Orthopedic Surgery Board Review: 100 High-Yield MCQs

About This Board Review Set

This is Part 201 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.
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Pro Tip: Use keyboard shortcuts A–E to select options, F to flag a question for review, and Enter to jump to the next unanswered question.

Topics Covered in Part 201

This module focuses heavily on: Dislocation, Foot, Fracture, Hip, Nerve, Shoulder, Spine, Trauma.

Sample Questions from This Set

Sample Question 1: A 20-year-old college athlete is seen for follow-up after sustaining an injury at football practice 2 days ago. He reports that he tackled a player and felt neck pain and numbness in both arms. The numbness resolved within seconds, but his ...

Sample Question 2: The anatomy of the sciatic nerve as it exits the pelvis is best described as exiting through the...

Sample Question 3: Which of the following medications may have a negative effect on bone healing following fracture?...

Sample Question 4: belowshowtheradiographsobtainedfromanyear-old-womanwhohashadchroniclefthippainforseveralyears.Shenowusesawalkerandawheelchairforambulation.Sheismedicallyhealthy. Whatisthemostappropriatesurgicalintervention?...

Sample Question 5: A 17-year-old high school football player sustains a traumatic anterior shoulder dislocation, resulting in a small bony Bankart lesion and small Hill-Sachs lesion. The patient undergoes an arthroscopic Bankart repair with incorporation of t...

Why Active MCQ Practice Works

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

Comprehensive 100-Question Exam

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Question 1

A 20-year-old college athlete is seen for follow-up after sustaining an injury at football practice 2 days ago. He reports that he tackled a player and felt neck pain and numbness in both arms. The numbness resolved within seconds, but his neck remains painful and stiff. He denies any history of neck pain or injury. Examination reveals limited neck motion. The neurologic examination and radiographs are normal. MRI scans of the cervical spine are shown in Figure 34. During counseling, the patient, his family, and his coach should be informed that he has an acute cervical disk herniation and cannot play

Explanation

DISCUSSION: A player who has an acute cervical disk herniation should not be allowed to return to play until the acute phase is over. Certain players with large herniations may require surgery before returning to play to eliminate the risk of disk-related stenosis and cord compression.
REFERENCES: Morganti C, Sweeney CA, Albanese SA, Burak C, Hosea T, Connolly PJ: Return to play after cervical spine injury. Spine 2001;26:1131-1136.
Vaccaro AR, Watkins B, Albert TJ, Pfaff WL, Klein GR, Silber JS: Cervical spine injuries in athletes: Current return-to-play criteria. Orthopedics 2001;24:699-705.

Question 2

The anatomy of the sciatic nerve as it exits the pelvis is best described as exiting through the

Explanation

DISCUSSION: The sciatic nerve is formed by the roots of the lumbosacral plexus. It exits the pelvis through the greater sciatic notch and appears in the buttock anterior to the piriformus. From that point, the sciatic nerve passes posteriorly over the superior gemellus, obturator internus, inferior gemellus, and quadratus femoris before it passes deep to the biceps femoris. The tendon of the obturator internus passes through the lesser sciatic notch.
REFERENCES: Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippincott, 1984, p 347.
Anderson JE: Grant’s Atlas of Anatomy, ed 7. Baltimore, MD, Lippincott Williams & Wilkins, 1978, pp 4-34, 4-36.
Hollingshead WH: Anatomy for Surgeons: The Back and Limbs, ed 2. Hagerstown, MD, Harper & Row, 1969, pp 607-609.

Question 3

Which of the following medications may have a negative effect on bone healing following fracture?

Explanation

DISCUSSION: Nonsteroidal anti-inflammatory drugs that are COX-1 primary inhibitors have been shown in animal studies to delay or inhibit fracture healing. COX-2 inhibitors also delay healing but to a lesser extent than COX-1 inhibitors. The other medications listed do not alter fracture callus formation.
REFERENCES: Gerstenfeld LC, Thiede M, Seibert K, et al: Differential inhibition of fracture healing by non-selective and cyclooxygenase-2 selective non-steroidal anti-inflammatory drugs. J Orthop Res 2003;21:670-675.
Harder AT, An YH: The mechanisms of the inhibitory effects of nonsteroidal anti-inflammatory drugs on bone healing: A concise review. J Clin Pharmacol 2003;43:807-815.

Question 4

below show the radiographs obtained from an year-old-woman who has had chronic left hip pain for several years. She now uses a walker and a wheelchair for ambulation. She is medically healthy. What is the most appropriate surgical intervention?

Explanation

DISCUSSION:
This 86-year-old woman has poor bone quality and osteoarthritis of the left hip. Her lateral radiograph confirms Dorr type C bone quality. A hybrid left THA with a cemented femoral stem would be the treatment of choice.

Question 5

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

Explanation

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

Question 6

A 51-year-old woman with shoulder pain responds transiently to a subacromial injection and physical therapy exercise program. When her symptoms recur, an arthroscopic subacromial decompression is recommended. During the surgery, a partial-thickness articular-sided supraspinatus tear is noted. The supraspinatus footprint is exposed for 3 mm from the articular margin. The remaining intra-articular structures are normal. Inspection from the bursal surface reveals the tendon to be intact. What is the most appropriate course of management? Review Topic

Explanation

The patient has a partial articular supraspinatus tendon avulsion (PASTA) lesion. Outcome studies suggest that articular-sided tears of this magnitude do well with arthroscopic decompression and debridement alone. Determination of lesion thickness is important in recommending treatment, and may be done with a variety of methods. Tears that involve exposure of less than 5 mm of the rotator cuff footprint likely measure less than half of the tendon thickness. In the absence of other associated pathology, bicipital tenotomy or synovectomy would be unnecessary. Completion of the tear or transtendinous repair would be considered for lesions of greater than 50% thickness.

Question 7

A 45-year-old IV drug abuser has sternoclavicular (SC) joint pain for the past 2 weeks. He is afebrile and physical exam findings include point tenderness and swelling. He most likely has septic arthritis of the sternoclavicular joint. If so, what is the most likely infecting organism?

Explanation

DISCUSSION: Risk factors for sternoclavicular septic arthritis include IV drug abuse, diabetes, and HIV.
According to the reference by Ross et al, Staphylococcus aureus accounts for 49% of infections. SC joint arthritis accounts for 1% of septic arthritis in the general population but 17% in the IV drug abuse population. Symptoms include spontaneous swelling with the appearance of joint subluxation and localized pain. These patients are not uncommonly afebrile.

Question 8

Optimal management of the injury shown in Figure 31 should include which of the following?

Explanation

DISCUSSION: The radiograph shows a displaced calcaneal beak fracture, a tongue-type fracture variant. The fracture fragment typically includes the insertion point of the Achilles tendon, which places marked tension on the thin overlying soft-tissue envelope and can lead to full-thickness necrosis if not acutely addressed. Cast immobilization does not adequately address the increased soft-tissue tension, as the fragment will be difficult to control. Arthroscopic-assisted techniques or primary arthrodesis are not indicated because calcaneal beak fractures are typically extra-articular.
REFERENCES: Sanders RW, Clare MP: Fractures of the calcaneus, in Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA, Mosby-Elsevier, 2007, vol 2, pp 2017-2073.
Sanders RW, Clare MP: Fractures of the calcaneus, in Bucholz RW, Heckman JD, Court-Brown C (eds): Rockwood and Green’s Fractures in Adults, ed 6. Philadelphia, PA, Lippincott Williams & Wilkins, 2006, vol 2, pp 2293-2336.

Question 9

below show the radiographs, and the CT obtained from a year-old woman who underwent cementless left total hip arthroplasty. Nine months after surgery, she continued to have groin pain when actively flexing her hip. She has trouble walking up stairs and getting out of her car. What is the most likely diagnosis?

Explanation

DISCUSSION:
Groin pain after total hip replacement has a number of possible causes, and an exact diagnosis may remain elusive in some patients. Infection should be ruled out with laboratory studies and, if indicated, diagnostic aspiration of the hip joint. Implant loosening should be evaluated by plain radiograph and bone scan, if indicated. Synovitis resulting from wear debris should be considered in patients with polyethylene liners who experience late-onset symptoms or in any patient with a metal-on-metal bearing. This patient's symptoms are classic for iliopsoas tendonitis. Physical examination usually reveals pain and weakness with resisted hip flexion. A cross-table lateral radiograph and CT show that the anterior edge of the acetabulum protrudes beyond the anterior wall, thereby acting as a source of iliopsoas tendon irritation. In such cases, acetabular component revision and repositioning are indicated. Fluoroscope-guided iliopsoas cortisone injection can help to establish the diagnosis and relieve groin pain. If the acetabular component is well positioned, then iliopsoas tenotomy should be considered.

Question 10

A 29-year-old woman who underwent an anterior cruciate ligament (ACL) reconstruction 6 months ago now reports difficulty achieving full knee extension, and physical therapy fails to provide relief. The knee is stable on ligament testing. Figure 3 shows the findings at a repeat arthroscopy. Treatment should now include

Explanation

DISCUSSION: The patient has a cyclops lesion. This is a nodule of fibroproliferative tissue that originates from either drilling debris from the tibial tunnel or remnants of the ACL stump; more rarely it is the result of broken graft fibers. The treatment of choice is excision of the nodule and, if needed, additional notchplasty. Marked improvements in function and symptoms have been noted after removal of the extension block and resumption of a rehabilitation program.

REFERENCES: Delince P, Krallis P, Descamps PY, et al: Different aspects of the cyclops lesion following anterior cruciate ligament reconstruction: A multifactorial etiopathogenesis. Arthroscopy 1998;14:869-876.
Fisher SE, Shelbourne KD: Arthroscopic treatment of symptomatic extension block complicating anterior cruciate ligament reconstruction. Am J Sports Med 1993;4:558-564.

Question 11

Which of the following complications is more likely with an inside-out repair technique compared to an all-inside techniques for a medial meniscus tear?

Explanation

DISCUSSION: All of the answers are possible complications of meniscal repair. There are large volumes of literature evaluating the results of meniscal repair, both for the all-inside technique, as well as the inside-out technique. Failure rates are similar. Intra-articular synovitis occurs with absorbable sutures and absorbable implants. Peroneal nerve injuries are more common with the lateral-sided repairs. Saphenous nerve injuries are more common with medial-sided tears. Because of the incision required and the technique of tying over soft tissue, the risk of a saphenous nerve injury is greater with an inside-out technique than with an all-inside technique.
REFERENCES: Farng E, Sherman O: Meniscal repair devices: A clinical and biomechanical literature review. Arthroscopy 2004;20:273-286.
Jones HP, Lemos MJ, Wilk RM, et al: Two-year follow-up of meniscal repair using a bioabsorbable arrow. Arthroscopy 2002;18:64-69.

Question 12

A 10-year-old boy has a painful, swollen knee after falling off his bicycle. Examination reveals that the knee is held in 45 degrees of flexion, and any attempt to actively or passively extend the knee produces pain and muscle spasms. A lateral radiograph is shown in Figure 4. What is the most likely diagnosis?

Explanation

DISCUSSION: This is a typical patellar sleeve fracture. The patellar tendon avulses a portion of the distal bony patella, along with the retinaculum and articular cartilage from the inferior pole of the patella. It is common in children between ages 8 and 10 years. Anatomic reduction and repair of the extensor mechanism are mandatory to reestablish full knee extension.
REFERENCES: Houghton GR, Ackroyd CE: Sleeve fractures of the patella in children: A report of three cases. J Bone Joint Surg Br 1979;61:165-168.
Wu CD, Huang SC, Liu TK: Sleeve fracture of the patella in children: A report of five cases. Am J Sports Med 1991;19:525-528.

Question 13

Which of the following complications occurs more commonly after antegrade femoral nail insertion when compared with retrograde insertion?

Explanation

DISCUSSION: There is no difference between the rates of union, malunion, range of motion of the hip or knee, muscle weakness, or infection for the two types of femoral nail insertion. The only difference is the location of the morbidity, which is around the insertion point of the rod. The antegrade technique has more morbidity about the hip, and the retrograde insertion technique has more morbidity about the knee.
REFERENCES: Morgan E, Ostrum RF, DiCicco J, McElroy J, Poka A: Effects of retrograde femoral intramedullary nailing on the patellofemoral articulation. J Orthop Trauma 1999;13:13-16.
Ricci WM, Bellabarba C, Evanoff B, Herscovici D, DiPasquale T, Sanders R: Retrograde versus antegrade nailing of femoral shaft fractures. J Orthop Trauma 2001;15:161-169.
Ostrum RF, Agarwal A, Lakatos R, Poka A: Prospective comparison of retrograde and antegrade femoral intramedullary nailing. J Orthop Trauma 2000;14:496-501.
Tornetta P III, Tiburzi D: Antegrade or retrograde reamed femoral nailing: A prospective, randomized trial. J Bone Joint Surg Br 2000;82:652-654.

Question 14

A 47-year-old woman underwent a bunionectomy and hallux valgus correction a few years ago. She now has the complication shown in Figures 38a and 38b. She has no pain with motion of the metatarsophalangeal or interphalangeal joints. What is the best reconstructive option in this setting?

Explanation

DISCUSSION: The patient has a flexible hallux varus that is a complication of the bunion surgery. With joints that are not arthritic and still flexible, a medial release is necessary to realign the joint. The extensor hallucis longus split transfer helps maintain position and still preserve motion at the interphalangeal joint level. Arthrodesis is a salvage procedure. Soft-tissue releases alone are most likely inadequate. Excision of the lateral sesamoid is contraindicated because that further compromises the forces resisting hallux varus. Phalangeal osteotomy would not address the medial subluxation at the metatarsophalangeal joint.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 27-32.
Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA, Mosby, 2007, pp 345-351.

Question 15

In the management of an open tibia fracture, what factor is considered most important in preventing deep infection?

Explanation

DISCUSSION: The most important aspect of management of any open fracture, and in particular the tibia, is the degree and the completeness of the debridement of the soft tissue and most importantly, the muscle. The ultimate function is determined by the amount of muscle left, as well as the ability to heal. The amount of necrotic muscle left in the wound also determines the predisposition to infection. The method of fixation, the size of the wound, and the amount of contamination are controlled by the surgeon or the injury and have little to do with the long-term outcome. Initial wound cultures have little predictive value.
REFERENCES: Clifford P: Open fractures, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 617-638.
Lee J: Efficacy of cultures in the management of open fractures. Clin Orthop 1997;339:71-75.
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Question 16

A 47-year-old man sustained a degloving injury over the pretibial surface and anterior ankle region in a motor vehicle accident. After debridement and irrigation, there is inadequate tissue for closure of the exposed anterior tibial tendon and tibia. Prior to definitive soft-tissue coverage, management should consist of

Explanation

DISCUSSION: With soft-tissue loss, local or free flap coverage may be necessary to treat exposed tendon and bone. However, a vacuum-assisted closure device is a good temporizing dressing. It prevents external contamination, reduces edema around the wound, increases oxygen tension in the wound, and promotes the formation of granulation tissue. The use of this negative pressure device has been described in both acute traumatic and in chronic wound scenarios. If sufficient granulation tissue forms, closure may be by split graft, avoiding a more complex coverage procedure. Immediate skin grafting over the exposed anterior tibial tendon and tibia would have a low likelihood of success. Dressing changes with sulfasalazine may be beneficial in a burn wound to assist with removal of skin slough; however, in a granulating wound, the material may be toxic to early epithelialization. Xenograft is a foreign body and should not be applied to an acute contaminated open wound. Historically, a cross-leg flap was a treatment alternative for lower extremity soft-tissue loss; however, its current applications are extremely limited.
REFERENCES: Webb LX: New techniques in wound management: Vacuum assisted wound closure. J Am Acad Orthop Surg 2002;10:303-311.
Clare MP, Fitzgibbons TC, McMullen ST, et al: Experience with the vacuum assisted closure negative pressure technique in the treatment of non-healing diabetic and dysvascular wounds. Foot Ankle Int 2002;23:896-901.

Question 17

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

Explanation

Unwitnessed spiral fractures should raise the possibility of child abuse, especially prior to walking age. With nonaccidental trauma being considered in the differential diagnosis, a skeletal survey is indicated to determine if there are other fractures in various stages of healing.
(SBQ13PE.60) If a child develops dynamic supination after treatment of idiopathic clubfoot with Ponseti casting, at what age would it be appropriate to consider transfer of the tibialis anterior tendon to the lateral dorsum of the foot? Review Topic
In the first six months of life, immediately following failed cast treatment
12 months
4 years
12 years
15 years
Tibialis tendon transfer to the dorsum of the foot should be performed to address dynamic supination when the lateral cuneiform has ossified. This is typically after at least 2 years of age and usually not before age 3.

Question 18

Figure 31 shows the radiograph of an 8-year-old boy who has a swollen forearm after falling out of a tree. Examination reveals that all three nerves are functionally intact, and there is no evidence of circulatory embarrassment. Management should consist of

Explanation

DISCUSSION: The patient has a Bado type IV Monteggia lesion. It involves dislocation of the radial head and fractures of both the radial and ulnar shafts. These fractures are very difficult to manage by closed reduction alone. The radial and ulnar shafts first have to be stabilized surgically to give a lever arm to reduce the radial head. In this age group, intramedullary pins are easy to insert percutaneously and cause less tissue trauma than plates and screws. In these types of injuries, the focus is often on the forearm fracture; the radial head dislocation may not be appreciated as was the case with this patient.
REFERENCES: Gibson WK, Timperlake RW: Operative treatment of a type IV Monteggia fracture-dislocation in a child. J Bone Joint Surg Br 1992;74:780-781.
Stanley EA, DeLaGarza JF: Part IV: Monteggia fracture. Dislocations in children, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 576-577.

Question 19

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

Explanation

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

2001;26:1522-1527.

Question 20

Glenohumeral disarticulation often leads to which of the following changes?

Explanation

Postural abnormalities are common after high upper extremity amputation. Normally the weight of the upper extremity and the shoulder girdle muscles keep the shoulder balanced. When the arm is amputated and the scapula remains, the shoulder girdle muscles are unopposed, resulting in upward movement often called "hiking" of the shoulder girdle. In a growing child, removal of the entire upper limb can result in scoliosis of the spine due to muscle imbalance. Abnormal shoulder elevation can often be minimized by corrective exercises and wearing a shoulder prosthesis.

Question 21

An otherwise healthy adolescent girl was treated for left slipped capital femoral epiphysis. The contralateral hip had not slipped, but was stabilized prophylactically with a single cannulated screw. The implants were removed after 1 year. The pelvic radiographs (Figures 215a and 215b) and the MRI scans of the hip that had not originally slipped (Figures 215c through 215e) were obtained 10 months after screw removal (22 months after the original fixation). Which findings are shown in these studies?

