Orthopedic Board Review MCQs: OITE & AAOS | Part 195

About This Board Review Set

This is Part 195 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 195

This module focuses heavily on: Ankle, Arthroplasty, Deformity, Foot, Trauma, Wrist.

Sample Questions from This Set

Sample Question 1: An 18-year-old high school football player exits the field after making a tackle on the opening kickoff. He reports “feeling out of it” and states that he has a headache. He does not recall any loss of consciousness and has no amnesia. He i...

Sample Question 2: What is the primary indication for performing a total wrist arthroplasty in a patient with painful rheumatoid arthritis?...

Sample Question 3: -A form of renal osteodystrophy that is characterized by pure osteomalacia is caused by...

Sample Question 4: A 14-year-old boy has medial ankle pain, progressive unilateral flatfoot deformity, and pain with most activities of daily living. He denies any recent injury. His parents recall that at age 7 years he sustained an injury that was treated a...

Sample Question 5: When balancing gaps in the coronal plane, what structure preferentially impacts the flexion space more than the extension space?...

Why Active MCQ Practice Works

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

Comprehensive 100-Question Exam

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Question 1

An 18-year-old high school football player exits the field after making a tackle on the opening kickoff. He reports “feeling out of it” and states that he has a headache. He does not recall any loss of consciousness and has no amnesia. He is unable to list the months of the year in reverse order on questioning. He does not return to the game and feels normal at the completion of the game. What is the most sensitive test in assessing deficits after mild traumatic brain injury?

Explanation

DISCUSSION: Most imaging studies in mild traumatic brain injury will be normal. Neuropsychologic testing is the most sensitive test in assessing mild deficits after traumatic brain injury. Sideline assessment is important but less sensitive in assessing deficits. The precise role of neuropsychologic testing in determining return to play has not been fully defined.
REFERENCES: Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 37-38.
62 • American Academy of Orthopaedic Surgeons
Maroon JC, Lovell MR, Norwig J, et al: Cerebral concussion in athletics: Evaluation and neuropsychological testing. Neurosurgery 2000;47:659-672.

Question 2

What is the primary indication for performing a total wrist arthroplasty in a patient with painful rheumatoid arthritis?

Explanation

The most conservative indications for a total wrist arthroplasty are to spare motion on one side and to improve activities of daily living. Component loosening, dislocation, and wound problems are frequent. Suitable patients can be of various ages, wrist motion, and radiographic stages of arthritis. Ipsilateral total elbow arthroplasty, type III degenerative changes of the wrist, age older than 55, and limited range of motion are neither primary indications nor contraindications to a total wrist arthroplasty.

Question 3

A form of renal osteodystrophy that is characterized by pure osteomalacia is caused by

Explanation

There are many causes of rickets and osteomalacia. Renal osteodystrophy is a common complication of chronic renal failure and is one of the most common causes of osteomalacia. Pure osteomalacia is caused by the aluminum in phosphate binders used to treat hyperphosphatemia in renal failure. Desferoxamine is an effective chelator of aluminum in patients with biopsy documented aluminum-associated osteomalacia. Pure osteomalacia also can be caused by hypophosphatemia. The other choices are part of the mechanism of bone changes in renal osteodystrophy.

Question 4

A 14-year-old boy has medial ankle pain, progressive unilateral flatfoot deformity, and pain with most activities of daily living. He denies any recent injury. His parents recall that at age 7 years he sustained an injury that was treated as a sprain. Examination reveals valgus deformity with painless, unrestricted passive motion of the ankle. He has grossly equal limb lengths. A radiograph of the affected ankle is shown in Figure 48a, and the contralateral ankle is shown in Figure 48b. Management should consist of

Explanation

DISCUSSION: Angular deformities of the ankle can occur following physeal injury. While an orthosis may be beneficial, the deformity is at the level of the ankle rather than the hindfoot. An epiphysiodesis or physeal bar resection would not be indicated as the growth plates are closed. Correction of the angular deformity should level the ankle joint and normalize the weight-bearing stresses on the ankle. This is most easily achieved with a closing wedge distal tibial osteotomy with or without concomitant osteotomy of the fibula.
REFERENCES: Thompson DM, Calhoun JH: Advanced techniques in foot and ankle reconstruction. Foot Ankle Clin 2000;5:417-442.
Ting AJ, Tarr RR, Sarmiento A, Wagner K, Resnick C: The role of subtalar motion and ankle contact pressure changes from angular deformities of the tibia. Foot Ankle 1987;7:290-299.
Tarr RR, Resnick CT, Wagner KS, Sarmiento A: Changes in tibiotalar joint contact areas following experimentally induced tibial angular deformities. Clin Orthop 1985;199:72-80.

Question 5

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

Explanation

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

Question 6

A 33-year-old woman sustains a C6 burst fracture diving into a swimming pool, resulting in a complete spinal cord injury. The canal compromise is shown in Figures 8a and 8b. Functional recovery would be maximized with

Explanation

DISCUSSION: Although the patient has sustained a complete spinal cord injury, an anterior decompression, even performed late, can gain an additional level of root function. In the quadriplegic patient, this can mean the difference between dependent and independent function. Posterior procedures do not afford adequate access to the retropulsed bony fragments compromising the canal.
REFERENCES: Bohlman HH, Anderson PA: Anterior decompression and arthrodesis of the cervical spine: Long-term motor improvement. Part I: Improvement in incomplete traumatic quadriparesis. J Bone Joint Surg Am 1992;74:671-682.
Benz R, Abitbol JJ, Ozanne S, Garfin SR: Cervical burst fractures, in Levine AM, Eismont FJ, Garfin SR, Zigler JE (eds): Spine Trauma. Philadelphia, PA, WB Saunders, 1998, pp 300-330.

Question 7

A 52-year-old woman who is right hand-dominant sustains an injury to her elbow in a fall. A radiograph is shown in Figure 60. The preferred treatment of this injury pattern should include

Explanation

DISCUSSION: The patient has a Bado type 2 variant Monteggia fracture with a radial head fracture. The type 2 variant is associated with a higher nonunion rate and poorer outcomes compared to other Bado-type Monteggia fractures. While it is potentially acceptable to repair the radial head, factors such as higher degrees of comminution and older age lead toward replacement as the treatment of choice. Plate and screw fixation is favored over Kirschner wire/tension band fixation because this is not a simple olecranon fracture. Plate placement in a type 2 fracture is dorsal to counteract very high tensile forces associated with fixation failure.
REFERENCES: Egol KA, Tejwani NC, Bazzi J, et al: Does a Monteggia variant lesion result in a poor functional outcome? A retrospective study. Clin Orthop Relat Res 2005;438:233-238.
Jupiter JB, Leibovic SJ, Ribbans W, et al: The posterior Monteggia lesion. J Orthop Trauma 1991;5:395-402.
Konrad GG, Kundel K, Kreuz PC, et al: Monteggia fractures in adults: Long-term results and prognostic factors. J Bone Joint Surg Br 2007;89:354-360.

Question 8

A 50-year-old patient underwent multiple debridements for an open radial shaft fracture with bone loss. The bed currently shows no evidence of infection but has a 14-cm diaphyseal bone defect. The most appropriate treatment includes open reduction and internal fixation along with

Explanation

The decision to perform fasciotomy of the fingers for a hand compartment syndrome is most appropriately made using
A. clinical examination.
B. invasive pressure measurement.
C. arterial Doppler study.
D. MRI.
Compartment syndrome of the hand can result from a variety of factors, including a traumatic event such as crush injury, fracture, vascular insult, a high-pressure injection injury, or an insect or spider bite. The treatment involves decompressive fasciotomy of the involved compartments. The diagnosis of hand compartment syndrome is determined by history, examination, and objective testing. Patients experience pain out of proportion to the injury, along with swelling and tense skin. Pain may occur with passive motion of the metacarpophalangeal joints as the intrinsic muscles are stretched. Invasive intracompartmental pressures can be measured in the compartments of the hand but not in the fingers. Arterial Doppler studies assess arterial blood flow,
and an abnormality would be a late finding. 41
MRI would show edema of the hand and fingers, but the decision to perform surgical release is less likely made from the findings. The most appropriate method of determining the need for finger fasciotomy is the history and physical examination.
45- Figures 1 and 2 show the MRI studies of a 35-year-old manual laborer with persistent wrist pain despite immobilization. At the time of surgery, collapse of the capitate and arthritic changes of the midcarpal joint are noted. What is the most appropriate procedure for this condition?
A. Local vascularized bone graft
B. Proximal row carpectomy
C. Midcarpal fusion
D. Total wrist arthroplasty
The T1-weighted MRI reveals decreased signal that is consistent with avascular necrosis (AVN) of the capitate. Figure 2 demonstrates increased signal of the capitate consistent with edema. The etiology of AVN of the capitate may be related to trauma, abnormal interosseous vascular supply, and hypermobility. Surgical treatment is considered for patients who have had persistent symptoms despite immobilization. At the time of surgery, collapse of the capitate and arthritic changes would be treated most appropriately with a salvage procedure. A midcarpal fusion is a motion-preserving salvage procedure and is the most appropriate option given to address the pain associated with the midcarpal arthritic changes. The alternative options are not appropriate for this patient. Local vascularized bone grafts are considered for situations in which no evidence of capitate collapse or arthritis is observed.

Question 9

A healthy, active year-old man trips and falls, landing on his left hip 10 weeks after an uncomplicated left primary uncemented total hip replacement. A radiograph taken 6 weeks after surgery and before the fall is shown in A radiograph taken after the fall is shown in He is unable to bear weight and is brought to the emergency department. Examination reveals a slightly shortened left lower extremity and some mild ecchymosis just distal to the left greater trochanteric region, but his skin is intact, without abrasions or lacerations. What is the most appropriate treatment?

Explanation

DISCUSSION:
This patient has a periprosthetic femoral fracture with a loose femoral stem and normal femoral bone stock, representing a Vancouver type B2 fracture. The most appropriate treatment is fixation of the fracture, along with revision of the stem. Considering his age, bone quality, and activity level, a longer uncemented stem is most predictable. Although a cylindrical stem may also be used, the fluted stem option is the only uncemented choice listed and is the most appropriate option. A cemented stem is a poorer choice because it is difficult to keep the cement out of the fracture site, which would pose a risk for nonunion at the fracture. Also, overall poorer results have been associated with long cemented stems in healthy, active people. Surgery does not need to be delayed to allow the ecchymosis to resolve, and simple open reduction and fixation does not address the loose stem.

Question 10

The superior glenohumeral ligament primarily restrains

Explanation

DISCUSSION: Several cutting studies have evaluated the primary static restraints and the role of the glenohumeral ligaments in providing static stability. With the arm at the side in adduction, the superior glenohumeral ligament and coracohumeral ligament are the primary restraints to inferior translation. The middle glenohumeral ligament functions with the arm in 45 degrees of abduction and resists anterior translation. The inferior glenohumeral ligament is the primary restraint to anterior translation at 90 degrees of abduction.
REFERENCES: Warner JJ, Deng XH, Warren RF, et al: Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint. Am J Sports Med 1992;20:675-685.
Griffin LY (ed): Orthopaedic Knowledge Update: Sports Medicine. Rosemont, IL, American Academy Orthopaedic Surgeons, 1994, pp 165-177.

Question 11

A 19-year-old girl has had pain and swelling in the right ankle for the past 4 months. She denies any history of trauma. Examination reveals a small soft-tissue mass over the anterior aspect of the ankle and slight pain with range of motion of the ankle joint. The examination is otherwise unremarkable. A radiograph and MRI scan are shown in Figures 45a and 45b, and biopsy specimens are shown in Figures 45c and 45d. What is the most likely diagnosis?

Explanation

DISCUSSION: Giant cell tumors typically occur in a juxta-articular location involving the epiphysis and metaphysis of long bones, usually eccentric in the bone. The radiographs show a destructive process within the distal tibia and an associated soft-tissue mass. The histology shows multinucleated giant cells in a bland matrix with a few scattered mitoses. Osteosarcoma can have a similar destructive appearance but a very different histologic pattern with osteoid production. Ewing’s sarcoma also can have a diffuse destructive process in the bone. The histologic pattern of Ewing’s sarcoma is diffuse round blue cells. Aneurysmal bone cysts typically are seen as a fluid-filled lesion on imaging studies and have only a scant amount of giant cells histologically. Metastatic adenocarcinoma does not demonstrate the pattern shown in the patient’s histology specimen.
REFERENCES: Wold LA, et al: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990, pp 198-199.
Simon M, et al: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, pp 200-202.

Question 12

A 43-year-old man sustained a closed, intra-articular pilon fracture. It has now been 1 year since he underwent open reduction and internal fixation. Which of the following statements most accurately describes his perceived outcome? Review Topic

Explanation

Marsh and associates retrospectively reviewed 56 tibial plafond fractures and found that the patients perceived improvement in their function and pain for an average of

Question 13

A football player sustains a traumatic anterior inferior dislocation of the shoulder in the last game of the season. It is reduced 20 minutes later in the locker room. The patient is neurologically intact and has regained motion. If the patient undergoes arthroscopic evaluation, what finding is seen most consistently?

Explanation

DISCUSSION: In an acute first-time dislocation, arthroscopy has been shown to reveal a Bankart lesion in most shoulders. The classic finding of labral detachment from the anterior inferior glenoid along with occasional hemorrhage within the inferior glenohumeral ligament is the most common sequelae of a traumatic anterior inferior dislocation. Acute treatment, if chosen, is repair of the labral tissue back to the glenoid plus or minus any capsular plication to address potential plastic deformation of the glenohumeral ligament. Acute treatment of a patient sustaining a first-time dislocation remains controversial. The potential indications may be patients whose dislocation occurs at the end of a season and when the desire to minimize risk of future instability outweighs the risks of surgical intervention.
REFERENCES: Taylor DC, Arciero RA: Pathologic changes associated with shoulder dislocations: Arthroscopic and physical examination findings in first-time, traumatic anterior dislocations. Am J Sports Med 1997;25:306-311.
DeBerardino TM, Arciero RA, Taylor DC, et al: Prospective evaluation of arthroscopic stabilization of acute, initial anterior shoulder dislocations in young athletes: Two- to five-year follow-up. Am J Sports Med 2001;29:586-592.
Bottoni CR, Wilckens JH, DeBerardino TM, et al: A prospective, randomized evaluation of arthroscopic stabilization versus nonoperative treatment in patients with acute, traumatic,

first-time shoulder dislocations. Am J Sports Med 2002;30:576-580.

Question 14

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

Explanation

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

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

Question 15

Which of the following radiographic parameters is most predictive of a poor result following multilevel fusion surgery for adult degenerative scoliosis? Review Topic

Explanation

Sagittal imbalance appears to be the greatest predictor of a poor surgical outcome in multilevel fusions for adult scoliosis. Coronal imbalance is better tolerated as long as it is not excessive. The amount of residual scoliosis does not seem to play a role as long as overall balance is achieved. The issue of including the L5-S1 level in long fusions remains debatable, and some residual foraminal stenosis can be tolerated, particularly when included within the stabilized/fused segments.

Question 16

Which of the following hip fracture patterns is at increased risk of proximal fragment flexion malreduction with dynamic hip screw fixation?

Explanation

DISCUSSION: Left-sided unstable intertrochanteric hip fractures are at increased risk of malreduction compared to unstable right-sided fractures fixed with dynamic hip screws. In left-sided fractures the rotational torque imparted to the proximal head and neck fragment can cause loss of reduction leading to potential failures of fixation. With these left sided injuries, the rotational torque can cause an anterior spike, whereas with right-sided injuries the rotational torque causes compression and reduction of the fracture. In addition, if a nail is used for these injuries and the proximal fracture fragment is not being held by the nail itself, this phenomenon can be seen as well.
Mohan et al conducted a study to assess the effect of clockwise rotational torque onto the fracture configuration in unstable and stable intertrochanteric fractures fixed with a dynamic hip screw construct. They found that 11 out of 30 unstable fractures showed an anterior spike (flexion malreduction) in left-sided fixations due to clockwise torque. This malreduction was not present in right-sided or stable fractures.

Question 17

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

Explanation

Increased immobilization and delayed weight bearing are indicated in the neuropathic population after treating an ankle fracture. Patients with diabetes mellitus and peripheral neuropathy have higher complication rates following ankle fractures treated surgically or nonsurgically. The elevated HgbA1c and neuropathy both predict a higher complication rate with this fracture. Outcomes after nonsurgical management of this fracture are poorer than after surgical treatment. Early bone grafting is not recommended in closed fractures, but the use of supplemental internal fixation is recommended because of the high risk of nonunion. More substantial constructs with supplemental fixation, locking fixation, fixation through the calcaneus and talus into the tibia, or external fixation are necessary. Primary arthrodesis is not recommended in this fracture pattern or in a relatively active patient.

Question 18

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

Explanation

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

Question 19

What is the most common neurologic complication following an anterior cervical diskectomy and fusion?

