Orthopedic Surgery Board Review MCQs: Adult Reconstruction, Trauma, & Spine | Part 199

Figures 5a and 5b show the radiographs of an active 52-year-old man who has increasing knee pain and progressive varus deformity after undergoing total knee arthroplasty 7 years ago. Examination reveals a small effusion, but he has good motion and stability. What is the most likely diagnosis?

A well-developed college football player reports swelling and a heaviness in the arm after lifting weights. Examination reveals that distal pulses are normal and equal in both arms. A venogram is shown in Figure 13. What is the most likely cause of this condition?

A 16-year-old girl was involved in a motorcycle accident that resulted in a significant right tibial fracture with soft-tissue loss over the distal 4 cm of the anterior medial tibia. The patient has had two irrigations and debridements and recently had an intramedullary nail placed for the skeletal injury. Vacuum-assisted closure (VAC) has been used to cover the defect since the injury. The risk of infection developing in the tibia is

Kyphosis from a vertebral osteoporotic compression fracture often results in progressive kyphosis due to

When making a comparison to autograft incorporation, the inflammatory process in allograft tissue anterior cruciate ligament (ACL) reconstruction

A 29-year-old man reports severe knee instability and popliteal pain. History reveals that he had polio of the left lower extremity as a child and has been brace-free his entire life. Examination reveals that he walks with 40° of knee hyperextension and has a fixed ankle equinus deformity of 30° . He has no active motors about the knee or ankle. Which of the following methods will provide knee stability and pain relief?

A 38-year-old woman is polytraumatized in a motor vehicle crash. She has multiple injuries including a unilateral femur fracture. The patient is felt to be borderline and, although she is currently stable, she could potentially deteriorate quickly. Which of the following parameters has been suggested as an indicator of which patients would benefit from damage control?

A 20-year-old football player has repeated episodes of heat cramps during summer training sessions. A deficiency of what electrolyte is most responsible for heat cramps?

What nerve is most at risk during placement of the anterolateral portal in elbow arthroscopy?

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?

Figure 9 shows a cross-sectional view of the spinal cord at the lower cervical level. Injury to the structure indicated by the black arrow will lead to what neurologic deficit?

A 20-year-old patient has foot pain. A radiograph and T 1 -weighted MRI scan are shown in Figures 8a and 8b. A biopsy specimen is shown in Figure 8c. Treatment should consist of

Radiographs of a pediatric patient reveal a suspected osteosarcoma of the distal femur. Additional staging studies should consist of

A 47-year-old woman has a painful bunion of the right foot, and shoe wear modifications have failed to provide relief. Examination reveals a severe hallux valgus with dorsal subluxation of the second toe. Radiographs are shown in Figures 14a and 14b. The most appropriate management should include

A 45-year-old female returns to your clinic with 10-weeks of severe pain that starts in her back and extends down her right leg to the top of her foot. On physical exam she has decreased sensation on the dorsal aspect of her foot and 4/5 strength in her EHL. She has a positive straight leg raise on the right. The remaining physical exam is unremarkable, including normal achilles and patellar reflexes bilaterally, no clonus, and a down-going Babinski sign. Her pain has not been relieved by NSAIDs, epidural steroids or physical therapy. Figure A is a sagittal MRI and figure B is a axial MRI through the L4/5 disc space. What is the best treatment option at this time? Review Topic

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?

Which of the following vertebrae has the smallest pedicle isthmic width in a nondeformity patient?

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

Compared to metal-on-polyethylene total hip bearing surfaces, the debris particles generated by metal-on-metal articulations are

Figures 1 through 5 are the MR images of a 12-year-old boy with left lateral-sided knee pain following a football injury. He has a several-year history of recurrent knee pain that improves with rest. An examination reveals a moderate effusion. Range of motion is 0° to 90° and is limited by pain in deep flexion. He has tenderness to palpation along the lateral joint line, and no instability is noted. Treatment should include

A 9-year-old child sustains a proximal tibial physeal fracture with a hyperextension mechanism. What structure is at most risk for serious injury?