Explanation

Question 22

A 20-year-old elite college football player has ecchymosis, swelling, and pain on the lateral side of his foot after a game. Radiographs are shown in Figures 31a through 31c. Management should consist of

Explanation

DISCUSSION: Metaphyseal-diaphyseal junction fractures of the fifth metatarsal require careful evaluation. In athletes, early intervention with a 4.5-mm intramedullary screw correlates with an earlier return to activity. One study examining the failure of surgically managed Jones fractures revealed that use of anything other than a 4.5-mm malleolar screw for internal fixation correlated with failure.
REFERENCES: Glasgow MT, Naranja RJ Jr, Glasgow SG, et al: Analysis of failed surgical management of fractures of the base of the fifth metatarsal distal to the tuberosity: The Jones fracture. Foot Ankle Int 1996;17:449-457.
Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 243-252.

Question 23

A 72-year-old woman who is right hand-dominant has severe pain in the right shoulder that has failed to respond to nonsurgical management. She reports night pain and significant disability. Examination reveals 30 degrees of active forward elevation. An AP radiograph is shown in Figure 27. Which of the following treatment options will provide the best functional improvement? Review Topic

Explanation

The patient has end-stage rotator cuff tear arthropathy. The radiograph shows complete proximal humeral migration (acromiohumeral interval of 0 mm), severe glenohumeral arthritis, and acetabularization of the acromion. In addition, she has "pseudoparalysis" with active elevation of only 30 degrees. Reverse shoulder arthroplasty affords her the best opportunity for pain relief and functional improvement. The other procedures have mixed results but typically are better for pain relief than they are for functional gains.

Question 24

Compared with retention of the native patella in primary total knee arthroplasty, routine patellar resurfacing is associated with

Explanation

DISCUSSION:
Despite concerns regarding fracture, osteonecrosis, and patellar clunk, the routine retention of the native patella during primary total knee replacement is associated with a 20% to 30% increased revision risk in
large joint registries. In addition, the retention of the native patella results in a 5.7% revision surgery rate in patients with anterior knee pain.

Question 25

Figures 2a and 2b are this patient’s proton density fat-saturated MR images. His tibial tubercle-trochlear groove (TT-TG) distance is 12 mm, and he has normal limb-alignment film findings. Treatment at this stage should include

Explanation

DISCUSSION
This patient’s examination and history indicate recurrent patellar dislocations. Radiographs show an osseous or osteochondral loose fragment. There is no evidence of an obvious nondisplaced fracture or physeal changes. In the setting of suspected patella dislocation or subluxation with loose fragment seen on radiograph, an MRI is indicated. Lateral release alone is seldom indicated in a knee that is normal before injury. The examination and MRI do not indicate a need for medial collateral ligament repair. Treatment should consist of arthroscopy or arthrotomy and attempted internal fixation of this fragment. If fixation is not possible, the loose body can be removed. Normal TT-TG values, an increased lateral patellar glide, and a history of recurrent patellar dislocations after trauma suggest MPFL incompetence and the need for reconstruction.

Question 26

Which of the following best describes heat stroke?

Explanation

DISCUSSION: Heat stroke consists of hyperthermia (greater than 105.8 degrees F
[41 degrees C]), central nervous system dysfunction, and cessation of sweating with hot, dry skin. It is a medical emergency that results from failure of the thermoregulatory mechanisms of the body. It has a high death rate and requires rapid reduction in body core temperature. Heat syncope is characterized by a transient loss of consciousness with peripheral vasodilation and decreased cardiac output with normal body temperature. Heat cramps involve painful contractions of large muscle groups because of decreased hydration and a decrease of serum sodium and chloride. Heat exhaustion is distinguished by a core temperature of less than

Question 27

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

Explanation

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

Question 28

The posterior cord of the brachial plexus terminates into what two main branches?

Explanation

DISCUSSION: The posterior cord of the brachial plexus terminates into the radial and axillary nerves. The lateral cord terminates in branches to the musculocutaneous and the lateral root of the median nerve. The medial cord terminates in branches to the ulnar and medial roots of the median nerve.
REFERENCE: Hollinshead WH: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, pp 228-236.

Question 29

In patients older than age 40 years who sustain a first-time anterior dislocation of the shoulder, prolonged morbidity is most commonly associated with

Explanation

DISCUSSION: In the study done by Pevny and associates, 35% of patients older than age 40 years sustained rotator cuff tears and 8% had axillary nerve palsies. All of the patients with axillary nerve palsy also had rotator cuff tears. Imaging of the rotator cuff is indicated in this age group. The incidence of recurrent instability in patients older than age 40 years is 10% to 15%.
REFERENCES: Pevny T, Hunter RE, Freeman JR: Primary traumatic anterior shoulder dislocation in patients 40 years of age and older. Arthroscopy 1998;14:289-294.
Sonnabend DH: Treatment of primary anterior shoulder dislocation in patients older than 40 years of age: Conservative versus operative. Clin Orthop 1994;304:74-77.
Hawkins RJ, Mohtadi NG: Controversy in anterior shoulder instability. Clin Orthop 1991;272:152-161.

Question 30

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

Explanation

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

Question 31

A 52-year-old man who dislocated his dominant shoulder has it reduced in the emergency department and he is placed in a sling. At his 5-day followup evaluation, he reports that this is his first shoulder dislocation and that the pain is mostly gone but he notes difficulty using his arm overhead and away from his body. Examination reveals minimal pain with passive range of motion, a positive apprehension and relocation test, and 3/5 strength with the empty can test and external rotation at the side compared with 5/5 with those tests on the contralateral side. Cutaneous sensation over the lateral aspect of the shoulder is intact. Radiographs show the glenohumeral joint is reduced with no fractures or degenerative changes. What is the next step in management? Review Topic

Explanation

Obtaining an MRI scan to evaluate for a rotator cuff tear is a reasonable next step. The patient sustained a first-time shoulder dislocation, and given his age and clinical presentation, it is likely that he injured the rotator cuff. Large, full-thickness rotator
cuff tears following dislocation in young individuals warrants early surgical intervention. Delay of surgical repair for large, full-thickness tears may lead to irreversible changes, including atrophy and retraction of the tendon. As a result, clinical outcomes may be compromised. CT will demonstrate bony changes, but it is not as effective as MRI for soft-tissue pathology. While in the short term a sling for comfort might be helpful, 6 weeks of immobilization is unnecessary because recurrent instability is rarely an issue. Physical therapy can be beneficial but could potentially delay identification of an acute rotator cuff tear. In the event the MRI does not reveal a large, full-thickness rotator cuff tear, physical therapy would be an appropriate next step. There is no indication for urgent shoulder arthroscopy.

Question 32

A 5-month-old girl with arthrogryposis has a limb-length discrepancy. Examination and radiographs reveal unilateral hip dislocation. Management should consist of

Explanation

DISCUSSION: In this age group of patients with arthrogryposis, open reduction through a medial approach is generally recommended. Open reduction through an anterior approach is reserved for patients in which a medial approach has failed or for older patients who require simultaneous femoral shortening and/or pelvic osteotomy. Closed treatment of unilateral hip dislocation in association with arthrogryposis is rarely successful. In bilateral hip dislocation associated with arthrogrypsis, the consensus is that the hips are best left unreduced because of the difficulty in obtaining excellent clinical and radiographic results bilaterally.
REFERENCES: Staheli LT, Chew DE, Elliot JS, Mosca VS: Management of hip dislocations in children with arthrogryposis. J Pediatr Orthop 1987;7:681-685.
Szoke G, Staheli LT, Jaffe K, Hall JG: Medial-approach open reduction of hip dislocation in amyoplasia-type arthrogryposis. J Pediatr Orthop 1996;16:127-130.
Richards BS (ed): Orthopaedic Knowledge Update: Pediatrics. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996.

Question 33

An 18-year-old man sustained a traumatic laceration of the common peroneal nerve when glass fell on the outer part of his leg 1 year ago. He has used a molded foot and ankle orthosis for the past 10 months, but would now like surgical intervention. Electromyography shows no function in the anterior or lateral compartments. He has 5/5 muscle strength of the superficial and deep posterior compartments. What is the most appropriate treatment?

Explanation

In a patient with a drop foot and with 5/5 muscle strength of the posterior tibial tendon, a split posterior tibial tendon transfer would be the most appropriate treatment option based on the options presented. The deep peroneal nerve innervates the anterior tibial tendon. This muscle has been affected by the injury; therefore, the anterior tibial tendon cannot be transferred. A subtalar fusion would help correct inversion and eversion deformities, but is not effective for plantar flexion deformities. The foot drop is caused by a neurologic condition in this patient, not a contracture of the gastrocsoleus complex. Therefore, a recession would not be beneficial. A flexor
hallucis longus tendon transfer would not take the deforming force and make it a corrective force.

Question 34

Compared to similar patients who do not donate autologous blood, patients with normal baseline hemoglobin who donate autologous blood prior to undergoing primary total hip arthroplasty are likely to

Explanation

DISCUSSION: Billote and associates compared patients with normal baseline hemoglobin levels who did and did not donate autologous blood prior to total hip arthroplasty. No patients received allogeneic blood perioperatively, and the autologous donors had significantly lower hemoglobin levels at the time of surgery and in the recovery room. Of the autologous donors, 69% received an autologous transfusion. The authors concluded that autologous donation was unnecessary in patients undergoing primary total hip arthroplasty who had a normal hemoglobin.
REFERENCES: Billote D, Glisson SN, Green D, Wixson RL: A prospective, randomized study of preoperative autologous donation for hip replacement surgery. J Bone Joint Surg Am 2002;84:1299-1304.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 47-53.

Question 35

Figures 31a and 31b are the radiographs of a 5-year-old boy with an elbow injury.

Explanation

DISCUSSION
Figure 26 shows lucent areas of both femoral condyles. This may represent a variation of ossification, in which case this boy’s knee pain is coincidental. Another possibility is atypical osteochondritis dissecans. An MRI will distinguish between the 2 entities and will guide treatment.
Figures 27a and 27b show healing rib and distal tibia fractures. These fractures likely are attributable to child abuse. A plain radiographic skeletal survey is sufficient for orthopaedic needs.
A triplane fracture of the distal tibia is revealed in Figure 28. A CT scan will quantify displacement and identify fracture fragments for planning of screw trajectories if open reduction and internal fixation is indicated (displacement > 2 mm).
In Figure 29, the linear lucency of the capitellum indicates an early osteochondritis dissecans. An MRI will allow staging of the lesion.
Figure 30 shows that the left radius and ulna do not align with the humerus; this is the likely result of a transphyseal fracture of the distal humerus. An arthrogram will outline the unossified distal humerus and allow for reduction. For an unstable neonate, this likely can be performed in the NICU.
Figures 31a and 31b reveal a widely displaced lateral condyle fracture for which open reduction and internal fixation is required. No advanced imaging is necessary.

Question 36

Which of the following represents a contraindication for interspinous process decompression for the treatment of lumbar spinal stenosis?

Explanation

DISCUSSION: Kondrashov and associates noted stable good outcomes at 4 years in 14 of 18 patients treated with X-STOP interspinous process decompression as defined as an improvement over preoperative Oswestry scores of 15 points or more. Similar results were seen after 1 year in a European study by Siddiqui and associates. Exclusion and inclusion criteria for these studies varied somewhat, but cauda equina syndrome was the only exclusion criteria listed in both studies. All of the other choices did not represent exclusion criteria in either study.
REFERENCES: Kondrashov DG, Hannibal M, Hsu KY, et al: Interspinous process decompression with the X-STOP device for lumbar spinal stenosis: A 4-year follow-up study.

J Spinal Disord Tech 2006;19:323-327.
Siddiqui M, Smith FW, Wardlaw D: One-year results of X Stop interspinous implant for the treatment of lumbar spinal stenosis. Spine 2007;32:1345-1348.

Question 37

A 19-year-old college cross-country runner is amenorrheic and has recurrent stress fractures. Long-term management should consist of

Explanation

DISCUSSION: The triad of menstrual dysfunction, disordered eating, and stress fracture is well recognized in women who participate in endurance sports. The best treatment remains to be determined, but at present, the combination of oral contraceptives to regulate menses, an increased intake of calcium and vitamin D, as well as nutritional counseling, is the recommended treatment for decreased bone mass related to exercise-induced amenorrhea.
REFERENCES: Nattiv A, Armsey TD Jr: Stress injury to bone in the female athlete. Clin Sports Med 1997;16:197-224.
Drinkwater BL: Exercise and bones: Lessons learned from female athletes. Am J Sports Med 1996;24:S33-S35.

Question 38

Figure 1 is the radiograph of a 21-year-old college lacrosse player who has a 2-year history of progressive left groin pain that is exacerbated by activity. Pain is preventing him from participating with his team. Examination reveals a fit man without tenderness to palpation around the hip. No clicking or popping occurs with hip range of motion. Strength of all muscles about the hip is normal, but there is some mild pain with resisted hip flexion and hip adduction. While lying supine, progressive hip flexion with internal rotation and adduction reproduces his groin pain.What is the most likely cause of this patient's pain?

Explanation

This clinical scenario describes a patient with FAI attributable to pincer (acetabular) deformity. This form of FAI, which involves prominence of the anterosuperior acetabular lip, may be more common among women. Decreased range of motion and pain occur secondary to the abutment of the femoral head against the acetabular labrum and rim. Hip flexion, combined with adduction and internal rotation, recreates this contact and causes pain, but CAM or pincer etiology remains unknown. The differential diagnosis of hip pain in a young athlete includes femoral neck stress reaction/fracture, sacroiliac arthritis, intra-articular loose body, trochanteric bursitis, osteitis pubis, and hernia. No information presented in this scenario suggests any of these causes. Diagnosis of FAI is best performed via MR imaging, with an arthrogram increasing the sensitivity and specificity for labral pathology. Ultrasonography may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping hip, but ultrasonography is not commonly used to diagnose labral pathology. Although concomitant chondral lesions of the femoral head are uncommon, the forced leverage of the anterosuperior femoral neck upon the anterior acetabulum may result in a “contra-coup” chondral injury on the posteroinferior acetabulum. This is the most common location of chondral lesions in this scenario. Without bony resection to prevent further impingement, this patient will continue to experience symptoms. Because there is no evidence of femoral neck prominence (CAM lesion), there is no indication for osteoplasty of the femoral neck; resection of the pincer lesion is necessary. This will often require take-down of the labrum in this location. If possible, iatrogenic or traumatic labral tears should subsequently be repaired after pincer debridement because the labrum has important functions for hip stability and maintenance of the suction seal of the joint.

Question 39

A 70-year-old man reports symptomatic medial knee pain that has become progressively worse during the past year. MRI reveals a complex, posterior horn medial meniscus tear with associated medial lateral and patellofemoral cartilage defects. Radiographs reveal medial joint space narrowing and osteophytes in the other compartments. What treatment is most likely to provide long-term, durable relief of symptoms?

Explanation

DISCUSSION:
Total knee replacement is a well-established surgery for diffuse, symptomatic osteoarthritis of the knee joint, and its efficacy has been shown in many studies. According to the 2008 AAOS Clinical Practice Guideline, Treatment of Osteoarthritis of the Knee, arthroscopy in the setting of existing osteoarthritis is efficacious for relieving the signs and symptoms of a torn meniscus but not for osteoarthritis. Likewise, in young and active patients, clinical outcomes show improvement after realignment osteotomy for single-compartment osteoarthritis. Unicondylar knee replacement is not indicated for tricompartmental disease of the knee.

Question 40

Figures below show the radiographs obtained from a 68-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/m2 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 41

A 45-year-old man sustains an acute closed posterolateral elbow dislocation. The elbow is reduced, and examination reveals that the elbow dislocates posteriorly at 35 degrees with the forearm placed in supination. What is the best course of action?

Explanation

DISCUSSION: Most closed simple dislocations are best managed with early range of motion. Posterior dislocation typically occurs through a posterolateral rotatory mechanism. When placed in pronation, the elbow has greater stability when the medial ligamentous structures are intact. In traumatic dislocations, MRI rarely provides additional information that will affect treatment. In elbows that remain unstable, primary repair is preferred over ligament reconstruction. Cast immobilization increases the risk of arthrofibrosis.
REFERENCE: O’Driscoll SW, Morrey BF, Korinek S, et al: Elbow subluxation and dislocation: A spectrum of instability. Clin Orthop 1992;280:186-197.

Question 42

Six months later, the patient’s fracture has healed and a CT scan to further evaluate the physis is performed (Video 85). Based on these findings, how should you advise the family?

Explanation

DISCUSSION
The hypertrophic zone is the weakest biomechanical zone of the physis and is most likely to fracture. The deep peroneal nerve supplies motor innervation to the ankle and toe
dorsiflexors (anterior compartment) and the first web space, which, in this history, have deficits. The superficial peroneal nerve supplies sensation to the dorsum of the foot and motor to the lateral compartment peroneal musculature (ankle evertors), which also has deficits. The injury must involve both peroneal branches (the common peroneal nerve). Because sensation to the sole of the foot and toe/ankle plantar flexion is intact, the tibial nerve is intact.
Because the nerve was visualized intact, a neuropraxia is the most likely type of nerve injury. This should recover in time and does not necessitate urgent exploration. In pediatric patients, an advancing Tinel sign and partial nerve recovery by 3 months is expected and can be followed clinically. If there is no sign of nerve recovery, an electromyogram should be ordered with consideration for nerve exploration if there is no sign of reinnervation. There is no sign of compartment syndrome because the patient has an unchanged neurologic deficit, is comfortable, and has no pain with passive range of motion.
These injuries are associated with a very high rate of growth arrest (up to 80% in some studies). The CT scan shows an asymmetric growth arrest, which suggests angulation through the distal femur.

Question 43

Figures 100a and 100b are the radiographs of a 90-year-old woman who is seen in the emergency department after a fall from a height. She has right hip and thigh pain and is unable to bear weight. Based on this patient’s history and imaging, what is the best next step?

Explanation

CLINICAL SITUATION FOR QUESTIONS 101 THROUGH 104
Figures 101a and 101b are the right hip radiographs of a 26-year-old active man who has had pain in his right hip for 4 months. His pain is worse with prolonged periods in a seated position. He has no pain at rest and denies pain in other joints or systemic illness. Examination reveals passive range of motion of full extension, 80 degrees of flexion, internal rotation in flexion of 0 degrees, and external rotation in flexion of 30 degrees. Forced flexion, internal rotation, and adduction are very painful. A flexion, abduction, and external rotation test result is negative.

Question 44

Which of the following types of iliac osteotomy provides the greatest potential for increased coverage?

