation. In males, it can be associated with 48-XXXY or 49-XXXXY. Radioulnar synostosis is not usually associated with muscle disorders, congenital heart disease, or renal anomalies. MRI of the forearm can reveal other soft-tissue anomalies, but this information is not particularly helpful in planning therapy. Osteotomy is sometimes indicated to improve rotational position of the wrist, but this patient’s rotation is quite functional for everyday tasks, and rotational osteotomy is

not indicated.
REFERENCE: Rimoin DL, Connor JM, Pyeritz RE, Korf BR: Emery & Rimoin’s Principles and Practice of Medical Genetics, ed 4. New York, NY, Churchill Livingstone, 2002,

pp 1196-1197.

Question 18

A 55-year-old man who works as a carpenter reports chronic right anterior shoulder pain and weakness. Examination reveals 90 degrees of external rotation (with the arm at the side) compared to 45 degrees on the left side. His lift-off examination is positive, along with a positive belly press finding. An MRI scan reveals a chronic, retracted atrophied subscapularis tendon. What is the most appropriate management of his shoulder pain and weakness? Review Topic

Explanation

Chronic subscapularis tendon ruptures preclude primary repair. In such instances, subcoracoid pectoralis major tendon transfers may improve function and diminish pain. The subcoracoid position of the transfer allows redirection of the pectoralis major in a direction recreating the vector of the subscapularis tendon. Shoulder fusion is a salvage procedure, and corticosteroid injection may reduce pain but will not improve function.

Question 19

Figure 12 shows the frog-lateral radiograph of a 45-year-old man who has a painful left hip. What is the most likely diagnosis?

Explanation

PHASE V: the crescent sign and articular collapse. The supporting bony architecture may become sufficiently weakened by continued resorption of trabecular bone and subchondral bone plate along the reactive interface that the stress of weight-bearing can result in subchondral bone plate fracture with focal articular cartilage buckling and eventual collapse. This is best seen in the frog-lateral radiograph.

Question 20

Figures 34a and 34b show the clinical photographs of a 46-year-old woman who has a painful deformity of the second toe. Surgical treatment consisting of metatarsophalangeal capsulotomy and proximal interphalangeal joint resection arthroplasty resulted in satisfactory correction, but the toe remains unstable at the metatarsophalangeal joint. What is the next most appropriate step?

Explanation

DISCUSSION: Crossover second toes are attributed to attenuation or rupture of the plantar plate and lateral collateral ligament and are associated with varying degrees of instability. Flexor-to-extensor transfer (Girdlestone/Taylor procedure) can provide intrinsic stability to the toe. Although plantar metatarsal head condylectomy can increase stability by resulting in scarring of the plantar plate, excision of the entire second metatarsal head carries a high risk of transfer metatarsalgia. Removal of the base of the proximal phalanx destabilizes the toe and should be reserved as a salvage procedure. Simple flexor tenotomy alone will not improve stability, and arthrodesis of the second metatarsophalangeal joint will limit motion and impair function.
REFERENCES: Coughlin MJ: Crossover second toe deformity. Foot Ankle 1987;8:29-39.
Thompson FM, Deland JT: Flexor tendon transfer for metatarsophalangeal instability of the second toe. Foot Ankle 1993;14:385-388.

Question 21

The MRI findings shown in Figure 51 would most likely create which of the following signs and symptoms?

Explanation

DISCUSSION: The MRI scan shows a far lateral disk herniation. With the L4-5 disk, a far lateral herniation abuts the left L4 nerve root. The findings would be consistent with those of a left L4 radiculopathy and would include pain or a sensory deficit on the anteromedial aspect of the knee, diminished patellar tendon reflex, and quadriceps weakness, perhaps making it difficult to walk up and down stairs.
REFERENCES: Fardin DF, Garfin SR (eds): Orthopaedic Knowledge Update: Spine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 329.
O’Hara LJ, Marshall RW: Far lateral lumbar disc herniation: The key to the intertransverse approach. J Bone Joint Surg Br 1997;79:943-947.

Question 22

Figure 199 is the clinical photograph of a 68-year-old man with a history of atrial fibrillation who was treated with warfarin. Nine days after undergoing elective total hip arthroplasty, he has a swollen left thigh. His wound remains dry and he is afebrile. His erythrocyte sedimentation rate (ESR) is 25 mm/h (reference range [rr], 0-20 mm/h) and C-reactive protein (CRP) level is 6.1 mg/L (rr, 0.08-3.1 mg/L). Aspiration reveals 3246 white blood cells (WBCs)/µL with 47% polymorphonucleocytes. Treatment at this time should consist of

Explanation

DISCUSSION
This patient has a large postsurgical hematoma. Although his ESR and CRP level are elevated, they are not considered elevated given his recent surgery. Additionally, the hip aspiration reveals a synovial cell count lower than 10000 WBC/µL along with a low percentage of polymorphonucleocytes. Treatment at this time should consist of observation. The hematoma is likely attributable to postsurgical anticoagulation, considering his history of atrial fibrillation.

Question 23

A 9-year-old girl has pain over the fifth toe that is aggravated by shoe wear. Clinical photographs are shown in Figures 28a and 28b. Treatment of this deformity should consist of

Explanation

DISCUSSION: The major obstacle to overcome in the surgical treatment of this cock-up deformity is recurrence. Dorsal releases can be performed; however, chronic dislocation of the fifth MTP joint usually needs to be addressed with plantar release as well. Chronic dorsal soft-tissue contractures may be overcome with translation of the toe into a plantar-based incision, as described originally by Cockin and accredited to Butler. This is the treatment of choice. Resection of the proximal phalanx improves symptoms but induces a secondary deformity; this procedure is usually reserved for skeletally mature individuals.
REFERENCES: Black GB, Grogan DP, Bobechko WP: Butler arthroplasty for correction of adducted fifth toe: A retrospective study of 36 operations between 1968 and 1982. J Pediatr Orthop 1985;5:439-441.
Paton RW: V-Y plasty for correction of varus fifth toe. J Pediatr Orthop 1990;10:248-249.
Coughlin MJ, Mann RA: Lesser toe deformities, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 5. St Louis, MO, Mosby, 1986, pp 132-157.

Question 24

An otherwise healthy 25-year-old man underwent a right anterior cruciate ligament reconstruction with a bone-patellar tendon-bone allograft. Routine preimplantation cultures of the allograft taken by the surgeon were positive for coagulase-negative Staphylococcus 5 days postoperatively. The patient has exhibited no evidence of clinical infection and his postoperative course has been uncomplicated during this time. What is the ideal management of this patient?

Explanation

The incidence of preimplantation positive cultures of musculoskeletal allografts used for anterior cruciate ligament reconstruction has varied between 4.8% and 13.3%. Interestingly, in none of the studies evaluating this issue did any of the patients
implanted with a "contaminated" graft develop a clinical infection. The results of the current literature suggest that the treatment of low-virulence organisms is unnecessary if no evidence of clinical infection exists. Preimplantation cultures do not appear to correlate with clinical infection. Therefore, the routine culture of allograft tissue is not recommended.

Question 25

The posterior horn of the medial meniscus receives its primary blood supply from what artery?

Explanation

DISCUSSION: The middle genicular artery supplies the posterior capsule and intracapsular structures (anterior cruciate ligament, posterior cruciate ligament, posterior horns of the meniscus). The medial and lateral inferior geniculates anastomose anteriorly to form a capillary network to supply the fat pad, synovial cavity, and patellar tendon. The lateral superior and inferior genicular arteries supply the lateral retinaculum.
REFERENCES: Insall J, Scott WN: Anatomy, in Surgery of the Knee, ed 3. Philadelphia, PA, Churchill Livingstone, 2001, pp 64-70.
Scapinelli R: Vascular anatomy of the human cruciate ligaments and surrounding structures. Clin Anat 1997;10:151-162.

Question 26

A 45-year-old man with a painful varus knee is being considered for an upper tibial osteotomy. Which of the following factors is considered the most compelling argument against this procedure?

Explanation

DISCUSSION: Proximal tibial osteotomy is appropriate for the younger and/or athletic patient who has mild to moderate medial compartment osteoarthritis. Relative contraindications include limited range of motion (eg, flexion contracture of 15°), anatomic varus of greater than 10°, advanced patellofemoral arthritis, and tibial subluxation. Inflammatory arthritides involve all the compartments and are a contraindication to osteotomies around the knee.
REFERENCE: Kelly MA: Nonprosthetic management of the arthritic knee, in Callaghan JJ, Dennis DA, Paprosky WG, Rosenberg AG (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1995, pp 245-249.

Question 27

Hip pain of 1-month duration has developed in a 72-year-old man with a previous total hip arthroplasty. He underwent dental work 6 weeks ago. Aspiration shows a white blood cell count of more than 6,000 cells/μL (reference range 4,500 to 11,000 cells/μL) and the presence of gram-positive cocci in clusters on Gram stain. The orthopaedic surgeon recommends urgent debridement and irrigation. Fixation of the components is judged to be stable, and the surgeon elects to retain the implants. What is this patient's prognosis for infection resolution?

Explanation

DISCUSSION:
The patient has a late infection of at least 4 weeks symptomatic duration that most likely is hematogenous in etiology. This infection is not an acute hematogenous infection that can successfully be treated with irrigation and debridement. Retention of the implants with debridement and irrigation alone has been associated with a poor prognosis. In a recent study, the success rate was only 44% in a series of 104 patients at a mean 5.7-year follow-up. In one study of 50 infections attributable to MRSA or methicillin-resistant Staphylococcus epidermidis organisms treated with a two-stage protocol, the failure rate was 21%. Patients who experienced successful infection treatment had lower functional outcome measures using the Western Ontario and McMaster Universities Osteoarthritis Index, the University of California Los Angeles Activity Score, and the 12-item Oxford Knee Score, however.

Question 28

When balancing gaps in the coronal plane, what structure preferentially impacts the flexion space more than the extension space?

Explanation

DISCUSSION:
In the setting of valgus deformities, TKA poses different challenges than those encountered when varus deformities are present. Most valgus alignment is attributable to a deformity of the distal femur rather than of the proximal tibia, as seen in varus knees. One of the major anatomical differences is a hypoplastic lateral femoral condyle which, when not recognized and used as a rotational reference point,
can lead to internal rotation of the femoral component. This malrotation in turn leads to patellofemoral maltracking or instability, which is a common complication associated with primary TKA.

Question 29

There is increasing concern about the ethical relationship of orthopaedists to the orthopaedic equipment industry. Which of the following describes the most appropriate relationship?

Explanation

DISCUSSION: It is appropriate for orthopaedic surgeons to have relationships with industry as long as the relationship is for the good of the patient and no “quid pro quo” intent exists. A grant to cover registration at a CME event is appropriate but travel and hotel for a spouse is not. For orthopaedists who are faculty at a meeting sponsored by industry, it is appropriate for travel and expenses to be covered for that faculty member. Care must be exercised that the faculty member contributes in an amount appropriate for the expenses paid. The faculty member must ensure that information presented is unbiased and based on reasonable data and opinion. Consulting agreements should spell out specifically the duties of the agreement and payment should be appropriate for the time spent. There should be a defined work product for the consulting. Agreements that are thinly veiled payments for use of a company’s products must be avoided. In all cases, the agreements must stand up to public scrutiny. Restricted grants for specific industry-sponsored programs aimed at residents are not appropriate. Unrestricted grants intended for attendance at approved CME courses are appropriate. Dinners at which information is presented about topics that can aid in patient care are appropriate as long as the expense is reasonable ($100 or less/person) and the guest list includes individuals who can use the information in a patient case. Clearly a “premium” dinner for office staff to review new surgical instrumentation would not pass this test.
REFERENCE: Opinions on ethics and professionalism, in Guide to The Ethical Practice of Orthopaedic Surgery, ed 6. American Academy of Orthopaedic Surgeons, Rosemont, IL, 2006, pp 38-42.

Question 30

4A 4B 4C A 30-year-old man was involved in a high-speed motorcycle collision and sustained the injury shown in Figure 4a. Hypotension ensued shortly after arrival in the emergency department. Figure 4b is the initial contrast pelvic CT image with an unrecognized blush consistent with arterial bleeding. During surgical repair, the patient was noted to have active bleeding and an angiogram was obtained (Figure 4c). Which structure is the likely cause of his bleeding?

Explanation

DISCUSSION
Pelvic bleeding occurs predominantly from disruption of the posterior venous plexus and bleeding from the fractured bone. Occasionally arterial bleeding is seen, with injury to the superior gluteal artery most common. Anterior pelvic bleeding occurs from injury to the obturator artery (commonly from a pubic bone fracture laceration) and less frequently from the pudendal artery near the symphysis. The location of the bleeding on CT and angiography images does not correspond to the superior gluteal, external iliac, or femoral arteries.
RECOMMENDED READINGS
Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography: competitive or complementary? Injury. 2009 Apr;40(4):343-53. Epub 2009 Mar 17. Review.PubMed PMID: 19278678. View Abstract at PubMed
Loffroy R, Yeguiayan JM, Guiu B, Cercueil JP, Krausé D. Stable fracture of the pubic rami: a rare cause of life-threatening bleeding from the inferior epigastric artery managed with transcatheter embolization. CJEM. 2008 Jul;10(4):392-5. PubMed PMID: 18652733. View Abstract at PubMed
White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures.Injury. 2009 Oct;40(10):1023-30. Epub 2009 Apr 16. Review. PubMed PMID:19371871. View Abstract at PubMed
RESPONSES FOR QUESTIONS 5 THROUGH 8

5B
- Avascular necrosis, head collapse, and screw penetration
- Fixation failure and varus collapse
- Humeral stem loosening
- Glenoid component loosening
- Hardware failure (breakage of plate or screws)
- Shoulder dislocation
Please choose from the responses to identify the most likely complication in each scenario.

Question 31

What is the most common fracture associated with a lateral subtalar dislocation?

Explanation

DISCUSSION: The most common tarsal fracture associated with lateral dislocations is the cuboid, although the anterior process of the calcaneus and the lateral process of the talus can also be affected. In medial dislocations, the dorsomedial talar head, the posterior tubercles of the talus, and the lateral navicular are most often fractured.
Post-reduction x-rays need to be scrutinized carefully for fractures of the tarsal bones as this is the most common injury associated with subtalar dislocations. Occult fractures of the lateral process of the talus are also associated with these injuries.
The referenced study by Wagner et al noted radiographic subtalar DJD in 2/3 of their patients, but noted no correlation between radiographic and clinical outcomes. The referenced study by Bibbo et al noted an 88% incidence of other concurrent injuries and an 89% rate of radiographic DJD at 5 year follow-up. The referenced article by Saltzman et al is a review of hindfoot dislocations.

Question 32

At the time of revision knee arthroplasty, a surgeon performs a rectus snip to gain exposure to the knee. When compared with a standard parapatellar approach, what is the expected outcome?

Explanation

DISCUSSION:
Rectus snip during total knee arthroplasty has no effect on motion or strength at long-term follow-up. It has not been associated with extensor mechanism lag.

Question 33

Figure 1 is the T2 coronal MRI scan(Massive atraumatic rotator cuff tear) of a 52-year-old woman with a 6-month history of shoulder pain. She does not recall a history of trauma. Physical therapy is recommended. What is the most significant predictor of failure of nonoperative treatment?

Explanation

The MRI reveals a large full thickness supraspinatus tear. A large, prospective study showed that physical therapy can be effective in the treatment of atraumatic full-thickness rotator cuff tears. Patient expectations regarding the role of rehabilitation were the strongest predictor of surgery. Other factors associated with surgery were higher activity level and not smoking. Anatomic features of the rotator
cuff tear and the severity of patient’s reported pain did not predict failure of nonoperative treatment. Patients who have low expectations regarding the effectiveness of physical therapy are more likely to fail nonoperative treatment.

Question 34

A 21-year-old male is brought to the emergency department after being involved in gang-related violence. A radiograph of his pelvis is shown in Figure A. The patient is hemodynamically stable. Which of the following imaging modalities is the next best step in evaluating this patient for the most common associated injury? Review Topic

Explanation

Low velocity gunshot wounds (GSW) to the hip are most commonly associated with bowel perforation. Consultation with general surgery (or in some facilities, trauma surgery) is necessary to exclude this.
The incidence of GSW is increasing and it is the 2nd leading cause of death in young males in the US after motor vehicle accidents. The incidence of a GSW to the buttock is approximately 8% of all GSW to the extremities. Potential complications of pelvic and acetabular GSW include septic arthritis, enterocutaneous, enteroacetabular, and vesicoacetabular fistulas, infected nonunion, malunion, and injuries to the iliac vessels. The presence or absence of intra-abdominal injuries affects treatment and outcome.
Bartkiw et al. reviewed 2808 GSW and found 1235 associated fractures including 42 fractures of the hip and pelvis. Ten orthopaedic operative procedures were performed in 7 patients. Associated nonorthopaedic injuries included 15 small/large bowel perforations (36%), 7 vessel lacerations (17%), and 2 urogenital injuries (5%) that required surgery.
Najibi et al. reviewed 39 GSW to acetabulum. They found 32 simple and 7 associated fracture patterns. The most common simple and associated patterns were anterior column and both column, respectively. Bowel injuries were the most common associated injures (42%). Predictors of poor outcome include high-velocity missile, involvement of acetabular dome, abdominal injury, nerve injury, vascular injury, and male gender. Deep infection was associated with primary anastomosis of bowel injury and an associated fracture pattern.
Figure A shows a GSW to the right hip with acetabular fracture and visible bullet fragment.
Incorrect Answers:

Question 35

Which of the following factors is most likely to contribute to pseudarthrosis in a patient who has undergone a single-level anterior decompression and fusion procedure for the treatment of cervical radiculopathy? Review Topic

Explanation

Various factors affect the pseudarthrosis rate in patients who undergo anterior cervical decompression and fusion. Patient factors, including history of smoking and history of
diabetes mellitus, have been shown to significantly increase pseudarthrosis rates. The literature has been mixed with regard to fusion rates for allograft versus autograft, especially for one-level fusions; in that category, there is minimal, if any, difference. Similarly, several authors have shown higher rates of fusion with uninstrumented single-level rather than instrumented anterior cervical decompressions and fusions. The level (ie, cranial or caudal) of fusion and sagittal alignment have not been correlated with fusion rates.