Figures 57a and 57b are the MRI scans of a 61-year-old man who is unable to elevate his dominant arm following a golf injury 24 hours ago. He has moderate pain during attempted arm elevation. Examination reveals significant spinati atrophy and he is only able to elevate his arm fully overhead while supine. The neurologic examination is normal. What is the next most appropriate step in management? Review Topic

Which of the following agents increases the risk for a nonunion following a posterior spinal fusion?

CLINICAL SITUATION Figures 1 and 2 are the radiographs of a 19-year-old man with a closed right humeral shaft fracture as well as a right femoral shaft fracture and a left ankle fracture-dislocation after a motor vehicle collision. On initial examination, he is noted to have a complete radial nerve palsy of his right upper extremity. Postoperative radiographs are shown in Figures 3 and 4. How does the plate function?

What is the most common maxillofacial/dental injury in ice hockey?

A 35-year-old man has profound deltoid weakness after sustaining a traumatic anterior shoulder dislocation 6 weeks ago. Electromyographic (EMG) studies confirm an axillary nerve injury. Follow-up examination at 3 months reveals no recovery of function. What is the best course of action?

With respect to femoral component design, stress relief osteopenia in the proximal femur following noncemented total hip arthroplasty appears to be most strongly influenced by the

A 64-year-old man who was involved in a high-speed motor vehicle accident 6 weeks ago has been in the ICU with a closed head injury. Examination reveals that his range of motion for external rotation to the side is -30 degrees. Radiographs are shown in Figures 28a and 28b. What is the most likely diagnosis?

A 78-year-old athletic woman has a history of severe back pain without antecedent trauma. She was in the emergency department 2 days ago with a T12 compression fracture. A dual x-ray absorptiometry (DEXA) scan performed earlier this year revealed a T-score of -2.8. Her condition may be attributable to

A 22-year-old man sustained a shoulder dislocation while playing collegiate football at age 18. Since that time, he has dislocated the shoulder three more times despite physical therapy. His last dislocation occurred 4 weeks ago while sleeping. What is the most appropriate management for this patient? Review Topic

Figures below show the radiographs, MRI, and MR arthrogram obtained from a 25-year-old collegiate soccer player who has new-onset left groin pain. He played competitive soccer from a young age and has competed or practiced 5 to 6 times per week since the age of 10. He denies any specific hip injury that necessitated treatment, but his trainer contends that he had a groin pull. He reports groin pain with passive flexion and internal rotation of the left hip, and his hip has less internal rotation than his asymptomatic right hip. He is otherwise healthy.When counseling patients who have a cam deformity, the orthopaedic surgeon should note that

Figures below demonstrate the radiographs obtained from a 56-year-old man with a 3-year history of right groin pain. A comprehensive nonsurgical program has failed, and the patient would like to proceed with total hip arthroplasty. He is seen by a pain management specialist and is currently taking 40 mg of sustained-release morphine twice daily with oxycodone 10 mg 2 to 3 times a day for severe pain. What is the recommended course of action regarding his chronic narcotic use?

Figures 1 and 2 are the radiograph and MRI scan of a 16-year-old boy who injured his right knee by a lateral side impact while playing football. The MRI indicates what structure was most likely injured?

Figure 242 is the anteroposterior radiograph of a 28-year-old man who underwent resection and reconstruction for an Ewing sarcoma. What is the most common functional deficit encountered during rehabilitation?

-A collegiate offensive football lineman has decreased bench-press strength and shoulder pain as off-season workouts begin. Examination revealed no atrophy, and deltoid and rotator cuff strength testing findings were normal. Translational testing was difficult to achieve because of his large size.Apprehension and relocation test findings were negative. An O’Brien’s active compression test result was negative. Jerk testing was positive on the affected side. Which diagnosis is most likely revealed on an MRI arthrogram?