Explanation

DISCUSSION: The degree of acetabular dysplasia and the age of the child are important considerations when choosing what type of osteotomy to perform. The ability to obtain concentric reduction is a prerequisite of all osteotomies that redirect the acetabulum. Procedures that cut all three pelvic bones allow more displacement and, therefore, correction of acetabular dysplasia. The closer the osteotomy is to the acetabulum, the greater the coverage of the femoral head. Compared with the other acetabular osteotomies, the Ganz periacetabular osteotomy provides the greatest potential for correcting acetabular deficiency because there are no bone or ligamentous restraints to limit correction, but it has the disadvantage of being a technically demanding procedure. The amount of coverage provided by the Salter osteotomy is limited.
REFERENCES: Millis MB, Poss R, Murphy SB: Osteotomies of the hip in the prevention and treatment of osteoarthritis, in Eilert RE (ed): Instructional Course Lectures XLI. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1992, pp 145-154.
Weinstein SL: Developmental hip dysplasia and dislocation, in Morrissy RT, Weinstein SL (eds): Lovell & Winter’s Pediatric Orthopaedics, ed 4. Philadelphia, Pa, Lippincott-Raven, 1996, pp 903-950.

Question 45

A 27-year-old man sustains a displaced femoral neck fracture and undergoes urgent open reduction internal fixation. What is the most prevalent complication after this injury?

Explanation

DISCUSSION: Femoral neck fractures in young patients are difficult to treat, and AVN is a significant concern. Despite advances in both imaging and implants, this injury often leads to functional impairment.
Haidukewych et al followed treatment of femoral neck fractures in young patients. They found almost 10% of displaced fractures were associated with the development of nonunion, where as 27% were associated with the development of osteonecrosis. Their results were influenced by fracture displacement and the quality of reduction. Varus malreduction most closely correlates with failure of fixation after reduction and cannulated screw fixation.
Swiontkowski reviews both the treatment and post operative complications in intracapsular hip fractures. In this Current Concept Review, the rate of AVN was discussed as being related to the pre-operative degree of displacement seen on radiographs.
Incorrect Responses:

Question 46

What radiographic measurement is best used to assess the adequacy of deformity correction for the patient shown in Figure 22?

Explanation

DISCUSSION: Developmental coxa vara develops in early childhood and results in a progressive decrease in the proximal femoral neck-shaft angle with growth. The characteristic radiographic features are seen in this patient and include a decreased neck-shaft angle, a more vertical position of the physeal plate, and a triangular metaphyseal fragment in the inferior femoral neck, surrounded by an inverted radiolucent Y pattern. The main goal of surgery is to correct the varus angulation into a more normal range. Valgus overcorrection is preferred. A recent study emphasized the importance of adequately correcting the Hilgenreiner physeal angle to less than 38 degrees to minimize the risk of recurrent angulation. No study has documented the use of any of the other listed radiographic measurements to the outcome of treating developmental coxa vara.
REFERENCES: Carroll K, Coleman S, Stevens PM: Coxa vara: Surgical outcomes of valgus osteotomies. J Pediatr Orthop 1997;17:220-224.
Cordes S, Dickens DR, Cole WG: Correction of coxa vara in childhood: The use of Pauwels’ Y-shaped osteotomy. J Bone Joint Surg Br 1991;73:3-6.

Question 47

When conducted at near physiologic strain rates, tensile studies of the inferior glenohumeral ligament (IGHL) have shown that the

Explanation

DISCUSSION: Tensile testing of the inferior glenohumeral ligament at near physiologic strain rates has shown that the anterior band of the IGHL has the greatest stiffness of the three ligament regions and the glenoid insertion site shows greater strain than the ligament midsubstance.
REFERENCES: Bigliani LU, Pollock RG, Soslowsky LJ, Flatow EL, Pawluk RJ, Mow VC: Tensile properties of the inferior glenohumeral ligament. J Orthop Res 1992;10:187-197.
Ticker JB, Bigliani LU, Soslowsky LJ, Pawluk RJ, Flatow EL, Mow VC: Inferior glenohumeral ligament: Geometric and strain-rate dependent properties. J Shoulder Elbow Surg 1996;5:269-279.

Question 48

What form of fixation is associated with the highest incidence of osseous union when using segmental allograft reconstruction following tumor resection?

Explanation

DISCUSSION: Plate and screw fixation of allograft is associated with the highest incidence of union but also the highest prevalence of allograft fracture. Conversely, intramedullary fixation is associated with a higher incidence of nonunion but fewer fractures. Step-cut osteotomies are not associated with a higher incidence of union.
REFERENCE: Vander Griend RA: The effect of internal fixation on the healing of large allografts. J Bone Joint Surg Am 1994;76:657-663.

Question 49

What is the most common cause for late revision (> 2 years post op) total knee arthroplasty?

Explanation

DISCUSSION: There are multiple causes for failure of total knee arthroplasty, and more than one may exist at the same time. Sharkey and associates reviewed a series of revision total knee arthroplasties, and found that polyethylene failure was the most common cause of failure followed closely by component loosening. The most common cause of early failure (< 2 years post op) was infection. Instability and malalignment are both complications of surgical technique, and if these categories are combined, they would be the most common cause of all total knee failures.
REFERENCE: Sharkey PF, Hozack WJ, Rothman RH, et al: Insall Award paper: Why are total knee arthroplasties failing today? Clin Orthop Relat Res 2002;404:7-13.

Question 50

Following surgery for an ankle fracture, which of the following is considered the most important factor in achieving a satisfactory outcome? Review Topic

Explanation

The only factor that is prognostic for outcomes is the quality of the reduction. None of the other factors has any effect on the outcome. Early range of motion or physical therapy may offer temporary effects, but these small advantages do not last beyond 3 months after surgery.

Question 51

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

Explanation

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

CLINICAL SITUATION FOR QUESTIONS 69 THROUGH 72
Figures 69a through 69c are the radiograph and MR images of a 37-year-old woman who has had a 2-month history of left hip pain.

Question 52

Figures 37a and 37b show radiographs of a 24-year-old man who has a humeral bone lesion that was found during a screening chest radiograph. He denies any symptoms despite leading a very active lifestyle. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiographs reveal a geographic, diaphyseal lesion with very subtle cortical expansion, cortical thinning, relatively sharp demarcation, and angular rather than rounded borders, suggesting a fibrous bone lesion. This lesion demonstrates the classic ground glass appearance of fibrous dysplasia. Ewing’s sarcoma, metastases, and aneurysmal bone cyst all typically have a more aggressive appearance.
REFERENCES: Parsons TW: Benign bone tumors, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 1027-1035.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 69-75.

Question 53

The clinical factors shown to most significantly predict the long-term outcome of Perthes disease of the hip include which of the following? Review Topic

Explanation

Age at presentation and range of motion of the hip are the two most significant predictors of long-term outcome. Younger patients and patients who maintain range of motion of the hip are more likely to have a good outcome. In Herring's study, children with a chronologic age of younger than 8 years or a bone age of less than 6 years had significantly more favorable outcomes compared with older children. Limited hip range of motion may be due to muscle spasm early on, or synovitis; but in late disease, it may reflect incongruity of the joint. Classifications based on femoral head shape have also been correlated to prognosis. Significant shortening of the affected hip is not common.
(SBQ13PE.87) A 4-week-old child is suspected to have classic arthrogryposis, also known as amyoplasia. Clinical examination and hip ultrasound reveal a unilateral, non-reducible, hip dislocation. What do you recommend to reduce the hip? Review Topic
Pavlik harness application
Semi-rigid abduction brace application
Skeletal traction
Early closed reduction and spica casting
Delayed open reduction with or without pelvic and femoral osteotomy
Delayed open reduction with or without pelvic and femoral osteotomy is recommended in the management of unilateral hip deformities associated with amyoplassia. This procedure should be performed at 6-9 months of age. In order to proceed with reduction, there must be a reasonable arc of flexion/extension and active movement of the lower limbs.
Amyoplasia is the most common recognizable form of arthrogryposis. It most commonly occurs as a sporadic symmetric contracture syndrome that is characterized by symmetrical limb involvement, normal to above-average intelligence, and often a midline facial hemangioma. Approximately 80% of children with amyoplasia will have involvement of the hip ranging from soft tissue contractures to unilateral or bilateral hip dislocations.
Bevan et al. reviewed arthrogryposis. They state that open hip reduction is recommended for the management of unilateral dislocation. There is more controversy with regard to the treatment of bilateral hip dislocations. Open reduction can be performed by a medial or anterolateral approach, with or without pelvic and
femoral osteotomy. This procedure is generally delayed for 6-9 months to facilitate the procedure.
Bernstein et al. also reviewed arthrogryposis. They state that the term 'arthrogryposis' encompasses a broad spectrum of diseases, all with the common phenotype of multiple congenital contractures.
Illustration A shows the characteristic features of an infant with severe arthrogryposis. Note the internal rotation of the shoulders, elbow and knee hyperextension, flexed and ulnarly deviated wrists, flexed finger, external rotation of hips and bilateral clubfeet.
Incorrect answers:

Question 54

A 51-year-old male 2-pack per day smoker presents with a hyperkeratotic light brown plaque on the dorsum of his left ring finger that has been present for 7 years. It measures 14 mm by 13 mm. Initially, it responded to topical wart treatments, but has failed to do so recently so he sought evaluation by a dermatologist who biopsied the lesion. The results revealed squamous cell carcinoma (SCC) in situ, and he was referred for further surgical management. He has no other skin lesions, no history of SCC and no axillary lymphadenopathy. What is the next step in management?

Explanation

EXPLANATION:
SCC in situ is a low-grade malignancy that typically presents as painless lesions on areas of high sun exposure such as the dorsum of the hand and fingers. The recommended treatment for lesions smaller than 100 mm is wide excision with 4 mm margins to a depth 1 layer below the tumor, along with any adjacent area of induration. Sentinel lymph node biopsy is typically not indicated in the setting of a low-grade tumor such as this one and in the absence of axillary lymphadenopathy.

Question 55

What is the primary benefit of using rhBMP-2 instead of autogenous bone graft inside an anterior spinal fusion cage?

Explanation

DISCUSSION: Radiographic fusion success rates are best described as slightly rather than substantially improved. Hospital stay and time to fusion also are not substantially decreased. Use of BMP does eliminate the need for autograft harvest for anterior lumbar interbody fusion/cage. The need for postoperative bracing is not altered based on graft choice. Early studies of posterolateral fusion applications appear to show a greater potential benefit of rhBMP-2 over autograft. Not all BMP formulations perform the same with regard to safety and effectiveness. Other osteoinductive proteins in clinical trials (BMP-7, GDF-5) will require individual analysis of these properties.
REFERENCE: Burkus JK, Gornet MF, Dickman CA, et al: Anterior lumbar interbody fusion using rhBMP-2 with tapered interbody cages. J Spinal Disord Tech 2002;15:337-349.

Question 56

A healthy, active collegiate soccer player returns to your office approximately 10 months after returning to full play and 18 months after undergoing ACL reconstruction with bone-patellar tendon-bone (BTB) autograft. The patient reports landing awkwardly after a jumping for a ball and felt his knee give way. He presents with pain, worse with weight bearing. On physical exam, there is a mild effusion and a grade 2B Lachman. Radiographs are shown in Figure A. What is the likely underlying cause of his current diagnosis? Review Topic

Explanation

The most common cause for early failure following ACL reconstruction is a malpositioned tunnel.
Ideal tunnel placement on the femoral side should be at the approximately 2 o'clock (for a left knee) or 10 o'clock (for a right knee) position on the lateral wall, which facilitates a more horizontal, anatomic graft. On the tibial side, the tunnel trajectory in the coronal plane should be about 60-75 degrees from the horizontal and the tunnel entrance should be approximately 10-11mm from the anterior border of the PCL.
Noyes et al. emphasize the importance of anatomic reconstruction. They recommended against using a transtibial tunnel to make the femoral tunnel because it will result in a vertical orientation. The authors summarized and recommended the use of individual drilling of each tunnel, and using a anteromedial portal to obtain the ideal femoral tunnel.
Driscoll et al. compared the rotational properties of a BTB graft placed centrally in the tibial footprint in both groups, but on the femoral side, placed in the anteromedial aspect versus central portion of the ACL femoral origin. They noted a significantly stronger resistance to rotational failure when placed centrally. Thus, noting the importance of placing the graft anatomically, within the central areas of both the tibial footprint and femoral origin.
Figure A exhibits malpositioned tunnels, both of which are too vertical. Illustration A exhibits well-placed tunnels, with the horizontality exhibited on the femoral side and approximately 75 degrees from the horizontal on the tibial side.
Incorrect answers:

Question 57

A 69-year-old patient with diabetes has had acute-onset back pain and difficulty with ambulation for several hours. Evaluation reveals a temperature of 38.3°C, a white blood cell (WBC) count of 14000/µL (reference range [rr], 4500-11000/µL), C-reactive protein (CRP) level of 120 mg/L (rr, 0.08-3.1 mg/L), erythrocyte sedimentation rate of 130 mm/h (rr, 0-20 mm/h), normal rectal examination findings, and normal sensation to light touch. Motor function testing of the lower extremities reveals 3/5 ankle dorsiflexion and 4/5 plantar flexion strength bilaterally. An MR image reveals a large epidural abscess from L1-5. What is the most appropriate treatment at this time?

Explanation

DISCUSSION
Epidural abscess is a serious and potentially disastrous condition. Although medical management is effective in some situations, surgical decompression is considered urgent with the presence of a neurological deficit. Medical management can be considered in the case of a neurologically intact patient, particularly when the microorganism has been identified. If medical management is chosen, careful observation and serial examination for neurologic deterioration is required. Surgical decompression is indicated if a patient's neurologic status worsens or if medical management failure is noted. Additionally, diabetes, a CRP level higher than 115 mg/L, WBC higher than 12500/µL , and bacteremia have proven predictive of medical treatment failure. This patient would be a better candidate for urgent surgical decompression and subsequent IV antibiotics than for medical management.
RECOMMENDED READINGS
Patel AR, Alton TB, Bransford RJ, Lee MJ, Bellabarba CB, Chapman JR. Spinal epidural abscesses: risk factors, medical versus surgical management, a retrospective review of 128 cases. Spine J. 2014 Feb 1;14(2):326-30. doi: 10.1016/j.spinee.2013.10.046. Epub 2013 Nov 12. PubMed PMID: 24231778.View Abstract at PubMed
Kim SD, Melikian R, Ju KL, Zurakowski D, Wood KB, Bono CM, Harris MB. Independent predictors of failure of nonoperative management of spinal epidural abscesses. Spine J. 2014 Aug 1;14(8):1673-9. doi: 10.1016/j.spinee.2013.10.011. Epub 2013 Oct 30. PubMed PMID:

Question 58

A 30-year-old man who sustained a tibial fracture with a peroneal nerve palsy 2 years ago now has a drop foot and weak eversion of the foot. He reports success with stretching exercises, but he catches his toes when his foot tires. Examination reveals that the foot is plantigrade and supple. What is the next most appropriate step in management?

Explanation

DISCUSSION: The patient has a supple plantigrade foot that would benefit from a drop foot brace to prevent catching of the toes. Tendon transfer should not be considered until the patient has undergone bracing. Achilles tendon lengthening is not necessary because the foot is plantigrade and flexible. Nerve grafting is not indicated because of the length of time the peroneal nerve palsy has been present.
REFERENCES: Dehne R: Congenital and acquired neurologic disorders, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, vol 1, pp 552-553.
Santi MD, Botte MJ: Nerve injury and repair in the foot and ankle. Foot Ankle Int

1996;17:425-439.

Question 59

A 12-year-old male sustains a ulnar fracture with an associated posterior-lateral radial head dislocation. After undergoing closed reduction, the radiocapitellar joint is noted to remain non-concentric. What is the most likely finding?

Explanation

DISCUSSION: In pediatric Monteggia fractures the annular ligament is commonly interposed in the radiocapitellar joint. Tan et al reviewed their treatment of 35 children with Type I and Type III Monteggia fractures. All radial heads were explored and the interposed annular ligament was stretched out of the joint space. They noted that none of the patients has any recurrent dislocation or subluxation. Bado initially described and classified Monteggia fractures. The most common injury pattern is an extension type 1 with anterior radial head dislocation and apex anterior ulnar shaft fracture. The apex of the ulna fracture determines the direction of the radial head subluxation or dislocation. Adults typically require ORIF of the ulna. These fractures in children are often treated non-operatively with closed reduction if the ulna fracture is transverse and stable. Type III is the one most commonly associated with irreducibility of the radial head because of interposition of the annular ligament. The incidence of posterior interosseous nerve injury is high with this lesion. The nerve deficit usually completely resolves rapidly and spontaneously. Ring et al in their review stress the importance of an anatomic reduction of the ulna to restore the reduction of the radial head

Question 60

A 36-year-old woman reports vague right shoulder pain. She denies any previous shoulder problems or any recent trauma. MRI scans are shown in Figures 81a and 81b. Weakness of which of the following is the most likely finding in her physical examination? Review Topic

Explanation

The MRI scans show a cyst formation within the suprascapular notch that can compress the suprascapular nerve. The suprascapular nerve innervates both the supraspinatus and the infraspinatus muscles. Therefore, patients with compression of this nerve may demonstrate weakness of shoulder abduction and external rotation with the arm at the side. If the nerve is compressed after its innervation of the supraspinatus muscle, however, patients will demonstrate weakness of shoulder external rotation only. Suprascapular nerve does not innervate muscles that control scapula motion or shoulder internal rotation.

Question 61

A 23-year-old soccer player sustains a grade III complete posterior cruciate ligament (PCL) tear after colliding with another player. In reconstructing the PCL, it is optimal to reconstruct the

Explanation

DISCUSSION: The PCL is a nonisometric structure with nonuniform tension during knee motion, with maximum tension at 90° of flexion. While the posteromedial PCL fibers have been found to be the most isometric, the anterolateral fibers represent the bulk of the ligament. Studies have suggested that anterior placement of the femoral tunnel is superior to placement in an isometric position. The anterolateral bundle tightens as the knee flexes; therefore, it is optimal to tension the graft at 90° of flexion.
REFERENCES: Harner CD, Xerogeanes JW, Livesay GA, et al: The human posterior cruciate ligament complex: An interdisciplinary study. Ligament morphology and biomechanical evaluation. Am J Sports Med 1995;23:736-745.
Burns WC II, Draganich LF, Pyevich M, Reider B: The effect of femoral tunnel position and graft tensioning technique on posterior laxity of the posterior cruciate ligament-reconstructed knee. Am J Sports Med 1995;23:424-430.

Question 62

Figures 21a and 21b show a transverse MRI scan at L4/5 and a lateral radiograph of a 75-year-old man with a 2-year history of worsening low back and bilateral leg pain that occurs with ambulation beyond approximately a half a block. Management consisting of physical therapy, anti-inflammatory medications, and muscle relaxants has failed to successfully resolve his symptoms. He has minimal medical comorbidities. What is the best treatment approach for this patient? Review Topic

Explanation

The patient has spinal stenosis and degenerative spondylolisthesis. Laminectomy and posterior spinal fusion have been demonstrated to be superior to both nonsurgical management and laminectomy without fusion in prospective randomized studies. The effect of instrumentation on improvement of clinical outcomes remains a matter of debate. This patient has exhausted physical therapy approaches per the history. Epidural steroid injections have not been shown to significantly alter the natural history of patients with degenerative lumbar spinal stenosis and spondylolisthesis. While minimal access decompression has been described, percutaneous endoscopic diskectomy would be more appropriate for a disk herniation.

