Orthopedic Surgery MCQ Review: Fracture, Hip & Nerve

About This Board Review Set

This is Part 191 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

How to Use the Interactive Quiz

Two distinct learning modes are available:

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

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

Topics Covered in Part 191

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

Sample Questions from This Set

Sample Question 1: Which nerve is not included in a standard popliteal nerve block?...

Sample Question 2: Figure 99 is the radiograph of an 18-year-old National Collegiate Athletic Association Division I basketball player who jumped for a basket. Afterlanding, he was unable to put weight on his left great toe. He developed pain, swelling, and e...

Sample Question 3: Which of the following structures may help maintain radial length after a radial head fracture?...

Sample Question 4: Of all the pelvic ring injury types, anteroposterior compression type III pelvic ring injuries have the highest rate of which of the following?...

Sample Question 5: A 2-week-old infant has been referred for evaluation of nonmovement of the left hip. History reveals that the patient was delivered 6 weeks premature by cesarean section. Examination reveals no fever, and there is mild swelling of the thigh...

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

00:00

Start Quiz

Question 1

Which nerve is not included in a standard popliteal nerve block?

Explanation

42A

B
Figures 42a and 42b are the radiographs of a 32-year-old man with an accessory navicular, pes planovalgus deformity, and an associated gastrocnemius contracture. He has been treated with custom orthotics and a physical therapy program for several years and has progressed to stage II posterior tibial tendon dysfunction (PTTD). This patient is now interested in surgery. Tendon reconstruction with bony procedure to correct alignment, medializing calcaneal osteotomy with lateral column lengthening, and a subtalar arthroereisis implant are discussed with the patient.

Question 2

Figure 99 is the radiograph of an 18-year-old National Collegiate Athletic Association Division I basketball player who jumped for a basket. After landing, he was unable to put weight on his left great toe. He developed pain, swelling, and ecchymosis maximally around the sesamoids. When assessing stability of the first metatarsophalangeal joint, he appears to have more laxity on the left. What is the best next step?

Explanation

DISCUSSION
This patient jumped on his forefoot and landed with pain in his great toe. His radiograph shows possible increased space between the sesamoids and the base of the phalanx. A comparison radiograph on the other side will reveal if this position is normal for this patient. If findings are asymmetric, turf toe injury is a possibility based on this patient's symptoms and mechanism of injury.
RECOMMENDED READINGS
Waldrop NE 3rd, Zirker CA, Wijdicks CA, Laprade RF, Clanton TO. Radiographic evaluation of plantar plate injury: an in vitro biomechanical study. Foot Ankle Int. 2013 Mar;34(3):403-8. doi: 10.1177/1071100712464953. Epub 2013 Jan 14. PubMed PMID: 23520299. View
Abstract at PubMed
McCormick JJ, Anderson RB. The great toe: failed turf toe, chronic turf toe, and complicated sesamoid injuries. Foot Ankle Clin. 2009 Jun;14(2):135-50. doi: 10.1016/j.fcl.2009.01.001. Review. PubMed PMID: 19501799. View Abstract at PubMed

Question 3

Which of the following structures may help maintain radial length after a radial head fracture?

Explanation

DISCUSSION: Essex-Lopresti injuries affect axial stability of the forearm. Injury to the interosseous membrane or the triangular fibrocartilage complex can result in proximal migration of the radius.
REFERENCES: Morrey BF, Chao EY, Hui FC: Biomechanical study of the elbow following excision of the radial head. J Bone Joint Surg Am 1979;61:63-68.
Coleman DA, Blair WF, Shurr D: Resection of the radial head for fracture of the radial head: Long-term follow-up of seventeen cases. J Bone Joint Surg Am 1987;69:385-392.

Question 4

Of all the pelvic ring injury types, anteroposterior compression type III pelvic ring injuries have the highest rate of which of the following?

Explanation

DISCUSSION: Of the pelvic ring injuries, APC type III have the highest rate of mortality, blood loss, and need for transfusion. They also have a high rate of urogenital injury and abdominal organ injury. Lateral compression injuries (especially type III) have the highest rate of head injury. Vertical shear and combined injuries also have significant rates of concomitant injuries. The referenced article by Dalal et al is a review of Shock Trauma's pelvic ring injuries; they found significant increases in associated injuries as the grade of pelvic ring injury increased, regardless of mechanism/pattern. The aforementioned information was also found to be true with their patient review.

Question 5

A 2-week-old infant has been referred for evaluation of nonmovement of the left hip. History reveals that the patient was delivered 6 weeks premature by cesarean section. Examination reveals no fever, and there is mild swelling of the thigh. Passive movement of the hip appears to elicit tenderness and very limited hip motion. A radiograph of the pelvis shows mild subluxation of the left hip. The next step in evaluation should consist of

Explanation

DISCUSSION: The diagnosis of bone and joint sepsis in a newborn is difficult because of the relative lack of obvious signs and symptoms. Fever is usually absent. A study of 34 newborns with osteomyelitis identified prematurity and delivery by cesarean section as predisposing factors. In that study, the most common clinical findings were pseudoparalysis, local swelling, and pain on passive movement. Because early diagnosis is so important, any infant who exhibits these findings should be suspected as having bone or joint sepsis. Once the area of involvement is identified, aspiration is mandatory. In newborns who have an infection about the hip, radiographs may reveal subluxation. In this patient, septic arthritis must be ruled out by aspiration of the hip. Developmental dysplasia of the hip is not painful and is not accompanied by localized swelling. If no purulent material is obtained at the time of hip aspiration, an arthrogram should be obtained to rule out epiphysiolysis of the proximal femur. Because the area of involvement has been identified by clinical examination, a gallium scan or MRI scan of the spine is not indicated.
REFERENCES: Knudsen CJ, Hoffman EB: Neonatal osteomyelitis. J Bone Joint Surg Br 1990;72:846-851.
Morrissy RT: Bone and joint sepsis, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 4. Philadelphia, Pa, Lippincott-Raven, 1996, pp 579-624.

Question 6

03 A 26-year-old woman has chronic toe pain after hitting a bedpost 3 months ago. A radiograph is shown in Figure 27. Her injury represents an avulsion of the

Explanation

The main function of the EDL is extension of the MTP joints of the lesser toes, so injury results in a claw toe deformity if left unrepaired. The EDL originates on the lateral tibial condyle, the anterior crest of the fibula, and the interosseous membrane and inserts on the base of the terminal phalanges of the four lesser toes. Innervated by the deep peroneal nerve, the EDL functions to extend the toes at the DIP joint and to dorsiflex and evert the foot. The EDL divides into two separate tendons beneath the superior retinaculum and then further divides into two lateral tendons to the fourth and fifth toes and two medial tendons to the second and third toes. The individual tendon of the EDL to each toe is joined on the lateral aspect by the tendon of the EDB. They are anchored at the level of the MTP joint by a fibroaponeurotic structure.
The EDB originates on the distal lateral and superior surface of the calcaneus and inserts on the
lateral aspect of the flexor digitorum longus tendon and also on to the base of the proximal phalanx of the first through fourth toes. There is no EDB tendon to the fifth toe. If an EDB laceration is easily identified at the time of an EDL repair, than it may be repaired as well, otherwise repair of the EDL alone is sufficient.
Heckman JD: Fractures and dislocation of the foot, in Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD (eds):Rockwood and Green’s Fractures in Adults, ed 3. Philadelphia, PA, JB Lippincott, 1991, pp 2166-2169.
Coughlin MJ: Disorders of tendons, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 787-788.
back to this question next question

Question 7

Which of the following forms of nonsurgical management is considered best for acute low back pain without radiculopathy?

Explanation

DISCUSSION: Temporary bed rest (less than 4 days) with gradual resumption of activities can be efficacious. Epidural steroid injections may be indicated for acute low back pain with radiculopathy. Acupuncture, facet joint injections, or ligamentous (sclerosant) injections are not indicated.
REFERENCES: Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, Appendix A15.
Helfgott SM: Sensible approach to low back pain. Bull Rheum Dis 2001;3:50.

Question 8

A 10-year-old boy who is active in soccer has had activity-related heel pain for the past 3 months. Examination reveals tenderness over the posterior heel and a tight Achilles tendon. Radiographs demonstrate a 2-cm cyst in the anterior body of the calcaneus. His physes have not closed. Based on these findings, what is the most appropriate management?

Explanation

DISCUSSION: The most likely diagnosis is Sever’s disease, which is considered either an apophysitis or a para-apophyseal stress fracture. It is common in athletic children and is associated with a tight Achilles tendon. Cast immobilization may be necessary if activity reduction fails. Calcaneal cysts are quite common and do not require any further diagnostic testing or treatment unless they occupy the full width of the calcaneus or one third of the length of the calcaneus.
REFERENCES: Ogden JA, Ganey TM, Hill JD, et al: Sever’s injury: A stress fracture of the immature calcaneal metaphysis. J Ped Orthop 2004;24:488-492.
Pogoda P, Priemel M, Linhart W, et al: Clinical relevance of calcaneal bone cysts: A study of 50 cysts in 47 patients. Clin Orthop Relat Res 2004;424:202-210.

Question 9

Following an acute dislocation of the patella, the risk of a recurrent dislocation is greater if the patient has which of the following findings?

Explanation

DISCUSSION: Recurrent dislocations may follow an earlier dislocation. One study found that in patients who had a patellar dislocation between the ages of 11 to 14 years, 60% had a recurrent dislocation. The incidence of recurrent dislocation dropped to 33% in patients who had a patellar dislocation between the ages of 15 to 18 years. The authors also found that the incidence of recurrence was greater in patients who demonstrated a predisposition to dislocation as determined by evaluation of the unaffected knee. Predisposing signs included passive lateral hypermobility of the patella, a dysplastic distal third of the vastus medialis obliquis muscle, and a high and/or lateral position of the patella. A second study found that the risk of redislocation was considerably higher in patients who were in their teens at the first episode of dislocation compared to older patients. There are no studies linking either a patella baja or a bipartite patella to an increased risk of redislocation.
REFERENCES: Cash JD, Hughston JC: Treatment of acute patellar dislocation. Am J Sports Med 1988;16:244-249.
Larsen E, Lauridsen F: Conservative treatment of patellar dislocations: Influence of evident factors on the tendency to redislocation and the theraputic result. Clin Orthop

1982;171:131-136.

Question 10

Which of the following cohorts of patients is at highest risk of a future anterior cruciate ligament (ACL) tear? Review Topic

Explanation

Hewett and associates reported in a study of 205 female athletes that female athletes, with increased dynamic valgus and high abduction loads, were at increased risk of ACL injury. The same investigators in an earlier study of 81 high school basketball players reported that female athletes landed with greater total valgus knee motion and a greater maximum valgus knee angle than male athletes. Female athletes were also found to have significant differences between their dominant and nondominant side in maximum valgus knee angle. Lephart and associates reported that in single-leg landing and forward hop tasks that female athletes had significantly less knee flexion and lower leg internal rotation maximum angular displacement, and less knee flexion time to maximum angular displacement than males. Females with an adduction moment during landing should have a lower incidence of ACL tears. Males in general have a lower incidence of ACL tears.

Question 11

During the ilioinguinal approach to the pelvis, the corona mortis artery must be identified and ligated if present. The corona mortis artery joins the external illiac artery with which other major artery?

Explanation

DISCUSSION: The "corona mortis" (translated as “crown of death”) artery is a vascular variant that joins the external illiac and the obturator artery as it crosses the superior pubic ramus. Tornetta et al did a study where "fifty cadaver halves were dissected to determine the occurrence and location of the corona mortis. Anastomoses between the obturator and external iliac systems occurred in 84% of the specimens. Thirty-four percent had an arterial connection, 70% had a venous connection, and 20% had both. The distance from the symphysis to the anastomotic vessels averaged 6.2 cm (range, 3-9 cm)." The corona mortis can be injured in superior ramus fractures and iatrogenically while plating pelvic ring injuries using the ilioinguinal approach.

Question 12

A 20-year-old-man sustained a scapular fracture after attempting to grab a beam as he fell through a ceiling at a job site 3 months ago. A clinical photograph is shown in Figure 36. He now reports pain in the anterior shoulder and difficulty with overhead activities. What nerve roots make up the involved peripheral nerve?

Explanation

DISCUSSION: The patient sustained an injury to the long thoracic nerve, which supplies the serratus anterior. Branches of C5 and C6 enter the scalenus medius, unite in the muscle, and emerge as a single trunk and pass down the axilla. On the surface of the serratus anterior, the long thoracic nerve is joined by the branch from C7 and descends in front of the serratus anterior, providing segmental innervation to the serratus anterior.
REFERENCE: Leffert RD: Anatomy of the Brachial Plexus in Brachial Plexus Injuries. Churchill Livingstone, New York, NY, 1985.

Question 13

Which laboratory findings would most support a diagnosis of prosthetic joint infection (PJI) in a hip or knee arthroplasty performed 3 weeks ago?

Explanation

DISCUSSION
The diagnosis of acute PJI is associated with different criteria than the diagnosis of a chronic PJI. There is no agreed-upon threshold for ESR during the acute period (6 weeks) following total joint arthroplasty. The CRP threshold is higher during the acute period (100 mg/L vs 10 mg/L for a chronic infection). The threshold for synovial fluid analysis for an acute PJI is 10000 cells/µL and more than 90% PMN neutrophils vs 3000 cells/µL and more than 80% PMN neutrophils for a chronic infection.

Question 14

A 68-year-old man fell off a 20-foot mountain cliff and was seen in the emergency department the following morning. A radiograph is shown in Figure 12. He is a nonsmoker with medical comorbidities of hypertension and hypercholesterolemia that is well controlled with medicine and diet. Capillary refill and sensation are intact distally and the patient is able to move his toes with mild discomfort. Serosanguinous fracture blisters are present laterally, and the foot is swollen and red. What is the most appropriate management?

Explanation

DISCUSSION: Whereas a patient age of older than 50 years used to be a contraindication for open reduction and internal fixation of displaced intra-articular calcaneal fractures, new data suggest that the presence of associated medical comorbidities that affect wound healing such as smoking, diabetes mellitus, and peripheral vascular disease are more relevant to postoperative functional outcome. Surgical treatment of Sanders II and III displaced intra-articular calcaneal fractures with initial Bohler angles of > 15 degrees results in better outcomes as compared to nonsurgical management. Indications for primary fusion might include Sanders IV fractures in which articular congruity or Bohler angles cannot be restored. Given the condition of the soft tissues at presentation, delayed fixation is recommended.
REFERENCES: Herscovici D Jr, Widmaier J, Scaduto JM, et al: Operative treatment of calcaneal fractures in elderly patients. J Bone Joint Surg Am 2005;87:1260-1264.
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 15

A 15-year-old high school soccer player collides with an opponent and is unconscious when the trainer arrives on the field. He is conscious within 15 seconds, breathing appropriately, and denies any headache, neck pain, or nausea. It is his first head injury. Provided that the athlete is free of symptoms, when should he be allowed to return to athletic activity?

Explanation

DISCUSSION: The loss of consciousness indicates a grade 2 concussion, which necessitates a
week period out of sport. The last week prior to return must be symptom-free and the athlete should not have symptoms in practice.
REFERENCES: Cantu RC: Return to play guidelines after a head injury. Clin Sports Med 1998;17:45-60.
Stevenson KL, Adelson PD: Pediatric sports-related head injuries, in Delee JC, Drez D (eds): Orthopaedic Sports Medicine, ed 2. Philadelphia, PA, WB Saunders, 2003, vol 1, p 781.

Question 16

It has been shown that bisphosphonate-based supportive therapy (pamidronate or zoledronate) reduces skeletal events (onset or progression of osteolytic lesions) both in patients with multiple myeloma and in cancer patients with bone metastasis. The use of biphosphonate therapy has been associated with Review Topic

Explanation

The use of bisphosphonates has been recently associated with the development of osteonecrosis of the jaw. Length of exposure seems to be the most important risk factor for this complication. The type of bisphosphonate may play a role and previous dental procedures may be a precipitating factor. Bisphosphonates are a class of therapeutic agents originally designed to treat loss of bone density (ie, alendronate). The primary mechanism of action of these drugs is inhibition of osteoclastic activity, and it has been shown that these drugs are useful in diseases with propensities toward osseous metastases. In particular, they are effective in diseases in which there is clear upregulation of osteoclastic or osteolytic activity, such as breast cancer and multiple myeloma, and have developed into a mainstay of treatment for individuals with these diseases. Although shown to reduce skeletal events, there has been no improvement in patient survival.

Question 17

What are the proposed biomechanical advantages of the Grammont reverse total shoulder arthroplasty when compared to a standard shoulder arthroplasty? Review Topic

Explanation

The Grammont reverse total shoulder arthroplasty is designed to medialize the center of rotation, thereby increasing the deltoid moment arm and lengthening the deltoid.

Question 18

A healed fracture of the tibia that demonstrates 25 degrees apex posterior angulation and 28 degrees varus angulation on AP and lateral radiographs is most accurately described as a

Explanation

Deformities that are seen simultaneously on the AP and lateral roentgenograms of the same bone are actually shadows of the true deformity. If, for example, angulation is seen at the site of a fracture on both of the standard roentgenograms, then the true plane of angulation is somewhere between the coronal and sagittal planes, and the actual amount of angulation is greater than that visualized on either roentgenogram. Because the standard roentgenograms are orthogonal (at right angles) to each other, it is possible to calculate the actual plane and angle of deformity on the basis of dimensions measured from the roentgenograms.

Question 19

A 9-year-old boy has a painless enlarged mass on the dorsum of his hand. Figures 14a through 14d show the clinical photograph, radiographs, and biopsy specimen. What is the most likely diagnosis?

Explanation

DISCUSSION: Multiple hereditary exostosis and enchondroma commonly present as multiple lesions in the hand. Multiple hereditary exostosis consists of cartilage capped bony exostoses arising from the metaphyseal end of rapidly growing bones. Osteosarcoma and chondrosarcoma rarely appear as multiple lesions. Fracture callus can exhibit enchondral ossification that is usually circumferential, but the radiographic findings are not consistent with fracture.
REFERENCES: Porter DE, Emerton ME, Villanueva-Lopez F, Simpson AH: Clinical and radiographic analysis of osteochondromas and growth disturbance in hereditary multiple exostoses. J Pediatr Orthop 2000;20:246-250.
Pierz KA, Stieber JR, Kusumi K, Dormans JP: Hereditary multiple exostoses: One center’s experience and review of etiology. Clin Orthop 2002;402:49-59.

Question 20

A 52-year-old man who weighs 325 lb is wheelchair-bound from severe degenerative arthritis of the left hip. Twenty-four hours after cementless total hip arthroplasty, he develops shortness of breath and evaluation shows a saddle pulmonary embolus. The patient is started on enoxaparin sodium at 150 mg every 12 hours. Two days later, the patient’s hematocrit is 20% despite four units of transfused packed cells, and he now has developed a complete sciatic nerve palsy. What is the best course of action?