Explanation

DISCUSSION: The recurrent laryngeal nerve provides innervation to the vocal cords and was the most common neurologic injury reported in a series of 36,000 patients. The nerve is felt to be more vulnerable during a right-sided approach because of its anatomic course. A recent study has also suggested a role for increased endotracheal cuff pressures in this nerve injury.
REFERENCES: Flynn TB: Neurologic complications of anterior cervical interbody fusion. Spine 1982;7:536-539.
Apfelbaum RI, Kriskovich MD, Haller JR: On the incidence, cause, and prevention of recurrent laryngeal nerve palsies during anterior cervical spine surgery. Spine 2000;25:2906-2912.

Question 20

A 72-year-old man with a history of Parkinson’s disease, stable coronary artery disease, and mild renal insufficiency is seen for hip arthroplasty. Which of the following is considered the most appropriate bearing of choice?

Explanation

DISCUSSION: The most appropriate bearing of those listed would be a large diameter metal head on cross-linked polyethylene. Because of the renal insufficiency, metal-on-metal should be avoided because metal ions are renally excreted. Ceramic-on-ceramic implants are not necessary in this patient because of the patient’s limited activity and life expectancy, as well as the downside of increased cost, the small but definite risk of ceramic fracture, and the increased technical demands of inserting ceramic implants. A highly cross-linked liner is favored to allow for maximum head size as the patient may be at increased risk of dislocation because of his neurologic disorder.
REFERENCES: Bragdon CR, Greene ME, Freiberg AA, et al: Radiostereometric analysis comparison of wear of highly cross-linked polyethylene against 36- vs 28-mm femoral heads. J Arthroplasty 2007;22:125-129.
MacDonald SJ: Metal-on-metal total hip arthroplasty: The concerns. Clin Orthop Relat Res 2004;429:86- 93.

Question 21

A 21-year-old man has had posterior neck discomfort for the past 6 months. A whole-body bone scan and a cervical single-photon emission CT reveal increased activity at the C7 spinous process. MRI reveals multifocal involvement of the spinous process lamina and facet of C7. A CT-directed needle biopsy reveals osteoblastoma. What is the best course of action?

Explanation

DISCUSSION: En bloc excision is the recommended treatment of osteoblastoma. Treatment should consist of en bloc removal of the lamina, facet, and spinous process. Facet removal would necessitate fusion. Radiation therapy is not recommended. Intralesional curettage has a high rate of recurrence.
REFERENCES: Bridwell KH, Ogilvie JW: Primary tumors of the spine, in Bridwell KH, DeWald RL (eds): The Textbook of Spinal Surgery. Philadelphia, PA, JB Lippincott, 1991, vol 2, pp 1143-1174.
Ozaki T, Liljenquist U, Hillmann A, et al: Osteoid osteoma and osteoblastoma of the spine: Experience with 22 patients. Clin Orthop 2002;397:394-402.

Question 22

A year-old active woman undergoes elective total hip replacement in which a posterior approach is used. She has minimal pain and is discharged to home 2 days after surgery. Four weeks later, she dislocates her hip while shaving her legs. She undergoes a closed reduction in the emergency department. Postreduction radiographs show a reduced hip with well-fixed components in satisfactory alignment. What is the most appropriate management of this condition from this point forward?

Explanation

DISCUSSION:
First-time early dislocations are often treated successfully without revision surgery, especially when no component malalignment is present. In this clinical scenario, it appears the patient would benefit from better education about dislocation precautions. Hip orthoses are of questionable benefit unless the patient is cognitively impaired. Revision surgery can be successful but is usually reserved for patients with recurrent dislocations.

Question 23

A radiograph, MRI scans, and a biopsy specimen of a 9-year-old boy with thigh pain are shown in Figures 37a through 37d. Management should consist of

Explanation

DISCUSSION: The patient has Ewing’s sarcoma. Management options for local tumor control include radiation therapy, resection, or a combination; however, in this patient wide resection is preferred over radiation therapy. Radiation therapy is associated with damage to the growth plate, pathologic fracture, radiation-induced sarcomas, and a local recurrence rate of approximately 10% to 12%. Radiation therapy is used for positive margins, unresectable tumors, or for tumors that have a poor response to chemotherapy. Amputation is not necessary since the tumor is resectable. Chemotherapy has improved overall survival rates to over 60% of patients.
REFERENCES: Sailer SL: The role of radiation therapy in localized Ewing’ sarcoma. Semin Radiat Oncol 1997;7:225-235.
Shankar AG, Pinkerton CR, Atra A, Ashley S, Lewis I, Spooner D, et al: Local therapy and other factors influencing site of relapse in patients with localised Ewing’s sarcoma. United Kingdom Children’s Cancer Study Group (UKCCSG). Eur J Cancer 1999;35:1698-1704.
Carrie C, Mascard E, Gomez F, Habrand JL, Alapetite C, Oberlin O, et al: Nonmetastatic pelvic Ewing sarcoma: Report of the French society of pediatric oncology. Med Pediatr Oncol 1999;33:444-449.
Terek RM, Brien EW, Marcove RC, Meyers PA, Lane JM, Healey JH: Treatment of femoral Ewing’s sarcoma. Cancer 1996;78:70-78.

Question 24

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

Explanation

DISCUSSION: The projection of the sacroiliac joint on the outer surface of the ilium should be well understood to avoid violation of the joint during bone graft harvesting and to help in insertion of the screw across the joint. The sacroiliac joint has superior and inferior limbs. The average lengths of the superior and inferior limbs are 4.4 cm and 5.6 cm, respectively. The average width of each limb is 2.0 cm. The average distance from the longitudinal axis of the superior limb to the posterior superior iliac spine is 5.5 cm. The average longitudinal axis of the inferior limb is 1.2 cm superior to the inferior margin of the posterior inferior iliac spine. The average angle between the two axes is 93 degrees. Figure 21c most closely shows the projection of the sacroiliac joint on the outer table of the ilium.
REFERENCES: Waldrop JT, Ebraheim NA, Yeasting RA, Jackson WT: The location of the sacroiliac joint on the outer table of the posterior ilium. J Orthop Trauma 1993;7:510-513.
Xu R, Ebraheim NA, Yeasting RA, Jackson WT: Anatomic considerations for posterior iliac bone harvesting. Spine 1996;21:1017-1020.

Question 25

below show the radiographs obtained from a year old man with progressively worsening right side hip pain over the last 8 months. He is 6 feet tall, with a BMI of 51 kg/m 2 and reports that his index total hip arthroplasty was performed 8 years ago. The preoperative work-up includes negative infectious laboratory results. What is the most appropriate surgical plan for revision of the femoral component in this patient?

Explanation

DISCUSSION:
Submit Answer
The patient’s radiographs demonstrate varus femoral remodeling around a broken cylindrical, distally fixed femoral stem. Proximal femoral remodeling around loose or fractured stems occurs in 21% to 42% of femoral revisions, based on the definitions outlined by Foran and associates. In definition 1, varus femoral remodeling occurs when the template falls within 2 mm of the endosteal cortex of the metaphysis on templating with a diaphyseal engaging stem. In definition 2, varus femoral remodeling = when the template crosses the lateral femoral cortex proximally. Based on the templating or drawing a line from the isthmus proximally along the lateral cortex, implantation of a straight stem would perforate the cortex proximally, indicating varus femoral remodeling. An extended trochanteric osteotomy would aid in the removal of the well-fixed distal segment and enable the safe insertion of the new femoral component. The approach is not the concern in this case, because extended trochanteric osteotomies have been described from the posterior and direct lateral approaches with excellent outcomes and union rates. The key is that the extended osteotomy is necessary and not a trochanteric slide or standard (shorter or incomplete trochanteric) osteotomy. These types would not provide access to the well-fixed distal stem, nor would they afford a straight tube in which to insert a new femoral component.

Question 26

Figures 34a through 34c show an axial proton density (spin echo long TR, short TE) image, a sagittal inversion recovery (STIR) image, and a sagittal T1-weighted (short TR, short TE) image of the left thigh. What is the most likely diagnosis?

Explanation

DISCUSSION: The images reveal a region of increased signal within the rectus femoris muscle with mild, ill-defined surrounding edema. The presence of high intensity signal on the T1-weighted image favors acute blood, in this case associated with a rectus femoris muscle tear or fatty tissue. However, because of fat suppression, a fatty lesion or lipoma would be dark on STIR, rather than bright as in this image. Most foreign bodies are low intensity signal and if small, are difficult to evaluate with MRI. The lack of adjacent subcutaneous soft-tissue edema or surrounding fluid makes pyomyositis an unlikely diagnosis.
REFERENCE: El-Khoury G: MRI of the Musculoskeletal System. Philadelphia, PA, JB Lippincott, 1998, p 123.

Question 27

The afferent pain innervation of the L3-L4 facet joint arises from the medial branch nerve of

Explanation

DISCUSSION: Afferent pain fibers to the lumbar facet joints arise from the medial branch nerves originating from the next two cephalad levels. Therefore, innervation of the L3-L4 facet joint arises from the L2 and L3 medial branch nerves. This effect should be taken into account when considering a medial branch block or facet denervation. The medial branch nerve arises from the dorsal ramus of the exiting nerve root.
REFERENCES: Nade SL, Bell E, Wyke BD: The innervation of the lumbar spinal joint and its significance. J Bone Joint Surg Br 1980;62:255-261
Kornick C, Kramarich SS, Lamer TJ, et al: Complications of lumbar facet radiofrequency denervation. Spine 2004;29:1352-1354.

Question 28

Explanation

Rheumatoid synovitis in the cervical spine causes pathologic changes in the ligaments with distention and rupture, articular cartilage destruction, and, in bone osteoporosis, cyst formation, and erosion. The specific deformity caused is dependent on the structure destroyed. The inflammatory cells involved in rheumatoid inflammation have been identified in biopsy specimens at the atlantoaxial junction and reflect the same cell types as found peripherally. Atlantoaxial subluxation is ascribed to erosive synovitis in the atlantoaxial, atlantoodontoid, and atlantooccipital joints as well as the synovium-lined bursa between the odontoid and the transverse ligament. In the figure (fig 10-1) contained in the text there are flexion and extension views depicting a widening of the space between the odontoid and the posterior aspect of the anterior ring. Atlantoaxial impaction (upward translocation of the odontoid, pseudobasilar invagination, cranial settling, vertical subluxation) describes the settling of the skull on the atlas and the atlas on the axis, resulting from erosion and bone loss in the occipitoatlantal and atlantoaxial joints. In the figure (10-2) Atlantoaxial impaction is seen on a lateral x-ray. The dens is noted above the clivus and is circumferentially eroded by synovitis. The ring of the atlas lies low on the body of C2.
In the context of viewing a lateral cervical spine to evaluate cranial setting, multiple lines can be used to assess anatomic relationships (i.e. McRae’s Chamberlin’s, or McGregor’s) McRae’s and Chamberlin’s use the foramen magnum as one land mark. Commonly, however, the margins of the foramen magnum are difficult to precisely identify. McGregor’s line connects the posterior margin of the hard palate to the most caudal point of the occiput and is easier to use. The tip of the odontoid should not project more than 4.5 mm above this line.
Anterior subluxation of more than 10-12 mm implies destruction of the entire ligamentous complex.
An atlantoaxial distance greater than 3.5mm is considered abnormal in an adult. The subaxial cervical spine is affected through involvement of the facets, interspinous ligaments, and intervertebral discs (spondylodiscitis). The initial site of destruction has been postulated to be through synovitis of the neurocentral joints with erosion of the adjacent disc and bone causing subluxation, or through primary facetal arthritis and ligamentous laxity causing secondary chronic discovertebraltrauma and destructive hypermobile segmentsis associated with disc destruction and toward the C2-C3 and C3-C4 segments, typically lack osteophytes, and often are at multiple levels, giving a stepladder appearance.

Question 29

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

Explanation

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

Question 30

A 70-year-old man undergoes removal of an infected total hip arthroplasty (THA) and insertion of an articulating antibiotic-loaded spacer to treat a deep periprosthetic hip infection. While in a nursing home receiving intravenous antibiotics 3 weeks after surgery, the patient trips and falls. Examination reveals swelling in the mid and distal thigh, intact skin and neurovascular structures, and severe pain with knee or hip movement. Radiographs of the femur are shown in Figures 1 through 4. What is the most appropriate treatment for the fracture below the implant?

Explanation

DISCUSSION:
This patient has a type C periprosthetic femoral fracture. The articulating spacer is not involved in the fracture, which is well distal to the implant. The most appropriate treatment is open reduction and internal fixation of the fracture. Traction is not appropriate for this fracture because the injury can be treated surgically despite the history of previous hip infection. Traction would also be needed for at least 5 weeks and would delay the surgical treatment of the periprosthetic fracture until the time of second-stage revision THA. The fracture is fairly distal, and revision to a longer antibiotic-loaded implant or uncemented stem is not suitable for this fracture pattern, because it extends well past the isthmus. A femoral stem in the distal fragment would provide little stability for the fracture. Removal of the articulating spacer and reimplantation using a long-stem fluted uncemented hip replacement is not appropriate, because it would be premature to reimplant the man's hip while he is still receiving treatment for a deep hip infection.

Question 31

In the treatment of thoracic disk herniations, what approach is associated with the highest risk of iatrogenic paraplegia?

Explanation

DISCUSSION: Laminectomy is associated with the highest risk of iatrogenic paraplegia because retraction on the cord is necessary for visualization, but retraction is difficult because of tethering of the intradural dentate ligaments. All of the other approaches allow for access to the disk herniation through an angle that avoids the cord itself, although other limitations may exist.
REFERENCES: Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 87-96.
Stillerman CB, Chen TC, Couldwell WT, Zhang W, Weiss MH: Experience in the surgical mangement of 82 symptomatic herniated thoracic discs and review of the literature. J Neurosurg 1998;88:623-633.

Question 32

What is the typical axial plane transverse angulation of the thoracic pedicles? Review Topic

Explanation

Thoracic pedicles typically are angled 25 degrees medially at T1 so the starting point is more lateral. T2 angles about 15 degrees, and then the pedicles average about 5 to 7 degrees down to T10. At T11 and 12, the angulation is minimal.

Question 33

With comparison to a below the knee amputation, each of the following are disadvantages of a through the knee amputation EXCEPT:

Explanation

Intravenous antibiotic coverage for Gram negative bacteria for 7 days

Surgical decompression and bullet fragment removal

Observation

Broad-spectrum oral antibiotic coverage for 7 days
Broad-spectrum intravenous antibiotic coverage for 7 days
DISCUSSION: The clinical presentation is consistent with a GSW with bowel perforation and a retained bullet in the vertebral body. Because the patient is neurologically intact broad-spectrum intravenous antibiotic coverage for 7 days is the most appropriate treatment.
Gunshot wounds to the spine present relatively little risk of infection in most cases. When there has been an injury to the small bowel, the risk of infection can be minimized with a 7-day course of broad-spectrum antibiotics. Indications for surgery include when a neurological deficit is present that correlates with imaging findings of neurological compression by the missile, or when the missile is in contact with the CSF posing a risk for metal toxicity.
Roffi et al performed a Level 4 study of 42 patients that sustained a gunshot wound that perforated the stomach or bowel and then entered the spinal column. They found that an extended regimen of broad spectrum antibiotics combined with bedrest appeared to significantly reduce the risk of spinal or paraspinal infection, whereas early bullet removal did not significantly prevent the occurrence of infection.
Velmahoos et al performed a Level 4 study including 24 patients that sustained a gunshot wound to the spine with associated colonic injury. They found that the incidence of sepsis was 8.4% (compared to 5% in non-bowel injuries) and concluded that retainment of the bullet did not increase the rate of sepsis.
Incorrect Answers:

Question 34

When performing the exposure for an anterior approach to the cervical spine, the surgical dissection should not enter the plane between the trachea and the esophagus and excessive retraction should be avoided to prevent injury to the

Explanation

DISCUSSION: The recurrent laryngeal nerve lies between the trachea and the esophagus. The vagus nerve lies in the carotid sheath. The sympathetic trunk lies anterior to the longus colli muscles. The hypoglossal and superior laryngeal nerves are both at risk during the exposure but are not located between the trachea and the esophagus.
REFERENCES: Flynn TB: Neurologic complications of anterior cervical interbody fusion. Spine 1982;7:536-539.
Patel CK, Fischgrund JS: Complications of anterior cervical spine surgery. Instr Course Lect 2003;52:465-469.

Question 35

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

Explanation

A systematic review of case studies looking at the results of surgical treatment for femoroacetabular impingement shows 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 17.6 years.

Question 36

What is the most common foot and ankle deformity in patients with arthrogryposis?

Explanation

DISCUSSION: Clubfoot (talipes equinovarus) in patients with arthrogryposis is a rigid and resistant deformity. However, multiple studies document limited success with nonsurgical management. Manipulation and casting are generally a preliminary treatment before surgery; successful correction will most like require a talectomy.
REFERENCES: Guidera KJ, Drennan JC: Foot and ankle deformities in arthrogryposis multiplex congenita. Clin Orthop 1985;194:93-98.
Handelsman JE, Badalamente MA: Neuromuscular studies in clubfoot. J Pediatr Orthop 1981;1:23-32.
Dias LS, Stern LS: Talectomy in the treatment of resistant talipes equinovarus deformity in myelomeningocele and arthrogryposis. J Pediatr Orthop 1987;7:39-41.

Question 37

Patients with patellar clunk syndrome are best managed by which of the following methods?