Question 63

What is the most common associated pathology in patients who have suprascapular nerve entrapment secondary to ganglion cysts?

Explanation

DISCUSSION: It is well known that suprascapular nerve entrapment can be secondary to many entities, and its association with ganglion cysts and SLAP lesions has been well documented. Because of a superior labral tear, synovial fluid will leak out of the joint underneath the labrum, causing the cyst and secondary compression of the nerve.
REFERENCES: Fehrman DA, Orwin JF, Jennings RM: Suprascapular nerve entrapment by ganglion cysts: A report of six cases with arthroscopic findings and review of the literature. Arthroscopy 1995;11:727-734.
Iannotti JP, Ramesey ML: Arthroscopic decompression of a ganglion cyst causing suprascapular nerve compression. Arthroscopy 1996;12:739-745.
Moore TP, Fritts HM, Quick DC, Buss DD: Suprascapular nerve entrapment caused by supraglenoid cyst compression. J Shoulder Elbow Surg 1997;6:455-462.

Question 64

A 17-year-old presents with persistent left knee pain after a twisting injury during a soccer match 24 hours ago. On physical exam he has a mild effusion. He has tenderness to palpation on the medial joint line. Lachman test, anterior drawer test and posterior drawer test are attempted but limited secondary to pain. Dial test reveals a side-to-side external rotation difference of roughly 5 degrees. His MRI images are seen in Figures A-D. These findings would be most consistent with: Review Topic

Explanation

The patient has sustained a complex tear involving the posterior horn of the medial meniscus. Localizing joint line tenderness is the most sensitive physical examination finding for this injury.
Many provocative tests have been described to aid in the diagnosis of meniscus tears.
The Apley test is performed with the patient prone, by axially loading the tibiofemoral joint at 90° of knee flexion. Pain with compression and external rotation (medial meniscus) or internal rotation (lateral meniscus) is considered positive.
The Ege's test is performed by having the patient squat with their knees maximally externally rotated or internally rotated. The test is positive when pain and/or a click is felt by the patient.
The McMurray test is performed by passively moving the knee from flexion to extension while externally or internally rotating the leg. A palpable click at the joint line with external rotation (medial meniscus) or internal rotation (lateral meniscus) is considered positive.
The Thessaly test is performed by supporting the patient as they internally or externally rotate their knee and body while keeping the foot planted, with the knee in 5° of flexion and then 20° of flexion. The test is positive when joint line pain and/or sense of locking/catching is experienced by the patient.
Ryzewicz et al. performed a systematic review of prospective cohort studies comparing magnetic resonance imaging (MRI) and clinical examination to arthroscopy in the diagnosis of meniscus tears. The Apley test, Ege's test, McMurray test and Thessaly test at 5° were shown have high specificity but low sensitivity. Joint line tenderness has a higher sensitivity, but lower specificity. The Thessaly test at 20° demonstrated the highest sensitivity and specificity, although there was only one available study evaluating this test.
Abdon et al. performed a prospective study looking at 68 clinical parameters to
determine which combinations of symptoms and signs indicated the presence of a meniscus tear. They found that joint-line tenderness and mechanical locking were predictive of a meniscus tear, while the McMurray sign did not prove valuable. Pain at rest, sick leave and medial patellar tenderness all negated the presence of a meniscus tear. The clinical accuracy in diagnosing meniscal tears was 61% in this study.
Figures A and B are T1 sagittal MR images demonstrating an intact anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL), respectively. Figures C and D are T2 coronal and sagittal MR images showing a complex tear of the posterior horn of the medial meniscus. Illustration A demonstrates the Ege's test. Illustration B shows the Thessaly test at 5° of flexion.
Incorrect

Question 65

04 Which of the following laboratory studies is predictive of wound healing prior to performing a lower extremity amputation?

Explanation

A serum albumin level of below 3.5 g/dl indicates malnourished patient. An absolute lymphocyte count below 1500/mm3 is a sign of immune deficiency. If possible, amputation surgery should be delayed in such patients. An absolute Doppler pressure of 70 mm Hg is the minimum inflow level. The ischemic index is the ratio of the Doppler pressure at the level being tested to the brachial systolic pressure. Genreally accepted to require an ischemic index of 0.5 or greater. Transcutaneous partial pressure of oxygen (TcpO2) is the present gold standard of vascular inflow. TcpO2 values of 40 mm Hg correlate with acceptable wound healing
(eliminates false positive predictions with using area under the Doppler waveform). Pressures less than 20 mm Hg are predictive of poor healing. Miller 505-6
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Question 66

A 7-year-old girl has pain and a mass in the left scapula. A MRI scan and biopsy specimen are shown in Figures 30a and 30b. After staging studies, initial management should consist of

Explanation

DISCUSSION: The histology shows small round blue cells that are uniform in appearance; these findings are consistent with Ewing’s sarcoma. The MRI scan shows infiltration of the marrow and a large surrounding soft-tissue mass. Based on these findings, the management of choice is systemic chemotherapy. Local control of the primary lesion is addressed by either surgical resection or radiation therapy or a combination of the two after the patient receives systemic chemotherapy. The clinical, radiographic, and histologic presentation of Ewing’s sarcoma often can be confused with osteomyelitis. The histology shows an absence of inflammatory cells.
REFERENCES: Grier HE: The Ewing family of tumors: Ewing’s sarcoma and primitive neuroectodermal tumors. Pediatr Clin North Am 1997;44:991-1004.
Arndt CA, Crist WM: Common musculoskeletal tumors of childhood and adolescence. N Engl J Med 1999;341:342-352.

Question 67

A 16-year-old high school football player has diffuse pain with attempted digital flexion after injuring the ring finger of the dominant hand 1 week ago. Examination reveals that he is unable to flex the distal interphalangeal joint. Management should consist of

Explanation

DISCUSSION: The patient has an avulsion of the flexor digitorum profundus. Treatment should include surgical exploration and tendon reinsertion. This is not an avulsion of the flexor digitorum superficialis because the patient’s deficiency is the inability to flex the distal interphalangeal joint, not the proximal interphalangeal joint. Surgical release of the anterior interosseous nerve is not indicated because the flexor digitorum profundus of the ring finger is innervated by the ulnar nerve. A median nerve contusion causes wrist pain and/or numbness and tingling in the median nerve distribution.
REFERENCES: Strickland JW: Flexor tendons: Acute injuries, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,

pp 1851-1897.
Leddy JP: Avulsions of the flexor digitorum profundus. Hand Clin 1985;1:77-83.

Question 68

Figures 18a and 18b show the radiographs of a 13-year-old baseball player who sustained a patellar dislocation with an associated lateral femoral condyle fracture. What ligament is attached to this fragment?

Explanation

DISCUSSION: The anterior cruciate ligament is attached to a portion of the lateral femoral condyle. The posterior cruciate ligament attaches to the medial femoral condyle. The lateral collateral and oblique popliteal ligaments attach proximal to this fragment. The intermeniscal ligament attaches the anterior horns of the menisci.
REFERENCES: Jobe CM, Wright M: Anatomy of the knee, in Fu FH, Harner CD, Vince KG (eds): Knee Surgery. Baltimore, MD, Williams & Wilkins, 1994, pp 1-54.
Moore KL, Dalley AF: Lower limb, in Moore KL, Dalley AF (eds): Clinically Oriented Anatomy, ed 4. Philadelphia, PA, Lippincott, Williams & Wilkins, 1999, pp 503-664.

Question 69

A 7-year-old boy has a swollen and deformed right arm after falling off his bicycle. Radiographs reveal a completely displaced posterolateral supracondylar humeral fracture. Examination reveals a warm, pink hand and forearm but absent pulses. What is the next most appropriate step in management?

Explanation

DISCUSSION: The incidence of vascular injury in supracondylar humeral fractures is directly related to the degree and direction of displacement. Significant posterior lateral displacement tends to result in brachial artery and median nerve injuries, and posterior medial displacement may lead to radial nerve injury. The brachial artery is always injured at the level of the fracture; therefore, angiography or MRA will not assist in locating the injury. The treatment of choice is surgical reduction and stabilization of the fracture, followed by reassessment of the vascular status. If the hand is pink and warm or pulses can be detected with doppler, it is reasonable to follow the extremity closely after surgery. If the arm becomes pulseless and white, immediate anterior exploration of the arm is indicated. The artery is often entrapped in the fracture and once extricated, will provide adequate blood flow. If the artery is injured, a primary repair or vein graft is needed.
REFERENCES: Shaw BA: The role of angiography in assessing vascular injuries associated with supracondylar humerus fractures remains controversial. J Pediatr Orthop 1998;18:273.
Sabharwal S, Tredwell SJ, Beauchamp RD, et al: Management of pulseless pink hand in pediatric supracondylar fractures of humerus. J Pediatr Orthop 1997;17:303-310.
Schoenecker PL, Delgado E, Rotman M, et al: Pulseless arm in association with totally displaced supracondylar fracture. J Orthop Trauma 1996;10:410-415.

Question 70

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

Explanation

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

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

Question 71

A 13-year-old girl has had pain in her ankle and difficulty with sporting activities for the past 6 months. Nonsteroidal anti-inflammatory drugs and use of a short leg cast have provided minimal relief. A radiograph and MRI scan are shown in Figures 43a and 43b. What is the next most appropriate step in treatment?

Explanation

DISCUSSION: The MRI scan shows an obvious talocalcaneal coalition of the medial facet. Because nonsurgical management has failed, surgical resection of the coalition is indicated. Arthrodesis would be indicated only if resection fails to relieve pain or if advanced degeneration of the hindfoot joints is present.
REFERENCES: McCormack TJ, Olney B, Asher M: Talocalcaneal coalition resection: A 10-year follow-up. J Pediatr Orthop 1997;17:13-15.
Thometz J: Tarsal coalition. Foot Ankle Clin 2000;5:103-118.

Question 72

Figure 1 is the anteroposterior radiograph of a 20-year-old dancer who fell during his routine and injured his right foot. What is the most appropriate treatment?

Explanation

A 38-year-old woman underwent left knee anterior cruciate ligament (ACL) reconstruction with patellar tendon autograft and medial meniscus repair 11 years ago. She has no complaints of instability since surgery. She presents with left knee pain, swelling and the inability to extend her knee after getting up from a kneeling position one week prior. She reports feeling a pop in her knee at the time of injury. On examination she lacks 5° of extension and has a symmetric Lachman test. Figure 1 is the radiograph of her knee. Figures 2 through 4 show the findings at the time of arthroscopy. What is the most appropriate treatment?

Question 73

A 30-year-old woman who runs approximately 30 miles a week has had right hip and groin pain for the past 3 weeks. Examination reveals an antalgic gait, limited motion of the right hip, and pain, especially with internal and external rotation. Plain radiographs are normal, and an MRI scan is shown in Figure 21. Management should consist of

Explanation

DISCUSSION: A stress fracture of the hip is a relatively common problem in endurance sports. These fractures are classified as compression-side, tension-side, and displaced femoral neck fractures. The MRI scan shows a compression-side stress fracture. Compression-side fractures usually occur in the inferior or calcar area of the proximal femur, and non-weight-bearing crutch ambulation for 6 to 7 weeks will most likely result in healing. Once the patient is walking without pain or a limp, activities can be slowly increased. Because tension-side fractures have a high risk of displacement, treatment should consist of immediate internal fixation.
REFERENCES: Griffin LY (ed): Orthopaedic Knowledge Update: Sports Medicine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 239-253.
Fullerton LR Jr, Snowdy HA: Femoral neck stress fractures. Am J Sports Med

1988;16:365-377.

Question 74

A 17-year-old girl with Charcot-Marie-Tooth disease reports the development of progressive instability when walking on uneven surfaces. Her involved heel is positioned in varus when viewed from behind. Examination reveals that she walks on the outer border of the involved foot. She has full passive motion of the ankle and hindfoot joints. She is able to dorsiflex the ankle against resistance. The heel varus fully corrects with the Coleman block test. Standing radiographs reveal a cavus deformity with valgus of the forefoot. She would like to avoid using an ankle-foot orthosis. What is the best surgical option?

Explanation

DISCUSSION: This deformity is early in the disease process. The foot is still flexible, as evidenced by correction with the Coleman block test. A simple dorsiflexion osteotomy of the first metatarsal should provide a plantigrade foot. More complex osteotomies are required later in the disease process when the foot is not flexible and the deformity does not correct with the Coleman block test. The patient may also require a tibialis anterior transfer later in the disease process but not at the present time.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Upate: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 135-144.
Dehne R: Congenital and acquired neurologic disorders, in Coughlan MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, vol 1, pp 525-557.

Question 75

Which study is most useful for diagnosis of exertional compartment syndrome?

Explanation

CLINICAL SITUATION FOR QUESTIONS 48 THROUGH 50
Figures 48a through 48f reveal the radiographs and MR images of a 30-year-old man who has a 1-year history of atraumatic medial-sided left knee pain refractory to nonsurgical measures.

Question 76

What factor is associated with a high risk of developing pseudotumors after metal-on-metal hip resurfacing?

Explanation

The recent experience of a large clinical cohort revealed the most likely risk factors as being female gender, age younger than 40, small components, and a diagnosis of hip dysplasia causing osteoarthritis. Failure was least likely among men and after procedures involving larger components. These data have prompted some authors to caution against using metal-on-metal hip resurfacing in women and to primarily target candidates who are men younger than age 50. Small components may be more prone to failure because of malpositioning and edge loading, which have been noted to be more common in dysplasia cases.

Question 77

A 19-year-old man has had back pain with activity, especially running in soccer and baseball, for the past 4 months. He denies any history of trauma. Examination reveals no motor weakness or sensory changes in the lower extremities. Range of motion shows increased pain with extension and mild limitation with flexion. A sitting straight leg raising test is limited at approximately 60 degrees bilaterally by back and buttocks pain. Plain radiographs are normal. MRI scans are shown in Figures 13a through 13e. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient has an isthmic spondylolysis. The plain radiographs are normal, but the MRI scans show increased marrow edema and signal at the L5 pars interarticularis. Findings of bilateral hamstring tightness and increased pain with extension over flexion suggests spondylolysis. The MRI scans do not show any signs of the other conditions.
REFERENCES: Wiltse LL, Rothman SL: Spondylolisthesis: Classification, diagnosis and natural history. Sem Spine Surg 1993;5:264-280.
Richards BS (ed): Orthopaedic Knowledge Update: Pediatrics. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 129-137.

Question 78

A patient reports pain in the hip with functional positioning. With the patient supine, pain in which of the following positions would be typical for femoral acetabular impingement? Review Topic

Explanation

Patients with dysplasia often have a hypertrophic labrum. Abnormal contact between the femoral neck and the acetabular rim leads to labral injury, especially in the anterior-superior acetabular zone. Typically, young patients with the condition report pain with activity or long periods of sitting or driving. The hips often have limited motion, in particular in internal rotation and flexion. Forceful adduction with the maneuver causes pain.
(SBQ13PE.10) Which statement is true regarding discoid menisci? Review Topic
Most commonly involves the medial meniscus
Bilateral in >75% of cases
Asymptomatic discoid meniscus should undergo saucerization
Radiographs will commonly show a hyperplastic lateral intercondylar spine
Radiographs will commonly show squaring of affected condyle with cupping of tibial plateau
Radiographs of knees with discoid menisci will commonly show squaring of affected condyle (lateral>medial) with cupping of tibial plateau.
Discoid meniscus refers to the abnormal development of a hypertrophic and discoid shaped meniscus. It occurs in 3-5% of the population and it is considered the most common cause of a symptomatic clicking or clunking in a childs knee. The lateral meniscus is most commonly affected and it will occur bilaterally in 25% of affected
people. The Watanabe Classification describes the 3 types of discoid menisci. Type 1
= Incomplete, Type 2 = Complete, Type 3 = Wrisberg (lack of posterior meniscotibial attachment to tibia)
Kramer et al. looked at the presentation of pediatric knee pain. They showed that the lateral meniscus is more commonly affected than the medial meniscus. The majority of discoid tears occur in the posterior or middle aspect of the discoid meniscus.
Lee et al. retrospectively reviewed 36 patients aged less than 15 years who underwent arthroscopic procedures for torn discoid menisci. The mean patient age at the time of surgery was 9.5 years. They showed that partial meniscectomy yielded better radiologic results than subtotal/total meniscectomy for torn discoid menisci in this population.
Illustration A shows the 3 classifications of discoid menisus as originally described by Watanabe. Type 4 is a ring type discoid that was not originally described by Watanabe in his 1978 paper. Illustration B shows an AP and lateral radiograph of a discoid meniscus knee. Note squaring of affected lateral condyle in the presence of a lateral discoid meniscus. Illustration C shows 4 consecutive sagittal MRI images with meniscus continuity. It is important to note that the diagnosis of discoid menisci can be made when 3 or more 5mm sagittal images show meniscal continuity.
Incorrect Answers:

Question 79

Figures 92a through 92c are the radiographs of a 34-year-old man with low-back pain and an inability to walk upright. What is the appropriate surgical treatment? A B C

Explanation

DISCUSSION
This patient has a marked fixed sagittal imbalance and a mild coronal imbalance. His fused sacroiliac joints indicate ankylosing spondylitis. Sufficient correction likely can be achieved with a pedicle subtraction osteotomy in the midlumbar spine. Smith-Petersen osteotomies necessitate flexibility of the anterior column, which is not associated with this diagnosis. Also, osteoclasis can result in vascular injuries. Vertebral column resection should not be needed in this case.
RECOMMENDED READINGS
Patel NM, Jenis LG. Inflammatory arthritis of the spine. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:339-349.
Kim KT, Suk KS, Cho YJ, Hong GP, Park BJ. Clinical outcome results of pedicle subtraction osteotomy in ankylosing spondylitis with kyphotic deformity. Spine (Phila Pa 1976). 2002 Mar 15;27(6):612-8. PubMed PMID: 11884909. View Abstract at PubMed

Question 80

Which of the following orthotic features best reduces pain in patients with hallux rigidus?

Explanation

DISCUSSION: Nonsurgical care for hallux rigidus involves limiting the motion of the first metatarsophalangeal joint during toe-off and ensuring that there is a deep enough toe box to accommodate dorsal osteophytes. A rigid shank or forefoot rocker both help to reduce the forces of extension during toe-off.
REFERENCES: Beskin JL: Hallux rigidus. Foot Ankle Clin 1999;4:335-353.
Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp 17-25.

Question 81

You are interested in learning a new technique for minimally invasive total knee arthroplasty. The Keyhole Genuflex system seems appealing to you because the instrumentation comes with wireless controls. Which of the following represents an acceptable arrangement?