Explanation

DISCUSSION: The purpose of this question is to draw attention to the early risks of therapeutic anticoagulation that will be instituted by an intensivist or pulmonologist to treat a life-threatening pulmonary embolus. The temporary vena cava filter is a recent innovation but will effectively reduce the risk of further pulmonary emboli. This requires reversal of anticoagulation for safe insertion of the filter and creates a safe situation for additional surgical solutions. Sciatic nerve compromise was caused by the expanding hematoma in this patient, which could be mitigated by exploration both to assess the nerve and to remove a large hematoma that presents its own longterm risks.
REFERENCES: Della Valle CJ, Steiger DJ, Di Cesare PE: Thromboembolism after hip and knee arthroplasty: Diagnosis and treatment. J Am Acad Orthop Surg 1998;6:327-336.
Weil Y, Mattan Y, Goldman V, et al: Sciatic nerve palsy due to hematoma after thrombolysis therapy for acute pulmonary embolism after total hip arthroplasty. J Arthroplasty 2006;21:456-459.
American Academy of Orthopaedic Surgeons Guideline on the Prevention of Symptomatic Pulmonary Embolism in Patients Undergoing Total Hip or Knee Arthroplasty, www.aaos.org/research/guidelines/ PEguide.asp

Question 21

Which structure is shown in Video 27? 27

Explanation

DISCUSSION
Video 27 shows the medial patellofemoral ligament running from the medial epicondyle of the femur to the medial portion of the patella. The posterior oblique ligament and the superficial medial collateral ligament run from medial epicondyle to the tibia.
RECOMMENDED READINGS
Babb JR, Detterline AJ, Noyes FR. AAOS Orthopaedic Video Theater. The Key to the Knee: A Layer-by-Layer Video Demonstration of Medial and Anterior Aatomy. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2009.
Hoppenfeld S, deBoer P. Surgical Exposures in Orthopedics. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003:493-568.

Question 22

Intramedullary nailing of proximal tibial shaft fractures are technically demanding, and use of an extended medial parapatellar incision with a semiextended technique can prevent what common deformity at the fracture site?

Explanation

DISCUSSION: Valgus and flexion is the most common deformity seen after intramedullary nailing of proximal tibia fractures. The semi-extended nailing position helps overcome the procurvatum or flexion deformity of the fracture.
Lang et al. reported in their study of 32 proximal third tibia fractures that 56% of the fractures had 5 degrees or more valgus angulation and 28% had 10 degrees or more valgus angulation. Angulation in the AP plane ranged from 0 degrees to 20 degrees, all of which was apex anterior. Nineteen (59%) fractures demonstrated 5 degrees or more angulation, and 7 (22%) fractures demonstrated 10 degrees of more angulation.
Tornetta advocates use of extended medial parapatellar incision with the leg in a semiextended position to allow for a more proximal and lateral starting point. This modified starting point forces the nail to overcome the tendency of the fracture to flex (apex anterior) and go into valgus.

Question 23

During revision total knee arthroplasty (TKA), there is significant laxity in 90° of flexion and 10° short of full extension. Correcting the gap imbalance is best achieved by

Explanation

Figures 1 through 5 are the radiographs and MRI scans of an 80-year-old woman who had a total hip arthroplasty (THA) 10 years ago and recently experienced an episode of dislocation that was reduced. She currently has no pain, but has a limp and moderate apprehension. Her erythrocyte sedimentation rate is 32 and C-reactive protein is 34. Her cobalt level is 32.8 ug/L (normal <1ug/L) and chromium level 14 ug/L (normal < 5ug/L). The hip aspiration is negative. What is the most appropriate treatment? 35
A. Nonoperative treatment with close radiographic follow-up
B. Revision THA with ceramic- on-polyethylene with abductor reconstruction
C. Removal of components and placement of spacer as stage 1 of 2-stage revision
D. Revision THA with metal-on- polyethylene and trochanteric slide

Question 24

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 25

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

Explanation

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

Question 26

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

Explanation

DISCUSSION: This is the first occurrence of diabetic foot-specific morbidity. The patient has a foot deformity, a history of a diabetic foot ulcer, and is insensate to the monofilament. He is at moderate risk for the development of a recurrent ulcer. This is best avoided with therapeutic footwear. Commercially available depth-inlay shoes should be combined with a custom accommodative foot orthosis to accommodative the deformity.
REFERENCES: Pinzur MS, Slovenkai MP, Trepman E, et al: Guidelines for diabetic foot care: Recommendations endorsed by the Diabetes Committee of the American Orthopaedic Foot and Ankle Society. Foot Ankle Int 2005;26:113-119.
Pinzur MS, Dart HC: Pedorthic management of the diabetic foot. Foot Ankle Clin 2001;6:205-214.

Question 27

Because of the ongoing pain and instability and the demonstration of radiographic instability when the ankle is stressed, what surgical procedure should be performed to restore stability to the ankle joint based on the CT findings?

Explanation

DISCUSSION FOR QUESTIONS 107 AND 108:
The fracture at the insertion of the AITFL into the fibula represents a syndesmosis injury. In some cases, a direct repair of the fracture will stabilize the syndesmosis, but in most cases this injury should most likely be reinforced by placing a screw or suture tensioning device across the syndesmosis for additional support.A Brostrom or allograft reconstruction is indicated for an ankle sprain involving the ATFL or CFL.Simply excising the fragment will leave the patient with an incompetent syndesmosis. Repairing the SPR with or without a groove deepening procedure is indicated if there is evidence of subluxated or dislocated peroneal tendons, which is not demonstrated on the CT scans. The bone has been avulsed off the fibula by the portion of the AITFL that attaches to the fibula, therefore indicating that there is a syndesmosis injury. Allograft lateral ligament reconstruction and excision of loose body/fracture fragment are incorrect procedures based on location. The deltoid is a medial structure and this fracture is lateral. The ATFL and CFL attach at the inferior margin of the fibula near the lateral process of the talus and calcaneus. A SPR avulsion would present as an avulsion off the lateral wall of the fibula, not superior and not into the syndesmotic space as shown on the CT scans.

Question 28

Figure 1 is an MRI scan of the right hip of a 19-year-old woman with a 6-month history of right groin pain. She was diagnosed with a stress fracture and was treated with 3 months of limited weight bearing. Figure 2 is a repeat MRI scan in which the edema pattern changed minimally but the pain worsened. Ibuprofen alleviates most of her pain. What is the best next step?

Explanation

An osteoid osteoma is a benign bone tumor. Osteoid osteomas tend to be small—typically <1.5 cm. Regardless of their size, they cause a large amount of reactive bone to form around them, and they make a new type of abnormal bone material called osteoid bone. This osteoid bone, along with the tumor
cells, forms the nidus of the tumor, which is easily identified on CT scans.

Question 29

An 18-year-old football player lands on a flexed knee and ankle after being tackled. Examination reveals increased external rotation and posterior translation and varus at 30° of flexion, which decreases as the knee is flexed to 90°. What is the most likely diagnosis?

Explanation

DISCUSSION: The flexed knee and ankle mechanism of injury can result in a PCL and/or posterolateral corner injury. The examination reveals an isolated injury to the posterolateral corner (arcuate, popliteus, posterolateral capsule). This results in increased posterior translation and external rotation, as well as varus that is most notable at 30° of flexion and decreases as the knee is further flexed to 90°. Combined PCL and posterolateral corner injuries are characterized by increasing instability as the knee is flexed to 90° from 30°, while isolated PCL tears show the greatest degree of instability at 90° of flexion. A rupture of the quadriceps tendon would not affect anterior or posterior stability, whereas an isolated rupture of the lateral collateral ligament, which is a rare injury, is characterized by varus instability at 30° of knee flexion without posterior translation.
REFERENCES: Harner CD, Hoher J: Evaluation and treatment of posterior cruciate ligament injuries. Am J Sports Med 1998;26:471-482.
Veltri DM, Warren RF: Isolated and combined posterior cruciate ligament injuries. J Am Acad Orthop Surg 1993;1:67-75.

Question 30

A patient reports progessive bilateral hand clumsiness and ataxia. Examination reveals a positive Hoffmann’s sign and intrinsic atrophy. MRI reveals multilevel cervical spondylosis, and lateral flexion and extension radiographs show cervical kyphosis in the neutral position, with restoration of lordosis on extension. Which of the following procedures is most likely to result in poor long-term results?

Explanation

DISCUSSION: Adequate decompression of the cervical cord can be achieved in a variety of ways depending on the pathoanatomy of the compression, but kyphosis is a relative contraindication to laminectomy alone. For laminectomy to be effective, the lordosis must be maintained so the cord can displace posteriorly away from the anterior structures. In addition, removing the posterior tension band increases the probability that the kyphosis will progress, therefore increasing the force against the front of the cord as it tents across the kyphosis.
REFERENCES: Albert TJ, Vaccaro A: Postlaminectomy kyphosis. Spine 1998;23:2738-2745.
Truumees E, Herkowitz HN: Cervical spondylotic myelopathy and radiculopthy. Instr Course Lect 2000;49:339-360.
Emery SE: Cervical spondylotic myelopathy: Diagnosis and treatment. J Am Acad Orthop Surg 2001;9:376-388.

Question 31

A 15-year-old boy has a fracture of the proximal tibia extending from the apophysis of the tubercle up through the posterior part of the proximal tibial epiphysis and into the joint. What is the most likely mechanism of injury?

Explanation

Tibial Tuberosity Fractures Fractures of the tibial tuberosity are uncommon avulsion injuries. Most are sportsrelated and occur in older adolescents. Type I fractures represent an avulsion of a small fragment of the tuberosity. Type II fractures involve the entire anterior tuberosity with extension proximally to the level of the horizontal portion of the proximal tibial physis. Type III injuries involve the entire tuberosity with extension proximally into the articular surface, a SalterHarris type III fracture. Patients present with pain, swelling, and tenderness over the tuberosity. Patella alta may be present. Surgical treatment of type I fractures is needed if patella alta (compared to the normal uninjured side) and a significant bony prominence are present. Displaced types II and III fractures are treated with open reduction and internal fixation. A cancellous interfragmentary screw may be placed through the tuberosity into the metaphysis. Because this injury occurs in patients near skeletal maturity, growth arrest with secondary genu recurvatum is rare.

Question 32

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

Explanation

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

Question 33

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

Explanation

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

Question 34

A 39-year-old woman fell onto her flexed elbow and sustained a comminuted displaced radial head and neck fracture. Radiographs confirm concentric reduction of the ulnohumeral joint. Examination reveals pain with compression of the radius and ulna at the wrist. What is the best treatment for the radial head fracture?

Explanation

DISCUSSION: Patients with comminuted radial neck and head fractures and associated wrist pain have a significant injury to the elbow and forearm. Nonsurgical management is an option, but initial casting will result in stiffness and early range of motion is likely to be unsuccessful secondary to pain. Surgical treatment with open reduction and internal fixation, although possible, is technically demanding and results are unpredictable with comminuted fractures. Excision alone in the face of wrist pain may lead to radial shortening. The treatment of choice is excision and metallic radial head arthroplasty. Silastic implants have been associated with synovitis and wear debris.
REFERENCES: Furry KL, Clinkscales CM: Comminuted fractures of the radial head: Arthroplasty versus internal fixation. Clin Orthop 1998;353:40-52.
Ring D, Quintero J, Jupiter JB: Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg Am 2002;84:1811-1815.

Question 35

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

Explanation

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

Question 36

MRI results are shown in Figure 1 for a 22-year-old, right-hand dominant collegiate athlete who reports a 6-month history of progressive weakness in his right arm. He denies any specific traumatic event. He has altered his weight-lifting activities and tried over-the-counter ibuprofen without benefit. No appreciable deformity or atrophy is found on examination of the upper extremities. He demonstrates full active shoulder range of motion, and there is no weakness with abduction in the plane of the scapula. Belly press test findings are normal, but weakness is seen in external rotation with the arm in adduction. He does not demonstrate anterior apprehension, and there is no instability with load and shift testing. Radiographs are unremarkable. What is the best surgical option?

Explanation

A 45-year-old woman diagnosed with lateral epicondylitis undergoes an open debridement of the extensor carpi radialis brevis. During surgery, resection extends posterior to the equator of the radiocapitellar joint. Postoperatively, she complains of persistent pain, despite appropriate rehabilitation. What other physical examination finding is she likely to have?
A. Pain with elbow extension in forearm pronation
B. Mechanical symptoms when rising from a chair
C. Valgus instability
D. Tenderness over the medial collateral ligament (MCL)
Excessive resection of the common extensor origin posterior to the equator of the radiocapitellar joint may lead to iatrogenic lateral collateral ligament (LCL) injury, causing posterior lateral rotatory instability (PLRI). Patients may present with lateral elbow pain, a positive lateral pivot shift test, or mechanical symptoms/subjective instability when pushing up from a chair (positive chair rise test). PLRI is often provoked with combined elbow extension and forearm supination, as the posterior support for the radiocapitellar joint has been lost. Therefore, placing the forearm in pronation during elbow extension places the radiocapitellar joint in a more stable position and is less likely to induce pain or mechanical symptoms. Valgus instability and MCL tenderness would be associated with an MCL injury.
56- A 75-year-old man presents with complaints of shoulder pain, bruising, and weakness following a fall onto his outstretched hand. He underwent an uncomplicated anatomic total shoulder arthroplasty 5 years prior with good range of motion and strength. His current radiographs are shown in Figures 1 and 2. What is the most appropriate next step to restore this patient’s function?

Question 37

A 77-year-old woman who underwent a cemented total hip arthroplasty 10 years ago now reports groin pain. Examination reveals a loosened acetabular component and a well-fixed femoral component. Treatment should consist of revision of

Explanation

DISCUSSION: Recent literature supports retention of well-fixed cemented femoral components when revising loosened cemented acetabular components. Current literature also supports the use of cementless components for revision of loosened cemented acetabular components.
REFERENCES: Peters CL, Kull L, Jacobs JJ, Rosenberg AG, Galante JO: The fate of well fixed cemented femoral components left in place at the time of revision of the acetabular component. J Bone Joint Surg Am 1997;79:701-706.
Poon ED, Lachiewicz PF: Results of isolated acetabular revisions: The fate of the unrevised femoral component. J Arthroplasty 1998;13:42-49.
Moskal JT, Shen FH, Brown TE: The fate of stable femoral components retained during isolated acetabular revision: A six- to twelve-year follow-up study. J Bone Joint Surg Am

2002;84:250-255.
Templeton JE, Callaghan JJ, Goetz DD, Sullivan PM, Johnston RC: Revision of a cemented acetabular component to a cementless acetabular component. A ten- to fourteen-year follow-up study. J Bone Joint Surg Am 2001;83:1706-1711.

Question 38

Which of the following knee ligament injury patterns is most associated with an increase in external tibial rotation with the knee at 90 degrees of flexion?

Explanation

DISCUSSION: Cadaveric studies have shown that external rotation of the tibia is most pronounced following transection of the posterior cruciate and lateral collateral ligaments with the knee at 90 degrees of flexion. Isolated release of the lateral collateral ligament results in increased external tibial rotation at 30 degrees.
REFERENCES: Gollehon DL, Torzilli PA, Warren RF: The role of the posterolateral and cruciate ligaments in the stability of the human knee: A biomechanical study. J Bone Joint Surg Am 1987;69:233-242.
Cooper DE: Tests for posterolateral instability of the knee in normal subjects: Results of examination under anesthesia. J Bone Joint Surg Am 1991;73:30-36.
Veltri DM, Xeng XH, Torzilli PA, et al: The role of the cruciate and posterolateral ligaments in stability of the knee: A biomechanical study. Am J Sports Med 1995;23:436-443.

Question 39

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

Explanation

The most likely concern, in a patient older than age 40 having a first-time shoulder dislocation, is a rotator cuff tear. The MRI scan shows a tear of the supraspinatus tendon. Recurrent instability is less likely to be a problem, so an external rotation brace for an extended period of time is unnecessary. The patient already has good passive range of motion, and with a full-thickness rotator cuff tear, physical therapy alone is unlikely to return him to full function. The MRI scan shows no labral tear, so arthroscopic or open repair is not indicated.

Question 40

A 12-year-old girl who is 3 months postmenarchal undergoes full-time brace treatment for scoliosis. The posteroanterior radiograph (Figure A ) taken at that time reveals a right thoracic curve measures 28 degrees, and the left lumbar curve measures 23 degrees. At age 15, after 3 years of bracing, a repeat posteroanterior radiograph is obtained, now revealing a right thoracic curve measuring 11 degrees and the left lumbar curve measuring 19 degree, and Risser 4. Which statement best represents the indicated course of action in this patient? Review Topic

Explanation

This patient has adolescent idiopathic scoliosis (AIS) and has reached skeletal maturity. Bracing was successful and discontinuation of bracing is appropriate.
Curves <25° can be treated with observation, while flexible curves from 25° to 45° in skeletally immature patients (Risser 0, 1, 2) should be treated with bracing. Bracing success is most commonly defined as <5° curve progression and failure is 6° or more curve progression at orthotic discontinuation (skeletal maturity), absolute progression to >45° either before or at skeletal maturity, or discontinuation in favor of surgery. Skeletal maturity is defined Risser sign 4, <1cm change in height over 2 visits 6 months apart, 2 years postmenarchal.
Richards et al. attempted to define parameters for future AIS bracing studies. Outcome measures should include patients with (1) <5° curve progression vs >6° progression at maturity, (2) curves exceeding 45° at maturity, or those who have had surgery recommendation/undergone.
Negrini et al. performed a Cochrane systematic review. Basing conclusions on 2
studies, they found that (1) a brace treated curve progression (74% success) better than observation (34% success) and electrical stimulation (33% success), and (2) a rigid brace is more successful than an elastic one (SpineCor) at curbing curve progression.
A
is
a
standing
PA
radiograph
showing.
Incorrect

Question 41

What is the most significant prognostic factor in nontraumatic osteonecrosis of the humeral head?

Explanation

DISCUSSION: Use of systemic steroids has been implicated in the development of nontraumatic osteonecrosis of the humeral head. Staging of the disease is most relevant to prognosis and treatment. Cruess has described a widely accepted staging system. Several authors have shown that patients who have a lower stage of disease (ie, stage I or II) have a much less likely chance of progression compared with those who are in the later stages (IV and V).
REFERENCES: Cruess RL: Osteonecrosis of bone: Current concepts as to etiology and pathogenesis. Clin Orthop 1986;208:30-39.
Cruess RL: Steroid-induced avascular necrosis of the humeral head: Natural history and management. J Bone Joint Surg Br 1976;58:313-317.
Rutherford CS, Cofield RH: Osteonecrosis of the shoulder. Orthop Trans 1987;11:239.
Hattrup SJ, Cofield RH: Osteonecrosis of the humeral head: Relationship of disease stage, extent, and cause to natural history. J Shoulder Elbow Surg 1999;8:559-564.

Question 42

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

Explanation

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

Question 43

A 15-year-old boy falls from his bicycle and sustains an injury to his elbow. Prereduction radiographs are shown in Figure 12a. Closed reduction is performed without difficulty and postreduction radiographs are shown in Figure 12b. What is the next most appropriate step in treatment?

Explanation

DISCUSSION: Elbow dislocations in children are rare injuries and usually result from a fall on an outstretched arm. The incidence of these injuries increases as patients age and concurrently the incidence of supracondylar humerus fractures decreases. In adolescent patients, simple elbow dislocations are treated with splint immobilization and the initiation of physical therapy once comfortable. The practitioner must be aware of structures that may get caught in the joint on reduction. These include the median nerve as well as the medial epicondyle. In this patient, the radiographs reveal a medial epicondyle fracture. Postreduction radiographs show the joint to be incongruous secondary to intra-articular displacement. At this point, the most appropriate treatment is to perform an open reduction and repair of the medial epicondyle fragment.
REFERENCES: Rasool MN: Dislocations of the elbow in children. J Bone Joint Surg Br 2004;86:1050-1058.
Beaty JH: Fractures and dislocations about the elbow in children. Instr Course Lect 1992;41:373-384.