Question 36

Halo treatment for preadolescent children typically requires the use of which of the following? Review Topic

Explanation

The complication rate with halo vest treatment in children is reported to be as high as 68% in contrast to a 36% complication rate in adults. These complications include not only pin tract infections, but also skull penetration. Multiple pins allow for the early removal of pins without fixation consequences should pin site infections begin to develop. Moreover, there is significant variability in the insertional torque applied by a variety halo pin torque wrenches, including those from the same manufacturer. Consequently, the use of a large number of pins (8 to 12) placed a very low insertional torque (1 to 5 in-lb) in children is recommended. A CT scan of the head should also be considered to assess for the thickest areas of the skull suitable for pin application.

Question 37

A 45-year-old man sustains a low-velocity gunshot wound to the base of the right thumb. The open wound is allowed to heal by secondary intention, resulting in a contracture of the first web space. Clinical photographs are shown in Figures 49a through 49c. Treatment should now consist of

Explanation

DISCUSSION: The contracture is too large for a Z-plasty, which allows a 75% increase in length. Excision of the scar with placement of a skin graft is prone to contracture. A posterior interosseous fasciocutaneous flap will provide enough well-vascularized tissue and is well suited to reach the first dorsal web space.
REFERENCES: Buchler U, Frey HP: Retrograde posterior interosseous flap. J Hand Surg Am 1991;16:283-292.
Brunelli F, Valenti P, Dumontier C, et al: The posterior interosseous reverse flap: Experience with 113 flaps. Ann Plast Surg 2001;47:25-30.

Question 38

Figures 32a and 32b show the AP and lateral radiographs of an 11-year-old boy who has a severe limp, a fever, and swelling and tenderness of the thigh. Aspiration of the bone reveals purulent material. The patient has most likely been symptomatic for

Explanation

DISCUSSION: In patients with an osteomyelitic infection, radiographic findings at 1 to 5 days usually show soft-tissue swelling only. Seven to 14 days after symptoms begin, radiographs will most likely show the classic signs of acute osteomyelitis. Reactive bone formation would be expected by 6 months.
REFERENCES: Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 149-161.
Song KM, Sloboda JF: Acute hematogenous osteomyelitis in children. J Am Acad Orthop Surg 2001;9:166-175.

Question 39

An intoxicated 68-year-old man fell at home. Examination reveals abrasions on his forehead, 2/5 weakness of his hand intrinsics and finger flexors, and 4/5 strength of the deltoid, biceps, and triceps bilaterally. Lower extremity motor function is 5/5. Sensory examination to pain and temperature is diminished in his hands but intact in his lower extremities. Deep tendon reflexes are depressed in all four extremities, but perianal sensation and rectal tone are intact. Foley catheterization yields 700 mL of urine. Radiographs of the cervical spine reveal multilevel spondylosis without fracture or subluxation. An MRI scan reveals high-intensity signal change within the cord substance at C5. What is the most likely diagnosis?

Explanation

DISCUSSION: Central cord syndrome is characterized by greater neurologic involvement of the upper extremities than the lower extremities. This is typically seen in older patients with cervical spondylosis without associated bony injury or joint subluxation. The prognosis for recovery is fair. Patients with Brown-Sequard syndrome have an ipsilateral motor deficit and contralateral loss of pain and temperature. Prognosis for recovery depends on the mechanism of injury, which is often of a penetrating nature. Anterior cord syndrome results from anterior compression such as occurs with a burst or teardrop fracture of the vertebral body; patients have bilateral motor loss, pain, and temperature loss with preservation of proprioception and vibratory sensation (posterior column function). The prognosis for recovery is generally poor. Posterior cord syndrome is rare and is associated with loss of posterior column function (proprioception and vibration).
REFERENCES: Northrup BE: Evaluation and early treatment of acute injuries to the spine and spinal cord, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott-Raven, 1998, pp 541-549.
Schneider RC, Thompson JM, Rebin J: The syndrome of acute central cervical spinal cord injury. J Neurol Neurosurg Psychiatry 1958;21:216-227.

Question 40

Figures 1 and 2 are the MR arthrogram images of a 16-year-old, right-hand-dominant baseball player who injured his left shoulder 4 weeks ago during a game. He now has pain, weakness, and the inability to swing a bat and can no longer do push-ups. He denies prior injury to his left shoulder. Radiographs are unremarkable. Which of the four muscles of the rotator cuff provides the most resistance to this patient's direction of instability?

Explanation

Posterior shoulder instability is a rare form of instability that often presents with pain rather than feelings of instability. It often occurs in young athletes during activities that put the shoulder in an “at-risk position” (flexion, adduction, internal rotation). Repetitive microtrauma can lead to posterior shoulder instability such as seen in football linemen. Swinging a bat or golf club places the lead arm in a flexed, adducted, and internally rotated position, which can lead to posterior translation of the humeral head that is forcibly reduced in follow-through, as seen in this patient. The glenohumeral joint relies on static and dynamic stabilizers. Static stabilizers help prevent instability at the end ranges of motion when the ligaments are taut. Dynamic stabilizers work to prevent subluxation at midranges of motion, at which the ligaments are lax. The rotator cuff is integral as a dynamic stabilizer of the shoulder. It works through a process called concavity compression. The four muscles of the rotator cuff compress the humeral head into the concavity of the glenoid-labrum. This prevents the humeral head from subluxing during the midranges of motion. Of the four rotator cuff muscles, the subscapularis is most important at preventing posterior subluxation. This patient has posterior instability, and various surgical techniques may be indicated depending on findings. Arthroscopic labral repair is indicated for anterior instability. Arthroscopic posterior labral repair is indicated for this patient because he has a posterior labral tear and posterior instability. If a patient has ligamentous laxity (not seen in this scenario because sulcus and Beighton sign findings would be negative), a posterior capsular shift with rotator interval closure is
indicated. If a patient has excessive glenoid retroversion (not seen in this scenario with 5 degrees of retroversion), a posterior opening-wedge osteotomy is appropriate.

Question 41

An 11-year-old boy has right shoulder pain and has been unwilling to use the arm after throwing a baseball in a Little League game 3 weeks ago. Examination reveals upper arm and shoulder tenderness with swelling. A radiograph and MRI scan are shown in Figures 27a and 27b. Management should consist of

Explanation

DISCUSSION: The radiograph is consistent with a unicameral (simple) bone cyst. The MRI scan reveals that the cyst is juxtaposed to the physis and therefore can be classified as active (latent cysts are more than 1 cm away from the physis). Active cysts are treated with aspiration and steroid injection, although repeated injections may be necessary. Curettage and bone grafting results in more reliable healing but may lead to growth arrest in active cysts.
REFERENCES: Iannotti JP, Williams GR: Disorders of the Shoulder: Diagnosis and Management, ed 1. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 945-946.
Malawer MM: Tumors of the shoulder girdle: Techniques of resection and description of surgical classification. Orthop Clin North Am 1991;22:7-35.

Question 42

Which of the following physical examination findings is most likely present in the condition producing the MRI findings shown in Figure 92? Review Topic

Explanation

The T2-weighted sagittal MRI scan shows the classic "bone bruise" pattern seen with an anterior cruciate ligament (ACL) tear. These lesions are thought to represent subcortical trabecular hemorrhages and are manifested as an increase in signal intensity on T2-weighted images and diminished signal intensity on T1-weighted images. They are classically located in the mid-portion of the lateral femoral condyle and posterior aspect of the lateral tibial plateau. This is due to the fact that an ACL tear typically is the result of a valgus-external rotation of the femur on the fixed tibia. This places most of the weight-bearing stress on the lateral femoral condyle, which rotates laterally and impacts the posterior lip of the lateral tibial plateau. This may result in an impaction fracture if the force is great enough, but more frequently causes merely a microfracture of the involved subcortical trabeculae.

Question 43

An anatomic reduction is obtained at the femoral neck. The most likely reason for development of avascular necrosis (AVN) in this scenario would be

Explanation

DISCUSSION
A damage-control approach is indicated for this patient. Debridement of the open fracture wound and rapid stabilization without an extensive surgical
approach are indicated. Rapid percutaneous fixation of the femoral neck would compromise long-term outcomes for this displaced fracture because obtaining a quality reduction and fixation construct is critical for the long-term outcome. This patient likely would not tolerate cephalomedullary nailing or open approaches very well at this time.
A vertically oriented (Pauwels 3) femoral neck fracture is more common in younger patients who sustain high-energy injuries. Because of the mechanism of injury, many of these patients have associated injuries. This is a biomechanically challenging fracture because the fracture is subject to shear forces rather than compression, making it inherently unstable. This type of fracture often necessitates different fixation strategies to counter shearing forces, such as use of a transversely oriented (Pauwels) screw to compress the fracture or a fixed-angle device.
The femoral neck fracture should be prioritized in this scenario. This does not necessarily mean that the femoral neck should be repaired first, but the strategy should emphasize optimal fixation of the femoral neck. It has been demonstrated that this is less successful when using a single implant to repair both fractures. It is possible to place femoral neck fixation around an antegrade femoral nail; however, it is much more likely that optimal fixation will be achieved with shaft fixation that does not obstruct placement of fixation for the femoral neck.
AVN is more common among physiologically young patients after femoral neck fractures. The higher energy of injury is a likely contributor. Closed reduction has not been shown to increase the risk for AVN when an anatomic reduction is obtained. A surgical delay of 24 hours does not cause AVN. Patients with associated femoral shaft fractures are not at increased risk for AVN; in fact, some studies have shown a relatively lower rate of AVN when a femoral neck fracture is associated with a femoral shaft fracture.
RECOMMENDED READINGS
Liporace F, Gaines R, Collinge C, Haidukewych GJ. Results of internal fixation of Pauwels type-
3 vertical femoral neck fractures. J Bone Joint Surg Am. 2008 Aug;90(8):1654-9. doi: 10.2106/JBJS.G.01353. PubMed PMID: 18676894. View Abstract at PubMed
Bedi A, Karunakar MA, Caron T, Sanders RW, Haidukewych GJ. Accuracy of reduction of ipsilateral femoral neck and shaft fractures--an analysis of various internal fixation strategies. J Orthop Trauma. 2009 Apr;23(4):249-53. doi: 10.1097/BOT.0b013e3181a03675. PubMed PMID: 19318867. View Abstract at PubMed
Haidukewych GJ, Rothwell WS, Jacofsky DJ, Torchia ME, Berry DJ. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg Am. 2004 Aug;86-A(8):1711-6. PubMed PMID: 15292419. View Abstract at PubMed Peljovich AE, Patterson BM. Ipsilateral femoral neck and shaft fractures. J Am Acad Orthop Surg. 1998 Mar-Apr;6(2):106-13. PubMed PMID: 9682073. View Abstract at PubMed
Upadhyay A, Jain P, Mishra P, Maini L, Gautum VK, Dhaon BK. Delayed internal fixation of fractures of the neck of the femur in young adults. A prospective, randomised study comparing closed and open reduction. J Bone Joint Surg Br. 2004 Sep;86(7):1035-40. PubMed PMID: 15446534. View Abstract at PubMed
RESPONSES FOR QUESTIONS 96 THROUGH 99
- Warfarin (Coumadin)
- Dabigatran (Pradaxa)
- Rivaroxaban (Xarelto)
- Apixaban (Eliquis)
Match the appropriate oral anticoagulant listed with the description.
This medication is a vitamin K antagonist and can be reversed.
- Warfarin (Coumadin)
- Dabigatran (Pradaxa)
- Rivaroxaban (Xarelto)
- Apixaban (Eliquis)

Question 44

Figure 35 shows the radiograph of a 35-year-old weightlifter who has had pain with overhead lifts for the past 7 months. Cortisone injections in the acromioclavicular joint provided only temporary relief. A bone scan reveals increased activity of the acromioclavicular joint. Treatment should now consist of

Explanation

DISCUSSION: Osteolysis of the distal clavicle is common in weightlifters; therefore, distal clavicle excision is the treatment of choice. A subacromial decompression alone would not alleviate the acromioclavicular joint symptoms. Interval closure, biceps degeneration, and superior labrum anterior and posterior repair would limit superior migration but would not explain the abnormal bone scan. Thermal capsular shrinkage does not have a role here.
REFERENCES: Flatow EL, Cordasco FA, McCluskey GM, Bigliani LU: Arthroscopic resection of the distal clavicle via a superior portal: A critical quantitative radiographic assessment of bone removal. Arthroscopy 1990;6:153-154.
Lyons FR, Rockwood CA: Osteolysis of the clavicle, in DeLee JC, Drez D (eds): Orthopaedic Sports Medicine. Philadelphia, PA, WB Saunders, 1994, pp 541-546.

Question 45

Based on the findings seen in the radiograph in Figure 26, emergent management should consist of

Explanation

DISCUSSION: The radiograph shows a volarly dislocated lunate. Initial emergent treatment of perilunate dislocations should consist of closed reduction and splinting, especially if the patient exhibits median nerve compression. Open reduction and pinning or ligament repair are necessary but are not emergent. A dorsal approach is sometimes required for ligament repair or bony visualization; however, this can be done in a more semi-elective manner.
REFERENCES: Isenberg J, Prokop A, Schellhammer F, et al: Palmar lunate dislocation. Unfallchirurg 2002;105:1133-1138.
Ruby LK: Fractures and dislocations of the carpus, in Browner BD, Jupiter JB (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 1367-1372.

Question 46

A 19-year-old man who plays college volleyball undergoes a routine preparticipation physical examination. Figure 35 shows a posterior view of his dominant shoulder. An electromyogram shows that this is a chronic injury, and an MRI scan shows no abnormalities. The best course of action should be

Explanation

DISCUSSION: Isolated palsy of the infraspinatus portion of the suprascapular nerve is common in volleyball players and is seen frequently in the throwing arm of baseball players. The exact cause is not known, but it may be the result of either tethering or traction on the nerve at the spinoglenoid notch. Synovial cysts in the spinoglenoid notch also can be a cause, but the patient’s negative MRI findings rule out that entity. Because many isolated nerve palsies of the infraspinatus branch are asymptomatic, initial management should always be nonsurgical. Surprisingly, many athletes with this injury can participate fully in sports. Surgical treatment with decompression at the notch is unpredictable and generally is indicated only if nonsurgical management fails.
REFERENCES: Ferretti A, Cerullo G, Russo G: Suprascapular neuropathy in volleyball players. J Bone Joint Surg Am 1987;69:260-263.
Martin SD, Warren RF, Martin TL, Kennedy K, O’Brien SJ, Wickiewicz TL: Suprascapular neuropathy: Results of non-operative treatment. J Bone Joint Surg Am 1997;79:1159-1165.

Question 47

A 25-year-old man sustains a left brachial plexus injury from a fall while rock climbing. Examination reveals poor intrinsic function of the hand, ptosis, and miosis. He is able to abduct and forward flex his shoulder with full strength. This combination of physical findings is most suggestive of what pattern of nerve injury?

Explanation

EXPLANATION:
A preganglionic lesion occurs proximal to the spinal foramen, whereas a postganglionic lesion occurs distal to the spinal foramen in the root, trunk, division, cord, or branches of the brachial plexus. The Horner sign, which is characterized by miosis, ptosis, anhydrosis, and enophthalmos, results from an injury to the sympathetic ganglion, which lies in close proximity to the T1 root level. The presence of a Horner sign is highly suggestive of a T1 preganglionic injury. Other physical examination indicators of a preganglionic injury include atrophy of the parascapular muscles (injury to the dorsal rami of the cervical spinal nerve roots), winged scapula (injury to the long thoracic nerve) and hemidiaphragmatic paralysis (phrenic nerve injury). The lack of intrinsic hand function in this patient is also suggestive of an injury at the level of C8-T1. Preservation of shoulder abduction and forward flexion would not typically be seen with an injury to the C5-C6 roots or the upper trunk.

Question 48

A 16-year-old boy has had a painful ingrown nail on his great toe for the past 3 months. When initial management consisting of soaking the foot in Epsom salts and trimming the nail failed to provide relief, his family physician recommended 2 weeks of oral antibiotics. His symptoms persist, and he is now seeking a second opinion. A clinical photograph is shown in Figure 18. Management should now consist of

Explanation

DISCUSSION: The patient has a chronic ingrown nail on his great toe, which is not an uncommon occurrence in teenagers because of improper nail care. There is local infection and a foreign body reaction because of the nail. Continued conservative management with soaks and antibiotics will not improve the clinical situation. In the presence of local chronic infection, nail matrix ablation is contraindicated. Additionally, in the absence of a history of an ingrown nail, a nail matrix ablation is not medically indicated. The appropriate treatment is partial removal of the nail plate. With nail plate removal, the inflammation and local infection will resolve rapidly.
REFERENCES: Pettine KA, Cofield RH, Johnson KA, Bussey RM: Ingrown toenail: Results of surgical treatment. Foot Ankle 1988;9:130-134.
Coughlin MJ, Mann RA: Toenail abnormalities, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, vol 2, pp 1033-1070.

Question 49

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. Risk for vascular injury during transtibial drilling for reconstruction of this injury is increased by

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 50

Figures 1 and 2 are the MR arthrogram images of a 20-year-old right-hand dominant collegiate basketball player who sustained an initial shoulder dislocation 1 year ago. In the month prior to presentation, he dislocated his shoulder two more times. Each time it occurred when going up for a rebound and an opponent grabbed the ball from behind him, hyperextending his shoulder. Physical examination demonstrates full range of motion, absence of atrophy, a positive apprehension sign and relocation test, and a positive Kim test. What is the best next step?

Explanation

The mechanism of injury/dislocation is most consistent with anterior glenohumeral joint instability. The axial cuts of the MR arthrogram reveals an anteroinferior labral tear, as well as a posterior labral tear. A Hill-Sachs lesion is also consistent with anterior glenohumeral joint instability. At the time of examination under anesthesia, this patient exhibited 2+ anterior and 2+ posterior glenohumeral joint instability. Patients with pan-labral tears and 270° tears can be challenging to diagnose, because patients can report anterior or posterior shoulder instability alone. The
physical examination and advanced imaging in these patients are crucial in directing appropriate treatment.

Question 51

Figures 39a and 39b show the radiographs of an otherwise healthy 10-year-old boy who has had thigh pain and a limp for the past 9 months. Examination reveals that the left lower extremity is 1 cm shorter, with reduced flexion, abduction, and internal rotation on the left side. The patient is at the 50th percentile for height and the 90th percentile for weight. Serum studies will most likely show

Explanation

DISCUSSION: The patient has a slipped capital femoral epiphysis (SCFE) at a younger than average age (average age 13.5 years for boys and 12.0 years for girls); therefore, an etiology that is not idiopathic must be considered. Hypothyroidism can result in a SCFE, but these children typically fall into the category of less than the 10th percentile for height. SCFE may develop in children with a growth hormone deficiency who have undergone hormonal replacement. Osteodystrophy caused by chronic renal failure may result in a SCFE, but the bone quality is markedly osteopenic on radiographs and the children are chronically ill with both low height and weight percentiles. An elevated estrogen level results in physeal closure and is protective to physeal slippage. Therefore, this child will most likely have normal laboratory values.
REFERENCES: Loder RT, Hensinger RN: Slipped capital femoral epiphysis associated with renal failure osteodystrophy. J Pediatr Orthop 1997;17:205-211.
Loder RT, Wittenberg B, DeSilva G: Slipped capital femoral epiphysis associated with endocrine disorders. J Pediatr Orthop 1995;15:349-356.