Explanation

Both the AAOS and AdvaMed, the medical device manufacturer's trade organization, have written guidelines that address potential conflicts of interest regarding interactions between physicians and manufacturer's representatives when it comes to patients' best interest. The AAOS feels that the orthopaedic profession exists for the primary purpose of caring for the patient and that the physician-patient relationship is the central focus of all ethical concerns. When an orthopaedic surgeon receives anything of significant value from industry, a potential conflict of interest exists. The AAOS believes that it is acceptable for industry to provide financial and other support to orthopaedic surgeons if such support has significant educational value and has the purpose of improving patient care. All dealings between orthopaedic surgeons and industry should benefit the patient and be able to withstand public scrutiny. A gift of any kind from industry should in no way influence the orthopaedic surgeon in determining the most appropriate treatment for his or her patient. Orthopaedic surgeons should not accept gifts or other financial support with conditions attached. Subsidies by industry to underwrite the costs of educational events where CME credits are provided can contribute to the improvement of patient care and are acceptable. A corporate subsidy received by the conference's sponsor is acceptable; however, direct industry reimbursement for an orthopaedic surgeon to attend a CME educational event is not appropriate. Special circumstances may arise in which orthopaedic surgeons may be required to learn new surgical techniques demonstrated by an expert or to review new implants or other devices on-site. In these circumstances, reimbursement for expenses may be appropriate.

Question 82

A well-healed bulk proximal tibia osteoarticular allograft is removed 10 years after implantation due to arthropathy. Histologic examination of the host allograft junction site will most likely reveal

Explanation

Retrieval studies of well-fixed bulk allografts reveal that the junction site heals with bridging external callus and there is persistence of callus perpendicular to the junction site. External callus is annealed to the surface of the allograft. There is very little penetration of the allograft and the bone graft is not remodeled. Direct osteonal penetration of the allograft with haversian remodeling defines primary bone healing seen in fractures, which does not occur with allografts. Fibrovascular tissue is seen early in the healing phase of the cancellous portion of the allografts.

Question 83

A 40-year-old woman is admitted to the hospital with a history of new-onset right lower extremity weakness resulting in frequent falls. She reports that a few weeks prior to the onset of the lower extremity symptoms, she experienced an episode of acute back pain, which has since resolved. Examination reveals 1-2/5 strength in the right hip flexors, abductors, and quadriceps. There is 0-1/5 strength

Explanation

Symptoms of thoracic disk herniation may present in one of three distinct patterns: axial pain, radicular pain, or myelopathy. This patient demonstrates obvious upper motor neuron signs, including lower extremity hyperflexia, clonus, and a positive Babinski sign; therefore, the next most appropriate step is a MRI scan of the thoracic spine. Thoracic disk herniations presenting with axial pain usually involve the mid to lower thoracic region. The pain is usually worsened with activity and improved with rest. Radicular pain syndromes are usually described as starting in the back and radiating anteriorly in a band-like pattern to the anterior chest wall. The pain and paresthesias generally follow a dermatomal distribution. The MRI scan of this patient's cervical spine demonstrates spondylotic changes; however, she denied neck or upper extremity symptoms and more importantly, has a normal neurologic examination. There are degenerative changes involving the lumbar spine, but these cannot explain the upper motor neuron findings.
(SBQ12SP.39) Which of the following is associated with increased risk of surgical site infection following lumbar spinal decompression? Review Topic
Use of intra-wound vancomycin powder
Hair removal by clipping at the time of surgery
Use of morphine nerve paste applied to the dura after spinal decompression
Skin preparation with an alcohol-based prep solution rather than povidone iodine
Failure to use chlorhexidine gluconate wash the night prior to surgery
The use of morphine nerve paste applied to the dura after decompressive spine surgery has been used in an effort to mitigate postoperative pain but has been associated with epidemic levels of surgical site infection.
Surgical site infection risk is modulated by a myriad of factors, both host factors and perioperative factors. Perioperative strategies to reduce infection that have been shown to be effective include: 1) hair removal by clipping (not shaving) at the time of surgery, 2) use of an alcohol based skin preparation agent, 3) use of perioperative prophylactic antibiotics, 4) limiting operating room traffic from OR personnel.
Kramer et al. did a retrospective analysis of 148 patients who underwent laminectomy in order to identify risk factors for infection in the context of a sudden increase in infections. Regression analysis showed that use of morphine paste resulted in an 18-fold increase in the risk of surgical site infection. 17 of 148 had developed infection during the epidemic period, compared to 15/995. Cultures were positive in 10 of 16 cases; 7 of these involved skin flora. Histological exam showed foreign body reaction.
Devin et al. did a multi-center analysis of patients undergoing spine surgery at seven spine centers to determine whether there was a difference in infection risk based on whether or not intra-wound vancomycin was used. They analyzed 2056 patients, of whom 47% had vancomycin used in their wounds. The risk of surgical site infection was higher in those patients that did not have vancomycin (relative risk 2.5).
Incorrect answers:

Question 84

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

Explanation

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

Question 85

Figure 1 shows the radiograph of a 68-year-old man who underwent revision hip arthroplasty with impaction grafting of the femur and cementing of a tapered component into the graft 2 years ago. The patient remains symptom-free. Which of the following best describes the most likely histologic appearance of the proximal femur if a biopsy was performed?

Explanation

DISCUSSION: The radiograph shows three zones: an outer regenerated cortical layer, an interface zone consisting of viable trabecular bone and occasional particles of bone cement, and an inner layer of necrotic bone embedded in cement. No fibrous membrane is noted, and there is no direct contact of cement with native bone. Based on these findings, it is believed that the middle layer is the result of incorporation of the allograft with further remodeling.
REFERENCES: Nelissen RG, Bauer TW, Weidenhielm LR, LeGolvan DP, Mikhail WE: Revision hip arthroplasty with the use of cement and impaction grafting: Histological analysis of four cases. J Bone Joint Surg Am 1995;77:412-422.
Gie GA, Linder L, Ling RS, Simon JP, Slooff TJ, Timperley AJ: Impacted cancellous allografts and cement for revision total hip arthroplasty. J Bone Joint Surg Br 1993;75:14-21.

Question 86

Which of the following statements about hoarseness due to vocal cord paralysis after anterior cervical diskectomy and fusion is most accurate?

Explanation

DISCUSSION: It has been traditionally taught that a left-sided approach to the anterior cervical spine is associated with a lower incidence of injury compared to the right-sided approach. This is due in part to the anatomic differences in the path the recurrent laryngeal nerve (RLN) takes on the right as compared to the left. Both nerves ascend in the tracheoesophageal groove after branching off the vagus nerve in the upper thorax. The left-sided RLN loops around the aortic arch and stays relatively medial as compared to the right-sided RLN which loops around the right subclavian artery and is somewhat more lateral at this point, and therefore is theoretically more vulnerable as it ascends toward the larynx before becoming protected in the tracheoesophageal groove. Furthermore, the variant of a nonrecurrent inferior laryngeal nerve branching directly off the vagus nerve at the level of the midcervical spine is much more common on the right than the left. Despite this reasoning, there has been no clinical evidence to suggest that laterality of approach for anterior cervical surgery makes any difference in the incidence of vocal cord paralysis. Furthermore, two recent studies have shown that the incidence of RLN injury and vocal cord paralysis is equal with either side of approach.
REFERENCES: Beutler WJ, Sweeney CA, Connolly PJ: Recurrent laryngeal nerve injury with anterior cervical spine surgery risk with laterality of surgical approach. Spine 2001;26:1337-1342.
Kilburg C, Sullivan HG, Mathiason MA: Effect of approach side during anterior cervical discectomy and fusion on the incidence of recurrent laryngeal nerve injury. J Neurosurg Spine 2006;4:273-277.

Question 87

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

Explanation

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

Question 88

Pacinian corpuscles are lamellated nerve endings that are responsible for providing the perception of

Explanation

DISCUSSION: Pacinian corpuscles are nerve endings that provide the perception of pressure.
REFERENCE: Sunderland SS: Nerves and Nerve Injuries, ed 2. New York, NY, Churchill Livingstone, 1978, pp 343-347.

Question 89

Which of the following definitions best describes Batson’s vertebral vein system?

Explanation

DISCUSSION: The venous plexus was described by Batson and helps to explain the common distribution of metastatic cells to the vertebrae, skull, ribs, and proximal long bones. Batson studied the vertebral vein system extensively by using contrast agents in human cadavers and live monkeys. Batson’s plexus is a valveless system that allows retrograde embolism from the major organs such as the breast, prostate, lung, kidney, and thyroid. It is located within the thoracoabdominal cavity and has connections to the proximal long bones and an intercommunicating network of thin-walled veins with a low intraluminal pressure.
REFERENCES: Batson OV: Function of vertebral veins and their role in spread of metastases. Ann Surg 1940;112:138-149.
Coman DR, de Long RP: Role of vertebral venous system in metastasis of cancer to spinal column: Experiments with tumor-cell suspensions in rats and rabbits. Cancer 1951;4:610-618.

Question 90

Free flap coverage for severe trauma to the upper extremity has the fewest complications when performed within what time period after injury?

Explanation

DISCUSSION: Flap necrosis and infection rates are lowest if free flap coverage is performed within 72 hours of injury. Delays beyond 72 hours are associated with a higher rate of complications.
REFERENCES: Godina M: Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78:285-292.
Manske PR (ed): Hand Surgery Update. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 31-37.

Question 91

A 35-year-old laborer who sustained a forefoot injury 10 years ago has returned to work but reports a progressively painful deformity of the hallux and continued midfoot pain that is aggravated by weight-bearing activities. Shoe wear modifications have failed to provide relief. Direct palpation reveals no pain at the first metatarsocuneiform joint. A radiograph is shown in Figure 11. What is the next most appropriate step in management?

Explanation

DISCUSSION: The patient has nonunions of the metatarsal fractures and a hallux valgus deformity with arthritic changes. To address all of the findings, management should consist of open treatment of the metatarsal nonunions and hallux metatarsophalangeal arthrodesis. Cast immobilization and a bone stimulator are unlikely to be beneficial at this time. Isolated correction of the hallux valgus deformity will not address the metatarsal nonunions or the arthritis at the hallux metatarsophalangeal joint.
REFERENCES: Kitaoka HB, Patzer GL: Arthrodesis versus resection arthroplasty for failed hallux valgus operations. Clin Orthop 1998;347:208-214.
McGarvey WC, Braly WG: Bone graft in hindfoot arthrodesis: Allograft vs autograft. Orthopedics 1996;19:389-394.
Ouzounian TJ: Metatarsophalangeal arthrodesis for salvage of failed hallux valgus surgery. Foot Ankle Clin 1997;2:741-752.

Question 92

Figures 1 and 2 show the radiographs obtained from a 68-year-old morbidly obese man who underwent left total hip replacement 7 years ago and did well, with no symptoms prior to the current presentation. He recently rose from a seated position and felt a pop in the hip, with immediate pain and inability to bear weight. Any pressure on the left foot now produces a painful, grinding sensation with loss of left hip stability. What is the best next step?

Explanation

DISCUSSION:
The modular femoral stem has fractured. Changing the liner to a constrained design is not warranted at this time based on the information provided. Revision of the acetabular implant is appropriate because of the potential for damage to the existing cup from metal debris and femoral implant contact and to convert from a metal-on-metal articulation. Nonsurgical management would not provide pain relief or improvement; revision of the total hip arthroplasty is recommended. The implant failed in a short time, and retention of the femoral stem is not recommended because of the concern for failure with only a neck exchange. A dual-mobility bearing may be a good option if the surgeon plans to retain the acetabular component. Extended trochanteric osteotomy is a useful technique for the removal of a well-fixed femoral implant. In this patient, femoral stem removal without
osteotomy would be difficult due to the fracture of the implant’s femoral neck and the inability to gain purchase for extraction.

Question 93

A 17-year-old girl who initially presented as a child with multiple skeletal lesions, café-au-lait spots, and precocious puberty now has bone pain. A recent bone scan reveals multiple areas of increased scintigraphic uptake, including bilateral proximal femurs. A radiograph is shown in Figure 19. Besides activity modification, what is the next best line of treatment for decreasing her pain? Review Topic

Explanation

McCune-Albright syndrome is the combination of polyostotic fibrous dysplasia, café-au-lait lesions, and endocrine dysfunction. The most common endocrine presentation is precocious development of secondary sexual characteristics. Compared with bone lesions in patients without polyostotic disease, the skeletal lesions in patients with the syndrome tend to be larger, more persistent, and associated with more complications. Bisphosphonate therapy has been shown in several studies to decrease the pain associated with the skeletal lesions of fibrous dysplasia.

Question 94

A 24-year-old collegiate pitcher has had increasing pain over his medial elbow for 3 months. He has point tenderness over his medial epicondyle and reproduction of his symptoms with a valgus stress test. What phase of the throwing cycle most likely will reproduce his symptoms? Review Topic

Explanation

This patient is experiencing soreness over his medial (ulnar) collateral ligament. Valgus overload is likely to reproduce his symptoms and is most pronounced during the late cocking phase of the throwing cycle. In wind up, very little elbow torque is required. In early cocking, the arm is getting loaded and maximum valgus is not yet achieved at the elbow. In acceleration and deceleration, more force is generated at the level of the shoulder joint.

Question 95

Figures 1 and 2 are the CT and MRI scans of a patient with shoulder instability. Contrasting these two imaging techniques for decision making in shoulder instability would suggest

Explanation

A 43-year-old woman is involved in a motor vehicle collision. She sustains the isolated injury shown in the radiograph in Figure 1. Her neurovascular examination is compromised. What is the most likely deficit?

A. Inability to flex the distal interphalangeal joint of the index finger

B. Positive Froment’s sign

C. Weakness with wrist extension

D. Decreased capillary refill

Question 96

A 75-year-old woman who sustained a fall now reports neck pain and upper extremity weakness. Examination reveals 4 of 5 strength in the upper extremities and 5 of 5 strength in the lower extremities. Radiographs show multilevel degenerative disk disease. An MRI scan is shown in Figure 96. Her clinical presentation is most compatible with which of the following? Review Topic

Explanation

The MRI scan shows advanced multilevel degenerative changes and moderate to severe stenosis at C3-C4 and C4-C5 with associated cord signal change. The patient has greater weakness in the upper extremities than in the lower extremities. This pattern is most compatible with central cord syndrome. Patients with brachial plexus injury will have unilateral weakness. Patients with anterior cord syndrome will have greater weakness in the legs than in the arms, and those with Brown-Séquard syndrome will have ipsilateral motor deficits and contralateral pain and temperature deficits.

Question 97

Figures 9a through 9c are the preoperative radiographs and a T2-weighted MR image of a patient treated with surgery for spondylolisthesis and neuroforaminal stenosis. Figure 9d is the postsurgical radiograph. Interbody fusion offers which advantage over posterolateral fusion (PLF)? A B C D

Explanation

DISCUSSION
Interbody fusion, when compared to PLF, is a predictor of more substantial blood loss. Multilevel posterior lumbar interbody fusion (PLIF) is an independent predictor of blood loss for posterior spine fusion. Some retrospective studies suggest that fusion rates are higher for transforaminal lumbar interbody fusion (TLIF) than PLF, but this finding has not been borne out in prospective studies. The main advantage of TLIF in the context of this question is restoration of neuroforaminal height, and many surgeons will consider TLIF or PLIF for that reason. The parasagittal MR image seen in Figure 9c shows neuroforaminal narrowing. The pre- and postsurgical radiographs show a difference in neuroforaminal height.
RECOMMENDED READINGS
DiPaola CP, Molinari RW. Posterior lumbar interbody fusion. J Am Acad Orthop Surg. 2008 Mar;16(3):130-9. Review. PubMed PMID: 18316711. View Abstract at PubMed
Eismont FJ, Norton RP, Hirsch BP. Surgical management of lumbar degenerative spondylolisthesis. J Am Acad Orthop Surg. 2014 Apr;22(4):203-13. doi: 10.5435/JAAOS-22-04-203. Review. PubMed PMID: 24668350. View Abstract at PubMed
McAfee PC, DeVine JG, Chaput CD, Prybis BG, Fedder IL, Cunningham BW, Farrell DJ, Hess SJ, Vigna FE. The indications for interbody fusion cages in the treatment of spondylolisthesis: analysis of 120 cases. Spine (Phila Pa 1976). 2005 Mar 15;30(6 Suppl):S60-5. PubMed PMID: 15767888. View Abstract at PubMed
RESPONSES FOR QUESTIONS 10 THROUGH 14
Postoperative deep surgical site infection
Proximal junctional kyphosis
Pedicle screw cut-out
Pseudarthrosis
Sagittal imbalance
Please match the scenario described below with the most likely complication listed above.

Question 98

An otherwise healthy 13-year-old boy sustains the fracture shown in Figure 40 while throwing a fastball. Management should consist of

Explanation

DISCUSSION: Nonsurgical management such as a functional brace, hanging arm cast, or sugar tong splint is the treatment of choice for a fracture of the humeral shaft that is the result of throwing. The fracture surface typically is wide and the degree of displacement is not large; therefore, surgery is not indicated in most patients.
REFERENCES: Ogawa K, Yoshida A: Throwing fracture of the humeral shaft: An analysis of 90 patients. Am J Sports Med 1998;26:242-246.
Kaplan H, Kiral A, Kuskucu M, et al: Report of eight cases of humeral fracture following the throwing of hand grenades. Arch Orthop Trauma Surg 1998;117:50-52.

Question 99

Figure 51 shows the radiograph of a 42-year-old construction worker who has pain and limited motion in his dominant elbow. Management consisting of nonsteroidal anti-inflammatory drugs and cortisone has failed to provide relief. What is the next most appropriate step in treatment?

Explanation

DISCUSSION: The patient has symptomatic primary osteoarthritis of the elbow with multiple loose bodies. Given his age and occupation, an elbow arthroplasty is not an option. Arthroscopic debridement and removal of loose bodies has been shown to be effective for osteoarthritis of the elbow.
REFERENCES: Gramstad GD, Galatz LM: Management of elbow osteoarthritis. J Bone Joint Surg Am 2006;88:421-430.
Steinmann SP, King GJ, Savoie FH III, et al: Arthroscopic treatment of the arthritic elbow.

J Bone Joint Surg Am 2005;87:2114-2121.

Question 100

A 68-year-old woman had advanced right knee arthritis and total knee replacement was planned. She learned she had primary biliary cirrhosis at age 41 and now has advancing liver failure. Preoperative coagulation tests show a baseline International Normalized Ratio (INR) of 1.36. Appropriate methods to prevent thromboembolic disease as recommended by the 2011 AAOS Clinical Practice Guideline, Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty , include

Explanation

The 2011 AAOS Clinical Practice Guideline, Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty, recommends the use of mechanical prophylaxis for patients at increased risk for bleeding (including those with liver disease or hemophilia). This recommendation is the consensus of the workgroup that established these guidelines because there was insufficient evidence to justify a stronger recommendation in this clinical scenario. The other responses use no prophylaxis or pharmacological prophylaxis. Pharmacological prophylaxis is not recommended in patients who are at increased risk for bleeding.