Explanation

DISCUSSION: Patellar clunk syndrome is usually the result of a fibrous nodule that forms on the undersurface of the distal quadriceps tendon. It may get entrapped in the intercondylar notch of the femoral component during flexion, and lead to a sudden snap as the nodule is pulled out of the notch during active extension. Nonsurgical management is rarely successful. Surgical debridement is usually curative, with only rare recurrence. More aggressive procedures such as realignment, revision, or patellectomy are usually not necessary, and are reserved for cases resistant to soft-tissue debridement.
REFERENCES: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update:

Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, p 329.
Diduch DR, Scuderi GR, Scott WN, et al: The efficacy of arthroscopy following total knee replacement. Arthroscopy 1997;13:166-171.
Lucas TS, DeLuca PF, Nazarian DG, et al: Arthroscopic treatment of patellar clunk. Clin Orthop 1999;367:226-229.

Question 38

During primary total knee arthroplasty, what is the maximum distance the joint line can be raised or lowered before poor motion, joint instability, and increased chance of revision occur?

Explanation

DISCUSSION: Positioning of the femoral and tibial components is a common cause of early failure of total knee arthroplasty. Two modes of possible position are raising or lowering the joint line from its anatomic level. Raising or lowering the joint line beyond an established threshold can cause limited range of motion, poor patellar function, and possible instability. It has been determined that a threshold of approximately 8 mm provides consistently good results after knee arthroplasty.
REFERENCE: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 339-365.

Question 39

What is the most likely diagnosis based on the MRI findings shown in Figures 87a and 87b? Review Topic

Explanation

The MRI scans reveal increased signal in the medial facet of the patella and the anterior aspect of the lateral femoral condyle. This pattern is typically seen in patients with acute patellar dislocations. In patients with ACL tears, the bone bruise of the lateral femoral condyle is usually seen in the central portion at the sulcus terminalis and the posterior half of the lateral tibial plateau and is not usually seen in the patella. This pattern of bone bruising is not seen with patellar tendon ruptures, LCL tears, and PCL tears.

Question 40

Figure 19 shows the radiograph of a 12-year-old boy who sustained an injury to his hand when another child fell on him. Management should consist of

Explanation

DISCUSSION: The patient has a Salter-Harris type III fracture of the proximal phalanx of the thumb. It is usually caused by an abduction injury where the ulnar collateral ligament avulses a fragment away from the proximal epiphysis and is the most common childhood gamekeeper’s injury. If there is greater than 1 mm of separation or a significant articular step-off, an open reduction, performed through an extensor aponeurosis-splitting approach, is required to reestablish joint congruity and stability. Percutaneous or closed methods of reduction are usually ineffective. The dorsal approach avoids the volar neurovascular structures. Since the ulnar collateral ligament is still attached, this area does not need to be visualized. The major goal is to reestablish joint congruity and bony stability. This can be easily performed via the dorsal approach.
REFERENCES: Carey TP: Fracture and dislocations of the phalanges, in Letts RM (ed): Management of Pediatric Fractures. New York, NY, Churchill Livingstone, 1994, pp 435-436.
Ogden JA: Skeletal Injury in the Child. New York, NY, Springer-Verlag, 2000, p 668.

Question 41

What is the most likely late complication associated with cementless total knee replacement?

Explanation

DISCUSSION: In cementless total knee replacement, the risk of osteolysis is 30% if both components are placed without cement and screws are used for tibial fixation. The risk is 10% when a cemented tibial component is used, and the risk is 0% when both components are cemented. Loss of motion, patellofemoral pain, heterotopic bone formation, and patellar clunk are complications that can occur after cemented or cementless components are placed.
REFERENCE: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 559-582.

Question 42

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

Explanation

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

Question 43

All of the following are considered contraindications to the use of functional bracing of a humeral shaft fracture EXCEPT:

Explanation

DISCUSSION: A closed mid-diaphyseal humerus fracture with a radial nerve palsy on presentation is not a contraindication to functional brace management.
Commonly accepted parameters for closed treatment include less than 30 degrees of varus angulation, 20 degrees of anterior/posterior angulation, and 3 cm of shortening. Operative indications are: associated vascular injuries, bilateral humeral shaft fractures, polytrauma patient (including paraplegia), segmental fractures, injury to the brachial plexus, pathological fractures, floating elbow, and floating shoulder.
The article by Rutgers and Ring found that proximal one-third oblique humeral shaft fractures had an unacceptably high 29% rate of nonunion treated with a functional brace.
The article by Sarmiento et al found a 97% rate of union, a radial nerve palsy incidence of 11%, and no contraindication to the use of functional braces in humeral shaft fractures associated with radial nerve palsy.
The review article by Defranco and Lawton states that 70% of these radial nerve injuries recover spontaneously. They note that it "seems reasonable, however, to consider surgical intervention (radial nerve exploration) between 4 and 6 months based on the patient’s clinical course."

Question 44

Rickets can be best characterized by which of the following radiographic changes in children?

Explanation

Rickets is a condition of inadequate mineralization of osteoid and cartilage at the growing ends of bone in children. It is associated with a nutritional deficiency in children that affects open physes, as opposed to osteomalacia which is a deficiency in people with closed growth plates. There are classic radiographic findings and disorders that mimic rickets. Classic findings are widened physes related to widening of the physis from accumulation of nonmineralized osteoid and cartilage, irregular metaphyses, and loss of definition of the zone of provisional calcification. The changes are seen predominantly in the bones with greatest growth (tibia, distal femur, distal radius) and rarely seen in slower growing bones such as the tubular bones in the hand. Widening of the anterior ribs, the rachitic rosary, may be seen. Hyperparathyroidism with accumulation of fibrous tissue in the metaphyses can produce lucencies that may appear similar to the nonmineralized osteoid of rickets. Hyperparathyroidism has erosion around the edge of the growth plate. There are punched out lesions and resorption subperiosteally. Rounded epiphyses and marked separation of the epiphysis and metaphysis are the classic differentiation of Jansen syndrome, a dominantly inherited metaphyseal chondrodysplasia. Sclerotic metaphyseal ends are similar to rickets, but with maturation, the spaces fill with irregular calcification classic to Jansen syndrome. Sclerotic of the vertebra, or "rugger jersey" spine, is typical of renal osteodystrophy.

Question 45

A 24-year-old woman has a spleen laceration and hypotension. Radiographs reveal a pulmonary contusion and a displaced mid-diaphyseal fracture of the femur. The trauma surgeon clears her for stabilization of the femoral fracture. What technique will offer the least potential for initial complications?

Explanation

DISCUSSION: A concern in the multiply injured patient who has a pulmonary contusion is the potential for further pulmonary compromise because of embolization of marrow, blood clot, or fat during manipulation of the medullary canal. Recent evidence has shown that the presence of a lung injury is the most important determining factor in future deterioration. However, despite the lung injury and its potential consequences, this patient’s femur fracture needs stabilization. Because damage control in the multiply injured patient requires a technique that can be performed rapidly and consistently, the treatment of choice is application of an external fixator. By placing two pins above and below the fracture and with longitudinal traction, the fracture is quickly realigned and stabilized. This allows the patient to be resuscitated and treated at a later date when definitive management of the fracture can be carried out. There is little difference between plate fixation and intramedullary nailing.
REFERENCES: Bosse MJ, MacKenzie EJ, Riemer BL, et al: Adult respiratory distress syndrome, pneumonia, and mortality following thoracic injury and a femoral fracture treated with either intramedullary nailing with reaming or with a plate: A comparative study. J Bone Joint Surg Am 1997;79:799-809.
Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME, Pollak AN: External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: Damage control orthopedics. J Trauma 2000;48:613-623.
Pape HC, Auf’m’Kolk M, Puffrath T, et al: Primary intramedullary femur fixation in multiple trauma patients with associated lung contusion: A cause of posttraumatic ARDS? J Trauma 1993;34:540-548.

Question 46

Figure 10 shows the MRI scan of a 56-year-old woman with metastatic breast cancer who now reports progressive paraparesis. Her general health remains good. Treatment should consist of

Explanation

DISCUSSION: If the patient’s medical condition and prognosis remain good in the presence of significant and progressive neurologic deficit from cord compression, then the most reliable means of restoring function is via surgical decompression and fusion. Decompression should be directed toward the compressing structure (eg, anteriorly if the compression is from the anterior side). This procedure can be done via a posterolateral technique, such as costotransversectomy in some cases.
REFERENCE: Fardin DF, Garfin SR, Abitbol J, et al (eds): Orthopaedic Knowledge Update: Spine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 123-133.

Question 47

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

Explanation

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

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

Question 48

During a dual incision fasciotomy of the leg, the soleus is elevated from the tibia to allow access to which of the following compartments?

Explanation

DISCUSSION: The soleus is elevated/released from the posterior tibia during the medial approach to allow access to the deep posterior compartment. Release of this compartment cannot be done without proper elevation of the soleus. The superficial posterior compartment mass is primarily located in the proximal half of the leg, while the deep posterior musculature is located in the distal 2/3 of the leg.

Question 49

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 50

A collegiate rower reports the sudden onset of right chest pain while rowing. The athlete states that the pain is worse with deep inspiration and coughing. Examination reveals localized tenderness over the posterolateral corner of the eighth rib. What is the most likely diagnosis?

Explanation

DISCUSSION: A rib stress fracture, the most common injury to the thorax in rowing athletes, generally occurs during periods of intense training with a low stroke rate and heavy loads. It is characterized by the sudden onset of sharp, localized chest pain while rowing. The fifth through the ninth rib is generally affected, and the diagnosis is best established with a bone scan. An intercostal muscle strain generally has an insidious onset and may be poorly localized. Costochondritis affects the anterior costochondral junction. A pneumothorax and an empyema can cause nonlocalized chest pain but are associated with respiratory distress and systemic physical findings.
REFERENCES: Karlson KA: Rib stress fractures in elite rowers. Am J Sports Med 1998;26:516-520.
Holden DL, Jackson DW: Stress fractures of the ribs in female rowers. Am J Sports Med 1985;13:342-348.

Question 51

Assuming that the fracture shown in this radiograph (Figure 1) is aligned on the anteroposterior radiograph and heals in this position, secondary to fracture malalignment, there will be loss of active

Explanation

EXPLANATION:
This is a transverse proximal phalanx fracture with apex volar angulation. The fracture displaces into an apex volar angulated position under the pull of the central slip on the distal fragment and the interossei insertions at the base of proximal phalanx. Although it is possible to lose motion in flexion or extension of the MP or PIP joints, the biomechanics will not allow full extension of the PIP joint. If allowed to heal in apex palmar malunion, the predicted corresponding extensor lags are for a 10-degree lag at 16 degrees of angular deformity, a 24-degree lag at 27 degrees of deformity, and a 66-degree lag at 46 degrees of deformity. These fractures usually can be treated with closed reduction with or without percutaneous pinning. With surgical treatment, there may be loss of motion both at the MP and PIP joints.

Question 52

Denosumab, a monoclonal antibody used to treat osteoporosis, works through inhibition of

Explanation

Denosumab is a monoclonal antibody that targets and inhibits RANKL binding to the RANK receptor, which is found on osteoclasts. As a result, it inhibits activation of osteoclast cells and slows the process of bone resorption and bone turnover via osteoclast inhibition. The end result is similar to bisphosphonates in terms of effector cell, but the mechanism of action is very different. RANKL binds to RANK, but OPG inhibits RANK binding to RANKL. TNF is an inflammatory cytokine, and monoclonal antibodies to TNF are used to treat systemic inflammatory disease such as rheumatoid arthritis.

Question 53

A B C Figures 89a through 89c are the radiographs of a 35-year-old woman who has had 7 years of progressive ankle pain. She experiences stiffness and pain despite the use of an ankle-foot orthosis. Examination reveals pain along the anterior tibiotalar joint without tenderness to the subtalar or talonavicular joints. What is the most appropriate surgical intervention?

Explanation

DISCUSSION
This patient has isolated posttraumatic ankle arthritis with significantly decreased ankle range of motion that is best treated with an isolated ankle arthrodesis to eliminate pain. Because this patient is younger than 50 years of age and has limited presurgical range of motion, she is not a candidate for ankle arthroplasty. Additionally, TAA outcomes among patients who have a posttraumatic etiology are worse than for those with osteoarthritis. Tibiotalocalcaneal arthrodesis is suited for patients with associated subtalar
arthritis or rigid hindfoot deformity that necessitates correction. Anterior tibial exostectomy will not resolve the underlying arthritic pain and is not indicated.
RECOMMENDED READINGS
Easley ME, Adams SB Jr, Hembree WC, DeOrio JK. Results of total ankle arthroplasty. J Bone Joint Surg Am. 2011 Aug 3;93(15):1455-68. doi: 10.2106/JBJS.J.00126. Review. PubMed PMID: 21915552. View Abstract at PubMed
Spirt AA, Assal M, Hansen ST Jr. Complications and failure after total ankle arthroplasty. J Bone Joint Surg Am. 2004 Jun;86-A(6):1172-8. PubMed PMID: 15173289. View Abstract at PubMed
Ajis A, Henriquez H, Myerson M. Postoperative range of motion trends following total ankle arthroplasty. Foot Ankle Int. 2013 May;34(5):645-56. doi: 10.1177/1071100713481433. Epub 2013 Mar 11. PubMed PMID: 23478890. View Abstract at PubMed
Thomas R, Daniels TR, Parker K. Gait analysis and functional outcomes following ankle arthrodesis for isolated ankle arthritis. J Bone Joint Surg Am. 2006 Mar;88(3):526-35. PubMed PMID: 16510818. View Abstract at PubMed
Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am. 2001 Feb;83-A(2):219-28. PubMed PMID: 11216683. View Abstract at PubMed

Question 54

A B C Figures 30a through 30c are the radiograph and MR images of a 54-year-old woman who has severe leg pain with walking. Her treatment has included 12 weeks of physical therapy, anti-inflammatory medications, and narcotic pain relievers, and she is interested in surgery. Minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) is recommended. When compared with open TLIF, MIS TLIF is associated with

Explanation

DISCUSSION
MIS TLIF involves a steep learning curve but is associated with similar longterm outcomes as open TLIF, arguably comparable or possibly lower complication rates, and equivalent fusion rates. The major distinguishing feature comparing open to minimally invasive surgery for this and other spinal diagnoses has been shorter hospital stays.
RECOMMENDED READINGS
Peng CW, Yue WM, Poh SY, Yeo W, Tan SB. Clinical and radiological outcomes of minimally invasive versus open transforaminal lumbar interbody fusion. Spine (Phila Pa 1976). 2009 Jun 1;34(13):1385-9. doi: 10.1097/BRS.0b013e3181a4e3be. PubMed PMID: 19478658. View
Abstract at PubMed
Lee KH, Yue WM, Yeo W, Soeharno H, Tan SB. Clinical and radiological outcomes of open versus minimally invasive transforaminal lumbar interbody fusion. Eur Spine J. 2012 Nov;21(11):2265-70. doi: 10.1007/s00586-012-2281-4. Epub 2012 Mar 28. PubMed PMID:

Question 55

What muscle is most often encountered during surgical approaches to C5-6?

Explanation

DISCUSSION: The omohyoid muscle crosses the surgical field from inferior lateral to anterior superior traveling from the scapula to the hyoid bone and may need to be transected. The posterior digastric crosses the field as well but higher near C3-4. The other muscles run longitudinally.
REFERENCES: Chang U, Lee MC, Kim DH: Anterior approach to the midcervical spine, in Kim DH, Henn JS, Vaccaro AR, et al (eds): Surgical Anatomy and Techniques to the Spine. Philadelphia, PA, Saunders Elsevier, 2006, pp 45-56.
Netter GH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy Corporation, 1989.

Question 56

A 23 year old man has a minimally comminuted midshaft fracture of the femur with 2cm entrance and exit wounds as a result of a low-velocity gunshot. Definitive management should be

Explanation

There is no clear treatment of these fractures the reference literature reviewed shows that soft-tissue tracks of low-velocity gunshot wounds are not rendered sterile by the bullet force. Despite this information, the majority of studies that have followed the healing of fractures secondary to gunshot wounds reveal a surprising low infection rate.

Question 57

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

Explanation

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

Question 58

An acute posterolateral disk herniation at the L4-5 level will most likely affect what nerve root? Review Topic

Explanation

Posterolateral disk herniations will generally compress the transversing nerve root. Therefore, a posterolateral disk herniation at the L4-5 level will typically compromise the L5 nerve root. Far lateral (extraforaminal) disk herniations generally compromise the exiting nerve root. Therefore, an extraforaminal herniation at the L4-5 level will typically compromise the exiting L4 nerve root.

Question 59

An otherwise healthy 35-year-old woman reports dorsal wrist pain and has trouble extending her thumb after sustaining a minimally displaced fracture of the distal radius 3 months ago. What is the next most appropriate step in management?

Explanation

DISCUSSION: Extensor pollicis longus tendon rupture can occur after a fracture of the distal radius, even a minimally displaced one. Poor vascularity of the tendon within the third dorsal compartment is the suspected etiology, not the displaced fracture fragments. Tendon transfer will suitably restore active extension of the thumb interphalangeal joint.
REFERENCES: Christophe K: Rupture of the extensor pollicis longus tendon following Colles fracture. J Bone Joint Surg Am 1953;35:1003-1005.
Hove LM: Delayed rupture of the thumb extensor tendon: A 5-year study of 18 consecutive cases. Acta Orthop Scand 1994;65:199-203.