Question 52

A 28-year-old man sustained a shoulder dislocation 2 years ago. It remained dislocated for 3 weeks and required an open reduction. He now reports constant pain and has only 60 degrees of forward elevation and 10 degrees of external rotation. He desires to return to some sporting activities. An AP radiograph and intraoperative photograph (a view of the humeral head through a deltopectoral approach) are shown in Figures 31a and 31b. What is the best treatment option to decrease pain and improve function? Review Topic

Explanation

The radiograph and intraoperative photograph show osteonecrosis with near complete head loss/collapse. A stemmed implant is more appropriate in this patient because there is very little bone to support a resurfacing implant. In a younger patient, a glenoid implant should be delayed as long as possible because of the eventual need for revision secondary to glenoid loosening and wear, especially in a young active male. The hemiarthroplasty may be converted to a total shoulder arthroplasty in the future.

Question 53

A 26-year-old professional rodeo bull rider sustained a grade III midshaft femoral fracture after being thrown from his bull. He underwent closed interlocking intermedullary nailing with a titanium rod, and his recovery was uneventful. Prior to returning to competition, the patient must

Explanation

DISCUSSION: While it is recommended that a patient gain full range of motion, pain-free function, and symmetric strength prior to returning to vigorous activities, it is absolutely essential that radiographs of the fracture site reveal a circumferential external bridging callus to prevent refracture. This is particularly important for comminuted femoral fractures with various sized fragments. It is also recommended that a return to rodeo riding be postponed for at

least 1 year.
REFERENCES: Brumback RJ, Ellison TS: Intermedullary nailing of femoral stress fractures. J Bone Joint Surg Am 1992;74:106-112.
Bucholz RW, Jones A: Fractures of the shaft of the femur. J Bone Joint Surg Am

1991;73:1561-1566.
Butler MS, Brumback RJ: Interlocking nailing for ipsilateral fractures of the femur, femoral shaft, and distal part of the femur. J Bone Joint Surg Am 1991;73:1492-1502.

Question 54

The wear resistance of ultra-high molecular weight polyethylene can be improved by exposing the polymer to high-energy radiation (eg, gamma or electron beam), followed by a thermal treatment. What is one detrimental side effect of this process?

Explanation

DISCUSSION: Highly cross-linked polyethylene has gained widespread acceptance for joint arthroplasty components because of reported experimental and early clinical accounts of significant reductions in wear. Cross-linking is increased by imparting additional energy into the polymer (above that conventionally used for sterilization). The thermal treatments after cross-linking stabilize the material against oxidative degradation by quenching free radicals and also reduce the elastic modulus. One disadvantage of the increased cross-linking is a reduction in toughness that makes the polyethylene more susceptible to crack initiation and propagation. The reduced toughness raises concerns for gross component fracture and fracture at stress concentrations that can arise with the locking mechanisms used to secure polyethylene inserts into metallic backings. Nonconsolidated polyethylene particles have been associated with increased subsurface density secondary to oxidative degradation in conventional polyethylene implants. The quenching of free radicals by thermal treatment in highly cross-linked polyethylene should prevent this problem.
REFERENCES: Collier JP, Currier BH, Kennedy FE, et al: Comparison of cross-linked polyethylene materials for orthopaedic applications. Clin Orthop 2003;414:289-304.
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 203-208.
Wright TM, Maher SA: Biomaterials, in Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations of Clinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, in press.

Question 55

Figures below depict the radiographs obtained from a 60-year-old man with instability and pain 1 year after primary right total knee arthroplasty. He states that he had surgery on two occasions for a tendon rupture that was repaired with sutures but that his knee popped again, and now the leg is unable to hold his weight. On examination, he is in no acute distress. His height is 6'3", and he weighs 240 pounds. He is ambulatory with crutches. Range of motion of the right knee is 50° to 120° actively and 0° to 120° passively. More than 10° of varus/valgus laxity and more than 5 mm of anteroposterior drawer are present. A palpable defect is observed in the tissue just proximal to the patella. The incision is well healed. The erythrocyte sedimentation rate is 46 mm/h (reference range 0 to 20 mm/h) and the C-reactive protein level is 2.04 mg/L (reference range 0.08 to 3.1 mg/L). Aspiration of the right knee reveals hazy yellow fluid with a white blood cell count of 120 and 1% neutrophils. No growth of organisms is seen on routine culture. What is the best next step?

Explanation

DISCUSSION:
This patient has a chronic quadriceps tendon rupture after total knee arthroplasty. Two previous primary repair attempts have failed, which is not surprising based on the poor results of primary repair reported in the literature. The patient also has an unstable knee and will require revision of some or all of the prosthesis to achieve a stable knee. Revision total knee arthroplasty with extensor mechanism allograft allows an allograft reconstruction of the ruptured quadriceps tendon. The other option is to utilize a synthetic mesh extensor mechanism reconstruction. These are likely to have the best result in this situation. Revision total knee arthroplasty with liner change and primary quadriceps repair is not the best form of management, because it involves a third attempt at primary tendon repair, which will likely fail again. Resection knee arthroplasty and arthrodesis with antegrade nail is a possible option but is not the best, because it would likely make driving and other daily activities difficult. Two-stage revision total
knee arthroplasty with extensor mechanism allograft is not the best option because the laboratory results show no signs of infection, so a single-stage procedure is preferred.

Question 56

.The least gliding resistance for a flexor tendon laceration at the thumb palmar-digital crease as shown inFigure 75 can be achieved with

Explanation

Question.9 . A 42-year-old woman has the injury shown in Figures 78a and 78b. The decision to treat the ulnar styloid surgically is based upon which finding?

Patient age
Displacement of the radius fracture
Displacement of the ulnar styloid fracture
Position of the ulnar styloid after open reduction and internal fixation of the radius
Stability of the distal radioulnar joint after open reduction and internal fixation of the radius

Question 57

During treatment of rupture of the subscapularis tendon with associated biceps instability, treatment of the biceps tendon should include which of the following?

Explanation

DISCUSSION: With subscapularis tendon ruptures that have biceps tendon pathology, treatment with tenodesis or tenotomy has improved clinical results. Subluxation or dislocation of the biceps tendon is common with subscapularis rupture. Dislocation of the biceps can occur either beneath the tendon, within the tendon, or extra-articularly. In all cases, the restraints to medial translations of the biceps have been disrupted. Attempts at recentering the biceps have not been successful, and clinical results appear to be improved when tenodesis or tenotomy is employed in the treatment of the unstable biceps associated with subscapularis tears.
REFERENCES: Edwards TB, Walch G, Sirvenaux F, et al: Repair of tears of the subscapularis: Surgical technique. J Bone Joint Surg Am 2006;88:1-10.
Deutsch A, Altchek DW, Veltri DM, et al: Traumatic tears of the subscapularis tendon: Clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Am J Sports Med 1997;25:13-22.
Edwards TB, Walch G, Sirveaux F, et al: Repair of tears of the subscapularis. J Bone Joint Surg Am 2005;87:725-730.

Question 58

A 60-year-old right hand-dominant women fell on her outstretched arm and sustained an anterior shoulder dislocation. The shoulder is reduced in the emergency department and she is seen for follow-up 1 week later wearing a sling. Examination reveals that she has significant difficulty raising her arm in forward elevation and has excessive external rotation compared to the contralateral shoulder. What is the next most appropriate step in management? Review Topic

Explanation

In patients older than age 40 years, a high suspicion of a rotator cuff tear should be kept in those patients with weakness after shoulder dislocation. Both posterior rotator cuff and subscapularis injuries have been documented. The next most appropriate step
in management should be MRI. If the findings are negative, suspicion of nerve injury should lead to electromyography.

Question 59

Eosinophilic granuloma frequently occurs as a solitary lesion in the tubular long bones. After biopsy, what is the best course of action?

Explanation

DISCUSSION: Most lesions of eosinophilic granuloma are simply observed, but larger aggressive lesions may require curettage and bone grafting. Frequently, biopsy is required to rule out a malignant diagnosis. The differential diagnosis of eosinophilic granuloma is osteomyelitis, Ewing’s sarcoma of bone, or osteogenic sarcoma. The biopsy alone can be followed by spontaneous resolution. In some patients, low-dose radiation therapy is used. Chemotherapy or amputation is not indicated for these benign lesions.
REFERENCE: Simon M, Springfield D, et al: Common Benign Bone Tumors: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 200.

Question 60

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 61

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

Explanation

Question 62

Figures 25a and 25b show the radiograph and MRI scan of a 7 1/2-year-old boy who has been limping for 1 year. His pain has worsened over the past 2 weeks, and his parents note swelling over the dorsum of the foot for the past 4 days. Examination reveals no fever, and laboratory studies show a WBC of 6,700/mm 3 , an erythrocyte sedimentation rate of 26 mm/h, and a normal C-reactive protein level. What is the most likely diagnosis?

Explanation

DISCUSSION: The diagnosis of tuberculous osteomyelitis in children is often delayed. In one series of 23 children, the average interval between the onset of symptoms and definite diagnosis was 4.3 months. In these patients, the presenting signs and symptoms were found to be mild, with the most common signs being localized swelling (69.6%) and a painful disability of the involved limbs (65.2%). A mild elevation of the erythrocyte sedimentation rate may be present, but the C-reactive protein level is usually normal. In patients who have osteoarticular tuberculosis, an MRI scan generally shows large intra-articular effusions, periarticular osteoporosis, and gross thickening of the synovial membrane. Differential diagnosis between tuberculosis and pyogenic arthritis is difficult, and an accurate diagnosis usually requires biopsy of synovial tissue. Aspiration of synovial fluid often results in insufficient information to make a diagnosis. Treatment generally consists of surgical debridement and combined antituberculous chemotherapy with isoniazid, ethambutol, and rifampin.
REFERENCES: Wang MN, Chen WM, Lee KS, Chin LS, Lo WH: Tuberculous osteomyelitis in young children. J Pediatr Orthop 1999;19:151-155.
Watts HG, Lifeso RM: Tuberculosis of the bones and joints. J Bone Joint Surg Am 1996;78:288-298.

Question 63

What mechanism is associated with the spontaneous resorption of herniated nucleus pulposus?

Explanation

DISCUSSION: Nonsurgical modalities remain the mainstay for treatment of herniated disks. Spontaneous resorption of herniated disks frequently is detected by MRI. Marked infiltration by macrophages and neovascularization are observed on histologic examination of herniated disks, and the resorption is believed to be related to this process. Many cytokines such as vascular endothelial growth factor, tumor necrosis factor-alpha, and metalloproteinases have been implicated in this process, but none has been found to be singularly responsible.
REFERENCES: Haro H, Kato T, Kamori H, et al: Vascular endothelial growth factor (VEGF)-induced angiogenesis in herniated disc resorption. J Orthop Res 2002;20:409-415.
Doita M, Kanatani T, Ozaki T, et al: Influence of macrophage infiltration of herniated disc tissue on the production of matrix metalloproteinases leading to disc resorption. Spine

2001;26:1522-1527.

Question 64

Serum phosphate levels are high. 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

Which of the following describes the histopathology of tumoral calcinosis:

Question 65

Figure 7 shows the CT scan of a 22-year-old professional baseball pitcher who has had elbow pain for the past 6 months despite rest from throwing. Management should consist of Review Topic

Explanation

The CT scan shows a stress fracture of the olecranon. This injury is the result of repetitive abutment of the olecranon into the olecranon fossa, traction from triceps activity during the deceleration phase of the throwing motion, and impaction of the medial olecranon onto the olecranon fossa from valgus forces. Fractures may be either transverse or oblique in orientation. Initial treatment consists of rest and temporary splinting. Electrical bone stimulation may also be considered. Open fixation with a large compression screw is recommended when nonsurgical management has failed to provide relief.

Question 66

A patient undergoes a simple excision of a 3-cm superficial mass in the thigh at another institution. The final pathology reveals a leiomyosarcoma, without reference to the margins. What is the recommendation for definitive treatment?

Explanation

DISCUSSION: Treatment of patients with unplanned excision of soft-tissue sarcomas is challenging. If the margins are positive or unclear, the patient is best managed with repeat excision of the tumor bed, and radiation therapy if the repeat excision does not yield wide margins. In patients with no detectable tumor on physical examination or imaging after unplanned excision, some studies have shown that up to 35% of patients will have residual disease and a poorer local recurrence rate (22% versus 7%). Therefore, whenever feasible,

a reexcision of the tumor bed is recommended.
REFERENCE: Noria S, Davis A, Kandel R, et al: Residual disease following unplanned excision of soft-tissue sarcoma of an extremity. J Bone Joint Surg Am 1996;78:650-655.

Question 67

A 20-year-old man sustained an isolated displaced type II odontoid fracture in a motor vehicle accident. He is neurologically intact. Treatment consists of placement in halo traction, and the fracture is reduced. What is the next most appropriate step in treatment?

Explanation

DISCUSSION: The traditional treatment of a reduced type II fracture is a halo vest. A 20-year-old man will tolerate a halo vest better than the elderly or women. Anterior screw fixation has gained increasing support; however, it too has risks and requires a significant learning curve. More recently, C1 lateral mass screws have become more popular. The long-term results and benefits have not yet been determined.
REFERENCES: Spivak JM, Connolly PF (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, p 193.
Kiovikko MP, Kiuru MJ, Koskinen SK, et al: Factors associated with nonunion in conservatively-treated type-II fractures of the odontoid process. J Bone Joint Surg Br 2004;86:1146-1151.
Herkowitz HN, Garfin SR, Eismont FJ: Rothman-Simone The Spine, ed 5. Philadelphia, PA, Saunders Elsevier, 2006, p 1091.
Fiore AJ, Haid RW, Rodts GE, et al: Atlantal lateral mass screws for posterior spinal reconstruction: Technical note and case series. Neurosurg Focus 2002;12:E5.

Question 68

Spontaneous recovery of upper extremtiy motor function after a cerebrovascular accident occurs in which of the following predictable patterns?

Explanation

DISCUSSION: Recovery of upper extremity motor function after a cerebrovascular accident follows a predictable pattern. The greatest amount of recovery is seen within the first 6 weeks. Return of function proceeds from proximal to distal. Shoulder flexion occurs first, followed by return of flexion to the elbow, wrist, and fingers. Return of forearm supination follows the return of finger flexion.
REFERENCE: Waters RL, Keenan ME: Surgical treatment of the upper extremity after stroke, in Chapman MW (ed): Operative Orthopedics. Philadelphia, PA, JB Lippincott, 1988, vol 2,

pp 1449-1450.

Question 69

The posterior horn of the medial meniscus receives its primary blood supply from what artery? Review Topic

Explanation

The middle genicular artery supplies the posterior capsule and intracapsular structures (anterior cruciate ligament, posterior cruciate ligament, posterior horns of the meniscus). The medial and lateral inferior geniculates anastomose anteriorly to form a capillary network to supply the fat pad, synovial cavity, and patellar tendon. The lateral superior and inferior genicular arteries supply the lateral retinaculum.

Question 70

At the time of revision knee arthroplasty, a surgeon performs a rectus snip to gain exposure to the knee. When compared to a standard parapatellar approach, what is the expected outcome?

Explanation

DISCUSSION
Rectus snip during total knee arthroplasty has no effect on motion or strength at long-term follow-up. It has not been associated with extensor mechanism lag.

RESPONSES FOR QUESTIONS 58 THROUGH 62
Nerve palsy
Skin necrosis
Flexion instability
Patellar instability
Anterior knee pain
Malalignment
Total knee arthroplasty (TKA) is performed to address each condition shown in Figures 58 through 62b. Which complication is most commonly associated with each image?

Question 71

A 19-year-old man sustains a complete spinal cord injury at the C7 level as a result of diving into a lake. He has a blood pressure of 90/50 mm Hg, a pulse of 60/min, and respirations of 20/min. These values most likely signify

Explanation

Neurogenic shock is defined as vascular hypotension with bradycardia as a result of spinal injury. The first few minutes after spinal cord injury are associated with hypertension and tachycardia, with a subsequent drop in pressure and pulse rate.

Question 72

What is the preferred treatment of displaced distal clavicle fractures in children less than eight years old?

Explanation

DISCUSSION: Pediatric distal clavicle fractures are typically treated non-operatively because of the great osteogenic capacity of the intact inferior periosteum. The coracoclavicular ligaments remain attached to the periosteum and new bone fills any remaining bony gaps within the periosteal sleeve. Recent articles by Nenopoulos et al recommend sling immobilization for the majority of fractures (84%) and only attempt surgical fixation for children >8 years old with severely displaced fractures (>2 cortical diameters). They found excellent function with conservative treatment and union in all fractures. Surgical care resulted in improved cosmetic appearance.

Question 73

A 22-year-old volleyball player reports the insidious onset of superior and posterior shoulder pain. Radiographs are normal. An MRI scan is shown in Figure 25. What is the most specific physical examination finding?

Explanation

DISCUSSION: Overhead athletes are prone to a number of problems involving the shoulder. Pitchers and volleyball players are susceptible to posterior superior labral tears and internal impingement. These patients will have posterior superior shoulder pain, a positive relocation sign, and a positive active compression test. Occasionally, these posterior superior labral tears are associated with a spinoglenoid cyst as seen in the MRI scan. These cysts cause compression of the suprascapular nerve which manifests primarily as weakness of the infraspinatus, resulting in weakness of external rotation.
REFERENCES: Romeo AA, Rotenberg DD, Bach BR Jr: Suprascapular neuropathy. J Am Acad Orthop Surg 1999;7:358-367.
Cummins CA, Messer TM, Nuber GW: Suprascapular nerve entrapment. J Bone Joint Surg Am 2000;82:415-424.

Question 74

Figure 56 shows an arthroscopic view of the long head of the biceps; it has an incompetent biceps sling and is unstable, and an axial glenohumeral MRI scan reveals that it is dislocated medially out of the intertubercular groove. What structure is also most likely injured?