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

until his symptoms resolve and the MRI findings return to normal.
until his symptoms resolve and his physical examination findings return to normal.
until he undergoes surgical decompression.
until he undergoes surgical decompression and fusion.
again because it is considered a career-ending injury.

Correct Answer: until his symptoms resolve and his physical examination findings return to normal.

Explanation:

Question 2:

The anatomy of the sciatic nerve as it exits the pelvis is best described as exiting through the

Options:

greater sciatic notch and passing between the inferior gemellus and the obturator externus.
greater sciatic notch and passing between the piriformis and the superior gemellus.
obturator foramen and passing between the obturator internus and the obturator externus.
lesser sciatic notch and passing between the piriformis and the superior gemellus.
lesser sciatic notch and passing between the superior gemellus and the inferior gemellus.

Correct Answer: greater sciatic notch and passing between the piriformis and the superior gemellus.

Explanation:

DISCUSSION: The sciatic nerve is formed by the roots of the lumbosacral plexus. It exits the pelvis through the greater sciatic notch and appears in the buttock anterior to the piriformus. From that point, the sciatic nerve passes posteriorly over the superior gemellus, obturator internus, inferior gemellus, and quadratus femoris before it passes deep to the biceps femoris. The tendon of the obturator internus passes through the lesser sciatic notch.
REFERENCES: Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippincott, 1984, p 347.
Anderson JE: Grant’s Atlas of Anatomy, ed 7. Baltimore, MD, Lippincott Williams & Wilkins, 1978, pp 4-34, 4-36.
Hollingshead WH: Anatomy for Surgeons: The Back and Limbs, ed 2. Hagerstown, MD, Harper & Row, 1969, pp 607-609.

Question 3:

Which of the following medications may have a negative effect on bone healing following fracture?

Options:

COX-1 nonsteroidal anti-inflammatory drugs
Phenytoin
Temazepam
Serotonin reuptake blockers (SSRIs)
Amitriptyline

Correct Answer: COX-1 nonsteroidal anti-inflammatory drugs

Explanation:

Question 4:

Options:

Cemented left total hip arthroplasty (THA)
Cementless left THA with a proximally porous coated femoral stem
Hybrid left THA
Cementless left THA with a diaphyseal engaging conical femoral stem

Correct Answer: Hybrid left THA

Explanation:

Question 5:

Options:

Revision arthroscopic Bankart repair with capsular shift
Open Bankart repair with capsular shift
Repair of infraspinatus tendon into the Hill-Sachs defect (remplissage procedure)
Coracoid transfer to the glenoid (Latarjet procedure)

Correct Answer: Coracoid transfer to the glenoid (Latarjet procedure)

Explanation:

Question 6:

Options:

Completion of the tear from the bursal surface and rotator cuff repair
Arthroscopic long head biceps tenotomy
Arthroscopic glenohumeral synovectomy
Arthroscopic tendon debridement and subacromial decompression
Transtendinous rotator cuff repair

Correct Answer: Arthroscopic tendon debridement and subacromial decompression

Explanation:

Question 7:

Options:

Streptococcus pneumoniae
Staphylococcus aureus
Pseudomonas aeruginosa
Staphylococcus epidermis
Propionibacterium acnes

Correct Answer: Streptococcus pneumoniae

Explanation:

Question 8:

Optimal management of the injury shown in Figure 31 should include which of the following?

Options:

Cast immobilization in equinus
Open reduction and internal fixation once the acute soft-tissue swelling has resolved
Urgent reduction and fixation
Arthroscopic-assisted percutaneous fixation
Open reduction and internal fixation with primary subtalar arthrodesis

Correct Answer: Urgent reduction and fixation

Explanation:

Question 9:

Options:

Trochanteric bursitis
Femoral component loosening
Iliopsoas tendonitis
Acetabular component loosening

Correct Answer: Iliopsoas tendonitis

Explanation:

Question 10:

Options:

revision of the failing ACL reconstruction.
arthroscopic lysis of adhesions and manipulation of the knee.
surgical removal of hypertrophic fibrous tissue.
excision of the torn medial meniscus.
continued aggressive physical therapy.

Correct Answer: surgical removal of hypertrophic fibrous tissue.

Explanation:

DISCUSSION: The patient has a cyclops lesion. This is a nodule of fibroproliferative tissue that originates from either drilling debris from the tibial tunnel or remnants of the ACL stump; more rarely it is the result of broken graft fibers. The treatment of choice is excision of the nodule and, if needed, additional notchplasty. Marked improvements in function and symptoms have been noted after removal of the extension block and resumption of a rehabilitation program.
REFERENCES: Delince P, Krallis P, Descamps PY, et al: Different aspects of the cyclops lesion following anterior cruciate ligament reconstruction: A multifactorial etiopathogenesis. Arthroscopy 1998;14:869-876.
Fisher SE, Shelbourne KD: Arthroscopic treatment of symptomatic extension block complicating anterior cruciate ligament reconstruction. Am J Sports Med 1993;4:558-564.

Question 11:

Which of the following complications is more likely with an inside-out repair technique compared to an all-inside techniques for a medial meniscus tear?

Options:

Failure
Intra-articular synovitis
Peroneal nerve injury
Saphenous nerve injury
Arthrofibrosis

Correct Answer: Saphenous nerve injury

Explanation:

Question 12:

Options:

Patellar sleeve fracture
Avulsion of the tibial tubercle
Avulsion of the anterior tibial spine
Osteochondral fracture of the femoral condyle
Osteochondral fracture of the patella

Correct Answer: Patellar sleeve fracture

Explanation:

Question 13:

Which of the following complications occurs more commonly after antegrade femoral nail insertion when compared with retrograde insertion?

Options:

Increased blood loss
Decreased range of motion of the knee
Infection
Hip pain
Muscle weakness

Correct Answer: Hip pain

Explanation:

Question 14:

Options:

Metatarsophalangeal joint arthrodesis
Medial capsular release with lengthening of the abductor hallucis
Medial capsular release with lateral sesamoid excision
Proximal phalangeal lateral closing wedge osteotomy
Medial capsular lengthening and split extensor hallucis longus tendon transfer

Correct Answer: Medial capsular lengthening and split extensor hallucis longus tendon transfer

Explanation:

DISCUSSION: The patient has a flexible hallux varus that is a complication of the bunion surgery. With joints that are not arthritic and still flexible, a medial release is necessary to realign the joint. The extensor hallucis longus split transfer helps maintain position and still preserve motion at the interphalangeal joint level. Arthrodesis is a salvage procedure. Soft-tissue releases alone are most likely inadequate. Excision of the lateral sesamoid is contraindicated because that further compromises the forces resisting hallux varus. Phalangeal osteotomy would not address the medial subluxation at the metatarsophalangeal joint.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 27-32.
Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA, Mosby, 2007, pp 345-351.

Question 15:

In the management of an open tibia fracture, what factor is considered most important in preventing deep infection?

Options:

Size of the skin lesion
Degree and the completeness of the debridement
Amount of contamination
Method of fixation
Cultures of the wound

Correct Answer: Degree and the completeness of the debridement

Explanation:

Question 16:

Options:

immediate split-thickness skin grafting.
immediate Xenograft application.
a vacuum-assisted closure device.
dressing changes with sulfasalazine cream.
a cross-leg flap.

Correct Answer: a vacuum-assisted closure device.

Explanation:

Question 17:

Options:

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

Correct Answer: DNA testing for osteogenesis imperfecta.

Explanation:

Unwitnessed spiral fractures should raise the possibility of child abuse, especially prior to walking age. With nonaccidental trauma being considered in the differential diagnosis, a skeletal survey is indicated to determine if there are other fractures in various stages of healing.
(SBQ13PE.60) If a child develops dynamic supination after treatment of idiopathic clubfoot with Ponseti casting, at what age would it be appropriate to consider transfer of the tibialis anterior tendon to the lateral dorsum of the foot?
Review Topic
In the first six months of life, immediately following failed cast treatment
12 months
4 years
12 years
15 years
Tibialis tendon transfer to the dorsum of the foot should be performed to address dynamic supination when the lateral cuneiform has ossified. This is typically after at least 2 years of age and usually not before age 3.

Question 18:

Options:

open reduction of both the radius and ulna with plate and screw fixation.
closed reduction and a long arm cast, with the elbow in 90 degrees of flexion and the forearm in neutral rotation.
closed reduction and a long arm cast, with the elbow in 120 degrees of flexion and the forearm in full supination.
closed reduction and a long arm cast, with the elbow extended and the forearm pronated.
closed reduction and intramedullary pin fixation of both the radius and ulna.

Correct Answer: closed reduction and intramedullary pin fixation of both the radius and ulna.

Explanation:

Question 19:

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

Options:

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

Correct Answer: Macrophage infiltration and phagocytosis

Explanation:

Question 20:

Glenohumeral disarticulation often leads to which of the following changes?

Options:

Hiking of the shoulder girdle
Hypertrophy of the amputated shoulder girdle
Improvement in thoracic spinal deformity
Protraction of the shoulder
Winging of the scapula

Correct Answer: Hiking of the shoulder girdle

Explanation:

Question 21:

Options:

Both hips are normal and no further assessments will be needed.
A neoplasm has developed in the femoral head on the unslipped side.
There is now increased risk for a slip in the hip and a new screw should be inserted.
Osteonecrosis has developed in the unslipped hip adjacent to the previous screw position.
The screw track in the bone has not filled spontaneously as expected and grafting should beconsidered.

Correct Answer: Osteonecrosis has developed in the unslipped hip adjacent to the previous screw position.

Question 22:

Options:

open reduction and internal fixation with a plate and screws.
open treatment with calcaneal bone graft.
percutaneous screw fixation with a 4.5-mm screw.
weight-bearing cast for 8 weeks.
spanning external fixation.

Correct Answer: percutaneous screw fixation with a 4.5-mm screw.

Explanation:

Question 23:

Options:

Arthroscopic debridement
Arthroscopic rotator cuff repair
Hemiarthroplasty with rotator cuff repair
Total shoulder arthroplasty
Reverse shoulder arthroplasty

Correct Answer: Reverse shoulder arthroplasty

Explanation:

Question 24:

Compared with retention of the native patella in primary total knee arthroplasty, routine patellar resurfacing is associated with

Options:

no patellar complications.
an increased occurrence of anterior knee pain.
a reduced patellar fracture rate.
a reduced risk for revision surgery.

Correct Answer: a reduced risk for revision surgery.

Explanation:

Question 25:

Options:

hinged knee bracing, protected weight bearing, and physical therapy.
anteromedialization of the tibial tubercle.
internal fixation and medial patellofemoral ligament (MPFL) reconstruction.
arthroscopic lateral retinacular release.

Correct Answer: internal fixation and medial patellofemoral ligament (MPFL) reconstruction.

Explanation:

Question 26:

Which of the following best describes heat stroke?

Options:

Transient loss of consciousness with peripheral vasodilation and decreased cardiac output with normal body temperature
A condition involving painful contractions of large muscle groups because of decreased hydration and a decrease of serum sodium and chloride
Hypernatremia in poorly conditioned athletes, manifested by thirst and oliguria with a core temperature of less than 102.2 degrees F (39 degrees C)
Hyperthermia, central nervous system dysfunction, and loss of thermoregulatory function
A transient condition that responds to glucose administration

Correct Answer: Hyperthermia, central nervous system dysfunction, and loss of thermoregulatory function

Explanation:

Question 27:

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

Options:

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

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

Explanation:

Question 28:

The posterior cord of the brachial plexus terminates into what two main branches?

Options:

Lateral and medial pectorals
Lateral pectoral and suprascapular
Radial and axillary nerves
Musculocutaneous and the lateral root of the median nerve
Ulnar and medial roots of the median nerve

Correct Answer: Radial and axillary nerves

Explanation:

Question 29:

In patients older than age 40 years who sustain a first-time anterior dislocation of the shoulder, prolonged morbidity is most commonly associated with

Options:

recurrent dislocation.
posttraumatic arthritis.
a rotator cuff tear.
stiffness secondary to immobilization.
nerve injury.

Correct Answer: a rotator cuff tear.

Explanation:

Question 30:

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

Options:

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

Correct Answer: tear of the subscapularis tendon.

Explanation:

Question 31:

Options:

CT of the shoulder
MRI of the shoulder
Application of a sling for 6 weeks
Surgery for diagnostic shoulder arthroscopy
Physical therapy to work on range of motion and strengthening

Correct Answer: MRI of the shoulder

Explanation:

Question 32:

A 5-month-old girl with arthrogryposis has a limb-length discrepancy. Examination and radiographs reveal unilateral hip dislocation. Management should consist of

Options:

a Pavlik harness.
observation.
closed reduction and a spica cast.
open reduction and femoral shortening.
open reduction.

Correct Answer: open reduction.

Explanation:

Question 33:

Options:

Gastrocsoleus recession
Subtalar fusion
Split anterior tibial tendon transfer
Split posterior tibial tendon transfer
Flexor hallucis longus tendon transfer

Correct Answer: Split posterior tibial tendon transfer

Explanation:

Question 34:

Compared to similar patients who do not donate autologous blood, patients with normal baseline hemoglobin who donate autologous blood prior to undergoing primary total hip arthroplasty are likely to

Options:

receive an allogeneic transfusion.
experience cardiac complications perioperatively.
have a greater likelihood of receiving a transfusion perioperatively.
have a higher hemoglobin at the time of discharge.
have deep venous thrombosis postoperatively.

Correct Answer: have a greater likelihood of receiving a transfusion perioperatively.

Explanation:

Question 35:

Figures 31a and 31b are the radiographs of a 5-year-old boy with an elbow injury.

Options:

Plain radiographs
CT scan
MRI
Arthrogram

Correct Answer: Plain radiographs

Explanation:

Question 36:

Which of the following represents a contraindication for interspinous process decompression for the treatment of lumbar spinal stenosis?

Options:

Grade I degenerative spondylolisthesis
Inability to walk at least 100 feet
Cauda equina syndrome
Fixed sensory deficit
Intermittent foot drop

Correct Answer: Cauda equina syndrome

Explanation:

DISCUSSION: Kondrashov and associates noted stable good outcomes at 4 years in 14 of 18 patients treated with X-STOP interspinous process decompression as defined as an improvement over preoperative Oswestry scores of 15 points or more. Similar results were seen after 1 year in a European study by Siddiqui and associates. Exclusion and inclusion criteria for these studies varied somewhat, but cauda equina syndrome was the only exclusion criteria listed in both studies. All of the other choices did not represent exclusion criteria in either study.
REFERENCES: Kondrashov DG, Hannibal M, Hsu KY, et al: Interspinous process decompression with the X-STOP device for lumbar spinal stenosis: A 4-year follow-up study.
J Spinal Disord Tech 2006;19:323-327.
Siddiqui M, Smith FW, Wardlaw D: One-year results of X Stop interspinous implant for the treatment of lumbar spinal stenosis. Spine 2007;32:1345-1348.

Question 37:

A 19-year-old college cross-country runner is amenorrheic and has recurrent stress fractures. Long-term management should consist of

Options:

cross training with swimming and cycling.
a complete cessation of running.
vitamin D and calcium supplements.
increased caloric intake.
oral contraceptives, vitamin D, and calcium supplements.

Correct Answer: oral contraceptives, vitamin D, and calcium supplements.

Explanation:

Question 38:

Options:

Femoroacetabular impingement (FAI)
Osteoarthritis of the sacroiliac joint
Intra-articular loose body
Trochanteric bursitis

Correct Answer: Femoroacetabular impingement (FAI)

Explanation:

This clinical scenario describes a patient with FAI attributable to pincer (acetabular) deformity. This form of FAI, which involves prominence of the anterosuperior acetabular lip, may be more common among women. Decreased range of motion and pain occur secondary to the abutment of the femoral head against the acetabular labrum and rim. Hip flexion, combined with adduction and internal rotation, recreates this contact and causes pain, but CAM or pincer etiology remains unknown. The differential diagnosis of hip pain in a young athlete includes femoral neck stress reaction/fracture, sacroiliac arthritis, intra-articular loose body, trochanteric bursitis, osteitis pubis, and hernia. No information presented in this scenario suggests any of these causes. Diagnosis of FAI is best performed via MR imaging, with an arthrogram increasing the sensitivity and specificity for labral pathology. Ultrasonography may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping hip, but ultrasonography is not commonly used to diagnose labral pathology. Although concomitant chondral lesions of the femoral head are uncommon, the forced leverage of the anterosuperior femoral neck upon the anterior acetabulum may result in a “contra-coup” chondral injury on the posteroinferior acetabulum. This is the most common location of chondral lesions in this scenario. Without bony resection to prevent further impingement, this patient will continue to experience symptoms. Because there is no evidence of femoral neck prominence (CAM lesion), there is no indication for osteoplasty of the femoral neck; resection of the pincer lesion is necessary. This will often require take-down of the labrum in this location. If possible, iatrogenic or traumatic labral tears should subsequently be repaired after pincer debridement because the labrum has
important functions for hip stability and maintenance of the suction seal of the joint.

Question 39:

Options:

High tibial osteotomy
Total knee replacement
Unicondylar knee replacement
Arthroscopic partial meniscectomy

Correct Answer: Total knee replacement

Explanation:

Question 40:

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 41:

Options:

Cast immobilization for 6 weeks
Hinged brace with early range of motion in supination
Hinged brace with early range of motion in pronation
Primary ligament repair
Lateral collateral ligament reconstruction with tendon graft

Correct Answer: Hinged brace with early range of motion in pronation

Explanation:

Question 42:

Six months later, the patient’s fracture has healed and a CT scan to further evaluate the physis is performed (Video 85). Based on these findings, how should you advise the family?

Options:

The fracture is healed and the physis is growing well with no problems expected.
Complete physeal closure has occurred. There will be no significant leg length difference because the patient is almost done growing.
Complete physeal closure has occurred. There will be a significant (> 2-cm) leg length difference if no other surgical treatment is offered.
Asymmetric physeal closure has occurred. There will be an increasing angular deformity at the knee as well as a significant (> 2-cm) leg length difference if no other surgical treatment is offered.

Correct Answer: Asymmetric physeal closure has occurred. There will be an increasing angular deformity at the knee as well as a significant (> 2-cm) leg length difference if no other surgical treatment is offered.