Question 44

Figure 24 shows the sitting AP and lateral spinal radiographs of a nonambulatory 12½-year-old boy with Duchenne muscular dystrophy who is being evaluated for scoliosis. The lumbar curve from T12 to L5 measures 36 degrees, and the thoracic curve from T3 to T12 measures 24 degrees on the AP radiograph. He has 5 degrees of pelvic obliquity. His forced vital capacity is 45% of predicted for height and weight. What is the most appropriate treatment for the spinal deformity?

Explanation

DISCUSSION: Posterior spinal fusion is the treatment of choice for scoliosis in patients with Duchenne muscular dystrophy once they are no longer able to walk. This treatment improves quality of life and upright wheelchair positioning. Its effect on pulmonary function is less clear, as pulmonary function will continue to decline because of the underlying muscle disease. While bracing and wheelchair modifications may slow the progression of the curve, progression will continue. Surgical intervention at this stage does not have to include the pelvis, which, in general, is indicated in curves of greater than 40 degrees, and when pelvic obliquity is greater than 10 degrees. Fixation to the pelvis should also be considered in lumbar curves where the apex is lower than L1. Surgical treatment usually can be safely performed if the vital capacity is greater than 35%.
REFERENCES: Hahn GV, Mubarak SJ: Muscular dystrophy, in Weinstein SL (ed): The Pediatric Spine, ed 2. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 819-832.
Mubarak SJ, Morin WD, Leach J: Spinal fusion in Duchenne muscular dystrophy: Fixation and fusion to the sacropelvis? J Pediatr Orthop 1993;13:752-757.

Question 45

What is the primary mechanism by which anabolic steroids increase muscle tissue? Review Topic

Explanation

Anabolic steroids have many effects on the body. Increased muscle mass occurs specifically through increased production of messenger RNA. HDL levels usually decrease but do not affect muscle. Also, steroids act to change the effects of cortisol to decrease catabolism.

Question 46

Figure 33 shows the radiograph of a 28-year-old avid golfer who has chronic right wrist pain. Management should consist of

Explanation

DISCUSSION: The patient’s chronic symptoms are associated with a fracture of the base of the hook of the hamate; therefore, the treatment of choice is simple excision of the fracture fragment, with reasonable expectations of functional return. Acute fractures may be difficult to treat because of the high incidence of nonunion, but once nonunion is discovered, nonsurgical management usually is unsuccessful. Bone grafting may be a surgical alternative, but successful outcomes with percutaneous fixation or trephination of the fibrous union have not been reported.
REFERENCES: Geissler WB: Carpal fractures in athletes. Clin Sports Med 2001;20:167-188.
Rettig ME, Dassa GL, Raskin KB, Melone CP Jr: Wrist fractures in the athlete: Distal radius and carpal fractures. Clin Sports Med 1988;17:469-489.

Question 47

Figure 50 shows the MRI scan of a 20-year-old female college soccer player with knee pain. What is the most likely diagnosis?

Explanation

DISCUSSION: The MRI scan shows an acute complete tear of the posterior cruciate ligament. No evidence is seen of a quadriceps tendon rupture, a tibia fracture, or a bone contusion.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 533-557.
Harner CD, Hoher J: Evaluation and treatment of posterior cruciate ligament injuries. Am J Sports Med 1998;26:471-482.

Question 48

A 40-year-old man who is a manual laborer has had 3 years of worsening medial-sided left knee pain that has inhibited his ability to work. He reports undergoing a left subtotal medial meniscectomy 10 years ago. He has been treated with nonsteroidal anti-inflammatory drugs and two different corticosteroids, with the most recent injection given 1 month ago. Each injection provided him with a few weeks of pain control. His medical history is unremarkable, and he has smoked 20 cigarettes per day for the last 15 years. His BMI is 22. On examination, he has varus alignment of the involved leg and medial joint line tenderness and no lateral or patellofemoral pain. His knee range of motion is 3° shy of full extension to 130° of flexion. He has negative Lachman and posterior drawer test results. He demonstrates no lateral thrust with ambulation. The patient is offered a VPHTO. What aspect of his history will determine the most appropriate VPHTO technique?

Explanation

This patient has a classic presentation of postmeniscectomy medial compartment arthritis. The appropriate diagnostic study is weight-bearing radiographs to confirm the diagnosis. An MRI scan will reveal medial compartment arthritis but will not provide information about alignment. A CT scan would be appropriate to detect an occult fracture; however, this condition is not suspected in this clinical scenario. Ultrasonography can provide information about fluid collection around the knee or a deep vein thrombosis; however, these conditions also are not suspected in this clinical scenario. Because the patient has a correctable deformity (gaps 3 mm with valgus stress), and his symptoms are localized to the involved
compartment, a trial of a medial unloader brace is appropriate both diagnostically and therapeutically. If unloading the medial compartment resolves the patient’s symptoms, he would be an excellent candidate for an osteotomy. An MRI scan may be obtained to evaluate ligamentous integrity or to evaluate degenerative involvement of the lateral and patellofemoral compartment for presurgical planning of an osteotomy; however, the integrity of the medial meniscus has no clinical importance in a patient with severe medial compartment arthritis. A repeat corticosteroid injection is not indicated within 1 month of his last injection, and referral to pain management is not appropriate with other options available to help this patient. A VPHTO is the appropriate intervention considering the patient’s young age, high-functional occupation, examination, radiographic findings, and response to medial unloader bracing. A revision knee arthroscopy would be appropriate for a recurrent medial meniscus tear, but not appropriate in a patient with severe medial compartment arthritis. The patient’s young age and high functional requirements are contraindications to TKA. The presence of severe arthritis is a contraindication to medial meniscus transplant. The patient is a candidate for a VPHTO. The technical options include a medial opening-wedge or a lateral closing-wedge osteotomy. Both techniques have advantages and disadvantages; however, a medial opening-wedge osteotomy is contraindicated in a smoker because of concern for nonunion. As a result, current smoking history is the only factor listed that would influence the technique used. The history of prior arthroscopy has no relevance in the decision about which type of osteotomy is appropriate. Normal BMI is between 18.5 and 24.9, so this patient’s BMI is considered normal and would not affect the surgical technique (if this patient were obese, a lateral closing-wedge osteotomy would be considered, but this is controversial). His age of 40 years is an indication for HTO but does not influence technique.

Question 49

03 Which of the following findings is the best indication for the use of temporary external fixation of a femoral shaft fracture?

Explanation

Tulane defines “Orthopaedic Tunnel Vision” as a condition commonly associated with a young MD at the Bulldog without a proper wing-man, trying to make advances on the wrong patron due to his relatively easy 80-hour work week schedule and a few too many refined hops.

Skeletal Trauma (p. 1967) describes “Orthopaedic Tunnel Vision” as looking at the orthopaedic injury without considering the patient’s injury in general. Femoral shaft fractures are typically high energy injuries which often do not occur in isolation. In these fractures, it is particularly important to not have tunnel vision.

Indications for temporary bridging external fixation includes hemodynamic instability
(ans. 2), acidosis, hypothermjia, hypoxemia, coagulopathy, sepsis or severely contaminated soft tissues that cannot be adequately debrided. Definitive fixation is performed after the general surgical and medical issues have resolved.

The other answer choices, including the type IIIA open fracture are not contraindications to definitive fixation in themselves (typically IM nailing—antegrade or retrograde).

Question 50

-A 30-year-old man sustained the injury seen in Figure 261. According to the Lauge-Hansen Classification System, the fracture should be classified as

Explanation

Question 51

What is the most common complication following surgical treatment of a displaced talar neck fracture?

Explanation

The most frequent complication is posttraumatic arthritis. With talar neck fractures, osteonecrosis is relatively common, occurring in up to 50% of patients. Fracture nonunion occurs in 10% to 12% of patients. Varus malunion can occur with medial comminution. Wound dehiscence and deep infection are much less frequently encountered.
(SBQ12TR.14) Elevated interleukin 6 (IL-6) is most closely associated to which of the following clinical outcomes in orthopedic trauma patients?
Decreased mortality rates
Increased mortality rates
Decreased osteomyelitis infection rates
Increased rhabdomyolysis rates
Increased compartmental syndrome rates
Elevated levels of Interleukin 6 (IL-6) is most closely associated with higher injury severity scores and increased mortality rates in polytrauma orthopaedic patients.
Hyperstimulation of the inflammatory system by major trauma is considered to be the key element in the pathogenesis of severe inflammatory response syndrome and multi-organ dysfunction syndrome. IL-6 is a complex acute-reactant cytokinase that is expressed by cells in response to tissue injury. IL-6 levels are associated with injury severity, complications, and mortality. Patients with the most severe injuries have the highest IL-6 serum levels.
Sears et al. reviewed the markers of inflammation in major trauma. They suggest that interleukin-6 and human leukocyte antigen-DR class II molecules appear to have the greatest potential for use in predicting the clinical course and outcome in trauma patients. Early identification of traumatic patients, based on inflammatory markers and genomic predisposition, could help to guide intervention and treatment.
Pape et al measured the perioperative concentrations of interleukin-6 in sixty-eight blunt trauma patients with non-life threatening pelvic fractures. Release of proinflammatory cytokines were higher in patients undergoing surgical procedures that cause increased blood loss. The release of markers seems to be related to the type and magnitude of surgery, rather than to the duration of the procedure.
Illustration A shows a diagram of the acute inflammatory response after major trauma Incorrect Answers:

Question 52

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

Explanation

The MRI scan reveals a HAGL lesion. It more commonly affects older patients and is associated with more violent trauma.

Question 53

Up to what time frame are the risks minimized in anterior revision disk replacement surgery? Review Topic

Explanation

Revision anterior exposure within 2 weeks of total disk replacement incurs relatively little additional morbidity because adhesion formation is minimal. Surgeons should have a low threshold for revising implants that are clearly dangerously malpositioned or show early migration within this 2-week window. Beyond this time period, a revision strategy must be individualized to the particular clinical situation. A posterior fusion with instrumentation with or without a laminectomy is currently the most effective salvage procedure.

Question 54

The examination finding shown in Video 1 is consistent with which defect?

Explanation

EXPLANATION:
The video shows the lack of tenodesis caused by the incompetence of the FDP tendon to the ring finger, which can be attributable to a laceration, tendon rupture, or avulsion. Note how the ring finger stays extended (compared to the other digits) when the extensor tendons are tightened during wrist extension. The other fingers are pulled into flexion by the FDP tendons when the extensor tendons are relaxed during wrist extension. With the wrist flexed, the extensor mechanism to all fingers appears to be functioning normally. Findings indicating a trigger finger would be locking in flexion of the proximal interphalangeal joint. FDS incompetence can only be detected by blocking FDP function of the other fingers and actively flexing the examined finger.

Question 55

A 55-year-old woman with a long history of low back and left lower extremity pain has failed to respond to exhaustive nonsurgical management. MRI scans show bulging and degeneration at L3-4 and L4-5 as well as a normal disk at L2-3 and L5-S1. She undergoes provocative lumbar diskography at L3-4, L4-5, and L5-S1. Post-diskography axial CT images of L3-4 and L4-5 are shown in Figures 6a and 6b, respectively. The injections at L3-4 and L4-5 produce no pain. The injection at L5-S1 produces 10/10 concordant back pain with radiation to the lower extremity. What is the most appropriate recommendation at this time? Review Topic

Explanation

The results of this patient’s lumbar diskography are equivocal at best. The two disks most likely to be her pain generators, based on their MRI appearance, produced 10/10 pain, however it was nonconcordant and did not reproduce any of her typical left-
sided radicular symptoms. The only disk that produced concordant back pain was the normal disk at the L5-S1 level and it reproduced radicular symptoms on the side opposite of her typical pain. Based on these findings, it would be difficult to select a level or levels to include in a lumbar fusion. As such, continued nonsurgical management is the safest treatment option at the current time. Brox and associates reported on a randomized clinical trial comparing lumbar fusion to cognitive intervention and exercise and found similar results in both groups, with significantly less risk in the latter.

Question 56

A 58-year-old man reports a 2-month onset of groin pain with no history of trauma. Examination reveals that range of motion of the hip is mildly restricted, and he has pain with both weight bearing and at rest. An MRI scan is shown in Figure 20. Treatment should consist of

Explanation

DISCUSSION: The MRI findings show highly increased signal through the entire femoral head and neck on STIR imaging, diagnostic of transient osteoporosis of the femoral head. This disease entity can be seen in middle-aged men, and should be treated nonsurgically. The natural history is that of self-resolution.
REFERENCES: Guerra JJ, Steinberg ME: Distinguishing transient osteoporosis from avascular necrosis of the hip. J Bone Joint Surg Am 1995;77:616-624.
Urbanski SR, de Lange EE, Eschenroeder HC Jr: Magnetic resonance imaging of transient osteoporosis of the hip: A case report. J Bone Joint Surg Am 1991;73:451-455.

Question 57

A 20-year-old college football player sustains a forceful hyperextension injury to his shoulder 4 months after undergoing an anterior capsular shift. Examination 2 weeks later reveals anterior tenderness. He is unable to lift the dorsum of his hand away from his back. What is the most likely diagnosis?

Explanation

Subscapularis rupture is most likely, given weakness with the lift-off test. The injury is usually caused by either forceful hyperextension or external rotation of the adducted arm. Patients will complain of anterior shoulder pain and weakness of the arm when used above and below shoulder level. SLAP lesions usually occur with a fall onto an outstretched arm in abduction and slight forward flexion. No mention was made of shoulder instability (answers 3&4), or deltoid weakness (answer 5).

Question 58

Figure 1 is the MR image of a high school soccer player who sustained a right knee injury during a game while making a cut toward the ball. He felt a pop and his leg gave way. During physical examination, as the knee is moved from full extension into flexion with an internal rotation and valgus force, you notice a "clunk" within the knee. What is the most likely biomechanical basis for the "clunk"?

Explanation

This patient sustained an isolated anterior cruciate ligament (ACL) injury based upon the mechanism described and examination findings. The finding that produces the “clunk” is the pivot-shift maneuver, which is positive in a knee with an incompetent ACL. With an ACL-deficient knee in full extension and internal rotation, the lateral tibial plateau subluxates anteriorly. As the knee is flexed, the lateral tibial plateau slides posteriorly into a reduced position, causing an audible clunk. Response D correctly describes the pathomechanics that result in the audible clunk heard during the pivot-shift maneuver. Responses A and B are incorrect because they describe the medial tibial plateau, which is not part of the pathomechanics of the pivot shift. Response C is incorrect because in extension, the lateral tibial plateau is subluxated, not reduced.

Question 59

Which of the following anatomic changes is observed as part of the normal aging process of the adult spine?

Explanation

DISCUSSION: The primary change that takes place in the aging spine is degeneration of the lumbar disks and loss of the overall lumbar lordosis. This also may be associated with osteopenic-related compression fractures. With these changes, the sagittal vertical line moves anteriorly relative to the sacrum; cervical scoliosis is uncommon and not part of the normal aging process. Overall kyphosis in the thoracic spine gradually increases, but the coronal balance remains essentially the same unless scoliosis develops.
REFERENCES: Gelb DE, Lenke LG, Bridwell KH, et al: An analysis of sagittal spinal alignment in 100 asymptomatic middle and older aged volunteers. Spine 1995;20:1351-1358.
Vedantam R, Lenke LG, Keeney JA, et al: Comparison of standing sagittal spinal alignment in asymptomatic adolescents and adults. Spine 1998;23:211-215.

Question 60

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

Explanation

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

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

Question 61

A 15-year-old wrestler sustains an abduction, hyperextension, and external rotation injury to his right shoulder. The MRI scan findings shown in Figures 27a and 27b are most consistent with

Explanation

DISCUSSION: An isolated avulsion of the lesser tuberosity occurs very rarely and usually is found in 12- and 13-year-old adolescents. The MRI scans reveal a tear of the humeral attachment of the inferior glenohumeral ligament, a so-called HAGL lesion. This injury to the inferior glenohumeral ligament occurs much less commonly than the classic Bankart lesion (anterior inferior labral tear). A tear of the subscapularis occurs with a similar mechanism of injury but generally occurs in older individuals.
REFERENCES: Bokor DJ, Conboy VB, Olson C: Anterior instability of the glenohumeral joint with humeral avulsion of the glenohumeral ligament: A review of 41 cases. J Bone Joint Surg Br 1999;81:93-96.
Wolf EM, Cheng JC, Dickson K: Humeral avulsion of the inferior glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy 1995;11:600-607.

Question 62

Risk of fat embolism is greatest during what step of total hip arthroplasty?

Explanation

DISCUSSION: Embolization of fat and bone marrow elements during total hip arthroplasty has been studied intraoperatively using transesophageal echocardiography. These studies showed the occurrence of a large number of embolic events during the insertion of a cemented femoral stem. Embolic events were rare during insertion of a cementless stem. Femoral broaching caused some embolic events, but they were not nearly as significant as those that occurred following insertion of a cemented stem. Additionally, relocation of the cemented hip was accompanied by significant embolic events. This may be related to the untwisting of blood vessels, with the subsequent release of emboli that were most likely generated during insertion of a cemented femoral stem.
REFERENCES: Pitto RP, Koessler M, Kuehle JW: Comparison of fixation of the femoral component without cement and fixation with use of a bone-vacuum cementing technique for the prevention of fat embolism during total hip arthroplasty. J Bone Joint Surg Am

1999;81:831-843.
Christie J, Burnett R, Potts HR, Pell AC: Echocardiography of transatrial embolism during cemented and uncemented hemiarthroplasty of the hip. J Bone Joint Surg Br 1994;76:409-412.

Question 63

Figures 3a through 3c show the radiographs and bone scan of a patient who reports increasing pain associated with activity for the past several months. Laboratory studies show an erythrocyte sedimentation rate of 14 mm/h and a C-reactive protein level of 0.4. Aspiration is negative for infection. Management should consist of

Explanation

DISCUSSION: The radiographs show polyethylene wear, but exchange of this will not necessarily provide pain relief. The presence of pain suggests the possibility of occult loosening, and the surgeon must be prepared for this option intraoperatively. There is little evidence of infection.
REFERENCES: Rand JA, Peterson LF, Bryan RS, Ilstrup DM: Revision total knee arthroplasty, in Anderson LD (ed): Instructional Course Lectures XXXV. Park Ridge, IL, American Academy of Orthopaedic Surgeons, 1986, pp 305-318.
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 317-322.

Question 64

Figure 5 is a T2-weighted MR image of a 26-year-old man who has had left leg pain for 3 months that has failed nonsurgical treatment. Surgical decompression is planned. Which approach would provide the most direct ability to perform surgical decompression?