Question 60

Figures 10a and 10b are the sagittal and coronal MRI scans of a 5-year-old boy who noticed “clicking” in his right knee. His family denied any trauma, but admitted that the child was active and fell frequently. Birth and developmental history were unremarkable, and specifically negative for other musculoskeletal conditions. On physical examination, there was no warmth, tenderness, or erythema, or effusion. The child had an audible and palpable clunk when the knee was taken from a position of extreme flexion to full extension. There was no anterior, posterior, medial, or lateral instability on examination or medial or lateral joint line tenderness. The child had not been systemically ill. Radiographs were unrevealing. What is the most likely diagnosis? Review Topic

Explanation

A discoid lateral meniscus is probably the most common cause of a symptomatic clicking or clunking in the knee in a young child. This is a congenital problem that can become symptomatic as soon as a child ambulates, or the condition may remain asymptomatic for several years. The meniscus develops from a cartilaginous anlage and at no point in its development is it discoid. The MRI scans reveal a band of meniscal tissue filling the joint's lateral compartment on both sagittal and coronal images. A medial meniscal tear is usually accompanied by a history of injury and an effusion, which are not present in this child. There is also no joint line tenderness, which makes this diagnosis less likely. Congenital absence of the anterior cruciate ligament may be found in children born with congenital knee hyperextension, which is ruled out in this case by normal history and examination findings. Children with osteomyelitis are often systemically ill. On examination, they may have warmth and tenderness. MRI scans will often show an area of increased signal on T1-weighted images.

Question 61

After making a tackle, a football player is found prone and unconscious without spontaneous respirations. Initial management should consist of

Explanation

DISCUSSION: The on-field evaluation and management of a seriously injured athlete requires that health care teams have a game plan in place and proper equipment that is readily available. The initial step, which consists of stabilizing the head and neck by manually holding them in a neutral position, is then followed by assessment of breathing, pulses, and level of consciousness. If the athlete is breathing, management should consist of mouth guard removal and airway maintenance. If the athlete is not breathing, the face mask should be removed, with the chin strap left in place. The airway must be established, followed by initiation of assisted breathing. CPR is instituted only when breathing and circulation are compromised. In the unconscious athlete or if a cervical spine injury is suspected, the helmet must not be removed until the athlete has been transported to an appropriate facility and the cervical spine has been completely evaluated.
REFERENCES: McSwain NE, Garnelli, RL: Helmet removal from injured patients. Bull of Am Coll Surg 1997;82:42-44.
Vegso JJ: Field evaluation and management of head and neck injuries. Post Grad Adv Sport Med 1987;10:2-10.

Question 62

Figure 26 shows the radiograph of an otherwise healthy Caucasian 5-year-old boy who has a painless limp. What is the best treatment option?

Explanation

DISCUSSION: The prognosis of Legg-Perthes disease in children younger than age 6 years is good. There is no indication that surgical treatment will improve the outcome. Range-of-motion exercises to prevent contracture may be helpful.
REFERENCES: Herring JA, Kim HT, Browne R: Legg-Calve-Perthes disease: Prospective multicenter study of the effect of treatment on outcome. J Bone Joint Surg Am 2004;86:2121-2134.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 1, pp 691-704.

Question 63

Figure 42 is a transverse MRI scan of the left shoulder. The arrow points to which of the following structures?

Explanation

DISCUSSION: The figure shows an axial image of the shoulder immediately inferior to the coracoid process. The subscapularis tendon, which can be traced from the myotendinous junction, is torn and detached from its lesser tuberosity attachment on the humerus. Lateral to the lesser tuberosity, the bicipital groove is empty. The arrow points to the subluxated biceps tendon. Superficial fibers of the subscapularis tendon are contiguous with the biceps retinaculum, which covers the bicipital groove and hold the biceps tendon in place. The vast majority of subscapularis tendon tears result in disruption of the biceps retinaculum with resultant subluxation of the tendon.
REFERENCES: Resnick D, Kang HS (eds): Internal Derangement of Joints: Emphasis on MR Imaging. Philadelphia, PA, WB Saunders, 1997, pp 308-317.
El-Khoury G: MRI of the Musculoskeletal System. Philadelphia, PA, JB Lippincott, 1998, p 234.

Question 64

A 44-year-old man reports persistent left leg pain following a L5-S1 hemilaminotomy and partial diskectomy. Examination shows a grade 4 weakness of the left extensor hallucis longus and a positive left straight leg raise. A radiograph is shown in Figure 1a, and sagittal and axial MRI scans are shown in Figures 1b and 1c. Nonsurgical management consisting of medication, physical therapy, and injections has failed to provide relief. Surgical management should consist of Review Topic

Explanation

The patient has a grade I isthmic spondylolisthesis at L5-S1. He has an L5 radiculopathy with foraminal stenosis. Any further treatment needs to include an arthrodesis and foraminal decompression. Isolated interbody fusion is contraindicated in patients with spondylolisthesis, as is total disk arthroplasty. Therefore, the best procedure is a posterior fusion with instrumentation and bone graft along with a foraminal decompression.

Question 65

Figure 26 is the radiograph of a 33-year-old woman who was involved in a high-speed motor vehicle crash. Her initial blood pressure is 80/50 mm Hg and she has a pulse rate of 120 bpm. After hemodynamic stabilization and temporizing measures have been performed, the patient is cleared for surgery. What is the most appropriate method of definitive fixation?

Explanation

The patient has sustained an anterior posterior compression (APC) grade II pelvic ring injury. Initial management should consist of pelvic volume reduction with pelvic binding or sheeting. Once the patient is hemodynamically stable, the decision for definitive management should be made. In a retrospective review of more than 200 patients, Sagi and Papp investigated plate osteosynthesis of the pubic symphysis. They found significantly fewer malunions in the multi-hole plate group and a trend toward fewer surgeries in the same group. Typically external fixation should be reserved for temporary fixation and not a definitive management in stable patients. Posterior fixation is reserved for injuries with disruption of the posterior ligamentous constraints, typically APC grade III injuries. Triangular osteosynthesis is a strategy for fixation of unstable vertical shear fractures that require fixation of the pelvis to the lumbar spine.

Question 66

New computer scanning technology for socket design has achieved which of the following improvements in amputee care?

Explanation

One of the new technologies available to the prosthetist is the use of digital scanners to obtain a model of the residual limb. Typically, a digital image of the residual limb is obtained by either running a wand over the surface anatomy, allowing the computer program to record the shape, or by using a ring-type scanner that does not make contact with the residual limb but records the shape by bouncing a laser beam off the limb. In either instance, the end result is a digital image that can then be viewed and modified on the computer to improve the weight-bearing aspects of a socket shape or take pressure off sensitive bony areas. The final shape is then carved out of a foam block for use in the socket fabrication process. Computer-aided socket design is still dependent on input from the prosthetist, and therefore does not represent an improvement in overall socket fit. Digital scanning works well on specific types of devices, such as transfemoral sockets, where there is more soft tissue relative to bone. The scanner does not have the ability to detect the density of tissue beneath the scanned surface. Heterotopic ossification and other anomalies will be missed if a thorough examination of the underlying anatomy is neglected. Therefore, the advantages of using scanning technology are for producing and fabricating a socket shape quickly, storing the shape digitally for future use, and increasing efficiency with a plasterless facility.

Question 67

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

Explanation

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

Question 68

A 16-year-old girl has had anterior leg pain and a mass for the past 8 months. Figures 2a and 2b show a radiograph and an H & E histologic specimen. Which of the following disorders is believed to be a precursor of this lesion?

Explanation

DISCUSSION: The radiograph and pathology are consistent with adamantinoma. While the mechanism underlying adamantinoma has not been identified, it is believed to be closely related to osteofibrous dysplasia, which may represent a precursor. The other diagnoses are not known to give rise to adamantinoma.
REFERENCE: Springfield DS, Rosenberg AE, Mankin HJ, et al: Relationship between osteofibrous dysplasia and adamantinoma. Clin Orthop 1994;309:234-244.

Question 69

Figure 1 shows a patient with an open tibia fracture who presents to the emergency department after a propeller injury in brackish water (river water and sea water). What is the most appropriate antibiotic coverage for this patient?

Explanation

Discussion: The clinical photo shows significant soft tissue wounds with associated tibia fracture. With the amount of soft tissue damage and periosteal stripping this would be classified as a Gustilo Type IIIB injury. The brackish water environment where this particular injury occurred influences the antibiotic choice secondary to the particular organisms found in this setting. Brackish water is made up of both fresh and salt water with common organisms that include Vibrio species, Aeromonas hydrophila, Pseudomonas species, Erysipelothrix rhusiopathiae, and Mycobacterium marinum. The combination of both Doxycycline (tetracycline) and Ceftazidime (third-generation cephalosporin) cover these particular pathogens. Standard antibiotic coverage for Gustilo Type I and II injures is 1st generation cephalosporin (cefazolin), with Type III being 1st generation cephalosporin and aminoglycoside (cefazolin and gentamicin) or a fluoroquinolone. In Type III injuries, Penicillin is commonly added in barnyard injuries for extended coverage of
soil-borne pathogens (clostridial species). Vancomycin is not indicated for coverage in marine environments, rather it is more commonly used for populations with a high prevalence of nosocomial infections. Sulfamethoxazole-trimethoprim is not used for open fracture coverage.

Question 70

A 38-year-old man sustains a complete avulsion with retraction of the ischial attachment of the hamstring muscles in a fall while water skiing. He indicates that he is an aggressive athlete who participates regularly in multiple running and cutting-type sports, and he strongly desires to continue his athletic competition. Management should consist of

Explanation

DISCUSSION: Several studies have identified a complete proximal avulsion of the hamstring muscles as an injury that leads to significant long-term disability, with a high percentage of athletes who must permanently restrict their activities following nonsurgical management. Early surgical repair and prolonged rehabilitation have yielded consistently better results than nonsurgical management.
REFERENCES: Orava S, Kujala UM: Rupture of the ischial origin of the hamstring muscles. Am J Sports Med 1995;23:702-705.
Clanton TO, Coupe KJ: Hamstring strains in the athlete: Diagnosis and treatment. J Am Acad Orthop Surg 1998;6:237-248.

Question 71

Sciatic nerve

Explanation

(999) Q1-1306:
The principal thrombogenic stimulus leading to the production of venous thromboembolic disease during total hip arthroplasty occurs at which time:

Question 72

Which of the following medications inhibits release of neurotransmitters by binding to presynaptic calcium channels?

Explanation

Gabapentin acts by inhibiting presynaptic calcium channels, thus preventing the release of neurotransmitters.
Gabapentin (also known as Neurontin) is a medication that is commonly used to treat neuropathic pain. It acts by binding the alpha2delta subunit of voltage-dependent calcium channels on the presynaptic membrane. This serves to increase GABA synthesis, as well as inhibit the release of excitatory neurotransmitters. These neurotransmitters are believed to be part of the pathway leading to neuropathic pain.
Bennett et al. provide a review of the pharmacology of gabapentin for the use of neuropathic pain. They note effective antihyperalgesic and antiallodynic properties of gabapentin but not significant anti-nociceptive action. Among patients with neuropathic pain they found an average pain score reduction of 2.05 points on an 11 point Likert scale, which compared favorably to placebo.
Mehta et al. explored outcomes of gabapentin and pregabalin (Lyrica) for use in patients with spinal cord injury. Both agents were found to decrease pain and secondary conditions such as sleep disturbance. They did not directly compare these agents to other analgesic medications.
Guy et al. present a meta-analysis of the use of anticonvulsants (such as gabapentin) to treat pain in patients with spinal cord injury. Large effect size was seen in 4 of 6 studies looking at the effectiveness of gabapentin.
Illustration A show the mechanism of currently available antiepileptic drugs (AEDs) that target several molecules at the excitatory synapse. Gabapentin and pregabalin bind to the a2d subunit of voltage-gated Ca2+ channels, which is thought to be associated with a decrease in neurotransmitter release.
Incorrect Answers

Question 73

Figure 36a shows the current radiograph of a 65-year-old woman who slipped and fell. History reveals that prior to the fall she was actively functioning without pain. Figure 36b shows a radiograph obtained 1 year ago. Based on the fracture pattern, the failure is most likely related to

Explanation

DISCUSSION: The radiograph shows a fracture distal to the prosthesis in a stable, apparently well-fixed prosthetic stem. The well-fixed prosthesis-bone composite is stiff, creating a modulus mismatch between the proximal and distal femur. Therefore, the risk of fracture, particularly in osteoporotic bone, is increased at this level. Revision of the stem to a longer construct is unnecessary, and standard plate and screw fixation has been shown to yield union rates of greater than 90%. Nonsurgical treatment of fractures distal to the tip of the prosthesis results in high nonunion rates, reported to be from 25% to 42%.
REFERENCES: Johansson JE, McBroom R, Barrington TW, Hunter GA: Fracture of the ipsilateral femur in patients with total hip replacement. J Bone Joint Surg Am 1981;63:1435-1442.
Bethea JS III, DeAndrade JR, Fleming LL, Lindenbaum SD, Welch RB: Proximal femoral fractures following total hip arthroplasty. Clin Orthop 1982;170:95-106.
Garbuz DS, Masri BA, Duncan CP: Periprosthetic fractures of the femur: Principles of prevention and management, in Cannon WD Jr (ed): Instructional Course Lectures 47. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 237-242.

Question 74

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

Explanation

Slide 1 Slide 2 Slide 3 Slide 4

Slide 5 Slide 6
A 50-year-old woman has had severe hip pain for 4 months. Her plain radiographs (Slide 1), technetium bone scan (Slide 2), computerized tomography scan (Slide 3), and coronal T1- and T2-weighted magnetic resonance images (Slide 4) are presented. A needle biopsy is also performed (Slides 5 and 6). Which of the following treatment regimens would be the most appropriate:

Question 75

Figure 3a is the initial radiograph of a 19-year-old man who sustained a closed clavicle fracture. Figures 3b and 3c show postoperative radiographs. If the patient had been treated nonsurgically, which of the following would most likely occur?

Explanation

Recent studies comparing surgical treatment with nonsurgical management in displaced clavicle fractures have revealed a decreased rate of malunion and nonunion with surgery. In addition, significant malunions can lead to functional deficits at the shoulder. Thus, with open reduction and internal fixation and anatomic or near-anatomic reduction, there should be a higher likelihood of normal shoulder strength and function. Infection and local sensory deficits would not be expected with nonsurgical management, whereas surgical treatment has a small risk of infection and a high likelihood of sensory deficits from iatrogenic damage to the supraclavicular nerves.

Question 76

A 70-year-old woman with a body mass index (BMI) of 34 and a history of hypercholesterolemia has elected to undergo total hip arthroplasty. Her son recently learned he has factor V Leiden following an episode of pulmonary embolism. What are this patient's risk factors for thromboembolic disease?

Explanation

DISCUSSION:
Risk stratification is one of the most critical clinical evaluations to undertake before performing total joint arthroplasty. Many factors have been identified that increase the risk for venous thromboembolism (VTE) The major factors include previous VTE, obesity, type of surgery (such as total joint arthroplasty), hypercoagulable states, myocardial infarction, congestive heart failure, family history of VTE, and hormone replacement therapy. Hypercholesterolemia is not a risk factor for thromboembolic disease.

Question 77

A high school football player asks you about an oral supplement that increases body mass and improves sprint times. He would like to use it to improve performance. What is the most likely agent? Review Topic

Explanation

The supplement is creatine. Approximately 17% of high school athletes and about 30% of high school football players use creatine. Creatine is a protein synthesized in the liver and the kidney, circulates in the bloodstream, and is incorporated into muscle. Its use is associated with increased muscle mass, short-term improvement in sprinting, and may allow for increased anaerobic resistance performance. Caffeine and ephedrine are taken orally but do not increase muscle mass. Testosterone and human growth hormone are both associated with increased body mass but must be injected.