A 35-year-old construction worker sustained a midshaft clavicle fracture that developed a hypertrophic nonunion. One year after the injury, it was internally fixed without bone graft. Four months after the surgery he was asymptomatic and he was released to full activity. Five months following surgery, the patient was digging a ditch and he felt pain in the clavicle. The 4-month and 5-month postoperative radiographs are shown in Figures 117a and 117b. What is the most likely cause of this failure? Review Topic

Figure 6 shows the radiograph of a 14-year-old baseball player who felt a pop and had an immediate onset of pain in his elbow after a hard throw from the outfield. The best course of action should be to

The patient undergoes right hip arthroscopy. During placement of a standard anterior portal, the 2 structures most at risk for iatrogenic injury are the

Which of the following clinical scenarios represents an appropriate indication for convex hemiepiphysiodesis/hemiarthrodesis in the treatment of a child with a congenital spinal deformity?

An Asian 45-year-old man has bilateral upper extremity dysfunction. Figure 35a shows a T2-weighted sagittal MRI scan of the cervical spine, and Figure 35b shows a T2-weighted axial MRI scan at the level of the C3 vertebral body. What is the most likely pathologic process?

When performing a long fusion to the sacrum in an osteopenic patient in whom optimal sagittal balance is restored, which of the following is a benefit of extending the distal fixation to the pelvis, rather than the sacrum alone?

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

• A 40-year old man has limited, painful motion in dorsiflexion at the metatarsophalangeal (MTP) joint of the right great toe, despite nonsurgical treatment. Radiographs show dorsal and medial osteophytes and minimal narrowing of the articular space. Treatment should consist of

What structure is considered the single most important soft-tissue restraint to anterior-posterior stability of the sternoclavicular joint?

..First-line treatment recommendations include

What is the primary indication for performing an arthroscopic synovectomy on a patient with hemophilia that is the result of factor VIII deficiency? Review Topic

Figures 1 and 2 demonstrate the radiographs obtained from a 35-year-old woman with end-stage debilitating osteoarthritis of the right hip. She is contemplating total hip arthroplasty (THA). She has a history of right hip dysplasia and underwent hip osteotomy as an adolescent. Over the years, nonsurgical treatment, including weight loss, activity modifications, and intra-articular injections, has failed. Her infection work-up reveals laboratory findings within defined limits.The patient undergoes successful primary THA with a metal-on-metal bearing. At 1-year follow-up, she reports no pain and is highly satisfied with the procedure. However, 3 years after the index procedure, she reports atraumatic right hip pain that worsens with activities. Radiographs reveal the implants in good position with no sign of loosening or lysis. An initial laboratory evaluation reveals a normal sedimentation rate and C-reactive protein (CRP) level. The most appropriate next diagnostic step is

Which of the following statements best describes the anatomy of the sartorial branch of the saphenous nerve during medial meniscal repair?

Which of the following is considered an advantage of metal femoral heads compared with ceramic heads?

Figure 14 is a sagittal-cut MR image from the hindfoot of a 54-year-old woman who has had plantar heel pain for 3 months. There is no history of trauma. Her pain is worse when she rises and at the end of the day. Upon examination she has localizable tenderness over the plantar medial tubercle of the calcaneus. The Achilles is intact and nontender, and subtalar joint motion is full and painless. A Tinel test result is negative. What is the most likely diagnosis?

A 29-year-old man reports a 2-week history of severe neck pain after being struck sharply on the back of the head and neck while moving a refrigerator down a flight of stairs. Initial evaluation in the emergency department revealed no obvious fracture and he was discharged in a soft collar. Neurologic examination is within normal limits, and radiographs taken in the office are shown in Figures 21a through 21c. Subsequent MRI scans show intra-substance rupture of the transverse atlantal ligament. What is the most appropriate treatment option at this time?

Osteophyte formation at the posteromedial olecranon and olecranon articulation in high-caliber throwing athletes is most often the result of underlying

Figures 163a through 163c show the radiograph and MRI scans of a 45-year-old woman with severe right arm pain. She has had symptoms for 6 months without resolution despite multiple nonsurgical treatments. Examination reveals weakness in the right triceps and wrist flexors with decreased sensation in the middle finger and a positive Spurling's sign. What is the most appropriate treatment for the patient's symptoms? Review Topic

What type of exercise is used early in the rehabilitation process to safely stimulate co-contraction of the scapular and rotator cuff muscles? Review Topic

Figure 10 shows the radiograph of an 18-year-old woman who sustained a spinal cord injury in a motor vehicle accident. Based on the radiographic findings, her injury is best described as

Which of the following statements is true regarding the superomedial fragment of an intra-articular calcaneus fracture?