Explanation

DISCUSSION
The MR image shows a far lateral disk herniation impinging on the exiting nerve root lateral to the exiting foramen. This is reached most directly with a far lateral (Wiltse) approach. This is a posterior paramedian approach that uses the interval between the paraspinal muscles (multifidus and longissimus) and arrives onto the facet joints. The intertransverse membrane can then be released, exposing the far lateral disk herniation. A posterior midline approach will allow easy access to the spinal canal, which is medial to the disk herniation, and will not allow for easy disk removal without the need for a facetectomy, which would destabilize the level. An anterior approach would not allow for access to the far lateral disk herniation, nor would a traditional retroperitoneal or newer transpsoas approach.
RECOMMENDED READINGS
Wiltse LL, Spencer CW. New uses and refinements of the paraspinal approach to the lumbar spine. Spine (Phila Pa 1976). 1988 Jun;13(6):696-706. PubMed PMID: 3175760. View Abstract at PubMed
Epstein NE. Evaluation of varied surgical approaches used in the management of 170 far-lateral lumbar disc herniations: indications and results. J Neurosurg. 1995 Oct;83(4):648-56. PubMed PMID: 7674015. View Abstract at PubMed

Question 65

A quarterback sustains a rough tackle after which he appears confused, has a dazed look on his face and an unsteady gait on standing. He denies loss of consciousness. Reexamination within 10 minutes is normal, the patient is lucid, and he wants to return to play. The coach and the player should be advised that he may

Explanation

DISCUSSION: The patient has a grade I (mild) concussion that can result in confusion and disorientation, without loss of consciousness. This concussion syndrome is completely reversible, with no long-term sequelae. Athletes who sustain a grade I concussion may return to play after 15 minutes if there are no lingering symptoms, such as headache or vertigo. A grade II concussion is characterized by loss of consciousness of less than 5 minutes. With this type of injury, the athlete can return to play in 1 week, if asymptomatic. If a grade III (severe) concussion is sustained, the athlete should avoid contact for a minimum of 1 month before considering a return to competition. A grade III concussion is characterized by a loss of consciousness of greater than 5 minutes or posttraumatic amnesia of greater than 24 hours. A CT scan is not indicated in a grade I injury. An athlete who sustains three grade I or grade II concussions, or two grade III concussions may not return to play for the season.
REFERENCES: Torg JS, Gennarelli TA: Head and cervical spine injuries, in DeLee JC, Drez D Jr (eds): Orthopaedic Sports Medicine Principles & Practice. Philadelphia, PA, WB Saunders, 1994, vol 1, pp 417-462.
Cantu RC: Criteria for return to competition after closed head injury, in Torg JS (ed): Athletic Injuries to the Head, Neck, and Face. St Louis, MO, Mosby, 1991.

Question 66

A 34-year-old man sustains an extra-articular fracture of the proximal phalanx of his right index finger in a fall. Examination reveals that the fracture is closed and oblique in orientation. Closed reduction and splinting fail to maintain the reduction. Management should now consist of

Explanation

DISCUSSION: The patient has an unstable oblique fracture of the proximal phalanx that is easily reducible but unstable; therefore, the treatment of choice is closed reduction and percutaneous pin fixation, followed by casting. Closed reduction and percutaneous pin fixation offers a better functional result than open reduction and plate fixation. Repeat closed reduction and buddy taping is inadequate because of the inherently unstable fracture pattern. Buddy taping will allow the dislocation to recur. The other options represent more aggressive surgical techniques than are necessary to treat this fracture.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,

pp 711-771.
Green DP, Anderson JR: Closed reduction and percutaneous pin fixation of fractured phalanges. J Bone Joint Surg Am 1973;55:1651-1653.

Question 67

A 58-year-old woman has had a painless periscapular mass for the past year. An MRI scan and biopsy specimen are shown in Figures 4a and 4b. What is the most likely diagnosis?

Explanation

DISCUSSION: Elastofibroma is a rare tumor that most commonly occurs in adults who are older than age 55 years. The lesions usually grow between the chest wall and the scapula, and 10% are bilateral. Histologic analysis shows that they are composed of equal amounts of elastin and collagen with occasional fibroblasts.
REFERENCES: Briccoli A, Casadei R, Di Renzo M, Favale L, Bacchini P, Bertoni F: Elastofibroma dorsi. Surg Today 2000;30:147-152.
Enzinger FM, Weiss SW: Soft Tissue Tumors, ed 3. St Louis, MO, Mosby Year Book, 1995, pp 165-201.

Question 68

A 23-year-old baseball pitcher who has diffuse pain along the posterior deltoid reports pain during late acceleration and follow-through. Examination of his arc of motion from external rotation to internal rotation at 90 degrees of shoulder abduction reveals a significant deficit in internal rotation when compared to the nonthrowing shoulder. Initial management should consist of

Explanation

DISCUSSION: Loss of internal rotation is common among overhead throwers and tennis players. Posterior capsular stretching can improve symptoms when accompanied by rest and gradual resumption of throwing. To avoid a false impression of improvement, cortisone injection is not recommended. Pitching through pain can cause further damage to the labrum and capsule. A sling and external rotator strengthening will not improve internal rotation.
REFERENCES: Kibler WB: Biomechanical analysis of the shoulder during tennis activities. Clin Sports Med 1995;14:79-85.
Jobe FW, Tibone JE, Jobe CM, Kvitne RS: The shoulder in sports, in Rockwood CA, Matsen FA (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1990, pp 961-990.

Question 69

A 25-year-old male professional lacrosse player collides with another player, with injury resulting from a knee impacting the athlete’s thigh. He has immediate pain in the mid-thigh area and is unable to return to the game because of difficulty with running. Examination reveals developing swelling in the anterior mid-thigh area. The thigh compartments are soft, and he is able to extend his knee against gravity. Knee flexion at 90° gives him discomfort in the thigh but no knee pain. The knee and hip examinations are otherwise unremarkable. Plain films of the femur are negative. What is the best next step?

Explanation

The lesion seen in the MRI scan in Figure 1 is treated with a marrow stimulation technique. The reparative tissue formed by this technique is predominantly composed of
A. only type 1 collagen.
B. only type 2 collagen.
C. type 1 and type 2 collagen.
D. neither type 1 or type 2 collagen.
The MRI scan shows a full-thickness cartilage defect. When treated with a marrow stimulation technique, such as a microfracture, the reparative tissue is fibrocartilage. Unlike hyaline cartilage, which is composed of only type 2 collagen, fibrocartilage is composed of both type 1 and type 2 collagen.
15- Figures 1 and 2 are the radiographs of a 58-year-old retired laborer who has had many years of right shoulder pain. He initially experienced relief with anti-inflammatory medication over the past year, but this no longer provides him pain relief. He has pain with overhead activities and is dissatisfied with his shoulder function. Examination indicates active and passive forward elevation to 130°, full strength with external rotation, and a negative belly press test. MRI demonstrates an intact rotator cuff. What is the best next step in treatment?
A. Anatomic total shoulder arthroplasty (TSA)
B. Hemiarthroplasty
C. Reverse shoulder arthroplasty
D. Arthroscopy with debridement and biceps tenodesis
The patient has glenohumeral osteoarthritis based on the radiograph. His examination demonstrates limited motion and no significant rotator cuff pathology – full strength with external rotation, negative belly press, and no pseudoparalysis. Of all the answer choices, an anatomic TSA would be the most appropriate treatment option. Hemiarthroplasty does not address glenoid pathology and provides inferior pain relief and function, compared with TSA. A reverse shoulder arthroplasty is utilized for patients with degenerative shoulder changes in conjunction with irreparable rotator cuff pathology. Shoulder arthroscopy with debridement and biceps tenodesis is not appropriate for those with severe degenerative changes of the shoulder.
16- According to the MRI scan shown in Figure 1, which pathologic finding is expected to be encountered during arthroscopy?
A. Figure 2
B. Figure 3
C. Figure 4
D. Figure 5
The sagittal MRI scan is a clear example of a double posterior cruciate ligament (PCL) sign. This sign has a high specificity for a displaced bucket handle tear of the medial meniscus as seen in Figure 4. The other arthroscopic
images show a flap tear of the medial meniscus (Figure 2), anterior cruciate ligament tear (Figure 3), and a full thickness articular cartilage defect (Figure 5). Other less likely causes of a double PCL sign include intermeniscal ligament, meniscofemoral ligaments, loose bodies, osteophytes, and fracture fragments. Correct answer : C 13
17- Figures 1 and 2 are the radiographs of a 21-year-old football player who underwent anterior cruciate ligament (ACL) reconstruction with patellar tendon autograft 1 year ago. He reports mild stiffness in his knee. Upon examination, he has a negative Lachman test, trace effusion, and range of motion from 0 to 85° of knee flexion. Which factor is most contributory to his examination findings?
A. Incorrect graft choice
B. Improper tunnel position
C. Tibial graft-tunnel mismatch
D. Femoral fixation at 80° flexion
Technical failure is the most common reason for ACL reconstruction failure. Tunnel position is the most frequent cause of technical failure. Malpositioning of the tunnel affects the length of the graft, causing either decreased range of motion or increased graft laxity. This patient has anterior and vertical placement of his femoral tunnel, which has been shown to cause stiffness in knee flexion. Although graft choice is an important factor when planning ACL reconstruction, overall outcomes with autograft tissues are fairly similar. Fixation of the graft at the femoral or tibial end is not as important as tunnel position. Fixing the graft in flexion can cause extension loss when isometry is not achieved, but this condition is not touched upon in this scenario.

Question 70

Examination of a 34-year-old man who has had left leg pain for the past 6 weeks reveals minimal weakness of the left extensor hallucis longus and normal ankle jerk and patellar reflexes. Figure 33 shows an axial MRI scan of the L4-5 disk. Based on these findings, the MRI scan results are consistent with compression of the

Explanation

DISCUSSION: The patient has an L5 radiculopathy secondary to an L4-5 disk herniation that is compressing the traversing L5 nerve root.
REFERENCE: McCulloch JA, Young PH: Essentials of Spinal Microsurgery. Philadelphia, PA, Lippincott-Raven, 1998.

Question 71

..Staging studies show no other lesions and surgical treatment is planned; when should a biopsy be performed?

Explanation

CLINICAL SITUATION FOR QUESTIONS 117 THROUGH 120
Figures 117a through 117c are the radiographs and MRI scan of a 16-year-old boy who has had a persistent fullness in his thigh since being kicked while playing soccer 4 weeks ago. He states that initially the area was painful, but now all symptoms other than the mass have resolved.

Question 72

Which of the following statements best describes the instantaneous axis of rotation (IAR) for the functional spinal unit? Review Topic

Explanation

The instantaneous axis of rotation is the axis about which each vertebral segment rotates, but is theoretical depending on how it is defined, and varies depending on multiple factors. It is not a fixed point but can move depending on the position of the spine, and it is affected by degenerative conditions, fractures, injuries, and other anatomic changes of the spine. There are three axes of movement with 6 degrees of freedom (rotation and translation movements about each axis).

Question 73

A 55-year-old man is about to undergo right total hip arthroplasty. A preoperative AP pelvis radiograph is shown in Figure below. The final acetabular component and polyethylene liner are implanted. With the broach in place, the surgeon trials a standard offset neck and neutral length femoral head. The leg lengths are approximately equal, but the hip is unstable. What is the best next step?

Explanation

DISCUSSION:
The radiograph shows that this patient has a high offset varus femoral morphology of both hips. Preoperative templating would identify this, and the surgeon should choose an implant system that has extended offset options to help match the native anatomy and biomechanics and minimize the risk of instability. Trialing a high offset neck, rather than a standard offset neck, is the next most appropriate step. Depending on the design of the implant system, this step can be accomplished by direct medialization of the femoral head, which would not affect leg length, or by lowering the neck angle, which would affect the leg length and would require a longer femoral head, because the leg lengths had previously been equal. Placement of a longer femoral head would likely improve hip stability but would also make the leg length uneven, which is a common cause of dissatisfaction after total hip arthroplasty. An offset acetabular liner also increases the leg length and does not correct the issue, which is on the femoral side. Trochanteric
advancement is sometimes used as a treatment for instability but would be inappropriate as the next step in this setting.

Question 74

Which of the following conditions is considered a relative contraindication to interscalene nerve block for patients scheduled to undergo shoulder surgery?

Explanation

DISCUSSION: A common side effect of interscalene nerve block for shoulder surgery is the blockade of the ipsilateral phrenic nerve. This, in turn, results in paresis of the diaphragm and up to a 30% reduction in pulmonary function volumes. Therefore, interscalene nerve block generally is not recommended for patients whose respiratory function is compromised. Other relative and absolute contraindications for interscalene nerve blocks include allergy to local anesthetics, infection at the injection site, uncontrolled seizure disorder, coagulation abnormality, and preexisting neurologic injury.
REFERENCES: Chelly JE: Indications for upper extremity blocks, in Chelly JE (ed): Peripheral Nerve Blocks, ed 2. Philadelphia, PA, Lippincott Williams & Wilkins, 2004, pp 19-27.
Misamore GW, Sallay PI: A prospective analysis of the safety and efficacy of interscalene brachial plexus block anesthesia for shoulder surgery. J Shoulder Elbow Surg 2007;16:e39.

Question 75

A patient was treated with a revision reamed intramedullary nail for a nonunion 6 months ago. A current radiograph is shown in Figure 62. Based on these findings, what is the most appropriate treatment?

Explanation

DISCUSSION: Nonunions after intramedullary nails are often treated with exchange reamed nailing. In a recent study, this resulted in a union rate of 53%. After failed exchange nailing, bone grafting and compression plating should be used. The other options resulted in less satisfactory results as compared to bone grafting and compression plating.
REFERENCES: Weresh MJ, Hakanson R, Stover MD, et al: Failure of exchange reamed intramedullary nails for ununited femoral shaft fractures. J Orthop Trauma 2000;14:335-338.
Bellabarba C, Ricci WM, Bolhofner BR: Results of indirect reduction and plating of femoral shaft nonunions after intramedullary nailing. J Orthop Trauma 2001;15:254-263.

Question 76

A 45-year-old man underwent a fingertip amputation through the distal phalanx after his ring finger was caught in a garage door. He was treated in the emergency department with a revision amputation by advancement of the flexor digitorum profundus (FDP) tendon to the extensor mechanism. Three months following the injury, he is able to fully flex his injured ring finger to touch his palm, but he reports that it is difficult for him to make a tight fist due to decreased flexion of his other fingers. What is this complication called?

Explanation

EXPLANATION:
The quadrigia effect can occur due to over-advancement of the FDP tendon during repair (usually greater than 1 cm), development of FDP tendon adhesions, and (as in this case) "over the top" repair of the FDP tendon to the extensor tendon after amputation at the distal phalanx level. All of these conditions result in a functionally shortened FDP tendon of the injured digit. Because the FDP tendons of the long, ring, and small digits share a common muscle belly, excursion of the combined tendons is equal to the shortest tendon. Therefore, the uninjured digits will not have full excursion of their respective FDP tendons and will not be able to close into a full fisting position. Treatment of this condition is most commonly release
of the injured FDP tendon. A lumbrical plus deformity can occur in amputations distal to the flexor digitorum superficialis insertion through the middle phalanx. The FDP tendon retracts and increases tension on the lumbrical muscle, which leads to paradoxical interphalangeal (IP) joint extension with attempted flexion. Intrinsic tightness and interphalangeal joint contractures can be caused by hand trauma but would not lead to the clinical condition this patient has.

Question 77

Stiffness can occur following total knee arthroplasty. What is the most appropriate management for a patient who has deteriorating arc of motion after undergoing a revision knee arthroplasty 9 months ago?

Explanation

DISCUSSION: Stiffness following total knee arthroplasty can be a disabling condition. There are many reasons for loss of knee motion following total knee arthroplasty. Technical errors, such as overstuffing of the patella, malpositioning of the components, and ligamentous imbalance, are all known to result in stiffness following total knee arthroplasty. In some patients with a possible genetic predisposition, aggressive arthrofibrosis may develop and result in loss of knee motion. In any patient who has deteriorating knee motion, particularly after revision arthroplasty, deep infection should be ruled out. Although on occasion surgical intervention may be required to address knee stiffness, the outcome of revision surgery is poor if no reason for stiffness can be determined.
REFERENCES: Kim J, Nelson CL, Lotke PA: Stiffness after total knee arthroplasty: Prevalence of the complication and outcomes of revision. J Bone Joint Surg Am 2004;86:1479-1484.
Gonzalez MH, Mekhail AO: The failed total knee arthroplasty: Evaluation and etiology. J Am Acad Orthop Surg 2004;12:436-446.

Question 78

A 37-year-old laborer falls 12 feet and sustains a comminuted tibial plafond fracture. Three years after treatment using standard techniques, what will be the most likely outcome?

Explanation

DISCUSSION: Two recent studies by Pollak and associates and Marsh and associates have focused on function after high-energy tibial plafond fractures. Findings are unfavorable even when anatomic reduction is performed in the best centers and patients are provided excellent rehabilitation. Function improves up to 2 years after injury, but even basic walking skills remain adversely affected. Virtually all patients have long-term adverse general health effects compared to their gender and age-matched peers. Posttraumatic degenerative arthritis is present in most ankles. Patients should be told early about the long-term prognosis, and early vocational/psychological counseling should be given. Despite these adverse outcomes, only a minority of patients require fusion or arthroplasty.
REFERENCES: Pollak AN, McCarthy ML, Bess RS, et al: Outcomes after treatment of high-energy tibial plafond fractures. J Bone Joint Surg Am 2003;85:1893-1900.
Marsh JL, Weigel DP, Dirschl DR: Tibial plafond fractures: How do these ankles function over time? J Bone Joint Surg Am 2003;85:287-295.

Question 79

A 66-year-old woman who requires a cane for ambulation now notes increasing difficulty in using the cane after undergoing total elbow arthroplasty 3 months ago. AP and lateral radiographs are shown in Figures 15a and 15b. What is the most likely diagnosis?

Explanation

DISCUSSION: The lateral radiograph reveals a triceps avulsion with a small portion of bone. Triceps weakness and insufficiency can be a symptomatic problem after total elbow arthroplasty and is probably underreported. Ulnar nerve neuritis, aseptic loosening, instability, and infection are all complications of total elbow arthroplasty but would not account for the radiographic findings.
REFERENCES: Koval K (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orhthopaedic Surgeons, 2002, pp 323-327.
Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000,

pp 598-601.

Question 80

A 42-year-old female undergoes a subtalar bone block distraction arthrodesis as sequelae of a nonoperatively treated calcaneus fracture ten years prior. This procedure addresses which of the following issues?

Explanation

DISCUSSION: The subtalar fusion technique involves distraction of the subtalar joint, insertion of a bone block, fusion, and rigid screw fixation. The distraction allows correction of the talocalcaneal relationship. In Carr’s series, pre- and postoperative radiographic analysis for tibiotalar impingement, lateral talocalcaneal angle, and talonavicular subluxation was performed, with improvement to a normal range seen in the cases analyzed. Bednarz did a radiographic analysis and showed an average increase of 8 mm in hindfoot height, 9 degrees in lateral talocalcaneal angle, and 11 degrees in lateral talar declination angle. Rammelt found that compared with the unaffected side, the talocalcaneal height was corrected by 61.8%, the talus-first metatarsal axis by 46.5%, the talar declination angle by 38.5% and the talocalcaneal angle by 35.4%. Based on these three references, this procedure ultimately addresses the lost hindfoot height, subtalar arthritis (joint is fused), ankle impingement (improvement of the talus 1st MT axis), and peroneal impingement. It does not address hindfoot valgus. However, the deformity after a calcaneus fracture is usually from lateral wall blowout and hidfoot varus

Question 81

Which of the following nerves supply the muscles on each side of internervous plane identified when performing the anterior (Smith-Petersen) approach to the hip?

Explanation

The anterior (Smith-Peterson) approach to the hip utilizes the superficial internervous plane between the sartorius (femoral nerve) and the tensor fascia lata (superior gluteal nerve). The deep internervous plane is between the rectus femoris (femoral nerve) and the gluteus medius (superior gluteal nerve).