Explanation

DISCUSSION: It is important to recognize that rotator cuff tears are a common finding in the setting of a dislocated long head of the biceps tendon (LHB) from the intertubercular groove of the shoulder. If a LHB tendon dislocation is found on examination or radiographic work-up (ultrasound or MRI), it is imperative to rule out associated rotator cuff pathology, specifically of the subscapularis tendon. Although very rare, injury to the lesser tuberosity should also be ruled out. There are a variety of methods to treat the dislocated biceps (tenotomy versus tenodesis); however, the entire rotator cuff, especially the subscapularis, should be carefully inspected and treated if necessary. The corollary is also true - if you find a tear of the subscapularis tendon insertion, especially the superior half, the LHB should be carefully inspected to ensure that it is not unstable as it exits the shoulder. If the LHB is unstable, this is also addressed surgically with either tenotomy or tenodesis. The middle glenohumeral ligament and Bankart tears are not stabilizers of the biceps.
REFERENCES: Sethi N, Wright R, Yamaguchi K: Disorders of the long head of the biceps tendon. J Shoulder Elbow Surg 1999;8:644-654.
Edwards TB, Walch G, Sirveaux F, et al: Repair of tears of the subscapularis: Surgical technique. J Bone Joint Surg Am 2006;88:1-10.
Tung GA, Yoo DC, Levine SM, et al: Subscapularis tendon tear: Primary and associated signs on MRI. J Comput Assist Tomogr 2001;25:417-424.
46 • American Academy of Orthopaedic Surgeons

Question 75

A 60-year-old man is evaluated in the ICU after a rollover motor vehicle accident 3 days ago. He has multiple upper and lower extremity trauma and was found unresponsive at the accident scene. Surgery is planned for the extremity trauma once the patient is medically stable. He remains intubated and the cervical spine is immobilized in a semi-rigid collar. Examination reveals mild erythema in the posterior occipital cervical region. Initial AP and lateral radiographs of the cervical spine have not revealed any obvious fracture. What is the most appropriate treatment option at this time? Review Topic

Explanation

Ackland and associates demonstrated that the failure to achieve early spinal clearance in an unconscious blunt trauma patient predisposed the patient to increased morbidity secondary to the prolonged used of cervical immobilization. They demonstrated that the four significant predictors of collar-related ulcers were ICU admission, mechanical ventilation, the necessity for cervical MRI, and the time to cervical spine clearance and collar removal. The risk of pressure-related ulceration increased by 66% for every 1-day increase in Philadelphia collar time and this highlights the need for definitive C-spine clearance.

Question 76

An elderly patient falls and sustains an extension injury to the neck that results in upper extremity weakness, spared perianal sensation, and lower extremity spasticity. These findings best describe what syndrome?

Explanation

DISCUSSION: These finding indicate central cord syndrome, and injury that is more common in the older population who have some degree of spondylosis. The physiologic insult can be a central spinal hematoma with resultant hematomyelia. Bowel and bladder functional return has a good prognosis, unlike the upper extremity motor loss. Cauda equina syndrome generally involves injury at the lumbar levels, with some degree of lower extremity motor loss. Posterior cord syndrome is characterized by preservation of motor function below the level of injury and position/vibratory sensory loss. Brown-Sequard syndrome, which is often produced by a penetrating injury, results in contralateral hypalgesia and ipsilateral weakness. Anterior cord syndrome has a poor prognosis for functional return; lower extremity findings include loss of light touch, sharp/dull, and temperature sensations below the level of injury, as well as

motor function.
REFERENCES: Apple DF Jr: Spinal cord injury rehabilitation, in Rothman RH, Simeone FA (eds): The Spine, ed 3. Philadelphia, PA, WB Saunders, 1992, Chapter 31.
Leventhal MR: Fractures, dislocations and fracture-dislocations of spine, in Crenshaw AH (ed): Campbell’s Operative Orthopaedics, ed 8. St. Louis, MO, Mosby, 1992.

Question 77

-What is the most likely mechanism of injury?

Explanation

DISCUSSION FOR QUESTIONS 56 THROUGH 58
The MRI scan shows a bone bruise of the lateral femoral condyle and lateral tibial plateau. This injury pattern is commonly associated with anterior cruciate ligament (ACL) rupture and an abnormal pivot shift test result. Treatment of an ACL tear in a high-demand athlete should consist of ligament reconstruction.In this patient, surgery should be delayed until she regains full range of motion to minimize risk for arthrofibrosis after surgery. Recent analysis has shown that the noncontact mechanism is more consistent with anterior translation, affecting both the medial and lateral compartments. The bone bruise in the lateral femoral condyle occurs more anterior than that of the medial femoral condyle, suggesting that internal rotation has occurred. The external rotation recurvatum test assesses for posterolateral corner injury, and a positive quadriceps active test is consistent with posterior cruciate ligament rupture. An abnormal patellar apprehension test result is suggestive of patellar instability. Nonsurgical treatment is unlikely to result in sufficient stability if this patient returns to sports at her preinjury level of activity.Primary ACL repair is associated with high failure rates. Although the precise mechanism of injury varies,injuries can be broadly classified into contact and noncontact injuries. Noncontact injuries occur with the knee in slight flexion, valgus, and internal rotation, and contact injuries typically involve a lateralside impact producing a valgus force to the knee. The valgus component of noncontact injuries has been thought to cause mainly lateral compartment bone bruising. Posterior translation is the most common mechanism of posterior cruciate ligament rupture, and hyperextension and varus is associated with posterolateral corner injury.

Question 78

Which of the following studies has the highest sensitivity and specificity in diagnosis of osteonecrosis of the femoral head?

Explanation

DISCUSSION: An MRI scan is both highly sensitive and specific for the evaluation of osteonecrosis. The measurement of increased intraosseous pressure can be technically difficult and the results have been variable. Plain radiographs can be normal early in the progression of osteonecrosis of the femoral head. The technetium Tc 99m bone scan is a very sensitive test. However, it is not specific; increased uptake can be noted in patients with arthritis, neoplastic disease, fracture, or sepsis. In addition, because of bilaterality, the frequency of false-negative scans is relatively high.
REFERENCES: Steinberg ME: Early diagnosis, evaluation, and staging of osteonecrosis, in Jackson DW (ed): Instructional Course Lectures 43. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 513-518.
Glickstein MF, Burk DL Jr, Schiebler ML, et al: Avascular necrosis versus other diseases of the hip: Sensitivity of MR imaging. Radiology 1988;169:213-215.

Question 79

The AP radiograph of a 5-year-old boy shows a 20-degree left thoracic scoliosis. He was noted by his pediatrician to have asymmetry on a forward bend test. On examination he is neurologically intact except for decreased sensation on the lateral aspect of both flanks and to pinprick in both hands. He has no pain. What is the best initial step in treatment at this time? Review Topic

Explanation

This patient has atypical scoliosis, given his young age and left thoracic curve. In addition, he has abnormal neurologic findings. MRI scan to evaluate for neural axis abnormalities is indicated. Abnormal MRI findings are present in 2% to 3.8% of all patients with presumed idiopathic scoliosis. Abnormal MRI findings are more likely if specific clinical factors are present, such as absence of thoracic apical segment lordosis, atypical curve pattern, an abnormal neurologic examination, male gender, and age younger than 11. In a patient with an atypical curve and neurologic indicators, the yield of MRI scan for a neuraxis abnormality has been shown to be 25%. This patient had both syringomyelia and a Chiari malformation that were treated neurosurgically. Observation would have missed these findings. Bracing or spinal instrumentation may eventually be treatment options for scoliosis given his young age, but establishing a diagnosis first with an MRI scan of the spine is the most appropriate initial step.

Question 80

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

Explanation

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

Question 81

A 10-year-old girl has been unable to walk for the past 5 days because of bilateral hip pain. Administration of IV morphine has provided some pain relief. She is afebrile. History reveals that she had an upper respiratory tract infection 3 weeks ago that resolved uneventfully. Examination reveals moderate pain with internal rotation and abduction, while log rolling maneuvers do not cause significant pain. An MRI scan shows a small effusion of one hip; however, a bone scan and plain radiographs are normal. Initial laboratory studies showed a markedly elevated WBC count, which subsequently declined to normal levels with IV antibiotics. Current studies show an erythrocyte sedimentation rate (ESR) of 100 mm/h. Aspiration of the hip obtains 3 mL of fluid; Gram stain is negative for bacteria, but a cell count shows a WBC count of 16,500/mm 3 . Streptozyme titer of the peripheral blood is 200 units (normal is less than 100 units). Management should now consist of

Explanation

DISCUSSION: This clinical situation requires careful analysis because some data suggest infection and some a noninfectious inflammatory process. Bilateral hip involvement, the absence of significant fluid collection or fever, the streptozyme level, and the history of upper respiratory infection all suggest poststreptococcal toxic synovitis as the most likely cause for the clinical presentation. In the first 24 hours, this type of presentation might warrant incision and drainage given uncertainty of the diagnosis and the risks associated with missing an infection. However, 5 days after onset, surgery is not warranted, especially given that the patient remains afebrile and her symptoms are improving. Cardiology consultation would be appropriate. There is no evidence to suggest slipped capital femoral epiphysis. Treatment with antibiotics is not advised because there is no bacteriologic data on which to base treatment.
REFERENCES: De Cunto CL, Giannini EH, Fink CW, et al: Prognosis of children with poststreptococcal reactive arthritis. J Pediatr Infect Dis 1988;7:683-686.
Haueisen DC, Weiner DS, Weiner SD: The characterization of “transient synovitis of the hip” in children. J Pediatr Orthop 1986;6:11-17.

Question 82

Figures 23a and 23b show the MRI scans of a 50-year-old woman who has increasing gait disturbance. She reports three falls in the past week. Examination reveals hyperreflexia, motor weakness in the biceps and triceps, and a positive Hoffman’s sign. What is the most appropriate treatment plan?

Explanation

DISCUSSION: The patient has obvious signs of progressive myelopathy. Based on her significant physical examination findings, nonsurgical management will not significantly impact her outcome. Cervical decompression alone is contraindicated in patients with cervical kyphosis such as seen here. Anterior cervical fusion is the best option.
REFERENCES: Emery SE, Bohlman HH, Bolesta MJ, et al: Anterior cervical decompression and arthrodesis for the treatment of cervical spondylotic myelopathy: Two to seventeen-year follow-up. J Bone Joint Surg Am 1998;80:941-951.
Ferguson RJ, Caplan LR: Cervical spondylotic myelopathy. Neurol Clin 1985;3:373-382.
Herkowitz HN: A comparison of anterior cervical fusion, cervical laminectomy, and cervical laminoplasty for the surgical management of multiple level spondylotic radiculopathy. Spine 1988;13:774-780.

Question 83

A 30-year-old patient underwent open reduction internal fixation of a talar neck fracture 8 weeks ago. His current radiographs demonstrate a subchondral radiolucency of the dome of the talus. What is the next most appropriate course of action?

Explanation

DISCUSSION: A subchondral radiolucency of the talar dome after a talar neck fracture is known as the "Hawkins sign" and is a well-described radiographic indication of viability of the talar body. Rockwood and Green state "by the 6th-8th week, if the patient has been non-weight-bearing, diffuse atrophy is evident by radiographs. An AP radiograph of the ankle reveals the presence or absence of subchondral atrophy in the dome of the talus. Subchondral atrophy excludes the diagnosis of avascular necrosis." Tezval et al in a retrospective review showed that a subchondral lucency seen on the AP radiograph was a good indicator of talus vascularity following fracture. They state it is unlikely that AVN will develop at a later stage after injury if a Hawkins sign was present. Illustration A shows the characteristic appearance of a Hawkins sign and subchondral sclerosis.

Question 84

Following a partial muscle laceration, keeping the affected extremity immobilized for 2 weeks before starting an exercise program will likely lead to: Review Topic

Explanation

Muscle lacerations immobilized for 2 weeks would likely experience significant muscle atrophy affecting final functional outcome. For muscle injuries, including partial lacerations, current literature suggests the affected extremity should be immobilized no more than 3-5 days, followed by a progressive strengthening and stretching program.
Healing a muscle injury involves two competing processes: regeneration of muscle fibers and formation of granulation tissue. Starting motion too soon after injury may increase the area of fibrous scar, and limit the ability of new muscle fibers to penetrate this area. Prolonged immobilization limits scar production but penetrating muscle fibers will lack appropriate orientation, and the muscle as whole begins to atrophy. Three to 5 days of immobilization has been shown to limit scar tissue production
while the early motion helps generate appropriately organized muscle fibers and maintain strength and range of motion.
Järvinen et al. present a review of muscle injury and healing. They found that immediate mobilization led to a large area of dense scar tissue that regenerating muscle fibers could not adequately penetrate. Prolonged immobilization allowed muscle fibers to regenerate but they lacked appropriate morphology. Following 3-5 days of immobilization they found less scar tissue, better penetration of regenerated muscle fibers, and the regenerated fibers were more well aligned with the uninjured fibers surrounding them.
Menetrey et al. present a mouse model of muscle laceration comparing a short period of immobilization (5 days) to suture repair of the muscle. They found quicker healing and greater strength in the suture repair group. Tetanus strength at one month after injury was (compared to an uninjured control) 81% for sutured muscle, 35% for the early mobilization only group, and 18% for the prolonged immobilization group.
Illustration A is a histology section of lacerated muscle after 7 days of immobilization. The area is infiltrated with granulation tissue and few regenerating myofibers. Illustration B is a histology section of lacerated muscle after 14 days of immobilization. Further infiltration with granulation tissue and mononuclear cells can be seen with regenerating myofibers only at the periphery.
Incorrect answers:

Question 85

During the early swing phase of the normal gait cycle, what lower extremity muscle is primarily contracting?

Explanation

DISCUSSION: Electromyography during walking reveals the tibialis anterior muscle is active during early swing, allowing the foot to clear the ground. All of the other muscles are quiet, as the limb moves forward through space with minimal muscular effort. The other muscles are primarily active during weight acceptance or push-off.
REFERENCES: Gage JR: An overview of normal walking. Instr Course Lect 1990;39:291-303.
Wootten ME, Kadaba MP, Cochran GV: Dynamic electromyography II: Normal patterns during gait. J Orthop Res 1990;8:259-265.

Question 86

Lateral malleolus fractures can be treated with a variety of techniques, including posterior antiglide plating or lateral neutralization plating. What is an advantage of using lateral neutralization plating instead of posterior antiglide plating?

Explanation

DISCUSSION: Posterior antiglide plating is a technique that involves placement of a plate on the posterior aspect of the distal fibula, using the plate as a reduction tool and direct buttress against distal fracture fragment displacement.
Schaffer et al showed from a biomechanical standpoint that posterior antiglide plating was superior to lateral neutralization plating for distal fibula fracture fixation.
Weber et al reported a (30/70) 43% rate of plate removal secondary to peroneal discomfort. In addition, peroneal tendon lesions were found in 9 of the 30 patients.

Question 87

A 65-year man has right hip pain after a fall. Radiographs reveal a reverse oblique intertrochanteric femoral fracture. Treatment consists of reduction and internal fixation. Which of the following implants is most commonly associated with nonunion and hardware failure?

Explanation

DISCUSSION: Reverse oblique intertrochanteric femoral fractures account for 5% of all intertrochanteric or subtrochanteric fractures. They are uncommon but not rare and will be encountered in practice. The sliding hip screw is associated with the most problems because of its design. When reverse oblique fractures are fixed with a sliding hip screw, the action of the construct causes medial displacement of the distal fragment rather than compression of the proximal and distal fragments. All of the other implants prevent medial displacement of the distal segment. It should not be assumed that simply using one of the other implants is reason for success. There is a significant failure rate for each of these implants with reverse oblique fractures. The implant must be ideally placed and the fracture must be reduced.
REFERENCES: Haidukewych GJ, Israel TA, Berry DB: Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643-650.
Sanders RW, Regazzoni P: Treatment of subtrochanteric femur fractures using the dynamic condylar screw. J Orthop Trauma 1989;3:206-213.
Baumgaertner MR, Chrostowski JH, Levy RN: Intertrochanteric hip fracture, in Browner BD, Jupiter JP, Levine AM, Trafton P (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 1833-1881.

Question 88

A 79-year-old healthy male has 1 year of progressively worse left hip pain. He denies any significant weight loss but does complain of night pain. Radiograph and MRI are shown in Figures A & B. Bone scan and histology is shown in Figures C-E. What is the definitive treatment of this?

Explanation

The history, imaging and pathology points to chondrosarcoma as the diagnosis, and therefore wide resection and reconstruction is the most appropriate treatment.
Chondrosarcoma tends to occur in an older individuals and the most common sites of origin are the femur, tibia, humerus, ribs, scapula then pelvis.
Chondrosarcomas grow slowly and patients present with dull aching pain.
X-rays typically have a subtle, radiolucent, permeative lesion or may have hazy or speckled calcifications with either a diffuse "salt & pepper" pattern or a more discrete "popcorn" pattern. The MRI defines the amount of marrow and soft-tissue involvment, and typically has high T2 signal intensity. Bone scintigraphy will be positive.
In pathological sections, low-power imaging demonstrates lobulated clusters of chondrocytes, and high-power imaging demonstrates a bland cellular appearance, extensive basophilic cytoplasm, and no mitotic figures (low grade chondrosarcoma).

Question 89

A 25-year-old motorcyclist has a knee dislocation that is reduced by the trauma surgeon in the emergency department. Radiographs show no fracture and a reduced knee joint. What is the most appropriate initial step for evaluation of a potential arterial injury?

Explanation

A high index of suspicion should exist for an arterial injury after any knee dislocation. Due to collateral circulation around the knee, pulses may still be present, as well as normal capillary refill. Though angiography is the gold standard for assessment of both major and minor (intimal) injury to the arterial system, it is invasive and not always readily available. Assessment of the ABI can be done without specialized equipment and personnel. When the ABI (systolic BP distal to injury/systolic BP of uninjured upper extremity) is less than 0.9, consideration of invasive testing or surgical exploration is recommended.

Question 90

Figure 63 shows the radiographs of a 23-year-old man who sustained a twisting injury at work. Swelling, tenderness, and ecchymosis are noted about the entire midfoot. What associated injury is most likely to be problematic?

Explanation

DISCUSSION: This cuboid compression fracture (“nutcracker” injury) is associated with subtle injury to the Lisfranc complex. This diagnosis must be made to ensure proper treatment.
REFERENCE: Early JS: Fractures and dislocations of the midfoot and forefoot, in Bucholz R, Heckman JD, Court-Brown CM (eds): Rockwood and Green’s Fractures in Adults. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, pp 2337-2400.