Question 78

A radiologist's report of a lateral knee radiograph comments that the height of the patella is 4 cm, and the length of the patellar tendon is 3 cm. Which of the following may lead to this measurement? Review Topic

Explanation

The question describes a knee with patella baja, which would likely be seen in the presence of a quadriceps tendon rupture.
The measurements described allow you measure an Insall-Salvati Index (ISI). The ISI is the ratio of the patellar tendon length to the patellar height (distance from the superior pole to the inferior pole). These measurements give a ratio of 0.75 which indicates the presence of patella baja. Normal values range from 0.8 to 1.2. A lower ratio is diagnostic of patella baja, while a higher ratio is diagnostic of patella alta. The ISI as well as some other measures of the patella's position within the trochlea are important when evaluating conditions such as patellar instability or patellofemoral
pain.
Insall and Salvati present their original paper describing the anatomy of the knee with respect to patellar positioning. They note that previous methods of determining patellar positioning was either too complicated, or too subjective. They found the length of the patellar tendon and the height of the patella to be approximately equal, and saw no variations greater than 20%. Thus they proposed the ISI with "normal" values ranging from 0.8 to 1.2.
Shabshin et al. present a study making similar calculations as the ISI but done on sagittal MRI rather than lateral radiographs. They found a slightly higher degree of variation, and defined "normal" as ranging from 0.79 to 1.52. They also noted females tended to have higher ratios on average compared to males.
Aglietti et al. compared various measurements of the patellofemoral joint in a group of asymptomatic knees compared to knees with recurrent patellar subluxation. The normal knees were found to have an ISI of about 1, average congruence angle of -8, and an average Q angle of 15°. The subluxating knees had higher ISIs (average 1.23), higher congruence angles (average +16), and a higher Q angles (average 20°).
Illustration A shows how to measure and calculate the ISI. Illustration B shows measurements of the patellofemoral joint that may help identify presence of trochlear dysplasia and patellar maltracking.
Incorrect Answers:

Question 79

A patient undergoes excision of a 3- x 3-cm soft-tissue sarcoma. The final histology results show tumor at the surgical margin. The surgical procedure performed is classified as

Explanation

DISCUSSION: Surgical margins are classified according to the plane of dissection in relation to the tumor. An intralesional procedure is where the plane of dissection passes through the tumor. A marginal resection involves a resection where the plane of dissection is through the reactive zone of the tumor. A wide resection is through completely normal tissue outside of the reactive zone. A radical resection removes all of the muscles and/or bone of the compartment that are involved by the tumor.
REFERENCE: Enneking WF, Spanier SS, Goodman MA: A system for the surgical staging of musculoskeletal sarcoma. Clin Orthop 1980;153:106-120.

Question 80

A 5-year-old boy reports intermittent left elbow pain. History reveals that he injured his elbow 4 months ago, but had no treatment. He is now using his arm normally but reports pain almost daily. Examination reveals tenderness over the lateral epicondyle and a prominence is evident. Range of motion is from -5 degrees to 120 degrees. Radiographs are shown in Figure 67. Management should include

Explanation

DISCUSSION: The patient has a nonunion of the lateral condyle of the left humerus. Observation or cast treatment at this stage is not likely to lead to healing of the fracture. MRI will not add any additional information. Open reduction, with minimal posterior soft-tissue stripping, is recommended to establish union of the fracture. Local or other bone graft may also be required. There are no studies that indicate that the displaced fracture will heal with late percutaneous fixation.
REFERENCES: Wattenbarger JM, Gerardi J, Johnson CE: Late open reduction internal fixation of lateral condyle fractures. J Pediatr Orthop 2002;223:94-398.

Flynn JC: Nonunion of slightly displaced fractures of the lateral humeral condyle in children: An update. J Pediatr Orthop 1989;9:691-696.

Question 81

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

Explanation

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

Question 82

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

Explanation

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

Question 83

A 55-year-old woman with type I diabetes mellitus has a chronic ulcer over the dorsum of her right foot and reports forefoot pain. Examination reveals 1- x 2-cm nondraining ulcer over the dorsum of the foot. The patient has 1-2+ pain with compression of the foot and ankle. She has a weakly palpable posterior tibial pulse and an absent dorsalis pedis pulse. There is no erythema, cellulitis, or drainage. Radiographs are normal. Which of the following diagnostic studies should be obtained?

Explanation

DISCUSSION: The presence of a dorsal ulcer in the presence of weak or absent pulses strongly suggests the possibility of arterial insufficiency. The best initial noninvasive study to assess for ischemia is the Doppler arterial study. A determination of the vascular status is of a greater priority than an assessment for infection or neuropathy because of the location and presentation of the ulcer. If ankle pressures are less than 45 mm Hg, there is a high risk that these lesions will not heal without revascularization.
REFERENCES: Wagner FW Jr: The dysvascular foot: A system for diagnosis and treatment. Foot Ankle 1981;2:64-122.
Apelqvist J, Castenfors J, Larson J, Stenstrom A, Agardh CD: Prognostic value of systolic ankle and toe blood pressure levels in outcome of diabetic foot ulcer. Diabetes Care 1989;12:373-378.

Question 84

Following application of topical lidocaine, copious arterial bleeding is noted from the region of 1 neurovascular bundle, and the digit remains cool and pale. What is the best next step?

Explanation

DISCUSSION
Used with permission from Benson LS, Williams CS, Kahle M. Dupuytren’s contracture. J Am Acad Surg. 1998
Jan-Feb;6(1):24-35. Review
The spiral cord seen in Dupuytren disease arises from the confluence of abnormal fascial thickening of the spiral bands, lateral digital sheet, and Grayson’s ligament. The orientation of these contributing structures results in a continuous band of fibrous tissue spiraling around the neurovascular bundle. As the developing spiral cord contractures from distal to proximal, the cord itself becomes increasingly linear and shorter, causing displacement of the neurovascular bundle both centrally and superficially. This displacement of the neurovascular bundle brings it closer to the skin and midline, making it more vulnerable to surgical trauma.
Studies have demonstrated a high association between a PIP joint flexion contracture and a spiral cord (Figure 52). Spiral cords are also seen in association with a soft, fleshy mass between the proximal digital flexion crease and distal palmar crease in the interdigital space referred to as an interdigital soft-tissue mass. This represents displacement of normal subcutaneous tissues by contracture of the diseased fascia associated with the spiral cord. Dupuytren diathesis, MCP joint contracture, and the presence of knuckle pads are not indicative of a spiral cord.
A complication following surgical treatment of Dupuytren contracture is trauma to the neurovascular bundle. This can be a consequence of blunt or sharp trauma. In the case of traumatic stretch injury from retraction, vasospasm may develop. The treatment of vasospasm includes flexion, warming the digit, and application of topical medication to treat vasospasm. Allowing the newly extended digit to flex is an important first step, particularly in the case of chronic and severe PIP joint contractures. In these cases, the vessel may have shortened over time, and full extension may cause intimal trauma and secondary vasospasm. Cold is also a stimulus for reactive vasospasm, so warming the digit with warm saline irrigation can be helpful. Finally, topically applied lidocaine (without vasoconstrictive additives) can help diminish vasospasm and lead to digital reperfusion. Phentolamine is useful in cases of prolonged vasospasm secondary to administration of anesthetics containing epinephrine. Streptokinase is a thrombolytic agent that may be useful in treatment of embolic or thrombotic vascular disease. Systemic heparin is useful for digital vessel repair but should not be necessary to treat simple vasospasm.
Copious bleeding in the region of the neurovascular bundle following palmar fasciectomy is an indication of potential arterial trauma. In the setting of arterial laceration, direct repair is necessary, particularly when the digit is dysvascular. This means that both digital vessels are involved or that the intact vessel is insufficient to adequately perfuse the digit. During surgery, the vessels can be directly visualized, and arteriography is unlikely to add additional information of value. Streptokinase is not indicated in this situation because it is useful for thrombolysis rather than vascular repair. Ligation of a traumatized digital artery might be appropriate for a digit that is otherwise well perfused; however, this is not appropriate in the setting of a dysvascular digit. Direct suture of the arterial laceration or segmental grafting necessary to restore adequate digital perfusion in this scenario.
RECOMMENDED READINGS
Rayan GM. Dupuytren disease: Anatomy, pathology, presentation, and treatment. J Bone Joint Surg Am. 2007 Jan;89(1):189-98. Review. PubMed PMID: 17256226. View Abstract at PubMed
Watson HK, Paul H Jr. Pathologic anatomy. Hand Clin. 1991 Nov;7(4):661-8. Review. PubMed PMID: 1769988. View Abstract at PubMed
Jones NF, Huang JI. Emergency microsurgical revascularization for critical ischemia during surgery for Dupuytren's contracture: a case report. J Hand Surg Am. 2001 Nov;26(6):1125-8. PubMed PMID: 11721263. View Abstract at PubMed

Question 85

A 23-year-old woman falls from a bicycle and sustains a right knee injury. Figures 12a through 12d show radiographs and MRI scans of the knee. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiographs and MRI scans both show an avulsion of the anterior cruciate ligament, which has been described by Meyers and McKeever in three different fracture patterns. Type I fractures are nondisplaced or have minimal displacement of the anterior margin. Type II fractures have superior displacement of their anterior aspect with an intact posterior hinge. Type III fractures are completely displaced. Although the injury is visible on the radiographs, it is more subtle in adults than children. Thus, MRI is helpful in clarifying this injury in adults. Open or arthroscopic reduction and internal fixation is recommended for type II and type III fractures that do not respond to closed reduction.
REFERENCES: Meyers MH, McKeever FM: Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1970;52:1677-1684.
Wiss DA, Watson JT: Fractures of the tibial plateau, in Rockwood CA, Green DP, Bucholz RW, et al (eds): Rockwood and Green’s Fractures in Adults. Philadelphia, PA, Lippincott-Raven, 1996, pp 1920-1953.
Lubowitz JH, Elson WS, Guttmann D: Arthroscopic treatment of tibial plateau fractures: Intercondylar eminence avulsion fractures. Arthroscopy 2005;21:86-92.

Question 86

A 55-year-old male is involved in a motorcycle crash and sustains a closed, right-sided, midshaft femur fracture. This is an isolated injury. He is treated with retrograde femoral nailing, and postoperatively is noted to have 30 degrees of internal rotation of the operative extremity, when compared with his nonsurgical side. Which of the following is the most likely cause of this malrotation deformity?

Explanation

Internal rotation of the distal segment of the femur relative to the proximal segment of the femur during nailing can cause a malrotation deformity.
Postsurgical internal malrotation after treatment for a diaphyseal femur fracture typically occurs either via internal rotation of the distal segment relative to the proximal or external rotation of the proximal segment relative to the distal. These clinical findings are consistent with an iatrogenic increase in femoral anteversion.
Dimitriou et al. performed a study to quantify the side-to-side anatomic variation in the proximal femur and the implications for preoperative planning and leg length discrepancy following hip arthroplasty. CT-based 3D femoral models were reconstructed for 122 paired femurs in 61 young healthy subjects with no history of hip pathology. Significant side-to-side differences were found in femoral anteversion, horizontal offset, and femoral head center location.
They concluded that relying on the anatomic landmarks of the contralateral femur during hip arthroplasty may not necessarily result in restoration of native anatomy and leg-length.
Karaman et al. conducted a study which saught to clarify the influence of a femoral rotational malalignment of ≥10° after intramedullary nailing on daily activities. They evaluated twenty-four femoral shaft fracture patients treated with closed antegrade IMN, and determined the presence of malrotation with post-operative CT scans. Ten of the 24 patients had a CT-detected true rotational malalignment of ≥10° compared with the unaffected side, and were noted to have significantly worse functional outcome scores compared with normally rotated femoral shaft patients.
Espinoza et al. present a technique using intraoperative fluoroscopy and the anteversion inherent to the IM nail for obtaining appropriate femoral rotational alignment during surgery. The authors state that their technique reliably sets the femoral anteversion within a normal physiologic range with minimal additional intraoperative steps and without preoperative measurements.
Illustration A shows a CT evaluation of femoral malrotation. The angle on the uninjured side measures 30°, while the malrotated fractured side measures only 3°, indicating a 27° external rotation deformity.
Incorrect Answers:

OrthoCash 2020

Question 87

04 A pt wishes to return to driving after undergoing surgery for a displaced fibular fracture of the right ankle. A return to nml braking

Explanation

Lower-Extremity Function for Driving an Automobile After Operative Treatment of Ankle Fracture. Kenneth A. Egol, MD et al JBJS 2003
A computerized driving simulator was developed andtested. Eleven healthy volunteers were tested once to establishnormal mean values (Group I), and a group of thirty-one volunteerswith a fracture of the right ankle were tested at six, nine,and twelve weeks following operative repair (Group II). Thesubjects were tested with a series of driving scenarios (city,suburban, and highway). Scores on the Short Form MusculoskeletalAssessment were recorded at six, nine, and twelve weeks andwere compared with the results of the driving test. The effect of the time of the visit and of the testing conditionon the braking times was investigated.
Conclusion: By nine weeks, the total braking time of patientswho have undergone fixation of a displaced right ankle fracturereturns to the normal, baseline value

Question 88

In the preoperative planning of revision acetabular reconstruction, the surgeon should identify significant posterior column deficiency by noting which of the following radiographic features?

Explanation

DISCUSSION: Proximal and medial migration of the femoral head usually indicates deficiencies of the dome or anterior column. Wear of the polyethylene may result in osteolysis and impingement, which are not indicative of any major bone deficiency. A significant osteolytic lesion in the ischium may represent a major posterior column deficiency that can create a technical challenge during the reconstruction.
REFERENCES: Paprosky WG, Magnus RE: Principles of bone grafting in revision total hip arthroplasty: Acetabular technique. Clin Orthop 1994;298:147-155.
Campbell DG, Masri BA, Garbuz DS, Duncan CP: Acetabular bone loss during revision total hip replacement: Preoperative investigation and planning, in Zuckerman J (ed): Instructional Course Lectures 48. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 43-56.

Question 89

Which of the following statements best describes labral tears in the hip? Review Topic

Explanation

Labral and chondral lesions are observed within the anterosuperior quadrant of the acetabulum. Tearing of the labrum markedly reduces resistance to joint motion, leading to instability. The most common associated lesions are chondral injuries. They can occur with or without abnormal bone morphology. The etiology for labral tears can be from traumatic and degenerative causes, structural abnormalities from femoroacetabular impingement, developmental abnormalities, and hip instability.

Question 90

When harvesting iliac crest bone graft during a posterior spinal decompression and fusion, injury to what structure can result in painful neuromas or numbness over the skin of the buttocks?

Explanation

DISCUSSION: The superior cluneal nerves (L1, L2, and L3) are most at risk when harvesting iliac crest bone graft during a posterior decompression and fusion. These nerves pierce the lumbodorsal fascia and cross the posterior iliac crest, beginning 8 cm lateral to the posterior superior iliac spine. The ilioinguinal nerve is more at risk during exposure of the anterior ilium during retraction of the iliacus and abdominal wall muscles. Iliohypogastric nerve injury may arise in a similar fashion to ilioinguinal neuralgia. The lateral femoral cutaneous nerve lies in close proximity to the anterior superior iliac spine and is also at risk with anterior iliac crest bone graft harvesting. The superior gluteal nerve courses through the sciatic notch and supplies motor branches to the gluteus medius, minimus, and tensor fascia lata muscles. Injury results in hip abduction weakness.
REFERENCES: An HS: Principles and Techniques of Spine Surgery. Baltimore, MD, Williams and Wilkins 1998, pp 770-773.
Kurz LT, Garfin SR, Booth RE Jr: Harvesting autogenous iliac bone grafts: A review of complications and techniques. Spine 1989;14:1324-1331.
Mrazik J, Amato C, Leban S, et al: The ilium as a source of autogenous bone grafting: Clinical considerations. J Oral Surg 1980;38:29-32.

Question 91

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

Explanation

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

Question 92

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

Explanation

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

Question 93

Figures 42a through 42c show the MRI scans of a 56-year-old woman with progressively worsening low back and bilateral lower extremity pain. Based on these images, what muscle or muscle group would be expected to be weak on physical examination? Review Topic

Explanation

Whereas subjective complaints of leg pain are common among patients seeking surgical treatment for spondylolisthesis, documented neurologic deficit or radiculopathy is seen less frequently. Subjective decreases to light touch over the dorsum of the foot and mild weakness of the extensor hallucis longus are the most common neurologic abnormalities, correlating with L5 nerve root irritation as seen
with L5-S1 spondylolisthesis. Many patients with spondylolisthesis report hamstring tightness; however, these structures are not usually weak. Quadriceps and tibialis anterior weakness is seen with L4 nerve root irritation. The gastrocnemius is generally weak in S1 nerve root syndromes.

Question 94

The implant shown in Figures 47a and 47b is introduced submuscularly employing a minimally invasive technique. A percutaneous method of screw insertion is used distally. What nerve is most at risk?

Explanation

Minimally invasive methods used for stabilizing complex periarticular fractures continue to evolve. Encouraging results suggest a diminished threat to the soft tissues and enhanced preservation of osseous blood supply. Contemporary locking implants combined with indirect reduction lead to desirable biomechanical and biologic environments for osseous and soft-tissue healing. Deangelis and associates, in a cadaveric tibial study, demonstrated the superficial peroneal nerve to be at significant risk during percutaneous screw placement in very distal targeted holes (within laterally applied tibial locking plates). Use of a larger incision and cautious dissection to the plate in this region were encouraged to minimize risk to this structure.

Question 95

A 58-year-old woman is seen in the emergency department after falling at home. History reveals that she underwent right total knee arthroplasty 2 years ago. Radiographs are shown in Figures 56a and 56b. What is the most appropriate treatment?

Explanation

DISCUSSION: The radiographs show an oblique periprosthetic distal femoral fracture. Of the options listed, open reduction and internal fixation is the most appropriate surgical option because a well-fixed, posterior stabilized closed box femoral component is present. Nonsurgical methods are not favored because of the highly displaced, unstable fracture pattern and prolonged immobility. Revision with a stemmed component is an option but would sacrifice more bone stock in this younger patient.
REFERENCES: Moran MC, Brick GW, Sledge CB, et al: Supracondylar femoral fracture following total knee arthroplasty. Clin Orthop 1996;324:196-209.
Raab GE, Davis CM III: Early healing with locked condylar plating of periprosthetic fractures around the knee. J Arthroplasty 2005;20:984-989.
Tharani R, Nakasone C, Vince KG: Periprosthetic fractures after total knee arhtroplasty.
J Arthroplasty 2005;20:27-32.