Question 82

A 48-year-old man undergoes arthroscopy to repair a rotator cuff tear. During the arthroscopy, the tear is characterized and found to involve the entire supraspinatus and a majority of the infraspinatus tendons. After mobilization, the posterior rotator cuff can reach the greater tuberosity. However, the supraspinatus tendon cannot reach its insertion point at the greater tuberosity. What is the most appropriate treatment? Review Topic

Explanation

If a complete rotator cuff repair is not possible, a partial rotator cuff repair should still be considered and is the appropriate treatment for this patient. In patients with an irreparable massive rotator cuff tear, acromioplasty with coracoacromial ligament
release, reverse acromioplasty, and tenotomy of the biceps tendon may improve shoulder pain. If these procedures fail, then a muscle transfer procedure can also be considered in select patients. If, however, a portion of the rotator cuff can be repaired, even partial repair can balance the coronal and axial forces about the shoulder to restore the kinematics of the joint. Reverse total shoulder arthroplasty is not appropriate for this relatively young patient.

Question 83

What are the most likely symptoms and examination findings related to the mass in zone 2 of Guyon’s canal seen in Figure 17?

Explanation

DISCUSSION: The lesion lies in zone II of the ulnar tunnel. In that zone the deep motor branch of the ulnar nerve is susceptible to compression. Distal to the hook of the hamate, the motor branch of the ulnar nerve dives deep to innervate the interossei as it begins to move from an ulnar to radial direction. Because of its course, it has little or no give in response to a mass effect from the floor of Guyon’s canal. Ganglions are the most common cause of ulnar nerve entrapment in the wrist. Lesions in zone I can affect both sensory and motor aspects of the ulnar nerve as well as the motor innervation of the hypothenar muscles. Lesions at the elbow or mid-to-proximal forearm are associated with dorsal hand numbness and tingling.
REFERENCES: Kuschner SH, Gelberman RH, Jennings C: Ulnar nerve compression at the wrist. J Hand Surg Am 1988;13:577-580.
Posner MA: Compressive neuropathies of the ulnar nerve at the elbow and wrist. Instr Course Lect 2000;49:305-317.

Question 84

A 72-year-old man with diabetic neuropathy and 5 degrees of valgus talar tilt; he has pursued nonsurgical treatment for 30 years and now has unrelenting pain

Explanation

DISCUSSION
Arthritis of the ankle and hindfoot can pose challenges. Depending upon patient age, comorbidities, and alignment, a variety of surgical interventions may be offered. A total ankle replacement may be considered for patients older than 60 years of age who have minimal misalignment and low-demand lifestyles. In all other cases, ankle fusion must be considered. The nonsurgical care of ankle arthritis includes anti-inflammatory medication, intra-articular steroid injections, bracing with customized products such as the Arizona brace, or a molded foot and ankle orthosis.
Patients with diabetes and Charcot arthropathy may be treated nonsurgically with total-contact casting during acute and active or "hot" phases and accommodative shoes during consolidation and stable or "cool" phases. When the patient has recurrent ulcers or major anatomy changes, surgical intervention must be considered. Tibiotalocalcaneal fusion helps to realign the foot and ankle and make it more braceable in the setting of ankle and hindfoot Charcot disease.
RECOMMENDED READINGS
Queen RM, Adams SB Jr, Viens NA, Friend JK, Easley ME, Deorio JK, Nunley JA. Differences in outcomes following total ankle replacement in patients with neutral alignment compared with tibiotalar joint malalignment. J Bone Joint Surg Am. 2013 Nov 6;95(21):1927-34. doi: 10.2106/JBJS.L.00404. PubMed PMID: 24196462. View Abstract at PubMed
Nunley JA, Caputo AM, Easley ME, Cook C. Intermediate to long-term outcomes of the STAR Total Ankle Replacement: the patient perspective. J Bone Joint Surg Am. 2012 Jan 4;94(1):43-8. doi: 10.2106/JBJS.J.01613. PubMed PMID: 22218381. View Abstract t PubMed
Saltzman CL, Mann RA, Ahrens JE, Amendola A, Anderson RB, Berlet GC, Brodsky JW, Chou LB, Clanton TO, Deland JT, Deorio JK, Horton GA, Lee TH, Mann JA, Nunley JA, Thordarson DB, Walling AK, Wapner KL, Coughlin MJ. Prospective controlled trial of STAR total ankle replacement versus ankle fusion: initial results. Foot Ankle Int. 2009 Jul;30(7):579-96. doi: 10.3113/FAI.2009.0579. PubMed PMID: 19589303. View Abstract at PubMed
Faraj AA, Loveday DT. Functional outcome following an ankle or subtalar arthrodesis in adults. Acta Orthop Belg. 2014 Jun;80(2):276-9. PubMed PMID: 25090803. View Abstract at PubMed Grear BJ, Rabinovich A, Brodsky JW. Charcot arthropathy of the foot and ankle associated with rheumatoid arthritis. Foot Ankle Int. 2013 Nov;34(11):1541-7. doi: 10.1177/1071100713500490. Epub 2013 Jul 30. PubMed PMID: 23900228. View Abstract at PubMed

Question 85

The MRI scan shown in Figure 33 reveals the sequelae of an acute traumatic anteroinferior shoulder dislocation. The image reveals the typical separation of what two commonly injured structures? Review Topic

Explanation

The MRI scan reveals the sequelae of an anteroinferior dislocation, specifically separation of the anteroinferior labrum from the bony glenoid. The separation does not classically occur only at the cartilage-labral junction, but extends to the bony surface of the medial glenoid neck. Separation of the biceps tendon from its origin on the supraglenoid tubercle (SLAP lesion) or separation of the anterior capsule with the proximal humerus (HAGL lesion) may occur but are not the most common sequelae and are not demonstrated in this MRI image. Anteroinferior shoulder dislocations normally do not affect the posterior labral structures. In their landmark study, Rowe and associates noted that this demonstrated lesion was the most common lesion, present in 85% of their series.

Question 86

All of the following techniques can help to prevent apex-anterior angulation during intramedullary nailing of proximal one-third tibia fractures EXCEPT:

Explanation

DISCUSSION: Sagittal malalignment is commonly seen after nailing proximal tibia fractures. The start point as well as the direction of the nail can lead to sagittal deformity. Freedman found in nailing tibia fractures that malalignment was seen in 58% of proximal third fractures, 7% of middle third fractures, and 8% of distal third fractures. Of the malaligned fractures, 83% were either segmental or comminuted. Lang found that a medialized nail entry point and a posteriorly and laterally directed nail insertion angle contributed to malalignment. It is logical that a fracture that is reamed and then nailed in the posterior direction will lead to a gap anteriorly, and that posterior comminution will lead to anterior angulation as the fracture hinges on the intact cortex anteriorly. An anterior starting hole will tend to lead to more of a posterior nail direction. Tornetta found that using only 15 degrees knee flexion (semi extended) eliminated the extension force of the quadriceps on the proximal fragment, which otherwise would have tended to cause anterior angulation at the fracture site; therefore interlocking in flexion leads to anterior angulation. Krettek found that a posteriorly placed blocking screw is meant to prevent posterior placement of the nail and therefore encourages decreased anterior angulation of the fracture. Henley found that if the fracture is high and the nail bend is within the distal fracture fragment, as the nail is inserted, the nail will drive the distal fragment posteriorly.

Question 87

A 48-year-old man is brought in by emergency services after falling down a flight of stairs. He complains of weakness in both hands. Examination reveals weak grip bilaterally. Injury CT scans are shown in Figure A. What is the most appropriate treatment option? Review Topic

Explanation

This patient has ankylosing spondylitis (AS) and has suffered a shear fracture through C5-6. Due to the presence of neurological deficits, posterior decompression and fusion with a long construct (such as from C3-T2) is indicated.
The C-spine is the most common site of fracture in AS and is most susceptible to hyperextension injuries. When surgical intervention is required, multiple points of fixation both above and below the fracture are necessary. This is due to co-existing osteoporosis and abnormally increased forces from long lever arms of the ankylosed spine, both of which make the construct susceptible to failure and screw pullout.
Kubiak et al. reviewed the orthopaedic management of AS. They report bone scan, MRI or fine-cut CT is necessary because fractures are often missed on plain x-rays because of distortion of anatomy or difficulty with positioning.
Whang et al. reviewed spinal injuries in 12 patients with AS and 18 patients with DISH. Most injuries involved C5-C7. Patients with AS were more likley to have severe neurologic injury (41% ASIA A) than DISH (44% ASIA E). There was 81% good-excellent outcome and 4 deaths related to halo vest use.
Figure A is a sagittal CT reconstructed image showing a nondisplaced shear fracture through the C6 vertebral body and C5 posterior elements. Illustrations A and B are postop AP and lateral radiographs showing posterior decompression and C3-T2 fusion with lateral mass fixation in the cervical spine and pedicle screw fixation in the upper thoracic spine.
Incorrect Answers:
performed through a posterior approach. If there is significant osteoporosis and the risk of construct failure is high, a 360-approach may be necessary.

Question 88

A 35-year-old man has had a mass on the bottom of his foot for the past 6 months. He reports that initially the mass was exquisitely painful but now is minimally tender. Examination reveals a 2.5- x 2.0-cm firm, noncompressible, nonmobile mass contiguous with the plantar fascia in the distal arch. The mass is particularly prominent with passive dorsiflexion of the ankle and toes. What is the best course of action?

Explanation

DISCUSSION: The history is most consistent with a plantar fibroma. The nodules typically are located within the substance of the plantar aponeurosis. The clinical appearance is usually diagnostic without the need for advanced imaging studies. While the lesion may be prominent and painful to direct palpation, the anatomic location is usually off of the weight-bearing surface. Observation with or without an accommodative orthotic is the treatment of choice. Recurrence is common following attempted excision.
REFERENCES: Sammarco GJ, Mangone PG: Classification and treatment of plantar fibromatosis. Foot Ankle Int 2000;21:563-569.
Durr HR, Krodel A, Trouillier H, Lienemann A, Refior HJ: Fibromatosis of the plantar fascia: Diagnosis and indications for surgical treatment. Foot Ankle Int 1999;20:13-17.

Question 89

What factor highly correlates with poor outcomes after surgery for femoroacetabular impingement? Review Topic

Explanation

A systematic review of case studies looking at the results of surgical treatment for femoroacetabular impingement showed good results for most patients, with the exception of those with preoperative radiographs showing osteoarthritis or Outerbridge grade III or grade IV cartilage damage noted intraoperatively. Both Byrd and Jones and Philippon and associates have shown good surgical results for this condition among professional athletes. Likewise, Fabricant and associates demonstrated good surgical results among adolescent patients with an average age of

Question 90

Figure 19 is the clinical photograph of a 54-year-old man who underwent a total ankle replacement (TAR). Three weeks after surgery he has increasing pain and a deep wound as seen in the photograph. What is the best next step?

Explanation

DISCUSSION
The patient is 3 weeks out from TAR. The wound is erythematous, and the tendon is visible. At 3 weeks this is an acute wound breakdown. The preferred treatment is a return to the operating room, an exchange of the polyethylene because the wound appears deep enough to go down to the joint, and a flap for coverage. Removal of the total ankle and placement of an antibiotic spacer should be considered in the settings of subacute (6 weeks postop) or chronic infection following TAR. A below-the-knee amputation may be considered with a failed salvage or a chronically infected TAR. Conversion to a fusion may be considered in situations in which the wound bed is not infected. In this case, there is concern for ongoing active infection, and an intercalary allograft is not appropriate.
RECOMMENDED READINGS
Cho EH, Garcia R, Pien I, Thomas S, Levin LS, Hollenbeck ST. An algorithmic approach for managing orthopaedic surgical wounds of the foot and ankle. Clin Orthop Relat Res. 2014 Jun;472(6):1921-9. doi: 10.1007/s11999-014-3536-7. Epub 2014 Feb 28. PubMed PMID:

Question 91

A 49-year-old male presents with right shoulder pain and weakness after undergoing open cervical lymph node biopsy approximately one year ago. A pertinent finding from the physical exam is seen in Figure A, with the patients arms by his side. Physical exam finding with the arms in a position of 90 degrees of forward elevation and 10 degrees of external rotation are shown in Figure B. What nerve is most likely injured? Review Topic

Explanation

The patient is presenting with LATERAL scapular winging which is a result of injury to the spinal accessory nerve and resultant trapezius muscle palsy.
The spinal accessory nerve is fundamental to scapulothoracic function and essential for scapulohumeral rhythm. This nerve is vulnerable along its superficial course. The majority of injuries to the spinal accessory nerve are iatrogenic and occur secondary to head and neck surgery. There is often a marked delay in recognition and initiating treatment. Surgical treatment with the Eden-Lange transfer lateralizes the levator scapulae and rhomboids (transfer from medial border to lateral border)
Camp et al. reviewed the results of 111 patients who underwent operative management of a lesion to the spinal accessory nerve. They found that the majority (~80%) of injuries were sustained iatrogenically and that diagnosis was delayed for approximately 12 months.
Pikkarainen et al. reviewed the natural history of isolated serratus palsy. They found that symptoms mostly recover in 2 years, but at least one-fourth of the patients will have long-lasting symptoms, especially pain.
Figure A depicts a patient with lateral scapular winging. Figure B demonstrates physical exam of this patient with their arms in a position of 90 degrees of forward elevation and 10 degrees of external rotation. Illustration A highlights the difference between medial and lateral scapular winging. Illustration B depicts another example of a patient with lateral scapular winging.
Incorrect Answers:
An injury to the long thoracic nerve would result in serratus anterior palsy which would lead to MEDIAL scapular winging.
An injury to the suprascapular nerve would result in weakness and wasting of the supraspinatus and/or infraspinatus.
An injury to the axillary nerve would result in deltoid muscle weakness.
An injury to the thoracodorsal nerve would result in latissimus dorsi weakness and would not cause scapular winging

Question 92

A 22-year-old professional baseball pitcher has had pain in the axillary region of his dominant shoulder for the past several weeks. While throwing a pitch during a game, he notes a sharp pulling sensation with a “pop” in his shoulder. Examination the following day reveals tenderness along the posterior axillary fold and pain and weakness with resisted extension of the shoulder. What is the most likely cause of his symptoms?

Explanation

DISCUSSION: Injury to the latissimus dorsi tendon recently has been reported as a cause of pain in the thrower’s shoulder. The etiology of this injury is felt to be eccentric overload during the follow-through of the throwing motion. Recommended management for this unusual injury consists of a short period of rest, followed by physical therapy to restore shoulder motion and strength. Throwing is allowed when the athlete demonstrates full, pain-free motion and good strength and balance of the rotator cuff and scapular rotator muscles. Currently there are no defined indications for surgical repair.
REFERENCES: Schickendantz MS, Ho CP, Keppler L, et al: MR imaging of the thrower’s shoulder: Internal impingement, latissimus dorsi/subscapularis strains and related injuries.

Magn Reson Imaging Clin N Am 1999;7:39-49.
Livesey JP, Brownson P, Wallace WA: Traumatic latissimus dorsi: Tendon rupture. J Shoulder Elbow Surg 2002;11:642-644.

Question 93

When using highly cross-linked ultra-high molecular weight polyethylene as an articulating surface for total knee arthroplasty, what property of the material raises concern?

Explanation

DISCUSSION: The decreased mobility of the polymer chains from cross-linking leads to decreased volumetric wear but also to decreases in ductility and fatigue resistance. Stresses at the knee are higher and varied in the point of application, leading to the concern for fatigue resistance and fracture.
REFERENCE: Koval KJ (ed): Orthopaedic Knowlegde Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 193-199.

Question 94

A Trendelenburg gait is most likely to be seen in association with

Explanation

DISCUSSION: A Trendelenburg gait results from weakness of the gluteus medius, which is innervated by the L5 nerve root. A paracentral disk herniation at L4-L5 most commonly results in an L5 radiculopathy and thus weakness of the gluteus medius. A paracentral herniation at L5-S1 most commonly affects the S1 nerve root. A paracentral herniation at L3-L4, a central herniation at L3-L4, and a far lateral herniation at L4-L5 all affect the L4 root.
REFERENCES: Fardon DF, Garfin SR, Abitbol J, et al (eds): Orthopedic Knowledge Update: Spine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 323-332.
Andersson GB, Deyo RA: History and physical examination in patients with herniated lumbar discs. Spine 1996;21:10S-18S.

Question 95

A 6-month-old child is seen in the emergency department with a spiral fracture of the tibia. The parents are vague about the etiology of the injury. There is no family history of a bone disease. In addition to casting of the fracture, initial management should include

Explanation

DISCUSSION: Unwitnessed spiral fractures should raise the possibility of child abuse, especially prior to walking age. With nonaccidental trauma being considered in the differential diagnosis, a skeletal survey is indicated to determine if there are other fractures in various stages of healing.
REFERENCES: Kempe CH, Silverman FN, Steele BF, et al: The battered-child syndrome. JAMA 1962;181:17-24.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 3, pp 2079-2082.

Question 96

A 52-year-old woman has right hip pain and obvious swelling 3 years after undergoing a resurfacing arthroplasty. Her implant consists of a 42-mm femoral component and 48-mm socket. Her components are well positioned, and her metal ion levels are slightly elevated (less than 4 ppm) with a normal erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level. What is the most likely cause of her discomfort?

Explanation

DISCUSSION
This patient likely has a soft-tissue reaction (pseudotumor) related to metal-on-metal articulation. Although the components are well positioned, patient gender and small head size are both known risk factors for failure of hip resurfacing arthroplasties. Metal ion levels are elevated but are not always markedly increased in the setting of a problematic metal-on-metal articulation. The patient should have a metal artifact reduction sequence MR imaging study to confirm the presence of a pseudotumor. Chronic infection is very unlikely in the setting of normal ESR and CRP findings. Impingement and lumbar disk disease would not explain the swelling around the hip.

Question 97

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

Explanation

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

Question 98

A 45-year-old diabetic woman with a gangrenous foot undegoes a Chopart amputation without tendon transfer or lengthening. Which type of deformity is the most likely complication of this procedure?

Explanation

DISCUSSION: The Chopart amputation is an amputation of the foot at the level of the calcaneocuboid and talonavicular level. Historically, its use has been criticized because an amputation at this level results in a muscular imbalance with flexor predominance and equinus deformity that eventually leads to stump breakdown. To prevent this complication it should be coupled with Achilles tenotomy (vs. lengthening) as well as transfer of the tibialis anterior insertion to the talar neck.
Advantages of the Chopart amputation include increased limb length and maintenance of heel proprioception that cannot be preserved with more proximal amputations.
Lieberman et al argue in patients with peripheral vascular disease, it is important to preserve as much tissue as possible to preserve maximum function. They recommend that with appropriate care, an amputation at the Chopart (calcaneocuboid-talonavicular) level can give a good functional result.

Question 99

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

Explanation

The patient has symptoms and examination findings of acute brachial neuritis which is often a diagnosis of exclusion. The recent viral flu-like symptoms have shown a correlation with the development of this disorder. The acute, severe shoulder weakness excludes calcific tendinitis, impingement, and poliomyelitis. A normal cervical spine examination makes cervical disk disease unlikely.