Explanation:

Question 43:

Options:

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

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

Explanation:

DISCUSSION
Periprosthetic fractures are the third-most-common (behind loosening and infection) reason for revision surgery after total hip arthroplasty (THA). Late periprosthetic fracture risk is 0.4% to 1.1% after primary THA and 2.1% to 4% after revision THA. Risk factors for periprosthetic fracture include patient age older than 70 years, decreasing bone mass, and loosening of implants and osteolysis. Risk for concomitant infection in the presence of a periprosthetic fracture is 11%, according to Chevillotte and associates. Obtaining presurgical aspiration or tissue for culture intrasurgically is recommended if concomitant infection is suspected.
CLINICAL SITUATION FOR QUESTIONS 101 THROUGH 104
Figures 101a and 101b are the right hip radiographs of a 26-year-old active man who has had pain in his right hip for 4 months. His pain is worse with prolonged periods in a seated position. He has no pain at rest and denies pain in other joints or systemic illness. Examination reveals passive range of motion of full extension, 80 degrees of flexion, internal rotation in flexion of 0 degrees, and external rotation in flexion of 30 degrees. Forced flexion, internal rotation, and adduction are very painful. A flexion, abduction, and external rotation test result is negative.

Question 44:

Which of the following types of iliac osteotomy provides the greatest potential for increased coverage?

Options:

Ganz periacetabular
Pemberton innominate
Salter innominate
Sutherland double innominate
Steele triple innominate

Correct Answer: Ganz periacetabular

Explanation:

Question 45:

A 27-year-old man sustains a displaced femoral neck fracture and undergoes urgent open reduction internal fixation. What is the most prevalent complication after this injury?

Options:

Flexion contracture
Hip instability
Nonunion
Abductor lurch
Osteonecrosis

Correct Answer: Flexion contracture

Explanation:

Question 46:

What radiographic measurement is best used to assess the adequacy of deformity correction for the patient shown in Figure 22?

Options:

Reimers index (migration index)
Acetabular index
Center edge angle of Wiberg
Hilgenreiner physeal angle
Head-shaft angle (Southwick angle)

Correct Answer: Hilgenreiner physeal angle

Explanation:

Question 47:

When conducted at near physiologic strain rates, tensile studies of the inferior glenohumeral ligament (IGHL) have shown that the

Options:

anterior band of the IGHL has the greatest stiffness and the glenoid insertion site shows greater strain than the ligament midsubstance.
anterior band of the IGHL has the greatest stiffness and the ligament midsubstance shows greater strain than the glenoid insertion site.
axillary pouch of the IGHL has the greatest stiffness and the glenoid insertion site shows greater strain than the ligament midsubstance.
axillary pouch of the IGHL has the greatest stiffness and the ligament midsubstance shows greater strain than the glenoid insertion site.
posterior portion of the IGHL has the greatest stiffness and the glenoid insertion site shows greater strain than the ligament midsubstance.

Correct Answer: anterior band of the IGHL has the greatest stiffness and the glenoid insertion site shows greater strain than the ligament midsubstance.

Explanation:

Question 48:

What form of fixation is associated with the highest incidence of osseous union when using segmental allograft reconstruction following tumor resection?

Options:

Plate and screw fixation
Fluted intramedullary rods
Interlocking intramedullary rods
Cemented intramedullary rods
Step-cut osteotomies and interlocking intramedullary rods

Correct Answer: Plate and screw fixation

Explanation:

Question 49:

What is the most common cause for late revision (> 2 years post op) total knee arthroplasty?

Options:

Infection
Polyethylene wear
Instability
Patellar complications
Malalignment

Correct Answer: Polyethylene wear

Explanation:

Question 50:

Following surgery for an ankle fracture, which of the following is considered the most important factor in achieving a satisfactory outcome? Review Topic

Options:

Physical therapy
Early weight bearing
Anatomic alignment
Early range of motion of the ankle
Calcium and vitamin D administration

Correct Answer: Anatomic alignment

Explanation:

Question 51:

Options:

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

Correct Answer: Obtain erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels

Explanation:

Question 52:

Options:

Fibrous dysplasia
Enchondroma
Ewing’s sarcoma
Metastatic carcinoma
Aneurysmal bone cyst

Correct Answer: Fibrous dysplasia

Explanation:

Question 53:

The clinical factors shown to most significantly predict the long-term outcome of Perthes disease of the hip include which of the following? Review Topic

Options:

Limb-length discrepancy, range of motion of the hip
Age at presentation, range of motion of the hip
Age at presentation, limb-length discrepancy
Range of motion, pain/limp for more than 6 months
Limb-length discrepancy, pain/limp for more than 6 months

Correct Answer: Limb-length discrepancy, range of motion of the hip

Explanation:

Age at presentation and range of motion of the hip are the two most significant predictors of long-term outcome. Younger patients and patients who maintain range of motion of the hip are more likely to have a good outcome. In Herring's study, children with a chronologic age of younger than 8 years or a bone age of less than 6 years had significantly more favorable outcomes compared with older children. Limited hip range of motion may be due to muscle spasm early on, or synovitis; but in late disease, it may reflect incongruity of the joint. Classifications based on femoral head shape have also been correlated to prognosis. Significant shortening of the affected hip is not common.
(SBQ13PE.87) A 4-week-old child is suspected to have classic arthrogryposis, also known as amyoplasia. Clinical examination and hip ultrasound reveal a unilateral, non-reducible, hip dislocation. What do you recommend to reduce the hip?
Review
Topic
Pavlik harness application
Semi-rigid abduction brace application
Skeletal traction
Early closed reduction and spica casting
Delayed open reduction with or without pelvic and femoral osteotomy
Delayed open reduction with or without pelvic and femoral osteotomy is recommended in the management of unilateral hip deformities associated with amyoplassia. This procedure should be performed at 6-9 months of age. In order to proceed with reduction, there must be a reasonable arc of flexion/extension and active movement of the lower limbs.
Amyoplasia is the most common recognizable form of arthrogryposis. It most commonly occurs as a sporadic symmetric contracture syndrome that is characterized by symmetrical limb involvement, normal to above-average intelligence, and often a midline facial hemangioma. Approximately 80% of children with amyoplasia will have involvement of the hip ranging from soft tissue contractures to unilateral or bilateral hip dislocations.
Bevan et al. reviewed arthrogryposis. They state that open hip reduction is recommended for the management of unilateral dislocation. There is more controversy with regard to the treatment of bilateral hip dislocations. Open reduction can be performed by a medial or anterolateral approach, with or without pelvic and
femoral osteotomy. This procedure is generally delayed for 6-9 months to facilitate the procedure.
Bernstein et al. also reviewed arthrogryposis. They state that the term 'arthrogryposis' encompasses a broad spectrum of diseases, all with the common phenotype of multiple congenital contractures.
Illustration A shows the characteristic features of an infant with severe arthrogryposis. Note the internal rotation of the shoulders, elbow and knee hyperextension, flexed and ulnarly deviated wrists, flexed finger, external rotation of hips and bilateral clubfeet.
Incorrect answers:

Question 54:

Options:

Continued observation and re-evaluation in 6 months
Sentinel lymph node biopsy
Wide excision
Primary ray resection

Correct Answer: Wide excision

Explanation:

Question 55:

What is the primary benefit of using rhBMP-2 instead of autogenous bone graft inside an anterior spinal fusion cage?

Options:

Substantially improved radiographic fusion success rate
Substantially decreased time to fusion healing
Substantially decreased hospital stay
Elimination of autograft harvest
Elimination of need for postoperative bracing

Correct Answer: Elimination of autograft harvest

Explanation:

Question 56:

Options:

Inappropriately early return to play
Improper rehabilitation and conditioning
Unstable meniscal tear
Malpositioned tunnel
Inadequate graft sizing

Correct Answer: Inappropriately early return to play

Explanation:

Question 57:

Options:

Medical management with intravenous (IV) antibiotics and observation
CT-guided aspiration of the abscess before initiating antibiotics
Surgical decompression and IV antibiotics
Blood cultures and re-evaluation in 24 hours

Correct Answer: Surgical decompression and IV antibiotics

Explanation:

DISCUSSION
Epidural abscess is a serious and potentially disastrous condition. Although medical management is effective in some situations, surgical decompression is considered urgent with the presence of a neurological deficit. Medical management can be considered in the case of a neurologically intact patient, particularly when the microorganism has been identified. If medical management is chosen, careful observation and serial examination for neurologic deterioration is required. Surgical decompression is indicated if a patient's neurologic status worsens or if medical management failure is noted. Additionally, diabetes, a CRP level higher than 115 mg/L, WBC higher than 12500/µL , and bacteremia have proven predictive of medical treatment failure. This patient would be a better candidate for urgent surgical decompression and subsequent IV antibiotics than for medical management.
RECOMMENDED READINGS
Patel AR, Alton TB, Bransford RJ, Lee MJ, Bellabarba CB, Chapman JR. Spinal epidural abscesses: risk factors, medical versus surgical management, a retrospective review of 128 cases. Spine J. 2014 Feb 1;14(2):326-30. doi: 10.1016/j.spinee.2013.10.046. Epub 2013 Nov 12. PubMed PMID: 24231778.
View
Abstract at PubMed
Kim SD, Melikian R, Ju KL, Zurakowski D, Wood KB, Bono CM, Harris MB. Independent predictors of failure of nonoperative management of spinal epidural abscesses. Spine J. 2014 Aug 1;14(8):1673-9. doi: 10.1016/j.spinee.2013.10.011. Epub 2013 Oct 30. PubMed PMID:

Question 58:

Options:

Posterior tibial tendon transfer to the cuboid
Anterior tibial tendon transfer to the cuboid
Achilles tendon lengthening
Ankle-foot orthosis with dorsiflexion assist
Nerve grafting

Correct Answer: Ankle-foot orthosis with dorsiflexion assist

Explanation:

Question 59:

Options:

Lateral ulnar collateral ligament disruption
Anterior band of the medial collateral disruption
Posterior band of the medial collateral ligament disruption
Annular ligament interposition
Anconeus muscle interposition

Correct Answer: Lateral ulnar collateral ligament disruption

Explanation:

Question 60:

Options:

Shoulder abduction and internal rotation
Shoulder external rotation and scapula protraction
Shoulder external rotation with the arm at the side
Shoulder internal rotation with the arm at the side
Scapula protraction

Correct Answer: Shoulder external rotation with the arm at the side

Explanation:

Question 61:

A 23-year-old soccer player sustains a grade III complete posterior cruciate ligament (PCL) tear after colliding with another player. In reconstructing the PCL, it is optimal to reconstruct the

Options:

anterolateral bundle and tension the graft at 10° of flexion.
anterolateral bundle and tension the graft at 90° of flexion.
posteromedial bundle and tension the graft at 10° of flexion.
posteromedial bundle and tension the graft at 45° of flexion.
posteromedial bundle and tension the graft at 90° of flexion.

Correct Answer: anterolateral bundle and tension the graft at 90° of flexion.

Explanation:

Question 62:

Options:

Initiation of lumbar flexion and core strengthening exercises
Laminectomy and posterior spinal fusion of L4/5
Laminectomy of L4 without fusion
Percutaneous endoscopic diskectomy
A course of three epidural steroid injections

Correct Answer: Laminectomy and posterior spinal fusion of L4/5

Explanation:

Question 63:

What is the most common associated pathology in patients who have suprascapular nerve entrapment secondary to ganglion cysts?

Options:

Glenohumeral arthritis
Fracture of the clavicle
Tear of the rotator cuff
Rupture of the long head of the biceps tendon
Superior labrum anterior and posterior (SLAP) lesion

Correct Answer: Superior labrum anterior and posterior (SLAP) lesion

Explanation:

Question 64:

Options:

ACL tear and medial meniscal tear
Medial mensical tear only
PCL tear and medial meniscal tear
PLC tear and meniscal tear
PCL tear only

Correct Answer: ACL tear and medial meniscal tear

Explanation:

Question 65:

04 Which of the following laboratory studies is predictive of wound healing prior to performing a lower extremity amputation?

Options:

Total protein level
Calcium level
Serum albumin level
Platelet count
ESR back answer Question 11.04

Correct Answer: Serum albumin level

Explanation:

Question 66:

A 7-year-old girl has pain and a mass in the left scapula. A MRI scan and biopsy specimen are shown in Figures 30a and 30b. After staging studies, initial management should consist of

Options:

radiation therapy to the scapula.
systemic chemotherapy.
total scapulectomy.
partial scapulectomy.
intravenous antibiotics.

Correct Answer: systemic chemotherapy.

Explanation:

Question 67:

Options:

surgical exploration and tendon reinsertion of the flexor digitorum profundis.
surgical exploration and tendon reinsertion of the flexor digitorum superficialis.
steroids and physical therapy.
surgical release of the anterior interosseous nerve.
surgical release of the median nerve.

Correct Answer: surgical exploration and tendon reinsertion of the flexor digitorum profundis.

Explanation:

DISCUSSION: The patient has an avulsion of the flexor digitorum profundus. Treatment should include surgical exploration and tendon reinsertion. This is not an avulsion of the flexor digitorum superficialis because the patient’s deficiency is the inability to flex the distal interphalangeal joint, not the proximal interphalangeal joint. Surgical release of the anterior interosseous nerve is not indicated because the flexor digitorum profundus of the ring finger is innervated by the ulnar nerve. A median nerve contusion causes wrist pain and/or numbness and tingling in the median nerve distribution.
REFERENCES: Strickland JW: Flexor tendons: Acute injuries, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,
pp 1851-1897.
Leddy JP: Avulsions of the flexor digitorum profundus. Hand Clin 1985;1:77-83.

Question 68:

Options:

Anterior cruciate
Posterior cruciate
Lateral collateral
Oblique popliteal
Intermeniscal

Correct Answer: Anterior cruciate

Explanation:

Question 69:

Options:

Angiography
Immediate closed reduction and casting in extension
Surgical exploration and repair of the artery, followed by skeletal stabilization
Closed reduction and pinning, followed by reassessment of the vascular status
Magnetic resonance angiography (MRA)

Correct Answer: Closed reduction and pinning, followed by reassessment of the vascular status

Explanation:

DISCUSSION: The incidence of vascular injury in supracondylar humeral fractures is directly related to the degree and direction of displacement. Significant posterior lateral displacement tends to result in brachial artery and median nerve injuries, and posterior medial displacement may lead to radial nerve injury. The brachial artery is always injured at the level of the fracture; therefore, angiography or MRA will not assist in locating the injury. The treatment of choice is surgical reduction and stabilization of the fracture, followed by reassessment of the vascular status. If the hand is pink and warm or pulses can be detected with doppler, it is reasonable to follow the extremity closely after surgery. If the arm becomes pulseless and white, immediate anterior exploration of the arm is indicated. The artery is often entrapped in the fracture and once extricated, will provide adequate blood flow. If the artery is injured, a primary repair or vein graft is needed.
REFERENCES: Shaw BA: The role of angiography in assessing vascular injuries associated with supracondylar humerus fractures remains controversial. J Pediatr Orthop 1998;18:273.
Sabharwal S, Tredwell SJ, Beauchamp RD, et al: Management of pulseless pink hand in pediatric supracondylar fractures of humerus. J Pediatr Orthop 1997;17:303-310.
Schoenecker PL
, Delgado E, Rotman M, et al: Pulseless arm in association with totally displaced supracondylar fracture. J Orthop Trauma 1996;10:410-415.

Question 70:

Options:

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

Correct Answer: Posterior cruciate ligament-substituting knee

Explanation:

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

Question 71:

Options:

Ankle ligament repair
Resection of the accessory navicular
Resection of the talocalcaneal coalition
Subtalar arthrodesis
Triple arthrodesis

Correct Answer: Resection of the talocalcaneal coalition

Explanation:

Question 72:

Figure 1 is the anteroposterior radiograph of a 20-year-old dancer who fell during his routine and injured his right foot. What is the most appropriate treatment?

Options:

Closed reduction and cast
Open reduction and internal fixation
In situ percutaneous pinning
Posterior splint immobilization and controlled ankle motion (CAM) walker ambulation This patient has sustained a Lisfranc fracture dislocation of the forefoot. To fully restore foot function, an open reduction and internal fixation should be performed to anatomically reduce this dislocation. Closed reduction is unlikely to restore normal foot biomechanics and would likely result in delayed arthritis and joint incongruity. Posterior splint immobilization, CAM walker ambulation, and in situ percutaneous pinning will not adequately reduce the fracture and restore normal function to the foot.

Correct Answer: Open reduction and internal fixation

Explanation:

Question 73:

Options:

immediate internal fixation of the right femoral neck stress fracture.
non-weight-bearing crutch ambulation until symptoms resolve, followed by a gradual resumption of activities.
ultrasound therapy to promote fracture healing.
a metabolic work-up.
a bone scan to look for other stress fractures.

Correct Answer: non-weight-bearing crutch ambulation until symptoms resolve, followed by a gradual resumption of activities.

Explanation:

Question 74:

Options:

Dorsiflexion osteotomy of the first metatarsal
Dorsiflexion osteotomy of the first metatarsal combined with anterior transfer of the tibialis posterior
Triplanar osteotomy at the apex of the deformity
Triplanar osteotomy at the apex of the deformity combined with valgus calcaneal osteotomy
Triplanar osteotomy at the apex of the deformity combined with anterior transfer of the tibialis posterior

Correct Answer: Dorsiflexion osteotomy of the first metatarsal

Explanation:

DISCUSSION: This deformity is early in the disease process. The foot is still flexible, as evidenced by correction with the Coleman block test. A simple dorsiflexion osteotomy of the first metatarsal should provide a plantigrade foot. More complex osteotomies are required later in the disease process when the foot is not flexible and the deformity does not correct with the Coleman block test. The patient may also require a tibialis anterior transfer later in the disease process but not at the present time.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Upate: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 135-144.
Dehne R: Congenital and acquired neurologic disorders, in Coughlan MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, vol 1, pp 525-557.

Question 75:

Which study is most useful for diagnosis of exertional compartment syndrome?

Options:

MRI
Arterial Doppler
Static compartment pressures
Exertional compartment pressures

Correct Answer: Exertional compartment pressures

Explanation:

DISCUSSION
The most sensitive study in the diagnosis of exertional compartment syndrome is intracompartmental pressures taken at rest (compared to pressures taken immediately after exercise). MRI often can reveal nonspecific muscle edema in exertional compartment syndrome, but this is usually not diagnostic. Arterial Doppler studies are usually unremarkable unless they are taken after exercise, in which case these findings may be abnormal.
CLINICAL SITUATION FOR QUESTIONS 48 THROUGH 50
Figures 48a through 48f reveal the radiographs and MR images of a 30-year-old man who has a 1-year history of atraumatic medial-sided left knee pain refractory to nonsurgical measures.

Question 76:

What factor is associated with a high risk of developing pseudotumors after metal-on-metal hip resurfacing?