Question 91

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

Explanation

DISCUSSION: A complete tear of the distal biceps brachii most often occurs from a large, rapid eccentric elbow extension load. A pop or tearing sensation usually occurs, and a palpable defect in the antecubital fossa is often present on examination. The treatment of choice is a direct primary repair by a two-incision technique. If left unrepaired, the most disabling consequence is the loss of forearm supination strength. It is unlikely that significant elbow or forearm motion will be lost if the rupture is left unrepaired and early motion exercises are initiated. Elbow flexion strength tends to return with time, but the loss of forearm supination strength remains problematic.
REFERENCES: D’Alessandro DF, Shields CL Jr, Tibone JE, Chandler RW: Repair of distal biceps tendon ruptures in athletes. Am J Sports Med 1993;21:114-119.
Agins HJ, Chess JL, Hoekstra DV, Teitge RA: Rupture of the distal insertion of the biceps brachii tendon. Clin Orthop 1988;234:34-38.

Question 92

Medial dislocation of the long head of the biceps tendon in the shoulder is most commonly caused by a Review Topic

Explanation

Medial dislocation of the biceps tendon in the shoulder is commonly associated with subscapularis tendon tears. Although type II SLAP tears can result in bicipital instability, type I SLAP lesions do not. Congenitally shallow grooves and tears of the transverse ligaments usually do not lead to dislocation of the biceps tendon. Supraspinatus tendon tears are associated with long head of the biceps tendon ruptures but do not cause biceps tendon dislocations.

Question 93

During total hip arthroplasty, profuse bleeding is noted following predrilling for placement of an acetabular component screw. The drill most likely penetrated too deep in the

Explanation

DISCUSSION: The acetabular quadrants are defined by two lines: one drawn from the anterosuperior iliac spine to the posterior fovea, forming acetabular halves, and a second drawn perpendicular to the first at the midpoint of the acetabulum, forming four quadrants. The anterior quadrants should be avoided because improper screw placement may injure the external iliac artery and vein, as well as the obturator nerve, artery, and vein. These structures lie close to the pelvic bone, with little protective interposition of soft tissue.
REFERENCES: Wasielewski RC, Cooperstein LA, Kruger MP, et al: Acetabular anatomy and the transacetabular fixation of screws in total hip arthroplasty. J Bone Joint Surg Am 1990;72:501-508.
Keating EM, Ritter MA, Faris PM: Structures at risk from medially placed acetabular screws.

J Bone Joint Surg Am 1990;72:509-511.

Question 94

A 45-year-old woman awakens with the acute onset of burning left shoulder pain that radiates toward the axilla. She denies any history of trauma. On examination, she is unable to abduct her arm but has full passive shoulder motion. Her sensation is intact. Cervical spine examination reveals full range of motion and a negative Spurling’s test. Radiographs and MRI studies are normal for the cervical spine and shoulder. What is the most likely diagnosis? Review Topic

Explanation

The definition of brachial neuritis or Parsonage-Turner syndrome is a rare disorder of unknown etiology that causes pain or weakness of the shoulder and upper extremity. The loss of active motion excludes cervical C6-7 radiculopathy and impingement. A normal MRI scan and full passive motion exclude a rotator cuff tear and adhesive capsulitis, respectively.

Question 95

Figure 40 shows the radiograph of a 16-year-old wrestler who injured his elbow when he was thrown to the mat by his opponent. Closed reduction is readily accomplished, and the elbow seems stable. Management should now consist of application of a splint for

Explanation

DISCUSSION: Flexion contractures are the most common complication of elbow dislocations. About 15% of patients lose more than 30 degrees of flexion. The risk of contracture is proportional to the duration of immobilization. Elbows should be moved within the first few days after reduction. The splinting is for comfort and protection only while the pain subsides.
REFERENCES: Mehlhoff TL, Noble PC, Bennett JB, Tullos HS: Simple dislocation of the elbow in the adult: Results after closed treatment. J Bone Joint Surg Am 1988;70:244-249.
Linscheid RL, O’Driscoll SW: Elbow dislocations, in Morrey BF (ed): The Elbow and Its Disorders, ed 2. Philadelphia, PA, WB Saunders, 1993, pp 441-452.
O’Driscoll SW, Jupiter JB, King GJ, Hotchkiss RN, Morrey BF: The unstable elbow. Instr Course Lect 2001;50:89-102.
Ross G, McDevitt ER, Chronister R, Ove PN: Treatment of simple elbow dislocation using an immediate motion protocol. Am J Sports Med 1999;27:308-311.

Question 96

03 A 28-year-old man who sustained the injury shown in Figure 31 is hemodynamically unstable. In addition to fluid resuscitation, the next most appropriate step in management should include

Explanation

The radiograph shows us a pelvic inlet view of an APC II or III pelvic ring injury with syndesmotic disruption greater than 5cm, and a right SI joint disruption as well. APC (and some VS) injuries are associated with increases in pelvic volume allowing occult blood loss. All of the responses are viable options, but on a spectrum of timing. ORIF and CRPSF are both more elective options that require appropriate pre-operative planning and a stable patient, not to be undertaken in a hemodynamically unstable patient. The article referenced from JBJS 2002 reviewed 150 patients with pelvis fractures and the use of angiography for the management of “haemorrhage.” They concluded/recommended skeletal stabilization as the first line of treatment, followed by possible laparotomy and packing of pelvic retroperitoneum as a second line of treatment, with pelvic angiography and embolization only in those patients that were unresponsive to both previous interventions. They based their recommendations also on anatomical studies that suggested that the surfaces of the fracture and veins, rather than arteries, were the major sources of bleeding in these patients. External pelvic stabilization in their study included external fixators, pneumatic anti-shock garments, and pelvic clamps.
Cook RE, Keating JF, Gillespie I: The role of angiography in the management of haemorrhage from major fractures of the pelvis. J Bone Joint Surg Br 2002;84:178-182.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp395-405.
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Question 97

Figure 42 shows the sagittal T2-weighted MRI scan of a patient’s right knee. These findings are most commonly seen with a complete tear of the

Explanation

DISCUSSION: The MRI scan reveals disruption of the lateral capsule and ligaments with

fluid in the soft tissues laterally. Additionally, there is a large bone bruise on the medial

femoral condyle. This combination indicates injury to the posterolateral complex. These injuries often have coexisting anterior and/or posterior cruciate ligament injuries. Failure to recognize the posterolateral corner injury can lead to failure of anterior or posterior cruciate ligament reconstructions.

REFERENCES: LaPrade RF, Gilbert TJ, Bollom TS, et al: The magnetic resonance imaging appearance of individual structures of the posterolateral knee: A prospective study of normal knees and knees with surgically verified grade III injuries. Am J Sports Med 2000;28:191-199.
Ross G, Chapman AW, Newberg AR, et al: Magnetic resonance imaging for the evaluation of acute posterolateral complex injuries of the knee. Am J Sports Med 1997;25:444-448.

Question 98

A 23-year-old man reports a 6-year history of recurrent instability in the right dominant shoulder. He has not undergone surgery and has essentially stopped all of his sporting activities. On examination, he has instability and apprehension in the midrange of motion (abduction of 45 to 60 degrees with external rotation) and a palpable clunk representing a transient dislocation over the anterior glenoid rim. A three-dimensional CT scan is shown in Figure 31. What is the most appropriate surgical intervention to provide him with reliable stability postoperatively?

Explanation

DISCUSSION: In the setting of significant anteroinferior glenoid bone deficiency (greater than 20% to 25%), both open and arthroscopic Bankart repairs have demonstrated higher rates of failure. Bony glenoid augmentation procedures such as the Bristow-Lataijet, which describe coracoid transfers to reconstruct the deficient glenoid, have led to decreased rates of recurrent shoulder instability. In this scenario, the patient has a significant loss of glenoid bone. There are also several clues in the history to suspect bone deficiency: multiple recurrences, a long history of recurrence, and instability in the midranges of motion.
A bony augmentation procedure such as the Lataijet has been well-described to provide a well functioning and stable shoulder joint. A hemiarthroplasty is not indicated in the absence of arthritis. Subscapularis
advancement will not address the bone loss.
REFERENCES: Hovelius L, Sandstrom B, Sundgren K, et al: One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: Study I— clinical results. J Shoulder Elbow Surg 2004;13:509-516.
Schroder DT, Provencher MT, Mologne TS, et al: The modified Bristow procedure for anterior shoulder instability: 26-year outcomes in Naval Academy midshipmen. Am J Sports Med 2006;34:778-786.
Itoi E, Lee SB, Berglund LJ, et al: The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: A cadaveric study. J Bone Joint Surg Am 2000;82:35-46.

Question 99

A 21-year-old male construction worker fell from a roof and sustained an injury to his left foot. Radiographs and CT scans are shown in Figures 24a through 24e. Compared to nonsurgical management, surgical treatment offers which of the following advantages?

Explanation

DISCUSSION: The radiographs and CT scans show a displaced intra-articular calcaneal fracture, with loss of calcaneal height and length. Recent multicenter, randomized, prospective studies suggest that surgical treatment of displaced intra-articular calcaneal fractures is associated with an almost six-fold decrease in the risk of posttraumatic subtalar arthritis (necessitating subtalar arthrodesis) compared to nonsurgical treatment. Despite ongoing controversy, surgical treatment has not been shown to be advantageous with respect to activity, time to return to work, or subtalar joint range of motion. A nonunion of a calcaneal fracture is exceedingly rare regardless of the treatment method.
REFERENCES: Buckley R, Tough S, McCormack R, et al: Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: A prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2002;84:1733-1744.
Csizy M, Buckley R, Tough S, et al: Displaced intra-articular calcaneal fractures: Variables predicting late subtalar fusion. J Orthop Trauma 2003;17:106-112.

Question 100

A 30-year-old man is brought to the emergency department after a motor vehicle accident. He has a closed midshaft femoral fracture and an intra-abdominal injury. He is currently in the operating room and the exploration of his abdomen has been completed. His initial blood pressure was 70/30 mm Hg and is now 90/50 mm Hg after 4 liters of fluid and 2 units of blood. His initial serum lactate was 3.0 mmol/L (normal < 2.5), 1 hour postinjury it was 3.5 mmol/L, and it is now 5 mmol/L. His core temperature is 93 degrees F (34 degrees C). What is the most appropriate management for the femoral shaft fracture at this point?

Explanation

DISCUSSION: The patient has several indications that he is not ready for definitive fixation of the femoral shaft fracture at this point. He is cold with a core temperature of 93 degrees F, and hypothermia of less than 95 degrees F (35 degrees C) has been shown to be associated with an increased mortality rate in trauma patients. The patient has also not been resuscitated based on his increasing lactate levels and although controversial, it has been shown that temporary external fixation leads to a lower incidence of multiple organ failure and acute respiratory distress syndrome.
REFERENCES: Shafi S, Elliot AC, Gentilello L: Is hypothermia simply a marker of shock and injury severity or an independent risk factor for mortality in trauma patients? Analysis of a large national trauma registry. J Trauma 2005;59:1081-1085.
Pape HC, Hildebrand F, Pertschy S, et al: Changes in the management of femoral shaft fractures in polytrauma patients: From early total care to damage control orthopedic surgery. J Trauma 2002;53:452-461.
Harwood PJ, Giannoudis PV, van Griensven M, et al: Alterations in the systemic inflammatory response after early total care and damage control procedures for femoral shaft fracture in severely injured patients. J Trauma 2005;58:446-454.

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

Posterior open reduction and fusion with fixation
Anterior open reduction and fusion with fixation
Technetium Tc 99m bone scan
Closed manipulation
MRI

Correct Answer: MRI

Explanation:

Question 2:

Options:

Rigid orthotic with a lateral post
Custom-molded leather and polypropylene orthosis (Arizona brace)
UCBL with lateral posting
One quarter-inch lateral heel and sole wedge applied to the shoe
Three-quarter heel lift

Correct Answer: Custom-molded leather and polypropylene orthosis (Arizona brace)

Explanation:

Question 3:

A 14-year-old girl reports hip pain that is exacerbated by weight bearing. A radiograph and biopsy specimen are shown in Figures 16a and 16b. The best course of management should be

Options:

a steroid injection.
curettage and bone grafting.
radiation therapy.
observation.
internal fixation without a bone graft.

Correct Answer: curettage and bone grafting.

Explanation:

Question 4:

A 25-year-old woman has had continuous pain after falling on her outstretched wrist 12 weeks ago. A current radiograph is shown in Figure 11. Management should consist of

Options:

open reduction and internal fixation with bone grafting.
closed reduction and percutaneous pin fixation.
aspiration and steroid injection.
closed manipulation and a long arm cast.
in situ open bone grafting.

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

Explanation:

DISCUSSION: The patient has a scaphoid fracture with cystic resorption of the distal aspect of the midthird of the scaphoid. This fracture is unlikely to heal without intervention. Percutaneous pinning, closed manipulation, and bone grafting will not restore alignment. Treatment requires restoration of scaphoid length, bone grafting, and internal fixation to obtain healing with normal alignment.
REFERENCES: Cooney WP, Linscheid RL, Dobyns JH, Wood MB: Scaphoid nonunion: Role of anterior interpositional bone grafts. J Hand Surg Am 1988;13:635-650.
Fernandez DL: A technique for anterior wedge-shaped grafts for scaphoid nonunions with carpal instability. J Hand Surg Am 1984;9:733-737.
Stark HH, Rickard TA, Zemel NP, Ashworth CR: Treatment of ununited fractures of the scaphoid by illiac bone grafts and Kirschner-wire fixation. J Bone Joint Surg Am
1988;70:982-991.
Feldman MD, Manske PR, Welch RL, Szerzinski JM: Evaluation of Herbert screw fixation for the treatment of displaced scaphoid nonunions. Orthopedics 1997;20:325-328.

Question 5:

Options:

Referral to a pain clinic for epidural injections
Activity modification and anti-inflammatory medications
Urgent hospital admission followed by hemilaminotomy and diskectomy
Hemilaminotomy and diskectomy scheduled as an elective procedure
Posterior laminectomy and fusion

Correct Answer: Referral to a pain clinic for epidural injections

Explanation:

The patient has an L5-S1 disk herniation, which has a favorable prognosis without surgical intervention. Most acute lumbar disk herniations resolve with nonsurgical management. The most appropriate course of initial treatment should be analgesics and activity modification, followed by rehabilitation as the symptoms allow. Although the MRI scan indicates a large disk herniation, he has no symptoms or signs that would warrant urgent surgical decompression. Planned elective diskectomy should be considered only if nonsurgical management fails to provide relief. Epidural injections could be considered if the initial course of treatment fails to give the patient significant relief. Posterior laminectomy and fusion is not indicated without the presence of instability.
(SBQ12SP.9) A 62-year-old male underwent posterior spinal instrumented fusion for degenerative lumbar spondylolithesis one year ago. He presents to office complaining of persistent lower back pain. The pain initially improved but over the last 6 months he has had recurring pain at the site of the surgery primarily with activity. He denies back pain at rest or night pain. Physical examination reveals a well healed wound and no physical abnormalities. He has no tenderness to palpation to the thoracic or lumbar spine. He has no neurological deficits. His laboratory results show an erythrocyte sedimentation rate (ESR) = 8 mm/h and C-reactive protein (CRP) = 3 mg/L at the last visit which are both within normal limits. Figure A shows a series of radiographs from his pre-operative, 3 month post-operative and 1 year post-operative clinic visits, respectively. Which of the following investigations would best confirm the suspected underlying diagnosis?
Review
Topic
MRI of lumbar spine
Repeat ESR/CRP and whole body bone scan
CT of lumbar spine
Dynamic flexion/extension plain film radiographs
Dynamic lateral bending plain film radiographs
This patient has clinical and radiographic features of failed spinal arthrodesis. CT scan have been shown to be the most relable method for assessing spinal fusion postoperatively.
Reported rates of nonunion following posterior spinal fusion range from 0-70%. Rates are variable due to the various operative techniques, underlying diagnoses as well as asymptomatic patients. Non-union may lead to changes in alignment, spinal instability and potential neurological injury. Static radiographs have long been used as a practical method of fusion assessment, but these tend to significantly overestimate the presence of a solid fusion. Lack of movement at a fused segment, on dynamic views, does not confirm fusion. CT offers excellent bony resolution and are less affected by metal artifact compared to MRI.
Patel et al. showed that tobacco use, malnutrition, oral anti-inflammatory use, multilevel fusion, prior spine surgery, and sagittal imbalance are all risk factors for spinal nonunion.
Mok et al. looked at erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels after spinal surgery and compared their usefulness as predictors of infectious complications in the early postoperative period. They found that CRP is more applicable, predictable, and responsive in the early postoperative period compared with ESR. Using a second rise or failure to decrease as expected for CRP is sensitive for infection.
Shelby et al. reviewed the radiological assessment of spinal fusion. They comment that fine-cut imaging, multiplanar reconstruction, and metal artifact reduction have increased the ability to assess fusion on CT.
Figure A shows a series of lateral radiographs of the lumbar spine with posterior spinal instrumentation. Illustration A shows a lateral CT scan image of multi-level pseudoarthrosis after posterior spinal instrumented fusion. Illustration B shows an
intra-operative
view
of
spinal
pseudoarthrosis
(white
arrow).
Incorrect
(SBQ12SP.19) A 41-year-old male presents with acute onset of low back pain that started when he was trying to lift a heavy box while helping his brother move apartments two days ago. The pain has been severe enough to cause him to miss work yesterday. He has no neurologic deficits. What are the chances he will return to work within 6 weeks?
Review Topic
1 80 to 90%
2 70 to 80%
3 60 to 70%
4 50 to 60%
5 40 to 50%
Most adults (up to 80%) will experience an episode of low back pain in their lifetime. In those whose pain is severe enough to cause them to miss work, 60 to 70% will return by 6 weeks, and 80 to 90% will return by 12 weeks.
Low back pain is common in adults. Most patients experience resolution of symptoms quickly and have no lasting loss of function. However, 5 to 10% develop chronic pain. Recurrence of pain is common, and is part of the natural history, occurring in 20 to 72% of patients. After 12 weeks, return to work rates are slow.
Shen et al. review the nonoperative management of acute and chronic low back pain. The authors note that none of the available interventions has been proven by high quality large randomized controlled trials. The authors believe that low dose oral
steroids are safe in the short term and that injection therapy should not be used without a reasonable presumptive diagnosis.
Madigan et al. review the management of lumbar degenerative disease. The authors emphasize that the majority of patients improve within 6 weeks with or without treatment. For patients that do not, the authors do not recommend epidural injection, as there are no good studies to support their use in the treatment of discogenic back pain. When surgical treatment is indicated they state that arthrodesis is the gold standard, although the long term results of total disk arthroplasty are being elucidated.
Illustration A shows a table of available non-operative treatment modalities for back pain. Illustration B shows a list of possible diagnoses associated with acute low back pain, with those associated with neurogenic pain italicized. Illustration C shows a list of 'red flag' symptoms indicating serious/emergent causes of low back pain.
Incorrect
2:
Longer
to than
90%