Question 100

A 71-year-old woman undergoes a posterior lumbar decompression and fusion from L4-S1. Thirty-six hours after the procedure, she reports severe right-sided chest pain and shortness of breath. Doppler ultrasound reveals a clot proximal to the knee within the femoral vein. A large pulmonary embolus is confirmed by CT angiography. The next most appropriate step in management should consist of

Explanation

DISCUSSION: In a review of 13,000 spinal procedures, nine patients were treated with heparin following development of pulmonary emboli. Of these patients, six had serious complications ranging from wound drainage to paralysis. Heparin therapy instituted within 10 days of the surgical procedure resulted in a 100% complication rate. Vena cava filter placement has a complication rate of 0.12% to 10.1%. Removable filters are currently in clinical trials.
REFERENCES: Cain JE Jr, Major MR, Lauerman WC, et al: The morbidity of heparin therapy after development of pulmonary embolus in patients undergoing thoracolumbar or lumbar spinal fusion. Spine 1995;20:1600-1603.
Roberts AC: Venous imaging and inferior vena cava filters. Curr Opin Radiol 1992;4:88-96.
Becker DM, Philbrick JT, Selby JB: Inferior vena cava filters. Arch Intern Med
1992;152:1985-1994.

Full Question & Answer Text (for Search Engines)

Question 1:

Which nerve is not included in a standard popliteal nerve block?

Options:

Sural nerve
Saphenous nerve
Superficial peroneal nerve
Deep peroneal nerve

Correct Answer: Saphenous nerve

Explanation:

DISCUSSION
A standard popliteal nerve block is performed with the patient prone. The injection aims for the area at, or close to, the peroneal and tibial nerves. The sural nerve branches distal to the injection site, so this nerve and the superficial peroneal, deep peroneal, and tibial nerves are covered with the injection. The saphenous nerve is in an anteromedial location at knee level and is not close enough to the area covered by the posterior injection to be included in the analgesic effect.
RECOMMENDED READINGS
Varitimidis SE, Venouziou AI, Dailiana ZH, Christou D, Dimitroulias A, Malizos KN. Triple nerve block at the knee for foot and ankle surgery performed by the surgeon: difficulties and efficiency. Foot Ankle Int. 2009 Sep;30(9):854-9. PubMed PMID: 19755069.
View Abstract at
PubMed
Hromádka R, Barták V, Popelka S, Jahoda D, Pokorný D, Sosna A. [Regional anaesthesia of the foot achieved from two cutaneous points of injection: an anatomical study]. Acta Chir Orthop Traumatol Cech. 2009 Apr;76(2):104-9. Czech. PubMed PMID: 19439129.
View
Abstract at PubMed
Tran D, Clemente A, Finlayson RJ. A review of approaches and techniques for lower extremity nerve blocks. Can J Anaesth. 2007 Nov;54(11):922-34. Review. PubMed PMID: 17975239.
View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 42 THROUGH 44
42A
B
Figures 42a and 42b are the radiographs of a 32-year-old man with an accessory navicular, pes planovalgus deformity, and an associated gastrocnemius contracture. He has been treated with custom orthotics and a physical therapy program for several years and has progressed to stage II posterior tibial tendon dysfunction (PTTD). This patient is now interested in surgery. Tendon reconstruction with bony procedure to correct alignment, medializing calcaneal osteotomy with lateral column lengthening, and a subtalar arthroereisis implant are discussed with the patient.

Question 2:

Options:

Standing radiographs of the right foot
MRI of the foot
Carbon fiber insole with a Morton extension
Surgery for reconstruction

Correct Answer: Standing radiographs of the right foot

Explanation:

DISCUSSION
This patient jumped on his forefoot and landed with pain in his great toe. His radiograph shows possible increased space between the sesamoids and the base of the phalanx. A comparison radiograph on the other side will reveal if this position is normal for this patient. If findings are asymmetric, turf toe injury is a possibility based on this patient's symptoms and mechanism of injury.
RECOMMENDED READINGS
Waldrop NE 3rd, Zirker CA, Wijdicks CA, Laprade RF, Clanton TO. Radiographic evaluation of plantar plate injury: an in vitro biomechanical study. Foot Ankle Int. 2013 Mar;34(3):403-8. doi: 10.1177/1071100712464953. Epub 2013 Jan 14. PubMed PMID: 23520299.
View
Abstract at PubMed
McCormick JJ, Anderson RB. The great toe: failed turf toe, chronic turf toe, and complicated sesamoid injuries. Foot Ankle Clin. 2009 Jun;14(2):135-50. doi: 10.1016/j.fcl.2009.01.001. Review. PubMed PMID: 19501799.
View Abstract at PubMed

Question 3:

Which of the following structures may help maintain radial length after a radial head fracture?

Options:

Triangular fibrocartilage complex
Medial ulnar collateral ligament
Lateral ulnar collateral ligament
Annular ligament
Coronoid

Correct Answer: Triangular fibrocartilage complex

Explanation:

DISCUSSION: Essex-Lopresti injuries affect axial stability of the forearm. Injury to the interosseous membrane or the triangular fibrocartilage complex can result in proximal migration of the radius.
REFERENCES: Morrey BF, Chao EY, Hui FC: Biomechanical study of the elbow following excision of the radial head. J Bone Joint Surg Am 1979;61:63-68.
Coleman DA, Blair WF, Shurr D: Resection of the radial head for fracture of the radial head: Long-term follow-up of seventeen cases. J Bone Joint Surg Am 1987;69:385-392.

Question 4:

Of all the pelvic ring injury types, anteroposterior compression type III pelvic ring injuries have the highest rate of which of the following?

Options:

Head injury
Pulmonary injury
Traumatic amputation
Need for transfusion
Upper extremity fractures

Correct Answer: Head injury

Explanation:

Question 5:

Options:

aspiration of the left hip.
application of a Pavlik harness.
a gallium scan.
an MRI scan of the spine.
modified Bryant traction.

Correct Answer: aspiration of the left hip.

Explanation:

Question 6:

03 A 26-year-old woman has chronic toe pain after hitting a bedpost 3 months ago. A radiograph is shown in Figure 27. Her injury represents an avulsion of the

Options:

lumbrical insertion.
extensor digitorum brevis.
extensor digitorum longus.
extensor hallucis longus.
flexor digitorum longus.
back answer Question 105.03

Correct Answer: extensor digitorum longus.

Explanation:

Question 7:

Which of the following forms of nonsurgical management is considered best for acute low back pain without radiculopathy?

Options:

Acupuncture
Epidural steroid injections
Facet joint injections
Sclerosant injections
Bed rest

Correct Answer: Bed rest

Explanation:

Question 8:

Options:

Bone scan
Curettage and bone grafting of the cyst
Cast immobilization
Observation with reduced activity
Skeletal survey

Correct Answer: Observation with reduced activity

Explanation:

DISCUSSION: The most likely diagnosis is Sever’s disease, which is considered either an apophysitis or a para-apophyseal stress fracture. It is common in athletic children and is associated with a tight Achilles tendon. Cast immobilization may be necessary if activity reduction fails. Calcaneal cysts are quite common and do not require any further diagnostic testing or treatment unless they occupy the full width of the calcaneus or one third of the length of the calcaneus.
REFERENCES: Ogden JA, Ganey TM, Hill JD, et al: Sever’s injury: A stress fracture of the immature calcaneal metaphysis. J Ped Orthop 2004;24:488-492.
Pogoda P, Priemel M, Linhart W, et al: Clinical relevance of calcaneal bone cysts: A study of 50 cysts in 47 patients. Clin Orthop Relat Res 2004;424:202-210.

Question 9:

Following an acute dislocation of the patella, the risk of a recurrent dislocation is greater if the patient has which of the following findings?

Options:

Bipartite patella
Age greater than 15 years at the time of the initial dislocation
Persistent atrophy of the vastus lateralis
Low-lying position of the patella (patella baja)
Passive lateral hypermobility of the unaffected knee

Correct Answer: Passive lateral hypermobility of the unaffected knee

Explanation:

Question 10:

Which of the following cohorts of patients is at highest risk of a future anterior cruciate ligament (ACL) tear? Review Topic

Options:

Men with a hip abduction moment during landing
Men with a neutral hip abduction-adduction moment during landing
Men with varus knee abduction moment during landing
Women with a hip adduction moment during landing
Women with a knee valgus moment during landing

Correct Answer: Women with a knee valgus moment during landing

Explanation:

Question 11:

Options:

Pudendal
Deep illiac circumflex
Hypogastric
Obturator
Testicular

Correct Answer: Pudendal

Explanation:

Question 12:

Options:

C3-T1
C4-C5
C5-C7
C6-C8
C8-T1

Correct Answer: C5-C7

Explanation:

Question 13:

Which laboratory findings would most support a diagnosis of prosthetic joint infection (PJI) in a hip or knee arthroplasty performed 3 weeks ago?

Options:

Erythrocyte sedimentation rate (ESR) higher than 30 mm/h
C-reactive protein (CRP) level higher than 10 mg/L
Synovial white blood cell count higher than 10000 cells/µL
Synovial percentage of polymorphonuclear (PMN) leukocytes higher than 60%

Correct Answer: Synovial white blood cell count higher than 10000 cells/µL

Explanation:

Question 14:

Options:

Short leg cast for 6 weeks
Splinting with early range of motion at 3 weeks
Immediate open reduction and internal fixation through a medial approach
Delayed open reduction and internal fixation
Fusion

Correct Answer: Delayed open reduction and internal fixation

Explanation:

DISCUSSION: Whereas a patient age of older than 50 years used to be a contraindication for open reduction and internal fixation of displaced intra-articular calcaneal fractures, new data suggest that the presence of associated medical comorbidities that affect wound healing such as smoking, diabetes mellitus, and peripheral vascular disease are more relevant to postoperative functional outcome. Surgical treatment of Sanders II and III displaced intra-articular calcaneal fractures with initial Bohler angles of > 15 degrees results in better outcomes as compared to nonsurgical management. Indications for primary fusion might include Sanders IV fractures in which articular congruity or Bohler angles cannot be restored. Given the condition of the soft tissues at presentation, delayed fixation is recommended.
REFERENCES: Herscovici D Jr, Widmaier J, Scaduto JM, et al: Operative treatment of calcaneal fractures in elderly patients. J Bone Joint Surg Am 2005;87:1260-1264.
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 15:

Options:

Immediately
After 30 minutes
After 24 hours
After 4 weeks
Next season

Correct Answer: After 4 weeks

Explanation:

Question 16:

Options:

increased medical complications of treatment.
osteonecrosis of the jaw.
improved long-term survival rates.
anorexia.
decreased quality of life measures.

Correct Answer: osteonecrosis of the jaw.

Explanation:

Question 17:

What are the proposed biomechanical advantages of the Grammont reverse total shoulder arthroplasty when compared to a standard shoulder arthroplasty? Review Topic

Options:

Lateralization of the center of rotation, lengthening the deltoid, and decreasing the deltoid moment arm
Lateralization of the center of rotation, shortening the deltoid, and decreasing acromial stress
Lateralization of the center of rotation, lengthening the deltoid, and increasing the transverse force couple
Medialization of the center of rotation, lengthening the deltoid, and increasing the deltoid moment arm
Medialization of the center of rotation, shortening the deltoid, and decreasing acromial stress

Correct Answer: Medialization of the center of rotation, lengthening the deltoid, and increasing the deltoid moment arm

Explanation:

The Grammont reverse total shoulder arthroplasty is designed to medialize the center of rotation, thereby increasing the deltoid moment arm and lengthening the deltoid.

Question 18:

- A healed fracture of the tibia that demonstrates 25 degrees apex posterior angulation and 28 degrees varus angulation on AP and lateral radiographs is most accurately described as a

Options:

Complex deformity with an angulation in two planes
Single deformity less than 20 degrees, apex posterolateral
Single deformity greater than 30 degrees, apex posterolateral
Single deformity less than 20 degrees, apex posteromedial
Single deformity greater than 30 degrees, apex posteromedial

Correct Answer: Single deformity greater than 30 degrees, apex posterolateral

Explanation:

Question 19:

A 9-year-old boy has a painless enlarged mass on the dorsum of his hand. Figures 14a through 14d show the clinical photograph, radiographs, and biopsy specimen. What is the most likely diagnosis?

Options:

Fracture callus
Enchondroma (Ollier’s disease)
Multiple hereditary exostosis
Osteosarcoma
Chondrosarcoma

Correct Answer: Multiple hereditary exostosis

Explanation:

Question 20:

Options:

Emergent exploration of the sciatic nerve
Transfusion to raise the hematocrit to 30% and sequential neurovascular examinations
Placement of a vena cava filter, halt anticoagulation, blood transfusion, and exploration of the sciatic nerve
Transfusion to raise the hematocrit to 30%, continued administration of enoxaparin, and sequential neurovascular examinations
Placement of a temporary vena cava filter and exploration of the sciatic nerve

Correct Answer: Placement of a vena cava filter, halt anticoagulation, blood transfusion, and exploration of the sciatic nerve

Explanation:

Question 21:

Which structure is shown in Video 27? 27

Options:

Superficial medial collateral ligament
Semimembranosus tendon
Posterior oblique ligament
Medial patellofemoral ligament

Correct Answer: Medial patellofemoral ligament

Explanation:

Question 22:

Options:

Valgus
Varus
Recurvatum
Procurvatum
Rotational deformity

Correct Answer: Valgus

Explanation:

Question 23:

During revision total knee arthroplasty (TKA), there is significant laxity in 90° of flexion and 10° short of full extension. Correcting the gap imbalance is best achieved by

Options:

resecting more tibia.
resecting more distal femur to raise the joint line, along with resecting more tibia.
increasing femoral component size.
resecting distal femur and increasing femoral component size. When performing revision TKA, the management of gap imbalance and joint line is of critical importance. The flexion gap is generally driven by femoral component size; increasing femoral component size by tightening the flexion gap and downsizing the femoral component size increases the flexion gap. Resecting more distal femur will open up the extension gap; augmenting the femur distally will tighten up the extension gap. Resecting more tibia affects both flexion and extension gaps equally.

Correct Answer: resecting distal femur and increasing femoral component size. When performing revision TKA, the management of gap imbalance and joint line is of critical importance. The flexion gap is generally driven by femoral component size; increasing femoral component size by tightening the flexion gap and downsizing the femoral component size increases the flexion gap. Resecting more distal femur will open up the extension gap; augmenting the femur distally will tighten up the extension gap. Resecting more tibia affects both flexion and extension gaps equally.

Explanation:

Question 24:

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 25:

Options:

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

Correct Answer: Reduced radial artery pulse

Explanation:

Question 26:

Options:

No further treatment is advised unless a second ulcer develops
Oxford shoes with a rubber sole
Depth-inlay shoes with a custom accommodative foot orthosis
Dorsiflexion third metatarsal osteotomy
Achilles tendon lengthening

Correct Answer: Depth-inlay shoes with a custom accommodative foot orthosis

Explanation:

DISCUSSION: This is the first occurrence of diabetic foot-specific morbidity. The patient has a foot deformity, a history of a diabetic foot ulcer, and is insensate to the monofilament. He is at moderate risk for the development of a recurrent ulcer. This is best avoided with therapeutic footwear. Commercially available depth-inlay shoes should be combined with a custom accommodative foot orthosis to accommodative the deformity.
REFERENCES: Pinzur MS, Slovenkai MP, Trepman E, et al: Guidelines for diabetic foot care: Recommendations endorsed by the Diabetes Committee of the American Orthopaedic Foot and Ankle Society. Foot Ankle Int 2005;26:113-119.
Pinzur MS, Dart HC: Pedorthic management of the diabetic foot. Foot Ankle Clin 2001;6:205-214.

Question 27:

Options:

Brostrom procedure
Syndesmosis repair or stabilization
Allograft lateral ligament reconstruction
Excision of loose body/fracture fragment
Repair of the SPR with possible fibular groove deepening

Correct Answer: Syndesmosis repair or stabilization

Explanation:

DISCUSSION FOR QUESTIONS 107 AND 108:
The fracture at the insertion of the AITFL into the fibula represents a syndesmosis injury. In some cases, a direct repair of the fracture will stabilize the syndesmosis, but in most cases this injury should most likely be reinforced by placing a screw or suture tensioning device across the syndesmosis for additional support.A Brostrom or allograft reconstruction is indicated for an ankle sprain involving the ATFL or CFL.Simply excising the fragment will leave the patient with an incompetent syndesmosis. Repairing the SPR with or without a groove deepening procedure is indicated if there is evidence of subluxated or dislocated peroneal tendons, which is not demonstrated on the CT scans. The bone has been avulsed off the fibula by the portion of the AITFL that attaches to the fibula, therefore indicating that there is a syndesmosis injury. Allograft lateral ligament reconstruction and excision of loose body/fracture fragment are incorrect procedures based on location. The deltoid is a medial structure and this fracture is lateral. The ATFL and CFL attach at the inferior margin of the fibula near the lateral process of the talus and calcaneus. A SPR avulsion would present as an avulsion off the lateral wall of the fibula, not superior and not into the syndesmotic space as shown on the CT scans.

Question 28:

Options:

Hip arthroscopy with labrum repair
MRI arthrogram
Percutaneous screw fixation
CT scan with fine cuts

Correct Answer: CT scan with fine cuts

Explanation:

Question 29:

Options:

Torn posterolateral corner
Torn posterior cruciate ligament (PCL) and posterolateral corner
Torn PCL
Rupture of the quadriceps tendon
Rupture of the lateral collateral ligament

Correct Answer: Torn posterolateral corner

Explanation:

Question 30:

Options:

Multilevel anterior cervical diskectomy with fusion
Anterior and posterior decompression with fusion
Anterior corpectomy and fusion with a fibula strut
Laminectomy and bilateral foraminotomies
Laminectomy and posterior fusion with lateral mass plating

Correct Answer: Laminectomy and bilateral foraminotomies

Explanation:

Question 31:

Options:

Varus stress
Valgus stress
Torsional loading
Hyperextension of the knee
Contraction of the quadriceps while axially loaded

Correct Answer: Contraction of the quadriceps while axially loaded

Explanation:

Question 32:

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

Options:

1 month
2 months
4 months
6 months
12 months

Correct Answer: 6 months

Explanation:

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

Question 33:

Options:

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

Correct Answer: Move the starting point slightly medial

Explanation:

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

Question 34:

Options:

Long arm cast for 2 weeks, followed by range of motion
Early range of motion
Metallic radial head arthroplasty
Silastic radial head arthroplasty
Excision of the radial head

Correct Answer: Metallic radial head arthroplasty

Explanation:

Question 35:

Options:

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

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

Explanation:

Question 36:

Options:

Arthroscopic labral debridement and biceps tenodesis
Shoulder arthroscopy with undersurface cuff debridement and acromioplasty
Cyst decompression at the spinoglenoid notch with possible labral repair
Cyst decompression at the suprascapular notch with possible labral repair This patient’s clinical and MRI findings are consistent with a posterior paralabral cyst with compression of the suprascapular nerve, specifically at the spinoglenoid notch. Compression of the suprascapular nerve can occur at either the suprascapular or spinoglenoid notch. Compression of the nerve at the suprascapular notch affects innervation to both the supraspinatus and infraspinatus muscles, resulting in weakness in both shoulder abduction and external rotation. However, compression at the spinoglenoid notch only affects innervation to the infraspinatus muscle, resulting in isolated weakness in external rotation. Compression at the spinoglenoid notch often is seen in overhead athletes, and studies have shown associated posterior labral tears (Piatt and associates). Several studies have addressed nonsurgical and surgical treatment options. The treatment decision should focus on the underlying cause (Martin and associates)—in this patient, the cyst. Nonsurgical treatment in the presence of a known lesion has been associated with a higher failure rate than addressing the lesion, which can result in functional improvement (Chen and associates, Cummins and associates). The best response in this scenario is decompression of the cyst at the spinoglenoid notch with possible labral repair.