Options:

Large-diameter components
Age 40 or older for men
Age 40 or younger for women
Diagnosis of primary osteoarthritis

Correct Answer: Age 40 or younger for women

Explanation:

Question 77:

Options:

Isthmic spondylolysis
Herniated nucleus pulposus at L5-S1
Lumbar sprain
Limbus fracture
Aseptic diskitis

Correct Answer: Isthmic spondylolysis

Explanation:

Question 78:

A patient reports pain in the hip with functional positioning. With the patient supine, pain in which of the following positions would be typical for femoral acetabular impingement? Review Topic

Options:

Hip is internally rotated, passively flexed to 90 degrees, and adducted
Hip is internally rotated, passively flexed to 90 degrees, and abducted
Hip is externally rotated, maximally flexed to 90 degrees, and adducted
Hip is externally rotated, passively flexed to 90 degrees, and abducted
Hip is externally rotated, maximally flexed, and abducted

Correct Answer: Hip is internally rotated, passively flexed to 90 degrees, and adducted

Explanation:

Patients with dysplasia often have a hypertrophic labrum. Abnormal contact between the femoral neck and the acetabular rim leads to labral injury, especially in the anterior-superior acetabular zone. Typically, young patients with the condition report pain with activity or long periods of sitting or driving. The hips often have limited motion, in particular in internal rotation and flexion. Forceful adduction with the maneuver causes pain.
(SBQ13PE.10) Which statement is true regarding discoid menisci?
Review Topic
Most commonly involves the medial meniscus
Bilateral in >75% of cases
Asymptomatic discoid meniscus should undergo saucerization
Radiographs will commonly show a hyperplastic lateral intercondylar spine
Radiographs will commonly show squaring of affected condyle with cupping of tibial plateau
Radiographs of knees with discoid menisci will commonly show squaring of affected condyle (lateral>medial) with cupping of tibial plateau.
Discoid meniscus refers to the abnormal development of a hypertrophic and discoid shaped meniscus. It occurs in 3-5% of the population and it is considered the most common cause of a symptomatic clicking or clunking in a childs knee. The lateral meniscus is most commonly affected and it will occur bilaterally in 25% of affected
people. The Watanabe Classification describes the 3 types of discoid menisci. Type 1
= Incomplete, Type 2 = Complete, Type 3 = Wrisberg (lack of posterior meniscotibial attachment to tibia)
Kramer et al. looked at the presentation of pediatric knee pain. They showed that the lateral meniscus is more commonly affected than the medial meniscus. The majority of discoid tears occur in the posterior or middle aspect of the discoid meniscus.
Lee et al. retrospectively reviewed 36 patients aged less than 15 years who underwent arthroscopic procedures for torn discoid menisci. The mean patient age at the time of surgery was 9.5 years. They showed that partial meniscectomy yielded better radiologic results than subtotal/total meniscectomy for torn discoid menisci in this population.
Illustration A shows the 3 classifications of discoid menisus as originally described by Watanabe. Type 4 is a ring type discoid that was not originally described by Watanabe in his 1978 paper. Illustration B shows an AP and lateral radiograph of a discoid meniscus knee. Note squaring of affected lateral condyle in the presence of a lateral discoid meniscus. Illustration C shows 4 consecutive sagittal MRI images with meniscus continuity. It is important to note that the diagnosis of discoid menisci can be made when 3 or more 5mm sagittal images show meniscal continuity.
Incorrect Answers:

Question 79:

Figures 92a through 92c are the radiographs of a 34-year-old man with low-back pain and an inability to walk upright. What is the appropriate surgical treatment? A B C

Options:

Smith-Peterson osteotomies at T12-L1, L1-L2 and L2-3.
Vertebral column resection through a posterior approach
Anterior-posterior osteotomy
Pedicle subtraction osteotomy at L3

Correct Answer: Pedicle subtraction osteotomy at L3

Explanation:

Question 80:

Which of the following orthotic features best reduces pain in patients with hallux rigidus?

Options:

Plastazote layer to absorb shock
Medial posting to offload the medial forefoot
Rigid shank or forefoot rocker
Metatarsal bar to offload the first metatarsal head
Full length as opposed to three-quarter length

Correct Answer: Rigid shank or forefoot rocker

Explanation:

Question 81:

Options:

The local Keyhole representative has invited you and your spouse out to dinner at a local restaurant to discuss your interest in their new minimally invasive total knee system, the Keyhole Genuflex knee.
Keyhole has offered to pay your tuition to attend a CME course sponsored by the American Association of Hip & Knee Surgeons where both the Genuflex and the competing Styph total knee are discussed and demonstrated.
Keyhole will pay your expenses to attend a workshop, in Phoenix at their company headquarters, to learn how to implant the Genuflex knee and to see how the implant is manufactured and tested.
Keyhole will pay you $500 for each knee that you implant if you switch from your current total knee system.
After you have implanted 25 Genuflex knees, Keyhole will list you on their website as a consultant, pay you a consulting fee of $5,000 per year, and invite you to a golf tournament for their consultants at a resort.

Correct Answer: Keyhole will pay your expenses to attend a workshop, in Phoenix at their company headquarters, to learn how to implant the Genuflex knee and to see how the implant is manufactured and tested.

Explanation:

Question 82:

Options:

bridging external callus along the allograft and perpendicular callus at the junction site.
direct osteonal penetration of the allograft with haversian remodeling.
complete incorporation of the allograft with obliteration of the host allograft junction site.
fibrovascular invasion with absence of callus formation.
gap formation with resorption of the allograft surface.

Correct Answer: bridging external callus along the allograft and perpendicular callus at the junction site.

Explanation:

Question 83:

Options:

Multilevel anterior cervical diskectomy and fusion
Cervical laminectomy
Lumbar laminectomy
Lumbar laminectomy and fusion
Thoracic MRI

Correct Answer: Multilevel anterior cervical diskectomy and fusion

Explanation:

Symptoms of thoracic disk herniation may present in one of three distinct patterns: axial pain, radicular pain, or myelopathy. This patient demonstrates obvious upper motor neuron signs, including lower extremity hyperflexia, clonus, and a positive Babinski sign; therefore, the next most appropriate step is a MRI scan of the thoracic spine. Thoracic disk herniations presenting with axial pain usually involve the mid to lower thoracic region. The pain is usually worsened with activity and improved with rest. Radicular pain syndromes are usually described as starting in the back and radiating anteriorly in a band-like pattern to the anterior chest wall. The pain and paresthesias generally follow a dermatomal distribution. The MRI scan of this patient's cervical spine demonstrates spondylotic changes; however, she denied neck or upper extremity symptoms and more importantly, has a normal neurologic examination. There are degenerative changes involving the lumbar spine, but these cannot explain the upper motor neuron findings.
(SBQ12SP.39) Which of the following is associated with increased risk of surgical site infection following lumbar spinal decompression?
Review Topic
Use of intra-wound vancomycin powder
Hair removal by clipping at the time of surgery
Use of morphine nerve paste applied to the dura after spinal decompression
Skin preparation with an alcohol-based prep solution rather than povidone iodine
Failure to use chlorhexidine gluconate wash the night prior to surgery
The use of morphine nerve paste applied to the dura after decompressive spine surgery has been used in an effort to mitigate postoperative pain but has been associated with epidemic levels of surgical site infection.
Surgical site infection risk is modulated by a myriad of factors, both host factors and perioperative factors. Perioperative strategies to reduce infection that have been shown to be effective include: 1) hair removal by clipping (not shaving) at the time of surgery, 2) use of an alcohol based skin preparation agent, 3) use of perioperative prophylactic antibiotics, 4) limiting operating room traffic from OR personnel.
Kramer et al. did a retrospective analysis of 148 patients who underwent laminectomy in order to identify risk factors for infection in the context of a sudden increase in infections. Regression analysis showed that use of morphine paste resulted in an 18-fold increase in the risk of surgical site infection. 17 of 148 had developed infection during the epidemic period, compared to 15/995. Cultures were positive in 10 of 16 cases; 7 of these involved skin flora. Histological exam showed foreign body reaction.
Devin et al. did a multi-center analysis of patients undergoing spine surgery at seven spine centers to determine whether there was a difference in infection risk based on whether or not intra-wound vancomycin was used. They analyzed 2056 patients, of whom 47% had vancomycin used in their wounds. The risk of surgical site infection was higher in those patients that did not have vancomycin (relative risk 2.5).
Incorrect answers:

Question 84:

Options:

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

Correct Answer: Malposition of the femoral tunnel

Explanation:

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

Question 85:

Options:

Complete restoration of the cortex, with interdigitation of cement into the patient’s native bone
Fibrous membrane encapsulating the stem, surrounded by a cement mantle and dead allograft
Healing by mixed endochondral ossification, similar to fracture healing, surrounding the cement mantle
Allograft resorption, with some cortical restoration because of osteoinduction
Viable trabecular bone resulting from incorporation and remodeling of allograft

Correct Answer: Viable trabecular bone resulting from incorporation and remodeling of allograft

Explanation:

Question 86:

Which of the following statements about hoarseness due to vocal cord paralysis after anterior cervical diskectomy and fusion is most accurate?

Options:

Vocal cord paralysis is three times as likely with a right-sided approach as compared to a left-sided approach.
Vocal cord paralysis is twice as likely with a right-sided approach as compared to a left-sided approach.
Vocal cord paralysis is equally likely with either a right-sided or a left-sided approach.
Vocal cord paralysis is three times as likely with a left-sided approach as compared to a right-sided approach.
Vocal cord paralysis is twice as likely with a left-sided approach as compared to a right-sided approach.

Correct Answer: Vocal cord paralysis is equally likely with either a right-sided or a left-sided approach.

Explanation:

DISCUSSION: It has been traditionally taught that a left-sided approach to the anterior cervical spine is associated with a lower incidence of injury compared to the right-sided approach. This is due in part to the anatomic differences in the path the recurrent laryngeal nerve (RLN) takes on the right as compared to the left. Both nerves ascend in the tracheoesophageal groove after branching off the vagus nerve in the upper thorax. The left-sided RLN loops around the aortic arch and stays relatively medial as compared to the right-sided RLN which loops around the right subclavian artery and is somewhat more lateral at this point, and therefore is theoretically more vulnerable as it ascends toward the larynx before becoming protected in the tracheoesophageal groove. Furthermore, the variant of a nonrecurrent inferior laryngeal nerve branching directly off the vagus nerve at the level of the midcervical spine is much more common on the right than the left. Despite this reasoning, there has been no clinical evidence to suggest that laterality of approach for anterior cervical surgery makes any difference in the incidence of vocal cord paralysis. Furthermore, two recent studies have shown that the incidence of RLN injury and vocal cord paralysis is equal with either side of approach.
REFERENCES: Beutler WJ, Sweeney CA, Connolly PJ: Recurrent laryngeal nerve injury with anterior cervical spine surgery risk with laterality of surgical approach. Spine 2001;26:1337-1342.
Kilburg C, Sullivan HG, Mathiason MA: Effect of approach side during anterior cervical discectomy and fusion on the incidence of recurrent laryngeal nerve injury. J Neurosurg Spine 2006;4:273-277.

Question 87:

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

Options:

Distal fibular fracture
Cuboid fracture
Calcaneus fracture
Talus fracture
Navicular fracture

Correct Answer: Distal fibular fracture

Explanation:

Question 88:

Pacinian corpuscles are lamellated nerve endings that are responsible for providing the perception of

Options:

pain.
light touch.
pressure.
temperature.
vibration.

Correct Answer: pressure.

Explanation:

Question 89:

Which of the following definitions best describes Batson’s vertebral vein system?

Options:

A system of valves that allows retrograde embolism
A vascular system that bypasses organs such as the breast, prostate, lung, kidney, and thyroid
A system of veins within the thoracoabdominal cavity that are not subject to compression or collapse by increases in intra-abdominal pressure
A series of valveless veins that allow tumor cell extravasation
A longitudinal vein system with a segmental distribution to the vertebra that extends from the dural venous sinuses of the skull to the sacrum

Correct Answer: A series of valveless veins that allow tumor cell extravasation

Explanation:

Question 90:

Free flap coverage for severe trauma to the upper extremity has the fewest complications when performed within what time period after injury?

Options:

72 hours
7 to 10 days
2 weeks
4 weeks
4 months

Correct Answer: 72 hours

Explanation:

Question 91:

Options:

Open treatment of the metatarsal malunion
Open treatment of the metatarsal nonunions and hallux metatarsophalangeal arthrodesis
Cast application and an external bone stimulator
Hallux valgus correction
Hallux metatarsophalangeal arthrodesis

Correct Answer: Open treatment of the metatarsal nonunions and hallux metatarsophalangeal arthrodesis

Explanation:

Question 92:

Options:

Revision of the acetabular implant to a constrained bearing with modular exchange of the femoral head and neck
Revision of the acetabular and femoral implants
Retention of the acetabular implant with modular exchange of the femoral head and neck
Revision of the femoral component alone with a new ceramic head

Correct Answer: Revision of the acetabular and femoral implants

Explanation:

Question 93:

Options:

Bisphosphonates
Calcitonin
Parathyroid hormone
Vitamin D and calcium
Methotrexate

Correct Answer: Bisphosphonates

Explanation:

Question 94:

Options:

Early cocking
Late cocking
Acceleration
Deceleration

Correct Answer: Late cocking

Explanation:

Question 95:

Figures 1 and 2 are the CT and MRI scans of a patient with shoulder instability. Contrasting these two imaging techniques for decision making in shoulder instability would suggest

Options:

Both CT and MRI have equivalent cost for the patient.
Both CT and MRI have equivalent safety for the patient.
Associated soft-tissue damage can be more reliably shown on CT scans.
Two-dimensional CT scans represent better definition of bone loss than two-dimensional MRI scans. Two-dimensional CT scan is generally accepted as a superior imaging modality for evaluating bone loss in shoulder instability than two-dimensional MRI scan. This advantage is offset by the relatively high radiation dose. Although CT in most situations is less costly, MRI can provide more data regarding associated soft-tissue damage that can be associated with recurrent instability. It should be noted that three-dimensional MRI has recently been shown as equivalent to three-dimensional CT in its ability to identify glenoid bone loss.

Correct Answer: Two-dimensional CT scans represent better definition of bone loss than two-dimensional MRI scans. Two-dimensional CT scan is generally accepted as a superior imaging modality for evaluating bone loss in shoulder instability than two-dimensional MRI scan. This advantage is offset by the relatively high radiation dose. Although CT in most situations is less costly, MRI can provide more data regarding associated soft-tissue damage that can be associated with recurrent instability. It should be noted that three-dimensional MRI has recently been shown as equivalent to three-dimensional CT in its ability to identify glenoid bone loss.

Explanation:

A 43-year-old woman is involved in a motor vehicle collision. She sustains the isolated injury shown in the radiograph in Figure 1. Her neurovascular examination is compromised. What is the most likely deficit?
A. Inability to flex the distal interphalangeal joint of the index finger
B. Positive Froment’s sign
C. Weakness with wrist extension
D. Decreased capillary refill

Question 96:

Options:

Brachial plexus injury
Anterior cord syndrome
Posterior cord syndrome
Central cord syndrome
Brown-Séquard syndrome

Correct Answer: Central cord syndrome

Explanation:

Question 97:

Options:

Decreased blood loss
Less neural retraction
Improved neuroforaminal height
Lower fusion rates

Correct Answer: Improved neuroforaminal height

Explanation:

DISCUSSION
Interbody fusion, when compared to PLF, is a predictor of more substantial blood loss. Multilevel posterior lumbar interbody fusion (PLIF) is an independent predictor of blood loss for posterior spine fusion. Some retrospective studies suggest that fusion rates are higher for transforaminal lumbar interbody fusion (TLIF) than PLF, but this finding has not been borne out in prospective studies. The main advantage of TLIF in the context of this question is restoration of neuroforaminal height, and many surgeons will consider TLIF or PLIF for that reason. The parasagittal MR image seen in Figure 9c shows neuroforaminal narrowing. The pre- and postsurgical radiographs show a difference in neuroforaminal height.
RECOMMENDED READINGS
DiPaola CP, Molinari RW. Posterior lumbar interbody fusion. J Am Acad Orthop Surg. 2008 Mar;16(3):130-9. Review. PubMed PMID: 18316711.
View Abstract at PubMed
Eismont FJ, Norton RP, Hirsch BP. Surgical management of lumbar degenerative spondylolisthesis. J Am Acad Orthop Surg. 2014 Apr;22(4):203-13. doi: 10.5435/JAAOS-22-04-203. Review. PubMed PMID: 24668350.
View Abstract at PubMed
McAfee PC, DeVine JG, Chaput CD, Prybis BG, Fedder IL, Cunningham BW, Farrell DJ, Hess SJ, Vigna FE. The indications for interbody fusion cages in the treatment of spondylolisthesis: analysis of 120 cases. Spine (Phila Pa 1976). 2005 Mar 15;30(6 Suppl):S60-5. PubMed PMID: 15767888.
View Abstract at PubMed
RESPONSES FOR QUESTIONS 10 THROUGH 14
Postoperative deep surgical site infection
Proximal junctional kyphosis
Pedicle screw cut-out
Pseudarthrosis
Sagittal imbalance
Please match the scenario described below with the most likely complication listed above.

Question 98:

An otherwise healthy 13-year-old boy sustains the fracture shown in Figure 40 while throwing a fastball. Management should consist of

Options:

an arm sling.
functional bracing supporting the humerus and arm.
closed reduction and a shoulder spica cast.
open reduction and internal fixation with retrograde rods.
open reduction and internal fixation with a rigid plate and screws.

Correct Answer: functional bracing supporting the humerus and arm.

Explanation:

Question 99:

Options:

Unlinked elbow arthroplasty
Linked elbow arthroplasty
Interposition arthroplasty
Arthroscopic or open debridement
Radial head excision

Correct Answer: Arthroscopic or open debridement

Explanation:

DISCUSSION: The patient has symptomatic primary osteoarthritis of the elbow with multiple loose bodies. Given his age and occupation, an elbow arthroplasty is not an option. Arthroscopic debridement and removal of loose bodies has been shown to be effective for osteoarthritis of the elbow.
REFERENCES: Gramstad GD, Galatz LM: Management of elbow osteoarthritis. J Bone Joint Surg Am 2006;88:421-430.
Steinmann SP, King GJ, Savoie FH III, et al: Arthroscopic treatment of the arthritic elbow.
J Bone Joint Surg Am 2005;87:2114-2121.

Question 100:

Options:

use of mechanical prophylaxis (eg, pneumatic calf compressors) while in the hospital.
oral warfarin with a goal INR between 2.0 and 3.0.
low-dose warfarin for 3 weeks postsurgically beginning 48 hours after surgery.
no prophylaxis because this patient already is partially anticoagulated secondary to her liver disease.

Correct Answer: use of mechanical prophylaxis (eg, pneumatic calf compressors) while in the hospital.

Explanation:

The 2011 AAOS Clinical Practice Guideline,
Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty
, recommends the use of mechanical prophylaxis for patients at increased risk for bleeding (including those with liver disease or hemophilia). This recommendation is the consensus of the workgroup that established these guidelines because there was insufficient evidence to justify a stronger recommendation in this clinical scenario. The other responses use no prophylaxis or pharmacological prophylaxis. Pharmacological prophylaxis is not recommended in patients who are at increased risk for bleeding.

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

Orthopedic Surgery Board Review MCQs: Spine, Trauma & Shoulder | Part 201

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 201

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index