Question 96

Mirror therapy is indicated for which of the following clinical conditions?

Explanation

Mirror therapy is a useful technique to improve phantom pain in amputees. Phantom limb pain is a painful sensation that is perceived within a body part that no longer exists.
Under mirror therapy, a patient is allowed to feel the imaginary movement of the removed body part behaving as normal body movement through a mirror. The mirror
image of the normal body part helps reorganize and integrate the mismatch between proprioception and visual feedback of the amputated segment.
Tilak et al. performed a randomized controlled trial of 26 patients with phantom limb pain, and found that mirror therapy as well as transcutaneous electrical nerve stimulation both significantly improved pain scores, but no difference was seen between the two groups. They recommend use of both modalities in treatment of phantom limb pain, as they are noninvasive and inexpensive.
Chan et al. reviewed 22 patients utilizing mirror therapy for amputation related phantom limb pain, and found that patients reported a significant decrease in pain when utilizing this treatment modality as compared to covered mirror therapy or mental imagery therapy.
Illustration A shows a patient with an upper extremity amputation using a mirror to perform movements during a mirror therapy session.
Incorrect Answers:

Question 97

A 66-year-old woman was a restrained passenger in an automobile accident. She sustained a direct blow to her nondominant left hand as the airbag in her automobile deployed and she now reports pain, swelling, and difficulty moving her fingers. Radiographs are shown in Figures 58a and 58b. Appropriate definitive treatment should consist of

Explanation

DISCUSSION: While most isolated metacarpal fractures can be treated nonsurgically, multiple metacarpal fractures are inherently unstable due to the loss of support that an intact adjacent metacarpal provides; therefore, treatment should consist of surgical fixation of all three metacarpal fractures.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 286.
Faraj AA, Davis TR: Percutaneous intramedullary fixation of metacarpal shaft fractures. J Hand Surg Br 1999;24:76-79.

Question 98

-What is the most common impediment to successful closed reduction of the injury seen in Figures 9aand 9b?

Explanation

Question 99

Endurance training stimulates which of the following physiologic adaptations in the athlete? Review Topic

Explanation

Endurance training causes selective hypertrophy of type I muscle fibers. It stimulates an increase in the enzymes of the Krebs cycle which increases the capacity for aerobic ATP resynthesis during exercise. There is a decrease in the rate of glycogen depletion. Depletion of glycogen has been linked to fatigue during endurance exercise. Endurance training blunts the catecholamine response and may contribute to the reduction in heart rate observed for the same exercise intensity following training. The greater use of lipid reduces the contribution of carbohydrate to ATP resynthesis and preserves muscle glycogen.

Question 100

Which of the following is most associated with local recurrence of the lesion seen in the radiograph and MRI scan shown in Figures 27a and 27b?

Explanation

DISCUSSION: The lesion is an aneurysmal bone cyst. These lesions are known to have a local recurrence rate of 5% to 50%. Young age, open physes, stage, and type of surgical removal and resulting margin have all been shown to affect the recurrence rate. Chemotherapy is not used in the treatment of aneurysmal bone cysts.
REFERENCES: Gibbs CP Jr, Hefele MC, Peabody TD, et al: Aneurysmal bone cyst of the extremities: Factors related to local recurrence after curettage with a high-speed burr. J Bone Joint Surg Am 1999;81:1671-1678.
Vergel De Dios AM, Bond JR, Shives TC, et al: Aneurysmal bone cyst: A clinicopathologic study of 238 cases. Cancer 1992;69:2921-2931.

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

Head CT
MRI of the head
Neuropsychologic testing
Radiographs of the skull
Sideline assessment

Correct Answer: Neuropsychologic testing

Explanation:

Question 2:

What is the primary indication for performing a total wrist arthroplasty in a patient with painful rheumatoid arthritis?

Options:

Ipsilateral total elbow arthroplasty
Contralateral wrist arthrodesis
Type III degenerative changes of the wrist
Age older than 55 years
Less than 30 degrees of wrist flexion/extension

Correct Answer: Contralateral wrist arthrodesis

Explanation:

Question 3:

- A form of renal osteodystrophy that is characterized by pure osteomalacia is caused by

Options:

Secondary hyperparathyroidism
Phosphate retention secondary to uremia
Insufficient renal synthesis of 1, 25 dihydroxy vitamin D
Aluminum deposition in bone from oral phosphate binders
Persistent acidosis aggravating the negative calcium balance

Correct Answer: Aluminum deposition in bone from oral phosphate binders

Explanation:

Question 4:

Options:

a University of California Biomechanics Laboratory (UCBL) orthosis.
subtalar arthrodesis.
physeal bar resection.
tibial epiphysiodesis.
closing wedge distal tibial osteotomy.

Correct Answer: closing wedge distal tibial osteotomy.

Explanation:

Question 5:

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

Options:

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

Correct Answer: Popliteus tendon

Explanation:

Question 6:

Options:

anterior corpectomy followed by strut grafting and instrumentation.
halo vest immobilization.
laminectomy and posterior wiring.
laminectomy followed by halo vest immobilization.
posterior lateral mass plating and fusion.

Correct Answer: anterior corpectomy followed by strut grafting and instrumentation.

Explanation:

Question 7:

A 52-year-old woman who is right hand-dominant sustains an injury to her elbow in a fall. A radiograph is shown in Figure 60. The preferred treatment of this injury pattern should include

Options:

lateral plating of the proximal ulna and fixation of the radial head.
Kirschner wire/tension band fixation of the proximal ulna alone.
closed reduction and casting.
dorsal plating of the proximal ulna and radial head replacement.
total elbow arthroplasty.

Correct Answer: dorsal plating of the proximal ulna and radial head replacement.

Explanation:

DISCUSSION: The patient has a Bado type 2 variant Monteggia fracture with a radial head fracture. The type 2 variant is associated with a higher nonunion rate and poorer outcomes compared to other Bado-type Monteggia fractures. While it is potentially acceptable to repair the radial head, factors such as higher degrees of comminution and older age lead toward replacement as the treatment of choice. Plate and screw fixation is favored over Kirschner wire/tension band fixation because this is not a simple olecranon fracture. Plate placement in a type 2 fracture is dorsal to counteract very high tensile forces associated with fixation failure.
REFERENCES: Egol KA, Tejwani NC, Bazzi J, et al: Does a Monteggia variant lesion result in a poor functional outcome? A retrospective study. Clin Orthop Relat Res 2005;438:233-238.
Jupiter JB, Leibovic SJ, Ribbans W, et al: The posterior Monteggia lesion. J Orthop Trauma 1991;5:395-402.
Konrad GG, Kundel K, Kreuz PC, et al: Monteggia fractures in adults: Long-term results and prognostic factors. J Bone Joint Surg Br 2007;89:354-360.

Question 8:

Options:

free vascularized fibula.
calcium sulfate pellets.
corticocancellous autograft.
demineralized bone matrix. The patient developed a large bone defect after undergoing multiple débridements for an open fracture. The most appropriate graft in this setting is a vascularized bone graft. Considering the length of the defect, a free vascularized fibular graft would be a suitable graft. The indications for a vascularized bone graft include infection, inadequate vascularity of the surrounding tissues, bone defects larger than 6 centimeters, and previous failed bone grafts. The osteocytes survive in the vascularized graft, allowing primary bone healing and thereby limiting a loss of graft strength. In contrast, nonvascularized bone graft heals by creeping substitution with a loss of its initial strength. Calcium sulfate pellets and calcium phosphate cement are synthetic bone substitutes with osteoconductive properties. Their role in fracture healing is limited. Demineralized bone matrix is the matrix remaining after allograft undergoes decalcification processing. These products alone would not be optimal in the treatment of such a large bone defect.

Correct Answer: free vascularized fibula.

Explanation:

Question 9:

Options:

Open reduction and cerclage fixation of the fracture
Open reduction and revision of the femoral implant to a long cemented stem
Open reduction and revision of the femoral implant to a long fluted and tapered uncemented stem
Application of balanced traction followed by surgery after the ecchymosis has resolved

Correct Answer: Application of balanced traction followed by surgery after the ecchymosis has resolved

Explanation:

Question 10:

The superior glenohumeral ligament primarily restrains

Options:

posterior translation of the humeral head with the arm in 90 degrees of abduction.
inferior translation of the humeral head with the arm in adduction.
anterior translation of the humeral head in 90 degrees of abduction.
anterior translation of the humeral head with the arm in 45 degrees of abduction.
anterior translation of the humeral head with the arm in 90 degrees of abduction and external rotation.

Correct Answer: inferior translation of the humeral head with the arm in adduction.

Explanation:

Question 11:

Options:

Osteogenic sarcoma
Ewing’s sarcoma
Giant cell tumor of bone
Aneurysmal bone cyst
Metastatic adenocarcinoma

Correct Answer: Giant cell tumor of bone

Explanation:

Question 12:

Options:

His clinical outcome will correlate closely with his initial reduction.
His outcome will correlate with his radiographic score on the Ankle Osteoarthritis Score.
He will likely require a late ankle arthrodesis.
He will demonstrate marked limitations with regard to recreational activities.
He will perceive improvements for a period of over 2 years.

Correct Answer: He will perceive improvements for a period of over 2 years.

Explanation:

Marsh and associates retrospectively reviewed 56 tibial plafond fractures and found that the patients perceived improvement in their function and pain for an average of

Question 13:

Options:

Superior labral detachment
Engaging Hill-Sachs lesion
Large glenoid rim fracture
Avulsion of the inferior glenohumeral ligament from the humerus
Avulsion of the anterior inferior glenoid labrum

Correct Answer: Avulsion of the anterior inferior glenoid labrum

Explanation:

DISCUSSION: In an acute first-time dislocation, arthroscopy has been shown to reveal a Bankart lesion in most shoulders. The classic finding of labral detachment from the anterior inferior glenoid along with occasional hemorrhage within the inferior glenohumeral ligament is the most common sequelae of a traumatic anterior inferior dislocation. Acute treatment, if chosen, is repair of the labral tissue back to the glenoid plus or minus any capsular plication to address potential plastic deformation of the glenohumeral ligament. Acute treatment of a patient sustaining a first-time dislocation remains controversial. The potential indications may be patients whose dislocation occurs at the end of a season and when the desire to minimize risk of future instability outweighs the risks of surgical intervention.
REFERENCES: Taylor DC, Arciero RA: Pathologic changes associated with shoulder dislocations: Arthroscopic and physical examination findings in first-time, traumatic anterior dislocations. Am J Sports Med 1997;25:306-311.
DeBerardino TM, Arciero RA, Taylor DC, et al: Prospective evaluation of arthroscopic stabilization of acute, initial anterior shoulder dislocations in young athletes: Two- to five-year follow-up. Am J Sports Med 2001;29:586-592.
Bottoni CR, Wilckens JH, DeBerardino TM, et al: A prospective, randomized evaluation of arthroscopic stabilization versus nonoperative treatment in patients with acute, traumatic,
first-time shoulder dislocations. Am J Sports Med 2002;30:576-580.

Question 14:

Options:

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

Correct Answer: 35% to 45%

Explanation:

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

Question 15:

Which of the following radiographic parameters is most predictive of a poor result following multilevel fusion surgery for adult degenerative scoliosis? Review Topic

Options:

An L5-S1 degenerative disk left out of the fusion
Coronal imbalance
Residual scoliosis of greater than 25 degrees
Residual foraminal stenosis
Sagittal imbalance

Correct Answer: Sagittal imbalance

Explanation:

Question 16:

Which of the following hip fracture patterns is at increased risk of proximal fragment flexion malreduction with dynamic hip screw fixation?

Options:

Right-sided unstable intertrochanteric fracture
Left-sided unstable intertrochanteric fracture
Left-sided stable intertrochanteric fracture
Right-sided stable intertrochanteric fracture
All unstable intertrochanteric fractures

Correct Answer: Right-sided unstable intertrochanteric fracture

Explanation:

Question 17:

Options:

Supplemental internal fixation
Primary ankle arthrodesis
Nonsurgical treatment to avoid infection
Early bone grafting because of poor bone quality
Early mobilization and weight bearing to minimize stiffness

Correct Answer: Supplemental internal fixation

Explanation:

Question 18:

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

Options:

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

Correct Answer: Net increase of type I collagen

Explanation:

Question 19:

What is the most common neurologic complication following an anterior cervical diskectomy and fusion?

Options:

Spinal cord injury
Nerve root injury
Vagus nerve injury
Recurrent laryngeal nerve injury
Horner’s syndrome

Correct Answer: Recurrent laryngeal nerve injury

Explanation:

Question 20:

Options:

Ceramic-on-ceramic
Large diameter metal head on highly cross-linked polyethylene liner
Ceramic head on metal liner
Large diameter metal-on-metal total hip arthroplasty
Metal on conventional polyethylene liner (noncross-linked)

Correct Answer: Large diameter metal head on highly cross-linked polyethylene liner

Explanation:

Question 21:

Options:

Observation
Radiation therapy
Curettage
En bloc excision with stabilization
En bloc excision followed by radiation therapy

Correct Answer: En bloc excision with stabilization

Explanation:

Question 22:

Options:

Observation and patient education regarding hip dislocation precautions
Revision to a larger-diameter femoral head
Revision to a constrained acetabular component
Application of a hip orthosis for 3 months

Correct Answer: Observation and patient education regarding hip dislocation precautions

Explanation:

Question 23:

A radiograph, MRI scans, and a biopsy specimen of a 9-year-old boy with thigh pain are shown in Figures 37a through 37d. Management should consist of

Options:

external beam radiation.
hemipelvectomy.
hip disarticulation.
wide resection of the femur and reconstruction.
antibiotics.

Correct Answer: wide resection of the femur and reconstruction.

Explanation:

Question 24:

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

Options:

Correct Answer: 21c

Explanation:

Question 25:

Options:

Superior approach with trochanteric slide
Direct anterior approach with a chevron modification of the standard greater trochanteric osteotomy
Lateral approach with a partial greater trochanter osteotomy
Posterolateral approach with an extended trochanteric osteotomy

Correct Answer: Posterolateral approach with an extended trochanteric osteotomy

Explanation:

Question 26:

Options:

Soft-tissue foreign body
Lipoma
Hematoma
Pyomyositis
Liposarcoma

Correct Answer: Hematoma

Explanation:

Question 27:

The afferent pain innervation of the L3-L4 facet joint arises from the medial branch nerve of

Options:

L2.
L3.
L4.
L2 and L3.
L3 and L4.

Correct Answer: L2 and L3.

Explanation:

Question 28:

Options:

Which of the following conditions associated with rheumatoid arthritis of the cervical spine is shown in the flexion-extension views in figures 45a and 45b?
Cranial setting
Cranial subluxation
Odontoid fracture
Lysis of the arch of the atlas
Atlantoaxial subluxation

Correct Answer: Lysis of the arch of the atlas

Explanation:

Question 29:

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

Options:

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

Correct Answer: total elbow arthroplasty.

Explanation:

Question 30:

Options:

Balanced traction to address concern for persistent infection with reoperation
Open reduction and internal fixation of the fracture with a lateral plate and screws
Removal of the articulating spacer and revision to a longer-stem antibiotic-loaded articulating spacer
Removal of the articulating spacer and reimplantation using a long-stem fluted uncemented hip replacement

Correct Answer: Open reduction and internal fixation of the fracture with a lateral plate and screws

Explanation:

Question 31:

In the treatment of thoracic disk herniations, what approach is associated with the highest risk of iatrogenic paraplegia?