Question 6:

Options:

Loose body
Discoid lateral meniscus
Transverse meniscal ligament
Displaced lateral meniscus tear
Displaced medial meniscus tear

Correct Answer: Discoid lateral meniscus

Explanation:

Question 7:

Options:

Medial malleolus
Deltoid ligament
Anterior talofibular ligament
Lateral malleolus
Calcaneonavicular ligament

Correct Answer: Deltoid ligament

Explanation:

Question 8:

Options:

with varus malalignment
with valgus malalignment
with external rotation malalignment
with internal rotation malalignment
with no malalignment

Correct Answer: with varus malalignment

Explanation:

When the lesser trochanter (LT) profile is larger than the uninjured side, the proximal fragment is externally rotated. This leads to an overall internal rotation (IR) malalignment of the distal fragment. Malalignment is described based on the distal fragment relative to the proximal fragment. For more proximal femoral fractures, the proximal fragment tends to be flexed and externally rotated due to the iliopsoas. Matching rotation requires external rotation of the distal fragment when the patient is supine on a fracture table.
Rotational malalignment is the most common complication of intramedullary nailing of a comminuted diaphyseal femoral fracture. The rotational profile of the lesser trochanter can be used to evaluate rotational alignment. The proximal femur is rotated until a neutral position is obtained as judged by the radiographic profile of the lesser trochanter. If the AP image shows a smaller lesser trochanter, there is IR of the LT. A larger LT indicates external rotation (ER) of the LT.
Jaarsma et al. describe CT imaging in determining rotational alignment. They note that the incidence of post-nailing malalignment > 10 ° is 40%, > 15 ° is 20-30%, and
> 20 ° is 16%. They also note that patients with ER deformities have more symptoms than those with IR deformities, and that small deformities <15 ° give rise to less complaints. This is because ER deformities lead to compensation with hip retroversion, which causes more symptoms than hip anteversion when compensating for IR deformities.
Incorrect Answers:
(SBQ12TR.37) A 44-year-old male presents with the isolated injury seen in Figure A after a motor vehicle accident and underwent the operative treatment seen in Figure B within 8 hours from the time of incident. Which of the following complications is this patient at highest risk of developing?
Pulmonary embolus
Periprosthetic fracture
Contralateral hip fracture
Osteonecrosis
Infection
This young male patient has sustained a displaced femoral neck fracture and underwent open reduction internal fixation with 3 cannulated screws. Based on the available options, the patient is most at risk of developing osteonecrosis of the femoral head.
Femoral neck fractures in young patients typically are the result of a high-energy trauma. Fracture displacement has been shown to disrupt vascular supply to the femoral head by interrupting retinacular vessels and ligament teres vascularization, as well as increasing intracapsular pressure, producing a tamponade effect. The incidence of osteonecrosis in patients younger than 60 years with displaced femoral neck fractures has been shown to be between 15-30%. Quality of reduction is one key factor that has been shown to influence outcomes postoperatively.
Loizou et al. prospectively studied 1,023 patients who sustained an intracapsular hip fracture that was treated with internal fixation using standard fixation modalities. They showed that osteonecrosis was less common for undisplaced (4.0%) than for displaced fractures (9.5%). The population at greatest risk were women younger than the age of 60 with displaced fractures.
Barnes et al. review subcapital hip fractures. They found that late segmental collapse was more common in displaced fractures in women younger than age 75 years than in those older than age 75 years treated with internal fixation.
Figure A shows a displaced, Garden 3/Pauwels I hip fracture. Figure B shows anatomical fixation with 3 cannulated screws.
Incorrect Answers:

Question 9:

- The stability of the longitudinal arch of the foot during standing with equal weight on both feet is due primarily to

Options:

plantar fascia and quadratus plantae tendon.
ligamentous structures connecting the tarsal bones.
shape of the tarsal bones and the intervening joints.
activity of the intrinsic muscles of the foot.
activity of the posterior tibialis and the peroneus longus muscles.

Correct Answer: ligamentous structures connecting the tarsal bones.

Explanation:

Question 10:

Options:

2% to 5%
15% to 20%
35% to 45%
60% to 70%
Greater than 90%

Correct Answer: 35% to 45%

Explanation:

DISCUSSION: The patient sustained an incomplete spinal cord injury known as central cord syndrome. Central cord syndrome characteristically has disproportionate involvement of the upper extremities with the lower extremities being relatively spared. It is most commonly seen after cervical injuries in elderly patients with spondylosis and spinal stenosis, often without fracture. Penrod and associates noted that 23 of 59 patients with central cord syndrome
(ASIA C and D) ultimately walked. The poorest prognosis, however, was in ASIA C patients older than age 50, in which only 40% walked.
REFERENCES: Penrod LE, Hegde SK, Ditunno JF Jr: Age effect on prognosis for functional recovery in acute, traumatic central cord syndrome. Arch Phys Med Rehab 1990;71:963-968.
Northrup BE: Acute injuries to the spine and spinal cord: Evaluation and early treatment, in Clark CR (ed): The Cervical Spine, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 2005, p 735.

Question 11:

What is the most consistent finding regarding glenohumeral kinematics in patients with symptomatic tears of the rotator cuff?

Options:

No superior translation during abduction
Retention of ball-and-socket kinematics with more than 30 degrees of abduction
Loss of ball-and-socket kinematics with less than 30 degrees of abduction
Superior translation of the humeral head with more than 30 degrees of abduction
Superior translation of the humeral head with external rotation

Correct Answer: Superior translation of the humeral head with more than 30 degrees of abduction

Explanation:

Question 12:

Options:

midfoot arthrodesis.
a rocker sole shoe with orthotic inserts.
shock wave or orthotripsy.
an ankle-foot orthosis.
triple arthrodesis.

Correct Answer: midfoot arthrodesis.

Explanation:

DISCUSSION: The patient has advanced arthrosis of the midfoot, and orthotic management has failed to provide relief. Therefore, the treatment of choice is midfoot arthrodesis. Shock wave treatment has not been shown to be beneficial for arthritis. An ankle-foot orthosis would not be appropriate based on findings of a normal ankle joint. Triple arthrodesis would not be helpful because the hindfoot joint is not affected in a Lisfranc injury.
REFERENCES: Sangeorzan BJ, Veith GR, Hansen ST Jr: Salvage of Lisfranc’s tarsometatarsal joints by arthrodesis. Foot Ankle 1990;10:193-200.
Komenda
GA
, Myerson MS, Biddinger KR: Results of arthrodesis of the tarsometatarsal joints after traumatic injury. J Bone Joint Surg Am 1996;78:1665-1676.

Question 13:

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

Options:

strand repair with 6-0 epitendinous suture with Bier block anesthesia
strand repair with 6-0 epitendinous suture under local anesthesia only
strand repair with regional anesthesia
Repair of the flexor tendon with incision of the remaining A2 pulley

Correct Answer: strand repair with 6-0 epitendinous suture under local anesthesia only

Explanation:

Question 14:

Options:

Open reduction and plate fixation
Open reduction and intramedullary rod fixation with casting
Cast immobilization with expected remodeling of the fracture and near-full motion
Cast immobilization, accepting malunion and some dysfunction because surgical treatment has a high rate of nonunion in OI DISCUSSION-Teenagers with displaced midshaft forearm fractures do not remodel fully if the angulation is beyond 10 degrees after reduction. Excellent outcomes have been shown with intramedullary rodding as well as plate fixation. In patients with bone fragility, plate fixation poses higher risks for fracture attributable to stress shielding. Load sharing with intramedullary rodding is preferred in surgical management of fractures whenever possible. This patient is 15 years old with unacceptable reduction, so remodeling of this fracture would not be expected with closed management. Patients with OI are not at higher risk for nonunion with surgery; there is no reason to withhold surgery for this patient.

Correct Answer: Open reduction and intramedullary rod fixation with casting

Question 15:

Options:

Anterior lumbar interbody fusion L4-5
L4-5 hemilaminotomy and diskectomy
Lumbar laminectomy L4-L5 posterior fusion
Lumbar laminectomy at L4-5

Correct Answer: Lumbar laminectomy L4-L5 posterior fusion

Explanation:

DISCUSSION
This patient has symptoms consistent with neurogenic claudication secondary to lumbar spinal stenosis and degenerative spondylolisthesis. Her symptoms are chronic and she has undergone an appropriate course of nonsurgical care. Nevertheless, her symptoms are worsening and surgical intervention is a
reasonable consideration. Studies have shown that patients with lumbar spinal stenosis with associated degenerative spondylolisthesis benefit most from decompression of the neural elements that are stenotic and subsequent fusion across the degenerative slip. Anterior lumbar interbody fusion likely will not address stenosis at the level of the slip and may not result in adequate neurologic decompression. Partial laminotomy and diskectomy likely will not provide adequate neural decompression because these procedures would only address unilateral compression and this patient has bilateral issues. Lumbar laminectomy without fusion could be performed but has been associated with results inferior to lumbar laminectomy with fusion when addressing stenosis with spondylolisthesis.
RECOMMENDED READINGS
Weinstein JN, Lurie JD, Tosteson TD, Zhao W, Blood EA, Tosteson AN, Birkmeyer N, Herkowitz H, Longley M, Lenke L, Emery S, Hu SS. Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am. 2009 Jun;91(6):1295-304. PubMed PMID: 19487505.
View Abstract at
PubMed
Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am. 1991 Jul;73(6):802-8. PubMed PMID: 2071615.
View
Abstract at PubMed
Lombardi JS, Wiltse LL, Reynolds J, Widell EH, Spencer C 3rd. Treatment of degenerative spondylolisthesis. Spine (Phila Pa 1976). 1985 Nov;10(9):821-7. PubMed PMID: 4089657.
View Abstract at PubMed
RESPONSES FOR QUESTIONS 66 THROUGH 69
Deep surgical-site infection
Adjacent segment degeneration
Pressure ulcers
Iatrogenic neurologic injury
Incidental durotomy
Hardware failure
Match the frequently encountered complication listed above with the appropriate clinical scenario below.

Question 16:

Options:

Arthroscopic rotator cuff repair
Shoulder hemiarthroplasty
Anatomic total shoulder arthroplasty
Anatomic total shoulder arthroplasty and pectoralis major transfer
Reverse total shoulder arthroplasty and latissmus dorsi transfer

Correct Answer: Anatomic total shoulder arthroplasty and pectoralis major transfer

Explanation:

Question 17:

Options:

Renal ultrasound
Echocardiography
Chromosome analysis
Creatine phosphokinase
MRI of the forearm

Correct Answer: Chromosome analysis

Explanation:

DISCUSSION: The patient has classic radioulnar synostosis. Patients with this disorder frequently have duplication of sex chromosomes. Synostosis is often seen in females with 48-XXXX or 49-XXXXX in association with delayed development and mental retardation. In males, it can be associated with 48-XXXY or 49-XXXXY. Radioulnar synostosis is not usually associated with muscle disorders, congenital heart disease, or renal anomalies. MRI of the forearm can reveal other soft-tissue anomalies, but this information is not particularly helpful in planning therapy. Osteotomy is sometimes indicated to improve rotational position of the wrist, but this patient’s rotation is quite functional for everyday tasks, and rotational osteotomy is
not indicated.
REFERENCE: Rimoin DL, Connor JM, Pyeritz RE, Korf BR: Emery & Rimoin’s Principles and Practice of Medical Genetics, ed 4. New York, NY, Churchill Livingstone, 2002,
pp 1196-1197.

Question 18:

Options:

Shoulder fusion
Arthroscopic subscapularis repair
Intra-articular corticosteroid injection
Open subscapularis repair
Pectoralis major transfer

Correct Answer: Pectoralis major transfer

Explanation:

Question 19:

- Figure 12 shows the frog-lateral radiograph of a 45-year-old man who has a painful left hip. What is the most likely diagnosis?

Options:

traumatic femoral head fracture
osteonecrosis
osteoarthritis
neuropathic joint
rheumatoid arthritis

Correct Answer: osteonecrosis

Explanation:

Question 20:

Options:

Flexor digitorum longus tenotomy
Resection of the metatarsal head and pin fixation
Transfer of the flexor digitorum longus to the extensor tendon
Excision at the base of the proximal phalanx and syndactyly with the third toe
Arthrodesis of the second metatarsophalangeal joint

Correct Answer: Transfer of the flexor digitorum longus to the extensor tendon

Explanation:

Question 21:

The MRI findings shown in Figure 51 would most likely create which of the following signs and symptoms?

Options:

Weakness of the left extensor hallucis longus and a sensory deficit in the first dorsal web space
Diminished right Achilles tendon reflex and weakness of the gastrocnemius-soleus complex
Pain radiating into the anteromedial aspect of the left knee, diminished patellar tendon reflex, and difficulty climbing stairs
Numbness in the right first dorsal web space and a slap foot gait
Urinary retention and right quadriceps weakness with diminished patellar tendon reflex

Correct Answer: Pain radiating into the anteromedial aspect of the left knee, diminished patellar tendon reflex, and difficulty climbing stairs

Explanation:

Question 22:

Options:

irrigation and debridement.
single-stage exchange.
stage exchange.
observation.

Correct Answer: observation.

Explanation:

Question 23:

A 9-year-old girl has pain over the fifth toe that is aggravated by shoe wear. Clinical photographs are shown in Figures 28a and 28b. Treatment of this deformity should consist of

Options:

extensor digitorum longus tenotomy.
extensor digitorum longus tenotomy with dorsal fifth metatarsophalangeal (MTP) joint capsulotomy.
dorsal V-Y plasty for skin contracture, combined with extensor digitorum longus tenotomy and dorsal fifth MTP capsulotomy.
a dorsal and plantar racquet-shaped incision around the fifth toe, combined with extensor digitorum longus tenotomy and circumferential fifth MTP joint release (Butler procedure).
plantar proximal phalangeal resection.

Correct Answer: a dorsal and plantar racquet-shaped incision around the fifth toe, combined with extensor digitorum longus tenotomy and circumferential fifth MTP joint release (Butler procedure).

Explanation:

DISCUSSION: The major obstacle to overcome in the surgical treatment of this cock-up deformity is recurrence. Dorsal releases can be performed; however, chronic dislocation of the fifth MTP joint usually needs to be addressed with plantar release as well. Chronic dorsal soft-tissue contractures may be overcome with translation of the toe into a plantar-based incision, as described originally by Cockin and accredited to Butler. This is the treatment of choice. Resection of the proximal phalanx improves symptoms but induces a secondary deformity; this procedure is usually reserved for skeletally mature individuals.
REFERENCES: Black GB, Grogan DP, Bobechko WP: Butler arthroplasty for correction of adducted fifth toe: A retrospective study of 36 operations between 1968 and 1982. J Pediatr Orthop 1985;5:439-441.
Paton RW: V-Y plasty for correction of varus fifth toe. J Pediatr Orthop 1990;10:248-249.
Coughlin MJ, Mann RA: Lesser toe deformities, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 5. St Louis, MO, Mosby, 1986, pp 132-157.

Question 24:

Options:

Observation
Oral antibiotics for 6 weeks
IV antibiotics for 6 weeks
Arthroscopic irrigation and debridement with graft retention
Arthroscopic irrigation and debridement with graft removal

Correct Answer: Observation

Explanation:

Question 25:

The posterior horn of the medial meniscus receives its primary blood supply from what artery?

Options:

Middle genicular
Medial inferior genicular
Medial superior genicular
Lateral superior genicular
Inferior lateral genicular

Correct Answer: Middle genicular

Explanation:

DISCUSSION: The middle genicular artery supplies the posterior capsule and intracapsular structures (anterior cruciate ligament, posterior cruciate ligament, posterior horns of the meniscus). The medial and lateral inferior geniculates anastomose anteriorly to form a capillary network to supply the fat pad, synovial cavity, and patellar tendon. The lateral superior and inferior genicular arteries supply the lateral retinaculum.
REFERENCES: Insall J, Scott WN: Anatomy, in Surgery of the Knee, ed 3. Philadelphia, PA, Churchill Livingstone, 2001, pp 64-70.
Scapinelli R: Vascular anatomy of the human cruciate ligaments and surrounding structures. Clin Anat 1997;10:151-162.

Question 26:

A 45-year-old man with a painful varus knee is being considered for an upper tibial osteotomy. Which of the following factors is considered the most compelling argument against this procedure?

Options:

Flexion contracture of 5°
Subchondral cyst in the medial tibial condyle
Lateral meniscal degeneration seen in an MRI scan
Rheumatoid arthropathy
Previous medial meniscectomy

Correct Answer: Rheumatoid arthropathy

Explanation:

Question 27:

Options:

Good because it is a gram-positive organism
Good because it is an acute infection
Poor because it is a gram-positive organism
Poor because it is a late infection

Correct Answer: Poor because it is a late infection

Explanation:

DISCUSSION:
The patient has a late infection of at least 4 weeks symptomatic duration that most likely is hematogenous in etiology. This infection is not an acute hematogenous infection that can successfully be treated with irrigation and debridement. Retention of the implants with debridement and irrigation alone has been associated with a poor prognosis. In a recent study, the success rate was only 44% in a series of 104 patients at a mean 5.7-year follow-up. In one study of 50 infections attributable to MRSA or methicillin-resistant
Staphylococcus epidermidis
organisms treated with a two-stage protocol, the failure rate was 21%. Patients who experienced successful infection treatment had lower functional outcome measures using the Western Ontario and McMaster Universities Osteoarthritis Index, the University of California Los Angeles Activity Score, and the 12-item Oxford Knee Score, however.

Question 28:

When balancing gaps in the coronal plane, what structure preferentially impacts the flexion space more than the extension space?

Options:

Iliotibial band
Popliteus tendon
Lateral collateral ligament
Lateral head of the gastrocnemius

Correct Answer: Popliteus tendon

Explanation:

Question 29:

There is increasing concern about the ethical relationship of orthopaedists to the orthopaedic equipment industry. Which of the following describes the most appropriate relationship?