Correct Answer: Shoulder arthroscopy with undersurface cuff debridement and acromioplasty

Explanation:

Question 37:

Options:

the acetabular component only using a cemented implant.
the acetabular component only using a cementless implant.
both components using cemented implants.
both components using cementless implants.
the acetabular component using a cementless implant and revision of the femoral component using a cemented implant.

Correct Answer: the acetabular component only using a cementless implant.

Explanation:

DISCUSSION: Recent literature supports retention of well-fixed cemented femoral components when revising loosened cemented acetabular components. Current literature also supports the use of cementless components for revision of loosened cemented acetabular components.
REFERENCES: Peters CL, Kull L, Jacobs JJ, Rosenberg AG, Galante JO: The fate of well fixed cemented femoral components left in place at the time of revision of the acetabular component. J Bone Joint Surg Am 1997;79:701-706.
Poon ED, Lachiewicz PF: Results of isolated acetabular revisions: The fate of the unrevised femoral component. J Arthroplasty 1998;13:42-49.
Moskal JT, Shen FH, Brown TE: The fate of stable femoral components retained during isolated acetabular revision: A six- to twelve-year follow-up study. J Bone Joint Surg Am
2002;84:250-255.
Templeton JE, Callaghan JJ, Goetz DD, Sullivan PM, Johnston RC: Revision of a cemented acetabular component to a cementless acetabular component. A ten- to fourteen-year follow-up study. J Bone Joint Surg Am 2001;83:1706-1711.

Question 38:

Which of the following knee ligament injury patterns is most associated with an increase in external tibial rotation with the knee at 90 degrees of flexion?

Options:

Isolated tear of the posterior cruciate ligament
Isolated tear of the lateral collateral ligament
Combined tears of the posterior cruciate and lateral collateral ligaments
Combined tears of the anterior cruciate and lateral collateral ligaments
Combined tears of the lateral collateral and medial collateral ligaments

Correct Answer: Combined tears of the posterior cruciate and lateral collateral ligaments

Explanation:

Question 39:

Options:

Coracoid transfer
Rotator cuff repair
Reverse total shoulder arthroplasty
Arthroscopic anteroinferior labral repair
Physical therapy for range of motion and strength improvements

Correct Answer: Rotator cuff repair

Explanation:

Question 40:

Options:

Discontinuation of bracing as she has reached skeletal maturity.
Continue full-time bracing until skeletal maturity.
Continue nocturnal bracing until skeletal maturity.
Posterior spinal fusion.
MRI of the cervical, thoracic and lumbar spine.

Correct Answer: Discontinuation of bracing as she has reached skeletal maturity.

Explanation:

Question 41:

What is the most significant prognostic factor in nontraumatic osteonecrosis of the humeral head?

Options:

Duration of symptoms
Age of the patient
Total amount of steroid use
Stage of the disease
Status of the rotator cuff

Correct Answer: Stage of the disease

Explanation:

Question 42:

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

Options:

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

Correct Answer: passive stretching.

Explanation:

Question 43:

Options:

Conversion to cast immobilization for 6 weeks
Application of an articulated external fixator
Begin early motion as soon as pain resolves
Open reduction
MRI to assess ligament integrity

Correct Answer: Open reduction

Explanation:

DISCUSSION: Elbow dislocations in children are rare injuries and usually result from a fall on an outstretched arm. The incidence of these injuries increases as patients age and concurrently the incidence of supracondylar humerus fractures decreases. In adolescent patients, simple elbow dislocations are treated with splint immobilization and the initiation of physical therapy once comfortable. The practitioner must be aware of structures that may get caught in the joint on reduction. These include the median nerve as well as the medial epicondyle. In this patient, the radiographs reveal a medial epicondyle fracture. Postreduction radiographs show the joint to be incongruous secondary to intra-articular displacement. At this point, the most appropriate treatment is to perform an open reduction and repair of the medial epicondyle fragment.
REFERENCES: Rasool MN: Dislocations of the elbow in children. J Bone Joint Surg Br 2004;86:1050-1058.
Beaty JH: Fractures and dislocations about the elbow in children. Instr Course Lect 1992;41:373-384.

Question 44:

Options:

Posterior spinal fusion from T2 to L5 with segmental instrumentation
Anterior spinal fusion from L1 to L4, followed by posterior spinal fusion from T2 to the sacrum with segmental instrumentation including iliac fixation
Custom-molded spinal orthosis worn 23 hours per day until skeletal maturity
A spinal orthosis until age 14 years, followed by posterior spinal fusion with segmental instrumentation
Adapted wheelchair seating with a custom-molded back support to correct scoliosis and kyphosis

Correct Answer: Posterior spinal fusion from T2 to L5 with segmental instrumentation

Explanation:

DISCUSSION: Posterior spinal fusion is the treatment of choice for scoliosis in patients with Duchenne muscular dystrophy once they are no longer able to walk. This treatment improves quality of life and upright wheelchair positioning. Its effect on pulmonary function is less clear, as pulmonary function will continue to decline because of the underlying muscle disease. While bracing and wheelchair modifications may slow the progression of the curve, progression will continue. Surgical intervention at this stage does not have to include the pelvis, which, in general, is indicated in curves of greater than 40 degrees, and when pelvic obliquity is greater than 10 degrees. Fixation to the pelvis should also be considered in lumbar curves where the apex is lower than L1. Surgical treatment usually can be safely performed if the vital capacity is greater than 35%.
REFERENCES: Hahn GV, Mubarak SJ: Muscular dystrophy, in Weinstein SL (ed): The Pediatric Spine, ed 2. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 819-832.
Mubarak SJ, Morin WD, Leach J: Spinal fusion in Duchenne muscular dystrophy: Fixation and fusion to the sacropelvis? J Pediatr Orthop 1993;13:752-757.

Question 45:

What is the primary mechanism by which anabolic steroids increase muscle tissue? Review Topic

Options:

Increased production of cortisol
Increased production of messenger RNA
Increased secretion of vascular endothelial factor
Decreased production of HDL
Attenuation of the effects of cortisol

Correct Answer: Increased production of messenger RNA

Explanation:

Question 46:

Figure 33 shows the radiograph of a 28-year-old avid golfer who has chronic right wrist pain. Management should consist of

Options:

cast immobilization.
splinting with a bone stimulator.
excision of the fracture fragment.
arthroscopically assisted percutaneous fixation.
trephination of the fibrous union.

Correct Answer: excision of the fracture fragment.

Explanation:

Question 47:

Figure 50 shows the MRI scan of a 20-year-old female college soccer player with knee pain. What is the most likely diagnosis?

Options:

Normal knee
Posterior cruciate ligament tear
Quadriceps tendon rupture
Proximal tibia fracture
Femoral subchondral contusion

Correct Answer: Posterior cruciate ligament tear

Explanation:

Question 48:

Options:

Prior arthroscopy
Current smoking history
BMI of 22
Age of 40

Correct Answer: Current smoking history

Explanation:

Question 49:

03 Which of the following findings is the best indication for the use of temporary external fixation of a femoral shaft fracture?

Options:

Type IIIA open fracture
back to this question next question
Hemodynamic instability
Segmental fracture
Distal one third fracture
Ipsilateral tibial shaft fracture 33.03

Correct Answer: back to this question next question

Explanation:

These days, femoral shaft fractures at Tulane / Charity are commonly encountered by orthopaedic residents on the night-float team.
Despite the presence of a well-rested 4th year surgeon, definitive orthopaedic fixation is not always the correct answer for each trauma patient.
Tulane defines “Orthopaedic Tunnel Vision” as a condition commonly associated with a young MD at the Bulldog without a proper
wing-man, trying to make advances on the wrong patron due to his relatively easy 80-hour work week schedule and a few too many refined hops.
Skeletal Trauma (p. 1967) describes “Orthopaedic Tunnel Vision” as looking at the orthopaedic injury without considering the
patient’s injury in general. Femoral shaft fractures are typically high energy injuries which often do not occur in isolation. In these fractures, it is particularly important to not have tunnel vision.
Indications for temporary bridging external fixation includes hemodynamic instability
(ans. 2), acidosis, hypothermjia, hypoxemia, coagulopathy, sepsis or severely contaminated soft tissues that cannot be adequately debrided. Definitive fixation is performed after the general surgical and medical issues have resolved.
The other answer choices, including the type IIIA open fracture are not contraindications to definitive fixation in themselves (typically IM nailing—antegrade or retrograde).

Question 50:

-A 30-year-old man sustained the injury seen in Figure 261. According to the Lauge-Hansen Classification System, the fracture should be classified as

Options:

pronation-abduction.
pronation-adduction.
pronation-external rotation.
supination-adduction.
supination-external rotation.

Correct Answer: supination-adduction.

Question 51:

What is the most common complication following surgical treatment of a displaced talar neck fracture?

Options:

Osteonecrosis
Varus malunion
Posttraumatic arthritis
Fracture delayed union/nonunion
Wound dehiscence/delayed wound healing

Correct Answer: Posttraumatic arthritis

Explanation:

Question 52:

Options:

Bankart lesion
Humeral avulsion of the glenohumeral ligament (HAGL) lesion
Superior labrum anterior-posterior (SLAP) lesion
Hill-Sach deformity
Glenoid fracture (bony Bankart)

Correct Answer: Humeral avulsion of the glenohumeral ligament (HAGL) lesion

Explanation:

The MRI scan reveals a HAGL lesion. It more commonly affects older patients and is associated with more violent trauma.

Question 53:

Up to what time frame are the risks minimized in anterior revision disk replacement surgery? Review Topic

Options:

3 days
1 week
10 days
2 weeks
6 weeks

Correct Answer: 2 weeks

Explanation:

Question 54:

The examination finding shown in Video 1 is consistent with which defect?

Options:

Trigger finger
Flexor digitorum profundus (FDP) incompetence
Flexor digitorum sublimis (FDS) incompetence
Extensor digitorum communis (EDC) incompetence

Correct Answer: Flexor digitorum profundus (FDP) incompetence

Explanation:

Question 55:

Options:

Consider fusion surgery
Intradiskal ozone therapy
Lumbar laminectomy
Vertebral augmentation
Cognitive intervention and exercise

Correct Answer: Cognitive intervention and exercise

Explanation:

Question 56:

Options:

protected weight bearing and anti-inflammatory drugs.
core decompression of the femoral head.
vascularized free fibular grafting to the femoral head.
bipolar hemiarthroplasty of the hip.
total hip arthroplasty.

Correct Answer: protected weight bearing and anti-inflammatory drugs.

Explanation:

DISCUSSION: The MRI findings show highly increased signal through the entire femoral head and neck on STIR imaging, diagnostic of transient osteoporosis of the femoral head. This disease entity can be seen in middle-aged men, and should be treated nonsurgically. The natural history is that of self-resolution.
REFERENCES: Guerra JJ, Steinberg ME: Distinguishing transient osteoporosis from avascular necrosis of the hip. J Bone Joint Surg Am 1995;77:616-624.
Urbanski SR, de Lange EE, Eschenroeder HC Jr: Magnetic resonance imaging of transient osteoporosis of the hip: A case report. J Bone Joint Surg Am 1991;73:451-455.

Question 57:

- A 20-year-old college football player sustains a forceful hyperextension injury to his shoulder 4 months after undergoing an anterior capsular shift. Examination 2 weeks later reveals anterior tenderness. He is unable to lift the dorsum of his hand away from his back. What is the most likely diagnosis?

Options:

Subscapularis rupture
Type III SLAP lesion
Disruption of capsular shift
Isolated traumatic subluxation
Injury to the axillary nerve after dislocation

Correct Answer: Subscapularis rupture

Explanation:

Question 58:

Options:

In extension with internal rotation/valgus force, the medial tibial plateau is subluxated; with flexion, the medial tibial plateau reduces.
In extension with internal rotation/valgus force, the medial tibial plateau is reduced; with flexion, the medial tibial plateau subluxates.
In extension with internal rotation/valgus force, the lateral tibial plateau is reduced; with flexion, the lateral plateau subluxates.
In extension with internal rotation/valgus force, the lateral tibial plateau is subluxated; with flexion, the lateral plateau reduces.

Correct Answer: In extension with internal rotation/valgus force, the lateral tibial plateau is subluxated; with flexion, the lateral plateau reduces.

Explanation:

Question 59:

Which of the following anatomic changes is observed as part of the normal aging process of the adult spine?

Options:

Overall kyphosis gradually decreases.
Overall lumbar lordosis gradually decreases.
The sagittal vertical line dropped from C7 gradually moves posteriorly relative to the sacrum.
Cervical scoliosis develops.
Coronal balance shifts laterally from the midsacrum.

Correct Answer: Overall lumbar lordosis gradually decreases.

Explanation:

Question 60:

Options:

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

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

Explanation:

Question 61:

A 15-year-old wrestler sustains an abduction, hyperextension, and external rotation injury to his right shoulder. The MRI scan findings shown in Figures 27a and 27b are most consistent with

Options:

an avulsion of the lesser tuberosity.
a midsubstance tear of the capsule.
a tear of the anterior inferior labrum.
a tear of the subscapularis.
a tear of the humeral insertion of the inferior glenohumeral ligament.

Correct Answer: a tear of the humeral insertion of the inferior glenohumeral ligament.

Explanation:

Question 62:

Risk of fat embolism is greatest during what step of total hip arthroplasty?

Options:

Osteotomy of the femoral neck
Dislocation of the hip
Broaching of the femoral canal
Insertion of a cemented femoral stem
Insertion of a cementless femoral stem

Correct Answer: Insertion of a cemented femoral stem

Explanation:

DISCUSSION: Embolization of fat and bone marrow elements during total hip arthroplasty has been studied intraoperatively using transesophageal echocardiography. These studies showed the occurrence of a large number of embolic events during the insertion of a cemented femoral stem. Embolic events were rare during insertion of a cementless stem. Femoral broaching caused some embolic events, but they were not nearly as significant as those that occurred following insertion of a cemented stem. Additionally, relocation of the cemented hip was accompanied by significant embolic events. This may be related to the untwisting of blood vessels, with the subsequent release of emboli that were most likely generated during insertion of a cemented femoral stem.
REFERENCES: Pitto RP, Koessler M, Kuehle JW: Comparison of fixation of the femoral component without cement and fixation with use of a bone-vacuum cementing technique for the prevention of fat embolism during total hip arthroplasty. J Bone Joint Surg Am
1999;81:831-843.
Christie J, Burnett R, Potts HR, Pell AC: Echocardiography of transatrial embolism during cemented and uncemented hemiarthroplasty of the hip. J Bone Joint Surg Br 1994;76:409-412.

Question 63:

Options:

antibiotics for 6 weeks.
use of an unlocked brace.
revision arthroplasty.
resection of the implants.
two-stage reimplantation.

Correct Answer: revision arthroplasty.

Explanation:

Question 64:

Options:

Posterior midline approach
Retroperitoneal approach
Far lateral approach
Transpsoas approach

Correct Answer: Far lateral approach

Explanation:

DISCUSSION
The MR image shows a far lateral disk herniation impinging on the exiting nerve root lateral to the exiting foramen. This is reached most directly with a far lateral (Wiltse) approach. This is a posterior paramedian approach that uses the interval between the paraspinal muscles (multifidus and longissimus) and arrives onto the facet joints. The intertransverse membrane can then be released, exposing the far lateral disk herniation. A posterior midline approach will allow easy access to the spinal canal, which is medial to the disk herniation, and will not allow for easy disk removal without the need for a facetectomy, which would destabilize the level. An anterior approach would not allow for access to the far lateral disk herniation, nor would a traditional retroperitoneal or newer transpsoas approach.
RECOMMENDED READINGS
Wiltse LL, Spencer CW. New uses and refinements of the paraspinal approach to the lumbar spine. Spine (Phila Pa 1976). 1988 Jun;13(6):696-706. PubMed PMID: 3175760.
View
Abstract at PubMed
Epstein NE. Evaluation of varied surgical approaches used in the management of 170 far-lateral lumbar disc herniations: indications and results. J Neurosurg. 1995 Oct;83(4):648-56. PubMed PMID: 7674015.
View Abstract at PubMed

Question 65:

Options:

return to play immediately.
return to play in 1 week, if asymptomatic.
return to play in 1 month, if asymptomatic.
return only after a screening CT scan.
not return to play for the season.

Correct Answer: return to play immediately.

Explanation:

Question 66:

Options:

repeat closed reduction and buddy taping.
closed reduction and percutaneous pin fixation, followed by casting.
open reduction and plate fixation, followed by casting.
open reduction and screw fixation, followed by splinting and early motion.
open reduction and intramedullary fixation with absorbable implants.

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

Explanation:

DISCUSSION: The patient has an unstable oblique fracture of the proximal phalanx that is easily reducible but unstable; therefore, the treatment of choice is closed reduction and percutaneous pin fixation, followed by casting. Closed reduction and percutaneous pin fixation offers a better functional result than open reduction and plate fixation. Repeat closed reduction and buddy taping is inadequate because of the inherently unstable fracture pattern. Buddy taping will allow the dislocation to recur. The other options represent more aggressive surgical techniques than are necessary to treat this fracture.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,
pp 711-771.
Green DP, Anderson JR: Closed reduction and percutaneous pin fixation of fractured phalanges. J Bone Joint Surg Am 1973;55:1651-1653.

Question 67:

A 58-year-old woman has had a painless periscapular mass for the past year. An MRI scan and biopsy specimen are shown in Figures 4a and 4b. What is the most likely diagnosis?

Options:

Elastofibroma
Desmoid tumor
Nodular fasciitis
Malignant fibrous histiocytoma
Atrophic serratus anterior

Correct Answer: Elastofibroma

Explanation:

Question 68:

Options:

a cortisone injection to the subscapular bursa.
posterior capsular stretching.
strengthening of the external rotators and scapular stabilizers.
continued pitching and working through the pain.
a sling and rest.

Correct Answer: posterior capsular stretching.

Explanation:

Question 69:

Options:

Intracompartmental pressure monitoring
Immobilization of the knee in a flexed position
Fasciotomy of the thigh
MRI scan of the femur This athlete has experienced a quadriceps contusion with hemorrhage and swelling into the anterior compartment of the thigh. Initial treatment for these injuries is immobilization of the knee in flexion to reduce the amount of bleeding into the anterior compartment. Rest and anti-inflammatory medication may be used in the rehabilitation process but should not take the place of immobilization in flexion. The compartments are soft and therefore, there is no indication for fasciotomy. MRI scan of the femur may demonstrate hematoma in the anterior thigh compartment but is not required to make the diagnosis.

Correct Answer: Immobilization of the knee in a flexed position

Explanation:

Question 70:

Options:

traversing L4 nerve root and the patient’s history and examination.
traversing L4 nerve root but inconsistent with the patient’s history and examination.
traversing L5 nerve root and the patient’s history and examination.
traversing L5 nerve root but inconsistent with the patient’s history and examination.
exiting L5 nerve root and the patient’s history and examination.

Correct Answer: traversing L5 nerve root and the patient’s history and examination.

Explanation:

Question 71:

..Staging studies show no other lesions and surgical treatment is planned; when should a biopsy be performed?