In a polytraumatized patient with a high lactate level, large base deficit, and pulmonary injury, what is the best initial treatment for a femoral shaft fracture?

A 13-year-old boy was evaluated for leg length difference. His pelvis balanced when a 1-inch (2.54 cm) block was placed under his left foot. History revealed he had a left distal femur physeal fracture treated with casting at age 10. Radiographs show normal limb alignment, but his left distal femoral physis is closed and his left femur is 2.5 cm shorter than the right. All other physes are open. His bone age is equal to his chronologic age. What surgical treatments will best equalize his discrepancy? Review Topic

An 18-year-old man sustains an injury to his lateral ankle after being kicked while playing soccer. He reports persistent pain on the lateral ankle as well as a popping sensation with attempted ankle dorsiflexion and eversion. Which of the following structures anatomically restrains the retracted structure shown in Figure 12?

Figures 11a and 11b show the radiographs of a 50-year-old man who was struck by a car. Treatment should consist of

Based on the current available best-evidence, what postoperative activities should be recommended for patients undergoing first-time lumbar diskectomy for disk herniation? Review Topic

What is the most likely complication following treatment of the humeral shaft fracture shown in Figure 6?

Figures 80a and 80b are the radiographs of a 21-year-old football player who underwent anterior cruciate ligament (ACL) reconstruction with patellar tendon autograft 1 year ago. He reports mild stiffness in his knee. Upon examination, he has a negative Lachman test result, trace effusion, and range of motion from 0 to 85 degrees of knee flexion. Which factor is most contributory to his examination findings?

Examination of a 13-year-old boy with asymptomatic poor posture reveals increased thoracic kyphosis that is fairly rigid and accentuates during forward bending. The neurologic examination is normal. Spinal radiographs show 10 degrees of scoliosis at Risser stage 2, and there is no evidence of spondylolisthesis. A standing lateral view of the thoracic spine is shown in Figure 41. The kyphosis corrects to 50 degrees. Management should consist of

Which Morton neuroma histology is most common?

A 12-year-old boy reports limping and chronic knee pain that is now inhibiting his ability to participate in sports. Clinical examination and radiographs of the knee are normal. Additional evaluation should include Review Topic

The injection shown in Figures 1a and 1b would most benefit a patient who reports which of the following symptoms? Review Topic

A 55-year-old man underwent cementless total hip arthroplasty for advanced painful osteoarthritis of the hip 2 years ago. The follow-up radiograph shown in Figure 30 shows

Figure 109 is the radiograph of an 11-year-old boy who felt a snap in his right hip while jumping hurdles during track practice yesterday. He complains of pain to his right groin region and is walking with a limp. What physical examination test will cause the patient to experience the most discomfort?

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

-If a physician elects to shorten a femur by 4 cm for traumatic bone loss treatment and places an intramedullary nail for fixation, which deformity will be created in the lower extremity?

The load versus deformation curve of the functional spinal unit (FSU) is made up of the neutral zone, the elastic zone, and the plastic zone. What is the plastic zone of the curve believed to represent?

Trabecular bone is remodeled through the formation of

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?

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

A 12½-year-old boy reports intermittent knee pain and limping that interferes with his ability to participate in sports. He actively participates in football, basketball, and baseball. He denies any history of injury. Examination shows full range of motion without effusion. Radiographs reveal an osteochondritis dissecans (OCD) lesion on the lateral aspect of the medial femoral condyle. MRI scans are shown in Figures 14a and 14b. Initial treatment should consist of Review Topic

A 54-year-old woman reports worsening pain in her buttock, especially when sitting for long periods of time. She has occasional pain and paresthesias radiating down her posterior leg. She has no significant medical history. MRI scans are shown in Figures 15a and 15b and a biopsy specimen is shown in Figure 15c. What is the most likely diagnosis?