Options:

Laminectomy
Costotransversectomy
Transpedicular
Transthoracic
Thoracoscopic

Correct Answer: Laminectomy

Explanation:

Question 32:

What is the typical axial plane transverse angulation of the thoracic pedicles? Review Topic

Options:

5 degrees medial at T1 and T2; 10 degrees from T3 to T10
5 degrees lateral at T1; neutral at T2; 5 degrees medial from T3 to T12
10 degrees medial from T1 to T10; 15 degrees medial at T11 and T12
10 degrees medial from T1 to T12
25 degrees medial at T1; 15 degrees at T2; and 10 degrees medial from T3 to T10

Correct Answer: 25 degrees medial at T1; 15 degrees at T2; and 10 degrees medial from T3 to T10

Explanation:

Question 33:

With comparison to a below the knee amputation, each of the following are disadvantages of a through the knee amputation EXCEPT:

Options:

Slower self-selected walking speeds
Worse performance on the Sickness Impact Profile (SIP)
Physicians were less satisfied with the cosmetic recovery
More severe pain at amputation site
Require more dependence with patient transfers

Correct Answer: Slower self-selected walking speeds

Explanation:

DISCUSSION: Through-the-knee amputation level is associated with the worst functional result 2 years after injury (compared to transmetatarsal, Symes, AKA, or BKA)
The cohort study by MacKenzie et al prospectively followed 161 patients that were part of the Lower Extremity Assessment Project (LEAP). These patients underwent an above-the-ankle amputation at a trauma center within 3 months following the injury and followed for 2 years. This study revealed that through-the-knee amputations had significantly worse scores for the objective performance measures of self-selected walking speed, independence in transfers, walking, and stair-climbing. Through-the-knee amputees also had worse SIP scores than AKA and BKA patients. Physicians were also less satisfied with both the clinical and the cosmetic recovery of the patients with a through-the-knee amputation. It should be noted that patients with a BKA had a faster walking speed than those with an AKA. Despite the worse SIP scores for through-the-knee amputations, patients actually reported less pain than those with an AKA or BKA, though this wasn't statistically significant.
(SBQ06.2)
A 21-year-old male presents to the emergency department after sustaining a gun shot wound to his back. Subsequent radiographs reveal a bullet in the L2 vertebral body. Physical exam shows no neurologic deficits. He undergoes emergent laparotomy and is found to have a small bowel laceration. What would be the preferred treatment following his exploratory laparotomy and small bowel repair?
Intravenous antibiotic coverage for Gram negative bacteria for 7 days
Surgical decompression and bullet fragment removal
Observation
Broad-spectrum oral antibiotic coverage for 7 days
Broad-spectrum intravenous antibiotic coverage for 7 days
DISCUSSION: The clinical presentation is consistent with a GSW with bowel perforation and a retained bullet in the vertebral body. Because the patient is neurologically intact broad-spectrum intravenous antibiotic coverage for 7 days is the most appropriate treatment.
Gunshot wounds to the spine present relatively little risk of infection in most cases. When there has been an injury to the small bowel, the risk of infection can be minimized with a 7-day course of broad-spectrum antibiotics. Indications for surgery include when a neurological deficit is present that correlates with imaging findings of neurological compression by the missile, or when the missile is in contact with the CSF posing a risk for metal toxicity.
Roffi et al performed a Level 4 study of 42 patients that sustained a gunshot wound that perforated the stomach or bowel and then entered the spinal column. They found that an extended regimen of broad spectrum antibiotics combined with bedrest appeared to significantly reduce the risk of spinal or paraspinal infection, whereas early bullet removal did not significantly prevent the occurrence of infection.
Velmahoos et al performed a Level 4 study including 24 patients that sustained a gunshot wound to the spine with associated colonic injury. They found that the incidence of sepsis was 8.4% (compared to 5% in non-bowel injuries) and concluded that retainment of the bullet did not increase the rate of sepsis.
Incorrect Answers:

Question 34:

Options:

vagus nerve.
recurrent laryngeal nerve.
superior laryngeal nerve.
hypoglossal nerve.
sympathetic trunk.

Correct Answer: recurrent laryngeal nerve.

Explanation:

Question 35:

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

Options:

Age <20
Tonnis grade 2
Prominence of the femoral head in cam impingement
The patient is a professional athlete

Correct Answer: Tonnis grade 2

Explanation:

Question 36:

What is the most common foot and ankle deformity in patients with arthrogryposis?

Options:

Talipes eqinovarus
Metatarsus adductus
Brachymetatarsia
Pes planus
Tarsal coalition

Correct Answer: Talipes eqinovarus

Explanation:

Question 37:

Patients with patellar clunk syndrome are best managed by which of the following methods?

Options:

Rest and nonsteroidal anti-inflammatory drugs
Surgical debridement
Patellectomy
Patellar revision
Lateral release/patellar realignment

Correct Answer: Surgical debridement

Explanation:

DISCUSSION: Patellar clunk syndrome is usually the result of a fibrous nodule that forms on the undersurface of the distal quadriceps tendon. It may get entrapped in the intercondylar notch of the femoral component during flexion, and lead to a sudden snap as the nodule is pulled out of the notch during active extension. Nonsurgical management is rarely successful. Surgical debridement is usually curative, with only rare recurrence. More aggressive procedures such as realignment, revision, or patellectomy are usually not necessary, and are reserved for cases resistant to soft-tissue debridement.
REFERENCES: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update:
Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, p 329.
Diduch DR, Scuderi GR, Scott WN, et al: The efficacy of arthroscopy following total knee replacement. Arthroscopy 1997;13:166-171.
Lucas TS, DeLuca PF, Nazarian DG, et al: Arthroscopic treatment of patellar clunk. Clin Orthop 1999;367:226-229.

Question 38:

During primary total knee arthroplasty, what is the maximum distance the joint line can be raised or lowered before poor motion, joint instability, and increased chance of revision occur?

Options:

4 mm
8 mm
12 mm
16 mm
20 mm

Correct Answer: 8 mm

Explanation:

Question 39:

What is the most likely diagnosis based on the MRI findings shown in Figures 87a and 87b? Review Topic

Options:

Anterior cruciate ligament (ACL) tear
Posterior cruciate ligament (PCL) tear
Lateral collateral (LCL) ligament tear
Patellar dislocation
Patellar tendon rupture

Correct Answer: Patellar dislocation

Explanation:

Question 40:

Figure 19 shows the radiograph of a 12-year-old boy who sustained an injury to his hand when another child fell on him. Management should consist of

Options:

early motion and muscle strengthening.
immobilization in a thumb spica cast with the thumb abducted.
open reduction and internal fixation through a volar approach.
open reduction and internal fixation through a dorsal approach.
closed reduction and percutaneous pin fixation.

Correct Answer: open reduction and internal fixation through a dorsal approach.

Explanation:

Question 41:

What is the most likely late complication associated with cementless total knee replacement?

Options:

Loss of motion
Patellofemoral pain
Osteolysis
Heterotopic ossification
Patellar clunk

Correct Answer: Osteolysis

Explanation:

Question 42:

Options:

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

Correct Answer: 7 to 14 days.

Explanation:

Question 43:

All of the following are considered contraindications to the use of functional bracing of a humeral shaft fracture EXCEPT:

Options:

Mid-diaphyseal segmental fracture with ipsilateral pilon fracture
Mid-diaphyseal fracture with radial nerve palsy from penetrating injury
Proximal one-third oblique fracture
Mid-diaphyseal closed fracture with a radial nerve palsy on presentation
Mid-diaphyseal fracture with a L1 burst fracture and paraplegia on presentation

Correct Answer: Mid-diaphyseal segmental fracture with ipsilateral pilon fracture

Explanation:

Question 44:

Rickets can be best characterized by which of the following radiographic changes in children?

Options:

Narrowed physes
Widening of the ribs anteriorly
Rounded epiphyses
Punched out metaphyseal defects with subperiosteal resorption
Sclerotic bands in the upper and lower margins of each vertebra

Correct Answer: Widening of the ribs anteriorly

Explanation:

Question 45:

Options:

External fixation
Plate fixation
Unreamed unlocked intramedullary nailing
Reamed statically locked intramedullary nailing
Reamed unlocked nailing

Correct Answer: External fixation

Explanation:

Question 46:

Figure 10 shows the MRI scan of a 56-year-old woman with metastatic breast cancer who now reports progressive paraparesis. Her general health remains good. Treatment should consist of

Options:

posterior spinal fusion for stabilization, followed by radiation therapy of the anterior tumor.
radiation therapy and a brace.
chemotherapy, then reevaluation.
anterior corpectomy and stabilization.
laminectomy.

Correct Answer: anterior corpectomy and stabilization.

Explanation:

Question 47:

Options:

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

Correct Answer: - Branch of the pudendal artery

Explanation:

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

Question 48:

During a dual incision fasciotomy of the leg, the soleus is elevated from the tibia to allow access to which of the following compartments?

Options:

Superficial posterior
Deep posterior
Lateral
Anterior
Mobile wad

Correct Answer: Superficial posterior

Explanation:

Question 49:

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 50:

Options:

Intercostal muscle strain
Rib stress fracture
Pneumothorax
Costochondritis
Empyema

Correct Answer: Rib stress fracture

Explanation:

Question 51:

Options:

metacarpophalangeal (MP) joint extension.
proximal interphalangeal (PIP) joint extension.
MP flexion.
PIP joint flexion.

Correct Answer: proximal interphalangeal (PIP) joint extension.

Explanation:

EXPLANATION:
This is a transverse proximal phalanx fracture with apex volar angulation. The fracture displaces into an apex volar angulated position under the pull of the central slip on the distal fragment and the interossei insertions at the base of proximal phalanx. Although it is possible to lose motion in flexion or extension of the MP or PIP joints, the biomechanics will not allow full extension of the PIP joint. If allowed to heal in apex palmar malunion, the predicted corresponding extensor lags are for a 10-degree lag at 16 degrees of angular deformity, a 24-degree lag at 27 degrees of deformity, and a 66-degree lag at 46 degrees of deformity. These fractures usually can be treated with closed reduction with or without percutaneous
pinning. With surgical treatment, there may be loss of motion both at the MP and PIP joints.

Question 52:

Denosumab, a monoclonal antibody used to treat osteoporosis, works through inhibition of

Options:

receptor activator of nuclear factor kappa beta (RANK).
RANK ligand (RANKL).
osteoprotegrin (OPG).
tumor necrosis factor (TNF).

Correct Answer: RANK ligand (RANKL).

Explanation:

Question 53:

Options:

Total ankle arthroplasty (TAA)
Ankle arthrodesis
Tibiotalocalcaneal arthrodesis
Anterior tibial exostectomy with Achilles lengthening

Correct Answer: Ankle arthrodesis

Explanation:

DISCUSSION
This patient has isolated posttraumatic ankle arthritis with significantly decreased ankle range of motion that is best treated with an isolated ankle arthrodesis to eliminate pain. Because this patient is younger than 50 years of age and has limited presurgical range of motion, she is not a candidate for ankle arthroplasty. Additionally, TAA outcomes among patients who have a posttraumatic etiology are worse than for those with osteoarthritis. Tibiotalocalcaneal arthrodesis is suited for patients with associated subtalar
arthritis or rigid hindfoot deformity that necessitates correction. Anterior tibial exostectomy will not resolve the underlying arthritic pain and is not indicated.
RECOMMENDED READINGS
Easley ME, Adams SB Jr, Hembree WC, DeOrio JK. Results of total ankle arthroplasty. J Bone Joint Surg Am. 2011 Aug 3;93(15):1455-68. doi: 10.2106/JBJS.J.00126. Review. PubMed PMID: 21915552.
View Abstract at PubMed
Spirt AA, Assal M, Hansen ST Jr. Complications and failure after total ankle arthroplasty. J Bone Joint Surg Am. 2004 Jun;86-A(6):1172-8. PubMed PMID: 15173289.
View Abstract at
PubMed
Ajis A, Henriquez H, Myerson M. Postoperative range of motion trends following total ankle arthroplasty. Foot Ankle Int. 2013 May;34(5):645-56. doi: 10.1177/1071100713481433. Epub 2013 Mar 11. PubMed PMID: 23478890.
View Abstract at PubMed
Thomas R, Daniels TR, Parker K. Gait analysis and functional outcomes following ankle arthrodesis for isolated ankle arthritis. J Bone Joint Surg Am. 2006 Mar;88(3):526-35. PubMed PMID: 16510818.
View Abstract at PubMed
Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am. 2001 Feb;83-A(2):219-28. PubMed PMID: 11216683.
View Abstract at PubMed

Question 54:

Options:

shorter hospital stay.
lower rates of fusion.
higher complication rates.
worse long-term outcomes.

Correct Answer: shorter hospital stay.

Explanation:

DISCUSSION
MIS TLIF involves a steep learning curve but is associated with similar longterm outcomes as open TLIF, arguably comparable or possibly lower complication rates, and equivalent fusion rates. The major distinguishing feature comparing open to minimally invasive surgery for this and other spinal diagnoses has been shorter hospital stays.
RECOMMENDED READINGS
Peng CW, Yue WM, Poh SY, Yeo W, Tan SB. Clinical and radiological outcomes of minimally invasive versus open transforaminal lumbar interbody fusion. Spine (Phila Pa 1976). 2009 Jun 1;34(13):1385-9. doi: 10.1097/BRS.0b013e3181a4e3be. PubMed PMID: 19478658.
View
Abstract at PubMed
Lee KH, Yue WM, Yeo W, Soeharno H, Tan SB. Clinical and radiological outcomes of open versus minimally invasive transforaminal lumbar interbody fusion. Eur Spine J. 2012 Nov;21(11):2265-70. doi: 10.1007/s00586-012-2281-4. Epub 2012 Mar 28. PubMed PMID:

Question 55:

What muscle is most often encountered during surgical approaches to C5-6?

Options:

Omohyoid
Cricohyoid
Splenius capitus
Thyrohyoid
Posterior digastric

Correct Answer: Omohyoid

Explanation:

DISCUSSION: The omohyoid muscle crosses the surgical field from inferior lateral to anterior superior traveling from the scapula to the hyoid bone and may need to be transected. The posterior digastric crosses the field as well but higher near C3-4. The other muscles run longitudinally.
REFERENCES: Chang U, Lee MC, Kim DH: Anterior approach to the midcervical spine, in Kim DH, Henn JS, Vaccaro AR, et al (eds): Surgical Anatomy and Techniques to the Spine. Philadelphia, PA, Saunders Elsevier, 2006, pp 45-56.
Netter GH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy Corporation, 1989.

Question 56:

- A 23 year old man has a minimally comminuted midshaft fracture of the femur with 2cm entrance and exit wounds as a result of a low-velocity gunshot. Definitive management should be

Options:

Debriding the skin edges and performing plate fixation of the fracture
Debriding the skin edges and intramedullary rodding of the fracture
Extending the wounds, debriding the bone ends, and applying distal femoral traction
Extending the wounds, debriding the bone ends, and performing plate fixation of the fracture
Extending the wounds, debriding the bone ends, and intramedullary rodding of the fracture

Correct Answer: Debriding the skin edges and intramedullary rodding of the fracture

Explanation:

Question 57:

Options:

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

Correct Answer: Anatomic total shoulder arthroplasty and pectoralis major transfer

Explanation:

Question 58:

An acute posterolateral disk herniation at the L4-5 level will most likely affect what nerve root? Review Topic

Options:

Correct Answer: L5

Explanation:

Question 59:

Options:

Neurophysiologic test to evaluate the posterior interosseous nerve
Transfer of the extensor indicis proprius to the extensor pollicis longus tendon
Interphalangeal joint arthrodesis of the thumb
Extension splinting of the thumb
Fine cut CT of the distal radius to evaluate Lister’s tubercle

Correct Answer: Transfer of the extensor indicis proprius to the extensor pollicis longus tendon

Explanation:

Question 60:

Options:

Discoid lateral meniscus
Congenital absence of the anterior cruciate ligament
Torn medial meniscus
Osteomyelitis of the distal femur

Correct Answer: Discoid lateral meniscus

Explanation:

Question 61:

After making a tackle, a football player is found prone and unconscious without spontaneous respirations. Initial management should consist of

Options:

log roll to a supine position, helmet removal, and initiation of assisted breathing.
log roll to a supine position, head and neck stabilization, face mask removal, and CPR.
log roll onto a spine board, head and neck stabilization, face mask removal, and CPR.
head and neck stabilization, log roll to a supine position, helmet removal, and initiation of assisted breathing.
head and neck stabilization, log roll to a supine position, face mask removal, and initiation of assisted breathing.

Correct Answer: head and neck stabilization, log roll to a supine position, face mask removal, and initiation of assisted breathing.

Explanation:

Question 62:

Figure 26 shows the radiograph of an otherwise healthy Caucasian 5-year-old boy who has a painless limp. What is the best treatment option?

Options:

Shelf procedure
Salter osteotomy
Chiari osteotomy
Varus derotation osteotomy
Physical therapy and range-of-motion exercises

Correct Answer: Physical therapy and range-of-motion exercises

Explanation:

DISCUSSION: The prognosis of Legg-Perthes disease in children younger than age 6 years is good. There is no indication that surgical treatment will improve the outcome. Range-of-motion exercises to prevent contracture may be helpful.
REFERENCES: Herring JA, Kim HT, Browne R: Legg-Calve-Perthes disease: Prospective multicenter study of the effect of treatment on outcome. J Bone Joint Surg Am 2004;86:2121-2134.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 1, pp 691-704.

Question 63:

Figure 42 is a transverse MRI scan of the left shoulder. The arrow points to which of the following structures?

Options:

Anterior labrum
Long head of the biceps tendon
Middle glenohumeral ligament
Lower glenohumeral ligament
Axillary nerve

Correct Answer: Long head of the biceps tendon

Explanation:

Question 64:

Options:

revision L5-S1 hemilaminotomy.
L5-S1 total disk arthroplasty.
L5 Gill laminectomy.
posterior foraminal decompression and fusion at L5-S1 with instrumentation and bone graft.
stand-alone posterior lumbar interbody fusion.

Correct Answer: posterior foraminal decompression and fusion at L5-S1 with instrumentation and bone graft.

Explanation:

Question 65:

Options:

External fixation
Open reduction and internal fixation of the pubic symphysis with a two-hole plate
Open reduction and internal fixation of the pubic symphysis with a two-hole plate and posterior triangular osteosynthesis
Open reduction and internal fixation of the pubic symphysis with a multi-hole plate
Open reduction and internal fixation of the pubic symphysis with a multi-hole plate and posterior plate osteosynthesis

Correct Answer: Open reduction and internal fixation of the pubic symphysis with a multi-hole plate

Explanation:

Question 66:

New computer scanning technology for socket design has achieved which of the following improvements in amputee care?