Options:

Before surgery
Intraoperatively after instrumentation
After surgery (reamings/curettings sent)
No biopsy is needed DISCUSSION… Patients with a metastatic lung carcinoma are best staged and imaged with a PET scan. Although many tumors are clinically evaluated with PET scans, metastatic lung cancer is one of the few “approved” indications for PET imaging. This imaging modality is sensitive for delineating the extent of disease and helpful for identifying areas that may also be at risk for pathologic fracture. Stabilization of painful, lytic lesions in weight-bearing bones is recommended to prevent pathologic fracture. Stabilization of an impending pathologic fracture is generally easier than stabilization of a pathologic fracture; once the patient in this vignette sustains a fracture, resection and reconstruction is indicated because stabilization alone is unlikely to heal and poses high risk for failure. In cases of extreme bone loss, especially in the epiphyseal region, reconstruction with tumor megaprostheses is desirable to avoid mechanical failure of additional internal fixation. Patients with widely metastatic disease may not be able to use ambulatory assistance aids effectively, placing traditional internal fixation at risk for failure. Use of megaprostheses obviates the need for adjuvant therapies to correct the loss of bone stock. Radiation therapy alone to lesions that are radiosensitive is effective but does not alleviate the risk for pathologic fracture. Chemotherapy alone is insufficient treatment for bone metastases. Hormonal therapy is acceptable for treatment of hormone-sensitive tumors; however, is not sufficient treatment for an impending pathologic fracture. For patients with remote diagnoses of carcinoma, biopsy of new-onset presumed metastases is mandatory to avoid an incorrect treatment regimen being employed. Patients can develop a secondary malignancy or infection, both of which will require a different treatment regimen. Biopsy should be done and diagnosis established either preoperatively or intraoperatively prior to instrumentation (with frozen section analysis) to avoid contamination of the femoral canal and soft-tissue envelope. Sending a specimen after instrumenting the femur or after surgery contaminates the femur if a sarcoma is diagnosed and lessens the likelihood of limb salvage.

Correct Answer: Before surgery

Explanation:

Question 72:

Which of the following statements best describes the instantaneous axis of rotation (IAR) for the functional spinal unit? Review Topic

Options:

The IAR is calculated by movement around six different axes.
The IAR consists of potential movements or 12 degrees of freedom.
The IAR is fixed and consistent and is the axis about which each vertebral segment rotates.
The IAR can be derived from AP and lateral radiographs.
Degenerative disease, fractures, and ligamentous injuries can affect the IAR.

Correct Answer: Degenerative disease, fractures, and ligamentous injuries can affect the IAR.

Explanation:

Question 73:

Options:

Choosing a longer femoral head and accepting a resulting leg-length discrepancy
Trialing a lateralized femoral neck component
Removing the acetabular liner and implanting an offset liner instead
Performing a trochanteric osteotomy with advancement

Correct Answer: Trialing a lateralized femoral neck component

Explanation:

Question 74:

Which of the following conditions is considered a relative contraindication to interscalene nerve block for patients scheduled to undergo shoulder surgery?

Options:

Prior shoulder surgery
History of deep venous thrombosis
Controlled seizure disorder
Respiratory insufficiency
Obesity

Correct Answer: Respiratory insufficiency

Explanation:

DISCUSSION: A common side effect of interscalene nerve block for shoulder surgery is the blockade of the ipsilateral phrenic nerve. This, in turn, results in paresis of the diaphragm and up to a 30% reduction in pulmonary function volumes. Therefore, interscalene nerve block generally is not recommended for patients whose respiratory function is compromised. Other relative and absolute contraindications for interscalene nerve blocks include allergy to local anesthetics, infection at the injection site, uncontrolled seizure disorder, coagulation abnormality, and preexisting neurologic injury.
REFERENCES: Chelly JE: Indications for upper extremity blocks, in Chelly JE (ed): Peripheral Nerve Blocks, ed 2. Philadelphia, PA, Lippincott Williams & Wilkins, 2004, pp 19-27.
Misamore GW, Sallay PI: A prospective analysis of the safety and efficacy of interscalene brachial plexus block anesthesia for shoulder surgery. J Shoulder Elbow Surg 2007;16:e39.

Question 75:

Options:

Electrical stimulation
Bone grafting
No weight bearing
Bone grafting and compression plating
Free vascularized bone transport

Correct Answer: Bone grafting and compression plating

Explanation:

DISCUSSION: Nonunions after intramedullary nails are often treated with exchange reamed nailing. In a recent study, this resulted in a union rate of 53%. After failed exchange nailing, bone grafting and compression plating should be used. The other options resulted in less satisfactory results as compared to bone grafting and compression plating.
REFERENCES: Weresh MJ, Hakanson R, Stover MD, et al: Failure of exchange reamed intramedullary nails for ununited femoral shaft fractures. J Orthop Trauma 2000;14:335-338.
Bellabarba C, Ricci WM, Bolhofner BR: Results of indirect reduction and plating of femoral shaft nonunions after intramedullary nailing. J Orthop Trauma 2001;15:254-263.

Question 76:

Options:

Lumbrical plus deformity
Intrinsic tightness
Quadrigia effect
Proximal interphalangeal joint contracture

Correct Answer: Quadrigia effect

Explanation:

EXPLANATION:
The quadrigia effect can occur due to over-advancement of the FDP tendon during repair (usually greater than 1 cm), development of FDP tendon adhesions, and (as in this case) "over the top" repair of the FDP tendon to the extensor tendon after amputation at the distal phalanx level. All of these conditions result in a functionally shortened FDP tendon of the injured digit. Because the FDP tendons of the long, ring, and small digits share a common muscle belly, excursion of the combined tendons is equal to the shortest tendon. Therefore, the uninjured digits will not have full excursion of their respective FDP tendons and will not be able to close into a full fisting position. Treatment of this condition is most commonly release
of the injured FDP tendon. A lumbrical plus deformity can occur in amputations distal to the flexor digitorum superficialis insertion through the middle phalanx. The FDP tendon retracts and increases tension on the lumbrical muscle, which leads to paradoxical interphalangeal (IP) joint extension with attempted flexion. Intrinsic tightness and interphalangeal joint contractures can be caused by hand trauma
but would not lead to the clinical condition this patient has.

Question 77:

Options:

Aggressive physical therapy
Manipulation under anesthesia
Investigation for periprosthetic infection
Revision knee arthroplasty
Resection arthroplasty

Correct Answer: Investigation for periprosthetic infection

Explanation:

DISCUSSION: Stiffness following total knee arthroplasty can be a disabling condition. There are many reasons for loss of knee motion following total knee arthroplasty. Technical errors, such as overstuffing of the patella, malpositioning of the components, and ligamentous imbalance, are all known to result in stiffness following total knee arthroplasty. In some patients with a possible genetic predisposition, aggressive arthrofibrosis may develop and result in loss of knee motion. In any patient who has deteriorating knee motion, particularly after revision arthroplasty, deep infection should be ruled out. Although on occasion surgical intervention may be required to address knee stiffness, the outcome of revision surgery is poor if no reason for stiffness can be determined.
REFERENCES: Kim J, Nelson CL, Lotke PA: Stiffness after total knee arthroplasty: Prevalence of the complication and outcomes of revision. J Bone Joint Surg Am 2004;86:1479-1484.
Gonzalez MH, Mekhail AO: The failed total knee arthroplasty: Evaluation and etiology. J Am Acad Orthop Surg 2004;12:436-446.

Question 78:

A 37-year-old laborer falls 12 feet and sustains a comminuted tibial plafond fracture. Three years after treatment using standard techniques, what will be the most likely outcome?

Options:

Need for ankle fusion or arthroplasty
Return to normal function
Ankle stiffness without pain
Severe constant pain and inability to work
Adversely affected general health status and posttraumatic arthritis

Correct Answer: Adversely affected general health status and posttraumatic arthritis

Explanation:

Question 79:

Options:

Ulnar nerve neuritis
Triceps insufficiency
Aseptic loosening
Instability
Infection

Correct Answer: Triceps insufficiency

Explanation:

Question 80:

Options:

Hindfoot valgus
Midfoot supination
Sinus tarsi impingement
Anterior ankle impingement
Hammertoe deformity

Correct Answer: Hindfoot valgus

Explanation:

Question 81:

- Which of the following nerves supply the muscles on each side of internervous plane identified when performing the anterior (Smith-Petersen) approach to the hip?

Options:

Femoral and obturator nerves
Femoral and superior gluteal nerves
Femoral and lateral femoral cutaneous nerves
Obturator and superior gluteal nerves
Obturator and lateral femoral cutaneous nerves

Correct Answer: Femoral and superior gluteal nerves

Explanation:

Question 82:

Options:

Conversion to a latissimus dorsi muscle tendon transfer
Acromioplasty and coracoacromial ligament release
Reverse acromioplasty (tuberoplasty)
Reverse total shoulder arthroplasty
Partial repair of the rotator cuff

Correct Answer: Partial repair of the rotator cuff

Explanation:

Question 83:

What are the most likely symptoms and examination findings related to the mass in zone 2 of Guyon’s canal seen in Figure 17?

Options:

Numbness and tingling in the little finger and the ulnar side of the ring finger
Weakness and atrophy of the first dorsal interosseous
Hypothenar muscle atrophy
Dorsal ulnar hand numbness and tingling
Weakness of the interossei of the hand and numbness and tingling of the little finger and the ulnar side of the ring finger

Correct Answer: Weakness and atrophy of the first dorsal interosseous

Explanation:

DISCUSSION: The lesion lies in zone II of the ulnar tunnel. In that zone the deep motor branch of the ulnar nerve is susceptible to compression. Distal to the hook of the hamate, the motor branch of the ulnar nerve dives deep to innervate the interossei as it begins to move from an ulnar to radial direction. Because of its course, it has little or no give in response to a mass effect from the floor of Guyon’s canal. Ganglions are the most common cause of ulnar nerve entrapment in the wrist. Lesions in zone I can affect both sensory and motor aspects of the ulnar nerve as well as the motor innervation of the hypothenar muscles. Lesions at the elbow or mid-to-proximal forearm are associated with dorsal hand numbness and tingling.
REFERENCES: Kuschner SH, Gelberman RH, Jennings C: Ulnar nerve compression at the wrist. J Hand Surg Am 1988;13:577-580.
Posner MA: Compressive neuropathies of the ulnar nerve at the elbow and wrist. Instr Course Lect 2000;49:305-317.

Question 84:

A 72-year-old man with diabetic neuropathy and 5 degrees of valgus talar tilt; he has pursued nonsurgical treatment for 30 years and now has unrelenting pain

Options:

Ankle replacement
Ankle fusion
Tibiotalocalcaneal fusion
Total contact cast
Intra-articular steroid injection

Correct Answer: Ankle fusion

Explanation:

DISCUSSION
Arthritis of the ankle and hindfoot can pose challenges. Depending upon patient age, comorbidities, and alignment, a variety of surgical interventions may be offered. A total ankle replacement may be considered for patients older than 60 years of age who have minimal misalignment and low-demand lifestyles. In all other cases, ankle fusion must be considered. The nonsurgical care of ankle arthritis includes anti-inflammatory medication, intra-articular steroid injections, bracing with customized products such as the Arizona brace, or a molded foot and ankle orthosis.
Patients with diabetes and Charcot arthropathy may be treated nonsurgically with total-contact casting during acute and active or "hot" phases and accommodative shoes during consolidation and stable or "cool" phases. When the patient has recurrent ulcers or major anatomy changes, surgical intervention must be considered. Tibiotalocalcaneal fusion helps to realign the foot and ankle and make it more braceable in the setting of ankle and hindfoot Charcot disease.
RECOMMENDED READINGS
Queen RM, Adams SB Jr, Viens NA, Friend JK, Easley ME, Deorio JK, Nunley JA. Differences in outcomes following total ankle replacement in patients with neutral alignment compared with tibiotalar joint malalignment. J Bone Joint Surg Am. 2013 Nov 6;95(21):1927-34. doi: 10.2106/JBJS.L.00404. PubMed PMID: 24196462.
View Abstract at PubMed
Nunley JA, Caputo AM, Easley ME, Cook C. Intermediate to long-term outcomes of the STAR Total Ankle Replacement: the patient perspective. J Bone Joint Surg Am. 2012 Jan 4;94(1):43-8. doi: 10.2106/JBJS.J.01613. PubMed PMID: 22218381.
View Abstract t
PubMed
Saltzman CL, Mann RA, Ahrens JE, Amendola A, Anderson RB, Berlet GC, Brodsky JW, Chou LB, Clanton TO, Deland JT, Deorio JK, Horton GA, Lee TH, Mann JA, Nunley JA, Thordarson DB, Walling AK, Wapner KL, Coughlin MJ. Prospective controlled trial of STAR total ankle replacement versus ankle fusion: initial results. Foot Ankle Int. 2009 Jul;30(7):579-96. doi: 10.3113/FAI.2009.0579. PubMed PMID: 19589303.
View Abstract at
PubMed
Faraj AA, Loveday DT. Functional outcome following an ankle or subtalar arthrodesis in adults. Acta Orthop Belg. 2014 Jun;80(2):276-9. PubMed PMID: 25090803.
View Abstract at PubMed
Grear BJ, Rabinovich A, Brodsky JW. Charcot arthropathy of the foot and ankle associated with rheumatoid arthritis. Foot Ankle Int. 2013 Nov;34(11):1541-7. doi: 10.1177/1071100713500490. Epub 2013 Jul 30. PubMed PMID: 23900228.
View Abstract at
PubMed

Question 85:

Options:

Anteroinferior labrum from the bony glenoid
Anteroinferior labrum from the cartilaginous surface of the glenoid
Biceps tendon from its origin on the supraglenoid tubercle
Anterior capsule from the proximal humerus
Posteroinferior labrum from the bony glenoid

Correct Answer: Anteroinferior labrum from the bony glenoid

Explanation:

Question 86:

All of the following techniques can help to prevent apex-anterior angulation during intramedullary nailing of proximal one-third tibia fractures EXCEPT:

Options:

posterior blocking screw
posterior starting hole
interlocking the nail in a semi-extended knee position
anteriorly directing the nail
anterior blocking screw

Correct Answer: posterior blocking screw

Explanation:

Question 87:

Options:

Hard cervical orthosis
Immobilization in cervico-thoraco-lumbo-sacral orthosis
Anterior decompression and fusion of C4-C7
Posterior decompression and fusion of C5-C6
Posterior decompression and fusion of C3-T2

Correct Answer: Hard cervical orthosis

Explanation:

Question 88:

Options:

Observation
Incisional biopsy
Excisional biopsy
MRI
Ultrasound

Correct Answer: Observation

Explanation:

Question 89:

What factor highly correlates with poor outcomes after surgery for femoroacetabular impingement? Review Topic

Options:

Age younger than 20
Degenerative arthritis
Prominence of the femoral head in cam impingement
The patient is a professional athlete

Correct Answer: Degenerative arthritis

Explanation:

Question 90:

Options:

Remove the total ankle and place an antibiotic spacer
Debride and exchange polyethylene
Perform a below-the-knee amputation
Convert to a fusion with an intercalary allograft

Correct Answer: Debride and exchange polyethylene

Explanation:

Question 91:

Options:

Long thoracic
Suprascapular
Spinal accessory
Axillary
Thoracodorsal

Correct Answer: Spinal accessory

Explanation:

Question 92:

Options:

Type 2 tear of the superior labrum anterior and posterior
Tear of the anterior labrum
Tear of the subscapularis tendon
Tear of the latissimus dorsi tendon
Tear of the supraspinatus tendon

Correct Answer: Tear of the latissimus dorsi tendon

Explanation:

DISCUSSION: Injury to the latissimus dorsi tendon recently has been reported as a cause of pain in the thrower’s shoulder. The etiology of this injury is felt to be eccentric overload during the follow-through of the throwing motion. Recommended management for this unusual injury consists of a short period of rest, followed by physical therapy to restore shoulder motion and strength. Throwing is allowed when the athlete demonstrates full, pain-free motion and good strength and balance of the rotator cuff and scapular rotator muscles. Currently there are no defined indications for surgical repair.
REFERENCES: Schickendantz MS, Ho CP, Keppler L, et al: MR imaging of the thrower’s shoulder: Internal impingement, latissimus dorsi/subscapularis strains and related injuries.
Magn Reson Imaging Clin N Am 1999;7:39-49.
Livesey JP, Brownson P, Wallace WA: Traumatic latissimus dorsi: Tendon rupture. J Shoulder Elbow Surg 2002;11:642-644.

Question 93:

When using highly cross-linked ultra-high molecular weight polyethylene as an articulating surface for total knee arthroplasty, what property of the material raises concern?

Options:

Decreased volumetric wear
Decreased ductility
Increased mobility of the ultra-high molecular weight polyethylene chains in the material
Increased fatigue resistance
Increased fracture toughness

Correct Answer: Decreased ductility

Explanation:

Question 94:

A Trendelenburg gait is most likely to be seen in association with

Options:

a central disk herniation at L3-L4.
an ipsilateral paracentral disk herniation at L3-L4.
an ipsilateral paracentral disk herniation at L4-L5.
an ipsilateral paracentral disk herniation at L5-S1.
an ipsilateral far lateral disk herniation at L4-L5.

Correct Answer: an ipsilateral paracentral disk herniation at L4-L5.

Explanation:

Question 95:

Options:

a skeletal survey to rule out other fractures.
a punch biopsy of the skin for collagen analysis to rule out osteogenesis imperfecta.
DNA testing for osteogenesis imperfecta.
blood studies for calcium, phosphorus, and alkaline phosphate levels.
blood studies for parathyroid hormone levels.

Correct Answer: a skeletal survey to rule out other fractures.

Explanation:

DISCUSSION: Unwitnessed spiral fractures should raise the possibility of child abuse, especially prior to walking age. With nonaccidental trauma being considered in the differential diagnosis, a skeletal survey is indicated to determine if there are other fractures in various stages of healing.
REFERENCES: Kempe CH, Silverman FN, Steele BF, et al: The battered-child syndrome. JAMA 1962;181:17-24.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 3, pp 2079-2082.

Question 96:

Options:

Pseudotumor from a local reaction to metal debris from the bearing surface
Chronic periprosthetic infection
Impingement of the femoral neck on the edge of the cup
Referred pain from lumbar disk disease

Correct Answer: Pseudotumor from a local reaction to metal debris from the bearing surface

Explanation:

Question 97:

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

Options:

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

Correct Answer: An infraspinatus-splitting approach

Explanation:

Question 98:

A 45-year-old diabetic woman with a gangrenous foot undegoes a Chopart amputation without tendon transfer or lengthening. Which type of deformity is the most likely complication of this procedure?

Options:

Valgus deformity
Varus deformity
Equinus deformity
Cavus deformity
Planus deformity

Correct Answer: Valgus deformity

Explanation:

Question 99:

Options:

Calcific tendinitis
Poliomyelitis
Diskogenic cervical spine disease
Impingement
Brachial neuritis

Correct Answer: Brachial neuritis

Explanation:

Question 100:

Options:

pneumatic compression stockings.
subcutaneous heparin administration.
a heparin bolus followed by therapeutic heparin anticoagulation.
warfarin anticoagulation.
placement of a vena cava filter.

Correct Answer: placement of a vena cava filter.

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

Orthopedic Surgery MCQ Mock Exam: Fracture, Hip & Nerve Review | Part 191

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 191

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index