Options:

Industry-paid travel, hotel (for the surgeon and spouse), and registration at a university-sponsored CME course
Industry-paid travel and hotel for a faculty member at an industry-sponsored meeting that is not CME approved
Consultation agreement ($50,000/annum) between the surgeon and the company for evaluation of the implant system with required oral reporting of impressions
A restricted grant from a company to an orthopaedic residency program with the stipulation that the third year residents be sent to an industry-sponsored course
Industry-paid dinner at a premium restaurant ($200/person) for surgeon and office staff at which a new set of surgical instrumentation is presented

Correct Answer: Industry-paid travel and hotel for a faculty member at an industry-sponsored meeting that is not CME approved

Explanation:

DISCUSSION: It is appropriate for orthopaedic surgeons to have relationships with industry as long as the relationship is for the good of the patient and no “quid pro quo” intent exists. A grant to cover registration at a CME event is appropriate but travel and hotel for a spouse is not. For orthopaedists who are faculty at a meeting sponsored by industry, it is appropriate for travel and expenses to be covered for that faculty member. Care must be exercised that the faculty member contributes in an amount appropriate for the expenses paid. The faculty member must ensure that information presented is unbiased and based on reasonable data and opinion. Consulting agreements should spell out specifically the duties of the agreement and payment should be appropriate for the time spent. There should be a defined work product for the consulting. Agreements that are thinly veiled payments for use of a company’s products must be avoided. In all cases, the agreements must stand up to public scrutiny. Restricted grants for specific industry-sponsored programs aimed at residents are not appropriate. Unrestricted grants intended for attendance at approved CME courses are appropriate. Dinners at which information is presented about topics that can aid in patient care are appropriate as long as the expense is reasonable ($100 or less/person) and the guest list includes individuals who can use the information in a patient case. Clearly a “premium” dinner for office staff to review new surgical instrumentation would not pass this test.
REFERENCE: Opinions on ethics and professionalism, in Guide to The Ethical Practice of Orthopaedic Surgery, ed 6. American Academy of Orthopaedic Surgeons, Rosemont, IL, 2006, pp 38-42.

Question 30:

Options:

- Superior gluteal artery
- Branch of the external iliac artery
- Branch of the pudendal artery
- Branch of the femoral artery

Correct Answer: - Branch of the pudendal artery

Explanation:

DISCUSSION
Pelvic bleeding occurs predominantly from disruption of the posterior venous plexus and bleeding from the fractured bone. Occasionally arterial bleeding is seen, with injury to the superior gluteal artery most common. Anterior pelvic bleeding occurs from injury to the obturator artery (commonly from a pubic bone fracture laceration) and less frequently from the pudendal artery near the symphysis. The location of the bleeding on CT and angiography images does not correspond to the superior gluteal, external iliac, or femoral arteries.
RECOMMENDED READINGS
Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography: competitive or complementary? Injury. 2009 Apr;40(4):343-53. Epub 2009 Mar 17. Review.PubMed PMID: 19278678.
View Abstract at PubMed
Loffroy R, Yeguiayan JM, Guiu B, Cercueil JP, Krausé D. Stable fracture of the pubic rami: a rare cause of life-threatening bleeding from the inferior epigastric artery managed with transcatheter embolization. CJEM. 2008 Jul;10(4):392-5. PubMed PMID: 18652733.
View
Abstract at PubMed
White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures.Injury. 2009 Oct;40(10):1023-30. Epub 2009 Apr 16. Review. PubMed PMID:19371871.
View Abstract at
PubMed
RESPONSES FOR QUESTIONS 5 THROUGH 8
5A
5B
- Avascular necrosis, head collapse, and screw penetration
- Fixation failure and varus collapse
- Humeral stem loosening
- Glenoid component loosening
- Hardware failure (breakage of plate or screws)
- Shoulder dislocation
Please choose from the responses to identify the most likely complication in each scenario.

Question 31:

What is the most common fracture associated with a lateral subtalar dislocation?

Options:

Distal fibular fracture
Cuboid fracture
Calcaneus fracture
Talus fracture
Navicular fracture

Correct Answer: Distal fibular fracture

Explanation:

Question 32:

At the time of revision knee arthroplasty, a surgeon performs a rectus snip to gain exposure to the knee. When compared with a standard parapatellar approach, what is the expected outcome?

Options:

Improvement in range of motion
Reduction in range of motion
Increase in extensor mechanism lag
No differences in motion and strength

Correct Answer: No differences in motion and strength

Explanation:

DISCUSSION:
Rectus snip during total knee arthroplasty has no effect on motion or strength at long-term follow-up. It has not been associated with extensor mechanism lag.

Question 33:

Options:

Tear size
Pain scale score
Strength deficit
Patient expectations

Correct Answer: Patient expectations

Explanation:

Question 34:

Options:

Ultrasound bladder to exclude bladder perforation
CT abdomen to exclude bowel perforation
MRI pelvis to exclude genital injuries
CT angiogram exclude laceration of major vessels
CT acetabulum to exclude intra-articular foreign body

Correct Answer: CT acetabulum to exclude intra-articular foreign body

Explanation:

Question 35:

Options:

Sagittal alignment
History of diabetes mellitus and tobacco use
Performance of an uninstrumented fusion (ie, no plate and screws)
Use of allograft (instead of autograft)
Fusion at the C3-C4 level

Correct Answer: History of diabetes mellitus and tobacco use

Explanation:

Question 36:

Halo treatment for preadolescent children typically requires the use of which of the following? Review Topic

Options:

4 to 6 pins with an insertional torque of 1 to 5 in-lb
4 to 6 pins with an insertional torque of 4 to 6 in-lb
4 to 6 pins with an insertional torque of 6 to 8 in-lb
8 to 12 pins with an insertional torque of 1 to 5 in-lb
8 to 12 pins with an insertional torque of 4 to 6 in-lb

Correct Answer: 8 to 12 pins with an insertional torque of 1 to 5 in-lb

Explanation:

Question 37:

Options:

Z-plasty.
a posterior interosseous fasciocutaneous flap.
a reverse cross-finger flap from the index finger.
excision of the contracture with placement of a full-thickness skin graft.
excision of the contracture with placement of a split-thickness skin graft.

Correct Answer: a posterior interosseous fasciocutaneous flap.

Explanation:

Question 38:

Options:

24 hours.
2 days.
5 days.
7 to 14 days.
6 months.

Correct Answer: 7 to 14 days.

Explanation:

Question 39:

Options:

Brown-Sequard syndrome
Central cord syndrome
Anterior cord syndrome
Posterior cord syndrome
Bilateral brachial plexus palsy

Correct Answer: Central cord syndrome

Explanation:

Question 40:

Options:

Subscapularis
Supraspinatus
Infraspinatus
Teres minor

Correct Answer: Subscapularis

Explanation:

Question 41:

Options:

irrigation, debridement, and IV antibiotics.
curettage and bone grafting.
preoperative chemotherapy followed by wide excision.
observation.
aspiration and injection with methylprednisolone.

Correct Answer: aspiration and injection with methylprednisolone.

Explanation:

Question 42:

Which of the following physical examination findings is most likely present in the condition producing the MRI findings shown in Figure 92? Review Topic

Options:

Valgus laxity at 30 degrees of knee flexion
Varus laxity at 30 degrees of knee flexion
Posterior drawer
Pivot shift
Patellar apprehension

Correct Answer: Pivot shift

Explanation:

Question 43:

An anatomic reduction is obtained at the femoral neck. The most likely reason for development of avascular necrosis (AVN) in this scenario would be

Options:

- an ORIF delay exceeding 24 hours because of hemodynamic ?instability.
- an associated femur fracture.
- patient age and mechanism of injury.
- treatment with a closed reduction.

Correct Answer: - an ORIF delay exceeding 24 hours because of hemodynamic ?instability.

Explanation:

DISCUSSION
A damage-control approach is indicated for this patient. Debridement of the open fracture wound and rapid stabilization without an extensive surgical
approach are indicated. Rapid percutaneous fixation of the femoral neck would compromise long-term outcomes for this displaced fracture because obtaining a quality reduction and fixation construct is critical for the long-term outcome. This patient likely would not tolerate cephalomedullary nailing or open approaches very well at this time.
A vertically oriented (Pauwels 3) femoral neck fracture is more common in younger patients who sustain high-energy injuries. Because of the mechanism of injury, many of these patients have associated injuries. This is a biomechanically challenging fracture because the fracture is subject to shear forces rather than compression, making it inherently unstable. This type of fracture often necessitates different fixation strategies to counter shearing forces, such as use of a transversely oriented (Pauwels) screw to compress the fracture or a fixed-angle device.
The femoral neck fracture should be prioritized in this scenario. This does not necessarily mean that the femoral neck should be repaired first, but the strategy should emphasize optimal fixation of the femoral neck. It has been demonstrated that this is less successful when using a single implant to repair both fractures. It is possible to place femoral neck fixation around an antegrade femoral nail; however, it is much more likely that optimal fixation will be achieved with shaft fixation that does not obstruct placement of fixation for the femoral neck.
AVN is more common among physiologically young patients after femoral neck fractures. The higher energy of injury is a likely contributor. Closed reduction has not been shown to increase the risk for AVN when an anatomic reduction is obtained. A surgical delay of 24 hours does not cause AVN. Patients with associated femoral shaft fractures are not at increased risk for AVN; in fact, some studies have shown a relatively lower rate of AVN when a femoral neck fracture is associated with a femoral shaft fracture.
RECOMMENDED READINGS
Liporace F, Gaines R, Collinge C, Haidukewych GJ. Results of internal fixation of Pauwels type-
3 vertical femoral neck fractures. J Bone Joint Surg Am. 2008 Aug;90(8):1654-9. doi: 10.2106/JBJS.G.01353. PubMed PMID: 18676894.
View Abstract at PubMed
Bedi A, Karunakar MA, Caron T, Sanders RW, Haidukewych GJ. Accuracy of reduction of ipsilateral femoral neck and shaft fractures--an analysis of various internal fixation strategies. J Orthop Trauma. 2009 Apr;23(4):249-53. doi: 10.1097/BOT.0b013e3181a03675. PubMed PMID: 19318867.
View
Abstract at PubMed
Haidukewych GJ, Rothwell WS, Jacofsky DJ, Torchia ME, Berry DJ. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg Am. 2004 Aug;86-A(8):1711-6. PubMed PMID: 15292419.
View Abstract at PubMed
Peljovich AE, Patterson BM. Ipsilateral femoral neck and shaft fractures. J Am Acad Orthop Surg. 1998 Mar-Apr;6(2):106-13. PubMed PMID: 9682073.
View
Abstract at PubMed
Upadhyay A, Jain P, Mishra P, Maini L, Gautum VK, Dhaon BK. Delayed internal fixation of fractures of the neck of the femur in young adults. A prospective, randomised study comparing closed and open reduction. J Bone Joint Surg Br. 2004 Sep;86(7):1035-40. PubMed PMID: 15446534.
View Abstract at PubMed
RESPONSES FOR QUESTIONS 96 THROUGH 99
- Warfarin (Coumadin)
- Dabigatran (Pradaxa)
- Rivaroxaban (Xarelto)
- Apixaban (Eliquis)
Match the appropriate oral anticoagulant listed with the description.
This medication is a vitamin K antagonist and can be reversed.
- Warfarin (Coumadin)
- Dabigatran (Pradaxa)
- Rivaroxaban (Xarelto)
- Apixaban (Eliquis)

Question 44:

Options:

rotator cuff interval closure.
distal clavicle excision.
superior labrum anterior and posterior repair.
biceps tenodesis.
thermal capsulorrhaphy.

Correct Answer: distal clavicle excision.

Explanation:

Question 45:

Based on the findings seen in the radiograph in Figure 26, emergent management should consist of

Options:

volar open reduction and pinning.
open reduction, ligament repair, and pinning.
closed reduction and splinting.
closed reduction and pinning.
dorsal open reduction and pinning.

Correct Answer: closed reduction and splinting.

Explanation:

Question 46:

Options:

a program of shoulder strengthening exercises.
decompression of the nerve at the spinoglenoid notch.
decompression of the nerve at the transverse suprascapular ligament.
release of the fascial elements of the muscle tethering the nerve.
arthroscopy, repair of the posterior labrum lesion, and an anterior capsular shift.

Correct Answer: a program of shoulder strengthening exercises.

Explanation:

Question 47:

Options:

C5-C6 postganglionic injury
C8-T1 preganglionic injury
C5 through C7 preganglionic injury
C8-T1 postganglionic injury

Correct Answer: C8-T1 preganglionic injury

Explanation:

Question 48:

Options:

povidone-iodine soaks and oral antibiotics.
povidone-iodine soaks and IV antibiotics.
partial nail plate removal.
phenol nail matrix ablation.
surgical nail matrix ablation.

Correct Answer: partial nail plate removal.

Explanation:

Question 49:

Options:

accessory incisions.
use of tapered drill bits.
use of oscillating drills.
greater knee extension.

Correct Answer: greater knee extension.

Explanation:

Question 50:

Options:

Anterior labral repair
Anterior labral repair and remplissage
Posterior labral repair and rotator interval closure
Anterior and posterior labral repair

Correct Answer: Anterior and posterior labral repair

Explanation:

Question 51:

Options:

an elevated thyroid-stimulating hormone level.
an elevated estrogen level.
elevated blood urea nitrogen and creatinine levels.
a growth hormone deficiency.
normal laboratory values.

Correct Answer: normal laboratory values.

Explanation:

Question 52:

Options:

Resurfacing hemiarthroplasty
Resurfacing hemiarthroplasty with fascial glenoid resurfacing
Resurfacing hemiarthroplasty with cemented glenoid component
Stemmed hemiarthroplasty
Stemmed total shoulder arthroplasty

Correct Answer: Stemmed hemiarthroplasty

Explanation:

Question 53:

Options:

be able to run and walk without pain.
refrain from vigorous activity for 6 months.
achieve full hip and knee range of motion.
achieve symmetric lower extremity strength.
have radiographic evidence of a circumferential external bridging callus.

Correct Answer: have radiographic evidence of a circumferential external bridging callus.

Explanation:

DISCUSSION: While it is recommended that a patient gain full range of motion, pain-free function, and symmetric strength prior to returning to vigorous activities, it is absolutely essential that radiographs of the fracture site reveal a circumferential external bridging callus to prevent refracture. This is particularly important for comminuted femoral fractures with various sized fragments. It is also recommended that a return to rodeo riding be postponed for at
least 1 year.
REFERENCES: Brumback RJ, Ellison TS: Intermedullary nailing of femoral stress fractures. J Bone Joint Surg Am 1992;74:106-112.
Bucholz RW, Jones A: Fractures of the shaft of the femur. J Bone Joint Surg Am
1991;73:1561-1566.
Butler MS, Brumback RJ: Interlocking nailing for ipsilateral fractures of the femur, femoral shaft, and distal part of the femur. J Bone Joint Surg Am 1991;73:1492-1502.

Question 54:

Options:

Decreased resistance to oxidative degradation
Decreased toughness
Increased density of nonconsolidated particles
Increased elastic modulus
High levels of residual free radicals

Correct Answer: Decreased toughness

Explanation:

Question 55:

Options:

Revision total knee arthroplasty with extensor mechanism allograft
Revision total knee arthroplasty with liner change and primary quadriceps repair
Resection knee arthroplasty and arthrodesis with antegrade nail
Two-stage revision total knee arthroplasty with extensor mechanism allograft

Correct Answer: Revision total knee arthroplasty with extensor mechanism allograft

Explanation:

Question 56:

.The least gliding resistance for a flexor tendon laceration at the thumb palmar-digital crease as shown inFigure 75 can be achieved with

Options:

a 6-strand repair.
a division and repair.
debridement of the partial laceration.
no debridement, motion therapy only.
multiple-strand core repair with epitendinous repair.

Correct Answer: multiple-strand core repair with epitendinous repair.

Explanation:

Question.9 . A 42-year-old woman has the injury shown in Figures 78a and 78b. The decision to treat the ulnar styloid surgically is based upon which finding?
Patient age
Displacement of the radius fracture
Displacement of the ulnar styloid fracture
Position of the ulnar styloid after open reduction and internal fixation of the radius
Stability of the distal radioulnar joint after open reduction and internal fixation of the radius

Question 57:

During treatment of rupture of the subscapularis tendon with associated biceps instability, treatment of the biceps tendon should include which of the following?

Options:

Tenosynovectomy
Recentering
Deepening of the bicipital groove
Tenodesis or tenotomy
Lysis of sheath adhesion

Correct Answer: Tenodesis or tenotomy

Explanation:

DISCUSSION: With subscapularis tendon ruptures that have biceps tendon pathology, treatment with tenodesis or tenotomy has improved clinical results. Subluxation or dislocation of the biceps tendon is common with subscapularis rupture. Dislocation of the biceps can occur either beneath the tendon, within the tendon, or extra-articularly. In all cases, the restraints to medial translations of the biceps have been disrupted. Attempts at recentering the biceps have not been successful, and clinical results appear to be improved when tenodesis or tenotomy is employed in the treatment of the unstable biceps associated with subscapularis tears.
REFERENCES: Edwards TB, Walch G, Sirvenaux F, et al: Repair of tears of the subscapularis: Surgical technique. J Bone Joint Surg Am 2006;88:1-10.
Deutsch A, Altchek DW, Veltri DM, et al: Traumatic tears of the subscapularis tendon: Clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Am J Sports Med 1997;25:13-22.
Edwards TB, Walch G, Sirveaux F, et al: Repair of tears of the subscapularis. J Bone Joint Surg Am 2005;87:725-730.

Question 58:

Options:

MRI
Electromyography
Open repair of the supraspinatus
Arthrography
Arthroscopic labral repair

Correct Answer: MRI

Explanation:

Question 59:

Eosinophilic granuloma frequently occurs as a solitary lesion in the tubular long bones. After biopsy, what is the best course of action?

Options:

Neoadjuvant chemotherapy
En bloc resection
Observation
Amputation
Chemotherapy followed by radiation therapy

Correct Answer: Observation

Explanation:

Question 60:

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 61:

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

Options:

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

Correct Answer: Anterior cruciate ligament (ACL) rupture

Question 62:

Options:

Acute hematogenous osteomyelitis
Kohler’s disease
Tarsal coalition
Tuberculosis
Lisfranc fracture-dislocation

Correct Answer: Tuberculosis

Explanation:

Question 63:

What mechanism is associated with the spontaneous resorption of herniated nucleus pulposus?

Options:

Macrophage infiltration and phagocytosis
Granuloma formation
Antibody mediated destruction
Complement cascade activation
Major histocompatibility complex mediated pathways

Correct Answer: Macrophage infiltration and phagocytosis

Explanation:

Question 64:

Options:

Serum calcium normal
Serum alkaline phosphatase normal
Urine calcium is low
Serum phosphate is often high When symptomatic, the masses are excised.