Options:

Improved socket fit
Reduced skin breakdown from excessive pressure on the residual limb
Reduced the time of socket fabrication
Reduced the cost of prosthetic devices
Decreased pain at the limb socket interface

Correct Answer: Reduced the time of socket fabrication

Explanation:

Question 67:

Options:

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

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

Explanation:

Question 68:

Options:

Nonossifying fibroma
Fibrous dysplasia
Unicameral bone cyst
Osteogenesis imperfecta
Osteofibrous dysplasia

Correct Answer: Osteofibrous dysplasia

Explanation:

Question 69:

Options:

Gentamicin and penicillin
Cefazolin and penicillin
Doxycycline and ceftazidime
Vancomycin and sulfamethoxazole-trimethoprim

Correct Answer: Doxycycline and ceftazidime

Explanation:

Question 70:

Options:

ultrasound, iontophoresis, and stretching, with an early return to sports.
a local corticosteroid injection and strengthening, with a delayed return to sports.
immobilization and rehabilitation, with a delayed return to sports.
early surgical repair, prolonged rehabilitation, and a return to sports.
rehabilitation, with delayed surgical repair if the patient is unable to return to sports.

Correct Answer: early surgical repair, prolonged rehabilitation, and a return to sports.

Explanation:

Question 71:

Sciatic nerve

Options:

The sciatic nerve is in the posterior compartment of the thigh and can be palpated at the midpoint between the ischial tuberosity and the greater trochanter when the hip is flexed.
The obturator nerve is in the medial compartment of the thigh. The femoral nerve is in the anterior compartment of the thigh.
The peroneal (common peroneal) nerve bifurcates into the deep peroneal and the superficial peroneal nerves which lie in the anterior and lateral compartments of the leg, respectively.

Correct Answer: The sciatic nerve is in the posterior compartment of the thigh and can be palpated at the midpoint between the ischial tuberosity and the greater trochanter when the hip is flexed.

Explanation:

(999) Q1-1306:
The principal thrombogenic stimulus leading to the production of venous thromboembolic disease during total hip arthroplasty occurs at which time:

Question 72:

Which of the following medications inhibits release of neurotransmitters by binding to presynaptic calcium channels?

Options:

Denosumab
Sertraline
Tramadol
Gabapentin
Linezolid

Correct Answer: Denosumab

Explanation:

Question 73:

Options:

repetitive loading and fatigue failure.
incomplete bone ingrowth with focal osteolysis.
rotational bone axial loading.
a fixed component with a modulus mismatch.
use of titanium instead of cobalt-chromium.

Correct Answer: a fixed component with a modulus mismatch.

Explanation:

Question 74:

Options:

Metastatic bone disease
Multiple myeloma
Lymphoma
Chondrosarcoma
Malignant fibrous histiocytoma The biopsy specimen shows round, epithelial-like cells that are grouped in clusters. The cells are arranged in a fibrous background. The diagnosis is metastatic bone disease.

Correct Answer: Metastatic bone disease

Explanation:

Slide 1 Slide 2 Slide 3 Slide 4
Slide 5 Slide 6
A 50-year-old woman has had severe hip pain for 4 months. Her plain radiographs (Slide 1), technetium bone scan (Slide 2), computerized tomography scan (Slide 3), and coronal T1- and T2-weighted magnetic resonance images (Slide 4) are presented. A needle biopsy is also performed (Slides 5 and 6). Which of the following treatment regimens would be the most appropriate:

Question 75:

Options:

Normal shoulder strength and function
Local sensory deficits
Fracture union
Infection
Malunion

Correct Answer: Malunion

Explanation:

Question 76:

Options:

Type of surgery, age, and BMI
Type of surgery, hypercholesterolemia, and age
Age, BMI, and hypercholesterolemia
BMI, type of surgery, and hypercholesterolemia

Correct Answer: Type of surgery, age, and BMI

Explanation:

Question 77:

Options:

Creatine
Caffeine
Testosterone
Human growth hormone
Ephedrine

Correct Answer: Creatine

Explanation:

Question 78:

Options:

Osteochondritis dissecans
Quadriceps tendon rupture
Inferior pole patellar sleeve avulsion
MPFL disruption
Nail-patella syndrome

Correct Answer: MPFL disruption

Explanation:

Question 79:

A patient undergoes excision of a 3- x 3-cm soft-tissue sarcoma. The final histology results show tumor at the surgical margin. The surgical procedure performed is classified as

Options:

intralesional.
marginal.
wide.
wide contaminated.
radical.

Correct Answer: intralesional.

Explanation:

Question 80:

Options:

open reduction and internal fixation.
cast immobilization.
percutaneous pin fixation.
observation, with follow-up in 3 months.
an MRI scan of the elbow.

Correct Answer: open reduction and internal fixation.

Explanation:

Question 81:

Options:

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

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

Explanation:

Question 82:

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

Options:

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

Correct Answer: hemiarthroplasty

Explanation:

Question 83:

Options:

MRI
Doppler arterial study
Arteriography
Electromyography
Triple phase bone scan (technetium Tc 99m)

Correct Answer: Doppler arterial study

Explanation:

Question 84:

Following application of topical lidocaine, copious arterial bleeding is noted from the region of 1 neurovascular bundle, and the digit remains cool and pale. What is the best next step?

Options:

Intraoperative arteriogram
Wound closure and observation
Ligation of the digital artery
Primary repair of the digital artery

Correct Answer: Primary repair of the digital artery

Explanation:

DISCUSSION
Used with permission from Benson LS, Williams CS, Kahle M. Dupuytren’s contracture. J Am Acad Surg. 1998
Jan-Feb;6(1):24-35. Review
The spiral cord seen in Dupuytren disease arises from the confluence of abnormal fascial thickening of the spiral bands, lateral digital sheet, and Grayson’s ligament. The orientation of these contributing structures results in a continuous band of fibrous tissue spiraling around the neurovascular bundle. As the developing spiral cord contractures from distal to proximal, the cord itself becomes increasingly linear and shorter, causing displacement of the neurovascular bundle both centrally and superficially. This displacement of the neurovascular bundle brings it closer to the skin and midline, making it more vulnerable to surgical trauma.
Studies have demonstrated a high association between a PIP joint flexion contracture and a spiral cord (Figure 52). Spiral cords are also seen in association with a soft, fleshy mass between the proximal digital flexion crease and distal palmar crease in the interdigital space referred to as an interdigital soft-tissue mass. This represents displacement of normal subcutaneous tissues by contracture of the diseased fascia associated with the spiral cord. Dupuytren diathesis, MCP joint contracture, and the presence of knuckle pads are not indicative of a spiral cord.
A complication following surgical treatment of Dupuytren contracture is trauma to the neurovascular bundle. This can be a consequence of blunt or sharp trauma. In the case of traumatic stretch injury from retraction, vasospasm may develop. The treatment of vasospasm includes flexion, warming the digit, and application of topical medication to treat vasospasm. Allowing the newly extended digit to flex is an important first step, particularly in the case of chronic and severe PIP joint contractures. In these cases, the vessel may have shortened over time, and full extension may cause intimal trauma and secondary vasospasm. Cold is also a stimulus for reactive vasospasm, so warming the digit with warm saline irrigation can be helpful. Finally, topically applied lidocaine (without vasoconstrictive additives) can help diminish vasospasm and lead to digital reperfusion. Phentolamine is useful in cases of prolonged vasospasm secondary to administration of anesthetics containing epinephrine. Streptokinase is a thrombolytic agent that may be useful in treatment of embolic or thrombotic vascular disease. Systemic heparin is useful for digital vessel repair but should not be necessary to treat simple vasospasm.
Copious bleeding in the region of the neurovascular bundle following palmar fasciectomy is an indication of potential arterial trauma. In the setting of arterial laceration, direct repair is necessary, particularly when the digit is dysvascular. This means that both digital vessels are involved or that the intact vessel is insufficient to adequately perfuse the digit. During surgery, the vessels can be directly visualized, and arteriography is unlikely to add additional information of value. Streptokinase is not indicated in this situation because it is useful for thrombolysis rather than vascular repair. Ligation of a traumatized digital artery might be appropriate for a digit that is otherwise well perfused; however, this is not appropriate in the setting of a dysvascular digit. Direct suture of the arterial laceration or segmental grafting necessary to restore adequate digital perfusion in this scenario.
RECOMMENDED READINGS
Rayan GM. Dupuytren disease: Anatomy, pathology, presentation, and treatment. J Bone Joint Surg Am. 2007 Jan;89(1):189-98. Review. PubMed PMID: 17256226.
View Abstract at PubMed
Watson HK, Paul H Jr. Pathologic anatomy. Hand Clin. 1991 Nov;7(4):661-8. Review. PubMed PMID: 1769988.
View Abstract at PubMed
Jones NF, Huang JI. Emergency microsurgical revascularization for critical ischemia during surgery for Dupuytren's contracture: a case report. J Hand Surg Am. 2001 Nov;26(6):1125-8. PubMed PMID: 11721263.
View Abstract at PubMed

Question 85:

A 23-year-old woman falls from a bicycle and sustains a right knee injury. Figures 12a through 12d show radiographs and MRI scans of the knee. What is the most likely diagnosis?

Options:

Posterior cruciate ligament avulsion from the tibia
Anterior cruciate ligament avulsion from the tibia
Avulsion of the lateral meniscus anterior horn
Midsubstance posterior cruciate ligament rupture
Midsubstance anterior cruciate ligament rupture

Correct Answer: Anterior cruciate ligament avulsion from the tibia

Explanation:

DISCUSSION: The radiographs and MRI scans both show an avulsion of the anterior cruciate ligament, which has been described by Meyers and McKeever in three different fracture patterns. Type I fractures are nondisplaced or have minimal displacement of the anterior margin. Type II fractures have superior displacement of their anterior aspect with an intact posterior hinge. Type III fractures are completely displaced. Although the injury is visible on the radiographs, it is more subtle in adults than children. Thus, MRI is helpful in clarifying this injury in adults. Open or arthroscopic reduction and internal fixation is recommended for type II and type III fractures that do not respond to closed reduction.
REFERENCES: Meyers MH, McKeever FM: Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1970;52:1677-1684.
Wiss DA, Watson JT: Fractures of the tibial plateau, in Rockwood CA, Green DP, Bucholz RW, et al (eds): Rockwood and Green’s Fractures in Adults. Philadelphia, PA, Lippincott-Raven, 1996, pp 1920-1953.
Lubowitz JH, Elson WS, Guttmann D: Arthroscopic treatment of tibial plateau fractures: Intercondylar eminence avulsion fractures. Arthroscopy 2005;21:86-92.

Question 86:

Options:

External rotation of the distal femoral segment relative to the proximal femoral segment during nailing
Internal rotation of the proximal femoral segment relative to the distal femoral segment during nailing
Iatrogenic decrease in femoral anteversion on the operative leg during nailing
Increased contralateral femoral retroversion during surgery
Internal rotation of the distal segment of the femur relative to the proximal segment of the femur during nailing

Correct Answer: External rotation of the distal femoral segment relative to the proximal femoral segment during nailing

Explanation:

Question 87:

04 A pt wishes to return to driving after undergoing surgery for a displaced fibular fracture of the right ankle. A return to nml braking

Options:

time can be expected how many weeks after surgery?
IV - 9 wks

Correct Answer: time can be expected how many weeks after surgery?

Explanation:

Question 88:

In the preoperative planning of revision acetabular reconstruction, the surgeon should identify significant posterior column deficiency by noting which of the following radiographic features?

Options:

Excessive vertical position of the acetabular component
Medial displacement of the hip center to the ilioischial line
Visible wear of the polyethylene articulation
Osteolysis in the ischium
Superior migration of 1 cm

Correct Answer: Osteolysis in the ischium

Explanation:

Question 89:

Which of the following statements best describes labral tears in the hip? Review Topic

Options:

They are unrelated to degenerative joint disease.
They lead to increased movement of the femur relative to the acetabulum.
They usually result from lesions of the ligamentum teres.
They only occur with abnormal bone morphology.
They commonly occur in the posteroinferior quadrant of the hip.

Correct Answer: They lead to increased movement of the femur relative to the acetabulum.

Explanation:

Question 90:

When harvesting iliac crest bone graft during a posterior spinal decompression and fusion, injury to what structure can result in painful neuromas or numbness over the skin of the buttocks?

Options:

Ilioinguinal nerve
Superior gluteal nerve
Superior cluneal nerves
Iliohypogastric nerves
Lateral femoral cutaneous nerve

Correct Answer: Superior cluneal nerves

Explanation:

Question 91:

Options:

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

Correct Answer: Femoroacetabular osteoplasty and labral repair

Explanation:

Question 92:

Options:

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

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

Explanation:

Question 93:

Options:

Quadriceps
Hamstrings
Hip adductors
Extensor hallucis longus
Gastrocnemius

Correct Answer: Extensor hallucis longus

Explanation:

Question 94:

The implant shown in Figures 47a and 47b is introduced submuscularly employing a minimally invasive technique. A percutaneous method of screw insertion is used distally. What nerve is most at risk?

Options:

Sural
Saphenous
Superficial peroneal
Deep peroneal
Posterior tibial

Correct Answer: Superficial peroneal

Explanation:

Question 95:

Options:

Closed reduction and casting
Bed rest and skeletal traction
Open reduction and internal fixation
Retrograde intramedullary nailing
Revision of the femoral component with a stemmed component

Correct Answer: Open reduction and internal fixation

Explanation:

DISCUSSION: The radiographs show an oblique periprosthetic distal femoral fracture. Of the options listed, open reduction and internal fixation is the most appropriate surgical option because a well-fixed, posterior stabilized closed box femoral component is present. Nonsurgical methods are not favored because of the highly displaced, unstable fracture pattern and prolonged immobility. Revision with a stemmed component is an option but would sacrifice more bone stock in this younger patient.
REFERENCES: Moran MC, Brick GW, Sledge CB, et al: Supracondylar femoral fracture following total knee arthroplasty. Clin Orthop 1996;324:196-209.
Raab GE, Davis CM III: Early healing with locked condylar plating of periprosthetic fractures around the knee. J Arthroplasty 2005;20:984-989.
Tharani R, Nakasone C, Vince KG: Periprosthetic fractures after total knee arhtroplasty.
J Arthroplasty 2005;20:27-32.

Question 96:

Mirror therapy is indicated for which of the following clinical conditions?

Options:

Impaired proprioception after lower extremity injury
Two-stage flexor tendon reconstruction
Plumbism
Anterior cruciate ligament reconstruction
Phantom pain

Correct Answer: Impaired proprioception after lower extremity injury

Explanation:

Question 97:

Options:

application of a compressive soft dressing, and aggressive edema control and range-of-motion exercises.
plaster immobilization without reduction of the fractures.
closed reduction and plaster immobilization.
surgical fixation of the middle finger metacarpal and closed treatment of the ring and little finger metacarpals.
surgical fixation of all three metacarpal fractures.

Correct Answer: surgical fixation of all three metacarpal fractures.

Explanation:

DISCUSSION: While most isolated metacarpal fractures can be treated nonsurgically, multiple metacarpal fractures are inherently unstable due to the loss of support that an intact adjacent metacarpal provides; therefore, treatment should consist of surgical fixation of all three metacarpal fractures.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 286.
Faraj AA, Davis TR: Percutaneous intramedullary fixation of metacarpal shaft fractures. J Hand Surg Br 1999;24:76-79.

Question 98:

-What is the most common impediment to successful closed reduction of the injury seen in Figures 9aand 9b?

Options:

Extensor retinaculum
Talonavicular joint capsule
Posterior tibial tendon
Peroneus teritus tendon
Flexor hallucis longus tendon

Correct Answer: Posterior tibial tendon

Question 99:

Endurance training stimulates which of the following physiologic adaptations in the athlete? Review Topic

Options:

Selective hypertrophy of type II muscle fibers
Decreased concentration of Krebs cycle enzymes
Increased rate of glycogen depletion
Increased sympathetic nervous system activity
Increased storage and utilization of intramuscular lipids

Correct Answer: Increased storage and utilization of intramuscular lipids

Explanation:

Question 100:

Which of the following is most associated with local recurrence of the lesion seen in the radiograph and MRI scan shown in Figures 27a and 27b?

Options:

Effectiveness of chemotherapy
Effect of local adjuvant
Open physes
Presence of giant cells
Effectiveness of embolization

Correct Answer: Open physes

Explanation:

DISCUSSION: The lesion is an aneurysmal bone cyst. These lesions are known to have a local recurrence rate of 5% to 50%. Young age, open physes, stage, and type of surgical removal and resulting margin have all been shown to affect the recurrence rate. Chemotherapy is not used in the treatment of aneurysmal bone cysts.
REFERENCES: Gibbs CP Jr, Hefele MC, Peabody TD, et al: Aneurysmal bone cyst of the extremities: Factors related to local recurrence after curettage with a high-speed burr. J Bone Joint Surg Am 1999;81:1671-1678.
Vergel De Dios AM, Bond JR, Shives TC, et al: Aneurysmal bone cyst: A clinicopathologic study of 238 cases. Cancer 1992;69:2921-2931.

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

Orthopedic Board Review MCQs: Trauma, Foot & Ankle, Arthroplasty | Part 195

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 195

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index