A 61-year-old woman has increasing pain in her left great toe. She states that she has had discomfort for years but now has pain with all shoe wear. A radiograph is shown in Figure 35. To provide the most predictable pain-free result, treatment should consist of

Which of the following genetic disorders has an X-linked recessive inheritance pattern?

Figures 12a through 12e show the radiograph, MRI scans, and biopsy specimens of a 17-year-old boy. What is the most likely diagnosis?

Use of titanium elastic nailing for treatment of pediatric femur fractures is associated with a higher complication rate among

The illustration shown in Figure 19 shows a Chamberlain line. What is the most likely diagnosis?

Decreased sun exposure leads to decreased bone health via what mechanism?

An 82-year-old man is seen in consultation after being admitted for a fall from ground level. There was no loss of consciousness and the patient recalls striking his head and sustaining a hyperextension-type injury to the cervical spine. Examination reveals an 8-cm head laceration with only mild axial neck tenderness. He has generalized weakness throughout the upper extremities and maintained motor function of the lower extremities. There are no obvious sensory deficits, and the bulbocavernous reflex and deep tendon reflexes are maintained. What is the most appropriate diagnosis at this time? Review Topic

What nerve is most likely to develop a traumatic neuroma following open reducation and internal fixation of a talar neck fracture via a posterolateral approach?

A 26-year-old male underwent statically locked intramedullary nail fixation for a comminuted left femur fracture. An early post-operative computed tomography (CT) scanogram was taken to check rotational alignment, as shown in Figure A. What would be the next best step in the management of this patient?

Immobilization with a sling

What is the primary intracellular signaling mediator for bone morphogenetic protein (BMP) activity?

A 59-year-old man underwent interposition arthroplasty for osteoarthritis of the elbow 9 years ago. Over the past year the patient has had increasing pain and elbow instability. There is no clinical evidence of infection, and radiographs show no new bony process. What is the best option for this patient?

A 17-year-old basketball player and pole vaulter who has had anterior knee pain for the past 18 months now reports a recent inability to jump. Based on the MRI scan shown in Figure 11, management should consist of Review Topic

A 40-year-old man fell 10 feet from a tree and sustained the closed isolated injury shown in Figures 35a and 35b. Management consists of splinting. At his 2-week follow-up visit, he clinically passes the wrinkle test. He agrees to open reduction and internal fixation. What is the best surgical approach to obtain anatomic reduction and limit wound dehiscence?

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

The Coleman block test is used to evaluate the cavovarus foot. What is the most important information obtained from this test?

..Further imaging shows pulmonary metastases without an obvious primary tumor of origin and an incomplete fracture of the right distal femur. A decision is made to surgically treat his distal femur fracture. What is the role of establishing a preoperative histologic diagnosis for this patient?

Thyroid hormone regulates skeletal growth at the physis by stimulation of

During the first 2 years of life, which of the following actions is most responsible for increasing structural stability of the physis?

A 25-year-old man sustained the closed injury shown in Figures 22a and 22b. Examination reveals that this is an isolated injury, and he is hemodynamically stable. Treatment should consist of

Figure 4a shows the radiograph of a 20-year-old man who has an injury to the right shoulder. Figure 4b shows an arthroscopic view (posterior portal). The arrow points to a Review Topic

Figures below demonstrate the radiographs obtained from a 63-year-old man who had right total hip arthroplasty (THA) 4 months ago. Progressive stiffness began 2 months after surgery, and he now reports pain only after prolonged physical activity. His examination reveals a normal gait and painless range of motion with flexion of 70°, extension of 0°, internal rotation of 20°, external rotation of 20°, abduction of 10°, and adduction of 10°. His erythrocyte sedimentation rate and C-reactive protein level are within defined limits. Physical therapy has produced no benefit. What is the most appropriate next step?

An 82-year-old woman reports right buttock pain after a car trip. Laboratory studies show an erythrocyte sedimentation rate of 30 mm/h and WBC of 4,600/mm 3 . Figure 34a shows a plain AP radiograph of the pelvis, and Figure 34b shows a delayed technetium Tc 99m bone scan. Management should consist of