Correct Answer: Serum calcium normal

Explanation:

Which of the following describes the histopathology of tumoral calcinosis:

Question 65:

Figure 7 shows the CT scan of a 22-year-old professional baseball pitcher who has had elbow pain for the past 6 months despite rest from throwing. Management should consist of Review Topic

Options:

cast immobilization for 6 weeks.
brief immobilization followed by rest for 6 weeks.
internal fixation with a compression screw.
internal fixation with a tension band wire.
bone stimulation.

Correct Answer: internal fixation with a compression screw.

Explanation:

Question 66:

Options:

Repeat wide excision of the tumor bed
Observation
Radiation therapy to the tumor bed only
Chemotherapy
Radiation therapy and chemotherapy

Correct Answer: Repeat wide excision of the tumor bed

Explanation:

DISCUSSION: Treatment of patients with unplanned excision of soft-tissue sarcomas is challenging. If the margins are positive or unclear, the patient is best managed with repeat excision of the tumor bed, and radiation therapy if the repeat excision does not yield wide margins. In patients with no detectable tumor on physical examination or imaging after unplanned excision, some studies have shown that up to 35% of patients will have residual disease and a poorer local recurrence rate (22% versus 7%). Therefore, whenever feasible,
a reexcision of the tumor bed is recommended.
REFERENCE: Noria S, Davis A, Kandel R, et al: Residual disease following unplanned excision of soft-tissue sarcoma of an extremity. J Bone Joint Surg Am 1996;78:650-655.

Question 67:

Options:

Conversion to a halo vest
Closed reduction and conversion to a halo vest
Posterior atlantoaxial arthrodesis
Odontoid screw fixation
Continued halo immobilization

Correct Answer: Conversion to a halo vest

Explanation:

DISCUSSION: The traditional treatment of a reduced type II fracture is a halo vest. A 20-year-old man will tolerate a halo vest better than the elderly or women. Anterior screw fixation has gained increasing support; however, it too has risks and requires a significant learning curve. More recently, C1 lateral mass screws have become more popular. The long-term results and benefits have not yet been determined.
REFERENCES: Spivak JM, Connolly PF (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, p 193.
Kiovikko MP, Kiuru MJ, Koskinen SK, et al: Factors associated with nonunion in conservatively-treated type-II fractures of the odontoid process. J Bone Joint Surg Br 2004;86:1146-1151.
Herkowitz HN, Garfin SR, Eismont FJ: Rothman-Simone The Spine, ed 5. Philadelphia, PA, Saunders Elsevier, 2006, p 1091.
Fiore AJ, Haid RW, Rodts GE, et al: Atlantal lateral mass screws for posterior spinal reconstruction: Technical note and case series. Neurosurg Focus 2002;12:E5.

Question 68:

Spontaneous recovery of upper extremtiy motor function after a cerebrovascular accident occurs in which of the following predictable patterns?

Options:

Shoulder flexion, elbow flexion, wrist flexion, finger flexion
Shoulder flexion, forearm supination, wrist flexion, finger flexion
Shoulder extension, elbow extension, wrist extension, finger extension
Finger flexion, wrist extension, elbow flexion, shoulder flexion
Finger flexion, wrist flexion, elbow flexion, shoulder flexion

Correct Answer: Shoulder flexion, elbow flexion, wrist flexion, finger flexion

Explanation:

Question 69:

The posterior horn of the medial meniscus receives its primary blood supply from what artery? Review Topic

Options:

Middle genicular
Medial inferior genicular
Medial superior genicular
Lateral superior genicular
Inferior lateral genicular

Correct Answer: Middle genicular

Explanation:

Question 70:

At the time of revision knee arthroplasty, a surgeon performs a rectus snip to gain exposure to the knee. When compared to a standard parapatellar approach, what is the expected outcome?

Options:

Improvement in range of motion
Reduction in range of motion
Increase in extensor mechanism lag
No differences in motion and strength

Correct Answer: No differences in motion and strength

Explanation:

DISCUSSION
Rectus snip during total knee arthroplasty has no effect on motion or strength at long-term follow-up. It has not been associated with extensor mechanism lag.
RESPONSES FOR QUESTIONS 58 THROUGH 62
Nerve palsy
Skin necrosis
Flexion instability
Patellar instability
Anterior knee pain
Malalignment
Total knee arthroplasty (TKA) is performed to address each condition shown in Figures 58 through 62b. Which complication is most commonly associated with each image?

Question 71:

- A 19-year-old man sustains a complete spinal cord injury at the C7 level as a result of diving into a lake. He has a blood pressure of 90/50 mm Hg, a pulse of 60/min, and respirations of 20/min. These values most likely signify

Options:

Spinal shock
Neurogenic shock
Hypovolemic shock
Pulmonary embolism
Fat embolus syndrome

Correct Answer: Neurogenic shock

Explanation:

Question 72:

What is the preferred treatment of displaced distal clavicle fractures in children less than eight years old?

Options:

Closed reduction and pinning of the fracture
Open reduction and plating
Sling immobilization
Coracoclavicular ligament reconstruction
Open reduction and suture fixation

Correct Answer: Closed reduction and pinning of the fracture

Explanation:

Question 73:

Options:

Positive impingement sign
Positive apprehension
Positive active compression
Weakness of external rotation
Weakness of abduction

Correct Answer: Weakness of external rotation

Explanation:

Question 74:

Options:

Middle glenohumeral ligament
Supraspinatus
Infraspinatus
Subscapularis
Bankart tear

Correct Answer: Subscapularis

Explanation:

Question 75:

Options:

Continued semi-rigid immobilization until the extremity surgeries are completed
Halo skeletal fixation prior to the extremity surgery
Definitive clearance of the cervical spine with CT and/or MRI
Removal of the semi-rigid collar and physical examination when the patient is responsive
Soft collar immobilization and local wound care

Correct Answer: Definitive clearance of the cervical spine with CT and/or MRI

Explanation:

Question 76:

Options:

Brown-Sequard
Cauda equina
Anterior cord
Posterior cord
Central cord

Correct Answer: Central cord

Explanation:

DISCUSSION: These finding indicate central cord syndrome, and injury that is more common in the older population who have some degree of spondylosis. The physiologic insult can be a central spinal hematoma with resultant hematomyelia. Bowel and bladder functional return has a good prognosis, unlike the upper extremity motor loss. Cauda equina syndrome generally involves injury at the lumbar levels, with some degree of lower extremity motor loss. Posterior cord syndrome is characterized by preservation of motor function below the level of injury and position/vibratory sensory loss. Brown-Sequard syndrome, which is often produced by a penetrating injury, results in contralateral hypalgesia and ipsilateral weakness. Anterior cord syndrome has a poor prognosis for functional return; lower extremity findings include loss of light touch, sharp/dull, and temperature sensations below the level of injury, as well as
motor function.
REFERENCES: Apple DF Jr: Spinal cord injury rehabilitation, in Rothman RH, Simeone FA (eds): The Spine, ed 3. Philadelphia, PA, WB Saunders, 1992, Chapter 31.
Leventhal MR: Fractures, dislocations and fracture-dislocations of spine, in Crenshaw AH (ed): Campbell’s Operative Orthopaedics, ed 8. St. Louis, MO, Mosby, 1992.

Question 77:

-What is the most likely mechanism of injury?

Options:

External rotation
Posterior translation
Hyperextension and varus
Anterior translation and internal rotation

Correct Answer: Anterior translation and internal rotation

Explanation:

DISCUSSION FOR QUESTIONS 56 THROUGH 58
The MRI scan shows a bone bruise of the lateral femoral condyle and lateral tibial plateau. This injury pattern is commonly associated with anterior cruciate ligament (ACL) rupture and an abnormal pivot shift test result. Treatment of an ACL tear in a high-demand athlete should consist of ligament reconstruction.In this patient, surgery should be delayed until she regains full range of motion to minimize risk for arthrofibrosis after surgery. Recent analysis has shown that the noncontact mechanism is more consistent with anterior translation, affecting both the medial and lateral compartments. The bone bruise in the lateral femoral condyle occurs more anterior than that of the medial femoral condyle, suggesting that internal rotation has occurred. The external rotation recurvatum test assesses for posterolateral corner injury, and a positive quadriceps active test is consistent with posterior cruciate ligament rupture. An abnormal patellar apprehension test result is suggestive of patellar instability. Nonsurgical treatment is unlikely to result in sufficient stability if this patient returns to sports at her preinjury level of activity.Primary ACL repair is associated with high failure rates. Although the precise mechanism of injury varies,injuries can be broadly classified into contact and noncontact injuries. Noncontact injuries occur with the knee in slight flexion, valgus, and internal rotation, and contact injuries typically involve a lateralside impact producing a valgus force to the knee. The valgus component of noncontact injuries has been thought to cause mainly lateral compartment bone bruising. Posterior translation is the most common mechanism of posterior cruciate ligament rupture, and hyperextension and varus is associated with posterolateral corner injury.

Question 78:

Which of the following studies has the highest sensitivity and specificity in diagnosis of osteonecrosis of the femoral head?

Options:

Intraosseous pressures
AP and frog-lateral radiographs
Technetium Tc 99m bone scan
MRI scan
CT scan

Correct Answer: MRI scan

Explanation:

Question 79:

Options:

Observation
Initiate bracing
MRI scan of the entire spine
Spinal instrumentation with growing rod construct

Correct Answer: MRI scan of the entire spine

Explanation:

Question 80:

Options:

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

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

Explanation:

Question 81:

Options:

discontinuation of antibiotics and administration of nonsteroidal anti-inflammatory drugs, followed by physical therapy.
incision and drainage of both hips.
in situ pinning of both hips.
broad-spectrum antibiotics in accordance with the recommendations of a pediatric infectious diseases consultant.
continued use of IV antibiotics for 2 weeks, followed by oral antibiotics until the ESR returns to normal.

Correct Answer: discontinuation of antibiotics and administration of nonsteroidal anti-inflammatory drugs, followed by physical therapy.

Explanation:

Question 82:

Options:

Observation
Physical therapy
Epidural steroid injections
Cervical laminectomy
Anterior cervical diskectomy and fusion

Correct Answer: Anterior cervical diskectomy and fusion

Explanation:

DISCUSSION: The patient has obvious signs of progressive myelopathy. Based on her significant physical examination findings, nonsurgical management will not significantly impact her outcome. Cervical decompression alone is contraindicated in patients with cervical kyphosis such as seen here. Anterior cervical fusion is the best option.
REFERENCES: Emery SE, Bohlman HH, Bolesta MJ, et al: Anterior cervical decompression and arthrodesis for the treatment of cervical spondylotic myelopathy: Two to seventeen-year follow-up. J Bone Joint Surg Am 1998;80:941-951.
Ferguson RJ, Caplan LR: Cervical spondylotic myelopathy. Neurol Clin 1985;3:373-382.
Herkowitz HN: A comparison of anterior cervical fusion, cervical laminectomy, and cervical laminoplasty for the surgical management of multiple level spondylotic radiculopathy. Spine 1988;13:774-780.

Question 83:

Options:

Injection of bone cement into the talus to prevent further avascular necrosis
Ankle fusion
Subtalar fusion
Ankle arthroscopy to address this osteochondral lesion
Continued observation as the vascularity to the talus is intact

Correct Answer: Injection of bone cement into the talus to prevent further avascular necrosis

Explanation:

Question 84:

Following a partial muscle laceration, keeping the affected extremity immobilized for 2 weeks before starting an exercise program will likely lead to: Review Topic

Options:

Greater area of fibrous scar tissue than immediate mobilization
Less fatty infiltration than immediate mobilization
Atrophy limiting final functional outcome
Better penetration of ingrowing muscle fibers than a shorter period of immobilization
More uniform orientation of ingrowing muscle fibers than a shorter period of immobilization

Correct Answer: Better penetration of ingrowing muscle fibers than a shorter period of immobilization

Explanation:

Question 85:

During the early swing phase of the normal gait cycle, what lower extremity muscle is primarily contracting?

Options:

Tibialis posterior
Tibialis anterior
Vastus medialis
Adductor longus
Gastrocnemius

Correct Answer: Tibialis anterior

Explanation:

DISCUSSION: Electromyography during walking reveals the tibialis anterior muscle is active during early swing, allowing the foot to clear the ground. All of the other muscles are quiet, as the limb moves forward through space with minimal muscular effort. The other muscles are primarily active during weight acceptance or push-off.
REFERENCES: Gage JR: An overview of normal walking. Instr Course Lect 1990;39:291-303.
Wootten ME, Kadaba MP, Cochran GV: Dynamic electromyography II: Normal patterns during gait. J Orthop Res 1990;8:259-265.

Question 86:

Options:

Decreased joint penetration of distal screws
Increased rigidity
Decreased need for delayed hardware removal
Decreased peroneal irritation
Improved distal fixation

Correct Answer: Decreased joint penetration of distal screws

Explanation:

Question 87:

Options:

Sliding hip screw
Dynamic condylar screw
95 blade plate
Cephalomedullary nail
Intramedullary hip screw

Correct Answer: Sliding hip screw

Explanation:

Question 88:

Options:

observation
radiation therapy alone
wide resection and reconstruction
wide resection, reconstruction and chemotherapy
wide resection, reconstruction and local radiation therapy.

Correct Answer: wide resection and reconstruction

Explanation:

Question 89:

Options:

Pulse oximeter measurement at the great toe
Angiography
Measurement of the ankle-brachial index (ABI)
Doppler ultrasound
Assessment of capillary refill in the nail beds

Correct Answer: Measurement of the ankle-brachial index (ABI)

Explanation:

Question 90:

Options:

Peroneal tendon tear
Lateral process talus fracture
Talar neck fracture
Lisfranc injury
Deltoid ligament tear

Correct Answer: Lisfranc injury

Explanation:

DISCUSSION: This cuboid compression fracture (“nutcracker” injury) is associated with subtle injury to the Lisfranc complex. This diagnosis must be made to ensure proper treatment.
REFERENCE: Early JS: Fractures and dislocations of the midfoot and forefoot, in Bucholz R, Heckman JD, Court-Brown CM (eds): Rockwood and Green’s Fractures in Adults. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, pp 2337-2400.

Question 91:

Options:

elbow extension motion.
elbow flexion strength.
forearm supination motion.
forearm pronation strength.
forearm supination strength.

Correct Answer: forearm supination strength.

Explanation:

Question 92:

Medial dislocation of the long head of the biceps tendon in the shoulder is most commonly caused by a Review Topic

Options:

tear of the subscapularis tendon.
tear of the supraspinatus tendon.
tear of the transverse ligament.
type I SLAP tear.
congenitally shallow bicipital groove.

Correct Answer: tear of the subscapularis tendon.

Explanation:

Question 93:

During total hip arthroplasty, profuse bleeding is noted following predrilling for placement of an acetabular component screw. The drill most likely penetrated too deep in the

Options:

anterior-superior acetabular quadrant.
posterior-superior acetabular quadrant.
posterior-inferior acetabular quadrant.
medial acetabular wall.
ischial body.

Correct Answer: anterior-superior acetabular quadrant.

Explanation:

Question 94:

Options:

Cervical C6-7 radiculopathy
Impingement
Rotator cuff tear
Brachial neuritis
Adhesive capsulitis

Correct Answer: Brachial neuritis

Explanation:

Question 95:

Options:

2 to 5 days, followed by initiation of assisted motion.
14 to 21 days, followed by initiation of assisted motion.
4 weeks, followed by active motion.
6 weeks, followed by physical therapy.
8 weeks, followed by active motion of the elbow.

Correct Answer: 2 to 5 days, followed by initiation of assisted motion.

Explanation:

Question 96:

03 A 28-year-old man who sustained the injury shown in Figure 31 is hemodynamically unstable. In addition to fluid resuscitation, the next most appropriate step in management should include

Options:

angiography and embolization.
an emergent exploratory laparotomy.
external pelvic stabilization.
open reduction and internal fixation.
closed reduction and percutaneous screw fixation. backanswer Question 112.03

Correct Answer: external pelvic stabilization.

Explanation:

Question 97:

Figure 42 shows the sagittal T2-weighted MRI scan of a patient’s right knee. These findings are most commonly seen with a complete tear of the

Options:

patellar tendon.
lateral collateral ligament.
medial collateral ligament.
posterior cruciate ligament.
anterior cruciate ligament.

Correct Answer: lateral collateral ligament.

Explanation:

DISCUSSION: The MRI scan reveals disruption of the lateral capsule and ligaments with
fluid in the soft tissues laterally. Additionally, there is a large bone bruise on the medial
femoral condyle. This combination indicates injury to the posterolateral complex. These injuries often have coexisting anterior and/or posterior cruciate ligament injuries. Failure to recognize the posterolateral corner injury can lead to failure of anterior or posterior cruciate ligament reconstructions.
REFERENCES: LaPrade RF, Gilbert TJ, Bollom TS, et al: The magnetic resonance imaging appearance of individual structures of the posterolateral knee: A prospective study of normal knees and knees with surgically verified grade III injuries. Am J Sports Med 2000;28:191-199.
Ross G, Chapman AW, Newberg AR, et al: Magnetic resonance imaging for the evaluation of acute posterolateral complex injuries of the knee. Am J Sports Med 1997;25:444-448.

Question 98:

Options:

Arthroscopic Bankart surgery
Bony glenoid augmentation procedure
Subscapularis advancement
Open capsular shift
Hemiarthroplasty

Correct Answer: Bony glenoid augmentation procedure

Explanation:

Question 99:

Options:

Quicker return to activities
Quicker return to work
Increased subtalar joint range of motion
Decreased risk of nonunion
Decreased risk of posttraumatic arthritis

Correct Answer: Decreased risk of posttraumatic arthritis

Explanation:

DISCUSSION: The radiographs and CT scans show a displaced intra-articular calcaneal fracture, with loss of calcaneal height and length. Recent multicenter, randomized, prospective studies suggest that surgical treatment of displaced intra-articular calcaneal fractures is associated with an almost six-fold decrease in the risk of posttraumatic subtalar arthritis (necessitating subtalar arthrodesis) compared to nonsurgical treatment. Despite ongoing controversy, surgical treatment has not been shown to be advantageous with respect to activity, time to return to work, or subtalar joint range of motion. A nonunion of a calcaneal fracture is exceedingly rare regardless of the treatment method.
REFERENCES: Buckley R, Tough S, McCormack R, et al: Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: A prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2002;84:1733-1744.
Csizy M, Buckley R, Tough S, et al: Displaced intra-articular calcaneal fractures: Variables predicting late subtalar fusion. J Orthop Trauma 2003;17:106-112.

Question 100:

Options:

Reamed intramedullary nailing
Traction
External fixation
Open plating
Mast suit

Correct Answer: External fixation

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

Orthopedic Board Review MCQs: Spine, Trauma, Foot & Wrist | Part 185

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 185

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index